hospital_name,last_updated_on,version,hospital_location,hospital_address,license_number|CA,"To the best of its knowledge and belief, the hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date indicated.",,,,,,,,,,,,,,,,,,,,,,
Ely-Bloomenson Community Hospital,7/1/2024,2.0.0,Ely-Bloomenson Community Hospital,"328 W Conan St, Ely, MN 55731",41-0808719,TRUE,,,,,,,,,,,,,,,,,,,,,,
description,code|1,code|1|type,code|2,code|2|type,code|3,code|3|type,modifiers,code|4,code|4|type,code|5,code|5|type,drug_unit_of_measurement,drug_type_of_measurement,standard_charge|gross,standard_charge|discounted_cash,payer_name,plan_name,setting,standard_charge|negotiated_percentage,standard_charge|negotiated_algorithm,estimated_amount,standard_charge|methodology,standard_charge|negotiated_dollar,additional_generic_notes,billing_class,financial_aid_policy,standard_charge|min,standard_charge|max
Anes Dx Shoulder Arthroscopy,PX01622.01,CDM,964,RC,1622,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Dx Shoulder Arthroscopy,PX01622.01,CDM,964,RC,1622,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Dx Shoulder Arthroscopy,PX01622.01,CDM,964,RC,1622,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Dx Shoulder Arthroscopy,PX01622.01,CDM,964,RC,1622,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Lower Intestinal Endoscopic Px Nos,PX00811.01,CDM,964,RC,811,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,10.48567783,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Lower Intestinal Endoscopic Px Nos,PX00811.01,CDM,964,RC,811,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Lower Intestinal Endoscopic Px Nos,PX00811.01,CDM,964,RC,811,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,30.46153846,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Lower Intestinal Endoscopic Px Nos,PX00811.01,CDM,964,RC,811,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Lower Intestinal Screening Colonoscopy,PX00812.01,CDM,964,RC,812,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Lower Intestinal Screening Colonoscopy,PX00812.01,CDM,964,RC,812,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Lower Intestinal Screening Colonoscopy,PX00812.01,CDM,964,RC,812,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Lower Intestinal Screening Colonoscopy,PX00812.01,CDM,964,RC,812,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Spine Transthor W/Vent,PX00626.01,CDM,964,RC,626,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Spine Transthor W/Vent,PX00626.01,CDM,964,RC,626,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Spine Transthor W/Vent,PX00626.01,CDM,964,RC,626,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Spine Transthor W/Vent,PX00626.01,CDM,964,RC,626,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Spine Tranthor W/O Vent,PX00625.01,CDM,964,RC,625,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Spine Tranthor W/O Vent,PX00625.01,CDM,964,RC,625,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Spine Tranthor W/O Vent,PX00625.01,CDM,964,RC,625,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Spine Tranthor W/O Vent,PX00625.01,CDM,964,RC,625,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Ther Interven Rad Art,PX01924.01,CDM,964,RC,1924,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Ther Interven Rad Art,PX01924.01,CDM,964,RC,1924,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Ther Interven Rad Art,PX01924.01,CDM,964,RC,1924,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Ther Interven Rad Art,PX01924.01,CDM,964,RC,1924,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Ther Interven Rad Car,PX01925.01,CDM,964,RC,1925,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Ther Interven Rad Car,PX01925.01,CDM,964,RC,1925,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Ther Interven Rad Car,PX01925.01,CDM,964,RC,1925,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Ther Interven Rad Car,PX01925.01,CDM,964,RC,1925,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Ther Interven Rad Tip,PX01931.01,CDM,964,RC,1931,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Ther Interven Rad Tip,PX01931.01,CDM,964,RC,1931,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Ther Interven Rad Tip,PX01931.01,CDM,964,RC,1931,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Ther Interven Rad Tip,PX01931.01,CDM,964,RC,1931,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Ther Interven Rad Vei,PX01930.01,CDM,964,RC,1930,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Ther Interven Rad Vei,PX01930.01,CDM,964,RC,1930,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Ther Interven Rad Vei,PX01930.01,CDM,964,RC,1930,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Ther Interven Rad Vei,PX01930.01,CDM,964,RC,1930,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Tx Interv Rad Cran V,PX01933.01,CDM,964,RC,1933,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Tx Interv Rad Cran V,PX01933.01,CDM,964,RC,1933,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Tx Interv Rad Cran V,PX01933.01,CDM,964,RC,1933,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Tx Interv Rad Cran V,PX01933.01,CDM,964,RC,1933,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Tx Interv Rad Hrt/Cran,PX01926.01,CDM,964,RC,1926,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Tx Interv Rad Hrt/Cran,PX01926.01,CDM,964,RC,1926,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Tx Interv Rad Hrt/Cran,PX01926.01,CDM,964,RC,1926,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Tx Interv Rad Hrt/Cran,PX01926.01,CDM,964,RC,1926,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Tx Interv Rad Th Vein,PX01932.01,CDM,964,RC,1932,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Tx Interv Rad Th Vein,PX01932.01,CDM,964,RC,1932,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Tx Interv Rad Th Vein,PX01932.01,CDM,964,RC,1932,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Tx Interv Rad Th Vein,PX01932.01,CDM,964,RC,1932,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Upper GI Endoscopic Px Ercp,PX00732.01,CDM,964,RC,732,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Upper GI Endoscopic Px Ercp,PX00732.01,CDM,964,RC,732,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Upper GI Endoscopic Px Ercp,PX00732.01,CDM,964,RC,732,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Upper GI Endoscopic Px Ercp,PX00732.01,CDM,964,RC,732,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Upper GI Endoscopic Px Nos,PX00731.01,CDM,964,RC,731,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Upper GI Endoscopic Px Nos,PX00731.01,CDM,964,RC,731,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Upper GI Endoscopic Px Nos,PX00731.01,CDM,964,RC,731,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Upper GI Endoscopic Px Nos,PX00731.01,CDM,964,RC,731,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Upper/Lower GI Endoscopic Px,PX00813.01,CDM,964,RC,813,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,7.2,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Upper/Lower GI Endoscopic Px,PX00813.01,CDM,964,RC,813,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Upper/Lower GI Endoscopic Px,PX00813.01,CDM,964,RC,813,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Upper/Lower GI Endoscopic Px,PX00813.01,CDM,964,RC,813,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes/Analg Cs Deliver Add-On,PX01968.01,CDM,964,RC,1968,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes/Analg Cs Deliver Add-On,PX01968.01,CDM,964,RC,1968,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes/Analg Cs Deliver Add-On,PX01968.01,CDM,964,RC,1968,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes/Analg Cs Deliver Add-On,PX01968.01,CDM,964,RC,1968,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Abdomen Vessel Surg,PX00880.01,CDM,964,RC,880,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Abdomen Vessel Surg,PX00880.01,CDM,964,RC,880,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Abdomen Vessel Surg,PX00880.01,CDM,964,RC,880,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Abdomen Vessel Surg,PX00880.01,CDM,964,RC,880,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Abdominal Wall Surg,PX00700.01,CDM,964,RC,700,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Abdominal Wall Surg,PX00700.01,CDM,964,RC,700,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Abdominal Wall Surg,PX00700.01,CDM,964,RC,700,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Abdominal Wall Surg,PX00700.01,CDM,964,RC,700,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Abdominal Wall Surg,PX00730.01,CDM,964,RC,730,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Abdominal Wall Surg,PX00730.01,CDM,964,RC,730,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Abdominal Wall Surg,PX00730.01,CDM,964,RC,730,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Abdominal Wall Surg,PX00730.01,CDM,964,RC,730,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Abdominal Wall Surg,PX00800.01,CDM,964,RC,800,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Abdominal Wall Surg,PX00800.01,CDM,964,RC,800,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Abdominal Wall Surg,PX00800.01,CDM,964,RC,800,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Abdominal Wall Surg,PX00800.01,CDM,964,RC,800,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Abdominal Wall Surg,PX00820.01,CDM,964,RC,820,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Abdominal Wall Surg,PX00820.01,CDM,964,RC,820,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Abdominal Wall Surg,PX00820.01,CDM,964,RC,820,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Abdominal Wall Surg,PX00820.01,CDM,964,RC,820,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Achilles Tendon Surg,PX01472.01,CDM,964,RC,1472,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Achilles Tendon Surg,PX01472.01,CDM,964,RC,1472,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Achilles Tendon Surg,PX01472.01,CDM,964,RC,1472,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Achilles Tendon Surg,PX01472.01,CDM,964,RC,1472,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Airplane Cast,PX01682.01,CDM,964,RC,1682,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Airplane Cast,PX01682.01,CDM,964,RC,1682,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Airplane Cast,PX01682.01,CDM,964,RC,1682,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Airplane Cast,PX01682.01,CDM,964,RC,1682,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Amniocentesis,PX00842.01,CDM,964,RC,842,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Amniocentesis,PX00842.01,CDM,964,RC,842,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Amniocentesis,PX00842.01,CDM,964,RC,842,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Amniocentesis,PX00842.01,CDM,964,RC,842,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Amputation at Knee,PX01404.01,CDM,964,RC,1404,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Amputation at Knee,PX01404.01,CDM,964,RC,1404,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Amputation at Knee,PX01404.01,CDM,964,RC,1404,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Amputation at Knee,PX01404.01,CDM,964,RC,1404,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Amputation at Pelvis,PX01140.01,CDM,964,RC,1140,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Amputation at Pelvis,PX01140.01,CDM,964,RC,1140,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Amputation at Pelvis,PX01140.01,CDM,964,RC,1140,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Amputation at Pelvis,PX01140.01,CDM,964,RC,1140,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Amputation of Femur,PX01232.01,CDM,964,RC,1232,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Amputation of Femur,PX01232.01,CDM,964,RC,1232,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Amputation of Femur,PX01232.01,CDM,964,RC,1232,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Amputation of Femur,PX01232.01,CDM,964,RC,1232,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Amputation of Penis,PX00932.01,CDM,964,RC,932,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Amputation of Penis,PX00932.01,CDM,964,RC,932,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Amputation of Penis,PX00932.01,CDM,964,RC,932,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Amputation of Penis,PX00932.01,CDM,964,RC,932,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Ankle Replacement,PX01486.01,CDM,964,RC,1486,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Ankle Replacement,PX01486.01,CDM,964,RC,1486,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Ankle Replacement,PX01486.01,CDM,964,RC,1486,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Ankle Replacement,PX01486.01,CDM,964,RC,1486,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Ankle/Ft Arthroscopy,PX01464.01,CDM,964,RC,1464,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Ankle/Ft Arthroscopy,PX01464.01,CDM,964,RC,1464,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Ankle/Ft Arthroscopy,PX01464.01,CDM,964,RC,1464,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Ankle/Ft Arthroscopy,PX01464.01,CDM,964,RC,1464,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Anorectal Surgery,PX00902.01,CDM,964,RC,902,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,7.2,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Anorectal Surgery,PX00902.01,CDM,964,RC,902,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Anorectal Surgery,PX00902.01,CDM,964,RC,902,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Anorectal Surgery,PX00902.01,CDM,964,RC,902,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Antepartum Manipul,PX01958.01,CDM,964,RC,1958,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Antepartum Manipul,PX01958.01,CDM,964,RC,1958,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Antepartum Manipul,PX01958.01,CDM,964,RC,1958,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Antepartum Manipul,PX01958.01,CDM,964,RC,1958,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Arm-Leg Vessel Surg,PX01656.01,CDM,964,RC,1656,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Arm-Leg Vessel Surg,PX01656.01,CDM,964,RC,1656,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Arm-Leg Vessel Surg,PX01656.01,CDM,964,RC,1656,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Arm-Leg Vessel Surg,PX01656.01,CDM,964,RC,1656,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Arthroscopy of Hip,PX01202.01,CDM,964,RC,1202,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Arthroscopy of Hip,PX01202.01,CDM,964,RC,1202,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Arthroscopy of Hip,PX01202.01,CDM,964,RC,1202,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Arthroscopy of Hip,PX01202.01,CDM,964,RC,1202,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Biceps Tendon Repair,PX01716.01,CDM,964,RC,1716,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Biceps Tendon Repair,PX01716.01,CDM,964,RC,1716,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Biceps Tendon Repair,PX01716.01,CDM,964,RC,1716,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Biceps Tendon Repair,PX01716.01,CDM,964,RC,1716,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Biopsy of Nose,PX00164.01,CDM,964,RC,164,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Biopsy of Nose,PX00164.01,CDM,964,RC,164,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Biopsy of Nose,PX00164.01,CDM,964,RC,164,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Biopsy of Nose,PX00164.01,CDM,964,RC,164,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Biopsy of Thyroid,PX00322.01,CDM,964,RC,322,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Biopsy of Thyroid,PX00322.01,CDM,964,RC,322,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Biopsy of Thyroid,PX00322.01,CDM,964,RC,322,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Biopsy of Thyroid,PX00322.01,CDM,964,RC,322,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Bladder Stone Surg,PX00870.01,CDM,964,RC,870,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Bladder Stone Surg,PX00870.01,CDM,964,RC,870,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Bladder Stone Surg,PX00870.01,CDM,964,RC,870,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Bladder Stone Surg,PX00870.01,CDM,964,RC,870,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Bladder Surgery,PX00910.01,CDM,964,RC,910,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Bladder Surgery,PX00910.01,CDM,964,RC,910,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Bladder Surgery,PX00910.01,CDM,964,RC,910,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Bladder Surgery,PX00910.01,CDM,964,RC,910,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Bladder Tumor Surg,PX00912.01,CDM,964,RC,912,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Bladder Tumor Surg,PX00912.01,CDM,964,RC,912,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Bladder Tumor Surg,PX00912.01,CDM,964,RC,912,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Bladder Tumor Surg,PX00912.01,CDM,964,RC,912,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Bleeding Control,PX00916.01,CDM,964,RC,916,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Bleeding Control,PX00916.01,CDM,964,RC,916,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Bleeding Control,PX00916.01,CDM,964,RC,916,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Bleeding Control,PX00916.01,CDM,964,RC,916,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Blepharoplasty,PX00103.01,CDM,964,RC,103,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Blepharoplasty,PX00103.01,CDM,964,RC,103,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Blepharoplasty,PX00103.01,CDM,964,RC,103,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Blepharoplasty,PX00103.01,CDM,964,RC,103,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Blood Vessel Repair,PX00770.01,CDM,964,RC,770,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Blood Vessel Repair,PX00770.01,CDM,964,RC,770,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Blood Vessel Repair,PX00770.01,CDM,964,RC,770,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Blood Vessel Repair,PX00770.01,CDM,964,RC,770,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Body Cast Procedure,PX01130.01,CDM,964,RC,1130,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Body Cast Procedure,PX01130.01,CDM,964,RC,1130,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Body Cast Procedure,PX01130.01,CDM,964,RC,1130,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Body Cast Procedure,PX01130.01,CDM,964,RC,1130,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Bone Aspirate/Bx,PX01112.01,CDM,964,RC,1112,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Bone Aspirate/Bx,PX01112.01,CDM,964,RC,1112,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Bone Aspirate/Bx,PX01112.01,CDM,964,RC,1112,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Bone Aspirate/Bx,PX01112.01,CDM,964,RC,1112,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Burn 4-9 Percent,PX01952.01,CDM,964,RC,1952,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Burn 4-9 Percent,PX01952.01,CDM,964,RC,1952,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Burn 4-9 Percent,PX01952.01,CDM,964,RC,1952,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Burn 4-9 Percent,PX01952.01,CDM,964,RC,1952,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Burn Each 9 Percent,PX01953.01,CDM,964,RC,1953,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Burn Each 9 Percent,PX01953.01,CDM,964,RC,1953,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Burn Each 9 Percent,PX01953.01,CDM,964,RC,1953,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Burn Each 9 Percent,PX01953.01,CDM,964,RC,1953,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Burn Less 4 Percent,PX01951.01,CDM,964,RC,1951,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Burn Less 4 Percent,PX01951.01,CDM,964,RC,1951,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Burn Less 4 Percent,PX01951.01,CDM,964,RC,1951,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Burn Less 4 Percent,PX01951.01,CDM,964,RC,1951,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cabg W/O Pump,PX00566.01,CDM,964,RC,566,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cabg W/O Pump,PX00566.01,CDM,964,RC,566,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cabg W/O Pump,PX00566.01,CDM,964,RC,566,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cabg W/O Pump,PX00566.01,CDM,964,RC,566,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cabg W/Pump,PX00567.01,CDM,964,RC,567,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cabg W/Pump,PX00567.01,CDM,964,RC,567,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cabg W/Pump,PX00567.01,CDM,964,RC,567,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cabg W/Pump,PX00567.01,CDM,964,RC,567,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cardiac Electrophys,PX00537.01,CDM,964,RC,537,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cardiac Electrophys,PX00537.01,CDM,964,RC,537,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cardiac Electrophys,PX00537.01,CDM,964,RC,537,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cardiac Electrophys,PX00537.01,CDM,964,RC,537,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cardioverter/Defib,PX00534.01,CDM,964,RC,534,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cardioverter/Defib,PX00534.01,CDM,964,RC,534,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cardioverter/Defib,PX00534.01,CDM,964,RC,534,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cardioverter/Defib,PX00534.01,CDM,964,RC,534,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cat or MRI Scan,PX01922.01,CDM,964,RC,1922,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cat or MRI Scan,PX01922.01,CDM,964,RC,1922,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cat or MRI Scan,PX01922.01,CDM,964,RC,1922,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cat or MRI Scan,PX01922.01,CDM,964,RC,1922,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Catheterize Heart,PX01920.01,CDM,964,RC,1920,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Catheterize Heart,PX01920.01,CDM,964,RC,1920,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Catheterize Heart,PX01920.01,CDM,964,RC,1920,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Catheterize Heart,PX01920.01,CDM,964,RC,1920,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Drainage,PX00524.01,CDM,964,RC,524,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Drainage,PX00524.01,CDM,964,RC,524,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Drainage,PX00524.01,CDM,964,RC,524,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Drainage,PX00524.01,CDM,964,RC,524,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Lining Biopsy,PX00522.01,CDM,964,RC,522,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Lining Biopsy,PX00522.01,CDM,964,RC,522,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Lining Biopsy,PX00522.01,CDM,964,RC,522,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Lining Biopsy,PX00522.01,CDM,964,RC,522,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Partition View,PX00528.01,CDM,964,RC,528,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Partition View,PX00528.01,CDM,964,RC,528,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Partition View,PX00528.01,CDM,964,RC,528,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Partition View,PX00528.01,CDM,964,RC,528,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Partition View,PX00529.01,CDM,964,RC,529,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Partition View,PX00529.01,CDM,964,RC,529,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Partition View,PX00529.01,CDM,964,RC,529,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Partition View,PX00529.01,CDM,964,RC,529,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Procedure,PX00520.01,CDM,964,RC,520,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Procedure,PX00520.01,CDM,964,RC,520,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Procedure,PX00520.01,CDM,964,RC,520,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Procedure,PX00520.01,CDM,964,RC,520,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Surgery,PX00540.01,CDM,964,RC,540,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Surgery,PX00540.01,CDM,964,RC,540,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Surgery,PX00540.01,CDM,964,RC,540,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Surgery,PX00540.01,CDM,964,RC,540,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Wall Repair,PX00472.01,CDM,964,RC,472,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Wall Repair,PX00472.01,CDM,964,RC,472,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Wall Repair,PX00472.01,CDM,964,RC,472,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Wall Repair,PX00472.01,CDM,964,RC,472,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cleft Palate Repair,PX00172.01,CDM,964,RC,172,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cleft Palate Repair,PX00172.01,CDM,964,RC,172,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cleft Palate Repair,PX00172.01,CDM,964,RC,172,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cleft Palate Repair,PX00172.01,CDM,964,RC,172,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Collar Bone Biopsy,PX00454.01,CDM,964,RC,454,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Collar Bone Biopsy,PX00454.01,CDM,964,RC,454,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Collar Bone Biopsy,PX00454.01,CDM,964,RC,454,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Collar Bone Biopsy,PX00454.01,CDM,964,RC,454,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Corneal Transplant,PX00144.01,CDM,964,RC,144,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Corneal Transplant,PX00144.01,CDM,964,RC,144,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Corneal Transplant,PX00144.01,CDM,964,RC,144,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Corneal Transplant,PX00144.01,CDM,964,RC,144,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Correct Heart Rhythm,PX00410.01,CDM,964,RC,410,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Correct Heart Rhythm,PX00410.01,CDM,964,RC,410,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Correct Heart Rhythm,PX00410.01,CDM,964,RC,410,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Correct Heart Rhythm,PX00410.01,CDM,964,RC,410,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cran Surg Hemotoma,PX00211.01,CDM,964,RC,211,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cran Surg Hemotoma,PX00211.01,CDM,964,RC,211,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cran Surg Hemotoma,PX00211.01,CDM,964,RC,211,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cran Surg Hemotoma,PX00211.01,CDM,964,RC,211,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cranial Surg Nos,PX00210.01,CDM,964,RC,210,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cranial Surg Nos,PX00210.01,CDM,964,RC,210,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cranial Surg Nos,PX00210.01,CDM,964,RC,210,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cranial Surg Nos,PX00210.01,CDM,964,RC,210,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cs Delivery,PX01961.01,CDM,964,RC,1961,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cs Delivery,PX01961.01,CDM,964,RC,1961,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cs Delivery,PX01961.01,CDM,964,RC,1961,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cs Delivery,PX01961.01,CDM,964,RC,1961,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cs Hysterectomy,PX01963.01,CDM,964,RC,1963,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cs Hysterectomy,PX01963.01,CDM,964,RC,1963,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cs Hysterectomy,PX01963.01,CDM,964,RC,1963,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cs Hysterectomy,PX01963.01,CDM,964,RC,1963,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Dx Arteriography,PX01916.01,CDM,964,RC,1916,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Dx Arteriography,PX01916.01,CDM,964,RC,1916,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Dx Arteriography,PX01916.01,CDM,964,RC,1916,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Dx Arteriography,PX01916.01,CDM,964,RC,1916,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Dx Elbow Arthroscopy,PX01732.01,CDM,964,RC,1732,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Dx Elbow Arthroscopy,PX01732.01,CDM,964,RC,1732,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Dx Elbow Arthroscopy,PX01732.01,CDM,964,RC,1732,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Dx Elbow Arthroscopy,PX01732.01,CDM,964,RC,1732,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Dx Knee Arthroscopy,PX01382.01,CDM,964,RC,1382,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Dx Knee Arthroscopy,PX01382.01,CDM,964,RC,1382,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Dx Knee Arthroscopy,PX01382.01,CDM,964,RC,1382,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Dx Knee Arthroscopy,PX01382.01,CDM,964,RC,1382,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Dx Wrist Arthroscopy,PX01829.01,CDM,964,RC,1829,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Dx Wrist Arthroscopy,PX01829.01,CDM,964,RC,1829,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Dx Wrist Arthroscopy,PX01829.01,CDM,964,RC,1829,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Dx Wrist Arthroscopy,PX01829.01,CDM,964,RC,1829,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Ear Exam,PX00124.01,CDM,964,RC,124,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Ear Exam,PX00124.01,CDM,964,RC,124,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Ear Exam,PX00124.01,CDM,964,RC,124,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Ear Exam,PX00124.01,CDM,964,RC,124,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Ear Surgery,PX00120.01,CDM,964,RC,120,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Ear Surgery,PX00120.01,CDM,964,RC,120,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Ear Surgery,PX00120.01,CDM,964,RC,120,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Ear Surgery,PX00120.01,CDM,964,RC,120,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Elbow Area Surgery,PX01710.01,CDM,964,RC,1710,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Elbow Area Surgery,PX01710.01,CDM,964,RC,1710,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Elbow Area Surgery,PX01710.01,CDM,964,RC,1710,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Elbow Area Surgery,PX01710.01,CDM,964,RC,1710,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Elbow Replacement,PX01760.01,CDM,964,RC,1760,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Elbow Replacement,PX01760.01,CDM,964,RC,1760,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Elbow Replacement,PX01760.01,CDM,964,RC,1760,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Elbow Replacement,PX01760.01,CDM,964,RC,1760,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Electroshock,PX00104.01,CDM,964,RC,104,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Electroshock,PX00104.01,CDM,964,RC,104,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Electroshock,PX00104.01,CDM,964,RC,104,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Electroshock,PX00104.01,CDM,964,RC,104,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Emer Hysterectomy,PX01962.01,CDM,964,RC,1962,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Emer Hysterectomy,PX01962.01,CDM,964,RC,1962,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Emer Hysterectomy,PX01962.01,CDM,964,RC,1962,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Emer Hysterectomy,PX01962.01,CDM,964,RC,1962,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Esophageal Surgery,PX00500.01,CDM,964,RC,500,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Esophageal Surgery,PX00500.01,CDM,964,RC,500,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Esophageal Surgery,PX00500.01,CDM,964,RC,500,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Esophageal Surgery,PX00500.01,CDM,964,RC,500,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Eye Exam,PX00148.01,CDM,964,RC,148,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Eye Exam,PX00148.01,CDM,964,RC,148,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Eye Exam,PX00148.01,CDM,964,RC,148,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Eye Exam,PX00148.01,CDM,964,RC,148,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Face/Skull Bone Surg,PX00190.01,CDM,964,RC,190,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Face/Skull Bone Surg,PX00190.01,CDM,964,RC,190,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Face/Skull Bone Surg,PX00190.01,CDM,964,RC,190,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Face/Skull Bone Surg,PX00190.01,CDM,964,RC,190,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Facial Bone Surgery,PX00192.01,CDM,964,RC,192,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Facial Bone Surgery,PX00192.01,CDM,964,RC,192,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Facial Bone Surgery,PX00192.01,CDM,964,RC,192,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Facial Bone Surgery,PX00192.01,CDM,964,RC,192,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Fat Layer Removal,PX00802.01,CDM,964,RC,802,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Fat Layer Removal,PX00802.01,CDM,964,RC,802,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Fat Layer Removal,PX00802.01,CDM,964,RC,802,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Fat Layer Removal,PX00802.01,CDM,964,RC,802,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Femoral Artery Surg,PX01272.01,CDM,964,RC,1272,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Femoral Artery Surg,PX01272.01,CDM,964,RC,1272,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Femoral Artery Surg,PX01272.01,CDM,964,RC,1272,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Femoral Artery Surg,PX01272.01,CDM,964,RC,1272,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Femoral Embolectomy,PX01274.01,CDM,964,RC,1274,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Femoral Embolectomy,PX01274.01,CDM,964,RC,1274,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Femoral Embolectomy,PX01274.01,CDM,964,RC,1274,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Femoral Embolectomy,PX01274.01,CDM,964,RC,1274,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth for Chemonucleolysis,PX00634.01,CDM,964,RC,634,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth for Chemonucleolysis,PX00634.01,CDM,964,RC,634,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth for Chemonucleolysis,PX00634.01,CDM,964,RC,634,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth for Chemonucleolysis,PX00634.01,CDM,964,RC,634,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth for Liver Biopsy,PX00702.01,CDM,964,RC,702,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth for Liver Biopsy,PX00702.01,CDM,964,RC,702,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth for Liver Biopsy,PX00702.01,CDM,964,RC,702,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth for Liver Biopsy,PX00702.01,CDM,964,RC,702,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth for Liver Transplant,PX00796.01,CDM,964,RC,796,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth for Liver Transplant,PX00796.01,CDM,964,RC,796,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth for Liver Transplant,PX00796.01,CDM,964,RC,796,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth for Liver Transplant,PX00796.01,CDM,964,RC,796,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Forequarter Amput,PX01636.01,CDM,964,RC,1636,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Forequarter Amput,PX01636.01,CDM,964,RC,1636,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Forequarter Amput,PX01636.01,CDM,964,RC,1636,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Forequarter Amput,PX01636.01,CDM,964,RC,1636,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Fx Repair Pelvis,PX01173.01,CDM,964,RC,1173,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Fx Repair Pelvis,PX01173.01,CDM,964,RC,1173,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Fx Repair Pelvis,PX01173.01,CDM,964,RC,1173,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Fx Repair Pelvis,PX01173.01,CDM,964,RC,1173,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Genitalia Surgery,PX00920.01,CDM,964,RC,920,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Genitalia Surgery,PX00920.01,CDM,964,RC,920,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Genitalia Surgery,PX00920.01,CDM,964,RC,920,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Genitalia Surgery,PX00920.01,CDM,964,RC,920,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Head Nerve Surgery,PX00222.01,CDM,964,RC,222,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Head Nerve Surgery,PX00222.01,CDM,964,RC,222,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Head Nerve Surgery,PX00222.01,CDM,964,RC,222,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Head Nerve Surgery,PX00222.01,CDM,964,RC,222,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Head Vessel Surgery,PX00216.01,CDM,964,RC,216,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Head Vessel Surgery,PX00216.01,CDM,964,RC,216,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Head Vessel Surgery,PX00216.01,CDM,964,RC,216,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Head Vessel Surgery,PX00216.01,CDM,964,RC,216,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Head/Neck/Ptrunk,PX00300.01,CDM,964,RC,300,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Head/Neck/Ptrunk,PX00300.01,CDM,964,RC,300,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Head/Neck/Ptrunk,PX00300.01,CDM,964,RC,300,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Head/Neck/Ptrunk,PX00300.01,CDM,964,RC,300,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Heart Surg < 1 Yr,PX00561.01,CDM,964,RC,561,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Heart Surg < 1 Yr,PX00561.01,CDM,964,RC,561,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Heart Surg < 1 Yr,PX00561.01,CDM,964,RC,561,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Heart Surg < 1 Yr,PX00561.01,CDM,964,RC,561,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Heart Surg W/Arrest,PX00563.01,CDM,964,RC,563,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Heart Surg W/Arrest,PX00563.01,CDM,964,RC,563,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Heart Surg W/Arrest,PX00563.01,CDM,964,RC,563,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Heart Surg W/Arrest,PX00563.01,CDM,964,RC,563,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Heart Surg W/O Pump,PX00560.01,CDM,964,RC,560,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Heart Surg W/O Pump,PX00560.01,CDM,964,RC,560,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Heart Surg W/O Pump,PX00560.01,CDM,964,RC,560,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Heart Surg W/O Pump,PX00560.01,CDM,964,RC,560,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Heart/Lung Transplnt,PX00580.01,CDM,964,RC,580,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Heart/Lung Transplnt,PX00580.01,CDM,964,RC,580,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Heart/Lung Transplnt,PX00580.01,CDM,964,RC,580,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Heart/Lung Transplnt,PX00580.01,CDM,964,RC,580,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hemorr/Excise Liver,PX00792.01,CDM,964,RC,792,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hemorr/Excise Liver,PX00792.01,CDM,964,RC,792,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hemorr/Excise Liver,PX00792.01,CDM,964,RC,792,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hemorr/Excise Liver,PX00792.01,CDM,964,RC,792,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hernia Repair < 1 Yr,PX00834.01,CDM,964,RC,834,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hernia Repair < 1 Yr,PX00834.01,CDM,964,RC,834,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hernia Repair < 1 Yr,PX00834.01,CDM,964,RC,834,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hernia Repair < 1 Yr,PX00834.01,CDM,964,RC,834,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hernia Repair Preemie,PX00836.01,CDM,964,RC,836,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hernia Repair Preemie,PX00836.01,CDM,964,RC,836,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hernia Repair Preemie,PX00836.01,CDM,964,RC,836,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hernia Repair Preemie,PX00836.01,CDM,964,RC,836,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hip Arthroplasty,PX01214.01,CDM,964,RC,1214,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hip Arthroplasty,PX01214.01,CDM,964,RC,1214,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hip Arthroplasty,PX01214.01,CDM,964,RC,1214,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hip Arthroplasty,PX01214.01,CDM,964,RC,1214,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hip Disarticulation,PX01212.01,CDM,964,RC,1212,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hip Disarticulation,PX01212.01,CDM,964,RC,1212,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hip Disarticulation,PX01212.01,CDM,964,RC,1212,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hip Disarticulation,PX01212.01,CDM,964,RC,1212,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hip Joint Procedure,PX01200.01,CDM,964,RC,1200,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hip Joint Procedure,PX01200.01,CDM,964,RC,1200,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hip Joint Procedure,PX01200.01,CDM,964,RC,1200,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hip Joint Procedure,PX01200.01,CDM,964,RC,1200,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hip Joint Surgery,PX01210.01,CDM,964,RC,1210,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hip Joint Surgery,PX01210.01,CDM,964,RC,1210,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hip Joint Surgery,PX01210.01,CDM,964,RC,1210,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hip Joint Surgery,PX01210.01,CDM,964,RC,1210,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hrt Surg W/Pmp Age 1+,PX00562.01,CDM,964,RC,562,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hrt Surg W/Pmp Age 1+,PX00562.01,CDM,964,RC,562,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hrt Surg W/Pmp Age 1+,PX00562.01,CDM,964,RC,562,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hrt Surg W/Pmp Age 1+,PX00562.01,CDM,964,RC,562,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Humeral Lesion Surg,PX01758.01,CDM,964,RC,1758,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Humeral Lesion Surg,PX01758.01,CDM,964,RC,1758,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Humeral Lesion Surg,PX01758.01,CDM,964,RC,1758,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Humeral Lesion Surg,PX01758.01,CDM,964,RC,1758,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Humerus Repair,PX01744.01,CDM,964,RC,1744,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Humerus Repair,PX01744.01,CDM,964,RC,1744,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Humerus Repair,PX01744.01,CDM,964,RC,1744,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Humerus Repair,PX01744.01,CDM,964,RC,1744,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Humerus Surgery,PX01742.01,CDM,964,RC,1742,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Humerus Surgery,PX01742.01,CDM,964,RC,1742,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Humerus Surgery,PX01742.01,CDM,964,RC,1742,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Humerus Surgery,PX01742.01,CDM,964,RC,1742,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hysterectomy,PX00846.01,CDM,964,RC,846,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hysterectomy,PX00846.01,CDM,964,RC,846,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hysterectomy,PX00846.01,CDM,964,RC,846,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hysterectomy,PX00846.01,CDM,964,RC,846,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hysteroscope/Graph,PX00952.01,CDM,964,RC,952,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hysteroscope/Graph,PX00952.01,CDM,964,RC,952,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hysteroscope/Graph,PX00952.01,CDM,964,RC,952,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hysteroscope/Graph,PX00952.01,CDM,964,RC,952,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Inc/Missed Ab Proc,PX01965.01,CDM,964,RC,1965,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Inc/Missed Ab Proc,PX01965.01,CDM,964,RC,1965,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Inc/Missed Ab Proc,PX01965.01,CDM,964,RC,1965,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Inc/Missed Ab Proc,PX01965.01,CDM,964,RC,1965,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Induced Ab Procedure,PX01966.01,CDM,964,RC,1966,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Induced Ab Procedure,PX01966.01,CDM,964,RC,1966,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Induced Ab Procedure,PX01966.01,CDM,964,RC,1966,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Induced Ab Procedure,PX01966.01,CDM,964,RC,1966,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Insert Penis Device,PX00938.01,CDM,964,RC,938,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Insert Penis Device,PX00938.01,CDM,964,RC,938,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Insert Penis Device,PX00938.01,CDM,964,RC,938,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Insert Penis Device,PX00938.01,CDM,964,RC,938,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Intrcrn Nerve,PX00220.01,CDM,964,RC,220,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Intrcrn Nerve,PX00220.01,CDM,964,RC,220,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Intrcrn Nerve,PX00220.01,CDM,964,RC,220,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Intrcrn Nerve,PX00220.01,CDM,964,RC,220,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Iridectomy,PX00147.01,CDM,964,RC,147,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Iridectomy,PX00147.01,CDM,964,RC,147,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Iridectomy,PX00147.01,CDM,964,RC,147,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Iridectomy,PX00147.01,CDM,964,RC,147,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Kidney Stone Destruct,PX00872.01,CDM,964,RC,872,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Kidney Stone Destruct,PX00872.01,CDM,964,RC,872,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Kidney Stone Destruct,PX00872.01,CDM,964,RC,872,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Kidney Stone Destruct,PX00872.01,CDM,964,RC,872,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Kidney Stone Destruct,PX00873.01,CDM,964,RC,873,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Kidney Stone Destruct,PX00873.01,CDM,964,RC,873,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Kidney Stone Destruct,PX00873.01,CDM,964,RC,873,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Kidney Stone Destruct,PX00873.01,CDM,964,RC,873,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Kidney Transplant,PX00868.01,CDM,964,RC,868,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Kidney Transplant,PX00868.01,CDM,964,RC,868,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Kidney Transplant,PX00868.01,CDM,964,RC,868,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Kidney Transplant,PX00868.01,CDM,964,RC,868,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Kidney/Ureter Surg,PX00862.01,CDM,964,RC,862,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Kidney/Ureter Surg,PX00862.01,CDM,964,RC,862,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Kidney/Ureter Surg,PX00862.01,CDM,964,RC,862,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Kidney/Ureter Surg,PX00862.01,CDM,964,RC,862,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Area Procedure,PX01340.01,CDM,964,RC,1340,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Area Procedure,PX01340.01,CDM,964,RC,1340,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Area Procedure,PX01340.01,CDM,964,RC,1340,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Area Procedure,PX01340.01,CDM,964,RC,1340,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Area Procedure,PX01390.01,CDM,964,RC,1390,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Area Procedure,PX01390.01,CDM,964,RC,1390,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Area Procedure,PX01390.01,CDM,964,RC,1390,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Area Procedure,PX01390.01,CDM,964,RC,1390,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Area Surgery,PX01320.01,CDM,964,RC,1320,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Area Surgery,PX01320.01,CDM,964,RC,1320,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Area Surgery,PX01320.01,CDM,964,RC,1320,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Area Surgery,PX01320.01,CDM,964,RC,1320,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Area Surgery,PX01360.01,CDM,964,RC,1360,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Area Surgery,PX01360.01,CDM,964,RC,1360,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Area Surgery,PX01360.01,CDM,964,RC,1360,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Area Surgery,PX01360.01,CDM,964,RC,1360,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Area Surgery,PX01392.01,CDM,964,RC,1392,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Area Surgery,PX01392.01,CDM,964,RC,1392,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Area Surgery,PX01392.01,CDM,964,RC,1392,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Area Surgery,PX01392.01,CDM,964,RC,1392,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Arteries Surg,PX01440.01,CDM,964,RC,1440,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Arteries Surg,PX01440.01,CDM,964,RC,1440,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Arteries Surg,PX01440.01,CDM,964,RC,1440,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Arteries Surg,PX01440.01,CDM,964,RC,1440,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Artery Repair,PX01444.01,CDM,964,RC,1444,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Artery Repair,PX01444.01,CDM,964,RC,1444,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Artery Repair,PX01444.01,CDM,964,RC,1444,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Artery Repair,PX01444.01,CDM,964,RC,1444,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Artery Surg,PX01442.01,CDM,964,RC,1442,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Artery Surg,PX01442.01,CDM,964,RC,1442,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Artery Surg,PX01442.01,CDM,964,RC,1442,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Artery Surg,PX01442.01,CDM,964,RC,1442,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Arthroplasty,PX01402.01,CDM,964,RC,1402,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Arthroplasty,PX01402.01,CDM,964,RC,1402,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Arthroplasty,PX01402.01,CDM,964,RC,1402,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Arthroplasty,PX01402.01,CDM,964,RC,1402,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Joint Casting,PX01420.01,CDM,964,RC,1420,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Joint Casting,PX01420.01,CDM,964,RC,1420,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Joint Casting,PX01420.01,CDM,964,RC,1420,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Joint Casting,PX01420.01,CDM,964,RC,1420,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Joint Procedure,PX01380.01,CDM,964,RC,1380,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Joint Procedure,PX01380.01,CDM,964,RC,1380,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Joint Procedure,PX01380.01,CDM,964,RC,1380,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Joint Procedure,PX01380.01,CDM,964,RC,1380,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Joint Surgery,PX01400.01,CDM,964,RC,1400,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Joint Surgery,PX01400.01,CDM,964,RC,1400,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Joint Surgery,PX01400.01,CDM,964,RC,1400,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Joint Surgery,PX01400.01,CDM,964,RC,1400,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Veins Surgery,PX01430.01,CDM,964,RC,1430,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Veins Surgery,PX01430.01,CDM,964,RC,1430,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Veins Surgery,PX01430.01,CDM,964,RC,1430,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Veins Surgery,PX01430.01,CDM,964,RC,1430,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Vessel Surg,PX01432.01,CDM,964,RC,1432,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Vessel Surg,PX01432.01,CDM,964,RC,1432,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Vessel Surg,PX01432.01,CDM,964,RC,1432,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Vessel Surg,PX01432.01,CDM,964,RC,1432,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Larynx/Trach < 1 Yr,PX00326.01,CDM,964,RC,326,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Larynx/Trach < 1 Yr,PX00326.01,CDM,964,RC,326,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Larynx/Trach < 1 Yr,PX00326.01,CDM,964,RC,326,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Larynx/Trach < 1 Yr,PX00326.01,CDM,964,RC,326,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Leg Arteries Surg,PX01500.01,CDM,964,RC,1500,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Leg Arteries Surg,PX01500.01,CDM,964,RC,1500,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Leg Arteries Surg,PX01500.01,CDM,964,RC,1500,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Leg Arteries Surg,PX01500.01,CDM,964,RC,1500,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lens Surgery,PX00142.01,CDM,964,RC,142,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lens Surgery,PX00142.01,CDM,964,RC,142,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lens Surgery,PX00142.01,CDM,964,RC,142,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lens Surgery,PX00142.01,CDM,964,RC,142,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Low Intestine Scope,PX00810.01,CDM,964,RC,810,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Low Intestine Scope,PX00810.01,CDM,964,RC,810,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Low Intestine Scope,PX00810.01,CDM,964,RC,810,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Low Intestine Scope,PX00810.01,CDM,964,RC,810,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Arm Casting,PX01860.01,CDM,964,RC,1860,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Arm Casting,PX01860.01,CDM,964,RC,1860,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Arm Casting,PX01860.01,CDM,964,RC,1860,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Arm Casting,PX01860.01,CDM,964,RC,1860,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Arm Procedure,PX01820.01,CDM,964,RC,1820,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Arm Procedure,PX01820.01,CDM,964,RC,1820,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Arm Procedure,PX01820.01,CDM,964,RC,1820,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Arm Procedure,PX01820.01,CDM,964,RC,1820,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Arm Surgery,PX01810.01,CDM,964,RC,1810,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Arm Surgery,PX01810.01,CDM,964,RC,1810,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Arm Surgery,PX01810.01,CDM,964,RC,1810,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Arm Surgery,PX01810.01,CDM,964,RC,1810,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Arm Surgery,PX01830.01,CDM,964,RC,1830,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Arm Surgery,PX01830.01,CDM,964,RC,1830,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Arm Surgery,PX01830.01,CDM,964,RC,1830,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Arm Surgery,PX01830.01,CDM,964,RC,1830,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Arm Vein Surg,PX01850.01,CDM,964,RC,1850,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Arm Vein Surg,PX01850.01,CDM,964,RC,1850,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Arm Vein Surg,PX01850.01,CDM,964,RC,1850,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Arm Vein Surg,PX01850.01,CDM,964,RC,1850,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Bone Surg,PX01480.01,CDM,964,RC,1480,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,30.53156863,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Bone Surg,PX01480.01,CDM,964,RC,1480,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Bone Surg,PX01480.01,CDM,964,RC,1480,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Bone Surg,PX01480.01,CDM,964,RC,1480,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Casting,PX01490.01,CDM,964,RC,1490,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Casting,PX01490.01,CDM,964,RC,1490,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Casting,PX01490.01,CDM,964,RC,1490,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Casting,PX01490.01,CDM,964,RC,1490,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Procedure,PX01462.01,CDM,964,RC,1462,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Procedure,PX01462.01,CDM,964,RC,1462,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Procedure,PX01462.01,CDM,964,RC,1462,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Procedure,PX01462.01,CDM,964,RC,1462,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Revision,PX01484.01,CDM,964,RC,1484,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Revision,PX01484.01,CDM,964,RC,1484,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Revision,PX01484.01,CDM,964,RC,1484,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Revision,PX01484.01,CDM,964,RC,1484,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Surgery,PX01470.01,CDM,964,RC,1470,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Surgery,PX01470.01,CDM,964,RC,1470,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Surgery,PX01470.01,CDM,964,RC,1470,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Surgery,PX01470.01,CDM,964,RC,1470,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Surgery,PX01474.01,CDM,964,RC,1474,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Surgery,PX01474.01,CDM,964,RC,1474,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Surgery,PX01474.01,CDM,964,RC,1474,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Surgery,PX01474.01,CDM,964,RC,1474,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Vein Surg,PX01520.01,CDM,964,RC,1520,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Vein Surg,PX01520.01,CDM,964,RC,1520,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Vein Surg,PX01520.01,CDM,964,RC,1520,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Vein Surg,PX01520.01,CDM,964,RC,1520,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Vein Surg,PX01522.01,CDM,964,RC,1522,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Vein Surg,PX01522.01,CDM,964,RC,1522,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Vein Surg,PX01522.01,CDM,964,RC,1522,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Vein Surg,PX01522.01,CDM,964,RC,1522,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lumbar Puncture,PX00635.01,CDM,964,RC,635,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lumbar Puncture,PX00635.01,CDM,964,RC,635,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lumbar Puncture,PX00635.01,CDM,964,RC,635,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lumbar Puncture,PX00635.01,CDM,964,RC,635,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lung Chest Wall Surg,PX00546.01,CDM,964,RC,546,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lung Chest Wall Surg,PX00546.01,CDM,964,RC,546,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lung Chest Wall Surg,PX00546.01,CDM,964,RC,546,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lung Chest Wall Surg,PX00546.01,CDM,964,RC,546,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lwr Arm Artery Surg,PX01840.01,CDM,964,RC,1840,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lwr Arm Artery Surg,PX01840.01,CDM,964,RC,1840,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lwr Arm Artery Surg,PX01840.01,CDM,964,RC,1840,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lwr Arm Artery Surg,PX01840.01,CDM,964,RC,1840,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lwr Arm Embolectomy,PX01842.01,CDM,964,RC,1842,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lwr Arm Embolectomy,PX01842.01,CDM,964,RC,1842,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lwr Arm Embolectomy,PX01842.01,CDM,964,RC,1842,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lwr Arm Embolectomy,PX01842.01,CDM,964,RC,1842,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lwr Arm Vein Repair,PX01852.01,CDM,964,RC,1852,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lwr Arm Vein Repair,PX01852.01,CDM,964,RC,1852,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lwr Arm Vein Repair,PX01852.01,CDM,964,RC,1852,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lwr Arm Vein Repair,PX01852.01,CDM,964,RC,1852,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lwr Leg Embolectomy,PX01502.01,CDM,964,RC,1502,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lwr Leg Embolectomy,PX01502.01,CDM,964,RC,1502,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lwr Leg Embolectomy,PX01502.01,CDM,964,RC,1502,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lwr Leg Embolectomy,PX01502.01,CDM,964,RC,1502,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Major Vein Ligation,PX00882.01,CDM,964,RC,882,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Major Vein Ligation,PX00882.01,CDM,964,RC,882,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Major Vein Ligation,PX00882.01,CDM,964,RC,882,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Major Vein Ligation,PX00882.01,CDM,964,RC,882,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth N Block/Inj Prone,PX01992.01,CDM,964,RC,1992,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth N Block/Inj Prone,PX01992.01,CDM,964,RC,1992,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth N Block/Inj Prone,PX01992.01,CDM,964,RC,1992,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth N Block/Inj Prone,PX01992.01,CDM,964,RC,1992,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Neck Organ 1 & Over,PX00320.01,CDM,964,RC,320,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Neck Organ 1 & Over,PX00320.01,CDM,964,RC,320,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Neck Organ 1 & Over,PX00320.01,CDM,964,RC,320,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Neck Organ 1 & Over,PX00320.01,CDM,964,RC,320,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Neck Vessel Surgery,PX00350.01,CDM,964,RC,350,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Neck Vessel Surgery,PX00350.01,CDM,964,RC,350,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Neck Vessel Surgery,PX00350.01,CDM,964,RC,350,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Neck Vessel Surgery,PX00350.01,CDM,964,RC,350,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Neck Vessel Surgery,PX00352.01,CDM,964,RC,352,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Neck Vessel Surgery,PX00352.01,CDM,964,RC,352,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Neck Vessel Surgery,PX00352.01,CDM,964,RC,352,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Neck Vessel Surgery,PX00352.01,CDM,964,RC,352,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Nerve Block/Inj,PX01991.01,CDM,964,RC,1991,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Nerve Block/Inj,PX01991.01,CDM,964,RC,1991,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Nerve Block/Inj,PX01991.01,CDM,964,RC,1991,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Nerve Block/Inj,PX01991.01,CDM,964,RC,1991,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Nose/Sinus Surgery,PX00160.01,CDM,964,RC,160,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Nose/Sinus Surgery,PX00160.01,CDM,964,RC,160,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Nose/Sinus Surgery,PX00160.01,CDM,964,RC,160,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Nose/Sinus Surgery,PX00160.01,CDM,964,RC,160,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Nose/Sinus Surgery,PX00162.01,CDM,964,RC,162,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Nose/Sinus Surgery,PX00162.01,CDM,964,RC,162,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Nose/Sinus Surgery,PX00162.01,CDM,964,RC,162,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Nose/Sinus Surgery,PX00162.01,CDM,964,RC,162,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth One Lung Ventilation,PX00541.01,CDM,964,RC,541,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth One Lung Ventilation,PX00541.01,CDM,964,RC,541,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth One Lung Ventilation,PX00541.01,CDM,964,RC,541,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth One Lung Ventilation,PX00541.01,CDM,964,RC,541,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pacemaker Insertion,PX00530.01,CDM,964,RC,530,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pacemaker Insertion,PX00530.01,CDM,964,RC,530,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pacemaker Insertion,PX00530.01,CDM,964,RC,530,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pacemaker Insertion,PX00530.01,CDM,964,RC,530,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pancreas Removal,PX00794.01,CDM,964,RC,794,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pancreas Removal,PX00794.01,CDM,964,RC,794,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pancreas Removal,PX00794.01,CDM,964,RC,794,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pancreas Removal,PX00794.01,CDM,964,RC,794,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvic Organ Surg,PX00848.01,CDM,964,RC,848,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvic Organ Surg,PX00848.01,CDM,964,RC,848,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvic Organ Surg,PX00848.01,CDM,964,RC,848,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvic Organ Surg,PX00848.01,CDM,964,RC,848,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvic Tumor Surgery,PX01150.01,CDM,964,RC,1150,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvic Tumor Surgery,PX01150.01,CDM,964,RC,1150,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvic Tumor Surgery,PX01150.01,CDM,964,RC,1150,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvic Tumor Surgery,PX01150.01,CDM,964,RC,1150,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Nerve Removal,PX01180.01,CDM,964,RC,1180,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Nerve Removal,PX01180.01,CDM,964,RC,1180,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Nerve Removal,PX01180.01,CDM,964,RC,1180,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Nerve Removal,PX01180.01,CDM,964,RC,1180,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Nerve Removal,PX01190.01,CDM,964,RC,1190,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Nerve Removal,PX01190.01,CDM,964,RC,1190,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Nerve Removal,PX01190.01,CDM,964,RC,1190,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Nerve Removal,PX01190.01,CDM,964,RC,1190,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Procedure,PX01160.01,CDM,964,RC,1160,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Procedure,PX01160.01,CDM,964,RC,1160,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Procedure,PX01160.01,CDM,964,RC,1160,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Procedure,PX01160.01,CDM,964,RC,1160,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Surgery,PX00844.01,CDM,964,RC,844,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Surgery,PX00844.01,CDM,964,RC,844,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Surgery,PX00844.01,CDM,964,RC,844,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Surgery,PX00844.01,CDM,964,RC,844,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Surgery,PX01120.01,CDM,964,RC,1120,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Surgery,PX01120.01,CDM,964,RC,1120,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Surgery,PX01120.01,CDM,964,RC,1120,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Surgery,PX01120.01,CDM,964,RC,1120,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Surgery,PX01170.01,CDM,964,RC,1170,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Surgery,PX01170.01,CDM,964,RC,1170,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Surgery,PX01170.01,CDM,964,RC,1170,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Surgery,PX01170.01,CDM,964,RC,1170,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Penis Nodes Removal,PX00934.01,CDM,964,RC,934,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Penis Nodes Removal,PX00934.01,CDM,964,RC,934,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Penis Nodes Removal,PX00934.01,CDM,964,RC,934,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Penis Nodes Removal,PX00934.01,CDM,964,RC,934,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Penis Nodes Removal,PX00936.01,CDM,964,RC,936,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Penis Nodes Removal,PX00936.01,CDM,964,RC,936,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Penis Nodes Removal,PX00936.01,CDM,964,RC,936,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Penis Nodes Removal,PX00936.01,CDM,964,RC,936,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Perc Img Dx Sp Proc,PX01935.01,CDM,964,RC,1935,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Perc Img Dx Sp Proc,PX01935.01,CDM,964,RC,1935,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Perc Img Dx Sp Proc,PX01935.01,CDM,964,RC,1935,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Perc Img Dx Sp Proc,PX01935.01,CDM,964,RC,1935,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Perc Img Tx Sp Proc,PX01936.01,CDM,964,RC,1936,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Perc Img Tx Sp Proc,PX01936.01,CDM,964,RC,1936,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Perc Img Tx Sp Proc,PX01936.01,CDM,964,RC,1936,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Perc Img Tx Sp Proc,PX01936.01,CDM,964,RC,1936,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Perineal Surgery,PX00904.01,CDM,964,RC,904,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Perineal Surgery,PX00904.01,CDM,964,RC,904,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Perineal Surgery,PX00904.01,CDM,964,RC,904,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Perineal Surgery,PX00904.01,CDM,964,RC,904,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pharyngeal Surgery,PX00174.01,CDM,964,RC,174,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pharyngeal Surgery,PX00174.01,CDM,964,RC,174,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pharyngeal Surgery,PX00174.01,CDM,964,RC,174,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pharyngeal Surgery,PX00174.01,CDM,964,RC,174,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pharyngeal Surgery,PX00176.01,CDM,964,RC,176,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pharyngeal Surgery,PX00176.01,CDM,964,RC,176,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pharyngeal Surgery,PX00176.01,CDM,964,RC,176,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pharyngeal Surgery,PX00176.01,CDM,964,RC,176,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Procedure on Femur,PX01220.01,CDM,964,RC,1220,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Procedure on Femur,PX01220.01,CDM,964,RC,1220,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Procedure on Femur,PX01220.01,CDM,964,RC,1220,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Procedure on Femur,PX01220.01,CDM,964,RC,1220,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Procedure on Mouth,PX00170.01,CDM,964,RC,170,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Procedure on Mouth,PX00170.01,CDM,964,RC,170,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Procedure on Mouth,PX00170.01,CDM,964,RC,170,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Procedure on Mouth,PX00170.01,CDM,964,RC,170,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Procedures on Eye,PX00140.01,CDM,964,RC,140,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Procedures on Eye,PX00140.01,CDM,964,RC,140,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Procedures on Eye,PX00140.01,CDM,964,RC,140,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Procedures on Eye,PX00140.01,CDM,964,RC,140,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Radical Femur Surg,PX01234.01,CDM,964,RC,1234,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Radical Femur Surg,PX01234.01,CDM,964,RC,1234,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Radical Femur Surg,PX01234.01,CDM,964,RC,1234,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Radical Femur Surg,PX01234.01,CDM,964,RC,1234,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Radical Humerus Surg,PX01756.01,CDM,964,RC,1756,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Radical Humerus Surg,PX01756.01,CDM,964,RC,1756,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Radical Humerus Surg,PX01756.01,CDM,964,RC,1756,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Radical Humerus Surg,PX01756.01,CDM,964,RC,1756,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Radical Leg Surgery,PX01482.01,CDM,964,RC,1482,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Radical Leg Surgery,PX01482.01,CDM,964,RC,1482,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Radical Leg Surgery,PX01482.01,CDM,964,RC,1482,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Radical Leg Surgery,PX01482.01,CDM,964,RC,1482,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Release of Lung,PX00542.01,CDM,964,RC,542,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Release of Lung,PX00542.01,CDM,964,RC,542,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Release of Lung,PX00542.01,CDM,964,RC,542,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Release of Lung,PX00542.01,CDM,964,RC,542,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Adrenal,PX00866.01,CDM,964,RC,866,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Adrenal,PX00866.01,CDM,964,RC,866,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Adrenal,PX00866.01,CDM,964,RC,866,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Adrenal,PX00866.01,CDM,964,RC,866,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Bladder,PX00864.01,CDM,964,RC,864,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Bladder,PX00864.01,CDM,964,RC,864,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Bladder,PX00864.01,CDM,964,RC,864,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Bladder,PX00864.01,CDM,964,RC,864,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Nerves,PX00622.01,CDM,964,RC,622,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Nerves,PX00622.01,CDM,964,RC,622,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Nerves,PX00622.01,CDM,964,RC,622,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Nerves,PX00622.01,CDM,964,RC,622,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Nerves,PX00632.01,CDM,964,RC,632,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Nerves,PX00632.01,CDM,964,RC,632,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Nerves,PX00632.01,CDM,964,RC,632,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Nerves,PX00632.01,CDM,964,RC,632,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Prostate,PX00865.01,CDM,964,RC,865,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Prostate,PX00865.01,CDM,964,RC,865,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Prostate,PX00865.01,CDM,964,RC,865,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Prostate,PX00865.01,CDM,964,RC,865,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Prostate,PX00908.01,CDM,964,RC,908,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Prostate,PX00908.01,CDM,964,RC,908,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Prostate,PX00908.01,CDM,964,RC,908,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Prostate,PX00908.01,CDM,964,RC,908,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Rib,PX00470.01,CDM,964,RC,470,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Rib,PX00470.01,CDM,964,RC,470,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Rib,PX00470.01,CDM,964,RC,470,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Rib,PX00470.01,CDM,964,RC,470,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Testis,PX00926.01,CDM,964,RC,926,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Testis,PX00926.01,CDM,964,RC,926,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Testis,PX00926.01,CDM,964,RC,926,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Testis,PX00926.01,CDM,964,RC,926,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Testis,PX00928.01,CDM,964,RC,928,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Testis,PX00928.01,CDM,964,RC,928,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Testis,PX00928.01,CDM,964,RC,928,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Testis,PX00928.01,CDM,964,RC,928,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Vulva,PX00906.01,CDM,964,RC,906,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Vulva,PX00906.01,CDM,964,RC,906,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Vulva,PX00906.01,CDM,964,RC,906,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Vulva,PX00906.01,CDM,964,RC,906,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Cervix,PX00948.01,CDM,964,RC,948,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Cervix,PX00948.01,CDM,964,RC,948,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Cervix,PX00948.01,CDM,964,RC,948,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Cervix,PX00948.01,CDM,964,RC,948,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Cleft Lip,PX00102.01,CDM,964,RC,102,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Cleft Lip,PX00102.01,CDM,964,RC,102,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Cleft Lip,PX00102.01,CDM,964,RC,102,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Cleft Lip,PX00102.01,CDM,964,RC,102,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00750.01,CDM,964,RC,750,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00750.01,CDM,964,RC,750,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00750.01,CDM,964,RC,750,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00750.01,CDM,964,RC,750,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00752.01,CDM,964,RC,752,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00752.01,CDM,964,RC,752,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00752.01,CDM,964,RC,752,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00752.01,CDM,964,RC,752,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00754.01,CDM,964,RC,754,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00754.01,CDM,964,RC,754,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00754.01,CDM,964,RC,754,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00754.01,CDM,964,RC,754,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00756.01,CDM,964,RC,756,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00756.01,CDM,964,RC,756,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00756.01,CDM,964,RC,756,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00756.01,CDM,964,RC,756,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00830.01,CDM,964,RC,830,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00830.01,CDM,964,RC,830,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00830.01,CDM,964,RC,830,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00830.01,CDM,964,RC,830,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00832.01,CDM,964,RC,832,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,7.2,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00832.01,CDM,964,RC,832,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00832.01,CDM,964,RC,832,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00832.01,CDM,964,RC,832,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Revise Hip Repair,PX01215.01,CDM,964,RC,1215,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Revise Hip Repair,PX01215.01,CDM,964,RC,1215,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Revise Hip Repair,PX01215.01,CDM,964,RC,1215,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Revise Hip Repair,PX01215.01,CDM,964,RC,1215,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Salivary Gland,PX00100.01,CDM,964,RC,100,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Salivary Gland,PX00100.01,CDM,964,RC,100,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Salivary Gland,PX00100.01,CDM,964,RC,100,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Salivary Gland,PX00100.01,CDM,964,RC,100,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Artery Surg,PX01650.01,CDM,964,RC,1650,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Artery Surg,PX01650.01,CDM,964,RC,1650,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Artery Surg,PX01650.01,CDM,964,RC,1650,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Artery Surg,PX01650.01,CDM,964,RC,1650,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Casting,PX01680.01,CDM,964,RC,1680,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Casting,PX01680.01,CDM,964,RC,1680,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Casting,PX01680.01,CDM,964,RC,1680,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Casting,PX01680.01,CDM,964,RC,1680,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Joint Amput,PX01634.01,CDM,964,RC,1634,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Joint Amput,PX01634.01,CDM,964,RC,1634,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Joint Amput,PX01634.01,CDM,964,RC,1634,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Joint Amput,PX01634.01,CDM,964,RC,1634,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Procedure,PX01620.01,CDM,964,RC,1620,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Procedure,PX01620.01,CDM,964,RC,1620,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Procedure,PX01620.01,CDM,964,RC,1620,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Procedure,PX01620.01,CDM,964,RC,1620,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Replacement,PX01638.01,CDM,964,RC,1638,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Replacement,PX01638.01,CDM,964,RC,1638,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Replacement,PX01638.01,CDM,964,RC,1638,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Replacement,PX01638.01,CDM,964,RC,1638,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Vein Surg,PX01670.01,CDM,964,RC,1670,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Vein Surg,PX01670.01,CDM,964,RC,1670,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Vein Surg,PX01670.01,CDM,964,RC,1670,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Vein Surg,PX01670.01,CDM,964,RC,1670,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Vessel Surg,PX01652.01,CDM,964,RC,1652,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Vessel Surg,PX01652.01,CDM,964,RC,1652,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Vessel Surg,PX01652.01,CDM,964,RC,1652,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Vessel Surg,PX01652.01,CDM,964,RC,1652,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Vessel Surg,PX01654.01,CDM,964,RC,1654,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Vessel Surg,PX01654.01,CDM,964,RC,1654,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Vessel Surg,PX01654.01,CDM,964,RC,1654,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Vessel Surg,PX01654.01,CDM,964,RC,1654,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Sitting Procedure,PX00604.01,CDM,964,RC,604,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Sitting Procedure,PX00604.01,CDM,964,RC,604,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Sitting Procedure,PX00604.01,CDM,964,RC,604,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Sitting Procedure,PX00604.01,CDM,964,RC,604,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Skin Ext/per/Atrunk,PX00400.01,CDM,964,RC,400,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,7.010752688,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Skin Ext/per/Atrunk,PX00400.01,CDM,964,RC,400,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Skin Ext/per/Atrunk,PX00400.01,CDM,964,RC,400,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Skin Ext/per/Atrunk,PX00400.01,CDM,964,RC,400,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Skull Drainage,PX00212.01,CDM,964,RC,212,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Skull Drainage,PX00212.01,CDM,964,RC,212,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Skull Drainage,PX00212.01,CDM,964,RC,212,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Skull Drainage,PX00212.01,CDM,964,RC,212,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Skull Drainage,PX00214.01,CDM,964,RC,214,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Skull Drainage,PX00214.01,CDM,964,RC,214,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Skull Drainage,PX00214.01,CDM,964,RC,214,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Skull Drainage,PX00214.01,CDM,964,RC,214,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Skull Repair/Fract,PX00215.01,CDM,964,RC,215,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Skull Repair/Fract,PX00215.01,CDM,964,RC,215,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Skull Repair/Fract,PX00215.01,CDM,964,RC,215,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Skull Repair/Fract,PX00215.01,CDM,964,RC,215,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Special Head Surgery,PX00218.01,CDM,964,RC,218,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Special Head Surgery,PX00218.01,CDM,964,RC,218,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Special Head Surgery,PX00218.01,CDM,964,RC,218,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Special Head Surgery,PX00218.01,CDM,964,RC,218,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Sperm Duct Surgery,PX00922.01,CDM,964,RC,922,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Sperm Duct Surgery,PX00922.01,CDM,964,RC,922,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Sperm Duct Surgery,PX00922.01,CDM,964,RC,922,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Sperm Duct Surgery,PX00922.01,CDM,964,RC,922,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Spine Cord Surgery,PX00600.01,CDM,964,RC,600,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Spine Cord Surgery,PX00600.01,CDM,964,RC,600,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Spine Cord Surgery,PX00600.01,CDM,964,RC,600,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Spine Cord Surgery,PX00600.01,CDM,964,RC,600,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Spine Cord Surgery,PX00620.01,CDM,964,RC,620,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Spine Cord Surgery,PX00620.01,CDM,964,RC,620,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Spine Cord Surgery,PX00620.01,CDM,964,RC,620,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Spine Cord Surgery,PX00620.01,CDM,964,RC,620,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Spine Cord Surgery,PX00630.01,CDM,964,RC,630,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Spine Cord Surgery,PX00630.01,CDM,964,RC,630,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Spine Cord Surgery,PX00630.01,CDM,964,RC,630,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Spine Cord Surgery,PX00630.01,CDM,964,RC,630,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Spine Cord Surgery,PX00670.01,CDM,964,RC,670,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Spine Cord Surgery,PX00670.01,CDM,964,RC,670,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Spine Cord Surgery,PX00670.01,CDM,964,RC,670,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Spine Cord Surgery,PX00670.01,CDM,964,RC,670,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Spine Manipulation,PX00640.01,CDM,964,RC,640,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Spine Manipulation,PX00640.01,CDM,964,RC,640,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Spine Manipulation,PX00640.01,CDM,964,RC,640,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Spine Manipulation,PX00640.01,CDM,964,RC,640,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Sternal Debridement,PX00550.01,CDM,964,RC,550,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Sternal Debridement,PX00550.01,CDM,964,RC,550,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Sternal Debridement,PX00550.01,CDM,964,RC,550,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Sternal Debridement,PX00550.01,CDM,964,RC,550,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Stone Removal,PX00918.01,CDM,964,RC,918,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Stone Removal,PX00918.01,CDM,964,RC,918,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Stone Removal,PX00918.01,CDM,964,RC,918,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Stone Removal,PX00918.01,CDM,964,RC,918,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surg Lower Abdomen,PX00840.01,CDM,964,RC,840,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,9.606032787,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surg Lower Abdomen,PX00840.01,CDM,964,RC,840,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surg Lower Abdomen,PX00840.01,CDM,964,RC,840,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surg Lower Abdomen,PX00840.01,CDM,964,RC,840,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surg on Vag/Urethral,PX00942.01,CDM,964,RC,942,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surg on Vag/Urethral,PX00942.01,CDM,964,RC,942,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surg on Vag/Urethral,PX00942.01,CDM,964,RC,942,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surg on Vag/Urethral,PX00942.01,CDM,964,RC,942,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surg Upper Abdomen,PX00790.01,CDM,964,RC,790,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,7.2,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surg Upper Abdomen,PX00790.01,CDM,964,RC,790,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surg Upper Abdomen,PX00790.01,CDM,964,RC,790,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surg Upper Abdomen,PX00790.01,CDM,964,RC,790,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery for Obesity,PX00797.01,CDM,964,RC,797,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery for Obesity,PX00797.01,CDM,964,RC,797,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery for Obesity,PX00797.01,CDM,964,RC,797,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery for Obesity,PX00797.01,CDM,964,RC,797,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Abdomen,PX00860.01,CDM,964,RC,860,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Abdomen,PX00860.01,CDM,964,RC,860,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Abdomen,PX00860.01,CDM,964,RC,860,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Abdomen,PX00860.01,CDM,964,RC,860,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Breast,PX00402.01,CDM,964,RC,402,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Breast,PX00402.01,CDM,964,RC,402,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Breast,PX00402.01,CDM,964,RC,402,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Breast,PX00402.01,CDM,964,RC,402,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Breast,PX00404.01,CDM,964,RC,404,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Breast,PX00404.01,CDM,964,RC,404,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Breast,PX00404.01,CDM,964,RC,404,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Breast,PX00404.01,CDM,964,RC,404,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Breast,PX00406.01,CDM,964,RC,406,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Breast,PX00406.01,CDM,964,RC,406,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Breast,PX00406.01,CDM,964,RC,406,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Breast,PX00406.01,CDM,964,RC,406,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Femur,PX01230.01,CDM,964,RC,1230,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Femur,PX01230.01,CDM,964,RC,1230,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Femur,PX01230.01,CDM,964,RC,1230,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Femur,PX01230.01,CDM,964,RC,1230,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Rib(S),PX00474.01,CDM,964,RC,474,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Rib(S),PX00474.01,CDM,964,RC,474,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Rib(S),PX00474.01,CDM,964,RC,474,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Rib(S),PX00474.01,CDM,964,RC,474,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Shoulder,PX00450.01,CDM,964,RC,450,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Shoulder,PX00450.01,CDM,964,RC,450,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Shoulder,PX00450.01,CDM,964,RC,450,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Shoulder,PX00450.01,CDM,964,RC,450,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Shoulder,PX00452.01,CDM,964,RC,452,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Shoulder,PX00452.01,CDM,964,RC,452,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Shoulder,PX00452.01,CDM,964,RC,452,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Shoulder,PX00452.01,CDM,964,RC,452,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Shoulder,PX01610.01,CDM,964,RC,1610,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Shoulder,PX01610.01,CDM,964,RC,1610,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Shoulder,PX01610.01,CDM,964,RC,1610,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Shoulder,PX01610.01,CDM,964,RC,1610,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Shoulder,PX01630.01,CDM,964,RC,1630,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Shoulder,PX01630.01,CDM,964,RC,1630,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Shoulder,PX01630.01,CDM,964,RC,1630,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Shoulder,PX01630.01,CDM,964,RC,1630,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Testis Exploration,PX00924.01,CDM,964,RC,924,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Testis Exploration,PX00924.01,CDM,964,RC,924,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Testis Exploration,PX00924.01,CDM,964,RC,924,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Testis Exploration,PX00924.01,CDM,964,RC,924,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Testis Suspension,PX00930.01,CDM,964,RC,930,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Testis Suspension,PX00930.01,CDM,964,RC,930,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Testis Suspension,PX00930.01,CDM,964,RC,930,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Testis Suspension,PX00930.01,CDM,964,RC,930,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Thigh Arteries Surg,PX01270.01,CDM,964,RC,1270,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Thigh Arteries Surg,PX01270.01,CDM,964,RC,1270,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Thigh Arteries Surg,PX01270.01,CDM,964,RC,1270,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Thigh Arteries Surg,PX01270.01,CDM,964,RC,1270,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Trach-Bronch Reconst,PX00539.01,CDM,964,RC,539,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Trach-Bronch Reconst,PX00539.01,CDM,964,RC,539,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Trach-Bronch Reconst,PX00539.01,CDM,964,RC,539,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Trach-Bronch Reconst,PX00539.01,CDM,964,RC,539,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Trachea Bronchi Surg,PX00548.01,CDM,964,RC,548,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Trachea Bronchi Surg,PX00548.01,CDM,964,RC,548,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Trachea Bronchi Surg,PX00548.01,CDM,964,RC,548,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Trachea Bronchi Surg,PX00548.01,CDM,964,RC,548,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Trans Resect of Prostate,PX00914.01,CDM,964,RC,914,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Trans Resect of Prostate,PX00914.01,CDM,964,RC,914,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Trans Resect of Prostate,PX00914.01,CDM,964,RC,914,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Trans Resect of Prostate,PX00914.01,CDM,964,RC,914,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Tubal Ligation,PX00851.01,CDM,964,RC,851,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Tubal Ligation,PX00851.01,CDM,964,RC,851,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Tubal Ligation,PX00851.01,CDM,964,RC,851,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Tubal Ligation,PX00851.01,CDM,964,RC,851,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Tympanotomy,PX00126.01,CDM,964,RC,126,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Tympanotomy,PX00126.01,CDM,964,RC,126,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Tympanotomy,PX00126.01,CDM,964,RC,126,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Tympanotomy,PX00126.01,CDM,964,RC,126,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Upper Arm Surgery,PX01740.01,CDM,964,RC,1740,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Upper Arm Surgery,PX01740.01,CDM,964,RC,1740,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Upper Arm Surgery,PX01740.01,CDM,964,RC,1740,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Upper Arm Surgery,PX01740.01,CDM,964,RC,1740,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Upper Arm Vein Surg,PX01780.01,CDM,964,RC,1780,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Upper Arm Vein Surg,PX01780.01,CDM,964,RC,1780,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Upper Arm Vein Surg,PX01780.01,CDM,964,RC,1780,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Upper Arm Vein Surg,PX01780.01,CDM,964,RC,1780,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Upper GI Visualize,PX00740.01,CDM,964,RC,740,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Upper GI Visualize,PX00740.01,CDM,964,RC,740,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Upper GI Visualize,PX00740.01,CDM,964,RC,740,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Upper GI Visualize,PX00740.01,CDM,964,RC,740,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Upper Leg Surgery,PX01250.01,CDM,964,RC,1250,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Upper Leg Surgery,PX01250.01,CDM,964,RC,1250,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Upper Leg Surgery,PX01250.01,CDM,964,RC,1250,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Upper Leg Surgery,PX01250.01,CDM,964,RC,1250,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Upper Leg Veins Surg,PX01260.01,CDM,964,RC,1260,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Upper Leg Veins Surg,PX01260.01,CDM,964,RC,1260,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Upper Leg Veins Surg,PX01260.01,CDM,964,RC,1260,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Upper Leg Veins Surg,PX01260.01,CDM,964,RC,1260,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Artery Surg,PX01770.01,CDM,964,RC,1770,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Artery Surg,PX01770.01,CDM,964,RC,1770,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Artery Surg,PX01770.01,CDM,964,RC,1770,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Artery Surg,PX01770.01,CDM,964,RC,1770,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Embolectomy,PX01772.01,CDM,964,RC,1772,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Embolectomy,PX01772.01,CDM,964,RC,1772,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Embolectomy,PX01772.01,CDM,964,RC,1772,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Embolectomy,PX01772.01,CDM,964,RC,1772,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Procedure,PX01730.01,CDM,964,RC,1730,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Procedure,PX01730.01,CDM,964,RC,1730,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Procedure,PX01730.01,CDM,964,RC,1730,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Procedure,PX01730.01,CDM,964,RC,1730,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Tendon Surg,PX01712.01,CDM,964,RC,1712,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Tendon Surg,PX01712.01,CDM,964,RC,1712,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Tendon Surg,PX01712.01,CDM,964,RC,1712,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Tendon Surg,PX01712.01,CDM,964,RC,1712,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Tendon Surg,PX01714.01,CDM,964,RC,1714,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Tendon Surg,PX01714.01,CDM,964,RC,1714,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Tendon Surg,PX01714.01,CDM,964,RC,1714,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Tendon Surg,PX01714.01,CDM,964,RC,1714,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Vein Repair,PX01782.01,CDM,964,RC,1782,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Vein Repair,PX01782.01,CDM,964,RC,1782,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Vein Repair,PX01782.01,CDM,964,RC,1782,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Vein Repair,PX01782.01,CDM,964,RC,1782,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vaginal Delivery,PX01960.01,CDM,964,RC,1960,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vaginal Delivery,PX01960.01,CDM,964,RC,1960,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vaginal Delivery,PX01960.01,CDM,964,RC,1960,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vaginal Delivery,PX01960.01,CDM,964,RC,1960,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vaginal Endoscopy,PX00950.01,CDM,964,RC,950,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vaginal Endoscopy,PX00950.01,CDM,964,RC,950,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vaginal Endoscopy,PX00950.01,CDM,964,RC,950,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vaginal Endoscopy,PX00950.01,CDM,964,RC,950,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vaginal Hysterectomy,PX00944.01,CDM,964,RC,944,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vaginal Hysterectomy,PX00944.01,CDM,964,RC,944,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vaginal Hysterectomy,PX00944.01,CDM,964,RC,944,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vaginal Hysterectomy,PX00944.01,CDM,964,RC,944,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vaginal Procedures,PX00940.01,CDM,964,RC,940,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vaginal Procedures,PX00940.01,CDM,964,RC,940,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vaginal Procedures,PX00940.01,CDM,964,RC,940,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vaginal Procedures,PX00940.01,CDM,964,RC,940,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vascular Access,PX00532.01,CDM,964,RC,532,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vascular Access,PX00532.01,CDM,964,RC,532,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vascular Access,PX00532.01,CDM,964,RC,532,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vascular Access,PX00532.01,CDM,964,RC,532,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vascular Shunt Surg,PX01844.01,CDM,964,RC,1844,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vascular Shunt Surg,PX01844.01,CDM,964,RC,1844,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vascular Shunt Surg,PX01844.01,CDM,964,RC,1844,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vascular Shunt Surg,PX01844.01,CDM,964,RC,1844,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vasectomy,PX00921.01,CDM,964,RC,921,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vasectomy,PX00921.01,CDM,964,RC,921,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vasectomy,PX00921.01,CDM,964,RC,921,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vasectomy,PX00921.01,CDM,964,RC,921,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vitreoretinal Surg,PX00145.01,CDM,964,RC,145,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vitreoretinal Surg,PX00145.01,CDM,964,RC,145,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vitreoretinal Surg,PX00145.01,CDM,964,RC,145,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vitreoretinal Surg,PX00145.01,CDM,964,RC,145,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Wrist Replacement,PX01832.01,CDM,964,RC,1832,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Wrist Replacement,PX01832.01,CDM,964,RC,1832,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Wrist Replacement,PX01832.01,CDM,964,RC,1832,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Wrist Replacement,PX01832.01,CDM,964,RC,1832,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth/Analg Cs Hyst Add-On,PX01969.01,CDM,964,RC,1969,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth/Analg Cs Hyst Add-On,PX01969.01,CDM,964,RC,1969,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth/Analg Cs Hyst Add-On,PX01969.01,CDM,964,RC,1969,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth/Analg Cs Hyst Add-On,PX01969.01,CDM,964,RC,1969,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth/Analg Vag Delivery,PX01967.01,CDM,964,RC,1967,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth/Analg Vag Delivery,PX01967.01,CDM,964,RC,1967,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth/Analg Vag Delivery,PX01967.01,CDM,964,RC,1967,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth/Analg Vag Delivery,PX01967.01,CDM,964,RC,1967,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT CAST LARGE 12-5/8 ORT290010L,120.247,CDM,274,RC,L3260,HCPCS,,204-MAIN,LOCAL,,,,,27,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
BOOT CAST LARGE 12-5/8 ORT290010L,120.247,CDM,274,RC,L3260,HCPCS,,204-MAIN,LOCAL,,,,,27,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
BOOT CAST MEDIUM 08148803,120.247,CDM,274,RC,L3260,HCPCS,,203-MAIN,LOCAL,,,,,27,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
BOOT CAST MEDIUM 08148803,120.247,CDM,274,RC,L3260,HCPCS,,203-MAIN,LOCAL,,,,,27,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
BOOT CAST X-LARGE 13X5-1/2IN ORT29200XL,120.247,CDM,274,RC,L3260,HCPCS,,206-MAIN,LOCAL,,,,,27,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
BOOT CAST X-LARGE 13X5-1/2IN ORT29200XL,120.247,CDM,274,RC,L3260,HCPCS,,206-MAIN,LOCAL,,,,,27,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
Hosp Manage Cont Drug Admin,PX01996.01,CDM,964,RC,1996,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hosp Manage Cont Drug Admin,PX01996.01,CDM,964,RC,1996,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hosp Manage Cont Drug Admin,PX01996.01,CDM,964,RC,1996,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hosp Manage Cont Drug Admin,PX01996.01,CDM,964,RC,1996,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP LARGE MALE MQM3B,120.237,CDM,274,RC,L3260,HCPCS,,794-MAIN,LOCAL,,,,,76,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP LARGE MALE MQM3B,120.237,CDM,274,RC,L3260,HCPCS,,794-MAIN,LOCAL,,,,,76,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP LARGE SQUARE TOE WOMENS ORT30300WL,120.237,CDM,274,RC,L3260,HCPCS,,10606-MAIN,LOCAL,,,,,76,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP LARGE SQUARE TOE WOMENS ORT30300WL,120.237,CDM,274,RC,L3260,HCPCS,,10606-MAIN,LOCAL,,,,,76,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP MEDIUM SQUARE TOE MALE ORT30300MM,120.237,CDM,274,RC,L3260,HCPCS,,10603-MAIN,LOCAL,,,,,76,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP MEDIUM SQUARE TOE MALE ORT30300MM,120.237,CDM,274,RC,L3260,HCPCS,,10603-MAIN,LOCAL,,,,,76,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP MEDIUM SQUARE TOE WOMENS ORT30300WM,120.237,CDM,274,RC,L3260,HCPCS,,10605-MAIN,LOCAL,,,,,76,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP MEDIUM SQUARE TOE WOMENS ORT30300WM,120.237,CDM,274,RC,L3260,HCPCS,,10605-MAIN,LOCAL,,,,,76,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP SMALL MALE 0814-1192,120.237,CDM,274,RC,L3260,HCPCS,,803-MAIN,LOCAL,,,,,76,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP SMALL MALE 0814-1192,120.237,CDM,274,RC,L3260,HCPCS,,803-MAIN,LOCAL,,,,,76,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP SMALL SQUARE TOE WOMENS MQW1B,120.237,CDM,274,RC,L3260,HCPCS,,10604-MAIN,LOCAL,,,,,76,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP SMALL SQUARE TOE WOMENS MQW1B,120.237,CDM,274,RC,L3260,HCPCS,,10604-MAIN,LOCAL,,,,,76,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP X-LARGE MALE DS1016-16,120.237,CDM,274,RC,L3260,HCPCS,,6337-MAIN,LOCAL,,,,,35,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP X-LARGE MALE DS1016-16,120.237,CDM,274,RC,L3260,HCPCS,,6337-MAIN,LOCAL,,,,,35,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
Support for Organ Donor,PX01990.01,CDM,964,RC,1990,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Support for Organ Donor,PX01990.01,CDM,964,RC,1990,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Support for Organ Donor,PX01990.01,CDM,964,RC,1990,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Support for Organ Donor,PX01990.01,CDM,964,RC,1990,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Unlisted Anesth Procedure,PX01999.01,CDM,964,RC,1999,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Unlisted Anesth Procedure,PX01999.01,CDM,964,RC,1999,CPT,QZ,,,,,,,36,,Health Partners,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Unlisted Anesth Procedure,PX01999.01,CDM,964,RC,1999,CPT,QZ,,,,,,,36,,Humana Choice Care,All Medicare plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Unlisted Anesth Procedure,PX01999.01,CDM,964,RC,1999,CPT,QZ,,,,,,,36,,United Healthcare,All Medicare advantage plans,both,101,,999999999,other,,101% of actual cost through Medicare Cost Report,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Inf Ag Detect by Nucleic Acid (Dna or Rna); (Sars-Cov-2,PXU0005,CDM,300,RC,U0005,HCPCS,,,,,,,,0.01,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,0.004154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.004154,0.0098
Inf Ag Detect by Nucleic Acid (Dna or Rna); (Sars-Cov-2,PXU0005,CDM,300,RC,U0005,HCPCS,,,,,,,,0.01,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,0.00429,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.004154,0.0098
Inf Ag Detect by Nucleic Acid (Dna or Rna); (Sars-Cov-2,PXU0005,CDM,300,RC,U0005,HCPCS,,,,,,,,0.01,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,0.0048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.004154,0.0098
Inf Ag Detect by Nucleic Acid (Dna or Rna); (Sars-Cov-2,PXU0005,CDM,300,RC,U0005,HCPCS,,,,,,,,0.01,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,0.0048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.004154,0.0098
Inf Ag Detect by Nucleic Acid (Dna or Rna); (Sars-Cov-2,PXU0005,CDM,300,RC,U0005,HCPCS,,,,,,,,0.01,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,0.0049,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.004154,0.0098
Inf Ag Detect by Nucleic Acid (Dna or Rna); (Sars-Cov-2,PXU0005,CDM,300,RC,U0005,HCPCS,,,,,,,,0.01,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,0.0049,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.004154,0.0098
Inf Ag Detect by Nucleic Acid (Dna or Rna); (Sars-Cov-2,PXU0005,CDM,300,RC,U0005,HCPCS,,,,,,,,0.01,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,0.0049,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.004154,0.0098
Inf Ag Detect by Nucleic Acid (Dna or Rna); (Sars-Cov-2,PXU0005,CDM,300,RC,U0005,HCPCS,,,,,,,,0.01,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,0.00495,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.004154,0.0098
Inf Ag Detect by Nucleic Acid (Dna or Rna); (Sars-Cov-2,PXU0005,CDM,300,RC,U0005,HCPCS,,,,,,,,0.01,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,0.00506,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.004154,0.0098
Inf Ag Detect by Nucleic Acid (Dna or Rna); (Sars-Cov-2,PXU0005,CDM,300,RC,U0005,HCPCS,,,,,,,,0.01,,First Health,Commercial,both,85,,999999999,percent of total billed charges,0.0085,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.004154,0.0098
Inf Ag Detect by Nucleic Acid (Dna or Rna); (Sars-Cov-2,PXU0005,CDM,300,RC,U0005,HCPCS,,,,,,,,0.01,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,0.00882,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.004154,0.0098
Inf Ag Detect by Nucleic Acid (Dna or Rna); (Sars-Cov-2,PXU0005,CDM,300,RC,U0005,HCPCS,,,,,,,,0.01,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,0.0089,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.004154,0.0098
Inf Ag Detect by Nucleic Acid (Dna or Rna); (Sars-Cov-2,PXU0005,CDM,300,RC,U0005,HCPCS,,,,,,,,0.01,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,0.00911,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.004154,0.0098
Inf Ag Detect by Nucleic Acid (Dna or Rna); (Sars-Cov-2,PXU0005,CDM,300,RC,U0005,HCPCS,,,,,,,,0.01,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,0.009733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.004154,0.0098
Inf Ag Detect by Nucleic Acid (Dna or Rna); (Sars-Cov-2,PXU0005,CDM,300,RC,U0005,HCPCS,,,,,,,,0.01,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,0.0098,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.004154,0.0098
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409115918,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.01,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409115918,NDC,1,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409115918,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409115918,NDC,1,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.01,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409115918,NDC,1,ML,30,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,0.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046401,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.01,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046401,NDC,1,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046401,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046401,NDC,1,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.01,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046401,NDC,1,ML,30,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,0.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046417,NDC,10,ML,54.6,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.01,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046417,NDC,10,ML,54.6,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046417,NDC,10,ML,54.6,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046417,NDC,10,ML,54.6,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.01,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046417,NDC,10,ML,54.6,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,0.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046402,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.01,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046402,NDC,1,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046402,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046402,NDC,1,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.01,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046402,NDC,1,ML,30,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,0.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046437,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.01,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046437,NDC,1,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046437,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046437,NDC,1,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.01,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046437,NDC,1,ML,30,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,0.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 50 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046557,NDC,30,ML,59.84,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.01,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
BUPivacaine 0.25 % Solution 50 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046557,NDC,30,ML,59.84,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
BUPivacaine 0.25 % Solution 50 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046557,NDC,30,ML,59.84,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
BUPivacaine 0.25 % Solution 50 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046557,NDC,30,ML,59.84,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.01,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
BUPivacaine 0.25 % Solution 50 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046557,NDC,30,ML,59.84,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,0.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine in dextrose 0.75-8.25 % Solution 2 mL Ampule,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409176162,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.01,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
BUPivacaine in dextrose 0.75-8.25 % Solution 2 mL Ampule,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409176162,NDC,2,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
BUPivacaine in dextrose 0.75-8.25 % Solution 2 mL Ampule,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409176162,NDC,2,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
BUPivacaine in dextrose 0.75-8.25 % Solution 2 mL Ampule,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409176162,NDC,2,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.01,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
BUPivacaine in dextrose 0.75-8.25 % Solution 2 mL Ampule,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409176162,NDC,2,ML,30,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,0.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine PF 0.5 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,55150016910,NDC,10,ML,39.84,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.01,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
BUPivacaine PF 0.5 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,55150016910,NDC,10,ML,39.84,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
BUPivacaine PF 0.5 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,55150016910,NDC,10,ML,39.84,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
BUPivacaine PF 0.5 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,55150016910,NDC,10,ML,39.84,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.01,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
BUPivacaine PF 0.5 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,55150016910,NDC,10,ML,39.84,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,0.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409116219,NDC,30,ML,32.07,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.01,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409116219,NDC,30,ML,32.07,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409116219,NDC,30,ML,32.07,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409116219,NDC,30,ML,32.07,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.01,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409116219,NDC,30,ML,32.07,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,0.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046601,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.01,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046601,NDC,1,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046601,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046601,NDC,1,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.01,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046601,NDC,1,ML,30,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,0.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306424,NDC,1,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306424,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306424,NDC,1,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.01,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253033335,NDC,5,ML,40.44,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253033335,NDC,5,ML,40.44,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253033335,NDC,5,ML,40.44,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.01,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306413,NDC,1,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306413,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306413,NDC,1,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.01,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306521,NDC,3,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306521,NDC,3,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306521,NDC,3,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.01,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253022233,NDC,3,ML,38.13,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253022233,NDC,3,ML,38.13,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253022233,NDC,3,ML,38.13,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.01,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
heparin lock flush 10 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306510,NDC,5,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
heparin lock flush 10 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306510,NDC,5,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
heparin lock flush 10 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306510,NDC,5,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.01,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614201,NDC,1,ML,88.69,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.01,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.32
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614225,NDC,1,ML,88.69,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.01,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.32
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641622901,NDC,1,ML,41.16,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.01,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.32
predniSONE 1 MG Tablet 100 Each Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,64380078206,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.01,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
predniSONE 1 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54873925,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.01,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
predniSONE 2.5 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54874025,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.01,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
predniSONE 5 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687012211,NDC,0.2,EA,3,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.01,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
predniSONE 5 mg/5 mL 5 MG/5ML Solution 120 mL Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54372250,NDC,120,ML,186.47,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.01,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
predniSONE 10 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687013411,NDC,0.1,EA,3,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.01,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001720,NDC,0.1,EA,3,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.01,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,63739051910,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.01,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
predniSONE 20 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014511,NDC,0.05,EA,3,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.01,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001820,NDC,0.05,EA,3,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.01,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014501,NDC,0.05,EA,3,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.01,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
sodium chloride 3 % 3 % Solution 500 mL Flex Cont,J7131.01,CDM,636,RC,J7131,HCPCS,,,,338005403,NDC,500,ML,99.12,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.04
sodium chloride 3 % 3 % Solution 500 mL Flex Cont,J7131.01,CDM,636,RC,J7131,HCPCS,,,,338005403,NDC,500,ML,99.12,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.04
sodium chloride 3 % 3 % Solution 500 mL Flex Cont,J7131.01,CDM,636,RC,J7131,HCPCS,,,,338005403,NDC,500,ML,99.12,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.01,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.04
sodium chloride 3 % 3 % Solution 500 mL Flex Cont,J7131.01,CDM,636,RC,J7131,HCPCS,,,,338005403,NDC,500,ML,99.12,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.016,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.04
sodium chloride 3 % 3 % Solution 500 mL Flex Cont,J7131.01,CDM,636,RC,J7131,HCPCS,,,,338005403,NDC,500,ML,99.12,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.016,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.04
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306424,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.02,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253033335,NDC,5,ML,40.44,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.02,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306413,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.02,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306521,NDC,3,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.02,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253022233,NDC,3,ML,38.13,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.02,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
heparin lock flush 10 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306510,NDC,5,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.02,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
lidocaine (preservative free) 4 % Solution 5 mL Ampule,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409428325,NDC,5,ML,48.62,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,0.03217
lidocaine (preservative free) 4 % Solution 5 mL Ampule,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409428325,NDC,5,ML,48.62,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,0.03217
lidocaine (preservative free) 4 % Solution 5 mL Ampule,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409428325,NDC,5,ML,48.62,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,0.03217
lidocaine 4-5 MG/ML-% Solution 500 mL Flex Cont,J2001.01,CDM,636,RC,J2001,HCPCS,,,,338040903,NDC,500,ML,55.82,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,0.03217
lidocaine 4-5 MG/ML-% Solution 500 mL Flex Cont,J2001.01,CDM,636,RC,J2001,HCPCS,,,,338040903,NDC,500,ML,55.82,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,0.03217
lidocaine 4-5 MG/ML-% Solution 500 mL Flex Cont,J2001.01,CDM,636,RC,J2001,HCPCS,,,,338040903,NDC,500,ML,55.82,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,0.03217
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409132305,NDC,5,ML,41.35,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,0.03217
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409132305,NDC,5,ML,41.35,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,0.03217
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409132305,NDC,5,ML,41.35,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,0.03217
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490311,NDC,5,ML,43.39,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,0.03217
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490311,NDC,5,ML,43.39,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,0.03217
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490311,NDC,5,ML,43.39,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,0.03217
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490334,NDC,5,ML,42.29,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,0.03217
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490334,NDC,5,ML,42.29,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,0.03217
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490334,NDC,5,ML,42.29,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,0.03217
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,76329339001,NDC,5,ML,64.63,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,0.03217
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,76329339001,NDC,5,ML,64.63,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,0.03217
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,76329339001,NDC,5,ML,64.63,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,0.03217
metroNIDAZOLE 500 MG/100ML Solution 100 mL Flex Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,409781124,NDC,100,ML,32.12,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.02,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,0.03217
metroNIDAZOLE 500 MG/100ML Solution 100 mL Flex Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,409781124,NDC,100,ML,32.12,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,0.03217
metroNIDAZOLE 500 MG/100ML Solution 100 mL Flex Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,409781124,NDC,100,ML,32.12,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,0.03217
metroNIDAZOLE 500 MG/100ML Solution 100 mL Flex Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,409781124,NDC,100,ML,32.12,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,0.03217
metroNIDAZOLE 500 MG/100ML Solution 100 mL Flex Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,409781124,NDC,100,ML,32.12,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,0.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,31.4776
metroNIDAZOLE 500 MG/100ML Solution 100 mL Plas Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,338954124,NDC,100,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.02,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,0.03217
metroNIDAZOLE 500 MG/100ML Solution 100 mL Plas Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,338954124,NDC,100,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,0.03217
metroNIDAZOLE 500 MG/100ML Solution 100 mL Plas Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,338954124,NDC,100,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,0.03217
metroNIDAZOLE 500 MG/100ML Solution 100 mL Plas Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,338954124,NDC,100,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,0.03217
metroNIDAZOLE 500 MG/100ML Solution 100 mL Plas Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,338954124,NDC,100,ML,30,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,0.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,31.4776
APPLICATOR CHLORAPREP 26ML WITH ORANGE 930815,27200000,CDM,272,RC,A4248,HCPCS,,10031-MAIN,LOCAL,,,,,19.65,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.03,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
APPLICATOR CHLORAPREP 26ML WITH ORANGE 930815,27200000,CDM,272,RC,A4248,HCPCS,,10031-MAIN,LOCAL,,,,,19.65,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
APPLICATOR CHLORAPREP 26ML WITH ORANGE 930815,27200000,CDM,272,RC,A4248,HCPCS,,10031-MAIN,LOCAL,,,,,19.65,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
APPLICATOR CHLORAPREP 26ML WITH ORANGE 930815,27200000,CDM,272,RC,A4248,HCPCS,,10031-MAIN,LOCAL,,,,,19.65,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
DAPTOmycin 500 MG Recon Soln 1 Each Vial,J0878.01,CDM,636,RC,J0878,HCPCS,,,,70594003402,NDC,1,EA,129.9,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.1
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338080304,NDC,1000,ML,69.59,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338080304,NDC,1000,ML,69.59,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338080304,NDC,1000,ML,69.59,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,409710709,NDC,1000,ML,36.53,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,409710709,NDC,1000,ML,36.53,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,409710709,NDC,1000,ML,36.53,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990710709,NDC,1000,ML,69.59,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990710709,NDC,1000,ML,69.59,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990710709,NDC,1000,ML,69.59,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,264763500,NDC,1000,ML,43.5,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,264763500,NDC,1000,ML,43.5,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,264763500,NDC,1000,ML,43.5,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338067104,NDC,1000,ML,53.06,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338067104,NDC,1000,ML,53.06,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338067104,NDC,1000,ML,53.06,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
hydrOXYzine pamoate 25 MG capsule 1 Each Blister,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084711,NDC,1,EA,3.22,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.31
hydrOXYzine pamoate 25 MG capsule 1 Each Blister,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084711,NDC,1,EA,3.22,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.31
hydrOXYzine pamoate 25 MG capsule 1 Each Blister,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084711,NDC,1,EA,3.22,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.31
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,51079007720,NDC,1,EA,3,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.31
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,51079007720,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.31
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,51079007720,NDC,1,EA,3,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.31
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084701,NDC,1,EA,3.22,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.31
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084701,NDC,1,EA,3.22,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.31
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084701,NDC,1,EA,3.22,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.31
lidocaine (preservative free) 4 % Solution 5 mL Ampule,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409428325,NDC,5,ML,48.62,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.03,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,0.03217
lidocaine 4-5 MG/ML-% Solution 500 mL Flex Cont,J2001.01,CDM,636,RC,J2001,HCPCS,,,,338040903,NDC,500,ML,55.82,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.03,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,0.03217
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409132305,NDC,5,ML,41.35,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.03,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,0.03217
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490311,NDC,5,ML,43.39,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.03,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,0.03217
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490334,NDC,5,ML,42.29,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.03,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,0.03217
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,76329339001,NDC,5,ML,64.63,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.03,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,0.03217
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665305,NDC,20,ML,49.97,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665305,NDC,20,ML,49.97,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665305,NDC,20,ML,49.97,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665318,NDC,20,ML,50.08,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665318,NDC,20,ML,50.08,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665318,NDC,20,ML,50.08,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070948,NDC,100,ML,42.59,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070948,NDC,100,ML,42.59,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070948,NDC,100,ML,42.59,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707426,NDC,100,ML,39.29,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707426,NDC,100,ML,39.29,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707426,NDC,100,ML,39.29,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Flex Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707526,NDC,100,ML,37.63,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Flex Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707526,NDC,100,ML,37.63,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Flex Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707526,NDC,100,ML,37.63,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070548,NDC,100,ML,40.94,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070548,NDC,100,ML,40.94,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070548,NDC,100,ML,40.94,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
predniSONE 1 MG Tablet 100 Each Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,64380078206,NDC,1,EA,3,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
predniSONE 1 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54873925,NDC,1,EA,3,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
predniSONE 2.5 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54874025,NDC,1,EA,3,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
predniSONE 5 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687012211,NDC,0.2,EA,3,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
predniSONE 5 mg/5 mL 5 MG/5ML Solution 120 mL Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54372250,NDC,120,ML,186.47,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
predniSONE 10 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687013411,NDC,0.1,EA,3,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001720,NDC,0.1,EA,3,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,63739051910,NDC,1,EA,3,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
predniSONE 20 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014511,NDC,0.05,EA,3,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001820,NDC,0.05,EA,3,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014501,NDC,0.05,EA,3,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338069104,NDC,1000,ML,99.12,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338069104,NDC,1000,ML,99.12,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338069104,NDC,1000,ML,99.12,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990711509,NDC,1000,ML,64.08,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990711509,NDC,1000,ML,64.08,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990711509,NDC,1000,ML,64.08,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
"sodium chloride 0.45 % 1,000 mL with potassium chloride 20 mEq 20-0.45 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070434,NDC,1000,ML,58.57,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
"sodium chloride 0.45 % 1,000 mL with potassium chloride 20 mEq 20-0.45 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070434,NDC,1000,ML,58.57,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
"sodium chloride 0.45 % 1,000 mL with potassium chloride 20 mEq 20-0.45 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070434,NDC,1000,ML,58.57,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409115918,NDC,1,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.03217,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046401,NDC,1,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.03217,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046417,NDC,10,ML,54.6,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.03217,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046402,NDC,1,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.03217,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046437,NDC,1,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.03217,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
BUPivacaine 0.25 % Solution 50 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046557,NDC,30,ML,59.84,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.03217,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
BUPivacaine in dextrose 0.75-8.25 % Solution 2 mL Ampule,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409176162,NDC,2,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.03217,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
BUPivacaine PF 0.5 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,55150016910,NDC,10,ML,39.84,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.03217,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409116219,NDC,30,ML,32.07,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.03217,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046601,NDC,1,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.03217,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323031119,NDC,10,ML,66.39,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.03217,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03217,0.05
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036001,NDC,10,ML,80.5,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.03217,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03217,0.05
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036019,NDC,10,ML,86.23,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.03217,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03217,0.05
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306424,NDC,1,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.03217,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253033335,NDC,5,ML,40.44,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.03217,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306413,NDC,1,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.03217,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306521,NDC,3,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.03217,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253022233,NDC,3,ML,38.13,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.03217,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
heparin lock flush 10 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306510,NDC,5,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.03217,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
lidocaine (preservative free) 4 % Solution 5 mL Ampule,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409428325,NDC,5,ML,48.62,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.03217,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,0.03217
lidocaine 4-5 MG/ML-% Solution 500 mL Flex Cont,J2001.01,CDM,636,RC,J2001,HCPCS,,,,338040903,NDC,500,ML,55.82,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.03217,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,0.03217
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409132305,NDC,5,ML,41.35,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.03217,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,0.03217
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490311,NDC,5,ML,43.39,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.03217,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,0.03217
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490334,NDC,5,ML,42.29,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.03217,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,0.03217
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,76329339001,NDC,5,ML,64.63,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.03217,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,0.03217
metroNIDAZOLE 500 MG/100ML Solution 100 mL Flex Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,409781124,NDC,100,ML,32.12,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.03217,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,0.03217
metroNIDAZOLE 500 MG/100ML Solution 100 mL Plas Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,338954124,NDC,100,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.03217,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,0.03217
predniSONE 1 MG Tablet 100 Each Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,64380078206,NDC,1,EA,3,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.03217,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
predniSONE 1 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54873925,NDC,1,EA,3,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.03217,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
predniSONE 2.5 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54874025,NDC,1,EA,3,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.03217,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
predniSONE 5 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687012211,NDC,0.2,EA,3,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.03217,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
predniSONE 5 mg/5 mL 5 MG/5ML Solution 120 mL Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54372250,NDC,120,ML,186.47,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.03217,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
predniSONE 10 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687013411,NDC,0.1,EA,3,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.03217,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001720,NDC,0.1,EA,3,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.03217,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,63739051910,NDC,1,EA,3,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.03217,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
predniSONE 20 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014511,NDC,0.05,EA,3,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.03217,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001820,NDC,0.05,EA,3,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.03217,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014501,NDC,0.05,EA,3,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.03217,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.03217
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315606,NDC,100,ML,264.64,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.04,0.06434
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315695,NDC,100,ML,264.64,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.04,0.06434
acyclovir 50 MG/ML Solution 10 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,55150015410,NDC,10,ML,108.16,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.04,0.06434
acyclovir 50 MG/ML Solution 20 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,63323032524,NDC,20,ML,76.86,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.04,0.06434
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323031119,NDC,10,ML,66.39,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03217,0.05
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323031119,NDC,10,ML,66.39,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03217,0.05
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323031119,NDC,10,ML,66.39,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03217,0.05
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036001,NDC,10,ML,80.5,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03217,0.05
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036001,NDC,10,ML,80.5,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03217,0.05
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036001,NDC,10,ML,80.5,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03217,0.05
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036019,NDC,10,ML,86.23,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03217,0.05
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036019,NDC,10,ML,86.23,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03217,0.05
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036019,NDC,10,ML,86.23,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03217,0.05
DAPTOmycin 500 MG Recon Soln 1 Each Vial,J0878.01,CDM,636,RC,J0878,HCPCS,,,,70594003402,NDC,1,EA,129.9,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.04,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.1
promethazine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,Q0169,HCPCS,,,,904646161,NDC,0.5,EA,3,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.04,0.48
promethazine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,Q0169,HCPCS,,,,904646161,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.04,0.48
promethazine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,Q0169,HCPCS,,,,904646161,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.04,0.48
sodium chloride 3 % 3 % Solution 500 mL Flex Cont,J7131.01,CDM,636,RC,J7131,HCPCS,,,,338005403,NDC,500,ML,99.12,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.04,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.04
APPLICATOR CHLORAPREP 26ML WITH ORANGE 930815,27200000,CDM,272,RC,A4248,HCPCS,,10031-MAIN,LOCAL,,,,,19.65,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.048,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
APPLICATOR CHLORAPREP 26ML WITH ORANGE 930815,27200000,CDM,272,RC,A4248,HCPCS,,10031-MAIN,LOCAL,,,,,19.65,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.048,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315606,NDC,100,ML,264.64,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.05,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.04,0.06434
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315606,NDC,100,ML,264.64,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.04,0.06434
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315606,NDC,100,ML,264.64,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.04,0.06434
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315695,NDC,100,ML,264.64,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.05,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.04,0.06434
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315695,NDC,100,ML,264.64,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.04,0.06434
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315695,NDC,100,ML,264.64,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.04,0.06434
acyclovir 50 MG/ML Solution 10 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,55150015410,NDC,10,ML,108.16,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.04,0.06434
acyclovir 50 MG/ML Solution 10 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,55150015410,NDC,10,ML,108.16,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.04,0.06434
acyclovir 50 MG/ML Solution 20 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,63323032524,NDC,20,ML,76.86,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.04,0.06434
acyclovir 50 MG/ML Solution 20 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,63323032524,NDC,20,ML,76.86,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.04,0.06434
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323031119,NDC,10,ML,66.39,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.05,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03217,0.05
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323031119,NDC,10,ML,66.39,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,0.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,84.5054
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036001,NDC,10,ML,80.5,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.05,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03217,0.05
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036001,NDC,10,ML,80.5,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,0.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,84.5054
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036019,NDC,10,ML,86.23,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.05,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03217,0.05
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036019,NDC,10,ML,86.23,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,0.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,84.5054
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188602,NDC,5,ML,45.46,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.05,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,0.06434
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188622,NDC,5,ML,45.46,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.05,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,0.06434
acyclovir 50 MG/ML Solution 10 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,55150015410,NDC,10,ML,108.16,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.06,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.04,0.06434
acyclovir 50 MG/ML Solution 20 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,63323032524,NDC,20,ML,76.86,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.06,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.04,0.06434
atropine (PF) 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517040125,NDC,1,ML,71.55,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
atropine (PF) 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517040125,NDC,1,ML,71.55,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
atropine (PF) 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517040125,NDC,1,ML,71.55,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.06,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
atropine (PF) 1 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517101025,NDC,1,ML,91.89,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
atropine (PF) 1 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517101025,NDC,1,ML,91.89,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
atropine (PF) 1 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517101025,NDC,1,ML,91.89,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.06,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
atropine 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100401,NDC,0.5,ML,50.91,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
atropine 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100401,NDC,0.5,ML,50.91,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
atropine 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100401,NDC,0.5,ML,50.91,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.06,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329333901,NDC,10,ML,79.51,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329333901,NDC,10,ML,79.51,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329333901,NDC,10,ML,79.51,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.06,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329334001,NDC,10,ML,88.88,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329334001,NDC,10,ML,88.88,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329334001,NDC,10,ML,88.88,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.06,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
atropine 1 mg/mL Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100101,NDC,0.2,ML,39.42,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
atropine 1 mg/mL Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100101,NDC,0.2,ML,39.42,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
atropine 1 mg/mL Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100101,NDC,0.2,ML,39.42,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.06,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,641600601,NDC,0.5,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,641600601,NDC,0.5,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,641600601,NDC,0.5,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.06,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058003,NDC,0.5,ML,31.57,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058003,NDC,0.5,ML,31.57,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058003,NDC,0.5,ML,31.57,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.06,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058020,NDC,0.5,ML,31.57,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058020,NDC,0.5,ML,31.57,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058020,NDC,0.5,ML,31.57,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.06,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188602,NDC,5,ML,45.46,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.06,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,0.06434
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188602,NDC,5,ML,45.46,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,0.06434
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188602,NDC,5,ML,45.46,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,0.06434
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188622,NDC,5,ML,45.46,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.06,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,0.06434
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188622,NDC,5,ML,45.46,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,0.06434
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188622,NDC,5,ML,45.46,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,0.06434
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003905,NDC,1,EA,58.77,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.27
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003905,NDC,1,EA,58.77,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.27
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003928,NDC,1,EA,39,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.27
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003928,NDC,1,EA,39,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.27
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003930,NDC,1,EA,58.99,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.27
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003930,NDC,1,EA,58.99,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.27
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004703,NDC,1,EA,75.45,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.27
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004703,NDC,1,EA,75.45,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.27
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004722,NDC,2,ML,88.35,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.27
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004722,NDC,2,ML,88.35,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.27
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004725,NDC,2,ML,131.52,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.27
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004725,NDC,2,ML,131.52,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.27
methylPREDNISolone sod succ 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,63323025803,NDC,0.4,EA,46.67,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.27
methylPREDNISolone sod succ 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,63323025803,NDC,0.4,EA,46.67,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.27
methylPREDNISolone sod succ 500 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9075801,NDC,0.25,EA,39,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.27
methylPREDNISolone sod succ 500 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9075801,NDC,0.25,EA,39,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.27
methylPREDNISolone sod succ 1000 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9001820,NDC,1,EA,271.97,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.27
methylPREDNISolone sod succ 1000 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9001820,NDC,1,EA,271.97,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.27
OXALiplatin 50 MG/10ML Solution 10 mL Vial,J9263.01,CDM,636,RC,J9263,HCPCS,,,,955173110,NDC,10,ML,228,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.06,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.07
ROPivacaine 2 MG/ML Solution 10 mL Vial,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028513,NDC,10,ML,52.01,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
ROPivacaine 2 MG/ML Solution 10 mL Vial,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028513,NDC,10,ML,52.01,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
ROPivacaine 2 MG/ML Solution 10 mL Vial,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028513,NDC,10,ML,52.01,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.06,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
ROPivacaine 2 MG/ML Solution 100 mL Bottle,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028568,NDC,100,ML,275.11,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
ROPivacaine 2 MG/ML Solution 100 mL Bottle,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028568,NDC,100,ML,275.11,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
ROPivacaine 2 MG/ML Solution 100 mL Bottle,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028568,NDC,100,ML,275.11,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.06,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315606,NDC,100,ML,264.64,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.06434,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.04,0.06434
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315695,NDC,100,ML,264.64,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.06434,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.04,0.06434
acyclovir 50 MG/ML Solution 10 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,55150015410,NDC,10,ML,108.16,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.06434,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.04,0.06434
acyclovir 50 MG/ML Solution 20 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,63323032524,NDC,20,ML,76.86,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.06434,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.04,0.06434
atropine (PF) 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517040125,NDC,1,ML,71.55,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.06434,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
atropine (PF) 1 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517101025,NDC,1,ML,91.89,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.06434,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
atropine 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100401,NDC,0.5,ML,50.91,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.06434,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329333901,NDC,10,ML,79.51,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.06434,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329334001,NDC,10,ML,88.88,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.06434,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
atropine 1 mg/mL Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100101,NDC,0.2,ML,39.42,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.06434,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,641600601,NDC,0.5,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.06434,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058003,NDC,0.5,ML,31.57,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.06434,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058020,NDC,0.5,ML,31.57,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.06434,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188602,NDC,5,ML,45.46,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.06434,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,0.06434
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188622,NDC,5,ML,45.46,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.06434,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,0.06434
OXALiplatin 50 MG/10ML Solution 10 mL Vial,J9263.01,CDM,636,RC,J9263,HCPCS,,,,955173110,NDC,10,ML,228,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.06434,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.07
ROPivacaine 2 MG/ML Solution 10 mL Vial,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028513,NDC,10,ML,52.01,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.06434,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
ROPivacaine 2 MG/ML Solution 100 mL Bottle,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028568,NDC,100,ML,275.11,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.06434,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,693390152,NDC,2.5,ML,13.5,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.07,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,0.432
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,68094002459,NDC,10,ML,14.67,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.07,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,0.432
diphenhydrAMINE 12.5 MG/5ML Liquid 118 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904698520,NDC,2.5,ML,13.5,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.07,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,0.432
diphenhydrAMINE 12.5 MG/5ML Liquid 120 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,58657052804,NDC,2.5,ML,13.5,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.07,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,0.432
diphenhydrAMINE 50 MG capsule 100 Each Box,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904205661,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.07,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,0.432
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,43598052936,NDC,0.5,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.07,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,1.28
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,63323041536,NDC,0.5,ML,44.05,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.07,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,1.28
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080601,NDC,0.5,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.07,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,1.28
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080610,NDC,0.5,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.07,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,1.28
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954201,NDC,10,ML,153.18,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.07,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,0.41
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954210,NDC,10,ML,153.18,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.07,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,0.41
OXALiplatin 50 MG/10ML Solution 10 mL Vial,J9263.01,CDM,636,RC,J9263,HCPCS,,,,955173110,NDC,10,ML,228,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.07,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.07
OXALiplatin 50 MG/10ML Solution 10 mL Vial,J9263.01,CDM,636,RC,J9263,HCPCS,,,,955173110,NDC,10,ML,228,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.07,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.07
OXALiplatin 50 MG/10ML Solution 10 mL Vial,J9263.01,CDM,636,RC,J9263,HCPCS,,,,955173110,NDC,10,ML,228,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.07,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.07
atropine (PF) 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517040125,NDC,1,ML,71.55,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.08,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
atropine (PF) 1 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517101025,NDC,1,ML,91.89,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.08,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
atropine 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100401,NDC,0.5,ML,50.91,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.08,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329333901,NDC,10,ML,79.51,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.08,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329334001,NDC,10,ML,88.88,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.08,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
atropine 1 mg/mL Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100101,NDC,0.2,ML,39.42,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.08,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,641600601,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.08,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058003,NDC,0.5,ML,31.57,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.08,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058020,NDC,0.5,ML,31.57,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.08,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,43598052936,NDC,0.5,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,1.28
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,43598052936,NDC,0.5,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,1.28
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,63323041536,NDC,0.5,ML,44.05,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,1.28
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,63323041536,NDC,0.5,ML,44.05,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,1.28
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080601,NDC,0.5,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,1.28
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080601,NDC,0.5,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,1.28
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080610,NDC,0.5,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,1.28
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080610,NDC,0.5,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,1.28
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954201,NDC,10,ML,153.18,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,0.41
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954201,NDC,10,ML,153.18,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,0.41
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954210,NDC,10,ML,153.18,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,0.41
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954210,NDC,10,ML,153.18,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,0.41
ROPivacaine 2 MG/ML Solution 10 mL Vial,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028513,NDC,10,ML,52.01,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.08,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
ROPivacaine 2 MG/ML Solution 100 mL Bottle,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028568,NDC,100,ML,275.11,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.08,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.08
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,409475503,NDC,2,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.09,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.09,0.1
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,409475503,NDC,2,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.09,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.09,0.1
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,409475503,NDC,2,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.09,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.09,0.1
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054731,NDC,2,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.09,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.09,0.1
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054731,NDC,2,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.09,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.09,0.1
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054731,NDC,2,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.09,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.09,0.1
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054831,NDC,2,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.09,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.09,0.1
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054831,NDC,2,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.09,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.09,0.1
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054831,NDC,2,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.09,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.09,0.1
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054842,NDC,2,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.09,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.09,0.1
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054842,NDC,2,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.09,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.09,0.1
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054842,NDC,2,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.09,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.09,0.1
PACLitaxel 30 MG/5ML Concentrate 5 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476401,NDC,5,ML,58.37,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.09,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.09,0.11
PACLitaxel 150 MG/25ML Concentrate 25 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321701,NDC,25,ML,300.96,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.09,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.09,0.11
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321801,NDC,50,ML,456,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.09,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.09,0.11
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476881,NDC,50,ML,579.12,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.09,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.09,0.11
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,63323076350,NDC,50,ML,589.57,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.09,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.09,0.11
DAPTOmycin 500 MG Recon Soln 1 Each Vial,J0878.01,CDM,636,RC,J0878,HCPCS,,,,70594003402,NDC,1,EA,129.9,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.09651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.1
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338080304,NDC,1000,ML,69.59,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.09651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,409710709,NDC,1000,ML,36.53,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.09651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990710709,NDC,1000,ML,69.59,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.09651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,264763500,NDC,1000,ML,43.5,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.09651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338067104,NDC,1000,ML,53.06,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.09651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,409475503,NDC,2,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.09651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.09,0.1
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054731,NDC,2,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.09651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.09,0.1
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054831,NDC,2,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.09651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.09,0.1
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054842,NDC,2,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.09651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.09,0.1
PACLitaxel 30 MG/5ML Concentrate 5 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476401,NDC,5,ML,58.37,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.09651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.09,0.11
PACLitaxel 150 MG/25ML Concentrate 25 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321701,NDC,25,ML,300.96,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.09651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.09,0.11
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321801,NDC,50,ML,456,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.09651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.09,0.11
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476881,NDC,50,ML,579.12,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.09651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.09,0.11
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,63323076350,NDC,50,ML,589.57,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.09651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.09,0.11
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665305,NDC,20,ML,49.97,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.09651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665318,NDC,20,ML,50.08,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.09651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070948,NDC,100,ML,42.59,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.09651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707426,NDC,100,ML,39.29,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.09651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Flex Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707526,NDC,100,ML,37.63,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.09651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070548,NDC,100,ML,40.94,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.09651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338069104,NDC,1000,ML,99.12,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.09651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990711509,NDC,1000,ML,64.08,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.09651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
"sodium chloride 0.45 % 1,000 mL with potassium chloride 20 mEq 20-0.45 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070434,NDC,1000,ML,58.57,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.09651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
DAPTOmycin 500 MG Recon Soln 1 Each Vial,J0878.01,CDM,636,RC,J0878,HCPCS,,,,70594003402,NDC,1,EA,129.9,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.1
DAPTOmycin 500 MG Recon Soln 1 Each Vial,J0878.01,CDM,636,RC,J0878,HCPCS,,,,70594003402,NDC,1,EA,129.9,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.1
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016501,NDC,1,ML,34.55,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.1,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.1,0.12868
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016502,NDC,0.5,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.1,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.1,0.12868
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016516,NDC,0.5,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.1,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.1,0.12868
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036721,NDC,1,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.1,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.1,0.12868
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036725,NDC,1,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.1,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.1,0.12868
dexAMETHasone 100 MG/10ML Solution 10 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323051610,NDC,0.5,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.1,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.1,0.12868
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050601,NDC,1,ML,68.33,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.1,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.1,0.12868
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050641,NDC,0.5,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.1,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.1,0.12868
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,409475503,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.1,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.09,0.1
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054731,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.1,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.09,0.1
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054831,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.1,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.09,0.1
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054842,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.1,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.09,0.1
PACLitaxel 30 MG/5ML Concentrate 5 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476401,NDC,5,ML,58.37,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.09,0.11
PACLitaxel 30 MG/5ML Concentrate 5 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476401,NDC,5,ML,58.37,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.09,0.11
PACLitaxel 150 MG/25ML Concentrate 25 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321701,NDC,25,ML,300.96,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.09,0.11
PACLitaxel 150 MG/25ML Concentrate 25 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321701,NDC,25,ML,300.96,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.09,0.11
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321801,NDC,50,ML,456,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.09,0.11
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321801,NDC,50,ML,456,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.09,0.11
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476881,NDC,50,ML,579.12,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.09,0.11
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476881,NDC,50,ML,579.12,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.09,0.11
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,63323076350,NDC,50,ML,589.57,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.09,0.11
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,63323076350,NDC,50,ML,589.57,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.09,0.11
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016501,NDC,1,ML,34.55,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.1,0.12868
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016501,NDC,1,ML,34.55,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.1,0.12868
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016502,NDC,0.5,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.1,0.12868
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016502,NDC,0.5,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.1,0.12868
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016516,NDC,0.5,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.1,0.12868
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016516,NDC,0.5,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.1,0.12868
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036721,NDC,1,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.1,0.12868
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036721,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.1,0.12868
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036725,NDC,1,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.1,0.12868
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036725,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.1,0.12868
dexAMETHasone 100 MG/10ML Solution 10 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323051610,NDC,0.5,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.1,0.12868
dexAMETHasone 100 MG/10ML Solution 10 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323051610,NDC,0.5,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.1,0.12868
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050601,NDC,1,ML,68.33,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.1,0.12868
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050601,NDC,1,ML,68.33,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.1,0.12868
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050641,NDC,0.5,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.1,0.12868
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050641,NDC,0.5,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.1,0.12868
PACLitaxel 30 MG/5ML Concentrate 5 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476401,NDC,5,ML,58.37,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.11,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.09,0.11
PACLitaxel 150 MG/25ML Concentrate 25 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321701,NDC,25,ML,300.96,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.11,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.09,0.11
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321801,NDC,50,ML,456,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.11,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.09,0.11
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476881,NDC,50,ML,579.12,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.11,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.09,0.11
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,63323076350,NDC,50,ML,589.57,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.11,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.09,0.11
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,409469930,NDC,20,ML,48.54,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.11,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.11,0.13
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060820,NDC,20,ML,58.57,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.11,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.11,0.13
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026994,NDC,20,ML,35.87,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.11,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.11,0.13
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060851,NDC,100,ML,213.4,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.11,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.11,0.13
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,43598054910,NDC,100,ML,205.14,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.11,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.11,0.13
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026969,NDC,100,ML,99.34,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.11,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.11,0.13
iohexol 300 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141363,NDC,100,ML,200,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.12868
iohexol 300 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141363,NDC,100,ML,200,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.12868
iohexol 300 MG/ML Solution 150 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141365,NDC,150,ML,300,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.12868
iohexol 300 MG/ML Solution 150 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141365,NDC,150,ML,300,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.12868
iohexol 350 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141491,NDC,100,ML,200,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.12868
iohexol 350 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141491,NDC,100,ML,200,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.12868
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,409469930,NDC,20,ML,48.54,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.11,0.13
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,409469930,NDC,20,ML,48.54,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.11,0.13
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060820,NDC,20,ML,58.57,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.11,0.13
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060820,NDC,20,ML,58.57,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.11,0.13
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026994,NDC,20,ML,35.87,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.11,0.13
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026994,NDC,20,ML,35.87,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.11,0.13
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060851,NDC,100,ML,213.4,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.11,0.13
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060851,NDC,100,ML,213.4,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.11,0.13
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,43598054910,NDC,100,ML,205.14,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.11,0.13
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,43598054910,NDC,100,ML,205.14,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.11,0.13
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026969,NDC,100,ML,99.34,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.11,0.13
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026969,NDC,100,ML,99.34,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.11,0.13
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016501,NDC,1,ML,34.55,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.12,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.1,0.12868
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016502,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.12,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.1,0.12868
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016516,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.12,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.1,0.12868
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036721,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.12,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.1,0.12868
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036725,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.12,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.1,0.12868
dexAMETHasone 100 MG/10ML Solution 10 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323051610,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.12,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.1,0.12868
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050601,NDC,1,ML,68.33,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.12,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.1,0.12868
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050641,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.12,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.1,0.12868
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338080304,NDC,1000,ML,69.59,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.12,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,409710709,NDC,1000,ML,36.53,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.12,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990710709,NDC,1000,ML,69.59,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.12,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,264763500,NDC,1000,ML,43.5,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.12,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338067104,NDC,1000,ML,53.06,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.12,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
iohexol 300 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141363,NDC,100,ML,200,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.12,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.12868
iohexol 300 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141363,NDC,100,ML,200,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.12,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.12868
iohexol 300 MG/ML Solution 150 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141365,NDC,150,ML,300,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.12,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.12868
iohexol 300 MG/ML Solution 150 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141365,NDC,150,ML,300,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.12,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.12868
iohexol 350 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141491,NDC,100,ML,200,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.12,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.12868
iohexol 350 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141491,NDC,100,ML,200,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.12,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.12868
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605701,NDC,2,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.12,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605725,NDC,1,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.12,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060031,NDC,2,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.12,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060041,NDC,2,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.12,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
midazolam 5 MG/ML Solution 1 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606101,NDC,0.2,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.12,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606001,NDC,10,ML,65.62,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.12,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606010,NDC,10,ML,65.62,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.12,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230504,NDC,0.5,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.12,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230505,NDC,5,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.12,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
midazolam PF 10 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230802,NDC,2,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.12,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665305,NDC,20,ML,49.97,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.12,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665318,NDC,20,ML,50.08,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.12,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070948,NDC,100,ML,42.59,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.12,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707426,NDC,100,ML,39.29,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.12,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Flex Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707526,NDC,100,ML,37.63,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.12,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070548,NDC,100,ML,40.94,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.12,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338069104,NDC,1000,ML,99.12,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.12,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990711509,NDC,1000,ML,64.08,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.12,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
"sodium chloride 0.45 % 1,000 mL with potassium chloride 20 mEq 20-0.45 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070434,NDC,1000,ML,58.57,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.12,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.12
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,43598052936,NDC,0.5,ML,30,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.128,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,1.28
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,43598052936,NDC,0.5,ML,30,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.128,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,1.28
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,63323041536,NDC,0.5,ML,44.05,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.128,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,1.28
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,63323041536,NDC,0.5,ML,44.05,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.128,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,1.28
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080601,NDC,0.5,ML,30,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.128,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,1.28
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080601,NDC,0.5,ML,30,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.128,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,1.28
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080610,NDC,0.5,ML,30,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.128,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,1.28
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080610,NDC,0.5,ML,30,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.128,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,1.28
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954201,NDC,10,ML,153.18,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.128,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,0.41
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954201,NDC,10,ML,153.18,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.128,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,0.41
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954210,NDC,10,ML,153.18,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.128,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,0.41
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954210,NDC,10,ML,153.18,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.128,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,0.41
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016501,NDC,1,ML,34.55,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.12868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.1,0.12868
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016502,NDC,0.5,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.12868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.1,0.12868
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016516,NDC,0.5,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.12868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.1,0.12868
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036721,NDC,1,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.12868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.1,0.12868
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036725,NDC,1,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.12868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.1,0.12868
dexAMETHasone 100 MG/10ML Solution 10 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323051610,NDC,0.5,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.12868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.1,0.12868
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050601,NDC,1,ML,68.33,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.12868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.1,0.12868
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050641,NDC,0.5,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.12868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.1,0.12868
gadoterate meglumine 10 mmol/20 mL Solution 20 mL Vial,A9575,CDM,636,RC,A9575,HCPCS,,,,67684200003,NDC,20,ML,668.27,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.12868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12868,0.21
iohexol 300 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141363,NDC,100,ML,200,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.12868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.12868
iohexol 300 MG/ML Solution 150 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141365,NDC,150,ML,300,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.12868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.12868
iohexol 350 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141491,NDC,100,ML,200,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.12868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.12868
methylPREDNISolone acetate 20 MG/ML Suspension 5 mL Vial,J1010.01,CDM,636,RC,J1010,HCPCS,,,,9027401,NDC,0.5,ML,41.3,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.12868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12868,0.13
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605701,NDC,2,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.12868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605725,NDC,1,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.12868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060031,NDC,2,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.12868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060041,NDC,2,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.12868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
midazolam 5 MG/ML Solution 1 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606101,NDC,0.2,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.12868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606001,NDC,10,ML,65.62,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.12868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606010,NDC,10,ML,65.62,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.12868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230504,NDC,0.5,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.12868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230505,NDC,5,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.12868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
midazolam PF 10 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230802,NDC,2,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.12868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,409469930,NDC,20,ML,48.54,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.12868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.11,0.13
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060820,NDC,20,ML,58.57,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.12868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.11,0.13
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026994,NDC,20,ML,35.87,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.12868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.11,0.13
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060851,NDC,100,ML,213.4,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.12868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.11,0.13
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,43598054910,NDC,100,ML,205.14,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.12868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.11,0.13
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026969,NDC,100,ML,99.34,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.12868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.11,0.13
gadoterate meglumine 10 mmol/20 mL Solution 20 mL Vial,A9575,CDM,636,RC,A9575,HCPCS,,,,67684200003,NDC,20,ML,668.27,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.13,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12868,0.21
methylPREDNISolone acetate 20 MG/ML Suspension 5 mL Vial,J1010.01,CDM,636,RC,J1010,HCPCS,,,,9027401,NDC,0.5,ML,41.3,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.13,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12868,0.13
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605701,NDC,2,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605701,NDC,2,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605725,NDC,1,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605725,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060031,NDC,2,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060031,NDC,2,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060041,NDC,2,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060041,NDC,2,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
midazolam 5 MG/ML Solution 1 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606101,NDC,0.2,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
midazolam 5 MG/ML Solution 1 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606101,NDC,0.2,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606001,NDC,10,ML,65.62,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606001,NDC,10,ML,65.62,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606010,NDC,10,ML,65.62,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606010,NDC,10,ML,65.62,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230504,NDC,0.5,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230504,NDC,0.5,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230505,NDC,5,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230505,NDC,5,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
midazolam PF 10 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230802,NDC,2,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
midazolam PF 10 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230802,NDC,2,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,409469930,NDC,20,ML,48.54,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.13,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.11,0.13
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060820,NDC,20,ML,58.57,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.13,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.11,0.13
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026994,NDC,20,ML,35.87,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.13,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.11,0.13
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060851,NDC,100,ML,213.4,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.13,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.11,0.13
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,43598054910,NDC,100,ML,205.14,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.13,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.11,0.13
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026969,NDC,100,ML,99.34,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.13,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.11,0.13
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,409662902,NDC,10,ML,146.84,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.13,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.13,1.06
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094310,NDC,10,ML,72.79,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.13,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.13,1.06
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094321,NDC,10,ML,72.79,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.13,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.13,1.06
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605701,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.14,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605725,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.14,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060031,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.14,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060041,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.14,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
midazolam 5 MG/ML Solution 1 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606101,NDC,0.2,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.14,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606001,NDC,10,ML,65.62,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.14,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606010,NDC,10,ML,65.62,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.14,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230504,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.14,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230505,NDC,5,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.14,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
midazolam PF 10 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230802,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.14,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12,0.14
mycophenolate 500 MG Tablet 100 Each Bottle,J7517.01,CDM,637,RC,J7517,HCPCS,,,,64380072506,NDC,1,EA,42.56,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.14,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.14,0.19302
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,409662902,NDC,10,ML,146.84,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.15,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.13,1.06
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,409662902,NDC,10,ML,146.84,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.15,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.13,1.06
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094310,NDC,10,ML,72.79,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.15,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.13,1.06
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094310,NDC,10,ML,72.79,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.15,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.13,1.06
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094321,NDC,10,ML,72.79,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.15,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.13,1.06
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094321,NDC,10,ML,72.79,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.15,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.13,1.06
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143932001,NDC,1,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.15,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.15,0.19
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143962201,NDC,1,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.15,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.15,0.19
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,409226720,NDC,1,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.15,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.15,0.19
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,47781058629,NDC,1,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.15,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.15,0.19
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,51991093498,NDC,1,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.15,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.15,0.19
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143932001,NDC,1,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.15,0.19
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143932001,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.15,0.19
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143932001,NDC,1,ML,30,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,0.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143962201,NDC,1,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.15,0.19
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143962201,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.15,0.19
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143962201,NDC,1,ML,30,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,0.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,409226720,NDC,1,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.15,0.19
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,409226720,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.15,0.19
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,409226720,NDC,1,ML,30,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,0.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,47781058629,NDC,1,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.15,0.19
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,47781058629,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.15,0.19
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,47781058629,NDC,1,ML,30,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,0.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,51991093498,NDC,1,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.15,0.19
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,51991093498,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.15,0.19
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,51991093498,NDC,1,ML,30,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,0.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
mycophenolate 500 MG Tablet 100 Each Bottle,J7517.01,CDM,637,RC,J7517,HCPCS,,,,64380072506,NDC,1,EA,42.56,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.14,0.19302
mycophenolate 500 MG Tablet 100 Each Bottle,J7517.01,CDM,637,RC,J7517,HCPCS,,,,64380072506,NDC,1,EA,42.56,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.14,0.19302
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143932001,NDC,1,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.16085,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.15,0.19
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143962201,NDC,1,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.16085,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.15,0.19
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,409226720,NDC,1,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.16085,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.15,0.19
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,47781058629,NDC,1,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.16085,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.15,0.19
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,51991093498,NDC,1,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.16085,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.15,0.19
gadoterate meglumine 10 mmol/20 mL Solution 20 mL Vial,A9575,CDM,636,RC,A9575,HCPCS,,,,67684200003,NDC,20,ML,668.27,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.18,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12868,0.21
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614201,NDC,1,ML,88.69,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.18,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.32
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614225,NDC,1,ML,88.69,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.18,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.32
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641622901,NDC,1,ML,41.16,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.18,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.32
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987501,NDC,3,ML,33.77,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.19,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.42
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987525,NDC,3,ML,33.22,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.19,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.42
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061601,NDC,3,ML,31.57,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.19,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.42
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061603,NDC,3,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.19,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.42
amiodarone 900 MG/18ML Solution 18 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,67457015318,NDC,18,ML,113.73,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.19,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.42
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234001,NDC,1.25,ML,91.55,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.19,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.22519
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234010,NDC,5,ML,306.2,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.19,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.22519
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234025,NDC,5,ML,306.2,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.19,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.22519
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234099,NDC,5,ML,306.2,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.19,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.22519
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231001,NDC,10,ML,649.64,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.19,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.22519
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231005,NDC,10,ML,649.64,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.19,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.22519
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143932001,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.19,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.15,0.19
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143962201,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.19,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.15,0.19
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,409226720,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.19,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.15,0.19
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,47781058629,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.19,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.15,0.19
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,51991093498,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.19,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.15,0.19
methylPREDNISolone 4 MG Tablet 100 Each Bottle,J7509.01,CDM,636,RC,J7509,HCPCS,,,,68382091601,NDC,0.5,EA,4.43,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.19,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.24
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,603459315,NDC,1,EA,7.67,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.19,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.24
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,781502207,NDC,1,EA,7.68,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.19,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.24
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,42806040021,NDC,1,EA,8.86,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.19,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.24
mycophenolate 500 MG Tablet 100 Each Bottle,J7517.01,CDM,637,RC,J7517,HCPCS,,,,64380072506,NDC,1,EA,42.56,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.19,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.14,0.19302
mycophenolate 500 MG Tablet 100 Each Bottle,J7517.01,CDM,637,RC,J7517,HCPCS,,,,64380072506,NDC,1,EA,42.56,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.19302,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.14,0.19302
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614201,NDC,1,ML,88.69,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.2,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.32
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614201,NDC,1,ML,88.69,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.2,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.32
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614225,NDC,1,ML,88.69,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.2,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.32
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614225,NDC,1,ML,88.69,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.2,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.32
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641622901,NDC,1,ML,41.16,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.2,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.32
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641622901,NDC,1,ML,41.16,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.2,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.32
tacrolimus 1 MG capsule 100 Each Bottle,J7507.01,CDM,636,RC,J7507,HCPCS,,,,16714009901,NDC,0.5,EA,11.95,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.2,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.2,0.27
gadoterate meglumine 10 mmol/20 mL Solution 20 mL Vial,A9575,CDM,636,RC,A9575,HCPCS,,,,67684200003,NDC,20,ML,668.27,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.21,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12868,0.21
gadoterate meglumine 10 mmol/20 mL Solution 20 mL Vial,A9575,CDM,636,RC,A9575,HCPCS,,,,67684200003,NDC,20,ML,668.27,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.21,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.12868,0.21
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987501,NDC,3,ML,33.77,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.42
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987501,NDC,3,ML,33.77,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.42
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987525,NDC,3,ML,33.22,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.42
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987525,NDC,3,ML,33.22,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.42
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061601,NDC,3,ML,31.57,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.42
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061601,NDC,3,ML,31.57,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.42
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061603,NDC,3,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.42
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061603,NDC,3,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.42
amiodarone 900 MG/18ML Solution 18 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,67457015318,NDC,18,ML,113.73,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.42
amiodarone 900 MG/18ML Solution 18 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,67457015318,NDC,18,ML,113.73,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.42
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018200,NDC,10,ML,68.21,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.22,0.26
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018200,NDC,10,ML,68.21,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.22,0.26
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018210,NDC,10,ML,68.21,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.22,0.26
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018210,NDC,10,ML,68.21,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.22,0.26
esmolol 2500 MG/250ML Solution 250 mL Flex Cont,J1805.01,CDM,636,RC,J1805,HCPCS,,,,10019067010,NDC,250,ML,1011.8,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.22,0.26
esmolol 2500 MG/250ML Solution 250 mL Flex Cont,J1805.01,CDM,636,RC,J1805,HCPCS,,,,10019067010,NDC,250,ML,1011.8,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.22,0.26
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234001,NDC,1.25,ML,91.55,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.22,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.22519
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234001,NDC,1.25,ML,91.55,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.22519
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234001,NDC,1.25,ML,91.55,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.22519
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234010,NDC,5,ML,306.2,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.22,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.22519
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234010,NDC,5,ML,306.2,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.22519
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234010,NDC,5,ML,306.2,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.22519
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234025,NDC,5,ML,306.2,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.22,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.22519
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234025,NDC,5,ML,306.2,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.22519
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234025,NDC,5,ML,306.2,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.22519
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234099,NDC,5,ML,306.2,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.22,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.22519
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234099,NDC,5,ML,306.2,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.22519
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234099,NDC,5,ML,306.2,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.22519
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231001,NDC,10,ML,649.64,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.22,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.22519
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231001,NDC,10,ML,649.64,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.22519
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231001,NDC,10,ML,649.64,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.22519
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231005,NDC,10,ML,649.64,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.22,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.22519
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231005,NDC,10,ML,649.64,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.22519
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231005,NDC,10,ML,649.64,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.22519
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018200,NDC,10,ML,68.21,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.22519,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.22,0.26
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018210,NDC,10,ML,68.21,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.22519,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.22,0.26
esmolol 2500 MG/250ML Solution 250 mL Flex Cont,J1805.01,CDM,636,RC,J1805,HCPCS,,,,10019067010,NDC,250,ML,1011.8,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.22519,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.22,0.26
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234001,NDC,1.25,ML,91.55,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.22519,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.22519
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234010,NDC,5,ML,306.2,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.22519,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.22519
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234025,NDC,5,ML,306.2,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.22519,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.22519
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234099,NDC,5,ML,306.2,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.22519,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.22519
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231001,NDC,10,ML,649.64,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.22519,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.22519
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231005,NDC,10,ML,649.64,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.22519,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.22519
methotrexate 2.5 MG Tablet 1 Each Blister,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067001,NDC,1,EA,33.51,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.22519,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.22519,0.27
methotrexate 2.5 MG Tablet 20 Each Box,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067005,NDC,1,EA,33.49,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.22519,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.22519,0.27
methylPREDNISolone 4 MG Tablet 100 Each Bottle,J7509.01,CDM,636,RC,J7509,HCPCS,,,,68382091601,NDC,0.5,EA,4.43,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.22519,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.24
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,603459315,NDC,1,EA,7.67,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.22519,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.24
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,781502207,NDC,1,EA,7.68,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.22519,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.24
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,42806040021,NDC,1,EA,8.86,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.22519,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.24
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018200,NDC,10,ML,68.21,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.23,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.22,0.26
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018210,NDC,10,ML,68.21,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.23,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.22,0.26
esmolol 2500 MG/250ML Solution 250 mL Flex Cont,J1805.01,CDM,636,RC,J1805,HCPCS,,,,10019067010,NDC,250,ML,1011.8,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.23,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.22,0.26
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272002,NDC,1,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.23,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272031,NDC,1,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.23,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,25021040010,NDC,1,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.23,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323054011,NDC,1,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.23,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095300,NDC,0.5,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.23,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095310,NDC,1,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.23,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,71288042095,NDC,0.5,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.23,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,264957710,NDC,500,ML,80.61,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.23,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052201,NDC,500,ML,80.61,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.23,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052277,NDC,500,ML,80.61,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.23,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011801,NDC,0.5,ML,52.63,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.23,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011805,NDC,0.5,ML,52.63,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.23,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
methotrexate 2.5 MG Tablet 1 Each Blister,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067001,NDC,1,EA,33.51,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.23,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.22519,0.27
methotrexate 2.5 MG Tablet 20 Each Box,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067005,NDC,1,EA,33.49,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.23,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.22519,0.27
methylPREDNISolone 4 MG Tablet 100 Each Bottle,J7509.01,CDM,636,RC,J7509,HCPCS,,,,68382091601,NDC,0.5,EA,4.43,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.23,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.24
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,603459315,NDC,1,EA,7.67,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.23,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.24
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,781502207,NDC,1,EA,7.68,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.23,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.24
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,42806040021,NDC,1,EA,8.86,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.23,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.24
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,693390152,NDC,2.5,ML,13.5,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,0.432
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,693390152,NDC,2.5,ML,13.5,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,0.432
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,68094002459,NDC,10,ML,14.67,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,0.432
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,68094002459,NDC,10,ML,14.67,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,0.432
diphenhydrAMINE 12.5 MG/5ML Liquid 118 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904698520,NDC,2.5,ML,13.5,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,0.432
diphenhydrAMINE 12.5 MG/5ML Liquid 118 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904698520,NDC,2.5,ML,13.5,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,0.432
diphenhydrAMINE 12.5 MG/5ML Liquid 120 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,58657052804,NDC,2.5,ML,13.5,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,0.432
diphenhydrAMINE 12.5 MG/5ML Liquid 120 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,58657052804,NDC,2.5,ML,13.5,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,0.432
diphenhydrAMINE 50 MG capsule 100 Each Box,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904205661,NDC,0.5,EA,3,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,0.432
diphenhydrAMINE 50 MG capsule 100 Each Box,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904205661,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,0.432
methotrexate 2.5 MG Tablet 1 Each Blister,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067001,NDC,1,EA,33.51,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.22519,0.27
methotrexate 2.5 MG Tablet 1 Each Blister,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067001,NDC,1,EA,33.51,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.22519,0.27
methotrexate 2.5 MG Tablet 20 Each Box,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067005,NDC,1,EA,33.49,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.22519,0.27
methotrexate 2.5 MG Tablet 20 Each Box,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067005,NDC,1,EA,33.49,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.22519,0.27
methylPREDNISolone 4 MG Tablet 100 Each Bottle,J7509.01,CDM,636,RC,J7509,HCPCS,,,,68382091601,NDC,0.5,EA,4.43,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.24
methylPREDNISolone 4 MG Tablet 100 Each Bottle,J7509.01,CDM,636,RC,J7509,HCPCS,,,,68382091601,NDC,0.5,EA,4.43,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.24
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,603459315,NDC,1,EA,7.67,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.24
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,603459315,NDC,1,EA,7.67,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.24
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,781502207,NDC,1,EA,7.68,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.24
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,781502207,NDC,1,EA,7.68,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.24
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,42806040021,NDC,1,EA,8.86,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.24
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,42806040021,NDC,1,EA,8.86,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.24
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,693390152,NDC,2.5,ML,13.5,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.24,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,0.432
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,68094002459,NDC,10,ML,14.67,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.24,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,0.432
diphenhydrAMINE 12.5 MG/5ML Liquid 118 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904698520,NDC,2.5,ML,13.5,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.24,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,0.432
diphenhydrAMINE 12.5 MG/5ML Liquid 120 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,58657052804,NDC,2.5,ML,13.5,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.24,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,0.432
diphenhydrAMINE 50 MG capsule 100 Each Box,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904205661,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.24,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,0.432
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018200,NDC,10,ML,68.21,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,0.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.24,991.564
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018210,NDC,10,ML,68.21,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,0.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.24,991.564
esmolol 2500 MG/250ML Solution 250 mL Flex Cont,J1805.01,CDM,636,RC,J1805,HCPCS,,,,10019067010,NDC,250,ML,1011.8,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,0.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.24,991.564
tacrolimus 1 MG capsule 100 Each Bottle,J7507.01,CDM,636,RC,J7507,HCPCS,,,,16714009901,NDC,0.5,EA,11.95,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.24,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.2,0.27
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,409662902,NDC,10,ML,146.84,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.24,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.13,1.06
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,409662902,NDC,10,ML,146.84,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.24,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.13,1.06
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094310,NDC,10,ML,72.79,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.24,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.13,1.06
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094310,NDC,10,ML,72.79,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.24,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.13,1.06
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094321,NDC,10,ML,72.79,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.24,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.13,1.06
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094321,NDC,10,ML,72.79,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.24,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.13,1.06
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272002,NDC,1,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.25736,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272031,NDC,1,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.25736,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,25021040010,NDC,1,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.25736,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323054011,NDC,1,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.25736,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095300,NDC,0.5,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.25736,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095310,NDC,1,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.25736,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,71288042095,NDC,0.5,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.25736,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,264957710,NDC,500,ML,80.61,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.25736,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052201,NDC,500,ML,80.61,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.25736,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052277,NDC,500,ML,80.61,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.25736,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011801,NDC,0.5,ML,52.63,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.25736,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011805,NDC,0.5,ML,52.63,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.25736,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003905,NDC,1,EA,58.77,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.25736,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.27
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003928,NDC,1,EA,39,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.25736,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.27
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003930,NDC,1,EA,58.99,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.25736,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.27
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004703,NDC,1,EA,75.45,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.25736,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.27
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004722,NDC,2,ML,88.35,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.25736,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.27
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004725,NDC,2,ML,131.52,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.25736,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.27
methylPREDNISolone sod succ 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,63323025803,NDC,0.4,EA,46.67,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.25736,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.27
methylPREDNISolone sod succ 500 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9075801,NDC,0.25,EA,39,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.25736,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.27
methylPREDNISolone sod succ 1000 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9001820,NDC,1,EA,271.97,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.25736,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.27
tacrolimus 1 MG capsule 100 Each Bottle,J7507.01,CDM,636,RC,J7507,HCPCS,,,,16714009901,NDC,0.5,EA,11.95,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.25736,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.2,0.27
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018200,NDC,10,ML,68.21,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.26,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.22,0.26
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018210,NDC,10,ML,68.21,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.26,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.22,0.26
esmolol 2500 MG/250ML Solution 250 mL Flex Cont,J1805.01,CDM,636,RC,J1805,HCPCS,,,,10019067010,NDC,250,ML,1011.8,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.26,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.22,0.26
filgrastim-sndz 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314031801,NDC,0.5,ML,1047.2,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.27,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.27,0.41821
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032601,NDC,0.5,ML,559.7,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.27,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.27,0.41821
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032605,NDC,0.8,ML,1663.54,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.27,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.27,0.41821
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272002,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.27,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272002,NDC,1,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272002,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272031,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.27,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272031,NDC,1,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272031,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,25021040010,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.27,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,25021040010,NDC,1,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,25021040010,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323054011,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.27,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323054011,NDC,1,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323054011,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095300,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.27,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095300,NDC,0.5,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095300,NDC,0.5,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095310,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.27,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095310,NDC,1,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095310,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,71288042095,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.27,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,71288042095,NDC,0.5,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,71288042095,NDC,0.5,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,264957710,NDC,500,ML,80.61,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.27,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,264957710,NDC,500,ML,80.61,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,264957710,NDC,500,ML,80.61,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052201,NDC,500,ML,80.61,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.27,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052201,NDC,500,ML,80.61,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052201,NDC,500,ML,80.61,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052277,NDC,500,ML,80.61,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.27,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052277,NDC,500,ML,80.61,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052277,NDC,500,ML,80.61,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011801,NDC,0.5,ML,52.63,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.27,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011801,NDC,0.5,ML,52.63,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011801,NDC,0.5,ML,52.63,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011805,NDC,0.5,ML,52.63,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.27,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011805,NDC,0.5,ML,52.63,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011805,NDC,0.5,ML,52.63,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.23,0.27
methotrexate 2.5 MG Tablet 1 Each Blister,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067001,NDC,1,EA,33.51,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.27,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.22519,0.27
methotrexate 2.5 MG Tablet 20 Each Box,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067005,NDC,1,EA,33.49,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.27,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.22519,0.27
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003905,NDC,1,EA,58.77,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.27,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.27
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003928,NDC,1,EA,39,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.27,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.27
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003930,NDC,1,EA,58.99,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.27,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.27
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004703,NDC,1,EA,75.45,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.27,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.27
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004722,NDC,2,ML,88.35,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.27,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.27
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004725,NDC,2,ML,131.52,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.27,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.27
methylPREDNISolone sod succ 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,63323025803,NDC,0.4,EA,46.67,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.27,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.27
methylPREDNISolone sod succ 500 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9075801,NDC,0.25,EA,39,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.27,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.27
methylPREDNISolone sod succ 1000 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9001820,NDC,1,EA,271.97,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.27,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.06,0.27
tacrolimus 1 MG capsule 100 Each Bottle,J7507.01,CDM,636,RC,J7507,HCPCS,,,,16714009901,NDC,0.5,EA,11.95,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.2,0.27
tacrolimus 1 MG capsule 100 Each Bottle,J7507.01,CDM,636,RC,J7507,HCPCS,,,,16714009901,NDC,0.5,EA,11.95,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.2,0.27
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004224,NDC,5,ML,13.5,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,0.42
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004224,NDC,5,ML,13.5,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,0.42
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,62135025037,NDC,1.666666667,ML,13.5,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,0.42
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,62135025037,NDC,1.666666667,ML,13.5,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,0.42
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,121090204,NDC,120,ML,503.56,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,0.42
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,121090204,NDC,120,ML,503.56,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,0.42
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004004,NDC,120,ML,502.95,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,0.42
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004004,NDC,120,ML,502.95,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,0.42
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600701,NDC,10,ML,39.73,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.28,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,0.67
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600710,NDC,2,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.28,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,0.67
filgrastim-sndz 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314031801,NDC,0.5,ML,1047.2,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,0.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,1630.2692
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032601,NDC,0.5,ML,559.7,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,0.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,1630.2692
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032605,NDC,0.8,ML,1663.54,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,0.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,1630.2692
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004224,NDC,5,ML,13.5,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.28953,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,0.42
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,62135025037,NDC,1.666666667,ML,13.5,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.28953,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,0.42
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,121090204,NDC,120,ML,503.56,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.28953,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,0.42
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004004,NDC,120,ML,502.95,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.28953,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,0.42
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,781325394,NDC,1,EA,1049.95,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.31,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.31,0.4
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598030562,NDC,1,EA,912,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.31,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.31,0.4
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598046562,NDC,1,EA,798,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.31,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.31,0.4
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,63323077139,NDC,1,EA,547.2,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.31,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.31,0.4
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,72485020101,NDC,1,EA,1049.95,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.31,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.31,0.4
ferumoxytol 510 MG/17ML Solution 17 mL Vial,Q0138.01,CDM,636,RC,Q0138,HCPCS,,,,781315401,NDC,17,ML,1846.91,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.31,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.31,0.39
hydrOXYzine pamoate 25 MG capsule 1 Each Blister,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084711,NDC,1,EA,3.22,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.31,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.31
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,51079007720,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.31,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.31
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084701,NDC,1,EA,3.22,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.31,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,0.31
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600701,NDC,10,ML,39.73,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.32,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,0.67
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600701,NDC,10,ML,39.73,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.32,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,0.67
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600710,NDC,2,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.32,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,0.67
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600710,NDC,2,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.32,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,0.67
ferumoxytol 510 MG/17ML Solution 17 mL Vial,Q0138.01,CDM,636,RC,Q0138,HCPCS,,,,781315401,NDC,17,ML,1846.91,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,0.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.32,1809.9718
filgrastim-sndz 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314031801,NDC,0.5,ML,1047.2,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.32,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.27,0.41821
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032601,NDC,0.5,ML,559.7,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.32,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.27,0.41821
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032605,NDC,0.8,ML,1663.54,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.32,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.27,0.41821
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614201,NDC,1,ML,88.69,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.32,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.32
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614201,NDC,1,ML,88.69,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.32,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.32
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614225,NDC,1,ML,88.69,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.32,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.32
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614225,NDC,1,ML,88.69,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.32,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.32
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641622901,NDC,1,ML,41.16,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.32,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.32
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641622901,NDC,1,ML,41.16,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.32,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,0.32
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,693390152,NDC,2.5,ML,13.5,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.3217,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,0.432
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,68094002459,NDC,10,ML,14.67,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.3217,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,0.432
diphenhydrAMINE 12.5 MG/5ML Liquid 118 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904698520,NDC,2.5,ML,13.5,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.3217,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,0.432
diphenhydrAMINE 12.5 MG/5ML Liquid 120 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,58657052804,NDC,2.5,ML,13.5,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.3217,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,0.432
diphenhydrAMINE 50 MG capsule 100 Each Box,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904205661,NDC,0.5,EA,3,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.3217,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,0.432
oxytocin 10 UNIT/ML Solution 1 mL Vial,J2590.01,CDM,636,RC,J2590,HCPCS,,,,42023011625,NDC,1,ML,43.8,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.3217,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3217,1.57
promethazine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,Q0169,HCPCS,,,,904646161,NDC,0.5,EA,3,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.3217,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.04,0.48
SPONGE XRAY DETECTABLE PEANUT MDS72038,27200000,CDM,272,RC,,,,10915-MAIN,LOCAL,,,,,0.79,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,0.3265044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SPONGE XRAY DETECTABLE PEANUT MDS72038,27200000,CDM,272,RC,,,,10915-MAIN,LOCAL,,,,,0.79,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,0.337194,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987501,NDC,3,ML,33.77,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.352,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.42
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987501,NDC,3,ML,33.77,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.352,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.42
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987525,NDC,3,ML,33.22,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.352,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.42
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987525,NDC,3,ML,33.22,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.352,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.42
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061601,NDC,3,ML,31.57,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.352,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.42
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061601,NDC,3,ML,31.57,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.352,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.42
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061603,NDC,3,ML,30,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.352,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.42
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061603,NDC,3,ML,30,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.352,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.42
amiodarone 900 MG/18ML Solution 18 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,67457015318,NDC,18,ML,113.73,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.352,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.42
amiodarone 900 MG/18ML Solution 18 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,67457015318,NDC,18,ML,113.73,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.352,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.42
ferumoxytol 510 MG/17ML Solution 17 mL Vial,Q0138.01,CDM,636,RC,Q0138,HCPCS,,,,781315401,NDC,17,ML,1846.91,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.36,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.31,0.39
medroxyPROGESTERone 150 MG/ML Suspension 1 mL Vial,J1050.01,CDM,636,RC,J1050,HCPCS,,,,67457088799,NDC,1,ML,437.38,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.36,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.928
NEEDLE ECHOGENIC 21G 110MM SONOTAP II WITH FACET TIP 1285-3F110,120.483,CDM,271,RC,A4215,HCPCS,,12201-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.36,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE ECHOGENIC 21G X 4IN (100MM) SONOBLOCK II NERVE BLOCK WITH FACET S TIP 001281-77,120.483,CDM,271,RC,A4215,HCPCS,,12761-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.36,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE ECHOGENIC 22G 80MM SONOTAP II WITH FACET TIP 1285-3E080,120.483,CDM,271,RC,A4215,HCPCS,,12103-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.36,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE ECHOGENIC 22G X 3.25IN (80MM) SONOBLOCK II  NERVE BLOCK WITH FACET S TIP 001281-71,120.483,CDM,271,RC,A4215,HCPCS,,12760-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.36,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE ECHOGENIC 22GX2 SONOPLEX II WITH FACET S TIP 001287-74,120.483,CDM,271,RC,A4215,HCPCS,,13110-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.36,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE HYPODERMIC 22GA 1-1/2IN STERILE 305156,27200000,CDM,272,RC,A4215,HCPCS,,8887-MAIN,LOCAL,,,,,10,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.36,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
NEEDLE INTRAOSSEOUS 15GA 15MM EZ-IO PEDS 9018,120.89,CDM,272,RC,A4215,HCPCS,,4964-MAIN,LOCAL,,,,,269,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.36,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE INTRAOSSEOUS SET 15GA 25MM STABILIZER EZ-IO 9001P,120.216,CDM,272,RC,A4215,HCPCS,,10648-MAIN,LOCAL,,,,,290,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.36,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE INTRAOSSEOUS SET 15GA 45MM STABILIZER EZ-IO 9079P,120.216,CDM,272,RC,A4215,HCPCS,,10297-MAIN,LOCAL,,,,,290,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.36,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE IV 19GA X .75IN HUBER POWERLOC SAFETY 0651934,120.85,CDM,272,RC,A4215,HCPCS,,12701-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.36,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE IV 19GA X 1 IN HUBER POWERLOC SAFETY 0651910,120.85,CDM,272,RC,A4215,HCPCS,,12702-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.36,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE IV 19GA X 1.5 IN HUBER POWERLOC SAFETY 0651915,120.85,CDM,272,RC,A4215,HCPCS,,12703-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.36,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE NON-STIMULATING 22GX2 SONOBLOCK II WITH FACET S TIP 001281-74,120.483,CDM,271,RC,A4215,HCPCS,,11459-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.36,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE SONOPLEX II STIMULATING WITH FACET S TIP 22GX3-1/4,120.483,CDM,271,RC,A4215,HCPCS,,11457-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.36,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE STIMULATING 21GX4  SONOPLEX II  WITH FACET S TIP 001287-77,120.483,CDM,271,RC,A4215,HCPCS,,11458-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.36,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004224,NDC,5,ML,13.5,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.36,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,0.42
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,62135025037,NDC,1.666666667,ML,13.5,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.36,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,0.42
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,121090204,NDC,120,ML,503.56,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.36,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,0.42
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004004,NDC,120,ML,502.95,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.36,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,0.42
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,781325394,NDC,1,EA,1049.95,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.37,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.31,0.4
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598030562,NDC,1,EA,912,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.37,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.31,0.4
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598046562,NDC,1,EA,798,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.37,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.31,0.4
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,63323077139,NDC,1,EA,547.2,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.37,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.31,0.4
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,72485020101,NDC,1,EA,1049.95,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.37,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.31,0.4
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733201,NDC,0.5,EA,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.37,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320885,NDC,0.5,EA,129.71,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.37,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320895,NDC,0.5,EA,129.71,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.37,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614800,NDC,1,EA,239.18,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.37,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733513,NDC,1,EA,39.12,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.37,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320990,NDC,1,EA,410.32,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.37,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320995,NDC,1,EA,410.32,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.37,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,25021010720,NDC,1,EA,48.35,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.37,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614900,NDC,1,EA,409.89,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.37,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733801,NDC,0.5,EA,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.37,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505615204,NDC,0.5,EA,86.76,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.37,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone in dextrose 1 g / 50 mL 1-3.74 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0696.01,CDM,636,RC,J0696,HCPCS,,,,264315311,NDC,1,EA,106.03,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.37,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
SPONGE XRAY DETECTABLE PEANUT MDS72038,27200000,CDM,272,RC,,,,10915-MAIN,LOCAL,,,,,0.79,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,0.37728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SPONGE XRAY DETECTABLE PEANUT MDS72038,27200000,CDM,272,RC,,,,10915-MAIN,LOCAL,,,,,0.79,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,0.37728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,781309894,NDC,1,EA,193.75,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.38,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.38,0.45
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,781309894,NDC,1,EA,193.75,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.38,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.38,0.45
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,55150020830,NDC,1,EA,82.96,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.38,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.38,0.45
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,55150020830,NDC,1,EA,82.96,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.38,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.38,0.45
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,63323050830,NDC,1,EA,134.48,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.38,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.38,0.45
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,63323050830,NDC,1,EA,134.48,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.38,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.38,0.45
SPONGE XRAY DETECTABLE PEANUT MDS72038,27200000,CDM,272,RC,,,,10915-MAIN,LOCAL,,,,,0.79,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,0.38514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SPONGE XRAY DETECTABLE PEANUT MDS72038,27200000,CDM,272,RC,,,,10915-MAIN,LOCAL,,,,,0.79,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,0.38514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SPONGE XRAY DETECTABLE PEANUT MDS72038,27200000,CDM,272,RC,,,,10915-MAIN,LOCAL,,,,,0.79,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,0.38514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,781325394,NDC,1,EA,1049.95,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.38604,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.31,0.4
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598030562,NDC,1,EA,912,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.38604,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.31,0.4
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598046562,NDC,1,EA,798,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.38604,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.31,0.4
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,63323077139,NDC,1,EA,547.2,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.38604,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.31,0.4
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,72485020101,NDC,1,EA,1049.95,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.38604,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.31,0.4
ferumoxytol 510 MG/17ML Solution 17 mL Vial,Q0138.01,CDM,636,RC,Q0138,HCPCS,,,,781315401,NDC,17,ML,1846.91,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.38604,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.31,0.39
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,781309894,NDC,1,EA,193.75,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.38604,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.38,0.45
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,55150020830,NDC,1,EA,82.96,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.38604,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.38,0.45
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,63323050830,NDC,1,EA,134.48,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.38604,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.38,0.45
SPONGE XRAY DETECTABLE PEANUT MDS72038,27200000,CDM,272,RC,,,,10915-MAIN,LOCAL,,,,,0.79,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,0.38907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ferumoxytol 510 MG/17ML Solution 17 mL Vial,Q0138.01,CDM,636,RC,Q0138,HCPCS,,,,781315401,NDC,17,ML,1846.91,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.31,0.39
ferumoxytol 510 MG/17ML Solution 17 mL Vial,Q0138.01,CDM,636,RC,Q0138,HCPCS,,,,781315401,NDC,17,ML,1846.91,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.31,0.39
prochlorperazine 5 MG Tablet 1 Each Blister,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054101,NDC,1,EA,3.28,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.39,1.04
prochlorperazine 5 MG Tablet 1 Each Blister,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054101,NDC,1,EA,3.28,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.39,1.04
prochlorperazine 5 MG Tablet 1 Each Blister,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054101,NDC,1,EA,3.28,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.39,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.39,1.04
prochlorperazine 5 MG Tablet 100 Each Bottle,63600000,CDM,636,RC,Q0164,HCPCS,,,,59746011306,NDC,1,EA,3.19,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.39,1.04
prochlorperazine 5 MG Tablet 100 Each Bottle,63600000,CDM,636,RC,Q0164,HCPCS,,,,59746011306,NDC,1,EA,3.19,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.39,1.04
prochlorperazine 5 MG Tablet 100 Each Bottle,63600000,CDM,636,RC,Q0164,HCPCS,,,,59746011306,NDC,1,EA,3.19,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.39,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.39,1.04
prochlorperazine 5 MG Tablet 100 Each Box,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054120,NDC,1,EA,3.29,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.39,1.04
prochlorperazine 5 MG Tablet 100 Each Box,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054120,NDC,1,EA,3.29,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.39,1.04
prochlorperazine 5 MG Tablet 100 Each Box,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054120,NDC,1,EA,3.29,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.39,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.39,1.04
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,574722612,NDC,1,EA,67.57,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.39,0.51
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,574722612,NDC,1,EA,67.57,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.39,0.51
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,574722612,NDC,1,EA,67.57,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.39,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.39,0.51
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,713013512,NDC,1,EA,65.83,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.39,0.51
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,713013512,NDC,1,EA,65.83,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.39,0.51
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,713013512,NDC,1,EA,65.83,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.39,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.39,0.51
SPONGE XRAY DETECTABLE PEANUT MDS72038,27200000,CDM,272,RC,,,,10915-MAIN,LOCAL,,,,,0.79,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,0.397716,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,781325394,NDC,1,EA,1049.95,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.31,0.4
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,781325394,NDC,1,EA,1049.95,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.31,0.4
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598030562,NDC,1,EA,912,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.31,0.4
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598030562,NDC,1,EA,912,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.31,0.4
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598046562,NDC,1,EA,798,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.31,0.4
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598046562,NDC,1,EA,798,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.31,0.4
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,63323077139,NDC,1,EA,547.2,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.31,0.4
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,63323077139,NDC,1,EA,547.2,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.31,0.4
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,72485020101,NDC,1,EA,1049.95,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.31,0.4
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,72485020101,NDC,1,EA,1049.95,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.31,0.4
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,781309894,NDC,1,EA,193.75,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.4,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.38,0.45
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,55150020830,NDC,1,EA,82.96,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.4,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.38,0.45
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,63323050830,NDC,1,EA,134.48,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.4,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.38,0.45
"Pertechnetate, Dia, per Mci",PXA9512,CDM,343,RC,A9512,HCPCS,,,,,,,,280,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.4,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.4,21.5539
filgrastim-sndz 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314031801,NDC,0.5,ML,1047.2,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.27,0.41821
filgrastim-sndz 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314031801,NDC,0.5,ML,1047.2,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.27,0.41821
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032601,NDC,0.5,ML,559.7,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.27,0.41821
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032601,NDC,0.5,ML,559.7,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.27,0.41821
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032605,NDC,0.8,ML,1663.54,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.27,0.41821
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032605,NDC,0.8,ML,1663.54,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.27,0.41821
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954201,NDC,10,ML,153.18,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.41,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,0.41
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954210,NDC,10,ML,153.18,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.41,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,0.41
"Supply Technetium Medronate,to 30 MC",PXA9503,CDM,343,RC,A9503,HCPCS,,,,,,,,531,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.41,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.41,91.6845
filgrastim-sndz 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314031801,NDC,0.5,ML,1047.2,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.41821,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.27,0.41821
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032601,NDC,0.5,ML,559.7,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.41821,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.27,0.41821
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032605,NDC,0.8,ML,1663.54,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.41821,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.27,0.41821
prochlorperazine 5 MG Tablet 1 Each Blister,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054101,NDC,1,EA,3.28,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.41821,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.39,1.04
prochlorperazine 5 MG Tablet 100 Each Bottle,63600000,CDM,636,RC,Q0164,HCPCS,,,,59746011306,NDC,1,EA,3.19,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.41821,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.39,1.04
prochlorperazine 5 MG Tablet 100 Each Box,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054120,NDC,1,EA,3.29,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.41821,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.39,1.04
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,574722612,NDC,1,EA,67.57,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.41821,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.39,0.51
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,713013512,NDC,1,EA,65.83,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.41821,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.39,0.51
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733201,NDC,0.5,EA,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733201,NDC,0.5,EA,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320885,NDC,0.5,EA,129.71,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320885,NDC,0.5,EA,129.71,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320895,NDC,0.5,EA,129.71,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320895,NDC,0.5,EA,129.71,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614800,NDC,1,EA,239.18,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614800,NDC,1,EA,239.18,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733513,NDC,1,EA,39.12,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733513,NDC,1,EA,39.12,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320990,NDC,1,EA,410.32,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320990,NDC,1,EA,410.32,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320995,NDC,1,EA,410.32,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320995,NDC,1,EA,410.32,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,25021010720,NDC,1,EA,48.35,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,25021010720,NDC,1,EA,48.35,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614900,NDC,1,EA,409.89,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614900,NDC,1,EA,409.89,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733801,NDC,0.5,EA,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733801,NDC,0.5,EA,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505615204,NDC,0.5,EA,86.76,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505615204,NDC,0.5,EA,86.76,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone in dextrose 1 g / 50 mL 1-3.74 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0696.01,CDM,636,RC,J0696,HCPCS,,,,264315311,NDC,1,EA,106.03,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone in dextrose 1 g / 50 mL 1-3.74 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0696.01,CDM,636,RC,J0696,HCPCS,,,,264315311,NDC,1,EA,106.03,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987501,NDC,3,ML,33.77,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.42,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.42
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987525,NDC,3,ML,33.22,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.42,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.42
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061601,NDC,3,ML,31.57,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.42,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.42
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061603,NDC,3,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.42,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.42
amiodarone 900 MG/18ML Solution 18 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,67457015318,NDC,18,ML,113.73,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.42,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.19,0.42
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016200,NDC,1,ML,52.22,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.42,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016216,NDC,1,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.42,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016243,NDC,0.5,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.42,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072201,NDC,0.5,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.42,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072225,NDC,0.5,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.42,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016226,NDC,0.5,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.42,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016245,NDC,0.5,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.42,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011901,NDC,0.5,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.42,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011925,NDC,0.5,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.42,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072501,NDC,0.5,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.42,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072525,NDC,0.5,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.42,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004224,NDC,5,ML,13.5,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.42,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,0.42
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,62135025037,NDC,1.666666667,ML,13.5,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.42,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,0.42
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,121090204,NDC,120,ML,503.56,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.42,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,0.42
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004004,NDC,120,ML,502.95,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.42,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,0.42
Temporary External Pacing,PX92953F,CDM,480,RC,92953,CPT,,,,,,,,678,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.43,1.75
Temporary External Pacing,PX92953F,CDM,480,RC,92953,CPT,,,,,,,,678,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.43,1.75
Temporary External Pacing,PX92953F,CDM,480,RC,92953,CPT,,,,,,,,678,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.43,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.43,1.75
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,693390152,NDC,2.5,ML,13.5,,UCare,Individual and Family Plans,both,,,7.63,fee schedule,0.432,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,0.432
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,693390152,NDC,2.5,ML,13.5,,UCare,Individual and Family Plans,both,,,7.63,fee schedule,0.432,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,0.432
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,68094002459,NDC,10,ML,14.67,,UCare,Individual and Family Plans,both,,,7.63,fee schedule,0.432,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,0.432
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,68094002459,NDC,10,ML,14.67,,UCare,Individual and Family Plans,both,,,7.63,fee schedule,0.432,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,0.432
diphenhydrAMINE 12.5 MG/5ML Liquid 118 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904698520,NDC,2.5,ML,13.5,,UCare,Individual and Family Plans,both,,,7.63,fee schedule,0.432,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,0.432
diphenhydrAMINE 12.5 MG/5ML Liquid 118 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904698520,NDC,2.5,ML,13.5,,UCare,Individual and Family Plans,both,,,7.63,fee schedule,0.432,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,0.432
diphenhydrAMINE 12.5 MG/5ML Liquid 120 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,58657052804,NDC,2.5,ML,13.5,,UCare,Individual and Family Plans,both,,,7.63,fee schedule,0.432,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,0.432
diphenhydrAMINE 12.5 MG/5ML Liquid 120 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,58657052804,NDC,2.5,ML,13.5,,UCare,Individual and Family Plans,both,,,7.63,fee schedule,0.432,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,0.432
diphenhydrAMINE 50 MG capsule 100 Each Box,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904205661,NDC,0.5,EA,3,,UCare,Individual and Family Plans,both,,,7.63,fee schedule,0.432,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,0.432
diphenhydrAMINE 50 MG capsule 100 Each Box,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904205661,NDC,0.5,EA,3,,UCare,Individual and Family Plans,both,,,7.63,fee schedule,0.432,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,0.432
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,781309894,NDC,1,EA,193.75,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.45,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.38,0.45
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,55150020830,NDC,1,EA,82.96,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.45,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.38,0.45
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,63323050830,NDC,1,EA,134.48,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.45,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.38,0.45
"Pertechnetate, Dia, per Mci",PXA9512,CDM,343,RC,A9512,HCPCS,,,,,,,,280,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.45,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.4,21.5539
"Pertechnetate, Dia, per Mci",PXA9512,CDM,343,RC,A9512,HCPCS,,,,,,,,280,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.4,21.5539
"Pertechnetate, Dia, per Mci",PXA9512,CDM,343,RC,A9512,HCPCS,,,,,,,,280,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.4,21.5539
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733201,NDC,0.5,EA,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.45038,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320885,NDC,0.5,EA,129.71,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.45038,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320895,NDC,0.5,EA,129.71,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.45038,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614800,NDC,1,EA,239.18,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.45038,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733513,NDC,1,EA,39.12,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.45038,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320990,NDC,1,EA,410.32,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.45038,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320995,NDC,1,EA,410.32,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.45038,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,25021010720,NDC,1,EA,48.35,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.45038,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614900,NDC,1,EA,409.89,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.45038,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733801,NDC,0.5,EA,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.45038,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505615204,NDC,0.5,EA,86.76,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.45038,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone in dextrose 1 g / 50 mL 1-3.74 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0696.01,CDM,636,RC,J0696,HCPCS,,,,264315311,NDC,1,EA,106.03,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.45038,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
oxytocin 10 UNIT/ML Solution 1 mL Vial,J2590.01,CDM,636,RC,J2590,HCPCS,,,,42023011625,NDC,1,ML,43.8,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.46,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3217,1.57
"Supply Technetium Medronate,to 30 MC",PXA9503,CDM,343,RC,A9503,HCPCS,,,,,,,,531,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.47,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.41,91.6845
"Supply Technetium Medronate,to 30 MC",PXA9503,CDM,343,RC,A9503,HCPCS,,,,,,,,531,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.47,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.41,91.6845
"Supply Technetium Medronate,to 30 MC",PXA9503,CDM,343,RC,A9503,HCPCS,,,,,,,,531,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.47,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.41,91.6845
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143992490,NDC,0.5,EA,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.48,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010110,NDC,0.5,EA,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.48,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010167,NDC,0.5,EA,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.48,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,44567070725,NDC,0.5,EA,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.48,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623100,NDC,1,EA,59.25,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.48,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623105,NDC,1,EA,59.27,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.48,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143998391,NDC,1,EA,83.25,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.48,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010269,NDC,1,EA,88.69,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.48,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010299,NDC,1,EA,88.69,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.48,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
ceFAZolin in D4W 1 g / 50 mL 1-4 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0690.01,CDM,636,RC,J0690,HCPCS,,,,264310311,NDC,1,EA,84.97,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.48,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
promethazine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,Q0169,HCPCS,,,,904646161,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.48,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.04,0.48
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,517460125,NDC,0.5,ML,58.76,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.48255,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48255,0.62
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,781382571,NDC,0.5,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.48255,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48255,0.62
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057811,NDC,0.5,ML,30.98,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.48255,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48255,0.62
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057841,NDC,0.5,ML,30.98,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.48255,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48255,0.62
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733201,NDC,0.5,EA,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.49,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320885,NDC,0.5,EA,129.71,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.49,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320895,NDC,0.5,EA,129.71,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.49,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614800,NDC,1,EA,239.18,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.49,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733513,NDC,1,EA,39.12,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.49,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320990,NDC,1,EA,410.32,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.49,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320995,NDC,1,EA,410.32,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.49,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,25021010720,NDC,1,EA,48.35,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.49,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614900,NDC,1,EA,409.89,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.49,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733801,NDC,0.5,EA,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.49,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505615204,NDC,0.5,EA,86.76,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.49,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
cefTRIAXone in dextrose 1 g / 50 mL 1-3.74 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0696.01,CDM,636,RC,J0696,HCPCS,,,,264315311,NDC,1,EA,106.03,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.49,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.37,0.49
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,517460125,NDC,0.5,ML,58.76,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48255,0.62
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,517460125,NDC,0.5,ML,58.76,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48255,0.62
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,781382571,NDC,0.5,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48255,0.62
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,781382571,NDC,0.5,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48255,0.62
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057811,NDC,0.5,ML,30.98,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48255,0.62
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057811,NDC,0.5,ML,30.98,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48255,0.62
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057841,NDC,0.5,ML,30.98,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48255,0.62
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057841,NDC,0.5,ML,30.98,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48255,0.62
indocyanine green 25 MG Recon Soln 1 Each Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,70100042402,NDC,1,EA,446.07,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.49,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.49,0.912
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016200,NDC,1,ML,52.22,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.49,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016216,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.49,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016243,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.49,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072201,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.49,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072225,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.49,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016226,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.49,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016245,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.49,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011901,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.49,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011925,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.49,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072501,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.49,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072525,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.49,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
methylene blue 1 % Solution 10 mL Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,54288014701,NDC,1,ML,139.25,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.49,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.49,0.912
methylene blue 50 MG/10ML Solution 10 mL Ampule,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,517037405,NDC,10,ML,1382.12,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.49,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.49,0.912
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028002,NDC,1,ML,40.43,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.5,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.5,0.61123
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028016,NDC,2,ML,41.29,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.5,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.5,0.61123
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028026,NDC,2,ML,41.42,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.5,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.5,0.61123
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,70860030242,NDC,1,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.5,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.5,0.61123
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,36000028425,NDC,2,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.5,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.5,0.61123
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028036,NDC,2,ML,36.12,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.5,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.5,0.61123
medroxyPROGESTERone 150 MG/ML Suspension 1 mL Vial,J1050.01,CDM,636,RC,J1050,HCPCS,,,,67457088799,NDC,1,ML,437.38,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.5,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.928
prochlorperazine 5 MG Tablet 1 Each Blister,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054101,NDC,1,EA,3.28,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.51,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.39,1.04
prochlorperazine 5 MG Tablet 100 Each Bottle,63600000,CDM,636,RC,Q0164,HCPCS,,,,59746011306,NDC,1,EA,3.19,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.51,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.39,1.04
prochlorperazine 5 MG Tablet 100 Each Box,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054120,NDC,1,EA,3.29,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.51,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.39,1.04
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,574722612,NDC,1,EA,67.57,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.51,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.39,0.51
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,713013512,NDC,1,EA,65.83,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.51,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.39,0.51
medroxyPROGESTERone 150 MG/ML Suspension 1 mL Vial,J1050.01,CDM,636,RC,J1050,HCPCS,,,,67457088799,NDC,1,ML,437.38,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.51472,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.928
NEEDLE ECHOGENIC 21G 110MM SONOTAP II WITH FACET TIP 1285-3F110,120.483,CDM,271,RC,A4215,HCPCS,,12201-MAIN,LOCAL,,,,,41,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE ECHOGENIC 21G 110MM SONOTAP II WITH FACET TIP 1285-3F110,120.483,CDM,271,RC,A4215,HCPCS,,12201-MAIN,LOCAL,,,,,41,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE ECHOGENIC 21G 110MM SONOTAP II WITH FACET TIP 1285-3F110,120.483,CDM,271,RC,A4215,HCPCS,,12201-MAIN,LOCAL,,,,,41,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.52,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE ECHOGENIC 21G X 4IN (100MM) SONOBLOCK II NERVE BLOCK WITH FACET S TIP 001281-77,120.483,CDM,271,RC,A4215,HCPCS,,12761-MAIN,LOCAL,,,,,41,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE ECHOGENIC 21G X 4IN (100MM) SONOBLOCK II NERVE BLOCK WITH FACET S TIP 001281-77,120.483,CDM,271,RC,A4215,HCPCS,,12761-MAIN,LOCAL,,,,,41,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE ECHOGENIC 21G X 4IN (100MM) SONOBLOCK II NERVE BLOCK WITH FACET S TIP 001281-77,120.483,CDM,271,RC,A4215,HCPCS,,12761-MAIN,LOCAL,,,,,41,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.52,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE ECHOGENIC 22G 80MM SONOTAP II WITH FACET TIP 1285-3E080,120.483,CDM,271,RC,A4215,HCPCS,,12103-MAIN,LOCAL,,,,,41,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE ECHOGENIC 22G 80MM SONOTAP II WITH FACET TIP 1285-3E080,120.483,CDM,271,RC,A4215,HCPCS,,12103-MAIN,LOCAL,,,,,41,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE ECHOGENIC 22G 80MM SONOTAP II WITH FACET TIP 1285-3E080,120.483,CDM,271,RC,A4215,HCPCS,,12103-MAIN,LOCAL,,,,,41,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.52,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE ECHOGENIC 22G X 3.25IN (80MM) SONOBLOCK II  NERVE BLOCK WITH FACET S TIP 001281-71,120.483,CDM,271,RC,A4215,HCPCS,,12760-MAIN,LOCAL,,,,,41,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE ECHOGENIC 22G X 3.25IN (80MM) SONOBLOCK II  NERVE BLOCK WITH FACET S TIP 001281-71,120.483,CDM,271,RC,A4215,HCPCS,,12760-MAIN,LOCAL,,,,,41,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE ECHOGENIC 22G X 3.25IN (80MM) SONOBLOCK II  NERVE BLOCK WITH FACET S TIP 001281-71,120.483,CDM,271,RC,A4215,HCPCS,,12760-MAIN,LOCAL,,,,,41,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.52,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE ECHOGENIC 22GX2 SONOPLEX II WITH FACET S TIP 001287-74,120.483,CDM,271,RC,A4215,HCPCS,,13110-MAIN,LOCAL,,,,,41,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE ECHOGENIC 22GX2 SONOPLEX II WITH FACET S TIP 001287-74,120.483,CDM,271,RC,A4215,HCPCS,,13110-MAIN,LOCAL,,,,,41,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE ECHOGENIC 22GX2 SONOPLEX II WITH FACET S TIP 001287-74,120.483,CDM,271,RC,A4215,HCPCS,,13110-MAIN,LOCAL,,,,,41,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.52,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE HYPODERMIC 22GA 1-1/2IN STERILE 305156,27200000,CDM,272,RC,A4215,HCPCS,,8887-MAIN,LOCAL,,,,,10,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
NEEDLE HYPODERMIC 22GA 1-1/2IN STERILE 305156,27200000,CDM,272,RC,A4215,HCPCS,,8887-MAIN,LOCAL,,,,,10,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
NEEDLE HYPODERMIC 22GA 1-1/2IN STERILE 305156,27200000,CDM,272,RC,A4215,HCPCS,,8887-MAIN,LOCAL,,,,,10,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.52,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
NEEDLE INTRAOSSEOUS 15GA 15MM EZ-IO PEDS 9018,120.89,CDM,272,RC,A4215,HCPCS,,4964-MAIN,LOCAL,,,,,269,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE INTRAOSSEOUS 15GA 15MM EZ-IO PEDS 9018,120.89,CDM,272,RC,A4215,HCPCS,,4964-MAIN,LOCAL,,,,,269,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE INTRAOSSEOUS 15GA 15MM EZ-IO PEDS 9018,120.89,CDM,272,RC,A4215,HCPCS,,4964-MAIN,LOCAL,,,,,269,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.52,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE INTRAOSSEOUS SET 15GA 25MM STABILIZER EZ-IO 9001P,120.216,CDM,272,RC,A4215,HCPCS,,10648-MAIN,LOCAL,,,,,290,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE INTRAOSSEOUS SET 15GA 25MM STABILIZER EZ-IO 9001P,120.216,CDM,272,RC,A4215,HCPCS,,10648-MAIN,LOCAL,,,,,290,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE INTRAOSSEOUS SET 15GA 25MM STABILIZER EZ-IO 9001P,120.216,CDM,272,RC,A4215,HCPCS,,10648-MAIN,LOCAL,,,,,290,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.52,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE INTRAOSSEOUS SET 15GA 45MM STABILIZER EZ-IO 9079P,120.216,CDM,272,RC,A4215,HCPCS,,10297-MAIN,LOCAL,,,,,290,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE INTRAOSSEOUS SET 15GA 45MM STABILIZER EZ-IO 9079P,120.216,CDM,272,RC,A4215,HCPCS,,10297-MAIN,LOCAL,,,,,290,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE INTRAOSSEOUS SET 15GA 45MM STABILIZER EZ-IO 9079P,120.216,CDM,272,RC,A4215,HCPCS,,10297-MAIN,LOCAL,,,,,290,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.52,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE IV 19GA X .75IN HUBER POWERLOC SAFETY 0651934,120.85,CDM,272,RC,A4215,HCPCS,,12701-MAIN,LOCAL,,,,,38,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE IV 19GA X .75IN HUBER POWERLOC SAFETY 0651934,120.85,CDM,272,RC,A4215,HCPCS,,12701-MAIN,LOCAL,,,,,38,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE IV 19GA X .75IN HUBER POWERLOC SAFETY 0651934,120.85,CDM,272,RC,A4215,HCPCS,,12701-MAIN,LOCAL,,,,,38,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.52,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE IV 19GA X 1 IN HUBER POWERLOC SAFETY 0651910,120.85,CDM,272,RC,A4215,HCPCS,,12702-MAIN,LOCAL,,,,,38,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE IV 19GA X 1 IN HUBER POWERLOC SAFETY 0651910,120.85,CDM,272,RC,A4215,HCPCS,,12702-MAIN,LOCAL,,,,,38,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE IV 19GA X 1 IN HUBER POWERLOC SAFETY 0651910,120.85,CDM,272,RC,A4215,HCPCS,,12702-MAIN,LOCAL,,,,,38,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.52,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE IV 19GA X 1.5 IN HUBER POWERLOC SAFETY 0651915,120.85,CDM,272,RC,A4215,HCPCS,,12703-MAIN,LOCAL,,,,,38,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE IV 19GA X 1.5 IN HUBER POWERLOC SAFETY 0651915,120.85,CDM,272,RC,A4215,HCPCS,,12703-MAIN,LOCAL,,,,,38,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE IV 19GA X 1.5 IN HUBER POWERLOC SAFETY 0651915,120.85,CDM,272,RC,A4215,HCPCS,,12703-MAIN,LOCAL,,,,,38,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.52,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE NON-STIMULATING 22GX2 SONOBLOCK II WITH FACET S TIP 001281-74,120.483,CDM,271,RC,A4215,HCPCS,,11459-MAIN,LOCAL,,,,,41,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE NON-STIMULATING 22GX2 SONOBLOCK II WITH FACET S TIP 001281-74,120.483,CDM,271,RC,A4215,HCPCS,,11459-MAIN,LOCAL,,,,,41,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE NON-STIMULATING 22GX2 SONOBLOCK II WITH FACET S TIP 001281-74,120.483,CDM,271,RC,A4215,HCPCS,,11459-MAIN,LOCAL,,,,,41,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.52,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE SONOPLEX II STIMULATING WITH FACET S TIP 22GX3-1/4,120.483,CDM,271,RC,A4215,HCPCS,,11457-MAIN,LOCAL,,,,,41,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE SONOPLEX II STIMULATING WITH FACET S TIP 22GX3-1/4,120.483,CDM,271,RC,A4215,HCPCS,,11457-MAIN,LOCAL,,,,,41,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE SONOPLEX II STIMULATING WITH FACET S TIP 22GX3-1/4,120.483,CDM,271,RC,A4215,HCPCS,,11457-MAIN,LOCAL,,,,,41,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.52,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE STIMULATING 21GX4  SONOPLEX II  WITH FACET S TIP 001287-77,120.483,CDM,271,RC,A4215,HCPCS,,11458-MAIN,LOCAL,,,,,41,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE STIMULATING 21GX4  SONOPLEX II  WITH FACET S TIP 001287-77,120.483,CDM,271,RC,A4215,HCPCS,,11458-MAIN,LOCAL,,,,,41,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE STIMULATING 21GX4  SONOPLEX II  WITH FACET S TIP 001287-77,120.483,CDM,271,RC,A4215,HCPCS,,11458-MAIN,LOCAL,,,,,41,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.52,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
oxytocin 10 UNIT/ML Solution 1 mL Vial,J2590.01,CDM,636,RC,J2590,HCPCS,,,,42023011625,NDC,1,ML,43.8,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3217,1.57
oxytocin 10 UNIT/ML Solution 1 mL Vial,J2590.01,CDM,636,RC,J2590,HCPCS,,,,42023011625,NDC,1,ML,43.8,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3217,1.57
adenosine 6 MG/2ML Solution 2 mL Syringe,J0153.01,CDM,636,RC,J0153,HCPCS,,,,25021030167,NDC,2,ML,123.1,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.53,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.53,0.6
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143992490,NDC,0.5,EA,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143992490,NDC,0.5,EA,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010110,NDC,0.5,EA,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010110,NDC,0.5,EA,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010167,NDC,0.5,EA,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010167,NDC,0.5,EA,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,44567070725,NDC,0.5,EA,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,44567070725,NDC,0.5,EA,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623100,NDC,1,EA,59.25,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623100,NDC,1,EA,59.25,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623105,NDC,1,EA,59.27,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623105,NDC,1,EA,59.27,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143998391,NDC,1,EA,83.25,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143998391,NDC,1,EA,83.25,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010269,NDC,1,EA,88.69,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010269,NDC,1,EA,88.69,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010299,NDC,1,EA,88.69,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010299,NDC,1,EA,88.69,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
ceFAZolin in D4W 1 g / 50 mL 1-4 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0690.01,CDM,636,RC,J0690,HCPCS,,,,264310311,NDC,1,EA,84.97,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
ceFAZolin in D4W 1 g / 50 mL 1-4 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0690.01,CDM,636,RC,J0690,HCPCS,,,,264310311,NDC,1,EA,84.97,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,517460125,NDC,0.5,ML,58.76,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.54,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48255,0.62
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,781382571,NDC,0.5,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.54,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48255,0.62
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057811,NDC,0.5,ML,30.98,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.54,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48255,0.62
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057841,NDC,0.5,ML,30.98,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.54,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48255,0.62
adenosine 6 MG/2ML Solution 2 mL Syringe,J0153.01,CDM,636,RC,J0153,HCPCS,,,,25021030167,NDC,2,ML,123.1,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.54689,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.53,0.6
adenosine 6 MG/2ML Solution 2 mL Syringe,J0153.01,CDM,636,RC,J0153,HCPCS,,,,25021030167,NDC,2,ML,123.1,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.53,0.6
adenosine 6 MG/2ML Solution 2 mL Syringe,J0153.01,CDM,636,RC,J0153,HCPCS,,,,25021030167,NDC,2,ML,123.1,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.53,0.6
indocyanine green 25 MG Recon Soln 1 Each Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,70100042402,NDC,1,EA,446.07,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.56,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.49,0.912
indocyanine green 25 MG Recon Soln 1 Each Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,70100042402,NDC,1,EA,446.07,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.56,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.49,0.912
methylene blue 1 % Solution 10 mL Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,54288014701,NDC,1,ML,139.25,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.56,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.49,0.912
methylene blue 1 % Solution 10 mL Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,54288014701,NDC,1,ML,139.25,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.56,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.49,0.912
methylene blue 50 MG/10ML Solution 10 mL Ampule,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,517037405,NDC,10,ML,1382.12,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.56,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.49,0.912
methylene blue 50 MG/10ML Solution 10 mL Ampule,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,517037405,NDC,10,ML,1382.12,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.56,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.49,0.912
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028002,NDC,1,ML,40.43,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.57,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.5,0.61123
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028016,NDC,2,ML,41.29,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.57,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.5,0.61123
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028026,NDC,2,ML,41.42,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.57,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.5,0.61123
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,70860030242,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.57,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.5,0.61123
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,36000028425,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.57,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.5,0.61123
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028036,NDC,2,ML,36.12,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.57,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.5,0.61123
medroxyPROGESTERone 150 MG/ML Suspension 1 mL Vial,J1050.01,CDM,636,RC,J1050,HCPCS,,,,67457088799,NDC,1,ML,437.38,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.928
medroxyPROGESTERone 150 MG/ML Suspension 1 mL Vial,J1050.01,CDM,636,RC,J1050,HCPCS,,,,67457088799,NDC,1,ML,437.38,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.928
magnesium sulfate 1 g in 100 ml D5W (premix) 1-5 GM/100ML-% Solution 100 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010802,NDC,100,ML,52.51,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.58,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.58,0.69
magnesium sulfate 4 GM/50ML Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010701,NDC,50,ML,73.72,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.58,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.58,0.69
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006401,NDC,2,ML,31.46,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.58,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.58,0.69
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006403,NDC,2,ML,30.45,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.58,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.58,0.69
magnesium sulfate 50 % Solution 10 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006404,NDC,2,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.58,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.58,0.69
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,409672924,NDC,50,ML,116.43,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.58,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.58,0.69
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010602,NDC,50,ML,126.07,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.58,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.58,0.69
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010605,NDC,50,ML,126.07,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.58,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.58,0.69
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010626,NDC,50,ML,84.47,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.58,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.58,0.69
adenosine 6 MG/2ML Solution 2 mL Syringe,J0153.01,CDM,636,RC,J0153,HCPCS,,,,25021030167,NDC,2,ML,123.1,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.6,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.53,0.6
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062430,NDC,0.3,ML,147.12,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.6,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801301,NDC,0.3,ML,147.12,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.6,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801310,NDC,0.3,ML,147.12,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.6,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714000601,NDC,0.3,ML,53.39,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.6,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062001,NDC,0.4,ML,189.48,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.6,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062040,NDC,0.4,ML,189.48,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.6,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801401,NDC,0.4,ML,189.48,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.6,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801410,NDC,0.4,ML,189.48,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.6,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714001601,NDC,0.4,ML,100.47,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.6,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062160,NDC,0.6,ML,274.53,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.6,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801601,NDC,0.6,ML,274.53,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.6,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801610,NDC,0.6,ML,274.53,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.6,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801801,NDC,0.8,ML,359.37,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.6,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801810,NDC,0.8,ML,359.37,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.6,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802001,NDC,1,ML,444.2,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.6,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802010,NDC,1,ML,444.2,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.6,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802201,NDC,0.8,ML,439.77,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.6,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802210,NDC,0.8,ML,439.77,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.6,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028002,NDC,1,ML,40.43,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.5,0.61123
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028002,NDC,1,ML,40.43,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.5,0.61123
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028016,NDC,2,ML,41.29,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.5,0.61123
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028016,NDC,2,ML,41.29,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.5,0.61123
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028026,NDC,2,ML,41.42,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.5,0.61123
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028026,NDC,2,ML,41.42,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.5,0.61123
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,70860030242,NDC,1,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.5,0.61123
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,70860030242,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.5,0.61123
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,36000028425,NDC,2,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.5,0.61123
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,36000028425,NDC,2,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.5,0.61123
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028036,NDC,2,ML,36.12,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.5,0.61123
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028036,NDC,2,ML,36.12,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.5,0.61123
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062430,NDC,0.3,ML,147.12,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062430,NDC,0.3,ML,147.12,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801301,NDC,0.3,ML,147.12,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801301,NDC,0.3,ML,147.12,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801310,NDC,0.3,ML,147.12,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801310,NDC,0.3,ML,147.12,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714000601,NDC,0.3,ML,53.39,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714000601,NDC,0.3,ML,53.39,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062001,NDC,0.4,ML,189.48,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062001,NDC,0.4,ML,189.48,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062040,NDC,0.4,ML,189.48,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062040,NDC,0.4,ML,189.48,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801401,NDC,0.4,ML,189.48,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801401,NDC,0.4,ML,189.48,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801410,NDC,0.4,ML,189.48,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801410,NDC,0.4,ML,189.48,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714001601,NDC,0.4,ML,100.47,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714001601,NDC,0.4,ML,100.47,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062160,NDC,0.6,ML,274.53,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062160,NDC,0.6,ML,274.53,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801601,NDC,0.6,ML,274.53,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801601,NDC,0.6,ML,274.53,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801610,NDC,0.6,ML,274.53,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801610,NDC,0.6,ML,274.53,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801801,NDC,0.8,ML,359.37,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801801,NDC,0.8,ML,359.37,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801810,NDC,0.8,ML,359.37,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801810,NDC,0.8,ML,359.37,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802001,NDC,1,ML,444.2,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802001,NDC,1,ML,444.2,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802010,NDC,1,ML,444.2,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802010,NDC,1,ML,444.2,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802201,NDC,0.8,ML,439.77,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802201,NDC,0.8,ML,439.77,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802210,NDC,0.8,ML,439.77,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802210,NDC,0.8,ML,439.77,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600701,NDC,10,ML,39.73,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.61123,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,0.67
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600710,NDC,2,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.61123,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,0.67
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062430,NDC,0.3,ML,147.12,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.61123,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801301,NDC,0.3,ML,147.12,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.61123,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801310,NDC,0.3,ML,147.12,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.61123,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714000601,NDC,0.3,ML,53.39,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.61123,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062001,NDC,0.4,ML,189.48,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.61123,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062040,NDC,0.4,ML,189.48,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.61123,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801401,NDC,0.4,ML,189.48,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.61123,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801410,NDC,0.4,ML,189.48,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.61123,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714001601,NDC,0.4,ML,100.47,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.61123,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062160,NDC,0.6,ML,274.53,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.61123,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801601,NDC,0.6,ML,274.53,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.61123,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801610,NDC,0.6,ML,274.53,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.61123,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801801,NDC,0.8,ML,359.37,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.61123,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801810,NDC,0.8,ML,359.37,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.61123,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802001,NDC,1,ML,444.2,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.61123,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802010,NDC,1,ML,444.2,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.61123,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802201,NDC,0.8,ML,439.77,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.61123,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802210,NDC,0.8,ML,439.77,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.61123,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028002,NDC,1,ML,40.43,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.61123,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.5,0.61123
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028016,NDC,2,ML,41.29,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.61123,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.5,0.61123
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028026,NDC,2,ML,41.42,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.61123,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.5,0.61123
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,70860030242,NDC,1,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.61123,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.5,0.61123
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,36000028425,NDC,2,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.61123,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.5,0.61123
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028036,NDC,2,ML,36.12,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.61123,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.5,0.61123
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096321,NDC,30,ML,1231.47,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.62,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.62,0.77208
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096330,NDC,30,ML,1231.47,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.62,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.62,0.77208
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,517460125,NDC,0.5,ML,58.76,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.62,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48255,0.62
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,781382571,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.62,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48255,0.62
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057811,NDC,0.5,ML,30.98,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.62,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48255,0.62
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057841,NDC,0.5,ML,30.98,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.62,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48255,0.62
OSTOMY DRAINABLE POUCH INVISICLOSE 1.75,27200000,CDM,272,RC,A5063,HCPCS,,12071-MAIN,LOCAL,,,,,1.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,0.6231,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
magnesium sulfate 1 g in 100 ml D5W (premix) 1-5 GM/100ML-% Solution 100 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010802,NDC,100,ML,52.51,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.58,0.69
magnesium sulfate 1 g in 100 ml D5W (premix) 1-5 GM/100ML-% Solution 100 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010802,NDC,100,ML,52.51,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.58,0.69
magnesium sulfate 4 GM/50ML Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010701,NDC,50,ML,73.72,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.58,0.69
magnesium sulfate 4 GM/50ML Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010701,NDC,50,ML,73.72,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.58,0.69
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006401,NDC,2,ML,31.46,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.58,0.69
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006401,NDC,2,ML,31.46,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.58,0.69
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006403,NDC,2,ML,30.45,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.58,0.69
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006403,NDC,2,ML,30.45,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.58,0.69
magnesium sulfate 50 % Solution 10 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006404,NDC,2,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.58,0.69
magnesium sulfate 50 % Solution 10 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006404,NDC,2,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.58,0.69
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,409672924,NDC,50,ML,116.43,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.58,0.69
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,409672924,NDC,50,ML,116.43,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.58,0.69
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010602,NDC,50,ML,126.07,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.58,0.69
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010602,NDC,50,ML,126.07,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.58,0.69
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010605,NDC,50,ML,126.07,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.58,0.69
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010605,NDC,50,ML,126.07,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.58,0.69
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010626,NDC,50,ML,84.47,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.58,0.69
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010626,NDC,50,ML,84.47,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.58,0.69
Temporary External Pacing,PX92953F,CDM,480,RC,92953,CPT,,,,,,,,678,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.643,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.43,1.75
caffeine citrate 60 MG/3ML Solution 3 mL Vial,J0706.01,CDM,636,RC,J0706,HCPCS,,,,63323040704,NDC,3,ML,73.84,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.6434,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6434,2.848
magnesium sulfate 1 g in 100 ml D5W (premix) 1-5 GM/100ML-% Solution 100 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010802,NDC,100,ML,52.51,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.6434,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.58,0.69
magnesium sulfate 4 GM/50ML Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010701,NDC,50,ML,73.72,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.6434,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.58,0.69
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006401,NDC,2,ML,31.46,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.6434,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.58,0.69
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006403,NDC,2,ML,30.45,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.6434,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.58,0.69
magnesium sulfate 50 % Solution 10 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006404,NDC,2,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.6434,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.58,0.69
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,409672924,NDC,50,ML,116.43,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.6434,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.58,0.69
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010602,NDC,50,ML,126.07,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.6434,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.58,0.69
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010605,NDC,50,ML,126.07,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.6434,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.58,0.69
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010626,NDC,50,ML,84.47,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.6434,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.58,0.69
OSTOMY DRAINABLE POUCH INVISICLOSE 1.75,27200000,CDM,272,RC,A5063,HCPCS,,12071-MAIN,LOCAL,,,,,1.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,0.6435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,93598627,NDC,1,EA,1241.11,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.65,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,115169449,NDC,1,EA,889.46,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.65,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010202,NDC,1,EA,680,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.65,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54505010202,NDC,1,EA,889.46,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.65,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 1 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010101,NDC,1,EA,680,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.65,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010102,NDC,1,EA,680,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.65,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502050102,NDC,1,EA,1305.38,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.65,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409492120,NDC,10,ML,54.66,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.65,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409493311,NDC,10,ML,66.06,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.65,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331601,NDC,10,ML,77.86,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.65,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331801,NDC,10,ML,102.65,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.65,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015901,NDC,0.3,ML,45.69,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.65,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015925,NDC,0.3,ML,45.69,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.65,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 30 MG/30ML Solution 30 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023016801,NDC,0.3,ML,32.24,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.65,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010301,NDC,0.3,ML,45.04,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.65,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010310,NDC,1,ML,103.48,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.65,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,25021019110,NDC,1,EA,809.89,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.66,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.66,0.76
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,63323072902,NDC,1,EA,265.95,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.66,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.66,0.76
SPONGE XRAY DETECTABLE PEANUT MDS72038,27200000,CDM,272,RC,,,,10915-MAIN,LOCAL,,,,,0.79,,First Health,Commercial,both,85,,999999999,percent of total billed charges,0.6681,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600701,NDC,10,ML,39.73,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.67,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,0.67
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600710,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.67,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,0.67
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016200,NDC,1,ML,52.22,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.67557,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016216,NDC,1,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.67557,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016243,NDC,0.5,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.67557,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072201,NDC,0.5,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.67557,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072225,NDC,0.5,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.67557,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016226,NDC,0.5,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.67557,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016245,NDC,0.5,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.67557,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011901,NDC,0.5,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.67557,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011925,NDC,0.5,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.67557,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072501,NDC,0.5,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.67557,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072525,NDC,0.5,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.67557,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,25021019110,NDC,1,EA,809.89,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.67557,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.66,0.76
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,63323072902,NDC,1,EA,265.95,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.67557,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.66,0.76
DOPamine 1600 mcg/mL in dextrose 5% 250 mL premix 1600 mcg/mL Solution 250 mL Plas Cont,J1265.01,CDM,636,RC,J1265,HCPCS,,,,338100702,NDC,250,ML,99.9,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.68,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.68,0.81
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062430,NDC,0.3,ML,147.12,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.68,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801301,NDC,0.3,ML,147.12,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.68,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801310,NDC,0.3,ML,147.12,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.68,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714000601,NDC,0.3,ML,53.39,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.68,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062001,NDC,0.4,ML,189.48,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.68,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062040,NDC,0.4,ML,189.48,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.68,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801401,NDC,0.4,ML,189.48,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.68,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801410,NDC,0.4,ML,189.48,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.68,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714001601,NDC,0.4,ML,100.47,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.68,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062160,NDC,0.6,ML,274.53,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.68,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801601,NDC,0.6,ML,274.53,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.68,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801610,NDC,0.6,ML,274.53,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.68,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801801,NDC,0.8,ML,359.37,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.68,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801810,NDC,0.8,ML,359.37,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.68,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802001,NDC,1,ML,444.2,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.68,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802010,NDC,1,ML,444.2,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.68,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802201,NDC,0.8,ML,439.77,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.68,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802210,NDC,0.8,ML,439.77,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.68,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6,0.68
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052083,NDC,1,EA,92.81,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.68,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.68,0.82
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052084,NDC,1,EA,92.46,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.68,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.68,0.82
magnesium sulfate 1 g in 100 ml D5W (premix) 1-5 GM/100ML-% Solution 100 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010802,NDC,100,ML,52.51,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.69,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.58,0.69
magnesium sulfate 4 GM/50ML Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010701,NDC,50,ML,73.72,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.69,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.58,0.69
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006401,NDC,2,ML,31.46,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.69,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.58,0.69
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006403,NDC,2,ML,30.45,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.69,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.58,0.69
magnesium sulfate 50 % Solution 10 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006404,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.69,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.58,0.69
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,409672924,NDC,50,ML,116.43,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.69,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.58,0.69
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010602,NDC,50,ML,126.07,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.69,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.58,0.69
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010605,NDC,50,ML,126.07,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.69,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.58,0.69
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010626,NDC,50,ML,84.47,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.69,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.58,0.69
SPONGE XRAY DETECTABLE PEANUT MDS72038,27200000,CDM,272,RC,,,,10915-MAIN,LOCAL,,,,,0.79,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,0.693252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SPONGE XRAY DETECTABLE PEANUT MDS72038,27200000,CDM,272,RC,,,,10915-MAIN,LOCAL,,,,,0.79,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,0.69954,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096321,NDC,30,ML,1231.47,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.7,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.62,0.77208
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096330,NDC,30,ML,1231.47,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.7,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.62,0.77208
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,641037621,NDC,0.25,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.7,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.7,0.82
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066416,NDC,1,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.7,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.7,0.82
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066441,NDC,0.25,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.7,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.7,0.82
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010101,NDC,0.25,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.7,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.7,0.82
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010125,NDC,1,ML,30.58,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.7,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.7,0.82
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016200,NDC,1,ML,52.22,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016200,NDC,1,ML,52.22,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016216,NDC,1,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016216,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016243,NDC,0.5,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016243,NDC,0.5,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072201,NDC,0.5,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072201,NDC,0.5,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072225,NDC,0.5,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072225,NDC,0.5,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016226,NDC,0.5,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016226,NDC,0.5,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016245,NDC,0.5,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016245,NDC,0.5,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011901,NDC,0.5,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011901,NDC,0.5,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011925,NDC,0.5,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011925,NDC,0.5,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072501,NDC,0.5,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072501,NDC,0.5,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072525,NDC,0.5,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072525,NDC,0.5,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.42,0.7
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,25021019110,NDC,1,EA,809.89,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.66,0.76
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,25021019110,NDC,1,EA,809.89,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.66,0.76
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,63323072902,NDC,1,EA,265.95,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.66,0.76
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,63323072902,NDC,1,EA,265.95,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.66,0.76
SPONGE XRAY DETECTABLE PEANUT MDS72038,27200000,CDM,272,RC,,,,10915-MAIN,LOCAL,,,,,0.79,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,0.716046,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,703903201,NDC,2,ML,44.46,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.72,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.72,0.86
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,23155029031,NDC,2,ML,98.99,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.72,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.72,0.86
OSTOMY DRAINABLE POUCH INVISICLOSE 1.75,27200000,CDM,272,RC,A5063,HCPCS,,12071-MAIN,LOCAL,,,,,1.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,0.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
OSTOMY DRAINABLE POUCH INVISICLOSE 1.75,27200000,CDM,272,RC,A5063,HCPCS,,12071-MAIN,LOCAL,,,,,1.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,0.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
OSTOMY DRAINABLE POUCH INVISICLOSE 1.75,27200000,CDM,272,RC,A5063,HCPCS,,12071-MAIN,LOCAL,,,,,1.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,0.735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
OSTOMY DRAINABLE POUCH INVISICLOSE 1.75,27200000,CDM,272,RC,A5063,HCPCS,,12071-MAIN,LOCAL,,,,,1.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,0.735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
OSTOMY DRAINABLE POUCH INVISICLOSE 1.75,27200000,CDM,272,RC,A5063,HCPCS,,12071-MAIN,LOCAL,,,,,1.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,0.735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,55111069407,NDC,5,ML,592.4,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.74,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.74,1.19
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,60505619301,NDC,5,ML,821.36,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.74,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.74,1.19
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,63323067305,NDC,5,ML,1029.71,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.74,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.74,1.19
OSTOMY DRAINABLE POUCH INVISICLOSE 1.75,27200000,CDM,272,RC,A5063,HCPCS,,12071-MAIN,LOCAL,,,,,1.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,0.7425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,93598627,NDC,1,EA,1241.11,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.75,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,115169449,NDC,1,EA,889.46,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.75,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010202,NDC,1,EA,680,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.75,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54505010202,NDC,1,EA,889.46,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.75,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 1 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010101,NDC,1,EA,680,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.75,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010102,NDC,1,EA,680,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.75,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502050102,NDC,1,EA,1305.38,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.75,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409492120,NDC,10,ML,54.66,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.75,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409493311,NDC,10,ML,66.06,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.75,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331601,NDC,10,ML,77.86,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.75,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331801,NDC,10,ML,102.65,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.75,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015901,NDC,0.3,ML,45.69,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.75,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015925,NDC,0.3,ML,45.69,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.75,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 30 MG/30ML Solution 30 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023016801,NDC,0.3,ML,32.24,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.75,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010301,NDC,0.3,ML,45.04,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.75,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010310,NDC,1,ML,103.48,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.75,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092401,NDC,0.5,ML,820.88,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.75,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.75,0.99
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092410,NDC,0.5,ML,820.89,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.75,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.75,0.99
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092491,NDC,0.5,ML,820.88,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.75,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.75,0.99
filgrastim 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513020991,NDC,0.5,ML,1228.49,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.75,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.75,0.99
OSTOMY DRAINABLE POUCH INVISICLOSE 1.75,27200000,CDM,272,RC,A5063,HCPCS,,12071-MAIN,LOCAL,,,,,1.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,0.759,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143992490,NDC,0.5,EA,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.76,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010110,NDC,0.5,EA,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.76,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010167,NDC,0.5,EA,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.76,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,44567070725,NDC,0.5,EA,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.76,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623100,NDC,1,EA,59.25,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.76,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623105,NDC,1,EA,59.27,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.76,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143998391,NDC,1,EA,83.25,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.76,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010269,NDC,1,EA,88.69,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.76,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010299,NDC,1,EA,88.69,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.76,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
ceFAZolin in D4W 1 g / 50 mL 1-4 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0690.01,CDM,636,RC,J0690,HCPCS,,,,264310311,NDC,1,EA,84.97,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.76,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,25021019110,NDC,1,EA,809.89,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.76,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.66,0.76
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,63323072902,NDC,1,EA,265.95,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.76,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.66,0.76
SPONGE XRAY DETECTABLE PEANUT MDS72038,27200000,CDM,272,RC,,,,10915-MAIN,LOCAL,,,,,0.79,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,0.7650138,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096321,NDC,30,ML,1231.47,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.77,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.62,0.77208
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096321,NDC,30,ML,1231.47,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.77,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.62,0.77208
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096330,NDC,30,ML,1231.47,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.77,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.62,0.77208
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096330,NDC,30,ML,1231.47,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.77,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.62,0.77208
DOPamine 1600 mcg/mL in dextrose 5% 250 mL premix 1600 mcg/mL Solution 250 mL Plas Cont,J1265.01,CDM,636,RC,J1265,HCPCS,,,,338100702,NDC,250,ML,99.9,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.77,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.68,0.81
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052083,NDC,1,EA,92.81,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.77,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.68,0.82
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052084,NDC,1,EA,92.46,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.77,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.68,0.82
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092821,NDC,1,ML,32.23,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.77,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.77,3.59
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092825,NDC,1,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.77,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.77,3.59
SPONGE XRAY DETECTABLE PEANUT MDS72038,27200000,CDM,272,RC,,,,10915-MAIN,LOCAL,,,,,0.79,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,0.77028,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096321,NDC,30,ML,1231.47,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.77208,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.62,0.77208
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096330,NDC,30,ML,1231.47,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.77208,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.62,0.77208
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092401,NDC,0.5,ML,820.88,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,0.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092410,NDC,0.5,ML,820.89,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,0.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092491,NDC,0.5,ML,820.88,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,0.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
filgrastim 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513020991,NDC,0.5,ML,1228.49,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,0.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073916,NDC,2,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.79,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073941,NDC,1,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.79,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,67457043300,NDC,1,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.79,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
insulin aspart 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169633910,NDC,3,ML,659.76,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.79,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
insulin aspart prot & aspart 70-30 (70-30) 100 UNIT/ML Suspension Pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169369619,NDC,3,ML,629.28,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.79,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221901,NDC,3,ML,506.9,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.79,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221905,NDC,3,ML,506.9,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.79,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2021301,NDC,3,ML,44.46,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.79,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821517,NDC,3,ML,275.33,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.79,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
insulin regular 100 UNIT/ML Solution 10 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821501,NDC,10,ML,307.46,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.79,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013266,NDC,50,ML,59.67,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.79,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,0.96
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004624,NDC,50,ML,50.58,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.79,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,0.96
levoFLOXacin in dextrose 5% 500 MG/100ML Solution 100 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004724,NDC,100,ML,64.63,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.79,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,0.96
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013268,NDC,150,ML,59.67,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.79,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,0.96
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004824,NDC,150,ML,69.59,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.79,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,0.96
sodium thiosulfate 250 MG/ML Solution 50 mL Vial,J0209.01,CDM,636,RC,J0209,HCPCS,,,,60267070550,NDC,50,ML,609.57,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.79,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,0.79
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,641037621,NDC,0.25,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.8,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.7,0.82
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066416,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.8,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.7,0.82
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066441,NDC,0.25,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.8,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.7,0.82
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010101,NDC,0.25,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.8,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.7,0.82
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010125,NDC,1,ML,30.58,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.8,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.7,0.82
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143992490,NDC,0.5,EA,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.80425,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010110,NDC,0.5,EA,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.80425,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010167,NDC,0.5,EA,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.80425,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,44567070725,NDC,0.5,EA,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.80425,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623100,NDC,1,EA,59.25,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.80425,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623105,NDC,1,EA,59.27,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.80425,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143998391,NDC,1,EA,83.25,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.80425,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010269,NDC,1,EA,88.69,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.80425,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010299,NDC,1,EA,88.69,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.80425,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
ceFAZolin in D4W 1 g / 50 mL 1-4 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0690.01,CDM,636,RC,J0690,HCPCS,,,,264310311,NDC,1,EA,84.97,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.80425,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.48,0.80425
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,641037621,NDC,0.25,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.80425,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.7,0.82
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066416,NDC,1,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.80425,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.7,0.82
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066441,NDC,0.25,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.80425,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.7,0.82
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010101,NDC,0.25,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.80425,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.7,0.82
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010125,NDC,1,ML,30.58,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.80425,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.7,0.82
DOPamine 1600 mcg/mL in dextrose 5% 250 mL premix 1600 mcg/mL Solution 250 mL Plas Cont,J1265.01,CDM,636,RC,J1265,HCPCS,,,,338100702,NDC,250,ML,99.9,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.80425,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.68,0.81
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,93598627,NDC,1,EA,1241.11,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.80425,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,115169449,NDC,1,EA,889.46,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.80425,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010202,NDC,1,EA,680,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.80425,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54505010202,NDC,1,EA,889.46,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.80425,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 1 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010101,NDC,1,EA,680,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.80425,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010102,NDC,1,EA,680,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.80425,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502050102,NDC,1,EA,1305.38,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.80425,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409492120,NDC,10,ML,54.66,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.80425,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409493311,NDC,10,ML,66.06,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.80425,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331601,NDC,10,ML,77.86,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.80425,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331801,NDC,10,ML,102.65,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.80425,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015901,NDC,0.3,ML,45.69,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.80425,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015925,NDC,0.3,ML,45.69,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.80425,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 30 MG/30ML Solution 30 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023016801,NDC,0.3,ML,32.24,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.80425,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010301,NDC,0.3,ML,45.04,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.80425,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010310,NDC,1,ML,103.48,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.80425,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052083,NDC,1,EA,92.81,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.80425,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.68,0.82
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052084,NDC,1,EA,92.46,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.80425,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.68,0.82
DOPamine 1600 mcg/mL in dextrose 5% 250 mL premix 1600 mcg/mL Solution 250 mL Plas Cont,J1265.01,CDM,636,RC,J1265,HCPCS,,,,338100702,NDC,250,ML,99.9,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.68,0.81
DOPamine 1600 mcg/mL in dextrose 5% 250 mL premix 1600 mcg/mL Solution 250 mL Plas Cont,J1265.01,CDM,636,RC,J1265,HCPCS,,,,338100702,NDC,250,ML,99.9,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.68,0.81
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,93598627,NDC,1,EA,1241.11,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,93598627,NDC,1,EA,1241.11,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,115169449,NDC,1,EA,889.46,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,115169449,NDC,1,EA,889.46,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010202,NDC,1,EA,680,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010202,NDC,1,EA,680,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54505010202,NDC,1,EA,889.46,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54505010202,NDC,1,EA,889.46,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 1 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010101,NDC,1,EA,680,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 1 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010101,NDC,1,EA,680,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010102,NDC,1,EA,680,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010102,NDC,1,EA,680,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502050102,NDC,1,EA,1305.38,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502050102,NDC,1,EA,1305.38,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409492120,NDC,10,ML,54.66,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409492120,NDC,10,ML,54.66,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409493311,NDC,10,ML,66.06,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409493311,NDC,10,ML,66.06,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331601,NDC,10,ML,77.86,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331601,NDC,10,ML,77.86,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331801,NDC,10,ML,102.65,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331801,NDC,10,ML,102.65,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015901,NDC,0.3,ML,45.69,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015901,NDC,0.3,ML,45.69,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015925,NDC,0.3,ML,45.69,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015925,NDC,0.3,ML,45.69,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 30 MG/30ML Solution 30 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023016801,NDC,0.3,ML,32.24,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine 30 MG/30ML Solution 30 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023016801,NDC,0.3,ML,32.24,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010301,NDC,0.3,ML,45.04,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010301,NDC,0.3,ML,45.04,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010310,NDC,1,ML,103.48,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010310,NDC,1,ML,103.48,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.65,0.81
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,641037621,NDC,0.25,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.7,0.82
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,641037621,NDC,0.25,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.7,0.82
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066416,NDC,1,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.7,0.82
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066416,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.7,0.82
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066441,NDC,0.25,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.7,0.82
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066441,NDC,0.25,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.7,0.82
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010101,NDC,0.25,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.7,0.82
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010101,NDC,0.25,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.7,0.82
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010125,NDC,1,ML,30.58,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.7,0.82
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010125,NDC,1,ML,30.58,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.7,0.82
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052083,NDC,1,EA,92.81,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.68,0.82
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052083,NDC,1,EA,92.81,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.68,0.82
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052084,NDC,1,EA,92.46,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.68,0.82
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052084,NDC,1,EA,92.46,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.68,0.82
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,703903201,NDC,2,ML,44.46,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.83,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.72,0.86
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,23155029031,NDC,2,ML,98.99,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.83,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.72,0.86
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073916,NDC,2,ML,30,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,0.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,29.4
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073941,NDC,1,ML,30,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,0.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,29.4
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,67457043300,NDC,1,ML,30,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,0.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,29.4
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,517095501,NDC,0.25,EA,69.19,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.83,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,0.95
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781315972,NDC,1,EA,217.96,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.83,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,0.95
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781910572,NDC,0.25,EA,69.49,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.83,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,0.95
triamcinolone acetonide 10 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3049420,NDC,0.25,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.83,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,1.08
triamcinolone acetonide 40 MG/ML Suspension 1 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029305,NDC,1,ML,73.57,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.83,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,1.08
triamcinolone acetonide 40 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029320,NDC,1,ML,72.65,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.83,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,1.08
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,703903201,NDC,2,ML,44.46,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.83642,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.72,0.86
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,23155029031,NDC,2,ML,98.99,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.83642,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.72,0.86
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.84,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.84,0.99
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909422,NDC,2,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.84,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.84,0.99
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.84,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.84,0.99
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.84,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.84,0.99
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.84,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.84,0.99
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.84,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.84,0.99
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.84,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.84,0.99
NEEDLE ECHOGENIC 21G 110MM SONOTAP II WITH FACET TIP 1285-3F110,120.483,CDM,271,RC,A4215,HCPCS,,12201-MAIN,LOCAL,,,,,41,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.848,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE ECHOGENIC 21G 110MM SONOTAP II WITH FACET TIP 1285-3F110,120.483,CDM,271,RC,A4215,HCPCS,,12201-MAIN,LOCAL,,,,,41,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.848,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE ECHOGENIC 21G X 4IN (100MM) SONOBLOCK II NERVE BLOCK WITH FACET S TIP 001281-77,120.483,CDM,271,RC,A4215,HCPCS,,12761-MAIN,LOCAL,,,,,41,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.848,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE ECHOGENIC 21G X 4IN (100MM) SONOBLOCK II NERVE BLOCK WITH FACET S TIP 001281-77,120.483,CDM,271,RC,A4215,HCPCS,,12761-MAIN,LOCAL,,,,,41,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.848,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE ECHOGENIC 22G 80MM SONOTAP II WITH FACET TIP 1285-3E080,120.483,CDM,271,RC,A4215,HCPCS,,12103-MAIN,LOCAL,,,,,41,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.848,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE ECHOGENIC 22G 80MM SONOTAP II WITH FACET TIP 1285-3E080,120.483,CDM,271,RC,A4215,HCPCS,,12103-MAIN,LOCAL,,,,,41,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.848,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE ECHOGENIC 22G X 3.25IN (80MM) SONOBLOCK II  NERVE BLOCK WITH FACET S TIP 001281-71,120.483,CDM,271,RC,A4215,HCPCS,,12760-MAIN,LOCAL,,,,,41,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.848,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE ECHOGENIC 22G X 3.25IN (80MM) SONOBLOCK II  NERVE BLOCK WITH FACET S TIP 001281-71,120.483,CDM,271,RC,A4215,HCPCS,,12760-MAIN,LOCAL,,,,,41,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.848,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE ECHOGENIC 22GX2 SONOPLEX II WITH FACET S TIP 001287-74,120.483,CDM,271,RC,A4215,HCPCS,,13110-MAIN,LOCAL,,,,,41,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.848,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE ECHOGENIC 22GX2 SONOPLEX II WITH FACET S TIP 001287-74,120.483,CDM,271,RC,A4215,HCPCS,,13110-MAIN,LOCAL,,,,,41,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.848,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE HYPODERMIC 22GA 1-1/2IN STERILE 305156,27200000,CDM,272,RC,A4215,HCPCS,,8887-MAIN,LOCAL,,,,,10,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.848,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
NEEDLE HYPODERMIC 22GA 1-1/2IN STERILE 305156,27200000,CDM,272,RC,A4215,HCPCS,,8887-MAIN,LOCAL,,,,,10,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.848,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
NEEDLE INTRAOSSEOUS 15GA 15MM EZ-IO PEDS 9018,120.89,CDM,272,RC,A4215,HCPCS,,4964-MAIN,LOCAL,,,,,269,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.848,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE INTRAOSSEOUS 15GA 15MM EZ-IO PEDS 9018,120.89,CDM,272,RC,A4215,HCPCS,,4964-MAIN,LOCAL,,,,,269,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.848,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE INTRAOSSEOUS SET 15GA 25MM STABILIZER EZ-IO 9001P,120.216,CDM,272,RC,A4215,HCPCS,,10648-MAIN,LOCAL,,,,,290,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.848,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE INTRAOSSEOUS SET 15GA 25MM STABILIZER EZ-IO 9001P,120.216,CDM,272,RC,A4215,HCPCS,,10648-MAIN,LOCAL,,,,,290,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.848,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE INTRAOSSEOUS SET 15GA 45MM STABILIZER EZ-IO 9079P,120.216,CDM,272,RC,A4215,HCPCS,,10297-MAIN,LOCAL,,,,,290,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.848,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE INTRAOSSEOUS SET 15GA 45MM STABILIZER EZ-IO 9079P,120.216,CDM,272,RC,A4215,HCPCS,,10297-MAIN,LOCAL,,,,,290,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.848,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE IV 19GA X .75IN HUBER POWERLOC SAFETY 0651934,120.85,CDM,272,RC,A4215,HCPCS,,12701-MAIN,LOCAL,,,,,38,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.848,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE IV 19GA X .75IN HUBER POWERLOC SAFETY 0651934,120.85,CDM,272,RC,A4215,HCPCS,,12701-MAIN,LOCAL,,,,,38,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.848,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE IV 19GA X 1 IN HUBER POWERLOC SAFETY 0651910,120.85,CDM,272,RC,A4215,HCPCS,,12702-MAIN,LOCAL,,,,,38,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.848,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE IV 19GA X 1 IN HUBER POWERLOC SAFETY 0651910,120.85,CDM,272,RC,A4215,HCPCS,,12702-MAIN,LOCAL,,,,,38,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.848,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE IV 19GA X 1.5 IN HUBER POWERLOC SAFETY 0651915,120.85,CDM,272,RC,A4215,HCPCS,,12703-MAIN,LOCAL,,,,,38,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.848,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE IV 19GA X 1.5 IN HUBER POWERLOC SAFETY 0651915,120.85,CDM,272,RC,A4215,HCPCS,,12703-MAIN,LOCAL,,,,,38,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.848,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE NON-STIMULATING 22GX2 SONOBLOCK II WITH FACET S TIP 001281-74,120.483,CDM,271,RC,A4215,HCPCS,,11459-MAIN,LOCAL,,,,,41,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.848,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE NON-STIMULATING 22GX2 SONOBLOCK II WITH FACET S TIP 001281-74,120.483,CDM,271,RC,A4215,HCPCS,,11459-MAIN,LOCAL,,,,,41,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.848,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE SONOPLEX II STIMULATING WITH FACET S TIP 22GX3-1/4,120.483,CDM,271,RC,A4215,HCPCS,,11457-MAIN,LOCAL,,,,,41,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.848,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE SONOPLEX II STIMULATING WITH FACET S TIP 22GX3-1/4,120.483,CDM,271,RC,A4215,HCPCS,,11457-MAIN,LOCAL,,,,,41,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.848,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE STIMULATING 21GX4  SONOPLEX II  WITH FACET S TIP 001287-77,120.483,CDM,271,RC,A4215,HCPCS,,11458-MAIN,LOCAL,,,,,41,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.848,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
NEEDLE STIMULATING 21GX4  SONOPLEX II  WITH FACET S TIP 001287-77,120.483,CDM,271,RC,A4215,HCPCS,,11458-MAIN,LOCAL,,,,,41,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.848,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.848
oxytocin 10 UNIT/ML Solution 1 mL Vial,J2590.01,CDM,636,RC,J2590,HCPCS,,,,42023011625,NDC,1,ML,43.8,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.848,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3217,1.57
oxytocin 10 UNIT/ML Solution 1 mL Vial,J2590.01,CDM,636,RC,J2590,HCPCS,,,,42023011625,NDC,1,ML,43.8,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.848,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3217,1.57
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092401,NDC,0.5,ML,820.88,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.75,0.99
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092401,NDC,0.5,ML,820.88,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.75,0.99
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092410,NDC,0.5,ML,820.89,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.75,0.99
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092410,NDC,0.5,ML,820.89,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.75,0.99
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092491,NDC,0.5,ML,820.88,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.75,0.99
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092491,NDC,0.5,ML,820.88,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.75,0.99
filgrastim 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513020991,NDC,0.5,ML,1228.49,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.75,0.99
filgrastim 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513020991,NDC,0.5,ML,1228.49,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.75,0.99
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,55111069407,NDC,5,ML,592.4,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.85,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.74,1.19
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,60505619301,NDC,5,ML,821.36,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.85,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.74,1.19
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,63323067305,NDC,5,ML,1029.71,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.85,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.74,1.19
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,703903201,NDC,2,ML,44.46,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.86,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.72,0.86
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,703903201,NDC,2,ML,44.46,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.86,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.72,0.86
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,23155029031,NDC,2,ML,98.99,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.86,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.72,0.86
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,23155029031,NDC,2,ML,98.99,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.86,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.72,0.86
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,517095501,NDC,0.25,EA,69.19,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,0.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86,213.6008
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781315972,NDC,1,EA,217.96,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,0.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86,213.6008
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781910572,NDC,0.25,EA,69.49,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,0.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86,213.6008
DOCEtaxel 20 MG/ML Concentrate 1 mL Vial,63600000,CDM,636,RC,J9171,HCPCS,,,,955102001,NDC,1,ML,1690.09,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.86859,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.39,1.04
DOCEtaxel 160 MG/16ML Solution 16 mL Vial,J9171.01,CDM,636,RC,J9171,HCPCS,,,,409173201,NDC,16,ML,2901.69,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.86859,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86859,1.04
DOCEtaxel 20 MG/ML Concentrate 1 mL Vial,63600000,CDM,636,RC,J9171,HCPCS,,,,955102001,NDC,1,ML,1690.09,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.39,1.04
DOCEtaxel 20 MG/ML Concentrate 1 mL Vial,63600000,CDM,636,RC,J9171,HCPCS,,,,955102001,NDC,1,ML,1690.09,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.39,1.04
DOCEtaxel 160 MG/16ML Solution 16 mL Vial,J9171.01,CDM,636,RC,J9171,HCPCS,,,,409173201,NDC,16,ML,2901.69,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86859,1.04
DOCEtaxel 160 MG/16ML Solution 16 mL Vial,J9171.01,CDM,636,RC,J9171,HCPCS,,,,409173201,NDC,16,ML,2901.69,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86859,1.04
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092821,NDC,1,ML,32.23,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.77,3.59
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092821,NDC,1,ML,32.23,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.77,3.59
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092825,NDC,1,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.77,3.59
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092825,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.77,3.59
DOCEtaxel 20 MG/ML Concentrate 1 mL Vial,63600000,CDM,636,RC,J9171,HCPCS,,,,955102001,NDC,1,ML,1690.09,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.87,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.39,1.04
DOCEtaxel 160 MG/16ML Solution 16 mL Vial,J9171.01,CDM,636,RC,J9171,HCPCS,,,,409173201,NDC,16,ML,2901.69,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.87,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86859,1.04
Etoposide 100 MG/5ML Solution 5 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,16729011431,NDC,5,ML,43.21,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.87,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.87,1.04
etoposide 500 MG/25ML Solution 25 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,703565601,NDC,25,ML,173.28,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.87,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.87,1.04
BANDAGE COBAN  4 IN 2 LAYER COMPRESSION SYSTEM  2094N,120.549,CDM,272,RC,A6441,HCPCS,,12366-MAIN,LOCAL,,,,,32,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.88,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.88,0.9651
BANDAGE COBAN LITE 4 IN 2 LAYER COMPRESSION SYSTEM 2794N,120.549,CDM,272,RC,A6441,HCPCS,,12922-MAIN,LOCAL,,,,,32,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.88,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.88,0.9651
ampicillin 1 GM Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781926185,NDC,0.5,EA,43.18,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.89,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.89,1.01
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927380,NDC,1,EA,99.91,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.89,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.89,1.01
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927395,NDC,1,EA,99.91,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.89,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.89,1.01
ampicillin 500 MG Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781925078,NDC,1,EA,44.28,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.89,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.89,1.01
SYRINGE BULB 60ML IRRIGATION STERILE DYND20125,27200000,CDM,272,RC,A4322,HCPCS,,10829-MAIN,LOCAL,,,,,2.16,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,0.897264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073916,NDC,2,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073916,NDC,2,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073941,NDC,1,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073941,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,67457043300,NDC,1,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,67457043300,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
insulin aspart 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169633910,NDC,3,ML,659.76,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.9,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
insulin aspart 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169633910,NDC,3,ML,659.76,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
insulin aspart 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169633910,NDC,3,ML,659.76,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
insulin aspart prot & aspart 70-30 (70-30) 100 UNIT/ML Suspension Pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169369619,NDC,3,ML,629.28,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.9,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
insulin aspart prot & aspart 70-30 (70-30) 100 UNIT/ML Suspension Pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169369619,NDC,3,ML,629.28,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
insulin aspart prot & aspart 70-30 (70-30) 100 UNIT/ML Suspension Pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169369619,NDC,3,ML,629.28,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221901,NDC,3,ML,506.9,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.9,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221901,NDC,3,ML,506.9,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221901,NDC,3,ML,506.9,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221905,NDC,3,ML,506.9,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.9,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221905,NDC,3,ML,506.9,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221905,NDC,3,ML,506.9,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2021301,NDC,3,ML,44.46,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.9,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2021301,NDC,3,ML,44.46,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2021301,NDC,3,ML,44.46,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821517,NDC,3,ML,275.33,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.9,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821517,NDC,3,ML,275.33,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821517,NDC,3,ML,275.33,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
insulin regular 100 UNIT/ML Solution 10 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821501,NDC,10,ML,307.46,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.9,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
insulin regular 100 UNIT/ML Solution 10 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821501,NDC,10,ML,307.46,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
insulin regular 100 UNIT/ML Solution 10 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821501,NDC,10,ML,307.46,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781324494,NDC,1,EA,1400.9,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.90076,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.90076,0.92
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,16714085701,NDC,1,EA,1403.5,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.90076,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.90076,0.92
cycloPHOSphamide 2 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,10019095701,NDC,1,EA,2988.6,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.90076,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.90076,0.92
cycloPHOSphamide 500 MG Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781323394,NDC,1,EA,1565.71,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.90076,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.90076,0.92
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781324494,NDC,1,EA,1400.9,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.90076,0.92
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781324494,NDC,1,EA,1400.9,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.90076,0.92
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,16714085701,NDC,1,EA,1403.5,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.90076,0.92
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,16714085701,NDC,1,EA,1403.5,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.90076,0.92
cycloPHOSphamide 2 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,10019095701,NDC,1,EA,2988.6,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.90076,0.92
cycloPHOSphamide 2 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,10019095701,NDC,1,EA,2988.6,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.90076,0.92
cycloPHOSphamide 500 MG Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781323394,NDC,1,EA,1565.71,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.90076,0.92
cycloPHOSphamide 500 MG Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781323394,NDC,1,EA,1565.71,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.90076,0.92
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073916,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.91,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073941,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.91,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,67457043300,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.91,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013266,NDC,50,ML,59.67,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.91,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,0.96
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004624,NDC,50,ML,50.58,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.91,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,0.96
levoFLOXacin in dextrose 5% 500 MG/100ML Solution 100 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004724,NDC,100,ML,64.63,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.91,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,0.96
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013268,NDC,150,ML,59.67,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.91,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,0.96
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004824,NDC,150,ML,69.59,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.91,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,0.96
indocyanine green 25 MG Recon Soln 1 Each Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,70100042402,NDC,1,EA,446.07,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.912,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.49,0.912
indocyanine green 25 MG Recon Soln 1 Each Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,70100042402,NDC,1,EA,446.07,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.912,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.49,0.912
methylene blue 1 % Solution 10 mL Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,54288014701,NDC,1,ML,139.25,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.912,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.49,0.912
methylene blue 1 % Solution 10 mL Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,54288014701,NDC,1,ML,139.25,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.912,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.49,0.912
methylene blue 50 MG/10ML Solution 10 mL Ampule,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,517037405,NDC,10,ML,1382.12,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.912,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.49,0.912
methylene blue 50 MG/10ML Solution 10 mL Ampule,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,517037405,NDC,10,ML,1382.12,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.912,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.49,0.912
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781324494,NDC,1,EA,1400.9,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.92,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.90076,0.92
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,16714085701,NDC,1,EA,1403.5,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.92,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.90076,0.92
cycloPHOSphamide 2 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,10019095701,NDC,1,EA,2988.6,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.92,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.90076,0.92
cycloPHOSphamide 500 MG Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781323394,NDC,1,EA,1565.71,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.92,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.90076,0.92
SYRINGE BULB 60ML IRRIGATION STERILE DYND20125,27200000,CDM,272,RC,A4322,HCPCS,,10829-MAIN,LOCAL,,,,,2.16,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,0.92664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
medroxyPROGESTERone 150 MG/ML Suspension 1 mL Vial,J1050.01,CDM,636,RC,J1050,HCPCS,,,,67457088799,NDC,1,ML,437.38,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.928,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.928
medroxyPROGESTERone 150 MG/ML Suspension 1 mL Vial,J1050.01,CDM,636,RC,J1050,HCPCS,,,,67457088799,NDC,1,ML,437.38,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,0.928,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.36,0.928
BANDAGE COBAN  4 IN 2 LAYER COMPRESSION SYSTEM  2094N,120.549,CDM,272,RC,A6441,HCPCS,,12366-MAIN,LOCAL,,,,,32,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.88,0.9651
BANDAGE COBAN  4 IN 2 LAYER COMPRESSION SYSTEM  2094N,120.549,CDM,272,RC,A6441,HCPCS,,12366-MAIN,LOCAL,,,,,32,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.88,0.9651
BANDAGE COBAN  4 IN 2 LAYER COMPRESSION SYSTEM  2094N,120.549,CDM,272,RC,A6441,HCPCS,,12366-MAIN,LOCAL,,,,,32,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.93,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.88,0.9651
BANDAGE COBAN LITE 4 IN 2 LAYER COMPRESSION SYSTEM 2794N,120.549,CDM,272,RC,A6441,HCPCS,,12922-MAIN,LOCAL,,,,,32,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.88,0.9651
BANDAGE COBAN LITE 4 IN 2 LAYER COMPRESSION SYSTEM 2794N,120.549,CDM,272,RC,A6441,HCPCS,,12922-MAIN,LOCAL,,,,,32,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.88,0.9651
BANDAGE COBAN LITE 4 IN 2 LAYER COMPRESSION SYSTEM 2794N,120.549,CDM,272,RC,A6441,HCPCS,,12922-MAIN,LOCAL,,,,,32,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.93,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.88,0.9651
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013266,NDC,50,ML,59.67,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.93293,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,0.96
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004624,NDC,50,ML,50.58,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.93293,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,0.96
levoFLOXacin in dextrose 5% 500 MG/100ML Solution 100 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004724,NDC,100,ML,64.63,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.93293,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,0.96
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013268,NDC,150,ML,59.67,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.93293,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,0.96
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004824,NDC,150,ML,69.59,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.93293,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,0.96
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,409677802,NDC,1,ML,31.11,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.93293,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.93293,1.12
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641600101,NDC,1,ML,32.56,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.93293,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.93293,1.12
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604401,NDC,1,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.93293,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.93293,1.12
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604425,NDC,1,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.93293,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.93293,1.12
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620701,NDC,0.25,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.93293,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.93293,1.12
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620725,NDC,1,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.93293,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.93293,1.12
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,17478004001,NDC,1,ML,42.39,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.93293,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.93293,1.12
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,517095501,NDC,0.25,EA,69.19,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.93293,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,0.95
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781315972,NDC,1,EA,217.96,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.93293,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,0.95
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781910572,NDC,0.25,EA,69.49,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.93293,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,0.95
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,517095501,NDC,0.25,EA,69.19,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,0.95
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,517095501,NDC,0.25,EA,69.19,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,0.95
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781315972,NDC,1,EA,217.96,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,0.95
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781315972,NDC,1,EA,217.96,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,0.95
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781910572,NDC,0.25,EA,69.49,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,0.95
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781910572,NDC,0.25,EA,69.49,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,0.95
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,517095501,NDC,0.25,EA,69.19,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.95,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,0.95
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781315972,NDC,1,EA,217.96,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.95,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,0.95
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781910572,NDC,0.25,EA,69.49,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.95,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,0.95
triamcinolone acetonide 10 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3049420,NDC,0.25,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.95,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,1.08
triamcinolone acetonide 40 MG/ML Suspension 1 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029305,NDC,1,ML,73.57,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.95,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,1.08
triamcinolone acetonide 40 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029320,NDC,1,ML,72.65,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.95,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,1.08
CANNULA ADULT LARGE OPTIFLOW OPT946,120.495,CDM,271,RC,A4615,HCPCS,,11622-MAIN,LOCAL,,,,,44,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.95,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.95,1
CANNULA ADULT MEDIUM OPTIFLOW OPT944,120.495,CDM,271,RC,A4615,HCPCS,,11621-MAIN,LOCAL,,,,,44,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.95,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.95,1
CANNULA ADULT SMALL OPTIFLOW OPT942,120.495,CDM,271,RC,A4615,HCPCS,,11620-MAIN,LOCAL,,,,,44,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.95,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.95,1
CANNULA JUNIOR 2 LARGE OPTIFLOW OJR416VT,120.561,CDM,272,RC,A4615,HCPCS,,12645-MAIN,LOCAL,,,,,98,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.95,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.95,1
CANNULA JUNIOR 2 MEDIUM OPTIFLOW OJR414VT,120.561,CDM,272,RC,A4615,HCPCS,,12644-MAIN,LOCAL,,,,,98,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.95,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.95,1
CANNULA OPTIFLOW JUNIOR 2 SMALL OJR412VT,120.561,CDM,272,RC,A4615,HCPCS,,12643-MAIN,LOCAL,,,,,98,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.95,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.95,1
CANNULA OPTIFLOW JUNIOR2+ XXL OJR520,120.494,CDM,271,RC,A4615,HCPCS,,11619-MAIN,LOCAL,,,,,84,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.95,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.95,1
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013266,NDC,50,ML,59.67,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,0.96
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013266,NDC,50,ML,59.67,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,0.96
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004624,NDC,50,ML,50.58,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,0.96
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004624,NDC,50,ML,50.58,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,0.96
levoFLOXacin in dextrose 5% 500 MG/100ML Solution 100 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004724,NDC,100,ML,64.63,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,0.96
levoFLOXacin in dextrose 5% 500 MG/100ML Solution 100 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004724,NDC,100,ML,64.63,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,0.96
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013268,NDC,150,ML,59.67,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,0.96
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013268,NDC,150,ML,59.67,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,0.96
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004824,NDC,150,ML,69.59,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,0.96
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004824,NDC,150,ML,69.59,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,0.96
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,409677802,NDC,1,ML,31.11,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.93293,1.12
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,409677802,NDC,1,ML,31.11,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.93293,1.12
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641600101,NDC,1,ML,32.56,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.93293,1.12
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641600101,NDC,1,ML,32.56,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.93293,1.12
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604401,NDC,1,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.93293,1.12
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604401,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.93293,1.12
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604425,NDC,1,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.93293,1.12
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604425,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.93293,1.12
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620701,NDC,0.25,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.93293,1.12
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620701,NDC,0.25,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.93293,1.12
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620725,NDC,1,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.93293,1.12
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620725,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.93293,1.12
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,17478004001,NDC,1,ML,42.39,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.93293,1.12
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,17478004001,NDC,1,ML,42.39,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.93293,1.12
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,703450284,NDC,2,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.96,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.96,1.09
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,23155024031,NDC,2,ML,34.55,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.96,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.96,1.09
ampicillin 1 GM Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781926185,NDC,0.5,EA,43.18,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.9651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.89,1.01
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927380,NDC,1,EA,99.91,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.9651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.89,1.01
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927395,NDC,1,EA,99.91,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.9651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.89,1.01
ampicillin 500 MG Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781925078,NDC,1,EA,44.28,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.9651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.89,1.01
BANDAGE COBAN  4 IN 2 LAYER COMPRESSION SYSTEM  2094N,120.549,CDM,272,RC,A6441,HCPCS,,12366-MAIN,LOCAL,,,,,32,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.9651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.88,0.9651
BANDAGE COBAN LITE 4 IN 2 LAYER COMPRESSION SYSTEM 2794N,120.549,CDM,272,RC,A6441,HCPCS,,12922-MAIN,LOCAL,,,,,32,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.9651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.88,0.9651
CANNULA ADULT LARGE OPTIFLOW OPT946,120.495,CDM,271,RC,A4615,HCPCS,,11622-MAIN,LOCAL,,,,,44,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.9651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.95,1
CANNULA ADULT MEDIUM OPTIFLOW OPT944,120.495,CDM,271,RC,A4615,HCPCS,,11621-MAIN,LOCAL,,,,,44,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.9651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.95,1
CANNULA ADULT SMALL OPTIFLOW OPT942,120.495,CDM,271,RC,A4615,HCPCS,,11620-MAIN,LOCAL,,,,,44,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.9651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.95,1
CANNULA JUNIOR 2 LARGE OPTIFLOW OJR416VT,120.561,CDM,272,RC,A4615,HCPCS,,12645-MAIN,LOCAL,,,,,98,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.9651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.95,1
CANNULA JUNIOR 2 MEDIUM OPTIFLOW OJR414VT,120.561,CDM,272,RC,A4615,HCPCS,,12644-MAIN,LOCAL,,,,,98,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.9651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.95,1
CANNULA OPTIFLOW JUNIOR 2 SMALL OJR412VT,120.561,CDM,272,RC,A4615,HCPCS,,12643-MAIN,LOCAL,,,,,98,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.9651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.95,1
CANNULA OPTIFLOW JUNIOR2+ XXL OJR520,120.494,CDM,271,RC,A4615,HCPCS,,11619-MAIN,LOCAL,,,,,84,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.9651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.95,1
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.9651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.84,0.99
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909422,NDC,2,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.9651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.84,0.99
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.9651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.84,0.99
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.9651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.84,0.99
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.9651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.84,0.99
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.9651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.84,0.99
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.9651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.84,0.99
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092401,NDC,0.5,ML,820.88,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.9651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.75,0.99
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092410,NDC,0.5,ML,820.89,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.9651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.75,0.99
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092491,NDC,0.5,ML,820.88,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.9651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.75,0.99
filgrastim 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513020991,NDC,0.5,ML,1228.49,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.9651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.75,0.99
insulin aspart 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169633910,NDC,3,ML,659.76,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.9651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
insulin aspart prot & aspart 70-30 (70-30) 100 UNIT/ML Suspension Pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169369619,NDC,3,ML,629.28,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.9651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221901,NDC,3,ML,506.9,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.9651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221905,NDC,3,ML,506.9,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.9651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2021301,NDC,3,ML,44.46,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.9651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821517,NDC,3,ML,275.33,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.9651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
insulin regular 100 UNIT/ML Solution 10 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821501,NDC,10,ML,307.46,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,0.9651,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.97,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.84,0.99
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909422,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.97,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.84,0.99
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.97,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.84,0.99
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.97,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.84,0.99
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.97,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.84,0.99
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.97,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.84,0.99
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.97,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.84,0.99
cocaine 4% 4 % Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527172874,NDC,4,ML,875.53,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.98,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.98,1.808
cocaine 4% 4 % Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527172874,NDC,4,ML,875.53,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.98,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.98,1.808
cocaine 4% 4 % Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527172874,NDC,4,ML,875.53,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.98,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.98,1.808
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527197174,NDC,4,ML,960.5,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.98,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.98,1.808
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527197174,NDC,4,ML,960.5,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.98,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.98,1.808
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527197174,NDC,4,ML,960.5,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.98,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.98,1.808
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,64950036204,NDC,4,ML,1067.22,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.98,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.98,1.808
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,64950036204,NDC,4,ML,1067.22,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.98,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.98,1.808
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,64950036204,NDC,4,ML,1067.22,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.98,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.98,1.808
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,70839036204,NDC,4,ML,1280.66,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.98,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.98,1.808
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,70839036204,NDC,4,ML,1280.66,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.98,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.98,1.808
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,70839036204,NDC,4,ML,1280.66,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.98,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.98,1.808
ampicillin 1 GM Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781926185,NDC,0.5,EA,43.18,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.89,1.01
ampicillin 1 GM Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781926185,NDC,0.5,EA,43.18,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.89,1.01
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927380,NDC,1,EA,99.91,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.89,1.01
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927380,NDC,1,EA,99.91,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.89,1.01
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927395,NDC,1,EA,99.91,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.89,1.01
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927395,NDC,1,EA,99.91,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.89,1.01
ampicillin 500 MG Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781925078,NDC,1,EA,44.28,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.89,1.01
ampicillin 500 MG Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781925078,NDC,1,EA,44.28,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.89,1.01
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.84,0.99
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.84,0.99
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909422,NDC,2,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.84,0.99
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909422,NDC,2,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.84,0.99
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.84,0.99
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.84,0.99
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.84,0.99
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.84,0.99
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.84,0.99
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.84,0.99
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.84,0.99
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.84,0.99
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,0.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.84,0.99
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,0.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.84,0.99
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092401,NDC,0.5,ML,820.88,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.99,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.75,0.99
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092410,NDC,0.5,ML,820.89,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.99,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.75,0.99
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092491,NDC,0.5,ML,820.88,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.99,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.75,0.99
filgrastim 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513020991,NDC,0.5,ML,1228.49,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,0.99,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.75,0.99
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,409677802,NDC,1,ML,31.11,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.99,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.93293,1.12
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641600101,NDC,1,ML,32.56,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.99,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.93293,1.12
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604401,NDC,1,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.99,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.93293,1.12
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604425,NDC,1,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.99,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.93293,1.12
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620701,NDC,0.25,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.99,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.93293,1.12
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620725,NDC,1,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.99,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.93293,1.12
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,17478004001,NDC,1,ML,42.39,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,0.99,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.93293,1.12
CANNULA ADULT LARGE OPTIFLOW OPT946,120.495,CDM,271,RC,A4615,HCPCS,,11622-MAIN,LOCAL,,,,,44,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.95,1
CANNULA ADULT LARGE OPTIFLOW OPT946,120.495,CDM,271,RC,A4615,HCPCS,,11622-MAIN,LOCAL,,,,,44,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.95,1
CANNULA ADULT LARGE OPTIFLOW OPT946,120.495,CDM,271,RC,A4615,HCPCS,,11622-MAIN,LOCAL,,,,,44,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.95,1
CANNULA ADULT MEDIUM OPTIFLOW OPT944,120.495,CDM,271,RC,A4615,HCPCS,,11621-MAIN,LOCAL,,,,,44,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.95,1
CANNULA ADULT MEDIUM OPTIFLOW OPT944,120.495,CDM,271,RC,A4615,HCPCS,,11621-MAIN,LOCAL,,,,,44,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.95,1
CANNULA ADULT MEDIUM OPTIFLOW OPT944,120.495,CDM,271,RC,A4615,HCPCS,,11621-MAIN,LOCAL,,,,,44,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.95,1
CANNULA ADULT SMALL OPTIFLOW OPT942,120.495,CDM,271,RC,A4615,HCPCS,,11620-MAIN,LOCAL,,,,,44,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.95,1
CANNULA ADULT SMALL OPTIFLOW OPT942,120.495,CDM,271,RC,A4615,HCPCS,,11620-MAIN,LOCAL,,,,,44,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.95,1
CANNULA ADULT SMALL OPTIFLOW OPT942,120.495,CDM,271,RC,A4615,HCPCS,,11620-MAIN,LOCAL,,,,,44,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.95,1
CANNULA JUNIOR 2 LARGE OPTIFLOW OJR416VT,120.561,CDM,272,RC,A4615,HCPCS,,12645-MAIN,LOCAL,,,,,98,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.95,1
CANNULA JUNIOR 2 LARGE OPTIFLOW OJR416VT,120.561,CDM,272,RC,A4615,HCPCS,,12645-MAIN,LOCAL,,,,,98,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.95,1
CANNULA JUNIOR 2 LARGE OPTIFLOW OJR416VT,120.561,CDM,272,RC,A4615,HCPCS,,12645-MAIN,LOCAL,,,,,98,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.95,1
CANNULA JUNIOR 2 MEDIUM OPTIFLOW OJR414VT,120.561,CDM,272,RC,A4615,HCPCS,,12644-MAIN,LOCAL,,,,,98,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.95,1
CANNULA JUNIOR 2 MEDIUM OPTIFLOW OJR414VT,120.561,CDM,272,RC,A4615,HCPCS,,12644-MAIN,LOCAL,,,,,98,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.95,1
CANNULA JUNIOR 2 MEDIUM OPTIFLOW OJR414VT,120.561,CDM,272,RC,A4615,HCPCS,,12644-MAIN,LOCAL,,,,,98,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.95,1
CANNULA OPTIFLOW JUNIOR 2 SMALL OJR412VT,120.561,CDM,272,RC,A4615,HCPCS,,12643-MAIN,LOCAL,,,,,98,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.95,1
CANNULA OPTIFLOW JUNIOR 2 SMALL OJR412VT,120.561,CDM,272,RC,A4615,HCPCS,,12643-MAIN,LOCAL,,,,,98,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.95,1
CANNULA OPTIFLOW JUNIOR 2 SMALL OJR412VT,120.561,CDM,272,RC,A4615,HCPCS,,12643-MAIN,LOCAL,,,,,98,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.95,1
CANNULA OPTIFLOW JUNIOR2+ XXL OJR520,120.494,CDM,271,RC,A4615,HCPCS,,11619-MAIN,LOCAL,,,,,84,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.95,1
CANNULA OPTIFLOW JUNIOR2+ XXL OJR520,120.494,CDM,271,RC,A4615,HCPCS,,11619-MAIN,LOCAL,,,,,84,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.95,1
CANNULA OPTIFLOW JUNIOR2+ XXL OJR520,120.494,CDM,271,RC,A4615,HCPCS,,11619-MAIN,LOCAL,,,,,84,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.95,1
ampicillin 1 GM Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781926185,NDC,0.5,EA,43.18,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.01,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.89,1.01
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927380,NDC,1,EA,99.91,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.01,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.89,1.01
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927395,NDC,1,EA,99.91,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.01,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.89,1.01
ampicillin 500 MG Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781925078,NDC,1,EA,44.28,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.01,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.89,1.01
Etoposide 100 MG/5ML Solution 5 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,16729011431,NDC,5,ML,43.21,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.02944,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.87,1.04
etoposide 500 MG/25ML Solution 25 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,703565601,NDC,25,ML,173.28,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.02944,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.87,1.04
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,703450284,NDC,2,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.02944,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.96,1.09
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,23155024031,NDC,2,ML,34.55,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.02944,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.96,1.09
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030926,NDC,1,EA,55.44,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.02944,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098121,NDC,1,EA,72.95,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.02944,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098141,NDC,1,EA,39.84,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.02944,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098153,NDC,1,EA,39.84,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.02944,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409338513,NDC,1,EA,74.09,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.02944,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615700,NDC,1,EA,101.95,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.02944,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615704,NDC,1,EA,101.92,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.02944,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030036,NDC,1,EA,56.73,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.02944,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098321,NDC,1,EA,99.39,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.02944,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098323,NDC,1,EA,99.39,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.02944,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098341,NDC,1,EA,56.73,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.02944,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052200,NDC,1,EA,99.39,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.02944,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052237,NDC,1,EA,99.39,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.02944,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409339004,NDC,1,EA,98.61,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.02944,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,55150012150,NDC,1,EA,151.41,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.02944,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615900,NDC,1,EA,123.75,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.02944,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615904,NDC,1,EA,123.75,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.02944,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032050,NDC,1,EA,120.51,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.02944,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032056,NDC,1,EA,68.97,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.02944,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,65219025915,NDC,1,EA,58.66,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.02944,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030926,NDC,1,EA,55.44,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098121,NDC,1,EA,72.95,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098141,NDC,1,EA,39.84,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098153,NDC,1,EA,39.84,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409338513,NDC,1,EA,74.09,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615700,NDC,1,EA,101.95,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615704,NDC,1,EA,101.92,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030036,NDC,1,EA,56.73,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098321,NDC,1,EA,99.39,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098323,NDC,1,EA,99.39,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098341,NDC,1,EA,56.73,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052200,NDC,1,EA,99.39,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052237,NDC,1,EA,99.39,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409339004,NDC,1,EA,98.61,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,55150012150,NDC,1,EA,151.41,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615900,NDC,1,EA,123.75,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615904,NDC,1,EA,123.75,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032050,NDC,1,EA,120.51,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032056,NDC,1,EA,68.97,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,65219025915,NDC,1,EA,58.66,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
SYRINGE BULB 60ML IRRIGATION STERILE DYND20125,27200000,CDM,272,RC,A4322,HCPCS,,10829-MAIN,LOCAL,,,,,2.16,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.0368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SYRINGE BULB 60ML IRRIGATION STERILE DYND20125,27200000,CDM,272,RC,A4322,HCPCS,,10829-MAIN,LOCAL,,,,,2.16,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.0368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DOCEtaxel 20 MG/ML Concentrate 1 mL Vial,63600000,CDM,636,RC,J9171,HCPCS,,,,955102001,NDC,1,ML,1690.09,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.04,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.39,1.04
DOCEtaxel 160 MG/16ML Solution 16 mL Vial,J9171.01,CDM,636,RC,J9171,HCPCS,,,,409173201,NDC,16,ML,2901.69,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.04,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86859,1.04
Etoposide 100 MG/5ML Solution 5 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,16729011431,NDC,5,ML,43.21,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.04,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.87,1.04
Etoposide 100 MG/5ML Solution 5 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,16729011431,NDC,5,ML,43.21,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.87,1.04
Etoposide 100 MG/5ML Solution 5 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,16729011431,NDC,5,ML,43.21,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.87,1.04
etoposide 500 MG/25ML Solution 25 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,703565601,NDC,25,ML,173.28,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.04,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.87,1.04
etoposide 500 MG/25ML Solution 25 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,703565601,NDC,25,ML,173.28,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.87,1.04
etoposide 500 MG/25ML Solution 25 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,703565601,NDC,25,ML,173.28,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.87,1.04
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,703450284,NDC,2,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.96,1.09
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,703450284,NDC,2,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.96,1.09
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,23155024031,NDC,2,ML,34.55,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.96,1.09
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,23155024031,NDC,2,ML,34.55,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.96,1.09
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703331101,NDC,0.75,ML,51.41,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.04,1.19
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037601,NDC,1,ML,76.9,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.04,1.19
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037604,NDC,0.75,ML,36.86,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.04,1.19
octreotide 200 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037805,NDC,1,ML,133.77,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.04,1.19
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703334301,NDC,0.5,ML,142.98,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.04,1.19
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037905,NDC,0.5,ML,229.88,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.04,1.19
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030926,NDC,1,EA,55.44,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030926,NDC,1,EA,55.44,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098121,NDC,1,EA,72.95,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098121,NDC,1,EA,72.95,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098141,NDC,1,EA,39.84,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098141,NDC,1,EA,39.84,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098153,NDC,1,EA,39.84,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098153,NDC,1,EA,39.84,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409338513,NDC,1,EA,74.09,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409338513,NDC,1,EA,74.09,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615700,NDC,1,EA,101.95,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615700,NDC,1,EA,101.95,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615704,NDC,1,EA,101.92,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615704,NDC,1,EA,101.92,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030036,NDC,1,EA,56.73,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030036,NDC,1,EA,56.73,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098321,NDC,1,EA,99.39,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098321,NDC,1,EA,99.39,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098323,NDC,1,EA,99.39,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098323,NDC,1,EA,99.39,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098341,NDC,1,EA,56.73,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098341,NDC,1,EA,56.73,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052200,NDC,1,EA,99.39,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052200,NDC,1,EA,99.39,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052237,NDC,1,EA,99.39,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052237,NDC,1,EA,99.39,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409339004,NDC,1,EA,98.61,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409339004,NDC,1,EA,98.61,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,55150012150,NDC,1,EA,151.41,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,55150012150,NDC,1,EA,151.41,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615900,NDC,1,EA,123.75,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615900,NDC,1,EA,123.75,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615904,NDC,1,EA,123.75,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615904,NDC,1,EA,123.75,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032050,NDC,1,EA,120.51,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032050,NDC,1,EA,120.51,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032056,NDC,1,EA,68.97,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032056,NDC,1,EA,68.97,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,65219025915,NDC,1,EA,58.66,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,65219025915,NDC,1,EA,58.66,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
SYRINGE BULB 60ML IRRIGATION STERILE DYND20125,27200000,CDM,272,RC,A4322,HCPCS,,10829-MAIN,LOCAL,,,,,2.16,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.0584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SYRINGE BULB 60ML IRRIGATION STERILE DYND20125,27200000,CDM,272,RC,A4322,HCPCS,,10829-MAIN,LOCAL,,,,,2.16,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.0584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SYRINGE BULB 60ML IRRIGATION STERILE DYND20125,27200000,CDM,272,RC,A4322,HCPCS,,10829-MAIN,LOCAL,,,,,2.16,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.0584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,409662902,NDC,10,ML,146.84,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.06,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.13,1.06
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094310,NDC,10,ML,72.79,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.06,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.13,1.06
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094321,NDC,10,ML,72.79,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.06,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.13,1.06
triamcinolone acetonide 10 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3049420,NDC,0.25,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.06161,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,1.08
triamcinolone acetonide 40 MG/ML Suspension 1 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029305,NDC,1,ML,73.57,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.06161,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,1.08
triamcinolone acetonide 40 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029320,NDC,1,ML,72.65,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.06161,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,1.08
SYRINGE BULB 60ML IRRIGATION STERILE DYND20125,27200000,CDM,272,RC,A4322,HCPCS,,10829-MAIN,LOCAL,,,,,2.16,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.0692,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DEFIBRILLATION PAD BIPHASIC ADULT,120.96,CDM,271,RC,A0392,HCPCS,,1321-MAIN,LOCAL,,,,,58,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.08,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.08,1.08
DEFIBRILLATION PAD MULTI FUNCTION ADULT,120.58,CDM,271,RC,A0392,HCPCS,,1320-MAIN,LOCAL,,,,,94,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.08,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.08,1.08
DEFIBRILLATION PAD PEDI PADZ PEDS,120.58,CDM,271,RC,A0392,HCPCS,,1322-MAIN,LOCAL,,,,,94,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.08,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.08,1.08
triamcinolone acetonide 10 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3049420,NDC,0.25,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,1.08
triamcinolone acetonide 10 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3049420,NDC,0.25,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,1.08
triamcinolone acetonide 40 MG/ML Suspension 1 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029305,NDC,1,ML,73.57,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,1.08
triamcinolone acetonide 40 MG/ML Suspension 1 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029305,NDC,1,ML,73.57,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,1.08
triamcinolone acetonide 40 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029320,NDC,1,ML,72.65,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,1.08
triamcinolone acetonide 40 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029320,NDC,1,ML,72.65,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,1.08
buprenorphine 2 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,50383092493,NDC,1,EA,24.34,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.09,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.09,2.016
buprenorphine 8 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,54017713,NDC,1,EA,41.56,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.09,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.09,2.016
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,703450284,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.09,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.96,1.09
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,23155024031,NDC,2,ML,34.55,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.09,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.96,1.09
SYRINGE BULB 60ML IRRIGATION STERILE DYND20125,27200000,CDM,272,RC,A4322,HCPCS,,10829-MAIN,LOCAL,,,,,2.16,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.09296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703331101,NDC,0.75,ML,51.41,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.09378,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.04,1.19
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037601,NDC,1,ML,76.9,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.09378,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.04,1.19
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037604,NDC,0.75,ML,36.86,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.09378,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.04,1.19
octreotide 200 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037805,NDC,1,ML,133.77,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.09378,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.04,1.19
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703334301,NDC,0.5,ML,142.98,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.09378,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.04,1.19
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037905,NDC,0.5,ML,229.88,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.09378,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.04,1.19
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012166,NDC,1,EA,58.66,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.11,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.11,1.33
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024010,NDC,1,EA,56.73,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.11,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.11,1.33
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505624500,NDC,1,EA,116.99,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.11,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.11,1.33
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012250,NDC,1,EA,77.24,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.11,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.11,1.33
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012267,NDC,1,EA,77.24,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.11,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.11,1.33
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024110,NDC,1,EA,76.1,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.11,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.11,1.33
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505614700,NDC,1,EA,212.52,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.11,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.11,1.33
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034020,NDC,1,EA,76.67,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.11,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.11,1.33
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034021,NDC,1,EA,76.67,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.11,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.11,1.33
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,409677802,NDC,1,ML,31.11,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.12,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.93293,1.12
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641600101,NDC,1,ML,32.56,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.12,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.93293,1.12
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604401,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.12,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.93293,1.12
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604425,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.12,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.93293,1.12
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620701,NDC,0.25,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.12,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.93293,1.12
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620725,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.12,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.93293,1.12
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,17478004001,NDC,1,ML,42.39,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.12,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.93293,1.12
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703331101,NDC,0.75,ML,51.41,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.04,1.19
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703331101,NDC,0.75,ML,51.41,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.04,1.19
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037601,NDC,1,ML,76.9,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.04,1.19
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037601,NDC,1,ML,76.9,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.04,1.19
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037604,NDC,0.75,ML,36.86,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.04,1.19
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037604,NDC,0.75,ML,36.86,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.04,1.19
octreotide 200 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037805,NDC,1,ML,133.77,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.04,1.19
octreotide 200 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037805,NDC,1,ML,133.77,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.04,1.19
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703334301,NDC,0.5,ML,142.98,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.04,1.19
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703334301,NDC,0.5,ML,142.98,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.04,1.19
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037905,NDC,0.5,ML,229.88,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.04,1.19
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037905,NDC,0.5,ML,229.88,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.04,1.19
"dextrose 5% and sodium chloride 0.2% 5-0.2 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338007704,NDC,1000,ML,99.12,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.12595,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.12595,1.59
"dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008904,NDC,1000,ML,99.12,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.12595,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.12595,1.59
dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 500 mL Flex Cont,J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008903,NDC,500,ML,99.12,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.12595,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.12595,1.59
"dextrose 5% and sodium chloride 0.45% 5-0.45 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008504,NDC,1000,ML,99.12,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.12595,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.12595,1.59
nitroglycerin in dextrose 5% 100-5 MCG/ML-% Solution 250 mL Glass Cont,J2305.01,CDM,636,RC,J2305,HCPCS,,,,338104702,NDC,250,ML,126.07,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.13,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.13,1.44
"dextrose 5% and sodium chloride 0.2% 5-0.2 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338007704,NDC,1000,ML,99.12,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.12595,1.59
"dextrose 5% and sodium chloride 0.2% 5-0.2 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338007704,NDC,1000,ML,99.12,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.12595,1.59
"dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008904,NDC,1000,ML,99.12,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.12595,1.59
"dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008904,NDC,1000,ML,99.12,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.12595,1.59
dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 500 mL Flex Cont,J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008903,NDC,500,ML,99.12,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.12595,1.59
dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 500 mL Flex Cont,J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008903,NDC,500,ML,99.12,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.12595,1.59
"dextrose 5% and sodium chloride 0.45% 5-0.45 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008504,NDC,1000,ML,99.12,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.12595,1.59
"dextrose 5% and sodium chloride 0.45% 5-0.45 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008504,NDC,1000,ML,99.12,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.12595,1.59
buprenorphine 2 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,50383092493,NDC,1,EA,24.34,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.14,40.7288
buprenorphine 8 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,54017713,NDC,1,EA,41.56,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.14,40.7288
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,55111069407,NDC,5,ML,592.4,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.15812,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.74,1.19
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,60505619301,NDC,5,ML,821.36,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.15812,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.74,1.19
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,63323067305,NDC,5,ML,1029.71,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.15812,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.74,1.19
nitroglycerin in dextrose 5% 100-5 MCG/ML-% Solution 250 mL Glass Cont,J2305.01,CDM,636,RC,J2305,HCPCS,,,,338104702,NDC,250,ML,126.07,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.17,123.5486
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030926,NDC,1,EA,55.44,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.18,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098121,NDC,1,EA,72.95,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.18,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098141,NDC,1,EA,39.84,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.18,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098153,NDC,1,EA,39.84,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.18,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409338513,NDC,1,EA,74.09,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.18,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615700,NDC,1,EA,101.95,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.18,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615704,NDC,1,EA,101.92,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.18,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030036,NDC,1,EA,56.73,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.18,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098321,NDC,1,EA,99.39,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.18,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098323,NDC,1,EA,99.39,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.18,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098341,NDC,1,EA,56.73,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.18,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052200,NDC,1,EA,99.39,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.18,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052237,NDC,1,EA,99.39,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.18,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409339004,NDC,1,EA,98.61,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.18,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,55150012150,NDC,1,EA,151.41,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.18,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615900,NDC,1,EA,123.75,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.18,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615904,NDC,1,EA,123.75,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.18,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032050,NDC,1,EA,120.51,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.18,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032056,NDC,1,EA,68.97,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.18,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,65219025915,NDC,1,EA,58.66,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.18,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.02944,1.18
sodium chloride 0.9 % 0.9 % Solution 50 mL Flex Cont,J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004941,NDC,50,ML,43.5,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.18,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.18,1.35
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Syringe,J7040.01,CDM,636,RC,J7040,HCPCS,,,,64253020230,NDC,10,ML,42.15,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.18,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.18,1.35
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488802,NDC,10,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.18,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.18,1.35
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018603,NDC,20,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.18,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.18,1.35
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018620,NDC,20,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.18,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.18,1.35
sodium chloride 0.9 % PF 0.9 % Solution 50 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488850,NDC,3,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.18,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.18,1.35
"sodium chloride 0.9% 0.9% Solution 1,000 mL Flex Cont",J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004904,NDC,1000,ML,99.12,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.18,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.18,1.35
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,55111069407,NDC,5,ML,592.4,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.74,1.19
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,55111069407,NDC,5,ML,592.4,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.74,1.19
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,60505619301,NDC,5,ML,821.36,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.74,1.19
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,60505619301,NDC,5,ML,821.36,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.74,1.19
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,63323067305,NDC,5,ML,1029.71,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.74,1.19
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,63323067305,NDC,5,ML,1029.71,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.74,1.19
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703331101,NDC,0.75,ML,51.41,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.19,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.04,1.19
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037601,NDC,1,ML,76.9,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.19,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.04,1.19
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037604,NDC,0.75,ML,36.86,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.19,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.04,1.19
octreotide 200 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037805,NDC,1,ML,133.77,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.19,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.04,1.19
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703334301,NDC,0.5,ML,142.98,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.19,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.04,1.19
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037905,NDC,0.5,ML,229.88,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.19,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.04,1.19
buprenorphine 2 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,50383092493,NDC,1,EA,24.34,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.09,2.016
buprenorphine 2 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,50383092493,NDC,1,EA,24.34,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.09,2.016
buprenorphine 8 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,54017713,NDC,1,EA,41.56,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.09,2.016
buprenorphine 8 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,54017713,NDC,1,EA,41.56,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.09,2.016
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600110,NDC,10,ML,589.63,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.24,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.24,7.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600121,NDC,10,ML,592.5,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.24,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.24,7.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040304,NDC,10,ML,168.77,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.24,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.24,7.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040310,NDC,10,ML,168.77,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.24,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.24,7.65
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,143931901,NDC,0.4,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.24,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.24,1.42
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,63323047401,NDC,1,ML,58.6,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.24,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.24,1.42
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904198261,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580045811,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580060002,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 750 Each Box,63700001,CDM,250,RC,,,,,,63739044001,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904198861,NDC,0.65,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904673061,NDC,0.65,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580045711,NDC,0.65,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 650 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,70010016001,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen-codeine 300-30 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406048423,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen-codeine 300-30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406048462,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020501,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584098811,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,53489015601,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904657161,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020520,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,62584098801,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862067701,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585961,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739064410,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amitriptyline 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268003711,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amitriptyline 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687043311,NDC,0.4,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amitriptyline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687043301,NDC,0.4,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687026311,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084025911,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687026301,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084025901,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714029903,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ascorbic acid 500 MG Tablet 100 Each Box,25000000,CDM,250,RC,,,,,,904052361,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
aspirin 81 MG Tablet Chewable 90 Each Bottle,63700001,CDM,250,RC,,,,,,904679489,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin 81 MG Tablet Chewable 500 Each Disp Pack,63700001,CDM,250,RC,,,,,,66553000201,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin 325 MG Tablet 500 Each Box,63700001,CDM,250,RC,,,,,,66553000101,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 81 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,63739021210,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 81 MG Tablet Delayed Release 120 Each Bottle,63700001,CDM,250,RC,,,,,,10135017362,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,536114801,NDC,0.249230769,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,536331301,NDC,0.249230769,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,603016921,NDC,0.249230769,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079068401,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020801,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629061,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020820,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020901,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629161,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020920,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079021001,NDC,0.125,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
azaTHIOprine 50 MG Tablet 1 Each Blister,J7500.01,CDM,636,RC,J7500,HCPCS,,,,68084022911,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2.94
baclofen 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904647561,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
baclofen 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739047910,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268011011,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 40 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547033810,NDC,0.125,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 1 Each Box,63700001,CDM,250,RC,,,,,,713010906,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574705012,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713010912,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,904505812,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl EC 5 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,904640761,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bismuth subsalicylate 262 MG Tablet Chewable 30 Each Box,63700001,CDM,250,RC,,,,,,904720546,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bumetanide 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,185012901,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buPROPion SR 150 MG Tablet Extended Release 12 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084070895,NDC,0.666666667,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buPROPion SR 150 MG Tablet Extended Release 12 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,68084070825,NDC,0.666666667,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcium carb-cholecalciferol 600-10 mg-mcg (600-400 mg-unit) Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,20555001700,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcium carbonate 500 MG Tablet Chewable 500 Each Box,63700001,CDM,250,RC,,,,,,66553000401,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
candesartan 32 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,49884066109,NDC,0.125,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 10-100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,72888010601,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687066111,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084009311,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687066101,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-250 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084009411,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carvedilol 12.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904630261,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cetirizine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904671761,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cholecalciferol (vitamin D3) 125 MCG (5000 UT) capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,80681013100,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637861,NDC,0.2,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904724361,NDC,0.2,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin 150 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904595961,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714075201,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16729013600,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloNIDine 0.1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687011311,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloNIDine 0.1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687011301,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloNIDine 0.1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739006010,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
codeine 30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54024424,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536136601,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536355601,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,74312001380,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079064401,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687055811,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687055801,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54417925,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54817925,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54817625,NDC,0.125,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 6 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54418625,NDC,0.041666667,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079028401,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,172392560,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079028420,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079028501,NDC,0.4,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,172392660,NDC,0.4,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079028520,NDC,0.4,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687019511,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687019501,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 180 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687020611,NDC,0.666666667,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 180 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687020601,NDC,0.666666667,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687021711,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739001610,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 25 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904530661,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 25 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904723761,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 50 MG capsule 100 Each Box,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904205661,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
divalproex 250 MG Tablet Delayed Release 1 Each Box,63700001,CDM,250,RC,,,,,,832712389,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 250 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,832712301,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
docusate sodium 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,10135011101,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
docusate sodium 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904645561,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
docusate sodium 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904718361,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
donepezil 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904647761,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxazosin 4 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68382078501,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
estradiol 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378145201,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
estradiol 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42806008701,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 25 Each Bottle,63700001,CDM,250,RC,,,,,,49348081705,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739064510,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"ferrous sulfate 325 (65 Fe) MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64376080910,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ferrous sulfate 325 (65 Fe) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904759161,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Fish Oil 1000 MG capsule 1 Each Blister,25000000,CDM,250,RC,,,,,,77333030825,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
folic acid 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687068111,NDC,0.4,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
folic acid 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687068101,NDC,0.4,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54829725,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904717861,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762403001,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904666561,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739059110,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739090210,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862019901,NDC,0.333333333,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904666661,NDC,0.333333333,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60505011300,NDC,0.333333333,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687059101,NDC,0.333333333,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739023610,NDC,0.333333333,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glimepiride 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547039410,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079081001,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079081020,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE ER 2.5 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714089401,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE ER 5 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714089501,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glyBURIDE 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,93834498,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glycerin 2 g Suppository 24 Each Jar,63700001,CDM,250,RC,,,,,,132007924,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 600 MG Tablet Extended Release 12 Hour 20 Each Box,63700001,CDM,250,RC,,,,,,63824000832,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
haloperidol 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079073420,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155000101,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904644161,NDC,0.4,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,64380073506,NDC,0.2,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904644261,NDC,0.2,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydroCHLOROthiazide 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547039710,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 5 MG Tablet 50 Each Bottle,63700001,CDM,250,RC,,,,,,59762007301,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762007401,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406324301,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,42858030125,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084042301,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine HCl 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155050101,NDC,0.4,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,51079007720,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,3.1556
ibuprofen 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904791461,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 600 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687045711,NDC,0.333333333,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 600 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739068410,NDC,0.333333333,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 800 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687046811,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 800 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687046801,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 800 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739069110,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
indomethacin 25 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,50268043011,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,781155601,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
labetalol 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,10135071101,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
labetalol 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687045011,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Lactase 9000 units Tablet 12 Each Box,63700001,CDM,250,RC,,,,,,45091012,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904700761,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031911,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084031901,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levETIRAcetam 250 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904712361,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 50 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079044001,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 50 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079044020,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
liothyronine 25 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762120701,NDC,0.2,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079098101,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679761,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,591040701,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679861,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679961,NDC,0.125,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687033301,NDC,0.125,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904680061,NDC,0.0625,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904720061,NDC,0.0625,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lithium 150 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,54252625,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lithium 150 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,54852625,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
loratadine 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714089801,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904600761,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739049910,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687035511,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904600861,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739050010,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904704861,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739068610,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Magnesium Cl-Calcium Carbonate 71.5-119 MG Tablet Delayed Release 60 Each Bottle,63700001,CDM,250,RC,,,,,,67618010760,NDC,2,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904660961,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,10006070028,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,64980033901,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
medroxyPROGESTERone 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,555087202,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
melatonin 3 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268052411,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
melatonin 3 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268052415,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
melatonin 3 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,904518252,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Melatonin 3-10 MG Tablet 120 Each Bottle,800000,CDM,,,,,,,,47469000852,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Melatonin 10 MG SL Tab 120 Each Bottle,63700001,CDM,250,RC,,,,,,40985027503,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904716261,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 850 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739070210,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 1000 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904669161,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 1000 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904716461,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methadone 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406575523,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methadone 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54855324,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methIMAzole 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155007001,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methIMAzole 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155007101,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methocarbamol 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687055911,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methocarbamol 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739016610,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methocarbamol 750 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687056811,NDC,0.666666667,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoclopramide 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93220401,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoclopramide 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739029310,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 50 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084066611,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 100 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,51079017101,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584026511,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904634061,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079080101,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904634161,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584026711,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,62584026701,NDC,0.125,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metroNIDAZOLE 500 MG Tablet 50 Each Bottle,63700001,CDM,250,RC,,,,,,29300022746,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
miSOPROStol 100 MCG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,70954044310,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
montelukast 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904680861,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine immediate release 15 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54023525,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine immediate release 15 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,832027311,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
multivitamin with minerals Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904549261,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
naproxen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739040310,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine polacrilex 4 MG Lozenge 24 Each Bottle,63700001,CDM,250,RC,,,,,,43598048772,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine polacrilex 4 MG Lozenge 72 Each Box,63700001,CDM,250,RC,,,,,,49348085316,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 1 Each Blister,63700001,CDM,250,RC,,,,,,68084012811,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,904691761,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,68084012801,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyBUTYnin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904702761,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406055223,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406055262,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739096310,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PHENobarbital 32.4 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904657561,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenytoin ER 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904618761,NDC,0.3,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenytoin ER 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,68084037601,NDC,0.3,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phosphorus 155-852-130 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,64980010401,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687059211,NDC,0.125,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
predniSONE 1 MG Tablet 100 Each Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,64380078206,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 1 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54873925,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 2.5 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54874025,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 5 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687012211,NDC,0.2,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 10 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687013411,NDC,0.1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001720,NDC,0.1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,63739051910,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 20 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014511,NDC,0.05,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001820,NDC,0.05,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014501,NDC,0.05,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
pregabalin 25 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,76282056890,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 75 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904700061,NDC,0.333333333,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prochlorperazine 10 MG Tablet 100 Each Bottle,25000000,CDM,250,RC,,,,,,59746011506,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
promethazine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,Q0169,HCPCS,,,,904646161,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904655061,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268070211,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687060911,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687060901,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Prosight Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,536509008,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
psyllium 0.52 GM capsule 160 Each Bottle,25000000,CDM,250,RC,,,,,,80681002200,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Psyllium 400 MG capsule 160 Each Bottle,25000000,CDM,250,RC,,,,,,10939081644,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pyridoxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536440601,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pyridoxine 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,77333094010,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904663861,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904664061,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739066510,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ramipril 5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,68382014601,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904736161,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rOPINIRole 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637461,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268071111,NDC,0.125,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268071115,NDC,0.125,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna 8.6 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904652261,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687062211,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,57896045806,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904633961,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687062201,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739043210,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018011,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904692461,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018001,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687024211,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018111,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687024201,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018101,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687025311,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904692661,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687025301,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simethicone 125 MG Tablet Chewable 18 Each Box,63700001,CDM,250,RC,,,,,,49348086348,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simethicone 125 MG Tablet Chewable 60 Each Bottle,63700001,CDM,250,RC,,,,,,69618003206,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simvastatin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739057010,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simvastatin 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739057310,NDC,0.125,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"sodium bicarbonate 650 MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64980018210,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"sodium bicarbonate 650 MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64980052810,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium chloride 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,223176001,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 12.5 mg Tablet 1 split tablet Blister,63700001,CDM,250,RC,,,,,,8888800438,NDC,2,UN,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079010301,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687046511,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079010320,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687046501,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739054410,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 800-160 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904272561,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 800-160 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739022810,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tamsulosin 0.4 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739056710,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079041801,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877014601,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079041820,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739023110,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terazosin 5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59746038506,NDC,0.2,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
therapeutic multivitamin Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904053961,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,77333093425,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,37864090599,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,77333093410,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268075611,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268075615,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54007725,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50111091701,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739067110,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traZODone 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904655461,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
valsartan 160 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342006410,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536333401,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904582461,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,10006070033,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,20555003300,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121201,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121301,NDC,0.4,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 3 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121401,NDC,0.333333333,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,832121689,NDC,0.2,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121601,NDC,0.2,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zinc gluconate 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,40093010153,NDC,1,EA,3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.2462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,143931901,NDC,0.4,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.25463,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.24,1.42
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,63323047401,NDC,1,ML,58.6,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.25463,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.24,1.42
amLODIPine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637161,NDC,0.25,EA,3.03,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.258662,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012166,NDC,1,EA,58.66,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.26,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.11,1.33
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024010,NDC,1,EA,56.73,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.26,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.11,1.33
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505624500,NDC,1,EA,116.99,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.26,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.11,1.33
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012250,NDC,1,EA,77.24,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.26,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.11,1.33
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012267,NDC,1,EA,77.24,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.26,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.11,1.33
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024110,NDC,1,EA,76.1,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.26,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.11,1.33
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505614700,NDC,1,EA,212.52,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.26,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.11,1.33
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034020,NDC,1,EA,76.67,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.26,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.11,1.33
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034021,NDC,1,EA,76.67,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.26,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.11,1.33
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,143931901,NDC,0.4,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.24,1.42
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,143931901,NDC,0.4,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.24,1.42
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,63323047401,NDC,1,ML,58.6,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.24,1.42
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,63323047401,NDC,1,ML,58.6,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.24,1.42
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,63323004401,NDC,1,ML,64.53,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.27,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.27,1.44
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,70069000501,NDC,0.1,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.27,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.27,1.44
OSTOMY DRAINABLE POUCH INVISICLOSE 1.75,27200000,CDM,272,RC,A5063,HCPCS,,12071-MAIN,LOCAL,,,,,1.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1.275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
metoprolol tartrate 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079080120,NDC,1,EA,3.07,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.275278,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,43598052936,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,1.28
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,63323041536,NDC,0.5,ML,44.05,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,1.28
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080601,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,1.28
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080610,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.07,1.28
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600110,NDC,10,ML,589.63,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.2868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.24,7.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600121,NDC,10,ML,592.5,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.2868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.24,7.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040304,NDC,10,ML,168.77,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.2868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.24,7.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040310,NDC,10,ML,168.77,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.2868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.24,7.65
sodium chloride 0.9 % 0.9 % Solution 50 mL Flex Cont,J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004941,NDC,50,ML,43.5,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.2868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.18,1.35
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Syringe,J7040.01,CDM,636,RC,J7040,HCPCS,,,,64253020230,NDC,10,ML,42.15,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.2868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.18,1.35
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488802,NDC,10,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.2868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.18,1.35
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018603,NDC,20,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.2868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.18,1.35
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018620,NDC,20,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.2868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.18,1.35
sodium chloride 0.9 % PF 0.9 % Solution 50 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488850,NDC,3,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.2868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.18,1.35
"sodium chloride 0.9% 0.9% Solution 1,000 mL Flex Cont",J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004904,NDC,1000,ML,99.12,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.2868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.18,1.35
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904198261,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580045811,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580060002,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 750 Each Box,63700001,CDM,250,RC,,,,,,63739044001,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904198861,NDC,0.65,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904673061,NDC,0.65,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580045711,NDC,0.65,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 650 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,70010016001,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen-codeine 300-30 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406048423,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen-codeine 300-30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406048462,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020501,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584098811,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,53489015601,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904657161,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020520,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,62584098801,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862067701,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585961,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739064410,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amitriptyline 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268003711,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amitriptyline 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687043311,NDC,0.4,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amitriptyline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687043301,NDC,0.4,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687026311,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084025911,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687026301,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084025901,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714029903,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ascorbic acid 500 MG Tablet 100 Each Box,25000000,CDM,250,RC,,,,,,904052361,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
aspirin 81 MG Tablet Chewable 90 Each Bottle,63700001,CDM,250,RC,,,,,,904679489,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin 81 MG Tablet Chewable 500 Each Disp Pack,63700001,CDM,250,RC,,,,,,66553000201,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin 325 MG Tablet 500 Each Box,63700001,CDM,250,RC,,,,,,66553000101,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 81 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,63739021210,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 81 MG Tablet Delayed Release 120 Each Bottle,63700001,CDM,250,RC,,,,,,10135017362,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,536114801,NDC,0.249230769,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,536331301,NDC,0.249230769,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,603016921,NDC,0.249230769,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079068401,NDC,0.25,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020801,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629061,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020820,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020901,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629161,NDC,0.25,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020920,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079021001,NDC,0.125,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
azaTHIOprine 50 MG Tablet 1 Each Blister,J7500.01,CDM,636,RC,J7500,HCPCS,,,,68084022911,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2.94
baclofen 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904647561,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
baclofen 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739047910,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268011011,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 40 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547033810,NDC,0.125,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 1 Each Box,63700001,CDM,250,RC,,,,,,713010906,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574705012,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713010912,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,904505812,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl EC 5 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,904640761,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bismuth subsalicylate 262 MG Tablet Chewable 30 Each Box,63700001,CDM,250,RC,,,,,,904720546,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bumetanide 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,185012901,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buPROPion SR 150 MG Tablet Extended Release 12 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084070895,NDC,0.666666667,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buPROPion SR 150 MG Tablet Extended Release 12 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,68084070825,NDC,0.666666667,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcium carb-cholecalciferol 600-10 mg-mcg (600-400 mg-unit) Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,20555001700,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcium carbonate 500 MG Tablet Chewable 500 Each Box,63700001,CDM,250,RC,,,,,,66553000401,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
candesartan 32 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,49884066109,NDC,0.125,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 10-100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,72888010601,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687066111,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084009311,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687066101,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-250 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084009411,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carvedilol 12.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904630261,NDC,0.25,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cetirizine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904671761,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cholecalciferol (vitamin D3) 125 MCG (5000 UT) capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,80681013100,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637861,NDC,0.2,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904724361,NDC,0.2,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin 150 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904595961,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714075201,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16729013600,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloNIDine 0.1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687011311,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloNIDine 0.1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687011301,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloNIDine 0.1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739006010,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
codeine 30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54024424,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536136601,NDC,0.25,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536355601,NDC,0.25,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,74312001380,NDC,0.25,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079064401,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687055811,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687055801,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54417925,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54817925,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54817625,NDC,0.125,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 6 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54418625,NDC,0.041666667,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079028401,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,172392560,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079028420,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079028501,NDC,0.4,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,172392660,NDC,0.4,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079028520,NDC,0.4,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687019511,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687019501,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 180 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687020611,NDC,0.666666667,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 180 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687020601,NDC,0.666666667,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687021711,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739001610,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 25 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904530661,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 25 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904723761,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 50 MG capsule 100 Each Box,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904205661,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
divalproex 250 MG Tablet Delayed Release 1 Each Box,63700001,CDM,250,RC,,,,,,832712389,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 250 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,832712301,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
docusate sodium 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,10135011101,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
docusate sodium 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904645561,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
docusate sodium 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904718361,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
donepezil 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904647761,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxazosin 4 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68382078501,NDC,0.25,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
estradiol 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378145201,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
estradiol 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42806008701,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 25 Each Bottle,63700001,CDM,250,RC,,,,,,49348081705,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739064510,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"ferrous sulfate 325 (65 Fe) MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64376080910,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ferrous sulfate 325 (65 Fe) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904759161,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Fish Oil 1000 MG capsule 1 Each Blister,25000000,CDM,250,RC,,,,,,77333030825,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
folic acid 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687068111,NDC,0.4,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
folic acid 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687068101,NDC,0.4,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54829725,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904717861,NDC,0.25,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762403001,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904666561,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739059110,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739090210,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862019901,NDC,0.333333333,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904666661,NDC,0.333333333,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60505011300,NDC,0.333333333,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687059101,NDC,0.333333333,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739023610,NDC,0.333333333,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glimepiride 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547039410,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079081001,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079081020,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE ER 2.5 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714089401,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE ER 5 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714089501,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glyBURIDE 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,93834498,NDC,0.25,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glycerin 2 g Suppository 24 Each Jar,63700001,CDM,250,RC,,,,,,132007924,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 600 MG Tablet Extended Release 12 Hour 20 Each Box,63700001,CDM,250,RC,,,,,,63824000832,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
haloperidol 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079073420,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155000101,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904644161,NDC,0.4,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,64380073506,NDC,0.2,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904644261,NDC,0.2,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydroCHLOROthiazide 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547039710,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 5 MG Tablet 50 Each Bottle,63700001,CDM,250,RC,,,,,,59762007301,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762007401,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406324301,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,42858030125,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084042301,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine HCl 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155050101,NDC,0.4,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,51079007720,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,3.1556
ibuprofen 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904791461,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 600 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687045711,NDC,0.333333333,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 600 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739068410,NDC,0.333333333,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 800 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687046811,NDC,0.25,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 800 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687046801,NDC,0.25,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 800 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739069110,NDC,0.25,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
indomethacin 25 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,50268043011,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,781155601,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
labetalol 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,10135071101,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
labetalol 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687045011,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Lactase 9000 units Tablet 12 Each Box,63700001,CDM,250,RC,,,,,,45091012,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904700761,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031911,NDC,0.25,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084031901,NDC,0.25,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levETIRAcetam 250 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904712361,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 50 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079044001,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 50 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079044020,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
liothyronine 25 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762120701,NDC,0.2,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079098101,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679761,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,591040701,NDC,0.25,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679861,NDC,0.25,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679961,NDC,0.125,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687033301,NDC,0.125,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904680061,NDC,0.0625,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904720061,NDC,0.0625,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lithium 150 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,54252625,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lithium 150 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,54852625,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
loratadine 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714089801,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904600761,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739049910,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687035511,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904600861,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739050010,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904704861,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739068610,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Magnesium Cl-Calcium Carbonate 71.5-119 MG Tablet Delayed Release 60 Each Bottle,63700001,CDM,250,RC,,,,,,67618010760,NDC,2,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904660961,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,10006070028,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,64980033901,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
medroxyPROGESTERone 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,555087202,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
melatonin 3 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268052411,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
melatonin 3 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268052415,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
melatonin 3 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,904518252,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Melatonin 3-10 MG Tablet 120 Each Bottle,800000,CDM,,,,,,,,47469000852,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Melatonin 10 MG SL Tab 120 Each Bottle,63700001,CDM,250,RC,,,,,,40985027503,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904716261,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 850 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739070210,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 1000 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904669161,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 1000 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904716461,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methadone 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406575523,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methadone 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54855324,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methIMAzole 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155007001,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methIMAzole 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155007101,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methocarbamol 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687055911,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methocarbamol 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739016610,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methocarbamol 750 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687056811,NDC,0.666666667,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoclopramide 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93220401,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoclopramide 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739029310,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 50 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084066611,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 100 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,51079017101,NDC,0.25,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584026511,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904634061,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079080101,NDC,0.25,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904634161,NDC,0.25,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584026711,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,62584026701,NDC,0.125,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metroNIDAZOLE 500 MG Tablet 50 Each Bottle,63700001,CDM,250,RC,,,,,,29300022746,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
miSOPROStol 100 MCG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,70954044310,NDC,0.25,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
montelukast 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904680861,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine immediate release 15 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54023525,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine immediate release 15 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,832027311,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
multivitamin with minerals Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904549261,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
naproxen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739040310,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine polacrilex 4 MG Lozenge 24 Each Bottle,63700001,CDM,250,RC,,,,,,43598048772,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine polacrilex 4 MG Lozenge 72 Each Box,63700001,CDM,250,RC,,,,,,49348085316,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 1 Each Blister,63700001,CDM,250,RC,,,,,,68084012811,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,904691761,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,68084012801,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyBUTYnin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904702761,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406055223,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406055262,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739096310,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PHENobarbital 32.4 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904657561,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenytoin ER 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904618761,NDC,0.3,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenytoin ER 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,68084037601,NDC,0.3,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phosphorus 155-852-130 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,64980010401,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687059211,NDC,0.125,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
predniSONE 1 MG Tablet 100 Each Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,64380078206,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 1 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54873925,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 2.5 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54874025,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 5 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687012211,NDC,0.2,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 10 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687013411,NDC,0.1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001720,NDC,0.1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,63739051910,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 20 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014511,NDC,0.05,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001820,NDC,0.05,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014501,NDC,0.05,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
pregabalin 25 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,76282056890,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 75 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904700061,NDC,0.333333333,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prochlorperazine 10 MG Tablet 100 Each Bottle,25000000,CDM,250,RC,,,,,,59746011506,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
promethazine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,Q0169,HCPCS,,,,904646161,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904655061,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268070211,NDC,0.25,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687060911,NDC,0.25,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687060901,NDC,0.25,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Prosight Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,536509008,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
psyllium 0.52 GM capsule 160 Each Bottle,25000000,CDM,250,RC,,,,,,80681002200,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Psyllium 400 MG capsule 160 Each Bottle,25000000,CDM,250,RC,,,,,,10939081644,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pyridoxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536440601,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pyridoxine 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,77333094010,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904663861,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904664061,NDC,0.25,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739066510,NDC,0.25,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ramipril 5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,68382014601,NDC,0.25,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904736161,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rOPINIRole 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637461,NDC,0.25,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268071111,NDC,0.125,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268071115,NDC,0.125,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna 8.6 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904652261,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687062211,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,57896045806,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904633961,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687062201,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739043210,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018011,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904692461,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018001,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687024211,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018111,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687024201,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018101,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687025311,NDC,0.25,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904692661,NDC,0.25,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687025301,NDC,0.25,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simethicone 125 MG Tablet Chewable 18 Each Box,63700001,CDM,250,RC,,,,,,49348086348,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simethicone 125 MG Tablet Chewable 60 Each Bottle,63700001,CDM,250,RC,,,,,,69618003206,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simvastatin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739057010,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simvastatin 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739057310,NDC,0.125,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"sodium bicarbonate 650 MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64980018210,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"sodium bicarbonate 650 MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64980052810,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium chloride 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,223176001,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 12.5 mg Tablet 1 split tablet Blister,63700001,CDM,250,RC,,,,,,8888800438,NDC,2,UN,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079010301,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687046511,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079010320,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687046501,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739054410,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 800-160 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904272561,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 800-160 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739022810,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tamsulosin 0.4 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739056710,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079041801,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877014601,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079041820,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739023110,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terazosin 5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59746038506,NDC,0.2,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
therapeutic multivitamin Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904053961,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,77333093425,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,37864090599,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,77333093410,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268075611,NDC,0.25,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268075615,NDC,0.25,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54007725,NDC,0.25,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50111091701,NDC,0.25,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739067110,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traZODone 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904655461,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
valsartan 160 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342006410,NDC,0.25,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536333401,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904582461,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,10006070033,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,20555003300,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121201,NDC,0.5,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121301,NDC,0.4,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 3 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121401,NDC,0.333333333,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,832121689,NDC,0.2,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121601,NDC,0.2,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zinc gluconate 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,40093010153,NDC,1,EA,3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600110,NDC,10,ML,589.63,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600121,NDC,10,ML,592.5,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040304,NDC,10,ML,168.77,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040310,NDC,10,ML,168.77,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
nitroglycerin in dextrose 5% 100-5 MCG/ML-% Solution 250 mL Glass Cont,J2305.01,CDM,636,RC,J2305,HCPCS,,,,338104702,NDC,250,ML,126.07,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.29,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.13,1.44
cyclobenzaprine 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69097084607,NDC,0.5,EA,3.11,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.291894,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637161,NDC,0.25,EA,3.03,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.29987,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Noninvasv Oxygen Satur;Single,PX94760,CDM,460,RC,94760,CPT,,,,,,,,131,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.3,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.3,4.65
sodium chloride 0.9 % 0.9 % Solution 50 mL Flex Cont,J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004941,NDC,50,ML,43.5,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.3,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.18,1.35
sodium chloride 0.9 % 0.9 % Solution 50 mL Flex Cont,J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004941,NDC,50,ML,43.5,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.3,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.18,1.35
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Syringe,J7040.01,CDM,636,RC,J7040,HCPCS,,,,64253020230,NDC,10,ML,42.15,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.3,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.18,1.35
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Syringe,J7040.01,CDM,636,RC,J7040,HCPCS,,,,64253020230,NDC,10,ML,42.15,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.3,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.18,1.35
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488802,NDC,10,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.3,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.18,1.35
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488802,NDC,10,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.3,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.18,1.35
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018603,NDC,20,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.3,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.18,1.35
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018603,NDC,20,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.3,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.18,1.35
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018620,NDC,20,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.3,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.18,1.35
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018620,NDC,20,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.3,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.18,1.35
sodium chloride 0.9 % PF 0.9 % Solution 50 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488850,NDC,3,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.3,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.18,1.35
sodium chloride 0.9 % PF 0.9 % Solution 50 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488850,NDC,3,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.3,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.18,1.35
"sodium chloride 0.9% 0.9% Solution 1,000 mL Flex Cont",J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004904,NDC,1000,ML,99.12,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.3,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.18,1.35
"sodium chloride 0.9% 0.9% Solution 1,000 mL Flex Cont",J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004904,NDC,1000,ML,99.12,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.3,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.18,1.35
acetaminophen 120 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802073230,NDC,1,EA,3.13,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.300202,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54829925,NDC,1,EA,3.15,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.30851,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nortriptyline 25 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,93081101,NDC,0.4,EA,3.15,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.30851,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gadoteridol 279.3 MG/ML Solution 5 mL Vial,A9576,CDM,636,RC,A9576,HCPCS,,,,270111104,NDC,10,ML,100,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.31,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.31,1.53
gadoteridol 279.3 MG/ML Solution 17 mL Syringe,A9576,CDM,636,RC,A9576,HCPCS,,,,270111145,NDC,17,ML,170,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.31,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.31,1.53
acetaminophen 120 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,713011806,NDC,1,EA,3.17,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.316818,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 120 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713011812,NDC,1,EA,3.17,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.316818,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079080120,NDC,1,EA,3.07,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.31703,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012166,NDC,1,EA,58.66,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.31897,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.11,1.33
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024010,NDC,1,EA,56.73,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.31897,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.11,1.33
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505624500,NDC,1,EA,116.99,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.31897,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.11,1.33
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012250,NDC,1,EA,77.24,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.31897,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.11,1.33
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012267,NDC,1,EA,77.24,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.31897,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.11,1.33
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024110,NDC,1,EA,76.1,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.31897,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.11,1.33
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505614700,NDC,1,EA,212.52,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.31897,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.11,1.33
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034020,NDC,1,EA,76.67,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.31897,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.11,1.33
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034021,NDC,1,EA,76.67,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.31897,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.11,1.33
benzonatate 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904715361,NDC,1,EA,3.18,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.320972,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
OSTOMY DRAINABLE POUCH INVISICLOSE 1.75,27200000,CDM,272,RC,A5063,HCPCS,,12071-MAIN,LOCAL,,,,,1.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1.323,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
prochlorperazine 5 MG Tablet 100 Each Bottle,63600000,CDM,636,RC,Q0164,HCPCS,,,,59746011306,NDC,1,EA,3.19,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.325126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012166,NDC,1,EA,58.66,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.11,1.33
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012166,NDC,1,EA,58.66,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.11,1.33
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024010,NDC,1,EA,56.73,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.11,1.33
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024010,NDC,1,EA,56.73,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.11,1.33
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505624500,NDC,1,EA,116.99,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.11,1.33
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505624500,NDC,1,EA,116.99,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.11,1.33
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012250,NDC,1,EA,77.24,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.11,1.33
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012250,NDC,1,EA,77.24,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.11,1.33
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012267,NDC,1,EA,77.24,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.11,1.33
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012267,NDC,1,EA,77.24,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.11,1.33
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024110,NDC,1,EA,76.1,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.11,1.33
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024110,NDC,1,EA,76.1,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.11,1.33
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505614700,NDC,1,EA,212.52,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.11,1.33
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505614700,NDC,1,EA,212.52,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.11,1.33
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034020,NDC,1,EA,76.67,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.11,1.33
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034020,NDC,1,EA,76.67,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.11,1.33
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034021,NDC,1,EA,76.67,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.11,1.33
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034021,NDC,1,EA,76.67,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.11,1.33
cyclobenzaprine 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69097084607,NDC,0.5,EA,3.11,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.33419,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
OSTOMY DRAINABLE POUCH INVISICLOSE 1.75,27200000,CDM,272,RC,A5063,HCPCS,,12071-MAIN,LOCAL,,,,,1.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1.335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
hydrOXYzine pamoate 25 MG capsule 1 Each Blister,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084711,NDC,1,EA,3.22,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.337588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,3.1556
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084701,NDC,1,EA,3.22,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.337588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,3.1556
losartan 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739067310,NDC,1,EA,3.22,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.337588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 120 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802073230,NDC,1,EA,3.13,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.34277,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
chlorthalidone 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378022201,NDC,0.5,EA,3.24,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.345896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium chloride 0.9 % 0.9 % Solution 50 mL Flex Cont,J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004941,NDC,50,ML,43.5,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.35,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.18,1.35
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Syringe,J7040.01,CDM,636,RC,J7040,HCPCS,,,,64253020230,NDC,10,ML,42.15,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.35,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.18,1.35
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488802,NDC,10,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.35,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.18,1.35
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018603,NDC,20,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.35,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.18,1.35
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018620,NDC,20,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.35,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.18,1.35
sodium chloride 0.9 % PF 0.9 % Solution 50 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488850,NDC,3,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.35,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.18,1.35
"sodium chloride 0.9% 0.9% Solution 1,000 mL Flex Cont",J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004904,NDC,1000,ML,99.12,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.35,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.18,1.35
furosemide 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54829925,NDC,1,EA,3.15,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.35135,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nortriptyline 25 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,93081101,NDC,0.4,EA,3.15,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.35135,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 120 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,713011806,NDC,1,EA,3.17,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.35993,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 120 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713011812,NDC,1,EA,3.17,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.35993,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prochlorperazine 5 MG Tablet 1 Each Blister,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054101,NDC,1,EA,3.28,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.362512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
benzonatate 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904715361,NDC,1,EA,3.18,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.36422,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
OSTOMY DRAINABLE POUCH INVISICLOSE 1.75,27200000,CDM,272,RC,A5063,HCPCS,,12071-MAIN,LOCAL,,,,,1.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1.3665,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
prochlorperazine 5 MG Tablet 100 Each Box,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054120,NDC,1,EA,3.29,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.366666,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
prochlorperazine 5 MG Tablet 100 Each Bottle,63600000,CDM,636,RC,Q0164,HCPCS,,,,59746011306,NDC,1,EA,3.19,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.36851,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,143971801,NDC,200,ML,230.48,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.37,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.37,1.56
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,409277602,NDC,200,ML,228.28,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.37,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.37,1.56
potassium chloride CR 10 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,66758017006,NDC,1,EA,3.32,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.379128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,245531701,NDC,1,EA,3.32,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.379128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,66758017013,NDC,1,EA,3.32,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.379128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine pamoate 25 MG capsule 1 Each Blister,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084711,NDC,1,EA,3.22,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.38138,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,3.1556
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084701,NDC,1,EA,3.22,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.38138,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,3.1556
losartan 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739067310,NDC,1,EA,3.22,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.38138,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 50 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904632361,NDC,0.5,EA,3.33,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.383282,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,42858000110,NDC,1,EA,3.33,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.383282,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,245531789,NDC,1,EA,3.33,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.383282,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,63323004401,NDC,1,ML,64.53,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.38331,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.27,1.44
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,70069000501,NDC,0.1,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.38331,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.27,1.44
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687064011,NDC,1,EA,3.34,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.387436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687064001,NDC,1,EA,3.34,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.387436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
chlorthalidone 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378022201,NDC,0.5,EA,3.24,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.38996,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"dextrose 5% and sodium chloride 0.2% 5-0.2 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338007704,NDC,1000,ML,99.12,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.39,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.12595,1.59
"dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008904,NDC,1000,ML,99.12,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.39,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.12595,1.59
dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 500 mL Flex Cont,J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008903,NDC,500,ML,99.12,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.39,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.12595,1.59
"dextrose 5% and sodium chloride 0.45% 5-0.45 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008504,NDC,1000,ML,99.12,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.39,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.12595,1.59
doxepin 10 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,51672421701,NDC,1,EA,3.36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.395744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084008211,NDC,0.5,EA,3.36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.395744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268075411,NDC,1,EA,3.36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.395744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 5 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268075415,NDC,1,EA,3.36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.395744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prochlorperazine 5 MG Tablet 1 Each Blister,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054101,NDC,1,EA,3.28,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.40712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600110,NDC,10,ML,589.63,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.24,7.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600110,NDC,10,ML,589.63,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.24,7.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600121,NDC,10,ML,592.5,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.24,7.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600121,NDC,10,ML,592.5,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.24,7.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040304,NDC,10,ML,168.77,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.24,7.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040304,NDC,10,ML,168.77,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.24,7.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040310,NDC,10,ML,168.77,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.24,7.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040310,NDC,10,ML,168.77,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.24,7.65
prochlorperazine 5 MG Tablet 100 Each Box,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054120,NDC,1,EA,3.29,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.41141,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
levothyroxine 112 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003901,NDC,0.892857143,EA,3.4,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.41236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin in dextrose 5% 100-5 MCG/ML-% Solution 250 mL Glass Cont,J2305.01,CDM,636,RC,J2305,HCPCS,,,,338104702,NDC,250,ML,126.07,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.41548,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.13,1.44
ALPRAZolam 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585861,NDC,1,EA,3.41,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.416514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine HCl 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714008110,NDC,1,EA,3.41,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.416514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50111091501,NDC,1,EA,3.41,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.416514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,63323004401,NDC,1,ML,64.53,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.27,1.44
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,63323004401,NDC,1,ML,64.53,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.27,1.44
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,70069000501,NDC,0.1,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.27,1.44
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,70069000501,NDC,0.1,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.27,1.44
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,143931901,NDC,0.4,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.42,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.24,1.42
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,63323047401,NDC,1,ML,58.6,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.42,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.24,1.42
potassium chloride CR 10 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,66758017006,NDC,1,EA,3.32,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.42428,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,245531701,NDC,1,EA,3.32,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.42428,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,66758017013,NDC,1,EA,3.32,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.42428,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carBAMazepine 100 MG Tablet Chewable 100 Each Box,63700001,CDM,250,RC,,,,,,904385461,NDC,1,EA,3.43,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.424822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxepin 10 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079043620,NDC,1,EA,3.43,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.424822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 50 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904632361,NDC,0.5,EA,3.33,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.42857,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,42858000110,NDC,1,EA,3.33,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.42857,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,245531789,NDC,1,EA,3.33,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.42857,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen-codeine 300-30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739000410,NDC,1,EA,3.44,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.428976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
penicillin v potassium 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714023501,NDC,0.5,EA,3.44,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.428976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenytoin ER 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084037611,NDC,1,EA,3.44,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.428976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687064011,NDC,1,EA,3.34,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.43286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687064001,NDC,1,EA,3.34,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.43286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,591024001,NDC,1,EA,3.45,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.43313,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904198261,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904198261,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580045811,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580045811,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580060002,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580060002,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 750 Each Box,63700001,CDM,250,RC,,,,,,63739044001,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 750 Each Box,63700001,CDM,250,RC,,,,,,63739044001,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904198861,NDC,0.65,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904198861,NDC,0.65,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904673061,NDC,0.65,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904673061,NDC,0.65,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580045711,NDC,0.65,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580045711,NDC,0.65,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 650 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,70010016001,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 650 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,70010016001,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen-codeine 300-30 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406048423,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen-codeine 300-30 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406048423,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen-codeine 300-30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406048462,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen-codeine 300-30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406048462,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020501,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020501,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584098811,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584098811,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,53489015601,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,53489015601,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904657161,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904657161,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020520,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020520,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,62584098801,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,62584098801,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862067701,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862067701,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585961,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585961,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739064410,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739064410,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amitriptyline 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268003711,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amitriptyline 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268003711,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amitriptyline 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687043311,NDC,0.4,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amitriptyline 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687043311,NDC,0.4,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amitriptyline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687043301,NDC,0.4,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amitriptyline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687043301,NDC,0.4,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687026311,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687026311,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084025911,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084025911,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687026301,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687026301,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084025901,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084025901,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714029903,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714029903,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ascorbic acid 500 MG Tablet 100 Each Box,25000000,CDM,250,RC,,,,,,904052361,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ascorbic acid 500 MG Tablet 100 Each Box,25000000,CDM,250,RC,,,,,,904052361,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
aspirin 81 MG Tablet Chewable 90 Each Bottle,63700001,CDM,250,RC,,,,,,904679489,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin 81 MG Tablet Chewable 90 Each Bottle,63700001,CDM,250,RC,,,,,,904679489,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin 81 MG Tablet Chewable 500 Each Disp Pack,63700001,CDM,250,RC,,,,,,66553000201,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin 81 MG Tablet Chewable 500 Each Disp Pack,63700001,CDM,250,RC,,,,,,66553000201,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin 325 MG Tablet 500 Each Box,63700001,CDM,250,RC,,,,,,66553000101,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin 325 MG Tablet 500 Each Box,63700001,CDM,250,RC,,,,,,66553000101,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 81 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,63739021210,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 81 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,63739021210,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 81 MG Tablet Delayed Release 120 Each Bottle,63700001,CDM,250,RC,,,,,,10135017362,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 81 MG Tablet Delayed Release 120 Each Bottle,63700001,CDM,250,RC,,,,,,10135017362,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,536114801,NDC,0.249230769,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,536114801,NDC,0.249230769,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,536331301,NDC,0.249230769,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,536331301,NDC,0.249230769,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,603016921,NDC,0.249230769,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,603016921,NDC,0.249230769,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079068401,NDC,0.25,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079068401,NDC,0.25,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020801,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020801,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629061,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629061,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020820,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020820,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020901,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020901,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629161,NDC,0.25,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629161,NDC,0.25,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020920,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020920,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079021001,NDC,0.125,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079021001,NDC,0.125,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
azaTHIOprine 50 MG Tablet 1 Each Blister,J7500.01,CDM,636,RC,J7500,HCPCS,,,,68084022911,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2.94
azaTHIOprine 50 MG Tablet 1 Each Blister,J7500.01,CDM,636,RC,J7500,HCPCS,,,,68084022911,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2.94
baclofen 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904647561,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
baclofen 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904647561,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
baclofen 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739047910,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
baclofen 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739047910,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268011011,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268011011,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 40 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547033810,NDC,0.125,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 40 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547033810,NDC,0.125,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 1 Each Box,63700001,CDM,250,RC,,,,,,713010906,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 1 Each Box,63700001,CDM,250,RC,,,,,,713010906,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574705012,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574705012,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713010912,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713010912,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,904505812,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,904505812,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl EC 5 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,904640761,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl EC 5 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,904640761,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bismuth subsalicylate 262 MG Tablet Chewable 30 Each Box,63700001,CDM,250,RC,,,,,,904720546,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bismuth subsalicylate 262 MG Tablet Chewable 30 Each Box,63700001,CDM,250,RC,,,,,,904720546,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bumetanide 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,185012901,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bumetanide 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,185012901,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buPROPion SR 150 MG Tablet Extended Release 12 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084070895,NDC,0.666666667,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buPROPion SR 150 MG Tablet Extended Release 12 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084070895,NDC,0.666666667,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buPROPion SR 150 MG Tablet Extended Release 12 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,68084070825,NDC,0.666666667,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buPROPion SR 150 MG Tablet Extended Release 12 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,68084070825,NDC,0.666666667,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcium carb-cholecalciferol 600-10 mg-mcg (600-400 mg-unit) Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,20555001700,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcium carb-cholecalciferol 600-10 mg-mcg (600-400 mg-unit) Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,20555001700,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcium carbonate 500 MG Tablet Chewable 500 Each Box,63700001,CDM,250,RC,,,,,,66553000401,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcium carbonate 500 MG Tablet Chewable 500 Each Box,63700001,CDM,250,RC,,,,,,66553000401,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
candesartan 32 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,49884066109,NDC,0.125,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
candesartan 32 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,49884066109,NDC,0.125,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 10-100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,72888010601,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 10-100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,72888010601,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687066111,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687066111,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084009311,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084009311,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687066101,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687066101,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-250 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084009411,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-250 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084009411,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carvedilol 12.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904630261,NDC,0.25,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carvedilol 12.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904630261,NDC,0.25,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cetirizine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904671761,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cetirizine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904671761,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cholecalciferol (vitamin D3) 125 MCG (5000 UT) capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,80681013100,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cholecalciferol (vitamin D3) 125 MCG (5000 UT) capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,80681013100,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637861,NDC,0.2,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637861,NDC,0.2,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904724361,NDC,0.2,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904724361,NDC,0.2,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin 150 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904595961,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin 150 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904595961,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714075201,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714075201,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16729013600,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16729013600,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloNIDine 0.1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687011311,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloNIDine 0.1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687011311,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloNIDine 0.1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687011301,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloNIDine 0.1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687011301,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloNIDine 0.1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739006010,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloNIDine 0.1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739006010,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
codeine 30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54024424,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
codeine 30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54024424,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536136601,NDC,0.25,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536136601,NDC,0.25,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536355601,NDC,0.25,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536355601,NDC,0.25,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,74312001380,NDC,0.25,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,74312001380,NDC,0.25,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,63323004401,NDC,1,ML,64.53,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.44,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.27,1.44
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,70069000501,NDC,0.1,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.44,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.27,1.44
cyclobenzaprine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079064401,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079064401,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687055811,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687055811,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687055801,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687055801,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54417925,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54417925,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54817925,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54817925,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54817625,NDC,0.125,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54817625,NDC,0.125,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 6 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54418625,NDC,0.041666667,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 6 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54418625,NDC,0.041666667,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079028401,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079028401,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,172392560,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,172392560,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079028420,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079028420,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079028501,NDC,0.4,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079028501,NDC,0.4,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,172392660,NDC,0.4,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,172392660,NDC,0.4,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079028520,NDC,0.4,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079028520,NDC,0.4,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687019511,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687019511,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687019501,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687019501,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 180 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687020611,NDC,0.666666667,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 180 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687020611,NDC,0.666666667,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 180 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687020601,NDC,0.666666667,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 180 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687020601,NDC,0.666666667,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687021711,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687021711,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739001610,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739001610,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 25 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904530661,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 25 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904530661,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 25 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904723761,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 25 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904723761,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 50 MG capsule 100 Each Box,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904205661,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,1.38,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
diphenhydrAMINE 50 MG capsule 100 Each Box,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904205661,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
divalproex 250 MG Tablet Delayed Release 1 Each Box,63700001,CDM,250,RC,,,,,,832712389,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 250 MG Tablet Delayed Release 1 Each Box,63700001,CDM,250,RC,,,,,,832712389,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 250 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,832712301,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 250 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,832712301,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
docusate sodium 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,10135011101,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
docusate sodium 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,10135011101,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
docusate sodium 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904645561,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
docusate sodium 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904645561,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
docusate sodium 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904718361,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
docusate sodium 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904718361,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
donepezil 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904647761,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
donepezil 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904647761,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxazosin 4 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68382078501,NDC,0.25,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxazosin 4 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68382078501,NDC,0.25,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
estradiol 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378145201,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
estradiol 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378145201,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
estradiol 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42806008701,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
estradiol 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42806008701,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 25 Each Bottle,63700001,CDM,250,RC,,,,,,49348081705,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 25 Each Bottle,63700001,CDM,250,RC,,,,,,49348081705,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739064510,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739064510,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"ferrous sulfate 325 (65 Fe) MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64376080910,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"ferrous sulfate 325 (65 Fe) MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64376080910,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ferrous sulfate 325 (65 Fe) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904759161,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ferrous sulfate 325 (65 Fe) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904759161,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Fish Oil 1000 MG capsule 1 Each Blister,25000000,CDM,250,RC,,,,,,77333030825,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Fish Oil 1000 MG capsule 1 Each Blister,25000000,CDM,250,RC,,,,,,77333030825,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
folic acid 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687068111,NDC,0.4,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
folic acid 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687068111,NDC,0.4,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
folic acid 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687068101,NDC,0.4,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
folic acid 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687068101,NDC,0.4,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54829725,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54829725,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904717861,NDC,0.25,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904717861,NDC,0.25,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762403001,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762403001,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904666561,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904666561,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739059110,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739059110,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739090210,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739090210,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862019901,NDC,0.333333333,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862019901,NDC,0.333333333,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904666661,NDC,0.333333333,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904666661,NDC,0.333333333,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60505011300,NDC,0.333333333,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60505011300,NDC,0.333333333,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687059101,NDC,0.333333333,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687059101,NDC,0.333333333,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739023610,NDC,0.333333333,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739023610,NDC,0.333333333,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glimepiride 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547039410,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glimepiride 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547039410,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079081001,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079081001,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079081020,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079081020,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE ER 2.5 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714089401,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE ER 2.5 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714089401,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE ER 5 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714089501,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE ER 5 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714089501,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glyBURIDE 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,93834498,NDC,0.25,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glyBURIDE 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,93834498,NDC,0.25,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glycerin 2 g Suppository 24 Each Jar,63700001,CDM,250,RC,,,,,,132007924,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glycerin 2 g Suppository 24 Each Jar,63700001,CDM,250,RC,,,,,,132007924,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 600 MG Tablet Extended Release 12 Hour 20 Each Box,63700001,CDM,250,RC,,,,,,63824000832,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 600 MG Tablet Extended Release 12 Hour 20 Each Box,63700001,CDM,250,RC,,,,,,63824000832,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
haloperidol 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079073420,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
haloperidol 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079073420,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155000101,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155000101,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904644161,NDC,0.4,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904644161,NDC,0.4,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,64380073506,NDC,0.2,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,64380073506,NDC,0.2,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904644261,NDC,0.2,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904644261,NDC,0.2,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydroCHLOROthiazide 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547039710,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydroCHLOROthiazide 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547039710,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 5 MG Tablet 50 Each Bottle,63700001,CDM,250,RC,,,,,,59762007301,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 5 MG Tablet 50 Each Bottle,63700001,CDM,250,RC,,,,,,59762007301,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762007401,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762007401,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406324301,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406324301,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,42858030125,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,42858030125,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084042301,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084042301,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine HCl 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155050101,NDC,0.4,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine HCl 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155050101,NDC,0.4,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,51079007720,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,3.1556
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,51079007720,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,3.1556
ibuprofen 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904791461,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904791461,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 600 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687045711,NDC,0.333333333,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 600 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687045711,NDC,0.333333333,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 600 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739068410,NDC,0.333333333,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 600 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739068410,NDC,0.333333333,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 800 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687046811,NDC,0.25,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 800 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687046811,NDC,0.25,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 800 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687046801,NDC,0.25,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 800 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687046801,NDC,0.25,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 800 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739069110,NDC,0.25,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 800 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739069110,NDC,0.25,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
indomethacin 25 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,50268043011,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
indomethacin 25 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,50268043011,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,781155601,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,781155601,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
labetalol 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,10135071101,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
labetalol 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,10135071101,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
labetalol 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687045011,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
labetalol 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687045011,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Lactase 9000 units Tablet 12 Each Box,63700001,CDM,250,RC,,,,,,45091012,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Lactase 9000 units Tablet 12 Each Box,63700001,CDM,250,RC,,,,,,45091012,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904700761,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904700761,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031911,NDC,0.25,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031911,NDC,0.25,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084031901,NDC,0.25,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084031901,NDC,0.25,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levETIRAcetam 250 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904712361,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levETIRAcetam 250 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904712361,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 50 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079044001,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 50 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079044001,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 50 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079044020,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 50 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079044020,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
liothyronine 25 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762120701,NDC,0.2,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
liothyronine 25 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762120701,NDC,0.2,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079098101,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079098101,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679761,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679761,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,591040701,NDC,0.25,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,591040701,NDC,0.25,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679861,NDC,0.25,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679861,NDC,0.25,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679961,NDC,0.125,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679961,NDC,0.125,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687033301,NDC,0.125,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687033301,NDC,0.125,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904680061,NDC,0.0625,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904680061,NDC,0.0625,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904720061,NDC,0.0625,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904720061,NDC,0.0625,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lithium 150 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,54252625,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lithium 150 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,54252625,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lithium 150 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,54852625,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lithium 150 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,54852625,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
loratadine 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714089801,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
loratadine 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714089801,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904600761,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904600761,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739049910,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739049910,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687035511,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687035511,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904600861,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904600861,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739050010,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739050010,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904704861,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904704861,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739068610,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739068610,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Magnesium Cl-Calcium Carbonate 71.5-119 MG Tablet Delayed Release 60 Each Bottle,63700001,CDM,250,RC,,,,,,67618010760,NDC,2,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Magnesium Cl-Calcium Carbonate 71.5-119 MG Tablet Delayed Release 60 Each Bottle,63700001,CDM,250,RC,,,,,,67618010760,NDC,2,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904660961,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904660961,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,10006070028,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,10006070028,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,64980033901,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,64980033901,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
medroxyPROGESTERone 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,555087202,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
medroxyPROGESTERone 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,555087202,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
melatonin 3 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268052411,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
melatonin 3 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268052411,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
melatonin 3 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268052415,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
melatonin 3 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268052415,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
melatonin 3 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,904518252,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
melatonin 3 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,904518252,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Melatonin 3-10 MG Tablet 120 Each Bottle,800000,CDM,,,,,,,,47469000852,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Melatonin 3-10 MG Tablet 120 Each Bottle,800000,CDM,,,,,,,,47469000852,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Melatonin 10 MG SL Tab 120 Each Bottle,63700001,CDM,250,RC,,,,,,40985027503,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Melatonin 10 MG SL Tab 120 Each Bottle,63700001,CDM,250,RC,,,,,,40985027503,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904716261,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904716261,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 850 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739070210,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 850 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739070210,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 1000 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904669161,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 1000 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904669161,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 1000 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904716461,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 1000 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904716461,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methadone 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406575523,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methadone 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406575523,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methadone 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54855324,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methadone 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54855324,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methIMAzole 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155007001,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methIMAzole 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155007001,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methIMAzole 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155007101,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methIMAzole 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155007101,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methocarbamol 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687055911,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methocarbamol 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687055911,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methocarbamol 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739016610,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methocarbamol 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739016610,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methocarbamol 750 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687056811,NDC,0.666666667,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methocarbamol 750 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687056811,NDC,0.666666667,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoclopramide 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93220401,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoclopramide 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93220401,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoclopramide 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739029310,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoclopramide 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739029310,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 50 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084066611,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 50 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084066611,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 100 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,51079017101,NDC,0.25,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 100 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,51079017101,NDC,0.25,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584026511,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584026511,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904634061,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904634061,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079080101,NDC,0.25,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079080101,NDC,0.25,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904634161,NDC,0.25,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904634161,NDC,0.25,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584026711,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584026711,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,62584026701,NDC,0.125,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,62584026701,NDC,0.125,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metroNIDAZOLE 500 MG Tablet 50 Each Bottle,63700001,CDM,250,RC,,,,,,29300022746,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metroNIDAZOLE 500 MG Tablet 50 Each Bottle,63700001,CDM,250,RC,,,,,,29300022746,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
miSOPROStol 100 MCG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,70954044310,NDC,0.25,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
miSOPROStol 100 MCG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,70954044310,NDC,0.25,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
montelukast 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904680861,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
montelukast 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904680861,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine immediate release 15 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54023525,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine immediate release 15 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54023525,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine immediate release 15 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,832027311,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine immediate release 15 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,832027311,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
multivitamin with minerals Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904549261,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
multivitamin with minerals Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904549261,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
naproxen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739040310,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
naproxen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739040310,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine polacrilex 4 MG Lozenge 24 Each Bottle,63700001,CDM,250,RC,,,,,,43598048772,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine polacrilex 4 MG Lozenge 24 Each Bottle,63700001,CDM,250,RC,,,,,,43598048772,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine polacrilex 4 MG Lozenge 72 Each Box,63700001,CDM,250,RC,,,,,,49348085316,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine polacrilex 4 MG Lozenge 72 Each Box,63700001,CDM,250,RC,,,,,,49348085316,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin in dextrose 5% 100-5 MCG/ML-% Solution 250 mL Glass Cont,J2305.01,CDM,636,RC,J2305,HCPCS,,,,338104702,NDC,250,ML,126.07,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.13,1.44
nitroglycerin in dextrose 5% 100-5 MCG/ML-% Solution 250 mL Glass Cont,J2305.01,CDM,636,RC,J2305,HCPCS,,,,338104702,NDC,250,ML,126.07,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.13,1.44
omeprazole 20 MG CAPSULE DELAYED RELEASE 1 Each Blister,63700001,CDM,250,RC,,,,,,68084012811,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 1 Each Blister,63700001,CDM,250,RC,,,,,,68084012811,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,904691761,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,904691761,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,68084012801,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,68084012801,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyBUTYnin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904702761,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyBUTYnin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904702761,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406055223,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406055223,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406055262,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406055262,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739096310,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739096310,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PHENobarbital 32.4 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904657561,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PHENobarbital 32.4 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904657561,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenytoin ER 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904618761,NDC,0.3,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenytoin ER 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904618761,NDC,0.3,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenytoin ER 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,68084037601,NDC,0.3,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenytoin ER 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,68084037601,NDC,0.3,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phosphorus 155-852-130 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,64980010401,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phosphorus 155-852-130 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,64980010401,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687059211,NDC,0.125,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687059211,NDC,0.125,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
predniSONE 1 MG Tablet 100 Each Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,64380078206,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,0.129529412,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 1 MG Tablet 100 Each Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,64380078206,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 1 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54873925,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,0.129529412,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 1 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54873925,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 2.5 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54874025,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,0.129529412,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 2.5 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54874025,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 5 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687012211,NDC,0.2,EA,3,,Health Partners,Health Partners Care Plans,both,48,,0.129529412,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 5 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687012211,NDC,0.2,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 10 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687013411,NDC,0.1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,0.129529412,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 10 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687013411,NDC,0.1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001720,NDC,0.1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,0.129529412,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001720,NDC,0.1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,63739051910,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,0.129529412,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,63739051910,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 20 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014511,NDC,0.05,EA,3,,Health Partners,Health Partners Care Plans,both,48,,0.129529412,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 20 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014511,NDC,0.05,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001820,NDC,0.05,EA,3,,Health Partners,Health Partners Care Plans,both,48,,0.129529412,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001820,NDC,0.05,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014501,NDC,0.05,EA,3,,Health Partners,Health Partners Care Plans,both,48,,0.129529412,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014501,NDC,0.05,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
pregabalin 25 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,76282056890,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 25 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,76282056890,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 75 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904700061,NDC,0.333333333,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 75 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904700061,NDC,0.333333333,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prochlorperazine 10 MG Tablet 100 Each Bottle,25000000,CDM,250,RC,,,,,,59746011506,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
prochlorperazine 10 MG Tablet 100 Each Bottle,25000000,CDM,250,RC,,,,,,59746011506,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
promethazine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,Q0169,HCPCS,,,,904646161,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
promethazine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,Q0169,HCPCS,,,,904646161,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904655061,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904655061,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268070211,NDC,0.25,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268070211,NDC,0.25,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687060911,NDC,0.25,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687060911,NDC,0.25,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687060901,NDC,0.25,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687060901,NDC,0.25,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Prosight Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,536509008,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Prosight Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,536509008,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
psyllium 0.52 GM capsule 160 Each Bottle,25000000,CDM,250,RC,,,,,,80681002200,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
psyllium 0.52 GM capsule 160 Each Bottle,25000000,CDM,250,RC,,,,,,80681002200,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Psyllium 400 MG capsule 160 Each Bottle,25000000,CDM,250,RC,,,,,,10939081644,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Psyllium 400 MG capsule 160 Each Bottle,25000000,CDM,250,RC,,,,,,10939081644,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pyridoxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536440601,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pyridoxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536440601,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pyridoxine 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,77333094010,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pyridoxine 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,77333094010,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904663861,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904663861,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904664061,NDC,0.25,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904664061,NDC,0.25,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739066510,NDC,0.25,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739066510,NDC,0.25,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ramipril 5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,68382014601,NDC,0.25,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ramipril 5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,68382014601,NDC,0.25,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904736161,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904736161,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rOPINIRole 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637461,NDC,0.25,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rOPINIRole 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637461,NDC,0.25,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268071111,NDC,0.125,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268071111,NDC,0.125,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268071115,NDC,0.125,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268071115,NDC,0.125,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna 8.6 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904652261,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna 8.6 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904652261,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687062211,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687062211,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,57896045806,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,57896045806,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904633961,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904633961,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687062201,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687062201,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739043210,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739043210,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018011,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018011,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904692461,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904692461,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018001,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018001,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687024211,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687024211,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018111,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018111,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687024201,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687024201,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018101,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018101,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687025311,NDC,0.25,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687025311,NDC,0.25,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904692661,NDC,0.25,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904692661,NDC,0.25,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687025301,NDC,0.25,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687025301,NDC,0.25,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simethicone 125 MG Tablet Chewable 18 Each Box,63700001,CDM,250,RC,,,,,,49348086348,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simethicone 125 MG Tablet Chewable 18 Each Box,63700001,CDM,250,RC,,,,,,49348086348,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simethicone 125 MG Tablet Chewable 60 Each Bottle,63700001,CDM,250,RC,,,,,,69618003206,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simethicone 125 MG Tablet Chewable 60 Each Bottle,63700001,CDM,250,RC,,,,,,69618003206,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simvastatin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739057010,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simvastatin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739057010,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simvastatin 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739057310,NDC,0.125,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simvastatin 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739057310,NDC,0.125,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"sodium bicarbonate 650 MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64980018210,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"sodium bicarbonate 650 MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64980018210,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"sodium bicarbonate 650 MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64980052810,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"sodium bicarbonate 650 MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64980052810,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium chloride 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,223176001,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium chloride 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,223176001,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 12.5 mg Tablet 1 split tablet Blister,63700001,CDM,250,RC,,,,,,8888800438,NDC,2,UN,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 12.5 mg Tablet 1 split tablet Blister,63700001,CDM,250,RC,,,,,,8888800438,NDC,2,UN,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079010301,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079010301,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687046511,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687046511,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079010320,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079010320,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687046501,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687046501,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739054410,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739054410,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 800-160 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904272561,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 800-160 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904272561,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 800-160 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739022810,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 800-160 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739022810,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tamsulosin 0.4 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739056710,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tamsulosin 0.4 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739056710,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079041801,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079041801,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877014601,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877014601,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079041820,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079041820,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739023110,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739023110,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terazosin 5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59746038506,NDC,0.2,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terazosin 5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59746038506,NDC,0.2,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
therapeutic multivitamin Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904053961,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
therapeutic multivitamin Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904053961,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,77333093425,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,77333093425,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,37864090599,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,37864090599,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,77333093410,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,77333093410,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268075611,NDC,0.25,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268075611,NDC,0.25,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268075615,NDC,0.25,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268075615,NDC,0.25,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54007725,NDC,0.25,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54007725,NDC,0.25,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50111091701,NDC,0.25,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50111091701,NDC,0.25,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739067110,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739067110,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traZODone 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904655461,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traZODone 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904655461,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
valsartan 160 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342006410,NDC,0.25,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
valsartan 160 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342006410,NDC,0.25,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536333401,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536333401,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904582461,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904582461,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,10006070033,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,10006070033,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,20555003300,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,20555003300,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121201,NDC,0.5,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121201,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121301,NDC,0.4,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121301,NDC,0.4,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 3 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121401,NDC,0.333333333,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 3 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121401,NDC,0.333333333,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,832121689,NDC,0.2,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,832121689,NDC,0.2,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121601,NDC,0.2,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121601,NDC,0.2,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zinc gluconate 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,40093010153,NDC,1,EA,3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zinc gluconate 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,40093010153,NDC,1,EA,3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxepin 10 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,51672421701,NDC,1,EA,3.36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.44144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084008211,NDC,0.5,EA,3.36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.44144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268075411,NDC,1,EA,3.36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.44144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 5 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268075415,NDC,1,EA,3.36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.44144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,603420921,NDC,1,EA,3.48,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.445592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68180051201,NDC,1,EA,3.48,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.445592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
protamine 10 MG/ML Solution 5 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022994,NDC,5,ML,84.74,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.45,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.45,2.12
protamine 10 MG/ML Solution 25 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022930,NDC,2.5,ML,44.37,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.45,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.45,2.12
amLODIPine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637161,NDC,0.25,EA,3.03,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.4544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637161,NDC,0.25,EA,3.03,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.4544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 112 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003901,NDC,0.892857143,EA,3.4,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.4586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
OSTOMY DRAINABLE POUCH INVISICLOSE 1.75,27200000,CDM,272,RC,A5063,HCPCS,,12071-MAIN,LOCAL,,,,,1.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1.45995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
XEROFORM GAUZE PETROLATUM 1X8INCH,27200000,CDM,272,RC,A6222,HCPCS,,10659-MAIN,LOCAL,,,,,3.52,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.462208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ALPRAZolam 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585861,NDC,1,EA,3.41,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.46289,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine HCl 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714008110,NDC,1,EA,3.41,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.46289,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50111091501,NDC,1,EA,3.41,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.46289,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904198261,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904198261,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904198261,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580045811,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580045811,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580045811,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580060002,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580060002,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580060002,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 750 Each Box,63700001,CDM,250,RC,,,,,,63739044001,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 750 Each Box,63700001,CDM,250,RC,,,,,,63739044001,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 750 Each Box,63700001,CDM,250,RC,,,,,,63739044001,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904198861,NDC,0.65,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904198861,NDC,0.65,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904198861,NDC,0.65,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904673061,NDC,0.65,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904673061,NDC,0.65,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904673061,NDC,0.65,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580045711,NDC,0.65,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580045711,NDC,0.65,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580045711,NDC,0.65,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 650 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,70010016001,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 650 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,70010016001,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 650 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,70010016001,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen-codeine 300-30 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406048423,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen-codeine 300-30 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406048423,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen-codeine 300-30 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406048423,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen-codeine 300-30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406048462,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen-codeine 300-30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406048462,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen-codeine 300-30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406048462,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020501,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020501,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020501,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584098811,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584098811,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584098811,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,53489015601,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,53489015601,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,53489015601,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904657161,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904657161,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904657161,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020520,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020520,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020520,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,62584098801,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,62584098801,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,62584098801,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862067701,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862067701,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862067701,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585961,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585961,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585961,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739064410,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739064410,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739064410,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amitriptyline 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268003711,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amitriptyline 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268003711,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amitriptyline 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268003711,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amitriptyline 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687043311,NDC,0.4,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amitriptyline 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687043311,NDC,0.4,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amitriptyline 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687043311,NDC,0.4,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amitriptyline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687043301,NDC,0.4,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amitriptyline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687043301,NDC,0.4,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amitriptyline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687043301,NDC,0.4,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687026311,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687026311,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687026311,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084025911,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084025911,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084025911,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687026301,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687026301,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687026301,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084025901,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084025901,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084025901,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714029903,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714029903,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714029903,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ascorbic acid 500 MG Tablet 100 Each Box,25000000,CDM,250,RC,,,,,,904052361,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ascorbic acid 500 MG Tablet 100 Each Box,25000000,CDM,250,RC,,,,,,904052361,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ascorbic acid 500 MG Tablet 100 Each Box,25000000,CDM,250,RC,,,,,,904052361,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
aspirin 81 MG Tablet Chewable 90 Each Bottle,63700001,CDM,250,RC,,,,,,904679489,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin 81 MG Tablet Chewable 90 Each Bottle,63700001,CDM,250,RC,,,,,,904679489,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin 81 MG Tablet Chewable 90 Each Bottle,63700001,CDM,250,RC,,,,,,904679489,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin 81 MG Tablet Chewable 500 Each Disp Pack,63700001,CDM,250,RC,,,,,,66553000201,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin 81 MG Tablet Chewable 500 Each Disp Pack,63700001,CDM,250,RC,,,,,,66553000201,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin 81 MG Tablet Chewable 500 Each Disp Pack,63700001,CDM,250,RC,,,,,,66553000201,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin 325 MG Tablet 500 Each Box,63700001,CDM,250,RC,,,,,,66553000101,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin 325 MG Tablet 500 Each Box,63700001,CDM,250,RC,,,,,,66553000101,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin 325 MG Tablet 500 Each Box,63700001,CDM,250,RC,,,,,,66553000101,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 81 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,63739021210,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 81 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,63739021210,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 81 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,63739021210,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 81 MG Tablet Delayed Release 120 Each Bottle,63700001,CDM,250,RC,,,,,,10135017362,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 81 MG Tablet Delayed Release 120 Each Bottle,63700001,CDM,250,RC,,,,,,10135017362,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 81 MG Tablet Delayed Release 120 Each Bottle,63700001,CDM,250,RC,,,,,,10135017362,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,536114801,NDC,0.249230769,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,536114801,NDC,0.249230769,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,536114801,NDC,0.249230769,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,536331301,NDC,0.249230769,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,536331301,NDC,0.249230769,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,536331301,NDC,0.249230769,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,603016921,NDC,0.249230769,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,603016921,NDC,0.249230769,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,603016921,NDC,0.249230769,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079068401,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079068401,NDC,0.25,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079068401,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020801,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020801,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020801,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629061,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629061,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629061,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020820,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020820,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020820,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020901,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020901,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020901,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629161,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629161,NDC,0.25,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629161,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020920,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020920,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020920,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079021001,NDC,0.125,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079021001,NDC,0.125,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079021001,NDC,0.125,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
azaTHIOprine 50 MG Tablet 1 Each Blister,J7500.01,CDM,636,RC,J7500,HCPCS,,,,68084022911,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2.94
azaTHIOprine 50 MG Tablet 1 Each Blister,J7500.01,CDM,636,RC,J7500,HCPCS,,,,68084022911,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2.94
azaTHIOprine 50 MG Tablet 1 Each Blister,J7500.01,CDM,636,RC,J7500,HCPCS,,,,68084022911,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2.94
baclofen 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904647561,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
baclofen 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904647561,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
baclofen 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904647561,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
baclofen 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739047910,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
baclofen 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739047910,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
baclofen 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739047910,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268011011,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268011011,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268011011,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 40 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547033810,NDC,0.125,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 40 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547033810,NDC,0.125,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 40 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547033810,NDC,0.125,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 1 Each Box,63700001,CDM,250,RC,,,,,,713010906,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 1 Each Box,63700001,CDM,250,RC,,,,,,713010906,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 1 Each Box,63700001,CDM,250,RC,,,,,,713010906,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574705012,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574705012,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574705012,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713010912,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713010912,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713010912,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,904505812,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,904505812,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,904505812,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl EC 5 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,904640761,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl EC 5 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,904640761,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl EC 5 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,904640761,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bismuth subsalicylate 262 MG Tablet Chewable 30 Each Box,63700001,CDM,250,RC,,,,,,904720546,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bismuth subsalicylate 262 MG Tablet Chewable 30 Each Box,63700001,CDM,250,RC,,,,,,904720546,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bismuth subsalicylate 262 MG Tablet Chewable 30 Each Box,63700001,CDM,250,RC,,,,,,904720546,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bumetanide 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,185012901,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bumetanide 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,185012901,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bumetanide 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,185012901,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buPROPion SR 150 MG Tablet Extended Release 12 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084070895,NDC,0.666666667,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buPROPion SR 150 MG Tablet Extended Release 12 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084070895,NDC,0.666666667,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buPROPion SR 150 MG Tablet Extended Release 12 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084070895,NDC,0.666666667,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buPROPion SR 150 MG Tablet Extended Release 12 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,68084070825,NDC,0.666666667,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buPROPion SR 150 MG Tablet Extended Release 12 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,68084070825,NDC,0.666666667,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buPROPion SR 150 MG Tablet Extended Release 12 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,68084070825,NDC,0.666666667,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcium carb-cholecalciferol 600-10 mg-mcg (600-400 mg-unit) Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,20555001700,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcium carb-cholecalciferol 600-10 mg-mcg (600-400 mg-unit) Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,20555001700,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcium carb-cholecalciferol 600-10 mg-mcg (600-400 mg-unit) Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,20555001700,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcium carbonate 500 MG Tablet Chewable 500 Each Box,63700001,CDM,250,RC,,,,,,66553000401,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcium carbonate 500 MG Tablet Chewable 500 Each Box,63700001,CDM,250,RC,,,,,,66553000401,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcium carbonate 500 MG Tablet Chewable 500 Each Box,63700001,CDM,250,RC,,,,,,66553000401,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
candesartan 32 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,49884066109,NDC,0.125,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
candesartan 32 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,49884066109,NDC,0.125,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
candesartan 32 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,49884066109,NDC,0.125,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 10-100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,72888010601,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 10-100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,72888010601,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 10-100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,72888010601,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687066111,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687066111,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687066111,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084009311,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084009311,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084009311,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687066101,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687066101,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687066101,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-250 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084009411,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-250 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084009411,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-250 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084009411,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carvedilol 12.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904630261,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carvedilol 12.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904630261,NDC,0.25,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carvedilol 12.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904630261,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cetirizine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904671761,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cetirizine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904671761,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cetirizine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904671761,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cholecalciferol (vitamin D3) 125 MCG (5000 UT) capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,80681013100,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cholecalciferol (vitamin D3) 125 MCG (5000 UT) capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,80681013100,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cholecalciferol (vitamin D3) 125 MCG (5000 UT) capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,80681013100,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637861,NDC,0.2,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637861,NDC,0.2,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637861,NDC,0.2,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904724361,NDC,0.2,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904724361,NDC,0.2,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904724361,NDC,0.2,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin 150 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904595961,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin 150 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904595961,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin 150 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904595961,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714075201,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714075201,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714075201,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16729013600,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16729013600,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16729013600,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloNIDine 0.1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687011311,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloNIDine 0.1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687011311,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloNIDine 0.1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687011311,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloNIDine 0.1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687011301,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloNIDine 0.1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687011301,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloNIDine 0.1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687011301,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloNIDine 0.1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739006010,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloNIDine 0.1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739006010,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloNIDine 0.1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739006010,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
codeine 30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54024424,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
codeine 30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54024424,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
codeine 30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54024424,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536136601,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536136601,NDC,0.25,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536136601,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536355601,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536355601,NDC,0.25,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536355601,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,74312001380,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,74312001380,NDC,0.25,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,74312001380,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079064401,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079064401,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079064401,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687055811,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687055811,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687055811,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687055801,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687055801,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687055801,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54417925,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54417925,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54417925,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54817925,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54817925,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54817925,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54817625,NDC,0.125,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54817625,NDC,0.125,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54817625,NDC,0.125,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 6 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54418625,NDC,0.041666667,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 6 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54418625,NDC,0.041666667,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 6 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54418625,NDC,0.041666667,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079028401,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079028401,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079028401,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,172392560,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,172392560,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,172392560,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079028420,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079028420,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079028420,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079028501,NDC,0.4,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079028501,NDC,0.4,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079028501,NDC,0.4,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,172392660,NDC,0.4,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,172392660,NDC,0.4,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,172392660,NDC,0.4,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079028520,NDC,0.4,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079028520,NDC,0.4,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079028520,NDC,0.4,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687019511,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687019511,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687019511,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687019501,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687019501,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687019501,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 180 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687020611,NDC,0.666666667,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 180 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687020611,NDC,0.666666667,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 180 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687020611,NDC,0.666666667,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 180 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687020601,NDC,0.666666667,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 180 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687020601,NDC,0.666666667,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 180 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687020601,NDC,0.666666667,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687021711,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687021711,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687021711,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739001610,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739001610,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739001610,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 25 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904530661,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 25 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904530661,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 25 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904530661,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 25 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904723761,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 25 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904723761,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 25 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904723761,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 50 MG capsule 100 Each Box,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904205661,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.6,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
diphenhydrAMINE 50 MG capsule 100 Each Box,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904205661,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
diphenhydrAMINE 50 MG capsule 100 Each Box,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904205661,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
divalproex 250 MG Tablet Delayed Release 1 Each Box,63700001,CDM,250,RC,,,,,,832712389,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 250 MG Tablet Delayed Release 1 Each Box,63700001,CDM,250,RC,,,,,,832712389,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 250 MG Tablet Delayed Release 1 Each Box,63700001,CDM,250,RC,,,,,,832712389,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 250 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,832712301,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 250 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,832712301,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 250 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,832712301,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
docusate sodium 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,10135011101,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
docusate sodium 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,10135011101,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
docusate sodium 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,10135011101,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
docusate sodium 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904645561,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
docusate sodium 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904645561,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
docusate sodium 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904645561,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
docusate sodium 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904718361,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
docusate sodium 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904718361,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
docusate sodium 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904718361,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
donepezil 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904647761,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
donepezil 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904647761,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
donepezil 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904647761,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxazosin 4 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68382078501,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxazosin 4 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68382078501,NDC,0.25,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxazosin 4 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68382078501,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
estradiol 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378145201,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
estradiol 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378145201,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
estradiol 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378145201,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
estradiol 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42806008701,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
estradiol 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42806008701,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
estradiol 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42806008701,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 25 Each Bottle,63700001,CDM,250,RC,,,,,,49348081705,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 25 Each Bottle,63700001,CDM,250,RC,,,,,,49348081705,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 25 Each Bottle,63700001,CDM,250,RC,,,,,,49348081705,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739064510,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739064510,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739064510,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"ferrous sulfate 325 (65 Fe) MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64376080910,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"ferrous sulfate 325 (65 Fe) MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64376080910,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"ferrous sulfate 325 (65 Fe) MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64376080910,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ferrous sulfate 325 (65 Fe) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904759161,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ferrous sulfate 325 (65 Fe) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904759161,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ferrous sulfate 325 (65 Fe) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904759161,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Fish Oil 1000 MG capsule 1 Each Blister,25000000,CDM,250,RC,,,,,,77333030825,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Fish Oil 1000 MG capsule 1 Each Blister,25000000,CDM,250,RC,,,,,,77333030825,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Fish Oil 1000 MG capsule 1 Each Blister,25000000,CDM,250,RC,,,,,,77333030825,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
folic acid 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687068111,NDC,0.4,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
folic acid 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687068111,NDC,0.4,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
folic acid 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687068111,NDC,0.4,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
folic acid 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687068101,NDC,0.4,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
folic acid 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687068101,NDC,0.4,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
folic acid 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687068101,NDC,0.4,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54829725,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54829725,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54829725,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904717861,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904717861,NDC,0.25,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904717861,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762403001,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762403001,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762403001,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904666561,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904666561,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904666561,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739059110,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739059110,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739059110,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739090210,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739090210,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739090210,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862019901,NDC,0.333333333,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862019901,NDC,0.333333333,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862019901,NDC,0.333333333,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904666661,NDC,0.333333333,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904666661,NDC,0.333333333,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904666661,NDC,0.333333333,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60505011300,NDC,0.333333333,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60505011300,NDC,0.333333333,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60505011300,NDC,0.333333333,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687059101,NDC,0.333333333,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687059101,NDC,0.333333333,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687059101,NDC,0.333333333,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739023610,NDC,0.333333333,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739023610,NDC,0.333333333,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739023610,NDC,0.333333333,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glimepiride 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547039410,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glimepiride 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547039410,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glimepiride 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547039410,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079081001,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079081001,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079081001,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079081020,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079081020,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079081020,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE ER 2.5 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714089401,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE ER 2.5 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714089401,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE ER 2.5 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714089401,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE ER 5 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714089501,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE ER 5 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714089501,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE ER 5 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714089501,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glyBURIDE 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,93834498,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glyBURIDE 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,93834498,NDC,0.25,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glyBURIDE 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,93834498,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glycerin 2 g Suppository 24 Each Jar,63700001,CDM,250,RC,,,,,,132007924,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glycerin 2 g Suppository 24 Each Jar,63700001,CDM,250,RC,,,,,,132007924,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glycerin 2 g Suppository 24 Each Jar,63700001,CDM,250,RC,,,,,,132007924,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 600 MG Tablet Extended Release 12 Hour 20 Each Box,63700001,CDM,250,RC,,,,,,63824000832,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 600 MG Tablet Extended Release 12 Hour 20 Each Box,63700001,CDM,250,RC,,,,,,63824000832,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 600 MG Tablet Extended Release 12 Hour 20 Each Box,63700001,CDM,250,RC,,,,,,63824000832,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
haloperidol 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079073420,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
haloperidol 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079073420,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
haloperidol 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079073420,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155000101,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155000101,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155000101,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904644161,NDC,0.4,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904644161,NDC,0.4,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904644161,NDC,0.4,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,64380073506,NDC,0.2,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,64380073506,NDC,0.2,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,64380073506,NDC,0.2,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904644261,NDC,0.2,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904644261,NDC,0.2,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904644261,NDC,0.2,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydroCHLOROthiazide 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547039710,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydroCHLOROthiazide 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547039710,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydroCHLOROthiazide 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547039710,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 5 MG Tablet 50 Each Bottle,63700001,CDM,250,RC,,,,,,59762007301,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 5 MG Tablet 50 Each Bottle,63700001,CDM,250,RC,,,,,,59762007301,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 5 MG Tablet 50 Each Bottle,63700001,CDM,250,RC,,,,,,59762007301,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762007401,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762007401,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762007401,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406324301,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406324301,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406324301,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,42858030125,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,42858030125,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,42858030125,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084042301,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084042301,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084042301,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine HCl 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155050101,NDC,0.4,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine HCl 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155050101,NDC,0.4,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine HCl 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155050101,NDC,0.4,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,51079007720,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,3.1556
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,51079007720,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,3.1556
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,51079007720,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,3.1556
ibuprofen 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904791461,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904791461,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904791461,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 600 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687045711,NDC,0.333333333,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 600 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687045711,NDC,0.333333333,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 600 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687045711,NDC,0.333333333,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 600 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739068410,NDC,0.333333333,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 600 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739068410,NDC,0.333333333,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 600 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739068410,NDC,0.333333333,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 800 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687046811,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 800 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687046811,NDC,0.25,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 800 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687046811,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 800 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687046801,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 800 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687046801,NDC,0.25,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 800 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687046801,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 800 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739069110,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 800 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739069110,NDC,0.25,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 800 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739069110,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
indomethacin 25 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,50268043011,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
indomethacin 25 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,50268043011,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
indomethacin 25 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,50268043011,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,781155601,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,781155601,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,781155601,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
labetalol 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,10135071101,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
labetalol 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,10135071101,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
labetalol 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,10135071101,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
labetalol 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687045011,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
labetalol 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687045011,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
labetalol 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687045011,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Lactase 9000 units Tablet 12 Each Box,63700001,CDM,250,RC,,,,,,45091012,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Lactase 9000 units Tablet 12 Each Box,63700001,CDM,250,RC,,,,,,45091012,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Lactase 9000 units Tablet 12 Each Box,63700001,CDM,250,RC,,,,,,45091012,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904700761,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904700761,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904700761,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031911,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031911,NDC,0.25,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031911,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084031901,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084031901,NDC,0.25,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084031901,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levETIRAcetam 250 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904712361,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levETIRAcetam 250 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904712361,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levETIRAcetam 250 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904712361,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 50 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079044001,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 50 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079044001,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 50 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079044001,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 50 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079044020,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 50 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079044020,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 50 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079044020,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
liothyronine 25 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762120701,NDC,0.2,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
liothyronine 25 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762120701,NDC,0.2,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
liothyronine 25 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762120701,NDC,0.2,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079098101,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079098101,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079098101,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679761,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679761,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679761,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,591040701,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,591040701,NDC,0.25,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,591040701,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679861,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679861,NDC,0.25,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679861,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679961,NDC,0.125,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679961,NDC,0.125,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679961,NDC,0.125,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687033301,NDC,0.125,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687033301,NDC,0.125,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687033301,NDC,0.125,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904680061,NDC,0.0625,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904680061,NDC,0.0625,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904680061,NDC,0.0625,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904720061,NDC,0.0625,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904720061,NDC,0.0625,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904720061,NDC,0.0625,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lithium 150 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,54252625,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lithium 150 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,54252625,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lithium 150 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,54252625,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lithium 150 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,54852625,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lithium 150 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,54852625,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lithium 150 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,54852625,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
loratadine 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714089801,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
loratadine 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714089801,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
loratadine 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714089801,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904600761,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904600761,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904600761,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739049910,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739049910,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739049910,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687035511,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687035511,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687035511,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904600861,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904600861,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904600861,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739050010,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739050010,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739050010,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904704861,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904704861,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904704861,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739068610,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739068610,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739068610,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Magnesium Cl-Calcium Carbonate 71.5-119 MG Tablet Delayed Release 60 Each Bottle,63700001,CDM,250,RC,,,,,,67618010760,NDC,2,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Magnesium Cl-Calcium Carbonate 71.5-119 MG Tablet Delayed Release 60 Each Bottle,63700001,CDM,250,RC,,,,,,67618010760,NDC,2,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Magnesium Cl-Calcium Carbonate 71.5-119 MG Tablet Delayed Release 60 Each Bottle,63700001,CDM,250,RC,,,,,,67618010760,NDC,2,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904660961,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904660961,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904660961,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,10006070028,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,10006070028,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,10006070028,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,64980033901,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,64980033901,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,64980033901,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
medroxyPROGESTERone 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,555087202,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
medroxyPROGESTERone 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,555087202,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
medroxyPROGESTERone 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,555087202,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
melatonin 3 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268052411,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
melatonin 3 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268052411,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
melatonin 3 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268052411,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
melatonin 3 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268052415,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
melatonin 3 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268052415,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
melatonin 3 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268052415,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
melatonin 3 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,904518252,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
melatonin 3 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,904518252,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
melatonin 3 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,904518252,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Melatonin 3-10 MG Tablet 120 Each Bottle,800000,CDM,,,,,,,,47469000852,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Melatonin 3-10 MG Tablet 120 Each Bottle,800000,CDM,,,,,,,,47469000852,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Melatonin 3-10 MG Tablet 120 Each Bottle,800000,CDM,,,,,,,,47469000852,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Melatonin 10 MG SL Tab 120 Each Bottle,63700001,CDM,250,RC,,,,,,40985027503,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Melatonin 10 MG SL Tab 120 Each Bottle,63700001,CDM,250,RC,,,,,,40985027503,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Melatonin 10 MG SL Tab 120 Each Bottle,63700001,CDM,250,RC,,,,,,40985027503,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904716261,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904716261,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904716261,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 850 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739070210,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 850 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739070210,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 850 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739070210,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 1000 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904669161,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 1000 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904669161,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 1000 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904669161,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 1000 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904716461,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 1000 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904716461,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 1000 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904716461,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methadone 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406575523,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methadone 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406575523,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methadone 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406575523,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methadone 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54855324,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methadone 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54855324,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methadone 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54855324,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methIMAzole 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155007001,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methIMAzole 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155007001,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methIMAzole 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155007001,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methIMAzole 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155007101,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methIMAzole 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155007101,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methIMAzole 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155007101,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methocarbamol 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687055911,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methocarbamol 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687055911,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methocarbamol 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687055911,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methocarbamol 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739016610,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methocarbamol 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739016610,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methocarbamol 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739016610,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methocarbamol 750 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687056811,NDC,0.666666667,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methocarbamol 750 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687056811,NDC,0.666666667,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methocarbamol 750 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687056811,NDC,0.666666667,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoclopramide 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93220401,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoclopramide 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93220401,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoclopramide 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93220401,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoclopramide 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739029310,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoclopramide 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739029310,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoclopramide 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739029310,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 50 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084066611,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 50 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084066611,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 50 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084066611,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 100 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,51079017101,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 100 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,51079017101,NDC,0.25,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 100 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,51079017101,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584026511,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584026511,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584026511,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904634061,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904634061,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904634061,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079080101,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079080101,NDC,0.25,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079080101,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904634161,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904634161,NDC,0.25,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904634161,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584026711,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584026711,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584026711,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,62584026701,NDC,0.125,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,62584026701,NDC,0.125,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,62584026701,NDC,0.125,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metroNIDAZOLE 500 MG Tablet 50 Each Bottle,63700001,CDM,250,RC,,,,,,29300022746,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metroNIDAZOLE 500 MG Tablet 50 Each Bottle,63700001,CDM,250,RC,,,,,,29300022746,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metroNIDAZOLE 500 MG Tablet 50 Each Bottle,63700001,CDM,250,RC,,,,,,29300022746,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
miSOPROStol 100 MCG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,70954044310,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
miSOPROStol 100 MCG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,70954044310,NDC,0.25,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
miSOPROStol 100 MCG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,70954044310,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
montelukast 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904680861,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
montelukast 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904680861,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
montelukast 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904680861,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine immediate release 15 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54023525,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine immediate release 15 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54023525,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine immediate release 15 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54023525,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine immediate release 15 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,832027311,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine immediate release 15 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,832027311,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine immediate release 15 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,832027311,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
multivitamin with minerals Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904549261,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
multivitamin with minerals Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904549261,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
multivitamin with minerals Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904549261,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
naproxen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739040310,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
naproxen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739040310,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
naproxen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739040310,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine polacrilex 4 MG Lozenge 24 Each Bottle,63700001,CDM,250,RC,,,,,,43598048772,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine polacrilex 4 MG Lozenge 24 Each Bottle,63700001,CDM,250,RC,,,,,,43598048772,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine polacrilex 4 MG Lozenge 24 Each Bottle,63700001,CDM,250,RC,,,,,,43598048772,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine polacrilex 4 MG Lozenge 72 Each Box,63700001,CDM,250,RC,,,,,,49348085316,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine polacrilex 4 MG Lozenge 72 Each Box,63700001,CDM,250,RC,,,,,,49348085316,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine polacrilex 4 MG Lozenge 72 Each Box,63700001,CDM,250,RC,,,,,,49348085316,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 1 Each Blister,63700001,CDM,250,RC,,,,,,68084012811,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 1 Each Blister,63700001,CDM,250,RC,,,,,,68084012811,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 1 Each Blister,63700001,CDM,250,RC,,,,,,68084012811,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,904691761,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,904691761,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,904691761,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,68084012801,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,68084012801,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,68084012801,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
OSTOMY DRAINABLE POUCH INVISICLOSE 1.75,27200000,CDM,272,RC,A5063,HCPCS,,12071-MAIN,LOCAL,,,,,1.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
oxyBUTYnin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904702761,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyBUTYnin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904702761,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyBUTYnin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904702761,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406055223,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406055223,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406055223,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406055262,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406055262,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406055262,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739096310,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739096310,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739096310,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PHENobarbital 32.4 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904657561,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PHENobarbital 32.4 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904657561,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PHENobarbital 32.4 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904657561,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenytoin ER 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904618761,NDC,0.3,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenytoin ER 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904618761,NDC,0.3,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenytoin ER 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904618761,NDC,0.3,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenytoin ER 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,68084037601,NDC,0.3,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenytoin ER 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,68084037601,NDC,0.3,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenytoin ER 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,68084037601,NDC,0.3,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phosphorus 155-852-130 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,64980010401,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phosphorus 155-852-130 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,64980010401,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phosphorus 155-852-130 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,64980010401,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687059211,NDC,0.125,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687059211,NDC,0.125,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687059211,NDC,0.125,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
predniSONE 1 MG Tablet 100 Each Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,64380078206,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.016111111,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 1 MG Tablet 100 Each Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,64380078206,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 1 MG Tablet 100 Each Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,64380078206,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 1 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54873925,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.016111111,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 1 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54873925,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 1 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54873925,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 2.5 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54874025,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.016111111,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 2.5 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54874025,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 2.5 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54874025,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 5 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687012211,NDC,0.2,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.016111111,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 5 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687012211,NDC,0.2,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 5 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687012211,NDC,0.2,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 10 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687013411,NDC,0.1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.016111111,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 10 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687013411,NDC,0.1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 10 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687013411,NDC,0.1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001720,NDC,0.1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.016111111,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001720,NDC,0.1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001720,NDC,0.1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,63739051910,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.016111111,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,63739051910,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,63739051910,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 20 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014511,NDC,0.05,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.016111111,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 20 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014511,NDC,0.05,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 20 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014511,NDC,0.05,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001820,NDC,0.05,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.016111111,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001820,NDC,0.05,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001820,NDC,0.05,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014501,NDC,0.05,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.016111111,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014501,NDC,0.05,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014501,NDC,0.05,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
pregabalin 25 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,76282056890,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 25 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,76282056890,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 25 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,76282056890,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 75 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904700061,NDC,0.333333333,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 75 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904700061,NDC,0.333333333,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 75 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904700061,NDC,0.333333333,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prochlorperazine 10 MG Tablet 100 Each Bottle,25000000,CDM,250,RC,,,,,,59746011506,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
prochlorperazine 10 MG Tablet 100 Each Bottle,25000000,CDM,250,RC,,,,,,59746011506,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
prochlorperazine 10 MG Tablet 100 Each Bottle,25000000,CDM,250,RC,,,,,,59746011506,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
promethazine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,Q0169,HCPCS,,,,904646161,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
promethazine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,Q0169,HCPCS,,,,904646161,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
promethazine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,Q0169,HCPCS,,,,904646161,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904655061,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904655061,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904655061,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268070211,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268070211,NDC,0.25,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268070211,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687060911,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687060911,NDC,0.25,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687060911,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687060901,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687060901,NDC,0.25,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687060901,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Prosight Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,536509008,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Prosight Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,536509008,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Prosight Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,536509008,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
psyllium 0.52 GM capsule 160 Each Bottle,25000000,CDM,250,RC,,,,,,80681002200,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
psyllium 0.52 GM capsule 160 Each Bottle,25000000,CDM,250,RC,,,,,,80681002200,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
psyllium 0.52 GM capsule 160 Each Bottle,25000000,CDM,250,RC,,,,,,80681002200,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Psyllium 400 MG capsule 160 Each Bottle,25000000,CDM,250,RC,,,,,,10939081644,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Psyllium 400 MG capsule 160 Each Bottle,25000000,CDM,250,RC,,,,,,10939081644,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Psyllium 400 MG capsule 160 Each Bottle,25000000,CDM,250,RC,,,,,,10939081644,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pyridoxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536440601,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pyridoxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536440601,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pyridoxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536440601,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pyridoxine 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,77333094010,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pyridoxine 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,77333094010,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pyridoxine 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,77333094010,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904663861,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904663861,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904663861,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904664061,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904664061,NDC,0.25,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904664061,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739066510,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739066510,NDC,0.25,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739066510,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ramipril 5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,68382014601,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ramipril 5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,68382014601,NDC,0.25,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ramipril 5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,68382014601,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904736161,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904736161,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904736161,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rOPINIRole 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637461,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rOPINIRole 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637461,NDC,0.25,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rOPINIRole 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637461,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268071111,NDC,0.125,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268071111,NDC,0.125,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268071111,NDC,0.125,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268071115,NDC,0.125,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268071115,NDC,0.125,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268071115,NDC,0.125,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna 8.6 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904652261,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna 8.6 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904652261,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna 8.6 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904652261,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687062211,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687062211,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687062211,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,57896045806,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,57896045806,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,57896045806,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904633961,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904633961,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904633961,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687062201,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687062201,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687062201,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739043210,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739043210,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739043210,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018011,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018011,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018011,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904692461,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904692461,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904692461,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018001,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018001,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018001,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687024211,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687024211,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687024211,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018111,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018111,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018111,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687024201,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687024201,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687024201,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018101,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018101,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018101,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687025311,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687025311,NDC,0.25,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687025311,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904692661,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904692661,NDC,0.25,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904692661,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687025301,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687025301,NDC,0.25,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687025301,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simethicone 125 MG Tablet Chewable 18 Each Box,63700001,CDM,250,RC,,,,,,49348086348,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simethicone 125 MG Tablet Chewable 18 Each Box,63700001,CDM,250,RC,,,,,,49348086348,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simethicone 125 MG Tablet Chewable 18 Each Box,63700001,CDM,250,RC,,,,,,49348086348,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simethicone 125 MG Tablet Chewable 60 Each Bottle,63700001,CDM,250,RC,,,,,,69618003206,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simethicone 125 MG Tablet Chewable 60 Each Bottle,63700001,CDM,250,RC,,,,,,69618003206,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simethicone 125 MG Tablet Chewable 60 Each Bottle,63700001,CDM,250,RC,,,,,,69618003206,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simvastatin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739057010,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simvastatin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739057010,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simvastatin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739057010,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simvastatin 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739057310,NDC,0.125,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simvastatin 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739057310,NDC,0.125,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simvastatin 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739057310,NDC,0.125,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"sodium bicarbonate 650 MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64980018210,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"sodium bicarbonate 650 MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64980018210,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"sodium bicarbonate 650 MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64980018210,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"sodium bicarbonate 650 MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64980052810,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"sodium bicarbonate 650 MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64980052810,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"sodium bicarbonate 650 MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64980052810,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium chloride 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,223176001,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium chloride 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,223176001,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium chloride 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,223176001,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 12.5 mg Tablet 1 split tablet Blister,63700001,CDM,250,RC,,,,,,8888800438,NDC,2,UN,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 12.5 mg Tablet 1 split tablet Blister,63700001,CDM,250,RC,,,,,,8888800438,NDC,2,UN,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 12.5 mg Tablet 1 split tablet Blister,63700001,CDM,250,RC,,,,,,8888800438,NDC,2,UN,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079010301,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079010301,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079010301,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687046511,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687046511,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687046511,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079010320,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079010320,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079010320,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687046501,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687046501,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687046501,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739054410,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739054410,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739054410,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
STOCKINETTE IMPERVIOUS 9X36 NON22530,27200000,CDM,272,RC,A6457,HCPCS,,10917-MAIN,LOCAL,,,,,14.73,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.47,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
STOCKINETTE IMPERVIOUS 12X48 NON22535,27200000,CDM,272,RC,A6457,HCPCS,,10918-MAIN,LOCAL,,,,,16.47,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.47,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
STOCKINETTE STERILE 4X48 NON22360,27200000,CDM,272,RC,A6457,HCPCS,,10658-MAIN,LOCAL,,,,,10.62,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.47,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
sulfamethoxazole-trimethoprim 800-160 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904272561,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 800-160 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904272561,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 800-160 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904272561,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 800-160 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739022810,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 800-160 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739022810,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 800-160 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739022810,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tamsulosin 0.4 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739056710,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tamsulosin 0.4 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739056710,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tamsulosin 0.4 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739056710,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079041801,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079041801,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079041801,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877014601,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877014601,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877014601,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079041820,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079041820,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079041820,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739023110,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739023110,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739023110,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terazosin 5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59746038506,NDC,0.2,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terazosin 5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59746038506,NDC,0.2,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terazosin 5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59746038506,NDC,0.2,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
therapeutic multivitamin Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904053961,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
therapeutic multivitamin Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904053961,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
therapeutic multivitamin Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904053961,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,77333093425,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,77333093425,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,77333093425,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,37864090599,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,37864090599,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,37864090599,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,77333093410,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,77333093410,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,77333093410,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268075611,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268075611,NDC,0.25,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268075611,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268075615,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268075615,NDC,0.25,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268075615,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54007725,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54007725,NDC,0.25,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54007725,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50111091701,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50111091701,NDC,0.25,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50111091701,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739067110,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739067110,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739067110,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traZODone 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904655461,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traZODone 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904655461,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traZODone 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904655461,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
valsartan 160 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342006410,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
valsartan 160 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342006410,NDC,0.25,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
valsartan 160 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342006410,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536333401,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536333401,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536333401,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904582461,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904582461,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904582461,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,10006070033,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,10006070033,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,10006070033,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,20555003300,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,20555003300,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,20555003300,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121201,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121201,NDC,0.5,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121201,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121301,NDC,0.4,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121301,NDC,0.4,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121301,NDC,0.4,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 3 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121401,NDC,0.333333333,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 3 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121401,NDC,0.333333333,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 3 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121401,NDC,0.333333333,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,832121689,NDC,0.2,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,832121689,NDC,0.2,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,832121689,NDC,0.2,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121601,NDC,0.2,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121601,NDC,0.2,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121601,NDC,0.2,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zinc gluconate 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,40093010153,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zinc gluconate 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,40093010153,NDC,1,EA,3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zinc gluconate 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,40093010153,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carBAMazepine 100 MG Tablet Chewable 100 Each Box,63700001,CDM,250,RC,,,,,,904385461,NDC,1,EA,3.43,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.47147,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxepin 10 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079043620,NDC,1,EA,3.43,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.47147,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073916,NDC,2,ML,30,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,1.472,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073916,NDC,2,ML,30,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,1.472,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073941,NDC,1,ML,30,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,1.472,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073941,NDC,1,ML,30,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,1.472,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,67457043300,NDC,1,ML,30,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,1.472,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,67457043300,NDC,1,ML,30,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,1.472,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
insulin aspart 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169633910,NDC,3,ML,659.76,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,1.472,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
insulin aspart 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169633910,NDC,3,ML,659.76,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,1.472,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
insulin aspart prot & aspart 70-30 (70-30) 100 UNIT/ML Suspension Pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169369619,NDC,3,ML,629.28,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,1.472,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
insulin aspart prot & aspart 70-30 (70-30) 100 UNIT/ML Suspension Pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169369619,NDC,3,ML,629.28,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,1.472,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221901,NDC,3,ML,506.9,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,1.472,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221901,NDC,3,ML,506.9,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,1.472,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221905,NDC,3,ML,506.9,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,1.472,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221905,NDC,3,ML,506.9,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,1.472,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2021301,NDC,3,ML,44.46,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,1.472,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2021301,NDC,3,ML,44.46,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,1.472,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821517,NDC,3,ML,275.33,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,1.472,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821517,NDC,3,ML,275.33,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,1.472,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
insulin regular 100 UNIT/ML Solution 10 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821501,NDC,10,ML,307.46,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,1.472,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
insulin regular 100 UNIT/ML Solution 10 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821501,NDC,10,ML,307.46,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,1.472,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.79,1.472
metoprolol tartrate 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079080120,NDC,1,EA,3.07,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.4736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079080120,NDC,1,EA,3.07,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.4736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluvoxaMINE 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,60505016601,NDC,0.25,EA,3.55,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.47467,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen-codeine 300-30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739000410,NDC,1,EA,3.44,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.47576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
penicillin v potassium 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714023501,NDC,0.5,EA,3.44,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.47576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenytoin ER 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084037611,NDC,1,EA,3.44,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.47576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gadoteridol 279.3 MG/ML Solution 5 mL Vial,A9576,CDM,636,RC,A9576,HCPCS,,,,270111104,NDC,10,ML,100,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.47982,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.31,1.53
gadoteridol 279.3 MG/ML Solution 17 mL Syringe,A9576,CDM,636,RC,A9576,HCPCS,,,,270111145,NDC,17,ML,170,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.47982,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.31,1.53
LORazepam 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,591024001,NDC,1,EA,3.45,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.48005,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 400-80 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237023201,NDC,1,EA,3.57,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.482978,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637161,NDC,0.25,EA,3.03,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.4847,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637161,NDC,0.25,EA,3.03,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.4847,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637161,NDC,0.25,EA,3.03,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.4847,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904198261,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580045811,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580060002,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 750 Each Box,63700001,CDM,250,RC,,,,,,63739044001,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904198861,NDC,0.65,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904673061,NDC,0.65,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580045711,NDC,0.65,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 650 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,70010016001,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen-codeine 300-30 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406048423,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen-codeine 300-30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406048462,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020501,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584098811,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,53489015601,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904657161,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020520,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,62584098801,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862067701,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585961,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739064410,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amitriptyline 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268003711,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amitriptyline 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687043311,NDC,0.4,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amitriptyline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687043301,NDC,0.4,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687026311,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084025911,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687026301,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084025901,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714029903,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ascorbic acid 500 MG Tablet 100 Each Box,25000000,CDM,250,RC,,,,,,904052361,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
aspirin 81 MG Tablet Chewable 90 Each Bottle,63700001,CDM,250,RC,,,,,,904679489,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin 81 MG Tablet Chewable 500 Each Disp Pack,63700001,CDM,250,RC,,,,,,66553000201,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin 325 MG Tablet 500 Each Box,63700001,CDM,250,RC,,,,,,66553000101,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 81 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,63739021210,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 81 MG Tablet Delayed Release 120 Each Bottle,63700001,CDM,250,RC,,,,,,10135017362,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,536114801,NDC,0.249230769,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,536331301,NDC,0.249230769,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,603016921,NDC,0.249230769,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079068401,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020801,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629061,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020820,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020901,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629161,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020920,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079021001,NDC,0.125,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
azaTHIOprine 50 MG Tablet 1 Each Blister,J7500.01,CDM,636,RC,J7500,HCPCS,,,,68084022911,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2.94
baclofen 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904647561,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
baclofen 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739047910,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268011011,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 40 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547033810,NDC,0.125,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 1 Each Box,63700001,CDM,250,RC,,,,,,713010906,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574705012,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713010912,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,904505812,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl EC 5 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,904640761,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bismuth subsalicylate 262 MG Tablet Chewable 30 Each Box,63700001,CDM,250,RC,,,,,,904720546,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bumetanide 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,185012901,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buPROPion SR 150 MG Tablet Extended Release 12 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084070895,NDC,0.666666667,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buPROPion SR 150 MG Tablet Extended Release 12 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,68084070825,NDC,0.666666667,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcium carb-cholecalciferol 600-10 mg-mcg (600-400 mg-unit) Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,20555001700,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcium carbonate 500 MG Tablet Chewable 500 Each Box,63700001,CDM,250,RC,,,,,,66553000401,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
candesartan 32 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,49884066109,NDC,0.125,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 10-100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,72888010601,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687066111,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084009311,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687066101,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-250 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084009411,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carvedilol 12.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904630261,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cetirizine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904671761,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cholecalciferol (vitamin D3) 125 MCG (5000 UT) capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,80681013100,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637861,NDC,0.2,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904724361,NDC,0.2,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin 150 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904595961,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714075201,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16729013600,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloNIDine 0.1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687011311,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloNIDine 0.1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687011301,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloNIDine 0.1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739006010,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
codeine 30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54024424,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536136601,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536355601,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,74312001380,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079064401,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687055811,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687055801,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54417925,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54817925,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54817625,NDC,0.125,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 6 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54418625,NDC,0.041666667,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079028401,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,172392560,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079028420,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079028501,NDC,0.4,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,172392660,NDC,0.4,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079028520,NDC,0.4,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687019511,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687019501,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 180 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687020611,NDC,0.666666667,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 180 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687020601,NDC,0.666666667,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687021711,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739001610,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 25 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904530661,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 25 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904723761,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 50 MG capsule 100 Each Box,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904205661,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
divalproex 250 MG Tablet Delayed Release 1 Each Box,63700001,CDM,250,RC,,,,,,832712389,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 250 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,832712301,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
docusate sodium 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,10135011101,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
docusate sodium 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904645561,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
docusate sodium 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904718361,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
donepezil 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904647761,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxazosin 4 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68382078501,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
estradiol 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378145201,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
estradiol 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42806008701,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 25 Each Bottle,63700001,CDM,250,RC,,,,,,49348081705,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739064510,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"ferrous sulfate 325 (65 Fe) MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64376080910,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ferrous sulfate 325 (65 Fe) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904759161,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Fish Oil 1000 MG capsule 1 Each Blister,25000000,CDM,250,RC,,,,,,77333030825,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
folic acid 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687068111,NDC,0.4,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
folic acid 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687068101,NDC,0.4,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54829725,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904717861,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762403001,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904666561,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739059110,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739090210,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862019901,NDC,0.333333333,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904666661,NDC,0.333333333,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60505011300,NDC,0.333333333,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687059101,NDC,0.333333333,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739023610,NDC,0.333333333,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glimepiride 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547039410,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079081001,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079081020,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE ER 2.5 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714089401,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE ER 5 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714089501,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glyBURIDE 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,93834498,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glycerin 2 g Suppository 24 Each Jar,63700001,CDM,250,RC,,,,,,132007924,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 600 MG Tablet Extended Release 12 Hour 20 Each Box,63700001,CDM,250,RC,,,,,,63824000832,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
haloperidol 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079073420,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155000101,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904644161,NDC,0.4,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,64380073506,NDC,0.2,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904644261,NDC,0.2,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydroCHLOROthiazide 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547039710,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 5 MG Tablet 50 Each Bottle,63700001,CDM,250,RC,,,,,,59762007301,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762007401,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406324301,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,42858030125,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084042301,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine HCl 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155050101,NDC,0.4,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,51079007720,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,3.1556
ibuprofen 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904791461,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 600 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687045711,NDC,0.333333333,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 600 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739068410,NDC,0.333333333,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 800 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687046811,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 800 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687046801,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 800 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739069110,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
indomethacin 25 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,50268043011,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,781155601,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
labetalol 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,10135071101,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
labetalol 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687045011,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Lactase 9000 units Tablet 12 Each Box,63700001,CDM,250,RC,,,,,,45091012,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904700761,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031911,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084031901,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levETIRAcetam 250 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904712361,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 50 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079044001,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 50 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079044020,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
liothyronine 25 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762120701,NDC,0.2,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079098101,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679761,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,591040701,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679861,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679961,NDC,0.125,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687033301,NDC,0.125,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904680061,NDC,0.0625,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904720061,NDC,0.0625,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lithium 150 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,54252625,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lithium 150 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,54852625,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
loratadine 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714089801,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904600761,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739049910,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687035511,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904600861,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739050010,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904704861,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739068610,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Magnesium Cl-Calcium Carbonate 71.5-119 MG Tablet Delayed Release 60 Each Bottle,63700001,CDM,250,RC,,,,,,67618010760,NDC,2,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904660961,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,10006070028,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,64980033901,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
medroxyPROGESTERone 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,555087202,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
melatonin 3 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268052411,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
melatonin 3 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268052415,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
melatonin 3 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,904518252,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Melatonin 3-10 MG Tablet 120 Each Bottle,800000,CDM,,,,,,,,47469000852,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Melatonin 10 MG SL Tab 120 Each Bottle,63700001,CDM,250,RC,,,,,,40985027503,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904716261,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 850 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739070210,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 1000 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904669161,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 1000 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904716461,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methadone 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406575523,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methadone 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54855324,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methIMAzole 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155007001,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methIMAzole 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155007101,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methocarbamol 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687055911,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methocarbamol 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739016610,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methocarbamol 750 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687056811,NDC,0.666666667,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoclopramide 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93220401,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoclopramide 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739029310,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 50 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084066611,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 100 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,51079017101,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584026511,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904634061,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079080101,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904634161,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584026711,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,62584026701,NDC,0.125,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metroNIDAZOLE 500 MG Tablet 50 Each Bottle,63700001,CDM,250,RC,,,,,,29300022746,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
miSOPROStol 100 MCG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,70954044310,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
montelukast 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904680861,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine immediate release 15 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54023525,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine immediate release 15 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,832027311,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
multivitamin with minerals Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904549261,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
naproxen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739040310,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine polacrilex 4 MG Lozenge 24 Each Bottle,63700001,CDM,250,RC,,,,,,43598048772,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine polacrilex 4 MG Lozenge 72 Each Box,63700001,CDM,250,RC,,,,,,49348085316,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 1 Each Blister,63700001,CDM,250,RC,,,,,,68084012811,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,904691761,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,68084012801,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyBUTYnin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904702761,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406055223,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406055262,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739096310,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PHENobarbital 32.4 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904657561,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenytoin ER 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904618761,NDC,0.3,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenytoin ER 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,68084037601,NDC,0.3,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phosphorus 155-852-130 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,64980010401,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687059211,NDC,0.125,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
predniSONE 1 MG Tablet 100 Each Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,64380078206,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 1 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54873925,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 2.5 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54874025,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 5 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687012211,NDC,0.2,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 10 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687013411,NDC,0.1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001720,NDC,0.1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,63739051910,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 20 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014511,NDC,0.05,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001820,NDC,0.05,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014501,NDC,0.05,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
pregabalin 25 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,76282056890,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 75 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904700061,NDC,0.333333333,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prochlorperazine 10 MG Tablet 100 Each Bottle,25000000,CDM,250,RC,,,,,,59746011506,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
promethazine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,Q0169,HCPCS,,,,904646161,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904655061,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268070211,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687060911,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687060901,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Prosight Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,536509008,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
psyllium 0.52 GM capsule 160 Each Bottle,25000000,CDM,250,RC,,,,,,80681002200,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Psyllium 400 MG capsule 160 Each Bottle,25000000,CDM,250,RC,,,,,,10939081644,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pyridoxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536440601,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pyridoxine 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,77333094010,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904663861,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904664061,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739066510,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ramipril 5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,68382014601,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904736161,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rOPINIRole 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637461,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268071111,NDC,0.125,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268071115,NDC,0.125,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna 8.6 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904652261,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687062211,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,57896045806,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904633961,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687062201,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739043210,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018011,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904692461,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018001,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687024211,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018111,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687024201,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018101,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687025311,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904692661,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687025301,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simethicone 125 MG Tablet Chewable 18 Each Box,63700001,CDM,250,RC,,,,,,49348086348,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simethicone 125 MG Tablet Chewable 60 Each Bottle,63700001,CDM,250,RC,,,,,,69618003206,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simvastatin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739057010,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simvastatin 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739057310,NDC,0.125,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"sodium bicarbonate 650 MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64980018210,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"sodium bicarbonate 650 MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64980052810,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium chloride 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,223176001,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 12.5 mg Tablet 1 split tablet Blister,63700001,CDM,250,RC,,,,,,8888800438,NDC,2,UN,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079010301,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687046511,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079010320,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687046501,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739054410,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 800-160 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904272561,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 800-160 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739022810,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tamsulosin 0.4 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739056710,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079041801,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877014601,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079041820,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739023110,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terazosin 5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59746038506,NDC,0.2,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
therapeutic multivitamin Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904053961,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,77333093425,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,37864090599,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,77333093410,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268075611,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268075615,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54007725,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50111091701,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739067110,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traZODone 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904655461,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
valsartan 160 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342006410,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536333401,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904582461,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,10006070033,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,20555003300,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121201,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121301,NDC,0.4,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 3 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121401,NDC,0.333333333,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,832121689,NDC,0.2,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121601,NDC,0.2,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zinc gluconate 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,40093010153,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 650 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802073030,NDC,1,EA,3.58,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.487132,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
silver nitrate - pot nitrate 75-25 % Misc 100 Each Package,63700001,CDM,250,RC,,,,,,12870000102,NDC,1,EA,3.58,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.487132,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cefTAZidime 1 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023525,NDC,1,EA,49,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.49,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.49,1.69
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,409508411,NDC,1,EA,73.86,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.49,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.49,1.69
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,25021012867,NDC,1,EA,82.96,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.49,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.49,1.69
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023610,NDC,1,EA,77.24,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.49,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.49,1.69
gadoteridol 279.3 MG/ML Solution 5 mL Vial,A9576,CDM,636,RC,A9576,HCPCS,,,,270111104,NDC,10,ML,100,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.31,1.53
gadoteridol 279.3 MG/ML Solution 5 mL Vial,A9576,CDM,636,RC,A9576,HCPCS,,,,270111104,NDC,10,ML,100,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.31,1.53
gadoteridol 279.3 MG/ML Solution 17 mL Syringe,A9576,CDM,636,RC,A9576,HCPCS,,,,270111145,NDC,17,ML,170,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.31,1.53
gadoteridol 279.3 MG/ML Solution 17 mL Syringe,A9576,CDM,636,RC,A9576,HCPCS,,,,270111145,NDC,17,ML,170,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.31,1.53
cyclobenzaprine 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69097084607,NDC,0.5,EA,3.11,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.4928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69097084607,NDC,0.5,EA,3.11,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.4928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,603420921,NDC,1,EA,3.48,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.49292,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68180051201,NDC,1,EA,3.48,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.49292,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 4 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,56016875,NDC,0.25,EA,3.6,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.49544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637161,NDC,0.25,EA,3.03,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.49985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 120 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802073230,NDC,1,EA,3.13,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.5024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 120 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802073230,NDC,1,EA,3.13,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.5024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 250 MG Tablet Chewable 100 Each Bottle,63700001,CDM,250,RC,,,,,,93226801,NDC,1,EA,3.62,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.503748,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
repaglinide 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,574024001,NDC,1,EA,3.62,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.503748,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079080120,NDC,1,EA,3.07,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.5043,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079080120,NDC,1,EA,3.07,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.5043,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079080120,NDC,1,EA,3.07,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.5043,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687016311,NDC,0.5,EA,3.63,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.507902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687016301,NDC,0.5,EA,3.63,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.507902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
XEROFORM GAUZE PETROLATUM 1X8INCH,27200000,CDM,272,RC,A6222,HCPCS,,10659-MAIN,LOCAL,,,,,3.52,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.51008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,143971801,NDC,200,ML,230.48,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.51199,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.37,1.56
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,409277602,NDC,200,ML,228.28,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.51199,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.37,1.56
furosemide 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54829925,NDC,1,EA,3.15,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54829925,NDC,1,EA,3.15,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nortriptyline 25 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,93081101,NDC,0.4,EA,3.15,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nortriptyline 25 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,93081101,NDC,0.4,EA,3.15,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,245531989,NDC,1,EA,3.65,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.51621,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,66758019006,NDC,1,EA,3.65,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.51621,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,245531901,NDC,1,EA,3.65,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.51621,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,66758019013,NDC,1,EA,3.65,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.51621,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904198261,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580045811,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580060002,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 750 Each Box,63700001,CDM,250,RC,,,,,,63739044001,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904198861,NDC,0.65,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904673061,NDC,0.65,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580045711,NDC,0.65,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 650 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,70010016001,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen-codeine 300-30 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406048423,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen-codeine 300-30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406048462,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020501,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584098811,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,53489015601,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904657161,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020520,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,62584098801,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862067701,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585961,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739064410,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amitriptyline 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268003711,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amitriptyline 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687043311,NDC,0.4,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amitriptyline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687043301,NDC,0.4,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687026311,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084025911,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687026301,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084025901,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714029903,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ascorbic acid 500 MG Tablet 100 Each Box,25000000,CDM,250,RC,,,,,,904052361,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
aspirin 81 MG Tablet Chewable 90 Each Bottle,63700001,CDM,250,RC,,,,,,904679489,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin 81 MG Tablet Chewable 500 Each Disp Pack,63700001,CDM,250,RC,,,,,,66553000201,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin 325 MG Tablet 500 Each Box,63700001,CDM,250,RC,,,,,,66553000101,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 81 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,63739021210,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 81 MG Tablet Delayed Release 120 Each Bottle,63700001,CDM,250,RC,,,,,,10135017362,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,536114801,NDC,0.249230769,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,536331301,NDC,0.249230769,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,603016921,NDC,0.249230769,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079068401,NDC,0.25,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020801,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629061,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020820,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020901,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629161,NDC,0.25,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020920,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079021001,NDC,0.125,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
azaTHIOprine 50 MG Tablet 1 Each Blister,J7500.01,CDM,636,RC,J7500,HCPCS,,,,68084022911,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2.94
baclofen 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904647561,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
baclofen 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739047910,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268011011,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 40 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547033810,NDC,0.125,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 1 Each Box,63700001,CDM,250,RC,,,,,,713010906,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574705012,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713010912,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,904505812,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl EC 5 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,904640761,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bismuth subsalicylate 262 MG Tablet Chewable 30 Each Box,63700001,CDM,250,RC,,,,,,904720546,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bumetanide 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,185012901,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buPROPion SR 150 MG Tablet Extended Release 12 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084070895,NDC,0.666666667,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buPROPion SR 150 MG Tablet Extended Release 12 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,68084070825,NDC,0.666666667,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcium carb-cholecalciferol 600-10 mg-mcg (600-400 mg-unit) Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,20555001700,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcium carbonate 500 MG Tablet Chewable 500 Each Box,63700001,CDM,250,RC,,,,,,66553000401,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
candesartan 32 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,49884066109,NDC,0.125,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 10-100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,72888010601,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687066111,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084009311,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687066101,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-250 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084009411,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carvedilol 12.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904630261,NDC,0.25,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cetirizine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904671761,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cholecalciferol (vitamin D3) 125 MCG (5000 UT) capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,80681013100,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637861,NDC,0.2,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904724361,NDC,0.2,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin 150 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904595961,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714075201,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16729013600,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloNIDine 0.1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687011311,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloNIDine 0.1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687011301,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloNIDine 0.1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739006010,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
codeine 30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54024424,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536136601,NDC,0.25,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536355601,NDC,0.25,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,74312001380,NDC,0.25,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079064401,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687055811,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687055801,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54417925,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54817925,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54817625,NDC,0.125,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 6 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54418625,NDC,0.041666667,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079028401,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,172392560,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079028420,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079028501,NDC,0.4,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,172392660,NDC,0.4,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079028520,NDC,0.4,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687019511,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687019501,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 180 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687020611,NDC,0.666666667,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 180 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687020601,NDC,0.666666667,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687021711,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739001610,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 25 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904530661,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 25 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904723761,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 50 MG capsule 100 Each Box,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904205661,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
divalproex 250 MG Tablet Delayed Release 1 Each Box,63700001,CDM,250,RC,,,,,,832712389,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 250 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,832712301,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
docusate sodium 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,10135011101,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
docusate sodium 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904645561,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
docusate sodium 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904718361,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
donepezil 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904647761,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxazosin 4 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68382078501,NDC,0.25,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
estradiol 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378145201,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
estradiol 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42806008701,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 25 Each Bottle,63700001,CDM,250,RC,,,,,,49348081705,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739064510,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"ferrous sulfate 325 (65 Fe) MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64376080910,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ferrous sulfate 325 (65 Fe) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904759161,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Fish Oil 1000 MG capsule 1 Each Blister,25000000,CDM,250,RC,,,,,,77333030825,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
folic acid 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687068111,NDC,0.4,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
folic acid 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687068101,NDC,0.4,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54829725,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904717861,NDC,0.25,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762403001,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904666561,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739059110,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739090210,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862019901,NDC,0.333333333,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904666661,NDC,0.333333333,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60505011300,NDC,0.333333333,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687059101,NDC,0.333333333,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739023610,NDC,0.333333333,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glimepiride 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547039410,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079081001,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079081020,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE ER 2.5 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714089401,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE ER 5 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714089501,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glyBURIDE 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,93834498,NDC,0.25,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glycerin 2 g Suppository 24 Each Jar,63700001,CDM,250,RC,,,,,,132007924,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 600 MG Tablet Extended Release 12 Hour 20 Each Box,63700001,CDM,250,RC,,,,,,63824000832,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
haloperidol 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079073420,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155000101,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904644161,NDC,0.4,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,64380073506,NDC,0.2,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904644261,NDC,0.2,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydroCHLOROthiazide 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547039710,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 5 MG Tablet 50 Each Bottle,63700001,CDM,250,RC,,,,,,59762007301,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762007401,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406324301,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,42858030125,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084042301,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine HCl 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155050101,NDC,0.4,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,51079007720,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,3.1556
ibuprofen 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904791461,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 600 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687045711,NDC,0.333333333,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 600 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739068410,NDC,0.333333333,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 800 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687046811,NDC,0.25,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 800 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687046801,NDC,0.25,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 800 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739069110,NDC,0.25,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
indomethacin 25 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,50268043011,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,781155601,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
labetalol 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,10135071101,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
labetalol 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687045011,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Lactase 9000 units Tablet 12 Each Box,63700001,CDM,250,RC,,,,,,45091012,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904700761,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031911,NDC,0.25,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084031901,NDC,0.25,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levETIRAcetam 250 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904712361,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 50 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079044001,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 50 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079044020,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
liothyronine 25 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762120701,NDC,0.2,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079098101,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679761,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,591040701,NDC,0.25,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679861,NDC,0.25,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679961,NDC,0.125,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687033301,NDC,0.125,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904680061,NDC,0.0625,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904720061,NDC,0.0625,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lithium 150 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,54252625,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lithium 150 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,54852625,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
loratadine 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714089801,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904600761,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739049910,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687035511,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904600861,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739050010,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904704861,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739068610,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Magnesium Cl-Calcium Carbonate 71.5-119 MG Tablet Delayed Release 60 Each Bottle,63700001,CDM,250,RC,,,,,,67618010760,NDC,2,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904660961,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,10006070028,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,64980033901,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
medroxyPROGESTERone 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,555087202,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
melatonin 3 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268052411,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
melatonin 3 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268052415,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
melatonin 3 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,904518252,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Melatonin 3-10 MG Tablet 120 Each Bottle,800000,CDM,,,,,,,,47469000852,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Melatonin 10 MG SL Tab 120 Each Bottle,63700001,CDM,250,RC,,,,,,40985027503,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904716261,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 850 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739070210,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 1000 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904669161,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 1000 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904716461,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methadone 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406575523,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methadone 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54855324,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methIMAzole 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155007001,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methIMAzole 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155007101,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methocarbamol 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687055911,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methocarbamol 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739016610,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methocarbamol 750 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687056811,NDC,0.666666667,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoclopramide 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93220401,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoclopramide 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739029310,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 50 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084066611,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 100 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,51079017101,NDC,0.25,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584026511,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904634061,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079080101,NDC,0.25,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904634161,NDC,0.25,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584026711,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,62584026701,NDC,0.125,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metroNIDAZOLE 500 MG Tablet 50 Each Bottle,63700001,CDM,250,RC,,,,,,29300022746,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
miSOPROStol 100 MCG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,70954044310,NDC,0.25,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
montelukast 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904680861,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine immediate release 15 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54023525,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine immediate release 15 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,832027311,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
multivitamin with minerals Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904549261,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
naproxen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739040310,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine polacrilex 4 MG Lozenge 24 Each Bottle,63700001,CDM,250,RC,,,,,,43598048772,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine polacrilex 4 MG Lozenge 72 Each Box,63700001,CDM,250,RC,,,,,,49348085316,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 1 Each Blister,63700001,CDM,250,RC,,,,,,68084012811,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,904691761,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,68084012801,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyBUTYnin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904702761,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406055223,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406055262,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739096310,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PHENobarbital 32.4 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904657561,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenytoin ER 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904618761,NDC,0.3,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenytoin ER 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,68084037601,NDC,0.3,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phosphorus 155-852-130 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,64980010401,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687059211,NDC,0.125,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
predniSONE 1 MG Tablet 100 Each Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,64380078206,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 1 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54873925,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 2.5 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54874025,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 5 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687012211,NDC,0.2,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 10 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687013411,NDC,0.1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001720,NDC,0.1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,63739051910,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 20 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014511,NDC,0.05,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001820,NDC,0.05,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014501,NDC,0.05,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
pregabalin 25 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,76282056890,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 75 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904700061,NDC,0.333333333,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prochlorperazine 10 MG Tablet 100 Each Bottle,25000000,CDM,250,RC,,,,,,59746011506,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
promethazine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,Q0169,HCPCS,,,,904646161,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904655061,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268070211,NDC,0.25,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687060911,NDC,0.25,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687060901,NDC,0.25,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Prosight Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,536509008,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
psyllium 0.52 GM capsule 160 Each Bottle,25000000,CDM,250,RC,,,,,,80681002200,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Psyllium 400 MG capsule 160 Each Bottle,25000000,CDM,250,RC,,,,,,10939081644,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pyridoxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536440601,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pyridoxine 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,77333094010,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904663861,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904664061,NDC,0.25,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739066510,NDC,0.25,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ramipril 5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,68382014601,NDC,0.25,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904736161,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rOPINIRole 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637461,NDC,0.25,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268071111,NDC,0.125,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268071115,NDC,0.125,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna 8.6 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904652261,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687062211,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,57896045806,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904633961,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687062201,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739043210,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018011,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904692461,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018001,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687024211,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018111,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687024201,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018101,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687025311,NDC,0.25,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904692661,NDC,0.25,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687025301,NDC,0.25,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simethicone 125 MG Tablet Chewable 18 Each Box,63700001,CDM,250,RC,,,,,,49348086348,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simethicone 125 MG Tablet Chewable 60 Each Bottle,63700001,CDM,250,RC,,,,,,69618003206,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simvastatin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739057010,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simvastatin 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739057310,NDC,0.125,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"sodium bicarbonate 650 MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64980018210,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"sodium bicarbonate 650 MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64980052810,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium chloride 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,223176001,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 12.5 mg Tablet 1 split tablet Blister,63700001,CDM,250,RC,,,,,,8888800438,NDC,2,UN,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079010301,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687046511,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079010320,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687046501,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739054410,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 800-160 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904272561,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 800-160 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739022810,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tamsulosin 0.4 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739056710,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079041801,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877014601,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079041820,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739023110,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terazosin 5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59746038506,NDC,0.2,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
therapeutic multivitamin Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904053961,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,77333093425,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,37864090599,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,77333093410,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268075611,NDC,0.25,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268075615,NDC,0.25,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54007725,NDC,0.25,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50111091701,NDC,0.25,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739067110,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traZODone 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904655461,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
valsartan 160 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342006410,NDC,0.25,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536333401,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904582461,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,10006070033,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,20555003300,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121201,NDC,0.5,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121301,NDC,0.4,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 3 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121401,NDC,0.333333333,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,832121689,NDC,0.2,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121601,NDC,0.2,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zinc gluconate 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,40093010153,NDC,1,EA,3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079080120,NDC,1,EA,3.07,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.51965,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Noninvasv Oxygen Satur;Single,PX94760,CDM,460,RC,94760,CPT,,,,,,,,131,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.3,4.65
Noninvasv Oxygen Satur;Single,PX94760,CDM,460,RC,94760,CPT,,,,,,,,131,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.3,4.65
acetaminophen 120 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,713011806,NDC,1,EA,3.17,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.5216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 120 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,713011806,NDC,1,EA,3.17,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.5216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 120 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713011812,NDC,1,EA,3.17,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.5216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 120 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713011812,NDC,1,EA,3.17,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.5216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluvoxaMINE 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,60505016601,NDC,0.25,EA,3.55,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.52295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69097084607,NDC,0.5,EA,3.11,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.5239,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69097084607,NDC,0.5,EA,3.11,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.5239,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69097084607,NDC,0.5,EA,3.11,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.5239,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzonatate 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904715361,NDC,1,EA,3.18,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.5264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzonatate 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904715361,NDC,1,EA,3.18,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.5264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gadoteridol 279.3 MG/ML Solution 5 mL Vial,A9576,CDM,636,RC,A9576,HCPCS,,,,270111104,NDC,10,ML,100,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.53,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.31,1.53
gadoteridol 279.3 MG/ML Solution 17 mL Syringe,A9576,CDM,636,RC,A9576,HCPCS,,,,270111145,NDC,17,ML,170,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.53,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.31,1.53
prochlorperazine 5 MG Tablet 100 Each Bottle,63600000,CDM,636,RC,Q0164,HCPCS,,,,59746011306,NDC,1,EA,3.19,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.5312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
prochlorperazine 5 MG Tablet 100 Each Bottle,63600000,CDM,636,RC,Q0164,HCPCS,,,,59746011306,NDC,1,EA,3.19,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.5312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
sulfamethoxazole-trimethoprim 400-80 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237023201,NDC,1,EA,3.57,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.53153,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637161,NDC,0.25,EA,3.03,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.53318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 120 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802073230,NDC,1,EA,3.13,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.5337,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 120 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802073230,NDC,1,EA,3.13,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.5337,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 120 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802073230,NDC,1,EA,3.13,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.5337,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 650 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802073030,NDC,1,EA,3.58,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.53582,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
silver nitrate - pot nitrate 75-25 % Misc 100 Each Package,63700001,CDM,250,RC,,,,,,12870000102,NDC,1,EA,3.58,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.53582,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69097084607,NDC,0.5,EA,3.11,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.53945,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
caffeine citrate 60 MG/3ML Solution 3 mL Vial,J0706.01,CDM,636,RC,J0706,HCPCS,,,,63323040704,NDC,3,ML,73.84,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.54,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6434,2.848
furosemide 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54829925,NDC,1,EA,3.15,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.5435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54829925,NDC,1,EA,3.15,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.5435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54829925,NDC,1,EA,3.15,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.5435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nortriptyline 25 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,93081101,NDC,0.4,EA,3.15,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.5435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nortriptyline 25 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,93081101,NDC,0.4,EA,3.15,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.5435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nortriptyline 25 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,93081101,NDC,0.4,EA,3.15,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.5435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 4 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,56016875,NDC,0.25,EA,3.6,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.5444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904563161,NDC,1,EA,3.72,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.545288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 5-325 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406012301,NDC,1,EA,3.72,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.545288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine pamoate 25 MG capsule 1 Each Blister,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084711,NDC,1,EA,3.22,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.5456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,3.1556
hydrOXYzine pamoate 25 MG capsule 1 Each Blister,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084711,NDC,1,EA,3.22,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.5456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,3.1556
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084701,NDC,1,EA,3.22,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.5456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,3.1556
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084701,NDC,1,EA,3.22,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.5456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,3.1556
losartan 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739067310,NDC,1,EA,3.22,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.5456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739067310,NDC,1,EA,3.22,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.5456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 120 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802073230,NDC,1,EA,3.13,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.54935,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,781106101,NDC,1,EA,3.73,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.549442,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,67253090010,NDC,1,EA,3.73,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.549442,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ampicillin-sulbactam 1.5 (1-0.5) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001381,NDC,1,EA,69.24,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.55,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.55,2.12
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001481,NDC,1,EA,102.12,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.55,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.55,2.12
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011701,NDC,1,EA,89.64,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.55,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.55,2.12
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011710,NDC,1,EA,89.64,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.55,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.55,2.12
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,143971801,NDC,200,ML,230.48,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.37,1.56
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,143971801,NDC,200,ML,230.48,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.37,1.56
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,409277602,NDC,200,ML,228.28,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.37,1.56
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,409277602,NDC,200,ML,228.28,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.37,1.56
STOCKINETTE IMPERVIOUS 9X36 NON22530,27200000,CDM,272,RC,A6457,HCPCS,,10917-MAIN,LOCAL,,,,,14.73,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
STOCKINETTE IMPERVIOUS 9X36 NON22530,27200000,CDM,272,RC,A6457,HCPCS,,10917-MAIN,LOCAL,,,,,14.73,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
STOCKINETTE IMPERVIOUS 9X36 NON22530,27200000,CDM,272,RC,A6457,HCPCS,,10917-MAIN,LOCAL,,,,,14.73,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.55,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
STOCKINETTE IMPERVIOUS 12X48 NON22535,27200000,CDM,272,RC,A6457,HCPCS,,10918-MAIN,LOCAL,,,,,16.47,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
STOCKINETTE IMPERVIOUS 12X48 NON22535,27200000,CDM,272,RC,A6457,HCPCS,,10918-MAIN,LOCAL,,,,,16.47,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
STOCKINETTE IMPERVIOUS 12X48 NON22535,27200000,CDM,272,RC,A6457,HCPCS,,10918-MAIN,LOCAL,,,,,16.47,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.55,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
STOCKINETTE STERILE 4X48 NON22360,27200000,CDM,272,RC,A6457,HCPCS,,10658-MAIN,LOCAL,,,,,10.62,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
STOCKINETTE STERILE 4X48 NON22360,27200000,CDM,272,RC,A6457,HCPCS,,10658-MAIN,LOCAL,,,,,10.62,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
STOCKINETTE STERILE 4X48 NON22360,27200000,CDM,272,RC,A6457,HCPCS,,10658-MAIN,LOCAL,,,,,10.62,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.55,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
amoxicillin 250 MG Tablet Chewable 100 Each Bottle,63700001,CDM,250,RC,,,,,,93226801,NDC,1,EA,3.62,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.55298,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
repaglinide 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,574024001,NDC,1,EA,3.62,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.55298,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 120 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,713011806,NDC,1,EA,3.17,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.5533,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 120 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,713011806,NDC,1,EA,3.17,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.5533,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 120 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,713011806,NDC,1,EA,3.17,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.5533,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 120 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713011812,NDC,1,EA,3.17,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.5533,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 120 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713011812,NDC,1,EA,3.17,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.5533,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 120 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713011812,NDC,1,EA,3.17,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.5533,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079080120,NDC,1,EA,3.07,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.55342,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
chlorthalidone 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378022201,NDC,0.5,EA,3.24,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.5552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
chlorthalidone 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378022201,NDC,0.5,EA,3.24,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.5552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687016311,NDC,0.5,EA,3.63,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.55727,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687016301,NDC,0.5,EA,3.63,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.55727,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzonatate 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904715361,NDC,1,EA,3.18,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.5582,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzonatate 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904715361,NDC,1,EA,3.18,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.5582,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzonatate 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904715361,NDC,1,EA,3.18,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.5582,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54829925,NDC,1,EA,3.15,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.55925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nortriptyline 25 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,93081101,NDC,0.4,EA,3.15,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.55925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cocaine 4% 4 % Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527172874,NDC,4,ML,875.53,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.56,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.98,1.808
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527197174,NDC,4,ML,960.5,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.56,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.98,1.808
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,64950036204,NDC,4,ML,1067.22,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.56,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.98,1.808
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,70839036204,NDC,4,ML,1280.66,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.56,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.98,1.808
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,143971801,NDC,200,ML,230.48,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.56,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.37,1.56
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,409277602,NDC,200,ML,228.28,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.56,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.37,1.56
diphenoxylate-atropine 2.5-0.025 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762106101,NDC,1,EA,3.76,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.561904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenoxylate-atropine 2.5-0.025 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,62559049001,NDC,1,EA,3.76,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.561904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prochlorperazine 5 MG Tablet 100 Each Bottle,63600000,CDM,636,RC,Q0164,HCPCS,,,,59746011306,NDC,1,EA,3.19,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.5631,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
prochlorperazine 5 MG Tablet 100 Each Bottle,63600000,CDM,636,RC,Q0164,HCPCS,,,,59746011306,NDC,1,EA,3.19,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.5631,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
prochlorperazine 5 MG Tablet 100 Each Bottle,63600000,CDM,636,RC,Q0164,HCPCS,,,,59746011306,NDC,1,EA,3.19,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.5631,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
potassium chloride CR 20 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,245531989,NDC,1,EA,3.65,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.56585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,66758019006,NDC,1,EA,3.65,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.56585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,245531901,NDC,1,EA,3.65,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.56585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,66758019013,NDC,1,EA,3.65,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.56585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 120 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,713011806,NDC,1,EA,3.17,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.56915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 120 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713011812,NDC,1,EA,3.17,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.56915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxytocin 10 UNIT/ML Solution 1 mL Vial,J2590.01,CDM,636,RC,J2590,HCPCS,,,,42023011625,NDC,1,ML,43.8,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.57,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3217,1.57
levothyroxine 100 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904695361,NDC,1,EA,3.78,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.570212,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69097084607,NDC,0.5,EA,3.11,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.57366,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzonatate 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904715361,NDC,1,EA,3.18,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.5741,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prochlorperazine 5 MG Tablet 1 Each Blister,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054101,NDC,1,EA,3.28,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.5744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
prochlorperazine 5 MG Tablet 1 Each Blister,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054101,NDC,1,EA,3.28,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.5744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
hydrOXYzine pamoate 25 MG capsule 1 Each Blister,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084711,NDC,1,EA,3.22,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.5778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,3.1556
hydrOXYzine pamoate 25 MG capsule 1 Each Blister,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084711,NDC,1,EA,3.22,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.5778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,3.1556
hydrOXYzine pamoate 25 MG capsule 1 Each Blister,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084711,NDC,1,EA,3.22,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.5778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,3.1556
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084701,NDC,1,EA,3.22,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.5778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,3.1556
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084701,NDC,1,EA,3.22,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.5778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,3.1556
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084701,NDC,1,EA,3.22,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.5778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,3.1556
losartan 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739067310,NDC,1,EA,3.22,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.5778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739067310,NDC,1,EA,3.22,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.5778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739067310,NDC,1,EA,3.22,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.5778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 650 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713016512,NDC,1,EA,3.8,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.57852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 850 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687014311,NDC,0.588235294,EA,3.8,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.57852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 850 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687014301,NDC,0.588235294,EA,3.8,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.57852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prochlorperazine 5 MG Tablet 100 Each Bottle,63600000,CDM,636,RC,Q0164,HCPCS,,,,59746011306,NDC,1,EA,3.19,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.57905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
prochlorperazine 5 MG Tablet 100 Each Box,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054120,NDC,1,EA,3.29,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.5792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
prochlorperazine 5 MG Tablet 100 Each Box,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054120,NDC,1,EA,3.29,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.5792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
sucralfate 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762040101,NDC,1,EA,3.81,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.582674,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 120 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802073230,NDC,1,EA,3.13,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.58378,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
chlorthalidone 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378022201,NDC,0.5,EA,3.24,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.5876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
chlorthalidone 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378022201,NDC,0.5,EA,3.24,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.5876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
chlorthalidone 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378022201,NDC,0.5,EA,3.24,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.5876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BUPivacaine liposome 1.3 % Suspension 20 mL Vial,C9290.01,CDM,636,RC,C9290,HCPCS,,,,65250026604,NDC,10,ML,976.43,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.59,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.59,1.59
"dextrose 5% and sodium chloride 0.2% 5-0.2 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338007704,NDC,1000,ML,99.12,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.59,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.12595,1.59
"dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008904,NDC,1000,ML,99.12,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.59,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.12595,1.59
dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 500 mL Flex Cont,J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008903,NDC,500,ML,99.12,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.59,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.12595,1.59
"dextrose 5% and sodium chloride 0.45% 5-0.45 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008504,NDC,1000,ML,99.12,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.59,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.12595,1.59
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016401,NDC,1,ML,854.49,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.59,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.59,1.88
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016410,NDC,1,ML,917.08,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.59,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.59,1.88
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016425,NDC,1,ML,779.43,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.59,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.59,1.88
atenolol 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904539261,NDC,1,EA,3.83,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.590982,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687015211,NDC,1,EA,3.83,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.590982,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687015201,NDC,1,EA,3.83,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.590982,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084042311,NDC,1,EA,3.83,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.590982,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prenatal plus vitamin with folic acid 1 mg 27-1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69367026701,NDC,1,EA,3.83,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.590982,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,66758017006,NDC,1,EA,3.32,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.5936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,66758017006,NDC,1,EA,3.32,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.5936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,245531701,NDC,1,EA,3.32,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.5936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,245531701,NDC,1,EA,3.32,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.5936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,66758017013,NDC,1,EA,3.32,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.5936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,66758017013,NDC,1,EA,3.32,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.5936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54829925,NDC,1,EA,3.15,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.5939,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nortriptyline 25 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,93081101,NDC,0.4,EA,3.15,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.5939,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine pamoate 25 MG capsule 1 Each Blister,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084711,NDC,1,EA,3.22,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.5939,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,3.1556
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084701,NDC,1,EA,3.22,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.5939,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,3.1556
losartan 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739067310,NDC,1,EA,3.22,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.5939,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904563161,NDC,1,EA,3.72,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.59588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 5-325 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406012301,NDC,1,EA,3.72,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.59588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 50 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904632361,NDC,0.5,EA,3.33,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.5984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 50 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904632361,NDC,0.5,EA,3.33,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.5984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,42858000110,NDC,1,EA,3.33,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.5984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,42858000110,NDC,1,EA,3.33,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.5984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,245531789,NDC,1,EA,3.33,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.5984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,245531789,NDC,1,EA,3.33,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.5984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,781106101,NDC,1,EA,3.73,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.60017,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,67253090010,NDC,1,EA,3.73,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.60017,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687064011,NDC,1,EA,3.34,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.6032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687064011,NDC,1,EA,3.34,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.6032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687064001,NDC,1,EA,3.34,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.6032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687064001,NDC,1,EA,3.34,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.6032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,69452015120,NDC,1,EA,3.86,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.603444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
chlorthalidone 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378022201,NDC,0.5,EA,3.24,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.6038,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 120 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,713011806,NDC,1,EA,3.17,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.60402,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 120 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713011812,NDC,1,EA,3.17,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.60402,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prochlorperazine 5 MG Tablet 1 Each Blister,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054101,NDC,1,EA,3.28,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.6072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
prochlorperazine 5 MG Tablet 1 Each Blister,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054101,NDC,1,EA,3.28,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.6072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
prochlorperazine 5 MG Tablet 1 Each Blister,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054101,NDC,1,EA,3.28,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.6072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
STOCKINETTE IMPERVIOUS 9X36 NON22530,27200000,CDM,272,RC,A6457,HCPCS,,10917-MAIN,LOCAL,,,,,14.73,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.6085,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
STOCKINETTE IMPERVIOUS 12X48 NON22535,27200000,CDM,272,RC,A6457,HCPCS,,10918-MAIN,LOCAL,,,,,16.47,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.6085,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
STOCKINETTE STERILE 4X48 NON22360,27200000,CDM,272,RC,A6457,HCPCS,,10658-MAIN,LOCAL,,,,,10.62,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.6085,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
benzonatate 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904715361,NDC,1,EA,3.18,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.60908,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prochlorperazine 5 MG Tablet 100 Each Box,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054120,NDC,1,EA,3.29,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.6121,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
prochlorperazine 5 MG Tablet 100 Each Box,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054120,NDC,1,EA,3.29,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.6121,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
prochlorperazine 5 MG Tablet 100 Each Box,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054120,NDC,1,EA,3.29,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.6121,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
doxepin 10 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,51672421701,NDC,1,EA,3.36,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.6128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxepin 10 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,51672421701,NDC,1,EA,3.36,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.6128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084008211,NDC,0.5,EA,3.36,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.6128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084008211,NDC,0.5,EA,3.36,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.6128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268075411,NDC,1,EA,3.36,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.6128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268075411,NDC,1,EA,3.36,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.6128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 5 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268075415,NDC,1,EA,3.36,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.6128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 5 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268075415,NDC,1,EA,3.36,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.6128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenoxylate-atropine 2.5-0.025 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762106101,NDC,1,EA,3.76,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.61304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenoxylate-atropine 2.5-0.025 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,62559049001,NDC,1,EA,3.76,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.61304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prochlorperazine 5 MG Tablet 100 Each Bottle,63600000,CDM,636,RC,Q0164,HCPCS,,,,59746011306,NDC,1,EA,3.19,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.61414,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
metFORMIN 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904632661,NDC,1,EA,3.89,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.615906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 100 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904695361,NDC,1,EA,3.78,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.62162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prochlorperazine 5 MG Tablet 1 Each Blister,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054101,NDC,1,EA,3.28,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.6236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
benzonatate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687034611,NDC,1,EA,3.91,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.624214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714031401,NDC,0.333333333,EA,3.91,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.624214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714065801,NDC,0.333333333,EA,3.91,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.624214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57664039588,NDC,0.333333333,EA,3.91,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.624214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,66758017006,NDC,1,EA,3.32,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.6268,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,66758017006,NDC,1,EA,3.32,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.6268,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,66758017006,NDC,1,EA,3.32,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.6268,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,245531701,NDC,1,EA,3.32,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.6268,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,245531701,NDC,1,EA,3.32,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.6268,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,245531701,NDC,1,EA,3.32,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.6268,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,66758017013,NDC,1,EA,3.32,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.6268,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,66758017013,NDC,1,EA,3.32,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.6268,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,66758017013,NDC,1,EA,3.32,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.6268,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methyldopa 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93293101,NDC,1,EA,3.92,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.628368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prochlorperazine 5 MG Tablet 100 Each Box,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054120,NDC,1,EA,3.29,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.62855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
hydrOXYzine pamoate 25 MG capsule 1 Each Blister,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084711,NDC,1,EA,3.22,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.62932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,3.1556
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084701,NDC,1,EA,3.22,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.62932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,3.1556
losartan 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739067310,NDC,1,EA,3.22,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.62932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 650 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713016512,NDC,1,EA,3.8,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.6302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 850 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687014311,NDC,0.588235294,EA,3.8,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.6302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 850 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687014301,NDC,0.588235294,EA,3.8,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.6302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 50 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904632361,NDC,0.5,EA,3.33,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.6317,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 50 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904632361,NDC,0.5,EA,3.33,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.6317,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 50 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904632361,NDC,0.5,EA,3.33,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.6317,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,42858000110,NDC,1,EA,3.33,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.6317,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,42858000110,NDC,1,EA,3.33,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.6317,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,42858000110,NDC,1,EA,3.33,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.6317,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,245531789,NDC,1,EA,3.33,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.6317,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,245531789,NDC,1,EA,3.33,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.6317,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,245531789,NDC,1,EA,3.33,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.6317,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 112 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003901,NDC,0.892857143,EA,3.4,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 112 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003901,NDC,0.892857143,EA,3.4,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tiZANidine 4 MG Tablet 150 Each Bottle,63700001,CDM,250,RC,,,,,,55111018015,NDC,0.5,EA,3.93,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.632522,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sucralfate 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762040101,NDC,1,EA,3.81,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.63449,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687064011,NDC,1,EA,3.34,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.6366,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687064011,NDC,1,EA,3.34,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.6366,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687064011,NDC,1,EA,3.34,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.6366,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687064001,NDC,1,EA,3.34,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.6366,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687064001,NDC,1,EA,3.34,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.6366,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687064001,NDC,1,EA,3.34,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.6366,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 75 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079044101,NDC,1.333333333,EA,3.94,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.636676,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585861,NDC,1,EA,3.41,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.6368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585861,NDC,1,EA,3.41,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.6368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine HCl 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714008110,NDC,1,EA,3.41,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.6368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine HCl 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714008110,NDC,1,EA,3.41,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.6368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50111091501,NDC,1,EA,3.41,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.6368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50111091501,NDC,1,EA,3.41,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.6368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
chlorthalidone 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378022201,NDC,0.5,EA,3.24,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.63944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cefTAZidime 1 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023525,NDC,1,EA,49,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.64067,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.49,1.69
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,409508411,NDC,1,EA,73.86,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.64067,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.49,1.69
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,25021012867,NDC,1,EA,82.96,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.64067,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.49,1.69
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023610,NDC,1,EA,77.24,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.64067,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.49,1.69
atenolol 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904539261,NDC,1,EA,3.83,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.64307,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687015211,NDC,1,EA,3.83,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.64307,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687015201,NDC,1,EA,3.83,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.64307,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084042311,NDC,1,EA,3.83,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.64307,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prenatal plus vitamin with folic acid 1 mg 27-1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69367026701,NDC,1,EA,3.83,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.64307,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,66758017006,NDC,1,EA,3.32,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.6434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,245531701,NDC,1,EA,3.32,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.6434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,66758017013,NDC,1,EA,3.32,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.6434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carBAMazepine 100 MG Tablet Chewable 100 Each Box,63700001,CDM,250,RC,,,,,,904385461,NDC,1,EA,3.43,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.6464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carBAMazepine 100 MG Tablet Chewable 100 Each Box,63700001,CDM,250,RC,,,,,,904385461,NDC,1,EA,3.43,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.6464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxepin 10 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,51672421701,NDC,1,EA,3.36,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.6464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxepin 10 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,51672421701,NDC,1,EA,3.36,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.6464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxepin 10 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,51672421701,NDC,1,EA,3.36,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.6464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxepin 10 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079043620,NDC,1,EA,3.43,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.6464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxepin 10 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079043620,NDC,1,EA,3.43,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.6464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084008211,NDC,0.5,EA,3.36,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.6464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084008211,NDC,0.5,EA,3.36,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.6464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084008211,NDC,0.5,EA,3.36,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.6464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268075411,NDC,1,EA,3.36,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.6464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268075411,NDC,1,EA,3.36,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.6464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268075411,NDC,1,EA,3.36,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.6464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 5 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268075415,NDC,1,EA,3.36,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.6464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 5 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268075415,NDC,1,EA,3.36,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.6464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 5 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268075415,NDC,1,EA,3.36,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.6464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 50 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904632361,NDC,0.5,EA,3.33,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.64835,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,42858000110,NDC,1,EA,3.33,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.64835,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,245531789,NDC,1,EA,3.33,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.64835,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pyRIDostigmine 60 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084049411,NDC,0.5,EA,3.97,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.649138,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cefTAZidime 1 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023525,NDC,1,EA,49,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.49,1.69
cefTAZidime 1 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023525,NDC,1,EA,49,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.49,1.69
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,409508411,NDC,1,EA,73.86,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.49,1.69
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,409508411,NDC,1,EA,73.86,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.49,1.69
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,25021012867,NDC,1,EA,82.96,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.49,1.69
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,25021012867,NDC,1,EA,82.96,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.49,1.69
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023610,NDC,1,EA,77.24,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.49,1.69
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023610,NDC,1,EA,77.24,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.49,1.69
acetaminophen-codeine 300-30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739000410,NDC,1,EA,3.44,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.6512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen-codeine 300-30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739000410,NDC,1,EA,3.44,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.6512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
penicillin v potassium 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714023501,NDC,0.5,EA,3.44,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.6512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
penicillin v potassium 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714023501,NDC,0.5,EA,3.44,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.6512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenytoin ER 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084037611,NDC,1,EA,3.44,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.6512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenytoin ER 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084037611,NDC,1,EA,3.44,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.6512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pyRIDostigmine 60 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084049401,NDC,0.5,EA,3.98,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.653292,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687064011,NDC,1,EA,3.34,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.6533,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687064001,NDC,1,EA,3.34,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.6533,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,69452015120,NDC,1,EA,3.86,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.65594,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,591024001,NDC,1,EA,3.45,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,591024001,NDC,1,EA,3.45,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prochlorperazine 5 MG Tablet 1 Each Blister,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054101,NDC,1,EA,3.28,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.65968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
protamine 10 MG/ML Solution 5 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022994,NDC,5,ML,84.74,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.66,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.45,2.12
protamine 10 MG/ML Solution 25 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022930,NDC,2.5,ML,44.37,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.66,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.45,2.12
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016401,NDC,1,ML,854.49,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.66,898.7384
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016410,NDC,1,ML,917.08,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.66,898.7384
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016425,NDC,1,ML,779.43,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.66,898.7384
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,185441601,NDC,1,EA,4,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.6616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756014201,NDC,1,EA,4,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.6616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SUTURE VICRYL TAPER 2-0 J317H,27200000,CDM,272,RC,,,,2615-MAIN,LOCAL,,,,,4,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.6616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
doxepin 10 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,51672421701,NDC,1,EA,3.36,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.6632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084008211,NDC,0.5,EA,3.36,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.6632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268075411,NDC,1,EA,3.36,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.6632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 5 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268075415,NDC,1,EA,3.36,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.6632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prochlorperazine 5 MG Tablet 100 Each Box,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054120,NDC,1,EA,3.29,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.66474,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
levothyroxine 112 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003901,NDC,0.892857143,EA,3.4,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.666,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 112 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003901,NDC,0.892857143,EA,3.4,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.666,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 112 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003901,NDC,0.892857143,EA,3.4,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.666,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904632661,NDC,1,EA,3.89,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.66881,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337501,NDC,50,ML,135.43,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.67,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.67,2.26
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337502,NDC,50,ML,135.43,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.67,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.67,2.26
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9678001,NDC,50,ML,135.43,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.67,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.67,2.26
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361250,NDC,50,ML,90.53,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.67,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.67,2.26
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361650,NDC,50,ML,90.53,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.67,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.67,2.26
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989001,NDC,50,ML,160.78,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.67,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.67,2.26
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989002,NDC,50,ML,160.78,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.67,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.67,2.26
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338411450,NDC,50,ML,106.23,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.67,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.67,2.26
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,781329091,NDC,50,ML,119.73,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.67,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.67,2.26
lisinopril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,603420921,NDC,1,EA,3.48,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.6704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,603420921,NDC,1,EA,3.48,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.6704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68180051201,NDC,1,EA,3.48,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.6704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68180051201,NDC,1,EA,3.48,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.6704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585861,NDC,1,EA,3.41,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.6709,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585861,NDC,1,EA,3.41,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.6709,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585861,NDC,1,EA,3.41,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.6709,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine HCl 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714008110,NDC,1,EA,3.41,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.6709,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine HCl 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714008110,NDC,1,EA,3.41,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.6709,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine HCl 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714008110,NDC,1,EA,3.41,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.6709,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50111091501,NDC,1,EA,3.41,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.6709,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50111091501,NDC,1,EA,3.41,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.6709,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50111091501,NDC,1,EA,3.41,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.6709,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzonatate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687034611,NDC,1,EA,3.91,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.67739,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714031401,NDC,0.333333333,EA,3.91,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.67739,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714065801,NDC,0.333333333,EA,3.91,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.67739,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57664039588,NDC,0.333333333,EA,3.91,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.67739,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,66758017006,NDC,1,EA,3.32,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.67992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,245531701,NDC,1,EA,3.32,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.67992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,66758017013,NDC,1,EA,3.32,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.67992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carBAMazepine 100 MG Tablet Chewable 100 Each Box,63700001,CDM,250,RC,,,,,,904385461,NDC,1,EA,3.43,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.6807,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carBAMazepine 100 MG Tablet Chewable 100 Each Box,63700001,CDM,250,RC,,,,,,904385461,NDC,1,EA,3.43,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.6807,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carBAMazepine 100 MG Tablet Chewable 100 Each Box,63700001,CDM,250,RC,,,,,,904385461,NDC,1,EA,3.43,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.6807,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxepin 10 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079043620,NDC,1,EA,3.43,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.6807,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxepin 10 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079043620,NDC,1,EA,3.43,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.6807,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxepin 10 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079043620,NDC,1,EA,3.43,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.6807,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methyldopa 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93293101,NDC,1,EA,3.92,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.68168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
desipramine 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50742011401,NDC,0.2,EA,4.05,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.68237,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 112 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003901,NDC,0.892857143,EA,3.4,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.683,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 50 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904632361,NDC,0.5,EA,3.33,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.68498,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,42858000110,NDC,1,EA,3.33,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.68498,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,245531789,NDC,1,EA,3.33,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.68498,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen-codeine 300-30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739000410,NDC,1,EA,3.44,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.6856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen-codeine 300-30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739000410,NDC,1,EA,3.44,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.6856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen-codeine 300-30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739000410,NDC,1,EA,3.44,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.6856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
penicillin v potassium 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714023501,NDC,0.5,EA,3.44,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.6856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
penicillin v potassium 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714023501,NDC,0.5,EA,3.44,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.6856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
penicillin v potassium 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714023501,NDC,0.5,EA,3.44,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.6856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenytoin ER 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084037611,NDC,1,EA,3.44,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.6856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenytoin ER 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084037611,NDC,1,EA,3.44,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.6856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenytoin ER 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084037611,NDC,1,EA,3.44,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.6856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tiZANidine 4 MG Tablet 150 Each Bottle,63700001,CDM,250,RC,,,,,,55111018015,NDC,0.5,EA,3.93,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.68597,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585861,NDC,1,EA,3.41,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.68795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine HCl 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714008110,NDC,1,EA,3.41,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.68795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50111091501,NDC,1,EA,3.41,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.68795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
XEROFORM GAUZE PETROLATUM 1X8INCH,27200000,CDM,272,RC,A6222,HCPCS,,10659-MAIN,LOCAL,,,,,3.52,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.6896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
XEROFORM GAUZE PETROLATUM 1X8INCH,27200000,CDM,272,RC,A6222,HCPCS,,10659-MAIN,LOCAL,,,,,3.52,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.6896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
cefTAZidime 1 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023525,NDC,1,EA,49,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.69,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.49,1.69
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,409508411,NDC,1,EA,73.86,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.69,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.49,1.69
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,25021012867,NDC,1,EA,82.96,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.69,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.49,1.69
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023610,NDC,1,EA,77.24,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.69,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.49,1.69
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687064011,NDC,1,EA,3.34,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.69004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687064001,NDC,1,EA,3.34,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.69004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 75 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079044101,NDC,1.333333333,EA,3.94,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.69026,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,591024001,NDC,1,EA,3.45,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.6905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,591024001,NDC,1,EA,3.45,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.6905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,591024001,NDC,1,EA,3.45,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.6905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268030315,NDC,0.5,EA,4.07,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.690678,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carBAMazepine 100 MG Tablet Chewable 100 Each Box,63700001,CDM,250,RC,,,,,,904385461,NDC,1,EA,3.43,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.69785,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxepin 10 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079043620,NDC,1,EA,3.43,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.69785,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,25021011487,NDC,200,ML,66.28,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.7,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.7,1.93
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,36000000924,NDC,200,ML,48.65,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.7,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.7,1.93
"dextrose 5 % 5 % Solution 1,000 mL Flex Cont",J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001704,NDC,1000,ML,99.12,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.7,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.7,1.93
dextrose 5 % 5 % Solution 50 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338055111,NDC,50,ML,43.5,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.7,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.7,1.93
dextrose 5 % 5 % Solution 100 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001748,NDC,100,ML,43.5,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.7,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.7,1.93
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001702,NDC,250,ML,99.12,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.7,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.7,1.93
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338634602,NDC,250,ML,99.12,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.7,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.7,1.93
dextrose 5 % 5 % Solution 500 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001703,NDC,500,ML,99.12,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.7,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.7,1.93
dextrose 5 % Non-DEHP bag 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,264751020,NDC,250,ML,99.12,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.7,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.7,1.93
doxepin 10 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,51672421701,NDC,1,EA,3.36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.70016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084008211,NDC,0.5,EA,3.36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.70016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268075411,NDC,1,EA,3.36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.70016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 5 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268075415,NDC,1,EA,3.36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.70016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen-codeine 300-30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739000410,NDC,1,EA,3.44,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.7028,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
penicillin v potassium 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714023501,NDC,0.5,EA,3.44,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.7028,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenytoin ER 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084037611,NDC,1,EA,3.44,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.7028,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pyRIDostigmine 60 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084049411,NDC,0.5,EA,3.97,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.70313,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
penicillin v potassium 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714023401,NDC,1,EA,4.1,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.70314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluvoxaMINE 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,60505016601,NDC,0.25,EA,3.55,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluvoxaMINE 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,60505016601,NDC,0.25,EA,3.55,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,603420921,NDC,1,EA,3.48,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.7052,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,603420921,NDC,1,EA,3.48,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.7052,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,603420921,NDC,1,EA,3.48,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.7052,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68180051201,NDC,1,EA,3.48,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.7052,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68180051201,NDC,1,EA,3.48,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.7052,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68180051201,NDC,1,EA,3.48,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.7052,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268064011,NDC,1,EA,4.11,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.707294,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268064015,NDC,1,EA,4.11,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.707294,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pyRIDostigmine 60 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084049401,NDC,0.5,EA,3.98,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.70742,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,591024001,NDC,1,EA,3.45,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.70775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcitRIOL 0.25 MCG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687034511,NDC,1,EA,4.12,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.711448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 400-80 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237023201,NDC,1,EA,3.57,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.7136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 400-80 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237023201,NDC,1,EA,3.57,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.7136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,185441601,NDC,1,EA,4,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.716,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756014201,NDC,1,EA,4,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.716,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SUTURE VICRYL TAPER 2-0 J317H,27200000,CDM,272,RC,,,,2615-MAIN,LOCAL,,,,,4,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.716,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
acetaminophen 650 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802073030,NDC,1,EA,3.58,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.7184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 650 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802073030,NDC,1,EA,3.58,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.7184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
silver nitrate - pot nitrate 75-25 % Misc 100 Each Package,63700001,CDM,250,RC,,,,,,12870000102,NDC,1,EA,3.58,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.7184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
silver nitrate - pot nitrate 75-25 % Misc 100 Each Package,63700001,CDM,250,RC,,,,,,12870000102,NDC,1,EA,3.58,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.7184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
busPIRone 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079098501,NDC,1,EA,4.14,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.719756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
busPIRone 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079098520,NDC,1,EA,4.14,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.719756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bortezomib 3.5 MG Recon Soln 1 Each Vial,J9041.01,CDM,636,RC,J9041,HCPCS,,,,63020004901,NDC,1,EA,3270.12,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.72,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.72,2.07
levothyroxine 112 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003901,NDC,0.892857143,EA,3.4,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.7204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,603420921,NDC,1,EA,3.48,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.7226,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68180051201,NDC,1,EA,3.48,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.7226,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
enalapril 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904550261,NDC,0.5,EA,4.15,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.72391,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
naproxen 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65162018810,NDC,1,EA,4.15,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.72391,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
XEROFORM GAUZE PETROLATUM 1X8INCH,27200000,CDM,272,RC,A6222,HCPCS,,10659-MAIN,LOCAL,,,,,3.52,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.7248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
XEROFORM GAUZE PETROLATUM 1X8INCH,27200000,CDM,272,RC,A6222,HCPCS,,10659-MAIN,LOCAL,,,,,3.52,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.7248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
XEROFORM GAUZE PETROLATUM 1X8INCH,27200000,CDM,272,RC,A6222,HCPCS,,10659-MAIN,LOCAL,,,,,3.52,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.7248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ALPRAZolam 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585861,NDC,1,EA,3.41,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.72546,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine HCl 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714008110,NDC,1,EA,3.41,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.72546,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50111091501,NDC,1,EA,3.41,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.72546,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 4 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,56016875,NDC,0.25,EA,3.6,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 4 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,56016875,NDC,0.25,EA,3.6,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carBAMazepine 100 MG Tablet Chewable 100 Each Box,63700001,CDM,250,RC,,,,,,904385461,NDC,1,EA,3.43,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.73558,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxepin 10 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079043620,NDC,1,EA,3.43,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.73558,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
desipramine 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50742011401,NDC,0.2,EA,4.05,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.73745,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 250 MG Tablet Chewable 100 Each Bottle,63700001,CDM,250,RC,,,,,,93226801,NDC,1,EA,3.62,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.7376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 250 MG Tablet Chewable 100 Each Bottle,63700001,CDM,250,RC,,,,,,93226801,NDC,1,EA,3.62,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.7376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
repaglinide 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,574024001,NDC,1,EA,3.62,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.7376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
repaglinide 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,574024001,NDC,1,EA,3.62,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.7376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluvoxaMINE 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,60505016601,NDC,0.25,EA,3.55,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.7395,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluvoxaMINE 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,60505016601,NDC,0.25,EA,3.55,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.7395,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluvoxaMINE 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,60505016601,NDC,0.25,EA,3.55,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.7395,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337501,NDC,50,ML,135.43,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337502,NDC,50,ML,135.43,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9678001,NDC,50,ML,135.43,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361250,NDC,50,ML,90.53,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361650,NDC,50,ML,90.53,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989001,NDC,50,ML,160.78,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989002,NDC,50,ML,160.78,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338411450,NDC,50,ML,106.23,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,781329091,NDC,50,ML,119.73,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
acetaminophen-codeine 300-30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739000410,NDC,1,EA,3.44,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.74064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
penicillin v potassium 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714023501,NDC,0.5,EA,3.44,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.74064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenytoin ER 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084037611,NDC,1,EA,3.44,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.74064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687016311,NDC,0.5,EA,3.63,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.7424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687016311,NDC,0.5,EA,3.63,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.7424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687016301,NDC,0.5,EA,3.63,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.7424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687016301,NDC,0.5,EA,3.63,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.7424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
XEROFORM GAUZE PETROLATUM 1X8INCH,27200000,CDM,272,RC,A6222,HCPCS,,10659-MAIN,LOCAL,,,,,3.52,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.7424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LORazepam 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,591024001,NDC,1,EA,3.45,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.7457,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268030315,NDC,0.5,EA,4.07,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.74603,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 400-80 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237023201,NDC,1,EA,3.57,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.7493,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 400-80 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237023201,NDC,1,EA,3.57,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.7493,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 400-80 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237023201,NDC,1,EA,3.57,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.7493,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
caffeine citrate 60 MG/3ML Solution 3 mL Vial,J0706.01,CDM,636,RC,J0706,HCPCS,,,,63323040704,NDC,3,ML,73.84,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6434,2.848
caffeine citrate 60 MG/3ML Solution 3 mL Vial,J0706.01,CDM,636,RC,J0706,HCPCS,,,,63323040704,NDC,3,ML,73.84,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6434,2.848
Temporary External Pacing,PX92953F,CDM,480,RC,92953,CPT,,,,,,,,678,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.43,1.75
Temporary External Pacing,PX92953F,CDM,480,RC,92953,CPT,,,,,,,,678,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.75,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.43,1.75
potassium chloride CR 20 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,245531989,NDC,1,EA,3.65,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,245531989,NDC,1,EA,3.65,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,66758019006,NDC,1,EA,3.65,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,66758019006,NDC,1,EA,3.65,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,245531901,NDC,1,EA,3.65,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,245531901,NDC,1,EA,3.65,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,66758019013,NDC,1,EA,3.65,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,66758019013,NDC,1,EA,3.65,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 650 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802073030,NDC,1,EA,3.58,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.7542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 650 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802073030,NDC,1,EA,3.58,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.7542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 650 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802073030,NDC,1,EA,3.58,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.7542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
silver nitrate - pot nitrate 75-25 % Misc 100 Each Package,63700001,CDM,250,RC,,,,,,12870000102,NDC,1,EA,3.58,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.7542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
silver nitrate - pot nitrate 75-25 % Misc 100 Each Package,63700001,CDM,250,RC,,,,,,12870000102,NDC,1,EA,3.58,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.7542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
silver nitrate - pot nitrate 75-25 % Misc 100 Each Package,63700001,CDM,250,RC,,,,,,12870000102,NDC,1,EA,3.58,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.7542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluvoxaMINE 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,60505016601,NDC,0.25,EA,3.55,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.75725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
penicillin v potassium 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714023401,NDC,1,EA,4.1,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.7589,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,603420921,NDC,1,EA,3.48,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.76088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68180051201,NDC,1,EA,3.48,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.76088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
primidone 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084020211,NDC,1,EA,4.24,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.761296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268064011,NDC,1,EA,4.11,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.76319,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268064015,NDC,1,EA,4.11,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.76319,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 4 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,56016875,NDC,0.25,EA,3.6,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.764,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 4 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,56016875,NDC,0.25,EA,3.6,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.764,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 4 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,56016875,NDC,0.25,EA,3.6,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.764,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
saccharomyces boulardii 250 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,4142000024,NDC,1,EA,4.25,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.76545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 400-80 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237023201,NDC,1,EA,3.57,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.76715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcitRIOL 0.25 MCG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687034511,NDC,1,EA,4.12,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.76748,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"dextrose 5 % 5 % Solution 1,000 mL Flex Cont",J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001704,NDC,1000,ML,99.12,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.76935,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.7,1.93
dextrose 5 % 5 % Solution 50 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338055111,NDC,50,ML,43.5,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.76935,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.7,1.93
dextrose 5 % 5 % Solution 100 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001748,NDC,100,ML,43.5,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.76935,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.7,1.93
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001702,NDC,250,ML,99.12,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.76935,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.7,1.93
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338634602,NDC,250,ML,99.12,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.76935,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.7,1.93
dextrose 5 % 5 % Solution 500 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001703,NDC,500,ML,99.12,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.76935,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.7,1.93
dextrose 5 % Non-DEHP bag 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,264751020,NDC,250,ML,99.12,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.76935,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.7,1.93
primidone 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084020201,NDC,1,EA,4.26,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.769604,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ampicillin-sulbactam 1.5 (1-0.5) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001381,NDC,1,EA,69.24,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.77,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.55,2.12
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001481,NDC,1,EA,102.12,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.77,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.55,2.12
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011701,NDC,1,EA,89.64,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.77,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.55,2.12
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011710,NDC,1,EA,89.64,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.77,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.55,2.12
acetaminophen 650 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802073030,NDC,1,EA,3.58,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.7721,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
silver nitrate - pot nitrate 75-25 % Misc 100 Each Package,63700001,CDM,250,RC,,,,,,12870000102,NDC,1,EA,3.58,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.7721,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406012323,NDC,1,EA,4.27,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.773758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406012362,NDC,1,EA,4.27,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.773758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 88 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904695261,NDC,1.136363636,EA,4.27,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.773758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079099101,NDC,1,EA,4.27,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.773758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079099120,NDC,1,EA,4.27,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.773758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 250 MG Tablet Chewable 100 Each Bottle,63700001,CDM,250,RC,,,,,,93226801,NDC,1,EA,3.62,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.7738,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 250 MG Tablet Chewable 100 Each Bottle,63700001,CDM,250,RC,,,,,,93226801,NDC,1,EA,3.62,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.7738,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 250 MG Tablet Chewable 100 Each Bottle,63700001,CDM,250,RC,,,,,,93226801,NDC,1,EA,3.62,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.7738,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
repaglinide 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,574024001,NDC,1,EA,3.62,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.7738,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
repaglinide 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,574024001,NDC,1,EA,3.62,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.7738,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
repaglinide 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,574024001,NDC,1,EA,3.62,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.7738,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
busPIRone 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079098501,NDC,1,EA,4.14,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.77606,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
busPIRone 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079098520,NDC,1,EA,4.14,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.77606,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 750 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877041401,NDC,0.666666667,EA,4.28,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.777912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687016311,NDC,0.5,EA,3.63,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.7787,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687016311,NDC,0.5,EA,3.63,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.7787,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687016311,NDC,0.5,EA,3.63,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.7787,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687016301,NDC,0.5,EA,3.63,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.7787,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687016301,NDC,0.5,EA,3.63,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.7787,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687016301,NDC,0.5,EA,3.63,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.7787,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
enalapril 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904550261,NDC,0.5,EA,4.15,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.78035,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
naproxen 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65162018810,NDC,1,EA,4.15,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.78035,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
XEROFORM GAUZE PETROLATUM 1X8INCH,27200000,CDM,272,RC,A6222,HCPCS,,10659-MAIN,LOCAL,,,,,3.52,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.78112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
warfarin 4 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,56016875,NDC,0.25,EA,3.6,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.782,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904563161,NDC,1,EA,3.72,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.7856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904563161,NDC,1,EA,3.72,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.7856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 5-325 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406012301,NDC,1,EA,3.72,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.7856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 5-325 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406012301,NDC,1,EA,3.72,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.7856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079075901,NDC,1,EA,4.3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.78622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine CR 12.5 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,42858070303,NDC,1,EA,4.3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.78622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,245531989,NDC,1,EA,3.65,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.7885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,245531989,NDC,1,EA,3.65,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.7885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,245531989,NDC,1,EA,3.65,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.7885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,66758019006,NDC,1,EA,3.65,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.7885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,66758019006,NDC,1,EA,3.65,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.7885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,66758019006,NDC,1,EA,3.65,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.7885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,245531901,NDC,1,EA,3.65,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.7885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,245531901,NDC,1,EA,3.65,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.7885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,245531901,NDC,1,EA,3.65,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.7885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,66758019013,NDC,1,EA,3.65,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.7885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,66758019013,NDC,1,EA,3.65,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.7885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,66758019013,NDC,1,EA,3.65,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.7885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bortezomib 3.5 MG Recon Soln 1 Each Vial,J9041.01,CDM,636,RC,J9041,HCPCS,,,,63020004901,NDC,1,EA,3270.12,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.79,3204.7176
ALPRAZolam 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,781106101,NDC,1,EA,3.73,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.7904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,781106101,NDC,1,EA,3.73,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.7904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,67253090010,NDC,1,EA,3.73,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.7904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,67253090010,NDC,1,EA,3.73,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.7904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 250 MG Tablet Chewable 100 Each Bottle,63700001,CDM,250,RC,,,,,,93226801,NDC,1,EA,3.62,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.7919,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
repaglinide 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,574024001,NDC,1,EA,3.62,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.7919,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739026310,NDC,1,EA,4.32,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.794528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluvoxaMINE 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,60505016601,NDC,0.25,EA,3.55,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.7963,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687016311,NDC,0.5,EA,3.63,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.79685,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687016301,NDC,0.5,EA,3.63,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.79685,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"dextrose 5 % 5 % Solution 1,000 mL Flex Cont",J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001704,NDC,1000,ML,99.12,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.7,1.93
"dextrose 5 % 5 % Solution 1,000 mL Flex Cont",J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001704,NDC,1000,ML,99.12,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.7,1.93
dextrose 5 % 5 % Solution 50 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338055111,NDC,50,ML,43.5,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.7,1.93
dextrose 5 % 5 % Solution 50 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338055111,NDC,50,ML,43.5,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.7,1.93
dextrose 5 % 5 % Solution 100 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001748,NDC,100,ML,43.5,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.7,1.93
dextrose 5 % 5 % Solution 100 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001748,NDC,100,ML,43.5,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.7,1.93
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001702,NDC,250,ML,99.12,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.7,1.93
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001702,NDC,250,ML,99.12,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.7,1.93
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338634602,NDC,250,ML,99.12,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.7,1.93
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338634602,NDC,250,ML,99.12,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.7,1.93
dextrose 5 % 5 % Solution 500 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001703,NDC,500,ML,99.12,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.7,1.93
dextrose 5 % 5 % Solution 500 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001703,NDC,500,ML,99.12,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.7,1.93
dextrose 5 % Non-DEHP bag 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,264751020,NDC,250,ML,99.12,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.7,1.93
dextrose 5 % Non-DEHP bag 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,264751020,NDC,250,ML,99.12,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.7,1.93
diphenoxylate-atropine 2.5-0.025 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762106101,NDC,1,EA,3.76,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.8048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenoxylate-atropine 2.5-0.025 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762106101,NDC,1,EA,3.76,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.8048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenoxylate-atropine 2.5-0.025 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,62559049001,NDC,1,EA,3.76,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.8048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenoxylate-atropine 2.5-0.025 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,62559049001,NDC,1,EA,3.76,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.8048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 400-80 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237023201,NDC,1,EA,3.57,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.80642,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,245531989,NDC,1,EA,3.65,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.80675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,66758019006,NDC,1,EA,3.65,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.80675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,245531901,NDC,1,EA,3.65,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.80675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,66758019013,NDC,1,EA,3.65,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.80675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cocaine 4% 4 % Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527172874,NDC,4,ML,875.53,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,1.808,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.98,1.808
cocaine 4% 4 % Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527172874,NDC,4,ML,875.53,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,1.808,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.98,1.808
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527197174,NDC,4,ML,960.5,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,1.808,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.98,1.808
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527197174,NDC,4,ML,960.5,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,1.808,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.98,1.808
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,64950036204,NDC,4,ML,1067.22,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,1.808,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.98,1.808
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,64950036204,NDC,4,ML,1067.22,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,1.808,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.98,1.808
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,70839036204,NDC,4,ML,1280.66,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,1.808,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.98,1.808
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,70839036204,NDC,4,ML,1280.66,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,1.808,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.98,1.808
acetaminophen 650 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802073030,NDC,1,EA,3.58,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.81148,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
silver nitrate - pot nitrate 75-25 % Misc 100 Each Package,63700001,CDM,250,RC,,,,,,12870000102,NDC,1,EA,3.58,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.81148,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 100 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904695361,NDC,1,EA,3.78,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.8144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 100 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904695361,NDC,1,EA,3.78,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.8144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
primidone 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084020211,NDC,1,EA,4.24,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.81896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016401,NDC,1,ML,854.49,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.82,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.59,1.88
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016410,NDC,1,ML,917.08,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.82,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.59,1.88
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016425,NDC,1,ML,779.43,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.82,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.59,1.88
warfarin 4 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,56016875,NDC,0.25,EA,3.6,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.8216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904563161,NDC,1,EA,3.72,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.8228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904563161,NDC,1,EA,3.72,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.8228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904563161,NDC,1,EA,3.72,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.8228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 5-325 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406012301,NDC,1,EA,3.72,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.8228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 5-325 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406012301,NDC,1,EA,3.72,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.8228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 5-325 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406012301,NDC,1,EA,3.72,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.8228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
saccharomyces boulardii 250 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,4142000024,NDC,1,EA,4.25,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.82325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
verapamil CR 240 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462026001,NDC,0.5,EA,4.39,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.823606,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 650 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713016512,NDC,1,EA,3.8,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 650 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713016512,NDC,1,EA,3.8,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 850 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687014311,NDC,0.588235294,EA,3.8,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 850 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687014311,NDC,0.588235294,EA,3.8,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 850 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687014301,NDC,0.588235294,EA,3.8,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 850 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687014301,NDC,0.588235294,EA,3.8,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
primidone 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084020201,NDC,1,EA,4.26,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.82754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,781106101,NDC,1,EA,3.73,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.8277,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,781106101,NDC,1,EA,3.73,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.8277,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,781106101,NDC,1,EA,3.73,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.8277,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,67253090010,NDC,1,EA,3.73,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.8277,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,67253090010,NDC,1,EA,3.73,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.8277,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,67253090010,NDC,1,EA,3.73,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.8277,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084009301,NDC,1,EA,4.4,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.82776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084080811,NDC,1,EA,4.4,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.82776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68084080801,NDC,1,EA,4.4,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.82776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sucralfate 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762040101,NDC,1,EA,3.81,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.8288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sucralfate 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762040101,NDC,1,EA,3.81,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.8288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 250 MG Tablet Chewable 100 Each Bottle,63700001,CDM,250,RC,,,,,,93226801,NDC,1,EA,3.62,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.83172,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
repaglinide 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,574024001,NDC,1,EA,3.62,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.83172,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406012323,NDC,1,EA,4.27,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.83183,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406012362,NDC,1,EA,4.27,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.83183,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 88 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904695261,NDC,1.136363636,EA,4.27,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.83183,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079099101,NDC,1,EA,4.27,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.83183,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079099120,NDC,1,EA,4.27,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.83183,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637061,NDC,0.5,EA,4.41,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.831914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,25021011487,NDC,200,ML,66.28,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.83369,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.7,1.93
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,36000000924,NDC,200,ML,48.65,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.83369,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.7,1.93
SYRINGE BULB 60ML IRRIGATION STERILE DYND20125,27200000,CDM,272,RC,A4322,HCPCS,,10829-MAIN,LOCAL,,,,,2.16,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1.836,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
cloZAPine 100 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,378086005,NDC,0.25,EA,4.42,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.836068,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 750 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877041401,NDC,0.666666667,EA,4.28,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.83612,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687016311,NDC,0.5,EA,3.63,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.83678,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687016301,NDC,0.5,EA,3.63,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.83678,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904539261,NDC,1,EA,3.83,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.8384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904539261,NDC,1,EA,3.83,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.8384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687015211,NDC,1,EA,3.83,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.8384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687015211,NDC,1,EA,3.83,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.8384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687015201,NDC,1,EA,3.83,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.8384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687015201,NDC,1,EA,3.83,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.8384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084042311,NDC,1,EA,3.83,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.8384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084042311,NDC,1,EA,3.83,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.8384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prenatal plus vitamin with folic acid 1 mg 27-1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69367026701,NDC,1,EA,3.83,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.8384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prenatal plus vitamin with folic acid 1 mg 27-1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69367026701,NDC,1,EA,3.83,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.8384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone 4 MG Tablet 100 Each Bottle,J7509.01,CDM,636,RC,J7509,HCPCS,,,,68382091601,NDC,0.5,EA,4.43,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.840222,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904563161,NDC,1,EA,3.72,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.8414,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 5-325 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406012301,NDC,1,EA,3.72,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.8414,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenoxylate-atropine 2.5-0.025 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762106101,NDC,1,EA,3.76,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.8424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenoxylate-atropine 2.5-0.025 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762106101,NDC,1,EA,3.76,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.8424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenoxylate-atropine 2.5-0.025 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762106101,NDC,1,EA,3.76,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.8424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenoxylate-atropine 2.5-0.025 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,62559049001,NDC,1,EA,3.76,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.8424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenoxylate-atropine 2.5-0.025 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,62559049001,NDC,1,EA,3.76,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.8424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenoxylate-atropine 2.5-0.025 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,62559049001,NDC,1,EA,3.76,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.8424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079075901,NDC,1,EA,4.3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.8447,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine CR 12.5 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,42858070303,NDC,1,EA,4.3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.8447,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,781106101,NDC,1,EA,3.73,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.84635,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,67253090010,NDC,1,EA,3.73,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.84635,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,245531989,NDC,1,EA,3.65,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.8469,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,66758019006,NDC,1,EA,3.65,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.8469,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,245531901,NDC,1,EA,3.65,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.8469,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,66758019013,NDC,1,EA,3.65,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.8469,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,25021011487,NDC,200,ML,66.28,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.7,1.93
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,25021011487,NDC,200,ML,66.28,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.7,1.93
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,36000000924,NDC,200,ML,48.65,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.7,1.93
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,36000000924,NDC,200,ML,48.65,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.7,1.93
levothyroxine 100 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904695361,NDC,1,EA,3.78,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.8522,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 100 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904695361,NDC,1,EA,3.78,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.8522,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 100 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904695361,NDC,1,EA,3.78,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.8522,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,69452015120,NDC,1,EA,3.86,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.8528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,69452015120,NDC,1,EA,3.86,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.8528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739026310,NDC,1,EA,4.32,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.85328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenoxylate-atropine 2.5-0.025 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762106101,NDC,1,EA,3.76,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.8612,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenoxylate-atropine 2.5-0.025 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,62559049001,NDC,1,EA,3.76,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.8612,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 650 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713016512,NDC,1,EA,3.8,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.862,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 650 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713016512,NDC,1,EA,3.8,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.862,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 650 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713016512,NDC,1,EA,3.8,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.862,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 850 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687014311,NDC,0.588235294,EA,3.8,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.862,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 850 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687014311,NDC,0.588235294,EA,3.8,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.862,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 850 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687014311,NDC,0.588235294,EA,3.8,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.862,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 850 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687014301,NDC,0.588235294,EA,3.8,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.862,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 850 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687014301,NDC,0.588235294,EA,3.8,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.862,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 850 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687014301,NDC,0.588235294,EA,3.8,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.862,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016401,NDC,1,ML,854.49,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.86586,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.59,1.88
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016410,NDC,1,ML,917.08,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.86586,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.59,1.88
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016425,NDC,1,ML,779.43,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.86586,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.59,1.88
sucralfate 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762040101,NDC,1,EA,3.81,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.8669,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sucralfate 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762040101,NDC,1,EA,3.81,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.8669,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sucralfate 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762040101,NDC,1,EA,3.81,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.8669,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904632661,NDC,1,EA,3.89,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.8672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904632661,NDC,1,EA,3.89,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.8672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
caffeine citrate 60 MG/3ML Solution 3 mL Vial,J0706.01,CDM,636,RC,J0706,HCPCS,,,,63323040704,NDC,3,ML,73.84,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.87,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6434,2.848
levothyroxine 100 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904695361,NDC,1,EA,3.78,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.8711,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904539261,NDC,1,EA,3.83,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.8767,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904539261,NDC,1,EA,3.83,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.8767,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904539261,NDC,1,EA,3.83,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.8767,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687015211,NDC,1,EA,3.83,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.8767,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687015211,NDC,1,EA,3.83,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.8767,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687015211,NDC,1,EA,3.83,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.8767,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687015201,NDC,1,EA,3.83,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.8767,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687015201,NDC,1,EA,3.83,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.8767,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687015201,NDC,1,EA,3.83,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.8767,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084042311,NDC,1,EA,3.83,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.8767,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084042311,NDC,1,EA,3.83,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.8767,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084042311,NDC,1,EA,3.83,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.8767,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prenatal plus vitamin with folic acid 1 mg 27-1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69367026701,NDC,1,EA,3.83,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.8767,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prenatal plus vitamin with folic acid 1 mg 27-1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69367026701,NDC,1,EA,3.83,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.8767,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prenatal plus vitamin with folic acid 1 mg 27-1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69367026701,NDC,1,EA,3.83,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.8767,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzonatate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687034611,NDC,1,EA,3.91,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.8768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzonatate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687034611,NDC,1,EA,3.91,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.8768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714031401,NDC,0.333333333,EA,3.91,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.8768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714031401,NDC,0.333333333,EA,3.91,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.8768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714065801,NDC,0.333333333,EA,3.91,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.8768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714065801,NDC,0.333333333,EA,3.91,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.8768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57664039588,NDC,0.333333333,EA,3.91,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.8768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57664039588,NDC,0.333333333,EA,3.91,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.8768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
digoxin 125 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904592161,NDC,0.5,EA,4.52,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.877608,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016401,NDC,1,ML,854.49,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.59,1.88
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016401,NDC,1,ML,854.49,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.59,1.88
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016410,NDC,1,ML,917.08,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.59,1.88
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016410,NDC,1,ML,917.08,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.59,1.88
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016425,NDC,1,ML,779.43,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.59,1.88
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016425,NDC,1,ML,779.43,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.59,1.88
droPERidol 2.5 MG/ML Solution 2 mL Vial,J1790.01,CDM,636,RC,J1790,HCPCS,,,,517970201,NDC,2,ML,75.47,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1.88,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.88,9.13
acetaminophen 650 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713016512,NDC,1,EA,3.8,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.881,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 850 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687014311,NDC,0.588235294,EA,3.8,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.881,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 850 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687014301,NDC,0.588235294,EA,3.8,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.881,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methyldopa 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93293101,NDC,1,EA,3.92,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.8816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methyldopa 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93293101,NDC,1,EA,3.92,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.8816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904563161,NDC,1,EA,3.72,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.88232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 5-325 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406012301,NDC,1,EA,3.72,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.88232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
verapamil CR 240 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462026001,NDC,0.5,EA,4.39,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.88331,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sucralfate 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762040101,NDC,1,EA,3.81,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.88595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tiZANidine 4 MG Tablet 150 Each Bottle,63700001,CDM,250,RC,,,,,,55111018015,NDC,0.5,EA,3.93,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.8864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tiZANidine 4 MG Tablet 150 Each Bottle,63700001,CDM,250,RC,,,,,,55111018015,NDC,0.5,EA,3.93,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.8864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,781106101,NDC,1,EA,3.73,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.88738,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,67253090010,NDC,1,EA,3.73,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.88738,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084009301,NDC,1,EA,4.4,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.8876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084080811,NDC,1,EA,4.4,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.8876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68084080801,NDC,1,EA,4.4,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.8876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 75 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079044101,NDC,1.333333333,EA,3.94,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.8912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 75 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079044101,NDC,1.333333333,EA,3.94,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.8912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,69452015120,NDC,1,EA,3.86,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.8914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,69452015120,NDC,1,EA,3.86,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.8914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,69452015120,NDC,1,EA,3.86,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.8914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637061,NDC,0.5,EA,4.41,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.89189,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hyoscyamine 0.125 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42192034001,NDC,1,EA,4.56,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.894224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904539261,NDC,1,EA,3.83,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.89585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687015211,NDC,1,EA,3.83,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.89585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687015201,NDC,1,EA,3.83,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.89585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084042311,NDC,1,EA,3.83,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.89585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prenatal plus vitamin with folic acid 1 mg 27-1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69367026701,NDC,1,EA,3.83,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.89585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloZAPine 100 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,378086005,NDC,0.25,EA,4.42,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.89618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337501,NDC,50,ML,135.43,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.9,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.67,2.26
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337502,NDC,50,ML,135.43,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.9,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.67,2.26
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9678001,NDC,50,ML,135.43,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.9,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.67,2.26
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361250,NDC,50,ML,90.53,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.9,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.67,2.26
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361650,NDC,50,ML,90.53,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.9,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.67,2.26
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989001,NDC,50,ML,160.78,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.9,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.67,2.26
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989002,NDC,50,ML,160.78,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.9,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.67,2.26
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338411450,NDC,50,ML,106.23,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.9,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.67,2.26
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,781329091,NDC,50,ML,119.73,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.9,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.67,2.26
methylPREDNISolone 4 MG Tablet 100 Each Bottle,J7509.01,CDM,636,RC,J7509,HCPCS,,,,68382091601,NDC,0.5,EA,4.43,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.90047,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
diphenoxylate-atropine 2.5-0.025 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762106101,NDC,1,EA,3.76,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.90256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenoxylate-atropine 2.5-0.025 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,62559049001,NDC,1,EA,3.76,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.90256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SYRINGE BULB 60ML IRRIGATION STERILE DYND20125,27200000,CDM,272,RC,A4322,HCPCS,,10829-MAIN,LOCAL,,,,,2.16,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1.90512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
pyRIDostigmine 60 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084049411,NDC,0.5,EA,3.97,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.9056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pyRIDostigmine 60 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084049411,NDC,0.5,EA,3.97,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.9056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904632661,NDC,1,EA,3.89,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.9061,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904632661,NDC,1,EA,3.89,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.9061,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904632661,NDC,1,EA,3.89,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.9061,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pyRIDostigmine 60 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084049401,NDC,0.5,EA,3.98,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.9104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pyRIDostigmine 60 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084049401,NDC,0.5,EA,3.98,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.9104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,69452015120,NDC,1,EA,3.86,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.9107,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
meclizine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084049111,NDC,1,EA,4.6,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.91084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
meclizine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084049101,NDC,1,EA,4.6,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.91084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 100 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904695361,NDC,1,EA,3.78,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.91268,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzonatate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687034611,NDC,1,EA,3.91,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.9159,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzonatate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687034611,NDC,1,EA,3.91,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.9159,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzonatate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687034611,NDC,1,EA,3.91,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.9159,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714031401,NDC,0.333333333,EA,3.91,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.9159,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714031401,NDC,0.333333333,EA,3.91,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.9159,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714031401,NDC,0.333333333,EA,3.91,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.9159,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714065801,NDC,0.333333333,EA,3.91,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.9159,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714065801,NDC,0.333333333,EA,3.91,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.9159,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714065801,NDC,0.333333333,EA,3.91,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.9159,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57664039588,NDC,0.333333333,EA,3.91,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.9159,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57664039588,NDC,0.333333333,EA,3.91,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.9159,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57664039588,NDC,0.333333333,EA,3.91,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.9159,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,185441601,NDC,1,EA,4,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,185441601,NDC,1,EA,4,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756014201,NDC,1,EA,4,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756014201,NDC,1,EA,4,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SUTURE VICRYL TAPER 2-0 J317H,27200000,CDM,272,RC,,,,2615-MAIN,LOCAL,,,,,4,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE VICRYL TAPER 2-0 J317H,27200000,CDM,272,RC,,,,2615-MAIN,LOCAL,,,,,4,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
methyldopa 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93293101,NDC,1,EA,3.92,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.9208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methyldopa 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93293101,NDC,1,EA,3.92,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.9208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methyldopa 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93293101,NDC,1,EA,3.92,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.9208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SYRINGE BULB 60ML IRRIGATION STERILE DYND20125,27200000,CDM,272,RC,A4322,HCPCS,,10829-MAIN,LOCAL,,,,,2.16,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1.9224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
acetaminophen 650 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713016512,NDC,1,EA,3.8,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.9228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 850 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687014311,NDC,0.588235294,EA,3.8,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.9228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 850 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687014301,NDC,0.588235294,EA,3.8,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.9228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904632661,NDC,1,EA,3.89,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.92555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tiZANidine 4 MG Tablet 150 Each Bottle,63700001,CDM,250,RC,,,,,,55111018015,NDC,0.5,EA,3.93,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.9257,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tiZANidine 4 MG Tablet 150 Each Bottle,63700001,CDM,250,RC,,,,,,55111018015,NDC,0.5,EA,3.93,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.9257,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tiZANidine 4 MG Tablet 150 Each Bottle,63700001,CDM,250,RC,,,,,,55111018015,NDC,0.5,EA,3.93,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.9257,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sucralfate 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762040101,NDC,1,EA,3.81,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.92786,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,25021011487,NDC,200,ML,66.28,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.93,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.7,1.93
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,36000000924,NDC,200,ML,48.65,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.93,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.7,1.93
"dextrose 5 % 5 % Solution 1,000 mL Flex Cont",J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001704,NDC,1000,ML,99.12,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.93,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.7,1.93
dextrose 5 % 5 % Solution 50 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338055111,NDC,50,ML,43.5,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.93,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.7,1.93
dextrose 5 % 5 % Solution 100 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001748,NDC,100,ML,43.5,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.93,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.7,1.93
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001702,NDC,250,ML,99.12,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.93,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.7,1.93
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338634602,NDC,250,ML,99.12,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.93,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.7,1.93
dextrose 5 % 5 % Solution 500 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001703,NDC,500,ML,99.12,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.93,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.7,1.93
dextrose 5 % Non-DEHP bag 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,264751020,NDC,250,ML,99.12,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1.93,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.7,1.93
droPERidol 2.5 MG/ML Solution 2 mL Vial,J1790.01,CDM,636,RC,J1790,HCPCS,,,,517970201,NDC,2,ML,75.47,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1.9302,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.88,9.13
levothyroxine 75 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079044101,NDC,1.333333333,EA,3.94,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.9306,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 75 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079044101,NDC,1.333333333,EA,3.94,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.9306,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 75 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079044101,NDC,1.333333333,EA,3.94,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.9306,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzonatate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687034611,NDC,1,EA,3.91,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.93545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714031401,NDC,0.333333333,EA,3.91,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.93545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714065801,NDC,0.333333333,EA,3.91,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.93545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57664039588,NDC,0.333333333,EA,3.91,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.93545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904539261,NDC,1,EA,3.83,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.93798,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687015211,NDC,1,EA,3.83,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.93798,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687015201,NDC,1,EA,3.83,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.93798,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084042311,NDC,1,EA,3.83,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.93798,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prenatal plus vitamin with folic acid 1 mg 27-1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69367026701,NDC,1,EA,3.83,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.93798,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
digoxin 125 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904592161,NDC,0.5,EA,4.52,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.93908,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 875 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862001501,NDC,1,EA,4.67,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.939918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
loperamide 2 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079069001,NDC,1,EA,4.67,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.939918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methyldopa 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93293101,NDC,1,EA,3.92,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.9404,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
desipramine 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50742011401,NDC,0.2,EA,4.05,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
desipramine 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50742011401,NDC,0.2,EA,4.05,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 250 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756079788,NDC,0.5,EA,4.68,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.944072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pyRIDostigmine 60 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084049411,NDC,0.5,EA,3.97,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.9453,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pyRIDostigmine 60 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084049411,NDC,0.5,EA,3.97,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.9453,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pyRIDostigmine 60 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084049411,NDC,0.5,EA,3.97,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.9453,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tiZANidine 4 MG Tablet 150 Each Bottle,63700001,CDM,250,RC,,,,,,55111018015,NDC,0.5,EA,3.93,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.94535,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pyRIDostigmine 60 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084049401,NDC,0.5,EA,3.98,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.9502,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pyRIDostigmine 60 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084049401,NDC,0.5,EA,3.98,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.9502,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pyRIDostigmine 60 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084049401,NDC,0.5,EA,3.98,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.9502,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 75 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079044101,NDC,1.333333333,EA,3.94,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.9503,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
loperamide 2 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079069020,NDC,1,EA,4.7,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.95238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,69452015120,NDC,1,EA,3.86,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.95316,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268030315,NDC,0.5,EA,4.07,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.9536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268030315,NDC,0.5,EA,4.07,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.9536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hyoscyamine 0.125 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42192034001,NDC,1,EA,4.56,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.95624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,185441601,NDC,1,EA,4,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,185441601,NDC,1,EA,4,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,185441601,NDC,1,EA,4,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756014201,NDC,1,EA,4,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756014201,NDC,1,EA,4,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756014201,NDC,1,EA,4,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SUTURE VICRYL TAPER 2-0 J317H,27200000,CDM,272,RC,,,,2615-MAIN,LOCAL,,,,,4,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE VICRYL TAPER 2-0 J317H,27200000,CDM,272,RC,,,,2615-MAIN,LOCAL,,,,,4,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE VICRYL TAPER 2-0 J317H,27200000,CDM,272,RC,,,,2615-MAIN,LOCAL,,,,,4,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
pyRIDostigmine 60 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084049411,NDC,0.5,EA,3.97,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.96515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SYRINGE BULB 60ML IRRIGATION STERILE DYND20125,27200000,CDM,272,RC,A4322,HCPCS,,10829-MAIN,LOCAL,,,,,2.16,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1.96776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
penicillin v potassium 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714023401,NDC,1,EA,4.1,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
penicillin v potassium 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714023401,NDC,1,EA,4.1,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904632661,NDC,1,EA,3.89,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.96834,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pyRIDostigmine 60 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084049401,NDC,0.5,EA,3.98,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.9701,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268064011,NDC,1,EA,4.11,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.9728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268064011,NDC,1,EA,4.11,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.9728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268064015,NDC,1,EA,4.11,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.9728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268064015,NDC,1,EA,4.11,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.9728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
meclizine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084049111,NDC,1,EA,4.6,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.9734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
meclizine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084049101,NDC,1,EA,4.6,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1.9734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 7.5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406012423,NDC,1,EA,4.76,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.977304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 7.5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406012462,NDC,1,EA,4.76,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.977304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcitRIOL 0.25 MCG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687034511,NDC,1,EA,4.12,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.9776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcitRIOL 0.25 MCG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687034511,NDC,1,EA,4.12,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.9776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzonatate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687034611,NDC,1,EA,3.91,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.97846,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714031401,NDC,0.333333333,EA,3.91,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.97846,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714065801,NDC,0.333333333,EA,3.91,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.97846,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57664039588,NDC,0.333333333,EA,3.91,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.97846,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,185441601,NDC,1,EA,4,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756014201,NDC,1,EA,4,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SUTURE VICRYL TAPER 2-0 J317H,27200000,CDM,272,RC,,,,2615-MAIN,LOCAL,,,,,4,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
methyldopa 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93293101,NDC,1,EA,3.92,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.98352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
desipramine 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50742011401,NDC,0.2,EA,4.05,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.9845,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
desipramine 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50742011401,NDC,0.2,EA,4.05,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.9845,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
desipramine 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50742011401,NDC,0.2,EA,4.05,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.9845,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
triamterene-hydroCHLOROthiazide 37.5-25 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,68084075025,NDC,1,EA,4.78,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.985612,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
busPIRone 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079098501,NDC,1,EA,4.14,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.9872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
busPIRone 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079098501,NDC,1,EA,4.14,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.9872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
busPIRone 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079098520,NDC,1,EA,4.14,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.9872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
busPIRone 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079098520,NDC,1,EA,4.14,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.9872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tiZANidine 4 MG Tablet 150 Each Bottle,63700001,CDM,250,RC,,,,,,55111018015,NDC,0.5,EA,3.93,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.98858,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079068420,NDC,1,EA,4.79,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.989766,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 3 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,56018875,NDC,0.333333333,EA,4.79,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.989766,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
enalapril 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904550261,NDC,0.5,EA,4.15,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
enalapril 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904550261,NDC,0.5,EA,4.15,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
naproxen 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65162018810,NDC,1,EA,4.15,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1.992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
naproxen 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65162018810,NDC,1,EA,4.15,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1.992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 75 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079044101,NDC,1.333333333,EA,3.94,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1.99364,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium chloride 0.9% IV FLUSH 0.9 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,8881570121,NDC,2.5,ML,4.8,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.99392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9% IV FLUSH 0.9 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,63807010001,NDC,2.5,ML,4.8,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.99392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
famotidine 20 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268030315,NDC,0.5,EA,4.07,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.9943,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268030315,NDC,0.5,EA,4.07,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1.9943,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268030315,NDC,0.5,EA,4.07,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1.9943,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prazosin 1 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,70954001950,NDC,1,EA,4.81,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1.998074,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 875 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862001501,NDC,1,EA,4.67,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.00343,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
loperamide 2 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079069001,NDC,1,EA,4.67,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.00343,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
desipramine 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50742011401,NDC,0.2,EA,4.05,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.00475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 250 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756079788,NDC,0.5,EA,4.68,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.00772,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pyRIDostigmine 60 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084049411,NDC,0.5,EA,3.97,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.00882,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
penicillin v potassium 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714023401,NDC,1,EA,4.1,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.009,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
penicillin v potassium 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714023401,NDC,1,EA,4.1,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.009,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
penicillin v potassium 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714023401,NDC,1,EA,4.1,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.009,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pyRIDostigmine 60 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084049401,NDC,0.5,EA,3.98,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.01388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268064011,NDC,1,EA,4.11,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.0139,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268064011,NDC,1,EA,4.11,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.0139,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268064011,NDC,1,EA,4.11,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.0139,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268064015,NDC,1,EA,4.11,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.0139,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268064015,NDC,1,EA,4.11,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.0139,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268064015,NDC,1,EA,4.11,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.0139,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268030315,NDC,0.5,EA,4.07,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.01465,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ramipril 2.5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237022301,NDC,0.5,EA,4.85,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.01469,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buprenorphine 2 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,50383092493,NDC,1,EA,24.34,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,2.016,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.09,2.016
buprenorphine 2 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,50383092493,NDC,1,EA,24.34,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,2.016,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.09,2.016
buprenorphine 8 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,54017713,NDC,1,EA,41.56,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,2.016,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.09,2.016
buprenorphine 8 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,54017713,NDC,1,EA,41.56,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,2.016,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.09,2.016
loperamide 2 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079069020,NDC,1,EA,4.7,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.0163,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcitRIOL 0.25 MCG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687034511,NDC,1,EA,4.12,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.0188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcitRIOL 0.25 MCG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687034511,NDC,1,EA,4.12,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.0188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcitRIOL 0.25 MCG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687034511,NDC,1,EA,4.12,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.0188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028401,NDC,1,EA,111.01,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028420,NDC,1,EA,111.01,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028426,NDC,1,EA,42.15,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028442,NDC,1,EA,47.71,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034000,NDC,1,EA,111.82,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034001,NDC,1,EA,111.81,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010520,NDC,1,EA,68.33,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010541,NDC,1,EA,68.33,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076501,NDC,1,EA,58.6,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076510,NDC,1,EA,58.6,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,47781059807,NDC,1,EA,39.84,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022116,NDC,1,EA,36.33,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022141,NDC,1,EA,36.33,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022143,NDC,1,EA,36.31,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457033900,NDC,1,EA,71.82,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
diclofenac EC 50 MG Tablet Delayed Release 14 Each Bottle,63700001,CDM,250,RC,,,,,,71335048107,NDC,1,EA,4.87,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.022998,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,185441601,NDC,1,EA,4,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756014201,NDC,1,EA,4,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SUTURE VICRYL TAPER 2-0 J317H,27200000,CDM,272,RC,,,,2615-MAIN,LOCAL,,,,,4,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
bortezomib 3.5 MG Recon Soln 1 Each Vial,J9041.01,CDM,636,RC,J9041,HCPCS,,,,63020004901,NDC,1,EA,3270.12,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.02671,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.72,2.07
busPIRone 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079098501,NDC,1,EA,4.14,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.0286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
busPIRone 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079098501,NDC,1,EA,4.14,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.0286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
busPIRone 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079098501,NDC,1,EA,4.14,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.0286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
busPIRone 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079098520,NDC,1,EA,4.14,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.0286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
busPIRone 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079098520,NDC,1,EA,4.14,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.0286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
busPIRone 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079098520,NDC,1,EA,4.14,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.0286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
penicillin v potassium 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714023401,NDC,1,EA,4.1,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.0295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
enalapril 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904550261,NDC,0.5,EA,4.15,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.0335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
enalapril 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904550261,NDC,0.5,EA,4.15,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.0335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
enalapril 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904550261,NDC,0.5,EA,4.15,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.0335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
naproxen 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65162018810,NDC,1,EA,4.15,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.0335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
naproxen 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65162018810,NDC,1,EA,4.15,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.0335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
naproxen 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65162018810,NDC,1,EA,4.15,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.0335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268064011,NDC,1,EA,4.11,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.03445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268064015,NDC,1,EA,4.11,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.03445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
primidone 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084020211,NDC,1,EA,4.24,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.0352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
primidone 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084020211,NDC,1,EA,4.24,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.0352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcitRIOL 0.25 MCG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687034511,NDC,1,EA,4.12,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.0394,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
saccharomyces boulardii 250 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,4142000024,NDC,1,EA,4.25,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
saccharomyces boulardii 250 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,4142000024,NDC,1,EA,4.25,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 7.5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406012423,NDC,1,EA,4.76,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.04204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 7.5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406012462,NDC,1,EA,4.76,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.04204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
primidone 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084020201,NDC,1,EA,4.26,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.0448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
primidone 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084020201,NDC,1,EA,4.26,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.0448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
busPIRone 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079098501,NDC,1,EA,4.14,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.0493,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
busPIRone 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079098520,NDC,1,EA,4.14,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.0493,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
desipramine 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50742011401,NDC,0.2,EA,4.05,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.0493,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406012323,NDC,1,EA,4.27,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.0496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406012323,NDC,1,EA,4.27,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.0496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406012362,NDC,1,EA,4.27,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.0496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406012362,NDC,1,EA,4.27,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.0496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 88 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904695261,NDC,1.136363636,EA,4.27,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.0496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 88 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904695261,NDC,1.136363636,EA,4.27,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.0496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079099101,NDC,1,EA,4.27,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.0496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079099101,NDC,1,EA,4.27,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.0496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079099120,NDC,1,EA,4.27,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.0496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079099120,NDC,1,EA,4.27,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.0496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
triamterene-hydroCHLOROthiazide 37.5-25 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,68084075025,NDC,1,EA,4.78,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.05062,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metroNIDAZOLE 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084096611,NDC,1,EA,4.94,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.052076,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metroNIDAZOLE 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084096601,NDC,1,EA,4.94,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.052076,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
enalapril 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904550261,NDC,0.5,EA,4.15,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.05425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
naproxen 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65162018810,NDC,1,EA,4.15,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.05425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 750 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877041401,NDC,0.666666667,EA,4.28,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.0544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 750 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877041401,NDC,0.666666667,EA,4.28,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.0544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079068420,NDC,1,EA,4.79,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.05491,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 3 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,56018875,NDC,0.333333333,EA,4.79,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.05491,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium chloride 0.9% IV FLUSH 0.9 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,8881570121,NDC,2.5,ML,4.8,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.0592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9% IV FLUSH 0.9 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,63807010001,NDC,2.5,ML,4.8,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.0592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
famotidine 20 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268030315,NDC,0.5,EA,4.07,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.05942,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bortezomib 3.5 MG Recon Soln 1 Each Vial,J9041.01,CDM,636,RC,J9041,HCPCS,,,,63020004901,NDC,1,EA,3270.12,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.06,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.72,2.07
"Urinalysis, Auto W/O Scope",PX81003,CDM,300,RC,81003,CPT,,,,,,,,149,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.06,146.02
prazosin 1 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,70954001950,NDC,1,EA,4.81,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.06349,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079075901,NDC,1,EA,4.3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079075901,NDC,1,EA,4.3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine CR 12.5 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,42858070303,NDC,1,EA,4.3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine CR 12.5 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,42858070303,NDC,1,EA,4.3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bortezomib 3.5 MG Recon Soln 1 Each Vial,J9041.01,CDM,636,RC,J9041,HCPCS,,,,63020004901,NDC,1,EA,3270.12,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.07,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.72,2.07
bortezomib 3.5 MG Recon Soln 1 Each Vial,J9041.01,CDM,636,RC,J9041,HCPCS,,,,63020004901,NDC,1,EA,3270.12,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.07,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.72,2.07
clonazePAM 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739026310,NDC,1,EA,4.32,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.0736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739026310,NDC,1,EA,4.32,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.0736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
penicillin v potassium 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714023401,NDC,1,EA,4.1,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.0746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DRESSING MESALT 6X6 IMPREGNATED GAUZE STERILE 285780,120.511,CDM,272,RC,A6223,HCPCS,,12059-SURG,LOCAL,,,,,5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.077,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.077,4.9
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,71041813,NDC,1,EA,5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.077,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
primidone 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084020211,NDC,1,EA,4.24,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.0776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
primidone 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084020211,NDC,1,EA,4.24,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.0776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
primidone 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084020211,NDC,1,EA,4.24,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.0776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268064011,NDC,1,EA,4.11,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.07966,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268064015,NDC,1,EA,4.11,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.07966,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ramipril 2.5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237022301,NDC,0.5,EA,4.85,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.08065,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
saccharomyces boulardii 250 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,4142000024,NDC,1,EA,4.25,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.0825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
saccharomyces boulardii 250 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,4142000024,NDC,1,EA,4.25,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.0825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
saccharomyces boulardii 250 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,4142000024,NDC,1,EA,4.25,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.0825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcitRIOL 0.25 MCG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687034511,NDC,1,EA,4.12,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.08472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"BANDAGE STERILE  2"" TETRA-FLEX CLIP FREE 0151-2SV",27200000,CDM,272,RC,A6449,HCPCS,,10660-MAIN,LOCAL,,,,,5.02,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.085308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
primidone 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084020201,NDC,1,EA,4.26,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.0874,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
primidone 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084020201,NDC,1,EA,4.26,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.0874,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
primidone 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084020201,NDC,1,EA,4.26,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.0874,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diclofenac EC 50 MG Tablet Delayed Release 14 Each Bottle,63700001,CDM,250,RC,,,,,,71335048107,NDC,1,EA,4.87,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.08923,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279210,NDC,10,ML,429.84,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.09,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.09,2.37
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279410,NDC,10,ML,429.84,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.09,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.09,2.37
ampicillin-sulbactam 1.5 (1-0.5) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001381,NDC,1,EA,69.24,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.09105,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.55,2.12
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001481,NDC,1,EA,102.12,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.09105,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.55,2.12
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011701,NDC,1,EA,89.64,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.09105,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.55,2.12
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011710,NDC,1,EA,89.64,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.09105,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.55,2.12
protamine 10 MG/ML Solution 5 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022994,NDC,5,ML,84.74,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.09105,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.45,2.12
protamine 10 MG/ML Solution 25 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022930,NDC,2.5,ML,44.37,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.09105,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.45,2.12
HYDROcodone-acetaminophen 5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406012323,NDC,1,EA,4.27,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.0923,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406012323,NDC,1,EA,4.27,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.0923,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406012323,NDC,1,EA,4.27,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.0923,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406012362,NDC,1,EA,4.27,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.0923,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406012362,NDC,1,EA,4.27,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.0923,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406012362,NDC,1,EA,4.27,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.0923,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 88 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904695261,NDC,1.136363636,EA,4.27,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.0923,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 88 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904695261,NDC,1.136363636,EA,4.27,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.0923,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 88 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904695261,NDC,1.136363636,EA,4.27,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.0923,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079099101,NDC,1,EA,4.27,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.0923,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079099101,NDC,1,EA,4.27,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.0923,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079099101,NDC,1,EA,4.27,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.0923,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079099120,NDC,1,EA,4.27,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.0923,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079099120,NDC,1,EA,4.27,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.0923,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079099120,NDC,1,EA,4.27,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.0923,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa CR 25-100 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756046188,NDC,1,EA,5.04,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.093616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
busPIRone 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079098501,NDC,1,EA,4.14,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.09484,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
busPIRone 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079098520,NDC,1,EA,4.14,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.09484,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 750 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877041401,NDC,0.666666667,EA,4.28,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.0972,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 750 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877041401,NDC,0.666666667,EA,4.28,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.0972,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 750 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877041401,NDC,0.666666667,EA,4.28,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.0972,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
primidone 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084020211,NDC,1,EA,4.24,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.0988,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
enalapril 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904550261,NDC,0.5,EA,4.15,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.0999,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
naproxen 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65162018810,NDC,1,EA,4.15,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.0999,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268011015,NDC,1,EA,5.06,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.101924,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SYRINGE BULB 60ML IRRIGATION STERILE DYND20125,27200000,CDM,272,RC,A4322,HCPCS,,10829-MAIN,LOCAL,,,,,2.16,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.102328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
saccharomyces boulardii 250 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,4142000024,NDC,1,EA,4.25,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.10375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079075901,NDC,1,EA,4.3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.107,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079075901,NDC,1,EA,4.3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.107,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079075901,NDC,1,EA,4.3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.107,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine CR 12.5 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,42858070303,NDC,1,EA,4.3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.107,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine CR 12.5 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,42858070303,NDC,1,EA,4.3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.107,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine CR 12.5 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,42858070303,NDC,1,EA,4.3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.107,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
verapamil CR 240 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462026001,NDC,0.5,EA,4.39,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.1072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
verapamil CR 240 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462026001,NDC,0.5,EA,4.39,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.1072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
primidone 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084020201,NDC,1,EA,4.26,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.1087,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084009301,NDC,1,EA,4.4,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084009301,NDC,1,EA,4.4,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084080811,NDC,1,EA,4.4,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084080811,NDC,1,EA,4.4,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68084080801,NDC,1,EA,4.4,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68084080801,NDC,1,EA,4.4,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406012323,NDC,1,EA,4.27,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.11365,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406012362,NDC,1,EA,4.27,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.11365,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 88 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904695261,NDC,1.136363636,EA,4.27,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.11365,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079099101,NDC,1,EA,4.27,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.11365,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079099120,NDC,1,EA,4.27,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.11365,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739026310,NDC,1,EA,4.32,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.1168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739026310,NDC,1,EA,4.32,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.1168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739026310,NDC,1,EA,4.32,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.1168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637061,NDC,0.5,EA,4.41,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.1168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637061,NDC,0.5,EA,4.41,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.1168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SYRINGE BULB 60ML IRRIGATION STERILE DYND20125,27200000,CDM,272,RC,A4322,HCPCS,,10829-MAIN,LOCAL,,,,,2.16,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.1168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
metFORMIN-XR 750 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877041401,NDC,0.666666667,EA,4.28,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.1186,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metroNIDAZOLE 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084096611,NDC,1,EA,4.94,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.11926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metroNIDAZOLE 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084096601,NDC,1,EA,4.94,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.11926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ampicillin-sulbactam 1.5 (1-0.5) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001381,NDC,1,EA,69.24,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.55,2.12
ampicillin-sulbactam 1.5 (1-0.5) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001381,NDC,1,EA,69.24,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.55,2.12
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001481,NDC,1,EA,102.12,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.55,2.12
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001481,NDC,1,EA,102.12,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.55,2.12
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011701,NDC,1,EA,89.64,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.55,2.12
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011701,NDC,1,EA,89.64,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.55,2.12
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011710,NDC,1,EA,89.64,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.55,2.12
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011710,NDC,1,EA,89.64,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.55,2.12
protamine 10 MG/ML Solution 5 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022994,NDC,5,ML,84.74,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.45,2.12
protamine 10 MG/ML Solution 5 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022994,NDC,5,ML,84.74,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.45,2.12
protamine 10 MG/ML Solution 25 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022930,NDC,2.5,ML,44.37,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.45,2.12
protamine 10 MG/ML Solution 25 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022930,NDC,2.5,ML,44.37,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.45,2.12
cloZAPine 100 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,378086005,NDC,0.25,EA,4.42,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.1216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloZAPine 100 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,378086005,NDC,0.25,EA,4.42,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.1216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone 4 MG Tablet 100 Each Bottle,J7509.01,CDM,636,RC,J7509,HCPCS,,,,68382091601,NDC,0.5,EA,4.43,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.1264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
methylPREDNISolone 4 MG Tablet 100 Each Bottle,J7509.01,CDM,636,RC,J7509,HCPCS,,,,68382091601,NDC,0.5,EA,4.43,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.1264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
atenolol 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079075901,NDC,1,EA,4.3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.1285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine CR 12.5 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,42858070303,NDC,1,EA,4.3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.1285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739026310,NDC,1,EA,4.32,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.1384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
droPERidol 2.5 MG/ML Solution 2 mL Vial,J1790.01,CDM,636,RC,J1790,HCPCS,,,,517970201,NDC,2,ML,75.47,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.14,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.88,9.13
droPERidol 2.5 MG/ML Solution 2 mL Vial,J1790.01,CDM,636,RC,J1790,HCPCS,,,,517970201,NDC,2,ML,75.47,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.14,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.88,9.13
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42937070110,NDC,1,EA,5.16,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.143464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
verapamil CR 180 MG Tablet Extended Release 100 Each Bottle,25000000,CDM,250,RC,,,,,,75834015801,NDC,0.666666667,EA,5.16,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.143464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
DRESSING MESALT 6X6 IMPREGNATED GAUZE STERILE 285780,120.511,CDM,272,RC,A6223,HCPCS,,12059-SURG,LOCAL,,,,,5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.145,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.077,4.9
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,71041813,NDC,1,EA,5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.145,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
primidone 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084020211,NDC,1,EA,4.24,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.14544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Urinalysis, Auto W/O Scope",PX81003,CDM,300,RC,81003,CPT,,,,,,,,149,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.15,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.15,2.25
"Urinalysis, Auto W/O Scope",PX81003,CDM,300,RC,81003,CPT,,,,,,,,149,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.15,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.15,2.25
saccharomyces boulardii 250 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,4142000024,NDC,1,EA,4.25,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.1505,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
verapamil CR 240 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462026001,NDC,0.5,EA,4.39,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.1511,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
verapamil CR 240 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462026001,NDC,0.5,EA,4.39,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.1511,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
verapamil CR 240 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462026001,NDC,0.5,EA,4.39,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.1511,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"BANDAGE STERILE  2"" TETRA-FLEX CLIP FREE 0151-2SV",27200000,CDM,272,RC,A6449,HCPCS,,10660-MAIN,LOCAL,,,,,5.02,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.15358,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279210,NDC,10,ML,429.84,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.15539,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.09,2.37
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279410,NDC,10,ML,429.84,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.15539,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.09,2.37
primidone 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084020201,NDC,1,EA,4.26,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.15556,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084009301,NDC,1,EA,4.4,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084009301,NDC,1,EA,4.4,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084009301,NDC,1,EA,4.4,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084080811,NDC,1,EA,4.4,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084080811,NDC,1,EA,4.4,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084080811,NDC,1,EA,4.4,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68084080801,NDC,1,EA,4.4,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68084080801,NDC,1,EA,4.4,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68084080801,NDC,1,EA,4.4,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,25021050002,NDC,1,ML,52.06,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.16,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.16,2.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001302,NDC,2,ML,86.79,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.16,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.16,2.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001326,NDC,1,ML,42.88,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.16,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.16,2.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001341,NDC,1,ML,42.88,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.16,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.16,2.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019600,NDC,1,ML,48.64,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.16,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.16,2.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019602,NDC,2,ML,77.29,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.16,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.16,2.46
cyclobenzaprine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079064420,NDC,1,EA,5.2,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.16008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406012323,NDC,1,EA,4.27,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.16062,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406012362,NDC,1,EA,4.27,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.16062,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 88 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904695261,NDC,1.136363636,EA,4.27,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.16062,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079099101,NDC,1,EA,4.27,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.16062,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079099120,NDC,1,EA,4.27,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.16062,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637061,NDC,0.5,EA,4.41,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.1609,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637061,NDC,0.5,EA,4.41,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.1609,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637061,NDC,0.5,EA,4.41,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.1609,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa CR 25-100 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756046188,NDC,1,EA,5.04,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.16216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 750 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877041401,NDC,0.666666667,EA,4.28,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.16568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloZAPine 100 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,378086005,NDC,0.25,EA,4.42,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.1658,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloZAPine 100 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,378086005,NDC,0.25,EA,4.42,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.1658,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloZAPine 100 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,378086005,NDC,0.25,EA,4.42,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.1658,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
digoxin 125 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904592161,NDC,0.5,EA,4.52,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.1696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
digoxin 125 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904592161,NDC,0.5,EA,4.52,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.1696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Hematocrit,PX85014,CDM,300,RC,85014,CPT,,,,,,,,58,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.17,56.84
Hemoglobin,PX85018,CDM,300,RC,85018,CPT,,,,,,,,68,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.17,66.64
Oximetry;Mult Determine,PX610,CDM,460,RC,94761,CPT,,,,,,,,142,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.17,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.17,6.98
methylPREDNISolone 4 MG Tablet 100 Each Bottle,J7509.01,CDM,636,RC,J7509,HCPCS,,,,68382091601,NDC,0.5,EA,4.43,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.1707,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
methylPREDNISolone 4 MG Tablet 100 Each Bottle,J7509.01,CDM,636,RC,J7509,HCPCS,,,,68382091601,NDC,0.5,EA,4.43,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.1707,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
methylPREDNISolone 4 MG Tablet 100 Each Bottle,J7509.01,CDM,636,RC,J7509,HCPCS,,,,68382091601,NDC,0.5,EA,4.43,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.1707,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
benazepril 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268011015,NDC,1,EA,5.06,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.17074,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,185060501,NDC,1,EA,5.23,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.172542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
verapamil CR 240 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462026001,NDC,0.5,EA,4.39,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.17305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079075901,NDC,1,EA,4.3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.1758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine CR 12.5 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,42858070303,NDC,1,EA,4.3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.1758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084009301,NDC,1,EA,4.4,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084080811,NDC,1,EA,4.4,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68084080801,NDC,1,EA,4.4,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279210,NDC,10,ML,429.84,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.18,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.09,2.37
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279210,NDC,10,ML,429.84,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.18,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.09,2.37
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279410,NDC,10,ML,429.84,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.18,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.09,2.37
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279410,NDC,10,ML,429.84,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.18,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.09,2.37
"Urinalysis, Auto W/O Scope",PX81003,CDM,300,RC,81003,CPT,,,,,,,,149,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.18,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.15,2.25
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637061,NDC,0.5,EA,4.41,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.18295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739026310,NDC,1,EA,4.32,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.18592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloZAPine 100 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,378086005,NDC,0.25,EA,4.42,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.1879,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hyoscyamine 0.125 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42192034001,NDC,1,EA,4.56,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.1888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hyoscyamine 0.125 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42192034001,NDC,1,EA,4.56,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.1888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone 4 MG Tablet 100 Each Bottle,J7509.01,CDM,636,RC,J7509,HCPCS,,,,68382091601,NDC,0.5,EA,4.43,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.19285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
"SUTURE SILK 2-0 BLK BR FS 18"" 685G",27200000,CDM,272,RC,,,,2668-MAIN,LOCAL,,,,,5.29,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.197466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
meclizine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084049111,NDC,1,EA,4.6,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
meclizine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084049111,NDC,1,EA,4.6,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
meclizine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084049101,NDC,1,EA,4.6,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
meclizine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084049101,NDC,1,EA,4.6,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42937070110,NDC,1,EA,5.16,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.21364,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
verapamil CR 180 MG Tablet Extended Release 100 Each Bottle,25000000,CDM,250,RC,,,,,,75834015801,NDC,0.666666667,EA,5.16,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.21364,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
digoxin 125 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904592161,NDC,0.5,EA,4.52,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.2148,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
digoxin 125 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904592161,NDC,0.5,EA,4.52,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.2148,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
digoxin 125 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904592161,NDC,0.5,EA,4.52,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.2148,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337501,NDC,50,ML,135.43,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.21973,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.67,2.26
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337502,NDC,50,ML,135.43,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.21973,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.67,2.26
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9678001,NDC,50,ML,135.43,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.21973,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.67,2.26
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361250,NDC,50,ML,90.53,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.21973,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.67,2.26
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361650,NDC,50,ML,90.53,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.21973,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.67,2.26
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989001,NDC,50,ML,160.78,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.21973,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.67,2.26
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989002,NDC,50,ML,160.78,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.21973,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.67,2.26
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338411450,NDC,50,ML,106.23,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.21973,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.67,2.26
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,781329091,NDC,50,ML,119.73,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.21973,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.67,2.26
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,25021050002,NDC,1,ML,52.06,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.21973,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.16,2.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001302,NDC,2,ML,86.79,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.21973,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.16,2.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001326,NDC,1,ML,42.88,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.21973,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.16,2.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001341,NDC,1,ML,42.88,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.21973,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.16,2.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019600,NDC,1,ML,48.64,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.21973,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.16,2.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019602,NDC,2,ML,77.29,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.21973,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.16,2.46
verapamil CR 240 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462026001,NDC,0.5,EA,4.39,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.22134,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084009301,NDC,1,EA,4.4,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.2264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084080811,NDC,1,EA,4.4,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.2264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68084080801,NDC,1,EA,4.4,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.2264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem 30 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93031801,NDC,1,EA,5.36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.226544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aztreonam 1 g Recon Soln 1 Each Vial,J0457.01,CDM,636,RC,J0457,HCPCS,,,,63323040124,NDC,1,EA,176.32,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.23,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.23,2.57
cyclobenzaprine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079064420,NDC,1,EA,5.2,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.2308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637061,NDC,0.5,EA,4.41,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.23146,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hyoscyamine 0.125 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42192034001,NDC,1,EA,4.56,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.2344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hyoscyamine 0.125 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42192034001,NDC,1,EA,4.56,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.2344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hyoscyamine 0.125 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42192034001,NDC,1,EA,4.56,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.2344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloZAPine 100 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,378086005,NDC,0.25,EA,4.42,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.23652,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
digoxin 125 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904592161,NDC,0.5,EA,4.52,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.2374,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone 4 MG Tablet 100 Each Bottle,J7509.01,CDM,636,RC,J7509,HCPCS,,,,68382091601,NDC,0.5,EA,4.43,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.24158,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
amoxicillin 875 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862001501,NDC,1,EA,4.67,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.2416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 875 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862001501,NDC,1,EA,4.67,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.2416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
loperamide 2 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079069001,NDC,1,EA,4.67,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.2416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
loperamide 2 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079069001,NDC,1,EA,4.67,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.2416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003201,NDC,0.125,EA,5.4,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.24316,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,185060501,NDC,1,EA,5.23,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.24367,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Hematocrit,PX85014,CDM,300,RC,85014,CPT,,,,,,,,58,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.2463,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.2463,2.37
Hemoglobin,PX85018,CDM,300,RC,85018,CPT,,,,,,,,68,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.2463,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.2463,2.37
"Urinalysis, Auto W/O Scope",PX81003,CDM,300,RC,81003,CPT,,,,,,,,149,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.2463,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.15,2.25
divalproex 250 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756079788,NDC,0.5,EA,4.68,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.2464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 250 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756079788,NDC,0.5,EA,4.68,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.2464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glimepiride 1 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268035815,NDC,1,EA,5.41,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.247314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Urinalysis, Auto W/O Scope",PX81003,CDM,300,RC,81003,CPT,,,,,,,,149,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.25,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.15,2.25
Noninvasv Oxygen Satur;Single,PX94760,CDM,460,RC,94760,CPT,,,,,,,,131,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.2505,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.3,4.65
"BANDAGE STERILE  2"" TETRA-FLEX CLIP FREE 0151-2SV",27200000,CDM,272,RC,A6449,HCPCS,,10660-MAIN,LOCAL,,,,,5.02,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.2519,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
"BANDAGE STERILE 3"" TETRA-FLEX CLIP FREE 0151-3SV",27200000,CDM,272,RC,A6449,HCPCS,,10661-MAIN,LOCAL,,,,,5.93,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.2519,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
"BANDAGE STERILE 4"" TETRA-FLEX CLIP FREE  0151-4SV",27200000,CDM,272,RC,A6449,HCPCS,,10662-MAIN,LOCAL,,,,,6.7,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.2519,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
meclizine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084049111,NDC,1,EA,4.6,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.254,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
meclizine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084049111,NDC,1,EA,4.6,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.254,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
meclizine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084049111,NDC,1,EA,4.6,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.254,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
meclizine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084049101,NDC,1,EA,4.6,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.254,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
meclizine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084049101,NDC,1,EA,4.6,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.254,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
meclizine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084049101,NDC,1,EA,4.6,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.254,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
loperamide 2 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079069020,NDC,1,EA,4.7,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
loperamide 2 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079069020,NDC,1,EA,4.7,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hyoscyamine 0.125 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42192034001,NDC,1,EA,4.56,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.2572,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337501,NDC,50,ML,135.43,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.67,2.26
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337501,NDC,50,ML,135.43,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.67,2.26
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337502,NDC,50,ML,135.43,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.67,2.26
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337502,NDC,50,ML,135.43,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.67,2.26
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9678001,NDC,50,ML,135.43,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.67,2.26
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9678001,NDC,50,ML,135.43,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.67,2.26
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361250,NDC,50,ML,90.53,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.67,2.26
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361250,NDC,50,ML,90.53,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.67,2.26
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361650,NDC,50,ML,90.53,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.67,2.26
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361650,NDC,50,ML,90.53,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.67,2.26
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989001,NDC,50,ML,160.78,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.67,2.26
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989001,NDC,50,ML,160.78,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.67,2.26
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989002,NDC,50,ML,160.78,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.67,2.26
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989002,NDC,50,ML,160.78,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.67,2.26
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338411450,NDC,50,ML,106.23,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.67,2.26
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338411450,NDC,50,ML,106.23,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.67,2.26
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,781329091,NDC,50,ML,119.73,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.67,2.26
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,781329091,NDC,50,ML,119.73,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.67,2.26
Hematocrit,PX85014,CDM,300,RC,85014,CPT,,,,,,,,58,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.2463,2.37
Hematocrit,PX85014,CDM,300,RC,85014,CPT,,,,,,,,58,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.2463,2.37
Hemoglobin,PX85018,CDM,300,RC,85018,CPT,,,,,,,,68,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.2463,2.37
Hemoglobin,PX85018,CDM,300,RC,85018,CPT,,,,,,,,68,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.2463,2.37
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,25021050002,NDC,1,ML,52.06,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.16,2.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,25021050002,NDC,1,ML,52.06,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.16,2.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001302,NDC,2,ML,86.79,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.16,2.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001302,NDC,2,ML,86.79,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.16,2.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001326,NDC,1,ML,42.88,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.16,2.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001326,NDC,1,ML,42.88,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.16,2.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001341,NDC,1,ML,42.88,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.16,2.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001341,NDC,1,ML,42.88,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.16,2.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019600,NDC,1,ML,48.64,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.16,2.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019600,NDC,1,ML,48.64,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.16,2.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019602,NDC,2,ML,77.29,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.16,2.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019602,NDC,2,ML,77.29,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.16,2.46
doxazosin 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904552261,NDC,1,EA,5.46,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.268084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,43598043635,NDC,1,EA,5.46,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.268084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"SUTURE SILK 2-0 BLK BR FS 18"" 685G",27200000,CDM,272,RC,,,,2668-MAIN,LOCAL,,,,,5.29,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.26941,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"BANDAGE STERILE  2"" TETRA-FLEX CLIP FREE 0151-2SV",27200000,CDM,272,RC,A6449,HCPCS,,10660-MAIN,LOCAL,,,,,5.02,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.27,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
"BANDAGE STERILE 3"" TETRA-FLEX CLIP FREE 0151-3SV",27200000,CDM,272,RC,A6449,HCPCS,,10661-MAIN,LOCAL,,,,,5.93,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.27,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
"BANDAGE STERILE 4"" TETRA-FLEX CLIP FREE  0151-4SV",27200000,CDM,272,RC,A6449,HCPCS,,10662-MAIN,LOCAL,,,,,6.7,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.27,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
meclizine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084049111,NDC,1,EA,4.6,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.277,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
meclizine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084049101,NDC,1,EA,4.6,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.277,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"dextrose 5% lactated ringers 5 % Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012504,NDC,1000,ML,43.5,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.28,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.28,2.59
dextrose 5% lactated ringers 5 % Solution 500 mL Flex Cont,J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012503,NDC,500,ML,99.12,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.28,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.28,2.59
"lactated ringers Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338011704,NDC,1000,ML,99.12,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.28,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.28,2.59
HYDROcodone-acetaminophen 7.5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406012423,NDC,1,EA,4.76,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.2848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 7.5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406012423,NDC,1,EA,4.76,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.2848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 7.5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406012462,NDC,1,EA,4.76,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.2848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 7.5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406012462,NDC,1,EA,4.76,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.2848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
digoxin 125 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904592161,NDC,0.5,EA,4.52,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.28712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 875 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862001501,NDC,1,EA,4.67,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.2883,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 875 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862001501,NDC,1,EA,4.67,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.2883,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 875 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862001501,NDC,1,EA,4.67,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.2883,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
loperamide 2 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079069001,NDC,1,EA,4.67,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.2883,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
loperamide 2 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079069001,NDC,1,EA,4.67,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.2883,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
loperamide 2 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079069001,NDC,1,EA,4.67,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.2883,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,10370083111,NDC,0.5,EA,5.51,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.288854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,68462063925,NDC,1,EA,5.51,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.288854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039801,NDC,1,EA,67.88,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.29,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.29,2.6
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039810,NDC,1,EA,67.88,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.29,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.29,2.6
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039814,NDC,1,EA,39.84,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.29,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.29,2.6
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039841,NDC,1,EA,43.14,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.29,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.29,2.6
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086000,NDC,1,EA,58.66,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.29,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.29,2.6
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086050,NDC,1,EA,58.66,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.29,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.29,2.6
divalproex 250 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756079788,NDC,0.5,EA,4.68,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.2932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 250 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756079788,NDC,0.5,EA,4.68,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.2932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 250 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756079788,NDC,0.5,EA,4.68,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.2932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
triamterene-hydroCHLOROthiazide 37.5-25 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,68084075025,NDC,1,EA,4.78,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.2944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
triamterene-hydroCHLOROthiazide 37.5-25 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,68084075025,NDC,1,EA,4.78,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.2944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079068420,NDC,1,EA,4.79,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.2992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079068420,NDC,1,EA,4.79,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.2992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 3 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,56018875,NDC,0.333333333,EA,4.79,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.2992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 3 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,56018875,NDC,0.333333333,EA,4.79,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.2992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem 30 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93031801,NDC,1,EA,5.36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.29944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Hematocrit,PX85014,CDM,300,RC,85014,CPT,,,,,,,,58,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.3,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.2463,2.37
Hemoglobin,PX85018,CDM,300,RC,85018,CPT,,,,,,,,68,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.3,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.2463,2.37
loperamide 2 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079069020,NDC,1,EA,4.7,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.303,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
loperamide 2 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079069020,NDC,1,EA,4.7,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.303,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
loperamide 2 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079069020,NDC,1,EA,4.7,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.303,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600110,NDC,10,ML,589.63,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,2.304,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.24,7.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600110,NDC,10,ML,589.63,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,2.304,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.24,7.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600121,NDC,10,ML,592.5,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,2.304,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.24,7.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600121,NDC,10,ML,592.5,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,2.304,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.24,7.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040304,NDC,10,ML,168.77,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,2.304,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.24,7.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040304,NDC,10,ML,168.77,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,2.304,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.24,7.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040310,NDC,10,ML,168.77,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,2.304,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.24,7.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040310,NDC,10,ML,168.77,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,2.304,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.24,7.65
sodium chloride 0.9% IV FLUSH 0.9 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,8881570121,NDC,2.5,ML,4.8,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9% IV FLUSH 0.9 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,8881570121,NDC,2.5,ML,4.8,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9% IV FLUSH 0.9 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,63807010001,NDC,2.5,ML,4.8,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9% IV FLUSH 0.9 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,63807010001,NDC,2.5,ML,4.8,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
hyoscyamine 0.125 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42192034001,NDC,1,EA,4.56,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.30736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prazosin 1 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,70954001950,NDC,1,EA,4.81,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.3088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prazosin 1 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,70954001950,NDC,1,EA,4.81,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.3088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prothrombin complex concentrate - human 500 units Kit 500 Units Box,J7168.01,CDM,636,RC,J7168,HCPCS,,,,63833038602,NDC,1500,UN,8007,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.31,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.31,4.272
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028401,NDC,1,EA,111.01,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.31,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028420,NDC,1,EA,111.01,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.31,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028426,NDC,1,EA,42.15,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.31,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028442,NDC,1,EA,47.71,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.31,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034000,NDC,1,EA,111.82,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.31,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034001,NDC,1,EA,111.81,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.31,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010520,NDC,1,EA,68.33,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.31,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010541,NDC,1,EA,68.33,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.31,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076501,NDC,1,EA,58.6,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.31,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076510,NDC,1,EA,58.6,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.31,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,47781059807,NDC,1,EA,39.84,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.31,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022116,NDC,1,EA,36.33,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.31,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022141,NDC,1,EA,36.33,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.31,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022143,NDC,1,EA,36.31,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.31,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457033900,NDC,1,EA,71.82,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.31,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
amoxicillin 875 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862001501,NDC,1,EA,4.67,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.31165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
loperamide 2 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079069001,NDC,1,EA,4.67,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.31165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 250 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756079788,NDC,0.5,EA,4.68,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.3166,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003201,NDC,0.125,EA,5.4,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.3166,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aztreonam 1 g Recon Soln 1 Each Vial,J0457.01,CDM,636,RC,J0457,HCPCS,,,,63323040124,NDC,1,EA,176.32,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.32,172.7936
glimepiride 1 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268035815,NDC,1,EA,5.41,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.32089,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
loperamide 2 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079069020,NDC,1,EA,4.7,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.3265,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
meclizine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084049111,NDC,1,EA,4.6,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.3276,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
meclizine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084049101,NDC,1,EA,4.6,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.3276,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ramipril 2.5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237022301,NDC,0.5,EA,4.85,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ramipril 2.5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237022301,NDC,0.5,EA,4.85,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Automated Leukocyte Count,PX85048,CDM,300,RC,85048,CPT,,,,,,,,58,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.33,56.84
HYDROcodone-acetaminophen 7.5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406012423,NDC,1,EA,4.76,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.3324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 7.5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406012423,NDC,1,EA,4.76,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.3324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 7.5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406012423,NDC,1,EA,4.76,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.3324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 7.5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406012462,NDC,1,EA,4.76,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.3324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 7.5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406012462,NDC,1,EA,4.76,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.3324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 7.5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406012462,NDC,1,EA,4.76,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.3324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methenamine 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862078201,NDC,0.5,EA,5.62,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.334548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diclofenac EC 50 MG Tablet Delayed Release 14 Each Bottle,63700001,CDM,250,RC,,,,,,71335048107,NDC,1,EA,4.87,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.3376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diclofenac EC 50 MG Tablet Delayed Release 14 Each Bottle,63700001,CDM,250,RC,,,,,,71335048107,NDC,1,EA,4.87,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.3376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tobramycin 80 MG/2ML Solution 2 mL Vial,J3260.01,CDM,636,RC,J3260,HCPCS,,,,67457047300,NDC,2,ML,33.09,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.34,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.34,2.66
triamterene-hydroCHLOROthiazide 37.5-25 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,68084075025,NDC,1,EA,4.78,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.3422,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
triamterene-hydroCHLOROthiazide 37.5-25 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,68084075025,NDC,1,EA,4.78,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.3422,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
triamterene-hydroCHLOROthiazide 37.5-25 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,68084075025,NDC,1,EA,4.78,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.3422,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxazosin 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904552261,NDC,1,EA,5.46,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.34234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,43598043635,NDC,1,EA,5.46,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.34234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 40 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862011801,NDC,1,EA,5.64,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.342856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carvedilol 3.125 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904630061,NDC,0.5,EA,5.64,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.342856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079068420,NDC,1,EA,4.79,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.3471,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079068420,NDC,1,EA,4.79,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.3471,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079068420,NDC,1,EA,4.79,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.3471,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 3 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,56018875,NDC,0.333333333,EA,4.79,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.3471,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 3 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,56018875,NDC,0.333333333,EA,4.79,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.3471,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 3 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,56018875,NDC,0.333333333,EA,4.79,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.3471,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium chloride 0.9% IV FLUSH 0.9 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,8881570121,NDC,2.5,ML,4.8,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9% IV FLUSH 0.9 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,8881570121,NDC,2.5,ML,4.8,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9% IV FLUSH 0.9 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,8881570121,NDC,2.5,ML,4.8,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9% IV FLUSH 0.9 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,63807010001,NDC,2.5,ML,4.8,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9% IV FLUSH 0.9 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,63807010001,NDC,2.5,ML,4.8,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9% IV FLUSH 0.9 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,63807010001,NDC,2.5,ML,4.8,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
HYDROcodone-acetaminophen 7.5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406012423,NDC,1,EA,4.76,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.3562,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 7.5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406012462,NDC,1,EA,4.76,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.3562,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prazosin 1 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,70954001950,NDC,1,EA,4.81,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.3569,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prazosin 1 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,70954001950,NDC,1,EA,4.81,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.3569,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prazosin 1 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,70954001950,NDC,1,EA,4.81,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.3569,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001001,NDC,1.5,ML,40.17,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.36,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.36,2.73
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001002,NDC,2,ML,43.42,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.36,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.36,2.73
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001094,NDC,2,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.36,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.36,2.73
amoxicillin 875 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862001501,NDC,1,EA,4.67,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.36302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
loperamide 2 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079069001,NDC,1,EA,4.67,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.36302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,10370083111,NDC,0.5,EA,5.51,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.36379,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,68462063925,NDC,1,EA,5.51,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.36379,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
triamterene-hydroCHLOROthiazide 37.5-25 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,68084075025,NDC,1,EA,4.78,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.3661,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 250 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756079788,NDC,0.5,EA,4.68,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.36808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Hematocrit,PX85014,CDM,300,RC,85014,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.37,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.2463,2.37
Hemoglobin,PX85018,CDM,300,RC,85018,CPT,,,,,,,,68,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.37,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.2463,2.37
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279210,NDC,10,ML,429.84,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.37,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.09,2.37
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279410,NDC,10,ML,429.84,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.37,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.09,2.37
atenolol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079068420,NDC,1,EA,4.79,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.37105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 3 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,56018875,NDC,0.333333333,EA,4.79,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.37105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metroNIDAZOLE 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084096611,NDC,1,EA,4.94,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.3712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metroNIDAZOLE 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084096611,NDC,1,EA,4.94,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.3712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metroNIDAZOLE 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084096601,NDC,1,EA,4.94,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.3712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metroNIDAZOLE 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084096601,NDC,1,EA,4.94,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.3712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium chloride 0.9% IV FLUSH 0.9 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,8881570121,NDC,2.5,ML,4.8,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9% IV FLUSH 0.9 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,63807010001,NDC,2.5,ML,4.8,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ramipril 2.5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237022301,NDC,0.5,EA,4.85,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.3765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ramipril 2.5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237022301,NDC,0.5,EA,4.85,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.3765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ramipril 2.5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237022301,NDC,0.5,EA,4.85,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.3765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
loperamide 2 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079069020,NDC,1,EA,4.7,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.3782,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carvedilol 3.125 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079077120,NDC,0.5,EA,5.73,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.380242,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039801,NDC,1,EA,67.88,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.38058,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.29,2.6
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039810,NDC,1,EA,67.88,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.38058,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.29,2.6
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039814,NDC,1,EA,39.84,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.38058,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.29,2.6
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039841,NDC,1,EA,43.14,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.38058,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.29,2.6
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086000,NDC,1,EA,58.66,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.38058,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.29,2.6
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086050,NDC,1,EA,58.66,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.38058,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.29,2.6
"dextrose 5% lactated ringers 5 % Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012504,NDC,1000,ML,43.5,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.38058,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.28,2.59
dextrose 5% lactated ringers 5 % Solution 500 mL Flex Cont,J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012503,NDC,500,ML,99.12,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.38058,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.28,2.59
"lactated ringers Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338011704,NDC,1000,ML,99.12,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.38058,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.28,2.59
prazosin 1 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,70954001950,NDC,1,EA,4.81,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.38095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 600 MG Tablet Extended Release 12 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904671839,NDC,1,EA,5.74,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.384396,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diclofenac EC 50 MG Tablet Delayed Release 14 Each Bottle,63700001,CDM,250,RC,,,,,,71335048107,NDC,1,EA,4.87,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.3863,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diclofenac EC 50 MG Tablet Delayed Release 14 Each Bottle,63700001,CDM,250,RC,,,,,,71335048107,NDC,1,EA,4.87,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.3863,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diclofenac EC 50 MG Tablet Delayed Release 14 Each Bottle,63700001,CDM,250,RC,,,,,,71335048107,NDC,1,EA,4.87,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.3863,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"BANDAGE STERILE  2"" TETRA-FLEX CLIP FREE 0151-2SV",27200000,CDM,272,RC,A6449,HCPCS,,10660-MAIN,LOCAL,,,,,5.02,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.39,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
"BANDAGE STERILE 3"" TETRA-FLEX CLIP FREE 0151-3SV",27200000,CDM,272,RC,A6449,HCPCS,,10661-MAIN,LOCAL,,,,,5.93,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.39,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
"BANDAGE STERILE 4"" TETRA-FLEX CLIP FREE  0151-4SV",27200000,CDM,272,RC,A6449,HCPCS,,10662-MAIN,LOCAL,,,,,6.7,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.39,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
"BANDAGE STERILE  2"" TETRA-FLEX CLIP FREE 0151-2SV",27200000,CDM,272,RC,A6449,HCPCS,,10660-MAIN,LOCAL,,,,,5.02,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
"BANDAGE STERILE  2"" TETRA-FLEX CLIP FREE 0151-2SV",27200000,CDM,272,RC,A6449,HCPCS,,10660-MAIN,LOCAL,,,,,5.02,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
"BANDAGE STERILE 3"" TETRA-FLEX CLIP FREE 0151-3SV",27200000,CDM,272,RC,A6449,HCPCS,,10661-MAIN,LOCAL,,,,,5.93,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
"BANDAGE STERILE 3"" TETRA-FLEX CLIP FREE 0151-3SV",27200000,CDM,272,RC,A6449,HCPCS,,10661-MAIN,LOCAL,,,,,5.93,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
"BANDAGE STERILE 4"" TETRA-FLEX CLIP FREE  0151-4SV",27200000,CDM,272,RC,A6449,HCPCS,,10662-MAIN,LOCAL,,,,,6.7,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
"BANDAGE STERILE 4"" TETRA-FLEX CLIP FREE  0151-4SV",27200000,CDM,272,RC,A6449,HCPCS,,10662-MAIN,LOCAL,,,,,6.7,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
Oximetry;Mult Determine,PX610,CDM,460,RC,94761,CPT,,,,,,,,142,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.17,6.98
Oximetry;Mult Determine,PX610,CDM,460,RC,94761,CPT,,,,,,,,142,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.17,6.98
verapamil CR 120 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462029201,NDC,1,EA,5.76,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.392704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039801,NDC,1,EA,67.88,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.29,2.6
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039801,NDC,1,EA,67.88,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.29,2.6
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039810,NDC,1,EA,67.88,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.29,2.6
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039810,NDC,1,EA,67.88,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.29,2.6
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039814,NDC,1,EA,39.84,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.29,2.6
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039814,NDC,1,EA,39.84,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.29,2.6
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039841,NDC,1,EA,43.14,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.29,2.6
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039841,NDC,1,EA,43.14,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.29,2.6
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086000,NDC,1,EA,58.66,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.29,2.6
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086000,NDC,1,EA,58.66,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.29,2.6
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086050,NDC,1,EA,58.66,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.29,2.6
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086050,NDC,1,EA,58.66,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.29,2.6
DRESSING MESALT 6X6 IMPREGNATED GAUZE STERILE 285780,120.511,CDM,272,RC,A6223,HCPCS,,12059-SURG,LOCAL,,,,,5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.077,4.9
DRESSING MESALT 6X6 IMPREGNATED GAUZE STERILE 285780,120.511,CDM,272,RC,A6223,HCPCS,,12059-SURG,LOCAL,,,,,5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.077,4.9
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,71041813,NDC,1,EA,5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,71041813,NDC,1,EA,5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prothrombin complex concentrate - human 500 units Kit 500 Units Box,J7168.01,CDM,636,RC,J7168,HCPCS,,,,63833038602,NDC,1500,UN,8007,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.4,7846.86
ramipril 2.5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237022301,NDC,0.5,EA,4.85,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.40075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glimepiride 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93725401,NDC,1,EA,5.79,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.405166,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 7.5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406012423,NDC,1,EA,4.76,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.40856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 7.5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406012462,NDC,1,EA,4.76,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.40856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"BANDAGE STERILE  2"" TETRA-FLEX CLIP FREE 0151-2SV",27200000,CDM,272,RC,A6449,HCPCS,,10660-MAIN,LOCAL,,,,,5.02,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.4096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"BANDAGE STERILE  2"" TETRA-FLEX CLIP FREE 0151-2SV",27200000,CDM,272,RC,A6449,HCPCS,,10660-MAIN,LOCAL,,,,,5.02,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.4096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
diclofenac EC 50 MG Tablet Delayed Release 14 Each Bottle,63700001,CDM,250,RC,,,,,,71335048107,NDC,1,EA,4.87,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.41065,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methenamine 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862078201,NDC,0.5,EA,5.62,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.41098,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
triamterene-hydroCHLOROthiazide 37.5-25 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,68084075025,NDC,1,EA,4.78,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.41868,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa CR 25-100 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756046188,NDC,1,EA,5.04,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.4192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa CR 25-100 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756046188,NDC,1,EA,5.04,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.4192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 40 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862011801,NDC,1,EA,5.64,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.41956,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carvedilol 3.125 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904630061,NDC,0.5,EA,5.64,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.41956,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"dextrose 5% lactated ringers 5 % Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012504,NDC,1000,ML,43.5,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.28,2.59
"dextrose 5% lactated ringers 5 % Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012504,NDC,1000,ML,43.5,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.28,2.59
dextrose 5% lactated ringers 5 % Solution 500 mL Flex Cont,J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012503,NDC,500,ML,99.12,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.28,2.59
dextrose 5% lactated ringers 5 % Solution 500 mL Flex Cont,J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012503,NDC,500,ML,99.12,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.28,2.59
DRESSING NASAL 4.5CM NON-INFLATABLE RAPID RHINO RR450,120.97,CDM,272,RC,A6407,HCPCS,,616-MAIN,LOCAL,,,,,94,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.42,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.42,2.5736
DRESSING NASAL 5.5CM INFLATABLE RAPID RHINO RR550,120.97,CDM,272,RC,A6407,HCPCS,,606-MAIN,LOCAL,,,,,94,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.42,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.42,2.5736
DRESSING NASAL 7.5CM INFLATABLE RAPID RHINO RR750,120.97,CDM,272,RC,A6407,HCPCS,,611-MAIN,LOCAL,,,,,94,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.42,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.42,2.5736
DRESSING NASAL 8CM LONGX1.5CM THICK X3CM HIGH ANATOMICAL 34-105,120.97,CDM,272,RC,A6407,HCPCS,,613-MAIN,LOCAL,,,,,94,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.42,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.42,2.5736
"lactated ringers Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338011704,NDC,1000,ML,99.12,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.28,2.59
"lactated ringers Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338011704,NDC,1000,ML,99.12,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.28,2.59
metroNIDAZOLE 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084096611,NDC,1,EA,4.94,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.4206,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metroNIDAZOLE 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084096611,NDC,1,EA,4.94,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.4206,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metroNIDAZOLE 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084096611,NDC,1,EA,4.94,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.4206,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metroNIDAZOLE 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084096601,NDC,1,EA,4.94,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.4206,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metroNIDAZOLE 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084096601,NDC,1,EA,4.94,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.4206,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metroNIDAZOLE 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084096601,NDC,1,EA,4.94,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.4206,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079068420,NDC,1,EA,4.79,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.42374,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 3 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,56018875,NDC,0.333333333,EA,4.79,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.42374,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268011015,NDC,1,EA,5.06,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.4288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268011015,NDC,1,EA,5.06,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.4288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium chloride 0.9% IV FLUSH 0.9 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,8881570121,NDC,2.5,ML,4.8,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.4288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9% IV FLUSH 0.9 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,63807010001,NDC,2.5,ML,4.8,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.4288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
prazosin 1 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,70954001950,NDC,1,EA,4.81,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.43386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metroNIDAZOLE 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084096611,NDC,1,EA,4.94,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.4453,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metroNIDAZOLE 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084096601,NDC,1,EA,4.94,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.4453,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DRESSING MESALT 6X6 IMPREGNATED GAUZE STERILE 285780,120.511,CDM,272,RC,A6223,HCPCS,,12059-SURG,LOCAL,,,,,5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.077,4.9
DRESSING MESALT 6X6 IMPREGNATED GAUZE STERILE 285780,120.511,CDM,272,RC,A6223,HCPCS,,12059-SURG,LOCAL,,,,,5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.077,4.9
DRESSING MESALT 6X6 IMPREGNATED GAUZE STERILE 285780,120.511,CDM,272,RC,A6223,HCPCS,,12059-SURG,LOCAL,,,,,5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.077,4.9
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,71041813,NDC,1,EA,5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,71041813,NDC,1,EA,5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,71041813,NDC,1,EA,5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ramipril 2.5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237022301,NDC,0.5,EA,4.85,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.4541,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carvedilol 3.125 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079077120,NDC,0.5,EA,5.73,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.45817,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
NIFEdipine CR osmotic 30 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,24979001101,NDC,1,EA,5.92,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.459168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"BANDAGE STERILE  2"" TETRA-FLEX CLIP FREE 0151-2SV",27200000,CDM,272,RC,A6449,HCPCS,,10660-MAIN,LOCAL,,,,,5.02,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.4598,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"BANDAGE STERILE  2"" TETRA-FLEX CLIP FREE 0151-2SV",27200000,CDM,272,RC,A6449,HCPCS,,10660-MAIN,LOCAL,,,,,5.02,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.4598,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"BANDAGE STERILE  2"" TETRA-FLEX CLIP FREE 0151-2SV",27200000,CDM,272,RC,A6449,HCPCS,,10660-MAIN,LOCAL,,,,,5.02,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.4598,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Automated Leukocyte Count,PX85048,CDM,300,RC,85048,CPT,,,,,,,,58,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.46,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.46,2.5672
Automated Leukocyte Count,PX85048,CDM,300,RC,85048,CPT,,,,,,,,58,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.46,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.46,2.5672
Automated Leukocyte Count,PX85048,CDM,300,RC,85048,CPT,,,,,,,,58,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.46,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.46,2.5672
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,25021018482,NDC,100,ML,79.51,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.46,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.46,2.8
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,70655000206,NDC,100,ML,59.67,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.46,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.46,2.8
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Plas Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,338604648,NDC,100,ML,143.42,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.46,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.46,2.8
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,25021050002,NDC,1,ML,52.06,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.46,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.16,2.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001302,NDC,2,ML,86.79,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.46,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.16,2.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001326,NDC,1,ML,42.88,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.46,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.16,2.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001341,NDC,1,ML,42.88,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.46,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.16,2.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019600,NDC,1,ML,48.64,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.46,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.16,2.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019602,NDC,2,ML,77.29,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.46,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.16,2.46
guaiFENesin 600 MG Tablet Extended Release 12 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904671839,NDC,1,EA,5.74,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.46246,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"BANDAGE STERILE 3"" TETRA-FLEX CLIP FREE 0151-3SV",27200000,CDM,272,RC,A6449,HCPCS,,10661-MAIN,LOCAL,,,,,5.93,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.463322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
diclofenac EC 50 MG Tablet Delayed Release 14 Each Bottle,63700001,CDM,250,RC,,,,,,71335048107,NDC,1,EA,4.87,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.46422,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa CR 25-100 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756046188,NDC,1,EA,5.04,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.4696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa CR 25-100 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756046188,NDC,1,EA,5.04,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.4696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa CR 25-100 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756046188,NDC,1,EA,5.04,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.4696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
verapamil CR 120 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462029201,NDC,1,EA,5.76,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.47104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DRESSING MESALT 6X6 IMPREGNATED GAUZE STERILE 285780,120.511,CDM,272,RC,A6223,HCPCS,,12059-SURG,LOCAL,,,,,5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.077,4.9
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,71041813,NDC,1,EA,5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42937070110,NDC,1,EA,5.16,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.4768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42937070110,NDC,1,EA,5.16,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.4768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
verapamil CR 180 MG Tablet Extended Release 100 Each Bottle,25000000,CDM,250,RC,,,,,,75834015801,NDC,0.666666667,EA,5.16,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.4768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
verapamil CR 180 MG Tablet Extended Release 100 Each Bottle,25000000,CDM,250,RC,,,,,,75834015801,NDC,0.666666667,EA,5.16,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.4768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
benazepril 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268011015,NDC,1,EA,5.06,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.4794,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268011015,NDC,1,EA,5.06,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.4794,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268011015,NDC,1,EA,5.06,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.4794,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"RBC Sed Rate, Auto",PX85652,CDM,300,RC,85652,CPT,,,,,,,,109,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.48,106.82
glimepiride 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93725401,NDC,1,EA,5.79,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.48391,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"BANDAGE STERILE  2"" TETRA-FLEX CLIP FREE 0151-2SV",27200000,CDM,272,RC,A6449,HCPCS,,10660-MAIN,LOCAL,,,,,5.02,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.4849,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
levothyroxine 88 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378180701,NDC,2,EA,5.99,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.488246,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084065911,NDC,1,EA,5.99,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.488246,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084065901,NDC,1,EA,5.99,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.488246,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862007701,NDC,0.2,EA,6,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.4924,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,72205000530,NDC,0.125,EA,6,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.4924,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa CR 25-100 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756046188,NDC,1,EA,5.04,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.4948,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079064420,NDC,1,EA,5.2,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079064420,NDC,1,EA,5.2,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metroNIDAZOLE 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084096611,NDC,1,EA,4.94,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.49964,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metroNIDAZOLE 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084096601,NDC,1,EA,4.94,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.49964,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268011015,NDC,1,EA,5.06,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.5047,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 150-4.21 MG/100ML-% Solution 100 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066015010,NDC,100,ML,249.22,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.50926,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.50926,11.28
amiodarone 360-4.14 MG/200ML-% Solution 200 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066036020,NDC,200,ML,325.25,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.50926,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.50926,11.28
azaTHIOprine 50 MG Tablet 1 Each Blister,J7500.01,CDM,636,RC,J7500,HCPCS,,,,68084022911,NDC,0.5,EA,3,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.50926,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.50926,4.56
tobramycin 80 MG/2ML Solution 2 mL Vial,J3260.01,CDM,636,RC,J3260,HCPCS,,,,67457047300,NDC,2,ML,33.09,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.50926,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.34,2.66
lisinopril 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,185060501,NDC,1,EA,5.23,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.5104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,185060501,NDC,1,EA,5.23,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.5104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42937070110,NDC,1,EA,5.16,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.5284,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42937070110,NDC,1,EA,5.16,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.5284,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42937070110,NDC,1,EA,5.16,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.5284,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
verapamil CR 180 MG Tablet Extended Release 100 Each Bottle,25000000,CDM,250,RC,,,,,,75834015801,NDC,0.666666667,EA,5.16,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.5284,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
verapamil CR 180 MG Tablet Extended Release 100 Each Bottle,25000000,CDM,250,RC,,,,,,75834015801,NDC,0.666666667,EA,5.16,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.5284,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
verapamil CR 180 MG Tablet Extended Release 100 Each Bottle,25000000,CDM,250,RC,,,,,,75834015801,NDC,0.666666667,EA,5.16,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.5284,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
DRESSING MESALT 6X6 IMPREGNATED GAUZE STERILE 285780,120.511,CDM,272,RC,A6223,HCPCS,,12059-SURG,LOCAL,,,,,5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.077,4.9
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,71041813,NDC,1,EA,5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"SUTURE SILK 2-0 BLK BR FS 18"" 685G",27200000,CDM,272,RC,,,,2668-MAIN,LOCAL,,,,,5.29,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.5392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"SUTURE SILK 2-0 BLK BR FS 18"" 685G",27200000,CDM,272,RC,,,,2668-MAIN,LOCAL,,,,,5.29,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.5392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NIFEdipine CR osmotic 30 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,24979001101,NDC,1,EA,5.92,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.53968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Automated Leukocyte Count,PX85048,CDM,300,RC,85048,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.54,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.46,2.5672
aztreonam 1 g Recon Soln 1 Each Vial,J0457.01,CDM,636,RC,J0457,HCPCS,,,,63323040124,NDC,1,EA,176.32,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.54,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.23,2.57
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915701,NDC,0.5,ML,44.33,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.54,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.54,2.9
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915731,NDC,0.5,ML,44.33,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.54,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.54,2.9
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915801,NDC,1,ML,267.19,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.54,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.54,2.9
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915850,NDC,0.2,ML,69.44,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.54,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.54,2.9
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,43598040516,NDC,0.2,ML,63.83,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.54,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.54,2.9
"BANDAGE STERILE  2"" TETRA-FLEX CLIP FREE 0151-2SV",27200000,CDM,272,RC,A6449,HCPCS,,10660-MAIN,LOCAL,,,,,5.02,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.54012,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
aztreonam 1 g Recon Soln 1 Each Vial,J0457.01,CDM,636,RC,J0457,HCPCS,,,,63323040124,NDC,1,EA,176.32,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.54143,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.23,2.57
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028401,NDC,1,EA,111.01,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.54143,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028420,NDC,1,EA,111.01,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.54143,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028426,NDC,1,EA,42.15,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.54143,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028442,NDC,1,EA,47.71,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.54143,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034000,NDC,1,EA,111.82,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.54143,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034001,NDC,1,EA,111.81,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.54143,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010520,NDC,1,EA,68.33,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.54143,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010541,NDC,1,EA,68.33,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.54143,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076501,NDC,1,EA,58.6,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.54143,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076510,NDC,1,EA,58.6,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.54143,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,47781059807,NDC,1,EA,39.84,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.54143,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022116,NDC,1,EA,36.33,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.54143,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022141,NDC,1,EA,36.33,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.54143,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022143,NDC,1,EA,36.31,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.54143,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457033900,NDC,1,EA,71.82,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.54143,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
"BANDAGE STERILE 3"" TETRA-FLEX CLIP FREE 0151-3SV",27200000,CDM,272,RC,A6449,HCPCS,,10661-MAIN,LOCAL,,,,,5.93,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.54397,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
cyclobenzaprine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079064420,NDC,1,EA,5.2,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079064420,NDC,1,EA,5.2,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079064420,NDC,1,EA,5.2,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904198261,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580045811,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580060002,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 750 Each Box,63700001,CDM,250,RC,,,,,,63739044001,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904198861,NDC,0.65,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904673061,NDC,0.65,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580045711,NDC,0.65,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 650 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,70010016001,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen-codeine 300-30 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406048423,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen-codeine 300-30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406048462,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020501,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584098811,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,53489015601,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904657161,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020520,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,62584098801,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862067701,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585961,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739064410,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amitriptyline 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268003711,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amitriptyline 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687043311,NDC,0.4,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amitriptyline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687043301,NDC,0.4,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687026311,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084025911,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687026301,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084025901,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714029903,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ascorbic acid 500 MG Tablet 100 Each Box,25000000,CDM,250,RC,,,,,,904052361,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
aspirin 81 MG Tablet Chewable 90 Each Bottle,63700001,CDM,250,RC,,,,,,904679489,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin 81 MG Tablet Chewable 500 Each Disp Pack,63700001,CDM,250,RC,,,,,,66553000201,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin 325 MG Tablet 500 Each Box,63700001,CDM,250,RC,,,,,,66553000101,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 81 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,63739021210,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 81 MG Tablet Delayed Release 120 Each Bottle,63700001,CDM,250,RC,,,,,,10135017362,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,536114801,NDC,0.249230769,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,536331301,NDC,0.249230769,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,603016921,NDC,0.249230769,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079068401,NDC,0.25,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020801,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629061,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020820,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020901,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629161,NDC,0.25,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020920,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079021001,NDC,0.125,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
azaTHIOprine 50 MG Tablet 1 Each Blister,J7500.01,CDM,636,RC,J7500,HCPCS,,,,68084022911,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2.94
azaTHIOprine 50 MG Tablet 1 Each Blister,J7500.01,CDM,636,RC,J7500,HCPCS,,,,68084022911,NDC,0.5,EA,3,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.50926,4.56
azaTHIOprine 50 MG Tablet 1 Each Blister,J7500.01,CDM,636,RC,J7500,HCPCS,,,,68084022911,NDC,0.5,EA,3,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.50926,4.56
baclofen 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904647561,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
baclofen 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739047910,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268011011,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 40 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547033810,NDC,0.125,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 1 Each Box,63700001,CDM,250,RC,,,,,,713010906,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574705012,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713010912,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,904505812,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl EC 5 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,904640761,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bismuth subsalicylate 262 MG Tablet Chewable 30 Each Box,63700001,CDM,250,RC,,,,,,904720546,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bumetanide 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,185012901,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buPROPion SR 150 MG Tablet Extended Release 12 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084070895,NDC,0.666666667,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buPROPion SR 150 MG Tablet Extended Release 12 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,68084070825,NDC,0.666666667,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcium carb-cholecalciferol 600-10 mg-mcg (600-400 mg-unit) Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,20555001700,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcium carbonate 500 MG Tablet Chewable 500 Each Box,63700001,CDM,250,RC,,,,,,66553000401,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
candesartan 32 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,49884066109,NDC,0.125,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 10-100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,72888010601,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687066111,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084009311,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687066101,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-250 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084009411,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carvedilol 12.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904630261,NDC,0.25,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cetirizine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904671761,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cholecalciferol (vitamin D3) 125 MCG (5000 UT) capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,80681013100,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637861,NDC,0.2,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904724361,NDC,0.2,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin 150 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904595961,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714075201,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16729013600,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloNIDine 0.1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687011311,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloNIDine 0.1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687011301,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloNIDine 0.1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739006010,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
codeine 30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54024424,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536136601,NDC,0.25,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536355601,NDC,0.25,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,74312001380,NDC,0.25,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079064401,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687055811,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687055801,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54417925,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54817925,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54817625,NDC,0.125,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 6 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54418625,NDC,0.041666667,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079028401,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,172392560,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079028420,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079028501,NDC,0.4,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,172392660,NDC,0.4,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079028520,NDC,0.4,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687019511,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687019501,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 180 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687020611,NDC,0.666666667,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 180 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687020601,NDC,0.666666667,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687021711,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739001610,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 25 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904530661,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 25 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904723761,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 50 MG capsule 100 Each Box,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904205661,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
divalproex 250 MG Tablet Delayed Release 1 Each Box,63700001,CDM,250,RC,,,,,,832712389,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 250 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,832712301,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
docusate sodium 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,10135011101,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
docusate sodium 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904645561,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
docusate sodium 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904718361,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
donepezil 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904647761,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxazosin 4 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68382078501,NDC,0.25,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DRESSING NASAL 4.5CM NON-INFLATABLE RAPID RHINO RR450,120.97,CDM,272,RC,A6407,HCPCS,,616-MAIN,LOCAL,,,,,94,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.42,2.5736
DRESSING NASAL 4.5CM NON-INFLATABLE RAPID RHINO RR450,120.97,CDM,272,RC,A6407,HCPCS,,616-MAIN,LOCAL,,,,,94,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.42,2.5736
DRESSING NASAL 4.5CM NON-INFLATABLE RAPID RHINO RR450,120.97,CDM,272,RC,A6407,HCPCS,,616-MAIN,LOCAL,,,,,94,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.55,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.42,2.5736
DRESSING NASAL 5.5CM INFLATABLE RAPID RHINO RR550,120.97,CDM,272,RC,A6407,HCPCS,,606-MAIN,LOCAL,,,,,94,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.42,2.5736
DRESSING NASAL 5.5CM INFLATABLE RAPID RHINO RR550,120.97,CDM,272,RC,A6407,HCPCS,,606-MAIN,LOCAL,,,,,94,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.42,2.5736
DRESSING NASAL 5.5CM INFLATABLE RAPID RHINO RR550,120.97,CDM,272,RC,A6407,HCPCS,,606-MAIN,LOCAL,,,,,94,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.55,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.42,2.5736
DRESSING NASAL 7.5CM INFLATABLE RAPID RHINO RR750,120.97,CDM,272,RC,A6407,HCPCS,,611-MAIN,LOCAL,,,,,94,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.42,2.5736
DRESSING NASAL 7.5CM INFLATABLE RAPID RHINO RR750,120.97,CDM,272,RC,A6407,HCPCS,,611-MAIN,LOCAL,,,,,94,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.42,2.5736
DRESSING NASAL 7.5CM INFLATABLE RAPID RHINO RR750,120.97,CDM,272,RC,A6407,HCPCS,,611-MAIN,LOCAL,,,,,94,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.55,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.42,2.5736
DRESSING NASAL 8CM LONGX1.5CM THICK X3CM HIGH ANATOMICAL 34-105,120.97,CDM,272,RC,A6407,HCPCS,,613-MAIN,LOCAL,,,,,94,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.42,2.5736
DRESSING NASAL 8CM LONGX1.5CM THICK X3CM HIGH ANATOMICAL 34-105,120.97,CDM,272,RC,A6407,HCPCS,,613-MAIN,LOCAL,,,,,94,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.42,2.5736
DRESSING NASAL 8CM LONGX1.5CM THICK X3CM HIGH ANATOMICAL 34-105,120.97,CDM,272,RC,A6407,HCPCS,,613-MAIN,LOCAL,,,,,94,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.55,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.42,2.5736
estradiol 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378145201,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
estradiol 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42806008701,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 25 Each Bottle,63700001,CDM,250,RC,,,,,,49348081705,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739064510,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"ferrous sulfate 325 (65 Fe) MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64376080910,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ferrous sulfate 325 (65 Fe) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904759161,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Fish Oil 1000 MG capsule 1 Each Blister,25000000,CDM,250,RC,,,,,,77333030825,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
folic acid 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687068111,NDC,0.4,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
folic acid 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687068101,NDC,0.4,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54829725,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904717861,NDC,0.25,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762403001,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904666561,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739059110,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739090210,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862019901,NDC,0.333333333,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904666661,NDC,0.333333333,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60505011300,NDC,0.333333333,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687059101,NDC,0.333333333,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739023610,NDC,0.333333333,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glimepiride 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547039410,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079081001,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079081020,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE ER 2.5 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714089401,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE ER 5 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714089501,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glyBURIDE 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,93834498,NDC,0.25,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glycerin 2 g Suppository 24 Each Jar,63700001,CDM,250,RC,,,,,,132007924,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 600 MG Tablet Extended Release 12 Hour 20 Each Box,63700001,CDM,250,RC,,,,,,63824000832,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
haloperidol 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079073420,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155000101,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904644161,NDC,0.4,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,64380073506,NDC,0.2,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904644261,NDC,0.2,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydroCHLOROthiazide 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547039710,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 5 MG Tablet 50 Each Bottle,63700001,CDM,250,RC,,,,,,59762007301,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762007401,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406324301,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,42858030125,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084042301,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine HCl 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155050101,NDC,0.4,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,51079007720,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,3.1556
ibuprofen 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904791461,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 600 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687045711,NDC,0.333333333,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 600 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739068410,NDC,0.333333333,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 800 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687046811,NDC,0.25,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 800 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687046801,NDC,0.25,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 800 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739069110,NDC,0.25,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
indomethacin 25 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,50268043011,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,781155601,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
labetalol 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,10135071101,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
labetalol 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687045011,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Lactase 9000 units Tablet 12 Each Box,63700001,CDM,250,RC,,,,,,45091012,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904700761,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031911,NDC,0.25,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084031901,NDC,0.25,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levETIRAcetam 250 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904712361,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 50 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079044001,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 50 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079044020,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
liothyronine 25 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762120701,NDC,0.2,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079098101,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679761,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,591040701,NDC,0.25,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679861,NDC,0.25,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679961,NDC,0.125,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687033301,NDC,0.125,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904680061,NDC,0.0625,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904720061,NDC,0.0625,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lithium 150 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,54252625,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lithium 150 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,54852625,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
loratadine 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714089801,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904600761,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739049910,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687035511,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904600861,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739050010,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904704861,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739068610,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Magnesium Cl-Calcium Carbonate 71.5-119 MG Tablet Delayed Release 60 Each Bottle,63700001,CDM,250,RC,,,,,,67618010760,NDC,2,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904660961,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,10006070028,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,64980033901,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
medroxyPROGESTERone 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,555087202,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
melatonin 3 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268052411,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
melatonin 3 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268052415,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
melatonin 3 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,904518252,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Melatonin 3-10 MG Tablet 120 Each Bottle,800000,CDM,,,,,,,,47469000852,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Melatonin 10 MG SL Tab 120 Each Bottle,63700001,CDM,250,RC,,,,,,40985027503,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904716261,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 850 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739070210,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 1000 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904669161,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 1000 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904716461,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methadone 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406575523,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methadone 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54855324,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methIMAzole 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155007001,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methIMAzole 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155007101,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methocarbamol 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687055911,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methocarbamol 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739016610,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methocarbamol 750 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687056811,NDC,0.666666667,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoclopramide 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93220401,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoclopramide 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739029310,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 50 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084066611,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 100 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,51079017101,NDC,0.25,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584026511,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904634061,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079080101,NDC,0.25,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904634161,NDC,0.25,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584026711,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,62584026701,NDC,0.125,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metroNIDAZOLE 500 MG Tablet 50 Each Bottle,63700001,CDM,250,RC,,,,,,29300022746,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
miSOPROStol 100 MCG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,70954044310,NDC,0.25,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
montelukast 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904680861,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine immediate release 15 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54023525,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine immediate release 15 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,832027311,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
multivitamin with minerals Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904549261,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
naproxen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739040310,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine polacrilex 4 MG Lozenge 24 Each Bottle,63700001,CDM,250,RC,,,,,,43598048772,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine polacrilex 4 MG Lozenge 72 Each Box,63700001,CDM,250,RC,,,,,,49348085316,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 1 Each Blister,63700001,CDM,250,RC,,,,,,68084012811,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,904691761,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,68084012801,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyBUTYnin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904702761,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406055223,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406055262,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739096310,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PHENobarbital 32.4 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904657561,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenytoin ER 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904618761,NDC,0.3,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenytoin ER 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,68084037601,NDC,0.3,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phosphorus 155-852-130 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,64980010401,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687059211,NDC,0.125,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
predniSONE 1 MG Tablet 100 Each Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,64380078206,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 1 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54873925,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 2.5 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54874025,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 5 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687012211,NDC,0.2,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 10 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687013411,NDC,0.1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001720,NDC,0.1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,63739051910,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 20 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014511,NDC,0.05,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001820,NDC,0.05,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014501,NDC,0.05,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
pregabalin 25 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,76282056890,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 75 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904700061,NDC,0.333333333,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prochlorperazine 10 MG Tablet 100 Each Bottle,25000000,CDM,250,RC,,,,,,59746011506,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
promethazine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,Q0169,HCPCS,,,,904646161,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904655061,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268070211,NDC,0.25,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687060911,NDC,0.25,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687060901,NDC,0.25,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Prosight Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,536509008,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
psyllium 0.52 GM capsule 160 Each Bottle,25000000,CDM,250,RC,,,,,,80681002200,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Psyllium 400 MG capsule 160 Each Bottle,25000000,CDM,250,RC,,,,,,10939081644,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pyridoxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536440601,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pyridoxine 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,77333094010,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904663861,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904664061,NDC,0.25,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739066510,NDC,0.25,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ramipril 5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,68382014601,NDC,0.25,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904736161,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rOPINIRole 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637461,NDC,0.25,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268071111,NDC,0.125,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268071115,NDC,0.125,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna 8.6 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904652261,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687062211,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,57896045806,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904633961,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687062201,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739043210,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018011,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904692461,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018001,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687024211,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018111,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687024201,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018101,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687025311,NDC,0.25,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904692661,NDC,0.25,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687025301,NDC,0.25,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simethicone 125 MG Tablet Chewable 18 Each Box,63700001,CDM,250,RC,,,,,,49348086348,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simethicone 125 MG Tablet Chewable 60 Each Bottle,63700001,CDM,250,RC,,,,,,69618003206,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simvastatin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739057010,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simvastatin 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739057310,NDC,0.125,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"sodium bicarbonate 650 MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64980018210,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"sodium bicarbonate 650 MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64980052810,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium chloride 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,223176001,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 12.5 mg Tablet 1 split tablet Blister,63700001,CDM,250,RC,,,,,,8888800438,NDC,2,UN,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079010301,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687046511,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079010320,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687046501,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739054410,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 800-160 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904272561,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 800-160 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739022810,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tamsulosin 0.4 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739056710,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079041801,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877014601,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079041820,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739023110,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terazosin 5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59746038506,NDC,0.2,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
therapeutic multivitamin Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904053961,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,77333093425,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,37864090599,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,77333093410,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tobramycin 80 MG/2ML Solution 2 mL Vial,J3260.01,CDM,636,RC,J3260,HCPCS,,,,67457047300,NDC,2,ML,33.09,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.34,2.66
tobramycin 80 MG/2ML Solution 2 mL Vial,J3260.01,CDM,636,RC,J3260,HCPCS,,,,67457047300,NDC,2,ML,33.09,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.34,2.66
torsemide 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268075611,NDC,0.25,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268075615,NDC,0.25,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54007725,NDC,0.25,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50111091701,NDC,0.25,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739067110,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traZODone 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904655461,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
valsartan 160 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342006410,NDC,0.25,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536333401,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904582461,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,10006070033,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,20555003300,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121201,NDC,0.5,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121301,NDC,0.4,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 3 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121401,NDC,0.333333333,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,832121689,NDC,0.2,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121601,NDC,0.2,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zinc gluconate 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,40093010153,NDC,1,EA,3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa CR 25-100 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756046188,NDC,1,EA,5.04,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.55024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 150 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084071311,NDC,0.25,EA,6.14,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.550556,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42937070110,NDC,1,EA,5.16,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.5542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
verapamil CR 180 MG Tablet Extended Release 100 Each Bottle,25000000,CDM,250,RC,,,,,,75834015801,NDC,0.666666667,EA,5.16,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.5542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
benazepril 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268011015,NDC,1,EA,5.06,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.56036,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,185060501,NDC,1,EA,5.23,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.5627,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,185060501,NDC,1,EA,5.23,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.5627,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,185060501,NDC,1,EA,5.23,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.5627,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Automated Leukocyte Count,PX85048,CDM,300,RC,85048,CPT,,,,,,,,58,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.5672,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.46,2.5672
"RBC Sed Rate, Auto",PX85652,CDM,300,RC,85652,CPT,,,,,,,,109,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.5672,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5672,2.7
levothyroxine 88 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378180701,NDC,2,EA,5.99,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.56971,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084065911,NDC,1,EA,5.99,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.56971,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084065901,NDC,1,EA,5.99,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.56971,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aztreonam 1 g Recon Soln 1 Each Vial,J0457.01,CDM,636,RC,J0457,HCPCS,,,,63323040124,NDC,1,EA,176.32,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.23,2.57
aztreonam 1 g Recon Soln 1 Each Vial,J0457.01,CDM,636,RC,J0457,HCPCS,,,,63323040124,NDC,1,EA,176.32,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.23,2.57
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028401,NDC,1,EA,111.01,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028401,NDC,1,EA,111.01,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028420,NDC,1,EA,111.01,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028420,NDC,1,EA,111.01,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028426,NDC,1,EA,42.15,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028426,NDC,1,EA,42.15,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028442,NDC,1,EA,47.71,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028442,NDC,1,EA,47.71,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034000,NDC,1,EA,111.82,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034000,NDC,1,EA,111.82,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034001,NDC,1,EA,111.81,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034001,NDC,1,EA,111.81,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010520,NDC,1,EA,68.33,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010520,NDC,1,EA,68.33,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010541,NDC,1,EA,68.33,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010541,NDC,1,EA,68.33,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076501,NDC,1,EA,58.6,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076501,NDC,1,EA,58.6,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076510,NDC,1,EA,58.6,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076510,NDC,1,EA,58.6,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,47781059807,NDC,1,EA,39.84,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,47781059807,NDC,1,EA,39.84,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022116,NDC,1,EA,36.33,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022116,NDC,1,EA,36.33,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022141,NDC,1,EA,36.33,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022141,NDC,1,EA,36.33,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022143,NDC,1,EA,36.31,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022143,NDC,1,EA,36.31,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457033900,NDC,1,EA,71.82,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457033900,NDC,1,EA,71.82,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.02,2.57
dilTIAZem 30 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93031801,NDC,1,EA,5.36,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.5728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem 30 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93031801,NDC,1,EA,5.36,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.5728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DRESSING NASAL 4.5CM NON-INFLATABLE RAPID RHINO RR450,120.97,CDM,272,RC,A6407,HCPCS,,616-MAIN,LOCAL,,,,,94,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.5736,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.42,2.5736
DRESSING NASAL 5.5CM INFLATABLE RAPID RHINO RR550,120.97,CDM,272,RC,A6407,HCPCS,,606-MAIN,LOCAL,,,,,94,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.5736,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.42,2.5736
DRESSING NASAL 7.5CM INFLATABLE RAPID RHINO RR750,120.97,CDM,272,RC,A6407,HCPCS,,611-MAIN,LOCAL,,,,,94,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.5736,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.42,2.5736
DRESSING NASAL 8CM LONGX1.5CM THICK X3CM HIGH ANATOMICAL 34-105,120.97,CDM,272,RC,A6407,HCPCS,,613-MAIN,LOCAL,,,,,94,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.5736,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.42,2.5736
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004904,NDC,1000,ML,99.12,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.5736,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954306,NDC,1000,ML,99.12,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.5736,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004941,NDC,250,ML,43.5,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.5736,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055311,NDC,250,ML,43.5,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.5736,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004948,NDC,300,ML,43.5,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.5736,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055318,NDC,300,ML,43.5,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.5736,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
sodium chloride 0.9% 0.9 % Solution 150 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,409798361,NDC,300,ML,43.5,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.5736,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004902,NDC,250,ML,99.12,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.5736,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954302,NDC,250,ML,99.12,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.5736,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
sodium chloride 0.9% 0.9 % Solution 500 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004903,NDC,500,ML,99.12,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.5736,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
ciprofloxacin 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862007701,NDC,0.2,EA,6,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.574,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079064420,NDC,1,EA,5.2,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.574,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,72205000530,NDC,0.125,EA,6,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.574,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637161,NDC,0.25,EA,3.03,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.5755,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
darbepoetin alfa 40 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002104,NDC,0.4,ML,1411.78,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.58,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.58,2.93
darbepoetin alfa 200 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002801,NDC,0.4,ML,3157.92,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.58,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.58,2.93
darbepoetin alfa 300 MCG/0.6ML solution prefilled syringe 0.6 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513011101,NDC,0.6,ML,4736.88,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.58,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.58,2.93
darbepoetin alfa 500 MCG/ML solution prefilled syringe 1 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513003201,NDC,0.3,ML,2368.44,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.58,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.58,2.93
"RBC Sed Rate, Auto",PX85652,CDM,300,RC,85652,CPT,,,,,,,,109,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.58,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5672,2.7
"RBC Sed Rate, Auto",PX85652,CDM,300,RC,85652,CPT,,,,,,,,109,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.58,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5672,2.7
lisinopril 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,185060501,NDC,1,EA,5.23,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.58885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"dextrose 5% lactated ringers 5 % Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012504,NDC,1000,ML,43.5,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.59,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.28,2.59
dextrose 5% lactated ringers 5 % Solution 500 mL Flex Cont,J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012503,NDC,500,ML,99.12,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.59,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.28,2.59
"lactated ringers Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338011704,NDC,1000,ML,99.12,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.59,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.28,2.59
rosuvastatin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003201,NDC,0.125,EA,5.4,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003201,NDC,0.125,EA,5.4,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"SUTURE SILK 2-0 BLK BR FS 18"" 685G",27200000,CDM,272,RC,,,,2668-MAIN,LOCAL,,,,,5.29,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.5921,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"SUTURE SILK 2-0 BLK BR FS 18"" 685G",27200000,CDM,272,RC,,,,2668-MAIN,LOCAL,,,,,5.29,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.5921,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"SUTURE SILK 2-0 BLK BR FS 18"" 685G",27200000,CDM,272,RC,,,,2668-MAIN,LOCAL,,,,,5.29,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.5921,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
glimepiride 1 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268035815,NDC,1,EA,5.41,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.5968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glimepiride 1 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268035815,NDC,1,EA,5.41,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.5968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039801,NDC,1,EA,67.88,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.6,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.29,2.6
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039810,NDC,1,EA,67.88,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.6,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.29,2.6
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039814,NDC,1,EA,39.84,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.6,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.29,2.6
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039841,NDC,1,EA,43.14,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.6,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.29,2.6
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086000,NDC,1,EA,58.66,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.6,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.29,2.6
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086050,NDC,1,EA,58.66,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.6,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.29,2.6
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004904,NDC,1000,ML,99.12,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004904,NDC,1000,ML,99.12,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954306,NDC,1000,ML,99.12,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954306,NDC,1000,ML,99.12,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004941,NDC,250,ML,43.5,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004941,NDC,250,ML,43.5,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055311,NDC,250,ML,43.5,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055311,NDC,250,ML,43.5,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004948,NDC,300,ML,43.5,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004948,NDC,300,ML,43.5,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055318,NDC,300,ML,43.5,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055318,NDC,300,ML,43.5,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
sodium chloride 0.9% 0.9 % Solution 150 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,409798361,NDC,300,ML,43.5,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
sodium chloride 0.9% 0.9 % Solution 150 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,409798361,NDC,300,ML,43.5,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004902,NDC,250,ML,99.12,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004902,NDC,250,ML,99.12,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954302,NDC,250,ML,99.12,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954302,NDC,250,ML,99.12,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
sodium chloride 0.9% 0.9 % Solution 500 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004903,NDC,500,ML,99.12,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
sodium chloride 0.9% 0.9 % Solution 500 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004903,NDC,500,ML,99.12,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
metoprolol tartrate 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079080120,NDC,1,EA,3.07,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.6095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42937070110,NDC,1,EA,5.16,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.61096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
verapamil CR 180 MG Tablet Extended Release 100 Each Bottle,25000000,CDM,250,RC,,,,,,75834015801,NDC,0.666666667,EA,5.16,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.61096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"SUTURE SILK 2-0 BLK BR FS 18"" 685G",27200000,CDM,272,RC,,,,2668-MAIN,LOCAL,,,,,5.29,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.61855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
prothrombin complex concentrate - human 500 units Kit 500 Units Box,J7168.01,CDM,636,RC,J7168,HCPCS,,,,63833038602,NDC,1500,UN,8007,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.62,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.31,4.272
prothrombin complex concentrate - human 500 units Kit 500 Units Box,J7168.01,CDM,636,RC,J7168,HCPCS,,,,63833038602,NDC,1500,UN,8007,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.62,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.31,4.272
"RBC Sed Rate, Auto",PX85652,CDM,300,RC,85652,CPT,,,,,,,,109,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.62,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5672,2.7
doxazosin 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904552261,NDC,1,EA,5.46,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.6208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxazosin 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904552261,NDC,1,EA,5.46,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.6208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,43598043635,NDC,1,EA,5.46,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.6208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,43598043635,NDC,1,EA,5.46,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.6208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nabumetone 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687037401,NDC,1,EA,6.32,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.625328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem 30 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93031801,NDC,1,EA,5.36,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.6264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem 30 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93031801,NDC,1,EA,5.36,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.6264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem 30 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93031801,NDC,1,EA,5.36,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.6264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
enalapril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714044201,NDC,1,EA,6.33,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.629482,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079064420,NDC,1,EA,5.2,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.6312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 150 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084071311,NDC,0.25,EA,6.14,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.63406,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Capillary Blood Collection,PX36416,CDM,300,RC,36416,CPT,,,,,,,,60,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.64,4.88
Capillary Blood Collection,PX36416,CDM,300,RC,36416,CPT,,,,,,,,60,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.64,4.88
cyclobenzaprine 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69097084607,NDC,0.5,EA,3.11,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.6435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,10370083111,NDC,0.5,EA,5.51,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.6448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,10370083111,NDC,0.5,EA,5.51,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.6448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,68462063925,NDC,1,EA,5.51,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.6448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,68462063925,NDC,1,EA,5.51,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.6448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904198261,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580045811,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580060002,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 750 Each Box,63700001,CDM,250,RC,,,,,,63739044001,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904198861,NDC,0.65,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904673061,NDC,0.65,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580045711,NDC,0.65,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 650 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,70010016001,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen-codeine 300-30 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406048423,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen-codeine 300-30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406048462,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020501,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584098811,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,53489015601,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904657161,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020520,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,62584098801,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862067701,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585961,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739064410,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amitriptyline 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268003711,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amitriptyline 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687043311,NDC,0.4,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amitriptyline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687043301,NDC,0.4,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687026311,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084025911,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687026301,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084025901,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714029903,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ascorbic acid 500 MG Tablet 100 Each Box,25000000,CDM,250,RC,,,,,,904052361,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
aspirin 81 MG Tablet Chewable 90 Each Bottle,63700001,CDM,250,RC,,,,,,904679489,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin 81 MG Tablet Chewable 500 Each Disp Pack,63700001,CDM,250,RC,,,,,,66553000201,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin 325 MG Tablet 500 Each Box,63700001,CDM,250,RC,,,,,,66553000101,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 81 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,63739021210,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 81 MG Tablet Delayed Release 120 Each Bottle,63700001,CDM,250,RC,,,,,,10135017362,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,536114801,NDC,0.249230769,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,536331301,NDC,0.249230769,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,603016921,NDC,0.249230769,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079068401,NDC,0.25,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020801,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629061,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020820,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020901,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629161,NDC,0.25,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020920,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079021001,NDC,0.125,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
azaTHIOprine 50 MG Tablet 1 Each Blister,J7500.01,CDM,636,RC,J7500,HCPCS,,,,68084022911,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2.94
baclofen 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904647561,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
baclofen 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739047910,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268011011,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 40 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547033810,NDC,0.125,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 1 Each Box,63700001,CDM,250,RC,,,,,,713010906,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574705012,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713010912,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,904505812,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl EC 5 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,904640761,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bismuth subsalicylate 262 MG Tablet Chewable 30 Each Box,63700001,CDM,250,RC,,,,,,904720546,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bumetanide 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,185012901,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buPROPion SR 150 MG Tablet Extended Release 12 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084070895,NDC,0.666666667,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buPROPion SR 150 MG Tablet Extended Release 12 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,68084070825,NDC,0.666666667,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcium carb-cholecalciferol 600-10 mg-mcg (600-400 mg-unit) Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,20555001700,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcium carbonate 500 MG Tablet Chewable 500 Each Box,63700001,CDM,250,RC,,,,,,66553000401,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
candesartan 32 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,49884066109,NDC,0.125,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 10-100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,72888010601,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687066111,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084009311,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687066101,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-250 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084009411,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carvedilol 12.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904630261,NDC,0.25,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cetirizine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904671761,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cholecalciferol (vitamin D3) 125 MCG (5000 UT) capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,80681013100,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637861,NDC,0.2,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904724361,NDC,0.2,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin 150 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904595961,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714075201,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16729013600,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloNIDine 0.1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687011311,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloNIDine 0.1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687011301,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloNIDine 0.1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739006010,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
codeine 30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54024424,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536136601,NDC,0.25,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536355601,NDC,0.25,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,74312001380,NDC,0.25,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079064401,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687055811,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687055801,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54417925,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54817925,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54817625,NDC,0.125,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 6 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54418625,NDC,0.041666667,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079028401,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,172392560,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079028420,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079028501,NDC,0.4,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,172392660,NDC,0.4,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079028520,NDC,0.4,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687019511,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687019501,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 180 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687020611,NDC,0.666666667,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 180 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687020601,NDC,0.666666667,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687021711,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739001610,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 25 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904530661,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 25 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904723761,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 50 MG capsule 100 Each Box,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904205661,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
divalproex 250 MG Tablet Delayed Release 1 Each Box,63700001,CDM,250,RC,,,,,,832712389,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 250 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,832712301,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
docusate sodium 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,10135011101,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
docusate sodium 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904645561,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
docusate sodium 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904718361,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
donepezil 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904647761,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxazosin 4 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68382078501,NDC,0.25,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
estradiol 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378145201,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
estradiol 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42806008701,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 25 Each Bottle,63700001,CDM,250,RC,,,,,,49348081705,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739064510,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"ferrous sulfate 325 (65 Fe) MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64376080910,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ferrous sulfate 325 (65 Fe) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904759161,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Fish Oil 1000 MG capsule 1 Each Blister,25000000,CDM,250,RC,,,,,,77333030825,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
folic acid 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687068111,NDC,0.4,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
folic acid 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687068101,NDC,0.4,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54829725,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904717861,NDC,0.25,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762403001,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904666561,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739059110,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739090210,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862019901,NDC,0.333333333,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904666661,NDC,0.333333333,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60505011300,NDC,0.333333333,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687059101,NDC,0.333333333,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739023610,NDC,0.333333333,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glimepiride 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547039410,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079081001,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079081020,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE ER 2.5 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714089401,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE ER 5 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714089501,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glyBURIDE 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,93834498,NDC,0.25,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glycerin 2 g Suppository 24 Each Jar,63700001,CDM,250,RC,,,,,,132007924,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 600 MG Tablet Extended Release 12 Hour 20 Each Box,63700001,CDM,250,RC,,,,,,63824000832,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
haloperidol 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079073420,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155000101,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904644161,NDC,0.4,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,64380073506,NDC,0.2,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904644261,NDC,0.2,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydroCHLOROthiazide 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547039710,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 5 MG Tablet 50 Each Bottle,63700001,CDM,250,RC,,,,,,59762007301,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762007401,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406324301,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,42858030125,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084042301,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine HCl 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155050101,NDC,0.4,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,51079007720,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,3.1556
ibuprofen 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904791461,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 600 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687045711,NDC,0.333333333,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 600 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739068410,NDC,0.333333333,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 800 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687046811,NDC,0.25,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 800 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687046801,NDC,0.25,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 800 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739069110,NDC,0.25,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
indomethacin 25 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,50268043011,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,781155601,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
labetalol 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,10135071101,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
labetalol 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687045011,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Lactase 9000 units Tablet 12 Each Box,63700001,CDM,250,RC,,,,,,45091012,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904700761,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031911,NDC,0.25,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084031901,NDC,0.25,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levETIRAcetam 250 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904712361,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 50 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079044001,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 50 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079044020,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
liothyronine 25 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762120701,NDC,0.2,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079098101,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679761,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,591040701,NDC,0.25,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679861,NDC,0.25,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679961,NDC,0.125,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687033301,NDC,0.125,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904680061,NDC,0.0625,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904720061,NDC,0.0625,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lithium 150 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,54252625,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lithium 150 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,54852625,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
loratadine 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714089801,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904600761,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739049910,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687035511,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904600861,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739050010,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904704861,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739068610,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Magnesium Cl-Calcium Carbonate 71.5-119 MG Tablet Delayed Release 60 Each Bottle,63700001,CDM,250,RC,,,,,,67618010760,NDC,2,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904660961,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,10006070028,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,64980033901,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
medroxyPROGESTERone 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,555087202,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
melatonin 3 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268052411,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
melatonin 3 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268052415,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
melatonin 3 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,904518252,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Melatonin 3-10 MG Tablet 120 Each Bottle,800000,CDM,,,,,,,,47469000852,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Melatonin 10 MG SL Tab 120 Each Bottle,63700001,CDM,250,RC,,,,,,40985027503,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904716261,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 850 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739070210,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 1000 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904669161,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 1000 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904716461,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methadone 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406575523,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methadone 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54855324,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methIMAzole 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155007001,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methIMAzole 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155007101,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methocarbamol 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687055911,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methocarbamol 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739016610,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methocarbamol 750 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687056811,NDC,0.666666667,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoclopramide 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93220401,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoclopramide 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739029310,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 50 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084066611,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 100 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,51079017101,NDC,0.25,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584026511,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904634061,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079080101,NDC,0.25,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904634161,NDC,0.25,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584026711,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,62584026701,NDC,0.125,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metroNIDAZOLE 500 MG Tablet 50 Each Bottle,63700001,CDM,250,RC,,,,,,29300022746,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
miSOPROStol 100 MCG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,70954044310,NDC,0.25,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
montelukast 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904680861,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine immediate release 15 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54023525,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine immediate release 15 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,832027311,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
multivitamin with minerals Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904549261,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
naproxen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739040310,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine polacrilex 4 MG Lozenge 24 Each Bottle,63700001,CDM,250,RC,,,,,,43598048772,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine polacrilex 4 MG Lozenge 72 Each Box,63700001,CDM,250,RC,,,,,,49348085316,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 1 Each Blister,63700001,CDM,250,RC,,,,,,68084012811,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,904691761,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,68084012801,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyBUTYnin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904702761,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406055223,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406055262,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739096310,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PHENobarbital 32.4 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904657561,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenytoin ER 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904618761,NDC,0.3,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenytoin ER 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,68084037601,NDC,0.3,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phosphorus 155-852-130 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,64980010401,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687059211,NDC,0.125,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
predniSONE 1 MG Tablet 100 Each Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,64380078206,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 1 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54873925,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 2.5 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54874025,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 5 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687012211,NDC,0.2,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 10 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687013411,NDC,0.1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001720,NDC,0.1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,63739051910,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 20 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014511,NDC,0.05,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001820,NDC,0.05,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014501,NDC,0.05,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
pregabalin 25 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,76282056890,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 75 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904700061,NDC,0.333333333,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prochlorperazine 10 MG Tablet 100 Each Bottle,25000000,CDM,250,RC,,,,,,59746011506,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
promethazine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,Q0169,HCPCS,,,,904646161,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904655061,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268070211,NDC,0.25,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687060911,NDC,0.25,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687060901,NDC,0.25,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Prosight Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,536509008,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
psyllium 0.52 GM capsule 160 Each Bottle,25000000,CDM,250,RC,,,,,,80681002200,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Psyllium 400 MG capsule 160 Each Bottle,25000000,CDM,250,RC,,,,,,10939081644,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pyridoxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536440601,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pyridoxine 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,77333094010,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904663861,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904664061,NDC,0.25,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739066510,NDC,0.25,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ramipril 5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,68382014601,NDC,0.25,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904736161,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rOPINIRole 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637461,NDC,0.25,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003201,NDC,0.125,EA,5.4,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003201,NDC,0.125,EA,5.4,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003201,NDC,0.125,EA,5.4,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268071111,NDC,0.125,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268071115,NDC,0.125,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna 8.6 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904652261,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687062211,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,57896045806,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904633961,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687062201,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739043210,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018011,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904692461,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018001,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687024211,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018111,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687024201,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018101,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687025311,NDC,0.25,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904692661,NDC,0.25,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687025301,NDC,0.25,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simethicone 125 MG Tablet Chewable 18 Each Box,63700001,CDM,250,RC,,,,,,49348086348,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simethicone 125 MG Tablet Chewable 60 Each Bottle,63700001,CDM,250,RC,,,,,,69618003206,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simvastatin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739057010,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simvastatin 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739057310,NDC,0.125,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"sodium bicarbonate 650 MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64980018210,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"sodium bicarbonate 650 MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64980052810,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium chloride 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,223176001,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 12.5 mg Tablet 1 split tablet Blister,63700001,CDM,250,RC,,,,,,8888800438,NDC,2,UN,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079010301,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687046511,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079010320,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687046501,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739054410,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 800-160 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904272561,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 800-160 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739022810,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tamsulosin 0.4 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739056710,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079041801,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877014601,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079041820,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739023110,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terazosin 5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59746038506,NDC,0.2,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
therapeutic multivitamin Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904053961,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,77333093425,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,37864090599,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,77333093410,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268075611,NDC,0.25,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268075615,NDC,0.25,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54007725,NDC,0.25,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50111091701,NDC,0.25,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739067110,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traZODone 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904655461,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
valsartan 160 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342006410,NDC,0.25,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536333401,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904582461,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,10006070033,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,20555003300,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121201,NDC,0.5,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121301,NDC,0.4,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 3 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121401,NDC,0.333333333,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,832121689,NDC,0.2,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121601,NDC,0.2,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zinc gluconate 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,40093010153,NDC,1,EA,3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lovastatin 20 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,93057606,NDC,0.5,EA,6.37,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.646098,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,185060501,NDC,1,EA,5.23,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.64638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glimepiride 1 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268035815,NDC,1,EA,5.41,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.6509,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glimepiride 1 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268035815,NDC,1,EA,5.41,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.6509,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glimepiride 1 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268035815,NDC,1,EA,5.41,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.6509,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem 30 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93031801,NDC,1,EA,5.36,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.6532,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 75 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079044120,NDC,2,EA,6.4,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.65856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tobramycin 80 MG/2ML Solution 2 mL Vial,J3260.01,CDM,636,RC,J3260,HCPCS,,,,67457047300,NDC,2,ML,33.09,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.66,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.34,2.66
acetaminophen 120 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802073230,NDC,1,EA,3.13,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.6605,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904198261,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580045811,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580060002,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 750 Each Box,63700001,CDM,250,RC,,,,,,63739044001,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904198861,NDC,0.65,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904673061,NDC,0.65,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580045711,NDC,0.65,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 650 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,70010016001,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen-codeine 300-30 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406048423,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen-codeine 300-30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406048462,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020501,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584098811,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,53489015601,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904657161,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020520,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,62584098801,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862067701,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585961,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739064410,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amitriptyline 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268003711,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amitriptyline 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687043311,NDC,0.4,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amitriptyline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687043301,NDC,0.4,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687026311,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084025911,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687026301,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084025901,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714029903,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ascorbic acid 500 MG Tablet 100 Each Box,25000000,CDM,250,RC,,,,,,904052361,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
aspirin 81 MG Tablet Chewable 90 Each Bottle,63700001,CDM,250,RC,,,,,,904679489,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin 81 MG Tablet Chewable 500 Each Disp Pack,63700001,CDM,250,RC,,,,,,66553000201,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin 325 MG Tablet 500 Each Box,63700001,CDM,250,RC,,,,,,66553000101,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 81 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,63739021210,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 81 MG Tablet Delayed Release 120 Each Bottle,63700001,CDM,250,RC,,,,,,10135017362,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,536114801,NDC,0.249230769,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,536331301,NDC,0.249230769,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,603016921,NDC,0.249230769,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079068401,NDC,0.25,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020801,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629061,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020820,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020901,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629161,NDC,0.25,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020920,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079021001,NDC,0.125,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
azaTHIOprine 50 MG Tablet 1 Each Blister,J7500.01,CDM,636,RC,J7500,HCPCS,,,,68084022911,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2.94
baclofen 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904647561,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
baclofen 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739047910,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268011011,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 40 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547033810,NDC,0.125,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 1 Each Box,63700001,CDM,250,RC,,,,,,713010906,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574705012,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713010912,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,904505812,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl EC 5 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,904640761,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bismuth subsalicylate 262 MG Tablet Chewable 30 Each Box,63700001,CDM,250,RC,,,,,,904720546,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bumetanide 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,185012901,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buPROPion SR 150 MG Tablet Extended Release 12 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084070895,NDC,0.666666667,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buPROPion SR 150 MG Tablet Extended Release 12 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,68084070825,NDC,0.666666667,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcium carb-cholecalciferol 600-10 mg-mcg (600-400 mg-unit) Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,20555001700,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcium carbonate 500 MG Tablet Chewable 500 Each Box,63700001,CDM,250,RC,,,,,,66553000401,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
candesartan 32 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,49884066109,NDC,0.125,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 10-100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,72888010601,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687066111,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084009311,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687066101,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-250 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084009411,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carvedilol 12.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904630261,NDC,0.25,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cetirizine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904671761,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cholecalciferol (vitamin D3) 125 MCG (5000 UT) capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,80681013100,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637861,NDC,0.2,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904724361,NDC,0.2,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin 150 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904595961,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714075201,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16729013600,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloNIDine 0.1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687011311,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloNIDine 0.1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687011301,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloNIDine 0.1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739006010,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
codeine 30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54024424,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536136601,NDC,0.25,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536355601,NDC,0.25,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,74312001380,NDC,0.25,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079064401,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687055811,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687055801,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54417925,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54817925,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54817625,NDC,0.125,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 6 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54418625,NDC,0.041666667,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079028401,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,172392560,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079028420,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079028501,NDC,0.4,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,172392660,NDC,0.4,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079028520,NDC,0.4,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687019511,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687019501,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 180 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687020611,NDC,0.666666667,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 180 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687020601,NDC,0.666666667,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687021711,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739001610,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 25 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904530661,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 25 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904723761,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 50 MG capsule 100 Each Box,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904205661,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
divalproex 250 MG Tablet Delayed Release 1 Each Box,63700001,CDM,250,RC,,,,,,832712389,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 250 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,832712301,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
docusate sodium 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,10135011101,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
docusate sodium 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904645561,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
docusate sodium 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904718361,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
donepezil 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904647761,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxazosin 4 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68382078501,NDC,0.25,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
estradiol 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378145201,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
estradiol 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42806008701,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 25 Each Bottle,63700001,CDM,250,RC,,,,,,49348081705,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739064510,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"ferrous sulfate 325 (65 Fe) MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64376080910,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ferrous sulfate 325 (65 Fe) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904759161,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Fish Oil 1000 MG capsule 1 Each Blister,25000000,CDM,250,RC,,,,,,77333030825,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
folic acid 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687068111,NDC,0.4,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
folic acid 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687068101,NDC,0.4,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54829725,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904717861,NDC,0.25,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762403001,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904666561,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739059110,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739090210,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862019901,NDC,0.333333333,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904666661,NDC,0.333333333,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60505011300,NDC,0.333333333,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687059101,NDC,0.333333333,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739023610,NDC,0.333333333,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glimepiride 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547039410,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079081001,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079081020,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE ER 2.5 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714089401,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE ER 5 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714089501,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glyBURIDE 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,93834498,NDC,0.25,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glycerin 2 g Suppository 24 Each Jar,63700001,CDM,250,RC,,,,,,132007924,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 600 MG Tablet Extended Release 12 Hour 20 Each Box,63700001,CDM,250,RC,,,,,,63824000832,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
haloperidol 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079073420,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155000101,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904644161,NDC,0.4,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,64380073506,NDC,0.2,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904644261,NDC,0.2,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydroCHLOROthiazide 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547039710,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 5 MG Tablet 50 Each Bottle,63700001,CDM,250,RC,,,,,,59762007301,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762007401,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406324301,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,42858030125,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084042301,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine HCl 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155050101,NDC,0.4,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,51079007720,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,3.1556
ibuprofen 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904791461,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 600 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687045711,NDC,0.333333333,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 600 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739068410,NDC,0.333333333,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 800 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687046811,NDC,0.25,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 800 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687046801,NDC,0.25,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 800 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739069110,NDC,0.25,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
indomethacin 25 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,50268043011,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,781155601,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
labetalol 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,10135071101,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
labetalol 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687045011,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Lactase 9000 units Tablet 12 Each Box,63700001,CDM,250,RC,,,,,,45091012,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904700761,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031911,NDC,0.25,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084031901,NDC,0.25,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levETIRAcetam 250 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904712361,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 50 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079044001,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 50 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079044020,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
liothyronine 25 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762120701,NDC,0.2,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079098101,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679761,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,591040701,NDC,0.25,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679861,NDC,0.25,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679961,NDC,0.125,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687033301,NDC,0.125,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904680061,NDC,0.0625,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904720061,NDC,0.0625,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lithium 150 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,54252625,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lithium 150 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,54852625,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
loratadine 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714089801,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904600761,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739049910,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687035511,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904600861,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739050010,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904704861,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739068610,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Magnesium Cl-Calcium Carbonate 71.5-119 MG Tablet Delayed Release 60 Each Bottle,63700001,CDM,250,RC,,,,,,67618010760,NDC,2,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904660961,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,10006070028,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,64980033901,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
medroxyPROGESTERone 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,555087202,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
melatonin 3 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268052411,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
melatonin 3 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268052415,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
melatonin 3 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,904518252,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Melatonin 3-10 MG Tablet 120 Each Bottle,800000,CDM,,,,,,,,47469000852,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Melatonin 10 MG SL Tab 120 Each Bottle,63700001,CDM,250,RC,,,,,,40985027503,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904716261,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 850 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739070210,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 1000 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904669161,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 1000 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904716461,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methadone 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406575523,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methadone 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54855324,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methIMAzole 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155007001,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methIMAzole 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155007101,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methocarbamol 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687055911,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methocarbamol 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739016610,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methocarbamol 750 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687056811,NDC,0.666666667,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoclopramide 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93220401,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoclopramide 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739029310,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 50 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084066611,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 100 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,51079017101,NDC,0.25,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584026511,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904634061,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079080101,NDC,0.25,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904634161,NDC,0.25,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584026711,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,62584026701,NDC,0.125,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metroNIDAZOLE 500 MG Tablet 50 Each Bottle,63700001,CDM,250,RC,,,,,,29300022746,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
miSOPROStol 100 MCG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,70954044310,NDC,0.25,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
montelukast 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904680861,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine immediate release 15 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54023525,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine immediate release 15 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,832027311,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
multivitamin with minerals Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904549261,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
naproxen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739040310,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine polacrilex 4 MG Lozenge 24 Each Bottle,63700001,CDM,250,RC,,,,,,43598048772,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine polacrilex 4 MG Lozenge 72 Each Box,63700001,CDM,250,RC,,,,,,49348085316,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 1 Each Blister,63700001,CDM,250,RC,,,,,,68084012811,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,904691761,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,68084012801,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyBUTYnin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904702761,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406055223,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406055262,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739096310,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PHENobarbital 32.4 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904657561,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenytoin ER 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904618761,NDC,0.3,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenytoin ER 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,68084037601,NDC,0.3,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phosphorus 155-852-130 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,64980010401,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687059211,NDC,0.125,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
predniSONE 1 MG Tablet 100 Each Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,64380078206,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 1 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54873925,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 2.5 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54874025,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 5 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687012211,NDC,0.2,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 10 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687013411,NDC,0.1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001720,NDC,0.1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,63739051910,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 20 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014511,NDC,0.05,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001820,NDC,0.05,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014501,NDC,0.05,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
pregabalin 25 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,76282056890,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 75 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904700061,NDC,0.333333333,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prochlorperazine 10 MG Tablet 100 Each Bottle,25000000,CDM,250,RC,,,,,,59746011506,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
promethazine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,Q0169,HCPCS,,,,904646161,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904655061,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268070211,NDC,0.25,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687060911,NDC,0.25,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687060901,NDC,0.25,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Prosight Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,536509008,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
psyllium 0.52 GM capsule 160 Each Bottle,25000000,CDM,250,RC,,,,,,80681002200,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Psyllium 400 MG capsule 160 Each Bottle,25000000,CDM,250,RC,,,,,,10939081644,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pyridoxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536440601,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pyridoxine 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,77333094010,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904663861,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904664061,NDC,0.25,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739066510,NDC,0.25,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ramipril 5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,68382014601,NDC,0.25,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904736161,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rOPINIRole 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637461,NDC,0.25,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268071111,NDC,0.125,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268071115,NDC,0.125,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna 8.6 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904652261,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687062211,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,57896045806,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904633961,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687062201,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739043210,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018011,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904692461,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018001,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687024211,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018111,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687024201,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018101,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687025311,NDC,0.25,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904692661,NDC,0.25,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687025301,NDC,0.25,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simethicone 125 MG Tablet Chewable 18 Each Box,63700001,CDM,250,RC,,,,,,49348086348,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simethicone 125 MG Tablet Chewable 60 Each Bottle,63700001,CDM,250,RC,,,,,,69618003206,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simvastatin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739057010,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simvastatin 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739057310,NDC,0.125,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"sodium bicarbonate 650 MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64980018210,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"sodium bicarbonate 650 MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64980052810,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium chloride 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,223176001,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 12.5 mg Tablet 1 split tablet Blister,63700001,CDM,250,RC,,,,,,8888800438,NDC,2,UN,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079010301,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687046511,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079010320,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687046501,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739054410,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 800-160 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904272561,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 800-160 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739022810,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tamsulosin 0.4 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739056710,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079041801,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877014601,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079041820,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739023110,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terazosin 5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59746038506,NDC,0.2,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
therapeutic multivitamin Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904053961,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,77333093425,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,37864090599,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,77333093410,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268075611,NDC,0.25,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268075615,NDC,0.25,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54007725,NDC,0.25,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50111091701,NDC,0.25,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739067110,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traZODone 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904655461,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
valsartan 160 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342006410,NDC,0.25,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536333401,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904582461,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,10006070033,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,20555003300,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121201,NDC,0.5,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121301,NDC,0.4,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 3 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121401,NDC,0.333333333,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,832121689,NDC,0.2,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121601,NDC,0.2,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zinc gluconate 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,40093010153,NDC,1,EA,3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001001,NDC,1.5,ML,40.17,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.67011,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.36,2.73
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001002,NDC,2,ML,43.42,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.67011,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.36,2.73
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001094,NDC,2,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.67011,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.36,2.73
amLODIPine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637161,NDC,0.25,EA,3.03,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.67246,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003201,NDC,0.125,EA,5.4,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.673,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxazosin 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904552261,NDC,1,EA,5.46,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.6754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxazosin 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904552261,NDC,1,EA,5.46,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.6754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxazosin 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904552261,NDC,1,EA,5.46,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.6754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,43598043635,NDC,1,EA,5.46,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.6754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,43598043635,NDC,1,EA,5.46,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.6754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,43598043635,NDC,1,EA,5.46,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.6754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"SUTURE SILK 2-0 BLK BR FS 18"" 685G",27200000,CDM,272,RC,,,,2668-MAIN,LOCAL,,,,,5.29,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.67674,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
furosemide 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54829925,NDC,1,EA,3.15,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.6775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nortriptyline 25 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,93081101,NDC,0.4,EA,3.15,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.6775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glimepiride 1 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268035815,NDC,1,EA,5.41,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.67795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
olmesartan 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862074330,NDC,0.125,EA,6.45,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.67933,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 112 MCG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,74929690,NDC,0.892857143,EA,6.47,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.687638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
darbepoetin alfa 40 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002104,NDC,0.4,ML,1411.78,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
darbepoetin alfa 200 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002801,NDC,0.4,ML,3157.92,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
darbepoetin alfa 300 MCG/0.6ML solution prefilled syringe 0.6 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513011101,NDC,0.6,ML,4736.88,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
darbepoetin alfa 500 MCG/ML solution prefilled syringe 1 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513003201,NDC,0.3,ML,2368.44,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001001,NDC,1.5,ML,40.17,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.69,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.36,2.73
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001002,NDC,2,ML,43.42,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.69,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.36,2.73
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001094,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.69,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.36,2.73
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004904,NDC,1000,ML,99.12,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.69,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004904,NDC,1000,ML,99.12,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.69,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954306,NDC,1000,ML,99.12,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.69,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954306,NDC,1000,ML,99.12,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.69,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004941,NDC,250,ML,43.5,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.69,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004941,NDC,250,ML,43.5,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.69,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055311,NDC,250,ML,43.5,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.69,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055311,NDC,250,ML,43.5,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.69,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004948,NDC,300,ML,43.5,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.69,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004948,NDC,300,ML,43.5,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.69,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055318,NDC,300,ML,43.5,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.69,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055318,NDC,300,ML,43.5,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.69,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
sodium chloride 0.9% 0.9 % Solution 150 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,409798361,NDC,300,ML,43.5,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.69,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
sodium chloride 0.9% 0.9 % Solution 150 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,409798361,NDC,300,ML,43.5,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.69,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004902,NDC,250,ML,99.12,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.69,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004902,NDC,250,ML,99.12,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.69,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954302,NDC,250,ML,99.12,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.69,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954302,NDC,250,ML,99.12,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.69,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
sodium chloride 0.9% 0.9 % Solution 500 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004903,NDC,500,ML,99.12,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.69,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
sodium chloride 0.9% 0.9 % Solution 500 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004903,NDC,500,ML,99.12,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.69,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5736,2.69
acetaminophen 120 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,713011806,NDC,1,EA,3.17,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.6945,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 120 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713011812,NDC,1,EA,3.17,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.6945,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637161,NDC,0.25,EA,3.03,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.6967,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methenamine 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862078201,NDC,0.5,EA,5.62,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.6976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methenamine 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862078201,NDC,0.5,EA,5.62,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.6976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,10370083111,NDC,0.5,EA,5.51,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.6999,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,10370083111,NDC,0.5,EA,5.51,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.6999,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,10370083111,NDC,0.5,EA,5.51,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.6999,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,68462063925,NDC,1,EA,5.51,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.6999,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,68462063925,NDC,1,EA,5.51,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.6999,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,68462063925,NDC,1,EA,5.51,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.6999,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"RBC Sed Rate, Auto",PX85652,CDM,300,RC,85652,CPT,,,,,,,,109,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.7,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.5672,2.7
calcitRIOL 0.25 MCG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155011801,NDC,1,EA,6.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.7001,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxazosin 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904552261,NDC,1,EA,5.46,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.7027,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,43598043635,NDC,1,EA,5.46,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.7027,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzonatate 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904715361,NDC,1,EA,3.18,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.703,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cetirizine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585261,NDC,0.5,EA,6.51,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.704254,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 40 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862011801,NDC,1,EA,5.64,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.7072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 40 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862011801,NDC,1,EA,5.64,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.7072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carvedilol 3.125 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904630061,NDC,0.5,EA,5.64,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.7072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carvedilol 3.125 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904630061,NDC,0.5,EA,5.64,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.7072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079080120,NDC,1,EA,3.07,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.70774,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
midodrine 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,42291056190,NDC,0.5,EA,6.52,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.708408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nabumetone 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687037401,NDC,1,EA,6.32,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.71128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prochlorperazine 5 MG Tablet 100 Each Bottle,63600000,CDM,636,RC,Q0164,HCPCS,,,,59746011306,NDC,1,EA,3.19,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.7115,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
dilTIAZem 30 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93031801,NDC,1,EA,5.36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.71216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
enalapril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714044201,NDC,1,EA,6.33,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.71557,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,50268015211,NDC,1,EA,6.56,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.725024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 50 Each Box,63700001,CDM,250,RC,,,,,,50268015215,NDC,1,EA,6.56,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.725024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,10370083111,NDC,0.5,EA,5.51,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.72745,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,68462063925,NDC,1,EA,5.51,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.72745,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001001,NDC,1.5,ML,40.17,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.73,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.36,2.73
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001001,NDC,1.5,ML,40.17,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.73,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.36,2.73
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001002,NDC,2,ML,43.42,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.73,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.36,2.73
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001002,NDC,2,ML,43.42,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.73,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.36,2.73
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001094,NDC,2,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.73,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.36,2.73
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001094,NDC,2,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.73,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.36,2.73
metoprolol tartrate 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079080120,NDC,1,EA,3.07,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.7323,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003201,NDC,0.125,EA,5.4,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.7324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lovastatin 20 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,93057606,NDC,0.5,EA,6.37,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.73273,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904198261,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580045811,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580060002,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 750 Each Box,63700001,CDM,250,RC,,,,,,63739044001,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904198861,NDC,0.65,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904673061,NDC,0.65,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580045711,NDC,0.65,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 650 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,70010016001,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen-codeine 300-30 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406048423,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen-codeine 300-30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406048462,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020501,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584098811,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,53489015601,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904657161,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020520,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,62584098801,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862067701,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585961,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739064410,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amitriptyline 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268003711,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amitriptyline 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687043311,NDC,0.4,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amitriptyline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687043301,NDC,0.4,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687026311,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084025911,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687026301,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084025901,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714029903,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ascorbic acid 500 MG Tablet 100 Each Box,25000000,CDM,250,RC,,,,,,904052361,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
aspirin 81 MG Tablet Chewable 90 Each Bottle,63700001,CDM,250,RC,,,,,,904679489,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin 81 MG Tablet Chewable 500 Each Disp Pack,63700001,CDM,250,RC,,,,,,66553000201,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin 325 MG Tablet 500 Each Box,63700001,CDM,250,RC,,,,,,66553000101,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 81 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,63739021210,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 81 MG Tablet Delayed Release 120 Each Bottle,63700001,CDM,250,RC,,,,,,10135017362,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,536114801,NDC,0.249230769,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,536331301,NDC,0.249230769,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,603016921,NDC,0.249230769,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079068401,NDC,0.25,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020801,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629061,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020820,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020901,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629161,NDC,0.25,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020920,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079021001,NDC,0.125,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
azaTHIOprine 50 MG Tablet 1 Each Blister,J7500.01,CDM,636,RC,J7500,HCPCS,,,,68084022911,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2.94
baclofen 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904647561,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
baclofen 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739047910,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268011011,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 40 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547033810,NDC,0.125,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 1 Each Box,63700001,CDM,250,RC,,,,,,713010906,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574705012,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713010912,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,904505812,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl EC 5 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,904640761,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bismuth subsalicylate 262 MG Tablet Chewable 30 Each Box,63700001,CDM,250,RC,,,,,,904720546,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bumetanide 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,185012901,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buPROPion SR 150 MG Tablet Extended Release 12 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084070895,NDC,0.666666667,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buPROPion SR 150 MG Tablet Extended Release 12 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,68084070825,NDC,0.666666667,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcium carb-cholecalciferol 600-10 mg-mcg (600-400 mg-unit) Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,20555001700,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcium carbonate 500 MG Tablet Chewable 500 Each Box,63700001,CDM,250,RC,,,,,,66553000401,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
candesartan 32 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,49884066109,NDC,0.125,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 10-100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,72888010601,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687066111,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084009311,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687066101,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-250 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084009411,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carvedilol 12.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904630261,NDC,0.25,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cetirizine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904671761,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cholecalciferol (vitamin D3) 125 MCG (5000 UT) capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,80681013100,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637861,NDC,0.2,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904724361,NDC,0.2,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin 150 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904595961,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714075201,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16729013600,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloNIDine 0.1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687011311,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloNIDine 0.1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687011301,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloNIDine 0.1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739006010,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
codeine 30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54024424,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536136601,NDC,0.25,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536355601,NDC,0.25,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,74312001380,NDC,0.25,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079064401,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687055811,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687055801,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54417925,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54817925,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54817625,NDC,0.125,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 6 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54418625,NDC,0.041666667,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079028401,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,172392560,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079028420,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079028501,NDC,0.4,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,172392660,NDC,0.4,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079028520,NDC,0.4,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687019511,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687019501,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 180 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687020611,NDC,0.666666667,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 180 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687020601,NDC,0.666666667,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687021711,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739001610,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 25 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904530661,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 25 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904723761,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 50 MG capsule 100 Each Box,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904205661,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,13.39,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
divalproex 250 MG Tablet Delayed Release 1 Each Box,63700001,CDM,250,RC,,,,,,832712389,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 250 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,832712301,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
docusate sodium 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,10135011101,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
docusate sodium 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904645561,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
docusate sodium 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904718361,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
donepezil 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904647761,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxazosin 4 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68382078501,NDC,0.25,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
estradiol 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378145201,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
estradiol 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42806008701,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 25 Each Bottle,63700001,CDM,250,RC,,,,,,49348081705,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739064510,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"ferrous sulfate 325 (65 Fe) MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64376080910,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ferrous sulfate 325 (65 Fe) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904759161,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Fish Oil 1000 MG capsule 1 Each Blister,25000000,CDM,250,RC,,,,,,77333030825,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
folic acid 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687068111,NDC,0.4,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
folic acid 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687068101,NDC,0.4,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54829725,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904717861,NDC,0.25,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762403001,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904666561,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739059110,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739090210,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862019901,NDC,0.333333333,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904666661,NDC,0.333333333,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60505011300,NDC,0.333333333,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687059101,NDC,0.333333333,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739023610,NDC,0.333333333,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glimepiride 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547039410,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079081001,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079081020,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE ER 2.5 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714089401,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE ER 5 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714089501,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glyBURIDE 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,93834498,NDC,0.25,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glycerin 2 g Suppository 24 Each Jar,63700001,CDM,250,RC,,,,,,132007924,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 600 MG Tablet Extended Release 12 Hour 20 Each Box,63700001,CDM,250,RC,,,,,,63824000832,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
haloperidol 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079073420,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155000101,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904644161,NDC,0.4,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,64380073506,NDC,0.2,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904644261,NDC,0.2,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydroCHLOROthiazide 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547039710,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 5 MG Tablet 50 Each Bottle,63700001,CDM,250,RC,,,,,,59762007301,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762007401,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406324301,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,42858030125,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084042301,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine HCl 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155050101,NDC,0.4,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,51079007720,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,3.1556
ibuprofen 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904791461,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 600 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687045711,NDC,0.333333333,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 600 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739068410,NDC,0.333333333,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 800 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687046811,NDC,0.25,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 800 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687046801,NDC,0.25,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 800 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739069110,NDC,0.25,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
indomethacin 25 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,50268043011,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,781155601,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
labetalol 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,10135071101,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
labetalol 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687045011,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Lactase 9000 units Tablet 12 Each Box,63700001,CDM,250,RC,,,,,,45091012,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904700761,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031911,NDC,0.25,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084031901,NDC,0.25,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levETIRAcetam 250 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904712361,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 50 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079044001,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 50 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079044020,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
liothyronine 25 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762120701,NDC,0.2,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079098101,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679761,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,591040701,NDC,0.25,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679861,NDC,0.25,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679961,NDC,0.125,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687033301,NDC,0.125,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904680061,NDC,0.0625,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904720061,NDC,0.0625,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lithium 150 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,54252625,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lithium 150 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,54852625,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
loratadine 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714089801,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904600761,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739049910,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687035511,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904600861,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739050010,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904704861,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739068610,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Magnesium Cl-Calcium Carbonate 71.5-119 MG Tablet Delayed Release 60 Each Bottle,63700001,CDM,250,RC,,,,,,67618010760,NDC,2,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904660961,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,10006070028,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,64980033901,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
medroxyPROGESTERone 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,555087202,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
melatonin 3 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268052411,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
melatonin 3 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268052415,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
melatonin 3 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,904518252,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Melatonin 3-10 MG Tablet 120 Each Bottle,800000,CDM,,,,,,,,47469000852,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Melatonin 10 MG SL Tab 120 Each Bottle,63700001,CDM,250,RC,,,,,,40985027503,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904716261,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 850 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739070210,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 1000 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904669161,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 1000 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904716461,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methadone 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406575523,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methadone 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54855324,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methIMAzole 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155007001,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methIMAzole 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155007101,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methocarbamol 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687055911,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methocarbamol 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739016610,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methocarbamol 750 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687056811,NDC,0.666666667,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoclopramide 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93220401,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoclopramide 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739029310,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 50 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084066611,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 100 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,51079017101,NDC,0.25,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584026511,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904634061,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079080101,NDC,0.25,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904634161,NDC,0.25,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584026711,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,62584026701,NDC,0.125,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metroNIDAZOLE 500 MG Tablet 50 Each Bottle,63700001,CDM,250,RC,,,,,,29300022746,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
miSOPROStol 100 MCG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,70954044310,NDC,0.25,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
montelukast 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904680861,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine immediate release 15 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54023525,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine immediate release 15 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,832027311,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
multivitamin with minerals Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904549261,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
naproxen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739040310,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine polacrilex 4 MG Lozenge 24 Each Bottle,63700001,CDM,250,RC,,,,,,43598048772,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine polacrilex 4 MG Lozenge 72 Each Box,63700001,CDM,250,RC,,,,,,49348085316,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 1 Each Blister,63700001,CDM,250,RC,,,,,,68084012811,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,904691761,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,68084012801,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyBUTYnin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904702761,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406055223,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406055262,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739096310,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PHENobarbital 32.4 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904657561,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenytoin ER 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904618761,NDC,0.3,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenytoin ER 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,68084037601,NDC,0.3,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phosphorus 155-852-130 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,64980010401,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687059211,NDC,0.125,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
predniSONE 1 MG Tablet 100 Each Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,64380078206,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 1 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54873925,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 2.5 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54874025,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 5 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687012211,NDC,0.2,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 10 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687013411,NDC,0.1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001720,NDC,0.1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,63739051910,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 20 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014511,NDC,0.05,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001820,NDC,0.05,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014501,NDC,0.05,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
pregabalin 25 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,76282056890,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 75 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904700061,NDC,0.333333333,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prochlorperazine 10 MG Tablet 100 Each Bottle,25000000,CDM,250,RC,,,,,,59746011506,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
promethazine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,Q0169,HCPCS,,,,904646161,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904655061,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268070211,NDC,0.25,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687060911,NDC,0.25,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687060901,NDC,0.25,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Prosight Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,536509008,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
psyllium 0.52 GM capsule 160 Each Bottle,25000000,CDM,250,RC,,,,,,80681002200,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Psyllium 400 MG capsule 160 Each Bottle,25000000,CDM,250,RC,,,,,,10939081644,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pyridoxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536440601,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pyridoxine 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,77333094010,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904663861,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904664061,NDC,0.25,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739066510,NDC,0.25,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ramipril 5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,68382014601,NDC,0.25,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904736161,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rOPINIRole 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637461,NDC,0.25,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268071111,NDC,0.125,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268071115,NDC,0.125,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna 8.6 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904652261,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687062211,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,57896045806,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904633961,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687062201,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739043210,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018011,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904692461,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018001,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687024211,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018111,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687024201,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018101,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687025311,NDC,0.25,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904692661,NDC,0.25,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687025301,NDC,0.25,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simethicone 125 MG Tablet Chewable 18 Each Box,63700001,CDM,250,RC,,,,,,49348086348,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simethicone 125 MG Tablet Chewable 60 Each Bottle,63700001,CDM,250,RC,,,,,,69618003206,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simvastatin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739057010,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simvastatin 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739057310,NDC,0.125,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"sodium bicarbonate 650 MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64980018210,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"sodium bicarbonate 650 MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64980052810,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium chloride 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,223176001,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 12.5 mg Tablet 1 split tablet Blister,63700001,CDM,250,RC,,,,,,8888800438,NDC,2,UN,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079010301,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687046511,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079010320,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687046501,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739054410,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 800-160 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904272561,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 800-160 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739022810,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tamsulosin 0.4 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739056710,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079041801,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877014601,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079041820,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739023110,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terazosin 5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59746038506,NDC,0.2,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
therapeutic multivitamin Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904053961,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,77333093425,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,37864090599,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,77333093410,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268075611,NDC,0.25,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268075615,NDC,0.25,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54007725,NDC,0.25,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50111091701,NDC,0.25,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739067110,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traZODone 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904655461,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
valsartan 160 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342006410,NDC,0.25,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536333401,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904582461,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,10006070033,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,20555003300,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121201,NDC,0.5,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121301,NDC,0.4,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 3 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121401,NDC,0.333333333,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,832121689,NDC,0.2,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121601,NDC,0.2,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zinc gluconate 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,40093010153,NDC,1,EA,3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,25021018482,NDC,100,ML,79.51,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.73445,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.46,2.8
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,70655000206,NDC,100,ML,59.67,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.73445,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.46,2.8
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Plas Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,338604648,NDC,100,ML,143.42,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.73445,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.46,2.8
hydrOXYzine pamoate 25 MG capsule 1 Each Blister,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084711,NDC,1,EA,3.22,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.737,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,3.1556
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084701,NDC,1,EA,3.22,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.737,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,3.1556
losartan 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739067310,NDC,1,EA,3.22,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.737,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glimepiride 1 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268035815,NDC,1,EA,5.41,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.73746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"SUTURE ETHILON 2-0 BLK MONO FS 18"" 664G",27200000,CDM,272,RC,,,,3663-MAIN,LOCAL,,,,,6.59,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.737486,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
cyclobenzaprine 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69097084607,NDC,0.5,EA,3.11,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.74302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 75 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079044120,NDC,2,EA,6.4,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.7456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carvedilol 3.125 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079077120,NDC,0.5,EA,5.73,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.7504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carvedilol 3.125 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079077120,NDC,0.5,EA,5.73,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.7504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methenamine 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862078201,NDC,0.5,EA,5.62,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.7538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methenamine 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862078201,NDC,0.5,EA,5.62,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.7538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methenamine 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862078201,NDC,0.5,EA,5.62,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.7538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
chlorthalidone 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378022201,NDC,0.5,EA,3.24,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 600 MG Tablet Extended Release 12 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904671839,NDC,1,EA,5.74,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.7552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 600 MG Tablet Extended Release 12 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904671839,NDC,1,EA,5.74,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.7552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
XEROFORM GAUZE PETROLATUM 1X8INCH,27200000,CDM,272,RC,A6222,HCPCS,,10659-MAIN,LOCAL,,,,,3.52,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.76,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
amLODIPine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637161,NDC,0.25,EA,3.03,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.76033,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 120 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802073230,NDC,1,EA,3.13,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.76066,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904632261,NDC,1,EA,6.65,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.76241,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nabumetone 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50228046501,NDC,1,EA,6.65,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.76241,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxazosin 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904552261,NDC,1,EA,5.46,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.76276,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,43598043635,NDC,1,EA,5.46,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.76276,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 40 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862011801,NDC,1,EA,5.64,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.7636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 40 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862011801,NDC,1,EA,5.64,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.7636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 40 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862011801,NDC,1,EA,5.64,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.7636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carvedilol 3.125 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904630061,NDC,0.5,EA,5.64,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.7636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carvedilol 3.125 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904630061,NDC,0.5,EA,5.64,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.7636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carvedilol 3.125 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904630061,NDC,0.5,EA,5.64,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.7636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
verapamil CR 120 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462029201,NDC,1,EA,5.76,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.7648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
verapamil CR 120 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462029201,NDC,1,EA,5.76,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.7648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915701,NDC,0.5,ML,44.33,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.76662,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.54,2.9
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915731,NDC,0.5,ML,44.33,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.76662,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.54,2.9
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915801,NDC,1,ML,267.19,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.76662,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.54,2.9
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915850,NDC,0.2,ML,69.44,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.76662,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.54,2.9
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,43598040516,NDC,0.2,ML,63.83,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.76662,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.54,2.9
olmesartan 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862074330,NDC,0.125,EA,6.45,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.76705,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69097084607,NDC,0.5,EA,3.11,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.7679,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,25021018482,NDC,100,ML,79.51,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.77,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.46,2.8
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,25021018482,NDC,100,ML,79.51,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.77,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.46,2.8
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,70655000206,NDC,100,ML,59.67,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.77,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.46,2.8
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,70655000206,NDC,100,ML,59.67,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.77,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.46,2.8
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Plas Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,338604648,NDC,100,ML,143.42,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.77,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.46,2.8
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Plas Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,338604648,NDC,100,ML,143.42,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.77,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.46,2.8
levothyroxine 112 MCG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,74929690,NDC,0.892857143,EA,6.47,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.77563,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54829925,NDC,1,EA,3.15,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.7783,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nortriptyline 25 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,93081101,NDC,0.4,EA,3.15,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.7783,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glimepiride 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93725401,NDC,1,EA,5.79,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.7792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glimepiride 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93725401,NDC,1,EA,5.79,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.7792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methenamine 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862078201,NDC,0.5,EA,5.62,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.7819,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"BANDAGE STERILE 4"" TETRA-FLEX CLIP FREE  0151-4SV",27200000,CDM,272,RC,A6449,HCPCS,,10662-MAIN,LOCAL,,,,,6.7,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.78318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
pravastatin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904589261,NDC,0.5,EA,6.7,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.78318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 120 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802073230,NDC,1,EA,3.13,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.7857,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prochlorperazine 5 MG Tablet 1 Each Blister,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054101,NDC,1,EA,3.28,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.788,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,10370083111,NDC,0.5,EA,5.51,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.78806,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,68462063925,NDC,1,EA,5.51,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.78806,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcitRIOL 0.25 MCG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155011801,NDC,1,EA,6.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.7885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 40 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862011801,NDC,1,EA,5.64,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.7918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carvedilol 3.125 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904630061,NDC,0.5,EA,5.64,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.7918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cetirizine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585261,NDC,0.5,EA,6.51,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.79279,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dicloxacillin 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,93312501,NDC,0.5,EA,6.73,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.795642,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 120 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,713011806,NDC,1,EA,3.17,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.79594,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 120 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713011812,NDC,1,EA,3.17,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.79594,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prochlorperazine 5 MG Tablet 100 Each Box,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054120,NDC,1,EA,3.29,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.7965,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
metoprolol tartrate 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079080120,NDC,1,EA,3.07,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.79677,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
midodrine 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,42291056190,NDC,0.5,EA,6.52,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.79708,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,25021018482,NDC,100,ML,79.51,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.8,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.46,2.8
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,70655000206,NDC,100,ML,59.67,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.8,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.46,2.8
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Plas Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,338604648,NDC,100,ML,143.42,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.8,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.46,2.8
Microscopic Exam of Urine,PX81015,CDM,300,RC,81015,CPT,,,,,,,,29,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.8,28.42
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915701,NDC,0.5,ML,44.33,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.54,2.9
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915701,NDC,0.5,ML,44.33,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.54,2.9
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915731,NDC,0.5,ML,44.33,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.54,2.9
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915731,NDC,0.5,ML,44.33,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.54,2.9
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915801,NDC,1,ML,267.19,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.54,2.9
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915801,NDC,1,ML,267.19,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.54,2.9
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915850,NDC,0.2,ML,69.44,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.54,2.9
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915850,NDC,0.2,ML,69.44,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.54,2.9
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,43598040516,NDC,0.2,ML,63.83,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.54,2.9
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,43598040516,NDC,0.2,ML,63.83,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.54,2.9
furosemide 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54829925,NDC,1,EA,3.15,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.8035,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nortriptyline 25 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,93081101,NDC,0.4,EA,3.15,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.8035,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzonatate 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904715361,NDC,1,EA,3.18,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.80476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carvedilol 3.125 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079077120,NDC,0.5,EA,5.73,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.8077,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carvedilol 3.125 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079077120,NDC,0.5,EA,5.73,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.8077,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carvedilol 3.125 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079077120,NDC,0.5,EA,5.73,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.8077,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 600 MG Tablet Extended Release 12 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904671839,NDC,1,EA,5.74,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.8126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 600 MG Tablet Extended Release 12 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904671839,NDC,1,EA,5.74,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.8126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 600 MG Tablet Extended Release 12 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904671839,NDC,1,EA,5.74,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.8126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prochlorperazine 5 MG Tablet 100 Each Bottle,63600000,CDM,636,RC,Q0164,HCPCS,,,,59746011306,NDC,1,EA,3.19,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.81358,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
cephALEXin 500 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,50268015211,NDC,1,EA,6.56,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.81424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 50 Each Box,63700001,CDM,250,RC,,,,,,50268015215,NDC,1,EA,6.56,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.81424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluorouracil 5 GM/100ML Solution 100 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,16729027638,NDC,100,ML,261.44,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.82,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.82,3.38
fluorouracil 500 MG/10ML Solution 10 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,63323011710,NDC,10,ML,39,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.82,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.82,3.38
acetaminophen 120 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,713011806,NDC,1,EA,3.17,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.8213,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 120 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713011812,NDC,1,EA,3.17,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.8213,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,66758017006,NDC,1,EA,3.32,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,245531701,NDC,1,EA,3.32,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,66758017013,NDC,1,EA,3.32,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
verapamil CR 120 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462029201,NDC,1,EA,5.76,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.8224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
verapamil CR 120 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462029201,NDC,1,EA,5.76,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.8224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
verapamil CR 120 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462029201,NDC,1,EA,5.76,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.8224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"SUTURE ETHILON 2-0 BLK MONO FS 18"" 664G",27200000,CDM,272,RC,,,,3663-MAIN,LOCAL,,,,,6.59,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.82711,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
benzonatate 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904715361,NDC,1,EA,3.18,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.8302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 50 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904632361,NDC,0.5,EA,3.33,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.8305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,42858000110,NDC,1,EA,3.33,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.8305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,245531789,NDC,1,EA,3.33,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.8305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 150 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862069730,NDC,0.25,EA,6.82,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.833028,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69097084607,NDC,0.5,EA,3.11,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.83321,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carvedilol 3.125 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079077120,NDC,0.5,EA,5.73,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.83635,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glimepiride 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93725401,NDC,1,EA,5.79,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.8371,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glimepiride 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93725401,NDC,1,EA,5.79,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.8371,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glimepiride 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93725401,NDC,1,EA,5.79,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.8371,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687064011,NDC,1,EA,3.34,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.839,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687064001,NDC,1,EA,3.34,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.839,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prochlorperazine 5 MG Tablet 100 Each Bottle,63600000,CDM,636,RC,Q0164,HCPCS,,,,59746011306,NDC,1,EA,3.19,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.8391,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
hydrOXYzine pamoate 25 MG capsule 1 Each Blister,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084711,NDC,1,EA,3.22,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.84004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,3.1556
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084701,NDC,1,EA,3.22,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.84004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,3.1556
losartan 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739067310,NDC,1,EA,3.22,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.84004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 600 MG Tablet Extended Release 12 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904671839,NDC,1,EA,5.74,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.8413,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
NIFEdipine CR osmotic 30 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,24979001101,NDC,1,EA,5.92,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.8416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
NIFEdipine CR osmotic 30 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,24979001101,NDC,1,EA,5.92,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.8416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methenamine 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862078201,NDC,0.5,EA,5.62,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.84372,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"BANDAGE STERILE 3"" TETRA-FLEX CLIP FREE 0151-3SV",27200000,CDM,272,RC,A6449,HCPCS,,10661-MAIN,LOCAL,,,,,5.93,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.8464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"BANDAGE STERILE 3"" TETRA-FLEX CLIP FREE 0151-3SV",27200000,CDM,272,RC,A6449,HCPCS,,10661-MAIN,LOCAL,,,,,5.93,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.8464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
caffeine citrate 60 MG/3ML Solution 3 mL Vial,J0706.01,CDM,636,RC,J0706,HCPCS,,,,63323040704,NDC,3,ML,73.84,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,2.848,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6434,2.848
caffeine citrate 60 MG/3ML Solution 3 mL Vial,J0706.01,CDM,636,RC,J0706,HCPCS,,,,63323040704,NDC,3,ML,73.84,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,2.848,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.6434,2.848
verapamil CR 120 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462029201,NDC,1,EA,5.76,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.8512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 120 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802073230,NDC,1,EA,3.13,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.85143,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904632261,NDC,1,EA,6.65,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.85285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nabumetone 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50228046501,NDC,1,EA,6.65,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.85285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline monohydrate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687071611,NDC,1,EA,6.87,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.853798,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 40 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862011801,NDC,1,EA,5.64,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.85384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carvedilol 3.125 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904630061,NDC,0.5,EA,5.64,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.85384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxepin 10 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,51672421701,NDC,1,EA,3.36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084008211,NDC,0.5,EA,3.36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268075411,NDC,1,EA,3.36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 5 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268075415,NDC,1,EA,3.36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
chlorthalidone 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378022201,NDC,0.5,EA,3.24,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.85768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
darbepoetin alfa 40 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002104,NDC,0.4,ML,1411.78,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.86313,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.58,2.93
darbepoetin alfa 200 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002801,NDC,0.4,ML,3157.92,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.86313,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.58,2.93
darbepoetin alfa 300 MCG/0.6ML solution prefilled syringe 0.6 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513011101,NDC,0.6,ML,4736.88,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.86313,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.58,2.93
darbepoetin alfa 500 MCG/ML solution prefilled syringe 1 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513003201,NDC,0.3,ML,2368.44,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.86313,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.58,2.93
hydrOXYzine pamoate 25 MG capsule 1 Each Blister,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084711,NDC,1,EA,3.22,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.8658,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,3.1556
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084701,NDC,1,EA,3.22,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.8658,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,3.1556
losartan 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739067310,NDC,1,EA,3.22,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.8658,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glimepiride 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93725401,NDC,1,EA,5.79,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.86605,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54829925,NDC,1,EA,3.15,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.86965,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nortriptyline 25 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,93081101,NDC,0.4,EA,3.15,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.86965,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"BANDAGE STERILE 4"" TETRA-FLEX CLIP FREE  0151-4SV",27200000,CDM,272,RC,A6449,HCPCS,,10662-MAIN,LOCAL,,,,,6.7,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.8743,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
pravastatin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904589261,NDC,0.5,EA,6.7,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.8743,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 88 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378180701,NDC,2,EA,5.99,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.8752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 88 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378180701,NDC,2,EA,5.99,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.8752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084065911,NDC,1,EA,5.99,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.8752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084065911,NDC,1,EA,5.99,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.8752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084065901,NDC,1,EA,5.99,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.8752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084065901,NDC,1,EA,5.99,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.8752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862007701,NDC,0.2,EA,6,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862007701,NDC,0.2,EA,6,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,72205000530,NDC,0.125,EA,6,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,72205000530,NDC,0.125,EA,6,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
chlorthalidone 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378022201,NDC,0.5,EA,3.24,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.8836,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dicloxacillin 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,93312501,NDC,0.5,EA,6.73,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.88717,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 120 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,713011806,NDC,1,EA,3.17,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.88787,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 120 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713011812,NDC,1,EA,3.17,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.88787,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Blood Typing Abo,PX86900,CDM,300,RC,86900,CPT,,,,,,,,92,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.8881,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.8881,2.99
Blood Typing Rh (D),PX86901,CDM,300,RC,86901,CPT,,,,,,,,92,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.8881,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.8881,2.99
Microscopic Exam of Urine,PX81015,CDM,300,RC,81015,CPT,,,,,,,,29,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.8881,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.8881,3.05
levothyroxine 112 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003901,NDC,0.892857143,EA,3.4,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prochlorperazine 5 MG Tablet 1 Each Blister,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054101,NDC,1,EA,3.28,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.89296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
fluorouracil 5 GM/100ML Solution 100 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,16729027638,NDC,100,ML,261.44,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.8953,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.82,3.38
fluorouracil 500 MG/10ML Solution 10 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,63323011710,NDC,10,ML,39,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.8953,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.82,3.38
XEROFORM GAUZE PETROLATUM 1X8INCH,27200000,CDM,272,RC,A6222,HCPCS,,10659-MAIN,LOCAL,,,,,3.52,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,2.8953,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
clindamycin 300 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084024411,NDC,1,EA,6.97,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.895338,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,68084024401,NDC,1,EA,6.97,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.895338,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzonatate 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904715361,NDC,1,EA,3.18,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.89698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585861,NDC,1,EA,3.41,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.8985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine HCl 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714008110,NDC,1,EA,3.41,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.8985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50111091501,NDC,1,EA,3.41,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.8985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carvedilol 3.125 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079077120,NDC,0.5,EA,5.73,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.89938,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 1 Each Blister,63700001,CDM,250,RC,,,,,,49884030752,NDC,1,EA,6.98,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.899492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Bottle,63700001,CDM,250,RC,,,,,,57664078486,NDC,1,EA,6.98,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.899492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Box,63700001,CDM,250,RC,,,,,,555009596,NDC,1,EA,6.98,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.899492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Box,63700001,CDM,250,RC,,,,,,49884030702,NDC,1,EA,6.98,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.899492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Blood Typing Abo,PX86900,CDM,300,RC,86900,CPT,,,,,,,,92,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.8881,2.99
Blood Typing Abo,PX86900,CDM,300,RC,86900,CPT,,,,,,,,92,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.8881,2.99
Blood Typing Abo,PX86900,CDM,300,RC,86900,CPT,,,,,,,,92,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.9,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.8881,2.99
Blood Typing Rh (D),PX86901,CDM,300,RC,86901,CPT,,,,,,,,92,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.8881,2.99
Blood Typing Rh (D),PX86901,CDM,300,RC,86901,CPT,,,,,,,,92,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.8881,2.99
Blood Typing Rh (D),PX86901,CDM,300,RC,86901,CPT,,,,,,,,92,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.9,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.8881,2.99
darbepoetin alfa 40 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002104,NDC,0.4,ML,1411.78,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.58,2.93
darbepoetin alfa 40 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002104,NDC,0.4,ML,1411.78,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.58,2.93
darbepoetin alfa 200 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002801,NDC,0.4,ML,3157.92,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.58,2.93
darbepoetin alfa 200 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002801,NDC,0.4,ML,3157.92,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.58,2.93
darbepoetin alfa 300 MCG/0.6ML solution prefilled syringe 0.6 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513011101,NDC,0.6,ML,4736.88,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.58,2.93
darbepoetin alfa 300 MCG/0.6ML solution prefilled syringe 0.6 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513011101,NDC,0.6,ML,4736.88,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.58,2.93
darbepoetin alfa 500 MCG/ML solution prefilled syringe 1 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513003201,NDC,0.3,ML,2368.44,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.58,2.93
darbepoetin alfa 500 MCG/ML solution prefilled syringe 1 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513003201,NDC,0.3,ML,2368.44,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.58,2.93
linezolid 600 MG/300ML Solution 300 mL Flex Cont,J2020.01,CDM,636,RC,J2020,HCPCS,,,,9514001,NDC,300,ML,332.42,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.9,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.9,3.62
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915701,NDC,0.5,ML,44.33,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.9,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.54,2.9
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915731,NDC,0.5,ML,44.33,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.9,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.54,2.9
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915801,NDC,1,ML,267.19,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.9,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.54,2.9
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915850,NDC,0.2,ML,69.44,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.9,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.54,2.9
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,43598040516,NDC,0.2,ML,63.83,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.9,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.54,2.9
NIFEdipine CR osmotic 30 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,24979001101,NDC,1,EA,5.92,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.9008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
NIFEdipine CR osmotic 30 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,24979001101,NDC,1,EA,5.92,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.9008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
NIFEdipine CR osmotic 30 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,24979001101,NDC,1,EA,5.92,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.9008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prochlorperazine 5 MG Tablet 100 Each Box,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054120,NDC,1,EA,3.29,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.90178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
guaiFENesin 600 MG Tablet Extended Release 12 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904671839,NDC,1,EA,5.74,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.90444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"BANDAGE STERILE 3"" TETRA-FLEX CLIP FREE 0151-3SV",27200000,CDM,272,RC,A6449,HCPCS,,10661-MAIN,LOCAL,,,,,5.93,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.9057,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"BANDAGE STERILE 3"" TETRA-FLEX CLIP FREE 0151-3SV",27200000,CDM,272,RC,A6449,HCPCS,,10661-MAIN,LOCAL,,,,,5.93,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.9057,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"BANDAGE STERILE 3"" TETRA-FLEX CLIP FREE 0151-3SV",27200000,CDM,272,RC,A6449,HCPCS,,10661-MAIN,LOCAL,,,,,5.93,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.9057,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
prochlorperazine 5 MG Tablet 100 Each Bottle,63600000,CDM,636,RC,Q0164,HCPCS,,,,59746011306,NDC,1,EA,3.19,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.90609,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
DERMAL TIP HYFRECATOR SHARP ANGLED STAINLESS STEEL BLADE STERILE DISPOSABLE,27200000,CDM,272,RC,,,,12459-MAIN,LOCAL,,,,,7,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.9078,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSTRUMENT POUCH INVISISHIELD LONG,27200000,CDM,272,RC,,,,12394-MAIN,LOCAL,,,,,7,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.9078,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
OSTOMY KIT 2 PIECE SURGICAL POST-OP,27200000,CDM,272,RC,,,,12070-MAIN,LOCAL,,,,,7,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.9078,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE PDS 3-0 27INCH ABSORBABLE VIOLET Z316H,27200000,CDM,272,RC,,,,12871-MAIN,LOCAL,,,,,7,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.9078,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE PROLENE TAPERPOINT CT-1 36MM 0 BLUE,27200000,CDM,272,RC,,,,12322-MAIN,LOCAL,,,,,7,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.9078,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Capillary Blood Collection,PX36416,CDM,300,RC,36416,CPT,,,,,,,,60,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.91,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.64,4.88
"Urinalysis, Auto, W/Scope",PX81001,CDM,300,RC,81001,CPT,,,,,,,,255,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.91,249.9
XEROFORM GAUZE PETROLATUM 1X8INCH,27200000,CDM,272,RC,A6222,HCPCS,,10659-MAIN,LOCAL,,,,,3.52,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.91,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
Microscopic Exam of Urine,PX81015,CDM,300,RC,81015,CPT,,,,,,,,29,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.8881,3.05
Microscopic Exam of Urine,PX81015,CDM,300,RC,81015,CPT,,,,,,,,29,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.8881,3.05
XEROFORM GAUZE PETROLATUM 1X8INCH,27200000,CDM,272,RC,A6222,HCPCS,,10659-MAIN,LOCAL,,,,,3.52,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
XEROFORM GAUZE PETROLATUM 1X8INCH,27200000,CDM,272,RC,A6222,HCPCS,,10659-MAIN,LOCAL,,,,,3.52,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
verapamil CR 120 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462029201,NDC,1,EA,5.76,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.91456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carBAMazepine 100 MG Tablet Chewable 100 Each Box,63700001,CDM,250,RC,,,,,,904385461,NDC,1,EA,3.43,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.9155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxepin 10 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079043620,NDC,1,EA,3.43,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.9155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prochlorperazine 5 MG Tablet 1 Each Blister,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054101,NDC,1,EA,3.28,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.9192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904198261,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580045811,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580060002,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 750 Each Box,63700001,CDM,250,RC,,,,,,63739044001,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904198861,NDC,0.65,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904673061,NDC,0.65,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580045711,NDC,0.65,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 650 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,70010016001,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen-codeine 300-30 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406048423,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen-codeine 300-30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406048462,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020501,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584098811,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,53489015601,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904657161,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020520,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,62584098801,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862067701,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585961,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739064410,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amitriptyline 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268003711,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amitriptyline 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687043311,NDC,0.4,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amitriptyline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687043301,NDC,0.4,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687026311,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084025911,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687026301,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084025901,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714029903,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ascorbic acid 500 MG Tablet 100 Each Box,25000000,CDM,250,RC,,,,,,904052361,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
aspirin 81 MG Tablet Chewable 90 Each Bottle,63700001,CDM,250,RC,,,,,,904679489,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin 81 MG Tablet Chewable 500 Each Disp Pack,63700001,CDM,250,RC,,,,,,66553000201,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin 325 MG Tablet 500 Each Box,63700001,CDM,250,RC,,,,,,66553000101,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 81 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,63739021210,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 81 MG Tablet Delayed Release 120 Each Bottle,63700001,CDM,250,RC,,,,,,10135017362,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,536114801,NDC,0.249230769,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,536331301,NDC,0.249230769,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,603016921,NDC,0.249230769,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079068401,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020801,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629061,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020820,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020901,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629161,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020920,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079021001,NDC,0.125,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
azaTHIOprine 50 MG Tablet 1 Each Blister,J7500.01,CDM,636,RC,J7500,HCPCS,,,,68084022911,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2.94
baclofen 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904647561,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
baclofen 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739047910,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268011011,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 40 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547033810,NDC,0.125,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 1 Each Box,63700001,CDM,250,RC,,,,,,713010906,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574705012,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713010912,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,904505812,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl EC 5 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,904640761,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bismuth subsalicylate 262 MG Tablet Chewable 30 Each Box,63700001,CDM,250,RC,,,,,,904720546,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bumetanide 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,185012901,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buPROPion SR 150 MG Tablet Extended Release 12 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084070895,NDC,0.666666667,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buPROPion SR 150 MG Tablet Extended Release 12 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,68084070825,NDC,0.666666667,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcium carb-cholecalciferol 600-10 mg-mcg (600-400 mg-unit) Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,20555001700,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcium carbonate 500 MG Tablet Chewable 500 Each Box,63700001,CDM,250,RC,,,,,,66553000401,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
candesartan 32 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,49884066109,NDC,0.125,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 10-100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,72888010601,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687066111,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084009311,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687066101,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-250 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084009411,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carvedilol 12.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904630261,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cetirizine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904671761,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cholecalciferol (vitamin D3) 125 MCG (5000 UT) capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,80681013100,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637861,NDC,0.2,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904724361,NDC,0.2,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin 150 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904595961,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714075201,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16729013600,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloNIDine 0.1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687011311,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloNIDine 0.1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687011301,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloNIDine 0.1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739006010,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
codeine 30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54024424,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536136601,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536355601,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,74312001380,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079064401,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687055811,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687055801,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54417925,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54817925,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54817625,NDC,0.125,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 6 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54418625,NDC,0.041666667,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079028401,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,172392560,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079028420,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079028501,NDC,0.4,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,172392660,NDC,0.4,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079028520,NDC,0.4,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687019511,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687019501,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 180 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687020611,NDC,0.666666667,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 180 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687020601,NDC,0.666666667,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687021711,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739001610,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 25 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904530661,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 25 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904723761,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 50 MG capsule 100 Each Box,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904205661,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,5.734,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
divalproex 250 MG Tablet Delayed Release 1 Each Box,63700001,CDM,250,RC,,,,,,832712389,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 250 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,832712301,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
docusate sodium 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,10135011101,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
docusate sodium 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904645561,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
docusate sodium 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904718361,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
donepezil 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904647761,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxazosin 4 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68382078501,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
estradiol 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378145201,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
estradiol 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42806008701,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 25 Each Bottle,63700001,CDM,250,RC,,,,,,49348081705,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739064510,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"ferrous sulfate 325 (65 Fe) MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64376080910,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ferrous sulfate 325 (65 Fe) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904759161,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Fish Oil 1000 MG capsule 1 Each Blister,25000000,CDM,250,RC,,,,,,77333030825,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
folic acid 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687068111,NDC,0.4,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
folic acid 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687068101,NDC,0.4,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54829725,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904717861,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762403001,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904666561,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739059110,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739090210,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862019901,NDC,0.333333333,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904666661,NDC,0.333333333,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60505011300,NDC,0.333333333,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687059101,NDC,0.333333333,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739023610,NDC,0.333333333,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glimepiride 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547039410,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079081001,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079081020,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE ER 2.5 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714089401,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE ER 5 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714089501,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glyBURIDE 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,93834498,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glycerin 2 g Suppository 24 Each Jar,63700001,CDM,250,RC,,,,,,132007924,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 600 MG Tablet Extended Release 12 Hour 20 Each Box,63700001,CDM,250,RC,,,,,,63824000832,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
haloperidol 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079073420,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155000101,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904644161,NDC,0.4,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,64380073506,NDC,0.2,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904644261,NDC,0.2,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydroCHLOROthiazide 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547039710,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 5 MG Tablet 50 Each Bottle,63700001,CDM,250,RC,,,,,,59762007301,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762007401,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406324301,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,42858030125,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084042301,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine HCl 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155050101,NDC,0.4,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,51079007720,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,3.1556
ibuprofen 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904791461,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 600 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687045711,NDC,0.333333333,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 600 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739068410,NDC,0.333333333,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 800 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687046811,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 800 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687046801,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 800 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739069110,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
indomethacin 25 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,50268043011,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,781155601,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
labetalol 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,10135071101,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
labetalol 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687045011,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Lactase 9000 units Tablet 12 Each Box,63700001,CDM,250,RC,,,,,,45091012,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904700761,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031911,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084031901,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levETIRAcetam 250 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904712361,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 50 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079044001,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 50 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079044020,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
liothyronine 25 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762120701,NDC,0.2,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079098101,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679761,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,591040701,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679861,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679961,NDC,0.125,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687033301,NDC,0.125,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904680061,NDC,0.0625,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904720061,NDC,0.0625,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lithium 150 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,54252625,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lithium 150 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,54852625,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
loratadine 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714089801,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904600761,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739049910,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687035511,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904600861,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739050010,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904704861,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739068610,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Magnesium Cl-Calcium Carbonate 71.5-119 MG Tablet Delayed Release 60 Each Bottle,63700001,CDM,250,RC,,,,,,67618010760,NDC,2,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904660961,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,10006070028,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,64980033901,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
medroxyPROGESTERone 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,555087202,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
melatonin 3 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268052411,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
melatonin 3 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268052415,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
melatonin 3 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,904518252,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Melatonin 3-10 MG Tablet 120 Each Bottle,800000,CDM,,,,,,,,47469000852,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Melatonin 10 MG SL Tab 120 Each Bottle,63700001,CDM,250,RC,,,,,,40985027503,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904716261,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 850 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739070210,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 1000 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904669161,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 1000 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904716461,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methadone 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406575523,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methadone 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54855324,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methIMAzole 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155007001,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methIMAzole 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155007101,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methocarbamol 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687055911,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methocarbamol 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739016610,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methocarbamol 750 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687056811,NDC,0.666666667,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoclopramide 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93220401,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoclopramide 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739029310,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 50 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084066611,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 100 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,51079017101,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584026511,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904634061,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079080101,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904634161,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584026711,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,62584026701,NDC,0.125,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metroNIDAZOLE 500 MG Tablet 50 Each Bottle,63700001,CDM,250,RC,,,,,,29300022746,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
miSOPROStol 100 MCG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,70954044310,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
montelukast 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904680861,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine immediate release 15 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54023525,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine immediate release 15 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,832027311,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
multivitamin with minerals Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904549261,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
naproxen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739040310,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine polacrilex 4 MG Lozenge 24 Each Bottle,63700001,CDM,250,RC,,,,,,43598048772,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine polacrilex 4 MG Lozenge 72 Each Box,63700001,CDM,250,RC,,,,,,49348085316,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 1 Each Blister,63700001,CDM,250,RC,,,,,,68084012811,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,904691761,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,68084012801,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyBUTYnin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904702761,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406055223,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406055262,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739096310,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PHENobarbital 32.4 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904657561,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenytoin ER 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904618761,NDC,0.3,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenytoin ER 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,68084037601,NDC,0.3,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phosphorus 155-852-130 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,64980010401,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687059211,NDC,0.125,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
predniSONE 1 MG Tablet 100 Each Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,64380078206,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.034877358,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 1 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54873925,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.034877358,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 2.5 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54874025,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.034877358,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 5 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687012211,NDC,0.2,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.034877358,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 10 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687013411,NDC,0.1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.034877358,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001720,NDC,0.1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.034877358,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,63739051910,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.034877358,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 20 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014511,NDC,0.05,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.034877358,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001820,NDC,0.05,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.034877358,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014501,NDC,0.05,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.034877358,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
pregabalin 25 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,76282056890,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 75 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904700061,NDC,0.333333333,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prochlorperazine 10 MG Tablet 100 Each Bottle,25000000,CDM,250,RC,,,,,,59746011506,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
promethazine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,Q0169,HCPCS,,,,904646161,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904655061,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268070211,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687060911,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687060901,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Prosight Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,536509008,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
psyllium 0.52 GM capsule 160 Each Bottle,25000000,CDM,250,RC,,,,,,80681002200,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Psyllium 400 MG capsule 160 Each Bottle,25000000,CDM,250,RC,,,,,,10939081644,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pyridoxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536440601,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pyridoxine 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,77333094010,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904663861,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904664061,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739066510,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ramipril 5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,68382014601,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904736161,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rOPINIRole 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637461,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268071111,NDC,0.125,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268071115,NDC,0.125,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna 8.6 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904652261,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687062211,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,57896045806,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904633961,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687062201,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739043210,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018011,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904692461,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018001,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687024211,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018111,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687024201,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018101,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687025311,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904692661,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687025301,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simethicone 125 MG Tablet Chewable 18 Each Box,63700001,CDM,250,RC,,,,,,49348086348,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simethicone 125 MG Tablet Chewable 60 Each Bottle,63700001,CDM,250,RC,,,,,,69618003206,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simvastatin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739057010,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simvastatin 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739057310,NDC,0.125,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"sodium bicarbonate 650 MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64980018210,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"sodium bicarbonate 650 MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64980052810,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium chloride 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,223176001,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 12.5 mg Tablet 1 split tablet Blister,63700001,CDM,250,RC,,,,,,8888800438,NDC,2,UN,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079010301,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687046511,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079010320,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687046501,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739054410,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 800-160 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904272561,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 800-160 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739022810,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tamsulosin 0.4 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739056710,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079041801,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877014601,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079041820,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739023110,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terazosin 5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59746038506,NDC,0.2,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
therapeutic multivitamin Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904053961,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,77333093425,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,37864090599,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,77333093410,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268075611,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268075615,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54007725,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50111091701,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739067110,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traZODone 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904655461,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
valsartan 160 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342006410,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536333401,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904582461,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,10006070033,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,20555003300,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121201,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121301,NDC,0.4,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 3 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121401,NDC,0.333333333,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,832121689,NDC,0.2,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121601,NDC,0.2,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zinc gluconate 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,40093010153,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen-codeine 300-30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739000410,NDC,1,EA,3.44,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.924,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
penicillin v potassium 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714023501,NDC,0.5,EA,3.44,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.924,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenytoin ER 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084037611,NDC,1,EA,3.44,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.924,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 150 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862069730,NDC,0.25,EA,6.82,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.92578,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prochlorperazine 5 MG Tablet 100 Each Box,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054120,NDC,1,EA,3.29,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.9281,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
potassium chloride CR 10 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,66758017006,NDC,1,EA,3.32,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.92824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,245531701,NDC,1,EA,3.32,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.92824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,66758017013,NDC,1,EA,3.32,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.92824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BANDAGE ESMARK 4X9 LATEX FREE DYNJ05916,27200000,CDM,272,RC,,,,5428-MAIN,LOCAL,,,,,7.05,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.92857,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
glimepiride 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93725401,NDC,1,EA,5.79,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.92974,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
darbepoetin alfa 40 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002104,NDC,0.4,ML,1411.78,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.93,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.58,2.93
darbepoetin alfa 200 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002801,NDC,0.4,ML,3157.92,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.93,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.58,2.93
darbepoetin alfa 300 MCG/0.6ML solution prefilled syringe 0.6 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513011101,NDC,0.6,ML,4736.88,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.93,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.58,2.93
darbepoetin alfa 500 MCG/ML solution prefilled syringe 1 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513003201,NDC,0.3,ML,2368.44,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.93,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.58,2.93
NIFEdipine CR osmotic 30 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,24979001101,NDC,1,EA,5.92,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.9304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,591024001,NDC,1,EA,3.45,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.9325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine pamoate 25 MG capsule 1 Each Blister,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084711,NDC,1,EA,3.22,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.93342,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,3.1556
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084701,NDC,1,EA,3.22,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.93342,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,3.1556
losartan 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739067310,NDC,1,EA,3.22,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.93342,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 88 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378180701,NDC,2,EA,5.99,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.9351,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 88 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378180701,NDC,2,EA,5.99,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.9351,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 88 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378180701,NDC,2,EA,5.99,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.9351,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084065911,NDC,1,EA,5.99,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.9351,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084065911,NDC,1,EA,5.99,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.9351,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084065911,NDC,1,EA,5.99,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.9351,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084065901,NDC,1,EA,5.99,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.9351,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084065901,NDC,1,EA,5.99,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.9351,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084065901,NDC,1,EA,5.99,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.9351,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"BANDAGE STERILE 3"" TETRA-FLEX CLIP FREE 0151-3SV",27200000,CDM,272,RC,A6449,HCPCS,,10661-MAIN,LOCAL,,,,,5.93,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.93535,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
metoprolol succinate 50 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904632361,NDC,0.5,EA,3.33,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.93706,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,42858000110,NDC,1,EA,3.33,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.93706,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,245531789,NDC,1,EA,3.33,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.93706,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904198261,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580045811,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580060002,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 325 MG Tablet 750 Each Box,63700001,CDM,250,RC,,,,,,63739044001,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904198861,NDC,0.65,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904673061,NDC,0.65,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580045711,NDC,0.65,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 650 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,70010016001,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen-codeine 300-30 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406048423,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen-codeine 300-30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406048462,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020501,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584098811,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,53489015601,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904657161,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020520,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,62584098801,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862067701,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585961,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739064410,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amitriptyline 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268003711,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amitriptyline 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687043311,NDC,0.4,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amitriptyline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687043301,NDC,0.4,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687026311,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084025911,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687026301,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084025901,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714029903,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ascorbic acid 500 MG Tablet 100 Each Box,25000000,CDM,250,RC,,,,,,904052361,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
aspirin 81 MG Tablet Chewable 90 Each Bottle,63700001,CDM,250,RC,,,,,,904679489,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin 81 MG Tablet Chewable 500 Each Disp Pack,63700001,CDM,250,RC,,,,,,66553000201,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin 325 MG Tablet 500 Each Box,63700001,CDM,250,RC,,,,,,66553000101,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 81 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,63739021210,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 81 MG Tablet Delayed Release 120 Each Bottle,63700001,CDM,250,RC,,,,,,10135017362,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,536114801,NDC,0.249230769,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,536331301,NDC,0.249230769,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,603016921,NDC,0.249230769,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079068401,NDC,0.25,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020801,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629061,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020820,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020901,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629161,NDC,0.25,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020920,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atorvaSTATin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079021001,NDC,0.125,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
azaTHIOprine 50 MG Tablet 1 Each Blister,J7500.01,CDM,636,RC,J7500,HCPCS,,,,68084022911,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2.94
baclofen 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904647561,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
baclofen 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739047910,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268011011,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 40 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547033810,NDC,0.125,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 1 Each Box,63700001,CDM,250,RC,,,,,,713010906,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574705012,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713010912,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,904505812,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisacodyl EC 5 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,904640761,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bismuth subsalicylate 262 MG Tablet Chewable 30 Each Box,63700001,CDM,250,RC,,,,,,904720546,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bumetanide 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,185012901,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buPROPion SR 150 MG Tablet Extended Release 12 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084070895,NDC,0.666666667,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buPROPion SR 150 MG Tablet Extended Release 12 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,68084070825,NDC,0.666666667,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcium carb-cholecalciferol 600-10 mg-mcg (600-400 mg-unit) Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,20555001700,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcium carbonate 500 MG Tablet Chewable 500 Each Box,63700001,CDM,250,RC,,,,,,66553000401,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
candesartan 32 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,49884066109,NDC,0.125,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 10-100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,72888010601,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687066111,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084009311,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687066101,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-250 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084009411,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carvedilol 12.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904630261,NDC,0.25,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cetirizine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904671761,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cholecalciferol (vitamin D3) 125 MCG (5000 UT) capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,80681013100,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862007701,NDC,0.2,EA,6,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862007701,NDC,0.2,EA,6,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862007701,NDC,0.2,EA,6,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637861,NDC,0.2,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904724361,NDC,0.2,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin 150 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904595961,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714075201,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16729013600,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloNIDine 0.1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687011311,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloNIDine 0.1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687011301,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloNIDine 0.1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739006010,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
codeine 30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54024424,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536136601,NDC,0.25,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536355601,NDC,0.25,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,74312001380,NDC,0.25,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079064401,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687055811,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687055801,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54417925,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54817925,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54817625,NDC,0.125,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 6 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54418625,NDC,0.041666667,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079028401,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,172392560,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079028420,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079028501,NDC,0.4,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,172392660,NDC,0.4,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079028520,NDC,0.4,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687019511,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687019501,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 180 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687020611,NDC,0.666666667,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 180 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687020601,NDC,0.666666667,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687021711,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739001610,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 25 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904530661,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 25 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904723761,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 50 MG capsule 100 Each Box,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904205661,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
divalproex 250 MG Tablet Delayed Release 1 Each Box,63700001,CDM,250,RC,,,,,,832712389,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 250 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,832712301,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
docusate sodium 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,10135011101,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
docusate sodium 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904645561,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
docusate sodium 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904718361,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
donepezil 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904647761,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxazosin 4 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68382078501,NDC,0.25,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
estradiol 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378145201,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
estradiol 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42806008701,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 25 Each Bottle,63700001,CDM,250,RC,,,,,,49348081705,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739064510,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"ferrous sulfate 325 (65 Fe) MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64376080910,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ferrous sulfate 325 (65 Fe) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904759161,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Fish Oil 1000 MG capsule 1 Each Blister,25000000,CDM,250,RC,,,,,,77333030825,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
folic acid 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687068111,NDC,0.4,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
folic acid 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687068101,NDC,0.4,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54829725,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904717861,NDC,0.25,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762403001,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904666561,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739059110,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739090210,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862019901,NDC,0.333333333,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904666661,NDC,0.333333333,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60505011300,NDC,0.333333333,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687059101,NDC,0.333333333,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739023610,NDC,0.333333333,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glimepiride 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547039410,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079081001,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079081020,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE ER 2.5 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714089401,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glipiZIDE ER 5 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714089501,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glyBURIDE 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,93834498,NDC,0.25,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glycerin 2 g Suppository 24 Each Jar,63700001,CDM,250,RC,,,,,,132007924,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 600 MG Tablet Extended Release 12 Hour 20 Each Box,63700001,CDM,250,RC,,,,,,63824000832,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
haloperidol 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079073420,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155000101,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904644161,NDC,0.4,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,64380073506,NDC,0.2,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904644261,NDC,0.2,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydroCHLOROthiazide 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547039710,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 5 MG Tablet 50 Each Bottle,63700001,CDM,250,RC,,,,,,59762007301,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762007401,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406324301,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,42858030125,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084042301,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine HCl 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155050101,NDC,0.4,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,51079007720,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,3.1556
ibuprofen 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904791461,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 600 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687045711,NDC,0.333333333,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 600 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739068410,NDC,0.333333333,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 800 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687046811,NDC,0.25,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 800 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687046801,NDC,0.25,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 800 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739069110,NDC,0.25,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
indomethacin 25 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,50268043011,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,781155601,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
labetalol 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,10135071101,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
labetalol 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687045011,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Lactase 9000 units Tablet 12 Each Box,63700001,CDM,250,RC,,,,,,45091012,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904700761,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031911,NDC,0.25,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084031901,NDC,0.25,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levETIRAcetam 250 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904712361,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 50 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079044001,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 50 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079044020,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
liothyronine 25 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762120701,NDC,0.2,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079098101,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679761,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,591040701,NDC,0.25,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679861,NDC,0.25,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679961,NDC,0.125,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687033301,NDC,0.125,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904680061,NDC,0.0625,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904720061,NDC,0.0625,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lithium 150 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,54252625,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lithium 150 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,54852625,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
loratadine 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714089801,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904600761,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739049910,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687035511,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904600861,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739050010,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904704861,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739068610,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Magnesium Cl-Calcium Carbonate 71.5-119 MG Tablet Delayed Release 60 Each Bottle,63700001,CDM,250,RC,,,,,,67618010760,NDC,2,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904660961,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,10006070028,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,64980033901,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
medroxyPROGESTERone 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,555087202,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
melatonin 3 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268052411,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
melatonin 3 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268052415,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
melatonin 3 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,904518252,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Melatonin 3-10 MG Tablet 120 Each Bottle,800000,CDM,,,,,,,,47469000852,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Melatonin 10 MG SL Tab 120 Each Bottle,63700001,CDM,250,RC,,,,,,40985027503,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904716261,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 850 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739070210,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 1000 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904669161,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 1000 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904716461,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methadone 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406575523,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methadone 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54855324,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methIMAzole 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155007001,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methIMAzole 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155007101,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methocarbamol 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687055911,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methocarbamol 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739016610,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methocarbamol 750 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687056811,NDC,0.666666667,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoclopramide 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93220401,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoclopramide 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739029310,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 50 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084066611,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 100 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,51079017101,NDC,0.25,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584026511,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904634061,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079080101,NDC,0.25,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904634161,NDC,0.25,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584026711,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,62584026701,NDC,0.125,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metroNIDAZOLE 500 MG Tablet 50 Each Bottle,63700001,CDM,250,RC,,,,,,29300022746,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
miSOPROStol 100 MCG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,70954044310,NDC,0.25,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
montelukast 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904680861,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine immediate release 15 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54023525,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine immediate release 15 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,832027311,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
multivitamin with minerals Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904549261,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
naproxen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739040310,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine polacrilex 4 MG Lozenge 24 Each Bottle,63700001,CDM,250,RC,,,,,,43598048772,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine polacrilex 4 MG Lozenge 72 Each Box,63700001,CDM,250,RC,,,,,,49348085316,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 1 Each Blister,63700001,CDM,250,RC,,,,,,68084012811,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,904691761,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,68084012801,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyBUTYnin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904702761,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406055223,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406055262,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739096310,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PHENobarbital 32.4 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904657561,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenytoin ER 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904618761,NDC,0.3,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenytoin ER 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,68084037601,NDC,0.3,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phosphorus 155-852-130 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,64980010401,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687059211,NDC,0.125,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
predniSONE 1 MG Tablet 100 Each Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,64380078206,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 1 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54873925,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 2.5 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54874025,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 5 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687012211,NDC,0.2,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 10 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687013411,NDC,0.1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001720,NDC,0.1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,63739051910,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 20 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014511,NDC,0.05,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001820,NDC,0.05,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014501,NDC,0.05,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
pregabalin 25 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,76282056890,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 75 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904700061,NDC,0.333333333,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prochlorperazine 10 MG Tablet 100 Each Bottle,25000000,CDM,250,RC,,,,,,59746011506,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
promethazine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,Q0169,HCPCS,,,,904646161,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904655061,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268070211,NDC,0.25,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687060911,NDC,0.25,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687060901,NDC,0.25,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Prosight Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,536509008,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
psyllium 0.52 GM capsule 160 Each Bottle,25000000,CDM,250,RC,,,,,,80681002200,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Psyllium 400 MG capsule 160 Each Bottle,25000000,CDM,250,RC,,,,,,10939081644,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pyridoxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536440601,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pyridoxine 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,77333094010,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904663861,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904664061,NDC,0.25,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739066510,NDC,0.25,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ramipril 5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,68382014601,NDC,0.25,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904736161,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rOPINIRole 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637461,NDC,0.25,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268071111,NDC,0.125,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,72205000530,NDC,0.125,EA,6,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,72205000530,NDC,0.125,EA,6,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,72205000530,NDC,0.125,EA,6,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268071115,NDC,0.125,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna 8.6 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904652261,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687062211,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,57896045806,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904633961,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687062201,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739043210,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018011,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904692461,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018001,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687024211,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018111,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687024201,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018101,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687025311,NDC,0.25,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904692661,NDC,0.25,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sertraline 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687025301,NDC,0.25,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simethicone 125 MG Tablet Chewable 18 Each Box,63700001,CDM,250,RC,,,,,,49348086348,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simethicone 125 MG Tablet Chewable 60 Each Bottle,63700001,CDM,250,RC,,,,,,69618003206,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simvastatin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739057010,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simvastatin 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739057310,NDC,0.125,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"sodium bicarbonate 650 MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64980018210,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"sodium bicarbonate 650 MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64980052810,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium chloride 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,223176001,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 12.5 mg Tablet 1 split tablet Blister,63700001,CDM,250,RC,,,,,,8888800438,NDC,2,UN,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079010301,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687046511,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079010320,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687046501,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739054410,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 800-160 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904272561,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 800-160 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739022810,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tamsulosin 0.4 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739056710,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079041801,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877014601,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079041820,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temazepam 15 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739023110,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terazosin 5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59746038506,NDC,0.2,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
therapeutic multivitamin Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904053961,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,77333093425,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,37864090599,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,77333093410,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268075611,NDC,0.25,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268075615,NDC,0.25,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54007725,NDC,0.25,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50111091701,NDC,0.25,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739067110,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traZODone 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904655461,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
valsartan 160 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342006410,NDC,0.25,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536333401,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904582461,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,10006070033,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,20555003300,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121201,NDC,0.5,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121301,NDC,0.4,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 3 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121401,NDC,0.333333333,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,832121689,NDC,0.2,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121601,NDC,0.2,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zinc gluconate 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,40093010153,NDC,1,EA,3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687064011,NDC,1,EA,3.34,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.94588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687064001,NDC,1,EA,3.34,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.94588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 150 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084071311,NDC,0.25,EA,6.14,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2.9472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 150 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084071311,NDC,0.25,EA,6.14,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2.9472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline monohydrate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687071611,NDC,1,EA,6.87,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.94723,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637161,NDC,0.25,EA,3.03,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.949099,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluorouracil 5 GM/100ML Solution 100 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,16729027638,NDC,100,ML,261.44,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.82,3.38
fluorouracil 5 GM/100ML Solution 100 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,16729027638,NDC,100,ML,261.44,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.82,3.38
fluorouracil 500 MG/10ML Solution 10 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,63323011710,NDC,10,ML,39,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,2.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.82,3.38
fluorouracil 500 MG/10ML Solution 10 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,63323011710,NDC,10,ML,39,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,2.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.82,3.38
chlorthalidone 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378022201,NDC,0.5,EA,3.24,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.95164,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,66758017006,NDC,1,EA,3.32,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.9548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,245531701,NDC,1,EA,3.32,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.9548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,66758017013,NDC,1,EA,3.32,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.9548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,603420921,NDC,1,EA,3.48,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.958,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68180051201,NDC,1,EA,3.48,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.958,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Microscopic Exam of Urine,PX81015,CDM,300,RC,81015,CPT,,,,,,,,29,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2.96,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.8881,3.05
doxepin 10 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,51672421701,NDC,1,EA,3.36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.96352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084008211,NDC,0.5,EA,3.36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.96352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268075411,NDC,1,EA,3.36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.96352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 5 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268075415,NDC,1,EA,3.36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.96352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 50 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904632361,NDC,0.5,EA,3.33,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.9637,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,42858000110,NDC,1,EA,3.33,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.9637,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,245531789,NDC,1,EA,3.33,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.9637,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 88 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378180701,NDC,2,EA,5.99,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.96505,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084065911,NDC,1,EA,5.99,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.96505,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084065901,NDC,1,EA,5.99,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.96505,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637161,NDC,0.25,EA,3.03,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2.9694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862007701,NDC,0.2,EA,6,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,72205000530,NDC,0.125,EA,6,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687064011,NDC,1,EA,3.34,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.9726,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687064001,NDC,1,EA,3.34,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.9726,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,50268053111,NDC,1,EA,7.19,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2.986726,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079080120,NDC,1,EA,3.07,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2.988031,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prochlorperazine 5 MG Tablet 1 Each Blister,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054101,NDC,1,EA,3.28,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.98808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
Blood Typing Abo,PX86900,CDM,300,RC,86900,CPT,,,,,,,,92,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.99,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.8881,2.99
Blood Typing Rh (D),PX86901,CDM,300,RC,86901,CPT,,,,,,,,92,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2.99,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.8881,2.99
clindamycin 300 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084024411,NDC,1,EA,6.97,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.99013,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,68084024401,NDC,1,EA,6.97,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.99013,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxepin 10 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,51672421701,NDC,1,EA,3.36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.9904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084008211,NDC,0.5,EA,3.36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.9904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268075411,NDC,1,EA,3.36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.9904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 5 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268075415,NDC,1,EA,3.36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2.9904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
XEROFORM GAUZE PETROLATUM 1X8INCH,27200000,CDM,272,RC,A6222,HCPCS,,10659-MAIN,LOCAL,,,,,3.52,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2.992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
clonazePAM 0.25 MG Tablet Disintegrating 1 Each Blister,63700001,CDM,250,RC,,,,,,49884030752,NDC,1,EA,6.98,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.99442,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Bottle,63700001,CDM,250,RC,,,,,,57664078486,NDC,1,EA,6.98,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.99442,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Box,63700001,CDM,250,RC,,,,,,555009596,NDC,1,EA,6.98,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.99442,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Box,63700001,CDM,250,RC,,,,,,49884030702,NDC,1,EA,6.98,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2.99442,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
NIFEdipine CR osmotic 30 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,24979001101,NDC,1,EA,5.92,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2.99552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prochlorperazine 5 MG Tablet 100 Each Box,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054120,NDC,1,EA,3.29,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2.99719,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
levothyroxine 112 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003901,NDC,0.892857143,EA,3.4,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2.9988,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Capillary Blood Collection,PX36416,CDM,300,RC,36416,CPT,,,,,,,,60,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,3,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.64,4.88
"BANDAGE STERILE 3"" TETRA-FLEX CLIP FREE 0151-3SV",27200000,CDM,272,RC,A6449,HCPCS,,10661-MAIN,LOCAL,,,,,5.93,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.00058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DERMAL TIP HYFRECATOR SHARP ANGLED STAINLESS STEEL BLADE STERILE DISPOSABLE,27200000,CDM,272,RC,,,,12459-MAIN,LOCAL,,,,,7,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.003,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSTRUMENT POUCH INVISISHIELD LONG,27200000,CDM,272,RC,,,,12394-MAIN,LOCAL,,,,,7,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.003,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
OSTOMY KIT 2 PIECE SURGICAL POST-OP,27200000,CDM,272,RC,,,,12070-MAIN,LOCAL,,,,,7,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.003,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE PDS 3-0 27INCH ABSORBABLE VIOLET Z316H,27200000,CDM,272,RC,,,,12871-MAIN,LOCAL,,,,,7,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.003,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE PROLENE TAPERPOINT CT-1 36MM 0 BLUE,27200000,CDM,272,RC,,,,12322-MAIN,LOCAL,,,,,7,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.003,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ALPRAZolam 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585861,NDC,1,EA,3.41,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.00762,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine HCl 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714008110,NDC,1,EA,3.41,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.00762,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50111091501,NDC,1,EA,3.41,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.00762,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol tartrate 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079080120,NDC,1,EA,3.07,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.0086,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 150 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084071311,NDC,0.25,EA,6.14,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.0086,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 150 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084071311,NDC,0.25,EA,6.14,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.0086,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 150 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084071311,NDC,0.25,EA,6.14,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.0086,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Glucose Blood Test,PX82962,CDM,300,RC,82962,CPT,,,,,,,,20,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,3.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.01,19.6
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052331,NDC,2,ML,125.89,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,3.01,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.01,3.94
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052341,NDC,2,ML,125.89,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,3.01,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.01,3.94
isosorbide dinitrate 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084008311,NDC,1,EA,7.25,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.01165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084008301,NDC,1,EA,7.25,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.01165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluvoxaMINE 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,60505016601,NDC,0.25,EA,3.55,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.0175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Tocilizumab 400 MG/20ML Solution 20 mL Vial,J3262.01,CDM,636,RC,J3262,HCPCS,,,,50242013701,NDC,20,ML,4703.83,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,3.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.02,6.12
BANDAGE ESMARK 4X9 LATEX FREE DYNJ05916,27200000,CDM,272,RC,,,,5428-MAIN,LOCAL,,,,,7.05,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.02445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
potassium chloride CR 10 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,66758017006,NDC,1,EA,3.32,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.02452,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,245531701,NDC,1,EA,3.32,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.02452,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,66758017013,NDC,1,EA,3.32,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.02452,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carBAMazepine 100 MG Tablet Chewable 100 Each Box,63700001,CDM,250,RC,,,,,,904385461,NDC,1,EA,3.43,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.02526,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxepin 10 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079043620,NDC,1,EA,3.43,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.02526,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 112 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003901,NDC,0.892857143,EA,3.4,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.026,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69097084607,NDC,0.5,EA,3.11,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.026963,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Urinalysis, Auto, W/Scope",PX81001,CDM,300,RC,81001,CPT,,,,,,,,255,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,3.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.03,3.209
"Urinalysis, Auto, W/Scope",PX81001,CDM,300,RC,81001,CPT,,,,,,,,255,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,3.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.03,3.209
levothyroxine 88 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378180701,NDC,2,EA,5.99,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.03094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084065911,NDC,1,EA,5.99,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.03094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084065901,NDC,1,EA,5.99,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.03094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nabumetone 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687037401,NDC,1,EA,6.32,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.0336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nabumetone 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687037401,NDC,1,EA,6.32,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.0336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 50 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904632361,NDC,0.5,EA,3.33,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.03363,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,42858000110,NDC,1,EA,3.33,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.03363,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,245531789,NDC,1,EA,3.33,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.03363,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen-codeine 300-30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739000410,NDC,1,EA,3.44,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.03408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
penicillin v potassium 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714023501,NDC,0.5,EA,3.44,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.03408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenytoin ER 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084037611,NDC,1,EA,3.44,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.03408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 400-80 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237023201,NDC,1,EA,3.57,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.0345,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585861,NDC,1,EA,3.41,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.0349,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine HCl 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714008110,NDC,1,EA,3.41,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.0349,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50111091501,NDC,1,EA,3.41,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.0349,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862007701,NDC,0.2,EA,6,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.036,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,72205000530,NDC,0.125,EA,6,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.036,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
enalapril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714044201,NDC,1,EA,6.33,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.0384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
enalapril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714044201,NDC,1,EA,6.33,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.0384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 150 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084071311,NDC,0.25,EA,6.14,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.0393,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prothrombin complex concentrate - human 500 units Kit 500 Units Box,J7168.01,CDM,636,RC,J7168,HCPCS,,,,63833038602,NDC,1500,UN,8007,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,3.04,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.31,4.272
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687064011,NDC,1,EA,3.34,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.04274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687064001,NDC,1,EA,3.34,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.04274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,591024001,NDC,1,EA,3.45,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.0429,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 650 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802073030,NDC,1,EA,3.58,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.043,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
silver nitrate - pot nitrate 75-25 % Misc 100 Each Package,63700001,CDM,250,RC,,,,,,12870000102,NDC,1,EA,3.58,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.043,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 120 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802073230,NDC,1,EA,3.13,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.046429,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69097084607,NDC,0.5,EA,3.11,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.0478,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Microscopic Exam of Urine,PX81015,CDM,300,RC,81015,CPT,,,,,,,,29,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,3.05,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.8881,3.05
carBAMazepine 100 MG Tablet Chewable 100 Each Box,63700001,CDM,250,RC,,,,,,904385461,NDC,1,EA,3.43,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.0527,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxepin 10 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079043620,NDC,1,EA,3.43,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.0527,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE-acetaminophen 5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406051262,NDC,1,EA,7.35,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.05319,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092821,NDC,1,ML,32.23,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,3.05615,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.77,3.59
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092825,NDC,1,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,3.05615,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.77,3.59
oxyCODONE-acetaminophen 5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406051223,NDC,1,EA,7.36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.057344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lovastatin 20 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,93057606,NDC,0.5,EA,6.37,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.0576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lovastatin 20 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,93057606,NDC,0.5,EA,6.37,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.0576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 4 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,56016875,NDC,0.25,EA,3.6,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxepin 10 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,51672421701,NDC,1,EA,3.36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.06096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084008211,NDC,0.5,EA,3.36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.06096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268075411,NDC,1,EA,3.36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.06096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 5 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268075415,NDC,1,EA,3.36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.06096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen-codeine 300-30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739000410,NDC,1,EA,3.44,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.0616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
penicillin v potassium 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714023501,NDC,0.5,EA,3.44,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.0616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenytoin ER 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084037611,NDC,1,EA,3.44,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.0616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54829925,NDC,1,EA,3.15,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.065895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nortriptyline 25 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,93081101,NDC,0.4,EA,3.15,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.065895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 120 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802073230,NDC,1,EA,3.13,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.0674,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,603420921,NDC,1,EA,3.48,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.06936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68180051201,NDC,1,EA,3.48,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.06936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Urinalysis, Auto, W/Scope",PX81001,CDM,300,RC,81001,CPT,,,,,,,,255,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,3.07,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.03,3.209
LORazepam 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,591024001,NDC,1,EA,3.45,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.0705,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 75 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079044120,NDC,2,EA,6.4,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 75 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079044120,NDC,2,EA,6.4,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 250 MG Tablet Chewable 100 Each Bottle,63700001,CDM,250,RC,,,,,,93226801,NDC,1,EA,3.62,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.077,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
repaglinide 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,574024001,NDC,1,EA,3.62,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.077,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,50268053111,NDC,1,EA,7.19,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.08451,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 120 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,713011806,NDC,1,EA,3.17,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.085361,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 120 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713011812,NDC,1,EA,3.17,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.085361,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687016311,NDC,0.5,EA,3.63,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.0855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687016301,NDC,0.5,EA,3.63,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.0855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simvastatin 10 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16714068202,NDC,0.5,EA,7.43,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.086422,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54829925,NDC,1,EA,3.15,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.087,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nortriptyline 25 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,93081101,NDC,0.4,EA,3.15,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.087,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzonatate 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904715361,NDC,1,EA,3.18,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.095094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
olmesartan 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862074330,NDC,0.125,EA,6.45,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
olmesartan 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862074330,NDC,0.125,EA,6.45,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nabumetone 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687037401,NDC,1,EA,6.32,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.0968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nabumetone 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687037401,NDC,1,EA,6.32,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.0968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nabumetone 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687037401,NDC,1,EA,6.32,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.0968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,603420921,NDC,1,EA,3.48,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.0972,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68180051201,NDC,1,EA,3.48,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.0972,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 112 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003901,NDC,0.892857143,EA,3.4,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.0974,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
enalapril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714044201,NDC,1,EA,6.33,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.1017,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
enalapril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714044201,NDC,1,EA,6.33,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.1017,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
enalapril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714044201,NDC,1,EA,6.33,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.1017,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,245531989,NDC,1,EA,3.65,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.1025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,66758019006,NDC,1,EA,3.65,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.1025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,245531901,NDC,1,EA,3.65,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.1025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,66758019013,NDC,1,EA,3.65,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.1025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
XEROFORM GAUZE PETROLATUM 1X8INCH,27200000,CDM,272,RC,A6222,HCPCS,,10659-MAIN,LOCAL,,,,,3.52,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.10464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
prochlorperazine 5 MG Tablet 100 Each Bottle,63600000,CDM,636,RC,Q0164,HCPCS,,,,59746011306,NDC,1,EA,3.19,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.104827,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
levothyroxine 112 MCG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,74929690,NDC,0.892857143,EA,6.47,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.1056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 112 MCG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,74929690,NDC,0.892857143,EA,6.47,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.1056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585861,NDC,1,EA,3.41,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.10651,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine HCl 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714008110,NDC,1,EA,3.41,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.10651,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50111091501,NDC,1,EA,3.41,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.10651,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 120 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,713011806,NDC,1,EA,3.17,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.1066,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 120 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713011812,NDC,1,EA,3.17,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.1066,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 150 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084071311,NDC,0.25,EA,6.14,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.10684,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084008311,NDC,1,EA,7.25,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.11025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084008301,NDC,1,EA,7.25,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.11025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084004511,NDC,0.5,EA,7.49,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.111346,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084004501,NDC,0.5,EA,7.49,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.111346,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzonatate 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904715361,NDC,1,EA,3.18,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.1164,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcitRIOL 0.25 MCG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155011801,NDC,1,EA,6.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcitRIOL 0.25 MCG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155011801,NDC,1,EA,6.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lovastatin 20 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,93057606,NDC,0.5,EA,6.37,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.1213,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lovastatin 20 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,93057606,NDC,0.5,EA,6.37,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.1213,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lovastatin 20 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,93057606,NDC,0.5,EA,6.37,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.1213,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carBAMazepine 100 MG Tablet Chewable 100 Each Box,63700001,CDM,250,RC,,,,,,904385461,NDC,1,EA,3.43,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.12473,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxepin 10 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079043620,NDC,1,EA,3.43,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.12473,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cetirizine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585261,NDC,0.5,EA,6.51,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.1248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cetirizine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585261,NDC,0.5,EA,6.51,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.1248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prochlorperazine 5 MG Tablet 100 Each Bottle,63600000,CDM,636,RC,Q0164,HCPCS,,,,59746011306,NDC,1,EA,3.19,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.1262,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
nabumetone 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687037401,NDC,1,EA,6.32,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.1284,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
midodrine 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,42291056190,NDC,0.5,EA,6.52,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.1296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
midodrine 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,42291056190,NDC,0.5,EA,6.52,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.1296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluvoxaMINE 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,60505016601,NDC,0.25,EA,3.55,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.1311,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
XEROFORM GAUZE PETROLATUM 1X8INCH,27200000,CDM,272,RC,A6222,HCPCS,,10659-MAIN,LOCAL,,,,,3.52,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.1328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
enalapril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714044201,NDC,1,EA,6.33,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.13335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen-codeine 300-30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739000410,NDC,1,EA,3.44,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.13384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
penicillin v potassium 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714023501,NDC,0.5,EA,3.44,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.13384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenytoin ER 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084037611,NDC,1,EA,3.44,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.13384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine pamoate 25 MG capsule 1 Each Blister,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084711,NDC,1,EA,3.22,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.134026,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,3.1556
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084701,NDC,1,EA,3.22,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.134026,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,3.1556
losartan 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739067310,NDC,1,EA,3.22,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.134026,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 75 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079044120,NDC,2,EA,6.4,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 75 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079044120,NDC,2,EA,6.4,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 75 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079044120,NDC,2,EA,6.4,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DRESSING MESALT 6X6 IMPREGNATED GAUZE STERILE 285780,120.511,CDM,272,RC,A6223,HCPCS,,12059-SURG,LOCAL,,,,,5,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,3.14,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.14,3.31
Tocilizumab 400 MG/20ML Solution 20 mL Vial,J3262.01,CDM,636,RC,J3262,HCPCS,,,,50242013701,NDC,20,ML,4703.83,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,3.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.14,4609.7534
LORazepam 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,591024001,NDC,1,EA,3.45,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.14295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 400-80 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237023201,NDC,1,EA,3.57,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.14874,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,50268015211,NDC,1,EA,6.56,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.1488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,50268015211,NDC,1,EA,6.56,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.1488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 50 Each Box,63700001,CDM,250,RC,,,,,,50268015215,NDC,1,EA,6.56,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.1488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 50 Each Box,63700001,CDM,250,RC,,,,,,50268015215,NDC,1,EA,6.56,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.1488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE-acetaminophen 5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406051262,NDC,1,EA,7.35,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.15315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lovastatin 20 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,93057606,NDC,0.5,EA,6.37,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.15315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
chlorthalidone 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378022201,NDC,0.5,EA,3.24,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.153492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine pamoate 25 MG capsule 1 Each Blister,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084711,NDC,1,EA,3.22,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.1556,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,3.1556
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084701,NDC,1,EA,3.22,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.1556,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,3.1556
losartan 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739067310,NDC,1,EA,3.22,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.1556,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 100 MCG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,74662490,NDC,1,EA,7.6,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.15704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE-acetaminophen 5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406051223,NDC,1,EA,7.36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.15744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 650 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802073030,NDC,1,EA,3.58,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.15756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
silver nitrate - pot nitrate 75-25 % Misc 100 Each Package,63700001,CDM,250,RC,,,,,,12870000102,NDC,1,EA,3.58,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.15756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluvoxaMINE 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,60505016601,NDC,0.25,EA,3.55,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.1595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424601,NDC,15,ML,95.76,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,3.16,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.16,3.78
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424681,NDC,15,ML,95.76,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,3.16,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.16,3.78
CARBOplatin 600 MG/60ML Solution 60 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703423981,NDC,60,ML,301.42,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,3.16,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.16,3.78
olmesartan 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862074330,NDC,0.125,EA,6.45,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.1605,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
olmesartan 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862074330,NDC,0.125,EA,6.45,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.1605,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
olmesartan 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862074330,NDC,0.125,EA,6.45,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.1605,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904563161,NDC,1,EA,3.72,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 5-325 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406012301,NDC,1,EA,3.72,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"SUTURE ETHILON 2-0 BLK MONO FS 18"" 664G",27200000,CDM,272,RC,,,,3663-MAIN,LOCAL,,,,,6.59,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.1632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"SUTURE ETHILON 2-0 BLK MONO FS 18"" 664G",27200000,CDM,272,RC,,,,3663-MAIN,LOCAL,,,,,6.59,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.1632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
divalproex 125 MG Capsule Delayed Release Sprinkle 100 Each Box,63700001,CDM,250,RC,,,,,,68084031301,NDC,1,EA,7.62,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.165348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 75 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079044120,NDC,2,EA,6.4,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 125 MG Capsule Delayed Release Sprinkle 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031311,NDC,1,EA,7.63,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.169502,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Urinalysis, Auto, W/Scope",PX81001,CDM,300,RC,81001,CPT,,,,,,,,255,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,3.17,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.03,3.209
lisinopril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,603420921,NDC,1,EA,3.48,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.17028,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68180051201,NDC,1,EA,3.48,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.17028,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 112 MCG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,74929690,NDC,0.892857143,EA,6.47,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.1703,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 112 MCG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,74929690,NDC,0.892857143,EA,6.47,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.1703,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 112 MCG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,74929690,NDC,0.892857143,EA,6.47,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.1703,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,781106101,NDC,1,EA,3.73,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.1705,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,67253090010,NDC,1,EA,3.73,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.1705,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
digoxin 125 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,115981101,NDC,1,EA,7.64,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.173656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
chlorthalidone 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378022201,NDC,0.5,EA,3.24,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.1752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 4 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,56016875,NDC,0.25,EA,3.6,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.1752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 400-80 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237023201,NDC,1,EA,3.57,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.1773,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Glucose Blood Test,PX82962,CDM,300,RC,82962,CPT,,,,,,,,20,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,3.18,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.18,3.28
Glucose Blood Test,PX82962,CDM,300,RC,82962,CPT,,,,,,,,20,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,3.18,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.18,3.28
Glucose Blood Test,PX82962,CDM,300,RC,82962,CPT,,,,,,,,20,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,3.18,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.18,3.28
calcitRIOL 0.25 MCG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155011801,NDC,1,EA,6.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.185,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcitRIOL 0.25 MCG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155011801,NDC,1,EA,6.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.185,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcitRIOL 0.25 MCG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155011801,NDC,1,EA,6.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.185,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,603459315,NDC,1,EA,7.67,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.186118,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
acetaminophen 650 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802073030,NDC,1,EA,3.58,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.1862,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
silver nitrate - pot nitrate 75-25 % Misc 100 Each Package,63700001,CDM,250,RC,,,,,,12870000102,NDC,1,EA,3.58,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.1862,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simvastatin 10 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16714068202,NDC,0.5,EA,7.43,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.18747,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cetirizine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585261,NDC,0.5,EA,6.51,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.1899,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cetirizine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585261,NDC,0.5,EA,6.51,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.1899,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cetirizine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585261,NDC,0.5,EA,6.51,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.1899,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,781502207,NDC,1,EA,7.68,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.190272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
mirtazapine 15 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904651961,NDC,0.5,EA,7.68,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.190272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904632261,NDC,1,EA,6.65,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904632261,NDC,1,EA,6.65,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nabumetone 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50228046501,NDC,1,EA,6.65,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nabumetone 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50228046501,NDC,1,EA,6.65,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prochlorperazine 5 MG Tablet 1 Each Blister,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054101,NDC,1,EA,3.28,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.192424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
olmesartan 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862074330,NDC,0.125,EA,6.45,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.19275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 250 MG Tablet Chewable 100 Each Bottle,63700001,CDM,250,RC,,,,,,93226801,NDC,1,EA,3.62,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.19284,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
repaglinide 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,574024001,NDC,1,EA,3.62,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.19284,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
theophylline SR (12 hour) 300 MG Tablet Extended Release 12 Hour 100 Each Bottle,25000000,CDM,250,RC,,,,,,68462072101,NDC,0.333333333,EA,7.69,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.194426,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
midodrine 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,42291056190,NDC,0.5,EA,6.52,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.1948,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
midodrine 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,42291056190,NDC,0.5,EA,6.52,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.1948,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
midodrine 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,42291056190,NDC,0.5,EA,6.52,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.1948,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenoxylate-atropine 2.5-0.025 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762106101,NDC,1,EA,3.76,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenoxylate-atropine 2.5-0.025 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,62559049001,NDC,1,EA,3.76,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nabumetone 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687037401,NDC,1,EA,6.32,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.19792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687016311,NDC,0.5,EA,3.63,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.20166,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687016301,NDC,0.5,EA,3.63,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.20166,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prochlorperazine 5 MG Tablet 100 Each Box,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054120,NDC,1,EA,3.29,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.202157,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
levothyroxine 112 MCG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,74929690,NDC,0.892857143,EA,6.47,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.20265,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,50458059160,NDC,1,EA,7.71,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.202734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
enalapril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714044201,NDC,1,EA,6.33,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.20298,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 4 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,56016875,NDC,0.25,EA,3.6,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
XEROFORM GAUZE PETROLATUM 1X8INCH,27200000,CDM,272,RC,A6222,HCPCS,,10659-MAIN,LOCAL,,,,,3.52,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.20672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Glucose Blood Test,PX82962,CDM,300,RC,82962,CPT,,,,,,,,20,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,3.209,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.18,3.28
"Urinalysis, Auto, W/Scope",PX81001,CDM,300,RC,81001,CPT,,,,,,,,255,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,3.209,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.03,3.209
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,45963061959,NDC,1,EA,638.4,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,3.21,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.21,3.83
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323012594,NDC,1,EA,190.99,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,3.21,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.21,3.83
gemcitabine 1 GM/26.3ML Solution 26.3 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018101,NDC,26.3,ML,203.58,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,3.21,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.21,3.83
gemcitabine 200 MG Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323010294,NDC,1,EA,39,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,3.21,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.21,3.83
gemcitabine 200 MG/5.26ML Solution 5.26 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018301,NDC,5.26,ML,40.74,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,3.21,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.21,3.83
levothyroxine 100 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904695361,NDC,1,EA,3.78,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.213,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084004511,NDC,0.5,EA,7.49,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.21321,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084004501,NDC,0.5,EA,7.49,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.21321,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,50268015211,NDC,1,EA,6.56,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.2144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,50268015211,NDC,1,EA,6.56,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.2144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,50268015211,NDC,1,EA,6.56,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.2144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 50 Each Box,63700001,CDM,250,RC,,,,,,50268015215,NDC,1,EA,6.56,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.2144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 50 Each Box,63700001,CDM,250,RC,,,,,,50268015215,NDC,1,EA,6.56,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.2144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 50 Each Box,63700001,CDM,250,RC,,,,,,50268015215,NDC,1,EA,6.56,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.2144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prochlorperazine 5 MG Tablet 1 Each Blister,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054101,NDC,1,EA,3.28,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.2144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
"BANDAGE STERILE 4"" TETRA-FLEX CLIP FREE  0151-4SV",27200000,CDM,272,RC,A6449,HCPCS,,10662-MAIN,LOCAL,,,,,6.7,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"BANDAGE STERILE 4"" TETRA-FLEX CLIP FREE  0151-4SV",27200000,CDM,272,RC,A6449,HCPCS,,10662-MAIN,LOCAL,,,,,6.7,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
pravastatin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904589261,NDC,0.5,EA,6.7,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pravastatin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904589261,NDC,0.5,EA,6.7,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CISplatin 50 MG/50ML Solution 50 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010351,NDC,50,ML,82.27,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,3.217,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.217,4.24
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,703574811,NDC,100,ML,183.92,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,3.217,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.217,4.24
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010365,NDC,100,ML,164.54,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,3.217,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.217,4.24
DRESSING MESALT 6X6 IMPREGNATED GAUZE STERILE 285780,120.511,CDM,272,RC,A6223,HCPCS,,12059-SURG,LOCAL,,,,,5,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,3.217,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.14,3.31
calcitRIOL 0.25 MCG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155011801,NDC,1,EA,6.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.2175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,245531989,NDC,1,EA,3.65,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.2193,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,66758019006,NDC,1,EA,3.65,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.2193,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,245531901,NDC,1,EA,3.65,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.2193,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,66758019013,NDC,1,EA,3.65,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.2193,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 250 MG Tablet Chewable 100 Each Bottle,63700001,CDM,250,RC,,,,,,93226801,NDC,1,EA,3.62,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.2218,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
repaglinide 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,574024001,NDC,1,EA,3.62,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.2218,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cetirizine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585261,NDC,0.5,EA,6.51,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.22245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lovastatin 20 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,93057606,NDC,0.5,EA,6.37,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.22322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prochlorperazine 5 MG Tablet 100 Each Box,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054120,NDC,1,EA,3.29,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.2242,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
midodrine 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,42291056190,NDC,0.5,EA,6.52,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.2274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"SUTURE ETHILON 2-0 BLK MONO FS 18"" 664G",27200000,CDM,272,RC,,,,3663-MAIN,LOCAL,,,,,6.59,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.2291,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"SUTURE ETHILON 2-0 BLK MONO FS 18"" 664G",27200000,CDM,272,RC,,,,3663-MAIN,LOCAL,,,,,6.59,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.2291,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"SUTURE ETHILON 2-0 BLK MONO FS 18"" 664G",27200000,CDM,272,RC,,,,3663-MAIN,LOCAL,,,,,6.59,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.2291,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
acetaminophen 650 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713016512,NDC,1,EA,3.8,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 850 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687014311,NDC,0.588235294,EA,3.8,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 850 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687014301,NDC,0.588235294,EA,3.8,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dicloxacillin 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,93312501,NDC,0.5,EA,6.73,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.2304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dicloxacillin 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,93312501,NDC,0.5,EA,6.73,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.2304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687016311,NDC,0.5,EA,3.63,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.2307,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687016301,NDC,0.5,EA,3.63,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.2307,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,66758017006,NDC,1,EA,3.32,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.231356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,245531701,NDC,1,EA,3.32,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.231356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,66758017013,NDC,1,EA,3.32,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.231356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluvoxaMINE 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,60505016601,NDC,0.25,EA,3.55,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.23405,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 75 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079044120,NDC,2,EA,6.4,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.2384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sucralfate 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762040101,NDC,1,EA,3.81,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.2385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 50 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904632361,NDC,0.5,EA,3.33,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.241089,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,42858000110,NDC,1,EA,3.33,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.241089,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,245531789,NDC,1,EA,3.33,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.241089,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,50268015211,NDC,1,EA,6.56,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.2472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 50 Each Box,63700001,CDM,250,RC,,,,,,50268015215,NDC,1,EA,6.56,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.2472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,245531989,NDC,1,EA,3.65,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.2485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,66758019006,NDC,1,EA,3.65,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.2485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,245531901,NDC,1,EA,3.65,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.2485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,66758019013,NDC,1,EA,3.65,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.2485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687064011,NDC,1,EA,3.34,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.250822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687064001,NDC,1,EA,3.34,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.250822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 400-80 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237023201,NDC,1,EA,3.57,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.25227,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin 300 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574703412,NDC,1,EA,7.83,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.252582,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084044011,NDC,0.5,EA,7.83,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.252582,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084044001,NDC,0.5,EA,7.83,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.252582,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,66758017006,NDC,1,EA,3.32,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.2536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,245531701,NDC,1,EA,3.32,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.2536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,66758017013,NDC,1,EA,3.32,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.2536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904539261,NDC,1,EA,3.83,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.2555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687015211,NDC,1,EA,3.83,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.2555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687015201,NDC,1,EA,3.83,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.2555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084042311,NDC,1,EA,3.83,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.2555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prenatal plus vitamin with folic acid 1 mg 27-1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69367026701,NDC,1,EA,3.83,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.2555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904632261,NDC,1,EA,6.65,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.2585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904632261,NDC,1,EA,6.65,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.2585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904632261,NDC,1,EA,6.65,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.2585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nabumetone 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50228046501,NDC,1,EA,6.65,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.2585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nabumetone 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50228046501,NDC,1,EA,6.65,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.2585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nabumetone 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50228046501,NDC,1,EA,6.65,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.2585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 100 MCG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,74662490,NDC,1,EA,7.6,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.2604,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,63739035810,NDC,0.5,EA,7.85,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.26089,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 650 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802073030,NDC,1,EA,3.58,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.26138,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
silver nitrate - pot nitrate 75-25 % Misc 100 Each Package,63700001,CDM,250,RC,,,,,,12870000102,NDC,1,EA,3.58,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.26138,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"SUTURE ETHILON 2-0 BLK MONO FS 18"" 664G",27200000,CDM,272,RC,,,,3663-MAIN,LOCAL,,,,,6.59,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.26205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
metoprolol succinate 50 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904632361,NDC,0.5,EA,3.33,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.2634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,42858000110,NDC,1,EA,3.33,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.2634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 10 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,245531789,NDC,1,EA,3.33,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.2634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
olmesartan 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862074330,NDC,0.125,EA,6.45,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.2637,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 125 MG Capsule Delayed Release Sprinkle 100 Each Box,63700001,CDM,250,RC,,,,,,68084031301,NDC,1,EA,7.62,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.26898,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CISplatin 50 MG/50ML Solution 50 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010351,NDC,50,ML,82.27,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,3.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.217,4.24
CISplatin 50 MG/50ML Solution 50 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010351,NDC,50,ML,82.27,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,3.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.217,4.24
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,703574811,NDC,100,ML,183.92,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,3.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.217,4.24
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,703574811,NDC,100,ML,183.92,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,3.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.217,4.24
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010365,NDC,100,ML,164.54,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,3.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.217,4.24
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010365,NDC,100,ML,164.54,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,3.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.217,4.24
doxepin 10 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,51672421701,NDC,1,EA,3.36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.270288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084008211,NDC,0.5,EA,3.36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.270288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268075411,NDC,1,EA,3.36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.270288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 5 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268075415,NDC,1,EA,3.36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.270288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687064011,NDC,1,EA,3.34,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.2732,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687064001,NDC,1,EA,3.34,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.2732,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 125 MG Capsule Delayed Release Sprinkle 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031311,NDC,1,EA,7.63,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.27327,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 150 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862069730,NDC,0.25,EA,6.82,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.2736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 150 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862069730,NDC,0.25,EA,6.82,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.2736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 112 MCG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,74929690,NDC,0.892857143,EA,6.47,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.27382,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
digoxin 125 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,115981101,NDC,1,EA,7.64,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.27756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 4 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,56016875,NDC,0.25,EA,3.6,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.2796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay Ph Body Fluids Nos,PX83986,CDM,300,RC,83986,CPT,,,,,,,,147,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,3.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.28,144.06
Glucose Blood Test,PX82962,CDM,300,RC,82962,CPT,,,,,,,,20,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,3.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.18,3.28
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,69452015120,NDC,1,EA,3.86,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.281,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904563161,NDC,1,EA,3.72,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.28104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 5-325 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406012301,NDC,1,EA,3.72,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.28104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"BANDAGE STERILE 4"" TETRA-FLEX CLIP FREE  0151-4SV",27200000,CDM,272,RC,A6449,HCPCS,,10662-MAIN,LOCAL,,,,,6.7,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.283,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"BANDAGE STERILE 4"" TETRA-FLEX CLIP FREE  0151-4SV",27200000,CDM,272,RC,A6449,HCPCS,,10662-MAIN,LOCAL,,,,,6.7,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.283,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"BANDAGE STERILE 4"" TETRA-FLEX CLIP FREE  0151-4SV",27200000,CDM,272,RC,A6449,HCPCS,,10662-MAIN,LOCAL,,,,,6.7,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.283,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
pravastatin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904589261,NDC,0.5,EA,6.7,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.283,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pravastatin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904589261,NDC,0.5,EA,6.7,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.283,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pravastatin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904589261,NDC,0.5,EA,6.7,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.283,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcitRIOL 0.25 MCG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155011801,NDC,1,EA,6.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.289,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,781106101,NDC,1,EA,3.73,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.28986,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,67253090010,NDC,1,EA,3.73,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.28986,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,42291053590,NDC,0.5,EA,7.92,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.289968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,603459315,NDC,1,EA,7.67,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.29043,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904632261,NDC,1,EA,6.65,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.29175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nabumetone 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50228046501,NDC,1,EA,6.65,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.29175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxepin 10 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,51672421701,NDC,1,EA,3.36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.2928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084008211,NDC,0.5,EA,3.36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.2928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268075411,NDC,1,EA,3.36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.2928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 5 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268075415,NDC,1,EA,3.36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.2928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cetirizine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585261,NDC,0.5,EA,6.51,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.29406,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,781502207,NDC,1,EA,7.68,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.29472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
mirtazapine 15 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904651961,NDC,0.5,EA,7.68,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.29472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline monohydrate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687071611,NDC,1,EA,6.87,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.2976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline monohydrate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687071611,NDC,1,EA,6.87,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.2976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dicloxacillin 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,93312501,NDC,0.5,EA,6.73,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.2977,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dicloxacillin 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,93312501,NDC,0.5,EA,6.73,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.2977,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dicloxacillin 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,93312501,NDC,0.5,EA,6.73,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.2977,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 250 MG Tablet Chewable 100 Each Bottle,63700001,CDM,250,RC,,,,,,93226801,NDC,1,EA,3.62,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.29782,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
repaglinide 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,574024001,NDC,1,EA,3.62,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.29782,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
theophylline SR (12 hour) 300 MG Tablet Extended Release 12 Hour 100 Each Bottle,25000000,CDM,250,RC,,,,,,68462072101,NDC,0.333333333,EA,7.69,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.29901,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
midodrine 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,42291056190,NDC,0.5,EA,6.52,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.29912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
linezolid 600 MG/300ML Solution 300 mL Flex Cont,J2020.01,CDM,636,RC,J2020,HCPCS,,,,9514001,NDC,300,ML,332.42,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,3.3,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.9,3.62
metFORMIN 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904632661,NDC,1,EA,3.89,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.3065,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687016311,NDC,0.5,EA,3.63,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.30693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687016301,NDC,0.5,EA,3.63,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.30693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,50458059160,NDC,1,EA,7.71,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.30759,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 112 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003901,NDC,0.892857143,EA,3.4,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.30922,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DRESSING MESALT 6X6 IMPREGNATED GAUZE STERILE 285780,120.511,CDM,272,RC,A6223,HCPCS,,12059-SURG,LOCAL,,,,,5,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,3.31,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.14,3.31
DRESSING MESALT 6X6 IMPREGNATED GAUZE STERILE 285780,120.511,CDM,272,RC,A6223,HCPCS,,12059-SURG,LOCAL,,,,,5,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,3.31,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.14,3.31
DRESSING MESALT 6X6 IMPREGNATED GAUZE STERILE 285780,120.511,CDM,272,RC,A6223,HCPCS,,12059-SURG,LOCAL,,,,,5,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,3.31,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.14,3.31
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904563161,NDC,1,EA,3.72,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.3108,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 5-325 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406012301,NDC,1,EA,3.72,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.3108,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenoxylate-atropine 2.5-0.025 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762106101,NDC,1,EA,3.76,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.31632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenoxylate-atropine 2.5-0.025 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,62559049001,NDC,1,EA,3.76,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.31632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"BANDAGE STERILE 4"" TETRA-FLEX CLIP FREE  0151-4SV",27200000,CDM,272,RC,A6449,HCPCS,,10662-MAIN,LOCAL,,,,,6.7,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.3165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
pravastatin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904589261,NDC,0.5,EA,6.7,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.3165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585861,NDC,1,EA,3.41,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.318953,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine HCl 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714008110,NDC,1,EA,3.41,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.318953,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50111091501,NDC,1,EA,3.41,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.318953,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,50268015211,NDC,1,EA,6.56,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.31936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 50 Each Box,63700001,CDM,250,RC,,,,,,50268015215,NDC,1,EA,6.56,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.31936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,781106101,NDC,1,EA,3.73,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.3197,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,67253090010,NDC,1,EA,3.73,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.3197,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzonatate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687034611,NDC,1,EA,3.91,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.3235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714031401,NDC,0.333333333,EA,3.91,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.3235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714065801,NDC,0.333333333,EA,3.91,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.3235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57664039588,NDC,0.333333333,EA,3.91,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.3235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,245531989,NDC,1,EA,3.65,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.32515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,66758019006,NDC,1,EA,3.65,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.32515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,245531901,NDC,1,EA,3.65,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.32515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,66758019013,NDC,1,EA,3.65,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.32515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dicloxacillin 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,93312501,NDC,0.5,EA,6.73,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.33135,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 112 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003901,NDC,0.892857143,EA,3.4,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.332,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methyldopa 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93293101,NDC,1,EA,3.92,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.332,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 100 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904695361,NDC,1,EA,3.78,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.33396,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"SUTURE ETHILON 2-0 BLK MONO FS 18"" 664G",27200000,CDM,272,RC,,,,3663-MAIN,LOCAL,,,,,6.59,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.33454,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
carBAMazepine 100 MG Tablet Chewable 100 Each Box,63700001,CDM,250,RC,,,,,,904385461,NDC,1,EA,3.43,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.338419,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxepin 10 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079043620,NDC,1,EA,3.43,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.338419,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739028310,NDC,1,EA,8.04,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.339816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tiZANidine 4 MG Tablet 150 Each Bottle,63700001,CDM,250,RC,,,,,,55111018015,NDC,0.5,EA,3.93,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.3405,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585861,NDC,1,EA,3.41,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.3418,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine HCl 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714008110,NDC,1,EA,3.41,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.3418,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
torsemide 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50111091501,NDC,1,EA,3.41,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.3418,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 150 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862069730,NDC,0.25,EA,6.82,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.3418,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 150 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862069730,NDC,0.25,EA,6.82,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.3418,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 150 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862069730,NDC,0.25,EA,6.82,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.3418,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin 300 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084024411,NDC,1,EA,6.97,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.3456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin 300 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084024411,NDC,1,EA,6.97,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.3456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,68084024401,NDC,1,EA,6.97,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.3456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,68084024401,NDC,1,EA,6.97,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.3456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenoxylate-atropine 2.5-0.025 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762106101,NDC,1,EA,3.76,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.3464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenoxylate-atropine 2.5-0.025 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,62559049001,NDC,1,EA,3.76,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.3464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 4 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,43547034406,NDC,0.125,EA,8.06,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.348124,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen-codeine 300-30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739000410,NDC,1,EA,3.44,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.348152,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
penicillin v potassium 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714023501,NDC,0.5,EA,3.44,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.348152,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenytoin ER 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084037611,NDC,1,EA,3.44,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.348152,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 75 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079044101,NDC,1.333333333,EA,3.94,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.349,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 1 Each Blister,63700001,CDM,250,RC,,,,,,49884030752,NDC,1,EA,6.98,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.3504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 1 Each Blister,63700001,CDM,250,RC,,,,,,49884030752,NDC,1,EA,6.98,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.3504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Bottle,63700001,CDM,250,RC,,,,,,57664078486,NDC,1,EA,6.98,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.3504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Bottle,63700001,CDM,250,RC,,,,,,57664078486,NDC,1,EA,6.98,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.3504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Box,63700001,CDM,250,RC,,,,,,555009596,NDC,1,EA,6.98,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.3504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Box,63700001,CDM,250,RC,,,,,,555009596,NDC,1,EA,6.98,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.3504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Box,63700001,CDM,250,RC,,,,,,49884030702,NDC,1,EA,6.98,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.3504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Box,63700001,CDM,250,RC,,,,,,49884030702,NDC,1,EA,6.98,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.3504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 650 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713016512,NDC,1,EA,3.8,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.3516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 850 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687014311,NDC,0.588235294,EA,3.8,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.3516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 850 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687014301,NDC,0.588235294,EA,3.8,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.3516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,591024001,NDC,1,EA,3.45,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.357885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin 300 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574703412,NDC,1,EA,7.83,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.35907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084044011,NDC,0.5,EA,7.83,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.35907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084044001,NDC,0.5,EA,7.83,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.35907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DERMAL TIP HYFRECATOR SHARP ANGLED STAINLESS STEEL BLADE STERILE DISPOSABLE,27200000,CDM,272,RC,,,,12459-MAIN,LOCAL,,,,,7,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DERMAL TIP HYFRECATOR SHARP ANGLED STAINLESS STEEL BLADE STERILE DISPOSABLE,27200000,CDM,272,RC,,,,12459-MAIN,LOCAL,,,,,7,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSTRUMENT POUCH INVISISHIELD LONG,27200000,CDM,272,RC,,,,12394-MAIN,LOCAL,,,,,7,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSTRUMENT POUCH INVISISHIELD LONG,27200000,CDM,272,RC,,,,12394-MAIN,LOCAL,,,,,7,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
OSTOMY KIT 2 PIECE SURGICAL POST-OP,27200000,CDM,272,RC,,,,12070-MAIN,LOCAL,,,,,7,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
OSTOMY KIT 2 PIECE SURGICAL POST-OP,27200000,CDM,272,RC,,,,12070-MAIN,LOCAL,,,,,7,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE PDS 3-0 27INCH ABSORBABLE VIOLET Z316H,27200000,CDM,272,RC,,,,12871-MAIN,LOCAL,,,,,7,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE PDS 3-0 27INCH ABSORBABLE VIOLET Z316H,27200000,CDM,272,RC,,,,12871-MAIN,LOCAL,,,,,7,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE PROLENE TAPERPOINT CT-1 36MM 0 BLUE,27200000,CDM,272,RC,,,,12322-MAIN,LOCAL,,,,,7,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE PROLENE TAPERPOINT CT-1 36MM 0 BLUE,27200000,CDM,272,RC,,,,12322-MAIN,LOCAL,,,,,7,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
sucralfate 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762040101,NDC,1,EA,3.81,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.36042,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carBAMazepine 100 MG Tablet Chewable 100 Each Box,63700001,CDM,250,RC,,,,,,904385461,NDC,1,EA,3.43,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.3614,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxepin 10 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079043620,NDC,1,EA,3.43,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.3614,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 100 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904695361,NDC,1,EA,3.78,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.3642,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
OXcarbazepine 150 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084084511,NDC,1,EA,8.1,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.36474,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904632261,NDC,1,EA,6.65,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.3649,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nabumetone 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50228046501,NDC,1,EA,6.65,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.3649,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline monohydrate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687071611,NDC,1,EA,6.87,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.3663,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline monohydrate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687071611,NDC,1,EA,6.87,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.3663,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline monohydrate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687071611,NDC,1,EA,6.87,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.3663,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,63739035810,NDC,0.5,EA,7.85,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.36765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of protein urine,PX84156,CDM,300,RC,84156,CPT,,,,,,,,190,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,3.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.37,186.2
"Protein, Total; Serum, Plasma or Whole Blood",PX84155,CDM,300,RC,84155,CPT,,,,,,,,170,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,3.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.37,166.6
acetaminophen-codeine 300-30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739000410,NDC,1,EA,3.44,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.3712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
penicillin v potassium 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714023501,NDC,0.5,EA,3.44,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.3712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenytoin ER 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084037611,NDC,1,EA,3.44,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.3712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pyRIDostigmine 60 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084049411,NDC,0.5,EA,3.97,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.3745,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 150 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862069730,NDC,0.25,EA,6.82,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.3759,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904539261,NDC,1,EA,3.83,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.37806,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687015211,NDC,1,EA,3.83,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.37806,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687015201,NDC,1,EA,3.83,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.37806,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084042311,NDC,1,EA,3.83,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.37806,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prenatal plus vitamin with folic acid 1 mg 27-1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69367026701,NDC,1,EA,3.83,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.37806,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluorouracil 5 GM/100ML Solution 100 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,16729027638,NDC,100,ML,261.44,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,3.38,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.82,3.38
fluorouracil 500 MG/10ML Solution 10 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,63323011710,NDC,10,ML,39,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,3.38,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.82,3.38
LORazepam 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,591024001,NDC,1,EA,3.45,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.381,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 650 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713016512,NDC,1,EA,3.8,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.382,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 850 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687014311,NDC,0.588235294,EA,3.8,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.382,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 850 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687014301,NDC,0.588235294,EA,3.8,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.382,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pyRIDostigmine 60 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084049401,NDC,0.5,EA,3.98,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.383,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BANDAGE ESMARK 4X9 LATEX FREE DYNJ05916,27200000,CDM,272,RC,,,,5428-MAIN,LOCAL,,,,,7.05,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
BANDAGE ESMARK 4X9 LATEX FREE DYNJ05916,27200000,CDM,272,RC,,,,5428-MAIN,LOCAL,,,,,7.05,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
lisinopril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,603420921,NDC,1,EA,3.48,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.387084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68180051201,NDC,1,EA,3.48,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.387084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904563161,NDC,1,EA,3.72,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.38892,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 5-325 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406012301,NDC,1,EA,3.72,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.38892,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"BANDAGE STERILE 4"" TETRA-FLEX CLIP FREE  0151-4SV",27200000,CDM,272,RC,A6449,HCPCS,,10662-MAIN,LOCAL,,,,,6.7,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.3902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
pravastatin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904589261,NDC,0.5,EA,6.7,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.3902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sucralfate 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762040101,NDC,1,EA,3.81,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.3909,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,42291053590,NDC,0.5,EA,7.92,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.39768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,781106101,NDC,1,EA,3.73,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.39803,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,67253090010,NDC,1,EA,3.73,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.39803,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,185441601,NDC,1,EA,4,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756014201,NDC,1,EA,4,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SUTURE VICRYL TAPER 2-0 J317H,27200000,CDM,272,RC,,,,2615-MAIN,LOCAL,,,,,4,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
doxycycline monohydrate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687071611,NDC,1,EA,6.87,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.40065,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,69452015120,NDC,1,EA,3.86,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.40452,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dicloxacillin 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,93312501,NDC,0.5,EA,6.73,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.40538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,904642286,NDC,1,EA,8.2,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.40628,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904539261,NDC,1,EA,3.83,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.4087,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687015211,NDC,1,EA,3.83,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.4087,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687015201,NDC,1,EA,3.83,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.4087,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084042311,NDC,1,EA,3.83,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.4087,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prenatal plus vitamin with folic acid 1 mg 27-1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69367026701,NDC,1,EA,3.83,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.4087,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,603420921,NDC,1,EA,3.48,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.4104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68180051201,NDC,1,EA,3.48,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.4104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acyclovir 200 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578961,NDC,1,EA,8.21,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.410434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin 300 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084024411,NDC,1,EA,6.97,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.4153,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin 300 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084024411,NDC,1,EA,6.97,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.4153,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin 300 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084024411,NDC,1,EA,6.97,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.4153,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,68084024401,NDC,1,EA,6.97,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.4153,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,68084024401,NDC,1,EA,6.97,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.4153,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,68084024401,NDC,1,EA,6.97,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.4153,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay Ph Body Fluids Nos,PX83986,CDM,300,RC,83986,CPT,,,,,,,,147,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,3.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.42,3.58
Assay Ph Body Fluids Nos,PX83986,CDM,300,RC,83986,CPT,,,,,,,,147,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,3.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.42,3.58
clonazePAM 0.25 MG Tablet Disintegrating 1 Each Blister,63700001,CDM,250,RC,,,,,,49884030752,NDC,1,EA,6.98,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.4202,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 1 Each Blister,63700001,CDM,250,RC,,,,,,49884030752,NDC,1,EA,6.98,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.4202,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 1 Each Blister,63700001,CDM,250,RC,,,,,,49884030752,NDC,1,EA,6.98,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.4202,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Bottle,63700001,CDM,250,RC,,,,,,57664078486,NDC,1,EA,6.98,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.4202,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Bottle,63700001,CDM,250,RC,,,,,,57664078486,NDC,1,EA,6.98,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.4202,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Bottle,63700001,CDM,250,RC,,,,,,57664078486,NDC,1,EA,6.98,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.4202,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Box,63700001,CDM,250,RC,,,,,,555009596,NDC,1,EA,6.98,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.4202,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Box,63700001,CDM,250,RC,,,,,,555009596,NDC,1,EA,6.98,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.4202,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Box,63700001,CDM,250,RC,,,,,,555009596,NDC,1,EA,6.98,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.4202,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Box,63700001,CDM,250,RC,,,,,,49884030702,NDC,1,EA,6.98,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.4202,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Box,63700001,CDM,250,RC,,,,,,49884030702,NDC,1,EA,6.98,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.4202,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Box,63700001,CDM,250,RC,,,,,,49884030702,NDC,1,EA,6.98,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.4202,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenoxylate-atropine 2.5-0.025 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762106101,NDC,1,EA,3.76,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.42536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenoxylate-atropine 2.5-0.025 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,62559049001,NDC,1,EA,3.76,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.42536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
XEROFORM GAUZE PETROLATUM 1X8INCH,27200000,CDM,272,RC,A6222,HCPCS,,10659-MAIN,LOCAL,,,,,3.52,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.426016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DERMAL TIP HYFRECATOR SHARP ANGLED STAINLESS STEEL BLADE STERILE DISPOSABLE,27200000,CDM,272,RC,,,,12459-MAIN,LOCAL,,,,,7,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DERMAL TIP HYFRECATOR SHARP ANGLED STAINLESS STEEL BLADE STERILE DISPOSABLE,27200000,CDM,272,RC,,,,12459-MAIN,LOCAL,,,,,7,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DERMAL TIP HYFRECATOR SHARP ANGLED STAINLESS STEEL BLADE STERILE DISPOSABLE,27200000,CDM,272,RC,,,,12459-MAIN,LOCAL,,,,,7,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSTRUMENT POUCH INVISISHIELD LONG,27200000,CDM,272,RC,,,,12394-MAIN,LOCAL,,,,,7,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSTRUMENT POUCH INVISISHIELD LONG,27200000,CDM,272,RC,,,,12394-MAIN,LOCAL,,,,,7,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSTRUMENT POUCH INVISISHIELD LONG,27200000,CDM,272,RC,,,,12394-MAIN,LOCAL,,,,,7,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
OSTOMY KIT 2 PIECE SURGICAL POST-OP,27200000,CDM,272,RC,,,,12070-MAIN,LOCAL,,,,,7,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
OSTOMY KIT 2 PIECE SURGICAL POST-OP,27200000,CDM,272,RC,,,,12070-MAIN,LOCAL,,,,,7,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
OSTOMY KIT 2 PIECE SURGICAL POST-OP,27200000,CDM,272,RC,,,,12070-MAIN,LOCAL,,,,,7,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052331,NDC,2,ML,125.89,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,3.43,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.01,3.94
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052341,NDC,2,ML,125.89,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,3.43,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.01,3.94
SUTURE PDS 3-0 27INCH ABSORBABLE VIOLET Z316H,27200000,CDM,272,RC,,,,12871-MAIN,LOCAL,,,,,7,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE PDS 3-0 27INCH ABSORBABLE VIOLET Z316H,27200000,CDM,272,RC,,,,12871-MAIN,LOCAL,,,,,7,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE PDS 3-0 27INCH ABSORBABLE VIOLET Z316H,27200000,CDM,272,RC,,,,12871-MAIN,LOCAL,,,,,7,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE PROLENE TAPERPOINT CT-1 36MM 0 BLUE,27200000,CDM,272,RC,,,,12322-MAIN,LOCAL,,,,,7,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE PROLENE TAPERPOINT CT-1 36MM 0 BLUE,27200000,CDM,272,RC,,,,12322-MAIN,LOCAL,,,,,7,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE PROLENE TAPERPOINT CT-1 36MM 0 BLUE,27200000,CDM,272,RC,,,,12322-MAIN,LOCAL,,,,,7,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Tocilizumab 400 MG/20ML Solution 20 mL Vial,J3262.01,CDM,636,RC,J3262,HCPCS,,,,50242013701,NDC,20,ML,4703.83,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,3.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.02,6.12
Tocilizumab 400 MG/20ML Solution 20 mL Vial,J3262.01,CDM,636,RC,J3262,HCPCS,,,,50242013701,NDC,20,ML,4703.83,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,3.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.02,6.12
metFORMIN 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904632661,NDC,1,EA,3.89,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.43098,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,69452015120,NDC,1,EA,3.86,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.4354,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
desipramine 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50742011401,NDC,0.2,EA,4.05,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.4425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 100 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904695361,NDC,1,EA,3.78,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.44358,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzonatate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687034611,NDC,1,EA,3.91,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.44862,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714031401,NDC,0.333333333,EA,3.91,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.44862,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714065801,NDC,0.333333333,EA,3.91,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.44862,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57664039588,NDC,0.333333333,EA,3.91,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.44862,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739028310,NDC,1,EA,8.04,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.44916,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
XEROFORM GAUZE PETROLATUM 1X8INCH,27200000,CDM,272,RC,A6222,HCPCS,,10659-MAIN,LOCAL,,,,,3.52,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.4496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
clindamycin 300 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084024411,NDC,1,EA,6.97,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.45015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,68084024401,NDC,1,EA,6.97,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.45015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 150 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862069730,NDC,0.25,EA,6.82,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.45092,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,50268053111,NDC,1,EA,7.19,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.4512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,50268053111,NDC,1,EA,7.19,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.4512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BANDAGE ESMARK 4X9 LATEX FREE DYNJ05916,27200000,CDM,272,RC,,,,5428-MAIN,LOCAL,,,,,7.05,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.4545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
BANDAGE ESMARK 4X9 LATEX FREE DYNJ05916,27200000,CDM,272,RC,,,,5428-MAIN,LOCAL,,,,,7.05,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.4545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
BANDAGE ESMARK 4X9 LATEX FREE DYNJ05916,27200000,CDM,272,RC,,,,5428-MAIN,LOCAL,,,,,7.05,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.4545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
clonazePAM 0.25 MG Tablet Disintegrating 1 Each Blister,63700001,CDM,250,RC,,,,,,49884030752,NDC,1,EA,6.98,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.4551,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Bottle,63700001,CDM,250,RC,,,,,,57664078486,NDC,1,EA,6.98,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.4551,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Box,63700001,CDM,250,RC,,,,,,555009596,NDC,1,EA,6.98,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.4551,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Box,63700001,CDM,250,RC,,,,,,49884030702,NDC,1,EA,6.98,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.4551,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluvoxaMINE 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,60505016601,NDC,0.25,EA,3.55,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.455215,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034411,NDC,0.25,EA,8.32,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.456128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034401,NDC,0.25,EA,8.32,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.456128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methyldopa 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93293101,NDC,1,EA,3.92,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.45744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 4 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,43547034406,NDC,0.125,EA,8.06,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.45774,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268030315,NDC,0.5,EA,4.07,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.4595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 650 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713016512,NDC,1,EA,3.8,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.4618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 850 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687014311,NDC,0.588235294,EA,3.8,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.4618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 850 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687014301,NDC,0.588235294,EA,3.8,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.4618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904632661,NDC,1,EA,3.89,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.4621,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DERMAL TIP HYFRECATOR SHARP ANGLED STAINLESS STEEL BLADE STERILE DISPOSABLE,27200000,CDM,272,RC,,,,12459-MAIN,LOCAL,,,,,7,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.465,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSTRUMENT POUCH INVISISHIELD LONG,27200000,CDM,272,RC,,,,12394-MAIN,LOCAL,,,,,7,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.465,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
OSTOMY KIT 2 PIECE SURGICAL POST-OP,27200000,CDM,272,RC,,,,12070-MAIN,LOCAL,,,,,7,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.465,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE PDS 3-0 27INCH ABSORBABLE VIOLET Z316H,27200000,CDM,272,RC,,,,12871-MAIN,LOCAL,,,,,7,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.465,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE PROLENE TAPERPOINT CT-1 36MM 0 BLUE,27200000,CDM,272,RC,,,,12322-MAIN,LOCAL,,,,,7,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.465,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
tiZANidine 4 MG Tablet 150 Each Bottle,63700001,CDM,250,RC,,,,,,55111018015,NDC,0.5,EA,3.93,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.46626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay Ph Body Fluids Nos,PX83986,CDM,300,RC,83986,CPT,,,,,,,,147,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,3.47,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.42,3.58
sucralfate 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762040101,NDC,1,EA,3.81,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.47091,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 400-80 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237023201,NDC,1,EA,3.57,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.474681,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
OXcarbazepine 150 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084084511,NDC,1,EA,8.1,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.4749,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 75 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079044101,NDC,1.333333333,EA,3.94,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.47508,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline monohydrate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687071611,NDC,1,EA,6.87,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.47622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluvoxaMINE 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,60505016601,NDC,0.25,EA,3.55,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.479,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzonatate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687034611,NDC,1,EA,3.91,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.4799,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714031401,NDC,0.333333333,EA,3.91,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.4799,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714065801,NDC,0.333333333,EA,3.91,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.4799,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57664039588,NDC,0.333333333,EA,3.91,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.4799,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084008311,NDC,1,EA,7.25,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084008311,NDC,1,EA,7.25,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084008301,NDC,1,EA,7.25,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084008301,NDC,1,EA,7.25,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 650 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802073030,NDC,1,EA,3.58,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.484414,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
silver nitrate - pot nitrate 75-25 % Misc 100 Each Package,63700001,CDM,250,RC,,,,,,12870000102,NDC,1,EA,3.58,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.484414,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
penicillin v potassium 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714023401,NDC,1,EA,4.1,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
droPERidol 2.5 MG/ML Solution 2 mL Vial,J1790.01,CDM,636,RC,J1790,HCPCS,,,,517970201,NDC,2,ML,75.47,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,3.488,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.88,9.13
droPERidol 2.5 MG/ML Solution 2 mL Vial,J1790.01,CDM,636,RC,J1790,HCPCS,,,,517970201,NDC,2,ML,75.47,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,3.488,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.88,9.13
methyldopa 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93293101,NDC,1,EA,3.92,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.4888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904539261,NDC,1,EA,3.83,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.48913,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687015211,NDC,1,EA,3.83,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.48913,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687015201,NDC,1,EA,3.83,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.48913,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084042311,NDC,1,EA,3.83,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.48913,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prenatal plus vitamin with folic acid 1 mg 27-1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69367026701,NDC,1,EA,3.83,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.48913,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BANDAGE ESMARK 4X9 LATEX FREE DYNJ05916,27200000,CDM,272,RC,,,,5428-MAIN,LOCAL,,,,,7.05,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.48975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PARoxetine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268064011,NDC,1,EA,4.11,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.4935,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268064015,NDC,1,EA,4.11,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.4935,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levETIRAcetam 750 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,16714035602,NDC,0.333333333,EA,8.41,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.493514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tiZANidine 4 MG Tablet 150 Each Bottle,63700001,CDM,250,RC,,,,,,55111018015,NDC,0.5,EA,3.93,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.4977,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 400-80 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237023201,NDC,1,EA,3.57,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.4986,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pyRIDostigmine 60 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084049411,NDC,0.5,EA,3.97,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.50154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcitRIOL 0.25 MCG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687034511,NDC,1,EA,4.12,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.502,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 4 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,56016875,NDC,0.25,EA,3.6,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.50388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 75 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079044101,NDC,1.333333333,EA,3.94,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.5066,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 650 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802073030,NDC,1,EA,3.58,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.5084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
silver nitrate - pot nitrate 75-25 % Misc 100 Each Package,63700001,CDM,250,RC,,,,,,12870000102,NDC,1,EA,3.58,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.5084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
OSTOMY DRAINABLE POUCH INVISICLOSE 1.75,27200000,CDM,272,RC,A5063,HCPCS,,12071-MAIN,LOCAL,,,,,1.5,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,3.51,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
pyRIDostigmine 60 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084049401,NDC,0.5,EA,3.98,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.51036,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,69452015120,NDC,1,EA,3.86,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.51646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,904642286,NDC,1,EA,8.2,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.5178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
busPIRone 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079098501,NDC,1,EA,4.14,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.519,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
busPIRone 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079098520,NDC,1,EA,4.14,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.519,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acyclovir 200 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578961,NDC,1,EA,8.21,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.52209,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buPROPion XL 150 MG Tablet Extended Release 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,904708404,NDC,1,EA,8.48,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.522592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
felodipine 5 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462023401,NDC,1,EA,8.48,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.522592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,50268053111,NDC,1,EA,7.19,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.5231,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,50268053111,NDC,1,EA,7.19,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.5231,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,50268053111,NDC,1,EA,7.19,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.5231,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 250 MG Tablet Chewable 100 Each Bottle,63700001,CDM,250,RC,,,,,,93226801,NDC,1,EA,3.62,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.523346,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
repaglinide 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,574024001,NDC,1,EA,3.62,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.523346,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin 300 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084024411,NDC,1,EA,6.97,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.52682,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,68084024401,NDC,1,EA,6.97,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.52682,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
enalapril 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904550261,NDC,0.5,EA,4.15,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.5275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
naproxen 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65162018810,NDC,1,EA,4.15,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.5275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE-acetaminophen 5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406051262,NDC,1,EA,7.35,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE-acetaminophen 5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406051262,NDC,1,EA,7.35,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,185441601,NDC,1,EA,4,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756014201,NDC,1,EA,4,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SUTURE VICRYL TAPER 2-0 J317H,27200000,CDM,272,RC,,,,2615-MAIN,LOCAL,,,,,4,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
warfarin 4 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,56016875,NDC,0.25,EA,3.6,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of protein urine,PX84156,CDM,300,RC,84156,CPT,,,,,,,,190,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,3.5299,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.5299,3.67
Assay Ph Body Fluids Nos,PX83986,CDM,300,RC,83986,CPT,,,,,,,,147,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,3.5299,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.42,3.58
"Protein, Total; Serum, Plasma or Whole Blood",PX84155,CDM,300,RC,84155,CPT,,,,,,,,170,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,3.5299,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.5299,3.67
pregabalin 25 MG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,904699104,NDC,1,EA,8.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.5309,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 1 Each Blister,63700001,CDM,250,RC,,,,,,49884030752,NDC,1,EA,6.98,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.53188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Bottle,63700001,CDM,250,RC,,,,,,57664078486,NDC,1,EA,6.98,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.53188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Box,63700001,CDM,250,RC,,,,,,555009596,NDC,1,EA,6.98,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.53188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Box,63700001,CDM,250,RC,,,,,,49884030702,NDC,1,EA,6.98,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.53188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE-acetaminophen 5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406051223,NDC,1,EA,7.36,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.5328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE-acetaminophen 5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406051223,NDC,1,EA,7.36,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.5328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687016311,NDC,0.5,EA,3.63,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.533079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687016301,NDC,0.5,EA,3.63,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.533079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pyRIDostigmine 60 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084049411,NDC,0.5,EA,3.97,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.5333,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Oximetry;Mult Determine,PX610,CDM,460,RC,94761,CPT,,,,,,,,142,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,3.5365,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.17,6.98
OSTOMY DRAINABLE POUCH INVISICLOSE 1.75,27200000,CDM,272,RC,A5063,HCPCS,,12071-MAIN,LOCAL,,,,,1.5,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,3.5387,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
DERMAL TIP HYFRECATOR SHARP ANGLED STAINLESS STEEL BLADE STERILE DISPOSABLE,27200000,CDM,272,RC,,,,12459-MAIN,LOCAL,,,,,7,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSTRUMENT POUCH INVISISHIELD LONG,27200000,CDM,272,RC,,,,12394-MAIN,LOCAL,,,,,7,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
OSTOMY KIT 2 PIECE SURGICAL POST-OP,27200000,CDM,272,RC,,,,12070-MAIN,LOCAL,,,,,7,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE PDS 3-0 27INCH ABSORBABLE VIOLET Z316H,27200000,CDM,272,RC,,,,12871-MAIN,LOCAL,,,,,7,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE PROLENE TAPERPOINT CT-1 36MM 0 BLUE,27200000,CDM,272,RC,,,,12322-MAIN,LOCAL,,,,,7,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
pyRIDostigmine 60 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084049401,NDC,0.5,EA,3.98,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.5422,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904632661,NDC,1,EA,3.89,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.54379,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 250 MG Tablet Chewable 100 Each Bottle,63700001,CDM,250,RC,,,,,,93226801,NDC,1,EA,3.62,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.5476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
repaglinide 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,574024001,NDC,1,EA,3.62,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.5476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CISplatin 50 MG/50ML Solution 50 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010351,NDC,50,ML,82.27,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,3.55,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.217,4.24
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,703574811,NDC,100,ML,183.92,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,3.55,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.217,4.24
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010365,NDC,100,ML,164.54,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,3.55,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.217,4.24
amLODIPine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904636961,NDC,1,EA,8.55,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.55167,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084008311,NDC,1,EA,7.25,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.5525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084008311,NDC,1,EA,7.25,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.5525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084008311,NDC,1,EA,7.25,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.5525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084008301,NDC,1,EA,7.25,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.5525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084008301,NDC,1,EA,7.25,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.5525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084008301,NDC,1,EA,7.25,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.5525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,245531989,NDC,1,EA,3.65,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.552545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,66758019006,NDC,1,EA,3.65,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.552545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,245531901,NDC,1,EA,3.65,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.552545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,66758019013,NDC,1,EA,3.65,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.552545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687016311,NDC,0.5,EA,3.63,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.5574,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687016301,NDC,0.5,EA,3.63,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.5574,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,50268053111,NDC,1,EA,7.19,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.55905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of protein urine,PX84156,CDM,300,RC,84156,CPT,,,,,,,,190,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,3.56,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.5299,3.67
Assay of protein urine,PX84156,CDM,300,RC,84156,CPT,,,,,,,,190,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,3.56,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.5299,3.67
Assay of protein urine,PX84156,CDM,300,RC,84156,CPT,,,,,,,,190,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,3.56,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.5299,3.67
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,185441601,NDC,1,EA,4,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756014201,NDC,1,EA,4,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Protein, Total; Serum, Plasma or Whole Blood",PX84155,CDM,300,RC,84155,CPT,,,,,,,,170,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,3.56,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.5299,3.67
"Protein, Total; Serum, Plasma or Whole Blood",PX84155,CDM,300,RC,84155,CPT,,,,,,,,170,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,3.56,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.5299,3.67
"Protein, Total; Serum, Plasma or Whole Blood",PX84155,CDM,300,RC,84155,CPT,,,,,,,,170,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,3.56,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.5299,3.67
SUTURE VICRYL TAPER 2-0 J317H,27200000,CDM,272,RC,,,,2615-MAIN,LOCAL,,,,,4,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
benzonatate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687034611,NDC,1,EA,3.91,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.56201,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714031401,NDC,0.333333333,EA,3.91,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.56201,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714065801,NDC,0.333333333,EA,3.91,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.56201,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57664039588,NDC,0.333333333,EA,3.91,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.56201,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simvastatin 10 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16714068202,NDC,0.5,EA,7.43,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.5664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simvastatin 10 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16714068202,NDC,0.5,EA,7.43,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.5664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BANDAGE ESMARK 4X9 LATEX FREE DYNJ05916,27200000,CDM,272,RC,,,,5428-MAIN,LOCAL,,,,,7.05,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.5673,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
balsalazide 750 MG capsule 280 Each Bottle,63700001,CDM,250,RC,,,,,,54007928,NDC,1,EA,8.59,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.568286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
balsalazide 750 MG capsule 280 Each Bottle,63700001,CDM,250,RC,,,,,,60505257507,NDC,1,EA,8.59,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.568286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034411,NDC,0.25,EA,8.32,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.56928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034401,NDC,0.25,EA,8.32,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.56928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
linezolid 600 MG/300ML Solution 300 mL Flex Cont,J2020.01,CDM,636,RC,J2020,HCPCS,,,,9514001,NDC,300,ML,332.42,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,3.57087,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.9,3.62
methyldopa 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93293101,NDC,1,EA,3.92,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.57112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
desipramine 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50742011401,NDC,0.2,EA,4.05,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.5721,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,245531989,NDC,1,EA,3.65,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.577,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,66758019006,NDC,1,EA,3.65,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.577,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,245531901,NDC,1,EA,3.65,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.577,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride CR 20 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,66758019013,NDC,1,EA,3.65,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.577,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay Ph Body Fluids Nos,PX83986,CDM,300,RC,83986,CPT,,,,,,,,147,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,3.58,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.42,3.58
tiZANidine 4 MG Tablet 150 Each Bottle,63700001,CDM,250,RC,,,,,,55111018015,NDC,0.5,EA,3.93,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.58023,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terazosin 1 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59746038306,NDC,1,EA,8.62,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.580748,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084008311,NDC,1,EA,7.25,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.58875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084008301,NDC,1,EA,7.25,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.58875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 75 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079044101,NDC,1.333333333,EA,3.94,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.58934,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268030315,NDC,0.5,EA,4.07,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.58974,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092821,NDC,1,ML,32.23,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,3.59,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.77,3.59
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092825,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,3.59,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.77,3.59
PARoxetine 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084004511,NDC,0.5,EA,7.49,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.5952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084004511,NDC,0.5,EA,7.49,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.5952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084004501,NDC,0.5,EA,7.49,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.5952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084004501,NDC,0.5,EA,7.49,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.5952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Assay, Glucose, Blood Quant",PX82947,CDM,300,RC,82947,CPT,,,,,,,,58,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,3.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.6,56.84
"Glucose, Body Fluid Other Than Blood",PX82945,CDM,300,RC,82945,CPT,,,,,,,,158,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,3.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.6,154.84
oxyCODONE-acetaminophen 5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406051262,NDC,1,EA,7.35,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.6015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE-acetaminophen 5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406051262,NDC,1,EA,7.35,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.6015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE-acetaminophen 5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406051262,NDC,1,EA,7.35,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.6015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,45963061959,NDC,1,EA,638.4,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,3.60304,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.21,3.83
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323012594,NDC,1,EA,190.99,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,3.60304,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.21,3.83
gemcitabine 1 GM/26.3ML Solution 26.3 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018101,NDC,26.3,ML,203.58,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,3.60304,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.21,3.83
gemcitabine 200 MG Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323010294,NDC,1,EA,39,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,3.60304,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.21,3.83
gemcitabine 200 MG/5.26ML Solution 5.26 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018301,NDC,5.26,ML,40.74,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,3.60304,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.21,3.83
primidone 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084020211,NDC,1,EA,4.24,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.604,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
desipramine 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50742011401,NDC,0.2,EA,4.05,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.6045,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE-acetaminophen 5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406051223,NDC,1,EA,7.36,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.6064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE-acetaminophen 5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406051223,NDC,1,EA,7.36,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.6064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE-acetaminophen 5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406051223,NDC,1,EA,7.36,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.6064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levETIRAcetam 750 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,16714035602,NDC,0.333333333,EA,8.41,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.60789,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
saccharomyces boulardii 250 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,4142000024,NDC,1,EA,4.25,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.6125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
penicillin v potassium 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714023401,NDC,1,EA,4.1,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.6162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pyRIDostigmine 60 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084049411,NDC,0.5,EA,3.97,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.61667,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of Urea Nitrogen,PX84520,CDM,300,RC,84520,CPT,,,,,,,,58,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,3.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.62,56.84
linezolid 600 MG/300ML Solution 300 mL Flex Cont,J2020.01,CDM,636,RC,J2020,HCPCS,,,,9514001,NDC,300,ML,332.42,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,3.62,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.9,3.62
linezolid 600 MG/300ML Solution 300 mL Flex Cont,J2020.01,CDM,636,RC,J2020,HCPCS,,,,9514001,NDC,300,ML,332.42,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,3.62,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.9,3.62
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904563161,NDC,1,EA,3.72,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.620676,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 5-325 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406012301,NDC,1,EA,3.72,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.620676,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
primidone 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084020201,NDC,1,EA,4.26,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.621,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268030315,NDC,0.5,EA,4.07,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.6223,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268064011,NDC,1,EA,4.11,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.62502,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268064015,NDC,1,EA,4.11,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.62502,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pyRIDostigmine 60 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084049401,NDC,0.5,EA,3.98,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.62578,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406012323,NDC,1,EA,4.27,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.6295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406012362,NDC,1,EA,4.27,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.6295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 88 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904695261,NDC,1.136363636,EA,4.27,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.6295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079099101,NDC,1,EA,4.27,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.6295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079099120,NDC,1,EA,4.27,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.6295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,781106101,NDC,1,EA,3.73,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.630409,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,67253090010,NDC,1,EA,3.73,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.630409,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcitRIOL 0.25 MCG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687034511,NDC,1,EA,4.12,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.63384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buPROPion XL 150 MG Tablet Extended Release 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,904708404,NDC,1,EA,8.48,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.63792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
felodipine 5 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462023401,NDC,1,EA,8.48,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.63792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 750 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877041401,NDC,0.666666667,EA,4.28,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,50268053111,NDC,1,EA,7.19,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.63814,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE-acetaminophen 5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406051262,NDC,1,EA,7.35,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.63825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simvastatin 10 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16714068202,NDC,0.5,EA,7.43,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.6407,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simvastatin 10 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16714068202,NDC,0.5,EA,7.43,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.6407,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simvastatin 10 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16714068202,NDC,0.5,EA,7.43,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.6407,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pravastatin 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079045801,NDC,0.5,EA,8.77,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.643058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE-acetaminophen 5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406051223,NDC,1,EA,7.36,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.6432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,185441601,NDC,1,EA,4,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756014201,NDC,1,EA,4,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SUTURE VICRYL TAPER 2-0 J317H,27200000,CDM,272,RC,,,,2615-MAIN,LOCAL,,,,,4,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904563161,NDC,1,EA,3.72,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.6456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 5-325 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406012301,NDC,1,EA,3.72,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.6456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 25 MG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,904699104,NDC,1,EA,8.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.6465,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 100 MCG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,74662490,NDC,1,EA,7.6,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 100 MCG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,74662490,NDC,1,EA,7.6,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
penicillin v potassium 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714023401,NDC,1,EA,4.1,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.649,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,45963061959,NDC,1,EA,638.4,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,3.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.21,3.83
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,45963061959,NDC,1,EA,638.4,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,3.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.21,3.83
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323012594,NDC,1,EA,190.99,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,3.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.21,3.83
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323012594,NDC,1,EA,190.99,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,3.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.21,3.83
gemcitabine 1 GM/26.3ML Solution 26.3 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018101,NDC,26.3,ML,203.58,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,3.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.21,3.83
gemcitabine 1 GM/26.3ML Solution 26.3 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018101,NDC,26.3,ML,203.58,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,3.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.21,3.83
gemcitabine 200 MG Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323010294,NDC,1,EA,39,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,3.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.21,3.83
gemcitabine 200 MG Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323010294,NDC,1,EA,39,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,3.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.21,3.83
gemcitabine 200 MG/5.26ML Solution 5.26 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018301,NDC,5.26,ML,40.74,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,3.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.21,3.83
gemcitabine 200 MG/5.26ML Solution 5.26 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018301,NDC,5.26,ML,40.74,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,3.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.21,3.83
busPIRone 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079098501,NDC,1,EA,4.14,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.65148,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
busPIRone 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079098520,NDC,1,EA,4.14,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.65148,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079075901,NDC,1,EA,4.3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.655,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine CR 12.5 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,42858070303,NDC,1,EA,4.3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.655,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,781106101,NDC,1,EA,3.73,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.6554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALPRAZolam 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,67253090010,NDC,1,EA,3.73,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.6554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 125 MG Capsule Delayed Release Sprinkle 100 Each Box,63700001,CDM,250,RC,,,,,,68084031301,NDC,1,EA,7.62,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.6576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 125 MG Capsule Delayed Release Sprinkle 100 Each Box,63700001,CDM,250,RC,,,,,,68084031301,NDC,1,EA,7.62,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.6576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268064011,NDC,1,EA,4.11,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.6579,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268064015,NDC,1,EA,4.11,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.6579,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenoxylate-atropine 2.5-0.025 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762106101,NDC,1,EA,3.76,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.659608,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenoxylate-atropine 2.5-0.025 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,62559049001,NDC,1,EA,3.76,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.659608,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Reticulocyte Count,Flow Cyto",PX85045,CDM,300,RC,85045,CPT,,,,,,,,92,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,3.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.66,90.16
enalapril 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904550261,NDC,0.5,EA,4.15,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.6603,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
naproxen 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65162018810,NDC,1,EA,4.15,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.6603,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 125 MG Capsule Delayed Release Sprinkle 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031311,NDC,1,EA,7.63,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.6624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 125 MG Capsule Delayed Release Sprinkle 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031311,NDC,1,EA,7.63,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.6624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcitRIOL 0.25 MCG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687034511,NDC,1,EA,4.12,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.6668,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
digoxin 125 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,115981101,NDC,1,EA,7.64,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.6672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
digoxin 125 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,115981101,NDC,1,EA,7.64,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.6672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424601,NDC,15,ML,95.76,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,3.66738,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.16,3.78
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424681,NDC,15,ML,95.76,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,3.66738,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.16,3.78
CARBOplatin 600 MG/60ML Solution 60 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703423981,NDC,60,ML,301.42,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,3.66738,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.16,3.78
amLODIPine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904636961,NDC,1,EA,8.55,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.66795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084008311,NDC,1,EA,7.25,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.6685,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084008301,NDC,1,EA,7.25,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.6685,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of protein urine,PX84156,CDM,300,RC,84156,CPT,,,,,,,,190,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,3.67,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.5299,3.67
"Protein, Total; Other Source",PX84157,CDM,300,RC,84157,CPT,,,,,,,,153,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,3.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.67,149.94
"Protein, Total; Serum, Plasma or Whole Blood",PX84155,CDM,300,RC,84155,CPT,,,,,,,,170,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,3.67,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.5299,3.67
PARoxetine 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084004511,NDC,0.5,EA,7.49,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.6701,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084004511,NDC,0.5,EA,7.49,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.6701,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084004511,NDC,0.5,EA,7.49,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.6701,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084004501,NDC,0.5,EA,7.49,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.6701,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084004501,NDC,0.5,EA,7.49,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.6701,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084004501,NDC,0.5,EA,7.49,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.6701,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739026310,NDC,1,EA,4.32,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simvastatin 10 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16714068202,NDC,0.5,EA,7.43,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.67785,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 100 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904695361,NDC,1,EA,3.78,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.679074,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
degarelix acetate 40 mg/mL Recon Soln 1 Each Vial,J9155.01,CDM,636,RC,J9155,HCPCS,,,,55566840301,NDC,2,EA,3109.33,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,3.68,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.68,4.4
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,42806040021,NDC,1,EA,8.86,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.680444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,603459315,NDC,1,EA,7.67,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.6816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,603459315,NDC,1,EA,7.67,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.6816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
busPIRone 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079098501,NDC,1,EA,4.14,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.6846,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
busPIRone 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079098520,NDC,1,EA,4.14,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.6846,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenoxylate-atropine 2.5-0.025 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762106101,NDC,1,EA,3.76,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.6848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenoxylate-atropine 2.5-0.025 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,62559049001,NDC,1,EA,3.76,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.6848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
balsalazide 750 MG capsule 280 Each Bottle,63700001,CDM,250,RC,,,,,,54007928,NDC,1,EA,8.59,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.68511,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
balsalazide 750 MG capsule 280 Each Bottle,63700001,CDM,250,RC,,,,,,60505257507,NDC,1,EA,8.59,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.68511,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,781502207,NDC,1,EA,7.68,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.6864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,781502207,NDC,1,EA,7.68,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.6864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
mirtazapine 15 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904651961,NDC,0.5,EA,7.68,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.6864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
mirtazapine 15 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904651961,NDC,0.5,EA,7.68,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.6864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
desipramine 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50742011401,NDC,0.2,EA,4.05,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.68955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
OSTOMY DRAINABLE POUCH INVISICLOSE 1.75,27200000,CDM,272,RC,A5063,HCPCS,,12071-MAIN,LOCAL,,,,,1.5,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,3.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
OSTOMY DRAINABLE POUCH INVISICLOSE 1.75,27200000,CDM,272,RC,A5063,HCPCS,,12071-MAIN,LOCAL,,,,,1.5,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,3.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
OSTOMY DRAINABLE POUCH INVISICLOSE 1.75,27200000,CDM,272,RC,A5063,HCPCS,,12071-MAIN,LOCAL,,,,,1.5,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,3.69,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
theophylline SR (12 hour) 300 MG Tablet Extended Release 12 Hour 100 Each Bottle,25000000,CDM,250,RC,,,,,,68462072101,NDC,0.333333333,EA,7.69,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.6912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
theophylline SR (12 hour) 300 MG Tablet Extended Release 12 Hour 100 Each Bottle,25000000,CDM,250,RC,,,,,,68462072101,NDC,0.333333333,EA,7.69,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.6912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
enalapril 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904550261,NDC,0.5,EA,4.15,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.6935,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
naproxen 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65162018810,NDC,1,EA,4.15,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.6935,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terazosin 1 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59746038306,NDC,1,EA,8.62,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.69798,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 650 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713016512,NDC,1,EA,3.8,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.69854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 850 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687014311,NDC,0.588235294,EA,3.8,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.69854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 850 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687014301,NDC,0.588235294,EA,3.8,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.69854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,50458059160,NDC,1,EA,7.71,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.7008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,50458059160,NDC,1,EA,7.71,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.7008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 100 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904695361,NDC,1,EA,3.78,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.7044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084004511,NDC,0.5,EA,7.49,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.70755,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084004501,NDC,0.5,EA,7.49,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.70755,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268030315,NDC,0.5,EA,4.07,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.70777,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sucralfate 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762040101,NDC,1,EA,3.81,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.708273,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE-acetaminophen 5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406051262,NDC,1,EA,7.35,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.7191,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424601,NDC,15,ML,95.76,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,3.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.16,3.78
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424601,NDC,15,ML,95.76,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,3.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.16,3.78
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424681,NDC,15,ML,95.76,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,3.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.16,3.78
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424681,NDC,15,ML,95.76,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,3.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.16,3.78
CARBOplatin 600 MG/60ML Solution 60 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703423981,NDC,60,ML,301.42,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,3.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.16,3.78
CARBOplatin 600 MG/60ML Solution 60 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703423981,NDC,60,ML,301.42,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,3.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.16,3.78
PRONEVIEW CUSHION INSERTS LARGE,120.557,CDM,272,RC,E0190,HCPCS,,12500-MAIN,LOCAL,,,,,76,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,3.72,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.72,37.23
acetaminophen 650 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713016512,NDC,1,EA,3.8,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.724,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 100 MCG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,74662490,NDC,1,EA,7.6,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.724,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 100 MCG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,74662490,NDC,1,EA,7.6,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.724,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 100 MCG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,74662490,NDC,1,EA,7.6,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.724,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 850 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687014311,NDC,0.588235294,EA,3.8,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.724,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 850 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687014301,NDC,0.588235294,EA,3.8,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.724,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE-acetaminophen 5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406051223,NDC,1,EA,7.36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.72416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 30 Each Box,63700001,CDM,250,RC,,,,,,904693176,NDC,1,EA,8.97,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.726138,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68462033190,NDC,0.5,EA,8.97,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.726138,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904539261,NDC,1,EA,3.83,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.727739,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687015211,NDC,1,EA,3.83,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.727739,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687015201,NDC,1,EA,3.83,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.727739,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084042311,NDC,1,EA,3.83,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.727739,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prenatal plus vitamin with folic acid 1 mg 27-1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69367026701,NDC,1,EA,3.83,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.727739,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
verapamil CR 240 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462026001,NDC,0.5,EA,4.39,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.7315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 125 MG Capsule Delayed Release Sprinkle 100 Each Box,63700001,CDM,250,RC,,,,,,68084031301,NDC,1,EA,7.62,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.7338,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 125 MG Capsule Delayed Release Sprinkle 100 Each Box,63700001,CDM,250,RC,,,,,,68084031301,NDC,1,EA,7.62,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.7338,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 125 MG Capsule Delayed Release Sprinkle 100 Each Box,63700001,CDM,250,RC,,,,,,68084031301,NDC,1,EA,7.62,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.7338,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sucralfate 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762040101,NDC,1,EA,3.81,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.7338,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
penicillin v potassium 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714023401,NDC,1,EA,4.1,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.7351,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Osmolality; Blood,PX83930,CDM,300,RC,83930,CPT,,,,,,,,9,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.7386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.7386,8.82
SUTURE ETHILON SIZE 0 96INCH TP1,27200000,CDM,272,RC,,,,12140-MAIN,LOCAL,,,,,9,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.7386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE PROLENE 3-0 BLUE SH NEEDLE MONOFILAMENT 30INCH,27200000,CDM,272,RC,,,,12840-MAIN,LOCAL,,,,,9,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.7386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
divalproex 125 MG Capsule Delayed Release Sprinkle 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031311,NDC,1,EA,7.63,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.7387,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 125 MG Capsule Delayed Release Sprinkle 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031311,NDC,1,EA,7.63,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.7387,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 125 MG Capsule Delayed Release Sprinkle 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031311,NDC,1,EA,7.63,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.7387,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
primidone 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084020211,NDC,1,EA,4.24,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.73968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084009301,NDC,1,EA,4.4,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084080811,NDC,1,EA,4.4,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68084080801,NDC,1,EA,4.4,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide mononitrate CR 30 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084059111,NDC,1,EA,9.01,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.742754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide mononitrate CR 30 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084059101,NDC,1,EA,9.01,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.742754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
digoxin 125 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,115981101,NDC,1,EA,7.64,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.7436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
digoxin 125 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,115981101,NDC,1,EA,7.64,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.7436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
digoxin 125 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,115981101,NDC,1,EA,7.64,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.7436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268064011,NDC,1,EA,4.11,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.74421,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268064015,NDC,1,EA,4.11,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.74421,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637061,NDC,0.5,EA,4.41,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.7485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
saccharomyces boulardii 250 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,4142000024,NDC,1,EA,4.25,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.7485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Assay, Glucose, Blood Quant",PX82947,CDM,300,RC,82947,CPT,,,,,,,,58,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,3.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.75,3.93
"Assay, Glucose, Blood Quant",PX82947,CDM,300,RC,82947,CPT,,,,,,,,58,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,3.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.75,3.93
calcitRIOL 0.25 MCG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687034511,NDC,1,EA,4.12,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.75332,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904539261,NDC,1,EA,3.83,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.7534,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687015211,NDC,1,EA,3.83,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.7534,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687015201,NDC,1,EA,3.83,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.7534,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084042311,NDC,1,EA,3.83,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.7534,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prenatal plus vitamin with folic acid 1 mg 27-1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69367026701,NDC,1,EA,3.83,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.7534,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,69452015120,NDC,1,EA,3.86,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.756938,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloZAPine 100 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,378086005,NDC,0.25,EA,4.42,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.757,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
primidone 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084020201,NDC,1,EA,4.26,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.75732,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,603459315,NDC,1,EA,7.67,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.7583,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,603459315,NDC,1,EA,7.67,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.7583,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,603459315,NDC,1,EA,7.67,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.7583,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
aspirin 300 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574703412,NDC,1,EA,7.83,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.7584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin 300 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574703412,NDC,1,EA,7.83,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.7584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084044011,NDC,0.5,EA,7.83,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.7584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084044011,NDC,0.5,EA,7.83,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.7584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084044001,NDC,0.5,EA,7.83,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.7584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084044001,NDC,0.5,EA,7.83,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.7584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,50111099001,NDC,1,EA,9.05,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.75937,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simvastatin 10 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16714068202,NDC,0.5,EA,7.43,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.75958,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 100 MCG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,74662490,NDC,1,EA,7.6,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.762,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pravastatin 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079045801,NDC,0.5,EA,8.77,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.76233,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,781502207,NDC,1,EA,7.68,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.7632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,781502207,NDC,1,EA,7.68,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.7632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,781502207,NDC,1,EA,7.68,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.7632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
mirtazapine 15 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904651961,NDC,0.5,EA,7.68,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.7632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
mirtazapine 15 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904651961,NDC,0.5,EA,7.68,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.7632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
mirtazapine 15 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904651961,NDC,0.5,EA,7.68,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.7632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone 4 MG Tablet 100 Each Bottle,J7509.01,CDM,636,RC,J7509,HCPCS,,,,68382091601,NDC,0.5,EA,4.43,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.7655,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
HYDROcodone-acetaminophen 5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406012323,NDC,1,EA,4.27,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.76614,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406012362,NDC,1,EA,4.27,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.76614,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 88 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904695261,NDC,1.136363636,EA,4.27,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.76614,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079099101,NDC,1,EA,4.27,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.76614,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079099120,NDC,1,EA,4.27,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.76614,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,63739035810,NDC,0.5,EA,7.85,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,63739035810,NDC,0.5,EA,7.85,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
theophylline SR (12 hour) 300 MG Tablet Extended Release 12 Hour 100 Each Bottle,25000000,CDM,250,RC,,,,,,68462072101,NDC,0.333333333,EA,7.69,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.7681,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
theophylline SR (12 hour) 300 MG Tablet Extended Release 12 Hour 100 Each Bottle,25000000,CDM,250,RC,,,,,,68462072101,NDC,0.333333333,EA,7.69,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.7681,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
theophylline SR (12 hour) 300 MG Tablet Extended Release 12 Hour 100 Each Bottle,25000000,CDM,250,RC,,,,,,68462072101,NDC,0.333333333,EA,7.69,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.7681,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
busPIRone 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079098501,NDC,1,EA,4.14,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.77154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
busPIRone 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079098520,NDC,1,EA,4.14,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.77154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739038710,NDC,0.5,EA,9.08,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.771832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 125 MG Capsule Delayed Release Sprinkle 100 Each Box,63700001,CDM,250,RC,,,,,,68084031301,NDC,1,EA,7.62,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.7719,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
primidone 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084020211,NDC,1,EA,4.24,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.7736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 750 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877041401,NDC,0.666666667,EA,4.28,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.77496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 125 MG Capsule Delayed Release Sprinkle 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031311,NDC,1,EA,7.63,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.77685,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,50458059160,NDC,1,EA,7.71,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.7779,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,50458059160,NDC,1,EA,7.71,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.7779,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,50458059160,NDC,1,EA,7.71,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.7779,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424601,NDC,15,ML,95.76,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,3.78,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.16,3.78
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424681,NDC,15,ML,95.76,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,3.78,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.16,3.78
CARBOplatin 600 MG/60ML Solution 60 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703423981,NDC,60,ML,301.42,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,3.78,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.16,3.78
enalapril 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904550261,NDC,0.5,EA,4.15,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.78065,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
naproxen 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65162018810,NDC,1,EA,4.15,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.78065,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
digoxin 125 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,115981101,NDC,1,EA,7.64,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.7818,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
saccharomyces boulardii 250 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,4142000024,NDC,1,EA,4.25,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.7825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,69452015120,NDC,1,EA,3.86,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.7828,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904632661,NDC,1,EA,3.89,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.786137,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tolterodine 2 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,59762080002,NDC,0.5,EA,9.12,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.788448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084004511,NDC,0.5,EA,7.49,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.78994,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084004501,NDC,0.5,EA,7.49,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.78994,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
primidone 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084020201,NDC,1,EA,4.26,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.7914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079075901,NDC,1,EA,4.3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.7926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine CR 12.5 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,42858070303,NDC,1,EA,4.3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.7926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,603459315,NDC,1,EA,7.67,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.79665,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
HYDROcodone-acetaminophen 5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406012323,NDC,1,EA,4.27,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.8003,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406012362,NDC,1,EA,4.27,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.8003,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 88 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904695261,NDC,1.136363636,EA,4.27,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.8003,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079099101,NDC,1,EA,4.27,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.8003,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079099120,NDC,1,EA,4.27,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.8003,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,42806040021,NDC,1,EA,8.86,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.80094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,781502207,NDC,1,EA,7.68,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.8016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
mirtazapine 15 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904651961,NDC,0.5,EA,7.68,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.8016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,42291053590,NDC,0.5,EA,7.92,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.8016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,42291053590,NDC,0.5,EA,7.92,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.8016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzonatate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687034611,NDC,1,EA,3.91,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.805603,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714031401,NDC,0.333333333,EA,3.91,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.805603,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714065801,NDC,0.333333333,EA,3.91,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.805603,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57664039588,NDC,0.333333333,EA,3.91,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.805603,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
theophylline SR (12 hour) 300 MG Tablet Extended Release 12 Hour 100 Each Bottle,25000000,CDM,250,RC,,,,,,68462072101,NDC,0.333333333,EA,7.69,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.80655,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metFORMIN-XR 750 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877041401,NDC,0.666666667,EA,4.28,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.8092,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Assay, Glucose, Blood Quant",PX82947,CDM,300,RC,82947,CPT,,,,,,,,58,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,3.81,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.75,3.93
"Glucose, Body Fluid Other Than Blood",PX82945,CDM,300,RC,82945,CPT,,,,,,,,158,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,3.81,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.81,3.93
"Glucose, Body Fluid Other Than Blood",PX82945,CDM,300,RC,82945,CPT,,,,,,,,158,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,3.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.81,3.93
"Glucose, Body Fluid Other Than Blood",PX82945,CDM,300,RC,82945,CPT,,,,,,,,158,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,3.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.81,3.93
clonazePAM 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739026310,NDC,1,EA,4.32,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.81024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904632661,NDC,1,EA,3.89,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.8122,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methyldopa 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93293101,NDC,1,EA,3.92,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.815336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,50458059160,NDC,1,EA,7.71,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.81645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tiZANidine 4 MG Tablet 150 Each Bottle,63700001,CDM,250,RC,,,,,,55111018015,NDC,0.5,EA,3.93,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.825069,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079075901,NDC,1,EA,4.3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.827,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine CR 12.5 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,42858070303,NDC,1,EA,4.3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.827,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of Urea Nitrogen,PX84520,CDM,300,RC,84520,CPT,,,,,,,,58,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,3.83,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.83,3.95
degarelix acetate 40 mg/mL Recon Soln 1 Each Vial,J9155.01,CDM,636,RC,J9155,HCPCS,,,,55566840301,NDC,2,EA,3109.33,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,3.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.83,3047.1434
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,45963061959,NDC,1,EA,638.4,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,3.83,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.21,3.83
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323012594,NDC,1,EA,190.99,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,3.83,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.21,3.83
gemcitabine 1 GM/26.3ML Solution 26.3 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018101,NDC,26.3,ML,203.58,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,3.83,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.21,3.83
gemcitabine 200 MG Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323010294,NDC,1,EA,39,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,3.83,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.21,3.83
gemcitabine 200 MG/5.26ML Solution 5.26 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018301,NDC,5.26,ML,40.74,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,3.83,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.21,3.83
Assay of Urea Nitrogen,PX84520,CDM,300,RC,84520,CPT,,,,,,,,58,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,3.83,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.83,3.95
Assay of Urea Nitrogen,PX84520,CDM,300,RC,84520,CPT,,,,,,,,58,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,3.83,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.83,3.95
benzonatate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687034611,NDC,1,EA,3.91,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.8318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714031401,NDC,0.333333333,EA,3.91,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.8318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714065801,NDC,0.333333333,EA,3.91,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.8318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57664039588,NDC,0.333333333,EA,3.91,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.8318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 75 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079044101,NDC,1.333333333,EA,3.94,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.834802,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin 300 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574703412,NDC,1,EA,7.83,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.8367,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin 300 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574703412,NDC,1,EA,7.83,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.8367,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin 300 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574703412,NDC,1,EA,7.83,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.8367,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084044011,NDC,0.5,EA,7.83,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.8367,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084044011,NDC,0.5,EA,7.83,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.8367,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084044011,NDC,0.5,EA,7.83,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.8367,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084044001,NDC,0.5,EA,7.83,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.8367,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084044001,NDC,0.5,EA,7.83,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.8367,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084044001,NDC,0.5,EA,7.83,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.8367,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 100 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,69097012403,NDC,0.25,EA,9.24,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.838296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methyldopa 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93293101,NDC,1,EA,3.92,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.8416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
digoxin 125 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904592161,NDC,0.5,EA,4.52,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.842,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739026310,NDC,1,EA,4.32,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.8448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 100 MCG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,74662490,NDC,1,EA,7.6,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.8456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,63739035810,NDC,0.5,EA,7.85,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.8465,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,63739035810,NDC,0.5,EA,7.85,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.8465,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,63739035810,NDC,0.5,EA,7.85,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.8465,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 30 Each Box,63700001,CDM,250,RC,,,,,,904693176,NDC,1,EA,8.97,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.84813,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68462033190,NDC,0.5,EA,8.97,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.84813,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PEMEtrexed 500 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2762301,NDC,1,EA,8086.02,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,3.85,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.85,4.59
PEMEtrexed Disodium 100 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2764001,NDC,1,EA,1539.32,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,3.85,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.85,4.59
Assay of Urea Nitrogen,PX84520,CDM,300,RC,84520,CPT,,,,,,,,58,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,3.8508,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.83,3.95
"Assay, Glucose, Blood Quant",PX82947,CDM,300,RC,82947,CPT,,,,,,,,58,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,3.8508,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.75,3.93
"Glucose, Body Fluid Other Than Blood",PX82945,CDM,300,RC,82945,CPT,,,,,,,,158,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,3.8508,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.81,3.93
"Protein, Total; Other Source",PX84157,CDM,300,RC,84157,CPT,,,,,,,,153,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,3.8508,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.8508,4
"Reticulocyte Count,Flow Cyto",PX85045,CDM,300,RC,85045,CPT,,,,,,,,92,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,3.8508,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.8508,3.99
tiZANidine 4 MG Tablet 150 Each Bottle,63700001,CDM,250,RC,,,,,,55111018015,NDC,0.5,EA,3.93,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.8514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 2.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079045001,NDC,1,EA,9.28,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.854912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079045020,NDC,1,EA,9.28,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.854912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 125 MG Capsule Delayed Release Sprinkle 100 Each Box,63700001,CDM,250,RC,,,,,,68084031301,NDC,1,EA,7.62,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.85572,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739028310,NDC,1,EA,8.04,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.8592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739028310,NDC,1,EA,8.04,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.8592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052331,NDC,2,ML,125.89,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,3.8604,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.01,3.94
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052341,NDC,2,ML,125.89,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,3.8604,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.01,3.94
divalproex 125 MG Capsule Delayed Release Sprinkle 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031311,NDC,1,EA,7.63,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.86078,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Osmolality; Blood,PX83930,CDM,300,RC,83930,CPT,,,,,,,,9,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.861,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.7386,8.82
SUTURE ETHILON SIZE 0 96INCH TP1,27200000,CDM,272,RC,,,,12140-MAIN,LOCAL,,,,,9,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.861,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE PROLENE 3-0 BLUE SH NEEDLE MONOFILAMENT 30INCH,27200000,CDM,272,RC,,,,12840-MAIN,LOCAL,,,,,9,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.861,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
levothyroxine 75 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079044101,NDC,1.333333333,EA,3.94,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.8612,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
primidone 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084020211,NDC,1,EA,4.24,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.86264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pyRIDostigmine 60 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084049411,NDC,0.5,EA,3.97,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.864001,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide mononitrate CR 30 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084059111,NDC,1,EA,9.01,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.86529,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide mononitrate CR 30 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084059101,NDC,1,EA,9.01,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.86529,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
digoxin 125 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,115981101,NDC,1,EA,7.64,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.86584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 4 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,43547034406,NDC,0.125,EA,8.06,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.8688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 4 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,43547034406,NDC,0.125,EA,8.06,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.8688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Reticulocyte Count,Flow Cyto",PX85045,CDM,300,RC,85045,CPT,,,,,,,,92,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,3.87,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.8508,3.99
"Reticulocyte Count,Flow Cyto",PX85045,CDM,300,RC,85045,CPT,,,,,,,,92,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,3.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.8508,3.99
"Reticulocyte Count,Flow Cyto",PX85045,CDM,300,RC,85045,CPT,,,,,,,,92,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,3.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.8508,3.99
saccharomyces boulardii 250 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,4142000024,NDC,1,EA,4.25,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.87175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
verapamil CR 240 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462026001,NDC,0.5,EA,4.39,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.87198,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pyRIDostigmine 60 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084049401,NDC,0.5,EA,3.98,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.873734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin 300 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574703412,NDC,1,EA,7.83,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.87585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084044011,NDC,0.5,EA,7.83,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.87585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084044001,NDC,0.5,EA,7.83,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.87585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hyoscyamine 0.125 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42192034001,NDC,1,EA,4.56,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079096601,NDC,1,EA,9.34,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.879836,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Blood Occult Peroxidase,PX82272,CDM,300,RC,82272,CPT,,,,,,,,64,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,3.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.88,62.72
"Protein, Total; Other Source",PX84157,CDM,300,RC,84157,CPT,,,,,,,,153,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,3.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.8508,4
"Protein, Total; Other Source",PX84157,CDM,300,RC,84157,CPT,,,,,,,,153,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,3.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.8508,4
"Protein, Total; Other Source",PX84157,CDM,300,RC,84157,CPT,,,,,,,,153,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,3.88,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.8508,4
pramipexole 0.25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,42291053590,NDC,0.5,EA,7.92,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.8808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,42291053590,NDC,0.5,EA,7.92,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.8808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,42291053590,NDC,0.5,EA,7.92,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.8808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084009301,NDC,1,EA,4.4,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.8808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084080811,NDC,1,EA,4.4,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.8808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68084080801,NDC,1,EA,4.4,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.8808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
primidone 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084020201,NDC,1,EA,4.26,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.88086,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,603459315,NDC,1,EA,7.67,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.88102,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,50111099001,NDC,1,EA,9.05,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.88245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,63739035810,NDC,0.5,EA,7.85,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.88575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,781502207,NDC,1,EA,7.68,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.88608,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
mirtazapine 15 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904651961,NDC,0.5,EA,7.68,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.88608,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
OXcarbazepine 150 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084084511,NDC,1,EA,8.1,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
OXcarbazepine 150 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084084511,NDC,1,EA,8.1,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637061,NDC,0.5,EA,4.41,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.88962,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406012323,NDC,1,EA,4.27,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.88997,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406012362,NDC,1,EA,4.27,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.88997,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 88 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904695261,NDC,1.136363636,EA,4.27,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.88997,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079099101,NDC,1,EA,4.27,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.88997,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079099120,NDC,1,EA,4.27,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.88997,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pyRIDostigmine 60 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084049411,NDC,0.5,EA,3.97,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.8906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
theophylline SR (12 hour) 300 MG Tablet Extended Release 12 Hour 100 Each Bottle,25000000,CDM,250,RC,,,,,,68462072101,NDC,0.333333333,EA,7.69,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.89114,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
PEMEtrexed 500 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2762301,NDC,1,EA,8086.02,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,3.89257,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.85,4.59
PEMEtrexed Disodium 100 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2764001,NDC,1,EA,1539.32,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,3.89257,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.85,4.59
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,185441601,NDC,1,EA,4,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.8932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756014201,NDC,1,EA,4,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.8932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SUTURE VICRYL TAPER 2-0 J317H,27200000,CDM,272,RC,,,,2615-MAIN,LOCAL,,,,,4,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.8932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
amiodarone 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739038710,NDC,0.5,EA,9.08,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.89532,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloZAPine 100 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,378086005,NDC,0.25,EA,4.42,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.89844,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 750 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877041401,NDC,0.666666667,EA,4.28,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.89908,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pyRIDostigmine 60 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084049401,NDC,0.5,EA,3.98,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.9004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,50458059160,NDC,1,EA,7.71,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.90126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
verapamil CR 240 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462026001,NDC,0.5,EA,4.39,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.9071,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone 4 MG Tablet 100 Each Bottle,J7509.01,CDM,636,RC,J7509,HCPCS,,,,68382091601,NDC,0.5,EA,4.43,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.90726,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
meclizine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084049111,NDC,1,EA,4.6,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
meclizine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084049101,NDC,1,EA,4.6,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tolterodine 2 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,59762080002,NDC,0.5,EA,9.12,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.91248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084009301,NDC,1,EA,4.4,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.916,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084080811,NDC,1,EA,4.4,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.916,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68084080801,NDC,1,EA,4.4,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.916,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zolpidem 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018911,NDC,1,EA,9.43,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.917222,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zolpidem 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018901,NDC,1,EA,9.43,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.917222,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079075901,NDC,1,EA,4.3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.9173,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine CR 12.5 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,42858070303,NDC,1,EA,4.3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.9173,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 150-4.21 MG/100ML-% Solution 100 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066015010,NDC,100,ML,249.22,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,3.92,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.50926,11.28
amiodarone 360-4.14 MG/200ML-% Solution 200 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066036020,NDC,200,ML,325.25,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,3.92,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.50926,11.28
"Ecg 12 Lead, Tracing Only",PX93005,CDM,730,RC,93005,CPT,,,,,,,,298,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,3.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,11.05
"Ecg 12 Lead, Tracing Only",PX93005,CDM,730,RC,93005,CPT,,,,,,,,298,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,3.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,11.05
"Ecg 12 Lead, Tracing Only",PX93005,CDM,730,RC,93005,CPT,,,,,,,,298,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,3.92,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,11.05
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,185441601,NDC,1,EA,4,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756014201,NDC,1,EA,4,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Pinworm Exam,PX87172,CDM,300,RC,87172,CPT,,,,,,,,46,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,3.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,45.08
Smear Gram Stain,PX87205,CDM,300,RC,87205,CPT,,,,,,,,109,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,3.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,106.82
SUTURE VICRYL TAPER 2-0 J317H,27200000,CDM,272,RC,,,,2615-MAIN,LOCAL,,,,,4,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SYRINGE BULB 60ML IRRIGATION STERILE DYND20125,27200000,CDM,272,RC,A4322,HCPCS,,10829-MAIN,LOCAL,,,,,2.16,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,3.92,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
Tissue Exam for Fungi,PX87220,CDM,300,RC,87220,CPT,,,,,,,,94,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,3.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,92.12
pramipexole 0.25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,42291053590,NDC,0.5,EA,7.92,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.9204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637061,NDC,0.5,EA,4.41,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.9249,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Assay, Glucose, Blood Quant",PX82947,CDM,300,RC,82947,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,3.93,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.75,3.93
"Glucose, Body Fluid Other Than Blood",PX82945,CDM,300,RC,82945,CPT,,,,,,,,158,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,3.93,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.81,3.93
leucovorin 10 mg/mL Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,25021081467,NDC,1,EA,40.13,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,3.93,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.93,5.13
leucovorin 350 MG Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,703514501,NDC,1,EA,86.41,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,3.93,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.93,5.13
Prothrombin Time (Pt/Inr),PX85610,CDM,300,RC,85610,CPT,,,,,,,,130,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,3.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.93,127.4
cloZAPine 100 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,378086005,NDC,0.25,EA,4.42,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.9338,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739026310,NDC,1,EA,4.32,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.93552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,904642286,NDC,1,EA,8.2,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,904642286,NDC,1,EA,8.2,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739028310,NDC,1,EA,8.04,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.9396,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739028310,NDC,1,EA,8.04,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.9396,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739028310,NDC,1,EA,8.04,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.9396,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052331,NDC,2,ML,125.89,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,3.94,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.01,3.94
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052331,NDC,2,ML,125.89,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,3.94,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.01,3.94
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052341,NDC,2,ML,125.89,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,3.94,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.01,3.94
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052341,NDC,2,ML,125.89,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,3.94,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.01,3.94
acyclovir 200 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578961,NDC,1,EA,8.21,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.9408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acyclovir 200 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578961,NDC,1,EA,8.21,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.9408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
desipramine 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50742011401,NDC,0.2,EA,4.05,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.941865,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone 4 MG Tablet 100 Each Bottle,J7509.01,CDM,636,RC,J7509,HCPCS,,,,68382091601,NDC,0.5,EA,4.43,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3.9427,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
risperiDONE 4 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,43547034406,NDC,0.125,EA,8.06,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.9494,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 4 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,43547034406,NDC,0.125,EA,8.06,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.9494,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 4 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,43547034406,NDC,0.125,EA,8.06,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.9494,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of Urea Nitrogen,PX84520,CDM,300,RC,84520,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,3.95,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.83,3.95
famotidine 20 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268030315,NDC,0.5,EA,4.07,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.961331,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin 300 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574703412,NDC,1,EA,7.83,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.96198,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084044011,NDC,0.5,EA,7.83,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.96198,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084044001,NDC,0.5,EA,7.83,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.96198,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"MAYO STAND COVERS 24X53""",27200000,CDM,272,RC,,,,644-MAIN,LOCAL,,,,,9.54,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3.962916,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
topiramate 100 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,69097012403,NDC,0.25,EA,9.24,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.96396,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
desipramine 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50742011401,NDC,0.2,EA,4.05,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.969,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
OXcarbazepine 150 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084084511,NDC,1,EA,8.1,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.969,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
OXcarbazepine 150 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084084511,NDC,1,EA,8.1,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3.969,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
OXcarbazepine 150 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084084511,NDC,1,EA,8.1,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3.969,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 875 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862001501,NDC,1,EA,4.67,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.9695,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
loperamide 2 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079069001,NDC,1,EA,4.67,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.9695,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PEMEtrexed 500 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2762301,NDC,1,EA,8086.02,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,3.97,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.85,4.59
PEMEtrexed 500 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2762301,NDC,1,EA,8086.02,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,3.97,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.85,4.59
PEMEtrexed Disodium 100 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2764001,NDC,1,EA,1539.32,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,3.97,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.85,4.59
PEMEtrexed Disodium 100 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2764001,NDC,1,EA,1539.32,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,3.97,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.85,4.59
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,63739035810,NDC,0.5,EA,7.85,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3.9721,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 250 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756079788,NDC,0.5,EA,4.68,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.978,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739028310,NDC,1,EA,8.04,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.9798,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 2.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079045001,NDC,1,EA,9.28,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.98112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079045020,NDC,1,EA,9.28,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3.98112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
digoxin 125 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904592161,NDC,0.5,EA,4.52,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3.98664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268030315,NDC,0.5,EA,4.07,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3.9886,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 4 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,43547034406,NDC,0.125,EA,8.06,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3.9897,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay Bld/Serum Cholesterol,PX82465,CDM,300,RC,82465,CPT,,,,,,,,69,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,3.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.99,67.62
"Reticulocyte Count,Flow Cyto",PX85045,CDM,300,RC,85045,CPT,,,,,,,,92,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,3.99,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.8508,3.99
penicillin v potassium 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714023401,NDC,1,EA,4.1,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3.99053,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034411,NDC,0.25,EA,8.32,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.9936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034411,NDC,0.25,EA,8.32,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.9936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034401,NDC,0.25,EA,8.32,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3.9936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034401,NDC,0.25,EA,8.32,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3.9936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
loperamide 2 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079069020,NDC,1,EA,4.7,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3.995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
verapamil CR 240 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462026001,NDC,0.5,EA,4.39,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3.99929,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
azaTHIOprine 50 MG Tablet 1 Each Blister,J7500.01,CDM,636,RC,J7500,HCPCS,,,,68084022911,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.50926,4.56
"Protein, Total; Other Source",PX84157,CDM,300,RC,84157,CPT,,,,,,,,153,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,4,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.8508,4
PARoxetine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268064011,NDC,1,EA,4.11,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.000263,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268064015,NDC,1,EA,4.11,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.000263,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079096601,NDC,1,EA,9.34,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.00686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,42291053590,NDC,0.5,EA,7.92,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4.00752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084009301,NDC,1,EA,4.4,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4.0084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084080811,NDC,1,EA,4.4,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4.0084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68084080801,NDC,1,EA,4.4,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4.0084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
OXcarbazepine 150 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084084511,NDC,1,EA,8.1,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.0095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcitRIOL 0.25 MCG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687034511,NDC,1,EA,4.12,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.009996,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PEMEtrexed 500 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2762301,NDC,1,EA,8086.02,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,4.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.01,7924.2996
PEMEtrexed Disodium 100 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2764001,NDC,1,EA,1539.32,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,4.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.01,7924.2996
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637061,NDC,0.5,EA,4.41,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4.01751,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
penicillin v potassium 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714023401,NDC,1,EA,4.1,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,904642286,NDC,1,EA,8.2,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,904642286,NDC,1,EA,8.2,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,904642286,NDC,1,EA,8.2,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hyoscyamine 0.125 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42192034001,NDC,1,EA,4.56,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4.02192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
digoxin 125 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904592161,NDC,0.5,EA,4.52,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4.0228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acyclovir 200 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578961,NDC,1,EA,8.21,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.0229,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acyclovir 200 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578961,NDC,1,EA,8.21,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.0229,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acyclovir 200 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578961,NDC,1,EA,8.21,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.0229,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloZAPine 100 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,378086005,NDC,0.25,EA,4.42,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4.02662,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268064011,NDC,1,EA,4.11,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.0278,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268064015,NDC,1,EA,4.11,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.0278,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol LA 80 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,228277911,NDC,0.75,EA,9.7,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.02938,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol LA 80 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,527411737,NDC,0.75,EA,9.7,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.02938,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
busPIRone 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079098501,NDC,1,EA,4.14,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.029462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
busPIRone 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079098520,NDC,1,EA,4.14,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.029462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone 4 MG Tablet 100 Each Bottle,J7509.01,CDM,636,RC,J7509,HCPCS,,,,68382091601,NDC,0.5,EA,4.43,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4.03573,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
levETIRAcetam 750 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,16714035602,NDC,0.333333333,EA,8.41,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4.0368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levETIRAcetam 750 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,16714035602,NDC,0.333333333,EA,8.41,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.0368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcitRIOL 0.25 MCG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687034511,NDC,1,EA,4.12,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.0376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
enalapril 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904550261,NDC,0.5,EA,4.15,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.039195,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
naproxen 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65162018810,NDC,1,EA,4.15,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.039195,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 0.1 MG/ML Solution 55 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,61553067976,NDC,55,ML,89.7,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.04,4.75
HYDROmorphone 1 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409128303,NDC,1,ML,36.93,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.04,4.75
HYDROmorphone 1 MG/ML Solution 1 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,76045000901,NDC,0.25,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.04,4.75
HYDROmorphone 2 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409131203,NDC,1,ML,38.18,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.04,4.75
zolpidem 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018911,NDC,1,EA,9.43,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.04547,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zolpidem 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018901,NDC,1,EA,9.43,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.04547,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714065102,NDC,0.4,EA,9.74,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.045996,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 7.5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406012423,NDC,1,EA,4.76,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4.046,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 7.5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406012462,NDC,1,EA,4.76,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4.046,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
busPIRone 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079098501,NDC,1,EA,4.14,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.0572,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
busPIRone 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079098520,NDC,1,EA,4.14,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.0572,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
meclizine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084049111,NDC,1,EA,4.6,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4.0572,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
meclizine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084049101,NDC,1,EA,4.6,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4.0572,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hyoscyamine 0.125 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42192034001,NDC,1,EA,4.56,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4.0584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,904642286,NDC,1,EA,8.2,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.059,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
triamterene-hydroCHLOROthiazide 37.5-25 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,68084075025,NDC,1,EA,4.78,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4.063,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acyclovir 200 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578961,NDC,1,EA,8.21,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.06395,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
enalapril 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904550261,NDC,0.5,EA,4.15,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.067,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
naproxen 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65162018810,NDC,1,EA,4.15,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.067,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739028310,NDC,1,EA,8.04,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4.06824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buPROPion XL 150 MG Tablet Extended Release 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,904708404,NDC,1,EA,8.48,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4.0704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buPROPion XL 150 MG Tablet Extended Release 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,904708404,NDC,1,EA,8.48,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.0704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
felodipine 5 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462023401,NDC,1,EA,8.48,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4.0704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
felodipine 5 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462023401,NDC,1,EA,8.48,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.0704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079068420,NDC,1,EA,4.79,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4.0715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 3 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,56018875,NDC,0.333333333,EA,4.79,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4.0715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034411,NDC,0.25,EA,8.32,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.0768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034411,NDC,0.25,EA,8.32,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.0768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034411,NDC,0.25,EA,8.32,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.0768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034401,NDC,0.25,EA,8.32,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.0768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034401,NDC,0.25,EA,8.32,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.0768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034401,NDC,0.25,EA,8.32,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.0768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 4 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,43547034406,NDC,0.125,EA,8.06,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4.07836,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 25 MG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,904699104,NDC,1,EA,8.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 25 MG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,904699104,NDC,1,EA,8.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Smear Gram Stain,PX87205,CDM,300,RC,87205,CPT,,,,,,,,109,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,4.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.08,4.27
Smear Gram Stain,PX87205,CDM,300,RC,87205,CPT,,,,,,,,109,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,4.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.08,4.27
sodium chloride 0.9% IV FLUSH 0.9 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,8881570121,NDC,2.5,ML,4.8,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9% IV FLUSH 0.9 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,63807010001,NDC,2.5,ML,4.8,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ciprofloxacin 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862007601,NDC,0.4,EA,9.84,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.087536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prazosin 1 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,70954001950,NDC,1,EA,4.81,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4.0885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"MAYO STAND COVERS 24X53""",27200000,CDM,272,RC,,,,644-MAIN,LOCAL,,,,,9.54,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.09266,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
meclizine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084049111,NDC,1,EA,4.6,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4.094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
meclizine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084049101,NDC,1,EA,4.6,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4.094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
OXcarbazepine 150 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084084511,NDC,1,EA,8.1,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4.0986,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Blood Occult Peroxidase,PX82272,CDM,300,RC,82272,CPT,,,,,,,,64,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,4.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.1,4.23
Blood Occult Peroxidase,PX82272,CDM,300,RC,82272,CPT,,,,,,,,64,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,4.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.1,4.23
Blood Occult Peroxidase,PX82272,CDM,300,RC,82272,CPT,,,,,,,,64,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4.1,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.1,4.23
morphine 1 MG/ML Solution 50 mL Syringe,J2270.01,CDM,636,RC,J2270,HCPCS,,,,61553064975,NDC,50,ML,81.71,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4.1,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.1,4.67
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189001,NDC,1,ML,34.11,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4.1,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.1,4.67
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189003,NDC,1,ML,34.11,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4.1,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.1,4.67
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189101,NDC,1,ML,32.43,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4.1,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.1,4.67
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189103,NDC,1,ML,32.89,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4.1,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.1,4.67
Prothrombin Time (Pt/Inr),PX85610,CDM,300,RC,85610,CPT,,,,,,,,130,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,4.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.1,4.29
Prothrombin Time (Pt/Inr),PX85610,CDM,300,RC,85610,CPT,,,,,,,,130,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,4.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.1,4.29
amLODIPine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904636961,NDC,1,EA,8.55,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4.104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904636961,NDC,1,EA,8.55,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine ER 15 MG Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,68084040311,NDC,1,EA,9.88,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.104152,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Lab Platelet Count,PX85049,CDM,300,RC,85049,CPT,,,,,,,,56,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,4.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.11,54.88
morphine ER 15 MG Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,68084040301,NDC,1,EA,9.9,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.11246,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
digoxin 125 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904592161,NDC,0.5,EA,4.52,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4.11772,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034411,NDC,0.25,EA,8.32,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.1184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034401,NDC,0.25,EA,8.32,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.1184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 875 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862001501,NDC,1,EA,4.67,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4.11894,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
loperamide 2 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079069001,NDC,1,EA,4.67,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4.11894,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levETIRAcetam 750 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,16714035602,NDC,0.333333333,EA,8.41,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.1209,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levETIRAcetam 750 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,16714035602,NDC,0.333333333,EA,8.41,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.1209,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levETIRAcetam 750 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,16714035602,NDC,0.333333333,EA,8.41,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.1209,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ramipril 2.5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237022301,NDC,0.5,EA,4.85,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4.1225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
balsalazide 750 MG capsule 280 Each Bottle,63700001,CDM,250,RC,,,,,,54007928,NDC,1,EA,8.59,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4.1232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
balsalazide 750 MG capsule 280 Each Bottle,63700001,CDM,250,RC,,,,,,54007928,NDC,1,EA,8.59,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.1232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
balsalazide 750 MG capsule 280 Each Bottle,63700001,CDM,250,RC,,,,,,60505257507,NDC,1,EA,8.59,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4.1232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
balsalazide 750 MG capsule 280 Each Bottle,63700001,CDM,250,RC,,,,,,60505257507,NDC,1,EA,8.59,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.1232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
primidone 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084020211,NDC,1,EA,4.24,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.126792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 250 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756079788,NDC,0.5,EA,4.68,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4.12776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SYRINGE BULB 60ML IRRIGATION STERILE DYND20125,27200000,CDM,272,RC,A4322,HCPCS,,10829-MAIN,LOCAL,,,,,2.16,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,4.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
SYRINGE BULB 60ML IRRIGATION STERILE DYND20125,27200000,CDM,272,RC,A4322,HCPCS,,10829-MAIN,LOCAL,,,,,2.16,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,4.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
SYRINGE BULB 60ML IRRIGATION STERILE DYND20125,27200000,CDM,272,RC,A4322,HCPCS,,10829-MAIN,LOCAL,,,,,2.16,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4.13,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
saccharomyces boulardii 250 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,4142000024,NDC,1,EA,4.25,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.136525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terazosin 1 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59746038306,NDC,1,EA,8.62,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4.1376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terazosin 1 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59746038306,NDC,1,EA,8.62,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.1376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diclofenac EC 50 MG Tablet Delayed Release 14 Each Bottle,63700001,CDM,250,RC,,,,,,71335048107,NDC,1,EA,4.87,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4.1395,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Pinworm Exam,PX87172,CDM,300,RC,87172,CPT,,,,,,,,46,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,4.14,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.14,4.27
Pinworm Exam,PX87172,CDM,300,RC,87172,CPT,,,,,,,,46,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,4.14,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.14,4.27
Pinworm Exam,PX87172,CDM,300,RC,87172,CPT,,,,,,,,46,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4.14,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.14,4.27
Smear Gram Stain,PX87205,CDM,300,RC,87205,CPT,,,,,,,,109,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4.14,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.08,4.27
Tissue Exam for Fungi,PX87220,CDM,300,RC,87220,CPT,,,,,,,,94,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,4.14,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.14,4.27
Tissue Exam for Fungi,PX87220,CDM,300,RC,87220,CPT,,,,,,,,94,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,4.14,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.14,4.27
Tissue Exam for Fungi,PX87220,CDM,300,RC,87220,CPT,,,,,,,,94,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4.14,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.14,4.27
Uric Acid; Blood,PX84550,CDM,300,RC,84550,CPT,,,,,,,,52,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,4.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.14,50.96
loperamide 2 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079069020,NDC,1,EA,4.7,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4.1454,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.1 MG/HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,378910216,NDC,1,EA,9.98,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.145692,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.1 MG/HR Patch 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,378910293,NDC,1,EA,9.98,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.145692,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
primidone 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084020201,NDC,1,EA,4.26,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.146258,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,904642286,NDC,1,EA,8.2,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4.1492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline monohydrate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084074333,NDC,1,EA,9.99,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.149846,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay Bld/Serum Cholesterol,PX82465,CDM,300,RC,82465,CPT,,,,,,,,69,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,4.15,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.15,4.35
Assay Bld/Serum Cholesterol,PX82465,CDM,300,RC,82465,CPT,,,,,,,,69,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,4.15,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.15,4.35
Antinuclear Antibodies,PX86038,CDM,300,RC,86038,CPT,,,,,,,,10,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,11.09
Calcium - Ref,PX8231090,CDM,300,RC,82310,CPT,90,,,,,,,10,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,9.8
DRAPE SURGICAL 23X17INCH INCISE 1050,27200000,CDM,272,RC,,,,12873-MAIN,LOCAL,,,,,10,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
KERRAMAX CARE SUPERABSORBENT DRESSING 5X6,120.548,CDM,272,RC,A6197,HCPCS,,12362-MAIN,LOCAL,,,,,10,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,9.8
NEEDLE HYPODERMIC 22GA 1-1/2IN STERILE 305156,27200000,CDM,272,RC,A4215,HCPCS,,8887-MAIN,LOCAL,,,,,10,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Needle Insertion W/O Injection 1 or 2 Muscles,PX20560,CDM,420,RC,20560,CPT,,,,,,,,10,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,26.01
Needle Insertion W/O Injection 3 or More Muscles,PX20561,CDM,420,RC,20561,CPT,,,,,,,,10,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,26.01
PAD GROUNDING 9 FT ADULT REM E7507,27200000,CDM,272,RC,,,,504-MAIN,LOCAL,,,,,10,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
hyoscyamine 0.125 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42192034001,NDC,1,EA,4.56,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4.15416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acyclovir 200 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578961,NDC,1,EA,8.21,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4.15426,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buPROPion XL 150 MG Tablet Extended Release 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,904708404,NDC,1,EA,8.48,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.1552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buPROPion XL 150 MG Tablet Extended Release 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,904708404,NDC,1,EA,8.48,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.1552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buPROPion XL 150 MG Tablet Extended Release 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,904708404,NDC,1,EA,8.48,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.1552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
felodipine 5 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462023401,NDC,1,EA,8.48,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.1552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
felodipine 5 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462023401,NDC,1,EA,8.48,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.1552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
felodipine 5 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462023401,NDC,1,EA,8.48,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.1552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
primidone 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084020211,NDC,1,EA,4.24,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.1552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406012323,NDC,1,EA,4.27,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.155991,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406012362,NDC,1,EA,4.27,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.155991,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 88 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904695261,NDC,1.136363636,EA,4.27,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.155991,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079099101,NDC,1,EA,4.27,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.155991,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079099120,NDC,1,EA,4.27,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.155991,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 875 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862001501,NDC,1,EA,4.67,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4.1563,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
loperamide 2 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079069001,NDC,1,EA,4.67,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4.1563,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Prothrombin Time (Pt/Inr),PX85610,CDM,300,RC,85610,CPT,,,,,,,,130,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4.16,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.1,4.29
propranolol LA 80 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,228277911,NDC,0.75,EA,9.7,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.1613,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol LA 80 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,527411737,NDC,0.75,EA,9.7,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.1613,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levETIRAcetam 750 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,16714035602,NDC,0.333333333,EA,8.41,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.16295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 25 MG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,904699104,NDC,1,EA,8.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 25 MG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,904699104,NDC,1,EA,8.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 25 MG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,904699104,NDC,1,EA,8.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
saccharomyces boulardii 250 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,4142000024,NDC,1,EA,4.25,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 250 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756079788,NDC,0.5,EA,4.68,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4.1652,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 750 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877041401,NDC,0.666666667,EA,4.28,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.165724,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay Bld/Serum Cholesterol,PX82465,CDM,300,RC,82465,CPT,,,,,,,,69,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,4.1717,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.15,4.35
Blood Occult Peroxidase,PX82272,CDM,300,RC,82272,CPT,,,,,,,,64,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,4.1717,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.1,4.23
Pinworm Exam,PX87172,CDM,300,RC,87172,CPT,,,,,,,,46,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,4.1717,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.14,4.27
Prothrombin Time (Pt/Inr),PX85610,CDM,300,RC,85610,CPT,,,,,,,,130,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,4.1717,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.1,4.29
Smear Gram Stain,PX87205,CDM,300,RC,87205,CPT,,,,,,,,109,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,4.1717,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.08,4.27
Tissue Exam for Fungi,PX87220,CDM,300,RC,87220,CPT,,,,,,,,94,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,4.1717,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.14,4.27
morphine ER 15 MG Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,406831523,NDC,1,EA,10.05,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.17477,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine ER 15 MG Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,406831562,NDC,1,EA,10.05,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.17477,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
primidone 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084020201,NDC,1,EA,4.26,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.1748,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714065102,NDC,0.4,EA,9.74,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.17846,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SYRINGE BULB 60ML IRRIGATION STERILE DYND20125,27200000,CDM,272,RC,A4322,HCPCS,,10829-MAIN,LOCAL,,,,,2.16,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,4.1821,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
loperamide 2 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079069020,NDC,1,EA,4.7,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4.183,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406012323,NDC,1,EA,4.27,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.1846,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406012362,NDC,1,EA,4.27,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.1846,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 88 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904695261,NDC,1.136363636,EA,4.27,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.1846,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079099101,NDC,1,EA,4.27,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.1846,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079099120,NDC,1,EA,4.27,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.1846,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079075901,NDC,1,EA,4.3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.18519,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine CR 12.5 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,42858070303,NDC,1,EA,4.3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.18519,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904636961,NDC,1,EA,8.55,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.1895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904636961,NDC,1,EA,8.55,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.1895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904636961,NDC,1,EA,8.55,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.1895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
meclizine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084049111,NDC,1,EA,4.6,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4.1906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
meclizine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084049101,NDC,1,EA,4.6,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4.1906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 750 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877041401,NDC,0.666666667,EA,4.28,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.1944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buPROPion XL 150 MG Tablet Extended Release 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,904708404,NDC,1,EA,8.48,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.1976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
felodipine 5 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462023401,NDC,1,EA,8.48,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.1976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 7.5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406012423,NDC,1,EA,4.76,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4.19832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 7.5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406012462,NDC,1,EA,4.76,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4.19832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metroNIDAZOLE 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084096611,NDC,1,EA,4.94,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metroNIDAZOLE 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084096601,NDC,1,EA,4.94,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739026310,NDC,1,EA,4.32,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.204656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 25 MG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,904699104,NDC,1,EA,8.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.2075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
balsalazide 750 MG capsule 280 Each Bottle,63700001,CDM,250,RC,,,,,,54007928,NDC,1,EA,8.59,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.2091,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
balsalazide 750 MG capsule 280 Each Bottle,63700001,CDM,250,RC,,,,,,54007928,NDC,1,EA,8.59,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.2091,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
balsalazide 750 MG capsule 280 Each Bottle,63700001,CDM,250,RC,,,,,,54007928,NDC,1,EA,8.59,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.2091,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
balsalazide 750 MG capsule 280 Each Bottle,63700001,CDM,250,RC,,,,,,60505257507,NDC,1,EA,8.59,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.2091,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
balsalazide 750 MG capsule 280 Each Bottle,63700001,CDM,250,RC,,,,,,60505257507,NDC,1,EA,8.59,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.2091,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
balsalazide 750 MG capsule 280 Each Bottle,63700001,CDM,250,RC,,,,,,60505257507,NDC,1,EA,8.59,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.2091,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pravastatin 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079045801,NDC,0.5,EA,8.77,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4.2096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pravastatin 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079045801,NDC,0.5,EA,8.77,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.2096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034411,NDC,0.25,EA,8.32,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4.20992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034401,NDC,0.25,EA,8.32,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4.20992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079075901,NDC,1,EA,4.3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine CR 12.5 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,42858070303,NDC,1,EA,4.3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
triamterene-hydroCHLOROthiazide 37.5-25 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,68084075025,NDC,1,EA,4.78,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4.21596,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay Bld/Serum Cholesterol,PX82465,CDM,300,RC,82465,CPT,,,,,,,,69,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4.22,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.15,4.35
DRESSING SURGICEL HEMOSTAT 4X8 ABSORBABLE 1952,120.123,CDM,272,RC,A6252,HCPCS,,1002-MAIN,LOCAL,,,,,125,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,4.22,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.22,4.5038
levothyroxine 100 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,74662411,NDC,1,EA,10.16,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.220464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,70677003201,NDC,1,EA,10.16,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.220464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862007601,NDC,0.4,EA,9.84,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.22136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terazosin 1 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59746038306,NDC,1,EA,8.62,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.2238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terazosin 1 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59746038306,NDC,1,EA,8.62,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.2238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terazosin 1 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59746038306,NDC,1,EA,8.62,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.2238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079068420,NDC,1,EA,4.79,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4.22478,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 3 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,56018875,NDC,0.333333333,EA,4.79,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4.22478,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Blood Occult Peroxidase,PX82272,CDM,300,RC,82272,CPT,,,,,,,,64,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,4.23,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.1,4.23
certolizumab 2 X 200 MG Kit 1 Each Box,J0717.01,CDM,636,RC,J0717,HCPCS,,,,50474070062,NDC,0.5,EA,4911.87,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4.23,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.23,4.82
amLODIPine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904636961,NDC,1,EA,8.55,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.23225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739026310,NDC,1,EA,4.32,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.2336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium chloride 0.9% IV FLUSH 0.9 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,8881570121,NDC,2.5,ML,4.8,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4.2336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9% IV FLUSH 0.9 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,63807010001,NDC,2.5,ML,4.8,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4.2336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
HYDROcodone-acetaminophen 7.5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406012423,NDC,1,EA,4.76,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4.2364,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 7.5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406012462,NDC,1,EA,4.76,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4.2364,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine ER 15 MG Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,68084040311,NDC,1,EA,9.88,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.23852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CISplatin 50 MG/50ML Solution 50 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010351,NDC,50,ML,82.27,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,4.24,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.217,4.24
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,703574811,NDC,100,ML,183.92,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,4.24,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.217,4.24
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010365,NDC,100,ML,164.54,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,4.24,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.217,4.24
nitroglycerin 0.2 MG/HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,378910416,NDC,1,EA,10.21,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.241234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.2 MG/HR Patch 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,378910493,NDC,1,EA,10.21,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.241234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prazosin 1 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,70954001950,NDC,1,EA,4.81,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4.24242,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine ER 15 MG Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,68084040301,NDC,1,EA,9.9,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.2471,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DRESSING MESALT 6X6 IMPREGNATED GAUZE STERILE 285780,120.511,CDM,272,RC,A6223,HCPCS,,12059-SURG,LOCAL,,,,,5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.077,4.9
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,71041813,NDC,1,EA,5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
balsalazide 750 MG capsule 280 Each Bottle,63700001,CDM,250,RC,,,,,,54007928,NDC,1,EA,8.59,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.25205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
balsalazide 750 MG capsule 280 Each Bottle,63700001,CDM,250,RC,,,,,,60505257507,NDC,1,EA,8.59,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.25205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,42806040021,NDC,1,EA,8.86,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4.2528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,42806040021,NDC,1,EA,8.86,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.2528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
triamterene-hydroCHLOROthiazide 37.5-25 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,68084075025,NDC,1,EA,4.78,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4.2542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 875 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862001501,NDC,1,EA,4.67,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4.25437,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
loperamide 2 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079069001,NDC,1,EA,4.67,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4.25437,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levETIRAcetam 750 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,16714035602,NDC,0.333333333,EA,8.41,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4.25546,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079068420,NDC,1,EA,4.79,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4.2631,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 3 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,56018875,NDC,0.333333333,EA,4.79,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4.2631,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 250 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756079788,NDC,0.5,EA,4.68,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4.26348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terazosin 1 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59746038306,NDC,1,EA,8.62,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.2669,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"BANDAGE STERILE  2"" TETRA-FLEX CLIP FREE 0151-2SV",27200000,CDM,272,RC,A6449,HCPCS,,10660-MAIN,LOCAL,,,,,5.02,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4.267,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Pinworm Exam,PX87172,CDM,300,RC,87172,CPT,,,,,,,,46,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,4.27,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.14,4.27
Smear Gram Stain,PX87205,CDM,300,RC,87205,CPT,,,,,,,,109,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,4.27,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.08,4.27
Tissue Exam for Fungi,PX87220,CDM,300,RC,87220,CPT,,,,,,,,94,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,4.27,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.14,4.27
prothrombin complex concentrate - human 500 units Kit 500 Units Box,J7168.01,CDM,636,RC,J7168,HCPCS,,,,63833038602,NDC,1500,UN,8007,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,4.272,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.31,4.272
prothrombin complex concentrate - human 500 units Kit 500 Units Box,J7168.01,CDM,636,RC,J7168,HCPCS,,,,63833038602,NDC,1500,UN,8007,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,4.272,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.31,4.272
sodium chloride 0.9% IV FLUSH 0.9 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,8881570121,NDC,2.5,ML,4.8,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4.272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9% IV FLUSH 0.9 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,63807010001,NDC,2.5,ML,4.8,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4.272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
verapamil CR 240 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462026001,NDC,0.5,EA,4.39,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.272787,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ramipril 2.5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237022301,NDC,0.5,EA,4.85,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4.2777,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
degarelix acetate 40 mg/mL Recon Soln 1 Each Vial,J9155.01,CDM,636,RC,J9155,HCPCS,,,,55566840301,NDC,2,EA,3109.33,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,4.27861,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.68,4.4
Lab Platelet Count,PX85049,CDM,300,RC,85049,CPT,,,,,,,,56,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,4.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.28,4.4926
Lab Platelet Count,PX85049,CDM,300,RC,85049,CPT,,,,,,,,56,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,4.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.28,4.4926
prazosin 1 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,70954001950,NDC,1,EA,4.81,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4.2809,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.1 MG/HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,378910216,NDC,1,EA,9.98,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.28142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.1 MG/HR Patch 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,378910293,NDC,1,EA,9.98,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.28142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
loperamide 2 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079069020,NDC,1,EA,4.7,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4.2817,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa 25-100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084009301,NDC,1,EA,4.4,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.28252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084080811,NDC,1,EA,4.4,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.28252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68084080801,NDC,1,EA,4.4,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.28252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa CR 25-100 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756046188,NDC,1,EA,5.04,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4.284,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline monohydrate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084074333,NDC,1,EA,9.99,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.28571,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Antinuclear Antibodies,PX86038,CDM,300,RC,86038,CPT,,,,,,,,10,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,11.09
Calcium - Ref,PX8231090,CDM,300,RC,82310,CPT,90,,,,,,,10,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,9.8
DRAPE SURGICAL 23X17INCH INCISE 1050,27200000,CDM,272,RC,,,,12873-MAIN,LOCAL,,,,,10,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
KERRAMAX CARE SUPERABSORBENT DRESSING 5X6,120.548,CDM,272,RC,A6197,HCPCS,,12362-MAIN,LOCAL,,,,,10,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,9.8
NEEDLE HYPODERMIC 22GA 1-1/2IN STERILE 305156,27200000,CDM,272,RC,A4215,HCPCS,,8887-MAIN,LOCAL,,,,,10,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Needle Insertion W/O Injection 1 or 2 Muscles,PX20560,CDM,420,RC,20560,CPT,,,,,,,,10,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,26.01
Needle Insertion W/O Injection 3 or More Muscles,PX20561,CDM,420,RC,20561,CPT,,,,,,,,10,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,26.01
PAD GROUNDING 9 FT ADULT REM E7507,27200000,CDM,272,RC,,,,504-MAIN,LOCAL,,,,,10,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Prothrombin Time (Pt/Inr),PX85610,CDM,300,RC,85610,CPT,,,,,,,,130,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,4.29,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.1,4.29
buPROPion XL 150 MG Tablet Extended Release 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,904708404,NDC,1,EA,8.48,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4.29088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
felodipine 5 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462023401,NDC,1,EA,8.48,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4.29088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637061,NDC,0.5,EA,4.41,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.292253,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diclofenac EC 50 MG Tablet Delayed Release 14 Each Bottle,63700001,CDM,250,RC,,,,,,71335048107,NDC,1,EA,4.87,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4.29534,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pravastatin 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079045801,NDC,0.5,EA,8.77,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.2973,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pravastatin 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079045801,NDC,0.5,EA,8.77,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.2973,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pravastatin 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079045801,NDC,0.5,EA,8.77,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.2973,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268011015,NDC,1,EA,5.06,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4.301,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 25 MG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,904699104,NDC,1,EA,8.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4.301,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloZAPine 100 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,378086005,NDC,0.25,EA,4.42,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.301986,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
verapamil CR 240 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462026001,NDC,0.5,EA,4.39,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.3022,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 30 Each Box,63700001,CDM,250,RC,,,,,,904693176,NDC,1,EA,8.97,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4.3056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 30 Each Box,63700001,CDM,250,RC,,,,,,904693176,NDC,1,EA,8.97,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.3056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68462033190,NDC,0.5,EA,8.97,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4.3056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68462033190,NDC,0.5,EA,8.97,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.3056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine ER 15 MG Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,406831523,NDC,1,EA,10.05,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.31145,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine ER 15 MG Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,406831562,NDC,1,EA,10.05,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.31145,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone 4 MG Tablet 100 Each Bottle,J7509.01,CDM,636,RC,J7509,HCPCS,,,,68382091601,NDC,0.5,EA,4.43,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.311719,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
carbidopa-levodopa 25-100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084009301,NDC,1,EA,4.4,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084080811,NDC,1,EA,4.4,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
traMADol 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68084080801,NDC,1,EA,4.4,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ramipril 2.5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237022301,NDC,0.5,EA,4.85,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4.3165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Osmolality; Blood,PX83930,CDM,300,RC,83930,CPT,,,,,,,,9,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.7386,8.82
Osmolality; Blood,PX83930,CDM,300,RC,83930,CPT,,,,,,,,9,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.7386,8.82
SUTURE ETHILON SIZE 0 96INCH TP1,27200000,CDM,272,RC,,,,12140-MAIN,LOCAL,,,,,9,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE ETHILON SIZE 0 96INCH TP1,27200000,CDM,272,RC,,,,12140-MAIN,LOCAL,,,,,9,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE PROLENE 3-0 BLUE SH NEEDLE MONOFILAMENT 30INCH,27200000,CDM,272,RC,,,,12840-MAIN,LOCAL,,,,,9,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE PROLENE 3-0 BLUE SH NEEDLE MONOFILAMENT 30INCH,27200000,CDM,272,RC,,,,12840-MAIN,LOCAL,,,,,9,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637061,NDC,0.5,EA,4.41,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.3218,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide mononitrate CR 30 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084059111,NDC,1,EA,9.01,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4.3248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide mononitrate CR 30 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084059111,NDC,1,EA,9.01,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.3248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide mononitrate CR 30 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084059101,NDC,1,EA,9.01,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4.3248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide mononitrate CR 30 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084059101,NDC,1,EA,9.01,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.3248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904636961,NDC,1,EA,8.55,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4.3263,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Body Fluid Cell Count,PX89050,CDM,300,RC,89050,CPT,,,,,,,,152,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,4.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.33,148.96
cloZAPine 100 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,378086005,NDC,0.25,EA,4.42,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.3316,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,57237017290,NDC,1,EA,10.43,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.332622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714031101,NDC,1,EA,10.43,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.332622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57664039288,NDC,1,EA,10.43,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.332622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diclofenac EC 50 MG Tablet Delayed Release 14 Each Bottle,63700001,CDM,250,RC,,,,,,71335048107,NDC,1,EA,4.87,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4.3343,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 7.5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406012423,NDC,1,EA,4.76,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4.33636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 7.5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406012462,NDC,1,EA,4.76,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4.33636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Potassium; Urine,PX84133,CDM,300,RC,84133,CPT,,,,,,,,50,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,4.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.34,49
pravastatin 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079045801,NDC,0.5,EA,8.77,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.34115,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone 4 MG Tablet 100 Each Bottle,J7509.01,CDM,636,RC,J7509,HCPCS,,,,68382091601,NDC,0.5,EA,4.43,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.3414,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,42806040021,NDC,1,EA,8.86,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.3414,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,42806040021,NDC,1,EA,8.86,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.3414,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,42806040021,NDC,1,EA,8.86,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.3414,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,50111099001,NDC,1,EA,9.05,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4.344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,50111099001,NDC,1,EA,9.05,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
balsalazide 750 MG capsule 280 Each Bottle,63700001,CDM,250,RC,,,,,,54007928,NDC,1,EA,8.59,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4.34654,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
balsalazide 750 MG capsule 280 Each Bottle,63700001,CDM,250,RC,,,,,,60505257507,NDC,1,EA,8.59,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4.34654,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay Bld/Serum Cholesterol,PX82465,CDM,300,RC,82465,CPT,,,,,,,,69,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,4.35,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.15,4.35
Assay of Phosphorus,PX84100,CDM,300,RC,84100,CPT,,,,,,,,150,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,4.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.35,147
degarelix acetate 40 mg/mL Recon Soln 1 Each Vial,J9155.01,CDM,636,RC,J9155,HCPCS,,,,55566840301,NDC,2,EA,3109.33,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,4.35,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.68,4.4
degarelix acetate 40 mg/mL Recon Soln 1 Each Vial,J9155.01,CDM,636,RC,J9155,HCPCS,,,,55566840301,NDC,2,EA,3109.33,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,4.35,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.68,4.4
Lab Platelet Count,PX85049,CDM,300,RC,85049,CPT,,,,,,,,56,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4.35,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.28,4.4926
Po4 Inorganic (Phosphate) - Ref,PX8410090,CDM,300,RC,84100,CPT,90,,,,,,,150,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,4.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.35,147
triamterene-hydroCHLOROthiazide 37.5-25 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,68084075025,NDC,1,EA,4.78,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4.35458,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metroNIDAZOLE 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084096611,NDC,1,EA,4.94,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4.35708,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metroNIDAZOLE 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084096601,NDC,1,EA,4.94,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4.35708,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739038710,NDC,0.5,EA,9.08,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4.3584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739038710,NDC,0.5,EA,9.08,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.3584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 100 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,74662411,NDC,1,EA,10.16,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.35864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,70677003201,NDC,1,EA,10.16,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.35864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Antibiotic Sens,Enzyme Detection,Each - Ref",PX8718590,CDM,300,RC,87185,CPT,90,,,,,,,13,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,4.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.36,12.74
Glucose Test,PX82950,CDM,300,RC,82950,CPT,,,,,,,,74,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,4.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.36,72.52
"Potassium; Serum, Plasma or Whole Blood",PX84132,CDM,300,RC,84132,CPT,,,,,,,,59,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,4.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.36,57.82
terazosin 1 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59746038306,NDC,1,EA,8.62,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4.36172,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079068420,NDC,1,EA,4.79,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4.36369,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 3 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,56018875,NDC,0.333333333,EA,4.79,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4.36369,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium chloride 0.9% IV FLUSH 0.9 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,8881570121,NDC,2.5,ML,4.8,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4.3728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9% IV FLUSH 0.9 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,63807010001,NDC,2.5,ML,4.8,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4.3728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
morphine 1 MG/ML Solution 50 mL Syringe,J2270.01,CDM,636,RC,J2270,HCPCS,,,,61553064975,NDC,50,ML,81.71,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,4.37512,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.1,4.67
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189001,NDC,1,ML,34.11,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,4.37512,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.1,4.67
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189003,NDC,1,ML,34.11,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,4.37512,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.1,4.67
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189101,NDC,1,ML,32.43,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,4.37512,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.1,4.67
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189103,NDC,1,ML,32.89,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,4.37512,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.1,4.67
tolterodine 2 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,59762080002,NDC,0.5,EA,9.12,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4.3776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tolterodine 2 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,59762080002,NDC,0.5,EA,9.12,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.3776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Uric Acid; Blood,PX84550,CDM,300,RC,84550,CPT,,,,,,,,52,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,4.38,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.38,4.52
Uric Acid; Blood,PX84550,CDM,300,RC,84550,CPT,,,,,,,,52,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,4.38,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.38,4.52
Uric Acid; Blood,PX84550,CDM,300,RC,84550,CPT,,,,,,,,52,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4.38,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.38,4.52
nitroglycerin 0.2 MG/HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,378910416,NDC,1,EA,10.21,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.38009,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.2 MG/HR Patch 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,378910493,NDC,1,EA,10.21,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.38009,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prazosin 1 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,70954001950,NDC,1,EA,4.81,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4.38191,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,42806040021,NDC,1,EA,8.86,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.3857,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42937070110,NDC,1,EA,5.16,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4.386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
verapamil CR 180 MG Tablet Extended Release 100 Each Bottle,25000000,CDM,250,RC,,,,,,75834015801,NDC,0.666666667,EA,5.16,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4.386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
polyethylene glycol 3350 17 g Packet 30 Each Box,63700001,CDM,250,RC,,,,,,904693176,NDC,1,EA,8.97,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.3953,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 30 Each Box,63700001,CDM,250,RC,,,,,,904693176,NDC,1,EA,8.97,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.3953,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 30 Each Box,63700001,CDM,250,RC,,,,,,904693176,NDC,1,EA,8.97,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.3953,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68462033190,NDC,0.5,EA,8.97,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.3953,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68462033190,NDC,0.5,EA,8.97,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.3953,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68462033190,NDC,0.5,EA,8.97,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.3953,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metroNIDAZOLE 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084096611,NDC,1,EA,4.94,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4.3966,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metroNIDAZOLE 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084096601,NDC,1,EA,4.94,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4.3966,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,51991060401,NDC,1,EA,10.59,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.399086,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,64380073706,NDC,1,EA,10.59,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.399086,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
digoxin 125 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904592161,NDC,0.5,EA,4.52,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.399316,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
degarelix acetate 40 mg/mL Recon Soln 1 Each Vial,J9155.01,CDM,636,RC,J9155,HCPCS,,,,55566840301,NDC,2,EA,3109.33,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,4.4,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.68,4.4
certolizumab 2 X 200 MG Kit 1 Each Box,J0717.01,CDM,636,RC,J0717,HCPCS,,,,50474070062,NDC,0.5,EA,4911.87,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,4.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.41,4813.6326
DRESSING MESALT 6X6 IMPREGNATED GAUZE STERILE 285780,120.511,CDM,272,RC,A6223,HCPCS,,12059-SURG,LOCAL,,,,,5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.077,4.9
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,71041813,NDC,1,EA,5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Osmolality; Blood,PX83930,CDM,300,RC,83930,CPT,,,,,,,,9,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,7.63,percent of total billed charges,4.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.7386,8.82
Osmolality; Blood,PX83930,CDM,300,RC,83930,CPT,,,,,,,,9,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.7386,8.82
Osmolality; Blood,PX83930,CDM,300,RC,83930,CPT,,,,,,,,9,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.7386,8.82
"Sodium; Serum, Plasma or Whole Blood",PX84295,CDM,300,RC,84295,CPT,,,,,,,,58,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,4.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.41,56.84
SUTURE ETHILON SIZE 0 96INCH TP1,27200000,CDM,272,RC,,,,12140-MAIN,LOCAL,,,,,9,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE ETHILON SIZE 0 96INCH TP1,27200000,CDM,272,RC,,,,12140-MAIN,LOCAL,,,,,9,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE ETHILON SIZE 0 96INCH TP1,27200000,CDM,272,RC,,,,12140-MAIN,LOCAL,,,,,9,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE PROLENE 3-0 BLUE SH NEEDLE MONOFILAMENT 30INCH,27200000,CDM,272,RC,,,,12840-MAIN,LOCAL,,,,,9,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE PROLENE 3-0 BLUE SH NEEDLE MONOFILAMENT 30INCH,27200000,CDM,272,RC,,,,12840-MAIN,LOCAL,,,,,9,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE PROLENE 3-0 BLUE SH NEEDLE MONOFILAMENT 30INCH,27200000,CDM,272,RC,,,,12840-MAIN,LOCAL,,,,,9,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STOCKINETTE STERILE 4X48 NON22360,27200000,CDM,272,RC,A6457,HCPCS,,10658-MAIN,LOCAL,,,,,10.62,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.411548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
isosorbide mononitrate CR 30 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084059111,NDC,1,EA,9.01,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.4149,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide mononitrate CR 30 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084059111,NDC,1,EA,9.01,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.4149,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide mononitrate CR 30 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084059111,NDC,1,EA,9.01,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.4149,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide mononitrate CR 30 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084059101,NDC,1,EA,9.01,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.4149,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide mononitrate CR 30 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084059101,NDC,1,EA,9.01,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.4149,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide mononitrate CR 30 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084059101,NDC,1,EA,9.01,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.4149,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ramipril 2.5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237022301,NDC,0.5,EA,4.85,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4.41835,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079064420,NDC,1,EA,5.2,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"BANDAGE STERILE  2"" TETRA-FLEX CLIP FREE 0151-2SV",27200000,CDM,272,RC,A6449,HCPCS,,10660-MAIN,LOCAL,,,,,5.02,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4.42764,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
digoxin 125 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904592161,NDC,0.5,EA,4.52,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.4296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,50111099001,NDC,1,EA,9.05,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.4345,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,50111099001,NDC,1,EA,9.05,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.4345,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,50111099001,NDC,1,EA,9.05,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.4345,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 100 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,69097012403,NDC,0.25,EA,9.24,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4.4352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 100 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,69097012403,NDC,0.25,EA,9.24,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.4352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
riFAMpin 150 MG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,68084035721,NDC,1,EA,10.68,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.436472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diclofenac EC 50 MG Tablet Delayed Release 14 Each Bottle,63700001,CDM,250,RC,,,,,,71335048107,NDC,1,EA,4.87,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4.43657,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pravastatin 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079045801,NDC,0.5,EA,8.77,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4.43762,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hyoscyamine 0.125 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42192034001,NDC,1,EA,4.56,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.438248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DRESSING SURGICEL HEMOSTAT 4X8 ABSORBABLE 1952,120.123,CDM,272,RC,A6252,HCPCS,,1002-MAIN,LOCAL,,,,,125,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,4.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.22,4.5038
DRESSING SURGICEL HEMOSTAT 4X8 ABSORBABLE 1952,120.123,CDM,272,RC,A6252,HCPCS,,1002-MAIN,LOCAL,,,,,125,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,4.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.22,4.5038
DRESSING SURGICEL HEMOSTAT 4X8 ABSORBABLE 1952,120.123,CDM,272,RC,A6252,HCPCS,,1002-MAIN,LOCAL,,,,,125,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4.44,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.22,4.5038
polyethylene glycol 3350 17 g Packet 30 Each Box,63700001,CDM,250,RC,,,,,,904693176,NDC,1,EA,8.97,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.44015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68462033190,NDC,0.5,EA,8.97,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.44015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa CR 25-100 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756046188,NDC,1,EA,5.04,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4.44528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,185060501,NDC,1,EA,5.23,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4.4455,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739038710,NDC,0.5,EA,9.08,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.4492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739038710,NDC,0.5,EA,9.08,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.4492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739038710,NDC,0.5,EA,9.08,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.4492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DRESSING MESALT 6X6 IMPREGNATED GAUZE STERILE 285780,120.511,CDM,272,RC,A6223,HCPCS,,12059-SURG,LOCAL,,,,,5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.077,4.9
morphine 1 MG/ML Solution 50 mL Syringe,J2270.01,CDM,636,RC,J2270,HCPCS,,,,61553064975,NDC,50,ML,81.71,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,4.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.1,4.67
morphine 1 MG/ML Solution 50 mL Syringe,J2270.01,CDM,636,RC,J2270,HCPCS,,,,61553064975,NDC,50,ML,81.71,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,4.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.1,4.67
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189001,NDC,1,ML,34.11,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,4.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.1,4.67
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189001,NDC,1,ML,34.11,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,4.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.1,4.67
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189003,NDC,1,ML,34.11,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,4.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.1,4.67
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189003,NDC,1,ML,34.11,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,4.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.1,4.67
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189101,NDC,1,ML,32.43,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,4.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.1,4.67
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189101,NDC,1,ML,32.43,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,4.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.1,4.67
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189103,NDC,1,ML,32.89,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,4.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.1,4.67
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189103,NDC,1,ML,32.89,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,4.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.1,4.67
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,71041813,NDC,1,EA,5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 2.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079045001,NDC,1,EA,9.28,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4.4544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 2.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079045001,NDC,1,EA,9.28,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.4544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079045020,NDC,1,EA,9.28,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4.4544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079045020,NDC,1,EA,9.28,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.4544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Osmolality; Blood,PX83930,CDM,300,RC,83930,CPT,,,,,,,,9,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.455,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.7386,8.82
SUTURE ETHILON SIZE 0 96INCH TP1,27200000,CDM,272,RC,,,,12140-MAIN,LOCAL,,,,,9,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.455,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE PROLENE 3-0 BLUE SH NEEDLE MONOFILAMENT 30INCH,27200000,CDM,272,RC,,,,12840-MAIN,LOCAL,,,,,9,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.455,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
isosorbide mononitrate CR 30 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084059111,NDC,1,EA,9.01,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.45995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide mononitrate CR 30 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084059101,NDC,1,EA,9.01,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.45995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cefOXitin 1 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021010910,NDC,1,EA,58.66,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4.46,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.46,5.08
cefOXitin 2 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021011020,NDC,1,EA,77.24,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4.46,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.46,5.08
"Sodium, Other Source - Ref",PX8430290,CDM,300,RC,84302,CPT,90,,,,,,,27,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,4.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.46,26.46
benazepril 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268011015,NDC,1,EA,5.06,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4.46292,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"BANDAGE STERILE  2"" TETRA-FLEX CLIP FREE 0151-2SV",27200000,CDM,272,RC,A6449,HCPCS,,10660-MAIN,LOCAL,,,,,5.02,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4.4678,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
hyoscyamine 0.125 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42192034001,NDC,1,EA,4.56,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.4688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tolterodine 2 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,59762080002,NDC,0.5,EA,9.12,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.4688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tolterodine 2 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,59762080002,NDC,0.5,EA,9.12,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.4688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tolterodine 2 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,59762080002,NDC,0.5,EA,9.12,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.4688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay Blood Carbon Dioxide,PX82374,CDM,300,RC,82374,CPT,,,,,,,,95,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,4.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.47,93.1
leucovorin 10 mg/mL Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,25021081467,NDC,1,EA,40.13,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,4.47,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.93,5.13
leucovorin 350 MG Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,703514501,NDC,1,EA,86.41,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,4.47,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.93,5.13
venlafaxine 25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,57237017290,NDC,1,EA,10.43,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.47447,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714031101,NDC,1,EA,10.43,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.47447,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57664039288,NDC,1,EA,10.43,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.47447,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
meclizine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084049111,NDC,1,EA,4.6,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.47718,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
meclizine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084049101,NDC,1,EA,4.6,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.47718,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,50111099001,NDC,1,EA,9.05,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.47975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Lab Platelet Count,PX85049,CDM,300,RC,85049,CPT,,,,,,,,56,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,4.48,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.28,4.4926
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,42806040021,NDC,1,EA,8.86,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4.48316,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
famotidine 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079096601,NDC,1,EA,9.34,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4.4832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079096601,NDC,1,EA,9.34,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.4832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa CR 25-100 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756046188,NDC,1,EA,5.04,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4.4856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of Phosphorus,PX84100,CDM,300,RC,84100,CPT,,,,,,,,150,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,4.4926,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.4926,4.74
Body Fluid Cell Count,PX89050,CDM,300,RC,89050,CPT,,,,,,,,152,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,4.4926,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.4926,4.72
Lab Platelet Count,PX85049,CDM,300,RC,85049,CPT,,,,,,,,56,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,4.4926,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.28,4.4926
Po4 Inorganic (Phosphate) - Ref,PX8410090,CDM,300,RC,84100,CPT,90,,,,,,,150,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,4.4926,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.4926,4.74
Potassium; Urine,PX84133,CDM,300,RC,84133,CPT,,,,,,,,50,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,4.4926,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.4926,4.73
Uric Acid; Blood,PX84550,CDM,300,RC,84550,CPT,,,,,,,,52,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,4.4926,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.38,4.52
amiodarone 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739038710,NDC,0.5,EA,9.08,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.4946,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"SUTURE SILK 2-0 BLK BR FS 18"" 685G",27200000,CDM,272,RC,,,,2668-MAIN,LOCAL,,,,,5.29,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4.4965,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
metroNIDAZOLE 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084096611,NDC,1,EA,4.94,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4.50034,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metroNIDAZOLE 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084096601,NDC,1,EA,4.94,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4.50034,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268011015,NDC,1,EA,5.06,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4.5034,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DRESSING SURGICEL HEMOSTAT 4X8 ABSORBABLE 1952,120.123,CDM,272,RC,A6252,HCPCS,,1002-MAIN,LOCAL,,,,,125,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,4.5038,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.22,4.5038
flecainide 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237006301,NDC,1,EA,10.85,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.50709,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
meclizine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084049111,NDC,1,EA,4.6,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.508,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
meclizine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084049101,NDC,1,EA,4.6,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.508,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tolterodine 2 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,59762080002,NDC,0.5,EA,9.12,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.5144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Uric Acid; Blood,PX84550,CDM,300,RC,84550,CPT,,,,,,,,52,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,4.52,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.38,4.52
zolpidem 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018911,NDC,1,EA,9.43,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4.5264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zolpidem 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018911,NDC,1,EA,9.43,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.5264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zolpidem 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018901,NDC,1,EA,9.43,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4.5264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zolpidem 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018901,NDC,1,EA,9.43,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.5264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 100 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,69097012403,NDC,0.25,EA,9.24,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.5276,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 100 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,69097012403,NDC,0.25,EA,9.24,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.5276,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 100 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,69097012403,NDC,0.25,EA,9.24,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.5276,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
certolizumab 2 X 200 MG Kit 1 Each Box,J0717.01,CDM,636,RC,J0717,HCPCS,,,,50474070062,NDC,0.5,EA,4911.87,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,4.53597,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.23,4.82
polyethylene glycol 3350 17 g Packet 30 Each Box,63700001,CDM,250,RC,,,,,,904693176,NDC,1,EA,8.97,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4.53882,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68462033190,NDC,0.5,EA,8.97,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4.53882,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Albumin, Blood",PX82040,CDM,300,RC,82040,CPT,90,,,,,,,58,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,4.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.54,56.84
"Albumin, Serum - Ref",PX8204090,CDM,300,RC,82040,CPT,90,,,,,,,57,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,4.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.54,55.86
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,51991060401,NDC,1,EA,10.59,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.54311,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,64380073706,NDC,1,EA,10.59,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.54311,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 875 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862001501,NDC,1,EA,4.67,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.545311,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
loperamide 2 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079069001,NDC,1,EA,4.67,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.545311,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 2.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079045001,NDC,1,EA,9.28,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.5472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 2.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079045001,NDC,1,EA,9.28,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.5472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 2.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079045001,NDC,1,EA,9.28,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.5472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079045020,NDC,1,EA,9.28,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.5472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079045020,NDC,1,EA,9.28,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.5472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079045020,NDC,1,EA,9.28,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.5472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42937070110,NDC,1,EA,5.16,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4.55112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
verapamil CR 180 MG Tablet Extended Release 100 Each Bottle,25000000,CDM,250,RC,,,,,,75834015801,NDC,0.666666667,EA,5.16,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4.55112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Osmolality; Blood,PX83930,CDM,300,RC,83930,CPT,,,,,,,,9,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4.554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.7386,8.82
SUTURE ETHILON SIZE 0 96INCH TP1,27200000,CDM,272,RC,,,,12140-MAIN,LOCAL,,,,,9,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4.554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE PROLENE 3-0 BLUE SH NEEDLE MONOFILAMENT 30INCH,27200000,CDM,272,RC,,,,12840-MAIN,LOCAL,,,,,9,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4.554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRESSING MESALT 6X6 IMPREGNATED GAUZE STERILE 285780,120.511,CDM,272,RC,A6223,HCPCS,,12059-SURG,LOCAL,,,,,5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4.555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.077,4.9
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,71041813,NDC,1,EA,5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4.555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 250 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756079788,NDC,0.5,EA,4.68,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.555044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
STOCKINETTE STERILE 4X48 NON22360,27200000,CDM,272,RC,A6457,HCPCS,,10658-MAIN,LOCAL,,,,,10.62,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.55598,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
dilTIAZem 30 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93031801,NDC,1,EA,5.36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4.556,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide mononitrate CR 30 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084059111,NDC,1,EA,9.01,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4.55906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide mononitrate CR 30 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084059101,NDC,1,EA,9.01,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4.55906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
azaTHIOprine 50 MG Tablet 1 Each Blister,J7500.01,CDM,636,RC,J7500,HCPCS,,,,68084022911,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,4.56,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.50926,4.56
ELECTRODES NEEDLE TIP PRECISE 2.4MM,27200000,CDM,272,RC,,,,12074-MAIN,LOCAL,,,,,11,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.5694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE ETHIBOND XTRA 0 SHSH 36 INCH,27200000,CDM,272,RC,,,,12678-MAIN,LOCAL,,,,,11,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.5694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"BANDAGE STERILE  2"" TETRA-FLEX CLIP FREE 0151-2SV",27200000,CDM,272,RC,A6449,HCPCS,,10660-MAIN,LOCAL,,,,,5.02,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4.57322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
topiramate 100 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,69097012403,NDC,0.25,EA,9.24,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.5738,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
loperamide 2 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079069020,NDC,1,EA,4.7,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.57451,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 875 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862001501,NDC,1,EA,4.67,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.5766,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079096601,NDC,1,EA,9.34,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.5766,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079096601,NDC,1,EA,9.34,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.5766,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079096601,NDC,1,EA,9.34,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.5766,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
loperamide 2 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079069001,NDC,1,EA,4.67,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.5766,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"MAYO STAND COVERS 24X53""",27200000,CDM,272,RC,,,,644-MAIN,LOCAL,,,,,9.54,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4.5792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"MAYO STAND COVERS 24X53""",27200000,CDM,272,RC,,,,644-MAIN,LOCAL,,,,,9.54,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.5792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,50111099001,NDC,1,EA,9.05,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4.5793,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay Other Fluid Chlorides - Ref,PX8243890,CDM,300,RC,82438,CPT,90,,,,,,,197,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,4.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.58,193.06
Body Fluid Cell Count,PX89050,CDM,300,RC,89050,CPT,,,,,,,,152,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,4.58,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.4926,4.72
Body Fluid Cell Count,PX89050,CDM,300,RC,89050,CPT,,,,,,,,152,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,4.58,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.4926,4.72
Body Fluid Cell Count,PX89050,CDM,300,RC,89050,CPT,,,,,,,,152,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4.58,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.4926,4.72
Dystrophic Nail Trimming Any Number,PXG0127F,CDM,940,RC,G0127,HCPCS,,,,,,,,53,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,4.58,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.58,41.88
Dystrophic Nail Trimming Any Number,PXG0127F,CDM,940,RC,G0127,HCPCS,,,,,,,,53,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,4.58,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.58,41.88
Dystrophic Nail Trimming Any Number,PXG0127F,CDM,940,RC,G0127,HCPCS,,,,,,,,53,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4.58,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.58,41.88
Fac/Trim Nail(S),PX11719F,CDM,510,RC,11719,CPT,,,,,,,,107,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,4.58,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.58,29.75
Fac/Trim Nail(S),PX11719F,CDM,510,RC,11719,CPT,,,,,,,,107,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,4.58,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.58,29.75
Fac/Trim Nail(S),PX11719F,CDM,510,RC,11719,CPT,,,,,,,,107,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4.58,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.58,29.75
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290101,NDC,1,EA,1966.88,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4.58,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.58,6.06
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290102,NDC,1,EA,1966.88,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4.58,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.58,6.06
"Trimming of Dystrophic Nails, Any Number",PXG0127P,CDM,983,RC,G0127,HCPCS,,,,,,,,35,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,4.58,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.58,41.88
"Trimming of Dystrophic Nails, Any Number",PXG0127P,CDM,983,RC,G0127,HCPCS,,,,,,,,35,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,4.58,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.58,41.88
"Trimming of Dystrophic Nails, Any Number",PXG0127P,CDM,983,RC,G0127,HCPCS,,,,,,,,35,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4.58,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.58,41.88
riFAMpin 150 MG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,68084035721,NDC,1,EA,10.68,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.58172,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 250 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756079788,NDC,0.5,EA,4.68,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.5864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079064420,NDC,1,EA,5.2,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4.5864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 0.1 MG/ML Solution 55 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,61553067976,NDC,55,ML,89.7,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,4.59,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.04,4.75
HYDROmorphone 1 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409128303,NDC,1,ML,36.93,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,4.59,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.04,4.75
HYDROmorphone 1 MG/ML Solution 1 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,76045000901,NDC,0.25,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,4.59,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.04,4.75
HYDROmorphone 2 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409131203,NDC,1,ML,38.18,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,4.59,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.04,4.75
PEMEtrexed 500 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2762301,NDC,1,EA,8086.02,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,4.59,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.85,4.59
PEMEtrexed Disodium 100 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2764001,NDC,1,EA,1539.32,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,4.59,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.85,4.59
Potassium; Urine,PX84133,CDM,300,RC,84133,CPT,,,,,,,,50,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,4.59,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.4926,4.73
Potassium; Urine,PX84133,CDM,300,RC,84133,CPT,,,,,,,,50,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,4.59,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.4926,4.73
Potassium; Urine,PX84133,CDM,300,RC,84133,CPT,,,,,,,,50,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4.59,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.4926,4.73
rosuvastatin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003201,NDC,0.125,EA,5.4,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol LA 60 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,527411637,NDC,1,EA,11.05,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.59017,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa CR 25-100 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756046188,NDC,1,EA,5.04,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4.59144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42937070110,NDC,1,EA,5.16,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4.5924,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
verapamil CR 180 MG Tablet Extended Release 100 Each Bottle,25000000,CDM,250,RC,,,,,,75834015801,NDC,0.666666667,EA,5.16,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4.5924,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
amLODIPine 2.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079045001,NDC,1,EA,9.28,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.5936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079045020,NDC,1,EA,9.28,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.5936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739038710,NDC,0.5,EA,9.08,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4.59448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glimepiride 1 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268035815,NDC,1,EA,5.41,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4.5985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of Phosphorus,PX84100,CDM,300,RC,84100,CPT,,,,,,,,150,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,4.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.4926,4.74
Assay of Phosphorus,PX84100,CDM,300,RC,84100,CPT,,,,,,,,150,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,4.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.4926,4.74
Assay of Phosphorus,PX84100,CDM,300,RC,84100,CPT,,,,,,,,150,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4.6,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.4926,4.74
Bilirubin Direct,PX82248,CDM,300,RC,82248,CPT,,,,,,,,150,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,4.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.6,147
Bilirubin Total,PX82247,CDM,300,RC,82247,CPT,,,,,,,,150,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,4.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.6,147
Po4 Inorganic (Phosphate) - Ref,PX8410090,CDM,300,RC,84100,CPT,90,,,,,,,150,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,4.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.4926,4.74
Po4 Inorganic (Phosphate) - Ref,PX8410090,CDM,300,RC,84100,CPT,90,,,,,,,150,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,4.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.4926,4.74
Po4 Inorganic (Phosphate) - Ref,PX8410090,CDM,300,RC,84100,CPT,90,,,,,,,150,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4.6,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.4926,4.74
loperamide 2 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079069020,NDC,1,EA,4.7,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.606,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268011015,NDC,1,EA,5.06,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4.60966,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Antibiotic Sens,Enzyme Detection,Each - Ref",PX8718590,CDM,300,RC,87185,CPT,90,,,,,,,13,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4.61,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.61,4.8135
Glucose Test,PX82950,CDM,300,RC,82950,CPT,,,,,,,,74,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4.61,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.61,4.8135
"Antibiotic Sens,Enzyme Detection,Each - Ref",PX8718590,CDM,300,RC,87185,CPT,90,,,,,,,13,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,4.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.61,4.8135
"Antibiotic Sens,Enzyme Detection,Each - Ref",PX8718590,CDM,300,RC,87185,CPT,90,,,,,,,13,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,4.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.61,4.8135
Glucose Test,PX82950,CDM,300,RC,82950,CPT,,,,,,,,74,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,4.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.61,4.8135
Glucose Test,PX82950,CDM,300,RC,82950,CPT,,,,,,,,74,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,4.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.61,4.8135
venlafaxine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084089695,NDC,1,EA,11.1,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.61094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,185060501,NDC,1,EA,5.23,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4.61286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tolterodine 2 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,59762080002,NDC,0.5,EA,9.12,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4.61472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Potassium; Serum, Plasma or Whole Blood",PX84132,CDM,300,RC,84132,CPT,,,,,,,,59,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4.62,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.62,4.8135
certolizumab 2 X 200 MG Kit 1 Each Box,J0717.01,CDM,636,RC,J0717,HCPCS,,,,50474070062,NDC,0.5,EA,4911.87,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,4.62,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.23,4.82
certolizumab 2 X 200 MG Kit 1 Each Box,J0717.01,CDM,636,RC,J0717,HCPCS,,,,50474070062,NDC,0.5,EA,4911.87,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,4.62,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.23,4.82
"Potassium; Serum, Plasma or Whole Blood",PX84132,CDM,300,RC,84132,CPT,,,,,,,,59,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,4.62,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.62,4.8135
"Potassium; Serum, Plasma or Whole Blood",PX84132,CDM,300,RC,84132,CPT,,,,,,,,59,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,4.62,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.62,4.8135
zolpidem 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018911,NDC,1,EA,9.43,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.6207,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zolpidem 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018911,NDC,1,EA,9.43,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.6207,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zolpidem 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018911,NDC,1,EA,9.43,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.6207,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zolpidem 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018901,NDC,1,EA,9.43,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.6207,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zolpidem 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018901,NDC,1,EA,9.43,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.6207,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zolpidem 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018901,NDC,1,EA,9.43,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.6207,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079096601,NDC,1,EA,9.34,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.6233,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
anastrozole 1 MG Tablet 1 Each Blister,25000000,CDM,250,RC,,,,,,60687011211,NDC,1,EA,11.13,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.623402,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
anastrozole 1 MG Tablet 30 Each Box,25000000,CDM,250,RC,,,,,,60687011221,NDC,1,EA,11.13,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.623402,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
cyclobenzaprine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079064420,NDC,1,EA,5.2,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4.628,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 7.5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406012423,NDC,1,EA,4.76,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.632908,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 7.5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406012462,NDC,1,EA,4.76,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.632908,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Sodium; Urine,PX84300,CDM,300,RC,84300,CPT,,,,,,,,119,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,4.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.64,116.62
doxazosin 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904552261,NDC,1,EA,5.46,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4.641,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,43598043635,NDC,1,EA,5.46,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4.641,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Noninvasv Oxygen Satur;Single,PX94760,CDM,460,RC,94760,CPT,,,,,,,,131,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,4.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.3,4.65
Noninvasv Oxygen Satur;Single,PX94760,CDM,460,RC,94760,CPT,,,,,,,,131,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,4.65,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.3,4.65
triamterene-hydroCHLOROthiazide 37.5-25 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,68084075025,NDC,1,EA,4.78,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.652374,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
flecainide 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237006301,NDC,1,EA,10.85,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.65465,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,185060501,NDC,1,EA,5.23,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4.6547,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol LA 80 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,228277911,NDC,0.75,EA,9.7,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4.656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol LA 80 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,228277911,NDC,0.75,EA,9.7,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol LA 80 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,527411737,NDC,0.75,EA,9.7,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4.656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol LA 80 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,527411737,NDC,0.75,EA,9.7,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atenolol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079068420,NDC,1,EA,4.79,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.662107,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 3 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,56018875,NDC,0.333333333,EA,4.79,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.662107,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 0.1 MG/ML Solution 55 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,61553067976,NDC,55,ML,89.7,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,4.66465,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.04,4.75
HYDROmorphone 1 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409128303,NDC,1,ML,36.93,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,4.66465,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.04,4.75
HYDROmorphone 1 MG/ML Solution 1 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,76045000901,NDC,0.25,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,4.66465,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.04,4.75
HYDROmorphone 2 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409131203,NDC,1,ML,38.18,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,4.66465,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.04,4.75
HYDROcodone-acetaminophen 7.5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406012423,NDC,1,EA,4.76,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.6648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROcodone-acetaminophen 7.5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406012462,NDC,1,EA,4.76,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.6648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"SUTURE SILK 2-0 BLK BR FS 18"" 685G",27200000,CDM,272,RC,,,,2668-MAIN,LOCAL,,,,,5.29,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4.66578,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
zolpidem 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018911,NDC,1,EA,9.43,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.66785,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zolpidem 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018901,NDC,1,EA,9.43,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.66785,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine 1 MG/ML Solution 50 mL Syringe,J2270.01,CDM,636,RC,J2270,HCPCS,,,,61553064975,NDC,50,ML,81.71,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,4.67,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.1,4.67
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189001,NDC,1,ML,34.11,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,4.67,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.1,4.67
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189003,NDC,1,ML,34.11,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,4.67,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.1,4.67
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189101,NDC,1,ML,32.43,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,4.67,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.1,4.67
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189103,NDC,1,ML,32.89,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,4.67,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.1,4.67
"Sodium; Serum, Plasma or Whole Blood",PX84295,CDM,300,RC,84295,CPT,,,,,,,,58,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,4.67,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.67,4.8135
"Sodium; Serum, Plasma or Whole Blood",PX84295,CDM,300,RC,84295,CPT,,,,,,,,58,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,4.67,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.67,4.8135
"Sodium; Serum, Plasma or Whole Blood",PX84295,CDM,300,RC,84295,CPT,,,,,,,,58,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4.67,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.67,4.8135
sodium chloride 0.9% IV FLUSH 0.9 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,8881570121,NDC,2.5,ML,4.8,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.67184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9% IV FLUSH 0.9 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,63807010001,NDC,2.5,ML,4.8,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.67184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"MAYO STAND COVERS 24X53""",27200000,CDM,272,RC,,,,644-MAIN,LOCAL,,,,,9.54,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.6746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"MAYO STAND COVERS 24X53""",27200000,CDM,272,RC,,,,644-MAIN,LOCAL,,,,,9.54,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.6746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"MAYO STAND COVERS 24X53""",27200000,CDM,272,RC,,,,644-MAIN,LOCAL,,,,,9.54,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.6746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ciprofloxacin 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714065102,NDC,0.4,EA,9.74,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4.6752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714065102,NDC,0.4,EA,9.74,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.6752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 100 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,69097012403,NDC,0.25,EA,9.24,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4.67544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prazosin 1 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,70954001950,NDC,1,EA,4.81,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.681573,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,10370083111,NDC,0.5,EA,5.51,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4.6835,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,68462063925,NDC,1,EA,5.51,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4.6835,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
triamterene-hydroCHLOROthiazide 37.5-25 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,68084075025,NDC,1,EA,4.78,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.6844,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034211,NDC,1,EA,11.28,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.685712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034201,NDC,1,EA,11.28,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.685712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of creatinine,PX82565,CDM,300,RC,82565,CPT,,,,,,,,58,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,4.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.69,56.84
atenolol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079068420,NDC,1,EA,4.79,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.6942,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 3 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,56018875,NDC,0.333333333,EA,4.79,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.6942,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 2.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079045001,NDC,1,EA,9.28,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4.69568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079045020,NDC,1,EA,9.28,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4.69568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42937070110,NDC,1,EA,5.16,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4.70076,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
verapamil CR 180 MG Tablet Extended Release 100 Each Bottle,25000000,CDM,250,RC,,,,,,75834015801,NDC,0.666666667,EA,5.16,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4.70076,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BITE BLOCK MAXI 20MM 60FR,27200000,CDM,272,RC,,,,8144-MAIN,LOCAL,,,,,11.32,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.702328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
sodium chloride 0.9% IV FLUSH 0.9 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,8881570121,NDC,2.5,ML,4.8,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9% IV FLUSH 0.9 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,63807010001,NDC,2.5,ML,4.8,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"SUTURE SILK 2-0 BLK BR FS 18"" 685G",27200000,CDM,272,RC,,,,2668-MAIN,LOCAL,,,,,5.29,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4.7081,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Sodium, Other Source - Ref",PX8430290,CDM,300,RC,84302,CPT,90,,,,,,,27,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,4.71,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.71,4.86
"Sodium, Other Source - Ref",PX8430290,CDM,300,RC,84302,CPT,90,,,,,,,27,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,4.71,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.71,4.86
"Sodium, Other Source - Ref",PX8430290,CDM,300,RC,84302,CPT,90,,,,,,,27,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4.71,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.71,4.86
prazosin 1 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,70954001950,NDC,1,EA,4.81,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.7138,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ELECTRODES NEEDLE TIP PRECISE 2.4MM,27200000,CDM,272,RC,,,,12074-MAIN,LOCAL,,,,,11,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.719,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE ETHIBOND XTRA 0 SHSH 36 INCH,27200000,CDM,272,RC,,,,12678-MAIN,LOCAL,,,,,11,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.719,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Body Fluid Cell Count,PX89050,CDM,300,RC,89050,CPT,,,,,,,,152,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,4.72,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.4926,4.72
ramipril 2.5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237022301,NDC,0.5,EA,4.85,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.720505,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"MAYO STAND COVERS 24X53""",27200000,CDM,272,RC,,,,644-MAIN,LOCAL,,,,,9.54,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.7223,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ciprofloxacin 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862007601,NDC,0.4,EA,9.84,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4.7232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862007601,NDC,0.4,EA,9.84,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.7232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079096601,NDC,1,EA,9.34,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4.72604,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem 30 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93031801,NDC,1,EA,5.36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4.72752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay Blood Carbon Dioxide,PX82374,CDM,300,RC,82374,CPT,,,,,,,,95,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,4.73,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.73,4.88
Assay Blood Carbon Dioxide,PX82374,CDM,300,RC,82374,CPT,,,,,,,,95,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,4.73,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.73,4.88
Assay Blood Carbon Dioxide,PX82374,CDM,300,RC,82374,CPT,,,,,,,,95,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4.73,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.73,4.88
Calcium - Ref,PX8231090,CDM,300,RC,82310,CPT,90,,,,,,,10,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,4.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,9.8
Calcium Total,PX82310,CDM,300,RC,82310,CPT,,,,,,,,57,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,4.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.73,55.86
Potassium; Urine,PX84133,CDM,300,RC,84133,CPT,,,,,,,,50,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,4.73,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.4926,4.73
rivastigmine 3 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,55111035360,NDC,0.5,EA,11.4,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.73556,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079064420,NDC,1,EA,5.2,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4.7372,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diclofenac EC 50 MG Tablet Delayed Release 14 Each Bottle,63700001,CDM,250,RC,,,,,,71335048107,NDC,1,EA,4.87,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.739971,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of Phosphorus,PX84100,CDM,300,RC,84100,CPT,,,,,,,,150,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,4.74,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.4926,4.74
Po4 Inorganic (Phosphate) - Ref,PX8410090,CDM,300,RC,84100,CPT,90,,,,,,,150,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,4.74,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.4926,4.74
propranolol LA 60 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,527411637,NDC,1,EA,11.05,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.74045,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine ER 15 MG Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,68084040311,NDC,1,EA,9.88,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4.7424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine ER 15 MG Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,68084040311,NDC,1,EA,9.88,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.7424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Antibiotic Sens,Enzyme Detection,Each - Ref",PX8718590,CDM,300,RC,87185,CPT,90,,,,,,,13,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,4.75,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.61,4.8135
Assay Alkaline Phosphatase,PX84075,CDM,300,RC,84075,CPT,,,,,,,,57,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,4.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,55.86
C-Reactive Protein,PX86140,CDM,300,RC,86140,CPT,,,,,,,,191,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,4.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,187.18
Creatinine; Other Source - Ref,PX82570,CDM,300,RC,82570,CPT,90,,,,,,,119,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,4.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,116.62
Culture Type Immunologic,PX87147,CDM,300,RC,87147,CPT,,,,,,,,42,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,4.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,41.16
Glucose Test,PX82950,CDM,300,RC,82950,CPT,,,,,,,,74,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,4.75,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.61,4.8135
Heterophile Antibodies,PX86308,CDM,300,RC,86308,CPT,,,,,,,,196,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,4.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,192.08
HYDROmorphone 0.1 MG/ML Solution 55 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,61553067976,NDC,55,ML,89.7,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,4.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.04,4.75
HYDROmorphone 0.1 MG/ML Solution 55 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,61553067976,NDC,55,ML,89.7,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,4.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.04,4.75
HYDROmorphone 1 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409128303,NDC,1,ML,36.93,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,4.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.04,4.75
HYDROmorphone 1 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409128303,NDC,1,ML,36.93,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,4.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.04,4.75
HYDROmorphone 1 MG/ML Solution 1 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,76045000901,NDC,0.25,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,4.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.04,4.75
HYDROmorphone 1 MG/ML Solution 1 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,76045000901,NDC,0.25,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,4.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.04,4.75
HYDROmorphone 2 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409131203,NDC,1,ML,38.18,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,4.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.04,4.75
HYDROmorphone 2 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409131203,NDC,1,ML,38.18,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,4.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.04,4.75
Transferase; Aspartate Amino (Ast) (Sgot),PX84450,CDM,300,RC,84450,CPT,,,,,,,,58,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,4.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,56.84
morphine ER 15 MG Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,68084040301,NDC,1,EA,9.9,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine ER 15 MG Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,68084040301,NDC,1,EA,9.9,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ramipril 2.5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237022301,NDC,0.5,EA,4.85,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.753,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol LA 80 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,228277911,NDC,0.75,EA,9.7,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.753,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol LA 80 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,228277911,NDC,0.75,EA,9.7,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.753,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol LA 80 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,228277911,NDC,0.75,EA,9.7,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.753,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol LA 80 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,527411737,NDC,0.75,EA,9.7,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.753,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol LA 80 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,527411737,NDC,0.75,EA,9.7,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.753,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol LA 80 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,527411737,NDC,0.75,EA,9.7,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.753,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Potassium; Serum, Plasma or Whole Blood",PX84132,CDM,300,RC,84132,CPT,,,,,,,,59,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,4.76,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.62,4.8135
carvedilol 3.125 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079077101,NDC,1,EA,11.46,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.760484,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 14 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,43598044774,NDC,1,EA,11.46,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.760484,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,43598044871,NDC,1,EA,11.46,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.760484,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084089695,NDC,1,EA,11.1,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.7619,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003201,NDC,0.125,EA,5.4,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4.7628,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,185060501,NDC,1,EA,5.23,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4.76453,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290101,NDC,1,EA,1966.88,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,4.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.77,1927.5424
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290102,NDC,1,EA,1966.88,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,4.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.77,1927.5424
dilTIAZem 30 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93031801,NDC,1,EA,5.36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4.7704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zolpidem 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018911,NDC,1,EA,9.43,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4.77158,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zolpidem 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018901,NDC,1,EA,9.43,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4.77158,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glimepiride 1 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268035815,NDC,1,EA,5.41,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4.77162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714065102,NDC,0.4,EA,9.74,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.7726,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714065102,NDC,0.4,EA,9.74,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.7726,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714065102,NDC,0.4,EA,9.74,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.7726,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diclofenac EC 50 MG Tablet Delayed Release 14 Each Bottle,63700001,CDM,250,RC,,,,,,71335048107,NDC,1,EA,4.87,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.7726,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
anastrozole 1 MG Tablet 1 Each Blister,25000000,CDM,250,RC,,,,,,60687011211,NDC,1,EA,11.13,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.77477,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
anastrozole 1 MG Tablet 30 Each Box,25000000,CDM,250,RC,,,,,,60687011221,NDC,1,EA,11.13,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.77477,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
methenamine 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862078201,NDC,0.5,EA,5.62,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4.777,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,536110888,NDC,1,EA,11.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.7771,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Lab Ige, Isocyan Hdi",PX86003,CDM,300,RC,86003,CPT,90,,,,,,,34,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,4.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.79,33.32
nitroglycerin 0.1 MG/HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,378910216,NDC,1,EA,9.98,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4.7904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.1 MG/HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,378910216,NDC,1,EA,9.98,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.7904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.1 MG/HR Patch 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,378910293,NDC,1,EA,9.98,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4.7904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.1 MG/HR Patch 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,378910293,NDC,1,EA,9.98,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.7904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 40 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862011801,NDC,1,EA,5.64,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4.794,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carvedilol 3.125 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904630061,NDC,0.5,EA,5.64,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4.794,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline monohydrate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084074333,NDC,1,EA,9.99,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4.7952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline monohydrate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084074333,NDC,1,EA,9.99,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.7952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Albumin, Blood",PX82040,CDM,300,RC,82040,CPT,90,,,,,,,58,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,4.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.8,4.95
"Albumin, Blood",PX82040,CDM,300,RC,82040,CPT,90,,,,,,,58,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,4.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.8,4.95
"Albumin, Blood",PX82040,CDM,300,RC,82040,CPT,90,,,,,,,58,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4.8,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.8,4.95
"Albumin, Serum - Ref",PX8204090,CDM,300,RC,82040,CPT,90,,,,,,,57,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,4.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.8,4.95
"Albumin, Serum - Ref",PX8204090,CDM,300,RC,82040,CPT,90,,,,,,,57,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,4.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.8,4.95
"Albumin, Serum - Ref",PX8204090,CDM,300,RC,82040,CPT,90,,,,,,,57,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4.8,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.8,4.95
Antinuclear Antibodies,PX86038,CDM,300,RC,86038,CPT,,,,,,,,10,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,11.09
Antinuclear Antibodies,PX86038,CDM,300,RC,86038,CPT,,,,,,,,10,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,11.09
Calcium - Ref,PX8231090,CDM,300,RC,82310,CPT,90,,,,,,,10,,Health Partners,Health Partners Care Plans,both,48,,26.44,percent of total billed charges,4.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,9.8
Calcium - Ref,PX8231090,CDM,300,RC,82310,CPT,90,,,,,,,10,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,9.8
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127303,NDC,2,ML,152.7,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4.8,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.8,6.53
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127332,NDC,2,ML,176.55,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4.8,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.8,6.53
DRAPE SURGICAL 23X17INCH INCISE 1050,27200000,CDM,272,RC,,,,12873-MAIN,LOCAL,,,,,10,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRAPE SURGICAL 23X17INCH INCISE 1050,27200000,CDM,272,RC,,,,12873-MAIN,LOCAL,,,,,10,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
KERRAMAX CARE SUPERABSORBENT DRESSING 5X6,120.548,CDM,272,RC,A6197,HCPCS,,12362-MAIN,LOCAL,,,,,10,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,9.8
KERRAMAX CARE SUPERABSORBENT DRESSING 5X6,120.548,CDM,272,RC,A6197,HCPCS,,12362-MAIN,LOCAL,,,,,10,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,9.8
NEEDLE HYPODERMIC 22GA 1-1/2IN STERILE 305156,27200000,CDM,272,RC,A4215,HCPCS,,8887-MAIN,LOCAL,,,,,10,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NEEDLE HYPODERMIC 22GA 1-1/2IN STERILE 305156,27200000,CDM,272,RC,A4215,HCPCS,,8887-MAIN,LOCAL,,,,,10,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Needle Insertion W/O Injection 1 or 2 Muscles,PX20560,CDM,420,RC,20560,CPT,,,,,,,,10,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,26.01
Needle Insertion W/O Injection 1 or 2 Muscles,PX20560,CDM,420,RC,20560,CPT,,,,,,,,10,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,26.01
Needle Insertion W/O Injection 3 or More Muscles,PX20561,CDM,420,RC,20561,CPT,,,,,,,,10,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,26.01
Needle Insertion W/O Injection 3 or More Muscles,PX20561,CDM,420,RC,20561,CPT,,,,,,,,10,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,26.01
PAD GROUNDING 9 FT ADULT REM E7507,27200000,CDM,272,RC,,,,504-MAIN,LOCAL,,,,,10,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PAD GROUNDING 9 FT ADULT REM E7507,27200000,CDM,272,RC,,,,504-MAIN,LOCAL,,,,,10,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
propranolol LA 80 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,228277911,NDC,0.75,EA,9.7,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.8015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol LA 80 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,527411737,NDC,0.75,EA,9.7,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.8015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003201,NDC,0.125,EA,5.4,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4.806,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metroNIDAZOLE 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084096611,NDC,1,EA,4.94,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.808102,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metroNIDAZOLE 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084096601,NDC,1,EA,4.94,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.808102,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Sodium; Serum, Plasma or Whole Blood",PX84295,CDM,300,RC,84295,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,4.81,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.67,4.8135
ketorolac 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69543038810,NDC,1,EA,11.58,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.810332,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Albumin, Blood",PX82040,CDM,300,RC,82040,CPT,90,,,,,,,58,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,4.8135,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.8,4.95
"Albumin, Serum - Ref",PX8204090,CDM,300,RC,82040,CPT,90,,,,,,,57,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,4.8135,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.8,4.95
"Antibiotic Sens,Enzyme Detection,Each - Ref",PX8718590,CDM,300,RC,87185,CPT,90,,,,,,,13,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,4.8135,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.61,4.8135
Assay Blood Carbon Dioxide,PX82374,CDM,300,RC,82374,CPT,,,,,,,,95,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,4.8135,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.73,4.88
Assay Other Fluid Chlorides - Ref,PX8243890,CDM,300,RC,82438,CPT,90,,,,,,,197,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,4.8135,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.8135,5
Bilirubin Direct,PX82248,CDM,300,RC,82248,CPT,,,,,,,,150,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,4.8135,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.8135,5.02
Bilirubin Total,PX82247,CDM,300,RC,82247,CPT,,,,,,,,150,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,4.8135,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.8135,5.02
Glucose Test,PX82950,CDM,300,RC,82950,CPT,,,,,,,,74,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,4.8135,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.61,4.8135
"Potassium; Serum, Plasma or Whole Blood",PX84132,CDM,300,RC,84132,CPT,,,,,,,,59,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,4.8135,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.62,4.8135
"Sodium, Other Source - Ref",PX8430290,CDM,300,RC,84302,CPT,90,,,,,,,27,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,4.8135,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.71,4.86
"Sodium; Serum, Plasma or Whole Blood",PX84295,CDM,300,RC,84295,CPT,,,,,,,,58,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,4.8135,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.67,4.8135
Sodium; Urine,PX84300,CDM,300,RC,84300,CPT,,,,,,,,119,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,4.8135,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.8135,5.06
"SUTURE CHROME GUT 3-0 CP-2 27""",27200000,CDM,272,RC,,,,4967-MAIN,LOCAL,,,,,11.59,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.814486,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
glimepiride 1 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268035815,NDC,1,EA,5.41,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4.8149,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxazosin 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904552261,NDC,1,EA,5.46,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4.81572,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,43598043635,NDC,1,EA,5.46,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4.81572,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"SUTURE SILK 2-0 BLK BR FS 18"" 685G",27200000,CDM,272,RC,,,,2668-MAIN,LOCAL,,,,,5.29,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4.81919,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
certolizumab 2 X 200 MG Kit 1 Each Box,J0717.01,CDM,636,RC,J0717,HCPCS,,,,50474070062,NDC,0.5,EA,4911.87,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,4.82,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.23,4.82
ciprofloxacin 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714065102,NDC,0.4,EA,9.74,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.8213,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862007601,NDC,0.4,EA,9.84,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.8216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862007601,NDC,0.4,EA,9.84,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.8216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862007601,NDC,0.4,EA,9.84,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.8216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine ER 15 MG Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,406831523,NDC,1,EA,10.05,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4.824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine ER 15 MG Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,406831523,NDC,1,EA,10.05,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine ER 15 MG Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,406831562,NDC,1,EA,10.05,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4.824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine ER 15 MG Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,406831562,NDC,1,EA,10.05,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cefOXitin 1 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021010910,NDC,1,EA,58.66,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,4.8255,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.46,5.08
cefOXitin 2 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021011020,NDC,1,EA,77.24,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,4.8255,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.46,5.08
"MAYO STAND COVERS 24X53""",27200000,CDM,272,RC,,,,644-MAIN,LOCAL,,,,,9.54,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4.82724,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
topiramate 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034211,NDC,1,EA,11.28,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.83912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034201,NDC,1,EA,11.28,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.83912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metroNIDAZOLE 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084096611,NDC,1,EA,4.94,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.8412,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metroNIDAZOLE 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084096601,NDC,1,EA,4.94,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.8412,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine ER 15 MG Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,68084040311,NDC,1,EA,9.88,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.8412,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine ER 15 MG Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,68084040311,NDC,1,EA,9.88,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.8412,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine ER 15 MG Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,68084040311,NDC,1,EA,9.88,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.8412,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay Other Fluid Chlorides - Ref,PX8243890,CDM,300,RC,82438,CPT,90,,,,,,,197,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,4.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.8135,5
Assay Other Fluid Chlorides - Ref,PX8243890,CDM,300,RC,82438,CPT,90,,,,,,,197,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,4.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.8135,5
Assay Other Fluid Chlorides - Ref,PX8243890,CDM,300,RC,82438,CPT,90,,,,,,,197,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4.85,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.8135,5
morphine ER 15 MG Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,68084040301,NDC,1,EA,9.9,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.851,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine ER 15 MG Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,68084040301,NDC,1,EA,9.9,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.851,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine ER 15 MG Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,68084040301,NDC,1,EA,9.9,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.851,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BITE BLOCK MAXI 20MM 60FR,27200000,CDM,272,RC,,,,8144-MAIN,LOCAL,,,,,11.32,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.85628,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
doxazosin 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904552261,NDC,1,EA,5.46,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4.8594,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,43598043635,NDC,1,EA,5.46,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4.8594,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,10370083111,NDC,0.5,EA,5.51,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4.85982,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,68462063925,NDC,1,EA,5.51,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4.85982,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Sodium, Other Source - Ref",PX8430290,CDM,300,RC,84302,CPT,90,,,,,,,27,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,4.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.71,4.86
Transferase; Alanine Amino (Alt) (Sgpt),PX84460,CDM,300,RC,84460,CPT,,,,,,,,58,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,4.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.86,56.84
DRESSING MESALT 6X6 IMPREGNATED GAUZE STERILE 285780,120.511,CDM,272,RC,A6223,HCPCS,,12059-SURG,LOCAL,,,,,5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.8665,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.077,4.9
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,71041813,NDC,1,EA,5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.8665,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Bilirubin Direct,PX82248,CDM,300,RC,82248,CPT,,,,,,,,150,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,4.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.8135,5.02
Bilirubin Direct,PX82248,CDM,300,RC,82248,CPT,,,,,,,,150,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,4.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.8135,5.02
Bilirubin Direct,PX82248,CDM,300,RC,82248,CPT,,,,,,,,150,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4.87,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.8135,5.02
Bilirubin Total,PX82247,CDM,300,RC,82247,CPT,,,,,,,,150,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,4.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.8135,5.02
Bilirubin Total,PX82247,CDM,300,RC,82247,CPT,,,,,,,,150,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,4.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.8135,5.02
Bilirubin Total,PX82247,CDM,300,RC,82247,CPT,,,,,,,,150,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4.87,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.8135,5.02
carvedilol 3.125 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079077120,NDC,0.5,EA,5.73,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4.8705,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862007601,NDC,0.4,EA,9.84,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.8708,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 100 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,74662411,NDC,1,EA,10.16,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4.8768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 100 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,74662411,NDC,1,EA,10.16,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.8768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,70677003201,NDC,1,EA,10.16,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4.8768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,70677003201,NDC,1,EA,10.16,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.8768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 600 MG Tablet Extended Release 12 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904671839,NDC,1,EA,5.74,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4.879,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay Blood Carbon Dioxide,PX82374,CDM,300,RC,82374,CPT,,,,,,,,95,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,4.88,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.73,4.88
"Blood, Occult, Other Sources",PX82271,CDM,300,RC,82271,CPT,,,,,,,,72,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,4.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.88,70.56
Capillary Blood Collection,PX36416,CDM,300,RC,36416,CPT,,,,,,,,60,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,4.88,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.64,4.88
Capillary Blood Collection,PX36416,CDM,300,RC,36416,CPT,,,,,,,,60,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,4.88,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.64,4.88
levothyroxine 25 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904694961,NDC,4,EA,11.75,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.88095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem 30 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93031801,NDC,1,EA,5.36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4.88296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
escitalopram 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904642661,NDC,0.5,EA,11.76,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.885104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"BANDAGE STERILE  2"" TETRA-FLEX CLIP FREE 0151-2SV",27200000,CDM,272,RC,A6449,HCPCS,,10660-MAIN,LOCAL,,,,,5.02,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.885966,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
cefOXitin 1 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021010910,NDC,1,EA,58.66,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,4.89,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.46,5.08
cefOXitin 1 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021010910,NDC,1,EA,58.66,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,4.89,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.46,5.08
cefOXitin 2 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021011020,NDC,1,EA,77.24,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,4.89,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.46,5.08
cefOXitin 2 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021011020,NDC,1,EA,77.24,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,4.89,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.46,5.08
nitroglycerin 0.1 MG/HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,378910216,NDC,1,EA,9.98,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.8902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.1 MG/HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,378910216,NDC,1,EA,9.98,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.8902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.1 MG/HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,378910216,NDC,1,EA,9.98,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.8902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.1 MG/HR Patch 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,378910293,NDC,1,EA,9.98,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.8902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.1 MG/HR Patch 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,378910293,NDC,1,EA,9.98,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.8902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.1 MG/HR Patch 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,378910293,NDC,1,EA,9.98,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.8902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine ER 15 MG Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,68084040311,NDC,1,EA,9.88,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.8906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rivastigmine 3 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,55111035360,NDC,0.5,EA,11.4,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.8906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline monohydrate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084074333,NDC,1,EA,9.99,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.8951,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline monohydrate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084074333,NDC,1,EA,9.99,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.8951,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline monohydrate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084074333,NDC,1,EA,9.99,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.8951,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
verapamil CR 120 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462029201,NDC,1,EA,5.76,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4.896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Antinuclear Antibodies,PX86038,CDM,300,RC,86038,CPT,,,,,,,,10,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,18.48,percent of total billed charges,4.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,11.09
Antinuclear Antibodies,PX86038,CDM,300,RC,86038,CPT,,,,,,,,10,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,11.09
Antinuclear Antibodies,PX86038,CDM,300,RC,86038,CPT,,,,,,,,10,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,11.09
Calcium - Ref,PX8231090,CDM,300,RC,82310,CPT,90,,,,,,,10,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,9.8
Calcium - Ref,PX8231090,CDM,300,RC,82310,CPT,90,,,,,,,10,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,9.8
Calcium - Ref,PX8231090,CDM,300,RC,82310,CPT,90,,,,,,,10,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,9.8
DRAPE SURGICAL 23X17INCH INCISE 1050,27200000,CDM,272,RC,,,,12873-MAIN,LOCAL,,,,,10,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRAPE SURGICAL 23X17INCH INCISE 1050,27200000,CDM,272,RC,,,,12873-MAIN,LOCAL,,,,,10,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRAPE SURGICAL 23X17INCH INCISE 1050,27200000,CDM,272,RC,,,,12873-MAIN,LOCAL,,,,,10,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRESSING MESALT 6X6 IMPREGNATED GAUZE STERILE 285780,120.511,CDM,272,RC,A6223,HCPCS,,12059-SURG,LOCAL,,,,,5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.077,4.9
KERRAMAX CARE SUPERABSORBENT DRESSING 5X6,120.548,CDM,272,RC,A6197,HCPCS,,12362-MAIN,LOCAL,,,,,10,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,9.8
KERRAMAX CARE SUPERABSORBENT DRESSING 5X6,120.548,CDM,272,RC,A6197,HCPCS,,12362-MAIN,LOCAL,,,,,10,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,9.8
KERRAMAX CARE SUPERABSORBENT DRESSING 5X6,120.548,CDM,272,RC,A6197,HCPCS,,12362-MAIN,LOCAL,,,,,10,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,9.8
NEEDLE HYPODERMIC 22GA 1-1/2IN STERILE 305156,27200000,CDM,272,RC,A4215,HCPCS,,8887-MAIN,LOCAL,,,,,10,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NEEDLE HYPODERMIC 22GA 1-1/2IN STERILE 305156,27200000,CDM,272,RC,A4215,HCPCS,,8887-MAIN,LOCAL,,,,,10,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NEEDLE HYPODERMIC 22GA 1-1/2IN STERILE 305156,27200000,CDM,272,RC,A4215,HCPCS,,8887-MAIN,LOCAL,,,,,10,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Needle Insertion W/O Injection 1 or 2 Muscles,PX20560,CDM,420,RC,20560,CPT,,,,,,,,10,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,26.01
Needle Insertion W/O Injection 1 or 2 Muscles,PX20560,CDM,420,RC,20560,CPT,,,,,,,,10,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,26.01
Needle Insertion W/O Injection 1 or 2 Muscles,PX20560,CDM,420,RC,20560,CPT,,,,,,,,10,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,26.01
Needle Insertion W/O Injection 3 or More Muscles,PX20561,CDM,420,RC,20561,CPT,,,,,,,,10,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,26.01
Needle Insertion W/O Injection 3 or More Muscles,PX20561,CDM,420,RC,20561,CPT,,,,,,,,10,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,26.01
Needle Insertion W/O Injection 3 or More Muscles,PX20561,CDM,420,RC,20561,CPT,,,,,,,,10,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,26.01
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,71041813,NDC,1,EA,5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PAD GROUNDING 9 FT ADULT REM E7507,27200000,CDM,272,RC,,,,504-MAIN,LOCAL,,,,,10,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PAD GROUNDING 9 FT ADULT REM E7507,27200000,CDM,272,RC,,,,504-MAIN,LOCAL,,,,,10,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PAD GROUNDING 9 FT ADULT REM E7507,27200000,CDM,272,RC,,,,504-MAIN,LOCAL,,,,,10,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
morphine ER 15 MG Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,68084040301,NDC,1,EA,9.9,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.9005,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.2 MG/HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,378910416,NDC,1,EA,10.21,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4.9008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.2 MG/HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,378910416,NDC,1,EA,10.21,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.9008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.2 MG/HR Patch 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,378910493,NDC,1,EA,10.21,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4.9008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.2 MG/HR Patch 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,378910493,NDC,1,EA,10.21,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4.9008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,10370083111,NDC,0.5,EA,5.51,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4.9039,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,68462063925,NDC,1,EA,5.51,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4.9039,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa CR 25-100 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756046188,NDC,1,EA,5.04,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.905432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol LA 80 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,228277911,NDC,0.75,EA,9.7,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4.9082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol LA 80 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,527411737,NDC,0.75,EA,9.7,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4.9082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061400,NDC,1,ML,101.95,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4.91,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.91,5.59
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061401,NDC,1,ML,94.87,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4.91,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.91,5.59
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061416,NDC,0.5,ML,31.57,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4.91,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.91,5.59
Sodium; Urine,PX84300,CDM,300,RC,84300,CPT,,,,,,,,119,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,4.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.8135,5.06
Sodium; Urine,PX84300,CDM,300,RC,84300,CPT,,,,,,,,119,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,4.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.8135,5.06
Sodium; Urine,PX84300,CDM,300,RC,84300,CPT,,,,,,,,119,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4.91,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.8135,5.06
carvedilol 3.125 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079077101,NDC,1,EA,11.46,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.91634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 14 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,43598044774,NDC,1,EA,11.46,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.91634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,43598044871,NDC,1,EA,11.46,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.91634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003201,NDC,0.125,EA,5.4,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4.9194,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"BANDAGE STERILE  2"" TETRA-FLEX CLIP FREE 0151-2SV",27200000,CDM,272,RC,A6449,HCPCS,,10660-MAIN,LOCAL,,,,,5.02,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.9196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
glimepiride 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93725401,NDC,1,EA,5.79,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4.9215,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine ER 15 MG Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,406831523,NDC,1,EA,10.05,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.9245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine ER 15 MG Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,406831523,NDC,1,EA,10.05,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.9245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine ER 15 MG Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,406831523,NDC,1,EA,10.05,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.9245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine ER 15 MG Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,406831562,NDC,1,EA,10.05,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.9245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine ER 15 MG Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,406831562,NDC,1,EA,10.05,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.9245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine ER 15 MG Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,406831562,NDC,1,EA,10.05,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.9245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268011015,NDC,1,EA,5.06,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4.924898,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714065102,NDC,0.4,EA,9.74,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4.92844,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glimepiride 1 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268035815,NDC,1,EA,5.41,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4.92851,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,536110888,NDC,1,EA,11.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.9335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbidopa-levodopa CR 25-100 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756046188,NDC,1,EA,5.04,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.9392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Flour. Afstain , Micro - Ref",PX8720690,CDM,300,RC,87206,CPT,90,,,,,,,68,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,4.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.94,66.64
hydroxocobalamin 5 g Recon Soln 1 Each Box,J3424.01,CDM,636,RC,J3424,HCPCS,,,,11704037001,NDC,1,EA,1991.16,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,4.94,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.94,4.94
Smear Fluorescent/Acid Stai,PX87206,CDM,300,RC,87206,CPT,,,,,,,,155,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,4.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.94,151.9
nitroglycerin 0.1 MG/HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,378910216,NDC,1,EA,9.98,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.9401,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.1 MG/HR Patch 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,378910293,NDC,1,EA,9.98,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.9401,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline monohydrate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084074333,NDC,1,EA,9.99,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.94505,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Albumin, Blood",PX82040,CDM,300,RC,82040,CPT,90,,,,,,,58,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,4.95,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.8,4.95
"Albumin, Serum - Ref",PX8204090,CDM,300,RC,82040,CPT,90,,,,,,,57,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,4.95,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.8,4.95
Antinuclear Antibodies,PX86038,CDM,300,RC,86038,CPT,,,,,,,,10,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,11.09
Calcium - Ref,PX8231090,CDM,300,RC,82310,CPT,90,,,,,,,10,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,9.8
DRAPE SURGICAL 23X17INCH INCISE 1050,27200000,CDM,272,RC,,,,12873-MAIN,LOCAL,,,,,10,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
KERRAMAX CARE SUPERABSORBENT DRESSING 5X6,120.548,CDM,272,RC,A6197,HCPCS,,12362-MAIN,LOCAL,,,,,10,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,9.8
NEEDLE HYPODERMIC 22GA 1-1/2IN STERILE 305156,27200000,CDM,272,RC,A4215,HCPCS,,8887-MAIN,LOCAL,,,,,10,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Needle Insertion W/O Injection 1 or 2 Muscles,PX20560,CDM,420,RC,20560,CPT,,,,,,,,10,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,26.01
Needle Insertion W/O Injection 3 or More Muscles,PX20561,CDM,420,RC,20561,CPT,,,,,,,,10,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,26.01
PAD GROUNDING 9 FT ADULT REM E7507,27200000,CDM,272,RC,,,,504-MAIN,LOCAL,,,,,10,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
methenamine 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862078201,NDC,0.5,EA,5.62,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4.95684,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268011015,NDC,1,EA,5.06,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4.9588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tacrolimus 1 MG capsule 100 Each Bottle,J7507.01,CDM,636,RC,J7507,HCPCS,,,,16714009901,NDC,0.5,EA,11.95,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.96403,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.96403,11.711
ketorolac 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69543038810,NDC,1,EA,11.58,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.96782,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of creatinine,PX82565,CDM,300,RC,82565,CPT,,,,,,,,58,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,4.97,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.97,5.1344
Assay of creatinine,PX82565,CDM,300,RC,82565,CPT,,,,,,,,58,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,4.97,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.97,5.1344
Assay of creatinine,PX82565,CDM,300,RC,82565,CPT,,,,,,,,58,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,4.97,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.97,5.1344
"SUTURE CHROME GUT 3-0 CP-2 27""",27200000,CDM,272,RC,,,,4967-MAIN,LOCAL,,,,,11.59,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4.97211,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
doxazosin 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904552261,NDC,1,EA,5.46,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4.97406,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,43598043635,NDC,1,EA,5.46,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4.97406,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 40 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862011801,NDC,1,EA,5.64,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4.97448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carvedilol 3.125 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904630061,NDC,0.5,EA,5.64,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4.97448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine ER 15 MG Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,406831523,NDC,1,EA,10.05,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.97475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine ER 15 MG Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,406831562,NDC,1,EA,10.05,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4.97475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 100 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,74662411,NDC,1,EA,10.16,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.9784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 100 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,74662411,NDC,1,EA,10.16,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.9784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 100 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,74662411,NDC,1,EA,10.16,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.9784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,70677003201,NDC,1,EA,10.16,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.9784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,70677003201,NDC,1,EA,10.16,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4.9784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,70677003201,NDC,1,EA,10.16,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4.9784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862007601,NDC,0.4,EA,9.84,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4.97904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BAG URINARY DRAINAGE DYND15405H,120.33,CDM,271,RC,A4357,HCPCS,,9112-MAIN,LOCAL,,,,,12,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.9848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
peak flow meter Device 1 Each Box,800000,CDM,,,,,,,,8373075500,NDC,1,EA,12,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4.9848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
morphine ER 15 MG Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,68084040311,NDC,1,EA,9.88,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4.99928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay Other Fluid Chlorides - Ref,PX8243890,CDM,300,RC,82438,CPT,90,,,,,,,197,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,5,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.8135,5
methenamine 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862078201,NDC,0.5,EA,5.62,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,5.0018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.2 MG/HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,378910416,NDC,1,EA,10.21,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.0029,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.2 MG/HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,378910416,NDC,1,EA,10.21,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.0029,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.2 MG/HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,378910416,NDC,1,EA,10.21,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,5.0029,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.2 MG/HR Patch 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,378910493,NDC,1,EA,10.21,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.0029,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.2 MG/HR Patch 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,378910493,NDC,1,EA,10.21,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.0029,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.2 MG/HR Patch 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,378910493,NDC,1,EA,10.21,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,5.0029,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,57237017290,NDC,1,EA,10.43,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,5.0064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,57237017290,NDC,1,EA,10.43,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,5.0064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714031101,NDC,1,EA,10.43,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,5.0064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714031101,NDC,1,EA,10.43,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,5.0064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57664039288,NDC,1,EA,10.43,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,5.0064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57664039288,NDC,1,EA,10.43,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,5.0064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine ER 15 MG Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,68084040301,NDC,1,EA,9.9,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,5.0094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Calcium - Ref,PX8231090,CDM,300,RC,82310,CPT,90,,,,,,,10,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,5.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.01,5.16
Calcium - Ref,PX8231090,CDM,300,RC,82310,CPT,90,,,,,,,10,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,5.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.01,5.16
Calcium - Ref,PX8231090,CDM,300,RC,82310,CPT,90,,,,,,,10,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,5.01,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.01,5.16
Calcium Total,PX82310,CDM,300,RC,82310,CPT,,,,,,,,57,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,5.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.01,5.16
Calcium Total,PX82310,CDM,300,RC,82310,CPT,,,,,,,,57,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,5.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.01,5.16
Calcium Total,PX82310,CDM,300,RC,82310,CPT,,,,,,,,57,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,5.01,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.01,5.16
losartan 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034711,NDC,1,EA,12.08,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.018032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034701,NDC,1,EA,12.08,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.018032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 14 MG/24HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,43598044771,NDC,1,EA,12.08,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.018032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 40 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862011801,NDC,1,EA,5.64,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,5.0196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carvedilol 3.125 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904630061,NDC,0.5,EA,5.64,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,5.0196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,10370083111,NDC,0.5,EA,5.51,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,5.01961,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,68462063925,NDC,1,EA,5.51,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,5.01961,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Airway Inhalation Treatment,PX94640F,CDM,410,RC,94640,CPT,,,,,,,,242,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,5.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.02,13.96
Airway Inhalation Treatment,PX94640F,CDM,410,RC,94640,CPT,,,,,,,,242,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,5.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.02,13.96
Assay Alkaline Phosphatase,PX84075,CDM,300,RC,84075,CPT,,,,,,,,57,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,5.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.02,5.18
Assay Alkaline Phosphatase,PX84075,CDM,300,RC,84075,CPT,,,,,,,,57,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,5.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.02,5.18
Assay Alkaline Phosphatase,PX84075,CDM,300,RC,84075,CPT,,,,,,,,57,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,5.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.02,5.18
Bilirubin Direct,PX82248,CDM,300,RC,82248,CPT,,,,,,,,150,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,5.02,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.8135,5.02
Bilirubin Total,PX82247,CDM,300,RC,82247,CPT,,,,,,,,150,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,5.02,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.8135,5.02
C-Reactive Protein,PX86140,CDM,300,RC,86140,CPT,,,,,,,,191,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,5.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.02,5.18
C-Reactive Protein,PX86140,CDM,300,RC,86140,CPT,,,,,,,,191,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,5.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.02,5.18
C-Reactive Protein,PX86140,CDM,300,RC,86140,CPT,,,,,,,,191,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,5.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.02,5.18
Creatinine; Other Source - Ref,PX82570,CDM,300,RC,82570,CPT,90,,,,,,,119,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,5.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.02,5.18
Creatinine; Other Source - Ref,PX82570,CDM,300,RC,82570,CPT,90,,,,,,,119,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,5.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.02,5.18
Creatinine; Other Source - Ref,PX82570,CDM,300,RC,82570,CPT,90,,,,,,,119,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,5.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.02,5.18
Culture Type Immunologic,PX87147,CDM,300,RC,87147,CPT,,,,,,,,42,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,5.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.02,5.18
Culture Type Immunologic,PX87147,CDM,300,RC,87147,CPT,,,,,,,,42,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,5.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.02,5.18
Culture Type Immunologic,PX87147,CDM,300,RC,87147,CPT,,,,,,,,42,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,5.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.02,5.18
"Ecg 12 Lead, Interp Only",PX93010,CDM,985,RC,93010,CPT,,,,,,,,29,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,5.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.02,28.42
"Ecg 12 Lead, Interp Only",PX93010,CDM,985,RC,93010,CPT,,,,,,,,29,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,5.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.02,28.42
"Ecg 12 Lead, Interp Only",PX93010,CDM,985,RC,93010,CPT,,,,,,,,29,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,5.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.02,28.42
Heterophile Antibodies,PX86308,CDM,300,RC,86308,CPT,,,,,,,,196,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,5.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.02,5.18
Heterophile Antibodies,PX86308,CDM,300,RC,86308,CPT,,,,,,,,196,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,5.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.02,5.18
Heterophile Antibodies,PX86308,CDM,300,RC,86308,CPT,,,,,,,,196,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,5.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.02,5.18
Transferase; Aspartate Amino (Ast) (Sgot),PX84450,CDM,300,RC,84450,CPT,,,,,,,,58,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,5.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.02,5.18
Transferase; Aspartate Amino (Ast) (Sgot),PX84450,CDM,300,RC,84450,CPT,,,,,,,,58,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,5.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.02,5.18
Transferase; Aspartate Amino (Ast) (Sgot),PX84450,CDM,300,RC,84450,CPT,,,,,,,,58,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,5.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.02,5.18
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42937070110,NDC,1,EA,5.16,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,5.022228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
verapamil CR 180 MG Tablet Extended Release 100 Each Bottle,25000000,CDM,250,RC,,,,,,75834015801,NDC,0.666666667,EA,5.16,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,5.022228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
bisoprolol 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714052901,NDC,1,EA,12.1,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.02634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 100 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,74662411,NDC,1,EA,10.16,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,5.0292,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,70677003201,NDC,1,EA,10.16,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,5.0292,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
NIFEdipine CR osmotic 30 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,24979001101,NDC,1,EA,5.92,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5.032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Sugars, Qual, Ea Spec - Ref",PX8437690,CDM,300,RC,84376,CPT,90,,,,,,,45,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,5.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.04,44.1
"BANDAGE STERILE 3"" TETRA-FLEX CLIP FREE 0151-3SV",27200000,CDM,272,RC,A6449,HCPCS,,10661-MAIN,LOCAL,,,,,5.93,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5.0405,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
levothyroxine 25 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904694961,NDC,4,EA,11.75,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.04075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
escitalopram 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904642661,NDC,0.5,EA,11.76,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.04504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.1 MG/HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,378910216,NDC,1,EA,9.98,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,5.04988,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.1 MG/HR Patch 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,378910293,NDC,1,EA,9.98,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,5.04988,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
leucovorin 10 mg/mL Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,25021081467,NDC,1,EA,40.13,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,5.05069,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.93,5.13
leucovorin 350 MG Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,703514501,NDC,1,EA,86.41,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,5.05069,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.93,5.13
carvedilol 3.125 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079077120,NDC,0.5,EA,5.73,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,5.05386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.2 MG/HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,378910416,NDC,1,EA,10.21,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,5.05395,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.2 MG/HR Patch 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,378910493,NDC,1,EA,10.21,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,5.05395,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline monohydrate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084074333,NDC,1,EA,9.99,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,5.05494,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42937070110,NDC,1,EA,5.16,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,5.0568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
verapamil CR 180 MG Tablet Extended Release 100 Each Bottle,25000000,CDM,250,RC,,,,,,75834015801,NDC,0.666666667,EA,5.16,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,5.0568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Lab Ige, Isocyan Hdi",PX86003,CDM,300,RC,86003,CPT,90,,,,,,,34,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,5.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.06,5.22
"Lab Ige, Isocyan Hdi",PX86003,CDM,300,RC,86003,CPT,90,,,,,,,34,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,5.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.06,5.22
"Lab Ige, Isocyan Hdi",PX86003,CDM,300,RC,86003,CPT,90,,,,,,,34,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,5.06,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.06,5.22
Sodium; Urine,PX84300,CDM,300,RC,84300,CPT,,,,,,,,119,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,5.06,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.8135,5.06
Antinuclear Antibodies,PX86038,CDM,300,RC,86038,CPT,,,,,,,,10,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,5.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,11.09
Calcium - Ref,PX8231090,CDM,300,RC,82310,CPT,90,,,,,,,10,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,5.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,9.8
DRAPE SURGICAL 23X17INCH INCISE 1050,27200000,CDM,272,RC,,,,12873-MAIN,LOCAL,,,,,10,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,5.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
KERRAMAX CARE SUPERABSORBENT DRESSING 5X6,120.548,CDM,272,RC,A6197,HCPCS,,12362-MAIN,LOCAL,,,,,10,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,5.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,9.8
NEEDLE HYPODERMIC 22GA 1-1/2IN STERILE 305156,27200000,CDM,272,RC,A4215,HCPCS,,8887-MAIN,LOCAL,,,,,10,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,5.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Needle Insertion W/O Injection 1 or 2 Muscles,PX20560,CDM,420,RC,20560,CPT,,,,,,,,10,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,5.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,26.01
Needle Insertion W/O Injection 3 or More Muscles,PX20561,CDM,420,RC,20561,CPT,,,,,,,,10,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,5.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,26.01
PAD GROUNDING 9 FT ADULT REM E7507,27200000,CDM,272,RC,,,,504-MAIN,LOCAL,,,,,10,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,5.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
cyclobenzaprine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079064420,NDC,1,EA,5.2,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,5.06116,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 600 MG Tablet Extended Release 12 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904671839,NDC,1,EA,5.74,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,5.06268,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline hyclate 100 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,904043004,NDC,0.5,EA,12.21,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.072034,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cefOXitin 1 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021010910,NDC,1,EA,58.66,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,5.08,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.46,5.08
cefOXitin 2 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021011020,NDC,1,EA,77.24,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,5.08,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.46,5.08
verapamil CR 120 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462029201,NDC,1,EA,5.76,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,5.08032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,51991060401,NDC,1,EA,10.59,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,5.0832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,51991060401,NDC,1,EA,10.59,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,5.0832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,64380073706,NDC,1,EA,10.59,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,5.0832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,64380073706,NDC,1,EA,10.59,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,5.0832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine ER 15 MG Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,406831523,NDC,1,EA,10.05,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,5.0853,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine ER 15 MG Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,406831562,NDC,1,EA,10.05,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,5.0853,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 800 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714033201,NDC,0.75,EA,12.25,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.08865,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lisinopril 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,185060501,NDC,1,EA,5.23,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,5.090359,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 88 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378180701,NDC,2,EA,5.99,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5.0915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084065911,NDC,1,EA,5.99,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5.0915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084065901,NDC,1,EA,5.99,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5.0915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclobenzaprine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079064420,NDC,1,EA,5.2,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,5.096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
STOCKINETTE STERILE 4X48 NON22360,27200000,CDM,272,RC,A6457,HCPCS,,10658-MAIN,LOCAL,,,,,10.62,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,5.0976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STOCKINETTE STERILE 4X48 NON22360,27200000,CDM,272,RC,A6457,HCPCS,,10658-MAIN,LOCAL,,,,,10.62,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,5.0976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
carvedilol 3.125 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079077120,NDC,0.5,EA,5.73,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,5.0997,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay Urine Urea-N,PX84540,CDM,300,RC,84540,CPT,,,,,,,,14,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,5.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.1,13.72
ciprofloxacin 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862007701,NDC,0.2,EA,6,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,72205000530,NDC,0.125,EA,6,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glimepiride 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93725401,NDC,1,EA,5.79,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,5.10678,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 600 MG Tablet Extended Release 12 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904671839,NDC,1,EA,5.74,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,5.1086,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Blood Count Reticulocytes Auto 1/> Cell Meas,PX85046,CDM,300,RC,85046,CPT,,,,,,,,47,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,5.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.11,46.06
venlafaxine 25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,57237017290,NDC,1,EA,10.43,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.1107,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,57237017290,NDC,1,EA,10.43,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.1107,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,57237017290,NDC,1,EA,10.43,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,5.1107,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714031101,NDC,1,EA,10.43,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.1107,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714031101,NDC,1,EA,10.43,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.1107,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714031101,NDC,1,EA,10.43,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,5.1107,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57664039288,NDC,1,EA,10.43,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.1107,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57664039288,NDC,1,EA,10.43,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.1107,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57664039288,NDC,1,EA,10.43,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,5.1107,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methenamine 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862078201,NDC,0.5,EA,5.62,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,5.11982,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of creatinine,PX82565,CDM,300,RC,82565,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,5.12,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.97,5.1344
lisinopril 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,185060501,NDC,1,EA,5.23,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,5.1254,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
riFAMpin 150 MG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,68084035721,NDC,1,EA,10.68,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,5.1264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
riFAMpin 150 MG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,68084035721,NDC,1,EA,10.68,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,5.1264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
verapamil CR 120 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462029201,NDC,1,EA,5.76,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,5.1264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tacrolimus 1 MG capsule 100 Each Bottle,J7507.01,CDM,636,RC,J7507,HCPCS,,,,16714009901,NDC,0.5,EA,11.95,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.12655,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.96403,11.711
Body Fluid Cell Count W Diff,PX89051,CDM,300,RC,89051,CPT,,,,,,,,224,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,5.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.13,219.52
leucovorin 10 mg/mL Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,25021081467,NDC,1,EA,40.13,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,5.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.93,5.13
leucovorin 10 mg/mL Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,25021081467,NDC,1,EA,40.13,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,5.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.93,5.13
leucovorin 350 MG Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,703514501,NDC,1,EA,86.41,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,5.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.93,5.13
leucovorin 350 MG Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,703514501,NDC,1,EA,86.41,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,5.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.93,5.13
Assay Alkaline Phosphatase,PX84075,CDM,300,RC,84075,CPT,,,,,,,,57,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,5.1344,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.02,5.18
Assay of creatinine,PX82565,CDM,300,RC,82565,CPT,,,,,,,,58,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,5.1344,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.97,5.1344
"Blood, Occult, Other Sources",PX82271,CDM,300,RC,82271,CPT,,,,,,,,72,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,5.1344,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.1344,5.32
C-Reactive Protein,PX86140,CDM,300,RC,86140,CPT,,,,,,,,191,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,5.1344,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.02,5.18
Calcium - Ref,PX8231090,CDM,300,RC,82310,CPT,90,,,,,,,10,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,5.1344,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.01,5.16
Calcium Total,PX82310,CDM,300,RC,82310,CPT,,,,,,,,57,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,5.1344,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.01,5.16
Creatinine; Other Source - Ref,PX82570,CDM,300,RC,82570,CPT,90,,,,,,,119,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,5.1344,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.02,5.18
Culture Type Immunologic,PX87147,CDM,300,RC,87147,CPT,,,,,,,,42,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,5.1344,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.02,5.18
"Flour. Afstain , Micro - Ref",PX8720690,CDM,300,RC,87206,CPT,90,,,,,,,68,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,5.1344,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.1344,5.39
Heterophile Antibodies,PX86308,CDM,300,RC,86308,CPT,,,,,,,,196,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,5.1344,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.02,5.18
Lab Direct Coombs,PX86880,CDM,300,RC,86880,CPT,,,,,,,,76,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,5.1344,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.1344,5.39
"Lab Ige, Isocyan Hdi",PX86003,CDM,300,RC,86003,CPT,90,,,,,,,34,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,5.1344,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.06,5.22
Smear Fluorescent/Acid Stai,PX87206,CDM,300,RC,87206,CPT,,,,,,,,155,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,5.1344,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.1344,5.39
Transferase; Alanine Amino (Alt) (Sgpt),PX84460,CDM,300,RC,84460,CPT,,,,,,,,58,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,5.1344,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.1344,5.3
Transferase; Aspartate Amino (Ast) (Sgot),PX84450,CDM,300,RC,84450,CPT,,,,,,,,58,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,5.1344,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.02,5.18
benazepril 40 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862011801,NDC,1,EA,5.64,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,5.13804,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carvedilol 3.125 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904630061,NDC,0.5,EA,5.64,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,5.13804,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Transferase; Alanine Amino (Alt) (Sgpt),PX84460,CDM,300,RC,84460,CPT,,,,,,,,58,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,5.14,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.1344,5.3
Transferase; Alanine Amino (Alt) (Sgpt),PX84460,CDM,300,RC,84460,CPT,,,,,,,,58,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,5.14,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.1344,5.3
Transferase; Alanine Amino (Alt) (Sgpt),PX84460,CDM,300,RC,84460,CPT,,,,,,,,58,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,5.14,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.1344,5.3
levothyroxine 100 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,74662411,NDC,1,EA,10.16,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,5.14096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,70677003201,NDC,1,EA,10.16,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,5.14096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BAG URINARY DRAINAGE DYND15405H,120.33,CDM,271,RC,A4357,HCPCS,,9112-MAIN,LOCAL,,,,,12,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.148,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
peak flow meter Device 1 Each Box,800000,CDM,,,,,,,,8373075500,NDC,1,EA,12,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.148,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
"SUTURE SILK 2-0 BLK BR FS 18"" 685G",27200000,CDM,272,RC,,,,2668-MAIN,LOCAL,,,,,5.29,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,5.148757,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Flour. Afstain , Micro - Ref",PX8720690,CDM,300,RC,87206,CPT,90,,,,,,,68,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,5.15,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.1344,5.39
"Flour. Afstain , Micro - Ref",PX8720690,CDM,300,RC,87206,CPT,90,,,,,,,68,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,5.15,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.1344,5.39
Smear Fluorescent/Acid Stai,PX87206,CDM,300,RC,87206,CPT,,,,,,,,155,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,5.15,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.1344,5.39
Smear Fluorescent/Acid Stai,PX87206,CDM,300,RC,87206,CPT,,,,,,,,155,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,5.15,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.1344,5.39
glimepiride 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93725401,NDC,1,EA,5.79,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,5.1531,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Blood, Occult, Other Sources",PX82271,CDM,300,RC,82271,CPT,,,,,,,,72,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,5.16,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.1344,5.32
Calcium - Ref,PX8231090,CDM,300,RC,82310,CPT,90,,,,,,,10,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,5.16,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.01,5.16
Calcium Total,PX82310,CDM,300,RC,82310,CPT,,,,,,,,57,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,5.16,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.01,5.16
"Blood, Occult, Other Sources",PX82271,CDM,300,RC,82271,CPT,,,,,,,,72,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,5.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.1344,5.32
"Blood, Occult, Other Sources",PX82271,CDM,300,RC,82271,CPT,,,,,,,,72,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,5.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.1344,5.32
venlafaxine 25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,57237017290,NDC,1,EA,10.43,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,5.16285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714031101,NDC,1,EA,10.43,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,5.16285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57664039288,NDC,1,EA,10.43,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,5.16285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.2 MG/HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,378910416,NDC,1,EA,10.21,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,5.16626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.2 MG/HR Patch 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,378910493,NDC,1,EA,10.21,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,5.16626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay Alkaline Phosphatase,PX84075,CDM,300,RC,84075,CPT,,,,,,,,57,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,5.18,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.02,5.18
C-Reactive Protein,PX86140,CDM,300,RC,86140,CPT,,,,,,,,191,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,5.18,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.02,5.18
Creatinine; Other Source - Ref,PX82570,CDM,300,RC,82570,CPT,90,,,,,,,119,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,5.18,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.02,5.18
Culture Type Immunologic,PX87147,CDM,300,RC,87147,CPT,,,,,,,,42,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,5.18,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.02,5.18
Heterophile Antibodies,PX86308,CDM,300,RC,86308,CPT,,,,,,,,196,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,5.18,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.02,5.18
Transferase; Aspartate Amino (Ast) (Sgot),PX84450,CDM,300,RC,84450,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,5.18,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.02,5.18
losartan 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034711,NDC,1,EA,12.08,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.18232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034701,NDC,1,EA,12.08,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.18232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 14 MG/24HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,43598044771,NDC,1,EA,12.08,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.18232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"SUTURE SILK 2-0 BLK BR FS 18"" 685G",27200000,CDM,272,RC,,,,2668-MAIN,LOCAL,,,,,5.29,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,5.1842,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,51991060401,NDC,1,EA,10.59,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.1891,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,51991060401,NDC,1,EA,10.59,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.1891,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,51991060401,NDC,1,EA,10.59,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,5.1891,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,64380073706,NDC,1,EA,10.59,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.1891,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,64380073706,NDC,1,EA,10.59,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.1891,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,64380073706,NDC,1,EA,10.59,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,5.1891,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisoprolol 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714052901,NDC,1,EA,12.1,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.1909,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290101,NDC,1,EA,1966.88,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,5.2,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.58,6.06
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290101,NDC,1,EA,1966.88,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,5.2,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.58,6.06
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290102,NDC,1,EA,1966.88,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,5.2,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.58,6.06
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290102,NDC,1,EA,1966.88,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,5.2,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.58,6.06
Rheumatoid Factor Quant,PX86431,CDM,300,RC,86431,CPT,,,,,,,,97,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,5.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.2,95.06
STOCKINETTE STERILE 4X48 NON22360,27200000,CDM,272,RC,A6457,HCPCS,,10658-MAIN,LOCAL,,,,,10.62,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.2038,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STOCKINETTE STERILE 4X48 NON22360,27200000,CDM,272,RC,A6457,HCPCS,,10658-MAIN,LOCAL,,,,,10.62,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.2038,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STOCKINETTE STERILE 4X48 NON22360,27200000,CDM,272,RC,A6457,HCPCS,,10658-MAIN,LOCAL,,,,,10.62,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,5.2038,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
flecainide 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237006301,NDC,1,EA,10.85,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,5.208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
flecainide 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237006301,NDC,1,EA,10.85,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,5.208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem 30 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93031801,NDC,1,EA,5.36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,5.216888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 150 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084071311,NDC,0.25,EA,6.14,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5.219,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Lab Ige, Isocyan Hdi",PX86003,CDM,300,RC,86003,CPT,90,,,,,,,34,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,5.22,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.06,5.22
carvedilol 3.125 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079077120,NDC,0.5,EA,5.73,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,5.22003,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
NIFEdipine CR osmotic 30 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,24979001101,NDC,1,EA,5.92,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,5.22144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 600 MG Tablet Extended Release 12 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904671839,NDC,1,EA,5.74,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,5.22914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Flour. Afstain , Micro - Ref",PX8720690,CDM,300,RC,87206,CPT,90,,,,,,,68,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,5.23,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.1344,5.39
Lab Direct Coombs,PX86880,CDM,300,RC,86880,CPT,,,,,,,,76,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,5.23,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.1344,5.39
Lab Direct Coombs,PX86880,CDM,300,RC,86880,CPT,,,,,,,,76,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,5.23,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.1344,5.39
Lab Direct Coombs,PX86880,CDM,300,RC,86880,CPT,,,,,,,,76,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,5.23,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.1344,5.39
Smear Fluorescent/Acid Stai,PX87206,CDM,300,RC,87206,CPT,,,,,,,,155,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,5.23,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.1344,5.39
"BANDAGE STERILE 3"" TETRA-FLEX CLIP FREE 0151-3SV",27200000,CDM,272,RC,A6449,HCPCS,,10661-MAIN,LOCAL,,,,,5.93,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,5.23026,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
riFAMpin 150 MG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,68084035721,NDC,1,EA,10.68,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.2332,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
riFAMpin 150 MG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,68084035721,NDC,1,EA,10.68,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.2332,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
riFAMpin 150 MG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,68084035721,NDC,1,EA,10.68,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,5.2332,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline hyclate 100 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,904043004,NDC,0.5,EA,12.21,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.23809,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,51991060401,NDC,1,EA,10.59,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,5.24205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,64380073706,NDC,1,EA,10.59,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,5.24205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
verapamil CR 120 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462029201,NDC,1,EA,5.76,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,5.24736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem 30 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93031801,NDC,1,EA,5.36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,5.2528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 800 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714033201,NDC,0.75,EA,12.25,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.25525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003201,NDC,0.125,EA,5.4,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,5.25582,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
STOCKINETTE STERILE 4X48 NON22360,27200000,CDM,272,RC,A6457,HCPCS,,10658-MAIN,LOCAL,,,,,10.62,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,5.2569,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Assay of Triglycerides,PX84478,CDM,300,RC,84478,CPT,,,,,,,,115,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,5.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.26,112.7
glimepiride 1 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268035815,NDC,1,EA,5.41,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,5.265553,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
NIFEdipine CR osmotic 30 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,24979001101,NDC,1,EA,5.92,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,5.2688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glimepiride 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93725401,NDC,1,EA,5.79,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,5.27469,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,57237017290,NDC,1,EA,10.43,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,5.27758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714031101,NDC,1,EA,10.43,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,5.27758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57664039288,NDC,1,EA,10.43,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,5.27758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"BANDAGE STERILE 3"" TETRA-FLEX CLIP FREE 0151-3SV",27200000,CDM,272,RC,A6449,HCPCS,,10661-MAIN,LOCAL,,,,,5.93,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,5.2777,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ELECTRODES NEEDLE TIP PRECISE 2.4MM,27200000,CDM,272,RC,,,,12074-MAIN,LOCAL,,,,,11,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,5.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ELECTRODES NEEDLE TIP PRECISE 2.4MM,27200000,CDM,272,RC,,,,12074-MAIN,LOCAL,,,,,11,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,5.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE ETHIBOND XTRA 0 SHSH 36 INCH,27200000,CDM,272,RC,,,,12678-MAIN,LOCAL,,,,,11,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,5.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE ETHIBOND XTRA 0 SHSH 36 INCH,27200000,CDM,272,RC,,,,12678-MAIN,LOCAL,,,,,11,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,5.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
levothyroxine 88 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378180701,NDC,2,EA,5.99,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,5.28318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084065911,NDC,1,EA,5.99,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,5.28318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084065901,NDC,1,EA,5.99,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,5.28318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
riFAMpin 150 MG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,68084035721,NDC,1,EA,10.68,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,5.2866,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
onabotulinumtoxinA 50 units Recon Soln 1 Each Vial,J0585.03,CDM,636,RC,J0585,HCPCS,,,,23391950,NDC,1,EA,1418.14,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,5.29,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.29,6.33
onabotulinumtoxinA 100 units Recon Soln 1 Each Vial,J0585.01,CDM,636,RC,J0585,HCPCS,,,,23114501,NDC,1,EA,2348.77,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,5.29,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.29,6.33
Thrombin Time Plasma,PX85670,CDM,300,RC,85670,CPT,,,,,,,,126,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,5.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.29,123.48
ciprofloxacin 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862007701,NDC,0.2,EA,6,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,5.292,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003201,NDC,0.125,EA,5.4,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,5.292,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,72205000530,NDC,0.125,EA,6,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,5.292,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Microalbumin Quantitative,PX82043,CDM,300,RC,82043,CPT,,,,,,,,167,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,5.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.3,163.66
Transferase; Alanine Amino (Alt) (Sgpt),PX84460,CDM,300,RC,84460,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,5.3,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.1344,5.3
glimepiride 1 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268035815,NDC,1,EA,5.41,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,5.3018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol LA 60 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,527411637,NDC,1,EA,11.05,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,5.304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol LA 60 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,527411637,NDC,1,EA,11.05,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,5.304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Nasal Sm for Eos,PX89190,CDM,300,RC,89190,CPT,,,,,,,,38,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,5.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.31,37.24
gabapentin 600 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268035111,NDC,1,EA,12.79,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.312966,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 600 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268035115,NDC,1,EA,12.79,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.312966,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxazosin 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904552261,NDC,1,EA,5.46,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,5.314218,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,43598043635,NDC,1,EA,5.46,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,5.314218,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
flecainide 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237006301,NDC,1,EA,10.85,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.3165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
flecainide 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237006301,NDC,1,EA,10.85,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.3165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
flecainide 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237006301,NDC,1,EA,10.85,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,5.3165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Blood, Occult, Other Sources",PX82271,CDM,300,RC,82271,CPT,,,,,,,,72,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,5.32,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.1344,5.32
venlafaxine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084089695,NDC,1,EA,11.1,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,5.328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084089695,NDC,1,EA,11.1,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,5.328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 88 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378180701,NDC,2,EA,5.99,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,5.3311,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084065911,NDC,1,EA,5.99,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,5.3311,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084065901,NDC,1,EA,5.99,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,5.3311,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 7 Each Box,63700001,CDM,250,RC,,,,,,536589653,NDC,1,EA,12.84,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.333736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862007701,NDC,0.2,EA,6,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,5.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,72205000530,NDC,0.125,EA,6,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,5.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Smear Wet Mount Saline/Ink,PX87210,CDM,300,RC,87210,CPT,,,,,,,,109,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,5.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.34,106.82
"Sugars, Qual, Ea Spec - Ref",PX8437690,CDM,300,RC,84376,CPT,90,,,,,,,45,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,5.34,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.34,5.5
"Sugars, Qual, Ea Spec - Ref",PX8437690,CDM,300,RC,84376,CPT,90,,,,,,,45,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,5.34,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.34,5.5
"Sugars, Qual, Ea Spec - Ref",PX8437690,CDM,300,RC,84376,CPT,90,,,,,,,45,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,5.34,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.34,5.5
anastrozole 1 MG Tablet 1 Each Blister,25000000,CDM,250,RC,,,,,,60687011211,NDC,1,EA,11.13,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,5.3424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
anastrozole 1 MG Tablet 1 Each Blister,25000000,CDM,250,RC,,,,,,60687011211,NDC,1,EA,11.13,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,5.3424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
anastrozole 1 MG Tablet 30 Each Box,25000000,CDM,250,RC,,,,,,60687011221,NDC,1,EA,11.13,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,5.3424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
anastrozole 1 MG Tablet 30 Each Box,25000000,CDM,250,RC,,,,,,60687011221,NDC,1,EA,11.13,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,5.3424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
doxazosin 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904552261,NDC,1,EA,5.46,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,5.3508,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,43598043635,NDC,1,EA,5.46,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,5.3508,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,75826011410,NDC,1,EA,12.89,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.354506,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56016901,NDC,1,EA,12.89,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.354506,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,51991060401,NDC,1,EA,10.59,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,5.35854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,64380073706,NDC,1,EA,10.59,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,5.35854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,10370083111,NDC,0.5,EA,5.51,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,5.362883,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,68462063925,NDC,1,EA,5.51,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,5.362883,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
flecainide 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237006301,NDC,1,EA,10.85,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,5.37075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nabumetone 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687037401,NDC,1,EA,6.32,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5.372,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
STOCKINETTE STERILE 4X48 NON22360,27200000,CDM,272,RC,A6457,HCPCS,,10658-MAIN,LOCAL,,,,,10.62,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,5.37372,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
enalapril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714044201,NDC,1,EA,6.33,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5.3805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PREP KIT SKIN PREMIUM,27200000,CDM,272,RC,,,,4108-MAIN,LOCAL,,,,,12.96,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.383584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Assay Urine Urea-N,PX84540,CDM,300,RC,84540,CPT,,,,,,,,14,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,5.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.39,5.56
Assay Urine Urea-N,PX84540,CDM,300,RC,84540,CPT,,,,,,,,14,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,5.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.39,5.56
Assay Urine Urea-N,PX84540,CDM,300,RC,84540,CPT,,,,,,,,14,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,5.39,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.39,5.56
ELECTRODES NEEDLE TIP PRECISE 2.4MM,27200000,CDM,272,RC,,,,12074-MAIN,LOCAL,,,,,11,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ELECTRODES NEEDLE TIP PRECISE 2.4MM,27200000,CDM,272,RC,,,,12074-MAIN,LOCAL,,,,,11,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ELECTRODES NEEDLE TIP PRECISE 2.4MM,27200000,CDM,272,RC,,,,12074-MAIN,LOCAL,,,,,11,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,5.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Flour. Afstain , Micro - Ref",PX8720690,CDM,300,RC,87206,CPT,90,,,,,,,68,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,5.39,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.1344,5.39
"Homogenization, Tissue for Culture",PX87176,CDM,300,RC,87176,CPT,,,,,,,,50,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,5.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.39,49
Lab Direct Coombs,PX86880,CDM,300,RC,86880,CPT,,,,,,,,76,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,5.39,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.1344,5.39
Smear Fluorescent/Acid Stai,PX87206,CDM,300,RC,87206,CPT,,,,,,,,155,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,5.39,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.1344,5.39
SUTURE ETHIBOND XTRA 0 SHSH 36 INCH,27200000,CDM,272,RC,,,,12678-MAIN,LOCAL,,,,,11,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE ETHIBOND XTRA 0 SHSH 36 INCH,27200000,CDM,272,RC,,,,12678-MAIN,LOCAL,,,,,11,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE ETHIBOND XTRA 0 SHSH 36 INCH,27200000,CDM,272,RC,,,,12678-MAIN,LOCAL,,,,,11,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,5.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NIFEdipine CR osmotic 30 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,24979001101,NDC,1,EA,5.92,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,5.39312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
FLUoxetine 10 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578461,NDC,1,EA,12.99,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.396046,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,10370083111,NDC,0.5,EA,5.51,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,5.3998,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,68462063925,NDC,1,EA,5.51,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,5.3998,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Blood Count Reticulocytes Auto 1/> Cell Meas,PX85046,CDM,300,RC,85046,CPT,,,,,,,,47,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,5.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.4,5.57
Blood Count Reticulocytes Auto 1/> Cell Meas,PX85046,CDM,300,RC,85046,CPT,,,,,,,,47,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,5.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.4,5.57
Blood Count Reticulocytes Auto 1/> Cell Meas,PX85046,CDM,300,RC,85046,CPT,,,,,,,,47,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,5.4,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.4,5.57
"Antibiotic Sens,Enzyme Detection,Each - Ref",PX8718590,CDM,300,RC,87185,CPT,90,,,,,,,13,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.4002,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.36,12.74
BONE WAX SUTURE 2.5G ETHICON,27200000,CDM,272,RC,,,,12566-MAIN,LOCAL,,,,,13,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.4002,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"BANDAGE STERILE 3"" TETRA-FLEX CLIP FREE 0151-3SV",27200000,CDM,272,RC,A6449,HCPCS,,10661-MAIN,LOCAL,,,,,5.93,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,5.40223,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
riFAMpin 150 MG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,68084035721,NDC,1,EA,10.68,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,5.40408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
citalopram 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904608461,NDC,1,EA,13.03,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.412662,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034211,NDC,1,EA,11.28,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,5.4144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034211,NDC,1,EA,11.28,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,5.4144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034201,NDC,1,EA,11.28,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,5.4144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034201,NDC,1,EA,11.28,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,5.4144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lovastatin 20 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,93057606,NDC,0.5,EA,6.37,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5.4145,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol LA 60 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,527411637,NDC,1,EA,11.05,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.4145,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol LA 60 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,527411637,NDC,1,EA,11.05,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.4145,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol LA 60 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,527411637,NDC,1,EA,11.05,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,5.4145,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 150 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084071311,NDC,0.25,EA,6.14,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,5.41548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Body Fluid Cell Count W Diff,PX89051,CDM,300,RC,89051,CPT,,,,,,,,224,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,5.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.43,5.6
Body Fluid Cell Count W Diff,PX89051,CDM,300,RC,89051,CPT,,,,,,,,224,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,5.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.43,5.6
Body Fluid Cell Count W Diff,PX89051,CDM,300,RC,89051,CPT,,,,,,,,224,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,5.43,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.43,5.6
BITE BLOCK MAXI 20MM 60FR,27200000,CDM,272,RC,,,,8144-MAIN,LOCAL,,,,,11.32,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,5.4336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
BITE BLOCK MAXI 20MM 60FR,27200000,CDM,272,RC,,,,8144-MAIN,LOCAL,,,,,11.32,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,5.4336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
venlafaxine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084089695,NDC,1,EA,11.1,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.439,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084089695,NDC,1,EA,11.1,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.439,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084089695,NDC,1,EA,11.1,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,5.439,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 75 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079044120,NDC,2,EA,6.4,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ELECTRODES NEEDLE TIP PRECISE 2.4MM,27200000,CDM,272,RC,,,,12074-MAIN,LOCAL,,,,,11,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,5.445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE ETHIBOND XTRA 0 SHSH 36 INCH,27200000,CDM,272,RC,,,,12678-MAIN,LOCAL,,,,,11,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,5.445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Cardiac Rehab,PX93797F,CDM,943,RC,93797,CPT,,,,,,,,45,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,5.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.45,29.67
Cardiac Rehab,PX93797F,CDM,943,RC,93797,CPT,,,,,,,,45,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,5.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.45,29.67
Cardiac Rehab,PX93797F,CDM,943,RC,93797,CPT,,,,,,,,45,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,5.45,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.45,29.67
Place Needle in Vein,PX36000P,CDM,983,RC,36000,CPT,,,,,,,,1034,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,5.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.45,1013.32
Place Needle in Vein,PX36000P,CDM,983,RC,36000,CPT,,,,,,,,1034,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,5.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.45,1013.32
Place Needle in Vein,PX36000P,CDM,983,RC,36000,CPT,,,,,,,,1034,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,5.45,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.45,1013.32
"Venipunc Need Phys Skill,Dx or Rx",PX36410,CDM,983,RC,36410,CPT,,,,,,,,132,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,5.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.45,129.36
"Venipunc Need Phys Skill,Dx or Rx",PX36410,CDM,983,RC,36410,CPT,,,,,,,,132,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,5.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.45,129.36
"Venipunc Need Phys Skill,Dx or Rx",PX36410,CDM,983,RC,36410,CPT,,,,,,,,132,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,5.45,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.45,129.36
"Venipunc Need Phys Skill,Dx or Rx",PX36410F,CDM,510,RC,36410,CPT,,,,,,,,34,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,5.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.45,36.67
"Venipunc Need Phys Skill,Dx or Rx",PX36410F,CDM,510,RC,36410,CPT,,,,,,,,34,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,5.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.45,36.67
"Venipunc Need Phys Skill,Dx or Rx",PX36410F,CDM,510,RC,36410,CPT,,,,,,,,34,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,5.45,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.45,36.67
"Venipunc Need Phys Skill,Dx or Rx",PX36410P,CDM,983,RC,36410,CPT,,,,,,,,129,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,5.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.45,126.42
"Venipunc Need Phys Skill,Dx or Rx",PX36410P,CDM,983,RC,36410,CPT,,,,,,,,129,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,5.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.45,126.42
"Venipunc Need Phys Skill,Dx or Rx",PX36410P,CDM,983,RC,36410,CPT,,,,,,,,129,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,5.45,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.45,126.42
"Venipuncture by Physician, Other Vein, Under Age 3 Years",PX36406,CDM,983,RC,36406,CPT,,,,,,,,45,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,5.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.45,44.1
"Venipuncture by Physician, Other Vein, Under Age 3 Years",PX36406,CDM,983,RC,36406,CPT,,,,,,,,45,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,5.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.45,44.1
"Venipuncture by Physician, Other Vein, Under Age 3 Years",PX36406,CDM,983,RC,36406,CPT,,,,,,,,45,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,5.45,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.45,44.1
anastrozole 1 MG Tablet 1 Each Blister,25000000,CDM,250,RC,,,,,,60687011211,NDC,1,EA,11.13,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.4537,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
anastrozole 1 MG Tablet 1 Each Blister,25000000,CDM,250,RC,,,,,,60687011211,NDC,1,EA,11.13,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.4537,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
anastrozole 1 MG Tablet 1 Each Blister,25000000,CDM,250,RC,,,,,,60687011211,NDC,1,EA,11.13,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,5.4537,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
anastrozole 1 MG Tablet 30 Each Box,25000000,CDM,250,RC,,,,,,60687011221,NDC,1,EA,11.13,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.4537,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
anastrozole 1 MG Tablet 30 Each Box,25000000,CDM,250,RC,,,,,,60687011221,NDC,1,EA,11.13,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.4537,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
anastrozole 1 MG Tablet 30 Each Box,25000000,CDM,250,RC,,,,,,60687011221,NDC,1,EA,11.13,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,5.4537,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Assay Urine Urea-N,PX84540,CDM,300,RC,84540,CPT,,,,,,,,14,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,5.4553,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.39,5.56
Blood Count Reticulocytes Auto 1/> Cell Meas,PX85046,CDM,300,RC,85046,CPT,,,,,,,,47,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,5.4553,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.4,5.57
Body Fluid Cell Count W Diff,PX89051,CDM,300,RC,89051,CPT,,,,,,,,224,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,5.4553,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.43,5.6
Rheumatoid Factor Quant,PX86431,CDM,300,RC,86431,CPT,,,,,,,,97,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,5.4553,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.4553,5.67
"Sugars, Qual, Ea Spec - Ref",PX8437690,CDM,300,RC,84376,CPT,90,,,,,,,45,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,5.4553,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.34,5.5
levothyroxine 88 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378180701,NDC,2,EA,5.99,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,5.45689,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084065911,NDC,1,EA,5.99,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,5.45689,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084065901,NDC,1,EA,5.99,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,5.45689,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex ER 250 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031011,NDC,1,EA,13.14,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.458356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex ER 250 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084031001,NDC,1,EA,13.14,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.458356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Office/Outpt Visit Est Level I,PX99211F,CDM,510,RC,99211,CPT,,,,,,,,119,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,5.46,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.46,41.86
Office/Outpt Visit Est Level I,PX99211P,CDM,983,RC,99211,CPT,,,,,,,,119,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,5.46,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.46,116.62
venlafaxine 150 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084071311,NDC,0.25,EA,6.14,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,5.4646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862007701,NDC,0.2,EA,6,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,5.466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,72205000530,NDC,0.125,EA,6,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,5.466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061400,NDC,1,ML,101.95,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,5.4689,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.91,5.59
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061401,NDC,1,ML,94.87,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,5.4689,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.91,5.59
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061416,NDC,0.5,ML,31.57,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,5.4689,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.91,5.59
propranolol LA 60 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,527411637,NDC,1,EA,11.05,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,5.46975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methenamine 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862078201,NDC,0.5,EA,5.62,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,5.469946,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127303,NDC,2,ML,152.7,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,5.47,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.8,6.53
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127332,NDC,2,ML,176.55,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,5.47,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.8,6.53
rivastigmine 3 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,55111035360,NDC,0.5,EA,11.4,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,5.472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rivastigmine 3 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,55111035360,NDC,0.5,EA,11.4,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,5.472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
olmesartan 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862074330,NDC,0.125,EA,6.45,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5.4825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 600 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268035111,NDC,1,EA,12.79,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.48691,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 600 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268035115,NDC,1,EA,12.79,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.48691,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 40 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862011801,NDC,1,EA,5.64,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,5.489412,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carvedilol 3.125 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904630061,NDC,0.5,EA,5.64,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,5.489412,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Smear Special Stain,PX87207,CDM,300,RC,87207,CPT,,,,,,,,81,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,5.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.49,79.38
Sp Stn for Inclusn Bodies - Ref,PX8720790,CDM,300,RC,87207,CPT,90,,,,,,,227,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,5.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.49,222.46
flecainide 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237006301,NDC,1,EA,10.85,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,5.4901,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084089695,NDC,1,EA,11.1,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,5.4945,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 112 MCG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,74929690,NDC,0.892857143,EA,6.47,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5.4995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Rheumatoid Factor Quant,PX86431,CDM,300,RC,86431,CPT,,,,,,,,97,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,5.5,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.4553,5.67
Rheumatoid Factor Quant,PX86431,CDM,300,RC,86431,CPT,,,,,,,,97,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,5.5,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.4553,5.67
Rheumatoid Factor Quant,PX86431,CDM,300,RC,86431,CPT,,,,,,,,97,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,5.5,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.4553,5.67
"Sugars, Qual, Ea Spec - Ref",PX8437690,CDM,300,RC,84376,CPT,90,,,,,,,45,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,5.5,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.34,5.5
carvedilol 3.125 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079077101,NDC,1,EA,11.46,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,5.5008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carvedilol 3.125 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079077101,NDC,1,EA,11.46,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,5.5008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 14 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,43598044774,NDC,1,EA,11.46,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,5.5008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 14 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,43598044774,NDC,1,EA,11.46,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,5.5008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,43598044871,NDC,1,EA,11.46,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,5.5008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,43598044871,NDC,1,EA,11.46,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,5.5008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methenamine 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862078201,NDC,0.5,EA,5.62,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,5.5076,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 7 Each Box,63700001,CDM,250,RC,,,,,,536589653,NDC,1,EA,12.84,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.50836,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
anastrozole 1 MG Tablet 1 Each Blister,25000000,CDM,250,RC,,,,,,60687011211,NDC,1,EA,11.13,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,5.50935,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
anastrozole 1 MG Tablet 30 Each Box,25000000,CDM,250,RC,,,,,,60687011221,NDC,1,EA,11.13,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,5.50935,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
onabotulinumtoxinA 50 units Recon Soln 1 Each Vial,J0585.03,CDM,636,RC,J0585,HCPCS,,,,23391950,NDC,1,EA,1418.14,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,5.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.51,1389.7772
onabotulinumtoxinA 100 units Recon Soln 1 Each Vial,J0585.01,CDM,636,RC,J0585,HCPCS,,,,23114501,NDC,1,EA,2348.77,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,5.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.51,2301.7946
Thromboplastin Time Partial,PX85730,CDM,300,RC,85730,CPT,,,,,,,,142,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,5.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.51,139.16
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,536110888,NDC,1,EA,11.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,5.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,536110888,NDC,1,EA,11.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,5.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739051610,NDC,1,EA,13.3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.52482,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcitRIOL 0.25 MCG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155011801,NDC,1,EA,6.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5.525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benazepril 40 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862011801,NDC,1,EA,5.64,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,5.5272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carvedilol 3.125 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904630061,NDC,0.5,EA,5.64,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,5.5272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034211,NDC,1,EA,11.28,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.5272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034211,NDC,1,EA,11.28,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.5272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034211,NDC,1,EA,11.28,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,5.5272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034201,NDC,1,EA,11.28,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.5272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034201,NDC,1,EA,11.28,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.5272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034201,NDC,1,EA,11.28,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,5.5272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,75826011410,NDC,1,EA,12.89,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.52981,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56016901,NDC,1,EA,12.89,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.52981,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cetirizine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585261,NDC,0.5,EA,6.51,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5.5335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Lactate (Ld) (Ldh) Enzyme,PX83615,CDM,300,RC,83615,CPT,,,,,,,,157,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,5.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.54,153.86
FLUoxetine 20 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578561,NDC,1,EA,13.34,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.541436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
midodrine 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,42291056190,NDC,0.5,EA,6.52,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5.542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BITE BLOCK MAXI 20MM 60FR,27200000,CDM,272,RC,,,,8144-MAIN,LOCAL,,,,,11.32,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.5468,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
BITE BLOCK MAXI 20MM 60FR,27200000,CDM,272,RC,,,,8144-MAIN,LOCAL,,,,,11.32,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.5468,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
BITE BLOCK MAXI 20MM 60FR,27200000,CDM,272,RC,,,,8144-MAIN,LOCAL,,,,,11.32,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,5.5468,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061400,NDC,1,ML,101.95,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,5.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.91,5.59
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061400,NDC,1,ML,101.95,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,5.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.91,5.59
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061401,NDC,1,ML,94.87,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,5.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.91,5.59
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061401,NDC,1,ML,94.87,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,5.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.91,5.59
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061416,NDC,0.5,ML,31.57,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,5.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.91,5.59
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061416,NDC,0.5,ML,31.57,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,5.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.91,5.59
ketorolac 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69543038810,NDC,1,EA,11.58,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,5.5584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ketorolac 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69543038810,NDC,1,EA,11.58,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,5.5584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PREP KIT SKIN PREMIUM,27200000,CDM,272,RC,,,,4108-MAIN,LOCAL,,,,,12.96,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.55984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Assay Urine Urea-N,PX84540,CDM,300,RC,84540,CPT,,,,,,,,14,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,5.56,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.39,5.56
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089901,NDC,0.25,ML,95.31,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,5.56,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.56,6.33
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089910,NDC,0.25,ML,95.31,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,5.56,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.56,6.33
Smear Wet Mount Saline/Ink,PX87210,CDM,300,RC,87210,CPT,,,,,,,,109,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,5.56,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.56,5.82
Smear Wet Mount Saline/Ink,PX87210,CDM,300,RC,87210,CPT,,,,,,,,109,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,5.56,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.56,5.82
"SUTURE CHROME GUT 3-0 CP-2 27""",27200000,CDM,272,RC,,,,4967-MAIN,LOCAL,,,,,11.59,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,5.5632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"SUTURE CHROME GUT 3-0 CP-2 27""",27200000,CDM,272,RC,,,,4967-MAIN,LOCAL,,,,,11.59,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,5.5632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ELECTRODES NEEDLE TIP PRECISE 2.4MM,27200000,CDM,272,RC,,,,12074-MAIN,LOCAL,,,,,11,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,5.566,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE ETHIBOND XTRA 0 SHSH 36 INCH,27200000,CDM,272,RC,,,,12678-MAIN,LOCAL,,,,,11,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,5.566,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Assay of Triglycerides,PX84478,CDM,300,RC,84478,CPT,,,,,,,,115,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,5.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.57,5.7762
Assay of Triglycerides,PX84478,CDM,300,RC,84478,CPT,,,,,,,,115,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,5.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.57,5.7762
Assay of Triglycerides,PX84478,CDM,300,RC,84478,CPT,,,,,,,,115,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,5.57,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.57,5.7762
Blood Count Reticulocytes Auto 1/> Cell Meas,PX85046,CDM,300,RC,85046,CPT,,,,,,,,47,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,5.57,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.4,5.57
FLUoxetine 10 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578461,NDC,1,EA,12.99,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.57271,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nabumetone 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687037401,NDC,1,EA,6.32,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,5.57424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,50268015211,NDC,1,EA,6.56,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5.576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 50 Each Box,63700001,CDM,250,RC,,,,,,50268015215,NDC,1,EA,6.56,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5.576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Antibiotic Sens,Enzyme Detection,Each - Ref",PX8718590,CDM,300,RC,87185,CPT,90,,,,,,,13,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.577,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.36,12.74
BONE WAX SUTURE 2.5G ETHICON,27200000,CDM,272,RC,,,,12566-MAIN,LOCAL,,,,,13,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.577,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
carvedilol 3.125 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079077120,NDC,0.5,EA,5.73,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,5.577009,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rOPINIRole 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547026810,NDC,1,EA,13.43,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.578822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56017001,NDC,1,EA,13.43,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.578822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzonatate 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877010501,NDC,1,EA,13.44,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.582976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
enalapril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714044201,NDC,1,EA,6.33,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,5.58306,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034211,NDC,1,EA,11.28,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,5.5836,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034201,NDC,1,EA,11.28,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,5.5836,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rivastigmine 3 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,55111035360,NDC,0.5,EA,11.4,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rivastigmine 3 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,55111035360,NDC,0.5,EA,11.4,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rivastigmine 3 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,55111035360,NDC,0.5,EA,11.4,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,5.586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 600 MG Tablet Extended Release 12 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904671839,NDC,1,EA,5.74,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,5.586742,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rOPINIRole 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462025301,NDC,1,EA,13.45,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.58713,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
citalopram 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904608461,NDC,1,EA,13.03,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.58987,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061400,NDC,1,ML,101.95,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,5.59,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.91,5.59
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061401,NDC,1,ML,94.87,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,5.59,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.91,5.59
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061416,NDC,0.5,ML,31.57,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,5.59,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.91,5.59
propranolol LA 60 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,527411637,NDC,1,EA,11.05,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,5.5913,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 150 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084071311,NDC,0.25,EA,6.14,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,5.59354,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Body Fluid Cell Count W Diff,PX89051,CDM,300,RC,89051,CPT,,,,,,,,224,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,5.6,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.43,5.6
Thrombin Time Plasma,PX85670,CDM,300,RC,85670,CPT,,,,,,,,126,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,5.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6,5.7762
Thrombin Time Plasma,PX85670,CDM,300,RC,85670,CPT,,,,,,,,126,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,5.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6,5.7762
Thrombin Time Plasma,PX85670,CDM,300,RC,85670,CPT,,,,,,,,126,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,5.6,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6,5.7762
"SUTURE ETHILON 2-0 BLK MONO FS 18"" 664G",27200000,CDM,272,RC,,,,3663-MAIN,LOCAL,,,,,6.59,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5.6015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
BITE BLOCK MAXI 20MM 60FR,27200000,CDM,272,RC,,,,8144-MAIN,LOCAL,,,,,11.32,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,5.6034,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
verapamil CR 120 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462029201,NDC,1,EA,5.76,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,5.606208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 160 MG/5ML Suspension 118 mL Bottle,63700001,CDM,250,RC,,,,,,45802020326,NDC,10.15625,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
albuterol (2.5 MG/3ML) 0.083% Nebulization Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487950101,NDC,3,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
albuterol 1.25 MG/3ML Nebulization Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487990425,NDC,3,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Alcohol Swabstick 70 % Pad 50 Each Box,800000,CDM,,,,,,,,18407061105,NDC,1,EA,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
amoxicillin 250 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,65862070755,NDC,5,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 400 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,65862007101,NDC,3.125,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Biotene Dry Mouth Liquid 473 mL Bottle,63700001,CDM,250,RC,,,,,,48582000330,NDC,5,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbamide peroxide 6.5% 6.5 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904662735,NDC,15,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,93417773,NDC,2.5,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,24979015514,NDC,2.5,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314065605,NDC,0.05,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dexAMETHasone 1 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,54317644,NDC,0.5,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dextromethorphan-guaiFENesin 20-200 MG/20ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904722320,NDC,118,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,693390152,NDC,2.5,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
diphenhydrAMINE 12.5 MG/5ML Liquid 118 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904698520,NDC,2.5,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
diphenhydrAMINE 12.5 MG/5ML Liquid 120 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,58657052804,NDC,2.5,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,57896018105,NDC,15,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,57896018405,NDC,15,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,603107554,NDC,5,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,69367027204,NDC,5,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904006100,NDC,5,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904676320,NDC,5,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,54838011740,NDC,5,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,61787006304,NDC,5,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 100 MG/5ML Suspension 120 mL Bottle,63700001,CDM,250,RC,,,,,,904530920,NDC,20,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ipratropium 0.02 % Solution 2.5 mL Plas Cont,25000000,CDM,250,RC,,,,,,76204010001,NDC,2.5,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487020101,NDC,3,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lactulose 10 GM/15ML Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,121457715,NDC,15,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lactulose encephalopathy 10 GM/15ML Solution 473 mL Bottle,25000000,CDM,250,RC,,,,,,50383079516,NDC,15,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
levalbuterol 1.25 MG/3ML Nebulization Solution 3 mL Box,63700001,CDM,250,RC,,,,,,76204090001,NDC,3,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levalbuterol 1.25 MG/3ML Nebulization Solution 3 mL Plas Cont,63700001,CDM,250,RC,,,,,,76204090011,NDC,3,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine viscous 2 % Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,121090315,NDC,5,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine viscous 2 % Solution 100 mL Bottle,63700001,CDM,250,RC,,,,,,72888012526,NDC,5,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,54353244,NDC,0.25,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,121077001,NDC,0.25,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,65162068784,NDC,0.25,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium citrate 1.745 GM/30ML Solution 296 mL Bottle,63700001,CDM,250,RC,,,,,,69452038998,NDC,150,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium citrate 1.745 GM/30ML Solution 296 mL Bottle,63700001,CDM,250,RC,,,,,,70677111101,NDC,150,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium hydroxide 400 MG/5ML Suspension 30 mL Cup,63700001,CDM,250,RC,,,,,,69339015301,NDC,5,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine 20 mg/mL Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,54051744,NDC,0.5,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine polacrilex 4 MG Lozenge 24 Each Bottle,63700001,CDM,250,RC,,,,,,113087303,NDC,0.5,EA,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,121086805,NDC,4,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,121086802,NDC,4,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,66689000802,NDC,4,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 473 mL Bottle,63700001,CDM,250,RC,,,,,,121086816,NDC,4,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
opium 10 MG/ML (1%) Tincture 0.3 mL Syringe,63700001,CDM,250,RC,,,,,,8888800392,NDC,0.3,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
opium 10 MG/ML (1%) Tincture 0.6 mL Syringe,63700001,CDM,250,RC,,,,,,88888800245,NDC,0.3,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
opium 10 MG/ML (1%) Tincture 118 mL Bottle,63700001,CDM,250,RC,,,,,,42799021701,NDC,0.3,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxymetazoline 0.05 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904571135,NDC,15,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,904693186,NDC,1,EA,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 100 Each Box,63700001,CDM,250,RC,,,,,,904642281,NDC,1,EA,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
povidone iodine 10 % Solution 59 mL Bottle,63700001,CDM,250,RC,,,,,,52380190502,NDC,59,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Povidone-Iodine 10 % SWAB 1 Each Package,25000000,CDM,250,RC,,,,,,67618015301,NDC,1,EA,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004224,NDC,5,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,62135025037,NDC,1.666666667,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
racEPINEPHrine 2.25 % Nebulization Solution 1 Each Plas Cont,25000000,CDM,250,RC,,,,,,487590199,NDC,1,EA,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9 % Nebulization Solution 3 mL Plas Cont,63700001,CDM,250,RC,,,,,,487930133,NDC,3,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium chloride 0.65 % Solution 44 mL Bottle,63700001,CDM,250,RC,,,,,,904386575,NDC,44,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium phosphate 7-19 GM/118ML Enema 133 mL Bottle,63700001,CDM,250,RC,,,,,,132020140,NDC,133,ML,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
white petrolatum Gel 52.5 g Jar,63700001,CDM,250,RC,,,,,,521231100,NDC,52.5,GR,13.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.6079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Microalbumin Quantitative,PX82043,CDM,300,RC,82043,CPT,,,,,,,,167,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,5.61,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.61,5.78
Microalbumin Quantitative,PX82043,CDM,300,RC,82043,CPT,,,,,,,,167,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,5.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.61,5.78
Microalbumin Quantitative,PX82043,CDM,300,RC,82043,CPT,,,,,,,,167,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,5.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.61,5.78
carvedilol 3.125 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079077101,NDC,1,EA,11.46,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.6154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carvedilol 3.125 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079077101,NDC,1,EA,11.46,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.6154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carvedilol 3.125 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079077101,NDC,1,EA,11.46,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,5.6154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carvedilol 3.125 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079077120,NDC,0.5,EA,5.73,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,5.6154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 14 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,43598044774,NDC,1,EA,11.46,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.6154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 14 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,43598044774,NDC,1,EA,11.46,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.6154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 14 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,43598044774,NDC,1,EA,11.46,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,5.6154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,43598044871,NDC,1,EA,11.46,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.6154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,43598044871,NDC,1,EA,11.46,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.6154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,43598044871,NDC,1,EA,11.46,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,5.6154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084089695,NDC,1,EA,11.1,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,5.6166,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lovastatin 20 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,93057606,NDC,0.5,EA,6.37,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,5.61834,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Nasal Sm for Eos,PX89190,CDM,300,RC,89190,CPT,,,,,,,,38,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,5.62,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.62,5.79
Nasal Sm for Eos,PX89190,CDM,300,RC,89190,CPT,,,,,,,,38,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,5.62,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.62,5.79
Nasal Sm for Eos,PX89190,CDM,300,RC,89190,CPT,,,,,,,,38,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,5.62,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.62,5.79
nicotine 7 MG/24HR Patch 24 Hour 7 Each Box,63700001,CDM,250,RC,,,,,,43598044670,NDC,1,EA,13.53,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.620362,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nabumetone 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687037401,NDC,1,EA,6.32,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,5.6248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 600 MG Tablet Extended Release 12 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904671839,NDC,1,EA,5.74,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,5.6252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
anastrozole 1 MG Tablet 1 Each Blister,25000000,CDM,250,RC,,,,,,60687011211,NDC,1,EA,11.13,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,5.63178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
anastrozole 1 MG Tablet 30 Each Box,25000000,CDM,250,RC,,,,,,60687011221,NDC,1,EA,11.13,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,5.63178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
topiramate 25 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,69097012203,NDC,1,EA,13.56,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.632824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
enalapril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714044201,NDC,1,EA,6.33,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,5.6337,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,536110888,NDC,1,EA,11.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.635,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,536110888,NDC,1,EA,11.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.635,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,536110888,NDC,1,EA,11.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,5.635,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glimepiride 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93725401,NDC,1,EA,5.79,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,5.635407,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex ER 250 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031011,NDC,1,EA,13.14,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.63706,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex ER 250 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084031001,NDC,1,EA,13.14,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.63706,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CUP HEEL LARGE WONDERSPUR 4502,120.43,CDM,274,RC,L3485,HCPCS,,11385-MAIN,LOCAL,,,,,41,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,5.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL MEDIUM WONDERSPUR 4501,120.43,CDM,274,RC,L3485,HCPCS,,11384-MAIN,LOCAL,,,,,41,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,5.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL SMALL WONDERSPUR 4500,120.43,CDM,274,RC,L3485,HCPCS,,11383-MAIN,LOCAL,,,,,41,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,5.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL XL WONDERSPUR 4503,120.43,CDM,274,RC,L3485,HCPCS,,11386-MAIN,LOCAL,,,,,41,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,5.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
levothyroxine 25 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904694961,NDC,4,EA,11.75,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,5.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 25 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904694961,NDC,4,EA,11.75,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,5.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
mineral oil Enema 133 mL Bottle,63700001,CDM,250,RC,,,,,,132030140,NDC,133,ML,13.58,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.641132,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rivastigmine 3 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,55111035360,NDC,0.5,EA,11.4,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,5.643,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
escitalopram 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904642661,NDC,0.5,EA,11.76,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,5.6448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
escitalopram 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904642661,NDC,0.5,EA,11.76,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,5.6448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 75 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079044120,NDC,2,EA,6.4,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,5.6448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
verapamil CR 120 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462029201,NDC,1,EA,5.76,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,5.6448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Smear Wet Mount Saline/Ink,PX87210,CDM,300,RC,87210,CPT,,,,,,,,109,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,5.65,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.56,5.82
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904632261,NDC,1,EA,6.65,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5.6525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nabumetone 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50228046501,NDC,1,EA,6.65,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5.6525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lovastatin 20 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,93057606,NDC,0.5,EA,6.37,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,5.6693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Airway Inhalation Treatment,PX94640F,CDM,410,RC,94640,CPT,,,,,,,,242,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,5.67,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.02,13.96
Rheumatoid Factor Quant,PX86431,CDM,300,RC,86431,CPT,,,,,,,,97,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,5.67,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.4553,5.67
carvedilol 3.125 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079077101,NDC,1,EA,11.46,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,5.6727,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 14 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,43598044774,NDC,1,EA,11.46,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,5.6727,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,43598044871,NDC,1,EA,11.46,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,5.6727,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glimepiride 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93725401,NDC,1,EA,5.79,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,5.6742,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ketorolac 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69543038810,NDC,1,EA,11.58,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.6742,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ketorolac 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69543038810,NDC,1,EA,11.58,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.6742,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ketorolac 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69543038810,NDC,1,EA,11.58,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,5.6742,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"SUTURE CHROME GUT 3-0 CP-2 27""",27200000,CDM,272,RC,,,,4967-MAIN,LOCAL,,,,,11.59,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.6791,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"SUTURE CHROME GUT 3-0 CP-2 27""",27200000,CDM,272,RC,,,,4967-MAIN,LOCAL,,,,,11.59,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.6791,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"SUTURE CHROME GUT 3-0 CP-2 27""",27200000,CDM,272,RC,,,,4967-MAIN,LOCAL,,,,,11.59,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,5.6791,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
olmesartan 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862074330,NDC,0.125,EA,6.45,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,5.6889,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,536110888,NDC,1,EA,11.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,5.6925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"BANDAGE STERILE 4"" TETRA-FLEX CLIP FREE  0151-4SV",27200000,CDM,272,RC,A6449,HCPCS,,10662-MAIN,LOCAL,,,,,6.7,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5.695,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
pravastatin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904589261,NDC,0.5,EA,6.7,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5.695,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 25 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,62756070786,NDC,1,EA,13.71,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.695134,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 75 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079044120,NDC,2,EA,6.4,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,5.696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Homogenization, Tissue for Culture",PX87176,CDM,300,RC,87176,CPT,,,,,,,,50,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,5.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.7,5.88
"Homogenization, Tissue for Culture",PX87176,CDM,300,RC,87176,CPT,,,,,,,,50,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,5.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.7,5.88
"Homogenization, Tissue for Culture",PX87176,CDM,300,RC,87176,CPT,,,,,,,,50,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,5.7,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.7,5.88
lamoTRIgine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739051610,NDC,1,EA,13.3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7057,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 112 MCG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,74929690,NDC,0.892857143,EA,6.47,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,5.70654,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034211,NDC,1,EA,11.28,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,5.70768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034201,NDC,1,EA,11.28,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,5.70768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739028510,NDC,1,EA,13.76,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.715904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sotalol 80 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,60505008000,NDC,1,EA,13.76,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.715904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Smear Special Stain,PX87207,CDM,300,RC,87207,CPT,,,,,,,,81,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,5.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.72,27.36
Smear Special Stain,PX87207,CDM,300,RC,87207,CPT,,,,,,,,81,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,5.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.72,27.36
Sp Stn for Inclusn Bodies - Ref,PX8720790,CDM,300,RC,87207,CPT,90,,,,,,,227,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,5.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.72,27.36
Sp Stn for Inclusn Bodies - Ref,PX8720790,CDM,300,RC,87207,CPT,90,,,,,,,227,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,5.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.72,27.36
dicloxacillin 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,93312501,NDC,0.5,EA,6.73,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5.7205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
FLUoxetine 20 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578561,NDC,1,EA,13.34,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.72286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BITE BLOCK MAXI 20MM 60FR,27200000,CDM,272,RC,,,,8144-MAIN,LOCAL,,,,,11.32,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,5.72792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ketorolac 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69543038810,NDC,1,EA,11.58,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,5.7321,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcitRIOL 0.25 MCG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155011801,NDC,1,EA,6.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,5.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tacrolimus 1 MG capsule 100 Each Bottle,J7507.01,CDM,636,RC,J7507,HCPCS,,,,16714009901,NDC,0.5,EA,11.95,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,5.736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.96403,11.711
tacrolimus 1 MG capsule 100 Each Bottle,J7507.01,CDM,636,RC,J7507,HCPCS,,,,16714009901,NDC,0.5,EA,11.95,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,5.736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.96403,11.711
nicotine 21 MG/24HR Patch 24 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505706300,NDC,1,EA,13.81,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.736674,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"SUTURE CHROME GUT 3-0 CP-2 27""",27200000,CDM,272,RC,,,,4967-MAIN,LOCAL,,,,,11.59,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,5.73705,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Assay of Triglycerides,PX84478,CDM,300,RC,84478,CPT,,,,,,,,115,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,5.74,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.57,5.7762
Thromboplastin Time Partial,PX85730,CDM,300,RC,85730,CPT,,,,,,,,142,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,5.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.74,6.01
Thromboplastin Time Partial,PX85730,CDM,300,RC,85730,CPT,,,,,,,,142,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,5.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.74,6.01
olmesartan 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862074330,NDC,0.125,EA,6.45,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,5.7405,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cetirizine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585261,NDC,0.5,EA,6.51,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,5.74182,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
midodrine 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,42291056190,NDC,0.5,EA,6.52,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,5.75064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56017601,NDC,1,EA,13.85,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.75329,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 25 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904694961,NDC,4,EA,11.75,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.7575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 25 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904694961,NDC,4,EA,11.75,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.7575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 25 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904694961,NDC,4,EA,11.75,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,5.7575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nabumetone 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687037401,NDC,1,EA,6.32,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,5.75752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 112 MCG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,74929690,NDC,0.892857143,EA,6.47,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,5.7583,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BAG URINARY DRAINAGE DYND15405H,120.33,CDM,271,RC,A4357,HCPCS,,9112-MAIN,LOCAL,,,,,12,,Health Partners,Health Partners Care Plans,both,48,,6.98,percent of total billed charges,5.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
BAG URINARY DRAINAGE DYND15405H,120.33,CDM,271,RC,A4357,HCPCS,,9112-MAIN,LOCAL,,,,,12,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,5.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
peak flow meter Device 1 Each Box,800000,CDM,,,,,,,,8373075500,NDC,1,EA,12,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,5.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
peak flow meter Device 1 Each Box,800000,CDM,,,,,,,,8373075500,NDC,1,EA,12,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,5.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
rOPINIRole 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547026810,NDC,1,EA,13.43,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.76147,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56017001,NDC,1,EA,13.43,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.76147,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
NIFEdipine CR osmotic 30 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,24979001101,NDC,1,EA,5.92,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,5.761936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
escitalopram 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904642661,NDC,0.5,EA,11.76,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.7624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
escitalopram 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904642661,NDC,0.5,EA,11.76,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.7624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
escitalopram 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904642661,NDC,0.5,EA,11.76,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,5.7624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzonatate 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877010501,NDC,1,EA,13.44,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.76576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
enalapril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714044201,NDC,1,EA,6.33,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,5.76663,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rivastigmine 3 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,55111035360,NDC,0.5,EA,11.4,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,5.7684,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Thrombin Time Plasma,PX85670,CDM,300,RC,85670,CPT,,,,,,,,126,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,5.77,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6,5.7762
rOPINIRole 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462025301,NDC,1,EA,13.45,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.77005,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"BANDAGE STERILE 3"" TETRA-FLEX CLIP FREE 0151-3SV",27200000,CDM,272,RC,A6449,HCPCS,,10661-MAIN,LOCAL,,,,,5.93,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,5.771669,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Assay of Triglycerides,PX84478,CDM,300,RC,84478,CPT,,,,,,,,115,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,5.7762,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.57,5.7762
"Homogenization, Tissue for Culture",PX87176,CDM,300,RC,87176,CPT,,,,,,,,50,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,5.7762,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.7,5.88
Lactate (Ld) (Ldh) Enzyme,PX83615,CDM,300,RC,83615,CPT,,,,,,,,157,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,5.7762,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.7762,6.04
Microalbumin Quantitative,PX82043,CDM,300,RC,82043,CPT,,,,,,,,167,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,5.7762,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.61,5.78
Nasal Sm for Eos,PX89190,CDM,300,RC,89190,CPT,,,,,,,,38,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,5.7762,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.62,5.79
Smear Special Stain,PX87207,CDM,300,RC,87207,CPT,,,,,,,,81,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,5.7762,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.72,27.36
Smear Wet Mount Saline/Ink,PX87210,CDM,300,RC,87210,CPT,,,,,,,,109,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,5.7762,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.56,5.82
Sp Stn for Inclusn Bodies - Ref,PX8720790,CDM,300,RC,87207,CPT,90,,,,,,,227,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,5.7762,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.72,27.36
Thrombin Time Plasma,PX85670,CDM,300,RC,85670,CPT,,,,,,,,126,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,5.7762,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6,5.7762
Thromboplastin Time Partial,PX85730,CDM,300,RC,85730,CPT,,,,,,,,142,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,5.7762,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.74,6.01
warfarin 4 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56016801,NDC,1,EA,13.91,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.778214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Microalbumin Quantitative,PX82043,CDM,300,RC,82043,CPT,,,,,,,,167,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,5.78,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.61,5.78
calcitRIOL 0.25 MCG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155011801,NDC,1,EA,6.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,5.785,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,50268015211,NDC,1,EA,6.56,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,5.78592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 50 Each Box,63700001,CDM,250,RC,,,,,,50268015215,NDC,1,EA,6.56,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,5.78592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Ecg 12 Lead, Tracing Only",PX93005,CDM,730,RC,93005,CPT,,,,,,,,298,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,5.7888,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,11.05
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089901,NDC,0.25,ML,95.31,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,5.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.79,93.4038
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089910,NDC,0.25,ML,95.31,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,5.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.79,93.4038
Nasal Sm for Eos,PX89190,CDM,300,RC,89190,CPT,,,,,,,,38,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,5.79,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.62,5.79
acetaminophen 160 MG/5ML Suspension 118 mL Bottle,63700001,CDM,250,RC,,,,,,45802020326,NDC,10.15625,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
albuterol (2.5 MG/3ML) 0.083% Nebulization Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487950101,NDC,3,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
albuterol 1.25 MG/3ML Nebulization Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487990425,NDC,3,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Alcohol Swabstick 70 % Pad 50 Each Box,800000,CDM,,,,,,,,18407061105,NDC,1,EA,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
amoxicillin 250 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,65862070755,NDC,5,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 400 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,65862007101,NDC,3.125,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Biotene Dry Mouth Liquid 473 mL Bottle,63700001,CDM,250,RC,,,,,,48582000330,NDC,5,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbamide peroxide 6.5% 6.5 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904662735,NDC,15,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,93417773,NDC,2.5,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,24979015514,NDC,2.5,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314065605,NDC,0.05,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dexAMETHasone 1 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,54317644,NDC,0.5,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dextromethorphan-guaiFENesin 20-200 MG/20ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904722320,NDC,118,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,693390152,NDC,2.5,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
diphenhydrAMINE 12.5 MG/5ML Liquid 118 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904698520,NDC,2.5,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
diphenhydrAMINE 12.5 MG/5ML Liquid 120 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,58657052804,NDC,2.5,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,57896018105,NDC,15,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,57896018405,NDC,15,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,603107554,NDC,5,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,69367027204,NDC,5,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904006100,NDC,5,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904676320,NDC,5,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,54838011740,NDC,5,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,61787006304,NDC,5,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 100 MG/5ML Suspension 120 mL Bottle,63700001,CDM,250,RC,,,,,,904530920,NDC,20,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ipratropium 0.02 % Solution 2.5 mL Plas Cont,25000000,CDM,250,RC,,,,,,76204010001,NDC,2.5,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487020101,NDC,3,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lactulose 10 GM/15ML Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,121457715,NDC,15,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lactulose encephalopathy 10 GM/15ML Solution 473 mL Bottle,25000000,CDM,250,RC,,,,,,50383079516,NDC,15,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
levalbuterol 1.25 MG/3ML Nebulization Solution 3 mL Box,63700001,CDM,250,RC,,,,,,76204090001,NDC,3,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levalbuterol 1.25 MG/3ML Nebulization Solution 3 mL Plas Cont,63700001,CDM,250,RC,,,,,,76204090011,NDC,3,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine viscous 2 % Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,121090315,NDC,5,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine viscous 2 % Solution 100 mL Bottle,63700001,CDM,250,RC,,,,,,72888012526,NDC,5,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,54353244,NDC,0.25,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,121077001,NDC,0.25,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,65162068784,NDC,0.25,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium citrate 1.745 GM/30ML Solution 296 mL Bottle,63700001,CDM,250,RC,,,,,,69452038998,NDC,150,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium citrate 1.745 GM/30ML Solution 296 mL Bottle,63700001,CDM,250,RC,,,,,,70677111101,NDC,150,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium hydroxide 400 MG/5ML Suspension 30 mL Cup,63700001,CDM,250,RC,,,,,,69339015301,NDC,5,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine 20 mg/mL Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,54051744,NDC,0.5,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine polacrilex 4 MG Lozenge 24 Each Bottle,63700001,CDM,250,RC,,,,,,113087303,NDC,0.5,EA,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,121086805,NDC,4,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,121086802,NDC,4,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,66689000802,NDC,4,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 473 mL Bottle,63700001,CDM,250,RC,,,,,,121086816,NDC,4,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
opium 10 MG/ML (1%) Tincture 0.3 mL Syringe,63700001,CDM,250,RC,,,,,,8888800392,NDC,0.3,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
opium 10 MG/ML (1%) Tincture 0.6 mL Syringe,63700001,CDM,250,RC,,,,,,88888800245,NDC,0.3,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
opium 10 MG/ML (1%) Tincture 118 mL Bottle,63700001,CDM,250,RC,,,,,,42799021701,NDC,0.3,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxymetazoline 0.05 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904571135,NDC,15,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,904693186,NDC,1,EA,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 100 Each Box,63700001,CDM,250,RC,,,,,,904642281,NDC,1,EA,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
povidone iodine 10 % Solution 59 mL Bottle,63700001,CDM,250,RC,,,,,,52380190502,NDC,59,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Povidone-Iodine 10 % SWAB 1 Each Package,25000000,CDM,250,RC,,,,,,67618015301,NDC,1,EA,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004224,NDC,5,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,62135025037,NDC,1.666666667,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
racEPINEPHrine 2.25 % Nebulization Solution 1 Each Plas Cont,25000000,CDM,250,RC,,,,,,487590199,NDC,1,EA,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9 % Nebulization Solution 3 mL Plas Cont,63700001,CDM,250,RC,,,,,,487930133,NDC,3,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium chloride 0.65 % Solution 44 mL Bottle,63700001,CDM,250,RC,,,,,,904386575,NDC,44,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium phosphate 7-19 GM/118ML Enema 133 mL Bottle,63700001,CDM,250,RC,,,,,,132020140,NDC,133,ML,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
white petrolatum Gel 52.5 g Jar,63700001,CDM,250,RC,,,,,,521231100,NDC,52.5,GR,13.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.7915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cetirizine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585261,NDC,0.5,EA,6.51,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,5.7939,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 150 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862069730,NDC,0.25,EA,6.82,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5.797,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034711,NDC,1,EA,12.08,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,5.7984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034711,NDC,1,EA,12.08,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,5.7984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034701,NDC,1,EA,12.08,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,5.7984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034701,NDC,1,EA,12.08,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,5.7984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 14 MG/24HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,43598044771,NDC,1,EA,12.08,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,5.7984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 14 MG/24HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,43598044771,NDC,1,EA,12.08,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,5.7984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carvedilol 3.125 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079077101,NDC,1,EA,11.46,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,5.79876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 14 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,43598044774,NDC,1,EA,11.46,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,5.79876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,43598044871,NDC,1,EA,11.46,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,5.79876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rOPINIRole 4 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462025801,NDC,1,EA,13.96,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.798984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
NIFEdipine CR osmotic 30 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,24979001101,NDC,1,EA,5.92,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,5.8016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
midodrine 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,42291056190,NDC,0.5,EA,6.52,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,5.8028,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lovastatin 20 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,93057606,NDC,0.5,EA,6.37,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,5.80307,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 7 MG/24HR Patch 24 Hour 7 Each Box,63700001,CDM,250,RC,,,,,,43598044670,NDC,1,EA,13.53,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.80437,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisoprolol 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714052901,NDC,1,EA,12.1,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,5.808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisoprolol 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714052901,NDC,1,EA,12.1,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,5.808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Smear Special Stain,PX87207,CDM,300,RC,87207,CPT,,,,,,,,81,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,5.81,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.72,27.36
Sp Stn for Inclusn Bodies - Ref,PX8720790,CDM,300,RC,87207,CPT,90,,,,,,,227,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,5.81,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.72,27.36
"BANDAGE STERILE 3"" TETRA-FLEX CLIP FREE 0151-3SV",27200000,CDM,272,RC,A6449,HCPCS,,10661-MAIN,LOCAL,,,,,5.93,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,5.8114,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"SUTURE ETHILON 2-0 BLK MONO FS 18"" 664G",27200000,CDM,272,RC,,,,3663-MAIN,LOCAL,,,,,6.59,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,5.81238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
AQUACEL EXTRA HYDOFIBER WOUND DRESSING 4X5,120.202,CDM,272,RC,A6197,HCPCS,,12047-MAIN,LOCAL,,,,,14,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.8156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
"AQUACEL FOAM DRESSING 4X4""",120.202,CDM,272,RC,A6209,HCPCS,,7939-MAIN,LOCAL,,,,,14,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.8156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
AQUACEL NONADHESIVE FOAM DRESSING 4X4,120.202,CDM,272,RC,A6209,HCPCS,,12046-MAIN,LOCAL,,,,,14,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.8156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
Assay Urine Urea-N,PX84540,CDM,300,RC,84540,CPT,,,,,,,,14,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.8156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.1,13.72
EZ CLEAN BLADE CAUTERY TIP 4 INCH,27200000,CDM,272,RC,,,,12826-MAIN,LOCAL,,,,,14,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.8156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Post Anesthesia Recovery,PX71000019,CDM,710,RC,,,,,,,,,,14,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.8156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
SAW WIRE 12 INCH GIGLI NL850,27200000,CDM,272,RC,,,,12901-MAIN,LOCAL,,,,,14,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.8156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
levothyroxine 25 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904694961,NDC,4,EA,11.75,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,5.81625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 25 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,69097012203,NDC,1,EA,13.56,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.81724,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,536110888,NDC,1,EA,11.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,5.819,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Smear Wet Mount Saline/Ink,PX87210,CDM,300,RC,87210,CPT,,,,,,,,109,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,5.82,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.56,5.82
escitalopram 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904642661,NDC,0.5,EA,11.76,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,5.8212,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
mineral oil Enema 133 mL Bottle,63700001,CDM,250,RC,,,,,,132030140,NDC,133,ML,13.58,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.82582,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Thromboplastin Time Partial,PX85730,CDM,300,RC,85730,CPT,,,,,,,,142,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,5.83,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.74,6.01
levothyroxine 88 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378180701,NDC,2,EA,5.99,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,5.830067,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084065911,NDC,1,EA,5.99,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,5.830067,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084065901,NDC,1,EA,5.99,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,5.830067,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 75 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079044120,NDC,2,EA,6.4,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,5.8304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DULoxetine 60 MG Capsule Delayed Release Particles 30 Each Bottle,63700001,CDM,250,RC,,,,,,43547038103,NDC,0.333333333,EA,14.04,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.832216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,50268015211,NDC,1,EA,6.56,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,5.8384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 50 Each Box,63700001,CDM,250,RC,,,,,,50268015215,NDC,1,EA,6.56,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,5.8384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline monohydrate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687071611,NDC,1,EA,6.87,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5.8395,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862007701,NDC,0.2,EA,6,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,5.8398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,72205000530,NDC,0.125,EA,6,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,5.8398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DULoxetine 60 MG Capsule Delayed Release Particles 30 Each Bottle,63700001,CDM,250,RC,,,,,,57237001930,NDC,0.333333333,EA,14.06,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.840524,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069030,NDC,3,ML,14.09,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.852986,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.852986,29.4
tacrolimus 1 MG capsule 100 Each Bottle,J7507.01,CDM,636,RC,J7507,HCPCS,,,,16714009901,NDC,0.5,EA,11.95,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.8555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.96403,11.711
tacrolimus 1 MG capsule 100 Each Bottle,J7507.01,CDM,636,RC,J7507,HCPCS,,,,16714009901,NDC,0.5,EA,11.95,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.8555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.96403,11.711
tacrolimus 1 MG capsule 100 Each Bottle,J7507.01,CDM,636,RC,J7507,HCPCS,,,,16714009901,NDC,0.5,EA,11.95,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,5.8555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.96403,11.711
ketorolac 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69543038810,NDC,1,EA,11.58,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,5.85948,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Lactate (Ld) (Ldh) Enzyme,PX83615,CDM,300,RC,83615,CPT,,,,,,,,157,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,5.86,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.7762,6.04
Lactate (Ld) (Ldh) Enzyme,PX83615,CDM,300,RC,83615,CPT,,,,,,,,157,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,5.86,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.7762,6.04
Lactate (Ld) (Ldh) Enzyme,PX83615,CDM,300,RC,83615,CPT,,,,,,,,157,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,5.86,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.7762,6.04
doxycycline hyclate 100 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,904043004,NDC,0.5,EA,12.21,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,5.8608,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline hyclate 100 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,904043004,NDC,0.5,EA,12.21,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,5.8608,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"SUTURE CHROME GUT 3-0 CP-2 27""",27200000,CDM,272,RC,,,,4967-MAIN,LOCAL,,,,,11.59,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,5.86454,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"SUTURE ETHILON 2-0 BLK MONO FS 18"" 664G",27200000,CDM,272,RC,,,,3663-MAIN,LOCAL,,,,,6.59,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,5.8651,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904632261,NDC,1,EA,6.65,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,5.8653,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nabumetone 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50228046501,NDC,1,EA,6.65,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,5.8653,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 88 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378180701,NDC,2,EA,5.99,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,5.8702,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084065911,NDC,1,EA,5.99,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,5.8702,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084065901,NDC,1,EA,5.99,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,5.8702,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
olmesartan 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862074330,NDC,0.125,EA,6.45,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,5.87595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BAG URINARY DRAINAGE DYND15405H,120.33,CDM,271,RC,A4357,HCPCS,,9112-MAIN,LOCAL,,,,,12,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,2.446666667,percent of total billed charges,5.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
BAG URINARY DRAINAGE DYND15405H,120.33,CDM,271,RC,A4357,HCPCS,,9112-MAIN,LOCAL,,,,,12,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
BAG URINARY DRAINAGE DYND15405H,120.33,CDM,271,RC,A4357,HCPCS,,9112-MAIN,LOCAL,,,,,12,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,5.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
ciprofloxacin 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862007701,NDC,0.2,EA,6,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,5.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 800 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714033201,NDC,0.75,EA,12.25,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,5.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 800 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714033201,NDC,0.75,EA,12.25,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,5.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Homogenization, Tissue for Culture",PX87176,CDM,300,RC,87176,CPT,,,,,,,,50,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,5.88,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.7,5.88
peak flow meter Device 1 Each Box,800000,CDM,,,,,,,,8373075500,NDC,1,EA,12,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
peak flow meter Device 1 Each Box,800000,CDM,,,,,,,,8373075500,NDC,1,EA,12,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
peak flow meter Device 1 Each Box,800000,CDM,,,,,,,,8373075500,NDC,1,EA,12,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,5.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
rosuvastatin 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,72205000530,NDC,0.125,EA,6,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,5.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 25 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,62756070786,NDC,1,EA,13.71,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.88159,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 112 MCG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,74929690,NDC,0.892857143,EA,6.47,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,5.89417,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fomepizole 1 GM/ML Solution 1.5 mL Vial,J1451.01,CDM,636,RC,J1451,HCPCS,,,,39822071001,NDC,1.5,ML,2600,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,5.9,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.9,15.3
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739028510,NDC,1,EA,13.76,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.90304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sotalol 80 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,60505008000,NDC,1,EA,13.76,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.90304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"BANDAGE STERILE 4"" TETRA-FLEX CLIP FREE  0151-4SV",27200000,CDM,272,RC,A6449,HCPCS,,10662-MAIN,LOCAL,,,,,6.7,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,5.9094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
pravastatin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904589261,NDC,0.5,EA,6.7,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,5.9094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tacrolimus 1 MG capsule 100 Each Bottle,J7507.01,CDM,636,RC,J7507,HCPCS,,,,16714009901,NDC,0.5,EA,11.95,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,5.91525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.96403,11.711
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904632261,NDC,1,EA,6.65,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,5.9185,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nabumetone 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50228046501,NDC,1,EA,6.65,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,5.9185,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034711,NDC,1,EA,12.08,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.9192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034711,NDC,1,EA,12.08,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.9192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034711,NDC,1,EA,12.08,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,5.9192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034701,NDC,1,EA,12.08,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.9192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034701,NDC,1,EA,12.08,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.9192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034701,NDC,1,EA,12.08,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,5.9192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 14 MG/24HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,43598044771,NDC,1,EA,12.08,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.9192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 14 MG/24HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,43598044771,NDC,1,EA,12.08,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.9192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 14 MG/24HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,43598044771,NDC,1,EA,12.08,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,5.9192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcitRIOL 0.25 MCG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155011801,NDC,1,EA,6.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,5.9215,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505706300,NDC,1,EA,13.81,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.92449,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin 300 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084024411,NDC,1,EA,6.97,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5.9245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,68084024401,NDC,1,EA,6.97,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5.9245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisoprolol 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714052901,NDC,1,EA,12.1,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.929,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisoprolol 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714052901,NDC,1,EA,12.1,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.929,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisoprolol 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714052901,NDC,1,EA,12.1,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,5.929,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay Cryoglobulin,PX82595,CDM,300,RC,82595,CPT,,,,,,,,75,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,5.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,73.5
Assay of Iron,PX83540,CDM,300,RC,83540,CPT,,,,,,,,122,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,5.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,119.56
Complete Cbc Automated,PX85027,CDM,300,RC,85027,CPT,,,,,,,,129,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,5.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,126.42
Iron - Ref,PX8354090,CDM,300,RC,83540,CPT,90,,,,,,,52,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,5.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,50.96
Lab Wbc and Differential,PX85004,CDM,300,RC,85004,CPT,,,,,,,,39,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,5.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,38.22
cetirizine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585261,NDC,0.5,EA,6.51,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,5.93061,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 1 Each Blister,63700001,CDM,250,RC,,,,,,49884030752,NDC,1,EA,6.98,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5.933,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Bottle,63700001,CDM,250,RC,,,,,,57664078486,NDC,1,EA,6.98,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5.933,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Box,63700001,CDM,250,RC,,,,,,555009596,NDC,1,EA,6.98,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5.933,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Box,63700001,CDM,250,RC,,,,,,49884030702,NDC,1,EA,6.98,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5.933,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dicloxacillin 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,93312501,NDC,0.5,EA,6.73,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,5.93586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
midodrine 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,42291056190,NDC,0.5,EA,6.52,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,5.93972,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BAG URINARY DRAINAGE DYND15405H,120.33,CDM,271,RC,A4357,HCPCS,,9112-MAIN,LOCAL,,,,,12,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,5.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
peak flow meter Device 1 Each Box,800000,CDM,,,,,,,,8373075500,NDC,1,EA,12,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,5.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Amylase - Ref,PX8215090,CDM,300,RC,82150,CPT,90,,,,,,,185,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,5.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.94,181.3
Assay of Amylase,PX82150,CDM,300,RC,82150,CPT,,,,,,,,191,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,5.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.94,187.18
warfarin 2.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56017601,NDC,1,EA,13.85,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.94165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 25 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904694961,NDC,4,EA,11.75,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,5.9455,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DERMAL TIP HYFRECATOR SHARP ANGLED STAINLESS STEEL BLADE STERILE DISPOSABLE,27200000,CDM,272,RC,,,,12459-MAIN,LOCAL,,,,,7,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSTRUMENT POUCH INVISISHIELD LONG,27200000,CDM,272,RC,,,,12394-MAIN,LOCAL,,,,,7,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
OSTOMY KIT 2 PIECE SURGICAL POST-OP,27200000,CDM,272,RC,,,,12070-MAIN,LOCAL,,,,,7,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE PDS 3-0 27INCH ABSORBABLE VIOLET Z316H,27200000,CDM,272,RC,,,,12871-MAIN,LOCAL,,,,,7,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE PROLENE TAPERPOINT CT-1 36MM 0 BLUE,27200000,CDM,272,RC,,,,12322-MAIN,LOCAL,,,,,7,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
escitalopram 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904642661,NDC,0.5,EA,11.76,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,5.95056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290101,NDC,1,EA,1966.88,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,5.95145,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.58,6.06
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290102,NDC,1,EA,1966.88,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,5.95145,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.58,6.06
Tocilizumab 400 MG/20ML Solution 20 mL Vial,J3262.01,CDM,636,RC,J3262,HCPCS,,,,50242013701,NDC,20,ML,4703.83,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,5.95145,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.02,6.12
PARoxetine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084004411,NDC,1,EA,14.35,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.96099,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084004401,NDC,1,EA,14.35,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.96099,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"BANDAGE STERILE 4"" TETRA-FLEX CLIP FREE  0151-4SV",27200000,CDM,272,RC,A6449,HCPCS,,10662-MAIN,LOCAL,,,,,6.7,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,5.963,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
pravastatin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904589261,NDC,0.5,EA,6.7,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,5.963,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 4 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56016801,NDC,1,EA,13.91,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.96739,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of CK (Cpk),PX82550,CDM,300,RC,82550,CPT,,,,,,,,150,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,5.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.97,147
venlafaxine 150 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084071311,NDC,0.25,EA,6.14,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,5.976062,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,50268015211,NDC,1,EA,6.56,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,5.97616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 50 Each Box,63700001,CDM,250,RC,,,,,,50268015215,NDC,1,EA,6.56,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,5.97616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034711,NDC,1,EA,12.08,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,5.9796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034701,NDC,1,EA,12.08,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,5.9796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 14 MG/24HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,43598044771,NDC,1,EA,12.08,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,5.9796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline hyclate 100 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,904043004,NDC,0.5,EA,12.21,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.9829,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline hyclate 100 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,904043004,NDC,0.5,EA,12.21,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5.9829,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline hyclate 100 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,904043004,NDC,0.5,EA,12.21,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,5.9829,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066500,NDC,0.25,ML,48.19,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,5.98362,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.98362,7.79
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066501,NDC,0.25,ML,45.74,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,5.98362,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.98362,7.79
rOPINIRole 4 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462025801,NDC,1,EA,13.96,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5.98884,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisoprolol 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714052901,NDC,1,EA,12.1,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,5.9895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dicloxacillin 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,93312501,NDC,0.5,EA,6.73,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,5.9897,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
betamethasone acetate-betamethasone sodium phosphate 6 (3-3) MG/ML Suspension 5 mL Vial,J0702.01,CDM,636,RC,J0702,HCPCS,,,,517072001,NDC,1,ML,78.96,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,5.99,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.99,6.88
BANDAGE ESMARK 4X9 LATEX FREE DYNJ05916,27200000,CDM,272,RC,,,,5428-MAIN,LOCAL,,,,,7.05,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5.9925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ziprasidone 80 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,781216860,NDC,0.25,EA,14.44,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5.998376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069030,NDC,3,ML,14.09,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,9.35
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,2,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,9.35
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,3,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,9.35
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8092351,NDC,1,EA,52.22,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,6,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,22.288
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400101,NDC,1,EA,52.22,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,6,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,22.288
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400125,NDC,1,EA,52.22,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,6,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,22.288
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,781323294,NDC,1,EA,52.89,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,6,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,22.288
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,55150020200,NDC,1,EA,65.65,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,6,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,22.288
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,72603012801,NDC,1,EA,57.64,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,6,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,22.288
gabapentin 800 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714033201,NDC,0.75,EA,12.25,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.0025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 800 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714033201,NDC,0.75,EA,12.25,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.0025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 800 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714033201,NDC,0.75,EA,12.25,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.0025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"SUTURE ETHILON 2-0 BLK MONO FS 18"" 664G",27200000,CDM,272,RC,,,,3663-MAIN,LOCAL,,,,,6.59,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,6.00349,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
AQUACEL EXTRA HYDOFIBER WOUND DRESSING 4X5,120.202,CDM,272,RC,A6197,HCPCS,,12047-MAIN,LOCAL,,,,,14,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,6.006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
"AQUACEL FOAM DRESSING 4X4""",120.202,CDM,272,RC,A6209,HCPCS,,7939-MAIN,LOCAL,,,,,14,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,6.006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
AQUACEL NONADHESIVE FOAM DRESSING 4X4,120.202,CDM,272,RC,A6209,HCPCS,,12046-MAIN,LOCAL,,,,,14,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,6.006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
Assay Urine Urea-N,PX84540,CDM,300,RC,84540,CPT,,,,,,,,14,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,6.006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.1,13.72
EZ CLEAN BLADE CAUTERY TIP 4 INCH,27200000,CDM,272,RC,,,,12826-MAIN,LOCAL,,,,,14,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,6.006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Post Anesthesia Recovery,PX71000019,CDM,710,RC,,,,,,,,,,14,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,6.006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
SAW WIRE 12 INCH GIGLI NL850,27200000,CDM,272,RC,,,,12901-MAIN,LOCAL,,,,,14,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,6.006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
citalopram 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904608561,NDC,1,EA,14.46,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,6.006684,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
onabotulinumtoxinA 50 units Recon Soln 1 Each Vial,J0585.03,CDM,636,RC,J0585,HCPCS,,,,23391950,NDC,1,EA,1418.14,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.29,6.33
onabotulinumtoxinA 50 units Recon Soln 1 Each Vial,J0585.03,CDM,636,RC,J0585,HCPCS,,,,23391950,NDC,1,EA,1418.14,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.29,6.33
onabotulinumtoxinA 100 units Recon Soln 1 Each Vial,J0585.01,CDM,636,RC,J0585,HCPCS,,,,23114501,NDC,1,EA,2348.77,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.29,6.33
onabotulinumtoxinA 100 units Recon Soln 1 Each Vial,J0585.01,CDM,636,RC,J0585,HCPCS,,,,23114501,NDC,1,EA,2348.77,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.29,6.33
Thromboplastin Time Partial,PX85730,CDM,300,RC,85730,CPT,,,,,,,,142,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,6.01,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.74,6.01
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097084034,NDC,3,ML,14.47,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,6.010838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097084053,NDC,3,ML,14.47,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,6.010838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
venlafaxine 150 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862069730,NDC,0.25,EA,6.82,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,6.01524,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 150 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084071311,NDC,0.25,EA,6.14,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,6.0172,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DULoxetine 60 MG Capsule Delayed Release Particles 30 Each Bottle,63700001,CDM,250,RC,,,,,,43547038103,NDC,0.333333333,EA,14.04,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,6.02316,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,51293081001,NDC,1,EA,14.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,6.0233,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65162068110,NDC,1,EA,14.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,6.0233,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DULoxetine 60 MG Capsule Delayed Release Particles 30 Each Bottle,63700001,CDM,250,RC,,,,,,57237001930,NDC,0.333333333,EA,14.06,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,6.03174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Lactate (Ld) (Ldh) Enzyme,PX83615,CDM,300,RC,83615,CPT,,,,,,,,157,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,6.04,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.7762,6.04
doxycycline hyclate 100 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,904043004,NDC,0.5,EA,12.21,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.04395,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069030,NDC,3,ML,14.09,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,6.04461,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.852986,29.4
tacrolimus 1 MG capsule 100 Each Bottle,J7507.01,CDM,636,RC,J7507,HCPCS,,,,16714009901,NDC,0.5,EA,11.95,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.0467,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.96403,11.711
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904632261,NDC,1,EA,6.65,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,6.05815,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nabumetone 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50228046501,NDC,1,EA,6.65,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,6.05815,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline monohydrate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687071611,NDC,1,EA,6.87,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,6.05934,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of Lithium,PX80178,CDM,300,RC,80178,CPT,,,,,,,,124,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,6.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.06,121.52
Office/Outpt Visit Est Level I,PX99211F,CDM,510,RC,99211,CPT,,,,,,,,119,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.46,41.86
Office/Outpt Visit Est Level I,PX99211F,CDM,510,RC,99211,CPT,,,,,,,,119,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.46,41.86
Office/Outpt Visit Est Level I,PX99211P,CDM,983,RC,99211,CPT,,,,,,,,119,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.46,116.62
Office/Outpt Visit Est Level I,PX99211P,CDM,983,RC,99211,CPT,,,,,,,,119,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.46,116.62
Osmolality; Blood,PX83930,CDM,300,RC,83930,CPT,,,,,,,,9,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,6.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.7386,8.82
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290101,NDC,1,EA,1966.88,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,6.06,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.58,6.06
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290102,NDC,1,EA,1966.88,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,6.06,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.58,6.06
gabapentin 800 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714033201,NDC,0.75,EA,12.25,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.06375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 150 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862069730,NDC,0.25,EA,6.82,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,6.0698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BAG URINARY DRAINAGE DYND15405H,120.33,CDM,271,RC,A4357,HCPCS,,9112-MAIN,LOCAL,,,,,12,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
peak flow meter Device 1 Each Box,800000,CDM,,,,,,,,8373075500,NDC,1,EA,12,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Culture Screen Only,PX87081,CDM,300,RC,87081,CPT,,,,,,,,276,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,6.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.08,270.48
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066500,NDC,0.25,ML,48.19,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.98362,7.79
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066500,NDC,0.25,ML,48.19,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.98362,7.79
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066501,NDC,0.25,ML,45.74,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.98362,7.79
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066501,NDC,0.25,ML,45.74,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.98362,7.79
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,68094002459,NDC,10,ML,14.67,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,6.093918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
Blood Type Antigen Donor Ea,PX86902,CDM,300,RC,86902,CPT,,,,,,,,43,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,6.0971,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.0971,6.35
amiodarone 150-4.21 MG/100ML-% Solution 100 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066015010,NDC,100,ML,249.22,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.1,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.50926,11.28
amiodarone 360-4.14 MG/200ML-% Solution 200 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066036020,NDC,200,ML,325.25,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.1,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.50926,11.28
"BANDAGE STERILE 4"" TETRA-FLEX CLIP FREE  0151-4SV",27200000,CDM,272,RC,A6449,HCPCS,,10662-MAIN,LOCAL,,,,,6.7,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,6.1037,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
pravastatin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904589261,NDC,0.5,EA,6.7,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,6.1037,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Tx/Pro/Dx Inj Same Drug Adon,PX96376,CDM,260,RC,96376,CPT,,,,,,,,164,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.11,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.11,11.296
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,50268053111,NDC,1,EA,7.19,,First Health,Commercial,both,85,,999999999,percent of total billed charges,6.1115,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fomepizole 1 GM/ML Solution 1.5 mL Vial,J1451.01,CDM,636,RC,J1451,HCPCS,,,,39822071001,NDC,1.5,ML,2600,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,6.1123,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.9,15.3
losartan 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034711,NDC,1,EA,12.08,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.11248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034701,NDC,1,EA,12.08,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.11248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 14 MG/24HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,43598044771,NDC,1,EA,12.08,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.11248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline monohydrate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687071611,NDC,1,EA,6.87,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,6.1143,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
STOCKINETTE IMPERVIOUS 9X36 NON22530,27200000,CDM,272,RC,A6457,HCPCS,,10917-MAIN,LOCAL,,,,,14.73,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,6.118842,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Specimen Concentration - Ref,PX8701590,CDM,300,RC,87015,CPT,90,,,,,,,105,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,6.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.12,102.9
Tocilizumab 400 MG/20ML Solution 20 mL Vial,J3262.01,CDM,636,RC,J3262,HCPCS,,,,50242013701,NDC,20,ML,4703.83,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,6.12,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.02,6.12
bisoprolol 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714052901,NDC,1,EA,12.1,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.1226,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dicloxacillin 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,93312501,NDC,0.5,EA,6.73,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,6.13103,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 600 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268035111,NDC,1,EA,12.79,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.1392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 600 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268035111,NDC,1,EA,12.79,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.1392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 600 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268035115,NDC,1,EA,12.79,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.1392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 600 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268035115,NDC,1,EA,12.79,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.1392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fomepizole 1 GM/ML Solution 1.5 mL Vial,J1451.01,CDM,636,RC,J1451,HCPCS,,,,39822071001,NDC,1.5,ML,2600,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,6.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.14,2548
Magnesium,PX83735,CDM,300,RC,83735,CPT,,,,,,,,150,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,6.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.14,147
Magnesium - Ref,PX8373590,CDM,300,RC,83735,CPT,90,,,,,,,150,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,6.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.14,147
pregabalin 75 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,71101468,NDC,0.333333333,EA,14.79,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,6.143766,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin 300 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084024411,NDC,1,EA,6.97,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,6.14754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,68084024401,NDC,1,EA,6.97,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,6.14754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CUP HEEL LARGE WONDERSPUR 4502,120.43,CDM,274,RC,L3485,HCPCS,,11385-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,6.15,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.15,10.016
CUP HEEL LARGE WONDERSPUR 4502,120.43,CDM,274,RC,L3485,HCPCS,,11385-MAIN,LOCAL,,,,,41,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.15,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.15,10.016
CUP HEEL MEDIUM WONDERSPUR 4501,120.43,CDM,274,RC,L3485,HCPCS,,11384-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,6.15,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.15,10.016
CUP HEEL MEDIUM WONDERSPUR 4501,120.43,CDM,274,RC,L3485,HCPCS,,11384-MAIN,LOCAL,,,,,41,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.15,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.15,10.016
CUP HEEL SMALL WONDERSPUR 4500,120.43,CDM,274,RC,L3485,HCPCS,,11383-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,6.15,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.15,10.016
CUP HEEL SMALL WONDERSPUR 4500,120.43,CDM,274,RC,L3485,HCPCS,,11383-MAIN,LOCAL,,,,,41,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.15,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.15,10.016
CUP HEEL XL WONDERSPUR 4503,120.43,CDM,274,RC,L3485,HCPCS,,11386-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,6.15,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.15,10.016
CUP HEEL XL WONDERSPUR 4503,120.43,CDM,274,RC,L3485,HCPCS,,11386-MAIN,LOCAL,,,,,41,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.15,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.15,10.016
CUP HEEL LARGE WONDERSPUR 4502,120.43,CDM,274,RC,L3485,HCPCS,,11385-MAIN,LOCAL,,,,,41,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.15,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.15,10.016
CUP HEEL LARGE WONDERSPUR 4502,120.43,CDM,274,RC,L3485,HCPCS,,11385-MAIN,LOCAL,,,,,41,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.15,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.15,10.016
CUP HEEL MEDIUM WONDERSPUR 4501,120.43,CDM,274,RC,L3485,HCPCS,,11384-MAIN,LOCAL,,,,,41,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.15,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.15,10.016
CUP HEEL MEDIUM WONDERSPUR 4501,120.43,CDM,274,RC,L3485,HCPCS,,11384-MAIN,LOCAL,,,,,41,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.15,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.15,10.016
CUP HEEL SMALL WONDERSPUR 4500,120.43,CDM,274,RC,L3485,HCPCS,,11383-MAIN,LOCAL,,,,,41,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.15,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.15,10.016
CUP HEEL SMALL WONDERSPUR 4500,120.43,CDM,274,RC,L3485,HCPCS,,11383-MAIN,LOCAL,,,,,41,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.15,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.15,10.016
CUP HEEL XL WONDERSPUR 4503,120.43,CDM,274,RC,L3485,HCPCS,,11386-MAIN,LOCAL,,,,,41,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.15,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.15,10.016
CUP HEEL XL WONDERSPUR 4503,120.43,CDM,274,RC,L3485,HCPCS,,11386-MAIN,LOCAL,,,,,41,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.15,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.15,10.016
nabumetone 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687037401,NDC,1,EA,6.32,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,6.151256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084004411,NDC,1,EA,14.35,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,6.15615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084004401,NDC,1,EA,14.35,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,6.15615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 1 Each Blister,63700001,CDM,250,RC,,,,,,49884030752,NDC,1,EA,6.98,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,6.15636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Bottle,63700001,CDM,250,RC,,,,,,57664078486,NDC,1,EA,6.98,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,6.15636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Box,63700001,CDM,250,RC,,,,,,555009596,NDC,1,EA,6.98,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,6.15636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Box,63700001,CDM,250,RC,,,,,,49884030702,NDC,1,EA,6.98,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,6.15636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Blood Type Antigen Donor Ea,PX86902,CDM,300,RC,86902,CPT,,,,,,,,43,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.16,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.0971,6.35
Blood Type Antigen Donor Ea,PX86902,CDM,300,RC,86902,CPT,,,,,,,,43,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.0971,6.35
Blood Type Antigen Donor Ea,PX86902,CDM,300,RC,86902,CPT,,,,,,,,43,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.0971,6.35
enalapril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714044201,NDC,1,EA,6.33,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,6.160989,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084008311,NDC,1,EA,7.25,,First Health,Commercial,both,85,,999999999,percent of total billed charges,6.1625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084008301,NDC,1,EA,7.25,,First Health,Commercial,both,85,,999999999,percent of total billed charges,6.1625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 7 Each Box,63700001,CDM,250,RC,,,,,,536589653,NDC,1,EA,12.84,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.1632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 7 Each Box,63700001,CDM,250,RC,,,,,,536589653,NDC,1,EA,12.84,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.1632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DERMAL TIP HYFRECATOR SHARP ANGLED STAINLESS STEEL BLADE STERILE DISPOSABLE,27200000,CDM,272,RC,,,,12459-MAIN,LOCAL,,,,,7,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,6.174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSTRUMENT POUCH INVISISHIELD LONG,27200000,CDM,272,RC,,,,12394-MAIN,LOCAL,,,,,7,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,6.174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
OSTOMY KIT 2 PIECE SURGICAL POST-OP,27200000,CDM,272,RC,,,,12070-MAIN,LOCAL,,,,,7,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,6.174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE PDS 3-0 27INCH ABSORBABLE VIOLET Z316H,27200000,CDM,272,RC,,,,12871-MAIN,LOCAL,,,,,7,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,6.174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE PROLENE TAPERPOINT CT-1 36MM 0 BLUE,27200000,CDM,272,RC,,,,12322-MAIN,LOCAL,,,,,7,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,6.174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089901,NDC,0.25,ML,95.31,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,6.17664,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.56,6.33
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089910,NDC,0.25,ML,95.31,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,6.17664,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.56,6.33
doxycycline hyclate 100 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,904043004,NDC,0.5,EA,12.21,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.17826,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Complete Cbc Automated,PX85027,CDM,300,RC,85027,CPT,,,,,,,,129,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.18,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.18,6.47
Complete Cbc Automated,PX85027,CDM,300,RC,85027,CPT,,,,,,,,129,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.18,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.18,6.47
Lab Wbc and Differential,PX85004,CDM,300,RC,85004,CPT,,,,,,,,39,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.18,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.18,6.47
Lab Wbc and Differential,PX85004,CDM,300,RC,85004,CPT,,,,,,,,39,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.18,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.18,6.47
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,75826011410,NDC,1,EA,12.89,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.1872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,75826011410,NDC,1,EA,12.89,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.1872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56016901,NDC,1,EA,12.89,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.1872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56016901,NDC,1,EA,12.89,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.1872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nabumetone 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687037401,NDC,1,EA,6.32,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,6.1936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ziprasidone 80 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,781216860,NDC,0.25,EA,14.44,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,6.19476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 800 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714033201,NDC,0.75,EA,12.25,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.1985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lovastatin 20 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,93057606,NDC,0.5,EA,6.37,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,6.199921,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin 300 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084024411,NDC,1,EA,6.97,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,6.2033,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,68084024401,NDC,1,EA,6.97,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,6.2033,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
citalopram 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904608561,NDC,1,EA,14.46,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,6.20334,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
enalapril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714044201,NDC,1,EA,6.33,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,6.2034,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097084034,NDC,3,ML,14.47,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,6.20763,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097084053,NDC,3,ML,14.47,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,6.20763,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
onabotulinumtoxinA 50 units Recon Soln 1 Each Vial,J0585.03,CDM,636,RC,J0585,HCPCS,,,,23391950,NDC,1,EA,1418.14,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,6.20881,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.29,6.33
onabotulinumtoxinA 100 units Recon Soln 1 Each Vial,J0585.01,CDM,636,RC,J0585,HCPCS,,,,23114501,NDC,1,EA,2348.77,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,6.20881,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.29,6.33
clonazePAM 0.25 MG Tablet Disintegrating 1 Each Blister,63700001,CDM,250,RC,,,,,,49884030752,NDC,1,EA,6.98,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,6.2122,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Bottle,63700001,CDM,250,RC,,,,,,57664078486,NDC,1,EA,6.98,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,6.2122,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Box,63700001,CDM,250,RC,,,,,,555009596,NDC,1,EA,6.98,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,6.2122,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Box,63700001,CDM,250,RC,,,,,,49884030702,NDC,1,EA,6.98,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,6.2122,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 150 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862069730,NDC,0.25,EA,6.82,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,6.21302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BANDAGE ESMARK 4X9 LATEX FREE DYNJ05916,27200000,CDM,272,RC,,,,5428-MAIN,LOCAL,,,,,7.05,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,6.2181,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,51293081001,NDC,1,EA,14.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,6.2205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65162068110,NDC,1,EA,14.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,6.2205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PREP KIT SKIN PREMIUM,27200000,CDM,272,RC,,,,4108-MAIN,LOCAL,,,,,12.96,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.2208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PREP KIT SKIN PREMIUM,27200000,CDM,272,RC,,,,4108-MAIN,LOCAL,,,,,12.96,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.2208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
levothyroxine 75 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079044120,NDC,2,EA,6.4,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,6.22912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DERMAL TIP HYFRECATOR SHARP ANGLED STAINLESS STEEL BLADE STERILE DISPOSABLE,27200000,CDM,272,RC,,,,12459-MAIN,LOCAL,,,,,7,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,6.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSTRUMENT POUCH INVISISHIELD LONG,27200000,CDM,272,RC,,,,12394-MAIN,LOCAL,,,,,7,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,6.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
OSTOMY KIT 2 PIECE SURGICAL POST-OP,27200000,CDM,272,RC,,,,12070-MAIN,LOCAL,,,,,7,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,6.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE PDS 3-0 27INCH ABSORBABLE VIOLET Z316H,27200000,CDM,272,RC,,,,12871-MAIN,LOCAL,,,,,7,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,6.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE PROLENE TAPERPOINT CT-1 36MM 0 BLUE,27200000,CDM,272,RC,,,,12322-MAIN,LOCAL,,,,,7,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,6.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
doxycycline hyclate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584069311,NDC,0.5,EA,15,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,6.231,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline hyclate 100 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,62584069321,NDC,0.5,EA,15,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,6.231,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Immunoassay - Ref,PX8351690,CDM,300,RC,83516,CPT,90,,,,,,,15,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,6.231,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.231,14.7
"Iontophoresis, Ea 15min",PX97033,CDM,420,RC,97033,CPT,,,,,,,,15,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,6.231,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.231,14.7
Phase II Recovery,PX71000047,CDM,710,RC,,,,,,,,,,15,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,6.231,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.231,14.7
FLUoxetine 10 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578461,NDC,1,EA,12.99,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.2352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
FLUoxetine 10 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578461,NDC,1,EA,12.99,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.2352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Antibiotic Sens,Enzyme Detection,Each - Ref",PX8718590,CDM,300,RC,87185,CPT,90,,,,,,,13,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.36,12.74
"Antibiotic Sens,Enzyme Detection,Each - Ref",PX8718590,CDM,300,RC,87185,CPT,90,,,,,,,13,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.36,12.74
BONE WAX SUTURE 2.5G ETHICON,27200000,CDM,272,RC,,,,12566-MAIN,LOCAL,,,,,13,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
BONE WAX SUTURE 2.5G ETHICON,27200000,CDM,272,RC,,,,12566-MAIN,LOCAL,,,,,13,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
lovastatin 20 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,93057606,NDC,0.5,EA,6.37,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,6.2426,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE-acetaminophen 5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406051262,NDC,1,EA,7.35,,First Health,Commercial,both,85,,999999999,percent of total billed charges,6.2475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069030,NDC,3,ML,14.09,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,6.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.852986,29.4
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,2,ML,30,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,6.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.852986,29.4
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,3,ML,30,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,6.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.852986,29.4
Osmolality; Urine,PX83935,CDM,300,RC,83935,CPT,,,,,,,,112,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,6.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.25,109.76
citalopram 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904608461,NDC,1,EA,13.03,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.2544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
citalopram 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904608461,NDC,1,EA,13.03,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.2544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE-acetaminophen 5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406051223,NDC,1,EA,7.36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,6.256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline monohydrate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687071611,NDC,1,EA,6.87,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,6.25857,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 75 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,59762134601,NDC,0.333333333,EA,15.08,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,6.264232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 600 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268035111,NDC,1,EA,12.79,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.2671,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 600 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268035111,NDC,1,EA,12.79,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.2671,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 600 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268035111,NDC,1,EA,12.79,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.2671,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 600 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268035115,NDC,1,EA,12.79,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.2671,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 600 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268035115,NDC,1,EA,12.79,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.2671,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 600 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268035115,NDC,1,EA,12.79,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.2671,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089901,NDC,0.25,ML,95.31,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.56,6.33
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089901,NDC,0.25,ML,95.31,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.56,6.33
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089910,NDC,0.25,ML,95.31,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.56,6.33
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089910,NDC,0.25,ML,95.31,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.56,6.33
levothyroxine 75 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079044120,NDC,2,EA,6.4,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,6.272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BANDAGE ESMARK 4X9 LATEX FREE DYNJ05916,27200000,CDM,272,RC,,,,5428-MAIN,LOCAL,,,,,7.05,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,6.2745,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
olmesartan 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862074330,NDC,0.125,EA,6.45,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,6.277785,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay Cryoglobulin,PX82595,CDM,300,RC,82595,CPT,,,,,,,,75,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.28,6.47
Assay Cryoglobulin,PX82595,CDM,300,RC,82595,CPT,,,,,,,,75,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.28,6.47
Assay Cryoglobulin,PX82595,CDM,300,RC,82595,CPT,,,,,,,,75,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.28,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.28,6.47
Assay of Iron,PX83540,CDM,300,RC,83540,CPT,,,,,,,,122,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.28,6.47
Assay of Iron,PX83540,CDM,300,RC,83540,CPT,,,,,,,,122,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.28,6.47
Assay of Iron,PX83540,CDM,300,RC,83540,CPT,,,,,,,,122,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.28,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.28,6.47
Complete Cbc Automated,PX85027,CDM,300,RC,85027,CPT,,,,,,,,129,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.28,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.18,6.47
Iron - Ref,PX8354090,CDM,300,RC,83540,CPT,90,,,,,,,52,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.28,6.47
Iron - Ref,PX8354090,CDM,300,RC,83540,CPT,90,,,,,,,52,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.28,6.47
Iron - Ref,PX8354090,CDM,300,RC,83540,CPT,90,,,,,,,52,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.28,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.28,6.47
Lab Wbc and Differential,PX85004,CDM,300,RC,85004,CPT,,,,,,,,39,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.28,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.18,6.47
Amylase - Ref,PX8215090,CDM,300,RC,82150,CPT,90,,,,,,,185,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.29,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.29,6.48
Amylase - Ref,PX8215090,CDM,300,RC,82150,CPT,90,,,,,,,185,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.29,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.29,6.48
Amylase - Ref,PX8215090,CDM,300,RC,82150,CPT,90,,,,,,,185,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.29,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.29,6.48
Assay of Amylase,PX82150,CDM,300,RC,82150,CPT,,,,,,,,191,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.29,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.29,6.48
Assay of Amylase,PX82150,CDM,300,RC,82150,CPT,,,,,,,,191,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.29,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.29,6.48
Assay of Amylase,PX82150,CDM,300,RC,82150,CPT,,,,,,,,191,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.29,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.29,6.48
nicotine 21 MG/24HR Patch 24 Hour 7 Each Box,63700001,CDM,250,RC,,,,,,536589653,NDC,1,EA,12.84,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.2916,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 7 Each Box,63700001,CDM,250,RC,,,,,,536589653,NDC,1,EA,12.84,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.2916,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 7 Each Box,63700001,CDM,250,RC,,,,,,536589653,NDC,1,EA,12.84,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.2916,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,68094002459,NDC,10,ML,14.67,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,6.29343,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
levothyroxine 112 MCG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,74929690,NDC,0.892857143,EA,6.47,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,6.297251,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Thyroxine, Total - Ref",PX8443690,CDM,300,RC,84436,CPT,90,,,,,,,95,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,6.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.3,93.1
divalproex ER 250 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031011,NDC,1,EA,13.14,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.3072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex ER 250 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031011,NDC,1,EA,13.14,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.3072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex ER 250 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084031001,NDC,1,EA,13.14,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.3072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex ER 250 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084031001,NDC,1,EA,13.14,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.3072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of CK (Cpk),PX82550,CDM,300,RC,82550,CPT,,,,,,,,150,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.31,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.31,6.51
Assay of CK (Cpk),PX82550,CDM,300,RC,82550,CPT,,,,,,,,150,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.31,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.31,6.51
Assay of CK (Cpk),PX82550,CDM,300,RC,82550,CPT,,,,,,,,150,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.31,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.31,6.51
simvastatin 10 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16714068202,NDC,0.5,EA,7.43,,First Health,Commercial,both,85,,999999999,percent of total billed charges,6.3155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,75826011410,NDC,1,EA,12.89,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.3161,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,75826011410,NDC,1,EA,12.89,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.3161,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,75826011410,NDC,1,EA,12.89,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.3161,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56016901,NDC,1,EA,12.89,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.3161,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56016901,NDC,1,EA,12.89,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.3161,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56016901,NDC,1,EA,12.89,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.3161,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
STOCKINETTE IMPERVIOUS 9X36 NON22530,27200000,CDM,272,RC,A6457,HCPCS,,10917-MAIN,LOCAL,,,,,14.73,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,6.31917,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Assay of Lipase,PX83690,CDM,300,RC,83690,CPT,,,,,,,,132,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,6.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.32,129.36
olmesartan 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862074330,NDC,0.125,EA,6.45,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,6.321,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcitRIOL 0.25 MCG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155011801,NDC,1,EA,6.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,6.32645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Culture Screen Only,PX87081,CDM,300,RC,87081,CPT,,,,,,,,276,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.33,6.63
Culture Screen Only,PX87081,CDM,300,RC,87081,CPT,,,,,,,,276,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.33,6.63
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089901,NDC,0.25,ML,95.31,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,6.33,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.56,6.33
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089910,NDC,0.25,ML,95.31,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,6.33,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.56,6.33
onabotulinumtoxinA 50 units Recon Soln 1 Each Vial,J0585.03,CDM,636,RC,J0585,HCPCS,,,,23391950,NDC,1,EA,1418.14,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,6.33,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.29,6.33
onabotulinumtoxinA 100 units Recon Soln 1 Each Vial,J0585.01,CDM,636,RC,J0585,HCPCS,,,,23114501,NDC,1,EA,2348.77,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,6.33,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.29,6.33
amoxicillin 250 MG/5ML Recon Susp 150 mL Package,63700001,CDM,250,RC,,,,,,99998805601,NDC,5,ML,15.24,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,6.330696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 600 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268035111,NDC,1,EA,12.79,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.33105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 600 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268035115,NDC,1,EA,12.79,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.33105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cetirizine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585261,NDC,0.5,EA,6.51,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,6.336183,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409421505,NDC,5,ML,271.86,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.34,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.34,7.21
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,16714081501,NDC,5,ML,998.95,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.34,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.34,7.21
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021080166,NDC,5,ML,820.8,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.34,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.34,7.21
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,60505611000,NDC,5,ML,1644.33,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.34,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.34,7.21
zoledronic acid 5 MG/100ML Solution 100 mL Bottle,J3489.01,CDM,636,RC,J3489,HCPCS,,,,55111068852,NDC,100,ML,1368,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.34,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.34,7.21
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409422801,NDC,100,ML,1026,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.34,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.34,7.21
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021083082,NDC,100,ML,1596,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.34,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.34,7.21
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,63323096600,NDC,100,ML,1368,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.34,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.34,7.21
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,67457061910,NDC,100,ML,1707.48,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.34,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.34,7.21
levothyroxine 112 MCG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,74929690,NDC,0.892857143,EA,6.47,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,6.3406,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,50268053111,NDC,1,EA,7.19,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,6.34158,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 75 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,71101468,NDC,0.333333333,EA,14.79,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,6.34491,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
midodrine 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,42291056190,NDC,0.5,EA,6.52,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,6.345916,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin 300 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084024411,NDC,1,EA,6.97,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,6.34967,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,68084024401,NDC,1,EA,6.97,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,6.34967,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 150-4.21 MG/100ML-% Solution 100 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066015010,NDC,100,ML,249.22,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,6.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.35,318.745
amiodarone 360-4.14 MG/200ML-% Solution 200 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066036020,NDC,200,ML,325.25,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,6.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.35,318.745
Blood Type Antigen Donor Ea,PX86902,CDM,300,RC,86902,CPT,,,,,,,,43,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,6.35,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.0971,6.35
PREP KIT SKIN PREMIUM,27200000,CDM,272,RC,,,,4108-MAIN,LOCAL,,,,,12.96,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.3504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PREP KIT SKIN PREMIUM,27200000,CDM,272,RC,,,,4108-MAIN,LOCAL,,,,,12.96,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.3504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PREP KIT SKIN PREMIUM,27200000,CDM,272,RC,,,,4108-MAIN,LOCAL,,,,,12.96,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.3504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,49348014446,NDC,1,EA,15.3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,6.35562,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 7 Each Box,63700001,CDM,250,RC,,,,,,536589653,NDC,1,EA,12.84,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.3558,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 1 Each Blister,63700001,CDM,250,RC,,,,,,49884030752,NDC,1,EA,6.98,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,6.35878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Bottle,63700001,CDM,250,RC,,,,,,57664078486,NDC,1,EA,6.98,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,6.35878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Box,63700001,CDM,250,RC,,,,,,555009596,NDC,1,EA,6.98,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,6.35878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Box,63700001,CDM,250,RC,,,,,,49884030702,NDC,1,EA,6.98,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,6.35878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
FLUoxetine 10 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578461,NDC,1,EA,12.99,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.3651,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
FLUoxetine 10 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578461,NDC,1,EA,12.99,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.3651,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
FLUoxetine 10 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578461,NDC,1,EA,12.99,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.3651,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084004511,NDC,0.5,EA,7.49,,First Health,Commercial,both,85,,999999999,percent of total billed charges,6.3665,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084004501,NDC,0.5,EA,7.49,,First Health,Commercial,both,85,,999999999,percent of total billed charges,6.3665,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Antibiotic Sens,Enzyme Detection,Each - Ref",PX8718590,CDM,300,RC,87185,CPT,90,,,,,,,13,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.36,12.74
"Antibiotic Sens,Enzyme Detection,Each - Ref",PX8718590,CDM,300,RC,87185,CPT,90,,,,,,,13,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.36,12.74
"Antibiotic Sens,Enzyme Detection,Each - Ref",PX8718590,CDM,300,RC,87185,CPT,90,,,,,,,13,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.36,12.74
BONE WAX SUTURE 2.5G ETHICON,27200000,CDM,272,RC,,,,12566-MAIN,LOCAL,,,,,13,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
BONE WAX SUTURE 2.5G ETHICON,27200000,CDM,272,RC,,,,12566-MAIN,LOCAL,,,,,13,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
BONE WAX SUTURE 2.5G ETHICON,27200000,CDM,272,RC,,,,12566-MAIN,LOCAL,,,,,13,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
calcitRIOL 0.25 MCG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155011801,NDC,1,EA,6.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,6.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DERMAL TIP HYFRECATOR SHARP ANGLED STAINLESS STEEL BLADE STERILE DISPOSABLE,27200000,CDM,272,RC,,,,12459-MAIN,LOCAL,,,,,7,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,6.377,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSTRUMENT POUCH INVISISHIELD LONG,27200000,CDM,272,RC,,,,12394-MAIN,LOCAL,,,,,7,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,6.377,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
OSTOMY KIT 2 PIECE SURGICAL POST-OP,27200000,CDM,272,RC,,,,12070-MAIN,LOCAL,,,,,7,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,6.377,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE PDS 3-0 27INCH ABSORBABLE VIOLET Z316H,27200000,CDM,272,RC,,,,12871-MAIN,LOCAL,,,,,7,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,6.377,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE PROLENE TAPERPOINT CT-1 36MM 0 BLUE,27200000,CDM,272,RC,,,,12322-MAIN,LOCAL,,,,,7,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,6.377,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
cetirizine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585261,NDC,0.5,EA,6.51,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,6.3798,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clotrimazole 1 % Cream 28 g Tube,25000000,CDM,250,RC,,,,,,536127222,NDC,28,GR,15.36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,6.380544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,75826011410,NDC,1,EA,12.89,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.38055,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56016901,NDC,1,EA,12.89,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.38055,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739051610,NDC,1,EA,13.3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739051610,NDC,1,EA,13.3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
citalopram 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904608461,NDC,1,EA,13.03,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.3847,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
citalopram 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904608461,NDC,1,EA,13.03,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.3847,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
citalopram 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904608461,NDC,1,EA,13.03,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.3847,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,50268015211,NDC,1,EA,6.56,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,6.384848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 50 Each Box,63700001,CDM,250,RC,,,,,,50268015215,NDC,1,EA,6.56,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,6.384848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
midodrine 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,42291056190,NDC,0.5,EA,6.52,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,6.3896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084008311,NDC,1,EA,7.25,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,6.3945,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084008301,NDC,1,EA,7.25,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,6.3945,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,50268053111,NDC,1,EA,7.19,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,6.3991,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
FLUoxetine 20 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578561,NDC,1,EA,13.34,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.4032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
FLUoxetine 20 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578561,NDC,1,EA,13.34,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.4032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of Lithium,PX80178,CDM,300,RC,80178,CPT,,,,,,,,124,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.41,6.61
Assay of Lithium,PX80178,CDM,300,RC,80178,CPT,,,,,,,,124,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.41,6.61
Assay of Lithium,PX80178,CDM,300,RC,80178,CPT,,,,,,,,124,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.41,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.41,6.61
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059900,NDC,1,ML,133.16,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.41,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.41,8.05
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059902,NDC,1,ML,133.16,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.41,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.41,8.05
naloxone 2 MG/2ML solution prefilled syringe 2 mL Syringe,J2310.01,CDM,636,RC,J2310,HCPCS,,,,76329346901,NDC,1,ML,114.45,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.41,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.41,8.05
Osmolality; Blood,PX83930,CDM,300,RC,83930,CPT,,,,,,,,9,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.41,6.61
Osmolality; Blood,PX83930,CDM,300,RC,83930,CPT,,,,,,,,9,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.41,6.61
Osmolality; Blood,PX83930,CDM,300,RC,83930,CPT,,,,,,,,9,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.41,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.41,6.61
"SUTURE ETHILON 2-0 BLK MONO FS 18"" 664G",27200000,CDM,272,RC,,,,3663-MAIN,LOCAL,,,,,6.59,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,6.414047,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PREP KIT SKIN PREMIUM,27200000,CDM,272,RC,,,,4108-MAIN,LOCAL,,,,,12.96,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.4152,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Amylase - Ref,PX8215090,CDM,300,RC,82150,CPT,90,,,,,,,185,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,6.418,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.29,6.48
Assay Cryoglobulin,PX82595,CDM,300,RC,82595,CPT,,,,,,,,75,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,6.418,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.28,6.47
Assay of Amylase,PX82150,CDM,300,RC,82150,CPT,,,,,,,,191,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,6.418,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.29,6.48
Assay of CK (Cpk),PX82550,CDM,300,RC,82550,CPT,,,,,,,,150,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,6.418,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.31,6.51
Assay of Iron,PX83540,CDM,300,RC,83540,CPT,,,,,,,,122,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,6.418,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.28,6.47
Assay of Lithium,PX80178,CDM,300,RC,80178,CPT,,,,,,,,124,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,6.418,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.41,6.61
Complete Cbc Automated,PX85027,CDM,300,RC,85027,CPT,,,,,,,,129,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,6.418,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.18,6.47
Culture Screen Only,PX87081,CDM,300,RC,87081,CPT,,,,,,,,276,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,6.418,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.33,6.63
Iron - Ref,PX8354090,CDM,300,RC,83540,CPT,90,,,,,,,52,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,6.418,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.28,6.47
Lab Wbc and Differential,PX85004,CDM,300,RC,85004,CPT,,,,,,,,39,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,6.418,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.18,6.47
Magnesium,PX83735,CDM,300,RC,83735,CPT,,,,,,,,150,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,6.418,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.418,6.7
Magnesium - Ref,PX8373590,CDM,300,RC,83735,CPT,90,,,,,,,150,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,6.418,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.418,6.7
Osmolality; Blood,PX83930,CDM,300,RC,83930,CPT,,,,,,,,9,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,6.418,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.41,6.61
Specimen Concentration - Ref,PX8701590,CDM,300,RC,87015,CPT,90,,,,,,,105,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,6.418,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.418,6.68
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120301,NDC,0.5,ML,34.45,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.42,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.42,7.3
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120311,NDC,0.5,ML,34.45,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.42,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.42,7.3
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117603,NDC,1,ML,58.93,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.42,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.42,7.3
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117630,NDC,1,ML,58.34,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.42,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.42,7.3
BANDAGE ESMARK 4X9 LATEX FREE DYNJ05916,27200000,CDM,272,RC,,,,5428-MAIN,LOCAL,,,,,7.05,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,6.42255,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
cephALEXin 500 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,50268015211,NDC,1,EA,6.56,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,6.4288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 500 MG capsule 50 Each Box,63700001,CDM,250,RC,,,,,,50268015215,NDC,1,EA,6.56,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,6.4288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Culture Screen Only,PX87081,CDM,300,RC,87081,CPT,,,,,,,,276,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.43,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.33,6.63
Electrolyte Panel,PX80051,CDM,300,RC,80051,CPT,,,,,,,,175,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,6.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.43,171.5
FLUoxetine 10 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578461,NDC,1,EA,12.99,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.43005,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127303,NDC,2,ML,152.7,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,6.434,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.8,6.53
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127332,NDC,2,ML,176.55,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,6.434,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.8,6.53
"Antibiotic Sens,Enzyme Detection,Each - Ref",PX8718590,CDM,300,RC,87185,CPT,90,,,,,,,13,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.36,12.74
BONE WAX SUTURE 2.5G ETHICON,27200000,CDM,272,RC,,,,12566-MAIN,LOCAL,,,,,13,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
doxycycline hyclate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584069311,NDC,0.5,EA,15,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,6.435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline hyclate 100 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,62584069321,NDC,0.5,EA,15,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,6.435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Immunoassay - Ref,PX8351690,CDM,300,RC,83516,CPT,90,,,,,,,15,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,6.435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.231,14.7
"Iontophoresis, Ea 15min",PX97033,CDM,420,RC,97033,CPT,,,,,,,,15,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,6.435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.231,14.7
Phase II Recovery,PX71000047,CDM,710,RC,,,,,,,,,,15,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,6.435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.231,14.7
divalproex ER 250 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031011,NDC,1,EA,13.14,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.4386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex ER 250 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031011,NDC,1,EA,13.14,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.4386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex ER 250 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031011,NDC,1,EA,13.14,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.4386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex ER 250 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084031001,NDC,1,EA,13.14,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.4386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex ER 250 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084031001,NDC,1,EA,13.14,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.4386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex ER 250 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084031001,NDC,1,EA,13.14,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.4386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rOPINIRole 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547026810,NDC,1,EA,13.43,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.4464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rOPINIRole 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547026810,NDC,1,EA,13.43,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.4464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56017001,NDC,1,EA,13.43,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.4464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56017001,NDC,1,EA,13.43,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.4464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
citalopram 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904608461,NDC,1,EA,13.03,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.44985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzonatate 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877010501,NDC,1,EA,13.44,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.4512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzonatate 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877010501,NDC,1,EA,13.44,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.4512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084008311,NDC,1,EA,7.25,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,6.4525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084008301,NDC,1,EA,7.25,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,6.4525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pravastatin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904589161,NDC,1,EA,15.54,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,6.455316,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rOPINIRole 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462025301,NDC,1,EA,13.45,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rOPINIRole 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462025301,NDC,1,EA,13.45,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"SUTURE ETHILON 2-0 BLK MONO FS 18"" 664G",27200000,CDM,272,RC,,,,3663-MAIN,LOCAL,,,,,6.59,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,6.4582,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
levothyroxine 100 MCG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,74662490,NDC,1,EA,7.6,,First Health,Commercial,both,85,,999999999,percent of total billed charges,6.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 75 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,59762134601,NDC,0.333333333,EA,15.08,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,6.46932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay Cryoglobulin,PX82595,CDM,300,RC,82595,CPT,,,,,,,,75,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,6.47,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.28,6.47
Assay of Iron,PX83540,CDM,300,RC,83540,CPT,,,,,,,,122,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,6.47,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.28,6.47
Complete Cbc Automated,PX85027,CDM,300,RC,85027,CPT,,,,,,,,129,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,6.47,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.18,6.47
Iron - Ref,PX8354090,CDM,300,RC,83540,CPT,90,,,,,,,52,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,6.47,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.28,6.47
Lab Wbc and Differential,PX85004,CDM,300,RC,85004,CPT,,,,,,,,39,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,6.47,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.18,6.47
gabapentin 600 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268035111,NDC,1,EA,12.79,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.47174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 600 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268035115,NDC,1,EA,12.79,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.47174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904632261,NDC,1,EA,6.65,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,6.472445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nabumetone 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50228046501,NDC,1,EA,6.65,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,6.472445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 125 MG Capsule Delayed Release Sprinkle 100 Each Box,63700001,CDM,250,RC,,,,,,68084031301,NDC,1,EA,7.62,,First Health,Commercial,both,85,,999999999,percent of total billed charges,6.477,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 160 MG/5ML Suspension 118 mL Bottle,63700001,CDM,250,RC,,,,,,45802020326,NDC,10.15625,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 160 MG/5ML Suspension 118 mL Bottle,63700001,CDM,250,RC,,,,,,45802020326,NDC,10.15625,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
albuterol (2.5 MG/3ML) 0.083% Nebulization Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487950101,NDC,3,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
albuterol (2.5 MG/3ML) 0.083% Nebulization Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487950101,NDC,3,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
albuterol 1.25 MG/3ML Nebulization Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487990425,NDC,3,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
albuterol 1.25 MG/3ML Nebulization Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487990425,NDC,3,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Alcohol Swabstick 70 % Pad 50 Each Box,800000,CDM,,,,,,,,18407061105,NDC,1,EA,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Alcohol Swabstick 70 % Pad 50 Each Box,800000,CDM,,,,,,,,18407061105,NDC,1,EA,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
amoxicillin 250 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,65862070755,NDC,5,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 250 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,65862070755,NDC,5,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 400 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,65862007101,NDC,3.125,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 400 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,65862007101,NDC,3.125,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Biotene Dry Mouth Liquid 473 mL Bottle,63700001,CDM,250,RC,,,,,,48582000330,NDC,5,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Biotene Dry Mouth Liquid 473 mL Bottle,63700001,CDM,250,RC,,,,,,48582000330,NDC,5,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbamide peroxide 6.5% 6.5 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904662735,NDC,15,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbamide peroxide 6.5% 6.5 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904662735,NDC,15,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,93417773,NDC,2.5,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,93417773,NDC,2.5,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,24979015514,NDC,2.5,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,24979015514,NDC,2.5,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314065605,NDC,0.05,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ciprofloxacin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314065605,NDC,0.05,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dexAMETHasone 1 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,54317644,NDC,0.5,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 1 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,54317644,NDC,0.5,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dextromethorphan-guaiFENesin 20-200 MG/20ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904722320,NDC,118,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dextromethorphan-guaiFENesin 20-200 MG/20ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904722320,NDC,118,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,693390152,NDC,2.5,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,1.38,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,693390152,NDC,2.5,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
diphenhydrAMINE 12.5 MG/5ML Liquid 118 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904698520,NDC,2.5,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,1.38,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
diphenhydrAMINE 12.5 MG/5ML Liquid 118 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904698520,NDC,2.5,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
diphenhydrAMINE 12.5 MG/5ML Liquid 120 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,58657052804,NDC,2.5,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,1.38,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
diphenhydrAMINE 12.5 MG/5ML Liquid 120 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,58657052804,NDC,2.5,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,57896018105,NDC,15,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,57896018105,NDC,15,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,57896018405,NDC,15,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,57896018405,NDC,15,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,603107554,NDC,5,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,603107554,NDC,5,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,69367027204,NDC,5,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,69367027204,NDC,5,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904006100,NDC,5,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904006100,NDC,5,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904676320,NDC,5,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904676320,NDC,5,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,54838011740,NDC,5,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,54838011740,NDC,5,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,61787006304,NDC,5,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,61787006304,NDC,5,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 100 MG/5ML Suspension 120 mL Bottle,63700001,CDM,250,RC,,,,,,904530920,NDC,20,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 100 MG/5ML Suspension 120 mL Bottle,63700001,CDM,250,RC,,,,,,904530920,NDC,20,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ipratropium 0.02 % Solution 2.5 mL Plas Cont,25000000,CDM,250,RC,,,,,,76204010001,NDC,2.5,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ipratropium 0.02 % Solution 2.5 mL Plas Cont,25000000,CDM,250,RC,,,,,,76204010001,NDC,2.5,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487020101,NDC,3,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487020101,NDC,3,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lactulose 10 GM/15ML Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,121457715,NDC,15,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lactulose 10 GM/15ML Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,121457715,NDC,15,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lactulose encephalopathy 10 GM/15ML Solution 473 mL Bottle,25000000,CDM,250,RC,,,,,,50383079516,NDC,15,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lactulose encephalopathy 10 GM/15ML Solution 473 mL Bottle,25000000,CDM,250,RC,,,,,,50383079516,NDC,15,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
levalbuterol 1.25 MG/3ML Nebulization Solution 3 mL Box,63700001,CDM,250,RC,,,,,,76204090001,NDC,3,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levalbuterol 1.25 MG/3ML Nebulization Solution 3 mL Box,63700001,CDM,250,RC,,,,,,76204090001,NDC,3,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levalbuterol 1.25 MG/3ML Nebulization Solution 3 mL Plas Cont,63700001,CDM,250,RC,,,,,,76204090011,NDC,3,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levalbuterol 1.25 MG/3ML Nebulization Solution 3 mL Plas Cont,63700001,CDM,250,RC,,,,,,76204090011,NDC,3,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine viscous 2 % Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,121090315,NDC,5,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine viscous 2 % Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,121090315,NDC,5,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine viscous 2 % Solution 100 mL Bottle,63700001,CDM,250,RC,,,,,,72888012526,NDC,5,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine viscous 2 % Solution 100 mL Bottle,63700001,CDM,250,RC,,,,,,72888012526,NDC,5,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,54353244,NDC,0.25,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,54353244,NDC,0.25,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,121077001,NDC,0.25,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,121077001,NDC,0.25,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,65162068784,NDC,0.25,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,65162068784,NDC,0.25,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium citrate 1.745 GM/30ML Solution 296 mL Bottle,63700001,CDM,250,RC,,,,,,69452038998,NDC,150,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium citrate 1.745 GM/30ML Solution 296 mL Bottle,63700001,CDM,250,RC,,,,,,69452038998,NDC,150,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium citrate 1.745 GM/30ML Solution 296 mL Bottle,63700001,CDM,250,RC,,,,,,70677111101,NDC,150,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium citrate 1.745 GM/30ML Solution 296 mL Bottle,63700001,CDM,250,RC,,,,,,70677111101,NDC,150,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium hydroxide 400 MG/5ML Suspension 30 mL Cup,63700001,CDM,250,RC,,,,,,69339015301,NDC,5,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium hydroxide 400 MG/5ML Suspension 30 mL Cup,63700001,CDM,250,RC,,,,,,69339015301,NDC,5,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine 20 mg/mL Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,54051744,NDC,0.5,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine 20 mg/mL Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,54051744,NDC,0.5,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine polacrilex 4 MG Lozenge 24 Each Bottle,63700001,CDM,250,RC,,,,,,113087303,NDC,0.5,EA,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine polacrilex 4 MG Lozenge 24 Each Bottle,63700001,CDM,250,RC,,,,,,113087303,NDC,0.5,EA,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,121086805,NDC,4,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,121086805,NDC,4,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,121086802,NDC,4,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,121086802,NDC,4,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,66689000802,NDC,4,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,66689000802,NDC,4,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 473 mL Bottle,63700001,CDM,250,RC,,,,,,121086816,NDC,4,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 473 mL Bottle,63700001,CDM,250,RC,,,,,,121086816,NDC,4,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
opium 10 MG/ML (1%) Tincture 0.3 mL Syringe,63700001,CDM,250,RC,,,,,,8888800392,NDC,0.3,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
opium 10 MG/ML (1%) Tincture 0.3 mL Syringe,63700001,CDM,250,RC,,,,,,8888800392,NDC,0.3,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
opium 10 MG/ML (1%) Tincture 0.6 mL Syringe,63700001,CDM,250,RC,,,,,,88888800245,NDC,0.3,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
opium 10 MG/ML (1%) Tincture 0.6 mL Syringe,63700001,CDM,250,RC,,,,,,88888800245,NDC,0.3,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
opium 10 MG/ML (1%) Tincture 118 mL Bottle,63700001,CDM,250,RC,,,,,,42799021701,NDC,0.3,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
opium 10 MG/ML (1%) Tincture 118 mL Bottle,63700001,CDM,250,RC,,,,,,42799021701,NDC,0.3,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxymetazoline 0.05 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904571135,NDC,15,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxymetazoline 0.05 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904571135,NDC,15,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,904693186,NDC,1,EA,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,904693186,NDC,1,EA,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 100 Each Box,63700001,CDM,250,RC,,,,,,904642281,NDC,1,EA,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 100 Each Box,63700001,CDM,250,RC,,,,,,904642281,NDC,1,EA,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
povidone iodine 10 % Solution 59 mL Bottle,63700001,CDM,250,RC,,,,,,52380190502,NDC,59,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
povidone iodine 10 % Solution 59 mL Bottle,63700001,CDM,250,RC,,,,,,52380190502,NDC,59,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Povidone-Iodine 10 % SWAB 1 Each Package,25000000,CDM,250,RC,,,,,,67618015301,NDC,1,EA,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Povidone-Iodine 10 % SWAB 1 Each Package,25000000,CDM,250,RC,,,,,,67618015301,NDC,1,EA,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004224,NDC,5,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004224,NDC,5,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,62135025037,NDC,1.666666667,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,62135025037,NDC,1.666666667,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
racEPINEPHrine 2.25 % Nebulization Solution 1 Each Plas Cont,25000000,CDM,250,RC,,,,,,487590199,NDC,1,EA,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
racEPINEPHrine 2.25 % Nebulization Solution 1 Each Plas Cont,25000000,CDM,250,RC,,,,,,487590199,NDC,1,EA,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9 % Nebulization Solution 3 mL Plas Cont,63700001,CDM,250,RC,,,,,,487930133,NDC,3,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium chloride 0.9 % Nebulization Solution 3 mL Plas Cont,63700001,CDM,250,RC,,,,,,487930133,NDC,3,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium chloride 0.65 % Solution 44 mL Bottle,63700001,CDM,250,RC,,,,,,904386575,NDC,44,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium chloride 0.65 % Solution 44 mL Bottle,63700001,CDM,250,RC,,,,,,904386575,NDC,44,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium phosphate 7-19 GM/118ML Enema 133 mL Bottle,63700001,CDM,250,RC,,,,,,132020140,NDC,133,ML,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium phosphate 7-19 GM/118ML Enema 133 mL Bottle,63700001,CDM,250,RC,,,,,,132020140,NDC,133,ML,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
white petrolatum Gel 52.5 g Jar,63700001,CDM,250,RC,,,,,,521231100,NDC,52.5,GR,13.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
white petrolatum Gel 52.5 g Jar,63700001,CDM,250,RC,,,,,,521231100,NDC,52.5,GR,13.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Amylase - Ref,PX8215090,CDM,300,RC,82150,CPT,90,,,,,,,185,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,6.48,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.29,6.48
Assay of Amylase,PX82150,CDM,300,RC,82150,CPT,,,,,,,,191,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,6.48,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.29,6.48
Specimen Concentration - Ref,PX8701590,CDM,300,RC,87015,CPT,90,,,,,,,105,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.48,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.418,6.68
Specimen Concentration - Ref,PX8701590,CDM,300,RC,87015,CPT,90,,,,,,,105,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.48,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.418,6.68
Specimen Concentration - Ref,PX8701590,CDM,300,RC,87015,CPT,90,,,,,,,105,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.48,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.418,6.68
lovastatin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739028110,NDC,1,EA,15.6,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,6.48024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE-acetaminophen 5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406051262,NDC,1,EA,7.35,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,6.4827,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 125 MG Capsule Delayed Release Sprinkle 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031311,NDC,1,EA,7.63,,First Health,Commercial,both,85,,999999999,percent of total billed charges,6.4855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE-acetaminophen 5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406051223,NDC,1,EA,7.36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,6.49152,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
digoxin 125 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,115981101,NDC,1,EA,7.64,,First Health,Commercial,both,85,,999999999,percent of total billed charges,6.494,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 7 MG/24HR Patch 24 Hour 7 Each Box,63700001,CDM,250,RC,,,,,,43598044670,NDC,1,EA,13.53,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.4944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 7 MG/24HR Patch 24 Hour 7 Each Box,63700001,CDM,250,RC,,,,,,43598044670,NDC,1,EA,13.53,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.4944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 7 Each Box,63700001,CDM,250,RC,,,,,,536589653,NDC,1,EA,12.84,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.49704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Magnesium,PX83735,CDM,300,RC,83735,CPT,,,,,,,,150,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.5,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.418,6.7
Magnesium,PX83735,CDM,300,RC,83735,CPT,,,,,,,,150,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.5,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.418,6.7
Magnesium,PX83735,CDM,300,RC,83735,CPT,,,,,,,,150,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.5,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.418,6.7
Magnesium - Ref,PX8373590,CDM,300,RC,83735,CPT,90,,,,,,,150,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.5,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.418,6.7
Magnesium - Ref,PX8373590,CDM,300,RC,83735,CPT,90,,,,,,,150,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.5,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.418,6.7
Magnesium - Ref,PX8373590,CDM,300,RC,83735,CPT,90,,,,,,,150,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.5,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.418,6.7
divalproex ER 250 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031011,NDC,1,EA,13.14,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.5043,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex ER 250 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084031001,NDC,1,EA,13.14,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.5043,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 25 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,69097012203,NDC,1,EA,13.56,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.5088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 25 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,69097012203,NDC,1,EA,13.56,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.5088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of CK (Cpk),PX82550,CDM,300,RC,82550,CPT,,,,,,,,150,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,6.51,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.31,6.51
irbesartan 75 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43547037403,NDC,1,EA,15.68,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,6.513472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
irbesartan 75 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,43547037409,NDC,1,EA,15.68,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,6.513472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904632261,NDC,1,EA,6.65,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,6.517,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nabumetone 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50228046501,NDC,1,EA,6.65,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,6.517,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739051610,NDC,1,EA,13.3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.517,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739051610,NDC,1,EA,13.3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.517,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739051610,NDC,1,EA,13.3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.517,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
mineral oil Enema 133 mL Bottle,63700001,CDM,250,RC,,,,,,132030140,NDC,133,ML,13.58,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.5184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
mineral oil Enema 133 mL Bottle,63700001,CDM,250,RC,,,,,,132030140,NDC,133,ML,13.58,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.5184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,603459315,NDC,1,EA,7.67,,First Health,Commercial,both,85,,999999999,percent of total billed charges,6.5195,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
"BANDAGE STERILE 4"" TETRA-FLEX CLIP FREE  0151-4SV",27200000,CDM,272,RC,A6449,HCPCS,,10662-MAIN,LOCAL,,,,,6.7,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,6.52111,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
pravastatin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904589261,NDC,0.5,EA,6.7,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,6.52111,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,75826011410,NDC,1,EA,12.89,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.52234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56016901,NDC,1,EA,12.89,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.52234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,781502207,NDC,1,EA,7.68,,First Health,Commercial,both,85,,999999999,percent of total billed charges,6.528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
mirtazapine 15 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904651961,NDC,0.5,EA,7.68,,First Health,Commercial,both,85,,999999999,percent of total billed charges,6.528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127303,NDC,2,ML,152.7,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.53,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.8,6.53
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127303,NDC,2,ML,152.7,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.53,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.8,6.53
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127332,NDC,2,ML,176.55,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.53,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.8,6.53
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127332,NDC,2,ML,176.55,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.53,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.8,6.53
theophylline SR (12 hour) 300 MG Tablet Extended Release 12 Hour 100 Each Bottle,25000000,CDM,250,RC,,,,,,68462072101,NDC,0.333333333,EA,7.69,,First Health,Commercial,both,85,,999999999,percent of total billed charges,6.5365,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
FLUoxetine 20 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578561,NDC,1,EA,13.34,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.5366,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
FLUoxetine 20 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578561,NDC,1,EA,13.34,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.5366,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
FLUoxetine 20 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578561,NDC,1,EA,13.34,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.5366,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 250 MG/5ML Recon Susp 150 mL Package,63700001,CDM,250,RC,,,,,,99998805601,NDC,5,ML,15.24,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,6.53796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE-acetaminophen 5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406051262,NDC,1,EA,7.35,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,6.5415,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,50268053111,NDC,1,EA,7.19,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,6.55009,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dicloxacillin 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,93312501,NDC,0.5,EA,6.73,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,6.550309,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE-acetaminophen 5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406051223,NDC,1,EA,7.36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,6.5504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simvastatin 10 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16714068202,NDC,0.5,EA,7.43,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,6.55326,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,50458059160,NDC,1,EA,7.71,,First Health,Commercial,both,85,,999999999,percent of total billed charges,6.5535,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PREP KIT SKIN PREMIUM,27200000,CDM,272,RC,,,,4108-MAIN,LOCAL,,,,,12.96,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.55776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
carbamide peroxide 6.5% 6.5 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904322035,NDC,15,ML,15.79,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,6.559166,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,49348014446,NDC,1,EA,15.3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,6.5637,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"BANDAGE STERILE 4"" TETRA-FLEX CLIP FREE  0151-4SV",27200000,CDM,272,RC,A6449,HCPCS,,10662-MAIN,LOCAL,,,,,6.7,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,6.566,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
pravastatin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904589261,NDC,0.5,EA,6.7,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,6.566,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
FLUoxetine 10 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578461,NDC,1,EA,12.99,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.57294,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Antibiotic Sens,Enzyme Detection,Each - Ref",PX8718590,CDM,300,RC,87185,CPT,90,,,,,,,13,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.578,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.36,12.74
BONE WAX SUTURE 2.5G ETHICON,27200000,CDM,272,RC,,,,12566-MAIN,LOCAL,,,,,13,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.578,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
rOPINIRole 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547026810,NDC,1,EA,13.43,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.5807,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rOPINIRole 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547026810,NDC,1,EA,13.43,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.5807,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rOPINIRole 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547026810,NDC,1,EA,13.43,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.5807,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56017001,NDC,1,EA,13.43,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.5807,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56017001,NDC,1,EA,13.43,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.5807,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56017001,NDC,1,EA,13.43,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.5807,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 25 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,62756070786,NDC,1,EA,13.71,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.5808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 25 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,62756070786,NDC,1,EA,13.71,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.5808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739051610,NDC,1,EA,13.3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.5835,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzonatate 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877010501,NDC,1,EA,13.44,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.5856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzonatate 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877010501,NDC,1,EA,13.44,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.5856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzonatate 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877010501,NDC,1,EA,13.44,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.5856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clotrimazole 1 % Cream 28 g Tube,25000000,CDM,250,RC,,,,,,536127222,NDC,28,GR,15.36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,6.58944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
rOPINIRole 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462025301,NDC,1,EA,13.45,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.5905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rOPINIRole 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462025301,NDC,1,EA,13.45,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.5905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rOPINIRole 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462025301,NDC,1,EA,13.45,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.5905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
citalopram 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904608461,NDC,1,EA,13.03,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.59318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dicloxacillin 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,93312501,NDC,0.5,EA,6.73,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,6.5954,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of Ggt,PX82977,CDM,300,RC,82977,CPT,,,,,,,,89,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,6.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6,87.22
FLUoxetine 20 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578561,NDC,1,EA,13.34,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6033,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084008311,NDC,1,EA,7.25,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,6.60475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084008301,NDC,1,EA,7.25,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,6.60475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739028510,NDC,1,EA,13.76,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.6048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739028510,NDC,1,EA,13.76,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.6048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sotalol 80 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,60505008000,NDC,1,EA,13.76,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.6048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sotalol 80 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,60505008000,NDC,1,EA,13.76,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.6048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084004511,NDC,0.5,EA,7.49,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,6.60618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084004501,NDC,0.5,EA,7.49,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,6.60618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of Lithium,PX80178,CDM,300,RC,80178,CPT,,,,,,,,124,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,6.61,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.41,6.61
Osmolality; Blood,PX83930,CDM,300,RC,83930,CPT,,,,,,,,9,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,6.61,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.41,6.61
simvastatin 10 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16714068202,NDC,0.5,EA,7.43,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,6.6127,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 160 MG/5ML Suspension 118 mL Bottle,63700001,CDM,250,RC,,,,,,45802020326,NDC,10.15625,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 160 MG/5ML Suspension 118 mL Bottle,63700001,CDM,250,RC,,,,,,45802020326,NDC,10.15625,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 160 MG/5ML Suspension 118 mL Bottle,63700001,CDM,250,RC,,,,,,45802020326,NDC,10.15625,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
albuterol (2.5 MG/3ML) 0.083% Nebulization Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487950101,NDC,3,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
albuterol (2.5 MG/3ML) 0.083% Nebulization Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487950101,NDC,3,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
albuterol (2.5 MG/3ML) 0.083% Nebulization Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487950101,NDC,3,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
albuterol 1.25 MG/3ML Nebulization Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487990425,NDC,3,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
albuterol 1.25 MG/3ML Nebulization Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487990425,NDC,3,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
albuterol 1.25 MG/3ML Nebulization Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487990425,NDC,3,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Alcohol Swabstick 70 % Pad 50 Each Box,800000,CDM,,,,,,,,18407061105,NDC,1,EA,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Alcohol Swabstick 70 % Pad 50 Each Box,800000,CDM,,,,,,,,18407061105,NDC,1,EA,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Alcohol Swabstick 70 % Pad 50 Each Box,800000,CDM,,,,,,,,18407061105,NDC,1,EA,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
amoxicillin 250 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,65862070755,NDC,5,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 250 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,65862070755,NDC,5,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 250 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,65862070755,NDC,5,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 400 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,65862007101,NDC,3.125,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 400 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,65862007101,NDC,3.125,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 400 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,65862007101,NDC,3.125,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Biotene Dry Mouth Liquid 473 mL Bottle,63700001,CDM,250,RC,,,,,,48582000330,NDC,5,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Biotene Dry Mouth Liquid 473 mL Bottle,63700001,CDM,250,RC,,,,,,48582000330,NDC,5,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Biotene Dry Mouth Liquid 473 mL Bottle,63700001,CDM,250,RC,,,,,,48582000330,NDC,5,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbamide peroxide 6.5% 6.5 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904662735,NDC,15,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbamide peroxide 6.5% 6.5 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904662735,NDC,15,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbamide peroxide 6.5% 6.5 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904662735,NDC,15,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,93417773,NDC,2.5,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,93417773,NDC,2.5,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,93417773,NDC,2.5,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,24979015514,NDC,2.5,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,24979015514,NDC,2.5,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,24979015514,NDC,2.5,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314065605,NDC,0.05,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ciprofloxacin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314065605,NDC,0.05,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ciprofloxacin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314065605,NDC,0.05,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dexAMETHasone 1 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,54317644,NDC,0.5,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 1 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,54317644,NDC,0.5,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 1 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,54317644,NDC,0.5,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dextromethorphan-guaiFENesin 20-200 MG/20ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904722320,NDC,118,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dextromethorphan-guaiFENesin 20-200 MG/20ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904722320,NDC,118,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dextromethorphan-guaiFENesin 20-200 MG/20ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904722320,NDC,118,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,693390152,NDC,2.5,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.6,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,693390152,NDC,2.5,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,693390152,NDC,2.5,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
diphenhydrAMINE 12.5 MG/5ML Liquid 118 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904698520,NDC,2.5,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.6,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
diphenhydrAMINE 12.5 MG/5ML Liquid 118 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904698520,NDC,2.5,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
diphenhydrAMINE 12.5 MG/5ML Liquid 118 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904698520,NDC,2.5,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
diphenhydrAMINE 12.5 MG/5ML Liquid 120 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,58657052804,NDC,2.5,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.6,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
diphenhydrAMINE 12.5 MG/5ML Liquid 120 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,58657052804,NDC,2.5,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
diphenhydrAMINE 12.5 MG/5ML Liquid 120 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,58657052804,NDC,2.5,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,57896018105,NDC,15,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,57896018105,NDC,15,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,57896018105,NDC,15,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,57896018405,NDC,15,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,57896018405,NDC,15,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,57896018405,NDC,15,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,603107554,NDC,5,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,603107554,NDC,5,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,603107554,NDC,5,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,69367027204,NDC,5,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,69367027204,NDC,5,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,69367027204,NDC,5,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904006100,NDC,5,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904006100,NDC,5,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904006100,NDC,5,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904676320,NDC,5,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904676320,NDC,5,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904676320,NDC,5,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,54838011740,NDC,5,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,54838011740,NDC,5,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,54838011740,NDC,5,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,61787006304,NDC,5,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,61787006304,NDC,5,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,61787006304,NDC,5,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 100 MG/5ML Suspension 120 mL Bottle,63700001,CDM,250,RC,,,,,,904530920,NDC,20,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 100 MG/5ML Suspension 120 mL Bottle,63700001,CDM,250,RC,,,,,,904530920,NDC,20,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 100 MG/5ML Suspension 120 mL Bottle,63700001,CDM,250,RC,,,,,,904530920,NDC,20,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ipratropium 0.02 % Solution 2.5 mL Plas Cont,25000000,CDM,250,RC,,,,,,76204010001,NDC,2.5,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ipratropium 0.02 % Solution 2.5 mL Plas Cont,25000000,CDM,250,RC,,,,,,76204010001,NDC,2.5,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ipratropium 0.02 % Solution 2.5 mL Plas Cont,25000000,CDM,250,RC,,,,,,76204010001,NDC,2.5,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487020101,NDC,3,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487020101,NDC,3,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487020101,NDC,3,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lactulose 10 GM/15ML Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,121457715,NDC,15,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lactulose 10 GM/15ML Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,121457715,NDC,15,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lactulose 10 GM/15ML Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,121457715,NDC,15,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lactulose encephalopathy 10 GM/15ML Solution 473 mL Bottle,25000000,CDM,250,RC,,,,,,50383079516,NDC,15,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lactulose encephalopathy 10 GM/15ML Solution 473 mL Bottle,25000000,CDM,250,RC,,,,,,50383079516,NDC,15,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lactulose encephalopathy 10 GM/15ML Solution 473 mL Bottle,25000000,CDM,250,RC,,,,,,50383079516,NDC,15,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
levalbuterol 1.25 MG/3ML Nebulization Solution 3 mL Box,63700001,CDM,250,RC,,,,,,76204090001,NDC,3,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levalbuterol 1.25 MG/3ML Nebulization Solution 3 mL Box,63700001,CDM,250,RC,,,,,,76204090001,NDC,3,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levalbuterol 1.25 MG/3ML Nebulization Solution 3 mL Box,63700001,CDM,250,RC,,,,,,76204090001,NDC,3,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levalbuterol 1.25 MG/3ML Nebulization Solution 3 mL Plas Cont,63700001,CDM,250,RC,,,,,,76204090011,NDC,3,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levalbuterol 1.25 MG/3ML Nebulization Solution 3 mL Plas Cont,63700001,CDM,250,RC,,,,,,76204090011,NDC,3,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levalbuterol 1.25 MG/3ML Nebulization Solution 3 mL Plas Cont,63700001,CDM,250,RC,,,,,,76204090011,NDC,3,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine viscous 2 % Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,121090315,NDC,5,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine viscous 2 % Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,121090315,NDC,5,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine viscous 2 % Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,121090315,NDC,5,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine viscous 2 % Solution 100 mL Bottle,63700001,CDM,250,RC,,,,,,72888012526,NDC,5,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine viscous 2 % Solution 100 mL Bottle,63700001,CDM,250,RC,,,,,,72888012526,NDC,5,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine viscous 2 % Solution 100 mL Bottle,63700001,CDM,250,RC,,,,,,72888012526,NDC,5,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,54353244,NDC,0.25,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,54353244,NDC,0.25,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,54353244,NDC,0.25,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,121077001,NDC,0.25,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,121077001,NDC,0.25,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,121077001,NDC,0.25,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,65162068784,NDC,0.25,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,65162068784,NDC,0.25,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,65162068784,NDC,0.25,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium citrate 1.745 GM/30ML Solution 296 mL Bottle,63700001,CDM,250,RC,,,,,,69452038998,NDC,150,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium citrate 1.745 GM/30ML Solution 296 mL Bottle,63700001,CDM,250,RC,,,,,,69452038998,NDC,150,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium citrate 1.745 GM/30ML Solution 296 mL Bottle,63700001,CDM,250,RC,,,,,,69452038998,NDC,150,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium citrate 1.745 GM/30ML Solution 296 mL Bottle,63700001,CDM,250,RC,,,,,,70677111101,NDC,150,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium citrate 1.745 GM/30ML Solution 296 mL Bottle,63700001,CDM,250,RC,,,,,,70677111101,NDC,150,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium citrate 1.745 GM/30ML Solution 296 mL Bottle,63700001,CDM,250,RC,,,,,,70677111101,NDC,150,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium hydroxide 400 MG/5ML Suspension 30 mL Cup,63700001,CDM,250,RC,,,,,,69339015301,NDC,5,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium hydroxide 400 MG/5ML Suspension 30 mL Cup,63700001,CDM,250,RC,,,,,,69339015301,NDC,5,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium hydroxide 400 MG/5ML Suspension 30 mL Cup,63700001,CDM,250,RC,,,,,,69339015301,NDC,5,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine 20 mg/mL Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,54051744,NDC,0.5,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine 20 mg/mL Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,54051744,NDC,0.5,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine 20 mg/mL Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,54051744,NDC,0.5,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine polacrilex 4 MG Lozenge 24 Each Bottle,63700001,CDM,250,RC,,,,,,113087303,NDC,0.5,EA,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine polacrilex 4 MG Lozenge 24 Each Bottle,63700001,CDM,250,RC,,,,,,113087303,NDC,0.5,EA,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine polacrilex 4 MG Lozenge 24 Each Bottle,63700001,CDM,250,RC,,,,,,113087303,NDC,0.5,EA,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,121086805,NDC,4,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,121086805,NDC,4,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,121086805,NDC,4,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,121086802,NDC,4,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,121086802,NDC,4,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,121086802,NDC,4,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,66689000802,NDC,4,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,66689000802,NDC,4,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,66689000802,NDC,4,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 473 mL Bottle,63700001,CDM,250,RC,,,,,,121086816,NDC,4,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 473 mL Bottle,63700001,CDM,250,RC,,,,,,121086816,NDC,4,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 473 mL Bottle,63700001,CDM,250,RC,,,,,,121086816,NDC,4,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
opium 10 MG/ML (1%) Tincture 0.3 mL Syringe,63700001,CDM,250,RC,,,,,,8888800392,NDC,0.3,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
opium 10 MG/ML (1%) Tincture 0.3 mL Syringe,63700001,CDM,250,RC,,,,,,8888800392,NDC,0.3,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
opium 10 MG/ML (1%) Tincture 0.3 mL Syringe,63700001,CDM,250,RC,,,,,,8888800392,NDC,0.3,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
opium 10 MG/ML (1%) Tincture 0.6 mL Syringe,63700001,CDM,250,RC,,,,,,88888800245,NDC,0.3,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
opium 10 MG/ML (1%) Tincture 0.6 mL Syringe,63700001,CDM,250,RC,,,,,,88888800245,NDC,0.3,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
opium 10 MG/ML (1%) Tincture 0.6 mL Syringe,63700001,CDM,250,RC,,,,,,88888800245,NDC,0.3,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
opium 10 MG/ML (1%) Tincture 118 mL Bottle,63700001,CDM,250,RC,,,,,,42799021701,NDC,0.3,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
opium 10 MG/ML (1%) Tincture 118 mL Bottle,63700001,CDM,250,RC,,,,,,42799021701,NDC,0.3,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
opium 10 MG/ML (1%) Tincture 118 mL Bottle,63700001,CDM,250,RC,,,,,,42799021701,NDC,0.3,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxymetazoline 0.05 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904571135,NDC,15,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxymetazoline 0.05 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904571135,NDC,15,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxymetazoline 0.05 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904571135,NDC,15,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,904693186,NDC,1,EA,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,904693186,NDC,1,EA,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,904693186,NDC,1,EA,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 100 Each Box,63700001,CDM,250,RC,,,,,,904642281,NDC,1,EA,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 100 Each Box,63700001,CDM,250,RC,,,,,,904642281,NDC,1,EA,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 100 Each Box,63700001,CDM,250,RC,,,,,,904642281,NDC,1,EA,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
povidone iodine 10 % Solution 59 mL Bottle,63700001,CDM,250,RC,,,,,,52380190502,NDC,59,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
povidone iodine 10 % Solution 59 mL Bottle,63700001,CDM,250,RC,,,,,,52380190502,NDC,59,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
povidone iodine 10 % Solution 59 mL Bottle,63700001,CDM,250,RC,,,,,,52380190502,NDC,59,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Povidone-Iodine 10 % SWAB 1 Each Package,25000000,CDM,250,RC,,,,,,67618015301,NDC,1,EA,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Povidone-Iodine 10 % SWAB 1 Each Package,25000000,CDM,250,RC,,,,,,67618015301,NDC,1,EA,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Povidone-Iodine 10 % SWAB 1 Each Package,25000000,CDM,250,RC,,,,,,67618015301,NDC,1,EA,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004224,NDC,5,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004224,NDC,5,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004224,NDC,5,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,62135025037,NDC,1.666666667,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,62135025037,NDC,1.666666667,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,62135025037,NDC,1.666666667,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
racEPINEPHrine 2.25 % Nebulization Solution 1 Each Plas Cont,25000000,CDM,250,RC,,,,,,487590199,NDC,1,EA,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
racEPINEPHrine 2.25 % Nebulization Solution 1 Each Plas Cont,25000000,CDM,250,RC,,,,,,487590199,NDC,1,EA,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
racEPINEPHrine 2.25 % Nebulization Solution 1 Each Plas Cont,25000000,CDM,250,RC,,,,,,487590199,NDC,1,EA,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9 % Nebulization Solution 3 mL Plas Cont,63700001,CDM,250,RC,,,,,,487930133,NDC,3,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium chloride 0.9 % Nebulization Solution 3 mL Plas Cont,63700001,CDM,250,RC,,,,,,487930133,NDC,3,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium chloride 0.9 % Nebulization Solution 3 mL Plas Cont,63700001,CDM,250,RC,,,,,,487930133,NDC,3,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium chloride 0.65 % Solution 44 mL Bottle,63700001,CDM,250,RC,,,,,,904386575,NDC,44,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium chloride 0.65 % Solution 44 mL Bottle,63700001,CDM,250,RC,,,,,,904386575,NDC,44,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium chloride 0.65 % Solution 44 mL Bottle,63700001,CDM,250,RC,,,,,,904386575,NDC,44,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium phosphate 7-19 GM/118ML Enema 133 mL Bottle,63700001,CDM,250,RC,,,,,,132020140,NDC,133,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium phosphate 7-19 GM/118ML Enema 133 mL Bottle,63700001,CDM,250,RC,,,,,,132020140,NDC,133,ML,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium phosphate 7-19 GM/118ML Enema 133 mL Bottle,63700001,CDM,250,RC,,,,,,132020140,NDC,133,ML,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
white petrolatum Gel 52.5 g Jar,63700001,CDM,250,RC,,,,,,521231100,NDC,52.5,GR,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
white petrolatum Gel 52.5 g Jar,63700001,CDM,250,RC,,,,,,521231100,NDC,52.5,GR,13.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
white petrolatum Gel 52.5 g Jar,63700001,CDM,250,RC,,,,,,521231100,NDC,52.5,GR,13.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Osmolality; Urine,PX83935,CDM,300,RC,83935,CPT,,,,,,,,112,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.62,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.62,6.82
Osmolality; Urine,PX83935,CDM,300,RC,83935,CPT,,,,,,,,112,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.62,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.62,6.82
Osmolality; Urine,PX83935,CDM,300,RC,83935,CPT,,,,,,,,112,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.62,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.62,6.82
nicotine 21 MG/24HR Patch 24 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505706300,NDC,1,EA,13.81,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.6288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505706300,NDC,1,EA,13.81,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.6288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 7 MG/24HR Patch 24 Hour 7 Each Box,63700001,CDM,250,RC,,,,,,43598044670,NDC,1,EA,13.53,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.6297,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 7 MG/24HR Patch 24 Hour 7 Each Box,63700001,CDM,250,RC,,,,,,43598044670,NDC,1,EA,13.53,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.6297,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 7 MG/24HR Patch 24 Hour 7 Each Box,63700001,CDM,250,RC,,,,,,43598044670,NDC,1,EA,13.53,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.6297,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Culture Screen Only,PX87081,CDM,300,RC,87081,CPT,,,,,,,,276,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,6.63,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.33,6.63
venlafaxine 150 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862069730,NDC,0.25,EA,6.82,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,6.637906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lactulose 10 GM/15ML Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,50383077915,NDC,15,ML,15.98,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,6.638092,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 25 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,69097012203,NDC,1,EA,13.56,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.6444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 25 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,69097012203,NDC,1,EA,13.56,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.6444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 25 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,69097012203,NDC,1,EA,13.56,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.6444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"BINDER ABDOMINAL 12"" HIGH 30-45INCH 4 PANEL ORT21300SM",120.238,CDM,271,RC,A4467,HCPCS,,11934-MAIN,LOCAL,,,,,16,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,6.6464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
DRESSING OPTIFOAM 10X4 POST-OP SILICONE FACED MSC21410Z,120.154,CDM,272,RC,A6213,HCPCS,,8632-MAIN,LOCAL,,,,,16,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,6.6464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,15.68
rOPINIRole 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547026810,NDC,1,EA,13.43,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.64785,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56017001,NDC,1,EA,13.43,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.64785,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56017601,NDC,1,EA,13.85,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56017601,NDC,1,EA,13.85,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex ER 250 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031011,NDC,1,EA,13.14,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.64884,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex ER 250 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084031001,NDC,1,EA,13.14,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.64884,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzonatate 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877010501,NDC,1,EA,13.44,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
mineral oil Enema 133 mL Bottle,63700001,CDM,250,RC,,,,,,132030140,NDC,133,ML,13.58,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.6542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
mineral oil Enema 133 mL Bottle,63700001,CDM,250,RC,,,,,,132030140,NDC,133,ML,13.58,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.6542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
mineral oil Enema 133 mL Bottle,63700001,CDM,250,RC,,,,,,132030140,NDC,133,ML,13.58,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.6542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin 300 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574703412,NDC,1,EA,7.83,,First Health,Commercial,both,85,,999999999,percent of total billed charges,6.6555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084044011,NDC,0.5,EA,7.83,,First Health,Commercial,both,85,,999999999,percent of total billed charges,6.6555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084044001,NDC,0.5,EA,7.83,,First Health,Commercial,both,85,,999999999,percent of total billed charges,6.6555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rOPINIRole 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462025301,NDC,1,EA,13.45,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.65775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Thyroxine, Total - Ref",PX8443690,CDM,300,RC,84436,CPT,90,,,,,,,95,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.66,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.66,6.87
"Thyroxine, Total - Ref",PX8443690,CDM,300,RC,84436,CPT,90,,,,,,,95,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.66,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.66,6.87
"Thyroxine, Total - Ref",PX8443690,CDM,300,RC,84436,CPT,90,,,,,,,95,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.66,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.66,6.87
PARoxetine 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084004511,NDC,0.5,EA,7.49,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,6.6661,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084004501,NDC,0.5,EA,7.49,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,6.6661,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pravastatin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904589161,NDC,1,EA,15.54,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,6.66666,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,63739035810,NDC,0.5,EA,7.85,,First Health,Commercial,both,85,,999999999,percent of total billed charges,6.6725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 4 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56016801,NDC,1,EA,13.91,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.6768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 4 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56016801,NDC,1,EA,13.91,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.6768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of Lipase,PX83690,CDM,300,RC,83690,CPT,,,,,,,,132,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.68,6.89
Assay of Lipase,PX83690,CDM,300,RC,83690,CPT,,,,,,,,132,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.68,6.89
Assay of Lipase,PX83690,CDM,300,RC,83690,CPT,,,,,,,,132,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.68,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.68,6.89
Specimen Concentration - Ref,PX8701590,CDM,300,RC,87015,CPT,90,,,,,,,105,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,6.68,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.418,6.68
acetaminophen 160 MG/5ML Suspension 118 mL Bottle,63700001,CDM,250,RC,,,,,,45802020326,NDC,10.15625,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
albuterol (2.5 MG/3ML) 0.083% Nebulization Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487950101,NDC,3,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
albuterol 1.25 MG/3ML Nebulization Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487990425,NDC,3,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Alcohol Swabstick 70 % Pad 50 Each Box,800000,CDM,,,,,,,,18407061105,NDC,1,EA,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
amoxicillin 250 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,65862070755,NDC,5,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 400 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,65862007101,NDC,3.125,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Biotene Dry Mouth Liquid 473 mL Bottle,63700001,CDM,250,RC,,,,,,48582000330,NDC,5,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbamide peroxide 6.5% 6.5 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904662735,NDC,15,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,93417773,NDC,2.5,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,24979015514,NDC,2.5,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314065605,NDC,0.05,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dexAMETHasone 1 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,54317644,NDC,0.5,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dextromethorphan-guaiFENesin 20-200 MG/20ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904722320,NDC,118,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,693390152,NDC,2.5,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
diphenhydrAMINE 12.5 MG/5ML Liquid 118 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904698520,NDC,2.5,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
diphenhydrAMINE 12.5 MG/5ML Liquid 120 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,58657052804,NDC,2.5,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,57896018105,NDC,15,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,57896018405,NDC,15,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,603107554,NDC,5,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,69367027204,NDC,5,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904006100,NDC,5,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904676320,NDC,5,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,54838011740,NDC,5,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,61787006304,NDC,5,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 100 MG/5ML Suspension 120 mL Bottle,63700001,CDM,250,RC,,,,,,904530920,NDC,20,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ipratropium 0.02 % Solution 2.5 mL Plas Cont,25000000,CDM,250,RC,,,,,,76204010001,NDC,2.5,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487020101,NDC,3,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lactulose 10 GM/15ML Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,121457715,NDC,15,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lactulose encephalopathy 10 GM/15ML Solution 473 mL Bottle,25000000,CDM,250,RC,,,,,,50383079516,NDC,15,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
levalbuterol 1.25 MG/3ML Nebulization Solution 3 mL Box,63700001,CDM,250,RC,,,,,,76204090001,NDC,3,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levalbuterol 1.25 MG/3ML Nebulization Solution 3 mL Plas Cont,63700001,CDM,250,RC,,,,,,76204090011,NDC,3,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine viscous 2 % Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,121090315,NDC,5,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine viscous 2 % Solution 100 mL Bottle,63700001,CDM,250,RC,,,,,,72888012526,NDC,5,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,54353244,NDC,0.25,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,121077001,NDC,0.25,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,65162068784,NDC,0.25,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium citrate 1.745 GM/30ML Solution 296 mL Bottle,63700001,CDM,250,RC,,,,,,69452038998,NDC,150,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium citrate 1.745 GM/30ML Solution 296 mL Bottle,63700001,CDM,250,RC,,,,,,70677111101,NDC,150,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium hydroxide 400 MG/5ML Suspension 30 mL Cup,63700001,CDM,250,RC,,,,,,69339015301,NDC,5,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine 20 mg/mL Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,54051744,NDC,0.5,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine polacrilex 4 MG Lozenge 24 Each Bottle,63700001,CDM,250,RC,,,,,,113087303,NDC,0.5,EA,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,121086805,NDC,4,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,121086802,NDC,4,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,66689000802,NDC,4,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 473 mL Bottle,63700001,CDM,250,RC,,,,,,121086816,NDC,4,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
opium 10 MG/ML (1%) Tincture 0.3 mL Syringe,63700001,CDM,250,RC,,,,,,8888800392,NDC,0.3,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
opium 10 MG/ML (1%) Tincture 0.6 mL Syringe,63700001,CDM,250,RC,,,,,,88888800245,NDC,0.3,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
opium 10 MG/ML (1%) Tincture 118 mL Bottle,63700001,CDM,250,RC,,,,,,42799021701,NDC,0.3,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxymetazoline 0.05 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904571135,NDC,15,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,904693186,NDC,1,EA,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 100 Each Box,63700001,CDM,250,RC,,,,,,904642281,NDC,1,EA,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
povidone iodine 10 % Solution 59 mL Bottle,63700001,CDM,250,RC,,,,,,52380190502,NDC,59,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Povidone-Iodine 10 % SWAB 1 Each Package,25000000,CDM,250,RC,,,,,,67618015301,NDC,1,EA,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004224,NDC,5,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,62135025037,NDC,1.666666667,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
racEPINEPHrine 2.25 % Nebulization Solution 1 Each Plas Cont,25000000,CDM,250,RC,,,,,,487590199,NDC,1,EA,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9 % Nebulization Solution 3 mL Plas Cont,63700001,CDM,250,RC,,,,,,487930133,NDC,3,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium chloride 0.65 % Solution 44 mL Bottle,63700001,CDM,250,RC,,,,,,904386575,NDC,44,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium phosphate 7-19 GM/118ML Enema 133 mL Bottle,63700001,CDM,250,RC,,,,,,132020140,NDC,133,ML,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
white petrolatum Gel 52.5 g Jar,63700001,CDM,250,RC,,,,,,521231100,NDC,52.5,GR,13.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.6825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 150 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862069730,NDC,0.25,EA,6.82,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,6.6836,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline monohydrate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687071611,NDC,1,EA,6.87,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,6.686571,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Skilled Srvc of a Lpn in Training and/or Education of Pt or Fam Ea 15 Min,PXG0496,CDM,551,RC,G0496,HCPCS,,,,,,,,75,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,6.69,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.69,6.69
lovastatin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739028110,NDC,1,EA,15.6,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,6.6924,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE-acetaminophen 5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406051262,NDC,1,EA,7.35,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,6.69585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 7 MG/24HR Patch 24 Hour 7 Each Box,63700001,CDM,250,RC,,,,,,43598044670,NDC,1,EA,13.53,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.69735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fomepizole 1 GM/ML Solution 1.5 mL Vial,J1451.01,CDM,636,RC,J1451,HCPCS,,,,39822071001,NDC,1.5,ML,2600,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.9,15.3
fomepizole 1 GM/ML Solution 1.5 mL Vial,J1451.01,CDM,636,RC,J1451,HCPCS,,,,39822071001,NDC,1.5,ML,2600,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.9,15.3
Magnesium,PX83735,CDM,300,RC,83735,CPT,,,,,,,,150,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,6.7,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.418,6.7
Magnesium - Ref,PX8373590,CDM,300,RC,83735,CPT,90,,,,,,,150,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,6.7,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.418,6.7
rOPINIRole 4 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462025801,NDC,1,EA,13.96,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.7008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rOPINIRole 4 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462025801,NDC,1,EA,13.96,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.7008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 100 MCG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,74662490,NDC,1,EA,7.6,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,6.7032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE-acetaminophen 5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406051223,NDC,1,EA,7.36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,6.70496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 25 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,69097012203,NDC,1,EA,13.56,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.7122,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 25 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,62756070786,NDC,1,EA,13.71,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.7179,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 25 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,62756070786,NDC,1,EA,13.71,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.7179,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 25 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,62756070786,NDC,1,EA,13.71,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.7179,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
AQUACEL EXTRA HYDOFIBER WOUND DRESSING 4X5,120.202,CDM,272,RC,A6197,HCPCS,,12047-MAIN,LOCAL,,,,,14,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
AQUACEL EXTRA HYDOFIBER WOUND DRESSING 4X5,120.202,CDM,272,RC,A6197,HCPCS,,12047-MAIN,LOCAL,,,,,14,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
"AQUACEL FOAM DRESSING 4X4""",120.202,CDM,272,RC,A6209,HCPCS,,7939-MAIN,LOCAL,,,,,14,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
"AQUACEL FOAM DRESSING 4X4""",120.202,CDM,272,RC,A6209,HCPCS,,7939-MAIN,LOCAL,,,,,14,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
AQUACEL NONADHESIVE FOAM DRESSING 4X4,120.202,CDM,272,RC,A6209,HCPCS,,12046-MAIN,LOCAL,,,,,14,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
AQUACEL NONADHESIVE FOAM DRESSING 4X4,120.202,CDM,272,RC,A6209,HCPCS,,12046-MAIN,LOCAL,,,,,14,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
Assay Urine Urea-N,PX84540,CDM,300,RC,84540,CPT,,,,,,,,14,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.1,13.72
Assay Urine Urea-N,PX84540,CDM,300,RC,84540,CPT,,,,,,,,14,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.1,13.72
"Exam,Synovial Fluid Crystals",PX89060,CDM,300,RC,89060,CPT,,,,,,,,85,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,6.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.72,83.3
EZ CLEAN BLADE CAUTERY TIP 4 INCH,27200000,CDM,272,RC,,,,12826-MAIN,LOCAL,,,,,14,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
EZ CLEAN BLADE CAUTERY TIP 4 INCH,27200000,CDM,272,RC,,,,12826-MAIN,LOCAL,,,,,14,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Post Anesthesia Recovery,PX71000019,CDM,710,RC,,,,,,,,,,14,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
Post Anesthesia Recovery,PX71000019,CDM,710,RC,,,,,,,,,,14,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
SAW WIRE 12 INCH GIGLI NL850,27200000,CDM,272,RC,,,,12901-MAIN,LOCAL,,,,,14,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SAW WIRE 12 INCH GIGLI NL850,27200000,CDM,272,RC,,,,12901-MAIN,LOCAL,,,,,14,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
divalproex 125 MG Capsule Delayed Release Sprinkle 100 Each Box,63700001,CDM,250,RC,,,,,,68084031301,NDC,1,EA,7.62,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,6.72084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
mineral oil Enema 133 mL Bottle,63700001,CDM,250,RC,,,,,,132030140,NDC,133,ML,13.58,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.7221,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
irbesartan 75 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43547037403,NDC,1,EA,15.68,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,6.72672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
irbesartan 75 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,43547037409,NDC,1,EA,15.68,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,6.72672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 125 MG Capsule Delayed Release Sprinkle 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031311,NDC,1,EA,7.63,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,6.72966,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739051610,NDC,1,EA,13.3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.7298,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,42291053590,NDC,0.5,EA,7.92,,First Health,Commercial,both,85,,999999999,percent of total billed charges,6.732,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline monohydrate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687071611,NDC,1,EA,6.87,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,6.7326,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
digoxin 125 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,115981101,NDC,1,EA,7.64,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,6.73848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of Lipase,PX83690,CDM,300,RC,83690,CPT,,,,,,,,132,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,6.7389,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.68,6.89
Electrolyte Panel,PX80051,CDM,300,RC,80051,CPT,,,,,,,,175,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,6.7389,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.7389,7.01
Osmolality; Urine,PX83935,CDM,300,RC,83935,CPT,,,,,,,,112,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,6.7389,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.62,6.82
"Thyroxine, Total - Ref",PX8443690,CDM,300,RC,84436,CPT,90,,,,,,,95,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,6.7389,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.66,6.87
DULoxetine 60 MG Capsule Delayed Release Particles 30 Each Bottle,63700001,CDM,250,RC,,,,,,43547038103,NDC,0.333333333,EA,14.04,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.7392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DULoxetine 60 MG Capsule Delayed Release Particles 30 Each Bottle,63700001,CDM,250,RC,,,,,,43547038103,NDC,0.333333333,EA,14.04,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.7392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739028510,NDC,1,EA,13.76,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.7424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739028510,NDC,1,EA,13.76,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.7424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739028510,NDC,1,EA,13.76,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.7424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sotalol 80 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,60505008000,NDC,1,EA,13.76,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.7424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sotalol 80 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,60505008000,NDC,1,EA,13.76,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.7424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sotalol 80 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,60505008000,NDC,1,EA,13.76,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.7424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Fac/Trim Nail(S),PX11719F,CDM,510,RC,11719,CPT,,,,,,,,107,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,6.7431,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.58,29.75
DULoxetine 60 MG Capsule Delayed Release Particles 30 Each Bottle,63700001,CDM,250,RC,,,,,,57237001930,NDC,0.333333333,EA,14.06,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.7488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DULoxetine 60 MG Capsule Delayed Release Particles 30 Each Bottle,63700001,CDM,250,RC,,,,,,57237001930,NDC,0.333333333,EA,14.06,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.7488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
FLUoxetine 20 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578561,NDC,1,EA,13.34,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.75004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
betamethasone acetate-betamethasone sodium phosphate 6 (3-3) MG/ML Suspension 5 mL Vial,J0702.01,CDM,636,RC,J0702,HCPCS,,,,517072001,NDC,1,ML,78.96,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,6.7557,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.99,6.88
Dystrophic Nail Trimming Any Number,PXG0127F,CDM,940,RC,G0127,HCPCS,,,,,,,,53,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,6.7557,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.58,41.88
"Trimming of Dystrophic Nails, Any Number",PXG0127P,CDM,983,RC,G0127,HCPCS,,,,,,,,35,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,6.7557,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.58,41.88
Resp Muscles 1:1 per 15 Min,PXG0237,CDM,948,RC,G0237,HCPCS,,,,,,,,65,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.76,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.76,19.78
Strapping of Toes,PX29550F,CDM,510,RC,29550,CPT,,,,,,,,113,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.76,40.12
Strapping of Toes,PX29550F,CDM,510,RC,29550,CPT,,,,,,,,113,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.76,40.12
Strapping of Toes,PX29550F,CDM,510,RC,29550,CPT,,,,,,,,113,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.76,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.76,40.12
US Urine Capacity Measure,PX51798F,CDM,510,RC,51798,CPT,,,,,,,,96,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.76,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.76,23.52
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069030,NDC,3,ML,14.09,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.7632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.852986,29.4
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069030,NDC,3,ML,14.09,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.7632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.852986,29.4
levothyroxine 100 MCG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,74662490,NDC,1,EA,7.6,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,6.764,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,603459315,NDC,1,EA,7.67,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,6.76494,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
nicotine 21 MG/24HR Patch 24 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505706300,NDC,1,EA,13.81,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.7669,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505706300,NDC,1,EA,13.81,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.7669,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505706300,NDC,1,EA,13.81,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.7669,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simvastatin 10 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16714068202,NDC,0.5,EA,7.43,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,6.76873,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,781502207,NDC,1,EA,7.68,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,6.77376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
mirtazapine 15 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904651961,NDC,0.5,EA,7.68,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,6.77376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbamide peroxide 6.5% 6.5 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904322035,NDC,15,ML,15.79,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,6.77391,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 125 MG Capsule Delayed Release Sprinkle 100 Each Box,63700001,CDM,250,RC,,,,,,68084031301,NDC,1,EA,7.62,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,6.7818,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
theophylline SR (12 hour) 300 MG Tablet Extended Release 12 Hour 100 Each Bottle,25000000,CDM,250,RC,,,,,,68462072101,NDC,0.333333333,EA,7.69,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,6.78258,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
clindamycin 300 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084024411,NDC,1,EA,6.97,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,6.783901,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,68084024401,NDC,1,EA,6.97,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,6.783901,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 25 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,62756070786,NDC,1,EA,13.71,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.78645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56017601,NDC,1,EA,13.85,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.7865,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56017601,NDC,1,EA,13.85,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.7865,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56017601,NDC,1,EA,13.85,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.7865,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120301,NDC,0.5,ML,34.45,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,6.78787,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.42,7.3
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120311,NDC,0.5,ML,34.45,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,6.78787,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.42,7.3
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117603,NDC,1,ML,58.93,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,6.78787,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.42,7.3
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117630,NDC,1,ML,58.34,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,6.78787,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.42,7.3
SCAR GEL SHEET,120.458,CDM,273,RC,A6025,HCPCS,,5796-MAIN,LOCAL,,,,,51,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,6.79,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.79,33.59
vinCRIStine 1 MG/ML Solution 2 mL Vial,J9370.01,CDM,636,RC,J9370,HCPCS,,,,61703030916,NDC,2,ML,48.72,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.79,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.79,8.11
divalproex 125 MG Capsule Delayed Release Sprinkle 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031311,NDC,1,EA,7.63,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,6.7907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 1 Each Blister,63700001,CDM,250,RC,,,,,,49884030752,NDC,1,EA,6.98,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,6.793634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Bottle,63700001,CDM,250,RC,,,,,,57664078486,NDC,1,EA,6.98,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,6.793634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Box,63700001,CDM,250,RC,,,,,,555009596,NDC,1,EA,6.98,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,6.793634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Box,63700001,CDM,250,RC,,,,,,49884030702,NDC,1,EA,6.98,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,6.793634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rOPINIRole 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547026810,NDC,1,EA,13.43,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.79558,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56017001,NDC,1,EA,13.43,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.79558,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
digoxin 125 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,115981101,NDC,1,EA,7.64,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,6.7996,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Electrolyte Panel,PX80051,CDM,300,RC,80051,CPT,,,,,,,,175,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.7389,7.01
Electrolyte Panel,PX80051,CDM,300,RC,80051,CPT,,,,,,,,175,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.7389,7.01
Electrolyte Panel,PX80051,CDM,300,RC,80051,CPT,,,,,,,,175,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.8,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.7389,7.01
memantine 10 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,72603011901,NDC,0.5,EA,16.37,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,6.800098,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,50458059160,NDC,1,EA,7.71,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,6.80022,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzonatate 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877010501,NDC,1,EA,13.44,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.80064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rOPINIRole 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462025301,NDC,1,EA,13.45,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.8057,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739028510,NDC,1,EA,13.76,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.8112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sotalol 80 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,60505008000,NDC,1,EA,13.76,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.8112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DERMAL TIP HYFRECATOR SHARP ANGLED STAINLESS STEEL BLADE STERILE DISPOSABLE,27200000,CDM,272,RC,,,,12459-MAIN,LOCAL,,,,,7,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,6.8131,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSTRUMENT POUCH INVISISHIELD LONG,27200000,CDM,272,RC,,,,12394-MAIN,LOCAL,,,,,7,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,6.8131,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
OSTOMY KIT 2 PIECE SURGICAL POST-OP,27200000,CDM,272,RC,,,,12070-MAIN,LOCAL,,,,,7,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,6.8131,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE PDS 3-0 27INCH ABSORBABLE VIOLET Z316H,27200000,CDM,272,RC,,,,12871-MAIN,LOCAL,,,,,7,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,6.8131,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE PROLENE TAPERPOINT CT-1 36MM 0 BLUE,27200000,CDM,272,RC,,,,12322-MAIN,LOCAL,,,,,7,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,6.8131,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
warfarin 4 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56016801,NDC,1,EA,13.91,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.8159,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 4 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56016801,NDC,1,EA,13.91,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.8159,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 4 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56016801,NDC,1,EA,13.91,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.8159,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
betamethasone acetate-betamethasone sodium phosphate 6 (3-3) MG/ML Suspension 5 mL Vial,J0702.01,CDM,636,RC,J0702,HCPCS,,,,517072001,NDC,1,ML,78.96,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,6.82,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.99,6.88
Osmolality; Urine,PX83935,CDM,300,RC,83935,CPT,,,,,,,,112,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,6.82,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.62,6.82
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409421505,NDC,5,ML,271.86,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,6.82004,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.34,7.21
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,16714081501,NDC,5,ML,998.95,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,6.82004,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.34,7.21
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021080166,NDC,5,ML,820.8,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,6.82004,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.34,7.21
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,60505611000,NDC,5,ML,1644.33,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,6.82004,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.34,7.21
zoledronic acid 5 MG/100ML Solution 100 mL Bottle,J3489.01,CDM,636,RC,J3489,HCPCS,,,,55111068852,NDC,100,ML,1368,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,6.82004,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.34,7.21
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409422801,NDC,100,ML,1026,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,6.82004,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.34,7.21
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021083082,NDC,100,ML,1596,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,6.82004,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.34,7.21
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,63323096600,NDC,100,ML,1368,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,6.82004,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.34,7.21
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,67457061910,NDC,100,ML,1707.48,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,6.82004,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.34,7.21
PARoxetine 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084004511,NDC,0.5,EA,7.49,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,6.82339,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084004501,NDC,0.5,EA,7.49,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,6.82339,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,603459315,NDC,1,EA,7.67,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,6.8263,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069030,NDC,3,ML,14.09,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,6.83,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,9.35
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,6.83,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,9.35
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,3,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,6.83,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,9.35
clindamycin 300 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084024411,NDC,1,EA,6.97,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,6.8306,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,68084024401,NDC,1,EA,6.97,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,6.8306,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 160 MG/5ML Suspension 118 mL Bottle,63700001,CDM,250,RC,,,,,,45802020326,NDC,10.15625,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
albuterol (2.5 MG/3ML) 0.083% Nebulization Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487950101,NDC,3,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
albuterol 1.25 MG/3ML Nebulization Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487990425,NDC,3,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Alcohol Swabstick 70 % Pad 50 Each Box,800000,CDM,,,,,,,,18407061105,NDC,1,EA,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
amoxicillin 250 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,65862070755,NDC,5,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 400 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,65862007101,NDC,3.125,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Biotene Dry Mouth Liquid 473 mL Bottle,63700001,CDM,250,RC,,,,,,48582000330,NDC,5,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbamide peroxide 6.5% 6.5 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904662735,NDC,15,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,93417773,NDC,2.5,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,24979015514,NDC,2.5,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314065605,NDC,0.05,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dexAMETHasone 1 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,54317644,NDC,0.5,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dextromethorphan-guaiFENesin 20-200 MG/20ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904722320,NDC,118,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,693390152,NDC,2.5,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
diphenhydrAMINE 12.5 MG/5ML Liquid 118 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904698520,NDC,2.5,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
diphenhydrAMINE 12.5 MG/5ML Liquid 120 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,58657052804,NDC,2.5,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,57896018105,NDC,15,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,57896018405,NDC,15,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,603107554,NDC,5,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,69367027204,NDC,5,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904006100,NDC,5,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904676320,NDC,5,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,54838011740,NDC,5,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,61787006304,NDC,5,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 100 MG/5ML Suspension 120 mL Bottle,63700001,CDM,250,RC,,,,,,904530920,NDC,20,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ipratropium 0.02 % Solution 2.5 mL Plas Cont,25000000,CDM,250,RC,,,,,,76204010001,NDC,2.5,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487020101,NDC,3,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lactulose 10 GM/15ML Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,121457715,NDC,15,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lactulose encephalopathy 10 GM/15ML Solution 473 mL Bottle,25000000,CDM,250,RC,,,,,,50383079516,NDC,15,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
levalbuterol 1.25 MG/3ML Nebulization Solution 3 mL Box,63700001,CDM,250,RC,,,,,,76204090001,NDC,3,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levalbuterol 1.25 MG/3ML Nebulization Solution 3 mL Plas Cont,63700001,CDM,250,RC,,,,,,76204090011,NDC,3,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine viscous 2 % Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,121090315,NDC,5,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine viscous 2 % Solution 100 mL Bottle,63700001,CDM,250,RC,,,,,,72888012526,NDC,5,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,54353244,NDC,0.25,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,121077001,NDC,0.25,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,65162068784,NDC,0.25,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium citrate 1.745 GM/30ML Solution 296 mL Bottle,63700001,CDM,250,RC,,,,,,69452038998,NDC,150,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium citrate 1.745 GM/30ML Solution 296 mL Bottle,63700001,CDM,250,RC,,,,,,70677111101,NDC,150,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium hydroxide 400 MG/5ML Suspension 30 mL Cup,63700001,CDM,250,RC,,,,,,69339015301,NDC,5,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine 20 mg/mL Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,54051744,NDC,0.5,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine polacrilex 4 MG Lozenge 24 Each Bottle,63700001,CDM,250,RC,,,,,,113087303,NDC,0.5,EA,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,121086805,NDC,4,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,121086802,NDC,4,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,66689000802,NDC,4,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 473 mL Bottle,63700001,CDM,250,RC,,,,,,121086816,NDC,4,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
opium 10 MG/ML (1%) Tincture 0.3 mL Syringe,63700001,CDM,250,RC,,,,,,8888800392,NDC,0.3,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
opium 10 MG/ML (1%) Tincture 0.6 mL Syringe,63700001,CDM,250,RC,,,,,,88888800245,NDC,0.3,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
opium 10 MG/ML (1%) Tincture 118 mL Bottle,63700001,CDM,250,RC,,,,,,42799021701,NDC,0.3,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxymetazoline 0.05 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904571135,NDC,15,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,904693186,NDC,1,EA,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 100 Each Box,63700001,CDM,250,RC,,,,,,904642281,NDC,1,EA,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
povidone iodine 10 % Solution 59 mL Bottle,63700001,CDM,250,RC,,,,,,52380190502,NDC,59,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Povidone-Iodine 10 % SWAB 1 Each Package,25000000,CDM,250,RC,,,,,,67618015301,NDC,1,EA,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004224,NDC,5,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,62135025037,NDC,1.666666667,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
racEPINEPHrine 2.25 % Nebulization Solution 1 Each Plas Cont,25000000,CDM,250,RC,,,,,,487590199,NDC,1,EA,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9 % Nebulization Solution 3 mL Plas Cont,63700001,CDM,250,RC,,,,,,487930133,NDC,3,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium chloride 0.65 % Solution 44 mL Bottle,63700001,CDM,250,RC,,,,,,904386575,NDC,44,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium phosphate 7-19 GM/118ML Enema 133 mL Bottle,63700001,CDM,250,RC,,,,,,132020140,NDC,133,ML,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
white petrolatum Gel 52.5 g Jar,63700001,CDM,250,RC,,,,,,521231100,NDC,52.5,GR,13.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739028310,NDC,1,EA,8.04,,First Health,Commercial,both,85,,999999999,percent of total billed charges,6.834,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,781502207,NDC,1,EA,7.68,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,6.8352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
mirtazapine 15 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904651961,NDC,0.5,EA,7.68,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,6.8352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505706300,NDC,1,EA,13.81,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.83595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ARTISTA AH 3GRAM ABSORBABLE HEMOSTATIC PARTICLES,27200000,CDM,272,RC,A6199,HCPCS,,10227-MAIN,LOCAL,,,,,486,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,6.84,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
DRAWTEX HYDROCONDUCTIVE NONADHERENT DRESSING,120.508,CDM,271,RC,A6199,HCPCS,,12022-MAIN,LOCAL,,,,,59,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,6.84,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.84,7.2
"DRESSING AQUACEL 3/4"" X 18"" AG HYDROFIBER 403771",120.31,CDM,272,RC,A6199,HCPCS,,8238-MAIN,LOCAL,,,,,33,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,6.84,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.84,7.2
clonazePAM 0.25 MG Tablet Disintegrating 1 Each Blister,63700001,CDM,250,RC,,,,,,49884030752,NDC,1,EA,6.98,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,6.8404,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Bottle,63700001,CDM,250,RC,,,,,,57664078486,NDC,1,EA,6.98,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,6.8404,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Box,63700001,CDM,250,RC,,,,,,555009596,NDC,1,EA,6.98,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,6.8404,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Box,63700001,CDM,250,RC,,,,,,49884030702,NDC,1,EA,6.98,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,6.8404,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rOPINIRole 4 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462025801,NDC,1,EA,13.96,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.8404,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rOPINIRole 4 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462025801,NDC,1,EA,13.96,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.8404,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rOPINIRole 4 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462025801,NDC,1,EA,13.96,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.8404,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
STOCKINETTE IMPERVIOUS 12X48 NON22535,27200000,CDM,272,RC,A6457,HCPCS,,10918-MAIN,LOCAL,,,,,16.47,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,6.841638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
theophylline SR (12 hour) 300 MG Tablet Extended Release 12 Hour 100 Each Bottle,25000000,CDM,250,RC,,,,,,68462072101,NDC,0.333333333,EA,7.69,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,6.8441,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
nicotine 7 MG/24HR Patch 24 Hour 7 Each Box,63700001,CDM,250,RC,,,,,,43598044670,NDC,1,EA,13.53,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.84618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 4 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,43547034406,NDC,0.125,EA,8.06,,First Health,Commercial,both,85,,999999999,percent of total billed charges,6.851,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lactulose 10 GM/15ML Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,50383077915,NDC,15,ML,15.98,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,6.85542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56017601,NDC,1,EA,13.85,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.85575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
AQUACEL EXTRA HYDOFIBER WOUND DRESSING 4X5,120.202,CDM,272,RC,A6197,HCPCS,,12047-MAIN,LOCAL,,,,,14,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
AQUACEL EXTRA HYDOFIBER WOUND DRESSING 4X5,120.202,CDM,272,RC,A6197,HCPCS,,12047-MAIN,LOCAL,,,,,14,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
AQUACEL EXTRA HYDOFIBER WOUND DRESSING 4X5,120.202,CDM,272,RC,A6197,HCPCS,,12047-MAIN,LOCAL,,,,,14,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
"AQUACEL FOAM DRESSING 4X4""",120.202,CDM,272,RC,A6209,HCPCS,,7939-MAIN,LOCAL,,,,,14,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
"AQUACEL FOAM DRESSING 4X4""",120.202,CDM,272,RC,A6209,HCPCS,,7939-MAIN,LOCAL,,,,,14,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
"AQUACEL FOAM DRESSING 4X4""",120.202,CDM,272,RC,A6209,HCPCS,,7939-MAIN,LOCAL,,,,,14,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
AQUACEL NONADHESIVE FOAM DRESSING 4X4,120.202,CDM,272,RC,A6209,HCPCS,,12046-MAIN,LOCAL,,,,,14,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
AQUACEL NONADHESIVE FOAM DRESSING 4X4,120.202,CDM,272,RC,A6209,HCPCS,,12046-MAIN,LOCAL,,,,,14,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
AQUACEL NONADHESIVE FOAM DRESSING 4X4,120.202,CDM,272,RC,A6209,HCPCS,,12046-MAIN,LOCAL,,,,,14,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
Assay Urine Urea-N,PX84540,CDM,300,RC,84540,CPT,,,,,,,,14,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.1,13.72
Assay Urine Urea-N,PX84540,CDM,300,RC,84540,CPT,,,,,,,,14,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.1,13.72
Assay Urine Urea-N,PX84540,CDM,300,RC,84540,CPT,,,,,,,,14,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.1,13.72
DERMAL TIP HYFRECATOR SHARP ANGLED STAINLESS STEEL BLADE STERILE DISPOSABLE,27200000,CDM,272,RC,,,,12459-MAIN,LOCAL,,,,,7,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,6.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
EZ CLEAN BLADE CAUTERY TIP 4 INCH,27200000,CDM,272,RC,,,,12826-MAIN,LOCAL,,,,,14,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
EZ CLEAN BLADE CAUTERY TIP 4 INCH,27200000,CDM,272,RC,,,,12826-MAIN,LOCAL,,,,,14,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
EZ CLEAN BLADE CAUTERY TIP 4 INCH,27200000,CDM,272,RC,,,,12826-MAIN,LOCAL,,,,,14,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSTRUMENT POUCH INVISISHIELD LONG,27200000,CDM,272,RC,,,,12394-MAIN,LOCAL,,,,,7,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,6.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
OSTOMY KIT 2 PIECE SURGICAL POST-OP,27200000,CDM,272,RC,,,,12070-MAIN,LOCAL,,,,,7,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,6.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Post Anesthesia Recovery,PX71000019,CDM,710,RC,,,,,,,,,,14,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
Post Anesthesia Recovery,PX71000019,CDM,710,RC,,,,,,,,,,14,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
Post Anesthesia Recovery,PX71000019,CDM,710,RC,,,,,,,,,,14,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
SAW WIRE 12 INCH GIGLI NL850,27200000,CDM,272,RC,,,,12901-MAIN,LOCAL,,,,,14,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SAW WIRE 12 INCH GIGLI NL850,27200000,CDM,272,RC,,,,12901-MAIN,LOCAL,,,,,14,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SAW WIRE 12 INCH GIGLI NL850,27200000,CDM,272,RC,,,,12901-MAIN,LOCAL,,,,,14,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE PDS 3-0 27INCH ABSORBABLE VIOLET Z316H,27200000,CDM,272,RC,,,,12871-MAIN,LOCAL,,,,,7,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,6.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE PROLENE TAPERPOINT CT-1 36MM 0 BLUE,27200000,CDM,272,RC,,,,12322-MAIN,LOCAL,,,,,7,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,6.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066500,NDC,0.25,ML,48.19,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.86,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.98362,7.79
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066501,NDC,0.25,ML,45.74,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.86,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.98362,7.79
topiramate 25 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,69097012203,NDC,1,EA,13.56,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.86136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BANDAGE ESMARK 4X9 LATEX FREE DYNJ05916,27200000,CDM,272,RC,,,,5428-MAIN,LOCAL,,,,,7.05,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,6.861765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
risperiDONE 0.5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,50458059160,NDC,1,EA,7.71,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,6.8619,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"BINDER ABDOMINAL 12"" HIGH 30-45INCH 4 PANEL ORT21300SM",120.238,CDM,271,RC,A4467,HCPCS,,11934-MAIN,LOCAL,,,,,16,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,6.864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
DRESSING OPTIFOAM 10X4 POST-OP SILICONE FACED MSC21410Z,120.154,CDM,272,RC,A6213,HCPCS,,8632-MAIN,LOCAL,,,,,16,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,6.864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,15.68
LEGGING PAIR 31X48 STERILE,27200000,CDM,272,RC,,,,10916-MAIN,LOCAL,,,,,16.53,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,6.866562,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Thyroxine, Total - Ref",PX8443690,CDM,300,RC,84436,CPT,90,,,,,,,95,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,6.87,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.66,6.87
mineral oil Enema 133 mL Bottle,63700001,CDM,250,RC,,,,,,132030140,NDC,133,ML,13.58,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.87148,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342003110,NDC,1,EA,16.56,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,6.879024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DULoxetine 60 MG Capsule Delayed Release Particles 30 Each Bottle,63700001,CDM,250,RC,,,,,,43547038103,NDC,0.333333333,EA,14.04,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.8796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DULoxetine 60 MG Capsule Delayed Release Particles 30 Each Bottle,63700001,CDM,250,RC,,,,,,43547038103,NDC,0.333333333,EA,14.04,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.8796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DULoxetine 60 MG Capsule Delayed Release Particles 30 Each Bottle,63700001,CDM,250,RC,,,,,,43547038103,NDC,0.333333333,EA,14.04,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.8796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
betamethasone acetate-betamethasone sodium phosphate 6 (3-3) MG/ML Suspension 5 mL Vial,J0702.01,CDM,636,RC,J0702,HCPCS,,,,517072001,NDC,1,ML,78.96,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.99,6.88
betamethasone acetate-betamethasone sodium phosphate 6 (3-3) MG/ML Suspension 5 mL Vial,J0702.01,CDM,636,RC,J0702,HCPCS,,,,517072001,NDC,1,ML,78.96,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.99,6.88
OXcarbazepine 150 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084084511,NDC,1,EA,8.1,,First Health,Commercial,both,85,,999999999,percent of total billed charges,6.885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 4 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56016801,NDC,1,EA,13.91,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.88545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084004411,NDC,1,EA,14.35,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084004411,NDC,1,EA,14.35,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084004401,NDC,1,EA,14.35,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084004401,NDC,1,EA,14.35,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DULoxetine 60 MG Capsule Delayed Release Particles 30 Each Bottle,63700001,CDM,250,RC,,,,,,57237001930,NDC,0.333333333,EA,14.06,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.8894,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DULoxetine 60 MG Capsule Delayed Release Particles 30 Each Bottle,63700001,CDM,250,RC,,,,,,57237001930,NDC,0.333333333,EA,14.06,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.8894,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DULoxetine 60 MG Capsule Delayed Release Particles 30 Each Bottle,63700001,CDM,250,RC,,,,,,57237001930,NDC,0.333333333,EA,14.06,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.8894,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of Lipase,PX83690,CDM,300,RC,83690,CPT,,,,,,,,132,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,6.89,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.68,6.89
"Gonadotropin, Chorionic (Hcg), Qualitative",PX84703,CDM,300,RC,84703,CPT,,,,,,,,175,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,6.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.9,171.5
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120301,NDC,0.5,ML,34.45,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.42,7.3
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120301,NDC,0.5,ML,34.45,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.42,7.3
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120311,NDC,0.5,ML,34.45,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.42,7.3
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120311,NDC,0.5,ML,34.45,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.42,7.3
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117603,NDC,1,ML,58.93,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.42,7.3
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117603,NDC,1,ML,58.93,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.42,7.3
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117630,NDC,1,ML,58.34,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.42,7.3
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117630,NDC,1,ML,58.34,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.42,7.3
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069030,NDC,3,ML,14.09,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.9041,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.852986,29.4
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069030,NDC,3,ML,14.09,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6.9041,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.852986,29.4
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069030,NDC,3,ML,14.09,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6.9041,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.852986,29.4
aspirin 300 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574703412,NDC,1,EA,7.83,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,6.90606,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084044011,NDC,0.5,EA,7.83,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,6.90606,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084044001,NDC,0.5,EA,7.83,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,6.90606,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BANDAGE ESMARK 4X9 LATEX FREE DYNJ05916,27200000,CDM,272,RC,,,,5428-MAIN,LOCAL,,,,,7.05,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,6.909,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
rOPINIRole 4 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462025801,NDC,1,EA,13.96,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.9102,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
meloxicam 7.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268052511,NDC,1,EA,16.64,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,6.912256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
RESERVOIR SILICONE BULB 100CC,27200000,CDM,272,RC,,,,4400-MAIN,LOCAL,,,,,16.65,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,6.91641,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,469650189,NDC,5,ML,1264.92,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,6.91655,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.91655,14.28
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,71288020185,NDC,5,ML,1021.7,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,6.91655,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.91655,14.28
levothyroxine 100 MCG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,74662490,NDC,1,EA,7.6,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,6.9236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,63739035810,NDC,0.5,EA,7.85,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,6.9237,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 150-4.21 MG/100ML-% Solution 100 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066015010,NDC,100,ML,249.22,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.50926,11.28
amiodarone 150-4.21 MG/100ML-% Solution 100 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066015010,NDC,100,ML,249.22,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.50926,11.28
amiodarone 360-4.14 MG/200ML-% Solution 200 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066036020,NDC,200,ML,325.25,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.50926,11.28
amiodarone 360-4.14 MG/200ML-% Solution 200 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066036020,NDC,200,ML,325.25,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.50926,11.28
AQUACEL EXTRA HYDOFIBER WOUND DRESSING 4X5,120.202,CDM,272,RC,A6197,HCPCS,,12047-MAIN,LOCAL,,,,,14,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
"AQUACEL FOAM DRESSING 4X4""",120.202,CDM,272,RC,A6209,HCPCS,,7939-MAIN,LOCAL,,,,,14,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
AQUACEL NONADHESIVE FOAM DRESSING 4X4,120.202,CDM,272,RC,A6209,HCPCS,,12046-MAIN,LOCAL,,,,,14,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
Assay Urine Urea-N,PX84540,CDM,300,RC,84540,CPT,,,,,,,,14,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.1,13.72
EZ CLEAN BLADE CAUTERY TIP 4 INCH,27200000,CDM,272,RC,,,,12826-MAIN,LOCAL,,,,,14,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Post Anesthesia Recovery,PX71000019,CDM,710,RC,,,,,,,,,,14,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
SAW WIRE 12 INCH GIGLI NL850,27200000,CDM,272,RC,,,,12901-MAIN,LOCAL,,,,,14,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409421505,NDC,5,ML,271.86,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.34,7.21
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409421505,NDC,5,ML,271.86,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.34,7.21
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,16714081501,NDC,5,ML,998.95,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.34,7.21
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,16714081501,NDC,5,ML,998.95,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.34,7.21
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021080166,NDC,5,ML,820.8,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.34,7.21
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021080166,NDC,5,ML,820.8,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.34,7.21
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,60505611000,NDC,5,ML,1644.33,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.34,7.21
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,60505611000,NDC,5,ML,1644.33,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.34,7.21
zoledronic acid 5 MG/100ML Solution 100 mL Bottle,J3489.01,CDM,636,RC,J3489,HCPCS,,,,55111068852,NDC,100,ML,1368,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.34,7.21
zoledronic acid 5 MG/100ML Solution 100 mL Bottle,J3489.01,CDM,636,RC,J3489,HCPCS,,,,55111068852,NDC,100,ML,1368,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.34,7.21
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409422801,NDC,100,ML,1026,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.34,7.21
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409422801,NDC,100,ML,1026,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.34,7.21
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021083082,NDC,100,ML,1596,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.34,7.21
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021083082,NDC,100,ML,1596,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.34,7.21
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,63323096600,NDC,100,ML,1368,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.34,7.21
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,63323096600,NDC,100,ML,1368,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.34,7.21
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,67457061910,NDC,100,ML,1707.48,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.34,7.21
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,67457061910,NDC,100,ML,1707.48,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.34,7.21
ziprasidone 80 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,781216860,NDC,0.25,EA,14.44,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.9312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ziprasidone 80 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,781216860,NDC,0.25,EA,14.44,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.9312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 25 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,62756070786,NDC,1,EA,13.71,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.93726,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Tx/Pro/Dx Inj Same Drug Adon,PX96376,CDM,260,RC,96376,CPT,,,,,,,,164,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.94,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.11,11.296
Tx/Pro/Dx Inj Same Drug Adon,PX96376,CDM,260,RC,96376,CPT,,,,,,,,164,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.94,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.11,11.296
citalopram 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904608561,NDC,1,EA,14.46,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.9408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
citalopram 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904608561,NDC,1,EA,14.46,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.9408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 125 MG Capsule Delayed Release Sprinkle 100 Each Box,63700001,CDM,250,RC,,,,,,68084031301,NDC,1,EA,7.62,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,6.94182,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097084034,NDC,3,ML,14.47,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.9456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097084034,NDC,3,ML,14.47,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.9456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097084053,NDC,3,ML,14.47,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.9456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097084053,NDC,3,ML,14.47,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.9456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
DULoxetine 60 MG Capsule Delayed Release Particles 30 Each Bottle,63700001,CDM,250,RC,,,,,,43547038103,NDC,0.333333333,EA,14.04,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.9498,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 125 MG Capsule Delayed Release Sprinkle 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031311,NDC,1,EA,7.63,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,6.95093,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DULoxetine 60 MG Capsule Delayed Release Particles 30 Each Bottle,63700001,CDM,250,RC,,,,,,57237001930,NDC,0.333333333,EA,14.06,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.9597,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,51293081001,NDC,1,EA,14.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,51293081001,NDC,1,EA,14.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65162068110,NDC,1,EA,14.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65162068110,NDC,1,EA,14.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
digoxin 125 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,115981101,NDC,1,EA,7.64,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,6.96004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739028510,NDC,1,EA,13.76,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.96256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sotalol 80 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,60505008000,NDC,1,EA,13.76,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.96256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin 300 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574703412,NDC,1,EA,7.83,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,6.9687,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084044011,NDC,0.5,EA,7.83,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,6.9687,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084044001,NDC,0.5,EA,7.83,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,6.9687,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,904642286,NDC,1,EA,8.2,,First Health,Commercial,both,85,,999999999,percent of total billed charges,6.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069030,NDC,3,ML,14.09,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6.97455,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.852986,29.4
finasteride 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862014930,NDC,1,EA,16.79,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,6.974566,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acyclovir 200 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578961,NDC,1,EA,8.21,,First Health,Commercial,both,85,,999999999,percent of total billed charges,6.9785,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of Ggt,PX82977,CDM,300,RC,82977,CPT,,,,,,,,89,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,6.98,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.98,7.2
Assay of Ggt,PX82977,CDM,300,RC,82977,CPT,,,,,,,,89,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,6.98,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.98,7.2
Assay of Ggt,PX82977,CDM,300,RC,82977,CPT,,,,,,,,89,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.98,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.98,7.2
Emergency Level I Visit,PX99281P,CDM,981,RC,99281,CPT,,,,,,,,224,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.98,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.98,219.52
Facility Emergency Level 1 Visit,PX99281F,CDM,450,RC,99281,CPT,,,,,,,,329,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.98,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.98,20.33
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153F,CDM,370,RC,99153,CPT,,,,,,,,225,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.98,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.98,20.36
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153P,CDM,983,RC,99153,CPT,,,,,,,,250,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,6.98,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.98,245
Oximetry;Mult Determine,PX610,CDM,460,RC,94761,CPT,,,,,,,,142,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,6.98,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.17,6.98
Oximetry;Mult Determine,PX610,CDM,460,RC,94761,CPT,,,,,,,,142,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,6.98,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.17,6.98
pramipexole 0.25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,42291053590,NDC,0.5,EA,7.92,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,6.98544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,63739035810,NDC,0.5,EA,7.85,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,6.9865,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,603459315,NDC,1,EA,7.67,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,6.98737,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
nicotine 21 MG/24HR Patch 24 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505706300,NDC,1,EA,13.81,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6.98786,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,781502207,NDC,1,EA,7.68,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,6.99648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
mirtazapine 15 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904651961,NDC,0.5,EA,7.68,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,6.99648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,50268053111,NDC,1,EA,7.19,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,6.998027,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
theophylline SR (12 hour) 300 MG Tablet Extended Release 12 Hour 100 Each Bottle,25000000,CDM,250,RC,,,,,,68462072101,NDC,0.333333333,EA,7.69,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,7.00559,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
warfarin 2.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56017601,NDC,1,EA,13.85,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,7.0081,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Electrolyte Panel,PX80051,CDM,300,RC,80051,CPT,,,,,,,,175,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,7.01,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.7389,7.01
memantine 10 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,72603011901,NDC,0.5,EA,16.37,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,7.02273,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,50458059160,NDC,1,EA,7.71,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,7.02381,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084004411,NDC,1,EA,14.35,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.0315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084004411,NDC,1,EA,14.35,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.0315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084004411,NDC,1,EA,14.35,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,7.0315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084004401,NDC,1,EA,14.35,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.0315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084004401,NDC,1,EA,14.35,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.0315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084004401,NDC,1,EA,14.35,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,7.0315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 4 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56016801,NDC,1,EA,13.91,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,7.03846,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,68094002459,NDC,10,ML,14.67,,Health Partners,Health Partners Care Plans,both,48,,1.38,percent of total billed charges,7.0416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,68094002459,NDC,10,ML,14.67,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,7.0416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,50268053111,NDC,1,EA,7.19,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,7.0462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,42291053590,NDC,0.5,EA,7.92,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,7.0488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,469650189,NDC,5,ML,1264.92,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,7.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.91655,14.28
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,469650189,NDC,5,ML,1264.92,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,7.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.91655,14.28
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,71288020185,NDC,5,ML,1021.7,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,7.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.91655,14.28
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,71288020185,NDC,5,ML,1021.7,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,7.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.91655,14.28
isosorbide dinitrate 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084008311,NDC,1,EA,7.25,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,7.056425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084008301,NDC,1,EA,7.25,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,7.056425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of Ggt,PX82977,CDM,300,RC,82977,CPT,,,,,,,,89,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,7.0598,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.98,7.2
"Exam,Synovial Fluid Crystals",PX89060,CDM,300,RC,89060,CPT,,,,,,,,85,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,7.0598,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.0598,27.36
Basic Metabolic Panel Ca Ion,PX80047,CDM,300,RC,80047,CPT,,,,,,,,17,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,7.0618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.0618,16.66
rOPINIRole 4 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462025801,NDC,1,EA,13.96,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,7.06376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
STOCKINETTE IMPERVIOUS 12X48 NON22535,27200000,CDM,272,RC,A6457,HCPCS,,10918-MAIN,LOCAL,,,,,16.47,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,7.06563,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
meloxicam 7.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,29300012401,NDC,1,EA,17.02,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,7.070108,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
STOCKINETTE IMPERVIOUS 9X36 NON22530,27200000,CDM,272,RC,A6457,HCPCS,,10917-MAIN,LOCAL,,,,,14.73,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,7.0704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STOCKINETTE IMPERVIOUS 9X36 NON22530,27200000,CDM,272,RC,A6457,HCPCS,,10917-MAIN,LOCAL,,,,,14.73,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,7.0704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
topiramate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034411,NDC,0.25,EA,8.32,,First Health,Commercial,both,85,,999999999,percent of total billed charges,7.072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034401,NDC,0.25,EA,8.32,,First Health,Commercial,both,85,,999999999,percent of total billed charges,7.072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ziprasidone 80 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,781216860,NDC,0.25,EA,14.44,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.0756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ziprasidone 80 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,781216860,NDC,0.25,EA,14.44,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.0756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ziprasidone 80 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,781216860,NDC,0.25,EA,14.44,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,7.0756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ARTISTA AH 3GRAM ABSORBABLE HEMOSTATIC PARTICLES,27200000,CDM,272,RC,A6199,HCPCS,,10227-MAIN,LOCAL,,,,,486,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,7.0774,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
DRAWTEX HYDROCONDUCTIVE NONADHERENT DRESSING,120.508,CDM,271,RC,A6199,HCPCS,,12022-MAIN,LOCAL,,,,,59,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,7.0774,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.84,7.2
"DRESSING AQUACEL 3/4"" X 18"" AG HYDROFIBER 403771",120.31,CDM,272,RC,A6199,HCPCS,,8238-MAIN,LOCAL,,,,,33,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,7.0774,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.84,7.2
famciclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,93811956,NDC,0.25,EA,17.04,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,7.078416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
AQUACEL EXTRA HYDOFIBER WOUND DRESSING 4X5,120.202,CDM,272,RC,A6197,HCPCS,,12047-MAIN,LOCAL,,,,,14,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,7.084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
"AQUACEL FOAM DRESSING 4X4""",120.202,CDM,272,RC,A6209,HCPCS,,7939-MAIN,LOCAL,,,,,14,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,7.084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
AQUACEL NONADHESIVE FOAM DRESSING 4X4,120.202,CDM,272,RC,A6209,HCPCS,,12046-MAIN,LOCAL,,,,,14,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,7.084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
Assay Urine Urea-N,PX84540,CDM,300,RC,84540,CPT,,,,,,,,14,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,7.084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.1,13.72
EZ CLEAN BLADE CAUTERY TIP 4 INCH,27200000,CDM,272,RC,,,,12826-MAIN,LOCAL,,,,,14,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,7.084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Post Anesthesia Recovery,PX71000019,CDM,710,RC,,,,,,,,,,14,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,7.084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
SAW WIRE 12 INCH GIGLI NL850,27200000,CDM,272,RC,,,,12901-MAIN,LOCAL,,,,,14,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,7.084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
citalopram 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904608561,NDC,1,EA,14.46,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.0854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
citalopram 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904608561,NDC,1,EA,14.46,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.0854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
citalopram 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904608561,NDC,1,EA,14.46,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,7.0854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097084034,NDC,3,ML,14.47,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.0903,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097084034,NDC,3,ML,14.47,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.0903,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097084034,NDC,3,ML,14.47,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,7.0903,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097084053,NDC,3,ML,14.47,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.0903,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097084053,NDC,3,ML,14.47,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.0903,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097084053,NDC,3,ML,14.47,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,7.0903,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739028310,NDC,1,EA,8.04,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,7.09128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LEGGING PAIR 31X48 STERILE,27200000,CDM,272,RC,,,,10916-MAIN,LOCAL,,,,,16.53,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,7.09137,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
pregabalin 75 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,71101468,NDC,0.333333333,EA,14.79,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,7.0992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 75 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,71101468,NDC,0.333333333,EA,14.79,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,7.0992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084004411,NDC,1,EA,14.35,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,7.10325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084004401,NDC,1,EA,14.35,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,7.10325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342003110,NDC,1,EA,16.56,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,7.10424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DULoxetine 60 MG Capsule Delayed Release Particles 30 Each Bottle,63700001,CDM,250,RC,,,,,,43547038103,NDC,0.333333333,EA,14.04,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,7.10424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084008311,NDC,1,EA,7.25,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,7.105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide dinitrate 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084008301,NDC,1,EA,7.25,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,7.105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,51293081001,NDC,1,EA,14.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,51293081001,NDC,1,EA,14.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,51293081001,NDC,1,EA,14.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,7.105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65162068110,NDC,1,EA,14.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65162068110,NDC,1,EA,14.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65162068110,NDC,1,EA,14.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,7.105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 4 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,43547034406,NDC,0.125,EA,8.06,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,7.10892,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Exam,Synovial Fluid Crystals",PX89060,CDM,300,RC,89060,CPT,,,,,,,,85,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,7.11,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.0598,27.36
"Exam,Synovial Fluid Crystals",PX89060,CDM,300,RC,89060,CPT,,,,,,,,85,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,7.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.0598,27.36
"Exam,Synovial Fluid Crystals",PX89060,CDM,300,RC,89060,CPT,,,,,,,,85,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,7.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.0598,27.36
DULoxetine 60 MG Capsule Delayed Release Particles 30 Each Bottle,63700001,CDM,250,RC,,,,,,57237001930,NDC,0.333333333,EA,14.06,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,7.11436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Complete Cbc W/Auto Diff Wbc,PX85025,CDM,300,RC,85025,CPT,,,,,,,,168,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,7.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.12,164.64
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069030,NDC,3,ML,14.09,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,7.12954,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.852986,29.4
"Albumin, Othr Source - Ref",PX8204290,CDM,300,RC,82042,CPT,90,,,,,,,57,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,7.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.13,55.86
"Albumin; Other Source, Quantitative, Each Specimen",PX82042,CDM,300,RC,82042,CPT,,,,,,,,28,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,7.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.13,27.44
imipenem-cilastatin 250 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323034925,NDC,1,EA,91.55,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,7.13,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.13,8.1
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032225,NDC,1,EA,176.72,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,7.13,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.13,8.1
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032294,NDC,1,EA,91.55,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,7.13,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.13,8.1
aspirin 300 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574703412,NDC,1,EA,7.83,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,7.13313,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084044011,NDC,0.5,EA,7.83,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,7.13313,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084044001,NDC,0.5,EA,7.83,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,7.13313,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
meloxicam 7.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268052511,NDC,1,EA,16.64,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,7.13856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine 2 MG/ML Solution 1 mL Syringe,J2272.01,CDM,636,RC,J2272,HCPCS,,,,76045000401,NDC,1,ML,38.98,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,7.14,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.14,7.43
morphine 2 MG/ML Solution 1 mL Syringe,J2272.01,CDM,636,RC,J2272,HCPCS,,,,76045000401,NDC,1,ML,38.98,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,7.14174,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.14,7.43
RESERVOIR SILICONE BULB 100CC,27200000,CDM,272,RC,,,,4400-MAIN,LOCAL,,,,,16.65,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,7.14285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
OXcarbazepine 150 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084084511,NDC,1,EA,8.1,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,7.1442,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ziprasidone 80 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,781216860,NDC,0.25,EA,14.44,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,7.1478,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levETIRAcetam 750 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,16714035602,NDC,0.333333333,EA,8.41,,First Health,Commercial,both,85,,999999999,percent of total billed charges,7.1485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Emergency Level I Visit,PX99281P,CDM,981,RC,99281,CPT,,,,,,,,224,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,7.15,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.98,219.52
Emergency Level I Visit,PX99281P,CDM,981,RC,99281,CPT,,,,,,,,224,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,7.15,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.98,219.52
Facility Emergency Level 1 Visit,PX99281F,CDM,450,RC,99281,CPT,,,,,,,,329,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,7.15,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.98,20.33
Facility Emergency Level 1 Visit,PX99281F,CDM,450,RC,99281,CPT,,,,,,,,329,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,7.15,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.98,20.33
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,63739035810,NDC,0.5,EA,7.85,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,7.15135,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE-acetaminophen 5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406051262,NDC,1,EA,7.35,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,7.153755,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739028310,NDC,1,EA,8.04,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,7.1556,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,185012201,NDC,1,EA,17.23,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,7.157342,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
citalopram 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904608561,NDC,1,EA,14.46,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,7.1577,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097084034,NDC,3,ML,14.47,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,7.16265,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097084053,NDC,3,ML,14.47,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,7.16265,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
oxyCODONE-acetaminophen 5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406051223,NDC,1,EA,7.36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,7.163488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pravastatin 10 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,60505016809,NDC,1,EA,17.26,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,7.169804,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 4 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,43547034406,NDC,0.125,EA,8.06,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,7.1734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,51293081001,NDC,1,EA,14.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,7.1775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65162068110,NDC,1,EA,14.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,7.1775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Gonadotropin, Chorionic (Hcg), Qualitative",PX84703,CDM,300,RC,84703,CPT,,,,,,,,175,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,7.18,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.18,7.52
"Gonadotropin, Chorionic (Hcg), Qualitative",PX84703,CDM,300,RC,84703,CPT,,,,,,,,175,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,7.18,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.18,7.52
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,68094002459,NDC,10,ML,14.67,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.6,percent of total billed charges,7.1883,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,68094002459,NDC,10,ML,14.67,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.1883,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,68094002459,NDC,10,ML,14.67,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,7.1883,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
doxycycline hyclate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584069311,NDC,0.5,EA,15,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,7.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline hyclate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584069311,NDC,0.5,EA,15,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,7.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline hyclate 100 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,62584069321,NDC,0.5,EA,15,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,7.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline hyclate 100 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,62584069321,NDC,0.5,EA,15,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,7.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Immunoassay - Ref,PX8351690,CDM,300,RC,83516,CPT,90,,,,,,,15,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,7.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.231,14.7
Immunoassay - Ref,PX8351690,CDM,300,RC,83516,CPT,90,,,,,,,15,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,7.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.231,14.7
"Iontophoresis, Ea 15min",PX97033,CDM,420,RC,97033,CPT,,,,,,,,15,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,7.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.231,14.7
"Iontophoresis, Ea 15min",PX97033,CDM,420,RC,97033,CPT,,,,,,,,15,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,7.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.231,14.7
Phase II Recovery,PX71000047,CDM,710,RC,,,,,,,,,,15,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,7.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.231,14.7
Phase II Recovery,PX71000047,CDM,710,RC,,,,,,,,,,15,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,7.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.231,14.7
ARTISTA AH 3GRAM ABSORBABLE HEMOSTATIC PARTICLES,27200000,CDM,272,RC,A6199,HCPCS,,10227-MAIN,LOCAL,,,,,486,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,7.2,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
ARTISTA AH 3GRAM ABSORBABLE HEMOSTATIC PARTICLES,27200000,CDM,272,RC,A6199,HCPCS,,10227-MAIN,LOCAL,,,,,486,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,7.2,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
ARTISTA AH 3GRAM ABSORBABLE HEMOSTATIC PARTICLES,27200000,CDM,272,RC,A6199,HCPCS,,10227-MAIN,LOCAL,,,,,486,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,7.2,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
Assay of Ggt,PX82977,CDM,300,RC,82977,CPT,,,,,,,,89,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,7.2,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.98,7.2
DRAWTEX HYDROCONDUCTIVE NONADHERENT DRESSING,120.508,CDM,271,RC,A6199,HCPCS,,12022-MAIN,LOCAL,,,,,59,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,7.2,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.84,7.2
DRAWTEX HYDROCONDUCTIVE NONADHERENT DRESSING,120.508,CDM,271,RC,A6199,HCPCS,,12022-MAIN,LOCAL,,,,,59,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,7.2,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.84,7.2
DRAWTEX HYDROCONDUCTIVE NONADHERENT DRESSING,120.508,CDM,271,RC,A6199,HCPCS,,12022-MAIN,LOCAL,,,,,59,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,7.2,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.84,7.2
"DRESSING AQUACEL 3/4"" X 18"" AG HYDROFIBER 403771",120.31,CDM,272,RC,A6199,HCPCS,,8238-MAIN,LOCAL,,,,,33,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,7.2,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.84,7.2
"DRESSING AQUACEL 3/4"" X 18"" AG HYDROFIBER 403771",120.31,CDM,272,RC,A6199,HCPCS,,8238-MAIN,LOCAL,,,,,33,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,7.2,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.84,7.2
"DRESSING AQUACEL 3/4"" X 18"" AG HYDROFIBER 403771",120.31,CDM,272,RC,A6199,HCPCS,,8238-MAIN,LOCAL,,,,,33,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,7.2,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.84,7.2
Smking Cess 4-10 Min,PX99406F,CDM,942,RC,99406,CPT,,,,,,,,65,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,7.2,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.2,26.31
Smking Cess 4-10 Min,PX99406P,CDM,983,RC,99406,CPT,,,,,,,,43,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,7.2,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.2,42.14
"US Complete Joint, Realtime W/ Img Tc",PX7688101,CDM,402,RC,76881,CPT,TC,,,,,,,415,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,7.2,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.2,21.69
"US Complete Joint, Realtime W/ Img Tc",PX7688101,CDM,402,RC,76881,CPT,TC,,,,,,,415,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,7.2,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.2,21.69
finasteride 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862014930,NDC,1,EA,16.79,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,7.20291,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE-acetaminophen 5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406051262,NDC,1,EA,7.35,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,7.203,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buPROPion XL 150 MG Tablet Extended Release 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,904708404,NDC,1,EA,8.48,,First Health,Commercial,both,85,,999999999,percent of total billed charges,7.208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
felodipine 5 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462023401,NDC,1,EA,8.48,,First Health,Commercial,both,85,,999999999,percent of total billed charges,7.208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
OXcarbazepine 150 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084084511,NDC,1,EA,8.1,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,7.209,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409421505,NDC,5,ML,271.86,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,7.21,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.34,7.21
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,16714081501,NDC,5,ML,998.95,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,7.21,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.34,7.21
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021080166,NDC,5,ML,820.8,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,7.21,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.34,7.21
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,60505611000,NDC,5,ML,1644.33,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,7.21,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.34,7.21
zoledronic acid 5 MG/100ML Solution 100 mL Bottle,J3489.01,CDM,636,RC,J3489,HCPCS,,,,55111068852,NDC,100,ML,1368,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,7.21,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.34,7.21
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409422801,NDC,100,ML,1026,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,7.21,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.34,7.21
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021083082,NDC,100,ML,1596,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,7.21,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.34,7.21
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,63323096600,NDC,100,ML,1368,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,7.21,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.34,7.21
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,67457061910,NDC,100,ML,1707.48,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,7.21,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.34,7.21
oxyCODONE-acetaminophen 5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406051223,NDC,1,EA,7.36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,7.2128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,42291053590,NDC,0.5,EA,7.92,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,7.21512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
STOCKINETTE IMPERVIOUS 9X36 NON22530,27200000,CDM,272,RC,A6457,HCPCS,,10917-MAIN,LOCAL,,,,,14.73,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.2177,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STOCKINETTE IMPERVIOUS 9X36 NON22530,27200000,CDM,272,RC,A6457,HCPCS,,10917-MAIN,LOCAL,,,,,14.73,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.2177,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STOCKINETTE IMPERVIOUS 9X36 NON22530,27200000,CDM,272,RC,A6457,HCPCS,,10917-MAIN,LOCAL,,,,,14.73,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,7.2177,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
pregabalin 25 MG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,904699104,NDC,1,EA,8.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,7.225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68382019616,NDC,1,EA,17.4,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,7.22796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simvastatin 10 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16714068202,NDC,0.5,EA,7.43,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,7.231619,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
riFAMpin 150 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,527139330,NDC,1,EA,17.41,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,7.232114,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
riFAMpin 150 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,68180065806,NDC,1,EA,17.41,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,7.232114,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,904642286,NDC,1,EA,8.2,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,7.2324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 75 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,59762134601,NDC,0.333333333,EA,15.08,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,7.2384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 75 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,59762134601,NDC,0.333333333,EA,15.08,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,7.2384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acyclovir 200 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578961,NDC,1,EA,8.21,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,7.24122,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 75 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,71101468,NDC,0.333333333,EA,14.79,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.2471,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 75 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,71101468,NDC,0.333333333,EA,14.79,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.2471,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 75 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,71101468,NDC,0.333333333,EA,14.79,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,7.2471,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084004411,NDC,1,EA,14.35,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,7.2611,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084004401,NDC,1,EA,14.35,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,7.2611,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,68094002459,NDC,10,ML,14.67,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,7.26165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
amLODIPine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904636961,NDC,1,EA,8.55,,First Health,Commercial,both,85,,999999999,percent of total billed charges,7.2675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simvastatin 10 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16714068202,NDC,0.5,EA,7.43,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,7.2814,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Gonadotropin, Chorionic (Hcg), Qualitative",PX84703,CDM,300,RC,84703,CPT,,,,,,,,175,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,7.29,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.18,7.52
indocyanine green 25 MG Recon Soln 1 Each Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,70100042402,NDC,1,EA,446.07,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,7.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.29,1354.4776
methylene blue 1 % Solution 10 mL Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,54288014701,NDC,1,ML,139.25,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,7.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.29,1354.4776
methylene blue 50 MG/10ML Solution 10 mL Ampule,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,517037405,NDC,10,ML,1382.12,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,7.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.29,1354.4776
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059900,NDC,1,ML,133.16,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,7.29,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.41,8.05
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059902,NDC,1,ML,133.16,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,7.29,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.41,8.05
naloxone 2 MG/2ML solution prefilled syringe 2 mL Syringe,J2310.01,CDM,636,RC,J2310,HCPCS,,,,76329346901,NDC,1,ML,114.45,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,7.29,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.41,8.05
PARoxetine 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084004511,NDC,0.5,EA,7.49,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,7.290017,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084004501,NDC,0.5,EA,7.49,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,7.290017,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
STOCKINETTE IMPERVIOUS 9X36 NON22530,27200000,CDM,272,RC,A6457,HCPCS,,10917-MAIN,LOCAL,,,,,14.73,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,7.29135,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Basic Metabolic Panel Ca Ion,PX80047,CDM,300,RC,80047,CPT,,,,,,,,17,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,7.293,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.0618,16.66
polyethylene glycol 3350 17 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,904642286,NDC,1,EA,8.2,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,7.298,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120301,NDC,0.5,ML,34.45,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,7.3,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.42,7.3
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120311,NDC,0.5,ML,34.45,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,7.3,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.42,7.3
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117603,NDC,1,ML,58.93,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,7.3,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.42,7.3
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117630,NDC,1,ML,58.34,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,7.3,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.42,7.3
balsalazide 750 MG capsule 280 Each Bottle,63700001,CDM,250,RC,,,,,,54007928,NDC,1,EA,8.59,,First Health,Commercial,both,85,,999999999,percent of total billed charges,7.3015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
balsalazide 750 MG capsule 280 Each Bottle,63700001,CDM,250,RC,,,,,,60505257507,NDC,1,EA,8.59,,First Health,Commercial,both,85,,999999999,percent of total billed charges,7.3015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
meloxicam 7.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,29300012401,NDC,1,EA,17.02,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,7.30158,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 2 % Ointment 1 g Packet,63700001,CDM,250,RC,,,,,,281032608,NDC,1,GR,17.58,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,7.302732,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ziprasidone 80 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,781216860,NDC,0.25,EA,14.44,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,7.30664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acyclovir 200 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578961,NDC,1,EA,8.21,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,7.3069,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famciclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,93811956,NDC,0.25,EA,17.04,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,7.31016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 250 MG/5ML Recon Susp 150 mL Package,63700001,CDM,250,RC,,,,,,99998805601,NDC,5,ML,15.24,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,7.3152,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 250 MG/5ML Recon Susp 150 mL Package,63700001,CDM,250,RC,,,,,,99998805601,NDC,5,ML,15.24,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,7.3152,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
citalopram 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904608561,NDC,1,EA,14.46,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,7.31676,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 75 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,71101468,NDC,0.333333333,EA,14.79,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,7.32105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097084034,NDC,3,ML,14.47,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,7.32182,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097084053,NDC,3,ML,14.47,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,7.32182,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739028310,NDC,1,EA,8.04,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,7.32444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terazosin 1 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59746038306,NDC,1,EA,8.62,,First Health,Commercial,both,85,,999999999,percent of total billed charges,7.327,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Tx/Pro/Dx Inj Same Drug Adon,PX96376,CDM,260,RC,96376,CPT,,,,,,,,164,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,7.33,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.11,11.296
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,51293081001,NDC,1,EA,14.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,7.337,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65162068110,NDC,1,EA,14.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,7.337,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034411,NDC,0.25,EA,8.32,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,7.33824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034401,NDC,0.25,EA,8.32,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,7.33824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084004511,NDC,0.5,EA,7.49,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,7.3402,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084004501,NDC,0.5,EA,7.49,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,7.3402,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 4 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,43547034406,NDC,0.125,EA,8.06,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,7.34266,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,49348014446,NDC,1,EA,15.3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,7.344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,49348014446,NDC,1,EA,15.3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,7.344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline hyclate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584069311,NDC,0.5,EA,15,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline hyclate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584069311,NDC,0.5,EA,15,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline hyclate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584069311,NDC,0.5,EA,15,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,7.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline hyclate 100 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,62584069321,NDC,0.5,EA,15,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline hyclate 100 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,62584069321,NDC,0.5,EA,15,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline hyclate 100 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,62584069321,NDC,0.5,EA,15,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,7.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Immunoassay - Ref,PX8351690,CDM,300,RC,83516,CPT,90,,,,,,,15,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.231,14.7
Immunoassay - Ref,PX8351690,CDM,300,RC,83516,CPT,90,,,,,,,15,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.231,14.7
Immunoassay - Ref,PX8351690,CDM,300,RC,83516,CPT,90,,,,,,,15,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,7.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.231,14.7
Immunoglobulin Subclasses - Ref,PX8278790,CDM,300,RC,82787,CPT,90,,,,,,,215,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,7.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.35,210.7
"Iontophoresis, Ea 15min",PX97033,CDM,420,RC,97033,CPT,,,,,,,,15,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.231,14.7
"Iontophoresis, Ea 15min",PX97033,CDM,420,RC,97033,CPT,,,,,,,,15,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.231,14.7
"Iontophoresis, Ea 15min",PX97033,CDM,420,RC,97033,CPT,,,,,,,,15,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,7.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.231,14.7
Phase II Recovery,PX71000047,CDM,710,RC,,,,,,,,,,15,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.231,14.7
Phase II Recovery,PX71000047,CDM,710,RC,,,,,,,,,,15,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.231,14.7
Phase II Recovery,PX71000047,CDM,710,RC,,,,,,,,,,15,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,7.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.231,14.7
clotrimazole 1 % Cream 28 g Tube,25000000,CDM,250,RC,,,,,,536127222,NDC,28,GR,15.36,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,7.3728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
clotrimazole 1 % Cream 28 g Tube,25000000,CDM,250,RC,,,,,,536127222,NDC,28,GR,15.36,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,7.3728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
OXcarbazepine 150 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084084511,NDC,1,EA,8.1,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,7.3791,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Gonadotropin, Chorionic (Hcg), Qualitative",PX84703,CDM,300,RC,84703,CPT,,,,,,,,175,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,7.3807,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.18,7.52
pregabalin 75 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,59762134601,NDC,0.333333333,EA,15.08,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.3892,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 75 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,59762134601,NDC,0.333333333,EA,15.08,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.3892,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 75 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,59762134601,NDC,0.333333333,EA,15.08,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,7.3892,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,185012201,NDC,1,EA,17.23,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,7.39167,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Ecg 12 Lead, Interp Only",PX93010,CDM,985,RC,93010,CPT,,,,,,,,29,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,7.3968,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.02,28.42
levothyroxine 100 MCG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,74662490,NDC,1,EA,7.6,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,7.39708,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Urine Culture/Colony Count,PX87086,CDM,300,RC,87086,CPT,,,,,,,,286,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,7.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4,280.28
pravastatin 10 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,60505016809,NDC,1,EA,17.26,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,7.40454,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034411,NDC,0.25,EA,8.32,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,7.4048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034401,NDC,0.25,EA,8.32,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,7.4048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Aerobic Isolate - Ref,PX8707790,CDM,300,RC,87077,CPT,90,,,,,,,168,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,7.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,164.64
Lab Org ID Anaerobic-Each,PX87076,CDM,300,RC,87076,CPT,,,,,,,,67,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,7.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,65.66
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153F,CDM,370,RC,99153,CPT,,,,,,,,225,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,7.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.98,20.36
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153F,CDM,370,RC,99153,CPT,,,,,,,,225,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,7.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.98,20.36
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153P,CDM,983,RC,99153,CPT,,,,,,,,250,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,7.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.98,245
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153P,CDM,983,RC,99153,CPT,,,,,,,,250,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,7.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.98,245
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152F,CDM,370,RC,99152,CPT,,,,,,,,235,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,7.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,87.84
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152F,CDM,370,RC,99152,CPT,,,,,,,,235,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,7.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,87.84
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152F,CDM,370,RC,99152,CPT,,,,,,,,235,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,7.41,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,87.84
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152P,CDM,983,RC,99152,CPT,,,,,,,,90,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,7.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,88.2
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152P,CDM,983,RC,99152,CPT,,,,,,,,90,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,7.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,88.2
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152P,CDM,983,RC,99152,CPT,,,,,,,,90,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,7.41,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,88.2
Org ID Aerobic-Each,PX87077,CDM,300,RC,87077,CPT,,,,,,,,168,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,7.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,164.64
"Organism ID, Anaerobic - Ref",PX8707690,CDM,300,RC,87076,CPT,90,,,,,,,95,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,7.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,93.1
Resp Muscles 1:1 per 15 Min,PXG0237,CDM,948,RC,G0237,HCPCS,,,,,,,,65,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,7.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.76,19.78
Resp Muscles 1:1 per 15 Min,PXG0237,CDM,948,RC,G0237,HCPCS,,,,,,,,65,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,7.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.76,19.78
US Urine Capacity Measure,PX51798F,CDM,510,RC,51798,CPT,,,,,,,,96,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,7.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.76,23.52
US Urine Capacity Measure,PX51798F,CDM,510,RC,51798,CPT,,,,,,,,96,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,7.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.76,23.52
divalproex 125 MG Capsule Delayed Release Sprinkle 100 Each Box,63700001,CDM,250,RC,,,,,,68084031301,NDC,1,EA,7.62,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,7.416546,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levETIRAcetam 750 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,16714035602,NDC,0.333333333,EA,8.41,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,7.41762,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Complete Cbc W/Auto Diff Wbc,PX85025,CDM,300,RC,85025,CPT,,,,,,,,168,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,7.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.42,7.77
Complete Cbc W/Auto Diff Wbc,PX85025,CDM,300,RC,85025,CPT,,,,,,,,168,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,7.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.42,7.77
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,68094002459,NDC,10,ML,14.67,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,7.42302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
doxycycline hyclate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584069311,NDC,0.5,EA,15,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,7.425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline hyclate 100 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,62584069321,NDC,0.5,EA,15,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,7.425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Immunoassay - Ref,PX8351690,CDM,300,RC,83516,CPT,90,,,,,,,15,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,7.425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.231,14.7
"Iontophoresis, Ea 15min",PX97033,CDM,420,RC,97033,CPT,,,,,,,,15,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,7.425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.231,14.7
Phase II Recovery,PX71000047,CDM,710,RC,,,,,,,,,,15,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,7.425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.231,14.7
divalproex 125 MG Capsule Delayed Release Sprinkle 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031311,NDC,1,EA,7.63,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,7.426279,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,310072010,NDC,5,ML,1977.83,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,7.43,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.43,8.87
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,781307912,NDC,5,ML,1854.23,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,7.43,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.43,8.87
morphine 2 MG/ML Solution 1 mL Syringe,J2272.01,CDM,636,RC,J2272,HCPCS,,,,76045000401,NDC,1,ML,38.98,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,7.43,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.14,7.43
"Spectrophotometry, Nos",PX84311,CDM,300,RC,84311,CPT,,,,,,,,21,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,7.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.43,20.58
imipenem-cilastatin 250 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323034925,NDC,1,EA,91.55,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,7.43127,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.13,8.1
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032225,NDC,1,EA,176.72,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,7.43127,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.13,8.1
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032294,NDC,1,EA,91.55,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,7.43127,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.13,8.1
digoxin 125 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,115981101,NDC,1,EA,7.64,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,7.436012,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 100 MCG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,74662490,NDC,1,EA,7.6,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,7.448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Strapping of Toes,PX29550F,CDM,510,RC,29550,CPT,,,,,,,,113,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,7.45,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.76,40.12
STOCKINETTE IMPERVIOUS 9X36 NON22530,27200000,CDM,272,RC,A6457,HCPCS,,10917-MAIN,LOCAL,,,,,14.73,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,7.45338,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
pravastatin 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079045801,NDC,0.5,EA,8.77,,First Health,Commercial,both,85,,999999999,percent of total billed charges,7.4545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68462033090,NDC,1,EA,17.95,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,7.45643,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pravastatin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904589161,NDC,1,EA,15.54,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,7.4592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pravastatin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904589161,NDC,1,EA,15.54,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,7.4592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68382019616,NDC,1,EA,17.4,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,7.4646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 75 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,59762134601,NDC,0.333333333,EA,15.08,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,7.4646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,603459315,NDC,1,EA,7.67,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,7.465211,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
amoxicillin 250 MG/5ML Recon Susp 150 mL Package,63700001,CDM,250,RC,,,,,,99998805601,NDC,5,ML,15.24,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.4676,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 250 MG/5ML Recon Susp 150 mL Package,63700001,CDM,250,RC,,,,,,99998805601,NDC,5,ML,15.24,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.4676,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 250 MG/5ML Recon Susp 150 mL Package,63700001,CDM,250,RC,,,,,,99998805601,NDC,5,ML,15.24,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,7.4676,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex 125 MG Capsule Delayed Release Sprinkle 100 Each Box,63700001,CDM,250,RC,,,,,,68084031301,NDC,1,EA,7.62,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,7.4676,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
riFAMpin 150 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,527139330,NDC,1,EA,17.41,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,7.46889,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
riFAMpin 150 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,68180065806,NDC,1,EA,17.41,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,7.46889,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,904642286,NDC,1,EA,8.2,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,7.4702,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,781502207,NDC,1,EA,7.68,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,7.474944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
mirtazapine 15 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904651961,NDC,0.5,EA,7.68,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,7.474944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"BINDER ABDOMINAL 12"" HIGH 46 TO 62 INCH L/XL 4 PANEL ORT21300LXL",120.238,CDM,271,RC,A4467,HCPCS,,11935-MAIN,LOCAL,,,,,18,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,7.4772,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BURETROL ADD ON SET 150ML,120.38,CDM,272,RC,A4222,HCPCS,,11118-MAIN,LOCAL,,,,,18,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,7.4772,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
TRAY TRACH CLEAN & CARE DYND40589,120.212,CDM,271,RC,,,,1173-MAIN,LOCAL,,,,,18,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,7.4772,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,17.64
TRAY TRACHEOTOMY CARE PEDS DYND40650H,120.212,CDM,272,RC,,,,11025-MAIN,LOCAL,,,,,18,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,7.4772,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,17.64
divalproex 125 MG Capsule Delayed Release Sprinkle 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031311,NDC,1,EA,7.63,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,7.4774,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acyclovir 200 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578961,NDC,1,EA,8.21,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,7.47931,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buPROPion XL 150 MG Tablet Extended Release 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,904708404,NDC,1,EA,8.48,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,7.47936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
felodipine 5 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462023401,NDC,1,EA,8.48,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,7.47936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 75 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,71101468,NDC,0.333333333,EA,14.79,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,7.48374,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
theophylline SR (12 hour) 300 MG Tablet Extended Release 12 Hour 100 Each Bottle,25000000,CDM,250,RC,,,,,,68462072101,NDC,0.333333333,EA,7.69,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,7.484677,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
levETIRAcetam 750 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,16714035602,NDC,0.333333333,EA,8.41,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,7.4849,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
digoxin 125 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,115981101,NDC,1,EA,7.64,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,7.4872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lovastatin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739028110,NDC,1,EA,15.6,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,7.488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lovastatin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739028110,NDC,1,EA,15.6,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,7.488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Acetone Assay,PX82010,CDM,300,RC,82010,CPT,,,,,,,,162,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,7.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.49,158.76
Hepatic Function Panel,PX80076,CDM,300,RC,80076,CPT,,,,,,,,171,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,7.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.49,167.58
oxyBUTYnin ER 5 MG Tablet Extended Release 24 Hour 50 Each Box,63700001,CDM,250,RC,,,,,,904657006,NDC,1,EA,18.04,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,7.493816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,49348014446,NDC,1,EA,15.3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.497,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,49348014446,NDC,1,EA,15.3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.497,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,49348014446,NDC,1,EA,15.3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,7.497,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 25 MG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,904699104,NDC,1,EA,8.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,7.497,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,50458059160,NDC,1,EA,7.71,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,7.504143,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,603459315,NDC,1,EA,7.67,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,7.5166,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
"Blood Typing, Rh Phenotype",PX86906,CDM,300,RC,86906,CPT,,,,,,,,115,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,7.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.52,7.75
"Blood Typing, Rh Phenotype",PX86906,CDM,300,RC,86906,CPT,,,,,,,,115,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,7.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.52,7.75
"Blood Typing, Rh Phenotype",PX86906,CDM,300,RC,86906,CPT,,,,,,,,115,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,7.52,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.52,7.75
"Gonadotropin, Chorionic (Hcg), Qualitative",PX84703,CDM,300,RC,84703,CPT,,,,,,,,175,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,7.52,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.18,7.52
irbesartan 75 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43547037403,NDC,1,EA,15.68,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,7.5264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
irbesartan 75 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43547037403,NDC,1,EA,15.68,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,7.5264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
irbesartan 75 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,43547037409,NDC,1,EA,15.68,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,7.5264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
irbesartan 75 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,43547037409,NDC,1,EA,15.68,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,7.5264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,781502207,NDC,1,EA,7.68,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,7.5264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
mirtazapine 15 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904651961,NDC,0.5,EA,7.68,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,7.5264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clotrimazole 1 % Cream 28 g Tube,25000000,CDM,250,RC,,,,,,536127222,NDC,28,GR,15.36,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.5264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
clotrimazole 1 % Cream 28 g Tube,25000000,CDM,250,RC,,,,,,536127222,NDC,28,GR,15.36,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.5264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
clotrimazole 1 % Cream 28 g Tube,25000000,CDM,250,RC,,,,,,536127222,NDC,28,GR,15.36,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,7.5264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,42806040021,NDC,1,EA,8.86,,First Health,Commercial,both,85,,999999999,percent of total billed charges,7.531,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
theophylline SR (12 hour) 300 MG Tablet Extended Release 12 Hour 100 Each Bottle,25000000,CDM,250,RC,,,,,,68462072101,NDC,0.333333333,EA,7.69,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,7.5362,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Complete Cbc W/Auto Diff Wbc,PX85025,CDM,300,RC,85025,CPT,,,,,,,,168,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,7.54,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.42,7.77
amLODIPine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904636961,NDC,1,EA,8.55,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,7.5411,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 2 % Ointment 1 g Packet,63700001,CDM,250,RC,,,,,,281032608,NDC,1,GR,17.58,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,7.54182,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 250 MG/5ML Recon Susp 150 mL Package,63700001,CDM,250,RC,,,,,,99998805601,NDC,5,ML,15.24,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,7.5438,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buPROPion XL 150 MG Tablet Extended Release 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,904708404,NDC,1,EA,8.48,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,7.5472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
felodipine 5 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462023401,NDC,1,EA,8.48,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,7.5472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Albumin, Othr Source - Ref",PX8204290,CDM,300,RC,82042,CPT,90,,,,,,,57,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,7.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.55,7.78
"Albumin, Othr Source - Ref",PX8204290,CDM,300,RC,82042,CPT,90,,,,,,,57,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,7.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.55,7.78
"Albumin, Othr Source - Ref",PX8204290,CDM,300,RC,82042,CPT,90,,,,,,,57,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,7.55,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.55,7.78
"Albumin; Other Source, Quantitative, Each Specimen",PX82042,CDM,300,RC,82042,CPT,,,,,,,,28,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,7.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.55,7.78
"Albumin; Other Source, Quantitative, Each Specimen",PX82042,CDM,300,RC,82042,CPT,,,,,,,,28,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,7.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.55,7.78
"Albumin; Other Source, Quantitative, Each Specimen",PX82042,CDM,300,RC,82042,CPT,,,,,,,,28,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,7.55,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.55,7.78
risperiDONE 0.5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,50458059160,NDC,1,EA,7.71,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,7.5558,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
imipenem-cilastatin 250 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323034925,NDC,1,EA,91.55,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,7.56,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.13,8.1
imipenem-cilastatin 250 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323034925,NDC,1,EA,91.55,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,7.56,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.13,8.1
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032225,NDC,1,EA,176.72,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,7.56,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.13,8.1
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032225,NDC,1,EA,176.72,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,7.56,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.13,8.1
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032294,NDC,1,EA,91.55,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,7.56,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.13,8.1
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032294,NDC,1,EA,91.55,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,7.56,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.13,8.1
nadolol 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,76385013301,NDC,1,EA,18.2,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,7.56028,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 25 MG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,904699104,NDC,1,EA,8.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,7.565,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,49348014446,NDC,1,EA,15.3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,7.5735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
balsalazide 750 MG capsule 280 Each Bottle,63700001,CDM,250,RC,,,,,,54007928,NDC,1,EA,8.59,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,7.57638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
balsalazide 750 MG capsule 280 Each Bottle,63700001,CDM,250,RC,,,,,,60505257507,NDC,1,EA,8.59,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,7.57638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbamide peroxide 6.5% 6.5 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904322035,NDC,15,ML,15.79,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,7.5792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbamide peroxide 6.5% 6.5 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904322035,NDC,15,ML,15.79,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,7.5792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034411,NDC,0.25,EA,8.32,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,7.57952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034401,NDC,0.25,EA,8.32,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,7.57952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline hyclate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584069311,NDC,0.5,EA,15,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,7.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline hyclate 100 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,62584069321,NDC,0.5,EA,15,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,7.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Immunoassay - Ref,PX8351690,CDM,300,RC,83516,CPT,90,,,,,,,15,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,7.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.231,14.7
"Iontophoresis, Ea 15min",PX97033,CDM,420,RC,97033,CPT,,,,,,,,15,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,7.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.231,14.7
Phase II Recovery,PX71000047,CDM,710,RC,,,,,,,,,,15,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,7.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.231,14.7
terazosin 1 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59746038306,NDC,1,EA,8.62,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,7.60284,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clotrimazole 1 % Cream 28 g Tube,25000000,CDM,250,RC,,,,,,536127222,NDC,28,GR,15.36,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,7.6032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
amLODIPine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904636961,NDC,1,EA,8.55,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,7.6095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pravastatin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904589161,NDC,1,EA,15.54,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.6146,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pravastatin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904589161,NDC,1,EA,15.54,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.6146,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pravastatin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904589161,NDC,1,EA,15.54,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,7.6146,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin 300 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574703412,NDC,1,EA,7.83,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,7.620939,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084044011,NDC,0.5,EA,7.83,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,7.620939,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084044001,NDC,0.5,EA,7.83,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,7.620939,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 30 Each Box,63700001,CDM,250,RC,,,,,,904693176,NDC,1,EA,8.97,,First Health,Commercial,both,85,,999999999,percent of total billed charges,7.6245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68462033190,NDC,0.5,EA,8.97,,First Health,Commercial,both,85,,999999999,percent of total billed charges,7.6245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Long Term Holter, 48 Hrs Up to 7 Days, Recording",PX93242,CDM,731,RC,93242,CPT,,,,,,,,58,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,7.63,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.63,20.94
"Long Term Holter, More Than 7 Days Up to 15 Days, Recording",PX93246,CDM,731,RC,93246,CPT,,,,,,,,58,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,7.63,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.63,20.94
pregabalin 75 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,59762134601,NDC,0.333333333,EA,15.08,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,7.63048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DRAPE SHEET 70X85 LARGE DYNJP2417,27200000,CDM,272,RC,,,,10914-MAIN,LOCAL,,,,,18.39,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,7.639206,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
levothyroxine 100 MCG/5ML Solution 5 mL Vial,J0651.01,CDM,636,RC,J0651,HCPCS,,,,63323088510,NDC,0.625,ML,99.32,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,7.64,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.64,9.74
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,63739035810,NDC,0.5,EA,7.85,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,7.640405,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lovastatin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739028110,NDC,1,EA,15.6,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lovastatin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739028110,NDC,1,EA,15.6,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lovastatin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739028110,NDC,1,EA,15.6,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,7.644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
balsalazide 750 MG capsule 280 Each Bottle,63700001,CDM,250,RC,,,,,,54007928,NDC,1,EA,8.59,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,7.6451,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
balsalazide 750 MG capsule 280 Each Bottle,63700001,CDM,250,RC,,,,,,60505257507,NDC,1,EA,8.59,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,7.6451,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600110,NDC,10,ML,589.63,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,7.65,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.24,7.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600121,NDC,10,ML,592.5,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,7.65,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.24,7.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040304,NDC,10,ML,168.77,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,7.65,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.24,7.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040310,NDC,10,ML,168.77,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,7.65,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.24,7.65
Osmolality; Blood,PX83930,CDM,300,RC,83930,CPT,,,,,,,,9,,First Health,Commercial,both,85,,999999999,percent of total billed charges,7.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.7386,8.82
SUTURE ETHILON SIZE 0 96INCH TP1,27200000,CDM,272,RC,,,,12140-MAIN,LOCAL,,,,,9,,First Health,Commercial,both,85,,999999999,percent of total billed charges,7.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE PROLENE 3-0 BLUE SH NEEDLE MONOFILAMENT 30INCH,27200000,CDM,272,RC,,,,12840-MAIN,LOCAL,,,,,9,,First Health,Commercial,both,85,,999999999,percent of total billed charges,7.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
URGOK2 DUAL COMPRESSION SYSTEM LARGE,120.491,CDM,271,RC,A6452,HCPCS,,11871-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,7.65,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.65,8.05
URGOK2 DUAL COMPRESSION SYSTEM REGULAR,120.491,CDM,271,RC,A6452,HCPCS,,11870-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,7.65,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.65,8.05
isosorbide mononitrate CR 30 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084059111,NDC,1,EA,9.01,,First Health,Commercial,both,85,,999999999,percent of total billed charges,7.6585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide mononitrate CR 30 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084059101,NDC,1,EA,9.01,,First Health,Commercial,both,85,,999999999,percent of total billed charges,7.6585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levETIRAcetam 750 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,16714035602,NDC,0.333333333,EA,8.41,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,7.66151,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lactulose 10 GM/15ML Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,50383077915,NDC,15,ML,15.98,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,7.6704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lactulose 10 GM/15ML Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,50383077915,NDC,15,ML,15.98,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,7.6704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terazosin 1 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59746038306,NDC,1,EA,8.62,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,7.6718,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin 300 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574703412,NDC,1,EA,7.83,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,7.6734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084044011,NDC,0.5,EA,7.83,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,7.6734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084044001,NDC,0.5,EA,7.83,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,7.6734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"BINDER ABDOMINAL 12"" HIGH 30-45INCH 4 PANEL ORT21300SM",120.238,CDM,271,RC,A4467,HCPCS,,11934-MAIN,LOCAL,,,,,16,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,7.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
"BINDER ABDOMINAL 12"" HIGH 30-45INCH 4 PANEL ORT21300SM",120.238,CDM,271,RC,A4467,HCPCS,,11934-MAIN,LOCAL,,,,,16,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,7.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
DRESSING OPTIFOAM 10X4 POST-OP SILICONE FACED MSC21410Z,120.154,CDM,272,RC,A6213,HCPCS,,8632-MAIN,LOCAL,,,,,16,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,7.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,15.68
DRESSING OPTIFOAM 10X4 POST-OP SILICONE FACED MSC21410Z,120.154,CDM,272,RC,A6213,HCPCS,,8632-MAIN,LOCAL,,,,,16,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,7.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,15.68
irbesartan 75 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43547037403,NDC,1,EA,15.68,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.6832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
irbesartan 75 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43547037403,NDC,1,EA,15.68,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.6832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
irbesartan 75 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43547037403,NDC,1,EA,15.68,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,7.6832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
irbesartan 75 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,43547037409,NDC,1,EA,15.68,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.6832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
irbesartan 75 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,43547037409,NDC,1,EA,15.68,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.6832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
irbesartan 75 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,43547037409,NDC,1,EA,15.68,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,7.6832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Direct skilled nursing services of a license practical nurse (lpn) in the home health or hospice setting, each 15 minutes",PXG0300,CDM,551,RC,G0300,HCPCS,,,,,,,,75,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,7.69,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.69,12.03
pravastatin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904589161,NDC,1,EA,15.54,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,7.6923,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,50111099001,NDC,1,EA,9.05,,First Health,Commercial,both,85,,999999999,percent of total billed charges,7.6925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,63739035810,NDC,0.5,EA,7.85,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,7.693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68462033090,NDC,1,EA,17.95,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,7.70055,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Albumin, Othr Source - Ref",PX8204290,CDM,300,RC,82042,CPT,90,,,,,,,57,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,7.7016,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.55,7.78
"Albumin; Other Source, Quantitative, Each Specimen",PX82042,CDM,300,RC,82042,CPT,,,,,,,,28,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,7.7016,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.55,7.78
"Blood Typing, Rh Phenotype",PX86906,CDM,300,RC,86906,CPT,,,,,,,,115,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,7.7016,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.52,7.75
Complete Cbc W/Auto Diff Wbc,PX85025,CDM,300,RC,85025,CPT,,,,,,,,168,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,7.7016,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.42,7.77
Immunoglobulin Subclasses - Ref,PX8278790,CDM,300,RC,82787,CPT,90,,,,,,,215,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,7.7016,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.7016,8.02
pramipexole 0.25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,42291053590,NDC,0.5,EA,7.92,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,7.708536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Fungal Culture, Other Source - Ref",PX8710290,CDM,300,RC,87102,CPT,90,,,,,,,157,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,7.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.71,153.86
Fungus Isolation Culture,PX87102,CDM,300,RC,87102,CPT,,,,,,,,167,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,7.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.71,163.66
Urine Culture/Colony Count,PX87086,CDM,300,RC,87086,CPT,,,,,,,,286,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,7.71,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.71,8.07
Urine Culture/Colony Count,PX87086,CDM,300,RC,87086,CPT,,,,,,,,286,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,7.71,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.71,8.07
amoxicillin 250 MG/5ML Recon Susp 150 mL Package,63700001,CDM,250,RC,,,,,,99998805601,NDC,5,ML,15.24,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,7.71144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Airway Inhalation Treatment,PX94640F,CDM,410,RC,94640,CPT,,,,,,,,242,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,7.716,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.02,13.96
amiodarone 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739038710,NDC,0.5,EA,9.08,,First Health,Commercial,both,85,,999999999,percent of total billed charges,7.718,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Bone Marrow Aspiration and Biopsy,PXG0364F,CDM,510,RC,G0364,HCPCS,,,,,,,,411,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,7.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.72,7.7208
"NEEDLE ASP 16GX3/16"" 1-7/8"" ILLINOIS STERNAL 8881245164",120.8,CDM,272,RC,G0364,HCPCS,,5730-MAIN,LOCAL,,,,,50,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,7.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.72,7.7208
"NEEDLE BONE MARROW 8G X 4"" BIOPSY/ASPIRATION 8881247087",120.8,CDM,272,RC,G0364,HCPCS,,166-MAIN,LOCAL,,,,,50,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,7.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.72,7.7208
"NEEDLE BONE MARROW 11G X 4"" 8881247111",120.8,CDM,272,RC,G0364,HCPCS,,162-MAIN,LOCAL,,,,,50,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,7.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.72,7.7208
Bone Marrow Aspiration and Biopsy,PXG0364F,CDM,510,RC,G0364,HCPCS,,,,,,,,411,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,7.7208,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.72,7.7208
"NEEDLE ASP 16GX3/16"" 1-7/8"" ILLINOIS STERNAL 8881245164",120.8,CDM,272,RC,G0364,HCPCS,,5730-MAIN,LOCAL,,,,,50,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,7.7208,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.72,7.7208
"NEEDLE BONE MARROW 8G X 4"" BIOPSY/ASPIRATION 8881247087",120.8,CDM,272,RC,G0364,HCPCS,,166-MAIN,LOCAL,,,,,50,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,7.7208,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.72,7.7208
"NEEDLE BONE MARROW 11G X 4"" 8881247111",120.8,CDM,272,RC,G0364,HCPCS,,162-MAIN,LOCAL,,,,,50,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,7.7208,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.72,7.7208
"BINDER ABDOMINAL 12"" HIGH 46 TO 62 INCH L/XL 4 PANEL ORT21300LXL",120.238,CDM,271,RC,A4467,HCPCS,,11935-MAIN,LOCAL,,,,,18,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,7.722,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BURETROL ADD ON SET 150ML,120.38,CDM,272,RC,A4222,HCPCS,,11118-MAIN,LOCAL,,,,,18,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,7.722,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
lovastatin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739028110,NDC,1,EA,15.6,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,7.722,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
TRAY TRACH CLEAN & CARE DYND40589,120.212,CDM,271,RC,,,,1173-MAIN,LOCAL,,,,,18,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,7.722,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,17.64
TRAY TRACHEOTOMY CARE PEDS DYND40650H,120.212,CDM,272,RC,,,,11025-MAIN,LOCAL,,,,,18,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,7.722,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,17.64
buPROPion XL 150 MG Tablet Extended Release 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,904708404,NDC,1,EA,8.48,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,7.72528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
felodipine 5 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462023401,NDC,1,EA,8.48,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,7.72528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pravastatin 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079045801,NDC,0.5,EA,8.77,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,7.73514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbamide peroxide 6.5% 6.5 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904322035,NDC,15,ML,15.79,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.7371,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbamide peroxide 6.5% 6.5 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904322035,NDC,15,ML,15.79,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.7371,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbamide peroxide 6.5% 6.5 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904322035,NDC,15,ML,15.79,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,7.7371,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyBUTYnin ER 5 MG Tablet Extended Release 24 Hour 50 Each Box,63700001,CDM,250,RC,,,,,,904657006,NDC,1,EA,18.04,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,7.73916,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,310072010,NDC,5,ML,1977.83,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,7.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.74,1938.2734
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,781307912,NDC,5,ML,1854.23,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,7.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.74,1938.2734
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,49348014446,NDC,1,EA,15.3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,7.7418,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 25 MG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,904699104,NDC,1,EA,8.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,7.7435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famciclovir 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,60505324603,NDC,0.5,EA,18.65,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,7.74721,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Blood Typing, Rh Phenotype",PX86906,CDM,300,RC,86906,CPT,,,,,,,,115,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,7.75,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.52,7.75
tolterodine 2 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,59762080002,NDC,0.5,EA,9.12,,First Health,Commercial,both,85,,999999999,percent of total billed charges,7.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyBUTYnin ER 5 MG Tablet Extended Release 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,63739054833,NDC,1,EA,18.67,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,7.755518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Lab Basic Metabolic Panel,PX80048,CDM,300,RC,80048,CPT,,,,,,,,236,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,7.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.76,231.28
irbesartan 75 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43547037403,NDC,1,EA,15.68,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,7.7616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
irbesartan 75 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,43547037409,NDC,1,EA,15.68,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,7.7616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,42291053590,NDC,0.5,EA,7.92,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,7.7616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Venipuncture, Lab",PX3641502,CDM,300,RC,36415,CPT,,,,,,,,61,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,7.77,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.77,8.83
"Venipuncture, Lab",PX3641502,CDM,300,RC,36415,CPT,,,,,,,,61,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,7.77,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.77,8.83
Complete Cbc W/Auto Diff Wbc,PX85025,CDM,300,RC,85025,CPT,,,,,,,,168,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,7.77,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.42,7.77
clotrimazole 1 % Cream 28 g Tube,25000000,CDM,250,RC,,,,,,536127222,NDC,28,GR,15.36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,7.77216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Albumin, Othr Source - Ref",PX8204290,CDM,300,RC,82042,CPT,90,,,,,,,57,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,7.78,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.55,7.78
"Albumin; Other Source, Quantitative, Each Specimen",PX82042,CDM,300,RC,82042,CPT,,,,,,,,28,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,7.78,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.55,7.78
Immunoglobulin Subclasses - Ref,PX8278790,CDM,300,RC,82787,CPT,90,,,,,,,215,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,7.78,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.7016,8.02
Immunoglobulin Subclasses - Ref,PX8278790,CDM,300,RC,82787,CPT,90,,,,,,,215,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,7.78,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.7016,8.02
Immunoglobulin Subclasses - Ref,PX8278790,CDM,300,RC,82787,CPT,90,,,,,,,215,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,7.78,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.7016,8.02
vinCRIStine 1 MG/ML Solution 2 mL Vial,J9370.01,CDM,636,RC,J9370,HCPCS,,,,61703030916,NDC,2,ML,48.72,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,7.78514,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.79,8.11
amLODIPine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904636961,NDC,1,EA,8.55,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,7.78905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066500,NDC,0.25,ML,48.19,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,7.79,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.98362,7.79
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066501,NDC,0.25,ML,45.74,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,7.79,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.98362,7.79
Hepatic Function Panel,PX80076,CDM,300,RC,80076,CPT,,,,,,,,171,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,7.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.8,8.17
Hepatic Function Panel,PX80076,CDM,300,RC,80076,CPT,,,,,,,,171,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,7.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.8,8.17
pravastatin 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079045801,NDC,0.5,EA,8.77,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,7.8053,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 200-40 MG/5ML Suspension 473 mL Bottle,63700001,CDM,250,RC,,,,,,65862049647,NDC,10,ML,18.79,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,7.805366,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nadolol 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,76385013301,NDC,1,EA,18.2,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,7.8078,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,42806040021,NDC,1,EA,8.86,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,7.81452,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
carbamide peroxide 6.5% 6.5 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904322035,NDC,15,ML,15.79,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,7.81605,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739028310,NDC,1,EA,8.04,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,7.825332,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
balsalazide 750 MG capsule 280 Each Bottle,63700001,CDM,250,RC,,,,,,54007928,NDC,1,EA,8.59,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,7.82549,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
balsalazide 750 MG capsule 280 Each Bottle,63700001,CDM,250,RC,,,,,,60505257507,NDC,1,EA,8.59,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,7.82549,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Urine Culture/Colony Count,PX87086,CDM,300,RC,87086,CPT,,,,,,,,286,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,7.83,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.71,8.07
lactulose 10 GM/15ML Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,50383077915,NDC,15,ML,15.98,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.8302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lactulose 10 GM/15ML Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,50383077915,NDC,15,ML,15.98,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.8302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lactulose 10 GM/15ML Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,50383077915,NDC,15,ML,15.98,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,7.8302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levETIRAcetam 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079082101,NDC,1,EA,18.87,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,7.838598,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Aerobic Isolate - Ref,PX8707790,CDM,300,RC,87077,CPT,90,,,,,,,168,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,7.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.84,8.08
Aerobic Isolate - Ref,PX8707790,CDM,300,RC,87077,CPT,90,,,,,,,168,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,7.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.84,8.08
Aerobic Isolate - Ref,PX8707790,CDM,300,RC,87077,CPT,90,,,,,,,168,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,7.84,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.84,8.08
"BINDER ABDOMINAL 12"" HIGH 30-45INCH 4 PANEL ORT21300SM",120.238,CDM,271,RC,A4467,HCPCS,,11934-MAIN,LOCAL,,,,,16,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
"BINDER ABDOMINAL 12"" HIGH 30-45INCH 4 PANEL ORT21300SM",120.238,CDM,271,RC,A4467,HCPCS,,11934-MAIN,LOCAL,,,,,16,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
"BINDER ABDOMINAL 12"" HIGH 30-45INCH 4 PANEL ORT21300SM",120.238,CDM,271,RC,A4467,HCPCS,,11934-MAIN,LOCAL,,,,,16,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,7.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
DRESSING OPTIFOAM 10X4 POST-OP SILICONE FACED MSC21410Z,120.154,CDM,272,RC,A6213,HCPCS,,8632-MAIN,LOCAL,,,,,16,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,15.68
DRESSING OPTIFOAM 10X4 POST-OP SILICONE FACED MSC21410Z,120.154,CDM,272,RC,A6213,HCPCS,,8632-MAIN,LOCAL,,,,,16,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,15.68
DRESSING OPTIFOAM 10X4 POST-OP SILICONE FACED MSC21410Z,120.154,CDM,272,RC,A6213,HCPCS,,8632-MAIN,LOCAL,,,,,16,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,7.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,15.68
Lab Org ID Anaerobic-Each,PX87076,CDM,300,RC,87076,CPT,,,,,,,,67,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,7.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.84,8.08
Lab Org ID Anaerobic-Each,PX87076,CDM,300,RC,87076,CPT,,,,,,,,67,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,7.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.84,8.08
Lab Org ID Anaerobic-Each,PX87076,CDM,300,RC,87076,CPT,,,,,,,,67,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,7.84,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.84,8.08
Org ID Aerobic-Each,PX87077,CDM,300,RC,87077,CPT,,,,,,,,168,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,7.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.84,8.08
Org ID Aerobic-Each,PX87077,CDM,300,RC,87077,CPT,,,,,,,,168,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,7.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.84,8.08
Org ID Aerobic-Each,PX87077,CDM,300,RC,87077,CPT,,,,,,,,168,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,7.84,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.84,8.08
"Organism ID, Anaerobic - Ref",PX8707690,CDM,300,RC,87076,CPT,90,,,,,,,95,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,7.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.84,8.08
"Organism ID, Anaerobic - Ref",PX8707690,CDM,300,RC,87076,CPT,90,,,,,,,95,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,7.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.84,8.08
"Organism ID, Anaerobic - Ref",PX8707690,CDM,300,RC,87076,CPT,90,,,,,,,95,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,7.84,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.84,8.08
risperiDONE 4 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,43547034406,NDC,0.125,EA,8.06,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,7.844798,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Each Add'l Hour IV Hydration,PX96361,CDM,260,RC,96361,CPT,,,,,,,,123,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,7.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.85,21.52
Each Add'l Hour IV Hydration,PX96361,CDM,260,RC,96361,CPT,,,,,,,,123,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,7.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.85,21.52
"Long Term Holter, 48 Hrs Up to 7 Days, Recording",PX93242,CDM,731,RC,93242,CPT,,,,,,,,58,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,7.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.63,20.94
"Long Term Holter, 48 Hrs Up to 7 Days, Recording",PX93242,CDM,731,RC,93242,CPT,,,,,,,,58,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,7.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.63,20.94
"Long Term Holter, More Than 7 Days Up to 15 Days, Recording",PX93246,CDM,731,RC,93246,CPT,,,,,,,,58,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,7.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.63,20.94
"Long Term Holter, More Than 7 Days Up to 15 Days, Recording",PX93246,CDM,731,RC,93246,CPT,,,,,,,,58,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,7.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.63,20.94
terazosin 1 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59746038306,NDC,1,EA,8.62,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,7.85282,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 100 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,69097012403,NDC,0.25,EA,9.24,,First Health,Commercial,both,85,,999999999,percent of total billed charges,7.854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
memantine 10 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,72603011901,NDC,0.5,EA,16.37,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,7.8576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
memantine 10 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,72603011901,NDC,0.5,EA,16.37,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,7.8576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Spectrophotometry, Nos",PX84311,CDM,300,RC,84311,CPT,,,,,,,,21,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,7.86,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.86,8.1
"Spectrophotometry, Nos",PX84311,CDM,300,RC,84311,CPT,,,,,,,,21,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,7.86,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.86,8.1
"Spectrophotometry, Nos",PX84311,CDM,300,RC,84311,CPT,,,,,,,,21,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,7.86,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.86,8.1
pravastatin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904589161,NDC,1,EA,15.54,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,7.86324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739028310,NDC,1,EA,8.04,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,7.8792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
OXcarbazepine 150 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084084511,NDC,1,EA,8.1,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,7.88373,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,42806040021,NDC,1,EA,8.86,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,7.8854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
amLODIPine 2.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079045001,NDC,1,EA,9.28,,First Health,Commercial,both,85,,999999999,percent of total billed charges,7.888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079045020,NDC,1,EA,9.28,,First Health,Commercial,both,85,,999999999,percent of total billed charges,7.888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DRAPE SHEET 70X85 LARGE DYNJP2417,27200000,CDM,272,RC,,,,10914-MAIN,LOCAL,,,,,18.39,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,7.88931,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Urine Pregnancy Test,PX81025,CDM,300,RC,81025,CPT,,,,,,,,191,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,7.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.89,187.18
SUTURE SILK 3-0 18INCH NONABSORBABLE BLACK M13T,27200000,CDM,272,RC,,,,12872-MAIN,LOCAL,,,,,19,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,7.8926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
lovastatin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739028110,NDC,1,EA,15.6,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,7.8936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 4 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,43547034406,NDC,0.125,EA,8.06,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,7.8988,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Lab Culture Bacteria,PX87070,CDM,300,RC,87070,CPT,,,,,,,,286,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,7.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.9,280.28
STOCKINETTE IMPERVIOUS 12X48 NON22535,27200000,CDM,272,RC,A6457,HCPCS,,10918-MAIN,LOCAL,,,,,16.47,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,7.9056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STOCKINETTE IMPERVIOUS 12X48 NON22535,27200000,CDM,272,RC,A6457,HCPCS,,10918-MAIN,LOCAL,,,,,16.47,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,7.9056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
vinCRIStine 1 MG/ML Solution 2 mL Vial,J9370.01,CDM,636,RC,J9370,HCPCS,,,,61703030916,NDC,2,ML,48.72,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,7.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.79,8.11
vinCRIStine 1 MG/ML Solution 2 mL Vial,J9370.01,CDM,636,RC,J9370,HCPCS,,,,61703030916,NDC,2,ML,48.72,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,7.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.79,8.11
lactulose 10 GM/15ML Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,50383077915,NDC,15,ML,15.98,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,7.9101,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 30 Each Box,63700001,CDM,250,RC,,,,,,904693176,NDC,1,EA,8.97,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,7.91154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68462033190,NDC,0.5,EA,8.97,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,7.91154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059900,NDC,1,ML,133.16,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,7.91382,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.41,8.05
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059902,NDC,1,ML,133.16,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,7.91382,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.41,8.05
naloxone 2 MG/2ML solution prefilled syringe 2 mL Syringe,J2310.01,CDM,636,RC,J2310,HCPCS,,,,76329346901,NDC,1,ML,114.45,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,7.91382,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.41,8.05
Acetone Assay,PX82010,CDM,300,RC,82010,CPT,,,,,,,,162,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,7.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.92,8.17
Acetone Assay,PX82010,CDM,300,RC,82010,CPT,,,,,,,,162,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,7.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.92,8.17
Acetone Assay,PX82010,CDM,300,RC,82010,CPT,,,,,,,,162,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,7.92,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.92,8.17
"BINDER ABDOMINAL 12"" HIGH 30-45INCH 4 PANEL ORT21300SM",120.238,CDM,271,RC,A4467,HCPCS,,11934-MAIN,LOCAL,,,,,16,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,7.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
DRESSING OPTIFOAM 10X4 POST-OP SILICONE FACED MSC21410Z,120.154,CDM,272,RC,A6213,HCPCS,,8632-MAIN,LOCAL,,,,,16,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,7.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,15.68
Hepatic Function Panel,PX80076,CDM,300,RC,80076,CPT,,,,,,,,171,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,7.92,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.8,8.17
Microbe Susceptible Mic,PX87186,CDM,300,RC,87186,CPT,,,,,,,,124,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,7.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.93,121.52
Nocardia Susceptibility - Ref,PX8718690,CDM,300,RC,87186,CPT,90,,,,,,,124,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,7.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.93,121.52
irbesartan 75 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43547037403,NDC,1,EA,15.68,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,7.93408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
irbesartan 75 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,43547037409,NDC,1,EA,15.68,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,7.93408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LEGGING PAIR 31X48 STERILE,27200000,CDM,272,RC,,,,10916-MAIN,LOCAL,,,,,16.53,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,7.9344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LEGGING PAIR 31X48 STERILE,27200000,CDM,272,RC,,,,10916-MAIN,LOCAL,,,,,16.53,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,7.9344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Osmolality; Blood,PX83930,CDM,300,RC,83930,CPT,,,,,,,,9,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,7.938,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.7386,8.82
OXcarbazepine 150 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084084511,NDC,1,EA,8.1,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,7.938,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SUTURE ETHILON SIZE 0 96INCH TP1,27200000,CDM,272,RC,,,,12140-MAIN,LOCAL,,,,,9,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,7.938,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE PROLENE 3-0 BLUE SH NEEDLE MONOFILAMENT 30INCH,27200000,CDM,272,RC,,,,12840-MAIN,LOCAL,,,,,9,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,7.938,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
famotidine 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079096601,NDC,1,EA,9.34,,First Health,Commercial,both,85,,999999999,percent of total billed charges,7.939,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide mononitrate CR 30 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084059111,NDC,1,EA,9.01,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,7.94682,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide mononitrate CR 30 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084059101,NDC,1,EA,9.01,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,7.94682,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342003110,NDC,1,EA,16.56,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,7.9488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342003110,NDC,1,EA,16.56,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,7.9488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 160 MG/5ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,68094023159,NDC,15,ML,19.14,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,7.950756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Renal Function Panel,PX80069,CDM,300,RC,80069,CPT,,,,,,,,264,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,7.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.96,258.72
rosuvastatin 10 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,60687024511,NDC,0.5,EA,19.18,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,7.967372,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,904642286,NDC,1,EA,8.2,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,7.98106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,50111099001,NDC,1,EA,9.05,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,7.9821,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 30 Each Box,63700001,CDM,250,RC,,,,,,904693176,NDC,1,EA,8.97,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,7.9833,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68462033190,NDC,0.5,EA,8.97,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,7.9833,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
meloxicam 7.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268052511,NDC,1,EA,16.64,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,7.9872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
meloxicam 7.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268052511,NDC,1,EA,16.64,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,7.9872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pravastatin 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079045801,NDC,0.5,EA,8.77,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,7.98947,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbamide peroxide 6.5% 6.5 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904322035,NDC,15,ML,15.79,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,7.98974,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acyclovir 200 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578961,NDC,1,EA,8.21,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,7.990793,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
RESERVOIR SILICONE BULB 100CC,27200000,CDM,272,RC,,,,4400-MAIN,LOCAL,,,,,16.65,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,7.992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RESERVOIR SILICONE BULB 100CC,27200000,CDM,272,RC,,,,4400-MAIN,LOCAL,,,,,16.65,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,7.992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Smking Cess 4-10 Min,PX99406F,CDM,942,RC,99406,CPT,,,,,,,,65,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.2,26.31
Smking Cess 4-10 Min,PX99406F,CDM,942,RC,99406,CPT,,,,,,,,65,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.2,26.31
Smking Cess 4-10 Min,PX99406P,CDM,983,RC,99406,CPT,,,,,,,,43,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.2,42.14
Smking Cess 4-10 Min,PX99406P,CDM,983,RC,99406,CPT,,,,,,,,43,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.2,42.14
famciclovir 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,60505324603,NDC,0.5,EA,18.65,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,8.00085,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739038710,NDC,0.5,EA,9.08,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,8.00856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyBUTYnin ER 5 MG Tablet Extended Release 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,63739054833,NDC,1,EA,18.67,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,8.00943,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Osmolality; Blood,PX83930,CDM,300,RC,83930,CPT,,,,,,,,9,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,8.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.7386,8.82
SUTURE ETHILON SIZE 0 96INCH TP1,27200000,CDM,272,RC,,,,12140-MAIN,LOCAL,,,,,9,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,8.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE PROLENE 3-0 BLUE SH NEEDLE MONOFILAMENT 30INCH,27200000,CDM,272,RC,,,,12840-MAIN,LOCAL,,,,,9,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,8.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,310072010,NDC,5,ML,1977.83,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,8.01033,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.43,8.87
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,781307912,NDC,5,ML,1854.23,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,8.01033,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.43,8.87
zolpidem 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018911,NDC,1,EA,9.43,,First Health,Commercial,both,85,,999999999,percent of total billed charges,8.0155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zolpidem 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018901,NDC,1,EA,9.43,,First Health,Commercial,both,85,,999999999,percent of total billed charges,8.0155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide mononitrate CR 30 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084059111,NDC,1,EA,9.01,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,8.0189,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide mononitrate CR 30 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084059101,NDC,1,EA,9.01,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,8.0189,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Immunoglobulin Subclasses - Ref,PX8278790,CDM,300,RC,82787,CPT,90,,,,,,,215,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,8.02,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.7016,8.02
memantine 10 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,72603011901,NDC,0.5,EA,16.37,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,8.0213,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
memantine 10 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,72603011901,NDC,0.5,EA,16.37,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,8.0213,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
memantine 10 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,72603011901,NDC,0.5,EA,16.37,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,8.0213,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Acetone Assay,PX82010,CDM,300,RC,82010,CPT,,,,,,,,162,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,8.0225,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.92,8.17
Aerobic Isolate - Ref,PX8707790,CDM,300,RC,87077,CPT,90,,,,,,,168,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,8.0225,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.84,8.08
Hepatic Function Panel,PX80076,CDM,300,RC,80076,CPT,,,,,,,,171,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,8.0225,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.8,8.17
Lab Org ID Anaerobic-Each,PX87076,CDM,300,RC,87076,CPT,,,,,,,,67,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,8.0225,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.84,8.08
Org ID Aerobic-Each,PX87077,CDM,300,RC,87077,CPT,,,,,,,,168,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,8.0225,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.84,8.08
"Organism ID, Anaerobic - Ref",PX8707690,CDM,300,RC,87076,CPT,90,,,,,,,95,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,8.0225,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.84,8.08
"Spectrophotometry, Nos",PX84311,CDM,300,RC,84311,CPT,,,,,,,,21,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,8.0225,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.86,8.1
Urine Culture/Colony Count,PX87086,CDM,300,RC,87086,CPT,,,,,,,,286,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,8.0225,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.71,8.07
"Venipuncture by Physician, Other Vein, Under Age 3 Years",PX36406,CDM,983,RC,36406,CPT,,,,,,,,45,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,8.0275,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.45,44.1
polyethylene glycol 3350 17 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,904642286,NDC,1,EA,8.2,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,8.036,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Cardiac Rehab,PX93797F,CDM,943,RC,93797,CPT,,,,,,,,45,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,8.0375,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.45,29.67
Office/Outpt Visit Est Level I,PX99211F,CDM,510,RC,99211,CPT,,,,,,,,119,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,8.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.46,41.86
Office/Outpt Visit Est Level I,PX99211P,CDM,983,RC,99211,CPT,,,,,,,,119,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,8.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.46,116.62
URGOK2 DUAL COMPRESSION SYSTEM LARGE,120.491,CDM,271,RC,A6452,HCPCS,,11871-MAIN,LOCAL,,,,,41,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,8.0425,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.65,8.05
URGOK2 DUAL COMPRESSION SYSTEM REGULAR,120.491,CDM,271,RC,A6452,HCPCS,,11870-MAIN,LOCAL,,,,,41,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,8.0425,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.65,8.05
tolterodine 2 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,59762080002,NDC,0.5,EA,9.12,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,8.04384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acyclovir 200 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578961,NDC,1,EA,8.21,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,8.0458,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059900,NDC,1,ML,133.16,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,8.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.41,8.05
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059900,NDC,1,ML,133.16,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,8.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.41,8.05
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059902,NDC,1,ML,133.16,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,8.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.41,8.05
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059902,NDC,1,ML,133.16,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,8.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.41,8.05
naloxone 2 MG/2ML solution prefilled syringe 2 mL Syringe,J2310.01,CDM,636,RC,J2310,HCPCS,,,,76329346901,NDC,1,ML,114.45,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,8.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.41,8.05
naloxone 2 MG/2ML solution prefilled syringe 2 mL Syringe,J2310.01,CDM,636,RC,J2310,HCPCS,,,,76329346901,NDC,1,ML,114.45,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,8.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.41,8.05
URGOK2 DUAL COMPRESSION SYSTEM LARGE,120.491,CDM,271,RC,A6452,HCPCS,,11871-MAIN,LOCAL,,,,,41,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,8.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.65,8.05
URGOK2 DUAL COMPRESSION SYSTEM LARGE,120.491,CDM,271,RC,A6452,HCPCS,,11871-MAIN,LOCAL,,,,,41,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,8.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.65,8.05
URGOK2 DUAL COMPRESSION SYSTEM LARGE,120.491,CDM,271,RC,A6452,HCPCS,,11871-MAIN,LOCAL,,,,,41,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,8.05,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.65,8.05
URGOK2 DUAL COMPRESSION SYSTEM REGULAR,120.491,CDM,271,RC,A6452,HCPCS,,11870-MAIN,LOCAL,,,,,41,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,8.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.65,8.05
URGOK2 DUAL COMPRESSION SYSTEM REGULAR,120.491,CDM,271,RC,A6452,HCPCS,,11870-MAIN,LOCAL,,,,,41,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,8.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.65,8.05
URGOK2 DUAL COMPRESSION SYSTEM REGULAR,120.491,CDM,271,RC,A6452,HCPCS,,11870-MAIN,LOCAL,,,,,41,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,8.05,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.65,8.05
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,50111099001,NDC,1,EA,9.05,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,8.0545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
finasteride 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862014930,NDC,1,EA,16.79,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,8.0592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
finasteride 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862014930,NDC,1,EA,16.79,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,8.0592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 200-40 MG/5ML Suspension 473 mL Bottle,63700001,CDM,250,RC,,,,,,65862049647,NDC,10,ML,18.79,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,8.06091,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Each Add'l Hour IV Hydration,PX96361,CDM,260,RC,96361,CPT,,,,,,,,123,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,8.07,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.85,21.52
Urine Culture/Colony Count,PX87086,CDM,300,RC,87086,CPT,,,,,,,,286,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,8.07,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.71,8.07
STOCKINETTE IMPERVIOUS 12X48 NON22535,27200000,CDM,272,RC,A6457,HCPCS,,10918-MAIN,LOCAL,,,,,16.47,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,8.0703,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STOCKINETTE IMPERVIOUS 12X48 NON22535,27200000,CDM,272,RC,A6457,HCPCS,,10918-MAIN,LOCAL,,,,,16.47,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,8.0703,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STOCKINETTE IMPERVIOUS 12X48 NON22535,27200000,CDM,272,RC,A6457,HCPCS,,10918-MAIN,LOCAL,,,,,16.47,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,8.0703,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,42806040021,NDC,1,EA,8.86,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,8.07146,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
Aerobic Isolate - Ref,PX8707790,CDM,300,RC,87077,CPT,90,,,,,,,168,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,8.08,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.84,8.08
Lab Org ID Anaerobic-Each,PX87076,CDM,300,RC,87076,CPT,,,,,,,,67,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,8.08,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.84,8.08
Org ID Aerobic-Each,PX87077,CDM,300,RC,87077,CPT,,,,,,,,168,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,8.08,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.84,8.08
"Organism ID, Anaerobic - Ref",PX8707690,CDM,300,RC,87076,CPT,90,,,,,,,95,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,8.08,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.84,8.08
amiodarone 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739038710,NDC,0.5,EA,9.08,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,8.0812,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lactulose 10 GM/15ML Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,50383077915,NDC,15,ML,15.98,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,8.08588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levETIRAcetam 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079082101,NDC,1,EA,18.87,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,8.09523,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"BINDER ABDOMINAL 12"" HIGH 30-45INCH 4 PANEL ORT21300SM",120.238,CDM,271,RC,A4467,HCPCS,,11934-MAIN,LOCAL,,,,,16,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,8.096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
DRESSING OPTIFOAM 10X4 POST-OP SILICONE FACED MSC21410Z,120.154,CDM,272,RC,A6213,HCPCS,,8632-MAIN,LOCAL,,,,,16,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,8.096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,15.68
topiramate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034411,NDC,0.25,EA,8.32,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,8.097856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034401,NDC,0.25,EA,8.32,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,8.097856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LEGGING PAIR 31X48 STERILE,27200000,CDM,272,RC,,,,10916-MAIN,LOCAL,,,,,16.53,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,8.0997,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LEGGING PAIR 31X48 STERILE,27200000,CDM,272,RC,,,,10916-MAIN,LOCAL,,,,,16.53,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,8.0997,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LEGGING PAIR 31X48 STERILE,27200000,CDM,272,RC,,,,10916-MAIN,LOCAL,,,,,16.53,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,8.0997,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Catheterize for Urine Spec,PXP9612,CDM,300,RC,P9612,HCPCS,,,,,,,,161,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,8.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.1,157.78
imipenem-cilastatin 250 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323034925,NDC,1,EA,91.55,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,8.1,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.13,8.1
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032225,NDC,1,EA,176.72,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,8.1,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.13,8.1
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032294,NDC,1,EA,91.55,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,8.1,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.13,8.1
"Spectrophotometry, Nos",PX84311,CDM,300,RC,84311,CPT,,,,,,,,21,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,8.1,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.86,8.1
"Venipuncture, Lab",PX3641502,CDM,300,RC,36415,CPT,,,,,,,,61,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,8.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.1,65.45
memantine 10 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,72603011901,NDC,0.5,EA,16.37,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,8.10315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"MAYO STAND COVERS 24X53""",27200000,CDM,272,RC,,,,644-MAIN,LOCAL,,,,,9.54,,First Health,Commercial,both,85,,999999999,percent of total billed charges,8.109,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
vinCRIStine 1 MG/ML Solution 2 mL Vial,J9370.01,CDM,636,RC,J9370,HCPCS,,,,61703030916,NDC,2,ML,48.72,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,8.11,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.79,8.11
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342003110,NDC,1,EA,16.56,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,8.1144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342003110,NDC,1,EA,16.56,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,8.1144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342003110,NDC,1,EA,16.56,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,8.1144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tolterodine 2 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,59762080002,NDC,0.5,EA,9.12,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,8.1168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 100 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,69097012403,NDC,0.25,EA,9.24,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,8.14968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SUTURE SILK 3-0 18INCH NONABSORBABLE BLACK M13T,27200000,CDM,272,RC,,,,12872-MAIN,LOCAL,,,,,19,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,8.151,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STOCKINETTE IMPERVIOUS 12X48 NON22535,27200000,CDM,272,RC,A6457,HCPCS,,10918-MAIN,LOCAL,,,,,16.47,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,8.15265,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
meloxicam 7.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268052511,NDC,1,EA,16.64,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,8.1536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
meloxicam 7.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268052511,NDC,1,EA,16.64,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,8.1536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
meloxicam 7.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268052511,NDC,1,EA,16.64,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,8.1536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034411,NDC,0.25,EA,8.32,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,8.1536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034401,NDC,0.25,EA,8.32,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,8.1536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
RESERVOIR SILICONE BULB 100CC,27200000,CDM,272,RC,,,,4400-MAIN,LOCAL,,,,,16.65,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,8.1585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RESERVOIR SILICONE BULB 100CC,27200000,CDM,272,RC,,,,4400-MAIN,LOCAL,,,,,16.65,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,8.1585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RESERVOIR SILICONE BULB 100CC,27200000,CDM,272,RC,,,,4400-MAIN,LOCAL,,,,,16.65,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,8.1585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Basic Metabolic Panel Ca Ion,PX80047,CDM,300,RC,80047,CPT,,,,,,,,17,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,8.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.0618,16.66
Basic Metabolic Panel Ca Ion,PX80047,CDM,300,RC,80047,CPT,,,,,,,,17,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,8.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.0618,16.66
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,310072010,NDC,5,ML,1977.83,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,8.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.43,8.87
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,310072010,NDC,5,ML,1977.83,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,8.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.43,8.87
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,781307912,NDC,5,ML,1854.23,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,8.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.43,8.87
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,781307912,NDC,5,ML,1854.23,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,8.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.43,8.87
"Fungal Culture, Other Source - Ref",PX8710290,CDM,300,RC,87102,CPT,90,,,,,,,157,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,8.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.16,8.41
"Fungal Culture, Other Source - Ref",PX8710290,CDM,300,RC,87102,CPT,90,,,,,,,157,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,8.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.16,8.41
"Fungal Culture, Other Source - Ref",PX8710290,CDM,300,RC,87102,CPT,90,,,,,,,157,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,8.16,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.16,8.41
Fungus Isolation Culture,PX87102,CDM,300,RC,87102,CPT,,,,,,,,167,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,8.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.16,8.41
Fungus Isolation Culture,PX87102,CDM,300,RC,87102,CPT,,,,,,,,167,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,8.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.16,8.41
Fungus Isolation Culture,PX87102,CDM,300,RC,87102,CPT,,,,,,,,167,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,8.16,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.16,8.41
APPLICATOR CHLORAPREP 26ML WITH ORANGE 930815,27200000,CDM,272,RC,A4248,HCPCS,,10031-MAIN,LOCAL,,,,,19.65,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,8.16261,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
meloxicam 7.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,29300012401,NDC,1,EA,17.02,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,8.1696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
meloxicam 7.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,29300012401,NDC,1,EA,17.02,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,8.1696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Acetone Assay,PX82010,CDM,300,RC,82010,CPT,,,,,,,,162,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,8.17,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.92,8.17
Hepatic Function Panel,PX80076,CDM,300,RC,80076,CPT,,,,,,,,171,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,8.17,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.8,8.17
polyethylene glycol 3350 17 g Packet 30 Each Box,63700001,CDM,250,RC,,,,,,904693176,NDC,1,EA,8.97,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,8.17167,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68462033190,NDC,0.5,EA,8.97,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,8.17167,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famciclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,93811956,NDC,0.25,EA,17.04,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,8.1792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famciclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,93811956,NDC,0.25,EA,17.04,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,8.1792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Electric Stimulation Therapy,PX97014,CDM,420,RC,97014,CPT,,,,,,,,135,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,8.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.18,132.3
LEGGING PAIR 31X48 STERILE,27200000,CDM,272,RC,,,,10916-MAIN,LOCAL,,,,,16.53,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,8.18235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
amLODIPine 2.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079045001,NDC,1,EA,9.28,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,8.18496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079045020,NDC,1,EA,9.28,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,8.18496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levETIRAcetam 750 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,16714035602,NDC,0.333333333,EA,8.41,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,8.185453,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342003110,NDC,1,EA,16.56,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,8.1972,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Osmolality; Blood,PX83930,CDM,300,RC,83930,CPT,,,,,,,,9,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,8.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.7386,8.82
SUTURE ETHILON SIZE 0 96INCH TP1,27200000,CDM,272,RC,,,,12140-MAIN,LOCAL,,,,,9,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,8.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE PROLENE 3-0 BLUE SH NEEDLE MONOFILAMENT 30INCH,27200000,CDM,272,RC,,,,12840-MAIN,LOCAL,,,,,9,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,8.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
isosorbide mononitrate CR 30 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084059111,NDC,1,EA,9.01,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,8.20811,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide mononitrate CR 30 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084059101,NDC,1,EA,9.01,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,8.20811,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Lab Basic Metabolic Panel,PX80048,CDM,300,RC,80048,CPT,,,,,,,,236,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,8.21,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.21,8.46
Lab Basic Metabolic Panel,PX80048,CDM,300,RC,80048,CPT,,,,,,,,236,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,8.21,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.21,8.46
Lab Basic Metabolic Panel,PX80048,CDM,300,RC,80048,CPT,,,,,,,,236,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,8.21,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.21,8.46
acetaminophen 160 MG/5ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,68094023159,NDC,15,ML,19.14,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,8.21106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Urine Pregnancy Test,PX81025,CDM,300,RC,81025,CPT,,,,,,,,191,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,8.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.22,8.61
Urine Pregnancy Test,PX81025,CDM,300,RC,81025,CPT,,,,,,,,191,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,8.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.22,8.61
topiramate 100 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,69097012403,NDC,0.25,EA,9.24,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,8.2236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
finasteride 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862014930,NDC,1,EA,16.79,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,8.2271,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
finasteride 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862014930,NDC,1,EA,16.79,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,8.2271,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
finasteride 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862014930,NDC,1,EA,16.79,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,8.2271,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 10 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,60687024511,NDC,0.5,EA,19.18,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,8.22822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Lab Culture Bacteria,PX87070,CDM,300,RC,87070,CPT,,,,,,,,286,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,8.23,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.23,8.62
Lab Culture Bacteria,PX87070,CDM,300,RC,87070,CPT,,,,,,,,286,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,8.23,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.23,8.62
meloxicam 7.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268052511,NDC,1,EA,16.64,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,8.2368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079096601,NDC,1,EA,9.34,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,8.23788,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Decalcify Tc,PX8831101,CDM,310,RC,88311,CPT,TC,,,,,,,107,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,8.24,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.24,13.824
Decalcify Tc,PX8831101,CDM,310,RC,88311,CPT,TC,,,,,,,107,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,8.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.24,13.824
Decalcify Tc,PX8831101,CDM,310,RC,88311,CPT,TC,,,,,,,107,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,8.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.24,13.824
RESERVOIR SILICONE BULB 100CC,27200000,CDM,272,RC,,,,4400-MAIN,LOCAL,,,,,16.65,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,8.24175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
levETIRAcetam 750 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,16714035602,NDC,0.333333333,EA,8.41,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,8.2418,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,50111099001,NDC,1,EA,9.05,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,8.24455,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol LA 80 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,228277911,NDC,0.75,EA,9.7,,First Health,Commercial,both,85,,999999999,percent of total billed charges,8.245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol LA 80 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,527411737,NDC,0.75,EA,9.7,,First Health,Commercial,both,85,,999999999,percent of total billed charges,8.245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buPROPion XL 150 MG Tablet Extended Release 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,904708404,NDC,1,EA,8.48,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,8.253584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
felodipine 5 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462023401,NDC,1,EA,8.48,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,8.253584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 2.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079045001,NDC,1,EA,9.28,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,8.2592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079045020,NDC,1,EA,9.28,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,8.2592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006111,NDC,0.5,EA,56.98,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,8.26,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.26,10.03704
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006158,NDC,0.5,EA,56.98,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,8.26,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.26,10.03704
povidone-iodine 10 % Ointment 28.35 g Tube,63700001,CDM,250,RC,,,,,,904110231,NDC,28.35,GR,19.9,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,8.26646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141031,NDC,0.5,ML,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,8.27,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.27,9.41
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141035,NDC,2,ML,56.37,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,8.27,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.27,9.41
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305972,NDC,2,ML,61.19,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,8.27,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.27,9.41
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305995,NDC,2,ML,61.19,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,8.27,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.27,9.41
"Thyroxin, Free (Free T4)",PX84439,CDM,300,RC,84439,CPT,,,,,,,,173,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,8.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.27,169.54
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,185012201,NDC,1,EA,17.23,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,8.2704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,185012201,NDC,1,EA,17.23,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,8.2704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739038710,NDC,0.5,EA,9.08,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,8.27188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 25 MG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,904699104,NDC,1,EA,8.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,8.27305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714065102,NDC,0.4,EA,9.74,,First Health,Commercial,both,85,,999999999,percent of total billed charges,8.279,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
memantine 10 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,72603011901,NDC,0.5,EA,16.37,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,8.28322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pravastatin 10 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,60505016809,NDC,1,EA,17.26,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,8.2848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pravastatin 10 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,60505016809,NDC,1,EA,17.26,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,8.2848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Cardiac Rehab II Eval,PX93798.05,CDM,943,RC,93798,CPT,,,,,,,,364,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,8.29,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.29,44.79
Cardiac Rehab II Eval,PX93798.05,CDM,943,RC,93798,CPT,,,,,,,,364,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,8.29,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.29,44.79
Cardiac Rehab II W/ Monitor,PX93798.02,CDM,943,RC,93798,CPT,,,,,,,,338,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,8.29,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.29,44.79
Cardiac Rehab II W/ Monitor,PX93798.02,CDM,943,RC,93798,CPT,,,,,,,,338,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,8.29,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.29,44.79
Cardiac Rehab II Eval,PX93798.05,CDM,943,RC,93798,CPT,,,,,,,,364,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,8.29,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.29,44.79
Cardiac Rehab II W/ Monitor,PX93798.02,CDM,943,RC,93798,CPT,,,,,,,,338,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,8.29,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.29,44.79
cefaDROXil 500 MG capsule 50 Each Bottle,63700001,CDM,250,RC,,,,,,16714038801,NDC,1,EA,19.98,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,8.299692,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Bacterium Nos, Antibody - Ref",PX8660990,CDM,300,RC,86609,CPT,90,,,,,,,20,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,8.308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
DRESSING QWICK NONADHESIVE 4.25X4 SUPERABSORBENT MSC5844,120.531,CDM,272,RC,A6197,HCPCS,,12301-MAIN,LOCAL,,,,,20,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,8.308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
Glucose Blood Test,PX82962,CDM,300,RC,82962,CPT,,,,,,,,20,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,8.308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.01,19.6
Phenobarbital Assay - Ref,PX8018490,CDM,300,RC,80184,CPT,90,,,,,,,20,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,8.308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
Primidone Assay - Ref,PX8018890,CDM,300,RC,80188,CPT,90,,,,,,,20,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,8.308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER  STRAIGHT TAPER TIP 20FR PVC,120.528,CDM,272,RC,,,,12247-MAIN,LOCAL,,,,,20,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,8.308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER  STRAIGHT TAPER TIP 24FR PVC,120.528,CDM,272,RC,,,,12248-MAIN,LOCAL,,,,,20,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,8.308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 8FR PVC,120.528,CDM,272,RC,,,,12253-MAIN,LOCAL,,,,,20,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,8.308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 10FR PVC,120.528,CDM,272,RC,,,,12254-MAIN,LOCAL,,,,,20,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,8.308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 12FR PVC,120.528,CDM,272,RC,,,,12255-MAIN,LOCAL,,,,,20,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,8.308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 16FR PVC,120.528,CDM,272,RC,,,,12256-MAIN,LOCAL,,,,,20,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,8.308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 28FR PVC,120.528,CDM,272,RC,,,,12249-MAIN,LOCAL,,,,,20,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,8.308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 32FR PVC,120.528,CDM,272,RC,,,,12250-MAIN,LOCAL,,,,,20,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,8.308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 36FR PVC,120.528,CDM,272,RC,,,,12251-MAIN,LOCAL,,,,,20,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,8.308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
tolterodine 2 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,59762080002,NDC,0.5,EA,9.12,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,8.30832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buPROPion XL 150 MG Tablet Extended Release 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,904708404,NDC,1,EA,8.48,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,8.3104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
felodipine 5 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462023401,NDC,1,EA,8.48,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,8.3104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
finasteride 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862014930,NDC,1,EA,16.79,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,8.31105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079096601,NDC,1,EA,9.34,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,8.3126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zolpidem 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018911,NDC,1,EA,9.43,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,8.31726,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zolpidem 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018901,NDC,1,EA,9.43,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,8.31726,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904636961,NDC,1,EA,8.55,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,8.321715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Basic Metabolic Panel Ca Ion,PX80047,CDM,300,RC,80047,CPT,,,,,,,,17,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,14.41,percent of total billed charges,8.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.0618,16.66
Basic Metabolic Panel Ca Ion,PX80047,CDM,300,RC,80047,CPT,,,,,,,,17,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,8.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.0618,16.66
Basic Metabolic Panel Ca Ion,PX80047,CDM,300,RC,80047,CPT,,,,,,,,17,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,8.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.0618,16.66
pregabalin 25 MG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,904699104,NDC,1,EA,8.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,8.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
STOCKINETTE IMPERVIOUS 12X48 NON22535,27200000,CDM,272,RC,A6457,HCPCS,,10918-MAIN,LOCAL,,,,,16.47,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,8.33382,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
meloxicam 7.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,29300012401,NDC,1,EA,17.02,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,8.3398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
meloxicam 7.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,29300012401,NDC,1,EA,17.02,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,8.3398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
meloxicam 7.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,29300012401,NDC,1,EA,17.02,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,8.3398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Fungal Culture, Other Source - Ref",PX8710290,CDM,300,RC,87102,CPT,90,,,,,,,157,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,8.3434,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.16,8.41
Fungus Isolation Culture,PX87102,CDM,300,RC,87102,CPT,,,,,,,,167,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,8.3434,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.16,8.41
Lab Basic Metabolic Panel,PX80048,CDM,300,RC,80048,CPT,,,,,,,,236,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,8.3434,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.21,8.46
Lab Culture Bacteria,PX87070,CDM,300,RC,87070,CPT,,,,,,,,286,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,8.3434,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.23,8.62
Microbe Susceptible Mic,PX87186,CDM,300,RC,87186,CPT,,,,,,,,124,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,8.3434,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.3434,8.65
Nocardia Susceptibility - Ref,PX8718690,CDM,300,RC,87186,CPT,90,,,,,,,124,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,8.3434,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.3434,8.65
Urine Pregnancy Test,PX81025,CDM,300,RC,81025,CPT,,,,,,,,191,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,8.3434,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.22,8.61
venlafaxine 37.5 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084069811,NDC,1,EA,20.09,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,8.345386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 37.5 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084069801,NDC,1,EA,20.09,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,8.345386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Place Needle in Vein,PX36000P,CDM,983,RC,36000,CPT,,,,,,,,1034,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,8.3486,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.45,1013.32
"Venipunc Need Phys Skill,Dx or Rx",PX36410,CDM,983,RC,36410,CPT,,,,,,,,132,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,8.3486,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.45,129.36
"Venipunc Need Phys Skill,Dx or Rx",PX36410F,CDM,510,RC,36410,CPT,,,,,,,,34,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,8.3486,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.45,36.67
"Venipunc Need Phys Skill,Dx or Rx",PX36410P,CDM,983,RC,36410,CPT,,,,,,,,129,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,8.3486,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.45,126.42
famciclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,93811956,NDC,0.25,EA,17.04,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,8.3496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famciclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,93811956,NDC,0.25,EA,17.04,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,8.3496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famciclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,93811956,NDC,0.25,EA,17.04,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,8.3496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Urine Pregnancy Test,PX81025,CDM,300,RC,81025,CPT,,,,,,,,191,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,8.35,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.22,8.61
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68382019616,NDC,1,EA,17.4,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,8.352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68382019616,NDC,1,EA,17.4,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,8.352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
riFAMpin 150 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,527139330,NDC,1,EA,17.41,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,8.3568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
riFAMpin 150 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,527139330,NDC,1,EA,17.41,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,8.3568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
riFAMpin 150 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,68180065806,NDC,1,EA,17.41,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,8.3568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
riFAMpin 150 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,68180065806,NDC,1,EA,17.41,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,8.3568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hyaluronate 48 MG/6ML solution prefilled syringe 6 mL Syringe,J7325.01,CDM,636,RC,J7325,HCPCS,,,,58468009003,NDC,6,ML,5274.4,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,8.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.36,5168.912
Lab Culture Bacteria,PX87070,CDM,300,RC,87070,CPT,,,,,,,,286,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,8.36,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.23,8.62
balsalazide 750 MG capsule 280 Each Bottle,63700001,CDM,250,RC,,,,,,54007928,NDC,1,EA,8.59,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,8.360647,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
balsalazide 750 MG capsule 280 Each Bottle,63700001,CDM,250,RC,,,,,,60505257507,NDC,1,EA,8.59,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,8.360647,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862007601,NDC,0.4,EA,9.84,,First Health,Commercial,both,85,,999999999,percent of total billed charges,8.364,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LEGGING PAIR 31X48 STERILE,27200000,CDM,272,RC,,,,10916-MAIN,LOCAL,,,,,16.53,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,8.36418,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
amLODIPine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904636961,NDC,1,EA,8.55,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,8.379,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342003110,NDC,1,EA,16.56,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,8.37936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxazosin 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079095701,NDC,1,EA,20.19,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,8.386926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terazosin 1 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59746038306,NDC,1,EA,8.62,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,8.389846,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Microbe Susceptible Mic,PX87186,CDM,300,RC,87186,CPT,,,,,,,,124,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,8.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.3434,8.65
Microbe Susceptible Mic,PX87186,CDM,300,RC,87186,CPT,,,,,,,,124,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,8.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.3434,8.65
Microbe Susceptible Mic,PX87186,CDM,300,RC,87186,CPT,,,,,,,,124,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,8.39,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.3434,8.65
Nocardia Susceptibility - Ref,PX8718690,CDM,300,RC,87186,CPT,90,,,,,,,124,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,8.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.3434,8.65
Nocardia Susceptibility - Ref,PX8718690,CDM,300,RC,87186,CPT,90,,,,,,,124,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,8.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.3434,8.65
Nocardia Susceptibility - Ref,PX8718690,CDM,300,RC,87186,CPT,90,,,,,,,124,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,8.39,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.3434,8.65
zolpidem 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018911,NDC,1,EA,9.43,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,8.3927,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zolpidem 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018901,NDC,1,EA,9.43,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,8.3927,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine ER 15 MG Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,68084040311,NDC,1,EA,9.88,,First Health,Commercial,both,85,,999999999,percent of total billed charges,8.398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxazosin 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079095720,NDC,1,EA,20.22,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,8.399388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Fungal Culture, Other Source - Ref",PX8710290,CDM,300,RC,87102,CPT,90,,,,,,,157,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,8.41,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.16,8.41
Fungus Isolation Culture,PX87102,CDM,300,RC,87102,CPT,,,,,,,,167,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,8.41,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.16,8.41
"MAYO STAND COVERS 24X53""",27200000,CDM,272,RC,,,,644-MAIN,LOCAL,,,,,9.54,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,8.41428,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Basic Metabolic Panel Ca Ion,PX80047,CDM,300,RC,80047,CPT,,,,,,,,17,,Humana Choice Care,All Medicare plans,outpatient,49.5,,16.66,percent of total billed charges,8.415,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.0618,16.66
morphine ER 15 MG Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,68084040301,NDC,1,EA,9.9,,First Health,Commercial,both,85,,999999999,percent of total billed charges,8.415,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 100 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,69097012403,NDC,0.25,EA,9.24,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,8.41764,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
balsalazide 750 MG capsule 280 Each Bottle,63700001,CDM,250,RC,,,,,,54007928,NDC,1,EA,8.59,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,8.4182,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
balsalazide 750 MG capsule 280 Each Bottle,63700001,CDM,250,RC,,,,,,60505257507,NDC,1,EA,8.59,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,8.4182,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
meloxicam 7.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268052511,NDC,1,EA,16.64,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,8.41984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Renal Function Panel,PX80069,CDM,300,RC,80069,CPT,,,,,,,,264,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,8.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.42,8.68
Renal Function Panel,PX80069,CDM,300,RC,80069,CPT,,,,,,,,264,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,8.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.42,8.68
Renal Function Panel,PX80069,CDM,300,RC,80069,CPT,,,,,,,,264,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,8.42,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.42,8.68
meloxicam 7.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,29300012401,NDC,1,EA,17.02,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,8.4249,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
RESERVOIR SILICONE BULB 100CC,27200000,CDM,272,RC,,,,4400-MAIN,LOCAL,,,,,16.65,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,8.4249,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
APPLICATOR CHLORAPREP 26ML WITH ORANGE 930815,27200000,CDM,272,RC,A4248,HCPCS,,10031-MAIN,LOCAL,,,,,19.65,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,8.42985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
famciclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,93811956,NDC,0.25,EA,17.04,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,8.4348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 2 % Ointment 1 g Packet,63700001,CDM,250,RC,,,,,,281032608,NDC,1,GR,17.58,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,8.4384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 2 % Ointment 1 g Packet,63700001,CDM,250,RC,,,,,,281032608,NDC,1,GR,17.58,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,8.4384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,185012201,NDC,1,EA,17.23,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,8.4427,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,185012201,NDC,1,EA,17.23,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,8.4427,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,185012201,NDC,1,EA,17.23,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,8.4427,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin-clavulanate 500-125 MG Tablet 20 Each Bottle,63700001,CDM,250,RC,,,,,,16714047701,NDC,1,EA,20.33,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,8.445082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terazosin 1 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59746038306,NDC,1,EA,8.62,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,8.4476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
celecoxib 200 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904650361,NDC,0.5,EA,20.35,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,8.45339,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 2.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079045001,NDC,1,EA,9.28,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,8.45408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079045020,NDC,1,EA,9.28,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,8.45408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pravastatin 10 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,60505016809,NDC,1,EA,17.26,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,8.4574,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pravastatin 10 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,60505016809,NDC,1,EA,17.26,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,8.4574,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pravastatin 10 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,60505016809,NDC,1,EA,17.26,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,8.4574,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Lab Basic Metabolic Panel,PX80048,CDM,300,RC,80048,CPT,,,,,,,,236,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,8.46,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.21,8.46
nitroglycerin 0.1 MG/HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,378910216,NDC,1,EA,9.98,,First Health,Commercial,both,85,,999999999,percent of total billed charges,8.483,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.1 MG/HR Patch 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,378910293,NDC,1,EA,9.98,,First Health,Commercial,both,85,,999999999,percent of total billed charges,8.483,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"MAYO STAND COVERS 24X53""",27200000,CDM,272,RC,,,,644-MAIN,LOCAL,,,,,9.54,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,8.4906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
doxycycline monohydrate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084074333,NDC,1,EA,9.99,,First Health,Commercial,both,85,,999999999,percent of total billed charges,8.4915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
finasteride 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862014930,NDC,1,EA,16.79,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,8.49574,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Antinuclear Antibodies,PX86038,CDM,300,RC,86038,CPT,,,,,,,,10,,First Health,Commercial,both,85,,999999999,percent of total billed charges,8.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,11.09
Calcium - Ref,PX8231090,CDM,300,RC,82310,CPT,90,,,,,,,10,,First Health,Commercial,both,85,,999999999,percent of total billed charges,8.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,9.8
DRAPE SURGICAL 23X17INCH INCISE 1050,27200000,CDM,272,RC,,,,12873-MAIN,LOCAL,,,,,10,,First Health,Commercial,both,85,,999999999,percent of total billed charges,8.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
KERRAMAX CARE SUPERABSORBENT DRESSING 5X6,120.548,CDM,272,RC,A6197,HCPCS,,12362-MAIN,LOCAL,,,,,10,,First Health,Commercial,both,85,,999999999,percent of total billed charges,8.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,9.8
NEEDLE HYPODERMIC 22GA 1-1/2IN STERILE 305156,27200000,CDM,272,RC,A4215,HCPCS,,8887-MAIN,LOCAL,,,,,10,,First Health,Commercial,both,85,,999999999,percent of total billed charges,8.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Needle Insertion W/O Injection 1 or 2 Muscles,PX20560,CDM,420,RC,20560,CPT,,,,,,,,10,,First Health,Commercial,both,85,,999999999,percent of total billed charges,8.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,26.01
Needle Insertion W/O Injection 3 or More Muscles,PX20561,CDM,420,RC,20561,CPT,,,,,,,,10,,First Health,Commercial,both,85,,999999999,percent of total billed charges,8.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,26.01
PAD GROUNDING 9 FT ADULT REM E7507,27200000,CDM,272,RC,,,,504-MAIN,LOCAL,,,,,10,,First Health,Commercial,both,85,,999999999,percent of total billed charges,8.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
bacitracin zinc 500 UNIT/GM Ointment 28.4 g Tube,25000000,CDM,250,RC,,,,,,49348015472,NDC,28.4,GR,20.47,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,8.503238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
famotidine 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079096601,NDC,1,EA,9.34,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,8.50874,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68382019616,NDC,1,EA,17.4,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,8.526,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68382019616,NDC,1,EA,17.4,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,8.526,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68382019616,NDC,1,EA,17.4,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,8.526,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,185012201,NDC,1,EA,17.23,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,8.52885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay Iga/Igd/Igg/Igm Each,PX82784,CDM,300,RC,82784,CPT,,,,,,,,315,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,8.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.53,308.7
"Gammaglobulin; Iga, Dg,M - Ref",PX8278490,CDM,300,RC,82784,CPT,90,,,,,,,90,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,8.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.53,88.2
riFAMpin 150 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,527139330,NDC,1,EA,17.41,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,8.5309,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
riFAMpin 150 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,527139330,NDC,1,EA,17.41,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,8.5309,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
riFAMpin 150 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,527139330,NDC,1,EA,17.41,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,8.5309,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
riFAMpin 150 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,68180065806,NDC,1,EA,17.41,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,8.5309,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
riFAMpin 150 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,68180065806,NDC,1,EA,17.41,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,8.5309,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
riFAMpin 150 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,68180065806,NDC,1,EA,17.41,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,8.5309,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pravastatin 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079045801,NDC,0.5,EA,8.77,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,8.535841,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
povidone-iodine 10 % Ointment 28.35 g Tube,63700001,CDM,250,RC,,,,,,904110231,NDC,28.35,GR,19.9,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,8.5371,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618201,NDC,2,ML,120.53,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,8.54,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.54,9.71
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618210,NDC,2,ML,120.53,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,8.54,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.54,9.71
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,17478053802,NDC,2,ML,125.91,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,8.54,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.54,9.71
morphine ER 15 MG Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,406831523,NDC,1,EA,10.05,,First Health,Commercial,both,85,,999999999,percent of total billed charges,8.5425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine ER 15 MG Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,406831562,NDC,1,EA,10.05,,First Health,Commercial,both,85,,999999999,percent of total billed charges,8.5425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pravastatin 10 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,60505016809,NDC,1,EA,17.26,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,8.5437,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol LA 80 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,228277911,NDC,0.75,EA,9.7,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,8.5554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol LA 80 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,527411737,NDC,0.75,EA,9.7,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,8.5554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Catheterize for Urine Spec,PXP9612,CDM,300,RC,P9612,HCPCS,,,,,,,,161,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,8.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.57,8.83
Catheterize for Urine Spec,PXP9612,CDM,300,RC,P9612,HCPCS,,,,,,,,161,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,8.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.57,8.83
Catheterize for Urine Spec,PXP9612,CDM,300,RC,P9612,HCPCS,,,,,,,,161,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,8.57,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.57,8.83
"Venipuncture, Lab",PX3641502,CDM,300,RC,36415,CPT,,,,,,,,61,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,8.57,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.77,8.83
cefaDROXil 500 MG capsule 50 Each Bottle,63700001,CDM,250,RC,,,,,,16714038801,NDC,1,EA,19.98,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,8.57142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Bacterium Nos, Antibody - Ref",PX8660990,CDM,300,RC,86609,CPT,90,,,,,,,20,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,8.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
DRESSING QWICK NONADHESIVE 4.25X4 SUPERABSORBENT MSC5844,120.531,CDM,272,RC,A6197,HCPCS,,12301-MAIN,LOCAL,,,,,20,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,8.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
Glucose Blood Test,PX82962,CDM,300,RC,82962,CPT,,,,,,,,20,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,8.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.01,19.6
Phenobarbital Assay - Ref,PX8018490,CDM,300,RC,80184,CPT,90,,,,,,,20,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,8.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
Primidone Assay - Ref,PX8018890,CDM,300,RC,80188,CPT,90,,,,,,,20,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,8.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER  STRAIGHT TAPER TIP 20FR PVC,120.528,CDM,272,RC,,,,12247-MAIN,LOCAL,,,,,20,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,8.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER  STRAIGHT TAPER TIP 24FR PVC,120.528,CDM,272,RC,,,,12248-MAIN,LOCAL,,,,,20,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,8.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 8FR PVC,120.528,CDM,272,RC,,,,12253-MAIN,LOCAL,,,,,20,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,8.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 10FR PVC,120.528,CDM,272,RC,,,,12254-MAIN,LOCAL,,,,,20,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,8.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 12FR PVC,120.528,CDM,272,RC,,,,12255-MAIN,LOCAL,,,,,20,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,8.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 16FR PVC,120.528,CDM,272,RC,,,,12256-MAIN,LOCAL,,,,,20,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,8.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 28FR PVC,120.528,CDM,272,RC,,,,12249-MAIN,LOCAL,,,,,20,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,8.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 32FR PVC,120.528,CDM,272,RC,,,,12250-MAIN,LOCAL,,,,,20,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,8.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 36FR PVC,120.528,CDM,272,RC,,,,12251-MAIN,LOCAL,,,,,20,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,8.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
ciprofloxacin 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714065102,NDC,0.4,EA,9.74,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,8.59068,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zolpidem 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018911,NDC,1,EA,9.43,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,8.59073,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zolpidem 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018901,NDC,1,EA,9.43,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,8.59073,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pravastatin 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079045801,NDC,0.5,EA,8.77,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,8.5946,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Basic Metabolic Panel Ca Ion,PX80047,CDM,300,RC,80047,CPT,,,,,,,,17,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,8.602,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.0618,16.66
Urine Pregnancy Test,PX81025,CDM,300,RC,81025,CPT,,,,,,,,191,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,8.61,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.22,8.61
meloxicam 7.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,29300012401,NDC,1,EA,17.02,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,8.61212,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68382019616,NDC,1,EA,17.4,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,8.613,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 2 % Ointment 1 g Packet,63700001,CDM,250,RC,,,,,,281032608,NDC,1,GR,17.58,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,8.6142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 2 % Ointment 1 g Packet,63700001,CDM,250,RC,,,,,,281032608,NDC,1,GR,17.58,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,8.6142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 2 % Ointment 1 g Packet,63700001,CDM,250,RC,,,,,,281032608,NDC,1,GR,17.58,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,8.6142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68462033090,NDC,1,EA,17.95,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,8.616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68462033090,NDC,1,EA,17.95,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,8.616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
riFAMpin 150 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,527139330,NDC,1,EA,17.41,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,8.61795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
riFAMpin 150 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,68180065806,NDC,1,EA,17.41,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,8.61795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 37.5 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084069811,NDC,1,EA,20.09,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,8.61861,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 37.5 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084069801,NDC,1,EA,20.09,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,8.61861,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Lab Culture Bacteria,PX87070,CDM,300,RC,87070,CPT,,,,,,,,286,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,8.62,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.23,8.62
famciclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,93811956,NDC,0.25,EA,17.04,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,8.62224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,42806040021,NDC,1,EA,8.86,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,8.623438,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
propranolol LA 80 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,228277911,NDC,0.75,EA,9.7,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,8.633,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol LA 80 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,527411737,NDC,0.75,EA,9.7,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,8.633,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 100 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,74662411,NDC,1,EA,10.16,,First Health,Commercial,both,85,,999999999,percent of total billed charges,8.636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,70677003201,NDC,1,EA,10.16,,First Health,Commercial,both,85,,999999999,percent of total billed charges,8.636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"BINDER ABDOMINAL 12"" HIGH 46 TO 62 INCH L/XL 4 PANEL ORT21300LXL",120.238,CDM,271,RC,A4467,HCPCS,,11935-MAIN,LOCAL,,,,,18,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,8.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
"BINDER ABDOMINAL 12"" HIGH 46 TO 62 INCH L/XL 4 PANEL ORT21300LXL",120.238,CDM,271,RC,A4467,HCPCS,,11935-MAIN,LOCAL,,,,,18,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,8.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BURETROL ADD ON SET 150ML,120.38,CDM,272,RC,A4222,HCPCS,,11118-MAIN,LOCAL,,,,,18,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,8.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
BURETROL ADD ON SET 150ML,120.38,CDM,272,RC,A4222,HCPCS,,11118-MAIN,LOCAL,,,,,18,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,8.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
TRAY TRACH CLEAN & CARE DYND40589,120.212,CDM,271,RC,,,,1173-MAIN,LOCAL,,,,,18,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,8.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,17.64
TRAY TRACH CLEAN & CARE DYND40589,120.212,CDM,271,RC,,,,1173-MAIN,LOCAL,,,,,18,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,8.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,17.64
TRAY TRACHEOTOMY CARE PEDS DYND40650H,120.212,CDM,272,RC,,,,11025-MAIN,LOCAL,,,,,18,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,8.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,17.64
TRAY TRACHEOTOMY CARE PEDS DYND40650H,120.212,CDM,272,RC,,,,11025-MAIN,LOCAL,,,,,18,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,8.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,17.64
Electric Stimulation Therapy,PX97014,CDM,420,RC,97014,CPT,,,,,,,,135,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,8.65,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.65,19.92
Microbe Susceptible Mic,PX87186,CDM,300,RC,87186,CPT,,,,,,,,124,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,8.65,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.3434,8.65
Nocardia Susceptibility - Ref,PX8718690,CDM,300,RC,87186,CPT,90,,,,,,,124,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,8.65,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.3434,8.65
oxyBUTYnin ER 5 MG Tablet Extended Release 24 Hour 50 Each Box,63700001,CDM,250,RC,,,,,,904657006,NDC,1,EA,18.04,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,8.6592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyBUTYnin ER 5 MG Tablet Extended Release 24 Hour 50 Each Box,63700001,CDM,250,RC,,,,,,904657006,NDC,1,EA,18.04,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,8.6592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DOBUTamine 1000 mcg/mL in dextrose 5% 250 mL premix 1000 mcg/ml Solution 250 mL Flex Cont,J1250.01,CDM,636,RC,J1250,HCPCS,,,,338107302,NDC,250,ML,146.73,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,8.66,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.66,9.85
doxazosin 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079095701,NDC,1,EA,20.19,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,8.66151,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Decalcify Tc,PX8831101,CDM,310,RC,88311,CPT,TC,,,,,,,107,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,8.6643,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.24,13.824
Renal Function Panel,PX80069,CDM,300,RC,80069,CPT,,,,,,,,264,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,8.6643,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.42,8.68
"Venipuncture, Lab",PX3641502,CDM,300,RC,36415,CPT,,,,,,,,61,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,8.6643,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.77,8.83
ciprofloxacin 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714065102,NDC,0.4,EA,9.74,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,8.6686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxazosin 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079095720,NDC,1,EA,20.22,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,8.67438,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.2 MG/HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,378910416,NDC,1,EA,10.21,,First Health,Commercial,both,85,,999999999,percent of total billed charges,8.6785,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.2 MG/HR Patch 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,378910493,NDC,1,EA,10.21,,First Health,Commercial,both,85,,999999999,percent of total billed charges,8.6785,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862007601,NDC,0.4,EA,9.84,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,8.67888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Renal Function Panel,PX80069,CDM,300,RC,80069,CPT,,,,,,,,264,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,8.68,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.42,8.68
Wound Culture Anaerobic,PX87075,CDM,300,RC,87075,CPT,,,,,,,,270,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,8.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.68,264.6
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,42806040021,NDC,1,EA,8.86,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,8.6828,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.840222,8.6828
Catheterize for Urine Spec,PXP9612,CDM,300,RC,P9612,HCPCS,,,,,,,,161,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,8.6859,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.57,8.83
risperiDONE 0.25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084027011,NDC,1,EA,20.91,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,8.686014,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084027001,NDC,1,EA,20.91,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,8.686014,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"MAYO STAND COVERS 24X53""",27200000,CDM,272,RC,,,,644-MAIN,LOCAL,,,,,9.54,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,8.69094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
nitroglycerin 2 % Ointment 1 g Packet,63700001,CDM,250,RC,,,,,,281032608,NDC,1,GR,17.58,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,8.7021,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine 50 MG/ML Solution 1 mL Vial,J3410.01,CDM,636,RC,J3410,HCPCS,,,,517560125,NDC,0.5,ML,83.68,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,8.71,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.71,13.86
Skilled srvc of an RN in training and/or education of pt or fam ea 15 min,PXG0495,CDM,551,RC,G0495,HCPCS,,,,,,,,75,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,8.71,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.71,8.71
morphine ER 15 MG Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,68084040311,NDC,1,EA,9.88,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,8.71416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hyaluronate 48 MG/6ML solution prefilled syringe 6 mL Syringe,J7325.01,CDM,636,RC,J7325,HCPCS,,,,58468009003,NDC,6,ML,5274.4,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,8.71807,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.71807,9.12
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,185012201,NDC,1,EA,17.23,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,8.71838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Debridement of Nail(S), 1-5",PX11720F,CDM,510,RC,11720,CPT,,,,,,,,89,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,8.72,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.72,68.49
"Debridement of Nail(S), 1-5",PX11720F,CDM,510,RC,11720,CPT,,,,,,,,89,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,8.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.72,68.49
"Debridement of Nail(S), 1-5",PX11720F,CDM,510,RC,11720,CPT,,,,,,,,89,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,8.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.72,68.49
amoxicillin-clavulanate 500-125 MG Tablet 20 Each Bottle,63700001,CDM,250,RC,,,,,,16714047701,NDC,1,EA,20.33,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,8.72157,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Anesthesia Level 4,PX37000018,CDM,370,RC,,,,,,,,,,21,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,8.7234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.7234,20.58
ANOSCOPE LIGHTED ANOSCOPE,120.52,CDM,272,RC,,,,10235-MAIN,LOCAL,,,,,21,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,8.7234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.7234,20.58
"Hepatitis B Core Antibody, Total",PX86704,CDM,300,RC,86704,CPT,,,,,,,,21,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,8.7234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.7234,20.58
"Spectrophotometry, Nos",PX84311,CDM,300,RC,84311,CPT,,,,,,,,21,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,8.7234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.43,20.58
celecoxib 200 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904650361,NDC,0.5,EA,20.35,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,8.73015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 30 Each Box,63700001,CDM,250,RC,,,,,,904693176,NDC,1,EA,8.97,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,8.730501,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68462033190,NDC,0.5,EA,8.97,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,8.730501,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine ER 15 MG Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,68084040301,NDC,1,EA,9.9,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,8.7318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pravastatin 10 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,60505016809,NDC,1,EA,17.26,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,8.73356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nadolol 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,76385013301,NDC,1,EA,18.2,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,8.736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nadolol 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,76385013301,NDC,1,EA,18.2,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,8.736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Thyroxin, Free (Free T4)",PX84439,CDM,300,RC,84439,CPT,,,,,,,,173,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,8.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.75,9.02
"Thyroxin, Free (Free T4)",PX84439,CDM,300,RC,84439,CPT,,,,,,,,173,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,8.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.75,9.02
"Thyroxin, Free (Free T4)",PX84439,CDM,300,RC,84439,CPT,,,,,,,,173,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,8.75,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.75,9.02
ciprofloxacin 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862007601,NDC,0.4,EA,9.84,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,8.7576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Osmolality; Blood,PX83930,CDM,300,RC,83930,CPT,,,,,,,,9,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,8.7597,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.7386,8.82
SUTURE ETHILON SIZE 0 96INCH TP1,27200000,CDM,272,RC,,,,12140-MAIN,LOCAL,,,,,9,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,8.7597,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE PROLENE 3-0 BLUE SH NEEDLE MONOFILAMENT 30INCH,27200000,CDM,272,RC,,,,12840-MAIN,LOCAL,,,,,9,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,8.7597,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
risperiDONE 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635861,NDC,1,EA,21.11,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,8.769094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide mononitrate CR 30 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084059111,NDC,1,EA,9.01,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,8.769433,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide mononitrate CR 30 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084059101,NDC,1,EA,9.01,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,8.769433,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Russell Viper Venom - Ref,PX8561390,CDM,300,RC,85613,CPT,90,,,,,,,93,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,8.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.78,91.14
bacitracin zinc 500 UNIT/GM Ointment 28.4 g Tube,25000000,CDM,250,RC,,,,,,49348015472,NDC,28.4,GR,20.47,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,8.78163,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
polyethylene glycol 3350 17 g Packet 30 Each Box,63700001,CDM,250,RC,,,,,,904693176,NDC,1,EA,8.97,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,8.7906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68462033190,NDC,0.5,EA,8.97,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,8.7906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine ER 15 MG Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,68084040311,NDC,1,EA,9.88,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,8.7932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68462033090,NDC,1,EA,17.95,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,8.7955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68462033090,NDC,1,EA,17.95,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,8.7955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68462033090,NDC,1,EA,17.95,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,8.7955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.1 MG/HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,378910216,NDC,1,EA,9.98,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,8.80236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.1 MG/HR Patch 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,378910293,NDC,1,EA,9.98,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,8.80236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68382019616,NDC,1,EA,17.4,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,8.8044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,50111099001,NDC,1,EA,9.05,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,8.808365,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
riFAMpin 150 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,527139330,NDC,1,EA,17.41,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,8.80946,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
riFAMpin 150 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,68180065806,NDC,1,EA,17.41,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,8.80946,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine ER 15 MG Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,68084040301,NDC,1,EA,9.9,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,8.811,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline monohydrate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084074333,NDC,1,EA,9.99,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,8.81118,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Antinuclear Antibodies,PX86038,CDM,300,RC,86038,CPT,,,,,,,,10,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,8.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,11.09
"BINDER ABDOMINAL 12"" HIGH 46 TO 62 INCH L/XL 4 PANEL ORT21300LXL",120.238,CDM,271,RC,A4467,HCPCS,,11935-MAIN,LOCAL,,,,,18,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,8.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
"BINDER ABDOMINAL 12"" HIGH 46 TO 62 INCH L/XL 4 PANEL ORT21300LXL",120.238,CDM,271,RC,A4467,HCPCS,,11935-MAIN,LOCAL,,,,,18,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,8.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
"BINDER ABDOMINAL 12"" HIGH 46 TO 62 INCH L/XL 4 PANEL ORT21300LXL",120.238,CDM,271,RC,A4467,HCPCS,,11935-MAIN,LOCAL,,,,,18,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,8.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BURETROL ADD ON SET 150ML,120.38,CDM,272,RC,A4222,HCPCS,,11118-MAIN,LOCAL,,,,,18,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,8.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
BURETROL ADD ON SET 150ML,120.38,CDM,272,RC,A4222,HCPCS,,11118-MAIN,LOCAL,,,,,18,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,8.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
BURETROL ADD ON SET 150ML,120.38,CDM,272,RC,A4222,HCPCS,,11118-MAIN,LOCAL,,,,,18,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,8.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
Calcium - Ref,PX8231090,CDM,300,RC,82310,CPT,90,,,,,,,10,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,8.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,9.8
DRAPE SURGICAL 23X17INCH INCISE 1050,27200000,CDM,272,RC,,,,12873-MAIN,LOCAL,,,,,10,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,8.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
KERRAMAX CARE SUPERABSORBENT DRESSING 5X6,120.548,CDM,272,RC,A6197,HCPCS,,12362-MAIN,LOCAL,,,,,10,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,8.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,9.8
NEEDLE HYPODERMIC 22GA 1-1/2IN STERILE 305156,27200000,CDM,272,RC,A4215,HCPCS,,8887-MAIN,LOCAL,,,,,10,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,8.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Needle Insertion W/O Injection 1 or 2 Muscles,PX20560,CDM,420,RC,20560,CPT,,,,,,,,10,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,8.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,26.01
Needle Insertion W/O Injection 3 or More Muscles,PX20561,CDM,420,RC,20561,CPT,,,,,,,,10,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,8.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,26.01
Osmolality; Blood,PX83930,CDM,300,RC,83930,CPT,,,,,,,,9,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,8.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.7386,8.82
PAD GROUNDING 9 FT ADULT REM E7507,27200000,CDM,272,RC,,,,504-MAIN,LOCAL,,,,,10,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,8.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE ETHILON SIZE 0 96INCH TP1,27200000,CDM,272,RC,,,,12140-MAIN,LOCAL,,,,,9,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,8.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE PROLENE 3-0 BLUE SH NEEDLE MONOFILAMENT 30INCH,27200000,CDM,272,RC,,,,12840-MAIN,LOCAL,,,,,9,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,8.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TRAY TRACH CLEAN & CARE DYND40589,120.212,CDM,271,RC,,,,1173-MAIN,LOCAL,,,,,18,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,8.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,17.64
TRAY TRACH CLEAN & CARE DYND40589,120.212,CDM,271,RC,,,,1173-MAIN,LOCAL,,,,,18,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,8.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,17.64
TRAY TRACH CLEAN & CARE DYND40589,120.212,CDM,271,RC,,,,1173-MAIN,LOCAL,,,,,18,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,8.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,17.64
TRAY TRACHEOTOMY CARE PEDS DYND40650H,120.212,CDM,272,RC,,,,11025-MAIN,LOCAL,,,,,18,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,8.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,17.64
TRAY TRACHEOTOMY CARE PEDS DYND40650H,120.212,CDM,272,RC,,,,11025-MAIN,LOCAL,,,,,18,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,8.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,17.64
TRAY TRACHEOTOMY CARE PEDS DYND40650H,120.212,CDM,272,RC,,,,11025-MAIN,LOCAL,,,,,18,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,8.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,17.64
DRAPE SHEET 70X85 LARGE DYNJP2417,27200000,CDM,272,RC,,,,10914-MAIN,LOCAL,,,,,18.39,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,8.8272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRAPE SHEET 70X85 LARGE DYNJP2417,27200000,CDM,272,RC,,,,10914-MAIN,LOCAL,,,,,18.39,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,8.8272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
isosorbide mononitrate CR 30 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084059111,NDC,1,EA,9.01,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,8.8298,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
isosorbide mononitrate CR 30 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084059101,NDC,1,EA,9.01,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,8.8298,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Catheterize for Urine Spec,PXP9612,CDM,300,RC,P9612,HCPCS,,,,,,,,161,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,8.83,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.57,8.83
"Venipuncture, Lab",PX3641502,CDM,300,RC,36415,CPT,,,,,,,,61,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,8.83,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.77,8.83
propranolol LA 80 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,228277911,NDC,0.75,EA,9.7,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,8.8367,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol LA 80 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,527411737,NDC,0.75,EA,9.7,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,8.8367,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739038710,NDC,0.5,EA,9.08,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,8.837564,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyBUTYnin ER 5 MG Tablet Extended Release 24 Hour 50 Each Box,63700001,CDM,250,RC,,,,,,904657006,NDC,1,EA,18.04,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,8.8396,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyBUTYnin ER 5 MG Tablet Extended Release 24 Hour 50 Each Box,63700001,CDM,250,RC,,,,,,904657006,NDC,1,EA,18.04,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,8.8396,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyBUTYnin ER 5 MG Tablet Extended Release 24 Hour 50 Each Box,63700001,CDM,250,RC,,,,,,904657006,NDC,1,EA,18.04,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,8.8396,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,245014789,NDC,0.5,EA,21.33,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,8.860482,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,245014701,NDC,0.5,EA,21.33,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,8.860482,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine ER 15 MG Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,406831523,NDC,1,EA,10.05,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,8.8641,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine ER 15 MG Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,406831562,NDC,1,EA,10.05,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,8.8641,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,57237017290,NDC,1,EA,10.43,,First Health,Commercial,both,85,,999999999,percent of total billed charges,8.8655,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714031101,NDC,1,EA,10.43,,First Health,Commercial,both,85,,999999999,percent of total billed charges,8.8655,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57664039288,NDC,1,EA,10.43,,First Health,Commercial,both,85,,999999999,percent of total billed charges,8.8655,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,50111099001,NDC,1,EA,9.05,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,8.869,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hyaluronate 48 MG/6ML solution prefilled syringe 6 mL Syringe,J7325.01,CDM,636,RC,J7325,HCPCS,,,,58468009003,NDC,6,ML,5274.4,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,8.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.71807,9.12
hyaluronate 48 MG/6ML solution prefilled syringe 6 mL Syringe,J7325.01,CDM,636,RC,J7325,HCPCS,,,,58468009003,NDC,6,ML,5274.4,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,8.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.71807,9.12
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,310072010,NDC,5,ML,1977.83,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,8.87,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.43,8.87
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,781307912,NDC,5,ML,1854.23,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,8.87,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.43,8.87
ciprofloxacin 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714065102,NDC,0.4,EA,9.74,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,8.87314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tolterodine 2 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,59762080002,NDC,0.5,EA,9.12,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,8.876496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.1 MG/HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,378910216,NDC,1,EA,9.98,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,8.8822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.1 MG/HR Patch 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,378910293,NDC,1,EA,9.98,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,8.8822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68462033090,NDC,1,EA,17.95,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,8.88525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
G6pd; Quant Screen - Ref,PX8295590,CDM,300,RC,82955,CPT,90,,,,,,,50,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,8.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.89,49
doxycycline monohydrate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084074333,NDC,1,EA,9.99,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,8.8911,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 2 % Ointment 1 g Packet,63700001,CDM,250,RC,,,,,,281032608,NDC,1,GR,17.58,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,8.89548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739038710,NDC,0.5,EA,9.08,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,8.8984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Aldolase - Ref,PX8208590,CDM,300,RC,82085,CPT,90,,,,,,,89,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,8.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.9,87.22
Antinuclear Antibodies,PX86038,CDM,300,RC,86038,CPT,,,,,,,,10,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,8.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,11.09
Calcium - Ref,PX8231090,CDM,300,RC,82310,CPT,90,,,,,,,10,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,8.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,9.8
DRAPE SURGICAL 23X17INCH INCISE 1050,27200000,CDM,272,RC,,,,12873-MAIN,LOCAL,,,,,10,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,8.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Glycosylated Hemoglobin Test,PX83036,CDM,300,RC,83036,CPT,,,,,,,,110,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,8.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.9,130.9
KERRAMAX CARE SUPERABSORBENT DRESSING 5X6,120.548,CDM,272,RC,A6197,HCPCS,,12362-MAIN,LOCAL,,,,,10,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,8.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,9.8
NEEDLE HYPODERMIC 22GA 1-1/2IN STERILE 305156,27200000,CDM,272,RC,A4215,HCPCS,,8887-MAIN,LOCAL,,,,,10,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,8.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Needle Insertion W/O Injection 1 or 2 Muscles,PX20560,CDM,420,RC,20560,CPT,,,,,,,,10,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,8.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,26.01
Needle Insertion W/O Injection 3 or More Muscles,PX20561,CDM,420,RC,20561,CPT,,,,,,,,10,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,8.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,26.01
PAD GROUNDING 9 FT ADULT REM E7507,27200000,CDM,272,RC,,,,504-MAIN,LOCAL,,,,,10,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,8.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"BINDER ABDOMINAL 12"" HIGH 46 TO 62 INCH L/XL 4 PANEL ORT21300LXL",120.238,CDM,271,RC,A4467,HCPCS,,11935-MAIN,LOCAL,,,,,18,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,8.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BURETROL ADD ON SET 150ML,120.38,CDM,272,RC,A4222,HCPCS,,11118-MAIN,LOCAL,,,,,18,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,8.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
Fibrinogen,PX7426,CDM,300,RC,85384,CPT,,,,,,,,234,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,8.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.91,229.32
Fibrinogen Activity - Ref,PX8538490,CDM,300,RC,85384,CPT,90,,,,,,,245,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,8.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.91,240.1
TRAY TRACH CLEAN & CARE DYND40589,120.212,CDM,271,RC,,,,1173-MAIN,LOCAL,,,,,18,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,8.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,17.64
TRAY TRACHEOTOMY CARE PEDS DYND40650H,120.212,CDM,272,RC,,,,11025-MAIN,LOCAL,,,,,18,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,8.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,17.64
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141031,NDC,0.5,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,8.91109,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.27,9.41
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141035,NDC,2,ML,56.37,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,8.91109,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.27,9.41
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305972,NDC,2,ML,61.19,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,8.91109,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.27,9.41
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305995,NDC,2,ML,61.19,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,8.91109,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.27,9.41
QUEtiapine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54022020,NDC,1,EA,21.46,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,8.914484,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nadolol 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,76385013301,NDC,1,EA,18.2,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,8.918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nadolol 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,76385013301,NDC,1,EA,18.2,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,8.918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nadolol 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,76385013301,NDC,1,EA,18.2,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,8.918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Electric Stimulation Therapy,PX97014,CDM,420,RC,97014,CPT,,,,,,,,135,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,8.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.65,19.92
Electric Stimulation Therapy,PX97014,CDM,420,RC,97014,CPT,,,,,,,,135,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,8.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.65,19.92
oxyBUTYnin ER 5 MG Tablet Extended Release 24 Hour 50 Each Box,63700001,CDM,250,RC,,,,,,904657006,NDC,1,EA,18.04,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,8.9298,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tolterodine 2 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,59762080002,NDC,0.5,EA,9.12,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,8.9376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Injection, Subq/Im",PX96372,CDM,260,RC,96372,CPT,,,,,,,,119,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,8.94,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.94,25.01
morphine ER 15 MG Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,406831523,NDC,1,EA,10.05,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,8.9445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine ER 15 MG Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,406831562,NDC,1,EA,10.05,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,8.9445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famciclovir 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,60505324603,NDC,0.5,EA,18.65,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,8.952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famciclovir 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,60505324603,NDC,0.5,EA,18.65,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,8.952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 100 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,74662411,NDC,1,EA,10.16,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,8.96112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,70677003201,NDC,1,EA,10.16,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,8.96112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyBUTYnin ER 5 MG Tablet Extended Release 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,63739054833,NDC,1,EA,18.67,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,8.9616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyBUTYnin ER 5 MG Tablet Extended Release 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,63739054833,NDC,1,EA,18.67,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,8.9616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862007601,NDC,0.4,EA,9.84,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,8.96424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003001,NDC,0.5,EA,21.59,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,8.968486,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084027011,NDC,1,EA,20.91,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,8.97039,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084027001,NDC,1,EA,20.91,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,8.97039,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618201,NDC,2,ML,120.53,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,8.97543,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.54,9.71
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618210,NDC,2,ML,120.53,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,8.97543,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.54,9.71
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,17478053802,NDC,2,ML,125.91,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,8.97543,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.54,9.71
Assay Iga/Igd/Igg/Igm Each,PX82784,CDM,300,RC,82784,CPT,,,,,,,,315,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,8.9852,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.9852,9.3
"Gammaglobulin; Iga, Dg,M - Ref",PX8278490,CDM,300,RC,82784,CPT,90,,,,,,,90,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,8.9852,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.9852,9.3
"Thyroxin, Free (Free T4)",PX84439,CDM,300,RC,84439,CPT,,,,,,,,173,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,8.9852,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.75,9.02
topiramate 100 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,69097012403,NDC,0.25,EA,9.24,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,8.993292,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine ER 15 MG Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,68084040311,NDC,1,EA,9.88,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,9.00068,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,51991060401,NDC,1,EA,10.59,,First Health,Commercial,both,85,,999999999,percent of total billed charges,9.0015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,64380073706,NDC,1,EA,10.59,,First Health,Commercial,both,85,,999999999,percent of total billed charges,9.0015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.2 MG/HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,378910416,NDC,1,EA,10.21,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,9.00522,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.2 MG/HR Patch 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,378910493,NDC,1,EA,10.21,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,9.00522,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Anesthesia Level 4,PX37000018,CDM,370,RC,,,,,,,,,,21,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,9.009,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.7234,20.58
ANOSCOPE LIGHTED ANOSCOPE,120.52,CDM,272,RC,,,,10235-MAIN,LOCAL,,,,,21,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,9.009,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.7234,20.58
"Hepatitis B Core Antibody, Total",PX86704,CDM,300,RC,86704,CPT,,,,,,,,21,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,9.009,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.7234,20.58
nadolol 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,76385013301,NDC,1,EA,18.2,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,9.009,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Spectrophotometry, Nos",PX84311,CDM,300,RC,84311,CPT,,,,,,,,21,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,9.009,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.43,20.58
DRAPE SHEET 70X85 LARGE DYNJP2417,27200000,CDM,272,RC,,,,10914-MAIN,LOCAL,,,,,18.39,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.0111,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRAPE SHEET 70X85 LARGE DYNJP2417,27200000,CDM,272,RC,,,,10914-MAIN,LOCAL,,,,,18.39,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.0111,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRAPE SHEET 70X85 LARGE DYNJP2417,27200000,CDM,272,RC,,,,10914-MAIN,LOCAL,,,,,18.39,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,9.0111,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
morphine ER 15 MG Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,68084040301,NDC,1,EA,9.9,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,9.0189,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 200-40 MG/5ML Suspension 473 mL Bottle,63700001,CDM,250,RC,,,,,,65862049647,NDC,10,ML,18.79,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,9.0192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 200-40 MG/5ML Suspension 473 mL Bottle,63700001,CDM,250,RC,,,,,,65862049647,NDC,10,ML,18.79,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,9.0192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay Iga/Igd/Igg/Igm Each,PX82784,CDM,300,RC,82784,CPT,,,,,,,,315,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,9.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.9852,9.3
Assay Iga/Igd/Igg/Igm Each,PX82784,CDM,300,RC,82784,CPT,,,,,,,,315,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,9.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.9852,9.3
Assay Iga/Igd/Igg/Igm Each,PX82784,CDM,300,RC,82784,CPT,,,,,,,,315,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,9.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.9852,9.3
"Gammaglobulin; Iga, Dg,M - Ref",PX8278490,CDM,300,RC,82784,CPT,90,,,,,,,90,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,9.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.9852,9.3
"Gammaglobulin; Iga, Dg,M - Ref",PX8278490,CDM,300,RC,82784,CPT,90,,,,,,,90,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,9.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.9852,9.3
"Gammaglobulin; Iga, Dg,M - Ref",PX8278490,CDM,300,RC,82784,CPT,90,,,,,,,90,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,9.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.9852,9.3
"Thyroxin, Free (Free T4)",PX84439,CDM,300,RC,84439,CPT,,,,,,,,173,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,9.02,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.75,9.02
STOCKINETTE STERILE 4X48 NON22360,27200000,CDM,272,RC,A6457,HCPCS,,10658-MAIN,LOCAL,,,,,10.62,,First Health,Commercial,both,85,,999999999,percent of total billed charges,9.027,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Reptilase Test - Ref,PX8563590,CDM,300,RC,85635,CPT,90,,,,,,,102,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,9.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.03,99.96
amLODIPine 2.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079045001,NDC,1,EA,9.28,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,9.032224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079045020,NDC,1,EA,9.28,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,9.032224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Wound Culture Anaerobic,PX87075,CDM,300,RC,87075,CPT,,,,,,,,270,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,9.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.04,9.47
Wound Culture Anaerobic,PX87075,CDM,300,RC,87075,CPT,,,,,,,,270,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,9.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.04,9.47
levothyroxine 100 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,74662411,NDC,1,EA,10.16,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,9.0424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,70677003201,NDC,1,EA,10.16,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,9.0424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 100 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,69097012403,NDC,0.25,EA,9.24,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,9.0552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635861,NDC,1,EA,21.11,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,9.05619,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levETIRAcetam 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079082101,NDC,1,EA,18.87,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,9.0576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levETIRAcetam 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079082101,NDC,1,EA,18.87,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,9.0576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141031,NDC,0.5,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,9.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.27,9.41
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141031,NDC,0.5,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,9.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.27,9.41
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141035,NDC,2,ML,56.37,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,9.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.27,9.41
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141035,NDC,2,ML,56.37,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,9.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.27,9.41
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305972,NDC,2,ML,61.19,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,9.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.27,9.41
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305972,NDC,2,ML,61.19,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,9.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.27,9.41
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305995,NDC,2,ML,61.19,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,9.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.27,9.41
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305995,NDC,2,ML,61.19,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,9.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.27,9.41
riFAMpin 150 MG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,68084035721,NDC,1,EA,10.68,,First Health,Commercial,both,85,,999999999,percent of total billed charges,9.078,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68462033090,NDC,1,EA,17.95,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,9.0827,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.2 MG/HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,378910416,NDC,1,EA,10.21,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,9.0869,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.2 MG/HR Patch 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,378910493,NDC,1,EA,10.21,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,9.0869,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079096601,NDC,1,EA,9.34,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,9.090622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.1 MG/HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,378910216,NDC,1,EA,9.98,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,9.09178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.1 MG/HR Patch 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,378910293,NDC,1,EA,9.98,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,9.09178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 2.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079045001,NDC,1,EA,9.28,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,9.0944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amLODIPine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079045020,NDC,1,EA,9.28,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,9.0944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline monohydrate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084074333,NDC,1,EA,9.99,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,9.10089,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DRAPE SHEET 70X85 LARGE DYNJP2417,27200000,CDM,272,RC,,,,10914-MAIN,LOCAL,,,,,18.39,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,9.10305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DOBUTamine 1000 mcg/mL in dextrose 5% 250 mL premix 1000 mcg/ml Solution 250 mL Flex Cont,J1250.01,CDM,636,RC,J1250,HCPCS,,,,338107302,NDC,250,ML,146.73,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,9.10411,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.66,9.85
"BINDER ABDOMINAL 12"" HIGH 46 TO 62 INCH L/XL 4 PANEL ORT21300LXL",120.238,CDM,271,RC,A4467,HCPCS,,11935-MAIN,LOCAL,,,,,18,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,9.108,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BURETROL ADD ON SET 150ML,120.38,CDM,272,RC,A4222,HCPCS,,11118-MAIN,LOCAL,,,,,18,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,9.108,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
TRAY TRACH CLEAN & CARE DYND40589,120.212,CDM,271,RC,,,,1173-MAIN,LOCAL,,,,,18,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,9.108,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,17.64
TRAY TRACHEOTOMY CARE PEDS DYND40650H,120.212,CDM,272,RC,,,,11025-MAIN,LOCAL,,,,,18,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,9.108,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,17.64
Antinuclear Antibodies,PX86038,CDM,300,RC,86038,CPT,,,,,,,,10,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,9.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,11.09
Calcium - Ref,PX8231090,CDM,300,RC,82310,CPT,90,,,,,,,10,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,9.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,9.8
DRAPE SURGICAL 23X17INCH INCISE 1050,27200000,CDM,272,RC,,,,12873-MAIN,LOCAL,,,,,10,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,9.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
KERRAMAX CARE SUPERABSORBENT DRESSING 5X6,120.548,CDM,272,RC,A6197,HCPCS,,12362-MAIN,LOCAL,,,,,10,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,9.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,9.8
NEEDLE HYPODERMIC 22GA 1-1/2IN STERILE 305156,27200000,CDM,272,RC,A4215,HCPCS,,8887-MAIN,LOCAL,,,,,10,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,9.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Needle Insertion W/O Injection 1 or 2 Muscles,PX20560,CDM,420,RC,20560,CPT,,,,,,,,10,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,9.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,26.01
Needle Insertion W/O Injection 3 or More Muscles,PX20561,CDM,420,RC,20561,CPT,,,,,,,,10,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,9.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,26.01
PAD GROUNDING 9 FT ADULT REM E7507,27200000,CDM,272,RC,,,,504-MAIN,LOCAL,,,,,10,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,9.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618201,NDC,2,ML,120.53,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,9.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.54,9.71
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618201,NDC,2,ML,120.53,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,9.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.54,9.71
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618210,NDC,2,ML,120.53,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,9.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.54,9.71
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618210,NDC,2,ML,120.53,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,9.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.54,9.71
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,17478053802,NDC,2,ML,125.91,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,9.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.54,9.71
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,17478053802,NDC,2,ML,125.91,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,9.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.54,9.71
SUTURE SILK 3-0 18INCH NONABSORBABLE BLACK M13T,27200000,CDM,272,RC,,,,12872-MAIN,LOCAL,,,,,19,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,9.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE SILK 3-0 18INCH NONABSORBABLE BLACK M13T,27200000,CDM,272,RC,,,,12872-MAIN,LOCAL,,,,,19,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,9.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
hyaluronate 48 MG/6ML solution prefilled syringe 6 mL Syringe,J7325.01,CDM,636,RC,J7325,HCPCS,,,,58468009003,NDC,6,ML,5274.4,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,9.12,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.71807,9.12
hyaluronate 48 MG/6ML solution prefilled syringe 6 mL Syringe,J7325.01,CDM,636,RC,J7325,HCPCS,,,,58468009003,NDC,6,ML,5274.4,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,9.12,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.71807,9.12
oxyBUTYnin ER 5 MG Tablet Extended Release 24 Hour 50 Each Box,63700001,CDM,250,RC,,,,,,904657006,NDC,1,EA,18.04,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,9.12824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
droPERidol 2.5 MG/ML Solution 2 mL Vial,J1790.01,CDM,636,RC,J1790,HCPCS,,,,517970201,NDC,2,ML,75.47,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,9.13,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.88,9.13
famciclovir 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,60505324603,NDC,0.5,EA,18.65,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.1385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famciclovir 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,60505324603,NDC,0.5,EA,18.65,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.1385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famciclovir 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,60505324603,NDC,0.5,EA,18.65,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,9.1385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Myoglobin - Ref,PX8387490,CDM,300,RC,83874,CPT,90,,,,,,,22,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,9.1388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.1388,21.56
SUTURE POLYSORB BRAIDED ABSORBABLE VIOLET SIZE 0 30IN WITH 5/8 CIRCLE TAPER POINT 27MM NEEDLE,27200000,CDM,272,RC,,,,11985-MAIN,LOCAL,,,,,22,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,9.1388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TEGADERM CHLORHEXIDINE-GLUCONATE,120.356,CDM,272,RC,A4221,HCPCS,,10708-MAIN,LOCAL,,,,,22,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,9.1388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.1388,21.56
oxyBUTYnin ER 5 MG Tablet Extended Release 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,63739054833,NDC,1,EA,18.67,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.1483,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyBUTYnin ER 5 MG Tablet Extended Release 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,63739054833,NDC,1,EA,18.67,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.1483,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyBUTYnin ER 5 MG Tablet Extended Release 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,63739054833,NDC,1,EA,18.67,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,9.1483,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,245014789,NDC,0.5,EA,21.33,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,9.15057,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,245014701,NDC,0.5,EA,21.33,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,9.15057,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famotidine 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079096601,NDC,1,EA,9.34,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,9.1532,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine ER 15 MG Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,406831523,NDC,1,EA,10.05,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,9.15555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine ER 15 MG Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,406831562,NDC,1,EA,10.05,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,9.15555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Immunization Administration; Each Add'l Vaccine (Single or Combo Vaccine/T*,PX90472,CDM,771,RC,90472,CPT,,,,,,,,48,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,9.16,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.16,25.59
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405F,CDM,510,RC,36405,CPT,,,,,,,,54,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,9.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.16,49.81
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405F,CDM,510,RC,36405,CPT,,,,,,,,54,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,9.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.16,49.81
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405F,CDM,510,RC,36405,CPT,,,,,,,,54,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,9.16,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.16,49.81
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405P,CDM,983,RC,36405,CPT,,,,,,,,36,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,9.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.16,49.81
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405P,CDM,983,RC,36405,CPT,,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,9.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.16,49.81
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405P,CDM,983,RC,36405,CPT,,,,,,,,36,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,9.16,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.16,49.81
Withdrawal of Arterial Blood,PX36600F,CDM,510,RC,36600,CPT,,,,,,,,250,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,9.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.16,56.73
Withdrawal of Arterial Blood,PX36600F,CDM,510,RC,36600,CPT,,,,,,,,250,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,9.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.16,56.73
Withdrawal of Arterial Blood,PX36600F,CDM,510,RC,36600,CPT,,,,,,,,250,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,9.16,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.16,56.73
zolpidem 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018911,NDC,1,EA,9.43,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,9.178219,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zolpidem 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018901,NDC,1,EA,9.43,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,9.178219,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 160 MG/5ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,68094023159,NDC,15,ML,19.14,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,9.1872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 160 MG/5ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,68094023159,NDC,15,ML,19.14,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,9.1872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Wound Culture Anaerobic,PX87075,CDM,300,RC,87075,CPT,,,,,,,,270,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,9.19,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.04,9.47
venlafaxine 25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,57237017290,NDC,1,EA,10.43,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,9.19926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714031101,NDC,1,EA,10.43,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,9.19926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57664039288,NDC,1,EA,10.43,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,9.19926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069030,NDC,3,ML,14.09,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,9.20062,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,9.35
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,2,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,9.20062,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,9.35
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,3,ML,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,9.20062,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,9.35
hydrocortisone 1 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,472034356,NDC,28,GR,22.15,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,9.20111,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54022020,NDC,1,EA,21.46,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,9.20634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 10 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,60687024511,NDC,0.5,EA,19.18,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,9.2064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 10 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,60687024511,NDC,0.5,EA,19.18,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,9.2064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 200-40 MG/5ML Suspension 473 mL Bottle,63700001,CDM,250,RC,,,,,,65862049647,NDC,10,ML,18.79,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.2071,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 200-40 MG/5ML Suspension 473 mL Bottle,63700001,CDM,250,RC,,,,,,65862049647,NDC,10,ML,18.79,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.2071,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 200-40 MG/5ML Suspension 473 mL Bottle,63700001,CDM,250,RC,,,,,,65862049647,NDC,10,ML,18.79,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,9.2071,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nadolol 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,76385013301,NDC,1,EA,18.2,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,9.2092,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 100 MG/5ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,68094049459,NDC,20,ML,22.2,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,9.22188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
flecainide 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237006301,NDC,1,EA,10.85,,First Health,Commercial,both,85,,999999999,percent of total billed charges,9.2225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famciclovir 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,60505324603,NDC,0.5,EA,18.65,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,9.23175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zolpidem 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018911,NDC,1,EA,9.43,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,9.2414,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zolpidem 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018901,NDC,1,EA,9.43,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,9.2414,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyBUTYnin ER 5 MG Tablet Extended Release 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,63739054833,NDC,1,EA,18.67,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,9.24165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levETIRAcetam 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079082101,NDC,1,EA,18.87,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.2463,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levETIRAcetam 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079082101,NDC,1,EA,18.87,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.2463,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levETIRAcetam 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079082101,NDC,1,EA,18.87,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,9.2463,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 100 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,74662411,NDC,1,EA,10.16,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,9.25576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,70677003201,NDC,1,EA,10.16,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,9.25576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DOBUTamine 1000 mcg/mL in dextrose 5% 250 mL premix 1000 mcg/ml Solution 250 mL Flex Cont,J1250.01,CDM,636,RC,J1250,HCPCS,,,,338107302,NDC,250,ML,146.73,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,9.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.66,9.85
DOBUTamine 1000 mcg/mL in dextrose 5% 250 mL premix 1000 mcg/ml Solution 250 mL Flex Cont,J1250.01,CDM,636,RC,J1250,HCPCS,,,,338107302,NDC,250,ML,146.73,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,9.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.66,9.85
rosuvastatin 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003001,NDC,0.5,EA,21.59,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,9.26211,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079049801,NDC,1,EA,22.34,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,9.280036,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,57237017290,NDC,1,EA,10.43,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,9.2827,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714031101,NDC,1,EA,10.43,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,9.2827,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57664039288,NDC,1,EA,10.43,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,9.2827,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"MAYO STAND COVERS 24X53""",27200000,CDM,272,RC,,,,644-MAIN,LOCAL,,,,,9.54,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,9.285282,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Russell Viper Venom - Ref,PX8561390,CDM,300,RC,85613,CPT,90,,,,,,,93,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,9.29,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.29,9.58
Russell Viper Venom - Ref,PX8561390,CDM,300,RC,85613,CPT,90,,,,,,,93,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,9.29,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.29,9.58
Russell Viper Venom - Ref,PX8561390,CDM,300,RC,85613,CPT,90,,,,,,,93,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,9.29,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.29,9.58
Assay Iga/Igd/Igg/Igm Each,PX82784,CDM,300,RC,82784,CPT,,,,,,,,315,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,9.3,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.9852,9.3
"Gammaglobulin; Iga, Dg,M - Ref",PX8278490,CDM,300,RC,82784,CPT,90,,,,,,,90,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,9.3,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.9852,9.3
simethicone 40 MG/0.6ML Suspension 30 mL Bottle,25000000,CDM,250,RC,,,,,,904589430,NDC,30,ML,22.39,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,9.300806,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sulfamethoxazole-trimethoprim 200-40 MG/5ML Suspension 473 mL Bottle,63700001,CDM,250,RC,,,,,,65862049647,NDC,10,ML,18.79,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,9.30105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.2 MG/HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,378910416,NDC,1,EA,10.21,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,9.30131,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.2 MG/HR Patch 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,378910493,NDC,1,EA,10.21,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,9.30131,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DRAPE SHEET 70X85 LARGE DYNJP2417,27200000,CDM,272,RC,,,,10914-MAIN,LOCAL,,,,,18.39,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,9.30534,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Russell Viper Venom - Ref,PX8561390,CDM,300,RC,85613,CPT,90,,,,,,,93,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,9.3061,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.29,9.58
Wound Culture Anaerobic,PX87075,CDM,300,RC,87075,CPT,,,,,,,,270,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,9.3061,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.04,9.47
SUTURE SILK 3-0 18INCH NONABSORBABLE BLACK M13T,27200000,CDM,272,RC,,,,12872-MAIN,LOCAL,,,,,19,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE SILK 3-0 18INCH NONABSORBABLE BLACK M13T,27200000,CDM,272,RC,,,,12872-MAIN,LOCAL,,,,,19,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE SILK 3-0 18INCH NONABSORBABLE BLACK M13T,27200000,CDM,272,RC,,,,12872-MAIN,LOCAL,,,,,19,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,9.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"D-Dimer, Quantitative - Ref",PX8537990,CDM,300,RC,85379,CPT,90,,,,,,,177,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,9.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.33,173.46
Ehrlichia (Anaplasma) Ab - Ref,PX8666690,CDM,300,RC,86666,CPT,90,,,,,,,163,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,9.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.33,159.74
Fibrin Degradation Quant,PX85379,CDM,300,RC,85379,CPT,,,,,,,,177,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,9.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.33,173.46
midazolam 2 MG/ML Syrup 5 mL Cup,63700001,CDM,250,RC,,,,,,68094076459,NDC,2.5,ML,22.47,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,9.334038,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
neomycin-bacitracin-polymyxin 3.5-400-5000 Ointment 28.4 g Tube,25000000,CDM,250,RC,,,,,,713026831,NDC,28.4,GR,22.47,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,9.334038,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,51991060401,NDC,1,EA,10.59,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,9.34038,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,64380073706,NDC,1,EA,10.59,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,9.34038,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levETIRAcetam 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079082101,NDC,1,EA,18.87,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,9.34065,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
apixaban 5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,3089421,NDC,0.5,EA,22.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,9.3465,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"MAYO STAND COVERS 24X53""",27200000,CDM,272,RC,,,,644-MAIN,LOCAL,,,,,9.54,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,9.3492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069030,NDC,3,ML,14.09,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,9.35,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,9.35
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069030,NDC,3,ML,14.09,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,9.35,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,9.35
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,2,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,9.35,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,9.35
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,2,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,9.35,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,9.35
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,3,ML,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,9.35,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,9.35
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,3,ML,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,9.35,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,9.35
ELECTRODES NEEDLE TIP PRECISE 2.4MM,27200000,CDM,272,RC,,,,12074-MAIN,LOCAL,,,,,11,,First Health,Commercial,both,85,,999999999,percent of total billed charges,9.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE ETHIBOND XTRA 0 SHSH 36 INCH,27200000,CDM,272,RC,,,,12678-MAIN,LOCAL,,,,,11,,First Health,Commercial,both,85,,999999999,percent of total billed charges,9.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STOCKINETTE STERILE 4X48 NON22360,27200000,CDM,272,RC,A6457,HCPCS,,10658-MAIN,LOCAL,,,,,10.62,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,9.36684,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Xray Shoulder 1 Vw,PX7302001,CDM,320,RC,73020,CPT,TC,,,,,,,267,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,9.37,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.37,28.27
Xray Shoulder 1 Vw,PX7302001,CDM,320,RC,73020,CPT,TC,,,,,,,267,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,9.37,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.37,28.27
Xray Shoulder 1 Vw,PX7302001,CDM,320,RC,73020,CPT,TC,,,,,,,267,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,9.37,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.37,28.27
acetaminophen 160 MG/5ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,68094023159,NDC,15,ML,19.14,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.3786,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 160 MG/5ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,68094023159,NDC,15,ML,19.14,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.3786,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 160 MG/5ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,68094023159,NDC,15,ML,19.14,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,9.3786,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tamsulosin 0.4 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904640161,NDC,1,EA,22.6,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,9.38804,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006111,NDC,0.5,EA,56.98,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,9.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.26,10.03704
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006111,NDC,0.5,EA,56.98,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,9.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.26,10.03704
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006158,NDC,0.5,EA,56.98,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,9.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.26,10.03704
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006158,NDC,0.5,EA,56.98,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,9.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.26,10.03704
propranolol LA 60 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,527411637,NDC,1,EA,11.05,,First Health,Commercial,both,85,,999999999,percent of total billed charges,9.3925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 10 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,60687024511,NDC,0.5,EA,19.18,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.3982,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 10 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,60687024511,NDC,0.5,EA,19.18,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.3982,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 10 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,60687024511,NDC,0.5,EA,19.18,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,9.3982,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SUTURE SILK 3-0 18INCH NONABSORBABLE BLACK M13T,27200000,CDM,272,RC,,,,12872-MAIN,LOCAL,,,,,19,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,9.405,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141031,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,9.41,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.27,9.41
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141035,NDC,2,ML,56.37,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,9.41,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.27,9.41
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305972,NDC,2,ML,61.19,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,9.41,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.27,9.41
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305995,NDC,2,ML,61.19,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,9.41,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.27,9.41
G6pd; Quant Screen - Ref,PX8295590,CDM,300,RC,82955,CPT,90,,,,,,,50,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,9.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.41,9.7
G6pd; Quant Screen - Ref,PX8295590,CDM,300,RC,82955,CPT,90,,,,,,,50,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,9.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.41,9.7
G6pd; Quant Screen - Ref,PX8295590,CDM,300,RC,82955,CPT,90,,,,,,,50,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,9.41,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.41,9.7
riFAMpin 150 MG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,68084035721,NDC,1,EA,10.68,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,9.41976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Aldolase - Ref,PX8208590,CDM,300,RC,82085,CPT,90,,,,,,,89,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,9.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.42,9.71
Aldolase - Ref,PX8208590,CDM,300,RC,82085,CPT,90,,,,,,,89,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,9.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.42,9.71
Aldolase - Ref,PX8208590,CDM,300,RC,82085,CPT,90,,,,,,,89,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,9.42,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.42,9.71
Glycosylated Hemoglobin Test,PX83036,CDM,300,RC,83036,CPT,,,,,,,,110,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,9.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.42,9.71
Glycosylated Hemoglobin Test,PX83036,CDM,300,RC,83036,CPT,,,,,,,,110,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,9.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.42,9.71
Glycosylated Hemoglobin Test,PX83036,CDM,300,RC,83036,CPT,,,,,,,,110,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,9.42,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.42,9.71
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,51991060401,NDC,1,EA,10.59,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,9.4251,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,64380073706,NDC,1,EA,10.59,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,9.4251,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Fibrinogen,PX7426,CDM,300,RC,85384,CPT,,,,,,,,234,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,9.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.43,9.72
Fibrinogen,PX7426,CDM,300,RC,85384,CPT,,,,,,,,234,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,9.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.43,9.72
Fibrinogen,PX7426,CDM,300,RC,85384,CPT,,,,,,,,234,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,9.43,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.43,9.72
Fibrinogen Activity - Ref,PX8538490,CDM,300,RC,85384,CPT,90,,,,,,,245,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,9.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.43,9.72
Fibrinogen Activity - Ref,PX8538490,CDM,300,RC,85384,CPT,90,,,,,,,245,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,9.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.43,9.72
Fibrinogen Activity - Ref,PX8538490,CDM,300,RC,85384,CPT,90,,,,,,,245,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,9.43,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.43,9.72
APPLICATOR CHLORAPREP 26ML WITH ORANGE 930815,27200000,CDM,272,RC,A4248,HCPCS,,10031-MAIN,LOCAL,,,,,19.65,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,9.432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
APPLICATOR CHLORAPREP 26ML WITH ORANGE 930815,27200000,CDM,272,RC,A4248,HCPCS,,10031-MAIN,LOCAL,,,,,19.65,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,9.432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
venlafaxine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084089695,NDC,1,EA,11.1,,First Health,Commercial,both,85,,999999999,percent of total billed charges,9.435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famciclovir 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,60505324603,NDC,0.5,EA,18.65,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,9.4369,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Myoglobin - Ref,PX8387490,CDM,300,RC,83874,CPT,90,,,,,,,22,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,9.438,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.1388,21.56
SUTURE POLYSORB BRAIDED ABSORBABLE VIOLET SIZE 0 30IN WITH 5/8 CIRCLE TAPER POINT 27MM NEEDLE,27200000,CDM,272,RC,,,,11985-MAIN,LOCAL,,,,,22,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,9.438,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TEGADERM CHLORHEXIDINE-GLUCONATE,120.356,CDM,272,RC,A4221,HCPCS,,10708-MAIN,LOCAL,,,,,22,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,9.438,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.1388,21.56
propranolol LA 80 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,228277911,NDC,0.75,EA,9.7,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,9.44101,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol LA 80 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,527411737,NDC,0.75,EA,9.7,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,9.44101,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyBUTYnin ER 5 MG Tablet Extended Release 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,63739054833,NDC,1,EA,18.67,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,9.44702,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
STOCKINETTE STERILE 4X48 NON22360,27200000,CDM,272,RC,A6457,HCPCS,,10658-MAIN,LOCAL,,,,,10.62,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,9.4518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Blood Culture for Bacteria,PX87040,CDM,300,RC,87040,CPT,,,,,,,,286,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,9.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.46,280.28
anastrozole 1 MG Tablet 1 Each Blister,25000000,CDM,250,RC,,,,,,60687011211,NDC,1,EA,11.13,,First Health,Commercial,both,85,,999999999,percent of total billed charges,9.4605,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
anastrozole 1 MG Tablet 30 Each Box,25000000,CDM,250,RC,,,,,,60687011221,NDC,1,EA,11.13,,First Health,Commercial,both,85,,999999999,percent of total billed charges,9.4605,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Hepatitis B Surface Antigen,PX87340,CDM,300,RC,87340,CPT,,,,,,,,98,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,9.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.47,96.04
Wound Culture Anaerobic,PX87075,CDM,300,RC,87075,CPT,,,,,,,,270,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,9.47,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.04,9.47
acetaminophen 160 MG/5ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,68094023159,NDC,15,ML,19.14,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,9.4743,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714065102,NDC,0.4,EA,9.74,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,9.479942,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
RBC Antibody Screen,PX86850,CDM,300,RC,86850,CPT,,,,,,,,173,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,9.48,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.48,9.77
RBC Antibody Screen,PX86850,CDM,300,RC,86850,CPT,,,,,,,,173,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,9.48,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.48,9.77
RBC Antibody Screen,PX86850,CDM,300,RC,86850,CPT,,,,,,,,173,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,9.48,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.48,9.77
rosuvastatin 10 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,60687024511,NDC,0.5,EA,19.18,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,9.4941,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,57237017290,NDC,1,EA,10.43,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,9.50173,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714031101,NDC,1,EA,10.43,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,9.50173,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57664039288,NDC,1,EA,10.43,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,9.50173,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 1 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,472034356,NDC,28,GR,22.15,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,9.50235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
riFAMpin 150 MG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,68084035721,NDC,1,EA,10.68,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,9.5052,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol LA 80 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,228277911,NDC,0.75,EA,9.7,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,9.506,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol LA 80 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,527411737,NDC,0.75,EA,9.7,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,9.506,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 200-40 MG/5ML Suspension 473 mL Bottle,63700001,CDM,250,RC,,,,,,65862049647,NDC,10,ML,18.79,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,9.50774,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 100 MG/5ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,68094049459,NDC,20,ML,22.2,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,9.5238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
naltrexone 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406117001,NDC,1,EA,22.96,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,9.537584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Contrast Bath Therapy,PX97034,CDM,420,RC,97034,CPT,,,,,,,,97,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,9.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,95.06
Electrical Stimulation,PX97032,CDM,420,RC,97032,CPT,,,,,,,,135,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,9.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,132.3
Mechanical Traction Therapy,PX97012,CDM,420,RC,97012,CPT,,,,,,,,135,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,9.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,132.3
MEPILEX ADH FOAM 4X10,120.63,CDM,272,RC,A6196,HCPCS,,8710-MAIN,LOCAL,,,,,25,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,9.54,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,10.04
MEPILEX SOFT SILICONE 6X6,120.63,CDM,272,RC,A6196,HCPCS,,5577-MAIN,LOCAL,,,,,25,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,9.54,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,10.04
OPTIFOAM GENTLE SA SILICCONE FACED FOAM & BOARDER,120.63,CDM,272,RC,A6196,HCPCS,,3938-MAIN,LOCAL,,,,,25,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,9.54,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,10.04
Ultrasound Therapy,PX97035,CDM,420,RC,97035,CPT,,,,,,,,135,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,9.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,132.3
triamcinolone acetonide 0.1 % Cream 15 g Tube,63700001,CDM,250,RC,,,,,,168000415,NDC,15,GR,22.97,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,9.541738,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zinc oxide 20 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,536131625,NDC,60,GR,22.97,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,9.541738,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714065102,NDC,0.4,EA,9.74,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,9.5452,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levETIRAcetam 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079082101,NDC,1,EA,18.87,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,9.54822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Reptilase Test - Ref,PX8563590,CDM,300,RC,85635,CPT,90,,,,,,,102,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,9.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.55,9.85
Reptilase Test - Ref,PX8563590,CDM,300,RC,85635,CPT,90,,,,,,,102,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,9.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.55,9.85
Reptilase Test - Ref,PX8563590,CDM,300,RC,85635,CPT,90,,,,,,,102,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,9.55,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.55,9.85
povidone-iodine 10 % Ointment 28.35 g Tube,63700001,CDM,250,RC,,,,,,904110231,NDC,28.35,GR,19.9,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,9.552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
povidone-iodine 10 % Ointment 28.35 g Tube,63700001,CDM,250,RC,,,,,,904110231,NDC,28.35,GR,19.9,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,9.552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BRACE WRIST 8-IN SM LEFT 10432,120.564,CDM,273,RC,L3809,HCPCS,,12720-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,9.5542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 8-IN SM RIGHT 10442,120.564,CDM,273,RC,L3809,HCPCS,,12716-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,9.5542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN LG RIGHT 10464,120.564,CDM,273,RC,L3809,HCPCS,,12719-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,9.5542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN SM LEFT 617083,120.564,CDM,273,RC,L3809,HCPCS,,12722-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,9.5542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN SM RIGHT 10462,120.564,CDM,273,RC,L3809,HCPCS,,12717-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,9.5542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN XL LEFT 10455,120.564,CDM,273,RC,L3809,HCPCS,,12721-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,9.5542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN XL RIGHT 10465,120.564,CDM,273,RC,L3809,HCPCS,,12715-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,9.5542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST WRISTPRO LEFT 10-IN LG,120.564,CDM,273,RC,L3809,HCPCS,,12724-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,9.5542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST WRISTPRO LEFT 10-IN MED,120.564,CDM,273,RC,L3809,HCPCS,,12723-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,9.5542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
Detection of Babesia Borrelia Miyamotoi by Amplified Nucleic Acid Probe Technique,PX8747890,CDM,300,RC,87478,CPT,90,,,,,,,23,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,9.5542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,32.17
Detection of Babesia Microtim by Amplified Nucleic Acid Probe Technique,PX8746990,CDM,300,RC,87469,CPT,90,,,,,,,23,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,9.5542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,32.17
FORCEPS COLD BIOPSY,27200000,CDM,272,RC,,,,12453-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,9.5542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE MAXON ABSORBABLE POLYGLYCONATE 2-0 30IN MONOFILAMENT DYED TAPER POINT 1/2 CIRCLE 27MM GS-22 G,27200000,CDM,272,RC,,,,11988-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,9.5542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE POLYSORB ABSORBABLE LACTOMER 2-0 30IN BRAIDED DYED TAPER POINT 1/2 CIRCLE 26MM V-20 VIOLET ST,27200000,CDM,272,RC,,,,11983-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,9.5542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
flecainide 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237006301,NDC,1,EA,10.85,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,9.5697,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862007601,NDC,0.4,EA,9.84,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,9.577272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Russell Viper Venom - Ref,PX8561390,CDM,300,RC,85613,CPT,90,,,,,,,93,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,9.58,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.29,9.58
lamoTRIgine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079049801,NDC,1,EA,22.34,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,9.58386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034211,NDC,1,EA,11.28,,First Health,Commercial,both,85,,999999999,percent of total billed charges,9.588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034201,NDC,1,EA,11.28,,First Health,Commercial,both,85,,999999999,percent of total billed charges,9.588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Pare/Cut Hyperkeratotic Skin Lesion, Single",PX11055F,CDM,510,RC,11055,CPT,,,,,,,,145,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,9.59,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.59,148.05
"Pare/Cut Hyperkeratotic Skin Lesion, Single",PX11055F,CDM,510,RC,11055,CPT,,,,,,,,145,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,9.59,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.59,148.05
"Pare/Cut Hyperkeratotic Skin Lesion, Single",PX11055F,CDM,510,RC,11055,CPT,,,,,,,,145,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,9.59,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.59,148.05
cefaDROXil 500 MG capsule 50 Each Bottle,63700001,CDM,250,RC,,,,,,16714038801,NDC,1,EA,19.98,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,9.5904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cefaDROXil 500 MG capsule 50 Each Bottle,63700001,CDM,250,RC,,,,,,16714038801,NDC,1,EA,19.98,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,9.5904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Bacterium Nos, Antibody - Ref",PX8660990,CDM,300,RC,86609,CPT,90,,,,,,,20,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,9.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
"Bacterium Nos, Antibody - Ref",PX8660990,CDM,300,RC,86609,CPT,90,,,,,,,20,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,9.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
DRESSING QWICK NONADHESIVE 4.25X4 SUPERABSORBENT MSC5844,120.531,CDM,272,RC,A6197,HCPCS,,12301-MAIN,LOCAL,,,,,20,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,9.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
DRESSING QWICK NONADHESIVE 4.25X4 SUPERABSORBENT MSC5844,120.531,CDM,272,RC,A6197,HCPCS,,12301-MAIN,LOCAL,,,,,20,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,9.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
Glucose Blood Test,PX82962,CDM,300,RC,82962,CPT,,,,,,,,20,,Health Partners,Health Partners Care Plans,both,48,,13.2075,percent of total billed charges,9.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.01,19.6
Glucose Blood Test,PX82962,CDM,300,RC,82962,CPT,,,,,,,,20,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,9.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.01,19.6
Phenobarbital Assay - Ref,PX8018490,CDM,300,RC,80184,CPT,90,,,,,,,20,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,9.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
Phenobarbital Assay - Ref,PX8018490,CDM,300,RC,80184,CPT,90,,,,,,,20,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,9.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
Primidone Assay - Ref,PX8018890,CDM,300,RC,80188,CPT,90,,,,,,,20,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,9.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
Primidone Assay - Ref,PX8018890,CDM,300,RC,80188,CPT,90,,,,,,,20,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,9.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER  STRAIGHT TAPER TIP 20FR PVC,120.528,CDM,272,RC,,,,12247-MAIN,LOCAL,,,,,20,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,9.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER  STRAIGHT TAPER TIP 20FR PVC,120.528,CDM,272,RC,,,,12247-MAIN,LOCAL,,,,,20,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,9.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER  STRAIGHT TAPER TIP 24FR PVC,120.528,CDM,272,RC,,,,12248-MAIN,LOCAL,,,,,20,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,9.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER  STRAIGHT TAPER TIP 24FR PVC,120.528,CDM,272,RC,,,,12248-MAIN,LOCAL,,,,,20,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,9.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 8FR PVC,120.528,CDM,272,RC,,,,12253-MAIN,LOCAL,,,,,20,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,9.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 8FR PVC,120.528,CDM,272,RC,,,,12253-MAIN,LOCAL,,,,,20,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,9.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 10FR PVC,120.528,CDM,272,RC,,,,12254-MAIN,LOCAL,,,,,20,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,9.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 10FR PVC,120.528,CDM,272,RC,,,,12254-MAIN,LOCAL,,,,,20,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,9.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 12FR PVC,120.528,CDM,272,RC,,,,12255-MAIN,LOCAL,,,,,20,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,9.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 12FR PVC,120.528,CDM,272,RC,,,,12255-MAIN,LOCAL,,,,,20,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,9.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 16FR PVC,120.528,CDM,272,RC,,,,12256-MAIN,LOCAL,,,,,20,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,9.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 16FR PVC,120.528,CDM,272,RC,,,,12256-MAIN,LOCAL,,,,,20,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,9.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 28FR PVC,120.528,CDM,272,RC,,,,12249-MAIN,LOCAL,,,,,20,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,9.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 28FR PVC,120.528,CDM,272,RC,,,,12249-MAIN,LOCAL,,,,,20,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,9.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 32FR PVC,120.528,CDM,272,RC,,,,12250-MAIN,LOCAL,,,,,20,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,9.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 32FR PVC,120.528,CDM,272,RC,,,,12250-MAIN,LOCAL,,,,,20,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,9.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 36FR PVC,120.528,CDM,272,RC,,,,12251-MAIN,LOCAL,,,,,20,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,9.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 36FR PVC,120.528,CDM,272,RC,,,,12251-MAIN,LOCAL,,,,,20,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,9.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
simethicone 40 MG/0.6ML Suspension 30 mL Bottle,25000000,CDM,250,RC,,,,,,904589430,NDC,30,ML,22.39,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,9.60531,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
buPROPion XL 150 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,70436001004,NDC,1,EA,23.14,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,9.612356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SUTURE SILK 3-0 18INCH NONABSORBABLE BLACK M13T,27200000,CDM,272,RC,,,,12872-MAIN,LOCAL,,,,,19,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,9.614,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
morphine ER 15 MG Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,68084040311,NDC,1,EA,9.88,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,9.616204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BITE BLOCK MAXI 20MM 60FR,27200000,CDM,272,RC,,,,8144-MAIN,LOCAL,,,,,11.32,,First Health,Commercial,both,85,,999999999,percent of total billed charges,9.622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Aldolase - Ref,PX8208590,CDM,300,RC,82085,CPT,90,,,,,,,89,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,9.627,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.42,9.71
Fibrinogen,PX7426,CDM,300,RC,85384,CPT,,,,,,,,234,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,9.627,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.43,9.72
Fibrinogen Activity - Ref,PX8538490,CDM,300,RC,85384,CPT,90,,,,,,,245,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,9.627,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.43,9.72
G6pd; Quant Screen - Ref,PX8295590,CDM,300,RC,82955,CPT,90,,,,,,,50,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,9.627,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.41,9.7
Glycosylated Hemoglobin Test,PX83036,CDM,300,RC,83036,CPT,,,,,,,,110,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,9.627,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.42,9.71
RBC Antibody Screen,PX86850,CDM,300,RC,86850,CPT,,,,,,,,173,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,9.627,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.48,9.77
Reptilase Test - Ref,PX8563590,CDM,300,RC,85635,CPT,90,,,,,,,102,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,9.627,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.55,9.85
APPLICATOR CHLORAPREP 26ML WITH ORANGE 930815,27200000,CDM,272,RC,A4248,HCPCS,,10031-MAIN,LOCAL,,,,,19.65,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.6285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
APPLICATOR CHLORAPREP 26ML WITH ORANGE 930815,27200000,CDM,272,RC,A4248,HCPCS,,10031-MAIN,LOCAL,,,,,19.65,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.6285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
APPLICATOR CHLORAPREP 26ML WITH ORANGE 930815,27200000,CDM,272,RC,A4248,HCPCS,,10031-MAIN,LOCAL,,,,,19.65,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,9.6285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Assay of Blood Lipoprotein,PX83721,CDM,300,RC,83721,CPT,,,,,,,,76,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,9.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.63,74.48
morphine ER 15 MG Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,68084040301,NDC,1,EA,9.9,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,9.63567,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
midazolam 2 MG/ML Syrup 5 mL Cup,63700001,CDM,250,RC,,,,,,68094076459,NDC,2.5,ML,22.47,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,9.63963,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
neomycin-bacitracin-polymyxin 3.5-400-5000 Ointment 28.4 g Tube,25000000,CDM,250,RC,,,,,,713026831,NDC,28.4,GR,22.47,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,9.63963,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ciprofloxacin 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862007601,NDC,0.4,EA,9.84,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,9.6432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 37.5 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084069811,NDC,1,EA,20.09,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,9.6432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 37.5 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084069811,NDC,1,EA,20.09,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,9.6432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 37.5 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084069801,NDC,1,EA,20.09,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,9.6432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 37.5 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084069801,NDC,1,EA,20.09,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,9.6432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,51991060401,NDC,1,EA,10.59,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,9.64749,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,64380073706,NDC,1,EA,10.59,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,9.64749,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
apixaban 5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,3089421,NDC,0.5,EA,22.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,9.6525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
flecainide 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237006301,NDC,1,EA,10.85,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,9.6565,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
STOCKINETTE STERILE 4X48 NON22360,27200000,CDM,272,RC,A6457,HCPCS,,10658-MAIN,LOCAL,,,,,10.62,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,9.67482,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Comprehensive Metabolic Panel,PX80053,CDM,300,RC,80053,CPT,,,,,,,,396,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,9.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.68,388.08
morphine ER 15 MG Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,68084040311,NDC,1,EA,9.88,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,9.6824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
eplerenone 25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16729029315,NDC,1,EA,23.31,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,9.682974,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 160 MG/5ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,68094023159,NDC,15,ML,19.14,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,9.68484,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"AQUACEL FOAM DRESSING 4X4""",120.202,CDM,272,RC,A6209,HCPCS,,7939-MAIN,LOCAL,,,,,14,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,9.69,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.69,22.44
AQUACEL NONADHESIVE FOAM DRESSING 4X4,120.202,CDM,272,RC,A6209,HCPCS,,12046-MAIN,LOCAL,,,,,14,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,9.69,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.69,22.44
DRESSING HYDROFERA 2-1/2X2-1/2  BLUE READY FOAM HBRS2520,120.488,CDM,271,RC,A6209,HCPCS,,11537-MAIN,LOCAL,,,,,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,9.69,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.69,10.02
rivastigmine 3 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,55111035360,NDC,0.5,EA,11.4,,First Health,Commercial,both,85,,999999999,percent of total billed charges,9.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxazosin 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079095701,NDC,1,EA,20.19,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,9.6912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxazosin 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079095701,NDC,1,EA,20.19,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,9.6912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tamsulosin 0.4 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904640161,NDC,1,EA,22.6,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,9.6954,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
G6pd; Quant Screen - Ref,PX8295590,CDM,300,RC,82955,CPT,90,,,,,,,50,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,9.7,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.41,9.7
ELECTRODES NEEDLE TIP PRECISE 2.4MM,27200000,CDM,272,RC,,,,12074-MAIN,LOCAL,,,,,11,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,9.702,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
morphine ER 15 MG Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,68084040301,NDC,1,EA,9.9,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,9.702,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SUTURE ETHIBOND XTRA 0 SHSH 36 INCH,27200000,CDM,272,RC,,,,12678-MAIN,LOCAL,,,,,11,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,9.702,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
rosuvastatin 10 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,60687024511,NDC,0.5,EA,19.18,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,9.70508,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxazosin 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079095720,NDC,1,EA,20.22,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,9.7056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxazosin 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079095720,NDC,1,EA,20.22,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,9.7056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Aldolase - Ref,PX8208590,CDM,300,RC,82085,CPT,90,,,,,,,89,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,9.71,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.42,9.71
Glycosylated Hemoglobin Test,PX83036,CDM,300,RC,83036,CPT,,,,,,,,110,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,9.71,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.42,9.71
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618201,NDC,2,ML,120.53,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,9.71,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.54,9.71
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618210,NDC,2,ML,120.53,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,9.71,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.54,9.71
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,17478053802,NDC,2,ML,125.91,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,9.71,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.54,9.71
nitroglycerin 0.1 MG/HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,378910216,NDC,1,EA,9.98,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,9.713534,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.1 MG/HR Patch 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,378910293,NDC,1,EA,9.98,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,9.713534,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Fibrinogen,PX7426,CDM,300,RC,85384,CPT,,,,,,,,234,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,9.72,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.43,9.72
Fibrinogen Activity - Ref,PX8538490,CDM,300,RC,85384,CPT,90,,,,,,,245,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,9.72,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.43,9.72
doxycycline monohydrate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084074333,NDC,1,EA,9.99,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,9.723267,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydroxychloroquine 200 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16571068701,NDC,1,EA,23.41,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,9.724514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
APPLICATOR CHLORAPREP 26ML WITH ORANGE 930815,27200000,CDM,272,RC,A4248,HCPCS,,10031-MAIN,LOCAL,,,,,19.65,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,9.72675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
clopidogrel 75 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629461,NDC,1,EA,23.42,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,9.728668,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
riFAMpin 150 MG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,68084035721,NDC,1,EA,10.68,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,9.72948,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Antinuclear Antibodies,PX86038,CDM,300,RC,86038,CPT,,,,,,,,10,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,9.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,11.09
Calcium - Ref,PX8231090,CDM,300,RC,82310,CPT,90,,,,,,,10,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,9.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,9.8
DRAPE SURGICAL 23X17INCH INCISE 1050,27200000,CDM,272,RC,,,,12873-MAIN,LOCAL,,,,,10,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,9.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
KERRAMAX CARE SUPERABSORBENT DRESSING 5X6,120.548,CDM,272,RC,A6197,HCPCS,,12362-MAIN,LOCAL,,,,,10,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,9.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,9.8
NEEDLE HYPODERMIC 22GA 1-1/2IN STERILE 305156,27200000,CDM,272,RC,A4215,HCPCS,,8887-MAIN,LOCAL,,,,,10,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,9.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Needle Insertion W/O Injection 1 or 2 Muscles,PX20560,CDM,420,RC,20560,CPT,,,,,,,,10,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,9.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,26.01
Needle Insertion W/O Injection 3 or More Muscles,PX20561,CDM,420,RC,20561,CPT,,,,,,,,10,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,9.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,26.01
PAD GROUNDING 9 FT ADULT REM E7507,27200000,CDM,272,RC,,,,504-MAIN,LOCAL,,,,,10,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,9.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
levothyroxine 100 MCG/5ML Solution 5 mL Vial,J0651.01,CDM,636,RC,J0651,HCPCS,,,,63323088510,NDC,0.625,ML,99.32,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,9.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.64,9.74
levothyroxine 100 MCG/5ML Solution 5 mL Vial,J0651.01,CDM,636,RC,J0651,HCPCS,,,,63323088510,NDC,0.625,ML,99.32,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,9.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.64,9.74
carvedilol 3.125 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079077101,NDC,1,EA,11.46,,First Health,Commercial,both,85,,999999999,percent of total billed charges,9.741,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 14 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,43598044774,NDC,1,EA,11.46,,First Health,Commercial,both,85,,999999999,percent of total billed charges,9.741,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,43598044871,NDC,1,EA,11.46,,First Health,Commercial,both,85,,999999999,percent of total billed charges,9.741,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
celecoxib 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904650261,NDC,1,EA,23.45,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,9.74113,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol LA 60 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,527411637,NDC,1,EA,11.05,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,9.7461,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
povidone-iodine 10 % Ointment 28.35 g Tube,63700001,CDM,250,RC,,,,,,904110231,NDC,28.35,GR,19.9,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.751,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
povidone-iodine 10 % Ointment 28.35 g Tube,63700001,CDM,250,RC,,,,,,904110231,NDC,28.35,GR,19.9,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.751,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
povidone-iodine 10 % Ointment 28.35 g Tube,63700001,CDM,250,RC,,,,,,904110231,NDC,28.35,GR,19.9,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,9.751,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin-clavulanate 500-125 MG Tablet 20 Each Bottle,63700001,CDM,250,RC,,,,,,16714047701,NDC,1,EA,20.33,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,9.7584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin-clavulanate 500-125 MG Tablet 20 Each Bottle,63700001,CDM,250,RC,,,,,,16714047701,NDC,1,EA,20.33,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,9.7584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006111,NDC,0.5,EA,56.98,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,9.76,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.26,10.03704
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006158,NDC,0.5,EA,56.98,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,9.76,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.26,10.03704
celecoxib 200 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904650361,NDC,0.5,EA,20.35,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,9.768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
celecoxib 200 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904650361,NDC,0.5,EA,20.35,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,9.768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
RBC Antibody Screen,PX86850,CDM,300,RC,86850,CPT,,,,,,,,173,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,9.77,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.48,9.77
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,536110888,NDC,1,EA,11.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,9.775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.1 MG/HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,378910216,NDC,1,EA,9.98,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,9.7804,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.1 MG/HR Patch 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,378910293,NDC,1,EA,9.98,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,9.7804,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine ER 15 MG Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,406831523,NDC,1,EA,10.05,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,9.781665,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine ER 15 MG Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,406831562,NDC,1,EA,10.05,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,9.781665,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluconazole 100 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069101,NDC,0.5,EA,23.55,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,9.78267,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ELECTRODES NEEDLE TIP PRECISE 2.4MM,27200000,CDM,272,RC,,,,12074-MAIN,LOCAL,,,,,11,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,9.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE ETHIBOND XTRA 0 SHSH 36 INCH,27200000,CDM,272,RC,,,,12678-MAIN,LOCAL,,,,,11,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,9.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
cefaDROXil 500 MG capsule 50 Each Bottle,63700001,CDM,250,RC,,,,,,16714038801,NDC,1,EA,19.98,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.7902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cefaDROXil 500 MG capsule 50 Each Bottle,63700001,CDM,250,RC,,,,,,16714038801,NDC,1,EA,19.98,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.7902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cefaDROXil 500 MG capsule 50 Each Bottle,63700001,CDM,250,RC,,,,,,16714038801,NDC,1,EA,19.98,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,9.7902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline monohydrate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084074333,NDC,1,EA,9.99,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,9.7902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084089695,NDC,1,EA,11.1,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,9.7902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydroxychloroquine 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292001101,NDC,1,EA,23.57,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,9.790978,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Antinuclear Antibodies,PX86038,CDM,300,RC,86038,CPT,,,,,,,,10,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,11.09
"Bacterium Nos, Antibody - Ref",PX8660990,CDM,300,RC,86609,CPT,90,,,,,,,20,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
"Bacterium Nos, Antibody - Ref",PX8660990,CDM,300,RC,86609,CPT,90,,,,,,,20,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
"Bacterium Nos, Antibody - Ref",PX8660990,CDM,300,RC,86609,CPT,90,,,,,,,20,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
Calcium - Ref,PX8231090,CDM,300,RC,82310,CPT,90,,,,,,,10,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,9.8
DRAPE SURGICAL 23X17INCH INCISE 1050,27200000,CDM,272,RC,,,,12873-MAIN,LOCAL,,,,,10,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRESSING QWICK NONADHESIVE 4.25X4 SUPERABSORBENT MSC5844,120.531,CDM,272,RC,A6197,HCPCS,,12301-MAIN,LOCAL,,,,,20,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
DRESSING QWICK NONADHESIVE 4.25X4 SUPERABSORBENT MSC5844,120.531,CDM,272,RC,A6197,HCPCS,,12301-MAIN,LOCAL,,,,,20,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
DRESSING QWICK NONADHESIVE 4.25X4 SUPERABSORBENT MSC5844,120.531,CDM,272,RC,A6197,HCPCS,,12301-MAIN,LOCAL,,,,,20,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
Glucose Blood Test,PX82962,CDM,300,RC,82962,CPT,,,,,,,,20,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,2.813676471,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.01,19.6
Glucose Blood Test,PX82962,CDM,300,RC,82962,CPT,,,,,,,,20,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.01,19.6
Glucose Blood Test,PX82962,CDM,300,RC,82962,CPT,,,,,,,,20,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.01,19.6
KERRAMAX CARE SUPERABSORBENT DRESSING 5X6,120.548,CDM,272,RC,A6197,HCPCS,,12362-MAIN,LOCAL,,,,,10,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,9.8
NEEDLE HYPODERMIC 22GA 1-1/2IN STERILE 305156,27200000,CDM,272,RC,A4215,HCPCS,,8887-MAIN,LOCAL,,,,,10,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Needle Insertion W/O Injection 1 or 2 Muscles,PX20560,CDM,420,RC,20560,CPT,,,,,,,,10,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,26.01
Needle Insertion W/O Injection 3 or More Muscles,PX20561,CDM,420,RC,20561,CPT,,,,,,,,10,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,26.01
PAD GROUNDING 9 FT ADULT REM E7507,27200000,CDM,272,RC,,,,504-MAIN,LOCAL,,,,,10,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Phenobarbital Assay - Ref,PX8018490,CDM,300,RC,80184,CPT,90,,,,,,,20,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
Phenobarbital Assay - Ref,PX8018490,CDM,300,RC,80184,CPT,90,,,,,,,20,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
Phenobarbital Assay - Ref,PX8018490,CDM,300,RC,80184,CPT,90,,,,,,,20,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
Primidone Assay - Ref,PX8018890,CDM,300,RC,80188,CPT,90,,,,,,,20,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
Primidone Assay - Ref,PX8018890,CDM,300,RC,80188,CPT,90,,,,,,,20,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
Primidone Assay - Ref,PX8018890,CDM,300,RC,80188,CPT,90,,,,,,,20,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER  STRAIGHT TAPER TIP 20FR PVC,120.528,CDM,272,RC,,,,12247-MAIN,LOCAL,,,,,20,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER  STRAIGHT TAPER TIP 20FR PVC,120.528,CDM,272,RC,,,,12247-MAIN,LOCAL,,,,,20,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER  STRAIGHT TAPER TIP 20FR PVC,120.528,CDM,272,RC,,,,12247-MAIN,LOCAL,,,,,20,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER  STRAIGHT TAPER TIP 24FR PVC,120.528,CDM,272,RC,,,,12248-MAIN,LOCAL,,,,,20,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER  STRAIGHT TAPER TIP 24FR PVC,120.528,CDM,272,RC,,,,12248-MAIN,LOCAL,,,,,20,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER  STRAIGHT TAPER TIP 24FR PVC,120.528,CDM,272,RC,,,,12248-MAIN,LOCAL,,,,,20,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 8FR PVC,120.528,CDM,272,RC,,,,12253-MAIN,LOCAL,,,,,20,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 8FR PVC,120.528,CDM,272,RC,,,,12253-MAIN,LOCAL,,,,,20,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 8FR PVC,120.528,CDM,272,RC,,,,12253-MAIN,LOCAL,,,,,20,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 10FR PVC,120.528,CDM,272,RC,,,,12254-MAIN,LOCAL,,,,,20,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 10FR PVC,120.528,CDM,272,RC,,,,12254-MAIN,LOCAL,,,,,20,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 10FR PVC,120.528,CDM,272,RC,,,,12254-MAIN,LOCAL,,,,,20,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 12FR PVC,120.528,CDM,272,RC,,,,12255-MAIN,LOCAL,,,,,20,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 12FR PVC,120.528,CDM,272,RC,,,,12255-MAIN,LOCAL,,,,,20,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 12FR PVC,120.528,CDM,272,RC,,,,12255-MAIN,LOCAL,,,,,20,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 16FR PVC,120.528,CDM,272,RC,,,,12256-MAIN,LOCAL,,,,,20,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 16FR PVC,120.528,CDM,272,RC,,,,12256-MAIN,LOCAL,,,,,20,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 16FR PVC,120.528,CDM,272,RC,,,,12256-MAIN,LOCAL,,,,,20,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 28FR PVC,120.528,CDM,272,RC,,,,12249-MAIN,LOCAL,,,,,20,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 28FR PVC,120.528,CDM,272,RC,,,,12249-MAIN,LOCAL,,,,,20,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 28FR PVC,120.528,CDM,272,RC,,,,12249-MAIN,LOCAL,,,,,20,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 32FR PVC,120.528,CDM,272,RC,,,,12250-MAIN,LOCAL,,,,,20,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 32FR PVC,120.528,CDM,272,RC,,,,12250-MAIN,LOCAL,,,,,20,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 32FR PVC,120.528,CDM,272,RC,,,,12250-MAIN,LOCAL,,,,,20,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 36FR PVC,120.528,CDM,272,RC,,,,12251-MAIN,LOCAL,,,,,20,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 36FR PVC,120.528,CDM,272,RC,,,,12251-MAIN,LOCAL,,,,,20,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 36FR PVC,120.528,CDM,272,RC,,,,12251-MAIN,LOCAL,,,,,20,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,9.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
Each Add'l Sequential Push New Drug,PX96375,CDM,260,RC,96375,CPT,,,,,,,,130,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,9.81,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.81,26.76
Xray Scapula Complete,PX7301001,CDM,320,RC,73010,CPT,TC,,,,,,,357,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,9.81,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.81,30.24
anastrozole 1 MG Tablet 1 Each Blister,25000000,CDM,250,RC,,,,,,60687011211,NDC,1,EA,11.13,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,9.81666,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
anastrozole 1 MG Tablet 30 Each Box,25000000,CDM,250,RC,,,,,,60687011221,NDC,1,EA,11.13,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,9.81666,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
bacitracin zinc 500 UNIT/GM Ointment 28.4 g Tube,25000000,CDM,250,RC,,,,,,49348015472,NDC,28.4,GR,20.47,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,9.8256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
bacitracin zinc 500 UNIT/GM Ointment 28.4 g Tube,25000000,CDM,250,RC,,,,,,49348015472,NDC,28.4,GR,20.47,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,9.8256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
propranolol LA 60 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,527411637,NDC,1,EA,11.05,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,9.8345,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ketorolac 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69543038810,NDC,1,EA,11.58,,First Health,Commercial,both,85,,999999999,percent of total billed charges,9.843,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 37.5 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084069811,NDC,1,EA,20.09,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.8441,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 37.5 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084069811,NDC,1,EA,20.09,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.8441,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 37.5 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084069811,NDC,1,EA,20.09,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,9.8441,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 37.5 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084069801,NDC,1,EA,20.09,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.8441,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 37.5 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084069801,NDC,1,EA,20.09,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.8441,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 37.5 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084069801,NDC,1,EA,20.09,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,9.8441,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine ER 15 MG Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,406831523,NDC,1,EA,10.05,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,9.849,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine ER 15 MG Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,406831562,NDC,1,EA,10.05,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,9.849,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
naltrexone 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406117001,NDC,1,EA,22.96,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,9.84984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Ceruloplasmin - Ref,PX8239090,CDM,300,RC,82390,CPT,90,,,,,,,78,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,9.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,76.44
DOBUTamine 1000 mcg/mL in dextrose 5% 250 mL premix 1000 mcg/ml Solution 250 mL Flex Cont,J1250.01,CDM,636,RC,J1250,HCPCS,,,,338107302,NDC,250,ML,146.73,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,9.85,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.66,9.85
Hepatitis B Surface Antibody,PX86706,CDM,300,RC,86706,CPT,,,,,,,,201,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,9.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,196.98
Protein E-Phoresis Serum,PX84165,CDM,300,RC,84165,CPT,,,,,,,,175,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,9.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,171.5
Protein Elp Interp,PX8416526,CDM,300,RC,84165,CPT,26,,,,,,,175,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,9.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,171.5
Reptilase Test - Ref,PX8563590,CDM,300,RC,85635,CPT,90,,,,,,,102,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,9.85,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.55,9.85
povidone-iodine 10 % Ointment 28.35 g Tube,63700001,CDM,250,RC,,,,,,904110231,NDC,28.35,GR,19.9,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,9.8505,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"SUTURE CHROME GUT 3-0 CP-2 27""",27200000,CDM,272,RC,,,,4967-MAIN,LOCAL,,,,,11.59,,First Health,Commercial,both,85,,999999999,percent of total billed charges,9.8515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
triamcinolone acetonide 0.1 % Cream 15 g Tube,63700001,CDM,250,RC,,,,,,168000415,NDC,15,GR,22.97,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,9.85413,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zinc oxide 20 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,536131625,NDC,60,GR,22.97,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,9.85413,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BRACE WRIST 8-IN SM LEFT 10432,120.564,CDM,273,RC,L3809,HCPCS,,12720-MAIN,LOCAL,,,,,23,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,9.867,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 8-IN SM RIGHT 10442,120.564,CDM,273,RC,L3809,HCPCS,,12716-MAIN,LOCAL,,,,,23,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,9.867,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN LG RIGHT 10464,120.564,CDM,273,RC,L3809,HCPCS,,12719-MAIN,LOCAL,,,,,23,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,9.867,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN SM LEFT 617083,120.564,CDM,273,RC,L3809,HCPCS,,12722-MAIN,LOCAL,,,,,23,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,9.867,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN SM RIGHT 10462,120.564,CDM,273,RC,L3809,HCPCS,,12717-MAIN,LOCAL,,,,,23,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,9.867,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN XL LEFT 10455,120.564,CDM,273,RC,L3809,HCPCS,,12721-MAIN,LOCAL,,,,,23,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,9.867,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN XL RIGHT 10465,120.564,CDM,273,RC,L3809,HCPCS,,12715-MAIN,LOCAL,,,,,23,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,9.867,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST WRISTPRO LEFT 10-IN LG,120.564,CDM,273,RC,L3809,HCPCS,,12724-MAIN,LOCAL,,,,,23,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,9.867,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST WRISTPRO LEFT 10-IN MED,120.564,CDM,273,RC,L3809,HCPCS,,12723-MAIN,LOCAL,,,,,23,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,9.867,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
Detection of Babesia Borrelia Miyamotoi by Amplified Nucleic Acid Probe Technique,PX8747890,CDM,300,RC,87478,CPT,90,,,,,,,23,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,9.867,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,32.17
Detection of Babesia Microtim by Amplified Nucleic Acid Probe Technique,PX8746990,CDM,300,RC,87469,CPT,90,,,,,,,23,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,9.867,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,32.17
FORCEPS COLD BIOPSY,27200000,CDM,272,RC,,,,12453-MAIN,LOCAL,,,,,23,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,9.867,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE MAXON ABSORBABLE POLYGLYCONATE 2-0 30IN MONOFILAMENT DYED TAPER POINT 1/2 CIRCLE 27MM GS-22 G,27200000,CDM,272,RC,,,,11988-MAIN,LOCAL,,,,,23,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,9.867,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE POLYSORB ABSORBABLE LACTOMER 2-0 30IN BRAIDED DYED TAPER POINT 1/2 CIRCLE 26MM V-20 VIOLET ST,27200000,CDM,272,RC,,,,11983-MAIN,LOCAL,,,,,23,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,9.867,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"D-Dimer, Quantitative - Ref",PX8537990,CDM,300,RC,85379,CPT,90,,,,,,,177,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,9.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.87,10.18
"D-Dimer, Quantitative - Ref",PX8537990,CDM,300,RC,85379,CPT,90,,,,,,,177,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,9.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.87,10.18
Ehrlichia (Anaplasma) Ab - Ref,PX8666690,CDM,300,RC,86666,CPT,90,,,,,,,163,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,9.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.87,10.18
Ehrlichia (Anaplasma) Ab - Ref,PX8666690,CDM,300,RC,86666,CPT,90,,,,,,,163,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,9.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.87,10.18
Fibrin Degradation Quant,PX85379,CDM,300,RC,85379,CPT,,,,,,,,177,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,9.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.87,10.18
Fibrin Degradation Quant,PX85379,CDM,300,RC,85379,CPT,,,,,,,,177,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,9.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.87,10.18
Hepatitis B Surface Antigen,PX87340,CDM,300,RC,87340,CPT,,,,,,,,98,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,9.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.87,10.33
Hepatitis B Surface Antigen,PX87340,CDM,300,RC,87340,CPT,,,,,,,,98,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,9.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.87,10.33
"D-Dimer, Quantitative - Ref",PX8537990,CDM,300,RC,85379,CPT,90,,,,,,,177,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,9.87,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.87,10.18
Ehrlichia (Anaplasma) Ab - Ref,PX8666690,CDM,300,RC,86666,CPT,90,,,,,,,163,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,9.87,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.87,10.18
Fibrin Degradation Quant,PX85379,CDM,300,RC,85379,CPT,,,,,,,,177,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,9.87,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.87,10.18
venlafaxine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084089695,NDC,1,EA,11.1,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,9.879,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
flecainide 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237006301,NDC,1,EA,10.85,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,9.88435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 100 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,74662411,NDC,1,EA,10.16,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,9.888728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,70677003201,NDC,1,EA,10.16,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,9.888728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601901,NDC,10,ML,211.47,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,9.89,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.89,14.43
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601910,NDC,10,ML,211.47,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,9.89,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.89,14.43
cefaDROXil 500 MG capsule 50 Each Bottle,63700001,CDM,250,RC,,,,,,16714038801,NDC,1,EA,19.98,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,9.8901,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxazosin 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079095701,NDC,1,EA,20.19,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.8931,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxazosin 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079095701,NDC,1,EA,20.19,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.8931,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxazosin 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079095701,NDC,1,EA,20.19,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,9.8931,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Bacterium Nos, Antibody - Ref",PX8660990,CDM,300,RC,86609,CPT,90,,,,,,,20,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,9.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
DRESSING QWICK NONADHESIVE 4.25X4 SUPERABSORBENT MSC5844,120.531,CDM,272,RC,A6197,HCPCS,,12301-MAIN,LOCAL,,,,,20,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,9.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
Glucose Blood Test,PX82962,CDM,300,RC,82962,CPT,,,,,,,,20,,Humana Choice Care,All Medicare plans,outpatient,49.5,,12.20545455,percent of total billed charges,9.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.01,19.6
Mycobacteria Culture - Ref,PX8711690,CDM,300,RC,87116,CPT,90,,,,,,,90,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,9.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9,88.2
Phenobarbital Assay - Ref,PX8018490,CDM,300,RC,80184,CPT,90,,,,,,,20,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,9.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
Primidone Assay - Ref,PX8018890,CDM,300,RC,80188,CPT,90,,,,,,,20,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,9.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER  STRAIGHT TAPER TIP 20FR PVC,120.528,CDM,272,RC,,,,12247-MAIN,LOCAL,,,,,20,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,9.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER  STRAIGHT TAPER TIP 24FR PVC,120.528,CDM,272,RC,,,,12248-MAIN,LOCAL,,,,,20,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,9.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 8FR PVC,120.528,CDM,272,RC,,,,12253-MAIN,LOCAL,,,,,20,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,9.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 10FR PVC,120.528,CDM,272,RC,,,,12254-MAIN,LOCAL,,,,,20,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,9.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 12FR PVC,120.528,CDM,272,RC,,,,12255-MAIN,LOCAL,,,,,20,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,9.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 16FR PVC,120.528,CDM,272,RC,,,,12256-MAIN,LOCAL,,,,,20,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,9.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 28FR PVC,120.528,CDM,272,RC,,,,12249-MAIN,LOCAL,,,,,20,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,9.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 32FR PVC,120.528,CDM,272,RC,,,,12250-MAIN,LOCAL,,,,,20,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,9.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 36FR PVC,120.528,CDM,272,RC,,,,12251-MAIN,LOCAL,,,,,20,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,9.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
Wound Cult/Afb,PX87116,CDM,300,RC,87116,CPT,,,,,,,,167,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,9.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9,163.66
anastrozole 1 MG Tablet 1 Each Blister,25000000,CDM,250,RC,,,,,,60687011211,NDC,1,EA,11.13,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,9.9057,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
anastrozole 1 MG Tablet 30 Each Box,25000000,CDM,250,RC,,,,,,60687011221,NDC,1,EA,11.13,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,9.9057,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
apixaban 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,3089431,NDC,0.5,EA,23.85,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,9.90729,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxazosin 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079095720,NDC,1,EA,20.22,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.9078,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxazosin 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079095720,NDC,1,EA,20.22,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.9078,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxazosin 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079095720,NDC,1,EA,20.22,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,9.9078,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Antithrombin III Ag Assay - Ref,PX8530190,CDM,300,RC,85301,CPT,90,,,,,,,116,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,9.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.91,113.68
hydrOXYzine 50 MG/ML Solution 1 mL Vial,J3410.01,CDM,636,RC,J3410,HCPCS,,,,517560125,NDC,0.5,ML,83.68,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,9.91,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.71,13.86
buPROPion XL 150 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,70436001004,NDC,1,EA,23.14,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,9.92706,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.2 MG/HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,378910416,NDC,1,EA,10.21,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,9.937393,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.2 MG/HR Patch 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,378910493,NDC,1,EA,10.21,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,9.937393,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Injection, Subq/Im",PX96372,CDM,260,RC,96372,CPT,,,,,,,,119,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,9.94,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.94,25.01
"Injection, Subq/Im",PX96372,CDM,260,RC,96372,CPT,,,,,,,,119,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,9.94,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.94,25.01
APPLICATOR CHLORAPREP 26ML WITH ORANGE 930815,27200000,CDM,272,RC,A4248,HCPCS,,10031-MAIN,LOCAL,,,,,19.65,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,9.9429,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
venlafaxine 37.5 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084069811,NDC,1,EA,20.09,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,9.94455,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 37.5 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084069801,NDC,1,EA,20.09,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,9.94455,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"D-Dimer, Quantitative - Ref",PX8537990,CDM,300,RC,85379,CPT,90,,,,,,,177,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,9.9479,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.87,10.18
Ehrlichia (Anaplasma) Ab - Ref,PX8666690,CDM,300,RC,86666,CPT,90,,,,,,,163,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,9.9479,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.87,10.18
Fibrin Degradation Quant,PX85379,CDM,300,RC,85379,CPT,,,,,,,,177,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,9.9479,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.87,10.18
topiramate 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034211,NDC,1,EA,11.28,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,9.94896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034201,NDC,1,EA,11.28,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,9.94896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BOOT CAST LARGE 12-5/8 ORT290010L,120.247,CDM,274,RC,L3260,HCPCS,,204-MAIN,LOCAL,,,,,27,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,9.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
BOOT CAST LARGE 12-5/8 ORT290010L,120.247,CDM,274,RC,L3260,HCPCS,,204-MAIN,LOCAL,,,,,27,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,9.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
BOOT CAST MEDIUM 08148803,120.247,CDM,274,RC,L3260,HCPCS,,203-MAIN,LOCAL,,,,,27,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,9.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
BOOT CAST MEDIUM 08148803,120.247,CDM,274,RC,L3260,HCPCS,,203-MAIN,LOCAL,,,,,27,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,9.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
BOOT CAST X-LARGE 13X5-1/2IN ORT29200XL,120.247,CDM,274,RC,L3260,HCPCS,,206-MAIN,LOCAL,,,,,27,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,9.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
BOOT CAST X-LARGE 13X5-1/2IN ORT29200XL,120.247,CDM,274,RC,L3260,HCPCS,,206-MAIN,LOCAL,,,,,27,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,9.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP LARGE MALE MQM3B,120.237,CDM,274,RC,L3260,HCPCS,,794-MAIN,LOCAL,,,,,76,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,9.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP LARGE MALE MQM3B,120.237,CDM,274,RC,L3260,HCPCS,,794-MAIN,LOCAL,,,,,76,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,9.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP LARGE SQUARE TOE WOMENS ORT30300WL,120.237,CDM,274,RC,L3260,HCPCS,,10606-MAIN,LOCAL,,,,,76,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,9.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP LARGE SQUARE TOE WOMENS ORT30300WL,120.237,CDM,274,RC,L3260,HCPCS,,10606-MAIN,LOCAL,,,,,76,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,9.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP MEDIUM SQUARE TOE MALE ORT30300MM,120.237,CDM,274,RC,L3260,HCPCS,,10603-MAIN,LOCAL,,,,,76,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,9.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP MEDIUM SQUARE TOE MALE ORT30300MM,120.237,CDM,274,RC,L3260,HCPCS,,10603-MAIN,LOCAL,,,,,76,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,9.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP MEDIUM SQUARE TOE WOMENS ORT30300WM,120.237,CDM,274,RC,L3260,HCPCS,,10605-MAIN,LOCAL,,,,,76,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,9.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP MEDIUM SQUARE TOE WOMENS ORT30300WM,120.237,CDM,274,RC,L3260,HCPCS,,10605-MAIN,LOCAL,,,,,76,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,9.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP SMALL MALE 0814-1192,120.237,CDM,274,RC,L3260,HCPCS,,803-MAIN,LOCAL,,,,,76,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,9.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP SMALL MALE 0814-1192,120.237,CDM,274,RC,L3260,HCPCS,,803-MAIN,LOCAL,,,,,76,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,9.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP SMALL SQUARE TOE WOMENS MQW1B,120.237,CDM,274,RC,L3260,HCPCS,,10604-MAIN,LOCAL,,,,,76,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,9.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP SMALL SQUARE TOE WOMENS MQW1B,120.237,CDM,274,RC,L3260,HCPCS,,10604-MAIN,LOCAL,,,,,76,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,9.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP X-LARGE MALE DS1016-16,120.237,CDM,274,RC,L3260,HCPCS,,6337-MAIN,LOCAL,,,,,35,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,9.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP X-LARGE MALE DS1016-16,120.237,CDM,274,RC,L3260,HCPCS,,6337-MAIN,LOCAL,,,,,35,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,9.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
BOOT CAST LARGE 12-5/8 ORT290010L,120.247,CDM,274,RC,L3260,HCPCS,,204-MAIN,LOCAL,,,,,27,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,9.95,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
BOOT CAST LARGE 12-5/8 ORT290010L,120.247,CDM,274,RC,L3260,HCPCS,,204-MAIN,LOCAL,,,,,27,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,9.95,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
BOOT CAST MEDIUM 08148803,120.247,CDM,274,RC,L3260,HCPCS,,203-MAIN,LOCAL,,,,,27,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,9.95,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
BOOT CAST MEDIUM 08148803,120.247,CDM,274,RC,L3260,HCPCS,,203-MAIN,LOCAL,,,,,27,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,9.95,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
BOOT CAST X-LARGE 13X5-1/2IN ORT29200XL,120.247,CDM,274,RC,L3260,HCPCS,,206-MAIN,LOCAL,,,,,27,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,9.95,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
BOOT CAST X-LARGE 13X5-1/2IN ORT29200XL,120.247,CDM,274,RC,L3260,HCPCS,,206-MAIN,LOCAL,,,,,27,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,9.95,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP LARGE MALE MQM3B,120.237,CDM,274,RC,L3260,HCPCS,,794-MAIN,LOCAL,,,,,76,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,9.95,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP LARGE MALE MQM3B,120.237,CDM,274,RC,L3260,HCPCS,,794-MAIN,LOCAL,,,,,76,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,9.95,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP LARGE SQUARE TOE WOMENS ORT30300WL,120.237,CDM,274,RC,L3260,HCPCS,,10606-MAIN,LOCAL,,,,,76,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,9.95,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP LARGE SQUARE TOE WOMENS ORT30300WL,120.237,CDM,274,RC,L3260,HCPCS,,10606-MAIN,LOCAL,,,,,76,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,9.95,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP MEDIUM SQUARE TOE MALE ORT30300MM,120.237,CDM,274,RC,L3260,HCPCS,,10603-MAIN,LOCAL,,,,,76,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,9.95,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP MEDIUM SQUARE TOE MALE ORT30300MM,120.237,CDM,274,RC,L3260,HCPCS,,10603-MAIN,LOCAL,,,,,76,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,9.95,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP MEDIUM SQUARE TOE WOMENS ORT30300WM,120.237,CDM,274,RC,L3260,HCPCS,,10605-MAIN,LOCAL,,,,,76,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,9.95,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP MEDIUM SQUARE TOE WOMENS ORT30300WM,120.237,CDM,274,RC,L3260,HCPCS,,10605-MAIN,LOCAL,,,,,76,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,9.95,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP SMALL MALE 0814-1192,120.237,CDM,274,RC,L3260,HCPCS,,803-MAIN,LOCAL,,,,,76,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,9.95,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP SMALL MALE 0814-1192,120.237,CDM,274,RC,L3260,HCPCS,,803-MAIN,LOCAL,,,,,76,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,9.95,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP SMALL SQUARE TOE WOMENS MQW1B,120.237,CDM,274,RC,L3260,HCPCS,,10604-MAIN,LOCAL,,,,,76,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,9.95,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP SMALL SQUARE TOE WOMENS MQW1B,120.237,CDM,274,RC,L3260,HCPCS,,10604-MAIN,LOCAL,,,,,76,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,9.95,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP X-LARGE MALE DS1016-16,120.237,CDM,274,RC,L3260,HCPCS,,6337-MAIN,LOCAL,,,,,35,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,9.95,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP X-LARGE MALE DS1016-16,120.237,CDM,274,RC,L3260,HCPCS,,6337-MAIN,LOCAL,,,,,35,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,9.95,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
levothyroxine 100 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,74662411,NDC,1,EA,10.16,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,9.9568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,70677003201,NDC,1,EA,10.16,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,9.9568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin-clavulanate 500-125 MG Tablet 20 Each Bottle,63700001,CDM,250,RC,,,,,,16714047701,NDC,1,EA,20.33,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.9617,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin-clavulanate 500-125 MG Tablet 20 Each Bottle,63700001,CDM,250,RC,,,,,,16714047701,NDC,1,EA,20.33,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.9617,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin-clavulanate 500-125 MG Tablet 20 Each Bottle,63700001,CDM,250,RC,,,,,,16714047701,NDC,1,EA,20.33,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,9.9617,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SLEEVE BALLOON 5MMX100MML KII STERILE CFS02,27200000,CDM,272,RC,,,,11704-MAIN,LOCAL,,,,,24,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,9.9696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STRAP CLAVICLE LARGE VP10123-040,120.191,CDM,274,RC,L3670,HCPCS,,12848-MAIN,LOCAL,,,,,24,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,9.9696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE MEDIUM VP10123-030,120.191,CDM,274,RC,L3670,HCPCS,,12847-MAIN,LOCAL,,,,,24,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,9.9696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE SMALL VP10123-020,120.191,CDM,274,RC,L3670,HCPCS,,12846-MAIN,LOCAL,,,,,24,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,9.9696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE XL 661 XL,120.191,CDM,274,RC,L3670,HCPCS,,12850-MAIN,LOCAL,,,,,24,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,9.9696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE XSMALL CHILD ORT14100XS,120.191,CDM,274,RC,L3670,HCPCS,,12849-MAIN,LOCAL,,,,,24,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,9.9696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
celecoxib 200 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904650361,NDC,0.5,EA,20.35,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.9715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
celecoxib 200 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904650361,NDC,0.5,EA,20.35,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9.9715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
celecoxib 200 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904650361,NDC,0.5,EA,20.35,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,9.9715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"AQUACEL FOAM DRESSING 4X4""",120.202,CDM,272,RC,A6209,HCPCS,,7939-MAIN,LOCAL,,,,,14,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,9.9727,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.69,22.44
AQUACEL NONADHESIVE FOAM DRESSING 4X4,120.202,CDM,272,RC,A6209,HCPCS,,12046-MAIN,LOCAL,,,,,14,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,9.9727,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.69,22.44
DRESSING HYDROFERA 2-1/2X2-1/2  BLUE READY FOAM HBRS2520,120.488,CDM,271,RC,A6209,HCPCS,,11537-MAIN,LOCAL,,,,,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,9.9727,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.69,10.02
MEPILEX ADH FOAM 4X10,120.63,CDM,272,RC,A6196,HCPCS,,8710-MAIN,LOCAL,,,,,25,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,9.9727,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,10.04
MEPILEX SOFT SILICONE 6X6,120.63,CDM,272,RC,A6196,HCPCS,,5577-MAIN,LOCAL,,,,,25,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,9.9727,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,10.04
OPTIFOAM GENTLE SA SILICCONE FACED FOAM & BOARDER,120.63,CDM,272,RC,A6196,HCPCS,,3938-MAIN,LOCAL,,,,,25,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,9.9727,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,10.04
SLING ARM CHILD PAD CANVAS NAVY 8004-02,120.54,CDM,273,RC,A4565,HCPCS,,878-MAIN,LOCAL,,,,,83,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,9.98,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.98,10.51
SLING ARM LARGE PAD CANVAS NAVY ORT11300L,120.54,CDM,273,RC,A4565,HCPCS,,870-MAIN,LOCAL,,,,,83,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,9.98,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.98,10.51
SLING ARM MEDIUM PAD CANVAS NAVY ORT11300M,120.54,CDM,273,RC,A4565,HCPCS,,872-MAIN,LOCAL,,,,,83,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,9.98,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.98,10.51
SLING ARM SMALL PAD CANVAS NAVY ORT11300S,120.54,CDM,273,RC,A4565,HCPCS,,874-MAIN,LOCAL,,,,,83,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,9.98,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.98,10.51
SLING ARM X-LARGE PAD ENVELOPE ORT11300XL,120.54,CDM,273,RC,A4565,HCPCS,,876-MAIN,LOCAL,,,,,83,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,9.98,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.98,10.51
BITE BLOCK MAXI 20MM 60FR,27200000,CDM,272,RC,,,,8144-MAIN,LOCAL,,,,,11.32,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,9.98424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
levothyroxine 25 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904694961,NDC,4,EA,11.75,,First Health,Commercial,both,85,,999999999,percent of total billed charges,9.9875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxazosin 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079095701,NDC,1,EA,20.19,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,9.99405,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
escitalopram 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904642661,NDC,0.5,EA,11.76,,First Health,Commercial,both,85,,999999999,percent of total billed charges,9.996,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
eplerenone 25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16729029315,NDC,1,EA,23.31,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,9.99999,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.2 MG/HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,378910416,NDC,1,EA,10.21,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,10.0058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 0.2 MG/HR Patch 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,378910493,NDC,1,EA,10.21,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,10.0058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
chlorhexidine 4 % Solution 118 mL Bottle,25000000,CDM,250,RC,,,,,,234057504,NDC,118,ML,24.09,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,10.006986,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
doxazosin 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079095720,NDC,1,EA,20.22,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,10.0089,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Blood Culture for Bacteria,PX87040,CDM,300,RC,87040,CPT,,,,,,,,286,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,10.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.01,10.32
Blood Culture for Bacteria,PX87040,CDM,300,RC,87040,CPT,,,,,,,,286,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,10.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.01,10.32
Blood Culture for Bacteria,PX87040,CDM,300,RC,87040,CPT,,,,,,,,286,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,10.01,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.01,10.32
CUP HEEL LARGE WONDERSPUR 4502,120.43,CDM,274,RC,L3485,HCPCS,,11385-MAIN,LOCAL,,,,,41,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,10.016,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.15,10.016
CUP HEEL LARGE WONDERSPUR 4502,120.43,CDM,274,RC,L3485,HCPCS,,11385-MAIN,LOCAL,,,,,41,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,10.016,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.15,10.016
CUP HEEL MEDIUM WONDERSPUR 4501,120.43,CDM,274,RC,L3485,HCPCS,,11384-MAIN,LOCAL,,,,,41,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,10.016,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.15,10.016
CUP HEEL MEDIUM WONDERSPUR 4501,120.43,CDM,274,RC,L3485,HCPCS,,11384-MAIN,LOCAL,,,,,41,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,10.016,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.15,10.016
CUP HEEL SMALL WONDERSPUR 4500,120.43,CDM,274,RC,L3485,HCPCS,,11383-MAIN,LOCAL,,,,,41,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,10.016,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.15,10.016
CUP HEEL SMALL WONDERSPUR 4500,120.43,CDM,274,RC,L3485,HCPCS,,11383-MAIN,LOCAL,,,,,41,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,10.016,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.15,10.016
CUP HEEL XL WONDERSPUR 4503,120.43,CDM,274,RC,L3485,HCPCS,,11386-MAIN,LOCAL,,,,,41,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,10.016,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.15,10.016
CUP HEEL XL WONDERSPUR 4503,120.43,CDM,274,RC,L3485,HCPCS,,11386-MAIN,LOCAL,,,,,41,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,10.016,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.15,10.016
aluminum & magnesium hydroxide-simethicone 200-200-20 MG/5ML Suspension 30 mL Cup,63700001,CDM,250,RC,,,,,,121176130,NDC,30,ML,24.12,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,10.019448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"AQUACEL FOAM DRESSING 4X4""",120.202,CDM,272,RC,A6209,HCPCS,,7939-MAIN,LOCAL,,,,,14,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,10.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.69,22.44
"AQUACEL FOAM DRESSING 4X4""",120.202,CDM,272,RC,A6209,HCPCS,,7939-MAIN,LOCAL,,,,,14,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,10.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.69,22.44
"AQUACEL FOAM DRESSING 4X4""",120.202,CDM,272,RC,A6209,HCPCS,,7939-MAIN,LOCAL,,,,,14,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,10.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.69,22.44
AQUACEL NONADHESIVE FOAM DRESSING 4X4,120.202,CDM,272,RC,A6209,HCPCS,,12046-MAIN,LOCAL,,,,,14,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,10.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.69,22.44
AQUACEL NONADHESIVE FOAM DRESSING 4X4,120.202,CDM,272,RC,A6209,HCPCS,,12046-MAIN,LOCAL,,,,,14,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,10.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.69,22.44
AQUACEL NONADHESIVE FOAM DRESSING 4X4,120.202,CDM,272,RC,A6209,HCPCS,,12046-MAIN,LOCAL,,,,,14,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,10.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.69,22.44
DRESSING HYDROFERA 2-1/2X2-1/2  BLUE READY FOAM HBRS2520,120.488,CDM,271,RC,A6209,HCPCS,,11537-MAIN,LOCAL,,,,,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,10.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.69,10.02
DRESSING HYDROFERA 2-1/2X2-1/2  BLUE READY FOAM HBRS2520,120.488,CDM,271,RC,A6209,HCPCS,,11537-MAIN,LOCAL,,,,,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,10.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.69,10.02
DRESSING HYDROFERA 2-1/2X2-1/2  BLUE READY FOAM HBRS2520,120.488,CDM,271,RC,A6209,HCPCS,,11537-MAIN,LOCAL,,,,,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,10.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.69,10.02
Hepatitis B Surface Antigen,PX87340,CDM,300,RC,87340,CPT,,,,,,,,98,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,10.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.87,10.33
HH Rn Initial Visit,PXG0154,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,10.02,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.02,12.03
HH Rn Routine Visit,PXG0154.01,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,10.02,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.02,12.03
ELECTRODES NEEDLE TIP PRECISE 2.4MM,27200000,CDM,272,RC,,,,12074-MAIN,LOCAL,,,,,11,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,10.021,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE ETHIBOND XTRA 0 SHSH 36 INCH,27200000,CDM,272,RC,,,,12678-MAIN,LOCAL,,,,,11,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,10.021,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Xray Scapula Complete,PX7301001,CDM,320,RC,73010,CPT,TC,,,,,,,357,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,10.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.81,30.24
Xray Scapula Complete,PX7301001,CDM,320,RC,73010,CPT,TC,,,,,,,357,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,10.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.81,30.24
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209F,CDM,510,RC,69209,CPT,,,,,,,,35,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,10.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.03,33.21
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209P,CDM,982,RC,69209,CPT,,,,,,,,113,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,10.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.03,110.74
bacitracin zinc 500 UNIT/GM Ointment 28.4 g Tube,25000000,CDM,250,RC,,,,,,49348015472,NDC,28.4,GR,20.47,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,10.0303,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
bacitracin zinc 500 UNIT/GM Ointment 28.4 g Tube,25000000,CDM,250,RC,,,,,,49348015472,NDC,28.4,GR,20.47,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,10.0303,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
bacitracin zinc 500 UNIT/GM Ointment 28.4 g Tube,25000000,CDM,250,RC,,,,,,49348015472,NDC,28.4,GR,20.47,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,10.0303,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
risperiDONE 0.25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084027011,NDC,1,EA,20.91,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,10.0368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084027011,NDC,1,EA,20.91,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,10.0368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084027001,NDC,1,EA,20.91,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,10.0368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084027001,NDC,1,EA,20.91,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,10.0368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006111,NDC,0.5,EA,56.98,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,10.03704,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.26,10.03704
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006158,NDC,0.5,EA,56.98,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,10.03704,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.26,10.03704
topiramate 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034211,NDC,1,EA,11.28,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,10.0392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034201,NDC,1,EA,11.28,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,10.0392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
MEPILEX ADH FOAM 4X10,120.63,CDM,272,RC,A6196,HCPCS,,8710-MAIN,LOCAL,,,,,25,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,10.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,10.04
MEPILEX ADH FOAM 4X10,120.63,CDM,272,RC,A6196,HCPCS,,8710-MAIN,LOCAL,,,,,25,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,10.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,10.04
MEPILEX SOFT SILICONE 6X6,120.63,CDM,272,RC,A6196,HCPCS,,5577-MAIN,LOCAL,,,,,25,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,10.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,10.04
MEPILEX SOFT SILICONE 6X6,120.63,CDM,272,RC,A6196,HCPCS,,5577-MAIN,LOCAL,,,,,25,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,10.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,10.04
OPTIFOAM GENTLE SA SILICCONE FACED FOAM & BOARDER,120.63,CDM,272,RC,A6196,HCPCS,,3938-MAIN,LOCAL,,,,,25,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,10.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,10.04
OPTIFOAM GENTLE SA SILICCONE FACED FOAM & BOARDER,120.63,CDM,272,RC,A6196,HCPCS,,3938-MAIN,LOCAL,,,,,25,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,10.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,10.04
MEPILEX ADH FOAM 4X10,120.63,CDM,272,RC,A6196,HCPCS,,8710-MAIN,LOCAL,,,,,25,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,10.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,10.04
MEPILEX SOFT SILICONE 6X6,120.63,CDM,272,RC,A6196,HCPCS,,5577-MAIN,LOCAL,,,,,25,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,10.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,10.04
OPTIFOAM GENTLE SA SILICCONE FACED FOAM & BOARDER,120.63,CDM,272,RC,A6196,HCPCS,,3938-MAIN,LOCAL,,,,,25,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,10.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,10.04
hydroxychloroquine 200 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16571068701,NDC,1,EA,23.41,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,10.04289,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clopidogrel 75 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629461,NDC,1,EA,23.42,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,10.04718,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rivastigmine 3 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,55111035360,NDC,0.5,EA,11.4,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,10.0548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenylephrine 0.25 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,69536002515,NDC,15,ML,24.21,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,10.056834,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
celecoxib 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904650261,NDC,1,EA,23.45,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,10.06005,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin-clavulanate 500-125 MG Tablet 20 Each Bottle,63700001,CDM,250,RC,,,,,,16714047701,NDC,1,EA,20.33,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,10.06335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol LA 60 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,527411637,NDC,1,EA,11.05,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,10.06655,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
povidone-iodine 10 % Ointment 28.35 g Tube,63700001,CDM,250,RC,,,,,,904110231,NDC,28.35,GR,19.9,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,10.0694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
celecoxib 200 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904650361,NDC,0.5,EA,20.35,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,10.07325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BITE BLOCK MAXI 20MM 60FR,27200000,CDM,272,RC,,,,8144-MAIN,LOCAL,,,,,11.32,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,10.0748,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Anesthesia Level 4,PX37000018,CDM,370,RC,,,,,,,,,,21,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,10.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.7234,20.58
Anesthesia Level 4,PX37000018,CDM,370,RC,,,,,,,,,,21,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,10.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.7234,20.58
ANOSCOPE LIGHTED ANOSCOPE,120.52,CDM,272,RC,,,,10235-MAIN,LOCAL,,,,,21,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,10.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.7234,20.58
ANOSCOPE LIGHTED ANOSCOPE,120.52,CDM,272,RC,,,,10235-MAIN,LOCAL,,,,,21,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,10.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.7234,20.58
"Hepatitis B Core Antibody, Total",PX86704,CDM,300,RC,86704,CPT,,,,,,,,21,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,10.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.7234,20.58
"Hepatitis B Core Antibody, Total",PX86704,CDM,300,RC,86704,CPT,,,,,,,,21,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,10.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.7234,20.58
"Spectrophotometry, Nos",PX84311,CDM,300,RC,84311,CPT,,,,,,,,21,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,10.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.43,20.58
"Spectrophotometry, Nos",PX84311,CDM,300,RC,84311,CPT,,,,,,,,21,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,10.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.43,20.58
Ph Venous Blood,PX82800,CDM,300,RC,82800,CPT,,,,,,,,147,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,10.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.09,144.06
Contrast Bath Therapy,PX97034,CDM,420,RC,97034,CPT,,,,,,,,97,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,10.1,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.1,18.45
Electrical Stimulation,PX97032,CDM,420,RC,97032,CPT,,,,,,,,135,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,10.1,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.1,18.89
Mechanical Traction Therapy,PX97012,CDM,420,RC,97012,CPT,,,,,,,,135,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,10.1,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.1,18.45
Ultrasound Therapy,PX97035,CDM,420,RC,97035,CPT,,,,,,,,135,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,10.1,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.1,18.45
fluconazole 100 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069101,NDC,0.5,EA,23.55,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,10.10295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluconazole 150 MG Tablet 12 Each Box,63700001,CDM,250,RC,,,,,,16714069211,NDC,0.333333333,EA,24.33,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,10.106682,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carvedilol 3.125 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079077101,NDC,1,EA,11.46,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,10.10772,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 14 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,43598044774,NDC,1,EA,11.46,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,10.10772,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,43598044871,NDC,1,EA,11.46,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,10.10772,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cefaDROXil 500 MG capsule 50 Each Bottle,63700001,CDM,250,RC,,,,,,16714038801,NDC,1,EA,19.98,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,10.10988,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buprenorphine 2 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,50383092493,NDC,1,EA,24.34,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,10.110836,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.14,40.7288
hydroxychloroquine 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292001101,NDC,1,EA,23.57,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,10.11153,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084089695,NDC,1,EA,11.1,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,10.1121,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Bacterium Nos, Antibody - Ref",PX8660990,CDM,300,RC,86609,CPT,90,,,,,,,20,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,10.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
DRESSING QWICK NONADHESIVE 4.25X4 SUPERABSORBENT MSC5844,120.531,CDM,272,RC,A6197,HCPCS,,12301-MAIN,LOCAL,,,,,20,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,10.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
Glucose Blood Test,PX82962,CDM,300,RC,82962,CPT,,,,,,,,20,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,10.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.01,19.6
Phenobarbital Assay - Ref,PX8018490,CDM,300,RC,80184,CPT,90,,,,,,,20,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,10.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
Primidone Assay - Ref,PX8018890,CDM,300,RC,80188,CPT,90,,,,,,,20,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,10.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER  STRAIGHT TAPER TIP 20FR PVC,120.528,CDM,272,RC,,,,12247-MAIN,LOCAL,,,,,20,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,10.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER  STRAIGHT TAPER TIP 24FR PVC,120.528,CDM,272,RC,,,,12248-MAIN,LOCAL,,,,,20,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,10.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 8FR PVC,120.528,CDM,272,RC,,,,12253-MAIN,LOCAL,,,,,20,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,10.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 10FR PVC,120.528,CDM,272,RC,,,,12254-MAIN,LOCAL,,,,,20,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,10.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 12FR PVC,120.528,CDM,272,RC,,,,12255-MAIN,LOCAL,,,,,20,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,10.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 16FR PVC,120.528,CDM,272,RC,,,,12256-MAIN,LOCAL,,,,,20,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,10.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 28FR PVC,120.528,CDM,272,RC,,,,12249-MAIN,LOCAL,,,,,20,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,10.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 32FR PVC,120.528,CDM,272,RC,,,,12250-MAIN,LOCAL,,,,,20,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,10.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 36FR PVC,120.528,CDM,272,RC,,,,12251-MAIN,LOCAL,,,,,20,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,10.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
entacapone 200 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,27241004910,NDC,1,EA,24.37,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,10.123298,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bacitracin zinc 500 UNIT/GM Ointment 28.4 g Tube,25000000,CDM,250,RC,,,,,,49348015472,NDC,28.4,GR,20.47,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,10.13265,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
risperiDONE 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635861,NDC,1,EA,21.11,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,10.1328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635861,NDC,1,EA,21.11,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,10.1328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
anastrozole 1 MG Tablet 1 Each Blister,25000000,CDM,250,RC,,,,,,60687011211,NDC,1,EA,11.13,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,10.13943,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
anastrozole 1 MG Tablet 30 Each Box,25000000,CDM,250,RC,,,,,,60687011221,NDC,1,EA,11.13,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,10.13943,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,536110888,NDC,1,EA,11.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,10.143,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rivastigmine 3 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,55111035360,NDC,0.5,EA,11.4,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,10.146,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,57237017290,NDC,1,EA,10.43,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,10.151519,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714031101,NDC,1,EA,10.43,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,10.151519,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57664039288,NDC,1,EA,10.43,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,10.151519,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tacrolimus 1 MG capsule 100 Each Bottle,J7507.01,CDM,636,RC,J7507,HCPCS,,,,16714009901,NDC,0.5,EA,11.95,,First Health,Commercial,both,85,,999999999,percent of total billed charges,10.1575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.96403,11.711
Contrast Bath Therapy,PX97034,CDM,420,RC,97034,CPT,,,,,,,,97,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,10.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.1,18.45
Contrast Bath Therapy,PX97034,CDM,420,RC,97034,CPT,,,,,,,,97,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,10.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.1,18.45
Mechanical Traction Therapy,PX97012,CDM,420,RC,97012,CPT,,,,,,,,135,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,10.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.1,18.45
Mechanical Traction Therapy,PX97012,CDM,420,RC,97012,CPT,,,,,,,,135,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,10.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.1,18.45
Ultrasound Therapy,PX97035,CDM,420,RC,97035,CPT,,,,,,,,135,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,10.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.1,18.45
Ultrasound Therapy,PX97035,CDM,420,RC,97035,CPT,,,,,,,,135,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,10.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.1,18.45
venlafaxine 37.5 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084069811,NDC,1,EA,20.09,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,10.16554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 37.5 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084069801,NDC,1,EA,20.09,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,10.16554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine Sodium 200 MCG Recon Soln 1 Each Vial,J0650.01,CDM,636,RC,J0650,HCPCS,,,,63323064710,NDC,0.0625,EA,75.75,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,10.17,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.17,10.77
levothyroxine Sodium 200 MCG Recon Soln 1 Each Vial,J0650.01,CDM,636,RC,J0650,HCPCS,,,,63323064710,NDC,0.0625,EA,75.75,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,10.17,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.17,10.77
"D-Dimer, Quantitative - Ref",PX8537990,CDM,300,RC,85379,CPT,90,,,,,,,177,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,10.18,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.87,10.18
Ehrlichia (Anaplasma) Ab - Ref,PX8666690,CDM,300,RC,86666,CPT,90,,,,,,,163,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,10.18,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.87,10.18
Fibrin Degradation Quant,PX85379,CDM,300,RC,85379,CPT,,,,,,,,177,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,10.18,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.87,10.18
Assay of Blood Lipoprotein,PX83721,CDM,300,RC,83721,CPT,,,,,,,,76,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,10.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.19,10.5
Assay of Blood Lipoprotein,PX83721,CDM,300,RC,83721,CPT,,,,,,,,76,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,10.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.19,10.5
Assay of Blood Lipoprotein,PX83721,CDM,300,RC,83721,CPT,,,,,,,,76,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,10.19,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.19,10.5
carvedilol 3.125 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079077101,NDC,1,EA,11.46,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,10.1994,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 14 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,43598044774,NDC,1,EA,11.46,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,10.1994,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,43598044871,NDC,1,EA,11.46,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,10.1994,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BAG URINARY DRAINAGE DYND15405H,120.33,CDM,271,RC,A4357,HCPCS,,9112-MAIN,LOCAL,,,,,12,,First Health,Commercial,both,85,,999999999,percent of total billed charges,10.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
peak flow meter Device 1 Each Box,800000,CDM,,,,,,,,8373075500,NDC,1,EA,12,,First Health,Commercial,both,85,,999999999,percent of total billed charges,10.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
ketorolac 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69543038810,NDC,1,EA,11.58,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,10.21356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxazosin 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079095701,NDC,1,EA,20.19,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,10.21614,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,57237017290,NDC,1,EA,10.43,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,10.2214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714031101,NDC,1,EA,10.43,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,10.2214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57664039288,NDC,1,EA,10.43,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,10.2214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"SUTURE CHROME GUT 3-0 CP-2 27""",27200000,CDM,272,RC,,,,4967-MAIN,LOCAL,,,,,11.59,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,10.22238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Antinuclear Ab(Ana) Titer - Ref,PX8603990,CDM,300,RC,86039,CPT,90,,,,,,,52,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,10.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.23,50.96
doxazosin 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079095720,NDC,1,EA,20.22,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,10.23132,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
apixaban 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,3089431,NDC,0.5,EA,23.85,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,10.23165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,536110888,NDC,1,EA,11.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,10.235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,245014789,NDC,0.5,EA,21.33,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,10.2384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,245014789,NDC,0.5,EA,21.33,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,10.2384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,245014701,NDC,0.5,EA,21.33,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,10.2384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,245014701,NDC,0.5,EA,21.33,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,10.2384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Comprehensive Metabolic Panel,PX80053,CDM,300,RC,80053,CPT,,,,,,,,396,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,10.24,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.24,10.56
Comprehensive Metabolic Panel,PX80053,CDM,300,RC,80053,CPT,,,,,,,,396,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,10.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.24,10.56
Comprehensive Metabolic Panel,PX80053,CDM,300,RC,80053,CPT,,,,,,,,396,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,10.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.24,10.56
risperiDONE 0.25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084027011,NDC,1,EA,20.91,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,10.2459,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084027011,NDC,1,EA,20.91,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,10.2459,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084027011,NDC,1,EA,20.91,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,10.2459,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084027001,NDC,1,EA,20.91,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,10.2459,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084027001,NDC,1,EA,20.91,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,10.2459,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084027001,NDC,1,EA,20.91,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,10.2459,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Joint Survey,PX7707726,CDM,982,RC,77077,CPT,26,,,,,,,286,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,10.25,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.25,280.28
Joint Survey,PX7707726,CDM,982,RC,77077,CPT,26,,,,,,,286,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,10.25,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.25,280.28
Joint Survey,PX7707726,CDM,982,RC,77077,CPT,26,,,,,,,286,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,10.25,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.25,280.28
simethicone 40 MG/0.6ML Suspension 30 mL Bottle,25000000,CDM,250,RC,,,,,,70677107801,NDC,30,ML,24.69,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,10.256226,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Hepatitis B Surface Antibody,PX86706,CDM,300,RC,86706,CPT,,,,,,,,201,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,10.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.26,10.74
Hepatitis B Surface Antibody,PX86706,CDM,300,RC,86706,CPT,,,,,,,,201,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,10.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.26,10.74
losartan 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034711,NDC,1,EA,12.08,,First Health,Commercial,both,85,,999999999,percent of total billed charges,10.268,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034701,NDC,1,EA,12.08,,First Health,Commercial,both,85,,999999999,percent of total billed charges,10.268,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 14 MG/24HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,43598044771,NDC,1,EA,12.08,,First Health,Commercial,both,85,,999999999,percent of total billed charges,10.268,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of Blood Lipoprotein,PX83721,CDM,300,RC,83721,CPT,,,,,,,,76,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,10.2688,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.19,10.5
Blood Culture for Bacteria,PX87040,CDM,300,RC,87040,CPT,,,,,,,,286,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,10.2688,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.01,10.32
Comprehensive Metabolic Panel,PX80053,CDM,300,RC,80053,CPT,,,,,,,,396,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,10.2688,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.24,10.56
Hepatitis B Surface Antigen,PX87340,CDM,300,RC,87340,CPT,,,,,,,,98,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,10.2688,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.87,10.33
Strapping of Toes,PX29550F,CDM,510,RC,29550,CPT,,,,,,,,113,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,10.2752,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.76,40.12
topiramate 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034211,NDC,1,EA,11.28,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,10.27608,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034201,NDC,1,EA,11.28,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,10.27608,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisoprolol 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714052901,NDC,1,EA,12.1,,First Health,Commercial,both,85,,999999999,percent of total billed charges,10.285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin-clavulanate 500-125 MG Tablet 20 Each Bottle,63700001,CDM,250,RC,,,,,,16714047701,NDC,1,EA,20.33,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,10.28698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pindolol 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,29033002801,NDC,1,EA,24.77,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,10.289458,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Anesthesia Level 4,PX37000018,CDM,370,RC,,,,,,,,,,21,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,10.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.7234,20.58
Anesthesia Level 4,PX37000018,CDM,370,RC,,,,,,,,,,21,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,10.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.7234,20.58
Anesthesia Level 4,PX37000018,CDM,370,RC,,,,,,,,,,21,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,10.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.7234,20.58
ANOSCOPE LIGHTED ANOSCOPE,120.52,CDM,272,RC,,,,10235-MAIN,LOCAL,,,,,21,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,10.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.7234,20.58
ANOSCOPE LIGHTED ANOSCOPE,120.52,CDM,272,RC,,,,10235-MAIN,LOCAL,,,,,21,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,10.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.7234,20.58
ANOSCOPE LIGHTED ANOSCOPE,120.52,CDM,272,RC,,,,10235-MAIN,LOCAL,,,,,21,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,10.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.7234,20.58
"Hepatitis B Core Antibody, Total",PX86704,CDM,300,RC,86704,CPT,,,,,,,,21,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,10.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.7234,20.58
"Hepatitis B Core Antibody, Total",PX86704,CDM,300,RC,86704,CPT,,,,,,,,21,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,10.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.7234,20.58
"Hepatitis B Core Antibody, Total",PX86704,CDM,300,RC,86704,CPT,,,,,,,,21,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,10.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.7234,20.58
"Spectrophotometry, Nos",PX84311,CDM,300,RC,84311,CPT,,,,,,,,21,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,10.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.43,20.58
"Spectrophotometry, Nos",PX84311,CDM,300,RC,84311,CPT,,,,,,,,21,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,10.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.43,20.58
"Spectrophotometry, Nos",PX84311,CDM,300,RC,84311,CPT,,,,,,,,21,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,10.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.43,20.58
Emergency Level I Visit,PX99281P,CDM,981,RC,99281,CPT,,,,,,,,224,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,10.2912,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.98,219.52
Facility Emergency Level 1 Visit,PX99281F,CDM,450,RC,99281,CPT,,,,,,,,329,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,10.2912,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.98,20.33
SLING ARM CHILD PAD CANVAS NAVY 8004-02,120.54,CDM,273,RC,A4565,HCPCS,,878-MAIN,LOCAL,,,,,83,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,10.2944,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.98,10.51
SLING ARM LARGE PAD CANVAS NAVY ORT11300L,120.54,CDM,273,RC,A4565,HCPCS,,870-MAIN,LOCAL,,,,,83,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,10.2944,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.98,10.51
SLING ARM MEDIUM PAD CANVAS NAVY ORT11300M,120.54,CDM,273,RC,A4565,HCPCS,,872-MAIN,LOCAL,,,,,83,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,10.2944,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.98,10.51
SLING ARM SMALL PAD CANVAS NAVY ORT11300S,120.54,CDM,273,RC,A4565,HCPCS,,874-MAIN,LOCAL,,,,,83,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,10.2944,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.98,10.51
SLING ARM X-LARGE PAD ENVELOPE ORT11300XL,120.54,CDM,273,RC,A4565,HCPCS,,876-MAIN,LOCAL,,,,,83,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,10.2944,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.98,10.51
SLEEVE BALLOON 5MMX100MML KII STERILE CFS02,27200000,CDM,272,RC,,,,11704-MAIN,LOCAL,,,,,24,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,10.296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STRAP CLAVICLE LARGE VP10123-040,120.191,CDM,274,RC,L3670,HCPCS,,12848-MAIN,LOCAL,,,,,24,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,10.296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE MEDIUM VP10123-030,120.191,CDM,274,RC,L3670,HCPCS,,12847-MAIN,LOCAL,,,,,24,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,10.296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE SMALL VP10123-020,120.191,CDM,274,RC,L3670,HCPCS,,12846-MAIN,LOCAL,,,,,24,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,10.296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE XL 661 XL,120.191,CDM,274,RC,L3670,HCPCS,,12850-MAIN,LOCAL,,,,,24,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,10.296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE XSMALL CHILD ORT14100XS,120.191,CDM,274,RC,L3670,HCPCS,,12849-MAIN,LOCAL,,,,,24,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,10.296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
celecoxib 200 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904650361,NDC,0.5,EA,20.35,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,10.2971,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54022020,NDC,1,EA,21.46,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,10.3008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54022020,NDC,1,EA,21.46,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,10.3008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zolpidem 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079072401,NDC,1,EA,24.81,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,10.306074,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zolpidem 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079072420,NDC,1,EA,24.81,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,10.306074,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ketorolac 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69543038810,NDC,1,EA,11.58,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,10.3062,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,51991060401,NDC,1,EA,10.59,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,10.307247,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,64380073706,NDC,1,EA,10.59,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,10.307247,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BITE BLOCK MAXI 20MM 60FR,27200000,CDM,272,RC,,,,8144-MAIN,LOCAL,,,,,11.32,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,10.31252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"SUTURE CHROME GUT 3-0 CP-2 27""",27200000,CDM,272,RC,,,,4967-MAIN,LOCAL,,,,,11.59,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,10.3151,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Blood Culture for Bacteria,PX87040,CDM,300,RC,87040,CPT,,,,,,,,286,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,10.32,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.01,10.32
Hepatitis a Igm Antibody,PX86709,CDM,300,RC,86709,CPT,,,,,,,,220,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,10.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.32,215.6
Hepatitis B Surface Antigen,PX87340,CDM,300,RC,87340,CPT,,,,,,,,98,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,10.33,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.87,10.33
chlorhexidine 4 % Solution 118 mL Bottle,25000000,CDM,250,RC,,,,,,234057504,NDC,118,ML,24.09,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,10.33461,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
STOCKINETTE STERILE 4X48 NON22360,27200000,CDM,272,RC,A6457,HCPCS,,10658-MAIN,LOCAL,,,,,10.62,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,10.336446,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
risperiDONE 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635861,NDC,1,EA,21.11,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,10.3439,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635861,NDC,1,EA,21.11,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,10.3439,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635861,NDC,1,EA,21.11,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,10.3439,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aluminum & magnesium hydroxide-simethicone 200-200-20 MG/5ML Suspension 30 mL Cup,63700001,CDM,250,RC,,,,,,121176130,NDC,30,ML,24.12,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,10.34748,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084027011,NDC,1,EA,20.91,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,10.35045,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084027001,NDC,1,EA,20.91,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,10.35045,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bacitracin zinc 500 UNIT/GM Ointment 28.4 g Tube,25000000,CDM,250,RC,,,,,,49348015472,NDC,28.4,GR,20.47,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,10.35782,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
rosuvastatin 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003001,NDC,0.5,EA,21.59,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,10.3632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003001,NDC,0.5,EA,21.59,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,10.3632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 25 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904694961,NDC,4,EA,11.75,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,10.3635,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
escitalopram 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904642661,NDC,0.5,EA,11.76,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,10.37232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,51991060401,NDC,1,EA,10.59,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,10.3782,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,64380073706,NDC,1,EA,10.59,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,10.3782,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline hyclate 100 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,904043004,NDC,0.5,EA,12.21,,First Health,Commercial,both,85,,999999999,percent of total billed charges,10.3785,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Carcinoembryonic Antigen,PX82378,CDM,300,RC,82378,CPT,,,,,,,,25,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,10.385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
"Gput, Quant",PX8277590,CDM,300,RC,82775,CPT,90,,,,,,,25,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,10.385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
MEPILEX ADH FOAM 4X10,120.63,CDM,272,RC,A6196,HCPCS,,8710-MAIN,LOCAL,,,,,25,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,10.385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
MEPILEX SOFT SILICONE 6X6,120.63,CDM,272,RC,A6196,HCPCS,,5577-MAIN,LOCAL,,,,,25,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,10.385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
OPTIFOAM GENTLE SA SILICCONE FACED FOAM & BOARDER,120.63,CDM,272,RC,A6196,HCPCS,,3938-MAIN,LOCAL,,,,,25,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,10.385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
Phase III Recovery Monthly,PX93799.01,CDM,943,RC,,,,,,,,,,25,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,10.385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
"Testosterone,Free - Ref",PX8440290,CDM,300,RC,84402,CPT,90,,,,,,,25,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,10.385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
rivastigmine 3 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,55111035360,NDC,0.5,EA,11.4,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,10.3854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenylephrine 0.25 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,69536002515,NDC,15,ML,24.21,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,10.38609,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
riFAMpin 150 MG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,68084035721,NDC,1,EA,10.68,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,10.394844,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Anesthesia Level 4,PX37000018,CDM,370,RC,,,,,,,,,,21,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,10.395,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.7234,20.58
ANOSCOPE LIGHTED ANOSCOPE,120.52,CDM,272,RC,,,,10235-MAIN,LOCAL,,,,,21,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,10.395,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.7234,20.58
"Hepatitis B Core Antibody, Total",PX86704,CDM,300,RC,86704,CPT,,,,,,,,21,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,10.395,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.7234,20.58
"Spectrophotometry, Nos",PX84311,CDM,300,RC,84311,CPT,,,,,,,,21,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,10.395,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.43,20.58
rivastigmine 1.5 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,62332006360,NDC,1,EA,25.03,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,10.397462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
STOCKINETTE STERILE 4X48 NON22360,27200000,CDM,272,RC,A6457,HCPCS,,10658-MAIN,LOCAL,,,,,10.62,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,10.4076,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Electrical Stimulation,PX97032,CDM,420,RC,97032,CPT,,,,,,,,135,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,10.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.1,18.89
Electrical Stimulation,PX97032,CDM,420,RC,97032,CPT,,,,,,,,135,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,10.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.1,18.89
gabapentin 800 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714033201,NDC,0.75,EA,12.25,,First Health,Commercial,both,85,,999999999,percent of total billed charges,10.4125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Ceruloplasmin - Ref,PX8239090,CDM,300,RC,82390,CPT,90,,,,,,,78,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,10.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.42,10.74
Ceruloplasmin - Ref,PX8239090,CDM,300,RC,82390,CPT,90,,,,,,,78,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,10.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.42,10.74
Ceruloplasmin - Ref,PX8239090,CDM,300,RC,82390,CPT,90,,,,,,,78,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,10.42,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.42,10.74
Hepatitis B Surface Antibody,PX86706,CDM,300,RC,86706,CPT,,,,,,,,201,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,10.42,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.26,10.74
Protein E-Phoresis Serum,PX84165,CDM,300,RC,84165,CPT,,,,,,,,175,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,10.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.42,27.36
Protein E-Phoresis Serum,PX84165,CDM,300,RC,84165,CPT,,,,,,,,175,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,10.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.42,27.36
Protein E-Phoresis Serum,PX84165,CDM,300,RC,84165,CPT,,,,,,,,175,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,10.42,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.42,27.36
glucose 40 % Gel 37.5 g Package,63700001,CDM,250,RC,,,,,,574006930,NDC,37.5,GR,25.12,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,10.434848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glucose 40 % Gel 37.5 g Tube,63700001,CDM,250,RC,,,,,,574006915,NDC,37.5,GR,25.12,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,10.434848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluconazole 150 MG Tablet 12 Each Box,63700001,CDM,250,RC,,,,,,16714069211,NDC,0.333333333,EA,24.33,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,10.43757,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carvedilol 3.125 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079077101,NDC,1,EA,11.46,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,10.44006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 14 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,43598044774,NDC,1,EA,11.46,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,10.44006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,43598044871,NDC,1,EA,11.46,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,10.44006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buprenorphine 2 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,50383092493,NDC,1,EA,24.34,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,10.44186,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.14,40.7288
risperiDONE 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635861,NDC,1,EA,21.11,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,10.44945,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,245014789,NDC,0.5,EA,21.33,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,10.4517,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,245014789,NDC,0.5,EA,21.33,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,10.4517,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,245014789,NDC,0.5,EA,21.33,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,10.4517,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,245014701,NDC,0.5,EA,21.33,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,10.4517,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,245014701,NDC,0.5,EA,21.33,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,10.4517,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,245014701,NDC,0.5,EA,21.33,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,10.4517,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
entacapone 200 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,27241004910,NDC,1,EA,24.37,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,10.45473,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 25 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904694961,NDC,4,EA,11.75,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,10.4575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209F,CDM,510,RC,69209,CPT,,,,,,,,35,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,10.46,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.03,33.21
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209F,CDM,510,RC,69209,CPT,,,,,,,,35,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,10.46,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.03,33.21
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209P,CDM,982,RC,69209,CPT,,,,,,,,113,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,10.46,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.03,110.74
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209P,CDM,982,RC,69209,CPT,,,,,,,,113,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,10.46,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.03,110.74
Remove Additional Nail Plate,PX11732F,CDM,510,RC,11732,CPT,,,,,,,,77,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,10.46,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.46,68.49
Remove Additional Nail Plate,PX11732F,CDM,510,RC,11732,CPT,,,,,,,,77,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,10.46,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.46,68.49
Remove Additional Nail Plate,PX11732F,CDM,510,RC,11732,CPT,,,,,,,,77,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,10.46,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.46,68.49
escitalopram 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904642661,NDC,0.5,EA,11.76,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,10.4664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
riFAMpin 150 MG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,68084035721,NDC,1,EA,10.68,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,10.4664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,536110888,NDC,1,EA,11.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,10.4765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Mycobacteria Culture - Ref,PX8711690,CDM,300,RC,87116,CPT,90,,,,,,,90,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,10.48,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.48,10.8
Mycobacteria Culture - Ref,PX8711690,CDM,300,RC,87116,CPT,90,,,,,,,90,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,10.48,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.48,10.8
Mycobacteria Culture - Ref,PX8711690,CDM,300,RC,87116,CPT,90,,,,,,,90,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,10.48,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.48,10.8
Wound Cult/Afb,PX87116,CDM,300,RC,87116,CPT,,,,,,,,167,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,10.48,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.48,10.8
Wound Cult/Afb,PX87116,CDM,300,RC,87116,CPT,,,,,,,,167,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,10.48,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.48,10.8
Wound Cult/Afb,PX87116,CDM,300,RC,87116,CPT,,,,,,,,167,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,10.48,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.48,10.8
Antithrombin III Ag Assay - Ref,PX8530190,CDM,300,RC,85301,CPT,90,,,,,,,116,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,10.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.49,10.81
Antithrombin III Ag Assay - Ref,PX8530190,CDM,300,RC,85301,CPT,90,,,,,,,116,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,10.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.49,10.81
Antithrombin III Ag Assay - Ref,PX8530190,CDM,300,RC,85301,CPT,90,,,,,,,116,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,10.49,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.49,10.81
Assay of Blood Lipoprotein,PX83721,CDM,300,RC,83721,CPT,,,,,,,,76,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,10.5,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.19,10.5
SLING ARM CHILD PAD CANVAS NAVY 8004-02,120.54,CDM,273,RC,A4565,HCPCS,,878-MAIN,LOCAL,,,,,83,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,10.51,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.98,10.51
SLING ARM CHILD PAD CANVAS NAVY 8004-02,120.54,CDM,273,RC,A4565,HCPCS,,878-MAIN,LOCAL,,,,,83,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,10.51,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.98,10.51
SLING ARM CHILD PAD CANVAS NAVY 8004-02,120.54,CDM,273,RC,A4565,HCPCS,,878-MAIN,LOCAL,,,,,83,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,10.51,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.98,10.51
SLING ARM LARGE PAD CANVAS NAVY ORT11300L,120.54,CDM,273,RC,A4565,HCPCS,,870-MAIN,LOCAL,,,,,83,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,10.51,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.98,10.51
SLING ARM LARGE PAD CANVAS NAVY ORT11300L,120.54,CDM,273,RC,A4565,HCPCS,,870-MAIN,LOCAL,,,,,83,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,10.51,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.98,10.51
SLING ARM LARGE PAD CANVAS NAVY ORT11300L,120.54,CDM,273,RC,A4565,HCPCS,,870-MAIN,LOCAL,,,,,83,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,10.51,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.98,10.51
SLING ARM MEDIUM PAD CANVAS NAVY ORT11300M,120.54,CDM,273,RC,A4565,HCPCS,,872-MAIN,LOCAL,,,,,83,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,10.51,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.98,10.51
SLING ARM MEDIUM PAD CANVAS NAVY ORT11300M,120.54,CDM,273,RC,A4565,HCPCS,,872-MAIN,LOCAL,,,,,83,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,10.51,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.98,10.51
SLING ARM MEDIUM PAD CANVAS NAVY ORT11300M,120.54,CDM,273,RC,A4565,HCPCS,,872-MAIN,LOCAL,,,,,83,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,10.51,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.98,10.51
SLING ARM SMALL PAD CANVAS NAVY ORT11300S,120.54,CDM,273,RC,A4565,HCPCS,,874-MAIN,LOCAL,,,,,83,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,10.51,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.98,10.51
SLING ARM SMALL PAD CANVAS NAVY ORT11300S,120.54,CDM,273,RC,A4565,HCPCS,,874-MAIN,LOCAL,,,,,83,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,10.51,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.98,10.51
SLING ARM SMALL PAD CANVAS NAVY ORT11300S,120.54,CDM,273,RC,A4565,HCPCS,,874-MAIN,LOCAL,,,,,83,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,10.51,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.98,10.51
SLING ARM X-LARGE PAD ENVELOPE ORT11300XL,120.54,CDM,273,RC,A4565,HCPCS,,876-MAIN,LOCAL,,,,,83,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,10.51,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.98,10.51
SLING ARM X-LARGE PAD ENVELOPE ORT11300XL,120.54,CDM,273,RC,A4565,HCPCS,,876-MAIN,LOCAL,,,,,83,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,10.51,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.98,10.51
SLING ARM X-LARGE PAD ENVELOPE ORT11300XL,120.54,CDM,273,RC,A4565,HCPCS,,876-MAIN,LOCAL,,,,,83,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,10.51,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.98,10.51
QUEtiapine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54022020,NDC,1,EA,21.46,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,10.5154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54022020,NDC,1,EA,21.46,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,10.5154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54022020,NDC,1,EA,21.46,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,10.5154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Coccidioides Antibody - Ref,PX8663590,CDM,300,RC,86635,CPT,90,,,,,,,94,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,10.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.52,92.12
cefoTEtan 2 g Recon Soln 1 Each Vial,800000,CDM,,,S0074,HCPCS,,,,63323038620,NDC,1,EA,240.2,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,10.53,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.53,15.49
cefoTEtan 2 g Recon Soln 1 Each Vial,800000,CDM,,,S0074,HCPCS,,,,63323038620,NDC,1,EA,240.2,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,10.53,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.53,15.49
tacrolimus 1 MG capsule 100 Each Bottle,J7507.01,CDM,636,RC,J7507,HCPCS,,,,16714009901,NDC,0.5,EA,11.95,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,10.5399,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.96403,11.711
ketorolac 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69543038810,NDC,1,EA,11.58,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,10.54938,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,245014789,NDC,0.5,EA,21.33,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,10.55835,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,245014701,NDC,0.5,EA,21.33,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,10.55835,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"SUTURE CHROME GUT 3-0 CP-2 27""",27200000,CDM,272,RC,,,,4967-MAIN,LOCAL,,,,,11.59,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,10.55849,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Myoglobin - Ref,PX8387490,CDM,300,RC,83874,CPT,90,,,,,,,22,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,10.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.1388,21.56
Myoglobin - Ref,PX8387490,CDM,300,RC,83874,CPT,90,,,,,,,22,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,10.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.1388,21.56
SUTURE POLYSORB BRAIDED ABSORBABLE VIOLET SIZE 0 30IN WITH 5/8 CIRCLE TAPER POINT 27MM NEEDLE,27200000,CDM,272,RC,,,,11985-MAIN,LOCAL,,,,,22,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,10.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE POLYSORB BRAIDED ABSORBABLE VIOLET SIZE 0 30IN WITH 5/8 CIRCLE TAPER POINT 27MM NEEDLE,27200000,CDM,272,RC,,,,11985-MAIN,LOCAL,,,,,22,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,10.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TEGADERM CHLORHEXIDINE-GLUCONATE,120.356,CDM,272,RC,A4221,HCPCS,,10708-MAIN,LOCAL,,,,,22,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,10.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.1388,21.56
TEGADERM CHLORHEXIDINE-GLUCONATE,120.356,CDM,272,RC,A4221,HCPCS,,10708-MAIN,LOCAL,,,,,22,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,10.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.1388,21.56
Comprehensive Metabolic Panel,PX80053,CDM,300,RC,80053,CPT,,,,,,,,396,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,10.56,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.24,10.56
flecainide 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237006301,NDC,1,EA,10.85,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,10.560305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Immunoassay - Ref,PX8351690,CDM,300,RC,83516,CPT,90,,,,,,,15,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,10.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.231,14.7
"Lab Immunoassay, Non Antibody",PX83516,CDM,300,RC,83516,CPT,,,,,,,,99,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,10.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.57,97.02
temporary tooth filling repair Misc 1 Each Package,25000000,CDM,250,RC,,,,,,47701000123,NDC,1,EA,25.46,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,10.576084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
rosuvastatin 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003001,NDC,0.5,EA,21.59,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,10.5791,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003001,NDC,0.5,EA,21.59,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,10.5791,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003001,NDC,0.5,EA,21.59,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,10.5791,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084027011,NDC,1,EA,20.91,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,10.58046,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084027001,NDC,1,EA,20.91,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,10.58046,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BAG URINARY DRAINAGE DYND15405H,120.33,CDM,271,RC,A4357,HCPCS,,9112-MAIN,LOCAL,,,,,12,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,10.584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
peak flow meter Device 1 Each Box,800000,CDM,,,,,,,,8373075500,NDC,1,EA,12,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,10.584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
PACK BASIN BASIC SINGLE DYNJ06610A,27200000,CDM,272,RC,,,,10921-MAIN,LOCAL,,,,,25.48,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,10.584392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Antithrombin III Ag Assay - Ref,PX8530190,CDM,300,RC,85301,CPT,90,,,,,,,116,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,10.5897,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.49,10.81
Ceruloplasmin - Ref,PX8239090,CDM,300,RC,82390,CPT,90,,,,,,,78,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,10.5897,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.42,10.74
Hepatitis B Surface Antibody,PX86706,CDM,300,RC,86706,CPT,,,,,,,,201,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,10.5897,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.26,10.74
Mycobacteria Culture - Ref,PX8711690,CDM,300,RC,87116,CPT,90,,,,,,,90,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,10.5897,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.48,10.8
Protein E-Phoresis Serum,PX84165,CDM,300,RC,84165,CPT,,,,,,,,175,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,10.5897,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.42,27.36
Wound Cult/Afb,PX87116,CDM,300,RC,87116,CPT,,,,,,,,167,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,10.5897,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.48,10.8
Creatine Mb Fraction,PX82553,CDM,300,RC,82553,CPT,,,,,,,,353,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,10.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.59,345.94
simethicone 40 MG/0.6ML Suspension 30 mL Bottle,25000000,CDM,250,RC,,,,,,70677107801,NDC,30,ML,24.69,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,10.59201,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Assay of Lactic Acid,PX83605,CDM,300,RC,83605,CPT,,,,,,,,150,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,10.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.61,147
Hepatitis Be Antibody - Ref,PX8670790,CDM,300,RC,86707,CPT,90,,,,,,,192,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,10.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.61,188.16
hydrocortisone 1 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,45802043803,NDC,28,GR,25.55,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,10.61347,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54022020,NDC,1,EA,21.46,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,10.6227,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Anesthesia Level 4,PX37000018,CDM,370,RC,,,,,,,,,,21,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,10.626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.7234,20.58
ANOSCOPE LIGHTED ANOSCOPE,120.52,CDM,272,RC,,,,10235-MAIN,LOCAL,,,,,21,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,10.626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.7234,20.58
"Hepatitis B Core Antibody, Total",PX86704,CDM,300,RC,86704,CPT,,,,,,,,21,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,10.626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.7234,20.58
"Spectrophotometry, Nos",PX84311,CDM,300,RC,84311,CPT,,,,,,,,21,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,10.626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.43,20.58
pindolol 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,29033002801,NDC,1,EA,24.77,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,10.62633,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 1 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,472034356,NDC,28,GR,22.15,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,10.632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 1 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,472034356,NDC,28,GR,22.15,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,10.632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
flecainide 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237006301,NDC,1,EA,10.85,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,10.633,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tacrolimus 1 MG capsule 100 Each Bottle,J7507.01,CDM,636,RC,J7507,HCPCS,,,,16714009901,NDC,0.5,EA,11.95,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,10.6355,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.96403,11.711
zolpidem 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079072401,NDC,1,EA,24.81,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,10.64349,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zolpidem 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079072420,NDC,1,EA,24.81,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,10.64349,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Vitamin a - Ref,PX8459090,CDM,300,RC,84590,CPT,90,,,,,,,63,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,10.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.65,61.74
losartan 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034711,NDC,1,EA,12.08,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,10.65456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034701,NDC,1,EA,12.08,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,10.65456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 14 MG/24HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,43598044771,NDC,1,EA,12.08,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,10.65456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 100 MG/5ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,68094049459,NDC,20,ML,22.2,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,10.656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 100 MG/5ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,68094049459,NDC,20,ML,22.2,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,10.656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Ph Venous Blood,PX82800,CDM,300,RC,82800,CPT,,,,,,,,147,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,10.67,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.67,11
Ph Venous Blood,PX82800,CDM,300,RC,82800,CPT,,,,,,,,147,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,10.67,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.67,11
Ph Venous Blood,PX82800,CDM,300,RC,82800,CPT,,,,,,,,147,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,10.67,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.67,11
bisoprolol 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714052901,NDC,1,EA,12.1,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,10.6722,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BAG URINARY DRAINAGE DYND15405H,120.33,CDM,271,RC,A4357,HCPCS,,9112-MAIN,LOCAL,,,,,12,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,10.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
peak flow meter Device 1 Each Box,800000,CDM,,,,,,,,8373075500,NDC,1,EA,12,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,10.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Strapping of Ankle,PX29540F,CDM,420,RC,29540,CPT,,,,,,,,271,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,10.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.68,58.11
Strapping of Ankle,PX29540F,CDM,420,RC,29540,CPT,,,,,,,,271,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,10.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.68,58.11
Strapping of Ankle,PX29540F,CDM,420,RC,29540,CPT,,,,,,,,271,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,10.68,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.68,58.11
risperiDONE 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635861,NDC,1,EA,21.11,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,10.68166,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003001,NDC,0.5,EA,21.59,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,10.68705,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Blood Viscosity Examination,PX85810,CDM,300,RC,85810,CPT,,,,,,,,95,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,10.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.7,93.1
levothyroxine 25 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904694961,NDC,4,EA,11.75,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,10.70425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ELECTRODES NEEDLE TIP PRECISE 2.4MM,27200000,CDM,272,RC,,,,12074-MAIN,LOCAL,,,,,11,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,10.7063,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE ETHIBOND XTRA 0 SHSH 36 INCH,27200000,CDM,272,RC,,,,12678-MAIN,LOCAL,,,,,11,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,10.7063,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
escitalopram 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904642661,NDC,0.5,EA,11.76,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,10.71336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079049801,NDC,1,EA,22.34,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,10.7232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079049801,NDC,1,EA,22.34,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,10.7232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Carcinoembryonic Antigen,PX82378,CDM,300,RC,82378,CPT,,,,,,,,25,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,10.725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
"Gput, Quant",PX8277590,CDM,300,RC,82775,CPT,90,,,,,,,25,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,10.725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
MEPILEX ADH FOAM 4X10,120.63,CDM,272,RC,A6196,HCPCS,,8710-MAIN,LOCAL,,,,,25,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,10.725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
MEPILEX SOFT SILICONE 6X6,120.63,CDM,272,RC,A6196,HCPCS,,5577-MAIN,LOCAL,,,,,25,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,10.725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
OPTIFOAM GENTLE SA SILICCONE FACED FOAM & BOARDER,120.63,CDM,272,RC,A6196,HCPCS,,3938-MAIN,LOCAL,,,,,25,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,10.725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
Phase III Recovery Monthly,PX93799.01,CDM,943,RC,,,,,,,,,,25,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,10.725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
"Testosterone,Free - Ref",PX8440290,CDM,300,RC,84402,CPT,90,,,,,,,25,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,10.725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
amoxicillin 125 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,143988815,NDC,150,ML,25.84,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,10.733936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 125 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,781603955,NDC,150,ML,25.84,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,10.733936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rivastigmine 1.5 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,62332006360,NDC,1,EA,25.03,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,10.73787,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Ceruloplasmin - Ref,PX8239090,CDM,300,RC,82390,CPT,90,,,,,,,78,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,10.74,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.42,10.74
Hepatitis B Surface Antibody,PX86706,CDM,300,RC,86706,CPT,,,,,,,,201,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,10.74,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.26,10.74
simethicone 40 MG/0.6ML Suspension 30 mL Bottle,25000000,CDM,250,RC,,,,,,904589430,NDC,30,ML,22.39,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,10.7472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
simethicone 40 MG/0.6ML Suspension 30 mL Bottle,25000000,CDM,250,RC,,,,,,904589430,NDC,30,ML,22.39,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,10.7472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
losartan 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034711,NDC,1,EA,12.08,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,10.7512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034701,NDC,1,EA,12.08,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,10.7512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 14 MG/24HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,43598044771,NDC,1,EA,12.08,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,10.7512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propranolol LA 60 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,527411637,NDC,1,EA,11.05,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,10.754965,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisoprolol 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714052901,NDC,1,EA,12.1,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,10.769,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline hyclate 100 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,904043004,NDC,0.5,EA,12.21,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,10.76922,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine Sodium 200 MCG Recon Soln 1 Each Vial,J0650.01,CDM,636,RC,J0650,HCPCS,,,,63323064710,NDC,0.0625,EA,75.75,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,10.77,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.17,10.77
glucose 40 % Gel 37.5 g Package,63700001,CDM,250,RC,,,,,,574006930,NDC,37.5,GR,25.12,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,10.77648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glucose 40 % Gel 37.5 g Tube,63700001,CDM,250,RC,,,,,,574006915,NDC,37.5,GR,25.12,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,10.77648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ELECTRODES NEEDLE TIP PRECISE 2.4MM,27200000,CDM,272,RC,,,,12074-MAIN,LOCAL,,,,,11,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,10.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Myoglobin - Ref,PX8387490,CDM,300,RC,83874,CPT,90,,,,,,,22,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,10.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.1388,21.56
Myoglobin - Ref,PX8387490,CDM,300,RC,83874,CPT,90,,,,,,,22,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,10.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.1388,21.56
Myoglobin - Ref,PX8387490,CDM,300,RC,83874,CPT,90,,,,,,,22,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,10.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.1388,21.56
SUTURE ETHIBOND XTRA 0 SHSH 36 INCH,27200000,CDM,272,RC,,,,12678-MAIN,LOCAL,,,,,11,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,10.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE POLYSORB BRAIDED ABSORBABLE VIOLET SIZE 0 30IN WITH 5/8 CIRCLE TAPER POINT 27MM NEEDLE,27200000,CDM,272,RC,,,,11985-MAIN,LOCAL,,,,,22,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,10.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE POLYSORB BRAIDED ABSORBABLE VIOLET SIZE 0 30IN WITH 5/8 CIRCLE TAPER POINT 27MM NEEDLE,27200000,CDM,272,RC,,,,11985-MAIN,LOCAL,,,,,22,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,10.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE POLYSORB BRAIDED ABSORBABLE VIOLET SIZE 0 30IN WITH 5/8 CIRCLE TAPER POINT 27MM NEEDLE,27200000,CDM,272,RC,,,,11985-MAIN,LOCAL,,,,,22,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,10.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TEGADERM CHLORHEXIDINE-GLUCONATE,120.356,CDM,272,RC,A4221,HCPCS,,10708-MAIN,LOCAL,,,,,22,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,10.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.1388,21.56
TEGADERM CHLORHEXIDINE-GLUCONATE,120.356,CDM,272,RC,A4221,HCPCS,,10708-MAIN,LOCAL,,,,,22,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,10.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.1388,21.56
TEGADERM CHLORHEXIDINE-GLUCONATE,120.356,CDM,272,RC,A4221,HCPCS,,10708-MAIN,LOCAL,,,,,22,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,10.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.1388,21.56
midazolam 2 MG/ML Syrup 5 mL Cup,63700001,CDM,250,RC,,,,,,68094076459,NDC,2.5,ML,22.47,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,10.7856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
midazolam 2 MG/ML Syrup 5 mL Cup,63700001,CDM,250,RC,,,,,,68094076459,NDC,2.5,ML,22.47,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,10.7856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
neomycin-bacitracin-polymyxin 3.5-400-5000 Ointment 28.4 g Tube,25000000,CDM,250,RC,,,,,,713026831,NDC,28.4,GR,22.47,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,10.7856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
neomycin-bacitracin-polymyxin 3.5-400-5000 Ointment 28.4 g Tube,25000000,CDM,250,RC,,,,,,713026831,NDC,28.4,GR,22.47,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,10.7856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
amiodarone 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,245014789,NDC,0.5,EA,21.33,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,10.79298,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,245014701,NDC,0.5,EA,21.33,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,10.79298,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
apixaban 5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,3089421,NDC,0.5,EA,22.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,10.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
apixaban 5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,3089421,NDC,0.5,EA,22.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,10.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Mycobacteria Culture - Ref,PX8711690,CDM,300,RC,87116,CPT,90,,,,,,,90,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,10.8,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.48,10.8
Wound Cult/Afb,PX87116,CDM,300,RC,87116,CPT,,,,,,,,167,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,10.8,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.48,10.8
SPIT SOCK HOODS 16719,120.367,CDM,271,RC,,,,10820-MAIN,LOCAL,,,,,26,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,10.8004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.8004,25.48
TEGADERM CHLORHEXIDINE 5X5 CHG IV PORT,120.207,CDM,272,RC,A6268,HCPCS,,10163-MAIN,LOCAL,,,,,26,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,10.8004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.8004,25.48
venlafaxine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084089695,NDC,1,EA,11.1,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,10.80363,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 800 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714033201,NDC,0.75,EA,12.25,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,10.8045,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Antithrombin III Ag Assay - Ref,PX8530190,CDM,300,RC,85301,CPT,90,,,,,,,116,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,10.81,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.49,10.81
propranolol LA 60 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,527411637,NDC,1,EA,11.05,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,10.829,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Antinuclear Ab(Ana) Titer - Ref,PX8603990,CDM,300,RC,86039,CPT,90,,,,,,,52,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,10.83,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.83,11.16
Antinuclear Ab(Ana) Titer - Ref,PX8603990,CDM,300,RC,86039,CPT,90,,,,,,,52,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,10.83,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.83,11.16
Antinuclear Ab(Ana) Titer - Ref,PX8603990,CDM,300,RC,86039,CPT,90,,,,,,,52,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,10.83,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.83,11.16
anastrozole 1 MG Tablet 1 Each Blister,25000000,CDM,250,RC,,,,,,60687011211,NDC,1,EA,11.13,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,10.832829,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
anastrozole 1 MG Tablet 30 Each Box,25000000,CDM,250,RC,,,,,,60687011221,NDC,1,EA,11.13,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,10.832829,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tamsulosin 0.4 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904640161,NDC,1,EA,22.6,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,10.848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tamsulosin 0.4 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904640161,NDC,1,EA,22.6,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,10.848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 1 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,472034356,NDC,28,GR,22.15,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,10.8535,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 1 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,472034356,NDC,28,GR,22.15,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,10.8535,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 1 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,472034356,NDC,28,GR,22.15,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,10.8535,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
QUEtiapine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54022020,NDC,1,EA,21.46,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,10.85876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
GOLIMumab 50 MG/4ML Solution 4 mL Vial,J1602.01,CDM,636,RC,J1602,HCPCS,,,,57894035001,NDC,4,ML,3709.76,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,10.86,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.86,12.34
doxycycline hyclate 100 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,904043004,NDC,0.5,EA,12.21,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,10.8669,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Antithrombin III Activity - Ref,PX8530090,CDM,300,RC,85300,CPT,90,,,,,,,158,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,10.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.87,154.84
gabapentin 600 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268035111,NDC,1,EA,12.79,,First Health,Commercial,both,85,,999999999,percent of total billed charges,10.8715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 600 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268035115,NDC,1,EA,12.79,,First Health,Commercial,both,85,,999999999,percent of total billed charges,10.8715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 100 MG/5ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,68094049459,NDC,20,ML,22.2,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,10.878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 100 MG/5ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,68094049459,NDC,20,ML,22.2,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,10.878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 100 MG/5ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,68094049459,NDC,20,ML,22.2,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,10.878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084089695,NDC,1,EA,11.1,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,10.878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
inFLIXimab-dyyb 100 MG Recon Soln 1 Each Vial,Q5103.01,CDM,636,RC,Q5103,HCPCS,,,,69080901,NDC,1,EA,1930.42,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,10.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.88,14.29
inFLIXimab-dyyb 100 MG Recon Soln 1 Each Vial,Q5103.01,CDM,636,RC,Q5103,HCPCS,,,,69080901,NDC,1,EA,1930.42,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,10.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.88,14.29
tacrolimus 1 MG capsule 100 Each Bottle,J7507.01,CDM,636,RC,J7507,HCPCS,,,,16714009901,NDC,0.5,EA,11.95,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,10.88645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.96403,11.711
Myoglobin - Ref,PX8387490,CDM,300,RC,83874,CPT,90,,,,,,,22,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,10.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.1388,21.56
SUTURE POLYSORB BRAIDED ABSORBABLE VIOLET SIZE 0 30IN WITH 5/8 CIRCLE TAPER POINT 27MM NEEDLE,27200000,CDM,272,RC,,,,11985-MAIN,LOCAL,,,,,22,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,10.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TEGADERM CHLORHEXIDINE-GLUCONATE,120.356,CDM,272,RC,A4221,HCPCS,,10708-MAIN,LOCAL,,,,,22,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,10.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.1388,21.56
Xray Spine Single Tc,PX7202001,CDM,320,RC,72020,CPT,TC,,,,,,,113,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,10.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.9,32.87
Xray Spine Single Tc,PX7202001,CDM,320,RC,72020,CPT,TC,,,,,,,113,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,10.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.9,32.87
gabapentin 800 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714033201,NDC,0.75,EA,12.25,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,10.9025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
inFLIXimab-dyyb 100 MG Recon Soln 1 Each Vial,Q5103.01,CDM,636,RC,Q5103,HCPCS,,,,69080901,NDC,1,EA,1930.42,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,10.90563,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.88,14.29
anastrozole 1 MG Tablet 1 Each Blister,25000000,CDM,250,RC,,,,,,60687011211,NDC,1,EA,11.13,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,10.9074,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
anastrozole 1 MG Tablet 30 Each Box,25000000,CDM,250,RC,,,,,,60687011221,NDC,1,EA,11.13,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,10.9074,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Antinuclear Ab(Ana) Titer - Ref,PX8603990,CDM,300,RC,86039,CPT,90,,,,,,,52,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,10.9106,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.83,11.16
Hepatitis a Igm Antibody,PX86709,CDM,300,RC,86709,CPT,,,,,,,,220,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,10.9106,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.9106,11.26
Ph Venous Blood,PX82800,CDM,300,RC,82800,CPT,,,,,,,,147,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,10.9106,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.67,11
fomepizole 1 GM/ML Solution 1.5 mL Vial,J1451.01,CDM,636,RC,J1451,HCPCS,,,,39822071001,NDC,1.5,ML,2600,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,10.912,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.9,15.3
fomepizole 1 GM/ML Solution 1.5 mL Vial,J1451.01,CDM,636,RC,J1451,HCPCS,,,,39822071001,NDC,1.5,ML,2600,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,10.912,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.9,15.3
nicotine 21 MG/24HR Patch 24 Hour 7 Each Box,63700001,CDM,250,RC,,,,,,536589653,NDC,1,EA,12.84,,First Health,Commercial,both,85,,999999999,percent of total billed charges,10.914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
US Urine Capacity Measure,PX51798F,CDM,510,RC,51798,CPT,,,,,,,,96,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,10.9174,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.76,23.52
Hepatitis a Igm Antibody,PX86709,CDM,300,RC,86709,CPT,,,,,,,,220,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,10.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.9106,11.26
Hepatitis a Igm Antibody,PX86709,CDM,300,RC,86709,CPT,,,,,,,,220,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,10.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.9106,11.26
Hepatitis a Igm Antibody,PX86709,CDM,300,RC,86709,CPT,,,,,,,,220,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,10.92,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.9106,11.26
temporary tooth filling repair Misc 1 Each Package,25000000,CDM,250,RC,,,,,,47701000123,NDC,1,EA,25.46,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,10.92234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
rosuvastatin 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003001,NDC,0.5,EA,21.59,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,10.92454,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Topiramate - Ref,PX8020190,CDM,300,RC,80201,CPT,90,,,,,,,195,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,10.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.93,191.1
PACK BASIN BASIC SINGLE DYNJ06610A,27200000,CDM,272,RC,,,,10921-MAIN,LOCAL,,,,,25.48,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,10.93092,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152F,CDM,370,RC,99152,CPT,,,,,,,,235,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,10.931,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,87.84
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152P,CDM,983,RC,99152,CPT,,,,,,,,90,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,10.931,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,88.2
BAG URINARY DRAINAGE DYND15405H,120.33,CDM,271,RC,A4357,HCPCS,,9112-MAIN,LOCAL,,,,,12,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,10.932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
peak flow meter Device 1 Each Box,800000,CDM,,,,,,,,8373075500,NDC,1,EA,12,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,10.932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Smking Cess 4-10 Min,PX99406F,CDM,942,RC,99406,CPT,,,,,,,,65,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,10.9344,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.2,26.31
Smking Cess 4-10 Min,PX99406P,CDM,983,RC,99406,CPT,,,,,,,,43,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,10.9344,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.2,42.14
Resp Muscles 1:1 per 15 Min,PXG0237,CDM,948,RC,G0237,HCPCS,,,,,,,,65,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,10.9378,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.76,19.78
"US Complete Joint, Realtime W/ Img Tc",PX7688101,CDM,402,RC,76881,CPT,TC,,,,,,,415,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,10.9412,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.2,21.69
lamoTRIgine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079049801,NDC,1,EA,22.34,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,10.9466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079049801,NDC,1,EA,22.34,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,10.9466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079049801,NDC,1,EA,22.34,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,10.9466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,75826011410,NDC,1,EA,12.89,,First Health,Commercial,both,85,,999999999,percent of total billed charges,10.9565,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56016901,NDC,1,EA,12.89,,First Health,Commercial,both,85,,999999999,percent of total billed charges,10.9565,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 1 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,45802043803,NDC,28,GR,25.55,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,10.96095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 1 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,472034356,NDC,28,GR,22.15,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,10.96425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simethicone 40 MG/0.6ML Suspension 30 mL Bottle,25000000,CDM,250,RC,,,,,,904589430,NDC,30,ML,22.39,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,10.9711,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
simethicone 40 MG/0.6ML Suspension 30 mL Bottle,25000000,CDM,250,RC,,,,,,904589430,NDC,30,ML,22.39,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,10.9711,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
simethicone 40 MG/0.6ML Suspension 30 mL Bottle,25000000,CDM,250,RC,,,,,,904589430,NDC,30,ML,22.39,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,10.9711,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
topiramate 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034211,NDC,1,EA,11.28,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,10.978824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034201,NDC,1,EA,11.28,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,10.978824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Ag Detect Nos Eia Mult,PX87449,CDM,300,RC,87449,CPT,,,,,,,,193,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,10.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,189.14
Aspergillus Ag - Ref,PX8730590,CDM,300,RC,87305,CPT,90,,,,,,,141,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,10.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,138.18
"Clostridium Ag, Eia",PX87324,CDM,300,RC,87324,CPT,,,,,,,,99,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,10.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,97.02
Giardia,PX87329,CDM,300,RC,87329,CPT,,,,,,,,117,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,10.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,114.66
"Infect Ag,Eia, Nos, Ea - Ref",PX8744990,CDM,300,RC,87449,CPT,90,,,,,,,187,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,10.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,183.26
ibuprofen 100 MG/5ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,68094049459,NDC,20,ML,22.2,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,10.989,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Complement; Antigen, Each Component",PX86160,CDM,300,RC,86160,CPT,,,,,,,,124,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11,121.52
Ph Venous Blood,PX82800,CDM,300,RC,82800,CPT,,,,,,,,147,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,11,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.67,11
losartan 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034711,NDC,1,EA,12.08,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,11.00488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034701,NDC,1,EA,12.08,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,11.00488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 14 MG/24HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,43598044771,NDC,1,EA,12.08,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,11.00488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
midazolam 2 MG/ML Syrup 5 mL Cup,63700001,CDM,250,RC,,,,,,68094076459,NDC,2.5,ML,22.47,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.0103,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
midazolam 2 MG/ML Syrup 5 mL Cup,63700001,CDM,250,RC,,,,,,68094076459,NDC,2.5,ML,22.47,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.0103,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
midazolam 2 MG/ML Syrup 5 mL Cup,63700001,CDM,250,RC,,,,,,68094076459,NDC,2.5,ML,22.47,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,11.0103,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
neomycin-bacitracin-polymyxin 3.5-400-5000 Ointment 28.4 g Tube,25000000,CDM,250,RC,,,,,,713026831,NDC,28.4,GR,22.47,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.0103,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
neomycin-bacitracin-polymyxin 3.5-400-5000 Ointment 28.4 g Tube,25000000,CDM,250,RC,,,,,,713026831,NDC,28.4,GR,22.47,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.0103,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
neomycin-bacitracin-polymyxin 3.5-400-5000 Ointment 28.4 g Tube,25000000,CDM,250,RC,,,,,,713026831,NDC,28.4,GR,22.47,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,11.0103,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
PREP KIT SKIN PREMIUM,27200000,CDM,272,RC,,,,4108-MAIN,LOCAL,,,,,12.96,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
BITE BLOCK MAXI 20MM 60FR,27200000,CDM,272,RC,,,,8144-MAIN,LOCAL,,,,,11.32,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,11.017756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
naltrexone 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406117001,NDC,1,EA,22.96,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,11.0208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
naltrexone 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406117001,NDC,1,EA,22.96,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,11.0208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisoprolol 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714052901,NDC,1,EA,12.1,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,11.0231,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
apixaban 5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,3089421,NDC,0.5,EA,22.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
apixaban 5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,3089421,NDC,0.5,EA,22.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
apixaban 5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,3089421,NDC,0.5,EA,22.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,11.025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
triamcinolone acetonide 0.1 % Cream 15 g Tube,63700001,CDM,250,RC,,,,,,168000415,NDC,15,GR,22.97,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,11.0256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
triamcinolone acetonide 0.1 % Cream 15 g Tube,63700001,CDM,250,RC,,,,,,168000415,NDC,15,GR,22.97,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,11.0256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zinc oxide 20 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,536131625,NDC,60,GR,22.97,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,11.0256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zinc oxide 20 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,536131625,NDC,60,GR,22.97,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,11.0256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BRACE WRIST 8-IN SM LEFT 10432,120.564,CDM,273,RC,L3809,HCPCS,,12720-MAIN,LOCAL,,,,,23,,Health Partners,Health Partners Care Plans,both,48,,34.92,percent of total billed charges,11.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 8-IN SM LEFT 10432,120.564,CDM,273,RC,L3809,HCPCS,,12720-MAIN,LOCAL,,,,,23,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,11.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 8-IN SM RIGHT 10442,120.564,CDM,273,RC,L3809,HCPCS,,12716-MAIN,LOCAL,,,,,23,,Health Partners,Health Partners Care Plans,both,48,,34.92,percent of total billed charges,11.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 8-IN SM RIGHT 10442,120.564,CDM,273,RC,L3809,HCPCS,,12716-MAIN,LOCAL,,,,,23,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,11.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN LG RIGHT 10464,120.564,CDM,273,RC,L3809,HCPCS,,12719-MAIN,LOCAL,,,,,23,,Health Partners,Health Partners Care Plans,both,48,,34.92,percent of total billed charges,11.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN LG RIGHT 10464,120.564,CDM,273,RC,L3809,HCPCS,,12719-MAIN,LOCAL,,,,,23,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,11.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN SM LEFT 617083,120.564,CDM,273,RC,L3809,HCPCS,,12722-MAIN,LOCAL,,,,,23,,Health Partners,Health Partners Care Plans,both,48,,34.92,percent of total billed charges,11.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN SM LEFT 617083,120.564,CDM,273,RC,L3809,HCPCS,,12722-MAIN,LOCAL,,,,,23,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,11.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN SM RIGHT 10462,120.564,CDM,273,RC,L3809,HCPCS,,12717-MAIN,LOCAL,,,,,23,,Health Partners,Health Partners Care Plans,both,48,,34.92,percent of total billed charges,11.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN SM RIGHT 10462,120.564,CDM,273,RC,L3809,HCPCS,,12717-MAIN,LOCAL,,,,,23,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,11.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN XL LEFT 10455,120.564,CDM,273,RC,L3809,HCPCS,,12721-MAIN,LOCAL,,,,,23,,Health Partners,Health Partners Care Plans,both,48,,34.92,percent of total billed charges,11.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN XL LEFT 10455,120.564,CDM,273,RC,L3809,HCPCS,,12721-MAIN,LOCAL,,,,,23,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,11.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN XL RIGHT 10465,120.564,CDM,273,RC,L3809,HCPCS,,12715-MAIN,LOCAL,,,,,23,,Health Partners,Health Partners Care Plans,both,48,,34.92,percent of total billed charges,11.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN XL RIGHT 10465,120.564,CDM,273,RC,L3809,HCPCS,,12715-MAIN,LOCAL,,,,,23,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,11.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST WRISTPRO LEFT 10-IN LG,120.564,CDM,273,RC,L3809,HCPCS,,12724-MAIN,LOCAL,,,,,23,,Health Partners,Health Partners Care Plans,both,48,,34.92,percent of total billed charges,11.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST WRISTPRO LEFT 10-IN LG,120.564,CDM,273,RC,L3809,HCPCS,,12724-MAIN,LOCAL,,,,,23,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,11.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST WRISTPRO LEFT 10-IN MED,120.564,CDM,273,RC,L3809,HCPCS,,12723-MAIN,LOCAL,,,,,23,,Health Partners,Health Partners Care Plans,both,48,,34.92,percent of total billed charges,11.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST WRISTPRO LEFT 10-IN MED,120.564,CDM,273,RC,L3809,HCPCS,,12723-MAIN,LOCAL,,,,,23,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,11.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
Detection of Babesia Borrelia Miyamotoi by Amplified Nucleic Acid Probe Technique,PX8747890,CDM,300,RC,87478,CPT,90,,,,,,,23,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,11.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,32.17
Detection of Babesia Borrelia Miyamotoi by Amplified Nucleic Acid Probe Technique,PX8747890,CDM,300,RC,87478,CPT,90,,,,,,,23,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,11.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,32.17
Detection of Babesia Microtim by Amplified Nucleic Acid Probe Technique,PX8746990,CDM,300,RC,87469,CPT,90,,,,,,,23,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,11.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,32.17
Detection of Babesia Microtim by Amplified Nucleic Acid Probe Technique,PX8746990,CDM,300,RC,87469,CPT,90,,,,,,,23,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,11.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,32.17
FORCEPS COLD BIOPSY,27200000,CDM,272,RC,,,,12453-MAIN,LOCAL,,,,,23,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,11.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
FORCEPS COLD BIOPSY,27200000,CDM,272,RC,,,,12453-MAIN,LOCAL,,,,,23,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,11.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE MAXON ABSORBABLE POLYGLYCONATE 2-0 30IN MONOFILAMENT DYED TAPER POINT 1/2 CIRCLE 27MM GS-22 G,27200000,CDM,272,RC,,,,11988-MAIN,LOCAL,,,,,23,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,11.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE MAXON ABSORBABLE POLYGLYCONATE 2-0 30IN MONOFILAMENT DYED TAPER POINT 1/2 CIRCLE 27MM GS-22 G,27200000,CDM,272,RC,,,,11988-MAIN,LOCAL,,,,,23,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,11.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE POLYSORB ABSORBABLE LACTOMER 2-0 30IN BRAIDED DYED TAPER POINT 1/2 CIRCLE 26MM V-20 VIOLET ST,27200000,CDM,272,RC,,,,11983-MAIN,LOCAL,,,,,23,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,11.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE POLYSORB ABSORBABLE LACTOMER 2-0 30IN BRAIDED DYED TAPER POINT 1/2 CIRCLE 26MM V-20 VIOLET ST,27200000,CDM,272,RC,,,,11983-MAIN,LOCAL,,,,,23,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,11.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
FLUoxetine 10 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578461,NDC,1,EA,12.99,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.0415,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin-clavulanate 875-125 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862050301,NDC,1,EA,26.59,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,11.045486,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Antibiotic Sens,Enzyme Detection,Each - Ref",PX8718590,CDM,300,RC,87185,CPT,90,,,,,,,13,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.36,12.74
BONE WAX SUTURE 2.5G ETHICON,27200000,CDM,272,RC,,,,12566-MAIN,LOCAL,,,,,13,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Actin Antibody Each,PX8601590,CDM,300,RC,86015,CPT,90,,,,,,,42,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,11.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.05,41.16
"Ecg 12 Lead, Tracing Only",PX93005,CDM,730,RC,93005,CPT,,,,,,,,298,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,11.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,11.05
"Ecg 12 Lead, Tracing Only",PX93005,CDM,730,RC,93005,CPT,,,,,,,,298,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,11.05,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,11.05
"Fluor Noninfect Ab Sc, Ea - Ref",PX8625590,CDM,300,RC,86255,CPT,90,,,,,,,121,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,11.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.05,118.58
"Hepatitis B Core Antibody, Total",PX86704,CDM,300,RC,86704,CPT,,,,,,,,21,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,11.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.7234,20.58
topiramate 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034211,NDC,1,EA,11.28,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,11.0544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034201,NDC,1,EA,11.28,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,11.0544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079049801,NDC,1,EA,22.34,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,11.0583,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE CR 10 MG Tablet ER 12 hour Abuse-Deterrent 20 Each Box,63700001,CDM,250,RC,,,,,,59011041020,NDC,1,EA,26.63,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,11.062102,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tamsulosin 0.4 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904640161,NDC,1,EA,22.6,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.074,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tamsulosin 0.4 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904640161,NDC,1,EA,22.6,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.074,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tamsulosin 0.4 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904640161,NDC,1,EA,22.6,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,11.074,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
citalopram 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904608461,NDC,1,EA,13.03,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.0755,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ivermectin 3 MG Tablet 20 Each Box,63700001,CDM,250,RC,,,,,,42799080601,NDC,1,EA,26.68,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,11.082872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simethicone 40 MG/0.6ML Suspension 30 mL Bottle,25000000,CDM,250,RC,,,,,,904589430,NDC,30,ML,22.39,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,11.08305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
amoxicillin 125 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,143988815,NDC,150,ML,25.84,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,11.08536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 125 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,781603955,NDC,150,ML,25.84,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,11.08536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Antinuclear Antibodies,PX86038,CDM,300,RC,86038,CPT,,,,,,,,10,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,11.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,11.09
Antinuclear Antibodiesana - Ref,PX8603890,CDM,300,RC,86038,CPT,90,,,,,,,43,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,11.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.09,42.14
BITE BLOCK MAXI 20MM 60FR,27200000,CDM,272,RC,,,,8144-MAIN,LOCAL,,,,,11.32,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,11.0936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
rivastigmine 3 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,55111035360,NDC,0.5,EA,11.4,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,11.09562,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ustekinumab 130 MG/26ML Solution 26 mL Vial,J3358.01,CDM,636,RC,J3358,HCPCS,,,,57894005427,NDC,26,ML,4130,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,11.1,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.1,12.62
buPROPion XL 150 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,70436001004,NDC,1,EA,23.14,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,11.1072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buPROPion XL 150 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,70436001004,NDC,1,EA,23.14,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,11.1072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
montelukast 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268057511,NDC,1,EA,26.75,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,11.11195,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
montelukast 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268057515,NDC,1,EA,26.75,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,11.11195,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Bone Age Studies Tc,PX7707201,CDM,320,RC,77072,CPT,TC,,,,,,,211,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,11.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.12,33.53
Bone Age Studies Tc,PX7707201,CDM,320,RC,77072,CPT,TC,,,,,,,211,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,11.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.12,33.53
Bone Age Studies Tc,PX7707201,CDM,320,RC,77072,CPT,TC,,,,,,,211,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,11.12,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.12,33.53
Strapping of Knee,PX29530F,CDM,420,RC,29530,CPT,,,,,,,,303,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,11.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.12,60.88
Strapping of Knee,PX29530F,CDM,420,RC,29530,CPT,,,,,,,,303,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,11.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.12,60.88
Strapping of Shoulder,PX29240F,CDM,420,RC,29240,CPT,,,,,,,,165,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,11.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.12,61.57
Strapping of Shoulder,PX29240F,CDM,420,RC,29240,CPT,,,,,,,,165,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,11.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.12,61.57
Strapping of Shoulder,PX29240P,CDM,983,RC,29240,CPT,,,,,,,,110,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,11.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.12,107.8
Strapping of Shoulder,PX29240P,CDM,983,RC,29240,CPT,,,,,,,,110,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,11.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.12,107.8
Xray Spine Single Tc,PX7202001,CDM,320,RC,72020,CPT,TC,,,,,,,113,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,11.12,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.9,32.87
midazolam 2 MG/ML Syrup 5 mL Cup,63700001,CDM,250,RC,,,,,,68094076459,NDC,2.5,ML,22.47,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,11.12265,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
neomycin-bacitracin-polymyxin 3.5-400-5000 Ointment 28.4 g Tube,25000000,CDM,250,RC,,,,,,713026831,NDC,28.4,GR,22.47,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,11.12265,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
doxycycline hyclate 100 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,904043004,NDC,0.5,EA,12.21,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,11.12331,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Coccidioides Antibody - Ref,PX8663590,CDM,300,RC,86635,CPT,90,,,,,,,94,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,11.13,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.13,11.47
Myoglobin - Ref,PX8387490,CDM,300,RC,83874,CPT,90,,,,,,,22,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,11.132,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.1388,21.56
SUTURE POLYSORB BRAIDED ABSORBABLE VIOLET SIZE 0 30IN WITH 5/8 CIRCLE TAPER POINT 27MM NEEDLE,27200000,CDM,272,RC,,,,11985-MAIN,LOCAL,,,,,22,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,11.132,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TEGADERM CHLORHEXIDINE-GLUCONATE,120.356,CDM,272,RC,A4221,HCPCS,,10708-MAIN,LOCAL,,,,,22,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,11.132,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.1388,21.56
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,76282066339,NDC,100,GR,26.8,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,11.13272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
apixaban 5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,3089421,NDC,0.5,EA,22.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,11.1375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SPIT SOCK HOODS 16719,120.367,CDM,271,RC,,,,10820-MAIN,LOCAL,,,,,26,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,11.154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.8004,25.48
TEGADERM CHLORHEXIDINE 5X5 CHG IV PORT,120.207,CDM,272,RC,A6268,HCPCS,,10163-MAIN,LOCAL,,,,,26,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,11.154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.8004,25.48
carvedilol 3.125 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079077101,NDC,1,EA,11.46,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,11.154018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 14 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,43598044774,NDC,1,EA,11.46,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,11.154018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,43598044871,NDC,1,EA,11.46,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,11.154018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 800 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714033201,NDC,0.75,EA,12.25,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,11.15975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Antinuclear Ab(Ana) Titer - Ref,PX8603990,CDM,300,RC,86039,CPT,90,,,,,,,52,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,11.16,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.83,11.16
fluvastatin 20 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,378802093,NDC,1,EA,26.88,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,11.165952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex ER 250 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031011,NDC,1,EA,13.14,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.169,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex ER 250 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084031001,NDC,1,EA,13.14,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.169,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Immunization Administration; Each Add'l Vaccine (Single or Combo Vaccine/T*,PX90472,CDM,771,RC,90472,CPT,,,,,,,,48,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,11.17,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.16,25.59
Immunization Administration; Each Add'l Vaccine (Single or Combo Vaccine/T*,PX90472,CDM,771,RC,90472,CPT,,,,,,,,48,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,11.17,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.16,25.59
rivastigmine 3 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,55111035360,NDC,0.5,EA,11.4,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,11.172,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Immunoassay - Ref,PX8351690,CDM,300,RC,83516,CPT,90,,,,,,,15,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,11.18,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.18,11.53
Immunoassay - Ref,PX8351690,CDM,300,RC,83516,CPT,90,,,,,,,15,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,11.18,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.18,11.53
Immunoassay - Ref,PX8351690,CDM,300,RC,83516,CPT,90,,,,,,,15,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,11.18,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.18,11.53
"Lab Immunoassay, Non Antibody",PX83516,CDM,300,RC,83516,CPT,,,,,,,,99,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,11.18,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.18,11.53
"Lab Immunoassay, Non Antibody",PX83516,CDM,300,RC,83516,CPT,,,,,,,,99,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,11.18,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.18,11.53
"Lab Immunoassay, Non Antibody",PX83516,CDM,300,RC,83516,CPT,,,,,,,,99,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,11.18,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.18,11.53
tamsulosin 0.4 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904640161,NDC,1,EA,22.6,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,11.187,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
eplerenone 25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16729029315,NDC,1,EA,23.31,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,11.1888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
eplerenone 25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16729029315,NDC,1,EA,23.31,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,11.1888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,536110888,NDC,1,EA,11.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,11.19295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Creatine Mb Fraction,PX82553,CDM,300,RC,82553,CPT,,,,,,,,353,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,11.2,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2,11.55
Creatine Mb Fraction,PX82553,CDM,300,RC,82553,CPT,,,,,,,,353,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,11.2,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2,11.55
Creatine Mb Fraction,PX82553,CDM,300,RC,82553,CPT,,,,,,,,353,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,11.2,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2,11.55
hydrocortisone 1 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,472034356,NDC,28,GR,22.15,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,11.2079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BOOT CAST LARGE 12-5/8 ORT290010L,120.247,CDM,274,RC,L3260,HCPCS,,204-MAIN,LOCAL,,,,,27,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,11.2158,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
BOOT CAST MEDIUM 08148803,120.247,CDM,274,RC,L3260,HCPCS,,203-MAIN,LOCAL,,,,,27,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,11.2158,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
BOOT CAST X-LARGE 13X5-1/2IN ORT29200XL,120.247,CDM,274,RC,L3260,HCPCS,,206-MAIN,LOCAL,,,,,27,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,11.2158,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
KERRAMAX CARE SUPERABSORBENT DRESSING 8X12,120.55,CDM,272,RC,A6197,HCPCS,,12363-MAIN,LOCAL,,,,,27,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,11.2158,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
Or Time,PX36000086,CDM,360,RC,,,,,,,,,,27,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,11.2158,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
"Sodium, Other Source - Ref",PX8430290,CDM,300,RC,84302,CPT,90,,,,,,,27,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,11.2158,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.46,26.46
Assay of Lactic Acid,PX83605,CDM,300,RC,83605,CPT,,,,,,,,150,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,11.22,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.22,11.57
Hepatitis Be Antibody - Ref,PX8670790,CDM,300,RC,86707,CPT,90,,,,,,,192,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,11.22,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.22,11.57
Assay of Lactic Acid,PX83605,CDM,300,RC,83605,CPT,,,,,,,,150,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,11.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.22,11.57
Assay of Lactic Acid,PX83605,CDM,300,RC,83605,CPT,,,,,,,,150,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,11.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.22,11.57
Hepatitis Be Antibody - Ref,PX8670790,CDM,300,RC,86707,CPT,90,,,,,,,192,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,11.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.22,11.57
Hepatitis Be Antibody - Ref,PX8670790,CDM,300,RC,86707,CPT,90,,,,,,,192,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,11.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.22,11.57
"Fungus Antibody, Nos - Ref",PX8667190,CDM,300,RC,86671,CPT,90,,,,,,,99,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,11.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.23,97.02
Tiss Trnsgltmnase Ea Ig Clas,PX86364,CDM,300,RC,86364,CPT,,,,,,,,57,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,11.23,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.23,11.53
carvedilol 3.125 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079077101,NDC,1,EA,11.46,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,11.2308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 14 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,43598044774,NDC,1,EA,11.46,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,11.2308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,43598044871,NDC,1,EA,11.46,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,11.2308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of Lactic Acid,PX83605,CDM,300,RC,83605,CPT,,,,,,,,150,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,11.2315,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.22,11.57
Coccidioides Antibody - Ref,PX8663590,CDM,300,RC,86635,CPT,90,,,,,,,94,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,11.2315,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.13,11.47
Creatine Mb Fraction,PX82553,CDM,300,RC,82553,CPT,,,,,,,,353,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,11.2315,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2,11.55
Hepatitis Be Antibody - Ref,PX8670790,CDM,300,RC,86707,CPT,90,,,,,,,192,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,11.2315,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.22,11.57
Immunoassay - Ref,PX8351690,CDM,300,RC,83516,CPT,90,,,,,,,15,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,11.2315,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.18,11.53
"Lab Immunoassay, Non Antibody",PX83516,CDM,300,RC,83516,CPT,,,,,,,,99,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,11.2315,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.18,11.53
Tiss Trnsgltmnase Ea Ig Clas,PX86364,CDM,300,RC,86364,CPT,,,,,,,,57,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,11.2315,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.23,11.53
Vitamin a - Ref,PX8459090,CDM,300,RC,84590,CPT,90,,,,,,,63,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,11.2315,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2315,11.61
ibuprofen 100 MG/5ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,68094049459,NDC,20,ML,22.2,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,11.2332,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydroxychloroquine 200 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16571068701,NDC,1,EA,23.41,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,11.2368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydroxychloroquine 200 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16571068701,NDC,1,EA,23.41,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,11.2368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601901,NDC,10,ML,211.47,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,11.24,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.89,14.43
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601910,NDC,10,ML,211.47,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,11.24,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.89,14.43
clopidogrel 75 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629461,NDC,1,EA,23.42,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,11.2416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clopidogrel 75 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629461,NDC,1,EA,23.42,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,11.2416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
naltrexone 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406117001,NDC,1,EA,22.96,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.2504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
naltrexone 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406117001,NDC,1,EA,22.96,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.2504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
naltrexone 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406117001,NDC,1,EA,22.96,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,11.2504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153F,CDM,370,RC,99153,CPT,,,,,,,,225,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,11.2525,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.98,20.36
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153P,CDM,983,RC,99153,CPT,,,,,,,,250,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,11.2525,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.98,245
triamcinolone acetonide 0.1 % Cream 15 g Tube,63700001,CDM,250,RC,,,,,,168000415,NDC,15,GR,22.97,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.2553,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
triamcinolone acetonide 0.1 % Cream 15 g Tube,63700001,CDM,250,RC,,,,,,168000415,NDC,15,GR,22.97,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.2553,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
triamcinolone acetonide 0.1 % Cream 15 g Tube,63700001,CDM,250,RC,,,,,,168000415,NDC,15,GR,22.97,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,11.2553,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zinc oxide 20 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,536131625,NDC,60,GR,22.97,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.2553,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zinc oxide 20 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,536131625,NDC,60,GR,22.97,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.2553,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zinc oxide 20 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,536131625,NDC,60,GR,22.97,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,11.2553,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
celecoxib 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904650261,NDC,1,EA,23.45,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,11.256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
celecoxib 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904650261,NDC,1,EA,23.45,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,11.256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Hepatitis a Igm Antibody,PX86709,CDM,300,RC,86709,CPT,,,,,,,,220,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,11.26,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.9106,11.26
Vitamin a - Ref,PX8459090,CDM,300,RC,84590,CPT,90,,,,,,,63,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,11.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2315,11.61
Vitamin a - Ref,PX8459090,CDM,300,RC,84590,CPT,90,,,,,,,63,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,11.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2315,11.61
Vitamin a - Ref,PX8459090,CDM,300,RC,84590,CPT,90,,,,,,,63,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,11.26,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2315,11.61
BRACE WRIST 8-IN SM LEFT 10432,120.564,CDM,273,RC,L3809,HCPCS,,12720-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,6.8,percent of total billed charges,11.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 8-IN SM LEFT 10432,120.564,CDM,273,RC,L3809,HCPCS,,12720-MAIN,LOCAL,,,,,23,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 8-IN SM LEFT 10432,120.564,CDM,273,RC,L3809,HCPCS,,12720-MAIN,LOCAL,,,,,23,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,11.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 8-IN SM RIGHT 10442,120.564,CDM,273,RC,L3809,HCPCS,,12716-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,6.8,percent of total billed charges,11.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 8-IN SM RIGHT 10442,120.564,CDM,273,RC,L3809,HCPCS,,12716-MAIN,LOCAL,,,,,23,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 8-IN SM RIGHT 10442,120.564,CDM,273,RC,L3809,HCPCS,,12716-MAIN,LOCAL,,,,,23,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,11.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN LG RIGHT 10464,120.564,CDM,273,RC,L3809,HCPCS,,12719-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,6.8,percent of total billed charges,11.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN LG RIGHT 10464,120.564,CDM,273,RC,L3809,HCPCS,,12719-MAIN,LOCAL,,,,,23,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN LG RIGHT 10464,120.564,CDM,273,RC,L3809,HCPCS,,12719-MAIN,LOCAL,,,,,23,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,11.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN SM LEFT 617083,120.564,CDM,273,RC,L3809,HCPCS,,12722-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,6.8,percent of total billed charges,11.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN SM LEFT 617083,120.564,CDM,273,RC,L3809,HCPCS,,12722-MAIN,LOCAL,,,,,23,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN SM LEFT 617083,120.564,CDM,273,RC,L3809,HCPCS,,12722-MAIN,LOCAL,,,,,23,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,11.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN SM RIGHT 10462,120.564,CDM,273,RC,L3809,HCPCS,,12717-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,6.8,percent of total billed charges,11.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN SM RIGHT 10462,120.564,CDM,273,RC,L3809,HCPCS,,12717-MAIN,LOCAL,,,,,23,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN SM RIGHT 10462,120.564,CDM,273,RC,L3809,HCPCS,,12717-MAIN,LOCAL,,,,,23,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,11.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN XL LEFT 10455,120.564,CDM,273,RC,L3809,HCPCS,,12721-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,6.8,percent of total billed charges,11.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN XL LEFT 10455,120.564,CDM,273,RC,L3809,HCPCS,,12721-MAIN,LOCAL,,,,,23,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN XL LEFT 10455,120.564,CDM,273,RC,L3809,HCPCS,,12721-MAIN,LOCAL,,,,,23,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,11.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN XL RIGHT 10465,120.564,CDM,273,RC,L3809,HCPCS,,12715-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,6.8,percent of total billed charges,11.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN XL RIGHT 10465,120.564,CDM,273,RC,L3809,HCPCS,,12715-MAIN,LOCAL,,,,,23,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN XL RIGHT 10465,120.564,CDM,273,RC,L3809,HCPCS,,12715-MAIN,LOCAL,,,,,23,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,11.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST WRISTPRO LEFT 10-IN LG,120.564,CDM,273,RC,L3809,HCPCS,,12724-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,6.8,percent of total billed charges,11.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST WRISTPRO LEFT 10-IN LG,120.564,CDM,273,RC,L3809,HCPCS,,12724-MAIN,LOCAL,,,,,23,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST WRISTPRO LEFT 10-IN LG,120.564,CDM,273,RC,L3809,HCPCS,,12724-MAIN,LOCAL,,,,,23,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,11.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST WRISTPRO LEFT 10-IN MED,120.564,CDM,273,RC,L3809,HCPCS,,12723-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,6.8,percent of total billed charges,11.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST WRISTPRO LEFT 10-IN MED,120.564,CDM,273,RC,L3809,HCPCS,,12723-MAIN,LOCAL,,,,,23,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST WRISTPRO LEFT 10-IN MED,120.564,CDM,273,RC,L3809,HCPCS,,12723-MAIN,LOCAL,,,,,23,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,11.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
Detection of Babesia Borrelia Miyamotoi by Amplified Nucleic Acid Probe Technique,PX8747890,CDM,300,RC,87478,CPT,90,,,,,,,23,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,32.17
Detection of Babesia Borrelia Miyamotoi by Amplified Nucleic Acid Probe Technique,PX8747890,CDM,300,RC,87478,CPT,90,,,,,,,23,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,32.17
Detection of Babesia Borrelia Miyamotoi by Amplified Nucleic Acid Probe Technique,PX8747890,CDM,300,RC,87478,CPT,90,,,,,,,23,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,11.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,32.17
Detection of Babesia Microtim by Amplified Nucleic Acid Probe Technique,PX8746990,CDM,300,RC,87469,CPT,90,,,,,,,23,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,32.17
Detection of Babesia Microtim by Amplified Nucleic Acid Probe Technique,PX8746990,CDM,300,RC,87469,CPT,90,,,,,,,23,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,32.17
Detection of Babesia Microtim by Amplified Nucleic Acid Probe Technique,PX8746990,CDM,300,RC,87469,CPT,90,,,,,,,23,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,11.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,32.17
FORCEPS COLD BIOPSY,27200000,CDM,272,RC,,,,12453-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
FORCEPS COLD BIOPSY,27200000,CDM,272,RC,,,,12453-MAIN,LOCAL,,,,,23,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
FORCEPS COLD BIOPSY,27200000,CDM,272,RC,,,,12453-MAIN,LOCAL,,,,,23,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,11.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,536110888,NDC,1,EA,11.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,11.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SUTURE MAXON ABSORBABLE POLYGLYCONATE 2-0 30IN MONOFILAMENT DYED TAPER POINT 1/2 CIRCLE 27MM GS-22 G,27200000,CDM,272,RC,,,,11988-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE MAXON ABSORBABLE POLYGLYCONATE 2-0 30IN MONOFILAMENT DYED TAPER POINT 1/2 CIRCLE 27MM GS-22 G,27200000,CDM,272,RC,,,,11988-MAIN,LOCAL,,,,,23,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE MAXON ABSORBABLE POLYGLYCONATE 2-0 30IN MONOFILAMENT DYED TAPER POINT 1/2 CIRCLE 27MM GS-22 G,27200000,CDM,272,RC,,,,11988-MAIN,LOCAL,,,,,23,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,11.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE POLYSORB ABSORBABLE LACTOMER 2-0 30IN BRAIDED DYED TAPER POINT 1/2 CIRCLE 26MM V-20 VIOLET ST,27200000,CDM,272,RC,,,,11983-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE POLYSORB ABSORBABLE LACTOMER 2-0 30IN BRAIDED DYED TAPER POINT 1/2 CIRCLE 26MM V-20 VIOLET ST,27200000,CDM,272,RC,,,,11983-MAIN,LOCAL,,,,,23,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE POLYSORB ABSORBABLE LACTOMER 2-0 30IN BRAIDED DYED TAPER POINT 1/2 CIRCLE 26MM V-20 VIOLET ST,27200000,CDM,272,RC,,,,11983-MAIN,LOCAL,,,,,23,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,11.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ketorolac 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69543038810,NDC,1,EA,11.58,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,11.270814,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 150-4.21 MG/100ML-% Solution 100 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066015010,NDC,100,ML,249.22,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,11.28,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.50926,11.28
amiodarone 150-4.21 MG/100ML-% Solution 100 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066015010,NDC,100,ML,249.22,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,11.28,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.50926,11.28
amiodarone 360-4.14 MG/200ML-% Solution 200 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066036020,NDC,200,ML,325.25,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,11.28,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.50926,11.28
amiodarone 360-4.14 MG/200ML-% Solution 200 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066036020,NDC,200,ML,325.25,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,11.28,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.50926,11.28
"SUTURE CHROME GUT 3-0 CP-2 27""",27200000,CDM,272,RC,,,,4967-MAIN,LOCAL,,,,,11.59,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,11.280547,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
gabapentin 600 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268035111,NDC,1,EA,12.79,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.28078,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 600 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268035115,NDC,1,EA,12.79,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.28078,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Tx/Pro/Dx Inj Same Drug Adon,PX96376,CDM,260,RC,96376,CPT,,,,,,,,164,,UCare,Individual and Family Plans,both,,,82.96175439,fee schedule,11.296,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.11,11.296
Tx/Pro/Dx Inj Same Drug Adon,PX96376,CDM,260,RC,96376,CPT,,,,,,,,164,,UCare,Individual and Family Plans,both,,,82.96175439,fee schedule,11.296,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.11,11.296
Assay Blood Carbon Monoxide,PX82375,CDM,300,RC,82375,CPT,,,,,,,,156,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,11.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.3,152.88
fluconazole 100 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069101,NDC,0.5,EA,23.55,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,11.304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluconazole 100 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069101,NDC,0.5,EA,23.55,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,11.304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079049801,NDC,1,EA,22.34,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,11.30404,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739051610,NDC,1,EA,13.3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Acetaminophen 167 MG/5ML Liquid 237 mL Bottle,63700001,CDM,250,RC,,,,,,904584709,NDC,237,ML,27.22,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,11.307188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
GOLIMumab 50 MG/4ML Solution 4 mL Vial,J1602.01,CDM,636,RC,J1602,HCPCS,,,,57894035001,NDC,4,ML,3709.76,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,11.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.31,3635.5648
hydroxychloroquine 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292001101,NDC,1,EA,23.57,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,11.3136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydroxychloroquine 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292001101,NDC,1,EA,23.57,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,11.3136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Blood Viscosity Examination,PX85810,CDM,300,RC,85810,CPT,,,,,,,,95,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,11.32,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.32,11.67
Blood Viscosity Examination,PX85810,CDM,300,RC,85810,CPT,,,,,,,,95,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,11.32,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.32,11.67
Blood Viscosity Examination,PX85810,CDM,300,RC,85810,CPT,,,,,,,,95,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,11.32,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.32,11.67
nicotine 21 MG/24HR Patch 24 Hour 7 Each Box,63700001,CDM,250,RC,,,,,,536589653,NDC,1,EA,12.84,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.32488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simethicone 40 MG/0.6ML Suspension 30 mL Bottle,25000000,CDM,250,RC,,,,,,904589430,NDC,30,ML,22.39,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,11.32934,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
buPROPion XL 150 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,70436001004,NDC,1,EA,23.14,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.3386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buPROPion XL 150 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,70436001004,NDC,1,EA,23.14,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.3386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buPROPion XL 150 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,70436001004,NDC,1,EA,23.14,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,11.3386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
FLUoxetine 20 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578561,NDC,1,EA,13.34,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.339,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Strapping of Knee,PX29530F,CDM,420,RC,29530,CPT,,,,,,,,303,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,11.34,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.12,60.88
Strapping of Shoulder,PX29240F,CDM,420,RC,29240,CPT,,,,,,,,165,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,11.34,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.12,61.57
Strapping of Shoulder,PX29240P,CDM,983,RC,29240,CPT,,,,,,,,110,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,11.34,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.12,107.8
X-Ray Exam Chest 1 View,PX7104501,CDM,320,RC,71045,CPT,TC,,,,,,,357,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,11.34,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.34,34.18
X-Ray Exam Chest 1 View,PX7104501,CDM,320,RC,71045,CPT,TC,,,,,,,357,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,11.34,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.34,34.18
X-Ray Exam Chest 1 View,PX7104501,CDM,320,RC,71045,CPT,TC,,,,,,,357,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,11.34,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.34,34.18
ketorolac 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69543038810,NDC,1,EA,11.58,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,11.3484,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"SUTURE CHROME GUT 3-0 CP-2 27""",27200000,CDM,272,RC,,,,4967-MAIN,LOCAL,,,,,11.59,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,11.3582,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Hepatitis a Antibody, Tot - Ref",PX8670890,CDM,300,RC,86708,CPT,90,,,,,,,201,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,11.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.36,196.98
"Protozoa Antibody, Nos - Ref",PX8675390,CDM,300,RC,86753,CPT,90,,,,,,,99,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,11.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.36,97.02
naltrexone 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406117001,NDC,1,EA,22.96,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,11.3652,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,75826011410,NDC,1,EA,12.89,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.36898,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56016901,NDC,1,EA,12.89,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.36898,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
midazolam 2 MG/ML Syrup 5 mL Cup,63700001,CDM,250,RC,,,,,,68094076459,NDC,2.5,ML,22.47,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,11.36982,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
neomycin-bacitracin-polymyxin 3.5-400-5000 Ointment 28.4 g Tube,25000000,CDM,250,RC,,,,,,713026831,NDC,28.4,GR,22.47,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,11.36982,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
triamcinolone acetonide 0.1 % Cream 15 g Tube,63700001,CDM,250,RC,,,,,,168000415,NDC,15,GR,22.97,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,11.37015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zinc oxide 20 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,536131625,NDC,60,GR,22.97,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,11.37015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079034801,NDC,1,EA,27.39,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,11.377806,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079034820,NDC,1,EA,27.39,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,11.377806,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Copper - Ref,PX8252590,CDM,300,RC,82525,CPT,90,,,,,,,94,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,11.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.38,92.12
gabapentin 600 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268035111,NDC,1,EA,12.79,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,11.3831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 600 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268035115,NDC,1,EA,12.79,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,11.3831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
apixaban 5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,3089421,NDC,0.5,EA,22.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,11.385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BRACE WRIST 8-IN SM LEFT 10432,120.564,CDM,273,RC,L3809,HCPCS,,12720-MAIN,LOCAL,,,,,23,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,11.385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 8-IN SM RIGHT 10442,120.564,CDM,273,RC,L3809,HCPCS,,12716-MAIN,LOCAL,,,,,23,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,11.385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN LG RIGHT 10464,120.564,CDM,273,RC,L3809,HCPCS,,12719-MAIN,LOCAL,,,,,23,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,11.385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN SM LEFT 617083,120.564,CDM,273,RC,L3809,HCPCS,,12722-MAIN,LOCAL,,,,,23,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,11.385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN SM RIGHT 10462,120.564,CDM,273,RC,L3809,HCPCS,,12717-MAIN,LOCAL,,,,,23,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,11.385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN XL LEFT 10455,120.564,CDM,273,RC,L3809,HCPCS,,12721-MAIN,LOCAL,,,,,23,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,11.385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN XL RIGHT 10465,120.564,CDM,273,RC,L3809,HCPCS,,12715-MAIN,LOCAL,,,,,23,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,11.385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST WRISTPRO LEFT 10-IN LG,120.564,CDM,273,RC,L3809,HCPCS,,12724-MAIN,LOCAL,,,,,23,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,11.385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST WRISTPRO LEFT 10-IN MED,120.564,CDM,273,RC,L3809,HCPCS,,12723-MAIN,LOCAL,,,,,23,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,11.385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
Detection of Babesia Borrelia Miyamotoi by Amplified Nucleic Acid Probe Technique,PX8747890,CDM,300,RC,87478,CPT,90,,,,,,,23,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,11.385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,32.17
Detection of Babesia Microtim by Amplified Nucleic Acid Probe Technique,PX8746990,CDM,300,RC,87469,CPT,90,,,,,,,23,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,11.385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,32.17
FORCEPS COLD BIOPSY,27200000,CDM,272,RC,,,,12453-MAIN,LOCAL,,,,,23,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,11.385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE MAXON ABSORBABLE POLYGLYCONATE 2-0 30IN MONOFILAMENT DYED TAPER POINT 1/2 CIRCLE 27MM GS-22 G,27200000,CDM,272,RC,,,,11988-MAIN,LOCAL,,,,,23,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,11.385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE POLYSORB ABSORBABLE LACTOMER 2-0 30IN BRAIDED DYED TAPER POINT 1/2 CIRCLE 26MM V-20 VIOLET ST,27200000,CDM,272,RC,,,,11983-MAIN,LOCAL,,,,,23,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,11.385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
cefdinir 300 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,67877054360,NDC,1,EA,27.42,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,11.390268,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cholestyramine light 4 g Packet 42 Each Box,63700001,CDM,250,RC,,,,,,245003642,NDC,1,EA,27.42,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,11.390268,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cholestyramine light 4 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,245003689,NDC,1,EA,27.44,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,11.398576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Each Add'l Sequential Push New Drug,PX96375,CDM,260,RC,96375,CPT,,,,,,,,130,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,11.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.81,26.76
Each Add'l Sequential Push New Drug,PX96375,CDM,260,RC,96375,CPT,,,,,,,,130,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,11.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.81,26.76
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,6384371,NDC,1,EA,563.46,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,11.4,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.4,12.97
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022101,NDC,1,EA,514.5,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,11.4,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.4,12.97
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022185,NDC,1,EA,514.5,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,11.4,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.4,12.97
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022189,NDC,1,EA,514.5,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,11.4,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.4,12.97
cefdinir 300 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,16714039102,NDC,1,EA,27.46,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,11.406884,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin-clavulanate 875-125 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862050301,NDC,1,EA,26.59,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,11.40711,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rOPINIRole 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547026810,NDC,1,EA,13.43,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.4155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56017001,NDC,1,EA,13.43,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.4155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
eplerenone 25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16729029315,NDC,1,EA,23.31,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.4219,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
eplerenone 25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16729029315,NDC,1,EA,23.31,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.4219,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
eplerenone 25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16729029315,NDC,1,EA,23.31,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,11.4219,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzonatate 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877010501,NDC,1,EA,13.44,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE CR 10 MG Tablet ER 12 hour Abuse-Deterrent 20 Each Box,63700001,CDM,250,RC,,,,,,59011041020,NDC,1,EA,26.63,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,11.42427,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 7 Each Box,63700001,CDM,250,RC,,,,,,536589653,NDC,1,EA,12.84,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,11.4276,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Troponin, Quantitative",PX84484,CDM,300,RC,84484,CPT,,,,,,,,289,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,11.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.43,283.22
PREP KIT SKIN PREMIUM,27200000,CDM,272,RC,,,,4108-MAIN,LOCAL,,,,,12.96,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.43072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
rOPINIRole 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462025301,NDC,1,EA,13.45,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.4325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tamsulosin 0.4 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904640161,NDC,1,EA,22.6,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,11.4356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 25 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904694961,NDC,4,EA,11.75,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,11.436275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Ag Detect Nos Eia Mult,PX87449,CDM,300,RC,87449,CPT,,,,,,,,193,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,11.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.44,11.98
Ag Detect Nos Eia Mult,PX87449,CDM,300,RC,87449,CPT,,,,,,,,193,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,11.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.44,11.98
"Infect Ag,Eia, Nos, Ea - Ref",PX8744990,CDM,300,RC,87449,CPT,90,,,,,,,187,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,11.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.44,11.98
"Infect Ag,Eia, Nos, Ea - Ref",PX8744990,CDM,300,RC,87449,CPT,90,,,,,,,187,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,11.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.44,11.98
ivermectin 3 MG Tablet 20 Each Box,63700001,CDM,250,RC,,,,,,42799080601,NDC,1,EA,26.68,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,11.44572,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
escitalopram 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904642661,NDC,0.5,EA,11.76,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,11.446008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
apixaban 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,3089431,NDC,0.5,EA,23.85,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,11.448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
apixaban 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,3089431,NDC,0.5,EA,23.85,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,11.448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buPROPion XL 150 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,70436001004,NDC,1,EA,23.14,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,11.4543,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
FLUoxetine 10 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578461,NDC,1,EA,12.99,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.45718,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Antibiotic Sens,Enzyme Detection,Each - Ref",PX8718590,CDM,300,RC,87185,CPT,90,,,,,,,13,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.36,12.74
BONE WAX SUTURE 2.5G ETHICON,27200000,CDM,272,RC,,,,12566-MAIN,LOCAL,,,,,13,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Coccidioides Antibody - Ref,PX8663590,CDM,300,RC,86635,CPT,90,,,,,,,94,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,11.47,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.13,11.47
Coccidioides Antibody - Ref,PX8663590,CDM,300,RC,86635,CPT,90,,,,,,,94,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,11.47,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.13,11.47
Coccidioides Antibody - Ref,PX8663590,CDM,300,RC,86635,CPT,90,,,,,,,94,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,11.47,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.13,11.47
hydroxychloroquine 200 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16571068701,NDC,1,EA,23.41,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.4709,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydroxychloroquine 200 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16571068701,NDC,1,EA,23.41,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.4709,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydroxychloroquine 200 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16571068701,NDC,1,EA,23.41,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,11.4709,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,75826011410,NDC,1,EA,12.89,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,11.4721,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56016901,NDC,1,EA,12.89,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,11.4721,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 160 MG/5ML Suspension 118 mL Bottle,63700001,CDM,250,RC,,,,,,45802020326,NDC,10.15625,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
albuterol (2.5 MG/3ML) 0.083% Nebulization Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487950101,NDC,3,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
albuterol 1.25 MG/3ML Nebulization Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487990425,NDC,3,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Alcohol Swabstick 70 % Pad 50 Each Box,800000,CDM,,,,,,,,18407061105,NDC,1,EA,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
amoxicillin 250 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,65862070755,NDC,5,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 400 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,65862007101,NDC,3.125,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Biotene Dry Mouth Liquid 473 mL Bottle,63700001,CDM,250,RC,,,,,,48582000330,NDC,5,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbamide peroxide 6.5% 6.5 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904662735,NDC,15,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,93417773,NDC,2.5,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,24979015514,NDC,2.5,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314065605,NDC,0.05,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dexAMETHasone 1 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,54317644,NDC,0.5,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dextromethorphan-guaiFENesin 20-200 MG/20ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904722320,NDC,118,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,693390152,NDC,2.5,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
diphenhydrAMINE 12.5 MG/5ML Liquid 118 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904698520,NDC,2.5,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
diphenhydrAMINE 12.5 MG/5ML Liquid 120 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,58657052804,NDC,2.5,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,57896018105,NDC,15,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,57896018405,NDC,15,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,603107554,NDC,5,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,69367027204,NDC,5,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904006100,NDC,5,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904676320,NDC,5,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,54838011740,NDC,5,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,61787006304,NDC,5,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 100 MG/5ML Suspension 120 mL Bottle,63700001,CDM,250,RC,,,,,,904530920,NDC,20,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ipratropium 0.02 % Solution 2.5 mL Plas Cont,25000000,CDM,250,RC,,,,,,76204010001,NDC,2.5,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487020101,NDC,3,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lactulose 10 GM/15ML Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,121457715,NDC,15,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lactulose encephalopathy 10 GM/15ML Solution 473 mL Bottle,25000000,CDM,250,RC,,,,,,50383079516,NDC,15,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
levalbuterol 1.25 MG/3ML Nebulization Solution 3 mL Box,63700001,CDM,250,RC,,,,,,76204090001,NDC,3,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levalbuterol 1.25 MG/3ML Nebulization Solution 3 mL Plas Cont,63700001,CDM,250,RC,,,,,,76204090011,NDC,3,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine viscous 2 % Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,121090315,NDC,5,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine viscous 2 % Solution 100 mL Bottle,63700001,CDM,250,RC,,,,,,72888012526,NDC,5,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,54353244,NDC,0.25,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,121077001,NDC,0.25,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,65162068784,NDC,0.25,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium citrate 1.745 GM/30ML Solution 296 mL Bottle,63700001,CDM,250,RC,,,,,,69452038998,NDC,150,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium citrate 1.745 GM/30ML Solution 296 mL Bottle,63700001,CDM,250,RC,,,,,,70677111101,NDC,150,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium hydroxide 400 MG/5ML Suspension 30 mL Cup,63700001,CDM,250,RC,,,,,,69339015301,NDC,5,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine 20 mg/mL Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,54051744,NDC,0.5,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine polacrilex 4 MG Lozenge 24 Each Bottle,63700001,CDM,250,RC,,,,,,113087303,NDC,0.5,EA,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,121086805,NDC,4,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,121086802,NDC,4,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,66689000802,NDC,4,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 473 mL Bottle,63700001,CDM,250,RC,,,,,,121086816,NDC,4,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
opium 10 MG/ML (1%) Tincture 0.3 mL Syringe,63700001,CDM,250,RC,,,,,,8888800392,NDC,0.3,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
opium 10 MG/ML (1%) Tincture 0.6 mL Syringe,63700001,CDM,250,RC,,,,,,88888800245,NDC,0.3,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
opium 10 MG/ML (1%) Tincture 118 mL Bottle,63700001,CDM,250,RC,,,,,,42799021701,NDC,0.3,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxymetazoline 0.05 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904571135,NDC,15,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,904693186,NDC,1,EA,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 100 Each Box,63700001,CDM,250,RC,,,,,,904642281,NDC,1,EA,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
povidone iodine 10 % Solution 59 mL Bottle,63700001,CDM,250,RC,,,,,,52380190502,NDC,59,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Povidone-Iodine 10 % SWAB 1 Each Package,25000000,CDM,250,RC,,,,,,67618015301,NDC,1,EA,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004224,NDC,5,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,62135025037,NDC,1.666666667,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
racEPINEPHrine 2.25 % Nebulization Solution 1 Each Plas Cont,25000000,CDM,250,RC,,,,,,487590199,NDC,1,EA,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9 % Nebulization Solution 3 mL Plas Cont,63700001,CDM,250,RC,,,,,,487930133,NDC,3,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium chloride 0.65 % Solution 44 mL Bottle,63700001,CDM,250,RC,,,,,,904386575,NDC,44,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium phosphate 7-19 GM/118ML Enema 133 mL Bottle,63700001,CDM,250,RC,,,,,,132020140,NDC,133,ML,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
white petrolatum Gel 52.5 g Jar,63700001,CDM,250,RC,,,,,,521231100,NDC,52.5,GR,13.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
montelukast 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268057511,NDC,1,EA,26.75,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,11.47575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
montelukast 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268057515,NDC,1,EA,26.75,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,11.47575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clopidogrel 75 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629461,NDC,1,EA,23.42,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.4758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clopidogrel 75 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629461,NDC,1,EA,23.42,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.4758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clopidogrel 75 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629461,NDC,1,EA,23.42,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,11.4758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Antithrombin III Activity - Ref,PX8530090,CDM,300,RC,85300,CPT,90,,,,,,,158,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,11.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.49,11.85
Antithrombin III Activity - Ref,PX8530090,CDM,300,RC,85300,CPT,90,,,,,,,158,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,11.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.49,11.85
Antithrombin III Activity - Ref,PX8530090,CDM,300,RC,85300,CPT,90,,,,,,,158,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,11.49,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.49,11.85
celecoxib 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904650261,NDC,1,EA,23.45,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.4905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
celecoxib 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904650261,NDC,1,EA,23.45,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.4905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
celecoxib 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904650261,NDC,1,EA,23.45,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,11.4905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
citalopram 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904608461,NDC,1,EA,13.03,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.49246,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,76282066339,NDC,100,GR,26.8,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,11.4972,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
nicotine 7 MG/24HR Patch 24 Hour 7 Each Box,63700001,CDM,250,RC,,,,,,43598044670,NDC,1,EA,13.53,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.5005,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine 25 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904694961,NDC,4,EA,11.75,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,11.515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SLEEVE BALLOON 5MMX100MML KII STERILE CFS02,27200000,CDM,272,RC,,,,11704-MAIN,LOCAL,,,,,24,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,11.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SLEEVE BALLOON 5MMX100MML KII STERILE CFS02,27200000,CDM,272,RC,,,,11704-MAIN,LOCAL,,,,,24,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,11.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STRAP CLAVICLE LARGE VP10123-040,120.191,CDM,274,RC,L3670,HCPCS,,12848-MAIN,LOCAL,,,,,24,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,11.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE LARGE VP10123-040,120.191,CDM,274,RC,L3670,HCPCS,,12848-MAIN,LOCAL,,,,,24,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,11.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE MEDIUM VP10123-030,120.191,CDM,274,RC,L3670,HCPCS,,12847-MAIN,LOCAL,,,,,24,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,11.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE MEDIUM VP10123-030,120.191,CDM,274,RC,L3670,HCPCS,,12847-MAIN,LOCAL,,,,,24,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,11.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE SMALL VP10123-020,120.191,CDM,274,RC,L3670,HCPCS,,12846-MAIN,LOCAL,,,,,24,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,11.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE SMALL VP10123-020,120.191,CDM,274,RC,L3670,HCPCS,,12846-MAIN,LOCAL,,,,,24,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,11.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE XL 661 XL,120.191,CDM,274,RC,L3670,HCPCS,,12850-MAIN,LOCAL,,,,,24,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,11.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE XL 661 XL,120.191,CDM,274,RC,L3670,HCPCS,,12850-MAIN,LOCAL,,,,,24,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,11.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE XSMALL CHILD ORT14100XS,120.191,CDM,274,RC,L3670,HCPCS,,12849-MAIN,LOCAL,,,,,24,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,11.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE XSMALL CHILD ORT14100XS,120.191,CDM,274,RC,L3670,HCPCS,,12849-MAIN,LOCAL,,,,,24,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,11.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
escitalopram 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904642661,NDC,0.5,EA,11.76,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,11.5248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 25 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,69097012203,NDC,1,EA,13.56,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.526,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Haptoglobin; Quantitative,PX83010,CDM,300,RC,83010,CPT,,,,,,,,265,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,11.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.53,259.7
Immunoassay - Ref,PX8351690,CDM,300,RC,83516,CPT,90,,,,,,,15,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,11.53,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.18,11.53
"Lab Immunoassay, Non Antibody",PX83516,CDM,300,RC,83516,CPT,,,,,,,,99,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,11.53,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.18,11.53
Tiss Trnsgltmnase Ea Ig Clas,PX86364,CDM,300,RC,86364,CPT,,,,,,,,57,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,11.53,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.23,11.53
fluvastatin 20 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,378802093,NDC,1,EA,26.88,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,11.53152,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PREP KIT SKIN PREMIUM,27200000,CDM,272,RC,,,,4108-MAIN,LOCAL,,,,,12.96,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,11.5344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
eplerenone 25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16729029315,NDC,1,EA,23.31,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,11.53845,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluconazole 100 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069101,NDC,0.5,EA,23.55,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.5395,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluconazole 100 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069101,NDC,0.5,EA,23.55,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.5395,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluconazole 100 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069101,NDC,0.5,EA,23.55,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,11.5395,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
mineral oil Enema 133 mL Bottle,63700001,CDM,250,RC,,,,,,132030140,NDC,133,ML,13.58,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.543,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydroxychloroquine 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292001101,NDC,1,EA,23.57,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.5493,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydroxychloroquine 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292001101,NDC,1,EA,23.57,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.5493,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydroxychloroquine 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292001101,NDC,1,EA,23.57,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,11.5493,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
B-Scan Global,PX7651201,CDM,402,RC,76512,CPT,TC,,,,,,,127,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,11.55,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.55,35.5
Creatine Mb Fraction,PX82553,CDM,300,RC,82553,CPT,,,,,,,,353,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,11.55,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2,11.55
Antithrombin III Activity - Ref,PX8530090,CDM,300,RC,85300,CPT,90,,,,,,,158,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,11.5524,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.49,11.85
Blood Viscosity Examination,PX85810,CDM,300,RC,85810,CPT,,,,,,,,95,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,11.5524,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.32,11.67
Topiramate - Ref,PX8020190,CDM,300,RC,80201,CPT,90,,,,,,,195,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,11.5524,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.5524,11.92
Topiramate - Ref,PX8020190,CDM,300,RC,80201,CPT,90,,,,,,,195,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,11.56,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.5524,11.92
Topiramate - Ref,PX8020190,CDM,300,RC,80201,CPT,90,,,,,,,195,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,11.56,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.5524,11.92
Topiramate - Ref,PX8020190,CDM,300,RC,80201,CPT,90,,,,,,,195,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,11.56,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.5524,11.92
ustekinumab 130 MG/26ML Solution 26 mL Vial,J3358.01,CDM,636,RC,J3358,HCPCS,,,,57894005427,NDC,26,ML,4130,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,11.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.56,4047.4
FLUoxetine 10 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578461,NDC,1,EA,12.99,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,11.5611,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
chlorhexidine 4 % Solution 118 mL Bottle,25000000,CDM,250,RC,,,,,,234057504,NDC,118,ML,24.09,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,11.5632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
chlorhexidine 4 % Solution 118 mL Bottle,25000000,CDM,250,RC,,,,,,234057504,NDC,118,ML,24.09,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,11.5632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Antibiotic Sens,Enzyme Detection,Each - Ref",PX8718590,CDM,300,RC,87185,CPT,90,,,,,,,13,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,11.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.36,12.74
Assay of Lactic Acid,PX83605,CDM,300,RC,83605,CPT,,,,,,,,150,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,11.57,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.22,11.57
BONE WAX SUTURE 2.5G ETHICON,27200000,CDM,272,RC,,,,12566-MAIN,LOCAL,,,,,13,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,11.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Hepatitis Be Antibody - Ref,PX8670790,CDM,300,RC,86707,CPT,90,,,,,,,192,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,11.57,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.22,11.57
aluminum & magnesium hydroxide-simethicone 200-200-20 MG/5ML Suspension 30 mL Cup,63700001,CDM,250,RC,,,,,,121176130,NDC,30,ML,24.12,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,11.5776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aluminum & magnesium hydroxide-simethicone 200-200-20 MG/5ML Suspension 30 mL Cup,63700001,CDM,250,RC,,,,,,121176130,NDC,30,ML,24.12,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,11.5776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Long Term Holter, 48 Hrs Up to 7 Days, Recording",PX93242,CDM,731,RC,93242,CPT,,,,,,,,58,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,11.5776,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.63,20.94
"Long Term Holter, More Than 7 Days Up to 15 Days, Recording",PX93246,CDM,731,RC,93246,CPT,,,,,,,,58,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,11.5776,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.63,20.94
GOLIMumab 50 MG/4ML Solution 4 mL Vial,J1602.01,CDM,636,RC,J1602,HCPCS,,,,57894035001,NDC,4,ML,3709.76,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,11.5812,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.86,12.34
BOOT CAST LARGE 12-5/8 ORT290010L,120.247,CDM,274,RC,L3260,HCPCS,,204-MAIN,LOCAL,,,,,27,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,11.583,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
BOOT CAST MEDIUM 08148803,120.247,CDM,274,RC,L3260,HCPCS,,203-MAIN,LOCAL,,,,,27,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,11.583,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
BOOT CAST X-LARGE 13X5-1/2IN ORT29200XL,120.247,CDM,274,RC,L3260,HCPCS,,206-MAIN,LOCAL,,,,,27,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,11.583,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
KERRAMAX CARE SUPERABSORBENT DRESSING 8X12,120.55,CDM,272,RC,A6197,HCPCS,,12363-MAIN,LOCAL,,,,,27,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,11.583,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
Or Time,PX36000086,CDM,360,RC,,,,,,,,,,27,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,11.583,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
"Sodium, Other Source - Ref",PX8430290,CDM,300,RC,84302,CPT,90,,,,,,,27,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,11.583,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.46,26.46
hydroxychloroquine 200 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16571068701,NDC,1,EA,23.41,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,11.58795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex ER 250 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031011,NDC,1,EA,13.14,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.58948,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex ER 250 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084031001,NDC,1,EA,13.14,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.58948,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clopidogrel 75 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629461,NDC,1,EA,23.42,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,11.5929,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
citalopram 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904608461,NDC,1,EA,13.03,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,11.5967,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Electric Stimulation Therapy,PX97014,CDM,420,RC,97014,CPT,,,,,,,,135,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,11.6064,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.65,19.92
celecoxib 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904650261,NDC,1,EA,23.45,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,11.60775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Vitamin a - Ref,PX8459090,CDM,300,RC,84590,CPT,90,,,,,,,63,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,11.61,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2315,11.61
naltrexone 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406117001,NDC,1,EA,22.96,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,11.61776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Ag Detect Nos Eia Mult,PX87449,CDM,300,RC,87449,CPT,,,,,,,,193,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,11.62,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.44,11.98
Aspergillus Ag - Ref,PX8730590,CDM,300,RC,87305,CPT,90,,,,,,,141,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,11.62,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.62,11.98
Aspergillus Ag - Ref,PX8730590,CDM,300,RC,87305,CPT,90,,,,,,,141,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,11.62,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.62,11.98
Aspergillus Ag - Ref,PX8730590,CDM,300,RC,87305,CPT,90,,,,,,,141,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,11.62,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.62,11.98
"Clostridium Ag, Eia",PX87324,CDM,300,RC,87324,CPT,,,,,,,,99,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,11.62,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.62,11.98
"Clostridium Ag, Eia",PX87324,CDM,300,RC,87324,CPT,,,,,,,,99,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,11.62,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.62,11.98
"Clostridium Ag, Eia",PX87324,CDM,300,RC,87324,CPT,,,,,,,,99,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,11.62,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.62,11.98
Giardia,PX87329,CDM,300,RC,87329,CPT,,,,,,,,117,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,11.62,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.62,11.98
Giardia,PX87329,CDM,300,RC,87329,CPT,,,,,,,,117,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,11.62,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.62,11.98
Giardia,PX87329,CDM,300,RC,87329,CPT,,,,,,,,117,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,11.62,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.62,11.98
"Infect Ag,Eia, Nos, Ea - Ref",PX8744990,CDM,300,RC,87449,CPT,90,,,,,,,187,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,11.62,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.44,11.98
phenylephrine 0.25 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,69536002515,NDC,15,ML,24.21,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,11.6208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenylephrine 0.25 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,69536002515,NDC,15,ML,24.21,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,11.6208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
triamcinolone acetonide 0.1 % Cream 15 g Tube,63700001,CDM,250,RC,,,,,,168000415,NDC,15,GR,22.97,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,11.62282,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zinc oxide 20 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,536131625,NDC,60,GR,22.97,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,11.62282,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tacrolimus 1 MG capsule 100 Each Bottle,J7507.01,CDM,636,RC,J7507,HCPCS,,,,16714009901,NDC,0.5,EA,11.95,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,11.630935,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.96403,11.711
"Albumin; Other Source, Quantitative, Each Specimen",PX82042,CDM,300,RC,82042,CPT,,,,,,,,28,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,11.6312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.13,27.44
Anesthesia Level - Regional,PX37000025,CDM,370,RC,,,,,,,,,,28,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,11.6312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
Gonadotropin (Lh),PX83002,CDM,300,RC,83002,CPT,,,,,,,,28,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,11.6312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
PROMOGRAN PRISMA AG COLLAGEN DRESSING 28CM,120.547,CDM,272,RC,A6021,HCPCS,,12361-MAIN,LOCAL,,,,,28,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,11.6312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
SCOPE BRONCHOSCOPE SZ 4 STERILE DISPOSABLE B120044,120.574,CDM,272,RC,,,,12868-MAIN,LOCAL,,,,,28,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,11.6312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
tranexamic acid 650 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,69918030130,NDC,1,EA,28,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,11.6312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Viral Neutralization - Ref,PX8638290,CDM,300,RC,86382,CPT,90,,,,,,,28,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,11.6312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
BRACE WRIST 8-IN SM LEFT 10432,120.564,CDM,273,RC,L3809,HCPCS,,12720-MAIN,LOCAL,,,,,23,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,11.638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 8-IN SM RIGHT 10442,120.564,CDM,273,RC,L3809,HCPCS,,12716-MAIN,LOCAL,,,,,23,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,11.638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN LG RIGHT 10464,120.564,CDM,273,RC,L3809,HCPCS,,12719-MAIN,LOCAL,,,,,23,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,11.638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN SM LEFT 617083,120.564,CDM,273,RC,L3809,HCPCS,,12722-MAIN,LOCAL,,,,,23,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,11.638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN SM RIGHT 10462,120.564,CDM,273,RC,L3809,HCPCS,,12717-MAIN,LOCAL,,,,,23,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,11.638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN XL LEFT 10455,120.564,CDM,273,RC,L3809,HCPCS,,12721-MAIN,LOCAL,,,,,23,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,11.638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN XL RIGHT 10465,120.564,CDM,273,RC,L3809,HCPCS,,12715-MAIN,LOCAL,,,,,23,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,11.638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST WRISTPRO LEFT 10-IN LG,120.564,CDM,273,RC,L3809,HCPCS,,12724-MAIN,LOCAL,,,,,23,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,11.638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST WRISTPRO LEFT 10-IN MED,120.564,CDM,273,RC,L3809,HCPCS,,12723-MAIN,LOCAL,,,,,23,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,11.638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
Detection of Babesia Borrelia Miyamotoi by Amplified Nucleic Acid Probe Technique,PX8747890,CDM,300,RC,87478,CPT,90,,,,,,,23,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,11.638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,32.17
Detection of Babesia Microtim by Amplified Nucleic Acid Probe Technique,PX8746990,CDM,300,RC,87469,CPT,90,,,,,,,23,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,11.638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,32.17
FORCEPS COLD BIOPSY,27200000,CDM,272,RC,,,,12453-MAIN,LOCAL,,,,,23,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,11.638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE MAXON ABSORBABLE POLYGLYCONATE 2-0 30IN MONOFILAMENT DYED TAPER POINT 1/2 CIRCLE 27MM GS-22 G,27200000,CDM,272,RC,,,,11988-MAIN,LOCAL,,,,,23,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,11.638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE POLYSORB ABSORBABLE LACTOMER 2-0 30IN BRAIDED DYED TAPER POINT 1/2 CIRCLE 26MM V-20 VIOLET ST,27200000,CDM,272,RC,,,,11983-MAIN,LOCAL,,,,,23,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,11.638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Complement; Antigen, Each Component",PX86160,CDM,300,RC,86160,CPT,,,,,,,,124,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,11.64,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.64,12
"Complement; Antigen, Each Component",PX86160,CDM,300,RC,86160,CPT,,,,,,,,124,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,11.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.64,12
"Complement; Antigen, Each Component",PX86160,CDM,300,RC,86160,CPT,,,,,,,,124,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,11.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.64,12
gabapentin 600 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268035111,NDC,1,EA,12.79,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,11.65169,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 600 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268035115,NDC,1,EA,12.79,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,11.65169,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 25 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,62756070786,NDC,1,EA,13.71,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.6535,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluconazole 100 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069101,NDC,0.5,EA,23.55,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,11.65725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydroxychloroquine 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292001101,NDC,1,EA,23.57,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,11.66715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Blood Viscosity Examination,PX85810,CDM,300,RC,85810,CPT,,,,,,,,95,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,11.67,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.32,11.67
Acetaminophen 167 MG/5ML Liquid 237 mL Bottle,63700001,CDM,250,RC,,,,,,904584709,NDC,237,ML,27.22,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,11.67738,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,6384371,NDC,1,EA,563.46,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,11.67771,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.4,12.97
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022101,NDC,1,EA,514.5,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,11.67771,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.4,12.97
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022185,NDC,1,EA,514.5,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,11.67771,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.4,12.97
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022189,NDC,1,EA,514.5,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,11.67771,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.4,12.97
fluconazole 150 MG Tablet 12 Each Box,63700001,CDM,250,RC,,,,,,16714069211,NDC,0.333333333,EA,24.33,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,11.6784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluconazole 150 MG Tablet 12 Each Box,63700001,CDM,250,RC,,,,,,16714069211,NDC,0.333333333,EA,24.33,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,11.6784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BAG URINARY DRAINAGE DYND15405H,120.33,CDM,271,RC,A4357,HCPCS,,9112-MAIN,LOCAL,,,,,12,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,11.6796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
peak flow meter Device 1 Each Box,800000,CDM,,,,,,,,8373075500,NDC,1,EA,12,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,11.6796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
buprenorphine 2 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,50383092493,NDC,1,EA,24.34,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,11.6832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.14,40.7288
buprenorphine 2 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,50383092493,NDC,1,EA,24.34,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,11.6832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.14,40.7288
apixaban 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,3089431,NDC,0.5,EA,23.85,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.6865,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
apixaban 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,3089431,NDC,0.5,EA,23.85,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.6865,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
apixaban 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,3089431,NDC,0.5,EA,23.85,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,11.6865,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Actin Antibody Each,PX8601590,CDM,300,RC,86015,CPT,90,,,,,,,42,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,11.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.69,12.05
Actin Antibody Each,PX8601590,CDM,300,RC,86015,CPT,90,,,,,,,42,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,11.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.69,12.05
Actin Antibody Each,PX8601590,CDM,300,RC,86015,CPT,90,,,,,,,42,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,11.69,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.69,12.05
"Fluor Noninfect Ab Sc, Ea - Ref",PX8625590,CDM,300,RC,86255,CPT,90,,,,,,,121,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,11.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.69,27.36
"Fluor Noninfect Ab Sc, Ea - Ref",PX8625590,CDM,300,RC,86255,CPT,90,,,,,,,121,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,11.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.69,27.36
"Fluor Noninfect Ab Sc, Ea - Ref",PX8625590,CDM,300,RC,86255,CPT,90,,,,,,,121,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,11.69,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.69,27.36
"Hepatitis B Core Antibody, Total",PX86704,CDM,300,RC,86704,CPT,,,,,,,,21,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,11.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.69,12.05
"Hepatitis B Core Antibody, Total",PX86704,CDM,300,RC,86704,CPT,,,,,,,,21,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,11.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.69,12.05
"Hepatitis B Core Antibody, Total",PX86704,CDM,300,RC,86704,CPT,,,,,,,,21,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,11.69,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.69,12.05
divalproex ER 250 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031011,NDC,1,EA,13.14,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,11.6946,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex ER 250 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084031001,NDC,1,EA,13.14,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,11.6946,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739028510,NDC,1,EA,13.76,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sotalol 80 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,60505008000,NDC,1,EA,13.76,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 7 Each Box,63700001,CDM,250,RC,,,,,,536589653,NDC,1,EA,12.84,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,11.69724,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
entacapone 200 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,27241004910,NDC,1,EA,24.37,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,11.6976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
entacapone 200 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,27241004910,NDC,1,EA,24.37,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,11.6976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of Transferrin,PX84466,CDM,300,RC,84466,CPT,,,,,,,,103,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,11.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.7,100.94
buPROPion XL 150 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,70436001004,NDC,1,EA,23.14,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,11.70884,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tacrolimus 1 MG capsule 100 Each Bottle,J7507.01,CDM,636,RC,J7507,HCPCS,,,,16714009901,NDC,0.5,EA,11.95,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,11.711,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.96403,11.711
Antinuclear Antibodies,PX86038,CDM,300,RC,86038,CPT,,,,,,,,10,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,11.73,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.73,12.09
Antinuclear Antibodiesana - Ref,PX8603890,CDM,300,RC,86038,CPT,90,,,,,,,43,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,11.73,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.73,12.09
Antinuclear Antibodies,PX86038,CDM,300,RC,86038,CPT,,,,,,,,10,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,11.73,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.73,12.09
Antinuclear Antibodies,PX86038,CDM,300,RC,86038,CPT,,,,,,,,10,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,11.73,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.73,12.09
Antinuclear Antibodiesana - Ref,PX8603890,CDM,300,RC,86038,CPT,90,,,,,,,43,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,11.73,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.73,12.09
Antinuclear Antibodiesana - Ref,PX8603890,CDM,300,RC,86038,CPT,90,,,,,,,43,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,11.73,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.73,12.09
lamoTRIgine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739051610,NDC,1,EA,13.3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.7306,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505706300,NDC,1,EA,13.81,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.7385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,75826011410,NDC,1,EA,12.89,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,11.74279,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56016901,NDC,1,EA,12.89,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,11.74279,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079034801,NDC,1,EA,27.39,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,11.75031,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079034820,NDC,1,EA,27.39,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,11.75031,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034711,NDC,1,EA,12.08,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,11.757464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034701,NDC,1,EA,12.08,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,11.757464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 14 MG/24HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,43598044771,NDC,1,EA,12.08,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,11.757464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BAG URINARY DRAINAGE DYND15405H,120.33,CDM,271,RC,A4357,HCPCS,,9112-MAIN,LOCAL,,,,,12,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,11.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
peak flow meter Device 1 Each Box,800000,CDM,,,,,,,,8373075500,NDC,1,EA,12,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,11.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
SLEEVE BALLOON 5MMX100MML KII STERILE CFS02,27200000,CDM,272,RC,,,,11704-MAIN,LOCAL,,,,,24,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SLEEVE BALLOON 5MMX100MML KII STERILE CFS02,27200000,CDM,272,RC,,,,11704-MAIN,LOCAL,,,,,24,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SLEEVE BALLOON 5MMX100MML KII STERILE CFS02,27200000,CDM,272,RC,,,,11704-MAIN,LOCAL,,,,,24,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,11.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STRAP CLAVICLE LARGE VP10123-040,120.191,CDM,274,RC,L3670,HCPCS,,12848-MAIN,LOCAL,,,,,24,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE LARGE VP10123-040,120.191,CDM,274,RC,L3670,HCPCS,,12848-MAIN,LOCAL,,,,,24,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE LARGE VP10123-040,120.191,CDM,274,RC,L3670,HCPCS,,12848-MAIN,LOCAL,,,,,24,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,11.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE MEDIUM VP10123-030,120.191,CDM,274,RC,L3670,HCPCS,,12847-MAIN,LOCAL,,,,,24,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE MEDIUM VP10123-030,120.191,CDM,274,RC,L3670,HCPCS,,12847-MAIN,LOCAL,,,,,24,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE MEDIUM VP10123-030,120.191,CDM,274,RC,L3670,HCPCS,,12847-MAIN,LOCAL,,,,,24,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,11.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE SMALL VP10123-020,120.191,CDM,274,RC,L3670,HCPCS,,12846-MAIN,LOCAL,,,,,24,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE SMALL VP10123-020,120.191,CDM,274,RC,L3670,HCPCS,,12846-MAIN,LOCAL,,,,,24,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE SMALL VP10123-020,120.191,CDM,274,RC,L3670,HCPCS,,12846-MAIN,LOCAL,,,,,24,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,11.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE XL 661 XL,120.191,CDM,274,RC,L3670,HCPCS,,12850-MAIN,LOCAL,,,,,24,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE XL 661 XL,120.191,CDM,274,RC,L3670,HCPCS,,12850-MAIN,LOCAL,,,,,24,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE XL 661 XL,120.191,CDM,274,RC,L3670,HCPCS,,12850-MAIN,LOCAL,,,,,24,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,11.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE XSMALL CHILD ORT14100XS,120.191,CDM,274,RC,L3670,HCPCS,,12849-MAIN,LOCAL,,,,,24,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE XSMALL CHILD ORT14100XS,120.191,CDM,274,RC,L3670,HCPCS,,12849-MAIN,LOCAL,,,,,24,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE XSMALL CHILD ORT14100XS,120.191,CDM,274,RC,L3670,HCPCS,,12849-MAIN,LOCAL,,,,,24,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,11.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
cefdinir 300 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,67877054360,NDC,1,EA,27.42,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,11.76318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cholestyramine light 4 g Packet 42 Each Box,63700001,CDM,250,RC,,,,,,245003642,NDC,1,EA,27.42,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,11.76318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
FLUoxetine 20 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578561,NDC,1,EA,13.34,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.76588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
B-Scan Global,PX7651201,CDM,402,RC,76512,CPT,TC,,,,,,,127,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,11.77,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.55,35.5
B-Scan Global,PX7651201,CDM,402,RC,76512,CPT,TC,,,,,,,127,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,11.77,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.55,35.5
Strapping of Elbow or Wrist,PX29260F,CDM,420,RC,29260,CPT,,,,,,,,64,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,11.77,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.77,60.19
Strapping of Elbow or Wrist,PX29260F,CDM,420,RC,29260,CPT,,,,,,,,64,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,11.77,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.77,60.19
Strapping of Elbow or Wrist,PX29260F,CDM,420,RC,29260,CPT,,,,,,,,64,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,11.77,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.77,60.19
cholestyramine light 4 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,245003689,NDC,1,EA,27.44,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,11.77176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56017601,NDC,1,EA,13.85,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.7725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisoprolol 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714052901,NDC,1,EA,12.1,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,11.77693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Strapping of Ankle,PX29540F,CDM,420,RC,29540,CPT,,,,,,,,271,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,11.78,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.68,58.11
cefdinir 300 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,16714039102,NDC,1,EA,27.46,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,11.78034,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
eplerenone 25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16729029315,NDC,1,EA,23.31,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,11.79486,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
GOLIMumab 50 MG/4ML Solution 4 mL Vial,J1602.01,CDM,636,RC,J1602,HCPCS,,,,57894035001,NDC,4,ML,3709.76,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,11.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.86,12.34
GOLIMumab 50 MG/4ML Solution 4 mL Vial,J1602.01,CDM,636,RC,J1602,HCPCS,,,,57894035001,NDC,4,ML,3709.76,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,11.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.86,12.34
chlorhexidine 4 % Solution 118 mL Bottle,25000000,CDM,250,RC,,,,,,234057504,NDC,118,ML,24.09,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.8041,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
chlorhexidine 4 % Solution 118 mL Bottle,25000000,CDM,250,RC,,,,,,234057504,NDC,118,ML,24.09,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.8041,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
chlorhexidine 4 % Solution 118 mL Bottle,25000000,CDM,250,RC,,,,,,234057504,NDC,118,ML,24.09,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,11.8041,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
apixaban 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,3089431,NDC,0.5,EA,23.85,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,11.80575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PREP KIT SKIN PREMIUM,27200000,CDM,272,RC,,,,4108-MAIN,LOCAL,,,,,12.96,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,11.80656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Bacterium Nos, Antibody - Ref",PX8660990,CDM,300,RC,86609,CPT,90,,,,,,,20,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,11.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
"Misc Virus Antibody, Nos - Ref",PX8679090,CDM,300,RC,86790,CPT,90,,,,,,,90,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,11.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.81,88.2
Rubeola Antibody,PX86765,CDM,300,RC,86765,CPT,,,,,,,,74,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,11.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.81,72.52
Varicella-Zoster Antibody,PX86787,CDM,300,RC,86787,CPT,,,,,,,,95,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,11.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.81,93.1
aluminum & magnesium hydroxide-simethicone 200-200-20 MG/5ML Suspension 30 mL Cup,63700001,CDM,250,RC,,,,,,121176130,NDC,30,ML,24.12,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.8188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aluminum & magnesium hydroxide-simethicone 200-200-20 MG/5ML Suspension 30 mL Cup,63700001,CDM,250,RC,,,,,,121176130,NDC,30,ML,24.12,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.8188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aluminum & magnesium hydroxide-simethicone 200-200-20 MG/5ML Suspension 30 mL Cup,63700001,CDM,250,RC,,,,,,121176130,NDC,30,ML,24.12,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,11.8188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Group Therapeutic Procedures,PX97150,CDM,420,RC,97150,CPT,,,,,,,,67,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,11.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.82,65.66
warfarin 4 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56016801,NDC,1,EA,13.91,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.8235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Blastomyces Antibody - Ref,PX8661290,CDM,300,RC,86612,CPT,90,,,,,,,97,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,11.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.83,95.06
"Calculus, Infrared Spec - Ref",PX8236590,CDM,300,RC,82365,CPT,90,,,,,,,145,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,11.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.83,142.1
Hiaa - Ref,PX8349790,CDM,300,RC,83497,CPT,90,,,,,,,84,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,11.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.83,82.32
FLUoxetine 10 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578461,NDC,1,EA,12.99,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,11.83389,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739051610,NDC,1,EA,13.3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,11.837,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034711,NDC,1,EA,12.08,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,11.8384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034701,NDC,1,EA,12.08,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,11.8384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 14 MG/24HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,43598044771,NDC,1,EA,12.08,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,11.8384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Antibiotic Sens,Enzyme Detection,Each - Ref",PX8718590,CDM,300,RC,87185,CPT,90,,,,,,,13,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,11.843,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.36,12.74
BONE WAX SUTURE 2.5G ETHICON,27200000,CDM,272,RC,,,,12566-MAIN,LOCAL,,,,,13,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,11.843,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
rOPINIRole 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547026810,NDC,1,EA,13.43,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.84526,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56017001,NDC,1,EA,13.43,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.84526,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydroxychloroquine 200 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16571068701,NDC,1,EA,23.41,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,11.84546,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Antithrombin III Activity - Ref,PX8530090,CDM,300,RC,85300,CPT,90,,,,,,,158,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,11.85,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.49,11.85
Myoglobin - Ref,PX8387490,CDM,300,RC,83874,CPT,90,,,,,,,22,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,11.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.1388,21.56
clopidogrel 75 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629461,NDC,1,EA,23.42,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,11.85052,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simethicone 40 MG/0.6ML Suspension 30 mL Bottle,25000000,CDM,250,RC,,,,,,70677107801,NDC,30,ML,24.69,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,11.8512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
simethicone 40 MG/0.6ML Suspension 30 mL Bottle,25000000,CDM,250,RC,,,,,,70677107801,NDC,30,ML,24.69,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,11.8512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
benzonatate 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877010501,NDC,1,EA,13.44,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.85408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisoprolol 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714052901,NDC,1,EA,12.1,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,11.858,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenylephrine 0.25 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,69536002515,NDC,15,ML,24.21,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.8629,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenylephrine 0.25 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,69536002515,NDC,15,ML,24.21,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.8629,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenylephrine 0.25 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,69536002515,NDC,15,ML,24.21,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,11.8629,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rOPINIRole 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462025301,NDC,1,EA,13.45,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.8629,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
celecoxib 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904650261,NDC,1,EA,23.45,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,11.8657,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rOPINIRole 4 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462025801,NDC,1,EA,13.96,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.866,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Anca Screen Each Antibody,PX8603690,CDM,300,RC,86036,CPT,90,,,,,,,82,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,11.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,12.05
CCP Antibody,PX86200,CDM,300,RC,86200,CPT,,,,,,,,176,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,11.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,172.48
"CCP, Antibody - Ref",PX8620090,CDM,300,RC,86200,CPT,90,,,,,,,171,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,11.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,167.58
High Sens Crp,PX86141,CDM,300,RC,86141,CPT,,,,,,,,97,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,11.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,95.06
citalopram 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904608461,NDC,1,EA,13.03,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,11.87033,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
FLUoxetine 20 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578561,NDC,1,EA,13.34,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,11.8726,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Actin Antibody Each,PX8601590,CDM,300,RC,86015,CPT,90,,,,,,,42,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,11.8733,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.69,12.05
Ag Detect Nos Eia Mult,PX87449,CDM,300,RC,87449,CPT,,,,,,,,193,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,11.8733,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.44,11.98
Anca Screen Each Antibody,PX8603690,CDM,300,RC,86036,CPT,90,,,,,,,82,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,11.8733,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,12.05
Antinuclear Antibodies,PX86038,CDM,300,RC,86038,CPT,,,,,,,,10,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,11.8733,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.73,12.09
Antinuclear Antibodiesana - Ref,PX8603890,CDM,300,RC,86038,CPT,90,,,,,,,43,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,11.8733,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.73,12.09
Aspergillus Ag - Ref,PX8730590,CDM,300,RC,87305,CPT,90,,,,,,,141,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,11.8733,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.62,11.98
"Clostridium Ag, Eia",PX87324,CDM,300,RC,87324,CPT,,,,,,,,99,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,11.8733,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.62,11.98
"Complement; Antigen, Each Component",PX86160,CDM,300,RC,86160,CPT,,,,,,,,124,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,11.8733,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.64,12
"Fluor Noninfect Ab Sc, Ea - Ref",PX8625590,CDM,300,RC,86255,CPT,90,,,,,,,121,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,11.8733,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.69,27.36
"Fungus Antibody, Nos - Ref",PX8667190,CDM,300,RC,86671,CPT,90,,,,,,,99,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,11.8733,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.8733,12.25
Giardia,PX87329,CDM,300,RC,87329,CPT,,,,,,,,117,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,11.8733,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.62,11.98
"Hepatitis B Core Antibody, Total",PX86704,CDM,300,RC,86704,CPT,,,,,,,,21,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,11.8733,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.69,12.05
"Infect Ag,Eia, Nos, Ea - Ref",PX8744990,CDM,300,RC,87449,CPT,90,,,,,,,187,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,11.8733,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.44,11.98
Each Add'l Hour IV Hydration,PX96361,CDM,260,RC,96361,CPT,,,,,,,,123,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,11.877,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.85,21.52
SLEEVE BALLOON 5MMX100MML KII STERILE CFS02,27200000,CDM,272,RC,,,,11704-MAIN,LOCAL,,,,,24,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,11.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STRAP CLAVICLE LARGE VP10123-040,120.191,CDM,274,RC,L3670,HCPCS,,12848-MAIN,LOCAL,,,,,24,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,11.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE MEDIUM VP10123-030,120.191,CDM,274,RC,L3670,HCPCS,,12847-MAIN,LOCAL,,,,,24,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,11.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE SMALL VP10123-020,120.191,CDM,274,RC,L3670,HCPCS,,12846-MAIN,LOCAL,,,,,24,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,11.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE XL 661 XL,120.191,CDM,274,RC,L3670,HCPCS,,12850-MAIN,LOCAL,,,,,24,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,11.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE XSMALL CHILD ORT14100XS,120.191,CDM,274,RC,L3670,HCPCS,,12849-MAIN,LOCAL,,,,,24,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,11.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
"Fungus Antibody, Nos - Ref",PX8667190,CDM,300,RC,86671,CPT,90,,,,,,,99,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,11.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.8733,12.25
"Fungus Antibody, Nos - Ref",PX8667190,CDM,300,RC,86671,CPT,90,,,,,,,99,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,11.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.8733,12.25
"Fungus Antibody, Nos - Ref",PX8667190,CDM,300,RC,86671,CPT,90,,,,,,,99,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,11.88,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.8733,12.25
doxycycline hyclate 100 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,904043004,NDC,0.5,EA,12.21,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,11.883993,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pindolol 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,29033002801,NDC,1,EA,24.77,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,11.8896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pindolol 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,29033002801,NDC,1,EA,24.77,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,11.8896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,6384371,NDC,1,EA,563.46,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,11.89,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.4,12.97
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,6384371,NDC,1,EA,563.46,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,11.89,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.4,12.97
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022101,NDC,1,EA,514.5,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,11.89,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.4,12.97
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022101,NDC,1,EA,514.5,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,11.89,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.4,12.97
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022185,NDC,1,EA,514.5,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,11.89,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.4,12.97
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022185,NDC,1,EA,514.5,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,11.89,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.4,12.97
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022189,NDC,1,EA,514.5,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,11.89,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.4,12.97
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022189,NDC,1,EA,514.5,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,11.89,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.4,12.97
AQUACEL EXTRA HYDOFIBER WOUND DRESSING 4X5,120.202,CDM,272,RC,A6197,HCPCS,,12047-MAIN,LOCAL,,,,,14,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
"AQUACEL FOAM DRESSING 4X4""",120.202,CDM,272,RC,A6209,HCPCS,,7939-MAIN,LOCAL,,,,,14,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
AQUACEL NONADHESIVE FOAM DRESSING 4X4,120.202,CDM,272,RC,A6209,HCPCS,,12046-MAIN,LOCAL,,,,,14,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
Assay Urine Urea-N,PX84540,CDM,300,RC,84540,CPT,,,,,,,,14,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.1,13.72
EZ CLEAN BLADE CAUTERY TIP 4 INCH,27200000,CDM,272,RC,,,,12826-MAIN,LOCAL,,,,,14,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Post Anesthesia Recovery,PX71000019,CDM,710,RC,,,,,,,,,,14,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
SAW WIRE 12 INCH GIGLI NL850,27200000,CDM,272,RC,,,,12901-MAIN,LOCAL,,,,,14,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
acetaminophen 160 MG/5ML Suspension 118 mL Bottle,63700001,CDM,250,RC,,,,,,45802020326,NDC,10.15625,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
albuterol (2.5 MG/3ML) 0.083% Nebulization Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487950101,NDC,3,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
albuterol 1.25 MG/3ML Nebulization Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487990425,NDC,3,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Alcohol Swabstick 70 % Pad 50 Each Box,800000,CDM,,,,,,,,18407061105,NDC,1,EA,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
amoxicillin 250 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,65862070755,NDC,5,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 400 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,65862007101,NDC,3.125,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Biotene Dry Mouth Liquid 473 mL Bottle,63700001,CDM,250,RC,,,,,,48582000330,NDC,5,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbamide peroxide 6.5% 6.5 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904662735,NDC,15,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,93417773,NDC,2.5,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,24979015514,NDC,2.5,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314065605,NDC,0.05,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dexAMETHasone 1 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,54317644,NDC,0.5,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dextromethorphan-guaiFENesin 20-200 MG/20ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904722320,NDC,118,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,693390152,NDC,2.5,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
diphenhydrAMINE 12.5 MG/5ML Liquid 118 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904698520,NDC,2.5,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
diphenhydrAMINE 12.5 MG/5ML Liquid 120 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,58657052804,NDC,2.5,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,57896018105,NDC,15,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,57896018405,NDC,15,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,603107554,NDC,5,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,69367027204,NDC,5,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904006100,NDC,5,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904676320,NDC,5,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,54838011740,NDC,5,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,61787006304,NDC,5,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 100 MG/5ML Suspension 120 mL Bottle,63700001,CDM,250,RC,,,,,,904530920,NDC,20,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ipratropium 0.02 % Solution 2.5 mL Plas Cont,25000000,CDM,250,RC,,,,,,76204010001,NDC,2.5,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487020101,NDC,3,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lactulose 10 GM/15ML Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,121457715,NDC,15,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lactulose encephalopathy 10 GM/15ML Solution 473 mL Bottle,25000000,CDM,250,RC,,,,,,50383079516,NDC,15,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
levalbuterol 1.25 MG/3ML Nebulization Solution 3 mL Box,63700001,CDM,250,RC,,,,,,76204090001,NDC,3,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levalbuterol 1.25 MG/3ML Nebulization Solution 3 mL Plas Cont,63700001,CDM,250,RC,,,,,,76204090011,NDC,3,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine viscous 2 % Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,121090315,NDC,5,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine viscous 2 % Solution 100 mL Bottle,63700001,CDM,250,RC,,,,,,72888012526,NDC,5,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,54353244,NDC,0.25,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,121077001,NDC,0.25,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,65162068784,NDC,0.25,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium citrate 1.745 GM/30ML Solution 296 mL Bottle,63700001,CDM,250,RC,,,,,,69452038998,NDC,150,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium citrate 1.745 GM/30ML Solution 296 mL Bottle,63700001,CDM,250,RC,,,,,,70677111101,NDC,150,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium hydroxide 400 MG/5ML Suspension 30 mL Cup,63700001,CDM,250,RC,,,,,,69339015301,NDC,5,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine 20 mg/mL Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,54051744,NDC,0.5,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine polacrilex 4 MG Lozenge 24 Each Bottle,63700001,CDM,250,RC,,,,,,113087303,NDC,0.5,EA,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,121086805,NDC,4,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,121086802,NDC,4,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,66689000802,NDC,4,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 473 mL Bottle,63700001,CDM,250,RC,,,,,,121086816,NDC,4,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
opium 10 MG/ML (1%) Tincture 0.3 mL Syringe,63700001,CDM,250,RC,,,,,,8888800392,NDC,0.3,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
opium 10 MG/ML (1%) Tincture 0.6 mL Syringe,63700001,CDM,250,RC,,,,,,88888800245,NDC,0.3,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
opium 10 MG/ML (1%) Tincture 118 mL Bottle,63700001,CDM,250,RC,,,,,,42799021701,NDC,0.3,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxymetazoline 0.05 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904571135,NDC,15,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,904693186,NDC,1,EA,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 100 Each Box,63700001,CDM,250,RC,,,,,,904642281,NDC,1,EA,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
povidone iodine 10 % Solution 59 mL Bottle,63700001,CDM,250,RC,,,,,,52380190502,NDC,59,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Povidone-Iodine 10 % SWAB 1 Each Package,25000000,CDM,250,RC,,,,,,67618015301,NDC,1,EA,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004224,NDC,5,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,62135025037,NDC,1.666666667,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
racEPINEPHrine 2.25 % Nebulization Solution 1 Each Plas Cont,25000000,CDM,250,RC,,,,,,487590199,NDC,1,EA,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9 % Nebulization Solution 3 mL Plas Cont,63700001,CDM,250,RC,,,,,,487930133,NDC,3,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium chloride 0.65 % Solution 44 mL Bottle,63700001,CDM,250,RC,,,,,,904386575,NDC,44,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium phosphate 7-19 GM/118ML Enema 133 mL Bottle,63700001,CDM,250,RC,,,,,,132020140,NDC,133,ML,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
white petrolatum Gel 52.5 g Jar,63700001,CDM,250,RC,,,,,,521231100,NDC,52.5,GR,13.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zolpidem 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079072401,NDC,1,EA,24.81,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,11.9088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zolpidem 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079072401,NDC,1,EA,24.81,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,11.9088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zolpidem 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079072420,NDC,1,EA,24.81,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,11.9088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zolpidem 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079072420,NDC,1,EA,24.81,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,11.9088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluconazole 100 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069101,NDC,0.5,EA,23.55,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,11.9163,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Topiramate - Ref,PX8020190,CDM,300,RC,80201,CPT,90,,,,,,,195,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,11.92,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.5524,11.92
fluconazole 150 MG Tablet 12 Each Box,63700001,CDM,250,RC,,,,,,16714069211,NDC,0.333333333,EA,24.33,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.9217,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluconazole 150 MG Tablet 12 Each Box,63700001,CDM,250,RC,,,,,,16714069211,NDC,0.333333333,EA,24.33,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.9217,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluconazole 150 MG Tablet 12 Each Box,63700001,CDM,250,RC,,,,,,16714069211,NDC,0.333333333,EA,24.33,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,11.9217,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 800 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714033201,NDC,0.75,EA,12.25,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,11.922925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
chlorhexidine 4 % Solution 118 mL Bottle,25000000,CDM,250,RC,,,,,,234057504,NDC,118,ML,24.09,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,11.92455,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
hydroxychloroquine 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292001101,NDC,1,EA,23.57,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,11.92642,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buprenorphine 2 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,50383092493,NDC,1,EA,24.34,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.9266,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.14,40.7288
buprenorphine 2 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,50383092493,NDC,1,EA,24.34,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.9266,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.14,40.7288
buprenorphine 2 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,50383092493,NDC,1,EA,24.34,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,11.9266,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.14,40.7288
nicotine 7 MG/24HR Patch 24 Hour 7 Each Box,63700001,CDM,250,RC,,,,,,43598044670,NDC,1,EA,13.53,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.93346,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DULoxetine 60 MG Capsule Delayed Release Particles 30 Each Bottle,63700001,CDM,250,RC,,,,,,43547038103,NDC,0.333333333,EA,14.04,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.934,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aluminum & magnesium hydroxide-simethicone 200-200-20 MG/5ML Suspension 30 mL Cup,63700001,CDM,250,RC,,,,,,121176130,NDC,30,ML,24.12,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,11.9394,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
entacapone 200 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,27241004910,NDC,1,EA,24.37,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.9413,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
entacapone 200 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,27241004910,NDC,1,EA,24.37,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,11.9413,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
entacapone 200 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,27241004910,NDC,1,EA,24.37,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,11.9413,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay Blood Carbon Monoxide,PX82375,CDM,300,RC,82375,CPT,,,,,,,,156,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,11.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.95,12.32
Assay Blood Carbon Monoxide,PX82375,CDM,300,RC,82375,CPT,,,,,,,,156,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,11.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.95,12.32
Assay Blood Carbon Monoxide,PX82375,CDM,300,RC,82375,CPT,,,,,,,,156,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,11.95,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.95,12.32
DULoxetine 60 MG Capsule Delayed Release Particles 30 Each Bottle,63700001,CDM,250,RC,,,,,,57237001930,NDC,0.333333333,EA,14.06,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.951,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rOPINIRole 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547026810,NDC,1,EA,13.43,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,11.9527,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56017001,NDC,1,EA,13.43,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,11.9527,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 25 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,69097012203,NDC,1,EA,13.56,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.95992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzonatate 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877010501,NDC,1,EA,13.44,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,11.9616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline hyclate 100 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,904043004,NDC,0.5,EA,12.21,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,11.9658,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Mumps,PX86735,CDM,300,RC,86735,CPT,,,,,,,,148,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,11.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.97,145.04
rOPINIRole 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462025301,NDC,1,EA,13.45,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,11.9705,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex ER 250 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031011,NDC,1,EA,13.14,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,11.97054,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex ER 250 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084031001,NDC,1,EA,13.14,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,11.97054,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069030,NDC,3,ML,14.09,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11.9765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.852986,29.4
mineral oil Enema 133 mL Bottle,63700001,CDM,250,RC,,,,,,132030140,NDC,133,ML,13.58,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11.97756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Ag Detect Nos Eia Mult,PX87449,CDM,300,RC,87449,CPT,,,,,,,,193,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,11.98,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.44,11.98
Aspergillus Ag - Ref,PX8730590,CDM,300,RC,87305,CPT,90,,,,,,,141,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,11.98,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.62,11.98
"Clostridium Ag, Eia",PX87324,CDM,300,RC,87324,CPT,,,,,,,,99,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,11.98,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.62,11.98
Giardia,PX87329,CDM,300,RC,87329,CPT,,,,,,,,117,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,11.98,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.62,11.98
"Infect Ag,Eia, Nos, Ea - Ref",PX8744990,CDM,300,RC,87449,CPT,90,,,,,,,187,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,11.98,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.44,11.98
phenylephrine 0.25 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,69536002515,NDC,15,ML,24.21,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,11.98395,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Carcinoembryonic Antigen,PX82378,CDM,300,RC,82378,CPT,,,,,,,,25,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
Carcinoembryonic Antigen,PX82378,CDM,300,RC,82378,CPT,,,,,,,,25,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
"Complement; Antigen, Each Component",PX86160,CDM,300,RC,86160,CPT,,,,,,,,124,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,12,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.64,12
"Gput, Quant",PX8277590,CDM,300,RC,82775,CPT,90,,,,,,,25,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
"Gput, Quant",PX8277590,CDM,300,RC,82775,CPT,90,,,,,,,25,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
Heparin Xa,PX85520,CDM,300,RC,85520,CPT,,,,,,,,128,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12,125.44
MEPILEX ADH FOAM 4X10,120.63,CDM,272,RC,A6196,HCPCS,,8710-MAIN,LOCAL,,,,,25,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
MEPILEX ADH FOAM 4X10,120.63,CDM,272,RC,A6196,HCPCS,,8710-MAIN,LOCAL,,,,,25,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
MEPILEX SOFT SILICONE 6X6,120.63,CDM,272,RC,A6196,HCPCS,,5577-MAIN,LOCAL,,,,,25,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
MEPILEX SOFT SILICONE 6X6,120.63,CDM,272,RC,A6196,HCPCS,,5577-MAIN,LOCAL,,,,,25,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
OPTIFOAM GENTLE SA SILICCONE FACED FOAM & BOARDER,120.63,CDM,272,RC,A6196,HCPCS,,3938-MAIN,LOCAL,,,,,25,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
OPTIFOAM GENTLE SA SILICCONE FACED FOAM & BOARDER,120.63,CDM,272,RC,A6196,HCPCS,,3938-MAIN,LOCAL,,,,,25,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
Phase III Recovery Monthly,PX93799.01,CDM,943,RC,,,,,,,,,,25,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
Phase III Recovery Monthly,PX93799.01,CDM,943,RC,,,,,,,,,,25,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
"Testosterone,Free - Ref",PX8440290,CDM,300,RC,84402,CPT,90,,,,,,,25,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
"Testosterone,Free - Ref",PX8440290,CDM,300,RC,84402,CPT,90,,,,,,,25,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
gabapentin 800 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714033201,NDC,0.75,EA,12.25,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,12.005,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Albumin; Other Source, Quantitative, Each Specimen",PX82042,CDM,300,RC,82042,CPT,,,,,,,,28,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.012,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.13,27.44
Anesthesia Level - Regional,PX37000025,CDM,370,RC,,,,,,,,,,28,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.012,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
Gonadotropin (Lh),PX83002,CDM,300,RC,83002,CPT,,,,,,,,28,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.012,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
PROMOGRAN PRISMA AG COLLAGEN DRESSING 28CM,120.547,CDM,272,RC,A6021,HCPCS,,12361-MAIN,LOCAL,,,,,28,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.012,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
SCOPE BRONCHOSCOPE SZ 4 STERILE DISPOSABLE B120044,120.574,CDM,272,RC,,,,12868-MAIN,LOCAL,,,,,28,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.012,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
tranexamic acid 650 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,69918030130,NDC,1,EA,28,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.012,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Viral Neutralization - Ref,PX8638290,CDM,300,RC,86382,CPT,90,,,,,,,28,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.012,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
rivastigmine 1.5 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,62332006360,NDC,1,EA,25.03,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,12.0144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rivastigmine 1.5 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,62332006360,NDC,1,EA,25.03,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,12.0144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 160 MG/5ML Suspension 118 mL Bottle,63700001,CDM,250,RC,,,,,,45802020326,NDC,10.15625,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
albuterol (2.5 MG/3ML) 0.083% Nebulization Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487950101,NDC,3,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
albuterol 1.25 MG/3ML Nebulization Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487990425,NDC,3,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Alcohol Swabstick 70 % Pad 50 Each Box,800000,CDM,,,,,,,,18407061105,NDC,1,EA,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
amoxicillin 250 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,65862070755,NDC,5,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 400 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,65862007101,NDC,3.125,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Biotene Dry Mouth Liquid 473 mL Bottle,63700001,CDM,250,RC,,,,,,48582000330,NDC,5,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbamide peroxide 6.5% 6.5 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904662735,NDC,15,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,93417773,NDC,2.5,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,24979015514,NDC,2.5,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314065605,NDC,0.05,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dexAMETHasone 1 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,54317644,NDC,0.5,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dextromethorphan-guaiFENesin 20-200 MG/20ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904722320,NDC,118,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,693390152,NDC,2.5,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
diphenhydrAMINE 12.5 MG/5ML Liquid 118 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904698520,NDC,2.5,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
diphenhydrAMINE 12.5 MG/5ML Liquid 120 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,58657052804,NDC,2.5,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,57896018105,NDC,15,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,57896018405,NDC,15,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,603107554,NDC,5,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,69367027204,NDC,5,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904006100,NDC,5,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904676320,NDC,5,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,54838011740,NDC,5,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,61787006304,NDC,5,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 100 MG/5ML Suspension 120 mL Bottle,63700001,CDM,250,RC,,,,,,904530920,NDC,20,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ipratropium 0.02 % Solution 2.5 mL Plas Cont,25000000,CDM,250,RC,,,,,,76204010001,NDC,2.5,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487020101,NDC,3,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lactulose 10 GM/15ML Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,121457715,NDC,15,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lactulose encephalopathy 10 GM/15ML Solution 473 mL Bottle,25000000,CDM,250,RC,,,,,,50383079516,NDC,15,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
levalbuterol 1.25 MG/3ML Nebulization Solution 3 mL Box,63700001,CDM,250,RC,,,,,,76204090001,NDC,3,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levalbuterol 1.25 MG/3ML Nebulization Solution 3 mL Plas Cont,63700001,CDM,250,RC,,,,,,76204090011,NDC,3,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine viscous 2 % Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,121090315,NDC,5,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine viscous 2 % Solution 100 mL Bottle,63700001,CDM,250,RC,,,,,,72888012526,NDC,5,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,54353244,NDC,0.25,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,121077001,NDC,0.25,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,65162068784,NDC,0.25,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium citrate 1.745 GM/30ML Solution 296 mL Bottle,63700001,CDM,250,RC,,,,,,69452038998,NDC,150,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium citrate 1.745 GM/30ML Solution 296 mL Bottle,63700001,CDM,250,RC,,,,,,70677111101,NDC,150,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium hydroxide 400 MG/5ML Suspension 30 mL Cup,63700001,CDM,250,RC,,,,,,69339015301,NDC,5,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine 20 mg/mL Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,54051744,NDC,0.5,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine polacrilex 4 MG Lozenge 24 Each Bottle,63700001,CDM,250,RC,,,,,,113087303,NDC,0.5,EA,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,121086805,NDC,4,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,121086802,NDC,4,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,66689000802,NDC,4,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 473 mL Bottle,63700001,CDM,250,RC,,,,,,121086816,NDC,4,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
opium 10 MG/ML (1%) Tincture 0.3 mL Syringe,63700001,CDM,250,RC,,,,,,8888800392,NDC,0.3,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
opium 10 MG/ML (1%) Tincture 0.6 mL Syringe,63700001,CDM,250,RC,,,,,,88888800245,NDC,0.3,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
opium 10 MG/ML (1%) Tincture 118 mL Bottle,63700001,CDM,250,RC,,,,,,42799021701,NDC,0.3,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxymetazoline 0.05 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904571135,NDC,15,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,904693186,NDC,1,EA,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 100 Each Box,63700001,CDM,250,RC,,,,,,904642281,NDC,1,EA,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
povidone iodine 10 % Solution 59 mL Bottle,63700001,CDM,250,RC,,,,,,52380190502,NDC,59,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Povidone-Iodine 10 % SWAB 1 Each Package,25000000,CDM,250,RC,,,,,,67618015301,NDC,1,EA,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004224,NDC,5,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,62135025037,NDC,1.666666667,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
racEPINEPHrine 2.25 % Nebulization Solution 1 Each Plas Cont,25000000,CDM,250,RC,,,,,,487590199,NDC,1,EA,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9 % Nebulization Solution 3 mL Plas Cont,63700001,CDM,250,RC,,,,,,487930133,NDC,3,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium chloride 0.65 % Solution 44 mL Bottle,63700001,CDM,250,RC,,,,,,904386575,NDC,44,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium phosphate 7-19 GM/118ML Enema 133 mL Bottle,63700001,CDM,250,RC,,,,,,132020140,NDC,133,ML,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
white petrolatum Gel 52.5 g Jar,63700001,CDM,250,RC,,,,,,521231100,NDC,52.5,GR,13.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Hepatitis a Antibody, Tot - Ref",PX8670890,CDM,300,RC,86708,CPT,90,,,,,,,201,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,12.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.02,12.39
"Hepatitis a Antibody, Tot - Ref",PX8670890,CDM,300,RC,86708,CPT,90,,,,,,,201,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,12.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.02,12.39
"Hepatitis a Antibody, Tot - Ref",PX8670890,CDM,300,RC,86708,CPT,90,,,,,,,201,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.02,12.39
"Protozoa Antibody, Nos - Ref",PX8675390,CDM,300,RC,86753,CPT,90,,,,,,,99,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,12.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.02,12.39
"Protozoa Antibody, Nos - Ref",PX8675390,CDM,300,RC,86753,CPT,90,,,,,,,99,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,12.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.02,12.39
"Protozoa Antibody, Nos - Ref",PX8675390,CDM,300,RC,86753,CPT,90,,,,,,,99,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.02,12.39
"Direct skilled nursing services of a license practical nurse (lpn) in the home health or hospice setting, each 15 minutes",PXG0300,CDM,551,RC,G0300,HCPCS,,,,,,,,75,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,12.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.69,12.03
"Direct skilled nursing services of a license practical nurse (lpn) in the home health or hospice setting, each 15 minutes",PXG0300,CDM,551,RC,G0300,HCPCS,,,,,,,,75,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,12.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.69,12.03
HH Rn Initial Visit,PXG0154,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,12.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.02,12.03
HH Rn Initial Visit,PXG0154,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,12.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.02,12.03
HH Rn Routine Visit,PXG0154.01,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,12.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.02,12.03
HH Rn Routine Visit,PXG0154.01,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,12.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.02,12.03
Copper - Ref,PX8252590,CDM,300,RC,82525,CPT,90,,,,,,,94,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,12.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.04,12.41
Copper - Ref,PX8252590,CDM,300,RC,82525,CPT,90,,,,,,,94,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,12.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.04,12.41
Copper - Ref,PX8252590,CDM,300,RC,82525,CPT,90,,,,,,,94,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.04,12.41
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8092351,NDC,1,EA,52.22,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,22.288
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400101,NDC,1,EA,52.22,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,22.288
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400125,NDC,1,EA,52.22,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,22.288
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,781323294,NDC,1,EA,52.89,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,22.288
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,55150020200,NDC,1,EA,65.65,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,22.288
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,72603012801,NDC,1,EA,57.64,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,22.288
nicotine 7 MG/24HR Patch 24 Hour 7 Each Box,63700001,CDM,250,RC,,,,,,43598044670,NDC,1,EA,13.53,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.0417,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluconazole 150 MG Tablet 12 Each Box,63700001,CDM,250,RC,,,,,,16714069211,NDC,0.333333333,EA,24.33,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,12.04335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Ecg 12 Lead, Interp Only",PX93010,CDM,985,RC,93010,CPT,,,,,,,,29,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.0466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.0466,28.2257
Microscopic Exam of Urine,PX81015,CDM,300,RC,81015,CPT,,,,,,,,29,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.0466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.8,28.42
TRAY ARTHROGRAM SAFE-T-ARTHRO 28-AR1CO,120.2,CDM,272,RC,,,,11499-MAIN,LOCAL,,,,,29,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.0466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.0466,194.04
buprenorphine 2 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,50383092493,NDC,1,EA,24.34,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,12.0483,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.14,40.7288
Actin Antibody Each,PX8601590,CDM,300,RC,86015,CPT,90,,,,,,,42,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,12.05,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.69,12.05
Anca Screen Each Antibody,PX8603690,CDM,300,RC,86036,CPT,90,,,,,,,82,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,12.05,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,12.05
denosumab 120 MG/1.7ML Solution 1.7 mL Vial,J0897.01,CDM,636,RC,J0897,HCPCS,,,,55513073001,NDC,1.7,ML,4658.83,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.05,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.05,25.2
"Hepatitis B Core Antibody, Total",PX86704,CDM,300,RC,86704,CPT,,,,,,,,21,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,12.05,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.69,12.05
glucose 40 % Gel 37.5 g Package,63700001,CDM,250,RC,,,,,,574006930,NDC,37.5,GR,25.12,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,12.0576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glucose 40 % Gel 37.5 g Package,63700001,CDM,250,RC,,,,,,574006930,NDC,37.5,GR,25.12,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,12.0576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glucose 40 % Gel 37.5 g Tube,63700001,CDM,250,RC,,,,,,574006915,NDC,37.5,GR,25.12,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,12.0576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glucose 40 % Gel 37.5 g Tube,63700001,CDM,250,RC,,,,,,574006915,NDC,37.5,GR,25.12,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,12.0576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
entacapone 200 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,27241004910,NDC,1,EA,24.37,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,12.06315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
apixaban 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,3089431,NDC,0.5,EA,23.85,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,12.0681,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 25 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,69097012203,NDC,1,EA,13.56,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.0684,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
mineral oil Enema 133 mL Bottle,63700001,CDM,250,RC,,,,,,132030140,NDC,133,ML,13.58,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.0862,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Antinuclear Antibodies,PX86038,CDM,300,RC,86038,CPT,,,,,,,,10,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,12.09,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.73,12.09
Antinuclear Antibodiesana - Ref,PX8603890,CDM,300,RC,86038,CPT,90,,,,,,,43,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,12.09,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.73,12.09
"La Crosse, Antibody - Ref",PX8665190,CDM,300,RC,86651,CPT,90,,,,,,,45,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,12.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.09,44.1
"St Louis, Antibody - Ref",PX8665390,CDM,300,RC,86653,CPT,90,,,,,,,45,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,12.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.09,44.1
"Western Equine, Ab - Ref",PX8665490,CDM,300,RC,86654,CPT,90,,,,,,,45,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,12.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.09,44.1
topiramate 25 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,62756070786,NDC,1,EA,13.71,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,12.09222,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simethicone 40 MG/0.6ML Suspension 30 mL Bottle,25000000,CDM,250,RC,,,,,,70677107801,NDC,30,ML,24.69,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,12.0981,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
simethicone 40 MG/0.6ML Suspension 30 mL Bottle,25000000,CDM,250,RC,,,,,,70677107801,NDC,30,ML,24.69,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,12.0981,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
simethicone 40 MG/0.6ML Suspension 30 mL Bottle,25000000,CDM,250,RC,,,,,,70677107801,NDC,30,ML,24.69,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,12.0981,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Troponin, Quantitative",PX84484,CDM,300,RC,84484,CPT,,,,,,,,289,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,12.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.1,12.47
"Troponin, Quantitative",PX84484,CDM,300,RC,84484,CPT,,,,,,,,289,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,12.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.1,12.47
"Troponin, Quantitative",PX84484,CDM,300,RC,84484,CPT,,,,,,,,289,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.1,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.1,12.47
lamoTRIgine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739051610,NDC,1,EA,13.3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.1163,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739028510,NDC,1,EA,13.76,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,12.13632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sotalol 80 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,60505008000,NDC,1,EA,13.76,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,12.13632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pindolol 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,29033002801,NDC,1,EA,24.77,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,12.1373,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pindolol 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,29033002801,NDC,1,EA,24.77,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,12.1373,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pindolol 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,29033002801,NDC,1,EA,24.77,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,12.1373,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Treponema Pallidum,PX86780,CDM,300,RC,86780,CPT,,,,,,,,36,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,12.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.14,35.28
Treponema Pallidum - Ref,PX8678090,CDM,300,RC,86780,CPT,90,,,,,,,39,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,12.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.14,38.22
SLEEVE BALLOON 5MMX100MML KII STERILE CFS02,27200000,CDM,272,RC,,,,11704-MAIN,LOCAL,,,,,24,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,12.144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STRAP CLAVICLE LARGE VP10123-040,120.191,CDM,274,RC,L3670,HCPCS,,12848-MAIN,LOCAL,,,,,24,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,12.144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE MEDIUM VP10123-030,120.191,CDM,274,RC,L3670,HCPCS,,12847-MAIN,LOCAL,,,,,24,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,12.144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE SMALL VP10123-020,120.191,CDM,274,RC,L3670,HCPCS,,12846-MAIN,LOCAL,,,,,24,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,12.144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE XL 661 XL,120.191,CDM,274,RC,L3670,HCPCS,,12850-MAIN,LOCAL,,,,,24,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,12.144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE XSMALL CHILD ORT14100XS,120.191,CDM,274,RC,L3670,HCPCS,,12849-MAIN,LOCAL,,,,,24,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,12.144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
Assay of Phenytoin Total,PX80185,CDM,300,RC,80185,CPT,,,,,,,,336,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,12.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,329.28
Deoxyribonuclease Ab,PX86215,CDM,300,RC,86215,CPT,,,,,,,,99,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,12.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,97.02
Levetiracetam - Ref,PX8017790,CDM,300,RC,80177,CPT,90,,,,,,,108,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,12.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,105.84
Oxcarbazepine - Ref,PX8018390,CDM,300,RC,80183,CPT,90,,,,,,,108,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,12.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,105.84
FLUoxetine 20 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578561,NDC,1,EA,13.34,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.15274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zolpidem 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079072401,NDC,1,EA,24.81,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,12.1569,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zolpidem 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079072401,NDC,1,EA,24.81,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,12.1569,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zolpidem 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079072401,NDC,1,EA,24.81,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,12.1569,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zolpidem 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079072420,NDC,1,EA,24.81,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,12.1569,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zolpidem 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079072420,NDC,1,EA,24.81,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,12.1569,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zolpidem 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079072420,NDC,1,EA,24.81,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,12.1569,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of Digoxin,PX80162,CDM,300,RC,80162,CPT,,,,,,,,290,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,12.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.18,284.2
nicotine 21 MG/24HR Patch 24 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505706300,NDC,1,EA,13.81,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,12.18042,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
chlorhexidine 4 % Solution 118 mL Bottle,25000000,CDM,250,RC,,,,,,234057504,NDC,118,ML,24.09,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,12.18954,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Assay Blood Carbon Monoxide,PX82375,CDM,300,RC,82375,CPT,,,,,,,,156,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,12.1942,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.95,12.32
Copper - Ref,PX8252590,CDM,300,RC,82525,CPT,90,,,,,,,94,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,12.1942,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.04,12.41
Haptoglobin; Quantitative,PX83010,CDM,300,RC,83010,CPT,,,,,,,,265,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,12.1942,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.1942,12.58
"Hepatitis a Antibody, Tot - Ref",PX8670890,CDM,300,RC,86708,CPT,90,,,,,,,201,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,12.1942,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.02,12.39
"Protozoa Antibody, Nos - Ref",PX8675390,CDM,300,RC,86753,CPT,90,,,,,,,99,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,12.1942,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.02,12.39
"Troponin, Quantitative",PX84484,CDM,300,RC,84484,CPT,,,,,,,,289,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,12.1942,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.1,12.47
PARoxetine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084004411,NDC,1,EA,14.35,,First Health,Commercial,both,85,,999999999,percent of total billed charges,12.1975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084004401,NDC,1,EA,14.35,,First Health,Commercial,both,85,,999999999,percent of total billed charges,12.1975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Haptoglobin; Quantitative,PX83010,CDM,300,RC,83010,CPT,,,,,,,,265,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,12.2,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.1942,12.58
Haptoglobin; Quantitative,PX83010,CDM,300,RC,83010,CPT,,,,,,,,265,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,12.2,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.1942,12.58
Haptoglobin; Quantitative,PX83010,CDM,300,RC,83010,CPT,,,,,,,,265,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.2,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.1942,12.58
topiramate 25 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,62756070786,NDC,1,EA,13.71,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.2019,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aluminum & magnesium hydroxide-simethicone 200-200-20 MG/5ML Suspension 30 mL Cup,63700001,CDM,250,RC,,,,,,121176130,NDC,30,ML,24.12,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,12.20472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Spirometry,PX9401001,CDM,460,RC,94010,CPT,TC,,,,,,,281,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.21,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.21,33.74
Spirometry Incl Graph Rec Tc,PX9401002,CDM,460,RC,94010,CPT,TC,,,,,,,288,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.21,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.21,33.74
Strapping of Hand or Finger,PX29280F,CDM,420,RC,29280,CPT,,,,,,,,64,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.21,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.21,62.26
Strapping of Hand or Finger,PX29280F,CDM,420,RC,29280,CPT,,,,,,,,64,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,12.21,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.21,62.26
Strapping of Hand or Finger,PX29280F,CDM,420,RC,29280,CPT,,,,,,,,64,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,12.21,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.21,62.26
warfarin 2.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56017601,NDC,1,EA,13.85,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,12.2157,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temporary tooth filling repair Misc 1 Each Package,25000000,CDM,250,RC,,,,,,47701000123,NDC,1,EA,25.46,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,12.2208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
temporary tooth filling repair Misc 1 Each Package,25000000,CDM,250,RC,,,,,,47701000123,NDC,1,EA,25.46,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,12.2208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
simethicone 40 MG/0.6ML Suspension 30 mL Bottle,25000000,CDM,250,RC,,,,,,70677107801,NDC,30,ML,24.69,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,12.22155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
PACK BASIN BASIC SINGLE DYNJ06610A,27200000,CDM,272,RC,,,,10921-MAIN,LOCAL,,,,,25.48,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,12.2304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PACK BASIN BASIC SINGLE DYNJ06610A,27200000,CDM,272,RC,,,,10921-MAIN,LOCAL,,,,,25.48,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,12.2304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
rOPINIRole 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547026810,NDC,1,EA,13.43,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.23473,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56017001,NDC,1,EA,13.43,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.23473,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzonatate 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877010501,NDC,1,EA,13.44,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.24384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739028510,NDC,1,EA,13.76,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.2464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sotalol 80 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,60505008000,NDC,1,EA,13.76,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.2464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Carcinoembryonic Antigen,PX82378,CDM,300,RC,82378,CPT,,,,,,,,25,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,12.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
Carcinoembryonic Antigen,PX82378,CDM,300,RC,82378,CPT,,,,,,,,25,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,12.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
Carcinoembryonic Antigen,PX82378,CDM,300,RC,82378,CPT,,,,,,,,25,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,12.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
"Fungus Antibody, Nos - Ref",PX8667190,CDM,300,RC,86671,CPT,90,,,,,,,99,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,12.25,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.8733,12.25
"Gput, Quant",PX8277590,CDM,300,RC,82775,CPT,90,,,,,,,25,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,12.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
"Gput, Quant",PX8277590,CDM,300,RC,82775,CPT,90,,,,,,,25,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,12.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
"Gput, Quant",PX8277590,CDM,300,RC,82775,CPT,90,,,,,,,25,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,12.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
MEPILEX ADH FOAM 4X10,120.63,CDM,272,RC,A6196,HCPCS,,8710-MAIN,LOCAL,,,,,25,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,12.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
MEPILEX ADH FOAM 4X10,120.63,CDM,272,RC,A6196,HCPCS,,8710-MAIN,LOCAL,,,,,25,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,12.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
MEPILEX ADH FOAM 4X10,120.63,CDM,272,RC,A6196,HCPCS,,8710-MAIN,LOCAL,,,,,25,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,12.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
MEPILEX SOFT SILICONE 6X6,120.63,CDM,272,RC,A6196,HCPCS,,5577-MAIN,LOCAL,,,,,25,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,12.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
MEPILEX SOFT SILICONE 6X6,120.63,CDM,272,RC,A6196,HCPCS,,5577-MAIN,LOCAL,,,,,25,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,12.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
MEPILEX SOFT SILICONE 6X6,120.63,CDM,272,RC,A6196,HCPCS,,5577-MAIN,LOCAL,,,,,25,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,12.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
OPTIFOAM GENTLE SA SILICCONE FACED FOAM & BOARDER,120.63,CDM,272,RC,A6196,HCPCS,,3938-MAIN,LOCAL,,,,,25,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,12.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
OPTIFOAM GENTLE SA SILICCONE FACED FOAM & BOARDER,120.63,CDM,272,RC,A6196,HCPCS,,3938-MAIN,LOCAL,,,,,25,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,12.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
OPTIFOAM GENTLE SA SILICCONE FACED FOAM & BOARDER,120.63,CDM,272,RC,A6196,HCPCS,,3938-MAIN,LOCAL,,,,,25,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,12.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
Phase III Recovery Monthly,PX93799.01,CDM,943,RC,,,,,,,,,,25,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,12.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
Phase III Recovery Monthly,PX93799.01,CDM,943,RC,,,,,,,,,,25,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,12.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
Phase III Recovery Monthly,PX93799.01,CDM,943,RC,,,,,,,,,,25,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,12.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
"Testosterone,Free - Ref",PX8440290,CDM,300,RC,84402,CPT,90,,,,,,,25,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,12.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
"Testosterone,Free - Ref",PX8440290,CDM,300,RC,84402,CPT,90,,,,,,,25,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,12.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
"Testosterone,Free - Ref",PX8440290,CDM,300,RC,84402,CPT,90,,,,,,,25,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,12.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
phenylephrine 0.25 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,69536002515,NDC,15,ML,24.21,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,12.25026,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rOPINIRole 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462025301,NDC,1,EA,13.45,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.25295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pindolol 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,29033002801,NDC,1,EA,24.77,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,12.26115,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 1 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,45802043803,NDC,28,GR,25.55,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,12.264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 1 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,45802043803,NDC,28,GR,25.55,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,12.264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rivastigmine 1.5 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,62332006360,NDC,1,EA,25.03,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,12.2647,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rivastigmine 1.5 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,62332006360,NDC,1,EA,25.03,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,12.2647,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rivastigmine 1.5 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,62332006360,NDC,1,EA,25.03,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,12.2647,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 4 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56016801,NDC,1,EA,13.91,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,12.26862,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ziprasidone 80 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,781216860,NDC,0.25,EA,14.44,,First Health,Commercial,both,85,,999999999,percent of total billed charges,12.274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Lipid Profile,PX80061,CDM,300,RC,80061,CPT,,,,,,,,245,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,12.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.28,240.1
zolpidem 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079072401,NDC,1,EA,24.81,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,12.28095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zolpidem 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079072420,NDC,1,EA,24.81,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,12.28095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ustekinumab 130 MG/26ML Solution 26 mL Vial,J3358.01,CDM,636,RC,J3358,HCPCS,,,,57894005427,NDC,26,ML,4130,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,12.28894,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.1,12.62
nicotine 21 MG/24HR Patch 24 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505706300,NDC,1,EA,13.81,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.2909,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
citalopram 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904608561,NDC,1,EA,14.46,,First Health,Commercial,both,85,,999999999,percent of total billed charges,12.291,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaminophen 160 MG/5ML Suspension 118 mL Bottle,63700001,CDM,250,RC,,,,,,45802020326,NDC,10.15625,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
albuterol (2.5 MG/3ML) 0.083% Nebulization Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487950101,NDC,3,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
albuterol 1.25 MG/3ML Nebulization Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487990425,NDC,3,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Alcohol Swabstick 70 % Pad 50 Each Box,800000,CDM,,,,,,,,18407061105,NDC,1,EA,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
amoxicillin 250 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,65862070755,NDC,5,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 400 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,65862007101,NDC,3.125,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Biotene Dry Mouth Liquid 473 mL Bottle,63700001,CDM,250,RC,,,,,,48582000330,NDC,5,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbamide peroxide 6.5% 6.5 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904662735,NDC,15,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,93417773,NDC,2.5,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,24979015514,NDC,2.5,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314065605,NDC,0.05,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dexAMETHasone 1 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,54317644,NDC,0.5,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dextromethorphan-guaiFENesin 20-200 MG/20ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904722320,NDC,118,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,693390152,NDC,2.5,ML,13.5,,Medica,Commercial,both,91.1,,13.39,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
diphenhydrAMINE 12.5 MG/5ML Liquid 118 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904698520,NDC,2.5,ML,13.5,,Medica,Commercial,both,91.1,,13.39,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
diphenhydrAMINE 12.5 MG/5ML Liquid 120 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,58657052804,NDC,2.5,ML,13.5,,Medica,Commercial,both,91.1,,13.39,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,57896018105,NDC,15,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,57896018405,NDC,15,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,603107554,NDC,5,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,69367027204,NDC,5,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904006100,NDC,5,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904676320,NDC,5,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,54838011740,NDC,5,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,61787006304,NDC,5,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 100 MG/5ML Suspension 120 mL Bottle,63700001,CDM,250,RC,,,,,,904530920,NDC,20,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ipratropium 0.02 % Solution 2.5 mL Plas Cont,25000000,CDM,250,RC,,,,,,76204010001,NDC,2.5,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487020101,NDC,3,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lactulose 10 GM/15ML Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,121457715,NDC,15,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lactulose encephalopathy 10 GM/15ML Solution 473 mL Bottle,25000000,CDM,250,RC,,,,,,50383079516,NDC,15,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
levalbuterol 1.25 MG/3ML Nebulization Solution 3 mL Box,63700001,CDM,250,RC,,,,,,76204090001,NDC,3,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levalbuterol 1.25 MG/3ML Nebulization Solution 3 mL Plas Cont,63700001,CDM,250,RC,,,,,,76204090011,NDC,3,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine viscous 2 % Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,121090315,NDC,5,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine viscous 2 % Solution 100 mL Bottle,63700001,CDM,250,RC,,,,,,72888012526,NDC,5,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,54353244,NDC,0.25,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,121077001,NDC,0.25,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,65162068784,NDC,0.25,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium citrate 1.745 GM/30ML Solution 296 mL Bottle,63700001,CDM,250,RC,,,,,,69452038998,NDC,150,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium citrate 1.745 GM/30ML Solution 296 mL Bottle,63700001,CDM,250,RC,,,,,,70677111101,NDC,150,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium hydroxide 400 MG/5ML Suspension 30 mL Cup,63700001,CDM,250,RC,,,,,,69339015301,NDC,5,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine 20 mg/mL Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,54051744,NDC,0.5,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine polacrilex 4 MG Lozenge 24 Each Bottle,63700001,CDM,250,RC,,,,,,113087303,NDC,0.5,EA,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,121086805,NDC,4,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,121086802,NDC,4,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,66689000802,NDC,4,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 473 mL Bottle,63700001,CDM,250,RC,,,,,,121086816,NDC,4,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
opium 10 MG/ML (1%) Tincture 0.3 mL Syringe,63700001,CDM,250,RC,,,,,,8888800392,NDC,0.3,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
opium 10 MG/ML (1%) Tincture 0.6 mL Syringe,63700001,CDM,250,RC,,,,,,88888800245,NDC,0.3,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
opium 10 MG/ML (1%) Tincture 118 mL Bottle,63700001,CDM,250,RC,,,,,,42799021701,NDC,0.3,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxymetazoline 0.05 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904571135,NDC,15,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,904693186,NDC,1,EA,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 100 Each Box,63700001,CDM,250,RC,,,,,,904642281,NDC,1,EA,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
povidone iodine 10 % Solution 59 mL Bottle,63700001,CDM,250,RC,,,,,,52380190502,NDC,59,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Povidone-Iodine 10 % SWAB 1 Each Package,25000000,CDM,250,RC,,,,,,67618015301,NDC,1,EA,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004224,NDC,5,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,62135025037,NDC,1.666666667,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
racEPINEPHrine 2.25 % Nebulization Solution 1 Each Plas Cont,25000000,CDM,250,RC,,,,,,487590199,NDC,1,EA,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9 % Nebulization Solution 3 mL Plas Cont,63700001,CDM,250,RC,,,,,,487930133,NDC,3,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium chloride 0.65 % Solution 44 mL Bottle,63700001,CDM,250,RC,,,,,,904386575,NDC,44,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium phosphate 7-19 GM/118ML Enema 133 mL Bottle,63700001,CDM,250,RC,,,,,,132020140,NDC,133,ML,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
white petrolatum Gel 52.5 g Jar,63700001,CDM,250,RC,,,,,,521231100,NDC,52.5,GR,13.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097084034,NDC,3,ML,14.47,,First Health,Commercial,both,85,,999999999,percent of total billed charges,12.2995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097084053,NDC,3,ML,14.47,,First Health,Commercial,both,85,,999999999,percent of total billed charges,12.2995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Cryptococcus Neoformans,PX87327,CDM,300,RC,87327,CPT,,,,,,,,45,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,12.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.3,44.1
glucose 40 % Gel 37.5 g Package,63700001,CDM,250,RC,,,,,,574006930,NDC,37.5,GR,25.12,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,12.3088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glucose 40 % Gel 37.5 g Package,63700001,CDM,250,RC,,,,,,574006930,NDC,37.5,GR,25.12,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,12.3088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glucose 40 % Gel 37.5 g Package,63700001,CDM,250,RC,,,,,,574006930,NDC,37.5,GR,25.12,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,12.3088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glucose 40 % Gel 37.5 g Tube,63700001,CDM,250,RC,,,,,,574006915,NDC,37.5,GR,25.12,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,12.3088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glucose 40 % Gel 37.5 g Tube,63700001,CDM,250,RC,,,,,,574006915,NDC,37.5,GR,25.12,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,12.3088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glucose 40 % Gel 37.5 g Tube,63700001,CDM,250,RC,,,,,,574006915,NDC,37.5,GR,25.12,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,12.3088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluconazole 150 MG Tablet 12 Each Box,63700001,CDM,250,RC,,,,,,16714069211,NDC,0.333333333,EA,24.33,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,12.31098,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rOPINIRole 4 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462025801,NDC,1,EA,13.96,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,12.31272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buprenorphine 2 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,50383092493,NDC,1,EA,24.34,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,12.31604,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.14,40.7288
Assay Blood Carbon Monoxide,PX82375,CDM,300,RC,82375,CPT,,,,,,,,156,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,12.32,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.95,12.32
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,51293081001,NDC,1,EA,14.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,12.325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65162068110,NDC,1,EA,14.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,12.325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 7 MG/24HR Patch 24 Hour 7 Each Box,63700001,CDM,250,RC,,,,,,43598044670,NDC,1,EA,13.53,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.32583,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56017601,NDC,1,EA,13.85,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.3265,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
entacapone 200 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,27241004910,NDC,1,EA,24.37,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,12.33122,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
GOLIMumab 50 MG/4ML Solution 4 mL Vial,J1602.01,CDM,636,RC,J1602,HCPCS,,,,57894035001,NDC,4,ML,3709.76,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,12.34,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.86,12.34
inFLIXimab-dyyb 100 MG Recon Soln 1 Each Vial,Q5103.01,CDM,636,RC,Q5103,HCPCS,,,,69080901,NDC,1,EA,1930.42,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.34,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.88,14.29
AQUACEL EXTRA HYDOFIBER WOUND DRESSING 4X5,120.202,CDM,272,RC,A6197,HCPCS,,12047-MAIN,LOCAL,,,,,14,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,12.348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
"AQUACEL FOAM DRESSING 4X4""",120.202,CDM,272,RC,A6209,HCPCS,,7939-MAIN,LOCAL,,,,,14,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,12.348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
AQUACEL NONADHESIVE FOAM DRESSING 4X4,120.202,CDM,272,RC,A6209,HCPCS,,12046-MAIN,LOCAL,,,,,14,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,12.348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
Assay Urine Urea-N,PX84540,CDM,300,RC,84540,CPT,,,,,,,,14,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,12.348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.1,13.72
EZ CLEAN BLADE CAUTERY TIP 4 INCH,27200000,CDM,272,RC,,,,12826-MAIN,LOCAL,,,,,14,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,12.348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Post Anesthesia Recovery,PX71000019,CDM,710,RC,,,,,,,,,,14,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,12.348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
SAW WIRE 12 INCH GIGLI NL850,27200000,CDM,272,RC,,,,12901-MAIN,LOCAL,,,,,14,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,12.348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
cefoTEtan 2 g Recon Soln 1 Each Vial,800000,CDM,,,S0074,HCPCS,,,,63323038620,NDC,1,EA,240.2,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,12.35,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.53,15.49
topiramate 25 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,69097012203,NDC,1,EA,13.56,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.35316,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
mineral oil Enema 133 mL Bottle,63700001,CDM,250,RC,,,,,,132030140,NDC,133,ML,13.58,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.37138,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Carcinoembryonic Antigen,PX82378,CDM,300,RC,82378,CPT,,,,,,,,25,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,12.375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
"Gput, Quant",PX8277590,CDM,300,RC,82775,CPT,90,,,,,,,25,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,12.375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
MEPILEX ADH FOAM 4X10,120.63,CDM,272,RC,A6196,HCPCS,,8710-MAIN,LOCAL,,,,,25,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,12.375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
MEPILEX SOFT SILICONE 6X6,120.63,CDM,272,RC,A6196,HCPCS,,5577-MAIN,LOCAL,,,,,25,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,12.375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
OPTIFOAM GENTLE SA SILICCONE FACED FOAM & BOARDER,120.63,CDM,272,RC,A6196,HCPCS,,3938-MAIN,LOCAL,,,,,25,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,12.375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
Phase III Recovery Monthly,PX93799.01,CDM,943,RC,,,,,,,,,,25,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,12.375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
"Testosterone,Free - Ref",PX8440290,CDM,300,RC,84402,CPT,90,,,,,,,25,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,12.375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
warfarin 4 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56016801,NDC,1,EA,13.91,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.3799,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of Transferrin,PX84466,CDM,300,RC,84466,CPT,,,,,,,,103,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,12.38,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.38,12.76
Assay of Transferrin,PX84466,CDM,300,RC,84466,CPT,,,,,,,,103,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,12.38,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.38,12.76
Assay of Transferrin,PX84466,CDM,300,RC,84466,CPT,,,,,,,,103,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.38,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.38,12.76
DULoxetine 60 MG Capsule Delayed Release Particles 30 Each Bottle,63700001,CDM,250,RC,,,,,,43547038103,NDC,0.333333333,EA,14.04,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,12.38328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rivastigmine 1.5 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,62332006360,NDC,1,EA,25.03,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,12.38985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Hepatitis a Antibody, Tot - Ref",PX8670890,CDM,300,RC,86708,CPT,90,,,,,,,201,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,12.39,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.02,12.39
"Protozoa Antibody, Nos - Ref",PX8675390,CDM,300,RC,86753,CPT,90,,,,,,,99,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,12.39,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.02,12.39
DULoxetine 60 MG Capsule Delayed Release Particles 30 Each Bottle,63700001,CDM,250,RC,,,,,,57237001930,NDC,0.333333333,EA,14.06,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,12.40092,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 125 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,143988815,NDC,150,ML,25.84,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,12.4032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 125 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,143988815,NDC,150,ML,25.84,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,12.4032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 125 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,781603955,NDC,150,ML,25.84,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,12.4032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 125 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,781603955,NDC,150,ML,25.84,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,12.4032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay Dipropylacetic Acid,PX80164,CDM,300,RC,80164,CPT,,,,,,,,132,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,12.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.41,129.36
Assay for Vancomycin,PX80202,CDM,300,RC,80202,CPT,,,,,,,,314,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,12.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.41,307.72
Copper - Ref,PX8252590,CDM,300,RC,82525,CPT,90,,,,,,,94,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,12.41,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.04,12.41
rOPINIRole 4 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462025801,NDC,1,EA,13.96,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.4244,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069030,NDC,3,ML,14.09,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,12.42738,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.852986,29.4
buprenorphine 75 MCG FILM 60 Each Box,63700001,CDM,250,RC,,,,,,59385002160,NDC,1,EA,29.92,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.428768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glucose 40 % Gel 37.5 g Package,63700001,CDM,250,RC,,,,,,574006930,NDC,37.5,GR,25.12,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,12.4344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glucose 40 % Gel 37.5 g Tube,63700001,CDM,250,RC,,,,,,574006915,NDC,37.5,GR,25.12,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,12.4344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Ecg 12 Lead, Interp Only",PX93010,CDM,985,RC,93010,CPT,,,,,,,,29,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.441,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.0466,28.2257
Microscopic Exam of Urine,PX81015,CDM,300,RC,81015,CPT,,,,,,,,29,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.441,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.8,28.42
TRAY ARTHROGRAM SAFE-T-ARTHRO 28-AR1CO,120.2,CDM,272,RC,,,,11499-MAIN,LOCAL,,,,,29,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.441,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.0466,194.04
gabapentin 600 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268035111,NDC,1,EA,12.79,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,12.448507,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 600 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268035115,NDC,1,EA,12.79,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,12.448507,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
AQUACEL EXTRA HYDOFIBER WOUND DRESSING 4X5,120.202,CDM,272,RC,A6197,HCPCS,,12047-MAIN,LOCAL,,,,,14,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
"AQUACEL FOAM DRESSING 4X4""",120.202,CDM,272,RC,A6209,HCPCS,,7939-MAIN,LOCAL,,,,,14,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
AQUACEL NONADHESIVE FOAM DRESSING 4X4,120.202,CDM,272,RC,A6209,HCPCS,,12046-MAIN,LOCAL,,,,,14,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
Assay Urine Urea-N,PX84540,CDM,300,RC,84540,CPT,,,,,,,,14,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.1,13.72
EZ CLEAN BLADE CAUTERY TIP 4 INCH,27200000,CDM,272,RC,,,,12826-MAIN,LOCAL,,,,,14,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Post Anesthesia Recovery,PX71000019,CDM,710,RC,,,,,,,,,,14,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
SAW WIRE 12 INCH GIGLI NL850,27200000,CDM,272,RC,,,,12901-MAIN,LOCAL,,,,,14,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM ENDOWRIST INSTRUMENTS MEDIUM LARGE CLIP APPLIER,27200000,CDM,272,RC,,,,11910-MAIN,LOCAL,,,,,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,2,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.852986,29.4
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,3,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.852986,29.4
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061603,NDC,3,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,641600601,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
bacteriostatic water(benz alc) Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409397703,NDC,30,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BULB RESERVOIR SILICONE 400CC,27200000,CDM,272,RC,,,,12463-MAIN,LOCAL,,,,,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600710,NDC,2,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,38.9354
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409115918,NDC,1,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046401,NDC,1,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046402,NDC,1,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046437,NDC,1,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,409174670,NDC,1,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046801,NDC,1,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046817,NDC,1,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BUPivacaine in dextrose 0.75-8.25 % Solution 2 mL Ampule,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409176162,NDC,2,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046601,NDC,1,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143992490,NDC,0.5,EA,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010110,NDC,0.5,EA,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010167,NDC,0.5,EA,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,44567070725,NDC,0.5,EA,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733201,NDC,0.5,EA,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733801,NDC,0.5,EA,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,70069000501,NDC,0.1,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,63.2394
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016502,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016516,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036721,NDC,1,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036725,NDC,1,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 100 MG/10ML Solution 10 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323051610,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050641,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141031,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,641037621,NDC,0.25,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066416,NDC,1,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066441,NDC,0.25,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010101,NDC,0.25,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
DRAPE SPLIT WITH ADHESIVE DYNJP8304A,27200000,CDM,272,RC,,,,4694-MAIN,LOCAL,,,,,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRESSING HYDROFERA 2-1/2X2-1/2  BLUE READY FOAM HBRS2520,120.488,CDM,271,RC,A6209,HCPCS,,11537-MAIN,LOCAL,,,,,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
"Ethanol, P",PX82077,CDM,300,RC,82077,CPT,,,,,,,,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073916,NDC,2,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,29.4
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073941,NDC,1,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,29.4
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,67457043300,NDC,1,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,29.4
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909422,NDC,2,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
folic acid 5 MG/ML Solution 10 mL Vial,J3490.94,CDM,636,RC,J3490,HCPCS,,,,39822110001,NDC,0.2,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,330.2012
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,70860030242,NDC,1,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,36000028425,NDC,2,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001094,NDC,2,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,42.5516
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,781382571,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,143931901,NDC,0.4,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.428
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272002,NDC,1,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272031,NDC,1,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,25021040010,NDC,1,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323054011,NDC,1,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095300,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095310,NDC,1,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,71288042095,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306424,NDC,1,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306413,NDC,1,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306521,NDC,3,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin lock flush 10 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306510,NDC,5,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
HYDROmorphone 1 MG/ML Solution 1 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,76045000901,NDC,0.25,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016216,NDC,1,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016243,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072201,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072225,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016226,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016245,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011901,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011925,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072501,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072525,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143932001,NDC,1,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143962201,NDC,1,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,409226720,NDC,1,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,47781058629,NDC,1,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,51991093498,NDC,1,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,409427616,NDC,20,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323048526,NDC,20,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,63323049241,NDC,2,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2% PF 2 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049526,NDC,5,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2% PF 2 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049541,NDC,5,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine buffered 1 % Solution 0.5 mL Syringe,25000000,CDM,250,RC,,,,,,8888800160,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604401,NDC,1,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604425,NDC,1,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620701,NDC,0.25,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620725,NDC,1,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
magnesium sulfate 50 % Solution 10 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006404,NDC,2,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,703450284,NDC,2,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.859
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,409177815,NDC,5,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,70860030005,NDC,1.25,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metroNIDAZOLE 500 MG/100ML Solution 100 mL Plas Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,338954124,NDC,100,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,31.4776
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605701,NDC,2,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605725,NDC,1,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060031,NDC,2,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060041,NDC,2,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 5 MG/ML Solution 1 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606101,NDC,0.2,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230504,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230505,NDC,5,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam PF 10 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230802,NDC,2,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,43598052936,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080601,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080610,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,409475503,NDC,2,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054731,NDC,2,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054831,NDC,2,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054842,NDC,2,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092825,NDC,1,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,31.5854
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488802,NDC,10,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018603,NDC,20,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018620,NDC,20,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 50 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488850,NDC,3,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride bacteriostatic 0.9 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409196602,NDC,30,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride bacteriostatic 0.9 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409196607,NDC,30,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,64253002030,NDC,10,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409488710,NDC,10,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409488717,NDC,10,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
SUTURE BIOSYN MONOFILAMENT ABSORBABLE UNDYED SIZE 4-0 18IN WITH 3/8 CIRCLE REVERSE CUTTING 19MM NEED,27200000,CDM,272,RC,,,,11987-MAIN,LOCAL,,,,,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE MONOFILAMENT SZ 4-0 BIOSYN ABSORBABLE UNDYED18IN WITH 3/8 CIRCLE REVERSE CUTTING 19MM NEED SM,27200000,CDM,272,RC,,,,11984-MAIN,LOCAL,,,,,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TRAY LUMBAR 22GAX3.5 PUNCTURE SAFE-T 4306CWSP,120.18,CDM,272,RC,,,,11584-MAIN,LOCAL,,,,,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
TRAY LUMBAR 22X1.5 PUNCTURE PEDS 4302CSP,120.18,CDM,272,RC,,,,652-MAIN,LOCAL,,,,,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
triamcinolone acetonide 10 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3049420,NDC,0.25,ML,30,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,72.0986
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,68094002459,NDC,10,ML,14.67,,First Health,Commercial,both,85,,999999999,percent of total billed charges,12.4695,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
"Nephelometry, Each, Nos - Ref",PX8388390,CDM,300,RC,83883,CPT,90,,,,,,,223,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,12.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.47,218.54
"Troponin, Quantitative",PX84484,CDM,300,RC,84484,CPT,,,,,,,,289,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,12.47,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.1,12.47
temporary tooth filling repair Misc 1 Each Package,25000000,CDM,250,RC,,,,,,47701000123,NDC,1,EA,25.46,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,12.4754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
temporary tooth filling repair Misc 1 Each Package,25000000,CDM,250,RC,,,,,,47701000123,NDC,1,EA,25.46,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,12.4754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
temporary tooth filling repair Misc 1 Each Package,25000000,CDM,250,RC,,,,,,47701000123,NDC,1,EA,25.46,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,12.4754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
SPIT SOCK HOODS 16719,120.367,CDM,271,RC,,,,10820-MAIN,LOCAL,,,,,26,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,12.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.8004,25.48
SPIT SOCK HOODS 16719,120.367,CDM,271,RC,,,,10820-MAIN,LOCAL,,,,,26,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,12.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.8004,25.48
TEGADERM CHLORHEXIDINE 5X5 CHG IV PORT,120.207,CDM,272,RC,A6268,HCPCS,,10163-MAIN,LOCAL,,,,,26,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,12.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.8004,25.48
TEGADERM CHLORHEXIDINE 5X5 CHG IV PORT,120.207,CDM,272,RC,A6268,HCPCS,,10163-MAIN,LOCAL,,,,,26,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,12.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.8004,25.48
PACK BASIN BASIC SINGLE DYNJ06610A,27200000,CDM,272,RC,,,,10921-MAIN,LOCAL,,,,,25.48,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,12.4852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PACK BASIN BASIC SINGLE DYNJ06610A,27200000,CDM,272,RC,,,,10921-MAIN,LOCAL,,,,,25.48,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,12.4852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PACK BASIN BASIC SINGLE DYNJ06610A,27200000,CDM,272,RC,,,,10921-MAIN,LOCAL,,,,,25.48,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,12.4852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
topiramate 25 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,62756070786,NDC,1,EA,13.71,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.48981,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Bacterium Nos, Antibody - Ref",PX8660990,CDM,300,RC,86609,CPT,90,,,,,,,20,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,12.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.49,12.88
"Bacterium Nos, Antibody - Ref",PX8660990,CDM,300,RC,86609,CPT,90,,,,,,,20,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,12.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.49,12.88
"Bacterium Nos, Antibody - Ref",PX8660990,CDM,300,RC,86609,CPT,90,,,,,,,20,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.49,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.49,12.88
"Misc Virus Antibody, Nos - Ref",PX8679090,CDM,300,RC,86790,CPT,90,,,,,,,90,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,12.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.49,12.88
"Misc Virus Antibody, Nos - Ref",PX8679090,CDM,300,RC,86790,CPT,90,,,,,,,90,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,12.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.49,12.88
"Misc Virus Antibody, Nos - Ref",PX8679090,CDM,300,RC,86790,CPT,90,,,,,,,90,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.49,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.49,12.88
Rubeola Antibody,PX86765,CDM,300,RC,86765,CPT,,,,,,,,74,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,12.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.49,12.88
Rubeola Antibody,PX86765,CDM,300,RC,86765,CPT,,,,,,,,74,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,12.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.49,12.88
Rubeola Antibody,PX86765,CDM,300,RC,86765,CPT,,,,,,,,74,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.49,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.49,12.88
ustekinumab 130 MG/26ML Solution 26 mL Vial,J3358.01,CDM,636,RC,J3358,HCPCS,,,,57894005427,NDC,26,ML,4130,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,12.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.1,12.62
ustekinumab 130 MG/26ML Solution 26 mL Vial,J3358.01,CDM,636,RC,J3358,HCPCS,,,,57894005427,NDC,26,ML,4130,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,12.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.1,12.62
Varicella-Zoster Antibody,PX86787,CDM,300,RC,86787,CPT,,,,,,,,95,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,12.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.49,12.88
Varicella-Zoster Antibody,PX86787,CDM,300,RC,86787,CPT,,,,,,,,95,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,12.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.49,12.88
Varicella-Zoster Antibody,PX86787,CDM,300,RC,86787,CPT,,,,,,,,95,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.49,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.49,12.88
simethicone 40 MG/0.6ML Suspension 30 mL Bottle,25000000,CDM,250,RC,,,,,,70677107801,NDC,30,ML,24.69,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,12.49314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
DULoxetine 60 MG Capsule Delayed Release Particles 30 Each Bottle,63700001,CDM,250,RC,,,,,,43547038103,NDC,0.333333333,EA,14.04,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.4956,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 7 Each Box,63700001,CDM,250,RC,,,,,,536589653,NDC,1,EA,12.84,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,12.497172,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of Ferritin,PX82728,CDM,300,RC,82728,CPT,,,,,,,,177,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,12.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.5,173.46
Group Therapeutic Procedures,PX97150,CDM,420,RC,97150,CPT,,,,,,,,67,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.5,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.5,23.72
Strapping of Knee,PX29530F,CDM,420,RC,29530,CPT,,,,,,,,303,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.5,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.12,60.88
Strapping of Shoulder,PX29240F,CDM,420,RC,29240,CPT,,,,,,,,165,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.5,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.12,61.57
Strapping of Shoulder,PX29240P,CDM,983,RC,29240,CPT,,,,,,,,110,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.5,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.12,107.8
Blastomyces Antibody - Ref,PX8661290,CDM,300,RC,86612,CPT,90,,,,,,,97,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,12.51,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.51,12.9
Blastomyces Antibody - Ref,PX8661290,CDM,300,RC,86612,CPT,90,,,,,,,97,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,12.51,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.51,12.9
Blastomyces Antibody - Ref,PX8661290,CDM,300,RC,86612,CPT,90,,,,,,,97,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.51,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.51,12.9
"Calculus, Infrared Spec - Ref",PX8236590,CDM,300,RC,82365,CPT,90,,,,,,,145,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,12.51,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.51,12.9
"Calculus, Infrared Spec - Ref",PX8236590,CDM,300,RC,82365,CPT,90,,,,,,,145,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,12.51,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.51,12.9
"Calculus, Infrared Spec - Ref",PX8236590,CDM,300,RC,82365,CPT,90,,,,,,,145,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.51,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.51,12.9
Hiaa - Ref,PX8349790,CDM,300,RC,83497,CPT,90,,,,,,,84,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,12.51,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.51,12.9
Hiaa - Ref,PX8349790,CDM,300,RC,83497,CPT,90,,,,,,,84,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,12.51,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.51,12.9
Hiaa - Ref,PX8349790,CDM,300,RC,83497,CPT,90,,,,,,,84,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.51,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.51,12.9
DULoxetine 60 MG Capsule Delayed Release Particles 30 Each Bottle,63700001,CDM,250,RC,,,,,,57237001930,NDC,0.333333333,EA,14.06,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.5134,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of Transferrin,PX84466,CDM,300,RC,84466,CPT,,,,,,,,103,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,12.5151,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.38,12.76
"Bacterium Nos, Antibody - Ref",PX8660990,CDM,300,RC,86609,CPT,90,,,,,,,20,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,12.5151,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.49,12.88
Blastomyces Antibody - Ref,PX8661290,CDM,300,RC,86612,CPT,90,,,,,,,97,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,12.5151,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.51,12.9
"Calculus, Infrared Spec - Ref",PX8236590,CDM,300,RC,82365,CPT,90,,,,,,,145,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,12.5151,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.51,12.9
Hiaa - Ref,PX8349790,CDM,300,RC,83497,CPT,90,,,,,,,84,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,12.5151,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.51,12.9
"Misc Virus Antibody, Nos - Ref",PX8679090,CDM,300,RC,86790,CPT,90,,,,,,,90,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,12.5151,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.49,12.88
Myoglobin - Ref,PX8387490,CDM,300,RC,83874,CPT,90,,,,,,,22,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,12.5151,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.5151,12.92
Rubeola Antibody,PX86765,CDM,300,RC,86765,CPT,,,,,,,,74,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,12.5151,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.49,12.88
Varicella-Zoster Antibody,PX86787,CDM,300,RC,86787,CPT,,,,,,,,95,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,12.5151,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.49,12.88
hydrocortisone 1 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,45802043803,NDC,28,GR,25.55,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,12.5195,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 1 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,45802043803,NDC,28,GR,25.55,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,12.5195,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 1 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,45802043803,NDC,28,GR,25.55,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,12.5195,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
STOCKINETTE IMPERVIOUS 9X36 NON22530,27200000,CDM,272,RC,A6457,HCPCS,,10917-MAIN,LOCAL,,,,,14.73,,First Health,Commercial,both,85,,999999999,percent of total billed charges,12.5205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Myoglobin - Ref,PX8387490,CDM,300,RC,83874,CPT,90,,,,,,,22,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,12.53,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.5151,12.92
Myoglobin - Ref,PX8387490,CDM,300,RC,83874,CPT,90,,,,,,,22,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,12.53,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.5151,12.92
Myoglobin - Ref,PX8387490,CDM,300,RC,83874,CPT,90,,,,,,,22,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.53,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.5151,12.92
pindolol 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,29033002801,NDC,1,EA,24.77,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,12.53362,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 600 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268035111,NDC,1,EA,12.79,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,12.5342,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gabapentin 600 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268035115,NDC,1,EA,12.79,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,12.5342,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739028510,NDC,1,EA,13.76,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.53536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sotalol 80 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,60505008000,NDC,1,EA,13.76,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.53536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Cardiac Rehab II Eval,PX93798.05,CDM,943,RC,93798,CPT,,,,,,,,364,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,12.5385,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.29,44.79
Cardiac Rehab II W/ Monitor,PX93798.02,CDM,943,RC,93798,CPT,,,,,,,,338,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,12.5385,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.29,44.79
"Assay Calcium, Ionized",PX82330,CDM,300,RC,82330,CPT,,,,,,,,110,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,12.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.54,107.8
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069030,NDC,3,ML,14.09,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.5401,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.852986,29.4
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,75826011410,NDC,1,EA,12.89,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,12.545837,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56016901,NDC,1,EA,12.89,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,12.545837,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
denosumab 120 MG/1.7ML Solution 1.7 mL Vial,J0897.01,CDM,636,RC,J0897,HCPCS,,,,55513073001,NDC,1.7,ML,4658.83,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,12.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.55,4565.6534
"Xray Chest 1 View, Tc",PX7101001,CDM,320,RC,71010,CPT,TC,,,,,,,357,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,12.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.55,12.5502
"Xray Chest 1 View, Tc",PX7101001,CDM,320,RC,71010,CPT,TC,,,,,,,357,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,12.5502,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.55,12.5502
zolpidem 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079072401,NDC,1,EA,24.81,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,12.55386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zolpidem 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079072420,NDC,1,EA,24.81,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,12.55386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CCP Antibody,PX86200,CDM,300,RC,86200,CPT,,,,,,,,176,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,12.56,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.56,12.95
CCP Antibody,PX86200,CDM,300,RC,86200,CPT,,,,,,,,176,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,12.56,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.56,12.95
CCP Antibody,PX86200,CDM,300,RC,86200,CPT,,,,,,,,176,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.56,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.56,12.95
"CCP, Antibody - Ref",PX8620090,CDM,300,RC,86200,CPT,90,,,,,,,171,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,12.56,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.56,12.95
"CCP, Antibody - Ref",PX8620090,CDM,300,RC,86200,CPT,90,,,,,,,171,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,12.56,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.56,12.95
"CCP, Antibody - Ref",PX8620090,CDM,300,RC,86200,CPT,90,,,,,,,171,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.56,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.56,12.95
High Sens Crp,PX86141,CDM,300,RC,86141,CPT,,,,,,,,97,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,12.56,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.56,12.95
High Sens Crp,PX86141,CDM,300,RC,86141,CPT,,,,,,,,97,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,12.56,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.56,12.95
High Sens Crp,PX86141,CDM,300,RC,86141,CPT,,,,,,,,97,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.56,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.56,12.95
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,469650189,NDC,5,ML,1264.92,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.57,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.91655,14.28
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,71288020185,NDC,5,ML,1021.7,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.57,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.91655,14.28
pregabalin 75 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,71101468,NDC,0.333333333,EA,14.79,,First Health,Commercial,both,85,,999999999,percent of total billed charges,12.5715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Haptoglobin; Quantitative,PX83010,CDM,300,RC,83010,CPT,,,,,,,,265,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,12.58,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.1942,12.58
PACLitaxel protein-bound particle 100 MG Recon Susp 1 Each Vial,J9264.01,CDM,636,RC,J9264,HCPCS,,,,68817013450,NDC,1,EA,2564.76,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.58,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.58,15.01
nicotine 21 MG/24HR Patch 24 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505706300,NDC,1,EA,13.81,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.58091,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 7 Each Box,63700001,CDM,250,RC,,,,,,536589653,NDC,1,EA,12.84,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,12.5832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BAG URINARY DRAINAGE 2000ML 6300,120.33,CDM,274,RC,A4357,HCPCS,,1283-MAIN,LOCAL,,,,,121,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,12.59,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,46.4
BAG URINARY DRAINAGE DYND15405H,120.33,CDM,271,RC,A4357,HCPCS,,9112-MAIN,LOCAL,,,,,12,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,12.59,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,46.4
Basic Metabolic Panel Ca Ion,PX80047,CDM,300,RC,80047,CPT,,,,,,,,17,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,12.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.0618,16.66
Everolimus,PX8016990,CDM,300,RC,80169,CPT,,,,,,,,79,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,12.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,77.42
MEPILEX BORDER AG POST OP 4X10,120.368,CDM,272,RC,A6212,HCPCS,,10839-MAIN,LOCAL,,,,,55,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,12.59,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,13.25
paliperidone palmitate ER 234 MG/1.5ML suspension prefilled syringe 1.5 mL Syringe,J2426.01,CDM,636,RC,J2426,HCPCS,,,,50458056401,NDC,0.25,ML,1142.14,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.59,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,14.32
Tacrolimus - Ref,PX8019790,CDM,300,RC,80197,CPT,90,,,,,,,81,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,12.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,79.38
temporary tooth filling repair Misc 1 Each Package,25000000,CDM,250,RC,,,,,,47701000123,NDC,1,EA,25.46,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,12.6027,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
PACK BASIN BASIC SINGLE DYNJ06610A,27200000,CDM,272,RC,,,,10921-MAIN,LOCAL,,,,,25.48,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,12.6126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PREP KIT SKIN PREMIUM,27200000,CDM,272,RC,,,,4108-MAIN,LOCAL,,,,,12.96,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,12.613968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
warfarin 2.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56017601,NDC,1,EA,13.85,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.61735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ustekinumab 130 MG/26ML Solution 26 mL Vial,J3358.01,CDM,636,RC,J3358,HCPCS,,,,57894005427,NDC,26,ML,4130,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,12.62,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.1,12.62
zinc oxide 20 % Ointment 56.7 g Tube,63700001,CDM,250,RC,,,,,,168006202,NDC,56.7,GR,30.39,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.624006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine buffered 1 % Solution 22.2 mL Vial,25000000,CDM,250,RC,,,,,,8888800251,NDC,22.2,ML,30.4,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.62816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine buffered 1% Solution 22.2 mL Vial,25000000,CDM,250,RC,,,,,,8888800251,NDC,22.2,ML,30.4,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.62816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,75826011410,NDC,1,EA,12.89,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,12.6322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56016901,NDC,1,EA,12.89,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,12.6322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Histoplasma Antibody - Ref,PX8669890,CDM,300,RC,86698,CPT,90,,,,,,,71,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,12.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.64,69.58
Treponema Pallidum,PX86780,CDM,300,RC,86780,CPT,,,,,,,,36,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,12.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.64,13.24
Treponema Pallidum,PX86780,CDM,300,RC,86780,CPT,,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,12.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.64,13.24
Treponema Pallidum - Ref,PX8678090,CDM,300,RC,86780,CPT,90,,,,,,,39,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,12.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.64,13.24
Treponema Pallidum - Ref,PX8678090,CDM,300,RC,86780,CPT,90,,,,,,,39,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,12.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.64,13.24
FLUoxetine 10 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578461,NDC,1,EA,12.99,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,12.643167,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 1 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,45802043803,NDC,28,GR,25.55,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,12.64725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006403,NDC,2,ML,30.45,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.64893,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
Carcinoembryonic Antigen,PX82378,CDM,300,RC,82378,CPT,,,,,,,,25,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,12.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
Gastric Intubation Treatment,PX43753F,CDM,510,RC,43753,CPT,,,,,,,,441,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,12.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.65,44.28
Gastric Intubation Treatment,PX43753F,CDM,510,RC,43753,CPT,,,,,,,,441,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,12.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.65,44.28
Gastric Intubation Treatment,PX43753F,CDM,510,RC,43753,CPT,,,,,,,,441,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.65,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.65,44.28
Gastric Intubation Treatment,PX43753P,CDM,983,RC,43753,CPT,,,,,,,,498,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,12.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.65,488.04
Gastric Intubation Treatment,PX43753P,CDM,983,RC,43753,CPT,,,,,,,,498,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,12.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.65,488.04
Gastric Intubation Treatment,PX43753P,CDM,983,RC,43753,CPT,,,,,,,,498,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.65,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.65,488.04
"Gput, Quant",PX8277590,CDM,300,RC,82775,CPT,90,,,,,,,25,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,12.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
MEPILEX ADH FOAM 4X10,120.63,CDM,272,RC,A6196,HCPCS,,8710-MAIN,LOCAL,,,,,25,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,12.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
MEPILEX SOFT SILICONE 6X6,120.63,CDM,272,RC,A6196,HCPCS,,5577-MAIN,LOCAL,,,,,25,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,12.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
OPTIFOAM GENTLE SA SILICCONE FACED FOAM & BOARDER,120.63,CDM,272,RC,A6196,HCPCS,,3938-MAIN,LOCAL,,,,,25,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,12.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
Phase III Recovery Monthly,PX93799.01,CDM,943,RC,,,,,,,,,,25,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,12.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
Spirometry,PX9401001,CDM,460,RC,94010,CPT,TC,,,,,,,281,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,12.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.21,33.74
Spirometry,PX9401001,CDM,460,RC,94010,CPT,TC,,,,,,,281,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,12.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.21,33.74
Spirometry Incl Graph Rec Tc,PX9401002,CDM,460,RC,94010,CPT,TC,,,,,,,288,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,12.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.21,33.74
Spirometry Incl Graph Rec Tc,PX9401002,CDM,460,RC,94010,CPT,TC,,,,,,,288,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,12.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.21,33.74
"Testosterone,Free - Ref",PX8440290,CDM,300,RC,84402,CPT,90,,,,,,,25,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,12.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
"Antibiotic Sens,Enzyme Detection,Each - Ref",PX8718590,CDM,300,RC,87185,CPT,90,,,,,,,13,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,12.6529,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.36,12.74
BONE WAX SUTURE 2.5G ETHICON,27200000,CDM,272,RC,,,,12566-MAIN,LOCAL,,,,,13,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,12.6529,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PARoxetine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084004411,NDC,1,EA,14.35,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,12.6567,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084004401,NDC,1,EA,14.35,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,12.6567,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Mumps,PX86735,CDM,300,RC,86735,CPT,,,,,,,,148,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,12.66,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.66,13.05
Mumps,PX86735,CDM,300,RC,86735,CPT,,,,,,,,148,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,12.66,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.66,13.05
Mumps,PX86735,CDM,300,RC,86735,CPT,,,,,,,,148,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.66,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.66,13.05
amoxicillin 125 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,143988815,NDC,150,ML,25.84,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,12.6616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 125 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,143988815,NDC,150,ML,25.84,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,12.6616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 125 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,143988815,NDC,150,ML,25.84,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,12.6616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 125 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,781603955,NDC,150,ML,25.84,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,12.6616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 125 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,781603955,NDC,150,ML,25.84,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,12.6616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 125 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,781603955,NDC,150,ML,25.84,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,12.6616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rivastigmine 1.5 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,62332006360,NDC,1,EA,25.03,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,12.66518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Cryptosporidum,PX87328,CDM,300,RC,87328,CPT,,,,,,,,117,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,12.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.67,114.66
warfarin 4 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56016801,NDC,1,EA,13.91,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.67201,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
citalopram 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904608461,NDC,1,EA,13.03,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,12.682099,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,49348009529,NDC,15,ML,30.53,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.682162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Protein C Activity - Ref,PX8530390,CDM,300,RC,85303,CPT,90,,,,,,,158,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,12.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.69,154.84
Heparin Xa,PX85520,CDM,300,RC,85520,CPT,,,,,,,,128,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,12.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.7,13.09
Heparin Xa,PX85520,CDM,300,RC,85520,CPT,,,,,,,,128,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,12.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.7,13.09
Heparin Xa,PX85520,CDM,300,RC,85520,CPT,,,,,,,,128,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.7,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.7,13.09
PREP KIT SKIN PREMIUM,27200000,CDM,272,RC,,,,4108-MAIN,LOCAL,,,,,12.96,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,12.7008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010125,NDC,1,ML,30.58,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.702932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323048541,NDC,20,ML,30.58,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.702932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
glucose 40 % Gel 37.5 g Package,63700001,CDM,250,RC,,,,,,574006930,NDC,37.5,GR,25.12,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,12.71072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glucose 40 % Gel 37.5 g Tube,63700001,CDM,250,RC,,,,,,574006915,NDC,37.5,GR,25.12,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,12.71072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
RESERVOIR WOUND DRAIN 15FR,27200000,CDM,272,RC,,,,4386-MAIN,LOCAL,,,,,30.6,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.71124,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SET DISPOSABLE COLLECTION,27100000,CDM,271,RC,,,,5439-MAIN,LOCAL,,,,,30.6,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.71124,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
SUTURE NUROLON 0 BLACK C527D,27200000,CDM,272,RC,,,,10415-MAIN,LOCAL,,,,,30.6,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.71124,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
rOPINIRole 4 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462025801,NDC,1,EA,13.96,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.71756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
FLUoxetine 10 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578461,NDC,1,EA,12.99,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,12.7302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ziprasidone 80 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,781216860,NDC,0.25,EA,14.44,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,12.73608,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Antibiotic Sens,Enzyme Detection,Each - Ref",PX8718590,CDM,300,RC,87185,CPT,90,,,,,,,13,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,12.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.36,12.74
BONE WAX SUTURE 2.5G ETHICON,27200000,CDM,272,RC,,,,12566-MAIN,LOCAL,,,,,13,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,12.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SPIT SOCK HOODS 16719,120.367,CDM,271,RC,,,,10820-MAIN,LOCAL,,,,,26,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,12.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.8004,25.48
SPIT SOCK HOODS 16719,120.367,CDM,271,RC,,,,10820-MAIN,LOCAL,,,,,26,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,12.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.8004,25.48
SPIT SOCK HOODS 16719,120.367,CDM,271,RC,,,,10820-MAIN,LOCAL,,,,,26,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,12.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.8004,25.48
TEGADERM CHLORHEXIDINE 5X5 CHG IV PORT,120.207,CDM,272,RC,A6268,HCPCS,,10163-MAIN,LOCAL,,,,,26,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,12.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.8004,25.48
TEGADERM CHLORHEXIDINE 5X5 CHG IV PORT,120.207,CDM,272,RC,A6268,HCPCS,,10163-MAIN,LOCAL,,,,,26,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,12.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.8004,25.48
TEGADERM CHLORHEXIDINE 5X5 CHG IV PORT,120.207,CDM,272,RC,A6268,HCPCS,,10163-MAIN,LOCAL,,,,,26,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,12.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.8004,25.48
doxycycline hyclate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584069311,NDC,0.5,EA,15,,First Health,Commercial,both,85,,999999999,percent of total billed charges,12.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline hyclate 100 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,62584069321,NDC,0.5,EA,15,,First Health,Commercial,both,85,,999999999,percent of total billed charges,12.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Immunoassay - Ref,PX8351690,CDM,300,RC,83516,CPT,90,,,,,,,15,,First Health,Commercial,both,85,,999999999,percent of total billed charges,12.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.231,14.7
"Iontophoresis, Ea 15min",PX97033,CDM,420,RC,97033,CPT,,,,,,,,15,,First Health,Commercial,both,85,,999999999,percent of total billed charges,12.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.231,14.7
Phase II Recovery,PX71000047,CDM,710,RC,,,,,,,,,,15,,First Health,Commercial,both,85,,999999999,percent of total billed charges,12.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.231,14.7
citalopram 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904608561,NDC,1,EA,14.46,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,12.75372,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
AQUACEL EXTRA HYDOFIBER WOUND DRESSING 4X5,120.202,CDM,272,RC,A6197,HCPCS,,12047-MAIN,LOCAL,,,,,14,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
"AQUACEL FOAM DRESSING 4X4""",120.202,CDM,272,RC,A6209,HCPCS,,7939-MAIN,LOCAL,,,,,14,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
AQUACEL NONADHESIVE FOAM DRESSING 4X4,120.202,CDM,272,RC,A6209,HCPCS,,12046-MAIN,LOCAL,,,,,14,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
Assay Urine Urea-N,PX84540,CDM,300,RC,84540,CPT,,,,,,,,14,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.1,13.72
EZ CLEAN BLADE CAUTERY TIP 4 INCH,27200000,CDM,272,RC,,,,12826-MAIN,LOCAL,,,,,14,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Post Anesthesia Recovery,PX71000019,CDM,710,RC,,,,,,,,,,14,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
SAW WIRE 12 INCH GIGLI NL850,27200000,CDM,272,RC,,,,12901-MAIN,LOCAL,,,,,14,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Assay of Transferrin,PX84466,CDM,300,RC,84466,CPT,,,,,,,,103,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,12.76,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.38,12.76
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097084034,NDC,3,ML,14.47,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,12.76254,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097084053,NDC,3,ML,14.47,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,12.76254,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
amoxicillin-clavulanate 875-125 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862050301,NDC,1,EA,26.59,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,12.7632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin-clavulanate 875-125 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862050301,NDC,1,EA,26.59,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,12.7632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,36000003310,NDC,5,ML,30.74,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.769396,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
citalopram 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904608461,NDC,1,EA,13.03,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,12.7694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084004411,NDC,1,EA,14.35,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.7715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084004401,NDC,1,EA,14.35,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.7715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE CR 10 MG Tablet ER 12 hour Abuse-Deterrent 20 Each Box,63700001,CDM,250,RC,,,,,,59011041020,NDC,1,EA,26.63,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,12.7824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE CR 10 MG Tablet ER 12 hour Abuse-Deterrent 20 Each Box,63700001,CDM,250,RC,,,,,,59011041020,NDC,1,EA,26.63,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,12.7824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,51293081001,NDC,1,EA,14.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,12.789,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65162068110,NDC,1,EA,14.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,12.789,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex ER 250 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031011,NDC,1,EA,13.14,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,12.789162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex ER 250 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084031001,NDC,1,EA,13.14,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,12.789162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"La Crosse, Antibody - Ref",PX8665190,CDM,300,RC,86651,CPT,90,,,,,,,45,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,12.79,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.79,13.19
"La Crosse, Antibody - Ref",PX8665190,CDM,300,RC,86651,CPT,90,,,,,,,45,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,12.79,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.79,13.19
"La Crosse, Antibody - Ref",PX8665190,CDM,300,RC,86651,CPT,90,,,,,,,45,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.79,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.79,13.19
Lipid Profile,PX80061,CDM,300,RC,80061,CPT,,,,,,,,245,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,12.79,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.79,13.39
Lipid Profile,PX80061,CDM,300,RC,80061,CPT,,,,,,,,245,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,12.79,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.79,13.39
"St Louis, Antibody - Ref",PX8665390,CDM,300,RC,86653,CPT,90,,,,,,,45,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,12.79,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.79,13.19
"St Louis, Antibody - Ref",PX8665390,CDM,300,RC,86653,CPT,90,,,,,,,45,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,12.79,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.79,13.19
"St Louis, Antibody - Ref",PX8665390,CDM,300,RC,86653,CPT,90,,,,,,,45,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.79,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.79,13.19
"Western Equine, Ab - Ref",PX8665490,CDM,300,RC,86654,CPT,90,,,,,,,45,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,12.79,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.79,13.19
"Western Equine, Ab - Ref",PX8665490,CDM,300,RC,86654,CPT,90,,,,,,,45,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,12.79,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.79,13.19
"Western Equine, Ab - Ref",PX8665490,CDM,300,RC,86654,CPT,90,,,,,,,45,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.79,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.79,13.19
DULoxetine 60 MG Capsule Delayed Release Particles 30 Each Bottle,63700001,CDM,250,RC,,,,,,43547038103,NDC,0.333333333,EA,14.04,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.79044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 125 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,143988815,NDC,150,ML,25.84,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,12.7908,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 125 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,781603955,NDC,150,ML,25.84,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,12.7908,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Dystrophic Nail Trimming Any Number,PXG0127F,CDM,940,RC,G0127,HCPCS,,,,,,,,53,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,12.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.58,41.88
"Trimming of Dystrophic Nails, Any Number",PXG0127P,CDM,983,RC,G0127,HCPCS,,,,,,,,35,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,12.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.58,41.88
ivermectin 3 MG Tablet 20 Each Box,63700001,CDM,250,RC,,,,,,42799080601,NDC,1,EA,26.68,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,12.8064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ivermectin 3 MG Tablet 20 Each Box,63700001,CDM,250,RC,,,,,,42799080601,NDC,1,EA,26.68,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,12.8064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DULoxetine 60 MG Capsule Delayed Release Particles 30 Each Bottle,63700001,CDM,250,RC,,,,,,57237001930,NDC,0.333333333,EA,14.06,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.80866,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 75 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,59762134601,NDC,0.333333333,EA,15.08,,First Health,Commercial,both,85,,999999999,percent of total billed charges,12.818,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buprenorphine 75 MCG FILM 60 Each Box,63700001,CDM,250,RC,,,,,,59385002160,NDC,1,EA,29.92,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.83568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069030,NDC,3,ML,14.09,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,12.83599,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.852986,29.4
Assay of Phenytoin Total,PX80185,CDM,300,RC,80185,CPT,,,,,,,,336,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,12.836,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.836,13.25
CCP Antibody,PX86200,CDM,300,RC,86200,CPT,,,,,,,,176,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,12.836,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.56,12.95
"CCP, Antibody - Ref",PX8620090,CDM,300,RC,86200,CPT,90,,,,,,,171,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,12.836,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.56,12.95
Deoxyribonuclease Ab,PX86215,CDM,300,RC,86215,CPT,,,,,,,,99,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,12.836,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.836,13.25
Heparin Xa,PX85520,CDM,300,RC,85520,CPT,,,,,,,,128,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,12.836,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.7,13.09
High Sens Crp,PX86141,CDM,300,RC,86141,CPT,,,,,,,,97,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,12.836,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.56,12.95
"La Crosse, Antibody - Ref",PX8665190,CDM,300,RC,86651,CPT,90,,,,,,,45,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,12.836,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.79,13.19
Levetiracetam - Ref,PX8017790,CDM,300,RC,80177,CPT,90,,,,,,,108,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,12.836,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.836,13.25
Mumps,PX86735,CDM,300,RC,86735,CPT,,,,,,,,148,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,12.836,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.66,13.05
Oxcarbazepine - Ref,PX8018390,CDM,300,RC,80183,CPT,90,,,,,,,108,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,12.836,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.836,13.25
"St Louis, Antibody - Ref",PX8665390,CDM,300,RC,86653,CPT,90,,,,,,,45,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,12.836,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.79,13.19
Treponema Pallidum,PX86780,CDM,300,RC,86780,CPT,,,,,,,,36,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,12.836,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.64,13.24
Treponema Pallidum - Ref,PX8678090,CDM,300,RC,86780,CPT,90,,,,,,,39,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,12.836,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.64,13.24
"Western Equine, Ab - Ref",PX8665490,CDM,300,RC,86654,CPT,90,,,,,,,45,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,12.836,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.79,13.19
montelukast 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268057511,NDC,1,EA,26.75,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,12.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
montelukast 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268057511,NDC,1,EA,26.75,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,12.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
montelukast 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268057515,NDC,1,EA,26.75,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,12.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
montelukast 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268057515,NDC,1,EA,26.75,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,12.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Treponema Pallidum,PX86780,CDM,300,RC,86780,CPT,,,,,,,,36,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.84,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.64,13.24
Treponema Pallidum - Ref,PX8678090,CDM,300,RC,86780,CPT,90,,,,,,,39,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.84,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.64,13.24
"Debridement of Nail(S), 1-5",PX11720F,CDM,510,RC,11720,CPT,,,,,,,,89,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,12.844,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.72,68.49
Assay of Phenytoin Total,PX80185,CDM,300,RC,80185,CPT,,,,,,,,336,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,12.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.836,13.25
Assay of Phenytoin Total,PX80185,CDM,300,RC,80185,CPT,,,,,,,,336,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,12.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.836,13.25
Deoxyribonuclease Ab,PX86215,CDM,300,RC,86215,CPT,,,,,,,,99,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,12.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.836,13.25
Deoxyribonuclease Ab,PX86215,CDM,300,RC,86215,CPT,,,,,,,,99,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,12.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.836,13.25
Levetiracetam - Ref,PX8017790,CDM,300,RC,80177,CPT,90,,,,,,,108,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,12.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.836,13.25
Levetiracetam - Ref,PX8017790,CDM,300,RC,80177,CPT,90,,,,,,,108,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,12.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.836,13.25
Oxcarbazepine - Ref,PX8018390,CDM,300,RC,80183,CPT,90,,,,,,,108,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,12.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.836,13.25
Oxcarbazepine - Ref,PX8018390,CDM,300,RC,80183,CPT,90,,,,,,,108,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,12.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.836,13.25
Assay of Phenytoin Total,PX80185,CDM,300,RC,80185,CPT,,,,,,,,336,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.85,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.836,13.25
Deoxyribonuclease Ab,PX86215,CDM,300,RC,86215,CPT,,,,,,,,99,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.85,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.836,13.25
inFLIXimab-dyyb 100 MG Recon Soln 1 Each Vial,Q5103.01,CDM,636,RC,Q5103,HCPCS,,,,69080901,NDC,1,EA,1930.42,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,12.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.85,1891.8116
Levetiracetam - Ref,PX8017790,CDM,300,RC,80177,CPT,90,,,,,,,108,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.85,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.836,13.25
Oxcarbazepine - Ref,PX8018390,CDM,300,RC,80183,CPT,90,,,,,,,108,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.85,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.836,13.25
ziprasidone 80 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,781216860,NDC,0.25,EA,14.44,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.8516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,76282066339,NDC,100,GR,26.8,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,12.864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,76282066339,NDC,100,GR,26.8,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,12.864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BAG URINARY DRAINAGE 2000ML 6300,120.33,CDM,274,RC,A4357,HCPCS,,1283-MAIN,LOCAL,,,,,121,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,12.868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,46.4
BAG URINARY DRAINAGE DYND15405H,120.33,CDM,271,RC,A4357,HCPCS,,9112-MAIN,LOCAL,,,,,12,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,12.868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,46.4
MEPILEX BORDER AG POST OP 4X10,120.368,CDM,272,RC,A6212,HCPCS,,10839-MAIN,LOCAL,,,,,55,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,12.868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,13.25
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057811,NDC,0.5,ML,30.98,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.869092,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057841,NDC,0.5,ML,30.98,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.869092,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
citalopram 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904608561,NDC,1,EA,14.46,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.8694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
8MM ENDOWRIST INSTRUMENTS MEDIUM LARGE CLIP APPLIER,27200000,CDM,272,RC,,,,11910-MAIN,LOCAL,,,,,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,2,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.852986,29.4
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,3,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.852986,29.4
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061603,NDC,3,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,641600601,NDC,0.5,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
bacteriostatic water(benz alc) Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409397703,NDC,30,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BULB RESERVOIR SILICONE 400CC,27200000,CDM,272,RC,,,,12463-MAIN,LOCAL,,,,,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600710,NDC,2,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,38.9354
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409115918,NDC,1,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046401,NDC,1,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046402,NDC,1,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046437,NDC,1,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,409174670,NDC,1,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046801,NDC,1,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046817,NDC,1,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BUPivacaine in dextrose 0.75-8.25 % Solution 2 mL Ampule,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409176162,NDC,2,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046601,NDC,1,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143992490,NDC,0.5,EA,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010110,NDC,0.5,EA,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010167,NDC,0.5,EA,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,44567070725,NDC,0.5,EA,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733201,NDC,0.5,EA,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733801,NDC,0.5,EA,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
Concurrent Infusion,PX96368,CDM,260,RC,96368,CPT,,,,,,,,102,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,12.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.87,34.32
Concurrent Infusion,PX96368,CDM,260,RC,96368,CPT,,,,,,,,102,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,12.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.87,34.32
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,70069000501,NDC,0.1,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,63.2394
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016502,NDC,0.5,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016516,NDC,0.5,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036721,NDC,1,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036725,NDC,1,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 100 MG/10ML Solution 10 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323051610,NDC,0.5,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050641,NDC,0.5,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141031,NDC,0.5,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,641037621,NDC,0.25,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066416,NDC,1,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066441,NDC,0.25,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010101,NDC,0.25,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
DRAPE SPLIT WITH ADHESIVE DYNJP8304A,27200000,CDM,272,RC,,,,4694-MAIN,LOCAL,,,,,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRESSING HYDROFERA 2-1/2X2-1/2  BLUE READY FOAM HBRS2520,120.488,CDM,271,RC,A6209,HCPCS,,11537-MAIN,LOCAL,,,,,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
"Ethanol, P",PX82077,CDM,300,RC,82077,CPT,,,,,,,,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073916,NDC,2,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,29.4
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073941,NDC,1,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,29.4
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,67457043300,NDC,1,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,29.4
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909422,NDC,2,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
folic acid 5 MG/ML Solution 10 mL Vial,J3490.94,CDM,636,RC,J3490,HCPCS,,,,39822110001,NDC,0.2,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,330.2012
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,70860030242,NDC,1,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,36000028425,NDC,2,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001094,NDC,2,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,42.5516
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,781382571,NDC,0.5,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,143931901,NDC,0.4,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.428
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272002,NDC,1,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272031,NDC,1,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,25021040010,NDC,1,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323054011,NDC,1,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095300,NDC,0.5,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095310,NDC,1,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,71288042095,NDC,0.5,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306424,NDC,1,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306413,NDC,1,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306521,NDC,3,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin lock flush 10 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306510,NDC,5,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
HYDROmorphone 1 MG/ML Solution 1 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,76045000901,NDC,0.25,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016216,NDC,1,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016243,NDC,0.5,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072201,NDC,0.5,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072225,NDC,0.5,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016226,NDC,0.5,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016245,NDC,0.5,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011901,NDC,0.5,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011925,NDC,0.5,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072501,NDC,0.5,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072525,NDC,0.5,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143932001,NDC,1,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143962201,NDC,1,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,409226720,NDC,1,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,47781058629,NDC,1,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,51991093498,NDC,1,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,409427616,NDC,20,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323048526,NDC,20,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,63323049241,NDC,2,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2% PF 2 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049526,NDC,5,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2% PF 2 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049541,NDC,5,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine buffered 1 % Solution 0.5 mL Syringe,25000000,CDM,250,RC,,,,,,8888800160,NDC,0.5,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604401,NDC,1,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604425,NDC,1,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620701,NDC,0.25,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620725,NDC,1,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
magnesium sulfate 50 % Solution 10 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006404,NDC,2,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,703450284,NDC,2,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.859
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,409177815,NDC,5,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,70860030005,NDC,1.25,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metroNIDAZOLE 500 MG/100ML Solution 100 mL Plas Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,338954124,NDC,100,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,31.4776
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605701,NDC,2,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605725,NDC,1,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060031,NDC,2,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060041,NDC,2,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 5 MG/ML Solution 1 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606101,NDC,0.2,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230504,NDC,0.5,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230505,NDC,5,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam PF 10 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230802,NDC,2,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,43598052936,NDC,0.5,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080601,NDC,0.5,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080610,NDC,0.5,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,409475503,NDC,2,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054731,NDC,2,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054831,NDC,2,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054842,NDC,2,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092825,NDC,1,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,31.5854
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488802,NDC,10,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018603,NDC,20,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018620,NDC,20,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 50 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488850,NDC,3,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride bacteriostatic 0.9 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409196602,NDC,30,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride bacteriostatic 0.9 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409196607,NDC,30,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
SPIT SOCK HOODS 16719,120.367,CDM,271,RC,,,,10820-MAIN,LOCAL,,,,,26,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.8004,25.48
sterile water (preservative free) Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,64253002030,NDC,10,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409488710,NDC,10,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409488717,NDC,10,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
SUTURE BIOSYN MONOFILAMENT ABSORBABLE UNDYED SIZE 4-0 18IN WITH 3/8 CIRCLE REVERSE CUTTING 19MM NEED,27200000,CDM,272,RC,,,,11987-MAIN,LOCAL,,,,,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE MONOFILAMENT SZ 4-0 BIOSYN ABSORBABLE UNDYED18IN WITH 3/8 CIRCLE REVERSE CUTTING 19MM NEED SM,27200000,CDM,272,RC,,,,11984-MAIN,LOCAL,,,,,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TEGADERM CHLORHEXIDINE 5X5 CHG IV PORT,120.207,CDM,272,RC,A6268,HCPCS,,10163-MAIN,LOCAL,,,,,26,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.8004,25.48
TRAY LUMBAR 22GAX3.5 PUNCTURE SAFE-T 4306CWSP,120.18,CDM,272,RC,,,,11584-MAIN,LOCAL,,,,,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
TRAY LUMBAR 22X1.5 PUNCTURE PEDS 4302CSP,120.18,CDM,272,RC,,,,652-MAIN,LOCAL,,,,,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
triamcinolone acetonide 10 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3049420,NDC,0.25,ML,30,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,72.0986
Xray Pelvis 1 or 2 Vws,PX7217001,CDM,320,RC,72170,CPT,TC,,,,,,,279,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,12.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.87,38.79
Xray Pelvis 1 or 2 Vws,PX7217001,CDM,320,RC,72170,CPT,TC,,,,,,,279,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,12.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.87,38.79
Concurrent Infusion,PX96368,CDM,260,RC,96368,CPT,,,,,,,,102,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.87,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.87,34.32
Xray Ac Joints(Bilateral),PX7305001,CDM,320,RC,73050,CPT,TC,,,,,,,519,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.87,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.87,39.44
Xray Pelvis 1 or 2 Vws,PX7217001,CDM,320,RC,72170,CPT,TC,,,,,,,279,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.87,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.87,38.79
divalproex ER 250 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031011,NDC,1,EA,13.14,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,12.8772,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
divalproex ER 250 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084031001,NDC,1,EA,13.14,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,12.8772,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DRAPE ABDOMINAL SURGICAL 14X12 POUCHES STERILE DYNJP3109,27200000,CDM,272,RC,,,,12896-MAIN,LOCAL,,,,,31,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.8774,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LITHOTOMY PACK VIII ECLIPSE,27200000,CDM,272,RC,,,,12210-MAIN,LOCAL,,,,,31,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.8774,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Rubella Antibody,PX86762,CDM,300,RC,86762,CPT,,,,,,,,31,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.8774,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.8774,30.38
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097084034,NDC,3,ML,14.47,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.8783,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097084053,NDC,3,ML,14.47,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.8783,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Assay of Digoxin,PX80162,CDM,300,RC,80162,CPT,,,,,,,,290,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,12.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.88,13.28
Assay of Digoxin,PX80162,CDM,300,RC,80162,CPT,,,,,,,,290,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,12.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.88,13.28
Assay of Digoxin,PX80162,CDM,300,RC,80162,CPT,,,,,,,,290,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.88,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.88,13.28
"Bacterium Nos, Antibody - Ref",PX8660990,CDM,300,RC,86609,CPT,90,,,,,,,20,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,12.88,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.49,12.88
"Misc Virus Antibody, Nos - Ref",PX8679090,CDM,300,RC,86790,CPT,90,,,,,,,90,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,12.88,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.49,12.88
Rubeola Antibody,PX86765,CDM,300,RC,86765,CPT,,,,,,,,74,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,12.88,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.49,12.88
Varicella-Zoster Antibody,PX86787,CDM,300,RC,86787,CPT,,,,,,,,95,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,12.88,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.49,12.88
temporary tooth filling repair Misc 1 Each Package,25000000,CDM,250,RC,,,,,,47701000123,NDC,1,EA,25.46,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,12.88276,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
PACK BASIN BASIC SINGLE DYNJ06610A,27200000,CDM,272,RC,,,,10921-MAIN,LOCAL,,,,,25.48,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,12.89288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Blastomyces Antibody - Ref,PX8661290,CDM,300,RC,86612,CPT,90,,,,,,,97,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,12.9,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.51,12.9
"Calculus, Infrared Spec - Ref",PX8236590,CDM,300,RC,82365,CPT,90,,,,,,,145,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,12.9,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.51,12.9
Hiaa - Ref,PX8349790,CDM,300,RC,83497,CPT,90,,,,,,,84,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,12.9,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.51,12.9
fluvastatin 20 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,378802093,NDC,1,EA,26.88,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,12.9024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluvastatin 20 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,378802093,NDC,1,EA,26.88,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,12.9024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,51293081001,NDC,1,EA,14.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65162068110,NDC,1,EA,14.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,12.905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
saliva substitute Solution 59 mL Bottle,63700001,CDM,250,RC,,,,,,50930009802,NDC,59,ML,31.1,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.91894,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Myoglobin - Ref,PX8387490,CDM,300,RC,83874,CPT,90,,,,,,,22,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,12.92,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.5151,12.92
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,409677802,NDC,1,ML,31.11,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,12.923094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
hydrocortisone 1 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,45802043803,NDC,28,GR,25.55,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,12.9283,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,68094002459,NDC,10,ML,14.67,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,12.93894,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
lamoTRIgine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739051610,NDC,1,EA,13.3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,12.94489,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CCP Antibody,PX86200,CDM,300,RC,86200,CPT,,,,,,,,176,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,12.95,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.56,12.95
"CCP, Antibody - Ref",PX8620090,CDM,300,RC,86200,CPT,90,,,,,,,171,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,12.95,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.56,12.95
Chemiluminescent Assay - Ref,PX8239790,CDM,300,RC,82397,CPT,90,,,,,,,78,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,12.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.95,76.44
High Sens Crp,PX86141,CDM,300,RC,86141,CPT,,,,,,,,97,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,12.95,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.56,12.95
amoxicillin 250 MG/5ML Recon Susp 150 mL Package,63700001,CDM,250,RC,,,,,,99998805601,NDC,5,ML,15.24,,First Health,Commercial,both,85,,999999999,percent of total billed charges,12.954,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BOOT CAST LARGE 12-5/8 ORT290010L,120.247,CDM,274,RC,L3260,HCPCS,,204-MAIN,LOCAL,,,,,27,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,12.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
BOOT CAST LARGE 12-5/8 ORT290010L,120.247,CDM,274,RC,L3260,HCPCS,,204-MAIN,LOCAL,,,,,27,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,12.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
BOOT CAST MEDIUM 08148803,120.247,CDM,274,RC,L3260,HCPCS,,203-MAIN,LOCAL,,,,,27,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,12.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
BOOT CAST MEDIUM 08148803,120.247,CDM,274,RC,L3260,HCPCS,,203-MAIN,LOCAL,,,,,27,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,12.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
BOOT CAST X-LARGE 13X5-1/2IN ORT29200XL,120.247,CDM,274,RC,L3260,HCPCS,,206-MAIN,LOCAL,,,,,27,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,12.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
BOOT CAST X-LARGE 13X5-1/2IN ORT29200XL,120.247,CDM,274,RC,L3260,HCPCS,,206-MAIN,LOCAL,,,,,27,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,12.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
KERRAMAX CARE SUPERABSORBENT DRESSING 8X12,120.55,CDM,272,RC,A6197,HCPCS,,12363-MAIN,LOCAL,,,,,27,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,12.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
KERRAMAX CARE SUPERABSORBENT DRESSING 8X12,120.55,CDM,272,RC,A6197,HCPCS,,12363-MAIN,LOCAL,,,,,27,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,12.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
Or Time,PX36000086,CDM,360,RC,,,,,,,,,,27,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,12.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
Or Time,PX36000086,CDM,360,RC,,,,,,,,,,27,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,12.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
"Sodium, Other Source - Ref",PX8430290,CDM,300,RC,84302,CPT,90,,,,,,,27,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,12.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.46,26.46
"Sodium, Other Source - Ref",PX8430290,CDM,300,RC,84302,CPT,90,,,,,,,27,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,12.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.46,26.46
Assay Cryofibrinogen,PX82585,CDM,300,RC,82585,CPT,,,,,,,,75,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,12.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.96,73.5
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,6384371,NDC,1,EA,563.46,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,12.97,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.4,12.97
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022101,NDC,1,EA,514.5,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,12.97,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.4,12.97
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022185,NDC,1,EA,514.5,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,12.97,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.4,12.97
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022189,NDC,1,EA,514.5,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,12.97,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.4,12.97
gadoxetate disodium 0.25 MOL/L Solution 10 mL Vial,A9581,CDM,636,RC,A9581,HCPCS,,,,50419032005,NDC,10,ML,200,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.97,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.97,14.74
bendamustine 100 MG/4ML Solution 4 mL Vial,800000,CDM,,,J9034,HCPCS,,,,63459034804,NDC,4,ML,5046.55,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.98,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.53,15.49
Francisella Tularensis Ab,PX8666890,CDM,300,RC,86668,CPT,90,,,,,,,294,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,12.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.98,288.12
Strapping of Elbow or Wrist,PX29260F,CDM,420,RC,29260,CPT,,,,,,,,64,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.98,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.77,60.19
FLUoxetine 20 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578561,NDC,1,EA,13.34,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,12.983822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Lipid Profile,PX80061,CDM,300,RC,80061,CPT,,,,,,,,245,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,12.99,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.79,13.39
STOCKINETTE IMPERVIOUS 9X36 NON22530,27200000,CDM,272,RC,A6457,HCPCS,,10917-MAIN,LOCAL,,,,,14.73,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,12.99186,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Triiodothyronine T3, Tot - Ref",PX8448090,CDM,300,RC,84480,CPT,90,,,,,,,158,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13,154.84
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,49348014446,NDC,1,EA,15.3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,13.005,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Cryptococcus Neoformans,PX87327,CDM,300,RC,87327,CPT,,,,,,,,45,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,13.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.02,13.42
Cryptococcus Neoformans,PX87327,CDM,300,RC,87327,CPT,,,,,,,,45,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,13.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.02,13.42
Cryptococcus Neoformans,PX87327,CDM,300,RC,87327,CPT,,,,,,,,45,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,13.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.02,13.42
amoxicillin-clavulanate 875-125 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862050301,NDC,1,EA,26.59,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.0291,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin-clavulanate 875-125 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862050301,NDC,1,EA,26.59,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.0291,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin-clavulanate 875-125 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862050301,NDC,1,EA,26.59,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,13.0291,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739051610,NDC,1,EA,13.3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.034,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zinc oxide 20 % Ointment 56.7 g Tube,63700001,CDM,250,RC,,,,,,168006202,NDC,56.7,GR,30.39,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,13.03731,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine buffered 1 % Solution 22.2 mL Vial,25000000,CDM,250,RC,,,,,,8888800251,NDC,22.2,ML,30.4,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,13.0416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine buffered 1% Solution 22.2 mL Vial,25000000,CDM,250,RC,,,,,,8888800251,NDC,22.2,ML,30.4,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,13.0416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pregabalin 75 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,71101468,NDC,0.333333333,EA,14.79,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,13.04478,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE CR 10 MG Tablet ER 12 hour Abuse-Deterrent 20 Each Box,63700001,CDM,250,RC,,,,,,59011041020,NDC,1,EA,26.63,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.0487,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE CR 10 MG Tablet ER 12 hour Abuse-Deterrent 20 Each Box,63700001,CDM,250,RC,,,,,,59011041020,NDC,1,EA,26.63,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.0487,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE CR 10 MG Tablet ER 12 hour Abuse-Deterrent 20 Each Box,63700001,CDM,250,RC,,,,,,59011041020,NDC,1,EA,26.63,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,13.0487,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Mumps,PX86735,CDM,300,RC,86735,CPT,,,,,,,,148,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,13.05,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.66,13.05
clotrimazole 1 % Cream 28 g Tube,25000000,CDM,250,RC,,,,,,536127222,NDC,28,GR,15.36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,13.056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,68094002459,NDC,10,ML,14.67,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,13.0563,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006403,NDC,2,ML,30.45,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,13.06305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
Acetaminophen 167 MG/5ML Liquid 237 mL Bottle,63700001,CDM,250,RC,,,,,,904584709,NDC,237,ML,27.22,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,13.0656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Acetaminophen 167 MG/5ML Liquid 237 mL Bottle,63700001,CDM,250,RC,,,,,,904584709,NDC,237,ML,27.22,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,13.0656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006401,NDC,2,ML,31.46,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,13.068484,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
rOPINIRole 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547026810,NDC,1,EA,13.43,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.071419,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56017001,NDC,1,EA,13.43,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.071419,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084004411,NDC,1,EA,14.35,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,13.07285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084004401,NDC,1,EA,14.35,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,13.07285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
FLUoxetine 20 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578561,NDC,1,EA,13.34,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.0732,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ivermectin 3 MG Tablet 20 Each Box,63700001,CDM,250,RC,,,,,,42799080601,NDC,1,EA,26.68,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.0732,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ivermectin 3 MG Tablet 20 Each Box,63700001,CDM,250,RC,,,,,,42799080601,NDC,1,EA,26.68,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.0732,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ivermectin 3 MG Tablet 20 Each Box,63700001,CDM,250,RC,,,,,,42799080601,NDC,1,EA,26.68,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,13.0732,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 125 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,143988815,NDC,150,ML,25.84,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,13.07504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 125 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,781603955,NDC,150,ML,25.84,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,13.07504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Hepatitis C Antibody,PX86803,CDM,300,RC,86803,CPT,,,,,,,,144,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,13.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.08,141.12
benzonatate 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877010501,NDC,1,EA,13.44,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.081152,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Admin Hep B,Adult 19+",PX3242,CDM,771,RC,90471,CPT,,,,,,,,48,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,13.09,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.09,36.07
Heparin Xa,PX85520,CDM,300,RC,85520,CPT,,,,,,,,128,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,13.09,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.7,13.09
Immunization Admin - Influenza,PX3241,CDM,771,RC,90471,CPT,,,,,,,,48,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,13.09,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.09,36.07
Immunization Administration; One Vaccine (Single or Combination Vaccine/To*,PX90471,CDM,771,RC,90471,CPT,,,,,,,,130,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,13.09,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.09,36.07
Xray Ac Joints(Bilateral),PX7305001,CDM,320,RC,73050,CPT,TC,,,,,,,519,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,13.09,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.87,39.44
Xray Ac Joints(Bilateral),PX7305001,CDM,320,RC,73050,CPT,TC,,,,,,,519,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,13.09,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.87,39.44
rOPINIRole 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462025301,NDC,1,EA,13.45,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.090885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049236,NDC,5,ML,31.52,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,13.093408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049243,NDC,5,ML,31.52,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,13.093408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,49348009529,NDC,15,ML,30.53,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,13.09737,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Glucagon - Ref,PX8294390,CDM,300,RC,82943,CPT,90,,,,,,,115,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,13.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.1,112.7
PACLitaxel protein-bound particle 100 MG Recon Susp 1 Each Vial,J9264.01,CDM,636,RC,J9264,HCPCS,,,,68817013450,NDC,1,EA,2564.76,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,13.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.1,2513.4648
montelukast 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268057511,NDC,1,EA,26.75,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.1075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
montelukast 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268057511,NDC,1,EA,26.75,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.1075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
montelukast 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268057511,NDC,1,EA,26.75,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,13.1075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
montelukast 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268057515,NDC,1,EA,26.75,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.1075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
montelukast 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268057515,NDC,1,EA,26.75,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.1075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
montelukast 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268057515,NDC,1,EA,26.75,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,13.1075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
STOCKINETTE IMPERVIOUS 9X36 NON22530,27200000,CDM,272,RC,A6457,HCPCS,,10917-MAIN,LOCAL,,,,,14.73,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,13.1097,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061601,NDC,3,ML,31.57,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,13.114178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058003,NDC,0.5,ML,31.57,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,13.114178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058020,NDC,0.5,ML,31.57,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,13.114178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061416,NDC,0.5,ML,31.57,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,13.114178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.114178,99.911
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010125,NDC,1,ML,30.58,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,13.11882,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323048541,NDC,20,ML,30.58,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,13.11882,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
paliperidone palmitate ER 234 MG/1.5ML suspension prefilled syringe 1.5 mL Syringe,J2426.01,CDM,636,RC,J2426,HCPCS,,,,50458056401,NDC,0.25,ML,1142.14,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,13.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.12,1119.2972
RESERVOIR WOUND DRAIN 15FR,27200000,CDM,272,RC,,,,4386-MAIN,LOCAL,,,,,30.6,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,13.1274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SET DISPOSABLE COLLECTION,27100000,CDM,271,RC,,,,5439-MAIN,LOCAL,,,,,30.6,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,13.1274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
SUTURE NUROLON 0 BLACK C527D,27200000,CDM,272,RC,,,,10415-MAIN,LOCAL,,,,,30.6,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,13.1274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Assay Dipropylacetic Acid,PX80164,CDM,300,RC,80164,CPT,,,,,,,,132,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,13.13,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.13,13.54
Assay for Vancomycin,PX80202,CDM,300,RC,80202,CPT,,,,,,,,314,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,13.13,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.13,13.54
Lipoprotein (a) - Ref,PX8369590,CDM,300,RC,83695,CPT,90,,,,,,,55,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,13.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.13,53.9
Assay Dipropylacetic Acid,PX80164,CDM,300,RC,80164,CPT,,,,,,,,132,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,13.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.13,13.54
Assay Dipropylacetic Acid,PX80164,CDM,300,RC,80164,CPT,,,,,,,,132,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,13.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.13,13.54
Assay for Vancomycin,PX80202,CDM,300,RC,80202,CPT,,,,,,,,314,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,13.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.13,13.54
Assay for Vancomycin,PX80202,CDM,300,RC,80202,CPT,,,,,,,,314,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,13.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.13,13.54
Group Therapeutic Procedures,PX97150,CDM,420,RC,97150,CPT,,,,,,,,67,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,13.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.5,23.72
Group Therapeutic Procedures,PX97150,CDM,420,RC,97150,CPT,,,,,,,,67,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,13.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.5,23.72
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,76282066339,NDC,100,GR,26.8,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.132,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,76282066339,NDC,100,GR,26.8,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.132,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,76282066339,NDC,100,GR,26.8,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,13.132,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,13.139102,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,13.139102,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
acetaminophen 160 MG/5ML Suspension 118 mL Bottle,63700001,CDM,250,RC,,,,,,45802020326,NDC,10.15625,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
albuterol (2.5 MG/3ML) 0.083% Nebulization Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487950101,NDC,3,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
albuterol 1.25 MG/3ML Nebulization Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487990425,NDC,3,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Alcohol Swabstick 70 % Pad 50 Each Box,800000,CDM,,,,,,,,18407061105,NDC,1,EA,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
amoxicillin 250 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,65862070755,NDC,5,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 400 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,65862007101,NDC,3.125,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Biotene Dry Mouth Liquid 473 mL Bottle,63700001,CDM,250,RC,,,,,,48582000330,NDC,5,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbamide peroxide 6.5% 6.5 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904662735,NDC,15,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,93417773,NDC,2.5,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,24979015514,NDC,2.5,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314065605,NDC,0.05,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dexAMETHasone 1 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,54317644,NDC,0.5,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dextromethorphan-guaiFENesin 20-200 MG/20ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904722320,NDC,118,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,693390152,NDC,2.5,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,5.734,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
diphenhydrAMINE 12.5 MG/5ML Liquid 118 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904698520,NDC,2.5,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,5.734,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
diphenhydrAMINE 12.5 MG/5ML Liquid 120 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,58657052804,NDC,2.5,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,5.734,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,57896018105,NDC,15,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,57896018405,NDC,15,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,603107554,NDC,5,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,69367027204,NDC,5,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904006100,NDC,5,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904676320,NDC,5,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,54838011740,NDC,5,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,61787006304,NDC,5,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 100 MG/5ML Suspension 120 mL Bottle,63700001,CDM,250,RC,,,,,,904530920,NDC,20,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ipratropium 0.02 % Solution 2.5 mL Plas Cont,25000000,CDM,250,RC,,,,,,76204010001,NDC,2.5,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487020101,NDC,3,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lactulose 10 GM/15ML Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,121457715,NDC,15,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lactulose encephalopathy 10 GM/15ML Solution 473 mL Bottle,25000000,CDM,250,RC,,,,,,50383079516,NDC,15,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
levalbuterol 1.25 MG/3ML Nebulization Solution 3 mL Box,63700001,CDM,250,RC,,,,,,76204090001,NDC,3,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levalbuterol 1.25 MG/3ML Nebulization Solution 3 mL Plas Cont,63700001,CDM,250,RC,,,,,,76204090011,NDC,3,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine viscous 2 % Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,121090315,NDC,5,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine viscous 2 % Solution 100 mL Bottle,63700001,CDM,250,RC,,,,,,72888012526,NDC,5,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,54353244,NDC,0.25,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,121077001,NDC,0.25,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,65162068784,NDC,0.25,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium citrate 1.745 GM/30ML Solution 296 mL Bottle,63700001,CDM,250,RC,,,,,,69452038998,NDC,150,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium citrate 1.745 GM/30ML Solution 296 mL Bottle,63700001,CDM,250,RC,,,,,,70677111101,NDC,150,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium hydroxide 400 MG/5ML Suspension 30 mL Cup,63700001,CDM,250,RC,,,,,,69339015301,NDC,5,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine 20 mg/mL Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,54051744,NDC,0.5,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine polacrilex 4 MG Lozenge 24 Each Bottle,63700001,CDM,250,RC,,,,,,113087303,NDC,0.5,EA,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,121086805,NDC,4,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,121086802,NDC,4,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,66689000802,NDC,4,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 473 mL Bottle,63700001,CDM,250,RC,,,,,,121086816,NDC,4,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
opium 10 MG/ML (1%) Tincture 0.3 mL Syringe,63700001,CDM,250,RC,,,,,,8888800392,NDC,0.3,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
opium 10 MG/ML (1%) Tincture 0.6 mL Syringe,63700001,CDM,250,RC,,,,,,88888800245,NDC,0.3,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
opium 10 MG/ML (1%) Tincture 118 mL Bottle,63700001,CDM,250,RC,,,,,,42799021701,NDC,0.3,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxymetazoline 0.05 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904571135,NDC,15,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,904693186,NDC,1,EA,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 100 Each Box,63700001,CDM,250,RC,,,,,,904642281,NDC,1,EA,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
povidone iodine 10 % Solution 59 mL Bottle,63700001,CDM,250,RC,,,,,,52380190502,NDC,59,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Povidone-Iodine 10 % SWAB 1 Each Package,25000000,CDM,250,RC,,,,,,67618015301,NDC,1,EA,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004224,NDC,5,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,62135025037,NDC,1.666666667,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
racEPINEPHrine 2.25 % Nebulization Solution 1 Each Plas Cont,25000000,CDM,250,RC,,,,,,487590199,NDC,1,EA,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9 % Nebulization Solution 3 mL Plas Cont,63700001,CDM,250,RC,,,,,,487930133,NDC,3,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium chloride 0.65 % Solution 44 mL Bottle,63700001,CDM,250,RC,,,,,,904386575,NDC,44,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium phosphate 7-19 GM/118ML Enema 133 mL Bottle,63700001,CDM,250,RC,,,,,,132020140,NDC,133,ML,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
white petrolatum Gel 52.5 g Jar,63700001,CDM,250,RC,,,,,,521231100,NDC,52.5,GR,13.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.13955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079034801,NDC,1,EA,27.39,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,13.1472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079034801,NDC,1,EA,27.39,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,13.1472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079034820,NDC,1,EA,27.39,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,13.1472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079034820,NDC,1,EA,27.39,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,13.1472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ziprasidone 80 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,781216860,NDC,0.25,EA,14.44,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,13.15484,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SPIT SOCK HOODS 16719,120.367,CDM,271,RC,,,,10820-MAIN,LOCAL,,,,,26,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,13.156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.8004,25.48
TEGADERM CHLORHEXIDINE 5X5 CHG IV PORT,120.207,CDM,272,RC,A6268,HCPCS,,10163-MAIN,LOCAL,,,,,26,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,13.156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.8004,25.48
Assay Dipropylacetic Acid,PX80164,CDM,300,RC,80164,CPT,,,,,,,,132,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,13.1569,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.13,13.54
Assay for Vancomycin,PX80202,CDM,300,RC,80202,CPT,,,,,,,,314,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,13.1569,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.13,13.54
Assay of Digoxin,PX80162,CDM,300,RC,80162,CPT,,,,,,,,290,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,13.1569,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.88,13.28
Cryptococcus Neoformans,PX87327,CDM,300,RC,87327,CPT,,,,,,,,45,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,13.1569,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.02,13.42
Lipid Profile,PX80061,CDM,300,RC,80061,CPT,,,,,,,,245,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,13.1569,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.79,13.39
"Protoporphyrin, RBC, Qnt - Ref",PX8420290,CDM,300,RC,84202,CPT,90,,,,,,,61,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,13.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.16,59.78
rOPINIRole 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547026810,NDC,1,EA,13.43,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.1614,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56017001,NDC,1,EA,13.43,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.1614,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cefdinir 300 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,67877054360,NDC,1,EA,27.42,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,13.1616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cefdinir 300 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,67877054360,NDC,1,EA,27.42,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,13.1616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cholestyramine light 4 g Packet 42 Each Box,63700001,CDM,250,RC,,,,,,245003642,NDC,1,EA,27.42,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,13.1616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cholestyramine light 4 g Packet 42 Each Box,63700001,CDM,250,RC,,,,,,245003642,NDC,1,EA,27.42,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,13.1616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin-clavulanate 875-125 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862050301,NDC,1,EA,26.59,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,13.16205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 75 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,71101468,NDC,0.333333333,EA,14.79,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,13.1631,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 7 MG/24HR Patch 24 Hour 7 Each Box,63700001,CDM,250,RC,,,,,,43598044670,NDC,1,EA,13.53,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.168749,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzonatate 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877010501,NDC,1,EA,13.44,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.1712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cholestyramine light 4 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,245003689,NDC,1,EA,27.44,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,13.1712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cholestyramine light 4 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,245003689,NDC,1,EA,27.44,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,13.1712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluvastatin 20 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,378802093,NDC,1,EA,26.88,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.1712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluvastatin 20 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,378802093,NDC,1,EA,26.88,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.1712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluvastatin 20 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,378802093,NDC,1,EA,26.88,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,13.1712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
citalopram 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904608561,NDC,1,EA,14.46,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,13.17306,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine HCl 4 % Cream 76.5 g Tube,63700001,CDM,250,RC,,,,,,41167005820,NDC,76.5,GR,31.72,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,13.176488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Iontophoresis, Ea 15min",PX97033,CDM,420,RC,97033,CPT,,,,,,,,15,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,13.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.231,14.7
cefdinir 300 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,16714039102,NDC,1,EA,27.46,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,13.1808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cefdinir 300 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,16714039102,NDC,1,EA,27.46,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,13.1808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rOPINIRole 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462025301,NDC,1,EA,13.45,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.181,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE CR 10 MG Tablet ER 12 hour Abuse-Deterrent 20 Each Box,63700001,CDM,250,RC,,,,,,59011041020,NDC,1,EA,26.63,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,13.18185,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097084034,NDC,3,ML,14.47,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,13.18217,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097084053,NDC,3,ML,14.47,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,13.18217,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,36000003310,NDC,5,ML,30.74,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,13.18746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Cmv Antibody - Ref,PX8664490,CDM,300,RC,86644,CPT,90,,,,,,,104,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,13.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,101.92
"La Crosse, Antibody - Ref",PX8665190,CDM,300,RC,86651,CPT,90,,,,,,,45,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,13.19,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.79,13.19
Lab H Pylori Stool Ag,PX87338,CDM,300,RC,87338,CPT,,,,,,,,424,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,13.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,415.52
"Nephelometry, Each, Nos - Ref",PX8388390,CDM,300,RC,83883,CPT,90,,,,,,,223,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,13.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,13.6
"Nephelometry, Each, Nos - Ref",PX8388390,CDM,300,RC,83883,CPT,90,,,,,,,223,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,13.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,13.6
"Nephelometry, Each, Nos - Ref",PX8388390,CDM,300,RC,83883,CPT,90,,,,,,,223,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,13.19,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,13.6
Rubella Antibody,PX86762,CDM,300,RC,86762,CPT,,,,,,,,31,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,13.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.8774,30.38
"St Louis, Antibody - Ref",PX8665390,CDM,300,RC,86653,CPT,90,,,,,,,45,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,13.19,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.79,13.19
"West Nile Ab, Igg - Ref",PX8678990,CDM,300,RC,86789,CPT,90,,,,,,,248,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,13.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,243.04
"Western Equine, Ab - Ref",PX8665490,CDM,300,RC,86654,CPT,90,,,,,,,45,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,13.19,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.79,13.19
topiramate 25 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,69097012203,NDC,1,EA,13.56,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.197948,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ivermectin 3 MG Tablet 20 Each Box,63700001,CDM,250,RC,,,,,,42799080601,NDC,1,EA,26.68,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,13.2066,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pravastatin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904589161,NDC,1,EA,15.54,,First Health,Commercial,both,85,,999999999,percent of total billed charges,13.209,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,51293081001,NDC,1,EA,14.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,13.2095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65162068110,NDC,1,EA,14.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,13.2095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
mineral oil Enema 133 mL Bottle,63700001,CDM,250,RC,,,,,,132030140,NDC,133,ML,13.58,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.217414,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Mechanical Traction Therapy,PX97012,CDM,420,RC,97012,CPT,,,,,,,,135,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,13.2184,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.1,18.45
Assay of Ferritin,PX82728,CDM,300,RC,82728,CPT,,,,,,,,177,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,13.22,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.22,13.63
Assay of Ferritin,PX82728,CDM,300,RC,82728,CPT,,,,,,,,177,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,13.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.22,13.63
Assay of Ferritin,PX82728,CDM,300,RC,82728,CPT,,,,,,,,177,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,13.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.22,13.63
acetaminophen 160 MG/5ML Suspension 118 mL Bottle,63700001,CDM,250,RC,,,,,,45802020326,NDC,10.15625,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
albuterol (2.5 MG/3ML) 0.083% Nebulization Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487950101,NDC,3,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
albuterol 1.25 MG/3ML Nebulization Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487990425,NDC,3,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Alcohol Swabstick 70 % Pad 50 Each Box,800000,CDM,,,,,,,,18407061105,NDC,1,EA,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
amoxicillin 250 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,65862070755,NDC,5,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 400 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,65862007101,NDC,3.125,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Biotene Dry Mouth Liquid 473 mL Bottle,63700001,CDM,250,RC,,,,,,48582000330,NDC,5,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BOOT CAST LARGE 12-5/8 ORT290010L,120.247,CDM,274,RC,L3260,HCPCS,,204-MAIN,LOCAL,,,,,27,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
BOOT CAST LARGE 12-5/8 ORT290010L,120.247,CDM,274,RC,L3260,HCPCS,,204-MAIN,LOCAL,,,,,27,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
BOOT CAST LARGE 12-5/8 ORT290010L,120.247,CDM,274,RC,L3260,HCPCS,,204-MAIN,LOCAL,,,,,27,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
BOOT CAST MEDIUM 08148803,120.247,CDM,274,RC,L3260,HCPCS,,203-MAIN,LOCAL,,,,,27,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
BOOT CAST MEDIUM 08148803,120.247,CDM,274,RC,L3260,HCPCS,,203-MAIN,LOCAL,,,,,27,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
BOOT CAST MEDIUM 08148803,120.247,CDM,274,RC,L3260,HCPCS,,203-MAIN,LOCAL,,,,,27,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
BOOT CAST X-LARGE 13X5-1/2IN ORT29200XL,120.247,CDM,274,RC,L3260,HCPCS,,206-MAIN,LOCAL,,,,,27,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
BOOT CAST X-LARGE 13X5-1/2IN ORT29200XL,120.247,CDM,274,RC,L3260,HCPCS,,206-MAIN,LOCAL,,,,,27,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
BOOT CAST X-LARGE 13X5-1/2IN ORT29200XL,120.247,CDM,274,RC,L3260,HCPCS,,206-MAIN,LOCAL,,,,,27,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
carbamide peroxide 6.5% 6.5 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904662735,NDC,15,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,93417773,NDC,2.5,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cephALEXin 250 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,24979015514,NDC,2.5,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314065605,NDC,0.05,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dexAMETHasone 1 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,54317644,NDC,0.5,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dextromethorphan-guaiFENesin 20-200 MG/20ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904722320,NDC,118,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,693390152,NDC,2.5,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
diphenhydrAMINE 12.5 MG/5ML Liquid 118 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904698520,NDC,2.5,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
diphenhydrAMINE 12.5 MG/5ML Liquid 120 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,58657052804,NDC,2.5,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
doxycycline hyclate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584069311,NDC,0.5,EA,15,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline hyclate 100 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,62584069321,NDC,0.5,EA,15,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,57896018105,NDC,15,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,57896018405,NDC,15,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,603107554,NDC,5,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,69367027204,NDC,5,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904006100,NDC,5,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904676320,NDC,5,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,54838011740,NDC,5,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,61787006304,NDC,5,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 100 MG/5ML Suspension 120 mL Bottle,63700001,CDM,250,RC,,,,,,904530920,NDC,20,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Immunoassay - Ref,PX8351690,CDM,300,RC,83516,CPT,90,,,,,,,15,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.231,14.7
"Iontophoresis, Ea 15min",PX97033,CDM,420,RC,97033,CPT,,,,,,,,15,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.231,14.7
ipratropium 0.02 % Solution 2.5 mL Plas Cont,25000000,CDM,250,RC,,,,,,76204010001,NDC,2.5,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487020101,NDC,3,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
KERRAMAX CARE SUPERABSORBENT DRESSING 8X12,120.55,CDM,272,RC,A6197,HCPCS,,12363-MAIN,LOCAL,,,,,27,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
KERRAMAX CARE SUPERABSORBENT DRESSING 8X12,120.55,CDM,272,RC,A6197,HCPCS,,12363-MAIN,LOCAL,,,,,27,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
KERRAMAX CARE SUPERABSORBENT DRESSING 8X12,120.55,CDM,272,RC,A6197,HCPCS,,12363-MAIN,LOCAL,,,,,27,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
lactulose 10 GM/15ML Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,121457715,NDC,15,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lactulose encephalopathy 10 GM/15ML Solution 473 mL Bottle,25000000,CDM,250,RC,,,,,,50383079516,NDC,15,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
levalbuterol 1.25 MG/3ML Nebulization Solution 3 mL Box,63700001,CDM,250,RC,,,,,,76204090001,NDC,3,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levalbuterol 1.25 MG/3ML Nebulization Solution 3 mL Plas Cont,63700001,CDM,250,RC,,,,,,76204090011,NDC,3,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine viscous 2 % Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,121090315,NDC,5,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine viscous 2 % Solution 100 mL Bottle,63700001,CDM,250,RC,,,,,,72888012526,NDC,5,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,54353244,NDC,0.25,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,121077001,NDC,0.25,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,65162068784,NDC,0.25,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium citrate 1.745 GM/30ML Solution 296 mL Bottle,63700001,CDM,250,RC,,,,,,69452038998,NDC,150,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium citrate 1.745 GM/30ML Solution 296 mL Bottle,63700001,CDM,250,RC,,,,,,70677111101,NDC,150,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium hydroxide 400 MG/5ML Suspension 30 mL Cup,63700001,CDM,250,RC,,,,,,69339015301,NDC,5,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine 20 mg/mL Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,54051744,NDC,0.5,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine polacrilex 4 MG Lozenge 24 Each Bottle,63700001,CDM,250,RC,,,,,,113087303,NDC,0.5,EA,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,121086805,NDC,4,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,121086802,NDC,4,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,66689000802,NDC,4,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 473 mL Bottle,63700001,CDM,250,RC,,,,,,121086816,NDC,4,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
opium 10 MG/ML (1%) Tincture 0.3 mL Syringe,63700001,CDM,250,RC,,,,,,8888800392,NDC,0.3,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
opium 10 MG/ML (1%) Tincture 0.6 mL Syringe,63700001,CDM,250,RC,,,,,,88888800245,NDC,0.3,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
opium 10 MG/ML (1%) Tincture 118 mL Bottle,63700001,CDM,250,RC,,,,,,42799021701,NDC,0.3,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Or Time,PX36000086,CDM,360,RC,,,,,,,,,,27,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
Or Time,PX36000086,CDM,360,RC,,,,,,,,,,27,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
Or Time,PX36000086,CDM,360,RC,,,,,,,,,,27,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
oxymetazoline 0.05 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904571135,NDC,15,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Phase II Recovery,PX71000047,CDM,710,RC,,,,,,,,,,15,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.231,14.7
polyethylene glycol 3350 17 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,904693186,NDC,1,EA,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyethylene glycol 3350 17 g Packet 100 Each Box,63700001,CDM,250,RC,,,,,,904642281,NDC,1,EA,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
povidone iodine 10 % Solution 59 mL Bottle,63700001,CDM,250,RC,,,,,,52380190502,NDC,59,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Povidone-Iodine 10 % SWAB 1 Each Package,25000000,CDM,250,RC,,,,,,67618015301,NDC,1,EA,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004224,NDC,5,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,62135025037,NDC,1.666666667,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
racEPINEPHrine 2.25 % Nebulization Solution 1 Each Plas Cont,25000000,CDM,250,RC,,,,,,487590199,NDC,1,EA,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9 % Nebulization Solution 3 mL Plas Cont,63700001,CDM,250,RC,,,,,,487930133,NDC,3,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium chloride 0.65 % Solution 44 mL Bottle,63700001,CDM,250,RC,,,,,,904386575,NDC,44,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium phosphate 7-19 GM/118ML Enema 133 mL Bottle,63700001,CDM,250,RC,,,,,,132020140,NDC,133,ML,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Sodium, Other Source - Ref",PX8430290,CDM,300,RC,84302,CPT,90,,,,,,,27,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.46,26.46
"Sodium, Other Source - Ref",PX8430290,CDM,300,RC,84302,CPT,90,,,,,,,27,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.46,26.46
"Sodium, Other Source - Ref",PX8430290,CDM,300,RC,84302,CPT,90,,,,,,,27,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.46,26.46
white petrolatum Gel 52.5 g Jar,63700001,CDM,250,RC,,,,,,521231100,NDC,52.5,GR,13.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Treponema Pallidum,PX86780,CDM,300,RC,86780,CPT,,,,,,,,36,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,13.24,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.64,13.24
Treponema Pallidum - Ref,PX8678090,CDM,300,RC,86780,CPT,90,,,,,,,39,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,13.24,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.64,13.24
montelukast 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268057511,NDC,1,EA,26.75,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,13.24125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
montelukast 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268057515,NDC,1,EA,26.75,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,13.24125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of Phenytoin Total,PX80185,CDM,300,RC,80185,CPT,,,,,,,,336,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,13.25,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.836,13.25
BAG URINARY DRAINAGE 2000ML 6300,120.33,CDM,274,RC,A4357,HCPCS,,1283-MAIN,LOCAL,,,,,121,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,13.25,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,46.4
BAG URINARY DRAINAGE 2000ML 6300,120.33,CDM,274,RC,A4357,HCPCS,,1283-MAIN,LOCAL,,,,,121,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,13.25,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,46.4
BAG URINARY DRAINAGE 2000ML 6300,120.33,CDM,274,RC,A4357,HCPCS,,1283-MAIN,LOCAL,,,,,121,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,13.25,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,46.4
BAG URINARY DRAINAGE DYND15405H,120.33,CDM,271,RC,A4357,HCPCS,,9112-MAIN,LOCAL,,,,,12,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,13.25,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,46.4
BAG URINARY DRAINAGE DYND15405H,120.33,CDM,271,RC,A4357,HCPCS,,9112-MAIN,LOCAL,,,,,12,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,13.25,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,46.4
BAG URINARY DRAINAGE DYND15405H,120.33,CDM,271,RC,A4357,HCPCS,,9112-MAIN,LOCAL,,,,,12,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,13.25,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,46.4
Deoxyribonuclease Ab,PX86215,CDM,300,RC,86215,CPT,,,,,,,,99,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,13.25,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.836,13.25
Levetiracetam - Ref,PX8017790,CDM,300,RC,80177,CPT,90,,,,,,,108,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,13.25,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.836,13.25
MEPILEX BORDER AG POST OP 4X10,120.368,CDM,272,RC,A6212,HCPCS,,10839-MAIN,LOCAL,,,,,55,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,13.25,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,13.25
MEPILEX BORDER AG POST OP 4X10,120.368,CDM,272,RC,A6212,HCPCS,,10839-MAIN,LOCAL,,,,,55,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,13.25,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,13.25
MEPILEX BORDER AG POST OP 4X10,120.368,CDM,272,RC,A6212,HCPCS,,10839-MAIN,LOCAL,,,,,55,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,13.25,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,13.25
Oxcarbazepine - Ref,PX8018390,CDM,300,RC,80183,CPT,90,,,,,,,108,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,13.25,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.836,13.25
"pediatric electrolyte Solution 1,000 mL Bottle",25000000,CDM,250,RC,,,,,,49348057041,NDC,1000,ML,31.9,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,13.25126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
nicotine 7 MG/24HR Patch 24 Hour 7 Each Box,63700001,CDM,250,RC,,,,,,43598044670,NDC,1,EA,13.53,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.2594,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lovastatin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739028110,NDC,1,EA,15.6,,First Health,Commercial,both,85,,999999999,percent of total billed charges,13.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,76282066339,NDC,100,GR,26.8,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,13.266,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Assay Calcium, Ionized",PX82330,CDM,300,RC,82330,CPT,,,,,,,,110,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,13.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.27,13.68
"Assay Calcium, Ionized",PX82330,CDM,300,RC,82330,CPT,,,,,,,,110,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,13.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.27,13.68
"Assay Calcium, Ionized",PX82330,CDM,300,RC,82330,CPT,,,,,,,,110,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,13.27,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.27,13.68
Assay of Digoxin,PX80162,CDM,300,RC,80162,CPT,,,,,,,,290,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,13.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.88,13.28
topiramate 25 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,69097012203,NDC,1,EA,13.56,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.2888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057811,NDC,0.5,ML,30.98,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,13.29042,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057841,NDC,0.5,ML,30.98,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,13.29042,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
BANDAGE COBAN  4 IN 2 LAYER COMPRESSION SYSTEM  2094N,120.549,CDM,272,RC,A6441,HCPCS,,12366-MAIN,LOCAL,,,,,32,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,13.2928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.2928,31.36
BANDAGE COBAN LITE 4 IN 2 LAYER COMPRESSION SYSTEM 2794N,120.549,CDM,272,RC,A6441,HCPCS,,12922-MAIN,LOCAL,,,,,32,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,13.2928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.2928,31.36
WOUND DRAIN FLAT WITH TROCAR 10MM FULL PERFORATED SILICONE,27200000,CDM,272,RC,,,,12462-MAIN,LOCAL,,,,,32,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,13.2928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRAPE ABDOMINAL SURGICAL 14X12 POUCHES STERILE DYNJP3109,27200000,CDM,272,RC,,,,12896-MAIN,LOCAL,,,,,31,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,13.299,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LITHOTOMY PACK VIII ECLIPSE,27200000,CDM,272,RC,,,,12210-MAIN,LOCAL,,,,,31,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,13.299,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Rubella Antibody,PX86762,CDM,300,RC,86762,CPT,,,,,,,,31,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,13.299,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.8774,30.38
pregabalin 75 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,59762134601,NDC,0.333333333,EA,15.08,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,13.30056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluvastatin 20 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,378802093,NDC,1,EA,26.88,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,13.3056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
mineral oil Enema 133 mL Bottle,63700001,CDM,250,RC,,,,,,132030140,NDC,133,ML,13.58,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.3084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Each Add'l Hour IV Infusion <8 Hour,PX96366,CDM,260,RC,96366,CPT,,,,,,,,161,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,13.31,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.31,35.48
Each Add'l Hour IV Infusion <8 Hour,PX96366,CDM,260,RC,96366,CPT,,,,,,,,161,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,13.31,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.31,35.48
Each Add'l Hour IV Infusion <8 Hour,PX96366,CDM,260,RC,96366,CPT,,,,,,,,161,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,13.31,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.31,35.48
Basic Metabolic Panel Ca Ion,PX80047,CDM,300,RC,80047,CPT,,,,,,,,17,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,13.32,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.32,13.73
Basic Metabolic Panel Ca Ion,PX80047,CDM,300,RC,80047,CPT,,,,,,,,17,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,13.32,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.32,13.73
Basic Metabolic Panel Ca Ion,PX80047,CDM,300,RC,80047,CPT,,,,,,,,17,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,13.32,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.32,13.73
Everolimus,PX8016990,CDM,300,RC,80169,CPT,,,,,,,,79,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,13.32,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.32,13.73
Everolimus,PX8016990,CDM,300,RC,80169,CPT,,,,,,,,79,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,13.32,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.32,13.73
Everolimus,PX8016990,CDM,300,RC,80169,CPT,,,,,,,,79,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,13.32,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.32,13.73
Tacrolimus - Ref,PX8019790,CDM,300,RC,80197,CPT,90,,,,,,,81,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,13.32,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.32,13.73
Tacrolimus - Ref,PX8019790,CDM,300,RC,80197,CPT,90,,,,,,,81,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,13.32,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.32,13.73
Tacrolimus - Ref,PX8019790,CDM,300,RC,80197,CPT,90,,,,,,,81,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,13.32,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.32,13.73
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409116219,NDC,30,ML,32.07,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,13.321878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
irbesartan 75 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43547037403,NDC,1,EA,15.68,,First Health,Commercial,both,85,,999999999,percent of total billed charges,13.328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
irbesartan 75 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,43547037409,NDC,1,EA,15.68,,First Health,Commercial,both,85,,999999999,percent of total billed charges,13.328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Acetaminophen 167 MG/5ML Liquid 237 mL Bottle,63700001,CDM,250,RC,,,,,,904584709,NDC,237,ML,27.22,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.3378,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Acetaminophen 167 MG/5ML Liquid 237 mL Bottle,63700001,CDM,250,RC,,,,,,904584709,NDC,237,ML,27.22,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.3378,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Acetaminophen 167 MG/5ML Liquid 237 mL Bottle,63700001,CDM,250,RC,,,,,,904584709,NDC,237,ML,27.22,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,13.3378,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Microsomal Antibody,PX7893,CDM,300,RC,86376,CPT,,,,,,,,115,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,13.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.34,112.7
saliva substitute Solution 59 mL Bottle,63700001,CDM,250,RC,,,,,,50930009802,NDC,59,ML,31.1,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,13.3419,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metroNIDAZOLE 500 MG/100ML Solution 100 mL Flex Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,409781124,NDC,100,ML,32.12,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,13.342648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,31.4776
topiramate 25 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,62756070786,NDC,1,EA,13.71,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.343943,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,409677802,NDC,1,ML,31.11,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,13.34619,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
doxycycline hyclate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584069311,NDC,0.5,EA,15,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,13.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline hyclate 100 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,62584069321,NDC,0.5,EA,15,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,13.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Immunoassay - Ref,PX8351690,CDM,300,RC,83516,CPT,90,,,,,,,15,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,13.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.231,14.7
"Iontophoresis, Ea 15min",PX97033,CDM,420,RC,97033,CPT,,,,,,,,15,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,13.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.231,14.7
Phase II Recovery,PX71000047,CDM,710,RC,,,,,,,,,,15,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,13.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.231,14.7
Assay Carbamazepine Total,PX80156,CDM,300,RC,80156,CPT,,,,,,,,145,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,13.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.36,142.1
Assay of ammonia,PX82140,CDM,300,RC,82140,CPT,,,,,,,,190,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,13.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.36,186.2
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,68094002459,NDC,10,ML,14.67,,Medica,Commercial,both,91.1,,13.39,percent of total billed charges,13.36437,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
BOOT CAST LARGE 12-5/8 ORT290010L,120.247,CDM,274,RC,L3260,HCPCS,,204-MAIN,LOCAL,,,,,27,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,13.365,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
BOOT CAST MEDIUM 08148803,120.247,CDM,274,RC,L3260,HCPCS,,203-MAIN,LOCAL,,,,,27,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,13.365,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
BOOT CAST X-LARGE 13X5-1/2IN ORT29200XL,120.247,CDM,274,RC,L3260,HCPCS,,206-MAIN,LOCAL,,,,,27,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,13.365,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
KERRAMAX CARE SUPERABSORBENT DRESSING 8X12,120.55,CDM,272,RC,A6197,HCPCS,,12363-MAIN,LOCAL,,,,,27,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,13.365,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
Or Time,PX36000086,CDM,360,RC,,,,,,,,,,27,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,13.365,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
"Sodium, Other Source - Ref",PX8430290,CDM,300,RC,84302,CPT,90,,,,,,,27,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,13.365,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.46,26.46
ELECTRODE ADULT PACING ONESTEP,120.214,CDM,272,RC,A4556,HCPCS,,10242-MAIN,LOCAL,,,,,153,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,13.38,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.38,14.08
ELECTRODE PEDS ONESTEP SINGLE,120.343,CDM,272,RC,A4556,HCPCS,,10296-MAIN,LOCAL,,,,,112,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,13.38,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.38,14.08
Histoplasma Antibody - Ref,PX8669890,CDM,300,RC,86698,CPT,90,,,,,,,71,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,13.38,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.38,13.79
Histoplasma Antibody - Ref,PX8669890,CDM,300,RC,86698,CPT,90,,,,,,,71,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,13.38,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.38,13.79
Histoplasma Antibody - Ref,PX8669890,CDM,300,RC,86698,CPT,90,,,,,,,71,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,13.38,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.38,13.79
Prealubimin,PX84134,CDM,300,RC,84134,CPT,,,,,,,,80,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,13.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.38,78.4
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092821,NDC,1,ML,32.23,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,13.388342,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,31.5854
VAGINAL PACKING 2',120.292,CDM,272,RC,,,,829-MAIN,LOCAL,,,,,32.23,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,13.388342,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.388342,31.5854
Ace - Ref,PX8216490,CDM,300,RC,82164,CPT,90,,,,,,,82,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,13.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.39,80.36
Lipid Profile,PX80061,CDM,300,RC,80061,CPT,,,,,,,,245,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,13.39,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.79,13.39
EPINEPHrine 30 MG/30ML Solution 30 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023016801,NDC,0.3,ML,32.24,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,13.392496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739028510,NDC,1,EA,13.76,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.392608,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sotalol 80 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,60505008000,NDC,1,EA,13.76,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.392608,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Cryptosporidum,PX87328,CDM,300,RC,87328,CPT,,,,,,,,117,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,13.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.41,13.82
Cryptosporidum,PX87328,CDM,300,RC,87328,CPT,,,,,,,,117,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,13.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.41,13.82
Cryptosporidum,PX87328,CDM,300,RC,87328,CPT,,,,,,,,117,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,13.41,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.41,13.82
clarithromycin 250 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,527193106,NDC,1,EA,32.3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,13.41742,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clarithromycin 250 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,65862022560,NDC,1,EA,32.3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,13.41742,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
STOCKINETTE IMPERVIOUS 9X36 NON22530,27200000,CDM,272,RC,A6457,HCPCS,,10917-MAIN,LOCAL,,,,,14.73,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,13.41903,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Cryptococcus Neoformans,PX87327,CDM,300,RC,87327,CPT,,,,,,,,45,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,13.42,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.02,13.42
Protein C Activity - Ref,PX8530390,CDM,300,RC,85303,CPT,90,,,,,,,158,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,13.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.42,13.84
Protein C Activity - Ref,PX8530390,CDM,300,RC,85303,CPT,90,,,,,,,158,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,13.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.42,13.84
Protein C Activity - Ref,PX8530390,CDM,300,RC,85303,CPT,90,,,,,,,158,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,13.42,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.42,13.84
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079034801,NDC,1,EA,27.39,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.4211,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079034801,NDC,1,EA,27.39,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.4211,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079034801,NDC,1,EA,27.39,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,13.4211,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079034820,NDC,1,EA,27.39,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.4211,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079034820,NDC,1,EA,27.39,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.4211,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079034820,NDC,1,EA,27.39,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,13.4211,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 75 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,59762134601,NDC,0.333333333,EA,15.08,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,13.4212,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbamide peroxide 6.5% 6.5 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904322035,NDC,15,ML,15.79,,First Health,Commercial,both,85,,999999999,percent of total billed charges,13.4215,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cefdinir 300 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,67877054360,NDC,1,EA,27.42,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.4358,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cefdinir 300 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,67877054360,NDC,1,EA,27.42,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.4358,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cefdinir 300 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,67877054360,NDC,1,EA,27.42,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,13.4358,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cholestyramine light 4 g Packet 42 Each Box,63700001,CDM,250,RC,,,,,,245003642,NDC,1,EA,27.42,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.4358,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cholestyramine light 4 g Packet 42 Each Box,63700001,CDM,250,RC,,,,,,245003642,NDC,1,EA,27.42,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.4358,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cholestyramine light 4 g Packet 42 Each Box,63700001,CDM,250,RC,,,,,,245003642,NDC,1,EA,27.42,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,13.4358,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
topiramate 25 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,62756070786,NDC,1,EA,13.71,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.4358,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Albumin; Other Source, Quantitative, Each Specimen",PX82042,CDM,300,RC,82042,CPT,,,,,,,,28,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,13.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.13,27.44
"Albumin; Other Source, Quantitative, Each Specimen",PX82042,CDM,300,RC,82042,CPT,,,,,,,,28,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,13.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.13,27.44
Anesthesia Level - Regional,PX37000025,CDM,370,RC,,,,,,,,,,28,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,13.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
Anesthesia Level - Regional,PX37000025,CDM,370,RC,,,,,,,,,,28,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,13.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
Gonadotropin (Lh),PX83002,CDM,300,RC,83002,CPT,,,,,,,,28,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,13.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
Gonadotropin (Lh),PX83002,CDM,300,RC,83002,CPT,,,,,,,,28,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,13.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
PROMOGRAN PRISMA AG COLLAGEN DRESSING 28CM,120.547,CDM,272,RC,A6021,HCPCS,,12361-MAIN,LOCAL,,,,,28,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,13.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
PROMOGRAN PRISMA AG COLLAGEN DRESSING 28CM,120.547,CDM,272,RC,A6021,HCPCS,,12361-MAIN,LOCAL,,,,,28,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,13.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
SCOPE BRONCHOSCOPE SZ 4 STERILE DISPOSABLE B120044,120.574,CDM,272,RC,,,,12868-MAIN,LOCAL,,,,,28,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,13.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
SCOPE BRONCHOSCOPE SZ 4 STERILE DISPOSABLE B120044,120.574,CDM,272,RC,,,,12868-MAIN,LOCAL,,,,,28,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,13.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
tranexamic acid 650 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,69918030130,NDC,1,EA,28,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,13.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tranexamic acid 650 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,69918030130,NDC,1,EA,28,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,13.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Viral Neutralization - Ref,PX8638290,CDM,300,RC,86382,CPT,90,,,,,,,28,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,13.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
Viral Neutralization - Ref,PX8638290,CDM,300,RC,86382,CPT,90,,,,,,,28,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,13.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
nicotine 21 MG/24HR Patch 24 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505706300,NDC,1,EA,13.81,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.441273,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 250 MG/5ML Recon Susp 150 mL Package,63700001,CDM,250,RC,,,,,,99998805601,NDC,5,ML,15.24,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,13.44168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cholestyramine light 4 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,245003689,NDC,1,EA,27.44,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.4456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cholestyramine light 4 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,245003689,NDC,1,EA,27.44,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.4456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cholestyramine light 4 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,245003689,NDC,1,EA,27.44,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,13.4456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin-clavulanate 875-125 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862050301,NDC,1,EA,26.59,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,13.45454,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cefdinir 300 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,16714039102,NDC,1,EA,27.46,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.4554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cefdinir 300 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,16714039102,NDC,1,EA,27.46,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.4554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cefdinir 300 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,16714039102,NDC,1,EA,27.46,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,13.4554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Strapping of Hand or Finger,PX29280F,CDM,420,RC,29280,CPT,,,,,,,,64,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,13.46,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.21,62.26
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189101,NDC,1,ML,32.43,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,13.471422,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
pregabalin 75 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,71101468,NDC,0.333333333,EA,14.79,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,13.47369,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Acetaminophen 167 MG/5ML Liquid 237 mL Bottle,63700001,CDM,250,RC,,,,,,904584709,NDC,237,ML,27.22,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,13.4739,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE CR 10 MG Tablet ER 12 hour Abuse-Deterrent 20 Each Box,63700001,CDM,250,RC,,,,,,59011041020,NDC,1,EA,26.63,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,13.47478,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Assay Calcium, Ionized",PX82330,CDM,300,RC,82330,CPT,,,,,,,,110,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,13.4778,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.27,13.68
Assay of Ferritin,PX82728,CDM,300,RC,82728,CPT,,,,,,,,177,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,13.4778,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.22,13.63
Basic Metabolic Panel Ca Ion,PX80047,CDM,300,RC,80047,CPT,,,,,,,,17,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,13.4778,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.32,13.73
Cryptosporidum,PX87328,CDM,300,RC,87328,CPT,,,,,,,,117,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,13.4778,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.41,13.82
Everolimus,PX8016990,CDM,300,RC,80169,CPT,,,,,,,,79,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,13.4778,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.32,13.73
Histoplasma Antibody - Ref,PX8669890,CDM,300,RC,86698,CPT,90,,,,,,,71,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,13.4778,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.38,13.79
"Nephelometry, Each, Nos - Ref",PX8388390,CDM,300,RC,83883,CPT,90,,,,,,,223,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,13.4778,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,13.6
Protein C Activity - Ref,PX8530390,CDM,300,RC,85303,CPT,90,,,,,,,158,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,13.4778,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.42,13.84
Tacrolimus - Ref,PX8019790,CDM,300,RC,80197,CPT,90,,,,,,,81,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,13.4778,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.32,13.73
PACLitaxel protein-bound particle 100 MG Recon Susp 1 Each Vial,J9264.01,CDM,636,RC,J9264,HCPCS,,,,68817013450,NDC,1,EA,2564.76,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,13.47923,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.58,15.01
"Folic Acid (Folate), Serum",PX82746,CDM,300,RC,82746,CPT,,,,,,,,56,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,13.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.48,54.88
warfarin 2.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56017601,NDC,1,EA,13.85,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.480205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739028510,NDC,1,EA,13.76,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.4848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sotalol 80 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,60505008000,NDC,1,EA,13.76,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.4848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,49348014446,NDC,1,EA,15.3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,13.4946,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006401,NDC,2,ML,31.46,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,13.49634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
dutasteride 0.5 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,42806054909,NDC,1,EA,32.49,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,13.496346,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ivermectin 3 MG Tablet 20 Each Box,63700001,CDM,250,RC,,,,,,42799080601,NDC,1,EA,26.68,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,13.50008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bacitracin zinc 500 UNIT/GM Ointment 28.35 g Tube,25000000,CDM,250,RC,,,,,,168001131,NDC,28.35,GR,32.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,13.5005,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Xray Abdomen Single Ap Vw,PX7400001,CDM,320,RC,74000,CPT,TC,,,,,,,358,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,13.5156,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.5156,13.52
bendamustine 100 MG/4ML Solution 4 mL Vial,800000,CDM,,,J9034,HCPCS,,,,63459034804,NDC,4,ML,5046.55,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,13.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Fac/Trm Hyperkeratotic Skn Lesn2-4,PX11056F,CDM,510,RC,11056,CPT,,,,,,,,158,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,13.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.52,171.57
Fac/Trm Hyperkeratotic Skn Lesn2-4,PX11056F,CDM,510,RC,11056,CPT,,,,,,,,158,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,13.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.52,171.57
Fac/Trm Hyperkeratotic Skn Lesn2-4,PX11056F,CDM,510,RC,11056,CPT,,,,,,,,158,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,13.52,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.52,171.57
Xray Abdomen Single Ap Vw,PX7400001,CDM,320,RC,74000,CPT,TC,,,,,,,358,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,13.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.5156,13.52
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049236,NDC,5,ML,31.52,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,13.52208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049243,NDC,5,ML,31.52,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,13.52208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048226,NDC,20,ML,32.56,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,13.525424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048241,NDC,20,ML,32.56,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,13.525424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641600101,NDC,1,ML,32.56,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,13.525424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
nicotine 21 MG/24HR Patch 24 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505706300,NDC,1,EA,13.81,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.5338,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
montelukast 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268057511,NDC,1,EA,26.75,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,13.5355,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
montelukast 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268057515,NDC,1,EA,26.75,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,13.5355,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 4 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56016801,NDC,1,EA,13.91,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.538603,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay Dipropylacetic Acid,PX80164,CDM,300,RC,80164,CPT,,,,,,,,132,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,13.54,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.13,13.54
Assay for Vancomycin,PX80202,CDM,300,RC,80202,CPT,,,,,,,,314,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,13.54,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.13,13.54
Contrast Bath Therapy,PX97034,CDM,420,RC,97034,CPT,,,,,,,,97,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,13.5408,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.1,18.45
Electrical Stimulation,PX97032,CDM,420,RC,97032,CPT,,,,,,,,135,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,13.5408,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.1,18.89
Ultrasound Therapy,PX97035,CDM,420,RC,97035,CPT,,,,,,,,135,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,13.5408,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.1,18.45
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061601,NDC,3,ML,31.57,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,13.54353,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058003,NDC,0.5,ML,31.57,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,13.54353,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058020,NDC,0.5,ML,31.57,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,13.54353,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061416,NDC,0.5,ML,31.57,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,13.54353,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.114178,99.911
clotrimazole 1 % Cream 28 g Tube,25000000,CDM,250,RC,,,,,,536127222,NDC,28,GR,15.36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,13.54752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079034801,NDC,1,EA,27.39,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,13.55805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079034820,NDC,1,EA,27.39,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,13.55805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,76282066339,NDC,100,GR,26.8,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,13.5608,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
amoxicillin 250 MG/5ML Recon Susp 150 mL Package,63700001,CDM,250,RC,,,,,,99998805601,NDC,5,ML,15.24,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,13.5636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,13.56927,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,13.56927,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
cefdinir 300 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,67877054360,NDC,1,EA,27.42,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,13.5729,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cholestyramine light 4 g Packet 42 Each Box,63700001,CDM,250,RC,,,,,,245003642,NDC,1,EA,27.42,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,13.5729,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
warfarin 2.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56017601,NDC,1,EA,13.85,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.573,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bendamustine 100 MG/4ML Solution 4 mL Vial,800000,CDM,,,J9034,HCPCS,,,,63459034804,NDC,4,ML,5046.55,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,13.57574,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.53,15.49
cholestyramine light 4 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,245003689,NDC,1,EA,27.44,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,13.5828,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lactulose 10 GM/15ML Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,50383077915,NDC,15,ML,15.98,,First Health,Commercial,both,85,,999999999,percent of total billed charges,13.583,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rOPINIRole 4 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462025801,NDC,1,EA,13.96,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.587268,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cefdinir 300 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,16714039102,NDC,1,EA,27.46,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,13.5927,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"BINDER ABDOMINAL 12"" HIGH 30-45INCH 4 PANEL ORT21300SM",120.238,CDM,271,RC,A4467,HCPCS,,11934-MAIN,LOCAL,,,,,16,,First Health,Commercial,both,85,,999999999,percent of total billed charges,13.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
DRESSING OPTIFOAM 10X4 POST-OP SILICONE FACED MSC21410Z,120.154,CDM,272,RC,A6213,HCPCS,,8632-MAIN,LOCAL,,,,,16,,First Health,Commercial,both,85,,999999999,percent of total billed charges,13.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,15.68
"Nephelometry, Each, Nos - Ref",PX8388390,CDM,300,RC,83883,CPT,90,,,,,,,223,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,13.6,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,13.6
fluvastatin 20 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,378802093,NDC,1,EA,26.88,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,13.60128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine HCl 4 % Cream 76.5 g Tube,63700001,CDM,250,RC,,,,,,41167005820,NDC,76.5,GR,31.72,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,13.60788,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,49348014446,NDC,1,EA,15.3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,13.617,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
AQUACEL EXTRA HYDOFIBER WOUND DRESSING 4X5,120.202,CDM,272,RC,A6197,HCPCS,,12047-MAIN,LOCAL,,,,,14,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.6262,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
"AQUACEL FOAM DRESSING 4X4""",120.202,CDM,272,RC,A6209,HCPCS,,7939-MAIN,LOCAL,,,,,14,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.6262,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
AQUACEL NONADHESIVE FOAM DRESSING 4X4,120.202,CDM,272,RC,A6209,HCPCS,,12046-MAIN,LOCAL,,,,,14,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.6262,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
Assay Urine Urea-N,PX84540,CDM,300,RC,84540,CPT,,,,,,,,14,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.6262,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.1,13.72
EZ CLEAN BLADE CAUTERY TIP 4 INCH,27200000,CDM,272,RC,,,,12826-MAIN,LOCAL,,,,,14,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.6262,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Post Anesthesia Recovery,PX71000019,CDM,710,RC,,,,,,,,,,14,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.6262,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
SAW WIRE 12 INCH GIGLI NL850,27200000,CDM,272,RC,,,,12901-MAIN,LOCAL,,,,,14,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.6262,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Assay of Ferritin,PX82728,CDM,300,RC,82728,CPT,,,,,,,,177,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,13.63,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.22,13.63
Hepatitis C Antibody,PX86803,CDM,300,RC,86803,CPT,,,,,,,,144,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,13.63,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.63,14.27
Hepatitis C Antibody,PX86803,CDM,300,RC,86803,CPT,,,,,,,,144,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,13.63,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.63,14.27
warfarin 4 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56016801,NDC,1,EA,13.91,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.6318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine 50 MG/ML Solution 1 mL Vial,J3410.01,CDM,636,RC,J3410,HCPCS,,,,517560125,NDC,0.5,ML,83.68,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,13.64008,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.71,13.86
BOOT CAST LARGE 12-5/8 ORT290010L,120.247,CDM,274,RC,L3260,HCPCS,,204-MAIN,LOCAL,,,,,27,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,13.662,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
BOOT CAST MEDIUM 08148803,120.247,CDM,274,RC,L3260,HCPCS,,203-MAIN,LOCAL,,,,,27,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,13.662,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
BOOT CAST X-LARGE 13X5-1/2IN ORT29200XL,120.247,CDM,274,RC,L3260,HCPCS,,206-MAIN,LOCAL,,,,,27,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,13.662,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
KERRAMAX CARE SUPERABSORBENT DRESSING 8X12,120.55,CDM,272,RC,A6197,HCPCS,,12363-MAIN,LOCAL,,,,,27,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,13.662,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
Or Time,PX36000086,CDM,360,RC,,,,,,,,,,27,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,13.662,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
"Sodium, Other Source - Ref",PX8430290,CDM,300,RC,84302,CPT,90,,,,,,,27,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,13.662,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.46,26.46
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189103,NDC,1,ML,32.89,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,13.662506,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
doxycycline hyclate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584069311,NDC,0.5,EA,15,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,13.665,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline hyclate 100 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,62584069321,NDC,0.5,EA,15,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,13.665,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Immunoassay - Ref,PX8351690,CDM,300,RC,83516,CPT,90,,,,,,,15,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,13.665,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.231,14.7
"Iontophoresis, Ea 15min",PX97033,CDM,420,RC,97033,CPT,,,,,,,,15,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,13.665,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.231,14.7
Phase II Recovery,PX71000047,CDM,710,RC,,,,,,,,,,15,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,13.665,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.231,14.7
DULoxetine 60 MG Capsule Delayed Release Particles 30 Each Bottle,63700001,CDM,250,RC,,,,,,43547038103,NDC,0.333333333,EA,14.04,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.665132,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clotrimazole 1 % Cream 28 g Tube,25000000,CDM,250,RC,,,,,,536127222,NDC,28,GR,15.36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,13.6704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Assay Calcium, Ionized",PX82330,CDM,300,RC,82330,CPT,,,,,,,,110,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,13.68,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.27,13.68
Decalcify Tc,PX8831101,CDM,310,RC,88311,CPT,TC,,,,,,,107,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,13.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.24,13.824
Decalcify Tc,PX8831101,CDM,310,RC,88311,CPT,TC,,,,,,,107,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,13.68,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.24,13.824
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8092351,NDC,1,EA,52.22,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,13.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,22.288
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8092351,NDC,1,EA,52.22,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,13.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,22.288
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400101,NDC,1,EA,52.22,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,13.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,22.288
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400101,NDC,1,EA,52.22,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,13.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,22.288
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400125,NDC,1,EA,52.22,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,13.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,22.288
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400125,NDC,1,EA,52.22,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,13.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,22.288
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,781323294,NDC,1,EA,52.89,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,13.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,22.288
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,781323294,NDC,1,EA,52.89,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,13.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,22.288
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,55150020200,NDC,1,EA,65.65,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,13.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,22.288
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,55150020200,NDC,1,EA,65.65,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,13.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,22.288
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,72603012801,NDC,1,EA,57.64,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,13.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,22.288
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,72603012801,NDC,1,EA,57.64,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,13.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,22.288
rOPINIRole 4 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462025801,NDC,1,EA,13.96,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.6808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DULoxetine 60 MG Capsule Delayed Release Particles 30 Each Bottle,63700001,CDM,250,RC,,,,,,57237001930,NDC,0.333333333,EA,14.06,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.684598,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"pediatric electrolyte Solution 1,000 mL Bottle",25000000,CDM,250,RC,,,,,,49348057041,NDC,1000,ML,31.9,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,13.6851,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
denosumab 120 MG/1.7ML Solution 1.7 mL Vial,J0897.01,CDM,636,RC,J0897,HCPCS,,,,55513073001,NDC,1.7,ML,4658.83,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,13.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.05,25.2
denosumab 120 MG/1.7ML Solution 1.7 mL Vial,J0897.01,CDM,636,RC,J0897,HCPCS,,,,55513073001,NDC,1.7,ML,4658.83,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,13.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.05,25.2
Chemiluminescent Assay - Ref,PX8239790,CDM,300,RC,82397,CPT,90,,,,,,,78,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,13.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7,14.12
Chemiluminescent Assay - Ref,PX8239790,CDM,300,RC,82397,CPT,90,,,,,,,78,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,13.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7,14.12
Chemiluminescent Assay - Ref,PX8239790,CDM,300,RC,82397,CPT,90,,,,,,,78,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,13.7,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7,14.12
pravastatin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904589161,NDC,1,EA,15.54,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,13.70628,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CATHETER FOLEY 18FR  3WAY 30CC 73018L,120.21,CDM,272,RC,A4346,HCPCS,,253-MAIN,LOCAL,,,,,33,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,13.7082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
CATHETER FOLEY 20FR 3WAY 30CC 0167L20,120.21,CDM,272,RC,A4346,HCPCS,,251-MAIN,LOCAL,,,,,33,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,13.7082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
CATHETER FOLEY 24FR 3WAY 30CC 0167L24,120.21,CDM,272,RC,A4346,HCPCS,,10455-MAIN,LOCAL,,,,,33,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,13.7082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
"DRESSING AQUACEL 3/4"" X 18"" AG HYDROFIBER 403771",120.31,CDM,272,RC,A6199,HCPCS,,8238-MAIN,LOCAL,,,,,33,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,13.7082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,32.34
Hospital Outpatient Clinic Visit Specimen Collection for Sars-Cov-2,PXC9803,CDM,300,RC,C9803,HCPCS,,,,,,,,33,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,13.7082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,32.34
MEPILEX AG 4X4 10X10,120.138,CDM,272,RC,A6213,HCPCS,,7248-MAIN,LOCAL,,,,,33,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,13.7082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,32.34
STANDARD HIGH FLOW INSUFFLATION FILTER TUBING,27200000,CDM,272,RC,,,,11885-MAIN,LOCAL,,,,,33,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,13.7082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PACLitaxel protein-bound particle 100 MG Recon Susp 1 Each Vial,J9264.01,CDM,636,RC,J9264,HCPCS,,,,68817013450,NDC,1,EA,2564.76,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,13.71,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.58,15.01
PACLitaxel protein-bound particle 100 MG Recon Susp 1 Each Vial,J9264.01,CDM,636,RC,J9264,HCPCS,,,,68817013450,NDC,1,EA,2564.76,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,13.71,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.58,15.01
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069030,NDC,3,ML,14.09,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.713797,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.852986,29.4
"Albumin; Other Source, Quantitative, Each Specimen",PX82042,CDM,300,RC,82042,CPT,,,,,,,,28,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.13,27.44
"Albumin; Other Source, Quantitative, Each Specimen",PX82042,CDM,300,RC,82042,CPT,,,,,,,,28,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.13,27.44
"Albumin; Other Source, Quantitative, Each Specimen",PX82042,CDM,300,RC,82042,CPT,,,,,,,,28,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,13.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.13,27.44
Anesthesia Level - Regional,PX37000025,CDM,370,RC,,,,,,,,,,28,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
Anesthesia Level - Regional,PX37000025,CDM,370,RC,,,,,,,,,,28,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
Anesthesia Level - Regional,PX37000025,CDM,370,RC,,,,,,,,,,28,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,13.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
AQUACEL EXTRA HYDOFIBER WOUND DRESSING 4X5,120.202,CDM,272,RC,A6197,HCPCS,,12047-MAIN,LOCAL,,,,,14,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
"AQUACEL FOAM DRESSING 4X4""",120.202,CDM,272,RC,A6209,HCPCS,,7939-MAIN,LOCAL,,,,,14,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
AQUACEL NONADHESIVE FOAM DRESSING 4X4,120.202,CDM,272,RC,A6209,HCPCS,,12046-MAIN,LOCAL,,,,,14,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
Assay Cryofibrinogen,PX82585,CDM,300,RC,82585,CPT,,,,,,,,75,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,13.72,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.72,14.14
Assay Urine Urea-N,PX84540,CDM,300,RC,84540,CPT,,,,,,,,14,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.1,13.72
EZ CLEAN BLADE CAUTERY TIP 4 INCH,27200000,CDM,272,RC,,,,12826-MAIN,LOCAL,,,,,14,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Gonadotropin (Lh),PX83002,CDM,300,RC,83002,CPT,,,,,,,,28,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
Gonadotropin (Lh),PX83002,CDM,300,RC,83002,CPT,,,,,,,,28,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
Gonadotropin (Lh),PX83002,CDM,300,RC,83002,CPT,,,,,,,,28,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,13.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
Post Anesthesia Recovery,PX71000019,CDM,710,RC,,,,,,,,,,14,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.8156,13.72
PROMOGRAN PRISMA AG COLLAGEN DRESSING 28CM,120.547,CDM,272,RC,A6021,HCPCS,,12361-MAIN,LOCAL,,,,,28,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
PROMOGRAN PRISMA AG COLLAGEN DRESSING 28CM,120.547,CDM,272,RC,A6021,HCPCS,,12361-MAIN,LOCAL,,,,,28,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
PROMOGRAN PRISMA AG COLLAGEN DRESSING 28CM,120.547,CDM,272,RC,A6021,HCPCS,,12361-MAIN,LOCAL,,,,,28,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,13.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
SAW WIRE 12 INCH GIGLI NL850,27200000,CDM,272,RC,,,,12901-MAIN,LOCAL,,,,,14,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SCOPE BRONCHOSCOPE SZ 4 STERILE DISPOSABLE B120044,120.574,CDM,272,RC,,,,12868-MAIN,LOCAL,,,,,28,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
SCOPE BRONCHOSCOPE SZ 4 STERILE DISPOSABLE B120044,120.574,CDM,272,RC,,,,12868-MAIN,LOCAL,,,,,28,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
SCOPE BRONCHOSCOPE SZ 4 STERILE DISPOSABLE B120044,120.574,CDM,272,RC,,,,12868-MAIN,LOCAL,,,,,28,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,13.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
tranexamic acid 650 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,69918030130,NDC,1,EA,28,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tranexamic acid 650 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,69918030130,NDC,1,EA,28,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tranexamic acid 650 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,69918030130,NDC,1,EA,28,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,13.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Viral Neutralization - Ref,PX8638290,CDM,300,RC,86382,CPT,90,,,,,,,28,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
Viral Neutralization - Ref,PX8638290,CDM,300,RC,86382,CPT,90,,,,,,,28,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
Viral Neutralization - Ref,PX8638290,CDM,300,RC,86382,CPT,90,,,,,,,28,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,13.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
Assay Cryofibrinogen,PX82585,CDM,300,RC,82585,CPT,,,,,,,,75,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,13.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.72,14.14
Assay Cryofibrinogen,PX82585,CDM,300,RC,82585,CPT,,,,,,,,75,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,13.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.72,14.14
BANDAGE COBAN  4 IN 2 LAYER COMPRESSION SYSTEM  2094N,120.549,CDM,272,RC,A6441,HCPCS,,12366-MAIN,LOCAL,,,,,32,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,13.728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.2928,31.36
BANDAGE COBAN LITE 4 IN 2 LAYER COMPRESSION SYSTEM 2794N,120.549,CDM,272,RC,A6441,HCPCS,,12922-MAIN,LOCAL,,,,,32,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,13.728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.2928,31.36
WOUND DRAIN FLAT WITH TROCAR 10MM FULL PERFORATED SILICONE,27200000,CDM,272,RC,,,,12462-MAIN,LOCAL,,,,,32,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,13.728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Basic Metabolic Panel Ca Ion,PX80047,CDM,300,RC,80047,CPT,,,,,,,,17,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,13.73,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.32,13.73
Everolimus,PX8016990,CDM,300,RC,80169,CPT,,,,,,,,79,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,13.73,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.32,13.73
Tacrolimus - Ref,PX8019790,CDM,300,RC,80197,CPT,90,,,,,,,81,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,13.73,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.32,13.73
pregabalin 75 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,59762134601,NDC,0.333333333,EA,15.08,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,13.73788,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Francisella Tularensis Ab,PX8666890,CDM,300,RC,86668,CPT,90,,,,,,,294,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,13.74,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.74,14.16
Xray Calcaneus Minimum 2 Vws,PX7365001,CDM,320,RC,73650,CPT,TC,,,,,,,365,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,13.74,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.74,41.42
Xray Foot 2 Vws,PX7362001,CDM,320,RC,73620,CPT,TC,,,,,,,367,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,13.74,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.74,42.07
Francisella Tularensis Ab,PX8666890,CDM,300,RC,86668,CPT,90,,,,,,,294,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,13.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.74,14.16
Francisella Tularensis Ab,PX8666890,CDM,300,RC,86668,CPT,90,,,,,,,294,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,13.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.74,14.16
Xray Calcaneus Minimum 2 Vws,PX7365001,CDM,320,RC,73650,CPT,TC,,,,,,,365,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,13.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.74,41.42
Xray Calcaneus Minimum 2 Vws,PX7365001,CDM,320,RC,73650,CPT,TC,,,,,,,365,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,13.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.74,41.42
tobramycin 80 MG/2ML Solution 2 mL Vial,J3260.01,CDM,636,RC,J3260,HCPCS,,,,67457047300,NDC,2,ML,33.09,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,13.745586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.745586,32.4282
"Triiodothyronine T3, Tot - Ref",PX8448090,CDM,300,RC,84480,CPT,90,,,,,,,158,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,13.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.75,14.18
"Triiodothyronine T3, Tot - Ref",PX8448090,CDM,300,RC,84480,CPT,90,,,,,,,158,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,13.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.75,14.18
"Triiodothyronine T3, Tot - Ref",PX8448090,CDM,300,RC,84480,CPT,90,,,,,,,158,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,13.75,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.75,14.18
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409116219,NDC,30,ML,32.07,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,13.75803,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
DULoxetine 60 MG Capsule Delayed Release Particles 30 Each Bottle,63700001,CDM,250,RC,,,,,,43547038103,NDC,0.333333333,EA,14.04,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.7592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lovastatin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739028110,NDC,1,EA,15.6,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,13.7592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
KIT ENDO COMPLETE PROCEDURE CARRY-ON 100802,27200000,CDM,272,RC,,,,10369-MAIN,LOCAL,,,,,33.15,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,13.77051,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Acetaminophen 167 MG/5ML Liquid 237 mL Bottle,63700001,CDM,250,RC,,,,,,904584709,NDC,237,ML,27.22,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,13.77332,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DULoxetine 60 MG Capsule Delayed Release Particles 30 Each Bottle,63700001,CDM,250,RC,,,,,,57237001930,NDC,0.333333333,EA,14.06,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.7788,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084007001,NDC,1,EA,33.17,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,13.778818,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metroNIDAZOLE 500 MG/100ML Solution 100 mL Flex Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,409781124,NDC,100,ML,32.12,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,13.77948,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,31.4776
Parvovirus Antibody - Ref,PX8674790,CDM,300,RC,86747,CPT,90,,,,,,,92,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,13.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.78,90.16
ciprofloxacin 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084007011,NDC,1,EA,33.19,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,13.787126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Histoplasma Antibody - Ref,PX8669890,CDM,300,RC,86698,CPT,90,,,,,,,71,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,13.79,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.38,13.79
Assay Cryofibrinogen,PX82585,CDM,300,RC,82585,CPT,,,,,,,,75,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,13.7987,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.72,14.14
Chemiluminescent Assay - Ref,PX8239790,CDM,300,RC,82397,CPT,90,,,,,,,78,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,13.7987,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7,14.12
Francisella Tularensis Ab,PX8666890,CDM,300,RC,86668,CPT,90,,,,,,,294,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,13.7987,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.74,14.16
"Triiodothyronine T3, Tot - Ref",PX8448090,CDM,300,RC,84480,CPT,90,,,,,,,158,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,13.7987,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.75,14.18
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987525,NDC,3,ML,33.22,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,13.799588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
Chorionic gonadotropin test,PX84702,CDM,300,RC,84702,CPT,,,,,,,,210,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,13.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.8,205.8
"Injection, Subq/Im",PX96372,CDM,260,RC,96372,CPT,,,,,,,,119,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,13.803,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.94,25.01
valACYclovir 1 GM Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862044930,NDC,0.5,EA,33.23,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,13.803742,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Needle Insertion W/O Injection 1 or 2 Muscles,PX20560,CDM,420,RC,20560,CPT,,,,,,,,10,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,13.8073,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.8073,53.27
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405F,CDM,510,RC,36405,CPT,,,,,,,,54,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,13.8073,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.16,49.81
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405P,CDM,983,RC,36405,CPT,,,,,,,,36,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,13.8073,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.16,49.81
Withdrawal of Arterial Blood,PX36600F,CDM,510,RC,36600,CPT,,,,,,,,250,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,13.8073,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.16,56.73
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069030,NDC,3,ML,14.09,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,13.8082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.852986,29.4
Needle Insertion W/O Injection 1 or 2 Muscles,PX20560,CDM,420,RC,20560,CPT,,,,,,,,10,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,13.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.8073,53.27
Cryptosporidum,PX87328,CDM,300,RC,87328,CPT,,,,,,,,117,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,13.82,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.41,13.82
Decalcify Tc,PX8831101,CDM,310,RC,88311,CPT,TC,,,,,,,107,,UCare,Individual and Family Plans,both,,,53.5,fee schedule,13.824,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.24,13.824
Decalcify Tc,PX8831101,CDM,310,RC,88311,CPT,TC,,,,,,,107,,UCare,Individual and Family Plans,both,,,53.5,fee schedule,13.824,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.24,13.824
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092821,NDC,1,ML,32.23,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,13.82667,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,31.5854
VAGINAL PACKING 2',120.292,CDM,272,RC,,,,829-MAIN,LOCAL,,,,,32.23,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,13.82667,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.388342,31.5854
irbesartan 75 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43547037403,NDC,1,EA,15.68,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,13.82976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
irbesartan 75 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,43547037409,NDC,1,EA,15.68,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,13.82976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bendamustine 100 MG/4ML Solution 4 mL Vial,800000,CDM,,,J9034,HCPCS,,,,63459034804,NDC,4,ML,5046.55,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,13.83,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.53,15.49
bendamustine 100 MG/4ML Solution 4 mL Vial,800000,CDM,,,J9034,HCPCS,,,,63459034804,NDC,4,ML,5046.55,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,13.83,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.53,15.49
Vitamin B-12,PX82607,CDM,300,RC,82607,CPT,,,,,,,,122,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,13.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.83,119.56
pravastatin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904589161,NDC,1,EA,15.54,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,13.8306,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
EPINEPHrine 30 MG/30ML Solution 30 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023016801,NDC,0.3,ML,32.24,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,13.83096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
benzocaine-menthol 20-0.5 % Aerosol 56 g Can,63700001,CDM,250,RC,,,,,,16864068002,NDC,56,GR,33.3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,13.83282,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ELECTRODE ADULT PACING ONESTEP,120.214,CDM,272,RC,A4556,HCPCS,,10242-MAIN,LOCAL,,,,,153,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,13.8331,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.38,14.08
ELECTRODE PEDS ONESTEP SINGLE,120.343,CDM,272,RC,A4556,HCPCS,,10296-MAIN,LOCAL,,,,,112,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,13.8331,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.38,14.08
Hepatitis C Antibody,PX86803,CDM,300,RC,86803,CPT,,,,,,,,144,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,13.84,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.63,14.27
Protein C Activity - Ref,PX8530390,CDM,300,RC,85303,CPT,90,,,,,,,158,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,13.84,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.42,13.84
clarithromycin 250 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,527193106,NDC,1,EA,32.3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,13.8567,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clarithromycin 250 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,65862022560,NDC,1,EA,32.3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,13.8567,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079034801,NDC,1,EA,27.39,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,13.85934,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079034820,NDC,1,EA,27.39,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,13.85934,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Albumin; Other Source, Quantitative, Each Specimen",PX82042,CDM,300,RC,82042,CPT,,,,,,,,28,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,13.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.13,27.44
Anesthesia Level - Regional,PX37000025,CDM,370,RC,,,,,,,,,,28,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,13.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
Glucagon - Ref,PX8294390,CDM,300,RC,82943,CPT,90,,,,,,,115,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,13.86,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.86,14.29
Glucagon - Ref,PX8294390,CDM,300,RC,82943,CPT,90,,,,,,,115,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,13.86,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.86,14.29
Gonadotropin (Lh),PX83002,CDM,300,RC,83002,CPT,,,,,,,,28,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,13.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
hydrOXYzine 50 MG/ML Solution 1 mL Vial,J3410.01,CDM,636,RC,J3410,HCPCS,,,,517560125,NDC,0.5,ML,83.68,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,13.86,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.71,13.86
hydrOXYzine 50 MG/ML Solution 1 mL Vial,J3410.01,CDM,636,RC,J3410,HCPCS,,,,517560125,NDC,0.5,ML,83.68,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,13.86,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.71,13.86
PROMOGRAN PRISMA AG COLLAGEN DRESSING 28CM,120.547,CDM,272,RC,A6021,HCPCS,,12361-MAIN,LOCAL,,,,,28,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,13.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
SCOPE BRONCHOSCOPE SZ 4 STERILE DISPOSABLE B120044,120.574,CDM,272,RC,,,,12868-MAIN,LOCAL,,,,,28,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,13.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
tranexamic acid 650 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,69918030130,NDC,1,EA,28,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,13.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Viral Neutralization - Ref,PX8638290,CDM,300,RC,86382,CPT,90,,,,,,,28,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,13.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
Glucagon - Ref,PX8294390,CDM,300,RC,82943,CPT,90,,,,,,,115,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,13.86,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.86,14.29
cefdinir 300 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,67877054360,NDC,1,EA,27.42,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,13.87452,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cholestyramine light 4 g Packet 42 Each Box,63700001,CDM,250,RC,,,,,,245003642,NDC,1,EA,27.42,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,13.87452,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 250 MG/5ML Recon Susp 150 mL Package,63700001,CDM,250,RC,,,,,,99998805601,NDC,5,ML,15.24,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,13.88364,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lovastatin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739028110,NDC,1,EA,15.6,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,13.884,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cholestyramine light 4 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,245003689,NDC,1,EA,27.44,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,13.88464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Lipoprotein (a) - Ref,PX8369590,CDM,300,RC,83695,CPT,90,,,,,,,55,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,13.89,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.89,14.32
Lipoprotein (a) - Ref,PX8369590,CDM,300,RC,83695,CPT,90,,,,,,,55,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,13.89,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.89,14.32
Lipoprotein (a) - Ref,PX8369590,CDM,300,RC,83695,CPT,90,,,,,,,55,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,13.89,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.89,14.32
cefdinir 300 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,16714039102,NDC,1,EA,27.46,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,13.89476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methotrexate 2.5 MG Tablet 20 Each Box,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067005,NDC,1,EA,33.49,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,13.911746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.911746,32.8398
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189101,NDC,1,ML,32.43,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,13.91247,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
memantine 10 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,72603011901,NDC,0.5,EA,16.37,,First Health,Commercial,both,85,,999999999,percent of total billed charges,13.9145,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Microscopic Exam of Urine,PX81015,CDM,300,RC,81015,CPT,,,,,,,,29,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,13.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.8,28.42
Microscopic Exam of Urine,PX81015,CDM,300,RC,81015,CPT,,,,,,,,29,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,13.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.8,28.42
"Protoporphyrin, RBC, Qnt - Ref",PX8420290,CDM,300,RC,84202,CPT,90,,,,,,,61,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,13.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.92,14.35
"Protoporphyrin, RBC, Qnt - Ref",PX8420290,CDM,300,RC,84202,CPT,90,,,,,,,61,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,13.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.92,14.35
"Protoporphyrin, RBC, Qnt - Ref",PX8420290,CDM,300,RC,84202,CPT,90,,,,,,,61,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,13.92,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.92,14.35
TRAY ARTHROGRAM SAFE-T-ARTHRO 28-AR1CO,120.2,CDM,272,RC,,,,11499-MAIN,LOCAL,,,,,29,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,13.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.0466,194.04
TRAY ARTHROGRAM SAFE-T-ARTHRO 28-AR1CO,120.2,CDM,272,RC,,,,11499-MAIN,LOCAL,,,,,29,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,13.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.0466,194.04
methotrexate 2.5 MG Tablet 1 Each Blister,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067001,NDC,1,EA,33.51,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,13.920054,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.911746,32.8398
carbamide peroxide 6.5% 6.5 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904322035,NDC,15,ML,15.79,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,13.92678,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dutasteride 0.5 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,42806054909,NDC,1,EA,32.49,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,13.93821,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,49348014446,NDC,1,EA,15.3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,13.9383,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Iontophoresis, Ea 15min",PX97033,CDM,420,RC,97033,CPT,,,,,,,,15,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,13.94,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.94,25.48
morphine 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574711212,NDC,1,EA,33.56,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,13.940824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bacitracin zinc 500 UNIT/GM Ointment 28.35 g Tube,25000000,CDM,250,RC,,,,,,168001131,NDC,28.35,GR,32.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,13.9425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
valACYclovir 1 GM Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069701,NDC,0.5,EA,33.58,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,13.949132,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Lab H Pylori Stool Ag,PX87338,CDM,300,RC,87338,CPT,,,,,,,,424,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,13.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.95,14.38
Lab H Pylori Stool Ag,PX87338,CDM,300,RC,87338,CPT,,,,,,,,424,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,13.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.95,14.38
Lab H Pylori Stool Ag,PX87338,CDM,300,RC,87338,CPT,,,,,,,,424,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,13.95,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.95,14.38
irbesartan 75 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43547037403,NDC,1,EA,15.68,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,13.9552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
irbesartan 75 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,43547037409,NDC,1,EA,15.68,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,13.9552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Airway Inhalation Treatment,PX94640F,CDM,410,RC,94640,CPT,,,,,,,,242,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,13.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.02,13.96
Airway Inhalation Treatment,PX94640F,CDM,410,RC,94640,CPT,,,,,,,,242,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,13.96,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.02,13.96
Cmv Antibody - Ref,PX8664490,CDM,300,RC,86644,CPT,90,,,,,,,104,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,13.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.96,14.39
Cmv Antibody - Ref,PX8664490,CDM,300,RC,86644,CPT,90,,,,,,,104,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,13.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.96,14.39
Cmv Antibody - Ref,PX8664490,CDM,300,RC,86644,CPT,90,,,,,,,104,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,13.96,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.96,14.39
"Ecg 12 Lead, Interp Only",PX93010,CDM,985,RC,93010,CPT,,,,,,,,29,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,13.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.02,28.42
"Ecg 12 Lead, Interp Only",PX93010,CDM,985,RC,93010,CPT,,,,,,,,29,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,13.96,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.02,28.42
Rubella Antibody,PX86762,CDM,300,RC,86762,CPT,,,,,,,,31,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,13.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.96,14.39
Rubella Antibody,PX86762,CDM,300,RC,86762,CPT,,,,,,,,31,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,13.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.96,14.39
Rubella Antibody,PX86762,CDM,300,RC,86762,CPT,,,,,,,,31,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,13.96,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.96,14.39
"West Nile Ab, Igg - Ref",PX8678990,CDM,300,RC,86789,CPT,90,,,,,,,248,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,13.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.96,14.39
"West Nile Ab, Igg - Ref",PX8678990,CDM,300,RC,86789,CPT,90,,,,,,,248,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,13.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.96,14.39
"West Nile Ab, Igg - Ref",PX8678990,CDM,300,RC,86789,CPT,90,,,,,,,248,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,13.96,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.96,14.39
X-Ray Exam Abdomen 1 View,PX7401801,CDM,320,RC,74018,CPT,TC,,,,,,,358,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,13.96,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.96,42.73
X-Ray Exam Femur 1 Vw,PX7355101,CDM,320,RC,73551,CPT,TC,,,,,,,142,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,13.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.96,42.07
X-Ray Exam Femur 1 Vw,PX7355101,CDM,320,RC,73551,CPT,TC,,,,,,,142,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,13.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.96,42.07
X-Ray Exam Femur 1 Vw,PX7355101,CDM,320,RC,73551,CPT,TC,,,,,,,142,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,13.96,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.96,42.07
Xray Elbow 2 Vws,PX7307001,CDM,320,RC,73070,CPT,TC,,,,,,,365,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,13.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.96,42.07
Xray Elbow 2 Vws,PX7307001,CDM,320,RC,73070,CPT,TC,,,,,,,365,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,13.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.96,42.07
Xray Elbow 2 Vws,PX7307001,CDM,320,RC,73070,CPT,TC,,,,,,,365,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,13.96,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.96,42.07
Xray Foot 2 Vws,PX7362001,CDM,320,RC,73620,CPT,TC,,,,,,,367,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,13.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.74,42.07
Xray Foot 2 Vws,PX7362001,CDM,320,RC,73620,CPT,TC,,,,,,,367,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,13.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.74,42.07
valproate 100 MG/ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049416,NDC,5,ML,33.61,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,13.961594,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
valproate 100 MG/ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049441,NDC,5,ML,33.61,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,13.961594,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
PARoxetine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084004411,NDC,1,EA,14.35,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.966855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084004401,NDC,1,EA,14.35,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,13.966855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Place Needle in Vein,PX36000P,CDM,983,RC,36000,CPT,,,,,,,,1034,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,13.968,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.45,1013.32
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048226,NDC,20,ML,32.56,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,13.96824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048241,NDC,20,ML,32.56,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,13.96824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641600101,NDC,1,ML,32.56,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,13.96824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
clotrimazole 1 % Cream 28 g Tube,25000000,CDM,250,RC,,,,,,536127222,NDC,28,GR,15.36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,13.99296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
STOCKINETTE IMPERVIOUS 12X48 NON22535,27200000,CDM,272,RC,A6457,HCPCS,,10918-MAIN,LOCAL,,,,,16.47,,First Health,Commercial,both,85,,999999999,percent of total billed charges,13.9995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Ebv, Nuclear Antigen - Ref",PX8666490,CDM,300,RC,86664,CPT,90,,,,,,,58,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,14.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.02,56.84
Epstein-barr antibody,PX86664,CDM,300,RC,86664,CPT,,,,,,,,72,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,14.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.02,70.56
paliperidone palmitate ER 234 MG/1.5ML suspension prefilled syringe 1.5 mL Syringe,J2426.01,CDM,636,RC,J2426,HCPCS,,,,50458056401,NDC,0.25,ML,1142.14,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,14.02612,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,14.32
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987501,NDC,3,ML,33.77,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.028058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
Legionella Antibody - Ref,PX8671390,CDM,300,RC,86713,CPT,90,,,,,,,71,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,14.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.03,69.58
Phenobarbital Assay - Ref,PX8018490,CDM,300,RC,80184,CPT,90,,,,,,,20,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,14.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
"Folic Acid (Folate), Serum",PX82746,CDM,300,RC,82746,CPT,,,,,,,,56,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,14.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.04,14.7
"Folic Acid (Folate), Serum",PX82746,CDM,300,RC,82746,CPT,,,,,,,,56,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,14.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.04,14.7
Apc Resistance Assay - Ref,PX8530790,CDM,300,RC,85307,CPT,90,,,,,,,390,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,14.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.05,382.2
"Protein S, Free - Ref",PX8530690,CDM,300,RC,85306,CPT,90,,,,,,,47,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,14.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.05,46.06
LEGGING PAIR 31X48 STERILE,27200000,CDM,272,RC,,,,10916-MAIN,LOCAL,,,,,16.53,,First Health,Commercial,both,85,,999999999,percent of total billed charges,14.0505,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
carbamide peroxide 6.5% 6.5 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904322035,NDC,15,ML,15.79,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,14.0531,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ziprasidone 80 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,781216860,NDC,0.25,EA,14.44,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,14.054452,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084004411,NDC,1,EA,14.35,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,14.063,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PARoxetine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084004401,NDC,1,EA,14.35,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,14.063,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vedolizumab 300 MG Recon Soln 1 Each Vial,J3380.01,CDM,636,RC,J3380,HCPCS,,,,64764030020,NDC,1,EA,12439.04,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,14.07,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.07,22.06
citalopram 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904608561,NDC,1,EA,14.46,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,14.073918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342003110,NDC,1,EA,16.56,,First Health,Commercial,both,85,,999999999,percent of total billed charges,14.076,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ELECTRODE ADULT PACING ONESTEP,120.214,CDM,272,RC,A4556,HCPCS,,10242-MAIN,LOCAL,,,,,153,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,14.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.38,14.08
ELECTRODE ADULT PACING ONESTEP,120.214,CDM,272,RC,A4556,HCPCS,,10242-MAIN,LOCAL,,,,,153,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,14.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.38,14.08
ELECTRODE ADULT PACING ONESTEP,120.214,CDM,272,RC,A4556,HCPCS,,10242-MAIN,LOCAL,,,,,153,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,14.08,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.38,14.08
ELECTRODE PEDS ONESTEP SINGLE,120.343,CDM,272,RC,A4556,HCPCS,,10296-MAIN,LOCAL,,,,,112,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,14.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.38,14.08
ELECTRODE PEDS ONESTEP SINGLE,120.343,CDM,272,RC,A4556,HCPCS,,10296-MAIN,LOCAL,,,,,112,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,14.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.38,14.08
ELECTRODE PEDS ONESTEP SINGLE,120.343,CDM,272,RC,A4556,HCPCS,,10296-MAIN,LOCAL,,,,,112,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,14.08,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.38,14.08
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097084034,NDC,3,ML,14.47,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,14.083651,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097084053,NDC,3,ML,14.47,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,14.083651,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lactulose 10 GM/15ML Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,50383077915,NDC,15,ML,15.98,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,14.09436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189103,NDC,1,ML,32.89,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,14.10981,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
Microsomal Antibody,PX7893,CDM,300,RC,86376,CPT,,,,,,,,115,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,14.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.11,14.55
Microsomal Antibody,PX7893,CDM,300,RC,86376,CPT,,,,,,,,115,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,14.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.11,14.55
Microsomal Antibody,PX7893,CDM,300,RC,86376,CPT,,,,,,,,115,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,14.11,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.11,14.55
"BINDER ABDOMINAL 12"" HIGH 30-45INCH 4 PANEL ORT21300SM",120.238,CDM,271,RC,A4467,HCPCS,,11934-MAIN,LOCAL,,,,,16,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,14.112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
DRESSING OPTIFOAM 10X4 POST-OP SILICONE FACED MSC21410Z,120.154,CDM,272,RC,A6213,HCPCS,,8632-MAIN,LOCAL,,,,,16,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,14.112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,15.68
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,51293081001,NDC,1,EA,14.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,14.11285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65162068110,NDC,1,EA,14.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,14.11285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay Carbamazepine Total,PX80156,CDM,300,RC,80156,CPT,,,,,,,,145,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,14.1196,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1196,14.57
Assay of ammonia,PX82140,CDM,300,RC,82140,CPT,,,,,,,,190,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,14.1196,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1196,14.57
Cmv Antibody - Ref,PX8664490,CDM,300,RC,86644,CPT,90,,,,,,,104,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,14.1196,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.96,14.39
Glucagon - Ref,PX8294390,CDM,300,RC,82943,CPT,90,,,,,,,115,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,14.1196,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.86,14.29
Hepatitis C Antibody,PX86803,CDM,300,RC,86803,CPT,,,,,,,,144,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,14.1196,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.63,14.27
Immunization Administration; Each Add'l Vaccine (Single or Combo Vaccine/T*,PX90472,CDM,771,RC,90472,CPT,,,,,,,,48,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,14.1196,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.16,25.59
Lab H Pylori Stool Ag,PX87338,CDM,300,RC,87338,CPT,,,,,,,,424,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,14.1196,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.95,14.38
Lipoprotein (a) - Ref,PX8369590,CDM,300,RC,83695,CPT,90,,,,,,,55,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,14.1196,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.89,14.32
Microsomal Antibody,PX7893,CDM,300,RC,86376,CPT,,,,,,,,115,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,14.1196,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.11,14.55
"Protoporphyrin, RBC, Qnt - Ref",PX8420290,CDM,300,RC,84202,CPT,90,,,,,,,61,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,14.1196,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.92,14.35
Rubella Antibody,PX86762,CDM,300,RC,86762,CPT,,,,,,,,31,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,14.1196,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.96,14.39
"West Nile Ab, Igg - Ref",PX8678990,CDM,300,RC,86789,CPT,90,,,,,,,248,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,14.1196,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.96,14.39
Chemiluminescent Assay - Ref,PX8239790,CDM,300,RC,82397,CPT,90,,,,,,,78,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,14.12,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7,14.12
BINDER ABDOMINAL S/M 9 INCH UP TO 45 INCHES TRI-PANNEL ABB3P45,120.238,CDM,271,RC,A4467,HCPCS,,47-MAIN,LOCAL,,,,,34,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.1236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.1236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.1236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
"Lab Ige, Isocyan Hdi",PX86003,CDM,300,RC,86003,CPT,90,,,,,,,34,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.1236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.79,33.32
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323020110,NDC,10,ML,34,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.1236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Metanephrines - Ref,PX8383590,CDM,300,RC,83835,CPT,90,,,,,,,34,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.1236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1236,33.32
SPLINT SAM 36INCH ROLLED 661121,120.362,CDM,271,RC,,,,10789-MAIN,LOCAL,,,,,34,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.1236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1236,33.32
"Venipunc Need Phys Skill,Dx or Rx",PX36410F,CDM,510,RC,36410,CPT,,,,,,,,34,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.1236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1236,33.32
"Pare/Cut Hyperkeratotic Skin Lesion, Single",PX11055F,CDM,510,RC,11055,CPT,,,,,,,,145,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,14.1284,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.59,148.05
Assay Carbamazepine Total,PX80156,CDM,300,RC,80156,CPT,,,,,,,,145,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,14.13,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1196,14.57
Assay of ammonia,PX82140,CDM,300,RC,82140,CPT,,,,,,,,190,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,14.13,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1196,14.57
Assay Carbamazepine Total,PX80156,CDM,300,RC,80156,CPT,,,,,,,,145,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,14.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1196,14.57
Assay Carbamazepine Total,PX80156,CDM,300,RC,80156,CPT,,,,,,,,145,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,14.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1196,14.57
Assay of ammonia,PX82140,CDM,300,RC,82140,CPT,,,,,,,,190,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,14.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1196,14.57
Assay of ammonia,PX82140,CDM,300,RC,82140,CPT,,,,,,,,190,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,14.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1196,14.57
Assay Cryofibrinogen,PX82585,CDM,300,RC,82585,CPT,,,,,,,,75,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,14.14,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.72,14.14
meloxicam 7.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268052511,NDC,1,EA,16.64,,First Health,Commercial,both,85,,999999999,percent of total billed charges,14.144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Prealubimin,PX84134,CDM,300,RC,84134,CPT,,,,,,,,80,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,14.15,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.15,14.59
Prealubimin,PX84134,CDM,300,RC,84134,CPT,,,,,,,,80,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,14.15,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.15,14.59
Prealubimin,PX84134,CDM,300,RC,84134,CPT,,,,,,,,80,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,14.15,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.15,14.59
ziprasidone 80 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,781216860,NDC,0.25,EA,14.44,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,14.1512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
RESERVOIR SILICONE BULB 100CC,27200000,CDM,272,RC,,,,4400-MAIN,LOCAL,,,,,16.65,,First Health,Commercial,both,85,,999999999,percent of total billed charges,14.1525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
pravastatin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904589161,NDC,1,EA,15.54,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,14.15694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CATHETER FOLEY 18FR  3WAY 30CC 73018L,120.21,CDM,272,RC,A4346,HCPCS,,253-MAIN,LOCAL,,,,,33,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,14.157,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
CATHETER FOLEY 20FR 3WAY 30CC 0167L20,120.21,CDM,272,RC,A4346,HCPCS,,251-MAIN,LOCAL,,,,,33,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,14.157,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
CATHETER FOLEY 24FR 3WAY 30CC 0167L24,120.21,CDM,272,RC,A4346,HCPCS,,10455-MAIN,LOCAL,,,,,33,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,14.157,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
"DRESSING AQUACEL 3/4"" X 18"" AG HYDROFIBER 403771",120.31,CDM,272,RC,A6199,HCPCS,,8238-MAIN,LOCAL,,,,,33,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,14.157,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,32.34
Hospital Outpatient Clinic Visit Specimen Collection for Sars-Cov-2,PXC9803,CDM,300,RC,C9803,HCPCS,,,,,,,,33,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,14.157,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,32.34
MEPILEX AG 4X4 10X10,120.138,CDM,272,RC,A6213,HCPCS,,7248-MAIN,LOCAL,,,,,33,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,14.157,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,32.34
STANDARD HIGH FLOW INSUFFLATION FILTER TUBING,27200000,CDM,272,RC,,,,11885-MAIN,LOCAL,,,,,33,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,14.157,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Xray Shoulder 1 Vw,PX7302001,CDM,320,RC,73020,CPT,TC,,,,,,,267,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,14.1592,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.37,28.27
Ace - Ref,PX8216490,CDM,300,RC,82164,CPT,90,,,,,,,82,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,14.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.16,14.6
Ace - Ref,PX8216490,CDM,300,RC,82164,CPT,90,,,,,,,82,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,14.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.16,14.6
Ace - Ref,PX8216490,CDM,300,RC,82164,CPT,90,,,,,,,82,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,14.16,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.16,14.6
Francisella Tularensis Ab,PX8666890,CDM,300,RC,86668,CPT,90,,,,,,,294,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,14.16,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.74,14.16
"Albumin; Other Source, Quantitative, Each Specimen",PX82042,CDM,300,RC,82042,CPT,,,,,,,,28,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,14.168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.13,27.44
Anesthesia Level - Regional,PX37000025,CDM,370,RC,,,,,,,,,,28,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,14.168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
Gonadotropin (Lh),PX83002,CDM,300,RC,83002,CPT,,,,,,,,28,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,14.168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
PROMOGRAN PRISMA AG COLLAGEN DRESSING 28CM,120.547,CDM,272,RC,A6021,HCPCS,,12361-MAIN,LOCAL,,,,,28,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,14.168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
SCOPE BRONCHOSCOPE SZ 4 STERILE DISPOSABLE B120044,120.574,CDM,272,RC,,,,12868-MAIN,LOCAL,,,,,28,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,14.168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
tranexamic acid 650 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,69918030130,NDC,1,EA,28,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,14.168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Viral Neutralization - Ref,PX8638290,CDM,300,RC,86382,CPT,90,,,,,,,28,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,14.168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409317801,NDC,20,ML,34.11,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.169294,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409317816,NDC,20,ML,34.11,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.169294,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189001,NDC,1,ML,34.11,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.169294,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189003,NDC,1,ML,34.11,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.169294,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
citalopram 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904608561,NDC,1,EA,14.46,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,14.1708,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"DXA, Bone Density Study, Radius/Wrist/Heel",PX7708101,CDM,320,RC,77081,CPT,TC,,,,,,,460,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,14.18,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.18,44.05
"Triiodothyronine T3, Tot - Ref",PX8448090,CDM,300,RC,84480,CPT,90,,,,,,,158,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,14.18,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.75,14.18
X-Ray Exam Abdomen 1 View,PX7401801,CDM,320,RC,74018,CPT,TC,,,,,,,358,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,14.18,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.96,42.73
X-Ray Exam Abdomen 1 View,PX7401801,CDM,320,RC,74018,CPT,TC,,,,,,,358,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,14.18,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.96,42.73
Xray Forearm 2 Vws,PX7309001,CDM,320,RC,73090,CPT,TC,,,,,,,364,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,14.18,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.18,42.73
Xray Forearm 2 Vws,PX7309001,CDM,320,RC,73090,CPT,TC,,,,,,,364,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,14.18,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.18,42.73
Xray Forearm 2 Vws,PX7309001,CDM,320,RC,73090,CPT,TC,,,,,,,364,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,14.18,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.18,42.73
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097084034,NDC,3,ML,14.47,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,14.1806,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097084053,NDC,3,ML,14.47,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,14.1806,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601901,NDC,10,ML,211.47,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,14.18697,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.89,14.43
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601910,NDC,10,ML,211.47,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,14.18697,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.89,14.43
Fibrinolysins Screen - Ref,PX8539090,CDM,300,RC,85390,CPT,90,,,,,,,118,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,14.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.19,115.64
tobramycin 80 MG/2ML Solution 2 mL Vial,J3260.01,CDM,636,RC,J3260,HCPCS,,,,67457047300,NDC,2,ML,33.09,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,14.19561,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.745586,32.4282
"Lyme Disease, Confirm Tst - Ref",PX8661790,CDM,300,RC,86617,CPT,90,,,,,,,95,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,14.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.2,93.1
"Ecg 12 Lead, Interp Only",PX93010,CDM,985,RC,93010,CPT,,,,,,,,29,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.0466,28.2257
"Ecg 12 Lead, Interp Only",PX93010,CDM,985,RC,93010,CPT,,,,,,,,29,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.0466,28.2257
"Ecg 12 Lead, Interp Only",PX93010,CDM,985,RC,93010,CPT,,,,,,,,29,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.0466,28.2257
Microscopic Exam of Urine,PX81015,CDM,300,RC,81015,CPT,,,,,,,,29,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.8,28.42
Microscopic Exam of Urine,PX81015,CDM,300,RC,81015,CPT,,,,,,,,29,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.8,28.42
Microscopic Exam of Urine,PX81015,CDM,300,RC,81015,CPT,,,,,,,,29,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.8,28.42
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,51293081001,NDC,1,EA,14.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,14.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65162068110,NDC,1,EA,14.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,14.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
TRAY ARTHROGRAM SAFE-T-ARTHRO 28-AR1CO,120.2,CDM,272,RC,,,,11499-MAIN,LOCAL,,,,,29,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.0466,194.04
TRAY ARTHROGRAM SAFE-T-ARTHRO 28-AR1CO,120.2,CDM,272,RC,,,,11499-MAIN,LOCAL,,,,,29,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.0466,194.04
TRAY ARTHROGRAM SAFE-T-ARTHRO 28-AR1CO,120.2,CDM,272,RC,,,,11499-MAIN,LOCAL,,,,,29,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.0466,194.04
lovastatin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739028110,NDC,1,EA,15.6,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,14.2116,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
KIT ENDO COMPLETE PROCEDURE CARRY-ON 100802,27200000,CDM,272,RC,,,,10369-MAIN,LOCAL,,,,,33.15,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,14.22135,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
lactulose 10 GM/15ML Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,50383077915,NDC,15,ML,15.98,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,14.2222,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084007001,NDC,1,EA,33.17,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,14.22993,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084007011,NDC,1,EA,33.19,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,14.23851,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"BINDER ABDOMINAL 12"" HIGH 30-45INCH 4 PANEL ORT21300SM",120.238,CDM,271,RC,A4467,HCPCS,,11934-MAIN,LOCAL,,,,,16,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,14.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
DRESSING OPTIFOAM 10X4 POST-OP SILICONE FACED MSC21410Z,120.154,CDM,272,RC,A6213,HCPCS,,8632-MAIN,LOCAL,,,,,16,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,14.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,15.68
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987525,NDC,3,ML,33.22,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,14.25138,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
valACYclovir 1 GM Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862044930,NDC,0.5,EA,33.23,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,14.25567,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Folic Acid (Folate), Serum",PX82746,CDM,300,RC,82746,CPT,,,,,,,,56,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,14.26,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.04,14.7
Hepatitis C Antibody,PX86803,CDM,300,RC,86803,CPT,,,,,,,,144,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,14.27,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.63,14.27
paliperidone palmitate ER 234 MG/1.5ML suspension prefilled syringe 1.5 mL Syringe,J2426.01,CDM,636,RC,J2426,HCPCS,,,,50458056401,NDC,0.25,ML,1142.14,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,14.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,14.32
paliperidone palmitate ER 234 MG/1.5ML suspension prefilled syringe 1.5 mL Syringe,J2426.01,CDM,636,RC,J2426,HCPCS,,,,50458056401,NDC,0.25,ML,1142.14,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,14.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,14.32
finasteride 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862014930,NDC,1,EA,16.79,,First Health,Commercial,both,85,,999999999,percent of total billed charges,14.2715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,68094002459,NDC,10,ML,14.67,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,5.734,percent of total billed charges,14.278311,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,469650189,NDC,5,ML,1264.92,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,14.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.91655,14.28
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,71288020185,NDC,5,ML,1021.7,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,14.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.91655,14.28
irbesartan 75 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43547037403,NDC,1,EA,15.68,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,14.28448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
irbesartan 75 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,43547037409,NDC,1,EA,15.68,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,14.28448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzocaine-menthol 20-0.5 % Aerosol 56 g Can,63700001,CDM,250,RC,,,,,,16864068002,NDC,56,GR,33.3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,14.2857,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Glucagon - Ref,PX8294390,CDM,300,RC,82943,CPT,90,,,,,,,115,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,14.29,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.86,14.29
inFLIXimab-dyyb 100 MG Recon Soln 1 Each Vial,Q5103.01,CDM,636,RC,Q5103,HCPCS,,,,69080901,NDC,1,EA,1930.42,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,14.29,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.88,14.29
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,641601301,NDC,5,ML,34.41,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.293914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
famciclovir 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714030401,NDC,1,EA,34.42,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.298068,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Cognitive Funct Ther Interv, Ea Addl 15 Min",PX97130,CDM,420,RC,97130,CPT,,,,,,,,82,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,14.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31,80.36
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120301,NDC,0.5,ML,34.45,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.31053,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120311,NDC,0.5,ML,34.45,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.31053,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
Lipoprotein (a) - Ref,PX8369590,CDM,300,RC,83695,CPT,90,,,,,,,55,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,14.32,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.89,14.32
paliperidone palmitate ER 234 MG/1.5ML suspension prefilled syringe 1.5 mL Syringe,J2426.01,CDM,636,RC,J2426,HCPCS,,,,50458056401,NDC,0.25,ML,1142.14,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,14.32,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,14.32
STOCKINETTE IMPERVIOUS 9X36 NON22530,27200000,CDM,272,RC,A6457,HCPCS,,10917-MAIN,LOCAL,,,,,14.73,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,14.336709,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Protoporphyrin, RBC, Qnt - Ref",PX8420290,CDM,300,RC,84202,CPT,90,,,,,,,61,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,14.35,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.92,14.35
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016501,NDC,1,ML,34.55,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.35207,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049226,NDC,30,ML,34.55,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.35207,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049245,NDC,30,ML,34.55,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.35207,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,23155024031,NDC,2,ML,34.55,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.35207,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.859
"Ecg 12 Lead, Interp Only",PX93010,CDM,985,RC,93010,CPT,,,,,,,,29,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.355,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.0466,28.2257
Microscopic Exam of Urine,PX81015,CDM,300,RC,81015,CPT,,,,,,,,29,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.355,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.8,28.42
TRAY ARTHROGRAM SAFE-T-ARTHRO 28-AR1CO,120.2,CDM,272,RC,,,,11499-MAIN,LOCAL,,,,,29,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.355,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.0466,194.04
buprenorphine 75 MCG FILM 60 Each Box,63700001,CDM,250,RC,,,,,,59385002160,NDC,1,EA,29.92,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.3616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buprenorphine 75 MCG FILM 60 Each Box,63700001,CDM,250,RC,,,,,,59385002160,NDC,1,EA,29.92,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.3616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methotrexate 2.5 MG Tablet 20 Each Box,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067005,NDC,1,EA,33.49,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,14.36721,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.911746,32.8398
Chorionic gonadotropin test,PX84702,CDM,300,RC,84702,CPT,,,,,,,,210,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,14.37,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.37,15.05
Chorionic gonadotropin test,PX84702,CDM,300,RC,84702,CPT,,,,,,,,210,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,14.37,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.37,15.05
"Iontophoresis, Ea 15min",PX97033,CDM,420,RC,97033,CPT,,,,,,,,15,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,14.37,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.94,25.48
"Iontophoresis, Ea 15min",PX97033,CDM,420,RC,97033,CPT,,,,,,,,15,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,14.37,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.94,25.48
methotrexate 2.5 MG Tablet 1 Each Blister,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067001,NDC,1,EA,33.51,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,14.37579,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.911746,32.8398
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,68094002459,NDC,10,ML,14.67,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,14.3766,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,14.3766
Lab H Pylori Stool Ag,PX87338,CDM,300,RC,87338,CPT,,,,,,,,424,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,14.38,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.95,14.38
carbamide peroxide 6.5% 6.5 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904322035,NDC,15,ML,15.79,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,14.38469,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Cmv Antibody - Ref,PX8664490,CDM,300,RC,86644,CPT,90,,,,,,,104,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,14.39,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.96,14.39
Rubella Antibody,PX86762,CDM,300,RC,86762,CPT,,,,,,,,31,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,14.39,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.96,14.39
"West Nile Ab, Igg - Ref",PX8678990,CDM,300,RC,86789,CPT,90,,,,,,,248,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,14.39,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.96,14.39
pregabalin 75 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,71101468,NDC,0.333333333,EA,14.79,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,14.395107,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574711212,NDC,1,EA,33.56,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,14.39724,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
8MM ENDOWRIST INSTRUMENTS MEDIUM LARGE CLIP APPLIER,27200000,CDM,272,RC,,,,11910-MAIN,LOCAL,,,,,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM ENDOWRIST INSTRUMENTS MEDIUM LARGE CLIP APPLIER,27200000,CDM,272,RC,,,,11910-MAIN,LOCAL,,,,,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,2,ML,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.852986,29.4
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,2,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.852986,29.4
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,3,ML,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.852986,29.4
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,3,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.852986,29.4
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061603,NDC,3,ML,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061603,NDC,3,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,641600601,NDC,0.5,ML,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,641600601,NDC,0.5,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
bacteriostatic water(benz alc) Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409397703,NDC,30,ML,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
bacteriostatic water(benz alc) Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409397703,NDC,30,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BULB RESERVOIR SILICONE 400CC,27200000,CDM,272,RC,,,,12463-MAIN,LOCAL,,,,,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
BULB RESERVOIR SILICONE 400CC,27200000,CDM,272,RC,,,,12463-MAIN,LOCAL,,,,,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600710,NDC,2,ML,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,38.9354
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600710,NDC,2,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,38.9354
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409115918,NDC,1,ML,30,,Health Partners,Health Partners Care Plans,both,48,,0.387,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409115918,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046401,NDC,1,ML,30,,Health Partners,Health Partners Care Plans,both,48,,0.387,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046401,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046402,NDC,1,ML,30,,Health Partners,Health Partners Care Plans,both,48,,0.387,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046402,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046437,NDC,1,ML,30,,Health Partners,Health Partners Care Plans,both,48,,0.387,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046437,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,409174670,NDC,1,ML,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,409174670,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046801,NDC,1,ML,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046801,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046817,NDC,1,ML,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046817,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BUPivacaine in dextrose 0.75-8.25 % Solution 2 mL Ampule,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409176162,NDC,2,ML,30,,Health Partners,Health Partners Care Plans,both,48,,0.387,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine in dextrose 0.75-8.25 % Solution 2 mL Ampule,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409176162,NDC,2,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046601,NDC,1,ML,30,,Health Partners,Health Partners Care Plans,both,48,,0.387,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046601,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143992490,NDC,0.5,EA,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143992490,NDC,0.5,EA,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010110,NDC,0.5,EA,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010110,NDC,0.5,EA,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010167,NDC,0.5,EA,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010167,NDC,0.5,EA,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,44567070725,NDC,0.5,EA,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,44567070725,NDC,0.5,EA,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733201,NDC,0.5,EA,30,,Health Partners,Health Partners Care Plans,both,48,,26.64321429,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733201,NDC,0.5,EA,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733801,NDC,0.5,EA,30,,Health Partners,Health Partners Care Plans,both,48,,26.64321429,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733801,NDC,0.5,EA,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,70069000501,NDC,0.1,ML,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,63.2394
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,70069000501,NDC,0.1,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,63.2394
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016502,NDC,0.5,ML,30,,Health Partners,Health Partners Care Plans,both,48,,1.5325,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016502,NDC,0.5,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016516,NDC,0.5,ML,30,,Health Partners,Health Partners Care Plans,both,48,,1.5325,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016516,NDC,0.5,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036721,NDC,1,ML,30,,Health Partners,Health Partners Care Plans,both,48,,1.5325,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036721,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036725,NDC,1,ML,30,,Health Partners,Health Partners Care Plans,both,48,,1.5325,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036725,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 100 MG/10ML Solution 10 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323051610,NDC,0.5,ML,30,,Health Partners,Health Partners Care Plans,both,48,,1.5325,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 100 MG/10ML Solution 10 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323051610,NDC,0.5,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050641,NDC,0.5,ML,30,,Health Partners,Health Partners Care Plans,both,48,,1.5325,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050641,NDC,0.5,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141031,NDC,0.5,ML,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141031,NDC,0.5,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,641037621,NDC,0.25,ML,30,,Health Partners,Health Partners Care Plans,both,48,,14.32944444,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,641037621,NDC,0.25,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066416,NDC,1,ML,30,,Health Partners,Health Partners Care Plans,both,48,,14.32944444,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066416,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066441,NDC,0.25,ML,30,,Health Partners,Health Partners Care Plans,both,48,,14.32944444,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066441,NDC,0.25,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010101,NDC,0.25,ML,30,,Health Partners,Health Partners Care Plans,both,48,,14.32944444,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010101,NDC,0.25,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
DRAPE SPLIT WITH ADHESIVE DYNJP8304A,27200000,CDM,272,RC,,,,4694-MAIN,LOCAL,,,,,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRAPE SPLIT WITH ADHESIVE DYNJP8304A,27200000,CDM,272,RC,,,,4694-MAIN,LOCAL,,,,,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRESSING HYDROFERA 2-1/2X2-1/2  BLUE READY FOAM HBRS2520,120.488,CDM,271,RC,A6209,HCPCS,,11537-MAIN,LOCAL,,,,,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
DRESSING HYDROFERA 2-1/2X2-1/2  BLUE READY FOAM HBRS2520,120.488,CDM,271,RC,A6209,HCPCS,,11537-MAIN,LOCAL,,,,,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
"Ethanol, P",PX82077,CDM,300,RC,82077,CPT,,,,,,,,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
"Ethanol, P",PX82077,CDM,300,RC,82077,CPT,,,,,,,,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073916,NDC,2,ML,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,29.4
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073916,NDC,2,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,29.4
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073941,NDC,1,ML,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,29.4
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073941,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,29.4
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,67457043300,NDC,1,ML,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,29.4
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,67457043300,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,29.4
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,Health Partners,Health Partners Care Plans,both,48,,21.6975,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909422,NDC,2,ML,30,,Health Partners,Health Partners Care Plans,both,48,,21.6975,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909422,NDC,2,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,Health Partners,Health Partners Care Plans,both,48,,21.6975,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
folic acid 5 MG/ML Solution 10 mL Vial,J3490.94,CDM,636,RC,J3490,HCPCS,,,,39822110001,NDC,0.2,ML,30,,Health Partners,Health Partners Care Plans,both,48,,31.91277778,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,330.2012
folic acid 5 MG/ML Solution 10 mL Vial,J3490.94,CDM,636,RC,J3490,HCPCS,,,,39822110001,NDC,0.2,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,330.2012
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,70860030242,NDC,1,ML,30,,Health Partners,Health Partners Care Plans,both,48,,7.095,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,70860030242,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,36000028425,NDC,2,ML,30,,Health Partners,Health Partners Care Plans,both,48,,7.095,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,36000028425,NDC,2,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001094,NDC,2,ML,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,42.5516
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001094,NDC,2,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,42.5516
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,781382571,NDC,0.5,ML,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,781382571,NDC,0.5,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,143931901,NDC,0.4,ML,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.428
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,143931901,NDC,0.4,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.428
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272002,NDC,1,ML,30,,Health Partners,Health Partners Care Plans,both,48,,1.83137931,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272002,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272031,NDC,1,ML,30,,Health Partners,Health Partners Care Plans,both,48,,1.83137931,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272031,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,25021040010,NDC,1,ML,30,,Health Partners,Health Partners Care Plans,both,48,,1.83137931,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,25021040010,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323054011,NDC,1,ML,30,,Health Partners,Health Partners Care Plans,both,48,,1.83137931,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323054011,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095300,NDC,0.5,ML,30,,Health Partners,Health Partners Care Plans,both,48,,1.83137931,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095300,NDC,0.5,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095310,NDC,1,ML,30,,Health Partners,Health Partners Care Plans,both,48,,1.83137931,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095310,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,71288042095,NDC,0.5,ML,30,,Health Partners,Health Partners Care Plans,both,48,,1.83137931,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,71288042095,NDC,0.5,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306424,NDC,1,ML,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306424,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306413,NDC,1,ML,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306413,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306521,NDC,3,ML,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306521,NDC,3,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin lock flush 10 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306510,NDC,5,ML,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin lock flush 10 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306510,NDC,5,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
HYDROmorphone 1 MG/ML Solution 1 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,76045000901,NDC,0.25,ML,30,,Health Partners,Health Partners Care Plans,both,48,,25.36411765,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
HYDROmorphone 1 MG/ML Solution 1 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,76045000901,NDC,0.25,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016216,NDC,1,ML,30,,Health Partners,Health Partners Care Plans,both,48,,13.774375,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016216,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016243,NDC,0.5,ML,30,,Health Partners,Health Partners Care Plans,both,48,,13.774375,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016243,NDC,0.5,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072201,NDC,0.5,ML,30,,Health Partners,Health Partners Care Plans,both,48,,13.774375,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072201,NDC,0.5,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072225,NDC,0.5,ML,30,,Health Partners,Health Partners Care Plans,both,48,,13.774375,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072225,NDC,0.5,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016226,NDC,0.5,ML,30,,Health Partners,Health Partners Care Plans,both,48,,13.774375,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016226,NDC,0.5,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016245,NDC,0.5,ML,30,,Health Partners,Health Partners Care Plans,both,48,,13.774375,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016245,NDC,0.5,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011901,NDC,0.5,ML,30,,Health Partners,Health Partners Care Plans,both,48,,13.774375,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011901,NDC,0.5,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011925,NDC,0.5,ML,30,,Health Partners,Health Partners Care Plans,both,48,,13.774375,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011925,NDC,0.5,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072501,NDC,0.5,ML,30,,Health Partners,Health Partners Care Plans,both,48,,13.774375,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072501,NDC,0.5,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072525,NDC,0.5,ML,30,,Health Partners,Health Partners Care Plans,both,48,,13.774375,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072525,NDC,0.5,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143932001,NDC,1,ML,30,,Health Partners,Health Partners Care Plans,both,48,,5.82,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143932001,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143962201,NDC,1,ML,30,,Health Partners,Health Partners Care Plans,both,48,,5.82,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143962201,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,409226720,NDC,1,ML,30,,Health Partners,Health Partners Care Plans,both,48,,5.82,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,409226720,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,47781058629,NDC,1,ML,30,,Health Partners,Health Partners Care Plans,both,48,,5.82,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,47781058629,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,51991093498,NDC,1,ML,30,,Health Partners,Health Partners Care Plans,both,48,,5.82,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,51991093498,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,409427616,NDC,20,ML,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,409427616,NDC,20,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323048526,NDC,20,ML,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323048526,NDC,20,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,63323049241,NDC,2,ML,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,63323049241,NDC,2,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2% PF 2 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049526,NDC,5,ML,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2% PF 2 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049526,NDC,5,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2% PF 2 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049541,NDC,5,ML,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2% PF 2 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049541,NDC,5,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine buffered 1 % Solution 0.5 mL Syringe,25000000,CDM,250,RC,,,,,,8888800160,NDC,0.5,ML,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine buffered 1 % Solution 0.5 mL Syringe,25000000,CDM,250,RC,,,,,,8888800160,NDC,0.5,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604401,NDC,1,ML,30,,Health Partners,Health Partners Care Plans,both,48,,17.635,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604401,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604425,NDC,1,ML,30,,Health Partners,Health Partners Care Plans,both,48,,17.635,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604425,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620701,NDC,0.25,ML,30,,Health Partners,Health Partners Care Plans,both,48,,17.635,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620701,NDC,0.25,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620725,NDC,1,ML,30,,Health Partners,Health Partners Care Plans,both,48,,17.635,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620725,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
magnesium sulfate 50 % Solution 10 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006404,NDC,2,ML,30,,Health Partners,Health Partners Care Plans,both,48,,14.6175,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
magnesium sulfate 50 % Solution 10 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006404,NDC,2,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,703450284,NDC,2,ML,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.859
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,703450284,NDC,2,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.859
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,409177815,NDC,5,ML,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,409177815,NDC,5,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,70860030005,NDC,1.25,ML,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,70860030005,NDC,1.25,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metroNIDAZOLE 500 MG/100ML Solution 100 mL Plas Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,338954124,NDC,100,ML,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,31.4776
metroNIDAZOLE 500 MG/100ML Solution 100 mL Plas Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,338954124,NDC,100,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,31.4776
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605701,NDC,2,ML,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605701,NDC,2,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605725,NDC,1,ML,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605725,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060031,NDC,2,ML,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060031,NDC,2,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060041,NDC,2,ML,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060041,NDC,2,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 5 MG/ML Solution 1 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606101,NDC,0.2,ML,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 5 MG/ML Solution 1 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606101,NDC,0.2,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230504,NDC,0.5,ML,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230504,NDC,0.5,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230505,NDC,5,ML,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230505,NDC,5,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam PF 10 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230802,NDC,2,ML,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam PF 10 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230802,NDC,2,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,43598052936,NDC,0.5,ML,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,43598052936,NDC,0.5,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080601,NDC,0.5,ML,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080601,NDC,0.5,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080610,NDC,0.5,ML,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080610,NDC,0.5,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,409475503,NDC,2,ML,30,,Health Partners,Health Partners Care Plans,both,48,,3.541052632,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,409475503,NDC,2,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054731,NDC,2,ML,30,,Health Partners,Health Partners Care Plans,both,48,,3.541052632,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054731,NDC,2,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054831,NDC,2,ML,30,,Health Partners,Health Partners Care Plans,both,48,,3.541052632,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054831,NDC,2,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054842,NDC,2,ML,30,,Health Partners,Health Partners Care Plans,both,48,,3.541052632,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054842,NDC,2,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092825,NDC,1,ML,30,,Health Partners,Health Partners Care Plans,both,48,,14.96,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,31.5854
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092825,NDC,1,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,31.5854
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488802,NDC,10,ML,30,,Health Partners,Health Partners Care Plans,both,48,,36.618125,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488802,NDC,10,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018603,NDC,20,ML,30,,Health Partners,Health Partners Care Plans,both,48,,36.618125,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018603,NDC,20,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018620,NDC,20,ML,30,,Health Partners,Health Partners Care Plans,both,48,,36.618125,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018620,NDC,20,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 50 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488850,NDC,3,ML,30,,Health Partners,Health Partners Care Plans,both,48,,36.618125,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 50 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488850,NDC,3,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride bacteriostatic 0.9 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409196602,NDC,30,ML,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride bacteriostatic 0.9 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409196602,NDC,30,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride bacteriostatic 0.9 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409196607,NDC,30,ML,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride bacteriostatic 0.9 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409196607,NDC,30,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,64253002030,NDC,10,ML,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,64253002030,NDC,10,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409488710,NDC,10,ML,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409488710,NDC,10,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409488717,NDC,10,ML,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409488717,NDC,10,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
SUTURE BIOSYN MONOFILAMENT ABSORBABLE UNDYED SIZE 4-0 18IN WITH 3/8 CIRCLE REVERSE CUTTING 19MM NEED,27200000,CDM,272,RC,,,,11987-MAIN,LOCAL,,,,,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE BIOSYN MONOFILAMENT ABSORBABLE UNDYED SIZE 4-0 18IN WITH 3/8 CIRCLE REVERSE CUTTING 19MM NEED,27200000,CDM,272,RC,,,,11987-MAIN,LOCAL,,,,,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE MONOFILAMENT SZ 4-0 BIOSYN ABSORBABLE UNDYED18IN WITH 3/8 CIRCLE REVERSE CUTTING 19MM NEED SM,27200000,CDM,272,RC,,,,11984-MAIN,LOCAL,,,,,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE MONOFILAMENT SZ 4-0 BIOSYN ABSORBABLE UNDYED18IN WITH 3/8 CIRCLE REVERSE CUTTING 19MM NEED SM,27200000,CDM,272,RC,,,,11984-MAIN,LOCAL,,,,,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TRAY LUMBAR 22GAX3.5 PUNCTURE SAFE-T 4306CWSP,120.18,CDM,272,RC,,,,11584-MAIN,LOCAL,,,,,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
TRAY LUMBAR 22GAX3.5 PUNCTURE SAFE-T 4306CWSP,120.18,CDM,272,RC,,,,11584-MAIN,LOCAL,,,,,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
TRAY LUMBAR 22X1.5 PUNCTURE PEDS 4302CSP,120.18,CDM,272,RC,,,,652-MAIN,LOCAL,,,,,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
TRAY LUMBAR 22X1.5 PUNCTURE PEDS 4302CSP,120.18,CDM,272,RC,,,,652-MAIN,LOCAL,,,,,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
triamcinolone acetonide 10 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3049420,NDC,0.25,ML,30,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,72.0986
triamcinolone acetonide 10 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3049420,NDC,0.25,ML,30,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,72.0986
valACYclovir 1 GM Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069701,NDC,0.5,EA,33.58,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,14.40582,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
valproate 100 MG/ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049416,NDC,5,ML,33.61,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,14.41869,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
valproate 100 MG/ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049441,NDC,5,ML,33.61,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,14.41869,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607F,CDM,761,RC,97607,CPT,,,,,,,,455,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,14.42,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.42,459.07
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607P,CDM,983,RC,97607,CPT,,,,,,,,303,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,14.42,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.42,459.07
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601901,NDC,10,ML,211.47,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,14.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.89,14.43
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601901,NDC,10,ML,211.47,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,14.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.89,14.43
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601910,NDC,10,ML,211.47,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,14.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.89,14.43
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601910,NDC,10,ML,211.47,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,14.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.89,14.43
lidocaine 1% PF 1 % Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,63323049227,NDC,2,ML,34.74,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.430996,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
STOCKINETTE IMPERVIOUS 9X36 NON22530,27200000,CDM,272,RC,A6457,HCPCS,,10917-MAIN,LOCAL,,,,,14.73,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,14.4354,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
memantine 10 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,72603011901,NDC,0.5,EA,16.37,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,14.43834,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Ace - Ref,PX8216490,CDM,300,RC,82164,CPT,90,,,,,,,82,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,14.4405,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.16,14.6
"Folic Acid (Folate), Serum",PX82746,CDM,300,RC,82746,CPT,,,,,,,,56,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,14.4405,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.04,14.7
Prealubimin,PX84134,CDM,300,RC,84134,CPT,,,,,,,,80,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,14.4405,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.15,14.59
Basic Metabolic Panel Ca Ion,PX80047,CDM,300,RC,80047,CPT,,,,,,,,17,,First Health,Commercial,both,85,,999999999,percent of total billed charges,14.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.0618,16.66
miconazole 2 % Powder 71 g Bottle,25000000,CDM,250,RC,,,,,,316023125,NDC,71,GR,34.82,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.464228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
meloxicam 7.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,29300012401,NDC,1,EA,17.02,,First Health,Commercial,both,85,,999999999,percent of total billed charges,14.467,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famciclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,93811956,NDC,0.25,EA,17.04,,First Health,Commercial,both,85,,999999999,percent of total billed charges,14.484,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987501,NDC,3,ML,33.77,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,14.48733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
sterile water (preservative free) Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409488724,NDC,50,ML,34.88,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.489152,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409488750,NDC,50,ML,34.88,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.489152,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pregabalin 75 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,71101468,NDC,0.333333333,EA,14.79,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,14.4942,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gadoxetate disodium 0.25 MOL/L Solution 10 mL Vial,A9581,CDM,636,RC,A9581,HCPCS,,,,50419032005,NDC,10,ML,200,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,14.50867,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.97,14.74
STOCKINETTE IMPERVIOUS 12X48 NON22535,27200000,CDM,272,RC,A6457,HCPCS,,10918-MAIN,LOCAL,,,,,16.47,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,14.52654,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,60432006547,NDC,10,ML,34.98,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.530692,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,17478081705,NDC,5,ML,34.99,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.534846,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209F,CDM,510,RC,69209,CPT,,,,,,,,35,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.539,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,53.44
SHOE POST OP X-LARGE MALE DS1016-16,120.237,CDM,274,RC,L3260,HCPCS,,6337-MAIN,LOCAL,,,,,35,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.539,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
"Trimming of Dystrophic Nails, Any Number",PXG0127P,CDM,983,RC,G0127,HCPCS,,,,,,,,35,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.539,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,53.44
Microsomal Antibody,PX7893,CDM,300,RC,86376,CPT,,,,,,,,115,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,14.55,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.11,14.55
lactulose 10 GM/15ML Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,50383077915,NDC,15,ML,15.98,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,14.55778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
memantine 10 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,72603011901,NDC,0.5,EA,16.37,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,14.5693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay Carbamazepine Total,PX80156,CDM,300,RC,80156,CPT,,,,,,,,145,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,14.57,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1196,14.57
Assay of ammonia,PX82140,CDM,300,RC,82140,CPT,,,,,,,,190,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,14.57,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1196,14.57
"BINDER ABDOMINAL 12"" HIGH 30-45INCH 4 PANEL ORT21300SM",120.238,CDM,271,RC,A4467,HCPCS,,11934-MAIN,LOCAL,,,,,16,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,14.576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
DRESSING OPTIFOAM 10X4 POST-OP SILICONE FACED MSC21410Z,120.154,CDM,272,RC,A6213,HCPCS,,8632-MAIN,LOCAL,,,,,16,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,14.576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,15.68
LEGGING PAIR 31X48 STERILE,27200000,CDM,272,RC,,,,10916-MAIN,LOCAL,,,,,16.53,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,14.57946,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Parvovirus Antibody - Ref,PX8674790,CDM,300,RC,86747,CPT,90,,,,,,,92,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,14.58,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.58,15.03
Parvovirus Antibody - Ref,PX8674790,CDM,300,RC,86747,CPT,90,,,,,,,92,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,14.58,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.58,15.03
Parvovirus Antibody - Ref,PX8674790,CDM,300,RC,86747,CPT,90,,,,,,,92,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,14.58,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.58,15.03
BINDER ABDOMINAL S/M 9 INCH UP TO 45 INCHES TRI-PANNEL ABB3P45,120.238,CDM,271,RC,A4467,HCPCS,,47-MAIN,LOCAL,,,,,34,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,14.586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,14.586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,14.586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
"Lab Ige, Isocyan Hdi",PX86003,CDM,300,RC,86003,CPT,90,,,,,,,34,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,14.586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.79,33.32
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323020110,NDC,10,ML,34,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,14.586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Metanephrines - Ref,PX8383590,CDM,300,RC,83835,CPT,90,,,,,,,34,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,14.586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1236,33.32
SPLINT SAM 36INCH ROLLED 661121,120.362,CDM,271,RC,,,,10789-MAIN,LOCAL,,,,,34,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,14.586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1236,33.32
"Venipunc Need Phys Skill,Dx or Rx",PX36410F,CDM,510,RC,36410,CPT,,,,,,,,34,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,14.586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1236,33.32
zinc oxide 20 % Ointment 56.7 g Tube,63700001,CDM,250,RC,,,,,,168006202,NDC,56.7,GR,30.39,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.5872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zinc oxide 20 % Ointment 56.7 g Tube,63700001,CDM,250,RC,,,,,,168006202,NDC,56.7,GR,30.39,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.5872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Prealubimin,PX84134,CDM,300,RC,84134,CPT,,,,,,,,80,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,14.59,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.15,14.59
Thyroglobulin Antibody,PX8680090,CDM,300,RC,86800,CPT,90,,,,,,,68,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,14.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.59,66.64
lidocaine buffered 1 % Solution 22.2 mL Vial,25000000,CDM,250,RC,,,,,,8888800251,NDC,22.2,ML,30.4,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine buffered 1 % Solution 22.2 mL Vial,25000000,CDM,250,RC,,,,,,8888800251,NDC,22.2,ML,30.4,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine buffered 1% Solution 22.2 mL Vial,25000000,CDM,250,RC,,,,,,8888800251,NDC,22.2,ML,30.4,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine buffered 1% Solution 22.2 mL Vial,25000000,CDM,250,RC,,,,,,8888800251,NDC,22.2,ML,30.4,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
doxycycline hyclate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584069311,NDC,0.5,EA,15,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,14.5995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline hyclate 100 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,62584069321,NDC,0.5,EA,15,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,14.5995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Immunoassay - Ref,PX8351690,CDM,300,RC,83516,CPT,90,,,,,,,15,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,14.5995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.231,14.7
"Iontophoresis, Ea 15min",PX97033,CDM,420,RC,97033,CPT,,,,,,,,15,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,14.5995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.231,14.7
Phase II Recovery,PX71000047,CDM,710,RC,,,,,,,,,,15,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,14.5995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.231,14.7
Ace - Ref,PX8216490,CDM,300,RC,82164,CPT,90,,,,,,,82,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,14.6,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.16,14.6
Chorionic gonadotropin test,PX84702,CDM,300,RC,84702,CPT,,,,,,,,210,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,14.6,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.37,15.05
Dx Occult Blood Immunoassay,PX82274,CDM,300,RC,82274,CPT,,,,,,,,105,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,14.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.6,102.9
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342003110,NDC,1,EA,16.56,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,14.60592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Fac/Debridement of Nails, 6 or Mor",PX11721F,CDM,510,RC,11721,CPT,,,,,,,,95,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,14.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.61,92.7
"Fac/Debridement of Nails, 6 or Mor",PX11721F,CDM,510,RC,11721,CPT,,,,,,,,95,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,14.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.61,92.7
"Fac/Debridement of Nails, 6 or Mor",PX11721F,CDM,510,RC,11721,CPT,,,,,,,,95,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,14.61,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.61,92.7
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006403,NDC,2,ML,30.45,,Health Partners,Health Partners Care Plans,both,48,,14.6175,percent of total billed charges,14.616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006403,NDC,2,ML,30.45,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607F,CDM,761,RC,97607,CPT,,,,,,,,455,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,14.62,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.42,459.07
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607F,CDM,761,RC,97607,CPT,,,,,,,,455,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,14.62,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.42,459.07
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607P,CDM,983,RC,97607,CPT,,,,,,,,303,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,14.62,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.42,459.07
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607P,CDM,983,RC,97607,CPT,,,,,,,,303,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,14.62,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.42,459.07
Vitamin B-12,PX82607,CDM,300,RC,82607,CPT,,,,,,,,122,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,14.63,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.63,15.08
Vitamin B-12,PX82607,CDM,300,RC,82607,CPT,,,,,,,,122,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,14.63,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.63,15.08
Vitamin B-12,PX82607,CDM,300,RC,82607,CPT,,,,,,,,122,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,14.63,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.63,15.08
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409317801,NDC,20,ML,34.11,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,14.63319,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409317816,NDC,20,ML,34.11,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,14.63319,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189001,NDC,1,ML,34.11,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,14.63319,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189003,NDC,1,ML,34.11,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,14.63319,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,185012201,NDC,1,EA,17.23,,First Health,Commercial,both,85,,999999999,percent of total billed charges,14.6455,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,49348009529,NDC,15,ML,30.53,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.6544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,49348009529,NDC,15,ML,30.53,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.6544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
STOCKINETTE IMPERVIOUS 12X48 NON22535,27200000,CDM,272,RC,A6457,HCPCS,,10918-MAIN,LOCAL,,,,,16.47,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,14.6583,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
vedolizumab 300 MG Recon Soln 1 Each Vial,J3380.01,CDM,636,RC,J3380,HCPCS,,,,64764030020,NDC,1,EA,12439.04,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,14.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.66,12190.2592
buprenorphine 75 MCG FILM 60 Each Box,63700001,CDM,250,RC,,,,,,59385002160,NDC,1,EA,29.92,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.6608,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buprenorphine 75 MCG FILM 60 Each Box,63700001,CDM,250,RC,,,,,,59385002160,NDC,1,EA,29.92,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.6608,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buprenorphine 75 MCG FILM 60 Each Box,63700001,CDM,250,RC,,,,,,59385002160,NDC,1,EA,29.92,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.6608,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pravastatin 10 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,60505016809,NDC,1,EA,17.26,,First Health,Commercial,both,85,,999999999,percent of total billed charges,14.671,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Ecg 12 Lead, Interp Only",PX93010,CDM,985,RC,93010,CPT,,,,,,,,29,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,14.674,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.0466,28.2257
Microscopic Exam of Urine,PX81015,CDM,300,RC,81015,CPT,,,,,,,,29,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,14.674,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.8,28.42
TRAY ARTHROGRAM SAFE-T-ARTHRO 28-AR1CO,120.2,CDM,272,RC,,,,11499-MAIN,LOCAL,,,,,29,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,14.674,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.0466,194.04
meloxicam 7.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268052511,NDC,1,EA,16.64,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,14.67648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 75 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,59762134601,NDC,0.333333333,EA,15.08,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,14.677364,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010125,NDC,1,ML,30.58,,Health Partners,Health Partners Care Plans,both,48,,14.32944444,percent of total billed charges,14.6784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010125,NDC,1,ML,30.58,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.6784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323048541,NDC,20,ML,30.58,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.6784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323048541,NDC,20,ML,30.58,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.6784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
RESERVOIR SILICONE BULB 100CC,27200000,CDM,272,RC,,,,4400-MAIN,LOCAL,,,,,16.65,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,14.6853,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RESERVOIR WOUND DRAIN 15FR,27200000,CDM,272,RC,,,,4386-MAIN,LOCAL,,,,,30.6,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RESERVOIR WOUND DRAIN 15FR,27200000,CDM,272,RC,,,,4386-MAIN,LOCAL,,,,,30.6,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SET DISPOSABLE COLLECTION,27100000,CDM,271,RC,,,,5439-MAIN,LOCAL,,,,,30.6,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
SET DISPOSABLE COLLECTION,27100000,CDM,271,RC,,,,5439-MAIN,LOCAL,,,,,30.6,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
SUTURE NUROLON 0 BLACK C527D,27200000,CDM,272,RC,,,,10415-MAIN,LOCAL,,,,,30.6,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE NUROLON 0 BLACK C527D,27200000,CDM,272,RC,,,,10415-MAIN,LOCAL,,,,,30.6,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
benzocaine-menthol 20-0.5 % Aerosol 78 g Can,63700001,CDM,250,RC,,,,,,75137085520,NDC,78,GR,35.38,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.696852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
8MM ENDOWRIST INSTRUMENTS MEDIUM LARGE CLIP APPLIER,27200000,CDM,272,RC,,,,11910-MAIN,LOCAL,,,,,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM ENDOWRIST INSTRUMENTS MEDIUM LARGE CLIP APPLIER,27200000,CDM,272,RC,,,,11910-MAIN,LOCAL,,,,,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM ENDOWRIST INSTRUMENTS MEDIUM LARGE CLIP APPLIER,27200000,CDM,272,RC,,,,11910-MAIN,LOCAL,,,,,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.852986,29.4
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,2,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.852986,29.4
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,2,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.852986,29.4
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,3,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.852986,29.4
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,3,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.852986,29.4
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,3,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.852986,29.4
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061603,NDC,3,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061603,NDC,3,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061603,NDC,3,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,641600601,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,641600601,NDC,0.5,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,641600601,NDC,0.5,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
bacteriostatic water(benz alc) Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409397703,NDC,30,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
bacteriostatic water(benz alc) Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409397703,NDC,30,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
bacteriostatic water(benz alc) Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409397703,NDC,30,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BULB RESERVOIR SILICONE 400CC,27200000,CDM,272,RC,,,,12463-MAIN,LOCAL,,,,,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
BULB RESERVOIR SILICONE 400CC,27200000,CDM,272,RC,,,,12463-MAIN,LOCAL,,,,,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
BULB RESERVOIR SILICONE 400CC,27200000,CDM,272,RC,,,,12463-MAIN,LOCAL,,,,,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600710,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,38.9354
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600710,NDC,2,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,38.9354
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600710,NDC,2,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,38.9354
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409115918,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.216692234,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409115918,NDC,1,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409115918,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046401,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.216692234,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046401,NDC,1,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046401,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046402,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.216692234,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046402,NDC,1,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046402,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046437,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.216692234,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046437,NDC,1,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046437,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,409174670,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,409174670,NDC,1,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,409174670,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046801,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046801,NDC,1,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046801,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046817,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046817,NDC,1,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046817,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BUPivacaine in dextrose 0.75-8.25 % Solution 2 mL Ampule,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409176162,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.216692234,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine in dextrose 0.75-8.25 % Solution 2 mL Ampule,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409176162,NDC,2,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine in dextrose 0.75-8.25 % Solution 2 mL Ampule,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409176162,NDC,2,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046601,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.216692234,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046601,NDC,1,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046601,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143992490,NDC,0.5,EA,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,7.351730769,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143992490,NDC,0.5,EA,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143992490,NDC,0.5,EA,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010110,NDC,0.5,EA,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,7.351730769,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010110,NDC,0.5,EA,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010110,NDC,0.5,EA,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010167,NDC,0.5,EA,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,7.351730769,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010167,NDC,0.5,EA,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010167,NDC,0.5,EA,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,44567070725,NDC,0.5,EA,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,7.351730769,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,44567070725,NDC,0.5,EA,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,44567070725,NDC,0.5,EA,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733201,NDC,0.5,EA,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,9.983703704,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733201,NDC,0.5,EA,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733201,NDC,0.5,EA,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,3.9675,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733801,NDC,0.5,EA,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,9.983703704,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733801,NDC,0.5,EA,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733801,NDC,0.5,EA,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,3.9675,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,70069000501,NDC,0.1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,63.2394
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,70069000501,NDC,0.1,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,63.2394
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,70069000501,NDC,0.1,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,63.2394
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016502,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1.136465517,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016502,NDC,0.5,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016502,NDC,0.5,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,1.675,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016516,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1.136465517,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016516,NDC,0.5,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016516,NDC,0.5,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,1.675,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036721,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1.136465517,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036721,NDC,1,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036721,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,1.675,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036725,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1.136465517,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036725,NDC,1,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036725,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,1.675,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 100 MG/10ML Solution 10 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323051610,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1.136465517,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 100 MG/10ML Solution 10 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323051610,NDC,0.5,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 100 MG/10ML Solution 10 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323051610,NDC,0.5,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,1.675,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050641,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1.136465517,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050641,NDC,0.5,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050641,NDC,0.5,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,1.675,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141031,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141031,NDC,0.5,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141031,NDC,0.5,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,641037621,NDC,0.25,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,12.09333333,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,641037621,NDC,0.25,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,641037621,NDC,0.25,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,15.9,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066416,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,12.09333333,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066416,NDC,1,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066416,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,15.9,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066441,NDC,0.25,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,12.09333333,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066441,NDC,0.25,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066441,NDC,0.25,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,15.9,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010101,NDC,0.25,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,12.09333333,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010101,NDC,0.25,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010101,NDC,0.25,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,15.9,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
doxycycline hyclate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584069311,NDC,0.5,EA,15,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline hyclate 100 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,62584069321,NDC,0.5,EA,15,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DRAPE SPLIT WITH ADHESIVE DYNJP8304A,27200000,CDM,272,RC,,,,4694-MAIN,LOCAL,,,,,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRAPE SPLIT WITH ADHESIVE DYNJP8304A,27200000,CDM,272,RC,,,,4694-MAIN,LOCAL,,,,,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRAPE SPLIT WITH ADHESIVE DYNJP8304A,27200000,CDM,272,RC,,,,4694-MAIN,LOCAL,,,,,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRESSING HYDROFERA 2-1/2X2-1/2  BLUE READY FOAM HBRS2520,120.488,CDM,271,RC,A6209,HCPCS,,11537-MAIN,LOCAL,,,,,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
DRESSING HYDROFERA 2-1/2X2-1/2  BLUE READY FOAM HBRS2520,120.488,CDM,271,RC,A6209,HCPCS,,11537-MAIN,LOCAL,,,,,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
DRESSING HYDROFERA 2-1/2X2-1/2  BLUE READY FOAM HBRS2520,120.488,CDM,271,RC,A6209,HCPCS,,11537-MAIN,LOCAL,,,,,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
"Ethanol, P",PX82077,CDM,300,RC,82077,CPT,,,,,,,,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
"Ethanol, P",PX82077,CDM,300,RC,82077,CPT,,,,,,,,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
"Ethanol, P",PX82077,CDM,300,RC,82077,CPT,,,,,,,,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073916,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,29.4
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073916,NDC,2,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,29.4
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073916,NDC,2,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,29.4
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073941,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,29.4
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073941,NDC,1,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,29.4
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073941,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,29.4
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,67457043300,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,29.4
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,67457043300,NDC,1,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,29.4
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,67457043300,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,29.4
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,6.215714286,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909422,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,6.215714286,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909422,NDC,2,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909422,NDC,2,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,6.215714286,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
"Folic Acid (Folate), Serum",PX82746,CDM,300,RC,82746,CPT,,,,,,,,56,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,14.7,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.04,14.7
folic acid 5 MG/ML Solution 10 mL Vial,J3490.94,CDM,636,RC,J3490,HCPCS,,,,39822110001,NDC,0.2,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,12.9192,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,330.2012
folic acid 5 MG/ML Solution 10 mL Vial,J3490.94,CDM,636,RC,J3490,HCPCS,,,,39822110001,NDC,0.2,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,330.2012
folic acid 5 MG/ML Solution 10 mL Vial,J3490.94,CDM,636,RC,J3490,HCPCS,,,,39822110001,NDC,0.2,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,330.2012
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,70860030242,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,7.169534884,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,70860030242,NDC,1,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,70860030242,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,36000028425,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,7.169534884,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,36000028425,NDC,2,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,36000028425,NDC,2,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001094,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,42.5516
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001094,NDC,2,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,42.5516
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001094,NDC,2,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,42.5516
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,781382571,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,781382571,NDC,0.5,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,781382571,NDC,0.5,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,143931901,NDC,0.4,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,4.21,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.428
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,143931901,NDC,0.4,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.428
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,143931901,NDC,0.4,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.428
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272002,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.717962963,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272002,NDC,1,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272002,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272031,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.717962963,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272031,NDC,1,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272031,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,25021040010,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.717962963,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,25021040010,NDC,1,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,25021040010,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323054011,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.717962963,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323054011,NDC,1,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323054011,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095300,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.717962963,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095300,NDC,0.5,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095300,NDC,0.5,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095310,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.717962963,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095310,NDC,1,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095310,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,71288042095,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.717962963,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,71288042095,NDC,0.5,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,71288042095,NDC,0.5,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306424,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.115241667,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306424,NDC,1,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306424,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306413,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.115241667,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306413,NDC,1,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306413,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306521,NDC,3,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.115241667,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306521,NDC,3,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306521,NDC,3,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin lock flush 10 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306510,NDC,5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.115241667,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin lock flush 10 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306510,NDC,5,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin lock flush 10 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306510,NDC,5,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
HYDROmorphone 1 MG/ML Solution 1 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,76045000901,NDC,0.25,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,10.0725,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
HYDROmorphone 1 MG/ML Solution 1 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,76045000901,NDC,0.25,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
HYDROmorphone 1 MG/ML Solution 1 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,76045000901,NDC,0.25,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
Immunoassay - Ref,PX8351690,CDM,300,RC,83516,CPT,90,,,,,,,15,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.231,14.7
"Iontophoresis, Ea 15min",PX97033,CDM,420,RC,97033,CPT,,,,,,,,15,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.231,14.7
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016216,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,6.702727273,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016216,NDC,1,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016216,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016243,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,6.702727273,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016243,NDC,0.5,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016243,NDC,0.5,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072201,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,6.702727273,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072201,NDC,0.5,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072201,NDC,0.5,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072225,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,6.702727273,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072225,NDC,0.5,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072225,NDC,0.5,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016226,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,6.702727273,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016226,NDC,0.5,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016226,NDC,0.5,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016245,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,6.702727273,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016245,NDC,0.5,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016245,NDC,0.5,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011901,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,6.702727273,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011901,NDC,0.5,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011901,NDC,0.5,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011925,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,6.702727273,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011925,NDC,0.5,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011925,NDC,0.5,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072501,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,6.702727273,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072501,NDC,0.5,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072501,NDC,0.5,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072525,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,6.702727273,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072525,NDC,0.5,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072525,NDC,0.5,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143932001,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.989787234,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143932001,NDC,1,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143932001,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143962201,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.989787234,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143962201,NDC,1,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143962201,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,409226720,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.989787234,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,409226720,NDC,1,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,409226720,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,47781058629,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.989787234,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,47781058629,NDC,1,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,47781058629,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,51991093498,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.989787234,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,51991093498,NDC,1,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,51991093498,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,409427616,NDC,20,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,409427616,NDC,20,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,409427616,NDC,20,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323048526,NDC,20,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323048526,NDC,20,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323048526,NDC,20,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,63323049241,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,63323049241,NDC,2,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,63323049241,NDC,2,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2% PF 2 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049526,NDC,5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2% PF 2 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049526,NDC,5,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2% PF 2 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049526,NDC,5,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2% PF 2 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049541,NDC,5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2% PF 2 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049541,NDC,5,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2% PF 2 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049541,NDC,5,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine buffered 1 % Solution 0.5 mL Syringe,25000000,CDM,250,RC,,,,,,8888800160,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine buffered 1 % Solution 0.5 mL Syringe,25000000,CDM,250,RC,,,,,,8888800160,NDC,0.5,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine buffered 1 % Solution 0.5 mL Syringe,25000000,CDM,250,RC,,,,,,8888800160,NDC,0.5,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604401,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,4.035,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604401,NDC,1,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604401,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604425,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,4.035,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604425,NDC,1,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604425,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620701,NDC,0.25,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,4.035,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620701,NDC,0.25,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620701,NDC,0.25,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620725,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,4.035,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620725,NDC,1,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620725,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
magnesium sulfate 50 % Solution 10 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006404,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,5.851071429,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
magnesium sulfate 50 % Solution 10 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006404,NDC,2,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
magnesium sulfate 50 % Solution 10 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006404,NDC,2,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,13.925,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,703450284,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.859
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,703450284,NDC,2,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.859
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,703450284,NDC,2,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.859
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,409177815,NDC,5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,409177815,NDC,5,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,409177815,NDC,5,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,70860030005,NDC,1.25,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,70860030005,NDC,1.25,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,70860030005,NDC,1.25,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metroNIDAZOLE 500 MG/100ML Solution 100 mL Plas Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,338954124,NDC,100,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,31.4776
metroNIDAZOLE 500 MG/100ML Solution 100 mL Plas Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,338954124,NDC,100,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,31.4776
metroNIDAZOLE 500 MG/100ML Solution 100 mL Plas Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,338954124,NDC,100,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,31.4776
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605701,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,3,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605701,NDC,2,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605701,NDC,2,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605725,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,3,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605725,NDC,1,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605725,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060031,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,3,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060031,NDC,2,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060031,NDC,2,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060041,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,3,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060041,NDC,2,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060041,NDC,2,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 5 MG/ML Solution 1 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606101,NDC,0.2,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,3,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 5 MG/ML Solution 1 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606101,NDC,0.2,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 5 MG/ML Solution 1 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606101,NDC,0.2,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230504,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,3,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230504,NDC,0.5,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230504,NDC,0.5,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230505,NDC,5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,3,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230505,NDC,5,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230505,NDC,5,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam PF 10 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230802,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,3,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam PF 10 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230802,NDC,2,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam PF 10 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230802,NDC,2,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,43598052936,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,43598052936,NDC,0.5,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,43598052936,NDC,0.5,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080601,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080601,NDC,0.5,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080601,NDC,0.5,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080610,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080610,NDC,0.5,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080610,NDC,0.5,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,409475503,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1.8942,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,409475503,NDC,2,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,409475503,NDC,2,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054731,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1.8942,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054731,NDC,2,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054731,NDC,2,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054831,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1.8942,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054831,NDC,2,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054831,NDC,2,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054842,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1.8942,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054842,NDC,2,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054842,NDC,2,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
Phase II Recovery,PX71000047,CDM,710,RC,,,,,,,,,,15,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.231,14.7
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092825,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,31.5854
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092825,NDC,1,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,31.5854
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092825,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,31.5854
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488802,NDC,10,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,14.79337121,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488802,NDC,10,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488802,NDC,10,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,25.20333333,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018603,NDC,20,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,14.79337121,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018603,NDC,20,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018603,NDC,20,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,25.20333333,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018620,NDC,20,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,14.79337121,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018620,NDC,20,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018620,NDC,20,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,25.20333333,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 50 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488850,NDC,3,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,14.79337121,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 50 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488850,NDC,3,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 50 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488850,NDC,3,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,25.20333333,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride bacteriostatic 0.9 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409196602,NDC,30,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride bacteriostatic 0.9 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409196602,NDC,30,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride bacteriostatic 0.9 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409196602,NDC,30,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride bacteriostatic 0.9 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409196607,NDC,30,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride bacteriostatic 0.9 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409196607,NDC,30,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride bacteriostatic 0.9 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409196607,NDC,30,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,64253002030,NDC,10,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,64253002030,NDC,10,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,64253002030,NDC,10,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409488710,NDC,10,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409488710,NDC,10,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409488710,NDC,10,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409488717,NDC,10,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409488717,NDC,10,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409488717,NDC,10,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
SUTURE BIOSYN MONOFILAMENT ABSORBABLE UNDYED SIZE 4-0 18IN WITH 3/8 CIRCLE REVERSE CUTTING 19MM NEED,27200000,CDM,272,RC,,,,11987-MAIN,LOCAL,,,,,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE BIOSYN MONOFILAMENT ABSORBABLE UNDYED SIZE 4-0 18IN WITH 3/8 CIRCLE REVERSE CUTTING 19MM NEED,27200000,CDM,272,RC,,,,11987-MAIN,LOCAL,,,,,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE BIOSYN MONOFILAMENT ABSORBABLE UNDYED SIZE 4-0 18IN WITH 3/8 CIRCLE REVERSE CUTTING 19MM NEED,27200000,CDM,272,RC,,,,11987-MAIN,LOCAL,,,,,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE MONOFILAMENT SZ 4-0 BIOSYN ABSORBABLE UNDYED18IN WITH 3/8 CIRCLE REVERSE CUTTING 19MM NEED SM,27200000,CDM,272,RC,,,,11984-MAIN,LOCAL,,,,,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE MONOFILAMENT SZ 4-0 BIOSYN ABSORBABLE UNDYED18IN WITH 3/8 CIRCLE REVERSE CUTTING 19MM NEED SM,27200000,CDM,272,RC,,,,11984-MAIN,LOCAL,,,,,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE MONOFILAMENT SZ 4-0 BIOSYN ABSORBABLE UNDYED18IN WITH 3/8 CIRCLE REVERSE CUTTING 19MM NEED SM,27200000,CDM,272,RC,,,,11984-MAIN,LOCAL,,,,,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TRAY LUMBAR 22GAX3.5 PUNCTURE SAFE-T 4306CWSP,120.18,CDM,272,RC,,,,11584-MAIN,LOCAL,,,,,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
TRAY LUMBAR 22GAX3.5 PUNCTURE SAFE-T 4306CWSP,120.18,CDM,272,RC,,,,11584-MAIN,LOCAL,,,,,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
TRAY LUMBAR 22GAX3.5 PUNCTURE SAFE-T 4306CWSP,120.18,CDM,272,RC,,,,11584-MAIN,LOCAL,,,,,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
TRAY LUMBAR 22X1.5 PUNCTURE PEDS 4302CSP,120.18,CDM,272,RC,,,,652-MAIN,LOCAL,,,,,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
TRAY LUMBAR 22X1.5 PUNCTURE PEDS 4302CSP,120.18,CDM,272,RC,,,,652-MAIN,LOCAL,,,,,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
TRAY LUMBAR 22X1.5 PUNCTURE PEDS 4302CSP,120.18,CDM,272,RC,,,,652-MAIN,LOCAL,,,,,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
triamcinolone acetonide 10 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3049420,NDC,0.25,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,3.733333333,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,72.0986
triamcinolone acetonide 10 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3049420,NDC,0.25,ML,30,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,72.0986
triamcinolone acetonide 10 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3049420,NDC,0.25,ML,30,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,72.0986
LEGGING PAIR 31X48 STERILE,27200000,CDM,272,RC,,,,10916-MAIN,LOCAL,,,,,16.53,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,14.7117,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
miconazole 2 % Powder 85 g Bottle,25000000,CDM,250,RC,,,,,,67094930,NDC,85,GR,35.43,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.717622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Thyroglobulin - Ref,PX8443290,CDM,300,RC,84432,CPT,90,,,,,,,68,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,14.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.73,66.64
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342003110,NDC,1,EA,16.56,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,14.7384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gadoxetate disodium 0.25 MOL/L Solution 10 mL Vial,A9581,CDM,636,RC,A9581,HCPCS,,,,50419032005,NDC,10,ML,200,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,14.74,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.97,14.74
gadoxetate disodium 0.25 MOL/L Solution 10 mL Vial,A9581,CDM,636,RC,A9581,HCPCS,,,,50419032005,NDC,10,ML,200,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,14.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.97,14.74
gadoxetate disodium 0.25 MOL/L Solution 10 mL Vial,A9581,CDM,636,RC,A9581,HCPCS,,,,50419032005,NDC,10,ML,200,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,14.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.97,14.74
DRAPE SHEET LAP T-DRAPE WITH INSTRUMENT PAD DYNJP3003,27200000,CDM,272,RC,,,,10913-MAIN,LOCAL,,,,,35.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.7467,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,36000003310,NDC,5,ML,30.74,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.7552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,36000003310,NDC,5,ML,30.74,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.7552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Chorionic gonadotropin test,PX84702,CDM,300,RC,84702,CPT,,,,,,,,210,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,14.7614,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.37,15.05
Parvovirus Antibody - Ref,PX8674790,CDM,300,RC,86747,CPT,90,,,,,,,92,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,14.7614,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.58,15.03
Vitamin B-12,PX82607,CDM,300,RC,82607,CPT,,,,,,,,122,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,14.7614,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.63,15.08
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,641601301,NDC,5,ML,34.41,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,14.76189,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Each Add'l Sequential Push New Drug,PX96375,CDM,260,RC,96375,CPT,,,,,,,,130,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,14.766,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.81,26.76
famciclovir 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714030401,NDC,1,EA,34.42,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,14.76618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 75 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,59762134601,NDC,0.333333333,EA,15.08,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,14.7784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120301,NDC,0.5,ML,34.45,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,14.77905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120311,NDC,0.5,ML,34.45,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,14.77905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68382019616,NDC,1,EA,17.4,,First Health,Commercial,both,85,,999999999,percent of total billed charges,14.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
riFAMpin 150 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,527139330,NDC,1,EA,17.41,,First Health,Commercial,both,85,,999999999,percent of total billed charges,14.7985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
riFAMpin 150 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,68180065806,NDC,1,EA,17.41,,First Health,Commercial,both,85,,999999999,percent of total billed charges,14.7985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
finasteride 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862014930,NDC,1,EA,16.79,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,14.80878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
meloxicam 7.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268052511,NDC,1,EA,16.64,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,14.8096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buprenorphine 75 MCG FILM 60 Each Box,63700001,CDM,250,RC,,,,,,59385002160,NDC,1,EA,29.92,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.8104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
RESERVOIR SILICONE BULB 100CC,27200000,CDM,272,RC,,,,4400-MAIN,LOCAL,,,,,16.65,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,14.8185,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
buprenorphine 75 MCG FILM 1 Each Package,63700001,CDM,250,RC,,,,,,59385002101,NDC,1,EA,35.68,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.821472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016501,NDC,1,ML,34.55,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,14.82195,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049226,NDC,30,ML,34.55,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,14.82195,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049245,NDC,30,ML,34.55,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,14.82195,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,23155024031,NDC,2,ML,34.55,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,14.82195,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.859
"Ebv, Nuclear Antigen - Ref",PX8666490,CDM,300,RC,86664,CPT,90,,,,,,,58,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,14.83,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.83,15.29
"Ebv, Nuclear Antigen - Ref",PX8666490,CDM,300,RC,86664,CPT,90,,,,,,,58,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,14.83,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.83,15.29
"Ebv, Nuclear Antigen - Ref",PX8666490,CDM,300,RC,86664,CPT,90,,,,,,,58,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,14.83,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.83,15.29
Epstein-barr antibody,PX86664,CDM,300,RC,86664,CPT,,,,,,,,72,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,14.83,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.83,15.29
Epstein-barr antibody,PX86664,CDM,300,RC,86664,CPT,,,,,,,,72,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,14.83,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.83,15.29
Epstein-barr antibody,PX86664,CDM,300,RC,86664,CPT,,,,,,,,72,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,14.83,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.83,15.29
Xray Facial Bones Less Than 3 Vws,PX7014001,CDM,320,RC,70140,CPT,TC,,,,,,,301,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,14.83,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.83,44.7
Xray Facial Bones Less Than 3 Vws,PX7014001,CDM,320,RC,70140,CPT,TC,,,,,,,301,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,14.83,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.83,44.7
Xray Facial Bones Less Than 3 Vws,PX7014001,CDM,320,RC,70140,CPT,TC,,,,,,,301,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,14.83,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.83,44.7
"Xray Neck, Soft Tissue",PX7036001,CDM,320,RC,70360,CPT,TC,,,,,,,277,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,14.83,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.83,44.7
"Xray Neck, Soft Tissue",PX7036001,CDM,320,RC,70360,CPT,TC,,,,,,,277,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,14.83,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.83,44.7
amoxicillin 250 MG/5ML Recon Susp 150 mL Package,63700001,CDM,250,RC,,,,,,99998805601,NDC,5,ML,15.24,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,14.833092,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Beta-2-Microglobulin - Ref,PX8223290,CDM,300,RC,82232,CPT,90,,,,,,,49,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,14.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.84,48.02
Legionella Antibody - Ref,PX8671390,CDM,300,RC,86713,CPT,90,,,,,,,71,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,14.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.84,15.3
Legionella Antibody - Ref,PX8671390,CDM,300,RC,86713,CPT,90,,,,,,,71,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,14.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.84,15.3
Legionella Antibody - Ref,PX8671390,CDM,300,RC,86713,CPT,90,,,,,,,71,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,14.84,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.84,15.3
Phenobarbital Assay - Ref,PX8018490,CDM,300,RC,80184,CPT,90,,,,,,,20,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,14.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.84,15.3
Phenobarbital Assay - Ref,PX8018490,CDM,300,RC,80184,CPT,90,,,,,,,20,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,14.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.84,15.3
Phenobarbital Assay - Ref,PX8018490,CDM,300,RC,80184,CPT,90,,,,,,,20,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,14.84,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.84,15.3
8MM ENDOWRIST INSTRUMENTS MEDIUM LARGE CLIP APPLIER,27200000,CDM,272,RC,,,,11910-MAIN,LOCAL,,,,,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,2,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.852986,29.4
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,3,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.852986,29.4
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061603,NDC,3,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,641600601,NDC,0.5,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
bacteriostatic water(benz alc) Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409397703,NDC,30,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BULB RESERVOIR SILICONE 400CC,27200000,CDM,272,RC,,,,12463-MAIN,LOCAL,,,,,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600710,NDC,2,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,38.9354
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409115918,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046401,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046402,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046437,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,409174670,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046801,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046817,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BUPivacaine in dextrose 0.75-8.25 % Solution 2 mL Ampule,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409176162,NDC,2,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046601,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143992490,NDC,0.5,EA,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010110,NDC,0.5,EA,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010167,NDC,0.5,EA,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,44567070725,NDC,0.5,EA,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733201,NDC,0.5,EA,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733801,NDC,0.5,EA,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,70069000501,NDC,0.1,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,63.2394
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016502,NDC,0.5,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016516,NDC,0.5,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036721,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036725,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 100 MG/10ML Solution 10 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323051610,NDC,0.5,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050641,NDC,0.5,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141031,NDC,0.5,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,641037621,NDC,0.25,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066416,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066441,NDC,0.25,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010101,NDC,0.25,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
DRAPE SPLIT WITH ADHESIVE DYNJP8304A,27200000,CDM,272,RC,,,,4694-MAIN,LOCAL,,,,,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRESSING HYDROFERA 2-1/2X2-1/2  BLUE READY FOAM HBRS2520,120.488,CDM,271,RC,A6209,HCPCS,,11537-MAIN,LOCAL,,,,,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
"Ethanol, P",PX82077,CDM,300,RC,82077,CPT,,,,,,,,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073916,NDC,2,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,29.4
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073941,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,29.4
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,67457043300,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,29.4
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909422,NDC,2,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
folic acid 5 MG/ML Solution 10 mL Vial,J3490.94,CDM,636,RC,J3490,HCPCS,,,,39822110001,NDC,0.2,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,330.2012
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,70860030242,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,36000028425,NDC,2,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001094,NDC,2,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,42.5516
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,781382571,NDC,0.5,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,143931901,NDC,0.4,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.428
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272002,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272031,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,25021040010,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323054011,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095300,NDC,0.5,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095310,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,71288042095,NDC,0.5,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306424,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306413,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306521,NDC,3,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin lock flush 10 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306510,NDC,5,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
HYDROmorphone 1 MG/ML Solution 1 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,76045000901,NDC,0.25,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016216,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016243,NDC,0.5,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072201,NDC,0.5,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072225,NDC,0.5,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016226,NDC,0.5,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016245,NDC,0.5,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011901,NDC,0.5,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011925,NDC,0.5,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072501,NDC,0.5,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072525,NDC,0.5,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143932001,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143962201,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,409226720,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,47781058629,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,51991093498,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,409427616,NDC,20,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323048526,NDC,20,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,63323049241,NDC,2,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2% PF 2 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049526,NDC,5,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2% PF 2 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049541,NDC,5,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine buffered 1 % Solution 0.5 mL Syringe,25000000,CDM,250,RC,,,,,,8888800160,NDC,0.5,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604401,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604425,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620701,NDC,0.25,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620725,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
magnesium sulfate 50 % Solution 10 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006404,NDC,2,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,703450284,NDC,2,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.859
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,409177815,NDC,5,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,70860030005,NDC,1.25,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metroNIDAZOLE 500 MG/100ML Solution 100 mL Plas Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,338954124,NDC,100,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,31.4776
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605701,NDC,2,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605725,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060031,NDC,2,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060041,NDC,2,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 5 MG/ML Solution 1 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606101,NDC,0.2,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230504,NDC,0.5,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230505,NDC,5,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam PF 10 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230802,NDC,2,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,43598052936,NDC,0.5,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080601,NDC,0.5,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080610,NDC,0.5,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,409475503,NDC,2,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054731,NDC,2,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054831,NDC,2,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054842,NDC,2,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092825,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,31.5854
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488802,NDC,10,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,2.714444444,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018603,NDC,20,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,2.714444444,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018620,NDC,20,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,2.714444444,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 50 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488850,NDC,3,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,2.714444444,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride bacteriostatic 0.9 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409196602,NDC,30,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride bacteriostatic 0.9 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409196607,NDC,30,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,64253002030,NDC,10,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409488710,NDC,10,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409488717,NDC,10,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
SUTURE BIOSYN MONOFILAMENT ABSORBABLE UNDYED SIZE 4-0 18IN WITH 3/8 CIRCLE REVERSE CUTTING 19MM NEED,27200000,CDM,272,RC,,,,11987-MAIN,LOCAL,,,,,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE MONOFILAMENT SZ 4-0 BIOSYN ABSORBABLE UNDYED18IN WITH 3/8 CIRCLE REVERSE CUTTING 19MM NEED SM,27200000,CDM,272,RC,,,,11984-MAIN,LOCAL,,,,,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TRAY LUMBAR 22GAX3.5 PUNCTURE SAFE-T 4306CWSP,120.18,CDM,272,RC,,,,11584-MAIN,LOCAL,,,,,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
TRAY LUMBAR 22X1.5 PUNCTURE PEDS 4302CSP,120.18,CDM,272,RC,,,,652-MAIN,LOCAL,,,,,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
triamcinolone acetonide 10 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3049420,NDC,0.25,ML,30,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,72.0986
Leptospira Antibody - Ref,PX8672090,CDM,300,RC,86720,CPT,90,,,,,,,220,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,14.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.85,215.6
Apc Resistance Assay - Ref,PX8530790,CDM,300,RC,85307,CPT,90,,,,,,,390,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,14.86,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.86,15.32
Apc Resistance Assay - Ref,PX8530790,CDM,300,RC,85307,CPT,90,,,,,,,390,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,14.86,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.86,15.32
"Protein S, Free - Ref",PX8530690,CDM,300,RC,85306,CPT,90,,,,,,,47,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,14.86,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.86,15.32
"Protein S, Free - Ref",PX8530690,CDM,300,RC,85306,CPT,90,,,,,,,47,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,14.86,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.86,15.32
Apc Resistance Assay - Ref,PX8530790,CDM,300,RC,85307,CPT,90,,,,,,,390,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,14.86,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.86,15.32
"Protein S, Free - Ref",PX8530690,CDM,300,RC,85306,CPT,90,,,,,,,47,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,14.86,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.86,15.32
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057811,NDC,0.5,ML,30.98,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.8704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057811,NDC,0.5,ML,30.98,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.8704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057841,NDC,0.5,ML,30.98,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.8704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057841,NDC,0.5,ML,30.98,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.8704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
DRAPE ABDOMINAL SURGICAL 14X12 POUCHES STERILE DYNJP3109,27200000,CDM,272,RC,,,,12896-MAIN,LOCAL,,,,,31,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRAPE ABDOMINAL SURGICAL 14X12 POUCHES STERILE DYNJP3109,27200000,CDM,272,RC,,,,12896-MAIN,LOCAL,,,,,31,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LITHOTOMY PACK VIII ECLIPSE,27200000,CDM,272,RC,,,,12210-MAIN,LOCAL,,,,,31,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LITHOTOMY PACK VIII ECLIPSE,27200000,CDM,272,RC,,,,12210-MAIN,LOCAL,,,,,31,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Rubella Antibody,PX86762,CDM,300,RC,86762,CPT,,,,,,,,31,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.8774,30.38
Rubella Antibody,PX86762,CDM,300,RC,86762,CPT,,,,,,,,31,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.8774,30.38
zinc oxide 20 % Ointment 56.7 g Tube,63700001,CDM,250,RC,,,,,,168006202,NDC,56.7,GR,30.39,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.8911,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zinc oxide 20 % Ointment 56.7 g Tube,63700001,CDM,250,RC,,,,,,168006202,NDC,56.7,GR,30.39,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.8911,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zinc oxide 20 % Ointment 56.7 g Tube,63700001,CDM,250,RC,,,,,,168006202,NDC,56.7,GR,30.39,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.8911,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,49348014446,NDC,1,EA,15.3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,14.89149,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine buffered 1 % Solution 22.2 mL Vial,25000000,CDM,250,RC,,,,,,8888800251,NDC,22.2,ML,30.4,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine buffered 1 % Solution 22.2 mL Vial,25000000,CDM,250,RC,,,,,,8888800251,NDC,22.2,ML,30.4,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine buffered 1 % Solution 22.2 mL Vial,25000000,CDM,250,RC,,,,,,8888800251,NDC,22.2,ML,30.4,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine buffered 1% Solution 22.2 mL Vial,25000000,CDM,250,RC,,,,,,8888800251,NDC,22.2,ML,30.4,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine buffered 1% Solution 22.2 mL Vial,25000000,CDM,250,RC,,,,,,8888800251,NDC,22.2,ML,30.4,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine buffered 1% Solution 22.2 mL Vial,25000000,CDM,250,RC,,,,,,8888800251,NDC,22.2,ML,30.4,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026994,NDC,20,ML,35.87,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.900398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
lidocaine 1% PF 1 % Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,63323049227,NDC,2,ML,34.74,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,14.90346,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"CUFF STERILE DISPOSABLE SPSB  STERILE 18""",27200000,CDM,272,RC,,,,7436-MAIN,LOCAL,,,,,35.89,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.908706,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
memantine 10 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,72603011901,NDC,0.5,EA,16.37,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,14.91307,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006403,NDC,2,ML,30.45,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,5.851071429,percent of total billed charges,14.9205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006403,NDC,2,ML,30.45,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.9205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006403,NDC,2,ML,30.45,,United Healthcare,All Medicare advantage plans,outpatient,49,,13.925,percent of total billed charges,14.9205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
saliva substitute Solution 59 mL Bottle,63700001,CDM,250,RC,,,,,,50930009802,NDC,59,ML,31.1,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,14.928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
saliva substitute Solution 59 mL Bottle,63700001,CDM,250,RC,,,,,,50930009802,NDC,59,ML,31.1,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,409677802,NDC,1,ML,31.11,,Health Partners,Health Partners Care Plans,both,48,,17.635,percent of total billed charges,14.9328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,409677802,NDC,1,ML,31.11,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,14.9328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
amoxicillin 250 MG/5ML Recon Susp 150 mL Package,63700001,CDM,250,RC,,,,,,99998805601,NDC,5,ML,15.24,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,14.9352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
miconazole 2 % Powder 71 g Bottle,25000000,CDM,250,RC,,,,,,316023125,NDC,71,GR,34.82,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,14.93778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
nitroglycerin 2 % Ointment 1 g Packet,63700001,CDM,250,RC,,,,,,281032608,NDC,1,GR,17.58,,First Health,Commercial,both,85,,999999999,percent of total billed charges,14.943,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
finasteride 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862014930,NDC,1,EA,16.79,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,14.9431,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clotrimazole 1 % Cream 28 g Tube,25000000,CDM,250,RC,,,,,,536127222,NDC,28,GR,15.36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,14.949888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Cortisol, Am",PX7152,CDM,300,RC,82533,CPT,,,,,,,,156,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,14.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.95,152.88
Total Cortisol,PX82533,CDM,300,RC,82533,CPT,,,,,,,,137,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,14.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.95,134.26
Anes Dx Shoulder Arthroscopy,PX01622.01,CDM,964,RC,1622,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Lower Intestinal Endoscopic Px Nos,PX00811.01,CDM,964,RC,811,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Lower Intestinal Screening Colonoscopy,PX00812.01,CDM,964,RC,812,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Spine Transthor W/Vent,PX00626.01,CDM,964,RC,626,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Spine Tranthor W/O Vent,PX00625.01,CDM,964,RC,625,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Ther Interven Rad Art,PX01924.01,CDM,964,RC,1924,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Ther Interven Rad Car,PX01925.01,CDM,964,RC,1925,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Ther Interven Rad Tip,PX01931.01,CDM,964,RC,1931,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Ther Interven Rad Vei,PX01930.01,CDM,964,RC,1930,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Tx Interv Rad Cran V,PX01933.01,CDM,964,RC,1933,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Tx Interv Rad Hrt/Cran,PX01926.01,CDM,964,RC,1926,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Tx Interv Rad Th Vein,PX01932.01,CDM,964,RC,1932,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Upper GI Endoscopic Px Ercp,PX00732.01,CDM,964,RC,732,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Upper GI Endoscopic Px Nos,PX00731.01,CDM,964,RC,731,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Upper/Lower GI Endoscopic Px,PX00813.01,CDM,964,RC,813,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes/Analg Cs Deliver Add-On,PX01968.01,CDM,964,RC,1968,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Abdomen Vessel Surg,PX00880.01,CDM,964,RC,880,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Abdominal Wall Surg,PX00700.01,CDM,964,RC,700,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Abdominal Wall Surg,PX00730.01,CDM,964,RC,730,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Abdominal Wall Surg,PX00800.01,CDM,964,RC,800,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Abdominal Wall Surg,PX00820.01,CDM,964,RC,820,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Achilles Tendon Surg,PX01472.01,CDM,964,RC,1472,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Airplane Cast,PX01682.01,CDM,964,RC,1682,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Amniocentesis,PX00842.01,CDM,964,RC,842,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Amputation at Knee,PX01404.01,CDM,964,RC,1404,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Amputation at Pelvis,PX01140.01,CDM,964,RC,1140,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Amputation of Femur,PX01232.01,CDM,964,RC,1232,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Amputation of Penis,PX00932.01,CDM,964,RC,932,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Ankle Replacement,PX01486.01,CDM,964,RC,1486,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Ankle/Ft Arthroscopy,PX01464.01,CDM,964,RC,1464,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Anorectal Surgery,PX00902.01,CDM,964,RC,902,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Antepartum Manipul,PX01958.01,CDM,964,RC,1958,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Arm-Leg Vessel Surg,PX01656.01,CDM,964,RC,1656,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Arthroscopy of Hip,PX01202.01,CDM,964,RC,1202,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Biceps Tendon Repair,PX01716.01,CDM,964,RC,1716,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Biopsy of Nose,PX00164.01,CDM,964,RC,164,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Biopsy of Thyroid,PX00322.01,CDM,964,RC,322,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Bladder Stone Surg,PX00870.01,CDM,964,RC,870,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Bladder Surgery,PX00910.01,CDM,964,RC,910,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Bladder Tumor Surg,PX00912.01,CDM,964,RC,912,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Bleeding Control,PX00916.01,CDM,964,RC,916,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Blepharoplasty,PX00103.01,CDM,964,RC,103,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Blood Vessel Repair,PX00770.01,CDM,964,RC,770,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Body Cast Procedure,PX01130.01,CDM,964,RC,1130,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Bone Aspirate/Bx,PX01112.01,CDM,964,RC,1112,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Burn 4-9 Percent,PX01952.01,CDM,964,RC,1952,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Burn Each 9 Percent,PX01953.01,CDM,964,RC,1953,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Burn Less 4 Percent,PX01951.01,CDM,964,RC,1951,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cabg W/O Pump,PX00566.01,CDM,964,RC,566,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cabg W/Pump,PX00567.01,CDM,964,RC,567,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cardiac Electrophys,PX00537.01,CDM,964,RC,537,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cardioverter/Defib,PX00534.01,CDM,964,RC,534,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cat or MRI Scan,PX01922.01,CDM,964,RC,1922,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Catheterize Heart,PX01920.01,CDM,964,RC,1920,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Drainage,PX00524.01,CDM,964,RC,524,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Lining Biopsy,PX00522.01,CDM,964,RC,522,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Partition View,PX00528.01,CDM,964,RC,528,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Partition View,PX00529.01,CDM,964,RC,529,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Procedure,PX00520.01,CDM,964,RC,520,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Surgery,PX00540.01,CDM,964,RC,540,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Wall Repair,PX00472.01,CDM,964,RC,472,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cleft Palate Repair,PX00172.01,CDM,964,RC,172,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Collar Bone Biopsy,PX00454.01,CDM,964,RC,454,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Corneal Transplant,PX00144.01,CDM,964,RC,144,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Correct Heart Rhythm,PX00410.01,CDM,964,RC,410,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cran Surg Hemotoma,PX00211.01,CDM,964,RC,211,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cranial Surg Nos,PX00210.01,CDM,964,RC,210,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cs Delivery,PX01961.01,CDM,964,RC,1961,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cs Hysterectomy,PX01963.01,CDM,964,RC,1963,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Dx Arteriography,PX01916.01,CDM,964,RC,1916,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Dx Elbow Arthroscopy,PX01732.01,CDM,964,RC,1732,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Dx Knee Arthroscopy,PX01382.01,CDM,964,RC,1382,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Dx Wrist Arthroscopy,PX01829.01,CDM,964,RC,1829,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Ear Exam,PX00124.01,CDM,964,RC,124,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Ear Surgery,PX00120.01,CDM,964,RC,120,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Elbow Area Surgery,PX01710.01,CDM,964,RC,1710,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Elbow Replacement,PX01760.01,CDM,964,RC,1760,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Electroshock,PX00104.01,CDM,964,RC,104,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Emer Hysterectomy,PX01962.01,CDM,964,RC,1962,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Esophageal Surgery,PX00500.01,CDM,964,RC,500,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Eye Exam,PX00148.01,CDM,964,RC,148,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Face/Skull Bone Surg,PX00190.01,CDM,964,RC,190,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Facial Bone Surgery,PX00192.01,CDM,964,RC,192,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Fat Layer Removal,PX00802.01,CDM,964,RC,802,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Femoral Artery Surg,PX01272.01,CDM,964,RC,1272,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Femoral Embolectomy,PX01274.01,CDM,964,RC,1274,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth for Chemonucleolysis,PX00634.01,CDM,964,RC,634,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth for Liver Biopsy,PX00702.01,CDM,964,RC,702,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth for Liver Transplant,PX00796.01,CDM,964,RC,796,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Forequarter Amput,PX01636.01,CDM,964,RC,1636,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Fx Repair Pelvis,PX01173.01,CDM,964,RC,1173,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Genitalia Surgery,PX00920.01,CDM,964,RC,920,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Head Nerve Surgery,PX00222.01,CDM,964,RC,222,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Head Vessel Surgery,PX00216.01,CDM,964,RC,216,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Head/Neck/Ptrunk,PX00300.01,CDM,964,RC,300,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Heart Surg < 1 Yr,PX00561.01,CDM,964,RC,561,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Heart Surg W/Arrest,PX00563.01,CDM,964,RC,563,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Heart Surg W/O Pump,PX00560.01,CDM,964,RC,560,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Heart/Lung Transplnt,PX00580.01,CDM,964,RC,580,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hemorr/Excise Liver,PX00792.01,CDM,964,RC,792,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hernia Repair < 1 Yr,PX00834.01,CDM,964,RC,834,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hernia Repair Preemie,PX00836.01,CDM,964,RC,836,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hip Arthroplasty,PX01214.01,CDM,964,RC,1214,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hip Disarticulation,PX01212.01,CDM,964,RC,1212,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hip Joint Procedure,PX01200.01,CDM,964,RC,1200,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hip Joint Surgery,PX01210.01,CDM,964,RC,1210,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hrt Surg W/Pmp Age 1+,PX00562.01,CDM,964,RC,562,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Humeral Lesion Surg,PX01758.01,CDM,964,RC,1758,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Humerus Repair,PX01744.01,CDM,964,RC,1744,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Humerus Surgery,PX01742.01,CDM,964,RC,1742,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hysterectomy,PX00846.01,CDM,964,RC,846,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hysteroscope/Graph,PX00952.01,CDM,964,RC,952,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Inc/Missed Ab Proc,PX01965.01,CDM,964,RC,1965,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Induced Ab Procedure,PX01966.01,CDM,964,RC,1966,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Insert Penis Device,PX00938.01,CDM,964,RC,938,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Intrcrn Nerve,PX00220.01,CDM,964,RC,220,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Iridectomy,PX00147.01,CDM,964,RC,147,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Kidney Stone Destruct,PX00872.01,CDM,964,RC,872,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Kidney Stone Destruct,PX00873.01,CDM,964,RC,873,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Kidney Transplant,PX00868.01,CDM,964,RC,868,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Kidney/Ureter Surg,PX00862.01,CDM,964,RC,862,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Area Procedure,PX01340.01,CDM,964,RC,1340,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Area Procedure,PX01390.01,CDM,964,RC,1390,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Area Surgery,PX01320.01,CDM,964,RC,1320,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Area Surgery,PX01360.01,CDM,964,RC,1360,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Area Surgery,PX01392.01,CDM,964,RC,1392,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Arteries Surg,PX01440.01,CDM,964,RC,1440,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Artery Repair,PX01444.01,CDM,964,RC,1444,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Artery Surg,PX01442.01,CDM,964,RC,1442,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Arthroplasty,PX01402.01,CDM,964,RC,1402,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Joint Casting,PX01420.01,CDM,964,RC,1420,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Joint Procedure,PX01380.01,CDM,964,RC,1380,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Joint Surgery,PX01400.01,CDM,964,RC,1400,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Veins Surgery,PX01430.01,CDM,964,RC,1430,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Vessel Surg,PX01432.01,CDM,964,RC,1432,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Larynx/Trach < 1 Yr,PX00326.01,CDM,964,RC,326,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Leg Arteries Surg,PX01500.01,CDM,964,RC,1500,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lens Surgery,PX00142.01,CDM,964,RC,142,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Low Intestine Scope,PX00810.01,CDM,964,RC,810,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Arm Casting,PX01860.01,CDM,964,RC,1860,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Arm Procedure,PX01820.01,CDM,964,RC,1820,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Arm Surgery,PX01810.01,CDM,964,RC,1810,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Arm Surgery,PX01830.01,CDM,964,RC,1830,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Arm Vein Surg,PX01850.01,CDM,964,RC,1850,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Bone Surg,PX01480.01,CDM,964,RC,1480,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Casting,PX01490.01,CDM,964,RC,1490,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Procedure,PX01462.01,CDM,964,RC,1462,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Revision,PX01484.01,CDM,964,RC,1484,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Surgery,PX01470.01,CDM,964,RC,1470,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Surgery,PX01474.01,CDM,964,RC,1474,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Vein Surg,PX01520.01,CDM,964,RC,1520,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Vein Surg,PX01522.01,CDM,964,RC,1522,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lumbar Puncture,PX00635.01,CDM,964,RC,635,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lung Chest Wall Surg,PX00546.01,CDM,964,RC,546,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lwr Arm Artery Surg,PX01840.01,CDM,964,RC,1840,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lwr Arm Embolectomy,PX01842.01,CDM,964,RC,1842,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lwr Arm Vein Repair,PX01852.01,CDM,964,RC,1852,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lwr Leg Embolectomy,PX01502.01,CDM,964,RC,1502,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Major Vein Ligation,PX00882.01,CDM,964,RC,882,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth N Block/Inj Prone,PX01992.01,CDM,964,RC,1992,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Neck Organ 1 & Over,PX00320.01,CDM,964,RC,320,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Neck Vessel Surgery,PX00350.01,CDM,964,RC,350,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Neck Vessel Surgery,PX00352.01,CDM,964,RC,352,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Nerve Block/Inj,PX01991.01,CDM,964,RC,1991,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Nose/Sinus Surgery,PX00160.01,CDM,964,RC,160,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Nose/Sinus Surgery,PX00162.01,CDM,964,RC,162,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth One Lung Ventilation,PX00541.01,CDM,964,RC,541,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pacemaker Insertion,PX00530.01,CDM,964,RC,530,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pancreas Removal,PX00794.01,CDM,964,RC,794,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvic Organ Surg,PX00848.01,CDM,964,RC,848,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvic Tumor Surgery,PX01150.01,CDM,964,RC,1150,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvis Nerve Removal,PX01180.01,CDM,964,RC,1180,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvis Nerve Removal,PX01190.01,CDM,964,RC,1190,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvis Procedure,PX01160.01,CDM,964,RC,1160,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvis Surgery,PX00844.01,CDM,964,RC,844,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvis Surgery,PX01120.01,CDM,964,RC,1120,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvis Surgery,PX01170.01,CDM,964,RC,1170,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Penis Nodes Removal,PX00934.01,CDM,964,RC,934,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Penis Nodes Removal,PX00936.01,CDM,964,RC,936,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Perc Img Dx Sp Proc,PX01935.01,CDM,964,RC,1935,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Perc Img Tx Sp Proc,PX01936.01,CDM,964,RC,1936,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Perineal Surgery,PX00904.01,CDM,964,RC,904,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pharyngeal Surgery,PX00174.01,CDM,964,RC,174,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pharyngeal Surgery,PX00176.01,CDM,964,RC,176,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Procedure on Femur,PX01220.01,CDM,964,RC,1220,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Procedure on Mouth,PX00170.01,CDM,964,RC,170,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Procedures on Eye,PX00140.01,CDM,964,RC,140,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Radical Femur Surg,PX01234.01,CDM,964,RC,1234,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Radical Humerus Surg,PX01756.01,CDM,964,RC,1756,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Radical Leg Surgery,PX01482.01,CDM,964,RC,1482,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Release of Lung,PX00542.01,CDM,964,RC,542,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Adrenal,PX00866.01,CDM,964,RC,866,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Bladder,PX00864.01,CDM,964,RC,864,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Nerves,PX00622.01,CDM,964,RC,622,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Nerves,PX00632.01,CDM,964,RC,632,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Prostate,PX00865.01,CDM,964,RC,865,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Prostate,PX00908.01,CDM,964,RC,908,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Rib,PX00470.01,CDM,964,RC,470,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Testis,PX00926.01,CDM,964,RC,926,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Testis,PX00928.01,CDM,964,RC,928,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Vulva,PX00906.01,CDM,964,RC,906,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Cervix,PX00948.01,CDM,964,RC,948,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Cleft Lip,PX00102.01,CDM,964,RC,102,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Hernia,PX00750.01,CDM,964,RC,750,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Hernia,PX00752.01,CDM,964,RC,752,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Hernia,PX00754.01,CDM,964,RC,754,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Hernia,PX00756.01,CDM,964,RC,756,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Hernia,PX00830.01,CDM,964,RC,830,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Hernia,PX00832.01,CDM,964,RC,832,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Revise Hip Repair,PX01215.01,CDM,964,RC,1215,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Salivary Gland,PX00100.01,CDM,964,RC,100,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Artery Surg,PX01650.01,CDM,964,RC,1650,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Casting,PX01680.01,CDM,964,RC,1680,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Joint Amput,PX01634.01,CDM,964,RC,1634,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Procedure,PX01620.01,CDM,964,RC,1620,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Replacement,PX01638.01,CDM,964,RC,1638,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Vein Surg,PX01670.01,CDM,964,RC,1670,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Vessel Surg,PX01652.01,CDM,964,RC,1652,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Vessel Surg,PX01654.01,CDM,964,RC,1654,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Sitting Procedure,PX00604.01,CDM,964,RC,604,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Skin Ext/per/Atrunk,PX00400.01,CDM,964,RC,400,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Skull Drainage,PX00212.01,CDM,964,RC,212,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Skull Drainage,PX00214.01,CDM,964,RC,214,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Skull Repair/Fract,PX00215.01,CDM,964,RC,215,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Special Head Surgery,PX00218.01,CDM,964,RC,218,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Sperm Duct Surgery,PX00922.01,CDM,964,RC,922,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Spine Cord Surgery,PX00600.01,CDM,964,RC,600,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Spine Cord Surgery,PX00620.01,CDM,964,RC,620,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Spine Cord Surgery,PX00630.01,CDM,964,RC,630,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Spine Cord Surgery,PX00670.01,CDM,964,RC,670,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Spine Manipulation,PX00640.01,CDM,964,RC,640,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Sternal Debridement,PX00550.01,CDM,964,RC,550,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Stone Removal,PX00918.01,CDM,964,RC,918,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surg Lower Abdomen,PX00840.01,CDM,964,RC,840,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surg on Vag/Urethral,PX00942.01,CDM,964,RC,942,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surg Upper Abdomen,PX00790.01,CDM,964,RC,790,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery for Obesity,PX00797.01,CDM,964,RC,797,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Abdomen,PX00860.01,CDM,964,RC,860,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Breast,PX00402.01,CDM,964,RC,402,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Breast,PX00404.01,CDM,964,RC,404,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Breast,PX00406.01,CDM,964,RC,406,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Femur,PX01230.01,CDM,964,RC,1230,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Rib(S),PX00474.01,CDM,964,RC,474,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Shoulder,PX00450.01,CDM,964,RC,450,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Shoulder,PX00452.01,CDM,964,RC,452,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Shoulder,PX01610.01,CDM,964,RC,1610,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Shoulder,PX01630.01,CDM,964,RC,1630,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Testis Exploration,PX00924.01,CDM,964,RC,924,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Testis Suspension,PX00930.01,CDM,964,RC,930,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Thigh Arteries Surg,PX01270.01,CDM,964,RC,1270,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Trach-Bronch Reconst,PX00539.01,CDM,964,RC,539,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Trachea Bronchi Surg,PX00548.01,CDM,964,RC,548,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Trans Resect of Prostate,PX00914.01,CDM,964,RC,914,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Tubal Ligation,PX00851.01,CDM,964,RC,851,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Tympanotomy,PX00126.01,CDM,964,RC,126,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Upper Arm Surgery,PX01740.01,CDM,964,RC,1740,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Upper Arm Vein Surg,PX01780.01,CDM,964,RC,1780,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Upper GI Visualize,PX00740.01,CDM,964,RC,740,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Upper Leg Surgery,PX01250.01,CDM,964,RC,1250,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Upper Leg Veins Surg,PX01260.01,CDM,964,RC,1260,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Uppr Arm Artery Surg,PX01770.01,CDM,964,RC,1770,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Uppr Arm Embolectomy,PX01772.01,CDM,964,RC,1772,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Uppr Arm Procedure,PX01730.01,CDM,964,RC,1730,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Uppr Arm Tendon Surg,PX01712.01,CDM,964,RC,1712,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Uppr Arm Tendon Surg,PX01714.01,CDM,964,RC,1714,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Uppr Arm Vein Repair,PX01782.01,CDM,964,RC,1782,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vaginal Delivery,PX01960.01,CDM,964,RC,1960,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vaginal Endoscopy,PX00950.01,CDM,964,RC,950,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vaginal Hysterectomy,PX00944.01,CDM,964,RC,944,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vaginal Procedures,PX00940.01,CDM,964,RC,940,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vascular Access,PX00532.01,CDM,964,RC,532,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vascular Shunt Surg,PX01844.01,CDM,964,RC,1844,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vasectomy,PX00921.01,CDM,964,RC,921,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vitreoretinal Surg,PX00145.01,CDM,964,RC,145,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Wrist Replacement,PX01832.01,CDM,964,RC,1832,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth/Analg Cs Hyst Add-On,PX01969.01,CDM,964,RC,1969,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth/Analg Vag Delivery,PX01967.01,CDM,964,RC,1967,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Hosp Manage Cont Drug Admin,PX01996.01,CDM,964,RC,1996,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
IMMOBILIZER SHOULDER LARGE 9008-03,120.38,CDM,274,RC,L3650,HCPCS,,906-MAIN,LOCAL,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER LARGE STRAP OSG3033,120.38,CDM,274,RC,L3650,HCPCS,,2910-MAIN,LOCAL,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER MEDIUM 9008-02,120.38,CDM,274,RC,L3650,HCPCS,,912-MAIN,LOCAL,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER MEDIUM OSG3032,120.38,CDM,274,RC,L3650,HCPCS,,915-MAIN,LOCAL,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER SMALL 9008-01,120.38,CDM,274,RC,L3650,HCPCS,,913-MAIN,LOCAL,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER SMALL WITH CLOTH 9001-02,120.38,CDM,274,RC,L3650,HCPCS,,914-MAIN,LOCAL,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER X-LARGE CLOTH 9001-05,120.38,CDM,274,RC,L3650,HCPCS,,917-MAIN,LOCAL,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER X-LARGE ORT16100XL,120.38,CDM,274,RC,L3650,HCPCS,,904-MAIN,LOCAL,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
Support for Organ Donor,PX01990.01,CDM,964,RC,1990,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Treponema Pallidum,PX86780,CDM,300,RC,86780,CPT,,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.14,35.28
Unlisted Anesth Procedure,PX01999.01,CDM,964,RC,1999,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405P,CDM,983,RC,36405,CPT,,,,,,,,36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,14.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,49348009529,NDC,15,ML,30.53,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.9597,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,49348009529,NDC,15,ML,30.53,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.9597,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,49348009529,NDC,15,ML,30.53,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.9597,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sterile water (preservative free) Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409488724,NDC,50,ML,34.88,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,14.96352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409488750,NDC,50,ML,34.88,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,14.96352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010125,NDC,1,ML,30.58,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,12.09333333,percent of total billed charges,14.9842,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010125,NDC,1,ML,30.58,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.9842,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010125,NDC,1,ML,30.58,,United Healthcare,All Medicare advantage plans,outpatient,49,,15.9,percent of total billed charges,14.9842,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323048541,NDC,20,ML,30.58,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.9842,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323048541,NDC,20,ML,30.58,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.9842,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323048541,NDC,20,ML,30.58,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.9842,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Basic Metabolic Panel Ca Ion,PX80047,CDM,300,RC,80047,CPT,,,,,,,,17,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,14.994,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.0618,16.66
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,49348014446,NDC,1,EA,15.3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,14.994,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
RESERVOIR WOUND DRAIN 15FR,27200000,CDM,272,RC,,,,4386-MAIN,LOCAL,,,,,30.6,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.994,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RESERVOIR WOUND DRAIN 15FR,27200000,CDM,272,RC,,,,4386-MAIN,LOCAL,,,,,30.6,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.994,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RESERVOIR WOUND DRAIN 15FR,27200000,CDM,272,RC,,,,4386-MAIN,LOCAL,,,,,30.6,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.994,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SET DISPOSABLE COLLECTION,27100000,CDM,271,RC,,,,5439-MAIN,LOCAL,,,,,30.6,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.994,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
SET DISPOSABLE COLLECTION,27100000,CDM,271,RC,,,,5439-MAIN,LOCAL,,,,,30.6,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.994,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
SET DISPOSABLE COLLECTION,27100000,CDM,271,RC,,,,5439-MAIN,LOCAL,,,,,30.6,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.994,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
SUTURE NUROLON 0 BLACK C527D,27200000,CDM,272,RC,,,,10415-MAIN,LOCAL,,,,,30.6,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.994,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE NUROLON 0 BLACK C527D,27200000,CDM,272,RC,,,,10415-MAIN,LOCAL,,,,,30.6,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,14.994,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE NUROLON 0 BLACK C527D,27200000,CDM,272,RC,,,,10415-MAIN,LOCAL,,,,,30.6,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,14.994,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Cognitive Funct Ther Interv, Initial 15 Min",PX97129,CDM,420,RC,97129,CPT,,,,,,,,85,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15,83.3
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,67457043800,NDC,0.5,EA,36.11,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.000094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,67457043810,NDC,0.5,EA,36.11,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.000094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
STOCKINETTE IMPERVIOUS 12X48 NON22535,27200000,CDM,272,RC,A6457,HCPCS,,10918-MAIN,LOCAL,,,,,16.47,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,15.00417,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028036,NDC,2,ML,36.12,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.004248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,60432006547,NDC,10,ML,34.98,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.00642,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PACLitaxel protein-bound particle 100 MG Recon Susp 1 Each Vial,J9264.01,CDM,636,RC,J9264,HCPCS,,,,68817013450,NDC,1,EA,2564.76,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,15.01,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.58,15.01
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,17478081705,NDC,5,ML,34.99,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.01071,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
meloxicam 7.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,29300012401,NDC,1,EA,17.02,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,15.01164,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323020103,NDC,10,ML,36.14,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.012556,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209F,CDM,510,RC,69209,CPT,,,,,,,,35,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,53.44
SHOE POST OP X-LARGE MALE DS1016-16,120.237,CDM,274,RC,L3260,HCPCS,,6337-MAIN,LOCAL,,,,,35,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
"Trimming of Dystrophic Nails, Any Number",PXG0127P,CDM,983,RC,G0127,HCPCS,,,,,,,,35,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,53.44
Fibrinolysins Screen - Ref,PX8539090,CDM,300,RC,85390,CPT,90,,,,,,,118,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,15.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.02,55.78
Fibrinolysins Screen - Ref,PX8539090,CDM,300,RC,85390,CPT,90,,,,,,,118,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,15.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.02,55.78
Fibrinolysins Screen - Ref,PX8539090,CDM,300,RC,85390,CPT,90,,,,,,,118,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,15.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.02,55.78
colchicine 0.6 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,49884017111,NDC,1,EA,36.17,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.025018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famciclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,93811956,NDC,0.25,EA,17.04,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,15.02928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Lyme Disease, Confirm Tst - Ref",PX8661790,CDM,300,RC,86617,CPT,90,,,,,,,95,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,15.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.03,15.49
"Lyme Disease, Confirm Tst - Ref",PX8661790,CDM,300,RC,86617,CPT,90,,,,,,,95,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,15.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.03,15.49
"Lyme Disease, Confirm Tst - Ref",PX8661790,CDM,300,RC,86617,CPT,90,,,,,,,95,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,15.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.03,15.49
Parvovirus Antibody - Ref,PX8674790,CDM,300,RC,86747,CPT,90,,,,,,,92,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,15.03,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.58,15.03
zinc oxide 20 % Ointment 56.7 g Tube,63700001,CDM,250,RC,,,,,,168006202,NDC,56.7,GR,30.39,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,15.04305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine buffered 1 % Solution 22.2 mL Vial,25000000,CDM,250,RC,,,,,,8888800251,NDC,22.2,ML,30.4,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,15.048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine buffered 1% Solution 22.2 mL Vial,25000000,CDM,250,RC,,,,,,8888800251,NDC,22.2,ML,30.4,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,15.048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Chest Wall Manipulation,Initial",PX94667,CDM,410,RC,94667,CPT,,,,,,,,121,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,15.05,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.05,43.63
Chorionic gonadotropin test,PX84702,CDM,300,RC,84702,CPT,,,,,,,,210,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,15.05,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.37,15.05
Debride Skin/Subq Ea Ad 20sqcm,PX11045F,CDM,510,RC,11045,CPT,,,,,,,,115,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,15.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.05,83.02
Debride Skin/Subq Ea Ad 20sqcm,PX11045F,CDM,510,RC,11045,CPT,,,,,,,,115,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,15.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.05,83.02
Debride Skin/Subq Ea Ad 20sqcm,PX11045F,CDM,510,RC,11045,CPT,,,,,,,,115,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,15.05,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.05,83.02
Debride Skin/Subq Ea Ad 20sqcm,PX11045P,CDM,983,RC,11045,CPT,,,,,,,,182,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,15.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.05,178.36
Debride Skin/Subq Ea Ad 20sqcm,PX11045P,CDM,983,RC,11045,CPT,,,,,,,,182,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,15.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.05,178.36
Debride Skin/Subq Ea Ad 20sqcm,PX11045P,CDM,983,RC,11045,CPT,,,,,,,,182,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,15.05,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.05,178.36
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151F,CDM,370,RC,99151,CPT,,,,,,,,176,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,15.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.05,105.87
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151F,CDM,370,RC,99151,CPT,,,,,,,,176,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,15.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.05,105.87
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151F,CDM,370,RC,99151,CPT,,,,,,,,176,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,15.05,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.05,105.87
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151P,CDM,983,RC,99151,CPT,,,,,,,,275,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,15.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.05,269.5
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151P,CDM,983,RC,99151,CPT,,,,,,,,275,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,15.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.05,269.5
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151P,CDM,983,RC,99151,CPT,,,,,,,,275,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,15.05,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.05,269.5
"Xray Neck, Soft Tissue",PX7036001,CDM,320,RC,70360,CPT,TC,,,,,,,277,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,15.05,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.83,44.7
Xray Toe(S) Tc,PX7366001,CDM,320,RC,73660,CPT,TC,,,,,,,282,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,15.05,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.05,45.36
clotrimazole 1 % Cream 28 g Tube,25000000,CDM,250,RC,,,,,,536127222,NDC,28,GR,15.36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,15.0528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
LEGGING PAIR 31X48 STERILE,27200000,CDM,272,RC,,,,10916-MAIN,LOCAL,,,,,16.53,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,15.05883,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,36000003310,NDC,5,ML,30.74,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.0626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,36000003310,NDC,5,ML,30.74,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.0626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,36000003310,NDC,5,ML,30.74,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,15.0626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006403,NDC,2,ML,30.45,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,15.07275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
Vitamin B-12,PX82607,CDM,300,RC,82607,CPT,,,,,,,,122,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,15.08,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.63,15.08
Apc Resistance Assay - Ref,PX8530790,CDM,300,RC,85307,CPT,90,,,,,,,390,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,15.0823,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.86,15.32
"Ebv, Nuclear Antigen - Ref",PX8666490,CDM,300,RC,86664,CPT,90,,,,,,,58,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,15.0823,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.83,15.29
Epstein-barr antibody,PX86664,CDM,300,RC,86664,CPT,,,,,,,,72,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,15.0823,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.83,15.29
Fibrinolysins Screen - Ref,PX8539090,CDM,300,RC,85390,CPT,90,,,,,,,118,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,15.0823,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.02,55.78
Legionella Antibody - Ref,PX8671390,CDM,300,RC,86713,CPT,90,,,,,,,71,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,15.0823,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.84,15.3
"Lyme Disease, Confirm Tst - Ref",PX8661790,CDM,300,RC,86617,CPT,90,,,,,,,95,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,15.0823,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.03,15.49
Phenobarbital Assay - Ref,PX8018490,CDM,300,RC,80184,CPT,90,,,,,,,20,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,15.0823,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.84,15.3
"Protein S, Free - Ref",PX8530690,CDM,300,RC,85306,CPT,90,,,,,,,47,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,15.0823,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.86,15.32
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022143,NDC,1,EA,36.31,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.083174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342003110,NDC,1,EA,16.56,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,15.08616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Gammaglobulin; Ige - Ref,PX8278590,CDM,300,RC,82785,CPT,90,,,,,,,45,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,15.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.09,44.1
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022116,NDC,1,EA,36.33,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.091482,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022141,NDC,1,EA,36.33,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.091482,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006401,NDC,2,ML,31.46,,Health Partners,Health Partners Care Plans,both,48,,14.6175,percent of total billed charges,15.1008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006401,NDC,2,ML,31.46,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,15.1008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,49348009529,NDC,15,ML,30.53,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,15.11235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Cardiac Rehab,PX93797F,CDM,943,RC,93797,CPT,,,,,,,,45,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,15.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.45,29.67
Xray Scapula Complete,PX7301001,CDM,320,RC,73010,CPT,TC,,,,,,,357,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,15.1246,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.81,30.24
pravastatin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904589161,NDC,1,EA,15.54,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,15.125082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049236,NDC,5,ML,31.52,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,15.1296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049236,NDC,5,ML,31.52,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,15.1296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049243,NDC,5,ML,31.52,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,15.1296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049243,NDC,5,ML,31.52,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,15.1296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Basic Metabolic Panel Ca Ion,PX80047,CDM,300,RC,80047,CPT,,,,,,,,17,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,15.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.0618,16.66
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010125,NDC,1,ML,30.58,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,15.1371,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323048541,NDC,20,ML,30.58,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,15.1371,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
buprenorphine 75 MCG FILM 60 Each Box,63700001,CDM,250,RC,,,,,,59385002160,NDC,1,EA,29.92,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.13952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Cognitive Funct Ther Interv, Ea Addl 15 Min",PX97130,CDM,420,RC,97130,CPT,,,,,,,,82,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,15.14,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.14,28.12
RESERVOIR WOUND DRAIN 15FR,27200000,CDM,272,RC,,,,4386-MAIN,LOCAL,,,,,30.6,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,15.147,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SET DISPOSABLE COLLECTION,27100000,CDM,271,RC,,,,5439-MAIN,LOCAL,,,,,30.6,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,15.147,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
SUTURE NUROLON 0 BLACK C527D,27200000,CDM,272,RC,,,,10415-MAIN,LOCAL,,,,,30.6,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,15.147,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
meloxicam 7.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,29300012401,NDC,1,EA,17.02,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,15.1478,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,487960130,NDC,2,ML,36.47,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.149638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061601,NDC,3,ML,31.57,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,15.1536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061601,NDC,3,ML,31.57,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,15.1536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058003,NDC,0.5,ML,31.57,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,15.1536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058003,NDC,0.5,ML,31.57,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,15.1536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058020,NDC,0.5,ML,31.57,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,15.1536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058020,NDC,0.5,ML,31.57,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,15.1536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061416,NDC,0.5,ML,31.57,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,15.1536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.114178,99.911
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061416,NDC,0.5,ML,31.57,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,15.1536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.114178,99.911
meloxicam 7.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268052511,NDC,1,EA,16.64,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,15.15904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Strep a Assay W/Optic,PX87880,CDM,300,RC,87880,CPT,,,,,,,,95,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,15.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.16,93.1
famciclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,93811956,NDC,0.25,EA,17.04,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,15.1656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
RESERVOIR SILICONE BULB 100CC,27200000,CDM,272,RC,,,,4400-MAIN,LOCAL,,,,,16.65,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,15.16815,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Influenza Assay W/Optic,PX87804,CDM,300,RC,87804,CPT,,,,,,,,127,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,15.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.17,124.46
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,409710709,NDC,1000,ML,36.53,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.174562,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5% and sodium chloride 0.45% with potassium chloride 10 mEq in 1000 mL 10-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,264763400,NDC,1000,ML,36.53,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.174562,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
benzocaine-menthol 20-0.5 % Aerosol 78 g Can,63700001,CDM,250,RC,,,,,,75137085520,NDC,78,GR,35.38,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.17802,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
8MM ENDOWRIST INSTRUMENTS MEDIUM LARGE CLIP APPLIER,27200000,CDM,272,RC,,,,11910-MAIN,LOCAL,,,,,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,2,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.852986,29.4
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,3,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.852986,29.4
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061603,NDC,3,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,641600601,NDC,0.5,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
bacteriostatic water(benz alc) Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409397703,NDC,30,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BULB RESERVOIR SILICONE 400CC,27200000,CDM,272,RC,,,,12463-MAIN,LOCAL,,,,,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600710,NDC,2,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,38.9354
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409115918,NDC,1,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046401,NDC,1,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046402,NDC,1,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046437,NDC,1,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,409174670,NDC,1,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046801,NDC,1,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046817,NDC,1,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BUPivacaine in dextrose 0.75-8.25 % Solution 2 mL Ampule,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409176162,NDC,2,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046601,NDC,1,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143992490,NDC,0.5,EA,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010110,NDC,0.5,EA,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010167,NDC,0.5,EA,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,44567070725,NDC,0.5,EA,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733201,NDC,0.5,EA,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733801,NDC,0.5,EA,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,70069000501,NDC,0.1,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,63.2394
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016502,NDC,0.5,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016516,NDC,0.5,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036721,NDC,1,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036725,NDC,1,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 100 MG/10ML Solution 10 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323051610,NDC,0.5,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050641,NDC,0.5,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141031,NDC,0.5,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,641037621,NDC,0.25,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066416,NDC,1,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066441,NDC,0.25,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010101,NDC,0.25,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
DRAPE SPLIT WITH ADHESIVE DYNJP8304A,27200000,CDM,272,RC,,,,4694-MAIN,LOCAL,,,,,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRESSING HYDROFERA 2-1/2X2-1/2  BLUE READY FOAM HBRS2520,120.488,CDM,271,RC,A6209,HCPCS,,11537-MAIN,LOCAL,,,,,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
"Ethanol, P",PX82077,CDM,300,RC,82077,CPT,,,,,,,,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073916,NDC,2,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,29.4
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073941,NDC,1,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,29.4
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,67457043300,NDC,1,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,29.4
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909422,NDC,2,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
folic acid 5 MG/ML Solution 10 mL Vial,J3490.94,CDM,636,RC,J3490,HCPCS,,,,39822110001,NDC,0.2,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,330.2012
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,70860030242,NDC,1,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,36000028425,NDC,2,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001094,NDC,2,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,42.5516
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,781382571,NDC,0.5,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,143931901,NDC,0.4,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.428
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272002,NDC,1,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272031,NDC,1,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,25021040010,NDC,1,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323054011,NDC,1,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095300,NDC,0.5,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095310,NDC,1,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,71288042095,NDC,0.5,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306424,NDC,1,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306413,NDC,1,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306521,NDC,3,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin lock flush 10 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306510,NDC,5,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
HYDROmorphone 1 MG/ML Solution 1 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,76045000901,NDC,0.25,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016216,NDC,1,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016243,NDC,0.5,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072201,NDC,0.5,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072225,NDC,0.5,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016226,NDC,0.5,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016245,NDC,0.5,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011901,NDC,0.5,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011925,NDC,0.5,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072501,NDC,0.5,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072525,NDC,0.5,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143932001,NDC,1,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143962201,NDC,1,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,409226720,NDC,1,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,47781058629,NDC,1,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,51991093498,NDC,1,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,409427616,NDC,20,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323048526,NDC,20,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,63323049241,NDC,2,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2% PF 2 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049526,NDC,5,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2% PF 2 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049541,NDC,5,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine buffered 1 % Solution 0.5 mL Syringe,25000000,CDM,250,RC,,,,,,8888800160,NDC,0.5,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604401,NDC,1,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604425,NDC,1,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620701,NDC,0.25,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620725,NDC,1,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
magnesium sulfate 50 % Solution 10 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006404,NDC,2,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,703450284,NDC,2,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.859
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,409177815,NDC,5,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,70860030005,NDC,1.25,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metroNIDAZOLE 500 MG/100ML Solution 100 mL Plas Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,338954124,NDC,100,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,31.4776
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605701,NDC,2,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605725,NDC,1,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060031,NDC,2,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060041,NDC,2,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 5 MG/ML Solution 1 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606101,NDC,0.2,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230504,NDC,0.5,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230505,NDC,5,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam PF 10 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230802,NDC,2,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,43598052936,NDC,0.5,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080601,NDC,0.5,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080610,NDC,0.5,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,409475503,NDC,2,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054731,NDC,2,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054831,NDC,2,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054842,NDC,2,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092825,NDC,1,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,31.5854
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488802,NDC,10,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018603,NDC,20,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018620,NDC,20,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 50 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488850,NDC,3,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride bacteriostatic 0.9 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409196602,NDC,30,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride bacteriostatic 0.9 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409196607,NDC,30,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,64253002030,NDC,10,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409488710,NDC,10,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409488717,NDC,10,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
SUTURE BIOSYN MONOFILAMENT ABSORBABLE UNDYED SIZE 4-0 18IN WITH 3/8 CIRCLE REVERSE CUTTING 19MM NEED,27200000,CDM,272,RC,,,,11987-MAIN,LOCAL,,,,,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE MONOFILAMENT SZ 4-0 BIOSYN ABSORBABLE UNDYED18IN WITH 3/8 CIRCLE REVERSE CUTTING 19MM NEED SM,27200000,CDM,272,RC,,,,11984-MAIN,LOCAL,,,,,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TRAY LUMBAR 22GAX3.5 PUNCTURE SAFE-T 4306CWSP,120.18,CDM,272,RC,,,,11584-MAIN,LOCAL,,,,,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
TRAY LUMBAR 22X1.5 PUNCTURE PEDS 4302CSP,120.18,CDM,272,RC,,,,652-MAIN,LOCAL,,,,,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
triamcinolone acetonide 10 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3049420,NDC,0.25,ML,30,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,72.0986
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057811,NDC,0.5,ML,30.98,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.1802,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057811,NDC,0.5,ML,30.98,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.1802,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057811,NDC,0.5,ML,30.98,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,15.1802,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057841,NDC,0.5,ML,30.98,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.1802,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057841,NDC,0.5,ML,30.98,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.1802,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057841,NDC,0.5,ML,30.98,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,15.1802,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,Health Partners,Health Partners Care Plans,both,48,,21.6975,percent of total billed charges,15.1824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,15.1824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,Health Partners,Health Partners Care Plans,both,48,,21.6975,percent of total billed charges,15.1824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,15.1824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
lovastatin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739028110,NDC,1,EA,15.6,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,15.18348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DRAPE ABDOMINAL SURGICAL 14X12 POUCHES STERILE DYNJP3109,27200000,CDM,272,RC,,,,12896-MAIN,LOCAL,,,,,31,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRAPE ABDOMINAL SURGICAL 14X12 POUCHES STERILE DYNJP3109,27200000,CDM,272,RC,,,,12896-MAIN,LOCAL,,,,,31,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRAPE ABDOMINAL SURGICAL 14X12 POUCHES STERILE DYNJP3109,27200000,CDM,272,RC,,,,12896-MAIN,LOCAL,,,,,31,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,15.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LITHOTOMY PACK VIII ECLIPSE,27200000,CDM,272,RC,,,,12210-MAIN,LOCAL,,,,,31,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LITHOTOMY PACK VIII ECLIPSE,27200000,CDM,272,RC,,,,12210-MAIN,LOCAL,,,,,31,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LITHOTOMY PACK VIII ECLIPSE,27200000,CDM,272,RC,,,,12210-MAIN,LOCAL,,,,,31,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,15.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Rubella Antibody,PX86762,CDM,300,RC,86762,CPT,,,,,,,,31,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.8774,30.38
Rubella Antibody,PX86762,CDM,300,RC,86762,CPT,,,,,,,,31,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.8774,30.38
Rubella Antibody,PX86762,CDM,300,RC,86762,CPT,,,,,,,,31,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,15.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.8774,30.38
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,185012201,NDC,1,EA,17.23,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,15.19686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
miconazole 2 % Powder 85 g Bottle,25000000,CDM,250,RC,,,,,,67094930,NDC,85,GR,35.43,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.19947,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Primidone Assay - Ref,PX8018890,CDM,300,RC,80188,CPT,90,,,,,,,20,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,15.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
ePHEDrine sulfate 50 MG/ML Solution 1 mL Vial,25000000,CDM,250,RC,,,,,,42023021689,NDC,0.1,ML,36.62,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.211948,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,36000003310,NDC,5,ML,30.74,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,15.2163,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Fac/Trim Nail(S),PX11719F,CDM,510,RC,11719,CPT,,,,,,,,107,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,15.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.58,29.75
pravastatin 10 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,60505016809,NDC,1,EA,17.26,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,15.22332,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine HCl 4 % Cream 76.5 g Tube,63700001,CDM,250,RC,,,,,,41167005820,NDC,76.5,GR,31.72,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,15.2256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine HCl 4 % Cream 76.5 g Tube,63700001,CDM,250,RC,,,,,,41167005820,NDC,76.5,GR,31.72,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,15.2256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pravastatin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904589161,NDC,1,EA,15.54,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,15.2292,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DRAPE SHEET LAP T-DRAPE WITH INSTRUMENT PAD DYNJP3003,27200000,CDM,272,RC,,,,10913-MAIN,LOCAL,,,,,35.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.2295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
saliva substitute Solution 59 mL Bottle,63700001,CDM,250,RC,,,,,,50930009802,NDC,59,ML,31.1,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.239,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
saliva substitute Solution 59 mL Bottle,63700001,CDM,250,RC,,,,,,50930009802,NDC,59,ML,31.1,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.239,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
saliva substitute Solution 59 mL Bottle,63700001,CDM,250,RC,,,,,,50930009802,NDC,59,ML,31.1,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,15.239,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608201,NDC,1,ML,66.6,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,15.24,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.24,17.32
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608210,NDC,1,ML,63.43,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,15.24,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.24,17.32
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093102,NDC,1,ML,60.47,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,15.24,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.24,17.32
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093107,NDC,1,ML,57.59,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,15.24,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.24,17.32
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,409677802,NDC,1,ML,31.11,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,4.035,percent of total billed charges,15.2439,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,409677802,NDC,1,ML,31.11,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.2439,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,409677802,NDC,1,ML,31.11,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,15.2439,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68462033090,NDC,1,EA,17.95,,First Health,Commercial,both,85,,999999999,percent of total billed charges,15.2575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
irbesartan 75 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43547037403,NDC,1,EA,15.68,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,15.261344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
irbesartan 75 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,43547037409,NDC,1,EA,15.68,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,15.261344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078121,NDC,0.5,EA,36.75,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.26595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078141,NDC,0.5,EA,36.75,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.26595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Insert Simple Cath Foley,PX51702F,CDM,510,RC,51702,CPT,,,,,,,,198,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,15.27,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.27,129.37
Insert Straight Catheter,PX51701F,CDM,510,RC,51701,CPT,,,,,,,,168,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,15.27,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.27,92.7
X-Ray Exam Chest 2 Views,PX7104601,CDM,320,RC,71046,CPT,TC,,,,,,,556,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,15.27,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.27,46.02
Xray Hand 2vws Tc,PX7312001,CDM,320,RC,73120,CPT,TC,,,,,,,365,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,15.27,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.27,46.68
Xray Thoracic Spine 2 Vws,PX7207001,CDM,320,RC,72070,CPT,TC,,,,,,,428,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,15.27,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.27,46.02
Xray Toe(S) Tc,PX7366001,CDM,320,RC,73660,CPT,TC,,,,,,,282,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,15.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.05,45.36
Xray Toe(S) Tc,PX7366001,CDM,320,RC,73660,CPT,TC,,,,,,,282,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,15.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.05,45.36
lovastatin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739028110,NDC,1,EA,15.6,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,15.288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Ebv, Nuclear Antigen - Ref",PX8666490,CDM,300,RC,86664,CPT,90,,,,,,,58,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,15.29,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.83,15.29
Epstein-barr antibody,PX86664,CDM,300,RC,86664,CPT,,,,,,,,72,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,15.29,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.83,15.29
finasteride 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862014930,NDC,1,EA,16.79,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,15.29569,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"BINDER ABDOMINAL 12"" HIGH 46 TO 62 INCH L/XL 4 PANEL ORT21300LXL",120.238,CDM,271,RC,A4467,HCPCS,,11935-MAIN,LOCAL,,,,,18,,First Health,Commercial,both,85,,999999999,percent of total billed charges,15.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BURETROL ADD ON SET 150ML,120.38,CDM,272,RC,A4222,HCPCS,,11118-MAIN,LOCAL,,,,,18,,First Health,Commercial,both,85,,999999999,percent of total billed charges,15.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
TRAY TRACH CLEAN & CARE DYND40589,120.212,CDM,271,RC,,,,1173-MAIN,LOCAL,,,,,18,,First Health,Commercial,both,85,,999999999,percent of total billed charges,15.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,17.64
TRAY TRACHEOTOMY CARE PEDS DYND40650H,120.212,CDM,272,RC,,,,11025-MAIN,LOCAL,,,,,18,,First Health,Commercial,both,85,,999999999,percent of total billed charges,15.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,17.64
fomepizole 1 GM/ML Solution 1.5 mL Vial,J1451.01,CDM,636,RC,J1451,HCPCS,,,,39822071001,NDC,1.5,ML,2600,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,15.3,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.9,15.3
Legionella Antibody - Ref,PX8671390,CDM,300,RC,86713,CPT,90,,,,,,,71,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,15.3,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.84,15.3
Phenobarbital Assay - Ref,PX8018490,CDM,300,RC,80184,CPT,90,,,,,,,20,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,15.3,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.84,15.3
buprenorphine 75 MCG FILM 1 Each Package,63700001,CDM,250,RC,,,,,,59385002101,NDC,1,EA,35.68,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.30672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037604,NDC,0.75,ML,36.86,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.311644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
"pediatric electrolyte Solution 1,000 mL Bottle",25000000,CDM,250,RC,,,,,,49348057041,NDC,1000,ML,31.9,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,15.312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"pediatric electrolyte Solution 1,000 mL Bottle",25000000,CDM,250,RC,,,,,,49348057041,NDC,1000,ML,31.9,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,15.312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Apc Resistance Assay - Ref,PX8530790,CDM,300,RC,85307,CPT,90,,,,,,,390,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,15.32,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.86,15.32
"Cortisol, Free - Ref",PX8253090,CDM,300,RC,82530,CPT,90,,,,,,,82,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,15.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.32,80.36
"Protein S, Free - Ref",PX8530690,CDM,300,RC,85306,CPT,90,,,,,,,47,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,15.32,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.86,15.32
oxyBUTYnin ER 5 MG Tablet Extended Release 24 Hour 50 Each Box,63700001,CDM,250,RC,,,,,,904657006,NDC,1,EA,18.04,,First Health,Commercial,both,85,,999999999,percent of total billed charges,15.334,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,185012201,NDC,1,EA,17.23,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,15.3347,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057811,NDC,0.5,ML,30.98,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,15.3351,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057841,NDC,0.5,ML,30.98,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,15.3351,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
HYDROmorphone 1 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409128303,NDC,1,ML,36.93,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.340722,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
DRAPE ABDOMINAL SURGICAL 14X12 POUCHES STERILE DYNJP3109,27200000,CDM,272,RC,,,,12896-MAIN,LOCAL,,,,,31,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,15.345,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LITHOTOMY PACK VIII ECLIPSE,27200000,CDM,272,RC,,,,12210-MAIN,LOCAL,,,,,31,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,15.345,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Rubella Antibody,PX86762,CDM,300,RC,86762,CPT,,,,,,,,31,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,15.345,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.8774,30.38
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68382019616,NDC,1,EA,17.4,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,15.3468,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
riFAMpin 150 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,527139330,NDC,1,EA,17.41,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,15.35562,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
riFAMpin 150 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,68180065806,NDC,1,EA,17.41,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,15.35562,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BANDAGE COBAN  4 IN 2 LAYER COMPRESSION SYSTEM  2094N,120.549,CDM,272,RC,A6441,HCPCS,,12366-MAIN,LOCAL,,,,,32,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,15.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.2928,31.36
BANDAGE COBAN  4 IN 2 LAYER COMPRESSION SYSTEM  2094N,120.549,CDM,272,RC,A6441,HCPCS,,12366-MAIN,LOCAL,,,,,32,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,15.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.2928,31.36
BANDAGE COBAN LITE 4 IN 2 LAYER COMPRESSION SYSTEM 2794N,120.549,CDM,272,RC,A6441,HCPCS,,12922-MAIN,LOCAL,,,,,32,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,15.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.2928,31.36
BANDAGE COBAN LITE 4 IN 2 LAYER COMPRESSION SYSTEM 2794N,120.549,CDM,272,RC,A6441,HCPCS,,12922-MAIN,LOCAL,,,,,32,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,15.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.2928,31.36
"Cognitive Funct Ther Interv, Ea Addl 15 Min",PX97130,CDM,420,RC,97130,CPT,,,,,,,,82,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,15.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.14,28.12
"Cognitive Funct Ther Interv, Ea Addl 15 Min",PX97130,CDM,420,RC,97130,CPT,,,,,,,,82,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,15.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.14,28.12
WOUND DRAIN FLAT WITH TROCAR 10MM FULL PERFORATED SILICONE,27200000,CDM,272,RC,,,,12462-MAIN,LOCAL,,,,,32,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,15.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
WOUND DRAIN FLAT WITH TROCAR 10MM FULL PERFORATED SILICONE,27200000,CDM,272,RC,,,,12462-MAIN,LOCAL,,,,,32,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,15.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
pravastatin 10 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,60505016809,NDC,1,EA,17.26,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,15.3614,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
irbesartan 75 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43547037403,NDC,1,EA,15.68,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,15.3664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
irbesartan 75 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,43547037409,NDC,1,EA,15.68,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,15.3664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carbamide peroxide 6.5% 6.5 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904322035,NDC,15,ML,15.79,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,15.368407,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
COLLAR CERVICAL LARGE WITH TRACH 2 PIECE PHP-T4L,120.184,CDM,274,RC,L0172,HCPCS,,10142-MAIN,LOCAL,,,,,37,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.3698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.3698,152.79
COLLAR CERVICAL MEDIUM WITH TRACH 2 PIECE PHP-T4M,120.183,CDM,274,RC,L0172,HCPCS,,10141-MAIN,LOCAL,,,,,37,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.3698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.3698,152.79
COLLAR CERVICAL SMALL WITH TRACH 2 PIECE PHP-T4S,120.182,CDM,274,RC,L0172,HCPCS,,10140-MAIN,LOCAL,,,,,37,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.3698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.3698,152.79
SUTURE TICRON 0 36IN BRAIDED DYED 1/2 CIRCLE DBLE ARM 25MM CV-305 BLUE STERILE,27200000,CDM,272,RC,,,,11956-MAIN,LOCAL,,,,,37,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.3698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Glycated Protein - Ref,PX8298590,CDM,300,RC,82985,CPT,90,,,,,,,49,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,15.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.37,48.02
zinc oxide 20 % Ointment 56.7 g Tube,63700001,CDM,250,RC,,,,,,168006202,NDC,56.7,GR,30.39,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.37734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Alpha-Fetoprotein Serum,PX82105,CDM,300,RC,82105,CPT,,,,,,,,77,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,15.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.38,75.46
"Alpha-Fetoprotein, Serum - Ref",PX8210590,CDM,300,RC,82105,CPT,90,,,,,,,80,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,15.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.38,78.4
lidocaine buffered 1 % Solution 22.2 mL Vial,25000000,CDM,250,RC,,,,,,8888800251,NDC,22.2,ML,30.4,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.3824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine buffered 1% Solution 22.2 mL Vial,25000000,CDM,250,RC,,,,,,8888800251,NDC,22.2,ML,30.4,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.3824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026994,NDC,20,ML,35.87,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.38823,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409116219,NDC,30,ML,32.07,,Health Partners,Health Partners Care Plans,both,48,,0.387,percent of total billed charges,15.3936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409116219,NDC,30,ML,32.07,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,15.3936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
saliva substitute Solution 59 mL Bottle,63700001,CDM,250,RC,,,,,,50930009802,NDC,59,ML,31.1,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,15.3945,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"CUFF STERILE DISPOSABLE SPSB  STERILE 18""",27200000,CDM,272,RC,,,,7436-MAIN,LOCAL,,,,,35.89,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.39681,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,409677802,NDC,1,ML,31.11,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,15.39945,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
Assay Thyroid Stim Hormone,PX84443,CDM,300,RC,84443,CPT,,,,,,,,294,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,15.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.4,288.12
"Fat/Lipids, Feces, Quant - Ref",PX8271090,CDM,300,RC,82710,CPT,90,,,,,,,95,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,15.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.4,93.1
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006403,NDC,2,ML,30.45,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.4077,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209F,CDM,510,RC,69209,CPT,,,,,,,,35,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,15.4128,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.03,33.21
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209P,CDM,982,RC,69209,CPT,,,,,,,,113,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,15.4128,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.03,110.74
Remove Additional Nail Plate,PX11732F,CDM,510,RC,11732,CPT,,,,,,,,77,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,15.4128,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.46,68.49
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006401,NDC,2,ML,31.46,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,5.851071429,percent of total billed charges,15.4154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006401,NDC,2,ML,31.46,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.4154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006401,NDC,2,ML,31.46,,United Healthcare,All Medicare advantage plans,outpatient,49,,13.925,percent of total billed charges,15.4154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
metroNIDAZOLE 500 MG/100ML Solution 100 mL Flex Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,409781124,NDC,100,ML,32.12,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,15.4176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,31.4776
metroNIDAZOLE 500 MG/100ML Solution 100 mL Flex Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,409781124,NDC,100,ML,32.12,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,15.4176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,31.4776
Thyroglobulin Antibody,PX8680090,CDM,300,RC,86800,CPT,90,,,,,,,68,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,15.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.43,15.91
Thyroglobulin Antibody,PX8680090,CDM,300,RC,86800,CPT,90,,,,,,,68,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,15.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.43,15.91
Thyroglobulin Antibody,PX8680090,CDM,300,RC,86800,CPT,90,,,,,,,68,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,15.43,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.43,15.91
Dx Occult Blood Immunoassay,PX82274,CDM,300,RC,82274,CPT,,,,,,,,105,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,15.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.44,15.92
Dx Occult Blood Immunoassay,PX82274,CDM,300,RC,82274,CPT,,,,,,,,105,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,15.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.44,15.92
Dx Occult Blood Immunoassay,PX82274,CDM,300,RC,82274,CPT,,,,,,,,105,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,15.44,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.44,15.92
Anes Dx Shoulder Arthroscopy,PX01622.01,CDM,964,RC,1622,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Lower Intestinal Endoscopic Px Nos,PX00811.01,CDM,964,RC,811,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Lower Intestinal Screening Colonoscopy,PX00812.01,CDM,964,RC,812,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Spine Transthor W/Vent,PX00626.01,CDM,964,RC,626,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Spine Tranthor W/O Vent,PX00625.01,CDM,964,RC,625,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Ther Interven Rad Art,PX01924.01,CDM,964,RC,1924,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Ther Interven Rad Car,PX01925.01,CDM,964,RC,1925,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Ther Interven Rad Tip,PX01931.01,CDM,964,RC,1931,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Ther Interven Rad Vei,PX01930.01,CDM,964,RC,1930,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Tx Interv Rad Cran V,PX01933.01,CDM,964,RC,1933,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Tx Interv Rad Hrt/Cran,PX01926.01,CDM,964,RC,1926,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Tx Interv Rad Th Vein,PX01932.01,CDM,964,RC,1932,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Upper GI Endoscopic Px Ercp,PX00732.01,CDM,964,RC,732,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Upper GI Endoscopic Px Nos,PX00731.01,CDM,964,RC,731,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Upper/Lower GI Endoscopic Px,PX00813.01,CDM,964,RC,813,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes/Analg Cs Deliver Add-On,PX01968.01,CDM,964,RC,1968,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Abdomen Vessel Surg,PX00880.01,CDM,964,RC,880,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Abdominal Wall Surg,PX00700.01,CDM,964,RC,700,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Abdominal Wall Surg,PX00730.01,CDM,964,RC,730,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Abdominal Wall Surg,PX00800.01,CDM,964,RC,800,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Abdominal Wall Surg,PX00820.01,CDM,964,RC,820,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Achilles Tendon Surg,PX01472.01,CDM,964,RC,1472,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Airplane Cast,PX01682.01,CDM,964,RC,1682,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Amniocentesis,PX00842.01,CDM,964,RC,842,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Amputation at Knee,PX01404.01,CDM,964,RC,1404,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Amputation at Pelvis,PX01140.01,CDM,964,RC,1140,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Amputation of Femur,PX01232.01,CDM,964,RC,1232,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Amputation of Penis,PX00932.01,CDM,964,RC,932,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Ankle Replacement,PX01486.01,CDM,964,RC,1486,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Ankle/Ft Arthroscopy,PX01464.01,CDM,964,RC,1464,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Anorectal Surgery,PX00902.01,CDM,964,RC,902,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Antepartum Manipul,PX01958.01,CDM,964,RC,1958,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Arm-Leg Vessel Surg,PX01656.01,CDM,964,RC,1656,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Arthroscopy of Hip,PX01202.01,CDM,964,RC,1202,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Biceps Tendon Repair,PX01716.01,CDM,964,RC,1716,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Biopsy of Nose,PX00164.01,CDM,964,RC,164,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Biopsy of Thyroid,PX00322.01,CDM,964,RC,322,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Bladder Stone Surg,PX00870.01,CDM,964,RC,870,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Bladder Surgery,PX00910.01,CDM,964,RC,910,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Bladder Tumor Surg,PX00912.01,CDM,964,RC,912,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Bleeding Control,PX00916.01,CDM,964,RC,916,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Blepharoplasty,PX00103.01,CDM,964,RC,103,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Blood Vessel Repair,PX00770.01,CDM,964,RC,770,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Body Cast Procedure,PX01130.01,CDM,964,RC,1130,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Bone Aspirate/Bx,PX01112.01,CDM,964,RC,1112,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Burn 4-9 Percent,PX01952.01,CDM,964,RC,1952,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Burn Each 9 Percent,PX01953.01,CDM,964,RC,1953,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Burn Less 4 Percent,PX01951.01,CDM,964,RC,1951,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cabg W/O Pump,PX00566.01,CDM,964,RC,566,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cabg W/Pump,PX00567.01,CDM,964,RC,567,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cardiac Electrophys,PX00537.01,CDM,964,RC,537,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cardioverter/Defib,PX00534.01,CDM,964,RC,534,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cat or MRI Scan,PX01922.01,CDM,964,RC,1922,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Catheterize Heart,PX01920.01,CDM,964,RC,1920,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Drainage,PX00524.01,CDM,964,RC,524,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Lining Biopsy,PX00522.01,CDM,964,RC,522,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Partition View,PX00528.01,CDM,964,RC,528,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Partition View,PX00529.01,CDM,964,RC,529,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Procedure,PX00520.01,CDM,964,RC,520,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Surgery,PX00540.01,CDM,964,RC,540,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Wall Repair,PX00472.01,CDM,964,RC,472,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cleft Palate Repair,PX00172.01,CDM,964,RC,172,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Collar Bone Biopsy,PX00454.01,CDM,964,RC,454,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Corneal Transplant,PX00144.01,CDM,964,RC,144,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Correct Heart Rhythm,PX00410.01,CDM,964,RC,410,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cran Surg Hemotoma,PX00211.01,CDM,964,RC,211,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cranial Surg Nos,PX00210.01,CDM,964,RC,210,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cs Delivery,PX01961.01,CDM,964,RC,1961,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cs Hysterectomy,PX01963.01,CDM,964,RC,1963,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Dx Arteriography,PX01916.01,CDM,964,RC,1916,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Dx Elbow Arthroscopy,PX01732.01,CDM,964,RC,1732,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Dx Knee Arthroscopy,PX01382.01,CDM,964,RC,1382,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Dx Wrist Arthroscopy,PX01829.01,CDM,964,RC,1829,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Ear Exam,PX00124.01,CDM,964,RC,124,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Ear Surgery,PX00120.01,CDM,964,RC,120,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Elbow Area Surgery,PX01710.01,CDM,964,RC,1710,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Elbow Replacement,PX01760.01,CDM,964,RC,1760,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Electroshock,PX00104.01,CDM,964,RC,104,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Emer Hysterectomy,PX01962.01,CDM,964,RC,1962,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Esophageal Surgery,PX00500.01,CDM,964,RC,500,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Eye Exam,PX00148.01,CDM,964,RC,148,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Face/Skull Bone Surg,PX00190.01,CDM,964,RC,190,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Facial Bone Surgery,PX00192.01,CDM,964,RC,192,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Fat Layer Removal,PX00802.01,CDM,964,RC,802,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Femoral Artery Surg,PX01272.01,CDM,964,RC,1272,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Femoral Embolectomy,PX01274.01,CDM,964,RC,1274,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth for Chemonucleolysis,PX00634.01,CDM,964,RC,634,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth for Liver Biopsy,PX00702.01,CDM,964,RC,702,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth for Liver Transplant,PX00796.01,CDM,964,RC,796,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Forequarter Amput,PX01636.01,CDM,964,RC,1636,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Fx Repair Pelvis,PX01173.01,CDM,964,RC,1173,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Genitalia Surgery,PX00920.01,CDM,964,RC,920,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Head Nerve Surgery,PX00222.01,CDM,964,RC,222,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Head Vessel Surgery,PX00216.01,CDM,964,RC,216,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Head/Neck/Ptrunk,PX00300.01,CDM,964,RC,300,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Heart Surg < 1 Yr,PX00561.01,CDM,964,RC,561,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Heart Surg W/Arrest,PX00563.01,CDM,964,RC,563,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Heart Surg W/O Pump,PX00560.01,CDM,964,RC,560,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Heart/Lung Transplnt,PX00580.01,CDM,964,RC,580,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hemorr/Excise Liver,PX00792.01,CDM,964,RC,792,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hernia Repair < 1 Yr,PX00834.01,CDM,964,RC,834,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hernia Repair Preemie,PX00836.01,CDM,964,RC,836,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hip Arthroplasty,PX01214.01,CDM,964,RC,1214,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hip Disarticulation,PX01212.01,CDM,964,RC,1212,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hip Joint Procedure,PX01200.01,CDM,964,RC,1200,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hip Joint Surgery,PX01210.01,CDM,964,RC,1210,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hrt Surg W/Pmp Age 1+,PX00562.01,CDM,964,RC,562,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Humeral Lesion Surg,PX01758.01,CDM,964,RC,1758,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Humerus Repair,PX01744.01,CDM,964,RC,1744,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Humerus Surgery,PX01742.01,CDM,964,RC,1742,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hysterectomy,PX00846.01,CDM,964,RC,846,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hysteroscope/Graph,PX00952.01,CDM,964,RC,952,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Inc/Missed Ab Proc,PX01965.01,CDM,964,RC,1965,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Induced Ab Procedure,PX01966.01,CDM,964,RC,1966,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Insert Penis Device,PX00938.01,CDM,964,RC,938,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Intrcrn Nerve,PX00220.01,CDM,964,RC,220,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Iridectomy,PX00147.01,CDM,964,RC,147,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Kidney Stone Destruct,PX00872.01,CDM,964,RC,872,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Kidney Stone Destruct,PX00873.01,CDM,964,RC,873,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Kidney Transplant,PX00868.01,CDM,964,RC,868,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Kidney/Ureter Surg,PX00862.01,CDM,964,RC,862,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Area Procedure,PX01340.01,CDM,964,RC,1340,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Area Procedure,PX01390.01,CDM,964,RC,1390,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Area Surgery,PX01320.01,CDM,964,RC,1320,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Area Surgery,PX01360.01,CDM,964,RC,1360,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Area Surgery,PX01392.01,CDM,964,RC,1392,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Arteries Surg,PX01440.01,CDM,964,RC,1440,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Artery Repair,PX01444.01,CDM,964,RC,1444,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Artery Surg,PX01442.01,CDM,964,RC,1442,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Arthroplasty,PX01402.01,CDM,964,RC,1402,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Joint Casting,PX01420.01,CDM,964,RC,1420,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Joint Procedure,PX01380.01,CDM,964,RC,1380,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Joint Surgery,PX01400.01,CDM,964,RC,1400,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Veins Surgery,PX01430.01,CDM,964,RC,1430,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Vessel Surg,PX01432.01,CDM,964,RC,1432,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Larynx/Trach < 1 Yr,PX00326.01,CDM,964,RC,326,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Leg Arteries Surg,PX01500.01,CDM,964,RC,1500,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lens Surgery,PX00142.01,CDM,964,RC,142,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Low Intestine Scope,PX00810.01,CDM,964,RC,810,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Arm Casting,PX01860.01,CDM,964,RC,1860,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Arm Procedure,PX01820.01,CDM,964,RC,1820,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Arm Surgery,PX01810.01,CDM,964,RC,1810,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Arm Surgery,PX01830.01,CDM,964,RC,1830,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Arm Vein Surg,PX01850.01,CDM,964,RC,1850,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Bone Surg,PX01480.01,CDM,964,RC,1480,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Casting,PX01490.01,CDM,964,RC,1490,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Procedure,PX01462.01,CDM,964,RC,1462,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Revision,PX01484.01,CDM,964,RC,1484,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Surgery,PX01470.01,CDM,964,RC,1470,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Surgery,PX01474.01,CDM,964,RC,1474,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Vein Surg,PX01520.01,CDM,964,RC,1520,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Vein Surg,PX01522.01,CDM,964,RC,1522,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lumbar Puncture,PX00635.01,CDM,964,RC,635,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lung Chest Wall Surg,PX00546.01,CDM,964,RC,546,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lwr Arm Artery Surg,PX01840.01,CDM,964,RC,1840,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lwr Arm Embolectomy,PX01842.01,CDM,964,RC,1842,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lwr Arm Vein Repair,PX01852.01,CDM,964,RC,1852,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lwr Leg Embolectomy,PX01502.01,CDM,964,RC,1502,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Major Vein Ligation,PX00882.01,CDM,964,RC,882,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth N Block/Inj Prone,PX01992.01,CDM,964,RC,1992,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Neck Organ 1 & Over,PX00320.01,CDM,964,RC,320,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Neck Vessel Surgery,PX00350.01,CDM,964,RC,350,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Neck Vessel Surgery,PX00352.01,CDM,964,RC,352,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Nerve Block/Inj,PX01991.01,CDM,964,RC,1991,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Nose/Sinus Surgery,PX00160.01,CDM,964,RC,160,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Nose/Sinus Surgery,PX00162.01,CDM,964,RC,162,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth One Lung Ventilation,PX00541.01,CDM,964,RC,541,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pacemaker Insertion,PX00530.01,CDM,964,RC,530,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pancreas Removal,PX00794.01,CDM,964,RC,794,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvic Organ Surg,PX00848.01,CDM,964,RC,848,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvic Tumor Surgery,PX01150.01,CDM,964,RC,1150,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvis Nerve Removal,PX01180.01,CDM,964,RC,1180,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvis Nerve Removal,PX01190.01,CDM,964,RC,1190,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvis Procedure,PX01160.01,CDM,964,RC,1160,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvis Surgery,PX00844.01,CDM,964,RC,844,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvis Surgery,PX01120.01,CDM,964,RC,1120,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvis Surgery,PX01170.01,CDM,964,RC,1170,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Penis Nodes Removal,PX00934.01,CDM,964,RC,934,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Penis Nodes Removal,PX00936.01,CDM,964,RC,936,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Perc Img Dx Sp Proc,PX01935.01,CDM,964,RC,1935,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Perc Img Tx Sp Proc,PX01936.01,CDM,964,RC,1936,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Perineal Surgery,PX00904.01,CDM,964,RC,904,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pharyngeal Surgery,PX00174.01,CDM,964,RC,174,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pharyngeal Surgery,PX00176.01,CDM,964,RC,176,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Procedure on Femur,PX01220.01,CDM,964,RC,1220,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Procedure on Mouth,PX00170.01,CDM,964,RC,170,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Procedures on Eye,PX00140.01,CDM,964,RC,140,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Radical Femur Surg,PX01234.01,CDM,964,RC,1234,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Radical Humerus Surg,PX01756.01,CDM,964,RC,1756,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Radical Leg Surgery,PX01482.01,CDM,964,RC,1482,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Release of Lung,PX00542.01,CDM,964,RC,542,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Adrenal,PX00866.01,CDM,964,RC,866,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Bladder,PX00864.01,CDM,964,RC,864,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Nerves,PX00622.01,CDM,964,RC,622,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Nerves,PX00632.01,CDM,964,RC,632,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Prostate,PX00865.01,CDM,964,RC,865,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Prostate,PX00908.01,CDM,964,RC,908,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Rib,PX00470.01,CDM,964,RC,470,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Testis,PX00926.01,CDM,964,RC,926,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Testis,PX00928.01,CDM,964,RC,928,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Vulva,PX00906.01,CDM,964,RC,906,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Cervix,PX00948.01,CDM,964,RC,948,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Cleft Lip,PX00102.01,CDM,964,RC,102,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Hernia,PX00750.01,CDM,964,RC,750,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Hernia,PX00752.01,CDM,964,RC,752,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Hernia,PX00754.01,CDM,964,RC,754,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Hernia,PX00756.01,CDM,964,RC,756,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Hernia,PX00830.01,CDM,964,RC,830,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Hernia,PX00832.01,CDM,964,RC,832,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Revise Hip Repair,PX01215.01,CDM,964,RC,1215,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Salivary Gland,PX00100.01,CDM,964,RC,100,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Artery Surg,PX01650.01,CDM,964,RC,1650,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Casting,PX01680.01,CDM,964,RC,1680,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Joint Amput,PX01634.01,CDM,964,RC,1634,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Procedure,PX01620.01,CDM,964,RC,1620,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Replacement,PX01638.01,CDM,964,RC,1638,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Vein Surg,PX01670.01,CDM,964,RC,1670,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Vessel Surg,PX01652.01,CDM,964,RC,1652,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Vessel Surg,PX01654.01,CDM,964,RC,1654,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Sitting Procedure,PX00604.01,CDM,964,RC,604,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Skin Ext/per/Atrunk,PX00400.01,CDM,964,RC,400,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Skull Drainage,PX00212.01,CDM,964,RC,212,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Skull Drainage,PX00214.01,CDM,964,RC,214,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Skull Repair/Fract,PX00215.01,CDM,964,RC,215,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Special Head Surgery,PX00218.01,CDM,964,RC,218,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Sperm Duct Surgery,PX00922.01,CDM,964,RC,922,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Spine Cord Surgery,PX00600.01,CDM,964,RC,600,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Spine Cord Surgery,PX00620.01,CDM,964,RC,620,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Spine Cord Surgery,PX00630.01,CDM,964,RC,630,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Spine Cord Surgery,PX00670.01,CDM,964,RC,670,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Spine Manipulation,PX00640.01,CDM,964,RC,640,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Sternal Debridement,PX00550.01,CDM,964,RC,550,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Stone Removal,PX00918.01,CDM,964,RC,918,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surg Lower Abdomen,PX00840.01,CDM,964,RC,840,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surg on Vag/Urethral,PX00942.01,CDM,964,RC,942,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surg Upper Abdomen,PX00790.01,CDM,964,RC,790,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery for Obesity,PX00797.01,CDM,964,RC,797,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Abdomen,PX00860.01,CDM,964,RC,860,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Breast,PX00402.01,CDM,964,RC,402,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Breast,PX00404.01,CDM,964,RC,404,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Breast,PX00406.01,CDM,964,RC,406,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Femur,PX01230.01,CDM,964,RC,1230,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Rib(S),PX00474.01,CDM,964,RC,474,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Shoulder,PX00450.01,CDM,964,RC,450,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Shoulder,PX00452.01,CDM,964,RC,452,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Shoulder,PX01610.01,CDM,964,RC,1610,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Shoulder,PX01630.01,CDM,964,RC,1630,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Testis Exploration,PX00924.01,CDM,964,RC,924,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Testis Suspension,PX00930.01,CDM,964,RC,930,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Thigh Arteries Surg,PX01270.01,CDM,964,RC,1270,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Trach-Bronch Reconst,PX00539.01,CDM,964,RC,539,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Trachea Bronchi Surg,PX00548.01,CDM,964,RC,548,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Trans Resect of Prostate,PX00914.01,CDM,964,RC,914,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Tubal Ligation,PX00851.01,CDM,964,RC,851,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Tympanotomy,PX00126.01,CDM,964,RC,126,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Upper Arm Surgery,PX01740.01,CDM,964,RC,1740,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Upper Arm Vein Surg,PX01780.01,CDM,964,RC,1780,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Upper GI Visualize,PX00740.01,CDM,964,RC,740,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Upper Leg Surgery,PX01250.01,CDM,964,RC,1250,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Upper Leg Veins Surg,PX01260.01,CDM,964,RC,1260,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Uppr Arm Artery Surg,PX01770.01,CDM,964,RC,1770,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Uppr Arm Embolectomy,PX01772.01,CDM,964,RC,1772,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Uppr Arm Procedure,PX01730.01,CDM,964,RC,1730,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Uppr Arm Tendon Surg,PX01712.01,CDM,964,RC,1712,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Uppr Arm Tendon Surg,PX01714.01,CDM,964,RC,1714,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Uppr Arm Vein Repair,PX01782.01,CDM,964,RC,1782,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vaginal Delivery,PX01960.01,CDM,964,RC,1960,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vaginal Endoscopy,PX00950.01,CDM,964,RC,950,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vaginal Hysterectomy,PX00944.01,CDM,964,RC,944,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vaginal Procedures,PX00940.01,CDM,964,RC,940,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vascular Access,PX00532.01,CDM,964,RC,532,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vascular Shunt Surg,PX01844.01,CDM,964,RC,1844,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vasectomy,PX00921.01,CDM,964,RC,921,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vitreoretinal Surg,PX00145.01,CDM,964,RC,145,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Wrist Replacement,PX01832.01,CDM,964,RC,1832,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth/Analg Cs Hyst Add-On,PX01969.01,CDM,964,RC,1969,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth/Analg Vag Delivery,PX01967.01,CDM,964,RC,1967,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Hosp Manage Cont Drug Admin,PX01996.01,CDM,964,RC,1996,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
IMMOBILIZER SHOULDER LARGE 9008-03,120.38,CDM,274,RC,L3650,HCPCS,,906-MAIN,LOCAL,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER LARGE STRAP OSG3033,120.38,CDM,274,RC,L3650,HCPCS,,2910-MAIN,LOCAL,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER MEDIUM 9008-02,120.38,CDM,274,RC,L3650,HCPCS,,912-MAIN,LOCAL,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER MEDIUM OSG3032,120.38,CDM,274,RC,L3650,HCPCS,,915-MAIN,LOCAL,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER SMALL 9008-01,120.38,CDM,274,RC,L3650,HCPCS,,913-MAIN,LOCAL,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER SMALL WITH CLOTH 9001-02,120.38,CDM,274,RC,L3650,HCPCS,,914-MAIN,LOCAL,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER X-LARGE CLOTH 9001-05,120.38,CDM,274,RC,L3650,HCPCS,,917-MAIN,LOCAL,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER X-LARGE ORT16100XL,120.38,CDM,274,RC,L3650,HCPCS,,904-MAIN,LOCAL,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
Support for Organ Donor,PX01990.01,CDM,964,RC,1990,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Treponema Pallidum,PX86780,CDM,300,RC,86780,CPT,,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.14,35.28
Unlisted Anesth Procedure,PX01999.01,CDM,964,RC,1999,CPT,QZ,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405P,CDM,983,RC,36405,CPT,,,,,,,,36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049236,NDC,5,ML,31.52,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.4448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049236,NDC,5,ML,31.52,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.4448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049236,NDC,5,ML,31.52,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,15.4448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049243,NDC,5,ML,31.52,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.4448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049243,NDC,5,ML,31.52,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.4448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049243,NDC,5,ML,31.52,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,15.4448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Joint Survey,PX7707726,CDM,982,RC,77077,CPT,26,,,,,,,286,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,15.4464,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.25,280.28
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,49348009529,NDC,15,ML,30.53,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.44818,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Cmv Igm Antibody - Ref,PX8664590,CDM,300,RC,86645,CPT,90,,,,,,,125,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,15.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.45,122.5
Helicobacter Pylori Ab,PX86677,CDM,300,RC,86677,CPT,,,,,,,,224,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,15.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.45,219.52
"West Nile Ab, Igm - Ref",PX8678890,CDM,300,RC,86788,CPT,90,,,,,,,109,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,15.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.45,106.82
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060002,NDC,2,ML,953.57,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,15.46,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.46,17.58
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060010,NDC,2,ML,953.57,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,15.46,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.46,17.58
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061601,NDC,3,ML,31.57,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.4693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061601,NDC,3,ML,31.57,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.4693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061601,NDC,3,ML,31.57,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,15.4693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058003,NDC,0.5,ML,31.57,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.4693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058003,NDC,0.5,ML,31.57,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.4693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058003,NDC,0.5,ML,31.57,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,15.4693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058020,NDC,0.5,ML,31.57,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.4693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058020,NDC,0.5,ML,31.57,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.4693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058020,NDC,0.5,ML,31.57,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,15.4693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061416,NDC,0.5,ML,31.57,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.4693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.114178,99.911
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061416,NDC,0.5,ML,31.57,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.4693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.114178,99.911
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061416,NDC,0.5,ML,31.57,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,15.4693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.114178,99.911
nadolol 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,76385013301,NDC,1,EA,18.2,,First Health,Commercial,both,85,,999999999,percent of total billed charges,15.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Acylcarnitines, Quant - Ref",PX8201790,CDM,300,RC,82017,CPT,90,,,,,,,110,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,15.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.47,107.8
Carnitine - Ref,PX8237990,CDM,300,RC,82379,CPT,90,,,,,,,104,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,15.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.47,101.92
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092821,NDC,1,ML,32.23,,Health Partners,Health Partners Care Plans,both,48,,14.96,percent of total billed charges,15.4704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,31.5854
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092821,NDC,1,ML,32.23,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,15.4704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,31.5854
VAGINAL PACKING 2',120.292,CDM,272,RC,,,,829-MAIN,LOCAL,,,,,32.23,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,15.4704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.388342,31.5854
VAGINAL PACKING 2',120.292,CDM,272,RC,,,,829-MAIN,LOCAL,,,,,32.23,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,15.4704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.388342,31.5854
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010125,NDC,1,ML,30.58,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.47348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323048541,NDC,20,ML,30.58,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.47348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
carbamide peroxide 6.5% 6.5 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904322035,NDC,15,ML,15.79,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,15.4742,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
EPINEPHrine 30 MG/30ML Solution 30 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023016801,NDC,0.3,ML,32.24,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,15.4752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 30 MG/30ML Solution 30 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023016801,NDC,0.3,ML,32.24,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,15.4752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
RESERVOIR WOUND DRAIN 15FR,27200000,CDM,272,RC,,,,4386-MAIN,LOCAL,,,,,30.6,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.4836,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SET DISPOSABLE COLLECTION,27100000,CDM,271,RC,,,,5439-MAIN,LOCAL,,,,,30.6,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.4836,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
SUTURE NUROLON 0 BLACK C527D,27200000,CDM,272,RC,,,,10415-MAIN,LOCAL,,,,,30.6,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.4836,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68382019616,NDC,1,EA,17.4,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,15.486,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Basic Metabolic Panel Ca Ion,PX80047,CDM,300,RC,80047,CPT,,,,,,,,17,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,15.487,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.0618,16.66
bendamustine 100 MG/4ML Solution 4 mL Vial,800000,CDM,,,J9034,HCPCS,,,,63459034804,NDC,4,ML,5046.55,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,15.49,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.53,15.49
Insert Simple Cath Foley,PX51702F,CDM,510,RC,51702,CPT,,,,,,,,198,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,15.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.27,129.37
Insert Simple Cath Foley,PX51702F,CDM,510,RC,51702,CPT,,,,,,,,198,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,15.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.27,129.37
Insert Straight Catheter,PX51701F,CDM,510,RC,51701,CPT,,,,,,,,168,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,15.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.27,92.7
Insert Straight Catheter,PX51701F,CDM,510,RC,51701,CPT,,,,,,,,168,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,15.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.27,92.7
"Lyme Disease, Confirm Tst - Ref",PX8661790,CDM,300,RC,86617,CPT,90,,,,,,,95,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,15.49,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.03,15.49
X-Ray Exam Chest 2 Views,PX7104601,CDM,320,RC,71046,CPT,TC,,,,,,,556,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,15.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.27,46.02
X-Ray Exam Chest 2 Views,PX7104601,CDM,320,RC,71046,CPT,TC,,,,,,,556,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,15.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.27,46.02
Xray Thoracic Spine 2 Vws,PX7207001,CDM,320,RC,72070,CPT,TC,,,,,,,428,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,15.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.27,46.02
Xray Thoracic Spine 2 Vws,PX7207001,CDM,320,RC,72070,CPT,TC,,,,,,,428,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,15.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.27,46.02
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,67457043800,NDC,0.5,EA,36.11,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.49119,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,67457043810,NDC,0.5,EA,36.11,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.49119,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
riFAMpin 150 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,527139330,NDC,1,EA,17.41,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,15.4949,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
riFAMpin 150 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,68180065806,NDC,1,EA,17.41,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,15.4949,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028036,NDC,2,ML,36.12,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.49548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,6.215714286,percent of total billed charges,15.4987,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.4987,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,15.4987,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,6.215714286,percent of total billed charges,15.4987,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.4987,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,15.4987,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
Viral Neutralization - Ref,PX8638290,CDM,300,RC,86382,CPT,90,,,,,,,28,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,15.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
clarithromycin 250 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,527193106,NDC,1,EA,32.3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,15.504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clarithromycin 250 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,527193106,NDC,1,EA,32.3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,15.504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clarithromycin 250 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,65862022560,NDC,1,EA,32.3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,15.504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clarithromycin 250 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,65862022560,NDC,1,EA,32.3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,15.504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323020103,NDC,10,ML,36.14,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.50406,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
meloxicam 7.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,29300012401,NDC,1,EA,17.02,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,15.50522,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 2 % Ointment 1 g Packet,63700001,CDM,250,RC,,,,,,281032608,NDC,1,GR,17.58,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,15.50556,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
colchicine 0.6 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,49884017111,NDC,1,EA,36.17,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.51693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famciclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,93811956,NDC,0.25,EA,17.04,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,15.52344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Metanephrines - Ref,PX8383590,CDM,300,RC,83835,CPT,90,,,,,,,34,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,15.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1236,33.32
"Triiodothyronine T3, Free (Free T3)",PX84481,CDM,300,RC,84481,CPT,,,,,,,,137,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,15.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.53,134.26
pancrelipase (lip-prot-amyl) 24000-76000 units Capsule Delayed Release Particles 100 Each Bottle,63700001,CDM,250,RC,,,,,,32122401,NDC,1,EA,37.41,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.540114,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine HCl 4 % Cream 76.5 g Tube,63700001,CDM,250,RC,,,,,,41167005820,NDC,76.5,GR,31.72,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.5428,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine HCl 4 % Cream 76.5 g Tube,63700001,CDM,250,RC,,,,,,41167005820,NDC,76.5,GR,31.72,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.5428,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine HCl 4 % Cream 76.5 g Tube,63700001,CDM,250,RC,,,,,,41167005820,NDC,76.5,GR,31.72,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,15.5428,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Office/Outpt Visit Est Level I,PX99211F,CDM,510,RC,99211,CPT,,,,,,,,119,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,15.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.46,41.86
Office/Outpt Visit Est Level I,PX99211P,CDM,983,RC,99211,CPT,,,,,,,,119,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,15.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.46,116.62
lactulose 10 GM/15ML Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,50383077915,NDC,15,ML,15.98,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,15.553334,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,36000003310,NDC,5,ML,30.74,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.55444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189101,NDC,1,ML,32.43,,Health Partners,Health Partners Care Plans,both,48,,31.91333333,percent of total billed charges,15.5664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189101,NDC,1,ML,32.43,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,15.5664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006401,NDC,2,ML,31.46,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,15.5727,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
"BINDER ABDOMINAL 12"" HIGH 30-45INCH 4 PANEL ORT21300SM",120.238,CDM,271,RC,A4467,HCPCS,,11934-MAIN,LOCAL,,,,,16,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,15.5728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
DRESSING OPTIFOAM 10X4 POST-OP SILICONE FACED MSC21410Z,120.154,CDM,272,RC,A6213,HCPCS,,8632-MAIN,LOCAL,,,,,16,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,15.5728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,15.68
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022143,NDC,1,EA,36.31,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.57699,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
"CUFF STERILE DISPOSABLE SPSB 24""",27200000,CDM,272,RC,,,,7437-MAIN,LOCAL,,,,,37.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.5775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ENDOCAVITY NEEDLE GUIDE,27200000,CDM,272,RC,,,,11134-MAIN,LOCAL,,,,,37.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.5775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR KII BALOON 5X100MM STERILE,27200000,CDM,272,RC,,,,11701-MAIN,LOCAL,,,,,37.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.5775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Thyroglobulin - Ref,PX8443290,CDM,300,RC,84432,CPT,90,,,,,,,68,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,15.58,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.58,16.06
Thyroglobulin - Ref,PX8443290,CDM,300,RC,84432,CPT,90,,,,,,,68,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,15.58,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.58,16.06
Thyroglobulin - Ref,PX8443290,CDM,300,RC,84432,CPT,90,,,,,,,68,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,15.58,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.58,16.06
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022116,NDC,1,EA,36.33,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.58557,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022141,NDC,1,EA,36.33,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.58557,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
dutasteride 0.5 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,42806054909,NDC,1,EA,32.49,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,15.5952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dutasteride 0.5 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,42806054909,NDC,1,EA,32.49,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,15.5952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bacitracin zinc 500 UNIT/GM Ointment 28.35 g Tube,25000000,CDM,250,RC,,,,,,168001131,NDC,28.35,GR,32.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,15.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
bacitracin zinc 500 UNIT/GM Ointment 28.35 g Tube,25000000,CDM,250,RC,,,,,,168001131,NDC,28.35,GR,32.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,15.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049236,NDC,5,ML,31.52,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,15.6024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049243,NDC,5,ML,31.52,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,15.6024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Lyme Disease Antibody,PX86618,CDM,300,RC,86618,CPT,,,,,,,,194,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,15.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.61,190.12
"Lyme Disease, Antibody - Ref",PX8661890,CDM,300,RC,86618,CPT,90,,,,,,,181,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,15.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.61,177.38
Lyme Screen,PX7585,CDM,300,RC,86618,CPT,,,,,,,,198,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,15.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.61,194.04
DULoxetine 20 MG Capsule Delayed Release Particles 60 Each Bottle,63700001,CDM,250,RC,,,,,,57237001760,NDC,1,EA,37.58,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.610732,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061601,NDC,3,ML,31.57,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,15.62715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058003,NDC,0.5,ML,31.57,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,15.62715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058020,NDC,0.5,ML,31.57,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,15.62715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061416,NDC,0.5,ML,31.57,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,15.62715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.114178,99.911
pioglitazone 15 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342005410,NDC,1,EA,37.62,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.627348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048226,NDC,20,ML,32.56,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,15.6288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048226,NDC,20,ML,32.56,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,15.6288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048241,NDC,20,ML,32.56,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,15.6288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048241,NDC,20,ML,32.56,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,15.6288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641600101,NDC,1,ML,32.56,,Health Partners,Health Partners Care Plans,both,48,,17.635,percent of total billed charges,15.6288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641600101,NDC,1,ML,32.56,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,15.6288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
"Cognitive Funct Ther Interv, Initial 15 Min",PX97129,CDM,420,RC,97129,CPT,,,,,,,,85,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,15.63,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.63,29.43
"pediatric electrolyte Solution 1,000 mL Bottle",25000000,CDM,250,RC,,,,,,49348057041,NDC,1000,ML,31.9,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.631,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"pediatric electrolyte Solution 1,000 mL Bottle",25000000,CDM,250,RC,,,,,,49348057041,NDC,1000,ML,31.9,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.631,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"pediatric electrolyte Solution 1,000 mL Bottle",25000000,CDM,250,RC,,,,,,49348057041,NDC,1000,ML,31.9,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,15.631,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
DRAPE SHEET 70X85 LARGE DYNJP2417,27200000,CDM,272,RC,,,,10914-MAIN,LOCAL,,,,,18.39,,First Health,Commercial,both,85,,999999999,percent of total billed charges,15.6315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Flex Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707526,NDC,100,ML,37.63,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.631502,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,487960130,NDC,2,ML,36.47,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.64563,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
nitroglycerin 2 % Ointment 1 g Packet,63700001,CDM,250,RC,,,,,,281032608,NDC,1,GR,17.58,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,15.6462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,15.65685,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,15.65685,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
lactulose 10 GM/15ML Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,50383077915,NDC,15,ML,15.98,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,15.6604,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,55150023501,NDC,0.5,EA,37.72,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.668888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,409710709,NDC,1000,ML,36.53,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.67137,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5% and sodium chloride 0.45% with potassium chloride 10 mEq in 1000 mL 10-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,264763400,NDC,1000,ML,36.53,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.67137,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057811,NDC,0.5,ML,30.98,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.67588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057841,NDC,0.5,ML,30.98,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.67588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
BANDAGE COBAN  4 IN 2 LAYER COMPRESSION SYSTEM  2094N,120.549,CDM,272,RC,A6441,HCPCS,,12366-MAIN,LOCAL,,,,,32,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.2928,31.36
BANDAGE COBAN  4 IN 2 LAYER COMPRESSION SYSTEM  2094N,120.549,CDM,272,RC,A6441,HCPCS,,12366-MAIN,LOCAL,,,,,32,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.2928,31.36
BANDAGE COBAN  4 IN 2 LAYER COMPRESSION SYSTEM  2094N,120.549,CDM,272,RC,A6441,HCPCS,,12366-MAIN,LOCAL,,,,,32,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,15.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.2928,31.36
BANDAGE COBAN LITE 4 IN 2 LAYER COMPRESSION SYSTEM 2794N,120.549,CDM,272,RC,A6441,HCPCS,,12922-MAIN,LOCAL,,,,,32,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.2928,31.36
BANDAGE COBAN LITE 4 IN 2 LAYER COMPRESSION SYSTEM 2794N,120.549,CDM,272,RC,A6441,HCPCS,,12922-MAIN,LOCAL,,,,,32,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.2928,31.36
BANDAGE COBAN LITE 4 IN 2 LAYER COMPRESSION SYSTEM 2794N,120.549,CDM,272,RC,A6441,HCPCS,,12922-MAIN,LOCAL,,,,,32,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,15.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.2928,31.36
"BINDER ABDOMINAL 12"" HIGH 30-45INCH 4 PANEL ORT21300SM",120.238,CDM,271,RC,A4467,HCPCS,,11934-MAIN,LOCAL,,,,,16,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,15.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
DRESSING OPTIFOAM 10X4 POST-OP SILICONE FACED MSC21410Z,120.154,CDM,272,RC,A6213,HCPCS,,8632-MAIN,LOCAL,,,,,16,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,15.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,15.68
WOUND DRAIN FLAT WITH TROCAR 10MM FULL PERFORATED SILICONE,27200000,CDM,272,RC,,,,12462-MAIN,LOCAL,,,,,32,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
WOUND DRAIN FLAT WITH TROCAR 10MM FULL PERFORATED SILICONE,27200000,CDM,272,RC,,,,12462-MAIN,LOCAL,,,,,32,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
WOUND DRAIN FLAT WITH TROCAR 10MM FULL PERFORATED SILICONE,27200000,CDM,272,RC,,,,12462-MAIN,LOCAL,,,,,32,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,15.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
neomycin-bacitracin-polymyxin 3.5-400-5000 Ointment 28 g Tube,25000000,CDM,250,RC,,,,,,45802014303,NDC,28,GR,37.76,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.685504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
DRAPE ABDOMINAL SURGICAL 14X12 POUCHES STERILE DYNJP3109,27200000,CDM,272,RC,,,,12896-MAIN,LOCAL,,,,,31,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LITHOTOMY PACK VIII ECLIPSE,27200000,CDM,272,RC,,,,12210-MAIN,LOCAL,,,,,31,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Rubella Antibody,PX86762,CDM,300,RC,86762,CPT,,,,,,,,31,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.8774,30.38
Beta-2-Microglobulin - Ref,PX8223290,CDM,300,RC,82232,CPT,90,,,,,,,49,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,15.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.69,16.18
Beta-2-Microglobulin - Ref,PX8223290,CDM,300,RC,82232,CPT,90,,,,,,,49,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,15.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.69,16.18
Beta-2-Microglobulin - Ref,PX8223290,CDM,300,RC,82232,CPT,90,,,,,,,49,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,15.69,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.69,16.18
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,185012201,NDC,1,EA,17.23,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,15.69653,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Bile Acids Total,PX8223990,CDM,300,RC,82239,CPT,90,,,,,,,232,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,15.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,227.36
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001103,NDC,1,EA,108.34,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,15.7,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,18.45
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001104,NDC,1,EA,108.29,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,15.7,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,18.45
hydrocortisone sodium succinate (preservative free) 250 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001305,NDC,1,EA,183.32,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,15.7,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,18.45
hydrocortisone sodium succinate (preservative free) 500 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001612,NDC,1,EA,298.53,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,15.7,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,18.45
hydrocortisone sodium succinate (preservative free) 1000 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9000501,NDC,1,EA,403.54,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,15.7,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,18.45
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105F,CDM,510,RC,11105,CPT,,,,,,,,171,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,15.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,123.83
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105F,CDM,510,RC,11105,CPT,,,,,,,,171,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,15.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,123.83
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105F,CDM,510,RC,11105,CPT,,,,,,,,171,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,15.7,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,123.83
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105P,CDM,983,RC,11105,CPT,,,,,,,,171,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,15.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,167.58
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105P,CDM,983,RC,11105,CPT,,,,,,,,171,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,15.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,167.58
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105P,CDM,983,RC,11105,CPT,,,,,,,,171,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,15.7,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,167.58
"X-Ray Exam Hip,Unilat W/Pelvis 1vw",PX7350101,CDM,320,RC,73501,CPT,TC,,,,,,,263,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,15.7,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,47.33
Xray Eye Foreign Body,PX7003001,CDM,320,RC,70030,CPT,TC,,,,,,,432,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,15.7,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,47.99
Xray Hand 2vws Tc,PX7312001,CDM,320,RC,73120,CPT,TC,,,,,,,365,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,15.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.27,46.68
Xray Hand 2vws Tc,PX7312001,CDM,320,RC,73120,CPT,TC,,,,,,,365,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,15.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.27,46.68
Xray Sinuses Less Than 3 Vws,PX7021001,CDM,320,RC,70210,CPT,TC,,,,,,,486,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,15.7,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,47.33
Xray Tibia & Fibula 2 Vws,PX7359001,CDM,320,RC,73590,CPT,TC,,,,,,,365,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,15.7,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,47.33
lidocaine HCl 4 % Cream 76.5 g Tube,63700001,CDM,250,RC,,,,,,41167005820,NDC,76.5,GR,31.72,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,15.7014,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ePHEDrine sulfate 50 MG/ML Solution 1 mL Vial,25000000,CDM,250,RC,,,,,,42023021689,NDC,0.1,ML,36.62,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.70998,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Leptospira Antibody - Ref,PX8672090,CDM,300,RC,86720,CPT,90,,,,,,,220,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,15.71,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.71,16.2
Leptospira Antibody - Ref,PX8672090,CDM,300,RC,86720,CPT,90,,,,,,,220,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,15.71,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.71,16.2
Leptospira Antibody - Ref,PX8672090,CDM,300,RC,86720,CPT,90,,,,,,,220,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,15.71,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.71,16.2
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143966001,NDC,5,ML,37.82,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.710428,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143966010,NDC,5,ML,37.82,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.710428,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409116219,NDC,30,ML,32.07,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.216692234,percent of total billed charges,15.7143,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409116219,NDC,30,ML,32.07,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.7143,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409116219,NDC,30,ML,32.07,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,15.7143,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,55150025110,NDC,10,ML,37.85,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.72289,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pravastatin 10 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,60505016809,NDC,1,EA,17.26,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,15.72386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Beta-2-Microglobulin - Ref,PX8223290,CDM,300,RC,82232,CPT,90,,,,,,,49,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,15.7241,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.69,16.18
Dx Occult Blood Immunoassay,PX82274,CDM,300,RC,82274,CPT,,,,,,,,105,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,15.7241,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.44,15.92
Leptospira Antibody - Ref,PX8672090,CDM,300,RC,86720,CPT,90,,,,,,,220,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,15.7241,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.71,16.2
Thyroglobulin - Ref,PX8443290,CDM,300,RC,84432,CPT,90,,,,,,,68,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,15.7241,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.58,16.06
Thyroglobulin Antibody,PX8680090,CDM,300,RC,86800,CPT,90,,,,,,,68,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,15.7241,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.43,15.91
Strapping of Ankle,PX29540F,CDM,420,RC,29540,CPT,,,,,,,,271,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,15.7339,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.68,58.11
saliva substitute Solution 59 mL Bottle,63700001,CDM,250,RC,,,,,,50930009802,NDC,59,ML,31.1,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.7366,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metroNIDAZOLE 500 MG/100ML Solution 100 mL Flex Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,409781124,NDC,100,ML,32.12,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.7388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,31.4776
metroNIDAZOLE 500 MG/100ML Solution 100 mL Flex Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,409781124,NDC,100,ML,32.12,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.7388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,31.4776
metroNIDAZOLE 500 MG/100ML Solution 100 mL Flex Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,409781124,NDC,100,ML,32.12,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,15.7388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,31.4776
"Admin Hep B,Adult 19+",PX3242,CDM,771,RC,90471,CPT,,,,,,,,48,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,15.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.09,36.07
"Admin Hep B,Adult 19+",PX3242,CDM,771,RC,90471,CPT,,,,,,,,48,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,15.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.09,36.07
Immunization Admin - Influenza,PX3241,CDM,771,RC,90471,CPT,,,,,,,,48,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,15.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.09,36.07
Immunization Admin - Influenza,PX3241,CDM,771,RC,90471,CPT,,,,,,,,48,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,15.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.09,36.07
Immunization Administration; One Vaccine (Single or Combination Vaccine/To*,PX90471,CDM,771,RC,90471,CPT,,,,,,,,130,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,15.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.09,36.07
Immunization Administration; One Vaccine (Single or Combination Vaccine/To*,PX90471,CDM,771,RC,90471,CPT,,,,,,,,130,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,15.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.09,36.07
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,409677802,NDC,1,ML,31.11,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.74166,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143978410,NDC,2,ML,37.91,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.747814,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078121,NDC,0.5,EA,36.75,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.76575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078141,NDC,0.5,EA,36.75,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.76575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Xray Chest 2 Views,PX7102001,CDM,320,RC,71020,CPT,TC,,,,,,,556,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,15.7682,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7682,15.77
Xray Chest 2 Views,PX7102001,CDM,320,RC,71020,CPT,TC,,,,,,,556,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,15.77,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7682,15.77
8MM-12MM CANNULA SEAL 5-8MM,27200000,CDM,272,RC,,,,11921-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.7852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRAPE COLUMN 470341,27200000,CDM,272,RC,,,,12013-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.7852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HH Hha Visit,PXG0156,CDM,571,RC,G0156,HCPCS,,,,,,,,38,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.7852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
Mitochondrial Antibody Each,PX8638190,CDM,300,RC,86381,CPT,90,,,,,,,38,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.7852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
Nasal Sm for Eos,PX89190,CDM,300,RC,89190,CPT,,,,,,,,38,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.7852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.31,37.24
NEEDLE IV 19GA X .75IN HUBER POWERLOC SAFETY 0651934,120.85,CDM,272,RC,A4215,HCPCS,,12701-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.7852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
NEEDLE IV 19GA X 1 IN HUBER POWERLOC SAFETY 0651910,120.85,CDM,272,RC,A4215,HCPCS,,12702-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.7852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
NEEDLE IV 19GA X 1.5 IN HUBER POWERLOC SAFETY 0651915,120.85,CDM,272,RC,A4215,HCPCS,,12703-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.7852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
PEZZER CATHETER DRAIN LATEX 14FR,27200000,CDM,272,RC,,,,12053-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.7852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PEZZER LATEX CATHETER DRAIN 10FR,27200000,CDM,272,RC,,,,12646-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.7852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PNEUVIEW SMOKE ELIMINATOR,27200000,CDM,272,RC,,,,11884-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.7852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Psa, Free - Ref",PX8415490,CDM,300,RC,84154,CPT,90,,,,,,,38,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.7852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
"Psa, Total - Ref",PX8415390,CDM,300,RC,84153,CPT,90,,,,,,,38,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.7852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
SPECULUM VAGINAL WITH BUILT IN LIGHT LARGE,120.133,CDM,272,RC,,,,8251-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.7852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
SPECULUM VAGINAL WITH BUILT IN LIGHT MEDIUM,120.133,CDM,272,RC,,,,8250-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.7852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
SPECULUM VAGINAL WITH BUILT IN LIGHT SMALL,120.133,CDM,272,RC,,,,8249-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.7852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
TROCAR KII FIOS SYSTEM BLADELSS Z-THREAD 5MMX100MM,27200000,CDM,272,RC,,,,12003-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.7852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189103,NDC,1,ML,32.89,,Health Partners,Health Partners Care Plans,both,48,,31.91333333,percent of total billed charges,15.7872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189103,NDC,1,ML,32.89,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,15.7872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
"pediatric electrolyte Solution 1,000 mL Bottle",25000000,CDM,250,RC,,,,,,49348057041,NDC,1000,ML,31.9,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,15.7905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092821,NDC,1,ML,32.23,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.7927,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,31.5854
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092821,NDC,1,ML,32.23,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.7927,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,31.5854
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092821,NDC,1,ML,32.23,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,15.7927,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,31.5854
VAGINAL PACKING 2',120.292,CDM,272,RC,,,,829-MAIN,LOCAL,,,,,32.23,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.7927,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.388342,31.5854
VAGINAL PACKING 2',120.292,CDM,272,RC,,,,829-MAIN,LOCAL,,,,,32.23,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.7927,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.388342,31.5854
VAGINAL PACKING 2',120.292,CDM,272,RC,,,,829-MAIN,LOCAL,,,,,32.23,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,15.7927,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.388342,31.5854
EPINEPHrine 30 MG/30ML Solution 30 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023016801,NDC,0.3,ML,32.24,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,150.5666667,percent of total billed charges,15.7976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 30 MG/30ML Solution 30 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023016801,NDC,0.3,ML,32.24,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.7976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 30 MG/30ML Solution 30 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023016801,NDC,0.3,ML,32.24,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,15.7976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
"Cortisol, Am",PX7152,CDM,300,RC,82533,CPT,,,,,,,,156,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,15.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.81,16.3
"Cortisol, Am",PX7152,CDM,300,RC,82533,CPT,,,,,,,,156,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,15.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.81,16.3
"Cortisol, Am",PX7152,CDM,300,RC,82533,CPT,,,,,,,,156,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,15.81,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.81,16.3
Total Cortisol,PX82533,CDM,300,RC,82533,CPT,,,,,,,,137,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,15.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.81,16.3
Total Cortisol,PX82533,CDM,300,RC,82533,CPT,,,,,,,,137,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,15.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.81,16.3
Total Cortisol,PX82533,CDM,300,RC,82533,CPT,,,,,,,,137,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,15.81,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.81,16.3
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037604,NDC,0.75,ML,36.86,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.81294,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
clarithromycin 250 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,527193106,NDC,1,EA,32.3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.827,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clarithromycin 250 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,527193106,NDC,1,EA,32.3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.827,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clarithromycin 250 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,527193106,NDC,1,EA,32.3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,15.827,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clarithromycin 250 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,65862022560,NDC,1,EA,32.3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.827,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clarithromycin 250 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,65862022560,NDC,1,EA,32.3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.827,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clarithromycin 250 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,65862022560,NDC,1,EA,32.3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,15.827,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Ethanol, P",PX82077,CDM,300,RC,82077,CPT,,,,,,,,30,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,15.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
Immunoassay Nos - Ref,PX8352090,CDM,300,RC,83520,CPT,90,,,,,,,220,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,15.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.83,215.6
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68462033090,NDC,1,EA,17.95,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,15.8319,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253022233,NDC,3,ML,38.13,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.839202,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
BANDAGE COBAN  4 IN 2 LAYER COMPRESSION SYSTEM  2094N,120.549,CDM,272,RC,A6441,HCPCS,,12366-MAIN,LOCAL,,,,,32,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,15.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.2928,31.36
BANDAGE COBAN LITE 4 IN 2 LAYER COMPRESSION SYSTEM 2794N,120.549,CDM,272,RC,A6441,HCPCS,,12922-MAIN,LOCAL,,,,,32,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,15.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.2928,31.36
CATHETER FOLEY 18FR  3WAY 30CC 73018L,120.21,CDM,272,RC,A4346,HCPCS,,253-MAIN,LOCAL,,,,,33,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,15.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
CATHETER FOLEY 18FR  3WAY 30CC 73018L,120.21,CDM,272,RC,A4346,HCPCS,,253-MAIN,LOCAL,,,,,33,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,15.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
CATHETER FOLEY 20FR 3WAY 30CC 0167L20,120.21,CDM,272,RC,A4346,HCPCS,,251-MAIN,LOCAL,,,,,33,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,15.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
CATHETER FOLEY 20FR 3WAY 30CC 0167L20,120.21,CDM,272,RC,A4346,HCPCS,,251-MAIN,LOCAL,,,,,33,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,15.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
CATHETER FOLEY 24FR 3WAY 30CC 0167L24,120.21,CDM,272,RC,A4346,HCPCS,,10455-MAIN,LOCAL,,,,,33,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,15.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
CATHETER FOLEY 24FR 3WAY 30CC 0167L24,120.21,CDM,272,RC,A4346,HCPCS,,10455-MAIN,LOCAL,,,,,33,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,15.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
"DRESSING AQUACEL 3/4"" X 18"" AG HYDROFIBER 403771",120.31,CDM,272,RC,A6199,HCPCS,,8238-MAIN,LOCAL,,,,,33,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,15.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,32.34
"DRESSING AQUACEL 3/4"" X 18"" AG HYDROFIBER 403771",120.31,CDM,272,RC,A6199,HCPCS,,8238-MAIN,LOCAL,,,,,33,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,15.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,32.34
Hospital Outpatient Clinic Visit Specimen Collection for Sars-Cov-2,PXC9803,CDM,300,RC,C9803,HCPCS,,,,,,,,33,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,15.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,32.34
Hospital Outpatient Clinic Visit Specimen Collection for Sars-Cov-2,PXC9803,CDM,300,RC,C9803,HCPCS,,,,,,,,33,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,15.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,32.34
MEPILEX AG 4X4 10X10,120.138,CDM,272,RC,A6213,HCPCS,,7248-MAIN,LOCAL,,,,,33,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,15.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,32.34
MEPILEX AG 4X4 10X10,120.138,CDM,272,RC,A6213,HCPCS,,7248-MAIN,LOCAL,,,,,33,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,15.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,32.34
STANDARD HIGH FLOW INSUFFLATION FILTER TUBING,27200000,CDM,272,RC,,,,11885-MAIN,LOCAL,,,,,33,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,15.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STANDARD HIGH FLOW INSUFFLATION FILTER TUBING,27200000,CDM,272,RC,,,,11885-MAIN,LOCAL,,,,,33,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,15.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
WOUND DRAIN FLAT WITH TROCAR 10MM FULL PERFORATED SILICONE,27200000,CDM,272,RC,,,,12462-MAIN,LOCAL,,,,,32,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,15.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HYDROmorphone 1 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409128303,NDC,1,ML,36.93,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.84297,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
"DXA, Bone Density Study, Radius/Wrist/Heel",PX7708101,CDM,320,RC,77081,CPT,TC,,,,,,,460,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,15.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.18,44.05
"DXA, Bone Density Study, Radius/Wrist/Heel",PX7708101,CDM,320,RC,77081,CPT,TC,,,,,,,460,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,15.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.18,44.05
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68382019616,NDC,1,EA,17.4,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,15.8514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famciclovir 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,60505324603,NDC,0.5,EA,18.65,,First Health,Commercial,both,85,,999999999,percent of total billed charges,15.8525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 2 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409131203,NDC,1,ML,38.18,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.859972,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
riFAMpin 150 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,527139330,NDC,1,EA,17.41,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,15.86051,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
riFAMpin 150 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,68180065806,NDC,1,EA,17.41,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,15.86051,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyBUTYnin ER 5 MG Tablet Extended Release 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,63739054833,NDC,1,EA,18.67,,First Health,Commercial,both,85,,999999999,percent of total billed charges,15.8695,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
COLLAR CERVICAL LARGE WITH TRACH 2 PIECE PHP-T4L,120.184,CDM,274,RC,L0172,HCPCS,,10142-MAIN,LOCAL,,,,,37,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.873,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.3698,152.79
COLLAR CERVICAL MEDIUM WITH TRACH 2 PIECE PHP-T4M,120.183,CDM,274,RC,L0172,HCPCS,,10141-MAIN,LOCAL,,,,,37,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.873,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.3698,152.79
COLLAR CERVICAL SMALL WITH TRACH 2 PIECE PHP-T4S,120.182,CDM,274,RC,L0172,HCPCS,,10140-MAIN,LOCAL,,,,,37,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.873,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.3698,152.79
SUTURE TICRON 0 36IN BRAIDED DYED 1/2 CIRCLE DBLE ARM 25MM CV-305 BLUE STERILE,27200000,CDM,272,RC,,,,11956-MAIN,LOCAL,,,,,37,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,15.873,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409116219,NDC,30,ML,32.07,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,15.87465,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
"BINDER ABDOMINAL 12"" HIGH 46 TO 62 INCH L/XL 4 PANEL ORT21300LXL",120.238,CDM,271,RC,A4467,HCPCS,,11935-MAIN,LOCAL,,,,,18,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,15.876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BURETROL ADD ON SET 150ML,120.38,CDM,272,RC,A4222,HCPCS,,11118-MAIN,LOCAL,,,,,18,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,15.876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
TRAY TRACH CLEAN & CARE DYND40589,120.212,CDM,271,RC,,,,1173-MAIN,LOCAL,,,,,18,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,15.876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,17.64
TRAY TRACHEOTOMY CARE PEDS DYND40650H,120.212,CDM,272,RC,,,,11025-MAIN,LOCAL,,,,,18,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,15.876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,17.64
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608201,NDC,1,ML,66.6,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,15.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608210,NDC,1,ML,63.43,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,15.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093102,NDC,1,ML,60.47,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,15.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093107,NDC,1,ML,57.59,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,15.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
tobramycin 80 MG/2ML Solution 2 mL Vial,J3260.01,CDM,636,RC,J3260,HCPCS,,,,67457047300,NDC,2,ML,33.09,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,15.8832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.745586,32.4282
tobramycin 80 MG/2ML Solution 2 mL Vial,J3260.01,CDM,636,RC,J3260,HCPCS,,,,67457047300,NDC,2,ML,33.09,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,15.8832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.745586,32.4282
BIOPSY FORCEPS HOT,27200000,CDM,272,RC,,,,4353-MAIN,LOCAL,,,,,38.25,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.88905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRESSING GEL FOAM SIZE 100SPONGE STERILE 00009034201,27200000,CDM,272,RC,A6248,HCPCS,,3378-MAIN,LOCAL,,,,,38.25,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.88905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFFLATION TUBING SET,27200000,CDM,272,RC,,,,4686-MAIN,LOCAL,,,,,38.25,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.88905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189101,NDC,1,ML,32.43,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,4.09125,percent of total billed charges,15.8907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189101,NDC,1,ML,32.43,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.8907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189101,NDC,1,ML,32.43,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,15.8907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
metroNIDAZOLE 500 MG/100ML Solution 100 mL Flex Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,409781124,NDC,100,ML,32.12,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,15.8994,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,31.4776
Thyroglobulin Antibody,PX8680090,CDM,300,RC,86800,CPT,90,,,,,,,68,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,15.91,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.43,15.91
oxyBUTYnin ER 5 MG Tablet Extended Release 24 Hour 50 Each Box,63700001,CDM,250,RC,,,,,,904657006,NDC,1,EA,18.04,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,15.91128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
KIT ENDO COMPLETE PROCEDURE CARRY-ON 100802,27200000,CDM,272,RC,,,,10369-MAIN,LOCAL,,,,,33.15,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,15.912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
KIT ENDO COMPLETE PROCEDURE CARRY-ON 100802,27200000,CDM,272,RC,,,,10369-MAIN,LOCAL,,,,,33.15,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,15.912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006401,NDC,2,ML,31.46,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.91876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
Apply of Paste Boot,PX29580F,CDM,510,RC,29580,CPT,,,,,,,,132,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,15.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,132.83
Apply of Paste Boot,PX29580F,CDM,510,RC,29580,CPT,,,,,,,,132,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,15.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,132.83
Apply of Paste Boot,PX29580F,CDM,510,RC,29580,CPT,,,,,,,,132,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,15.92,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,132.83
Apply of Paste Boot,PX29580P,CDM,983,RC,29580,CPT,,,,,,,,88,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,15.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,132.83
Apply of Paste Boot,PX29580P,CDM,983,RC,29580,CPT,,,,,,,,88,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,15.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,132.83
Apply of Paste Boot,PX29580P,CDM,983,RC,29580,CPT,,,,,,,,88,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,15.92,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,132.83
"Breast Tomosynthesis,Screen Tc",PX7706301,CDM,403,RC,77063,CPT,TC,,,,,,,166,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,15.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,47.33
"Breast Tomosynthesis,Screen Tc",PX7706301,CDM,403,RC,77063,CPT,TC,,,,,,,166,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,15.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,47.33
"Breast Tomosynthesis,Screen Tc",PX7706301,CDM,403,RC,77063,CPT,TC,,,,,,,166,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,15.92,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,47.33
Dx Occult Blood Immunoassay,PX82274,CDM,300,RC,82274,CPT,,,,,,,,105,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,15.92,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.44,15.92
"X-Ray Exam Hip,Unilat W/Pelvis 1vw",PX7350101,CDM,320,RC,73501,CPT,TC,,,,,,,263,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,15.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,47.33
"X-Ray Exam Hip,Unilat W/Pelvis 1vw",PX7350101,CDM,320,RC,73501,CPT,TC,,,,,,,263,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,15.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,47.33
Xray Clavicle Complete,PX7300001,CDM,320,RC,73000,CPT,TC,,,,,,,365,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,15.92,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,48.65
Xray Elbow 3+Vws Tc,PX7308001,CDM,320,RC,73080,CPT,TC,,,,,,,370,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,15.92,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,48.65
Xray Humerus Minimum 2 Vws,PX7306001,CDM,320,RC,73060,CPT,TC,,,,,,,365,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,15.92,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,47.99
Xray Sacrum/ Coccyx Minimum 2 Vws,PX7222001,CDM,320,RC,72220,CPT,TC,,,,,,,540,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,15.92,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,47.99
Xray Sinuses Less Than 3 Vws,PX7021001,CDM,320,RC,70210,CPT,TC,,,,,,,486,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,15.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,47.33
Xray Sinuses Less Than 3 Vws,PX7021001,CDM,320,RC,70210,CPT,TC,,,,,,,486,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,15.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,47.33
Xray Sternum 2vws Tc,PX7112001,CDM,320,RC,71120,CPT,TC,,,,,,,365,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,15.92,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,47.99
Xray Tibia & Fibula 2 Vws,PX7359001,CDM,320,RC,73590,CPT,TC,,,,,,,365,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,15.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,47.33
Xray Tibia & Fibula 2 Vws,PX7359001,CDM,320,RC,73590,CPT,TC,,,,,,,365,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,15.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,47.33
dutasteride 0.5 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,42806054909,NDC,1,EA,32.49,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.9201,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dutasteride 0.5 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,42806054909,NDC,1,EA,32.49,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.9201,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dutasteride 0.5 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,42806054909,NDC,1,EA,32.49,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,15.9201,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084007001,NDC,1,EA,33.17,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,15.9216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084007001,NDC,1,EA,33.17,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,15.9216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078110,NDC,0.5,EA,38.33,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.922282,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
bacitracin zinc 500 UNIT/GM Ointment 28.35 g Tube,25000000,CDM,250,RC,,,,,,168001131,NDC,28.35,GR,32.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
bacitracin zinc 500 UNIT/GM Ointment 28.35 g Tube,25000000,CDM,250,RC,,,,,,168001131,NDC,28.35,GR,32.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
bacitracin zinc 500 UNIT/GM Ointment 28.35 g Tube,25000000,CDM,250,RC,,,,,,168001131,NDC,28.35,GR,32.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,15.925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ciprofloxacin 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084007011,NDC,1,EA,33.19,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,15.9312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084007011,NDC,1,EA,33.19,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,15.9312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
memantine 10 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,72603011901,NDC,0.5,EA,16.37,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,15.932921,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987525,NDC,3,ML,33.22,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,15.9456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987525,NDC,3,ML,33.22,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,15.9456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049236,NDC,5,ML,31.52,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.94912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049243,NDC,5,ML,31.52,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.94912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
valACYclovir 1 GM Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862044930,NDC,0.5,EA,33.23,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,15.9504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
valACYclovir 1 GM Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862044930,NDC,0.5,EA,33.23,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,15.9504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092821,NDC,1,ML,32.23,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,15.95385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,31.5854
VAGINAL PACKING 2',120.292,CDM,272,RC,,,,829-MAIN,LOCAL,,,,,32.23,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,15.95385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.388342,31.5854
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048226,NDC,20,ML,32.56,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048226,NDC,20,ML,32.56,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048226,NDC,20,ML,32.56,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,15.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048241,NDC,20,ML,32.56,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048241,NDC,20,ML,32.56,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048241,NDC,20,ML,32.56,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,15.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641600101,NDC,1,ML,32.56,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,4.035,percent of total billed charges,15.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641600101,NDC,1,ML,32.56,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,15.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641600101,NDC,1,ML,32.56,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,15.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
EPINEPHrine 30 MG/30ML Solution 30 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023016801,NDC,0.3,ML,32.24,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,15.9588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
Gammaglobulin; Ige - Ref,PX8278590,CDM,300,RC,82785,CPT,90,,,,,,,45,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,15.97,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.97,16.46
Gammaglobulin; Ige - Ref,PX8278590,CDM,300,RC,82785,CPT,90,,,,,,,45,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,15.97,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.97,16.46
Gammaglobulin; Ige - Ref,PX8278590,CDM,300,RC,82785,CPT,90,,,,,,,45,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,15.97,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.97,16.46
sulfamethoxazole-trimethoprim 200-40 MG/5ML Suspension 473 mL Bottle,63700001,CDM,250,RC,,,,,,65862049647,NDC,10,ML,18.79,,First Health,Commercial,both,85,,999999999,percent of total billed charges,15.9715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061601,NDC,3,ML,31.57,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.97442,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058003,NDC,0.5,ML,31.57,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.97442,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058020,NDC,0.5,ML,31.57,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.97442,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061416,NDC,0.5,ML,31.57,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,15.97442,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.114178,99.911
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68462033090,NDC,1,EA,17.95,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,15.9755,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409427602,NDC,50,ML,38.46,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,15.976284,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
benzocaine-menthol 20-0.5 % Aerosol 56 g Can,63700001,CDM,250,RC,,,,,,16864068002,NDC,56,GR,33.3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,15.984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzocaine-menthol 20-0.5 % Aerosol 56 g Can,63700001,CDM,250,RC,,,,,,16864068002,NDC,56,GR,33.3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,15.984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clarithromycin 250 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,527193106,NDC,1,EA,32.3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,15.9885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clarithromycin 250 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,65862022560,NDC,1,EA,32.3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,15.9885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vedolizumab 300 MG Recon Soln 1 Each Vial,J3380.01,CDM,636,RC,J3380,HCPCS,,,,64764030020,NDC,1,EA,12439.04,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,15.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.07,22.06
vedolizumab 300 MG Recon Soln 1 Each Vial,J3380.01,CDM,636,RC,J3380,HCPCS,,,,64764030020,NDC,1,EA,12439.04,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,15.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.07,22.06
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,16.00478,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,16.00478,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
valACYclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069801,NDC,1,EA,38.55,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.01367,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitroglycerin 2 % Ointment 1 g Packet,63700001,CDM,250,RC,,,,,,281032608,NDC,1,GR,17.58,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,16.01538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"BINDER ABDOMINAL 12"" HIGH 46 TO 62 INCH L/XL 4 PANEL ORT21300LXL",120.238,CDM,271,RC,A4467,HCPCS,,11935-MAIN,LOCAL,,,,,18,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,16.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BURETROL ADD ON SET 150ML,120.38,CDM,272,RC,A4222,HCPCS,,11118-MAIN,LOCAL,,,,,18,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,16.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
TRAY TRACH CLEAN & CARE DYND40589,120.212,CDM,271,RC,,,,1173-MAIN,LOCAL,,,,,18,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,16.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,17.64
TRAY TRACHEOTOMY CARE PEDS DYND40650H,120.212,CDM,272,RC,,,,11025-MAIN,LOCAL,,,,,18,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,16.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,17.64
Strep a Assay W/Optic,PX87880,CDM,300,RC,87880,CPT,,,,,,,,95,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,16.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.03,16.53
Strep a Assay W/Optic,PX87880,CDM,300,RC,87880,CPT,,,,,,,,95,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,16.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.03,16.53
Strep a Assay W/Optic,PX87880,CDM,300,RC,87880,CPT,,,,,,,,95,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,16.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.03,16.53
STOCKINETTE IMPERVIOUS 12X48 NON22535,27200000,CDM,272,RC,A6457,HCPCS,,10918-MAIN,LOCAL,,,,,16.47,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,16.030251,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
levETIRAcetam 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079082101,NDC,1,EA,18.87,,First Health,Commercial,both,85,,999999999,percent of total billed charges,16.0395,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay Thyroid Stim Hormone,PX84443,CDM,300,RC,84443,CPT,,,,,,,,294,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,16.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.04,16.8
Assay Thyroid Stim Hormone,PX84443,CDM,300,RC,84443,CPT,,,,,,,,294,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,16.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.04,16.8
memantine 10 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,72603011901,NDC,0.5,EA,16.37,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,16.0426,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Cortisol, Am",PX7152,CDM,300,RC,82533,CPT,,,,,,,,156,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,16.045,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.81,16.3
Gammaglobulin; Ige - Ref,PX8278590,CDM,300,RC,82785,CPT,90,,,,,,,45,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,16.045,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.97,16.46
Strep a Assay W/Optic,PX87880,CDM,300,RC,87880,CPT,,,,,,,,95,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,16.045,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.03,16.53
Total Cortisol,PX82533,CDM,300,RC,82533,CPT,,,,,,,,137,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,16.045,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.81,16.3
pancrelipase (lip-prot-amyl) 24000-76000 units Capsule Delayed Release Particles 100 Each Bottle,63700001,CDM,250,RC,,,,,,32122401,NDC,1,EA,37.41,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.04889,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Influenza Assay W/Optic,PX87804,CDM,300,RC,87804,CPT,,,,,,,,127,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,16.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.05,16.55
Influenza Assay W/Optic,PX87804,CDM,300,RC,87804,CPT,,,,,,,,127,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,16.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.05,16.55
Influenza Assay W/Optic,PX87804,CDM,300,RC,87804,CPT,,,,,,,,127,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,16.05,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.05,16.55
lidocaine HCl 4 % Cream 76.5 g Tube,63700001,CDM,250,RC,,,,,,41167005820,NDC,76.5,GR,31.72,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,16.05032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nadolol 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,76385013301,NDC,1,EA,18.2,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,16.0524,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189101,NDC,1,ML,32.43,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,16.05285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
oxyBUTYnin ER 5 MG Tablet Extended Release 24 Hour 50 Each Box,63700001,CDM,250,RC,,,,,,904657006,NDC,1,EA,18.04,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,16.0556,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Thyroglobulin - Ref,PX8443290,CDM,300,RC,84432,CPT,90,,,,,,,68,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,16.06,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.58,16.06
methotrexate 2.5 MG Tablet 20 Each Box,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067005,NDC,1,EA,33.49,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,16.0752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.911746,32.8398
methotrexate 2.5 MG Tablet 20 Each Box,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067005,NDC,1,EA,33.49,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,16.0752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.911746,32.8398
azithromycin 200 MG/5ML Recon Susp 15 mL Bottle,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,59762312001,NDC,15,ML,196.35,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,16.08,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.08,29.76
azithromycin 250 MG Tablet 6 Each Box,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096104,NDC,1,EA,41.72,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,16.08,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.08,29.76
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,50111078751,NDC,1,EA,41.79,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,16.08,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.08,29.76
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096105,NDC,1,EA,41.73,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,16.08,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.08,29.76
dutasteride 0.5 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,42806054909,NDC,1,EA,32.49,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,16.08255,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methotrexate 2.5 MG Tablet 1 Each Blister,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067001,NDC,1,EA,33.51,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,16.0848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.911746,32.8398
methotrexate 2.5 MG Tablet 1 Each Blister,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067001,NDC,1,EA,33.51,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,16.0848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.911746,32.8398
bacitracin zinc 500 UNIT/GM Ointment 28.35 g Tube,25000000,CDM,250,RC,,,,,,168001131,NDC,28.35,GR,32.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,16.0875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"CUFF STERILE DISPOSABLE SPSB 24""",27200000,CDM,272,RC,,,,7437-MAIN,LOCAL,,,,,37.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.0875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ENDOCAVITY NEEDLE GUIDE,27200000,CDM,272,RC,,,,11134-MAIN,LOCAL,,,,,37.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.0875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR KII BALOON 5X100MM STERILE,27200000,CDM,272,RC,,,,11701-MAIN,LOCAL,,,,,37.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.0875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LEGGING PAIR 31X48 STERILE,27200000,CDM,272,RC,,,,10916-MAIN,LOCAL,,,,,16.53,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,16.088649,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Primidone Assay - Ref,PX8018890,CDM,300,RC,80188,CPT,90,,,,,,,20,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,16.09,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.09,16.59
Primidone Assay - Ref,PX8018890,CDM,300,RC,80188,CPT,90,,,,,,,20,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,16.09,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.09,16.59
Primidone Assay - Ref,PX8018890,CDM,300,RC,80188,CPT,90,,,,,,,20,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,16.09,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.09,16.59
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,36000014801,NDC,2,ML,38.76,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.100904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
morphine 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574711212,NDC,1,EA,33.56,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,16.1088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574711212,NDC,1,EA,33.56,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,16.1088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Cognitive Funct Ther Interv, Initial 15 Min",PX97129,CDM,420,RC,97129,CPT,,,,,,,,85,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,16.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.63,29.43
"Cognitive Funct Ther Interv, Initial 15 Min",PX97129,CDM,420,RC,97129,CPT,,,,,,,,85,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,16.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.63,29.43
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060002,NDC,2,ML,953.57,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,16.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.11,934.4986
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060010,NDC,2,ML,953.57,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,16.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.11,934.4986
valACYclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,31722070430,NDC,1,EA,38.79,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.113366,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189103,NDC,1,ML,32.89,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,4.09125,percent of total billed charges,16.1161,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189103,NDC,1,ML,32.89,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.1161,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189103,NDC,1,ML,32.89,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,16.1161,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048226,NDC,20,ML,32.56,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,16.1172,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048241,NDC,20,ML,32.56,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,16.1172,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641600101,NDC,1,ML,32.56,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,16.1172,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342003110,NDC,1,EA,16.56,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,16.117848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
valACYclovir 1 GM Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069701,NDC,0.5,EA,33.58,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,16.1184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
valACYclovir 1 GM Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069701,NDC,0.5,EA,33.58,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,16.1184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DULoxetine 20 MG Capsule Delayed Release Particles 60 Each Bottle,63700001,CDM,250,RC,,,,,,57237001760,NDC,1,EA,37.58,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.12182,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
valproate 100 MG/ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049416,NDC,5,ML,33.61,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,16.1328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
valproate 100 MG/ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049416,NDC,5,ML,33.61,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,16.1328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
valproate 100 MG/ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049441,NDC,5,ML,33.61,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,16.1328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
valproate 100 MG/ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049441,NDC,5,ML,33.61,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,16.1328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pioglitazone 15 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342005410,NDC,1,EA,37.62,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.13898,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Xray Ankle 2 Vws,PX7360001,CDM,320,RC,73600,CPT,TC,,,,,,,163,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,16.14,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.14,48.65
Xray Eye Foreign Body,PX7003001,CDM,320,RC,70030,CPT,TC,,,,,,,432,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,16.14,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,47.99
Xray Eye Foreign Body,PX7003001,CDM,320,RC,70030,CPT,TC,,,,,,,432,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,16.14,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,47.99
Xray Humerus Minimum 2 Vws,PX7306001,CDM,320,RC,73060,CPT,TC,,,,,,,365,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,16.14,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,47.99
Xray Humerus Minimum 2 Vws,PX7306001,CDM,320,RC,73060,CPT,TC,,,,,,,365,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,16.14,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,47.99
Xray Sacrum/ Coccyx Minimum 2 Vws,PX7222001,CDM,320,RC,72220,CPT,TC,,,,,,,540,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,16.14,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,47.99
Xray Sacrum/ Coccyx Minimum 2 Vws,PX7222001,CDM,320,RC,72220,CPT,TC,,,,,,,540,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,16.14,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,47.99
Xray Sternum 2vws Tc,PX7112001,CDM,320,RC,71120,CPT,TC,,,,,,,365,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,16.14,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,47.99
Xray Sternum 2vws Tc,PX7112001,CDM,320,RC,71120,CPT,TC,,,,,,,365,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,16.14,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,47.99
Xray Thoracolumbar 2 Vws,PX7208001,CDM,320,RC,72080,CPT,TC,,,,,,,306,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,16.14,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.14,48.65
STOCKINETTE IMPERVIOUS 12X48 NON22535,27200000,CDM,272,RC,A6457,HCPCS,,10918-MAIN,LOCAL,,,,,16.47,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,16.1406,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"pediatric electrolyte Solution 1,000 mL Bottle",25000000,CDM,250,RC,,,,,,49348057041,NDC,1000,ML,31.9,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,16.1414,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Flex Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707526,NDC,100,ML,37.63,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.14327,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
fluticasone-salmeterol 100-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069500,NDC,1,EA,38.87,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.146598,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SUTURE SILK 3-0 18INCH NONABSORBABLE BLACK M13T,27200000,CDM,272,RC,,,,12872-MAIN,LOCAL,,,,,19,,First Health,Commercial,both,85,,999999999,percent of total billed charges,16.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Gastrin - Ref,PX8294190,CDM,300,RC,82941,CPT,90,,,,,,,65,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,16.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.16,63.7
CATHETER FOLEY 18FR  3WAY 30CC 73018L,120.21,CDM,272,RC,A4346,HCPCS,,253-MAIN,LOCAL,,,,,33,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
CATHETER FOLEY 18FR  3WAY 30CC 73018L,120.21,CDM,272,RC,A4346,HCPCS,,253-MAIN,LOCAL,,,,,33,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
CATHETER FOLEY 18FR  3WAY 30CC 73018L,120.21,CDM,272,RC,A4346,HCPCS,,253-MAIN,LOCAL,,,,,33,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,16.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
CATHETER FOLEY 20FR 3WAY 30CC 0167L20,120.21,CDM,272,RC,A4346,HCPCS,,251-MAIN,LOCAL,,,,,33,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
CATHETER FOLEY 20FR 3WAY 30CC 0167L20,120.21,CDM,272,RC,A4346,HCPCS,,251-MAIN,LOCAL,,,,,33,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
CATHETER FOLEY 20FR 3WAY 30CC 0167L20,120.21,CDM,272,RC,A4346,HCPCS,,251-MAIN,LOCAL,,,,,33,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,16.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
CATHETER FOLEY 24FR 3WAY 30CC 0167L24,120.21,CDM,272,RC,A4346,HCPCS,,10455-MAIN,LOCAL,,,,,33,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
CATHETER FOLEY 24FR 3WAY 30CC 0167L24,120.21,CDM,272,RC,A4346,HCPCS,,10455-MAIN,LOCAL,,,,,33,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
CATHETER FOLEY 24FR 3WAY 30CC 0167L24,120.21,CDM,272,RC,A4346,HCPCS,,10455-MAIN,LOCAL,,,,,33,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,16.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
"DRESSING AQUACEL 3/4"" X 18"" AG HYDROFIBER 403771",120.31,CDM,272,RC,A6199,HCPCS,,8238-MAIN,LOCAL,,,,,33,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,32.34
"DRESSING AQUACEL 3/4"" X 18"" AG HYDROFIBER 403771",120.31,CDM,272,RC,A6199,HCPCS,,8238-MAIN,LOCAL,,,,,33,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,32.34
"DRESSING AQUACEL 3/4"" X 18"" AG HYDROFIBER 403771",120.31,CDM,272,RC,A6199,HCPCS,,8238-MAIN,LOCAL,,,,,33,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,16.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,32.34
Hospital Outpatient Clinic Visit Specimen Collection for Sars-Cov-2,PXC9803,CDM,300,RC,C9803,HCPCS,,,,,,,,33,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,32.34
Hospital Outpatient Clinic Visit Specimen Collection for Sars-Cov-2,PXC9803,CDM,300,RC,C9803,HCPCS,,,,,,,,33,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,32.34
Hospital Outpatient Clinic Visit Specimen Collection for Sars-Cov-2,PXC9803,CDM,300,RC,C9803,HCPCS,,,,,,,,33,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,16.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,32.34
MEPILEX AG 4X4 10X10,120.138,CDM,272,RC,A6213,HCPCS,,7248-MAIN,LOCAL,,,,,33,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,32.34
MEPILEX AG 4X4 10X10,120.138,CDM,272,RC,A6213,HCPCS,,7248-MAIN,LOCAL,,,,,33,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,32.34
MEPILEX AG 4X4 10X10,120.138,CDM,272,RC,A6213,HCPCS,,7248-MAIN,LOCAL,,,,,33,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,16.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,32.34
STANDARD HIGH FLOW INSUFFLATION FILTER TUBING,27200000,CDM,272,RC,,,,11885-MAIN,LOCAL,,,,,33,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STANDARD HIGH FLOW INSUFFLATION FILTER TUBING,27200000,CDM,272,RC,,,,11885-MAIN,LOCAL,,,,,33,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STANDARD HIGH FLOW INSUFFLATION FILTER TUBING,27200000,CDM,272,RC,,,,11885-MAIN,LOCAL,,,,,33,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,16.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Beta-2-Microglobulin - Ref,PX8223290,CDM,300,RC,82232,CPT,90,,,,,,,49,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,16.18,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.69,16.18
Blood Clot Factor V Test,PX85220,CDM,300,RC,85220,CPT,,,,,,,,260,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,16.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.18,254.8
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,55150023501,NDC,0.5,EA,37.72,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.18188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BANDAGE COBAN  4 IN 2 LAYER COMPRESSION SYSTEM  2094N,120.549,CDM,272,RC,A6441,HCPCS,,12366-MAIN,LOCAL,,,,,32,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,16.192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.2928,31.36
BANDAGE COBAN LITE 4 IN 2 LAYER COMPRESSION SYSTEM 2794N,120.549,CDM,272,RC,A6441,HCPCS,,12922-MAIN,LOCAL,,,,,32,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,16.192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.2928,31.36
WOUND DRAIN FLAT WITH TROCAR 10MM FULL PERFORATED SILICONE,27200000,CDM,272,RC,,,,12462-MAIN,LOCAL,,,,,32,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,16.192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
morphine 2 MG/ML Solution 1 mL Syringe,J2272.01,CDM,636,RC,J2272,HCPCS,,,,76045000401,NDC,1,ML,38.98,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.192292,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.192292,38.2004
meloxicam 7.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268052511,NDC,1,EA,16.64,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,16.195712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nadolol 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,76385013301,NDC,1,EA,18.2,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,16.198,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
neomycin-bacitracin-polymyxin 3.5-400-5000 Ointment 28 g Tube,25000000,CDM,250,RC,,,,,,45802014303,NDC,28,GR,37.76,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.19904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
LEGGING PAIR 31X48 STERILE,27200000,CDM,272,RC,,,,10916-MAIN,LOCAL,,,,,16.53,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,16.1994,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Leptospira Antibody - Ref,PX8672090,CDM,300,RC,86720,CPT,90,,,,,,,220,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,16.2,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.71,16.2
CLOSED WOUND ROUND CHANNEL DRAIN WITH TROCAR 15FR FULL FLUTED,27200000,CDM,272,RC,,,,12223-MAIN,LOCAL,,,,,39,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.2006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
fluorouracil 500 MG/10ML Solution 10 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,63323011710,NDC,10,ML,39,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.2006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,256.2112
gemcitabine 200 MG Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323010294,NDC,1,EA,39,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.2006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
Lab Wbc and Differential,PX85004,CDM,300,RC,85004,CPT,,,,,,,,39,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.2006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,38.22
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003928,NDC,1,EA,39,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.2006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
methylPREDNISolone sod succ 500 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9075801,NDC,0.25,EA,39,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.2006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
NEEDLE JAMSHIDI 11G X 101MM BIOPSY DJ4011X,27200000,CDM,272,RC,,,,12798-MAIN,LOCAL,,,,,39,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.2006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
O2 SENSOR ADULT ADHESIVE SINGLE PATIENT 040-003382-00,120.576,CDM,272,RC,,,,12930-MAIN,LOCAL,,,,,39,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.2006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
O2 SENSOR INFANT ADHESIVE SINGLE PATIENT 040-003384-00,120.576,CDM,272,RC,,,,12932-MAIN,LOCAL,,,,,39,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.2006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
O2 SENSOR PEDIATRIC ADHESIVE SINGLE PATIENT 040-003383-00,120.576,CDM,272,RC,,,,12931-MAIN,LOCAL,,,,,39,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.2006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
SLEEVE ACHILLES LG/XL PROTECTION 92437145348,120.422,CDM,271,RC,,,,11378-MAIN,LOCAL,,,,,39,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.2006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
SLEEVE ACHILLES SM/MED PROTECTION 92437145324,120.422,CDM,271,RC,,,,11377-MAIN,LOCAL,,,,,39,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.2006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
Treponema Pallidum - Ref,PX8678090,CDM,300,RC,86780,CPT,90,,,,,,,39,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.2006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.14,38.22
TROCAR KII FIOS SYSTEM BLADELSS Z-THREAD 5MMX150MM,27200000,CDM,272,RC,,,,12827-MAIN,LOCAL,,,,,39,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.2006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409427617,NDC,50,ML,39.01,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.204754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
RESERVOIR SILICONE BULB 100CC,27200000,CDM,272,RC,,,,4400-MAIN,LOCAL,,,,,16.65,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,16.205445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
BOOT CAST LARGE 12-5/8 ORT290010L,120.247,CDM,274,RC,L3260,HCPCS,,204-MAIN,LOCAL,,,,,27,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,16.208,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
BOOT CAST LARGE 12-5/8 ORT290010L,120.247,CDM,274,RC,L3260,HCPCS,,204-MAIN,LOCAL,,,,,27,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,16.208,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
BOOT CAST MEDIUM 08148803,120.247,CDM,274,RC,L3260,HCPCS,,203-MAIN,LOCAL,,,,,27,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,16.208,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
BOOT CAST MEDIUM 08148803,120.247,CDM,274,RC,L3260,HCPCS,,203-MAIN,LOCAL,,,,,27,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,16.208,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
BOOT CAST X-LARGE 13X5-1/2IN ORT29200XL,120.247,CDM,274,RC,L3260,HCPCS,,206-MAIN,LOCAL,,,,,27,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,16.208,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
BOOT CAST X-LARGE 13X5-1/2IN ORT29200XL,120.247,CDM,274,RC,L3260,HCPCS,,206-MAIN,LOCAL,,,,,27,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,16.208,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP LARGE MALE MQM3B,120.237,CDM,274,RC,L3260,HCPCS,,794-MAIN,LOCAL,,,,,76,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,16.208,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP LARGE MALE MQM3B,120.237,CDM,274,RC,L3260,HCPCS,,794-MAIN,LOCAL,,,,,76,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,16.208,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP LARGE SQUARE TOE WOMENS ORT30300WL,120.237,CDM,274,RC,L3260,HCPCS,,10606-MAIN,LOCAL,,,,,76,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,16.208,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP LARGE SQUARE TOE WOMENS ORT30300WL,120.237,CDM,274,RC,L3260,HCPCS,,10606-MAIN,LOCAL,,,,,76,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,16.208,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP MEDIUM SQUARE TOE MALE ORT30300MM,120.237,CDM,274,RC,L3260,HCPCS,,10603-MAIN,LOCAL,,,,,76,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,16.208,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP MEDIUM SQUARE TOE MALE ORT30300MM,120.237,CDM,274,RC,L3260,HCPCS,,10603-MAIN,LOCAL,,,,,76,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,16.208,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP MEDIUM SQUARE TOE WOMENS ORT30300WM,120.237,CDM,274,RC,L3260,HCPCS,,10605-MAIN,LOCAL,,,,,76,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,16.208,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP MEDIUM SQUARE TOE WOMENS ORT30300WM,120.237,CDM,274,RC,L3260,HCPCS,,10605-MAIN,LOCAL,,,,,76,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,16.208,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP SMALL MALE 0814-1192,120.237,CDM,274,RC,L3260,HCPCS,,803-MAIN,LOCAL,,,,,76,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,16.208,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP SMALL MALE 0814-1192,120.237,CDM,274,RC,L3260,HCPCS,,803-MAIN,LOCAL,,,,,76,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,16.208,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP SMALL SQUARE TOE WOMENS MQW1B,120.237,CDM,274,RC,L3260,HCPCS,,10604-MAIN,LOCAL,,,,,76,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,16.208,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP SMALL SQUARE TOE WOMENS MQW1B,120.237,CDM,274,RC,L3260,HCPCS,,10604-MAIN,LOCAL,,,,,76,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,16.208,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP X-LARGE MALE DS1016-16,120.237,CDM,274,RC,L3260,HCPCS,,6337-MAIN,LOCAL,,,,,35,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,16.208,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
SHOE POST OP X-LARGE MALE DS1016-16,120.237,CDM,274,RC,L3260,HCPCS,,6337-MAIN,LOCAL,,,,,35,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,16.208,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.95,16.208
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987501,NDC,3,ML,33.77,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,16.2096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987501,NDC,3,ML,33.77,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,16.2096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
"Cortisol, Free - Ref",PX8253090,CDM,300,RC,82530,CPT,90,,,,,,,82,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,16.21,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.21,16.71
"Cortisol, Free - Ref",PX8253090,CDM,300,RC,82530,CPT,90,,,,,,,82,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,16.21,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.21,16.71
"Cortisol, Free - Ref",PX8253090,CDM,300,RC,82530,CPT,90,,,,,,,82,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,16.21,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.21,16.71
tobramycin 80 MG/2ML Solution 2 mL Vial,J3260.01,CDM,636,RC,J3260,HCPCS,,,,67457047300,NDC,2,ML,33.09,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.2141,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.745586,32.4282
tobramycin 80 MG/2ML Solution 2 mL Vial,J3260.01,CDM,636,RC,J3260,HCPCS,,,,67457047300,NDC,2,ML,33.09,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.2141,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.745586,32.4282
tobramycin 80 MG/2ML Solution 2 mL Vial,J3260.01,CDM,636,RC,J3260,HCPCS,,,,67457047300,NDC,2,ML,33.09,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,16.2141,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.745586,32.4282
DRAPE SHEET 70X85 LARGE DYNJP2417,27200000,CDM,272,RC,,,,10914-MAIN,LOCAL,,,,,18.39,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,16.21998,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143966001,NDC,5,ML,37.82,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.22478,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143966010,NDC,5,ML,37.82,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.22478,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409116219,NDC,30,ML,32.07,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,16.22742,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342003110,NDC,1,EA,16.56,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,16.2288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,55150025110,NDC,10,ML,37.85,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.23765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
KIT ENDO COMPLETE PROCEDURE CARRY-ON 100802,27200000,CDM,272,RC,,,,10369-MAIN,LOCAL,,,,,33.15,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.2435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
KIT ENDO COMPLETE PROCEDURE CARRY-ON 100802,27200000,CDM,272,RC,,,,10369-MAIN,LOCAL,,,,,33.15,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.2435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
KIT ENDO COMPLETE PROCEDURE CARRY-ON 100802,27200000,CDM,272,RC,,,,10369-MAIN,LOCAL,,,,,33.15,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,16.2435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Electric Stimulation Therapy,PX97014,CDM,420,RC,97014,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,16.25,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.65,19.92
Electric Stimulation Therapy,PX97014,CDM,420,RC,97014,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,16.25,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.65,19.92
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733513,NDC,1,EA,39.12,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.250448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
metroNIDAZOLE 500 MG/100ML Solution 100 mL Flex Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,409781124,NDC,100,ML,32.12,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,16.25272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,31.4776
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084007001,NDC,1,EA,33.17,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.2533,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084007001,NDC,1,EA,33.17,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.2533,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084007001,NDC,1,EA,33.17,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,16.2533,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levoFLOXacin 750 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635361,NDC,0.333333333,EA,39.14,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.258756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Glycated Protein - Ref,PX8298590,CDM,300,RC,82985,CPT,90,,,,,,,49,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,16.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.26,16.76
Glycated Protein - Ref,PX8298590,CDM,300,RC,82985,CPT,90,,,,,,,49,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,16.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.26,16.76
Glycated Protein - Ref,PX8298590,CDM,300,RC,82985,CPT,90,,,,,,,49,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,16.26,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.26,16.76
ciprofloxacin 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084007011,NDC,1,EA,33.19,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.2631,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084007011,NDC,1,EA,33.19,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.2631,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084007011,NDC,1,EA,33.19,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,16.2631,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143978410,NDC,2,ML,37.91,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.26339,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
acetaminophen 160 MG/5ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,68094023159,NDC,15,ML,19.14,,First Health,Commercial,both,85,,999999999,percent of total billed charges,16.269,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Alpha-Fetoprotein Serum,PX82105,CDM,300,RC,82105,CPT,,,,,,,,77,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,16.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.27,16.77
Alpha-Fetoprotein Serum,PX82105,CDM,300,RC,82105,CPT,,,,,,,,77,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,16.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.27,16.77
Alpha-Fetoprotein Serum,PX82105,CDM,300,RC,82105,CPT,,,,,,,,77,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,16.27,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.27,16.77
"Alpha-Fetoprotein, Serum - Ref",PX8210590,CDM,300,RC,82105,CPT,90,,,,,,,80,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,16.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.27,16.77
"Alpha-Fetoprotein, Serum - Ref",PX8210590,CDM,300,RC,82105,CPT,90,,,,,,,80,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,16.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.27,16.77
"Alpha-Fetoprotein, Serum - Ref",PX8210590,CDM,300,RC,82105,CPT,90,,,,,,,80,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,16.27,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.27,16.77
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987525,NDC,3,ML,33.22,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.2778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987525,NDC,3,ML,33.22,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.2778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987525,NDC,3,ML,33.22,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,16.2778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189103,NDC,1,ML,32.89,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,16.28055,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
valACYclovir 1 GM Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862044930,NDC,0.5,EA,33.23,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.2827,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
valACYclovir 1 GM Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862044930,NDC,0.5,EA,33.23,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.2827,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
valACYclovir 1 GM Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862044930,NDC,0.5,EA,33.23,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,16.2827,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay Thyroid Stim Hormone,PX84443,CDM,300,RC,84443,CPT,,,,,,,,294,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,16.3,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.04,16.8
"Cortisol, Am",PX7152,CDM,300,RC,82533,CPT,,,,,,,,156,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,16.3,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.81,16.3
"Fat/Lipids, Feces, Quant - Ref",PX8271090,CDM,300,RC,82710,CPT,90,,,,,,,95,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,16.3,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.3,16.8
"Fat/Lipids, Feces, Quant - Ref",PX8271090,CDM,300,RC,82710,CPT,90,,,,,,,95,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,16.3,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.3,16.8
"Fat/Lipids, Feces, Quant - Ref",PX8271090,CDM,300,RC,82710,CPT,90,,,,,,,95,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,16.3,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.3,16.8
Total Cortisol,PX82533,CDM,300,RC,82533,CPT,,,,,,,,137,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,16.3,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.81,16.3
8MM-12MM CANNULA SEAL 5-8MM,27200000,CDM,272,RC,,,,11921-MAIN,LOCAL,,,,,38,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRAPE COLUMN 470341,27200000,CDM,272,RC,,,,12013-MAIN,LOCAL,,,,,38,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HH Hha Visit,PXG0156,CDM,571,RC,G0156,HCPCS,,,,,,,,38,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
Mitochondrial Antibody Each,PX8638190,CDM,300,RC,86381,CPT,90,,,,,,,38,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
Nasal Sm for Eos,PX89190,CDM,300,RC,89190,CPT,,,,,,,,38,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.31,37.24
NEEDLE IV 19GA X .75IN HUBER POWERLOC SAFETY 0651934,120.85,CDM,272,RC,A4215,HCPCS,,12701-MAIN,LOCAL,,,,,38,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
NEEDLE IV 19GA X 1 IN HUBER POWERLOC SAFETY 0651910,120.85,CDM,272,RC,A4215,HCPCS,,12702-MAIN,LOCAL,,,,,38,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
NEEDLE IV 19GA X 1.5 IN HUBER POWERLOC SAFETY 0651915,120.85,CDM,272,RC,A4215,HCPCS,,12703-MAIN,LOCAL,,,,,38,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
PEZZER CATHETER DRAIN LATEX 14FR,27200000,CDM,272,RC,,,,12053-MAIN,LOCAL,,,,,38,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PEZZER LATEX CATHETER DRAIN 10FR,27200000,CDM,272,RC,,,,12646-MAIN,LOCAL,,,,,38,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PNEUVIEW SMOKE ELIMINATOR,27200000,CDM,272,RC,,,,11884-MAIN,LOCAL,,,,,38,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Psa, Free - Ref",PX8415490,CDM,300,RC,84154,CPT,90,,,,,,,38,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
"Psa, Total - Ref",PX8415390,CDM,300,RC,84153,CPT,90,,,,,,,38,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
SPECULUM VAGINAL WITH BUILT IN LIGHT LARGE,120.133,CDM,272,RC,,,,8251-MAIN,LOCAL,,,,,38,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
SPECULUM VAGINAL WITH BUILT IN LIGHT MEDIUM,120.133,CDM,272,RC,,,,8250-MAIN,LOCAL,,,,,38,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
SPECULUM VAGINAL WITH BUILT IN LIGHT SMALL,120.133,CDM,272,RC,,,,8249-MAIN,LOCAL,,,,,38,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
TROCAR KII FIOS SYSTEM BLADELSS Z-THREAD 5MMX100MM,27200000,CDM,272,RC,,,,12003-MAIN,LOCAL,,,,,38,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
rosuvastatin 10 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,60687024511,NDC,0.5,EA,19.18,,First Health,Commercial,both,85,,999999999,percent of total billed charges,16.303,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
meloxicam 7.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268052511,NDC,1,EA,16.64,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,16.3072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092821,NDC,1,ML,32.23,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,16.30838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,31.5854
VAGINAL PACKING 2',120.292,CDM,272,RC,,,,829-MAIN,LOCAL,,,,,32.23,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,16.30838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.388342,31.5854
EPINEPHrine 30 MG/30ML Solution 30 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023016801,NDC,0.3,ML,32.24,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,16.31344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
RESERVOIR SILICONE BULB 100CC,27200000,CDM,272,RC,,,,4400-MAIN,LOCAL,,,,,16.65,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,16.317,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
benzocaine-menthol 20-0.5 % Aerosol 56 g Can,63700001,CDM,250,RC,,,,,,16864068002,NDC,56,GR,33.3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.317,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzocaine-menthol 20-0.5 % Aerosol 56 g Can,63700001,CDM,250,RC,,,,,,16864068002,NDC,56,GR,33.3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.317,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzocaine-menthol 20-0.5 % Aerosol 56 g Can,63700001,CDM,250,RC,,,,,,16864068002,NDC,56,GR,33.3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,16.317,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BINDER ABDOMINAL S/M 9 INCH UP TO 45 INCHES TRI-PANNEL ABB3P45,120.238,CDM,271,RC,A4467,HCPCS,,47-MAIN,LOCAL,,,,,34,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,16.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL S/M 9 INCH UP TO 45 INCHES TRI-PANNEL ABB3P45,120.238,CDM,271,RC,A4467,HCPCS,,47-MAIN,LOCAL,,,,,34,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,16.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,Health Partners,Health Partners Care Plans,both,48,,21.6975,percent of total billed charges,16.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,16.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,Health Partners,Health Partners Care Plans,both,48,,21.6975,percent of total billed charges,16.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,16.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
"Lab Ige, Isocyan Hdi",PX86003,CDM,300,RC,86003,CPT,90,,,,,,,34,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,16.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.79,33.32
"Lab Ige, Isocyan Hdi",PX86003,CDM,300,RC,86003,CPT,90,,,,,,,34,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,16.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.79,33.32
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323020110,NDC,10,ML,34,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,16.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323020110,NDC,10,ML,34,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,16.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Metanephrines - Ref,PX8383590,CDM,300,RC,83835,CPT,90,,,,,,,34,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,16.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1236,33.32
Metanephrines - Ref,PX8383590,CDM,300,RC,83835,CPT,90,,,,,,,34,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,16.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1236,33.32
SPLINT SAM 36INCH ROLLED 661121,120.362,CDM,271,RC,,,,10789-MAIN,LOCAL,,,,,34,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,16.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1236,33.32
SPLINT SAM 36INCH ROLLED 661121,120.362,CDM,271,RC,,,,10789-MAIN,LOCAL,,,,,34,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,16.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1236,33.32
"Venipunc Need Phys Skill,Dx or Rx",PX36410F,CDM,510,RC,36410,CPT,,,,,,,,34,,Health Partners,Health Partners Care Plans,both,48,,76.63,percent of total billed charges,16.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1236,33.32
"Venipunc Need Phys Skill,Dx or Rx",PX36410F,CDM,510,RC,36410,CPT,,,,,,,,34,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,16.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1236,33.32
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707426,NDC,100,ML,39.29,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.321066,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
CATHETER FOLEY 18FR  3WAY 30CC 73018L,120.21,CDM,272,RC,A4346,HCPCS,,253-MAIN,LOCAL,,,,,33,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,16.335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
CATHETER FOLEY 20FR 3WAY 30CC 0167L20,120.21,CDM,272,RC,A4346,HCPCS,,251-MAIN,LOCAL,,,,,33,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,16.335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
CATHETER FOLEY 24FR 3WAY 30CC 0167L24,120.21,CDM,272,RC,A4346,HCPCS,,10455-MAIN,LOCAL,,,,,33,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,16.335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
"DRESSING AQUACEL 3/4"" X 18"" AG HYDROFIBER 403771",120.31,CDM,272,RC,A6199,HCPCS,,8238-MAIN,LOCAL,,,,,33,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,16.335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,32.34
Hospital Outpatient Clinic Visit Specimen Collection for Sars-Cov-2,PXC9803,CDM,300,RC,C9803,HCPCS,,,,,,,,33,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,16.335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,32.34
MEPILEX AG 4X4 10X10,120.138,CDM,272,RC,A6213,HCPCS,,7248-MAIN,LOCAL,,,,,33,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,16.335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,32.34
STANDARD HIGH FLOW INSUFFLATION FILTER TUBING,27200000,CDM,272,RC,,,,11885-MAIN,LOCAL,,,,,33,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,16.335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Cmv Igm Antibody - Ref,PX8664590,CDM,300,RC,86645,CPT,90,,,,,,,125,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,16.34,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.34,16.85
Cmv Igm Antibody - Ref,PX8664590,CDM,300,RC,86645,CPT,90,,,,,,,125,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,16.34,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.34,16.85
Cmv Igm Antibody - Ref,PX8664590,CDM,300,RC,86645,CPT,90,,,,,,,125,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,16.34,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.34,16.85
Helicobacter Pylori Ab,PX86677,CDM,300,RC,86677,CPT,,,,,,,,224,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,16.34,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.34,16.85
Helicobacter Pylori Ab,PX86677,CDM,300,RC,86677,CPT,,,,,,,,224,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,16.34,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.34,16.85
Helicobacter Pylori Ab,PX86677,CDM,300,RC,86677,CPT,,,,,,,,224,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,16.34,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.34,16.85
"West Nile Ab, Igm - Ref",PX8678890,CDM,300,RC,86788,CPT,90,,,,,,,109,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,16.34,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.34,16.85
"West Nile Ab, Igm - Ref",PX8678890,CDM,300,RC,86788,CPT,90,,,,,,,109,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,16.34,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.34,16.85
"West Nile Ab, Igm - Ref",PX8678890,CDM,300,RC,86788,CPT,90,,,,,,,109,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,16.34,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.34,16.85
finasteride 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862014930,NDC,1,EA,16.79,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,16.341707,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clarithromycin 250 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,527193106,NDC,1,EA,32.3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,16.3438,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clarithromycin 250 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,65862022560,NDC,1,EA,32.3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,16.3438,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Protein Elp,PX84166,CDM,300,RC,84166,CPT,,,,,,,,180,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,16.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.35,176.4
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68462033090,NDC,1,EA,17.95,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,16.35245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253022233,NDC,3,ML,38.13,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.35777,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
"Acylcarnitines, Quant - Ref",PX8201790,CDM,300,RC,82017,CPT,90,,,,,,,110,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,16.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.36,16.87
"Acylcarnitines, Quant - Ref",PX8201790,CDM,300,RC,82017,CPT,90,,,,,,,110,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,16.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.36,16.87
"Acylcarnitines, Quant - Ref",PX8201790,CDM,300,RC,82017,CPT,90,,,,,,,110,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,16.36,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.36,16.87
Carnitine - Ref,PX8237990,CDM,300,RC,82379,CPT,90,,,,,,,104,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,16.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.36,16.87
Carnitine - Ref,PX8237990,CDM,300,RC,82379,CPT,90,,,,,,,104,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,16.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.36,16.87
Carnitine - Ref,PX8237990,CDM,300,RC,82379,CPT,90,,,,,,,104,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,16.36,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.36,16.87
"Chest Wall Manipulation,Initial",PX94667,CDM,410,RC,94667,CPT,,,,,,,,121,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,16.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.05,43.63
"Chest Wall Manipulation,Initial",PX94667,CDM,410,RC,94667,CPT,,,,,,,,121,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,16.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.05,43.63
"US Guide, Vascular Access",PX7693701,CDM,402,RC,76937,CPT,TC,,,,,,,760,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,16.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.36,48.65
"US Guide, Vascular Access",PX7693701,CDM,402,RC,76937,CPT,TC,,,,,,,760,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,16.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.36,48.65
Xray Ankle 2 Vws,PX7360001,CDM,320,RC,73600,CPT,TC,,,,,,,163,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,16.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.14,48.65
Xray Ankle 2 Vws,PX7360001,CDM,320,RC,73600,CPT,TC,,,,,,,163,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,16.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.14,48.65
Xray Clavicle Complete,PX7300001,CDM,320,RC,73000,CPT,TC,,,,,,,365,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,16.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,48.65
Xray Clavicle Complete,PX7300001,CDM,320,RC,73000,CPT,TC,,,,,,,365,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,16.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,48.65
Xray Elbow 3+Vws Tc,PX7308001,CDM,320,RC,73080,CPT,TC,,,,,,,370,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,16.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,48.65
Xray Elbow 3+Vws Tc,PX7308001,CDM,320,RC,73080,CPT,TC,,,,,,,370,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,16.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,48.65
Xray Sacroiliac Jnts Less Than 3 Vws,PX7220001,CDM,320,RC,72200,CPT,TC,,,,,,,555,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,16.36,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.36,49.96
Xray Thoracolumbar 2 Vws,PX7208001,CDM,320,RC,72080,CPT,TC,,,,,,,306,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,16.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.14,48.65
Xray Thoracolumbar 2 Vws,PX7208001,CDM,320,RC,72080,CPT,TC,,,,,,,306,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,16.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.14,48.65
Alpha-Fetoprotein Serum,PX82105,CDM,300,RC,82105,CPT,,,,,,,,77,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,16.3659,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.27,16.77
"Alpha-Fetoprotein, Serum - Ref",PX8210590,CDM,300,RC,82105,CPT,90,,,,,,,80,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,16.3659,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.27,16.77
Assay Thyroid Stim Hormone,PX84443,CDM,300,RC,84443,CPT,,,,,,,,294,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,16.3659,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.04,16.8
Cmv Igm Antibody - Ref,PX8664590,CDM,300,RC,86645,CPT,90,,,,,,,125,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,16.3659,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.34,16.85
"Cortisol, Free - Ref",PX8253090,CDM,300,RC,82530,CPT,90,,,,,,,82,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,16.3659,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.21,16.71
"Fat/Lipids, Feces, Quant - Ref",PX8271090,CDM,300,RC,82710,CPT,90,,,,,,,95,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,16.3659,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.3,16.8
Glycated Protein - Ref,PX8298590,CDM,300,RC,82985,CPT,90,,,,,,,49,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,16.3659,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.26,16.76
Helicobacter Pylori Ab,PX86677,CDM,300,RC,86677,CPT,,,,,,,,224,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,16.3659,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.34,16.85
Influenza Assay W/Optic,PX87804,CDM,300,RC,87804,CPT,,,,,,,,127,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,16.3659,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.05,16.55
Primidone Assay - Ref,PX8018890,CDM,300,RC,80188,CPT,90,,,,,,,20,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,16.3659,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.09,16.59
Protein Elp Interp,PX8416526,CDM,300,RC,84165,CPT,26,,,,,,,175,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,16.3659,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.3659,27.536
"West Nile Ab, Igm - Ref",PX8678890,CDM,300,RC,86788,CPT,90,,,,,,,109,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,16.3659,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.34,16.85
DRAPE SHEET 70X85 LARGE DYNJP2417,27200000,CDM,272,RC,,,,10914-MAIN,LOCAL,,,,,18.39,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,16.3671,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409317801,NDC,20,ML,34.11,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,16.3728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409317801,NDC,20,ML,34.11,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,16.3728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409317816,NDC,20,ML,34.11,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,16.3728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409317816,NDC,20,ML,34.11,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,16.3728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189001,NDC,1,ML,34.11,,Health Partners,Health Partners Care Plans,both,48,,31.91333333,percent of total billed charges,16.3728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189001,NDC,1,ML,34.11,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,16.3728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189003,NDC,1,ML,34.11,,Health Partners,Health Partners Care Plans,both,48,,31.91333333,percent of total billed charges,16.3728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189003,NDC,1,ML,34.11,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,16.3728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
atropine 1 mg/mL Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100101,NDC,0.2,ML,39.42,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.375068,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
HYDROmorphone 2 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409131203,NDC,1,ML,38.18,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.37922,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
tobramycin 80 MG/2ML Solution 2 mL Vial,J3260.01,CDM,636,RC,J3260,HCPCS,,,,67457047300,NDC,2,ML,33.09,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,16.37955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.745586,32.4282
ursodiol 300 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,591315901,NDC,1,EA,39.47,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.395838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"BINDER ABDOMINAL 12"" HIGH 46 TO 62 INCH L/XL 4 PANEL ORT21300LXL",120.238,CDM,271,RC,A4467,HCPCS,,11935-MAIN,LOCAL,,,,,18,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,16.398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BURETROL ADD ON SET 150ML,120.38,CDM,272,RC,A4222,HCPCS,,11118-MAIN,LOCAL,,,,,18,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,16.398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
TRAY TRACH CLEAN & CARE DYND40589,120.212,CDM,271,RC,,,,1173-MAIN,LOCAL,,,,,18,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,16.398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,17.64
TRAY TRACHEOTOMY CARE PEDS DYND40650H,120.212,CDM,272,RC,,,,11025-MAIN,LOCAL,,,,,18,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,16.398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,17.64
Protein Elp Interp,PX8416526,CDM,300,RC,84165,CPT,26,,,,,,,175,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,16.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.3659,27.536
Protein Elp Interp,PX8416526,CDM,300,RC,84165,CPT,26,,,,,,,175,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,16.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.3659,27.536
Protein Elp Interp,PX8416526,CDM,300,RC,84165,CPT,26,,,,,,,175,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,16.4,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.3659,27.536
Viral Neutralization - Ref,PX8638290,CDM,300,RC,86382,CPT,90,,,,,,,28,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,16.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.4,16.91
Viral Neutralization - Ref,PX8638290,CDM,300,RC,86382,CPT,90,,,,,,,28,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,16.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.4,16.91
Viral Neutralization - Ref,PX8638290,CDM,300,RC,86382,CPT,90,,,,,,,28,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,16.4,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.4,16.91
BIOPSY FORCEPS HOT,27200000,CDM,272,RC,,,,4353-MAIN,LOCAL,,,,,38.25,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.40925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRESSING GEL FOAM SIZE 100SPONGE STERILE 00009034201,27200000,CDM,272,RC,A6248,HCPCS,,3378-MAIN,LOCAL,,,,,38.25,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.40925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFFLATION TUBING SET,27200000,CDM,272,RC,,,,4686-MAIN,LOCAL,,,,,38.25,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.40925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
KIT ENDO COMPLETE PROCEDURE CARRY-ON 100802,27200000,CDM,272,RC,,,,10369-MAIN,LOCAL,,,,,33.15,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,16.40925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189101,NDC,1,ML,32.43,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,16.40958,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
Factor VII - Ref,PX8523090,CDM,300,RC,85230,CPT,90,,,,,,,125,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,16.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.41,122.5
Factor VIII (Ahg) 1-Stage,PX85240,CDM,300,RC,85240,CPT,,,,,,,,997,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,16.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.41,977.06
methotrexate 2.5 MG Tablet 20 Each Box,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067005,NDC,1,EA,33.49,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.4101,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.911746,32.8398
methotrexate 2.5 MG Tablet 20 Each Box,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067005,NDC,1,EA,33.49,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.4101,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.911746,32.8398
methotrexate 2.5 MG Tablet 20 Each Box,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067005,NDC,1,EA,33.49,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,16.4101,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.911746,32.8398
Xray Spine Single Tc,PX7202001,CDM,320,RC,72020,CPT,TC,,,,,,,113,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,16.4118,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.9,32.87
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084007001,NDC,1,EA,33.17,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,16.41915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methotrexate 2.5 MG Tablet 1 Each Blister,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067001,NDC,1,EA,33.51,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.4199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.911746,32.8398
methotrexate 2.5 MG Tablet 1 Each Blister,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067001,NDC,1,EA,33.51,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.4199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.911746,32.8398
methotrexate 2.5 MG Tablet 1 Each Blister,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067001,NDC,1,EA,33.51,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,16.4199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.911746,32.8398
ciprofloxacin 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084007011,NDC,1,EA,33.19,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,16.42905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Homocysteine,PX83090,CDM,300,RC,83090,CPT,,,,,,,,44,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,16.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.43,43.12
Metanephrines - Ref,PX8383590,CDM,300,RC,83835,CPT,90,,,,,,,34,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,16.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.43,16.94
Metanephrines - Ref,PX8383590,CDM,300,RC,83835,CPT,90,,,,,,,34,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,16.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.43,16.94
Metanephrines - Ref,PX8383590,CDM,300,RC,83835,CPT,90,,,,,,,34,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,16.43,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.43,16.94
"Triiodothyronine T3, Free (Free T3)",PX84481,CDM,300,RC,84481,CPT,,,,,,,,137,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,16.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.43,16.94
"Triiodothyronine T3, Free (Free T3)",PX84481,CDM,300,RC,84481,CPT,,,,,,,,137,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,16.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.43,16.94
"Triiodothyronine T3, Free (Free T3)",PX84481,CDM,300,RC,84481,CPT,,,,,,,,137,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,16.43,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.43,16.94
oxyBUTYnin ER 5 MG Tablet Extended Release 24 Hour 50 Each Box,63700001,CDM,250,RC,,,,,,904657006,NDC,1,EA,18.04,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,16.43444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisoprolol-hydroCHLOROthiazide 5-6.25 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,42799092102,NDC,1,EA,39.57,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.437378,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dutasteride 0.5 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,42806054909,NDC,1,EA,32.49,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,16.43994,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Extractable Nuclear Antigen, Each Antigen",PX86235,CDM,300,RC,86235,CPT,90,,,,,,,99,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,16.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.44,97.02
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078110,NDC,0.5,EA,38.33,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.44357,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987525,NDC,3,ML,33.22,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,16.4439,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
morphine 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574711212,NDC,1,EA,33.56,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.4444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574711212,NDC,1,EA,33.56,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.4444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574711212,NDC,1,EA,33.56,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,16.4444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bacitracin zinc 500 UNIT/GM Ointment 28.35 g Tube,25000000,CDM,250,RC,,,,,,168001131,NDC,28.35,GR,32.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,16.445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
valACYclovir 1 GM Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862044930,NDC,0.5,EA,33.23,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,16.44885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famciclovir 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,60505324603,NDC,0.5,EA,18.65,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,16.4493,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
finasteride 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862014930,NDC,1,EA,16.79,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,16.4542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
valACYclovir 1 GM Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069701,NDC,0.5,EA,33.58,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.4542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
valACYclovir 1 GM Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069701,NDC,0.5,EA,33.58,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.4542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
valACYclovir 1 GM Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069701,NDC,0.5,EA,33.58,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,16.4542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DRESSING OPTIFOAM 10X4 POST-OP SILICONE FACED MSC21410Z,120.154,CDM,272,RC,A6213,HCPCS,,8632-MAIN,LOCAL,,,,,16,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,16.46,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.46,26.816
DRESSING OPTIFOAM 10X4 POST-OP SILICONE FACED MSC21410Z,120.154,CDM,272,RC,A6213,HCPCS,,8632-MAIN,LOCAL,,,,,16,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,16.46,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.46,26.816
Gammaglobulin; Ige - Ref,PX8278590,CDM,300,RC,82785,CPT,90,,,,,,,45,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,16.46,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.97,16.46
MEPILEX AG 4X4 10X10,120.138,CDM,272,RC,A6213,HCPCS,,7248-MAIN,LOCAL,,,,,33,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,16.46,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.46,26.816
MEPILEX AG 4X4 10X10,120.138,CDM,272,RC,A6213,HCPCS,,7248-MAIN,LOCAL,,,,,33,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,16.46,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.46,26.816
MEPILEX AG FOAM 4X4,120.192,CDM,272,RC,A6213,HCPCS,,8480-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,16.46,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.46,26.816
MEPILEX AG FOAM 4X4,120.192,CDM,272,RC,A6213,HCPCS,,8480-MAIN,LOCAL,,,,,42,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,16.46,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.46,26.816
MEPILEX AG FOAM 4X8,120.192,CDM,272,RC,A6213,HCPCS,,8479-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,16.46,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.46,26.816
MEPILEX AG FOAM 4X8,120.192,CDM,272,RC,A6213,HCPCS,,8479-MAIN,LOCAL,,,,,42,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,16.46,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.46,26.816
DRESSING OPTIFOAM 10X4 POST-OP SILICONE FACED MSC21410Z,120.154,CDM,272,RC,A6213,HCPCS,,8632-MAIN,LOCAL,,,,,16,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,16.46,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.46,26.816
DRESSING OPTIFOAM 10X4 POST-OP SILICONE FACED MSC21410Z,120.154,CDM,272,RC,A6213,HCPCS,,8632-MAIN,LOCAL,,,,,16,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,16.46,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.46,26.816
MEPILEX AG 4X4 10X10,120.138,CDM,272,RC,A6213,HCPCS,,7248-MAIN,LOCAL,,,,,33,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,16.46,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.46,26.816
MEPILEX AG 4X4 10X10,120.138,CDM,272,RC,A6213,HCPCS,,7248-MAIN,LOCAL,,,,,33,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,16.46,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.46,26.816
MEPILEX AG FOAM 4X4,120.192,CDM,272,RC,A6213,HCPCS,,8480-MAIN,LOCAL,,,,,42,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,16.46,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.46,26.816
MEPILEX AG FOAM 4X4,120.192,CDM,272,RC,A6213,HCPCS,,8480-MAIN,LOCAL,,,,,42,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,16.46,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.46,26.816
MEPILEX AG FOAM 4X8,120.192,CDM,272,RC,A6213,HCPCS,,8479-MAIN,LOCAL,,,,,42,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,16.46,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.46,26.816
MEPILEX AG FOAM 4X8,120.192,CDM,272,RC,A6213,HCPCS,,8479-MAIN,LOCAL,,,,,42,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,16.46,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.46,26.816
oxyBUTYnin ER 5 MG Tablet Extended Release 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,63739054833,NDC,1,EA,18.67,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,16.46694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
valproate 100 MG/ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049416,NDC,5,ML,33.61,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.4689,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
valproate 100 MG/ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049416,NDC,5,ML,33.61,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.4689,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
valproate 100 MG/ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049416,NDC,5,ML,33.61,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,16.4689,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
valproate 100 MG/ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049441,NDC,5,ML,33.61,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.4689,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
valproate 100 MG/ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049441,NDC,5,ML,33.61,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.4689,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
valproate 100 MG/ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049441,NDC,5,ML,33.61,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,16.4689,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048226,NDC,20,ML,32.56,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,16.47536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048241,NDC,20,ML,32.56,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,16.47536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641600101,NDC,1,ML,32.56,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,16.47536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
benzocaine-menthol 20-0.5 % Aerosol 56 g Can,63700001,CDM,250,RC,,,,,,16864068002,NDC,56,GR,33.3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,16.4835,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409427602,NDC,50,ML,38.46,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.49934,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600701,NDC,10,ML,39.73,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.503842,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,38.9354
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,641601301,NDC,5,ML,34.41,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,16.5168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,641601301,NDC,5,ML,34.41,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,16.5168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Lyme Disease Antibody,PX86618,CDM,300,RC,86618,CPT,,,,,,,,194,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,16.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.52,17.03
Lyme Disease Antibody,PX86618,CDM,300,RC,86618,CPT,,,,,,,,194,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,16.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.52,17.03
Lyme Disease Antibody,PX86618,CDM,300,RC,86618,CPT,,,,,,,,194,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,16.52,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.52,17.03
"Lyme Disease, Antibody - Ref",PX8661890,CDM,300,RC,86618,CPT,90,,,,,,,181,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,16.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.52,17.03
"Lyme Disease, Antibody - Ref",PX8661890,CDM,300,RC,86618,CPT,90,,,,,,,181,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,16.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.52,17.03
"Lyme Disease, Antibody - Ref",PX8661890,CDM,300,RC,86618,CPT,90,,,,,,,181,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,16.52,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.52,17.03
Lyme Screen,PX7585,CDM,300,RC,86618,CPT,,,,,,,,198,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,16.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.52,17.03
Lyme Screen,PX7585,CDM,300,RC,86618,CPT,,,,,,,,198,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,16.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.52,17.03
Lyme Screen,PX7585,CDM,300,RC,86618,CPT,,,,,,,,198,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,16.52,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.52,17.03
famciclovir 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714030401,NDC,1,EA,34.42,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,16.5216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famciclovir 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714030401,NDC,1,EA,34.42,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,16.5216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323048201,NDC,10,ML,39.78,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.524612,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323048217,NDC,10,ML,39.78,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.524612,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Strep a Assay W/Optic,PX87880,CDM,300,RC,87880,CPT,,,,,,,,95,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,16.53,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.03,16.53
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120301,NDC,0.5,ML,34.45,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,16.536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120301,NDC,0.5,ML,34.45,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,16.536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120311,NDC,0.5,ML,34.45,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,16.536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120311,NDC,0.5,ML,34.45,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,16.536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
valACYclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069801,NDC,1,EA,38.55,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.53795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dabigatran 75 MG capsule 60 Each Box,63700001,CDM,250,RC,,,,,,597014960,NDC,1,EA,39.83,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.545382,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Basic Metabolic Panel Ca Ion,PX80047,CDM,300,RC,80047,CPT,,,,,,,,17,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,16.5461,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.0618,16.66
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987501,NDC,3,ML,33.77,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.5473,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987501,NDC,3,ML,33.77,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.5473,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987501,NDC,3,ML,33.77,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,16.5473,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039814,NDC,1,EA,39.84,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.549536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
BUPivacaine PF 0.5 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,55150016910,NDC,10,ML,39.84,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.549536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
enalaprilat 1.25 MG/ML Injectable 1 mL Vial,25000000,CDM,250,RC,,,,,,143978710,NDC,1,ML,39.84,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.549536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098141,NDC,1,EA,39.84,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.549536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098153,NDC,1,EA,39.84,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.549536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,47781059807,NDC,1,EA,39.84,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.549536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
Cyclosporine - Ref,PX8015890,CDM,300,RC,80158,CPT,90,,,,,,,95,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,16.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.55,93.1
Influenza Assay W/Optic,PX87804,CDM,300,RC,87804,CPT,,,,,,,,127,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,16.55,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.05,16.55
Mycophenolate Mycophenolicacid - Ref,PX8018090,CDM,300,RC,80180,CPT,90,,,,,,,56,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,16.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.55,54.88
meloxicam 7.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,29300012401,NDC,1,EA,17.02,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,16.565566,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 200-40 MG/5ML Suspension 473 mL Bottle,63700001,CDM,250,RC,,,,,,65862049647,NDC,10,ML,18.79,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,16.57278,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methotrexate 2.5 MG Tablet 20 Each Box,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067005,NDC,1,EA,33.49,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,16.57755,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.911746,32.8398
Irri Implted Drug Dlvr Device,PX96523,CDM,260,RC,96523,CPT,,,,,,,,119,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,16.58,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.58,43.63
"Noninvasv Oxygen Satut,Continuous",PX94762,CDM,460,RC,94762,CPT,,,,,,,,242,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,16.58,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.58,44.21
US Follicles-Limited Tc,PX7685701,CDM,402,RC,76857,CPT,TC,,,,,,,300,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,16.58,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.58,51.93
Irri Implted Drug Dlvr Device,PX96523,CDM,260,RC,96523,CPT,,,,,,,,119,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,16.58,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.58,43.63
Irri Implted Drug Dlvr Device,PX96523,CDM,260,RC,96523,CPT,,,,,,,,119,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,16.58,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.58,43.63
nadolol 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,76385013301,NDC,1,EA,18.2,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,16.5802,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016501,NDC,1,ML,34.55,,Health Partners,Health Partners Care Plans,both,48,,1.5325,percent of total billed charges,16.584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016501,NDC,1,ML,34.55,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,16.584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049226,NDC,30,ML,34.55,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,16.584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049226,NDC,30,ML,34.55,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,16.584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049245,NDC,30,ML,34.55,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,16.584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049245,NDC,30,ML,34.55,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,16.584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,23155024031,NDC,2,ML,34.55,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,16.584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.859
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,23155024031,NDC,2,ML,34.55,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,16.584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.859
famciclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,93811956,NDC,0.25,EA,17.04,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,16.585032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methotrexate 2.5 MG Tablet 1 Each Blister,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067001,NDC,1,EA,33.51,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,16.58745,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.911746,32.8398
"Breast Tomosynthesis,Screen Tc",PX7706301,CDM,403,RC,77063,CPT,TC,,,,,,,166,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,16.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.59,280.5
Primidone Assay - Ref,PX8018890,CDM,300,RC,80188,CPT,90,,,,,,,20,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,16.59,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.09,16.59
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598F,CDM,510,RC,97598,CPT,,,,,,,,406,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,16.59,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.59,59.31
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598P,CDM,982,RC,97598,CPT,,,,,,,,325,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,16.59,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.59,318.5
famciclovir 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,60505324603,NDC,0.5,EA,18.65,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,16.5985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Bile Acids Total,PX8223990,CDM,300,RC,82239,CPT,90,,,,,,,232,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,16.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.61,17.12
Bile Acids Total,PX8223990,CDM,300,RC,82239,CPT,90,,,,,,,232,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,16.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.61,17.12
Bile Acids Total,PX8223990,CDM,300,RC,82239,CPT,90,,,,,,,232,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,16.61,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.61,17.12
morphine 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574711212,NDC,1,EA,33.56,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,16.6122,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
8MM-12MM TIP COVER ACCESSORY,27200000,CDM,272,RC,,,,11918-MAIN,LOCAL,,,,,40,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CATHETER URETERAL  5FR TIGERTAIL OPEN TIP FLEXIBLE 139005,27200000,CDM,272,RC,A4340,HCPCS,,12302-MAIN,LOCAL,,,,,40,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NEEDLE BIOPSY 14GAX4 1/2 2N2702X,120.211,CDM,272,RC,,,,724-MAIN,LOCAL,,,,,40,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.616,39.2
STAPLER CANNULA SEAL 12 mm 470380,27200000,CDM,272,RC,,,,11962-MAIN,LOCAL,,,,,40,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"SUTURE V-LOC 22G NEEDLE 9"" 180 GREEN VLOCL2145",27200000,CDM,272,RC,,,,11930-MAIN,LOCAL,,,,,40,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"SUTURE V-LOC SZ 0.9"" 180 GREEN GS-21 NEEDLE VLOCL0346",27200000,CDM,272,RC,,,,11933-MAIN,LOCAL,,,,,40,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Telehealth Origin Site Fac Fee,PXQ3014,CDM,780,RC,Q3014,HCPCS,,,,,,,,40,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.616,39.2
oxyBUTYnin ER 5 MG Tablet Extended Release 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,63739054833,NDC,1,EA,18.67,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,16.6163,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
valACYclovir 1 GM Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069701,NDC,0.5,EA,33.58,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,16.6221,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,36000014801,NDC,2,ML,38.76,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.62804,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Ebv, Viral Capsid Ab - Ref",PX8666590,CDM,300,RC,86665,CPT,90,,,,,,,58,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,16.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.63,56.84
Epstein-barr antibody,PX86665,CDM,300,RC,86665,CPT,,,,,,,,86,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,16.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.63,84.28
valproate 100 MG/ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049416,NDC,5,ML,33.61,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,16.63695,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
valproate 100 MG/ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049441,NDC,5,ML,33.61,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,16.63695,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
valACYclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,31722070430,NDC,1,EA,38.79,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.64091,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189103,NDC,1,ML,32.89,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,16.64234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
levETIRAcetam 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079082101,NDC,1,EA,18.87,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,16.64334,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Basic Metabolic Panel Ca Ion,PX80047,CDM,300,RC,80047,CPT,,,,,,,,17,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,16.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.0618,16.66
BINDER ABDOMINAL S/M 9 INCH UP TO 45 INCHES TRI-PANNEL ABB3P45,120.238,CDM,271,RC,A4467,HCPCS,,47-MAIN,LOCAL,,,,,34,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL S/M 9 INCH UP TO 45 INCHES TRI-PANNEL ABB3P45,120.238,CDM,271,RC,A4467,HCPCS,,47-MAIN,LOCAL,,,,,34,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL S/M 9 INCH UP TO 45 INCHES TRI-PANNEL ABB3P45,120.238,CDM,271,RC,A4467,HCPCS,,47-MAIN,LOCAL,,,,,34,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,16.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,6.215714286,percent of total billed charges,16.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,16.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,6.215714286,percent of total billed charges,16.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,16.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
"Lab Ige, Isocyan Hdi",PX86003,CDM,300,RC,86003,CPT,90,,,,,,,34,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.79,33.32
"Lab Ige, Isocyan Hdi",PX86003,CDM,300,RC,86003,CPT,90,,,,,,,34,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.79,33.32
"Lab Ige, Isocyan Hdi",PX86003,CDM,300,RC,86003,CPT,90,,,,,,,34,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,16.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.79,33.32
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323020110,NDC,10,ML,34,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323020110,NDC,10,ML,34,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323020110,NDC,10,ML,34,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,16.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Metanephrines - Ref,PX8383590,CDM,300,RC,83835,CPT,90,,,,,,,34,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1236,33.32
Metanephrines - Ref,PX8383590,CDM,300,RC,83835,CPT,90,,,,,,,34,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1236,33.32
Metanephrines - Ref,PX8383590,CDM,300,RC,83835,CPT,90,,,,,,,34,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,16.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1236,33.32
SPLINT SAM 36INCH ROLLED 661121,120.362,CDM,271,RC,,,,10789-MAIN,LOCAL,,,,,34,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1236,33.32
SPLINT SAM 36INCH ROLLED 661121,120.362,CDM,271,RC,,,,10789-MAIN,LOCAL,,,,,34,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1236,33.32
SPLINT SAM 36INCH ROLLED 661121,120.362,CDM,271,RC,,,,10789-MAIN,LOCAL,,,,,34,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,16.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1236,33.32
"Venipunc Need Phys Skill,Dx or Rx",PX36410F,CDM,510,RC,36410,CPT,,,,,,,,34,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,2.85,percent of total billed charges,16.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1236,33.32
"Venipunc Need Phys Skill,Dx or Rx",PX36410F,CDM,510,RC,36410,CPT,,,,,,,,34,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1236,33.32
"Venipunc Need Phys Skill,Dx or Rx",PX36410F,CDM,510,RC,36410,CPT,,,,,,,,34,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,16.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1236,33.32
leucovorin 10 mg/mL Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,25021081467,NDC,1,EA,40.13,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.670002,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.670002,84.6818
lidocaine 1% PF 1 % Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,63323049227,NDC,2,ML,34.74,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,16.6752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,63323049227,NDC,2,ML,34.74,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,16.6752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fluticasone-salmeterol 100-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069500,NDC,1,EA,38.87,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.67523,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
meloxicam 7.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,29300012401,NDC,1,EA,17.02,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,16.6796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001001,NDC,1.5,ML,40.17,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.686618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,42.5516
"Acylcarnitines, Quant - Ref",PX8201790,CDM,300,RC,82017,CPT,90,,,,,,,110,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,16.6868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.36,16.87
Bile Acids Total,PX8223990,CDM,300,RC,82239,CPT,90,,,,,,,232,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,16.6868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.61,17.12
Carnitine - Ref,PX8237990,CDM,300,RC,82379,CPT,90,,,,,,,104,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,16.6868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.36,16.87
Lyme Disease Antibody,PX86618,CDM,300,RC,86618,CPT,,,,,,,,194,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,16.6868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.52,17.03
"Lyme Disease, Antibody - Ref",PX8661890,CDM,300,RC,86618,CPT,90,,,,,,,181,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,16.6868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.52,17.03
Lyme Screen,PX7585,CDM,300,RC,86618,CPT,,,,,,,,198,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,16.6868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.52,17.03
Metanephrines - Ref,PX8383590,CDM,300,RC,83835,CPT,90,,,,,,,34,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,16.6868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.43,16.94
"Triiodothyronine T3, Free (Free T3)",PX84481,CDM,300,RC,84481,CPT,,,,,,,,137,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,16.6868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.43,16.94
Viral Neutralization - Ref,PX8638290,CDM,300,RC,86382,CPT,90,,,,,,,28,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,16.6868,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.4,16.91
Strapping of Knee,PX29530F,CDM,420,RC,29530,CPT,,,,,,,,303,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,16.6972,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.12,60.88
Strapping of Shoulder,PX29240F,CDM,420,RC,29240,CPT,,,,,,,,165,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,16.6972,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.12,61.57
Strapping of Shoulder,PX29240P,CDM,983,RC,29240,CPT,,,,,,,,110,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,16.6972,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.12,107.8
CATHETER FOLEY 18FR  3WAY 30CC 73018L,120.21,CDM,272,RC,A4346,HCPCS,,253-MAIN,LOCAL,,,,,33,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,16.698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
CATHETER FOLEY 20FR 3WAY 30CC 0167L20,120.21,CDM,272,RC,A4346,HCPCS,,251-MAIN,LOCAL,,,,,33,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,16.698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
CATHETER FOLEY 24FR 3WAY 30CC 0167L24,120.21,CDM,272,RC,A4346,HCPCS,,10455-MAIN,LOCAL,,,,,33,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,16.698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
"DRESSING AQUACEL 3/4"" X 18"" AG HYDROFIBER 403771",120.31,CDM,272,RC,A6199,HCPCS,,8238-MAIN,LOCAL,,,,,33,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,16.698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,32.34
Hospital Outpatient Clinic Visit Specimen Collection for Sars-Cov-2,PXC9803,CDM,300,RC,C9803,HCPCS,,,,,,,,33,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,16.698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,32.34
MEPILEX AG 4X4 10X10,120.138,CDM,272,RC,A6213,HCPCS,,7248-MAIN,LOCAL,,,,,33,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,16.698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,32.34
STANDARD HIGH FLOW INSUFFLATION FILTER TUBING,27200000,CDM,272,RC,,,,11885-MAIN,LOCAL,,,,,33,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,16.698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
famciclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,93811956,NDC,0.25,EA,17.04,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,16.6992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
APPLICATOR CHLORAPREP 26ML WITH ORANGE 930815,27200000,CDM,272,RC,A4248,HCPCS,,10031-MAIN,LOCAL,,,,,19.65,,First Health,Commercial,both,85,,999999999,percent of total billed charges,16.7025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Cortisol, Free - Ref",PX8253090,CDM,300,RC,82530,CPT,90,,,,,,,82,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,16.71,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.21,16.71
miconazole 2 % Powder 71 g Bottle,25000000,CDM,250,RC,,,,,,316023125,NDC,71,GR,34.82,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,16.7136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
miconazole 2 % Powder 71 g Bottle,25000000,CDM,250,RC,,,,,,316023125,NDC,71,GR,34.82,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,16.7136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409317801,NDC,20,ML,34.11,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.7139,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409317801,NDC,20,ML,34.11,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.7139,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409317801,NDC,20,ML,34.11,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,16.7139,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409317816,NDC,20,ML,34.11,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.7139,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409317816,NDC,20,ML,34.11,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.7139,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409317816,NDC,20,ML,34.11,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,16.7139,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189001,NDC,1,ML,34.11,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,4.09125,percent of total billed charges,16.7139,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189001,NDC,1,ML,34.11,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.7139,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189001,NDC,1,ML,34.11,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,16.7139,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189003,NDC,1,ML,34.11,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,4.09125,percent of total billed charges,16.7139,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189003,NDC,1,ML,34.11,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.7139,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189003,NDC,1,ML,34.11,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,16.7139,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987501,NDC,3,ML,33.77,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,16.71615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
morphine 2 MG/ML Solution 1 mL Syringe,J2272.01,CDM,636,RC,J2272,HCPCS,,,,76045000401,NDC,1,ML,38.98,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.72242,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.192292,38.2004
sulfamethoxazole-trimethoprim 200-40 MG/5ML Suspension 473 mL Bottle,63700001,CDM,250,RC,,,,,,65862049647,NDC,10,ML,18.79,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,16.7231,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CLOSED WOUND ROUND CHANNEL DRAIN WITH TROCAR 15FR FULL FLUTED,27200000,CDM,272,RC,,,,12223-MAIN,LOCAL,,,,,39,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.731,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
fluorouracil 500 MG/10ML Solution 10 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,63323011710,NDC,10,ML,39,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.731,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,256.2112
gemcitabine 200 MG Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323010294,NDC,1,EA,39,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.731,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
Lab Wbc and Differential,PX85004,CDM,300,RC,85004,CPT,,,,,,,,39,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.731,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,38.22
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003928,NDC,1,EA,39,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.731,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
methylPREDNISolone sod succ 500 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9075801,NDC,0.25,EA,39,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.731,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
NEEDLE JAMSHIDI 11G X 101MM BIOPSY DJ4011X,27200000,CDM,272,RC,,,,12798-MAIN,LOCAL,,,,,39,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.731,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
O2 SENSOR ADULT ADHESIVE SINGLE PATIENT 040-003382-00,120.576,CDM,272,RC,,,,12930-MAIN,LOCAL,,,,,39,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.731,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
O2 SENSOR INFANT ADHESIVE SINGLE PATIENT 040-003384-00,120.576,CDM,272,RC,,,,12932-MAIN,LOCAL,,,,,39,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.731,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
O2 SENSOR PEDIATRIC ADHESIVE SINGLE PATIENT 040-003383-00,120.576,CDM,272,RC,,,,12931-MAIN,LOCAL,,,,,39,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.731,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
SLEEVE ACHILLES LG/XL PROTECTION 92437145348,120.422,CDM,271,RC,,,,11378-MAIN,LOCAL,,,,,39,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.731,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
SLEEVE ACHILLES SM/MED PROTECTION 92437145324,120.422,CDM,271,RC,,,,11377-MAIN,LOCAL,,,,,39,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.731,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
Treponema Pallidum - Ref,PX8678090,CDM,300,RC,86780,CPT,90,,,,,,,39,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.731,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.14,38.22
TROCAR KII FIOS SYSTEM BLADELSS Z-THREAD 5MMX150MM,27200000,CDM,272,RC,,,,12827-MAIN,LOCAL,,,,,39,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.731,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Bone Age Studies Tc,PX7707201,CDM,320,RC,77072,CPT,TC,,,,,,,211,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,16.7336,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.12,33.53
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409427617,NDC,50,ML,39.01,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.73529,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,703291401,NDC,0.5,EA,40.3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.74062,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409488724,NDC,50,ML,34.88,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,16.7424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409488724,NDC,50,ML,34.88,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,16.7424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409488750,NDC,50,ML,34.88,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,16.7424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409488750,NDC,50,ML,34.88,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,16.7424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tobramycin 80 MG/2ML Solution 2 mL Vial,J3260.01,CDM,636,RC,J3260,HCPCS,,,,67457047300,NDC,2,ML,33.09,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,16.74354,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.745586,32.4282
azithromycin 200 MG/5ML Recon Susp 15 mL Bottle,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,59762312001,NDC,15,ML,196.35,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,16.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
azithromycin 250 MG Tablet 6 Each Box,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096104,NDC,1,EA,41.72,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,16.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,50111078751,NDC,1,EA,41.79,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,16.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096105,NDC,1,EA,41.73,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,16.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
"Ethanol, P",PX82077,CDM,300,RC,82077,CPT,,,,,,,,30,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,16.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,17.27
"Ethanol, P",PX82077,CDM,300,RC,82077,CPT,,,,,,,,30,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,16.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,17.27
"Ethanol, P",PX82077,CDM,300,RC,82077,CPT,,,,,,,,30,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,16.75,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,17.27
Immunoassay Nos - Ref,PX8352090,CDM,300,RC,83520,CPT,90,,,,,,,220,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,16.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,17.27
Immunoassay Nos - Ref,PX8352090,CDM,300,RC,83520,CPT,90,,,,,,,220,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,16.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,17.27
Immunoassay Nos - Ref,PX8352090,CDM,300,RC,83520,CPT,90,,,,,,,220,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,16.75,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,17.27
DRAPE SHEET 70X85 LARGE DYNJP2417,27200000,CDM,272,RC,,,,10914-MAIN,LOCAL,,,,,18.39,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,16.75329,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE SILK 3-0 18INCH NONABSORBABLE BLACK M13T,27200000,CDM,272,RC,,,,12872-MAIN,LOCAL,,,,,19,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,16.758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Glycated Protein - Ref,PX8298590,CDM,300,RC,82985,CPT,90,,,,,,,49,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,16.76,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.26,16.76
Somatostatin - Ref,PX8430790,CDM,300,RC,84307,CPT,90,,,,,,,325,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,16.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.76,318.5
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,185012201,NDC,1,EA,17.23,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,16.769959,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Alpha-Fetoprotein Serum,PX82105,CDM,300,RC,82105,CPT,,,,,,,,77,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,16.77,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.27,16.77
"Alpha-Fetoprotein, Serum - Ref",PX8210590,CDM,300,RC,82105,CPT,90,,,,,,,80,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,16.77,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.27,16.77
KIT ENDO COMPLETE PROCEDURE CARRY-ON 100802,27200000,CDM,272,RC,,,,10369-MAIN,LOCAL,,,,,33.15,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,16.7739,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
enalaprilat 1.25 MG/ML Injectable 1 mL Vial,25000000,CDM,250,RC,,,,,,143978701,NDC,1,ML,40.39,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.778006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733513,NDC,1,EA,39.12,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.78248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084007001,NDC,1,EA,33.17,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,16.78402,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Noninvasv Oxygen Satut,Continuous",PX94762,CDM,460,RC,94762,CPT,,,,,,,,242,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,16.79,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.58,44.21
"Noninvasv Oxygen Satut,Continuous",PX94762,CDM,460,RC,94762,CPT,,,,,,,,242,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,16.79,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.58,44.21
Surgical Cleansing of Skin,PX11000P,CDM,983,RC,11000,CPT,,,,,,,,145,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,16.79,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.79,142.1
"US Guide, Vascular Access",PX7693701,CDM,402,RC,76937,CPT,TC,,,,,,,760,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,16.79,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.36,48.65
Xray Sacroiliac Jnts Less Than 3 Vws,PX7220001,CDM,320,RC,72200,CPT,TC,,,,,,,555,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,16.79,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.36,49.96
Xray Sacroiliac Jnts Less Than 3 Vws,PX7220001,CDM,320,RC,72200,CPT,TC,,,,,,,555,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,16.79,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.36,49.96
Xray Shoulder Minimum 2 Vws,PX7303001,CDM,320,RC,73030,CPT,TC,,,,,,,365,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,16.79,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.79,51.28
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,60432006547,NDC,10,ML,34.98,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,16.7904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,60432006547,NDC,10,ML,34.98,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,16.7904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levoFLOXacin 750 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635361,NDC,0.333333333,EA,39.14,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.79106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084007011,NDC,1,EA,33.19,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,16.79414,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levETIRAcetam 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079082101,NDC,1,EA,18.87,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,16.7943,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028002,NDC,1,ML,40.43,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.794622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,17478081705,NDC,5,ML,34.99,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,16.7952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,17478081705,NDC,5,ML,34.99,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,16.7952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253033335,NDC,5,ML,40.44,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.798776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
pravastatin 10 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,60505016809,NDC,1,EA,17.26,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,16.799158,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay Thyroid Stim Hormone,PX84443,CDM,300,RC,84443,CPT,,,,,,,,294,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,16.8,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.04,16.8
"Fat/Lipids, Feces, Quant - Ref",PX8271090,CDM,300,RC,82710,CPT,90,,,,,,,95,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,16.8,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.3,16.8
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209F,CDM,510,RC,69209,CPT,,,,,,,,35,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,16.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,53.44
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209F,CDM,510,RC,69209,CPT,,,,,,,,35,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,16.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,53.44
SHOE POST OP X-LARGE MALE DS1016-16,120.237,CDM,274,RC,L3260,HCPCS,,6337-MAIN,LOCAL,,,,,35,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,16.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP X-LARGE MALE DS1016-16,120.237,CDM,274,RC,L3260,HCPCS,,6337-MAIN,LOCAL,,,,,35,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,16.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987525,NDC,3,ML,33.22,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,16.80932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
valACYclovir 1 GM Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862044930,NDC,0.5,EA,33.23,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,16.81438,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BINDER ABDOMINAL S/M 9 INCH UP TO 45 INCHES TRI-PANNEL ABB3P45,120.238,CDM,271,RC,A4467,HCPCS,,47-MAIN,LOCAL,,,,,34,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,16.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,16.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,16.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
"Lab Ige, Isocyan Hdi",PX86003,CDM,300,RC,86003,CPT,90,,,,,,,34,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,16.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.79,33.32
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323020110,NDC,10,ML,34,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,16.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Metanephrines - Ref,PX8383590,CDM,300,RC,83835,CPT,90,,,,,,,34,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,16.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1236,33.32
SPLINT SAM 36INCH ROLLED 661121,120.362,CDM,271,RC,,,,10789-MAIN,LOCAL,,,,,34,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,16.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1236,33.32
"Venipunc Need Phys Skill,Dx or Rx",PX36410F,CDM,510,RC,36410,CPT,,,,,,,,34,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,16.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1236,33.32
Platelet Antibodies - Ref,PX8602290,CDM,300,RC,86022,CPT,90,,,,,,,245,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,16.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.84,240.1
benzocaine-menthol 20-0.5 % Aerosol 56 g Can,63700001,CDM,250,RC,,,,,,16864068002,NDC,56,GR,33.3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,16.8498,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Cmv Igm Antibody - Ref,PX8664590,CDM,300,RC,86645,CPT,90,,,,,,,125,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,16.85,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.34,16.85
Helicobacter Pylori Ab,PX86677,CDM,300,RC,86677,CPT,,,,,,,,224,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,16.85,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.34,16.85
"West Nile Ab, Igm - Ref",PX8678890,CDM,300,RC,86788,CPT,90,,,,,,,109,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,16.85,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.34,16.85
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707426,NDC,100,ML,39.29,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.85541,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,641601310,NDC,5,ML,40.58,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.856932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Assay of Psa Total,PX84153,CDM,300,RC,84153,CPT,,,,,,,,157,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,16.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.86,153.86
"Psa, Free - Ref",PX8415490,CDM,300,RC,84154,CPT,90,,,,,,,38,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,16.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
"Psa, Total - Ref",PX8415390,CDM,300,RC,84153,CPT,90,,,,,,,38,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,16.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,641601301,NDC,5,ML,34.41,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.8609,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,641601301,NDC,5,ML,34.41,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.8609,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,641601301,NDC,5,ML,34.41,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,16.8609,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
famciclovir 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714030401,NDC,1,EA,34.42,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.8658,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famciclovir 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714030401,NDC,1,EA,34.42,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.8658,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famciclovir 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714030401,NDC,1,EA,34.42,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,16.8658,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
skin oil Oil 236.6 mL Bottle,63700001,CDM,250,RC,,,,,,67211008,NDC,236.6,ML,40.61,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.869394,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Acylcarnitines, Quant - Ref",PX8201790,CDM,300,RC,82017,CPT,90,,,,,,,110,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,16.87,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.36,16.87
Carnitine - Ref,PX8237990,CDM,300,RC,82379,CPT,90,,,,,,,104,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,16.87,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.36,16.87
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120301,NDC,0.5,ML,34.45,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.8805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120301,NDC,0.5,ML,34.45,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.8805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120301,NDC,0.5,ML,34.45,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,16.8805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120311,NDC,0.5,ML,34.45,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.8805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120311,NDC,0.5,ML,34.45,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.8805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120311,NDC,0.5,ML,34.45,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,16.8805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
acetaminophen 160 MG/5ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,68094023159,NDC,15,ML,19.14,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,16.88148,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409317801,NDC,20,ML,34.11,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,16.88445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409317816,NDC,20,ML,34.11,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,16.88445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189001,NDC,1,ML,34.11,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,16.88445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189003,NDC,1,ML,34.11,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,16.88445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,185012201,NDC,1,EA,17.23,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,16.8854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SUTURE SILK 3-0 18INCH NONABSORBABLE BLACK M13T,27200000,CDM,272,RC,,,,12872-MAIN,LOCAL,,,,,19,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,16.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Viral Neutralization - Ref,PX8638290,CDM,300,RC,86382,CPT,90,,,,,,,28,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,16.91,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.4,16.91
atropine 1 mg/mL Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100101,NDC,0.2,ML,39.42,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.91118,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
pravastatin 10 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,60505016809,NDC,1,EA,17.26,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,16.9148,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
povidone-iodine 10 % Ointment 28.35 g Tube,63700001,CDM,250,RC,,,,,,904110231,NDC,28.35,GR,19.9,,First Health,Commercial,both,85,,999999999,percent of total billed charges,16.915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 10 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,60687024511,NDC,0.5,EA,19.18,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,16.91676,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gemcitabine 200 MG/5.26ML Solution 5.26 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018301,NDC,5.26,ML,40.74,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.923396,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016501,NDC,1,ML,34.55,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1.136465517,percent of total billed charges,16.9295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016501,NDC,1,ML,34.55,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.9295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016501,NDC,1,ML,34.55,,United Healthcare,All Medicare advantage plans,outpatient,49,,1.675,percent of total billed charges,16.9295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049226,NDC,30,ML,34.55,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.9295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049226,NDC,30,ML,34.55,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.9295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049226,NDC,30,ML,34.55,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,16.9295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049245,NDC,30,ML,34.55,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.9295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049245,NDC,30,ML,34.55,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.9295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049245,NDC,30,ML,34.55,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,16.9295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,23155024031,NDC,2,ML,34.55,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.9295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.859
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,23155024031,NDC,2,ML,34.55,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16.9295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.859
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,23155024031,NDC,2,ML,34.55,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,16.9295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.859
ursodiol 300 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,591315901,NDC,1,EA,39.47,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.93263,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68382019616,NDC,1,EA,17.4,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,16.93542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Metanephrines - Ref,PX8383590,CDM,300,RC,83835,CPT,90,,,,,,,34,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,16.94,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.43,16.94
"Triiodothyronine T3, Free (Free T3)",PX84481,CDM,300,RC,84481,CPT,,,,,,,,137,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,16.94,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.43,16.94
riFAMpin 150 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,527139330,NDC,1,EA,17.41,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,16.945153,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
riFAMpin 150 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,68180065806,NDC,1,EA,17.41,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,16.945153,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methotrexate 2.5 MG Tablet 20 Each Box,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067005,NDC,1,EA,33.49,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,16.94594,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.911746,32.8398
FLEXITIP APPLICATOR 38CM,27200000,CDM,272,RC,,,,10200-MAIN,LOCAL,,,,,40.8,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,16.94832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
methotrexate 2.5 MG Tablet 1 Each Blister,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067001,NDC,1,EA,33.51,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,16.95606,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.911746,32.8398
bisoprolol-hydroCHLOROthiazide 5-6.25 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,42799092102,NDC,1,EA,39.57,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,16.97553,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Cystatin C - Ref,PX8261090,CDM,300,RC,82610,CPT,90,,,,,,,130,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,16.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.98,127.4
Gonadotropin (Lh),PX83002,CDM,300,RC,83002,CPT,,,,,,,,28,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,16.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
morphine 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574711212,NDC,1,EA,33.56,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,16.98136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzocaine-menthol 20-0.5 % Aerosol 78 g Can,63700001,CDM,250,RC,,,,,,75137085520,NDC,78,GR,35.38,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,16.9824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzocaine-menthol 20-0.5 % Aerosol 78 g Can,63700001,CDM,250,RC,,,,,,75137085520,NDC,78,GR,35.38,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,16.9824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cefaDROXil 500 MG capsule 50 Each Bottle,63700001,CDM,250,RC,,,,,,16714038801,NDC,1,EA,19.98,,First Health,Commercial,both,85,,999999999,percent of total billed charges,16.983,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famciclovir 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,60505324603,NDC,0.5,EA,18.65,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,16.99015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
valACYclovir 1 GM Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069701,NDC,0.5,EA,33.58,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,16.99148,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Bacterium Nos, Antibody - Ref",PX8660990,CDM,300,RC,86609,CPT,90,,,,,,,20,,First Health,Commercial,both,85,,999999999,percent of total billed charges,17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
DRESSING QWICK NONADHESIVE 4.25X4 SUPERABSORBENT MSC5844,120.531,CDM,272,RC,A6197,HCPCS,,12301-MAIN,LOCAL,,,,,20,,First Health,Commercial,both,85,,999999999,percent of total billed charges,17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
Glucose Blood Test,PX82962,CDM,300,RC,82962,CPT,,,,,,,,20,,First Health,Commercial,both,85,,999999999,percent of total billed charges,17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.01,19.6
Phenobarbital Assay - Ref,PX8018490,CDM,300,RC,80184,CPT,90,,,,,,,20,,First Health,Commercial,both,85,,999999999,percent of total billed charges,17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
Primidone Assay - Ref,PX8018890,CDM,300,RC,80188,CPT,90,,,,,,,20,,First Health,Commercial,both,85,,999999999,percent of total billed charges,17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER  STRAIGHT TAPER TIP 20FR PVC,120.528,CDM,272,RC,,,,12247-MAIN,LOCAL,,,,,20,,First Health,Commercial,both,85,,999999999,percent of total billed charges,17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER  STRAIGHT TAPER TIP 24FR PVC,120.528,CDM,272,RC,,,,12248-MAIN,LOCAL,,,,,20,,First Health,Commercial,both,85,,999999999,percent of total billed charges,17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 8FR PVC,120.528,CDM,272,RC,,,,12253-MAIN,LOCAL,,,,,20,,First Health,Commercial,both,85,,999999999,percent of total billed charges,17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 10FR PVC,120.528,CDM,272,RC,,,,12254-MAIN,LOCAL,,,,,20,,First Health,Commercial,both,85,,999999999,percent of total billed charges,17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 12FR PVC,120.528,CDM,272,RC,,,,12255-MAIN,LOCAL,,,,,20,,First Health,Commercial,both,85,,999999999,percent of total billed charges,17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 16FR PVC,120.528,CDM,272,RC,,,,12256-MAIN,LOCAL,,,,,20,,First Health,Commercial,both,85,,999999999,percent of total billed charges,17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 28FR PVC,120.528,CDM,272,RC,,,,12249-MAIN,LOCAL,,,,,20,,First Health,Commercial,both,85,,999999999,percent of total billed charges,17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 32FR PVC,120.528,CDM,272,RC,,,,12250-MAIN,LOCAL,,,,,20,,First Health,Commercial,both,85,,999999999,percent of total billed charges,17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 36FR PVC,120.528,CDM,272,RC,,,,12251-MAIN,LOCAL,,,,,20,,First Health,Commercial,both,85,,999999999,percent of total billed charges,17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
miconazole 2 % Powder 85 g Bottle,25000000,CDM,250,RC,,,,,,67094930,NDC,85,GR,35.43,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,17.0064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
miconazole 2 % Powder 85 g Bottle,25000000,CDM,250,RC,,,,,,67094930,NDC,85,GR,35.43,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,17.0064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070548,NDC,100,ML,40.94,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.006476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
valproate 100 MG/ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049416,NDC,5,ML,33.61,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,17.00666,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
valproate 100 MG/ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049441,NDC,5,ML,33.61,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,17.00666,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Asay of Interleukin-6 (Il-6),PX8352990,CDM,300,RC,83529,CPT,90,,,,,,,170,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,17.0077,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0077,17.27
"Ethanol, P",PX82077,CDM,300,RC,82077,CPT,,,,,,,,30,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,17.0077,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,17.27
Immunoassay Nos - Ref,PX8352090,CDM,300,RC,83520,CPT,90,,,,,,,220,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,17.0077,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,17.27
oxyBUTYnin ER 5 MG Tablet Extended Release 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,63739054833,NDC,1,EA,18.67,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,17.00837,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Apply Multlay Comprs Lwr Leg,PX29581F,CDM,510,RC,29581,CPT,,,,,,,,213,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,17.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.01,182.64
Apply Multlay Comprs Lwr Leg,PX29581F,CDM,510,RC,29581,CPT,,,,,,,,213,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,17.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.01,182.64
Apply Multlay Comprs Lwr Leg,PX29581P,CDM,983,RC,29581,CPT,,,,,,,,142,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,17.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.01,182.64
Apply Multlay Comprs Lwr Leg,PX29581P,CDM,983,RC,29581,CPT,,,,,,,,142,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,17.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.01,182.64
Asay of Interleukin-6 (Il-6),PX8352990,CDM,300,RC,83529,CPT,90,,,,,,,170,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,17.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0077,17.27
Surgical Cleansing of Skin,PX11000P,CDM,983,RC,11000,CPT,,,,,,,,145,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,17.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.79,142.1
Surgical Cleansing of Skin,PX11000P,CDM,983,RC,11000,CPT,,,,,,,,145,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,17.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.79,142.1
Apply Multlay Comprs Lwr Leg,PX29581F,CDM,510,RC,29581,CPT,,,,,,,,213,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,17.01,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.01,182.64
Apply Multlay Comprs Lwr Leg,PX29581P,CDM,983,RC,29581,CPT,,,,,,,,142,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,17.01,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.01,182.64
X-Ray Exam Abdomen 2 Views,PX7401901,CDM,320,RC,74019,CPT,TC,,,,,,,436,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,17.01,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.01,51.28
Xray Temporomandib Jnt Unilat,PX7032801,CDM,320,RC,70328,CPT,TC,,,,,,,385,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,17.01,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.01,51.28
Xray Wrist 2 Vws,PX7310001,CDM,320,RC,73100,CPT,TC,,,,,,,365,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,17.01,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.01,51.28
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608201,NDC,1,ML,66.6,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,17.01793,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.24,17.32
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608210,NDC,1,ML,63.43,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,17.01793,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.24,17.32
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093102,NDC,1,ML,60.47,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,17.01793,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.24,17.32
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093107,NDC,1,ML,57.59,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,17.01793,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.24,17.32
lidocaine 1% PF 1 % Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,63323049227,NDC,2,ML,34.74,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.0226,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,63323049227,NDC,2,ML,34.74,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.0226,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,63323049227,NDC,2,ML,34.74,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,17.0226,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Lyme Disease Antibody,PX86618,CDM,300,RC,86618,CPT,,,,,,,,194,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,17.03,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.52,17.03
"Lyme Disease, Antibody - Ref",PX8661890,CDM,300,RC,86618,CPT,90,,,,,,,181,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,17.03,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.52,17.03
Lyme Screen,PX7585,CDM,300,RC,86618,CPT,,,,,,,,198,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,17.03,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.52,17.03
CANNULA SEAL 5-12MM UNIVERSAL 470500,27200000,CDM,272,RC,,,,12885-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.0314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CUP HEEL LARGE WONDERSPUR 4502,120.43,CDM,274,RC,L3485,HCPCS,,11385-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.0314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL MEDIUM WONDERSPUR 4501,120.43,CDM,274,RC,L3485,HCPCS,,11384-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.0314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL SMALL WONDERSPUR 4500,120.43,CDM,274,RC,L3485,HCPCS,,11383-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.0314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL XL WONDERSPUR 4503,120.43,CDM,274,RC,L3485,HCPCS,,11386-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.0314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
Detection of Anaplasma Phagocytophilum by Amplified Nucleic Acid Probe Technique,PX8746890,CDM,300,RC,87468,CPT,90,,,,,,,41,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.0314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
Detection of Ehrlichia Chaffeensis by Amplified Nucleic Acid Probe Technique,PX8748490,CDM,300,RC,87484,CPT,90,,,,,,,41,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.0314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 21G 110MM SONOTAP II WITH FACET TIP 1285-3F110,120.483,CDM,271,RC,A4215,HCPCS,,12201-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.0314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 21G X 4IN (100MM) SONOBLOCK II NERVE BLOCK WITH FACET S TIP 001281-77,120.483,CDM,271,RC,A4215,HCPCS,,12761-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.0314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 22G 80MM SONOTAP II WITH FACET TIP 1285-3E080,120.483,CDM,271,RC,A4215,HCPCS,,12103-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.0314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 22G X 3.25IN (80MM) SONOBLOCK II  NERVE BLOCK WITH FACET S TIP 001281-71,120.483,CDM,271,RC,A4215,HCPCS,,12760-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.0314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 22GX2 SONOPLEX II WITH FACET S TIP 001287-74,120.483,CDM,271,RC,A4215,HCPCS,,13110-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.0314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE NON-STIMULATING 22GX2 SONOBLOCK II WITH FACET S TIP 001281-74,120.483,CDM,271,RC,A4215,HCPCS,,11459-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.0314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE SONOPLEX II STIMULATING WITH FACET S TIP 22GX3-1/4,120.483,CDM,271,RC,A4215,HCPCS,,11457-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.0314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE STIMULATING 21GX4  SONOPLEX II  WITH FACET S TIP 001287-77,120.483,CDM,271,RC,A4215,HCPCS,,11458-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.0314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
STRAP FOOT LG/XL GEL UNIVERSAL 10165,120.428,CDM,271,RC,,,,11382-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.0314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
STRAP FOOT SM/MED GEL UNIVERSAL 10155,120.428,CDM,271,RC,,,,11381-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.0314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
SUTURE V-LOC SZ 1/2 180 GREEN GS-21 VLOCL0316,27200000,CDM,272,RC,,,,11932-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.0314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
URGOK2 DUAL COMPRESSION SYSTEM LARGE,120.491,CDM,271,RC,A6452,HCPCS,,11871-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.0314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
URGOK2 DUAL COMPRESSION SYSTEM REGULAR,120.491,CDM,271,RC,A6452,HCPCS,,11870-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.0314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,641601301,NDC,5,ML,34.41,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,17.03295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
acetaminophen 160 MG/5ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,68094023159,NDC,15,ML,19.14,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,17.0346,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famciclovir 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714030401,NDC,1,EA,34.42,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,17.0379,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DRAPE SHEET LAP T-DRAPE WITH INSTRUMENT PAD DYNJP3003,27200000,CDM,272,RC,,,,10913-MAIN,LOCAL,,,,,35.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,17.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRAPE SHEET LAP T-DRAPE WITH INSTRUMENT PAD DYNJP3003,27200000,CDM,272,RC,,,,10913-MAIN,LOCAL,,,,,35.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,17.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600701,NDC,10,ML,39.73,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.04417,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,38.9354
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060002,NDC,2,ML,953.57,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,17.0501,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.46,17.58
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060010,NDC,2,ML,953.57,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,17.0501,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.46,17.58
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68382019616,NDC,1,EA,17.4,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,17.052,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120301,NDC,0.5,ML,34.45,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,17.05275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120311,NDC,0.5,ML,34.45,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,17.05275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
X-Ray Exam Chest 1 View,PX7104501,CDM,320,RC,71045,CPT,TC,,,,,,,357,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,17.0554,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.34,34.18
miconazole 2 % Powder 71 g Bottle,25000000,CDM,250,RC,,,,,,316023125,NDC,71,GR,34.82,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.0618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
miconazole 2 % Powder 71 g Bottle,25000000,CDM,250,RC,,,,,,316023125,NDC,71,GR,34.82,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.0618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
miconazole 2 % Powder 71 g Bottle,25000000,CDM,250,RC,,,,,,316023125,NDC,71,GR,34.82,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,17.0618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
riFAMpin 150 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,527139330,NDC,1,EA,17.41,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,17.0618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
riFAMpin 150 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,68180065806,NDC,1,EA,17.41,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,17.0618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323048201,NDC,10,ML,39.78,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.06562,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323048217,NDC,10,ML,39.78,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.06562,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
rosuvastatin 10 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,60687024511,NDC,0.5,EA,19.18,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,17.0702,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 37.5 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084069811,NDC,1,EA,20.09,,First Health,Commercial,both,85,,999999999,percent of total billed charges,17.0765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 37.5 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084069801,NDC,1,EA,20.09,,First Health,Commercial,both,85,,999999999,percent of total billed charges,17.0765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dabigatran 75 MG capsule 60 Each Box,63700001,CDM,250,RC,,,,,,597014960,NDC,1,EA,39.83,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.08707,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987501,NDC,3,ML,33.77,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,17.08762,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
TROCAR KII BALLOON 12MM STERILE,27200000,CDM,272,RC,,,,11703-MAIN,LOCAL,,,,,41.14,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.089556,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR KII BALLOON BLUNT 12MM STERILE,27200000,CDM,272,RC,,,,11702-MAIN,LOCAL,,,,,41.14,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.089556,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Quantitation Drug Nos - Ref,PX8029990,CDM,300,RC,80299,CPT,90,,,,,,,112,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,17.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.09,109.76
sterile water (preservative free) Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409488724,NDC,50,ML,34.88,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.0912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409488724,NDC,50,ML,34.88,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.0912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409488724,NDC,50,ML,34.88,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,17.0912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409488750,NDC,50,ML,34.88,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.0912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409488750,NDC,50,ML,34.88,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.0912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409488750,NDC,50,ML,34.88,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,17.0912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039814,NDC,1,EA,39.84,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.09136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
BUPivacaine PF 0.5 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,55150016910,NDC,10,ML,39.84,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.09136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
enalaprilat 1.25 MG/ML Injectable 1 mL Vial,25000000,CDM,250,RC,,,,,,143978710,NDC,1,ML,39.84,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.09136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098141,NDC,1,EA,39.84,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.09136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098153,NDC,1,EA,39.84,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.09136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,47781059807,NDC,1,EA,39.84,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.09136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641622901,NDC,1,ML,41.16,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.097864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.097864,86.9162
Gastrin - Ref,PX8294190,CDM,300,RC,82941,CPT,90,,,,,,,65,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,17.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.1,17.63
Gastrin - Ref,PX8294190,CDM,300,RC,82941,CPT,90,,,,,,,65,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,17.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.1,17.63
Gastrin - Ref,PX8294190,CDM,300,RC,82941,CPT,90,,,,,,,65,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,17.1,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.1,17.63
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598F,CDM,510,RC,97598,CPT,,,,,,,,406,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,17.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.59,59.31
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598F,CDM,510,RC,97598,CPT,,,,,,,,406,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,17.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.59,59.31
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598P,CDM,982,RC,97598,CPT,,,,,,,,325,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,17.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.59,318.5
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598P,CDM,982,RC,97598,CPT,,,,,,,,325,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,17.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.59,318.5
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016501,NDC,1,ML,34.55,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,17.10225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049226,NDC,30,ML,34.55,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,17.10225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049245,NDC,30,ML,34.55,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,17.10225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,23155024031,NDC,2,ML,34.55,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,17.10225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.859
nitroglycerin 2 % Ointment 1 g Packet,63700001,CDM,250,RC,,,,,,281032608,NDC,1,GR,17.58,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,17.110614,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 200-40 MG/5ML Suspension 473 mL Bottle,63700001,CDM,250,RC,,,,,,65862049647,NDC,10,ML,18.79,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,17.11769,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Bile Acids Total,PX8223990,CDM,300,RC,82239,CPT,90,,,,,,,232,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,17.12,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.61,17.12
Blood Clot Factor V Test,PX85220,CDM,300,RC,85220,CPT,,,,,,,,260,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,17.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.12,17.65
Blood Clot Factor V Test,PX85220,CDM,300,RC,85220,CPT,,,,,,,,260,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,17.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.12,17.65
Blood Clot Factor V Test,PX85220,CDM,300,RC,85220,CPT,,,,,,,,260,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,17.12,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.12,17.65
buprenorphine 75 MCG FILM 1 Each Package,63700001,CDM,250,RC,,,,,,59385002101,NDC,1,EA,35.68,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,17.1264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buprenorphine 75 MCG FILM 1 Each Package,63700001,CDM,250,RC,,,,,,59385002101,NDC,1,EA,35.68,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,17.1264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Collagen Cross Links - Ref,PX8252390,CDM,300,RC,82523,CPT,90,,,,,,,170,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,17.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.13,166.6
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,60432006547,NDC,10,ML,34.98,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.1402,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,60432006547,NDC,10,ML,34.98,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.1402,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,60432006547,NDC,10,ML,34.98,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,17.1402,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,17478081705,NDC,5,ML,34.99,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.1451,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,17478081705,NDC,5,ML,34.99,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.1451,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,17478081705,NDC,5,ML,34.99,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,17.1451,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209F,CDM,510,RC,69209,CPT,,,,,,,,35,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,53.44
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209F,CDM,510,RC,69209,CPT,,,,,,,,35,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,53.44
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209F,CDM,510,RC,69209,CPT,,,,,,,,35,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,17.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,53.44
SHOE POST OP X-LARGE MALE DS1016-16,120.237,CDM,274,RC,L3260,HCPCS,,6337-MAIN,LOCAL,,,,,35,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP X-LARGE MALE DS1016-16,120.237,CDM,274,RC,L3260,HCPCS,,6337-MAIN,LOCAL,,,,,35,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP X-LARGE MALE DS1016-16,120.237,CDM,274,RC,L3260,HCPCS,,6337-MAIN,LOCAL,,,,,35,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,17.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
"Trimming of Dystrophic Nails, Any Number",PXG0127P,CDM,983,RC,G0127,HCPCS,,,,,,,,35,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,53.44
"Trimming of Dystrophic Nails, Any Number",PXG0127P,CDM,983,RC,G0127,HCPCS,,,,,,,,35,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,53.44
"Trimming of Dystrophic Nails, Any Number",PXG0127P,CDM,983,RC,G0127,HCPCS,,,,,,,,35,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,17.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,53.44
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028016,NDC,2,ML,41.29,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.151866,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
methylPREDNISolone acetate 20 MG/ML Suspension 5 mL Vial,J1010.01,CDM,636,RC,J1010,HCPCS,,,,9027401,NDC,0.5,ML,41.3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.15602,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.15602,40.474
8MM-12MM TIP COVER ACCESSORY,27200000,CDM,272,RC,,,,11918-MAIN,LOCAL,,,,,40,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CATHETER URETERAL  5FR TIGERTAIL OPEN TIP FLEXIBLE 139005,27200000,CDM,272,RC,A4340,HCPCS,,12302-MAIN,LOCAL,,,,,40,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NEEDLE BIOPSY 14GAX4 1/2 2N2702X,120.211,CDM,272,RC,,,,724-MAIN,LOCAL,,,,,40,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.616,39.2
STAPLER CANNULA SEAL 12 mm 470380,27200000,CDM,272,RC,,,,11962-MAIN,LOCAL,,,,,40,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"SUTURE V-LOC 22G NEEDLE 9"" 180 GREEN VLOCL2145",27200000,CDM,272,RC,,,,11930-MAIN,LOCAL,,,,,40,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"SUTURE V-LOC SZ 0.9"" 180 GREEN GS-21 NEEDLE VLOCL0346",27200000,CDM,272,RC,,,,11933-MAIN,LOCAL,,,,,40,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Telehealth Origin Site Fac Fee,PXQ3014,CDM,780,RC,Q3014,HCPCS,,,,,,,,40,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.616,39.2
FORCEPS SERRATED WITH SPIKE JUMBO 230CM,27200000,CDM,272,RC,,,,7416-MAIN,LOCAL,,,,,41.31,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.160174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
doxazosin 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079095701,NDC,1,EA,20.19,,First Health,Commercial,both,85,,999999999,percent of total billed charges,17.1615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409132305,NDC,5,ML,41.35,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.17679,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
doxazosin 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079095720,NDC,1,EA,20.22,,First Health,Commercial,both,85,,999999999,percent of total billed charges,17.187,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levETIRAcetam 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079082101,NDC,1,EA,18.87,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,17.19057,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 1% PF 1 % Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,63323049227,NDC,2,ML,34.74,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,17.1963,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Alcohol Biomarkers; 1 or 2 - Ref,PX8032190,CDM,300,RC,80321,CPT,90,,,,,,,181,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,17.2,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.2,17.2
Alcohols - Ref,PX8032090,CDM,300,RC,80320,CPT,90,,,,,,,189,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,17.2,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.2,17.2
BINDER ABDOMINAL S/M 9 INCH UP TO 45 INCHES TRI-PANNEL ABB3P45,120.238,CDM,271,RC,A4467,HCPCS,,47-MAIN,LOCAL,,,,,34,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,17.204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,17.204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,17.204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
"Lab Ige, Isocyan Hdi",PX86003,CDM,300,RC,86003,CPT,90,,,,,,,34,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,17.204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.79,33.32
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323020110,NDC,10,ML,34,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,17.204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Metanephrines - Ref,PX8383590,CDM,300,RC,83835,CPT,90,,,,,,,34,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,17.204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1236,33.32
SPLINT SAM 36INCH ROLLED 661121,120.362,CDM,271,RC,,,,10789-MAIN,LOCAL,,,,,34,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,17.204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1236,33.32
"Venipunc Need Phys Skill,Dx or Rx",PX36410F,CDM,510,RC,36410,CPT,,,,,,,,34,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,17.204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1236,33.32
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028026,NDC,2,ML,41.42,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.205868,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
leucovorin 10 mg/mL Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,25021081467,NDC,1,EA,40.13,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.21577,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.670002,84.6818
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026994,NDC,20,ML,35.87,,Health Partners,Health Partners Care Plans,both,48,,1.259785714,percent of total billed charges,17.2176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026994,NDC,20,ML,35.87,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,17.2176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
"CUFF STERILE DISPOSABLE SPSB  STERILE 18""",27200000,CDM,272,RC,,,,7436-MAIN,LOCAL,,,,,35.89,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,17.2272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"CUFF STERILE DISPOSABLE SPSB  STERILE 18""",27200000,CDM,272,RC,,,,7436-MAIN,LOCAL,,,,,35.89,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,17.2272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
nitroglycerin 2 % Ointment 1 g Packet,63700001,CDM,250,RC,,,,,,281032608,NDC,1,GR,17.58,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,17.2284,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of Erythropoietin,PX82668,CDM,300,RC,82668,CPT,,,,,,,,114,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,17.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,111.72
Erythropietin - Ref,PX8266890,CDM,300,RC,82668,CPT,90,,,,,,,108,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,17.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,105.84
X-Ray Exam Abdomen 2 Views,PX7401901,CDM,320,RC,74019,CPT,TC,,,,,,,436,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,17.23,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.01,51.28
X-Ray Exam Abdomen 2 Views,PX7401901,CDM,320,RC,74019,CPT,TC,,,,,,,436,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,17.23,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.01,51.28
Xray Foot Minimum 3 Vws,PX7363001,CDM,320,RC,73630,CPT,TC,,,,,,,404,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,17.23,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,51.93
Xray Knee 1 or 2 Vws,PX7356001,CDM,320,RC,73560,CPT,TC,,,,,,,303,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,17.23,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,51.93
Xray Ribs Unilat 2 Vws,PX7110001,CDM,320,RC,71100,CPT,TC,,,,,,,437,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,17.23,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,51.93
Xray Shoulder Minimum 2 Vws,PX7303001,CDM,320,RC,73030,CPT,TC,,,,,,,365,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,17.23,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.79,51.28
Xray Shoulder Minimum 2 Vws,PX7303001,CDM,320,RC,73030,CPT,TC,,,,,,,365,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,17.23,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.79,51.28
Xray Temporomandib Jnt Unilat,PX7032801,CDM,320,RC,70328,CPT,TC,,,,,,,385,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,17.23,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.01,51.28
Xray Temporomandib Jnt Unilat,PX7032801,CDM,320,RC,70328,CPT,TC,,,,,,,385,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,17.23,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.01,51.28
Xray Wrist 2 Vws,PX7310001,CDM,320,RC,73100,CPT,TC,,,,,,,365,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,17.23,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.01,51.28
Xray Wrist 2 Vws,PX7310001,CDM,320,RC,73100,CPT,TC,,,,,,,365,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,17.23,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.01,51.28
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001001,NDC,1.5,ML,40.17,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.23293,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,42.5516
miconazole 2 % Powder 71 g Bottle,25000000,CDM,250,RC,,,,,,316023125,NDC,71,GR,34.82,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,17.2359,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
methylergonovine 0.2 MG/ML Solution 1 mL Ampule,J2210.01,CDM,636,RC,J2210,HCPCS,,,,51991014417,NDC,1,ML,133.11,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,17.25,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.25,20.87
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409317801,NDC,20,ML,34.11,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,17.25966,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409317816,NDC,20,ML,34.11,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,17.25966,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189001,NDC,1,ML,34.11,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,17.25966,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189003,NDC,1,ML,34.11,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,17.25966,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
buprenorphine 8 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,54017713,NDC,1,EA,41.56,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.264024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.14,40.7288
sterile water (preservative free) Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409488724,NDC,50,ML,34.88,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,17.2656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409488750,NDC,50,ML,34.88,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,17.2656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Asay of Interleukin-6 (Il-6),PX8352990,CDM,300,RC,83529,CPT,90,,,,,,,170,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,17.27,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0077,17.27
"Ethanol, P",PX82077,CDM,300,RC,82077,CPT,,,,,,,,30,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,17.27,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,17.27
Immunoassay Nos - Ref,PX8352090,CDM,300,RC,83520,CPT,90,,,,,,,220,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,17.27,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,17.27
IMMOBILIZER SHOULDER LARGE 9008-03,120.38,CDM,274,RC,L3650,HCPCS,,906-MAIN,LOCAL,,,,,36,,Health Partners,Health Partners Care Plans,both,48,,17.28,percent of total billed charges,17.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER LARGE 9008-03,120.38,CDM,274,RC,L3650,HCPCS,,906-MAIN,LOCAL,,,,,36,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,17.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER LARGE STRAP OSG3033,120.38,CDM,274,RC,L3650,HCPCS,,2910-MAIN,LOCAL,,,,,36,,Health Partners,Health Partners Care Plans,both,48,,17.28,percent of total billed charges,17.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER LARGE STRAP OSG3033,120.38,CDM,274,RC,L3650,HCPCS,,2910-MAIN,LOCAL,,,,,36,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,17.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER MEDIUM 9008-02,120.38,CDM,274,RC,L3650,HCPCS,,912-MAIN,LOCAL,,,,,36,,Health Partners,Health Partners Care Plans,both,48,,17.28,percent of total billed charges,17.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER MEDIUM 9008-02,120.38,CDM,274,RC,L3650,HCPCS,,912-MAIN,LOCAL,,,,,36,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,17.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER MEDIUM OSG3032,120.38,CDM,274,RC,L3650,HCPCS,,915-MAIN,LOCAL,,,,,36,,Health Partners,Health Partners Care Plans,both,48,,17.28,percent of total billed charges,17.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER MEDIUM OSG3032,120.38,CDM,274,RC,L3650,HCPCS,,915-MAIN,LOCAL,,,,,36,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,17.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER SMALL 9008-01,120.38,CDM,274,RC,L3650,HCPCS,,913-MAIN,LOCAL,,,,,36,,Health Partners,Health Partners Care Plans,both,48,,17.28,percent of total billed charges,17.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER SMALL 9008-01,120.38,CDM,274,RC,L3650,HCPCS,,913-MAIN,LOCAL,,,,,36,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,17.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER SMALL WITH CLOTH 9001-02,120.38,CDM,274,RC,L3650,HCPCS,,914-MAIN,LOCAL,,,,,36,,Health Partners,Health Partners Care Plans,both,48,,17.28,percent of total billed charges,17.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER SMALL WITH CLOTH 9001-02,120.38,CDM,274,RC,L3650,HCPCS,,914-MAIN,LOCAL,,,,,36,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,17.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER X-LARGE CLOTH 9001-05,120.38,CDM,274,RC,L3650,HCPCS,,917-MAIN,LOCAL,,,,,36,,Health Partners,Health Partners Care Plans,both,48,,17.28,percent of total billed charges,17.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER X-LARGE CLOTH 9001-05,120.38,CDM,274,RC,L3650,HCPCS,,917-MAIN,LOCAL,,,,,36,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,17.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER X-LARGE ORT16100XL,120.38,CDM,274,RC,L3650,HCPCS,,904-MAIN,LOCAL,,,,,36,,Health Partners,Health Partners Care Plans,both,48,,17.28,percent of total billed charges,17.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER X-LARGE ORT16100XL,120.38,CDM,274,RC,L3650,HCPCS,,904-MAIN,LOCAL,,,,,36,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,17.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
Treponema Pallidum,PX86780,CDM,300,RC,86780,CPT,,,,,,,,36,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,17.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.14,35.28
Treponema Pallidum,PX86780,CDM,300,RC,86780,CPT,,,,,,,,36,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,17.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.14,35.28
amoxicillin-clavulanate 500-125 MG Tablet 20 Each Bottle,63700001,CDM,250,RC,,,,,,16714047701,NDC,1,EA,20.33,,First Health,Commercial,both,85,,999999999,percent of total billed charges,17.2805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,703291401,NDC,0.5,EA,40.3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.2887,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
celecoxib 200 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904650361,NDC,0.5,EA,20.35,,First Health,Commercial,both,85,,999999999,percent of total billed charges,17.2975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Neg Pressure Wound Therapy Dme </=50 Sq Cm,PX97605F,CDM,510,RC,97605,CPT,,,,,,,,396,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,17.3,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.3,56.67
Protein Elp,PX84166,CDM,300,RC,84166,CPT,,,,,,,,180,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,17.3,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.3,27.36
Protein Elp,PX84166,CDM,300,RC,84166,CPT,,,,,,,,180,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,17.3,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.3,27.36
Protein Elp,PX84166,CDM,300,RC,84166,CPT,,,,,,,,180,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,17.3,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.3,27.36
SUTURE SILK 3-0 18INCH NONABSORBABLE BLACK M13T,27200000,CDM,272,RC,,,,12872-MAIN,LOCAL,,,,,19,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,17.309,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608201,NDC,1,ML,66.6,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,17.31,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.24,17.32
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608201,NDC,1,ML,66.6,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,17.31,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.24,17.32
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608210,NDC,1,ML,63.43,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,17.31,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.24,17.32
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608210,NDC,1,ML,63.43,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,17.31,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.24,17.32
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093102,NDC,1,ML,60.47,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,17.31,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.24,17.32
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093102,NDC,1,ML,60.47,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,17.31,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.24,17.32
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093107,NDC,1,ML,57.59,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,17.31,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.24,17.32
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093107,NDC,1,ML,57.59,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,17.31,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.24,17.32
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,60432006547,NDC,10,ML,34.98,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,17.3151,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608201,NDC,1,ML,66.6,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,17.32,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.24,17.32
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608210,NDC,1,ML,63.43,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,17.32,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.24,17.32
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093102,NDC,1,ML,60.47,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,17.32,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.24,17.32
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093107,NDC,1,ML,57.59,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,17.32,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.24,17.32
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,17478081705,NDC,5,ML,34.99,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,17.32005,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209F,CDM,510,RC,69209,CPT,,,,,,,,35,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,17.325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,53.44
SHOE POST OP X-LARGE MALE DS1016-16,120.237,CDM,274,RC,L3260,HCPCS,,6337-MAIN,LOCAL,,,,,35,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,17.325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
"Trimming of Dystrophic Nails, Any Number",PXG0127P,CDM,983,RC,G0127,HCPCS,,,,,,,,35,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,17.325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,53.44
enalaprilat 1.25 MG/ML Injectable 1 mL Vial,25000000,CDM,250,RC,,,,,,143978701,NDC,1,ML,40.39,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.32731,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Blood Clot Factor V Test,PX85220,CDM,300,RC,85220,CPT,,,,,,,,260,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,17.3286,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.12,17.65
Gastrin - Ref,PX8294190,CDM,300,RC,82941,CPT,90,,,,,,,65,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,17.3286,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.1,17.63
Protein Elp,PX84166,CDM,300,RC,84166,CPT,,,,,,,,180,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,17.3286,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.3,27.36
azithromycin 250 MG Tablet 6 Each Box,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096104,NDC,1,EA,41.72,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.330488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
APPLICATOR CHLORAPREP 26ML WITH ORANGE 930815,27200000,CDM,272,RC,A4248,HCPCS,,10031-MAIN,LOCAL,,,,,19.65,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,17.3313,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,67457043800,NDC,0.5,EA,36.11,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,17.3328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,67457043800,NDC,0.5,EA,36.11,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,17.3328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,67457043810,NDC,0.5,EA,36.11,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,17.3328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,67457043810,NDC,0.5,EA,36.11,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,17.3328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096105,NDC,1,EA,41.73,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.334642,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
benzocaine-menthol 20-0.5 % Aerosol 78 g Can,63700001,CDM,250,RC,,,,,,75137085520,NDC,78,GR,35.38,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.3362,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzocaine-menthol 20-0.5 % Aerosol 78 g Can,63700001,CDM,250,RC,,,,,,75137085520,NDC,78,GR,35.38,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.3362,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzocaine-menthol 20-0.5 % Aerosol 78 g Can,63700001,CDM,250,RC,,,,,,75137085520,NDC,78,GR,35.38,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,17.3362,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028036,NDC,2,ML,36.12,,Health Partners,Health Partners Care Plans,both,48,,7.095,percent of total billed charges,17.3376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028036,NDC,2,ML,36.12,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,17.3376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
Strapping of Elbow or Wrist,PX29260F,CDM,420,RC,29260,CPT,,,,,,,,64,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,17.3394,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.77,60.19
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028002,NDC,1,ML,40.43,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.34447,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
DULoxetine 20 MG Capsule Delayed Release Particles 60 Each Bottle,63700001,CDM,250,RC,,,,,,2323560,NDC,1,EA,41.76,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.347104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323020103,NDC,10,ML,36.14,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,17.3472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323020103,NDC,10,ML,36.14,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,17.3472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253033335,NDC,5,ML,40.44,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.34876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,50111078751,NDC,1,EA,41.79,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.359566,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
donepezil 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904640861,NDC,1,EA,41.79,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.359566,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Factor VII - Ref,PX8523090,CDM,300,RC,85230,CPT,90,,,,,,,125,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,17.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.36,17.9
Factor VII - Ref,PX8523090,CDM,300,RC,85230,CPT,90,,,,,,,125,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,17.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.36,17.9
Factor VII - Ref,PX8523090,CDM,300,RC,85230,CPT,90,,,,,,,125,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,17.36,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.36,17.9
Factor VIII (Ahg) 1-Stage,PX85240,CDM,300,RC,85240,CPT,,,,,,,,997,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,17.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.36,17.9
Factor VIII (Ahg) 1-Stage,PX85240,CDM,300,RC,85240,CPT,,,,,,,,997,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,17.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.36,17.9
Factor VIII (Ahg) 1-Stage,PX85240,CDM,300,RC,85240,CPT,,,,,,,,997,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,17.36,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.36,17.9
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060002,NDC,2,ML,953.57,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,17.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.46,17.58
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060002,NDC,2,ML,953.57,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,17.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.46,17.58
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060010,NDC,2,ML,953.57,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,17.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.46,17.58
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060010,NDC,2,ML,953.57,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,17.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.46,17.58
miconazole 2 % Powder 85 g Bottle,25000000,CDM,250,RC,,,,,,67094930,NDC,85,GR,35.43,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.3607,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
miconazole 2 % Powder 85 g Bottle,25000000,CDM,250,RC,,,,,,67094930,NDC,85,GR,35.43,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.3607,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
miconazole 2 % Powder 85 g Bottle,25000000,CDM,250,RC,,,,,,67094930,NDC,85,GR,35.43,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,17.3607,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
colchicine 0.6 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,49884017111,NDC,1,EA,36.17,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,17.3616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
colchicine 0.6 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,49884017111,NDC,1,EA,36.17,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,17.3616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Carcinoembryonic Antigen,PX82378,CDM,300,RC,82378,CPT,,,,,,,,25,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,17.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
Homocysteine,PX83090,CDM,300,RC,83090,CPT,,,,,,,,44,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,17.38,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.38,17.92
Homocysteine,PX83090,CDM,300,RC,83090,CPT,,,,,,,,44,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,17.38,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.38,17.92
Homocysteine,PX83090,CDM,300,RC,83090,CPT,,,,,,,,44,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,17.38,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.38,17.92
nafcillin 2 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,S0032,HCPCS,,,,63323032820,NDC,1,EA,185.37,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,17.38,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.38,37.648
"Extractable Nuclear Antigen, Each Antigen",PX86235,CDM,300,RC,86235,CPT,90,,,,,,,99,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,17.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.39,17.93
"Extractable Nuclear Antigen, Each Antigen",PX86235,CDM,300,RC,86235,CPT,90,,,,,,,99,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,17.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.39,17.93
"Extractable Nuclear Antigen, Each Antigen",PX86235,CDM,300,RC,86235,CPT,90,,,,,,,99,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,17.39,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.39,17.93
DRAPE SHEET LAP T-DRAPE WITH INSTRUMENT PAD DYNJP3003,27200000,CDM,272,RC,,,,10913-MAIN,LOCAL,,,,,35.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.395,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRAPE SHEET LAP T-DRAPE WITH INSTRUMENT PAD DYNJP3003,27200000,CDM,272,RC,,,,10913-MAIN,LOCAL,,,,,35.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.395,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRAPE SHEET LAP T-DRAPE WITH INSTRUMENT PAD DYNJP3003,27200000,CDM,272,RC,,,,10913-MAIN,LOCAL,,,,,35.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,17.395,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
bacitracin zinc 500 UNIT/GM Ointment 28.4 g Tube,25000000,CDM,250,RC,,,,,,49348015472,NDC,28.4,GR,20.47,,First Health,Commercial,both,85,,999999999,percent of total billed charges,17.3995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,641601310,NDC,5,ML,40.58,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.40882,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Group Therapeutic Procedures,PX97150,CDM,420,RC,97150,CPT,,,,,,,,67,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,17.4096,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.5,23.72
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,641601301,NDC,5,ML,34.41,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,17.41146,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
famciclovir 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714030401,NDC,1,EA,34.42,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,17.41652,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
skin oil Oil 236.6 mL Bottle,63700001,CDM,250,RC,,,,,,67211008,NDC,236.6,ML,40.61,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.42169,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022143,NDC,1,EA,36.31,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,17.4288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022143,NDC,1,EA,36.31,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,17.4288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120301,NDC,0.5,ML,34.45,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,17.4317,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120311,NDC,0.5,ML,34.45,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,17.4317,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
"SUTURE ETHIBOND #0 CT-1 CR 8-18"" CX21D",27200000,CDM,272,RC,,,,6415-MAIN,LOCAL,,,,,41.97,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.434338,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
acetaminophen 160 MG/5ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,68094023159,NDC,15,ML,19.14,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,17.43654,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022116,NDC,1,EA,36.33,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,17.4384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022116,NDC,1,EA,36.33,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,17.4384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022141,NDC,1,EA,36.33,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,17.4384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022141,NDC,1,EA,36.33,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,17.4384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
Actin Antibody Each,PX8601590,CDM,300,RC,86015,CPT,90,,,,,,,42,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.4468,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.05,41.16
Assay Vitamin B-6,PX84207,CDM,300,RC,84207,CPT,90,,,,,,,42,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.4468,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
"BOUGIE TRACH 10FR 70CM COUDE 	9-0211-70",120.199,CDM,272,RC,A7520,HCPCS,,11112-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.4468,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
BOUGIE TRACHEAL TUBE & GUIDE 100123515,120.199,CDM,272,RC,A7520,HCPCS,,8950-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.4468,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
CATHETER PUREWICK FEMALE EXTERNAL PWF030K,120.414,CDM,272,RC,A6590,HCPCS,,11836-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.4468,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
Culture Type Immunologic,PX87147,CDM,300,RC,87147,CPT,,,,,,,,42,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.4468,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,41.16
EZ-STABILIZER DRESSING,120.415,CDM,272,RC,,,,9058-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.4468,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
MEPILEX AG FOAM 4X4,120.192,CDM,272,RC,A6213,HCPCS,,8480-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.4468,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
MEPILEX AG FOAM 4X8,120.192,CDM,272,RC,A6213,HCPCS,,8479-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.4468,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY CENTRAL LINE DRESSING WITH CHLORAPREP DYND75234,120.68,CDM,272,RC,,,,10923-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.4468,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY FOLEY 14FR CATHETER A300414A,120.414,CDM,272,RC,A4344,HCPCS,,11281-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.4468,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY FOLEY 16FR CATHETER 300416A,120.414,CDM,272,RC,A4344,HCPCS,,11774-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.4468,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
"TRAY SPINAL  25GX3.5"" WITH WHITEACRE 405671",120.275,CDM,272,RC,,,,3284-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.4468,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY SPINAL 25G ANESTH SADDLE BLOCK NLD-4795-20,120.275,CDM,272,RC,,,,935-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.4468,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
azithromycin 200 MG/5ML Recon Susp 15 mL Bottle,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,59762312001,NDC,15,ML,196.35,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,17.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.08,29.76
azithromycin 200 MG/5ML Recon Susp 15 mL Bottle,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,59762312001,NDC,15,ML,196.35,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,17.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.08,29.76
azithromycin 250 MG Tablet 6 Each Box,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096104,NDC,1,EA,41.72,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,17.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.08,29.76
azithromycin 250 MG Tablet 6 Each Box,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096104,NDC,1,EA,41.72,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,17.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.08,29.76
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,50111078751,NDC,1,EA,41.79,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,17.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.08,29.76
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,50111078751,NDC,1,EA,41.79,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,17.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.08,29.76
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096105,NDC,1,EA,41.73,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,17.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.08,29.76
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096105,NDC,1,EA,41.73,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,17.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.08,29.76
Draw Blood Off Venous Device,PX36591F,CDM,510,RC,36591,CPT,,,,,,,,211,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,17.45,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.45,57.42
Xray Foot Minimum 3 Vws,PX7363001,CDM,320,RC,73630,CPT,TC,,,,,,,404,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,17.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,51.93
Xray Foot Minimum 3 Vws,PX7363001,CDM,320,RC,73630,CPT,TC,,,,,,,404,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,17.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,51.93
Xray Knee 1 or 2 Vws,PX7356001,CDM,320,RC,73560,CPT,TC,,,,,,,303,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,17.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,51.93
Xray Knee 1 or 2 Vws,PX7356001,CDM,320,RC,73560,CPT,TC,,,,,,,303,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,17.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,51.93
Xray Ribs Unilat 2 Vws,PX7110001,CDM,320,RC,71100,CPT,TC,,,,,,,437,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,17.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,51.93
Xray Ribs Unilat 2 Vws,PX7110001,CDM,320,RC,71100,CPT,TC,,,,,,,437,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,17.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,51.93
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68462033090,NDC,1,EA,17.95,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,17.470735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 10 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,60687024511,NDC,0.5,EA,19.18,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,17.47298,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gemcitabine 200 MG/5.26ML Solution 5.26 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018301,NDC,5.26,ML,40.74,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.47746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016501,NDC,1,ML,34.55,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,17.4823,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049226,NDC,30,ML,34.55,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,17.4823,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049245,NDC,30,ML,34.55,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,17.4823,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,23155024031,NDC,2,ML,34.55,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,17.4823,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.859
buprenorphine 75 MCG FILM 1 Each Package,63700001,CDM,250,RC,,,,,,59385002101,NDC,1,EA,35.68,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.4832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buprenorphine 75 MCG FILM 1 Each Package,63700001,CDM,250,RC,,,,,,59385002101,NDC,1,EA,35.68,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.4832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buprenorphine 75 MCG FILM 1 Each Package,63700001,CDM,250,RC,,,,,,59385002101,NDC,1,EA,35.68,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,17.4832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
APPLICATOR CHLORAPREP 26ML WITH ORANGE 930815,27200000,CDM,272,RC,A4248,HCPCS,,10031-MAIN,LOCAL,,,,,19.65,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,17.4885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
FLEXITIP APPLICATOR 38CM,27200000,CDM,272,RC,,,,10200-MAIN,LOCAL,,,,,40.8,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.5032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,487960130,NDC,2,ML,36.47,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,17.5056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,487960130,NDC,2,ML,36.47,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,17.5056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Syringe,J7040.01,CDM,636,RC,J7040,HCPCS,,,,64253020230,NDC,10,ML,42.15,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.50911,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028426,NDC,1,EA,42.15,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.50911,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
Cyclosporine - Ref,PX8015890,CDM,300,RC,80158,CPT,90,,,,,,,95,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,17.51,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.51,18.05
Cyclosporine - Ref,PX8015890,CDM,300,RC,80158,CPT,90,,,,,,,95,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,17.51,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.51,18.05
Mycophenolate Mycophenolicacid - Ref,PX8018090,CDM,300,RC,80180,CPT,90,,,,,,,56,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,17.51,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.51,18.05
Mycophenolate Mycophenolicacid - Ref,PX8018090,CDM,300,RC,80180,CPT,90,,,,,,,56,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,17.51,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.51,18.05
Cyclosporine - Ref,PX8015890,CDM,300,RC,80158,CPT,90,,,,,,,95,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,17.51,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.51,18.05
Mycophenolate Mycophenolicacid - Ref,PX8018090,CDM,300,RC,80180,CPT,90,,,,,,,56,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,17.51,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.51,18.05
benzocaine-menthol 20-0.5 % Aerosol 78 g Can,63700001,CDM,250,RC,,,,,,75137085520,NDC,78,GR,35.38,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,17.5131,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DULoxetine 30 MG Capsule Delayed Release Particles 90 Each Bottle,63700001,CDM,250,RC,,,,,,57237001890,NDC,1,EA,42.17,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.517418,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"BINDER ABDOMINAL 12"" HIGH 46 TO 62 INCH L/XL 4 PANEL ORT21300LXL",120.238,CDM,271,RC,A4467,HCPCS,,11935-MAIN,LOCAL,,,,,18,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,17.5194,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BURETROL ADD ON SET 150ML,120.38,CDM,272,RC,A4222,HCPCS,,11118-MAIN,LOCAL,,,,,18,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,17.5194,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
TRAY TRACH CLEAN & CARE DYND40589,120.212,CDM,271,RC,,,,1173-MAIN,LOCAL,,,,,18,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,17.5194,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,17.64
TRAY TRACHEOTOMY CARE PEDS DYND40650H,120.212,CDM,272,RC,,,,11025-MAIN,LOCAL,,,,,18,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,17.5194,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,17.64
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,409710709,NDC,1000,ML,36.53,,Health Partners,Health Partners Care Plans,both,48,,6.034333333,percent of total billed charges,17.5344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,409710709,NDC,1000,ML,36.53,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,17.5344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5% and sodium chloride 0.45% with potassium chloride 10 mEq in 1000 mL 10-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,264763400,NDC,1000,ML,36.53,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,17.5344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"dextrose 5% and sodium chloride 0.45% with potassium chloride 10 mEq in 1000 mL 10-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,264763400,NDC,1000,ML,36.53,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,17.5344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
miconazole 2 % Powder 85 g Bottle,25000000,CDM,250,RC,,,,,,67094930,NDC,85,GR,35.43,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,17.53785,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Apply of Paste Boot,PX29580F,CDM,510,RC,29580,CPT,,,,,,,,132,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,17.55,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,132.83
Apply of Paste Boot,PX29580P,CDM,983,RC,29580,CPT,,,,,,,,88,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,17.55,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,132.83
povidone-iodine 10 % Ointment 28.35 g Tube,63700001,CDM,250,RC,,,,,,904110231,NDC,28.35,GR,19.9,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,17.5518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyBUTYnin ER 5 MG Tablet Extended Release 24 Hour 50 Each Box,63700001,CDM,250,RC,,,,,,904657006,NDC,1,EA,18.04,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,17.558332,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SUCTION TIP POOLE STERILE 35040,27200000,CDM,272,RC,,,,977-MAIN,LOCAL,,,,,42.28,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.563112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070548,NDC,100,ML,40.94,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.56326,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490334,NDC,5,ML,42.29,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.567266,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
tetracycline 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,51991090701,NDC,0.5,EA,42.29,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.567266,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DRAPE SHEET LAP T-DRAPE WITH INSTRUMENT PAD DYNJP3003,27200000,CDM,272,RC,,,,10913-MAIN,LOCAL,,,,,35.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,17.5725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026994,NDC,20,ML,35.87,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.619455696,percent of total billed charges,17.5763,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026994,NDC,20,ML,35.87,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.5763,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026994,NDC,20,ML,35.87,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,17.5763,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
ePHEDrine sulfate 50 MG/ML Solution 1 mL Vial,25000000,CDM,250,RC,,,,,,42023021689,NDC,0.1,ML,36.62,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,17.5776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ePHEDrine sulfate 50 MG/ML Solution 1 mL Vial,25000000,CDM,250,RC,,,,,,42023021689,NDC,0.1,ML,36.62,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,17.5776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,63323049227,NDC,2,ML,34.74,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,17.57844,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,55150016205,NDC,5,ML,42.32,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.579728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060002,NDC,2,ML,953.57,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,17.58,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.46,17.58
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060010,NDC,2,ML,953.57,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,17.58,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.46,17.58
"CUFF STERILE DISPOSABLE SPSB  STERILE 18""",27200000,CDM,272,RC,,,,7436-MAIN,LOCAL,,,,,35.89,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.5861,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"CUFF STERILE DISPOSABLE SPSB  STERILE 18""",27200000,CDM,272,RC,,,,7436-MAIN,LOCAL,,,,,35.89,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.5861,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"CUFF STERILE DISPOSABLE SPSB  STERILE 18""",27200000,CDM,272,RC,,,,7436-MAIN,LOCAL,,,,,35.89,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,17.5861,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CANNULA SEAL 5-12MM UNIVERSAL 470500,27200000,CDM,272,RC,,,,12885-MAIN,LOCAL,,,,,41,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.589,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CUP HEEL LARGE WONDERSPUR 4502,120.43,CDM,274,RC,L3485,HCPCS,,11385-MAIN,LOCAL,,,,,41,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.589,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL MEDIUM WONDERSPUR 4501,120.43,CDM,274,RC,L3485,HCPCS,,11384-MAIN,LOCAL,,,,,41,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.589,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL SMALL WONDERSPUR 4500,120.43,CDM,274,RC,L3485,HCPCS,,11383-MAIN,LOCAL,,,,,41,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.589,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL XL WONDERSPUR 4503,120.43,CDM,274,RC,L3485,HCPCS,,11386-MAIN,LOCAL,,,,,41,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.589,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
Detection of Anaplasma Phagocytophilum by Amplified Nucleic Acid Probe Technique,PX8746890,CDM,300,RC,87468,CPT,90,,,,,,,41,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.589,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
Detection of Ehrlichia Chaffeensis by Amplified Nucleic Acid Probe Technique,PX8748490,CDM,300,RC,87484,CPT,90,,,,,,,41,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.589,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 21G 110MM SONOTAP II WITH FACET TIP 1285-3F110,120.483,CDM,271,RC,A4215,HCPCS,,12201-MAIN,LOCAL,,,,,41,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.589,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 21G X 4IN (100MM) SONOBLOCK II NERVE BLOCK WITH FACET S TIP 001281-77,120.483,CDM,271,RC,A4215,HCPCS,,12761-MAIN,LOCAL,,,,,41,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.589,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 22G 80MM SONOTAP II WITH FACET TIP 1285-3E080,120.483,CDM,271,RC,A4215,HCPCS,,12103-MAIN,LOCAL,,,,,41,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.589,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 22G X 3.25IN (80MM) SONOBLOCK II  NERVE BLOCK WITH FACET S TIP 001281-71,120.483,CDM,271,RC,A4215,HCPCS,,12760-MAIN,LOCAL,,,,,41,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.589,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 22GX2 SONOPLEX II WITH FACET S TIP 001287-74,120.483,CDM,271,RC,A4215,HCPCS,,13110-MAIN,LOCAL,,,,,41,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.589,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE NON-STIMULATING 22GX2 SONOBLOCK II WITH FACET S TIP 001281-74,120.483,CDM,271,RC,A4215,HCPCS,,11459-MAIN,LOCAL,,,,,41,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.589,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE SONOPLEX II STIMULATING WITH FACET S TIP 22GX3-1/4,120.483,CDM,271,RC,A4215,HCPCS,,11457-MAIN,LOCAL,,,,,41,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.589,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE STIMULATING 21GX4  SONOPLEX II  WITH FACET S TIP 001287-77,120.483,CDM,271,RC,A4215,HCPCS,,11458-MAIN,LOCAL,,,,,41,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.589,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
STRAP FOOT LG/XL GEL UNIVERSAL 10165,120.428,CDM,271,RC,,,,11382-MAIN,LOCAL,,,,,41,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.589,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
STRAP FOOT SM/MED GEL UNIVERSAL 10155,120.428,CDM,271,RC,,,,11381-MAIN,LOCAL,,,,,41,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.589,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
SUTURE V-LOC SZ 1/2 180 GREEN GS-21 VLOCL0316,27200000,CDM,272,RC,,,,11932-MAIN,LOCAL,,,,,41,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.589,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
URGOK2 DUAL COMPRESSION SYSTEM LARGE,120.491,CDM,271,RC,A6452,HCPCS,,11871-MAIN,LOCAL,,,,,41,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.589,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
URGOK2 DUAL COMPRESSION SYSTEM REGULAR,120.491,CDM,271,RC,A6452,HCPCS,,11870-MAIN,LOCAL,,,,,41,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.589,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68462033090,NDC,1,EA,17.95,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,17.591,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Ebv, Viral Capsid Ab - Ref",PX8666590,CDM,300,RC,86665,CPT,90,,,,,,,58,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,17.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.6,18.14
"Ebv, Viral Capsid Ab - Ref",PX8666590,CDM,300,RC,86665,CPT,90,,,,,,,58,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,17.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.6,18.14
"Ebv, Viral Capsid Ab - Ref",PX8666590,CDM,300,RC,86665,CPT,90,,,,,,,58,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,17.6,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.6,18.14
Epstein-barr antibody,PX86665,CDM,300,RC,86665,CPT,,,,,,,,86,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,17.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.6,18.14
Epstein-barr antibody,PX86665,CDM,300,RC,86665,CPT,,,,,,,,86,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,17.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.6,18.14
Epstein-barr antibody,PX86665,CDM,300,RC,86665,CPT,,,,,,,,86,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,17.6,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.6,18.14
Neg Pressure Wound Therapy Dme </=50 Sq Cm,PX97605F,CDM,510,RC,97605,CPT,,,,,,,,396,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,17.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.3,56.67
Neg Pressure Wound Therapy Dme </=50 Sq Cm,PX97605F,CDM,510,RC,97605,CPT,,,,,,,,396,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,17.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.3,56.67
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,17478004001,NDC,1,ML,42.39,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.608806,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
miconazole 2 % Powder 71 g Bottle,25000000,CDM,250,RC,,,,,,316023125,NDC,71,GR,34.82,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,17.61892,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
cefaDROXil 500 MG capsule 50 Each Bottle,63700001,CDM,250,RC,,,,,,16714038801,NDC,1,EA,19.98,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,17.62236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049257,NDC,5,ML,42.43,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.625422,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Gastrin - Ref,PX8294190,CDM,300,RC,82941,CPT,90,,,,,,,65,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,17.63,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.1,17.63
"Bacterium Nos, Antibody - Ref",PX8660990,CDM,300,RC,86609,CPT,90,,,,,,,20,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
"BINDER ABDOMINAL 12"" HIGH 46 TO 62 INCH L/XL 4 PANEL ORT21300LXL",120.238,CDM,271,RC,A4467,HCPCS,,11935-MAIN,LOCAL,,,,,18,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BURETROL ADD ON SET 150ML,120.38,CDM,272,RC,A4222,HCPCS,,11118-MAIN,LOCAL,,,,,18,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
DRESSING QWICK NONADHESIVE 4.25X4 SUPERABSORBENT MSC5844,120.531,CDM,272,RC,A6197,HCPCS,,12301-MAIN,LOCAL,,,,,20,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
Glucose Blood Test,PX82962,CDM,300,RC,82962,CPT,,,,,,,,20,,United Healthcare,All Payer,outpatient,88.2,,6.415,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.01,19.6
IMMOBILIZER SHOULDER LARGE 9008-03,120.38,CDM,274,RC,L3650,HCPCS,,906-MAIN,LOCAL,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER LARGE 9008-03,120.38,CDM,274,RC,L3650,HCPCS,,906-MAIN,LOCAL,,,,,36,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER LARGE 9008-03,120.38,CDM,274,RC,L3650,HCPCS,,906-MAIN,LOCAL,,,,,36,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER LARGE STRAP OSG3033,120.38,CDM,274,RC,L3650,HCPCS,,2910-MAIN,LOCAL,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER LARGE STRAP OSG3033,120.38,CDM,274,RC,L3650,HCPCS,,2910-MAIN,LOCAL,,,,,36,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER LARGE STRAP OSG3033,120.38,CDM,274,RC,L3650,HCPCS,,2910-MAIN,LOCAL,,,,,36,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER MEDIUM 9008-02,120.38,CDM,274,RC,L3650,HCPCS,,912-MAIN,LOCAL,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER MEDIUM 9008-02,120.38,CDM,274,RC,L3650,HCPCS,,912-MAIN,LOCAL,,,,,36,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER MEDIUM 9008-02,120.38,CDM,274,RC,L3650,HCPCS,,912-MAIN,LOCAL,,,,,36,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER MEDIUM OSG3032,120.38,CDM,274,RC,L3650,HCPCS,,915-MAIN,LOCAL,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER MEDIUM OSG3032,120.38,CDM,274,RC,L3650,HCPCS,,915-MAIN,LOCAL,,,,,36,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER MEDIUM OSG3032,120.38,CDM,274,RC,L3650,HCPCS,,915-MAIN,LOCAL,,,,,36,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER SMALL 9008-01,120.38,CDM,274,RC,L3650,HCPCS,,913-MAIN,LOCAL,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER SMALL 9008-01,120.38,CDM,274,RC,L3650,HCPCS,,913-MAIN,LOCAL,,,,,36,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER SMALL 9008-01,120.38,CDM,274,RC,L3650,HCPCS,,913-MAIN,LOCAL,,,,,36,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER SMALL WITH CLOTH 9001-02,120.38,CDM,274,RC,L3650,HCPCS,,914-MAIN,LOCAL,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER SMALL WITH CLOTH 9001-02,120.38,CDM,274,RC,L3650,HCPCS,,914-MAIN,LOCAL,,,,,36,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER SMALL WITH CLOTH 9001-02,120.38,CDM,274,RC,L3650,HCPCS,,914-MAIN,LOCAL,,,,,36,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER X-LARGE CLOTH 9001-05,120.38,CDM,274,RC,L3650,HCPCS,,917-MAIN,LOCAL,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER X-LARGE CLOTH 9001-05,120.38,CDM,274,RC,L3650,HCPCS,,917-MAIN,LOCAL,,,,,36,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER X-LARGE CLOTH 9001-05,120.38,CDM,274,RC,L3650,HCPCS,,917-MAIN,LOCAL,,,,,36,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER X-LARGE ORT16100XL,120.38,CDM,274,RC,L3650,HCPCS,,904-MAIN,LOCAL,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER X-LARGE ORT16100XL,120.38,CDM,274,RC,L3650,HCPCS,,904-MAIN,LOCAL,,,,,36,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER X-LARGE ORT16100XL,120.38,CDM,274,RC,L3650,HCPCS,,904-MAIN,LOCAL,,,,,36,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
Phenobarbital Assay - Ref,PX8018490,CDM,300,RC,80184,CPT,90,,,,,,,20,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
Primidone Assay - Ref,PX8018890,CDM,300,RC,80188,CPT,90,,,,,,,20,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER  STRAIGHT TAPER TIP 20FR PVC,120.528,CDM,272,RC,,,,12247-MAIN,LOCAL,,,,,20,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER  STRAIGHT TAPER TIP 24FR PVC,120.528,CDM,272,RC,,,,12248-MAIN,LOCAL,,,,,20,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 8FR PVC,120.528,CDM,272,RC,,,,12253-MAIN,LOCAL,,,,,20,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 10FR PVC,120.528,CDM,272,RC,,,,12254-MAIN,LOCAL,,,,,20,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 12FR PVC,120.528,CDM,272,RC,,,,12255-MAIN,LOCAL,,,,,20,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 16FR PVC,120.528,CDM,272,RC,,,,12256-MAIN,LOCAL,,,,,20,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 28FR PVC,120.528,CDM,272,RC,,,,12249-MAIN,LOCAL,,,,,20,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 32FR PVC,120.528,CDM,272,RC,,,,12250-MAIN,LOCAL,,,,,20,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 36FR PVC,120.528,CDM,272,RC,,,,12251-MAIN,LOCAL,,,,,20,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
TRAY TRACH CLEAN & CARE DYND40589,120.212,CDM,271,RC,,,,1173-MAIN,LOCAL,,,,,18,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,17.64
TRAY TRACHEOTOMY CARE PEDS DYND40650H,120.212,CDM,272,RC,,,,11025-MAIN,LOCAL,,,,,18,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,17.64
Treponema Pallidum,PX86780,CDM,300,RC,86780,CPT,,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.14,35.28
Treponema Pallidum,PX86780,CDM,300,RC,86780,CPT,,,,,,,,36,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.14,35.28
Treponema Pallidum,PX86780,CDM,300,RC,86780,CPT,,,,,,,,36,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.14,35.28
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078121,NDC,0.5,EA,36.75,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078121,NDC,0.5,EA,36.75,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078141,NDC,0.5,EA,36.75,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078141,NDC,0.5,EA,36.75,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405P,CDM,983,RC,36405,CPT,,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405P,CDM,983,RC,36405,CPT,,,,,,,,36,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405P,CDM,983,RC,36405,CPT,,,,,,,,36,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,17.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
TROCAR KII BALLOON 12MM STERILE,27200000,CDM,272,RC,,,,11703-MAIN,LOCAL,,,,,41.14,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.64906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR KII BALLOON BLUNT 12MM STERILE,27200000,CDM,272,RC,,,,11702-MAIN,LOCAL,,,,,41.14,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.64906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
sterile water (preservative free) Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409488724,NDC,50,ML,34.88,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,17.64928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409488750,NDC,50,ML,34.88,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,17.64928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Cyclosporine - Ref,PX8015890,CDM,300,RC,80158,CPT,90,,,,,,,95,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,17.6495,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.51,18.05
"Ebv, Viral Capsid Ab - Ref",PX8666590,CDM,300,RC,86665,CPT,90,,,,,,,58,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,17.6495,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.6,18.14
Epstein-barr antibody,PX86665,CDM,300,RC,86665,CPT,,,,,,,,86,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,17.6495,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.6,18.14
"Extractable Nuclear Antigen, Each Antigen",PX86235,CDM,300,RC,86235,CPT,90,,,,,,,99,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,17.6495,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.39,17.93
Factor VII - Ref,PX8523090,CDM,300,RC,85230,CPT,90,,,,,,,125,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,17.6495,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.36,17.9
Factor VIII (Ahg) 1-Stage,PX85240,CDM,300,RC,85240,CPT,,,,,,,,997,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,17.6495,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.36,17.9
Homocysteine,PX83090,CDM,300,RC,83090,CPT,,,,,,,,44,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,17.6495,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.38,17.92
Mycophenolate Mycophenolicacid - Ref,PX8018090,CDM,300,RC,80180,CPT,90,,,,,,,56,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,17.6495,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.51,18.05
Blood Clot Factor V Test,PX85220,CDM,300,RC,85220,CPT,,,,,,,,260,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,17.65,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.12,17.65
ketorolac 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314012605,NDC,5,ML,42.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.6545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Appl on-Body Injector for Timed Subq Injection,PX96377,CDM,260,RC,96377,CPT,,,,,,,,13093,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,17.655,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.655,31.99
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641622901,NDC,1,ML,41.16,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.65764,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.097864,86.9162
Appl on-Body Injector for Timed Subq Injection,PX96377,CDM,260,RC,96377,CPT,,,,,,,,13093,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,17.66,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.655,31.99
"Apply Finger Splint,Static",PX29130F,CDM,420,RC,29130,CPT,,,,,,,,196,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,17.66,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.66,88.55
"Apply Finger Splint,Static",PX29130F,CDM,420,RC,29130,CPT,,,,,,,,196,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,17.66,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.66,88.55
"Apply Finger Splint,Static",PX29130F,CDM,420,RC,29130,CPT,,,,,,,,196,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,17.66,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.66,88.55
"Apply Finger Splint,Static",PX29130P,CDM,983,RC,29130,CPT,,,,,,,,223,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,17.66,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.66,218.54
"Apply Finger Splint,Static",PX29130P,CDM,983,RC,29130,CPT,,,,,,,,223,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,17.66,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.66,218.54
"Apply Finger Splint,Static",PX29130P,CDM,983,RC,29130,CPT,,,,,,,,223,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,17.66,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.66,218.54
"Fac/Trm Hyperkeratotic Skn Lesn,>4",PX11057F,CDM,510,RC,11057,CPT,,,,,,,,175,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,17.66,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.66,187.48
"Fac/Trm Hyperkeratotic Skn Lesn,>4",PX11057F,CDM,510,RC,11057,CPT,,,,,,,,175,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,17.66,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.66,187.48
"Fac/Trm Hyperkeratotic Skn Lesn,>4",PX11057F,CDM,510,RC,11057,CPT,,,,,,,,175,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,17.66,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.66,187.48
X-Ray Exam Femur Min 2 Vws,PX7355201,CDM,320,RC,73552,CPT,TC,,,,,,,365,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,17.66,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.66,53.25
Xray Orbits Optic Foramina,PX7019001,CDM,320,RC,70190,CPT,TC,,,,,,,66,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,17.66,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.66,53.25
buprenorphine 75 MCG FILM 1 Each Package,63700001,CDM,250,RC,,,,,,59385002101,NDC,1,EA,35.68,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,17.6616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyBUTYnin ER 5 MG Tablet Extended Release 24 Hour 50 Each Box,63700001,CDM,250,RC,,,,,,904657006,NDC,1,EA,18.04,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,17.6792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
mycophenolate 500 MG Tablet 100 Each Bottle,J7517.01,CDM,637,RC,J7517,HCPCS,,,,64380072506,NDC,1,EA,42.56,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.679424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.679424,41.7088
Gonadotropin (Lh),PX83002,CDM,300,RC,83002,CPT,,,,,,,,28,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,17.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.69,18.52
Gonadotropin (Lh),PX83002,CDM,300,RC,83002,CPT,,,,,,,,28,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,17.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.69,18.52
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070948,NDC,100,ML,42.59,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.691886,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037604,NDC,0.75,ML,36.86,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,17.6928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037604,NDC,0.75,ML,36.86,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,17.6928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,67457043800,NDC,0.5,EA,36.11,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.6939,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,67457043800,NDC,0.5,EA,36.11,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.6939,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,67457043800,NDC,0.5,EA,36.11,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,17.6939,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,67457043810,NDC,0.5,EA,36.11,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.6939,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,67457043810,NDC,0.5,EA,36.11,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.6939,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,67457043810,NDC,0.5,EA,36.11,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,17.6939,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028036,NDC,2,ML,36.12,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,7.169534884,percent of total billed charges,17.6988,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028036,NDC,2,ML,36.12,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.6988,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028036,NDC,2,ML,36.12,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,17.6988,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
B-Scan Global,PX7651201,CDM,402,RC,76512,CPT,TC,,,,,,,127,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,17.699,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.55,35.5
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,60432006547,NDC,10,ML,34.98,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,17.69988,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,17478081705,NDC,5,ML,34.99,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,17.70494,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323020103,NDC,10,ML,36.14,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.7086,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323020103,NDC,10,ML,36.14,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.7086,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323020103,NDC,10,ML,36.14,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,17.7086,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Psa Screening,PXG0103,CDM,300,RC,G0103,HCPCS,,,,,,,,157,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,17.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.71,153.86
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209F,CDM,510,RC,69209,CPT,,,,,,,,35,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,17.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,53.44
SHOE POST OP X-LARGE MALE DS1016-16,120.237,CDM,274,RC,L3260,HCPCS,,6337-MAIN,LOCAL,,,,,35,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,17.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
"Trimming of Dystrophic Nails, Any Number",PXG0127P,CDM,983,RC,G0127,HCPCS,,,,,,,,35,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,17.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,53.44
povidone-iodine 10 % Ointment 28.35 g Tube,63700001,CDM,250,RC,,,,,,904110231,NDC,28.35,GR,19.9,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,17.711,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028016,NDC,2,ML,41.29,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.71341,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
nadolol 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,76385013301,NDC,1,EA,18.2,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,17.71406,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone acetate 20 MG/ML Suspension 5 mL Vial,J1010.01,CDM,636,RC,J1010,HCPCS,,,,9027401,NDC,0.5,ML,41.3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.7177,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.15602,40.474
venlafaxine 37.5 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084069811,NDC,1,EA,20.09,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,17.71938,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 37.5 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084069801,NDC,1,EA,20.09,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,17.71938,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
FORCEPS SERRATED WITH SPIKE JUMBO 230CM,27200000,CDM,272,RC,,,,7416-MAIN,LOCAL,,,,,41.31,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.72199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
colchicine 0.6 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,49884017111,NDC,1,EA,36.17,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.7233,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
colchicine 0.6 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,49884017111,NDC,1,EA,36.17,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.7233,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
colchicine 0.6 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,49884017111,NDC,1,EA,36.17,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,17.7233,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 1 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409128303,NDC,1,ML,36.93,,Health Partners,Health Partners Care Plans,both,48,,25.36411765,percent of total billed charges,17.7264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
HYDROmorphone 1 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409128303,NDC,1,ML,36.93,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,17.7264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
Somatostatin - Ref,PX8430790,CDM,300,RC,84307,CPT,90,,,,,,,325,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,17.73,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.73,18.28
Somatostatin - Ref,PX8430790,CDM,300,RC,84307,CPT,90,,,,,,,325,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,17.73,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.73,18.28
Somatostatin - Ref,PX8430790,CDM,300,RC,84307,CPT,90,,,,,,,325,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,17.73,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.73,18.28
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409132305,NDC,5,ML,41.35,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.73915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
Rickettsia Antibody - Ref,PX8675790,CDM,300,RC,86757,CPT,90,,,,,,,52,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,17.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.74,50.96
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026994,NDC,20,ML,35.87,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,17.75565,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
COLLAR CERVICAL LARGE WITH TRACH 2 PIECE PHP-T4L,120.184,CDM,274,RC,L0172,HCPCS,,10142-MAIN,LOCAL,,,,,37,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,17.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.3698,152.79
COLLAR CERVICAL LARGE WITH TRACH 2 PIECE PHP-T4L,120.184,CDM,274,RC,L0172,HCPCS,,10142-MAIN,LOCAL,,,,,37,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,17.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.3698,152.79
COLLAR CERVICAL MEDIUM WITH TRACH 2 PIECE PHP-T4M,120.183,CDM,274,RC,L0172,HCPCS,,10141-MAIN,LOCAL,,,,,37,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,17.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.3698,152.79
COLLAR CERVICAL MEDIUM WITH TRACH 2 PIECE PHP-T4M,120.183,CDM,274,RC,L0172,HCPCS,,10141-MAIN,LOCAL,,,,,37,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,17.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.3698,152.79
COLLAR CERVICAL SMALL WITH TRACH 2 PIECE PHP-T4S,120.182,CDM,274,RC,L0172,HCPCS,,10140-MAIN,LOCAL,,,,,37,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,17.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.3698,152.79
COLLAR CERVICAL SMALL WITH TRACH 2 PIECE PHP-T4S,120.182,CDM,274,RC,L0172,HCPCS,,10140-MAIN,LOCAL,,,,,37,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,17.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.3698,152.79
SUTURE TICRON 0 36IN BRAIDED DYED 1/2 CIRCLE DBLE ARM 25MM CV-305 BLUE STERILE,27200000,CDM,272,RC,,,,11956-MAIN,LOCAL,,,,,37,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,17.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE TICRON 0 36IN BRAIDED DYED 1/2 CIRCLE DBLE ARM 25MM CV-305 BLUE STERILE,27200000,CDM,272,RC,,,,11956-MAIN,LOCAL,,,,,37,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,17.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"CUFF STERILE DISPOSABLE SPSB  STERILE 18""",27200000,CDM,272,RC,,,,7436-MAIN,LOCAL,,,,,35.89,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,17.76555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028026,NDC,2,ML,41.42,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.76918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
Prolactin,PX84146,CDM,300,RC,84146,CPT,,,,,,,,112,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,17.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.77,109.76
risperiDONE 0.25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084027011,NDC,1,EA,20.91,,First Health,Commercial,both,85,,999999999,percent of total billed charges,17.7735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084027001,NDC,1,EA,20.91,,First Health,Commercial,both,85,,999999999,percent of total billed charges,17.7735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cefaDROXil 500 MG capsule 50 Each Bottle,63700001,CDM,250,RC,,,,,,16714038801,NDC,1,EA,19.98,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,17.7822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022143,NDC,1,EA,36.31,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,12.3175,percent of total billed charges,17.7919,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022143,NDC,1,EA,36.31,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.7919,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022143,NDC,1,EA,36.31,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,17.7919,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
"Bacterium Nos, Antibody - Ref",PX8660990,CDM,300,RC,86609,CPT,90,,,,,,,20,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,17.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
DRESSING QWICK NONADHESIVE 4.25X4 SUPERABSORBENT MSC5844,120.531,CDM,272,RC,A6197,HCPCS,,12301-MAIN,LOCAL,,,,,20,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,17.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
Glucose Blood Test,PX82962,CDM,300,RC,82962,CPT,,,,,,,,20,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,17.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.01,19.6
Phenobarbital Assay - Ref,PX8018490,CDM,300,RC,80184,CPT,90,,,,,,,20,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,17.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
Primidone Assay - Ref,PX8018890,CDM,300,RC,80188,CPT,90,,,,,,,20,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,17.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER  STRAIGHT TAPER TIP 20FR PVC,120.528,CDM,272,RC,,,,12247-MAIN,LOCAL,,,,,20,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,17.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER  STRAIGHT TAPER TIP 24FR PVC,120.528,CDM,272,RC,,,,12248-MAIN,LOCAL,,,,,20,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,17.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 8FR PVC,120.528,CDM,272,RC,,,,12253-MAIN,LOCAL,,,,,20,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,17.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 10FR PVC,120.528,CDM,272,RC,,,,12254-MAIN,LOCAL,,,,,20,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,17.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 12FR PVC,120.528,CDM,272,RC,,,,12255-MAIN,LOCAL,,,,,20,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,17.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 16FR PVC,120.528,CDM,272,RC,,,,12256-MAIN,LOCAL,,,,,20,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,17.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 28FR PVC,120.528,CDM,272,RC,,,,12249-MAIN,LOCAL,,,,,20,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,17.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 32FR PVC,120.528,CDM,272,RC,,,,12250-MAIN,LOCAL,,,,,20,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,17.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 36FR PVC,120.528,CDM,272,RC,,,,12251-MAIN,LOCAL,,,,,20,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,17.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022116,NDC,1,EA,36.33,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,12.3175,percent of total billed charges,17.8017,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022116,NDC,1,EA,36.33,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.8017,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022116,NDC,1,EA,36.33,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,17.8017,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022141,NDC,1,EA,36.33,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,12.3175,percent of total billed charges,17.8017,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022141,NDC,1,EA,36.33,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.8017,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022141,NDC,1,EA,36.33,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,17.8017,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
doxazosin 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079095701,NDC,1,EA,20.19,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,17.80758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001326,NDC,1,ML,42.88,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.812352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001341,NDC,1,ML,42.88,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.812352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
IMMOBILIZER SHOULDER LARGE 9008-03,120.38,CDM,274,RC,L3650,HCPCS,,906-MAIN,LOCAL,,,,,36,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,17.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER LARGE STRAP OSG3033,120.38,CDM,274,RC,L3650,HCPCS,,2910-MAIN,LOCAL,,,,,36,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,17.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER MEDIUM 9008-02,120.38,CDM,274,RC,L3650,HCPCS,,912-MAIN,LOCAL,,,,,36,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,17.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER MEDIUM OSG3032,120.38,CDM,274,RC,L3650,HCPCS,,915-MAIN,LOCAL,,,,,36,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,17.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER SMALL 9008-01,120.38,CDM,274,RC,L3650,HCPCS,,913-MAIN,LOCAL,,,,,36,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,17.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER SMALL WITH CLOTH 9001-02,120.38,CDM,274,RC,L3650,HCPCS,,914-MAIN,LOCAL,,,,,36,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,17.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER X-LARGE CLOTH 9001-05,120.38,CDM,274,RC,L3650,HCPCS,,917-MAIN,LOCAL,,,,,36,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,17.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER X-LARGE ORT16100XL,120.38,CDM,274,RC,L3650,HCPCS,,904-MAIN,LOCAL,,,,,36,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,17.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
Platelet Antibodies - Ref,PX8602290,CDM,300,RC,86022,CPT,90,,,,,,,245,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,17.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.82,18.37
Platelet Antibodies - Ref,PX8602290,CDM,300,RC,86022,CPT,90,,,,,,,245,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,17.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.82,18.37
Platelet Antibodies - Ref,PX8602290,CDM,300,RC,86022,CPT,90,,,,,,,245,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,17.82,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.82,18.37
Treponema Pallidum,PX86780,CDM,300,RC,86780,CPT,,,,,,,,36,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,17.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.14,35.28
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405P,CDM,983,RC,36405,CPT,,,,,,,,36,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,17.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
buprenorphine 8 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,54017713,NDC,1,EA,41.56,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.82924,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.14,40.7288
doxazosin 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079095720,NDC,1,EA,20.22,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,17.83404,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nadolol 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,76385013301,NDC,1,EA,18.2,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,17.836,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of Psa Total,PX84153,CDM,300,RC,84153,CPT,,,,,,,,157,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,17.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.84,18.39
Assay of Psa Total,PX84153,CDM,300,RC,84153,CPT,,,,,,,,157,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,17.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.84,18.39
Assay of Psa Total,PX84153,CDM,300,RC,84153,CPT,,,,,,,,157,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,17.84,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.84,18.39
"Psa, Free - Ref",PX8415490,CDM,300,RC,84154,CPT,90,,,,,,,38,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,17.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.84,18.39
"Psa, Free - Ref",PX8415490,CDM,300,RC,84154,CPT,90,,,,,,,38,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,17.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.84,18.39
"Psa, Free - Ref",PX8415490,CDM,300,RC,84154,CPT,90,,,,,,,38,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,17.84,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.84,18.39
"Psa, Total - Ref",PX8415390,CDM,300,RC,84153,CPT,90,,,,,,,38,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,17.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.84,18.39
"Psa, Total - Ref",PX8415390,CDM,300,RC,84153,CPT,90,,,,,,,38,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,17.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.84,18.39
"Psa, Total - Ref",PX8415390,CDM,300,RC,84153,CPT,90,,,,,,,38,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,17.84,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.84,18.39
Anesthesia Level 4,PX37000018,CDM,370,RC,,,,,,,,,,21,,First Health,Commercial,both,85,,999999999,percent of total billed charges,17.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.7234,20.58
ANOSCOPE LIGHTED ANOSCOPE,120.52,CDM,272,RC,,,,10235-MAIN,LOCAL,,,,,21,,First Health,Commercial,both,85,,999999999,percent of total billed charges,17.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.7234,20.58
"Hepatitis B Core Antibody, Total",PX86704,CDM,300,RC,86704,CPT,,,,,,,,21,,First Health,Commercial,both,85,,999999999,percent of total billed charges,17.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.7234,20.58
"Spectrophotometry, Nos",PX84311,CDM,300,RC,84311,CPT,,,,,,,,21,,First Health,Commercial,both,85,,999999999,percent of total billed charges,17.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.43,20.58
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001103,NDC,1,EA,108.34,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,17.85,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,18.45
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001104,NDC,1,EA,108.29,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,17.85,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,18.45
hydrocortisone sodium succinate (preservative free) 250 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001305,NDC,1,EA,183.32,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,17.85,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,18.45
hydrocortisone sodium succinate (preservative free) 500 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001612,NDC,1,EA,298.53,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,17.85,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,18.45
hydrocortisone sodium succinate (preservative free) 1000 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9000501,NDC,1,EA,403.54,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,17.85,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,18.45
Antinuclear Antibodiesana - Ref,PX8603890,CDM,300,RC,86038,CPT,90,,,,,,,43,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.8622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.09,42.14
Blood Type Antigen Donor Ea,PX86902,CDM,300,RC,86902,CPT,,,,,,,,43,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.8622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.8622,314.02
ETRAP POLYP TRAP,27200000,CDM,272,RC,,,,11282-MAIN,LOCAL,,,,,43,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.8622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Smking Cess 4-10 Min,PX99406P,CDM,983,RC,99406,CPT,,,,,,,,43,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.8622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.8622,41.8519
"Testosterone, Total - Ref",PX8440390,CDM,300,RC,84403,CPT,90,,,,,,,43,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.8622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.8622,42.14
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,487960130,NDC,2,ML,36.47,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.8703,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,487960130,NDC,2,ML,36.47,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.8703,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,487960130,NDC,2,ML,36.47,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,17.8703,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,67457043800,NDC,0.5,EA,36.11,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,17.87445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,67457043810,NDC,0.5,EA,36.11,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,17.87445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028036,NDC,2,ML,36.12,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,17.8794,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
X-Ray Exam Femur Min 2 Vws,PX7355201,CDM,320,RC,73552,CPT,TC,,,,,,,365,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,17.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.66,53.25
X-Ray Exam Femur Min 2 Vws,PX7355201,CDM,320,RC,73552,CPT,TC,,,,,,,365,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,17.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.66,53.25
Xray Orbits Optic Foramina,PX7019001,CDM,320,RC,70190,CPT,TC,,,,,,,66,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,17.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.66,53.25
Xray Orbits Optic Foramina,PX7019001,CDM,320,RC,70190,CPT,TC,,,,,,,66,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,17.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.66,53.25
Xray Sinuses Minimum 3 Vws,PX7022001,CDM,320,RC,70220,CPT,TC,,,,,,,354,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,17.88,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.88,53.91
Xray Skull Less Than 4 Vws,PX7025001,CDM,320,RC,70250,CPT,TC,,,,,,,311,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,17.88,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.88,53.91
venlafaxine 37.5 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084069811,NDC,1,EA,20.09,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,17.8801,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 37.5 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084069801,NDC,1,EA,20.09,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,17.8801,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323020103,NDC,10,ML,36.14,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,17.8893,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
azithromycin 250 MG Tablet 6 Each Box,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096104,NDC,1,EA,41.72,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.89788,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
DRAPE SHEET 70X85 LARGE DYNJP2417,27200000,CDM,272,RC,,,,10914-MAIN,LOCAL,,,,,18.39,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,17.898987,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323018507,NDC,10,ML,43.09,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.899586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,409710709,NDC,1000,ML,36.53,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1.633818182,percent of total billed charges,17.8997,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,409710709,NDC,1000,ML,36.53,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.8997,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,409710709,NDC,1000,ML,36.53,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,17.8997,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5% and sodium chloride 0.45% with potassium chloride 10 mEq in 1000 mL 10-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,264763400,NDC,1000,ML,36.53,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.8997,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"dextrose 5% and sodium chloride 0.45% with potassium chloride 10 mEq in 1000 mL 10-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,264763400,NDC,1000,ML,36.53,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.8997,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"dextrose 5% and sodium chloride 0.45% with potassium chloride 10 mEq in 1000 mL 10-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,264763400,NDC,1000,ML,36.53,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,17.8997,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Compatibility Test,Antiglob Tech",PX86922,CDM,300,RC,86922,CPT,,,,,,,,120,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,17.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.9,30.048
"Compatibility Test,Antiglob Tech",PX86922,CDM,300,RC,86922,CPT,,,,,,,,120,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,17.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.9,30.048
"Compatibility Test,Antiglob Tech",PX86922,CDM,300,RC,86922,CPT,,,,,,,,120,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,17.9,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.9,30.048
Factor VII - Ref,PX8523090,CDM,300,RC,85230,CPT,90,,,,,,,125,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,17.9,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.36,17.9
Factor VIII (Ahg) 1-Stage,PX85240,CDM,300,RC,85240,CPT,,,,,,,,997,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,17.9,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.36,17.9
APPLICATOR CHLORAPREP 26ML WITH ORANGE 930815,27200000,CDM,272,RC,A4248,HCPCS,,10031-MAIN,LOCAL,,,,,19.65,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,17.90115,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096105,NDC,1,EA,41.73,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.90217,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
benzocaine-menthol 20-0.5 % Aerosol 78 g Can,63700001,CDM,250,RC,,,,,,75137085520,NDC,78,GR,35.38,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,17.90228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
colchicine 0.6 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,49884017111,NDC,1,EA,36.17,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,17.90415,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DULoxetine 20 MG Capsule Delayed Release Particles 60 Each Bottle,63700001,CDM,250,RC,,,,,,2323560,NDC,1,EA,41.76,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.91504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Homocysteine,PX83090,CDM,300,RC,83090,CPT,,,,,,,,44,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,17.92,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.38,17.92
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039841,NDC,1,EA,43.14,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.920356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
tolterodine ER 2 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,43975032203,NDC,1,EA,43.15,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.92451,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
miconazole 2 % Powder 85 g Bottle,25000000,CDM,250,RC,,,,,,67094930,NDC,85,GR,35.43,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,17.92758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,50111078751,NDC,1,EA,41.79,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.92791,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
donepezil 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904640861,NDC,1,EA,41.79,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,17.92791,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Extractable Nuclear Antigen, Each Antigen",PX86235,CDM,300,RC,86235,CPT,90,,,,,,,99,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,17.93,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.39,17.93
amoxicillin-clavulanate 500-125 MG Tablet 20 Each Bottle,63700001,CDM,250,RC,,,,,,16714047701,NDC,1,EA,20.33,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,17.93106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ampicillin 1 GM Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781926185,NDC,0.5,EA,43.18,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.936972,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
risperiDONE 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635861,NDC,1,EA,21.11,,First Health,Commercial,both,85,,999999999,percent of total billed charges,17.9435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ePHEDrine sulfate 50 MG/ML Solution 1 mL Vial,25000000,CDM,250,RC,,,,,,42023021689,NDC,0.1,ML,36.62,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.9438,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ePHEDrine sulfate 50 MG/ML Solution 1 mL Vial,25000000,CDM,250,RC,,,,,,42023021689,NDC,0.1,ML,36.62,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,17.9438,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ePHEDrine sulfate 50 MG/ML Solution 1 mL Vial,25000000,CDM,250,RC,,,,,,42023021689,NDC,0.1,ML,36.62,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,17.9438,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
celecoxib 200 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904650361,NDC,0.5,EA,20.35,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,17.9487,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Etoposide 100 MG/5ML Solution 5 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,16729011431,NDC,5,ML,43.21,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.949434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.949434,169.8144
amoxicillin 250 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,93415580,NDC,150,ML,43.22,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.953588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pancrelipase (lip-prot-amyl) 24000-76000 units Capsule Delayed Release Particles 100 Each Bottle,63700001,CDM,250,RC,,,,,,32122401,NDC,1,EA,37.41,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,17.9568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pancrelipase (lip-prot-amyl) 24000-76000 units Capsule Delayed Release Particles 100 Each Bottle,63700001,CDM,250,RC,,,,,,32122401,NDC,1,EA,37.41,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,17.9568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Cystatin C - Ref,PX8261090,CDM,300,RC,82610,CPT,90,,,,,,,130,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,17.96,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.96,18.52
Gonadotropin (Lh),PX83002,CDM,300,RC,83002,CPT,,,,,,,,28,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,17.96,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.69,18.52
Cystatin C - Ref,PX8261090,CDM,300,RC,82610,CPT,90,,,,,,,130,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,17.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.96,18.52
Cystatin C - Ref,PX8261090,CDM,300,RC,82610,CPT,90,,,,,,,130,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,17.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.96,18.52
DRAPE SHEET LAP T-DRAPE WITH INSTRUMENT PAD DYNJP3003,27200000,CDM,272,RC,,,,10913-MAIN,LOCAL,,,,,35.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,17.963,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
doxazosin 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079095701,NDC,1,EA,20.19,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,17.9691,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of Psa Total,PX84153,CDM,300,RC,84153,CPT,,,,,,,,157,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,17.9704,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.84,18.39
Platelet Antibodies - Ref,PX8602290,CDM,300,RC,86022,CPT,90,,,,,,,245,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,17.9704,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.82,18.37
"Psa, Free - Ref",PX8415490,CDM,300,RC,84154,CPT,90,,,,,,,38,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,17.9704,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.84,18.39
"Psa, Total - Ref",PX8415390,CDM,300,RC,84153,CPT,90,,,,,,,38,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,17.9704,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.84,18.39
Somatostatin - Ref,PX8430790,CDM,300,RC,84307,CPT,90,,,,,,,325,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,17.9704,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.73,18.28
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022143,NDC,1,EA,36.31,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,17.97345,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022116,NDC,1,EA,36.33,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,17.98335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022141,NDC,1,EA,36.33,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,17.98335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
"Venipuncture by Physician, Other Vein, Under Age 3 Years",PX36406,CDM,983,RC,36406,CPT,,,,,,,,45,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,17.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.45,44.1
"CUFF STERILE DISPOSABLE SPSB 12""",27200000,CDM,272,RC,,,,7435-MAIN,LOCAL,,,,,43.31,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,17.990974,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
doxazosin 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079095720,NDC,1,EA,20.22,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,17.9958,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Calprotectin, Fecal - Ref",PX8399390,CDM,300,RC,83993,CPT,90,,,,,,,401,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18,392.98
"CUFF STERILE DISPOSABLE SPSB 24""",27200000,CDM,272,RC,,,,7437-MAIN,LOCAL,,,,,37.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"CUFF STERILE DISPOSABLE SPSB 24""",27200000,CDM,272,RC,,,,7437-MAIN,LOCAL,,,,,37.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ENDOCAVITY NEEDLE GUIDE,27200000,CDM,272,RC,,,,11134-MAIN,LOCAL,,,,,37.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ENDOCAVITY NEEDLE GUIDE,27200000,CDM,272,RC,,,,11134-MAIN,LOCAL,,,,,37.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR KII BALOON 5X100MM STERILE,27200000,CDM,272,RC,,,,11701-MAIN,LOCAL,,,,,37.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR KII BALOON 5X100MM STERILE,27200000,CDM,272,RC,,,,11701-MAIN,LOCAL,,,,,37.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"SUTURE ETHIBOND #0 CT-1 CR 8-18"" CX21D",27200000,CDM,272,RC,,,,6415-MAIN,LOCAL,,,,,41.97,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.00513,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078121,NDC,0.5,EA,36.75,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.0075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078121,NDC,0.5,EA,36.75,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.0075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078121,NDC,0.5,EA,36.75,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,18.0075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078141,NDC,0.5,EA,36.75,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.0075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078141,NDC,0.5,EA,36.75,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.0075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078141,NDC,0.5,EA,36.75,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,18.0075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Actin Antibody Each,PX8601590,CDM,300,RC,86015,CPT,90,,,,,,,42,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.05,41.16
Assay Vitamin B-6,PX84207,CDM,300,RC,84207,CPT,90,,,,,,,42,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
"BOUGIE TRACH 10FR 70CM COUDE 	9-0211-70",120.199,CDM,272,RC,A7520,HCPCS,,11112-MAIN,LOCAL,,,,,42,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
BOUGIE TRACHEAL TUBE & GUIDE 100123515,120.199,CDM,272,RC,A7520,HCPCS,,8950-MAIN,LOCAL,,,,,42,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
CATHETER PUREWICK FEMALE EXTERNAL PWF030K,120.414,CDM,272,RC,A6590,HCPCS,,11836-MAIN,LOCAL,,,,,42,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
Culture Type Immunologic,PX87147,CDM,300,RC,87147,CPT,,,,,,,,42,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,41.16
EZ-STABILIZER DRESSING,120.415,CDM,272,RC,,,,9058-MAIN,LOCAL,,,,,42,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
MEPILEX AG FOAM 4X4,120.192,CDM,272,RC,A6213,HCPCS,,8480-MAIN,LOCAL,,,,,42,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
MEPILEX AG FOAM 4X8,120.192,CDM,272,RC,A6213,HCPCS,,8479-MAIN,LOCAL,,,,,42,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY CENTRAL LINE DRESSING WITH CHLORAPREP DYND75234,120.68,CDM,272,RC,,,,10923-MAIN,LOCAL,,,,,42,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY FOLEY 14FR CATHETER A300414A,120.414,CDM,272,RC,A4344,HCPCS,,11281-MAIN,LOCAL,,,,,42,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY FOLEY 16FR CATHETER 300416A,120.414,CDM,272,RC,A4344,HCPCS,,11774-MAIN,LOCAL,,,,,42,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
"TRAY SPINAL  25GX3.5"" WITH WHITEACRE 405671",120.275,CDM,272,RC,,,,3284-MAIN,LOCAL,,,,,42,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY SPINAL 25G ANESTH SADDLE BLOCK NLD-4795-20,120.275,CDM,272,RC,,,,935-MAIN,LOCAL,,,,,42,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
DRAPE SHEET 70X85 LARGE DYNJP2417,27200000,CDM,272,RC,,,,10914-MAIN,LOCAL,,,,,18.39,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,18.0222,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490311,NDC,5,ML,43.39,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.024206,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
Dimethicone 1.5 % Cream 118 mL Tube,800000,CDM,,,,,,,,53329016104,NDC,118,ML,43.4,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.02836,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001002,NDC,2,ML,43.42,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.036668,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,42.5516
DULoxetine 20 MG Capsule Delayed Release Particles 60 Each Bottle,63700001,CDM,250,RC,,,,,,57237001760,NDC,1,EA,37.58,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.0384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DULoxetine 20 MG Capsule Delayed Release Particles 60 Each Bottle,63700001,CDM,250,RC,,,,,,57237001760,NDC,1,EA,37.58,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.0384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Cyclosporine - Ref,PX8015890,CDM,300,RC,80158,CPT,90,,,,,,,95,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,18.05,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.51,18.05
Mycophenolate Mycophenolicacid - Ref,PX8018090,CDM,300,RC,80180,CPT,90,,,,,,,56,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,18.05,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.51,18.05
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,487960130,NDC,2,ML,36.47,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,18.05265,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
buprenorphine 75 MCG FILM 1 Each Package,63700001,CDM,250,RC,,,,,,59385002101,NDC,1,EA,35.68,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.05408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bacitracin zinc 500 UNIT/GM Ointment 28.4 g Tube,25000000,CDM,250,RC,,,,,,49348015472,NDC,28.4,GR,20.47,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,18.05454,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pioglitazone 15 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342005410,NDC,1,EA,37.62,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.0576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pioglitazone 15 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342005410,NDC,1,EA,37.62,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.0576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Lactoferrin, Fecal; Qual",PX83630,CDM,300,RC,83630,CPT,,,,,,,,103,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,18.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.06,100.94
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037604,NDC,0.75,ML,36.86,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,12.26041667,percent of total billed charges,18.0614,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037604,NDC,0.75,ML,36.86,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.0614,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037604,NDC,0.75,ML,36.86,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,18.0614,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Flex Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707526,NDC,100,ML,37.63,,Health Partners,Health Partners Care Plans,both,48,,6.034333333,percent of total billed charges,18.0624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Flex Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707526,NDC,100,ML,37.63,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.0624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
dextrose 5 % 5 % Solution 50 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338055111,NDC,50,ML,43.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.0699,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 100 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001748,NDC,100,ML,43.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.0699,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,264763500,NDC,1000,ML,43.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.0699,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5% lactated ringers 5 % Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012504,NDC,1000,ML,43.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.0699,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329330201,NDC,25,ML,43.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.0699,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9 % 0.9 % Solution 50 mL Flex Cont,J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004941,NDC,50,ML,43.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.0699,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004941,NDC,250,ML,43.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.0699,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055311,NDC,250,ML,43.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.0699,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004948,NDC,300,ML,43.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.0699,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055318,NDC,300,ML,43.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.0699,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 150 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,409798361,NDC,300,ML,43.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.0699,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9% irrigation 0.9 % Solution 3,000 mL Plas Cont",25000000,CDM,250,RC,,,,,,338004727,NDC,3000,ML,43.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.0699,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9% IV LINE FLUSH 0.9% Solution 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,338004948,NDC,100,ML,43.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.0699,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Quantitation Drug Nos - Ref,PX8029990,CDM,300,RC,80299,CPT,90,,,,,,,112,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,18.08,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.08,18.64
Quantitation Drug Nos - Ref,PX8029990,CDM,300,RC,80299,CPT,90,,,,,,,112,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,18.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.08,18.64
Quantitation Drug Nos - Ref,PX8029990,CDM,300,RC,80299,CPT,90,,,,,,,112,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,18.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.08,18.64
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Syringe,J7040.01,CDM,636,RC,J7040,HCPCS,,,,64253020230,NDC,10,ML,42.15,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.08235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028426,NDC,1,EA,42.15,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.08235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,409710709,NDC,1000,ML,36.53,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,18.08235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5% and sodium chloride 0.45% with potassium chloride 10 mEq in 1000 mL 10-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,264763400,NDC,1000,ML,36.53,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,18.08235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
empagliflozin 25 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,597015330,NDC,0.4,EA,43.54,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.086516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
empagliflozin 25 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,597015337,NDC,0.4,EA,43.54,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.086516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DULoxetine 30 MG Capsule Delayed Release Particles 90 Each Bottle,63700001,CDM,250,RC,,,,,,57237001890,NDC,1,EA,42.17,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.09093,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin-clavulanate 500-125 MG Tablet 20 Each Bottle,63700001,CDM,250,RC,,,,,,16714047701,NDC,1,EA,20.33,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,18.0937,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 1 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409128303,NDC,1,ML,36.93,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,10.0725,percent of total billed charges,18.0957,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
HYDROmorphone 1 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409128303,NDC,1,ML,36.93,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.0957,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
HYDROmorphone 1 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409128303,NDC,1,ML,36.93,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,18.0957,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
"Chemotherapy, IV Infusion, Add'l Hour",PX96415,CDM,335,RC,96415,CPT,,,,,,,,191,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,18.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.1,48.28
"Chemotherapy, IV Infusion, Add'l Hour",PX96415,CDM,335,RC,96415,CPT,,,,,,,,191,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,18.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.1,48.28
"Chemotherapy, IV Infusion, Add'l Hour",PX96415,CDM,335,RC,96415,CPT,,,,,,,,191,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,18.1,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.1,48.28
Fac/Irrigation of Bladder,PX51700F,CDM,510,RC,51700,CPT,,,,,,,,358,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,18.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.1,159.11
Fac/Irrigation of Bladder,PX51700F,CDM,510,RC,51700,CPT,,,,,,,,358,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,18.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.1,159.11
"Remv F.B.,Eye,Superf Conjunc",PX65205F,CDM,510,RC,65205,CPT,,,,,,,,132,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,18.1,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.1,59.49
"Remv F.B.,Eye,Superf Conjunc",PX65205P,CDM,983,RC,65205,CPT,,,,,,,,132,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,18.1,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.1,129.36
Xray Sinuses Minimum 3 Vws,PX7022001,CDM,320,RC,70220,CPT,TC,,,,,,,354,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,18.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.88,53.91
Xray Sinuses Minimum 3 Vws,PX7022001,CDM,320,RC,70220,CPT,TC,,,,,,,354,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,18.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.88,53.91
Xray Skull Less Than 4 Vws,PX7025001,CDM,320,RC,70250,CPT,TC,,,,,,,311,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,18.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.88,53.91
Xray Skull Less Than 4 Vws,PX7025001,CDM,320,RC,70250,CPT,TC,,,,,,,311,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,18.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.88,53.91
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,55150023501,NDC,0.5,EA,37.72,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.1056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,55150023501,NDC,0.5,EA,37.72,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.1056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
celecoxib 200 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904650361,NDC,0.5,EA,20.35,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,18.1115,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Collagen Cross Links - Ref,PX8252390,CDM,300,RC,82523,CPT,90,,,,,,,170,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,18.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.12,18.68
Collagen Cross Links - Ref,PX8252390,CDM,300,RC,82523,CPT,90,,,,,,,170,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,18.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.12,18.68
Collagen Cross Links - Ref,PX8252390,CDM,300,RC,82523,CPT,90,,,,,,,170,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,18.12,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.12,18.68
neomycin-bacitracin-polymyxin 3.5-400-5000 Ointment 28 g Tube,25000000,CDM,250,RC,,,,,,45802014303,NDC,28,GR,37.76,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.1248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
neomycin-bacitracin-polymyxin 3.5-400-5000 Ointment 28 g Tube,25000000,CDM,250,RC,,,,,,45802014303,NDC,28,GR,37.76,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.1248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ePHEDrine sulfate 50 MG/ML Solution 1 mL Vial,25000000,CDM,250,RC,,,,,,42023021689,NDC,0.1,ML,36.62,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,18.1269,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
povidone-iodine 10 % Ointment 28.35 g Tube,63700001,CDM,250,RC,,,,,,904110231,NDC,28.35,GR,19.9,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,18.1289,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
COLLAR CERVICAL LARGE WITH TRACH 2 PIECE PHP-T4L,120.184,CDM,274,RC,L0172,HCPCS,,10142-MAIN,LOCAL,,,,,37,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,7.4,percent of total billed charges,18.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.3698,152.79
COLLAR CERVICAL LARGE WITH TRACH 2 PIECE PHP-T4L,120.184,CDM,274,RC,L0172,HCPCS,,10142-MAIN,LOCAL,,,,,37,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.3698,152.79
COLLAR CERVICAL LARGE WITH TRACH 2 PIECE PHP-T4L,120.184,CDM,274,RC,L0172,HCPCS,,10142-MAIN,LOCAL,,,,,37,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,18.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.3698,152.79
COLLAR CERVICAL MEDIUM WITH TRACH 2 PIECE PHP-T4M,120.183,CDM,274,RC,L0172,HCPCS,,10141-MAIN,LOCAL,,,,,37,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,7.4,percent of total billed charges,18.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.3698,152.79
COLLAR CERVICAL MEDIUM WITH TRACH 2 PIECE PHP-T4M,120.183,CDM,274,RC,L0172,HCPCS,,10141-MAIN,LOCAL,,,,,37,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.3698,152.79
COLLAR CERVICAL MEDIUM WITH TRACH 2 PIECE PHP-T4M,120.183,CDM,274,RC,L0172,HCPCS,,10141-MAIN,LOCAL,,,,,37,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,18.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.3698,152.79
COLLAR CERVICAL SMALL WITH TRACH 2 PIECE PHP-T4S,120.182,CDM,274,RC,L0172,HCPCS,,10140-MAIN,LOCAL,,,,,37,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,7.4,percent of total billed charges,18.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.3698,152.79
COLLAR CERVICAL SMALL WITH TRACH 2 PIECE PHP-T4S,120.182,CDM,274,RC,L0172,HCPCS,,10140-MAIN,LOCAL,,,,,37,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.3698,152.79
COLLAR CERVICAL SMALL WITH TRACH 2 PIECE PHP-T4S,120.182,CDM,274,RC,L0172,HCPCS,,10140-MAIN,LOCAL,,,,,37,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,18.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.3698,152.79
SUTURE TICRON 0 36IN BRAIDED DYED 1/2 CIRCLE DBLE ARM 25MM CV-305 BLUE STERILE,27200000,CDM,272,RC,,,,11956-MAIN,LOCAL,,,,,37,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE TICRON 0 36IN BRAIDED DYED 1/2 CIRCLE DBLE ARM 25MM CV-305 BLUE STERILE,27200000,CDM,272,RC,,,,11956-MAIN,LOCAL,,,,,37,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE TICRON 0 36IN BRAIDED DYED 1/2 CIRCLE DBLE ARM 25MM CV-305 BLUE STERILE,27200000,CDM,272,RC,,,,11956-MAIN,LOCAL,,,,,37,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,18.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
amiodarone 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,245014789,NDC,0.5,EA,21.33,,First Health,Commercial,both,85,,999999999,percent of total billed charges,18.1305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,245014701,NDC,0.5,EA,21.33,,First Health,Commercial,both,85,,999999999,percent of total billed charges,18.1305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,409163221,NDC,0.5,EA,43.65,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.13221,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
SUCTION TIP POOLE STERILE 35040,27200000,CDM,272,RC,,,,977-MAIN,LOCAL,,,,,42.28,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.13812,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Ebv, Viral Capsid Ab - Ref",PX8666590,CDM,300,RC,86665,CPT,90,,,,,,,58,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,18.14,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.6,18.14
Epstein-barr antibody,PX86665,CDM,300,RC,86665,CPT,,,,,,,,86,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,18.14,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.6,18.14
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490334,NDC,5,ML,42.29,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.14241,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
tetracycline 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,51991090701,NDC,0.5,EA,42.29,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.14241,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001103,NDC,1,EA,108.34,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,18.14388,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,18.45
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001104,NDC,1,EA,108.29,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,18.14388,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,18.45
hydrocortisone sodium succinate (preservative free) 250 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001305,NDC,1,EA,183.32,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,18.14388,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,18.45
hydrocortisone sodium succinate (preservative free) 500 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001612,NDC,1,EA,298.53,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,18.14388,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,18.45
hydrocortisone sodium succinate (preservative free) 1000 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9000501,NDC,1,EA,403.54,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,18.14388,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,18.45
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026994,NDC,20,ML,35.87,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.15022,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
famciclovir 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,60505324603,NDC,0.5,EA,18.65,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,18.152045,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143966001,NDC,5,ML,37.82,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.1536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143966001,NDC,5,ML,37.82,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.1536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143966010,NDC,5,ML,37.82,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.1536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143966010,NDC,5,ML,37.82,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.1536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,55150016205,NDC,5,ML,42.32,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.15528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"CUFF STERILE DISPOSABLE SPSB  STERILE 18""",27200000,CDM,272,RC,,,,7436-MAIN,LOCAL,,,,,35.89,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.16034,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,55150025110,NDC,10,ML,37.85,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,55150025110,NDC,10,ML,37.85,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
oxyBUTYnin ER 5 MG Tablet Extended Release 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,63739054833,NDC,1,EA,18.67,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,18.171511,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,17478004001,NDC,1,ML,42.39,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.18531,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078121,NDC,0.5,EA,36.75,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,18.19125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078141,NDC,0.5,EA,36.75,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,18.19125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
oxytocin 10 UNIT/ML Solution 1 mL Vial,J2590.01,CDM,636,RC,J2590,HCPCS,,,,42023011625,NDC,1,ML,43.8,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.19452,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.19452,42.924
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143978410,NDC,2,ML,37.91,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.1968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143978410,NDC,2,ML,37.91,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.1968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
cefaDROXil 500 MG capsule 50 Each Bottle,63700001,CDM,250,RC,,,,,,16714038801,NDC,1,EA,19.98,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,18.20178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049257,NDC,5,ML,42.43,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.20247,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Anes Dx Shoulder Arthroscopy,PX01622.01,CDM,964,RC,1622,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Lower Intestinal Endoscopic Px Nos,PX00811.01,CDM,964,RC,811,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Lower Intestinal Screening Colonoscopy,PX00812.01,CDM,964,RC,812,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Spine Transthor W/Vent,PX00626.01,CDM,964,RC,626,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Spine Tranthor W/O Vent,PX00625.01,CDM,964,RC,625,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Ther Interven Rad Art,PX01924.01,CDM,964,RC,1924,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Ther Interven Rad Car,PX01925.01,CDM,964,RC,1925,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Ther Interven Rad Tip,PX01931.01,CDM,964,RC,1931,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Ther Interven Rad Vei,PX01930.01,CDM,964,RC,1930,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Tx Interv Rad Cran V,PX01933.01,CDM,964,RC,1933,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Tx Interv Rad Hrt/Cran,PX01926.01,CDM,964,RC,1926,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Tx Interv Rad Th Vein,PX01932.01,CDM,964,RC,1932,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Upper GI Endoscopic Px Ercp,PX00732.01,CDM,964,RC,732,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Upper GI Endoscopic Px Nos,PX00731.01,CDM,964,RC,731,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Upper/Lower GI Endoscopic Px,PX00813.01,CDM,964,RC,813,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes/Analg Cs Deliver Add-On,PX01968.01,CDM,964,RC,1968,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Abdomen Vessel Surg,PX00880.01,CDM,964,RC,880,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Abdominal Wall Surg,PX00700.01,CDM,964,RC,700,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Abdominal Wall Surg,PX00730.01,CDM,964,RC,730,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Abdominal Wall Surg,PX00800.01,CDM,964,RC,800,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Abdominal Wall Surg,PX00820.01,CDM,964,RC,820,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Achilles Tendon Surg,PX01472.01,CDM,964,RC,1472,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Airplane Cast,PX01682.01,CDM,964,RC,1682,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Amniocentesis,PX00842.01,CDM,964,RC,842,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Amputation at Knee,PX01404.01,CDM,964,RC,1404,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Amputation at Pelvis,PX01140.01,CDM,964,RC,1140,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Amputation of Femur,PX01232.01,CDM,964,RC,1232,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Amputation of Penis,PX00932.01,CDM,964,RC,932,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Ankle Replacement,PX01486.01,CDM,964,RC,1486,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Ankle/Ft Arthroscopy,PX01464.01,CDM,964,RC,1464,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Anorectal Surgery,PX00902.01,CDM,964,RC,902,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Antepartum Manipul,PX01958.01,CDM,964,RC,1958,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Arm-Leg Vessel Surg,PX01656.01,CDM,964,RC,1656,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Arthroscopy of Hip,PX01202.01,CDM,964,RC,1202,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Biceps Tendon Repair,PX01716.01,CDM,964,RC,1716,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Biopsy of Nose,PX00164.01,CDM,964,RC,164,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Biopsy of Thyroid,PX00322.01,CDM,964,RC,322,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Bladder Stone Surg,PX00870.01,CDM,964,RC,870,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Bladder Surgery,PX00910.01,CDM,964,RC,910,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Bladder Tumor Surg,PX00912.01,CDM,964,RC,912,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Bleeding Control,PX00916.01,CDM,964,RC,916,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Blepharoplasty,PX00103.01,CDM,964,RC,103,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Blood Vessel Repair,PX00770.01,CDM,964,RC,770,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Body Cast Procedure,PX01130.01,CDM,964,RC,1130,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Bone Aspirate/Bx,PX01112.01,CDM,964,RC,1112,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Burn 4-9 Percent,PX01952.01,CDM,964,RC,1952,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Burn Each 9 Percent,PX01953.01,CDM,964,RC,1953,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Burn Less 4 Percent,PX01951.01,CDM,964,RC,1951,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cabg W/O Pump,PX00566.01,CDM,964,RC,566,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cabg W/Pump,PX00567.01,CDM,964,RC,567,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cardiac Electrophys,PX00537.01,CDM,964,RC,537,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cardioverter/Defib,PX00534.01,CDM,964,RC,534,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cat or MRI Scan,PX01922.01,CDM,964,RC,1922,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Catheterize Heart,PX01920.01,CDM,964,RC,1920,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Drainage,PX00524.01,CDM,964,RC,524,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Lining Biopsy,PX00522.01,CDM,964,RC,522,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Partition View,PX00528.01,CDM,964,RC,528,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Partition View,PX00529.01,CDM,964,RC,529,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Procedure,PX00520.01,CDM,964,RC,520,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Surgery,PX00540.01,CDM,964,RC,540,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Wall Repair,PX00472.01,CDM,964,RC,472,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cleft Palate Repair,PX00172.01,CDM,964,RC,172,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Collar Bone Biopsy,PX00454.01,CDM,964,RC,454,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Corneal Transplant,PX00144.01,CDM,964,RC,144,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Correct Heart Rhythm,PX00410.01,CDM,964,RC,410,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cran Surg Hemotoma,PX00211.01,CDM,964,RC,211,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cranial Surg Nos,PX00210.01,CDM,964,RC,210,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cs Delivery,PX01961.01,CDM,964,RC,1961,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cs Hysterectomy,PX01963.01,CDM,964,RC,1963,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Dx Arteriography,PX01916.01,CDM,964,RC,1916,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Dx Elbow Arthroscopy,PX01732.01,CDM,964,RC,1732,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Dx Knee Arthroscopy,PX01382.01,CDM,964,RC,1382,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Dx Wrist Arthroscopy,PX01829.01,CDM,964,RC,1829,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Ear Exam,PX00124.01,CDM,964,RC,124,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Ear Surgery,PX00120.01,CDM,964,RC,120,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Elbow Area Surgery,PX01710.01,CDM,964,RC,1710,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Elbow Replacement,PX01760.01,CDM,964,RC,1760,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Electroshock,PX00104.01,CDM,964,RC,104,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Emer Hysterectomy,PX01962.01,CDM,964,RC,1962,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Esophageal Surgery,PX00500.01,CDM,964,RC,500,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Eye Exam,PX00148.01,CDM,964,RC,148,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Face/Skull Bone Surg,PX00190.01,CDM,964,RC,190,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Facial Bone Surgery,PX00192.01,CDM,964,RC,192,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Fat Layer Removal,PX00802.01,CDM,964,RC,802,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Femoral Artery Surg,PX01272.01,CDM,964,RC,1272,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Femoral Embolectomy,PX01274.01,CDM,964,RC,1274,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth for Chemonucleolysis,PX00634.01,CDM,964,RC,634,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth for Liver Biopsy,PX00702.01,CDM,964,RC,702,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth for Liver Transplant,PX00796.01,CDM,964,RC,796,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Forequarter Amput,PX01636.01,CDM,964,RC,1636,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Fx Repair Pelvis,PX01173.01,CDM,964,RC,1173,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Genitalia Surgery,PX00920.01,CDM,964,RC,920,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Head Nerve Surgery,PX00222.01,CDM,964,RC,222,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Head Vessel Surgery,PX00216.01,CDM,964,RC,216,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Head/Neck/Ptrunk,PX00300.01,CDM,964,RC,300,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Heart Surg < 1 Yr,PX00561.01,CDM,964,RC,561,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Heart Surg W/Arrest,PX00563.01,CDM,964,RC,563,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Heart Surg W/O Pump,PX00560.01,CDM,964,RC,560,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Heart/Lung Transplnt,PX00580.01,CDM,964,RC,580,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hemorr/Excise Liver,PX00792.01,CDM,964,RC,792,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hernia Repair < 1 Yr,PX00834.01,CDM,964,RC,834,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hernia Repair Preemie,PX00836.01,CDM,964,RC,836,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hip Arthroplasty,PX01214.01,CDM,964,RC,1214,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hip Disarticulation,PX01212.01,CDM,964,RC,1212,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hip Joint Procedure,PX01200.01,CDM,964,RC,1200,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hip Joint Surgery,PX01210.01,CDM,964,RC,1210,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hrt Surg W/Pmp Age 1+,PX00562.01,CDM,964,RC,562,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Humeral Lesion Surg,PX01758.01,CDM,964,RC,1758,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Humerus Repair,PX01744.01,CDM,964,RC,1744,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Humerus Surgery,PX01742.01,CDM,964,RC,1742,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hysterectomy,PX00846.01,CDM,964,RC,846,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hysteroscope/Graph,PX00952.01,CDM,964,RC,952,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Inc/Missed Ab Proc,PX01965.01,CDM,964,RC,1965,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Induced Ab Procedure,PX01966.01,CDM,964,RC,1966,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Insert Penis Device,PX00938.01,CDM,964,RC,938,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Intrcrn Nerve,PX00220.01,CDM,964,RC,220,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Iridectomy,PX00147.01,CDM,964,RC,147,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Kidney Stone Destruct,PX00872.01,CDM,964,RC,872,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Kidney Stone Destruct,PX00873.01,CDM,964,RC,873,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Kidney Transplant,PX00868.01,CDM,964,RC,868,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Kidney/Ureter Surg,PX00862.01,CDM,964,RC,862,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Area Procedure,PX01340.01,CDM,964,RC,1340,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Area Procedure,PX01390.01,CDM,964,RC,1390,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Area Surgery,PX01320.01,CDM,964,RC,1320,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Area Surgery,PX01360.01,CDM,964,RC,1360,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Area Surgery,PX01392.01,CDM,964,RC,1392,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Arteries Surg,PX01440.01,CDM,964,RC,1440,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Artery Repair,PX01444.01,CDM,964,RC,1444,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Artery Surg,PX01442.01,CDM,964,RC,1442,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Arthroplasty,PX01402.01,CDM,964,RC,1402,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Joint Casting,PX01420.01,CDM,964,RC,1420,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Joint Procedure,PX01380.01,CDM,964,RC,1380,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Joint Surgery,PX01400.01,CDM,964,RC,1400,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Veins Surgery,PX01430.01,CDM,964,RC,1430,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Vessel Surg,PX01432.01,CDM,964,RC,1432,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Larynx/Trach < 1 Yr,PX00326.01,CDM,964,RC,326,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Leg Arteries Surg,PX01500.01,CDM,964,RC,1500,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lens Surgery,PX00142.01,CDM,964,RC,142,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Low Intestine Scope,PX00810.01,CDM,964,RC,810,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Arm Casting,PX01860.01,CDM,964,RC,1860,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Arm Procedure,PX01820.01,CDM,964,RC,1820,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Arm Surgery,PX01810.01,CDM,964,RC,1810,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Arm Surgery,PX01830.01,CDM,964,RC,1830,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Arm Vein Surg,PX01850.01,CDM,964,RC,1850,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Bone Surg,PX01480.01,CDM,964,RC,1480,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Casting,PX01490.01,CDM,964,RC,1490,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Procedure,PX01462.01,CDM,964,RC,1462,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Revision,PX01484.01,CDM,964,RC,1484,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Surgery,PX01470.01,CDM,964,RC,1470,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Surgery,PX01474.01,CDM,964,RC,1474,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Vein Surg,PX01520.01,CDM,964,RC,1520,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Vein Surg,PX01522.01,CDM,964,RC,1522,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lumbar Puncture,PX00635.01,CDM,964,RC,635,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lung Chest Wall Surg,PX00546.01,CDM,964,RC,546,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lwr Arm Artery Surg,PX01840.01,CDM,964,RC,1840,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lwr Arm Embolectomy,PX01842.01,CDM,964,RC,1842,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lwr Arm Vein Repair,PX01852.01,CDM,964,RC,1852,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lwr Leg Embolectomy,PX01502.01,CDM,964,RC,1502,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Major Vein Ligation,PX00882.01,CDM,964,RC,882,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth N Block/Inj Prone,PX01992.01,CDM,964,RC,1992,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Neck Organ 1 & Over,PX00320.01,CDM,964,RC,320,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Neck Vessel Surgery,PX00350.01,CDM,964,RC,350,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Neck Vessel Surgery,PX00352.01,CDM,964,RC,352,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Nerve Block/Inj,PX01991.01,CDM,964,RC,1991,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Nose/Sinus Surgery,PX00160.01,CDM,964,RC,160,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Nose/Sinus Surgery,PX00162.01,CDM,964,RC,162,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth One Lung Ventilation,PX00541.01,CDM,964,RC,541,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pacemaker Insertion,PX00530.01,CDM,964,RC,530,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pancreas Removal,PX00794.01,CDM,964,RC,794,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvic Organ Surg,PX00848.01,CDM,964,RC,848,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvic Tumor Surgery,PX01150.01,CDM,964,RC,1150,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvis Nerve Removal,PX01180.01,CDM,964,RC,1180,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvis Nerve Removal,PX01190.01,CDM,964,RC,1190,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvis Procedure,PX01160.01,CDM,964,RC,1160,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvis Surgery,PX00844.01,CDM,964,RC,844,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvis Surgery,PX01120.01,CDM,964,RC,1120,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvis Surgery,PX01170.01,CDM,964,RC,1170,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Penis Nodes Removal,PX00934.01,CDM,964,RC,934,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Penis Nodes Removal,PX00936.01,CDM,964,RC,936,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Perc Img Dx Sp Proc,PX01935.01,CDM,964,RC,1935,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Perc Img Tx Sp Proc,PX01936.01,CDM,964,RC,1936,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Perineal Surgery,PX00904.01,CDM,964,RC,904,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pharyngeal Surgery,PX00174.01,CDM,964,RC,174,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pharyngeal Surgery,PX00176.01,CDM,964,RC,176,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Procedure on Femur,PX01220.01,CDM,964,RC,1220,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Procedure on Mouth,PX00170.01,CDM,964,RC,170,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Procedures on Eye,PX00140.01,CDM,964,RC,140,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Radical Femur Surg,PX01234.01,CDM,964,RC,1234,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Radical Humerus Surg,PX01756.01,CDM,964,RC,1756,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Radical Leg Surgery,PX01482.01,CDM,964,RC,1482,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Release of Lung,PX00542.01,CDM,964,RC,542,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Adrenal,PX00866.01,CDM,964,RC,866,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Bladder,PX00864.01,CDM,964,RC,864,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Nerves,PX00622.01,CDM,964,RC,622,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Nerves,PX00632.01,CDM,964,RC,632,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Prostate,PX00865.01,CDM,964,RC,865,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Prostate,PX00908.01,CDM,964,RC,908,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Rib,PX00470.01,CDM,964,RC,470,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Testis,PX00926.01,CDM,964,RC,926,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Testis,PX00928.01,CDM,964,RC,928,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Vulva,PX00906.01,CDM,964,RC,906,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Cervix,PX00948.01,CDM,964,RC,948,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Cleft Lip,PX00102.01,CDM,964,RC,102,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Hernia,PX00750.01,CDM,964,RC,750,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Hernia,PX00752.01,CDM,964,RC,752,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Hernia,PX00754.01,CDM,964,RC,754,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Hernia,PX00756.01,CDM,964,RC,756,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Hernia,PX00830.01,CDM,964,RC,830,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Hernia,PX00832.01,CDM,964,RC,832,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Revise Hip Repair,PX01215.01,CDM,964,RC,1215,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Salivary Gland,PX00100.01,CDM,964,RC,100,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Artery Surg,PX01650.01,CDM,964,RC,1650,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Casting,PX01680.01,CDM,964,RC,1680,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Joint Amput,PX01634.01,CDM,964,RC,1634,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Procedure,PX01620.01,CDM,964,RC,1620,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Replacement,PX01638.01,CDM,964,RC,1638,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Vein Surg,PX01670.01,CDM,964,RC,1670,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Vessel Surg,PX01652.01,CDM,964,RC,1652,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Vessel Surg,PX01654.01,CDM,964,RC,1654,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Sitting Procedure,PX00604.01,CDM,964,RC,604,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Skin Ext/per/Atrunk,PX00400.01,CDM,964,RC,400,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Skull Drainage,PX00212.01,CDM,964,RC,212,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Skull Drainage,PX00214.01,CDM,964,RC,214,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Skull Repair/Fract,PX00215.01,CDM,964,RC,215,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Special Head Surgery,PX00218.01,CDM,964,RC,218,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Sperm Duct Surgery,PX00922.01,CDM,964,RC,922,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Spine Cord Surgery,PX00600.01,CDM,964,RC,600,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Spine Cord Surgery,PX00620.01,CDM,964,RC,620,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Spine Cord Surgery,PX00630.01,CDM,964,RC,630,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Spine Cord Surgery,PX00670.01,CDM,964,RC,670,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Spine Manipulation,PX00640.01,CDM,964,RC,640,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Sternal Debridement,PX00550.01,CDM,964,RC,550,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Stone Removal,PX00918.01,CDM,964,RC,918,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surg Lower Abdomen,PX00840.01,CDM,964,RC,840,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surg on Vag/Urethral,PX00942.01,CDM,964,RC,942,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surg Upper Abdomen,PX00790.01,CDM,964,RC,790,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery for Obesity,PX00797.01,CDM,964,RC,797,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Abdomen,PX00860.01,CDM,964,RC,860,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Breast,PX00402.01,CDM,964,RC,402,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Breast,PX00404.01,CDM,964,RC,404,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Breast,PX00406.01,CDM,964,RC,406,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Femur,PX01230.01,CDM,964,RC,1230,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Rib(S),PX00474.01,CDM,964,RC,474,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Shoulder,PX00450.01,CDM,964,RC,450,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Shoulder,PX00452.01,CDM,964,RC,452,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Shoulder,PX01610.01,CDM,964,RC,1610,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Shoulder,PX01630.01,CDM,964,RC,1630,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Testis Exploration,PX00924.01,CDM,964,RC,924,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Testis Suspension,PX00930.01,CDM,964,RC,930,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Thigh Arteries Surg,PX01270.01,CDM,964,RC,1270,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Trach-Bronch Reconst,PX00539.01,CDM,964,RC,539,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Trachea Bronchi Surg,PX00548.01,CDM,964,RC,548,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Trans Resect of Prostate,PX00914.01,CDM,964,RC,914,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Tubal Ligation,PX00851.01,CDM,964,RC,851,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Tympanotomy,PX00126.01,CDM,964,RC,126,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Upper Arm Surgery,PX01740.01,CDM,964,RC,1740,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Upper Arm Vein Surg,PX01780.01,CDM,964,RC,1780,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Upper GI Visualize,PX00740.01,CDM,964,RC,740,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Upper Leg Surgery,PX01250.01,CDM,964,RC,1250,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Upper Leg Veins Surg,PX01260.01,CDM,964,RC,1260,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Uppr Arm Artery Surg,PX01770.01,CDM,964,RC,1770,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Uppr Arm Embolectomy,PX01772.01,CDM,964,RC,1772,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Uppr Arm Procedure,PX01730.01,CDM,964,RC,1730,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Uppr Arm Tendon Surg,PX01712.01,CDM,964,RC,1712,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Uppr Arm Tendon Surg,PX01714.01,CDM,964,RC,1714,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Uppr Arm Vein Repair,PX01782.01,CDM,964,RC,1782,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vaginal Delivery,PX01960.01,CDM,964,RC,1960,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vaginal Endoscopy,PX00950.01,CDM,964,RC,950,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vaginal Hysterectomy,PX00944.01,CDM,964,RC,944,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vaginal Procedures,PX00940.01,CDM,964,RC,940,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vascular Access,PX00532.01,CDM,964,RC,532,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vascular Shunt Surg,PX01844.01,CDM,964,RC,1844,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vasectomy,PX00921.01,CDM,964,RC,921,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vitreoretinal Surg,PX00145.01,CDM,964,RC,145,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Wrist Replacement,PX01832.01,CDM,964,RC,1832,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth/Analg Cs Hyst Add-On,PX01969.01,CDM,964,RC,1969,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth/Analg Vag Delivery,PX01967.01,CDM,964,RC,1967,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Hosp Manage Cont Drug Admin,PX01996.01,CDM,964,RC,1996,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
IMMOBILIZER SHOULDER LARGE 9008-03,120.38,CDM,274,RC,L3650,HCPCS,,906-MAIN,LOCAL,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER LARGE STRAP OSG3033,120.38,CDM,274,RC,L3650,HCPCS,,2910-MAIN,LOCAL,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER MEDIUM 9008-02,120.38,CDM,274,RC,L3650,HCPCS,,912-MAIN,LOCAL,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER MEDIUM OSG3032,120.38,CDM,274,RC,L3650,HCPCS,,915-MAIN,LOCAL,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER SMALL 9008-01,120.38,CDM,274,RC,L3650,HCPCS,,913-MAIN,LOCAL,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER SMALL WITH CLOTH 9001-02,120.38,CDM,274,RC,L3650,HCPCS,,914-MAIN,LOCAL,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER X-LARGE CLOTH 9001-05,120.38,CDM,274,RC,L3650,HCPCS,,917-MAIN,LOCAL,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER X-LARGE ORT16100XL,120.38,CDM,274,RC,L3650,HCPCS,,904-MAIN,LOCAL,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
Support for Organ Donor,PX01990.01,CDM,964,RC,1990,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Treponema Pallidum,PX86780,CDM,300,RC,86780,CPT,,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.14,35.28
Unlisted Anesth Procedure,PX01999.01,CDM,964,RC,1999,CPT,QZ,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405P,CDM,983,RC,36405,CPT,,,,,,,,36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
bacitracin zinc 500 UNIT/GM Ointment 28.4 g Tube,25000000,CDM,250,RC,,,,,,49348015472,NDC,28.4,GR,20.47,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,18.2183,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Bacterium Nos, Antibody - Ref",PX8660990,CDM,300,RC,86609,CPT,90,,,,,,,20,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,18.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
DRESSING QWICK NONADHESIVE 4.25X4 SUPERABSORBENT MSC5844,120.531,CDM,272,RC,A6197,HCPCS,,12301-MAIN,LOCAL,,,,,20,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,18.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
Glucose Blood Test,PX82962,CDM,300,RC,82962,CPT,,,,,,,,20,,Medica,Commercial,both,91.1,,1.458,percent of total billed charges,18.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.01,19.6
Phenobarbital Assay - Ref,PX8018490,CDM,300,RC,80184,CPT,90,,,,,,,20,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,18.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
Primidone Assay - Ref,PX8018890,CDM,300,RC,80188,CPT,90,,,,,,,20,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,18.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER  STRAIGHT TAPER TIP 20FR PVC,120.528,CDM,272,RC,,,,12247-MAIN,LOCAL,,,,,20,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,18.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER  STRAIGHT TAPER TIP 24FR PVC,120.528,CDM,272,RC,,,,12248-MAIN,LOCAL,,,,,20,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,18.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 8FR PVC,120.528,CDM,272,RC,,,,12253-MAIN,LOCAL,,,,,20,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,18.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 10FR PVC,120.528,CDM,272,RC,,,,12254-MAIN,LOCAL,,,,,20,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,18.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 12FR PVC,120.528,CDM,272,RC,,,,12255-MAIN,LOCAL,,,,,20,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,18.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 16FR PVC,120.528,CDM,272,RC,,,,12256-MAIN,LOCAL,,,,,20,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,18.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 28FR PVC,120.528,CDM,272,RC,,,,12249-MAIN,LOCAL,,,,,20,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,18.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 32FR PVC,120.528,CDM,272,RC,,,,12250-MAIN,LOCAL,,,,,20,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,18.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 36FR PVC,120.528,CDM,272,RC,,,,12251-MAIN,LOCAL,,,,,20,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,18.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
Assay of Erythropoietin,PX82668,CDM,300,RC,82668,CPT,,,,,,,,114,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,18.23,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.23,18.79
Assay of Erythropoietin,PX82668,CDM,300,RC,82668,CPT,,,,,,,,114,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,18.23,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.23,18.79
Assay of Erythropoietin,PX82668,CDM,300,RC,82668,CPT,,,,,,,,114,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,18.23,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.23,18.79
Erythropietin - Ref,PX8266890,CDM,300,RC,82668,CPT,90,,,,,,,108,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,18.23,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.23,18.79
Erythropietin - Ref,PX8266890,CDM,300,RC,82668,CPT,90,,,,,,,108,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,18.23,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.23,18.79
Erythropietin - Ref,PX8266890,CDM,300,RC,82668,CPT,90,,,,,,,108,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,18.23,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.23,18.79
ketorolac 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314012605,NDC,5,ML,42.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.2325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
8MM-12MM CANNULA SEAL 5-8MM,27200000,CDM,272,RC,,,,11921-MAIN,LOCAL,,,,,38,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM-12MM CANNULA SEAL 5-8MM,27200000,CDM,272,RC,,,,11921-MAIN,LOCAL,,,,,38,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRAPE COLUMN 470341,27200000,CDM,272,RC,,,,12013-MAIN,LOCAL,,,,,38,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRAPE COLUMN 470341,27200000,CDM,272,RC,,,,12013-MAIN,LOCAL,,,,,38,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HH Hha Visit,PXG0156,CDM,571,RC,G0156,HCPCS,,,,,,,,38,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
HH Hha Visit,PXG0156,CDM,571,RC,G0156,HCPCS,,,,,,,,38,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
Mitochondrial Antibody Each,PX8638190,CDM,300,RC,86381,CPT,90,,,,,,,38,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
Mitochondrial Antibody Each,PX8638190,CDM,300,RC,86381,CPT,90,,,,,,,38,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
Nasal Sm for Eos,PX89190,CDM,300,RC,89190,CPT,,,,,,,,38,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.31,37.24
Nasal Sm for Eos,PX89190,CDM,300,RC,89190,CPT,,,,,,,,38,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.31,37.24
NEEDLE IV 19GA X .75IN HUBER POWERLOC SAFETY 0651934,120.85,CDM,272,RC,A4215,HCPCS,,12701-MAIN,LOCAL,,,,,38,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
NEEDLE IV 19GA X .75IN HUBER POWERLOC SAFETY 0651934,120.85,CDM,272,RC,A4215,HCPCS,,12701-MAIN,LOCAL,,,,,38,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
NEEDLE IV 19GA X 1 IN HUBER POWERLOC SAFETY 0651910,120.85,CDM,272,RC,A4215,HCPCS,,12702-MAIN,LOCAL,,,,,38,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
NEEDLE IV 19GA X 1 IN HUBER POWERLOC SAFETY 0651910,120.85,CDM,272,RC,A4215,HCPCS,,12702-MAIN,LOCAL,,,,,38,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
NEEDLE IV 19GA X 1.5 IN HUBER POWERLOC SAFETY 0651915,120.85,CDM,272,RC,A4215,HCPCS,,12703-MAIN,LOCAL,,,,,38,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
NEEDLE IV 19GA X 1.5 IN HUBER POWERLOC SAFETY 0651915,120.85,CDM,272,RC,A4215,HCPCS,,12703-MAIN,LOCAL,,,,,38,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
PEZZER CATHETER DRAIN LATEX 14FR,27200000,CDM,272,RC,,,,12053-MAIN,LOCAL,,,,,38,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PEZZER CATHETER DRAIN LATEX 14FR,27200000,CDM,272,RC,,,,12053-MAIN,LOCAL,,,,,38,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PEZZER LATEX CATHETER DRAIN 10FR,27200000,CDM,272,RC,,,,12646-MAIN,LOCAL,,,,,38,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PEZZER LATEX CATHETER DRAIN 10FR,27200000,CDM,272,RC,,,,12646-MAIN,LOCAL,,,,,38,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PNEUVIEW SMOKE ELIMINATOR,27200000,CDM,272,RC,,,,11884-MAIN,LOCAL,,,,,38,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PNEUVIEW SMOKE ELIMINATOR,27200000,CDM,272,RC,,,,11884-MAIN,LOCAL,,,,,38,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Psa, Free - Ref",PX8415490,CDM,300,RC,84154,CPT,90,,,,,,,38,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
"Psa, Free - Ref",PX8415490,CDM,300,RC,84154,CPT,90,,,,,,,38,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
"Psa, Total - Ref",PX8415390,CDM,300,RC,84153,CPT,90,,,,,,,38,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
"Psa, Total - Ref",PX8415390,CDM,300,RC,84153,CPT,90,,,,,,,38,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
SPECULUM VAGINAL WITH BUILT IN LIGHT LARGE,120.133,CDM,272,RC,,,,8251-MAIN,LOCAL,,,,,38,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
SPECULUM VAGINAL WITH BUILT IN LIGHT LARGE,120.133,CDM,272,RC,,,,8251-MAIN,LOCAL,,,,,38,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
SPECULUM VAGINAL WITH BUILT IN LIGHT MEDIUM,120.133,CDM,272,RC,,,,8250-MAIN,LOCAL,,,,,38,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
SPECULUM VAGINAL WITH BUILT IN LIGHT MEDIUM,120.133,CDM,272,RC,,,,8250-MAIN,LOCAL,,,,,38,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
SPECULUM VAGINAL WITH BUILT IN LIGHT SMALL,120.133,CDM,272,RC,,,,8249-MAIN,LOCAL,,,,,38,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
SPECULUM VAGINAL WITH BUILT IN LIGHT SMALL,120.133,CDM,272,RC,,,,8249-MAIN,LOCAL,,,,,38,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
TROCAR KII FIOS SYSTEM BLADELSS Z-THREAD 5MMX100MM,27200000,CDM,272,RC,,,,12003-MAIN,LOCAL,,,,,38,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR KII FIOS SYSTEM BLADELSS Z-THREAD 5MMX100MM,27200000,CDM,272,RC,,,,12003-MAIN,LOCAL,,,,,38,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
QUEtiapine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54022020,NDC,1,EA,21.46,,First Health,Commercial,both,85,,999999999,percent of total billed charges,18.241,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037604,NDC,0.75,ML,36.86,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,18.2457,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
mycophenolate 500 MG Tablet 100 Each Bottle,J7517.01,CDM,637,RC,J7517,HCPCS,,,,64380072506,NDC,1,EA,42.56,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.25824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.679424,41.7088
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070948,NDC,100,ML,42.59,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.27111,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,67457043800,NDC,0.5,EA,36.11,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.27166,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,67457043810,NDC,0.5,EA,36.11,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.27166,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028036,NDC,2,ML,36.12,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.27672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
famciclovir 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,60505324603,NDC,0.5,EA,18.65,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,18.277,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CANNULA ADULT LARGE OPTIFLOW OPT946,120.495,CDM,271,RC,A4615,HCPCS,,11622-MAIN,LOCAL,,,,,44,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.2776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
CANNULA ADULT MEDIUM OPTIFLOW OPT944,120.495,CDM,271,RC,A4615,HCPCS,,11621-MAIN,LOCAL,,,,,44,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.2776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
CANNULA ADULT SMALL OPTIFLOW OPT942,120.495,CDM,271,RC,A4615,HCPCS,,11620-MAIN,LOCAL,,,,,44,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.2776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
Homocysteine,PX83090,CDM,300,RC,83090,CPT,,,,,,,,44,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.2776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.43,43.12
KIT GASTRIC LAVAGE 2075,120.257,CDM,272,RC,C7510,HCPCS,,410-MAIN,LOCAL,,,,,44,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.2776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
SUTURE V-LOC 1/2 CIRCLE NEEDLE WOUND CLOSURE DEVICE VLOCN0306,27200000,CDM,272,RC,,,,11931-MAIN,LOCAL,,,,,44,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.2776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE V-LOC SZ 3-0 180 GREEN V-20 9 INCH VLOCL0644,27200000,CDM,272,RC,,,,13056-SURG,LOCAL,,,,,44,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.2776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Somatostatin - Ref,PX8430790,CDM,300,RC,84307,CPT,90,,,,,,,325,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,18.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.73,18.28
HYDROmorphone 1 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409128303,NDC,1,ML,36.93,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,18.28035,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323020103,NDC,10,ML,36.14,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.28684,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sulfamethoxazole-trimethoprim 200-40 MG/5ML Suspension 473 mL Bottle,63700001,CDM,250,RC,,,,,,65862049647,NDC,10,ML,18.79,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,18.288307,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of Erythropoietin,PX82668,CDM,300,RC,82668,CPT,,,,,,,,114,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,18.2913,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.23,18.79
Collagen Cross Links - Ref,PX8252390,CDM,300,RC,82523,CPT,90,,,,,,,170,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,18.2913,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.12,18.68
Cystatin C - Ref,PX8261090,CDM,300,RC,82610,CPT,90,,,,,,,130,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,18.2913,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.96,18.52
Erythropietin - Ref,PX8266890,CDM,300,RC,82668,CPT,90,,,,,,,108,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,18.2913,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.23,18.79
Gonadotropin (Lh),PX83002,CDM,300,RC,83002,CPT,,,,,,,,28,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,18.2913,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.69,18.52
Quantitation Drug Nos - Ref,PX8029990,CDM,300,RC,80299,CPT,90,,,,,,,112,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,18.2913,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.08,18.64
oxyBUTYnin ER 5 MG Tablet Extended Release 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,63739054833,NDC,1,EA,18.67,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,18.2966,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,63323041536,NDC,0.5,ML,44.05,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.29837,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
venlafaxine 37.5 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084069811,NDC,1,EA,20.09,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,18.30199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 37.5 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084069801,NDC,1,EA,20.09,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,18.30199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
colchicine 0.6 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,49884017111,NDC,1,EA,36.17,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.30202,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253022233,NDC,3,ML,38.13,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.3024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253022233,NDC,3,ML,38.13,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.3024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
Strapping of Hand or Finger,PX29280F,CDM,420,RC,29280,CPT,,,,,,,,64,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,18.3027,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.21,62.26
COLLAR CERVICAL LARGE WITH TRACH 2 PIECE PHP-T4L,120.184,CDM,274,RC,L0172,HCPCS,,10142-MAIN,LOCAL,,,,,37,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,18.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.3698,152.79
COLLAR CERVICAL MEDIUM WITH TRACH 2 PIECE PHP-T4M,120.183,CDM,274,RC,L0172,HCPCS,,10141-MAIN,LOCAL,,,,,37,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,18.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.3698,152.79
COLLAR CERVICAL SMALL WITH TRACH 2 PIECE PHP-T4S,120.182,CDM,274,RC,L0172,HCPCS,,10140-MAIN,LOCAL,,,,,37,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,18.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.3698,152.79
SUTURE TICRON 0 36IN BRAIDED DYED 1/2 CIRCLE DBLE ARM 25MM CV-305 BLUE STERILE,27200000,CDM,272,RC,,,,11956-MAIN,LOCAL,,,,,37,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,18.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
leflunomide 20 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,70748013006,NDC,0.5,EA,44.1,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.31914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Draw Blood Off Venous Device,PX36591F,CDM,510,RC,36591,CPT,,,,,,,,211,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,18.32,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.45,57.42
Draw Blood Off Venous Device,PX36591F,CDM,510,RC,36591,CPT,,,,,,,,211,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,18.32,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.45,57.42
Fac/Irrigation of Bladder,PX51700F,CDM,510,RC,51700,CPT,,,,,,,,358,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,18.32,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.1,159.11
Fluoroscope Examination Tc,PX7600001,CDM,320,RC,76000,CPT,TC,,,,,,,597,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,18.32,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.32,55.22
"Remv F.B.,Eye,Superf Conjunc",PX65205F,CDM,510,RC,65205,CPT,,,,,,,,132,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,18.32,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.1,59.49
"Remv F.B.,Eye,Superf Conjunc",PX65205F,CDM,510,RC,65205,CPT,,,,,,,,132,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,18.32,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.1,59.49
"Remv F.B.,Eye,Superf Conjunc",PX65205P,CDM,983,RC,65205,CPT,,,,,,,,132,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,18.32,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.1,129.36
"Remv F.B.,Eye,Superf Conjunc",PX65205P,CDM,983,RC,65205,CPT,,,,,,,,132,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,18.32,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.1,129.36
US Guide Needle Bx S&I,PX7694201,CDM,402,RC,76942,CPT,TC,,,,,,,747,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,18.32,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.32,55.88
HYDROmorphone 2 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409131203,NDC,1,ML,38.18,,Health Partners,Health Partners Care Plans,both,48,,25.36411765,percent of total billed charges,18.3264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
HYDROmorphone 2 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409131203,NDC,1,ML,38.18,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.3264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
DIMETHICONE (TOPICAL) 5 % Cream 118 mL Tube,800000,CDM,,,,,,,,53329015104,NDC,118,ML,44.12,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.327448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
phenol-glycerin 1.5-33 % Liquid 118 mL Bottle,25000000,CDM,250,RC,,,,,,78112000068,NDC,118,ML,44.12,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.327448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pancrelipase (lip-prot-amyl) 24000-76000 units Capsule Delayed Release Particles 100 Each Bottle,63700001,CDM,250,RC,,,,,,32122401,NDC,1,EA,37.41,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.3309,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pancrelipase (lip-prot-amyl) 24000-76000 units Capsule Delayed Release Particles 100 Each Bottle,63700001,CDM,250,RC,,,,,,32122401,NDC,1,EA,37.41,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.3309,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pancrelipase (lip-prot-amyl) 24000-76000 units Capsule Delayed Release Particles 100 Each Bottle,63700001,CDM,250,RC,,,,,,32122401,NDC,1,EA,37.41,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,18.3309,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"dextran 70, glycerin, hypromellose 0.1-0.2-0.3 % Solution 15 mL Bottle",63700001,CDM,250,RC,,,,,,65042636,NDC,15,ML,44.14,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.335756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Lab Imm Spin X-Match,PX8837,CDM,300,RC,86920,CPT,,,,,,,,402,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,18.35,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.35,30.816
Lab Imm Spin X-Match,PX8837,CDM,300,RC,86920,CPT,,,,,,,,402,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,18.35,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.35,30.816
Lab Imm Spin X-Match,PX8837,CDM,300,RC,86920,CPT,,,,,,,,402,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,18.35,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.35,30.816
rosuvastatin 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003001,NDC,0.5,EA,21.59,,First Health,Commercial,both,85,,999999999,percent of total billed charges,18.3515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BIOPSY FORCEPS HOT,27200000,CDM,272,RC,,,,4353-MAIN,LOCAL,,,,,38.25,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
BIOPSY FORCEPS HOT,27200000,CDM,272,RC,,,,4353-MAIN,LOCAL,,,,,38.25,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRESSING GEL FOAM SIZE 100SPONGE STERILE 00009034201,27200000,CDM,272,RC,A6248,HCPCS,,3378-MAIN,LOCAL,,,,,38.25,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRESSING GEL FOAM SIZE 100SPONGE STERILE 00009034201,27200000,CDM,272,RC,A6248,HCPCS,,3378-MAIN,LOCAL,,,,,38.25,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFFLATION TUBING SET,27200000,CDM,272,RC,,,,4686-MAIN,LOCAL,,,,,38.25,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFFLATION TUBING SET,27200000,CDM,272,RC,,,,4686-MAIN,LOCAL,,,,,38.25,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
levETIRAcetam 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079082101,NDC,1,EA,18.87,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,18.366171,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Platelet Antibodies - Ref,PX8602290,CDM,300,RC,86022,CPT,90,,,,,,,245,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,18.37,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.82,18.37
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022143,NDC,1,EA,36.31,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.37286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
"CUFF STERILE DISPOSABLE SPSB 24""",27200000,CDM,272,RC,,,,7437-MAIN,LOCAL,,,,,37.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"CUFF STERILE DISPOSABLE SPSB 24""",27200000,CDM,272,RC,,,,7437-MAIN,LOCAL,,,,,37.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"CUFF STERILE DISPOSABLE SPSB 24""",27200000,CDM,272,RC,,,,7437-MAIN,LOCAL,,,,,37.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,18.375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ENDOCAVITY NEEDLE GUIDE,27200000,CDM,272,RC,,,,11134-MAIN,LOCAL,,,,,37.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ENDOCAVITY NEEDLE GUIDE,27200000,CDM,272,RC,,,,11134-MAIN,LOCAL,,,,,37.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ENDOCAVITY NEEDLE GUIDE,27200000,CDM,272,RC,,,,11134-MAIN,LOCAL,,,,,37.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,18.375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR KII BALOON 5X100MM STERILE,27200000,CDM,272,RC,,,,11701-MAIN,LOCAL,,,,,37.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR KII BALOON 5X100MM STERILE,27200000,CDM,272,RC,,,,11701-MAIN,LOCAL,,,,,37.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR KII BALOON 5X100MM STERILE,27200000,CDM,272,RC,,,,11701-MAIN,LOCAL,,,,,37.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,18.375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,143957501,NDC,50,ML,44.24,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.377296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,143957510,NDC,50,ML,44.24,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.377296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Candida Dna Dir Probe,PX87480,CDM,300,RC,87480,CPT,,,,,,,,127,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,18.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.38,124.46
Gardner Vag Dna Dir Probe,PX87510,CDM,300,RC,87510,CPT,,,,,,,,127,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,18.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.38,124.46
Trichomonas Vagin Dir Probe,PX87660,CDM,300,RC,87660,CPT,,,,,,,,127,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,18.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.38,124.46
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022116,NDC,1,EA,36.33,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.38298,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022141,NDC,1,EA,36.33,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.38298,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
Assay of Psa Total,PX84153,CDM,300,RC,84153,CPT,,,,,,,,157,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,18.39,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.84,18.39
Carcinoembryonic Antigen,PX82378,CDM,300,RC,82378,CPT,,,,,,,,25,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,18.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.39,18.96
Carcinoembryonic Antigen,PX82378,CDM,300,RC,82378,CPT,,,,,,,,25,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,18.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.39,18.96
Carcinoembryonic Antigen,PX82378,CDM,300,RC,82378,CPT,,,,,,,,25,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,18.39,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.39,18.96
"Psa, Free - Ref",PX8415490,CDM,300,RC,84154,CPT,90,,,,,,,38,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,18.39,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.84,18.39
"Psa, Total - Ref",PX8415390,CDM,300,RC,84153,CPT,90,,,,,,,38,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,18.39,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.84,18.39
doxazosin 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079095701,NDC,1,EA,20.19,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,18.39309,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ampicillin 500 MG Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781925078,NDC,1,EA,44.28,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.393912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001326,NDC,1,ML,42.88,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.39552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001341,NDC,1,ML,42.88,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.39552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078110,NDC,0.5,EA,38.33,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.3984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078110,NDC,0.5,EA,38.33,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.3984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Manual Ther Tech,1+Regions,Ea 15 Min",PX97140,CDM,420,RC,97140,CPT,,,,,,,,135,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,18.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.4,215.05
DULoxetine 20 MG Capsule Delayed Release Particles 60 Each Bottle,63700001,CDM,250,RC,,,,,,57237001760,NDC,1,EA,37.58,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.4142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DULoxetine 20 MG Capsule Delayed Release Particles 60 Each Bottle,63700001,CDM,250,RC,,,,,,57237001760,NDC,1,EA,37.58,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.4142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DULoxetine 20 MG Capsule Delayed Release Particles 60 Each Bottle,63700001,CDM,250,RC,,,,,,57237001760,NDC,1,EA,37.58,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,18.4142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 200-40 MG/5ML Suspension 473 mL Bottle,63700001,CDM,250,RC,,,,,,65862049647,NDC,10,ML,18.79,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,18.4142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915701,NDC,0.5,ML,44.33,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.414682,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915731,NDC,0.5,ML,44.33,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.414682,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,47335093140,NDC,0.5,EA,44.33,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.414682,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,47335093144,NDC,0.5,EA,44.33,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.414682,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
doxazosin 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079095720,NDC,1,EA,20.22,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,18.42042,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ticagrelor 90 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,186077739,NDC,1,EA,44.35,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.42299,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
protamine 10 MG/ML Solution 25 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022930,NDC,2.5,ML,44.37,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.431298,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.431298,83.0452
pioglitazone 15 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342005410,NDC,1,EA,37.62,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.4338,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pioglitazone 15 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342005410,NDC,1,EA,37.62,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.4338,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pioglitazone 15 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342005410,NDC,1,EA,37.62,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,18.4338,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Flex Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707526,NDC,100,ML,37.63,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1.633818182,percent of total billed charges,18.4387,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Flex Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707526,NDC,100,ML,37.63,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.4387,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Flex Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707526,NDC,100,ML,37.63,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,18.4387,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
risperiDONE 0.25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084027011,NDC,1,EA,20.91,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,18.44262,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084027001,NDC,1,EA,20.91,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,18.44262,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Antinuclear Antibodiesana - Ref,PX8603890,CDM,300,RC,86038,CPT,90,,,,,,,43,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.447,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.09,42.14
Blood Type Antigen Donor Ea,PX86902,CDM,300,RC,86902,CPT,,,,,,,,43,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.447,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.8622,314.02
ETRAP POLYP TRAP,27200000,CDM,272,RC,,,,11282-MAIN,LOCAL,,,,,43,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.447,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Smking Cess 4-10 Min,PX99406P,CDM,983,RC,99406,CPT,,,,,,,,43,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.447,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.8622,41.8519
"Testosterone, Total - Ref",PX8440390,CDM,300,RC,84403,CPT,90,,,,,,,43,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.447,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.8622,42.14
"Compatibility Test,Antiglob Tech",PX86922,CDM,300,RC,86922,CPT,,,,,,,,120,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,18.45,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.9,30.048
Contrast Bath Therapy,PX97034,CDM,420,RC,97034,CPT,,,,,,,,97,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,18.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.1,18.45
Contrast Bath Therapy,PX97034,CDM,420,RC,97034,CPT,,,,,,,,97,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,18.45,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.1,18.45
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001103,NDC,1,EA,108.34,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,18.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,18.45
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001103,NDC,1,EA,108.34,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,18.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,18.45
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001104,NDC,1,EA,108.29,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,18.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,18.45
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001104,NDC,1,EA,108.29,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,18.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,18.45
hydrocortisone sodium succinate (preservative free) 250 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001305,NDC,1,EA,183.32,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,18.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,18.45
hydrocortisone sodium succinate (preservative free) 250 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001305,NDC,1,EA,183.32,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,18.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,18.45
hydrocortisone sodium succinate (preservative free) 500 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001612,NDC,1,EA,298.53,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,18.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,18.45
hydrocortisone sodium succinate (preservative free) 500 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001612,NDC,1,EA,298.53,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,18.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,18.45
hydrocortisone sodium succinate (preservative free) 1000 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9000501,NDC,1,EA,403.54,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,18.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,18.45
hydrocortisone sodium succinate (preservative free) 1000 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9000501,NDC,1,EA,403.54,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,18.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,18.45
Mechanical Traction Therapy,PX97012,CDM,420,RC,97012,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,18.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.1,18.45
Mechanical Traction Therapy,PX97012,CDM,420,RC,97012,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,18.45,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.1,18.45
Ultrasound Therapy,PX97035,CDM,420,RC,97035,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,18.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.1,18.45
Ultrasound Therapy,PX97035,CDM,420,RC,97035,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,18.45,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.1,18.45
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021515,NDC,0.5,ML,187.24,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,18.45175,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.45175,30.34
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021588,NDC,0.5,ML,203.87,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,18.45175,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.45175,30.34
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,487960130,NDC,2,ML,36.47,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.45382,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409427602,NDC,50,ML,38.46,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.4608,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409427602,NDC,50,ML,38.46,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.4608,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,703903201,NDC,2,ML,44.46,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.468684,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,97.0102
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2021301,NDC,3,ML,44.46,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.468684,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
Clozapine - Ref,PX8015990,CDM,300,RC,80159,CPT,90,,,,,,,65,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,18.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.48,63.7
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,55150023501,NDC,0.5,EA,37.72,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.4828,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,55150023501,NDC,0.5,EA,37.72,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.4828,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,55150023501,NDC,0.5,EA,37.72,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,18.4828,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,409710709,NDC,1000,ML,36.53,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.48418,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5% and sodium chloride 0.45% with potassium chloride 10 mEq in 1000 mL 10-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,264763400,NDC,1000,ML,36.53,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.48418,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323018507,NDC,10,ML,43.09,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.48561,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
levETIRAcetam 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079082101,NDC,1,EA,18.87,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,18.4926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SUTURE SILK 3-0 18INCH NONABSORBABLE BLACK M13T,27200000,CDM,272,RC,,,,12872-MAIN,LOCAL,,,,,19,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,18.4927,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049209,NDC,5,ML,44.52,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.493608,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
neomycin-bacitracin-polymyxin 3.5-400-5000 Ointment 28 g Tube,25000000,CDM,250,RC,,,,,,45802014303,NDC,28,GR,37.76,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.5024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
neomycin-bacitracin-polymyxin 3.5-400-5000 Ointment 28 g Tube,25000000,CDM,250,RC,,,,,,45802014303,NDC,28,GR,37.76,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.5024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
neomycin-bacitracin-polymyxin 3.5-400-5000 Ointment 28 g Tube,25000000,CDM,250,RC,,,,,,45802014303,NDC,28,GR,37.76,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,18.5024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
valACYclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069801,NDC,1,EA,38.55,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
valACYclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069801,NDC,1,EA,38.55,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039841,NDC,1,EA,43.14,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.50706,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
Prolactin,PX84146,CDM,300,RC,84146,CPT,,,,,,,,112,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,18.51,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.51,19.38
Prolactin,PX84146,CDM,300,RC,84146,CPT,,,,,,,,112,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,18.51,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.51,19.38
tolterodine ER 2 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,43975032203,NDC,1,EA,43.15,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.51135,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pancrelipase (lip-prot-amyl) 24000-76000 units Capsule Delayed Release Particles 100 Each Bottle,63700001,CDM,250,RC,,,,,,32122401,NDC,1,EA,37.41,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,18.51795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Cystatin C - Ref,PX8261090,CDM,300,RC,82610,CPT,90,,,,,,,130,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,18.52,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.96,18.52
Gonadotropin (Lh),PX83002,CDM,300,RC,83002,CPT,,,,,,,,28,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,18.52,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.69,18.52
amoxicillin-clavulanate 500-125 MG Tablet 20 Each Bottle,63700001,CDM,250,RC,,,,,,16714047701,NDC,1,EA,20.33,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,18.52063,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Anesthesia Level 4,PX37000018,CDM,370,RC,,,,,,,,,,21,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,18.522,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.7234,20.58
ANOSCOPE LIGHTED ANOSCOPE,120.52,CDM,272,RC,,,,10235-MAIN,LOCAL,,,,,21,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,18.522,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.7234,20.58
"Hepatitis B Core Antibody, Total",PX86704,CDM,300,RC,86704,CPT,,,,,,,,21,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,18.522,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.7234,20.58
"Spectrophotometry, Nos",PX84311,CDM,300,RC,84311,CPT,,,,,,,,21,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,18.522,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.43,20.58
ampicillin 1 GM Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781926185,NDC,0.5,EA,43.18,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.52422,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
ePHEDrine sulfate 50 MG/ML Solution 1 mL Vial,25000000,CDM,250,RC,,,,,,42023021689,NDC,0.1,ML,36.62,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.52972,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143966001,NDC,5,ML,37.82,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.5318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143966001,NDC,5,ML,37.82,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.5318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143966001,NDC,5,ML,37.82,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,18.5318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143966010,NDC,5,ML,37.82,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.5318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143966010,NDC,5,ML,37.82,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.5318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143966010,NDC,5,ML,37.82,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,18.5318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Etoposide 100 MG/5ML Solution 5 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,16729011431,NDC,5,ML,43.21,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.53709,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.949434,169.8144
celecoxib 200 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904650361,NDC,0.5,EA,20.35,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,18.53885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Each Add'l Sequential IV Infusion <1 Hour,PX96367,CDM,260,RC,96367,CPT,,,,,,,,190,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,18.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.54,49.44
Each Add'l Sequential IV Infusion <1 Hour,PX96367,CDM,260,RC,96367,CPT,,,,,,,,190,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,18.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.54,49.44
Fluoroscope Examination Tc,PX7600001,CDM,320,RC,76000,CPT,TC,,,,,,,597,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,18.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.32,55.22
Fluoroscope Examination Tc,PX7600001,CDM,320,RC,76000,CPT,TC,,,,,,,597,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,18.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.32,55.22
Reduce Temporomandibl Disloc,PX21480F,CDM,510,RC,21480,CPT,,,,,,,,335,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,18.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.54,294.02
Reduce Temporomandibl Disloc,PX21480F,CDM,510,RC,21480,CPT,,,,,,,,335,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,18.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.54,294.02
Reduce Temporomandibl Disloc,PX21480F,CDM,510,RC,21480,CPT,,,,,,,,335,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,18.54,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.54,294.02
Reduce Temporomandibl Disloc,PX21480P,CDM,983,RC,21480,CPT,,,,,,,,223,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,18.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.54,294.02
Reduce Temporomandibl Disloc,PX21480P,CDM,983,RC,21480,CPT,,,,,,,,223,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,18.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.54,294.02
Reduce Temporomandibl Disloc,PX21480P,CDM,983,RC,21480,CPT,,,,,,,,223,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,18.54,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.54,294.02
amoxicillin 250 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,93415580,NDC,150,ML,43.22,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.54138,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,55150025110,NDC,10,ML,37.85,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.5465,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,55150025110,NDC,10,ML,37.85,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.5465,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,55150025110,NDC,10,ML,37.85,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,18.5465,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"CUFF STERILE DISPOSABLE SPSB 24""",27200000,CDM,272,RC,,,,7437-MAIN,LOCAL,,,,,37.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,18.5625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ENDOCAVITY NEEDLE GUIDE,27200000,CDM,272,RC,,,,11134-MAIN,LOCAL,,,,,37.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,18.5625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR KII BALOON 5X100MM STERILE,27200000,CDM,272,RC,,,,11701-MAIN,LOCAL,,,,,37.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,18.5625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143978410,NDC,2,ML,37.91,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.5759,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143978410,NDC,2,ML,37.91,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.5759,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143978410,NDC,2,ML,37.91,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,18.5759,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"CUFF STERILE DISPOSABLE SPSB 12""",27200000,CDM,272,RC,,,,7435-MAIN,LOCAL,,,,,43.31,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.57999,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078121,NDC,0.5,EA,36.75,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.5955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078141,NDC,0.5,EA,36.75,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.5955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
DULoxetine 20 MG Capsule Delayed Release Particles 60 Each Bottle,63700001,CDM,250,RC,,,,,,57237001760,NDC,1,EA,37.58,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,18.6021,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,36000014801,NDC,2,ML,38.76,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.6048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,36000014801,NDC,2,ML,38.76,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.6048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
risperiDONE 0.25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084027011,NDC,1,EA,20.91,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,18.6099,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084027001,NDC,1,EA,20.91,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,18.6099,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048203,NDC,20,ML,44.8,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.60992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048227,NDC,20,ML,44.8,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.60992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Carcinoembryonic Antigen,PX82378,CDM,300,RC,82378,CPT,,,,,,,,25,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,18.6122,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.39,18.96
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490311,NDC,5,ML,43.39,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.61431,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
Dimethicone 1.5 % Cream 118 mL Tube,800000,CDM,,,,,,,,53329016104,NDC,118,ML,43.4,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.6186,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
risperiDONE 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635861,NDC,1,EA,21.11,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,18.61902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
valACYclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,31722070430,NDC,1,EA,38.79,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.6192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
valACYclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,31722070430,NDC,1,EA,38.79,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.6192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
8MM-12MM CANNULA SEAL 5-8MM,27200000,CDM,272,RC,,,,11921-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM-12MM CANNULA SEAL 5-8MM,27200000,CDM,272,RC,,,,11921-MAIN,LOCAL,,,,,38,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM-12MM CANNULA SEAL 5-8MM,27200000,CDM,272,RC,,,,11921-MAIN,LOCAL,,,,,38,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRAPE COLUMN 470341,27200000,CDM,272,RC,,,,12013-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRAPE COLUMN 470341,27200000,CDM,272,RC,,,,12013-MAIN,LOCAL,,,,,38,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRAPE COLUMN 470341,27200000,CDM,272,RC,,,,12013-MAIN,LOCAL,,,,,38,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HH Hha Visit,PXG0156,CDM,571,RC,G0156,HCPCS,,,,,,,,38,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
HH Hha Visit,PXG0156,CDM,571,RC,G0156,HCPCS,,,,,,,,38,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
HH Hha Visit,PXG0156,CDM,571,RC,G0156,HCPCS,,,,,,,,38,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
Mitochondrial Antibody Each,PX8638190,CDM,300,RC,86381,CPT,90,,,,,,,38,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
Mitochondrial Antibody Each,PX8638190,CDM,300,RC,86381,CPT,90,,,,,,,38,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
Mitochondrial Antibody Each,PX8638190,CDM,300,RC,86381,CPT,90,,,,,,,38,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
Nasal Sm for Eos,PX89190,CDM,300,RC,89190,CPT,,,,,,,,38,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.31,37.24
Nasal Sm for Eos,PX89190,CDM,300,RC,89190,CPT,,,,,,,,38,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.31,37.24
Nasal Sm for Eos,PX89190,CDM,300,RC,89190,CPT,,,,,,,,38,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.31,37.24
NEEDLE IV 19GA X .75IN HUBER POWERLOC SAFETY 0651934,120.85,CDM,272,RC,A4215,HCPCS,,12701-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
NEEDLE IV 19GA X .75IN HUBER POWERLOC SAFETY 0651934,120.85,CDM,272,RC,A4215,HCPCS,,12701-MAIN,LOCAL,,,,,38,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
NEEDLE IV 19GA X .75IN HUBER POWERLOC SAFETY 0651934,120.85,CDM,272,RC,A4215,HCPCS,,12701-MAIN,LOCAL,,,,,38,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
NEEDLE IV 19GA X 1 IN HUBER POWERLOC SAFETY 0651910,120.85,CDM,272,RC,A4215,HCPCS,,12702-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
NEEDLE IV 19GA X 1 IN HUBER POWERLOC SAFETY 0651910,120.85,CDM,272,RC,A4215,HCPCS,,12702-MAIN,LOCAL,,,,,38,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
NEEDLE IV 19GA X 1 IN HUBER POWERLOC SAFETY 0651910,120.85,CDM,272,RC,A4215,HCPCS,,12702-MAIN,LOCAL,,,,,38,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
NEEDLE IV 19GA X 1.5 IN HUBER POWERLOC SAFETY 0651915,120.85,CDM,272,RC,A4215,HCPCS,,12703-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
NEEDLE IV 19GA X 1.5 IN HUBER POWERLOC SAFETY 0651915,120.85,CDM,272,RC,A4215,HCPCS,,12703-MAIN,LOCAL,,,,,38,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
NEEDLE IV 19GA X 1.5 IN HUBER POWERLOC SAFETY 0651915,120.85,CDM,272,RC,A4215,HCPCS,,12703-MAIN,LOCAL,,,,,38,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
PEZZER CATHETER DRAIN LATEX 14FR,27200000,CDM,272,RC,,,,12053-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PEZZER CATHETER DRAIN LATEX 14FR,27200000,CDM,272,RC,,,,12053-MAIN,LOCAL,,,,,38,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PEZZER CATHETER DRAIN LATEX 14FR,27200000,CDM,272,RC,,,,12053-MAIN,LOCAL,,,,,38,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PEZZER LATEX CATHETER DRAIN 10FR,27200000,CDM,272,RC,,,,12646-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PEZZER LATEX CATHETER DRAIN 10FR,27200000,CDM,272,RC,,,,12646-MAIN,LOCAL,,,,,38,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PEZZER LATEX CATHETER DRAIN 10FR,27200000,CDM,272,RC,,,,12646-MAIN,LOCAL,,,,,38,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PNEUVIEW SMOKE ELIMINATOR,27200000,CDM,272,RC,,,,11884-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PNEUVIEW SMOKE ELIMINATOR,27200000,CDM,272,RC,,,,11884-MAIN,LOCAL,,,,,38,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PNEUVIEW SMOKE ELIMINATOR,27200000,CDM,272,RC,,,,11884-MAIN,LOCAL,,,,,38,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Psa, Free - Ref",PX8415490,CDM,300,RC,84154,CPT,90,,,,,,,38,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
"Psa, Free - Ref",PX8415490,CDM,300,RC,84154,CPT,90,,,,,,,38,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
"Psa, Free - Ref",PX8415490,CDM,300,RC,84154,CPT,90,,,,,,,38,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
"Psa, Total - Ref",PX8415390,CDM,300,RC,84153,CPT,90,,,,,,,38,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
"Psa, Total - Ref",PX8415390,CDM,300,RC,84153,CPT,90,,,,,,,38,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
"Psa, Total - Ref",PX8415390,CDM,300,RC,84153,CPT,90,,,,,,,38,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
SPECULUM VAGINAL WITH BUILT IN LIGHT LARGE,120.133,CDM,272,RC,,,,8251-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
SPECULUM VAGINAL WITH BUILT IN LIGHT LARGE,120.133,CDM,272,RC,,,,8251-MAIN,LOCAL,,,,,38,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
SPECULUM VAGINAL WITH BUILT IN LIGHT LARGE,120.133,CDM,272,RC,,,,8251-MAIN,LOCAL,,,,,38,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
SPECULUM VAGINAL WITH BUILT IN LIGHT MEDIUM,120.133,CDM,272,RC,,,,8250-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
SPECULUM VAGINAL WITH BUILT IN LIGHT MEDIUM,120.133,CDM,272,RC,,,,8250-MAIN,LOCAL,,,,,38,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
SPECULUM VAGINAL WITH BUILT IN LIGHT MEDIUM,120.133,CDM,272,RC,,,,8250-MAIN,LOCAL,,,,,38,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
SPECULUM VAGINAL WITH BUILT IN LIGHT SMALL,120.133,CDM,272,RC,,,,8249-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
SPECULUM VAGINAL WITH BUILT IN LIGHT SMALL,120.133,CDM,272,RC,,,,8249-MAIN,LOCAL,,,,,38,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
SPECULUM VAGINAL WITH BUILT IN LIGHT SMALL,120.133,CDM,272,RC,,,,8249-MAIN,LOCAL,,,,,38,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
SUTURE SILK 3-0 18INCH NONABSORBABLE BLACK M13T,27200000,CDM,272,RC,,,,12872-MAIN,LOCAL,,,,,19,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR KII FIOS SYSTEM BLADELSS Z-THREAD 5MMX100MM,27200000,CDM,272,RC,,,,12003-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR KII FIOS SYSTEM BLADELSS Z-THREAD 5MMX100MM,27200000,CDM,272,RC,,,,12003-MAIN,LOCAL,,,,,38,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR KII FIOS SYSTEM BLADELSS Z-THREAD 5MMX100MM,27200000,CDM,272,RC,,,,12003-MAIN,LOCAL,,,,,38,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,18.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
pioglitazone 15 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342005410,NDC,1,EA,37.62,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,18.6219,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Gastric Intubation Treatment,PX43753F,CDM,510,RC,43753,CPT,,,,,,,,441,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,18.6238,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.65,44.28
Gastric Intubation Treatment,PX43753P,CDM,983,RC,43753,CPT,,,,,,,,498,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,18.6238,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.65,488.04
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Flex Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707526,NDC,100,ML,37.63,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,18.62685,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001002,NDC,2,ML,43.42,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.62718,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,42.5516
acetaminophen 160 MG/5ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,68094023159,NDC,15,ML,19.14,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,18.628962,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Compliment, Total (Ch50) - Ref",PX8616290,CDM,300,RC,86162,CPT,90,,,,,,,122,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,18.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.63,119.56
Quantitation Drug Nos - Ref,PX8029990,CDM,300,RC,80299,CPT,90,,,,,,,112,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,18.64,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.08,18.64
bacitracin zinc 500 UNIT/GM Ointment 28.4 g Tube,25000000,CDM,250,RC,,,,,,49348015472,NDC,28.4,GR,20.47,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,18.64817,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037604,NDC,0.75,ML,36.86,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.65116,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
ezetimibe 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714081301,NDC,1,EA,44.91,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.655614,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone-salmeterol 100-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069500,NDC,1,EA,38.87,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.6576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone-salmeterol 100-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069500,NDC,1,EA,38.87,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.6576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dextrose 5 % 5 % Solution 50 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338055111,NDC,50,ML,43.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.6615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 100 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001748,NDC,100,ML,43.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.6615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,264763500,NDC,1000,ML,43.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.6615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5% lactated ringers 5 % Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012504,NDC,1000,ML,43.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.6615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329330201,NDC,25,ML,43.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.6615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9 % 0.9 % Solution 50 mL Flex Cont,J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004941,NDC,50,ML,43.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.6615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004941,NDC,250,ML,43.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.6615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055311,NDC,250,ML,43.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.6615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004948,NDC,300,ML,43.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.6615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055318,NDC,300,ML,43.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.6615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 150 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,409798361,NDC,300,ML,43.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.6615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9% irrigation 0.9 % Solution 3,000 mL Plas Cont",25000000,CDM,250,RC,,,,,,338004727,NDC,3000,ML,43.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.6615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9% IV LINE FLUSH 0.9% Solution 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,338004948,NDC,100,ML,43.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.6615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
rosuvastatin 10 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,60687024511,NDC,0.5,EA,19.18,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,18.667894,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,55150023501,NDC,0.5,EA,37.72,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,18.6714,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
empagliflozin 25 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,597015330,NDC,0.4,EA,43.54,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.67866,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
empagliflozin 25 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,597015337,NDC,0.4,EA,43.54,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.67866,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Collagen Cross Links - Ref,PX8252390,CDM,300,RC,82523,CPT,90,,,,,,,170,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,18.68,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.12,18.68
Place Needle in Vein,PX36000P,CDM,983,RC,36000,CPT,,,,,,,,1034,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,18.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.45,1013.32
"Venipunc Need Phys Skill,Dx or Rx",PX36410,CDM,983,RC,36410,CPT,,,,,,,,132,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,18.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.45,129.36
"Venipunc Need Phys Skill,Dx or Rx",PX36410F,CDM,510,RC,36410,CPT,,,,,,,,34,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,18.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.45,36.67
"Venipunc Need Phys Skill,Dx or Rx",PX36410P,CDM,983,RC,36410,CPT,,,,,,,,129,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,18.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.45,126.42
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253022233,NDC,3,ML,38.13,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.115241667,percent of total billed charges,18.6837,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253022233,NDC,3,ML,38.13,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.6837,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253022233,NDC,3,ML,38.13,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,18.6837,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
HYDROmorphone 1 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409128303,NDC,1,ML,36.93,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.68658,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
Anesthesia Level 4,PX37000018,CDM,370,RC,,,,,,,,,,21,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,18.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.7234,20.58
ANOSCOPE LIGHTED ANOSCOPE,120.52,CDM,272,RC,,,,10235-MAIN,LOCAL,,,,,21,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,18.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.7234,20.58
"Hepatitis B Core Antibody, Total",PX86704,CDM,300,RC,86704,CPT,,,,,,,,21,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,18.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.7234,20.58
"Spectrophotometry, Nos",PX84311,CDM,300,RC,84311,CPT,,,,,,,,21,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,18.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.43,20.58
neomycin-bacitracin-polymyxin 3.5-400-5000 Ointment 28 g Tube,25000000,CDM,250,RC,,,,,,45802014303,NDC,28,GR,37.76,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,18.6912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Cardiac Rehab,PX93797F,CDM,943,RC,93797,CPT,,,,,,,,45,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,115.44
CATHETER TEMP-SENSING 8FR LUBRISIL PEDS DYND110508,120.363,CDM,272,RC,A4340,HCPCS,,12777-MAIN,LOCAL,,,,,45,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
CATHETER TEMP-SENSING 12FR LUBRISIL 119212M,120.363,CDM,272,RC,A4340,HCPCS,,10750-MAIN,LOCAL,,,,,45,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
CATHETER TEMP-SENSING 14FR LUBRISIL 119214M,120.363,CDM,272,RC,A4340,HCPCS,,10751-MAIN,LOCAL,,,,,45,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
CATHETER TEMP-SENSING 16FR LUBRISIL 119216M,120.363,CDM,272,RC,A4340,HCPCS,,10752-MAIN,LOCAL,,,,,45,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
Cryptococcus Neoformans,PX87327,CDM,300,RC,87327,CPT,,,,,,,,45,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.3,44.1
Gammaglobulin; Ige - Ref,PX8278590,CDM,300,RC,82785,CPT,90,,,,,,,45,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.09,44.1
GASTRONOMY FEEDING TUBE MIC BALLOONED 20FR 7-10ML 0112-20,27200000,CDM,272,RC,B4087,HCPCS,,13098-MAIN,LOCAL,,,,,45,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRES 1.6MM,27200000,CDM,272,RC,C1769,HCPCS,,11852-MAIN,LOCAL,,,,,45,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"La Crosse, Antibody - Ref",PX8665190,CDM,300,RC,86651,CPT,90,,,,,,,45,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.09,44.1
MELGISORB AG SILVER CALCIUM STERILE 6X6,120.502,CDM,272,RC,A6197,HCPCS,,11844-MAIN,LOCAL,,,,,45,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
"St Louis, Antibody - Ref",PX8665390,CDM,300,RC,86653,CPT,90,,,,,,,45,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.09,44.1
"Sugars, Qual, Ea Spec - Ref",PX8437690,CDM,300,RC,84376,CPT,90,,,,,,,45,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.04,44.1
"Venipuncture by Physician, Other Vein, Under Age 3 Years",PX36406,CDM,983,RC,36406,CPT,,,,,,,,45,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,43.7985
"Western Equine, Ab - Ref",PX8665490,CDM,300,RC,86654,CPT,90,,,,,,,45,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.09,44.1
"Iontophoresis, Ea 15min",PX97033,CDM,420,RC,97033,CPT,,,,,,,,15,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,18.6992,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.94,25.48
Myoglobin - Ref,PX8387490,CDM,300,RC,83874,CPT,90,,,,,,,22,,First Health,Commercial,both,85,,999999999,percent of total billed charges,18.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.1388,21.56
SUTURE POLYSORB BRAIDED ABSORBABLE VIOLET SIZE 0 30IN WITH 5/8 CIRCLE TAPER POINT 27MM NEEDLE,27200000,CDM,272,RC,,,,11985-MAIN,LOCAL,,,,,22,,First Health,Commercial,both,85,,999999999,percent of total billed charges,18.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TEGADERM CHLORHEXIDINE-GLUCONATE,120.356,CDM,272,RC,A4221,HCPCS,,10708-MAIN,LOCAL,,,,,22,,First Health,Commercial,both,85,,999999999,percent of total billed charges,18.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.1388,21.56
HYDROmorphone 2 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409131203,NDC,1,ML,38.18,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,10.0725,percent of total billed charges,18.7082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
HYDROmorphone 2 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409131203,NDC,1,ML,38.18,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.7082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
HYDROmorphone 2 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409131203,NDC,1,ML,38.18,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,18.7082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010301,NDC,0.3,ML,45.04,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.709616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
morphine 2 MG/ML Solution 1 mL Syringe,J2272.01,CDM,636,RC,J2272,HCPCS,,,,76045000401,NDC,1,ML,38.98,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.7104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.192292,38.2004
morphine 2 MG/ML Solution 1 mL Syringe,J2272.01,CDM,636,RC,J2272,HCPCS,,,,76045000401,NDC,1,ML,38.98,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.7104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.192292,38.2004
CLOSED WOUND ROUND CHANNEL DRAIN WITH TROCAR 15FR FULL FLUTED,27200000,CDM,272,RC,,,,12223-MAIN,LOCAL,,,,,39,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CLOSED WOUND ROUND CHANNEL DRAIN WITH TROCAR 15FR FULL FLUTED,27200000,CDM,272,RC,,,,12223-MAIN,LOCAL,,,,,39,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
fluorouracil 500 MG/10ML Solution 10 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,63323011710,NDC,10,ML,39,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,256.2112
fluorouracil 500 MG/10ML Solution 10 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,63323011710,NDC,10,ML,39,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,256.2112
gemcitabine 200 MG Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323010294,NDC,1,EA,39,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
gemcitabine 200 MG Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323010294,NDC,1,EA,39,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
Lab Wbc and Differential,PX85004,CDM,300,RC,85004,CPT,,,,,,,,39,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,38.22
Lab Wbc and Differential,PX85004,CDM,300,RC,85004,CPT,,,,,,,,39,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,38.22
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003928,NDC,1,EA,39,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003928,NDC,1,EA,39,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
methylPREDNISolone sod succ 500 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9075801,NDC,0.25,EA,39,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
methylPREDNISolone sod succ 500 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9075801,NDC,0.25,EA,39,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
NEEDLE JAMSHIDI 11G X 101MM BIOPSY DJ4011X,27200000,CDM,272,RC,,,,12798-MAIN,LOCAL,,,,,39,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NEEDLE JAMSHIDI 11G X 101MM BIOPSY DJ4011X,27200000,CDM,272,RC,,,,12798-MAIN,LOCAL,,,,,39,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
O2 SENSOR ADULT ADHESIVE SINGLE PATIENT 040-003382-00,120.576,CDM,272,RC,,,,12930-MAIN,LOCAL,,,,,39,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
O2 SENSOR ADULT ADHESIVE SINGLE PATIENT 040-003382-00,120.576,CDM,272,RC,,,,12930-MAIN,LOCAL,,,,,39,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
O2 SENSOR INFANT ADHESIVE SINGLE PATIENT 040-003384-00,120.576,CDM,272,RC,,,,12932-MAIN,LOCAL,,,,,39,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
O2 SENSOR INFANT ADHESIVE SINGLE PATIENT 040-003384-00,120.576,CDM,272,RC,,,,12932-MAIN,LOCAL,,,,,39,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
O2 SENSOR PEDIATRIC ADHESIVE SINGLE PATIENT 040-003383-00,120.576,CDM,272,RC,,,,12931-MAIN,LOCAL,,,,,39,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
O2 SENSOR PEDIATRIC ADHESIVE SINGLE PATIENT 040-003383-00,120.576,CDM,272,RC,,,,12931-MAIN,LOCAL,,,,,39,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
SLEEVE ACHILLES LG/XL PROTECTION 92437145348,120.422,CDM,271,RC,,,,11378-MAIN,LOCAL,,,,,39,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
SLEEVE ACHILLES LG/XL PROTECTION 92437145348,120.422,CDM,271,RC,,,,11378-MAIN,LOCAL,,,,,39,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
SLEEVE ACHILLES SM/MED PROTECTION 92437145324,120.422,CDM,271,RC,,,,11377-MAIN,LOCAL,,,,,39,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
SLEEVE ACHILLES SM/MED PROTECTION 92437145324,120.422,CDM,271,RC,,,,11377-MAIN,LOCAL,,,,,39,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
Treponema Pallidum - Ref,PX8678090,CDM,300,RC,86780,CPT,90,,,,,,,39,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.14,38.22
Treponema Pallidum - Ref,PX8678090,CDM,300,RC,86780,CPT,90,,,,,,,39,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.14,38.22
TROCAR KII FIOS SYSTEM BLADELSS Z-THREAD 5MMX150MM,27200000,CDM,272,RC,,,,12827-MAIN,LOCAL,,,,,39,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR KII FIOS SYSTEM BLADELSS Z-THREAD 5MMX150MM,27200000,CDM,272,RC,,,,12827-MAIN,LOCAL,,,,,39,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143966001,NDC,5,ML,37.82,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,18.7209,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143966010,NDC,5,ML,37.82,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,18.7209,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
COLLAR CERVICAL LARGE WITH TRACH 2 PIECE PHP-T4L,120.184,CDM,274,RC,L0172,HCPCS,,10142-MAIN,LOCAL,,,,,37,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.722,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.3698,152.79
COLLAR CERVICAL MEDIUM WITH TRACH 2 PIECE PHP-T4M,120.183,CDM,274,RC,L0172,HCPCS,,10141-MAIN,LOCAL,,,,,37,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.722,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.3698,152.79
COLLAR CERVICAL SMALL WITH TRACH 2 PIECE PHP-T4S,120.182,CDM,274,RC,L0172,HCPCS,,10140-MAIN,LOCAL,,,,,37,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.722,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.3698,152.79
SUTURE TICRON 0 36IN BRAIDED DYED 1/2 CIRCLE DBLE ARM 25MM CV-305 BLUE STERILE,27200000,CDM,272,RC,,,,11956-MAIN,LOCAL,,,,,37,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.722,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409427617,NDC,50,ML,39.01,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.7248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409427617,NDC,50,ML,39.01,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.7248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,409163221,NDC,0.5,EA,43.65,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.72585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Psa Screening,PXG0103,CDM,300,RC,G0103,HCPCS,,,,,,,,157,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,18.73,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.73,19.31
Psa Screening,PXG0103,CDM,300,RC,G0103,HCPCS,,,,,,,,157,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,18.73,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.73,19.31
Psa Screening,PXG0103,CDM,300,RC,G0103,HCPCS,,,,,,,,157,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,18.73,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.73,19.31
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,55150025110,NDC,10,ML,37.85,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,18.73575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BIOPSY FORCEPS HOT,27200000,CDM,272,RC,,,,4353-MAIN,LOCAL,,,,,38.25,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.7425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
BIOPSY FORCEPS HOT,27200000,CDM,272,RC,,,,4353-MAIN,LOCAL,,,,,38.25,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.7425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
BIOPSY FORCEPS HOT,27200000,CDM,272,RC,,,,4353-MAIN,LOCAL,,,,,38.25,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,18.7425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRESSING GEL FOAM SIZE 100SPONGE STERILE 00009034201,27200000,CDM,272,RC,A6248,HCPCS,,3378-MAIN,LOCAL,,,,,38.25,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.7425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRESSING GEL FOAM SIZE 100SPONGE STERILE 00009034201,27200000,CDM,272,RC,A6248,HCPCS,,3378-MAIN,LOCAL,,,,,38.25,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.7425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRESSING GEL FOAM SIZE 100SPONGE STERILE 00009034201,27200000,CDM,272,RC,A6248,HCPCS,,3378-MAIN,LOCAL,,,,,38.25,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,18.7425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFFLATION TUBING SET,27200000,CDM,272,RC,,,,4686-MAIN,LOCAL,,,,,38.25,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.7425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFFLATION TUBING SET,27200000,CDM,272,RC,,,,4686-MAIN,LOCAL,,,,,38.25,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.7425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFFLATION TUBING SET,27200000,CDM,272,RC,,,,4686-MAIN,LOCAL,,,,,38.25,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,18.7425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Apply Multlay Comprs Lwr Leg,PX29581F,CDM,510,RC,29581,CPT,,,,,,,,213,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,18.75,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.01,182.64
Apply Multlay Comprs Lwr Leg,PX29581P,CDM,983,RC,29581,CPT,,,,,,,,142,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,18.75,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.01,182.64
"DXA, Bone Density Study, Hips/Pelv/Spine",PX7708001,CDM,320,RC,77080,CPT,TC,,,,,,,575,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,18.75,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.75,58.51
Each Add'l Sequential IV Infusion <1 Hour,PX96367,CDM,260,RC,96367,CPT,,,,,,,,190,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,18.75,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.54,49.44
Neg Pressure Wound Therapy Dme >50 Sq Cm,PX97606F,CDM,761,RC,97606,CPT,,,,,,,,404,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,18.75,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.75,67.21
US Guide Needle Bx S&I,PX7694201,CDM,402,RC,76942,CPT,TC,,,,,,,747,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,18.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.32,55.88
US Guide Needle Bx S&I,PX7694201,CDM,402,RC,76942,CPT,TC,,,,,,,747,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,18.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.32,55.88
Xray Ankle Minimum 3 Vws,PX7361001,CDM,320,RC,73610,CPT,TC,,,,,,,365,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,18.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.75,55.88
Xray Ankle Minimum 3 Vws,PX7361001,CDM,320,RC,73610,CPT,TC,,,,,,,365,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,18.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.75,55.88
Xray Ankle Minimum 3 Vws,PX7361001,CDM,320,RC,73610,CPT,TC,,,,,,,365,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,18.75,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.75,55.88
Xray Hand 3vws Tc,PX7313001,CDM,320,RC,73130,CPT,TC,,,,,,,374,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,18.75,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.75,57.19
Xray Sacroiliac Jnts 3 or More Vws,PX7220201,CDM,320,RC,72202,CPT,TC,,,,,,,285,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,18.75,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.75,56.54
Xray Thoracic Spine 3 Vws,PX7207201,CDM,320,RC,72072,CPT,TC,,,,,,,522,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,18.75,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.75,57.19
acetaminophen 160 MG/5ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,68094023159,NDC,15,ML,19.14,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,18.7572,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levoFLOXacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635261,NDC,0.5,EA,45.16,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.759464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143978410,NDC,2,ML,37.91,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,18.76545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Rickettsia Antibody - Ref,PX8675790,CDM,300,RC,86757,CPT,90,,,,,,,52,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,18.77,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.77,19.35
Rickettsia Antibody - Ref,PX8675790,CDM,300,RC,86757,CPT,90,,,,,,,52,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,18.77,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.77,19.35
Rickettsia Antibody - Ref,PX8675790,CDM,300,RC,86757,CPT,90,,,,,,,52,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,18.77,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.77,19.35
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733513,NDC,1,EA,39.12,,Health Partners,Health Partners Care Plans,both,48,,26.64321429,percent of total billed charges,18.7776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733513,NDC,1,EA,39.12,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.7776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078110,NDC,0.5,EA,38.33,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.7817,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078110,NDC,0.5,EA,38.33,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.7817,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078110,NDC,0.5,EA,38.33,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,18.7817,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
levoFLOXacin 750 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635361,NDC,0.333333333,EA,39.14,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.7872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levoFLOXacin 750 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635361,NDC,0.333333333,EA,39.14,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.7872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635861,NDC,1,EA,21.11,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,18.7879,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of Erythropoietin,PX82668,CDM,300,RC,82668,CPT,,,,,,,,114,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,18.79,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.23,18.79
Erythropietin - Ref,PX8266890,CDM,300,RC,82668,CPT,90,,,,,,,108,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,18.79,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.23,18.79
oxytocin 10 UNIT/ML Solution 1 mL Vial,J2590.01,CDM,636,RC,J2590,HCPCS,,,,42023011625,NDC,1,ML,43.8,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.7902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.19452,42.924
rosuvastatin 10 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,60687024511,NDC,0.5,EA,19.18,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,18.7964,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Prolactin,PX84146,CDM,300,RC,84146,CPT,,,,,,,,112,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,18.8,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.51,19.38
8MM-12MM CANNULA SEAL 5-8MM,27200000,CDM,272,RC,,,,11921-MAIN,LOCAL,,,,,38,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,18.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRAPE COLUMN 470341,27200000,CDM,272,RC,,,,12013-MAIN,LOCAL,,,,,38,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,18.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HH Hha Visit,PXG0156,CDM,571,RC,G0156,HCPCS,,,,,,,,38,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,18.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
Mitochondrial Antibody Each,PX8638190,CDM,300,RC,86381,CPT,90,,,,,,,38,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,18.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
Nasal Sm for Eos,PX89190,CDM,300,RC,89190,CPT,,,,,,,,38,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,18.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.31,37.24
NEEDLE IV 19GA X .75IN HUBER POWERLOC SAFETY 0651934,120.85,CDM,272,RC,A4215,HCPCS,,12701-MAIN,LOCAL,,,,,38,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,18.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
NEEDLE IV 19GA X 1 IN HUBER POWERLOC SAFETY 0651910,120.85,CDM,272,RC,A4215,HCPCS,,12702-MAIN,LOCAL,,,,,38,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,18.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
NEEDLE IV 19GA X 1.5 IN HUBER POWERLOC SAFETY 0651915,120.85,CDM,272,RC,A4215,HCPCS,,12703-MAIN,LOCAL,,,,,38,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,18.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
PEZZER CATHETER DRAIN LATEX 14FR,27200000,CDM,272,RC,,,,12053-MAIN,LOCAL,,,,,38,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,18.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PEZZER LATEX CATHETER DRAIN 10FR,27200000,CDM,272,RC,,,,12646-MAIN,LOCAL,,,,,38,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,18.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PNEUVIEW SMOKE ELIMINATOR,27200000,CDM,272,RC,,,,11884-MAIN,LOCAL,,,,,38,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,18.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Psa, Free - Ref",PX8415490,CDM,300,RC,84154,CPT,90,,,,,,,38,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,18.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
"Psa, Total - Ref",PX8415390,CDM,300,RC,84153,CPT,90,,,,,,,38,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,18.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
SPECULUM VAGINAL WITH BUILT IN LIGHT LARGE,120.133,CDM,272,RC,,,,8251-MAIN,LOCAL,,,,,38,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,18.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
SPECULUM VAGINAL WITH BUILT IN LIGHT MEDIUM,120.133,CDM,272,RC,,,,8250-MAIN,LOCAL,,,,,38,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,18.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
SPECULUM VAGINAL WITH BUILT IN LIGHT SMALL,120.133,CDM,272,RC,,,,8249-MAIN,LOCAL,,,,,38,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,18.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
TROCAR KII FIOS SYSTEM BLADELSS Z-THREAD 5MMX100MM,27200000,CDM,272,RC,,,,12003-MAIN,LOCAL,,,,,38,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,18.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
amiodarone 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,245014789,NDC,0.5,EA,21.33,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,18.81306,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,245014701,NDC,0.5,EA,21.33,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,18.81306,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021515,NDC,0.5,ML,187.24,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,18.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.45175,30.34
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021515,NDC,0.5,ML,187.24,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,18.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.45175,30.34
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021588,NDC,0.5,ML,203.87,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,18.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.45175,30.34
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021588,NDC,0.5,ML,203.87,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,18.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.45175,30.34
hydrocortisone 1 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,472034356,NDC,28,GR,22.15,,First Health,Commercial,both,85,,999999999,percent of total billed charges,18.8275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409427602,NDC,50,ML,38.46,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.8454,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409427602,NDC,50,ML,38.46,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.8454,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409427602,NDC,50,ML,38.46,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,18.8454,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707426,NDC,100,ML,39.29,,Health Partners,Health Partners Care Plans,both,48,,6.034333333,percent of total billed charges,18.8592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707426,NDC,100,ML,39.29,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.8592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
polyvinyl alcohol 1.4 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,50268067815,NDC,15,ML,45.42,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.867468,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 100 MG/5ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,68094049459,NDC,20,ML,22.2,,First Health,Commercial,both,85,,999999999,percent of total billed charges,18.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253022233,NDC,3,ML,38.13,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,18.87435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
CANNULA ADULT LARGE OPTIFLOW OPT946,120.495,CDM,271,RC,A4615,HCPCS,,11622-MAIN,LOCAL,,,,,44,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
CANNULA ADULT MEDIUM OPTIFLOW OPT944,120.495,CDM,271,RC,A4615,HCPCS,,11621-MAIN,LOCAL,,,,,44,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
CANNULA ADULT SMALL OPTIFLOW OPT942,120.495,CDM,271,RC,A4615,HCPCS,,11620-MAIN,LOCAL,,,,,44,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
Homocysteine,PX83090,CDM,300,RC,83090,CPT,,,,,,,,44,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.43,43.12
KIT GASTRIC LAVAGE 2075,120.257,CDM,272,RC,C7510,HCPCS,,410-MAIN,LOCAL,,,,,44,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
SUTURE V-LOC 1/2 CIRCLE NEEDLE WOUND CLOSURE DEVICE VLOCN0306,27200000,CDM,272,RC,,,,11931-MAIN,LOCAL,,,,,44,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE V-LOC SZ 3-0 180 GREEN V-20 9 INCH VLOCL0644,27200000,CDM,272,RC,,,,13056-SURG,LOCAL,,,,,44,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188602,NDC,5,ML,45.46,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.884084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.884084,44.5508
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188622,NDC,5,ML,45.46,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.884084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.884084,44.5508
valACYclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069801,NDC,1,EA,38.55,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.8895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
valACYclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069801,NDC,1,EA,38.55,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.8895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
valACYclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069801,NDC,1,EA,38.55,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,18.8895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Electrical Stimulation,PX97032,CDM,420,RC,97032,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,18.89,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.1,18.89
Electrical Stimulation,PX97032,CDM,420,RC,97032,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,18.89,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.1,18.89
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,63323041536,NDC,0.5,ML,44.05,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.89745,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
HYDROmorphone 2 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409131203,NDC,1,ML,38.18,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,18.8991,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
leflunomide 20 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,70748013006,NDC,0.5,EA,44.1,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.9189,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Lab Imm Spin X-Match,PX8837,CDM,300,RC,86920,CPT,,,,,,,,402,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,18.92,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.35,30.816
"US Complete Joint, Realtime W/ Img Tc",PX7688101,CDM,402,RC,76881,CPT,TC,,,,,,,415,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,18.92,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.2,21.69
atropine 1 mg/mL Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100101,NDC,0.2,ML,39.42,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.9216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
atropine 1 mg/mL Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100101,NDC,0.2,ML,39.42,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.9216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
DIMETHICONE (TOPICAL) 5 % Cream 118 mL Tube,800000,CDM,,,,,,,,53329015104,NDC,118,ML,44.12,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.92748,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
phenol-glycerin 1.5-33 % Liquid 118 mL Bottle,25000000,CDM,250,RC,,,,,,78112000068,NDC,118,ML,44.12,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.92748,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
QUEtiapine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54022020,NDC,1,EA,21.46,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,18.92772,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pancrelipase (lip-prot-amyl) 24000-76000 units Capsule Delayed Release Particles 100 Each Bottle,63700001,CDM,250,RC,,,,,,32122401,NDC,1,EA,37.41,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.92946,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Prolactin,PX84146,CDM,300,RC,84146,CPT,,,,,,,,112,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,18.9331,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.51,19.38
Rickettsia Antibody - Ref,PX8675790,CDM,300,RC,86757,CPT,90,,,,,,,52,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,18.9331,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.77,19.35
BIOPSY FORCEPS HOT,27200000,CDM,272,RC,,,,4353-MAIN,LOCAL,,,,,38.25,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,18.93375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRESSING GEL FOAM SIZE 100SPONGE STERILE 00009034201,27200000,CDM,272,RC,A6248,HCPCS,,3378-MAIN,LOCAL,,,,,38.25,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,18.93375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFFLATION TUBING SET,27200000,CDM,272,RC,,,,4686-MAIN,LOCAL,,,,,38.25,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,18.93375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"dextran 70, glycerin, hypromellose 0.1-0.2-0.3 % Solution 15 mL Bottle",63700001,CDM,250,RC,,,,,,65042636,NDC,15,ML,44.14,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.93606,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Concurrent Infusion,PX96368,CDM,260,RC,96368,CPT,,,,,,,,102,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,18.939,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.87,34.32
US Follicles-Limited Tc,PX7685701,CDM,402,RC,76857,CPT,TC,,,,,,,300,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,18.94,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.58,51.93
US Follicles-Limited Tc,PX7685701,CDM,402,RC,76857,CPT,TC,,,,,,,300,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,18.94,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.58,51.93
ursodiol 300 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,591315901,NDC,1,EA,39.47,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.9456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ursodiol 300 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,591315901,NDC,1,EA,39.47,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.9456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Carcinoembryonic Antigen,PX82378,CDM,300,RC,82378,CPT,,,,,,,,25,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,18.96,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.39,18.96
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607F,CDM,761,RC,97607,CPT,,,,,,,,455,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,18.9685,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.42,459.07
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607P,CDM,983,RC,97607,CPT,,,,,,,,303,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,18.9685,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.42,459.07
Collect Blood From Picc,PX36592,CDM,949,RC,36592,CPT,,,,,,,,198,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,18.97,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.97,62.26
Collect Blood From Picc,PX36592F,CDM,510,RC,36592,CPT,,,,,,,,211,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,18.97,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.97,62.26
US Guide Needle Bx S&I,PX7694226,CDM,982,RC,76942,CPT,26,,,,,,,148,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,18.97,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.97,145.04
US Guide Needle Bx S&I,PX7694226,CDM,982,RC,76942,CPT,26,,,,,,,148,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,18.97,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.97,145.04
US Guide Needle Bx S&I,PX7694226,CDM,982,RC,76942,CPT,26,,,,,,,148,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,18.97,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.97,145.04
Xray Cervical Spine 2 or 3 Vws,PX7204001,CDM,320,RC,72040,CPT,TC,,,,,,,436,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,18.97,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.97,57.19
Xray Sacroiliac Jnts 3 or More Vws,PX7220201,CDM,320,RC,72202,CPT,TC,,,,,,,285,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,18.97,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.75,56.54
Xray Sacroiliac Jnts 3 or More Vws,PX7220201,CDM,320,RC,72202,CPT,TC,,,,,,,285,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,18.97,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.75,56.54
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078110,NDC,0.5,EA,38.33,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,18.97335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"CUFF STERILE DISPOSABLE SPSB 24""",27200000,CDM,272,RC,,,,7437-MAIN,LOCAL,,,,,37.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ENDOCAVITY NEEDLE GUIDE,27200000,CDM,272,RC,,,,11134-MAIN,LOCAL,,,,,37.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR KII BALOON 5X100MM STERILE,27200000,CDM,272,RC,,,,11701-MAIN,LOCAL,,,,,37.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,18.975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,143957501,NDC,50,ML,44.24,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.97896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,143957510,NDC,50,ML,44.24,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.97896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015901,NDC,0.3,ML,45.69,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.979626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015925,NDC,0.3,ML,45.69,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,18.979626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
Psa Screening,PXG0103,CDM,300,RC,G0103,HCPCS,,,,,,,,157,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,18.9803,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.73,19.31
amiodarone 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,245014789,NDC,0.5,EA,21.33,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,18.9837,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,245014701,NDC,0.5,EA,21.33,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,18.9837,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079049801,NDC,1,EA,22.34,,First Health,Commercial,both,85,,999999999,percent of total billed charges,18.989,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,36000014801,NDC,2,ML,38.76,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.9924,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,36000014801,NDC,2,ML,38.76,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,18.9924,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,36000014801,NDC,2,ML,38.76,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,18.9924,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
bisoprolol-hydroCHLOROthiazide 5-6.25 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,42799092102,NDC,1,EA,39.57,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,18.9936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisoprolol-hydroCHLOROthiazide 5-6.25 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,42799092102,NDC,1,EA,39.57,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,18.9936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ampicillin 500 MG Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781925078,NDC,1,EA,44.28,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,18.99612,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066501,NDC,0.25,ML,45.74,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,19.000396,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.000396,47.2262
ACUSNARE POLYPECTOMY SNARE,27200000,CDM,272,RC,,,,7733-MAIN,LOCAL,,,,,45.75,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,19.00455,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
valACYclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,31722070430,NDC,1,EA,38.79,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.0071,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
valACYclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,31722070430,NDC,1,EA,38.79,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.0071,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
valACYclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,31722070430,NDC,1,EA,38.79,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.0071,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DULoxetine 20 MG Capsule Delayed Release Particles 60 Each Bottle,63700001,CDM,250,RC,,,,,,57237001760,NDC,1,EA,37.58,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.01548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915701,NDC,0.5,ML,44.33,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,19.01757,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915731,NDC,0.5,ML,44.33,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,19.01757,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,47335093140,NDC,0.5,EA,44.33,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,19.01757,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,47335093144,NDC,0.5,EA,44.33,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,19.01757,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ticagrelor 90 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,186077739,NDC,1,EA,44.35,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,19.02615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simethicone 40 MG/0.6ML Suspension 30 mL Bottle,25000000,CDM,250,RC,,,,,,904589430,NDC,30,ML,22.39,,First Health,Commercial,both,85,,999999999,percent of total billed charges,19.0315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
protamine 10 MG/ML Solution 25 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022930,NDC,2.5,ML,44.37,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,19.03473,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.431298,83.0452
pioglitazone 15 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342005410,NDC,1,EA,37.62,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.03572,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409427602,NDC,50,ML,38.46,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,19.0377,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Calprotectin, Fecal - Ref",PX8399390,CDM,300,RC,83993,CPT,90,,,,,,,401,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,19.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.04,19.63
"Calprotectin, Fecal - Ref",PX8399390,CDM,300,RC,83993,CPT,90,,,,,,,401,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,19.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.04,19.63
"Calprotectin, Fecal - Ref",PX8399390,CDM,300,RC,83993,CPT,90,,,,,,,401,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,19.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.04,19.63
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Flex Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707526,NDC,100,ML,37.63,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.04078,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
rosuvastatin 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003001,NDC,0.5,EA,21.59,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,19.04238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone-salmeterol 100-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069500,NDC,1,EA,38.87,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.0463,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone-salmeterol 100-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069500,NDC,1,EA,38.87,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.0463,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone-salmeterol 100-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069500,NDC,1,EA,38.87,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.0463,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084027011,NDC,1,EA,20.91,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,19.04901,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084027001,NDC,1,EA,20.91,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,19.04901,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone-salmeterol 250-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,54032756,NDC,1,EA,45.88,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,19.058552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600701,NDC,10,ML,39.73,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.0704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,38.9354
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600701,NDC,10,ML,39.73,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.0704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,38.9354
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,703903201,NDC,2,ML,44.46,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,19.07334,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,97.0102
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2021301,NDC,3,ML,44.46,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,19.07334,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
benzoin Tincture 59 mL Bottle,25000000,CDM,250,RC,,,,,,49348080130,NDC,59,ML,45.93,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,19.079322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
C-Peptide - Ref,PX8468190,CDM,300,RC,84681,CPT,90,,,,,,,180,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,19.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,176.4
Ca 19-9,PX86301,CDM,300,RC,86301,CPT,,,,,,,,116,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,19.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,113.68
"Immuno for Tumor Ag, Qn - Ref",PX8631690,CDM,300,RC,86316,CPT,90,,,,,,,115,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,19.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,112.7
"Immunoassay,Ca15-3(27.29) - Ref",PX8630090,CDM,300,RC,86300,CPT,90,,,,,,,124,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,19.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,121.52
"Tumor Antigen, Ca-125",PX86304,CDM,300,RC,86304,CPT,,,,,,,,190,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,19.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,186.2
valACYclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069801,NDC,1,EA,38.55,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,19.08225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,55150023501,NDC,0.5,EA,37.72,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.08632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323048201,NDC,10,ML,39.78,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.0944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323048201,NDC,10,ML,39.78,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.0944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323048217,NDC,10,ML,39.78,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.0944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323048217,NDC,10,ML,39.78,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.0944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049209,NDC,5,ML,44.52,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,19.09908,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
QUEtiapine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54022020,NDC,1,EA,21.46,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,19.0994,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
midazolam 2 MG/ML Syrup 5 mL Cup,63700001,CDM,250,RC,,,,,,68094076459,NDC,2.5,ML,22.47,,First Health,Commercial,both,85,,999999999,percent of total billed charges,19.0995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
neomycin-bacitracin-polymyxin 3.5-400-5000 Ointment 28.4 g Tube,25000000,CDM,250,RC,,,,,,713026831,NDC,28.4,GR,22.47,,First Health,Commercial,both,85,,999999999,percent of total billed charges,19.0995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
morphine 2 MG/ML Solution 1 mL Syringe,J2272.01,CDM,636,RC,J2272,HCPCS,,,,76045000401,NDC,1,ML,38.98,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.1002,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.192292,38.2004
morphine 2 MG/ML Solution 1 mL Syringe,J2272.01,CDM,636,RC,J2272,HCPCS,,,,76045000401,NDC,1,ML,38.98,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.1002,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.192292,38.2004
morphine 2 MG/ML Solution 1 mL Syringe,J2272.01,CDM,636,RC,J2272,HCPCS,,,,76045000401,NDC,1,ML,38.98,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.1002,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.192292,38.2004
neomycin-bacitracin-polymyxin 3.5-400-5000 Ointment 28 g Tube,25000000,CDM,250,RC,,,,,,45802014303,NDC,28,GR,37.76,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.10656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
DERMABOND ADVANCED TOPICAL SKIN ADHESIVE,120.198,CDM,272,RC,,,,9101-MAIN,LOCAL,,,,,46,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,19.1084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.1084,45.08
Pinworm Exam,PX87172,CDM,300,RC,87172,CPT,,,,,,,,46,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,19.1084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,45.08
CLOSED WOUND ROUND CHANNEL DRAIN WITH TROCAR 15FR FULL FLUTED,27200000,CDM,272,RC,,,,12223-MAIN,LOCAL,,,,,39,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CLOSED WOUND ROUND CHANNEL DRAIN WITH TROCAR 15FR FULL FLUTED,27200000,CDM,272,RC,,,,12223-MAIN,LOCAL,,,,,39,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CLOSED WOUND ROUND CHANNEL DRAIN WITH TROCAR 15FR FULL FLUTED,27200000,CDM,272,RC,,,,12223-MAIN,LOCAL,,,,,39,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
fluorouracil 500 MG/10ML Solution 10 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,63323011710,NDC,10,ML,39,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,256.2112
fluorouracil 500 MG/10ML Solution 10 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,63323011710,NDC,10,ML,39,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,256.2112
fluorouracil 500 MG/10ML Solution 10 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,63323011710,NDC,10,ML,39,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,256.2112
gemcitabine 200 MG Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323010294,NDC,1,EA,39,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
gemcitabine 200 MG Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323010294,NDC,1,EA,39,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
gemcitabine 200 MG Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323010294,NDC,1,EA,39,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
Lab Wbc and Differential,PX85004,CDM,300,RC,85004,CPT,,,,,,,,39,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,38.22
Lab Wbc and Differential,PX85004,CDM,300,RC,85004,CPT,,,,,,,,39,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,38.22
Lab Wbc and Differential,PX85004,CDM,300,RC,85004,CPT,,,,,,,,39,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,38.22
"Lactoferrin, Fecal; Qual",PX83630,CDM,300,RC,83630,CPT,,,,,,,,103,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,19.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.11,19.7
"Lactoferrin, Fecal; Qual",PX83630,CDM,300,RC,83630,CPT,,,,,,,,103,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,19.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.11,19.7
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003928,NDC,1,EA,39,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003928,NDC,1,EA,39,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003928,NDC,1,EA,39,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
methylPREDNISolone sod succ 500 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9075801,NDC,0.25,EA,39,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
methylPREDNISolone sod succ 500 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9075801,NDC,0.25,EA,39,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
methylPREDNISolone sod succ 500 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9075801,NDC,0.25,EA,39,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
NEEDLE JAMSHIDI 11G X 101MM BIOPSY DJ4011X,27200000,CDM,272,RC,,,,12798-MAIN,LOCAL,,,,,39,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NEEDLE JAMSHIDI 11G X 101MM BIOPSY DJ4011X,27200000,CDM,272,RC,,,,12798-MAIN,LOCAL,,,,,39,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NEEDLE JAMSHIDI 11G X 101MM BIOPSY DJ4011X,27200000,CDM,272,RC,,,,12798-MAIN,LOCAL,,,,,39,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
O2 SENSOR ADULT ADHESIVE SINGLE PATIENT 040-003382-00,120.576,CDM,272,RC,,,,12930-MAIN,LOCAL,,,,,39,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
O2 SENSOR ADULT ADHESIVE SINGLE PATIENT 040-003382-00,120.576,CDM,272,RC,,,,12930-MAIN,LOCAL,,,,,39,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
O2 SENSOR ADULT ADHESIVE SINGLE PATIENT 040-003382-00,120.576,CDM,272,RC,,,,12930-MAIN,LOCAL,,,,,39,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
O2 SENSOR INFANT ADHESIVE SINGLE PATIENT 040-003384-00,120.576,CDM,272,RC,,,,12932-MAIN,LOCAL,,,,,39,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
O2 SENSOR INFANT ADHESIVE SINGLE PATIENT 040-003384-00,120.576,CDM,272,RC,,,,12932-MAIN,LOCAL,,,,,39,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
O2 SENSOR INFANT ADHESIVE SINGLE PATIENT 040-003384-00,120.576,CDM,272,RC,,,,12932-MAIN,LOCAL,,,,,39,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
O2 SENSOR PEDIATRIC ADHESIVE SINGLE PATIENT 040-003383-00,120.576,CDM,272,RC,,,,12931-MAIN,LOCAL,,,,,39,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
O2 SENSOR PEDIATRIC ADHESIVE SINGLE PATIENT 040-003383-00,120.576,CDM,272,RC,,,,12931-MAIN,LOCAL,,,,,39,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
O2 SENSOR PEDIATRIC ADHESIVE SINGLE PATIENT 040-003383-00,120.576,CDM,272,RC,,,,12931-MAIN,LOCAL,,,,,39,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
SLEEVE ACHILLES LG/XL PROTECTION 92437145348,120.422,CDM,271,RC,,,,11378-MAIN,LOCAL,,,,,39,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
SLEEVE ACHILLES LG/XL PROTECTION 92437145348,120.422,CDM,271,RC,,,,11378-MAIN,LOCAL,,,,,39,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
SLEEVE ACHILLES LG/XL PROTECTION 92437145348,120.422,CDM,271,RC,,,,11378-MAIN,LOCAL,,,,,39,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
SLEEVE ACHILLES SM/MED PROTECTION 92437145324,120.422,CDM,271,RC,,,,11377-MAIN,LOCAL,,,,,39,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
SLEEVE ACHILLES SM/MED PROTECTION 92437145324,120.422,CDM,271,RC,,,,11377-MAIN,LOCAL,,,,,39,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
SLEEVE ACHILLES SM/MED PROTECTION 92437145324,120.422,CDM,271,RC,,,,11377-MAIN,LOCAL,,,,,39,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
Treponema Pallidum - Ref,PX8678090,CDM,300,RC,86780,CPT,90,,,,,,,39,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.14,38.22
Treponema Pallidum - Ref,PX8678090,CDM,300,RC,86780,CPT,90,,,,,,,39,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.14,38.22
Treponema Pallidum - Ref,PX8678090,CDM,300,RC,86780,CPT,90,,,,,,,39,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.14,38.22
TROCAR KII FIOS SYSTEM BLADELSS Z-THREAD 5MMX150MM,27200000,CDM,272,RC,,,,12827-MAIN,LOCAL,,,,,39,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR KII FIOS SYSTEM BLADELSS Z-THREAD 5MMX150MM,27200000,CDM,272,RC,,,,12827-MAIN,LOCAL,,,,,39,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR KII FIOS SYSTEM BLADELSS Z-THREAD 5MMX150MM,27200000,CDM,272,RC,,,,12827-MAIN,LOCAL,,,,,39,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Lactoferrin, Fecal; Qual",PX83630,CDM,300,RC,83630,CPT,,,,,,,,103,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,19.11,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.11,19.7
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409427617,NDC,50,ML,39.01,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.1149,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409427617,NDC,50,ML,39.01,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.1149,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409427617,NDC,50,ML,39.01,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.1149,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dabigatran 75 MG capsule 60 Each Box,63700001,CDM,250,RC,,,,,,597014960,NDC,1,EA,39.83,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.1184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dabigatran 75 MG capsule 60 Each Box,63700001,CDM,250,RC,,,,,,597014960,NDC,1,EA,39.83,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.1184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070102,NDC,1,ML,383.6,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,19.12,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.12,21.99
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070110,NDC,1,ML,459.95,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,19.12,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.12,21.99
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039814,NDC,1,EA,39.84,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.1232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039814,NDC,1,EA,39.84,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.1232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
BUPivacaine PF 0.5 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,55150016910,NDC,10,ML,39.84,,Health Partners,Health Partners Care Plans,both,48,,0.387,percent of total billed charges,19.1232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine PF 0.5 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,55150016910,NDC,10,ML,39.84,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.1232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
enalaprilat 1.25 MG/ML Injectable 1 mL Vial,25000000,CDM,250,RC,,,,,,143978710,NDC,1,ML,39.84,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.1232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
enalaprilat 1.25 MG/ML Injectable 1 mL Vial,25000000,CDM,250,RC,,,,,,143978710,NDC,1,ML,39.84,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.1232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098141,NDC,1,EA,39.84,,Health Partners,Health Partners Care Plans,both,48,,6.796666667,percent of total billed charges,19.1232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098141,NDC,1,EA,39.84,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.1232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098153,NDC,1,EA,39.84,,Health Partners,Health Partners Care Plans,both,48,,6.796666667,percent of total billed charges,19.1232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098153,NDC,1,EA,39.84,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.1232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,47781059807,NDC,1,EA,39.84,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.1232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,47781059807,NDC,1,EA,39.84,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.1232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
apixaban 5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,3089421,NDC,0.5,EA,22.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,19.125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
APPLICATOR CHLORAPREP 26ML WITH ORANGE 930815,27200000,CDM,272,RC,A4248,HCPCS,,10031-MAIN,LOCAL,,,,,19.65,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,19.125345,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Progesterone,PX84144,CDM,300,RC,84144,CPT,,,,,,,,56,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,19.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.13,54.88
Anesthesia Level 4,PX37000018,CDM,370,RC,,,,,,,,,,21,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,19.131,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.7234,20.58
ANOSCOPE LIGHTED ANOSCOPE,120.52,CDM,272,RC,,,,10235-MAIN,LOCAL,,,,,21,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,19.131,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.7234,20.58
"Hepatitis B Core Antibody, Total",PX86704,CDM,300,RC,86704,CPT,,,,,,,,21,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,19.131,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.7234,20.58
"Spectrophotometry, Nos",PX84311,CDM,300,RC,84311,CPT,,,,,,,,21,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,19.131,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.43,20.58
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143966001,NDC,5,ML,37.82,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.13692,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143966010,NDC,5,ML,37.82,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.13692,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,55150025110,NDC,10,ML,37.85,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.1521,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733513,NDC,1,EA,39.12,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,9.983703704,percent of total billed charges,19.1688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733513,NDC,1,EA,39.12,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.1688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733513,NDC,1,EA,39.12,,United Healthcare,All Medicare advantage plans,outpatient,49,,3.9675,percent of total billed charges,19.1688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
levoFLOXacin 750 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635361,NDC,0.333333333,EA,39.14,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.1786,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levoFLOXacin 750 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635361,NDC,0.333333333,EA,39.14,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.1786,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levoFLOXacin 750 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635361,NDC,0.333333333,EA,39.14,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.1786,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143978410,NDC,2,ML,37.91,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.18246,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
rosuvastatin 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16714098801,NDC,1,EA,46.18,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,19.183172,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,36000014801,NDC,2,ML,38.76,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,19.1862,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
US Chest Tc,PX7660401,CDM,402,RC,76604,CPT,TC,,,,,,,248,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,19.19,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.19,59.82
X-Ray Exam Chest 3 Views,PX7104701,CDM,320,RC,71047,CPT,TC,,,,,,,340,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,19.19,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.19,57.85
Xray Cervical Spine 2 or 3 Vws,PX7204001,CDM,320,RC,72040,CPT,TC,,,,,,,436,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,19.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.97,57.19
Xray Cervical Spine 2 or 3 Vws,PX7204001,CDM,320,RC,72040,CPT,TC,,,,,,,436,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,19.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.97,57.19
Xray Hand 3vws Tc,PX7313001,CDM,320,RC,73130,CPT,TC,,,,,,,374,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,19.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.75,57.19
Xray Hand 3vws Tc,PX7313001,CDM,320,RC,73130,CPT,TC,,,,,,,374,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,19.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.75,57.19
Xray Lumbosacral 2 or 3 Vws,PX7210001,CDM,320,RC,72100,CPT,TC,,,,,,,399,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,19.19,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.19,57.85
Xray Thoracic Spine 3 Vws,PX7207201,CDM,320,RC,72072,CPT,TC,,,,,,,522,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,19.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.75,57.19
Xray Thoracic Spine 3 Vws,PX7207201,CDM,320,RC,72072,CPT,TC,,,,,,,522,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,19.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.75,57.19
8MM-12MM TIP COVER ACCESSORY,27200000,CDM,272,RC,,,,11918-MAIN,LOCAL,,,,,40,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM-12MM TIP COVER ACCESSORY,27200000,CDM,272,RC,,,,11918-MAIN,LOCAL,,,,,40,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CATHETER URETERAL  5FR TIGERTAIL OPEN TIP FLEXIBLE 139005,27200000,CDM,272,RC,A4340,HCPCS,,12302-MAIN,LOCAL,,,,,40,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CATHETER URETERAL  5FR TIGERTAIL OPEN TIP FLEXIBLE 139005,27200000,CDM,272,RC,A4340,HCPCS,,12302-MAIN,LOCAL,,,,,40,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NEEDLE BIOPSY 14GAX4 1/2 2N2702X,120.211,CDM,272,RC,,,,724-MAIN,LOCAL,,,,,40,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.616,39.2
NEEDLE BIOPSY 14GAX4 1/2 2N2702X,120.211,CDM,272,RC,,,,724-MAIN,LOCAL,,,,,40,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.616,39.2
STAPLER CANNULA SEAL 12 mm 470380,27200000,CDM,272,RC,,,,11962-MAIN,LOCAL,,,,,40,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STAPLER CANNULA SEAL 12 mm 470380,27200000,CDM,272,RC,,,,11962-MAIN,LOCAL,,,,,40,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"SUTURE V-LOC 22G NEEDLE 9"" 180 GREEN VLOCL2145",27200000,CDM,272,RC,,,,11930-MAIN,LOCAL,,,,,40,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"SUTURE V-LOC 22G NEEDLE 9"" 180 GREEN VLOCL2145",27200000,CDM,272,RC,,,,11930-MAIN,LOCAL,,,,,40,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"SUTURE V-LOC SZ 0.9"" 180 GREEN GS-21 NEEDLE VLOCL0346",27200000,CDM,272,RC,,,,11933-MAIN,LOCAL,,,,,40,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"SUTURE V-LOC SZ 0.9"" 180 GREEN GS-21 NEEDLE VLOCL0346",27200000,CDM,272,RC,,,,11933-MAIN,LOCAL,,,,,40,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Telehealth Origin Site Fac Fee,PXQ3014,CDM,780,RC,Q3014,HCPCS,,,,,,,,40,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.616,39.2
Telehealth Origin Site Fac Fee,PXQ3014,CDM,780,RC,Q3014,HCPCS,,,,,,,,40,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.616,39.2
valACYclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,31722070430,NDC,1,EA,38.79,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,19.20105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tamsulosin 0.4 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904640161,NDC,1,EA,22.6,,First Health,Commercial,both,85,,999999999,percent of total billed charges,19.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003001,NDC,0.5,EA,21.59,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,19.2151,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048203,NDC,20,ML,44.8,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,19.2192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048227,NDC,20,ML,44.8,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,19.2192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
8MM-12MM CANNULA SEAL 5-8MM,27200000,CDM,272,RC,,,,11921-MAIN,LOCAL,,,,,38,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRAPE COLUMN 470341,27200000,CDM,272,RC,,,,12013-MAIN,LOCAL,,,,,38,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HH Hha Visit,PXG0156,CDM,571,RC,G0156,HCPCS,,,,,,,,38,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
Mitochondrial Antibody Each,PX8638190,CDM,300,RC,86381,CPT,90,,,,,,,38,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
Nasal Sm for Eos,PX89190,CDM,300,RC,89190,CPT,,,,,,,,38,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.31,37.24
NEEDLE IV 19GA X .75IN HUBER POWERLOC SAFETY 0651934,120.85,CDM,272,RC,A4215,HCPCS,,12701-MAIN,LOCAL,,,,,38,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
NEEDLE IV 19GA X 1 IN HUBER POWERLOC SAFETY 0651910,120.85,CDM,272,RC,A4215,HCPCS,,12702-MAIN,LOCAL,,,,,38,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
NEEDLE IV 19GA X 1.5 IN HUBER POWERLOC SAFETY 0651915,120.85,CDM,272,RC,A4215,HCPCS,,12703-MAIN,LOCAL,,,,,38,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
PEZZER CATHETER DRAIN LATEX 14FR,27200000,CDM,272,RC,,,,12053-MAIN,LOCAL,,,,,38,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PEZZER LATEX CATHETER DRAIN 10FR,27200000,CDM,272,RC,,,,12646-MAIN,LOCAL,,,,,38,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PNEUVIEW SMOKE ELIMINATOR,27200000,CDM,272,RC,,,,11884-MAIN,LOCAL,,,,,38,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Psa, Free - Ref",PX8415490,CDM,300,RC,84154,CPT,90,,,,,,,38,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
"Psa, Total - Ref",PX8415390,CDM,300,RC,84153,CPT,90,,,,,,,38,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
SPECULUM VAGINAL WITH BUILT IN LIGHT LARGE,120.133,CDM,272,RC,,,,8251-MAIN,LOCAL,,,,,38,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
SPECULUM VAGINAL WITH BUILT IN LIGHT MEDIUM,120.133,CDM,272,RC,,,,8250-MAIN,LOCAL,,,,,38,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
SPECULUM VAGINAL WITH BUILT IN LIGHT SMALL,120.133,CDM,272,RC,,,,8249-MAIN,LOCAL,,,,,38,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
TROCAR KII FIOS SYSTEM BLADELSS Z-THREAD 5MMX100MM,27200000,CDM,272,RC,,,,12003-MAIN,LOCAL,,,,,38,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
risperiDONE 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635861,NDC,1,EA,21.11,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,19.23121,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone-salmeterol 100-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069500,NDC,1,EA,38.87,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,19.24065,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Venipuncture, Lab",PX3641502,CDM,300,RC,36415,CPT,,,,,,,,61,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,19.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.1,65.45
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707426,NDC,100,ML,39.29,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1.633818182,percent of total billed charges,19.2521,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707426,NDC,100,ML,39.29,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.2521,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707426,NDC,100,ML,39.29,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.2521,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"Calprotectin, Fecal - Ref",PX8399390,CDM,300,RC,83993,CPT,90,,,,,,,401,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,19.254,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.04,19.63
"Lactoferrin, Fecal; Qual",PX83630,CDM,300,RC,83630,CPT,,,,,,,,103,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,19.254,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.11,19.7
APPLICATOR CHLORAPREP 26ML WITH ORANGE 930815,27200000,CDM,272,RC,A4248,HCPCS,,10031-MAIN,LOCAL,,,,,19.65,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,19.257,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
leucovorin 10 mg/mL Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,25021081467,NDC,1,EA,40.13,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.2624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.670002,84.6818
leucovorin 10 mg/mL Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,25021081467,NDC,1,EA,40.13,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.2624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.670002,84.6818
ezetimibe 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714081301,NDC,1,EA,44.91,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,19.26639,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001001,NDC,1.5,ML,40.17,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.2816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,42.5516
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001001,NDC,1.5,ML,40.17,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.2816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,42.5516
Spirometry,PX9401001,CDM,460,RC,94010,CPT,TC,,,,,,,281,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,19.29,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.21,33.74
Spirometry Incl Graph Rec Tc,PX9401002,CDM,460,RC,94010,CPT,TC,,,,,,,288,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,19.29,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.21,33.74
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253022233,NDC,3,ML,38.13,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.29378,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
morphine 2 MG/ML Solution 1 mL Syringe,J2272.01,CDM,636,RC,J2272,HCPCS,,,,76045000401,NDC,1,ML,38.98,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,19.2951,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.192292,38.2004
Cardiac Rehab,PX93797F,CDM,943,RC,93797,CPT,,,,,,,,45,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,19.305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,115.44
CATHETER TEMP-SENSING 8FR LUBRISIL PEDS DYND110508,120.363,CDM,272,RC,A4340,HCPCS,,12777-MAIN,LOCAL,,,,,45,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,19.305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
CATHETER TEMP-SENSING 12FR LUBRISIL 119212M,120.363,CDM,272,RC,A4340,HCPCS,,10750-MAIN,LOCAL,,,,,45,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,19.305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
CATHETER TEMP-SENSING 14FR LUBRISIL 119214M,120.363,CDM,272,RC,A4340,HCPCS,,10751-MAIN,LOCAL,,,,,45,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,19.305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
CATHETER TEMP-SENSING 16FR LUBRISIL 119216M,120.363,CDM,272,RC,A4340,HCPCS,,10752-MAIN,LOCAL,,,,,45,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,19.305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
CLOSED WOUND ROUND CHANNEL DRAIN WITH TROCAR 15FR FULL FLUTED,27200000,CDM,272,RC,,,,12223-MAIN,LOCAL,,,,,39,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,19.305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Cryptococcus Neoformans,PX87327,CDM,300,RC,87327,CPT,,,,,,,,45,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,19.305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.3,44.1
fluorouracil 500 MG/10ML Solution 10 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,63323011710,NDC,10,ML,39,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,19.305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,256.2112
Gammaglobulin; Ige - Ref,PX8278590,CDM,300,RC,82785,CPT,90,,,,,,,45,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,19.305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.09,44.1
GASTRONOMY FEEDING TUBE MIC BALLOONED 20FR 7-10ML 0112-20,27200000,CDM,272,RC,B4087,HCPCS,,13098-MAIN,LOCAL,,,,,45,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,19.305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
gemcitabine 200 MG Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323010294,NDC,1,EA,39,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,19.305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
K-WIRES 1.6MM,27200000,CDM,272,RC,C1769,HCPCS,,11852-MAIN,LOCAL,,,,,45,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,19.305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"La Crosse, Antibody - Ref",PX8665190,CDM,300,RC,86651,CPT,90,,,,,,,45,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,19.305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.09,44.1
Lab Wbc and Differential,PX85004,CDM,300,RC,85004,CPT,,,,,,,,39,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,19.305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,38.22
MELGISORB AG SILVER CALCIUM STERILE 6X6,120.502,CDM,272,RC,A6197,HCPCS,,11844-MAIN,LOCAL,,,,,45,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,19.305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003928,NDC,1,EA,39,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,19.305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
methylPREDNISolone sod succ 500 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9075801,NDC,0.25,EA,39,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,19.305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
NEEDLE JAMSHIDI 11G X 101MM BIOPSY DJ4011X,27200000,CDM,272,RC,,,,12798-MAIN,LOCAL,,,,,39,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,19.305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
O2 SENSOR ADULT ADHESIVE SINGLE PATIENT 040-003382-00,120.576,CDM,272,RC,,,,12930-MAIN,LOCAL,,,,,39,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,19.305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
O2 SENSOR INFANT ADHESIVE SINGLE PATIENT 040-003384-00,120.576,CDM,272,RC,,,,12932-MAIN,LOCAL,,,,,39,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,19.305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
O2 SENSOR PEDIATRIC ADHESIVE SINGLE PATIENT 040-003383-00,120.576,CDM,272,RC,,,,12931-MAIN,LOCAL,,,,,39,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,19.305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
SLEEVE ACHILLES LG/XL PROTECTION 92437145348,120.422,CDM,271,RC,,,,11378-MAIN,LOCAL,,,,,39,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,19.305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
SLEEVE ACHILLES SM/MED PROTECTION 92437145324,120.422,CDM,271,RC,,,,11377-MAIN,LOCAL,,,,,39,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,19.305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
"St Louis, Antibody - Ref",PX8665390,CDM,300,RC,86653,CPT,90,,,,,,,45,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,19.305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.09,44.1
"Sugars, Qual, Ea Spec - Ref",PX8437690,CDM,300,RC,84376,CPT,90,,,,,,,45,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,19.305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.04,44.1
Treponema Pallidum - Ref,PX8678090,CDM,300,RC,86780,CPT,90,,,,,,,39,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,19.305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.14,38.22
TROCAR KII FIOS SYSTEM BLADELSS Z-THREAD 5MMX150MM,27200000,CDM,272,RC,,,,12827-MAIN,LOCAL,,,,,39,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,19.305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Venipuncture by Physician, Other Vein, Under Age 3 Years",PX36406,CDM,983,RC,36406,CPT,,,,,,,,45,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,19.305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,43.7985
"Western Equine, Ab - Ref",PX8665490,CDM,300,RC,86654,CPT,90,,,,,,,45,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,19.305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.09,44.1
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409427617,NDC,50,ML,39.01,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,19.30995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Psa Screening,PXG0103,CDM,300,RC,G0103,HCPCS,,,,,,,,157,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,19.31,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.73,19.31
atropine 1 mg/mL Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100101,NDC,0.2,ML,39.42,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.3158,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
atropine 1 mg/mL Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100101,NDC,0.2,ML,39.42,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.3158,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
atropine 1 mg/mL Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100101,NDC,0.2,ML,39.42,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.3158,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
HYDROmorphone 2 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409131203,NDC,1,ML,38.18,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.31908,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
"Gput, Quant",PX8277590,CDM,300,RC,82775,CPT,90,,,,,,,25,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,19.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010301,NDC,0.3,ML,45.04,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,19.32216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
Neg Pressure Wound Therapy Dme >50 Sq Cm,PX97606F,CDM,761,RC,97606,CPT,,,,,,,,404,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,19.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.75,67.21
Neg Pressure Wound Therapy Dme >50 Sq Cm,PX97606F,CDM,761,RC,97606,CPT,,,,,,,,404,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,19.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.75,67.21
"Cognitive Skill Dev, Ea 15 Min",PX97532,CDM,420,RC,97532,CPT,,,,,,,,157,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,19.34,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.34,19.344
ursodiol 300 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,591315901,NDC,1,EA,39.47,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.3403,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ursodiol 300 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,591315901,NDC,1,EA,39.47,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.3403,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ursodiol 300 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,591315901,NDC,1,EA,39.47,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.3403,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Cognitive Skill Dev, Ea 15 Min",PX97532,CDM,420,RC,97532,CPT,,,,,,,,157,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,19.344,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.34,19.344
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,703291401,NDC,0.5,EA,40.3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,703291401,NDC,0.5,EA,40.3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Rickettsia Antibody - Ref,PX8675790,CDM,300,RC,86757,CPT,90,,,,,,,52,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,19.35,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.77,19.35
BIOPSY FORCEPS HOT,27200000,CDM,272,RC,,,,4353-MAIN,LOCAL,,,,,38.25,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.3545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRESSING GEL FOAM SIZE 100SPONGE STERILE 00009034201,27200000,CDM,272,RC,A6248,HCPCS,,3378-MAIN,LOCAL,,,,,38.25,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.3545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFFLATION TUBING SET,27200000,CDM,272,RC,,,,4686-MAIN,LOCAL,,,,,38.25,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.3545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733513,NDC,1,EA,39.12,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,19.3644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
povidone-iodine 10 % Ointment 28.35 g Tube,63700001,CDM,250,RC,,,,,,904110231,NDC,28.35,GR,19.9,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,19.36867,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levoFLOXacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635261,NDC,0.5,EA,45.16,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,19.37364,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levoFLOXacin 750 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635361,NDC,0.333333333,EA,39.14,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,19.3743,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Prolactin,PX84146,CDM,300,RC,84146,CPT,,,,,,,,112,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,19.38,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.51,19.38
methylPREDNISolone sod succ 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,63323025803,NDC,0.4,EA,46.67,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,19.386718,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
enalaprilat 1.25 MG/ML Injectable 1 mL Vial,25000000,CDM,250,RC,,,,,,143978701,NDC,1,ML,40.39,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.3872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
enalaprilat 1.25 MG/ML Injectable 1 mL Vial,25000000,CDM,250,RC,,,,,,143978701,NDC,1,ML,40.39,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.3872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
bisoprolol-hydroCHLOROthiazide 5-6.25 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,42799092102,NDC,1,EA,39.57,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.3893,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisoprolol-hydroCHLOROthiazide 5-6.25 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,42799092102,NDC,1,EA,39.57,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.3893,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bisoprolol-hydroCHLOROthiazide 5-6.25 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,42799092102,NDC,1,EA,39.57,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.3893,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078110,NDC,0.5,EA,38.33,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.39498,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Myoglobin - Ref,PX8387490,CDM,300,RC,83874,CPT,90,,,,,,,22,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,19.404,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.1388,21.56
SUTURE POLYSORB BRAIDED ABSORBABLE VIOLET SIZE 0 30IN WITH 5/8 CIRCLE TAPER POINT 27MM NEEDLE,27200000,CDM,272,RC,,,,11985-MAIN,LOCAL,,,,,22,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,19.404,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TEGADERM CHLORHEXIDINE-GLUCONATE,120.356,CDM,272,RC,A4221,HCPCS,,10708-MAIN,LOCAL,,,,,22,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,19.404,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.1388,21.56
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028002,NDC,1,ML,40.43,,Health Partners,Health Partners Care Plans,both,48,,7.095,percent of total billed charges,19.4064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028002,NDC,1,ML,40.43,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.4064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
X-Ray Exam Chest 3 Views,PX7104701,CDM,320,RC,71047,CPT,TC,,,,,,,340,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,19.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.19,57.85
X-Ray Exam Chest 3 Views,PX7104701,CDM,320,RC,71047,CPT,TC,,,,,,,340,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,19.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.19,57.85
Xray Lumbosacral 2 or 3 Vws,PX7210001,CDM,320,RC,72100,CPT,TC,,,,,,,399,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,19.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.19,57.85
Xray Lumbosacral 2 or 3 Vws,PX7210001,CDM,320,RC,72100,CPT,TC,,,,,,,399,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,19.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.19,57.85
Xray Ribs Unilat 2 Vws With Pa Chest,PX7110101,CDM,320,RC,71101,CPT,TC,,,,,,,792,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,19.41,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.41,58.51
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253033335,NDC,5,ML,40.44,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.4112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253033335,NDC,5,ML,40.44,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.4112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
SAW BLADE 300 SAGITTAL 25X9.4X0.7,27200000,CDM,272,RC,,,,11592-MAIN,LOCAL,,,,,46.75,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,19.41995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SAW BLADE 300 SAGITTAL 40X14X0.6MM,27200000,CDM,272,RC,,,,11591-MAIN,LOCAL,,,,,46.75,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,19.41995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
amiodarone 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,245014789,NDC,0.5,EA,21.33,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,19.43163,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,245014701,NDC,0.5,EA,21.33,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,19.43163,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cefaDROXil 500 MG capsule 50 Each Bottle,63700001,CDM,250,RC,,,,,,16714038801,NDC,1,EA,19.98,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,19.446534,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707426,NDC,100,ML,39.29,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,19.44855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
Candida Dna Dir Probe,PX87480,CDM,300,RC,87480,CPT,,,,,,,,127,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,19.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.45,20.05
Candida Dna Dir Probe,PX87480,CDM,300,RC,87480,CPT,,,,,,,,127,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,19.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.45,20.05
Candida Dna Dir Probe,PX87480,CDM,300,RC,87480,CPT,,,,,,,,127,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,19.45,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.45,20.05
Gardner Vag Dna Dir Probe,PX87510,CDM,300,RC,87510,CPT,,,,,,,,127,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,19.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.45,20.05
Gardner Vag Dna Dir Probe,PX87510,CDM,300,RC,87510,CPT,,,,,,,,127,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,19.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.45,20.05
Gardner Vag Dna Dir Probe,PX87510,CDM,300,RC,87510,CPT,,,,,,,,127,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,19.45,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.45,20.05
"Organic Acid, Single, Qnt - Ref",PX8392190,CDM,300,RC,83921,CPT,90,,,,,,,209,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,19.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.45,204.82
Trichomonas Vagin Dir Probe,PX87660,CDM,300,RC,87660,CPT,,,,,,,,127,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,19.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.45,20.05
Trichomonas Vagin Dir Probe,PX87660,CDM,300,RC,87660,CPT,,,,,,,,127,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,19.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.45,20.05
Trichomonas Vagin Dir Probe,PX87660,CDM,300,RC,87660,CPT,,,,,,,,127,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,19.45,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.45,20.05
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409427602,NDC,50,ML,38.46,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.46076,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Bacterium Nos, Antibody - Ref",PX8660990,CDM,300,RC,86609,CPT,90,,,,,,,20,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,19.466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
DRESSING QWICK NONADHESIVE 4.25X4 SUPERABSORBENT MSC5844,120.531,CDM,272,RC,A6197,HCPCS,,12301-MAIN,LOCAL,,,,,20,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,19.466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
Glucose Blood Test,PX82962,CDM,300,RC,82962,CPT,,,,,,,,20,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,7.848363636,percent of total billed charges,19.466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.01,19.6
Phenobarbital Assay - Ref,PX8018490,CDM,300,RC,80184,CPT,90,,,,,,,20,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,19.466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
Primidone Assay - Ref,PX8018890,CDM,300,RC,80188,CPT,90,,,,,,,20,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,19.466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER  STRAIGHT TAPER TIP 20FR PVC,120.528,CDM,272,RC,,,,12247-MAIN,LOCAL,,,,,20,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,19.466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER  STRAIGHT TAPER TIP 24FR PVC,120.528,CDM,272,RC,,,,12248-MAIN,LOCAL,,,,,20,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,19.466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 8FR PVC,120.528,CDM,272,RC,,,,12253-MAIN,LOCAL,,,,,20,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,19.466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 10FR PVC,120.528,CDM,272,RC,,,,12254-MAIN,LOCAL,,,,,20,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,19.466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 12FR PVC,120.528,CDM,272,RC,,,,12255-MAIN,LOCAL,,,,,20,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,19.466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 16FR PVC,120.528,CDM,272,RC,,,,12256-MAIN,LOCAL,,,,,20,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,19.466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 28FR PVC,120.528,CDM,272,RC,,,,12249-MAIN,LOCAL,,,,,20,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,19.466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 32FR PVC,120.528,CDM,272,RC,,,,12250-MAIN,LOCAL,,,,,20,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,19.466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 36FR PVC,120.528,CDM,272,RC,,,,12251-MAIN,LOCAL,,,,,20,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,19.466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600701,NDC,10,ML,39.73,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.4677,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,38.9354
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600701,NDC,10,ML,39.73,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.4677,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,38.9354
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600701,NDC,10,ML,39.73,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.4677,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,38.9354
"Apply Finger Splint,Static",PX29130F,CDM,420,RC,29130,CPT,,,,,,,,196,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,19.47,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.66,88.55
"Apply Finger Splint,Static",PX29130P,CDM,983,RC,29130,CPT,,,,,,,,223,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,19.47,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.66,218.54
"Manual Ther Tech,1+Regions,Ea 15 Min",PX97140,CDM,420,RC,97140,CPT,,,,,,,,135,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,19.47,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.47,35.58
Vitamin B-1 - Ref,PX8442590,CDM,300,RC,84425,CPT,90,,,,,,,130,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,19.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.47,127.4
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,641601310,NDC,5,ML,40.58,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.4784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,641601310,NDC,5,ML,40.58,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.4784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
polyvinyl alcohol 1.4 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,50268067815,NDC,15,ML,45.42,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,19.48518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323048201,NDC,10,ML,39.78,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.4922,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323048201,NDC,10,ML,39.78,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.4922,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323048201,NDC,10,ML,39.78,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.4922,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323048217,NDC,10,ML,39.78,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.4922,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323048217,NDC,10,ML,39.78,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.4922,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323048217,NDC,10,ML,39.78,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.4922,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
skin oil Oil 236.6 mL Bottle,63700001,CDM,250,RC,,,,,,67211008,NDC,236.6,ML,40.61,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.4928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
skin oil Oil 236.6 mL Bottle,63700001,CDM,250,RC,,,,,,67211008,NDC,236.6,ML,40.61,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.4928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
povidone-iodine 10 % Ointment 28.35 g Tube,63700001,CDM,250,RC,,,,,,904110231,NDC,28.35,GR,19.9,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,19.502,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188602,NDC,5,ML,45.46,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,19.50234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.884084,44.5508
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188622,NDC,5,ML,45.46,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,19.50234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.884084,44.5508
valACYclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069801,NDC,1,EA,38.55,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.5063,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atropine 1 mg/mL Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100101,NDC,0.2,ML,39.42,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,19.5129,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
naltrexone 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406117001,NDC,1,EA,22.96,,First Health,Commercial,both,85,,999999999,percent of total billed charges,19.516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dabigatran 75 MG capsule 60 Each Box,63700001,CDM,250,RC,,,,,,597014960,NDC,1,EA,39.83,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.5167,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dabigatran 75 MG capsule 60 Each Box,63700001,CDM,250,RC,,,,,,597014960,NDC,1,EA,39.83,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.5167,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dabigatran 75 MG capsule 60 Each Box,63700001,CDM,250,RC,,,,,,597014960,NDC,1,EA,39.83,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.5167,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039814,NDC,1,EA,39.84,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,11.105,percent of total billed charges,19.5216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039814,NDC,1,EA,39.84,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.5216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039814,NDC,1,EA,39.84,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.5216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
BUPivacaine PF 0.5 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,55150016910,NDC,10,ML,39.84,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.216692234,percent of total billed charges,19.5216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine PF 0.5 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,55150016910,NDC,10,ML,39.84,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.5216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine PF 0.5 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,55150016910,NDC,10,ML,39.84,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.5216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
enalaprilat 1.25 MG/ML Injectable 1 mL Vial,25000000,CDM,250,RC,,,,,,143978710,NDC,1,ML,39.84,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.5216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
enalaprilat 1.25 MG/ML Injectable 1 mL Vial,25000000,CDM,250,RC,,,,,,143978710,NDC,1,ML,39.84,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.5216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
enalaprilat 1.25 MG/ML Injectable 1 mL Vial,25000000,CDM,250,RC,,,,,,143978710,NDC,1,ML,39.84,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.5216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098141,NDC,1,EA,39.84,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,14.99111111,percent of total billed charges,19.5216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098141,NDC,1,EA,39.84,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.5216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098141,NDC,1,EA,39.84,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.5216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098153,NDC,1,EA,39.84,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,14.99111111,percent of total billed charges,19.5216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098153,NDC,1,EA,39.84,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.5216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098153,NDC,1,EA,39.84,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.5216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,47781059807,NDC,1,EA,39.84,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,12.3175,percent of total billed charges,19.5216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,47781059807,NDC,1,EA,39.84,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.5216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,47781059807,NDC,1,EA,39.84,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.5216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
Blood Count Reticulocytes Auto 1/> Cell Meas,PX85046,CDM,300,RC,85046,CPT,,,,,,,,47,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,19.5238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.11,46.06
"PAD BED SENSOR 10X28"" P-107517",120.124,CDM,271,RC,,,,8377-MAIN,LOCAL,,,,,47,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,19.5238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.5238,46.06
"PAD CHAIR SENSOR 10x15"" 106380",120.124,CDM,271,RC,,,,8378-MAIN,LOCAL,,,,,47,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,19.5238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.5238,46.06
"Protein S, Free - Ref",PX8530690,CDM,300,RC,85306,CPT,90,,,,,,,47,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,19.5238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.05,46.06
REDUCER 12 - 8MM,27200000,CDM,272,RC,,,,11961-MAIN,LOCAL,,,,,47,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,19.5238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
triamcinolone acetonide 0.1 % Cream 15 g Tube,63700001,CDM,250,RC,,,,,,168000415,NDC,15,GR,22.97,,First Health,Commercial,both,85,,999999999,percent of total billed charges,19.5245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zinc oxide 20 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,536131625,NDC,60,GR,22.97,,First Health,Commercial,both,85,,999999999,percent of total billed charges,19.5245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 1 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,472034356,NDC,28,GR,22.15,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,19.5363,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ursodiol 300 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,591315901,NDC,1,EA,39.47,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,19.53765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BRACE WRIST 8-IN SM LEFT 10432,120.564,CDM,273,RC,L3809,HCPCS,,12720-MAIN,LOCAL,,,,,23,,First Health,Commercial,both,85,,999999999,percent of total billed charges,19.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 8-IN SM RIGHT 10442,120.564,CDM,273,RC,L3809,HCPCS,,12716-MAIN,LOCAL,,,,,23,,First Health,Commercial,both,85,,999999999,percent of total billed charges,19.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN LG RIGHT 10464,120.564,CDM,273,RC,L3809,HCPCS,,12719-MAIN,LOCAL,,,,,23,,First Health,Commercial,both,85,,999999999,percent of total billed charges,19.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN SM LEFT 617083,120.564,CDM,273,RC,L3809,HCPCS,,12722-MAIN,LOCAL,,,,,23,,First Health,Commercial,both,85,,999999999,percent of total billed charges,19.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN SM RIGHT 10462,120.564,CDM,273,RC,L3809,HCPCS,,12717-MAIN,LOCAL,,,,,23,,First Health,Commercial,both,85,,999999999,percent of total billed charges,19.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN XL LEFT 10455,120.564,CDM,273,RC,L3809,HCPCS,,12721-MAIN,LOCAL,,,,,23,,First Health,Commercial,both,85,,999999999,percent of total billed charges,19.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN XL RIGHT 10465,120.564,CDM,273,RC,L3809,HCPCS,,12715-MAIN,LOCAL,,,,,23,,First Health,Commercial,both,85,,999999999,percent of total billed charges,19.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST WRISTPRO LEFT 10-IN LG,120.564,CDM,273,RC,L3809,HCPCS,,12724-MAIN,LOCAL,,,,,23,,First Health,Commercial,both,85,,999999999,percent of total billed charges,19.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST WRISTPRO LEFT 10-IN MED,120.564,CDM,273,RC,L3809,HCPCS,,12723-MAIN,LOCAL,,,,,23,,First Health,Commercial,both,85,,999999999,percent of total billed charges,19.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
Clozapine - Ref,PX8015990,CDM,300,RC,80159,CPT,90,,,,,,,65,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,19.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.55,20.15
Clozapine - Ref,PX8015990,CDM,300,RC,80159,CPT,90,,,,,,,65,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,19.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.55,20.15
Clozapine - Ref,PX8015990,CDM,300,RC,80159,CPT,90,,,,,,,65,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,19.55,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.55,20.15
Detection of Babesia Borrelia Miyamotoi by Amplified Nucleic Acid Probe Technique,PX8747890,CDM,300,RC,87478,CPT,90,,,,,,,23,,First Health,Commercial,both,85,,999999999,percent of total billed charges,19.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,32.17
Detection of Babesia Microtim by Amplified Nucleic Acid Probe Technique,PX8746990,CDM,300,RC,87469,CPT,90,,,,,,,23,,First Health,Commercial,both,85,,999999999,percent of total billed charges,19.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,32.17
FORCEPS COLD BIOPSY,27200000,CDM,272,RC,,,,12453-MAIN,LOCAL,,,,,23,,First Health,Commercial,both,85,,999999999,percent of total billed charges,19.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE MAXON ABSORBABLE POLYGLYCONATE 2-0 30IN MONOFILAMENT DYED TAPER POINT 1/2 CIRCLE 27MM GS-22 G,27200000,CDM,272,RC,,,,11988-MAIN,LOCAL,,,,,23,,First Health,Commercial,both,85,,999999999,percent of total billed charges,19.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE POLYSORB ABSORBABLE LACTOMER 2-0 30IN BRAIDED DYED TAPER POINT 1/2 CIRCLE 26MM V-20 VIOLET ST,27200000,CDM,272,RC,,,,11983-MAIN,LOCAL,,,,,23,,First Health,Commercial,both,85,,999999999,percent of total billed charges,19.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
QUEtiapine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54022020,NDC,1,EA,21.46,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,19.55006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 37.5 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084069811,NDC,1,EA,20.09,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,19.553597,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 37.5 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084069801,NDC,1,EA,20.09,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,19.553597,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gemcitabine 200 MG/5.26ML Solution 5.26 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018301,NDC,5.26,ML,40.74,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.5552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
gemcitabine 200 MG/5.26ML Solution 5.26 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018301,NDC,5.26,ML,40.74,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.5552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
Candida Dna Dir Probe,PX87480,CDM,300,RC,87480,CPT,,,,,,,,127,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,19.5749,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.45,20.05
Gardner Vag Dna Dir Probe,PX87510,CDM,300,RC,87510,CPT,,,,,,,,127,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,19.5749,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.45,20.05
Trichomonas Vagin Dir Probe,PX87660,CDM,300,RC,87660,CPT,,,,,,,,127,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,19.5749,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.45,20.05
Myoglobin - Ref,PX8387490,CDM,300,RC,83874,CPT,90,,,,,,,22,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,19.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.1388,21.56
SUTURE POLYSORB BRAIDED ABSORBABLE VIOLET SIZE 0 30IN WITH 5/8 CIRCLE TAPER POINT 27MM NEEDLE,27200000,CDM,272,RC,,,,11985-MAIN,LOCAL,,,,,22,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,19.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TEGADERM CHLORHEXIDINE-GLUCONATE,120.356,CDM,272,RC,A4221,HCPCS,,10708-MAIN,LOCAL,,,,,22,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,19.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.1388,21.56
cefaDROXil 500 MG capsule 50 Each Bottle,63700001,CDM,250,RC,,,,,,16714038801,NDC,1,EA,19.98,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,19.5804,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 100 MG/5ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,68094049459,NDC,20,ML,22.2,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,19.5804,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Each Add'l Hour IV Infusion <8 Hour,PX96366,CDM,260,RC,96366,CPT,,,,,,,,161,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,19.581,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.31,35.48
FLEXITIP APPLICATOR 38CM,27200000,CDM,272,RC,,,,10200-MAIN,LOCAL,,,,,40.8,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
FLEXITIP APPLICATOR 38CM,27200000,CDM,272,RC,,,,10200-MAIN,LOCAL,,,,,40.8,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
bisoprolol-hydroCHLOROthiazide 5-6.25 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,42799092102,NDC,1,EA,39.57,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,19.58715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
8MM-12MM TIP COVER ACCESSORY,27200000,CDM,272,RC,,,,11918-MAIN,LOCAL,,,,,40,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM-12MM TIP COVER ACCESSORY,27200000,CDM,272,RC,,,,11918-MAIN,LOCAL,,,,,40,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM-12MM TIP COVER ACCESSORY,27200000,CDM,272,RC,,,,11918-MAIN,LOCAL,,,,,40,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Bacterium Nos, Antibody - Ref",PX8660990,CDM,300,RC,86609,CPT,90,,,,,,,20,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,19.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
CATHETER URETERAL  5FR TIGERTAIL OPEN TIP FLEXIBLE 139005,27200000,CDM,272,RC,A4340,HCPCS,,12302-MAIN,LOCAL,,,,,40,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CATHETER URETERAL  5FR TIGERTAIL OPEN TIP FLEXIBLE 139005,27200000,CDM,272,RC,A4340,HCPCS,,12302-MAIN,LOCAL,,,,,40,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CATHETER URETERAL  5FR TIGERTAIL OPEN TIP FLEXIBLE 139005,27200000,CDM,272,RC,A4340,HCPCS,,12302-MAIN,LOCAL,,,,,40,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRESSING QWICK NONADHESIVE 4.25X4 SUPERABSORBENT MSC5844,120.531,CDM,272,RC,A6197,HCPCS,,12301-MAIN,LOCAL,,,,,20,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,19.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
Glucose Blood Test,PX82962,CDM,300,RC,82962,CPT,,,,,,,,20,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,19.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.01,19.6
methylergonovine 0.2 MG/ML Solution 1 mL Ampule,J2210.01,CDM,636,RC,J2210,HCPCS,,,,51991014417,NDC,1,ML,133.11,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,19.6,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.25,20.87
NEEDLE BIOPSY 14GAX4 1/2 2N2702X,120.211,CDM,272,RC,,,,724-MAIN,LOCAL,,,,,40,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.616,39.2
NEEDLE BIOPSY 14GAX4 1/2 2N2702X,120.211,CDM,272,RC,,,,724-MAIN,LOCAL,,,,,40,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.616,39.2
NEEDLE BIOPSY 14GAX4 1/2 2N2702X,120.211,CDM,272,RC,,,,724-MAIN,LOCAL,,,,,40,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.616,39.2
Phenobarbital Assay - Ref,PX8018490,CDM,300,RC,80184,CPT,90,,,,,,,20,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,19.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
Primidone Assay - Ref,PX8018890,CDM,300,RC,80188,CPT,90,,,,,,,20,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,19.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
STAPLER CANNULA SEAL 12 mm 470380,27200000,CDM,272,RC,,,,11962-MAIN,LOCAL,,,,,40,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STAPLER CANNULA SEAL 12 mm 470380,27200000,CDM,272,RC,,,,11962-MAIN,LOCAL,,,,,40,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STAPLER CANNULA SEAL 12 mm 470380,27200000,CDM,272,RC,,,,11962-MAIN,LOCAL,,,,,40,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"SUTURE V-LOC 22G NEEDLE 9"" 180 GREEN VLOCL2145",27200000,CDM,272,RC,,,,11930-MAIN,LOCAL,,,,,40,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"SUTURE V-LOC 22G NEEDLE 9"" 180 GREEN VLOCL2145",27200000,CDM,272,RC,,,,11930-MAIN,LOCAL,,,,,40,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"SUTURE V-LOC 22G NEEDLE 9"" 180 GREEN VLOCL2145",27200000,CDM,272,RC,,,,11930-MAIN,LOCAL,,,,,40,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"SUTURE V-LOC SZ 0.9"" 180 GREEN GS-21 NEEDLE VLOCL0346",27200000,CDM,272,RC,,,,11933-MAIN,LOCAL,,,,,40,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"SUTURE V-LOC SZ 0.9"" 180 GREEN GS-21 NEEDLE VLOCL0346",27200000,CDM,272,RC,,,,11933-MAIN,LOCAL,,,,,40,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"SUTURE V-LOC SZ 0.9"" 180 GREEN GS-21 NEEDLE VLOCL0346",27200000,CDM,272,RC,,,,11933-MAIN,LOCAL,,,,,40,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Telehealth Origin Site Fac Fee,PXQ3014,CDM,780,RC,Q3014,HCPCS,,,,,,,,40,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,5.73,percent of total billed charges,19.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.616,39.2
Telehealth Origin Site Fac Fee,PXQ3014,CDM,780,RC,Q3014,HCPCS,,,,,,,,40,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.616,39.2
Telehealth Origin Site Fac Fee,PXQ3014,CDM,780,RC,Q3014,HCPCS,,,,,,,,40,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.616,39.2
THORACIC CATHETER  STRAIGHT TAPER TIP 20FR PVC,120.528,CDM,272,RC,,,,12247-MAIN,LOCAL,,,,,20,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,19.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER  STRAIGHT TAPER TIP 24FR PVC,120.528,CDM,272,RC,,,,12248-MAIN,LOCAL,,,,,20,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,19.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 8FR PVC,120.528,CDM,272,RC,,,,12253-MAIN,LOCAL,,,,,20,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,19.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 10FR PVC,120.528,CDM,272,RC,,,,12254-MAIN,LOCAL,,,,,20,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,19.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 12FR PVC,120.528,CDM,272,RC,,,,12255-MAIN,LOCAL,,,,,20,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,19.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 16FR PVC,120.528,CDM,272,RC,,,,12256-MAIN,LOCAL,,,,,20,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,19.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 28FR PVC,120.528,CDM,272,RC,,,,12249-MAIN,LOCAL,,,,,20,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,19.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 32FR PVC,120.528,CDM,272,RC,,,,12250-MAIN,LOCAL,,,,,20,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,19.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
THORACIC CATHETER STRAIGHT TAPER TIP 36FR PVC,120.528,CDM,272,RC,,,,12251-MAIN,LOCAL,,,,,20,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,19.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.308,19.6
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015901,NDC,0.3,ML,45.69,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,19.60101,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015925,NDC,0.3,ML,45.69,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,19.60101,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,36000014801,NDC,2,ML,38.76,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.61256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066501,NDC,0.25,ML,45.74,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,19.62246,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.000396,47.2262
ACUSNARE POLYPECTOMY SNARE,27200000,CDM,272,RC,,,,7733-MAIN,LOCAL,,,,,45.75,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,19.62675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
valACYclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,31722070430,NDC,1,EA,38.79,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.62774,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Xray Pelvis 1 or 2 Vws,PX7217001,CDM,320,RC,72170,CPT,TC,,,,,,,279,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,19.6298,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.87,38.79
Xray Nasal Bones Minimum 3 Vws,PX7016001,CDM,320,RC,70160,CPT,TC,,,,,,,456,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,19.63,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.63,58.51
Xray Nasal Bones Minimum 3 Vws,PX7016001,CDM,320,RC,70160,CPT,TC,,,,,,,456,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,19.63,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.63,58.51
Xray Ribs Unilat 2 Vws With Pa Chest,PX7110101,CDM,320,RC,71101,CPT,TC,,,,,,,792,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,19.63,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.41,58.51
Xray Ribs Unilat 2 Vws With Pa Chest,PX7110101,CDM,320,RC,71101,CPT,TC,,,,,,,792,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,19.63,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.41,58.51
"Calprotectin, Fecal - Ref",PX8399390,CDM,300,RC,83993,CPT,90,,,,,,,401,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,19.63,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.04,19.63
Insulin Ab - Ref,PX8633790,CDM,300,RC,86337,CPT,90,,,,,,,65,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,19.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.63,63.7
"Molecular Cytog, Ea Probe - Ref",PX8827190,CDM,310,RC,88271,CPT,90,,,,,,,277,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,19.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.64,271.46
doxazosin 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079095701,NDC,1,EA,20.19,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,19.650927,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070548,NDC,100,ML,40.94,,Health Partners,Health Partners Care Plans,both,48,,6.034333333,percent of total billed charges,19.6512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070548,NDC,100,ML,40.94,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.6512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
leucovorin 10 mg/mL Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,25021081467,NDC,1,EA,40.13,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.6637,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.670002,84.6818
leucovorin 10 mg/mL Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,25021081467,NDC,1,EA,40.13,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.6637,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.670002,84.6818
leucovorin 10 mg/mL Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,25021081467,NDC,1,EA,40.13,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.6637,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.670002,84.6818
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600701,NDC,10,ML,39.73,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,19.66635,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,38.9354
fluticasone-salmeterol 100-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069500,NDC,1,EA,38.87,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.66822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003001,NDC,0.5,EA,21.59,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,19.66849,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buPROPion XL 150 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,70436001004,NDC,1,EA,23.14,,First Health,Commercial,both,85,,999999999,percent of total billed charges,19.669,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042350,NDC,0.5,ML,132.37,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,19.67,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.67,22.35
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042388,NDC,0.5,ML,132.37,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,19.67,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.67,22.35
CANNULA SEAL 5-12MM UNIVERSAL 470500,27200000,CDM,272,RC,,,,12885-MAIN,LOCAL,,,,,41,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CANNULA SEAL 5-12MM UNIVERSAL 470500,27200000,CDM,272,RC,,,,12885-MAIN,LOCAL,,,,,41,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CUP HEEL LARGE WONDERSPUR 4502,120.43,CDM,274,RC,L3485,HCPCS,,11385-MAIN,LOCAL,,,,,41,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL LARGE WONDERSPUR 4502,120.43,CDM,274,RC,L3485,HCPCS,,11385-MAIN,LOCAL,,,,,41,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL MEDIUM WONDERSPUR 4501,120.43,CDM,274,RC,L3485,HCPCS,,11384-MAIN,LOCAL,,,,,41,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL MEDIUM WONDERSPUR 4501,120.43,CDM,274,RC,L3485,HCPCS,,11384-MAIN,LOCAL,,,,,41,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL SMALL WONDERSPUR 4500,120.43,CDM,274,RC,L3485,HCPCS,,11383-MAIN,LOCAL,,,,,41,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL SMALL WONDERSPUR 4500,120.43,CDM,274,RC,L3485,HCPCS,,11383-MAIN,LOCAL,,,,,41,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL XL WONDERSPUR 4503,120.43,CDM,274,RC,L3485,HCPCS,,11386-MAIN,LOCAL,,,,,41,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL XL WONDERSPUR 4503,120.43,CDM,274,RC,L3485,HCPCS,,11386-MAIN,LOCAL,,,,,41,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
Detection of Anaplasma Phagocytophilum by Amplified Nucleic Acid Probe Technique,PX8746890,CDM,300,RC,87468,CPT,90,,,,,,,41,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
Detection of Anaplasma Phagocytophilum by Amplified Nucleic Acid Probe Technique,PX8746890,CDM,300,RC,87468,CPT,90,,,,,,,41,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
Detection of Ehrlichia Chaffeensis by Amplified Nucleic Acid Probe Technique,PX8748490,CDM,300,RC,87484,CPT,90,,,,,,,41,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
Detection of Ehrlichia Chaffeensis by Amplified Nucleic Acid Probe Technique,PX8748490,CDM,300,RC,87484,CPT,90,,,,,,,41,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 21G 110MM SONOTAP II WITH FACET TIP 1285-3F110,120.483,CDM,271,RC,A4215,HCPCS,,12201-MAIN,LOCAL,,,,,41,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 21G 110MM SONOTAP II WITH FACET TIP 1285-3F110,120.483,CDM,271,RC,A4215,HCPCS,,12201-MAIN,LOCAL,,,,,41,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 21G X 4IN (100MM) SONOBLOCK II NERVE BLOCK WITH FACET S TIP 001281-77,120.483,CDM,271,RC,A4215,HCPCS,,12761-MAIN,LOCAL,,,,,41,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 21G X 4IN (100MM) SONOBLOCK II NERVE BLOCK WITH FACET S TIP 001281-77,120.483,CDM,271,RC,A4215,HCPCS,,12761-MAIN,LOCAL,,,,,41,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 22G 80MM SONOTAP II WITH FACET TIP 1285-3E080,120.483,CDM,271,RC,A4215,HCPCS,,12103-MAIN,LOCAL,,,,,41,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 22G 80MM SONOTAP II WITH FACET TIP 1285-3E080,120.483,CDM,271,RC,A4215,HCPCS,,12103-MAIN,LOCAL,,,,,41,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 22G X 3.25IN (80MM) SONOBLOCK II  NERVE BLOCK WITH FACET S TIP 001281-71,120.483,CDM,271,RC,A4215,HCPCS,,12760-MAIN,LOCAL,,,,,41,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 22G X 3.25IN (80MM) SONOBLOCK II  NERVE BLOCK WITH FACET S TIP 001281-71,120.483,CDM,271,RC,A4215,HCPCS,,12760-MAIN,LOCAL,,,,,41,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 22GX2 SONOPLEX II WITH FACET S TIP 001287-74,120.483,CDM,271,RC,A4215,HCPCS,,13110-MAIN,LOCAL,,,,,41,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 22GX2 SONOPLEX II WITH FACET S TIP 001287-74,120.483,CDM,271,RC,A4215,HCPCS,,13110-MAIN,LOCAL,,,,,41,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE NON-STIMULATING 22GX2 SONOBLOCK II WITH FACET S TIP 001281-74,120.483,CDM,271,RC,A4215,HCPCS,,11459-MAIN,LOCAL,,,,,41,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE NON-STIMULATING 22GX2 SONOBLOCK II WITH FACET S TIP 001281-74,120.483,CDM,271,RC,A4215,HCPCS,,11459-MAIN,LOCAL,,,,,41,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE SONOPLEX II STIMULATING WITH FACET S TIP 22GX3-1/4,120.483,CDM,271,RC,A4215,HCPCS,,11457-MAIN,LOCAL,,,,,41,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE SONOPLEX II STIMULATING WITH FACET S TIP 22GX3-1/4,120.483,CDM,271,RC,A4215,HCPCS,,11457-MAIN,LOCAL,,,,,41,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE STIMULATING 21GX4  SONOPLEX II  WITH FACET S TIP 001287-77,120.483,CDM,271,RC,A4215,HCPCS,,11458-MAIN,LOCAL,,,,,41,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE STIMULATING 21GX4  SONOPLEX II  WITH FACET S TIP 001287-77,120.483,CDM,271,RC,A4215,HCPCS,,11458-MAIN,LOCAL,,,,,41,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
STRAP FOOT LG/XL GEL UNIVERSAL 10165,120.428,CDM,271,RC,,,,11382-MAIN,LOCAL,,,,,41,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
STRAP FOOT LG/XL GEL UNIVERSAL 10165,120.428,CDM,271,RC,,,,11382-MAIN,LOCAL,,,,,41,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
STRAP FOOT SM/MED GEL UNIVERSAL 10155,120.428,CDM,271,RC,,,,11381-MAIN,LOCAL,,,,,41,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
STRAP FOOT SM/MED GEL UNIVERSAL 10155,120.428,CDM,271,RC,,,,11381-MAIN,LOCAL,,,,,41,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
SUTURE V-LOC SZ 1/2 180 GREEN GS-21 VLOCL0316,27200000,CDM,272,RC,,,,11932-MAIN,LOCAL,,,,,41,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE V-LOC SZ 1/2 180 GREEN GS-21 VLOCL0316,27200000,CDM,272,RC,,,,11932-MAIN,LOCAL,,,,,41,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
URGOK2 DUAL COMPRESSION SYSTEM LARGE,120.491,CDM,271,RC,A6452,HCPCS,,11871-MAIN,LOCAL,,,,,41,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
URGOK2 DUAL COMPRESSION SYSTEM LARGE,120.491,CDM,271,RC,A6452,HCPCS,,11871-MAIN,LOCAL,,,,,41,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
URGOK2 DUAL COMPRESSION SYSTEM REGULAR,120.491,CDM,271,RC,A6452,HCPCS,,11870-MAIN,LOCAL,,,,,41,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
URGOK2 DUAL COMPRESSION SYSTEM REGULAR,120.491,CDM,271,RC,A6452,HCPCS,,11870-MAIN,LOCAL,,,,,41,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
doxazosin 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079095720,NDC,1,EA,20.22,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,19.680126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone-salmeterol 250-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,54032756,NDC,1,EA,45.88,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,19.68252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001001,NDC,1.5,ML,40.17,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.6833,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,42.5516
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001001,NDC,1.5,ML,40.17,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.6833,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,42.5516
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001001,NDC,1.5,ML,40.17,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.6833,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,42.5516
venlafaxine 37.5 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084069811,NDC,1,EA,20.09,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,19.6882,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venlafaxine 37.5 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084069801,NDC,1,EA,20.09,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,19.6882,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323048201,NDC,10,ML,39.78,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,19.6911,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323048217,NDC,10,ML,39.78,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,19.6911,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Lactoferrin, Fecal; Qual",PX83630,CDM,300,RC,83630,CPT,,,,,,,,103,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,19.7,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.11,19.7
lamoTRIgine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079049801,NDC,1,EA,22.34,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,19.70388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzoin Tincture 59 mL Bottle,25000000,CDM,250,RC,,,,,,49348080130,NDC,59,ML,45.93,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,19.70397,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Compliment, Total (Ch50) - Ref",PX8616290,CDM,300,RC,86162,CPT,90,,,,,,,122,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,19.71,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.71,20.32
"Compliment, Total (Ch50) - Ref",PX8616290,CDM,300,RC,86162,CPT,90,,,,,,,122,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,19.71,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.71,20.32
"Compliment, Total (Ch50) - Ref",PX8616290,CDM,300,RC,86162,CPT,90,,,,,,,122,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,19.71,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.71,20.32
hydrocortisone 1 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,472034356,NDC,28,GR,22.15,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,19.7135,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dabigatran 75 MG capsule 60 Each Box,63700001,CDM,250,RC,,,,,,597014960,NDC,1,EA,39.83,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,19.71585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039814,NDC,1,EA,39.84,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,19.7208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
BUPivacaine PF 0.5 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,55150016910,NDC,10,ML,39.84,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,19.7208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
enalaprilat 1.25 MG/ML Injectable 1 mL Vial,25000000,CDM,250,RC,,,,,,143978710,NDC,1,ML,39.84,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,19.7208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098141,NDC,1,EA,39.84,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,19.7208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098153,NDC,1,EA,39.84,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,19.7208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,47781059807,NDC,1,EA,39.84,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,19.7208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
morphine 2 MG/ML Solution 1 mL Syringe,J2272.01,CDM,636,RC,J2272,HCPCS,,,,76045000401,NDC,1,ML,38.98,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.72388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.192292,38.2004
DERMABOND ADVANCED TOPICAL SKIN ADHESIVE,120.198,CDM,272,RC,,,,9101-MAIN,LOCAL,,,,,46,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,19.734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.1084,45.08
Pinworm Exam,PX87172,CDM,300,RC,87172,CPT,,,,,,,,46,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,19.734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,45.08
CLOSED WOUND ROUND CHANNEL DRAIN WITH TROCAR 15FR FULL FLUTED,27200000,CDM,272,RC,,,,12223-MAIN,LOCAL,,,,,39,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
fluorouracil 500 MG/10ML Solution 10 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,63323011710,NDC,10,ML,39,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,256.2112
gemcitabine 200 MG Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323010294,NDC,1,EA,39,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
Lab Wbc and Differential,PX85004,CDM,300,RC,85004,CPT,,,,,,,,39,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,38.22
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003928,NDC,1,EA,39,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
methylPREDNISolone sod succ 500 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9075801,NDC,0.25,EA,39,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
NEEDLE JAMSHIDI 11G X 101MM BIOPSY DJ4011X,27200000,CDM,272,RC,,,,12798-MAIN,LOCAL,,,,,39,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
O2 SENSOR ADULT ADHESIVE SINGLE PATIENT 040-003382-00,120.576,CDM,272,RC,,,,12930-MAIN,LOCAL,,,,,39,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
O2 SENSOR INFANT ADHESIVE SINGLE PATIENT 040-003384-00,120.576,CDM,272,RC,,,,12932-MAIN,LOCAL,,,,,39,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
O2 SENSOR PEDIATRIC ADHESIVE SINGLE PATIENT 040-003383-00,120.576,CDM,272,RC,,,,12931-MAIN,LOCAL,,,,,39,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
SLEEVE ACHILLES LG/XL PROTECTION 92437145348,120.422,CDM,271,RC,,,,11378-MAIN,LOCAL,,,,,39,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
SLEEVE ACHILLES SM/MED PROTECTION 92437145324,120.422,CDM,271,RC,,,,11377-MAIN,LOCAL,,,,,39,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
Treponema Pallidum - Ref,PX8678090,CDM,300,RC,86780,CPT,90,,,,,,,39,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.14,38.22
TROCAR KII FIOS SYSTEM BLADELSS Z-THREAD 5MMX150MM,27200000,CDM,272,RC,,,,12827-MAIN,LOCAL,,,,,39,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409427617,NDC,50,ML,39.01,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.73906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,703291401,NDC,0.5,EA,40.3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.747,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,703291401,NDC,0.5,EA,40.3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.747,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,703291401,NDC,0.5,EA,40.3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.747,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
TROCAR KII BALLOON 12MM STERILE,27200000,CDM,272,RC,,,,11703-MAIN,LOCAL,,,,,41.14,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.7472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR KII BALLOON 12MM STERILE,27200000,CDM,272,RC,,,,11703-MAIN,LOCAL,,,,,41.14,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.7472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR KII BALLOON BLUNT 12MM STERILE,27200000,CDM,272,RC,,,,11702-MAIN,LOCAL,,,,,41.14,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.7472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR KII BALLOON BLUNT 12MM STERILE,27200000,CDM,272,RC,,,,11702-MAIN,LOCAL,,,,,41.14,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.7472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
simethicone 40 MG/0.6ML Suspension 30 mL Bottle,25000000,CDM,250,RC,,,,,,904589430,NDC,30,ML,22.39,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,19.74798,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
promethazine 25 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802075930,NDC,0.5,EA,47.54,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,19.748116,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
promethazine 25 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,45802075900,NDC,0.5,EA,47.55,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,19.75227,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641622901,NDC,1,ML,41.16,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.7568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.097864,86.9162
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641622901,NDC,1,ML,41.16,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.7568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.097864,86.9162
ibuprofen 100 MG/5ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,68094049459,NDC,20,ML,22.2,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,19.758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SCISSORS ENDOSCOPIC 5MM STANDARD STERILE,27200000,CDM,272,RC,,,,11706-MAIN,LOCAL,,,,,47.6,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,19.77304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Resp Muscles 1:1 per 15 Min,PXG0237,CDM,948,RC,G0237,HCPCS,,,,,,,,65,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,19.78,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.76,19.78
Resp Muscles 1:1 per 15 Min,PXG0237,CDM,948,RC,G0237,HCPCS,,,,,,,,65,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,19.78,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.76,19.78
doxazosin 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079095701,NDC,1,EA,20.19,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,19.7862,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin-clavulanate 500-125 MG Tablet 20 Each Bottle,63700001,CDM,250,RC,,,,,,16714047701,NDC,1,EA,20.33,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,19.787189,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
enalaprilat 1.25 MG/ML Injectable 1 mL Vial,25000000,CDM,250,RC,,,,,,143978701,NDC,1,ML,40.39,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.7911,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
enalaprilat 1.25 MG/ML Injectable 1 mL Vial,25000000,CDM,250,RC,,,,,,143978701,NDC,1,ML,40.39,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.7911,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
enalaprilat 1.25 MG/ML Injectable 1 mL Vial,25000000,CDM,250,RC,,,,,,143978701,NDC,1,ML,40.39,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.7911,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733513,NDC,1,EA,39.12,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.79472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
8MM-12MM TIP COVER ACCESSORY,27200000,CDM,272,RC,,,,11918-MAIN,LOCAL,,,,,40,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,19.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CATHETER URETERAL  5FR TIGERTAIL OPEN TIP FLEXIBLE 139005,27200000,CDM,272,RC,A4340,HCPCS,,12302-MAIN,LOCAL,,,,,40,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,19.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NEEDLE BIOPSY 14GAX4 1/2 2N2702X,120.211,CDM,272,RC,,,,724-MAIN,LOCAL,,,,,40,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,19.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.616,39.2
STAPLER CANNULA SEAL 12 mm 470380,27200000,CDM,272,RC,,,,11962-MAIN,LOCAL,,,,,40,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,19.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"SUTURE V-LOC 22G NEEDLE 9"" 180 GREEN VLOCL2145",27200000,CDM,272,RC,,,,11930-MAIN,LOCAL,,,,,40,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,19.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"SUTURE V-LOC SZ 0.9"" 180 GREEN GS-21 NEEDLE VLOCL0346",27200000,CDM,272,RC,,,,11933-MAIN,LOCAL,,,,,40,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,19.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Telehealth Origin Site Fac Fee,PXQ3014,CDM,780,RC,Q3014,HCPCS,,,,,,,,40,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,19.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.616,39.2
levoFLOXacin 750 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635361,NDC,0.333333333,EA,39.14,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.80484,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
celecoxib 200 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904650361,NDC,0.5,EA,20.35,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,19.806655,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028002,NDC,1,ML,40.43,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,7.169534884,percent of total billed charges,19.8107,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028002,NDC,1,ML,40.43,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.8107,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028002,NDC,1,ML,40.43,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.8107,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
rosuvastatin 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16714098801,NDC,1,EA,46.18,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,19.81122,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
eplerenone 25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16729029315,NDC,1,EA,23.31,,First Health,Commercial,both,85,,999999999,percent of total billed charges,19.8135,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxazosin 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079095720,NDC,1,EA,20.22,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,19.8156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253033335,NDC,5,ML,40.44,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.115241667,percent of total billed charges,19.8156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253033335,NDC,5,ML,40.44,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.8156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253033335,NDC,5,ML,40.44,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.8156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
midazolam 2 MG/ML Syrup 5 mL Cup,63700001,CDM,250,RC,,,,,,68094076459,NDC,2.5,ML,22.47,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,19.81854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
neomycin-bacitracin-polymyxin 3.5-400-5000 Ointment 28.4 g Tube,25000000,CDM,250,RC,,,,,,713026831,NDC,28.4,GR,22.47,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,19.81854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028442,NDC,1,EA,47.71,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,19.818734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028016,NDC,2,ML,41.29,,Health Partners,Health Partners Care Plans,both,48,,7.095,percent of total billed charges,19.8192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028016,NDC,2,ML,41.29,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.8192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
methylPREDNISolone acetate 20 MG/ML Suspension 5 mL Vial,J1010.01,CDM,636,RC,J1010,HCPCS,,,,9027401,NDC,0.5,ML,41.3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.15602,40.474
methylPREDNISolone acetate 20 MG/ML Suspension 5 mL Vial,J1010.01,CDM,636,RC,J1010,HCPCS,,,,9027401,NDC,0.5,ML,41.3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.15602,40.474
FORCEPS SERRATED WITH SPIKE JUMBO 230CM,27200000,CDM,272,RC,,,,7416-MAIN,LOCAL,,,,,41.31,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.8288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
FORCEPS SERRATED WITH SPIKE JUMBO 230CM,27200000,CDM,272,RC,,,,7416-MAIN,LOCAL,,,,,41.31,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.8288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Collect Blood From Picc,PX36592,CDM,949,RC,36592,CPT,,,,,,,,198,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,19.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.97,62.26
Collect Blood From Picc,PX36592,CDM,949,RC,36592,CPT,,,,,,,,198,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,19.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.97,62.26
Collect Blood From Picc,PX36592F,CDM,510,RC,36592,CPT,,,,,,,,211,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,19.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.97,62.26
Collect Blood From Picc,PX36592F,CDM,510,RC,36592,CPT,,,,,,,,211,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,19.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.97,62.26
Xray Ls Spine Bend Tc,PX7212001,CDM,320,RC,72120,CPT,TC,,,,,,,323,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,19.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.84,59.17
Xray Ls Spine Bend Tc,PX7212001,CDM,320,RC,72120,CPT,TC,,,,,,,323,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,19.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.84,59.17
Xray Ls Spine Bend Tc,PX7212001,CDM,320,RC,72120,CPT,TC,,,,,,,323,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,19.84,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.84,59.17
Xray Mandible Partial Less Than 4 Vws,PX7010001,CDM,320,RC,70100,CPT,TC,,,,,,,347,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,19.84,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.84,59.82
Xray Nasal Bones Minimum 3 Vws,PX7016001,CDM,320,RC,70160,CPT,TC,,,,,,,456,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,19.84,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.63,58.51
apixaban 5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,3089421,NDC,0.5,EA,22.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,19.845,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409132305,NDC,5,ML,41.35,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409132305,NDC,5,ML,41.35,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
leucovorin 10 mg/mL Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,25021081467,NDC,1,EA,40.13,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,19.86435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.670002,84.6818
Gabapentin - Ref,PX8017190,CDM,300,RC,80171,CPT,90,,,,,,,71,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,19.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.87,69.58
TRAY FOLEY 14FR CATHETER A300414A,120.414,CDM,272,RC,A4344,HCPCS,,11281-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,19.87,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.87,406.9505
TRAY FOLEY 16FR CATHETER 300416A,120.414,CDM,272,RC,A4344,HCPCS,,11774-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,19.87,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.87,406.9505
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707426,NDC,100,ML,39.29,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.88074,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028026,NDC,2,ML,41.42,,Health Partners,Health Partners Care Plans,both,48,,7.095,percent of total billed charges,19.8816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028026,NDC,2,ML,41.42,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.8816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
lamoTRIgine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079049801,NDC,1,EA,22.34,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,19.8826,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001001,NDC,1.5,ML,40.17,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,19.88415,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,42.5516
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,641601310,NDC,5,ML,40.58,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.8842,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,641601310,NDC,5,ML,40.58,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.8842,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,641601310,NDC,5,ML,40.58,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.8842,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Admin Hep B,Adult 19+",PX3242,CDM,771,RC,90471,CPT,,,,,,,,48,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,19.8958,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.09,36.07
Clozapine - Ref,PX8015990,CDM,300,RC,80159,CPT,90,,,,,,,65,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,19.8958,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.55,20.15
"Compliment, Total (Ch50) - Ref",PX8616290,CDM,300,RC,86162,CPT,90,,,,,,,122,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,19.8958,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.71,20.32
Immunization Admin - Influenza,PX3241,CDM,771,RC,90471,CPT,,,,,,,,48,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,19.8958,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.09,36.07
Immunization Administration; One Vaccine (Single or Combination Vaccine/To*,PX90471,CDM,771,RC,90471,CPT,,,,,,,,130,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,19.8958,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.09,36.07
hydroxychloroquine 200 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16571068701,NDC,1,EA,23.41,,First Health,Commercial,both,85,,999999999,percent of total billed charges,19.8985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
skin oil Oil 236.6 mL Bottle,63700001,CDM,250,RC,,,,,,67211008,NDC,236.6,ML,40.61,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.8989,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
skin oil Oil 236.6 mL Bottle,63700001,CDM,250,RC,,,,,,67211008,NDC,236.6,ML,40.61,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.8989,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
skin oil Oil 236.6 mL Bottle,63700001,CDM,250,RC,,,,,,67211008,NDC,236.6,ML,40.61,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.8989,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clopidogrel 75 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629461,NDC,1,EA,23.42,,First Health,Commercial,both,85,,999999999,percent of total billed charges,19.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Fac/Trm Hyperkeratotic Skn Lesn2-4,PX11056F,CDM,510,RC,11056,CPT,,,,,,,,158,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,19.9082,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.52,171.57
Electric Stimulation Therapy,PX97014,CDM,420,RC,97014,CPT,,,,,,,,135,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,19.92,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.65,19.92
Electric Stimulation Therapy,PX97014,CDM,420,RC,97014,CPT,,,,,,,,135,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,19.92,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.65,19.92
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070102,NDC,1,ML,383.6,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,19.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.92,450.751
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070110,NDC,1,ML,459.95,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,19.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.92,450.751
amoxicillin-clavulanate 500-125 MG Tablet 20 Each Bottle,63700001,CDM,250,RC,,,,,,16714047701,NDC,1,EA,20.33,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,19.9234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bacitracin zinc 500 UNIT/GM Ointment 28.4 g Tube,25000000,CDM,250,RC,,,,,,49348015472,NDC,28.4,GR,20.47,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,19.923451,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
simethicone 40 MG/0.6ML Suspension 30 mL Bottle,25000000,CDM,250,RC,,,,,,904589430,NDC,30,ML,22.39,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,19.9271,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
celecoxib 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904650261,NDC,1,EA,23.45,,First Health,Commercial,both,85,,999999999,percent of total billed charges,19.9325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tamsulosin 0.4 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904640161,NDC,1,EA,22.6,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,19.9332,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Admin Hep B,Adult 19+",PX3242,CDM,771,RC,90471,CPT,,,,,,,,48,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,19.9392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,61.54
Amphetamines; 3 or 4,PX8032590,CDM,300,RC,80325,CPT,90,,,,,,,48,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,19.9392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,47.04
Immunization Admin - Influenza,PX3241,CDM,771,RC,90471,CPT,,,,,,,,48,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,19.9392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,61.54
Immunization Administration; Each Add'l Vaccine (Single or Combo Vaccine/T*,PX90472,CDM,771,RC,90472,CPT,,,,,,,,48,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,19.9392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,47.04
celecoxib 200 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904650361,NDC,0.5,EA,20.35,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,19.943,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atropine 1 mg/mL Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100101,NDC,0.2,ML,39.42,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.94652,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,703291401,NDC,0.5,EA,40.3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,19.9485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
buprenorphine 8 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,54017713,NDC,1,EA,41.56,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,19.9488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.14,40.7288
buprenorphine 8 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,54017713,NDC,1,EA,41.56,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,19.9488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.14,40.7288
Xray Ac Joints(Bilateral),PX7305001,CDM,320,RC,73050,CPT,TC,,,,,,,519,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,19.9516,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.87,39.44
gemcitabine 200 MG/5.26ML Solution 5.26 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018301,NDC,5.26,ML,40.74,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.9626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
gemcitabine 200 MG/5.26ML Solution 5.26 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018301,NDC,5.26,ML,40.74,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.9626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
gemcitabine 200 MG/5.26ML Solution 5.26 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018301,NDC,5.26,ML,40.74,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.9626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
ursodiol 300 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,591315901,NDC,1,EA,39.47,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,19.97182,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Cognitive Funct Ther Interv, Ea Addl 15 Min",PX97130,CDM,420,RC,97130,CPT,,,,,,,,82,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,19.9888,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.14,28.12
FLEXITIP APPLICATOR 38CM,27200000,CDM,272,RC,,,,10200-MAIN,LOCAL,,,,,40.8,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
FLEXITIP APPLICATOR 38CM,27200000,CDM,272,RC,,,,10200-MAIN,LOCAL,,,,,40.8,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,19.992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
FLEXITIP APPLICATOR 38CM,27200000,CDM,272,RC,,,,10200-MAIN,LOCAL,,,,,40.8,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,19.992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
enalaprilat 1.25 MG/ML Injectable 1 mL Vial,25000000,CDM,250,RC,,,,,,143978701,NDC,1,ML,40.39,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,19.99305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
midazolam 2 MG/ML Syrup 5 mL Cup,63700001,CDM,250,RC,,,,,,68094076459,NDC,2.5,ML,22.47,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,19.9983,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
neomycin-bacitracin-polymyxin 3.5-400-5000 Ointment 28.4 g Tube,25000000,CDM,250,RC,,,,,,713026831,NDC,28.4,GR,22.47,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,19.9983,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Gait Training Therapy,PX97116,CDM,420,RC,97116,CPT,,,,,,,,135,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,20,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20,132.3
Therapeutic Exercises,PX97110,CDM,420,RC,97110,CPT,,,,,,,,135,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,20,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20,215.05
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028002,NDC,1,ML,40.43,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.01285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
fluconazole 100 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069101,NDC,0.5,EA,23.55,,First Health,Commercial,both,85,,999999999,percent of total billed charges,20.0175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253033335,NDC,5,ML,40.44,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.0178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066500,NDC,0.25,ML,48.19,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,20.018126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.000396,47.2262
methylPREDNISolone sod succ 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,63323025803,NDC,0.4,EA,46.67,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,20.02143,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
bisoprolol-hydroCHLOROthiazide 5-6.25 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,42799092102,NDC,1,EA,39.57,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.02242,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
apixaban 5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,3089421,NDC,0.5,EA,22.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,20.025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
azithromycin 250 MG Tablet 6 Each Box,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096104,NDC,1,EA,41.72,,Health Partners,Health Partners Care Plans,both,48,,29.925,percent of total billed charges,20.0256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
azithromycin 250 MG Tablet 6 Each Box,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096104,NDC,1,EA,41.72,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.0256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096105,NDC,1,EA,41.73,,Health Partners,Health Partners Care Plans,both,48,,29.925,percent of total billed charges,20.0304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096105,NDC,1,EA,41.73,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.0304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
hydroxychloroquine 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292001101,NDC,1,EA,23.57,,First Health,Commercial,both,85,,999999999,percent of total billed charges,20.0345,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Myoglobin - Ref,PX8387490,CDM,300,RC,83874,CPT,90,,,,,,,22,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,20.042,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.1388,21.56
SUTURE POLYSORB BRAIDED ABSORBABLE VIOLET SIZE 0 30IN WITH 5/8 CIRCLE TAPER POINT 27MM NEEDLE,27200000,CDM,272,RC,,,,11985-MAIN,LOCAL,,,,,22,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,20.042,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TEGADERM CHLORHEXIDINE-GLUCONATE,120.356,CDM,272,RC,A4221,HCPCS,,10708-MAIN,LOCAL,,,,,22,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,20.042,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.1388,21.56
DULoxetine 20 MG Capsule Delayed Release Particles 60 Each Bottle,63700001,CDM,250,RC,,,,,,2323560,NDC,1,EA,41.76,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,20.0448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DULoxetine 20 MG Capsule Delayed Release Particles 60 Each Bottle,63700001,CDM,250,RC,,,,,,2323560,NDC,1,EA,41.76,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.0448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Candida Dna Dir Probe,PX87480,CDM,300,RC,87480,CPT,,,,,,,,127,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,20.05,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.45,20.05
Gardner Vag Dna Dir Probe,PX87510,CDM,300,RC,87510,CPT,,,,,,,,127,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,20.05,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.45,20.05
Trichomonas Vagin Dir Probe,PX87660,CDM,300,RC,87660,CPT,,,,,,,,127,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,20.05,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.45,20.05
SAW BLADE 300 SAGITTAL 25X9.4X0.7,27200000,CDM,272,RC,,,,11592-MAIN,LOCAL,,,,,46.75,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,20.05575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SAW BLADE 300 SAGITTAL 40X14X0.6MM,27200000,CDM,272,RC,,,,11591-MAIN,LOCAL,,,,,46.75,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,20.05575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,50111078751,NDC,1,EA,41.79,,Health Partners,Health Partners Care Plans,both,48,,29.925,percent of total billed charges,20.0592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,50111078751,NDC,1,EA,41.79,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.0592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
donepezil 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904640861,NDC,1,EA,41.79,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,20.0592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
donepezil 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904640861,NDC,1,EA,41.79,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.0592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Remove Impacted Ear Wax,PX69210F,CDM,510,RC,69210,CPT,,,,,,,,213,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,20.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.06,99.62
Remove Impacted Ear Wax,PX69210F,CDM,510,RC,69210,CPT,,,,,,,,213,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,20.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.06,99.62
Remove Impacted Ear Wax,PX69210F,CDM,510,RC,69210,CPT,,,,,,,,213,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,20.06,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.06,99.62
Remove Impacted Ear Wax,PX69210P,CDM,983,RC,69210,CPT,,,,,,,,221,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,20.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.06,216.58
Remove Impacted Ear Wax,PX69210P,CDM,983,RC,69210,CPT,,,,,,,,221,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,20.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.06,216.58
Remove Impacted Ear Wax,PX69210P,CDM,983,RC,69210,CPT,,,,,,,,221,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,20.06,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.06,216.58
US Chest Tc,PX7660401,CDM,402,RC,76604,CPT,TC,,,,,,,248,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,20.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.19,59.82
US Chest Tc,PX7660401,CDM,402,RC,76604,CPT,TC,,,,,,,248,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,20.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.19,59.82
X-Ray Exam Entire Spine 1vw,PX7208101,CDM,320,RC,72081,CPT,TC,,,,,,,414,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,20.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.06,59.82
X-Ray Exam Entire Spine 1vw,PX7208101,CDM,320,RC,72081,CPT,TC,,,,,,,414,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,20.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.06,59.82
X-Ray Exam Entire Spine 1vw,PX7208101,CDM,320,RC,72081,CPT,TC,,,,,,,414,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,20.06,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.06,59.82
Xray Mandible Partial Less Than 4 Vws,PX7010001,CDM,320,RC,70100,CPT,TC,,,,,,,347,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,20.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.84,59.82
Xray Mandible Partial Less Than 4 Vws,PX7010001,CDM,320,RC,70100,CPT,TC,,,,,,,347,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,20.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.84,59.82
Xray Pelvis Compl 3+ Tc,PX7219001,CDM,320,RC,72190,CPT,TC,,,,,,,563,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,20.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.06,59.82
Xray Pelvis Compl 3+ Tc,PX7219001,CDM,320,RC,72190,CPT,TC,,,,,,,563,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,20.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.06,59.82
Xray Pelvis Compl 3+ Tc,PX7219001,CDM,320,RC,72190,CPT,TC,,,,,,,563,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,20.06,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.06,59.82
Xray Ribs Bil 3vws Tc,PX7111001,CDM,320,RC,71110,CPT,TC,,,,,,,533,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,20.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.06,59.82
Xray Ribs Bil 3vws Tc,PX7111001,CDM,320,RC,71110,CPT,TC,,,,,,,533,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,20.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.06,59.82
Xray Ribs Bil 3vws Tc,PX7111001,CDM,320,RC,71110,CPT,TC,,,,,,,533,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,20.06,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.06,59.82
bacitracin zinc 500 UNIT/GM Ointment 28.4 g Tube,25000000,CDM,250,RC,,,,,,49348015472,NDC,28.4,GR,20.47,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,20.0606,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070548,NDC,100,ML,40.94,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1.633818182,percent of total billed charges,20.0606,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070548,NDC,100,ML,40.94,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.0606,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070548,NDC,100,ML,40.94,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.0606,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"Manual Ther Tech,1+Regions,Ea 15 Min",PX97140,CDM,420,RC,97140,CPT,,,,,,,,135,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,20.07,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.47,35.58
"Manual Ther Tech,1+Regions,Ea 15 Min",PX97140,CDM,420,RC,97140,CPT,,,,,,,,135,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,20.07,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.47,35.58
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,25021010720,NDC,1,EA,48.35,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,20.08459,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,641601310,NDC,5,ML,40.58,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.0871,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
CANNULA SEAL 5-12MM UNIVERSAL 470500,27200000,CDM,272,RC,,,,12885-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CANNULA SEAL 5-12MM UNIVERSAL 470500,27200000,CDM,272,RC,,,,12885-MAIN,LOCAL,,,,,41,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CANNULA SEAL 5-12MM UNIVERSAL 470500,27200000,CDM,272,RC,,,,12885-MAIN,LOCAL,,,,,41,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CUP HEEL LARGE WONDERSPUR 4502,120.43,CDM,274,RC,L3485,HCPCS,,11385-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL LARGE WONDERSPUR 4502,120.43,CDM,274,RC,L3485,HCPCS,,11385-MAIN,LOCAL,,,,,41,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL LARGE WONDERSPUR 4502,120.43,CDM,274,RC,L3485,HCPCS,,11385-MAIN,LOCAL,,,,,41,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL MEDIUM WONDERSPUR 4501,120.43,CDM,274,RC,L3485,HCPCS,,11384-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL MEDIUM WONDERSPUR 4501,120.43,CDM,274,RC,L3485,HCPCS,,11384-MAIN,LOCAL,,,,,41,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL MEDIUM WONDERSPUR 4501,120.43,CDM,274,RC,L3485,HCPCS,,11384-MAIN,LOCAL,,,,,41,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL SMALL WONDERSPUR 4500,120.43,CDM,274,RC,L3485,HCPCS,,11383-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL SMALL WONDERSPUR 4500,120.43,CDM,274,RC,L3485,HCPCS,,11383-MAIN,LOCAL,,,,,41,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL SMALL WONDERSPUR 4500,120.43,CDM,274,RC,L3485,HCPCS,,11383-MAIN,LOCAL,,,,,41,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL XL WONDERSPUR 4503,120.43,CDM,274,RC,L3485,HCPCS,,11386-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL XL WONDERSPUR 4503,120.43,CDM,274,RC,L3485,HCPCS,,11386-MAIN,LOCAL,,,,,41,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL XL WONDERSPUR 4503,120.43,CDM,274,RC,L3485,HCPCS,,11386-MAIN,LOCAL,,,,,41,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
Detection of Anaplasma Phagocytophilum by Amplified Nucleic Acid Probe Technique,PX8746890,CDM,300,RC,87468,CPT,90,,,,,,,41,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
Detection of Anaplasma Phagocytophilum by Amplified Nucleic Acid Probe Technique,PX8746890,CDM,300,RC,87468,CPT,90,,,,,,,41,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
Detection of Anaplasma Phagocytophilum by Amplified Nucleic Acid Probe Technique,PX8746890,CDM,300,RC,87468,CPT,90,,,,,,,41,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
Detection of Ehrlichia Chaffeensis by Amplified Nucleic Acid Probe Technique,PX8748490,CDM,300,RC,87484,CPT,90,,,,,,,41,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
Detection of Ehrlichia Chaffeensis by Amplified Nucleic Acid Probe Technique,PX8748490,CDM,300,RC,87484,CPT,90,,,,,,,41,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
Detection of Ehrlichia Chaffeensis by Amplified Nucleic Acid Probe Technique,PX8748490,CDM,300,RC,87484,CPT,90,,,,,,,41,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 21G 110MM SONOTAP II WITH FACET TIP 1285-3F110,120.483,CDM,271,RC,A4215,HCPCS,,12201-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 21G 110MM SONOTAP II WITH FACET TIP 1285-3F110,120.483,CDM,271,RC,A4215,HCPCS,,12201-MAIN,LOCAL,,,,,41,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 21G 110MM SONOTAP II WITH FACET TIP 1285-3F110,120.483,CDM,271,RC,A4215,HCPCS,,12201-MAIN,LOCAL,,,,,41,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 21G X 4IN (100MM) SONOBLOCK II NERVE BLOCK WITH FACET S TIP 001281-77,120.483,CDM,271,RC,A4215,HCPCS,,12761-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 21G X 4IN (100MM) SONOBLOCK II NERVE BLOCK WITH FACET S TIP 001281-77,120.483,CDM,271,RC,A4215,HCPCS,,12761-MAIN,LOCAL,,,,,41,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 21G X 4IN (100MM) SONOBLOCK II NERVE BLOCK WITH FACET S TIP 001281-77,120.483,CDM,271,RC,A4215,HCPCS,,12761-MAIN,LOCAL,,,,,41,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 22G 80MM SONOTAP II WITH FACET TIP 1285-3E080,120.483,CDM,271,RC,A4215,HCPCS,,12103-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 22G 80MM SONOTAP II WITH FACET TIP 1285-3E080,120.483,CDM,271,RC,A4215,HCPCS,,12103-MAIN,LOCAL,,,,,41,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 22G 80MM SONOTAP II WITH FACET TIP 1285-3E080,120.483,CDM,271,RC,A4215,HCPCS,,12103-MAIN,LOCAL,,,,,41,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 22G X 3.25IN (80MM) SONOBLOCK II  NERVE BLOCK WITH FACET S TIP 001281-71,120.483,CDM,271,RC,A4215,HCPCS,,12760-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 22G X 3.25IN (80MM) SONOBLOCK II  NERVE BLOCK WITH FACET S TIP 001281-71,120.483,CDM,271,RC,A4215,HCPCS,,12760-MAIN,LOCAL,,,,,41,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 22G X 3.25IN (80MM) SONOBLOCK II  NERVE BLOCK WITH FACET S TIP 001281-71,120.483,CDM,271,RC,A4215,HCPCS,,12760-MAIN,LOCAL,,,,,41,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 22GX2 SONOPLEX II WITH FACET S TIP 001287-74,120.483,CDM,271,RC,A4215,HCPCS,,13110-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 22GX2 SONOPLEX II WITH FACET S TIP 001287-74,120.483,CDM,271,RC,A4215,HCPCS,,13110-MAIN,LOCAL,,,,,41,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 22GX2 SONOPLEX II WITH FACET S TIP 001287-74,120.483,CDM,271,RC,A4215,HCPCS,,13110-MAIN,LOCAL,,,,,41,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE NON-STIMULATING 22GX2 SONOBLOCK II WITH FACET S TIP 001281-74,120.483,CDM,271,RC,A4215,HCPCS,,11459-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE NON-STIMULATING 22GX2 SONOBLOCK II WITH FACET S TIP 001281-74,120.483,CDM,271,RC,A4215,HCPCS,,11459-MAIN,LOCAL,,,,,41,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE NON-STIMULATING 22GX2 SONOBLOCK II WITH FACET S TIP 001281-74,120.483,CDM,271,RC,A4215,HCPCS,,11459-MAIN,LOCAL,,,,,41,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE SONOPLEX II STIMULATING WITH FACET S TIP 22GX3-1/4,120.483,CDM,271,RC,A4215,HCPCS,,11457-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE SONOPLEX II STIMULATING WITH FACET S TIP 22GX3-1/4,120.483,CDM,271,RC,A4215,HCPCS,,11457-MAIN,LOCAL,,,,,41,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE SONOPLEX II STIMULATING WITH FACET S TIP 22GX3-1/4,120.483,CDM,271,RC,A4215,HCPCS,,11457-MAIN,LOCAL,,,,,41,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE STIMULATING 21GX4  SONOPLEX II  WITH FACET S TIP 001287-77,120.483,CDM,271,RC,A4215,HCPCS,,11458-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE STIMULATING 21GX4  SONOPLEX II  WITH FACET S TIP 001287-77,120.483,CDM,271,RC,A4215,HCPCS,,11458-MAIN,LOCAL,,,,,41,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE STIMULATING 21GX4  SONOPLEX II  WITH FACET S TIP 001287-77,120.483,CDM,271,RC,A4215,HCPCS,,11458-MAIN,LOCAL,,,,,41,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
STRAP FOOT LG/XL GEL UNIVERSAL 10165,120.428,CDM,271,RC,,,,11382-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
STRAP FOOT LG/XL GEL UNIVERSAL 10165,120.428,CDM,271,RC,,,,11382-MAIN,LOCAL,,,,,41,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
STRAP FOOT LG/XL GEL UNIVERSAL 10165,120.428,CDM,271,RC,,,,11382-MAIN,LOCAL,,,,,41,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
STRAP FOOT SM/MED GEL UNIVERSAL 10155,120.428,CDM,271,RC,,,,11381-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
STRAP FOOT SM/MED GEL UNIVERSAL 10155,120.428,CDM,271,RC,,,,11381-MAIN,LOCAL,,,,,41,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
STRAP FOOT SM/MED GEL UNIVERSAL 10155,120.428,CDM,271,RC,,,,11381-MAIN,LOCAL,,,,,41,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
SUTURE V-LOC SZ 1/2 180 GREEN GS-21 VLOCL0316,27200000,CDM,272,RC,,,,11932-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE V-LOC SZ 1/2 180 GREEN GS-21 VLOCL0316,27200000,CDM,272,RC,,,,11932-MAIN,LOCAL,,,,,41,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE V-LOC SZ 1/2 180 GREEN GS-21 VLOCL0316,27200000,CDM,272,RC,,,,11932-MAIN,LOCAL,,,,,41,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
URGOK2 DUAL COMPRESSION SYSTEM LARGE,120.491,CDM,271,RC,A6452,HCPCS,,11871-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
URGOK2 DUAL COMPRESSION SYSTEM LARGE,120.491,CDM,271,RC,A6452,HCPCS,,11871-MAIN,LOCAL,,,,,41,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
URGOK2 DUAL COMPRESSION SYSTEM LARGE,120.491,CDM,271,RC,A6452,HCPCS,,11871-MAIN,LOCAL,,,,,41,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
URGOK2 DUAL COMPRESSION SYSTEM REGULAR,120.491,CDM,271,RC,A6452,HCPCS,,11870-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
URGOK2 DUAL COMPRESSION SYSTEM REGULAR,120.491,CDM,271,RC,A6452,HCPCS,,11870-MAIN,LOCAL,,,,,41,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
URGOK2 DUAL COMPRESSION SYSTEM REGULAR,120.491,CDM,271,RC,A6452,HCPCS,,11870-MAIN,LOCAL,,,,,41,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
skin oil Oil 236.6 mL Bottle,63700001,CDM,250,RC,,,,,,67211008,NDC,236.6,ML,40.61,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.10195,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600701,NDC,10,ML,39.73,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.10338,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,38.9354
tamsulosin 0.4 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904640161,NDC,1,EA,22.6,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,20.114,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323048201,NDC,10,ML,39.78,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.12868,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323048217,NDC,10,ML,39.78,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.12868,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"SUTURE ETHIBOND #0 CT-1 CR 8-18"" CX21D",27200000,CDM,272,RC,,,,6415-MAIN,LOCAL,,,,,41.97,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,20.1456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"SUTURE ETHIBOND #0 CT-1 CR 8-18"" CX21D",27200000,CDM,272,RC,,,,6415-MAIN,LOCAL,,,,,41.97,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.1456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Clozapine - Ref,PX8015990,CDM,300,RC,80159,CPT,90,,,,,,,65,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,20.15,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.55,20.15
dabigatran 75 MG capsule 60 Each Box,63700001,CDM,250,RC,,,,,,597014960,NDC,1,EA,39.83,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.15398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
TROCAR KII BALLOON 12MM STERILE,27200000,CDM,272,RC,,,,11703-MAIN,LOCAL,,,,,41.14,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.1586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR KII BALLOON 12MM STERILE,27200000,CDM,272,RC,,,,11703-MAIN,LOCAL,,,,,41.14,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.1586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR KII BALLOON 12MM STERILE,27200000,CDM,272,RC,,,,11703-MAIN,LOCAL,,,,,41.14,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.1586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR KII BALLOON BLUNT 12MM STERILE,27200000,CDM,272,RC,,,,11702-MAIN,LOCAL,,,,,41.14,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.1586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR KII BALLOON BLUNT 12MM STERILE,27200000,CDM,272,RC,,,,11702-MAIN,LOCAL,,,,,41.14,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.1586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR KII BALLOON BLUNT 12MM STERILE,27200000,CDM,272,RC,,,,11702-MAIN,LOCAL,,,,,41.14,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.1586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039814,NDC,1,EA,39.84,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.15904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
BUPivacaine PF 0.5 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,55150016910,NDC,10,ML,39.84,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.15904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
enalaprilat 1.25 MG/ML Injectable 1 mL Vial,25000000,CDM,250,RC,,,,,,143978710,NDC,1,ML,39.84,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.15904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098141,NDC,1,EA,39.84,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.15904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098153,NDC,1,EA,39.84,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.15904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,47781059807,NDC,1,EA,39.84,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.15904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
Actin Antibody Each,PX8601590,CDM,300,RC,86015,CPT,90,,,,,,,42,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,20.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.05,41.16
Actin Antibody Each,PX8601590,CDM,300,RC,86015,CPT,90,,,,,,,42,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.05,41.16
Assay Vitamin B-6,PX84207,CDM,300,RC,84207,CPT,90,,,,,,,42,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,20.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
Assay Vitamin B-6,PX84207,CDM,300,RC,84207,CPT,90,,,,,,,42,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
"BOUGIE TRACH 10FR 70CM COUDE 	9-0211-70",120.199,CDM,272,RC,A7520,HCPCS,,11112-MAIN,LOCAL,,,,,42,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,20.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
"BOUGIE TRACH 10FR 70CM COUDE 	9-0211-70",120.199,CDM,272,RC,A7520,HCPCS,,11112-MAIN,LOCAL,,,,,42,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
BOUGIE TRACHEAL TUBE & GUIDE 100123515,120.199,CDM,272,RC,A7520,HCPCS,,8950-MAIN,LOCAL,,,,,42,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,20.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
BOUGIE TRACHEAL TUBE & GUIDE 100123515,120.199,CDM,272,RC,A7520,HCPCS,,8950-MAIN,LOCAL,,,,,42,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
CATHETER PUREWICK FEMALE EXTERNAL PWF030K,120.414,CDM,272,RC,A6590,HCPCS,,11836-MAIN,LOCAL,,,,,42,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,20.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
CATHETER PUREWICK FEMALE EXTERNAL PWF030K,120.414,CDM,272,RC,A6590,HCPCS,,11836-MAIN,LOCAL,,,,,42,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
Culture Type Immunologic,PX87147,CDM,300,RC,87147,CPT,,,,,,,,42,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,20.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,41.16
Culture Type Immunologic,PX87147,CDM,300,RC,87147,CPT,,,,,,,,42,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,41.16
EZ-STABILIZER DRESSING,120.415,CDM,272,RC,,,,9058-MAIN,LOCAL,,,,,42,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,20.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
EZ-STABILIZER DRESSING,120.415,CDM,272,RC,,,,9058-MAIN,LOCAL,,,,,42,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
MEPILEX AG FOAM 4X4,120.192,CDM,272,RC,A6213,HCPCS,,8480-MAIN,LOCAL,,,,,42,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,20.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
MEPILEX AG FOAM 4X4,120.192,CDM,272,RC,A6213,HCPCS,,8480-MAIN,LOCAL,,,,,42,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
MEPILEX AG FOAM 4X8,120.192,CDM,272,RC,A6213,HCPCS,,8479-MAIN,LOCAL,,,,,42,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,20.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
MEPILEX AG FOAM 4X8,120.192,CDM,272,RC,A6213,HCPCS,,8479-MAIN,LOCAL,,,,,42,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
Renin - Ref,PX8424490,CDM,300,RC,84244,CPT,90,,,,,,,53,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,20.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.16,51.94
TRAY CENTRAL LINE DRESSING WITH CHLORAPREP DYND75234,120.68,CDM,272,RC,,,,10923-MAIN,LOCAL,,,,,42,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,20.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY CENTRAL LINE DRESSING WITH CHLORAPREP DYND75234,120.68,CDM,272,RC,,,,10923-MAIN,LOCAL,,,,,42,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY FOLEY 14FR CATHETER A300414A,120.414,CDM,272,RC,A4344,HCPCS,,11281-MAIN,LOCAL,,,,,42,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,20.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY FOLEY 14FR CATHETER A300414A,120.414,CDM,272,RC,A4344,HCPCS,,11281-MAIN,LOCAL,,,,,42,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY FOLEY 16FR CATHETER 300416A,120.414,CDM,272,RC,A4344,HCPCS,,11774-MAIN,LOCAL,,,,,42,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,20.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY FOLEY 16FR CATHETER 300416A,120.414,CDM,272,RC,A4344,HCPCS,,11774-MAIN,LOCAL,,,,,42,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
"TRAY SPINAL  25GX3.5"" WITH WHITEACRE 405671",120.275,CDM,272,RC,,,,3284-MAIN,LOCAL,,,,,42,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,20.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
"TRAY SPINAL  25GX3.5"" WITH WHITEACRE 405671",120.275,CDM,272,RC,,,,3284-MAIN,LOCAL,,,,,42,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY SPINAL 25G ANESTH SADDLE BLOCK NLD-4795-20,120.275,CDM,272,RC,,,,935-MAIN,LOCAL,,,,,42,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,20.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY SPINAL 25G ANESTH SADDLE BLOCK NLD-4795-20,120.275,CDM,272,RC,,,,935-MAIN,LOCAL,,,,,42,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
Blood Count Reticulocytes Auto 1/> Cell Meas,PX85046,CDM,300,RC,85046,CPT,,,,,,,,47,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,20.163,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.11,46.06
"PAD BED SENSOR 10X28"" P-107517",120.124,CDM,271,RC,,,,8377-MAIN,LOCAL,,,,,47,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,20.163,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.5238,46.06
"PAD CHAIR SENSOR 10x15"" 106380",120.124,CDM,271,RC,,,,8378-MAIN,LOCAL,,,,,47,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,20.163,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.5238,46.06
"Protein S, Free - Ref",PX8530690,CDM,300,RC,85306,CPT,90,,,,,,,47,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,20.163,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.05,46.06
REDUCER 12 - 8MM,27200000,CDM,272,RC,,,,11961-MAIN,LOCAL,,,,,47,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,20.163,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,409469930,NDC,20,ML,48.54,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,20.163516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
gemcitabine 200 MG/5.26ML Solution 5.26 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018301,NDC,5.26,ML,40.74,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.1663,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641622901,NDC,1,ML,41.16,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.1684,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.097864,86.9162
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641622901,NDC,1,ML,41.16,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.1684,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.097864,86.9162
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641622901,NDC,1,ML,41.16,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.1684,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.097864,86.9162
hydrocortisone 1 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,472034356,NDC,28,GR,22.15,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,20.17865,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omalizumab 150 MG Recon Soln 1 Each Vial,J2357.01,CDM,636,RC,J2357,HCPCS,,,,50242004062,NDC,1,EA,2212.7,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,20.18,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.18,39.46
C-Peptide - Ref,PX8468190,CDM,300,RC,84681,CPT,90,,,,,,,180,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,20.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.19,20.81
C-Peptide - Ref,PX8468190,CDM,300,RC,84681,CPT,90,,,,,,,180,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,20.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.19,20.81
C-Peptide - Ref,PX8468190,CDM,300,RC,84681,CPT,90,,,,,,,180,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,20.19,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.19,20.81
Ca 19-9,PX86301,CDM,300,RC,86301,CPT,,,,,,,,116,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,20.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.19,20.81
Ca 19-9,PX86301,CDM,300,RC,86301,CPT,,,,,,,,116,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,20.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.19,20.81
Ca 19-9,PX86301,CDM,300,RC,86301,CPT,,,,,,,,116,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,20.19,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.19,20.81
"Immuno for Tumor Ag, Qn - Ref",PX8631690,CDM,300,RC,86316,CPT,90,,,,,,,115,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,20.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.19,20.81
"Immuno for Tumor Ag, Qn - Ref",PX8631690,CDM,300,RC,86316,CPT,90,,,,,,,115,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,20.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.19,20.81
"Immuno for Tumor Ag, Qn - Ref",PX8631690,CDM,300,RC,86316,CPT,90,,,,,,,115,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,20.19,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.19,20.81
"Immunoassay,Ca15-3(27.29) - Ref",PX8630090,CDM,300,RC,86300,CPT,90,,,,,,,124,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,20.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.19,20.81
"Immunoassay,Ca15-3(27.29) - Ref",PX8630090,CDM,300,RC,86300,CPT,90,,,,,,,124,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,20.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.19,20.81
"Immunoassay,Ca15-3(27.29) - Ref",PX8630090,CDM,300,RC,86300,CPT,90,,,,,,,124,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,20.19,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.19,20.81
"Tumor Antigen, Ca-125",PX86304,CDM,300,RC,86304,CPT,,,,,,,,190,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,20.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.19,20.81
"Tumor Antigen, Ca-125",PX86304,CDM,300,RC,86304,CPT,,,,,,,,190,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,20.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.19,20.81
"Tumor Antigen, Ca-125",PX86304,CDM,300,RC,86304,CPT,,,,,,,,190,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,20.19,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.19,20.81
FLEXITIP APPLICATOR 38CM,27200000,CDM,272,RC,,,,10200-MAIN,LOCAL,,,,,40.8,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
lidocaine (preservative free) 4 % Solution 5 mL Ampule,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409428325,NDC,5,ML,48.62,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,20.196748,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019600,NDC,1,ML,48.64,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,20.205056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,36000000924,NDC,200,ML,48.65,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,20.20921,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.20921,64.9544
ibuprofen 100 MG/5ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,68094049459,NDC,20,ML,22.2,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,20.2242,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Progesterone,PX84144,CDM,300,RC,84144,CPT,,,,,,,,56,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,20.23,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.23,20.86
Progesterone,PX84144,CDM,300,RC,84144,CPT,,,,,,,,56,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,20.23,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.23,20.86
Progesterone,PX84144,CDM,300,RC,84144,CPT,,,,,,,,56,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,20.23,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.23,20.86
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Syringe,J7040.01,CDM,636,RC,J7040,HCPCS,,,,64253020230,NDC,10,ML,42.15,,Health Partners,Health Partners Care Plans,both,48,,36.618125,percent of total billed charges,20.232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Syringe,J7040.01,CDM,636,RC,J7040,HCPCS,,,,64253020230,NDC,10,ML,42.15,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028426,NDC,1,EA,42.15,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,20.232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028426,NDC,1,EA,42.15,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028016,NDC,2,ML,41.29,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,7.169534884,percent of total billed charges,20.2321,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028016,NDC,2,ML,41.29,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.2321,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028016,NDC,2,ML,41.29,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.2321,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
methylPREDNISolone acetate 20 MG/ML Suspension 5 mL Vial,J1010.01,CDM,636,RC,J1010,HCPCS,,,,9027401,NDC,0.5,ML,41.3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.237,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.15602,40.474
methylPREDNISolone acetate 20 MG/ML Suspension 5 mL Vial,J1010.01,CDM,636,RC,J1010,HCPCS,,,,9027401,NDC,0.5,ML,41.3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.237,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.15602,40.474
methylPREDNISolone acetate 20 MG/ML Suspension 5 mL Vial,J1010.01,CDM,636,RC,J1010,HCPCS,,,,9027401,NDC,0.5,ML,41.3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.237,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.15602,40.474
vinCRIStine 1 MG/ML Solution 2 mL Vial,J9370.01,CDM,636,RC,J9370,HCPCS,,,,61703030916,NDC,2,ML,48.72,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,20.238288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.238288,47.7456
8MM-12MM TIP COVER ACCESSORY,27200000,CDM,272,RC,,,,11918-MAIN,LOCAL,,,,,40,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CATHETER URETERAL  5FR TIGERTAIL OPEN TIP FLEXIBLE 139005,27200000,CDM,272,RC,A4340,HCPCS,,12302-MAIN,LOCAL,,,,,40,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NEEDLE BIOPSY 14GAX4 1/2 2N2702X,120.211,CDM,272,RC,,,,724-MAIN,LOCAL,,,,,40,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.616,39.2
STAPLER CANNULA SEAL 12 mm 470380,27200000,CDM,272,RC,,,,11962-MAIN,LOCAL,,,,,40,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"SUTURE V-LOC 22G NEEDLE 9"" 180 GREEN VLOCL2145",27200000,CDM,272,RC,,,,11930-MAIN,LOCAL,,,,,40,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"SUTURE V-LOC SZ 0.9"" 180 GREEN GS-21 NEEDLE VLOCL0346",27200000,CDM,272,RC,,,,11933-MAIN,LOCAL,,,,,40,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Telehealth Origin Site Fac Fee,PXQ3014,CDM,780,RC,Q3014,HCPCS,,,,,,,,40,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.616,39.2
DULoxetine 30 MG Capsule Delayed Release Particles 90 Each Bottle,63700001,CDM,250,RC,,,,,,57237001890,NDC,1,EA,42.17,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,20.2416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DULoxetine 30 MG Capsule Delayed Release Particles 90 Each Bottle,63700001,CDM,250,RC,,,,,,57237001890,NDC,1,EA,42.17,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.2416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
FORCEPS SERRATED WITH SPIKE JUMBO 230CM,27200000,CDM,272,RC,,,,7416-MAIN,LOCAL,,,,,41.31,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.2419,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
FORCEPS SERRATED WITH SPIKE JUMBO 230CM,27200000,CDM,272,RC,,,,7416-MAIN,LOCAL,,,,,41.31,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.2419,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
FORCEPS SERRATED WITH SPIKE JUMBO 230CM,27200000,CDM,272,RC,,,,7416-MAIN,LOCAL,,,,,41.31,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.2419,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
naltrexone 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406117001,NDC,1,EA,22.96,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,20.25072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
triamcinolone acetonide 0.1 % Cream 15 g Tube,63700001,CDM,250,RC,,,,,,168000415,NDC,15,GR,22.97,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,20.25954,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zinc oxide 20 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,536131625,NDC,60,GR,22.97,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,20.25954,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409132305,NDC,5,ML,41.35,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.2615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409132305,NDC,5,ML,41.35,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.2615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409132305,NDC,5,ML,41.35,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.2615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070548,NDC,100,ML,40.94,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.2653,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
apixaban 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,3089431,NDC,0.5,EA,23.85,,First Health,Commercial,both,85,,999999999,percent of total billed charges,20.2725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Drain Blood From Under Nail,PX11740F,CDM,510,RC,11740,CPT,,,,,,,,117,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,20.28,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.28,120.37
Joint Survey Tc,PX7707701,CDM,320,RC,77077,CPT,TC,,,,,,,304,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,20.28,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.28,60.48
"X-Ray Exam Hip,Bilat W/Pelvis 2 Vws",PX7352101,CDM,320,RC,73521,CPT,TC,,,,,,,399,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,20.28,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.28,60.48
Joint Survey Tc,PX7707701,CDM,320,RC,77077,CPT,TC,,,,,,,304,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,20.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.28,60.48
Joint Survey Tc,PX7707701,CDM,320,RC,77077,CPT,TC,,,,,,,304,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,20.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.28,60.48
"X-Ray Exam Hip,Bilat W/Pelvis 2 Vws",PX7352101,CDM,320,RC,73521,CPT,TC,,,,,,,399,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,20.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.28,60.48
"X-Ray Exam Hip,Bilat W/Pelvis 2 Vws",PX7352101,CDM,320,RC,73521,CPT,TC,,,,,,,399,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,20.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.28,60.48
BRACE WRIST 8-IN SM LEFT 10432,120.564,CDM,273,RC,L3809,HCPCS,,12720-MAIN,LOCAL,,,,,23,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,20.286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 8-IN SM RIGHT 10442,120.564,CDM,273,RC,L3809,HCPCS,,12716-MAIN,LOCAL,,,,,23,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,20.286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN LG RIGHT 10464,120.564,CDM,273,RC,L3809,HCPCS,,12719-MAIN,LOCAL,,,,,23,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,20.286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN SM LEFT 617083,120.564,CDM,273,RC,L3809,HCPCS,,12722-MAIN,LOCAL,,,,,23,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,20.286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN SM RIGHT 10462,120.564,CDM,273,RC,L3809,HCPCS,,12717-MAIN,LOCAL,,,,,23,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,20.286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN XL LEFT 10455,120.564,CDM,273,RC,L3809,HCPCS,,12721-MAIN,LOCAL,,,,,23,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,20.286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN XL RIGHT 10465,120.564,CDM,273,RC,L3809,HCPCS,,12715-MAIN,LOCAL,,,,,23,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,20.286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST WRISTPRO LEFT 10-IN LG,120.564,CDM,273,RC,L3809,HCPCS,,12724-MAIN,LOCAL,,,,,23,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,20.286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST WRISTPRO LEFT 10-IN MED,120.564,CDM,273,RC,L3809,HCPCS,,12723-MAIN,LOCAL,,,,,23,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,20.286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
Detection of Babesia Borrelia Miyamotoi by Amplified Nucleic Acid Probe Technique,PX8747890,CDM,300,RC,87478,CPT,90,,,,,,,23,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,20.286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,32.17
Detection of Babesia Microtim by Amplified Nucleic Acid Probe Technique,PX8746990,CDM,300,RC,87469,CPT,90,,,,,,,23,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,20.286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,32.17
FORCEPS COLD BIOPSY,27200000,CDM,272,RC,,,,12453-MAIN,LOCAL,,,,,23,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,20.286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE MAXON ABSORBABLE POLYGLYCONATE 2-0 30IN MONOFILAMENT DYED TAPER POINT 1/2 CIRCLE 27MM GS-22 G,27200000,CDM,272,RC,,,,11988-MAIN,LOCAL,,,,,23,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,20.286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE POLYSORB ABSORBABLE LACTOMER 2-0 30IN BRAIDED DYED TAPER POINT 1/2 CIRCLE 26MM V-20 VIOLET ST,27200000,CDM,272,RC,,,,11983-MAIN,LOCAL,,,,,23,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,20.286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUCTION TIP POOLE STERILE 35040,27200000,CDM,272,RC,,,,977-MAIN,LOCAL,,,,,42.28,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,20.2944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUCTION TIP POOLE STERILE 35040,27200000,CDM,272,RC,,,,977-MAIN,LOCAL,,,,,42.28,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.2944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CANNULA SEAL 5-12MM UNIVERSAL 470500,27200000,CDM,272,RC,,,,12885-MAIN,LOCAL,,,,,41,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CUP HEEL LARGE WONDERSPUR 4502,120.43,CDM,274,RC,L3485,HCPCS,,11385-MAIN,LOCAL,,,,,41,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL MEDIUM WONDERSPUR 4501,120.43,CDM,274,RC,L3485,HCPCS,,11384-MAIN,LOCAL,,,,,41,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL SMALL WONDERSPUR 4500,120.43,CDM,274,RC,L3485,HCPCS,,11383-MAIN,LOCAL,,,,,41,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL XL WONDERSPUR 4503,120.43,CDM,274,RC,L3485,HCPCS,,11386-MAIN,LOCAL,,,,,41,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
Detection of Anaplasma Phagocytophilum by Amplified Nucleic Acid Probe Technique,PX8746890,CDM,300,RC,87468,CPT,90,,,,,,,41,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
Detection of Ehrlichia Chaffeensis by Amplified Nucleic Acid Probe Technique,PX8748490,CDM,300,RC,87484,CPT,90,,,,,,,41,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 21G 110MM SONOTAP II WITH FACET TIP 1285-3F110,120.483,CDM,271,RC,A4215,HCPCS,,12201-MAIN,LOCAL,,,,,41,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 21G X 4IN (100MM) SONOBLOCK II NERVE BLOCK WITH FACET S TIP 001281-77,120.483,CDM,271,RC,A4215,HCPCS,,12761-MAIN,LOCAL,,,,,41,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 22G 80MM SONOTAP II WITH FACET TIP 1285-3E080,120.483,CDM,271,RC,A4215,HCPCS,,12103-MAIN,LOCAL,,,,,41,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 22G X 3.25IN (80MM) SONOBLOCK II  NERVE BLOCK WITH FACET S TIP 001281-71,120.483,CDM,271,RC,A4215,HCPCS,,12760-MAIN,LOCAL,,,,,41,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 22GX2 SONOPLEX II WITH FACET S TIP 001287-74,120.483,CDM,271,RC,A4215,HCPCS,,13110-MAIN,LOCAL,,,,,41,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE NON-STIMULATING 22GX2 SONOBLOCK II WITH FACET S TIP 001281-74,120.483,CDM,271,RC,A4215,HCPCS,,11459-MAIN,LOCAL,,,,,41,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE SONOPLEX II STIMULATING WITH FACET S TIP 22GX3-1/4,120.483,CDM,271,RC,A4215,HCPCS,,11457-MAIN,LOCAL,,,,,41,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE STIMULATING 21GX4  SONOPLEX II  WITH FACET S TIP 001287-77,120.483,CDM,271,RC,A4215,HCPCS,,11458-MAIN,LOCAL,,,,,41,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
STRAP FOOT LG/XL GEL UNIVERSAL 10165,120.428,CDM,271,RC,,,,11382-MAIN,LOCAL,,,,,41,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
STRAP FOOT SM/MED GEL UNIVERSAL 10155,120.428,CDM,271,RC,,,,11381-MAIN,LOCAL,,,,,41,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
SUTURE V-LOC SZ 1/2 180 GREEN GS-21 VLOCL0316,27200000,CDM,272,RC,,,,11932-MAIN,LOCAL,,,,,41,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
URGOK2 DUAL COMPRESSION SYSTEM LARGE,120.491,CDM,271,RC,A6452,HCPCS,,11871-MAIN,LOCAL,,,,,41,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
URGOK2 DUAL COMPRESSION SYSTEM REGULAR,120.491,CDM,271,RC,A6452,HCPCS,,11870-MAIN,LOCAL,,,,,41,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028026,NDC,2,ML,41.42,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,7.169534884,percent of total billed charges,20.2958,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028026,NDC,2,ML,41.42,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.2958,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028026,NDC,2,ML,41.42,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.2958,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490334,NDC,5,ML,42.29,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,20.2992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490334,NDC,5,ML,42.29,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.2992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
tetracycline 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,51991090701,NDC,0.5,EA,42.29,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,20.2992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tetracycline 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,51991090701,NDC,0.5,EA,42.29,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.2992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
leucovorin 10 mg/mL Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,25021081467,NDC,1,EA,40.13,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.30578,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.670002,84.6818
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,55150016205,NDC,5,ML,42.32,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,20.3136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,55150016205,NDC,5,ML,42.32,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.3136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Compliment, Total (Ch50) - Ref",PX8616290,CDM,300,RC,86162,CPT,90,,,,,,,122,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,20.32,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.71,20.32
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001001,NDC,1.5,ML,40.17,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.32602,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,42.5516
Emergency Level I Visit,PX99281P,CDM,981,RC,99281,CPT,,,,,,,,224,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,20.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.98,219.52
Emergency Level I Visit,PX99281P,CDM,981,RC,99281,CPT,,,,,,,,224,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,20.33,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.98,219.52
"Enzyme Act, Nonradioact - Ref",PX8265790,CDM,300,RC,82657,CPT,90,,,,,,,560,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,20.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.33,548.8
Facility Emergency Level 1 Visit,PX99281F,CDM,450,RC,99281,CPT,,,,,,,,329,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,20.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.98,20.33
Facility Emergency Level 1 Visit,PX99281F,CDM,450,RC,99281,CPT,,,,,,,,329,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,20.33,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.98,20.33
nafcillin 2 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,S0032,HCPCS,,,,63323032820,NDC,1,EA,185.37,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,20.34,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.38,37.648
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,17478004001,NDC,1,ML,42.39,,Health Partners,Health Partners Care Plans,both,48,,17.635,percent of total billed charges,20.3472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,17478004001,NDC,1,ML,42.39,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.3472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
risperiDONE 0.25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084027011,NDC,1,EA,20.91,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,20.351703,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084027001,NDC,1,EA,20.91,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,20.351703,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079049801,NDC,1,EA,22.34,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,20.35174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Beta-2-Microglobulin - Ref,PX8223290,CDM,300,RC,82232,CPT,90,,,,,,,49,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,20.3546,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.84,48.02
"Cannabinoids, Natural - Ref",PX8034990,CDM,300,RC,80349,CPT,90,,,,,,,49,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,20.3546,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,48.02
cefTAZidime 1 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023525,NDC,1,EA,49,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,20.3546,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
COLLAR CERVICAL X-LARGE WITH TRACH 2 PIECE OSG2404,120.185,CDM,274,RC,L0172,HCPCS,,10143-MAIN,LOCAL,,,,,49,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,20.3546,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,152.79
Glycated Protein - Ref,PX8298590,CDM,300,RC,82985,CPT,90,,,,,,,49,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,20.3546,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.37,48.02
"SUTURE V-LOC SZ 0 180 GREEN GS21 NEEDLE 18"" VLOCL0326",27200000,CDM,272,RC,,,,12218-MAIN,LOCAL,,,,,49,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,20.3546,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153F,CDM,370,RC,99153,CPT,,,,,,,,225,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,20.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.98,20.36
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153F,CDM,370,RC,99153,CPT,,,,,,,,225,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,20.36,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.98,20.36
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153P,CDM,983,RC,99153,CPT,,,,,,,,250,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,20.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.98,245
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153P,CDM,983,RC,99153,CPT,,,,,,,,250,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,20.36,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.98,245
TROCAR KII BALLOON 12MM STERILE,27200000,CDM,272,RC,,,,11703-MAIN,LOCAL,,,,,41.14,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.3643,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR KII BALLOON BLUNT 12MM STERILE,27200000,CDM,272,RC,,,,11702-MAIN,LOCAL,,,,,41.14,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.3643,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
buprenorphine 8 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,54017713,NDC,1,EA,41.56,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.3644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.14,40.7288
buprenorphine 8 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,54017713,NDC,1,EA,41.56,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.3644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.14,40.7288
buprenorphine 8 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,54017713,NDC,1,EA,41.56,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.3644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.14,40.7288
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049257,NDC,5,ML,42.43,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,20.3664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049257,NDC,5,ML,42.43,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.3664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641622901,NDC,1,ML,41.16,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.3742,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.097864,86.9162
Dhea-S - Ref,PX8262790,CDM,300,RC,82627,CPT,90,,,,,,,57,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,20.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.38,55.86
ON Q PAIN BUSTER,27100000,CDM,271,RC,A4305,HCPCS,,6751-MAIN,LOCAL,,,,,194.26,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,20.39,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.39,20.39
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,703291401,NDC,0.5,EA,40.3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.3918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
promethazine 25 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802075930,NDC,0.5,EA,47.54,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,20.39466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simethicone 40 MG/0.6ML Suspension 30 mL Bottle,25000000,CDM,250,RC,,,,,,904589430,NDC,30,ML,22.39,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,20.39729,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
promethazine 25 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,45802075900,NDC,0.5,EA,47.55,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,20.39895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ketorolac 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314012605,NDC,5,ML,42.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,20.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ketorolac 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314012605,NDC,5,ML,42.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
SLEEVE BALLOON 5MMX100MML KII STERILE CFS02,27200000,CDM,272,RC,,,,11704-MAIN,LOCAL,,,,,24,,First Health,Commercial,both,85,,999999999,percent of total billed charges,20.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STRAP CLAVICLE LARGE VP10123-040,120.191,CDM,274,RC,L3670,HCPCS,,12848-MAIN,LOCAL,,,,,24,,First Health,Commercial,both,85,,999999999,percent of total billed charges,20.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE MEDIUM VP10123-030,120.191,CDM,274,RC,L3670,HCPCS,,12847-MAIN,LOCAL,,,,,24,,First Health,Commercial,both,85,,999999999,percent of total billed charges,20.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE SMALL VP10123-020,120.191,CDM,274,RC,L3670,HCPCS,,12846-MAIN,LOCAL,,,,,24,,First Health,Commercial,both,85,,999999999,percent of total billed charges,20.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE XL 661 XL,120.191,CDM,274,RC,L3670,HCPCS,,12850-MAIN,LOCAL,,,,,24,,First Health,Commercial,both,85,,999999999,percent of total billed charges,20.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE XSMALL CHILD ORT14100XS,120.191,CDM,274,RC,L3670,HCPCS,,12849-MAIN,LOCAL,,,,,24,,First Health,Commercial,both,85,,999999999,percent of total billed charges,20.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
buPROPion XL 150 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,70436001004,NDC,1,EA,23.14,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,20.40948,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SCISSORS ENDOSCOPIC 5MM STANDARD STERILE,27200000,CDM,272,RC,,,,11706-MAIN,LOCAL,,,,,47.6,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,20.4204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
mycophenolate 500 MG Tablet 100 Each Bottle,J7517.01,CDM,637,RC,J7517,HCPCS,,,,64380072506,NDC,1,EA,42.56,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,20.4288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.679424,41.7088
mycophenolate 500 MG Tablet 100 Each Bottle,J7517.01,CDM,637,RC,J7517,HCPCS,,,,64380072506,NDC,1,EA,42.56,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.4288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.679424,41.7088
naltrexone 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406117001,NDC,1,EA,22.96,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,20.4344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
enalaprilat 1.25 MG/ML Injectable 1 mL Vial,25000000,CDM,250,RC,,,,,,143978701,NDC,1,ML,40.39,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.43734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028016,NDC,2,ML,41.29,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.43855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
Anesthesia Level 4,PX37000018,CDM,370,RC,,,,,,,,,,21,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,20.4393,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.7234,20.58
ANOSCOPE LIGHTED ANOSCOPE,120.52,CDM,272,RC,,,,10235-MAIN,LOCAL,,,,,21,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,20.4393,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.7234,20.58
"Hepatitis B Core Antibody, Total",PX86704,CDM,300,RC,86704,CPT,,,,,,,,21,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,20.4393,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.7234,20.58
"Spectrophotometry, Nos",PX84311,CDM,300,RC,84311,CPT,,,,,,,,21,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,20.4393,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.43,20.58
"Gput, Quant",PX8277590,CDM,300,RC,82775,CPT,90,,,,,,,25,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,20.44,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.44,21.07
"Gput, Quant",PX8277590,CDM,300,RC,82775,CPT,90,,,,,,,25,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,20.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.44,21.07
"Gput, Quant",PX8277590,CDM,300,RC,82775,CPT,90,,,,,,,25,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,20.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.44,21.07
azithromycin 250 MG Tablet 6 Each Box,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096104,NDC,1,EA,41.72,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.4428,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
azithromycin 250 MG Tablet 6 Each Box,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096104,NDC,1,EA,41.72,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.4428,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
azithromycin 250 MG Tablet 6 Each Box,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096104,NDC,1,EA,41.72,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.4428,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070948,NDC,100,ML,42.59,,Health Partners,Health Partners Care Plans,both,48,,6.034333333,percent of total billed charges,20.4432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070948,NDC,100,ML,42.59,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.4432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
triamcinolone acetonide 0.1 % Cream 15 g Tube,63700001,CDM,250,RC,,,,,,168000415,NDC,15,GR,22.97,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,20.4433,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zinc oxide 20 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,536131625,NDC,60,GR,22.97,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,20.4433,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone acetate 20 MG/ML Suspension 5 mL Vial,J1010.01,CDM,636,RC,J1010,HCPCS,,,,9027401,NDC,0.5,ML,41.3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.4435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.15602,40.474
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096105,NDC,1,EA,41.73,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.4477,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096105,NDC,1,EA,41.73,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.4477,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096105,NDC,1,EA,41.73,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.4477,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
FORCEPS SERRATED WITH SPIKE JUMBO 230CM,27200000,CDM,272,RC,,,,7416-MAIN,LOCAL,,,,,41.31,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.44845,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028002,NDC,1,ML,40.43,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.45758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
DULoxetine 20 MG Capsule Delayed Release Particles 60 Each Bottle,63700001,CDM,250,RC,,,,,,2323560,NDC,1,EA,41.76,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.4624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DULoxetine 20 MG Capsule Delayed Release Particles 60 Each Bottle,63700001,CDM,250,RC,,,,,,2323560,NDC,1,EA,41.76,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.4624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DULoxetine 20 MG Capsule Delayed Release Particles 60 Each Bottle,63700001,CDM,250,RC,,,,,,2323560,NDC,1,EA,41.76,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.4624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253033335,NDC,5,ML,40.44,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.46264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028442,NDC,1,EA,47.71,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,20.46759,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409132305,NDC,5,ML,41.35,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.46825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
BRACE WRIST 8-IN SM LEFT 10432,120.564,CDM,273,RC,L3809,HCPCS,,12720-MAIN,LOCAL,,,,,23,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,20.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 8-IN SM RIGHT 10442,120.564,CDM,273,RC,L3809,HCPCS,,12716-MAIN,LOCAL,,,,,23,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,20.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN LG RIGHT 10464,120.564,CDM,273,RC,L3809,HCPCS,,12719-MAIN,LOCAL,,,,,23,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,20.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN SM LEFT 617083,120.564,CDM,273,RC,L3809,HCPCS,,12722-MAIN,LOCAL,,,,,23,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,20.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN SM RIGHT 10462,120.564,CDM,273,RC,L3809,HCPCS,,12717-MAIN,LOCAL,,,,,23,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,20.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN XL LEFT 10455,120.564,CDM,273,RC,L3809,HCPCS,,12721-MAIN,LOCAL,,,,,23,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,20.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN XL RIGHT 10465,120.564,CDM,273,RC,L3809,HCPCS,,12715-MAIN,LOCAL,,,,,23,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,20.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST WRISTPRO LEFT 10-IN LG,120.564,CDM,273,RC,L3809,HCPCS,,12724-MAIN,LOCAL,,,,,23,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,20.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST WRISTPRO LEFT 10-IN MED,120.564,CDM,273,RC,L3809,HCPCS,,12723-MAIN,LOCAL,,,,,23,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,20.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
Detection of Babesia Borrelia Miyamotoi by Amplified Nucleic Acid Probe Technique,PX8747890,CDM,300,RC,87478,CPT,90,,,,,,,23,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,20.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,32.17
Detection of Babesia Microtim by Amplified Nucleic Acid Probe Technique,PX8746990,CDM,300,RC,87469,CPT,90,,,,,,,23,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,20.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,32.17
FORCEPS COLD BIOPSY,27200000,CDM,272,RC,,,,12453-MAIN,LOCAL,,,,,23,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,20.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE MAXON ABSORBABLE POLYGLYCONATE 2-0 30IN MONOFILAMENT DYED TAPER POINT 1/2 CIRCLE 27MM GS-22 G,27200000,CDM,272,RC,,,,11988-MAIN,LOCAL,,,,,23,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,20.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE POLYSORB ABSORBABLE LACTOMER 2-0 30IN BRAIDED DYED TAPER POINT 1/2 CIRCLE 26MM V-20 VIOLET ST,27200000,CDM,272,RC,,,,11983-MAIN,LOCAL,,,,,23,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,20.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
midazolam 2 MG/ML Syrup 5 mL Cup,63700001,CDM,250,RC,,,,,,68094076459,NDC,2.5,ML,22.47,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,20.47017,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
neomycin-bacitracin-polymyxin 3.5-400-5000 Ointment 28.4 g Tube,25000000,CDM,250,RC,,,,,,713026831,NDC,28.4,GR,22.47,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,20.47017,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
chlorhexidine 4 % Solution 118 mL Bottle,25000000,CDM,250,RC,,,,,,234057504,NDC,118,ML,24.09,,First Health,Commercial,both,85,,999999999,percent of total billed charges,20.4765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,50111078751,NDC,1,EA,41.79,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.4771,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,50111078751,NDC,1,EA,41.79,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.4771,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,50111078751,NDC,1,EA,41.79,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.4771,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
donepezil 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904640861,NDC,1,EA,41.79,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.4771,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
donepezil 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904640861,NDC,1,EA,41.79,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.4771,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
donepezil 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904640861,NDC,1,EA,41.79,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.4771,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Immunofixation Electrophoresis; Serum,PX86334,CDM,300,RC,86334,CPT,,,,,,,,145,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,20.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.48,142.1
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042350,NDC,0.5,ML,132.37,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,20.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.49,129.7226
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042388,NDC,0.5,ML,132.37,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,20.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.49,129.7226
risperiDONE 0.25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084027011,NDC,1,EA,20.91,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,20.4918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084027001,NDC,1,EA,20.91,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,20.4918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylergonovine 0.2 MG/ML Solution 1 mL Ampule,J2210.01,CDM,636,RC,J2210,HCPCS,,,,51991014417,NDC,1,ML,133.11,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,20.49229,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.25,20.87
apixaban 5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,3089421,NDC,0.5,EA,22.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,20.4975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
US Ext Non-Vasc Img Lmtd,PX7688201,CDM,402,RC,76882,CPT,TC,,,,,,,425,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,20.5,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.5,61.14
US Ext Non-Vasc Img Lmtd,PX7688201,CDM,402,RC,76882,CPT,TC,,,,,,,425,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,20.5,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.5,61.14
aluminum & magnesium hydroxide-simethicone 200-200-20 MG/5ML Suspension 30 mL Cup,63700001,CDM,250,RC,,,,,,121176130,NDC,30,ML,24.12,,First Health,Commercial,both,85,,999999999,percent of total billed charges,20.502,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028026,NDC,2,ML,41.42,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.5029,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,641601310,NDC,5,ML,40.58,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.53348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
C-Peptide - Ref,PX8468190,CDM,300,RC,84681,CPT,90,,,,,,,180,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,20.5376,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.19,20.81
Ca 19-9,PX86301,CDM,300,RC,86301,CPT,,,,,,,,116,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,20.5376,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.19,20.81
"Gput, Quant",PX8277590,CDM,300,RC,82775,CPT,90,,,,,,,25,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,20.5376,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.44,21.07
"Immuno for Tumor Ag, Qn - Ref",PX8631690,CDM,300,RC,86316,CPT,90,,,,,,,115,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,20.5376,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.19,20.81
"Immunoassay,Ca15-3(27.29) - Ref",PX8630090,CDM,300,RC,86300,CPT,90,,,,,,,124,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,20.5376,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.19,20.81
Progesterone,PX84144,CDM,300,RC,84144,CPT,,,,,,,,56,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,20.5376,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.23,20.86
"Tumor Antigen, Ca-125",PX86304,CDM,300,RC,86304,CPT,,,,,,,,190,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,20.5376,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.19,20.81
risperiDONE 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635861,NDC,1,EA,21.11,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,20.546363,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
skin oil Oil 236.6 mL Bottle,63700001,CDM,250,RC,,,,,,67211008,NDC,236.6,ML,40.61,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.54866,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
eplerenone 25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16729029315,NDC,1,EA,23.31,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,20.55942,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"SUTURE ETHIBOND #0 CT-1 CR 8-18"" CX21D",27200000,CDM,272,RC,,,,6415-MAIN,LOCAL,,,,,41.97,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.5653,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"SUTURE ETHIBOND #0 CT-1 CR 8-18"" CX21D",27200000,CDM,272,RC,,,,6415-MAIN,LOCAL,,,,,41.97,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.5653,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"SUTURE ETHIBOND #0 CT-1 CR 8-18"" CX21D",27200000,CDM,272,RC,,,,6415-MAIN,LOCAL,,,,,41.97,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.5653,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Organic Acid, Single, Qnt - Ref",PX8392190,CDM,300,RC,83921,CPT,90,,,,,,,209,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,20.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.57,21.21
"Organic Acid, Single, Qnt - Ref",PX8392190,CDM,300,RC,83921,CPT,90,,,,,,,209,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,20.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.57,21.21
"Organic Acid, Single, Qnt - Ref",PX8392190,CDM,300,RC,83921,CPT,90,,,,,,,209,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,20.57,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.57,21.21
buprenorphine 8 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,54017713,NDC,1,EA,41.56,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.5722,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.14,40.7288
phenylephrine 0.25 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,69536002515,NDC,15,ML,24.21,,First Health,Commercial,both,85,,999999999,percent of total billed charges,20.5785,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Actin Antibody Each,PX8601590,CDM,300,RC,86015,CPT,90,,,,,,,42,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.05,41.16
Actin Antibody Each,PX8601590,CDM,300,RC,86015,CPT,90,,,,,,,42,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.05,41.16
Actin Antibody Each,PX8601590,CDM,300,RC,86015,CPT,90,,,,,,,42,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.05,41.16
Anesthesia Level 4,PX37000018,CDM,370,RC,,,,,,,,,,21,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,20.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.7234,20.58
ANOSCOPE LIGHTED ANOSCOPE,120.52,CDM,272,RC,,,,10235-MAIN,LOCAL,,,,,21,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,20.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.7234,20.58
Assay Vitamin B-6,PX84207,CDM,300,RC,84207,CPT,90,,,,,,,42,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
Assay Vitamin B-6,PX84207,CDM,300,RC,84207,CPT,90,,,,,,,42,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
Assay Vitamin B-6,PX84207,CDM,300,RC,84207,CPT,90,,,,,,,42,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
"BOUGIE TRACH 10FR 70CM COUDE 	9-0211-70",120.199,CDM,272,RC,A7520,HCPCS,,11112-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
"BOUGIE TRACH 10FR 70CM COUDE 	9-0211-70",120.199,CDM,272,RC,A7520,HCPCS,,11112-MAIN,LOCAL,,,,,42,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
"BOUGIE TRACH 10FR 70CM COUDE 	9-0211-70",120.199,CDM,272,RC,A7520,HCPCS,,11112-MAIN,LOCAL,,,,,42,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
BOUGIE TRACHEAL TUBE & GUIDE 100123515,120.199,CDM,272,RC,A7520,HCPCS,,8950-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
BOUGIE TRACHEAL TUBE & GUIDE 100123515,120.199,CDM,272,RC,A7520,HCPCS,,8950-MAIN,LOCAL,,,,,42,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
BOUGIE TRACHEAL TUBE & GUIDE 100123515,120.199,CDM,272,RC,A7520,HCPCS,,8950-MAIN,LOCAL,,,,,42,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
CATHETER PUREWICK FEMALE EXTERNAL PWF030K,120.414,CDM,272,RC,A6590,HCPCS,,11836-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
CATHETER PUREWICK FEMALE EXTERNAL PWF030K,120.414,CDM,272,RC,A6590,HCPCS,,11836-MAIN,LOCAL,,,,,42,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
CATHETER PUREWICK FEMALE EXTERNAL PWF030K,120.414,CDM,272,RC,A6590,HCPCS,,11836-MAIN,LOCAL,,,,,42,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
Culture Type Immunologic,PX87147,CDM,300,RC,87147,CPT,,,,,,,,42,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,41.16
Culture Type Immunologic,PX87147,CDM,300,RC,87147,CPT,,,,,,,,42,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,41.16
Culture Type Immunologic,PX87147,CDM,300,RC,87147,CPT,,,,,,,,42,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,41.16
EZ-STABILIZER DRESSING,120.415,CDM,272,RC,,,,9058-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
EZ-STABILIZER DRESSING,120.415,CDM,272,RC,,,,9058-MAIN,LOCAL,,,,,42,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
EZ-STABILIZER DRESSING,120.415,CDM,272,RC,,,,9058-MAIN,LOCAL,,,,,42,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
"Hepatitis B Core Antibody, Total",PX86704,CDM,300,RC,86704,CPT,,,,,,,,21,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,20.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.7234,20.58
MEPILEX AG FOAM 4X4,120.192,CDM,272,RC,A6213,HCPCS,,8480-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
MEPILEX AG FOAM 4X4,120.192,CDM,272,RC,A6213,HCPCS,,8480-MAIN,LOCAL,,,,,42,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
MEPILEX AG FOAM 4X4,120.192,CDM,272,RC,A6213,HCPCS,,8480-MAIN,LOCAL,,,,,42,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
MEPILEX AG FOAM 4X8,120.192,CDM,272,RC,A6213,HCPCS,,8479-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
MEPILEX AG FOAM 4X8,120.192,CDM,272,RC,A6213,HCPCS,,8479-MAIN,LOCAL,,,,,42,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
MEPILEX AG FOAM 4X8,120.192,CDM,272,RC,A6213,HCPCS,,8479-MAIN,LOCAL,,,,,42,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
"Spectrophotometry, Nos",PX84311,CDM,300,RC,84311,CPT,,,,,,,,21,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,20.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.43,20.58
TRAY CENTRAL LINE DRESSING WITH CHLORAPREP DYND75234,120.68,CDM,272,RC,,,,10923-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY CENTRAL LINE DRESSING WITH CHLORAPREP DYND75234,120.68,CDM,272,RC,,,,10923-MAIN,LOCAL,,,,,42,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY CENTRAL LINE DRESSING WITH CHLORAPREP DYND75234,120.68,CDM,272,RC,,,,10923-MAIN,LOCAL,,,,,42,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY FOLEY 14FR CATHETER A300414A,120.414,CDM,272,RC,A4344,HCPCS,,11281-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY FOLEY 14FR CATHETER A300414A,120.414,CDM,272,RC,A4344,HCPCS,,11281-MAIN,LOCAL,,,,,42,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY FOLEY 14FR CATHETER A300414A,120.414,CDM,272,RC,A4344,HCPCS,,11281-MAIN,LOCAL,,,,,42,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY FOLEY 16FR CATHETER 300416A,120.414,CDM,272,RC,A4344,HCPCS,,11774-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY FOLEY 16FR CATHETER 300416A,120.414,CDM,272,RC,A4344,HCPCS,,11774-MAIN,LOCAL,,,,,42,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY FOLEY 16FR CATHETER 300416A,120.414,CDM,272,RC,A4344,HCPCS,,11774-MAIN,LOCAL,,,,,42,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
"TRAY SPINAL  25GX3.5"" WITH WHITEACRE 405671",120.275,CDM,272,RC,,,,3284-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
"TRAY SPINAL  25GX3.5"" WITH WHITEACRE 405671",120.275,CDM,272,RC,,,,3284-MAIN,LOCAL,,,,,42,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
"TRAY SPINAL  25GX3.5"" WITH WHITEACRE 405671",120.275,CDM,272,RC,,,,3284-MAIN,LOCAL,,,,,42,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY SPINAL 25G ANESTH SADDLE BLOCK NLD-4795-20,120.275,CDM,272,RC,,,,935-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY SPINAL 25G ANESTH SADDLE BLOCK NLD-4795-20,120.275,CDM,272,RC,,,,935-MAIN,LOCAL,,,,,42,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY SPINAL 25G ANESTH SADDLE BLOCK NLD-4795-20,120.275,CDM,272,RC,,,,935-MAIN,LOCAL,,,,,42,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001326,NDC,1,ML,42.88,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,20.5824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001326,NDC,1,ML,42.88,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.5824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001341,NDC,1,ML,42.88,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,20.5824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001341,NDC,1,ML,42.88,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.5824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
tamsulosin 0.4 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904640161,NDC,1,EA,22.6,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,20.5886,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
TRAY FOLEY 14FR CATHETER A300414A,120.414,CDM,272,RC,A4344,HCPCS,,11281-MAIN,LOCAL,,,,,42,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,20.5888,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.87,406.9505
TRAY FOLEY 16FR CATHETER 300416A,120.414,CDM,272,RC,A4344,HCPCS,,11774-MAIN,LOCAL,,,,,42,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,20.5888,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.87,406.9505
Vitamin B-1 - Ref,PX8442590,CDM,300,RC,84425,CPT,90,,,,,,,130,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,20.59,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.59,21.23
Vitamin B-1 - Ref,PX8442590,CDM,300,RC,84425,CPT,90,,,,,,,130,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,20.59,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.59,21.23
Vitamin B-1 - Ref,PX8442590,CDM,300,RC,84425,CPT,90,,,,,,,130,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,20.59,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.59,21.23
"Admin Hep B,Adult 19+",PX3242,CDM,771,RC,90471,CPT,,,,,,,,48,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,20.592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,61.54
Amphetamines; 3 or 4,PX8032590,CDM,300,RC,80325,CPT,90,,,,,,,48,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,20.592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,47.04
Immunization Admin - Influenza,PX3241,CDM,771,RC,90471,CPT,,,,,,,,48,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,20.592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,61.54
Immunization Administration; Each Add'l Vaccine (Single or Combo Vaccine/T*,PX90472,CDM,771,RC,90472,CPT,,,,,,,,48,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,20.592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,47.04
buPROPion XL 150 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,70436001004,NDC,1,EA,23.14,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,20.5946,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gemcitabine 200 MG/5.26ML Solution 5.26 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018301,NDC,5.26,ML,40.74,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.61444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
Antinuclear Antibodiesana - Ref,PX8603890,CDM,300,RC,86038,CPT,90,,,,,,,43,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,20.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.09,42.14
Antinuclear Antibodiesana - Ref,PX8603890,CDM,300,RC,86038,CPT,90,,,,,,,43,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.09,42.14
Blood Type Antigen Donor Ea,PX86902,CDM,300,RC,86902,CPT,,,,,,,,43,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,20.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.8622,314.02
Blood Type Antigen Donor Ea,PX86902,CDM,300,RC,86902,CPT,,,,,,,,43,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.8622,314.02
ETRAP POLYP TRAP,27200000,CDM,272,RC,,,,11282-MAIN,LOCAL,,,,,43,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,20.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ETRAP POLYP TRAP,27200000,CDM,272,RC,,,,11282-MAIN,LOCAL,,,,,43,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Testosterone, Total - Ref",PX8440390,CDM,300,RC,84403,CPT,90,,,,,,,43,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,20.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.8622,42.14
"Testosterone, Total - Ref",PX8440390,CDM,300,RC,84403,CPT,90,,,,,,,43,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.8622,42.14
FLEXITIP APPLICATOR 38CM,27200000,CDM,272,RC,,,,10200-MAIN,LOCAL,,,,,40.8,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.6448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
hydroxychloroquine 200 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16571068701,NDC,1,EA,23.41,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,20.64762,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
azithromycin 250 MG Tablet 6 Each Box,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096104,NDC,1,EA,41.72,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.6514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Syringe,J7040.01,CDM,636,RC,J7040,HCPCS,,,,64253020230,NDC,10,ML,42.15,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,14.79337121,percent of total billed charges,20.6535,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Syringe,J7040.01,CDM,636,RC,J7040,HCPCS,,,,64253020230,NDC,10,ML,42.15,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.6535,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Syringe,J7040.01,CDM,636,RC,J7040,HCPCS,,,,64253020230,NDC,10,ML,42.15,,United Healthcare,All Medicare advantage plans,outpatient,49,,25.20333333,percent of total billed charges,20.6535,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028426,NDC,1,EA,42.15,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,12.3175,percent of total billed charges,20.6535,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028426,NDC,1,EA,42.15,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.6535,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028426,NDC,1,EA,42.15,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.6535,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096105,NDC,1,EA,41.73,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.65635,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
clopidogrel 75 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629461,NDC,1,EA,23.42,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,20.65644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DULoxetine 30 MG Capsule Delayed Release Particles 90 Each Bottle,63700001,CDM,250,RC,,,,,,57237001890,NDC,1,EA,42.17,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.6633,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DULoxetine 30 MG Capsule Delayed Release Particles 90 Each Bottle,63700001,CDM,250,RC,,,,,,57237001890,NDC,1,EA,42.17,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.6633,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DULoxetine 30 MG Capsule Delayed Release Particles 90 Each Bottle,63700001,CDM,250,RC,,,,,,57237001890,NDC,1,EA,42.17,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.6633,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DULoxetine 20 MG Capsule Delayed Release Particles 60 Each Bottle,63700001,CDM,250,RC,,,,,,2323560,NDC,1,EA,41.76,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.6712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066500,NDC,0.25,ML,48.19,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,20.67351,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.000396,47.2262
fluconazole 150 MG Tablet 12 Each Box,63700001,CDM,250,RC,,,,,,16714069211,NDC,0.333333333,EA,24.33,,First Health,Commercial,both,85,,999999999,percent of total billed charges,20.6805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
celecoxib 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904650261,NDC,1,EA,23.45,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,20.6829,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323018507,NDC,10,ML,43.09,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,20.6832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323018507,NDC,10,ML,43.09,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.6832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,50111078751,NDC,1,EA,41.79,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.68605,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
donepezil 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904640861,NDC,1,EA,41.79,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.68605,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
risperiDONE 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635861,NDC,1,EA,21.11,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,20.6878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buprenorphine 2 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,50383092493,NDC,1,EA,24.34,,First Health,Commercial,both,85,,999999999,percent of total billed charges,20.689,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.14,40.7288
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039841,NDC,1,EA,43.14,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,20.7072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039841,NDC,1,EA,43.14,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.7072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
"lidocaine 2% -EPINEPHRine 1:200,000 2 %-1:200000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409318301,NDC,20,ML,49.86,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,20.711844,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tolterodine ER 2 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,43975032203,NDC,1,EA,43.15,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,20.712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tolterodine ER 2 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,43975032203,NDC,1,EA,43.15,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
entacapone 200 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,27241004910,NDC,1,EA,24.37,,First Health,Commercial,both,85,,999999999,percent of total billed charges,20.7145,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070548,NDC,100,ML,40.94,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.71564,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
SUCTION TIP POOLE STERILE 35040,27200000,CDM,272,RC,,,,977-MAIN,LOCAL,,,,,42.28,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.7172,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUCTION TIP POOLE STERILE 35040,27200000,CDM,272,RC,,,,977-MAIN,LOCAL,,,,,42.28,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.7172,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUCTION TIP POOLE STERILE 35040,27200000,CDM,272,RC,,,,977-MAIN,LOCAL,,,,,42.28,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.7172,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"N Block Inj, Plantar Digit",PX64455F,CDM,510,RC,64455,CPT,,,,,,,,385,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,20.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.72,103.77
"N Block Inj, Plantar Digit",PX64455F,CDM,510,RC,64455,CPT,,,,,,,,385,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,20.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.72,103.77
"N Block Inj, Plantar Digit",PX64455F,CDM,510,RC,64455,CPT,,,,,,,,385,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,20.72,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.72,103.77
"N Block Inj, Plantar Digit",PX64455P,CDM,983,RC,64455,CPT,,,,,,,,385,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,20.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.72,377.3
"N Block Inj, Plantar Digit",PX64455P,CDM,983,RC,64455,CPT,,,,,,,,385,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,20.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.72,377.3
"N Block Inj, Plantar Digit",PX64455P,CDM,983,RC,64455,CPT,,,,,,,,385,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,20.72,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.72,377.3
Xray Finger(S) Tc,PX7314001,CDM,320,RC,73140,CPT,TC,,,,,,,282,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,20.72,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.72,62.45
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490334,NDC,5,ML,42.29,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.7221,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490334,NDC,5,ML,42.29,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.7221,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490334,NDC,5,ML,42.29,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.7221,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
tetracycline 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,51991090701,NDC,0.5,EA,42.29,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.7221,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tetracycline 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,51991090701,NDC,0.5,EA,42.29,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.7221,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tetracycline 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,51991090701,NDC,0.5,EA,42.29,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.7221,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ampicillin 1 GM Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781926185,NDC,0.5,EA,43.18,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,20.7264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
ampicillin 1 GM Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781926185,NDC,0.5,EA,43.18,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.7264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,55150016205,NDC,5,ML,42.32,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.7368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,55150016205,NDC,5,ML,42.32,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.7368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,55150016205,NDC,5,ML,42.32,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.7368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Etoposide 100 MG/5ML Solution 5 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,16729011431,NDC,5,ML,43.21,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,20.7408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.949434,169.8144
Etoposide 100 MG/5ML Solution 5 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,16729011431,NDC,5,ML,43.21,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.7408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.949434,169.8144
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,25021010720,NDC,1,EA,48.35,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,20.74215,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
amoxicillin 250 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,93415580,NDC,150,ML,43.22,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,20.7456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 250 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,93415580,NDC,150,ML,43.22,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.7456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
eplerenone 25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16729029315,NDC,1,EA,23.31,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,20.7459,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CANNULA SEAL 5-12MM UNIVERSAL 470500,27200000,CDM,272,RC,,,,12885-MAIN,LOCAL,,,,,41,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CUP HEEL LARGE WONDERSPUR 4502,120.43,CDM,274,RC,L3485,HCPCS,,11385-MAIN,LOCAL,,,,,41,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL MEDIUM WONDERSPUR 4501,120.43,CDM,274,RC,L3485,HCPCS,,11384-MAIN,LOCAL,,,,,41,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL SMALL WONDERSPUR 4500,120.43,CDM,274,RC,L3485,HCPCS,,11383-MAIN,LOCAL,,,,,41,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL XL WONDERSPUR 4503,120.43,CDM,274,RC,L3485,HCPCS,,11386-MAIN,LOCAL,,,,,41,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
Detection of Anaplasma Phagocytophilum by Amplified Nucleic Acid Probe Technique,PX8746890,CDM,300,RC,87468,CPT,90,,,,,,,41,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
Detection of Ehrlichia Chaffeensis by Amplified Nucleic Acid Probe Technique,PX8748490,CDM,300,RC,87484,CPT,90,,,,,,,41,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 21G 110MM SONOTAP II WITH FACET TIP 1285-3F110,120.483,CDM,271,RC,A4215,HCPCS,,12201-MAIN,LOCAL,,,,,41,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 21G X 4IN (100MM) SONOBLOCK II NERVE BLOCK WITH FACET S TIP 001281-77,120.483,CDM,271,RC,A4215,HCPCS,,12761-MAIN,LOCAL,,,,,41,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 22G 80MM SONOTAP II WITH FACET TIP 1285-3E080,120.483,CDM,271,RC,A4215,HCPCS,,12103-MAIN,LOCAL,,,,,41,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 22G X 3.25IN (80MM) SONOBLOCK II  NERVE BLOCK WITH FACET S TIP 001281-71,120.483,CDM,271,RC,A4215,HCPCS,,12760-MAIN,LOCAL,,,,,41,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 22GX2 SONOPLEX II WITH FACET S TIP 001287-74,120.483,CDM,271,RC,A4215,HCPCS,,13110-MAIN,LOCAL,,,,,41,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE NON-STIMULATING 22GX2 SONOBLOCK II WITH FACET S TIP 001281-74,120.483,CDM,271,RC,A4215,HCPCS,,11459-MAIN,LOCAL,,,,,41,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE SONOPLEX II STIMULATING WITH FACET S TIP 22GX3-1/4,120.483,CDM,271,RC,A4215,HCPCS,,11457-MAIN,LOCAL,,,,,41,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE STIMULATING 21GX4  SONOPLEX II  WITH FACET S TIP 001287-77,120.483,CDM,271,RC,A4215,HCPCS,,11458-MAIN,LOCAL,,,,,41,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
STRAP FOOT LG/XL GEL UNIVERSAL 10165,120.428,CDM,271,RC,,,,11382-MAIN,LOCAL,,,,,41,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
STRAP FOOT SM/MED GEL UNIVERSAL 10155,120.428,CDM,271,RC,,,,11381-MAIN,LOCAL,,,,,41,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
SUTURE V-LOC SZ 1/2 180 GREEN GS-21 VLOCL0316,27200000,CDM,272,RC,,,,11932-MAIN,LOCAL,,,,,41,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
URGOK2 DUAL COMPRESSION SYSTEM LARGE,120.491,CDM,271,RC,A6452,HCPCS,,11871-MAIN,LOCAL,,,,,41,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
URGOK2 DUAL COMPRESSION SYSTEM REGULAR,120.491,CDM,271,RC,A6452,HCPCS,,11870-MAIN,LOCAL,,,,,41,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665305,NDC,20,ML,49.97,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,20.757538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
amiodarone 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,245014789,NDC,0.5,EA,21.33,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,20.760489,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,245014701,NDC,0.5,EA,21.33,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,20.760489,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ERBEFLO CLEVERCAP CO2 TUBING CAP SET,27200000,CDM,272,RC,,,,11831-MAIN,LOCAL,,,,,50,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,20.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
G6pd; Quant Screen - Ref,PX8295590,CDM,300,RC,82955,CPT,90,,,,,,,50,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,20.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.89,49
"Homogenization, Tissue for Culture",PX87176,CDM,300,RC,87176,CPT,,,,,,,,50,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,20.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.39,49
Insulin Ab - Ref,PX8633790,CDM,300,RC,86337,CPT,90,,,,,,,65,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,20.77,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,21.41
Insulin Ab - Ref,PX8633790,CDM,300,RC,86337,CPT,90,,,,,,,65,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,20.77,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,21.41
Insulin Ab - Ref,PX8633790,CDM,300,RC,86337,CPT,90,,,,,,,65,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,20.77,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,21.41
"NEEDLE ASP 16GX3/16"" 1-7/8"" ILLINOIS STERNAL 8881245164",120.8,CDM,272,RC,G0364,HCPCS,,5730-MAIN,LOCAL,,,,,50,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,20.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,49
"NEEDLE BONE MARROW 8G X 4"" BIOPSY/ASPIRATION 8881247087",120.8,CDM,272,RC,G0364,HCPCS,,166-MAIN,LOCAL,,,,,50,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,20.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,49
"NEEDLE BONE MARROW 11G X 4"" 8881247111",120.8,CDM,272,RC,G0364,HCPCS,,162-MAIN,LOCAL,,,,,50,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,20.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,49
Potassium; Urine,PX84133,CDM,300,RC,84133,CPT,,,,,,,,50,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,20.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.34,49
fluconazole 100 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069101,NDC,0.5,EA,23.55,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,20.7711,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,17478004001,NDC,1,ML,42.39,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,4.035,percent of total billed charges,20.7711,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,17478004001,NDC,1,ML,42.39,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.7711,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,17478004001,NDC,1,ML,42.39,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.7711,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
"SUTURE ETHIBOND #0 CT-1 CR 8-18"" CX21D",27200000,CDM,272,RC,,,,6415-MAIN,LOCAL,,,,,41.97,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.77515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Molecular Cytog, Ea Probe - Ref",PX8827190,CDM,310,RC,88271,CPT,90,,,,,,,277,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,20.78,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.78,21.42
"Molecular Cytog, Ea Probe - Ref",PX8827190,CDM,310,RC,88271,CPT,90,,,,,,,277,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,20.78,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.78,21.42
"Molecular Cytog, Ea Probe - Ref",PX8827190,CDM,310,RC,88271,CPT,90,,,,,,,277,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,20.78,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.78,21.42
hydroxychloroquine 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292001101,NDC,1,EA,23.57,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,20.78874,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"CUFF STERILE DISPOSABLE SPSB 12""",27200000,CDM,272,RC,,,,7435-MAIN,LOCAL,,,,,43.31,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,20.7888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"CUFF STERILE DISPOSABLE SPSB 12""",27200000,CDM,272,RC,,,,7435-MAIN,LOCAL,,,,,43.31,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.7888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Actin Antibody Each,PX8601590,CDM,300,RC,86015,CPT,90,,,,,,,42,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.05,41.16
Assay Vitamin B-6,PX84207,CDM,300,RC,84207,CPT,90,,,,,,,42,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
"BOUGIE TRACH 10FR 70CM COUDE 	9-0211-70",120.199,CDM,272,RC,A7520,HCPCS,,11112-MAIN,LOCAL,,,,,42,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
BOUGIE TRACHEAL TUBE & GUIDE 100123515,120.199,CDM,272,RC,A7520,HCPCS,,8950-MAIN,LOCAL,,,,,42,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
CATHETER PUREWICK FEMALE EXTERNAL PWF030K,120.414,CDM,272,RC,A6590,HCPCS,,11836-MAIN,LOCAL,,,,,42,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
Culture Type Immunologic,PX87147,CDM,300,RC,87147,CPT,,,,,,,,42,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,41.16
EZ-STABILIZER DRESSING,120.415,CDM,272,RC,,,,9058-MAIN,LOCAL,,,,,42,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
MEPILEX AG FOAM 4X4,120.192,CDM,272,RC,A6213,HCPCS,,8480-MAIN,LOCAL,,,,,42,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
MEPILEX AG FOAM 4X8,120.192,CDM,272,RC,A6213,HCPCS,,8479-MAIN,LOCAL,,,,,42,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY CENTRAL LINE DRESSING WITH CHLORAPREP DYND75234,120.68,CDM,272,RC,,,,10923-MAIN,LOCAL,,,,,42,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY FOLEY 14FR CATHETER A300414A,120.414,CDM,272,RC,A4344,HCPCS,,11281-MAIN,LOCAL,,,,,42,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY FOLEY 16FR CATHETER 300416A,120.414,CDM,272,RC,A4344,HCPCS,,11774-MAIN,LOCAL,,,,,42,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
"TRAY SPINAL  25GX3.5"" WITH WHITEACRE 405671",120.275,CDM,272,RC,,,,3284-MAIN,LOCAL,,,,,42,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY SPINAL 25G ANESTH SADDLE BLOCK NLD-4795-20,120.275,CDM,272,RC,,,,935-MAIN,LOCAL,,,,,42,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049257,NDC,5,ML,42.43,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.7907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049257,NDC,5,ML,42.43,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.7907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049257,NDC,5,ML,42.43,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.7907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665318,NDC,20,ML,50.08,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,20.803232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
sterile water (preservative free) Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323018520,NDC,20,ML,50.08,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,20.803232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
C-Peptide - Ref,PX8468190,CDM,300,RC,84681,CPT,90,,,,,,,180,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,20.81,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.19,20.81
Ca 19-9,PX86301,CDM,300,RC,86301,CPT,,,,,,,,116,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,20.81,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.19,20.81
"Immuno for Tumor Ag, Qn - Ref",PX8631690,CDM,300,RC,86316,CPT,90,,,,,,,115,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,20.81,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.19,20.81
"Immunoassay,Ca15-3(27.29) - Ref",PX8630090,CDM,300,RC,86300,CPT,90,,,,,,,124,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,20.81,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.19,20.81
"Tumor Antigen, Ca-125",PX86304,CDM,300,RC,86304,CPT,,,,,,,,190,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,20.81,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.19,20.81
TROCAR KII BALLOON 12MM STERILE,27200000,CDM,272,RC,,,,11703-MAIN,LOCAL,,,,,41.14,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.81684,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR KII BALLOON BLUNT 12MM STERILE,27200000,CDM,272,RC,,,,11702-MAIN,LOCAL,,,,,41.14,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.81684,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,409469930,NDC,20,ML,48.54,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,20.82366,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
ketorolac 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314012605,NDC,5,ML,42.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ketorolac 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314012605,NDC,5,ML,42.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ketorolac 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314012605,NDC,5,ML,42.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641622901,NDC,1,ML,41.16,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.82696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.097864,86.9162
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490311,NDC,5,ML,43.39,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,20.8272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490311,NDC,5,ML,43.39,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.8272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
artificial tears Ointment 3.5 g Tube,63700001,CDM,250,RC,,,,,,10119002239,NDC,3.5,GR,50.14,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,20.828156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Dimethicone 1.5 % Cream 118 mL Tube,800000,CDM,,,,,,,,53329016104,NDC,118,ML,43.4,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,20.832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Dimethicone 1.5 % Cream 118 mL Tube,800000,CDM,,,,,,,,53329016104,NDC,118,ML,43.4,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
hydroxychloroquine 200 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16571068701,NDC,1,EA,23.41,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,20.8349,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001002,NDC,2,ML,43.42,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,20.8416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,42.5516
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001002,NDC,2,ML,43.42,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.8416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,42.5516
clopidogrel 75 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629461,NDC,1,EA,23.42,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,20.8438,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
mycophenolate 500 MG Tablet 100 Each Bottle,J7517.01,CDM,637,RC,J7517,HCPCS,,,,64380072506,NDC,1,EA,42.56,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.8544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.679424,41.7088
mycophenolate 500 MG Tablet 100 Each Bottle,J7517.01,CDM,637,RC,J7517,HCPCS,,,,64380072506,NDC,1,EA,42.56,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.8544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.679424,41.7088
mycophenolate 500 MG Tablet 100 Each Bottle,J7517.01,CDM,637,RC,J7517,HCPCS,,,,64380072506,NDC,1,EA,42.56,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.8544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.679424,41.7088
lidocaine (preservative free) 4 % Solution 5 mL Ampule,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409428325,NDC,5,ML,48.62,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,20.85798,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
Insulin Ab - Ref,PX8633790,CDM,300,RC,86337,CPT,90,,,,,,,65,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,20.8585,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,21.41
"Molecular Cytog, Ea Probe - Ref",PX8827190,CDM,310,RC,88271,CPT,90,,,,,,,277,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,20.8585,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.78,21.42
"Organic Acid, Single, Qnt - Ref",PX8392190,CDM,300,RC,83921,CPT,90,,,,,,,209,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,20.8585,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.57,21.21
Vitamin B-1 - Ref,PX8442590,CDM,300,RC,84425,CPT,90,,,,,,,130,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,20.8585,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.59,21.23
Progesterone,PX84144,CDM,300,RC,84144,CPT,,,,,,,,56,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,20.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.23,20.86
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Syringe,J7040.01,CDM,636,RC,J7040,HCPCS,,,,64253020230,NDC,10,ML,42.15,,Humana Choice Care,All Medicare plans,outpatient,49.5,,2.714444444,percent of total billed charges,20.86425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028426,NDC,1,EA,42.15,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.86425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019600,NDC,1,ML,48.64,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,20.86656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070948,NDC,100,ML,42.59,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1.633818182,percent of total billed charges,20.8691,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070948,NDC,100,ML,42.59,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,20.8691,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070948,NDC,100,ML,42.59,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,20.8691,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
methylergonovine 0.2 MG/ML Solution 1 mL Ampule,J2210.01,CDM,636,RC,J2210,HCPCS,,,,51991014417,NDC,1,ML,133.11,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,20.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.25,20.87
methylergonovine 0.2 MG/ML Solution 1 mL Ampule,J2210.01,CDM,636,RC,J2210,HCPCS,,,,51991014417,NDC,1,ML,133.11,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,20.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.25,20.87
Needle Insertion W/O Injection 3 or More Muscles,PX20561,CDM,420,RC,20561,CPT,,,,,,,,10,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,20.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.87,76.79
celecoxib 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904650261,NDC,1,EA,23.45,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,20.8705,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,36000000924,NDC,200,ML,48.65,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,20.87085,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.20921,64.9544
Needle Insertion W/O Injection 3 or More Muscles,PX20561,CDM,420,RC,20561,CPT,,,,,,,,10,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,20.8715,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.87,76.79
DULoxetine 30 MG Capsule Delayed Release Particles 90 Each Bottle,63700001,CDM,250,RC,,,,,,57237001890,NDC,1,EA,42.17,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.87415,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 5 % Patch 1 Each Box,63700001,CDM,250,RC,,,,,,591352511,NDC,1,EA,50.26,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,20.878004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 5 % Patch 30 Each Box,63700001,CDM,250,RC,,,,,,591352530,NDC,1,EA,50.26,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,20.878004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dextrose 5 % 5 % Solution 50 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338055111,NDC,50,ML,43.5,,Health Partners,Health Partners Care Plans,both,48,,43.88894737,percent of total billed charges,20.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 50 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338055111,NDC,50,ML,43.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 100 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001748,NDC,100,ML,43.5,,Health Partners,Health Partners Care Plans,both,48,,43.88894737,percent of total billed charges,20.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 100 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001748,NDC,100,ML,43.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,264763500,NDC,1000,ML,43.5,,Health Partners,Health Partners Care Plans,both,48,,6.034333333,percent of total billed charges,20.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,264763500,NDC,1000,ML,43.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5% lactated ringers 5 % Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012504,NDC,1000,ML,43.5,,Health Partners,Health Partners Care Plans,both,48,,62.59384615,percent of total billed charges,20.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"dextrose 5% lactated ringers 5 % Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012504,NDC,1000,ML,43.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329330201,NDC,25,ML,43.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,20.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329330201,NDC,25,ML,43.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9 % 0.9 % Solution 50 mL Flex Cont,J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004941,NDC,50,ML,43.5,,Health Partners,Health Partners Care Plans,both,48,,36.618125,percent of total billed charges,20.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % 0.9 % Solution 50 mL Flex Cont,J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004941,NDC,50,ML,43.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004941,NDC,250,ML,43.5,,Health Partners,Health Partners Care Plans,both,48,,38.34875,percent of total billed charges,20.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004941,NDC,250,ML,43.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055311,NDC,250,ML,43.5,,Health Partners,Health Partners Care Plans,both,48,,38.34875,percent of total billed charges,20.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055311,NDC,250,ML,43.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004948,NDC,300,ML,43.5,,Health Partners,Health Partners Care Plans,both,48,,38.34875,percent of total billed charges,20.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004948,NDC,300,ML,43.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055318,NDC,300,ML,43.5,,Health Partners,Health Partners Care Plans,both,48,,38.34875,percent of total billed charges,20.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055318,NDC,300,ML,43.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 150 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,409798361,NDC,300,ML,43.5,,Health Partners,Health Partners Care Plans,both,48,,38.34875,percent of total billed charges,20.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 150 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,409798361,NDC,300,ML,43.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9% irrigation 0.9 % Solution 3,000 mL Plas Cont",25000000,CDM,250,RC,,,,,,338004727,NDC,3000,ML,43.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,20.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"sodium chloride 0.9% irrigation 0.9 % Solution 3,000 mL Plas Cont",25000000,CDM,250,RC,,,,,,338004727,NDC,3000,ML,43.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9% IV LINE FLUSH 0.9% Solution 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,338004948,NDC,100,ML,43.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,20.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9% IV LINE FLUSH 0.9% Solution 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,338004948,NDC,100,ML,43.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
QUEtiapine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54022020,NDC,1,EA,21.46,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,20.887018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028016,NDC,2,ML,41.29,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.89274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
methylPREDNISolone acetate 20 MG/ML Suspension 5 mL Vial,J1010.01,CDM,636,RC,J1010,HCPCS,,,,9027401,NDC,0.5,ML,41.3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.8978,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.15602,40.474
empagliflozin 25 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,597015330,NDC,0.4,EA,43.54,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,20.8992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
empagliflozin 25 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,597015330,NDC,0.4,EA,43.54,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.8992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
empagliflozin 25 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,597015337,NDC,0.4,EA,43.54,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,20.8992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
empagliflozin 25 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,597015337,NDC,0.4,EA,43.54,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.8992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vinCRIStine 1 MG/ML Solution 2 mL Vial,J9370.01,CDM,636,RC,J9370,HCPCS,,,,61703030916,NDC,2,ML,48.72,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,20.90088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.238288,47.7456
FORCEPS SERRATED WITH SPIKE JUMBO 230CM,27200000,CDM,272,RC,,,,7416-MAIN,LOCAL,,,,,41.31,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.90286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
amiodarone 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,245014789,NDC,0.5,EA,21.33,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,20.9034,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,245014701,NDC,0.5,EA,21.33,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,20.9034,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
naltrexone 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406117001,NDC,1,EA,22.96,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,20.91656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Xray Calcaneus Minimum 2 Vws,PX7365001,CDM,320,RC,73650,CPT,TC,,,,,,,365,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,20.917,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.74,41.42
TRAY FOLEY 14FR CATHETER A300414A,120.414,CDM,272,RC,A4344,HCPCS,,11281-MAIN,LOCAL,,,,,42,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,20.92,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.87,406.9505
TRAY FOLEY 16FR CATHETER 300416A,120.414,CDM,272,RC,A4344,HCPCS,,11774-MAIN,LOCAL,,,,,42,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,20.92,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.87,406.9505
TRAY FOLEY 14FR CATHETER A300414A,120.414,CDM,272,RC,A4344,HCPCS,,11281-MAIN,LOCAL,,,,,42,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,20.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.87,406.9505
TRAY FOLEY 14FR CATHETER A300414A,120.414,CDM,272,RC,A4344,HCPCS,,11281-MAIN,LOCAL,,,,,42,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,20.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.87,406.9505
TRAY FOLEY 16FR CATHETER 300416A,120.414,CDM,272,RC,A4344,HCPCS,,11774-MAIN,LOCAL,,,,,42,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,20.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.87,406.9505
TRAY FOLEY 16FR CATHETER 300416A,120.414,CDM,272,RC,A4344,HCPCS,,11774-MAIN,LOCAL,,,,,42,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,20.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.87,406.9505
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409132305,NDC,5,ML,41.35,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.9231,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
triamcinolone acetonide 0.1 % Cream 15 g Tube,63700001,CDM,250,RC,,,,,,168000415,NDC,15,GR,22.97,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,20.92567,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zinc oxide 20 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,536131625,NDC,60,GR,22.97,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,20.92567,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SUCTION TIP POOLE STERILE 35040,27200000,CDM,272,RC,,,,977-MAIN,LOCAL,,,,,42.28,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.9286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Smking Cess 4-10 Min,PX99406F,CDM,942,RC,99406,CPT,,,,,,,,65,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,20.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.2,26.31
Smking Cess 4-10 Min,PX99406P,CDM,983,RC,99406,CPT,,,,,,,,43,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,20.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.2,42.14
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490334,NDC,5,ML,42.29,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.93355,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
tetracycline 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,51991090701,NDC,0.5,EA,42.29,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.93355,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Long Term Holter, 48 Hrs Up to 7 Days, Recording",PX93242,CDM,731,RC,93242,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,20.94,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.63,20.94
"Long Term Holter, 48 Hrs Up to 7 Days, Recording",PX93242,CDM,731,RC,93242,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,20.94,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.63,20.94
"Long Term Holter, More Than 7 Days Up to 15 Days, Recording",PX93246,CDM,731,RC,93246,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,20.94,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.63,20.94
"Long Term Holter, More Than 7 Days Up to 15 Days, Recording",PX93246,CDM,731,RC,93246,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,20.94,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.63,20.94
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152F,CDM,370,RC,99152,CPT,,,,,,,,235,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,20.94,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,87.84
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152P,CDM,983,RC,99152,CPT,,,,,,,,90,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,20.94,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,88.2
US Renal Retroperit Ltd,PX7677501,CDM,402,RC,76775,CPT,TC,,,,,,,566,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,20.94,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.94,64.43
Xray Knee (Both) Ap Stand,PX7356501,CDM,320,RC,73565,CPT,TC,,,,,,,543,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,20.94,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.94,63.11
Xray Knee 3 Vws,PX7356201,CDM,320,RC,73562,CPT,TC,,,,,,,404,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,20.94,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.94,63.11
"Xray Mandible Compl, Min 4 Vws",PX7011001,CDM,320,RC,70110,CPT,TC,,,,,,,381,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,20.94,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.94,63.11
Drain Blood From Under Nail,PX11740F,CDM,510,RC,11740,CPT,,,,,,,,117,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,20.94,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.28,120.37
Drain Blood From Under Nail,PX11740F,CDM,510,RC,11740,CPT,,,,,,,,117,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,20.94,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.28,120.37
Xray Finger(S) Tc,PX7314001,CDM,320,RC,73140,CPT,TC,,,,,,,282,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,20.94,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.72,62.45
Xray Finger(S) Tc,PX7314001,CDM,320,RC,73140,CPT,TC,,,,,,,282,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,20.94,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.72,62.45
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,55150016205,NDC,5,ML,42.32,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.9484,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,409163221,NDC,0.5,EA,43.65,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,20.952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,409163221,NDC,0.5,EA,43.65,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,20.952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BRACE WRIST 8-IN SM LEFT 10432,120.564,CDM,273,RC,L3809,HCPCS,,12720-MAIN,LOCAL,,,,,23,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,20.953,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 8-IN SM RIGHT 10442,120.564,CDM,273,RC,L3809,HCPCS,,12716-MAIN,LOCAL,,,,,23,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,20.953,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN LG RIGHT 10464,120.564,CDM,273,RC,L3809,HCPCS,,12719-MAIN,LOCAL,,,,,23,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,20.953,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN SM LEFT 617083,120.564,CDM,273,RC,L3809,HCPCS,,12722-MAIN,LOCAL,,,,,23,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,20.953,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN SM RIGHT 10462,120.564,CDM,273,RC,L3809,HCPCS,,12717-MAIN,LOCAL,,,,,23,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,20.953,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN XL LEFT 10455,120.564,CDM,273,RC,L3809,HCPCS,,12721-MAIN,LOCAL,,,,,23,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,20.953,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN XL RIGHT 10465,120.564,CDM,273,RC,L3809,HCPCS,,12715-MAIN,LOCAL,,,,,23,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,20.953,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST WRISTPRO LEFT 10-IN LG,120.564,CDM,273,RC,L3809,HCPCS,,12724-MAIN,LOCAL,,,,,23,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,20.953,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST WRISTPRO LEFT 10-IN MED,120.564,CDM,273,RC,L3809,HCPCS,,12723-MAIN,LOCAL,,,,,23,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,20.953,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
Detection of Babesia Borrelia Miyamotoi by Amplified Nucleic Acid Probe Technique,PX8747890,CDM,300,RC,87478,CPT,90,,,,,,,23,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,20.953,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,32.17
Detection of Babesia Microtim by Amplified Nucleic Acid Probe Technique,PX8746990,CDM,300,RC,87469,CPT,90,,,,,,,23,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,20.953,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,32.17
FORCEPS COLD BIOPSY,27200000,CDM,272,RC,,,,12453-MAIN,LOCAL,,,,,23,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,20.953,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE MAXON ABSORBABLE POLYGLYCONATE 2-0 30IN MONOFILAMENT DYED TAPER POINT 1/2 CIRCLE 27MM GS-22 G,27200000,CDM,272,RC,,,,11988-MAIN,LOCAL,,,,,23,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,20.953,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE POLYSORB ABSORBABLE LACTOMER 2-0 30IN BRAIDED DYED TAPER POINT 1/2 CIRCLE 26MM V-20 VIOLET ST,27200000,CDM,272,RC,,,,11983-MAIN,LOCAL,,,,,23,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,20.953,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Cognitive Funct Ther Interv, Initial 15 Min",PX97129,CDM,420,RC,97129,CPT,,,,,,,,85,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,20.956,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.63,29.43
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028026,NDC,2,ML,41.42,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,20.95852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
fluconazole 100 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069101,NDC,0.5,EA,23.55,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,20.9595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydroxychloroquine 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292001101,NDC,1,EA,23.57,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,20.9773,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,17478004001,NDC,1,ML,42.39,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,20.98305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
simethicone 40 MG/0.6ML Suspension 30 mL Bottle,25000000,CDM,250,RC,,,,,,70677107801,NDC,30,ML,24.69,,First Health,Commercial,both,85,,999999999,percent of total billed charges,20.9865,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049257,NDC,5,ML,42.43,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.00285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
apixaban 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,3089331,NDC,1,EA,50.57,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,21.006778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
etomidate 2 MG/ML Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,55150022220,NDC,10,ML,50.58,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,21.010932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004624,NDC,50,ML,50.58,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,21.010932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001326,NDC,1,ML,42.88,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.0112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001326,NDC,1,ML,42.88,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.0112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001326,NDC,1,ML,42.88,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.0112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001341,NDC,1,ML,42.88,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.0112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001341,NDC,1,ML,42.88,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.0112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001341,NDC,1,ML,42.88,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.0112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
rosuvastatin 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003001,NDC,0.5,EA,21.59,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,21.013547,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Gabapentin - Ref,PX8017190,CDM,300,RC,80171,CPT,90,,,,,,,71,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,21.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.02,21.67
Gabapentin - Ref,PX8017190,CDM,300,RC,80171,CPT,90,,,,,,,71,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,21.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.02,21.67
Gabapentin - Ref,PX8017190,CDM,300,RC,80171,CPT,90,,,,,,,71,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,21.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.02,21.67
omalizumab 150 MG Recon Soln 1 Each Vial,J2357.01,CDM,636,RC,J2357,HCPCS,,,,50242004062,NDC,1,EA,2212.7,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,21.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.02,2168.446
Beta-2-Microglobulin - Ref,PX8223290,CDM,300,RC,82232,CPT,90,,,,,,,49,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,21.021,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.84,48.02
"Cannabinoids, Natural - Ref",PX8034990,CDM,300,RC,80349,CPT,90,,,,,,,49,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,21.021,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,48.02
cefTAZidime 1 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023525,NDC,1,EA,49,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,21.021,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
COLLAR CERVICAL X-LARGE WITH TRACH 2 PIECE OSG2404,120.185,CDM,274,RC,L0172,HCPCS,,10143-MAIN,LOCAL,,,,,49,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,21.021,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,152.79
Glycated Protein - Ref,PX8298590,CDM,300,RC,82985,CPT,90,,,,,,,49,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,21.021,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.37,48.02
"SUTURE V-LOC SZ 0 180 GREEN GS21 NEEDLE 18"" VLOCL0326",27200000,CDM,272,RC,,,,12218-MAIN,LOCAL,,,,,49,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,21.021,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
oxytocin 10 UNIT/ML Solution 1 mL Vial,J2590.01,CDM,636,RC,J2590,HCPCS,,,,42023011625,NDC,1,ML,43.8,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.19452,42.924
oxytocin 10 UNIT/ML Solution 1 mL Vial,J2590.01,CDM,636,RC,J2590,HCPCS,,,,42023011625,NDC,1,ML,43.8,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.19452,42.924
buprenorphine 8 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,54017713,NDC,1,EA,41.56,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.02936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.14,40.7288
Blood Clot Factor VIII Test,PX85247,CDM,300,RC,85247,CPT,,,,,,,,169,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,21.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.03,165.62
QUEtiapine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54022020,NDC,1,EA,21.46,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,21.0308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
apixaban 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,3089431,NDC,0.5,EA,23.85,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,21.0357,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ketorolac 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314012605,NDC,5,ML,42.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.0375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pindolol 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,29033002801,NDC,1,EA,24.77,,First Health,Commercial,both,85,,999999999,percent of total billed charges,21.0545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DRESSING GEL FOAM SIZE 100SPONGE STERILE 00009034201,27200000,CDM,272,RC,A6248,HCPCS,,3378-MAIN,LOCAL,,,,,38.25,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,21.06,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,781523806,NDC,1,EA,106.34,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,21.06,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.06,21.06
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714020010,NDC,1,EA,107.64,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,21.06,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.06,21.06
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,68462015740,NDC,1,EA,110.25,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,21.06,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.06,21.06
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,781523864,NDC,1,EA,106.34,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,21.06,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.06,21.06
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714020030,NDC,1,EA,107.64,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,21.06,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.06,21.06
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,65862039010,NDC,1,EA,106.34,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,21.06,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.06,21.06
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,68462015713,NDC,1,EA,110.25,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,21.06,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.06,21.06
ondansetron 4 MG/5ML Solution 25 mL Bottle,S0119.01,CDM,636,RC,S0119,HCPCS,,,,99998-8001-,NDC,25,ML,494.57,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,21.06,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.06,21.06
ondansetron 4 MG/5ML Solution 50 mL Bottle,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714067102,NDC,5,ML,98.91,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,21.06,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.06,21.06
mycophenolate 500 MG Tablet 100 Each Bottle,J7517.01,CDM,637,RC,J7517,HCPCS,,,,64380072506,NDC,1,EA,42.56,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.0672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.679424,41.7088
Antinuclear Antibodiesana - Ref,PX8603890,CDM,300,RC,86038,CPT,90,,,,,,,43,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,18.48,percent of total billed charges,21.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.09,42.14
Antinuclear Antibodiesana - Ref,PX8603890,CDM,300,RC,86038,CPT,90,,,,,,,43,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.09,42.14
Antinuclear Antibodiesana - Ref,PX8603890,CDM,300,RC,86038,CPT,90,,,,,,,43,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.09,42.14
Blood Type Antigen Donor Ea,PX86902,CDM,300,RC,86902,CPT,,,,,,,,43,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.8622,314.02
Blood Type Antigen Donor Ea,PX86902,CDM,300,RC,86902,CPT,,,,,,,,43,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.8622,314.02
Blood Type Antigen Donor Ea,PX86902,CDM,300,RC,86902,CPT,,,,,,,,43,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.8622,314.02
ETRAP POLYP TRAP,27200000,CDM,272,RC,,,,11282-MAIN,LOCAL,,,,,43,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ETRAP POLYP TRAP,27200000,CDM,272,RC,,,,11282-MAIN,LOCAL,,,,,43,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ETRAP POLYP TRAP,27200000,CDM,272,RC,,,,11282-MAIN,LOCAL,,,,,43,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Gput, Quant",PX8277590,CDM,300,RC,82775,CPT,90,,,,,,,25,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,21.07,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.44,21.07
Smking Cess 4-10 Min,PX99406P,CDM,983,RC,99406,CPT,,,,,,,,43,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.8622,41.8519
Smking Cess 4-10 Min,PX99406P,CDM,983,RC,99406,CPT,,,,,,,,43,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.8622,41.8519
Smking Cess 4-10 Min,PX99406P,CDM,983,RC,99406,CPT,,,,,,,,43,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.8622,41.8519
"Testosterone, Total - Ref",PX8440390,CDM,300,RC,84403,CPT,90,,,,,,,43,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.8622,42.14
"Testosterone, Total - Ref",PX8440390,CDM,300,RC,84403,CPT,90,,,,,,,43,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.8622,42.14
"Testosterone, Total - Ref",PX8440390,CDM,300,RC,84403,CPT,90,,,,,,,43,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.8622,42.14
buPROPion XL 150 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,70436001004,NDC,1,EA,23.14,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,21.08054,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clotrimazole 1 % Cream 28.35 g Tube,25000000,CDM,250,RC,,,,,,904782231,NDC,28.35,GR,50.75,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,21.08155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070948,NDC,100,ML,42.59,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.08205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
zolpidem 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079072401,NDC,1,EA,24.81,,First Health,Commercial,both,85,,999999999,percent of total billed charges,21.0885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zolpidem 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079072420,NDC,1,EA,24.81,,First Health,Commercial,both,85,,999999999,percent of total billed charges,21.0885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
azithromycin 250 MG Tablet 6 Each Box,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096104,NDC,1,EA,41.72,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.11032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323018507,NDC,10,ML,43.09,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.1141,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323018507,NDC,10,ML,43.09,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.1141,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323018507,NDC,10,ML,43.09,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.1141,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096105,NDC,1,EA,41.73,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.11538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
CANNULA ADULT LARGE OPTIFLOW OPT946,120.495,CDM,271,RC,A4615,HCPCS,,11622-MAIN,LOCAL,,,,,44,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
CANNULA ADULT LARGE OPTIFLOW OPT946,120.495,CDM,271,RC,A4615,HCPCS,,11622-MAIN,LOCAL,,,,,44,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
CANNULA ADULT MEDIUM OPTIFLOW OPT944,120.495,CDM,271,RC,A4615,HCPCS,,11621-MAIN,LOCAL,,,,,44,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
CANNULA ADULT MEDIUM OPTIFLOW OPT944,120.495,CDM,271,RC,A4615,HCPCS,,11621-MAIN,LOCAL,,,,,44,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
CANNULA ADULT SMALL OPTIFLOW OPT942,120.495,CDM,271,RC,A4615,HCPCS,,11620-MAIN,LOCAL,,,,,44,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
CANNULA ADULT SMALL OPTIFLOW OPT942,120.495,CDM,271,RC,A4615,HCPCS,,11620-MAIN,LOCAL,,,,,44,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
Homocysteine,PX83090,CDM,300,RC,83090,CPT,,,,,,,,44,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.43,43.12
Homocysteine,PX83090,CDM,300,RC,83090,CPT,,,,,,,,44,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.43,43.12
KIT GASTRIC LAVAGE 2075,120.257,CDM,272,RC,C7510,HCPCS,,410-MAIN,LOCAL,,,,,44,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
KIT GASTRIC LAVAGE 2075,120.257,CDM,272,RC,C7510,HCPCS,,410-MAIN,LOCAL,,,,,44,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
SUTURE V-LOC 1/2 CIRCLE NEEDLE WOUND CLOSURE DEVICE VLOCN0306,27200000,CDM,272,RC,,,,11931-MAIN,LOCAL,,,,,44,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE V-LOC 1/2 CIRCLE NEEDLE WOUND CLOSURE DEVICE VLOCN0306,27200000,CDM,272,RC,,,,11931-MAIN,LOCAL,,,,,44,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE V-LOC SZ 3-0 180 GREEN V-20 9 INCH VLOCL0644,27200000,CDM,272,RC,,,,13056-SURG,LOCAL,,,,,44,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE V-LOC SZ 3-0 180 GREEN V-20 9 INCH VLOCL0644,27200000,CDM,272,RC,,,,13056-SURG,LOCAL,,,,,44,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DULoxetine 20 MG Capsule Delayed Release Particles 60 Each Bottle,63700001,CDM,250,RC,,,,,,2323560,NDC,1,EA,41.76,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.13056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039841,NDC,1,EA,43.14,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,11.105,percent of total billed charges,21.1386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039841,NDC,1,EA,43.14,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.1386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039841,NDC,1,EA,43.14,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.1386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
tolterodine ER 2 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,43975032203,NDC,1,EA,43.15,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.1435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tolterodine ER 2 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,43975032203,NDC,1,EA,43.15,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.1435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tolterodine ER 2 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,43975032203,NDC,1,EA,43.15,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.1435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,63323041536,NDC,0.5,ML,44.05,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,63323041536,NDC,0.5,ML,44.05,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,50111078751,NDC,1,EA,41.79,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.14574,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
donepezil 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904640861,NDC,1,EA,41.79,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.14574,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atropine 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100401,NDC,0.5,ML,50.91,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,21.148014,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
ampicillin 1 GM Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781926185,NDC,0.5,EA,43.18,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.1582,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
ampicillin 1 GM Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781926185,NDC,0.5,EA,43.18,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.1582,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
ampicillin 1 GM Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781926185,NDC,0.5,EA,43.18,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.1582,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
rosuvastatin 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003001,NDC,0.5,EA,21.59,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,21.1582,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
First Hour IV Hydration <1 Hour,PX96360,CDM,260,RC,96360,CPT,,,,,,,,260,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,21.16,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.16,56.42
Gait Training Therapy,PX97116,CDM,420,RC,97116,CPT,,,,,,,,135,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,21.16,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.16,38.66
Therapeutic Exercises,PX97110,CDM,420,RC,97110,CPT,,,,,,,,135,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,21.16,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.16,38.66
Xray Knee (Both) Ap Stand,PX7356501,CDM,320,RC,73565,CPT,TC,,,,,,,543,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,21.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.94,63.11
Xray Knee (Both) Ap Stand,PX7356501,CDM,320,RC,73565,CPT,TC,,,,,,,543,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,21.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.94,63.11
Xray Knee 3 Vws,PX7356201,CDM,320,RC,73562,CPT,TC,,,,,,,404,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,21.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.94,63.11
Xray Knee 3 Vws,PX7356201,CDM,320,RC,73562,CPT,TC,,,,,,,404,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,21.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.94,63.11
"Xray Mandible Compl, Min 4 Vws",PX7011001,CDM,320,RC,70110,CPT,TC,,,,,,,381,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,21.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.94,63.11
"Xray Mandible Compl, Min 4 Vws",PX7011001,CDM,320,RC,70110,CPT,TC,,,,,,,381,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,21.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.94,63.11
leflunomide 20 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,70748013006,NDC,0.5,EA,44.1,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
leflunomide 20 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,70748013006,NDC,0.5,EA,44.1,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SLEEVE BALLOON 5MMX100MML KII STERILE CFS02,27200000,CDM,272,RC,,,,11704-MAIN,LOCAL,,,,,24,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,21.168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STRAP CLAVICLE LARGE VP10123-040,120.191,CDM,274,RC,L3670,HCPCS,,12848-MAIN,LOCAL,,,,,24,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,21.168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE MEDIUM VP10123-030,120.191,CDM,274,RC,L3670,HCPCS,,12847-MAIN,LOCAL,,,,,24,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,21.168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE SMALL VP10123-020,120.191,CDM,274,RC,L3670,HCPCS,,12846-MAIN,LOCAL,,,,,24,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,21.168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE XL 661 XL,120.191,CDM,274,RC,L3670,HCPCS,,12850-MAIN,LOCAL,,,,,24,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,21.168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE XSMALL CHILD ORT14100XS,120.191,CDM,274,RC,L3670,HCPCS,,12849-MAIN,LOCAL,,,,,24,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,21.168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
Etoposide 100 MG/5ML Solution 5 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,16729011431,NDC,5,ML,43.21,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.1729,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.949434,169.8144
Etoposide 100 MG/5ML Solution 5 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,16729011431,NDC,5,ML,43.21,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.1729,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.949434,169.8144
Etoposide 100 MG/5ML Solution 5 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,16729011431,NDC,5,ML,43.21,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.1729,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.949434,169.8144
DIMETHICONE (TOPICAL) 5 % Cream 118 mL Tube,800000,CDM,,,,,,,,53329015104,NDC,118,ML,44.12,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.1776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
DIMETHICONE (TOPICAL) 5 % Cream 118 mL Tube,800000,CDM,,,,,,,,53329015104,NDC,118,ML,44.12,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.1776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
phenol-glycerin 1.5-33 % Liquid 118 mL Bottle,25000000,CDM,250,RC,,,,,,78112000068,NDC,118,ML,44.12,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.1776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
phenol-glycerin 1.5-33 % Liquid 118 mL Bottle,25000000,CDM,250,RC,,,,,,78112000068,NDC,118,ML,44.12,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.1776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
amoxicillin 250 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,93415580,NDC,150,ML,43.22,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.1778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 250 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,93415580,NDC,150,ML,43.22,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.1778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 250 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,93415580,NDC,150,ML,43.22,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.1778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Gabapentin - Ref,PX8017190,CDM,300,RC,80171,CPT,90,,,,,,,71,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,21.1794,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.02,21.67
DRAPE STERILE 109X100X110 ROBOTIC DYNJP9108,27200000,CDM,272,RC,,,,12020-MAIN,LOCAL,,,,,51,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,21.1854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Immunohisto Antibody Slide Ea Multiplex,PX8834401,CDM,310,RC,88344,CPT,TC,,,,,,,51,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,21.1854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,314.02
RANGER UNIT TUBING FLUID WARMING,120.229,CDM,272,RC,,,,10612-MAIN,LOCAL,,,,,51,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,21.1854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,49.98
SCAR GEL SHEET,120.458,CDM,273,RC,A6025,HCPCS,,5796-MAIN,LOCAL,,,,,51,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,21.1854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,49.98
TUBE FEEDING DECLOGGING SYSTEM CLOG ZAPPER 20-0002,120.277,CDM,272,RC,,,,4226-MAIN,LOCAL,,,,,51,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,21.1854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,49.98
"dextran 70, glycerin, hypromellose 0.1-0.2-0.3 % Solution 15 mL Bottle",63700001,CDM,250,RC,,,,,,65042636,NDC,15,ML,44.14,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.1872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"dextran 70, glycerin, hypromellose 0.1-0.2-0.3 % Solution 15 mL Bottle",63700001,CDM,250,RC,,,,,,65042636,NDC,15,ML,44.14,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.1872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nafcillin 2 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,S0032,HCPCS,,,,63323032820,NDC,1,EA,185.37,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,21.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Organic Acid, Single, Qnt - Ref",PX8392190,CDM,300,RC,83921,CPT,90,,,,,,,209,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,21.21,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.57,21.21
"CUFF STERILE DISPOSABLE SPSB 12""",27200000,CDM,272,RC,,,,7435-MAIN,LOCAL,,,,,43.31,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.2219,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"CUFF STERILE DISPOSABLE SPSB 12""",27200000,CDM,272,RC,,,,7435-MAIN,LOCAL,,,,,43.31,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.2219,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"CUFF STERILE DISPOSABLE SPSB 12""",27200000,CDM,272,RC,,,,7435-MAIN,LOCAL,,,,,43.31,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.2219,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001326,NDC,1,ML,42.88,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.2256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001341,NDC,1,ML,42.88,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.2256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
apixaban 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,3089431,NDC,0.5,EA,23.85,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,21.2265,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Vitamin B-1 - Ref,PX8442590,CDM,300,RC,84425,CPT,90,,,,,,,130,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,21.23,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.59,21.23
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,143957501,NDC,50,ML,44.24,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.2352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,143957501,NDC,50,ML,44.24,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.2352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,143957510,NDC,50,ML,44.24,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.2352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,143957510,NDC,50,ML,44.24,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.2352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
eplerenone 25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16729029315,NDC,1,EA,23.31,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,21.23541,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"SUTURE ETHIBOND #0 CT-1 CR 8-18"" CX21D",27200000,CDM,272,RC,,,,6415-MAIN,LOCAL,,,,,41.97,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.23682,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
X-Ray Exam Femur 1 Vw,PX7355101,CDM,320,RC,73551,CPT,TC,,,,,,,142,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,21.2388,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.96,42.07
Xray Elbow 2 Vws,PX7307001,CDM,320,RC,73070,CPT,TC,,,,,,,365,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,21.2388,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.96,42.07
Xray Foot 2 Vws,PX7362001,CDM,320,RC,73620,CPT,TC,,,,,,,367,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,21.2388,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.74,42.07
chlorhexidine 4 % Solution 118 mL Bottle,25000000,CDM,250,RC,,,,,,234057504,NDC,118,ML,24.09,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,21.24738,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Carcinoembryonic Antigen,PX82378,CDM,300,RC,82378,CPT,,,,,,,,25,,First Health,Commercial,both,85,,999999999,percent of total billed charges,21.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
"Gput, Quant",PX8277590,CDM,300,RC,82775,CPT,90,,,,,,,25,,First Health,Commercial,both,85,,999999999,percent of total billed charges,21.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
MEPILEX ADH FOAM 4X10,120.63,CDM,272,RC,A6196,HCPCS,,8710-MAIN,LOCAL,,,,,25,,First Health,Commercial,both,85,,999999999,percent of total billed charges,21.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
MEPILEX SOFT SILICONE 6X6,120.63,CDM,272,RC,A6196,HCPCS,,5577-MAIN,LOCAL,,,,,25,,First Health,Commercial,both,85,,999999999,percent of total billed charges,21.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
OPTIFOAM GENTLE SA SILICCONE FACED FOAM & BOARDER,120.63,CDM,272,RC,A6196,HCPCS,,3938-MAIN,LOCAL,,,,,25,,First Health,Commercial,both,85,,999999999,percent of total billed charges,21.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
Phase III Recovery Monthly,PX93799.01,CDM,943,RC,,,,,,,,,,25,,First Health,Commercial,both,85,,999999999,percent of total billed charges,21.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
"Testosterone,Free - Ref",PX8440290,CDM,300,RC,84402,CPT,90,,,,,,,25,,First Health,Commercial,both,85,,999999999,percent of total billed charges,21.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
Actin Antibody Each,PX8601590,CDM,300,RC,86015,CPT,90,,,,,,,42,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.05,41.16
Assay Vitamin B-6,PX84207,CDM,300,RC,84207,CPT,90,,,,,,,42,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
"BOUGIE TRACH 10FR 70CM COUDE 	9-0211-70",120.199,CDM,272,RC,A7520,HCPCS,,11112-MAIN,LOCAL,,,,,42,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
BOUGIE TRACHEAL TUBE & GUIDE 100123515,120.199,CDM,272,RC,A7520,HCPCS,,8950-MAIN,LOCAL,,,,,42,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
CATHETER PUREWICK FEMALE EXTERNAL PWF030K,120.414,CDM,272,RC,A6590,HCPCS,,11836-MAIN,LOCAL,,,,,42,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
Culture Type Immunologic,PX87147,CDM,300,RC,87147,CPT,,,,,,,,42,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,41.16
EZ-STABILIZER DRESSING,120.415,CDM,272,RC,,,,9058-MAIN,LOCAL,,,,,42,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
MEPILEX AG FOAM 4X4,120.192,CDM,272,RC,A6213,HCPCS,,8480-MAIN,LOCAL,,,,,42,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
MEPILEX AG FOAM 4X8,120.192,CDM,272,RC,A6213,HCPCS,,8479-MAIN,LOCAL,,,,,42,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY CENTRAL LINE DRESSING WITH CHLORAPREP DYND75234,120.68,CDM,272,RC,,,,10923-MAIN,LOCAL,,,,,42,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY FOLEY 14FR CATHETER A300414A,120.414,CDM,272,RC,A4344,HCPCS,,11281-MAIN,LOCAL,,,,,42,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY FOLEY 16FR CATHETER 300416A,120.414,CDM,272,RC,A4344,HCPCS,,11774-MAIN,LOCAL,,,,,42,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
"TRAY SPINAL  25GX3.5"" WITH WHITEACRE 405671",120.275,CDM,272,RC,,,,3284-MAIN,LOCAL,,,,,42,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY SPINAL 25G ANESTH SADDLE BLOCK NLD-4795-20,120.275,CDM,272,RC,,,,935-MAIN,LOCAL,,,,,42,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
ampicillin 500 MG Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781925078,NDC,1,EA,44.28,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.2544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
ampicillin 500 MG Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781925078,NDC,1,EA,44.28,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.2544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490311,NDC,5,ML,43.39,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.2611,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490311,NDC,5,ML,43.39,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.2611,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490311,NDC,5,ML,43.39,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.2611,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
Dimethicone 1.5 % Cream 118 mL Tube,800000,CDM,,,,,,,,53329016104,NDC,118,ML,43.4,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.266,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Dimethicone 1.5 % Cream 118 mL Tube,800000,CDM,,,,,,,,53329016104,NDC,118,ML,43.4,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.266,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Dimethicone 1.5 % Cream 118 mL Tube,800000,CDM,,,,,,,,53329016104,NDC,118,ML,43.4,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.266,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
aluminum & magnesium hydroxide-simethicone 200-200-20 MG/5ML Suspension 30 mL Cup,63700001,CDM,250,RC,,,,,,121176130,NDC,30,ML,24.12,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,21.27384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rivastigmine 1.5 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,62332006360,NDC,1,EA,25.03,,First Health,Commercial,both,85,,999999999,percent of total billed charges,21.2755,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001002,NDC,2,ML,43.42,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.2758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,42.5516
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001002,NDC,2,ML,43.42,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.2758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,42.5516
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001002,NDC,2,ML,43.42,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.2758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,42.5516
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915701,NDC,0.5,ML,44.33,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.2784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915701,NDC,0.5,ML,44.33,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.2784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915731,NDC,0.5,ML,44.33,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.2784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915731,NDC,0.5,ML,44.33,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.2784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,47335093140,NDC,0.5,EA,44.33,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.2784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,47335093140,NDC,0.5,EA,44.33,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.2784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,47335093144,NDC,0.5,EA,44.33,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.2784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,47335093144,NDC,0.5,EA,44.33,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.2784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Antinuclear Antibodiesana - Ref,PX8603890,CDM,300,RC,86038,CPT,90,,,,,,,43,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.09,42.14
Blood Type Antigen Donor Ea,PX86902,CDM,300,RC,86902,CPT,,,,,,,,43,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.8622,314.02
ETRAP POLYP TRAP,27200000,CDM,272,RC,,,,11282-MAIN,LOCAL,,,,,43,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Smking Cess 4-10 Min,PX99406P,CDM,983,RC,99406,CPT,,,,,,,,43,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.8622,41.8519
"Testosterone, Total - Ref",PX8440390,CDM,300,RC,84403,CPT,90,,,,,,,43,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.8622,42.14
ticagrelor 90 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,186077739,NDC,1,EA,44.35,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ticagrelor 90 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,186077739,NDC,1,EA,44.35,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
protamine 10 MG/ML Solution 25 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022930,NDC,2.5,ML,44.37,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.2976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.431298,83.0452
protamine 10 MG/ML Solution 25 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022930,NDC,2.5,ML,44.37,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.2976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.431298,83.0452
"DXA, Bone Density Study, Hips/Pelv/Spine",PX7708001,CDM,320,RC,77080,CPT,TC,,,,,,,575,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,21.31,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.75,58.51
"DXA, Bone Density Study, Hips/Pelv/Spine",PX7708001,CDM,320,RC,77080,CPT,TC,,,,,,,575,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,21.31,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.75,58.51
dextrose 5 % 5 % Solution 50 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338055111,NDC,50,ML,43.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,58.38,percent of total billed charges,21.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 50 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338055111,NDC,50,ML,43.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 50 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338055111,NDC,50,ML,43.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 100 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001748,NDC,100,ML,43.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,58.38,percent of total billed charges,21.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 100 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001748,NDC,100,ML,43.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 100 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001748,NDC,100,ML,43.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,264763500,NDC,1000,ML,43.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1.633818182,percent of total billed charges,21.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,264763500,NDC,1000,ML,43.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,264763500,NDC,1000,ML,43.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5% lactated ringers 5 % Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012504,NDC,1000,ML,43.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,30.11839286,percent of total billed charges,21.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"dextrose 5% lactated ringers 5 % Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012504,NDC,1000,ML,43.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"dextrose 5% lactated ringers 5 % Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012504,NDC,1000,ML,43.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329330201,NDC,25,ML,43.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329330201,NDC,25,ML,43.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329330201,NDC,25,ML,43.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9 % 0.9 % Solution 50 mL Flex Cont,J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004941,NDC,50,ML,43.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,14.79337121,percent of total billed charges,21.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % 0.9 % Solution 50 mL Flex Cont,J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004941,NDC,50,ML,43.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % 0.9 % Solution 50 mL Flex Cont,J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004941,NDC,50,ML,43.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,25.20333333,percent of total billed charges,21.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004941,NDC,250,ML,43.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,21.61375,percent of total billed charges,21.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004941,NDC,250,ML,43.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004941,NDC,250,ML,43.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055311,NDC,250,ML,43.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,21.61375,percent of total billed charges,21.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055311,NDC,250,ML,43.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055311,NDC,250,ML,43.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004948,NDC,300,ML,43.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,21.61375,percent of total billed charges,21.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004948,NDC,300,ML,43.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004948,NDC,300,ML,43.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055318,NDC,300,ML,43.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,21.61375,percent of total billed charges,21.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055318,NDC,300,ML,43.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055318,NDC,300,ML,43.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 150 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,409798361,NDC,300,ML,43.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,21.61375,percent of total billed charges,21.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 150 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,409798361,NDC,300,ML,43.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 150 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,409798361,NDC,300,ML,43.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9% irrigation 0.9 % Solution 3,000 mL Plas Cont",25000000,CDM,250,RC,,,,,,338004727,NDC,3000,ML,43.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"sodium chloride 0.9% irrigation 0.9 % Solution 3,000 mL Plas Cont",25000000,CDM,250,RC,,,,,,338004727,NDC,3000,ML,43.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"sodium chloride 0.9% irrigation 0.9 % Solution 3,000 mL Plas Cont",25000000,CDM,250,RC,,,,,,338004727,NDC,3000,ML,43.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9% IV LINE FLUSH 0.9% Solution 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,338004948,NDC,100,ML,43.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9% IV LINE FLUSH 0.9% Solution 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,338004948,NDC,100,ML,43.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9% IV LINE FLUSH 0.9% Solution 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,338004948,NDC,100,ML,43.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
AQUACEL EXTRA HYDOFIBER WOUND DRESSING 4X5,120.202,CDM,272,RC,A6197,HCPCS,,12047-MAIN,LOCAL,,,,,14,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,21.32,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.69,22.44
DRESSING QWICK NONADHESIVE 4.25X4 SUPERABSORBENT MSC5844,120.531,CDM,272,RC,A6197,HCPCS,,12301-MAIN,LOCAL,,,,,20,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,21.32,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.32,22.44
KERRAMAX CARE SUPERABSORBENT DRESSING 5X6,120.548,CDM,272,RC,A6197,HCPCS,,12362-MAIN,LOCAL,,,,,10,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,21.32,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.32,22.44
KERRAMAX CARE SUPERABSORBENT DRESSING 8X12,120.55,CDM,272,RC,A6197,HCPCS,,12363-MAIN,LOCAL,,,,,27,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,21.32,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.32,22.44
MELGISORB AG SILVER CALCIUM STERILE 6X6,120.502,CDM,272,RC,A6197,HCPCS,,11844-MAIN,LOCAL,,,,,45,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,21.32,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.32,22.44
hydroxychloroquine 200 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16571068701,NDC,1,EA,23.41,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,21.32651,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Syringe,J7040.01,CDM,636,RC,J7040,HCPCS,,,,64253020230,NDC,10,ML,42.15,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.3279,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028426,NDC,1,EA,42.15,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.3279,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323018507,NDC,10,ML,43.09,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.32955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Renin - Ref,PX8424490,CDM,300,RC,84244,CPT,90,,,,,,,53,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,21.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.33,21.99
Renin - Ref,PX8424490,CDM,300,RC,84244,CPT,90,,,,,,,53,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,21.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.33,21.99
Renin - Ref,PX8424490,CDM,300,RC,84244,CPT,90,,,,,,,53,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,21.33,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.33,21.99
empagliflozin 25 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,597015330,NDC,0.4,EA,43.54,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.3346,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
empagliflozin 25 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,597015330,NDC,0.4,EA,43.54,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.3346,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
empagliflozin 25 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,597015330,NDC,0.4,EA,43.54,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.3346,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
empagliflozin 25 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,597015337,NDC,0.4,EA,43.54,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.3346,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
empagliflozin 25 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,597015337,NDC,0.4,EA,43.54,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.3346,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
empagliflozin 25 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,597015337,NDC,0.4,EA,43.54,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.3346,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clopidogrel 75 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629461,NDC,1,EA,23.42,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,21.33562,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DULoxetine 30 MG Capsule Delayed Release Particles 90 Each Bottle,63700001,CDM,250,RC,,,,,,57237001890,NDC,1,EA,42.17,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.33802,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,703903201,NDC,2,ML,44.46,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.3408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,97.0102
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,703903201,NDC,2,ML,44.46,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.3408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,97.0102
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2021301,NDC,3,ML,44.46,,Health Partners,Health Partners Care Plans,both,48,,4.547805556,percent of total billed charges,21.3408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2021301,NDC,3,ML,44.46,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.3408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
glucose 40 % Gel 37.5 g Package,63700001,CDM,250,RC,,,,,,574006930,NDC,37.5,GR,25.12,,First Health,Commercial,both,85,,999999999,percent of total billed charges,21.352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glucose 40 % Gel 37.5 g Tube,63700001,CDM,250,RC,,,,,,574006915,NDC,37.5,GR,25.12,,First Health,Commercial,both,85,,999999999,percent of total billed charges,21.352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenylephrine 0.25 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,69536002515,NDC,15,ML,24.21,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,21.35322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039841,NDC,1,EA,43.14,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.3543,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703331101,NDC,0.75,ML,51.41,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,21.355714,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
tolterodine ER 2 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,43975032203,NDC,1,EA,43.15,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.35925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SLEEVE BALLOON 5MMX100MML KII STERILE CFS02,27200000,CDM,272,RC,,,,11704-MAIN,LOCAL,,,,,24,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,21.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STRAP CLAVICLE LARGE VP10123-040,120.191,CDM,274,RC,L3670,HCPCS,,12848-MAIN,LOCAL,,,,,24,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,21.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE MEDIUM VP10123-030,120.191,CDM,274,RC,L3670,HCPCS,,12847-MAIN,LOCAL,,,,,24,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,21.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE SMALL VP10123-020,120.191,CDM,274,RC,L3670,HCPCS,,12846-MAIN,LOCAL,,,,,24,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,21.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE XL 661 XL,120.191,CDM,274,RC,L3670,HCPCS,,12850-MAIN,LOCAL,,,,,24,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,21.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE XSMALL CHILD ORT14100XS,120.191,CDM,274,RC,L3670,HCPCS,,12849-MAIN,LOCAL,,,,,24,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,21.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
Hospital Outpatient Clinic Visit Specimen Collection for Sars-Cov-2,PXC9803,CDM,300,RC,C9803,HCPCS,,,,,,,,33,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,21.36088,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.36088,22.98
celecoxib 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904650261,NDC,1,EA,23.45,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,21.36295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049209,NDC,5,ML,44.52,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.3696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049209,NDC,5,ML,44.52,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.3696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ampicillin 1 GM Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781926185,NDC,0.5,EA,43.18,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.3741,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
First Hour IV Hydration <1 Hour,PX96360,CDM,260,RC,96360,CPT,,,,,,,,260,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,21.38,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.16,56.42
First Hour IV Hydration <1 Hour,PX96360,CDM,260,RC,96360,CPT,,,,,,,,260,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,21.38,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.16,56.42
Pulmonary Stress Test,PX94618,CDM,976,RC,94618,CPT,,,,,,,,153,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,21.38,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.38,149.94
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,409163221,NDC,0.5,EA,43.65,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.3885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,409163221,NDC,0.5,EA,43.65,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.3885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,409163221,NDC,0.5,EA,43.65,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.3885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 4 % Cream 5 g Tube,63700001,CDM,250,RC,,,,,,496088205,NDC,5,GR,51.49,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,21.388946,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Etoposide 100 MG/5ML Solution 5 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,16729011431,NDC,5,ML,43.21,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.38895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.949434,169.8144
"lidocaine 2% -EPINEPHRine 1:200,000 2 %-1:200000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409318301,NDC,20,ML,49.86,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,21.38994,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
SUCTION TIP POOLE STERILE 35040,27200000,CDM,272,RC,,,,977-MAIN,LOCAL,,,,,42.28,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.39368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
amoxicillin 250 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,93415580,NDC,150,ML,43.22,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.3939,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490334,NDC,5,ML,42.29,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.39874,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
tetracycline 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,51991090701,NDC,0.5,EA,42.29,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.39874,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Insulin Ab - Ref,PX8633790,CDM,300,RC,86337,CPT,90,,,,,,,65,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,21.41,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,21.41
Myoglobin - Ref,PX8387490,CDM,300,RC,83874,CPT,90,,,,,,,22,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,21.4126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.1388,21.56
SUTURE POLYSORB BRAIDED ABSORBABLE VIOLET SIZE 0 30IN WITH 5/8 CIRCLE TAPER POINT 27MM NEEDLE,27200000,CDM,272,RC,,,,11985-MAIN,LOCAL,,,,,22,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,21.4126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TEGADERM CHLORHEXIDINE-GLUCONATE,120.356,CDM,272,RC,A4221,HCPCS,,10708-MAIN,LOCAL,,,,,22,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,21.4126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.1388,21.56
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,55150016205,NDC,5,ML,42.32,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.41392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Molecular Cytog, Ea Probe - Ref",PX8827190,CDM,310,RC,88271,CPT,90,,,,,,,277,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,21.42,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.78,21.42
"lidocaine 2%-EPINEPHrine 1:100,000 2 %-1:100000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,409318221,NDC,30,ML,51.57,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,21.422178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665305,NDC,20,ML,49.97,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,21.43713,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"CUFF STERILE DISPOSABLE SPSB 12""",27200000,CDM,272,RC,,,,7435-MAIN,LOCAL,,,,,43.31,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.43845,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
chlorhexidine 4 % Solution 118 mL Bottle,25000000,CDM,250,RC,,,,,,234057504,NDC,118,ML,24.09,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,21.4401,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,17478004001,NDC,1,ML,42.39,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.44934,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
ERBEFLO CLEVERCAP CO2 TUBING CAP SET,27200000,CDM,272,RC,,,,11831-MAIN,LOCAL,,,,,50,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,21.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
G6pd; Quant Screen - Ref,PX8295590,CDM,300,RC,82955,CPT,90,,,,,,,50,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,21.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.89,49
"Homogenization, Tissue for Culture",PX87176,CDM,300,RC,87176,CPT,,,,,,,,50,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,21.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.39,49
"NEEDLE ASP 16GX3/16"" 1-7/8"" ILLINOIS STERNAL 8881245164",120.8,CDM,272,RC,G0364,HCPCS,,5730-MAIN,LOCAL,,,,,50,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,21.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,49
"NEEDLE BONE MARROW 8G X 4"" BIOPSY/ASPIRATION 8881247087",120.8,CDM,272,RC,G0364,HCPCS,,166-MAIN,LOCAL,,,,,50,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,21.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,49
"NEEDLE BONE MARROW 11G X 4"" 8881247111",120.8,CDM,272,RC,G0364,HCPCS,,162-MAIN,LOCAL,,,,,50,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,21.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,49
Potassium; Urine,PX84133,CDM,300,RC,84133,CPT,,,,,,,,50,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,21.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.34,49
fluconazole 100 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069101,NDC,0.5,EA,23.55,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,21.45405,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vedolizumab 300 MG Recon Soln 1 Each Vial,J3380.01,CDM,636,RC,J3380,HCPCS,,,,64764030020,NDC,1,EA,12439.04,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,21.45739,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.07,22.06
fluconazole 150 MG Tablet 12 Each Box,63700001,CDM,250,RC,,,,,,16714069211,NDC,0.333333333,EA,24.33,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,21.45906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxytocin 10 UNIT/ML Solution 1 mL Vial,J2590.01,CDM,636,RC,J2590,HCPCS,,,,42023011625,NDC,1,ML,43.8,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.19452,42.924
oxytocin 10 UNIT/ML Solution 1 mL Vial,J2590.01,CDM,636,RC,J2590,HCPCS,,,,42023011625,NDC,1,ML,43.8,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.19452,42.924
oxytocin 10 UNIT/ML Solution 1 mL Vial,J2590.01,CDM,636,RC,J2590,HCPCS,,,,42023011625,NDC,1,ML,43.8,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.19452,42.924
aluminum & magnesium hydroxide-simethicone 200-200-20 MG/5ML Suspension 30 mL Cup,63700001,CDM,250,RC,,,,,,121176130,NDC,30,ML,24.12,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,21.4668,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buprenorphine 2 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,50383092493,NDC,1,EA,24.34,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,21.46788,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.14,40.7288
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049257,NDC,5,ML,42.43,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.46958,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
hydroxychloroquine 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292001101,NDC,1,EA,23.57,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,21.47227,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490311,NDC,5,ML,43.39,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.47805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
Dimethicone 1.5 % Cream 118 mL Tube,800000,CDM,,,,,,,,53329016104,NDC,118,ML,43.4,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.483,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665318,NDC,20,ML,50.08,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,21.48432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
sterile water (preservative free) Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323018520,NDC,20,ML,50.08,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,21.48432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001002,NDC,2,ML,43.42,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.4929,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,42.5516
entacapone 200 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,27241004910,NDC,1,EA,24.37,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,21.49434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Enzyme Act, Nonradioact - Ref",PX8265790,CDM,300,RC,82657,CPT,90,,,,,,,560,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,21.5,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.5,22.17
"Enzyme Act, Nonradioact - Ref",PX8265790,CDM,300,RC,82657,CPT,90,,,,,,,560,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,21.5,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.5,22.17
"Enzyme Act, Nonradioact - Ref",PX8265790,CDM,300,RC,82657,CPT,90,,,,,,,560,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,21.5,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.5,22.17
Renin - Ref,PX8424490,CDM,300,RC,84244,CPT,90,,,,,,,53,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,21.5003,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.33,21.99
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048203,NDC,20,ML,44.8,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048203,NDC,20,ML,44.8,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048227,NDC,20,ML,44.8,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048227,NDC,20,ML,44.8,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ketorolac 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314012605,NDC,5,ML,42.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.505,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
artificial tears Ointment 3.5 g Tube,63700001,CDM,250,RC,,,,,,10119002239,NDC,3.5,GR,50.14,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,21.51006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Fac/Debridement of Nails, 6 or Mor",PX11721F,CDM,510,RC,11721,CPT,,,,,,,,95,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,21.5137,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.61,92.7
Each Add'l Hour IV Hydration,PX96361,CDM,260,RC,96361,CPT,,,,,,,,123,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,21.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.85,21.52
Each Add'l Hour IV Hydration,PX96361,CDM,260,RC,96361,CPT,,,,,,,,123,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,21.52,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.85,21.52
natalizumab 300 MG/15ML Concentrate 15 mL Vial,J2323.01,CDM,636,RC,J2323,HCPCS,,,,64406000801,NDC,15,ML,15226.53,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,21.52,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.52,24.45
dextrose 5 % 5 % Solution 50 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338055111,NDC,50,ML,43.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.5325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 100 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001748,NDC,100,ML,43.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.5325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,264763500,NDC,1000,ML,43.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.5325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5% lactated ringers 5 % Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012504,NDC,1000,ML,43.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.5325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329330201,NDC,25,ML,43.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.5325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9 % 0.9 % Solution 50 mL Flex Cont,J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004941,NDC,50,ML,43.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,2.714444444,percent of total billed charges,21.5325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004941,NDC,250,ML,43.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.5325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055311,NDC,250,ML,43.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.5325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004948,NDC,300,ML,43.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.5325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055318,NDC,300,ML,43.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.5325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 150 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,409798361,NDC,300,ML,43.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.5325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9% irrigation 0.9 % Solution 3,000 mL Plas Cont",25000000,CDM,250,RC,,,,,,338004727,NDC,3000,ML,43.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.5325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9% IV LINE FLUSH 0.9% Solution 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,338004948,NDC,100,ML,43.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.5325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
mycophenolate 500 MG Tablet 100 Each Bottle,J7517.01,CDM,637,RC,J7517,HCPCS,,,,64380072506,NDC,1,EA,42.56,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.53536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.679424,41.7088
phenylephrine 0.25 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,69536002515,NDC,15,ML,24.21,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,21.5469,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070948,NDC,100,ML,42.59,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.55054,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
empagliflozin 25 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,597015330,NDC,0.4,EA,43.54,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.5523,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
empagliflozin 25 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,597015337,NDC,0.4,EA,43.54,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.5523,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Pertechnetate, Dia, per Mci",PXA9512,CDM,343,RC,A9512,HCPCS,,,,,,,,280,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,21.5539,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.4,21.5539
ezetimibe 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714081301,NDC,1,EA,44.91,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.5568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ezetimibe 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714081301,NDC,1,EA,44.91,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.5568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 1 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,472034356,NDC,28,GR,22.15,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,21.558595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CANNULA ADULT LARGE OPTIFLOW OPT946,120.495,CDM,271,RC,A4615,HCPCS,,11622-MAIN,LOCAL,,,,,44,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
CANNULA ADULT LARGE OPTIFLOW OPT946,120.495,CDM,271,RC,A4615,HCPCS,,11622-MAIN,LOCAL,,,,,44,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
CANNULA ADULT LARGE OPTIFLOW OPT946,120.495,CDM,271,RC,A4615,HCPCS,,11622-MAIN,LOCAL,,,,,44,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
CANNULA ADULT MEDIUM OPTIFLOW OPT944,120.495,CDM,271,RC,A4615,HCPCS,,11621-MAIN,LOCAL,,,,,44,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
CANNULA ADULT MEDIUM OPTIFLOW OPT944,120.495,CDM,271,RC,A4615,HCPCS,,11621-MAIN,LOCAL,,,,,44,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
CANNULA ADULT MEDIUM OPTIFLOW OPT944,120.495,CDM,271,RC,A4615,HCPCS,,11621-MAIN,LOCAL,,,,,44,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
CANNULA ADULT SMALL OPTIFLOW OPT942,120.495,CDM,271,RC,A4615,HCPCS,,11620-MAIN,LOCAL,,,,,44,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
CANNULA ADULT SMALL OPTIFLOW OPT942,120.495,CDM,271,RC,A4615,HCPCS,,11620-MAIN,LOCAL,,,,,44,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
CANNULA ADULT SMALL OPTIFLOW OPT942,120.495,CDM,271,RC,A4615,HCPCS,,11620-MAIN,LOCAL,,,,,44,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
Dhea-S - Ref,PX8262790,CDM,300,RC,82627,CPT,90,,,,,,,57,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,21.56,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.56,22.23
Dhea-S - Ref,PX8262790,CDM,300,RC,82627,CPT,90,,,,,,,57,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,21.56,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.56,22.23
Dhea-S - Ref,PX8262790,CDM,300,RC,82627,CPT,90,,,,,,,57,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,21.56,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.56,22.23
Homocysteine,PX83090,CDM,300,RC,83090,CPT,,,,,,,,44,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.43,43.12
Homocysteine,PX83090,CDM,300,RC,83090,CPT,,,,,,,,44,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.43,43.12
Homocysteine,PX83090,CDM,300,RC,83090,CPT,,,,,,,,44,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.43,43.12
KIT GASTRIC LAVAGE 2075,120.257,CDM,272,RC,C7510,HCPCS,,410-MAIN,LOCAL,,,,,44,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
KIT GASTRIC LAVAGE 2075,120.257,CDM,272,RC,C7510,HCPCS,,410-MAIN,LOCAL,,,,,44,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
KIT GASTRIC LAVAGE 2075,120.257,CDM,272,RC,C7510,HCPCS,,410-MAIN,LOCAL,,,,,44,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
Myoglobin - Ref,PX8387490,CDM,300,RC,83874,CPT,90,,,,,,,22,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,21.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.1388,21.56
SUTURE POLYSORB BRAIDED ABSORBABLE VIOLET SIZE 0 30IN WITH 5/8 CIRCLE TAPER POINT 27MM NEEDLE,27200000,CDM,272,RC,,,,11985-MAIN,LOCAL,,,,,22,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,21.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE V-LOC 1/2 CIRCLE NEEDLE WOUND CLOSURE DEVICE VLOCN0306,27200000,CDM,272,RC,,,,11931-MAIN,LOCAL,,,,,44,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE V-LOC 1/2 CIRCLE NEEDLE WOUND CLOSURE DEVICE VLOCN0306,27200000,CDM,272,RC,,,,11931-MAIN,LOCAL,,,,,44,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE V-LOC 1/2 CIRCLE NEEDLE WOUND CLOSURE DEVICE VLOCN0306,27200000,CDM,272,RC,,,,11931-MAIN,LOCAL,,,,,44,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE V-LOC SZ 3-0 180 GREEN V-20 9 INCH VLOCL0644,27200000,CDM,272,RC,,,,13056-SURG,LOCAL,,,,,44,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE V-LOC SZ 3-0 180 GREEN V-20 9 INCH VLOCL0644,27200000,CDM,272,RC,,,,13056-SURG,LOCAL,,,,,44,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE V-LOC SZ 3-0 180 GREEN V-20 9 INCH VLOCL0644,27200000,CDM,272,RC,,,,13056-SURG,LOCAL,,,,,44,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TEGADERM CHLORHEXIDINE-GLUCONATE,120.356,CDM,272,RC,A4221,HCPCS,,10708-MAIN,LOCAL,,,,,22,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,21.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.1388,21.56
Xray Abdomen Comp Incl Decub and/or Erect,PX7402001,CDM,320,RC,74020,CPT,TC,,,,,,,436,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,21.56,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.56,21.5606
X-Ray Exam Abdomen 1 View,PX7401801,CDM,320,RC,74018,CPT,TC,,,,,,,358,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,21.5606,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.96,42.73
Xray Abdomen Comp Incl Decub and/or Erect,PX7402001,CDM,320,RC,74020,CPT,TC,,,,,,,436,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,21.5606,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.56,21.5606
Xray Forearm 2 Vws,PX7309001,CDM,320,RC,73090,CPT,TC,,,,,,,364,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,21.5606,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.18,42.73
lidocaine 5 % Patch 1 Each Box,63700001,CDM,250,RC,,,,,,591352511,NDC,1,EA,50.26,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,21.56154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 5 % Patch 30 Each Box,63700001,CDM,250,RC,,,,,,591352530,NDC,1,EA,50.26,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,21.56154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,63323041536,NDC,0.5,ML,44.05,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.5845,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,63323041536,NDC,0.5,ML,44.05,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.5845,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,63323041536,NDC,0.5,ML,44.05,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.5845,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
Wheelchair Mngement Training,PX97542,CDM,420,RC,97542,CPT,,,,,,,,145,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,21.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.59,142.1
Cardiac Rehab,PX93797F,CDM,943,RC,93797,CPT,,,,,,,,45,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,115.44
Cardiac Rehab,PX93797F,CDM,943,RC,93797,CPT,,,,,,,,45,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,115.44
CATHETER TEMP-SENSING 8FR LUBRISIL PEDS DYND110508,120.363,CDM,272,RC,A4340,HCPCS,,12777-MAIN,LOCAL,,,,,45,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
CATHETER TEMP-SENSING 8FR LUBRISIL PEDS DYND110508,120.363,CDM,272,RC,A4340,HCPCS,,12777-MAIN,LOCAL,,,,,45,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
CATHETER TEMP-SENSING 12FR LUBRISIL 119212M,120.363,CDM,272,RC,A4340,HCPCS,,10750-MAIN,LOCAL,,,,,45,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
CATHETER TEMP-SENSING 12FR LUBRISIL 119212M,120.363,CDM,272,RC,A4340,HCPCS,,10750-MAIN,LOCAL,,,,,45,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
CATHETER TEMP-SENSING 14FR LUBRISIL 119214M,120.363,CDM,272,RC,A4340,HCPCS,,10751-MAIN,LOCAL,,,,,45,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
CATHETER TEMP-SENSING 14FR LUBRISIL 119214M,120.363,CDM,272,RC,A4340,HCPCS,,10751-MAIN,LOCAL,,,,,45,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
CATHETER TEMP-SENSING 16FR LUBRISIL 119216M,120.363,CDM,272,RC,A4340,HCPCS,,10752-MAIN,LOCAL,,,,,45,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
CATHETER TEMP-SENSING 16FR LUBRISIL 119216M,120.363,CDM,272,RC,A4340,HCPCS,,10752-MAIN,LOCAL,,,,,45,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
Cryptococcus Neoformans,PX87327,CDM,300,RC,87327,CPT,,,,,,,,45,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.3,44.1
Cryptococcus Neoformans,PX87327,CDM,300,RC,87327,CPT,,,,,,,,45,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.3,44.1
Gammaglobulin; Ige - Ref,PX8278590,CDM,300,RC,82785,CPT,90,,,,,,,45,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.09,44.1
Gammaglobulin; Ige - Ref,PX8278590,CDM,300,RC,82785,CPT,90,,,,,,,45,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.09,44.1
GASTRONOMY FEEDING TUBE MIC BALLOONED 20FR 7-10ML 0112-20,27200000,CDM,272,RC,B4087,HCPCS,,13098-MAIN,LOCAL,,,,,45,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
GASTRONOMY FEEDING TUBE MIC BALLOONED 20FR 7-10ML 0112-20,27200000,CDM,272,RC,B4087,HCPCS,,13098-MAIN,LOCAL,,,,,45,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRES 1.6MM,27200000,CDM,272,RC,C1769,HCPCS,,11852-MAIN,LOCAL,,,,,45,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRES 1.6MM,27200000,CDM,272,RC,C1769,HCPCS,,11852-MAIN,LOCAL,,,,,45,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"La Crosse, Antibody - Ref",PX8665190,CDM,300,RC,86651,CPT,90,,,,,,,45,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.09,44.1
"La Crosse, Antibody - Ref",PX8665190,CDM,300,RC,86651,CPT,90,,,,,,,45,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.09,44.1
MELGISORB AG SILVER CALCIUM STERILE 6X6,120.502,CDM,272,RC,A6197,HCPCS,,11844-MAIN,LOCAL,,,,,45,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
MELGISORB AG SILVER CALCIUM STERILE 6X6,120.502,CDM,272,RC,A6197,HCPCS,,11844-MAIN,LOCAL,,,,,45,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
"St Louis, Antibody - Ref",PX8665390,CDM,300,RC,86653,CPT,90,,,,,,,45,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.09,44.1
"St Louis, Antibody - Ref",PX8665390,CDM,300,RC,86653,CPT,90,,,,,,,45,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.09,44.1
"Sugars, Qual, Ea Spec - Ref",PX8437690,CDM,300,RC,84376,CPT,90,,,,,,,45,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.04,44.1
"Sugars, Qual, Ea Spec - Ref",PX8437690,CDM,300,RC,84376,CPT,90,,,,,,,45,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.04,44.1
"Western Equine, Ab - Ref",PX8665490,CDM,300,RC,86654,CPT,90,,,,,,,45,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.09,44.1
"Western Equine, Ab - Ref",PX8665490,CDM,300,RC,86654,CPT,90,,,,,,,45,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.09,44.1
Declot Vascular Access Device,PX36593F,CDM,510,RC,36593,CPT,,,,,,,,358,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,21.6,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.6,71.95
US Renal Retroperit Ltd,PX7677501,CDM,402,RC,76775,CPT,TC,,,,,,,566,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,21.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.94,64.43
US Renal Retroperit Ltd,PX7677501,CDM,402,RC,76775,CPT,TC,,,,,,,566,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,21.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.94,64.43
Xray Wrist Minimum 3 Vws,PX7311001,CDM,320,RC,73110,CPT,TC,,,,,,,375,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,21.6,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.6,65.08
Antinuclear Ab(Ana) Titer - Ref,PX8603990,CDM,300,RC,86039,CPT,90,,,,,,,52,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,21.6008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.23,50.96
Assay Biovlbl Testosterone Direct Measurement - Ref,PX8441090,CDM,300,RC,84410,CPT,90,,,,,,,52,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,21.6008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.6008,50.96
"Beta 2 Glycoprot 1 Ab,Ea - Ref",PX8614690,CDM,300,RC,86146,CPT,90,,,,,,,52,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,21.6008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.6008,50.96
Iron - Ref,PX8354090,CDM,300,RC,83540,CPT,90,,,,,,,52,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,21.6008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,50.96
Rickettsia Antibody - Ref,PX8675790,CDM,300,RC,86757,CPT,90,,,,,,,52,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,21.6008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.74,50.96
Uric Acid; Blood,PX84550,CDM,300,RC,84550,CPT,,,,,,,,52,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,21.6008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.14,50.96
ROPivacaine 2 MG/ML Solution 10 mL Vial,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028513,NDC,10,ML,52.01,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,21.604954,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.604954,269.6078
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,409163221,NDC,0.5,EA,43.65,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.60675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ibuprofen 100 MG/5ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,68094049459,NDC,20,ML,22.2,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,21.60726,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
leflunomide 20 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,70748013006,NDC,0.5,EA,44.1,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.609,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
leflunomide 20 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,70748013006,NDC,0.5,EA,44.1,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.609,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
leflunomide 20 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,70748013006,NDC,0.5,EA,44.1,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.609,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Islet Cell Antibody - Ref,PX8634190,CDM,300,RC,86341,CPT,90,,,,,,,146,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,21.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.61,143.08
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070102,NDC,1,ML,383.6,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,21.61824,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.12,21.99
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070110,NDC,1,ML,459.95,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,21.61824,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.12,21.99
DIMETHICONE (TOPICAL) 5 % Cream 118 mL Tube,800000,CDM,,,,,,,,53329015104,NDC,118,ML,44.12,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.6188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
DIMETHICONE (TOPICAL) 5 % Cream 118 mL Tube,800000,CDM,,,,,,,,53329015104,NDC,118,ML,44.12,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.6188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
DIMETHICONE (TOPICAL) 5 % Cream 118 mL Tube,800000,CDM,,,,,,,,53329015104,NDC,118,ML,44.12,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.6188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
phenol-glycerin 1.5-33 % Liquid 118 mL Bottle,25000000,CDM,250,RC,,,,,,78112000068,NDC,118,ML,44.12,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.6188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
phenol-glycerin 1.5-33 % Liquid 118 mL Bottle,25000000,CDM,250,RC,,,,,,78112000068,NDC,118,ML,44.12,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.6188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
phenol-glycerin 1.5-33 % Liquid 118 mL Bottle,25000000,CDM,250,RC,,,,,,78112000068,NDC,118,ML,44.12,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.6188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010301,NDC,0.3,ML,45.04,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.6192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010301,NDC,0.3,ML,45.04,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.6192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,25021050002,NDC,1,ML,52.06,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,21.625724,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
"dextran 70, glycerin, hypromellose 0.1-0.2-0.3 % Solution 15 mL Bottle",63700001,CDM,250,RC,,,,,,65042636,NDC,15,ML,44.14,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.6286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"dextran 70, glycerin, hypromellose 0.1-0.2-0.3 % Solution 15 mL Bottle",63700001,CDM,250,RC,,,,,,65042636,NDC,15,ML,44.14,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.6286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"dextran 70, glycerin, hypromellose 0.1-0.2-0.3 % Solution 15 mL Bottle",63700001,CDM,250,RC,,,,,,65042636,NDC,15,ML,44.14,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.6286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE CR 20 MG Tablet ER 12 hour Abuse-Deterrent 20 Each Box,63700001,CDM,250,RC,,,,,,59011042020,NDC,1,EA,52.09,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,21.638186,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temporary tooth filling repair Misc 1 Each Package,25000000,CDM,250,RC,,,,,,47701000123,NDC,1,EA,25.46,,First Health,Commercial,both,85,,999999999,percent of total billed charges,21.641,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fluconazole 150 MG Tablet 12 Each Box,63700001,CDM,250,RC,,,,,,16714069211,NDC,0.333333333,EA,24.33,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,21.6537,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PACK BASIN BASIC SINGLE DYNJ06610A,27200000,CDM,272,RC,,,,10921-MAIN,LOCAL,,,,,25.48,,First Health,Commercial,both,85,,999999999,percent of total billed charges,21.658,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
buprenorphine 2 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,50383092493,NDC,1,EA,24.34,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,21.6626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.14,40.7288
Gabapentin - Ref,PX8017190,CDM,300,RC,80171,CPT,90,,,,,,,71,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,21.67,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.02,21.67
Immunofixation Electrophoresis; Serum,PX86334,CDM,300,RC,86334,CPT,,,,,,,,145,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,21.67,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.67,27.36
Immunofixation Electrophoresis; Serum,PX86334,CDM,300,RC,86334,CPT,,,,,,,,145,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,21.67,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.67,27.36
Immunofixation Electrophoresis; Serum,PX86334,CDM,300,RC,86334,CPT,,,,,,,,145,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,21.67,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.67,27.36
levoFLOXacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635261,NDC,0.5,EA,45.16,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.6768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levoFLOXacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635261,NDC,0.5,EA,45.16,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.6768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,143957501,NDC,50,ML,44.24,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.6776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,143957501,NDC,50,ML,44.24,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.6776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,143957501,NDC,50,ML,44.24,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.6776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,143957510,NDC,50,ML,44.24,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.6776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,143957510,NDC,50,ML,44.24,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.6776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,143957510,NDC,50,ML,44.24,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.6776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
oxytocin 10 UNIT/ML Solution 1 mL Vial,J2590.01,CDM,636,RC,J2590,HCPCS,,,,42023011625,NDC,1,ML,43.8,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.681,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.19452,42.924
entacapone 200 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,27241004910,NDC,1,EA,24.37,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,21.6893,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"US Complete Joint, Realtime W/ Img Tc",PX7688101,CDM,402,RC,76881,CPT,TC,,,,,,,415,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,21.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.2,21.69
"US Complete Joint, Realtime W/ Img Tc",PX7688101,CDM,402,RC,76881,CPT,TC,,,,,,,415,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,21.69,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.2,21.69
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016200,NDC,1,ML,52.22,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,21.692188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8092351,NDC,1,EA,52.22,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,21.692188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400101,NDC,1,EA,52.22,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,21.692188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400125,NDC,1,EA,52.22,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,21.692188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
apixaban 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,3089331,NDC,1,EA,50.57,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,21.69453,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ampicillin 500 MG Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781925078,NDC,1,EA,44.28,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.6972,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
ampicillin 500 MG Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781925078,NDC,1,EA,44.28,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.6972,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
ampicillin 500 MG Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781925078,NDC,1,EA,44.28,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.6972,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001326,NDC,1,ML,42.88,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.69728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001341,NDC,1,ML,42.88,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.69728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
etomidate 2 MG/ML Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,55150022220,NDC,10,ML,50.58,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,21.69882,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004624,NDC,50,ML,50.58,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,21.69882,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
hydrocortisone 1 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,472034356,NDC,28,GR,22.15,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,21.707,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 1 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,45802043803,NDC,28,GR,25.55,,First Health,Commercial,both,85,,999999999,percent of total billed charges,21.7175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915701,NDC,0.5,ML,44.33,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.7217,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915701,NDC,0.5,ML,44.33,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.7217,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915701,NDC,0.5,ML,44.33,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.7217,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915731,NDC,0.5,ML,44.33,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.7217,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915731,NDC,0.5,ML,44.33,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.7217,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915731,NDC,0.5,ML,44.33,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.7217,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,47335093140,NDC,0.5,EA,44.33,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.7217,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,47335093140,NDC,0.5,EA,44.33,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.7217,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,47335093140,NDC,0.5,EA,44.33,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.7217,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,47335093144,NDC,0.5,EA,44.33,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.7217,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,47335093144,NDC,0.5,EA,44.33,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.7217,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,47335093144,NDC,0.5,EA,44.33,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.7217,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
apixaban 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,3089431,NDC,0.5,EA,23.85,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,21.72735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070102,NDC,1,ML,383.6,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,21.73,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.12,21.99
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070110,NDC,1,ML,459.95,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,21.73,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.12,21.99
ticagrelor 90 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,186077739,NDC,1,EA,44.35,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.7315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ticagrelor 90 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,186077739,NDC,1,EA,44.35,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.7315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ticagrelor 90 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,186077739,NDC,1,EA,44.35,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.7315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
protamine 10 MG/ML Solution 25 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022930,NDC,2.5,ML,44.37,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.7413,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.431298,83.0452
protamine 10 MG/ML Solution 25 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022930,NDC,2.5,ML,44.37,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.7413,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.431298,83.0452
protamine 10 MG/ML Solution 25 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022930,NDC,2.5,ML,44.37,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.7413,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.431298,83.0452
lamoTRIgine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079049801,NDC,1,EA,22.34,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,21.743522,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 100 MG/5ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,68094049459,NDC,20,ML,22.2,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,21.756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Antinuclear Antibodiesana - Ref,PX8603890,CDM,300,RC,86038,CPT,90,,,,,,,43,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.09,42.14
Blood Type Antigen Donor Ea,PX86902,CDM,300,RC,86902,CPT,,,,,,,,43,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.8622,314.02
ETRAP POLYP TRAP,27200000,CDM,272,RC,,,,11282-MAIN,LOCAL,,,,,43,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Smking Cess 4-10 Min,PX99406P,CDM,983,RC,99406,CPT,,,,,,,,43,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.8622,41.8519
"Testosterone, Total - Ref",PX8440390,CDM,300,RC,84403,CPT,90,,,,,,,43,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.8622,42.14
clotrimazole 1 % Cream 28.35 g Tube,25000000,CDM,250,RC,,,,,,904782231,NDC,28.35,GR,50.75,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,21.77175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
simethicone 40 MG/0.6ML Suspension 30 mL Bottle,25000000,CDM,250,RC,,,,,,70677107801,NDC,30,ML,24.69,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,21.77658,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
CANNULA ADULT LARGE OPTIFLOW OPT946,120.495,CDM,271,RC,A4615,HCPCS,,11622-MAIN,LOCAL,,,,,44,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
CANNULA ADULT MEDIUM OPTIFLOW OPT944,120.495,CDM,271,RC,A4615,HCPCS,,11621-MAIN,LOCAL,,,,,44,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
CANNULA ADULT SMALL OPTIFLOW OPT942,120.495,CDM,271,RC,A4615,HCPCS,,11620-MAIN,LOCAL,,,,,44,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
Homocysteine,PX83090,CDM,300,RC,83090,CPT,,,,,,,,44,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.43,43.12
KIT GASTRIC LAVAGE 2075,120.257,CDM,272,RC,C7510,HCPCS,,410-MAIN,LOCAL,,,,,44,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
SUTURE V-LOC 1/2 CIRCLE NEEDLE WOUND CLOSURE DEVICE VLOCN0306,27200000,CDM,272,RC,,,,11931-MAIN,LOCAL,,,,,44,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE V-LOC SZ 3-0 180 GREEN V-20 9 INCH VLOCL0644,27200000,CDM,272,RC,,,,13056-SURG,LOCAL,,,,,44,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,703903201,NDC,2,ML,44.46,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.7854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,97.0102
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,703903201,NDC,2,ML,44.46,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.7854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,97.0102
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,703903201,NDC,2,ML,44.46,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.7854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,97.0102
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2021301,NDC,3,ML,44.46,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,3.1136,percent of total billed charges,21.7854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2021301,NDC,3,ML,44.46,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.7854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2021301,NDC,3,ML,44.46,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.7854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
simethicone 40 MG/0.6ML Suspension 30 mL Bottle,25000000,CDM,250,RC,,,,,,904589430,NDC,30,ML,22.39,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,21.792187,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
polyvinyl alcohol 1.4 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,50268067815,NDC,15,ML,45.42,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.8016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyvinyl alcohol 1.4 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,50268067815,NDC,15,ML,45.42,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.8016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323018507,NDC,10,ML,43.09,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.80354,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,63323041536,NDC,0.5,ML,44.05,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.80475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
Gait Training Therapy,PX97116,CDM,420,RC,97116,CPT,,,,,,,,135,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,21.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.16,38.66
Gait Training Therapy,PX97116,CDM,420,RC,97116,CPT,,,,,,,,135,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,21.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.16,38.66
Therapeutic Exercises,PX97110,CDM,420,RC,97110,CPT,,,,,,,,135,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,21.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.16,38.66
Therapeutic Exercises,PX97110,CDM,420,RC,97110,CPT,,,,,,,,135,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,21.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.16,38.66
magnesium sulfate 1 g in 100 ml D5W (premix) 1-5 GM/100ML-% Solution 100 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010802,NDC,100,ML,52.51,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,21.812654,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049209,NDC,5,ML,44.52,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.8148,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049209,NDC,5,ML,44.52,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.8148,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049209,NDC,5,ML,44.52,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.8148,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Drain/Inject Small Joint/Bursa,PX20600F,CDM,510,RC,20600,CPT,,,,,,,,161,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,21.82,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.82,112.07
Drain/Inject Small Joint/Bursa,PX20600P,CDM,983,RC,20600,CPT,,,,,,,,161,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,21.82,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.82,157.78
Xray Wrist Minimum 3 Vws,PX7311001,CDM,320,RC,73110,CPT,TC,,,,,,,375,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,21.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.6,65.08
Xray Wrist Minimum 3 Vws,PX7311001,CDM,320,RC,73110,CPT,TC,,,,,,,375,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,21.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.6,65.08
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188602,NDC,5,ML,45.46,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.8208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.884084,44.5508
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188602,NDC,5,ML,45.46,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.8208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.884084,44.5508
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188622,NDC,5,ML,45.46,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.8208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.884084,44.5508
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188622,NDC,5,ML,45.46,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.8208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.884084,44.5508
Dhea-S - Ref,PX8262790,CDM,300,RC,82627,CPT,90,,,,,,,57,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,21.8212,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.56,22.23
"Enzyme Act, Nonradioact - Ref",PX8265790,CDM,300,RC,82657,CPT,90,,,,,,,560,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,21.8212,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.5,22.17
Immunofixation Electrophoresis; Serum,PX86334,CDM,300,RC,86334,CPT,,,,,,,,145,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,21.8212,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.67,27.36
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039841,NDC,1,EA,43.14,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.82884,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
leflunomide 20 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,70748013006,NDC,0.5,EA,44.1,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.8295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tolterodine ER 2 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,43975032203,NDC,1,EA,43.15,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.8339,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DIMETHICONE (TOPICAL) 5 % Cream 118 mL Tube,800000,CDM,,,,,,,,53329015104,NDC,118,ML,44.12,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.8394,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
phenol-glycerin 1.5-33 % Liquid 118 mL Bottle,25000000,CDM,250,RC,,,,,,78112000068,NDC,118,ML,44.12,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.8394,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
atropine 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100401,NDC,0.5,ML,50.91,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,21.84039,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
pindolol 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,29033002801,NDC,1,EA,24.77,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,21.84714,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ampicillin 1 GM Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781926185,NDC,0.5,EA,43.18,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.84908,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
"dextran 70, glycerin, hypromellose 0.1-0.2-0.3 % Solution 15 mL Bottle",63700001,CDM,250,RC,,,,,,65042636,NDC,15,ML,44.14,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.8493,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011801,NDC,0.5,ML,52.63,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,21.862502,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011805,NDC,0.5,ML,52.63,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,21.862502,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
SLEEVE BALLOON 5MMX100MML KII STERILE CFS02,27200000,CDM,272,RC,,,,11704-MAIN,LOCAL,,,,,24,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,21.864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STRAP CLAVICLE LARGE VP10123-040,120.191,CDM,274,RC,L3670,HCPCS,,12848-MAIN,LOCAL,,,,,24,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,21.864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE MEDIUM VP10123-030,120.191,CDM,274,RC,L3670,HCPCS,,12847-MAIN,LOCAL,,,,,24,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,21.864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE SMALL VP10123-020,120.191,CDM,274,RC,L3670,HCPCS,,12846-MAIN,LOCAL,,,,,24,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,21.864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE XL 661 XL,120.191,CDM,274,RC,L3670,HCPCS,,12850-MAIN,LOCAL,,,,,24,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,21.864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE XSMALL CHILD ORT14100XS,120.191,CDM,274,RC,L3670,HCPCS,,12849-MAIN,LOCAL,,,,,24,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,21.864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
Etoposide 100 MG/5ML Solution 5 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,16729011431,NDC,5,ML,43.21,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.86426,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.949434,169.8144
amoxicillin 250 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,93415580,NDC,150,ML,43.22,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.86932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
midazolam 2 MG/ML Syrup 5 mL Cup,63700001,CDM,250,RC,,,,,,68094076459,NDC,2.5,ML,22.47,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,21.870051,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
neomycin-bacitracin-polymyxin 3.5-400-5000 Ointment 28.4 g Tube,25000000,CDM,250,RC,,,,,,713026831,NDC,28.4,GR,22.47,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,21.870051,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
DRESSING GEL FOAM SIZE 100SPONGE STERILE 00009034201,27200000,CDM,272,RC,A6248,HCPCS,,3378-MAIN,LOCAL,,,,,38.25,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,21.8756,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
DRAPE STERILE 109X100X110 ROBOTIC DYNJP9108,27200000,CDM,272,RC,,,,12020-MAIN,LOCAL,,,,,51,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,21.879,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Immunohisto Antibody Slide Ea Multiplex,PX8834401,CDM,310,RC,88344,CPT,TC,,,,,,,51,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,21.879,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,314.02
RANGER UNIT TUBING FLUID WARMING,120.229,CDM,272,RC,,,,10612-MAIN,LOCAL,,,,,51,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,21.879,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,49.98
SCAR GEL SHEET,120.458,CDM,273,RC,A6025,HCPCS,,5796-MAIN,LOCAL,,,,,51,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,21.879,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,49.98
TUBE FEEDING DECLOGGING SYSTEM CLOG ZAPPER 20-0002,120.277,CDM,272,RC,,,,4226-MAIN,LOCAL,,,,,51,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,21.879,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,49.98
zolpidem 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079072401,NDC,1,EA,24.81,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,21.88242,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zolpidem 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079072420,NDC,1,EA,24.81,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,21.88242,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lamoTRIgine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079049801,NDC,1,EA,22.34,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,21.8932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,143957501,NDC,50,ML,44.24,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.8988,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,143957510,NDC,50,ML,44.24,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.8988,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
apixaban 5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,3089421,NDC,0.5,EA,22.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,21.89925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"CUFF STERILE DISPOSABLE SPSB 12""",27200000,CDM,272,RC,,,,7435-MAIN,LOCAL,,,,,43.31,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.91486,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042350,NDC,0.5,ML,132.37,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,21.91747,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.67,22.35
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042388,NDC,0.5,ML,132.37,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,21.91747,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.67,22.35
ampicillin 500 MG Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781925078,NDC,1,EA,44.28,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.9186,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048557,NDC,50,ML,52.78,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,21.924812,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015901,NDC,0.3,ML,45.69,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.9312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015901,NDC,0.3,ML,45.69,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.9312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015925,NDC,0.3,ML,45.69,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.9312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015925,NDC,0.3,ML,45.69,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.9312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
simethicone 40 MG/0.6ML Suspension 30 mL Bottle,25000000,CDM,250,RC,,,,,,904589430,NDC,30,ML,22.39,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,21.9422,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915701,NDC,0.5,ML,44.33,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.94335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915731,NDC,0.5,ML,44.33,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.94335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,47335093140,NDC,0.5,EA,44.33,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.94335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,47335093144,NDC,0.5,EA,44.33,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.94335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
chlorhexidine 4 % Solution 118 mL Bottle,25000000,CDM,250,RC,,,,,,234057504,NDC,118,ML,24.09,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,21.94599,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048203,NDC,20,ML,44.8,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048203,NDC,20,ML,44.8,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048203,NDC,20,ML,44.8,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048227,NDC,20,ML,44.8,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048227,NDC,20,ML,44.8,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,21.952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048227,NDC,20,ML,44.8,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,21.952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ticagrelor 90 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,186077739,NDC,1,EA,44.35,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.95325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066501,NDC,0.25,ML,45.74,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.9552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.000396,47.2262
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066501,NDC,0.25,ML,45.74,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.9552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.000396,47.2262
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490311,NDC,5,ML,43.39,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.95534,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
ACUSNARE POLYPECTOMY SNARE,27200000,CDM,272,RC,,,,7733-MAIN,LOCAL,,,,,45.75,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,21.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ACUSNARE POLYPECTOMY SNARE,27200000,CDM,272,RC,,,,7733-MAIN,LOCAL,,,,,45.75,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,21.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Dimethicone 1.5 % Cream 118 mL Tube,800000,CDM,,,,,,,,53329016104,NDC,118,ML,43.4,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.9604,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
protamine 10 MG/ML Solution 25 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022930,NDC,2.5,ML,44.37,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,21.96315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.431298,83.0452
amoxicillin 125 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,143988815,NDC,150,ML,25.84,,First Health,Commercial,both,85,,999999999,percent of total billed charges,21.964,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 125 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,781603955,NDC,150,ML,25.84,,First Health,Commercial,both,85,,999999999,percent of total billed charges,21.964,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,781323294,NDC,1,EA,52.89,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,21.970506,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001002,NDC,2,ML,43.42,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,21.97052,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,42.5516
aluminum & magnesium hydroxide-simethicone 200-200-20 MG/5ML Suspension 30 mL Cup,63700001,CDM,250,RC,,,,,,121176130,NDC,30,ML,24.12,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,21.97332,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simethicone 40 MG/0.6ML Suspension 30 mL Bottle,25000000,CDM,250,RC,,,,,,70677107801,NDC,30,ML,24.69,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,21.9741,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070102,NDC,1,ML,383.6,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,21.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.12,21.99
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070102,NDC,1,ML,383.6,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,21.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.12,21.99
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070110,NDC,1,ML,459.95,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,21.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.12,21.99
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070110,NDC,1,ML,459.95,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,21.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.12,21.99
Renin - Ref,PX8424490,CDM,300,RC,84244,CPT,90,,,,,,,53,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,21.99,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.33,21.99
tamsulosin 0.4 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904640161,NDC,1,EA,22.6,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,21.99658,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ezetimibe 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714081301,NDC,1,EA,44.91,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.0059,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ezetimibe 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714081301,NDC,1,EA,44.91,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.0059,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ezetimibe 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714081301,NDC,1,EA,44.91,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,22.0059,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,703903201,NDC,2,ML,44.46,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,22.0077,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,97.0102
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2021301,NDC,3,ML,44.46,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,22.0077,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
dextrose 5 % 5 % Solution 50 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338055111,NDC,50,ML,43.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.011,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 100 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001748,NDC,100,ML,43.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.011,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,264763500,NDC,1000,ML,43.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.011,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5% lactated ringers 5 % Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012504,NDC,1000,ML,43.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.011,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329330201,NDC,25,ML,43.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.011,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9 % 0.9 % Solution 50 mL Flex Cont,J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004941,NDC,50,ML,43.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.011,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004941,NDC,250,ML,43.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.011,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055311,NDC,250,ML,43.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.011,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004948,NDC,300,ML,43.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.011,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055318,NDC,300,ML,43.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.011,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 150 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,409798361,NDC,300,ML,43.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.011,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9% irrigation 0.9 % Solution 3,000 mL Plas Cont",25000000,CDM,250,RC,,,,,,338004727,NDC,3000,ML,43.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.011,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9% IV LINE FLUSH 0.9% Solution 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,338004948,NDC,100,ML,43.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.011,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine HCl 4 % Cream 133 g Tube,63700001,CDM,250,RC,,,,,,41167005828,NDC,133,GR,52.99,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,22.012046,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Dystrophic Nail Trimming Any Number,PXG0127F,CDM,940,RC,G0127,HCPCS,,,,,,,,53,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,22.0162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.0162,53.44
Renin - Ref,PX8424490,CDM,300,RC,84244,CPT,90,,,,,,,53,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,22.0162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.16,51.94
midazolam 2 MG/ML Syrup 5 mL Cup,63700001,CDM,250,RC,,,,,,68094076459,NDC,2.5,ML,22.47,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,22.0206,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
neomycin-bacitracin-polymyxin 3.5-400-5000 Ointment 28.4 g Tube,25000000,CDM,250,RC,,,,,,713026831,NDC,28.4,GR,22.47,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,22.0206,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fluticasone-salmeterol 250-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,54032756,NDC,1,EA,45.88,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,22.0224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone-salmeterol 250-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,54032756,NDC,1,EA,45.88,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,22.0224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Chemo Ad Sq/Im Hormnl Anti-Neo,PX96402,CDM,335,RC,96402,CPT,,,,,,,,130,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,22.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.03,61.66
Drain/Inject Small Joint/Bursa,PX20600F,CDM,510,RC,20600,CPT,,,,,,,,161,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,22.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.82,112.07
Drain/Inject Small Joint/Bursa,PX20600F,CDM,510,RC,20600,CPT,,,,,,,,161,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,22.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.82,112.07
Drain/Inject Small Joint/Bursa,PX20600P,CDM,983,RC,20600,CPT,,,,,,,,161,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,22.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.82,157.78
Drain/Inject Small Joint/Bursa,PX20600P,CDM,983,RC,20600,CPT,,,,,,,,161,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,22.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.82,157.78
Pulmonary Stress Test,PX94618,CDM,976,RC,94618,CPT,,,,,,,,153,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,22.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.38,149.94
Pulmonary Stress Test,PX94618,CDM,976,RC,94618,CPT,,,,,,,,153,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,22.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.38,149.94
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762F,CDM,510,RC,43762,CPT,,,,,,,,492,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,22.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.03,467.66
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762F,CDM,510,RC,43762,CPT,,,,,,,,492,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,22.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.03,467.66
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762F,CDM,510,RC,43762,CPT,,,,,,,,492,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,22.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.03,467.66
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762P,CDM,983,RC,43762,CPT,,,,,,,,328,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,22.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.03,467.66
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762P,CDM,983,RC,43762,CPT,,,,,,,,328,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,22.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.03,467.66
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762P,CDM,983,RC,43762,CPT,,,,,,,,328,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,22.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.03,467.66
empagliflozin 25 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,597015330,NDC,0.4,EA,43.54,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.03124,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
empagliflozin 25 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,597015337,NDC,0.4,EA,43.54,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.03124,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049209,NDC,5,ML,44.52,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,22.0374,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Office/Outpt Visit,Est,Levl II",PX99212F,CDM,510,RC,99212,CPT,,,,,,,,155,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,22.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.04,101.66
"Office/Outpt Visit,Est,Levl II",PX99212P,CDM,983,RC,99212,CPT,,,,,,,,155,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,22.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.04,151.9
US Ext Non-Vasc Img Lmtd,PX7688201,CDM,402,RC,76882,CPT,TC,,,,,,,425,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,22.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.5,61.14
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338067104,NDC,1000,ML,53.06,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,22.041124,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
pindolol 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,29033002801,NDC,1,EA,24.77,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,22.0453,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzoin Tincture 59 mL Bottle,25000000,CDM,250,RC,,,,,,49348080130,NDC,59,ML,45.93,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,22.0464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
benzoin Tincture 59 mL Bottle,25000000,CDM,250,RC,,,,,,49348080130,NDC,59,ML,45.93,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,22.0464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
apixaban 5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,3089421,NDC,0.5,EA,22.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Carcinoembryonic Antigen,PX82378,CDM,300,RC,82378,CPT,,,,,,,,25,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
Cardiac Rehab,PX93797F,CDM,943,RC,93797,CPT,,,,,,,,45,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,115.44
Cardiac Rehab,PX93797F,CDM,943,RC,93797,CPT,,,,,,,,45,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,115.44
Cardiac Rehab,PX93797F,CDM,943,RC,93797,CPT,,,,,,,,45,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,115.44
CATHETER TEMP-SENSING 8FR LUBRISIL PEDS DYND110508,120.363,CDM,272,RC,A4340,HCPCS,,12777-MAIN,LOCAL,,,,,45,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
CATHETER TEMP-SENSING 8FR LUBRISIL PEDS DYND110508,120.363,CDM,272,RC,A4340,HCPCS,,12777-MAIN,LOCAL,,,,,45,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
CATHETER TEMP-SENSING 8FR LUBRISIL PEDS DYND110508,120.363,CDM,272,RC,A4340,HCPCS,,12777-MAIN,LOCAL,,,,,45,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
CATHETER TEMP-SENSING 12FR LUBRISIL 119212M,120.363,CDM,272,RC,A4340,HCPCS,,10750-MAIN,LOCAL,,,,,45,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
CATHETER TEMP-SENSING 12FR LUBRISIL 119212M,120.363,CDM,272,RC,A4340,HCPCS,,10750-MAIN,LOCAL,,,,,45,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
CATHETER TEMP-SENSING 12FR LUBRISIL 119212M,120.363,CDM,272,RC,A4340,HCPCS,,10750-MAIN,LOCAL,,,,,45,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
CATHETER TEMP-SENSING 14FR LUBRISIL 119214M,120.363,CDM,272,RC,A4340,HCPCS,,10751-MAIN,LOCAL,,,,,45,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
CATHETER TEMP-SENSING 14FR LUBRISIL 119214M,120.363,CDM,272,RC,A4340,HCPCS,,10751-MAIN,LOCAL,,,,,45,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
CATHETER TEMP-SENSING 14FR LUBRISIL 119214M,120.363,CDM,272,RC,A4340,HCPCS,,10751-MAIN,LOCAL,,,,,45,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
CATHETER TEMP-SENSING 16FR LUBRISIL 119216M,120.363,CDM,272,RC,A4340,HCPCS,,10752-MAIN,LOCAL,,,,,45,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
CATHETER TEMP-SENSING 16FR LUBRISIL 119216M,120.363,CDM,272,RC,A4340,HCPCS,,10752-MAIN,LOCAL,,,,,45,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
CATHETER TEMP-SENSING 16FR LUBRISIL 119216M,120.363,CDM,272,RC,A4340,HCPCS,,10752-MAIN,LOCAL,,,,,45,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
Cryptococcus Neoformans,PX87327,CDM,300,RC,87327,CPT,,,,,,,,45,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.3,44.1
Cryptococcus Neoformans,PX87327,CDM,300,RC,87327,CPT,,,,,,,,45,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.3,44.1
Cryptococcus Neoformans,PX87327,CDM,300,RC,87327,CPT,,,,,,,,45,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.3,44.1
Gammaglobulin; Ige - Ref,PX8278590,CDM,300,RC,82785,CPT,90,,,,,,,45,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.09,44.1
Gammaglobulin; Ige - Ref,PX8278590,CDM,300,RC,82785,CPT,90,,,,,,,45,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.09,44.1
Gammaglobulin; Ige - Ref,PX8278590,CDM,300,RC,82785,CPT,90,,,,,,,45,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.09,44.1
GASTRONOMY FEEDING TUBE MIC BALLOONED 20FR 7-10ML 0112-20,27200000,CDM,272,RC,B4087,HCPCS,,13098-MAIN,LOCAL,,,,,45,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
GASTRONOMY FEEDING TUBE MIC BALLOONED 20FR 7-10ML 0112-20,27200000,CDM,272,RC,B4087,HCPCS,,13098-MAIN,LOCAL,,,,,45,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
GASTRONOMY FEEDING TUBE MIC BALLOONED 20FR 7-10ML 0112-20,27200000,CDM,272,RC,B4087,HCPCS,,13098-MAIN,LOCAL,,,,,45,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Gput, Quant",PX8277590,CDM,300,RC,82775,CPT,90,,,,,,,25,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
K-WIRES 1.6MM,27200000,CDM,272,RC,C1769,HCPCS,,11852-MAIN,LOCAL,,,,,45,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRES 1.6MM,27200000,CDM,272,RC,C1769,HCPCS,,11852-MAIN,LOCAL,,,,,45,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRES 1.6MM,27200000,CDM,272,RC,C1769,HCPCS,,11852-MAIN,LOCAL,,,,,45,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"La Crosse, Antibody - Ref",PX8665190,CDM,300,RC,86651,CPT,90,,,,,,,45,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.09,44.1
"La Crosse, Antibody - Ref",PX8665190,CDM,300,RC,86651,CPT,90,,,,,,,45,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.09,44.1
"La Crosse, Antibody - Ref",PX8665190,CDM,300,RC,86651,CPT,90,,,,,,,45,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.09,44.1
MELGISORB AG SILVER CALCIUM STERILE 6X6,120.502,CDM,272,RC,A6197,HCPCS,,11844-MAIN,LOCAL,,,,,45,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
MELGISORB AG SILVER CALCIUM STERILE 6X6,120.502,CDM,272,RC,A6197,HCPCS,,11844-MAIN,LOCAL,,,,,45,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
MELGISORB AG SILVER CALCIUM STERILE 6X6,120.502,CDM,272,RC,A6197,HCPCS,,11844-MAIN,LOCAL,,,,,45,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
MEPILEX ADH FOAM 4X10,120.63,CDM,272,RC,A6196,HCPCS,,8710-MAIN,LOCAL,,,,,25,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
MEPILEX SOFT SILICONE 6X6,120.63,CDM,272,RC,A6196,HCPCS,,5577-MAIN,LOCAL,,,,,25,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
OPTIFOAM GENTLE SA SILICCONE FACED FOAM & BOARDER,120.63,CDM,272,RC,A6196,HCPCS,,3938-MAIN,LOCAL,,,,,25,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
Phase III Recovery Monthly,PX93799.01,CDM,943,RC,,,,,,,,,,25,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
"St Louis, Antibody - Ref",PX8665390,CDM,300,RC,86653,CPT,90,,,,,,,45,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.09,44.1
"St Louis, Antibody - Ref",PX8665390,CDM,300,RC,86653,CPT,90,,,,,,,45,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.09,44.1
"St Louis, Antibody - Ref",PX8665390,CDM,300,RC,86653,CPT,90,,,,,,,45,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.09,44.1
"Sugars, Qual, Ea Spec - Ref",PX8437690,CDM,300,RC,84376,CPT,90,,,,,,,45,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.04,44.1
"Sugars, Qual, Ea Spec - Ref",PX8437690,CDM,300,RC,84376,CPT,90,,,,,,,45,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.04,44.1
"Sugars, Qual, Ea Spec - Ref",PX8437690,CDM,300,RC,84376,CPT,90,,,,,,,45,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.04,44.1
"Testosterone,Free - Ref",PX8440290,CDM,300,RC,84402,CPT,90,,,,,,,25,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
"Venipuncture by Physician, Other Vein, Under Age 3 Years",PX36406,CDM,983,RC,36406,CPT,,,,,,,,45,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,43.7985
"Venipuncture by Physician, Other Vein, Under Age 3 Years",PX36406,CDM,983,RC,36406,CPT,,,,,,,,45,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,43.7985
"Venipuncture by Physician, Other Vein, Under Age 3 Years",PX36406,CDM,983,RC,36406,CPT,,,,,,,,45,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,43.7985
"Western Equine, Ab - Ref",PX8665490,CDM,300,RC,86654,CPT,90,,,,,,,45,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.09,44.1
"Western Equine, Ab - Ref",PX8665490,CDM,300,RC,86654,CPT,90,,,,,,,45,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.09,44.1
"Western Equine, Ab - Ref",PX8665490,CDM,300,RC,86654,CPT,90,,,,,,,45,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,22.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.09,44.1
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703331101,NDC,0.75,ML,51.41,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,22.05489,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
phenylephrine 0.25 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,69536002515,NDC,15,ML,24.21,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,22.05531,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vedolizumab 300 MG Recon Soln 1 Each Vial,J3380.01,CDM,636,RC,J3380,HCPCS,,,,64764030020,NDC,1,EA,12439.04,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,22.06,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.07,22.06
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010301,NDC,0.3,ML,45.04,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,150.5666667,percent of total billed charges,22.0696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010301,NDC,0.3,ML,45.04,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.0696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010301,NDC,0.3,ML,45.04,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,22.0696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
rivastigmine 1.5 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,62332006360,NDC,1,EA,25.03,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,22.07646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DERMABOND ADVANCED TOPICAL SKIN ADHESIVE,120.198,CDM,272,RC,,,,9101-MAIN,LOCAL,,,,,46,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,22.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.1084,45.08
DERMABOND ADVANCED TOPICAL SKIN ADHESIVE,120.198,CDM,272,RC,,,,9101-MAIN,LOCAL,,,,,46,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,22.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.1084,45.08
Hiv-1 Antigens W/Hiv 1/2 Antib,PX87389,CDM,300,RC,87389,CPT,,,,,,,,194,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,22.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.08,190.12
Pinworm Exam,PX87172,CDM,300,RC,87172,CPT,,,,,,,,46,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,22.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,45.08
Pinworm Exam,PX87172,CDM,300,RC,87172,CPT,,,,,,,,46,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,22.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,45.08
zolpidem 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079072401,NDC,1,EA,24.81,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,22.0809,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zolpidem 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079072420,NDC,1,EA,24.81,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,22.0809,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,409163221,NDC,0.5,EA,43.65,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.0869,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 4 % Cream 5 g Tube,63700001,CDM,250,RC,,,,,,496088205,NDC,5,GR,51.49,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,22.08921,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Column Chrom Ms, Quant - Ref",PX8254290,CDM,300,RC,82542,CPT,90,,,,,,,557,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,22.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.09,545.86
SPIT SOCK HOODS 16719,120.367,CDM,271,RC,,,,10820-MAIN,LOCAL,,,,,26,,First Health,Commercial,both,85,,999999999,percent of total billed charges,22.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.8004,25.48
TEGADERM CHLORHEXIDINE 5X5 CHG IV PORT,120.207,CDM,272,RC,A6268,HCPCS,,10163-MAIN,LOCAL,,,,,26,,First Health,Commercial,both,85,,999999999,percent of total billed charges,22.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.8004,25.48
"lidocaine 2%-EPINEPHrine 1:100,000 2 %-1:100000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,409318221,NDC,30,ML,51.57,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,22.12353,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dabigatran 75 MG capsule 60 Each Box,63700001,CDM,250,RC,,,,,,597035556,NDC,1,EA,53.27,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,22.128358,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levoFLOXacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635261,NDC,0.5,EA,45.16,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.1284,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levoFLOXacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635261,NDC,0.5,EA,45.16,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.1284,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levoFLOXacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635261,NDC,0.5,EA,45.16,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,22.1284,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tamsulosin 0.4 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904640161,NDC,1,EA,22.6,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,22.148,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glucose 40 % Gel 37.5 g Package,63700001,CDM,250,RC,,,,,,574006930,NDC,37.5,GR,25.12,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,22.15584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glucose 40 % Gel 37.5 g Tube,63700001,CDM,250,RC,,,,,,574006915,NDC,37.5,GR,25.12,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,22.15584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Debride Skin/Subq Ea Ad 20sqcm,PX11045F,CDM,510,RC,11045,CPT,,,,,,,,115,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,22.1559,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.05,83.02
Debride Skin/Subq Ea Ad 20sqcm,PX11045P,CDM,983,RC,11045,CPT,,,,,,,,182,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,22.1559,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.05,178.36
oxytocin 10 UNIT/ML Solution 1 mL Vial,J2590.01,CDM,636,RC,J2590,HCPCS,,,,42023011625,NDC,1,ML,43.8,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.1628,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.19452,42.924
fluconazole 150 MG Tablet 12 Each Box,63700001,CDM,250,RC,,,,,,16714069211,NDC,0.333333333,EA,24.33,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,22.16463,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16714098801,NDC,1,EA,46.18,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,22.1664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16714098801,NDC,1,EA,46.18,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,22.1664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DRESSING GEL FOAM SIZE 100SPONGE STERILE 00009034201,27200000,CDM,272,RC,A6248,HCPCS,,3378-MAIN,LOCAL,,,,,38.25,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,22.17,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
DRESSING GEL FOAM SIZE 100SPONGE STERILE 00009034201,27200000,CDM,272,RC,A6248,HCPCS,,3378-MAIN,LOCAL,,,,,38.25,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,22.17,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
DRESSING GEL FOAM SIZE 100SPONGE STERILE 00009034201,27200000,CDM,272,RC,A6248,HCPCS,,3378-MAIN,LOCAL,,,,,38.25,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,22.17,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
"Enzyme Act, Nonradioact - Ref",PX8265790,CDM,300,RC,82657,CPT,90,,,,,,,560,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,22.17,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.5,22.17
buprenorphine 2 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,50383092493,NDC,1,EA,24.34,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,22.17374,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.14,40.7288
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048203,NDC,20,ML,44.8,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,22.176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048227,NDC,20,ML,44.8,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,22.176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714000601,NDC,0.3,ML,53.39,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,22.178206,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151F,CDM,370,RC,99151,CPT,,,,,,,,176,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,22.1835,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.05,105.87
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151P,CDM,983,RC,99151,CPT,,,,,,,,275,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,22.1835,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.05,269.5
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598F,CDM,510,RC,97598,CPT,,,,,,,,406,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,22.1835,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.59,59.31
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598P,CDM,982,RC,97598,CPT,,,,,,,,325,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,22.1835,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.59,318.5
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,67457022800,NDC,5,ML,53.42,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,22.190668,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,67457057305,NDC,5,ML,53.42,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,22.190668,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
AQUACEL EXTRA HYDOFIBER WOUND DRESSING 4X5,120.202,CDM,272,RC,A6197,HCPCS,,12047-MAIN,LOCAL,,,,,14,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,22.1973,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.69,22.44
DRESSING QWICK NONADHESIVE 4.25X4 SUPERABSORBENT MSC5844,120.531,CDM,272,RC,A6197,HCPCS,,12301-MAIN,LOCAL,,,,,20,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,22.1973,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.32,22.44
KERRAMAX CARE SUPERABSORBENT DRESSING 5X6,120.548,CDM,272,RC,A6197,HCPCS,,12362-MAIN,LOCAL,,,,,10,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,22.1973,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.32,22.44
KERRAMAX CARE SUPERABSORBENT DRESSING 8X12,120.55,CDM,272,RC,A6197,HCPCS,,12363-MAIN,LOCAL,,,,,27,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,22.1973,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.32,22.44
MELGISORB AG SILVER CALCIUM STERILE 6X6,120.502,CDM,272,RC,A6197,HCPCS,,11844-MAIN,LOCAL,,,,,45,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,22.1973,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.32,22.44
entacapone 200 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,27241004910,NDC,1,EA,24.37,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,22.20107,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"DXA, Bone Density Study, Radius/Wrist/Heel",PX7708101,CDM,320,RC,77081,CPT,TC,,,,,,,460,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,22.2042,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.18,44.05
Dhea-S - Ref,PX8262790,CDM,300,RC,82627,CPT,90,,,,,,,57,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,22.23,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.56,22.23
ezetimibe 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714081301,NDC,1,EA,44.91,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,22.23045,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Blood Clot Factor VIII Test,PX85247,CDM,300,RC,85247,CPT,,,,,,,,169,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,22.25,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.25,22.94
Blood Clot Factor VIII Test,PX85247,CDM,300,RC,85247,CPT,,,,,,,,169,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,22.25,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.25,22.94
Blood Clot Factor VIII Test,PX85247,CDM,300,RC,85247,CPT,,,,,,,,169,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,22.25,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.25,22.94
Carcinoembryonic Antigen,PX82378,CDM,300,RC,82378,CPT,,,,,,,,25,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,22.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
"Gput, Quant",PX8277590,CDM,300,RC,82775,CPT,90,,,,,,,25,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,22.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
MEPILEX ADH FOAM 4X10,120.63,CDM,272,RC,A6196,HCPCS,,8710-MAIN,LOCAL,,,,,25,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,22.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
MEPILEX SOFT SILICONE 6X6,120.63,CDM,272,RC,A6196,HCPCS,,5577-MAIN,LOCAL,,,,,25,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,22.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
OPTIFOAM GENTLE SA SILICCONE FACED FOAM & BOARDER,120.63,CDM,272,RC,A6196,HCPCS,,3938-MAIN,LOCAL,,,,,25,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,22.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
Phase III Recovery Monthly,PX93799.01,CDM,943,RC,,,,,,,,,,25,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,22.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
"Testosterone,Free - Ref",PX8440290,CDM,300,RC,84402,CPT,90,,,,,,,25,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,22.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
polyvinyl alcohol 1.4 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,50268067815,NDC,15,ML,45.42,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.2558,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyvinyl alcohol 1.4 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,50268067815,NDC,15,ML,45.42,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.2558,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyvinyl alcohol 1.4 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,50268067815,NDC,15,ML,45.42,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,22.2558,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CANNULA ADULT LARGE OPTIFLOW OPT946,120.495,CDM,271,RC,A4615,HCPCS,,11622-MAIN,LOCAL,,,,,44,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
CANNULA ADULT MEDIUM OPTIFLOW OPT944,120.495,CDM,271,RC,A4615,HCPCS,,11621-MAIN,LOCAL,,,,,44,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
CANNULA ADULT SMALL OPTIFLOW OPT942,120.495,CDM,271,RC,A4615,HCPCS,,11620-MAIN,LOCAL,,,,,44,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
Homocysteine,PX83090,CDM,300,RC,83090,CPT,,,,,,,,44,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.43,43.12
KIT GASTRIC LAVAGE 2075,120.257,CDM,272,RC,C7510,HCPCS,,410-MAIN,LOCAL,,,,,44,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
SUTURE V-LOC 1/2 CIRCLE NEEDLE WOUND CLOSURE DEVICE VLOCN0306,27200000,CDM,272,RC,,,,11931-MAIN,LOCAL,,,,,44,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE V-LOC SZ 3-0 180 GREEN V-20 9 INCH VLOCL0644,27200000,CDM,272,RC,,,,13056-SURG,LOCAL,,,,,44,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Self Care Mngment Training,PX97535,CDM,420,RC,97535,CPT,,,,,,,,135,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,22.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.27,132.3
Cardiac Rehab,PX93797F,CDM,943,RC,93797,CPT,,,,,,,,45,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,22.275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,115.44
CATHETER TEMP-SENSING 8FR LUBRISIL PEDS DYND110508,120.363,CDM,272,RC,A4340,HCPCS,,12777-MAIN,LOCAL,,,,,45,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,22.275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
CATHETER TEMP-SENSING 12FR LUBRISIL 119212M,120.363,CDM,272,RC,A4340,HCPCS,,10750-MAIN,LOCAL,,,,,45,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,22.275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
CATHETER TEMP-SENSING 14FR LUBRISIL 119214M,120.363,CDM,272,RC,A4340,HCPCS,,10751-MAIN,LOCAL,,,,,45,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,22.275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
CATHETER TEMP-SENSING 16FR LUBRISIL 119216M,120.363,CDM,272,RC,A4340,HCPCS,,10752-MAIN,LOCAL,,,,,45,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,22.275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
Cryptococcus Neoformans,PX87327,CDM,300,RC,87327,CPT,,,,,,,,45,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,22.275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.3,44.1
Gammaglobulin; Ige - Ref,PX8278590,CDM,300,RC,82785,CPT,90,,,,,,,45,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,22.275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.09,44.1
GASTRONOMY FEEDING TUBE MIC BALLOONED 20FR 7-10ML 0112-20,27200000,CDM,272,RC,B4087,HCPCS,,13098-MAIN,LOCAL,,,,,45,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,22.275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRES 1.6MM,27200000,CDM,272,RC,C1769,HCPCS,,11852-MAIN,LOCAL,,,,,45,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,22.275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"La Crosse, Antibody - Ref",PX8665190,CDM,300,RC,86651,CPT,90,,,,,,,45,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,22.275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.09,44.1
MELGISORB AG SILVER CALCIUM STERILE 6X6,120.502,CDM,272,RC,A6197,HCPCS,,11844-MAIN,LOCAL,,,,,45,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,22.275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
"St Louis, Antibody - Ref",PX8665390,CDM,300,RC,86653,CPT,90,,,,,,,45,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,22.275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.09,44.1
"Sugars, Qual, Ea Spec - Ref",PX8437690,CDM,300,RC,84376,CPT,90,,,,,,,45,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,22.275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.04,44.1
"Venipuncture by Physician, Other Vein, Under Age 3 Years",PX36406,CDM,983,RC,36406,CPT,,,,,,,,45,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,22.275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,43.7985
"Western Equine, Ab - Ref",PX8665490,CDM,300,RC,86654,CPT,90,,,,,,,45,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,22.275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.09,44.1
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188602,NDC,5,ML,45.46,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.20235,percent of total billed charges,22.2754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.884084,44.5508
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188602,NDC,5,ML,45.46,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.2754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.884084,44.5508
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188602,NDC,5,ML,45.46,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,22.2754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.884084,44.5508
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188622,NDC,5,ML,45.46,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.20235,percent of total billed charges,22.2754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.884084,44.5508
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188622,NDC,5,ML,45.46,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.2754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.884084,44.5508
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188622,NDC,5,ML,45.46,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,22.2754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.884084,44.5508
rivastigmine 1.5 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,62332006360,NDC,1,EA,25.03,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,22.2767,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8092351,NDC,1,EA,52.22,,UCare,Individual and Family Plans,both,,,27.14,fee schedule,22.288,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,22.288
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8092351,NDC,1,EA,52.22,,UCare,Individual and Family Plans,both,,,27.14,fee schedule,22.288,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,22.288
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400101,NDC,1,EA,52.22,,UCare,Individual and Family Plans,both,,,27.14,fee schedule,22.288,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,22.288
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400101,NDC,1,EA,52.22,,UCare,Individual and Family Plans,both,,,27.14,fee schedule,22.288,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,22.288
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400125,NDC,1,EA,52.22,,UCare,Individual and Family Plans,both,,,27.14,fee schedule,22.288,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,22.288
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400125,NDC,1,EA,52.22,,UCare,Individual and Family Plans,both,,,27.14,fee schedule,22.288,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,22.288
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,781323294,NDC,1,EA,52.89,,UCare,Individual and Family Plans,both,,,27.14,fee schedule,22.288,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,22.288
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,781323294,NDC,1,EA,52.89,,UCare,Individual and Family Plans,both,,,27.14,fee schedule,22.288,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,22.288
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,55150020200,NDC,1,EA,65.65,,UCare,Individual and Family Plans,both,,,27.14,fee schedule,22.288,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,22.288
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,55150020200,NDC,1,EA,65.65,,UCare,Individual and Family Plans,both,,,27.14,fee schedule,22.288,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,22.288
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,72603012801,NDC,1,EA,57.64,,UCare,Individual and Family Plans,both,,,27.14,fee schedule,22.288,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,22.288
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,72603012801,NDC,1,EA,57.64,,UCare,Individual and Family Plans,both,,,27.14,fee schedule,22.288,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6,22.288
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,63323041536,NDC,0.5,ML,44.05,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.2893,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010301,NDC,0.3,ML,45.04,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,22.2948,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
Antinuclear Ab(Ana) Titer - Ref,PX8603990,CDM,300,RC,86039,CPT,90,,,,,,,52,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,22.308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.23,50.96
Assay Biovlbl Testosterone Direct Measurement - Ref,PX8441090,CDM,300,RC,84410,CPT,90,,,,,,,52,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,22.308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.6008,50.96
"Beta 2 Glycoprot 1 Ab,Ea - Ref",PX8614690,CDM,300,RC,86146,CPT,90,,,,,,,52,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,22.308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.6008,50.96
Iron - Ref,PX8354090,CDM,300,RC,83540,CPT,90,,,,,,,52,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,22.308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,50.96
Rickettsia Antibody - Ref,PX8675790,CDM,300,RC,86757,CPT,90,,,,,,,52,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,22.308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.74,50.96
Uric Acid; Blood,PX84550,CDM,300,RC,84550,CPT,,,,,,,,52,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,22.308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.14,50.96
ROPivacaine 2 MG/ML Solution 10 mL Vial,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028513,NDC,10,ML,52.01,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,22.31229,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.604954,269.6078
leflunomide 20 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,70748013006,NDC,0.5,EA,44.1,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.3146,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DIMETHICONE (TOPICAL) 5 % Cream 118 mL Tube,800000,CDM,,,,,,,,53329015104,NDC,118,ML,44.12,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.32472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
phenol-glycerin 1.5-33 % Liquid 118 mL Bottle,25000000,CDM,250,RC,,,,,,78112000068,NDC,118,ML,44.12,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.32472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,25021050002,NDC,1,ML,52.06,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,22.33374,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
"dextran 70, glycerin, hypromellose 0.1-0.2-0.3 % Solution 15 mL Bottle",63700001,CDM,250,RC,,,,,,65042636,NDC,15,ML,44.14,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.33484,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE CR 20 MG Tablet ER 12 hour Abuse-Deterrent 20 Each Box,63700001,CDM,250,RC,,,,,,59011042020,NDC,1,EA,52.09,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,22.34661,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
naltrexone 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406117001,NDC,1,EA,22.96,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,22.346968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042350,NDC,0.5,ML,132.37,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,22.35,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.67,22.35
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042350,NDC,0.5,ML,132.37,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,22.35,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.67,22.35
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042350,NDC,0.5,ML,132.37,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,22.35,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.67,22.35
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042388,NDC,0.5,ML,132.37,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,22.35,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.67,22.35
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042388,NDC,0.5,ML,132.37,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,22.35,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.67,22.35
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042388,NDC,0.5,ML,132.37,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,22.35,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.67,22.35
levoFLOXacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635261,NDC,0.5,EA,45.16,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,22.3542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
triamcinolone acetonide 0.1 % Cream 15 g Tube,63700001,CDM,250,RC,,,,,,168000415,NDC,15,GR,22.97,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,22.356701,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zinc oxide 20 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,536131625,NDC,60,GR,22.97,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,22.356701,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glucose 40 % Gel 37.5 g Package,63700001,CDM,250,RC,,,,,,574006930,NDC,37.5,GR,25.12,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,22.3568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glucose 40 % Gel 37.5 g Tube,63700001,CDM,250,RC,,,,,,574006915,NDC,37.5,GR,25.12,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,22.3568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,143957501,NDC,50,ML,44.24,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.38544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,143957510,NDC,50,ML,44.24,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.38544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BRACE WRIST 8-IN SM LEFT 10432,120.564,CDM,273,RC,L3809,HCPCS,,12720-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,22.3859,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 8-IN SM RIGHT 10442,120.564,CDM,273,RC,L3809,HCPCS,,12716-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,22.3859,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN LG RIGHT 10464,120.564,CDM,273,RC,L3809,HCPCS,,12719-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,22.3859,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN SM LEFT 617083,120.564,CDM,273,RC,L3809,HCPCS,,12722-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,22.3859,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN SM RIGHT 10462,120.564,CDM,273,RC,L3809,HCPCS,,12717-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,22.3859,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN XL LEFT 10455,120.564,CDM,273,RC,L3809,HCPCS,,12721-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,22.3859,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN XL RIGHT 10465,120.564,CDM,273,RC,L3809,HCPCS,,12715-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,22.3859,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST WRISTPRO LEFT 10-IN LG,120.564,CDM,273,RC,L3809,HCPCS,,12724-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,22.3859,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST WRISTPRO LEFT 10-IN MED,120.564,CDM,273,RC,L3809,HCPCS,,12723-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,22.3859,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
Detection of Babesia Borrelia Miyamotoi by Amplified Nucleic Acid Probe Technique,PX8747890,CDM,300,RC,87478,CPT,90,,,,,,,23,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,22.3859,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,32.17
Detection of Babesia Microtim by Amplified Nucleic Acid Probe Technique,PX8746990,CDM,300,RC,87469,CPT,90,,,,,,,23,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,22.3859,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,32.17
FORCEPS COLD BIOPSY,27200000,CDM,272,RC,,,,12453-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,22.3859,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE MAXON ABSORBABLE POLYGLYCONATE 2-0 30IN MONOFILAMENT DYED TAPER POINT 1/2 CIRCLE 27MM GS-22 G,27200000,CDM,272,RC,,,,11988-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,22.3859,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE POLYSORB ABSORBABLE LACTOMER 2-0 30IN BRAIDED DYED TAPER POINT 1/2 CIRCLE 26MM V-20 VIOLET ST,27200000,CDM,272,RC,,,,11983-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,22.3859,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015901,NDC,0.3,ML,45.69,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,150.5666667,percent of total billed charges,22.3881,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015901,NDC,0.3,ML,45.69,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.3881,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015901,NDC,0.3,ML,45.69,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,22.3881,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015925,NDC,0.3,ML,45.69,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,150.5666667,percent of total billed charges,22.3881,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015925,NDC,0.3,ML,45.69,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.3881,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015925,NDC,0.3,ML,45.69,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,22.3881,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
methylPREDNISolone sod succ 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,63323025803,NDC,0.4,EA,46.67,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,22.4016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
methylPREDNISolone sod succ 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,63323025803,NDC,0.4,EA,46.67,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,22.4016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016200,NDC,1,ML,52.22,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,22.40238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8092351,NDC,1,EA,52.22,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,22.40238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400101,NDC,1,EA,52.22,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,22.40238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400125,NDC,1,EA,52.22,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,22.40238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
ampicillin 500 MG Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781925078,NDC,1,EA,44.28,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.40568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066501,NDC,0.25,ML,45.74,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.4126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.000396,47.2262
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066501,NDC,0.25,ML,45.74,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.4126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.000396,47.2262
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066501,NDC,0.25,ML,45.74,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,22.4126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.000396,47.2262
ACUSNARE POLYPECTOMY SNARE,27200000,CDM,272,RC,,,,7733-MAIN,LOCAL,,,,,45.75,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.4175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ACUSNARE POLYPECTOMY SNARE,27200000,CDM,272,RC,,,,7733-MAIN,LOCAL,,,,,45.75,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.4175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ACUSNARE POLYPECTOMY SNARE,27200000,CDM,272,RC,,,,7733-MAIN,LOCAL,,,,,45.75,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,22.4175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
natalizumab 300 MG/15ML Concentrate 15 mL Vial,J2323.01,CDM,636,RC,J2323,HCPCS,,,,64406000801,NDC,15,ML,15226.53,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,22.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.42,14921.9994
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915701,NDC,0.5,ML,44.33,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.43098,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915731,NDC,0.5,ML,44.33,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.43098,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,47335093140,NDC,0.5,EA,44.33,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.43098,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,47335093144,NDC,0.5,EA,44.33,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.43098,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405F,CDM,510,RC,36405,CPT,,,,,,,,54,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,22.4316,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.4316,52.92
AQUACEL EXTRA HYDOFIBER WOUND DRESSING 4X5,120.202,CDM,272,RC,A6197,HCPCS,,12047-MAIN,LOCAL,,,,,14,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,22.44,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.69,22.44
DRESSING QWICK NONADHESIVE 4.25X4 SUPERABSORBENT MSC5844,120.531,CDM,272,RC,A6197,HCPCS,,12301-MAIN,LOCAL,,,,,20,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,22.44,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.32,22.44
KERRAMAX CARE SUPERABSORBENT DRESSING 5X6,120.548,CDM,272,RC,A6197,HCPCS,,12362-MAIN,LOCAL,,,,,10,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,22.44,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.32,22.44
KERRAMAX CARE SUPERABSORBENT DRESSING 8X12,120.55,CDM,272,RC,A6197,HCPCS,,12363-MAIN,LOCAL,,,,,27,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,22.44,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.32,22.44
MELGISORB AG SILVER CALCIUM STERILE 6X6,120.502,CDM,272,RC,A6197,HCPCS,,11844-MAIN,LOCAL,,,,,45,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,22.44,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.32,22.44
SAW BLADE 300 SAGITTAL 25X9.4X0.7,27200000,CDM,272,RC,,,,11592-MAIN,LOCAL,,,,,46.75,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,22.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SAW BLADE 300 SAGITTAL 25X9.4X0.7,27200000,CDM,272,RC,,,,11592-MAIN,LOCAL,,,,,46.75,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,22.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SAW BLADE 300 SAGITTAL 40X14X0.6MM,27200000,CDM,272,RC,,,,11591-MAIN,LOCAL,,,,,46.75,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,22.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SAW BLADE 300 SAGITTAL 40X14X0.6MM,27200000,CDM,272,RC,,,,11591-MAIN,LOCAL,,,,,46.75,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,22.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
AQUACEL EXTRA HYDOFIBER WOUND DRESSING 4X5,120.202,CDM,272,RC,A6197,HCPCS,,12047-MAIN,LOCAL,,,,,14,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,22.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.69,22.44
AQUACEL EXTRA HYDOFIBER WOUND DRESSING 4X5,120.202,CDM,272,RC,A6197,HCPCS,,12047-MAIN,LOCAL,,,,,14,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,22.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.69,22.44
DRESSING QWICK NONADHESIVE 4.25X4 SUPERABSORBENT MSC5844,120.531,CDM,272,RC,A6197,HCPCS,,12301-MAIN,LOCAL,,,,,20,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,22.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.32,22.44
DRESSING QWICK NONADHESIVE 4.25X4 SUPERABSORBENT MSC5844,120.531,CDM,272,RC,A6197,HCPCS,,12301-MAIN,LOCAL,,,,,20,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,22.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.32,22.44
KERRAMAX CARE SUPERABSORBENT DRESSING 5X6,120.548,CDM,272,RC,A6197,HCPCS,,12362-MAIN,LOCAL,,,,,10,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,22.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.32,22.44
KERRAMAX CARE SUPERABSORBENT DRESSING 5X6,120.548,CDM,272,RC,A6197,HCPCS,,12362-MAIN,LOCAL,,,,,10,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,22.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.32,22.44
KERRAMAX CARE SUPERABSORBENT DRESSING 8X12,120.55,CDM,272,RC,A6197,HCPCS,,12363-MAIN,LOCAL,,,,,27,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,22.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.32,22.44
KERRAMAX CARE SUPERABSORBENT DRESSING 8X12,120.55,CDM,272,RC,A6197,HCPCS,,12363-MAIN,LOCAL,,,,,27,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,22.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.32,22.44
MELGISORB AG SILVER CALCIUM STERILE 6X6,120.502,CDM,272,RC,A6197,HCPCS,,11844-MAIN,LOCAL,,,,,45,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,22.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.32,22.44
MELGISORB AG SILVER CALCIUM STERILE 6X6,120.502,CDM,272,RC,A6197,HCPCS,,11844-MAIN,LOCAL,,,,,45,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,22.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.32,22.44
ticagrelor 90 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,186077739,NDC,1,EA,44.35,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.4411,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
protamine 10 MG/ML Solution 25 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022930,NDC,2.5,ML,44.37,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.45122,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.431298,83.0452
temporary tooth filling repair Misc 1 Each Package,25000000,CDM,250,RC,,,,,,47701000123,NDC,1,EA,25.46,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,22.45572,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
El-1 Fecal Quantitative,PX8265390,CDM,300,RC,82653,CPT,90,,,,,,,383,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,22.46,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.46,22.97
Blood Clot Factor VIII Test,PX85247,CDM,300,RC,85247,CPT,,,,,,,,169,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,22.463,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.25,22.94
El-1 Fecal Quantitative,PX8265390,CDM,300,RC,82653,CPT,90,,,,,,,383,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,22.463,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.46,22.97
Drain/Inject Medium Joint/Bursa,PX20605F,CDM,510,RC,20605,CPT,,,,,,,,247,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,22.47,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.47,114.84
Drain/Inject Medium Joint/Bursa,PX20605P,CDM,983,RC,20605,CPT,,,,,,,,318,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,22.47,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.47,311.64
PACK BASIN BASIC SINGLE DYNJ06610A,27200000,CDM,272,RC,,,,10921-MAIN,LOCAL,,,,,25.48,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,22.47336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
fluticasone-salmeterol 250-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,54032756,NDC,1,EA,45.88,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.4812,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone-salmeterol 250-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,54032756,NDC,1,EA,45.88,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.4812,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone-salmeterol 250-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,54032756,NDC,1,EA,45.88,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,22.4812,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyvinyl alcohol 1.4 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,50268067815,NDC,15,ML,45.42,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,22.4829,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simethicone 40 MG/0.6ML Suspension 30 mL Bottle,25000000,CDM,250,RC,,,,,,70677107801,NDC,30,ML,24.69,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,22.49259,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,703903201,NDC,2,ML,44.46,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.49676,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,97.0102
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2021301,NDC,3,ML,44.46,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.49676,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
naltrexone 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406117001,NDC,1,EA,22.96,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,22.5008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188602,NDC,5,ML,45.46,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,22.5027,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.884084,44.5508
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188622,NDC,5,ML,45.46,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,22.5027,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.884084,44.5508
benzoin Tincture 59 mL Bottle,25000000,CDM,250,RC,,,,,,49348080130,NDC,59,ML,45.93,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.5057,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
benzoin Tincture 59 mL Bottle,25000000,CDM,250,RC,,,,,,49348080130,NDC,59,ML,45.93,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.5057,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
benzoin Tincture 59 mL Bottle,25000000,CDM,250,RC,,,,,,49348080130,NDC,59,ML,45.93,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,22.5057,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
triamcinolone acetonide 0.1 % Cream 15 g Tube,63700001,CDM,250,RC,,,,,,168000415,NDC,15,GR,22.97,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,22.5106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zinc oxide 20 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,536131625,NDC,60,GR,22.97,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,22.5106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buPROPion XL 150 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,70436001004,NDC,1,EA,23.14,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,22.522162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Xray Facial Bones Less Than 3 Vws,PX7014001,CDM,320,RC,70140,CPT,TC,,,,,,,301,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,22.526,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.83,44.7
"Xray Neck, Soft Tissue",PX7036001,CDM,320,RC,70360,CPT,TC,,,,,,,277,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,22.526,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.83,44.7
magnesium sulfate 1 g in 100 ml D5W (premix) 1-5 GM/100ML-% Solution 100 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010802,NDC,100,ML,52.51,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,22.52679,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049209,NDC,5,ML,44.52,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.52712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
hydrocortisone 1 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,45802043803,NDC,28,GR,25.55,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,22.5351,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BRACE WRIST 8-IN SM LEFT 10432,120.564,CDM,273,RC,L3809,HCPCS,,12720-MAIN,LOCAL,,,,,23,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,22.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 8-IN SM RIGHT 10442,120.564,CDM,273,RC,L3809,HCPCS,,12716-MAIN,LOCAL,,,,,23,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,22.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN LG RIGHT 10464,120.564,CDM,273,RC,L3809,HCPCS,,12719-MAIN,LOCAL,,,,,23,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,22.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN SM LEFT 617083,120.564,CDM,273,RC,L3809,HCPCS,,12722-MAIN,LOCAL,,,,,23,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,22.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN SM RIGHT 10462,120.564,CDM,273,RC,L3809,HCPCS,,12717-MAIN,LOCAL,,,,,23,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,22.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN XL LEFT 10455,120.564,CDM,273,RC,L3809,HCPCS,,12721-MAIN,LOCAL,,,,,23,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,22.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN XL RIGHT 10465,120.564,CDM,273,RC,L3809,HCPCS,,12715-MAIN,LOCAL,,,,,23,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,22.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST WRISTPRO LEFT 10-IN LG,120.564,CDM,273,RC,L3809,HCPCS,,12724-MAIN,LOCAL,,,,,23,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,22.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST WRISTPRO LEFT 10-IN MED,120.564,CDM,273,RC,L3809,HCPCS,,12723-MAIN,LOCAL,,,,,23,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,22.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
DERMABOND ADVANCED TOPICAL SKIN ADHESIVE,120.198,CDM,272,RC,,,,9101-MAIN,LOCAL,,,,,46,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.1084,45.08
DERMABOND ADVANCED TOPICAL SKIN ADHESIVE,120.198,CDM,272,RC,,,,9101-MAIN,LOCAL,,,,,46,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.1084,45.08
DERMABOND ADVANCED TOPICAL SKIN ADHESIVE,120.198,CDM,272,RC,,,,9101-MAIN,LOCAL,,,,,46,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,22.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.1084,45.08
Detection of Babesia Borrelia Miyamotoi by Amplified Nucleic Acid Probe Technique,PX8747890,CDM,300,RC,87478,CPT,90,,,,,,,23,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,22.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,32.17
Detection of Babesia Microtim by Amplified Nucleic Acid Probe Technique,PX8746990,CDM,300,RC,87469,CPT,90,,,,,,,23,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,22.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,32.17
FORCEPS COLD BIOPSY,27200000,CDM,272,RC,,,,12453-MAIN,LOCAL,,,,,23,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,22.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Pinworm Exam,PX87172,CDM,300,RC,87172,CPT,,,,,,,,46,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,45.08
Pinworm Exam,PX87172,CDM,300,RC,87172,CPT,,,,,,,,46,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,45.08
Pinworm Exam,PX87172,CDM,300,RC,87172,CPT,,,,,,,,46,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,22.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,45.08
SUTURE MAXON ABSORBABLE POLYGLYCONATE 2-0 30IN MONOFILAMENT DYED TAPER POINT 1/2 CIRCLE 27MM GS-22 G,27200000,CDM,272,RC,,,,11988-MAIN,LOCAL,,,,,23,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,22.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE POLYSORB ABSORBABLE LACTOMER 2-0 30IN BRAIDED DYED TAPER POINT 1/2 CIRCLE 26MM V-20 VIOLET ST,27200000,CDM,272,RC,,,,11983-MAIN,LOCAL,,,,,23,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,22.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RBC Pretreatment,PX8697002,CDM,300,RC,86970,CPT,,,,,,,,117,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,22.55,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.55,22.55
Blood Count Reticulocytes Auto 1/> Cell Meas,PX85046,CDM,300,RC,85046,CPT,,,,,,,,47,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,22.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.11,46.06
Blood Count Reticulocytes Auto 1/> Cell Meas,PX85046,CDM,300,RC,85046,CPT,,,,,,,,47,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,22.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.11,46.06
mepolizumab 100 MG Recon Soln 1 Each Vial,J2182.01,CDM,636,RC,J2182,HCPCS,,,,173088101,NDC,1,EA,6959.95,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,22.56,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.56,30.51
"PAD BED SENSOR 10X28"" P-107517",120.124,CDM,271,RC,,,,8377-MAIN,LOCAL,,,,,47,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,22.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.5238,46.06
"PAD BED SENSOR 10X28"" P-107517",120.124,CDM,271,RC,,,,8377-MAIN,LOCAL,,,,,47,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,22.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.5238,46.06
"PAD CHAIR SENSOR 10x15"" 106380",120.124,CDM,271,RC,,,,8378-MAIN,LOCAL,,,,,47,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,22.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.5238,46.06
"PAD CHAIR SENSOR 10x15"" 106380",120.124,CDM,271,RC,,,,8378-MAIN,LOCAL,,,,,47,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,22.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.5238,46.06
"Protein S, Free - Ref",PX8530690,CDM,300,RC,85306,CPT,90,,,,,,,47,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,22.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.05,46.06
"Protein S, Free - Ref",PX8530690,CDM,300,RC,85306,CPT,90,,,,,,,47,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,22.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.05,46.06
REDUCER 12 - 8MM,27200000,CDM,272,RC,,,,11961-MAIN,LOCAL,,,,,47,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,22.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
REDUCER 12 - 8MM,27200000,CDM,272,RC,,,,11961-MAIN,LOCAL,,,,,47,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,22.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
pindolol 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,29033002801,NDC,1,EA,24.77,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,22.56547,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011801,NDC,0.5,ML,52.63,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,22.57827,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011805,NDC,0.5,ML,52.63,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,22.57827,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
amoxicillin-clavulanate 875-125 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862050301,NDC,1,EA,26.59,,First Health,Commercial,both,85,,999999999,percent of total billed charges,22.6015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zolpidem 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079072401,NDC,1,EA,24.81,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,22.60191,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zolpidem 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079072420,NDC,1,EA,24.81,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,22.60191,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015901,NDC,0.3,ML,45.69,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,22.61655,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015925,NDC,0.3,ML,45.69,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,22.61655,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
rosuvastatin 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16714098801,NDC,1,EA,46.18,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.6282,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16714098801,NDC,1,EA,46.18,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.6282,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16714098801,NDC,1,EA,46.18,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,22.6282,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE CR 10 MG Tablet ER 12 hour Abuse-Deterrent 20 Each Box,63700001,CDM,250,RC,,,,,,59011041020,NDC,1,EA,26.63,,First Health,Commercial,both,85,,999999999,percent of total billed charges,22.6355,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066501,NDC,0.25,ML,45.74,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,22.6413,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.000396,47.2262
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048557,NDC,50,ML,52.78,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,22.64262,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ACUSNARE POLYPECTOMY SNARE,27200000,CDM,272,RC,,,,7733-MAIN,LOCAL,,,,,45.75,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,22.64625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
temporary tooth filling repair Misc 1 Each Package,25000000,CDM,250,RC,,,,,,47701000123,NDC,1,EA,25.46,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,22.6594,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048203,NDC,20,ML,44.8,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.6688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048227,NDC,20,ML,44.8,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.6688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
buPROPion XL 150 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,70436001004,NDC,1,EA,23.14,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,22.6772,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PACK BASIN BASIC SINGLE DYNJ06610A,27200000,CDM,272,RC,,,,10921-MAIN,LOCAL,,,,,25.48,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,22.6772,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ivermectin 3 MG Tablet 20 Each Box,63700001,CDM,250,RC,,,,,,42799080601,NDC,1,EA,26.68,,First Health,Commercial,both,85,,999999999,percent of total billed charges,22.678,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046417,NDC,10,ML,54.6,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,22.68084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
eplerenone 25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16729029315,NDC,1,EA,23.31,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,22.687623,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,781323294,NDC,1,EA,52.89,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,22.68981,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
Canalith Repositioning,PX95992,CDM,420,RC,95992,CPT,,,,,,,,128,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,22.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.69,73.88
Canalith Repositioning,PX95992,CDM,420,RC,95992,CPT,,,,,,,,128,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,22.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.69,73.88
Canalith Repositioning,PX95992,CDM,420,RC,95992,CPT,,,,,,,,128,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,22.69,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.69,73.88
Drain/Inject Medium Joint/Bursa,PX20605F,CDM,510,RC,20605,CPT,,,,,,,,247,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,22.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.47,114.84
Drain/Inject Medium Joint/Bursa,PX20605F,CDM,510,RC,20605,CPT,,,,,,,,247,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,22.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.47,114.84
Drain/Inject Medium Joint/Bursa,PX20605P,CDM,983,RC,20605,CPT,,,,,,,,318,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,22.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.47,311.64
Drain/Inject Medium Joint/Bursa,PX20605P,CDM,983,RC,20605,CPT,,,,,,,,318,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,22.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.47,311.64
"Remv F.B.,Eye,Embed Conjunc",PX65210F,CDM,510,RC,65210,CPT,,,,,,,,325,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,22.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.69,78.87
"Remv F.B.,Eye,Embed Conjunc",PX65210F,CDM,510,RC,65210,CPT,,,,,,,,325,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,22.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.69,78.87
"Remv F.B.,Eye,Embed Conjunc",PX65210F,CDM,510,RC,65210,CPT,,,,,,,,325,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,22.69,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.69,78.87
"Remv F.B.,Eye,Embed Conjunc",PX65210P,CDM,983,RC,65210,CPT,,,,,,,,216,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,22.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.69,211.68
"Remv F.B.,Eye,Embed Conjunc",PX65210P,CDM,983,RC,65210,CPT,,,,,,,,216,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,22.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.69,211.68
"Remv F.B.,Eye,Embed Conjunc",PX65210P,CDM,983,RC,65210,CPT,,,,,,,,216,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,22.69,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.69,211.68
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409492120,NDC,10,ML,54.66,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,22.705764,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
fluticasone-salmeterol 250-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,54032756,NDC,1,EA,45.88,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,22.7106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ezetimibe 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714081301,NDC,1,EA,44.91,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.72446,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine HCl 4 % Cream 133 g Tube,63700001,CDM,250,RC,,,,,,41167005828,NDC,133,GR,52.99,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,22.73271,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzoin Tincture 59 mL Bottle,25000000,CDM,250,RC,,,,,,49348080130,NDC,59,ML,45.93,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,22.73535,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Dystrophic Nail Trimming Any Number,PXG0127F,CDM,940,RC,G0127,HCPCS,,,,,,,,53,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,22.737,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.0162,53.44
Renin - Ref,PX8424490,CDM,300,RC,84244,CPT,90,,,,,,,53,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,22.737,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.16,51.94
montelukast 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268057511,NDC,1,EA,26.75,,First Health,Commercial,both,85,,999999999,percent of total billed charges,22.7375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
montelukast 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268057515,NDC,1,EA,26.75,,First Health,Commercial,both,85,,999999999,percent of total billed charges,22.7375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 1 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,45802043803,NDC,28,GR,25.55,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,22.7395,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338067104,NDC,1000,ML,53.06,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,22.76274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
Cardiac Rehab,PX93797F,CDM,943,RC,93797,CPT,,,,,,,,45,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,115.44
CATHETER TEMP-SENSING 8FR LUBRISIL PEDS DYND110508,120.363,CDM,272,RC,A4340,HCPCS,,12777-MAIN,LOCAL,,,,,45,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
CATHETER TEMP-SENSING 12FR LUBRISIL 119212M,120.363,CDM,272,RC,A4340,HCPCS,,10750-MAIN,LOCAL,,,,,45,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
CATHETER TEMP-SENSING 14FR LUBRISIL 119214M,120.363,CDM,272,RC,A4340,HCPCS,,10751-MAIN,LOCAL,,,,,45,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
CATHETER TEMP-SENSING 16FR LUBRISIL 119216M,120.363,CDM,272,RC,A4340,HCPCS,,10752-MAIN,LOCAL,,,,,45,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
Cryptococcus Neoformans,PX87327,CDM,300,RC,87327,CPT,,,,,,,,45,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.3,44.1
DERMABOND ADVANCED TOPICAL SKIN ADHESIVE,120.198,CDM,272,RC,,,,9101-MAIN,LOCAL,,,,,46,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,22.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.1084,45.08
Gammaglobulin; Ige - Ref,PX8278590,CDM,300,RC,82785,CPT,90,,,,,,,45,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.09,44.1
GASTRONOMY FEEDING TUBE MIC BALLOONED 20FR 7-10ML 0112-20,27200000,CDM,272,RC,B4087,HCPCS,,13098-MAIN,LOCAL,,,,,45,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRES 1.6MM,27200000,CDM,272,RC,C1769,HCPCS,,11852-MAIN,LOCAL,,,,,45,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"La Crosse, Antibody - Ref",PX8665190,CDM,300,RC,86651,CPT,90,,,,,,,45,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.09,44.1
MELGISORB AG SILVER CALCIUM STERILE 6X6,120.502,CDM,272,RC,A6197,HCPCS,,11844-MAIN,LOCAL,,,,,45,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
Pinworm Exam,PX87172,CDM,300,RC,87172,CPT,,,,,,,,46,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,22.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,45.08
"St Louis, Antibody - Ref",PX8665390,CDM,300,RC,86653,CPT,90,,,,,,,45,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.09,44.1
"Sugars, Qual, Ea Spec - Ref",PX8437690,CDM,300,RC,84376,CPT,90,,,,,,,45,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.04,44.1
"Venipuncture by Physician, Other Vein, Under Age 3 Years",PX36406,CDM,983,RC,36406,CPT,,,,,,,,45,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,43.7985
"Western Equine, Ab - Ref",PX8665490,CDM,300,RC,86654,CPT,90,,,,,,,45,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.09,44.1
Carcinoembryonic Antigen,PX82378,CDM,300,RC,82378,CPT,,,,,,,,25,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,22.775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
"Gput, Quant",PX8277590,CDM,300,RC,82775,CPT,90,,,,,,,25,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,22.775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
MEPILEX ADH FOAM 4X10,120.63,CDM,272,RC,A6196,HCPCS,,8710-MAIN,LOCAL,,,,,25,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,22.775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
MEPILEX SOFT SILICONE 6X6,120.63,CDM,272,RC,A6196,HCPCS,,5577-MAIN,LOCAL,,,,,25,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,22.775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
OPTIFOAM GENTLE SA SILICCONE FACED FOAM & BOARDER,120.63,CDM,272,RC,A6196,HCPCS,,3938-MAIN,LOCAL,,,,,25,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,22.775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
Phase III Recovery Monthly,PX93799.01,CDM,943,RC,,,,,,,,,,25,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,22.775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
"Testosterone,Free - Ref",PX8440290,CDM,300,RC,84402,CPT,90,,,,,,,25,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,22.775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,76282066339,NDC,100,GR,26.8,,First Health,Commercial,both,85,,999999999,percent of total billed charges,22.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
hydroxychloroquine 200 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16571068701,NDC,1,EA,23.41,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,22.784953,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cemiplimab-rwlc 350 MG/7ML Solution 7 mL Vial,J9119.01,CDM,636,RC,J9119,HCPCS,,,,61755000801,NDC,7,ML,19219.32,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,22.79,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.79,28.83
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010301,NDC,0.3,ML,45.04,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.79024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
amoxicillin 125 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,143988815,NDC,150,ML,25.84,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,22.79088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 125 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,781603955,NDC,150,ML,25.84,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,22.79088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clopidogrel 75 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629461,NDC,1,EA,23.42,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,22.794686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Insert Simple Cath Foley,PX51702F,CDM,510,RC,51702,CPT,,,,,,,,198,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,22.7981,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.27,129.37
Insert Straight Catheter,PX51701F,CDM,510,RC,51701,CPT,,,,,,,,168,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,22.7981,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.27,92.7
rivastigmine 1.5 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,62332006360,NDC,1,EA,25.03,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,22.80233,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
promethazine 25 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802075930,NDC,0.5,EA,47.54,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,22.8192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
promethazine 25 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802075930,NDC,0.5,EA,47.54,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,22.8192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
celecoxib 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904650261,NDC,1,EA,23.45,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,22.823885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
promethazine 25 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,45802075900,NDC,0.5,EA,47.55,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,22.824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
promethazine 25 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,45802075900,NDC,0.5,EA,47.55,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,22.824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Neg Pressure Wound Therapy Dme </=50 Sq Cm,PX97605F,CDM,510,RC,97605,CPT,,,,,,,,396,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,22.8265,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.3,56.67
Strapping of Toes,PX29550F,CDM,510,RC,29550,CPT,,,,,,,,113,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,22.83,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.76,40.12
ibuprofen 100 MG/5ML Suspension 118 mL Bottle,63700001,CDM,250,RC,,,,,,45802089726,NDC,118,ML,54.97,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,22.834538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Wheelchair Mngement Training,PX97542,CDM,420,RC,97542,CPT,,,,,,,,145,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,22.84,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.84,41.73
lopinavir-ritonavir 200-50 MG Tablet 120 Each Bottle,63700001,CDM,250,RC,,,,,,74679922,NDC,1,EA,54.99,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,22.842846,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
eplerenone 25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16729029315,NDC,1,EA,23.31,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,22.8438,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Endocrine E2,PX82670,CDM,300,RC,82670,CPT,90,,,,,,,55,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,22.847,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,53.9
"Immunofluo Direct, Ea Ab - Ref",PX8834690,CDM,310,RC,88346,CPT,90,,,,,,,55,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,22.847,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,149.22
Lipoprotein (a) - Ref,PX8369590,CDM,300,RC,83695,CPT,90,,,,,,,55,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,22.847,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.13,53.9
MEPILEX BORDER AG POST OP 4X10,120.368,CDM,272,RC,A6212,HCPCS,,10839-MAIN,LOCAL,,,,,55,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,22.847,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,53.9
SURGIFOAM ABSORBABLE GELATIN SPONGE 3.1 IN X 4.9IN X 10MM,120.371,CDM,272,RC,A4649,HCPCS,,10864-MAIN,LOCAL,,,,,55,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,22.847,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,53.9
Xray Toe(S) Tc,PX7366001,CDM,320,RC,73660,CPT,TC,,,,,,,282,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,22.8478,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.05,45.36
fluvastatin 20 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,378802093,NDC,1,EA,26.88,,First Health,Commercial,both,85,,999999999,percent of total billed charges,22.848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SCISSORS ENDOSCOPIC 5MM STANDARD STERILE,27200000,CDM,272,RC,,,,11706-MAIN,LOCAL,,,,,47.6,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,22.848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SCISSORS ENDOSCOPIC 5MM STANDARD STERILE,27200000,CDM,272,RC,,,,11706-MAIN,LOCAL,,,,,47.6,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,22.848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
levoFLOXacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635261,NDC,0.5,EA,45.16,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.85096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dabigatran 75 MG capsule 60 Each Box,63700001,CDM,250,RC,,,,,,597035556,NDC,1,EA,53.27,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,22.85283,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16714098801,NDC,1,EA,46.18,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,22.8591,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Islet Cell Antibody - Ref,PX8634190,CDM,300,RC,86341,CPT,90,,,,,,,146,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,22.86,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.86,23.57
Islet Cell Antibody - Ref,PX8634190,CDM,300,RC,86341,CPT,90,,,,,,,146,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,22.86,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.86,23.57
Islet Cell Antibody - Ref,PX8634190,CDM,300,RC,86341,CPT,90,,,,,,,146,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,22.86,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.86,23.57
methylPREDNISolone sod succ 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,63323025803,NDC,0.4,EA,46.67,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.8683,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
methylPREDNISolone sod succ 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,63323025803,NDC,0.4,EA,46.67,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.8683,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
methylPREDNISolone sod succ 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,63323025803,NDC,0.4,EA,46.67,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,22.8683,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
glucose 40 % Gel 37.5 g Package,63700001,CDM,250,RC,,,,,,574006930,NDC,37.5,GR,25.12,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,22.88432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glucose 40 % Gel 37.5 g Tube,63700001,CDM,250,RC,,,,,,574006915,NDC,37.5,GR,25.12,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,22.88432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Cpap/Bipap Mgmnt-Pt Own Equipment,PX94660.02F,CDM,410,RC,94660,CPT,,,,,,,,497,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,22.9,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.9,112.85
Declot Vascular Access Device,PX36593F,CDM,510,RC,36593,CPT,,,,,,,,358,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,22.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.6,71.95
Declot Vascular Access Device,PX36593F,CDM,510,RC,36593,CPT,,,,,,,,358,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,22.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.6,71.95
"Inject Trigger Point, 1 or 2",PX20552F,CDM,510,RC,20552,CPT,,,,,,,,252,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,22.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.9,109.3
"Inject Trigger Point, 1 or 2",PX20552F,CDM,510,RC,20552,CPT,,,,,,,,252,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,22.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.9,109.3
"Inject Trigger Point, 1 or 2",PX20552F,CDM,510,RC,20552,CPT,,,,,,,,252,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,22.9,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.9,109.3
"Inject Trigger Point, 1 or 2",PX20552P,CDM,983,RC,20552,CPT,,,,,,,,210,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,22.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.9,205.8
"Inject Trigger Point, 1 or 2",PX20552P,CDM,983,RC,20552,CPT,,,,,,,,210,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,22.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.9,205.8
"Inject Trigger Point, 1 or 2",PX20552P,CDM,983,RC,20552,CPT,,,,,,,,210,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,22.9,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.9,205.8
"POS Airway Pressure, Bipap",PX94660.01F,CDM,410,RC,94660,CPT,,,,,,,,468,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,22.9,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.9,112.85
"POS Airway Pressure, Cpap",PX94660F,CDM,410,RC,94660,CPT,,,,,,,,498,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,22.9,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.9,112.85
X-Ray Abdomen 2+ Views W/ Single Vw Chest (Tc),PX7402201,CDM,320,RC,74022,CPT,TC,,,,,,,334,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,22.9,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.9,69.03
Xray Facial Bones Minimum 3 Vws,PX7015001,CDM,320,RC,70150,CPT,TC,,,,,,,551,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,22.9,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.9,69.03
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028442,NDC,1,EA,47.71,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,22.9008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028442,NDC,1,EA,47.71,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,22.9008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714000601,NDC,0.3,ML,53.39,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,22.90431,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
SAW BLADE 300 SAGITTAL 25X9.4X0.7,27200000,CDM,272,RC,,,,11592-MAIN,LOCAL,,,,,46.75,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.9075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SAW BLADE 300 SAGITTAL 25X9.4X0.7,27200000,CDM,272,RC,,,,11592-MAIN,LOCAL,,,,,46.75,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.9075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SAW BLADE 300 SAGITTAL 25X9.4X0.7,27200000,CDM,272,RC,,,,11592-MAIN,LOCAL,,,,,46.75,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,22.9075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SAW BLADE 300 SAGITTAL 40X14X0.6MM,27200000,CDM,272,RC,,,,11591-MAIN,LOCAL,,,,,46.75,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.9075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SAW BLADE 300 SAGITTAL 40X14X0.6MM,27200000,CDM,272,RC,,,,11591-MAIN,LOCAL,,,,,46.75,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,22.9075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SAW BLADE 300 SAGITTAL 40X14X0.6MM,27200000,CDM,272,RC,,,,11591-MAIN,LOCAL,,,,,46.75,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,22.9075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,67457022800,NDC,5,ML,53.42,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,22.91718,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,67457057305,NDC,5,ML,53.42,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,22.91718,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fluconazole 100 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069101,NDC,0.5,EA,23.55,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,22.921215,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 5 % Patch 30 Each Box,63700001,CDM,250,RC,,,,,,603188016,NDC,1,EA,55.18,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,22.921772,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omalizumab 150 MG Recon Soln 1 Each Vial,J2357.01,CDM,636,RC,J2357,HCPCS,,,,50242004062,NDC,1,EA,2212.7,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,22.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.18,39.46
omalizumab 150 MG Recon Soln 1 Each Vial,J2357.01,CDM,636,RC,J2357,HCPCS,,,,50242004062,NDC,1,EA,2212.7,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,22.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.18,39.46
lidocaine 5 % Patch 1 Each Box,63700001,CDM,250,RC,,,,,,603188010,NDC,1,EA,55.2,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,22.93008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SPIT SOCK HOODS 16719,120.367,CDM,271,RC,,,,10820-MAIN,LOCAL,,,,,26,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,22.932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.8004,25.48
TEGADERM CHLORHEXIDINE 5X5 CHG IV PORT,120.207,CDM,272,RC,A6268,HCPCS,,10163-MAIN,LOCAL,,,,,26,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,22.932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.8004,25.48
Blood Clot Factor VIII Test,PX85247,CDM,300,RC,85247,CPT,,,,,,,,169,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,22.94,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.25,22.94
hydroxychloroquine 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292001101,NDC,1,EA,23.57,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,22.940681,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydroxychloroquine 200 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16571068701,NDC,1,EA,23.41,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,22.9418,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BOOT CAST LARGE 12-5/8 ORT290010L,120.247,CDM,274,RC,L3260,HCPCS,,204-MAIN,LOCAL,,,,,27,,First Health,Commercial,both,85,,999999999,percent of total billed charges,22.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
BOOT CAST MEDIUM 08148803,120.247,CDM,274,RC,L3260,HCPCS,,203-MAIN,LOCAL,,,,,27,,First Health,Commercial,both,85,,999999999,percent of total billed charges,22.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
BOOT CAST X-LARGE 13X5-1/2IN ORT29200XL,120.247,CDM,274,RC,L3260,HCPCS,,206-MAIN,LOCAL,,,,,27,,First Health,Commercial,both,85,,999999999,percent of total billed charges,22.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
KERRAMAX CARE SUPERABSORBENT DRESSING 8X12,120.55,CDM,272,RC,A6197,HCPCS,,12363-MAIN,LOCAL,,,,,27,,First Health,Commercial,both,85,,999999999,percent of total billed charges,22.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
Neuromuscular Re-Education,PX97112,CDM,420,RC,97112,CPT,,,,,,,,135,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,22.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.95,215.05
Or Time,PX36000086,CDM,360,RC,,,,,,,,,,27,,First Health,Commercial,both,85,,999999999,percent of total billed charges,22.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
"Sodium, Other Source - Ref",PX8430290,CDM,300,RC,84302,CPT,90,,,,,,,27,,First Health,Commercial,both,85,,999999999,percent of total billed charges,22.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.46,26.46
clopidogrel 75 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629461,NDC,1,EA,23.42,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,22.9516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
El-1 Fecal Quantitative,PX8265390,CDM,300,RC,82653,CPT,90,,,,,,,383,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,22.97,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.46,22.97
Hospital Outpatient Clinic Visit Specimen Collection for Sars-Cov-2,PXC9803,CDM,300,RC,C9803,HCPCS,,,,,,,,33,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,22.98,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.36088,22.98
Hospital Outpatient Clinic Visit Specimen Collection for Sars-Cov-2,PXC9803,CDM,300,RC,C9803,HCPCS,,,,,,,,33,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,22.98,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.36088,22.98
celecoxib 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904650261,NDC,1,EA,23.45,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,22.981,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polyvinyl alcohol 1.4 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,50268067815,NDC,15,ML,45.42,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,22.98252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 25 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,71101268,NDC,1,EA,55.33,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,22.984082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 125 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,143988815,NDC,150,ML,25.84,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,22.9976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 125 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,781603955,NDC,150,ML,25.84,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,22.9976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Hiv-1 Antigens W/Hiv 1/2 Antib,PX87389,CDM,300,RC,87389,CPT,,,,,,,,194,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,23,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23,24.08
Hiv-1 Antigens W/Hiv 1/2 Antib,PX87389,CDM,300,RC,87389,CPT,,,,,,,,194,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,23,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23,24.08
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188602,NDC,5,ML,45.46,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,23.00276,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.884084,44.5508
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188622,NDC,5,ML,45.46,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,23.00276,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.884084,44.5508
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030926,NDC,1,EA,55.44,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,23.029776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
Blood Count Reticulocytes Auto 1/> Cell Meas,PX85046,CDM,300,RC,85046,CPT,,,,,,,,47,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,23.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.11,46.06
Blood Count Reticulocytes Auto 1/> Cell Meas,PX85046,CDM,300,RC,85046,CPT,,,,,,,,47,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,23.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.11,46.06
Blood Count Reticulocytes Auto 1/> Cell Meas,PX85046,CDM,300,RC,85046,CPT,,,,,,,,47,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,23.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.11,46.06
"PAD BED SENSOR 10X28"" P-107517",120.124,CDM,271,RC,,,,8377-MAIN,LOCAL,,,,,47,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,23.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.5238,46.06
"PAD BED SENSOR 10X28"" P-107517",120.124,CDM,271,RC,,,,8377-MAIN,LOCAL,,,,,47,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,23.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.5238,46.06
"PAD BED SENSOR 10X28"" P-107517",120.124,CDM,271,RC,,,,8377-MAIN,LOCAL,,,,,47,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,23.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.5238,46.06
"PAD CHAIR SENSOR 10x15"" 106380",120.124,CDM,271,RC,,,,8378-MAIN,LOCAL,,,,,47,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,23.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.5238,46.06
"PAD CHAIR SENSOR 10x15"" 106380",120.124,CDM,271,RC,,,,8378-MAIN,LOCAL,,,,,47,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,23.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.5238,46.06
"PAD CHAIR SENSOR 10x15"" 106380",120.124,CDM,271,RC,,,,8378-MAIN,LOCAL,,,,,47,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,23.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.5238,46.06
"Protein S, Free - Ref",PX8530690,CDM,300,RC,85306,CPT,90,,,,,,,47,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,23.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.05,46.06
"Protein S, Free - Ref",PX8530690,CDM,300,RC,85306,CPT,90,,,,,,,47,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,23.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.05,46.06
"Protein S, Free - Ref",PX8530690,CDM,300,RC,85306,CPT,90,,,,,,,47,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,23.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.05,46.06
REDUCER 12 - 8MM,27200000,CDM,272,RC,,,,11961-MAIN,LOCAL,,,,,47,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,23.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
REDUCER 12 - 8MM,27200000,CDM,272,RC,,,,11961-MAIN,LOCAL,,,,,47,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,23.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
REDUCER 12 - 8MM,27200000,CDM,272,RC,,,,11961-MAIN,LOCAL,,,,,47,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,23.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Admin Hep B,Adult 19+",PX3242,CDM,771,RC,90471,CPT,,,,,,,,48,,Health Partners,Health Partners Care Plans,both,48,,73.38285714,percent of total billed charges,23.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,61.54
"Admin Hep B,Adult 19+",PX3242,CDM,771,RC,90471,CPT,,,,,,,,48,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,23.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,61.54
Amphetamines; 3 or 4,PX8032590,CDM,300,RC,80325,CPT,90,,,,,,,48,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,23.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,47.04
Amphetamines; 3 or 4,PX8032590,CDM,300,RC,80325,CPT,90,,,,,,,48,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,23.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,47.04
Immunization Admin - Influenza,PX3241,CDM,771,RC,90471,CPT,,,,,,,,48,,Health Partners,Health Partners Care Plans,both,48,,73.38285714,percent of total billed charges,23.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,61.54
Immunization Admin - Influenza,PX3241,CDM,771,RC,90471,CPT,,,,,,,,48,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,23.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,61.54
Immunization Administration; Each Add'l Vaccine (Single or Combo Vaccine/T*,PX90472,CDM,771,RC,90472,CPT,,,,,,,,48,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,23.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,47.04
Immunization Administration; Each Add'l Vaccine (Single or Combo Vaccine/T*,PX90472,CDM,771,RC,90472,CPT,,,,,,,,48,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,23.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,47.04
fluconazole 100 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069101,NDC,0.5,EA,23.55,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,23.079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydroxychloroquine 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292001101,NDC,1,EA,23.57,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,23.0986,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone sod succ 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,63323025803,NDC,0.4,EA,46.67,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,23.10165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
Islet Cell Antibody - Ref,PX8634190,CDM,300,RC,86341,CPT,90,,,,,,,146,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,23.1048,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.86,23.57
nafcillin 2 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,S0032,HCPCS,,,,63323032820,NDC,1,EA,185.37,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,23.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.38,37.648
nafcillin 2 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,S0032,HCPCS,,,,63323032820,NDC,1,EA,185.37,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,23.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.38,37.648
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015901,NDC,0.3,ML,45.69,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,23.11914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015925,NDC,0.3,ML,45.69,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,23.11914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
Chem Cautery Granulatn Tissue,PX17250F,CDM,510,RC,17250,CPT,,,,,,,,170,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,23.12,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.12,181.25
Chem Cautery Granulatn Tissue,PX17250P,CDM,983,RC,17250,CPT,,,,,,,,402,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,23.12,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.12,393.96
Chemo Ad Sq/Im Hormnl Anti-Neo,PX96402,CDM,335,RC,96402,CPT,,,,,,,,130,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,23.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.03,61.66
Chemo Ad Sq/Im Hormnl Anti-Neo,PX96402,CDM,335,RC,96402,CPT,,,,,,,,130,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,23.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.03,61.66
Cpap/Bipap Mgmnt-Pt Own Equipment,PX94660.02F,CDM,410,RC,94660,CPT,,,,,,,,497,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,23.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.9,112.85
Cpap/Bipap Mgmnt-Pt Own Equipment,PX94660.02F,CDM,410,RC,94660,CPT,,,,,,,,497,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,23.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.9,112.85
Flow Cyto Ea Addtl Marker - Ref,PX8818590,CDM,310,RC,88185,CPT,90,,,,,,,165,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,23.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.12,38.816
Flow Cyto Ea Addtl Marker - Ref,PX8818590,CDM,310,RC,88185,CPT,90,,,,,,,165,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,23.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.12,38.816
Flow Cyto Ea Addtl Marker - Ref,PX8818590,CDM,310,RC,88185,CPT,90,,,,,,,165,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,23.12,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.12,38.816
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; Add'l",PX88185,CDM,310,RC,88185,CPT,,,,,,,,96,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,23.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.12,38.816
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; Add'l",PX88185,CDM,310,RC,88185,CPT,,,,,,,,96,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,23.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.12,38.816
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; Add'l",PX88185,CDM,310,RC,88185,CPT,,,,,,,,96,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,23.12,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.12,38.816
"POS Airway Pressure, Bipap",PX94660.01F,CDM,410,RC,94660,CPT,,,,,,,,468,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,23.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.9,112.85
"POS Airway Pressure, Bipap",PX94660.01F,CDM,410,RC,94660,CPT,,,,,,,,468,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,23.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.9,112.85
"POS Airway Pressure, Cpap",PX94660F,CDM,410,RC,94660,CPT,,,,,,,,498,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,23.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.9,112.85
"POS Airway Pressure, Cpap",PX94660F,CDM,410,RC,94660,CPT,,,,,,,,498,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,23.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.9,112.85
X-Ray Abdomen 2+ Views W/ Single Vw Chest (Tc),PX7402201,CDM,320,RC,74022,CPT,TC,,,,,,,334,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,23.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.9,69.03
X-Ray Abdomen 2+ Views W/ Single Vw Chest (Tc),PX7402201,CDM,320,RC,74022,CPT,TC,,,,,,,334,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,23.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.9,69.03
Xray Facial Bones Minimum 3 Vws,PX7015001,CDM,320,RC,70150,CPT,TC,,,,,,,551,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,23.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.9,69.03
Xray Facial Bones Minimum 3 Vws,PX7015001,CDM,320,RC,70150,CPT,TC,,,,,,,551,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,23.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.9,69.03
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066500,NDC,0.25,ML,48.19,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,23.1312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.000396,47.2262
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066500,NDC,0.25,ML,48.19,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,23.1312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.000396,47.2262
Acetaminophen 167 MG/5ML Liquid 237 mL Bottle,63700001,CDM,250,RC,,,,,,904584709,NDC,237,ML,27.22,,First Health,Commercial,both,85,,999999999,percent of total billed charges,23.137,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SPIT SOCK HOODS 16719,120.367,CDM,271,RC,,,,10820-MAIN,LOCAL,,,,,26,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,23.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.8004,25.48
TEGADERM CHLORHEXIDINE 5X5 CHG IV PORT,120.207,CDM,272,RC,A6268,HCPCS,,10163-MAIN,LOCAL,,,,,26,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,23.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.8004,25.48
SAW BLADE 300 SAGITTAL 25X9.4X0.7,27200000,CDM,272,RC,,,,11592-MAIN,LOCAL,,,,,46.75,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,23.14125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SAW BLADE 300 SAGITTAL 40X14X0.6MM,27200000,CDM,272,RC,,,,11591-MAIN,LOCAL,,,,,46.75,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,23.14125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066501,NDC,0.25,ML,45.74,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,23.14444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.000396,47.2262
ACUSNARE POLYPECTOMY SNARE,27200000,CDM,272,RC,,,,7733-MAIN,LOCAL,,,,,45.75,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,23.1495,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Catecholamines, Fraction - Ref",PX8238490,CDM,300,RC,82384,CPT,90,,,,,,,145,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,23.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.15,142.1
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405F,CDM,510,RC,36405,CPT,,,,,,,,54,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,23.166,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.4316,52.92
X-Ray Exam Chest 2 Views,PX7104601,CDM,320,RC,71046,CPT,TC,,,,,,,556,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,23.1696,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.27,46.02
Xray Thoracic Spine 2 Vws,PX7207001,CDM,320,RC,72070,CPT,TC,,,,,,,428,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,23.1696,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.27,46.02
dexmedeTOMIDine 200 MCG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,70860060541,NDC,2,ML,55.82,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,23.187628,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 4-5 MG/ML-% Solution 500 mL Flex Cont,J2001.01,CDM,636,RC,J2001,HCPCS,,,,338040903,NDC,500,ML,55.82,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,23.187628,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
temporary tooth filling repair Misc 1 Each Package,25000000,CDM,250,RC,,,,,,47701000123,NDC,1,EA,25.46,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,23.19406,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,25021010720,NDC,1,EA,48.35,,Health Partners,Health Partners Care Plans,both,48,,26.64321429,percent of total billed charges,23.208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,25021010720,NDC,1,EA,48.35,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,23.208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
PACK BASIN BASIC SINGLE DYNJ06610A,27200000,CDM,272,RC,,,,10921-MAIN,LOCAL,,,,,25.48,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,23.21228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
apixaban 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,3089431,NDC,0.5,EA,23.85,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,23.213205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone-salmeterol 250-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,54032756,NDC,1,EA,45.88,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,23.21528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Inf Ag Detect by Nucleic Acid (Dna or Rna); (Sars-Cov-2,PXU0005,CDM,300,RC,U0005,HCPCS,,,,,,,,0.01,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,23.22674,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.22674,25
benzoin Tincture 59 mL Bottle,25000000,CDM,250,RC,,,,,,49348080130,NDC,59,ML,45.93,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,23.24058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
8MM-12MM BLADELESS OBTURATOR 8MM,27200000,CDM,272,RC,,,,11919-MAIN,LOCAL,,,,,56,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,23.2624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM-12MM BLADELESS OBTURATOR 8MM LONG,27200000,CDM,272,RC,,,,11920-MAIN,LOCAL,,,,,56,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,23.2624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"B Cells, Total Count",PX86355,CDM,300,RC,86355,CPT,,,,,,,,56,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,23.2624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.2624,54.88
Citrate - Ref,PX8250790,CDM,300,RC,82507,CPT,90,,,,,,,56,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,23.2624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.2624,54.88
"Folic Acid (Folate), Serum",PX82746,CDM,300,RC,82746,CPT,,,,,,,,56,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,23.2624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.48,54.88
Lab Platelet Count,PX85049,CDM,300,RC,85049,CPT,,,,,,,,56,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,23.2624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.11,54.88
Mycophenolate Mycophenolicacid - Ref,PX8018090,CDM,300,RC,80180,CPT,90,,,,,,,56,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,23.2624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.55,54.88
Progesterone,PX84144,CDM,300,RC,84144,CPT,,,,,,,,56,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,23.2624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.13,54.88
Blood Count Reticulocytes Auto 1/> Cell Meas,PX85046,CDM,300,RC,85046,CPT,,,,,,,,47,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,23.265,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.11,46.06
"PAD BED SENSOR 10X28"" P-107517",120.124,CDM,271,RC,,,,8377-MAIN,LOCAL,,,,,47,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,23.265,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.5238,46.06
"PAD CHAIR SENSOR 10x15"" 106380",120.124,CDM,271,RC,,,,8378-MAIN,LOCAL,,,,,47,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,23.265,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.5238,46.06
"Protein S, Free - Ref",PX8530690,CDM,300,RC,85306,CPT,90,,,,,,,47,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,23.265,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.05,46.06
REDUCER 12 - 8MM,27200000,CDM,272,RC,,,,11961-MAIN,LOCAL,,,,,47,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,23.265,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Cardiac Rehab II Eval,PX93798.05,CDM,943,RC,93798,CPT,,,,,,,,364,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,23.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.29,44.79
Cardiac Rehab II W/ Monitor,PX93798.02,CDM,943,RC,93798,CPT,,,,,,,,338,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,23.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.29,44.79
DERMABOND ADVANCED TOPICAL SKIN ADHESIVE,120.198,CDM,272,RC,,,,9101-MAIN,LOCAL,,,,,46,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,23.276,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.1084,45.08
Pinworm Exam,PX87172,CDM,300,RC,87172,CPT,,,,,,,,46,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,23.276,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,45.08
hydrocortisone 1 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,45802043803,NDC,28,GR,25.55,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,23.27605,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,310075430,NDC,1,EA,56.04,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,23.279016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079034801,NDC,1,EA,27.39,,First Health,Commercial,both,85,,999999999,percent of total billed charges,23.2815,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079034820,NDC,1,EA,27.39,,First Health,Commercial,both,85,,999999999,percent of total billed charges,23.2815,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
promethazine 25 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802075930,NDC,0.5,EA,47.54,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,23.2946,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
promethazine 25 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802075930,NDC,0.5,EA,47.54,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,23.2946,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
promethazine 25 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802075930,NDC,0.5,EA,47.54,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,23.2946,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,409469930,NDC,20,ML,48.54,,Health Partners,Health Partners Care Plans,both,48,,1.259785714,percent of total billed charges,23.2992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,409469930,NDC,20,ML,48.54,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,23.2992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
promethazine 25 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,45802075900,NDC,0.5,EA,47.55,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,23.2995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
promethazine 25 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,45802075900,NDC,0.5,EA,47.55,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,23.2995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
promethazine 25 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,45802075900,NDC,0.5,EA,47.55,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,23.2995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cefdinir 300 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,67877054360,NDC,1,EA,27.42,,First Health,Commercial,both,85,,999999999,percent of total billed charges,23.307,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cholestyramine light 4 g Packet 42 Each Box,63700001,CDM,250,RC,,,,,,245003642,NDC,1,EA,27.42,,First Health,Commercial,both,85,,999999999,percent of total billed charges,23.307,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cholestyramine light 4 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,245003689,NDC,1,EA,27.44,,First Health,Commercial,both,85,,999999999,percent of total billed charges,23.324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SCISSORS ENDOSCOPIC 5MM STANDARD STERILE,27200000,CDM,272,RC,,,,11706-MAIN,LOCAL,,,,,47.6,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,23.324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SCISSORS ENDOSCOPIC 5MM STANDARD STERILE,27200000,CDM,272,RC,,,,11706-MAIN,LOCAL,,,,,47.6,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,23.324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SCISSORS ENDOSCOPIC 5MM STANDARD STERILE,27200000,CDM,272,RC,,,,11706-MAIN,LOCAL,,,,,47.6,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,23.324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RBC Antibody Elution,PX86860,CDM,300,RC,86860,CPT,,,,,,,,360,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,23.33,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.33,23.33
lidocaine (preservative free) 4 % Solution 5 mL Ampule,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409428325,NDC,5,ML,48.62,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,23.3376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
lidocaine (preservative free) 4 % Solution 5 mL Ampule,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409428325,NDC,5,ML,48.62,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,23.3376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
"Beta 2 Glycoprot 1 Ab,Ea - Ref",PX8614690,CDM,300,RC,86146,CPT,90,,,,,,,52,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,23.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.6008,50.96
"Cardiac Stress Tst,Tracing Only",PX93017,CDM,482,RC,93017,CPT,,,,,,,,1959,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,23.34,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.34,65.73
"Cardiolipin Ab, Ea Lg - Ref",PX8614790,CDM,300,RC,86147,CPT,90,,,,,,,133,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,23.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.34,130.34
cefdinir 300 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,16714039102,NDC,1,EA,27.46,,First Health,Commercial,both,85,,999999999,percent of total billed charges,23.341,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019600,NDC,1,ML,48.64,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,23.3472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019600,NDC,1,ML,48.64,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,23.3472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
"Testosterone,Free - Ref",PX8440290,CDM,300,RC,84402,CPT,90,,,,,,,25,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,23.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,36000000924,NDC,200,ML,48.65,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,23.352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.20921,64.9544
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,36000000924,NDC,200,ML,48.65,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,23.352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.20921,64.9544
SLEEVE BALLOON 5MMX100MML KII STERILE CFS02,27200000,CDM,272,RC,,,,11704-MAIN,LOCAL,,,,,24,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,23.3592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STRAP CLAVICLE LARGE VP10123-040,120.191,CDM,274,RC,L3670,HCPCS,,12848-MAIN,LOCAL,,,,,24,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,23.3592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE MEDIUM VP10123-030,120.191,CDM,274,RC,L3670,HCPCS,,12847-MAIN,LOCAL,,,,,24,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,23.3592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE SMALL VP10123-020,120.191,CDM,274,RC,L3670,HCPCS,,12846-MAIN,LOCAL,,,,,24,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,23.3592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE XL 661 XL,120.191,CDM,274,RC,L3670,HCPCS,,12850-MAIN,LOCAL,,,,,24,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,23.3592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE XSMALL CHILD ORT14100XS,120.191,CDM,274,RC,L3670,HCPCS,,12849-MAIN,LOCAL,,,,,24,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,23.3592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
Hiv-1 Antigens W/Hiv 1/2 Antib,PX87389,CDM,300,RC,87389,CPT,,,,,,,,194,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,23.36,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23,24.08
rosuvastatin 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16714098801,NDC,1,EA,46.18,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,23.36708,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Column Chrom Ms, Quant - Ref",PX8254290,CDM,300,RC,82542,CPT,90,,,,,,,557,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,23.37,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.37,24.09
"Column Chrom Ms, Quant - Ref",PX8254290,CDM,300,RC,82542,CPT,90,,,,,,,557,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,23.37,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.37,24.09
"Column Chrom Ms, Quant - Ref",PX8254290,CDM,300,RC,82542,CPT,90,,,,,,,557,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,23.37,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.37,24.09
apixaban 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,3089431,NDC,0.5,EA,23.85,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,23.373,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028442,NDC,1,EA,47.71,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,12.3175,percent of total billed charges,23.3779,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028442,NDC,1,EA,47.71,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,23.3779,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028442,NDC,1,EA,47.71,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,23.3779,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vinCRIStine 1 MG/ML Solution 2 mL Vial,J9370.01,CDM,636,RC,J9370,HCPCS,,,,61703030916,NDC,2,ML,48.72,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,23.3856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.238288,47.7456
vinCRIStine 1 MG/ML Solution 2 mL Vial,J9370.01,CDM,636,RC,J9370,HCPCS,,,,61703030916,NDC,2,ML,48.72,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,23.3856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.238288,47.7456
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141035,NDC,2,ML,56.37,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,23.416098,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,65219044501,NDC,10,ML,56.37,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,23.416098,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,65219044510,NDC,10,ML,56.37,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,23.416098,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046417,NDC,10,ML,54.6,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,23.4234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
Flow Cyto Ea Addtl Marker - Ref,PX8818590,CDM,310,RC,88185,CPT,90,,,,,,,165,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,23.4257,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.12,38.816
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; Add'l",PX88185,CDM,310,RC,88185,CPT,,,,,,,,96,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,23.4257,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.12,38.816
Apply of Paste Boot,PX29580F,CDM,510,RC,29580,CPT,,,,,,,,132,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,23.4403,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,132.83
Apply of Paste Boot,PX29580P,CDM,983,RC,29580,CPT,,,,,,,,88,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,23.4403,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,132.83
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105F,CDM,510,RC,11105,CPT,,,,,,,,171,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,23.4403,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,123.83
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105P,CDM,983,RC,11105,CPT,,,,,,,,171,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,23.4403,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,167.58
chlorhexidine 4 % Solution 118 mL Bottle,25000000,CDM,250,RC,,,,,,234057504,NDC,118,ML,24.09,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,23.446797,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409492120,NDC,10,ML,54.66,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,23.44914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
amoxicillin-clavulanate 875-125 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862050301,NDC,1,EA,26.59,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,23.45238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,990771512,NDC,62.5,ML,56.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,23.4701,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.4701,303.0944
aluminum & magnesium hydroxide-simethicone 200-200-20 MG/5ML Suspension 30 mL Cup,63700001,CDM,250,RC,,,,,,121176130,NDC,30,ML,24.12,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,23.475996,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE CR 10 MG Tablet ER 12 hour Abuse-Deterrent 20 Each Box,63700001,CDM,250,RC,,,,,,59011041020,NDC,1,EA,26.63,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,23.48766,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Breast Tomosynthesis,Screen Tc",PX7706301,CDM,403,RC,77063,CPT,TC,,,,,,,166,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,23.4914,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,47.33
Xray Hand 2vws Tc,PX7312001,CDM,320,RC,73120,CPT,TC,,,,,,,365,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,23.4914,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.27,46.68
mepolizumab 100 MG Recon Soln 1 Each Vial,J2182.01,CDM,636,RC,J2182,HCPCS,,,,173088101,NDC,1,EA,6959.95,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,23.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.51,6820.751
"Admin Hep B,Adult 19+",PX3242,CDM,771,RC,90471,CPT,,,,,,,,48,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,88.75,percent of total billed charges,23.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,61.54
"Admin Hep B,Adult 19+",PX3242,CDM,771,RC,90471,CPT,,,,,,,,48,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,23.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,61.54
"Admin Hep B,Adult 19+",PX3242,CDM,771,RC,90471,CPT,,,,,,,,48,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,23.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,61.54
Amphetamines; 3 or 4,PX8032590,CDM,300,RC,80325,CPT,90,,,,,,,48,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,23.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,47.04
Amphetamines; 3 or 4,PX8032590,CDM,300,RC,80325,CPT,90,,,,,,,48,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,23.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,47.04
Amphetamines; 3 or 4,PX8032590,CDM,300,RC,80325,CPT,90,,,,,,,48,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,23.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,47.04
Beta-2-Microglobulin - Ref,PX8223290,CDM,300,RC,82232,CPT,90,,,,,,,49,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,23.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.84,48.02
Beta-2-Microglobulin - Ref,PX8223290,CDM,300,RC,82232,CPT,90,,,,,,,49,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,23.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.84,48.02
"Cannabinoids, Natural - Ref",PX8034990,CDM,300,RC,80349,CPT,90,,,,,,,49,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,23.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,48.02
"Cannabinoids, Natural - Ref",PX8034990,CDM,300,RC,80349,CPT,90,,,,,,,49,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,23.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,48.02
cefTAZidime 1 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023525,NDC,1,EA,49,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,23.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
cefTAZidime 1 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023525,NDC,1,EA,49,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,23.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
COLLAR CERVICAL X-LARGE WITH TRACH 2 PIECE OSG2404,120.185,CDM,274,RC,L0172,HCPCS,,10143-MAIN,LOCAL,,,,,49,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,23.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,152.79
COLLAR CERVICAL X-LARGE WITH TRACH 2 PIECE OSG2404,120.185,CDM,274,RC,L0172,HCPCS,,10143-MAIN,LOCAL,,,,,49,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,23.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,152.79
Glycated Protein - Ref,PX8298590,CDM,300,RC,82985,CPT,90,,,,,,,49,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,23.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.37,48.02
Glycated Protein - Ref,PX8298590,CDM,300,RC,82985,CPT,90,,,,,,,49,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,23.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.37,48.02
Immunization Admin - Influenza,PX3241,CDM,771,RC,90471,CPT,,,,,,,,48,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,88.75,percent of total billed charges,23.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,61.54
Immunization Admin - Influenza,PX3241,CDM,771,RC,90471,CPT,,,,,,,,48,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,23.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,61.54
Immunization Admin - Influenza,PX3241,CDM,771,RC,90471,CPT,,,,,,,,48,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,23.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,61.54
Immunization Administration; Each Add'l Vaccine (Single or Combo Vaccine/T*,PX90472,CDM,771,RC,90472,CPT,,,,,,,,48,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,23.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,47.04
Immunization Administration; Each Add'l Vaccine (Single or Combo Vaccine/T*,PX90472,CDM,771,RC,90472,CPT,,,,,,,,48,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,23.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,47.04
Immunization Administration; Each Add'l Vaccine (Single or Combo Vaccine/T*,PX90472,CDM,771,RC,90472,CPT,,,,,,,,48,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,23.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,47.04
SLEEVE BALLOON 5MMX100MML KII STERILE CFS02,27200000,CDM,272,RC,,,,11704-MAIN,LOCAL,,,,,24,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,23.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STRAP CLAVICLE LARGE VP10123-040,120.191,CDM,274,RC,L3670,HCPCS,,12848-MAIN,LOCAL,,,,,24,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,23.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE MEDIUM VP10123-030,120.191,CDM,274,RC,L3670,HCPCS,,12847-MAIN,LOCAL,,,,,24,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,23.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE SMALL VP10123-020,120.191,CDM,274,RC,L3670,HCPCS,,12846-MAIN,LOCAL,,,,,24,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,23.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE XL 661 XL,120.191,CDM,274,RC,L3670,HCPCS,,12850-MAIN,LOCAL,,,,,24,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,23.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE XSMALL CHILD ORT14100XS,120.191,CDM,274,RC,L3670,HCPCS,,12849-MAIN,LOCAL,,,,,24,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,23.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
"SUTURE V-LOC SZ 0 180 GREEN GS21 NEEDLE 18"" VLOCL0326",27200000,CDM,272,RC,,,,12218-MAIN,LOCAL,,,,,49,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,23.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"SUTURE V-LOC SZ 0 180 GREEN GS21 NEEDLE 18"" VLOCL0326",27200000,CDM,272,RC,,,,12218-MAIN,LOCAL,,,,,49,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,23.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
US Urine Capacity Measure,PX51798F,CDM,510,RC,51798,CPT,,,,,,,,96,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,23.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.76,23.52
US Urine Capacity Measure,PX51798F,CDM,510,RC,51798,CPT,,,,,,,,96,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,23.52,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.76,23.52
ivermectin 3 MG Tablet 20 Each Box,63700001,CDM,250,RC,,,,,,42799080601,NDC,1,EA,26.68,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,23.53176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
promethazine 25 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802075930,NDC,0.5,EA,47.54,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,23.5323,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
promethazine 25 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,45802075900,NDC,0.5,EA,47.55,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,23.53725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 125 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,143988815,NDC,150,ML,25.84,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,23.54024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 125 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,781603955,NDC,150,ML,25.84,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,23.54024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Wheelchair Mngement Training,PX97542,CDM,420,RC,97542,CPT,,,,,,,,145,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,23.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.84,41.73
Wheelchair Mngement Training,PX97542,CDM,420,RC,97542,CPT,,,,,,,,145,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,23.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.84,41.73
Chem Cautery Granulatn Tissue,PX17250F,CDM,510,RC,17250,CPT,,,,,,,,170,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,23.56,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.12,181.25
Chem Cautery Granulatn Tissue,PX17250F,CDM,510,RC,17250,CPT,,,,,,,,170,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,23.56,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.12,181.25
Chem Cautery Granulatn Tissue,PX17250P,CDM,983,RC,17250,CPT,,,,,,,,402,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,23.56,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.12,393.96
Chem Cautery Granulatn Tissue,PX17250P,CDM,983,RC,17250,CPT,,,,,,,,402,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,23.56,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.12,393.96
Self Care Mngment Training,PX97535,CDM,420,RC,97535,CPT,,,,,,,,135,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,23.56,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.56,43.05
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102F,CDM,510,RC,11102,CPT,,,,,,,,171,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,23.56,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.56,208.92
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102F,CDM,510,RC,11102,CPT,,,,,,,,171,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,23.56,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.56,208.92
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102F,CDM,510,RC,11102,CPT,,,,,,,,171,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,23.56,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.56,208.92
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102P,CDM,983,RC,11102,CPT,,,,,,,,465,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,23.56,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.56,455.7
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102P,CDM,983,RC,11102,CPT,,,,,,,,465,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,23.56,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.56,455.7
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102P,CDM,983,RC,11102,CPT,,,,,,,,465,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,23.56,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.56,455.7
Xray Knee 4 or More Vws,PX7356401,CDM,320,RC,73564,CPT,TC,,,,,,,490,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,23.56,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.56,71.66
SCISSORS ENDOSCOPIC 5MM STANDARD STERILE,27200000,CDM,272,RC,,,,11706-MAIN,LOCAL,,,,,47.6,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,23.562,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
phenylephrine 0.25 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,69536002515,NDC,15,ML,24.21,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,23.563593,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024010,NDC,1,EA,56.73,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,23.565642,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030036,NDC,1,EA,56.73,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,23.565642,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098341,NDC,1,EA,56.73,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,23.565642,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
Islet Cell Antibody - Ref,PX8634190,CDM,300,RC,86341,CPT,90,,,,,,,146,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,23.57,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.86,23.57
ibuprofen 100 MG/5ML Suspension 118 mL Bottle,63700001,CDM,250,RC,,,,,,45802089726,NDC,118,ML,54.97,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,23.58213,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lopinavir-ritonavir 200-50 MG Tablet 120 Each Bottle,63700001,CDM,250,RC,,,,,,74679922,NDC,1,EA,54.99,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,23.59071,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
montelukast 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268057511,NDC,1,EA,26.75,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,23.5935,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
montelukast 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268057515,NDC,1,EA,26.75,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,23.5935,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Endocrine E2,PX82670,CDM,300,RC,82670,CPT,90,,,,,,,55,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,23.595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,53.9
"Immunofluo Direct, Ea Ab - Ref",PX8834690,CDM,310,RC,88346,CPT,90,,,,,,,55,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,23.595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,149.22
Lipoprotein (a) - Ref,PX8369590,CDM,300,RC,83695,CPT,90,,,,,,,55,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,23.595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.13,53.9
MEPILEX BORDER AG POST OP 4X10,120.368,CDM,272,RC,A6212,HCPCS,,10839-MAIN,LOCAL,,,,,55,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,23.595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,53.9
SURGIFOAM ABSORBABLE GELATIN SPONGE 3.1 IN X 4.9IN X 10MM,120.371,CDM,272,RC,A4649,HCPCS,,10864-MAIN,LOCAL,,,,,55,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,23.595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,53.9
chlorhexidine 4 % Solution 118 mL Bottle,25000000,CDM,250,RC,,,,,,234057504,NDC,118,ML,24.09,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,23.6082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066500,NDC,0.25,ML,48.19,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,23.6131,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.000396,47.2262
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066500,NDC,0.25,ML,48.19,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,23.6131,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.000396,47.2262
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066500,NDC,0.25,ML,48.19,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,23.6131,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.000396,47.2262
methylPREDNISolone sod succ 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,63323025803,NDC,0.4,EA,46.67,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,23.61502,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028442,NDC,1,EA,47.71,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,23.61645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
aluminum & magnesium hydroxide-simethicone 200-200-20 MG/5ML Suspension 30 mL Cup,63700001,CDM,250,RC,,,,,,121176130,NDC,30,ML,24.12,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,23.6376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,76282066339,NDC,100,GR,26.8,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,23.6376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
SAW BLADE 300 SAGITTAL 25X9.4X0.7,27200000,CDM,272,RC,,,,11592-MAIN,LOCAL,,,,,46.75,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,23.6555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SAW BLADE 300 SAGITTAL 40X14X0.6MM,27200000,CDM,272,RC,,,,11591-MAIN,LOCAL,,,,,46.75,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,23.6555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"PDS II ENDOLOOP LIGATURE SIZE 0 18""",27200000,CDM,272,RC,,,,11700-MAIN,LOCAL,,,,,56.96,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,23.661184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
amoxicillin-clavulanate 875-125 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862050301,NDC,1,EA,26.59,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,23.6651,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409669501,NDC,10,ML,56.97,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,23.665338,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006111,NDC,0.5,EA,56.98,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,23.669492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.669492,55.8404
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006158,NDC,0.5,EA,56.98,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,23.669492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.669492,55.8404
"Hla a, B or C, Single Ag - Ref",PX8681290,CDM,300,RC,86812,CPT,90,,,,,,,89,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,23.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.67,87.22
"Testosterone, Total - Ref",PX8440390,CDM,300,RC,84403,CPT,90,,,,,,,43,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,23.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.8622,42.14
lidocaine 5 % Patch 30 Each Box,63700001,CDM,250,RC,,,,,,603188016,NDC,1,EA,55.18,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,23.67222,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Albumin, Othr Source - Ref",PX8204290,CDM,300,RC,82042,CPT,90,,,,,,,57,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,23.6778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.13,55.86
"Albumin, Serum - Ref",PX8204090,CDM,300,RC,82040,CPT,90,,,,,,,57,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,23.6778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.54,55.86
Assay Alkaline Phosphatase,PX84075,CDM,300,RC,84075,CPT,,,,,,,,57,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,23.6778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,55.86
Calcium Total,PX82310,CDM,300,RC,82310,CPT,,,,,,,,57,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,23.6778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.73,55.86
Dhea-S - Ref,PX8262790,CDM,300,RC,82627,CPT,90,,,,,,,57,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,23.6778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.38,55.86
Tiss Trnsgltmnase Ea Ig Clas,PX86364,CDM,300,RC,86364,CPT,,,,,,,,57,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,23.6778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.6778,55.86
fluconazole 150 MG Tablet 12 Each Box,63700001,CDM,250,RC,,,,,,16714069211,NDC,0.333333333,EA,24.33,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,23.680389,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 5 % Patch 1 Each Box,63700001,CDM,250,RC,,,,,,603188010,NDC,1,EA,55.2,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,23.6808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SPIT SOCK HOODS 16719,120.367,CDM,271,RC,,,,10820-MAIN,LOCAL,,,,,26,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,23.686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.8004,25.48
TEGADERM CHLORHEXIDINE 5X5 CHG IV PORT,120.207,CDM,272,RC,A6268,HCPCS,,10163-MAIN,LOCAL,,,,,26,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,23.686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.8004,25.48
buprenorphine 2 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,50383092493,NDC,1,EA,24.34,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,23.690122,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.14,40.7288
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,25021010720,NDC,1,EA,48.35,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,9.983703704,percent of total billed charges,23.6915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,25021010720,NDC,1,EA,48.35,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,23.6915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,25021010720,NDC,1,EA,48.35,,United Healthcare,All Medicare advantage plans,outpatient,49,,3.9675,percent of total billed charges,23.6915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
oxyCODONE CR 10 MG Tablet ER 12 hour Abuse-Deterrent 20 Each Box,63700001,CDM,250,RC,,,,,,59011041020,NDC,1,EA,26.63,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,23.7007,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluvastatin 20 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,378802093,NDC,1,EA,26.88,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,23.70816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
entacapone 200 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,27241004910,NDC,1,EA,24.37,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,23.719321,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Group Therapeutic Procedures,PX97150,CDM,420,RC,97150,CPT,,,,,,,,67,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,23.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.5,23.72
Group Therapeutic Procedures,PX97150,CDM,420,RC,97150,CPT,,,,,,,,67,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,23.72,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.5,23.72
phenylephrine 0.25 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,69536002515,NDC,15,ML,24.21,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,23.7258,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 25 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,71101268,NDC,1,EA,55.33,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,23.73657,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ivermectin 3 MG Tablet 20 Each Box,63700001,CDM,250,RC,,,,,,42799080601,NDC,1,EA,26.68,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,23.7452,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Column Chrom Ms, Quant - Ref",PX8254290,CDM,300,RC,82542,CPT,90,,,,,,,557,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,23.7466,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.37,24.09
Hiv-1 Antigens W/Hiv 1/2 Antib,PX87389,CDM,300,RC,87389,CPT,,,,,,,,194,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,23.7466,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23,24.08
cemiplimab-rwlc 350 MG/7ML Solution 7 mL Vial,J9119.01,CDM,636,RC,J9119,HCPCS,,,,61755000801,NDC,7,ML,19219.32,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,23.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.75,18834.9336
"Admin Hep B,Adult 19+",PX3242,CDM,771,RC,90471,CPT,,,,,,,,48,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,23.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,61.54
Amphetamines; 3 or 4,PX8032590,CDM,300,RC,80325,CPT,90,,,,,,,48,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,23.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,47.04
Immunization Admin - Influenza,PX3241,CDM,771,RC,90471,CPT,,,,,,,,48,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,23.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,61.54
Immunization Administration; Each Add'l Vaccine (Single or Combo Vaccine/T*,PX90472,CDM,771,RC,90472,CPT,,,,,,,,48,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,23.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,47.04
"Chest Wall Manipulation,Subsequent",PX94668F,CDM,410,RC,94668,CPT,,,,,,,,192,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,23.78,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.78,68.64
Inj Tendon/Ligament/Cyst,PX20550F,CDM,510,RC,20550,CPT,,,,,,,,177,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,23.78,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.78,120.37
Inj Tendon/Ligament/Cyst,PX20550P,CDM,983,RC,20550,CPT,,,,,,,,264,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,23.78,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.78,258.72
Inj Tendon/Ligament/Cyst,PX20550F,CDM,510,RC,20550,CPT,,,,,,,,177,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,23.78,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.78,120.37
Inj Tendon/Ligament/Cyst,PX20550F,CDM,510,RC,20550,CPT,,,,,,,,177,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,23.78,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.78,120.37
Inj Tendon/Ligament/Cyst,PX20550P,CDM,983,RC,20550,CPT,,,,,,,,264,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,23.78,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.78,258.72
Inj Tendon/Ligament/Cyst,PX20550P,CDM,983,RC,20550,CPT,,,,,,,,264,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,23.78,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.78,258.72
Blood Count Reticulocytes Auto 1/> Cell Meas,PX85046,CDM,300,RC,85046,CPT,,,,,,,,47,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,23.782,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.11,46.06
"PAD BED SENSOR 10X28"" P-107517",120.124,CDM,271,RC,,,,8377-MAIN,LOCAL,,,,,47,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,23.782,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.5238,46.06
"PAD CHAIR SENSOR 10x15"" 106380",120.124,CDM,271,RC,,,,8378-MAIN,LOCAL,,,,,47,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,23.782,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.5238,46.06
"Protein S, Free - Ref",PX8530690,CDM,300,RC,85306,CPT,90,,,,,,,47,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,23.782,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.05,46.06
REDUCER 12 - 8MM,27200000,CDM,272,RC,,,,11961-MAIN,LOCAL,,,,,47,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,23.782,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030926,NDC,1,EA,55.44,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,23.78376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,409469930,NDC,20,ML,48.54,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.619455696,percent of total billed charges,23.7846,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,409469930,NDC,20,ML,48.54,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,23.7846,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,409469930,NDC,20,ML,48.54,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,23.7846,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
"Albumin; Other Source, Quantitative, Each Specimen",PX82042,CDM,300,RC,82042,CPT,,,,,,,,28,,First Health,Commercial,both,85,,999999999,percent of total billed charges,23.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.13,27.44
Anesthesia Level - Regional,PX37000025,CDM,370,RC,,,,,,,,,,28,,First Health,Commercial,both,85,,999999999,percent of total billed charges,23.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
Gonadotropin (Lh),PX83002,CDM,300,RC,83002,CPT,,,,,,,,28,,First Health,Commercial,both,85,,999999999,percent of total billed charges,23.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
PROMOGRAN PRISMA AG COLLAGEN DRESSING 28CM,120.547,CDM,272,RC,A6021,HCPCS,,12361-MAIN,LOCAL,,,,,28,,First Health,Commercial,both,85,,999999999,percent of total billed charges,23.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
SCOPE BRONCHOSCOPE SZ 4 STERILE DISPOSABLE B120044,120.574,CDM,272,RC,,,,12868-MAIN,LOCAL,,,,,28,,First Health,Commercial,both,85,,999999999,percent of total billed charges,23.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
tranexamic acid 650 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,69918030130,NDC,1,EA,28,,First Health,Commercial,both,85,,999999999,percent of total billed charges,23.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Viral Neutralization - Ref,PX8638290,CDM,300,RC,86382,CPT,90,,,,,,,28,,First Health,Commercial,both,85,,999999999,percent of total billed charges,23.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
natalizumab 300 MG/15ML Concentrate 15 mL Vial,J2323.01,CDM,636,RC,J2323,HCPCS,,,,64406000801,NDC,15,ML,15226.53,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,23.8058,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.52,24.45
montelukast 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268057511,NDC,1,EA,26.75,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,23.8075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
montelukast 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268057515,NDC,1,EA,26.75,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,23.8075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"X-Ray Exam Hip,Unilat W/Pelvis 1vw",PX7350101,CDM,320,RC,73501,CPT,TC,,,,,,,263,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,23.8132,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,47.33
Xray Sinuses Less Than 3 Vws,PX7021001,CDM,320,RC,70210,CPT,TC,,,,,,,486,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,23.8132,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,47.33
Xray Tibia & Fibula 2 Vws,PX7359001,CDM,320,RC,73590,CPT,TC,,,,,,,365,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,23.8132,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,47.33
BOOT CAST LARGE 12-5/8 ORT290010L,120.247,CDM,274,RC,L3260,HCPCS,,204-MAIN,LOCAL,,,,,27,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,23.814,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
BOOT CAST MEDIUM 08148803,120.247,CDM,274,RC,L3260,HCPCS,,203-MAIN,LOCAL,,,,,27,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,23.814,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
BOOT CAST X-LARGE 13X5-1/2IN ORT29200XL,120.247,CDM,274,RC,L3260,HCPCS,,206-MAIN,LOCAL,,,,,27,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,23.814,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
KERRAMAX CARE SUPERABSORBENT DRESSING 8X12,120.55,CDM,272,RC,A6197,HCPCS,,12363-MAIN,LOCAL,,,,,27,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,23.814,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
Or Time,PX36000086,CDM,360,RC,,,,,,,,,,27,,United Healthcare,All Payer,outpatient,88.2,,999999999,case rate,23.814,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.814,6141.46
"Sodium, Other Source - Ref",PX8430290,CDM,300,RC,84302,CPT,90,,,,,,,27,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,23.814,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.46,26.46
"Drug(S) or Substance(S), Definitive, Qualitative or Quantitative, Not Otherwise Specified; 1-3 - Ref",PX8037590,CDM,300,RC,80375,CPT,90,,,,,,,150,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,23.82,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.82,23.82
lidocaine (preservative free) 4 % Solution 5 mL Ampule,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409428325,NDC,5,ML,48.62,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,23.8238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
lidocaine (preservative free) 4 % Solution 5 mL Ampule,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409428325,NDC,5,ML,48.62,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,23.8238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
lidocaine (preservative free) 4 % Solution 5 mL Ampule,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409428325,NDC,5,ML,48.62,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,23.8238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019600,NDC,1,ML,48.64,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,23.8336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019600,NDC,1,ML,48.64,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,23.8336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019600,NDC,1,ML,48.64,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,23.8336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,36000000924,NDC,200,ML,48.65,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,23.8385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.20921,64.9544
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,36000000924,NDC,200,ML,48.65,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,23.8385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.20921,64.9544
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,36000000924,NDC,200,ML,48.65,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,23.8385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.20921,64.9544
fluconazole 150 MG Tablet 12 Each Box,63700001,CDM,250,RC,,,,,,16714069211,NDC,0.333333333,EA,24.33,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,23.8434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,76282066339,NDC,100,GR,26.8,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,23.852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
buprenorphine 2 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,50383092493,NDC,1,EA,24.34,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,23.8532,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.14,40.7288
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066500,NDC,0.25,ML,48.19,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,23.85405,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.000396,47.2262
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,548590000,NDC,1,EA,470.19,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,23.86,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.86,28.59
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,781344071,NDC,1,EA,430.94,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,23.86,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.86,28.59
vinCRIStine 1 MG/ML Solution 2 mL Vial,J9370.01,CDM,636,RC,J9370,HCPCS,,,,61703030916,NDC,2,ML,48.72,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,23.8728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.238288,47.7456
vinCRIStine 1 MG/ML Solution 2 mL Vial,J9370.01,CDM,636,RC,J9370,HCPCS,,,,61703030916,NDC,2,ML,48.72,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,23.8728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.238288,47.7456
vinCRIStine 1 MG/ML Solution 2 mL Vial,J9370.01,CDM,636,RC,J9370,HCPCS,,,,61703030916,NDC,2,ML,48.72,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,23.8728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.238288,47.7456
entacapone 200 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,27241004910,NDC,1,EA,24.37,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,23.8826,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Blood Gases: Ph, Po2 & Pco2",PX82803,CDM,300,RC,82803,CPT,,,,,,,,518,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,23.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.9,507.64
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093107,NDC,1,ML,57.59,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,23.922886,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
fluvastatin 20 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,378802093,NDC,1,EA,26.88,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,23.9232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"lidocaine 2% -EPINEPHRine 1:200,000 2 %-1:200000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409318301,NDC,20,ML,49.86,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,23.9328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 2% -EPINEPHRine 1:200,000 2 %-1:200000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409318301,NDC,20,ML,49.86,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,23.9328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,25021010720,NDC,1,EA,48.35,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,23.93325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,72603012801,NDC,1,EA,57.64,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,23.943656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
dexmedeTOMIDine 200 MCG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,70860060541,NDC,2,ML,55.82,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,23.94678,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 4-5 MG/ML-% Solution 500 mL Flex Cont,J2001.01,CDM,636,RC,J2001,HCPCS,,,,338040903,NDC,500,ML,55.82,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,23.94678,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
potassium chloride 20 MEQ Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,245036089,NDC,1,EA,57.67,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,23.956118,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,93681545,NDC,2,ML,57.71,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,23.972734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,93681573,NDC,2,ML,57.71,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,23.972734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048503,NDC,50,ML,57.74,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,23.985196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665305,NDC,20,ML,49.97,,Health Partners,Health Partners Care Plans,both,48,,6.034333333,percent of total billed charges,23.9856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665305,NDC,20,ML,49.97,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,23.9856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"X-Ray Exam Hip,Unilat W/Pelvis 2-3 Vws",PX7350201,CDM,320,RC,73502,CPT,TC,,,,,,,436,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,23.99,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.99,72.97
ERBEFLO CLEVERCAP CO2 TUBING CAP SET,27200000,CDM,272,RC,,,,11831-MAIN,LOCAL,,,,,50,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ERBEFLO CLEVERCAP CO2 TUBING CAP SET,27200000,CDM,272,RC,,,,11831-MAIN,LOCAL,,,,,50,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
G6pd; Quant Screen - Ref,PX8295590,CDM,300,RC,82955,CPT,90,,,,,,,50,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.89,49
G6pd; Quant Screen - Ref,PX8295590,CDM,300,RC,82955,CPT,90,,,,,,,50,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.89,49
"Homogenization, Tissue for Culture",PX87176,CDM,300,RC,87176,CPT,,,,,,,,50,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.39,49
"Homogenization, Tissue for Culture",PX87176,CDM,300,RC,87176,CPT,,,,,,,,50,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.39,49
"NEEDLE ASP 16GX3/16"" 1-7/8"" ILLINOIS STERNAL 8881245164",120.8,CDM,272,RC,G0364,HCPCS,,5730-MAIN,LOCAL,,,,,50,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,49
"NEEDLE ASP 16GX3/16"" 1-7/8"" ILLINOIS STERNAL 8881245164",120.8,CDM,272,RC,G0364,HCPCS,,5730-MAIN,LOCAL,,,,,50,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,49
"NEEDLE BONE MARROW 8G X 4"" BIOPSY/ASPIRATION 8881247087",120.8,CDM,272,RC,G0364,HCPCS,,166-MAIN,LOCAL,,,,,50,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,49
"NEEDLE BONE MARROW 8G X 4"" BIOPSY/ASPIRATION 8881247087",120.8,CDM,272,RC,G0364,HCPCS,,166-MAIN,LOCAL,,,,,50,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,49
"NEEDLE BONE MARROW 11G X 4"" 8881247111",120.8,CDM,272,RC,G0364,HCPCS,,162-MAIN,LOCAL,,,,,50,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,49
"NEEDLE BONE MARROW 11G X 4"" 8881247111",120.8,CDM,272,RC,G0364,HCPCS,,162-MAIN,LOCAL,,,,,50,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,49
Potassium; Urine,PX84133,CDM,300,RC,84133,CPT,,,,,,,,50,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.34,49
Potassium; Urine,PX84133,CDM,300,RC,84133,CPT,,,,,,,,50,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.34,49
Acetaminophen 167 MG/5ML Liquid 237 mL Bottle,63700001,CDM,250,RC,,,,,,904584709,NDC,237,ML,27.22,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,24.00804,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Beta-2-Microglobulin - Ref,PX8223290,CDM,300,RC,82232,CPT,90,,,,,,,49,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.84,48.02
Beta-2-Microglobulin - Ref,PX8223290,CDM,300,RC,82232,CPT,90,,,,,,,49,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.84,48.02
Beta-2-Microglobulin - Ref,PX8223290,CDM,300,RC,82232,CPT,90,,,,,,,49,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,24.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.84,48.02
"Cannabinoids, Natural - Ref",PX8034990,CDM,300,RC,80349,CPT,90,,,,,,,49,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,48.02
"Cannabinoids, Natural - Ref",PX8034990,CDM,300,RC,80349,CPT,90,,,,,,,49,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,48.02
"Cannabinoids, Natural - Ref",PX8034990,CDM,300,RC,80349,CPT,90,,,,,,,49,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,24.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,48.02
cefTAZidime 1 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023525,NDC,1,EA,49,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
cefTAZidime 1 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023525,NDC,1,EA,49,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
cefTAZidime 1 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023525,NDC,1,EA,49,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,24.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
COLLAR CERVICAL X-LARGE WITH TRACH 2 PIECE OSG2404,120.185,CDM,274,RC,L0172,HCPCS,,10143-MAIN,LOCAL,,,,,49,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,7.4,percent of total billed charges,24.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,152.79
COLLAR CERVICAL X-LARGE WITH TRACH 2 PIECE OSG2404,120.185,CDM,274,RC,L0172,HCPCS,,10143-MAIN,LOCAL,,,,,49,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,152.79
COLLAR CERVICAL X-LARGE WITH TRACH 2 PIECE OSG2404,120.185,CDM,274,RC,L0172,HCPCS,,10143-MAIN,LOCAL,,,,,49,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,24.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,152.79
Glycated Protein - Ref,PX8298590,CDM,300,RC,82985,CPT,90,,,,,,,49,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.37,48.02
Glycated Protein - Ref,PX8298590,CDM,300,RC,82985,CPT,90,,,,,,,49,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.37,48.02
Glycated Protein - Ref,PX8298590,CDM,300,RC,82985,CPT,90,,,,,,,49,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,24.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.37,48.02
"SUTURE V-LOC SZ 0 180 GREEN GS21 NEEDLE 18"" VLOCL0326",27200000,CDM,272,RC,,,,12218-MAIN,LOCAL,,,,,49,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"SUTURE V-LOC SZ 0 180 GREEN GS21 NEEDLE 18"" VLOCL0326",27200000,CDM,272,RC,,,,12218-MAIN,LOCAL,,,,,49,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"SUTURE V-LOC SZ 0 180 GREEN GS21 NEEDLE 18"" VLOCL0326",27200000,CDM,272,RC,,,,12218-MAIN,LOCAL,,,,,49,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,24.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
tuberculin 5 UNIT/0.1ML Solution 1 mL Vial,25000000,CDM,250,RC,,,,,,42023010401,NDC,0.1,ML,57.82,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.018428,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
8MM-12MM BLADELESS OBTURATOR 8MM,27200000,CDM,272,RC,,,,11919-MAIN,LOCAL,,,,,56,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,24.024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM-12MM BLADELESS OBTURATOR 8MM LONG,27200000,CDM,272,RC,,,,11920-MAIN,LOCAL,,,,,56,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,24.024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"B Cells, Total Count",PX86355,CDM,300,RC,86355,CPT,,,,,,,,56,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,24.024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.2624,54.88
Citrate - Ref,PX8250790,CDM,300,RC,82507,CPT,90,,,,,,,56,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,24.024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.2624,54.88
"Folic Acid (Folate), Serum",PX82746,CDM,300,RC,82746,CPT,,,,,,,,56,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,24.024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.48,54.88
Lab Platelet Count,PX85049,CDM,300,RC,85049,CPT,,,,,,,,56,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,24.024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.11,54.88
Mycophenolate Mycophenolicacid - Ref,PX8018090,CDM,300,RC,80180,CPT,90,,,,,,,56,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,24.024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.55,54.88
Progesterone,PX84144,CDM,300,RC,84144,CPT,,,,,,,,56,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,24.024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.13,54.88
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,409469930,NDC,20,ML,48.54,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,24.0273,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
BOOT CAST LARGE 12-5/8 ORT290010L,120.247,CDM,274,RC,L3260,HCPCS,,204-MAIN,LOCAL,,,,,27,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,24.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
BOOT CAST MEDIUM 08148803,120.247,CDM,274,RC,L3260,HCPCS,,203-MAIN,LOCAL,,,,,27,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,24.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
BOOT CAST X-LARGE 13X5-1/2IN ORT29200XL,120.247,CDM,274,RC,L3260,HCPCS,,206-MAIN,LOCAL,,,,,27,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,24.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
KERRAMAX CARE SUPERABSORBENT DRESSING 8X12,120.55,CDM,272,RC,A6197,HCPCS,,12363-MAIN,LOCAL,,,,,27,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,24.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
Or Time,PX36000086,CDM,360,RC,,,,,,,,,,27,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,24.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
"Sodium, Other Source - Ref",PX8430290,CDM,300,RC,84302,CPT,90,,,,,,,27,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,24.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.46,26.46
simethicone 40 MG/0.6ML Suspension 30 mL Bottle,25000000,CDM,250,RC,,,,,,70677107801,NDC,30,ML,24.69,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,24.030777,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665318,NDC,20,ML,50.08,,Health Partners,Health Partners Care Plans,both,48,,6.034333333,percent of total billed charges,24.0384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665318,NDC,20,ML,50.08,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,24.0384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
sterile water (preservative free) Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323018520,NDC,20,ML,50.08,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,24.0384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323018520,NDC,20,ML,50.08,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,24.0384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
rosuvastatin 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,310075430,NDC,1,EA,56.04,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,24.04116,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
promethazine 25 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802075930,NDC,0.5,EA,47.54,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,24.05524,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
promethazine 25 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,45802075900,NDC,0.5,EA,47.55,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,24.0603,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine (preservative free) 4 % Solution 5 mL Ampule,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409428325,NDC,5,ML,48.62,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,24.0669,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
artificial tears Ointment 3.5 g Tube,63700001,CDM,250,RC,,,,,,10119002239,NDC,3.5,GR,50.14,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,24.0672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
artificial tears Ointment 3.5 g Tube,63700001,CDM,250,RC,,,,,,10119002239,NDC,3.5,GR,50.14,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,24.0672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019600,NDC,1,ML,48.64,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,24.0768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
Hiv-1 Antigens W/Hiv 1/2 Antib,PX87389,CDM,300,RC,87389,CPT,,,,,,,,194,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,24.08,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23,24.08
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,36000000924,NDC,200,ML,48.65,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,24.08175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.20921,64.9544
SCISSORS ENDOSCOPIC 5MM STANDARD STERILE,27200000,CDM,272,RC,,,,11706-MAIN,LOCAL,,,,,47.6,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,24.0856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Column Chrom Ms, Quant - Ref",PX8254290,CDM,300,RC,82542,CPT,90,,,,,,,557,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,24.09,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.37,24.09
"Albumin, Blood",PX82040,CDM,300,RC,82040,CPT,90,,,,,,,58,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.0932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.54,56.84
Assay of creatinine,PX82565,CDM,300,RC,82565,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.0932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.69,56.84
Assay of Urea Nitrogen,PX84520,CDM,300,RC,84520,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.0932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.62,56.84
"Assay, Glucose, Blood Quant",PX82947,CDM,300,RC,82947,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.0932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.6,56.84
Automated Leukocyte Count,PX85048,CDM,300,RC,85048,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.0932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.33,56.84
DEFIBRILLATION PAD BIPHASIC ADULT,120.96,CDM,271,RC,A0392,HCPCS,,1321-MAIN,LOCAL,,,,,58,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.0932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.0932,56.84
"Ebv, Nuclear Antigen - Ref",PX8666490,CDM,300,RC,86664,CPT,90,,,,,,,58,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.0932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.02,56.84
"Ebv, Viral Capsid Ab - Ref",PX8666590,CDM,300,RC,86665,CPT,90,,,,,,,58,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.0932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.63,56.84
Hematocrit,PX85014,CDM,300,RC,85014,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.0932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.17,56.84
"Long Term Holter, 48 Hrs Up to 7 Days, Recording",PX93242,CDM,731,RC,93242,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.0932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.0932,56.84
"Long Term Holter, More Than 7 Days Up to 15 Days, Recording",PX93246,CDM,731,RC,93246,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.0932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.0932,56.84
"Sodium; Serum, Plasma or Whole Blood",PX84295,CDM,300,RC,84295,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.0932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.41,56.84
SUTURE V-LOC SZ 1 PBT WOUND CLOSURE DEVICE BLUE 18 IN GS 21 NEEDLE VLOCN0327,27200000,CDM,272,RC,,,,12828-MAIN,LOCAL,,,,,58,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.0932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Transferase; Alanine Amino (Alt) (Sgpt),PX84460,CDM,300,RC,84460,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.0932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.86,56.84
Transferase; Aspartate Amino (Ast) (Sgot),PX84450,CDM,300,RC,84450,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.0932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,56.84
pindolol 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,29033002801,NDC,1,EA,24.77,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,24.108641,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vinCRIStine 1 MG/ML Solution 2 mL Vial,J9370.01,CDM,636,RC,J9370,HCPCS,,,,61703030916,NDC,2,ML,48.72,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,24.1164,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.238288,47.7456
lidocaine 5 % Patch 1 Each Box,63700001,CDM,250,RC,,,,,,591352511,NDC,1,EA,50.26,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,24.1248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 5 % Patch 1 Each Box,63700001,CDM,250,RC,,,,,,591352511,NDC,1,EA,50.26,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,24.1248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 5 % Patch 30 Each Box,63700001,CDM,250,RC,,,,,,591352530,NDC,1,EA,50.26,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,24.1248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 5 % Patch 30 Each Box,63700001,CDM,250,RC,,,,,,591352530,NDC,1,EA,50.26,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,24.1248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
TEGADERM CHLORHEXIDINE-GLUCONATE,120.356,CDM,272,RC,A4221,HCPCS,,10708-MAIN,LOCAL,,,,,22,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,24.1275,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.1275,26.29
"US Guide, Vascular Access",PX7693701,CDM,402,RC,76937,CPT,TC,,,,,,,760,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,24.135,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.36,48.65
Xray Eye Foreign Body,PX7003001,CDM,320,RC,70030,CPT,TC,,,,,,,432,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,24.135,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,47.99
Xray Humerus Minimum 2 Vws,PX7306001,CDM,320,RC,73060,CPT,TC,,,,,,,365,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,24.135,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,47.99
Xray Sacrum/ Coccyx Minimum 2 Vws,PX7222001,CDM,320,RC,72220,CPT,TC,,,,,,,540,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,24.135,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,47.99
Xray Sternum 2vws Tc,PX7112001,CDM,320,RC,71120,CPT,TC,,,,,,,365,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,24.135,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,47.99
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028442,NDC,1,EA,47.71,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,24.14126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
zolpidem 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079072401,NDC,1,EA,24.81,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,24.147573,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zolpidem 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079072420,NDC,1,EA,24.81,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,24.147573,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079034801,NDC,1,EA,27.39,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,24.15798,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079034820,NDC,1,EA,27.39,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,24.15798,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141035,NDC,2,ML,56.37,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,24.18273,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,65219044501,NDC,10,ML,56.37,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,24.18273,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,65219044510,NDC,10,ML,56.37,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,24.18273,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
cefdinir 300 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,67877054360,NDC,1,EA,27.42,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,24.18444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cholestyramine light 4 g Packet 42 Each Box,63700001,CDM,250,RC,,,,,,245003642,NDC,1,EA,27.42,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,24.18444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
simethicone 40 MG/0.6ML Suspension 30 mL Bottle,25000000,CDM,250,RC,,,,,,70677107801,NDC,30,ML,24.69,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,24.1962,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
cholestyramine light 4 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,245003689,NDC,1,EA,27.44,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,24.20208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"IV Push, Single/1st Drug",PX96374,CDM,260,RC,96374,CPT,,,,,,,,259,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,24.21,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.21,63.99
Naso/Orogastric Tube,PX43752F,CDM,510,RC,43752,CPT,,,,,,,,464,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,24.21,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.21,81.63
Naso/Orogastric Tube,PX43752F,CDM,510,RC,43752,CPT,,,,,,,,464,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,24.21,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.21,81.63
Naso/Orogastric Tube,PX43752P,CDM,983,RC,43752,CPT,,,,,,,,309,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,24.21,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.21,302.82
Naso/Orogastric Tube,PX43752P,CDM,983,RC,43752,CPT,,,,,,,,309,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,24.21,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.21,302.82
Xray Knee 4 or More Vws,PX7356401,CDM,320,RC,73564,CPT,TC,,,,,,,490,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,24.21,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.56,71.66
Xray Knee 4 or More Vws,PX7356401,CDM,320,RC,73564,CPT,TC,,,,,,,490,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,24.21,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.56,71.66
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,641601501,NDC,25,ML,58.29,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.213666,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
cefdinir 300 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,16714039102,NDC,1,EA,27.46,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,24.21972,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
carfilzomib 30 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010201,NDC,1,EA,2785.91,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,24.22,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.22,49.44
carfilzomib 60 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010101,NDC,1,EA,5571.82,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,24.22,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.22,49.44
natalizumab 300 MG/15ML Concentrate 15 mL Vial,J2323.01,CDM,636,RC,J2323,HCPCS,,,,64406000801,NDC,15,ML,15226.53,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,24.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.52,24.45
natalizumab 300 MG/15ML Concentrate 15 mL Vial,J2323.01,CDM,636,RC,J2323,HCPCS,,,,64406000801,NDC,15,ML,15226.53,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,24.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.52,24.45
amoxicillin-clavulanate 875-125 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862050301,NDC,1,EA,26.59,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,24.22349,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Acetaminophen 167 MG/5ML Liquid 237 mL Bottle,63700001,CDM,250,RC,,,,,,904584709,NDC,237,ML,27.22,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,24.2258,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117630,NDC,1,ML,58.34,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.234436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,990771512,NDC,62.5,ML,56.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,24.2385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.4701,303.0944
PACLitaxel 30 MG/5ML Concentrate 5 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476401,NDC,5,ML,58.37,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.246898,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
Beta-2-Microglobulin - Ref,PX8223290,CDM,300,RC,82232,CPT,90,,,,,,,49,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,24.255,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.84,48.02
"Cannabinoids, Natural - Ref",PX8034990,CDM,300,RC,80349,CPT,90,,,,,,,49,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,24.255,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,48.02
cefTAZidime 1 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023525,NDC,1,EA,49,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,24.255,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
COLLAR CERVICAL X-LARGE WITH TRACH 2 PIECE OSG2404,120.185,CDM,274,RC,L0172,HCPCS,,10143-MAIN,LOCAL,,,,,49,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,24.255,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,152.79
Glycated Protein - Ref,PX8298590,CDM,300,RC,82985,CPT,90,,,,,,,49,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,24.255,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.37,48.02
"SUTURE V-LOC SZ 0 180 GREEN GS21 NEEDLE 18"" VLOCL0326",27200000,CDM,272,RC,,,,12218-MAIN,LOCAL,,,,,49,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,24.255,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
oxyCODONE CR 10 MG Tablet ER 12 hour Abuse-Deterrent 20 Each Box,63700001,CDM,250,RC,,,,,,59011041020,NDC,1,EA,26.63,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,24.25993,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
apixaban 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,3089331,NDC,1,EA,50.57,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,24.2736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
apixaban 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,3089331,NDC,1,EA,50.57,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,24.2736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pindolol 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,29033002801,NDC,1,EA,24.77,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,24.2746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
etomidate 2 MG/ML Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,55150022220,NDC,10,ML,50.58,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,24.2784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
etomidate 2 MG/ML Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,55150022220,NDC,10,ML,50.58,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,24.2784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004624,NDC,50,ML,50.58,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,24.2784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004624,NDC,50,ML,50.58,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,24.2784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
Neuromuscular Re-Education,PX97112,CDM,420,RC,97112,CPT,,,,,,,,135,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,24.28,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.28,44.37
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001501,NDC,1,EA,2340,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,24.28,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.28,27.6
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001503,NDC,1,EA,2340,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,24.28,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.28,27.6
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,70842014003,NDC,1,EA,2409.61,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,24.28,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.28,27.6
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597F,CDM,510,RC,97597,CPT,,,,,,,,266,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,24.28,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.28,133.11
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597P,CDM,983,RC,97597,CPT,,,,,,,,274,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,24.28,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.28,268.52
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,143950801,NDC,10,ML,58.46,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.284284,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
"Admin Hep B,Adult 19+",PX3242,CDM,771,RC,90471,CPT,,,,,,,,48,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,24.288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,61.54
Amphetamines; 3 or 4,PX8032590,CDM,300,RC,80325,CPT,90,,,,,,,48,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,24.288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,47.04
Immunization Admin - Influenza,PX3241,CDM,771,RC,90471,CPT,,,,,,,,48,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,24.288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,61.54
Immunization Administration; Each Add'l Vaccine (Single or Combo Vaccine/T*,PX90472,CDM,771,RC,90472,CPT,,,,,,,,48,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,24.288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,47.04
Self Care Mngment Training,PX97535,CDM,420,RC,97535,CPT,,,,,,,,135,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,24.29,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.56,43.05
Self Care Mngment Training,PX97535,CDM,420,RC,97535,CPT,,,,,,,,135,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,24.29,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.56,43.05
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,143950810,NDC,10,ML,58.51,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.305054,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
Sacubitril-Valsartan 49-51 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,78077720,NDC,1,EA,58.51,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.305054,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ivermectin 3 MG Tablet 20 Each Box,63700001,CDM,250,RC,,,,,,42799080601,NDC,1,EA,26.68,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,24.30548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zolpidem 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079072401,NDC,1,EA,24.81,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,24.3138,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zolpidem 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079072420,NDC,1,EA,24.81,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,24.3138,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060820,NDC,20,ML,58.57,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.329978,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
"sodium chloride 0.45 % 1,000 mL with potassium chloride 20 mEq 20-0.45 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070434,NDC,1000,ML,58.57,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.329978,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
Carcinoembryonic Antigen,PX82378,CDM,300,RC,82378,CPT,,,,,,,,25,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,24.3325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
"Gput, Quant",PX8277590,CDM,300,RC,82775,CPT,90,,,,,,,25,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,24.3325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
MEPILEX ADH FOAM 4X10,120.63,CDM,272,RC,A6196,HCPCS,,8710-MAIN,LOCAL,,,,,25,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,24.3325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
MEPILEX SOFT SILICONE 6X6,120.63,CDM,272,RC,A6196,HCPCS,,5577-MAIN,LOCAL,,,,,25,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,24.3325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
OPTIFOAM GENTLE SA SILICCONE FACED FOAM & BOARDER,120.63,CDM,272,RC,A6196,HCPCS,,3938-MAIN,LOCAL,,,,,25,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,24.3325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
Phase III Recovery Monthly,PX93799.01,CDM,943,RC,,,,,,,,,,25,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,24.3325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
"Testosterone,Free - Ref",PX8440290,CDM,300,RC,84402,CPT,90,,,,,,,25,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,24.3325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024010,NDC,1,EA,56.73,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,24.33717,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030036,NDC,1,EA,56.73,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,24.33717,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098341,NDC,1,EA,56.73,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,24.33717,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,63323047401,NDC,1,ML,58.6,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.34244,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.428
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076501,NDC,1,EA,58.6,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.34244,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076510,NDC,1,EA,58.6,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.34244,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
clotrimazole 1 % Cream 28.35 g Tube,25000000,CDM,250,RC,,,,,,904782231,NDC,28.35,GR,50.75,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,24.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
clotrimazole 1 % Cream 28.35 g Tube,25000000,CDM,250,RC,,,,,,904782231,NDC,28.35,GR,50.75,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,24.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
rivastigmine 1.5 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,62332006360,NDC,1,EA,25.03,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,24.361699,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086000,NDC,1,EA,58.66,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.367364,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086050,NDC,1,EA,58.66,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.367364,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012166,NDC,1,EA,58.66,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.367364,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
cefOXitin 1 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021010910,NDC,1,EA,58.66,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.367364,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.367364,75.6952
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,65219025915,NDC,1,EA,58.66,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.367364,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
montelukast 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268057511,NDC,1,EA,26.75,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,24.36925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
montelukast 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268057515,NDC,1,EA,26.75,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,24.36925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079034801,NDC,1,EA,27.39,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,24.3771,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079034820,NDC,1,EA,27.39,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,24.3771,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066500,NDC,0.25,ML,48.19,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,24.38414,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.000396,47.2262
Irri Implted Drug Dlvr Device,PX96523,CDM,260,RC,96523,CPT,,,,,,,,119,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,24.396,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.58,43.63
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,43598020453,NDC,10,ML,58.73,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.396442,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,72508020415,NDC,10,ML,58.73,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.396442,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cefdinir 300 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,67877054360,NDC,1,EA,27.42,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,24.4038,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cholestyramine light 4 g Packet 42 Each Box,63700001,CDM,250,RC,,,,,,245003642,NDC,1,EA,27.42,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,24.4038,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,517460125,NDC,0.5,ML,58.76,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.408904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003905,NDC,1,EA,58.77,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.413058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,76282066339,NDC,100,GR,26.8,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,24.4148,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
cholestyramine light 4 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,245003689,NDC,1,EA,27.44,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,24.4216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Naso/Orogastric Tube,PX43752F,CDM,510,RC,43752,CPT,,,,,,,,464,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,24.43,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.21,81.63
Naso/Orogastric Tube,PX43752P,CDM,983,RC,43752,CPT,,,,,,,,309,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,24.43,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.21,302.82
"lidocaine 2% -EPINEPHRine 1:200,000 2 %-1:200000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409318301,NDC,20,ML,49.86,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.4314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 2% -EPINEPHRine 1:200,000 2 %-1:200000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409318301,NDC,20,ML,49.86,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.4314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 2% -EPINEPHRine 1:200,000 2 %-1:200000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409318301,NDC,20,ML,49.86,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,24.4314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Chest Wall Manipulation,Initial",PX94667,CDM,410,RC,94667,CPT,,,,,,,,121,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,24.434,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.05,43.63
"PDS II ENDOLOOP LIGATURE SIZE 0 18""",27200000,CDM,272,RC,,,,11700-MAIN,LOCAL,,,,,56.96,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,24.43584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
atropine 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100401,NDC,0.5,ML,50.91,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,24.4368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
atropine 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100401,NDC,0.5,ML,50.91,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,24.4368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
cefdinir 300 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,16714039102,NDC,1,EA,27.46,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,24.4394,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409669501,NDC,10,ML,56.97,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,24.44013,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006111,NDC,0.5,EA,56.98,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,24.44442,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.669492,55.8404
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006158,NDC,0.5,EA,56.98,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,24.44442,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.669492,55.8404
glucose 40 % Gel 37.5 g Package,63700001,CDM,250,RC,,,,,,574006930,NDC,37.5,GR,25.12,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,24.449296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glucose 40 % Gel 37.5 g Tube,63700001,CDM,250,RC,,,,,,574006915,NDC,37.5,GR,25.12,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,24.449296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
natalizumab 300 MG/15ML Concentrate 15 mL Vial,J2323.01,CDM,636,RC,J2323,HCPCS,,,,64406000801,NDC,15,ML,15226.53,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,24.45,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.52,24.45
"Albumin, Othr Source - Ref",PX8204290,CDM,300,RC,82042,CPT,90,,,,,,,57,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,24.453,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.13,55.86
"Albumin, Serum - Ref",PX8204090,CDM,300,RC,82040,CPT,90,,,,,,,57,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,24.453,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.54,55.86
Assay Alkaline Phosphatase,PX84075,CDM,300,RC,84075,CPT,,,,,,,,57,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,24.453,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,55.86
Calcium Total,PX82310,CDM,300,RC,82310,CPT,,,,,,,,57,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,24.453,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.73,55.86
Dhea-S - Ref,PX8262790,CDM,300,RC,82627,CPT,90,,,,,,,57,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,24.453,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.38,55.86
Tiss Trnsgltmnase Ea Ig Clas,PX86364,CDM,300,RC,86364,CPT,,,,,,,,57,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,24.453,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.6778,55.86
Xray Ankle 2 Vws,PX7360001,CDM,320,RC,73600,CPT,TC,,,,,,,163,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,24.4568,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.14,48.65
Xray Clavicle Complete,PX7300001,CDM,320,RC,73000,CPT,TC,,,,,,,365,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,24.4568,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,48.65
Xray Elbow 3+Vws Tc,PX7308001,CDM,320,RC,73080,CPT,TC,,,,,,,370,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,24.4568,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,48.65
Xray Thoracolumbar 2 Vws,PX7208001,CDM,320,RC,72080,CPT,TC,,,,,,,306,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,24.4568,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.14,48.65
TEGADERM CHLORHEXIDINE-GLUCONATE,120.356,CDM,272,RC,A4221,HCPCS,,10708-MAIN,LOCAL,,,,,22,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,24.46,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.1275,26.29
TEGADERM CHLORHEXIDINE-GLUCONATE,120.356,CDM,272,RC,A4221,HCPCS,,10708-MAIN,LOCAL,,,,,22,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,24.46,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.1275,26.29
TEGADERM CHLORHEXIDINE-GLUCONATE,120.356,CDM,272,RC,A4221,HCPCS,,10708-MAIN,LOCAL,,,,,22,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,24.46,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.1275,26.29
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,25021010720,NDC,1,EA,48.35,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,24.4651,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117603,NDC,1,ML,58.93,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.479522,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
DRAPE STERILE 109X100X110 ROBOTIC DYNJP9108,27200000,CDM,272,RC,,,,12020-MAIN,LOCAL,,,,,51,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,24.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRAPE STERILE 109X100X110 ROBOTIC DYNJP9108,27200000,CDM,272,RC,,,,12020-MAIN,LOCAL,,,,,51,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,24.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Immunohisto Antibody Slide Ea Multiplex,PX8834401,CDM,310,RC,88344,CPT,TC,,,,,,,51,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,24.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,314.02
Immunohisto Antibody Slide Ea Multiplex,PX8834401,CDM,310,RC,88344,CPT,TC,,,,,,,51,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,24.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,314.02
RANGER UNIT TUBING FLUID WARMING,120.229,CDM,272,RC,,,,10612-MAIN,LOCAL,,,,,51,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,24.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,49.98
RANGER UNIT TUBING FLUID WARMING,120.229,CDM,272,RC,,,,10612-MAIN,LOCAL,,,,,51,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,24.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,49.98
SCAR GEL SHEET,120.458,CDM,273,RC,A6025,HCPCS,,5796-MAIN,LOCAL,,,,,51,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,24.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,49.98
SCAR GEL SHEET,120.458,CDM,273,RC,A6025,HCPCS,,5796-MAIN,LOCAL,,,,,51,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,24.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,49.98
TUBE FEEDING DECLOGGING SYSTEM CLOG ZAPPER 20-0002,120.277,CDM,272,RC,,,,4226-MAIN,LOCAL,,,,,51,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,24.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,49.98
TUBE FEEDING DECLOGGING SYSTEM CLOG ZAPPER 20-0002,120.277,CDM,272,RC,,,,4226-MAIN,LOCAL,,,,,51,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,24.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,49.98
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665305,NDC,20,ML,49.97,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1.633818182,percent of total billed charges,24.4853,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665305,NDC,20,ML,49.97,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.4853,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665305,NDC,20,ML,49.97,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,24.4853,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
fluvastatin 20 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,378802093,NDC,1,EA,26.88,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,24.48768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Catecholamines, Fraction - Ref",PX8238490,CDM,300,RC,82384,CPT,90,,,,,,,145,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,24.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.49,25.25
"Catecholamines, Fraction - Ref",PX8238490,CDM,300,RC,82384,CPT,90,,,,,,,145,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,24.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.49,25.25
"Catecholamines, Fraction - Ref",PX8238490,CDM,300,RC,82384,CPT,90,,,,,,,145,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,24.49,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.49,25.25
Carcinoembryonic Antigen,PX82378,CDM,300,RC,82378,CPT,,,,,,,,25,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,24.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
ERBEFLO CLEVERCAP CO2 TUBING CAP SET,27200000,CDM,272,RC,,,,11831-MAIN,LOCAL,,,,,50,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ERBEFLO CLEVERCAP CO2 TUBING CAP SET,27200000,CDM,272,RC,,,,11831-MAIN,LOCAL,,,,,50,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ERBEFLO CLEVERCAP CO2 TUBING CAP SET,27200000,CDM,272,RC,,,,11831-MAIN,LOCAL,,,,,50,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,24.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
G6pd; Quant Screen - Ref,PX8295590,CDM,300,RC,82955,CPT,90,,,,,,,50,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.89,49
G6pd; Quant Screen - Ref,PX8295590,CDM,300,RC,82955,CPT,90,,,,,,,50,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.89,49
G6pd; Quant Screen - Ref,PX8295590,CDM,300,RC,82955,CPT,90,,,,,,,50,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,24.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.89,49
"Gput, Quant",PX8277590,CDM,300,RC,82775,CPT,90,,,,,,,25,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,24.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
"Homogenization, Tissue for Culture",PX87176,CDM,300,RC,87176,CPT,,,,,,,,50,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.39,49
"Homogenization, Tissue for Culture",PX87176,CDM,300,RC,87176,CPT,,,,,,,,50,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.39,49
"Homogenization, Tissue for Culture",PX87176,CDM,300,RC,87176,CPT,,,,,,,,50,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,24.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.39,49
MEPILEX ADH FOAM 4X10,120.63,CDM,272,RC,A6196,HCPCS,,8710-MAIN,LOCAL,,,,,25,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,24.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
MEPILEX SOFT SILICONE 6X6,120.63,CDM,272,RC,A6196,HCPCS,,5577-MAIN,LOCAL,,,,,25,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,24.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
"NEEDLE ASP 16GX3/16"" 1-7/8"" ILLINOIS STERNAL 8881245164",120.8,CDM,272,RC,G0364,HCPCS,,5730-MAIN,LOCAL,,,,,50,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,49
"NEEDLE ASP 16GX3/16"" 1-7/8"" ILLINOIS STERNAL 8881245164",120.8,CDM,272,RC,G0364,HCPCS,,5730-MAIN,LOCAL,,,,,50,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,49
"NEEDLE ASP 16GX3/16"" 1-7/8"" ILLINOIS STERNAL 8881245164",120.8,CDM,272,RC,G0364,HCPCS,,5730-MAIN,LOCAL,,,,,50,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,24.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,49
"NEEDLE BONE MARROW 8G X 4"" BIOPSY/ASPIRATION 8881247087",120.8,CDM,272,RC,G0364,HCPCS,,166-MAIN,LOCAL,,,,,50,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,49
"NEEDLE BONE MARROW 8G X 4"" BIOPSY/ASPIRATION 8881247087",120.8,CDM,272,RC,G0364,HCPCS,,166-MAIN,LOCAL,,,,,50,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,49
"NEEDLE BONE MARROW 8G X 4"" BIOPSY/ASPIRATION 8881247087",120.8,CDM,272,RC,G0364,HCPCS,,166-MAIN,LOCAL,,,,,50,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,24.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,49
"NEEDLE BONE MARROW 11G X 4"" 8881247111",120.8,CDM,272,RC,G0364,HCPCS,,162-MAIN,LOCAL,,,,,50,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,49
"NEEDLE BONE MARROW 11G X 4"" 8881247111",120.8,CDM,272,RC,G0364,HCPCS,,162-MAIN,LOCAL,,,,,50,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,49
"NEEDLE BONE MARROW 11G X 4"" 8881247111",120.8,CDM,272,RC,G0364,HCPCS,,162-MAIN,LOCAL,,,,,50,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,24.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,49
"Office/Outpt Visit,Est,Levl II",PX99212F,CDM,510,RC,99212,CPT,,,,,,,,155,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,24.5,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.04,101.66
"Office/Outpt Visit,Est,Levl II",PX99212F,CDM,510,RC,99212,CPT,,,,,,,,155,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,24.5,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.04,101.66
"Office/Outpt Visit,Est,Levl II",PX99212P,CDM,983,RC,99212,CPT,,,,,,,,155,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,24.5,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.04,151.9
"Office/Outpt Visit,Est,Levl II",PX99212P,CDM,983,RC,99212,CPT,,,,,,,,155,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,24.5,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.04,151.9
OPTIFOAM GENTLE SA SILICCONE FACED FOAM & BOARDER,120.63,CDM,272,RC,A6196,HCPCS,,3938-MAIN,LOCAL,,,,,25,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,24.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
Phase III Recovery Monthly,PX93799.01,CDM,943,RC,,,,,,,,,,25,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,24.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
Potassium; Urine,PX84133,CDM,300,RC,84133,CPT,,,,,,,,50,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.34,49
Potassium; Urine,PX84133,CDM,300,RC,84133,CPT,,,,,,,,50,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.34,49
Potassium; Urine,PX84133,CDM,300,RC,84133,CPT,,,,,,,,50,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,24.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.34,49
"Testosterone,Free - Ref",PX8440290,CDM,300,RC,84402,CPT,90,,,,,,,25,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,24.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.385,24.5
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003930,NDC,1,EA,58.99,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.504446,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
DRAWTEX HYDROCONDUCTIVE NONADHERENT DRESSING,120.508,CDM,271,RC,A6199,HCPCS,,12022-MAIN,LOCAL,,,,,59,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.5086,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.5086,57.82
"Potassium; Serum, Plasma or Whole Blood",PX84132,CDM,300,RC,84132,CPT,,,,,,,,59,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.5086,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.36,57.82
rivastigmine 1.5 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,62332006360,NDC,1,EA,25.03,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,24.5294,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665318,NDC,20,ML,50.08,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1.633818182,percent of total billed charges,24.5392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665318,NDC,20,ML,50.08,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.5392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665318,NDC,20,ML,50.08,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,24.5392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
sterile water (preservative free) Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323018520,NDC,20,ML,50.08,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.5392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323018520,NDC,20,ML,50.08,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.5392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323018520,NDC,20,ML,50.08,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,24.5392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,409469930,NDC,20,ML,48.54,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,24.56124,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
artificial tears Ointment 3.5 g Tube,63700001,CDM,250,RC,,,,,,10119002239,NDC,3.5,GR,50.14,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.5686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
artificial tears Ointment 3.5 g Tube,63700001,CDM,250,RC,,,,,,10119002239,NDC,3.5,GR,50.14,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.5686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
artificial tears Ointment 3.5 g Tube,63700001,CDM,250,RC,,,,,,10119002239,NDC,3.5,GR,50.14,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,24.5686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BOOT CAST LARGE 12-5/8 ORT290010L,120.247,CDM,274,RC,L3260,HCPCS,,204-MAIN,LOCAL,,,,,27,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,24.597,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
BOOT CAST MEDIUM 08148803,120.247,CDM,274,RC,L3260,HCPCS,,203-MAIN,LOCAL,,,,,27,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,24.597,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
BOOT CAST X-LARGE 13X5-1/2IN ORT29200XL,120.247,CDM,274,RC,L3260,HCPCS,,206-MAIN,LOCAL,,,,,27,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,24.597,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
KERRAMAX CARE SUPERABSORBENT DRESSING 8X12,120.55,CDM,272,RC,A6197,HCPCS,,12363-MAIN,LOCAL,,,,,27,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,24.597,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
Or Time,PX36000086,CDM,360,RC,,,,,,,,,,27,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,24.597,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
"Sodium, Other Source - Ref",PX8430290,CDM,300,RC,84302,CPT,90,,,,,,,27,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,24.597,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.46,26.46
triamcinolone acetonide 0.1 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,16714098602,NDC,30,GR,59.22,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.599988,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine (preservative free) 4 % Solution 5 mL Ampule,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409428325,NDC,5,ML,48.62,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,24.60172,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019600,NDC,1,ML,48.64,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,24.61184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623100,NDC,1,EA,59.25,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.61245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,36000000924,NDC,200,ML,48.65,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,24.6169,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.20921,64.9544
glucose 40 % Gel 37.5 g Package,63700001,CDM,250,RC,,,,,,574006930,NDC,37.5,GR,25.12,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,24.6176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glucose 40 % Gel 37.5 g Tube,63700001,CDM,250,RC,,,,,,574006915,NDC,37.5,GR,25.12,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,24.6176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623105,NDC,1,EA,59.27,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.620758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
lidocaine 5 % Patch 1 Each Box,63700001,CDM,250,RC,,,,,,591352511,NDC,1,EA,50.26,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.6274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 5 % Patch 1 Each Box,63700001,CDM,250,RC,,,,,,591352511,NDC,1,EA,50.26,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.6274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 5 % Patch 1 Each Box,63700001,CDM,250,RC,,,,,,591352511,NDC,1,EA,50.26,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,24.6274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 5 % Patch 30 Each Box,63700001,CDM,250,RC,,,,,,591352530,NDC,1,EA,50.26,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.6274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 5 % Patch 30 Each Box,63700001,CDM,250,RC,,,,,,591352530,NDC,1,EA,50.26,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.6274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 5 % Patch 30 Each Box,63700001,CDM,250,RC,,,,,,591352530,NDC,1,EA,50.26,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,24.6274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Ecg 12 Lead, Interp Only",PX93010,CDM,985,RC,93010,CPT,,,,,,,,29,,First Health,Commercial,both,85,,999999999,percent of total billed charges,24.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.0466,28.2257
Microscopic Exam of Urine,PX81015,CDM,300,RC,81015,CPT,,,,,,,,29,,First Health,Commercial,both,85,,999999999,percent of total billed charges,24.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.8,28.42
TRAY ARTHROGRAM SAFE-T-ARTHRO 28-AR1CO,120.2,CDM,272,RC,,,,11499-MAIN,LOCAL,,,,,29,,First Health,Commercial,both,85,,999999999,percent of total billed charges,24.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.0466,194.04
"X-Ray Exam Hip,Unilat W/Pelvis 2-3 Vws",PX7350201,CDM,320,RC,73502,CPT,TC,,,,,,,436,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,24.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.99,72.97
"X-Ray Exam Hip,Unilat W/Pelvis 2-3 Vws",PX7350201,CDM,320,RC,73502,CPT,TC,,,,,,,436,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,24.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.99,72.97
Xray Ribs Bilat 3 Vws With Pa Chest,PX7111101,CDM,320,RC,71111,CPT,TC,,,,,,,417,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,24.65,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.65,73.63
vinCRIStine 1 MG/ML Solution 2 mL Vial,J9370.01,CDM,636,RC,J9370,HCPCS,,,,61703030916,NDC,2,ML,48.72,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,24.65232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.238288,47.7456
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703331101,NDC,0.75,ML,51.41,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,24.6768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703331101,NDC,0.75,ML,51.41,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,24.6768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
"lidocaine 2% -EPINEPHRine 1:200,000 2 %-1:200000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409318301,NDC,20,ML,49.86,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,24.6807,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Beta 2 Glycoprot 1 Ab,Ea - Ref",PX8614690,CDM,300,RC,86146,CPT,90,,,,,,,52,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,24.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.69,25.45
"Beta 2 Glycoprot 1 Ab,Ea - Ref",PX8614690,CDM,300,RC,86146,CPT,90,,,,,,,52,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,24.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.69,25.45
"Beta 2 Glycoprot 1 Ab,Ea - Ref",PX8614690,CDM,300,RC,86146,CPT,90,,,,,,,52,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,24.69,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.69,25.45
"Cardiolipin Ab, Ea Lg - Ref",PX8614790,CDM,300,RC,86147,CPT,90,,,,,,,133,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,24.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.69,25.45
"Cardiolipin Ab, Ea Lg - Ref",PX8614790,CDM,300,RC,86147,CPT,90,,,,,,,133,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,24.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.69,25.45
"Cardiolipin Ab, Ea Lg - Ref",PX8614790,CDM,300,RC,86147,CPT,90,,,,,,,133,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,24.69,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.69,25.45
"Albumin; Other Source, Quantitative, Each Specimen",PX82042,CDM,300,RC,82042,CPT,,,,,,,,28,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,24.696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.13,27.44
Anesthesia Level - Regional,PX37000025,CDM,370,RC,,,,,,,,,,28,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,24.696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
Gonadotropin (Lh),PX83002,CDM,300,RC,83002,CPT,,,,,,,,28,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,24.696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
PROMOGRAN PRISMA AG COLLAGEN DRESSING 28CM,120.547,CDM,272,RC,A6021,HCPCS,,12361-MAIN,LOCAL,,,,,28,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,24.696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
SCOPE BRONCHOSCOPE SZ 4 STERILE DISPOSABLE B120044,120.574,CDM,272,RC,,,,12868-MAIN,LOCAL,,,,,28,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,24.696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
tranexamic acid 650 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,69918030130,NDC,1,EA,28,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,24.696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Viral Neutralization - Ref,PX8638290,CDM,300,RC,86382,CPT,90,,,,,,,28,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,24.696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093107,NDC,1,ML,57.59,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,24.70611,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
"Catecholamines, Fraction - Ref",PX8238490,CDM,300,RC,82384,CPT,90,,,,,,,145,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,24.7093,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.49,25.25
"Testosterone,Free - Ref",PX8440290,CDM,300,RC,84402,CPT,90,,,,,,,25,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,24.71,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.71,25.47
"Testosterone,Free - Ref",PX8440290,CDM,300,RC,84402,CPT,90,,,,,,,25,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,24.71,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.71,25.47
"Testosterone,Free - Ref",PX8440290,CDM,300,RC,84402,CPT,90,,,,,,,25,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,24.71,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.71,25.47
lidocaine 4 % Cream 5 g Tube,63700001,CDM,250,RC,,,,,,496088205,NDC,5,GR,51.49,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,24.7152,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 4 % Cream 5 g Tube,63700001,CDM,250,RC,,,,,,496088205,NDC,5,GR,51.49,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,24.7152,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,72603012801,NDC,1,EA,57.64,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,24.72756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665305,NDC,20,ML,49.97,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,24.73515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
denosumab 120 MG/1.7ML Solution 1.7 mL Vial,J0897.01,CDM,636,RC,J0897,HCPCS,,,,55513073001,NDC,1.7,ML,4658.83,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,24.73873,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.05,25.2
acetaZOLAMIDE 500 MG Recon Soln 1 Each Vial,J1120.01,CDM,636,RC,J1120,HCPCS,,,,39822019001,NDC,1,EA,207.84,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,24.74,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.74,28.12
potassium chloride 20 MEQ Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,245036089,NDC,1,EA,57.67,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,24.74043,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ERBEFLO CLEVERCAP CO2 TUBING CAP SET,27200000,CDM,272,RC,,,,11831-MAIN,LOCAL,,,,,50,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,24.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
G6pd; Quant Screen - Ref,PX8295590,CDM,300,RC,82955,CPT,90,,,,,,,50,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,24.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.89,49
"Homogenization, Tissue for Culture",PX87176,CDM,300,RC,87176,CPT,,,,,,,,50,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,24.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.39,49
"NEEDLE ASP 16GX3/16"" 1-7/8"" ILLINOIS STERNAL 8881245164",120.8,CDM,272,RC,G0364,HCPCS,,5730-MAIN,LOCAL,,,,,50,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,24.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,49
"NEEDLE BONE MARROW 8G X 4"" BIOPSY/ASPIRATION 8881247087",120.8,CDM,272,RC,G0364,HCPCS,,166-MAIN,LOCAL,,,,,50,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,24.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,49
"NEEDLE BONE MARROW 11G X 4"" 8881247111",120.8,CDM,272,RC,G0364,HCPCS,,162-MAIN,LOCAL,,,,,50,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,24.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,49
Potassium; Urine,PX84133,CDM,300,RC,84133,CPT,,,,,,,,50,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,24.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.34,49
"lidocaine 2%-EPINEPHrine 1:100,000 2 %-1:100000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,409318221,NDC,30,ML,51.57,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,24.7536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 2%-EPINEPHrine 1:100,000 2 %-1:100000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,409318221,NDC,30,ML,51.57,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,24.7536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Noninvasv Oxygen Satut,Continuous",PX94762,CDM,460,RC,94762,CPT,,,,,,,,242,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,24.7555,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.58,44.21
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,93681545,NDC,2,ML,57.71,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,24.75759,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,93681573,NDC,2,ML,57.71,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,24.75759,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
azithromycin 200 MG/5ML Recon Susp 15 mL Bottle,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,59762312001,NDC,15,ML,196.35,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,24.76,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.08,29.76
azithromycin 250 MG Tablet 6 Each Box,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096104,NDC,1,EA,41.72,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,24.76,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.08,29.76
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,50111078751,NDC,1,EA,41.79,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,24.76,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.08,29.76
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096105,NDC,1,EA,41.73,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,24.76,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.08,29.76
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048503,NDC,50,ML,57.74,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,24.77046,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
apixaban 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,3089331,NDC,1,EA,50.57,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.7793,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
apixaban 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,3089331,NDC,1,EA,50.57,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.7793,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
apixaban 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,3089331,NDC,1,EA,50.57,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,24.7793,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
temporary tooth filling repair Misc 1 Each Package,25000000,CDM,250,RC,,,,,,47701000123,NDC,1,EA,25.46,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,24.780218,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
etomidate 2 MG/ML Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,55150022220,NDC,10,ML,50.58,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.7842,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
etomidate 2 MG/ML Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,55150022220,NDC,10,ML,50.58,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.7842,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
etomidate 2 MG/ML Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,55150022220,NDC,10,ML,50.58,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,24.7842,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004624,NDC,50,ML,50.58,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,4.651111111,percent of total billed charges,24.7842,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004624,NDC,50,ML,50.58,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.7842,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004624,NDC,50,ML,50.58,,United Healthcare,All Medicare advantage plans,outpatient,49,,17.13,percent of total billed charges,24.7842,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,70655000206,NDC,100,ML,59.67,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.786918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.786918,140.5516
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457000110,NDC,10,ML,59.67,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.786918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013266,NDC,50,ML,59.67,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.786918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013268,NDC,150,ML,59.67,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.786918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665318,NDC,20,ML,50.08,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,24.7896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
sterile water (preservative free) Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323018520,NDC,20,ML,50.08,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,24.7896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Cannabinoids, Natural - Ref",PX8034990,CDM,300,RC,80349,CPT,90,,,,,,,49,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,24.79,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.79,24.79
Fentanyl - Ref,PX8035490,CDM,300,RC,80354,CPT,90,,,,,,,353,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,24.79,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.79,24.79
Tramadol - Ref,PX8037390,CDM,300,RC,80373,CPT,90,,,,,,,197,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,24.79,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.79,24.79
Beta-2-Microglobulin - Ref,PX8223290,CDM,300,RC,82232,CPT,90,,,,,,,49,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,24.794,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.84,48.02
"Cannabinoids, Natural - Ref",PX8034990,CDM,300,RC,80349,CPT,90,,,,,,,49,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,24.794,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,48.02
cefTAZidime 1 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023525,NDC,1,EA,49,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,24.794,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
COLLAR CERVICAL X-LARGE WITH TRACH 2 PIECE OSG2404,120.185,CDM,274,RC,L0172,HCPCS,,10143-MAIN,LOCAL,,,,,49,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,24.794,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,152.79
Glycated Protein - Ref,PX8298590,CDM,300,RC,82985,CPT,90,,,,,,,49,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,24.794,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.37,48.02
"SUTURE V-LOC SZ 0 180 GREEN GS21 NEEDLE 18"" VLOCL0326",27200000,CDM,272,RC,,,,12218-MAIN,LOCAL,,,,,49,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,24.794,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Acetaminophen 167 MG/5ML Liquid 237 mL Bottle,63700001,CDM,250,RC,,,,,,904584709,NDC,237,ML,27.22,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,24.79742,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PACK BASIN BASIC SINGLE DYNJ06610A,27200000,CDM,272,RC,,,,10921-MAIN,LOCAL,,,,,25.48,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,24.799684,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
tuberculin 5 UNIT/0.1ML Solution 1 mL Vial,25000000,CDM,250,RC,,,,,,42023010401,NDC,0.1,ML,57.82,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,24.80478,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
artificial tears Ointment 3.5 g Tube,63700001,CDM,250,RC,,,,,,10119002239,NDC,3.5,GR,50.14,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,24.8193,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BUPivacaine 0.25 % Solution 50 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046557,NDC,30,ML,59.84,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.857536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
Itraconazole,PX8018990,CDM,300,RC,80189,CPT,90,,,,,,,124,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,24.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.86,121.52
Lacosamide - Ref,PX8023590,CDM,300,RC,80235,CPT,90,,,,,,,200,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,24.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.86,196
Voriconazole - Ref,PX8028590,CDM,300,RC,80285,CPT,90,,,,,,,183,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,24.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.86,179.34
clotrimazole 1 % Cream 28.35 g Tube,25000000,CDM,250,RC,,,,,,904782231,NDC,28.35,GR,50.75,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.8675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
clotrimazole 1 % Cream 28.35 g Tube,25000000,CDM,250,RC,,,,,,904782231,NDC,28.35,GR,50.75,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.8675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
clotrimazole 1 % Cream 28.35 g Tube,25000000,CDM,250,RC,,,,,,904782231,NDC,28.35,GR,50.75,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,24.8675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
hydrocortisone 1 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,45802043803,NDC,28,GR,25.55,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,24.867815,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Apply Long Arm Splint,PX29105F,CDM,510,RC,29105,CPT,,,,,,,,290,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,24.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.87,175.72
Apply Long Arm Splint,PX29105F,CDM,510,RC,29105,CPT,,,,,,,,290,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,24.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.87,175.72
Apply Long Arm Splint,PX29105P,CDM,983,RC,29105,CPT,,,,,,,,385,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,24.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.87,377.3
Apply Long Arm Splint,PX29105P,CDM,983,RC,29105,CPT,,,,,,,,385,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,24.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.87,377.3
"Cardiac Stress Tst,Tracing Only",PX93017,CDM,482,RC,93017,CPT,,,,,,,,1959,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,24.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.34,65.73
"Cardiac Stress Tst,Tracing Only",PX93017,CDM,482,RC,93017,CPT,,,,,,,,1959,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,24.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.34,65.73
Xray Ribs Bilat 3 Vws With Pa Chest,PX7111101,CDM,320,RC,71111,CPT,TC,,,,,,,417,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,24.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.65,73.63
Xray Ribs Bilat 3 Vws With Pa Chest,PX7111101,CDM,320,RC,71111,CPT,TC,,,,,,,417,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,24.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.65,73.63
lidocaine 5 % Patch 1 Each Box,63700001,CDM,250,RC,,,,,,591352511,NDC,1,EA,50.26,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,24.8787,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 5 % Patch 30 Each Box,63700001,CDM,250,RC,,,,,,591352530,NDC,1,EA,50.26,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,24.8787,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Albumin, Blood",PX82040,CDM,300,RC,82040,CPT,90,,,,,,,58,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,24.882,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.54,56.84
Assay of creatinine,PX82565,CDM,300,RC,82565,CPT,,,,,,,,58,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,24.882,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.69,56.84
Assay of Urea Nitrogen,PX84520,CDM,300,RC,84520,CPT,,,,,,,,58,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,24.882,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.62,56.84
"Assay, Glucose, Blood Quant",PX82947,CDM,300,RC,82947,CPT,,,,,,,,58,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,24.882,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.6,56.84
Automated Leukocyte Count,PX85048,CDM,300,RC,85048,CPT,,,,,,,,58,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,24.882,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.33,56.84
DEFIBRILLATION PAD BIPHASIC ADULT,120.96,CDM,271,RC,A0392,HCPCS,,1321-MAIN,LOCAL,,,,,58,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,24.882,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.0932,56.84
"Ebv, Nuclear Antigen - Ref",PX8666490,CDM,300,RC,86664,CPT,90,,,,,,,58,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,24.882,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.02,56.84
"Ebv, Viral Capsid Ab - Ref",PX8666590,CDM,300,RC,86665,CPT,90,,,,,,,58,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,24.882,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.63,56.84
Hematocrit,PX85014,CDM,300,RC,85014,CPT,,,,,,,,58,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,24.882,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.17,56.84
"Long Term Holter, 48 Hrs Up to 7 Days, Recording",PX93242,CDM,731,RC,93242,CPT,,,,,,,,58,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,24.882,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.0932,56.84
"Long Term Holter, More Than 7 Days Up to 15 Days, Recording",PX93246,CDM,731,RC,93246,CPT,,,,,,,,58,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,24.882,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.0932,56.84
"Sodium; Serum, Plasma or Whole Blood",PX84295,CDM,300,RC,84295,CPT,,,,,,,,58,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,24.882,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.41,56.84
SUTURE V-LOC SZ 1 PBT WOUND CLOSURE DEVICE BLUE 18 IN GS 21 NEEDLE VLOCN0327,27200000,CDM,272,RC,,,,12828-MAIN,LOCAL,,,,,58,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,24.882,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Transferase; Alanine Amino (Alt) (Sgpt),PX84460,CDM,300,RC,84460,CPT,,,,,,,,58,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,24.882,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.86,56.84
Transferase; Aspartate Amino (Ast) (Sgot),PX84450,CDM,300,RC,84450,CPT,,,,,,,,58,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,24.882,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,56.84
"Hydroxyprogesterone, 17-D - Ref",PX8349890,CDM,300,RC,83498,CPT,90,,,,,,,67,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,24.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.91,65.66
"Albumin; Other Source, Quantitative, Each Specimen",PX82042,CDM,300,RC,82042,CPT,,,,,,,,28,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,24.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.13,27.44
Anesthesia Level - Regional,PX37000025,CDM,370,RC,,,,,,,,,,28,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,24.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
Gonadotropin (Lh),PX83002,CDM,300,RC,83002,CPT,,,,,,,,28,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,24.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
PROMOGRAN PRISMA AG COLLAGEN DRESSING 28CM,120.547,CDM,272,RC,A6021,HCPCS,,12361-MAIN,LOCAL,,,,,28,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,24.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
SCOPE BRONCHOSCOPE SZ 4 STERILE DISPOSABLE B120044,120.574,CDM,272,RC,,,,12868-MAIN,LOCAL,,,,,28,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,24.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
tranexamic acid 650 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,69918030130,NDC,1,EA,28,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,24.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Viral Neutralization - Ref,PX8638290,CDM,300,RC,86382,CPT,90,,,,,,,28,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,24.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
Capillary Blood Collection,PX36416,CDM,300,RC,36416,CPT,,,,,,,,60,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.924,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,58.8
HERNIA BELT MENS TRUSS LARGE,120.526,CDM,274,RC,L8310,HCPCS,,12221-MAIN,LOCAL,,,,,60,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.924,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,160.6
HERNIA BELT MENS TRUSS MEDIUM,120.526,CDM,274,RC,L8310,HCPCS,,12220-MAIN,LOCAL,,,,,60,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.924,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,160.6
HERNIA BELT MENS TRUSS XLARGE,120.526,CDM,274,RC,L8310,HCPCS,,12222-MAIN,LOCAL,,,,,60,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.924,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,160.6
"IMMOBILIZER KNEE  24"" 7041-44",120.22,CDM,274,RC,L1830,HCPCS,,595-MAIN,LOCAL,,,,,60,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.924,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE 16"" UNIVERSAL 7088-04",120.22,CDM,274,RC,L1830,HCPCS,,589-MAIN,LOCAL,,,,,60,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.924,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
IMMOBILIZER KNEE 20 INCH ORT2420019,120.22,CDM,274,RC,L1830,HCPCS,,587-MAIN,LOCAL,,,,,60,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.924,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE 20"" LARGE FOAM COUNTOURED STAYS 7062-03",120.22,CDM,274,RC,L1830,HCPCS,,593-MAIN,LOCAL,,,,,60,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.924,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE 20"" QUICK-WRAP ORT2440020S",120.22,CDM,274,RC,L1830,HCPCS,,591-MAIN,LOCAL,,,,,60,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.924,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
IMMOBILIZER KNEE CUTAWAY STRAIGHT 2 7041-05,120.22,CDM,274,RC,L1830,HCPCS,,596-MAIN,LOCAL,,,,,60,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.924,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
atropine 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100401,NDC,0.5,ML,50.91,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.9459,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
atropine 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100401,NDC,0.5,ML,50.91,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.9459,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
atropine 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100401,NDC,0.5,ML,50.91,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,24.9459,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
temporary tooth filling repair Misc 1 Each Package,25000000,CDM,250,RC,,,,,,47701000123,NDC,1,EA,25.46,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,24.9508,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079034801,NDC,1,EA,27.39,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,24.95229,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079034820,NDC,1,EA,27.39,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,24.95229,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Procalcitonin,PX84145,CDM,300,RC,84145,CPT,,,,,,,,217,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,24.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.96,212.66
Antinuclear Ab(Ana) Titer - Ref,PX8603990,CDM,300,RC,86039,CPT,90,,,,,,,52,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,24.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.23,50.96
Antinuclear Ab(Ana) Titer - Ref,PX8603990,CDM,300,RC,86039,CPT,90,,,,,,,52,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,24.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.23,50.96
Assay Biovlbl Testosterone Direct Measurement - Ref,PX8441090,CDM,300,RC,84410,CPT,90,,,,,,,52,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,24.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.6008,50.96
Assay Biovlbl Testosterone Direct Measurement - Ref,PX8441090,CDM,300,RC,84410,CPT,90,,,,,,,52,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,24.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.6008,50.96
"Beta 2 Glycoprot 1 Ab,Ea - Ref",PX8614690,CDM,300,RC,86146,CPT,90,,,,,,,52,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,24.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.6008,50.96
"Beta 2 Glycoprot 1 Ab,Ea - Ref",PX8614690,CDM,300,RC,86146,CPT,90,,,,,,,52,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,24.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.6008,50.96
Iron - Ref,PX8354090,CDM,300,RC,83540,CPT,90,,,,,,,52,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,24.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,50.96
Iron - Ref,PX8354090,CDM,300,RC,83540,CPT,90,,,,,,,52,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,24.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,50.96
Rickettsia Antibody - Ref,PX8675790,CDM,300,RC,86757,CPT,90,,,,,,,52,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,24.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.74,50.96
Rickettsia Antibody - Ref,PX8675790,CDM,300,RC,86757,CPT,90,,,,,,,52,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,24.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.74,50.96
Uric Acid; Blood,PX84550,CDM,300,RC,84550,CPT,,,,,,,,52,,Health Partners,Health Partners Care Plans,both,48,,24.11,percent of total billed charges,24.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.14,50.96
Uric Acid; Blood,PX84550,CDM,300,RC,84550,CPT,,,,,,,,52,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,24.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.14,50.96
ROPivacaine 2 MG/ML Solution 10 mL Vial,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028513,NDC,10,ML,52.01,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,24.9648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.604954,269.6078
ROPivacaine 2 MG/ML Solution 10 mL Vial,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028513,NDC,10,ML,52.01,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,24.9648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.604954,269.6078
PACK BASIN BASIC SINGLE DYNJ06610A,27200000,CDM,272,RC,,,,10921-MAIN,LOCAL,,,,,25.48,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,24.9704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
OLANZapine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60505311000,NDC,1,EA,60.13,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,24.978002,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cefdinir 300 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,67877054360,NDC,1,EA,27.42,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,24.97962,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cholestyramine light 4 g Packet 42 Each Box,63700001,CDM,250,RC,,,,,,245003642,NDC,1,EA,27.42,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,24.97962,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,25021050002,NDC,1,ML,52.06,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,24.9888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,25021050002,NDC,1,ML,52.06,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,24.9888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
DRAPE STERILE 109X100X110 ROBOTIC DYNJP9108,27200000,CDM,272,RC,,,,12020-MAIN,LOCAL,,,,,51,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRAPE STERILE 109X100X110 ROBOTIC DYNJP9108,27200000,CDM,272,RC,,,,12020-MAIN,LOCAL,,,,,51,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRAPE STERILE 109X100X110 ROBOTIC DYNJP9108,27200000,CDM,272,RC,,,,12020-MAIN,LOCAL,,,,,51,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,24.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Immunohisto Antibody Slide Ea Multiplex,PX8834401,CDM,310,RC,88344,CPT,TC,,,,,,,51,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,314.02
Immunohisto Antibody Slide Ea Multiplex,PX8834401,CDM,310,RC,88344,CPT,TC,,,,,,,51,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,314.02
Immunohisto Antibody Slide Ea Multiplex,PX8834401,CDM,310,RC,88344,CPT,TC,,,,,,,51,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,24.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,314.02
RANGER UNIT TUBING FLUID WARMING,120.229,CDM,272,RC,,,,10612-MAIN,LOCAL,,,,,51,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,49.98
RANGER UNIT TUBING FLUID WARMING,120.229,CDM,272,RC,,,,10612-MAIN,LOCAL,,,,,51,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,49.98
RANGER UNIT TUBING FLUID WARMING,120.229,CDM,272,RC,,,,10612-MAIN,LOCAL,,,,,51,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,24.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,49.98
SCAR GEL SHEET,120.458,CDM,273,RC,A6025,HCPCS,,5796-MAIN,LOCAL,,,,,51,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,49.98
SCAR GEL SHEET,120.458,CDM,273,RC,A6025,HCPCS,,5796-MAIN,LOCAL,,,,,51,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,49.98
SCAR GEL SHEET,120.458,CDM,273,RC,A6025,HCPCS,,5796-MAIN,LOCAL,,,,,51,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,24.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,49.98
TUBE FEEDING DECLOGGING SYSTEM CLOG ZAPPER 20-0002,120.277,CDM,272,RC,,,,4226-MAIN,LOCAL,,,,,51,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,49.98
TUBE FEEDING DECLOGGING SYSTEM CLOG ZAPPER 20-0002,120.277,CDM,272,RC,,,,4226-MAIN,LOCAL,,,,,51,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,24.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,49.98
TUBE FEEDING DECLOGGING SYSTEM CLOG ZAPPER 20-0002,120.277,CDM,272,RC,,,,4226-MAIN,LOCAL,,,,,51,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,24.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,49.98
cholestyramine light 4 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,245003689,NDC,1,EA,27.44,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,24.99784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Inf Ag Detect by Nucleic Acid (Dna or Rna); (Sars-Cov-2,PXU0005,CDM,300,RC,U0005,HCPCS,,,,,,,,0.01,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,25,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.22674,25
Inf Ag Detect by Nucleic Acid (Dna or Rna); (Sars-Cov-2,PXU0005,CDM,300,RC,U0005,HCPCS,,,,,,,,0.01,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,25,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.22674,25
oxyCODONE CR 20 MG Tablet ER 12 hour Abuse-Deterrent 20 Each Box,63700001,CDM,250,RC,,,,,,59011042020,NDC,1,EA,52.09,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,25.0032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE CR 20 MG Tablet ER 12 hour Abuse-Deterrent 20 Each Box,63700001,CDM,250,RC,,,,,,59011042020,NDC,1,EA,52.09,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,25.0032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,641601501,NDC,25,ML,58.29,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,25.00641,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Canalith Repositioning,PX95992,CDM,420,RC,95992,CPT,,,,,,,,128,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,25.01,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.69,73.88
"Injection, Subq/Im",PX96372,CDM,260,RC,96372,CPT,,,,,,,,119,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,25.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.94,25.01
"Injection, Subq/Im",PX96372,CDM,260,RC,96372,CPT,,,,,,,,119,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,25.01,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.94,25.01
cefdinir 300 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,16714039102,NDC,1,EA,27.46,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,25.01606,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117630,NDC,1,ML,58.34,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,25.02786,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
Mitochondrial Antibody Each,PX8638190,CDM,300,RC,86381,CPT,90,,,,,,,38,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,25.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.03,25.45
Neuromuscular Re-Education,PX97112,CDM,420,RC,97112,CPT,,,,,,,,135,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,25.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.28,44.37
Neuromuscular Re-Education,PX97112,CDM,420,RC,97112,CPT,,,,,,,,135,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,25.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.28,44.37
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597F,CDM,510,RC,97597,CPT,,,,,,,,266,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,25.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.28,133.11
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597F,CDM,510,RC,97597,CPT,,,,,,,,266,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,25.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.28,133.11
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597P,CDM,983,RC,97597,CPT,,,,,,,,274,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,25.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.28,268.52
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597P,CDM,983,RC,97597,CPT,,,,,,,,274,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,25.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.28,268.52
"Beta 2 Glycoprot 1 Ab,Ea - Ref",PX8614690,CDM,300,RC,86146,CPT,90,,,,,,,52,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,25.0302,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.69,25.45
"Cardiolipin Ab, Ea Lg - Ref",PX8614790,CDM,300,RC,86147,CPT,90,,,,,,,133,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,25.0302,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.69,25.45
Mitochondrial Antibody Each,PX8638190,CDM,300,RC,86381,CPT,90,,,,,,,38,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,25.0302,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.03,25.45
"Testosterone,Free - Ref",PX8440290,CDM,300,RC,84402,CPT,90,,,,,,,25,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,25.0302,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.71,25.47
apixaban 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,3089331,NDC,1,EA,50.57,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,25.03215,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
etomidate 2 MG/ML Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,55150022220,NDC,10,ML,50.58,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,25.0371,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004624,NDC,50,ML,50.58,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,25.0371,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
hydrocortisone 1 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,45802043803,NDC,28,GR,25.55,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,25.039,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Hla a, B or C, Single Ag - Ref",PX8681290,CDM,300,RC,86812,CPT,90,,,,,,,89,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,25.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.04,25.81
"Hla a, B or C, Single Ag - Ref",PX8681290,CDM,300,RC,86812,CPT,90,,,,,,,89,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,25.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.04,25.81
"Hla a, B or C, Single Ag - Ref",PX8681290,CDM,300,RC,86812,CPT,90,,,,,,,89,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,25.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.04,25.81
"Testosterone, Total - Ref",PX8440390,CDM,300,RC,84403,CPT,90,,,,,,,43,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,25.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.04,25.81
"Testosterone, Total - Ref",PX8440390,CDM,300,RC,84403,CPT,90,,,,,,,43,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,25.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.04,25.81
"Testosterone, Total - Ref",PX8440390,CDM,300,RC,84403,CPT,90,,,,,,,43,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,25.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.04,25.81
PACLitaxel 30 MG/5ML Concentrate 5 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476401,NDC,5,ML,58.37,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,25.04073,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
Apply Multlay Comprs Lwr Leg,PX29581F,CDM,510,RC,29581,CPT,,,,,,,,213,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,25.0458,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.01,182.64
Apply Multlay Comprs Lwr Leg,PX29581P,CDM,983,RC,29581,CPT,,,,,,,,142,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,25.0458,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.01,182.64
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016200,NDC,1,ML,52.22,,Health Partners,Health Partners Care Plans,both,48,,13.774375,percent of total billed charges,25.0656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016200,NDC,1,ML,52.22,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,25.0656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8092351,NDC,1,EA,52.22,,Health Partners,Health Partners Care Plans,both,48,,23.19555556,percent of total billed charges,25.0656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8092351,NDC,1,EA,52.22,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,25.0656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400101,NDC,1,EA,52.22,,Health Partners,Health Partners Care Plans,both,48,,23.19555556,percent of total billed charges,25.0656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400101,NDC,1,EA,52.22,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,25.0656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400125,NDC,1,EA,52.22,,Health Partners,Health Partners Care Plans,both,48,,23.19555556,percent of total billed charges,25.0656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400125,NDC,1,EA,52.22,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,25.0656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
Smking Cess 4-10 Min,PX99406F,CDM,942,RC,99406,CPT,,,,,,,,65,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,25.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.07,63.7
Smking Cess 4-10 Min,PX99406P,CDM,983,RC,99406,CPT,,,,,,,,43,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,25.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.8622,41.8519
Neg Pressure Wound Therapy Dme >50 Sq Cm,PX97606F,CDM,761,RC,97606,CPT,,,,,,,,404,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,25.077,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.75,67.21
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,143950801,NDC,10,ML,58.46,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,25.07934,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
"Apply Forearm Splint,Static",PX29125F,CDM,510,RC,29125,CPT,,,,,,,,223,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,25.08,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.08,141.82
"Apply Forearm Splint,Static",PX29125P,CDM,983,RC,29125,CPT,,,,,,,,296,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,25.08,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.08,290.08
Apply Long Arm Splint,PX29105F,CDM,510,RC,29105,CPT,,,,,,,,290,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,25.08,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.87,175.72
Apply Long Arm Splint,PX29105P,CDM,983,RC,29105,CPT,,,,,,,,385,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,25.08,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.87,377.3
Eval of Bronchospasm,PX94060,CDM,983,RC,94060,CPT,,,,,,,,176,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,25.08,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.08,172.48
Xray Sacroiliac Jnts Less Than 3 Vws,PX7220001,CDM,320,RC,72200,CPT,TC,,,,,,,555,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,25.1004,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.36,49.96
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,143950810,NDC,10,ML,58.51,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,25.10079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
Sacubitril-Valsartan 49-51 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,78077720,NDC,1,EA,58.51,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,25.10079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Oligoclonal Bands - Ref,PX8391690,CDM,300,RC,83916,CPT,90,,,,,,,124,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,25.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.11,121.52
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093102,NDC,1,ML,60.47,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,25.119238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
clotrimazole 1 % Cream 28.35 g Tube,25000000,CDM,250,RC,,,,,,904782231,NDC,28.35,GR,50.75,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,25.12125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060820,NDC,20,ML,58.57,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,25.12653,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
"sodium chloride 0.45 % 1,000 mL with potassium chloride 20 mEq 20-0.45 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070434,NDC,1000,ML,58.57,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,25.12653,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,63323047401,NDC,1,ML,58.6,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,25.1394,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.428
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076501,NDC,1,EA,58.6,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,25.1394,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076510,NDC,1,EA,58.6,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,25.1394,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
amoxicillin 125 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,143988815,NDC,150,ML,25.84,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,25.150072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 125 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,781603955,NDC,150,ML,25.84,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,25.150072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086000,NDC,1,EA,58.66,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,25.16514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086050,NDC,1,EA,58.66,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,25.16514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012166,NDC,1,EA,58.66,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,25.16514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
cefOXitin 1 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021010910,NDC,1,EA,58.66,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,25.16514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.367364,75.6952
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,65219025915,NDC,1,EA,58.66,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,25.16514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
LAP SPONGES 18x18 7INCH LOOP,27200000,CDM,272,RC,,,,604-MAIN,LOCAL,,,,,60.64,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,25.189856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703331101,NDC,0.75,ML,51.41,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,12.26041667,percent of total billed charges,25.1909,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703331101,NDC,0.75,ML,51.41,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,25.1909,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703331101,NDC,0.75,ML,51.41,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,25.1909,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,43598020453,NDC,10,ML,58.73,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,25.19517,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,72508020415,NDC,10,ML,58.73,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,25.19517,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ezetimibe 10 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,16729043316,NDC,1,EA,60.66,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,25.198164,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
denosumab 120 MG/1.7ML Solution 1.7 mL Vial,J0897.01,CDM,636,RC,J0897,HCPCS,,,,55513073001,NDC,1.7,ML,4658.83,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,25.2,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.05,25.2
atropine 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100401,NDC,0.5,ML,50.91,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,25.20045,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
magnesium sulfate 1 g in 100 ml D5W (premix) 1-5 GM/100ML-% Solution 100 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010802,NDC,100,ML,52.51,,Health Partners,Health Partners Care Plans,both,48,,14.6175,percent of total billed charges,25.2048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
magnesium sulfate 1 g in 100 ml D5W (premix) 1-5 GM/100ML-% Solution 100 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010802,NDC,100,ML,52.51,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,25.2048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,517460125,NDC,0.5,ML,58.76,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,25.20804,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003905,NDC,1,EA,58.77,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,25.21233,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
Therapeutic Activities,PX97530,CDM,420,RC,97530,CPT,,,,,,,,135,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,25.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.22,205.7
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714078401,NDC,0.4,EA,60.72,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,25.223088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"lidocaine 2% -EPINEPHRine 1:200,000 2 %-1:200000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409318301,NDC,20,ML,49.86,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,25.22916,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
carfilzomib 30 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010201,NDC,1,EA,2785.91,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,25.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.23,5460.3836
carfilzomib 60 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010101,NDC,1,EA,5571.82,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,25.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.23,5460.3836
lidocaine 4 % Cream 5 g Tube,63700001,CDM,250,RC,,,,,,496088205,NDC,5,GR,51.49,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,25.2301,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 4 % Cream 5 g Tube,63700001,CDM,250,RC,,,,,,496088205,NDC,5,GR,51.49,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,25.2301,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 4 % Cream 5 g Tube,63700001,CDM,250,RC,,,,,,496088205,NDC,5,GR,51.49,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,25.2301,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DRAPE STERILE 109X100X110 ROBOTIC DYNJP9108,27200000,CDM,272,RC,,,,12020-MAIN,LOCAL,,,,,51,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,25.245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Immunohisto Antibody Slide Ea Multiplex,PX8834401,CDM,310,RC,88344,CPT,TC,,,,,,,51,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,25.245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,314.02
RANGER UNIT TUBING FLUID WARMING,120.229,CDM,272,RC,,,,10612-MAIN,LOCAL,,,,,51,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,25.245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,49.98
SCAR GEL SHEET,120.458,CDM,273,RC,A6025,HCPCS,,5796-MAIN,LOCAL,,,,,51,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,25.245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,49.98
TUBE FEEDING DECLOGGING SYSTEM CLOG ZAPPER 20-0002,120.277,CDM,272,RC,,,,4226-MAIN,LOCAL,,,,,51,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,25.245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,49.98
"Catecholamines, Fraction - Ref",PX8238490,CDM,300,RC,82384,CPT,90,,,,,,,145,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,25.25,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.49,25.25
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011801,NDC,0.5,ML,52.63,,Health Partners,Health Partners Care Plans,both,48,,1.83137931,percent of total billed charges,25.2624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011801,NDC,0.5,ML,52.63,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,25.2624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011805,NDC,0.5,ML,52.63,,Health Partners,Health Partners Care Plans,both,48,,1.83137931,percent of total billed charges,25.2624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011805,NDC,0.5,ML,52.63,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,25.2624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
"lidocaine 2%-EPINEPHrine 1:100,000 2 %-1:100000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,409318221,NDC,30,ML,51.57,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,25.2693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 2%-EPINEPHrine 1:100,000 2 %-1:100000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,409318221,NDC,30,ML,51.57,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,25.2693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 2%-EPINEPHrine 1:100,000 2 %-1:100000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,409318221,NDC,30,ML,51.57,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,25.2693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
hydrocortisone 2.5 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,45802000403,NDC,28,GR,60.85,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,25.27709,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117603,NDC,1,ML,58.93,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,25.28097,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665305,NDC,20,ML,49.97,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,25.28482,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"Blood Gases: Ph, Po2 & Pco2",PX82803,CDM,300,RC,82803,CPT,,,,,,,,518,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,25.29,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.29,26.07
"Blood Gases: Ph, Po2 & Pco2",PX82803,CDM,300,RC,82803,CPT,,,,,,,,518,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,25.29,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.29,26.07
"Blood Gases: Ph, Po2 & Pco2",PX82803,CDM,300,RC,82803,CPT,,,,,,,,518,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,25.29,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.29,26.07
ERBEFLO CLEVERCAP CO2 TUBING CAP SET,27200000,CDM,272,RC,,,,11831-MAIN,LOCAL,,,,,50,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,25.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
G6pd; Quant Screen - Ref,PX8295590,CDM,300,RC,82955,CPT,90,,,,,,,50,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,25.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.89,49
"Homogenization, Tissue for Culture",PX87176,CDM,300,RC,87176,CPT,,,,,,,,50,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,25.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.39,49
"NEEDLE ASP 16GX3/16"" 1-7/8"" ILLINOIS STERNAL 8881245164",120.8,CDM,272,RC,G0364,HCPCS,,5730-MAIN,LOCAL,,,,,50,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,25.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,49
"NEEDLE BONE MARROW 8G X 4"" BIOPSY/ASPIRATION 8881247087",120.8,CDM,272,RC,G0364,HCPCS,,166-MAIN,LOCAL,,,,,50,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,25.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,49
"NEEDLE BONE MARROW 11G X 4"" 8881247111",120.8,CDM,272,RC,G0364,HCPCS,,162-MAIN,LOCAL,,,,,50,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,25.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,49
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001501,NDC,1,EA,2340,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,25.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.3,2361.4178
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001503,NDC,1,EA,2340,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,25.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.3,2361.4178
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,70842014003,NDC,1,EA,2409.61,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,25.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.3,2361.4178
Potassium; Urine,PX84133,CDM,300,RC,84133,CPT,,,,,,,,50,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,25.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.34,49
SPIT SOCK HOODS 16719,120.367,CDM,271,RC,,,,10820-MAIN,LOCAL,,,,,26,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,25.3058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.8004,25.48
TEGADERM CHLORHEXIDINE 5X5 CHG IV PORT,120.207,CDM,272,RC,A6268,HCPCS,,10163-MAIN,LOCAL,,,,,26,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,25.3058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.8004,25.48
sucralfate 1 GM/10ML Suspension 10 mL Cup,63700001,CDM,250,RC,,,,,,68094004359,NDC,10,ML,60.92,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,25.306168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003930,NDC,1,EA,58.99,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,25.30671,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
DRAWTEX HYDROCONDUCTIVE NONADHERENT DRESSING,120.508,CDM,271,RC,A6199,HCPCS,,12022-MAIN,LOCAL,,,,,59,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,25.311,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.5086,57.82
"Potassium; Serum, Plasma or Whole Blood",PX84132,CDM,300,RC,84132,CPT,,,,,,,,59,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,25.311,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.36,57.82
amoxicillin 125 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,143988815,NDC,150,ML,25.84,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,25.3232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin 125 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,781603955,NDC,150,ML,25.84,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,25.3232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048557,NDC,50,ML,52.78,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,25.3344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048557,NDC,50,ML,52.78,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,25.3344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Protoporphyrin, RBC, Qnt - Ref",PX8420290,CDM,300,RC,84202,CPT,90,,,,,,,61,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,25.3394,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.16,59.78
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665318,NDC,20,ML,50.08,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,25.34048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
sterile water (preservative free) Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323018520,NDC,20,ML,50.08,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,25.34048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Hla a, B or C, Single Ag - Ref",PX8681290,CDM,300,RC,86812,CPT,90,,,,,,,89,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,25.3511,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.04,25.81
"Testosterone, Total - Ref",PX8440390,CDM,300,RC,84403,CPT,90,,,,,,,43,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,25.3511,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.04,25.81
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048657,NDC,50,ML,61.05,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,25.36017,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Surgical Cleansing of Skin,PX11000P,CDM,983,RC,11000,CPT,,,,,,,,145,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,25.3669,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.79,142.1
artificial tears Ointment 3.5 g Tube,63700001,CDM,250,RC,,,,,,10119002239,NDC,3.5,GR,50.14,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,25.37084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CATHETER FOLEY 18FR  3WAY 30CC 73018L,120.21,CDM,272,RC,A4346,HCPCS,,253-MAIN,LOCAL,,,,,33,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,25.38,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.38,26.72
CATHETER FOLEY 20FR 3WAY 30CC 0167L20,120.21,CDM,272,RC,A4346,HCPCS,,251-MAIN,LOCAL,,,,,33,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,25.38,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.38,26.72
CATHETER FOLEY 24FR 3WAY 30CC 0167L24,120.21,CDM,272,RC,A4346,HCPCS,,10455-MAIN,LOCAL,,,,,33,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,25.38,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.38,26.72
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,143950601,NDC,10,ML,61.1,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,25.38094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,143950610,NDC,10,ML,61.1,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,25.38094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,781323294,NDC,1,EA,52.89,,Health Partners,Health Partners Care Plans,both,48,,23.19555556,percent of total billed charges,25.3872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,781323294,NDC,1,EA,52.89,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,25.3872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
triamcinolone acetonide 0.1 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,16714098602,NDC,30,GR,59.22,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,25.40538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Surg Pathology-Level 2-Tc,PX3932,CDM,310,RC,88302,CPT,TC,,,,,,,66,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,25.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.41,43.344
Surg Pathology-Level 2-Tc,PX3932,CDM,310,RC,88302,CPT,TC,,,,,,,66,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,25.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.41,43.344
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623100,NDC,1,EA,59.25,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,25.41825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305972,NDC,2,ML,61.19,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,25.418326,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305995,NDC,2,ML,61.19,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,25.418326,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623105,NDC,1,EA,59.27,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,25.42683,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
lidocaine 5 % Patch 1 Each Box,63700001,CDM,250,RC,,,,,,591352511,NDC,1,EA,50.26,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,25.43156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 5 % Patch 30 Each Box,63700001,CDM,250,RC,,,,,,591352530,NDC,1,EA,50.26,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,25.43156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buprenorphine 75 MCG FILM 60 Each Box,63700001,CDM,250,RC,,,,,,59385002160,NDC,1,EA,29.92,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine HCl 4 % Cream 133 g Tube,63700001,CDM,250,RC,,,,,,41167005828,NDC,133,GR,52.99,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,25.4352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine HCl 4 % Cream 133 g Tube,63700001,CDM,250,RC,,,,,,41167005828,NDC,133,GR,52.99,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,25.4352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Dystrophic Nail Trimming Any Number,PXG0127F,CDM,940,RC,G0127,HCPCS,,,,,,,,53,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,25.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.0162,53.44
Dystrophic Nail Trimming Any Number,PXG0127F,CDM,940,RC,G0127,HCPCS,,,,,,,,53,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,25.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.0162,53.44
Renin - Ref,PX8424490,CDM,300,RC,84244,CPT,90,,,,,,,53,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,25.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.16,51.94
Renin - Ref,PX8424490,CDM,300,RC,84244,CPT,90,,,,,,,53,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,25.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.16,51.94
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43598055530,NDC,0.4,EA,61.26,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,25.447404,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43598096630,NDC,0.4,EA,61.26,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,25.447404,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703331101,NDC,0.75,ML,51.41,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,25.44795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
"Beta 2 Glycoprot 1 Ab,Ea - Ref",PX8614690,CDM,300,RC,86146,CPT,90,,,,,,,52,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,25.45,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.69,25.45
"Cardiolipin Ab, Ea Lg - Ref",PX8614790,CDM,300,RC,86147,CPT,90,,,,,,,133,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,25.45,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.69,25.45
Mitochondrial Antibody Each,PX8638190,CDM,300,RC,86381,CPT,90,,,,,,,38,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,25.45,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.03,25.45
tropicamide 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,24208058559,NDC,2,ML,61.3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,25.46402,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338067104,NDC,1000,ML,53.06,,Health Partners,Health Partners Care Plans,both,48,,6.034333333,percent of total billed charges,25.4688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338067104,NDC,1000,ML,53.06,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,25.4688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"Testosterone,Free - Ref",PX8440290,CDM,300,RC,84402,CPT,90,,,,,,,25,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,25.47,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.71,25.47
"Iontophoresis, Ea 15min",PX97033,CDM,420,RC,97033,CPT,,,,,,,,15,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,25.48,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.94,25.48
"Iontophoresis, Ea 15min",PX97033,CDM,420,RC,97033,CPT,,,,,,,,15,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,25.48,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.94,25.48
Antinuclear Ab(Ana) Titer - Ref,PX8603990,CDM,300,RC,86039,CPT,90,,,,,,,52,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,25.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.23,50.96
Antinuclear Ab(Ana) Titer - Ref,PX8603990,CDM,300,RC,86039,CPT,90,,,,,,,52,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,25.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.23,50.96
Antinuclear Ab(Ana) Titer - Ref,PX8603990,CDM,300,RC,86039,CPT,90,,,,,,,52,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,25.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.23,50.96
Assay Biovlbl Testosterone Direct Measurement - Ref,PX8441090,CDM,300,RC,84410,CPT,90,,,,,,,52,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,25.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.6008,50.96
Assay Biovlbl Testosterone Direct Measurement - Ref,PX8441090,CDM,300,RC,84410,CPT,90,,,,,,,52,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,25.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.6008,50.96
Assay Biovlbl Testosterone Direct Measurement - Ref,PX8441090,CDM,300,RC,84410,CPT,90,,,,,,,52,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,25.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.6008,50.96
"Beta 2 Glycoprot 1 Ab,Ea - Ref",PX8614690,CDM,300,RC,86146,CPT,90,,,,,,,52,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,25.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.6008,50.96
"Beta 2 Glycoprot 1 Ab,Ea - Ref",PX8614690,CDM,300,RC,86146,CPT,90,,,,,,,52,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,25.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.6008,50.96
"Beta 2 Glycoprot 1 Ab,Ea - Ref",PX8614690,CDM,300,RC,86146,CPT,90,,,,,,,52,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,25.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.6008,50.96
Iron - Ref,PX8354090,CDM,300,RC,83540,CPT,90,,,,,,,52,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,25.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,50.96
Iron - Ref,PX8354090,CDM,300,RC,83540,CPT,90,,,,,,,52,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,25.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,50.96
Iron - Ref,PX8354090,CDM,300,RC,83540,CPT,90,,,,,,,52,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,25.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,50.96
Rickettsia Antibody - Ref,PX8675790,CDM,300,RC,86757,CPT,90,,,,,,,52,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,25.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.74,50.96
Rickettsia Antibody - Ref,PX8675790,CDM,300,RC,86757,CPT,90,,,,,,,52,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,25.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.74,50.96
Rickettsia Antibody - Ref,PX8675790,CDM,300,RC,86757,CPT,90,,,,,,,52,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,25.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.74,50.96
SPIT SOCK HOODS 16719,120.367,CDM,271,RC,,,,10820-MAIN,LOCAL,,,,,26,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,25.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.8004,25.48
TEGADERM CHLORHEXIDINE 5X5 CHG IV PORT,120.207,CDM,272,RC,A6268,HCPCS,,10163-MAIN,LOCAL,,,,,26,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,25.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.8004,25.48
Uric Acid; Blood,PX84550,CDM,300,RC,84550,CPT,,,,,,,,52,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,22.35,percent of total billed charges,25.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.14,50.96
Uric Acid; Blood,PX84550,CDM,300,RC,84550,CPT,,,,,,,,52,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,25.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.14,50.96
Uric Acid; Blood,PX84550,CDM,300,RC,84550,CPT,,,,,,,,52,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,25.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.14,50.96
ROPivacaine 2 MG/ML Solution 10 mL Vial,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028513,NDC,10,ML,52.01,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,25.4849,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.604954,269.6078
ROPivacaine 2 MG/ML Solution 10 mL Vial,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028513,NDC,10,ML,52.01,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,25.4849,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.604954,269.6078
ROPivacaine 2 MG/ML Solution 10 mL Vial,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028513,NDC,10,ML,52.01,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,25.4849,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.604954,269.6078
lidocaine 4 % Cream 5 g Tube,63700001,CDM,250,RC,,,,,,496088205,NDC,5,GR,51.49,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,25.48755,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Citrate - Ref,PX8250790,CDM,300,RC,82507,CPT,90,,,,,,,56,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,25.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.2624,54.88
8MM ENDOWRIST INSTRUMENTS MEDIUM LARGE CLIP APPLIER,27200000,CDM,272,RC,,,,11910-MAIN,LOCAL,,,,,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,2,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.852986,29.4
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,3,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.852986,29.4
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061603,NDC,3,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,641600601,NDC,0.5,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
bacteriostatic water(benz alc) Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409397703,NDC,30,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BULB RESERVOIR SILICONE 400CC,27200000,CDM,272,RC,,,,12463-MAIN,LOCAL,,,,,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600710,NDC,2,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,38.9354
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409115918,NDC,1,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046401,NDC,1,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046402,NDC,1,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046437,NDC,1,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,409174670,NDC,1,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046801,NDC,1,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046817,NDC,1,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BUPivacaine in dextrose 0.75-8.25 % Solution 2 mL Ampule,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409176162,NDC,2,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046601,NDC,1,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143992490,NDC,0.5,EA,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010110,NDC,0.5,EA,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010167,NDC,0.5,EA,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,44567070725,NDC,0.5,EA,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733201,NDC,0.5,EA,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733801,NDC,0.5,EA,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,70069000501,NDC,0.1,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,63.2394
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016502,NDC,0.5,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016516,NDC,0.5,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036721,NDC,1,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036725,NDC,1,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 100 MG/10ML Solution 10 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323051610,NDC,0.5,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050641,NDC,0.5,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141031,NDC,0.5,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,641037621,NDC,0.25,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066416,NDC,1,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066441,NDC,0.25,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010101,NDC,0.25,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
DRAPE SPLIT WITH ADHESIVE DYNJP8304A,27200000,CDM,272,RC,,,,4694-MAIN,LOCAL,,,,,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRESSING HYDROFERA 2-1/2X2-1/2  BLUE READY FOAM HBRS2520,120.488,CDM,271,RC,A6209,HCPCS,,11537-MAIN,LOCAL,,,,,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
"Ethanol, P",PX82077,CDM,300,RC,82077,CPT,,,,,,,,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073916,NDC,2,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,29.4
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073941,NDC,1,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,29.4
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,67457043300,NDC,1,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,29.4
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909422,NDC,2,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
folic acid 5 MG/ML Solution 10 mL Vial,J3490.94,CDM,636,RC,J3490,HCPCS,,,,39822110001,NDC,0.2,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,330.2012
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,70860030242,NDC,1,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,36000028425,NDC,2,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001094,NDC,2,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,42.5516
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,781382571,NDC,0.5,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,143931901,NDC,0.4,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.428
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272002,NDC,1,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272031,NDC,1,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,25021040010,NDC,1,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323054011,NDC,1,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095300,NDC,0.5,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095310,NDC,1,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,71288042095,NDC,0.5,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306424,NDC,1,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306413,NDC,1,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306521,NDC,3,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin lock flush 10 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306510,NDC,5,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
HYDROmorphone 1 MG/ML Solution 1 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,76045000901,NDC,0.25,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016216,NDC,1,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016243,NDC,0.5,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072201,NDC,0.5,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072225,NDC,0.5,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016226,NDC,0.5,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016245,NDC,0.5,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011901,NDC,0.5,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011925,NDC,0.5,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072501,NDC,0.5,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072525,NDC,0.5,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143932001,NDC,1,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143962201,NDC,1,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,409226720,NDC,1,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,47781058629,NDC,1,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,51991093498,NDC,1,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,409427616,NDC,20,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323048526,NDC,20,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,63323049241,NDC,2,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2% PF 2 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049526,NDC,5,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2% PF 2 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049541,NDC,5,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine buffered 1 % Solution 0.5 mL Syringe,25000000,CDM,250,RC,,,,,,8888800160,NDC,0.5,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604401,NDC,1,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604425,NDC,1,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620701,NDC,0.25,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620725,NDC,1,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
magnesium sulfate 50 % Solution 10 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006404,NDC,2,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,703450284,NDC,2,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.859
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,409177815,NDC,5,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,70860030005,NDC,1.25,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metroNIDAZOLE 500 MG/100ML Solution 100 mL Plas Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,338954124,NDC,100,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,31.4776
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605701,NDC,2,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605725,NDC,1,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060031,NDC,2,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060041,NDC,2,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 5 MG/ML Solution 1 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606101,NDC,0.2,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230504,NDC,0.5,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230505,NDC,5,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam PF 10 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230802,NDC,2,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,43598052936,NDC,0.5,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080601,NDC,0.5,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080610,NDC,0.5,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,409475503,NDC,2,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054731,NDC,2,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054831,NDC,2,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054842,NDC,2,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092825,NDC,1,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,31.5854
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488802,NDC,10,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018603,NDC,20,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018620,NDC,20,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 50 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488850,NDC,3,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride bacteriostatic 0.9 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409196602,NDC,30,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride bacteriostatic 0.9 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409196607,NDC,30,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,64253002030,NDC,10,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409488710,NDC,10,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409488717,NDC,10,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
SUTURE BIOSYN MONOFILAMENT ABSORBABLE UNDYED SIZE 4-0 18IN WITH 3/8 CIRCLE REVERSE CUTTING 19MM NEED,27200000,CDM,272,RC,,,,11987-MAIN,LOCAL,,,,,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE MONOFILAMENT SZ 4-0 BIOSYN ABSORBABLE UNDYED18IN WITH 3/8 CIRCLE REVERSE CUTTING 19MM NEED SM,27200000,CDM,272,RC,,,,11984-MAIN,LOCAL,,,,,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TRAY LUMBAR 22GAX3.5 PUNCTURE SAFE-T 4306CWSP,120.18,CDM,272,RC,,,,11584-MAIN,LOCAL,,,,,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
TRAY LUMBAR 22X1.5 PUNCTURE PEDS 4302CSP,120.18,CDM,272,RC,,,,652-MAIN,LOCAL,,,,,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
triamcinolone acetonide 10 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3049420,NDC,0.25,ML,30,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,72.0986
"Albumin; Other Source, Quantitative, Each Specimen",PX82042,CDM,300,RC,82042,CPT,,,,,,,,28,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,25.508,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.13,27.44
Anesthesia Level - Regional,PX37000025,CDM,370,RC,,,,,,,,,,28,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,25.508,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
Gonadotropin (Lh),PX83002,CDM,300,RC,83002,CPT,,,,,,,,28,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,25.508,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
PROMOGRAN PRISMA AG COLLAGEN DRESSING 28CM,120.547,CDM,272,RC,A6021,HCPCS,,12361-MAIN,LOCAL,,,,,28,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,25.508,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
SCOPE BRONCHOSCOPE SZ 4 STERILE DISPOSABLE B120044,120.574,CDM,272,RC,,,,12868-MAIN,LOCAL,,,,,28,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,25.508,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
tranexamic acid 650 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,69918030130,NDC,1,EA,28,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,25.508,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Viral Neutralization - Ref,PX8638290,CDM,300,RC,86382,CPT,90,,,,,,,28,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,25.508,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,25021050002,NDC,1,ML,52.06,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,25.5094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,25021050002,NDC,1,ML,52.06,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,25.5094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,25021050002,NDC,1,ML,52.06,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,25.5094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
"Apply Forearm Splint,Static",PX29125F,CDM,510,RC,29125,CPT,,,,,,,,223,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,25.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.08,141.82
"Apply Forearm Splint,Static",PX29125F,CDM,510,RC,29125,CPT,,,,,,,,223,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,25.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.08,141.82
"Apply Forearm Splint,Static",PX29125P,CDM,983,RC,29125,CPT,,,,,,,,296,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,25.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.08,290.08
"Apply Forearm Splint,Static",PX29125P,CDM,983,RC,29125,CPT,,,,,,,,296,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,25.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.08,290.08
Blood Transfusion Service,PX36430,CDM,391,RC,36430,CPT,,,,,,,,839,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,25.52,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.52,87.86
Diagnostic Anoscopy,PX46600F,CDM,510,RC,46600,CPT,,,,,,,,505,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,25.52,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.52,244.9
Diagnostic Anoscopy,PX46600P,CDM,983,RC,46600,CPT,,,,,,,,405,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,25.52,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.52,396.9
Eval of Bronchospasm,PX94060,CDM,983,RC,94060,CPT,,,,,,,,176,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,25.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.08,172.48
Eval of Bronchospasm,PX94060,CDM,983,RC,94060,CPT,,,,,,,,176,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,25.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.08,172.48
"Remv F.B.,Eye,Cornea,No Slit",PX65220F,CDM,510,RC,65220,CPT,,,,,,,,334,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,25.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.52,125.91
"Remv F.B.,Eye,Cornea,No Slit",PX65220F,CDM,510,RC,65220,CPT,,,,,,,,334,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,25.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.52,125.91
"Remv F.B.,Eye,Cornea,No Slit",PX65220F,CDM,510,RC,65220,CPT,,,,,,,,334,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,25.52,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.52,125.91
"Remv F.B.,Eye,Cornea,No Slit",PX65220P,CDM,983,RC,65220,CPT,,,,,,,,318,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,25.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.52,311.64
"Remv F.B.,Eye,Cornea,No Slit",PX65220P,CDM,983,RC,65220,CPT,,,,,,,,318,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,25.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.52,311.64
"Remv F.B.,Eye,Cornea,No Slit",PX65220P,CDM,983,RC,65220,CPT,,,,,,,,318,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,25.52,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.52,311.64
oxyCODONE CR 20 MG Tablet ER 12 hour Abuse-Deterrent 20 Each Box,63700001,CDM,250,RC,,,,,,59011042020,NDC,1,EA,52.09,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,25.5241,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE CR 20 MG Tablet ER 12 hour Abuse-Deterrent 20 Each Box,63700001,CDM,250,RC,,,,,,59011042020,NDC,1,EA,52.09,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,25.5241,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE CR 20 MG Tablet ER 12 hour Abuse-Deterrent 20 Each Box,63700001,CDM,250,RC,,,,,,59011042020,NDC,1,EA,52.09,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,25.5241,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"lidocaine 2%-EPINEPHrine 1:100,000 2 %-1:100000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,409318221,NDC,30,ML,51.57,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,25.52715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Emergency Level II Visit,PX99282P,CDM,981,RC,99282,CPT,,,,,,,,337,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,25.53,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.53,330.26
Facility Emergency Level II Visit,PX99282F,CDM,450,RC,99282,CPT,,,,,,,,387,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,25.53,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.53,74.15
dabigatran 75 MG capsule 60 Each Box,63700001,CDM,250,RC,,,,,,597035556,NDC,1,EA,53.27,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,25.5696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dabigatran 75 MG capsule 60 Each Box,63700001,CDM,250,RC,,,,,,597035556,NDC,1,EA,53.27,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,25.5696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Ecg 12 Lead, Interp Only",PX93010,CDM,985,RC,93010,CPT,,,,,,,,29,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,25.578,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.0466,28.2257
Microscopic Exam of Urine,PX81015,CDM,300,RC,81015,CPT,,,,,,,,29,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,25.578,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.8,28.42
TRAY ARTHROGRAM SAFE-T-ARTHRO 28-AR1CO,120.2,CDM,272,RC,,,,11499-MAIN,LOCAL,,,,,29,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,25.578,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.0466,194.04
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016200,NDC,1,ML,52.22,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,6.702727273,percent of total billed charges,25.5878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016200,NDC,1,ML,52.22,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,25.5878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016200,NDC,1,ML,52.22,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,25.5878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8092351,NDC,1,EA,52.22,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,24.94142857,percent of total billed charges,25.5878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8092351,NDC,1,EA,52.22,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,25.5878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8092351,NDC,1,EA,52.22,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,25.5878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400101,NDC,1,EA,52.22,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,24.94142857,percent of total billed charges,25.5878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400101,NDC,1,EA,52.22,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,25.5878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400101,NDC,1,EA,52.22,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,25.5878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400125,NDC,1,EA,52.22,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,24.94142857,percent of total billed charges,25.5878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400125,NDC,1,EA,52.22,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,25.5878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400125,NDC,1,EA,52.22,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,25.5878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
apixaban 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,3089331,NDC,1,EA,50.57,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,25.58842,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Immunization Administration; Each Add'l Vaccine (Single or Combo Vaccine/T*,PX90472,CDM,771,RC,90472,CPT,,,,,,,,48,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,25.59,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.16,25.59
Immunization Administration; Each Add'l Vaccine (Single or Combo Vaccine/T*,PX90472,CDM,771,RC,90472,CPT,,,,,,,,48,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,25.59,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.16,25.59
etomidate 2 MG/ML Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,55150022220,NDC,10,ML,50.58,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,25.59348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004624,NDC,50,ML,50.58,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,25.59348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,70655000206,NDC,100,ML,59.67,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,25.59843,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.786918,140.5516
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457000110,NDC,10,ML,59.67,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,25.59843,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013266,NDC,50,ML,59.67,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,25.59843,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013268,NDC,150,ML,59.67,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,25.59843,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
Endocrine E2,PX82670,CDM,300,RC,82670,CPT,90,,,,,,,55,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,25.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,53.9
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714000601,NDC,0.3,ML,53.39,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,25.6272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714000601,NDC,0.3,ML,53.39,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,25.6272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
mepolizumab 100 MG Recon Soln 1 Each Vial,J2182.01,CDM,636,RC,J2182,HCPCS,,,,173088101,NDC,1,EA,6959.95,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,25.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.56,30.51
mepolizumab 100 MG Recon Soln 1 Each Vial,J2182.01,CDM,636,RC,J2182,HCPCS,,,,173088101,NDC,1,EA,6959.95,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,25.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.56,30.51
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,67457022800,NDC,5,ML,53.42,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,25.6416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,67457022800,NDC,5,ML,53.42,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,25.6416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,67457057305,NDC,5,ML,53.42,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,25.6416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,67457057305,NDC,5,ML,53.42,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,25.6416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BUPivacaine 0.25 % Solution 50 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046557,NDC,30,ML,59.84,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,25.67136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
"Blood Gases: Ph, Po2 & Pco2",PX82803,CDM,300,RC,82803,CPT,,,,,,,,518,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,25.672,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.29,26.07
clotrimazole 1 % Cream 28.35 g Tube,25000000,CDM,250,RC,,,,,,904782231,NDC,28.35,GR,50.75,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,25.6795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
magnesium sulfate 1 g in 100 ml D5W (premix) 1-5 GM/100ML-% Solution 100 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010802,NDC,100,ML,52.51,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,5.851071429,percent of total billed charges,25.7299,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
magnesium sulfate 1 g in 100 ml D5W (premix) 1-5 GM/100ML-% Solution 100 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010802,NDC,100,ML,52.51,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,25.7299,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
magnesium sulfate 1 g in 100 ml D5W (premix) 1-5 GM/100ML-% Solution 100 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010802,NDC,100,ML,52.51,,United Healthcare,All Medicare advantage plans,outpatient,49,,13.925,percent of total billed charges,25.7299,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
Antinuclear Ab(Ana) Titer - Ref,PX8603990,CDM,300,RC,86039,CPT,90,,,,,,,52,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,25.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.23,50.96
Assay Biovlbl Testosterone Direct Measurement - Ref,PX8441090,CDM,300,RC,84410,CPT,90,,,,,,,52,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,25.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.6008,50.96
"Beta 2 Glycoprot 1 Ab,Ea - Ref",PX8614690,CDM,300,RC,86146,CPT,90,,,,,,,52,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,25.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.6008,50.96
Capillary Blood Collection,PX36416,CDM,300,RC,36416,CPT,,,,,,,,60,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,25.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,58.8
"Chest Wall Manipulation,Subsequent",PX94668F,CDM,410,RC,94668,CPT,,,,,,,,192,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,25.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.78,68.64
"Chest Wall Manipulation,Subsequent",PX94668F,CDM,410,RC,94668,CPT,,,,,,,,192,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,25.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.78,68.64
HERNIA BELT MENS TRUSS LARGE,120.526,CDM,274,RC,L8310,HCPCS,,12221-MAIN,LOCAL,,,,,60,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,25.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,160.6
HERNIA BELT MENS TRUSS MEDIUM,120.526,CDM,274,RC,L8310,HCPCS,,12220-MAIN,LOCAL,,,,,60,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,25.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,160.6
HERNIA BELT MENS TRUSS XLARGE,120.526,CDM,274,RC,L8310,HCPCS,,12222-MAIN,LOCAL,,,,,60,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,25.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,160.6
"IMMOBILIZER KNEE  24"" 7041-44",120.22,CDM,274,RC,L1830,HCPCS,,595-MAIN,LOCAL,,,,,60,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,25.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE 16"" UNIVERSAL 7088-04",120.22,CDM,274,RC,L1830,HCPCS,,589-MAIN,LOCAL,,,,,60,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,25.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
IMMOBILIZER KNEE 20 INCH ORT2420019,120.22,CDM,274,RC,L1830,HCPCS,,587-MAIN,LOCAL,,,,,60,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,25.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE 20"" LARGE FOAM COUNTOURED STAYS 7062-03",120.22,CDM,274,RC,L1830,HCPCS,,593-MAIN,LOCAL,,,,,60,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,25.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE 20"" QUICK-WRAP ORT2440020S",120.22,CDM,274,RC,L1830,HCPCS,,591-MAIN,LOCAL,,,,,60,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,25.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
IMMOBILIZER KNEE CUTAWAY STRAIGHT 2 7041-05,120.22,CDM,274,RC,L1830,HCPCS,,596-MAIN,LOCAL,,,,,60,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,25.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
Iron - Ref,PX8354090,CDM,300,RC,83540,CPT,90,,,,,,,52,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,25.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,50.96
Rickettsia Antibody - Ref,PX8675790,CDM,300,RC,86757,CPT,90,,,,,,,52,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,25.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.74,50.96
Uric Acid; Blood,PX84550,CDM,300,RC,84550,CPT,,,,,,,,52,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,25.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.14,50.96
Xray Lumbosacral Minimum 4 Vws,PX7211001,CDM,320,RC,72110,CPT,TC,,,,,,,565,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,25.74,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.74,78.23
US Follicles-Limited Tc,PX7685701,CDM,402,RC,76857,CPT,TC,,,,,,,300,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,25.744,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.58,51.93
X-Ray Exam Abdomen 2 Views,PX7401901,CDM,320,RC,74019,CPT,TC,,,,,,,436,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,25.744,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.01,51.28
Xray Shoulder Minimum 2 Vws,PX7303001,CDM,320,RC,73030,CPT,TC,,,,,,,365,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,25.744,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.79,51.28
Xray Temporomandib Jnt Unilat,PX7032801,CDM,320,RC,70328,CPT,TC,,,,,,,385,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,25.744,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.01,51.28
Xray Wrist 2 Vws,PX7310001,CDM,320,RC,73100,CPT,TC,,,,,,,365,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,25.744,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.01,51.28
ROPivacaine 2 MG/ML Solution 10 mL Vial,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028513,NDC,10,ML,52.01,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,25.74495,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.604954,269.6078
hydrocortisone 2.5 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,168008031,NDC,30,GR,61.99,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,25.750646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay Vitamin B-6,PX84207,CDM,300,RC,84207,CPT,90,,,,,,,42,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,25.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
atropine 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100401,NDC,0.5,ML,50.91,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,25.76046,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
acetaZOLAMIDE 500 MG Recon Soln 1 Each Vial,J1120.01,CDM,636,RC,J1120,HCPCS,,,,39822019001,NDC,1,EA,207.84,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,25.76817,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.74,28.12
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,25021050002,NDC,1,ML,52.06,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,25.7697,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
oxyCODONE CR 20 MG Tablet ER 12 hour Abuse-Deterrent 20 Each Box,63700001,CDM,250,RC,,,,,,59011042020,NDC,1,EA,52.09,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,25.78455,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011801,NDC,0.5,ML,52.63,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.717962963,percent of total billed charges,25.7887,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011801,NDC,0.5,ML,52.63,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,25.7887,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011801,NDC,0.5,ML,52.63,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,25.7887,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011805,NDC,0.5,ML,52.63,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.717962963,percent of total billed charges,25.7887,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011805,NDC,0.5,ML,52.63,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,25.7887,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011805,NDC,0.5,ML,52.63,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,25.7887,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
OLANZapine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60505311000,NDC,1,EA,60.13,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,25.79577,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DRAPE STERILE 109X100X110 ROBOTIC DYNJP9108,27200000,CDM,272,RC,,,,12020-MAIN,LOCAL,,,,,51,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,25.806,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Immunohisto Antibody Slide Ea Multiplex,PX8834401,CDM,310,RC,88344,CPT,TC,,,,,,,51,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,25.806,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,314.02
RANGER UNIT TUBING FLUID WARMING,120.229,CDM,272,RC,,,,10612-MAIN,LOCAL,,,,,51,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,25.806,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,49.98
SCAR GEL SHEET,120.458,CDM,273,RC,A6025,HCPCS,,5796-MAIN,LOCAL,,,,,51,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,25.806,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,49.98
TUBE FEEDING DECLOGGING SYSTEM CLOG ZAPPER 20-0002,120.277,CDM,272,RC,,,,4226-MAIN,LOCAL,,,,,51,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,25.806,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,49.98
"Ecg 12 Lead, Interp Only",PX93010,CDM,985,RC,93010,CPT,,,,,,,,29,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,25.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.0466,28.2257
Microscopic Exam of Urine,PX81015,CDM,300,RC,81015,CPT,,,,,,,,29,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,25.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.8,28.42
TRAY ARTHROGRAM SAFE-T-ARTHRO 28-AR1CO,120.2,CDM,272,RC,,,,11499-MAIN,LOCAL,,,,,29,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,25.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.0466,194.04
"Hla a, B or C, Single Ag - Ref",PX8681290,CDM,300,RC,86812,CPT,90,,,,,,,89,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,25.81,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.04,25.81
Surg Pathology-Level 2-Tc,PX3932,CDM,310,RC,88302,CPT,TC,,,,,,,66,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,25.81,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.41,43.344
"Testosterone, Total - Ref",PX8440390,CDM,300,RC,84403,CPT,90,,,,,,,43,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,25.81,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.04,25.81
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,16714001905,NDC,2,ML,62.17,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,25.825418,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,16714001930,NDC,2,ML,62.17,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,25.825418,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
zinc oxide 20 % Ointment 56.7 g Tube,63700001,CDM,250,RC,,,,,,168006202,NDC,56.7,GR,30.39,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.8315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine buffered 1 % Solution 22.2 mL Vial,25000000,CDM,250,RC,,,,,,8888800251,NDC,22.2,ML,30.4,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine buffered 1% Solution 22.2 mL Vial,25000000,CDM,250,RC,,,,,,8888800251,NDC,22.2,ML,30.4,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016200,NDC,1,ML,52.22,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,25.8489,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8092351,NDC,1,EA,52.22,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,25.8489,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400101,NDC,1,EA,52.22,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,25.8489,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400125,NDC,1,EA,52.22,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,25.8489,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048557,NDC,50,ML,52.78,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,25.8622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048557,NDC,50,ML,52.78,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,25.8622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048557,NDC,50,ML,52.78,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,25.8622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
amoxicillin-clavulanate 875-125 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862050301,NDC,1,EA,26.59,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,25.880047,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006403,NDC,2,ML,30.45,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.8825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
cemiplimab-rwlc 350 MG/7ML Solution 7 mL Vial,J9119.01,CDM,636,RC,J9119,HCPCS,,,,61755000801,NDC,7,ML,19219.32,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,25.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.79,28.83
cemiplimab-rwlc 350 MG/7ML Solution 7 mL Vial,J9119.01,CDM,636,RC,J9119,HCPCS,,,,61755000801,NDC,7,ML,19219.32,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,25.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.79,28.83
budesonide 0.5 MG/2ML Suspension 2 mL Ampule,25000000,CDM,250,RC,,,,,,68180098405,NDC,2,ML,62.38,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,25.912652,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,781751614,NDC,2,ML,62.38,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,25.912652,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,781751687,NDC,2,ML,62.38,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,25.912652,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097031986,NDC,2,ML,62.38,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,25.912652,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,781323294,NDC,1,EA,52.89,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,24.94142857,percent of total billed charges,25.9161,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,781323294,NDC,1,EA,52.89,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,25.9161,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,781323294,NDC,1,EA,52.89,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,25.9161,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
oxyCODONE CR 10 MG Tablet ER 12 hour Abuse-Deterrent 20 Each Box,63700001,CDM,250,RC,,,,,,59011041020,NDC,1,EA,26.63,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,25.918979,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405F,CDM,510,RC,36405,CPT,,,,,,,,54,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,25.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.4316,52.92
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405F,CDM,510,RC,36405,CPT,,,,,,,,54,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,25.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.4316,52.92
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093102,NDC,1,ML,60.47,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,25.94163,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,49348009529,NDC,15,ML,30.53,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.9505,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Inject Nerv Blck,Othr Periph Nerv",PX64450F,CDM,510,RC,64450,CPT,,,,,,,,757,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,25.96,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.96,156.35
"Inject Nerv Blck,Othr Periph Nerv",PX64450P,CDM,983,RC,64450,CPT,,,,,,,,904,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,25.96,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.96,885.92
Diagnostic Anoscopy,PX46600F,CDM,510,RC,46600,CPT,,,,,,,,505,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,25.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.52,244.9
Diagnostic Anoscopy,PX46600F,CDM,510,RC,46600,CPT,,,,,,,,505,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,25.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.52,244.9
Diagnostic Anoscopy,PX46600P,CDM,983,RC,46600,CPT,,,,,,,,405,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,25.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.52,396.9
Diagnostic Anoscopy,PX46600P,CDM,983,RC,46600,CPT,,,,,,,,405,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,25.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.52,396.9
"Inject Nerv Blck,Othr Periph Nerv",PX64450F,CDM,510,RC,64450,CPT,,,,,,,,757,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,25.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.96,156.35
"Inject Nerv Blck,Othr Periph Nerv",PX64450F,CDM,510,RC,64450,CPT,,,,,,,,757,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,25.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.96,156.35
"Inject Nerv Blck,Othr Periph Nerv",PX64450P,CDM,983,RC,64450,CPT,,,,,,,,904,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,25.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.96,885.92
"Inject Nerv Blck,Othr Periph Nerv",PX64450P,CDM,983,RC,64450,CPT,,,,,,,,904,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,25.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.96,885.92
lidocaine HCl 4 % Cream 133 g Tube,63700001,CDM,250,RC,,,,,,41167005828,NDC,133,GR,52.99,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,25.9651,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine HCl 4 % Cream 133 g Tube,63700001,CDM,250,RC,,,,,,41167005828,NDC,133,GR,52.99,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,25.9651,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine HCl 4 % Cream 133 g Tube,63700001,CDM,250,RC,,,,,,41167005828,NDC,133,GR,52.99,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,25.9651,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ivermectin 3 MG Tablet 20 Each Box,63700001,CDM,250,RC,,,,,,42799080601,NDC,1,EA,26.68,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,25.967644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Dystrophic Nail Trimming Any Number,PXG0127F,CDM,940,RC,G0127,HCPCS,,,,,,,,53,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,25.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.0162,53.44
Dystrophic Nail Trimming Any Number,PXG0127F,CDM,940,RC,G0127,HCPCS,,,,,,,,53,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,25.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.0162,53.44
Dystrophic Nail Trimming Any Number,PXG0127F,CDM,940,RC,G0127,HCPCS,,,,,,,,53,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,25.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.0162,53.44
Renin - Ref,PX8424490,CDM,300,RC,84244,CPT,90,,,,,,,53,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,25.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.16,51.94
Renin - Ref,PX8424490,CDM,300,RC,84244,CPT,90,,,,,,,53,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,25.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.16,51.94
Renin - Ref,PX8424490,CDM,300,RC,84244,CPT,90,,,,,,,53,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,25.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.16,51.94
magnesium sulfate 1 g in 100 ml D5W (premix) 1-5 GM/100ML-% Solution 100 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010802,NDC,100,ML,52.51,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,25.99245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010125,NDC,1,ML,30.58,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.993,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323048541,NDC,20,ML,30.58,,First Health,Commercial,both,85,,999999999,percent of total billed charges,25.993,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338067104,NDC,1000,ML,53.06,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1.633818182,percent of total billed charges,25.9994,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338067104,NDC,1000,ML,53.06,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,25.9994,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338067104,NDC,1000,ML,53.06,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,25.9994,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
sacubitril-valsartan 24-26 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,78065920,NDC,1,EA,62.6,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,26.00404,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Needle Insertion W/O Injection 1 or 2 Muscles,PX20560,CDM,420,RC,20560,CPT,,,,,,,,10,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,26.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,26.01
Needle Insertion W/O Injection 3 or More Muscles,PX20561,CDM,420,RC,20561,CPT,,,,,,,,10,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,26.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.154,26.01
RESERVOIR WOUND DRAIN 15FR,27200000,CDM,272,RC,,,,4386-MAIN,LOCAL,,,,,30.6,,First Health,Commercial,both,85,,999999999,percent of total billed charges,26.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Resp Muscles 1:1 per 15 Min,PXG0237,CDM,948,RC,G0237,HCPCS,,,,,,,,65,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,26.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.01,63.7
SET DISPOSABLE COLLECTION,27100000,CDM,271,RC,,,,5439-MAIN,LOCAL,,,,,30.6,,First Health,Commercial,both,85,,999999999,percent of total billed charges,26.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
Surg Pathology-Level 2-Tc,PX3932,CDM,310,RC,88302,CPT,TC,,,,,,,66,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,26.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.01,64.68
SUTURE NUROLON 0 BLACK C527D,27200000,CDM,272,RC,,,,10415-MAIN,LOCAL,,,,,30.6,,First Health,Commercial,both,85,,999999999,percent of total billed charges,26.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703331101,NDC,0.75,ML,51.41,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,26.01346,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
LAP SPONGES 18x18 7INCH LOOP,27200000,CDM,272,RC,,,,604-MAIN,LOCAL,,,,,60.64,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,26.01456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ezetimibe 10 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,16729043316,NDC,1,EA,60.66,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,26.02314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
montelukast 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268057511,NDC,1,EA,26.75,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,26.035775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
montelukast 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268057515,NDC,1,EA,26.75,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,26.035775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714078401,NDC,0.4,EA,60.72,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,26.04888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011801,NDC,0.5,ML,52.63,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,26.05185,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011805,NDC,0.5,ML,52.63,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,26.05185,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
lidocaine 4 % Cream 5 g Tube,63700001,CDM,250,RC,,,,,,496088205,NDC,5,GR,51.49,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,26.05394,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin-clavulanate 875-125 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862050301,NDC,1,EA,26.59,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,26.0582,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Xray Foot Minimum 3 Vws,PX7363001,CDM,320,RC,73630,CPT,TC,,,,,,,404,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,26.0658,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,51.93
Xray Knee 1 or 2 Vws,PX7356001,CDM,320,RC,73560,CPT,TC,,,,,,,303,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,26.0658,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,51.93
Xray Ribs Unilat 2 Vws,PX7110001,CDM,320,RC,71100,CPT,TC,,,,,,,437,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,26.0658,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,51.93
"Blood Gases: Ph, Po2 & Pco2",PX82803,CDM,300,RC,82803,CPT,,,,,,,,518,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,26.07,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.29,26.07
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,76282066339,NDC,100,GR,26.8,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,26.08444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 2%-EPINEPHrine 1:100,000 2 %-1:100000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,409318221,NDC,30,ML,51.57,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,26.09442,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
oxyCODONE CR 10 MG Tablet ER 12 hour Abuse-Deterrent 20 Each Box,63700001,CDM,250,RC,,,,,,59011041020,NDC,1,EA,26.63,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,26.0974,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dabigatran 75 MG capsule 60 Each Box,63700001,CDM,250,RC,,,,,,597035556,NDC,1,EA,53.27,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,26.1023,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dabigatran 75 MG capsule 60 Each Box,63700001,CDM,250,RC,,,,,,597035556,NDC,1,EA,53.27,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,26.1023,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dabigatran 75 MG capsule 60 Each Box,63700001,CDM,250,RC,,,,,,597035556,NDC,1,EA,53.27,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,26.1023,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 2.5 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,45802000403,NDC,28,GR,60.85,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,26.10465,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Manual Ther Tech,1+Regions,Ea 15 Min",PX97140,CDM,420,RC,97140,CPT,,,,,,,,135,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,26.1144,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.47,35.58
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048557,NDC,50,ML,52.78,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,26.1261,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,36000003310,NDC,5,ML,30.74,,First Health,Commercial,both,85,,999999999,percent of total billed charges,26.129,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sucralfate 1 GM/10ML Suspension 10 mL Cup,63700001,CDM,250,RC,,,,,,68094004359,NDC,10,ML,60.92,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,26.13468,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Emergency Level II Visit,PX99282P,CDM,981,RC,99282,CPT,,,,,,,,337,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,26.14,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.53,330.26
Emergency Level II Visit,PX99282P,CDM,981,RC,99282,CPT,,,,,,,,337,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,26.14,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.53,330.26
Facility Emergency Level II Visit,PX99282F,CDM,450,RC,99282,CPT,,,,,,,,387,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,26.14,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.53,74.15
Facility Emergency Level II Visit,PX99282F,CDM,450,RC,99282,CPT,,,,,,,,387,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,26.14,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.53,74.15
ivermectin 3 MG Tablet 20 Each Box,63700001,CDM,250,RC,,,,,,42799080601,NDC,1,EA,26.68,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,26.1464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714000601,NDC,0.3,ML,53.39,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,9.81,percent of total billed charges,26.1611,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714000601,NDC,0.3,ML,53.39,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,26.1611,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714000601,NDC,0.3,ML,53.39,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,26.1611,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
dexmedeTOMIDine 200 MCG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,143953201,NDC,2,ML,62.98,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,26.161892,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fluvastatin 20 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,378802093,NDC,1,EA,26.88,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,26.162304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Protoporphyrin, RBC, Qnt - Ref",PX8420290,CDM,300,RC,84202,CPT,90,,,,,,,61,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,26.169,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.16,59.78
"Venipuncture, Lab",PX3641502,CDM,300,RC,36415,CPT,,,,,,,,61,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,26.169,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.1,65.45
K-WIRE SMOOTH 1.4MM X 100MM,C1713,CDM,272,RC,C1713,HCPCS,,12634-MAIN,LOCAL,,,,,63,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,26.1702,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
SUTURE MAXON MONOFILAMENT ABSORBABLE GREEN SIZE 1 96IN WITH 1/2 CIRCLE TAPER POINT 65MM NEEDLE,27200000,CDM,272,RC,,,,11986-MAIN,LOCAL,,,,,63,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,26.1702,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Vitamin a - Ref,PX8459090,CDM,300,RC,84590,CPT,90,,,,,,,63,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,26.1702,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.65,61.74
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,67457022800,NDC,5,ML,53.42,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,26.1758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,67457022800,NDC,5,ML,53.42,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,26.1758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,67457022800,NDC,5,ML,53.42,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,26.1758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,67457057305,NDC,5,ML,53.42,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,26.1758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,67457057305,NDC,5,ML,53.42,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,26.1758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,67457057305,NDC,5,ML,53.42,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,26.1758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,781323294,NDC,1,EA,52.89,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,26.18055,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048657,NDC,50,ML,61.05,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,26.19045,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046417,NDC,10,ML,54.6,,Health Partners,Health Partners Care Plans,both,48,,0.387,percent of total billed charges,26.208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046417,NDC,10,ML,54.6,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,26.208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031801,NDC,1,ML,185.37,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,26.21,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.21,29.79
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031825,NDC,1,ML,185.37,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,26.21,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.21,29.79
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,143950601,NDC,10,ML,61.1,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,26.2119,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,143950610,NDC,10,ML,61.1,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,26.2119,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
montelukast 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268057511,NDC,1,EA,26.75,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,26.215,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
montelukast 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268057515,NDC,1,EA,26.75,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,26.215,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
KUMAR CHOLANGIOGRAPHY CATHETER,27200000,CDM,272,RC,,,,10230-MAIN,LOCAL,,,,,63.11,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,26.215894,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
acetaZOLAMIDE 500 MG Recon Soln 1 Each Vial,J1120.01,CDM,636,RC,J1120,HCPCS,,,,39822019001,NDC,1,EA,207.84,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,26.23,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.74,28.12
acetaZOLAMIDE 500 MG Recon Soln 1 Each Vial,J1120.01,CDM,636,RC,J1120,HCPCS,,,,39822019001,NDC,1,EA,207.84,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,26.23,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.74,28.12
lidocaine HCl 4 % Cream 133 g Tube,63700001,CDM,250,RC,,,,,,41167005828,NDC,133,GR,52.99,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,26.23005,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Dystrophic Nail Trimming Any Number,PXG0127F,CDM,940,RC,G0127,HCPCS,,,,,,,,53,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,26.235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.0162,53.44
Renin - Ref,PX8424490,CDM,300,RC,84244,CPT,90,,,,,,,53,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,26.235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.16,51.94
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409492120,NDC,10,ML,54.66,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,26.2368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409492120,NDC,10,ML,54.66,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,26.2368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305972,NDC,2,ML,61.19,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,26.25051,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305995,NDC,2,ML,61.19,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,26.25051,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,76282066339,NDC,100,GR,26.8,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,26.264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338067104,NDC,1000,ML,53.06,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,26.2647,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
BOOT CAST LARGE 12-5/8 ORT290010L,120.247,CDM,274,RC,L3260,HCPCS,,204-MAIN,LOCAL,,,,,27,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,26.2791,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
BOOT CAST MEDIUM 08148803,120.247,CDM,274,RC,L3260,HCPCS,,203-MAIN,LOCAL,,,,,27,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,26.2791,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
BOOT CAST X-LARGE 13X5-1/2IN ORT29200XL,120.247,CDM,274,RC,L3260,HCPCS,,206-MAIN,LOCAL,,,,,27,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,26.2791,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
KERRAMAX CARE SUPERABSORBENT DRESSING 8X12,120.55,CDM,272,RC,A6197,HCPCS,,12363-MAIN,LOCAL,,,,,27,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,26.2791,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
Or Time,PX36000086,CDM,360,RC,,,,,,,,,,27,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,26.2791,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
"Sodium, Other Source - Ref",PX8430290,CDM,300,RC,84302,CPT,90,,,,,,,27,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,26.2791,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.46,26.46
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43598055530,NDC,0.4,EA,61.26,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,26.28054,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43598096630,NDC,0.4,EA,61.26,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,26.28054,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
TEGADERM CHLORHEXIDINE-GLUCONATE,120.356,CDM,272,RC,A4221,HCPCS,,10708-MAIN,LOCAL,,,,,22,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,26.29,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.1275,26.29
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,45802011222,NDC,22,GR,63.29,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,26.290666,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tropicamide 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,24208058559,NDC,2,ML,61.3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,26.2977,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Itraconazole,PX8018990,CDM,300,RC,80189,CPT,90,,,,,,,124,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,26.3,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.3,27.11
Itraconazole,PX8018990,CDM,300,RC,80189,CPT,90,,,,,,,124,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,26.3,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.3,27.11
Itraconazole,PX8018990,CDM,300,RC,80189,CPT,90,,,,,,,124,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,26.3,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.3,27.11
Lacosamide - Ref,PX8023590,CDM,300,RC,80235,CPT,90,,,,,,,200,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,26.3,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.3,27.11
Lacosamide - Ref,PX8023590,CDM,300,RC,80235,CPT,90,,,,,,,200,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,26.3,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.3,27.11
Lacosamide - Ref,PX8023590,CDM,300,RC,80235,CPT,90,,,,,,,200,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,26.3,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.3,27.11
Voriconazole - Ref,PX8028590,CDM,300,RC,80285,CPT,90,,,,,,,183,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,26.3,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.3,27.11
Voriconazole - Ref,PX8028590,CDM,300,RC,80285,CPT,90,,,,,,,183,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,26.3,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.3,27.11
Voriconazole - Ref,PX8028590,CDM,300,RC,80285,CPT,90,,,,,,,183,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,26.3,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.3,27.11
Smking Cess 4-10 Min,PX99406F,CDM,942,RC,99406,CPT,,,,,,,,65,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,26.31,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.2,26.31
Smking Cess 4-10 Min,PX99406P,CDM,983,RC,99406,CPT,,,,,,,,43,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,26.31,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.2,42.14
Antinuclear Ab(Ana) Titer - Ref,PX8603990,CDM,300,RC,86039,CPT,90,,,,,,,52,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,26.312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.23,50.96
Assay Biovlbl Testosterone Direct Measurement - Ref,PX8441090,CDM,300,RC,84410,CPT,90,,,,,,,52,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,26.312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.6008,50.96
"Beta 2 Glycoprot 1 Ab,Ea - Ref",PX8614690,CDM,300,RC,86146,CPT,90,,,,,,,52,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,26.312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.6008,50.96
Iron - Ref,PX8354090,CDM,300,RC,83540,CPT,90,,,,,,,52,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,26.312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,50.96
Rickettsia Antibody - Ref,PX8675790,CDM,300,RC,86757,CPT,90,,,,,,,52,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,26.312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.74,50.96
Uric Acid; Blood,PX84550,CDM,300,RC,84550,CPT,,,,,,,,52,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,26.312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.14,50.96
Surg Pathology-Level 2-Tc,PX3932,CDM,310,RC,88302,CPT,TC,,,,,,,66,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,26.3138,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.41,43.344
ROPivacaine 2 MG/ML Solution 10 mL Vial,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028513,NDC,10,ML,52.01,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,26.31706,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.604954,269.6078
"Apply Finger Splint,Static",PX29130F,CDM,420,RC,29130,CPT,,,,,,,,196,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,26.3302,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.66,88.55
"Apply Finger Splint,Static",PX29130P,CDM,983,RC,29130,CPT,,,,,,,,223,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,26.3302,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.66,218.54
"Fac/Trm Hyperkeratotic Skn Lesn,>4",PX11057F,CDM,510,RC,11057,CPT,,,,,,,,175,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,26.3302,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.66,187.48
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057811,NDC,0.5,ML,30.98,,First Health,Commercial,both,85,,999999999,percent of total billed charges,26.333,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057841,NDC,0.5,ML,30.98,,First Health,Commercial,both,85,,999999999,percent of total billed charges,26.333,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,25021050002,NDC,1,ML,52.06,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,26.34236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
fluvastatin 20 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,378802093,NDC,1,EA,26.88,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,26.3424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608210,NDC,1,ML,63.43,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,26.348822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
DRAPE ABDOMINAL SURGICAL 14X12 POUCHES STERILE DYNJP3109,27200000,CDM,272,RC,,,,12896-MAIN,LOCAL,,,,,31,,First Health,Commercial,both,85,,999999999,percent of total billed charges,26.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LITHOTOMY PACK VIII ECLIPSE,27200000,CDM,272,RC,,,,12210-MAIN,LOCAL,,,,,31,,First Health,Commercial,both,85,,999999999,percent of total billed charges,26.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Rubella Antibody,PX86762,CDM,300,RC,86762,CPT,,,,,,,,31,,First Health,Commercial,both,85,,999999999,percent of total billed charges,26.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.8774,30.38
"Hydroxyprogesterone, 17-D - Ref",PX8349890,CDM,300,RC,83498,CPT,90,,,,,,,67,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,26.35,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.35,27.17
"Hydroxyprogesterone, 17-D - Ref",PX8349890,CDM,300,RC,83498,CPT,90,,,,,,,67,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,26.35,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.35,27.17
"Hydroxyprogesterone, 17-D - Ref",PX8349890,CDM,300,RC,83498,CPT,90,,,,,,,67,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,26.35,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.35,27.17
oxyCODONE CR 20 MG Tablet ER 12 hour Abuse-Deterrent 20 Each Box,63700001,CDM,250,RC,,,,,,59011042020,NDC,1,EA,52.09,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,26.35754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dabigatran 75 MG capsule 60 Each Box,63700001,CDM,250,RC,,,,,,597035556,NDC,1,EA,53.27,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,26.36865,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CATHETER FOLEY 18FR  3WAY 30CC 73018L,120.21,CDM,272,RC,A4346,HCPCS,,253-MAIN,LOCAL,,,,,33,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,26.3794,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.38,26.72
CATHETER FOLEY 20FR 3WAY 30CC 0167L20,120.21,CDM,272,RC,A4346,HCPCS,,251-MAIN,LOCAL,,,,,33,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,26.3794,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.38,26.72
CATHETER FOLEY 24FR 3WAY 30CC 0167L24,120.21,CDM,272,RC,A4346,HCPCS,,10455-MAIN,LOCAL,,,,,33,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,26.3794,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.38,26.72
ibuprofen 100 MG/5ML Suspension 118 mL Bottle,63700001,CDM,250,RC,,,,,,45802089726,NDC,118,ML,54.97,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,26.3856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 100 MG/5ML Suspension 118 mL Bottle,63700001,CDM,250,RC,,,,,,45802089726,NDC,118,ML,54.97,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,26.3856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buprenorphine 75 MCG FILM 60 Each Box,63700001,CDM,250,RC,,,,,,59385002160,NDC,1,EA,29.92,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.38944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Xray Lumbosacral Minimum 4 Vws,PX7211001,CDM,320,RC,72110,CPT,TC,,,,,,,565,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,26.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.74,78.23
Xray Lumbosacral Minimum 4 Vws,PX7211001,CDM,320,RC,72110,CPT,TC,,,,,,,565,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,26.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.74,78.23
lopinavir-ritonavir 200-50 MG Tablet 120 Each Bottle,63700001,CDM,250,RC,,,,,,74679922,NDC,1,EA,54.99,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,26.3952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lopinavir-ritonavir 200-50 MG Tablet 120 Each Bottle,63700001,CDM,250,RC,,,,,,74679922,NDC,1,EA,54.99,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,26.3952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Endocrine E2,PX82670,CDM,300,RC,82670,CPT,90,,,,,,,55,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,26.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,53.9
Endocrine E2,PX82670,CDM,300,RC,82670,CPT,90,,,,,,,55,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,26.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,53.9
"Immunofluo Direct, Ea Ab - Ref",PX8834690,CDM,310,RC,88346,CPT,90,,,,,,,55,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,26.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,149.22
"Immunofluo Direct, Ea Ab - Ref",PX8834690,CDM,310,RC,88346,CPT,90,,,,,,,55,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,26.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,149.22
Lipoprotein (a) - Ref,PX8369590,CDM,300,RC,83695,CPT,90,,,,,,,55,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,26.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.13,53.9
Lipoprotein (a) - Ref,PX8369590,CDM,300,RC,83695,CPT,90,,,,,,,55,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,26.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.13,53.9
MEPILEX BORDER AG POST OP 4X10,120.368,CDM,272,RC,A6212,HCPCS,,10839-MAIN,LOCAL,,,,,55,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,26.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,53.9
MEPILEX BORDER AG POST OP 4X10,120.368,CDM,272,RC,A6212,HCPCS,,10839-MAIN,LOCAL,,,,,55,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,26.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,53.9
Procalcitonin,PX84145,CDM,300,RC,84145,CPT,,,,,,,,217,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,26.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.4,27.22
Procalcitonin,PX84145,CDM,300,RC,84145,CPT,,,,,,,,217,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,26.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.4,27.22
Procalcitonin,PX84145,CDM,300,RC,84145,CPT,,,,,,,,217,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,26.4,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.4,27.22
SURGIFOAM ABSORBABLE GELATIN SPONGE 3.1 IN X 4.9IN X 10MM,120.371,CDM,272,RC,A4649,HCPCS,,10864-MAIN,LOCAL,,,,,55,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,26.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,53.9
SURGIFOAM ABSORBABLE GELATIN SPONGE 3.1 IN X 4.9IN X 10MM,120.371,CDM,272,RC,A4649,HCPCS,,10864-MAIN,LOCAL,,,,,55,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,26.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,53.9
"Ecg 12 Lead, Interp Only",PX93010,CDM,985,RC,93010,CPT,,,,,,,,29,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,26.419,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.0466,28.2257
Microscopic Exam of Urine,PX81015,CDM,300,RC,81015,CPT,,,,,,,,29,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,26.419,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.8,28.42
TRAY ARTHROGRAM SAFE-T-ARTHRO 28-AR1CO,120.2,CDM,272,RC,,,,11499-MAIN,LOCAL,,,,,29,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,26.419,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.0466,194.04
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016200,NDC,1,ML,52.22,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,26.42332,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8092351,NDC,1,EA,52.22,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,26.42332,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400101,NDC,1,EA,52.22,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,26.42332,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400125,NDC,1,EA,52.22,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,26.42332,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714000601,NDC,0.3,ML,53.39,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,26.42805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
saliva substitute Solution 59 mL Bottle,63700001,CDM,250,RC,,,,,,50930009802,NDC,59,ML,31.1,,First Health,Commercial,both,85,,999999999,percent of total billed charges,26.435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,67457022800,NDC,5,ML,53.42,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,26.4429,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,67457057305,NDC,5,ML,53.42,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,26.4429,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,409677802,NDC,1,ML,31.11,,First Health,Commercial,both,85,,999999999,percent of total billed charges,26.4435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001501,NDC,1,EA,2340,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,26.44374,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.28,27.6
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001503,NDC,1,EA,2340,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,26.44374,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.28,27.6
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,70842014003,NDC,1,EA,2409.61,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,26.44374,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.28,27.6
8MM ENDOWRIST INSTRUMENTS MEDIUM LARGE CLIP APPLIER,27200000,CDM,272,RC,,,,11910-MAIN,LOCAL,,,,,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,2,ML,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.852986,29.4
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,3,ML,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.852986,29.4
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061603,NDC,3,ML,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,641600601,NDC,0.5,ML,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
bacteriostatic water(benz alc) Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409397703,NDC,30,ML,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BOOT CAST LARGE 12-5/8 ORT290010L,120.247,CDM,274,RC,L3260,HCPCS,,204-MAIN,LOCAL,,,,,27,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
BOOT CAST MEDIUM 08148803,120.247,CDM,274,RC,L3260,HCPCS,,203-MAIN,LOCAL,,,,,27,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
BOOT CAST X-LARGE 13X5-1/2IN ORT29200XL,120.247,CDM,274,RC,L3260,HCPCS,,206-MAIN,LOCAL,,,,,27,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
BULB RESERVOIR SILICONE 400CC,27200000,CDM,272,RC,,,,12463-MAIN,LOCAL,,,,,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600710,NDC,2,ML,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,38.9354
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409115918,NDC,1,ML,30,,United Healthcare,All Payer,outpatient,88.2,,12.82416667,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046401,NDC,1,ML,30,,United Healthcare,All Payer,outpatient,88.2,,12.82416667,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046402,NDC,1,ML,30,,United Healthcare,All Payer,outpatient,88.2,,12.82416667,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046437,NDC,1,ML,30,,United Healthcare,All Payer,outpatient,88.2,,12.82416667,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,409174670,NDC,1,ML,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046801,NDC,1,ML,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046817,NDC,1,ML,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BUPivacaine in dextrose 0.75-8.25 % Solution 2 mL Ampule,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409176162,NDC,2,ML,30,,United Healthcare,All Payer,outpatient,88.2,,12.82416667,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046601,NDC,1,ML,30,,United Healthcare,All Payer,outpatient,88.2,,12.82416667,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143992490,NDC,0.5,EA,30,,United Healthcare,All Payer,outpatient,88.2,,20.73428571,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010110,NDC,0.5,EA,30,,United Healthcare,All Payer,outpatient,88.2,,20.73428571,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010167,NDC,0.5,EA,30,,United Healthcare,All Payer,outpatient,88.2,,20.73428571,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,44567070725,NDC,0.5,EA,30,,United Healthcare,All Payer,outpatient,88.2,,20.73428571,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733201,NDC,0.5,EA,30,,United Healthcare,All Payer,outpatient,88.2,,201.07,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733801,NDC,0.5,EA,30,,United Healthcare,All Payer,outpatient,88.2,,201.07,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,70069000501,NDC,0.1,ML,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,63.2394
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016502,NDC,0.5,ML,30,,United Healthcare,All Payer,outpatient,88.2,,23.48,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016516,NDC,0.5,ML,30,,United Healthcare,All Payer,outpatient,88.2,,23.48,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036721,NDC,1,ML,30,,United Healthcare,All Payer,outpatient,88.2,,23.48,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036725,NDC,1,ML,30,,United Healthcare,All Payer,outpatient,88.2,,23.48,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 100 MG/10ML Solution 10 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323051610,NDC,0.5,ML,30,,United Healthcare,All Payer,outpatient,88.2,,23.48,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050641,NDC,0.5,ML,30,,United Healthcare,All Payer,outpatient,88.2,,23.48,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141031,NDC,0.5,ML,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,641037621,NDC,0.25,ML,30,,United Healthcare,All Payer,outpatient,88.2,,15.59,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066416,NDC,1,ML,30,,United Healthcare,All Payer,outpatient,88.2,,15.59,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066441,NDC,0.25,ML,30,,United Healthcare,All Payer,outpatient,88.2,,15.59,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010101,NDC,0.25,ML,30,,United Healthcare,All Payer,outpatient,88.2,,15.59,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
DRAPE SPLIT WITH ADHESIVE DYNJP8304A,27200000,CDM,272,RC,,,,4694-MAIN,LOCAL,,,,,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRESSING HYDROFERA 2-1/2X2-1/2  BLUE READY FOAM HBRS2520,120.488,CDM,271,RC,A6209,HCPCS,,11537-MAIN,LOCAL,,,,,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
"Ethanol, P",PX82077,CDM,300,RC,82077,CPT,,,,,,,,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073916,NDC,2,ML,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,29.4
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073941,NDC,1,ML,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,29.4
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,67457043300,NDC,1,ML,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,29.4
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,United Healthcare,All Payer,outpatient,88.2,,14.47333333,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909422,NDC,2,ML,30,,United Healthcare,All Payer,outpatient,88.2,,14.47333333,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,United Healthcare,All Payer,outpatient,88.2,,14.47333333,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
folic acid 5 MG/ML Solution 10 mL Vial,J3490.94,CDM,636,RC,J3490,HCPCS,,,,39822110001,NDC,0.2,ML,30,,United Healthcare,All Payer,outpatient,88.2,,7.6225,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,330.2012
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,70860030242,NDC,1,ML,30,,United Healthcare,All Payer,outpatient,88.2,,8.0425,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,36000028425,NDC,2,ML,30,,United Healthcare,All Payer,outpatient,88.2,,8.0425,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001094,NDC,2,ML,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,42.5516
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,781382571,NDC,0.5,ML,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,143931901,NDC,0.4,ML,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.428
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272002,NDC,1,ML,30,,United Healthcare,All Payer,outpatient,88.2,,0.211744841,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272031,NDC,1,ML,30,,United Healthcare,All Payer,outpatient,88.2,,0.211744841,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,25021040010,NDC,1,ML,30,,United Healthcare,All Payer,outpatient,88.2,,0.211744841,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323054011,NDC,1,ML,30,,United Healthcare,All Payer,outpatient,88.2,,0.211744841,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095300,NDC,0.5,ML,30,,United Healthcare,All Payer,outpatient,88.2,,0.211744841,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095310,NDC,1,ML,30,,United Healthcare,All Payer,outpatient,88.2,,0.211744841,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,71288042095,NDC,0.5,ML,30,,United Healthcare,All Payer,outpatient,88.2,,0.211744841,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306424,NDC,1,ML,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306413,NDC,1,ML,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306521,NDC,3,ML,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin lock flush 10 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306510,NDC,5,ML,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
HYDROmorphone 1 MG/ML Solution 1 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,76045000901,NDC,0.25,ML,30,,United Healthcare,All Payer,outpatient,88.2,,34.74,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
KERRAMAX CARE SUPERABSORBENT DRESSING 8X12,120.55,CDM,272,RC,A6197,HCPCS,,12363-MAIN,LOCAL,,,,,27,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016216,NDC,1,ML,30,,United Healthcare,All Payer,outpatient,88.2,,12.05571429,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016243,NDC,0.5,ML,30,,United Healthcare,All Payer,outpatient,88.2,,12.05571429,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072201,NDC,0.5,ML,30,,United Healthcare,All Payer,outpatient,88.2,,12.05571429,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072225,NDC,0.5,ML,30,,United Healthcare,All Payer,outpatient,88.2,,12.05571429,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016226,NDC,0.5,ML,30,,United Healthcare,All Payer,outpatient,88.2,,12.05571429,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016245,NDC,0.5,ML,30,,United Healthcare,All Payer,outpatient,88.2,,12.05571429,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011901,NDC,0.5,ML,30,,United Healthcare,All Payer,outpatient,88.2,,12.05571429,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011925,NDC,0.5,ML,30,,United Healthcare,All Payer,outpatient,88.2,,12.05571429,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072501,NDC,0.5,ML,30,,United Healthcare,All Payer,outpatient,88.2,,12.05571429,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072525,NDC,0.5,ML,30,,United Healthcare,All Payer,outpatient,88.2,,12.05571429,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143932001,NDC,1,ML,30,,United Healthcare,All Payer,outpatient,88.2,,7.35,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143962201,NDC,1,ML,30,,United Healthcare,All Payer,outpatient,88.2,,7.35,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,409226720,NDC,1,ML,30,,United Healthcare,All Payer,outpatient,88.2,,7.35,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,47781058629,NDC,1,ML,30,,United Healthcare,All Payer,outpatient,88.2,,7.35,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,51991093498,NDC,1,ML,30,,United Healthcare,All Payer,outpatient,88.2,,7.35,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,409427616,NDC,20,ML,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323048526,NDC,20,ML,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,63323049241,NDC,2,ML,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2% PF 2 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049526,NDC,5,ML,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2% PF 2 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049541,NDC,5,ML,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine buffered 1 % Solution 0.5 mL Syringe,25000000,CDM,250,RC,,,,,,8888800160,NDC,0.5,ML,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604401,NDC,1,ML,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604425,NDC,1,ML,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620701,NDC,0.25,ML,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620725,NDC,1,ML,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
magnesium sulfate 50 % Solution 10 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006404,NDC,2,ML,30,,United Healthcare,All Payer,outpatient,88.2,,13.925,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,703450284,NDC,2,ML,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.859
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,409177815,NDC,5,ML,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,70860030005,NDC,1.25,ML,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metroNIDAZOLE 500 MG/100ML Solution 100 mL Plas Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,338954124,NDC,100,ML,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,31.4776
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605701,NDC,2,ML,30,,United Healthcare,All Payer,outpatient,88.2,,25.35,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605725,NDC,1,ML,30,,United Healthcare,All Payer,outpatient,88.2,,25.35,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060031,NDC,2,ML,30,,United Healthcare,All Payer,outpatient,88.2,,25.35,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060041,NDC,2,ML,30,,United Healthcare,All Payer,outpatient,88.2,,25.35,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 5 MG/ML Solution 1 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606101,NDC,0.2,ML,30,,United Healthcare,All Payer,outpatient,88.2,,25.35,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230504,NDC,0.5,ML,30,,United Healthcare,All Payer,outpatient,88.2,,25.35,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230505,NDC,5,ML,30,,United Healthcare,All Payer,outpatient,88.2,,25.35,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam PF 10 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230802,NDC,2,ML,30,,United Healthcare,All Payer,outpatient,88.2,,25.35,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,43598052936,NDC,0.5,ML,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080601,NDC,0.5,ML,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080610,NDC,0.5,ML,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,409475503,NDC,2,ML,30,,United Healthcare,All Payer,outpatient,88.2,,6.762173913,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054731,NDC,2,ML,30,,United Healthcare,All Payer,outpatient,88.2,,6.762173913,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054831,NDC,2,ML,30,,United Healthcare,All Payer,outpatient,88.2,,6.762173913,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054842,NDC,2,ML,30,,United Healthcare,All Payer,outpatient,88.2,,6.762173913,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
Or Time,PX36000086,CDM,360,RC,,,,,,,,,,27,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.2158,26.46
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092825,NDC,1,ML,30,,United Healthcare,All Payer,outpatient,88.2,,9.41,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,31.5854
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488802,NDC,10,ML,30,,United Healthcare,All Payer,outpatient,88.2,,0.191910792,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018603,NDC,20,ML,30,,United Healthcare,All Payer,outpatient,88.2,,0.191910792,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018620,NDC,20,ML,30,,United Healthcare,All Payer,outpatient,88.2,,0.191910792,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 50 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488850,NDC,3,ML,30,,United Healthcare,All Payer,outpatient,88.2,,0.191910792,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride bacteriostatic 0.9 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409196602,NDC,30,ML,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride bacteriostatic 0.9 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409196607,NDC,30,ML,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Sodium, Other Source - Ref",PX8430290,CDM,300,RC,84302,CPT,90,,,,,,,27,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.46,26.46
sterile water (preservative free) Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,64253002030,NDC,10,ML,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409488710,NDC,10,ML,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409488717,NDC,10,ML,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
SUTURE BIOSYN MONOFILAMENT ABSORBABLE UNDYED SIZE 4-0 18IN WITH 3/8 CIRCLE REVERSE CUTTING 19MM NEED,27200000,CDM,272,RC,,,,11987-MAIN,LOCAL,,,,,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE MONOFILAMENT SZ 4-0 BIOSYN ABSORBABLE UNDYED18IN WITH 3/8 CIRCLE REVERSE CUTTING 19MM NEED SM,27200000,CDM,272,RC,,,,11984-MAIN,LOCAL,,,,,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TRAY LUMBAR 22GAX3.5 PUNCTURE SAFE-T 4306CWSP,120.18,CDM,272,RC,,,,11584-MAIN,LOCAL,,,,,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
TRAY LUMBAR 22X1.5 PUNCTURE PEDS 4302CSP,120.18,CDM,272,RC,,,,652-MAIN,LOCAL,,,,,30,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
triamcinolone acetonide 10 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3049420,NDC,0.25,ML,30,,United Healthcare,All Payer,outpatient,88.2,,39.2,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,72.0986
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405F,CDM,510,RC,36405,CPT,,,,,,,,54,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.4316,52.92
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405F,CDM,510,RC,36405,CPT,,,,,,,,54,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.4316,52.92
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405F,CDM,510,RC,36405,CPT,,,,,,,,54,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,26.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.4316,52.92
lidocaine 5 % Patch 30 Each Box,63700001,CDM,250,RC,,,,,,603188016,NDC,1,EA,55.18,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,26.4864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 5 % Patch 30 Each Box,63700001,CDM,250,RC,,,,,,603188016,NDC,1,EA,55.18,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,26.4864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Acetaminophen 167 MG/5ML Liquid 237 mL Bottle,63700001,CDM,250,RC,,,,,,904584709,NDC,237,ML,27.22,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,26.493226,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 5 % Patch 1 Each Box,63700001,CDM,250,RC,,,,,,603188010,NDC,1,EA,55.2,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,26.496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 5 % Patch 1 Each Box,63700001,CDM,250,RC,,,,,,603188010,NDC,1,EA,55.2,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,26.496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,43598040516,NDC,0.2,ML,63.83,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,26.514982,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
apixaban 2.5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,3089321,NDC,1,EA,63.84,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,26.519136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 25 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,71101268,NDC,1,EA,55.33,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,26.5584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 25 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,71101268,NDC,1,EA,55.33,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,26.5584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Oligoclonal Bands - Ref,PX8391690,CDM,300,RC,83916,CPT,90,,,,,,,124,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,26.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.57,27.39
Oligoclonal Bands - Ref,PX8391690,CDM,300,RC,83916,CPT,90,,,,,,,124,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,26.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.57,27.39
Oligoclonal Bands - Ref,PX8391690,CDM,300,RC,83916,CPT,90,,,,,,,124,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,26.57,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.57,27.39
magnesium sulfate 1 g in 100 ml D5W (premix) 1-5 GM/100ML-% Solution 100 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010802,NDC,100,ML,52.51,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,26.57006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
Blood Occult Peroxidase,PX82272,CDM,300,RC,82272,CPT,,,,,,,,64,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,26.5856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.88,62.72
Strapping of Elbow or Wrist,PX29260F,CDM,420,RC,29260,CPT,,,,,,,,64,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,26.5856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.5856,62.72
Strapping of Hand or Finger,PX29280F,CDM,420,RC,29280,CPT,,,,,,,,64,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,26.5856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.5856,62.72
hydrocortisone 2.5 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,168008031,NDC,30,GR,61.99,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,26.59371,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Xray Cervical Spine 4 or 5 Vws,PX7205001,CDM,320,RC,72050,CPT,TC,,,,,,,664,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,26.61,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.61,80.86
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030926,NDC,1,EA,55.44,,Health Partners,Health Partners Care Plans,both,48,,6.796666667,percent of total billed charges,26.6112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030926,NDC,1,EA,55.44,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,26.6112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990711509,NDC,1000,ML,64.08,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,26.618832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
buprenorphine 75 MCG FILM 60 Each Box,63700001,CDM,250,RC,,,,,,59385002160,NDC,1,EA,29.92,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.6288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011801,NDC,0.5,ML,52.63,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,26.63078,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011805,NDC,0.5,ML,52.63,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,26.63078,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
"Hydroxyprogesterone, 17-D - Ref",PX8349890,CDM,300,RC,83498,CPT,90,,,,,,,67,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,26.6347,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.35,27.17
Itraconazole,PX8018990,CDM,300,RC,80189,CPT,90,,,,,,,124,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,26.6347,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.3,27.11
Lacosamide - Ref,PX8023590,CDM,300,RC,80235,CPT,90,,,,,,,200,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,26.6347,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.3,27.11
Procalcitonin,PX84145,CDM,300,RC,84145,CPT,,,,,,,,217,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,26.6347,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.4,27.22
Voriconazole - Ref,PX8028590,CDM,300,RC,80285,CPT,90,,,,,,,183,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,26.6347,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.3,27.11
Telehealth Origin Site Fac Fee,PXQ3014,CDM,780,RC,Q3014,HCPCS,,,,,,,,40,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,26.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.65,48.8
Telehealth Origin Site Fac Fee,PXQ3014,CDM,780,RC,Q3014,HCPCS,,,,,,,,40,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,26.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.65,48.8
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079034801,NDC,1,EA,27.39,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,26.658687,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079034820,NDC,1,EA,27.39,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,26.658687,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,16714001905,NDC,2,ML,62.17,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,26.67093,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,16714001930,NDC,2,ML,62.17,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,26.67093,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Acetaminophen 167 MG/5ML Liquid 237 mL Bottle,63700001,CDM,250,RC,,,,,,904584709,NDC,237,ML,27.22,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,26.6756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Endocrine E2,PX82670,CDM,300,RC,82670,CPT,90,,,,,,,55,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,26.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.68,27.94
Endocrine E2,PX82670,CDM,300,RC,82670,CPT,90,,,,,,,55,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,26.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.68,27.94
Therapeutic Activities,PX97530,CDM,420,RC,97530,CPT,,,,,,,,135,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,26.68,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.68,48.32
cefdinir 300 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,67877054360,NDC,1,EA,27.42,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,26.687886,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cholestyramine light 4 g Packet 42 Each Box,63700001,CDM,250,RC,,,,,,245003642,NDC,1,EA,27.42,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,26.687886,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
8MM ENDOWRIST INSTRUMENTS MEDIUM LARGE CLIP APPLIER,27200000,CDM,272,RC,,,,11910-MAIN,LOCAL,,,,,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,2,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.852986,29.4
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,3,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.852986,29.4
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061603,NDC,3,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,641600601,NDC,0.5,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
bacteriostatic water(benz alc) Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409397703,NDC,30,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BULB RESERVOIR SILICONE 400CC,27200000,CDM,272,RC,,,,12463-MAIN,LOCAL,,,,,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600710,NDC,2,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,38.9354
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409115918,NDC,1,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046401,NDC,1,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046402,NDC,1,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046437,NDC,1,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,409174670,NDC,1,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046801,NDC,1,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046817,NDC,1,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BUPivacaine in dextrose 0.75-8.25 % Solution 2 mL Ampule,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409176162,NDC,2,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046601,NDC,1,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143992490,NDC,0.5,EA,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010110,NDC,0.5,EA,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010167,NDC,0.5,EA,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,44567070725,NDC,0.5,EA,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733201,NDC,0.5,EA,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733801,NDC,0.5,EA,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,70069000501,NDC,0.1,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,63.2394
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016502,NDC,0.5,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016516,NDC,0.5,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036721,NDC,1,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036725,NDC,1,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 100 MG/10ML Solution 10 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323051610,NDC,0.5,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050641,NDC,0.5,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141031,NDC,0.5,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,641037621,NDC,0.25,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066416,NDC,1,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066441,NDC,0.25,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010101,NDC,0.25,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
DRAPE SPLIT WITH ADHESIVE DYNJP8304A,27200000,CDM,272,RC,,,,4694-MAIN,LOCAL,,,,,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRESSING HYDROFERA 2-1/2X2-1/2  BLUE READY FOAM HBRS2520,120.488,CDM,271,RC,A6209,HCPCS,,11537-MAIN,LOCAL,,,,,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
"Ethanol, P",PX82077,CDM,300,RC,82077,CPT,,,,,,,,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073916,NDC,2,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,29.4
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073941,NDC,1,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,29.4
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,67457043300,NDC,1,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,29.4
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909422,NDC,2,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
folic acid 5 MG/ML Solution 10 mL Vial,J3490.94,CDM,636,RC,J3490,HCPCS,,,,39822110001,NDC,0.2,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,330.2012
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,70860030242,NDC,1,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,36000028425,NDC,2,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001094,NDC,2,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,42.5516
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,781382571,NDC,0.5,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,143931901,NDC,0.4,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.428
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272002,NDC,1,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272031,NDC,1,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,25021040010,NDC,1,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323054011,NDC,1,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095300,NDC,0.5,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095310,NDC,1,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,71288042095,NDC,0.5,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306424,NDC,1,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306413,NDC,1,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306521,NDC,3,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin lock flush 10 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306510,NDC,5,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
HYDROmorphone 1 MG/ML Solution 1 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,76045000901,NDC,0.25,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016216,NDC,1,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016243,NDC,0.5,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072201,NDC,0.5,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072225,NDC,0.5,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016226,NDC,0.5,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016245,NDC,0.5,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011901,NDC,0.5,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011925,NDC,0.5,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072501,NDC,0.5,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072525,NDC,0.5,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143932001,NDC,1,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143962201,NDC,1,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,409226720,NDC,1,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,47781058629,NDC,1,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,51991093498,NDC,1,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,409427616,NDC,20,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323048526,NDC,20,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,63323049241,NDC,2,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2% PF 2 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049526,NDC,5,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2% PF 2 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049541,NDC,5,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine buffered 1 % Solution 0.5 mL Syringe,25000000,CDM,250,RC,,,,,,8888800160,NDC,0.5,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604401,NDC,1,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604425,NDC,1,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620701,NDC,0.25,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620725,NDC,1,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
magnesium sulfate 50 % Solution 10 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006404,NDC,2,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,703450284,NDC,2,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.859
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,409177815,NDC,5,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,70860030005,NDC,1.25,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metroNIDAZOLE 500 MG/100ML Solution 100 mL Plas Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,338954124,NDC,100,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,31.4776
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605701,NDC,2,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605725,NDC,1,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060031,NDC,2,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060041,NDC,2,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 5 MG/ML Solution 1 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606101,NDC,0.2,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230504,NDC,0.5,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230505,NDC,5,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam PF 10 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230802,NDC,2,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,43598052936,NDC,0.5,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080601,NDC,0.5,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080610,NDC,0.5,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,409475503,NDC,2,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054731,NDC,2,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054831,NDC,2,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054842,NDC,2,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092825,NDC,1,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,31.5854
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488802,NDC,10,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018603,NDC,20,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018620,NDC,20,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 50 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488850,NDC,3,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride bacteriostatic 0.9 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409196602,NDC,30,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride bacteriostatic 0.9 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409196607,NDC,30,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,64253002030,NDC,10,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409488710,NDC,10,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409488717,NDC,10,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
SUTURE BIOSYN MONOFILAMENT ABSORBABLE UNDYED SIZE 4-0 18IN WITH 3/8 CIRCLE REVERSE CUTTING 19MM NEED,27200000,CDM,272,RC,,,,11987-MAIN,LOCAL,,,,,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE MONOFILAMENT SZ 4-0 BIOSYN ABSORBABLE UNDYED18IN WITH 3/8 CIRCLE REVERSE CUTTING 19MM NEED SM,27200000,CDM,272,RC,,,,11984-MAIN,LOCAL,,,,,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021515,NDC,0.5,ML,187.24,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,26.7,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.45175,30.34
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021588,NDC,0.5,ML,203.87,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,26.7,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.45175,30.34
TRAY LUMBAR 22GAX3.5 PUNCTURE SAFE-T 4306CWSP,120.18,CDM,272,RC,,,,11584-MAIN,LOCAL,,,,,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
TRAY LUMBAR 22X1.5 PUNCTURE PEDS 4302CSP,120.18,CDM,272,RC,,,,652-MAIN,LOCAL,,,,,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
triamcinolone acetonide 10 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3049420,NDC,0.25,ML,30,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,26.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,72.0986
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048557,NDC,50,ML,52.78,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,26.70668,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
cholestyramine light 4 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,245003689,NDC,1,EA,27.44,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,26.707352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
X-Ray Exam Femur Min 2 Vws,PX7355201,CDM,320,RC,73552,CPT,TC,,,,,,,365,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,26.7094,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.66,53.25
Xray Orbits Optic Foramina,PX7019001,CDM,320,RC,70190,CPT,TC,,,,,,,66,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,26.7094,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.66,53.25
CATHETER FOLEY 18FR  3WAY 30CC 73018L,120.21,CDM,272,RC,A4346,HCPCS,,253-MAIN,LOCAL,,,,,33,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,26.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.38,26.72
CATHETER FOLEY 18FR  3WAY 30CC 73018L,120.21,CDM,272,RC,A4346,HCPCS,,253-MAIN,LOCAL,,,,,33,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,26.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.38,26.72
CATHETER FOLEY 18FR  3WAY 30CC 73018L,120.21,CDM,272,RC,A4346,HCPCS,,253-MAIN,LOCAL,,,,,33,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,26.72,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.38,26.72
CATHETER FOLEY 20FR 3WAY 30CC 0167L20,120.21,CDM,272,RC,A4346,HCPCS,,251-MAIN,LOCAL,,,,,33,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,26.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.38,26.72
CATHETER FOLEY 20FR 3WAY 30CC 0167L20,120.21,CDM,272,RC,A4346,HCPCS,,251-MAIN,LOCAL,,,,,33,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,26.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.38,26.72
CATHETER FOLEY 20FR 3WAY 30CC 0167L20,120.21,CDM,272,RC,A4346,HCPCS,,251-MAIN,LOCAL,,,,,33,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,26.72,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.38,26.72
CATHETER FOLEY 24FR 3WAY 30CC 0167L24,120.21,CDM,272,RC,A4346,HCPCS,,10455-MAIN,LOCAL,,,,,33,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,26.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.38,26.72
CATHETER FOLEY 24FR 3WAY 30CC 0167L24,120.21,CDM,272,RC,A4346,HCPCS,,10455-MAIN,LOCAL,,,,,33,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,26.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.38,26.72
CATHETER FOLEY 24FR 3WAY 30CC 0167L24,120.21,CDM,272,RC,A4346,HCPCS,,10455-MAIN,LOCAL,,,,,33,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,26.72,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.38,26.72
cefdinir 300 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,16714039102,NDC,1,EA,27.46,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,26.726818,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405F,CDM,510,RC,36405,CPT,,,,,,,,54,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,26.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.4316,52.92
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006401,NDC,2,ML,31.46,,First Health,Commercial,both,85,,999999999,percent of total billed charges,26.741,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046417,NDC,10,ML,54.6,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.216692234,percent of total billed charges,26.754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046417,NDC,10,ML,54.6,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,26.754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046417,NDC,10,ML,54.6,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,26.754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
Each Add'l Sequential Push New Drug,PX96375,CDM,260,RC,96375,CPT,,,,,,,,130,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,26.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.81,26.76
Each Add'l Sequential Push New Drug,PX96375,CDM,260,RC,96375,CPT,,,,,,,,130,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,26.76,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.81,26.76
budesonide 0.5 MG/2ML Suspension 2 mL Ampule,25000000,CDM,250,RC,,,,,,68180098405,NDC,2,ML,62.38,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,26.76102,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,781751614,NDC,2,ML,62.38,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,26.76102,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,781751687,NDC,2,ML,62.38,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,26.76102,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097031986,NDC,2,ML,62.38,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,26.76102,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,781323294,NDC,1,EA,52.89,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,26.76234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409492120,NDC,10,ML,54.66,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,150.5666667,percent of total billed charges,26.7834,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409492120,NDC,10,ML,54.66,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,26.7834,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409492120,NDC,10,ML,54.66,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,26.7834,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049236,NDC,5,ML,31.52,,First Health,Commercial,both,85,,999999999,percent of total billed charges,26.792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049243,NDC,5,ML,31.52,,First Health,Commercial,both,85,,999999999,percent of total billed charges,26.792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dexmedeTOMIDine 200 MCG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,70860060541,NDC,2,ML,55.82,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,26.7936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dexmedeTOMIDine 200 MCG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,70860060541,NDC,2,ML,55.82,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,26.7936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 4-5 MG/ML-% Solution 500 mL Flex Cont,J2001.01,CDM,636,RC,J2001,HCPCS,,,,338040903,NDC,500,ML,55.82,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,26.7936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
lidocaine 4-5 MG/ML-% Solution 500 mL Flex Cont,J2001.01,CDM,636,RC,J2001,HCPCS,,,,338040903,NDC,500,ML,55.82,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,26.7936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
zinc oxide 20 % Ointment 56.7 g Tube,63700001,CDM,250,RC,,,,,,168006202,NDC,56.7,GR,30.39,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.80398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,63323004401,NDC,1,ML,64.53,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,26.805762,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,63.2394
lidocaine buffered 1 % Solution 22.2 mL Vial,25000000,CDM,250,RC,,,,,,8888800251,NDC,22.2,ML,30.4,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.8128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine buffered 1% Solution 22.2 mL Vial,25000000,CDM,250,RC,,,,,,8888800251,NDC,22.2,ML,30.4,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.8128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine HCl 4 % Cream 133 g Tube,63700001,CDM,250,RC,,,,,,41167005828,NDC,133,GR,52.99,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,26.81294,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DRESSING OPTIFOAM 10X4 POST-OP SILICONE FACED MSC21410Z,120.154,CDM,272,RC,A6213,HCPCS,,8632-MAIN,LOCAL,,,,,16,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,26.816,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.46,26.816
DRESSING OPTIFOAM 10X4 POST-OP SILICONE FACED MSC21410Z,120.154,CDM,272,RC,A6213,HCPCS,,8632-MAIN,LOCAL,,,,,16,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,26.816,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.46,26.816
MEPILEX AG 4X4 10X10,120.138,CDM,272,RC,A6213,HCPCS,,7248-MAIN,LOCAL,,,,,33,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,26.816,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.46,26.816
MEPILEX AG 4X4 10X10,120.138,CDM,272,RC,A6213,HCPCS,,7248-MAIN,LOCAL,,,,,33,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,26.816,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.46,26.816
MEPILEX AG FOAM 4X4,120.192,CDM,272,RC,A6213,HCPCS,,8480-MAIN,LOCAL,,,,,42,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,26.816,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.46,26.816
MEPILEX AG FOAM 4X4,120.192,CDM,272,RC,A6213,HCPCS,,8480-MAIN,LOCAL,,,,,42,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,26.816,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.46,26.816
MEPILEX AG FOAM 4X8,120.192,CDM,272,RC,A6213,HCPCS,,8479-MAIN,LOCAL,,,,,42,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,26.816,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.46,26.816
MEPILEX AG FOAM 4X8,120.192,CDM,272,RC,A6213,HCPCS,,8479-MAIN,LOCAL,,,,,42,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,26.816,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.46,26.816
Dystrophic Nail Trimming Any Number,PXG0127F,CDM,940,RC,G0127,HCPCS,,,,,,,,53,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,26.818,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.0162,53.44
Renin - Ref,PX8424490,CDM,300,RC,84244,CPT,90,,,,,,,53,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,26.818,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.16,51.94
Repr Superf Wnd Body <2.5cm,PX12001F,CDM,510,RC,12001,CPT,,,,,,,,311,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,26.83,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.83,196.47
Repr Superf Wnd Body <2.5cm,PX12001F,CDM,510,RC,12001,CPT,,,,,,,,311,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,26.83,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.83,196.47
Repr Superf Wnd Body <2.5cm,PX12001P,CDM,983,RC,12001,CPT,,,,,,,,293,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,26.83,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.83,287.14
Repr Superf Wnd Body <2.5cm,PX12001P,CDM,983,RC,12001,CPT,,,,,,,,293,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,26.83,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.83,287.14
Repr Superf Wnd Body <2.5cm,PX12001F,CDM,510,RC,12001,CPT,,,,,,,,311,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,26.83,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.83,196.47
Repr Superf Wnd Body <2.5cm,PX12001P,CDM,983,RC,12001,CPT,,,,,,,,293,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,26.83,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.83,287.14
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061601,NDC,3,ML,31.57,,First Health,Commercial,both,85,,999999999,percent of total billed charges,26.8345,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058003,NDC,0.5,ML,31.57,,First Health,Commercial,both,85,,999999999,percent of total billed charges,26.8345,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058020,NDC,0.5,ML,31.57,,First Health,Commercial,both,85,,999999999,percent of total billed charges,26.8345,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061416,NDC,0.5,ML,31.57,,First Health,Commercial,both,85,,999999999,percent of total billed charges,26.8345,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.114178,99.911
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079034801,NDC,1,EA,27.39,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,26.8422,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079034820,NDC,1,EA,27.39,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,26.8422,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
TRAY HAND SURGICAL II DYNJS0806,27200000,CDM,272,RC,,,,11024-MAIN,LOCAL,,,,,64.62,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,26.843148,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
levoFLOXacin in dextrose 5% 500 MG/100ML Solution 100 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004724,NDC,100,ML,64.63,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,26.847302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,76329339001,NDC,5,ML,64.63,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,26.847302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338067104,NDC,1000,ML,53.06,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,26.84836,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
Androsetenedione - Ref,PX8215790,CDM,300,RC,82157,CPT,90,,,,,,,107,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,26.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.85,104.86
sacubitril-valsartan 24-26 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,78065920,NDC,1,EA,62.6,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,26.8554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006403,NDC,2,ML,30.45,,United Healthcare,All Payer,outpatient,88.2,,13.925,percent of total billed charges,26.8569,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
cefdinir 300 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,67877054360,NDC,1,EA,27.42,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,26.8716,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cholestyramine light 4 g Packet 42 Each Box,63700001,CDM,250,RC,,,,,,245003642,NDC,1,EA,27.42,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,26.8716,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
8MM-12MM BLADELESS OBTURATOR 8MM,27200000,CDM,272,RC,,,,11919-MAIN,LOCAL,,,,,56,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,26.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM-12MM BLADELESS OBTURATOR 8MM,27200000,CDM,272,RC,,,,11919-MAIN,LOCAL,,,,,56,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,26.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM-12MM BLADELESS OBTURATOR 8MM LONG,27200000,CDM,272,RC,,,,11920-MAIN,LOCAL,,,,,56,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,26.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM-12MM BLADELESS OBTURATOR 8MM LONG,27200000,CDM,272,RC,,,,11920-MAIN,LOCAL,,,,,56,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,26.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"B Cells, Total Count",PX86355,CDM,300,RC,86355,CPT,,,,,,,,56,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,26.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.2624,54.88
"B Cells, Total Count",PX86355,CDM,300,RC,86355,CPT,,,,,,,,56,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,26.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.2624,54.88
Citrate - Ref,PX8250790,CDM,300,RC,82507,CPT,90,,,,,,,56,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,26.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.2624,54.88
Citrate - Ref,PX8250790,CDM,300,RC,82507,CPT,90,,,,,,,56,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,26.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.2624,54.88
"Folic Acid (Folate), Serum",PX82746,CDM,300,RC,82746,CPT,,,,,,,,56,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,26.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.48,54.88
"Folic Acid (Folate), Serum",PX82746,CDM,300,RC,82746,CPT,,,,,,,,56,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,26.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.48,54.88
Lab Platelet Count,PX85049,CDM,300,RC,85049,CPT,,,,,,,,56,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,26.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.11,54.88
Lab Platelet Count,PX85049,CDM,300,RC,85049,CPT,,,,,,,,56,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,26.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.11,54.88
Mycophenolate Mycophenolicacid - Ref,PX8018090,CDM,300,RC,80180,CPT,90,,,,,,,56,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,26.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.55,54.88
Mycophenolate Mycophenolicacid - Ref,PX8018090,CDM,300,RC,80180,CPT,90,,,,,,,56,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,26.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.55,54.88
Progesterone,PX84144,CDM,300,RC,84144,CPT,,,,,,,,56,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,26.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.13,54.88
Progesterone,PX84144,CDM,300,RC,84144,CPT,,,,,,,,56,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,26.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.13,54.88
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,First Health,Commercial,both,85,,999999999,percent of total billed charges,26.8855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,First Health,Commercial,both,85,,999999999,percent of total billed charges,26.8855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
cholestyramine light 4 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,245003689,NDC,1,EA,27.44,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,26.8912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,310075430,NDC,1,EA,56.04,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,26.8992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,310075430,NDC,1,EA,56.04,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,26.8992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001501,NDC,1,EA,2340,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,26.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.28,27.6
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001501,NDC,1,EA,2340,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,26.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.28,27.6
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001503,NDC,1,EA,2340,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,26.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.28,27.6
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001503,NDC,1,EA,2340,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,26.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.28,27.6
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,70842014003,NDC,1,EA,2409.61,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,26.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.28,27.6
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,70842014003,NDC,1,EA,2409.61,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,26.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.28,27.6
Immunofix Elp,PX86335,CDM,300,RC,86335,CPT,,,,,,,,214,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,26.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.91,209.72
cefdinir 300 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,16714039102,NDC,1,EA,27.46,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,26.9108,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323042605,NDC,5,ML,64.8,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,26.91792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323042405,NDC,5,ML,64.82,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,26.926228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,49348009529,NDC,15,ML,30.53,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.92746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 100 MG/5ML Suspension 118 mL Bottle,63700001,CDM,250,RC,,,,,,45802089726,NDC,118,ML,54.97,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,26.9353,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 100 MG/5ML Suspension 118 mL Bottle,63700001,CDM,250,RC,,,,,,45802089726,NDC,118,ML,54.97,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,26.9353,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 100 MG/5ML Suspension 118 mL Bottle,63700001,CDM,250,RC,,,,,,45802089726,NDC,118,ML,54.97,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,26.9353,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcium CHLORIDE 10 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409163140,NDC,10,ML,64.85,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,26.93869,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lopinavir-ritonavir 200-50 MG Tablet 120 Each Bottle,63700001,CDM,250,RC,,,,,,74679922,NDC,1,EA,54.99,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,26.9451,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lopinavir-ritonavir 200-50 MG Tablet 120 Each Bottle,63700001,CDM,250,RC,,,,,,74679922,NDC,1,EA,54.99,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,26.9451,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lopinavir-ritonavir 200-50 MG Tablet 120 Each Bottle,63700001,CDM,250,RC,,,,,,74679922,NDC,1,EA,54.99,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,26.9451,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Endocrine E2,PX82670,CDM,300,RC,82670,CPT,90,,,,,,,55,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,26.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,53.9
Endocrine E2,PX82670,CDM,300,RC,82670,CPT,90,,,,,,,55,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,26.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,53.9
Endocrine E2,PX82670,CDM,300,RC,82670,CPT,90,,,,,,,55,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,26.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,53.9
"Immunofluo Direct, Ea Ab - Ref",PX8834690,CDM,310,RC,88346,CPT,90,,,,,,,55,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,26.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,149.22
"Immunofluo Direct, Ea Ab - Ref",PX8834690,CDM,310,RC,88346,CPT,90,,,,,,,55,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,26.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,149.22
"Immunofluo Direct, Ea Ab - Ref",PX8834690,CDM,310,RC,88346,CPT,90,,,,,,,55,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,26.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,149.22
Lipoprotein (a) - Ref,PX8369590,CDM,300,RC,83695,CPT,90,,,,,,,55,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,26.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.13,53.9
Lipoprotein (a) - Ref,PX8369590,CDM,300,RC,83695,CPT,90,,,,,,,55,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,26.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.13,53.9
Lipoprotein (a) - Ref,PX8369590,CDM,300,RC,83695,CPT,90,,,,,,,55,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,26.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.13,53.9
MEPILEX BORDER AG POST OP 4X10,120.368,CDM,272,RC,A6212,HCPCS,,10839-MAIN,LOCAL,,,,,55,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,26.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,53.9
MEPILEX BORDER AG POST OP 4X10,120.368,CDM,272,RC,A6212,HCPCS,,10839-MAIN,LOCAL,,,,,55,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,26.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,53.9
MEPILEX BORDER AG POST OP 4X10,120.368,CDM,272,RC,A6212,HCPCS,,10839-MAIN,LOCAL,,,,,55,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,26.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,53.9
SURGIFOAM ABSORBABLE GELATIN SPONGE 3.1 IN X 4.9IN X 10MM,120.371,CDM,272,RC,A4649,HCPCS,,10864-MAIN,LOCAL,,,,,55,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,26.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,53.9
SURGIFOAM ABSORBABLE GELATIN SPONGE 3.1 IN X 4.9IN X 10MM,120.371,CDM,272,RC,A4649,HCPCS,,10864-MAIN,LOCAL,,,,,55,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,26.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,53.9
SURGIFOAM ABSORBABLE GELATIN SPONGE 3.1 IN X 4.9IN X 10MM,120.371,CDM,272,RC,A4649,HCPCS,,10864-MAIN,LOCAL,,,,,55,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,26.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,53.9
dabigatran 75 MG capsule 60 Each Box,63700001,CDM,250,RC,,,,,,597035556,NDC,1,EA,53.27,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,26.95462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Draw Blood Off Venous Device,PX36591F,CDM,510,RC,36591,CPT,,,,,,,,211,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,26.9556,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.45,57.42
Ext Ecg > 48hr to 21 Day Rcrd W/Conect Intl Rcrd,PX0296T,CDM,731,RC,0296T,HCPCS,,,,,,,,389,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,26.9556,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.9556,26.96
Oligoclonal Bands - Ref,PX8391690,CDM,300,RC,83916,CPT,90,,,,,,,124,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,26.9556,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.57,27.39
Ext Ecg > 48hr to 21 Day Rcrd W/Conect Intl Rcrd,PX0296T,CDM,731,RC,0296T,HCPCS,,,,,,,,389,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,26.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.9556,26.96
lidocaine HCl 4 % Cream 76.5 g Tube,63700001,CDM,250,RC,,,,,,41167005820,NDC,76.5,GR,31.72,,First Health,Commercial,both,85,,999999999,percent of total billed charges,26.962,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Chemotherapy, IV Infusion, Add'l Hour",PX96415,CDM,335,RC,96415,CPT,,,,,,,,191,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,26.964,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.1,48.28
Citrate - Ref,PX8250790,CDM,300,RC,82507,CPT,90,,,,,,,56,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,26.97,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.97,27.8
Citrate - Ref,PX8250790,CDM,300,RC,82507,CPT,90,,,,,,,56,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,26.97,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.97,27.8
Citrate - Ref,PX8250790,CDM,300,RC,82507,CPT,90,,,,,,,56,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,26.97,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.97,27.8
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010125,NDC,1,ML,30.58,,United Healthcare,All Payer,outpatient,88.2,,15.59,percent of total billed charges,26.97156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323048541,NDC,20,ML,30.58,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.97156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Fac/Irrigation of Bladder,PX51700F,CDM,510,RC,51700,CPT,,,,,,,,358,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,26.9724,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.1,159.11
budesonide 1 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097032187,NDC,1,ML,64.97,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,26.988538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
RESERVOIR WOUND DRAIN 15FR,27200000,CDM,272,RC,,,,4386-MAIN,LOCAL,,,,,30.6,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.9892,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SET DISPOSABLE COLLECTION,27100000,CDM,271,RC,,,,5439-MAIN,LOCAL,,,,,30.6,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.9892,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
SUTURE NUROLON 0 BLACK C527D,27200000,CDM,272,RC,,,,10415-MAIN,LOCAL,,,,,30.6,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,26.9892,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Alkaloids, Not Otherwise Specified - Ref",PX8032390,CDM,300,RC,80323,CPT,90,,,,,,,65,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,27.001,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.001,63.7
Anesthesia Level 3,PX37000017,CDM,370,RC,,,,,,,,,,65,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,27.001,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.001,63.7
Clozapine - Ref,PX8015990,CDM,300,RC,80159,CPT,90,,,,,,,65,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,27.001,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.48,63.7
Gastrin - Ref,PX8294190,CDM,300,RC,82941,CPT,90,,,,,,,65,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,27.001,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.16,63.7
Insulin Ab - Ref,PX8633790,CDM,300,RC,86337,CPT,90,,,,,,,65,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,27.001,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.63,63.7
Resp Muscles 1:1 per 15 Min,PXG0237,CDM,948,RC,G0237,HCPCS,,,,,,,,65,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,27.001,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.01,63.7
Smking Cess 4-10 Min,PX99406F,CDM,942,RC,99406,CPT,,,,,,,,65,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,27.001,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.07,63.7
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714000601,NDC,0.3,ML,53.39,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,27.01534,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
dexmedeTOMIDine 200 MCG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,143953201,NDC,2,ML,62.98,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,27.01842,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046417,NDC,10,ML,54.6,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,27.027,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
K-WIRE SMOOTH 1.4MM X 100MM,C1713,CDM,272,RC,C1713,HCPCS,,12634-MAIN,LOCAL,,,,,63,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,27.027,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
SUTURE MAXON MONOFILAMENT ABSORBABLE GREEN SIZE 1 96IN WITH 1/2 CIRCLE TAPER POINT 65MM NEEDLE,27200000,CDM,272,RC,,,,11986-MAIN,LOCAL,,,,,63,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,27.027,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Vitamin a - Ref,PX8459090,CDM,300,RC,84590,CPT,90,,,,,,,63,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,27.027,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.65,61.74
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,67457022800,NDC,5,ML,53.42,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,27.03052,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,67457057305,NDC,5,ML,53.42,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,27.03052,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Xray Sinuses Minimum 3 Vws,PX7022001,CDM,320,RC,70220,CPT,TC,,,,,,,354,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,27.0312,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.88,53.91
Xray Skull Less Than 4 Vws,PX7025001,CDM,320,RC,70250,CPT,TC,,,,,,,311,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,27.0312,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.88,53.91
lidocaine 5 % Patch 30 Each Box,63700001,CDM,250,RC,,,,,,603188016,NDC,1,EA,55.18,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.0382,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 5 % Patch 30 Each Box,63700001,CDM,250,RC,,,,,,603188016,NDC,1,EA,55.18,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.0382,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 5 % Patch 30 Each Box,63700001,CDM,250,RC,,,,,,603188016,NDC,1,EA,55.18,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,27.0382,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zinc oxide 20 % Ointment 56.7 g Tube,63700001,CDM,250,RC,,,,,,168006202,NDC,56.7,GR,30.39,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,27.0471,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 5 % Patch 1 Each Box,63700001,CDM,250,RC,,,,,,603188010,NDC,1,EA,55.2,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 5 % Patch 1 Each Box,63700001,CDM,250,RC,,,,,,603188010,NDC,1,EA,55.2,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 5 % Patch 1 Each Box,63700001,CDM,250,RC,,,,,,603188010,NDC,1,EA,55.2,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,27.048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine buffered 1 % Solution 22.2 mL Vial,25000000,CDM,250,RC,,,,,,8888800251,NDC,22.2,ML,30.4,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,27.056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine buffered 1% Solution 22.2 mL Vial,25000000,CDM,250,RC,,,,,,8888800251,NDC,22.2,ML,30.4,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,27.056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409492120,NDC,10,ML,54.66,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,27.0567,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141035,NDC,2,ML,56.37,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,27.0576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141035,NDC,2,ML,56.37,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,27.0576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,65219044501,NDC,10,ML,56.37,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,27.0576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,65219044501,NDC,10,ML,56.37,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,27.0576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,65219044510,NDC,10,ML,56.37,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,27.0576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,65219044510,NDC,10,ML,56.37,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,27.0576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
KUMAR CHOLANGIOGRAPHY CATHETER,27200000,CDM,272,RC,,,,10230-MAIN,LOCAL,,,,,63.11,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,27.07419,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
cemiplimab-rwlc 350 MG/7ML Solution 7 mL Vial,J9119.01,CDM,636,RC,J9119,HCPCS,,,,61755000801,NDC,7,ML,19219.32,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,27.08714,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.79,28.83
"Antipsychotics, Not Otherwise Specified; 1-3 - Ref",PX8034290,CDM,300,RC,80342,CPT,90,,,,,,,152,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,27.09,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.09,27.09
Endocrine E2,PX82670,CDM,300,RC,82670,CPT,90,,,,,,,55,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,27.1,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.68,27.94
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006403,NDC,2,ML,30.45,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,27.1005,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,548590000,NDC,1,EA,470.19,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,27.11,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.86,28.59
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,781344071,NDC,1,EA,430.94,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,27.11,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.86,28.59
Itraconazole,PX8018990,CDM,300,RC,80189,CPT,90,,,,,,,124,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,27.11,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.3,27.11
Lacosamide - Ref,PX8023590,CDM,300,RC,80235,CPT,90,,,,,,,200,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,27.11,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.3,27.11
Voriconazole - Ref,PX8028590,CDM,300,RC,80285,CPT,90,,,,,,,183,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,27.11,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.3,27.11
pregabalin 25 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,71101268,NDC,1,EA,55.33,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.1117,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 25 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,71101268,NDC,1,EA,55.33,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.1117,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 25 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,71101268,NDC,1,EA,55.33,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,27.1117,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,36000003310,NDC,5,ML,30.74,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,27.11268,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"pediatric electrolyte Solution 1,000 mL Bottle",25000000,CDM,250,RC,,,,,,49348057041,NDC,1000,ML,31.9,,First Health,Commercial,both,85,,999999999,percent of total billed charges,27.115,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,990771512,NDC,62.5,ML,56.5,,Health Partners,Health Partners Care Plans,both,48,,31.91277778,percent of total billed charges,27.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.4701,303.0944
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,990771512,NDC,62.5,ML,56.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,27.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.4701,303.0944
"Vitamin D, 25 Hydroxy",PX82306,CDM,300,RC,82306,CPT,,,,,,,,235,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,27.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.14,230.3
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,45802011222,NDC,22,GR,63.29,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,27.15141,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030926,NDC,1,EA,55.44,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,14.99111111,percent of total billed charges,27.1656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030926,NDC,1,EA,55.44,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.1656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030926,NDC,1,EA,55.44,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,27.1656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
"Hydroxyprogesterone, 17-D - Ref",PX8349890,CDM,300,RC,83498,CPT,90,,,,,,,67,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,27.17,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.35,27.17
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,49348009529,NDC,15,ML,30.53,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,27.1717,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BANDAGE COBAN  4 IN 2 LAYER COMPRESSION SYSTEM  2094N,120.549,CDM,272,RC,A6441,HCPCS,,12366-MAIN,LOCAL,,,,,32,,First Health,Commercial,both,85,,999999999,percent of total billed charges,27.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.2928,31.36
BANDAGE COBAN LITE 4 IN 2 LAYER COMPRESSION SYSTEM 2794N,120.549,CDM,272,RC,A6441,HCPCS,,12922-MAIN,LOCAL,,,,,32,,First Health,Commercial,both,85,,999999999,percent of total billed charges,27.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.2928,31.36
WOUND DRAIN FLAT WITH TROCAR 10MM FULL PERFORATED SILICONE,27200000,CDM,272,RC,,,,12462-MAIN,LOCAL,,,,,32,,First Health,Commercial,both,85,,999999999,percent of total billed charges,27.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ibuprofen 100 MG/5ML Suspension 118 mL Bottle,63700001,CDM,250,RC,,,,,,45802089726,NDC,118,ML,54.97,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,27.21015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608210,NDC,1,ML,63.43,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,27.21147,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010125,NDC,1,ML,30.58,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,27.2162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323048541,NDC,20,ML,30.58,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,27.2162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Procalcitonin,PX84145,CDM,300,RC,84145,CPT,,,,,,,,217,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,27.22,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.4,27.22
lopinavir-ritonavir 200-50 MG Tablet 120 Each Bottle,63700001,CDM,250,RC,,,,,,74679922,NDC,1,EA,54.99,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,27.22005,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Endocrine E2,PX82670,CDM,300,RC,82670,CPT,90,,,,,,,55,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,27.225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,53.9
"Immunofluo Direct, Ea Ab - Ref",PX8834690,CDM,310,RC,88346,CPT,90,,,,,,,55,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,27.225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,149.22
Lipoprotein (a) - Ref,PX8369590,CDM,300,RC,83695,CPT,90,,,,,,,55,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,27.225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.13,53.9
MEPILEX BORDER AG POST OP 4X10,120.368,CDM,272,RC,A6212,HCPCS,,10839-MAIN,LOCAL,,,,,55,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,27.225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,53.9
SURGIFOAM ABSORBABLE GELATIN SPONGE 3.1 IN X 4.9IN X 10MM,120.371,CDM,272,RC,A4649,HCPCS,,10864-MAIN,LOCAL,,,,,55,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,27.225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,53.9
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024010,NDC,1,EA,56.73,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,27.2304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024010,NDC,1,EA,56.73,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,27.2304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030036,NDC,1,EA,56.73,,Health Partners,Health Partners Care Plans,both,48,,6.796666667,percent of total billed charges,27.2304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030036,NDC,1,EA,56.73,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,27.2304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098341,NDC,1,EA,56.73,,Health Partners,Health Partners Care Plans,both,48,,6.796666667,percent of total billed charges,27.2304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098341,NDC,1,EA,56.73,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,27.2304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
RESERVOIR WOUND DRAIN 15FR,27200000,CDM,272,RC,,,,4386-MAIN,LOCAL,,,,,30.6,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,27.234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SET DISPOSABLE COLLECTION,27100000,CDM,271,RC,,,,5439-MAIN,LOCAL,,,,,30.6,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,27.234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
SUTURE NUROLON 0 BLACK C527D,27200000,CDM,272,RC,,,,10415-MAIN,LOCAL,,,,,30.6,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,27.234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Albumin; Other Source, Quantitative, Each Specimen",PX82042,CDM,300,RC,82042,CPT,,,,,,,,28,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,27.2524,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.13,27.44
Anesthesia Level - Regional,PX37000025,CDM,370,RC,,,,,,,,,,28,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,27.2524,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
Gonadotropin (Lh),PX83002,CDM,300,RC,83002,CPT,,,,,,,,28,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,27.2524,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
PROMOGRAN PRISMA AG COLLAGEN DRESSING 28CM,120.547,CDM,272,RC,A6021,HCPCS,,12361-MAIN,LOCAL,,,,,28,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,27.2524,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
SCOPE BRONCHOSCOPE SZ 4 STERILE DISPOSABLE B120044,120.574,CDM,272,RC,,,,12868-MAIN,LOCAL,,,,,28,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,27.2524,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
tranexamic acid 650 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,69918030130,NDC,1,EA,28,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,27.2524,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Viral Neutralization - Ref,PX8638290,CDM,300,RC,86382,CPT,90,,,,,,,28,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,27.2524,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
buprenorphine 75 MCG FILM 60 Each Box,63700001,CDM,250,RC,,,,,,59385002160,NDC,1,EA,29.92,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.25712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606001,NDC,10,ML,65.62,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,27.258548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606010,NDC,10,ML,65.62,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,27.258548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409116219,NDC,30,ML,32.07,,First Health,Commercial,both,85,,999999999,percent of total billed charges,27.2595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
Assay Vitamin B-6,PX84207,CDM,300,RC,84207,CPT,90,,,,,,,42,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,27.26,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.26,28.1
PROMOGRAN PRISMA AG COLLAGEN DRESSING 28CM,120.547,CDM,272,RC,A6021,HCPCS,,12361-MAIN,LOCAL,,,,,28,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,27.26,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.26,28.69
Assay Vitamin B-6,PX84207,CDM,300,RC,84207,CPT,90,,,,,,,42,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,27.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.26,28.1
Assay Vitamin B-6,PX84207,CDM,300,RC,84207,CPT,90,,,,,,,42,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,27.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.26,28.1
"IV Push, Single/1st Drug",PX96374,CDM,260,RC,96374,CPT,,,,,,,,259,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,27.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.21,63.99
"IV Push, Single/1st Drug",PX96374,CDM,260,RC,96374,CPT,,,,,,,,259,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,27.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.21,63.99
Therapeutic Activities,PX97530,CDM,420,RC,97530,CPT,,,,,,,,135,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,27.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.68,48.32
Therapeutic Activities,PX97530,CDM,420,RC,97530,CPT,,,,,,,,135,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,27.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.68,48.32
Xray Cervical Spine 4 or 5 Vws,PX7205001,CDM,320,RC,72050,CPT,TC,,,,,,,664,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,27.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.61,80.86
Xray Cervical Spine 4 or 5 Vws,PX7205001,CDM,320,RC,72050,CPT,TC,,,,,,,664,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,27.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.61,80.86
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,55150020200,NDC,1,EA,65.65,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,27.27101,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
Citrate - Ref,PX8250790,CDM,300,RC,82507,CPT,90,,,,,,,56,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,27.2765,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.97,27.8
Endocrine E2,PX82670,CDM,300,RC,82670,CPT,90,,,,,,,55,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,27.2765,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.68,27.94
"Remv F.B.,Eye,Superf Conjunc",PX65205F,CDM,510,RC,65205,CPT,,,,,,,,132,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,27.2935,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.1,59.49
"Remv F.B.,Eye,Superf Conjunc",PX65205P,CDM,983,RC,65205,CPT,,,,,,,,132,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,27.2935,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.1,129.36
metroNIDAZOLE 500 MG/100ML Solution 100 mL Flex Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,409781124,NDC,100,ML,32.12,,First Health,Commercial,both,85,,999999999,percent of total billed charges,27.302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,31.4776
lidocaine 5 % Patch 30 Each Box,63700001,CDM,250,RC,,,,,,603188016,NDC,1,EA,55.18,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,27.3141,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
triamcinolone acetonide 0.1 % Cream 80 g Tube,63700001,CDM,250,RC,,,,,,16714098603,NDC,80,GR,65.76,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,27.316704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 5 % Patch 1 Each Box,63700001,CDM,250,RC,,,,,,603188010,NDC,1,EA,55.2,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,27.324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405F,CDM,510,RC,36405,CPT,,,,,,,,54,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,27.324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.4316,52.92
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057811,NDC,0.5,ML,30.98,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,27.32436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057841,NDC,0.5,ML,30.98,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,27.32436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
8MM ENDOWRIST INSTRUMENTS MEDIUM LARGE CLIP APPLIER,27200000,CDM,272,RC,,,,11910-MAIN,LOCAL,,,,,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,2,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.852986,29.4
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,3,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.852986,29.4
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061603,NDC,3,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,641600601,NDC,0.5,ML,30,,Medica,Commercial,both,91.1,,1.63075,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
bacteriostatic water(benz alc) Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409397703,NDC,30,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BULB RESERVOIR SILICONE 400CC,27200000,CDM,272,RC,,,,12463-MAIN,LOCAL,,,,,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600710,NDC,2,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,38.9354
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409115918,NDC,1,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046401,NDC,1,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046402,NDC,1,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046437,NDC,1,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,409174670,NDC,1,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046801,NDC,1,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046817,NDC,1,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BUPivacaine in dextrose 0.75-8.25 % Solution 2 mL Ampule,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409176162,NDC,2,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046601,NDC,1,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143992490,NDC,0.5,EA,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010110,NDC,0.5,EA,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010167,NDC,0.5,EA,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,44567070725,NDC,0.5,EA,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733201,NDC,0.5,EA,30,,Medica,Commercial,both,91.1,,6.892980769,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733801,NDC,0.5,EA,30,,Medica,Commercial,both,91.1,,6.892980769,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,70069000501,NDC,0.1,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,63.2394
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016502,NDC,0.5,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016516,NDC,0.5,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036721,NDC,1,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036725,NDC,1,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 100 MG/10ML Solution 10 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323051610,NDC,0.5,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050641,NDC,0.5,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141031,NDC,0.5,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,641037621,NDC,0.25,ML,30,,Medica,Commercial,both,91.1,,2,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066416,NDC,1,ML,30,,Medica,Commercial,both,91.1,,2,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066441,NDC,0.25,ML,30,,Medica,Commercial,both,91.1,,2,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010101,NDC,0.25,ML,30,,Medica,Commercial,both,91.1,,2,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
DRAPE SPLIT WITH ADHESIVE DYNJP8304A,27200000,CDM,272,RC,,,,4694-MAIN,LOCAL,,,,,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRESSING HYDROFERA 2-1/2X2-1/2  BLUE READY FOAM HBRS2520,120.488,CDM,271,RC,A6209,HCPCS,,11537-MAIN,LOCAL,,,,,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
"Ethanol, P",PX82077,CDM,300,RC,82077,CPT,,,,,,,,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073916,NDC,2,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,29.4
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073941,NDC,1,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,29.4
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,67457043300,NDC,1,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,29.4
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909422,NDC,2,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
folic acid 5 MG/ML Solution 10 mL Vial,J3490.94,CDM,636,RC,J3490,HCPCS,,,,39822110001,NDC,0.2,ML,30,,Medica,Commercial,both,91.1,,7.37,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,330.2012
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,70860030242,NDC,1,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,36000028425,NDC,2,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001094,NDC,2,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,42.5516
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,781382571,NDC,0.5,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,143931901,NDC,0.4,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.428
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272002,NDC,1,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272031,NDC,1,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,25021040010,NDC,1,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323054011,NDC,1,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095300,NDC,0.5,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095310,NDC,1,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,71288042095,NDC,0.5,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306424,NDC,1,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306413,NDC,1,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306521,NDC,3,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin lock flush 10 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306510,NDC,5,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
HYDROmorphone 1 MG/ML Solution 1 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,76045000901,NDC,0.25,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016216,NDC,1,ML,30,,Medica,Commercial,both,91.1,,3.497586207,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016243,NDC,0.5,ML,30,,Medica,Commercial,both,91.1,,3.497586207,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072201,NDC,0.5,ML,30,,Medica,Commercial,both,91.1,,3.497586207,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072225,NDC,0.5,ML,30,,Medica,Commercial,both,91.1,,3.497586207,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016226,NDC,0.5,ML,30,,Medica,Commercial,both,91.1,,3.497586207,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016245,NDC,0.5,ML,30,,Medica,Commercial,both,91.1,,3.497586207,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011901,NDC,0.5,ML,30,,Medica,Commercial,both,91.1,,3.497586207,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011925,NDC,0.5,ML,30,,Medica,Commercial,both,91.1,,3.497586207,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072501,NDC,0.5,ML,30,,Medica,Commercial,both,91.1,,3.497586207,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072525,NDC,0.5,ML,30,,Medica,Commercial,both,91.1,,3.497586207,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143932001,NDC,1,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143962201,NDC,1,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,409226720,NDC,1,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,47781058629,NDC,1,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,51991093498,NDC,1,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,409427616,NDC,20,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323048526,NDC,20,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,63323049241,NDC,2,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2% PF 2 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049526,NDC,5,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2% PF 2 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049541,NDC,5,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine buffered 1 % Solution 0.5 mL Syringe,25000000,CDM,250,RC,,,,,,8888800160,NDC,0.5,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604401,NDC,1,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604425,NDC,1,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620701,NDC,0.25,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620725,NDC,1,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
magnesium sulfate 50 % Solution 10 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006404,NDC,2,ML,30,,Medica,Commercial,both,91.1,,6.305,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,703450284,NDC,2,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.859
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,409177815,NDC,5,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,70860030005,NDC,1.25,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metroNIDAZOLE 500 MG/100ML Solution 100 mL Plas Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,338954124,NDC,100,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,31.4776
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605701,NDC,2,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605725,NDC,1,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060031,NDC,2,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060041,NDC,2,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 5 MG/ML Solution 1 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606101,NDC,0.2,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230504,NDC,0.5,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230505,NDC,5,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam PF 10 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230802,NDC,2,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,43598052936,NDC,0.5,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080601,NDC,0.5,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080610,NDC,0.5,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,409475503,NDC,2,ML,30,,Medica,Commercial,both,91.1,,2.028541667,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054731,NDC,2,ML,30,,Medica,Commercial,both,91.1,,2.028541667,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054831,NDC,2,ML,30,,Medica,Commercial,both,91.1,,2.028541667,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054842,NDC,2,ML,30,,Medica,Commercial,both,91.1,,2.028541667,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092825,NDC,1,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,31.5854
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488802,NDC,10,ML,30,,Medica,Commercial,both,91.1,,7.872391304,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018603,NDC,20,ML,30,,Medica,Commercial,both,91.1,,7.872391304,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018620,NDC,20,ML,30,,Medica,Commercial,both,91.1,,7.872391304,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 50 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488850,NDC,3,ML,30,,Medica,Commercial,both,91.1,,7.872391304,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride bacteriostatic 0.9 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409196602,NDC,30,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride bacteriostatic 0.9 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409196607,NDC,30,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,64253002030,NDC,10,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409488710,NDC,10,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409488717,NDC,10,ML,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
SUTURE BIOSYN MONOFILAMENT ABSORBABLE UNDYED SIZE 4-0 18IN WITH 3/8 CIRCLE REVERSE CUTTING 19MM NEED,27200000,CDM,272,RC,,,,11987-MAIN,LOCAL,,,,,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE MONOFILAMENT SZ 4-0 BIOSYN ABSORBABLE UNDYED18IN WITH 3/8 CIRCLE REVERSE CUTTING 19MM NEED SM,27200000,CDM,272,RC,,,,11984-MAIN,LOCAL,,,,,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TRAY LUMBAR 22GAX3.5 PUNCTURE SAFE-T 4306CWSP,120.18,CDM,272,RC,,,,11584-MAIN,LOCAL,,,,,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
TRAY LUMBAR 22X1.5 PUNCTURE PEDS 4302CSP,120.18,CDM,272,RC,,,,652-MAIN,LOCAL,,,,,30,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
triamcinolone acetonide 10 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3049420,NDC,0.25,ML,30,,Medica,Commercial,both,91.1,,1.066666667,percent of total billed charges,27.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,72.0986
"PDS II ENDOLOOP LIGATURE SIZE 0 18""",27200000,CDM,272,RC,,,,11700-MAIN,LOCAL,,,,,56.96,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,27.3408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"PDS II ENDOLOOP LIGATURE SIZE 0 18""",27200000,CDM,272,RC,,,,11700-MAIN,LOCAL,,,,,56.96,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,27.3408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRAPE ABDOMINAL SURGICAL 14X12 POUCHES STERILE DYNJP3109,27200000,CDM,272,RC,,,,12896-MAIN,LOCAL,,,,,31,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,27.342,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LITHOTOMY PACK VIII ECLIPSE,27200000,CDM,272,RC,,,,12210-MAIN,LOCAL,,,,,31,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,27.342,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Rubella Antibody,PX86762,CDM,300,RC,86762,CPT,,,,,,,,31,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,27.342,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.8774,30.38
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409669501,NDC,10,ML,56.97,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,27.3456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409669501,NDC,10,ML,56.97,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,27.3456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,713013512,NDC,1,EA,65.83,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,27.345782,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.345782,66.2186
nivolumab 40 MG/4ML Solution 4 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377211,NDC,4,ML,2171.7,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,27.35,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.35,32.64
nivolumab 100 MG/10ML Solution 10 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377412,NDC,10,ML,5429.27,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,27.35,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.35,32.64
nivolumab 240 MG/24ML Solution 24 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3373413,NDC,24,ML,13030.26,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,27.35,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.35,32.64
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006111,NDC,0.5,EA,56.98,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,27.3504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.669492,55.8404
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006111,NDC,0.5,EA,56.98,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,27.3504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.669492,55.8404
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006158,NDC,0.5,EA,56.98,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,27.3504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.669492,55.8404
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006158,NDC,0.5,EA,56.98,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,27.3504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.669492,55.8404
dexmedeTOMIDine 200 MCG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,70860060541,NDC,2,ML,55.82,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.3518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dexmedeTOMIDine 200 MCG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,70860060541,NDC,2,ML,55.82,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.3518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dexmedeTOMIDine 200 MCG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,70860060541,NDC,2,ML,55.82,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,27.3518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 4-5 MG/ML-% Solution 500 mL Flex Cont,J2001.01,CDM,636,RC,J2001,HCPCS,,,,338040903,NDC,500,ML,55.82,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.3518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
lidocaine 4-5 MG/ML-% Solution 500 mL Flex Cont,J2001.01,CDM,636,RC,J2001,HCPCS,,,,338040903,NDC,500,ML,55.82,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.3518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
lidocaine 4-5 MG/ML-% Solution 500 mL Flex Cont,J2001.01,CDM,636,RC,J2001,HCPCS,,,,338040903,NDC,500,ML,55.82,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,27.3518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
Fluoroscope Examination Tc,PX7600001,CDM,320,RC,76000,CPT,TC,,,,,,,597,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,27.353,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.32,55.22
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,36000003310,NDC,5,ML,30.74,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,27.3586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Albumin, Othr Source - Ref",PX8204290,CDM,300,RC,82042,CPT,90,,,,,,,57,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,27.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.13,55.86
"Albumin, Othr Source - Ref",PX8204290,CDM,300,RC,82042,CPT,90,,,,,,,57,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,27.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.13,55.86
"Albumin, Serum - Ref",PX8204090,CDM,300,RC,82040,CPT,90,,,,,,,57,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,27.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.54,55.86
"Albumin, Serum - Ref",PX8204090,CDM,300,RC,82040,CPT,90,,,,,,,57,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,27.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.54,55.86
Assay Alkaline Phosphatase,PX84075,CDM,300,RC,84075,CPT,,,,,,,,57,,Health Partners,Health Partners Care Plans,both,48,,34.68285714,percent of total billed charges,27.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,55.86
Assay Alkaline Phosphatase,PX84075,CDM,300,RC,84075,CPT,,,,,,,,57,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,27.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,55.86
Calcium Total,PX82310,CDM,300,RC,82310,CPT,,,,,,,,57,,Health Partners,Health Partners Care Plans,both,48,,26.44,percent of total billed charges,27.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.73,55.86
Calcium Total,PX82310,CDM,300,RC,82310,CPT,,,,,,,,57,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,27.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.73,55.86
Dhea-S - Ref,PX8262790,CDM,300,RC,82627,CPT,90,,,,,,,57,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,27.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.38,55.86
Dhea-S - Ref,PX8262790,CDM,300,RC,82627,CPT,90,,,,,,,57,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,27.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.38,55.86
"Exam,Synovial Fluid Crystals",PX89060,CDM,300,RC,89060,CPT,,,,,,,,85,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,27.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.0598,27.36
"Exam,Synovial Fluid Crystals",PX89060,CDM,300,RC,89060,CPT,,,,,,,,85,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,27.36,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.0598,27.36
"Fluor Noninfect Ab Sc, Ea - Ref",PX8625590,CDM,300,RC,86255,CPT,90,,,,,,,121,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,27.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.69,27.36
"Fluor Noninfect Ab Sc, Ea - Ref",PX8625590,CDM,300,RC,86255,CPT,90,,,,,,,121,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,27.36,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.69,27.36
Immunofix Elp,PX86335,CDM,300,RC,86335,CPT,,,,,,,,214,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,27.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.36,28.881
Immunofix Elp,PX86335,CDM,300,RC,86335,CPT,,,,,,,,214,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,27.36,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.36,28.881
Immunofixation Electrophoresis; Serum,PX86334,CDM,300,RC,86334,CPT,,,,,,,,145,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,27.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.67,27.36
Immunofixation Electrophoresis; Serum,PX86334,CDM,300,RC,86334,CPT,,,,,,,,145,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,27.36,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.67,27.36
Protein E-Phoresis Serum,PX84165,CDM,300,RC,84165,CPT,,,,,,,,175,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,27.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.42,27.36
Protein E-Phoresis Serum,PX84165,CDM,300,RC,84165,CPT,,,,,,,,175,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,27.36,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.42,27.36
Protein Elp,PX84166,CDM,300,RC,84166,CPT,,,,,,,,180,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,27.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.3,27.36
Protein Elp,PX84166,CDM,300,RC,84166,CPT,,,,,,,,180,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,27.36,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.3,27.36
Protein Elp Interp,PX8416526,CDM,300,RC,84165,CPT,26,,,,,,,175,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,27.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.3659,27.536
Protein Elp Interp,PX8416526,CDM,300,RC,84165,CPT,26,,,,,,,175,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,27.36,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.3659,27.536
Smear Special Stain,PX87207,CDM,300,RC,87207,CPT,,,,,,,,81,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,27.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.72,27.36
Smear Special Stain,PX87207,CDM,300,RC,87207,CPT,,,,,,,,81,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,27.36,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.72,27.36
Sp Stn for Inclusn Bodies - Ref,PX8720790,CDM,300,RC,87207,CPT,90,,,,,,,227,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,27.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.72,27.36
Sp Stn for Inclusn Bodies - Ref,PX8720790,CDM,300,RC,87207,CPT,90,,,,,,,227,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,27.36,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.72,27.36
Tiss Trnsgltmnase Ea Ig Clas,PX86364,CDM,300,RC,86364,CPT,,,,,,,,57,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,27.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.6778,55.86
Tiss Trnsgltmnase Ea Ig Clas,PX86364,CDM,300,RC,86364,CPT,,,,,,,,57,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,27.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.6778,55.86
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,43598040516,NDC,0.2,ML,63.83,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,27.38307,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
apixaban 2.5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,3089321,NDC,1,EA,63.84,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,27.38736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 25 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,71101268,NDC,1,EA,55.33,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,27.38835,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Oligoclonal Bands - Ref,PX8391690,CDM,300,RC,83916,CPT,90,,,,,,,124,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,27.39,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.57,27.39
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092821,NDC,1,ML,32.23,,First Health,Commercial,both,85,,999999999,percent of total billed charges,27.3955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,31.5854
VAGINAL PACKING 2',120.292,CDM,272,RC,,,,829-MAIN,LOCAL,,,,,32.23,,First Health,Commercial,both,85,,999999999,percent of total billed charges,27.3955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.388342,31.5854
EPINEPHrine 30 MG/30ML Solution 30 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023016801,NDC,0.3,ML,32.24,,First Health,Commercial,both,85,,999999999,percent of total billed charges,27.404,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
Ig Paraprotein Qual Bld/UR,PX0077U90,CDM,300,RC,0077U,HCPCS,90,,,,,,,66,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,27.4164,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
"Level III - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3933,CDM,310,RC,88304,CPT,TC,,,,,,,66,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,27.4164,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
Ot Contracted Service/Msho/MA,PX120.178,CDM,431,RC,,,,,,,,,,66,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,27.4164,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
Pt Contracted Service/Msho,PX120.176,CDM,421,RC,,,,,,,,,,66,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,27.4164,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
Surg Pathology-Level 2-Tc,PX3932,CDM,310,RC,88302,CPT,TC,,,,,,,66,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,27.4164,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.01,64.68
Xray Orbits Optic Foramina,PX7019001,CDM,320,RC,70190,CPT,TC,,,,,,,66,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,27.4164,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,79.39
saliva substitute Solution 59 mL Bottle,63700001,CDM,250,RC,,,,,,50930009802,NDC,59,ML,31.1,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,27.4302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,409677802,NDC,1,ML,31.11,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,27.43902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
8MM-12MM BLADELESS OBTURATOR 8MM,27200000,CDM,272,RC,,,,11919-MAIN,LOCAL,,,,,56,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM-12MM BLADELESS OBTURATOR 8MM,27200000,CDM,272,RC,,,,11919-MAIN,LOCAL,,,,,56,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM-12MM BLADELESS OBTURATOR 8MM,27200000,CDM,272,RC,,,,11919-MAIN,LOCAL,,,,,56,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,27.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM-12MM BLADELESS OBTURATOR 8MM LONG,27200000,CDM,272,RC,,,,11920-MAIN,LOCAL,,,,,56,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM-12MM BLADELESS OBTURATOR 8MM LONG,27200000,CDM,272,RC,,,,11920-MAIN,LOCAL,,,,,56,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM-12MM BLADELESS OBTURATOR 8MM LONG,27200000,CDM,272,RC,,,,11920-MAIN,LOCAL,,,,,56,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,27.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Albumin; Other Source, Quantitative, Each Specimen",PX82042,CDM,300,RC,82042,CPT,,,,,,,,28,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,27.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.13,27.44
Anesthesia Level - Regional,PX37000025,CDM,370,RC,,,,,,,,,,28,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,27.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
"B Cells, Total Count",PX86355,CDM,300,RC,86355,CPT,,,,,,,,56,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.2624,54.88
"B Cells, Total Count",PX86355,CDM,300,RC,86355,CPT,,,,,,,,56,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.2624,54.88
"B Cells, Total Count",PX86355,CDM,300,RC,86355,CPT,,,,,,,,56,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,27.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.2624,54.88
Citrate - Ref,PX8250790,CDM,300,RC,82507,CPT,90,,,,,,,56,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.2624,54.88
Citrate - Ref,PX8250790,CDM,300,RC,82507,CPT,90,,,,,,,56,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.2624,54.88
Citrate - Ref,PX8250790,CDM,300,RC,82507,CPT,90,,,,,,,56,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,27.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.2624,54.88
"Folic Acid (Folate), Serum",PX82746,CDM,300,RC,82746,CPT,,,,,,,,56,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.48,54.88
"Folic Acid (Folate), Serum",PX82746,CDM,300,RC,82746,CPT,,,,,,,,56,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.48,54.88
"Folic Acid (Folate), Serum",PX82746,CDM,300,RC,82746,CPT,,,,,,,,56,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,27.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.48,54.88
Gonadotropin (Lh),PX83002,CDM,300,RC,83002,CPT,,,,,,,,28,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,27.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
Lab Platelet Count,PX85049,CDM,300,RC,85049,CPT,,,,,,,,56,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.11,54.88
Lab Platelet Count,PX85049,CDM,300,RC,85049,CPT,,,,,,,,56,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.11,54.88
Lab Platelet Count,PX85049,CDM,300,RC,85049,CPT,,,,,,,,56,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,27.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.11,54.88
Mycophenolate Mycophenolicacid - Ref,PX8018090,CDM,300,RC,80180,CPT,90,,,,,,,56,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.55,54.88
Mycophenolate Mycophenolicacid - Ref,PX8018090,CDM,300,RC,80180,CPT,90,,,,,,,56,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.55,54.88
Mycophenolate Mycophenolicacid - Ref,PX8018090,CDM,300,RC,80180,CPT,90,,,,,,,56,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,27.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.55,54.88
Progesterone,PX84144,CDM,300,RC,84144,CPT,,,,,,,,56,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.13,54.88
Progesterone,PX84144,CDM,300,RC,84144,CPT,,,,,,,,56,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.13,54.88
Progesterone,PX84144,CDM,300,RC,84144,CPT,,,,,,,,56,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,27.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.13,54.88
PROMOGRAN PRISMA AG COLLAGEN DRESSING 28CM,120.547,CDM,272,RC,A6021,HCPCS,,12361-MAIN,LOCAL,,,,,28,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,27.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
SCOPE BRONCHOSCOPE SZ 4 STERILE DISPOSABLE B120044,120.574,CDM,272,RC,,,,12868-MAIN,LOCAL,,,,,28,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,27.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
tranexamic acid 650 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,69918030130,NDC,1,EA,28,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,27.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Viral Neutralization - Ref,PX8638290,CDM,300,RC,86382,CPT,90,,,,,,,28,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,27.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.6312,27.44
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031801,NDC,1,ML,185.37,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,27.44101,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.21,29.79
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031825,NDC,1,ML,185.37,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,27.44101,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.21,29.79
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409493311,NDC,10,ML,66.06,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,27.441324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030926,NDC,1,EA,55.44,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,27.4428,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
clarithromycin 250 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,527193106,NDC,1,EA,32.3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,27.455,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clarithromycin 250 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,65862022560,NDC,1,EA,32.3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,27.455,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Blood Occult Peroxidase,PX82272,CDM,300,RC,82272,CPT,,,,,,,,64,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,27.456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.88,62.72
Strapping of Elbow or Wrist,PX29260F,CDM,420,RC,29260,CPT,,,,,,,,64,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,27.456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.5856,62.72
Strapping of Hand or Finger,PX29280F,CDM,420,RC,29280,CPT,,,,,,,,64,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,27.456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.5856,62.72
rosuvastatin 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,310075430,NDC,1,EA,56.04,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.4596,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,310075430,NDC,1,EA,56.04,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.4596,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,310075430,NDC,1,EA,56.04,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,27.4596,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Drain/Inject Large Joint/Bursa,PX20610F,CDM,510,RC,20610,CPT,,,,,,,,364,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,27.48,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.48,135.59
Drain/Inject Large Joint/Bursa,PX20610P,CDM,983,RC,20610,CPT,,,,,,,,291,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,27.48,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.48,285.18
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990711509,NDC,1000,ML,64.08,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,27.49032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
carfilzomib 30 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010201,NDC,1,EA,2785.91,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,27.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.22,49.44
carfilzomib 30 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010201,NDC,1,EA,2785.91,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,27.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.22,49.44
carfilzomib 60 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010101,NDC,1,EA,5571.82,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,27.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.22,49.44
carfilzomib 60 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010101,NDC,1,EA,5571.82,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,27.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.22,49.44
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,25021011487,NDC,200,ML,66.28,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,27.532712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.20921,64.9544
Protein Elp Interp,PX8416526,CDM,300,RC,84165,CPT,26,,,,,,,175,,UCare,Individual and Family Plans,both,,,87.78,fee schedule,27.536,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.3659,27.536
Protein Elp Interp,PX8416526,CDM,300,RC,84165,CPT,26,,,,,,,175,,UCare,Individual and Family Plans,both,,,87.78,fee schedule,27.536,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.3659,27.536
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189101,NDC,1,ML,32.43,,First Health,Commercial,both,85,,999999999,percent of total billed charges,27.5655,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
Amphetamines; 3 or 4,PX8032590,CDM,300,RC,80325,CPT,90,,,,,,,48,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,27.57,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.57,27.57
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057811,NDC,0.5,ML,30.98,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,27.5722,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057841,NDC,0.5,ML,30.98,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,27.5722,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323031119,NDC,10,ML,66.39,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,27.578406,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,84.5054
vedolizumab 300 MG Recon Soln 1 Each Vial,J3380.01,CDM,636,RC,J3380,HCPCS,,,,64764030020,NDC,1,EA,12439.04,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,27.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.66,12190.2592
DRAPE ABDOMINAL SURGICAL 14X12 POUCHES STERILE DYNJP3109,27200000,CDM,272,RC,,,,12896-MAIN,LOCAL,,,,,31,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,27.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LITHOTOMY PACK VIII ECLIPSE,27200000,CDM,272,RC,,,,12210-MAIN,LOCAL,,,,,31,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,27.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Rubella Antibody,PX86762,CDM,300,RC,86762,CPT,,,,,,,,31,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,27.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.8774,30.38
Assay Vitamin B-6,PX84207,CDM,300,RC,84207,CPT,90,,,,,,,42,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,27.5974,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.26,28.1
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001501,NDC,1,EA,2340,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,27.6,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.28,27.6
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001503,NDC,1,EA,2340,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,27.6,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.28,27.6
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,70842014003,NDC,1,EA,2409.61,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,27.6,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.28,27.6
Each Add'l Sequential IV Infusion <1 Hour,PX96367,CDM,260,RC,96367,CPT,,,,,,,,190,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,27.606,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.54,49.44
Reduce Temporomandibl Disloc,PX21480F,CDM,510,RC,21480,CPT,,,,,,,,335,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,27.6146,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.54,294.02
Reduce Temporomandibl Disloc,PX21480P,CDM,983,RC,21480,CPT,,,,,,,,223,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,27.6146,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.54,294.02
dutasteride 0.5 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,42806054909,NDC,1,EA,32.49,,First Health,Commercial,both,85,,999999999,percent of total billed charges,27.6165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141035,NDC,2,ML,56.37,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.6213,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141035,NDC,2,ML,56.37,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.6213,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141035,NDC,2,ML,56.37,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,27.6213,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,65219044501,NDC,10,ML,56.37,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.6213,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,65219044501,NDC,10,ML,56.37,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.6213,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,65219044501,NDC,10,ML,56.37,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,27.6213,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,65219044510,NDC,10,ML,56.37,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.6213,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,65219044510,NDC,10,ML,56.37,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.6213,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,65219044510,NDC,10,ML,56.37,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,27.6213,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
bacitracin zinc 500 UNIT/GM Ointment 28.35 g Tube,25000000,CDM,250,RC,,,,,,168001131,NDC,28.35,GR,32.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,27.625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046417,NDC,10,ML,54.6,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,27.6276,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,63739003807,NDC,1,EA,66.51,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,27.628254,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexmedeTOMIDine 200 MCG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,70860060541,NDC,2,ML,55.82,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,27.6309,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 4-5 MG/ML-% Solution 500 mL Flex Cont,J2001.01,CDM,636,RC,J2001,HCPCS,,,,338040903,NDC,500,ML,55.82,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,27.6309,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093107,NDC,1,ML,57.59,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,27.6432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093107,NDC,1,ML,57.59,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,27.6432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
cyclopentolate 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,17478010002,NDC,2,ML,66.55,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,27.64487,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Apply Forearm Splint,Static",PX29125F,CDM,510,RC,29125,CPT,,,,,,,,223,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,27.65,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.08,141.82
"Apply Forearm Splint,Static",PX29125P,CDM,983,RC,29125,CPT,,,,,,,,296,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,27.65,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.08,290.08
Apply Long Arm Splint,PX29105F,CDM,510,RC,29105,CPT,,,,,,,,290,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,27.65,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.87,175.72
Apply Long Arm Splint,PX29105P,CDM,983,RC,29105,CPT,,,,,,,,385,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,27.65,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.87,377.3
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409492120,NDC,10,ML,54.66,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,27.65796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
PHENobarbital 130 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047721,NDC,1,ML,338.93,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,27.66,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.66,32.8
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047621,NDC,1,ML,157.28,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,27.66,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.66,32.8
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047625,NDC,0.769230769,ML,111.59,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,27.66,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.66,32.8
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608201,NDC,1,ML,66.6,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,27.66564,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,72603012801,NDC,1,EA,57.64,,Health Partners,Health Partners Care Plans,both,48,,23.19555556,percent of total billed charges,27.6672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,72603012801,NDC,1,EA,57.64,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,27.6672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048226,NDC,20,ML,32.56,,First Health,Commercial,both,85,,999999999,percent of total billed charges,27.676,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048241,NDC,20,ML,32.56,,First Health,Commercial,both,85,,999999999,percent of total billed charges,27.676,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641600101,NDC,1,ML,32.56,,First Health,Commercial,both,85,,999999999,percent of total billed charges,27.676,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
saliva substitute Solution 59 mL Bottle,63700001,CDM,250,RC,,,,,,50930009802,NDC,59,ML,31.1,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,27.679,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Cognitive Funct Ther Interv, Ea Addl 15 Min",PX97130,CDM,420,RC,97130,CPT,,,,,,,,82,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,27.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.14,28.12
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607F,CDM,761,RC,97607,CPT,,,,,,,,455,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,27.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.42,459.07
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607P,CDM,983,RC,97607,CPT,,,,,,,,303,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,27.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.42,459.07
potassium chloride 20 MEQ Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,245036089,NDC,1,EA,57.67,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,27.6816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride 20 MEQ Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,245036089,NDC,1,EA,57.67,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,27.6816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,63323004401,NDC,1,ML,64.53,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,27.68337,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,63.2394
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,990771512,NDC,62.5,ML,56.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,12.9192,percent of total billed charges,27.685,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.4701,303.0944
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,990771512,NDC,62.5,ML,56.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.685,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.4701,303.0944
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,990771512,NDC,62.5,ML,56.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,27.685,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.4701,303.0944
zinc oxide 20 % Ointment 56.7 g Tube,63700001,CDM,250,RC,,,,,,168006202,NDC,56.7,GR,30.39,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.68529,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,409677802,NDC,1,ML,31.11,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,27.6879,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
lidocaine buffered 1 % Solution 22.2 mL Vial,25000000,CDM,250,RC,,,,,,8888800251,NDC,22.2,ML,30.4,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.6944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine buffered 1% Solution 22.2 mL Vial,25000000,CDM,250,RC,,,,,,8888800251,NDC,22.2,ML,30.4,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.6944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Initial Rx Burn(S) 1st Degree,PX16000F,CDM,510,RC,16000,CPT,,,,,,,,338,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,27.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.7,166.03
Initial Rx Burn(S) 1st Degree,PX16000F,CDM,510,RC,16000,CPT,,,,,,,,338,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,27.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.7,166.03
Initial Rx Burn(S) 1st Degree,PX16000F,CDM,510,RC,16000,CPT,,,,,,,,338,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,27.7,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.7,166.03
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,93681545,NDC,2,ML,57.71,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,27.7008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,93681545,NDC,2,ML,57.71,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,27.7008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,93681573,NDC,2,ML,57.71,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,27.7008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,93681573,NDC,2,ML,57.71,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,27.7008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048503,NDC,50,ML,57.74,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,27.7152,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048503,NDC,50,ML,57.74,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,27.7152,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
8MM-12MM BLADELESS OBTURATOR 8MM,27200000,CDM,272,RC,,,,11919-MAIN,LOCAL,,,,,56,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,27.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM-12MM BLADELESS OBTURATOR 8MM LONG,27200000,CDM,272,RC,,,,11920-MAIN,LOCAL,,,,,56,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,27.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"B Cells, Total Count",PX86355,CDM,300,RC,86355,CPT,,,,,,,,56,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,27.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.2624,54.88
Citrate - Ref,PX8250790,CDM,300,RC,82507,CPT,90,,,,,,,56,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,27.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.2624,54.88
"Folic Acid (Folate), Serum",PX82746,CDM,300,RC,82746,CPT,,,,,,,,56,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,27.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.48,54.88
Lab Platelet Count,PX85049,CDM,300,RC,85049,CPT,,,,,,,,56,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,27.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.11,54.88
Mycophenolate Mycophenolicacid - Ref,PX8018090,CDM,300,RC,80180,CPT,90,,,,,,,56,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,27.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.55,54.88
Progesterone,PX84144,CDM,300,RC,84144,CPT,,,,,,,,56,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,27.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.13,54.88
TRAY HAND SURGICAL II DYNJS0806,27200000,CDM,272,RC,,,,11024-MAIN,LOCAL,,,,,64.62,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,27.72198,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
levoFLOXacin in dextrose 5% 500 MG/100ML Solution 100 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004724,NDC,100,ML,64.63,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,27.72627,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,76329339001,NDC,5,ML,64.63,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,27.72627,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
rosuvastatin 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,310075430,NDC,1,EA,56.04,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,27.7398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006403,NDC,2,ML,30.45,,Medica,Commercial,both,91.1,,6.305,percent of total billed charges,27.73995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006401,NDC,2,ML,31.46,,United Healthcare,All Payer,outpatient,88.2,,13.925,percent of total billed charges,27.74772,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
tuberculin 5 UNIT/0.1ML Solution 1 mL Vial,25000000,CDM,250,RC,,,,,,42023010401,NDC,0.1,ML,57.82,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,27.7536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tuberculin 5 UNIT/0.1ML Solution 1 mL Vial,25000000,CDM,250,RC,,,,,,42023010401,NDC,0.1,ML,57.82,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,27.7536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
charcoal activated Liquid 240 mL Bottle,63700001,CDM,250,RC,,,,,,574012108,NDC,120,ML,66.88,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,27.781952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024010,NDC,1,EA,56.73,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.7977,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024010,NDC,1,EA,56.73,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.7977,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024010,NDC,1,EA,56.73,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,27.7977,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030036,NDC,1,EA,56.73,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,14.99111111,percent of total billed charges,27.7977,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030036,NDC,1,EA,56.73,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.7977,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030036,NDC,1,EA,56.73,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,27.7977,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098341,NDC,1,EA,56.73,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,14.99111111,percent of total billed charges,27.7977,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098341,NDC,1,EA,56.73,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.7977,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098341,NDC,1,EA,56.73,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,27.7977,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323042605,NDC,5,ML,64.8,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,27.7992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Citrate - Ref,PX8250790,CDM,300,RC,82507,CPT,90,,,,,,,56,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,27.8,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.97,27.8
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049236,NDC,5,ML,31.52,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,27.80064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049243,NDC,5,ML,31.52,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,27.80064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323042405,NDC,5,ML,64.82,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,27.80778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,49348009529,NDC,15,ML,30.53,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.81283,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 100 MG/5ML Suspension 118 mL Bottle,63700001,CDM,250,RC,,,,,,45802089726,NDC,118,ML,54.97,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,27.81482,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcium CHLORIDE 10 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409163140,NDC,10,ML,64.85,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,27.82065,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lopinavir-ritonavir 200-50 MG Tablet 120 Each Bottle,63700001,CDM,250,RC,,,,,,74679922,NDC,1,EA,54.99,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,27.82494,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Endocrine E2,PX82670,CDM,300,RC,82670,CPT,90,,,,,,,55,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,27.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,53.9
"Immunofluo Direct, Ea Ab - Ref",PX8834690,CDM,310,RC,88346,CPT,90,,,,,,,55,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,27.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,149.22
Lipoprotein (a) - Ref,PX8369590,CDM,300,RC,83695,CPT,90,,,,,,,55,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,27.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.13,53.9
MEPILEX BORDER AG POST OP 4X10,120.368,CDM,272,RC,A6212,HCPCS,,10839-MAIN,LOCAL,,,,,55,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,27.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,53.9
SURGIFOAM ABSORBABLE GELATIN SPONGE 3.1 IN X 4.9IN X 10MM,120.371,CDM,272,RC,A4649,HCPCS,,10864-MAIN,LOCAL,,,,,55,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,27.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,53.9
Group Therapeutic Procedures,PX97150,CDM,420,RC,97150,CPT,,,,,,,,67,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,27.8318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.82,65.66
"Hydroxyprogesterone, 17-D - Ref",PX8349890,CDM,300,RC,83498,CPT,90,,,,,,,67,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,27.8318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.91,65.66
Lab Org ID Anaerobic-Each,PX87076,CDM,300,RC,87076,CPT,,,,,,,,67,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,27.8318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,65.66
"Albumin, Blood",PX82040,CDM,300,RC,82040,CPT,90,,,,,,,58,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,27.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.54,56.84
"Albumin, Blood",PX82040,CDM,300,RC,82040,CPT,90,,,,,,,58,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,27.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.54,56.84
Assay of creatinine,PX82565,CDM,300,RC,82565,CPT,,,,,,,,58,,Health Partners,Health Partners Care Plans,both,48,,42.29428571,percent of total billed charges,27.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.69,56.84
Assay of creatinine,PX82565,CDM,300,RC,82565,CPT,,,,,,,,58,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,27.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.69,56.84
Assay of Urea Nitrogen,PX84520,CDM,300,RC,84520,CPT,,,,,,,,58,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,27.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.62,56.84
Assay of Urea Nitrogen,PX84520,CDM,300,RC,84520,CPT,,,,,,,,58,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,27.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.62,56.84
"Assay, Glucose, Blood Quant",PX82947,CDM,300,RC,82947,CPT,,,,,,,,58,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,27.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.6,56.84
"Assay, Glucose, Blood Quant",PX82947,CDM,300,RC,82947,CPT,,,,,,,,58,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,27.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.6,56.84
Automated Leukocyte Count,PX85048,CDM,300,RC,85048,CPT,,,,,,,,58,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,27.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.33,56.84
Automated Leukocyte Count,PX85048,CDM,300,RC,85048,CPT,,,,,,,,58,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,27.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.33,56.84
DEFIBRILLATION PAD BIPHASIC ADULT,120.96,CDM,271,RC,A0392,HCPCS,,1321-MAIN,LOCAL,,,,,58,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,27.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.0932,56.84
DEFIBRILLATION PAD BIPHASIC ADULT,120.96,CDM,271,RC,A0392,HCPCS,,1321-MAIN,LOCAL,,,,,58,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,27.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.0932,56.84
"Ebv, Nuclear Antigen - Ref",PX8666490,CDM,300,RC,86664,CPT,90,,,,,,,58,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,27.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.02,56.84
"Ebv, Nuclear Antigen - Ref",PX8666490,CDM,300,RC,86664,CPT,90,,,,,,,58,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,27.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.02,56.84
"Ebv, Viral Capsid Ab - Ref",PX8666590,CDM,300,RC,86665,CPT,90,,,,,,,58,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,27.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.63,56.84
"Ebv, Viral Capsid Ab - Ref",PX8666590,CDM,300,RC,86665,CPT,90,,,,,,,58,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,27.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.63,56.84
Hematocrit,PX85014,CDM,300,RC,85014,CPT,,,,,,,,58,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,27.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.17,56.84
Hematocrit,PX85014,CDM,300,RC,85014,CPT,,,,,,,,58,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,27.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.17,56.84
"Long Term Holter, 48 Hrs Up to 7 Days, Recording",PX93242,CDM,731,RC,93242,CPT,,,,,,,,58,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,27.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.0932,56.84
"Long Term Holter, 48 Hrs Up to 7 Days, Recording",PX93242,CDM,731,RC,93242,CPT,,,,,,,,58,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,27.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.0932,56.84
"Long Term Holter, More Than 7 Days Up to 15 Days, Recording",PX93246,CDM,731,RC,93246,CPT,,,,,,,,58,,Health Partners,Health Partners Care Plans,both,48,,41.58,percent of total billed charges,27.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.0932,56.84
"Long Term Holter, More Than 7 Days Up to 15 Days, Recording",PX93246,CDM,731,RC,93246,CPT,,,,,,,,58,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,27.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.0932,56.84
"Sodium; Serum, Plasma or Whole Blood",PX84295,CDM,300,RC,84295,CPT,,,,,,,,58,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,27.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.41,56.84
"Sodium; Serum, Plasma or Whole Blood",PX84295,CDM,300,RC,84295,CPT,,,,,,,,58,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,27.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.41,56.84
SUTURE V-LOC SZ 1 PBT WOUND CLOSURE DEVICE BLUE 18 IN GS 21 NEEDLE VLOCN0327,27200000,CDM,272,RC,,,,12828-MAIN,LOCAL,,,,,58,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,27.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE V-LOC SZ 1 PBT WOUND CLOSURE DEVICE BLUE 18 IN GS 21 NEEDLE VLOCN0327,27200000,CDM,272,RC,,,,12828-MAIN,LOCAL,,,,,58,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,27.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Transferase; Alanine Amino (Alt) (Sgpt),PX84460,CDM,300,RC,84460,CPT,,,,,,,,58,,Health Partners,Health Partners Care Plans,both,48,,36.68333333,percent of total billed charges,27.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.86,56.84
Transferase; Alanine Amino (Alt) (Sgpt),PX84460,CDM,300,RC,84460,CPT,,,,,,,,58,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,27.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.86,56.84
Transferase; Aspartate Amino (Ast) (Sgot),PX84450,CDM,300,RC,84450,CPT,,,,,,,,58,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,27.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,56.84
Transferase; Aspartate Amino (Ast) (Sgot),PX84450,CDM,300,RC,84450,CPT,,,,,,,,58,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,27.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,56.84
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061601,NDC,3,ML,31.57,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,27.84474,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058003,NDC,0.5,ML,31.57,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,27.84474,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058020,NDC,0.5,ML,31.57,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,27.84474,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061416,NDC,0.5,ML,31.57,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,27.84474,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.114178,99.911
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010125,NDC,1,ML,30.58,,Medica,Commercial,both,91.1,,2,percent of total billed charges,27.85838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323048541,NDC,20,ML,30.58,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.85838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 1 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097032187,NDC,1,ML,64.97,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,27.87213,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
RESERVOIR WOUND DRAIN 15FR,27200000,CDM,272,RC,,,,4386-MAIN,LOCAL,,,,,30.6,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.8766,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SET DISPOSABLE COLLECTION,27100000,CDM,271,RC,,,,5439-MAIN,LOCAL,,,,,30.6,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.8766,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
SUTURE NUROLON 0 BLACK C527D,27200000,CDM,272,RC,,,,10415-MAIN,LOCAL,,,,,30.6,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,27.8766,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Alkaloids, Not Otherwise Specified - Ref",PX8032390,CDM,300,RC,80323,CPT,90,,,,,,,65,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,27.885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.001,63.7
Anesthesia Level 3,PX37000017,CDM,370,RC,,,,,,,,,,65,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,27.885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.001,63.7
Clozapine - Ref,PX8015990,CDM,300,RC,80159,CPT,90,,,,,,,65,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,27.885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.48,63.7
Gastrin - Ref,PX8294190,CDM,300,RC,82941,CPT,90,,,,,,,65,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,27.885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.16,63.7
Insulin Ab - Ref,PX8633790,CDM,300,RC,86337,CPT,90,,,,,,,65,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,27.885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.63,63.7
Resp Muscles 1:1 per 15 Min,PXG0237,CDM,948,RC,G0237,HCPCS,,,,,,,,65,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,27.885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.01,63.7
Smking Cess 4-10 Min,PX99406F,CDM,942,RC,99406,CPT,,,,,,,,65,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,27.885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.07,63.7
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,United Healthcare,All Payer,outpatient,88.2,,14.47333333,percent of total billed charges,27.89766,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,United Healthcare,All Payer,outpatient,88.2,,14.47333333,percent of total billed charges,27.89766,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141035,NDC,2,ML,56.37,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,27.90315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,65219044501,NDC,10,ML,56.37,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,27.90315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,65219044510,NDC,10,ML,56.37,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,27.90315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"PDS II ENDOLOOP LIGATURE SIZE 0 18""",27200000,CDM,272,RC,,,,11700-MAIN,LOCAL,,,,,56.96,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.9104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"PDS II ENDOLOOP LIGATURE SIZE 0 18""",27200000,CDM,272,RC,,,,11700-MAIN,LOCAL,,,,,56.96,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.9104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"PDS II ENDOLOOP LIGATURE SIZE 0 18""",27200000,CDM,272,RC,,,,11700-MAIN,LOCAL,,,,,56.96,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,27.9104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409669501,NDC,10,ML,56.97,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.9153,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409669501,NDC,10,ML,56.97,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.9153,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409669501,NDC,10,ML,56.97,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,27.9153,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Blood Transfusion Service,PX36430,CDM,391,RC,36430,CPT,,,,,,,,839,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,27.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.52,87.86
Blood Transfusion Service,PX36430,CDM,391,RC,36430,CPT,,,,,,,,839,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,27.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.52,87.86
Drain/Inject Large Joint/Bursa,PX20610F,CDM,510,RC,20610,CPT,,,,,,,,364,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,27.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.48,135.59
Drain/Inject Large Joint/Bursa,PX20610F,CDM,510,RC,20610,CPT,,,,,,,,364,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,27.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.48,135.59
Drain/Inject Large Joint/Bursa,PX20610P,CDM,983,RC,20610,CPT,,,,,,,,291,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,27.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.48,285.18
Drain/Inject Large Joint/Bursa,PX20610P,CDM,983,RC,20610,CPT,,,,,,,,291,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,27.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.48,285.18
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006111,NDC,0.5,EA,56.98,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.9202,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.669492,55.8404
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006111,NDC,0.5,EA,56.98,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.9202,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.669492,55.8404
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006111,NDC,0.5,EA,56.98,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,27.9202,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.669492,55.8404
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006158,NDC,0.5,EA,56.98,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.9202,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.669492,55.8404
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006158,NDC,0.5,EA,56.98,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.9202,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.669492,55.8404
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006158,NDC,0.5,EA,56.98,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,27.9202,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.669492,55.8404
lidocaine 5 % Patch 30 Each Box,63700001,CDM,250,RC,,,,,,603188016,NDC,1,EA,55.18,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,27.92108,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Albumin, Othr Source - Ref",PX8204290,CDM,300,RC,82042,CPT,90,,,,,,,57,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.13,55.86
"Albumin, Othr Source - Ref",PX8204290,CDM,300,RC,82042,CPT,90,,,,,,,57,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.13,55.86
"Albumin, Othr Source - Ref",PX8204290,CDM,300,RC,82042,CPT,90,,,,,,,57,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,27.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.13,55.86
"Albumin, Serum - Ref",PX8204090,CDM,300,RC,82040,CPT,90,,,,,,,57,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.54,55.86
"Albumin, Serum - Ref",PX8204090,CDM,300,RC,82040,CPT,90,,,,,,,57,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.54,55.86
"Albumin, Serum - Ref",PX8204090,CDM,300,RC,82040,CPT,90,,,,,,,57,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,27.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.54,55.86
Assay Alkaline Phosphatase,PX84075,CDM,300,RC,84075,CPT,,,,,,,,57,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,55.86
Assay Alkaline Phosphatase,PX84075,CDM,300,RC,84075,CPT,,,,,,,,57,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,55.86
Assay Alkaline Phosphatase,PX84075,CDM,300,RC,84075,CPT,,,,,,,,57,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,27.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,55.86
Calcium Total,PX82310,CDM,300,RC,82310,CPT,,,,,,,,57,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.73,55.86
Calcium Total,PX82310,CDM,300,RC,82310,CPT,,,,,,,,57,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.73,55.86
Calcium Total,PX82310,CDM,300,RC,82310,CPT,,,,,,,,57,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,27.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.73,55.86
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031801,NDC,1,ML,185.37,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,27.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.21,29.79
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031801,NDC,1,ML,185.37,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,27.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.21,29.79
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031825,NDC,1,ML,185.37,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,27.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.21,29.79
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031825,NDC,1,ML,185.37,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,27.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.21,29.79
Dhea-S - Ref,PX8262790,CDM,300,RC,82627,CPT,90,,,,,,,57,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.38,55.86
Dhea-S - Ref,PX8262790,CDM,300,RC,82627,CPT,90,,,,,,,57,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.38,55.86
Dhea-S - Ref,PX8262790,CDM,300,RC,82627,CPT,90,,,,,,,57,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,27.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.38,55.86
Tiss Trnsgltmnase Ea Ig Clas,PX86364,CDM,300,RC,86364,CPT,,,,,,,,57,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.6778,55.86
Tiss Trnsgltmnase Ea Ig Clas,PX86364,CDM,300,RC,86364,CPT,,,,,,,,57,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,27.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.6778,55.86
Tiss Trnsgltmnase Ea Ig Clas,PX86364,CDM,300,RC,86364,CPT,,,,,,,,57,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,27.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.6778,55.86
lidocaine 5 % Patch 1 Each Box,63700001,CDM,250,RC,,,,,,603188010,NDC,1,EA,55.2,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,27.9312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Endocrine E2,PX82670,CDM,300,RC,82670,CPT,90,,,,,,,55,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,27.94,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.68,27.94
rivaroxaban 15 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50458057830,NDC,0.666666667,EA,67.3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,27.95642,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189103,NDC,1,ML,32.89,,First Health,Commercial,both,85,,999999999,percent of total billed charges,27.9565,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,990771512,NDC,62.5,ML,56.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,27.9675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.4701,303.0944
lidocaine HCl 4 % Cream 76.5 g Tube,63700001,CDM,250,RC,,,,,,41167005820,NDC,76.5,GR,31.72,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,27.97704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,641601501,NDC,25,ML,58.29,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,27.9792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,641601501,NDC,25,ML,58.29,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,27.9792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
US Guide Needle Bx S&I,PX7694201,CDM,402,RC,76942,CPT,TC,,,,,,,747,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,27.9966,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.32,55.88
US Guide Needle Bx S&I,PX7694226,CDM,982,RC,76942,CPT,26,,,,,,,148,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,27.9966,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.97,145.04
Xray Ankle Minimum 3 Vws,PX7361001,CDM,320,RC,73610,CPT,TC,,,,,,,365,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,27.9966,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.75,55.88
pregabalin 25 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,71101268,NDC,1,EA,55.33,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,27.99698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006401,NDC,2,ML,31.46,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,27.9994,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117630,NDC,1,ML,58.34,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,28.0032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117630,NDC,1,ML,58.34,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,28.0032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,36000003310,NDC,5,ML,30.74,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,28.00414,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
PACLitaxel 30 MG/5ML Concentrate 5 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476401,NDC,5,ML,58.37,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,28.0176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
PACLitaxel 30 MG/5ML Concentrate 5 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476401,NDC,5,ML,58.37,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,28.0176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
CATHETER FOLEY 18FR  3WAY 30CC 73018L,120.21,CDM,272,RC,A4346,HCPCS,,253-MAIN,LOCAL,,,,,33,,First Health,Commercial,both,85,,999999999,percent of total billed charges,28.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
CATHETER FOLEY 20FR 3WAY 30CC 0167L20,120.21,CDM,272,RC,A4346,HCPCS,,251-MAIN,LOCAL,,,,,33,,First Health,Commercial,both,85,,999999999,percent of total billed charges,28.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
CATHETER FOLEY 24FR 3WAY 30CC 0167L24,120.21,CDM,272,RC,A4346,HCPCS,,10455-MAIN,LOCAL,,,,,33,,First Health,Commercial,both,85,,999999999,percent of total billed charges,28.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
"DRESSING AQUACEL 3/4"" X 18"" AG HYDROFIBER 403771",120.31,CDM,272,RC,A6199,HCPCS,,8238-MAIN,LOCAL,,,,,33,,First Health,Commercial,both,85,,999999999,percent of total billed charges,28.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,32.34
Hospital Outpatient Clinic Visit Specimen Collection for Sars-Cov-2,PXC9803,CDM,300,RC,C9803,HCPCS,,,,,,,,33,,First Health,Commercial,both,85,,999999999,percent of total billed charges,28.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,32.34
MEPILEX AG 4X4 10X10,120.138,CDM,272,RC,A6213,HCPCS,,7248-MAIN,LOCAL,,,,,33,,First Health,Commercial,both,85,,999999999,percent of total billed charges,28.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,32.34
STANDARD HIGH FLOW INSUFFLATION FILTER TUBING,27200000,CDM,272,RC,,,,11885-MAIN,LOCAL,,,,,33,,First Health,Commercial,both,85,,999999999,percent of total billed charges,28.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030926,NDC,1,EA,55.44,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,28.05264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049236,NDC,5,ML,31.52,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,28.0528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049243,NDC,5,ML,31.52,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,28.0528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,143950801,NDC,10,ML,58.46,,Health Partners,Health Partners Care Plans,both,48,,31.91277778,percent of total billed charges,28.0608,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,143950801,NDC,10,ML,58.46,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,28.0608,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,58602060407,NDC,100,GR,67.56,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,28.064424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,574722612,NDC,1,EA,67.57,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,28.068578,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.345782,66.2186
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024010,NDC,1,EA,56.73,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,28.08135,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030036,NDC,1,EA,56.73,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,28.08135,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098341,NDC,1,EA,56.73,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,28.08135,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,548590000,NDC,1,EA,470.19,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,28.08441,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.86,28.59
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,781344071,NDC,1,EA,430.94,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,28.08441,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.86,28.59
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,143950810,NDC,10,ML,58.51,,Health Partners,Health Partners Care Plans,both,48,,31.91277778,percent of total billed charges,28.0848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,143950810,NDC,10,ML,58.51,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,28.0848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
Sacubitril-Valsartan 49-51 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,78077720,NDC,1,EA,58.51,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,28.0848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Sacubitril-Valsartan 49-51 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,78077720,NDC,1,EA,58.51,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,28.0848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061601,NDC,3,ML,31.57,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,28.0973,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058003,NDC,0.5,ML,31.57,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,28.0973,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058020,NDC,0.5,ML,31.57,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,28.0973,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061416,NDC,0.5,ML,31.57,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,28.0973,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.114178,99.911
Assay Vitamin B-6,PX84207,CDM,300,RC,84207,CPT,90,,,,,,,42,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,28.1,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.26,28.1
aspirin-dipyridamole 25-200 MG Capsule Extended Release 12 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687030533,NDC,1,EA,67.66,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,28.105964,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin-dipyridamole 25-200 MG Capsule Extended Release 12 Hour 20 Each Box,63700001,CDM,250,RC,,,,,,60687030532,NDC,1,EA,67.66,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,28.105964,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060820,NDC,20,ML,58.57,,Health Partners,Health Partners Care Plans,both,48,,1.259785714,percent of total billed charges,28.1136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060820,NDC,20,ML,58.57,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,28.1136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
"sodium chloride 0.45 % 1,000 mL with potassium chloride 20 mEq 20-0.45 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070434,NDC,1000,ML,58.57,,Health Partners,Health Partners Care Plans,both,48,,6.034333333,percent of total billed charges,28.1136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"sodium chloride 0.45 % 1,000 mL with potassium chloride 20 mEq 20-0.45 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070434,NDC,1000,ML,58.57,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,28.1136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
acetaZOLAMIDE 500 MG Recon Soln 1 Each Vial,J1120.01,CDM,636,RC,J1120,HCPCS,,,,39822019001,NDC,1,EA,207.84,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,28.12,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.74,28.12
Amphetamines; 1 or 2 - Ref,PX8032490,CDM,300,RC,80324,CPT,90,,,,,,,147,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,28.12,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.12,28.12
"Cognitive Funct Ther Interv, Ea Addl 15 Min",PX97130,CDM,420,RC,97130,CPT,,,,,,,,82,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,28.12,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.14,28.12
"Methlenedioxyamphetamines (Mda, Mdea, Mdma) - Ref",PX8035990,CDM,300,RC,80359,CPT,90,,,,,,,147,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,28.12,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.12,28.12
tobramycin 80 MG/2ML Solution 2 mL Vial,J3260.01,CDM,636,RC,J3260,HCPCS,,,,67457047300,NDC,2,ML,33.09,,First Health,Commercial,both,85,,999999999,percent of total billed charges,28.1265,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.745586,32.4282
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,63323047401,NDC,1,ML,58.6,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,28.128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.428
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,63323047401,NDC,1,ML,58.6,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,28.128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.428
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076501,NDC,1,EA,58.6,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,28.128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076501,NDC,1,EA,58.6,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,28.128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076510,NDC,1,EA,58.6,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,28.128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076510,NDC,1,EA,58.6,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,28.128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604F,CDM,510,RC,20604,CPT,,,,,,,,344,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,28.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.13,172.26
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604F,CDM,510,RC,20604,CPT,,,,,,,,344,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,28.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.13,172.26
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604P,CDM,983,RC,20604,CPT,,,,,,,,229,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,28.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.13,224.42
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604P,CDM,983,RC,20604,CPT,,,,,,,,229,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,28.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.13,224.42
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604F,CDM,510,RC,20604,CPT,,,,,,,,344,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,28.13,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.13,172.26
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604P,CDM,983,RC,20604,CPT,,,,,,,,229,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,28.13,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.13,224.42
"pediatric electrolyte Solution 1,000 mL Bottle",25000000,CDM,250,RC,,,,,,49348057041,NDC,1000,ML,31.9,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,28.1358,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,28.1507,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,28.1507,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606001,NDC,10,ML,65.62,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,28.15098,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606010,NDC,10,ML,65.62,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,28.15098,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086000,NDC,1,EA,58.66,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,28.1568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086000,NDC,1,EA,58.66,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,28.1568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086050,NDC,1,EA,58.66,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,28.1568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086050,NDC,1,EA,58.66,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,28.1568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012166,NDC,1,EA,58.66,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,28.1568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012166,NDC,1,EA,58.66,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,28.1568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
cefOXitin 1 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021010910,NDC,1,EA,58.66,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,28.1568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.367364,75.6952
cefOXitin 1 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021010910,NDC,1,EA,58.66,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,28.1568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.367364,75.6952
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,65219025915,NDC,1,EA,58.66,,Health Partners,Health Partners Care Plans,both,48,,6.796666667,percent of total billed charges,28.1568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,65219025915,NDC,1,EA,58.66,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,28.1568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,55150020200,NDC,1,EA,65.65,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,28.16385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
KIT ENDO COMPLETE PROCEDURE CARRY-ON 100802,27200000,CDM,272,RC,,,,10369-MAIN,LOCAL,,,,,33.15,,First Health,Commercial,both,85,,999999999,percent of total billed charges,28.1775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,43598020453,NDC,10,ML,58.73,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,28.1904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,43598020453,NDC,10,ML,58.73,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,28.1904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,72508020415,NDC,10,ML,58.73,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,28.1904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,72508020415,NDC,10,ML,58.73,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,28.1904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084007001,NDC,1,EA,33.17,,First Health,Commercial,both,85,,999999999,percent of total billed charges,28.1945,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"PDS II ENDOLOOP LIGATURE SIZE 0 18""",27200000,CDM,272,RC,,,,11700-MAIN,LOCAL,,,,,56.96,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,28.1952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039801,NDC,1,EA,67.88,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,28.197352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039810,NDC,1,EA,67.88,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,28.197352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409669501,NDC,10,ML,56.97,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,28.20015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,517460125,NDC,0.5,ML,58.76,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,28.2048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,517460125,NDC,0.5,ML,58.76,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,28.2048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006111,NDC,0.5,EA,56.98,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,28.2051,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.669492,55.8404
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006158,NDC,0.5,EA,56.98,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,28.2051,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.669492,55.8404
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003905,NDC,1,EA,58.77,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,28.2096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003905,NDC,1,EA,58.77,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,28.2096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
triamcinolone acetonide 0.1 % Cream 80 g Tube,63700001,CDM,250,RC,,,,,,16714098603,NDC,80,GR,65.76,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,28.21104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084007011,NDC,1,EA,33.19,,First Health,Commercial,both,85,,999999999,percent of total billed charges,28.2115,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Albumin, Othr Source - Ref",PX8204290,CDM,300,RC,82042,CPT,90,,,,,,,57,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,28.215,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.13,55.86
"Albumin, Serum - Ref",PX8204090,CDM,300,RC,82040,CPT,90,,,,,,,57,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,28.215,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.54,55.86
Assay Alkaline Phosphatase,PX84075,CDM,300,RC,84075,CPT,,,,,,,,57,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,28.215,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,55.86
Calcium Total,PX82310,CDM,300,RC,82310,CPT,,,,,,,,57,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,28.215,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.73,55.86
Dhea-S - Ref,PX8262790,CDM,300,RC,82627,CPT,90,,,,,,,57,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,28.215,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.38,55.86
Tiss Trnsgltmnase Ea Ig Clas,PX86364,CDM,300,RC,86364,CPT,,,,,,,,57,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,28.215,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.6778,55.86
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093107,NDC,1,ML,57.59,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,9.513809524,percent of total billed charges,28.2191,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093107,NDC,1,ML,57.59,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.2191,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093107,NDC,1,ML,57.59,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,28.2191,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057811,NDC,0.5,ML,30.98,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,28.22278,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057841,NDC,0.5,ML,30.98,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,28.22278,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
BANDAGE COBAN  4 IN 2 LAYER COMPRESSION SYSTEM  2094N,120.549,CDM,272,RC,A6441,HCPCS,,12366-MAIN,LOCAL,,,,,32,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,28.224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.2928,31.36
BANDAGE COBAN LITE 4 IN 2 LAYER COMPRESSION SYSTEM 2794N,120.549,CDM,272,RC,A6441,HCPCS,,12922-MAIN,LOCAL,,,,,32,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,28.224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.2928,31.36
WOUND DRAIN FLAT WITH TROCAR 10MM FULL PERFORATED SILICONE,27200000,CDM,272,RC,,,,12462-MAIN,LOCAL,,,,,32,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,28.224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Ecg 12 Lead, Interp Only",PX93010,CDM,985,RC,93010,CPT,,,,,,,,29,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,28.2257,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.0466,28.2257
Microscopic Exam of Urine,PX81015,CDM,300,RC,81015,CPT,,,,,,,,29,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,28.2257,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.8,28.42
TRAY ARTHROGRAM SAFE-T-ARTHRO 28-AR1CO,120.2,CDM,272,RC,,,,11499-MAIN,LOCAL,,,,,29,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,28.2257,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.0466,194.04
lidocaine HCl 4 % Cream 76.5 g Tube,63700001,CDM,250,RC,,,,,,41167005820,NDC,76.5,GR,31.72,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,28.2308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987525,NDC,3,ML,33.22,,First Health,Commercial,both,85,,999999999,percent of total billed charges,28.237,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
DRAPE ABDOMINAL SURGICAL 14X12 POUCHES STERILE DYNJP3109,27200000,CDM,272,RC,,,,12896-MAIN,LOCAL,,,,,31,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,28.241,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LITHOTOMY PACK VIII ECLIPSE,27200000,CDM,272,RC,,,,12210-MAIN,LOCAL,,,,,31,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,28.241,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Rubella Antibody,PX86762,CDM,300,RC,86762,CPT,,,,,,,,31,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,28.241,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.8774,30.38
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,713013512,NDC,1,EA,65.83,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,28.24107,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.345782,66.2186
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,72603012801,NDC,1,EA,57.64,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,24.94142857,percent of total billed charges,28.2436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,72603012801,NDC,1,EA,57.64,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.2436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,72603012801,NDC,1,EA,57.64,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,28.2436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
dexmedeTOMIDine 200 MCG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,70860060541,NDC,2,ML,55.82,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,28.24492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 4-5 MG/ML-% Solution 500 mL Flex Cont,J2001.01,CDM,636,RC,J2001,HCPCS,,,,338040903,NDC,500,ML,55.82,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,28.24492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
valACYclovir 1 GM Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862044930,NDC,0.5,EA,33.23,,First Health,Commercial,both,85,,999999999,percent of total billed charges,28.2455,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Flour. Afstain , Micro - Ref",PX8720690,CDM,300,RC,87206,CPT,90,,,,,,,68,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,28.2472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.94,66.64
Hemoglobin,PX85018,CDM,300,RC,85018,CPT,,,,,,,,68,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,28.2472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.17,66.64
Thyroglobulin - Ref,PX8443290,CDM,300,RC,84432,CPT,90,,,,,,,68,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,28.2472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.73,66.64
Thyroglobulin Antibody,PX8680090,CDM,300,RC,86800,CPT,90,,,,,,,68,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,28.2472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.59,66.64
potassium chloride 20 MEQ Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,245036089,NDC,1,EA,57.67,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.2583,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride 20 MEQ Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,245036089,NDC,1,EA,57.67,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.2583,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride 20 MEQ Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,245036089,NDC,1,EA,57.67,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,28.2583,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terbinafine 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714079501,NDC,1,EA,68.03,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,28.259662,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terbinafine 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714050101,NDC,1,EA,68.04,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,28.263816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Xray Shoulder 1 Vw,PX7302001,CDM,320,RC,73020,CPT,TC,,,,,,,267,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,28.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.37,28.27
Xray Shoulder 1 Vw,PX7302001,CDM,320,RC,73020,CPT,TC,,,,,,,267,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,28.27,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.37,28.27
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,93681545,NDC,2,ML,57.71,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.2779,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,93681545,NDC,2,ML,57.71,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.2779,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,93681545,NDC,2,ML,57.71,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,28.2779,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,93681573,NDC,2,ML,57.71,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.2779,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,93681573,NDC,2,ML,57.71,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.2779,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,93681573,NDC,2,ML,57.71,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,28.2779,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409116219,NDC,30,ML,32.07,,United Healthcare,All Payer,outpatient,88.2,,12.82416667,percent of total billed charges,28.28574,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117603,NDC,1,ML,58.93,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,28.2864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117603,NDC,1,ML,58.93,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,28.2864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048503,NDC,50,ML,57.74,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.2926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048503,NDC,50,ML,57.74,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.2926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048503,NDC,50,ML,57.74,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,28.2926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Clotting Function Activity - Ref,PX8539790,CDM,300,RC,85397,CPT,90,,,,,,,334,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,28.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.3,327.32
inFLIXimab 100 MG Recon Soln 1 Each Vial,J1745.01,CDM,636,RC,J1745,HCPCS,,,,57894003001,NDC,1,EA,2382.35,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,28.3,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.3,32.16
benzocaine-menthol 20-0.5 % Aerosol 56 g Can,63700001,CDM,250,RC,,,,,,16864068002,NDC,56,GR,33.3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,28.305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PROMOGRAN PRISMA AG COLLAGEN DRESSING 28CM,120.547,CDM,272,RC,A6021,HCPCS,,12361-MAIN,LOCAL,,,,,28,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,28.3096,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.26,28.69
Ig Paraprotein Qual Bld/UR,PX0077U90,CDM,300,RC,0077U,HCPCS,90,,,,,,,66,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,28.314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
"Level III - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3933,CDM,310,RC,88304,CPT,TC,,,,,,,66,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,28.314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
Ot Contracted Service/Msho/MA,PX120.178,CDM,431,RC,,,,,,,,,,66,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,28.314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
Pt Contracted Service/Msho,PX120.176,CDM,421,RC,,,,,,,,,,66,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,28.314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
Surg Pathology-Level 2-Tc,PX3932,CDM,310,RC,88302,CPT,TC,,,,,,,66,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,28.314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.01,64.68
Xray Orbits Optic Foramina,PX7019001,CDM,320,RC,70190,CPT,TC,,,,,,,66,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,28.314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,79.39
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003930,NDC,1,EA,58.99,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,28.3152,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003930,NDC,1,EA,58.99,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,28.3152,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
Xray Sacroiliac Jnts 3 or More Vws,PX7220201,CDM,320,RC,72202,CPT,TC,,,,,,,285,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,28.3184,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.75,56.54
DRAWTEX HYDROCONDUCTIVE NONADHERENT DRESSING,120.508,CDM,271,RC,A6199,HCPCS,,12022-MAIN,LOCAL,,,,,59,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,28.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.5086,57.82
DRAWTEX HYDROCONDUCTIVE NONADHERENT DRESSING,120.508,CDM,271,RC,A6199,HCPCS,,12022-MAIN,LOCAL,,,,,59,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,28.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.5086,57.82
"Potassium; Serum, Plasma or Whole Blood",PX84132,CDM,300,RC,84132,CPT,,,,,,,,59,,Health Partners,Health Partners Care Plans,both,48,,41.835,percent of total billed charges,28.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.36,57.82
"Potassium; Serum, Plasma or Whole Blood",PX84132,CDM,300,RC,84132,CPT,,,,,,,,59,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,28.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.36,57.82
metroNIDAZOLE 500 MG/100ML Solution 100 mL Flex Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,409781124,NDC,100,ML,32.12,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,28.32984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,31.4776
tuberculin 5 UNIT/0.1ML Solution 1 mL Vial,25000000,CDM,250,RC,,,,,,42023010401,NDC,0.1,ML,57.82,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.3318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tuberculin 5 UNIT/0.1ML Solution 1 mL Vial,25000000,CDM,250,RC,,,,,,42023010401,NDC,0.1,ML,57.82,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.3318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tuberculin 5 UNIT/0.1ML Solution 1 mL Vial,25000000,CDM,250,RC,,,,,,42023010401,NDC,0.1,ML,57.82,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,28.3318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
saliva substitute Solution 59 mL Bottle,63700001,CDM,250,RC,,,,,,50930009802,NDC,59,ML,31.1,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,28.3321,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018200,NDC,10,ML,68.21,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,28.334434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.24,991.564
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018210,NDC,10,ML,68.21,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,28.334434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.24,991.564
8MM-12MM BLADELESS OBTURATOR 8MM,27200000,CDM,272,RC,,,,11919-MAIN,LOCAL,,,,,56,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,28.336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM-12MM BLADELESS OBTURATOR 8MM LONG,27200000,CDM,272,RC,,,,11920-MAIN,LOCAL,,,,,56,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,28.336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"B Cells, Total Count",PX86355,CDM,300,RC,86355,CPT,,,,,,,,56,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,28.336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.2624,54.88
Citrate - Ref,PX8250790,CDM,300,RC,82507,CPT,90,,,,,,,56,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,28.336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.2624,54.88
"Folic Acid (Folate), Serum",PX82746,CDM,300,RC,82746,CPT,,,,,,,,56,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,28.336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.48,54.88
Lab Platelet Count,PX85049,CDM,300,RC,85049,CPT,,,,,,,,56,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,28.336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.11,54.88
Mycophenolate Mycophenolicacid - Ref,PX8018090,CDM,300,RC,80180,CPT,90,,,,,,,56,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,28.336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.55,54.88
Progesterone,PX84144,CDM,300,RC,84144,CPT,,,,,,,,56,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,28.336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.13,54.88
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409493311,NDC,10,ML,66.06,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,28.33974,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,409677802,NDC,1,ML,31.11,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,28.34121,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
rosuvastatin 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,310075430,NDC,1,EA,56.04,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,28.35624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Gait Training Therapy,PX97116,CDM,420,RC,97116,CPT,,,,,,,,135,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,28.3712,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.16,38.66
Therapeutic Exercises,PX97110,CDM,420,RC,97110,CPT,,,,,,,,135,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,28.3712,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.16,38.66
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050601,NDC,1,ML,68.33,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,28.384282,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010520,NDC,1,EA,68.33,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,28.384282,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010541,NDC,1,EA,68.33,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,28.384282,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
pramox-PE-glycerin-petrolatum 1-0.25-14.4-15 % Cream 51 g Tube,63700001,CDM,250,RC,,,,,,573286898,NDC,51,GR,68.34,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,28.388436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"pediatric electrolyte Solution 1,000 mL Bottle",25000000,CDM,250,RC,,,,,,49348057041,NDC,1000,ML,31.9,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,28.391,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Androsetenedione - Ref,PX8215790,CDM,300,RC,82157,CPT,90,,,,,,,107,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,28.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.4,29.28
Androsetenedione - Ref,PX8215790,CDM,300,RC,82157,CPT,90,,,,,,,107,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,28.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.4,29.28
Androsetenedione - Ref,PX8215790,CDM,300,RC,82157,CPT,90,,,,,,,107,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,28.4,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.4,29.28
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457000100,NDC,10,ML,68.38,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,28.405052,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
"Prosthetic Training, Initial, Each 15 Mins",PX97761,CDM,420,RC,97761,CPT,,,,,,,,121,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,28.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.41,118.58
"Albumin, Blood",PX82040,CDM,300,RC,82040,CPT,90,,,,,,,58,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.54,56.84
"Albumin, Blood",PX82040,CDM,300,RC,82040,CPT,90,,,,,,,58,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.54,56.84
"Albumin, Blood",PX82040,CDM,300,RC,82040,CPT,90,,,,,,,58,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,28.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.54,56.84
Assay of creatinine,PX82565,CDM,300,RC,82565,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,6.580666667,percent of total billed charges,28.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.69,56.84
Assay of creatinine,PX82565,CDM,300,RC,82565,CPT,,,,,,,,58,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.69,56.84
Assay of creatinine,PX82565,CDM,300,RC,82565,CPT,,,,,,,,58,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,28.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.69,56.84
Assay of Urea Nitrogen,PX84520,CDM,300,RC,84520,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.62,56.84
Assay of Urea Nitrogen,PX84520,CDM,300,RC,84520,CPT,,,,,,,,58,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.62,56.84
Assay of Urea Nitrogen,PX84520,CDM,300,RC,84520,CPT,,,,,,,,58,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,28.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.62,56.84
"Assay, Glucose, Blood Quant",PX82947,CDM,300,RC,82947,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,49.18,percent of total billed charges,28.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.6,56.84
"Assay, Glucose, Blood Quant",PX82947,CDM,300,RC,82947,CPT,,,,,,,,58,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.6,56.84
"Assay, Glucose, Blood Quant",PX82947,CDM,300,RC,82947,CPT,,,,,,,,58,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,28.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.6,56.84
Automated Leukocyte Count,PX85048,CDM,300,RC,85048,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.33,56.84
Automated Leukocyte Count,PX85048,CDM,300,RC,85048,CPT,,,,,,,,58,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.33,56.84
Automated Leukocyte Count,PX85048,CDM,300,RC,85048,CPT,,,,,,,,58,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,28.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.33,56.84
DEFIBRILLATION PAD BIPHASIC ADULT,120.96,CDM,271,RC,A0392,HCPCS,,1321-MAIN,LOCAL,,,,,58,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.0932,56.84
DEFIBRILLATION PAD BIPHASIC ADULT,120.96,CDM,271,RC,A0392,HCPCS,,1321-MAIN,LOCAL,,,,,58,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.0932,56.84
DEFIBRILLATION PAD BIPHASIC ADULT,120.96,CDM,271,RC,A0392,HCPCS,,1321-MAIN,LOCAL,,,,,58,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,28.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.0932,56.84
"Ebv, Nuclear Antigen - Ref",PX8666490,CDM,300,RC,86664,CPT,90,,,,,,,58,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.02,56.84
"Ebv, Nuclear Antigen - Ref",PX8666490,CDM,300,RC,86664,CPT,90,,,,,,,58,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.02,56.84
"Ebv, Nuclear Antigen - Ref",PX8666490,CDM,300,RC,86664,CPT,90,,,,,,,58,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,28.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.02,56.84
"Ebv, Viral Capsid Ab - Ref",PX8666590,CDM,300,RC,86665,CPT,90,,,,,,,58,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.63,56.84
"Ebv, Viral Capsid Ab - Ref",PX8666590,CDM,300,RC,86665,CPT,90,,,,,,,58,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.63,56.84
"Ebv, Viral Capsid Ab - Ref",PX8666590,CDM,300,RC,86665,CPT,90,,,,,,,58,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,28.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.63,56.84
"Ecg 12 Lead, Interp Only",PX93010,CDM,985,RC,93010,CPT,,,,,,,,29,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,28.42,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.02,28.42
Hematocrit,PX85014,CDM,300,RC,85014,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.17,56.84
Hematocrit,PX85014,CDM,300,RC,85014,CPT,,,,,,,,58,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.17,56.84
Hematocrit,PX85014,CDM,300,RC,85014,CPT,,,,,,,,58,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,28.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.17,56.84
"Long Term Holter, 48 Hrs Up to 7 Days, Recording",PX93242,CDM,731,RC,93242,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,5.91,percent of total billed charges,28.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.0932,56.84
"Long Term Holter, 48 Hrs Up to 7 Days, Recording",PX93242,CDM,731,RC,93242,CPT,,,,,,,,58,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.0932,56.84
"Long Term Holter, 48 Hrs Up to 7 Days, Recording",PX93242,CDM,731,RC,93242,CPT,,,,,,,,58,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,28.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.0932,56.84
"Long Term Holter, More Than 7 Days Up to 15 Days, Recording",PX93246,CDM,731,RC,93246,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,16.75555556,percent of total billed charges,28.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.0932,56.84
"Long Term Holter, More Than 7 Days Up to 15 Days, Recording",PX93246,CDM,731,RC,93246,CPT,,,,,,,,58,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.0932,56.84
"Long Term Holter, More Than 7 Days Up to 15 Days, Recording",PX93246,CDM,731,RC,93246,CPT,,,,,,,,58,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,28.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.0932,56.84
Microscopic Exam of Urine,PX81015,CDM,300,RC,81015,CPT,,,,,,,,29,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,28.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.8,28.42
"Sodium; Serum, Plasma or Whole Blood",PX84295,CDM,300,RC,84295,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.41,56.84
"Sodium; Serum, Plasma or Whole Blood",PX84295,CDM,300,RC,84295,CPT,,,,,,,,58,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.41,56.84
"Sodium; Serum, Plasma or Whole Blood",PX84295,CDM,300,RC,84295,CPT,,,,,,,,58,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,28.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.41,56.84
SUTURE V-LOC SZ 1 PBT WOUND CLOSURE DEVICE BLUE 18 IN GS 21 NEEDLE VLOCN0327,27200000,CDM,272,RC,,,,12828-MAIN,LOCAL,,,,,58,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE V-LOC SZ 1 PBT WOUND CLOSURE DEVICE BLUE 18 IN GS 21 NEEDLE VLOCN0327,27200000,CDM,272,RC,,,,12828-MAIN,LOCAL,,,,,58,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE V-LOC SZ 1 PBT WOUND CLOSURE DEVICE BLUE 18 IN GS 21 NEEDLE VLOCN0327,27200000,CDM,272,RC,,,,12828-MAIN,LOCAL,,,,,58,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,28.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Transferase; Alanine Amino (Alt) (Sgpt),PX84460,CDM,300,RC,84460,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,24.94,percent of total billed charges,28.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.86,56.84
Transferase; Alanine Amino (Alt) (Sgpt),PX84460,CDM,300,RC,84460,CPT,,,,,,,,58,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.86,56.84
Transferase; Alanine Amino (Alt) (Sgpt),PX84460,CDM,300,RC,84460,CPT,,,,,,,,58,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,28.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.86,56.84
Transferase; Aspartate Amino (Ast) (Sgot),PX84450,CDM,300,RC,84450,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,24.14333333,percent of total billed charges,28.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,56.84
Transferase; Aspartate Amino (Ast) (Sgot),PX84450,CDM,300,RC,84450,CPT,,,,,,,,58,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,56.84
Transferase; Aspartate Amino (Ast) (Sgot),PX84450,CDM,300,RC,84450,CPT,,,,,,,,58,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,28.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,56.84
TRAY ARTHROGRAM SAFE-T-ARTHRO 28-AR1CO,120.2,CDM,272,RC,,,,11499-MAIN,LOCAL,,,,,29,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,28.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.0466,194.04
triamcinolone acetonide 0.1 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,16714098602,NDC,30,GR,59.22,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,28.4256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
triamcinolone acetonide 0.1 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,16714098602,NDC,30,GR,59.22,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,28.4256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092821,NDC,1,ML,32.23,,United Healthcare,All Payer,outpatient,88.2,,9.41,percent of total billed charges,28.42686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,31.5854
VAGINAL PACKING 2',120.292,CDM,272,RC,,,,829-MAIN,LOCAL,,,,,32.23,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,28.42686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.388342,31.5854
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,25021011487,NDC,200,ML,66.28,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,28.43412,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.20921,64.9544
EPINEPHrine 30 MG/30ML Solution 30 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023016801,NDC,0.3,ML,32.24,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,28.43568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623100,NDC,1,EA,59.25,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,28.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623100,NDC,1,EA,59.25,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,28.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623105,NDC,1,EA,59.27,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,28.4496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623105,NDC,1,EA,59.27,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,28.4496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
methotrexate 2.5 MG Tablet 20 Each Box,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067005,NDC,1,EA,33.49,,First Health,Commercial,both,85,,999999999,percent of total billed charges,28.4665,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.911746,32.8398
Immunofix Elp,PX86335,CDM,300,RC,86335,CPT,,,,,,,,214,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,28.47,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.36,28.881
Immunofix Elp,PX86335,CDM,300,RC,86335,CPT,,,,,,,,214,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,28.47,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.36,28.881
Immunofix Elp,PX86335,CDM,300,RC,86335,CPT,,,,,,,,214,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,28.47,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.36,28.881
BANDAGE COBAN  4 IN 2 LAYER COMPRESSION SYSTEM  2094N,120.549,CDM,272,RC,A6441,HCPCS,,12366-MAIN,LOCAL,,,,,32,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,28.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.2928,31.36
BANDAGE COBAN LITE 4 IN 2 LAYER COMPRESSION SYSTEM 2794N,120.549,CDM,272,RC,A6441,HCPCS,,12922-MAIN,LOCAL,,,,,32,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,28.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.2928,31.36
WOUND DRAIN FLAT WITH TROCAR 10MM FULL PERFORATED SILICONE,27200000,CDM,272,RC,,,,12462-MAIN,LOCAL,,,,,32,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,28.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323031119,NDC,10,ML,66.39,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,28.48131,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,84.5054
methotrexate 2.5 MG Tablet 1 Each Blister,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067001,NDC,1,EA,33.51,,First Health,Commercial,both,85,,999999999,percent of total billed charges,28.4835,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.911746,32.8398
clarithromycin 250 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,527193106,NDC,1,EA,32.3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,28.4886,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clarithromycin 250 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,65862022560,NDC,1,EA,32.3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,28.4886,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"BUPivacaine 0.25%-EPINEPHrine 1:200,000 0.25% -1:200000 Solution 50 mL Vial",25000000,CDM,250,RC,,,,,,409175250,NDC,30,ML,68.6,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,28.49644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
nivolumab 40 MG/4ML Solution 4 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377211,NDC,4,ML,2171.7,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,28.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.5,12769.6548
nivolumab 100 MG/10ML Solution 10 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377412,NDC,10,ML,5429.27,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,28.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.5,12769.6548
nivolumab 240 MG/24ML Solution 24 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3373413,NDC,24,ML,13030.26,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,28.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.5,12769.6548
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093107,NDC,1,ML,57.59,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,28.50705,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141035,NDC,2,ML,56.37,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,28.52322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,65219044501,NDC,10,ML,56.37,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,28.52322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,65219044510,NDC,10,ML,56.37,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,28.52322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
morphine 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574711212,NDC,1,EA,33.56,,First Health,Commercial,both,85,,999999999,percent of total billed charges,28.526,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"COLLAR CERVICAL 2"" SMALL UNIVERSAL 08140039",120.249,CDM,274,RC,L0120,HCPCS,,270-MAIN,LOCAL,,,,,101,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,28.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 2X20"" SMALL 1003-02",120.249,CDM,274,RC,L0120,HCPCS,,272-MAIN,LOCAL,,,,,101,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,28.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 2X23.5"" MEDIUM XNARROW 1003-04",120.249,CDM,274,RC,L0120,HCPCS,,273-MAIN,LOCAL,,,,,101,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,28.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 10-15"" SMALL XLONG 1005-06",120.249,CDM,274,RC,L0120,HCPCS,,267-MAIN,LOCAL,,,,,101,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,28.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL LARGE 21.5""X5"" 1005-04",120.249,CDM,274,RC,L0120,HCPCS,,268-MAIN,LOCAL,,,,,101,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,28.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL MEDIUM 20-1/2X4"" 1005-03",120.249,CDM,274,RC,L0120,HCPCS,,269-MAIN,LOCAL,,,,,101,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,28.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
COLLAR CERVICAL SMALL 1005-02,120.249,CDM,274,RC,L0120,HCPCS,,266-MAIN,LOCAL,,,,,101,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,28.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,72603012801,NDC,1,EA,57.64,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,28.5318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,63739003807,NDC,1,EA,66.51,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,28.53279,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409116219,NDC,30,ML,32.07,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,28.5423,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
valACYclovir 1 GM Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069701,NDC,0.5,EA,33.58,,First Health,Commercial,both,85,,999999999,percent of total billed charges,28.543,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride 20 MEQ Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,245036089,NDC,1,EA,57.67,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,28.54665,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclopentolate 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,17478010002,NDC,2,ML,66.55,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,28.54995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
perflutren protein A microsphere Suspension 3 mL Vial,Q9956,CDM,636,RC,Q9956,HCPCS,,,,407270703,NDC,3,ML,739.41,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,28.56,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.56,43.68686
Androsetenedione - Ref,PX8215790,CDM,300,RC,82157,CPT,90,,,,,,,107,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,28.5601,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.4,29.28
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,641601501,NDC,25,ML,58.29,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.5621,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,641601501,NDC,25,ML,58.29,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.5621,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,641601501,NDC,25,ML,58.29,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,28.5621,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,93681545,NDC,2,ML,57.71,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,28.56645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,93681573,NDC,2,ML,57.71,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,28.56645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
valproate 100 MG/ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049416,NDC,5,ML,33.61,,First Health,Commercial,both,85,,999999999,percent of total billed charges,28.5685,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
valproate 100 MG/ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049441,NDC,5,ML,33.61,,First Health,Commercial,both,85,,999999999,percent of total billed charges,28.5685,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608201,NDC,1,ML,66.6,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,28.5714,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048503,NDC,50,ML,57.74,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,28.5813,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117630,NDC,1,ML,58.34,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.5866,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117630,NDC,1,ML,58.34,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.5866,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117630,NDC,1,ML,58.34,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,28.5866,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
metroNIDAZOLE 500 MG/100ML Solution 100 mL Flex Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,409781124,NDC,100,ML,32.12,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,28.5868,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,31.4776
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,990771512,NDC,62.5,ML,56.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,28.589,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.4701,303.0944
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,548590000,NDC,1,EA,470.19,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,28.59,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.86,28.59
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,548590000,NDC,1,EA,470.19,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,28.59,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.86,28.59
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,781344071,NDC,1,EA,430.94,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,28.59,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.86,28.59
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,781344071,NDC,1,EA,430.94,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,28.59,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.86,28.59
PACLitaxel 30 MG/5ML Concentrate 5 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476401,NDC,5,ML,58.37,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.6013,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
PACLitaxel 30 MG/5ML Concentrate 5 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476401,NDC,5,ML,58.37,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.6013,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
PACLitaxel 30 MG/5ML Concentrate 5 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476401,NDC,5,ML,58.37,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,28.6013,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189101,NDC,1,ML,32.43,,United Healthcare,All Payer,outpatient,88.2,,16.488,percent of total billed charges,28.60326,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
tuberculin 5 UNIT/0.1ML Solution 1 mL Vial,25000000,CDM,250,RC,,,,,,42023010401,NDC,0.1,ML,57.82,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,28.6209,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Telehealth Origin Site Fac Fee,PXQ3014,CDM,780,RC,Q3014,HCPCS,,,,,,,,40,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,28.64,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.65,48.8
Xray Cervical Spine 2 or 3 Vws,PX7204001,CDM,320,RC,72040,CPT,TC,,,,,,,436,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,28.6402,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.97,57.19
Xray Hand 3vws Tc,PX7313001,CDM,320,RC,73130,CPT,TC,,,,,,,374,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,28.6402,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.75,57.19
Xray Thoracic Spine 3 Vws,PX7207201,CDM,320,RC,72072,CPT,TC,,,,,,,522,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,28.6402,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.75,57.19
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,70655000206,NDC,100,ML,59.67,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,28.6416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.786918,140.5516
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,70655000206,NDC,100,ML,59.67,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,28.6416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.786918,140.5516
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457000110,NDC,10,ML,59.67,,Health Partners,Health Partners Care Plans,both,48,,31.91277778,percent of total billed charges,28.6416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457000110,NDC,10,ML,59.67,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,28.6416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013266,NDC,50,ML,59.67,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,28.6416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013266,NDC,50,ML,59.67,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,28.6416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013268,NDC,150,ML,59.67,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,28.6416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013268,NDC,150,ML,59.67,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,28.6416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,143950801,NDC,10,ML,58.46,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,12.9192,percent of total billed charges,28.6454,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,143950801,NDC,10,ML,58.46,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.6454,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,143950801,NDC,10,ML,58.46,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,28.6454,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032056,NDC,1,EA,68.97,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,28.650138,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
dutasteride 0.5 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,42806054909,NDC,1,EA,32.49,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,28.65618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006401,NDC,2,ML,31.46,,Medica,Commercial,both,91.1,,6.305,percent of total billed charges,28.66006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
Assay Bld/Serum Cholesterol,PX82465,CDM,300,RC,82465,CPT,,,,,,,,69,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,28.6626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.99,67.62
"Astrazeneca Covid-19 Vaccine, Administration, 1st Dose",PX0021A,CDM,771,RC,,,,,,,,,,69,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,28.6626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Astrazeneca Covid-19 Vaccine, Adminstration, 2nd Dose",PX0022A,CDM,771,RC,,,,,,,,,,69,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,28.6626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Janssen Covid-19 Vaccine, Administration",PX0031A,CDM,771,RC,0031A,HCPCS,,,,,,,,69,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,28.6626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 1st Dose",PX0011A,CDM,771,RC,0011A,HCPCS,,,,,,,,69,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,28.6626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 2nd Dose",PX0012A,CDM,771,RC,0012A,HCPCS,,,,,,,,69,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,28.6626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 3rd Dose",PX0013A,CDM,771,RC,0013A,HCPCS,,,,,,,,69,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,28.6626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
Novavax Covid-19 Vaccine Administration 1st Dose,PX0041A,CDM,771,RC,0041A,HCPCS,,,,,,,,69,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,28.6626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
Novavax Covid-19 Vaccine Administration 2nd Dose,PX0042A,CDM,771,RC,0042A,HCPCS,,,,,,,,69,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,28.6626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Pfizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 2nd Dose",PX0002A,CDM,771,RC,0002A,HCPCS,,,,,,,,69,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,28.6626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Pfizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 3rd Dose",PX0003A,CDM,771,RC,0003A,HCPCS,,,,,,,,69,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,28.6626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Pifizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 1st Dose",PX0001A,CDM,771,RC,0001A,HCPCS,,,,,,,,69,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,28.6626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
bacitracin zinc 500 UNIT/GM Ointment 28.35 g Tube,25000000,CDM,250,RC,,,,,,168001131,NDC,28.35,GR,32.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,28.665,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,143950810,NDC,10,ML,58.51,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,12.9192,percent of total billed charges,28.6699,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,143950810,NDC,10,ML,58.51,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.6699,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,143950810,NDC,10,ML,58.51,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,28.6699,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
Sacubitril-Valsartan 49-51 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,78077720,NDC,1,EA,58.51,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.6699,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Sacubitril-Valsartan 49-51 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,78077720,NDC,1,EA,58.51,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.6699,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Sacubitril-Valsartan 49-51 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,78077720,NDC,1,EA,58.51,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,28.6699,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092821,NDC,1,ML,32.23,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,28.6847,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,31.5854
VAGINAL PACKING 2',120.292,CDM,272,RC,,,,829-MAIN,LOCAL,,,,,32.23,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,28.6847,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.388342,31.5854
PROMOGRAN PRISMA AG COLLAGEN DRESSING 28CM,120.547,CDM,272,RC,A6021,HCPCS,,12361-MAIN,LOCAL,,,,,28,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,28.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.26,28.69
PROMOGRAN PRISMA AG COLLAGEN DRESSING 28CM,120.547,CDM,272,RC,A6021,HCPCS,,12361-MAIN,LOCAL,,,,,28,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,28.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.26,28.69
PROMOGRAN PRISMA AG COLLAGEN DRESSING 28CM,120.547,CDM,272,RC,A6021,HCPCS,,12361-MAIN,LOCAL,,,,,28,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,28.69,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.26,28.69
charcoal activated Liquid 240 mL Bottle,63700001,CDM,250,RC,,,,,,574012108,NDC,120,ML,66.88,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,28.69152,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
EPINEPHrine 30 MG/30ML Solution 30 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023016801,NDC,0.3,ML,32.24,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,28.6936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060820,NDC,20,ML,58.57,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.619455696,percent of total billed charges,28.6993,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060820,NDC,20,ML,58.57,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.6993,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060820,NDC,20,ML,58.57,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,28.6993,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
"sodium chloride 0.45 % 1,000 mL with potassium chloride 20 mEq 20-0.45 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070434,NDC,1000,ML,58.57,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1.633818182,percent of total billed charges,28.6993,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"sodium chloride 0.45 % 1,000 mL with potassium chloride 20 mEq 20-0.45 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070434,NDC,1000,ML,58.57,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.6993,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"sodium chloride 0.45 % 1,000 mL with potassium chloride 20 mEq 20-0.45 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070434,NDC,1000,ML,58.57,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,28.6993,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987501,NDC,3,ML,33.77,,First Health,Commercial,both,85,,999999999,percent of total billed charges,28.7045,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024010,NDC,1,EA,56.73,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,28.70538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030036,NDC,1,EA,56.73,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,28.70538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098341,NDC,1,EA,56.73,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,28.70538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
"Albumin, Blood",PX82040,CDM,300,RC,82040,CPT,90,,,,,,,58,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,28.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.54,56.84
Assay of creatinine,PX82565,CDM,300,RC,82565,CPT,,,,,,,,58,,Humana Choice Care,All Medicare plans,outpatient,49.5,,56.84,percent of total billed charges,28.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.69,56.84
Assay of Urea Nitrogen,PX84520,CDM,300,RC,84520,CPT,,,,,,,,58,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,28.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.62,56.84
"Assay, Glucose, Blood Quant",PX82947,CDM,300,RC,82947,CPT,,,,,,,,58,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,28.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.6,56.84
Automated Leukocyte Count,PX85048,CDM,300,RC,85048,CPT,,,,,,,,58,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,28.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.33,56.84
DEFIBRILLATION PAD BIPHASIC ADULT,120.96,CDM,271,RC,A0392,HCPCS,,1321-MAIN,LOCAL,,,,,58,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,28.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.0932,56.84
"Ebv, Nuclear Antigen - Ref",PX8666490,CDM,300,RC,86664,CPT,90,,,,,,,58,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,28.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.02,56.84
"Ebv, Viral Capsid Ab - Ref",PX8666590,CDM,300,RC,86665,CPT,90,,,,,,,58,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,28.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.63,56.84
Hematocrit,PX85014,CDM,300,RC,85014,CPT,,,,,,,,58,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,28.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.17,56.84
"Long Term Holter, 48 Hrs Up to 7 Days, Recording",PX93242,CDM,731,RC,93242,CPT,,,,,,,,58,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,28.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.0932,56.84
"Long Term Holter, More Than 7 Days Up to 15 Days, Recording",PX93246,CDM,731,RC,93246,CPT,,,,,,,,58,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,28.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.0932,56.84
"Sodium; Serum, Plasma or Whole Blood",PX84295,CDM,300,RC,84295,CPT,,,,,,,,58,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,28.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.41,56.84
SUTURE V-LOC SZ 1 PBT WOUND CLOSURE DEVICE BLUE 18 IN GS 21 NEEDLE VLOCN0327,27200000,CDM,272,RC,,,,12828-MAIN,LOCAL,,,,,58,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,28.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Transferase; Alanine Amino (Alt) (Sgpt),PX84460,CDM,300,RC,84460,CPT,,,,,,,,58,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,28.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.86,56.84
Transferase; Aspartate Amino (Ast) (Sgot),PX84450,CDM,300,RC,84450,CPT,,,,,,,,58,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,28.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,56.84
"Vitamin D, 25 Hydroxy",PX82306,CDM,300,RC,82306,CPT,,,,,,,,235,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,28.71,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.71,29.6
"Vitamin D, 25 Hydroxy",PX82306,CDM,300,RC,82306,CPT,,,,,,,,235,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,28.71,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.71,29.6
"Vitamin D, 25 Hydroxy",PX82306,CDM,300,RC,82306,CPT,,,,,,,,235,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,28.71,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.71,29.6
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,63323047401,NDC,1,ML,58.6,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,4.21,percent of total billed charges,28.714,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.428
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,63323047401,NDC,1,ML,58.6,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.714,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.428
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,63323047401,NDC,1,ML,58.6,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,28.714,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.428
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076501,NDC,1,EA,58.6,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,12.3175,percent of total billed charges,28.714,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076501,NDC,1,EA,58.6,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.714,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076501,NDC,1,EA,58.6,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,28.714,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076510,NDC,1,EA,58.6,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,12.3175,percent of total billed charges,28.714,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076510,NDC,1,EA,58.6,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.714,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076510,NDC,1,EA,58.6,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,28.714,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049236,NDC,5,ML,31.52,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,28.71472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049243,NDC,5,ML,31.52,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,28.71472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048226,NDC,20,ML,32.56,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,28.71792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048241,NDC,20,ML,32.56,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,28.71792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641600101,NDC,1,ML,32.56,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,28.71792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
BUPivacaine 0.25 % Solution 50 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046557,NDC,30,ML,59.84,,Health Partners,Health Partners Care Plans,both,48,,0.387,percent of total billed charges,28.7232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 50 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046557,NDC,30,ML,59.84,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,28.7232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,517095501,NDC,0.25,EA,69.19,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,28.741526,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86,213.6008
Group Therapeutic Procedures,PX97150,CDM,420,RC,97150,CPT,,,,,,,,67,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,28.743,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.82,65.66
"Hydroxyprogesterone, 17-D - Ref",PX8349890,CDM,300,RC,83498,CPT,90,,,,,,,67,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,28.743,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.91,65.66
Lab Org ID Anaerobic-Each,PX87076,CDM,300,RC,87076,CPT,,,,,,,,67,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,28.743,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,65.66
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086000,NDC,1,EA,58.66,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,11.105,percent of total billed charges,28.7434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086000,NDC,1,EA,58.66,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.7434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086000,NDC,1,EA,58.66,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,28.7434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086050,NDC,1,EA,58.66,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,11.105,percent of total billed charges,28.7434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086050,NDC,1,EA,58.66,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.7434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086050,NDC,1,EA,58.66,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,28.7434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012166,NDC,1,EA,58.66,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.7434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012166,NDC,1,EA,58.66,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.7434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012166,NDC,1,EA,58.66,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,28.7434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
cefOXitin 1 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021010910,NDC,1,EA,58.66,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.7434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.367364,75.6952
cefOXitin 1 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021010910,NDC,1,EA,58.66,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.7434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.367364,75.6952
cefOXitin 1 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021010910,NDC,1,EA,58.66,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,28.7434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.367364,75.6952
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,65219025915,NDC,1,EA,58.66,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,14.99111111,percent of total billed charges,28.7434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,65219025915,NDC,1,EA,58.66,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.7434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,65219025915,NDC,1,EA,58.66,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,28.7434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
clarithromycin 250 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,527193106,NDC,1,EA,32.3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,28.747,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clarithromycin 250 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,65862022560,NDC,1,EA,32.3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,28.747,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061601,NDC,3,ML,31.57,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,28.76027,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058003,NDC,0.5,ML,31.57,,Medica,Commercial,both,91.1,,1.63075,percent of total billed charges,28.76027,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058020,NDC,0.5,ML,31.57,,Medica,Commercial,both,91.1,,1.63075,percent of total billed charges,28.76027,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061416,NDC,0.5,ML,31.57,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,28.76027,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.114178,99.911
ampicillin-sulbactam 1.5 (1-0.5) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001381,NDC,1,EA,69.24,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,28.762296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,43598020453,NDC,10,ML,58.73,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.7777,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,43598020453,NDC,10,ML,58.73,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.7777,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,43598020453,NDC,10,ML,58.73,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,28.7777,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,72508020415,NDC,10,ML,58.73,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.7777,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,72508020415,NDC,10,ML,58.73,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.7777,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,72508020415,NDC,10,ML,58.73,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,28.7777,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,517460125,NDC,0.5,ML,58.76,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.7924,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,517460125,NDC,0.5,ML,58.76,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.7924,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,517460125,NDC,0.5,ML,58.76,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,28.7924,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003905,NDC,1,EA,58.77,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.7973,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003905,NDC,1,EA,58.77,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.7973,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003905,NDC,1,EA,58.77,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,28.7973,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
Capillary Blood Collection,PX36416,CDM,300,RC,36416,CPT,,,,,,,,60,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,28.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,58.8
Capillary Blood Collection,PX36416,CDM,300,RC,36416,CPT,,,,,,,,60,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,28.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,58.8
HERNIA BELT MENS TRUSS LARGE,120.526,CDM,274,RC,L8310,HCPCS,,12221-MAIN,LOCAL,,,,,60,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,28.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,160.6
HERNIA BELT MENS TRUSS LARGE,120.526,CDM,274,RC,L8310,HCPCS,,12221-MAIN,LOCAL,,,,,60,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,28.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,160.6
HERNIA BELT MENS TRUSS MEDIUM,120.526,CDM,274,RC,L8310,HCPCS,,12220-MAIN,LOCAL,,,,,60,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,28.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,160.6
HERNIA BELT MENS TRUSS MEDIUM,120.526,CDM,274,RC,L8310,HCPCS,,12220-MAIN,LOCAL,,,,,60,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,28.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,160.6
HERNIA BELT MENS TRUSS XLARGE,120.526,CDM,274,RC,L8310,HCPCS,,12222-MAIN,LOCAL,,,,,60,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,28.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,160.6
HERNIA BELT MENS TRUSS XLARGE,120.526,CDM,274,RC,L8310,HCPCS,,12222-MAIN,LOCAL,,,,,60,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,28.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,160.6
"IMMOBILIZER KNEE  24"" 7041-44",120.22,CDM,274,RC,L1830,HCPCS,,595-MAIN,LOCAL,,,,,60,,Health Partners,Health Partners Care Plans,both,48,,31.63625,percent of total billed charges,28.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE  24"" 7041-44",120.22,CDM,274,RC,L1830,HCPCS,,595-MAIN,LOCAL,,,,,60,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,28.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE 16"" UNIVERSAL 7088-04",120.22,CDM,274,RC,L1830,HCPCS,,589-MAIN,LOCAL,,,,,60,,Health Partners,Health Partners Care Plans,both,48,,31.63625,percent of total billed charges,28.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE 16"" UNIVERSAL 7088-04",120.22,CDM,274,RC,L1830,HCPCS,,589-MAIN,LOCAL,,,,,60,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,28.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
IMMOBILIZER KNEE 20 INCH ORT2420019,120.22,CDM,274,RC,L1830,HCPCS,,587-MAIN,LOCAL,,,,,60,,Health Partners,Health Partners Care Plans,both,48,,31.63625,percent of total billed charges,28.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
IMMOBILIZER KNEE 20 INCH ORT2420019,120.22,CDM,274,RC,L1830,HCPCS,,587-MAIN,LOCAL,,,,,60,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,28.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE 20"" LARGE FOAM COUNTOURED STAYS 7062-03",120.22,CDM,274,RC,L1830,HCPCS,,593-MAIN,LOCAL,,,,,60,,Health Partners,Health Partners Care Plans,both,48,,31.63625,percent of total billed charges,28.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE 20"" LARGE FOAM COUNTOURED STAYS 7062-03",120.22,CDM,274,RC,L1830,HCPCS,,593-MAIN,LOCAL,,,,,60,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,28.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE 20"" QUICK-WRAP ORT2440020S",120.22,CDM,274,RC,L1830,HCPCS,,591-MAIN,LOCAL,,,,,60,,Health Partners,Health Partners Care Plans,both,48,,31.63625,percent of total billed charges,28.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE 20"" QUICK-WRAP ORT2440020S",120.22,CDM,274,RC,L1830,HCPCS,,591-MAIN,LOCAL,,,,,60,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,28.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
IMMOBILIZER KNEE CUTAWAY STRAIGHT 2 7041-05,120.22,CDM,274,RC,L1830,HCPCS,,596-MAIN,LOCAL,,,,,60,,Health Partners,Health Partners Care Plans,both,48,,31.63625,percent of total billed charges,28.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
IMMOBILIZER KNEE CUTAWAY STRAIGHT 2 7041-05,120.22,CDM,274,RC,L1830,HCPCS,,596-MAIN,LOCAL,,,,,60,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,28.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,28.81493,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,28.81493,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
"PDS II ENDOLOOP LIGATURE SIZE 0 18""",27200000,CDM,272,RC,,,,11700-MAIN,LOCAL,,,,,56.96,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,28.82176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409669501,NDC,10,ML,56.97,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,28.82682,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
cemiplimab-rwlc 350 MG/7ML Solution 7 mL Vial,J9119.01,CDM,636,RC,J9119,HCPCS,,,,61755000801,NDC,7,ML,19219.32,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,28.83,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.79,28.83
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006111,NDC,0.5,EA,56.98,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,28.83188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.669492,55.8404
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006158,NDC,0.5,EA,56.98,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,28.83188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.669492,55.8404
"Albumin, Othr Source - Ref",PX8204290,CDM,300,RC,82042,CPT,90,,,,,,,57,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,28.842,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.13,55.86
"Albumin, Serum - Ref",PX8204090,CDM,300,RC,82040,CPT,90,,,,,,,57,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,28.842,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.54,55.86
Assay Alkaline Phosphatase,PX84075,CDM,300,RC,84075,CPT,,,,,,,,57,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,28.842,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,55.86
Calcium Total,PX82310,CDM,300,RC,82310,CPT,,,,,,,,57,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,28.842,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.73,55.86
Dhea-S - Ref,PX8262790,CDM,300,RC,82627,CPT,90,,,,,,,57,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,28.842,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.38,55.86
Tiss Trnsgltmnase Ea Ig Clas,PX86364,CDM,300,RC,86364,CPT,,,,,,,,57,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,28.842,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.6778,55.86
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915850,NDC,0.2,ML,69.44,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,28.845376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,641601501,NDC,25,ML,58.29,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,28.85355,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Canalith Repositioning,PX95992,CDM,420,RC,95992,CPT,,,,,,,,128,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,28.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.86,125.44
OLANZapine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60505311000,NDC,1,EA,60.13,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,28.8624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
OLANZapine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60505311000,NDC,1,EA,60.13,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,28.8624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189101,NDC,1,ML,32.43,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,28.8627,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781910572,NDC,0.25,EA,69.49,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,28.866146,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86,213.6008
rivaroxaban 15 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50458057830,NDC,0.666666667,EA,67.3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,28.8717,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117603,NDC,1,ML,58.93,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.8757,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117603,NDC,1,ML,58.93,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.8757,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117603,NDC,1,ML,58.93,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,28.8757,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117630,NDC,1,ML,58.34,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,28.8783,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
Immunofix Elp,PX86335,CDM,300,RC,86335,CPT,,,,,,,,214,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,28.881,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.36,28.881
"Vitamin D, 25 Hydroxy",PX82306,CDM,300,RC,82306,CPT,,,,,,,,235,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,28.881,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.71,29.6
PACLitaxel 30 MG/5ML Concentrate 5 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476401,NDC,5,ML,58.37,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,28.89315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
lidocaine HCl 4 % Cream 76.5 g Tube,63700001,CDM,250,RC,,,,,,41167005820,NDC,76.5,GR,31.72,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,28.89692,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BINDER ABDOMINAL S/M 9 INCH UP TO 45 INCHES TRI-PANNEL ABB3P45,120.238,CDM,271,RC,A4467,HCPCS,,47-MAIN,LOCAL,,,,,34,,First Health,Commercial,both,85,,999999999,percent of total billed charges,28.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,First Health,Commercial,both,85,,999999999,percent of total billed charges,28.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,First Health,Commercial,both,85,,999999999,percent of total billed charges,28.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
"Lab Ige, Isocyan Hdi",PX86003,CDM,300,RC,86003,CPT,90,,,,,,,34,,First Health,Commercial,both,85,,999999999,percent of total billed charges,28.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.79,33.32
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323020110,NDC,10,ML,34,,First Health,Commercial,both,85,,999999999,percent of total billed charges,28.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Metanephrines - Ref,PX8383590,CDM,300,RC,83835,CPT,90,,,,,,,34,,First Health,Commercial,both,85,,999999999,percent of total billed charges,28.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1236,33.32
SPLINT SAM 36INCH ROLLED 661121,120.362,CDM,271,RC,,,,10789-MAIN,LOCAL,,,,,34,,First Health,Commercial,both,85,,999999999,percent of total billed charges,28.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1236,33.32
"Venipunc Need Phys Skill,Dx or Rx",PX36410F,CDM,510,RC,36410,CPT,,,,,,,,34,,First Health,Commercial,both,85,,999999999,percent of total billed charges,28.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1236,33.32
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003930,NDC,1,EA,58.99,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.9051,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003930,NDC,1,EA,58.99,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.9051,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003930,NDC,1,EA,58.99,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,28.9051,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338080304,NDC,1000,ML,69.59,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,28.907686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990710709,NDC,1000,ML,69.59,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,28.907686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004824,NDC,150,ML,69.59,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,28.907686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
DRAWTEX HYDROCONDUCTIVE NONADHERENT DRESSING,120.508,CDM,271,RC,A6199,HCPCS,,12022-MAIN,LOCAL,,,,,59,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.5086,57.82
DRAWTEX HYDROCONDUCTIVE NONADHERENT DRESSING,120.508,CDM,271,RC,A6199,HCPCS,,12022-MAIN,LOCAL,,,,,59,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.5086,57.82
DRAWTEX HYDROCONDUCTIVE NONADHERENT DRESSING,120.508,CDM,271,RC,A6199,HCPCS,,12022-MAIN,LOCAL,,,,,59,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,28.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.5086,57.82
"Potassium; Serum, Plasma or Whole Blood",PX84132,CDM,300,RC,84132,CPT,,,,,,,,59,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.36,57.82
"Potassium; Serum, Plasma or Whole Blood",PX84132,CDM,300,RC,84132,CPT,,,,,,,,59,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,28.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.36,57.82
"Potassium; Serum, Plasma or Whole Blood",PX84132,CDM,300,RC,84132,CPT,,,,,,,,59,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,28.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.36,57.82
dutasteride 0.5 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,42806054909,NDC,1,EA,32.49,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,28.9161,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bacitracin zinc 500 UNIT/GM Ointment 28.35 g Tube,25000000,CDM,250,RC,,,,,,168001131,NDC,28.35,GR,32.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,28.925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,143950801,NDC,10,ML,58.46,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,28.9377,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
X-Ray Exam Chest 3 Views,PX7104701,CDM,320,RC,71047,CPT,TC,,,,,,,340,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,28.962,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.19,57.85
Xray Lumbosacral 2 or 3 Vws,PX7210001,CDM,320,RC,72100,CPT,TC,,,,,,,399,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,28.962,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.19,57.85
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,143950810,NDC,10,ML,58.51,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,28.96245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
Sacubitril-Valsartan 49-51 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,78077720,NDC,1,EA,58.51,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,28.96245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048226,NDC,20,ML,32.56,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,28.9784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048241,NDC,20,ML,32.56,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,28.9784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641600101,NDC,1,ML,32.56,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,28.9784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,58602060407,NDC,100,GR,67.56,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,28.98324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,574722612,NDC,1,EA,67.57,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,28.98753,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.345782,66.2186
"Cognitive Funct Ther Interv, Initial 15 Min",PX97129,CDM,420,RC,97129,CPT,,,,,,,,85,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,28.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.63,29.43
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060820,NDC,20,ML,58.57,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,28.99215,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
"sodium chloride 0.45 % 1,000 mL with potassium chloride 20 mEq 20-0.45 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070434,NDC,1000,ML,58.57,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,28.99215,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409317801,NDC,20,ML,34.11,,First Health,Commercial,both,85,,999999999,percent of total billed charges,28.9935,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409317816,NDC,20,ML,34.11,,First Health,Commercial,both,85,,999999999,percent of total billed charges,28.9935,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189001,NDC,1,ML,34.11,,First Health,Commercial,both,85,,999999999,percent of total billed charges,28.9935,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189003,NDC,1,ML,34.11,,First Health,Commercial,both,85,,999999999,percent of total billed charges,28.9935,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310001,NDC,0.528,ML,785.14,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,29,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29,32.96
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310002,NDC,0.528,ML,894.9,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,29,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29,32.96
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,63323047401,NDC,1,ML,58.6,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,29.007,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.428
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076501,NDC,1,EA,58.6,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,29.007,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076510,NDC,1,EA,58.6,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,29.007,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189103,NDC,1,ML,32.89,,United Healthcare,All Payer,outpatient,88.2,,16.488,percent of total billed charges,29.00898,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
triamcinolone acetonide 0.1 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,16714098602,NDC,30,GR,59.22,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.0178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
triamcinolone acetonide 0.1 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,16714098602,NDC,30,GR,59.22,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.0178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
triamcinolone acetonide 0.1 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,16714098602,NDC,30,GR,59.22,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,29.0178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093102,NDC,1,ML,60.47,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,29.0256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093102,NDC,1,ML,60.47,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,29.0256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
aspirin-dipyridamole 25-200 MG Capsule Extended Release 12 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687030533,NDC,1,EA,67.66,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,29.02614,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin-dipyridamole 25-200 MG Capsule Extended Release 12 Hour 20 Each Box,63700001,CDM,250,RC,,,,,,60687030532,NDC,1,EA,67.66,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,29.02614,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623100,NDC,1,EA,59.25,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,7.351730769,percent of total billed charges,29.0325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623100,NDC,1,EA,59.25,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.0325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623100,NDC,1,EA,59.25,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,29.0325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086000,NDC,1,EA,58.66,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,29.0367,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086050,NDC,1,EA,58.66,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,29.0367,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012166,NDC,1,EA,58.66,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,29.0367,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
cefOXitin 1 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021010910,NDC,1,EA,58.66,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,29.0367,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.367364,75.6952
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,65219025915,NDC,1,EA,58.66,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,29.0367,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623105,NDC,1,EA,59.27,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,7.351730769,percent of total billed charges,29.0423,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623105,NDC,1,EA,59.27,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.0423,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623105,NDC,1,EA,59.27,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,29.0423,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
"Debridement of Nail(S), 1-5",PX11720F,CDM,510,RC,11720,CPT,,,,,,,,89,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,29.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.72,68.49
"pediatric electrolyte Solution 1,000 mL Bottle",25000000,CDM,250,RC,,,,,,49348057041,NDC,1000,ML,31.9,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,29.0609,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,43598020453,NDC,10,ML,58.73,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,29.07135,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,72508020415,NDC,10,ML,58.73,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,29.07135,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,517460125,NDC,0.5,ML,58.76,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,29.0862,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003905,NDC,1,EA,58.77,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,29.09115,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
CATHETER FOLEY 18FR  3WAY 30CC 73018L,120.21,CDM,272,RC,A4346,HCPCS,,253-MAIN,LOCAL,,,,,33,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,29.106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
CATHETER FOLEY 20FR 3WAY 30CC 0167L20,120.21,CDM,272,RC,A4346,HCPCS,,251-MAIN,LOCAL,,,,,33,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,29.106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
CATHETER FOLEY 24FR 3WAY 30CC 0167L24,120.21,CDM,272,RC,A4346,HCPCS,,10455-MAIN,LOCAL,,,,,33,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,29.106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
"DRESSING AQUACEL 3/4"" X 18"" AG HYDROFIBER 403771",120.31,CDM,272,RC,A6199,HCPCS,,8238-MAIN,LOCAL,,,,,33,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,29.106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,32.34
Hospital Outpatient Clinic Visit Specimen Collection for Sars-Cov-2,PXC9803,CDM,300,RC,C9803,HCPCS,,,,,,,,33,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,29.106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,32.34
MEPILEX AG 4X4 10X10,120.138,CDM,272,RC,A6213,HCPCS,,7248-MAIN,LOCAL,,,,,33,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,29.106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,32.34
STANDARD HIGH FLOW INSUFFLATION FILTER TUBING,27200000,CDM,272,RC,,,,11885-MAIN,LOCAL,,,,,33,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,29.106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LAP SPONGES 18x18 7INCH LOOP,27200000,CDM,272,RC,,,,604-MAIN,LOCAL,,,,,60.64,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,29.1072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LAP SPONGES 18x18 7INCH LOOP,27200000,CDM,272,RC,,,,604-MAIN,LOCAL,,,,,60.64,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,29.1072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ezetimibe 10 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,16729043316,NDC,1,EA,60.66,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,29.1168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ezetimibe 10 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,16729043316,NDC,1,EA,60.66,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,29.1168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039801,NDC,1,EA,67.88,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,29.12052,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039810,NDC,1,EA,67.88,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,29.12052,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
buprenorphine 75 MCG FILM 60 Each Box,63700001,CDM,250,RC,,,,,,59385002160,NDC,1,EA,29.92,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.121136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093107,NDC,1,ML,57.59,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,29.14054,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714078401,NDC,0.4,EA,60.72,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,29.1456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714078401,NDC,0.4,EA,60.72,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,29.1456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BANDAGE COBAN  4 IN 2 LAYER COMPRESSION SYSTEM  2094N,120.549,CDM,272,RC,A6441,HCPCS,,12366-MAIN,LOCAL,,,,,32,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,29.152,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.2928,31.36
BANDAGE COBAN LITE 4 IN 2 LAYER COMPRESSION SYSTEM 2794N,120.549,CDM,272,RC,A6441,HCPCS,,12922-MAIN,LOCAL,,,,,32,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,29.152,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.2928,31.36
WOUND DRAIN FLAT WITH TROCAR 10MM FULL PERFORATED SILICONE,27200000,CDM,272,RC,,,,12462-MAIN,LOCAL,,,,,32,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,29.152,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,72603012801,NDC,1,EA,57.64,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,29.16584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117603,NDC,1,ML,58.93,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,29.17035,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
"Flour. Afstain , Micro - Ref",PX8720690,CDM,300,RC,87206,CPT,90,,,,,,,68,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,29.172,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.94,66.64
Hemoglobin,PX85018,CDM,300,RC,85018,CPT,,,,,,,,68,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,29.172,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.17,66.64
Thyroglobulin - Ref,PX8443290,CDM,300,RC,84432,CPT,90,,,,,,,68,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,29.172,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.73,66.64
Thyroglobulin Antibody,PX8680090,CDM,300,RC,86800,CPT,90,,,,,,,68,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,29.172,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.59,66.64
potassium chloride 20 MEQ Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,245036089,NDC,1,EA,57.67,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,29.18102,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terbinafine 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714079501,NDC,1,EA,68.03,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,29.18487,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tobramycin 80 MG/2ML Solution 2 mL Vial,J3260.01,CDM,636,RC,J3260,HCPCS,,,,67457047300,NDC,2,ML,33.09,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,29.18538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.745586,32.4282
terbinafine 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714050101,NDC,1,EA,68.04,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,29.18916,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
8MM ENDOWRIST INSTRUMENTS MEDIUM LARGE CLIP APPLIER,27200000,CDM,272,RC,,,,11910-MAIN,LOCAL,,,,,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.852986,29.4
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,3,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.852986,29.4
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061603,NDC,3,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,641600601,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1.253,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
bacteriostatic water(benz alc) Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409397703,NDC,30,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BULB RESERVOIR SILICONE 400CC,27200000,CDM,272,RC,,,,12463-MAIN,LOCAL,,,,,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600710,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,38.9354
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409115918,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.296682081,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046401,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.296682081,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046402,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.296682081,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046437,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.296682081,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,409174670,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046801,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046817,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BUPivacaine in dextrose 0.75-8.25 % Solution 2 mL Ampule,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409176162,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.296682081,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046601,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.296682081,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143992490,NDC,0.5,EA,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,23.54375,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010110,NDC,0.5,EA,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,23.54375,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010167,NDC,0.5,EA,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,23.54375,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,44567070725,NDC,0.5,EA,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,23.54375,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733201,NDC,0.5,EA,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,18.43861111,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733801,NDC,0.5,EA,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,18.43861111,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,70069000501,NDC,0.1,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,63.2394
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016502,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1.579660194,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016516,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1.579660194,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036721,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1.579660194,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036725,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1.579660194,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 100 MG/10ML Solution 10 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323051610,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1.579660194,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050641,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1.579660194,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141031,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,641037621,NDC,0.25,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,15.95777778,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066416,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,15.95777778,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066441,NDC,0.25,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,15.95777778,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010101,NDC,0.25,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,15.95777778,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
DRAPE SPLIT WITH ADHESIVE DYNJP8304A,27200000,CDM,272,RC,,,,4694-MAIN,LOCAL,,,,,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRESSING HYDROFERA 2-1/2X2-1/2  BLUE READY FOAM HBRS2520,120.488,CDM,271,RC,A6209,HCPCS,,11537-MAIN,LOCAL,,,,,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
"Ethanol, P",PX82077,CDM,300,RC,82077,CPT,,,,,,,,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073916,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,29.4
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073941,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,29.4
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,67457043300,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,29.4
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,13.86384615,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909422,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,13.86384615,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,13.86384615,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
folic acid 5 MG/ML Solution 10 mL Vial,J3490.94,CDM,636,RC,J3490,HCPCS,,,,39822110001,NDC,0.2,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,11.07921788,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,330.2012
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,70860030242,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,4.556666667,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,36000028425,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,4.556666667,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001094,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,42.5516
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,781382571,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,143931901,NDC,0.4,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.428
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272002,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.983043478,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272031,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.983043478,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,25021040010,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.983043478,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323054011,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.983043478,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095300,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.983043478,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095310,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.983043478,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,71288042095,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.983043478,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306424,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.46575,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306413,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.46575,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306521,NDC,3,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.46575,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin lock flush 10 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306510,NDC,5,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.46575,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
HYDROmorphone 1 MG/ML Solution 1 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,76045000901,NDC,0.25,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,15.571,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016216,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,6.156509434,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016243,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,6.156509434,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072201,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,6.156509434,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072225,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,6.156509434,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016226,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,6.156509434,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016245,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,6.156509434,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011901,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,6.156509434,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011925,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,6.156509434,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072501,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,6.156509434,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072525,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,6.156509434,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143932001,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143962201,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,409226720,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,47781058629,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,51991093498,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,409427616,NDC,20,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323048526,NDC,20,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,63323049241,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2% PF 2 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049526,NDC,5,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2% PF 2 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049541,NDC,5,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine buffered 1 % Solution 0.5 mL Syringe,25000000,CDM,250,RC,,,,,,8888800160,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604401,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,10.90473684,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604425,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,10.90473684,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620701,NDC,0.25,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,10.90473684,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620725,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,10.90473684,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
magnesium sulfate 50 % Solution 10 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006404,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,14.23621053,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,703450284,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1.12,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.859
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,409177815,NDC,5,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,70860030005,NDC,1.25,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metroNIDAZOLE 500 MG/100ML Solution 100 mL Plas Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,338954124,NDC,100,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,31.4776
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605701,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,6.89375,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605725,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,6.89375,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060031,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,6.89375,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060041,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,6.89375,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 5 MG/ML Solution 1 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606101,NDC,0.2,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,6.89375,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230504,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,6.89375,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230505,NDC,5,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,6.89375,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam PF 10 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230802,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,6.89375,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,43598052936,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080601,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080610,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,409475503,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,3.03421875,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054731,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,3.03421875,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054831,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,3.03421875,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054842,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,3.03421875,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092825,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,13.87,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,31.5854
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488802,NDC,10,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,26.00411043,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018603,NDC,20,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,26.00411043,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018620,NDC,20,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,26.00411043,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 50 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488850,NDC,3,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,26.00411043,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride bacteriostatic 0.9 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409196602,NDC,30,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride bacteriostatic 0.9 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409196607,NDC,30,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,64253002030,NDC,10,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409488710,NDC,10,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409488717,NDC,10,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
SUTURE BIOSYN MONOFILAMENT ABSORBABLE UNDYED SIZE 4-0 18IN WITH 3/8 CIRCLE REVERSE CUTTING 19MM NEED,27200000,CDM,272,RC,,,,11987-MAIN,LOCAL,,,,,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE MONOFILAMENT SZ 4-0 BIOSYN ABSORBABLE UNDYED18IN WITH 3/8 CIRCLE REVERSE CUTTING 19MM NEED SM,27200000,CDM,272,RC,,,,11984-MAIN,LOCAL,,,,,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TRAY LUMBAR 22GAX3.5 PUNCTURE SAFE-T 4306CWSP,120.18,CDM,272,RC,,,,11584-MAIN,LOCAL,,,,,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
TRAY LUMBAR 22X1.5 PUNCTURE PEDS 4302CSP,120.18,CDM,272,RC,,,,652-MAIN,LOCAL,,,,,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
triamcinolone acetonide 10 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3049420,NDC,0.25,ML,30,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,6.011428571,percent of total billed charges,29.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,72.0986
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003930,NDC,1,EA,58.99,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,29.20005,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,93681545,NDC,2,ML,57.71,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,29.20126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,93681573,NDC,2,ML,57.71,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,29.20126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Collect Blood From Picc,PX36592,CDM,949,RC,36592,CPT,,,,,,,,198,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,29.2019,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.97,62.26
Collect Blood From Picc,PX36592F,CDM,510,RC,36592,CPT,,,,,,,,211,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,29.2019,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.97,62.26
DRAWTEX HYDROCONDUCTIVE NONADHERENT DRESSING,120.508,CDM,271,RC,A6199,HCPCS,,12022-MAIN,LOCAL,,,,,59,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,29.205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.5086,57.82
"Potassium; Serum, Plasma or Whole Blood",PX84132,CDM,300,RC,84132,CPT,,,,,,,,59,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,29.205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.36,57.82
hydrocortisone 2.5 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,45802000403,NDC,28,GR,60.85,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,29.208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 2.5 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,45802000403,NDC,28,GR,60.85,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,29.208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409116219,NDC,30,ML,32.07,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,29.21577,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048503,NDC,50,ML,57.74,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,29.21644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Remv Ext Canal Foreign Body,PX69200F,CDM,510,RC,69200,CPT,,,,,,,,235,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,29.22,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.22,167.42
Remv Ext Canal Foreign Body,PX69200P,CDM,983,RC,69200,CPT,,,,,,,,157,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,29.22,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.22,167.42
brimonidine 0.2 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,70069023101,NDC,5,ML,70.38,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,29.235852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,70655000206,NDC,100,ML,59.67,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.2383,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.786918,140.5516
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,70655000206,NDC,100,ML,59.67,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.2383,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.786918,140.5516
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,70655000206,NDC,100,ML,59.67,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,29.2383,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.786918,140.5516
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457000110,NDC,10,ML,59.67,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,12.9192,percent of total billed charges,29.2383,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457000110,NDC,10,ML,59.67,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.2383,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457000110,NDC,10,ML,59.67,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,29.2383,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
KIT ENDO COMPLETE PROCEDURE CARRY-ON 100802,27200000,CDM,272,RC,,,,10369-MAIN,LOCAL,,,,,33.15,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,29.2383,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013266,NDC,50,ML,59.67,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,4.651111111,percent of total billed charges,29.2383,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013266,NDC,50,ML,59.67,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.2383,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013266,NDC,50,ML,59.67,,United Healthcare,All Medicare advantage plans,outpatient,49,,17.13,percent of total billed charges,29.2383,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013268,NDC,150,ML,59.67,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,4.651111111,percent of total billed charges,29.2383,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013268,NDC,150,ML,59.67,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.2383,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013268,NDC,150,ML,59.67,,United Healthcare,All Medicare advantage plans,outpatient,49,,17.13,percent of total billed charges,29.2383,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
sucralfate 1 GM/10ML Suspension 10 mL Cup,63700001,CDM,250,RC,,,,,,68094004359,NDC,10,ML,60.92,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,29.2416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sucralfate 1 GM/10ML Suspension 10 mL Cup,63700001,CDM,250,RC,,,,,,68094004359,NDC,10,ML,60.92,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,29.2416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,641601301,NDC,5,ML,34.41,,First Health,Commercial,both,85,,999999999,percent of total billed charges,29.2485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084007001,NDC,1,EA,33.17,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,29.25594,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tuberculin 5 UNIT/0.1ML Solution 1 mL Vial,25000000,CDM,250,RC,,,,,,42023010401,NDC,0.1,ML,57.82,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,29.25692,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
famciclovir 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714030401,NDC,1,EA,34.42,,First Health,Commercial,both,85,,999999999,percent of total billed charges,29.257,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metroNIDAZOLE 500 MG/100ML Solution 100 mL Flex Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,409781124,NDC,100,ML,32.12,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,29.26132,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,31.4776
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018200,NDC,10,ML,68.21,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,29.26209,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.24,991.564
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018210,NDC,10,ML,68.21,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,29.26209,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.24,991.564
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189103,NDC,1,ML,32.89,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,29.2721,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
ciprofloxacin 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084007011,NDC,1,EA,33.19,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,29.27358,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Androsetenedione - Ref,PX8215790,CDM,300,RC,82157,CPT,90,,,,,,,107,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,29.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.4,29.28
"Protoporphyrin, RBC, Qnt - Ref",PX8420290,CDM,300,RC,84202,CPT,90,,,,,,,61,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,29.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.16,59.78
"Protoporphyrin, RBC, Qnt - Ref",PX8420290,CDM,300,RC,84202,CPT,90,,,,,,,61,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,29.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.16,59.78
"Venipuncture, Lab",PX3641502,CDM,300,RC,36415,CPT,,,,,,,,61,,Health Partners,Health Partners Care Plans,both,48,,29.66827586,percent of total billed charges,29.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.1,65.45
"Venipuncture, Lab",PX3641502,CDM,300,RC,36415,CPT,,,,,,,,61,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,29.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.1,65.45
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120301,NDC,0.5,ML,34.45,,First Health,Commercial,both,85,,999999999,percent of total billed charges,29.2825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120311,NDC,0.5,ML,34.45,,First Health,Commercial,both,85,,999999999,percent of total billed charges,29.2825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
"DXA, Bone Density Study, Hips/Pelv/Spine",PX7708001,CDM,320,RC,77080,CPT,TC,,,,,,,575,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,29.2838,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.75,58.51
Xray Nasal Bones Minimum 3 Vws,PX7016001,CDM,320,RC,70160,CPT,TC,,,,,,,456,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,29.2838,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.63,58.51
Xray Ribs Unilat 2 Vws With Pa Chest,PX7110101,CDM,320,RC,71101,CPT,TC,,,,,,,792,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,29.2838,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.41,58.51
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987525,NDC,3,ML,33.22,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,29.30004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048657,NDC,50,ML,61.05,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,29.304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048657,NDC,50,ML,61.05,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,29.304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
valACYclovir 1 GM Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862044930,NDC,0.5,EA,33.23,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,29.30886,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050601,NDC,1,ML,68.33,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,29.31357,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010520,NDC,1,EA,68.33,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,29.31357,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010541,NDC,1,EA,68.33,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,29.31357,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
triamcinolone acetonide 0.1 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,16714098602,NDC,30,GR,59.22,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,29.3139,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramox-PE-glycerin-petrolatum 1-0.25-14.4-15 % Cream 51 g Tube,63700001,CDM,250,RC,,,,,,573286898,NDC,51,GR,68.34,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,29.31786,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BUPivacaine 0.25 % Solution 50 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046557,NDC,30,ML,59.84,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.216692234,percent of total billed charges,29.3216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 50 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046557,NDC,30,ML,59.84,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.3216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 50 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046557,NDC,30,ML,59.84,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,29.3216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
buprenorphine 75 MCG FILM 60 Each Box,63700001,CDM,250,RC,,,,,,59385002160,NDC,1,EA,29.92,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.3216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,143950601,NDC,10,ML,61.1,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,29.328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,143950601,NDC,10,ML,61.1,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,29.328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,143950610,NDC,10,ML,61.1,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,29.328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,143950610,NDC,10,ML,61.1,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,29.328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623100,NDC,1,EA,59.25,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,29.32875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457000100,NDC,10,ML,68.38,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,29.33502,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623105,NDC,1,EA,59.27,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,29.33865,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
"Albumin, Blood",PX82040,CDM,300,RC,82040,CPT,90,,,,,,,58,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,29.348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.54,56.84
Assay of creatinine,PX82565,CDM,300,RC,82565,CPT,,,,,,,,58,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,29.348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.69,56.84
Assay of Urea Nitrogen,PX84520,CDM,300,RC,84520,CPT,,,,,,,,58,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,29.348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.62,56.84
"Assay, Glucose, Blood Quant",PX82947,CDM,300,RC,82947,CPT,,,,,,,,58,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,29.348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.6,56.84
Automated Leukocyte Count,PX85048,CDM,300,RC,85048,CPT,,,,,,,,58,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,29.348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.33,56.84
DEFIBRILLATION PAD BIPHASIC ADULT,120.96,CDM,271,RC,A0392,HCPCS,,1321-MAIN,LOCAL,,,,,58,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,29.348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.0932,56.84
"Ebv, Nuclear Antigen - Ref",PX8666490,CDM,300,RC,86664,CPT,90,,,,,,,58,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,29.348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.02,56.84
"Ebv, Viral Capsid Ab - Ref",PX8666590,CDM,300,RC,86665,CPT,90,,,,,,,58,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,29.348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.63,56.84
Hematocrit,PX85014,CDM,300,RC,85014,CPT,,,,,,,,58,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,29.348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.17,56.84
"Long Term Holter, 48 Hrs Up to 7 Days, Recording",PX93242,CDM,731,RC,93242,CPT,,,,,,,,58,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,29.348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.0932,56.84
"Long Term Holter, More Than 7 Days Up to 15 Days, Recording",PX93246,CDM,731,RC,93246,CPT,,,,,,,,58,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,29.348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.0932,56.84
"Sodium; Serum, Plasma or Whole Blood",PX84295,CDM,300,RC,84295,CPT,,,,,,,,58,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,29.348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.41,56.84
SUTURE V-LOC SZ 1 PBT WOUND CLOSURE DEVICE BLUE 18 IN GS 21 NEEDLE VLOCN0327,27200000,CDM,272,RC,,,,12828-MAIN,LOCAL,,,,,58,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,29.348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Transferase; Alanine Amino (Alt) (Sgpt),PX84460,CDM,300,RC,84460,CPT,,,,,,,,58,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,29.348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.86,56.84
Transferase; Aspartate Amino (Ast) (Sgot),PX84450,CDM,300,RC,84450,CPT,,,,,,,,58,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,29.348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,56.84
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092821,NDC,1,ML,32.23,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,29.36153,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,31.5854
VAGINAL PACKING 2',120.292,CDM,272,RC,,,,829-MAIN,LOCAL,,,,,32.23,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,29.36153,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.388342,31.5854
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016501,NDC,1,ML,34.55,,First Health,Commercial,both,85,,999999999,percent of total billed charges,29.3675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049226,NDC,30,ML,34.55,,First Health,Commercial,both,85,,999999999,percent of total billed charges,29.3675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049245,NDC,30,ML,34.55,,First Health,Commercial,both,85,,999999999,percent of total billed charges,29.3675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,23155024031,NDC,2,ML,34.55,,First Health,Commercial,both,85,,999999999,percent of total billed charges,29.3675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.859
CATHETER FOLEY 18FR  3WAY 30CC 73018L,120.21,CDM,272,RC,A4346,HCPCS,,253-MAIN,LOCAL,,,,,33,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,29.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
CATHETER FOLEY 20FR 3WAY 30CC 0167L20,120.21,CDM,272,RC,A4346,HCPCS,,251-MAIN,LOCAL,,,,,33,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,29.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
CATHETER FOLEY 24FR 3WAY 30CC 0167L24,120.21,CDM,272,RC,A4346,HCPCS,,10455-MAIN,LOCAL,,,,,33,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,29.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
"DRESSING AQUACEL 3/4"" X 18"" AG HYDROFIBER 403771",120.31,CDM,272,RC,A6199,HCPCS,,8238-MAIN,LOCAL,,,,,33,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,29.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,32.34
Hospital Outpatient Clinic Visit Specimen Collection for Sars-Cov-2,PXC9803,CDM,300,RC,C9803,HCPCS,,,,,,,,33,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,29.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,32.34
MEPILEX AG 4X4 10X10,120.138,CDM,272,RC,A6213,HCPCS,,7248-MAIN,LOCAL,,,,,33,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,29.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,32.34
STANDARD HIGH FLOW INSUFFLATION FILTER TUBING,27200000,CDM,272,RC,,,,11885-MAIN,LOCAL,,,,,33,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,29.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
benzocaine-menthol 20-0.5 % Aerosol 56 g Can,63700001,CDM,250,RC,,,,,,16864068002,NDC,56,GR,33.3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,29.3706,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
EPINEPHrine 30 MG/30ML Solution 30 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023016801,NDC,0.3,ML,32.24,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,29.37064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305972,NDC,2,ML,61.19,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,29.3712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305972,NDC,2,ML,61.19,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,29.3712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305995,NDC,2,ML,61.19,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,29.3712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305995,NDC,2,ML,61.19,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,29.3712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
8MM ENDOWRIST INSTRUMENTS MEDIUM LARGE CLIP APPLIER,27200000,CDM,272,RC,,,,11910-MAIN,LOCAL,,,,,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,2,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.852986,29.4
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,3,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.852986,29.4
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061603,NDC,3,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,641600601,NDC,0.5,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
bacteriostatic water(benz alc) Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409397703,NDC,30,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BULB RESERVOIR SILICONE 400CC,27200000,CDM,272,RC,,,,12463-MAIN,LOCAL,,,,,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600710,NDC,2,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,38.9354
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409115918,NDC,1,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046401,NDC,1,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046402,NDC,1,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046437,NDC,1,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,409174670,NDC,1,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046801,NDC,1,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046817,NDC,1,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BUPivacaine in dextrose 0.75-8.25 % Solution 2 mL Ampule,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409176162,NDC,2,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046601,NDC,1,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
Capillary Blood Collection,PX36416,CDM,300,RC,36416,CPT,,,,,,,,60,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,58.8
Capillary Blood Collection,PX36416,CDM,300,RC,36416,CPT,,,,,,,,60,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,58.8
Capillary Blood Collection,PX36416,CDM,300,RC,36416,CPT,,,,,,,,60,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,58.8
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143992490,NDC,0.5,EA,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010110,NDC,0.5,EA,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010167,NDC,0.5,EA,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,44567070725,NDC,0.5,EA,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733201,NDC,0.5,EA,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733801,NDC,0.5,EA,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,70069000501,NDC,0.1,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,63.2394
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016502,NDC,0.5,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016516,NDC,0.5,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036721,NDC,1,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036725,NDC,1,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone 100 MG/10ML Solution 10 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323051610,NDC,0.5,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050641,NDC,0.5,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141031,NDC,0.5,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,641037621,NDC,0.25,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066416,NDC,1,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066441,NDC,0.25,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010101,NDC,0.25,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
DRAPE SPLIT WITH ADHESIVE DYNJP8304A,27200000,CDM,272,RC,,,,4694-MAIN,LOCAL,,,,,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRESSING HYDROFERA 2-1/2X2-1/2  BLUE READY FOAM HBRS2520,120.488,CDM,271,RC,A6209,HCPCS,,11537-MAIN,LOCAL,,,,,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
"Ethanol, P",PX82077,CDM,300,RC,82077,CPT,,,,,,,,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073916,NDC,2,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,29.4
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073941,NDC,1,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,29.4
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,67457043300,NDC,1,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.83,29.4
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909422,NDC,2,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
folic acid 5 MG/ML Solution 10 mL Vial,J3490.94,CDM,636,RC,J3490,HCPCS,,,,39822110001,NDC,0.2,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,330.2012
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,70860030242,NDC,1,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,36000028425,NDC,2,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001094,NDC,2,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,42.5516
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,781382571,NDC,0.5,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,143931901,NDC,0.4,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.428
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272002,NDC,1,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272031,NDC,1,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,25021040010,NDC,1,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323054011,NDC,1,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095300,NDC,0.5,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095310,NDC,1,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,71288042095,NDC,0.5,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306424,NDC,1,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306413,NDC,1,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306521,NDC,3,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
heparin lock flush 10 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306510,NDC,5,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
HERNIA BELT MENS TRUSS LARGE,120.526,CDM,274,RC,L8310,HCPCS,,12221-MAIN,LOCAL,,,,,60,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,160.6
HERNIA BELT MENS TRUSS LARGE,120.526,CDM,274,RC,L8310,HCPCS,,12221-MAIN,LOCAL,,,,,60,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,160.6
HERNIA BELT MENS TRUSS LARGE,120.526,CDM,274,RC,L8310,HCPCS,,12221-MAIN,LOCAL,,,,,60,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,160.6
HERNIA BELT MENS TRUSS MEDIUM,120.526,CDM,274,RC,L8310,HCPCS,,12220-MAIN,LOCAL,,,,,60,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,160.6
HERNIA BELT MENS TRUSS MEDIUM,120.526,CDM,274,RC,L8310,HCPCS,,12220-MAIN,LOCAL,,,,,60,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,160.6
HERNIA BELT MENS TRUSS MEDIUM,120.526,CDM,274,RC,L8310,HCPCS,,12220-MAIN,LOCAL,,,,,60,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,160.6
HERNIA BELT MENS TRUSS XLARGE,120.526,CDM,274,RC,L8310,HCPCS,,12222-MAIN,LOCAL,,,,,60,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,160.6
HERNIA BELT MENS TRUSS XLARGE,120.526,CDM,274,RC,L8310,HCPCS,,12222-MAIN,LOCAL,,,,,60,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,160.6
HERNIA BELT MENS TRUSS XLARGE,120.526,CDM,274,RC,L8310,HCPCS,,12222-MAIN,LOCAL,,,,,60,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,160.6
HYDROmorphone 1 MG/ML Solution 1 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,76045000901,NDC,0.25,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
"IMMOBILIZER KNEE  24"" 7041-44",120.22,CDM,274,RC,L1830,HCPCS,,595-MAIN,LOCAL,,,,,60,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,14.92,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE  24"" 7041-44",120.22,CDM,274,RC,L1830,HCPCS,,595-MAIN,LOCAL,,,,,60,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE  24"" 7041-44",120.22,CDM,274,RC,L1830,HCPCS,,595-MAIN,LOCAL,,,,,60,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE 16"" UNIVERSAL 7088-04",120.22,CDM,274,RC,L1830,HCPCS,,589-MAIN,LOCAL,,,,,60,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,14.92,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE 16"" UNIVERSAL 7088-04",120.22,CDM,274,RC,L1830,HCPCS,,589-MAIN,LOCAL,,,,,60,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE 16"" UNIVERSAL 7088-04",120.22,CDM,274,RC,L1830,HCPCS,,589-MAIN,LOCAL,,,,,60,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
IMMOBILIZER KNEE 20 INCH ORT2420019,120.22,CDM,274,RC,L1830,HCPCS,,587-MAIN,LOCAL,,,,,60,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,14.92,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
IMMOBILIZER KNEE 20 INCH ORT2420019,120.22,CDM,274,RC,L1830,HCPCS,,587-MAIN,LOCAL,,,,,60,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
IMMOBILIZER KNEE 20 INCH ORT2420019,120.22,CDM,274,RC,L1830,HCPCS,,587-MAIN,LOCAL,,,,,60,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE 20"" LARGE FOAM COUNTOURED STAYS 7062-03",120.22,CDM,274,RC,L1830,HCPCS,,593-MAIN,LOCAL,,,,,60,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,14.92,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE 20"" LARGE FOAM COUNTOURED STAYS 7062-03",120.22,CDM,274,RC,L1830,HCPCS,,593-MAIN,LOCAL,,,,,60,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE 20"" LARGE FOAM COUNTOURED STAYS 7062-03",120.22,CDM,274,RC,L1830,HCPCS,,593-MAIN,LOCAL,,,,,60,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE 20"" QUICK-WRAP ORT2440020S",120.22,CDM,274,RC,L1830,HCPCS,,591-MAIN,LOCAL,,,,,60,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,14.92,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE 20"" QUICK-WRAP ORT2440020S",120.22,CDM,274,RC,L1830,HCPCS,,591-MAIN,LOCAL,,,,,60,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE 20"" QUICK-WRAP ORT2440020S",120.22,CDM,274,RC,L1830,HCPCS,,591-MAIN,LOCAL,,,,,60,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
IMMOBILIZER KNEE CUTAWAY STRAIGHT 2 7041-05,120.22,CDM,274,RC,L1830,HCPCS,,596-MAIN,LOCAL,,,,,60,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,14.92,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
IMMOBILIZER KNEE CUTAWAY STRAIGHT 2 7041-05,120.22,CDM,274,RC,L1830,HCPCS,,596-MAIN,LOCAL,,,,,60,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
IMMOBILIZER KNEE CUTAWAY STRAIGHT 2 7041-05,120.22,CDM,274,RC,L1830,HCPCS,,596-MAIN,LOCAL,,,,,60,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016216,NDC,1,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016243,NDC,0.5,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072201,NDC,0.5,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072225,NDC,0.5,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016226,NDC,0.5,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016245,NDC,0.5,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011901,NDC,0.5,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011925,NDC,0.5,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072501,NDC,0.5,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072525,NDC,0.5,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143932001,NDC,1,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143962201,NDC,1,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,409226720,NDC,1,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,47781058629,NDC,1,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,51991093498,NDC,1,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.16,29.4
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,409427616,NDC,20,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323048526,NDC,20,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,63323049241,NDC,2,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2% PF 2 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049526,NDC,5,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2% PF 2 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049541,NDC,5,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine buffered 1 % Solution 0.5 mL Syringe,25000000,CDM,250,RC,,,,,,8888800160,NDC,0.5,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604401,NDC,1,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604425,NDC,1,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620701,NDC,0.25,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620725,NDC,1,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
magnesium sulfate 50 % Solution 10 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006404,NDC,2,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,703450284,NDC,2,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.859
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,409177815,NDC,5,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,70860030005,NDC,1.25,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metroNIDAZOLE 500 MG/100ML Solution 100 mL Plas Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,338954124,NDC,100,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,31.4776
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605701,NDC,2,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605725,NDC,1,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060031,NDC,2,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060041,NDC,2,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 5 MG/ML Solution 1 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606101,NDC,0.2,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230504,NDC,0.5,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230505,NDC,5,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam PF 10 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230802,NDC,2,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,43598052936,NDC,0.5,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080601,NDC,0.5,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080610,NDC,0.5,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,409475503,NDC,2,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054731,NDC,2,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054831,NDC,2,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054842,NDC,2,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092825,NDC,1,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,31.5854
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488802,NDC,10,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018603,NDC,20,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018620,NDC,20,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9 % PF 0.9 % Solution 50 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488850,NDC,3,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride bacteriostatic 0.9 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409196602,NDC,30,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride bacteriostatic 0.9 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409196607,NDC,30,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,64253002030,NDC,10,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409488710,NDC,10,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409488717,NDC,10,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
SUTURE BIOSYN MONOFILAMENT ABSORBABLE UNDYED SIZE 4-0 18IN WITH 3/8 CIRCLE REVERSE CUTTING 19MM NEED,27200000,CDM,272,RC,,,,11987-MAIN,LOCAL,,,,,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE MONOFILAMENT SZ 4-0 BIOSYN ABSORBABLE UNDYED18IN WITH 3/8 CIRCLE REVERSE CUTTING 19MM NEED SM,27200000,CDM,272,RC,,,,11984-MAIN,LOCAL,,,,,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TRAY LUMBAR 22GAX3.5 PUNCTURE SAFE-T 4306CWSP,120.18,CDM,272,RC,,,,11584-MAIN,LOCAL,,,,,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
TRAY LUMBAR 22X1.5 PUNCTURE PEDS 4302CSP,120.18,CDM,272,RC,,,,652-MAIN,LOCAL,,,,,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.4
triamcinolone acetonide 10 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3049420,NDC,0.25,ML,30,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,72.0986
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43598055530,NDC,0.4,EA,61.26,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,29.4048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43598055530,NDC,0.4,EA,61.26,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,29.4048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43598096630,NDC,0.4,EA,61.26,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,29.4048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43598096630,NDC,0.4,EA,61.26,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,29.4048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tropicamide 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,24208058559,NDC,2,ML,61.3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,29.424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tropicamide 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,24208058559,NDC,2,ML,61.3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,29.424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
clarithromycin 250 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,527193106,NDC,1,EA,32.3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,29.4253,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clarithromycin 250 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,65862022560,NDC,1,EA,32.3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,29.4253,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"BUPivacaine 0.25%-EPINEPHrine 1:200,000 0.25% -1:200000 Solution 50 mL Vial",25000000,CDM,250,RC,,,,,,409175250,NDC,30,ML,68.6,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,29.4294,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Cognitive Funct Ther Interv, Initial 15 Min",PX97129,CDM,420,RC,97129,CPT,,,,,,,,85,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,29.43,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.63,29.43
Remv Ext Canal Foreign Body,PX69200F,CDM,510,RC,69200,CPT,,,,,,,,235,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,29.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.22,167.42
Remv Ext Canal Foreign Body,PX69200F,CDM,510,RC,69200,CPT,,,,,,,,235,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,29.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.22,167.42
Remv Ext Canal Foreign Body,PX69200P,CDM,983,RC,69200,CPT,,,,,,,,157,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,29.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.22,167.42
Remv Ext Canal Foreign Body,PX69200P,CDM,983,RC,69200,CPT,,,,,,,,157,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,29.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.22,167.42
tobramycin 80 MG/2ML Solution 2 mL Vial,J3260.01,CDM,636,RC,J3260,HCPCS,,,,67457047300,NDC,2,ML,33.09,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,29.4501,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.745586,32.4282
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046203,NDC,30,ML,70.91,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,29.456014,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
OLANZapine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60505311000,NDC,1,EA,60.13,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.4637,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
OLANZapine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60505311000,NDC,1,EA,60.13,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.4637,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
OLANZapine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60505311000,NDC,1,EA,60.13,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,29.4637,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
inFLIXimab 100 MG Recon Soln 1 Each Vial,J1745.01,CDM,636,RC,J1745,HCPCS,,,,57894003001,NDC,1,EA,2382.35,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,29.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.49,2334.703
Gabapentin - Ref,PX8017190,CDM,300,RC,80171,CPT,90,,,,,,,71,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,29.4934,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.87,69.58
Histoplasma Antibody - Ref,PX8669890,CDM,300,RC,86698,CPT,90,,,,,,,71,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,29.4934,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.64,69.58
Legionella Antibody - Ref,PX8671390,CDM,300,RC,86713,CPT,90,,,,,,,71,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,29.4934,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.03,69.58
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,641601501,NDC,25,ML,58.29,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,29.49474,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
KIT ENDO COMPLETE PROCEDURE CARRY-ON 100802,27200000,CDM,272,RC,,,,10369-MAIN,LOCAL,,,,,33.15,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,29.5035,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117630,NDC,1,ML,58.34,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,29.52004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084007001,NDC,1,EA,33.17,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,29.5213,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 1% PF 1 % Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,63323049227,NDC,2,ML,34.74,,First Health,Commercial,both,85,,999999999,percent of total billed charges,29.529,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
PACLitaxel 30 MG/5ML Concentrate 5 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476401,NDC,5,ML,58.37,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,29.53522,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,70655000206,NDC,100,ML,59.67,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,29.53665,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.786918,140.5516
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457000110,NDC,10,ML,59.67,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,29.53665,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013266,NDC,50,ML,59.67,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,29.53665,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013268,NDC,150,ML,59.67,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,29.53665,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
methotrexate 2.5 MG Tablet 20 Each Box,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067005,NDC,1,EA,33.49,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,29.53818,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.911746,32.8398
ciprofloxacin 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084007011,NDC,1,EA,33.19,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,29.5391,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Remove Impacted Ear Wax,PX69210F,CDM,510,RC,69210,CPT,,,,,,,,213,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,29.5412,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.06,99.62
Remove Impacted Ear Wax,PX69210P,CDM,983,RC,69210,CPT,,,,,,,,221,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,29.5412,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.06,216.58
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189101,NDC,1,ML,32.43,,Medica,Commercial,both,91.1,,7.3275,percent of total billed charges,29.54373,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
methotrexate 2.5 MG Tablet 1 Each Blister,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067001,NDC,1,EA,33.51,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,29.55582,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.911746,32.8398
"COLLAR CERVICAL 2"" SMALL UNIVERSAL 08140039",120.249,CDM,274,RC,L0120,HCPCS,,270-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,29.56,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.56,31.12
"COLLAR CERVICAL 2X20"" SMALL 1003-02",120.249,CDM,274,RC,L0120,HCPCS,,272-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,29.56,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.56,31.12
"COLLAR CERVICAL 2X23.5"" MEDIUM XNARROW 1003-04",120.249,CDM,274,RC,L0120,HCPCS,,273-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,29.56,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.56,31.12
"COLLAR CERVICAL 10-15"" SMALL XLONG 1005-06",120.249,CDM,274,RC,L0120,HCPCS,,267-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,29.56,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.56,31.12
"COLLAR CERVICAL LARGE 21.5""X5"" 1005-04",120.249,CDM,274,RC,L0120,HCPCS,,268-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,29.56,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.56,31.12
"COLLAR CERVICAL MEDIUM 20-1/2X4"" 1005-03",120.249,CDM,274,RC,L0120,HCPCS,,269-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,29.56,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.56,31.12
COLLAR CERVICAL SMALL 1005-02,120.249,CDM,274,RC,L0120,HCPCS,,266-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,29.56,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.56,31.12
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987525,NDC,3,ML,33.22,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,29.5658,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
valACYclovir 1 GM Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862044930,NDC,0.5,EA,33.23,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,29.5747,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zinc oxide 20 % Ointment 56.7 g Tube,63700001,CDM,250,RC,,,,,,168006202,NDC,56.7,GR,30.39,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.578587,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,143950801,NDC,10,ML,58.46,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,29.58076,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032056,NDC,1,EA,68.97,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,29.58813,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
lidocaine buffered 1 % Solution 22.2 mL Vial,25000000,CDM,250,RC,,,,,,8888800251,NDC,22.2,ML,30.4,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.58832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine buffered 1% Solution 22.2 mL Vial,25000000,CDM,250,RC,,,,,,8888800251,NDC,22.2,ML,30.4,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.58832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
miconazole 2 % Powder 71 g Bottle,25000000,CDM,250,RC,,,,,,316023125,NDC,71,GR,34.82,,First Health,Commercial,both,85,,999999999,percent of total billed charges,29.597,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dutasteride 0.5 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,42806054909,NDC,1,EA,32.49,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,29.59839,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574711212,NDC,1,EA,33.56,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,29.59992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Vitamin D, 25 Hydroxy",PX82306,CDM,300,RC,82306,CPT,,,,,,,,235,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,29.6,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.71,29.6
Assay Bld/Serum Cholesterol,PX82465,CDM,300,RC,82465,CPT,,,,,,,,69,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,29.601,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.99,67.62
"Astrazeneca Covid-19 Vaccine, Administration, 1st Dose",PX0021A,CDM,771,RC,,,,,,,,,,69,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,29.601,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Astrazeneca Covid-19 Vaccine, Adminstration, 2nd Dose",PX0022A,CDM,771,RC,,,,,,,,,,69,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,29.601,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Janssen Covid-19 Vaccine, Administration",PX0031A,CDM,771,RC,0031A,HCPCS,,,,,,,,69,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,29.601,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 1st Dose",PX0011A,CDM,771,RC,0011A,HCPCS,,,,,,,,69,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,29.601,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 2nd Dose",PX0012A,CDM,771,RC,0012A,HCPCS,,,,,,,,69,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,29.601,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 3rd Dose",PX0013A,CDM,771,RC,0013A,HCPCS,,,,,,,,69,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,29.601,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
Novavax Covid-19 Vaccine Administration 1st Dose,PX0041A,CDM,771,RC,0041A,HCPCS,,,,,,,,69,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,29.601,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
Novavax Covid-19 Vaccine Administration 2nd Dose,PX0042A,CDM,771,RC,0042A,HCPCS,,,,,,,,69,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,29.601,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Pfizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 2nd Dose",PX0002A,CDM,771,RC,0002A,HCPCS,,,,,,,,69,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,29.601,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Pfizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 3rd Dose",PX0003A,CDM,771,RC,0003A,HCPCS,,,,,,,,69,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,29.601,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Pifizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 1st Dose",PX0001A,CDM,771,RC,0001A,HCPCS,,,,,,,,69,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,29.601,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
Xray Ls Spine Bend Tc,PX7212001,CDM,320,RC,72120,CPT,TC,,,,,,,323,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,29.6056,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.84,59.17
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,143950810,NDC,10,ML,58.51,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,29.60606,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
Sacubitril-Valsartan 49-51 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,78077720,NDC,1,EA,58.51,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,29.60606,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bacitracin zinc 500 UNIT/GM Ointment 28.35 g Tube,25000000,CDM,250,RC,,,,,,168001131,NDC,28.35,GR,32.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,29.6075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
valACYclovir 1 GM Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069701,NDC,0.5,EA,33.58,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,29.61756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BUPivacaine 0.25 % Solution 50 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046557,NDC,30,ML,59.84,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,29.6208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093102,NDC,1,ML,60.47,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,9.513809524,percent of total billed charges,29.6303,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093102,NDC,1,ML,60.47,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.6303,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093102,NDC,1,ML,60.47,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,29.6303,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060820,NDC,20,ML,58.57,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,29.63642,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
"sodium chloride 0.45 % 1,000 mL with potassium chloride 20 mEq 20-0.45 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070434,NDC,1000,ML,58.57,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,29.63642,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006403,NDC,2,ML,30.45,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,14.23621053,percent of total billed charges,29.636985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
benzocaine-menthol 20-0.5 % Aerosol 56 g Can,63700001,CDM,250,RC,,,,,,16864068002,NDC,56,GR,33.3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,29.637,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
valproate 100 MG/ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049416,NDC,5,ML,33.61,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,29.64402,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
valproate 100 MG/ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049441,NDC,5,ML,33.61,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,29.64402,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409488724,NDC,50,ML,34.88,,First Health,Commercial,both,85,,999999999,percent of total billed charges,29.648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409488750,NDC,50,ML,34.88,,First Health,Commercial,both,85,,999999999,percent of total billed charges,29.648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,63323047401,NDC,1,ML,58.6,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,29.6516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.428
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076501,NDC,1,EA,58.6,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,29.6516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076510,NDC,1,EA,58.6,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,29.6516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048226,NDC,20,ML,32.56,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,29.66216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048241,NDC,20,ML,32.56,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,29.66216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641600101,NDC,1,ML,32.56,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,29.66216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
Cardiac Rehab,PX93797F,CDM,943,RC,93797,CPT,,,,,,,,45,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,29.67,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.45,29.67
anastrozole 1 MG Tablet 30 Each Bottle,25000000,CDM,250,RC,,,,,,16729003510,NDC,1,EA,71.44,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,29.676176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086000,NDC,1,EA,58.66,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,29.68196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086050,NDC,1,EA,58.66,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,29.68196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012166,NDC,1,EA,58.66,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,29.68196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
cefOXitin 1 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021010910,NDC,1,EA,58.66,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,29.68196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.367364,75.6952
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,65219025915,NDC,1,EA,58.66,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,29.68196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,517095501,NDC,0.25,EA,69.19,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,29.68251,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86,213.6008
Hosp Manage Cont Drug Admin,PX01996.01,CDM,964,RC,1996,CPT,QZ,,,,,,,36,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,29.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.69,107.06
Hosp Manage Cont Drug Admin,PX01996.01,CDM,964,RC,1996,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,29.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.69,107.06
Hosp Manage Cont Drug Admin,PX01996.01,CDM,964,RC,1996,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,29.69,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.69,107.06
Capillary Blood Collection,PX36416,CDM,300,RC,36416,CPT,,,,,,,,60,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,29.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,58.8
HERNIA BELT MENS TRUSS LARGE,120.526,CDM,274,RC,L8310,HCPCS,,12221-MAIN,LOCAL,,,,,60,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,29.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,160.6
HERNIA BELT MENS TRUSS MEDIUM,120.526,CDM,274,RC,L8310,HCPCS,,12220-MAIN,LOCAL,,,,,60,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,29.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,160.6
HERNIA BELT MENS TRUSS XLARGE,120.526,CDM,274,RC,L8310,HCPCS,,12222-MAIN,LOCAL,,,,,60,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,29.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,160.6
"IMMOBILIZER KNEE  24"" 7041-44",120.22,CDM,274,RC,L1830,HCPCS,,595-MAIN,LOCAL,,,,,60,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,29.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE 16"" UNIVERSAL 7088-04",120.22,CDM,274,RC,L1830,HCPCS,,589-MAIN,LOCAL,,,,,60,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,29.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
IMMOBILIZER KNEE 20 INCH ORT2420019,120.22,CDM,274,RC,L1830,HCPCS,,587-MAIN,LOCAL,,,,,60,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,29.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE 20"" LARGE FOAM COUNTOURED STAYS 7062-03",120.22,CDM,274,RC,L1830,HCPCS,,593-MAIN,LOCAL,,,,,60,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,29.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE 20"" QUICK-WRAP ORT2440020S",120.22,CDM,274,RC,L1830,HCPCS,,591-MAIN,LOCAL,,,,,60,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,29.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
IMMOBILIZER KNEE CUTAWAY STRAIGHT 2 7041-05,120.22,CDM,274,RC,L1830,HCPCS,,596-MAIN,LOCAL,,,,,60,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,29.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
ampicillin-sulbactam 1.5 (1-0.5) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001381,NDC,1,EA,69.24,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,29.70396,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
LAP SPONGES 18x18 7INCH LOOP,27200000,CDM,272,RC,,,,604-MAIN,LOCAL,,,,,60.64,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.7136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LAP SPONGES 18x18 7INCH LOOP,27200000,CDM,272,RC,,,,604-MAIN,LOCAL,,,,,60.64,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.7136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LAP SPONGES 18x18 7INCH LOOP,27200000,CDM,272,RC,,,,604-MAIN,LOCAL,,,,,60.64,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,29.7136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,49348009529,NDC,15,ML,30.53,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.714849,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,43598020453,NDC,10,ML,58.73,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,29.71738,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,72508020415,NDC,10,ML,58.73,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,29.71738,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atropine (PF) 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517040125,NDC,1,ML,71.55,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,29.72187,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
tetracaine 0.5 % Solution 4 mL Plas Cont,25000000,CDM,250,RC,,,,,,65074114,NDC,4,ML,71.55,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,29.72187,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ezetimibe 10 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,16729043316,NDC,1,EA,60.66,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.7234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ezetimibe 10 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,16729043316,NDC,1,EA,60.66,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.7234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ezetimibe 10 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,16729043316,NDC,1,EA,60.66,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,29.7234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,517460125,NDC,0.5,ML,58.76,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,29.73256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,60432006547,NDC,10,ML,34.98,,First Health,Commercial,both,85,,999999999,percent of total billed charges,29.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003905,NDC,1,EA,58.77,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,29.73762,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,17478081705,NDC,5,ML,34.99,,First Health,Commercial,both,85,,999999999,percent of total billed charges,29.7415,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Fac/Trim Nail(S),PX11719F,CDM,510,RC,11719,CPT,,,,,,,,107,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,29.75,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.58,29.75
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209F,CDM,510,RC,69209,CPT,,,,,,,,35,,First Health,Commercial,both,85,,999999999,percent of total billed charges,29.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,53.44
SHOE POST OP X-LARGE MALE DS1016-16,120.237,CDM,274,RC,L3260,HCPCS,,6337-MAIN,LOCAL,,,,,35,,First Health,Commercial,both,85,,999999999,percent of total billed charges,29.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
"Trimming of Dystrophic Nails, Any Number",PXG0127P,CDM,983,RC,G0127,HCPCS,,,,,,,,35,,First Health,Commercial,both,85,,999999999,percent of total billed charges,29.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,53.44
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714078401,NDC,0.4,EA,60.72,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.7528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714078401,NDC,0.4,EA,60.72,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.7528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714078401,NDC,0.4,EA,60.72,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,29.7528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 2.5 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,168008031,NDC,30,GR,61.99,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,29.7552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 2.5 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,168008031,NDC,30,GR,61.99,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,29.7552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
azithromycin 200 MG/5ML Recon Susp 15 mL Bottle,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,59762312001,NDC,15,ML,196.35,,UCare,Individual and Family Plans,both,,,11.3,fee schedule,29.76,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.08,29.76
azithromycin 200 MG/5ML Recon Susp 15 mL Bottle,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,59762312001,NDC,15,ML,196.35,,UCare,Individual and Family Plans,both,,,11.3,fee schedule,29.76,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.08,29.76
azithromycin 250 MG Tablet 6 Each Box,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096104,NDC,1,EA,41.72,,UCare,Individual and Family Plans,both,,,11.3,fee schedule,29.76,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.08,29.76
azithromycin 250 MG Tablet 6 Each Box,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096104,NDC,1,EA,41.72,,UCare,Individual and Family Plans,both,,,11.3,fee schedule,29.76,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.08,29.76
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,50111078751,NDC,1,EA,41.79,,UCare,Individual and Family Plans,both,,,11.3,fee schedule,29.76,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.08,29.76
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,50111078751,NDC,1,EA,41.79,,UCare,Individual and Family Plans,both,,,11.3,fee schedule,29.76,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.08,29.76
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096105,NDC,1,EA,41.73,,UCare,Individual and Family Plans,both,,,11.3,fee schedule,29.76,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.08,29.76
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096105,NDC,1,EA,41.73,,UCare,Individual and Family Plans,both,,,11.3,fee schedule,29.76,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.08,29.76
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010125,NDC,1,ML,30.58,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,15.95777778,percent of total billed charges,29.763514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323048541,NDC,20,ML,30.58,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.763514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
OLANZapine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60505311000,NDC,1,EA,60.13,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,29.76435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zinc oxide 20 % Ointment 56.7 g Tube,63700001,CDM,250,RC,,,,,,168006202,NDC,56.7,GR,30.39,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.7822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
RESERVOIR WOUND DRAIN 15FR,27200000,CDM,272,RC,,,,4386-MAIN,LOCAL,,,,,30.6,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.78298,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SET DISPOSABLE COLLECTION,27100000,CDM,271,RC,,,,5439-MAIN,LOCAL,,,,,30.6,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.78298,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
SUTURE NUROLON 0 BLACK C527D,27200000,CDM,272,RC,,,,10415-MAIN,LOCAL,,,,,30.6,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.78298,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987501,NDC,3,ML,33.77,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,29.78514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915850,NDC,0.2,ML,69.44,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,29.78976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031801,NDC,1,ML,185.37,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,29.79,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.21,29.79
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031825,NDC,1,ML,185.37,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,29.79,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.21,29.79
lidocaine buffered 1 % Solution 22.2 mL Vial,25000000,CDM,250,RC,,,,,,8888800251,NDC,22.2,ML,30.4,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine buffered 1% Solution 22.2 mL Vial,25000000,CDM,250,RC,,,,,,8888800251,NDC,22.2,ML,30.4,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
methotrexate 2.5 MG Tablet 20 Each Box,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067005,NDC,1,EA,33.49,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,29.8061,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.911746,32.8398
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781910572,NDC,0.25,EA,69.49,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,29.81121,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86,213.6008
hydrocortisone 2.5 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,45802000403,NDC,28,GR,60.85,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.8165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 2.5 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,45802000403,NDC,28,GR,60.85,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.8165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 2.5 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,45802000403,NDC,28,GR,60.85,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,29.8165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117603,NDC,1,ML,58.93,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,29.81858,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
methotrexate 2.5 MG Tablet 1 Each Blister,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067001,NDC,1,EA,33.51,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,29.8239,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.911746,32.8398
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457033900,NDC,1,EA,71.82,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,29.834028,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006403,NDC,2,ML,30.45,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.841,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,16714001905,NDC,2,ML,62.17,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,29.8416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,16714001905,NDC,2,ML,62.17,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,29.8416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,16714001930,NDC,2,ML,62.17,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,29.8416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,16714001930,NDC,2,ML,62.17,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,29.8416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003930,NDC,1,EA,58.99,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,29.84894,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
sucralfate 1 GM/10ML Suspension 10 mL Cup,63700001,CDM,250,RC,,,,,,68094004359,NDC,10,ML,60.92,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.8508,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sucralfate 1 GM/10ML Suspension 10 mL Cup,63700001,CDM,250,RC,,,,,,68094004359,NDC,10,ML,60.92,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.8508,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sucralfate 1 GM/10ML Suspension 10 mL Cup,63700001,CDM,250,RC,,,,,,68094004359,NDC,10,ML,60.92,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,29.8508,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DRAWTEX HYDROCONDUCTIVE NONADHERENT DRESSING,120.508,CDM,271,RC,A6199,HCPCS,,12022-MAIN,LOCAL,,,,,59,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,29.854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.5086,57.82
"Potassium; Serum, Plasma or Whole Blood",PX84132,CDM,300,RC,84132,CPT,,,,,,,,59,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,29.854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.36,57.82
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338080304,NDC,1000,ML,69.59,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,29.85411,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990710709,NDC,1000,ML,69.59,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,29.85411,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004824,NDC,150,ML,69.59,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,29.85411,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
morphine 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574711212,NDC,1,EA,33.56,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,29.8684,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
valACYclovir 1 GM Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069701,NDC,0.5,EA,33.58,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,29.8862,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Office/Outpt Visit,New,Levl II",PX99202F,CDM,510,RC,99202,CPT,,,,,,,,123,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,29.89,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.89,129.77
"Office/Outpt Visit,New,Levl II",PX99202P,CDM,983,RC,99202,CPT,,,,,,,,123,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,29.89,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.89,129.77
"Protoporphyrin, RBC, Qnt - Ref",PX8420290,CDM,300,RC,84202,CPT,90,,,,,,,61,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.16,59.78
"Protoporphyrin, RBC, Qnt - Ref",PX8420290,CDM,300,RC,84202,CPT,90,,,,,,,61,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.16,59.78
"Protoporphyrin, RBC, Qnt - Ref",PX8420290,CDM,300,RC,84202,CPT,90,,,,,,,61,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,29.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.16,59.78
"Venipuncture, Lab",PX3641502,CDM,300,RC,36415,CPT,,,,,,,,61,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,4.80377451,percent of total billed charges,29.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.1,65.45
"Venipuncture, Lab",PX3641502,CDM,300,RC,36415,CPT,,,,,,,,61,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.1,65.45
"Venipuncture, Lab",PX3641502,CDM,300,RC,36415,CPT,,,,,,,,61,,United Healthcare,All Medicare advantage plans,outpatient,49,,31.8,percent of total billed charges,29.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.1,65.45
"B.Burgdorferi, Amp Probe - Ref",PX8747690,CDM,300,RC,87476,CPT,90,,,,,,,72,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,29.9088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.9088,70.56
"Blood, Occult, Other Sources",PX82271,CDM,300,RC,82271,CPT,,,,,,,,72,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,29.9088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.88,70.56
Epstein-barr antibody,PX86664,CDM,300,RC,86664,CPT,,,,,,,,72,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,29.9088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.02,70.56
valproate 100 MG/ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049416,NDC,5,ML,33.61,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,29.9129,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
valproate 100 MG/ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049441,NDC,5,ML,33.61,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,29.9129,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048657,NDC,50,ML,61.05,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.9145,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048657,NDC,50,ML,61.05,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.9145,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048657,NDC,50,ML,61.05,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,29.9145,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
GASTRONOMY FEEDING TUBE MIC BALLOONED 20FR 7-10ML 0112-20,27200000,CDM,272,RC,B4087,HCPCS,,13098-MAIN,LOCAL,,,,,45,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,29.9181,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
TUBE GASTROSTOMY 18FR REPLACEMENT DYND70318,120.256,CDM,271,RC,B4087,HCPCS,,407-MAIN,LOCAL,,,,,179,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,29.9181,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.9181,38.26
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,36000003310,NDC,5,ML,30.74,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,29.919242,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,49348009529,NDC,15,ML,30.53,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.9194,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
US Chest Tc,PX7660401,CDM,402,RC,76604,CPT,TC,,,,,,,248,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,29.9274,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.19,59.82
Xray Mandible Partial Less Than 4 Vws,PX7010001,CDM,320,RC,70100,CPT,TC,,,,,,,347,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,29.9274,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.84,59.82
Clotting Function Activity - Ref,PX8539790,CDM,300,RC,85397,CPT,90,,,,,,,334,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,29.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.93,30.86
Clotting Function Activity - Ref,PX8539790,CDM,300,RC,85397,CPT,90,,,,,,,334,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,29.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.93,30.86
Clotting Function Activity - Ref,PX8539790,CDM,300,RC,85397,CPT,90,,,,,,,334,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,29.93,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.93,30.86
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093102,NDC,1,ML,60.47,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,29.93265,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,143950601,NDC,10,ML,61.1,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.939,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,143950601,NDC,10,ML,61.1,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.939,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,143950601,NDC,10,ML,61.1,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,29.939,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,143950610,NDC,10,ML,61.1,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.939,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,143950610,NDC,10,ML,61.1,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.939,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,143950610,NDC,10,ML,61.1,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,29.939,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Ampule,25000000,CDM,250,RC,,,,,,68180098405,NDC,2,ML,62.38,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,29.9424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Ampule,25000000,CDM,250,RC,,,,,,68180098405,NDC,2,ML,62.38,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,29.9424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,781751614,NDC,2,ML,62.38,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,29.9424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,781751614,NDC,2,ML,62.38,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,29.9424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,781751687,NDC,2,ML,62.38,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,29.9424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,781751687,NDC,2,ML,62.38,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,29.9424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097031986,NDC,2,ML,62.38,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,29.9424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097031986,NDC,2,ML,62.38,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,29.9424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Cytogen, Interp/Report - Ref",PX8829190,CDM,310,RC,88291,CPT,90,,,,,,,2874,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,29.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.95,2816.52
mepolizumab 100 MG Recon Soln 1 Each Vial,J2182.01,CDM,636,RC,J2182,HCPCS,,,,173088101,NDC,1,EA,6959.95,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,29.95027,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.56,30.51
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189103,NDC,1,ML,32.89,,Medica,Commercial,both,91.1,,7.3275,percent of total billed charges,29.96279,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
triamcinolone acetonide 0.1 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,16714098602,NDC,30,GR,59.22,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,29.96532,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010125,NDC,1,ML,30.58,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.9684,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,29.9684
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323048541,NDC,20,ML,30.58,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.9684,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623100,NDC,1,EA,59.25,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,29.9805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305972,NDC,2,ML,61.19,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.9831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305972,NDC,2,ML,61.19,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.9831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305972,NDC,2,ML,61.19,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,29.9831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305995,NDC,2,ML,61.19,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.9831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305995,NDC,2,ML,61.19,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,29.9831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305995,NDC,2,ML,61.19,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,29.9831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
BINDER ABDOMINAL S/M 9 INCH UP TO 45 INCHES TRI-PANNEL ABB3P45,120.238,CDM,271,RC,A4467,HCPCS,,47-MAIN,LOCAL,,,,,34,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,29.988,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,United Healthcare,All Payer,outpatient,88.2,,14.47333333,percent of total billed charges,29.988,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,United Healthcare,All Payer,outpatient,88.2,,14.47333333,percent of total billed charges,29.988,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
"Lab Ige, Isocyan Hdi",PX86003,CDM,300,RC,86003,CPT,90,,,,,,,34,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,29.988,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.79,33.32
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323020110,NDC,10,ML,34,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,29.988,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Metanephrines - Ref,PX8383590,CDM,300,RC,83835,CPT,90,,,,,,,34,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,29.988,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1236,33.32
RESERVOIR WOUND DRAIN 15FR,27200000,CDM,272,RC,,,,4386-MAIN,LOCAL,,,,,30.6,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.988,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SET DISPOSABLE COLLECTION,27100000,CDM,271,RC,,,,5439-MAIN,LOCAL,,,,,30.6,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.988,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
SPLINT SAM 36INCH ROLLED 661121,120.362,CDM,271,RC,,,,10789-MAIN,LOCAL,,,,,34,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,29.988,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1236,33.32
SUTURE NUROLON 0 BLACK C527D,27200000,CDM,272,RC,,,,10415-MAIN,LOCAL,,,,,30.6,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,29.988,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Venipunc Need Phys Skill,Dx or Rx",PX36410F,CDM,510,RC,36410,CPT,,,,,,,,34,,United Healthcare,All Payer,outpatient,88.2,,8.745,percent of total billed charges,29.988,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1236,33.32
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623105,NDC,1,EA,59.27,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,29.99062,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
LAP SPONGES 18x18 7INCH LOOP,27200000,CDM,272,RC,,,,604-MAIN,LOCAL,,,,,60.64,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,30.0168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43598055530,NDC,0.4,EA,61.26,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,30.0174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43598055530,NDC,0.4,EA,61.26,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,30.0174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43598055530,NDC,0.4,EA,61.26,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,30.0174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43598096630,NDC,0.4,EA,61.26,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,30.0174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43598096630,NDC,0.4,EA,61.26,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,30.0174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43598096630,NDC,0.4,EA,61.26,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,30.0174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ezetimibe 10 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,16729043316,NDC,1,EA,60.66,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,30.0267,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tropicamide 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,24208058559,NDC,2,ML,61.3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,30.037,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tropicamide 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,24208058559,NDC,2,ML,61.3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,30.037,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tropicamide 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,24208058559,NDC,2,ML,61.3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,30.037,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Compatibility Test,Antiglob Tech",PX86922,CDM,300,RC,86922,CPT,,,,,,,,120,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,30.048,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.9,30.048
"Compatibility Test,Antiglob Tech",PX86922,CDM,300,RC,86922,CPT,,,,,,,,120,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,30.048,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.9,30.048
sacubitril-valsartan 24-26 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,78065920,NDC,1,EA,62.6,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,30.048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sacubitril-valsartan 24-26 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,78065920,NDC,1,EA,62.6,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,30.048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Prosthetic Training, Initial, Each 15 Mins",PX97761,CDM,420,RC,97761,CPT,,,,,,,,121,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,30.05,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.05,54.91
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987501,NDC,3,ML,33.77,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,30.0553,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714078401,NDC,0.4,EA,60.72,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,30.0564,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CATHETER FOLEY 18FR  3WAY 30CC 73018L,120.21,CDM,272,RC,A4346,HCPCS,,253-MAIN,LOCAL,,,,,33,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,30.063,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
CATHETER FOLEY 20FR 3WAY 30CC 0167L20,120.21,CDM,272,RC,A4346,HCPCS,,251-MAIN,LOCAL,,,,,33,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,30.063,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
CATHETER FOLEY 24FR 3WAY 30CC 0167L24,120.21,CDM,272,RC,A4346,HCPCS,,10455-MAIN,LOCAL,,,,,33,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,30.063,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
"DRESSING AQUACEL 3/4"" X 18"" AG HYDROFIBER 403771",120.31,CDM,272,RC,A6199,HCPCS,,8238-MAIN,LOCAL,,,,,33,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,30.063,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,32.34
Hospital Outpatient Clinic Visit Specimen Collection for Sars-Cov-2,PXC9803,CDM,300,RC,C9803,HCPCS,,,,,,,,33,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,30.063,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,32.34
MEPILEX AG 4X4 10X10,120.138,CDM,272,RC,A6213,HCPCS,,7248-MAIN,LOCAL,,,,,33,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,30.063,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,32.34
STANDARD HIGH FLOW INSUFFLATION FILTER TUBING,27200000,CDM,272,RC,,,,11885-MAIN,LOCAL,,,,,33,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,30.063,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
benzocaine-menthol 20-0.5 % Aerosol 78 g Can,63700001,CDM,250,RC,,,,,,75137085520,NDC,78,GR,35.38,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.073,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
APLIGRAF LIVING BI-LAYERED SKIN SUBSTITUTE,120.514,CDM,278,RC,Q4101,HCPCS,,12082-MAIN,LOCAL,,,,,2569,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,30.07895,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.07895,30.62
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409317801,NDC,20,ML,34.11,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,30.08502,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409317816,NDC,20,ML,34.11,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,30.08502,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189001,NDC,1,ML,34.11,,United Healthcare,All Payer,outpatient,88.2,,16.488,percent of total billed charges,30.08502,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189003,NDC,1,ML,34.11,,United Healthcare,All Payer,outpatient,88.2,,16.488,percent of total billed charges,30.08502,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,17478070311,NDC,10,ML,72.46,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,30.099884,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Inject Nerv Blck,Trigeminal",PX64400F,CDM,510,RC,64400,CPT,,,,,,,,255,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,30.1,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.1,236.6
"Inject Nerv Blck,Trigeminal",PX64400P,CDM,983,RC,64400,CPT,,,,,,,,170,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,30.1,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.1,236.6
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310001,NDC,0.528,ML,785.14,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,30.11112,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29,32.96
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310002,NDC,0.528,ML,894.9,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,30.11112,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29,32.96
miconazole 2 % Powder 85 g Bottle,25000000,CDM,250,RC,,,,,,67094930,NDC,85,GR,35.43,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.1155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
hydrocortisone 2.5 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,45802000403,NDC,28,GR,60.85,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,30.12075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,36000003310,NDC,5,ML,30.74,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,30.1252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tobramycin 80 MG/2ML Solution 2 mL Vial,J3260.01,CDM,636,RC,J3260,HCPCS,,,,67457047300,NDC,2,ML,33.09,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,30.14499,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.745586,32.4282
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057811,NDC,0.5,ML,30.98,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,30.152834,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057841,NDC,0.5,ML,30.98,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,30.152834,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
sucralfate 1 GM/10ML Suspension 10 mL Cup,63700001,CDM,250,RC,,,,,,68094004359,NDC,10,ML,60.92,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,30.1554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Clotting Function Activity - Ref,PX8539790,CDM,300,RC,85397,CPT,90,,,,,,,334,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,30.1646,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.93,30.86
DRAPE ABDOMINAL SURGICAL 14X12 POUCHES STERILE DYNJP3109,27200000,CDM,272,RC,,,,12896-MAIN,LOCAL,,,,,31,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,30.1723,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LITHOTOMY PACK VIII ECLIPSE,27200000,CDM,272,RC,,,,12210-MAIN,LOCAL,,,,,31,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,30.1723,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Rubella Antibody,PX86762,CDM,300,RC,86762,CPT,,,,,,,,31,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,30.1723,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.8774,30.38
DRAPE SHEET LAP T-DRAPE WITH INSTRUMENT PAD DYNJP3003,27200000,CDM,272,RC,,,,10913-MAIN,LOCAL,,,,,35.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
triamcinolone acetonide 40 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029320,NDC,1,ML,72.65,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,30.17881,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,72.0986
brimonidine 0.2 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,70069023101,NDC,5,ML,70.38,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,30.19302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,70655000206,NDC,100,ML,59.67,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,30.19302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.786918,140.5516
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457000110,NDC,10,ML,59.67,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,30.19302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013266,NDC,50,ML,59.67,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,30.19302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013268,NDC,150,ML,59.67,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,30.19302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
"Protoporphyrin, RBC, Qnt - Ref",PX8420290,CDM,300,RC,84202,CPT,90,,,,,,,61,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,30.195,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.16,59.78
"Venipuncture, Lab",PX3641502,CDM,300,RC,36415,CPT,,,,,,,,61,,Humana Choice Care,All Medicare plans,outpatient,49.5,,46.53659091,percent of total billed charges,30.195,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.1,65.45
KIT ENDO COMPLETE PROCEDURE CARRY-ON 100802,27200000,CDM,272,RC,,,,10369-MAIN,LOCAL,,,,,33.15,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,30.19965,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084007001,NDC,1,EA,33.17,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,30.21787,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048657,NDC,50,ML,61.05,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,30.21975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310001,NDC,0.528,ML,785.14,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,30.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.22,877.002
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310002,NDC,0.528,ML,894.9,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,30.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.22,877.002
dexmedeTOMIDine 200 MCG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,143953201,NDC,2,ML,62.98,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,30.2304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dexmedeTOMIDine 200 MCG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,143953201,NDC,2,ML,62.98,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,30.2304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ciprofloxacin 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084007011,NDC,1,EA,33.19,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,30.23609,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094310,NDC,10,ML,72.79,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,30.236966,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.236966,143.9032
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094321,NDC,10,ML,72.79,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,30.236966,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.236966,143.9032
K-WIRE SMOOTH 1.4MM X 100MM,C1713,CDM,272,RC,C1713,HCPCS,,12634-MAIN,LOCAL,,,,,63,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,30.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
K-WIRE SMOOTH 1.4MM X 100MM,C1713,CDM,272,RC,C1713,HCPCS,,12634-MAIN,LOCAL,,,,,63,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,30.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
SUTURE MAXON MONOFILAMENT ABSORBABLE GREEN SIZE 1 96IN WITH 1/2 CIRCLE TAPER POINT 65MM NEEDLE,27200000,CDM,272,RC,,,,11986-MAIN,LOCAL,,,,,63,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,30.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE MAXON MONOFILAMENT ABSORBABLE GREEN SIZE 1 96IN WITH 1/2 CIRCLE TAPER POINT 65MM NEEDLE,27200000,CDM,272,RC,,,,11986-MAIN,LOCAL,,,,,63,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,30.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Vitamin a - Ref,PX8459090,CDM,300,RC,84590,CPT,90,,,,,,,63,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,30.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.65,61.74
Vitamin a - Ref,PX8459090,CDM,300,RC,84590,CPT,90,,,,,,,63,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,30.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.65,61.74
Xray Scapula Complete,PX7301001,CDM,320,RC,73010,CPT,TC,,,,,,,357,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,30.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.81,30.24
Xray Scapula Complete,PX7301001,CDM,320,RC,73010,CPT,TC,,,,,,,357,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,30.24,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.81,30.24
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,143950601,NDC,10,ML,61.1,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,30.2445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,143950610,NDC,10,ML,61.1,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,30.2445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Joint Survey Tc,PX7707701,CDM,320,RC,77077,CPT,TC,,,,,,,304,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,30.2492,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.28,60.48
X-Ray Exam Entire Spine 1vw,PX7208101,CDM,320,RC,72081,CPT,TC,,,,,,,414,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,30.2492,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.06,59.82
Xray Pelvis Compl 3+ Tc,PX7219001,CDM,320,RC,72190,CPT,TC,,,,,,,563,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,30.2492,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.06,59.82
Xray Ribs Bil 3vws Tc,PX7111001,CDM,320,RC,71110,CPT,TC,,,,,,,533,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,30.2492,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.06,59.82
BINDER ABDOMINAL S/M 9 INCH UP TO 45 INCHES TRI-PANNEL ABB3P45,120.238,CDM,271,RC,A4467,HCPCS,,47-MAIN,LOCAL,,,,,34,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,30.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,30.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,30.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
"Lab Ige, Isocyan Hdi",PX86003,CDM,300,RC,86003,CPT,90,,,,,,,34,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,30.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.79,33.32
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323020110,NDC,10,ML,34,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,30.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Metanephrines - Ref,PX8383590,CDM,300,RC,83835,CPT,90,,,,,,,34,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,30.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1236,33.32
SPLINT SAM 36INCH ROLLED 661121,120.362,CDM,271,RC,,,,10789-MAIN,LOCAL,,,,,34,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,30.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1236,33.32
"Venipunc Need Phys Skill,Dx or Rx",PX36410F,CDM,510,RC,36410,CPT,,,,,,,,34,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,30.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1236,33.32
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987525,NDC,3,ML,33.22,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,30.26342,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
saliva substitute Solution 59 mL Bottle,63700001,CDM,250,RC,,,,,,50930009802,NDC,59,ML,31.1,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,30.26963,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
valACYclovir 1 GM Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862044930,NDC,0.5,EA,33.23,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,30.27253,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BUPivacaine 0.25 % Solution 50 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046557,NDC,30,ML,59.84,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,30.27904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,409677802,NDC,1,ML,31.11,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,10.90473684,percent of total billed charges,30.279363,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409751716,NDC,50,ML,72.9,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,30.28266,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305972,NDC,2,ML,61.19,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,30.28905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305995,NDC,2,ML,61.19,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,30.28905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
KUMAR CHOLANGIOGRAPHY CATHETER,27200000,CDM,272,RC,,,,10230-MAIN,LOCAL,,,,,63.11,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,30.2928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
KUMAR CHOLANGIOGRAPHY CATHETER,27200000,CDM,272,RC,,,,10230-MAIN,LOCAL,,,,,63.11,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,30.2928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098121,NDC,1,EA,72.95,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,30.30343,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
fluconazole 150 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,16714069210,NDC,1,EA,72.98,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,30.315892,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43598055530,NDC,0.4,EA,61.26,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,30.3237,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43598096630,NDC,0.4,EA,61.26,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,30.3237,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BALLOON EXTRACTOR PEDS,120.358,CDM,272,RC,,,,10771-MAIN,LOCAL,,,,,73,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,30.3242,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.3242,71.54
buprenorphine 75 MCG FILM 1 Each Package,63700001,CDM,250,RC,,,,,,59385002101,NDC,1,EA,35.68,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzocaine-menthol 20-0.5 % Aerosol 56 g Can,63700001,CDM,250,RC,,,,,,16864068002,NDC,56,GR,33.3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,30.3363,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021515,NDC,0.5,ML,187.24,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,30.34,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.45175,30.34
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021588,NDC,0.5,ML,203.87,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,30.34,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.45175,30.34
tropicamide 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,24208058559,NDC,2,ML,61.3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,30.3435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,641601301,NDC,5,ML,34.41,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,30.34962,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409317801,NDC,20,ML,34.11,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,30.3579,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409317816,NDC,20,ML,34.11,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,30.3579,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189001,NDC,1,ML,34.11,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,30.3579,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189003,NDC,1,ML,34.11,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,30.3579,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
famciclovir 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714030401,NDC,1,EA,34.42,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,30.35844,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Capillary Blood Collection,PX36416,CDM,300,RC,36416,CPT,,,,,,,,60,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,30.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,58.8
HERNIA BELT MENS TRUSS LARGE,120.526,CDM,274,RC,L8310,HCPCS,,12221-MAIN,LOCAL,,,,,60,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,30.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,160.6
HERNIA BELT MENS TRUSS MEDIUM,120.526,CDM,274,RC,L8310,HCPCS,,12220-MAIN,LOCAL,,,,,60,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,30.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,160.6
HERNIA BELT MENS TRUSS XLARGE,120.526,CDM,274,RC,L8310,HCPCS,,12222-MAIN,LOCAL,,,,,60,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,30.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,160.6
"IMMOBILIZER KNEE  24"" 7041-44",120.22,CDM,274,RC,L1830,HCPCS,,595-MAIN,LOCAL,,,,,60,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,30.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE 16"" UNIVERSAL 7088-04",120.22,CDM,274,RC,L1830,HCPCS,,589-MAIN,LOCAL,,,,,60,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,30.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
IMMOBILIZER KNEE 20 INCH ORT2420019,120.22,CDM,274,RC,L1830,HCPCS,,587-MAIN,LOCAL,,,,,60,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,30.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE 20"" LARGE FOAM COUNTOURED STAYS 7062-03",120.22,CDM,274,RC,L1830,HCPCS,,593-MAIN,LOCAL,,,,,60,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,30.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE 20"" QUICK-WRAP ORT2440020S",120.22,CDM,274,RC,L1830,HCPCS,,591-MAIN,LOCAL,,,,,60,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,30.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
IMMOBILIZER KNEE CUTAWAY STRAIGHT 2 7041-05,120.22,CDM,274,RC,L1830,HCPCS,,596-MAIN,LOCAL,,,,,60,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,30.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057811,NDC,0.5,ML,30.98,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,30.3604,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057841,NDC,0.5,ML,30.98,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,30.3604,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
hydrocortisone 2.5 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,168008031,NDC,30,GR,61.99,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,30.3751,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 2.5 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,168008031,NDC,30,GR,61.99,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,30.3751,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 2.5 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,168008031,NDC,30,GR,61.99,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,30.3751,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,45802011222,NDC,22,GR,63.29,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,30.3792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,45802011222,NDC,22,GR,63.29,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,30.3792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
DRAPE ABDOMINAL SURGICAL 14X12 POUCHES STERILE DYNJP3109,27200000,CDM,272,RC,,,,12896-MAIN,LOCAL,,,,,31,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,30.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LITHOTOMY PACK VIII ECLIPSE,27200000,CDM,272,RC,,,,12210-MAIN,LOCAL,,,,,31,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,30.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Rubella Antibody,PX86762,CDM,300,RC,86762,CPT,,,,,,,,31,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,30.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.8774,30.38
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120301,NDC,0.5,ML,34.45,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,30.3849,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120311,NDC,0.5,ML,34.45,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,30.3849,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
APLIGRAF LIVING BI-LAYERED SKIN SUBSTITUTE,120.514,CDM,278,RC,Q4101,HCPCS,,12082-MAIN,LOCAL,,,,,2569,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,30.4,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.07895,30.62
APLIGRAF LIVING BI-LAYERED SKIN SUBSTITUTE,120.514,CDM,278,RC,Q4101,HCPCS,,12082-MAIN,LOCAL,,,,,2569,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,30.4,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.07895,30.62
riTUXimab-abbs 500 MG/50ML Solution 50 mL Vial,Q5115.01,CDM,636,RC,Q5115,HCPCS,,,,63459010450,NDC,50,ML,8624.61,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,30.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.4,35.89
riTUXimab-abbs 500 MG/50ML Solution 50 mL Vial,Q5115.01,CDM,636,RC,Q5115,HCPCS,,,,63459010450,NDC,50,ML,8624.61,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,30.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.4,35.89
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046203,NDC,30,ML,70.91,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,30.42039,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
OLANZapine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60505311000,NDC,1,EA,60.13,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,30.42578,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
riTUXimab-abbs 500 MG/50ML Solution 50 mL Vial,Q5115.01,CDM,636,RC,Q5115,HCPCS,,,,63459010450,NDC,50,ML,8624.61,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,30.43282,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.4,35.89
Needle Insertion W/O Injection 1 or 2 Muscles,PX20560,CDM,420,RC,20560,CPT,,,,,,,,10,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,30.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.8073,53.27
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405F,CDM,510,RC,36405,CPT,,,,,,,,54,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,30.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.16,49.81
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405P,CDM,983,RC,36405,CPT,,,,,,,,36,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,30.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.16,49.81
Withdrawal of Arterial Blood,PX36600F,CDM,510,RC,36600,CPT,,,,,,,,250,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,30.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.16,56.73
TRAY SURGICAL PODIATRY II EXTREMITY DYNJS0803,27200000,CDM,272,RC,,,,10920-MAIN,LOCAL,,,,,73.29,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,30.444666,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608210,NDC,1,ML,63.43,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,30.4464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608210,NDC,1,ML,63.43,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,30.4464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
Gabapentin - Ref,PX8017190,CDM,300,RC,80171,CPT,90,,,,,,,71,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,30.459,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.87,69.58
Histoplasma Antibody - Ref,PX8669890,CDM,300,RC,86698,CPT,90,,,,,,,71,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,30.459,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.64,69.58
Legionella Antibody - Ref,PX8671390,CDM,300,RC,86713,CPT,90,,,,,,,71,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,30.459,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.03,69.58
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,16714001905,NDC,2,ML,62.17,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,30.4633,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,16714001905,NDC,2,ML,62.17,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,30.4633,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,16714001905,NDC,2,ML,62.17,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,30.4633,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,16714001930,NDC,2,ML,62.17,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,30.4633,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,16714001930,NDC,2,ML,62.17,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,30.4633,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,16714001930,NDC,2,ML,62.17,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,30.4633,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,63739005007,NDC,1,EA,73.35,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,30.46959,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016501,NDC,1,ML,34.55,,United Healthcare,All Payer,outpatient,88.2,,23.48,percent of total billed charges,30.4731,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049226,NDC,30,ML,34.55,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,30.4731,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049245,NDC,30,ML,34.55,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,30.4731,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,23155024031,NDC,2,ML,34.55,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,30.4731,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.859
saliva substitute Solution 59 mL Bottle,63700001,CDM,250,RC,,,,,,50930009802,NDC,59,ML,31.1,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,30.478,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BINDER ABDOMINAL 9 INCH 46 TO 62 INCH XL ORT21100LXL,120.238,CDM,271,RC,A4467,HCPCS,,2989-MAIN,LOCAL,,,,,75,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,30.48,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.48,30.48
BINDER ABDOMINAL 9 INCH 63 TO 74 INCH 3- PANEL ORT211002XL,120.238,CDM,271,RC,A4467,HCPCS,,37-MAIN,LOCAL,,,,,75,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,30.48,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.48,30.48
BINDER ABDOMINAL 10 INCH 26 TO 50 INCHES ABB1050,120.238,CDM,271,RC,A4467,HCPCS,,52-MAIN,LOCAL,,,,,75,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,30.48,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.48,30.48
"BINDER ABDOMINAL 12"" HIGH 2XL 60-75INCH 4 PANEL ORT213002XL",120.238,CDM,271,RC,A4467,HCPCS,,12536-MAIN,LOCAL,,,,,75,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,30.48,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.48,30.48
"BINDER ABDOMINAL 12"" HIGH 30-45INCH 4 PANEL ORT21300SM",120.238,CDM,271,RC,A4467,HCPCS,,11934-MAIN,LOCAL,,,,,16,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,30.48,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.48,30.48
"BINDER ABDOMINAL 12"" HIGH 46 TO 62 INCH L/XL 4 PANEL ORT21300LXL",120.238,CDM,271,RC,A4467,HCPCS,,11935-MAIN,LOCAL,,,,,18,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,30.48,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.48,30.48
BINDER ABDOMINAL S/M 9 INCH UP TO 45 INCHES TRI-PANNEL ABB3P45,120.238,CDM,271,RC,A4467,HCPCS,,47-MAIN,LOCAL,,,,,34,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,30.48,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.48,30.48
BINDER ABDOMINAL UNISIZE 46-62IN 9 IN MDS169024,120.238,CDM,271,RC,A4467,HCPCS,,63-MAIN,LOCAL,,,,,75,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,30.48,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.48,30.48
BINDER PELVIC ADULT STABILIZATION T-PODR,120.357,CDM,271,RC,A4467,HCPCS,,10734-MAIN,LOCAL,,,,,244,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,30.48,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.48,30.48
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,409677802,NDC,1,ML,31.11,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,30.4878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026994,NDC,20,ML,35.87,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.4895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
"N Block Inj, Plantar Digit",PX64455F,CDM,510,RC,64455,CPT,,,,,,,,385,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,30.5045,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.72,103.77
"N Block Inj, Plantar Digit",PX64455P,CDM,983,RC,64455,CPT,,,,,,,,385,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,30.5045,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.72,377.3
"CUFF STERILE DISPOSABLE SPSB  STERILE 18""",27200000,CDM,272,RC,,,,7436-MAIN,LOCAL,,,,,35.89,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.5065,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
methotrexate 2.5 MG Tablet 20 Each Box,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067005,NDC,1,EA,33.49,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,30.50939,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.911746,32.8398
mepolizumab 100 MG Recon Soln 1 Each Vial,J2182.01,CDM,636,RC,J2182,HCPCS,,,,173088101,NDC,1,EA,6959.95,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,30.51,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.56,30.51
methotrexate 2.5 MG Tablet 1 Each Blister,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067001,NDC,1,EA,33.51,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,30.52761,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.911746,32.8398
Apply Lower Leg Splint,PX29515F,CDM,510,RC,29515,CPT,,,,,,,,296,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,30.54,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.54,152.89
Apply Lower Leg Splint,PX29515P,CDM,983,RC,29515,CPT,,,,,,,,311,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,30.54,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.54,304.78
Injection for Shoulder Arthrogram,PX23350F,CDM,510,RC,23350,CPT,,,,,,,,675,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,30.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.54,335.52
Injection for Shoulder Arthrogram,PX23350F,CDM,510,RC,23350,CPT,,,,,,,,675,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,30.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.54,335.52
Lvl 1 Sub Hosp Low Mdm or 25 Minutes,PX99231,CDM,982,RC,99231,CPT,,,,,,,,133,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,30.55,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.55,130.34
triamcinolone acetonide 40 MG/ML Suspension 1 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029305,NDC,1,ML,73.57,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,30.560978,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,72.0986
"COLLAR CERVICAL 2"" SMALL UNIVERSAL 08140039",120.249,CDM,274,RC,L0120,HCPCS,,270-MAIN,LOCAL,,,,,101,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,30.5615,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.56,31.12
"COLLAR CERVICAL 2X20"" SMALL 1003-02",120.249,CDM,274,RC,L0120,HCPCS,,272-MAIN,LOCAL,,,,,101,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,30.5615,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.56,31.12
"COLLAR CERVICAL 2X23.5"" MEDIUM XNARROW 1003-04",120.249,CDM,274,RC,L0120,HCPCS,,273-MAIN,LOCAL,,,,,101,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,30.5615,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.56,31.12
"COLLAR CERVICAL 10-15"" SMALL XLONG 1005-06",120.249,CDM,274,RC,L0120,HCPCS,,267-MAIN,LOCAL,,,,,101,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,30.5615,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.56,31.12
"COLLAR CERVICAL LARGE 21.5""X5"" 1005-04",120.249,CDM,274,RC,L0120,HCPCS,,268-MAIN,LOCAL,,,,,101,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,30.5615,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.56,31.12
"COLLAR CERVICAL MEDIUM 20-1/2X4"" 1005-03",120.249,CDM,274,RC,L0120,HCPCS,,269-MAIN,LOCAL,,,,,101,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,30.5615,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.56,31.12
COLLAR CERVICAL SMALL 1005-02,120.249,CDM,274,RC,L0120,HCPCS,,266-MAIN,LOCAL,,,,,101,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,30.5615,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.56,31.12
nivolumab 40 MG/4ML Solution 4 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377211,NDC,4,ML,2171.7,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,30.5615,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.35,32.64
nivolumab 100 MG/10ML Solution 10 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377412,NDC,10,ML,5429.27,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,30.5615,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.35,32.64
nivolumab 240 MG/24ML Solution 24 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3373413,NDC,24,ML,13030.26,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,30.5615,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.35,32.64
budesonide 0.5 MG/2ML Suspension 2 mL Ampule,25000000,CDM,250,RC,,,,,,68180098405,NDC,2,ML,62.38,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,30.5662,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Ampule,25000000,CDM,250,RC,,,,,,68180098405,NDC,2,ML,62.38,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,30.5662,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Ampule,25000000,CDM,250,RC,,,,,,68180098405,NDC,2,ML,62.38,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,30.5662,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,781751614,NDC,2,ML,62.38,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,30.5662,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,781751614,NDC,2,ML,62.38,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,30.5662,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,781751614,NDC,2,ML,62.38,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,30.5662,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,781751687,NDC,2,ML,62.38,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,30.5662,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,781751687,NDC,2,ML,62.38,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,30.5662,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,781751687,NDC,2,ML,62.38,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,30.5662,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097031986,NDC,2,ML,62.38,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,30.5662,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097031986,NDC,2,ML,62.38,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,30.5662,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097031986,NDC,2,ML,62.38,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,30.5662,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
US Ext Non-Vasc Img Lmtd,PX7688201,CDM,402,RC,76882,CPT,TC,,,,,,,425,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,30.571,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.5,61.14
"X-Ray Exam Hip,Bilat W/Pelvis 2 Vws",PX7352101,CDM,320,RC,73521,CPT,TC,,,,,,,399,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,30.571,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.28,60.48
morphine 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574711212,NDC,1,EA,33.56,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,30.57316,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
valACYclovir 1 GM Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069701,NDC,0.5,EA,33.58,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,30.59138,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093102,NDC,1,ML,60.47,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,30.59782,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
Anes Dx Shoulder Arthroscopy,PX01622.01,CDM,964,RC,1622,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Lower Intestinal Endoscopic Px Nos,PX00811.01,CDM,964,RC,811,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Lower Intestinal Screening Colonoscopy,PX00812.01,CDM,964,RC,812,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Spine Transthor W/Vent,PX00626.01,CDM,964,RC,626,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Spine Tranthor W/O Vent,PX00625.01,CDM,964,RC,625,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Ther Interven Rad Art,PX01924.01,CDM,964,RC,1924,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Ther Interven Rad Car,PX01925.01,CDM,964,RC,1925,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Ther Interven Rad Tip,PX01931.01,CDM,964,RC,1931,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Ther Interven Rad Vei,PX01930.01,CDM,964,RC,1930,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Tx Interv Rad Cran V,PX01933.01,CDM,964,RC,1933,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Tx Interv Rad Hrt/Cran,PX01926.01,CDM,964,RC,1926,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Tx Interv Rad Th Vein,PX01932.01,CDM,964,RC,1932,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Upper GI Endoscopic Px Ercp,PX00732.01,CDM,964,RC,732,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Upper GI Endoscopic Px Nos,PX00731.01,CDM,964,RC,731,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Upper/Lower GI Endoscopic Px,PX00813.01,CDM,964,RC,813,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes/Analg Cs Deliver Add-On,PX01968.01,CDM,964,RC,1968,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Abdomen Vessel Surg,PX00880.01,CDM,964,RC,880,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Abdominal Wall Surg,PX00700.01,CDM,964,RC,700,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Abdominal Wall Surg,PX00730.01,CDM,964,RC,730,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Abdominal Wall Surg,PX00800.01,CDM,964,RC,800,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Abdominal Wall Surg,PX00820.01,CDM,964,RC,820,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Achilles Tendon Surg,PX01472.01,CDM,964,RC,1472,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Airplane Cast,PX01682.01,CDM,964,RC,1682,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Amniocentesis,PX00842.01,CDM,964,RC,842,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Amputation at Knee,PX01404.01,CDM,964,RC,1404,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Amputation at Pelvis,PX01140.01,CDM,964,RC,1140,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Amputation of Femur,PX01232.01,CDM,964,RC,1232,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Amputation of Penis,PX00932.01,CDM,964,RC,932,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Ankle Replacement,PX01486.01,CDM,964,RC,1486,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Ankle/Ft Arthroscopy,PX01464.01,CDM,964,RC,1464,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Anorectal Surgery,PX00902.01,CDM,964,RC,902,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Antepartum Manipul,PX01958.01,CDM,964,RC,1958,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Arm-Leg Vessel Surg,PX01656.01,CDM,964,RC,1656,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Arthroscopy of Hip,PX01202.01,CDM,964,RC,1202,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Biceps Tendon Repair,PX01716.01,CDM,964,RC,1716,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Biopsy of Nose,PX00164.01,CDM,964,RC,164,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Biopsy of Thyroid,PX00322.01,CDM,964,RC,322,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Bladder Stone Surg,PX00870.01,CDM,964,RC,870,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Bladder Surgery,PX00910.01,CDM,964,RC,910,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Bladder Tumor Surg,PX00912.01,CDM,964,RC,912,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Bleeding Control,PX00916.01,CDM,964,RC,916,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Blepharoplasty,PX00103.01,CDM,964,RC,103,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Blood Vessel Repair,PX00770.01,CDM,964,RC,770,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Body Cast Procedure,PX01130.01,CDM,964,RC,1130,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Bone Aspirate/Bx,PX01112.01,CDM,964,RC,1112,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Burn 4-9 Percent,PX01952.01,CDM,964,RC,1952,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Burn Each 9 Percent,PX01953.01,CDM,964,RC,1953,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Burn Less 4 Percent,PX01951.01,CDM,964,RC,1951,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cabg W/O Pump,PX00566.01,CDM,964,RC,566,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cabg W/Pump,PX00567.01,CDM,964,RC,567,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cardiac Electrophys,PX00537.01,CDM,964,RC,537,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cardioverter/Defib,PX00534.01,CDM,964,RC,534,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cat or MRI Scan,PX01922.01,CDM,964,RC,1922,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Catheterize Heart,PX01920.01,CDM,964,RC,1920,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Drainage,PX00524.01,CDM,964,RC,524,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Lining Biopsy,PX00522.01,CDM,964,RC,522,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Partition View,PX00528.01,CDM,964,RC,528,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Partition View,PX00529.01,CDM,964,RC,529,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Procedure,PX00520.01,CDM,964,RC,520,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Surgery,PX00540.01,CDM,964,RC,540,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Wall Repair,PX00472.01,CDM,964,RC,472,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cleft Palate Repair,PX00172.01,CDM,964,RC,172,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Collar Bone Biopsy,PX00454.01,CDM,964,RC,454,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Corneal Transplant,PX00144.01,CDM,964,RC,144,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Correct Heart Rhythm,PX00410.01,CDM,964,RC,410,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cran Surg Hemotoma,PX00211.01,CDM,964,RC,211,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cranial Surg Nos,PX00210.01,CDM,964,RC,210,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cs Delivery,PX01961.01,CDM,964,RC,1961,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cs Hysterectomy,PX01963.01,CDM,964,RC,1963,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Dx Arteriography,PX01916.01,CDM,964,RC,1916,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Dx Elbow Arthroscopy,PX01732.01,CDM,964,RC,1732,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Dx Knee Arthroscopy,PX01382.01,CDM,964,RC,1382,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Dx Wrist Arthroscopy,PX01829.01,CDM,964,RC,1829,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Ear Exam,PX00124.01,CDM,964,RC,124,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Ear Surgery,PX00120.01,CDM,964,RC,120,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Elbow Area Surgery,PX01710.01,CDM,964,RC,1710,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Elbow Replacement,PX01760.01,CDM,964,RC,1760,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Electroshock,PX00104.01,CDM,964,RC,104,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Emer Hysterectomy,PX01962.01,CDM,964,RC,1962,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Esophageal Surgery,PX00500.01,CDM,964,RC,500,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Eye Exam,PX00148.01,CDM,964,RC,148,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Face/Skull Bone Surg,PX00190.01,CDM,964,RC,190,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Facial Bone Surgery,PX00192.01,CDM,964,RC,192,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Fat Layer Removal,PX00802.01,CDM,964,RC,802,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Femoral Artery Surg,PX01272.01,CDM,964,RC,1272,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Femoral Embolectomy,PX01274.01,CDM,964,RC,1274,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth for Chemonucleolysis,PX00634.01,CDM,964,RC,634,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth for Liver Biopsy,PX00702.01,CDM,964,RC,702,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth for Liver Transplant,PX00796.01,CDM,964,RC,796,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Forequarter Amput,PX01636.01,CDM,964,RC,1636,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Fx Repair Pelvis,PX01173.01,CDM,964,RC,1173,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Genitalia Surgery,PX00920.01,CDM,964,RC,920,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Head Nerve Surgery,PX00222.01,CDM,964,RC,222,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Head Vessel Surgery,PX00216.01,CDM,964,RC,216,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Head/Neck/Ptrunk,PX00300.01,CDM,964,RC,300,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Heart Surg < 1 Yr,PX00561.01,CDM,964,RC,561,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Heart Surg W/Arrest,PX00563.01,CDM,964,RC,563,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Heart Surg W/O Pump,PX00560.01,CDM,964,RC,560,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Heart/Lung Transplnt,PX00580.01,CDM,964,RC,580,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hemorr/Excise Liver,PX00792.01,CDM,964,RC,792,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hernia Repair < 1 Yr,PX00834.01,CDM,964,RC,834,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hernia Repair Preemie,PX00836.01,CDM,964,RC,836,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hip Arthroplasty,PX01214.01,CDM,964,RC,1214,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hip Disarticulation,PX01212.01,CDM,964,RC,1212,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hip Joint Procedure,PX01200.01,CDM,964,RC,1200,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hip Joint Surgery,PX01210.01,CDM,964,RC,1210,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hrt Surg W/Pmp Age 1+,PX00562.01,CDM,964,RC,562,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Humeral Lesion Surg,PX01758.01,CDM,964,RC,1758,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Humerus Repair,PX01744.01,CDM,964,RC,1744,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Humerus Surgery,PX01742.01,CDM,964,RC,1742,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hysterectomy,PX00846.01,CDM,964,RC,846,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hysteroscope/Graph,PX00952.01,CDM,964,RC,952,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Inc/Missed Ab Proc,PX01965.01,CDM,964,RC,1965,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Induced Ab Procedure,PX01966.01,CDM,964,RC,1966,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Insert Penis Device,PX00938.01,CDM,964,RC,938,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Intrcrn Nerve,PX00220.01,CDM,964,RC,220,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Iridectomy,PX00147.01,CDM,964,RC,147,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Kidney Stone Destruct,PX00872.01,CDM,964,RC,872,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Kidney Stone Destruct,PX00873.01,CDM,964,RC,873,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Kidney Transplant,PX00868.01,CDM,964,RC,868,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Kidney/Ureter Surg,PX00862.01,CDM,964,RC,862,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Area Procedure,PX01340.01,CDM,964,RC,1340,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Area Procedure,PX01390.01,CDM,964,RC,1390,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Area Surgery,PX01320.01,CDM,964,RC,1320,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Area Surgery,PX01360.01,CDM,964,RC,1360,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Area Surgery,PX01392.01,CDM,964,RC,1392,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Arteries Surg,PX01440.01,CDM,964,RC,1440,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Artery Repair,PX01444.01,CDM,964,RC,1444,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Artery Surg,PX01442.01,CDM,964,RC,1442,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Arthroplasty,PX01402.01,CDM,964,RC,1402,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Joint Casting,PX01420.01,CDM,964,RC,1420,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Joint Procedure,PX01380.01,CDM,964,RC,1380,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Joint Surgery,PX01400.01,CDM,964,RC,1400,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Veins Surgery,PX01430.01,CDM,964,RC,1430,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Vessel Surg,PX01432.01,CDM,964,RC,1432,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Larynx/Trach < 1 Yr,PX00326.01,CDM,964,RC,326,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Leg Arteries Surg,PX01500.01,CDM,964,RC,1500,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lens Surgery,PX00142.01,CDM,964,RC,142,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Low Intestine Scope,PX00810.01,CDM,964,RC,810,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Arm Casting,PX01860.01,CDM,964,RC,1860,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Arm Procedure,PX01820.01,CDM,964,RC,1820,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Arm Surgery,PX01810.01,CDM,964,RC,1810,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Arm Surgery,PX01830.01,CDM,964,RC,1830,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Arm Vein Surg,PX01850.01,CDM,964,RC,1850,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Bone Surg,PX01480.01,CDM,964,RC,1480,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Casting,PX01490.01,CDM,964,RC,1490,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Procedure,PX01462.01,CDM,964,RC,1462,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Revision,PX01484.01,CDM,964,RC,1484,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Surgery,PX01470.01,CDM,964,RC,1470,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Surgery,PX01474.01,CDM,964,RC,1474,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Vein Surg,PX01520.01,CDM,964,RC,1520,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Vein Surg,PX01522.01,CDM,964,RC,1522,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lumbar Puncture,PX00635.01,CDM,964,RC,635,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lung Chest Wall Surg,PX00546.01,CDM,964,RC,546,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lwr Arm Artery Surg,PX01840.01,CDM,964,RC,1840,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lwr Arm Embolectomy,PX01842.01,CDM,964,RC,1842,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lwr Arm Vein Repair,PX01852.01,CDM,964,RC,1852,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lwr Leg Embolectomy,PX01502.01,CDM,964,RC,1502,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Major Vein Ligation,PX00882.01,CDM,964,RC,882,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth N Block/Inj Prone,PX01992.01,CDM,964,RC,1992,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Neck Organ 1 & Over,PX00320.01,CDM,964,RC,320,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Neck Vessel Surgery,PX00350.01,CDM,964,RC,350,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Neck Vessel Surgery,PX00352.01,CDM,964,RC,352,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Nerve Block/Inj,PX01991.01,CDM,964,RC,1991,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Nose/Sinus Surgery,PX00160.01,CDM,964,RC,160,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Nose/Sinus Surgery,PX00162.01,CDM,964,RC,162,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth One Lung Ventilation,PX00541.01,CDM,964,RC,541,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pacemaker Insertion,PX00530.01,CDM,964,RC,530,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pancreas Removal,PX00794.01,CDM,964,RC,794,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvic Organ Surg,PX00848.01,CDM,964,RC,848,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvic Tumor Surgery,PX01150.01,CDM,964,RC,1150,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvis Nerve Removal,PX01180.01,CDM,964,RC,1180,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvis Nerve Removal,PX01190.01,CDM,964,RC,1190,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvis Procedure,PX01160.01,CDM,964,RC,1160,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvis Surgery,PX00844.01,CDM,964,RC,844,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvis Surgery,PX01120.01,CDM,964,RC,1120,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvis Surgery,PX01170.01,CDM,964,RC,1170,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Penis Nodes Removal,PX00934.01,CDM,964,RC,934,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Penis Nodes Removal,PX00936.01,CDM,964,RC,936,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Perc Img Dx Sp Proc,PX01935.01,CDM,964,RC,1935,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Perc Img Tx Sp Proc,PX01936.01,CDM,964,RC,1936,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Perineal Surgery,PX00904.01,CDM,964,RC,904,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pharyngeal Surgery,PX00174.01,CDM,964,RC,174,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pharyngeal Surgery,PX00176.01,CDM,964,RC,176,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Procedure on Femur,PX01220.01,CDM,964,RC,1220,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Procedure on Mouth,PX00170.01,CDM,964,RC,170,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Procedures on Eye,PX00140.01,CDM,964,RC,140,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Radical Femur Surg,PX01234.01,CDM,964,RC,1234,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Radical Humerus Surg,PX01756.01,CDM,964,RC,1756,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Radical Leg Surgery,PX01482.01,CDM,964,RC,1482,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Release of Lung,PX00542.01,CDM,964,RC,542,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Adrenal,PX00866.01,CDM,964,RC,866,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Bladder,PX00864.01,CDM,964,RC,864,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Nerves,PX00622.01,CDM,964,RC,622,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Nerves,PX00632.01,CDM,964,RC,632,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Prostate,PX00865.01,CDM,964,RC,865,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Prostate,PX00908.01,CDM,964,RC,908,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Rib,PX00470.01,CDM,964,RC,470,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Testis,PX00926.01,CDM,964,RC,926,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Testis,PX00928.01,CDM,964,RC,928,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Vulva,PX00906.01,CDM,964,RC,906,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Cervix,PX00948.01,CDM,964,RC,948,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Cleft Lip,PX00102.01,CDM,964,RC,102,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Hernia,PX00750.01,CDM,964,RC,750,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Hernia,PX00752.01,CDM,964,RC,752,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Hernia,PX00754.01,CDM,964,RC,754,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Hernia,PX00756.01,CDM,964,RC,756,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Hernia,PX00830.01,CDM,964,RC,830,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Hernia,PX00832.01,CDM,964,RC,832,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Revise Hip Repair,PX01215.01,CDM,964,RC,1215,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Salivary Gland,PX00100.01,CDM,964,RC,100,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Artery Surg,PX01650.01,CDM,964,RC,1650,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Casting,PX01680.01,CDM,964,RC,1680,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Joint Amput,PX01634.01,CDM,964,RC,1634,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Procedure,PX01620.01,CDM,964,RC,1620,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Replacement,PX01638.01,CDM,964,RC,1638,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Vein Surg,PX01670.01,CDM,964,RC,1670,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Vessel Surg,PX01652.01,CDM,964,RC,1652,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Vessel Surg,PX01654.01,CDM,964,RC,1654,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Sitting Procedure,PX00604.01,CDM,964,RC,604,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Skin Ext/per/Atrunk,PX00400.01,CDM,964,RC,400,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Skull Drainage,PX00212.01,CDM,964,RC,212,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Skull Drainage,PX00214.01,CDM,964,RC,214,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Skull Repair/Fract,PX00215.01,CDM,964,RC,215,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Special Head Surgery,PX00218.01,CDM,964,RC,218,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Sperm Duct Surgery,PX00922.01,CDM,964,RC,922,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Spine Cord Surgery,PX00600.01,CDM,964,RC,600,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Spine Cord Surgery,PX00620.01,CDM,964,RC,620,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Spine Cord Surgery,PX00630.01,CDM,964,RC,630,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Spine Cord Surgery,PX00670.01,CDM,964,RC,670,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Spine Manipulation,PX00640.01,CDM,964,RC,640,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Sternal Debridement,PX00550.01,CDM,964,RC,550,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Stone Removal,PX00918.01,CDM,964,RC,918,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surg Lower Abdomen,PX00840.01,CDM,964,RC,840,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surg on Vag/Urethral,PX00942.01,CDM,964,RC,942,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surg Upper Abdomen,PX00790.01,CDM,964,RC,790,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery for Obesity,PX00797.01,CDM,964,RC,797,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Abdomen,PX00860.01,CDM,964,RC,860,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Breast,PX00402.01,CDM,964,RC,402,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Breast,PX00404.01,CDM,964,RC,404,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Breast,PX00406.01,CDM,964,RC,406,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Femur,PX01230.01,CDM,964,RC,1230,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Rib(S),PX00474.01,CDM,964,RC,474,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Shoulder,PX00450.01,CDM,964,RC,450,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Shoulder,PX00452.01,CDM,964,RC,452,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Shoulder,PX01610.01,CDM,964,RC,1610,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Shoulder,PX01630.01,CDM,964,RC,1630,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Testis Exploration,PX00924.01,CDM,964,RC,924,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Testis Suspension,PX00930.01,CDM,964,RC,930,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Thigh Arteries Surg,PX01270.01,CDM,964,RC,1270,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Trach-Bronch Reconst,PX00539.01,CDM,964,RC,539,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Trachea Bronchi Surg,PX00548.01,CDM,964,RC,548,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Trans Resect of Prostate,PX00914.01,CDM,964,RC,914,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Tubal Ligation,PX00851.01,CDM,964,RC,851,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Tympanotomy,PX00126.01,CDM,964,RC,126,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Upper Arm Surgery,PX01740.01,CDM,964,RC,1740,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Upper Arm Vein Surg,PX01780.01,CDM,964,RC,1780,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Upper GI Visualize,PX00740.01,CDM,964,RC,740,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Upper Leg Surgery,PX01250.01,CDM,964,RC,1250,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Upper Leg Veins Surg,PX01260.01,CDM,964,RC,1260,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Uppr Arm Artery Surg,PX01770.01,CDM,964,RC,1770,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Uppr Arm Embolectomy,PX01772.01,CDM,964,RC,1772,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Uppr Arm Procedure,PX01730.01,CDM,964,RC,1730,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Uppr Arm Tendon Surg,PX01712.01,CDM,964,RC,1712,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Uppr Arm Tendon Surg,PX01714.01,CDM,964,RC,1714,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Uppr Arm Vein Repair,PX01782.01,CDM,964,RC,1782,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vaginal Delivery,PX01960.01,CDM,964,RC,1960,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vaginal Endoscopy,PX00950.01,CDM,964,RC,950,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vaginal Hysterectomy,PX00944.01,CDM,964,RC,944,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vaginal Procedures,PX00940.01,CDM,964,RC,940,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vascular Access,PX00532.01,CDM,964,RC,532,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vascular Shunt Surg,PX01844.01,CDM,964,RC,1844,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vasectomy,PX00921.01,CDM,964,RC,921,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vitreoretinal Surg,PX00145.01,CDM,964,RC,145,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Wrist Replacement,PX01832.01,CDM,964,RC,1832,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth/Analg Cs Hyst Add-On,PX01969.01,CDM,964,RC,1969,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth/Analg Vag Delivery,PX01967.01,CDM,964,RC,1967,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Hosp Manage Cont Drug Admin,PX01996.01,CDM,964,RC,1996,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
IMMOBILIZER SHOULDER LARGE 9008-03,120.38,CDM,274,RC,L3650,HCPCS,,906-MAIN,LOCAL,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER LARGE STRAP OSG3033,120.38,CDM,274,RC,L3650,HCPCS,,2910-MAIN,LOCAL,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER MEDIUM 9008-02,120.38,CDM,274,RC,L3650,HCPCS,,912-MAIN,LOCAL,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER MEDIUM OSG3032,120.38,CDM,274,RC,L3650,HCPCS,,915-MAIN,LOCAL,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER SMALL 9008-01,120.38,CDM,274,RC,L3650,HCPCS,,913-MAIN,LOCAL,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER SMALL WITH CLOTH 9001-02,120.38,CDM,274,RC,L3650,HCPCS,,914-MAIN,LOCAL,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER X-LARGE CLOTH 9001-05,120.38,CDM,274,RC,L3650,HCPCS,,917-MAIN,LOCAL,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER X-LARGE ORT16100XL,120.38,CDM,274,RC,L3650,HCPCS,,904-MAIN,LOCAL,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
Support for Organ Donor,PX01990.01,CDM,964,RC,1990,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Treponema Pallidum,PX86780,CDM,300,RC,86780,CPT,,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.14,35.28
Unlisted Anesth Procedure,PX01999.01,CDM,964,RC,1999,CPT,QZ,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405P,CDM,983,RC,36405,CPT,,,,,,,,36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
valproate 100 MG/ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049416,NDC,5,ML,33.61,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,30.61871,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
valproate 100 MG/ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049441,NDC,5,ML,33.61,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,30.61871,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
APLIGRAF LIVING BI-LAYERED SKIN SUBSTITUTE,120.514,CDM,278,RC,Q4101,HCPCS,,12082-MAIN,LOCAL,,,,,2569,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,30.62,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.07895,30.62
APLIGRAF LIVING BI-LAYERED SKIN SUBSTITUTE,120.514,CDM,278,RC,Q4101,HCPCS,,12082-MAIN,LOCAL,,,,,2569,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,30.62,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.07895,30.62
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006401,NDC,2,ML,31.46,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,14.23621053,percent of total billed charges,30.620018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
magnesium sulfate 4 GM/50ML Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010701,NDC,50,ML,73.72,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,30.623288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,641601301,NDC,5,ML,34.41,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,30.6249,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Wheelchair Mngement Training,PX97542,CDM,420,RC,97542,CPT,,,,,,,,145,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,30.628,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.84,41.73
famciclovir 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714030401,NDC,1,EA,34.42,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,30.6338,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,43598040516,NDC,0.2,ML,63.83,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,30.6384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,43598040516,NDC,0.2,ML,63.83,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,30.6384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310001,NDC,0.528,ML,785.14,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,30.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29,32.96
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310001,NDC,0.528,ML,785.14,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,30.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29,32.96
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310002,NDC,0.528,ML,894.9,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,30.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29,32.96
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310002,NDC,0.528,ML,894.9,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,30.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29,32.96
lidocaine 1% PF 1 % Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,63323049227,NDC,2,ML,34.74,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,30.64068,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
apixaban 2.5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,3089321,NDC,1,EA,63.84,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,30.6432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
apixaban 2.5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,3089321,NDC,1,EA,63.84,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,30.6432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
anastrozole 1 MG Tablet 30 Each Bottle,25000000,CDM,250,RC,,,,,,16729003510,NDC,1,EA,71.44,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,30.64776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120301,NDC,0.5,ML,34.45,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,30.6605,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120311,NDC,0.5,ML,34.45,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,30.6605,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
caffeine citrate 60 MG/3ML Solution 3 mL Vial,J0706.01,CDM,636,RC,J0706,HCPCS,,,,63323040704,NDC,3,ML,73.84,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,30.673136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.673136,72.3632
sacubitril-valsartan 24-26 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,78065920,NDC,1,EA,62.6,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,30.674,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sacubitril-valsartan 24-26 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,78065920,NDC,1,EA,62.6,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,30.674,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sacubitril-valsartan 24-26 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,78065920,NDC,1,EA,62.6,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,30.674,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049236,NDC,5,ML,31.52,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,30.678416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049243,NDC,5,ML,31.52,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,30.678416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,409508411,NDC,1,EA,73.86,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,30.681444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
LAP SPONGES 18x18 7INCH LOOP,27200000,CDM,272,RC,,,,604-MAIN,LOCAL,,,,,60.64,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,30.68384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
hydrocortisone 2.5 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,168008031,NDC,30,GR,61.99,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,30.68505,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,67457043800,NDC,0.5,EA,36.11,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6935,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,67457043810,NDC,0.5,EA,36.11,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.6935,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ezetimibe 10 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,16729043316,NDC,1,EA,60.66,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,30.69396,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atropine (PF) 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517040125,NDC,1,ML,71.55,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,30.69495,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
tetracaine 0.5 % Solution 4 mL Plas Cont,25000000,CDM,250,RC,,,,,,65074114,NDC,4,ML,71.55,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,30.69495,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028036,NDC,2,ML,36.12,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.702,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
miconazole 2 % Powder 71 g Bottle,25000000,CDM,250,RC,,,,,,316023125,NDC,71,GR,34.82,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,30.71124,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323020103,NDC,10,ML,36.14,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.719,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Blood Occult Peroxidase,PX82272,CDM,300,RC,82272,CPT,,,,,,,,64,,Health Partners,Health Partners Care Plans,both,48,,29.67,percent of total billed charges,30.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.88,62.72
Blood Occult Peroxidase,PX82272,CDM,300,RC,82272,CPT,,,,,,,,64,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,30.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.88,62.72
Strapping of Elbow or Wrist,PX29260F,CDM,420,RC,29260,CPT,,,,,,,,64,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,30.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.5856,62.72
Strapping of Elbow or Wrist,PX29260F,CDM,420,RC,29260,CPT,,,,,,,,64,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,30.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.5856,62.72
Strapping of Hand or Finger,PX29280F,CDM,420,RC,29280,CPT,,,,,,,,64,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,30.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.5856,62.72
Strapping of Hand or Finger,PX29280F,CDM,420,RC,29280,CPT,,,,,,,,64,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,30.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.5856,62.72
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714078401,NDC,0.4,EA,60.72,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,30.72432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061601,NDC,3,ML,31.57,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,30.727081,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058003,NDC,0.5,ML,31.57,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1.253,percent of total billed charges,30.727081,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058020,NDC,0.5,ML,31.57,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1.253,percent of total billed charges,30.727081,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061416,NDC,0.5,ML,31.57,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,30.727081,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.114178,99.911
Glucose Test,PX82950,CDM,300,RC,82950,CPT,,,,,,,,74,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,30.7396,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.36,72.52
KIT EMERGENCY BIRTH DYNJS0600,120.317,CDM,272,RC,,,,8344-MAIN,LOCAL,,,,,74,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,30.7396,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.7396,72.52
Rubeola Antibody,PX86765,CDM,300,RC,86765,CPT,,,,,,,,74,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,30.7396,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.81,72.52
colchicine 0.6 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,49884017111,NDC,1,EA,36.17,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.7445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016501,NDC,1,ML,34.55,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,30.7495,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049226,NDC,30,ML,34.55,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,30.7495,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049245,NDC,30,ML,34.55,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,30.7495,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,23155024031,NDC,2,ML,34.55,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,30.7495,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.859
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990711509,NDC,1000,ML,64.08,,Health Partners,Health Partners Care Plans,both,48,,6.034333333,percent of total billed charges,30.7584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990711509,NDC,1000,ML,64.08,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,30.7584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006F,CDM,510,RC,10006,CPT,,,,,,,,213,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,30.76,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.76,124.52
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006P,CDM,983,RC,10006,CPT,,,,,,,,142,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,30.76,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.76,139.16
Injection for Shoulder Arthrogram,PX23350F,CDM,510,RC,23350,CPT,,,,,,,,675,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,30.76,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.54,335.52
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006F,CDM,510,RC,10006,CPT,,,,,,,,213,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,30.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.76,124.52
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006F,CDM,510,RC,10006,CPT,,,,,,,,213,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,30.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.76,124.52
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006P,CDM,983,RC,10006,CPT,,,,,,,,142,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,30.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.76,139.16
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006P,CDM,983,RC,10006,CPT,,,,,,,,142,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,30.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.76,139.16
"Inject Nerv Blck,Trigeminal",PX64400F,CDM,510,RC,64400,CPT,,,,,,,,255,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,30.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.1,236.6
"Inject Nerv Blck,Trigeminal",PX64400F,CDM,510,RC,64400,CPT,,,,,,,,255,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,30.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.1,236.6
"Inject Nerv Blck,Trigeminal",PX64400P,CDM,983,RC,64400,CPT,,,,,,,,170,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,30.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.1,236.6
"Inject Nerv Blck,Trigeminal",PX64400P,CDM,983,RC,64400,CPT,,,,,,,,170,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,30.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.1,236.6
sterile water (preservative free) Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409488724,NDC,50,ML,34.88,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,30.76416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409488750,NDC,50,ML,34.88,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,30.76416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987501,NDC,3,ML,33.77,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,30.76447,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,16714001905,NDC,2,ML,62.17,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,30.77415,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,16714001930,NDC,2,ML,62.17,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,30.77415,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409338513,NDC,1,EA,74.09,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,30.776986,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,13.86384615,percent of total billed charges,30.785479,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,13.86384615,percent of total billed charges,30.785479,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
hydrocortisone 2.5 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,45802000403,NDC,28,GR,60.85,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,30.7901,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457033900,NDC,1,EA,71.82,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,30.81078,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
Lab Imm Spin X-Match,PX8837,CDM,300,RC,86920,CPT,,,,,,,,402,,UCare,Individual and Family Plans,both,,,205.685,fee schedule,30.816,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.35,30.816
Lab Imm Spin X-Match,PX8837,CDM,300,RC,86920,CPT,,,,,,,,402,,UCare,Individual and Family Plans,both,,,205.685,fee schedule,30.816,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.35,30.816
sucralfate 1 GM/10ML Suspension 10 mL Cup,63700001,CDM,250,RC,,,,,,68094004359,NDC,10,ML,60.92,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,30.82552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Drain Blood From Under Nail,PX11740F,CDM,510,RC,11740,CPT,,,,,,,,117,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,30.8256,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.28,120.37
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006401,NDC,2,ML,31.46,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,30.8308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,60432006547,NDC,10,ML,34.98,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,30.85236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Clotting Function Activity - Ref,PX8539790,CDM,300,RC,85397,CPT,90,,,,,,,334,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,30.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.93,30.86
dexmedeTOMIDine 200 MCG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,143953201,NDC,2,ML,62.98,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,30.8602,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dexmedeTOMIDine 200 MCG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,143953201,NDC,2,ML,62.98,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,30.8602,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dexmedeTOMIDine 200 MCG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,143953201,NDC,2,ML,62.98,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,30.8602,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,17478081705,NDC,5,ML,34.99,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,30.86118,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022143,NDC,1,EA,36.31,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.8635,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
"Protoporphyrin, RBC, Qnt - Ref",PX8420290,CDM,300,RC,84202,CPT,90,,,,,,,61,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,30.866,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.16,59.78
"Venipuncture, Lab",PX3641502,CDM,300,RC,36415,CPT,,,,,,,,61,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,30.866,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.1,65.45
K-WIRE SMOOTH 1.4MM X 100MM,C1713,CDM,272,RC,C1713,HCPCS,,12634-MAIN,LOCAL,,,,,63,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,30.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
K-WIRE SMOOTH 1.4MM X 100MM,C1713,CDM,272,RC,C1713,HCPCS,,12634-MAIN,LOCAL,,,,,63,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,30.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
K-WIRE SMOOTH 1.4MM X 100MM,C1713,CDM,272,RC,C1713,HCPCS,,12634-MAIN,LOCAL,,,,,63,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,30.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209F,CDM,510,RC,69209,CPT,,,,,,,,35,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,30.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,53.44
SHOE POST OP X-LARGE MALE DS1016-16,120.237,CDM,274,RC,L3260,HCPCS,,6337-MAIN,LOCAL,,,,,35,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,30.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SUTURE MAXON MONOFILAMENT ABSORBABLE GREEN SIZE 1 96IN WITH 1/2 CIRCLE TAPER POINT 65MM NEEDLE,27200000,CDM,272,RC,,,,11986-MAIN,LOCAL,,,,,63,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,30.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE MAXON MONOFILAMENT ABSORBABLE GREEN SIZE 1 96IN WITH 1/2 CIRCLE TAPER POINT 65MM NEEDLE,27200000,CDM,272,RC,,,,11986-MAIN,LOCAL,,,,,63,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,30.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE MAXON MONOFILAMENT ABSORBABLE GREEN SIZE 1 96IN WITH 1/2 CIRCLE TAPER POINT 65MM NEEDLE,27200000,CDM,272,RC,,,,11986-MAIN,LOCAL,,,,,63,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,30.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Trimming of Dystrophic Nails, Any Number",PXG0127P,CDM,983,RC,G0127,HCPCS,,,,,,,,35,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,30.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,53.44
Vitamin a - Ref,PX8459090,CDM,300,RC,84590,CPT,90,,,,,,,63,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,30.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.65,61.74
Vitamin a - Ref,PX8459090,CDM,300,RC,84590,CPT,90,,,,,,,63,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,30.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.65,61.74
Vitamin a - Ref,PX8459090,CDM,300,RC,84590,CPT,90,,,,,,,63,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,30.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.65,61.74
lidocaine HCl 4 % Cream 76.5 g Tube,63700001,CDM,250,RC,,,,,,41167005820,NDC,76.5,GR,31.72,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,30.873076,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
budesonide 0.5 MG/2ML Suspension 2 mL Ampule,25000000,CDM,250,RC,,,,,,68180098405,NDC,2,ML,62.38,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,30.8781,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,781751614,NDC,2,ML,62.38,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,30.8781,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,781751687,NDC,2,ML,62.38,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,30.8781,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097031986,NDC,2,ML,62.38,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,30.8781,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022116,NDC,1,EA,36.33,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.8805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022141,NDC,1,EA,36.33,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.8805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
"B.Burgdorferi, Amp Probe - Ref",PX8747690,CDM,300,RC,87476,CPT,90,,,,,,,72,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,30.888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.9088,70.56
"Blood, Occult, Other Sources",PX82271,CDM,300,RC,82271,CPT,,,,,,,,72,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,30.888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.88,70.56
Epstein-barr antibody,PX86664,CDM,300,RC,86664,CPT,,,,,,,,72,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,30.888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.02,70.56
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049236,NDC,5,ML,31.52,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,30.8896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049243,NDC,5,ML,31.52,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,30.8896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048657,NDC,50,ML,61.05,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,30.8913,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,143950601,NDC,10,ML,61.1,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,30.9166,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,143950610,NDC,10,ML,61.1,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,30.9166,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,63323049227,NDC,2,ML,34.74,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,30.9186,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
KUMAR CHOLANGIOGRAPHY CATHETER,27200000,CDM,272,RC,,,,10230-MAIN,LOCAL,,,,,63.11,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,30.9239,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
KUMAR CHOLANGIOGRAPHY CATHETER,27200000,CDM,272,RC,,,,10230-MAIN,LOCAL,,,,,63.11,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,30.9239,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
KUMAR CHOLANGIOGRAPHY CATHETER,27200000,CDM,272,RC,,,,10230-MAIN,LOCAL,,,,,63.11,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,30.9239,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061601,NDC,3,ML,31.57,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,30.9386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058003,NDC,0.5,ML,31.57,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,30.9386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058020,NDC,0.5,ML,31.57,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,30.9386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061416,NDC,0.5,ML,31.57,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,30.9386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.114178,99.911
solifenacin 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50228042730,NDC,1,EA,74.52,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,30.955608,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305972,NDC,2,ML,61.19,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,30.96214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305995,NDC,2,ML,61.19,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,30.96214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
BINDER ABDOMINAL S/M 9 INCH UP TO 45 INCHES TRI-PANNEL ABB3P45,120.238,CDM,271,RC,A4467,HCPCS,,47-MAIN,LOCAL,,,,,34,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,30.974,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,30.974,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,30.974,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
"Lab Ige, Isocyan Hdi",PX86003,CDM,300,RC,86003,CPT,90,,,,,,,34,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,30.974,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.79,33.32
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323020110,NDC,10,ML,34,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,30.974,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Metanephrines - Ref,PX8383590,CDM,300,RC,83835,CPT,90,,,,,,,34,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,30.974,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1236,33.32
SPLINT SAM 36INCH ROLLED 661121,120.362,CDM,271,RC,,,,10789-MAIN,LOCAL,,,,,34,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,30.974,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1236,33.32
"Venipunc Need Phys Skill,Dx or Rx",PX36410F,CDM,510,RC,36410,CPT,,,,,,,,34,,Medica,Commercial,both,91.1,,14.27,percent of total billed charges,30.974,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1236,33.32
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,63323004401,NDC,1,ML,64.53,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,30.9744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,63.2394
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,63323004401,NDC,1,ML,64.53,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,30.9744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,63.2394
sacubitril-valsartan 24-26 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,78065920,NDC,1,EA,62.6,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,30.987,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
miconazole 2 % Powder 71 g Bottle,25000000,CDM,250,RC,,,,,,316023125,NDC,71,GR,34.82,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,30.9898,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
riTUXimab-abbs 500 MG/50ML Solution 50 mL Vial,Q5115.01,CDM,636,RC,Q5115,HCPCS,,,,63459010450,NDC,50,ML,8624.61,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,30.99,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.4,35.89
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,30.9974,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,30.9974,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43598055530,NDC,0.4,EA,61.26,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,30.99756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43598096630,NDC,0.4,EA,61.26,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,30.99756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,487960130,NDC,2,ML,36.47,,First Health,Commercial,both,85,,999999999,percent of total billed charges,30.9995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,45802011222,NDC,22,GR,63.29,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,31.0121,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,45802011222,NDC,22,GR,63.29,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,31.0121,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,45802011222,NDC,22,GR,63.29,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,31.0121,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
TRAY HAND SURGICAL II DYNJS0806,27200000,CDM,272,RC,,,,11024-MAIN,LOCAL,,,,,64.62,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,31.0176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TRAY HAND SURGICAL II DYNJS0806,27200000,CDM,272,RC,,,,11024-MAIN,LOCAL,,,,,64.62,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,31.0176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
tropicamide 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,24208058559,NDC,2,ML,61.3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,31.0178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Level III - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3933,CDM,310,RC,88304,CPT,TC,,,,,,,66,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,31.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.02,52.096
"Level III - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3933,CDM,310,RC,88304,CPT,TC,,,,,,,66,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,31.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.02,52.096
"Level III - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3933,CDM,310,RC,88304,CPT,TC,,,,,,,66,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,31.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.02,52.096
levoFLOXacin in dextrose 5% 500 MG/100ML Solution 100 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004724,NDC,100,ML,64.63,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,31.0224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
levoFLOXacin in dextrose 5% 500 MG/100ML Solution 100 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004724,NDC,100,ML,64.63,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,31.0224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,76329339001,NDC,5,ML,64.63,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,31.0224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,76329339001,NDC,5,ML,64.63,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,31.0224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
sterile water (preservative free) Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409488724,NDC,50,ML,34.88,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,31.0432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409488750,NDC,50,ML,34.88,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,31.0432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"pediatric electrolyte Solution 1,000 mL Bottle",25000000,CDM,250,RC,,,,,,49348057041,NDC,1000,ML,31.9,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,31.04827,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,409710709,NDC,1000,ML,36.53,,First Health,Commercial,both,85,,999999999,percent of total billed charges,31.0505,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5% and sodium chloride 0.45% with potassium chloride 10 mEq in 1000 mL 10-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,264763400,NDC,1000,ML,36.53,,First Health,Commercial,both,85,,999999999,percent of total billed charges,31.0505,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
RETRIEVAL BAG 10MM,27200000,CDM,272,RC,,,,11707-MAIN,LOCAL,,,,,74.8,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,31.07192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409317801,NDC,20,ML,34.11,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,31.07421,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409317816,NDC,20,ML,34.11,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,31.07421,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189001,NDC,1,ML,34.11,,Medica,Commercial,both,91.1,,7.3275,percent of total billed charges,31.07421,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189003,NDC,1,ML,34.11,,Medica,Commercial,both,91.1,,7.3275,percent of total billed charges,31.07421,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
levOCARNitine 200 MG/ML Solution 5 mL Vial,J1955.01,CDM,636,RC,J1955,HCPCS,,,,517104501,NDC,5,ML,249.86,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,31.08,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.08,35.32
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608210,NDC,1,ML,63.43,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,9.513809524,percent of total billed charges,31.0807,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608210,NDC,1,ML,63.43,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,31.0807,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608210,NDC,1,ML,63.43,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,31.0807,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,17478070311,NDC,10,ML,72.46,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,31.08534,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine HCl 4 % Cream 76.5 g Tube,63700001,CDM,250,RC,,,,,,41167005820,NDC,76.5,GR,31.72,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,31.0856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nivolumab 40 MG/4ML Solution 4 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377211,NDC,4,ML,2171.7,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,31.09,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.35,32.64
nivolumab 40 MG/4ML Solution 4 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377211,NDC,4,ML,2171.7,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,31.09,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.35,32.64
nivolumab 100 MG/10ML Solution 10 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377412,NDC,10,ML,5429.27,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,31.09,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.35,32.64
nivolumab 100 MG/10ML Solution 10 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377412,NDC,10,ML,5429.27,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,31.09,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.35,32.64
nivolumab 240 MG/24ML Solution 24 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3373413,NDC,24,ML,13030.26,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,31.09,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.35,32.64
nivolumab 240 MG/24ML Solution 24 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3373413,NDC,24,ML,13030.26,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,31.09,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.35,32.64
"Flow Interp,2-8 Markers - Ref",PX8818790,CDM,310,RC,88187,CPT,90,,,,,,,162,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,31.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.1,158.76
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323042605,NDC,5,ML,64.8,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,31.104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323042605,NDC,5,ML,64.8,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,31.104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
inFLIXimab 100 MG Recon Soln 1 Each Vial,J1745.01,CDM,636,RC,J1745,HCPCS,,,,57894003001,NDC,1,EA,2382.35,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,31.10839,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.3,32.16
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323042405,NDC,5,ML,64.82,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,31.1136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323042405,NDC,5,ML,64.82,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,31.1136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"COLLAR CERVICAL 2"" SMALL UNIVERSAL 08140039",120.249,CDM,274,RC,L0120,HCPCS,,270-MAIN,LOCAL,,,,,101,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,31.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.56,31.12
"COLLAR CERVICAL 2"" SMALL UNIVERSAL 08140039",120.249,CDM,274,RC,L0120,HCPCS,,270-MAIN,LOCAL,,,,,101,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,31.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.56,31.12
"COLLAR CERVICAL 2"" SMALL UNIVERSAL 08140039",120.249,CDM,274,RC,L0120,HCPCS,,270-MAIN,LOCAL,,,,,101,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,31.12,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.56,31.12
"COLLAR CERVICAL 2X20"" SMALL 1003-02",120.249,CDM,274,RC,L0120,HCPCS,,272-MAIN,LOCAL,,,,,101,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,31.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.56,31.12
"COLLAR CERVICAL 2X20"" SMALL 1003-02",120.249,CDM,274,RC,L0120,HCPCS,,272-MAIN,LOCAL,,,,,101,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,31.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.56,31.12
"COLLAR CERVICAL 2X20"" SMALL 1003-02",120.249,CDM,274,RC,L0120,HCPCS,,272-MAIN,LOCAL,,,,,101,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,31.12,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.56,31.12
"COLLAR CERVICAL 2X23.5"" MEDIUM XNARROW 1003-04",120.249,CDM,274,RC,L0120,HCPCS,,273-MAIN,LOCAL,,,,,101,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,31.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.56,31.12
"COLLAR CERVICAL 2X23.5"" MEDIUM XNARROW 1003-04",120.249,CDM,274,RC,L0120,HCPCS,,273-MAIN,LOCAL,,,,,101,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,31.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.56,31.12
"COLLAR CERVICAL 2X23.5"" MEDIUM XNARROW 1003-04",120.249,CDM,274,RC,L0120,HCPCS,,273-MAIN,LOCAL,,,,,101,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,31.12,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.56,31.12
"COLLAR CERVICAL 10-15"" SMALL XLONG 1005-06",120.249,CDM,274,RC,L0120,HCPCS,,267-MAIN,LOCAL,,,,,101,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,31.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.56,31.12
"COLLAR CERVICAL 10-15"" SMALL XLONG 1005-06",120.249,CDM,274,RC,L0120,HCPCS,,267-MAIN,LOCAL,,,,,101,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,31.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.56,31.12
"COLLAR CERVICAL 10-15"" SMALL XLONG 1005-06",120.249,CDM,274,RC,L0120,HCPCS,,267-MAIN,LOCAL,,,,,101,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,31.12,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.56,31.12
"COLLAR CERVICAL LARGE 21.5""X5"" 1005-04",120.249,CDM,274,RC,L0120,HCPCS,,268-MAIN,LOCAL,,,,,101,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,31.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.56,31.12
"COLLAR CERVICAL LARGE 21.5""X5"" 1005-04",120.249,CDM,274,RC,L0120,HCPCS,,268-MAIN,LOCAL,,,,,101,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,31.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.56,31.12
"COLLAR CERVICAL LARGE 21.5""X5"" 1005-04",120.249,CDM,274,RC,L0120,HCPCS,,268-MAIN,LOCAL,,,,,101,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,31.12,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.56,31.12
"COLLAR CERVICAL MEDIUM 20-1/2X4"" 1005-03",120.249,CDM,274,RC,L0120,HCPCS,,269-MAIN,LOCAL,,,,,101,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,31.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.56,31.12
"COLLAR CERVICAL MEDIUM 20-1/2X4"" 1005-03",120.249,CDM,274,RC,L0120,HCPCS,,269-MAIN,LOCAL,,,,,101,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,31.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.56,31.12
"COLLAR CERVICAL MEDIUM 20-1/2X4"" 1005-03",120.249,CDM,274,RC,L0120,HCPCS,,269-MAIN,LOCAL,,,,,101,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,31.12,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.56,31.12
COLLAR CERVICAL SMALL 1005-02,120.249,CDM,274,RC,L0120,HCPCS,,266-MAIN,LOCAL,,,,,101,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,31.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.56,31.12
COLLAR CERVICAL SMALL 1005-02,120.249,CDM,274,RC,L0120,HCPCS,,266-MAIN,LOCAL,,,,,101,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,31.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.56,31.12
COLLAR CERVICAL SMALL 1005-02,120.249,CDM,274,RC,L0120,HCPCS,,266-MAIN,LOCAL,,,,,101,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,31.12,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.56,31.12
ePHEDrine sulfate 50 MG/ML Solution 1 mL Vial,25000000,CDM,250,RC,,,,,,42023021689,NDC,0.1,ML,36.62,,First Health,Commercial,both,85,,999999999,percent of total billed charges,31.127,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
calcium CHLORIDE 10 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409163140,NDC,10,ML,64.85,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,31.128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
calcium CHLORIDE 10 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409163140,NDC,10,ML,64.85,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,31.128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,60432006547,NDC,10,ML,34.98,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,31.1322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,17478081705,NDC,5,ML,34.99,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,31.1411,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BANDAGE COBAN  4 IN 2 LAYER COMPRESSION SYSTEM  2094N,120.549,CDM,272,RC,A6441,HCPCS,,12366-MAIN,LOCAL,,,,,32,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,31.1456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.2928,31.36
BANDAGE COBAN LITE 4 IN 2 LAYER COMPRESSION SYSTEM 2794N,120.549,CDM,272,RC,A6441,HCPCS,,12922-MAIN,LOCAL,,,,,32,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,31.1456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.2928,31.36
WOUND DRAIN FLAT WITH TROCAR 10MM FULL PERFORATED SILICONE,27200000,CDM,272,RC,,,,12462-MAIN,LOCAL,,,,,32,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,31.1456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209F,CDM,510,RC,69209,CPT,,,,,,,,35,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,31.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,53.44
SHOE POST OP X-LARGE MALE DS1016-16,120.237,CDM,274,RC,L3260,HCPCS,,6337-MAIN,LOCAL,,,,,35,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,31.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
"Trimming of Dystrophic Nails, Any Number",PXG0127P,CDM,983,RC,G0127,HCPCS,,,,,,,,35,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,31.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,53.44
Assay Cryofibrinogen,PX82585,CDM,300,RC,82585,CPT,,,,,,,,75,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,31.155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.96,73.5
Assay Cryoglobulin,PX82595,CDM,300,RC,82595,CPT,,,,,,,,75,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,31.155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,73.5
BINDER ABDOMINAL 9 INCH 46 TO 62 INCH XL ORT21100LXL,120.238,CDM,271,RC,A4467,HCPCS,,2989-MAIN,LOCAL,,,,,75,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,31.155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL 9 INCH 63 TO 74 INCH 3- PANEL ORT211002XL,120.238,CDM,271,RC,A4467,HCPCS,,37-MAIN,LOCAL,,,,,75,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,31.155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL 10 INCH 26 TO 50 INCHES ABB1050,120.238,CDM,271,RC,A4467,HCPCS,,52-MAIN,LOCAL,,,,,75,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,31.155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
"BINDER ABDOMINAL 12"" HIGH 2XL 60-75INCH 4 PANEL ORT213002XL",120.238,CDM,271,RC,A4467,HCPCS,,12536-MAIN,LOCAL,,,,,75,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,31.155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL UNISIZE 46-62IN 9 IN MDS169024,120.238,CDM,271,RC,A4467,HCPCS,,63-MAIN,LOCAL,,,,,75,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,31.155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
"Direct skilled nursing services of a license practical nurse (lpn) in the home health or hospice setting, each 15 minutes",PXG0300,CDM,551,RC,G0300,HCPCS,,,,,,,,75,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,31.155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
HH Rn Initial Visit,PXG0154,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,31.155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
HH Rn Routine Visit,PXG0154.01,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,31.155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
Skilled Srvc of a Lpn in Training and/or Education of Pt or Fam Ea 15 Min,PXG0496,CDM,551,RC,G0496,HCPCS,,,,,,,,75,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,31.155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
Skilled srvc of an RN in training and/or education of pt or fam ea 15 min,PXG0495,CDM,551,RC,G0495,HCPCS,,,,,,,,75,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,31.155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
triamcinolone acetonide 40 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029320,NDC,1,ML,72.65,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,31.16685,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,72.0986
dexmedeTOMIDine 200 MCG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,143953201,NDC,2,ML,62.98,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,31.1751,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
K-WIRE SMOOTH 1.4MM X 100MM,C1713,CDM,272,RC,C1713,HCPCS,,12634-MAIN,LOCAL,,,,,63,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,31.185,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
SUTURE MAXON MONOFILAMENT ABSORBABLE GREEN SIZE 1 96IN WITH 1/2 CIRCLE TAPER POINT 65MM NEEDLE,27200000,CDM,272,RC,,,,11986-MAIN,LOCAL,,,,,63,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,31.185,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Vitamin a - Ref,PX8459090,CDM,300,RC,84590,CPT,90,,,,,,,63,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,31.185,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.65,61.74
budesonide 1 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097032187,NDC,1,ML,64.97,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,31.1856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 1 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097032187,NDC,1,ML,64.97,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,31.1856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Apply Lower Leg Splint,PX29515F,CDM,510,RC,29515,CPT,,,,,,,,296,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,31.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.54,152.89
Apply Lower Leg Splint,PX29515F,CDM,510,RC,29515,CPT,,,,,,,,296,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,31.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.54,152.89
Apply Lower Leg Splint,PX29515P,CDM,983,RC,29515,CPT,,,,,,,,311,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,31.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.54,304.78
Apply Lower Leg Splint,PX29515P,CDM,983,RC,29515,CPT,,,,,,,,311,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,31.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.54,304.78
"Alkaloids, Not Otherwise Specified - Ref",PX8032390,CDM,300,RC,80323,CPT,90,,,,,,,65,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,31.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.001,63.7
"Alkaloids, Not Otherwise Specified - Ref",PX8032390,CDM,300,RC,80323,CPT,90,,,,,,,65,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,31.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.001,63.7
Anesthesia Level 3,PX37000017,CDM,370,RC,,,,,,,,,,65,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,31.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.001,63.7
Anesthesia Level 3,PX37000017,CDM,370,RC,,,,,,,,,,65,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,31.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.001,63.7
Clozapine - Ref,PX8015990,CDM,300,RC,80159,CPT,90,,,,,,,65,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,31.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.48,63.7
Clozapine - Ref,PX8015990,CDM,300,RC,80159,CPT,90,,,,,,,65,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,31.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.48,63.7
Gastrin - Ref,PX8294190,CDM,300,RC,82941,CPT,90,,,,,,,65,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,31.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.16,63.7
Gastrin - Ref,PX8294190,CDM,300,RC,82941,CPT,90,,,,,,,65,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,31.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.16,63.7
Insulin Ab - Ref,PX8633790,CDM,300,RC,86337,CPT,90,,,,,,,65,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,31.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.63,63.7
Insulin Ab - Ref,PX8633790,CDM,300,RC,86337,CPT,90,,,,,,,65,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,31.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.63,63.7
Resp Muscles 1:1 per 15 Min,PXG0237,CDM,948,RC,G0237,HCPCS,,,,,,,,65,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,31.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.01,63.7
Resp Muscles 1:1 per 15 Min,PXG0237,CDM,948,RC,G0237,HCPCS,,,,,,,,65,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,31.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.01,63.7
Smking Cess 4-10 Min,PX99406F,CDM,942,RC,99406,CPT,,,,,,,,65,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,31.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.07,63.7
Smking Cess 4-10 Min,PX99406F,CDM,942,RC,99406,CPT,,,,,,,,65,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,31.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.07,63.7
benzocaine-menthol 20-0.5 % Aerosol 78 g Can,63700001,CDM,250,RC,,,,,,75137085520,NDC,78,GR,35.38,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.20516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409116219,NDC,30,ML,32.07,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.296682081,percent of total billed charges,31.213731,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094310,NDC,10,ML,72.79,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,31.22691,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.236966,143.9032
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094321,NDC,10,ML,72.79,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,31.22691,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.236966,143.9032
"Prosthetic Training, Initial, Each 15 Mins",PX97761,CDM,420,RC,97761,CPT,,,,,,,,121,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,31.23,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.05,54.91
"Prosthetic Training, Initial, Each 15 Mins",PX97761,CDM,420,RC,97761,CPT,,,,,,,,121,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,31.23,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.05,54.91
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078121,NDC,0.5,EA,36.75,,First Health,Commercial,both,85,,999999999,percent of total billed charges,31.2375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078141,NDC,0.5,EA,36.75,,First Health,Commercial,both,85,,999999999,percent of total billed charges,31.2375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
KUMAR CHOLANGIOGRAPHY CATHETER,27200000,CDM,272,RC,,,,10230-MAIN,LOCAL,,,,,63.11,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,31.23945,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
miconazole 2 % Powder 85 g Bottle,25000000,CDM,250,RC,,,,,,67094930,NDC,85,GR,35.43,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.24926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"pediatric electrolyte Solution 1,000 mL Bottle",25000000,CDM,250,RC,,,,,,49348057041,NDC,1000,ML,31.9,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,31.262,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metroNIDAZOLE 500 MG/100ML Solution 100 mL Flex Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,409781124,NDC,100,ML,32.12,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,31.262396,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,31.4776
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409751716,NDC,50,ML,72.9,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,31.2741,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,43598040516,NDC,0.2,ML,63.83,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,31.2767,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,43598040516,NDC,0.2,ML,63.83,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,31.2767,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,43598040516,NDC,0.2,ML,63.83,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,31.2767,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
apixaban 2.5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,3089321,NDC,1,EA,63.84,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,31.2816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
apixaban 2.5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,3089321,NDC,1,EA,63.84,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,31.2816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
apixaban 2.5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,3089321,NDC,1,EA,63.84,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,31.2816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098121,NDC,1,EA,72.95,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,31.29555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
fluconazole 150 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,16714069210,NDC,1,EA,72.98,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,31.30842,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DRAPE SHEET LAP T-DRAPE WITH INSTRUMENT PAD DYNJP3003,27200000,CDM,272,RC,,,,10913-MAIN,LOCAL,,,,,35.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.311,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
BALLOON EXTRACTOR PEDS,120.358,CDM,272,RC,,,,10771-MAIN,LOCAL,,,,,73,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,31.317,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.3242,71.54
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,45802011222,NDC,22,GR,63.29,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,31.32855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037604,NDC,0.75,ML,36.86,,First Health,Commercial,both,85,,999999999,percent of total billed charges,31.331,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004703,NDC,1,EA,75.45,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,31.34193,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,641601301,NDC,5,ML,34.41,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,31.34751,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
droPERidol 2.5 MG/ML Solution 2 mL Vial,J1790.01,CDM,636,RC,J1790,HCPCS,,,,517970201,NDC,2,ML,75.47,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,31.350238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.350238,73.9606
famciclovir 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714030401,NDC,1,EA,34.42,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,31.35662,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BANDAGE COBAN  4 IN 2 LAYER COMPRESSION SYSTEM  2094N,120.549,CDM,272,RC,A6441,HCPCS,,12366-MAIN,LOCAL,,,,,32,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,31.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.2928,31.36
BANDAGE COBAN LITE 4 IN 2 LAYER COMPRESSION SYSTEM 2794N,120.549,CDM,272,RC,A6441,HCPCS,,12922-MAIN,LOCAL,,,,,32,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,31.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.2928,31.36
Blood Occult Peroxidase,PX82272,CDM,300,RC,82272,CPT,,,,,,,,64,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,31.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.88,62.72
Blood Occult Peroxidase,PX82272,CDM,300,RC,82272,CPT,,,,,,,,64,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,31.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.88,62.72
Blood Occult Peroxidase,PX82272,CDM,300,RC,82272,CPT,,,,,,,,64,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,31.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.88,62.72
Strapping of Elbow or Wrist,PX29260F,CDM,420,RC,29260,CPT,,,,,,,,64,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,31.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.5856,62.72
Strapping of Elbow or Wrist,PX29260F,CDM,420,RC,29260,CPT,,,,,,,,64,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,31.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.5856,62.72
Strapping of Elbow or Wrist,PX29260F,CDM,420,RC,29260,CPT,,,,,,,,64,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,31.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.5856,62.72
Strapping of Hand or Finger,PX29280F,CDM,420,RC,29280,CPT,,,,,,,,64,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,31.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.5856,62.72
Strapping of Hand or Finger,PX29280F,CDM,420,RC,29280,CPT,,,,,,,,64,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,31.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.5856,62.72
Strapping of Hand or Finger,PX29280F,CDM,420,RC,29280,CPT,,,,,,,,64,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,31.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.5856,62.72
WOUND DRAIN FLAT WITH TROCAR 10MM FULL PERFORATED SILICONE,27200000,CDM,272,RC,,,,12462-MAIN,LOCAL,,,,,32,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,31.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
hydrocortisone 2.5 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,168008031,NDC,30,GR,61.99,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,31.36694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092821,NDC,1,ML,32.23,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,13.87,percent of total billed charges,31.369459,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,31.5854
VAGINAL PACKING 2',120.292,CDM,272,RC,,,,829-MAIN,LOCAL,,,,,32.23,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,31.369459,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.388342,31.5854
EPINEPHrine 30 MG/30ML Solution 30 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023016801,NDC,0.3,ML,32.24,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,229.0777778,percent of total billed charges,31.379192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046837,NDC,30,ML,75.54,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,31.379316,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120301,NDC,0.5,ML,34.45,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,31.38395,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120311,NDC,0.5,ML,34.45,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,31.38395,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
HYDROmorphone 1 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409128303,NDC,1,ML,36.93,,First Health,Commercial,both,85,,999999999,percent of total billed charges,31.3905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608210,NDC,1,ML,63.43,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,31.39785,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990711509,NDC,1000,ML,64.08,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1.633818182,percent of total billed charges,31.3992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990711509,NDC,1000,ML,64.08,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,31.3992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990711509,NDC,1000,ML,64.08,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,31.3992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
enalaprilat 1.25 MG/ML Injectable 2 mL Vial,25000000,CDM,250,RC,,,,,,143978601,NDC,2,ML,75.63,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,31.416702,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409116219,NDC,30,ML,32.07,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,31.4286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
PHENobarbital 130 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047721,NDC,1,ML,338.93,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,31.43,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.66,32.8
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047621,NDC,1,ML,157.28,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,31.43,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.66,32.8
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047625,NDC,0.769230769,ML,111.59,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,31.43,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.66,32.8
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,24208031510,NDC,10,ML,75.67,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,31.433318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
clarithromycin 250 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,527193106,NDC,1,EA,32.3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,31.43759,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clarithromycin 250 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,65862022560,NDC,1,EA,32.3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,31.43759,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
TRAY SURGICAL PODIATRY II EXTREMITY DYNJS0803,27200000,CDM,272,RC,,,,10920-MAIN,LOCAL,,,,,73.29,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,31.44141,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
COLLAR CERVICAL LARGE WITH TRACH 2 PIECE PHP-T4L,120.184,CDM,274,RC,L0172,HCPCS,,10142-MAIN,LOCAL,,,,,37,,First Health,Commercial,both,85,,999999999,percent of total billed charges,31.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.3698,152.79
COLLAR CERVICAL MEDIUM WITH TRACH 2 PIECE PHP-T4M,120.183,CDM,274,RC,L0172,HCPCS,,10141-MAIN,LOCAL,,,,,37,,First Health,Commercial,both,85,,999999999,percent of total billed charges,31.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.3698,152.79
COLLAR CERVICAL SMALL WITH TRACH 2 PIECE PHP-T4S,120.182,CDM,274,RC,L0172,HCPCS,,10140-MAIN,LOCAL,,,,,37,,First Health,Commercial,both,85,,999999999,percent of total billed charges,31.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.3698,152.79
SUTURE TICRON 0 36IN BRAIDED DYED 1/2 CIRCLE DBLE ARM 25MM CV-305 BLUE STERILE,27200000,CDM,272,RC,,,,11956-MAIN,LOCAL,,,,,37,,First Health,Commercial,both,85,,999999999,percent of total billed charges,31.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
First Hour IV Hydration <1 Hour,PX96360,CDM,260,RC,96360,CPT,,,,,,,,260,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,31.458,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.16,56.42
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,16714001905,NDC,2,ML,62.17,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,31.45802,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,16714001930,NDC,2,ML,62.17,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,31.45802,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
levothyroxine Sodium 200 MCG Recon Soln 1 Each Vial,J0650.01,CDM,636,RC,J0650,HCPCS,,,,63323064710,NDC,0.0625,EA,75.75,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,31.46655,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.46655,74.235
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,63739005007,NDC,1,EA,73.35,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,31.46715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buprenorphine 75 MCG FILM 1 Each Package,63700001,CDM,250,RC,,,,,,59385002101,NDC,1,EA,35.68,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.46976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016501,NDC,1,ML,34.55,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,31.47505,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049226,NDC,30,ML,34.55,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,31.47505,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049245,NDC,30,ML,34.55,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,31.47505,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,23155024031,NDC,2,ML,34.55,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,31.47505,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.859
metroNIDAZOLE 500 MG/100ML Solution 100 mL Flex Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,409781124,NDC,100,ML,32.12,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,31.4776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.02,31.4776
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,16714081701,NDC,1,EA,75.78,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,31.479012,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzocaine-menthol 20-0.5 % Aerosol 78 g Can,63700001,CDM,250,RC,,,,,,75137085520,NDC,78,GR,35.38,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,31.4882,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606001,NDC,10,ML,65.62,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,31.4976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606001,NDC,10,ML,65.62,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,31.4976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606010,NDC,10,ML,65.62,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,31.4976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606010,NDC,10,ML,65.62,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,31.4976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
Lvl 1 Sub Hosp Low Mdm or 25 Minutes,PX99231,CDM,982,RC,99231,CPT,,,,,,,,133,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,31.51,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.55,130.34
Lvl 1 Sub Hosp Low Mdm or 25 Minutes,PX99231,CDM,982,RC,99231,CPT,,,,,,,,133,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,31.51,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.55,130.34
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,55150020200,NDC,1,EA,65.65,,Health Partners,Health Partners Care Plans,both,48,,23.19555556,percent of total billed charges,31.512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,55150020200,NDC,1,EA,65.65,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,31.512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
miconazole 2 % Powder 85 g Bottle,25000000,CDM,250,RC,,,,,,67094930,NDC,85,GR,35.43,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,31.5327,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Xray Finger(S) Tc,PX7314001,CDM,320,RC,73140,CPT,TC,,,,,,,282,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,31.5364,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.72,62.45
triamcinolone acetonide 40 MG/ML Suspension 1 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029305,NDC,1,ML,73.57,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,31.56153,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,72.0986
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189101,NDC,1,ML,32.43,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,10.32421053,percent of total billed charges,31.564119,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
budesonide 0.5 MG/2ML Suspension 2 mL Ampule,25000000,CDM,250,RC,,,,,,68180098405,NDC,2,ML,62.38,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,31.56428,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,781751614,NDC,2,ML,62.38,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,31.56428,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,781751687,NDC,2,ML,62.38,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,31.56428,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097031986,NDC,2,ML,62.38,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,31.56428,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
triamcinolone acetonide 0.1 % Cream 80 g Tube,63700001,CDM,250,RC,,,,,,16714098603,NDC,80,GR,65.76,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,31.5648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
triamcinolone acetonide 0.1 % Cream 80 g Tube,63700001,CDM,250,RC,,,,,,16714098603,NDC,80,GR,65.76,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,31.5648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of Blood Lipoprotein,PX83721,CDM,300,RC,83721,CPT,,,,,,,,76,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,31.5704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.63,74.48
Lab Direct Coombs,PX86880,CDM,300,RC,86880,CPT,,,,,,,,76,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,31.5704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.5704,74.48
PRONEVIEW CUSHION INSERTS LARGE,120.557,CDM,272,RC,E0190,HCPCS,,12500-MAIN,LOCAL,,,,,76,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,31.5704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.5704,74.48
SHOE POST OP LARGE MALE MQM3B,120.237,CDM,274,RC,L3260,HCPCS,,794-MAIN,LOCAL,,,,,76,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,31.5704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP LARGE SQUARE TOE WOMENS ORT30300WL,120.237,CDM,274,RC,L3260,HCPCS,,10606-MAIN,LOCAL,,,,,76,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,31.5704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP MEDIUM SQUARE TOE MALE ORT30300MM,120.237,CDM,274,RC,L3260,HCPCS,,10603-MAIN,LOCAL,,,,,76,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,31.5704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP MEDIUM SQUARE TOE WOMENS ORT30300WM,120.237,CDM,274,RC,L3260,HCPCS,,10605-MAIN,LOCAL,,,,,76,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,31.5704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP SMALL MALE 0814-1192,120.237,CDM,274,RC,L3260,HCPCS,,803-MAIN,LOCAL,,,,,76,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,31.5704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP SMALL SQUARE TOE WOMENS MQW1B,120.237,CDM,274,RC,L3260,HCPCS,,10604-MAIN,LOCAL,,,,,76,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,31.5704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092821,NDC,1,ML,32.23,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,31.5854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,31.5854
VAGINAL PACKING 2',120.292,CDM,272,RC,,,,829-MAIN,LOCAL,,,,,32.23,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,31.5854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.388342,31.5854
DRAPE SHEET LAP T-DRAPE WITH INSTRUMENT PAD DYNJP3003,27200000,CDM,272,RC,,,,10913-MAIN,LOCAL,,,,,35.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,31.595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Self Care Mngment Training,PX97535,CDM,420,RC,97535,CPT,,,,,,,,135,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,31.5952,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.56,43.05
EPINEPHrine 30 MG/30ML Solution 30 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023016801,NDC,0.3,ML,32.24,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,31.5952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,43598040516,NDC,0.2,ML,63.83,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,31.59585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,713013512,NDC,1,EA,65.83,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,31.5984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.345782,66.2186
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,713013512,NDC,1,EA,65.83,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,31.5984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.345782,66.2186
apixaban 2.5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,3089321,NDC,1,EA,63.84,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,31.6008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium polystyrene sulfonate Powder 15 g Bottle,25000000,CDM,250,RC,,,,,,10702003615,NDC,15,GR,76.09,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,31.607786,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024110,NDC,1,EA,76.1,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,31.61194,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,63323004401,NDC,1,ML,64.53,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,31.6197,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,63.2394
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,63323004401,NDC,1,ML,64.53,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,31.6197,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,63.2394
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,63323004401,NDC,1,ML,64.53,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,31.6197,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,63.2394
dutasteride 0.5 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,42806054909,NDC,1,EA,32.49,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,31.622517,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium sulfate 4 GM/50ML Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010701,NDC,50,ML,73.72,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,31.62588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
Neg Pressure Wound Therapy Dme </=50 Sq Cm,PX97605F,CDM,510,RC,97605,CPT,,,,,,,,396,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,31.63,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.3,56.67
bacitracin zinc 500 UNIT/GM Ointment 28.35 g Tube,25000000,CDM,250,RC,,,,,,168001131,NDC,28.35,GR,32.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,31.63225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,47781046813,NDC,1,EA,76.15,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,31.63271,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,64380079701,NDC,1,EA,76.15,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,31.63271,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026994,NDC,20,ML,35.87,,United Healthcare,All Payer,outpatient,88.2,,1.151420557,percent of total billed charges,31.63734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
lidocaine 1% PF 1 % Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,63323049227,NDC,2,ML,34.74,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,31.64814,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
clarithromycin 250 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,527193106,NDC,1,EA,32.3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,31.654,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clarithromycin 250 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,65862022560,NDC,1,EA,32.3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,31.654,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"CUFF STERILE DISPOSABLE SPSB  STERILE 18""",27200000,CDM,272,RC,,,,7436-MAIN,LOCAL,,,,,35.89,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.65498,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TRAY HAND SURGICAL II DYNJS0806,27200000,CDM,272,RC,,,,11024-MAIN,LOCAL,,,,,64.62,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,31.6638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TRAY HAND SURGICAL II DYNJS0806,27200000,CDM,272,RC,,,,11024-MAIN,LOCAL,,,,,64.62,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,31.6638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TRAY HAND SURGICAL II DYNJS0806,27200000,CDM,272,RC,,,,11024-MAIN,LOCAL,,,,,64.62,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,31.6638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
levoFLOXacin in dextrose 5% 500 MG/100ML Solution 100 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004724,NDC,100,ML,64.63,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,4.651111111,percent of total billed charges,31.6687,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
levoFLOXacin in dextrose 5% 500 MG/100ML Solution 100 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004724,NDC,100,ML,64.63,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,31.6687,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
levoFLOXacin in dextrose 5% 500 MG/100ML Solution 100 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004724,NDC,100,ML,64.63,,United Healthcare,All Medicare advantage plans,outpatient,49,,17.13,percent of total billed charges,31.6687,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,76329339001,NDC,5,ML,64.63,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,31.6687,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,76329339001,NDC,5,ML,64.63,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,31.6687,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,76329339001,NDC,5,ML,64.63,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,31.6687,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
inFLIXimab 100 MG Recon Soln 1 Each Vial,J1745.01,CDM,636,RC,J1745,HCPCS,,,,57894003001,NDC,1,EA,2382.35,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,31.67,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.3,32.16
inFLIXimab 100 MG Recon Soln 1 Each Vial,J1745.01,CDM,636,RC,J1745,HCPCS,,,,57894003001,NDC,1,EA,2382.35,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,31.67,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.3,32.16
sacubitril-valsartan 24-26 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,78065920,NDC,1,EA,62.6,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,31.6756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
caffeine citrate 60 MG/3ML Solution 3 mL Vial,J0706.01,CDM,636,RC,J0706,HCPCS,,,,63323040704,NDC,3,ML,73.84,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,31.67736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.673136,72.3632
Blood Occult Peroxidase,PX82272,CDM,300,RC,82272,CPT,,,,,,,,64,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,31.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.88,62.72
"Cytogen, Interp/Report - Ref",PX8829190,CDM,310,RC,88291,CPT,90,,,,,,,2874,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,31.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.68,53.2
"Cytogen, Interp/Report - Ref",PX8829190,CDM,310,RC,88291,CPT,90,,,,,,,2874,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,31.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.68,53.2
"Cytogen, Interp/Report - Ref",PX8829190,CDM,310,RC,88291,CPT,90,,,,,,,2874,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,31.68,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.68,53.2
Ig Paraprotein Qual Bld/UR,PX0077U90,CDM,300,RC,0077U,HCPCS,90,,,,,,,66,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,31.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
Ig Paraprotein Qual Bld/UR,PX0077U90,CDM,300,RC,0077U,HCPCS,90,,,,,,,66,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,31.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
"Level III - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3933,CDM,310,RC,88304,CPT,TC,,,,,,,66,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,31.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
"Level III - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3933,CDM,310,RC,88304,CPT,TC,,,,,,,66,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,31.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
Ot Contracted Service/Msho/MA,PX120.178,CDM,431,RC,,,,,,,,,,66,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,31.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
Ot Contracted Service/Msho/MA,PX120.178,CDM,431,RC,,,,,,,,,,66,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,31.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
Pt Contracted Service/Msho,PX120.176,CDM,421,RC,,,,,,,,,,66,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,31.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
Pt Contracted Service/Msho,PX120.176,CDM,421,RC,,,,,,,,,,66,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,31.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
Strapping of Elbow or Wrist,PX29260F,CDM,420,RC,29260,CPT,,,,,,,,64,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,31.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.5856,62.72
Strapping of Hand or Finger,PX29280F,CDM,420,RC,29280,CPT,,,,,,,,64,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,31.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.5856,62.72
Surg Pathology-Level 2-Tc,PX3932,CDM,310,RC,88302,CPT,TC,,,,,,,66,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,31.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.01,64.68
Surg Pathology-Level 2-Tc,PX3932,CDM,310,RC,88302,CPT,TC,,,,,,,66,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,31.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.01,64.68
Xray Orbits Optic Foramina,PX7019001,CDM,320,RC,70190,CPT,TC,,,,,,,66,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,31.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,79.39
Xray Orbits Optic Foramina,PX7019001,CDM,320,RC,70190,CPT,TC,,,,,,,66,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,31.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,79.39
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,409508411,NDC,1,EA,73.86,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,31.68594,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048226,NDC,20,ML,32.56,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,31.690648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048241,NDC,20,ML,32.56,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,31.690648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641600101,NDC,1,ML,32.56,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,10.90473684,percent of total billed charges,31.690648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409493311,NDC,10,ML,66.06,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,31.7088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409493311,NDC,10,ML,66.06,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,31.7088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990711509,NDC,1000,ML,64.08,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,31.7196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
miconazole 2 % Powder 71 g Bottle,25000000,CDM,250,RC,,,,,,316023125,NDC,71,GR,34.82,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,31.72102,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Glucose Test,PX82950,CDM,300,RC,82950,CPT,,,,,,,,74,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,31.746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.36,72.52
KIT EMERGENCY BIRTH DYNJS0600,120.317,CDM,272,RC,,,,8344-MAIN,LOCAL,,,,,74,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,31.746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.7396,72.52
Rubeola Antibody,PX86765,CDM,300,RC,86765,CPT,,,,,,,,74,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,31.746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.81,72.52
Anes Dx Shoulder Arthroscopy,PX01622.01,CDM,964,RC,1622,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Lower Intestinal Endoscopic Px Nos,PX00811.01,CDM,964,RC,811,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,3.629371257,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Lower Intestinal Screening Colonoscopy,PX00812.01,CDM,964,RC,812,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,3.7225,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Spine Transthor W/Vent,PX00626.01,CDM,964,RC,626,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Spine Tranthor W/O Vent,PX00625.01,CDM,964,RC,625,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Ther Interven Rad Art,PX01924.01,CDM,964,RC,1924,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Ther Interven Rad Car,PX01925.01,CDM,964,RC,1925,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Ther Interven Rad Tip,PX01931.01,CDM,964,RC,1931,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Ther Interven Rad Vei,PX01930.01,CDM,964,RC,1930,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Tx Interv Rad Cran V,PX01933.01,CDM,964,RC,1933,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Tx Interv Rad Hrt/Cran,PX01926.01,CDM,964,RC,1926,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Tx Interv Rad Th Vein,PX01932.01,CDM,964,RC,1932,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Upper GI Endoscopic Px Ercp,PX00732.01,CDM,964,RC,732,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Upper GI Endoscopic Px Nos,PX00731.01,CDM,964,RC,731,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,6.118732394,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Upper/Lower GI Endoscopic Px,PX00813.01,CDM,964,RC,813,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,2.775724638,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes/Analg Cs Deliver Add-On,PX01968.01,CDM,964,RC,1968,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Abdomen Vessel Surg,PX00880.01,CDM,964,RC,880,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Abdominal Wall Surg,PX00700.01,CDM,964,RC,700,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Abdominal Wall Surg,PX00730.01,CDM,964,RC,730,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Abdominal Wall Surg,PX00800.01,CDM,964,RC,800,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Abdominal Wall Surg,PX00820.01,CDM,964,RC,820,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Achilles Tendon Surg,PX01472.01,CDM,964,RC,1472,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Airplane Cast,PX01682.01,CDM,964,RC,1682,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Amniocentesis,PX00842.01,CDM,964,RC,842,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Amputation at Knee,PX01404.01,CDM,964,RC,1404,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Amputation at Pelvis,PX01140.01,CDM,964,RC,1140,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Amputation of Femur,PX01232.01,CDM,964,RC,1232,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Amputation of Penis,PX00932.01,CDM,964,RC,932,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Ankle Replacement,PX01486.01,CDM,964,RC,1486,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Ankle/Ft Arthroscopy,PX01464.01,CDM,964,RC,1464,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Anorectal Surgery,PX00902.01,CDM,964,RC,902,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Antepartum Manipul,PX01958.01,CDM,964,RC,1958,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Arm-Leg Vessel Surg,PX01656.01,CDM,964,RC,1656,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Arthroscopy of Hip,PX01202.01,CDM,964,RC,1202,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Biceps Tendon Repair,PX01716.01,CDM,964,RC,1716,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Biopsy of Nose,PX00164.01,CDM,964,RC,164,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Biopsy of Thyroid,PX00322.01,CDM,964,RC,322,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Bladder Stone Surg,PX00870.01,CDM,964,RC,870,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Bladder Surgery,PX00910.01,CDM,964,RC,910,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Bladder Tumor Surg,PX00912.01,CDM,964,RC,912,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Bleeding Control,PX00916.01,CDM,964,RC,916,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Blepharoplasty,PX00103.01,CDM,964,RC,103,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Blood Vessel Repair,PX00770.01,CDM,964,RC,770,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Body Cast Procedure,PX01130.01,CDM,964,RC,1130,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Bone Aspirate/Bx,PX01112.01,CDM,964,RC,1112,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Burn 4-9 Percent,PX01952.01,CDM,964,RC,1952,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Burn Each 9 Percent,PX01953.01,CDM,964,RC,1953,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Burn Less 4 Percent,PX01951.01,CDM,964,RC,1951,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cabg W/O Pump,PX00566.01,CDM,964,RC,566,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cabg W/Pump,PX00567.01,CDM,964,RC,567,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cardiac Electrophys,PX00537.01,CDM,964,RC,537,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cardioverter/Defib,PX00534.01,CDM,964,RC,534,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cat or MRI Scan,PX01922.01,CDM,964,RC,1922,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Catheterize Heart,PX01920.01,CDM,964,RC,1920,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Drainage,PX00524.01,CDM,964,RC,524,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Lining Biopsy,PX00522.01,CDM,964,RC,522,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Partition View,PX00528.01,CDM,964,RC,528,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Partition View,PX00529.01,CDM,964,RC,529,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Procedure,PX00520.01,CDM,964,RC,520,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Surgery,PX00540.01,CDM,964,RC,540,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Wall Repair,PX00472.01,CDM,964,RC,472,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cleft Palate Repair,PX00172.01,CDM,964,RC,172,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Collar Bone Biopsy,PX00454.01,CDM,964,RC,454,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Corneal Transplant,PX00144.01,CDM,964,RC,144,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Correct Heart Rhythm,PX00410.01,CDM,964,RC,410,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cran Surg Hemotoma,PX00211.01,CDM,964,RC,211,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cranial Surg Nos,PX00210.01,CDM,964,RC,210,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cs Delivery,PX01961.01,CDM,964,RC,1961,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cs Hysterectomy,PX01963.01,CDM,964,RC,1963,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Dx Arteriography,PX01916.01,CDM,964,RC,1916,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Dx Elbow Arthroscopy,PX01732.01,CDM,964,RC,1732,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Dx Knee Arthroscopy,PX01382.01,CDM,964,RC,1382,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Dx Wrist Arthroscopy,PX01829.01,CDM,964,RC,1829,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Ear Exam,PX00124.01,CDM,964,RC,124,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Ear Surgery,PX00120.01,CDM,964,RC,120,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Elbow Area Surgery,PX01710.01,CDM,964,RC,1710,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,3.031276596,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Elbow Replacement,PX01760.01,CDM,964,RC,1760,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Electroshock,PX00104.01,CDM,964,RC,104,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Emer Hysterectomy,PX01962.01,CDM,964,RC,1962,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Esophageal Surgery,PX00500.01,CDM,964,RC,500,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Eye Exam,PX00148.01,CDM,964,RC,148,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Face/Skull Bone Surg,PX00190.01,CDM,964,RC,190,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Facial Bone Surgery,PX00192.01,CDM,964,RC,192,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Fat Layer Removal,PX00802.01,CDM,964,RC,802,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Femoral Artery Surg,PX01272.01,CDM,964,RC,1272,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Femoral Embolectomy,PX01274.01,CDM,964,RC,1274,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth for Chemonucleolysis,PX00634.01,CDM,964,RC,634,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth for Liver Biopsy,PX00702.01,CDM,964,RC,702,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth for Liver Transplant,PX00796.01,CDM,964,RC,796,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Forequarter Amput,PX01636.01,CDM,964,RC,1636,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Fx Repair Pelvis,PX01173.01,CDM,964,RC,1173,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Genitalia Surgery,PX00920.01,CDM,964,RC,920,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Head Nerve Surgery,PX00222.01,CDM,964,RC,222,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Head Vessel Surgery,PX00216.01,CDM,964,RC,216,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Head/Neck/Ptrunk,PX00300.01,CDM,964,RC,300,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Heart Surg < 1 Yr,PX00561.01,CDM,964,RC,561,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Heart Surg W/Arrest,PX00563.01,CDM,964,RC,563,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Heart Surg W/O Pump,PX00560.01,CDM,964,RC,560,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Heart/Lung Transplnt,PX00580.01,CDM,964,RC,580,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hemorr/Excise Liver,PX00792.01,CDM,964,RC,792,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hernia Repair < 1 Yr,PX00834.01,CDM,964,RC,834,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hernia Repair Preemie,PX00836.01,CDM,964,RC,836,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hip Arthroplasty,PX01214.01,CDM,964,RC,1214,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hip Disarticulation,PX01212.01,CDM,964,RC,1212,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hip Joint Procedure,PX01200.01,CDM,964,RC,1200,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hip Joint Surgery,PX01210.01,CDM,964,RC,1210,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hrt Surg W/Pmp Age 1+,PX00562.01,CDM,964,RC,562,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Humeral Lesion Surg,PX01758.01,CDM,964,RC,1758,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Humerus Repair,PX01744.01,CDM,964,RC,1744,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Humerus Surgery,PX01742.01,CDM,964,RC,1742,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hysterectomy,PX00846.01,CDM,964,RC,846,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hysteroscope/Graph,PX00952.01,CDM,964,RC,952,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Inc/Missed Ab Proc,PX01965.01,CDM,964,RC,1965,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Induced Ab Procedure,PX01966.01,CDM,964,RC,1966,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Insert Penis Device,PX00938.01,CDM,964,RC,938,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Intrcrn Nerve,PX00220.01,CDM,964,RC,220,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Iridectomy,PX00147.01,CDM,964,RC,147,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Kidney Stone Destruct,PX00872.01,CDM,964,RC,872,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Kidney Stone Destruct,PX00873.01,CDM,964,RC,873,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Kidney Transplant,PX00868.01,CDM,964,RC,868,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Kidney/Ureter Surg,PX00862.01,CDM,964,RC,862,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Area Procedure,PX01340.01,CDM,964,RC,1340,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Area Procedure,PX01390.01,CDM,964,RC,1390,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Area Surgery,PX01320.01,CDM,964,RC,1320,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Area Surgery,PX01360.01,CDM,964,RC,1360,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Area Surgery,PX01392.01,CDM,964,RC,1392,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Arteries Surg,PX01440.01,CDM,964,RC,1440,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Artery Repair,PX01444.01,CDM,964,RC,1444,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Artery Surg,PX01442.01,CDM,964,RC,1442,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Arthroplasty,PX01402.01,CDM,964,RC,1402,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Joint Casting,PX01420.01,CDM,964,RC,1420,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Joint Procedure,PX01380.01,CDM,964,RC,1380,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Joint Surgery,PX01400.01,CDM,964,RC,1400,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Veins Surgery,PX01430.01,CDM,964,RC,1430,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Vessel Surg,PX01432.01,CDM,964,RC,1432,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Larynx/Trach < 1 Yr,PX00326.01,CDM,964,RC,326,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Leg Arteries Surg,PX01500.01,CDM,964,RC,1500,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lens Surgery,PX00142.01,CDM,964,RC,142,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Low Intestine Scope,PX00810.01,CDM,964,RC,810,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Arm Casting,PX01860.01,CDM,964,RC,1860,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Arm Procedure,PX01820.01,CDM,964,RC,1820,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Arm Surgery,PX01810.01,CDM,964,RC,1810,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Arm Surgery,PX01830.01,CDM,964,RC,1830,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Arm Vein Surg,PX01850.01,CDM,964,RC,1850,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Bone Surg,PX01480.01,CDM,964,RC,1480,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Casting,PX01490.01,CDM,964,RC,1490,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Procedure,PX01462.01,CDM,964,RC,1462,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Revision,PX01484.01,CDM,964,RC,1484,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Surgery,PX01470.01,CDM,964,RC,1470,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Surgery,PX01474.01,CDM,964,RC,1474,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Vein Surg,PX01520.01,CDM,964,RC,1520,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Vein Surg,PX01522.01,CDM,964,RC,1522,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lumbar Puncture,PX00635.01,CDM,964,RC,635,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lung Chest Wall Surg,PX00546.01,CDM,964,RC,546,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lwr Arm Artery Surg,PX01840.01,CDM,964,RC,1840,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lwr Arm Embolectomy,PX01842.01,CDM,964,RC,1842,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lwr Arm Vein Repair,PX01852.01,CDM,964,RC,1852,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lwr Leg Embolectomy,PX01502.01,CDM,964,RC,1502,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Major Vein Ligation,PX00882.01,CDM,964,RC,882,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth N Block/Inj Prone,PX01992.01,CDM,964,RC,1992,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Neck Organ 1 & Over,PX00320.01,CDM,964,RC,320,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Neck Vessel Surgery,PX00350.01,CDM,964,RC,350,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Neck Vessel Surgery,PX00352.01,CDM,964,RC,352,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Nerve Block/Inj,PX01991.01,CDM,964,RC,1991,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Nose/Sinus Surgery,PX00160.01,CDM,964,RC,160,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Nose/Sinus Surgery,PX00162.01,CDM,964,RC,162,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth One Lung Ventilation,PX00541.01,CDM,964,RC,541,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pacemaker Insertion,PX00530.01,CDM,964,RC,530,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pancreas Removal,PX00794.01,CDM,964,RC,794,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvic Organ Surg,PX00848.01,CDM,964,RC,848,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvic Tumor Surgery,PX01150.01,CDM,964,RC,1150,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvis Nerve Removal,PX01180.01,CDM,964,RC,1180,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvis Nerve Removal,PX01190.01,CDM,964,RC,1190,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvis Procedure,PX01160.01,CDM,964,RC,1160,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvis Surgery,PX00844.01,CDM,964,RC,844,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvis Surgery,PX01120.01,CDM,964,RC,1120,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvis Surgery,PX01170.01,CDM,964,RC,1170,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Penis Nodes Removal,PX00934.01,CDM,964,RC,934,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Penis Nodes Removal,PX00936.01,CDM,964,RC,936,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Perc Img Dx Sp Proc,PX01935.01,CDM,964,RC,1935,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Perc Img Tx Sp Proc,PX01936.01,CDM,964,RC,1936,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Perineal Surgery,PX00904.01,CDM,964,RC,904,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pharyngeal Surgery,PX00174.01,CDM,964,RC,174,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pharyngeal Surgery,PX00176.01,CDM,964,RC,176,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Procedure on Femur,PX01220.01,CDM,964,RC,1220,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Procedure on Mouth,PX00170.01,CDM,964,RC,170,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Procedures on Eye,PX00140.01,CDM,964,RC,140,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Radical Femur Surg,PX01234.01,CDM,964,RC,1234,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Radical Humerus Surg,PX01756.01,CDM,964,RC,1756,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Radical Leg Surgery,PX01482.01,CDM,964,RC,1482,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Release of Lung,PX00542.01,CDM,964,RC,542,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Adrenal,PX00866.01,CDM,964,RC,866,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Bladder,PX00864.01,CDM,964,RC,864,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Nerves,PX00622.01,CDM,964,RC,622,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Nerves,PX00632.01,CDM,964,RC,632,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Prostate,PX00865.01,CDM,964,RC,865,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Prostate,PX00908.01,CDM,964,RC,908,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Rib,PX00470.01,CDM,964,RC,470,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Testis,PX00926.01,CDM,964,RC,926,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Testis,PX00928.01,CDM,964,RC,928,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Vulva,PX00906.01,CDM,964,RC,906,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Cervix,PX00948.01,CDM,964,RC,948,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Cleft Lip,PX00102.01,CDM,964,RC,102,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Hernia,PX00750.01,CDM,964,RC,750,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Hernia,PX00752.01,CDM,964,RC,752,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Hernia,PX00754.01,CDM,964,RC,754,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Hernia,PX00756.01,CDM,964,RC,756,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Hernia,PX00830.01,CDM,964,RC,830,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Hernia,PX00832.01,CDM,964,RC,832,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Revise Hip Repair,PX01215.01,CDM,964,RC,1215,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Salivary Gland,PX00100.01,CDM,964,RC,100,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Artery Surg,PX01650.01,CDM,964,RC,1650,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Casting,PX01680.01,CDM,964,RC,1680,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Joint Amput,PX01634.01,CDM,964,RC,1634,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Procedure,PX01620.01,CDM,964,RC,1620,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,574.48,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Replacement,PX01638.01,CDM,964,RC,1638,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Vein Surg,PX01670.01,CDM,964,RC,1670,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Vessel Surg,PX01652.01,CDM,964,RC,1652,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Vessel Surg,PX01654.01,CDM,964,RC,1654,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Sitting Procedure,PX00604.01,CDM,964,RC,604,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Skin Ext/per/Atrunk,PX00400.01,CDM,964,RC,400,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Skull Drainage,PX00212.01,CDM,964,RC,212,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Skull Drainage,PX00214.01,CDM,964,RC,214,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Skull Repair/Fract,PX00215.01,CDM,964,RC,215,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Special Head Surgery,PX00218.01,CDM,964,RC,218,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Sperm Duct Surgery,PX00922.01,CDM,964,RC,922,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Spine Cord Surgery,PX00600.01,CDM,964,RC,600,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Spine Cord Surgery,PX00620.01,CDM,964,RC,620,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Spine Cord Surgery,PX00630.01,CDM,964,RC,630,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Spine Cord Surgery,PX00670.01,CDM,964,RC,670,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Spine Manipulation,PX00640.01,CDM,964,RC,640,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Sternal Debridement,PX00550.01,CDM,964,RC,550,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Stone Removal,PX00918.01,CDM,964,RC,918,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surg Lower Abdomen,PX00840.01,CDM,964,RC,840,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surg on Vag/Urethral,PX00942.01,CDM,964,RC,942,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surg Upper Abdomen,PX00790.01,CDM,964,RC,790,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery for Obesity,PX00797.01,CDM,964,RC,797,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Abdomen,PX00860.01,CDM,964,RC,860,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Breast,PX00402.01,CDM,964,RC,402,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Breast,PX00404.01,CDM,964,RC,404,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Breast,PX00406.01,CDM,964,RC,406,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Femur,PX01230.01,CDM,964,RC,1230,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Rib(S),PX00474.01,CDM,964,RC,474,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Shoulder,PX00450.01,CDM,964,RC,450,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Shoulder,PX00452.01,CDM,964,RC,452,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Shoulder,PX01610.01,CDM,964,RC,1610,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Shoulder,PX01630.01,CDM,964,RC,1630,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Testis Exploration,PX00924.01,CDM,964,RC,924,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Testis Suspension,PX00930.01,CDM,964,RC,930,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Thigh Arteries Surg,PX01270.01,CDM,964,RC,1270,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Trach-Bronch Reconst,PX00539.01,CDM,964,RC,539,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Trachea Bronchi Surg,PX00548.01,CDM,964,RC,548,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Trans Resect of Prostate,PX00914.01,CDM,964,RC,914,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Tubal Ligation,PX00851.01,CDM,964,RC,851,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Tympanotomy,PX00126.01,CDM,964,RC,126,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Upper Arm Surgery,PX01740.01,CDM,964,RC,1740,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Upper Arm Vein Surg,PX01780.01,CDM,964,RC,1780,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Upper GI Visualize,PX00740.01,CDM,964,RC,740,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Upper Leg Surgery,PX01250.01,CDM,964,RC,1250,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Upper Leg Veins Surg,PX01260.01,CDM,964,RC,1260,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Uppr Arm Artery Surg,PX01770.01,CDM,964,RC,1770,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Uppr Arm Embolectomy,PX01772.01,CDM,964,RC,1772,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Uppr Arm Procedure,PX01730.01,CDM,964,RC,1730,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Uppr Arm Tendon Surg,PX01712.01,CDM,964,RC,1712,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Uppr Arm Tendon Surg,PX01714.01,CDM,964,RC,1714,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Uppr Arm Vein Repair,PX01782.01,CDM,964,RC,1782,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vaginal Delivery,PX01960.01,CDM,964,RC,1960,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vaginal Endoscopy,PX00950.01,CDM,964,RC,950,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vaginal Hysterectomy,PX00944.01,CDM,964,RC,944,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vaginal Procedures,PX00940.01,CDM,964,RC,940,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vascular Access,PX00532.01,CDM,964,RC,532,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vascular Shunt Surg,PX01844.01,CDM,964,RC,1844,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vasectomy,PX00921.01,CDM,964,RC,921,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vitreoretinal Surg,PX00145.01,CDM,964,RC,145,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Wrist Replacement,PX01832.01,CDM,964,RC,1832,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth/Analg Cs Hyst Add-On,PX01969.01,CDM,964,RC,1969,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth/Analg Vag Delivery,PX01967.01,CDM,964,RC,1967,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Hosp Manage Cont Drug Admin,PX01996.01,CDM,964,RC,1996,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
IMMOBILIZER SHOULDER LARGE 9008-03,120.38,CDM,274,RC,L3650,HCPCS,,906-MAIN,LOCAL,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,14.36,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER LARGE STRAP OSG3033,120.38,CDM,274,RC,L3650,HCPCS,,2910-MAIN,LOCAL,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,14.36,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER MEDIUM 9008-02,120.38,CDM,274,RC,L3650,HCPCS,,912-MAIN,LOCAL,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,14.36,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER MEDIUM OSG3032,120.38,CDM,274,RC,L3650,HCPCS,,915-MAIN,LOCAL,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,14.36,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER SMALL 9008-01,120.38,CDM,274,RC,L3650,HCPCS,,913-MAIN,LOCAL,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,14.36,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER SMALL WITH CLOTH 9001-02,120.38,CDM,274,RC,L3650,HCPCS,,914-MAIN,LOCAL,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,14.36,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER X-LARGE CLOTH 9001-05,120.38,CDM,274,RC,L3650,HCPCS,,917-MAIN,LOCAL,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,14.36,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER X-LARGE ORT16100XL,120.38,CDM,274,RC,L3650,HCPCS,,904-MAIN,LOCAL,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,14.36,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323042605,NDC,5,ML,64.8,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323042605,NDC,5,ML,64.8,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323042605,NDC,5,ML,64.8,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Support for Organ Donor,PX01990.01,CDM,964,RC,1990,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Treponema Pallidum,PX86780,CDM,300,RC,86780,CPT,,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.14,35.28
Unlisted Anesth Procedure,PX01999.01,CDM,964,RC,1999,CPT,QZ,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405P,CDM,983,RC,36405,CPT,,,,,,,,36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
buprenorphine 75 MCG FILM 1 Each Package,63700001,CDM,250,RC,,,,,,59385002101,NDC,1,EA,35.68,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,31.7552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323042405,NDC,5,ML,64.82,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,31.7618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323042405,NDC,5,ML,64.82,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,31.7618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323042405,NDC,5,ML,64.82,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,31.7618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Level III - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3933,CDM,310,RC,88304,CPT,TC,,,,,,,66,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,31.7691,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.02,52.096
sterile water (preservative free) Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409488724,NDC,50,ML,34.88,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,31.77568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409488750,NDC,50,ML,34.88,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,31.77568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
calcium CHLORIDE 10 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409163140,NDC,10,ML,64.85,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,31.7765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
calcium CHLORIDE 10 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409163140,NDC,10,ML,64.85,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,31.7765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
calcium CHLORIDE 10 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409163140,NDC,10,ML,64.85,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,31.7765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189101,NDC,1,ML,32.43,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,31.7814,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409338513,NDC,1,EA,74.09,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,31.78461,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
pancrelipase (lip-prot-amyl) 24000-76000 units Capsule Delayed Release Particles 100 Each Bottle,63700001,CDM,250,RC,,,,,,32122401,NDC,1,EA,37.41,,First Health,Commercial,both,85,,999999999,percent of total billed charges,31.7985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,25021011487,NDC,200,ML,66.28,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,31.8144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.20921,64.9544
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,25021011487,NDC,200,ML,66.28,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,31.8144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.20921,64.9544
"Pare/Cut Hyperkeratotic Skin Lesion, Single",PX11055F,CDM,510,RC,11055,CPT,,,,,,,,145,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,31.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.59,148.05
budesonide 1 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097032187,NDC,1,ML,64.97,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,31.8353,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 1 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097032187,NDC,1,ML,64.97,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,31.8353,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 1 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097032187,NDC,1,ML,64.97,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,31.8353,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dutasteride 0.5 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,42806054909,NDC,1,EA,32.49,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,31.8402,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034020,NDC,1,EA,76.67,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,31.848718,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034021,NDC,1,EA,76.67,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,31.848718,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,67457043800,NDC,0.5,EA,36.11,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.84902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,67457043810,NDC,0.5,EA,36.11,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.84902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Alkaloids, Not Otherwise Specified - Ref",PX8032390,CDM,300,RC,80323,CPT,90,,,,,,,65,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,31.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.001,63.7
"Alkaloids, Not Otherwise Specified - Ref",PX8032390,CDM,300,RC,80323,CPT,90,,,,,,,65,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,31.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.001,63.7
"Alkaloids, Not Otherwise Specified - Ref",PX8032390,CDM,300,RC,80323,CPT,90,,,,,,,65,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,31.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.001,63.7
Anesthesia Level 3,PX37000017,CDM,370,RC,,,,,,,,,,65,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,31.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.001,63.7
Anesthesia Level 3,PX37000017,CDM,370,RC,,,,,,,,,,65,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,31.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.001,63.7
Anesthesia Level 3,PX37000017,CDM,370,RC,,,,,,,,,,65,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,31.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.001,63.7
bacitracin zinc 500 UNIT/GM Ointment 28.35 g Tube,25000000,CDM,250,RC,,,,,,168001131,NDC,28.35,GR,32.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,31.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Clozapine - Ref,PX8015990,CDM,300,RC,80159,CPT,90,,,,,,,65,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,31.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.48,63.7
Clozapine - Ref,PX8015990,CDM,300,RC,80159,CPT,90,,,,,,,65,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,31.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.48,63.7
Clozapine - Ref,PX8015990,CDM,300,RC,80159,CPT,90,,,,,,,65,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,31.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.48,63.7
Gastrin - Ref,PX8294190,CDM,300,RC,82941,CPT,90,,,,,,,65,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,31.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.16,63.7
Gastrin - Ref,PX8294190,CDM,300,RC,82941,CPT,90,,,,,,,65,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,31.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.16,63.7
Gastrin - Ref,PX8294190,CDM,300,RC,82941,CPT,90,,,,,,,65,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,31.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.16,63.7
Insulin Ab - Ref,PX8633790,CDM,300,RC,86337,CPT,90,,,,,,,65,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,31.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.63,63.7
Insulin Ab - Ref,PX8633790,CDM,300,RC,86337,CPT,90,,,,,,,65,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,31.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.63,63.7
Insulin Ab - Ref,PX8633790,CDM,300,RC,86337,CPT,90,,,,,,,65,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,31.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.63,63.7
Resp Muscles 1:1 per 15 Min,PXG0237,CDM,948,RC,G0237,HCPCS,,,,,,,,65,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,31.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.01,63.7
Resp Muscles 1:1 per 15 Min,PXG0237,CDM,948,RC,G0237,HCPCS,,,,,,,,65,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,31.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.01,63.7
Resp Muscles 1:1 per 15 Min,PXG0237,CDM,948,RC,G0237,HCPCS,,,,,,,,65,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,31.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.01,63.7
Smking Cess 4-10 Min,PX99406F,CDM,942,RC,99406,CPT,,,,,,,,65,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,31.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.07,63.7
Smking Cess 4-10 Min,PX99406F,CDM,942,RC,99406,CPT,,,,,,,,65,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,31.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.07,63.7
Smking Cess 4-10 Min,PX99406F,CDM,942,RC,99406,CPT,,,,,,,,65,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,31.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.07,63.7
Drain/Inject Med Joint/Brusa W/US Guide,PX20606F,CDM,510,RC,20606,CPT,,,,,,,,387,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,31.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.85,187.48
Drain/Inject Med Joint/Brusa W/US Guide,PX20606F,CDM,510,RC,20606,CPT,,,,,,,,387,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,31.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.85,187.48
Drain/Inject Med Joint/Brusa W/US Guide,PX20606F,CDM,510,RC,20606,CPT,,,,,,,,387,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,31.85,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.85,187.48
Drain/Inject Med Joint/Brusa W/US Guide,PX20606P,CDM,983,RC,20606,CPT,,,,,,,,309,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,31.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.85,302.82
Drain/Inject Med Joint/Brusa W/US Guide,PX20606P,CDM,983,RC,20606,CPT,,,,,,,,309,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,31.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.85,302.82
Drain/Inject Med Joint/Brusa W/US Guide,PX20606P,CDM,983,RC,20606,CPT,,,,,,,,309,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,31.85,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.85,302.82
Xray Cervical Spine 6 or More Vws,PX7205201,CDM,320,RC,72052,CPT,TC,,,,,,,664,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,31.85,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.85,95.32
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028036,NDC,2,ML,36.12,,United Healthcare,All Payer,outpatient,88.2,,8.0425,percent of total billed charges,31.85784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
US Renal Retroperit Ltd,PX7677501,CDM,402,RC,76775,CPT,TC,,,,,,,566,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,31.8582,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.94,64.43
Xray Knee (Both) Ap Stand,PX7356501,CDM,320,RC,73565,CPT,TC,,,,,,,543,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,31.8582,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.94,63.11
Xray Knee 3 Vws,PX7356201,CDM,320,RC,73562,CPT,TC,,,,,,,404,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,31.8582,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.94,63.11
"Xray Mandible Compl, Min 4 Vws",PX7011001,CDM,320,RC,70110,CPT,TC,,,,,,,381,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,31.8582,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.94,63.11
Fetal Profile W/O Stress,PX7681901,CDM,402,RC,76819,CPT,TC,,,,,,,248,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,31.86,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.86,97.95
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,60432006547,NDC,10,ML,34.98,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,31.86678,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323031119,NDC,10,ML,66.39,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,31.8672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,84.5054
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323031119,NDC,10,ML,66.39,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,31.8672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,84.5054
dexmedeTOMIDine 200 MCG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,143953201,NDC,2,ML,62.98,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,31.86788,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"CUFF STERILE DISPOSABLE SPSB 24""",27200000,CDM,272,RC,,,,7437-MAIN,LOCAL,,,,,37.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,31.875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ENDOCAVITY NEEDLE GUIDE,27200000,CDM,272,RC,,,,11134-MAIN,LOCAL,,,,,37.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,31.875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR KII BALOON 5X100MM STERILE,27200000,CDM,272,RC,,,,11701-MAIN,LOCAL,,,,,37.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,31.875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323020103,NDC,10,ML,36.14,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.87548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,17478081705,NDC,5,ML,34.99,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,31.87589,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
K-WIRE SMOOTH 1.4MM X 100MM,C1713,CDM,272,RC,C1713,HCPCS,,12634-MAIN,LOCAL,,,,,63,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,31.878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
SUTURE MAXON MONOFILAMENT ABSORBABLE GREEN SIZE 1 96IN WITH 1/2 CIRCLE TAPER POINT 65MM NEEDLE,27200000,CDM,272,RC,,,,11986-MAIN,LOCAL,,,,,63,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,31.878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Vitamin a - Ref,PX8459090,CDM,300,RC,84590,CPT,90,,,,,,,63,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,31.878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.65,61.74
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209F,CDM,510,RC,69209,CPT,,,,,,,,35,,Medica,Commercial,both,91.1,,49.65,percent of total billed charges,31.885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,53.44
SHOE POST OP X-LARGE MALE DS1016-16,120.237,CDM,274,RC,L3260,HCPCS,,6337-MAIN,LOCAL,,,,,35,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,31.885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
"Trimming of Dystrophic Nails, Any Number",PXG0127P,CDM,983,RC,G0127,HCPCS,,,,,,,,35,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,31.885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,53.44
colchicine 0.6 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,49884017111,NDC,1,EA,36.17,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,31.90194,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048226,NDC,20,ML,32.56,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,31.9088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048241,NDC,20,ML,32.56,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,31.9088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641600101,NDC,1,ML,32.56,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,31.9088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026994,NDC,20,ML,35.87,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,31.9243,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,63739003807,NDC,1,EA,66.51,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,31.9248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,63739003807,NDC,1,EA,66.51,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,31.9248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acyclovir 50 MG/ML Solution 20 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,63323032524,NDC,20,ML,76.86,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,31.927644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.927644,105.9968
KUMAR CHOLANGIOGRAPHY CATHETER,27200000,CDM,272,RC,,,,10230-MAIN,LOCAL,,,,,63.11,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,31.93366,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"CUFF STERILE DISPOSABLE SPSB  STERILE 18""",27200000,CDM,272,RC,,,,7436-MAIN,LOCAL,,,,,35.89,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,31.9421,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,63323004401,NDC,1,ML,64.53,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,31.94235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,63.2394
DULoxetine 20 MG Capsule Delayed Release Particles 60 Each Bottle,63700001,CDM,250,RC,,,,,,57237001760,NDC,1,EA,37.58,,First Health,Commercial,both,85,,999999999,percent of total billed charges,31.943,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclopentolate 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,17478010002,NDC,2,ML,66.55,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,31.944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
cyclopentolate 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,17478010002,NDC,2,ML,66.55,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,31.944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037601,NDC,1,ML,76.9,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,31.94426,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608201,NDC,1,ML,66.6,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,31.968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608201,NDC,1,ML,66.6,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,31.968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
solifenacin 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50228042730,NDC,1,EA,74.52,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,31.96908,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pioglitazone 15 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342005410,NDC,1,EA,37.62,,First Health,Commercial,both,85,,999999999,percent of total billed charges,31.977,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Flex Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707526,NDC,100,ML,37.63,,First Health,Commercial,both,85,,999999999,percent of total billed charges,31.9855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
Alpha-Fetoprotein Serum,PX82105,CDM,300,RC,82105,CPT,,,,,,,,77,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,31.9858,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.38,75.46
BRACE WRIST HAND THUMB LEFT 455-LT,120.315,CDM,274,RC,L3809,HCPCS,,8283-MAIN,LOCAL,,,,,77,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,31.9858,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.9858,245.51
BRACE WRIST HAND THUMB RIGHT 455-RT,120.315,CDM,274,RC,L3809,HCPCS,,8284-MAIN,LOCAL,,,,,77,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,31.9858,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.9858,245.51
CAUTERY HIGH TEMP LOOP TIP,120.21,CDM,272,RC,,,,332-MAIN,LOCAL,,,,,77,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,31.9858,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
NEEDLE ACUJECT 25GA VARIABLE INJECTION VIN-25,27200000,CDM,272,RC,,,,7412-MAIN,LOCAL,,,,,77,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,31.9858,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Remove Additional Nail Plate,PX11732F,CDM,510,RC,11732,CPT,,,,,,,,77,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,31.9858,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.9858,75.46
TRAY HAND SURGICAL II DYNJS0806,27200000,CDM,272,RC,,,,11024-MAIN,LOCAL,,,,,64.62,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,31.9869,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Appl on-Body Injector for Timed Subq Injection,PX96377,CDM,260,RC,96377,CPT,,,,,,,,13093,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,31.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.655,31.99
Appl on-Body Injector for Timed Subq Injection,PX96377,CDM,260,RC,96377,CPT,,,,,,,,13093,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,31.99,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.655,31.99
levoFLOXacin in dextrose 5% 500 MG/100ML Solution 100 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004724,NDC,100,ML,64.63,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,31.99185,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,76329339001,NDC,5,ML,64.63,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,31.99185,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189103,NDC,1,ML,32.89,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,10.32421053,percent of total billed charges,32.011837,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,45802011222,NDC,22,GR,63.29,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,32.02474,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022143,NDC,1,EA,36.31,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,32.02542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
Anes Dx Shoulder Arthroscopy,PX01622.01,CDM,964,RC,1622,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Lower Intestinal Endoscopic Px Nos,PX00811.01,CDM,964,RC,811,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Lower Intestinal Screening Colonoscopy,PX00812.01,CDM,964,RC,812,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Spine Transthor W/Vent,PX00626.01,CDM,964,RC,626,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Spine Tranthor W/O Vent,PX00625.01,CDM,964,RC,625,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Ther Interven Rad Art,PX01924.01,CDM,964,RC,1924,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Ther Interven Rad Car,PX01925.01,CDM,964,RC,1925,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Ther Interven Rad Tip,PX01931.01,CDM,964,RC,1931,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Ther Interven Rad Vei,PX01930.01,CDM,964,RC,1930,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Tx Interv Rad Cran V,PX01933.01,CDM,964,RC,1933,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Tx Interv Rad Hrt/Cran,PX01926.01,CDM,964,RC,1926,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Tx Interv Rad Th Vein,PX01932.01,CDM,964,RC,1932,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Upper GI Endoscopic Px Ercp,PX00732.01,CDM,964,RC,732,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Upper GI Endoscopic Px Nos,PX00731.01,CDM,964,RC,731,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Upper/Lower GI Endoscopic Px,PX00813.01,CDM,964,RC,813,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes/Analg Cs Deliver Add-On,PX01968.01,CDM,964,RC,1968,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Abdomen Vessel Surg,PX00880.01,CDM,964,RC,880,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Abdominal Wall Surg,PX00700.01,CDM,964,RC,700,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Abdominal Wall Surg,PX00730.01,CDM,964,RC,730,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Abdominal Wall Surg,PX00800.01,CDM,964,RC,800,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Abdominal Wall Surg,PX00820.01,CDM,964,RC,820,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Achilles Tendon Surg,PX01472.01,CDM,964,RC,1472,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Airplane Cast,PX01682.01,CDM,964,RC,1682,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Amniocentesis,PX00842.01,CDM,964,RC,842,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Amputation at Knee,PX01404.01,CDM,964,RC,1404,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Amputation at Pelvis,PX01140.01,CDM,964,RC,1140,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Amputation of Femur,PX01232.01,CDM,964,RC,1232,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Amputation of Penis,PX00932.01,CDM,964,RC,932,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Ankle Replacement,PX01486.01,CDM,964,RC,1486,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Ankle/Ft Arthroscopy,PX01464.01,CDM,964,RC,1464,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Anorectal Surgery,PX00902.01,CDM,964,RC,902,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Antepartum Manipul,PX01958.01,CDM,964,RC,1958,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Arm-Leg Vessel Surg,PX01656.01,CDM,964,RC,1656,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Arthroscopy of Hip,PX01202.01,CDM,964,RC,1202,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Biceps Tendon Repair,PX01716.01,CDM,964,RC,1716,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Biopsy of Nose,PX00164.01,CDM,964,RC,164,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Biopsy of Thyroid,PX00322.01,CDM,964,RC,322,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Bladder Stone Surg,PX00870.01,CDM,964,RC,870,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Bladder Surgery,PX00910.01,CDM,964,RC,910,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Bladder Tumor Surg,PX00912.01,CDM,964,RC,912,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Bleeding Control,PX00916.01,CDM,964,RC,916,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Blepharoplasty,PX00103.01,CDM,964,RC,103,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Blood Vessel Repair,PX00770.01,CDM,964,RC,770,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Body Cast Procedure,PX01130.01,CDM,964,RC,1130,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Bone Aspirate/Bx,PX01112.01,CDM,964,RC,1112,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Burn 4-9 Percent,PX01952.01,CDM,964,RC,1952,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Burn Each 9 Percent,PX01953.01,CDM,964,RC,1953,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Burn Less 4 Percent,PX01951.01,CDM,964,RC,1951,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cabg W/O Pump,PX00566.01,CDM,964,RC,566,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cabg W/Pump,PX00567.01,CDM,964,RC,567,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cardiac Electrophys,PX00537.01,CDM,964,RC,537,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cardioverter/Defib,PX00534.01,CDM,964,RC,534,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cat or MRI Scan,PX01922.01,CDM,964,RC,1922,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Catheterize Heart,PX01920.01,CDM,964,RC,1920,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Drainage,PX00524.01,CDM,964,RC,524,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Lining Biopsy,PX00522.01,CDM,964,RC,522,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Partition View,PX00528.01,CDM,964,RC,528,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Partition View,PX00529.01,CDM,964,RC,529,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Procedure,PX00520.01,CDM,964,RC,520,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Surgery,PX00540.01,CDM,964,RC,540,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Wall Repair,PX00472.01,CDM,964,RC,472,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cleft Palate Repair,PX00172.01,CDM,964,RC,172,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Collar Bone Biopsy,PX00454.01,CDM,964,RC,454,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Corneal Transplant,PX00144.01,CDM,964,RC,144,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Correct Heart Rhythm,PX00410.01,CDM,964,RC,410,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cran Surg Hemotoma,PX00211.01,CDM,964,RC,211,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cranial Surg Nos,PX00210.01,CDM,964,RC,210,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cs Delivery,PX01961.01,CDM,964,RC,1961,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cs Hysterectomy,PX01963.01,CDM,964,RC,1963,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Dx Arteriography,PX01916.01,CDM,964,RC,1916,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Dx Elbow Arthroscopy,PX01732.01,CDM,964,RC,1732,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Dx Knee Arthroscopy,PX01382.01,CDM,964,RC,1382,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Dx Wrist Arthroscopy,PX01829.01,CDM,964,RC,1829,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Ear Exam,PX00124.01,CDM,964,RC,124,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Ear Surgery,PX00120.01,CDM,964,RC,120,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Elbow Area Surgery,PX01710.01,CDM,964,RC,1710,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Elbow Replacement,PX01760.01,CDM,964,RC,1760,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Electroshock,PX00104.01,CDM,964,RC,104,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Emer Hysterectomy,PX01962.01,CDM,964,RC,1962,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Esophageal Surgery,PX00500.01,CDM,964,RC,500,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Eye Exam,PX00148.01,CDM,964,RC,148,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Face/Skull Bone Surg,PX00190.01,CDM,964,RC,190,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Facial Bone Surgery,PX00192.01,CDM,964,RC,192,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Fat Layer Removal,PX00802.01,CDM,964,RC,802,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Femoral Artery Surg,PX01272.01,CDM,964,RC,1272,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Femoral Embolectomy,PX01274.01,CDM,964,RC,1274,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth for Chemonucleolysis,PX00634.01,CDM,964,RC,634,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth for Liver Biopsy,PX00702.01,CDM,964,RC,702,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth for Liver Transplant,PX00796.01,CDM,964,RC,796,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Forequarter Amput,PX01636.01,CDM,964,RC,1636,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Fx Repair Pelvis,PX01173.01,CDM,964,RC,1173,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Genitalia Surgery,PX00920.01,CDM,964,RC,920,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Head Nerve Surgery,PX00222.01,CDM,964,RC,222,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Head Vessel Surgery,PX00216.01,CDM,964,RC,216,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Head/Neck/Ptrunk,PX00300.01,CDM,964,RC,300,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Heart Surg < 1 Yr,PX00561.01,CDM,964,RC,561,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Heart Surg W/Arrest,PX00563.01,CDM,964,RC,563,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Heart Surg W/O Pump,PX00560.01,CDM,964,RC,560,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Heart/Lung Transplnt,PX00580.01,CDM,964,RC,580,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hemorr/Excise Liver,PX00792.01,CDM,964,RC,792,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hernia Repair < 1 Yr,PX00834.01,CDM,964,RC,834,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hernia Repair Preemie,PX00836.01,CDM,964,RC,836,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hip Arthroplasty,PX01214.01,CDM,964,RC,1214,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hip Disarticulation,PX01212.01,CDM,964,RC,1212,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hip Joint Procedure,PX01200.01,CDM,964,RC,1200,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hip Joint Surgery,PX01210.01,CDM,964,RC,1210,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hrt Surg W/Pmp Age 1+,PX00562.01,CDM,964,RC,562,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Humeral Lesion Surg,PX01758.01,CDM,964,RC,1758,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Humerus Repair,PX01744.01,CDM,964,RC,1744,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Humerus Surgery,PX01742.01,CDM,964,RC,1742,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hysterectomy,PX00846.01,CDM,964,RC,846,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hysteroscope/Graph,PX00952.01,CDM,964,RC,952,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Inc/Missed Ab Proc,PX01965.01,CDM,964,RC,1965,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Induced Ab Procedure,PX01966.01,CDM,964,RC,1966,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Insert Penis Device,PX00938.01,CDM,964,RC,938,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Intrcrn Nerve,PX00220.01,CDM,964,RC,220,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Iridectomy,PX00147.01,CDM,964,RC,147,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Kidney Stone Destruct,PX00872.01,CDM,964,RC,872,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Kidney Stone Destruct,PX00873.01,CDM,964,RC,873,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Kidney Transplant,PX00868.01,CDM,964,RC,868,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Kidney/Ureter Surg,PX00862.01,CDM,964,RC,862,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Area Procedure,PX01340.01,CDM,964,RC,1340,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Area Procedure,PX01390.01,CDM,964,RC,1390,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Area Surgery,PX01320.01,CDM,964,RC,1320,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Area Surgery,PX01360.01,CDM,964,RC,1360,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Area Surgery,PX01392.01,CDM,964,RC,1392,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Arteries Surg,PX01440.01,CDM,964,RC,1440,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Artery Repair,PX01444.01,CDM,964,RC,1444,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Artery Surg,PX01442.01,CDM,964,RC,1442,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Arthroplasty,PX01402.01,CDM,964,RC,1402,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Joint Casting,PX01420.01,CDM,964,RC,1420,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Joint Procedure,PX01380.01,CDM,964,RC,1380,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Joint Surgery,PX01400.01,CDM,964,RC,1400,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Veins Surgery,PX01430.01,CDM,964,RC,1430,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Vessel Surg,PX01432.01,CDM,964,RC,1432,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Larynx/Trach < 1 Yr,PX00326.01,CDM,964,RC,326,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Leg Arteries Surg,PX01500.01,CDM,964,RC,1500,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lens Surgery,PX00142.01,CDM,964,RC,142,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Low Intestine Scope,PX00810.01,CDM,964,RC,810,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Arm Casting,PX01860.01,CDM,964,RC,1860,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Arm Procedure,PX01820.01,CDM,964,RC,1820,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Arm Surgery,PX01810.01,CDM,964,RC,1810,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Arm Surgery,PX01830.01,CDM,964,RC,1830,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Arm Vein Surg,PX01850.01,CDM,964,RC,1850,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Bone Surg,PX01480.01,CDM,964,RC,1480,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Casting,PX01490.01,CDM,964,RC,1490,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Procedure,PX01462.01,CDM,964,RC,1462,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Revision,PX01484.01,CDM,964,RC,1484,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Surgery,PX01470.01,CDM,964,RC,1470,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Surgery,PX01474.01,CDM,964,RC,1474,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Vein Surg,PX01520.01,CDM,964,RC,1520,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Vein Surg,PX01522.01,CDM,964,RC,1522,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lumbar Puncture,PX00635.01,CDM,964,RC,635,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lung Chest Wall Surg,PX00546.01,CDM,964,RC,546,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lwr Arm Artery Surg,PX01840.01,CDM,964,RC,1840,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lwr Arm Embolectomy,PX01842.01,CDM,964,RC,1842,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lwr Arm Vein Repair,PX01852.01,CDM,964,RC,1852,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lwr Leg Embolectomy,PX01502.01,CDM,964,RC,1502,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Major Vein Ligation,PX00882.01,CDM,964,RC,882,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth N Block/Inj Prone,PX01992.01,CDM,964,RC,1992,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Neck Organ 1 & Over,PX00320.01,CDM,964,RC,320,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Neck Vessel Surgery,PX00350.01,CDM,964,RC,350,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Neck Vessel Surgery,PX00352.01,CDM,964,RC,352,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Nerve Block/Inj,PX01991.01,CDM,964,RC,1991,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Nose/Sinus Surgery,PX00160.01,CDM,964,RC,160,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Nose/Sinus Surgery,PX00162.01,CDM,964,RC,162,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth One Lung Ventilation,PX00541.01,CDM,964,RC,541,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pacemaker Insertion,PX00530.01,CDM,964,RC,530,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pancreas Removal,PX00794.01,CDM,964,RC,794,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvic Organ Surg,PX00848.01,CDM,964,RC,848,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvic Tumor Surgery,PX01150.01,CDM,964,RC,1150,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvis Nerve Removal,PX01180.01,CDM,964,RC,1180,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvis Nerve Removal,PX01190.01,CDM,964,RC,1190,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvis Procedure,PX01160.01,CDM,964,RC,1160,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvis Surgery,PX00844.01,CDM,964,RC,844,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvis Surgery,PX01120.01,CDM,964,RC,1120,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvis Surgery,PX01170.01,CDM,964,RC,1170,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Penis Nodes Removal,PX00934.01,CDM,964,RC,934,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Penis Nodes Removal,PX00936.01,CDM,964,RC,936,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Perc Img Dx Sp Proc,PX01935.01,CDM,964,RC,1935,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Perc Img Tx Sp Proc,PX01936.01,CDM,964,RC,1936,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Perineal Surgery,PX00904.01,CDM,964,RC,904,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pharyngeal Surgery,PX00174.01,CDM,964,RC,174,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pharyngeal Surgery,PX00176.01,CDM,964,RC,176,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Procedure on Femur,PX01220.01,CDM,964,RC,1220,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Procedure on Mouth,PX00170.01,CDM,964,RC,170,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Procedures on Eye,PX00140.01,CDM,964,RC,140,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Radical Femur Surg,PX01234.01,CDM,964,RC,1234,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Radical Humerus Surg,PX01756.01,CDM,964,RC,1756,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Radical Leg Surgery,PX01482.01,CDM,964,RC,1482,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Release of Lung,PX00542.01,CDM,964,RC,542,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Adrenal,PX00866.01,CDM,964,RC,866,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Bladder,PX00864.01,CDM,964,RC,864,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Nerves,PX00622.01,CDM,964,RC,622,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Nerves,PX00632.01,CDM,964,RC,632,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Prostate,PX00865.01,CDM,964,RC,865,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Prostate,PX00908.01,CDM,964,RC,908,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Rib,PX00470.01,CDM,964,RC,470,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Testis,PX00926.01,CDM,964,RC,926,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Testis,PX00928.01,CDM,964,RC,928,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Vulva,PX00906.01,CDM,964,RC,906,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Cervix,PX00948.01,CDM,964,RC,948,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Cleft Lip,PX00102.01,CDM,964,RC,102,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Hernia,PX00750.01,CDM,964,RC,750,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Hernia,PX00752.01,CDM,964,RC,752,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Hernia,PX00754.01,CDM,964,RC,754,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Hernia,PX00756.01,CDM,964,RC,756,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Hernia,PX00830.01,CDM,964,RC,830,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Hernia,PX00832.01,CDM,964,RC,832,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Revise Hip Repair,PX01215.01,CDM,964,RC,1215,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Salivary Gland,PX00100.01,CDM,964,RC,100,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Artery Surg,PX01650.01,CDM,964,RC,1650,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Casting,PX01680.01,CDM,964,RC,1680,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Joint Amput,PX01634.01,CDM,964,RC,1634,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Procedure,PX01620.01,CDM,964,RC,1620,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Replacement,PX01638.01,CDM,964,RC,1638,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Vein Surg,PX01670.01,CDM,964,RC,1670,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Vessel Surg,PX01652.01,CDM,964,RC,1652,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Vessel Surg,PX01654.01,CDM,964,RC,1654,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Sitting Procedure,PX00604.01,CDM,964,RC,604,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Skin Ext/per/Atrunk,PX00400.01,CDM,964,RC,400,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Skull Drainage,PX00212.01,CDM,964,RC,212,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Skull Drainage,PX00214.01,CDM,964,RC,214,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Skull Repair/Fract,PX00215.01,CDM,964,RC,215,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Special Head Surgery,PX00218.01,CDM,964,RC,218,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Sperm Duct Surgery,PX00922.01,CDM,964,RC,922,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Spine Cord Surgery,PX00600.01,CDM,964,RC,600,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Spine Cord Surgery,PX00620.01,CDM,964,RC,620,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Spine Cord Surgery,PX00630.01,CDM,964,RC,630,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Spine Cord Surgery,PX00670.01,CDM,964,RC,670,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Spine Manipulation,PX00640.01,CDM,964,RC,640,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Sternal Debridement,PX00550.01,CDM,964,RC,550,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Stone Removal,PX00918.01,CDM,964,RC,918,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surg Lower Abdomen,PX00840.01,CDM,964,RC,840,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surg on Vag/Urethral,PX00942.01,CDM,964,RC,942,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surg Upper Abdomen,PX00790.01,CDM,964,RC,790,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery for Obesity,PX00797.01,CDM,964,RC,797,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Abdomen,PX00860.01,CDM,964,RC,860,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Breast,PX00402.01,CDM,964,RC,402,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Breast,PX00404.01,CDM,964,RC,404,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Breast,PX00406.01,CDM,964,RC,406,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Femur,PX01230.01,CDM,964,RC,1230,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Rib(S),PX00474.01,CDM,964,RC,474,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Shoulder,PX00450.01,CDM,964,RC,450,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Shoulder,PX00452.01,CDM,964,RC,452,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Shoulder,PX01610.01,CDM,964,RC,1610,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Shoulder,PX01630.01,CDM,964,RC,1630,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Testis Exploration,PX00924.01,CDM,964,RC,924,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Testis Suspension,PX00930.01,CDM,964,RC,930,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Thigh Arteries Surg,PX01270.01,CDM,964,RC,1270,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Trach-Bronch Reconst,PX00539.01,CDM,964,RC,539,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Trachea Bronchi Surg,PX00548.01,CDM,964,RC,548,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Trans Resect of Prostate,PX00914.01,CDM,964,RC,914,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Tubal Ligation,PX00851.01,CDM,964,RC,851,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Tympanotomy,PX00126.01,CDM,964,RC,126,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Upper Arm Surgery,PX01740.01,CDM,964,RC,1740,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Upper Arm Vein Surg,PX01780.01,CDM,964,RC,1780,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Upper GI Visualize,PX00740.01,CDM,964,RC,740,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Upper Leg Surgery,PX01250.01,CDM,964,RC,1250,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Upper Leg Veins Surg,PX01260.01,CDM,964,RC,1260,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Uppr Arm Artery Surg,PX01770.01,CDM,964,RC,1770,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Uppr Arm Embolectomy,PX01772.01,CDM,964,RC,1772,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Uppr Arm Procedure,PX01730.01,CDM,964,RC,1730,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Uppr Arm Tendon Surg,PX01712.01,CDM,964,RC,1712,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Uppr Arm Tendon Surg,PX01714.01,CDM,964,RC,1714,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Uppr Arm Vein Repair,PX01782.01,CDM,964,RC,1782,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vaginal Delivery,PX01960.01,CDM,964,RC,1960,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vaginal Endoscopy,PX00950.01,CDM,964,RC,950,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vaginal Hysterectomy,PX00944.01,CDM,964,RC,944,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vaginal Procedures,PX00940.01,CDM,964,RC,940,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vascular Access,PX00532.01,CDM,964,RC,532,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vascular Shunt Surg,PX01844.01,CDM,964,RC,1844,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vasectomy,PX00921.01,CDM,964,RC,921,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vitreoretinal Surg,PX00145.01,CDM,964,RC,145,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Wrist Replacement,PX01832.01,CDM,964,RC,1832,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth/Analg Cs Hyst Add-On,PX01969.01,CDM,964,RC,1969,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth/Analg Vag Delivery,PX01967.01,CDM,964,RC,1967,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Hosp Manage Cont Drug Admin,PX01996.01,CDM,964,RC,1996,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
IMMOBILIZER SHOULDER LARGE 9008-03,120.38,CDM,274,RC,L3650,HCPCS,,906-MAIN,LOCAL,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER LARGE STRAP OSG3033,120.38,CDM,274,RC,L3650,HCPCS,,2910-MAIN,LOCAL,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER MEDIUM 9008-02,120.38,CDM,274,RC,L3650,HCPCS,,912-MAIN,LOCAL,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER MEDIUM OSG3032,120.38,CDM,274,RC,L3650,HCPCS,,915-MAIN,LOCAL,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER SMALL 9008-01,120.38,CDM,274,RC,L3650,HCPCS,,913-MAIN,LOCAL,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER SMALL WITH CLOTH 9001-02,120.38,CDM,274,RC,L3650,HCPCS,,914-MAIN,LOCAL,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER X-LARGE CLOTH 9001-05,120.38,CDM,274,RC,L3650,HCPCS,,917-MAIN,LOCAL,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER X-LARGE ORT16100XL,120.38,CDM,274,RC,L3650,HCPCS,,904-MAIN,LOCAL,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
Support for Organ Donor,PX01990.01,CDM,964,RC,1990,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Treponema Pallidum,PX86780,CDM,300,RC,86780,CPT,,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.14,35.28
Unlisted Anesth Procedure,PX01999.01,CDM,964,RC,1999,CPT,QZ,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405P,CDM,983,RC,36405,CPT,,,,,,,,36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022116,NDC,1,EA,36.33,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,32.04306,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022141,NDC,1,EA,36.33,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,32.04306,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,55150023501,NDC,0.5,EA,37.72,,First Health,Commercial,both,85,,999999999,percent of total billed charges,32.062,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598F,CDM,510,RC,97598,CPT,,,,,,,,406,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,32.07,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.59,59.31
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598P,CDM,982,RC,97598,CPT,,,,,,,,325,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,32.07,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.59,318.5
Xray Cervical Spine 6 or More Vws,PX7205201,CDM,320,RC,72052,CPT,TC,,,,,,,664,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,32.07,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.85,95.32
Xray Cervical Spine 6 or More Vws,PX7205201,CDM,320,RC,72052,CPT,TC,,,,,,,664,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,32.07,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.85,95.32
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323042605,NDC,5,ML,64.8,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,32.076,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,436067216,NDC,473,ML,77.23,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,32.081342,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,39328006412,NDC,473,ML,77.23,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,32.081342,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012250,NDC,1,EA,77.24,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,32.085496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012267,NDC,1,EA,77.24,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,32.085496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
cefOXitin 2 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021011020,NDC,1,EA,77.24,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,32.085496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.367364,75.6952
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023610,NDC,1,EA,77.24,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,32.085496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323042405,NDC,5,ML,64.82,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,32.0859,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
RETRIEVAL BAG 10MM,27200000,CDM,272,RC,,,,11707-MAIN,LOCAL,,,,,74.8,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,32.0892,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Cytogen, Interp/Report - Ref",PX8829190,CDM,310,RC,88291,CPT,90,,,,,,,2874,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,32.09,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.68,53.2
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608210,NDC,1,ML,63.43,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,32.09558,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
neomycin-bacitracin-polymyxin 3.5-400-5000 Ointment 28 g Tube,25000000,CDM,250,RC,,,,,,45802014303,NDC,28,GR,37.76,,First Health,Commercial,both,85,,999999999,percent of total billed charges,32.096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
calcium CHLORIDE 10 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409163140,NDC,10,ML,64.85,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,32.10075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
charcoal activated Liquid 240 mL Bottle,63700001,CDM,250,RC,,,,,,574012108,NDC,120,ML,66.88,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,32.1024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
charcoal activated Liquid 240 mL Bottle,63700001,CDM,250,RC,,,,,,574012108,NDC,120,ML,66.88,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,32.1024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019602,NDC,2,ML,77.29,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,32.106266,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
CATHETER FOLEY 18FR  3WAY 30CC 73018L,120.21,CDM,272,RC,A4346,HCPCS,,253-MAIN,LOCAL,,,,,33,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,32.1189,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
CATHETER FOLEY 20FR 3WAY 30CC 0167L20,120.21,CDM,272,RC,A4346,HCPCS,,251-MAIN,LOCAL,,,,,33,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,32.1189,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
CATHETER FOLEY 24FR 3WAY 30CC 0167L24,120.21,CDM,272,RC,A4346,HCPCS,,10455-MAIN,LOCAL,,,,,33,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,32.1189,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
"DRESSING AQUACEL 3/4"" X 18"" AG HYDROFIBER 403771",120.31,CDM,272,RC,A6199,HCPCS,,8238-MAIN,LOCAL,,,,,33,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,32.1189,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,32.34
Hospital Outpatient Clinic Visit Specimen Collection for Sars-Cov-2,PXC9803,CDM,300,RC,C9803,HCPCS,,,,,,,,33,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,32.1189,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,32.34
MEPILEX AG 4X4 10X10,120.138,CDM,272,RC,A6213,HCPCS,,7248-MAIN,LOCAL,,,,,33,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,32.1189,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,32.34
STANDARD HIGH FLOW INSUFFLATION FILTER TUBING,27200000,CDM,272,RC,,,,11885-MAIN,LOCAL,,,,,33,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,32.1189,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,67457043800,NDC,0.5,EA,36.11,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.1379,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,67457043810,NDC,0.5,EA,36.11,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.1379,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028036,NDC,2,ML,36.12,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.1468,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143966001,NDC,5,ML,37.82,,First Health,Commercial,both,85,,999999999,percent of total billed charges,32.147,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143966010,NDC,5,ML,37.82,,First Health,Commercial,both,85,,999999999,percent of total billed charges,32.147,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606001,NDC,10,ML,65.62,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,3,percent of total billed charges,32.1538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606001,NDC,10,ML,65.62,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,32.1538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606001,NDC,10,ML,65.62,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,32.1538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606010,NDC,10,ML,65.62,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,3,percent of total billed charges,32.1538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606010,NDC,10,ML,65.62,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,32.1538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606010,NDC,10,ML,65.62,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,32.1538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
Group Therapeutic Procedures,PX97150,CDM,420,RC,97150,CPT,,,,,,,,67,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,32.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.82,65.66
Group Therapeutic Procedures,PX97150,CDM,420,RC,97150,CPT,,,,,,,,67,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,32.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.82,65.66
"Hydroxyprogesterone, 17-D - Ref",PX8349890,CDM,300,RC,83498,CPT,90,,,,,,,67,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,32.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.91,65.66
"Hydroxyprogesterone, 17-D - Ref",PX8349890,CDM,300,RC,83498,CPT,90,,,,,,,67,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,32.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.91,65.66
Lab Org ID Anaerobic-Each,PX87076,CDM,300,RC,87076,CPT,,,,,,,,67,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,32.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,65.66
Lab Org ID Anaerobic-Each,PX87076,CDM,300,RC,87076,CPT,,,,,,,,67,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,32.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,65.66
inFLIXimab 100 MG Recon Soln 1 Each Vial,J1745.01,CDM,636,RC,J1745,HCPCS,,,,57894003001,NDC,1,EA,2382.35,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,32.16,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.3,32.16
budesonide 1 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097032187,NDC,1,ML,64.97,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,32.16015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323020103,NDC,10,ML,36.14,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.1646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,487960130,NDC,2,ML,36.47,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,32.16654,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,55150020200,NDC,1,EA,65.65,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,24.94142857,percent of total billed charges,32.1685,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,55150020200,NDC,1,EA,65.65,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,32.1685,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,55150020200,NDC,1,EA,65.65,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,32.1685,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
"B.Burgdorferi, Amp Probe - Ref",PX8747690,CDM,300,RC,87476,CPT,90,,,,,,,72,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,32.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.9088,70.56
"Chlamydia Trachomatis Dna, Amp Probe",PX87491,CDM,300,RC,87491,CPT,,,,,,,,157,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,32.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,153.86
"Cmv Detect, Amplifi Probe - Ref",PX8749690,CDM,300,RC,87496,CPT,90,,,,,,,147,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,32.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,144.06
Detect Agent Nos Dna Amp,PX87798,CDM,300,RC,87798,CPT,,,,,,,,176,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,32.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,172.48
Detection of Anaplasma Phagocytophilum by Amplified Nucleic Acid Probe Technique,PX8746890,CDM,300,RC,87468,CPT,90,,,,,,,41,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,32.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
Detection of Babesia Borrelia Miyamotoi by Amplified Nucleic Acid Probe Technique,PX8747890,CDM,300,RC,87478,CPT,90,,,,,,,23,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,32.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,32.17
Detection of Babesia Microtim by Amplified Nucleic Acid Probe Technique,PX8746990,CDM,300,RC,87469,CPT,90,,,,,,,23,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,32.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,32.17
Detection of Ehrlichia Chaffeensis by Amplified Nucleic Acid Probe Technique,PX8748490,CDM,300,RC,87484,CPT,90,,,,,,,41,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,32.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
"Hsv Detect, Amplif Probe - Ref",PX8752990,CDM,300,RC,87529,CPT,90,,,,,,,150,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,32.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,147
Hsv Dna Amp Probe,PX87529,CDM,300,RC,87529,CPT,,,,,,,,145,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,32.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,142.1
Iadna Streptococcus Group a Amplified Probe Tq,PX87651,CDM,300,RC,87651,CPT,,,,,,,,113,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,32.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,110.74
"Infect Ea Organ, Amp Prob - Ref",PX8779890,CDM,300,RC,87798,CPT,90,,,,,,,180,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,32.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,176.4
Mrsa by Amplification Na,PX87641,CDM,300,RC,87641,CPT,,,,,,,,180,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,32.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,176.4
"Neisseria Gonorrhoeae Dna, Amp Probe",PX87591,CDM,300,RC,87591,CPT,,,,,,,,157,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,32.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,153.86
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,55150025110,NDC,10,ML,37.85,,First Health,Commercial,both,85,,999999999,percent of total billed charges,32.1725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Alkaloids, Not Otherwise Specified - Ref",PX8032390,CDM,300,RC,80323,CPT,90,,,,,,,65,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,32.175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.001,63.7
Anesthesia Level 3,PX37000017,CDM,370,RC,,,,,,,,,,65,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,32.175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.001,63.7
Assay Cryofibrinogen,PX82585,CDM,300,RC,82585,CPT,,,,,,,,75,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,32.175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.96,73.5
Assay Cryoglobulin,PX82595,CDM,300,RC,82595,CPT,,,,,,,,75,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,32.175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,73.5
BINDER ABDOMINAL 9 INCH 46 TO 62 INCH XL ORT21100LXL,120.238,CDM,271,RC,A4467,HCPCS,,2989-MAIN,LOCAL,,,,,75,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,32.175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL 9 INCH 63 TO 74 INCH 3- PANEL ORT211002XL,120.238,CDM,271,RC,A4467,HCPCS,,37-MAIN,LOCAL,,,,,75,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,32.175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL 10 INCH 26 TO 50 INCHES ABB1050,120.238,CDM,271,RC,A4467,HCPCS,,52-MAIN,LOCAL,,,,,75,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,32.175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
"BINDER ABDOMINAL 12"" HIGH 2XL 60-75INCH 4 PANEL ORT213002XL",120.238,CDM,271,RC,A4467,HCPCS,,12536-MAIN,LOCAL,,,,,75,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,32.175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL UNISIZE 46-62IN 9 IN MDS169024,120.238,CDM,271,RC,A4467,HCPCS,,63-MAIN,LOCAL,,,,,75,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,32.175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
Clozapine - Ref,PX8015990,CDM,300,RC,80159,CPT,90,,,,,,,65,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,32.175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.48,63.7
"Direct skilled nursing services of a license practical nurse (lpn) in the home health or hospice setting, each 15 minutes",PXG0300,CDM,551,RC,G0300,HCPCS,,,,,,,,75,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,32.175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
Gastrin - Ref,PX8294190,CDM,300,RC,82941,CPT,90,,,,,,,65,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,32.175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.16,63.7
HH Rn Initial Visit,PXG0154,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,32.175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
HH Rn Routine Visit,PXG0154.01,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,32.175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
Insulin Ab - Ref,PX8633790,CDM,300,RC,86337,CPT,90,,,,,,,65,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,32.175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.63,63.7
Resp Muscles 1:1 per 15 Min,PXG0237,CDM,948,RC,G0237,HCPCS,,,,,,,,65,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,32.175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.01,63.7
Skilled Srvc of a Lpn in Training and/or Education of Pt or Fam Ea 15 Min,PXG0496,CDM,551,RC,G0496,HCPCS,,,,,,,,75,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,32.175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
Skilled srvc of an RN in training and/or education of pt or fam ea 15 min,PXG0495,CDM,551,RC,G0495,HCPCS,,,,,,,,75,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,32.175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
Smking Cess 4-10 Min,PX99406F,CDM,942,RC,99406,CPT,,,,,,,,65,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,32.175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.07,63.7
colchicine 0.6 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,49884017111,NDC,1,EA,36.17,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.1913,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 25 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,591319872,NDC,1,EA,77.51,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,32.197654,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tobramycin 80 MG/2ML Solution 2 mL Vial,J3260.01,CDM,636,RC,J3260,HCPCS,,,,67457047300,NDC,2,ML,33.09,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,32.206497,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.745586,32.4282
Joint Survey,PX7707726,CDM,982,RC,77077,CPT,26,,,,,,,286,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,32.21,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.25,280.28
Joint Survey,PX7707726,CDM,982,RC,77077,CPT,26,,,,,,,286,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,32.21,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.25,280.28
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,409710709,NDC,1000,ML,36.53,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,32.21946,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5% and sodium chloride 0.45% with potassium chloride 10 mEq in 1000 mL 10-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,264763400,NDC,1000,ML,36.53,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,32.21946,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
triamcinolone acetonide 0.1 % Cream 80 g Tube,63700001,CDM,250,RC,,,,,,16714098603,NDC,80,GR,65.76,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,32.2224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
triamcinolone acetonide 0.1 % Cream 80 g Tube,63700001,CDM,250,RC,,,,,,16714098603,NDC,80,GR,65.76,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,32.2224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
triamcinolone acetonide 0.1 % Cream 80 g Tube,63700001,CDM,250,RC,,,,,,16714098603,NDC,80,GR,65.76,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,32.2224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143978410,NDC,2,ML,37.91,,First Health,Commercial,both,85,,999999999,percent of total billed charges,32.2235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
benzocaine-menthol 20-0.5 % Aerosol 78 g Can,63700001,CDM,250,RC,,,,,,75137085520,NDC,78,GR,35.38,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.23118,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189103,NDC,1,ML,32.89,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,32.2322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
PHENobarbital 130 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047721,NDC,1,ML,338.93,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,32.23434,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.66,32.8
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047621,NDC,1,ML,157.28,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,32.23434,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.66,32.8
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047625,NDC,0.769230769,ML,111.59,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,32.23434,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.66,32.8
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,713013512,NDC,1,EA,65.83,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,32.2567,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.345782,66.2186
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,713013512,NDC,1,EA,65.83,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,32.2567,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.345782,66.2186
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,713013512,NDC,1,EA,65.83,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,32.2567,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.345782,66.2186
KIT ENDO COMPLETE PROCEDURE CARRY-ON 100802,27200000,CDM,272,RC,,,,10369-MAIN,LOCAL,,,,,33.15,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,32.264895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
miconazole 2 % Powder 85 g Bottle,25000000,CDM,250,RC,,,,,,67094930,NDC,85,GR,35.43,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.27673,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Apply Long Leg Splint,PX29505F,CDM,510,RC,29505,CPT,,,,,,,,320,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,32.28,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.28,190.25
Apply Long Leg Splint,PX29505P,CDM,983,RC,29505,CPT,,,,,,,,385,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,32.28,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.28,377.3
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084007001,NDC,1,EA,33.17,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,32.284361,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
riTUXimab-abbs 500 MG/50ML Solution 50 mL Vial,Q5115.01,CDM,636,RC,Q5115,HCPCS,,,,63459010450,NDC,50,ML,8624.61,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,32.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.29,8452.1178
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,43598040516,NDC,0.2,ML,63.83,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,32.29798,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
ePHEDrine sulfate 50 MG/ML Solution 1 mL Vial,25000000,CDM,250,RC,,,,,,42023021689,NDC,0.1,ML,36.62,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,32.29884,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
8MM-12MM CANNULA SEAL 5-8MM,27200000,CDM,272,RC,,,,11921-MAIN,LOCAL,,,,,38,,First Health,Commercial,both,85,,999999999,percent of total billed charges,32.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRAPE COLUMN 470341,27200000,CDM,272,RC,,,,12013-MAIN,LOCAL,,,,,38,,First Health,Commercial,both,85,,999999999,percent of total billed charges,32.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HH Hha Visit,PXG0156,CDM,571,RC,G0156,HCPCS,,,,,,,,38,,First Health,Commercial,both,85,,999999999,percent of total billed charges,32.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
Mitochondrial Antibody Each,PX8638190,CDM,300,RC,86381,CPT,90,,,,,,,38,,First Health,Commercial,both,85,,999999999,percent of total billed charges,32.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
Nasal Sm for Eos,PX89190,CDM,300,RC,89190,CPT,,,,,,,,38,,First Health,Commercial,both,85,,999999999,percent of total billed charges,32.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.31,37.24
NEEDLE IV 19GA X .75IN HUBER POWERLOC SAFETY 0651934,120.85,CDM,272,RC,A4215,HCPCS,,12701-MAIN,LOCAL,,,,,38,,First Health,Commercial,both,85,,999999999,percent of total billed charges,32.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
NEEDLE IV 19GA X 1 IN HUBER POWERLOC SAFETY 0651910,120.85,CDM,272,RC,A4215,HCPCS,,12702-MAIN,LOCAL,,,,,38,,First Health,Commercial,both,85,,999999999,percent of total billed charges,32.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
NEEDLE IV 19GA X 1.5 IN HUBER POWERLOC SAFETY 0651915,120.85,CDM,272,RC,A4215,HCPCS,,12703-MAIN,LOCAL,,,,,38,,First Health,Commercial,both,85,,999999999,percent of total billed charges,32.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
PEZZER CATHETER DRAIN LATEX 14FR,27200000,CDM,272,RC,,,,12053-MAIN,LOCAL,,,,,38,,First Health,Commercial,both,85,,999999999,percent of total billed charges,32.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PEZZER LATEX CATHETER DRAIN 10FR,27200000,CDM,272,RC,,,,12646-MAIN,LOCAL,,,,,38,,First Health,Commercial,both,85,,999999999,percent of total billed charges,32.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PNEUVIEW SMOKE ELIMINATOR,27200000,CDM,272,RC,,,,11884-MAIN,LOCAL,,,,,38,,First Health,Commercial,both,85,,999999999,percent of total billed charges,32.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Psa, Free - Ref",PX8415490,CDM,300,RC,84154,CPT,90,,,,,,,38,,First Health,Commercial,both,85,,999999999,percent of total billed charges,32.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
"Psa, Total - Ref",PX8415390,CDM,300,RC,84153,CPT,90,,,,,,,38,,First Health,Commercial,both,85,,999999999,percent of total billed charges,32.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
SPECULUM VAGINAL WITH BUILT IN LIGHT LARGE,120.133,CDM,272,RC,,,,8251-MAIN,LOCAL,,,,,38,,First Health,Commercial,both,85,,999999999,percent of total billed charges,32.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
SPECULUM VAGINAL WITH BUILT IN LIGHT MEDIUM,120.133,CDM,272,RC,,,,8250-MAIN,LOCAL,,,,,38,,First Health,Commercial,both,85,,999999999,percent of total billed charges,32.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
SPECULUM VAGINAL WITH BUILT IN LIGHT SMALL,120.133,CDM,272,RC,,,,8249-MAIN,LOCAL,,,,,38,,First Health,Commercial,both,85,,999999999,percent of total billed charges,32.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
TROCAR KII FIOS SYSTEM BLADELSS Z-THREAD 5MMX100MM,27200000,CDM,272,RC,,,,12003-MAIN,LOCAL,,,,,38,,First Health,Commercial,both,85,,999999999,percent of total billed charges,32.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
apixaban 2.5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,3089321,NDC,1,EA,63.84,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,32.30304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084007011,NDC,1,EA,33.19,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,32.303827,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rivaroxaban 15 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50458057830,NDC,0.666666667,EA,67.3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,32.304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rivaroxaban 15 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50458057830,NDC,0.666666667,EA,67.3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,32.304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022143,NDC,1,EA,36.31,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.3159,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987525,NDC,3,ML,33.22,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,32.333026,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022116,NDC,1,EA,36.33,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.3337,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022141,NDC,1,EA,36.33,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.3337,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
CATHETER FOLEY 18FR  3WAY 30CC 73018L,120.21,CDM,272,RC,A4346,HCPCS,,253-MAIN,LOCAL,,,,,33,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,32.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
CATHETER FOLEY 20FR 3WAY 30CC 0167L20,120.21,CDM,272,RC,A4346,HCPCS,,251-MAIN,LOCAL,,,,,33,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,32.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
CATHETER FOLEY 24FR 3WAY 30CC 0167L24,120.21,CDM,272,RC,A4346,HCPCS,,10455-MAIN,LOCAL,,,,,33,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,32.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
"DRESSING AQUACEL 3/4"" X 18"" AG HYDROFIBER 403771",120.31,CDM,272,RC,A6199,HCPCS,,8238-MAIN,LOCAL,,,,,33,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,32.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,32.34
Hospital Outpatient Clinic Visit Specimen Collection for Sars-Cov-2,PXC9803,CDM,300,RC,C9803,HCPCS,,,,,,,,33,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,32.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,32.34
Ig Paraprotein Qual Bld/UR,PX0077U90,CDM,300,RC,0077U,HCPCS,90,,,,,,,66,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,32.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
Ig Paraprotein Qual Bld/UR,PX0077U90,CDM,300,RC,0077U,HCPCS,90,,,,,,,66,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,32.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
Ig Paraprotein Qual Bld/UR,PX0077U90,CDM,300,RC,0077U,HCPCS,90,,,,,,,66,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,32.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
"Level III - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3933,CDM,310,RC,88304,CPT,TC,,,,,,,66,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,13.2,percent of total billed charges,32.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
"Level III - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3933,CDM,310,RC,88304,CPT,TC,,,,,,,66,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,32.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
"Level III - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3933,CDM,310,RC,88304,CPT,TC,,,,,,,66,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,32.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
MEPILEX AG 4X4 10X10,120.138,CDM,272,RC,A6213,HCPCS,,7248-MAIN,LOCAL,,,,,33,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,32.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,32.34
Ot Contracted Service/Msho/MA,PX120.178,CDM,431,RC,,,,,,,,,,66,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,32.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
Ot Contracted Service/Msho/MA,PX120.178,CDM,431,RC,,,,,,,,,,66,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,32.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
Ot Contracted Service/Msho/MA,PX120.178,CDM,431,RC,,,,,,,,,,66,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,32.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
Pt Contracted Service/Msho,PX120.176,CDM,421,RC,,,,,,,,,,66,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,32.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
Pt Contracted Service/Msho,PX120.176,CDM,421,RC,,,,,,,,,,66,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,32.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
Pt Contracted Service/Msho,PX120.176,CDM,421,RC,,,,,,,,,,66,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,32.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
STANDARD HIGH FLOW INSUFFLATION FILTER TUBING,27200000,CDM,272,RC,,,,11885-MAIN,LOCAL,,,,,33,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,32.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Surg Pathology-Level 2-Tc,PX3932,CDM,310,RC,88302,CPT,TC,,,,,,,66,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,32.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.01,64.68
Surg Pathology-Level 2-Tc,PX3932,CDM,310,RC,88302,CPT,TC,,,,,,,66,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,32.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.01,64.68
Surg Pathology-Level 2-Tc,PX3932,CDM,310,RC,88302,CPT,TC,,,,,,,66,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,32.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.01,64.68
Xray Orbits Optic Foramina,PX7019001,CDM,320,RC,70190,CPT,TC,,,,,,,66,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,32.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,79.39
Xray Orbits Optic Foramina,PX7019001,CDM,320,RC,70190,CPT,TC,,,,,,,66,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,32.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,79.39
Xray Orbits Optic Foramina,PX7019001,CDM,320,RC,70190,CPT,TC,,,,,,,66,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,32.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,79.39
DRAPE SHEET LAP T-DRAPE WITH INSTRUMENT PAD DYNJP3003,27200000,CDM,272,RC,,,,10913-MAIN,LOCAL,,,,,35.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.3405,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
valACYclovir 1 GM Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862044930,NDC,0.5,EA,33.23,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,32.342759,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331601,NDC,10,ML,77.86,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,32.343044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004703,NDC,1,EA,75.45,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,32.36805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409493311,NDC,10,ML,66.06,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,150.5666667,percent of total billed charges,32.3694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409493311,NDC,10,ML,66.06,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,32.3694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409493311,NDC,10,ML,66.06,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,32.3694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
belimumab (400v) 400 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010201,NDC,1,EA,3523.71,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,32.37,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.37,53.14484
belimumab 120 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010101,NDC,1,EA,1015.95,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,32.37,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.37,53.14484
droPERidol 2.5 MG/ML Solution 2 mL Vial,J1790.01,CDM,636,RC,J1790,HCPCS,,,,517970201,NDC,2,ML,75.47,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,32.37663,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.350238,73.9606
Blood Occult Peroxidase,PX82272,CDM,300,RC,82272,CPT,,,,,,,,64,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,32.384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.88,62.72
Strapping of Elbow or Wrist,PX29260F,CDM,420,RC,29260,CPT,,,,,,,,64,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,32.384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.5856,62.72
Strapping of Hand or Finger,PX29280F,CDM,420,RC,29280,CPT,,,,,,,,64,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,32.384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.5856,62.72
Iaad Ia Severe Aqt Respir Synd Coronavirus,PX87426,CDM,300,RC,87426,CPT,,,,,,,,159,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,32.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.39,155.82
Ceruloplasmin - Ref,PX8239090,CDM,300,RC,82390,CPT,90,,,,,,,78,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,32.4012,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,76.44
Chemiluminescent Assay - Ref,PX8239790,CDM,300,RC,82397,CPT,90,,,,,,,78,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,32.4012,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.95,76.44
VISUALIZATION SYSTEM CLEARIFY LAPAROSCOPE STERILE,27200000,CDM,272,RC,,,,11875-MAIN,LOCAL,,,,,78,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,32.4012,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046837,NDC,30,ML,75.54,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,32.40666,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253022233,NDC,3,ML,38.13,,First Health,Commercial,both,85,,999999999,percent of total billed charges,32.4105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
benzocaine-menthol 20-0.5 % Aerosol 56 g Can,63700001,CDM,250,RC,,,,,,16864068002,NDC,56,GR,33.3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,32.41089,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078121,NDC,0.5,EA,36.75,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,32.4135,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078141,NDC,0.5,EA,36.75,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,32.4135,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990711509,NDC,1000,ML,64.08,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,32.42448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
tobramycin 80 MG/2ML Solution 2 mL Vial,J3260.01,CDM,636,RC,J3260,HCPCS,,,,67457047300,NDC,2,ML,33.09,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,32.4282,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.745586,32.4282
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,58602060407,NDC,100,GR,67.56,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,32.4288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,58602060407,NDC,100,GR,67.56,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,32.4288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,574722612,NDC,1,EA,67.57,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,32.4336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.345782,66.2186
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,574722612,NDC,1,EA,67.57,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,32.4336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.345782,66.2186
enalaprilat 1.25 MG/ML Injectable 2 mL Vial,25000000,CDM,250,RC,,,,,,143978601,NDC,2,ML,75.63,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,32.44527,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
HYDROmorphone 2 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409131203,NDC,1,ML,38.18,,First Health,Commercial,both,85,,999999999,percent of total billed charges,32.453,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,487960130,NDC,2,ML,36.47,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.4583,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
perflutren protein A microsphere Suspension 3 mL Vial,Q9956,CDM,636,RC,Q9956,HCPCS,,,,407270703,NDC,3,ML,739.41,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,32.46,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.56,43.68686
perflutren protein A microsphere Suspension 3 mL Vial,Q9956,CDM,636,RC,Q9956,HCPCS,,,,407270703,NDC,3,ML,739.41,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,32.46,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.56,43.68686
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,24208031510,NDC,10,ML,75.67,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,32.46243,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Pulmonary Stress Test,PX94618,CDM,976,RC,94618,CPT,,,,,,,,153,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,32.4715,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.38,149.94
aspirin-dipyridamole 25-200 MG Capsule Extended Release 12 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687030533,NDC,1,EA,67.66,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,32.4768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin-dipyridamole 25-200 MG Capsule Extended Release 12 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687030533,NDC,1,EA,67.66,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,32.4768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin-dipyridamole 25-200 MG Capsule Extended Release 12 Hour 20 Each Box,63700001,CDM,250,RC,,,,,,60687030532,NDC,1,EA,67.66,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,32.4768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin-dipyridamole 25-200 MG Capsule Extended Release 12 Hour 20 Each Box,63700001,CDM,250,RC,,,,,,60687030532,NDC,1,EA,67.66,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,32.4768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,25021011487,NDC,200,ML,66.28,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,32.4772,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.20921,64.9544
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,25021011487,NDC,200,ML,66.28,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,32.4772,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.20921,64.9544
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,25021011487,NDC,200,ML,66.28,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,32.4772,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.20921,64.9544
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606001,NDC,10,ML,65.62,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,32.4819,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606010,NDC,10,ML,65.62,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,32.4819,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
KIT ENDO COMPLETE PROCEDURE CARRY-ON 100802,27200000,CDM,272,RC,,,,10369-MAIN,LOCAL,,,,,33.15,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,32.487,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
levothyroxine Sodium 200 MCG Recon Soln 1 Each Vial,J0650.01,CDM,636,RC,J0650,HCPCS,,,,63323064710,NDC,0.0625,EA,75.75,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,32.49675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.46655,74.235
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,55150020200,NDC,1,EA,65.65,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,32.49675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
Debride Muscle Ea Add 20 Sqcm,PX11046F,CDM,510,RC,11046,CPT,,,,,,,,248,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,32.5,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.5,151.5
Debride Muscle Ea Add 20 Sqcm,PX11046P,CDM,983,RC,11046,CPT,,,,,,,,198,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,32.5,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.5,194.04
buprenorphine 75 MCG FILM 1 Each Package,63700001,CDM,250,RC,,,,,,59385002101,NDC,1,EA,35.68,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.50448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084007001,NDC,1,EA,33.17,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,32.5066,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,16714081701,NDC,1,EA,75.78,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,32.50962,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037604,NDC,0.75,ML,36.86,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,32.51052,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,409710709,NDC,1000,ML,36.53,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.5117,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5% and sodium chloride 0.45% with potassium chloride 10 mEq in 1000 mL 10-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,264763400,NDC,1000,ML,36.53,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.5117,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BIOPSY FORCEPS HOT,27200000,CDM,272,RC,,,,4353-MAIN,LOCAL,,,,,38.25,,First Health,Commercial,both,85,,999999999,percent of total billed charges,32.5125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRESSING GEL FOAM SIZE 100SPONGE STERILE 00009034201,27200000,CDM,272,RC,A6248,HCPCS,,3378-MAIN,LOCAL,,,,,38.25,,First Health,Commercial,both,85,,999999999,percent of total billed charges,32.5125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFFLATION TUBING SET,27200000,CDM,272,RC,,,,4686-MAIN,LOCAL,,,,,38.25,,First Health,Commercial,both,85,,999999999,percent of total billed charges,32.5125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LAP KIT BASIC,27200000,CDM,272,RC,,,,4829-MAIN,LOCAL,,,,,78.29,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,32.521666,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ciprofloxacin 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084007011,NDC,1,EA,33.19,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,32.5262,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323031119,NDC,10,ML,66.39,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.141,percent of total billed charges,32.5311,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,84.5054
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323031119,NDC,10,ML,66.39,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,32.5311,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,84.5054
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323031119,NDC,10,ML,66.39,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,32.5311,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,84.5054
triamcinolone acetonide 0.1 % Cream 80 g Tube,63700001,CDM,250,RC,,,,,,16714098603,NDC,80,GR,65.76,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,32.5512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987525,NDC,3,ML,33.22,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,32.5556,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
Neuromuscular Re-Education,PX97112,CDM,420,RC,97112,CPT,,,,,,,,135,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,32.5624,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.28,44.37
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,69543025204,NDC,118,ML,78.39,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,32.563206,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
valACYclovir 1 GM Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862044930,NDC,0.5,EA,33.23,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,32.5654,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 1 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409128303,NDC,1,ML,36.93,,United Healthcare,All Payer,outpatient,88.2,,34.74,percent of total billed charges,32.57226,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078110,NDC,0.5,EA,38.33,,First Health,Commercial,both,85,,999999999,percent of total billed charges,32.5805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039801,NDC,1,EA,67.88,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,32.5824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039801,NDC,1,EA,67.88,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,32.5824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039810,NDC,1,EA,67.88,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,32.5824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039810,NDC,1,EA,67.88,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,32.5824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,713013512,NDC,1,EA,65.83,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,32.58585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.345782,66.2186
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,63739003807,NDC,1,EA,66.51,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,32.5899,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,63739003807,NDC,1,EA,66.51,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,32.5899,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,63739003807,NDC,1,EA,66.51,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,32.5899,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ePHEDrine sulfate 50 MG/ML Solution 1 mL Vial,25000000,CDM,250,RC,,,,,,42023021689,NDC,0.1,ML,36.62,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.5918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
methotrexate 2.5 MG Tablet 20 Each Box,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067005,NDC,1,EA,33.49,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,32.595817,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.911746,32.8398
Assay of Blood Lipoprotein,PX83721,CDM,300,RC,83721,CPT,,,,,,,,76,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,32.604,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.63,74.48
Lab Direct Coombs,PX86880,CDM,300,RC,86880,CPT,,,,,,,,76,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,32.604,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.5704,74.48
PRONEVIEW CUSHION INSERTS LARGE,120.557,CDM,272,RC,E0190,HCPCS,,12500-MAIN,LOCAL,,,,,76,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,32.604,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.5704,74.48
SHOE POST OP LARGE MALE MQM3B,120.237,CDM,274,RC,L3260,HCPCS,,794-MAIN,LOCAL,,,,,76,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,32.604,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP LARGE SQUARE TOE WOMENS ORT30300WL,120.237,CDM,274,RC,L3260,HCPCS,,10606-MAIN,LOCAL,,,,,76,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,32.604,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP MEDIUM SQUARE TOE MALE ORT30300MM,120.237,CDM,274,RC,L3260,HCPCS,,10603-MAIN,LOCAL,,,,,76,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,32.604,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP MEDIUM SQUARE TOE WOMENS ORT30300WM,120.237,CDM,274,RC,L3260,HCPCS,,10605-MAIN,LOCAL,,,,,76,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,32.604,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP SMALL MALE 0814-1192,120.237,CDM,274,RC,L3260,HCPCS,,803-MAIN,LOCAL,,,,,76,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,32.604,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP SMALL SQUARE TOE WOMENS MQW1B,120.237,CDM,274,RC,L3260,HCPCS,,10604-MAIN,LOCAL,,,,,76,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,32.604,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
cyclopentolate 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,17478010002,NDC,2,ML,66.55,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,32.6095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
cyclopentolate 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,17478010002,NDC,2,ML,66.55,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,32.6095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
cyclopentolate 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,17478010002,NDC,2,ML,66.55,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,32.6095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
methotrexate 2.5 MG Tablet 1 Each Blister,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067001,NDC,1,EA,33.51,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,32.615283,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.911746,32.8398
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608201,NDC,1,ML,66.6,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,9.513809524,percent of total billed charges,32.634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608201,NDC,1,ML,66.6,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,32.634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608201,NDC,1,ML,66.6,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,32.634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
COLLAR CERVICAL LARGE WITH TRACH 2 PIECE PHP-T4L,120.184,CDM,274,RC,L0172,HCPCS,,10142-MAIN,LOCAL,,,,,37,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,32.634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.3698,152.79
COLLAR CERVICAL MEDIUM WITH TRACH 2 PIECE PHP-T4M,120.183,CDM,274,RC,L0172,HCPCS,,10141-MAIN,LOCAL,,,,,37,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,32.634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.3698,152.79
COLLAR CERVICAL SMALL WITH TRACH 2 PIECE PHP-T4S,120.182,CDM,274,RC,L0172,HCPCS,,10140-MAIN,LOCAL,,,,,37,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,32.634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.3698,152.79
SUTURE TICRON 0 36IN BRAIDED DYED 1/2 CIRCLE DBLE ARM 25MM CV-305 BLUE STERILE,27200000,CDM,272,RC,,,,11956-MAIN,LOCAL,,,,,37,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,32.634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
benzocaine-menthol 20-0.5 % Aerosol 56 g Can,63700001,CDM,250,RC,,,,,,16864068002,NDC,56,GR,33.3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,32.634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Flour. Afstain , Micro - Ref",PX8720690,CDM,300,RC,87206,CPT,90,,,,,,,68,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,32.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.94,66.64
"Flour. Afstain , Micro - Ref",PX8720690,CDM,300,RC,87206,CPT,90,,,,,,,68,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,32.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.94,66.64
Hemoglobin,PX85018,CDM,300,RC,85018,CPT,,,,,,,,68,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,32.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.17,66.64
Hemoglobin,PX85018,CDM,300,RC,85018,CPT,,,,,,,,68,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,32.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.17,66.64
nivolumab 40 MG/4ML Solution 4 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377211,NDC,4,ML,2171.7,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,32.64,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.35,32.64
nivolumab 100 MG/10ML Solution 10 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377412,NDC,10,ML,5429.27,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,32.64,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.35,32.64
nivolumab 240 MG/24ML Solution 24 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3373413,NDC,24,ML,13030.26,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,32.64,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.35,32.64
Thyroglobulin - Ref,PX8443290,CDM,300,RC,84432,CPT,90,,,,,,,68,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,32.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.73,66.64
Thyroglobulin - Ref,PX8443290,CDM,300,RC,84432,CPT,90,,,,,,,68,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,32.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.73,66.64
Thyroglobulin Antibody,PX8680090,CDM,300,RC,86800,CPT,90,,,,,,,68,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,32.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.59,66.64
Thyroglobulin Antibody,PX8680090,CDM,300,RC,86800,CPT,90,,,,,,,68,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,32.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.59,66.64
sodium polystyrene sulfonate Powder 15 g Bottle,25000000,CDM,250,RC,,,,,,10702003615,NDC,15,GR,76.09,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,32.64261,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024110,NDC,1,EA,76.1,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,32.6469,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,63323004401,NDC,1,ML,64.53,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,32.65218,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,63.2394
terbinafine 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714079501,NDC,1,EA,68.03,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,32.6544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terbinafine 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714079501,NDC,1,EA,68.03,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,32.6544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terbinafine 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714050101,NDC,1,EA,68.04,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,32.6592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terbinafine 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714050101,NDC,1,EA,68.04,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,32.6592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574711212,NDC,1,EA,33.56,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,32.663948,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,47781046813,NDC,1,EA,76.15,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,32.66835,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,64380079701,NDC,1,EA,76.15,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,32.66835,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Ig Paraprotein Qual Bld/UR,PX0077U90,CDM,300,RC,0077U,HCPCS,90,,,,,,,66,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,32.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
"Level III - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3933,CDM,310,RC,88304,CPT,TC,,,,,,,66,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,32.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
Ot Contracted Service/Msho/MA,PX120.178,CDM,431,RC,,,,,,,,,,66,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,32.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
Pt Contracted Service/Msho,PX120.176,CDM,421,RC,,,,,,,,,,66,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,32.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
Surg Pathology-Level 2-Tc,PX3932,CDM,310,RC,88302,CPT,TC,,,,,,,66,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,32.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.01,64.68
Xray Orbits Optic Foramina,PX7019001,CDM,320,RC,70190,CPT,TC,,,,,,,66,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,32.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,79.39
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026994,NDC,20,ML,35.87,,Medica,Commercial,both,91.1,,0.687108295,percent of total billed charges,32.67757,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
valACYclovir 1 GM Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069701,NDC,0.5,EA,33.58,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,32.683414,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409427602,NDC,50,ML,38.46,,First Health,Commercial,both,85,,999999999,percent of total billed charges,32.691,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"CUFF STERILE DISPOSABLE SPSB  STERILE 18""",27200000,CDM,272,RC,,,,7436-MAIN,LOCAL,,,,,35.89,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.69579,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TRAY HAND SURGICAL II DYNJS0806,27200000,CDM,272,RC,,,,11024-MAIN,LOCAL,,,,,64.62,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,32.69772,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409493311,NDC,10,ML,66.06,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,32.6997,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
levoFLOXacin in dextrose 5% 500 MG/100ML Solution 100 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004724,NDC,100,ML,64.63,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,32.70278,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,76329339001,NDC,5,ML,64.63,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,32.70278,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078121,NDC,0.5,EA,36.75,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.7075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078141,NDC,0.5,EA,36.75,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.7075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
valproate 100 MG/ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049416,NDC,5,ML,33.61,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,32.712613,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
valproate 100 MG/ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049441,NDC,5,ML,33.61,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,32.712613,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Debride Muscle Ea Add 20 Sqcm,PX11046F,CDM,510,RC,11046,CPT,,,,,,,,248,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,32.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.5,151.5
Debride Muscle Ea Add 20 Sqcm,PX11046F,CDM,510,RC,11046,CPT,,,,,,,,248,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,32.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.5,151.5
Debride Muscle Ea Add 20 Sqcm,PX11046P,CDM,983,RC,11046,CPT,,,,,,,,198,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,32.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.5,194.04
Debride Muscle Ea Add 20 Sqcm,PX11046P,CDM,983,RC,11046,CPT,,,,,,,,198,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,32.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.5,194.04
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018200,NDC,10,ML,68.21,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,32.7408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.24,991.564
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018200,NDC,10,ML,68.21,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,32.7408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.24,991.564
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018210,NDC,10,ML,68.21,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,32.7408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.24,991.564
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018210,NDC,10,ML,68.21,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,32.7408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.24,991.564
Drain/Inject Small Joint/Bursa,PX20600F,CDM,510,RC,20600,CPT,,,,,,,,161,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,32.7522,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.82,112.07
Drain/Inject Small Joint/Bursa,PX20600P,CDM,983,RC,20600,CPT,,,,,,,,161,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,32.7522,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.82,157.78
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762F,CDM,510,RC,43762,CPT,,,,,,,,492,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,32.7522,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.03,467.66
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762P,CDM,983,RC,43762,CPT,,,,,,,,328,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,32.7522,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.03,467.66
valACYclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069801,NDC,1,EA,38.55,,First Health,Commercial,both,85,,999999999,percent of total billed charges,32.7675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
charcoal activated Liquid 240 mL Bottle,63700001,CDM,250,RC,,,,,,574012108,NDC,120,ML,66.88,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,32.7712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
charcoal activated Liquid 240 mL Bottle,63700001,CDM,250,RC,,,,,,574012108,NDC,120,ML,66.88,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,32.7712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
charcoal activated Liquid 240 mL Bottle,63700001,CDM,250,RC,,,,,,574012108,NDC,120,ML,66.88,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,32.7712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323042605,NDC,5,ML,64.8,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,32.7888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597F,CDM,510,RC,97597,CPT,,,,,,,,266,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,32.793,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.28,133.11
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597P,CDM,983,RC,97597,CPT,,,,,,,,274,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,32.793,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.28,268.52
Anes Dx Shoulder Arthroscopy,PX01622.01,CDM,964,RC,1622,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Lower Intestinal Endoscopic Px Nos,PX00811.01,CDM,964,RC,811,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,29.06351563,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Lower Intestinal Screening Colonoscopy,PX00812.01,CDM,964,RC,812,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Spine Transthor W/Vent,PX00626.01,CDM,964,RC,626,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Spine Tranthor W/O Vent,PX00625.01,CDM,964,RC,625,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Ther Interven Rad Art,PX01924.01,CDM,964,RC,1924,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Ther Interven Rad Car,PX01925.01,CDM,964,RC,1925,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Ther Interven Rad Tip,PX01931.01,CDM,964,RC,1931,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Ther Interven Rad Vei,PX01930.01,CDM,964,RC,1930,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Tx Interv Rad Cran V,PX01933.01,CDM,964,RC,1933,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Tx Interv Rad Hrt/Cran,PX01926.01,CDM,964,RC,1926,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Tx Interv Rad Th Vein,PX01932.01,CDM,964,RC,1932,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Upper GI Endoscopic Px Ercp,PX00732.01,CDM,964,RC,732,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Upper GI Endoscopic Px Nos,PX00731.01,CDM,964,RC,731,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,12.45591837,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Upper/Lower GI Endoscopic Px,PX00813.01,CDM,964,RC,813,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,31.76988506,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes/Analg Cs Deliver Add-On,PX01968.01,CDM,964,RC,1968,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Abdomen Vessel Surg,PX00880.01,CDM,964,RC,880,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Abdominal Wall Surg,PX00700.01,CDM,964,RC,700,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Abdominal Wall Surg,PX00730.01,CDM,964,RC,730,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Abdominal Wall Surg,PX00800.01,CDM,964,RC,800,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Abdominal Wall Surg,PX00820.01,CDM,964,RC,820,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Achilles Tendon Surg,PX01472.01,CDM,964,RC,1472,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Airplane Cast,PX01682.01,CDM,964,RC,1682,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Amniocentesis,PX00842.01,CDM,964,RC,842,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Amputation at Knee,PX01404.01,CDM,964,RC,1404,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Amputation at Pelvis,PX01140.01,CDM,964,RC,1140,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Amputation of Femur,PX01232.01,CDM,964,RC,1232,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Amputation of Penis,PX00932.01,CDM,964,RC,932,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Ankle Replacement,PX01486.01,CDM,964,RC,1486,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Ankle/Ft Arthroscopy,PX01464.01,CDM,964,RC,1464,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Anorectal Surgery,PX00902.01,CDM,964,RC,902,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Antepartum Manipul,PX01958.01,CDM,964,RC,1958,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Arm-Leg Vessel Surg,PX01656.01,CDM,964,RC,1656,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Arthroscopy of Hip,PX01202.01,CDM,964,RC,1202,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Biceps Tendon Repair,PX01716.01,CDM,964,RC,1716,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Biopsy of Nose,PX00164.01,CDM,964,RC,164,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Biopsy of Thyroid,PX00322.01,CDM,964,RC,322,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Bladder Stone Surg,PX00870.01,CDM,964,RC,870,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Bladder Surgery,PX00910.01,CDM,964,RC,910,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Bladder Tumor Surg,PX00912.01,CDM,964,RC,912,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Bleeding Control,PX00916.01,CDM,964,RC,916,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Blepharoplasty,PX00103.01,CDM,964,RC,103,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Blood Vessel Repair,PX00770.01,CDM,964,RC,770,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Body Cast Procedure,PX01130.01,CDM,964,RC,1130,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Bone Aspirate/Bx,PX01112.01,CDM,964,RC,1112,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Burn 4-9 Percent,PX01952.01,CDM,964,RC,1952,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Burn Each 9 Percent,PX01953.01,CDM,964,RC,1953,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Burn Less 4 Percent,PX01951.01,CDM,964,RC,1951,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cabg W/O Pump,PX00566.01,CDM,964,RC,566,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cabg W/Pump,PX00567.01,CDM,964,RC,567,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cardiac Electrophys,PX00537.01,CDM,964,RC,537,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cardioverter/Defib,PX00534.01,CDM,964,RC,534,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cat or MRI Scan,PX01922.01,CDM,964,RC,1922,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Catheterize Heart,PX01920.01,CDM,964,RC,1920,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Drainage,PX00524.01,CDM,964,RC,524,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Lining Biopsy,PX00522.01,CDM,964,RC,522,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Partition View,PX00528.01,CDM,964,RC,528,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Partition View,PX00529.01,CDM,964,RC,529,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Procedure,PX00520.01,CDM,964,RC,520,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Surgery,PX00540.01,CDM,964,RC,540,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Wall Repair,PX00472.01,CDM,964,RC,472,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cleft Palate Repair,PX00172.01,CDM,964,RC,172,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Collar Bone Biopsy,PX00454.01,CDM,964,RC,454,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Corneal Transplant,PX00144.01,CDM,964,RC,144,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Correct Heart Rhythm,PX00410.01,CDM,964,RC,410,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cran Surg Hemotoma,PX00211.01,CDM,964,RC,211,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cranial Surg Nos,PX00210.01,CDM,964,RC,210,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cs Delivery,PX01961.01,CDM,964,RC,1961,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cs Hysterectomy,PX01963.01,CDM,964,RC,1963,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Dx Arteriography,PX01916.01,CDM,964,RC,1916,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Dx Elbow Arthroscopy,PX01732.01,CDM,964,RC,1732,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Dx Knee Arthroscopy,PX01382.01,CDM,964,RC,1382,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Dx Wrist Arthroscopy,PX01829.01,CDM,964,RC,1829,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Ear Exam,PX00124.01,CDM,964,RC,124,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Ear Surgery,PX00120.01,CDM,964,RC,120,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Elbow Area Surgery,PX01710.01,CDM,964,RC,1710,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Elbow Replacement,PX01760.01,CDM,964,RC,1760,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Electroshock,PX00104.01,CDM,964,RC,104,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Emer Hysterectomy,PX01962.01,CDM,964,RC,1962,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Esophageal Surgery,PX00500.01,CDM,964,RC,500,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Eye Exam,PX00148.01,CDM,964,RC,148,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Face/Skull Bone Surg,PX00190.01,CDM,964,RC,190,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Facial Bone Surgery,PX00192.01,CDM,964,RC,192,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Fat Layer Removal,PX00802.01,CDM,964,RC,802,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Femoral Artery Surg,PX01272.01,CDM,964,RC,1272,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Femoral Embolectomy,PX01274.01,CDM,964,RC,1274,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth for Chemonucleolysis,PX00634.01,CDM,964,RC,634,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth for Liver Biopsy,PX00702.01,CDM,964,RC,702,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth for Liver Transplant,PX00796.01,CDM,964,RC,796,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Forequarter Amput,PX01636.01,CDM,964,RC,1636,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Fx Repair Pelvis,PX01173.01,CDM,964,RC,1173,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Genitalia Surgery,PX00920.01,CDM,964,RC,920,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Head Nerve Surgery,PX00222.01,CDM,964,RC,222,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Head Vessel Surgery,PX00216.01,CDM,964,RC,216,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Head/Neck/Ptrunk,PX00300.01,CDM,964,RC,300,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Heart Surg < 1 Yr,PX00561.01,CDM,964,RC,561,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Heart Surg W/Arrest,PX00563.01,CDM,964,RC,563,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Heart Surg W/O Pump,PX00560.01,CDM,964,RC,560,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Heart/Lung Transplnt,PX00580.01,CDM,964,RC,580,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hemorr/Excise Liver,PX00792.01,CDM,964,RC,792,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hernia Repair < 1 Yr,PX00834.01,CDM,964,RC,834,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hernia Repair Preemie,PX00836.01,CDM,964,RC,836,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hip Arthroplasty,PX01214.01,CDM,964,RC,1214,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hip Disarticulation,PX01212.01,CDM,964,RC,1212,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hip Joint Procedure,PX01200.01,CDM,964,RC,1200,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hip Joint Surgery,PX01210.01,CDM,964,RC,1210,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hrt Surg W/Pmp Age 1+,PX00562.01,CDM,964,RC,562,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Humeral Lesion Surg,PX01758.01,CDM,964,RC,1758,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Humerus Repair,PX01744.01,CDM,964,RC,1744,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Humerus Surgery,PX01742.01,CDM,964,RC,1742,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hysterectomy,PX00846.01,CDM,964,RC,846,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hysteroscope/Graph,PX00952.01,CDM,964,RC,952,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Inc/Missed Ab Proc,PX01965.01,CDM,964,RC,1965,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Induced Ab Procedure,PX01966.01,CDM,964,RC,1966,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Insert Penis Device,PX00938.01,CDM,964,RC,938,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Intrcrn Nerve,PX00220.01,CDM,964,RC,220,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Iridectomy,PX00147.01,CDM,964,RC,147,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Kidney Stone Destruct,PX00872.01,CDM,964,RC,872,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Kidney Stone Destruct,PX00873.01,CDM,964,RC,873,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Kidney Transplant,PX00868.01,CDM,964,RC,868,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Kidney/Ureter Surg,PX00862.01,CDM,964,RC,862,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Area Procedure,PX01340.01,CDM,964,RC,1340,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Area Procedure,PX01390.01,CDM,964,RC,1390,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Area Surgery,PX01320.01,CDM,964,RC,1320,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Area Surgery,PX01360.01,CDM,964,RC,1360,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Area Surgery,PX01392.01,CDM,964,RC,1392,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Arteries Surg,PX01440.01,CDM,964,RC,1440,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Artery Repair,PX01444.01,CDM,964,RC,1444,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Artery Surg,PX01442.01,CDM,964,RC,1442,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Arthroplasty,PX01402.01,CDM,964,RC,1402,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Joint Casting,PX01420.01,CDM,964,RC,1420,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Joint Procedure,PX01380.01,CDM,964,RC,1380,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Joint Surgery,PX01400.01,CDM,964,RC,1400,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Veins Surgery,PX01430.01,CDM,964,RC,1430,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Vessel Surg,PX01432.01,CDM,964,RC,1432,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Larynx/Trach < 1 Yr,PX00326.01,CDM,964,RC,326,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Leg Arteries Surg,PX01500.01,CDM,964,RC,1500,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lens Surgery,PX00142.01,CDM,964,RC,142,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Low Intestine Scope,PX00810.01,CDM,964,RC,810,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Arm Casting,PX01860.01,CDM,964,RC,1860,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Arm Procedure,PX01820.01,CDM,964,RC,1820,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Arm Surgery,PX01810.01,CDM,964,RC,1810,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Arm Surgery,PX01830.01,CDM,964,RC,1830,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Arm Vein Surg,PX01850.01,CDM,964,RC,1850,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Bone Surg,PX01480.01,CDM,964,RC,1480,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Casting,PX01490.01,CDM,964,RC,1490,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Procedure,PX01462.01,CDM,964,RC,1462,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Revision,PX01484.01,CDM,964,RC,1484,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Surgery,PX01470.01,CDM,964,RC,1470,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Surgery,PX01474.01,CDM,964,RC,1474,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Vein Surg,PX01520.01,CDM,964,RC,1520,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Vein Surg,PX01522.01,CDM,964,RC,1522,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lumbar Puncture,PX00635.01,CDM,964,RC,635,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lung Chest Wall Surg,PX00546.01,CDM,964,RC,546,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lwr Arm Artery Surg,PX01840.01,CDM,964,RC,1840,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lwr Arm Embolectomy,PX01842.01,CDM,964,RC,1842,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lwr Arm Vein Repair,PX01852.01,CDM,964,RC,1852,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lwr Leg Embolectomy,PX01502.01,CDM,964,RC,1502,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Major Vein Ligation,PX00882.01,CDM,964,RC,882,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth N Block/Inj Prone,PX01992.01,CDM,964,RC,1992,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Neck Organ 1 & Over,PX00320.01,CDM,964,RC,320,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Neck Vessel Surgery,PX00350.01,CDM,964,RC,350,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Neck Vessel Surgery,PX00352.01,CDM,964,RC,352,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Nerve Block/Inj,PX01991.01,CDM,964,RC,1991,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Nose/Sinus Surgery,PX00160.01,CDM,964,RC,160,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Nose/Sinus Surgery,PX00162.01,CDM,964,RC,162,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth One Lung Ventilation,PX00541.01,CDM,964,RC,541,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pacemaker Insertion,PX00530.01,CDM,964,RC,530,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pancreas Removal,PX00794.01,CDM,964,RC,794,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvic Organ Surg,PX00848.01,CDM,964,RC,848,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvic Tumor Surgery,PX01150.01,CDM,964,RC,1150,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvis Nerve Removal,PX01180.01,CDM,964,RC,1180,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvis Nerve Removal,PX01190.01,CDM,964,RC,1190,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvis Procedure,PX01160.01,CDM,964,RC,1160,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvis Surgery,PX00844.01,CDM,964,RC,844,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvis Surgery,PX01120.01,CDM,964,RC,1120,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvis Surgery,PX01170.01,CDM,964,RC,1170,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Penis Nodes Removal,PX00934.01,CDM,964,RC,934,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Penis Nodes Removal,PX00936.01,CDM,964,RC,936,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Perc Img Dx Sp Proc,PX01935.01,CDM,964,RC,1935,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Perc Img Tx Sp Proc,PX01936.01,CDM,964,RC,1936,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Perineal Surgery,PX00904.01,CDM,964,RC,904,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pharyngeal Surgery,PX00174.01,CDM,964,RC,174,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pharyngeal Surgery,PX00176.01,CDM,964,RC,176,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Procedure on Femur,PX01220.01,CDM,964,RC,1220,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Procedure on Mouth,PX00170.01,CDM,964,RC,170,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Procedures on Eye,PX00140.01,CDM,964,RC,140,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Radical Femur Surg,PX01234.01,CDM,964,RC,1234,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Radical Humerus Surg,PX01756.01,CDM,964,RC,1756,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Radical Leg Surgery,PX01482.01,CDM,964,RC,1482,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Release of Lung,PX00542.01,CDM,964,RC,542,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Adrenal,PX00866.01,CDM,964,RC,866,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Bladder,PX00864.01,CDM,964,RC,864,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Nerves,PX00622.01,CDM,964,RC,622,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Nerves,PX00632.01,CDM,964,RC,632,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Prostate,PX00865.01,CDM,964,RC,865,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Prostate,PX00908.01,CDM,964,RC,908,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Rib,PX00470.01,CDM,964,RC,470,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Testis,PX00926.01,CDM,964,RC,926,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Testis,PX00928.01,CDM,964,RC,928,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Vulva,PX00906.01,CDM,964,RC,906,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Cervix,PX00948.01,CDM,964,RC,948,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Cleft Lip,PX00102.01,CDM,964,RC,102,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Hernia,PX00750.01,CDM,964,RC,750,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Hernia,PX00752.01,CDM,964,RC,752,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Hernia,PX00754.01,CDM,964,RC,754,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Hernia,PX00756.01,CDM,964,RC,756,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Hernia,PX00830.01,CDM,964,RC,830,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Hernia,PX00832.01,CDM,964,RC,832,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Revise Hip Repair,PX01215.01,CDM,964,RC,1215,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Salivary Gland,PX00100.01,CDM,964,RC,100,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Artery Surg,PX01650.01,CDM,964,RC,1650,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Casting,PX01680.01,CDM,964,RC,1680,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Joint Amput,PX01634.01,CDM,964,RC,1634,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Procedure,PX01620.01,CDM,964,RC,1620,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Replacement,PX01638.01,CDM,964,RC,1638,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Vein Surg,PX01670.01,CDM,964,RC,1670,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Vessel Surg,PX01652.01,CDM,964,RC,1652,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Vessel Surg,PX01654.01,CDM,964,RC,1654,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Sitting Procedure,PX00604.01,CDM,964,RC,604,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Skin Ext/per/Atrunk,PX00400.01,CDM,964,RC,400,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Skull Drainage,PX00212.01,CDM,964,RC,212,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Skull Drainage,PX00214.01,CDM,964,RC,214,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Skull Repair/Fract,PX00215.01,CDM,964,RC,215,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Special Head Surgery,PX00218.01,CDM,964,RC,218,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Sperm Duct Surgery,PX00922.01,CDM,964,RC,922,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Spine Cord Surgery,PX00600.01,CDM,964,RC,600,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Spine Cord Surgery,PX00620.01,CDM,964,RC,620,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Spine Cord Surgery,PX00630.01,CDM,964,RC,630,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Spine Cord Surgery,PX00670.01,CDM,964,RC,670,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Spine Manipulation,PX00640.01,CDM,964,RC,640,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Sternal Debridement,PX00550.01,CDM,964,RC,550,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Stone Removal,PX00918.01,CDM,964,RC,918,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surg Lower Abdomen,PX00840.01,CDM,964,RC,840,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surg on Vag/Urethral,PX00942.01,CDM,964,RC,942,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surg Upper Abdomen,PX00790.01,CDM,964,RC,790,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery for Obesity,PX00797.01,CDM,964,RC,797,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Abdomen,PX00860.01,CDM,964,RC,860,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Breast,PX00402.01,CDM,964,RC,402,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Breast,PX00404.01,CDM,964,RC,404,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Breast,PX00406.01,CDM,964,RC,406,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Femur,PX01230.01,CDM,964,RC,1230,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Rib(S),PX00474.01,CDM,964,RC,474,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Shoulder,PX00450.01,CDM,964,RC,450,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Shoulder,PX00452.01,CDM,964,RC,452,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Shoulder,PX01610.01,CDM,964,RC,1610,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Shoulder,PX01630.01,CDM,964,RC,1630,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Testis Exploration,PX00924.01,CDM,964,RC,924,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Testis Suspension,PX00930.01,CDM,964,RC,930,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Thigh Arteries Surg,PX01270.01,CDM,964,RC,1270,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Trach-Bronch Reconst,PX00539.01,CDM,964,RC,539,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Trachea Bronchi Surg,PX00548.01,CDM,964,RC,548,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Trans Resect of Prostate,PX00914.01,CDM,964,RC,914,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Tubal Ligation,PX00851.01,CDM,964,RC,851,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Tympanotomy,PX00126.01,CDM,964,RC,126,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Upper Arm Surgery,PX01740.01,CDM,964,RC,1740,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Upper Arm Vein Surg,PX01780.01,CDM,964,RC,1780,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Upper GI Visualize,PX00740.01,CDM,964,RC,740,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Upper Leg Surgery,PX01250.01,CDM,964,RC,1250,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Upper Leg Veins Surg,PX01260.01,CDM,964,RC,1260,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Uppr Arm Artery Surg,PX01770.01,CDM,964,RC,1770,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Uppr Arm Embolectomy,PX01772.01,CDM,964,RC,1772,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Uppr Arm Procedure,PX01730.01,CDM,964,RC,1730,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Uppr Arm Tendon Surg,PX01712.01,CDM,964,RC,1712,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Uppr Arm Tendon Surg,PX01714.01,CDM,964,RC,1714,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Uppr Arm Vein Repair,PX01782.01,CDM,964,RC,1782,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vaginal Delivery,PX01960.01,CDM,964,RC,1960,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vaginal Endoscopy,PX00950.01,CDM,964,RC,950,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vaginal Hysterectomy,PX00944.01,CDM,964,RC,944,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vaginal Procedures,PX00940.01,CDM,964,RC,940,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vascular Access,PX00532.01,CDM,964,RC,532,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vascular Shunt Surg,PX01844.01,CDM,964,RC,1844,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vasectomy,PX00921.01,CDM,964,RC,921,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vitreoretinal Surg,PX00145.01,CDM,964,RC,145,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Wrist Replacement,PX01832.01,CDM,964,RC,1832,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth/Analg Cs Hyst Add-On,PX01969.01,CDM,964,RC,1969,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth/Analg Vag Delivery,PX01967.01,CDM,964,RC,1967,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Hosp Manage Cont Drug Admin,PX01996.01,CDM,964,RC,1996,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
IMMOBILIZER SHOULDER LARGE 9008-03,120.38,CDM,274,RC,L3650,HCPCS,,906-MAIN,LOCAL,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER LARGE STRAP OSG3033,120.38,CDM,274,RC,L3650,HCPCS,,2910-MAIN,LOCAL,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER MEDIUM 9008-02,120.38,CDM,274,RC,L3650,HCPCS,,912-MAIN,LOCAL,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER MEDIUM OSG3032,120.38,CDM,274,RC,L3650,HCPCS,,915-MAIN,LOCAL,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER SMALL 9008-01,120.38,CDM,274,RC,L3650,HCPCS,,913-MAIN,LOCAL,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER SMALL WITH CLOTH 9001-02,120.38,CDM,274,RC,L3650,HCPCS,,914-MAIN,LOCAL,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER X-LARGE CLOTH 9001-05,120.38,CDM,274,RC,L3650,HCPCS,,917-MAIN,LOCAL,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER X-LARGE ORT16100XL,120.38,CDM,274,RC,L3650,HCPCS,,904-MAIN,LOCAL,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
Support for Organ Donor,PX01990.01,CDM,964,RC,1990,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Treponema Pallidum,PX86780,CDM,300,RC,86780,CPT,,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.14,35.28
Unlisted Anesth Procedure,PX01999.01,CDM,964,RC,1999,CPT,QZ,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405P,CDM,983,RC,36405,CPT,,,,,,,,36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050601,NDC,1,ML,68.33,,Health Partners,Health Partners Care Plans,both,48,,1.5325,percent of total billed charges,32.7984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050601,NDC,1,ML,68.33,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,32.7984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010520,NDC,1,EA,68.33,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,32.7984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010520,NDC,1,EA,68.33,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,32.7984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010541,NDC,1,EA,68.33,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,32.7984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010541,NDC,1,EA,68.33,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,32.7984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323042405,NDC,5,ML,64.82,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,32.79892,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
betamethasone acetate-betamethasone sodium phosphate 6 (3-3) MG/ML Suspension 5 mL Vial,J0702.01,CDM,636,RC,J0702,HCPCS,,,,517072001,NDC,1,ML,78.96,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,32.799984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.799984,77.3808
PHENobarbital 130 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047721,NDC,1,ML,338.93,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,32.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.66,32.8
PHENobarbital 130 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047721,NDC,1,ML,338.93,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,32.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.66,32.8
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047621,NDC,1,ML,157.28,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,32.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.66,32.8
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047621,NDC,1,ML,157.28,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,32.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.66,32.8
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047625,NDC,0.769230769,ML,111.59,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,32.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.66,32.8
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047625,NDC,0.769230769,ML,111.59,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,32.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.66,32.8
"Office/Outpt Visit,Est,Levl II",PX99212F,CDM,510,RC,99212,CPT,,,,,,,,155,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,32.8032,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.04,101.66
"Office/Outpt Visit,Est,Levl II",PX99212P,CDM,983,RC,99212,CPT,,,,,,,,155,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,32.8032,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.04,151.9
pramox-PE-glycerin-petrolatum 1-0.25-14.4-15 % Cream 51 g Tube,63700001,CDM,250,RC,,,,,,573286898,NDC,51,GR,68.34,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,32.8032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramox-PE-glycerin-petrolatum 1-0.25-14.4-15 % Cream 51 g Tube,63700001,CDM,250,RC,,,,,,573286898,NDC,51,GR,68.34,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,32.8032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037604,NDC,0.75,ML,36.86,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.8054,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,25021011487,NDC,200,ML,66.28,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,32.8086,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.20921,64.9544
calcium CHLORIDE 10 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409163140,NDC,10,ML,64.85,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,32.8141,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Everolimus,PX8016990,CDM,300,RC,80169,CPT,,,,,,,,79,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,32.8166,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,77.42
methotrexate 2.5 MG Tablet 20 Each Box,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067005,NDC,1,EA,33.49,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,32.8202,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.911746,32.8398
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457000100,NDC,10,ML,68.38,,Health Partners,Health Partners Care Plans,both,48,,31.91277778,percent of total billed charges,32.8224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457000100,NDC,10,ML,68.38,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,32.8224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
Xray Wrist Minimum 3 Vws,PX7311001,CDM,320,RC,73110,CPT,TC,,,,,,,375,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,32.8236,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.6,65.08
Group Therapeutic Procedures,PX97150,CDM,420,RC,97150,CPT,,,,,,,,67,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,32.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.82,65.66
Group Therapeutic Procedures,PX97150,CDM,420,RC,97150,CPT,,,,,,,,67,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,32.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.82,65.66
Group Therapeutic Procedures,PX97150,CDM,420,RC,97150,CPT,,,,,,,,67,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,32.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.82,65.66
"Hydroxyprogesterone, 17-D - Ref",PX8349890,CDM,300,RC,83498,CPT,90,,,,,,,67,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,32.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.91,65.66
"Hydroxyprogesterone, 17-D - Ref",PX8349890,CDM,300,RC,83498,CPT,90,,,,,,,67,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,32.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.91,65.66
"Hydroxyprogesterone, 17-D - Ref",PX8349890,CDM,300,RC,83498,CPT,90,,,,,,,67,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,32.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.91,65.66
Lab Org ID Anaerobic-Each,PX87076,CDM,300,RC,87076,CPT,,,,,,,,67,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,32.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,65.66
Lab Org ID Anaerobic-Each,PX87076,CDM,300,RC,87076,CPT,,,,,,,,67,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,32.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,65.66
Lab Org ID Anaerobic-Each,PX87076,CDM,300,RC,87076,CPT,,,,,,,,67,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,32.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,65.66
methotrexate 2.5 MG Tablet 1 Each Blister,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067001,NDC,1,EA,33.51,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,32.8398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.911746,32.8398
levoFLOXacin 250 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635161,NDC,1,EA,79.08,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,32.849832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323031119,NDC,10,ML,66.39,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,32.86305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,84.5054
HYDROmorphone 1 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409128303,NDC,1,ML,36.93,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.8677,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987501,NDC,3,ML,33.77,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,32.868341,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
Xray Spine Single Tc,PX7202001,CDM,320,RC,72020,CPT,TC,,,,,,,113,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,32.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.9,32.87
Xray Spine Single Tc,PX7202001,CDM,320,RC,72020,CPT,TC,,,,,,,113,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,32.87,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.9,32.87
budesonide 1 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097032187,NDC,1,ML,64.97,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,32.87482,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
morphine 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574711212,NDC,1,EA,33.56,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,32.8888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Alkaloids, Not Otherwise Specified - Ref",PX8032390,CDM,300,RC,80323,CPT,90,,,,,,,65,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,32.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.001,63.7
Anesthesia Level 3,PX37000017,CDM,370,RC,,,,,,,,,,65,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,32.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.001,63.7
Clozapine - Ref,PX8015990,CDM,300,RC,80159,CPT,90,,,,,,,65,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,32.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.48,63.7
Gastrin - Ref,PX8294190,CDM,300,RC,82941,CPT,90,,,,,,,65,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,32.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.16,63.7
Insulin Ab - Ref,PX8633790,CDM,300,RC,86337,CPT,90,,,,,,,65,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,32.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.63,63.7
Resp Muscles 1:1 per 15 Min,PXG0237,CDM,948,RC,G0237,HCPCS,,,,,,,,65,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,32.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.01,63.7
Smking Cess 4-10 Min,PX99406F,CDM,942,RC,99406,CPT,,,,,,,,65,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,32.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.07,63.7
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034020,NDC,1,EA,76.67,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,32.89143,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034021,NDC,1,EA,76.67,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,32.89143,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,67457043800,NDC,0.5,EA,36.11,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.89621,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,67457043810,NDC,0.5,EA,36.11,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.89621,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Flow Interp,2-8 Markers - Ref",PX8818790,CDM,310,RC,88187,CPT,90,,,,,,,162,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,32.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.9,55.25
"Flow Interp,2-8 Markers - Ref",PX8818790,CDM,310,RC,88187,CPT,90,,,,,,,162,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,32.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.9,55.25
"Flow Interp,2-8 Markers - Ref",PX8818790,CDM,310,RC,88187,CPT,90,,,,,,,162,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,32.9,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.9,55.25
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028036,NDC,2,ML,36.12,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.90532,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
valACYclovir 1 GM Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069701,NDC,0.5,EA,33.58,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,32.9084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,63739003807,NDC,1,EA,66.51,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,32.92245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323020103,NDC,10,ML,36.14,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.92354,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.25%-EPINEPHrine 1:200,000 0.25% -1:200000 Solution 50 mL Vial",25000000,CDM,250,RC,,,,,,409175250,NDC,30,ML,68.6,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,32.928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.25%-EPINEPHrine 1:200,000 0.25% -1:200000 Solution 50 mL Vial",25000000,CDM,250,RC,,,,,,409175250,NDC,30,ML,68.6,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,32.928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
COLLAR CERVICAL LARGE WITH TRACH 2 PIECE PHP-T4L,120.184,CDM,274,RC,L0172,HCPCS,,10142-MAIN,LOCAL,,,,,37,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.3698,152.79
COLLAR CERVICAL MEDIUM WITH TRACH 2 PIECE PHP-T4M,120.183,CDM,274,RC,L0172,HCPCS,,10141-MAIN,LOCAL,,,,,37,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.3698,152.79
COLLAR CERVICAL SMALL WITH TRACH 2 PIECE PHP-T4S,120.182,CDM,274,RC,L0172,HCPCS,,10140-MAIN,LOCAL,,,,,37,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.3698,152.79
SUTURE TICRON 0 36IN BRAIDED DYED 1/2 CIRCLE DBLE ARM 25MM CV-305 BLUE STERILE,27200000,CDM,272,RC,,,,11956-MAIN,LOCAL,,,,,37,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,32.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
valproate 100 MG/ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049416,NDC,5,ML,33.61,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,32.9378,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
valproate 100 MG/ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049441,NDC,5,ML,33.61,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,32.9378,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Apply Long Leg Splint,PX29505F,CDM,510,RC,29505,CPT,,,,,,,,320,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,32.94,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.28,190.25
Apply Long Leg Splint,PX29505F,CDM,510,RC,29505,CPT,,,,,,,,320,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,32.94,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.28,190.25
Apply Long Leg Splint,PX29505P,CDM,983,RC,29505,CPT,,,,,,,,385,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,32.94,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.28,377.3
Apply Long Leg Splint,PX29505P,CDM,983,RC,29505,CPT,,,,,,,,385,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,32.94,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.28,377.3
Repr Superf Wnd Face <2.5cm,PX12011F,CDM,510,RC,12011,CPT,,,,,,,,335,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,32.94,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.94,233.83
Repr Superf Wnd Face <2.5cm,PX12011P,CDM,983,RC,12011,CPT,,,,,,,,461,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,32.94,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.94,451.78
cyclopentolate 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,17478010002,NDC,2,ML,66.55,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,32.94225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,36000014801,NDC,2,ML,38.76,,First Health,Commercial,both,85,,999999999,percent of total billed charges,32.946,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Ex for Speech Device Rx Addl,PX92608,CDM,444,RC,92608,CPT,,,,,,,,160,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,32.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.95,156.8
colchicine 0.6 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,49884017111,NDC,1,EA,36.17,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,32.95087,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310001,NDC,0.528,ML,785.14,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,32.96,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29,32.96
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310002,NDC,0.528,ML,894.9,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,32.96,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29,32.96
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608201,NDC,1,ML,66.6,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,32.967,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
valACYclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,31722070430,NDC,1,EA,38.79,,First Health,Commercial,both,85,,999999999,percent of total billed charges,32.9715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acyclovir 50 MG/ML Solution 20 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,63323032524,NDC,20,ML,76.86,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,32.97294,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.927644,105.9968
rivaroxaban 15 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50458057830,NDC,0.666666667,EA,67.3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,32.977,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rivaroxaban 15 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50458057830,NDC,0.666666667,EA,67.3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,32.977,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rivaroxaban 15 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50458057830,NDC,0.666666667,EA,67.3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,32.977,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Office/Outpt Visit,New,Levl II",PX99202F,CDM,510,RC,99202,CPT,,,,,,,,123,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,32.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.89,129.77
"Office/Outpt Visit,New,Levl II",PX99202F,CDM,510,RC,99202,CPT,,,,,,,,123,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,32.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.89,129.77
"Office/Outpt Visit,New,Levl II",PX99202P,CDM,983,RC,99202,CPT,,,,,,,,123,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,32.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.89,129.77
"Office/Outpt Visit,New,Levl II",PX99202P,CDM,983,RC,99202,CPT,,,,,,,,123,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,32.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.89,129.77
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037601,NDC,1,ML,76.9,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,32.9901,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
pancrelipase (lip-prot-amyl) 24000-76000 units Capsule Delayed Release Particles 100 Each Bottle,63700001,CDM,250,RC,,,,,,32122401,NDC,1,EA,37.41,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,32.99562,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329333901,NDC,10,ML,79.51,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,33.028454,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
calcium CHLORIDE 10 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,76329330401,NDC,10,ML,79.51,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,33.028454,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,25021018482,NDC,100,ML,79.51,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,33.028454,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.786918,140.5516
menthol-zinc oxide Paste 113 g Tube,63700001,CDM,250,RC,,,,,,53329016544,NDC,113,GR,79.52,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,33.032608,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Alpha-Fetoprotein Serum,PX82105,CDM,300,RC,82105,CPT,,,,,,,,77,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,33.033,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.38,75.46
BRACE WRIST HAND THUMB LEFT 455-LT,120.315,CDM,274,RC,L3809,HCPCS,,8283-MAIN,LOCAL,,,,,77,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,33.033,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.9858,245.51
BRACE WRIST HAND THUMB RIGHT 455-RT,120.315,CDM,274,RC,L3809,HCPCS,,8284-MAIN,LOCAL,,,,,77,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,33.033,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.9858,245.51
CAUTERY HIGH TEMP LOOP TIP,120.21,CDM,272,RC,,,,332-MAIN,LOCAL,,,,,77,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,33.033,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
NEEDLE ACUJECT 25GA VARIABLE INJECTION VIN-25,27200000,CDM,272,RC,,,,7412-MAIN,LOCAL,,,,,77,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,33.033,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Remove Additional Nail Plate,PX11732F,CDM,510,RC,11732,CPT,,,,,,,,77,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,33.033,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.9858,75.46
fluticasone-salmeterol 100-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069500,NDC,1,EA,38.87,,First Health,Commercial,both,85,,999999999,percent of total billed charges,33.0395,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"CUFF STERILE DISPOSABLE SPSB 24""",27200000,CDM,272,RC,,,,7437-MAIN,LOCAL,,,,,37.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,33.075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ENDOCAVITY NEEDLE GUIDE,27200000,CDM,272,RC,,,,11134-MAIN,LOCAL,,,,,37.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,33.075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR KII BALOON 5X100MM STERILE,27200000,CDM,272,RC,,,,11701-MAIN,LOCAL,,,,,37.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,33.075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022143,NDC,1,EA,36.31,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,33.07841,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
BINDER ABDOMINAL S/M 9 INCH UP TO 45 INCHES TRI-PANNEL ABB3P45,120.238,CDM,271,RC,A4467,HCPCS,,47-MAIN,LOCAL,,,,,34,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,33.0922,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,13.86384615,percent of total billed charges,33.0922,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,13.86384615,percent of total billed charges,33.0922,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
"Lab Ige, Isocyan Hdi",PX86003,CDM,300,RC,86003,CPT,90,,,,,,,34,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,33.0922,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.79,33.32
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323020110,NDC,10,ML,34,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,33.0922,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Metanephrines - Ref,PX8383590,CDM,300,RC,83835,CPT,90,,,,,,,34,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,33.0922,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1236,33.32
SPLINT SAM 36INCH ROLLED 661121,120.362,CDM,271,RC,,,,10789-MAIN,LOCAL,,,,,34,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,33.0922,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1236,33.32
"Venipunc Need Phys Skill,Dx or Rx",PX36410F,CDM,510,RC,36410,CPT,,,,,,,,34,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,25.72625,percent of total billed charges,33.0922,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1236,33.32
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987501,NDC,3,ML,33.77,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,33.0946,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022116,NDC,1,EA,36.33,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,33.09663,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022141,NDC,1,EA,36.33,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,33.09663,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,58602060407,NDC,100,GR,67.56,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.1044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,58602060407,NDC,100,GR,67.56,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.1044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,58602060407,NDC,100,GR,67.56,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,33.1044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
charcoal activated Liquid 240 mL Bottle,63700001,CDM,250,RC,,,,,,574012108,NDC,120,ML,66.88,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,33.1056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032056,NDC,1,EA,68.97,,Health Partners,Health Partners Care Plans,both,48,,6.796666667,percent of total billed charges,33.1056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032056,NDC,1,EA,68.97,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,33.1056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,574722612,NDC,1,EA,67.57,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.1093,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.345782,66.2186
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,574722612,NDC,1,EA,67.57,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.1093,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.345782,66.2186
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,574722612,NDC,1,EA,67.57,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,33.1093,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.345782,66.2186
Assay Bld/Serum Cholesterol,PX82465,CDM,300,RC,82465,CPT,,,,,,,,69,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,33.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.99,67.62
Assay Bld/Serum Cholesterol,PX82465,CDM,300,RC,82465,CPT,,,,,,,,69,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,33.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.99,67.62
"Astrazeneca Covid-19 Vaccine, Administration, 1st Dose",PX0021A,CDM,771,RC,,,,,,,,,,69,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,33.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Astrazeneca Covid-19 Vaccine, Administration, 1st Dose",PX0021A,CDM,771,RC,,,,,,,,,,69,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,33.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Astrazeneca Covid-19 Vaccine, Adminstration, 2nd Dose",PX0022A,CDM,771,RC,,,,,,,,,,69,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,33.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Astrazeneca Covid-19 Vaccine, Adminstration, 2nd Dose",PX0022A,CDM,771,RC,,,,,,,,,,69,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,33.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Janssen Covid-19 Vaccine, Administration",PX0031A,CDM,771,RC,0031A,HCPCS,,,,,,,,69,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,33.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Janssen Covid-19 Vaccine, Administration",PX0031A,CDM,771,RC,0031A,HCPCS,,,,,,,,69,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,33.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 1st Dose",PX0011A,CDM,771,RC,0011A,HCPCS,,,,,,,,69,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,33.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 1st Dose",PX0011A,CDM,771,RC,0011A,HCPCS,,,,,,,,69,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,33.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 2nd Dose",PX0012A,CDM,771,RC,0012A,HCPCS,,,,,,,,69,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,33.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 2nd Dose",PX0012A,CDM,771,RC,0012A,HCPCS,,,,,,,,69,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,33.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 3rd Dose",PX0013A,CDM,771,RC,0013A,HCPCS,,,,,,,,69,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,33.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 3rd Dose",PX0013A,CDM,771,RC,0013A,HCPCS,,,,,,,,69,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,33.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
Novavax Covid-19 Vaccine Administration 1st Dose,PX0041A,CDM,771,RC,0041A,HCPCS,,,,,,,,69,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,33.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
Novavax Covid-19 Vaccine Administration 1st Dose,PX0041A,CDM,771,RC,0041A,HCPCS,,,,,,,,69,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,33.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
Novavax Covid-19 Vaccine Administration 2nd Dose,PX0042A,CDM,771,RC,0042A,HCPCS,,,,,,,,69,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,33.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
Novavax Covid-19 Vaccine Administration 2nd Dose,PX0042A,CDM,771,RC,0042A,HCPCS,,,,,,,,69,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,33.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Pfizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 2nd Dose",PX0002A,CDM,771,RC,0002A,HCPCS,,,,,,,,69,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,33.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Pfizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 2nd Dose",PX0002A,CDM,771,RC,0002A,HCPCS,,,,,,,,69,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,33.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Pfizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 3rd Dose",PX0003A,CDM,771,RC,0003A,HCPCS,,,,,,,,69,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,33.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Pfizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 3rd Dose",PX0003A,CDM,771,RC,0003A,HCPCS,,,,,,,,69,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,33.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Pifizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 1st Dose",PX0001A,CDM,771,RC,0001A,HCPCS,,,,,,,,69,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,33.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Pifizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 1st Dose",PX0001A,CDM,771,RC,0001A,HCPCS,,,,,,,,69,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,33.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,436067216,NDC,473,ML,77.23,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,33.13167,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,39328006412,NDC,473,ML,77.23,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,33.13167,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine 2 MG/ML Solution 1 mL Syringe,J2272.01,CDM,636,RC,J2272,HCPCS,,,,76045000401,NDC,1,ML,38.98,,First Health,Commercial,both,85,,999999999,percent of total billed charges,33.133,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.192292,38.2004
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012250,NDC,1,EA,77.24,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,33.13596,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012267,NDC,1,EA,77.24,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,33.13596,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
cefOXitin 2 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021011020,NDC,1,EA,77.24,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,33.13596,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.367364,75.6952
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023610,NDC,1,EA,77.24,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,33.13596,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
DULoxetine 20 MG Capsule Delayed Release Particles 60 Each Bottle,63700001,CDM,250,RC,,,,,,57237001760,NDC,1,EA,37.58,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,33.14556,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CLOSED WOUND ROUND CHANNEL DRAIN WITH TROCAR 15FR FULL FLUTED,27200000,CDM,272,RC,,,,12223-MAIN,LOCAL,,,,,39,,First Health,Commercial,both,85,,999999999,percent of total billed charges,33.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
fluorouracil 500 MG/10ML Solution 10 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,63323011710,NDC,10,ML,39,,First Health,Commercial,both,85,,999999999,percent of total billed charges,33.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,256.2112
gemcitabine 200 MG Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323010294,NDC,1,EA,39,,First Health,Commercial,both,85,,999999999,percent of total billed charges,33.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
Lab Wbc and Differential,PX85004,CDM,300,RC,85004,CPT,,,,,,,,39,,First Health,Commercial,both,85,,999999999,percent of total billed charges,33.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,38.22
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003928,NDC,1,EA,39,,First Health,Commercial,both,85,,999999999,percent of total billed charges,33.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
methylPREDNISolone sod succ 500 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9075801,NDC,0.25,EA,39,,First Health,Commercial,both,85,,999999999,percent of total billed charges,33.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
NEEDLE JAMSHIDI 11G X 101MM BIOPSY DJ4011X,27200000,CDM,272,RC,,,,12798-MAIN,LOCAL,,,,,39,,First Health,Commercial,both,85,,999999999,percent of total billed charges,33.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
O2 SENSOR ADULT ADHESIVE SINGLE PATIENT 040-003382-00,120.576,CDM,272,RC,,,,12930-MAIN,LOCAL,,,,,39,,First Health,Commercial,both,85,,999999999,percent of total billed charges,33.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
O2 SENSOR INFANT ADHESIVE SINGLE PATIENT 040-003384-00,120.576,CDM,272,RC,,,,12932-MAIN,LOCAL,,,,,39,,First Health,Commercial,both,85,,999999999,percent of total billed charges,33.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
O2 SENSOR PEDIATRIC ADHESIVE SINGLE PATIENT 040-003383-00,120.576,CDM,272,RC,,,,12931-MAIN,LOCAL,,,,,39,,First Health,Commercial,both,85,,999999999,percent of total billed charges,33.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
SLEEVE ACHILLES LG/XL PROTECTION 92437145348,120.422,CDM,271,RC,,,,11378-MAIN,LOCAL,,,,,39,,First Health,Commercial,both,85,,999999999,percent of total billed charges,33.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
SLEEVE ACHILLES SM/MED PROTECTION 92437145324,120.422,CDM,271,RC,,,,11377-MAIN,LOCAL,,,,,39,,First Health,Commercial,both,85,,999999999,percent of total billed charges,33.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
Treponema Pallidum - Ref,PX8678090,CDM,300,RC,86780,CPT,90,,,,,,,39,,First Health,Commercial,both,85,,999999999,percent of total billed charges,33.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.14,38.22
TROCAR KII FIOS SYSTEM BLADELSS Z-THREAD 5MMX150MM,27200000,CDM,272,RC,,,,12827-MAIN,LOCAL,,,,,39,,First Health,Commercial,both,85,,999999999,percent of total billed charges,33.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
aspirin-dipyridamole 25-200 MG Capsule Extended Release 12 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687030533,NDC,1,EA,67.66,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.1534,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin-dipyridamole 25-200 MG Capsule Extended Release 12 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687030533,NDC,1,EA,67.66,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.1534,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin-dipyridamole 25-200 MG Capsule Extended Release 12 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687030533,NDC,1,EA,67.66,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,33.1534,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin-dipyridamole 25-200 MG Capsule Extended Release 12 Hour 20 Each Box,63700001,CDM,250,RC,,,,,,60687030532,NDC,1,EA,67.66,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.1534,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin-dipyridamole 25-200 MG Capsule Extended Release 12 Hour 20 Each Box,63700001,CDM,250,RC,,,,,,60687030532,NDC,1,EA,67.66,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.1534,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin-dipyridamole 25-200 MG Capsule Extended Release 12 Hour 20 Each Box,63700001,CDM,250,RC,,,,,,60687030532,NDC,1,EA,67.66,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,33.1534,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019602,NDC,2,ML,77.29,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,33.15741,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409427617,NDC,50,ML,39.01,,First Health,Commercial,both,85,,999999999,percent of total billed charges,33.1585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Repr Superf Wnd Face <2.5cm,PX12011F,CDM,510,RC,12011,CPT,,,,,,,,335,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,33.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.94,233.83
Repr Superf Wnd Face <2.5cm,PX12011F,CDM,510,RC,12011,CPT,,,,,,,,335,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,33.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.94,233.83
Repr Superf Wnd Face <2.5cm,PX12011P,CDM,983,RC,12011,CPT,,,,,,,,461,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,33.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.94,451.78
Repr Superf Wnd Face <2.5cm,PX12011P,CDM,983,RC,12011,CPT,,,,,,,,461,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,33.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.94,451.78
"Thrombolysis,Coronary,IV Infusn",PX92977F,CDM,480,RC,92977,CPT,,,,,,,,595,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,33.16,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.16,96.56
Group Therapeutic Procedures,PX97150,CDM,420,RC,97150,CPT,,,,,,,,67,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,33.165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.82,65.66
"Hydroxyprogesterone, 17-D - Ref",PX8349890,CDM,300,RC,83498,CPT,90,,,,,,,67,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,33.165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.91,65.66
Lab Org ID Anaerobic-Each,PX87076,CDM,300,RC,87076,CPT,,,,,,,,67,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,33.165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,65.66
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046201,NDC,30,ML,79.84,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,33.165536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760,CDM,420,RC,97760,CPT,,,,,,,,142,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,33.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.18,139.16
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760F,CDM,510,RC,97760,CPT,,,,,,,,142,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,33.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.18,139.16
pioglitazone 15 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342005410,NDC,1,EA,37.62,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,33.18084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Flex Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707526,NDC,100,ML,37.63,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,33.18966,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409317801,NDC,20,ML,34.11,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,33.199263,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409317816,NDC,20,ML,34.11,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,33.199263,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189001,NDC,1,ML,34.11,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,10.32421053,percent of total billed charges,33.199263,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189003,NDC,1,ML,34.11,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,10.32421053,percent of total billed charges,33.199263,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606001,NDC,10,ML,65.62,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,33.20372,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606010,NDC,10,ML,65.62,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,33.20372,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209F,CDM,510,RC,69209,CPT,,,,,,,,35,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,33.21,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.03,33.21
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209F,CDM,510,RC,69209,CPT,,,,,,,,35,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,33.21,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.03,33.21
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209P,CDM,982,RC,69209,CPT,,,,,,,,113,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,33.21,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.03,110.74
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209P,CDM,982,RC,69209,CPT,,,,,,,,113,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,33.21,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.03,110.74
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,517095501,NDC,0.25,EA,69.19,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,33.2112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86,213.6008
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,517095501,NDC,0.25,EA,69.19,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,33.2112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86,213.6008
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,55150020200,NDC,1,EA,65.65,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,33.2189,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,487960130,NDC,2,ML,36.47,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,33.22417,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Alpha-Fetoprotein, Serum - Ref",PX8210590,CDM,300,RC,82105,CPT,90,,,,,,,80,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,33.232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.38,78.4
Prealubimin,PX84134,CDM,300,RC,84134,CPT,,,,,,,,80,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,33.232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.38,78.4
ampicillin-sulbactam 1.5 (1-0.5) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001381,NDC,1,EA,69.24,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,33.2352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
ampicillin-sulbactam 1.5 (1-0.5) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001381,NDC,1,EA,69.24,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,33.2352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
fentaNYL 25 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,591319872,NDC,1,EA,77.51,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,33.25179,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733513,NDC,1,EA,39.12,,First Health,Commercial,both,85,,999999999,percent of total billed charges,33.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039801,NDC,1,EA,67.88,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,11.105,percent of total billed charges,33.2612,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039801,NDC,1,EA,67.88,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.2612,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039801,NDC,1,EA,67.88,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,33.2612,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039810,NDC,1,EA,67.88,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,11.105,percent of total billed charges,33.2612,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039810,NDC,1,EA,67.88,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.2612,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039810,NDC,1,EA,67.88,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,33.2612,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
levoFLOXacin 750 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635361,NDC,0.333333333,EA,39.14,,First Health,Commercial,both,85,,999999999,percent of total billed charges,33.269,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,55150023501,NDC,0.5,EA,37.72,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,33.26904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
triamcinolone acetonide 0.1 % Cream 80 g Tube,63700001,CDM,250,RC,,,,,,16714098603,NDC,80,GR,65.76,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,33.27456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,409710709,NDC,1000,ML,36.53,,Medica,Commercial,both,91.1,,1.111818182,percent of total billed charges,33.27883,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5% and sodium chloride 0.45% with potassium chloride 10 mEq in 1000 mL 10-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,264763400,NDC,1000,ML,36.53,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,33.27883,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pancrelipase (lip-prot-amyl) 24000-76000 units Capsule Delayed Release Particles 100 Each Bottle,63700001,CDM,250,RC,,,,,,32122401,NDC,1,EA,37.41,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,33.2949,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
neomycin-bacitracin-polymyxin 3.5-400-5000 Ointment 28 g Tube,25000000,CDM,250,RC,,,,,,45802014303,NDC,28,GR,37.76,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,33.30432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,713013512,NDC,1,EA,65.83,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,33.30998,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.345782,66.2186
bezlotoxumab 1000 MG/40ML Solution 40 mL Vial,J0565.01,CDM,636,RC,J0565,HCPCS,,,,6302500,NDC,40,ML,7752,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,33.31,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.31,39.86
rivaroxaban 15 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50458057830,NDC,0.666666667,EA,67.3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,33.3135,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BINDER ABDOMINAL S/M 9 INCH UP TO 45 INCHES TRI-PANNEL ABB3P45,120.238,CDM,271,RC,A4467,HCPCS,,47-MAIN,LOCAL,,,,,34,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,33.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,33.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,33.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.32
"Flour. Afstain , Micro - Ref",PX8720690,CDM,300,RC,87206,CPT,90,,,,,,,68,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.94,66.64
"Flour. Afstain , Micro - Ref",PX8720690,CDM,300,RC,87206,CPT,90,,,,,,,68,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.94,66.64
"Flour. Afstain , Micro - Ref",PX8720690,CDM,300,RC,87206,CPT,90,,,,,,,68,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,33.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.94,66.64
Hemoglobin,PX85018,CDM,300,RC,85018,CPT,,,,,,,,68,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.17,66.64
Hemoglobin,PX85018,CDM,300,RC,85018,CPT,,,,,,,,68,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.17,66.64
Hemoglobin,PX85018,CDM,300,RC,85018,CPT,,,,,,,,68,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,33.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.17,66.64
"Lab Ige, Isocyan Hdi",PX86003,CDM,300,RC,86003,CPT,90,,,,,,,34,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,33.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.79,33.32
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323020110,NDC,10,ML,34,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,33.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Metanephrines - Ref,PX8383590,CDM,300,RC,83835,CPT,90,,,,,,,34,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,33.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1236,33.32
SPLINT SAM 36INCH ROLLED 661121,120.362,CDM,271,RC,,,,10789-MAIN,LOCAL,,,,,34,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,33.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1236,33.32
Thyroglobulin - Ref,PX8443290,CDM,300,RC,84432,CPT,90,,,,,,,68,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.73,66.64
Thyroglobulin - Ref,PX8443290,CDM,300,RC,84432,CPT,90,,,,,,,68,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.73,66.64
Thyroglobulin - Ref,PX8443290,CDM,300,RC,84432,CPT,90,,,,,,,68,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,33.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.73,66.64
Thyroglobulin Antibody,PX8680090,CDM,300,RC,86800,CPT,90,,,,,,,68,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.59,66.64
Thyroglobulin Antibody,PX8680090,CDM,300,RC,86800,CPT,90,,,,,,,68,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.59,66.64
Thyroglobulin Antibody,PX8680090,CDM,300,RC,86800,CPT,90,,,,,,,68,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,33.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.59,66.64
"Venipunc Need Phys Skill,Dx or Rx",PX36410F,CDM,510,RC,36410,CPT,,,,,,,,34,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,33.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.1236,33.32
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915850,NDC,0.2,ML,69.44,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,33.3312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915850,NDC,0.2,ML,69.44,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,33.3312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
terbinafine 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714079501,NDC,1,EA,68.03,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.3347,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terbinafine 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714079501,NDC,1,EA,68.03,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.3347,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terbinafine 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714079501,NDC,1,EA,68.03,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,33.3347,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terbinafine 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714050101,NDC,1,EA,68.04,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.3396,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terbinafine 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714050101,NDC,1,EA,68.04,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.3396,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terbinafine 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714050101,NDC,1,EA,68.04,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,33.3396,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781910572,NDC,0.25,EA,69.49,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,33.3552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86,213.6008
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781910572,NDC,0.25,EA,69.49,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,33.3552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86,213.6008
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143966001,NDC,5,ML,37.82,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,33.35724,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143966010,NDC,5,ML,37.82,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,33.35724,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ePHEDrine sulfate 50 MG/ML Solution 1 mL Vial,25000000,CDM,250,RC,,,,,,42023021689,NDC,0.1,ML,36.62,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,33.36082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Removal of Nail Plate,PX11730F,CDM,510,RC,11730,CPT,,,,,,,,229,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,33.37,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.37,239.36
"Flow Interp,2-8 Markers - Ref",PX8818790,CDM,310,RC,88187,CPT,90,,,,,,,162,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,33.3736,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.9,55.25
"CUFF STERILE DISPOSABLE SPSB 24""",27200000,CDM,272,RC,,,,7437-MAIN,LOCAL,,,,,37.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,33.375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ENDOCAVITY NEEDLE GUIDE,27200000,CDM,272,RC,,,,11134-MAIN,LOCAL,,,,,37.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,33.375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR KII BALOON 5X100MM STERILE,27200000,CDM,272,RC,,,,11701-MAIN,LOCAL,,,,,37.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,33.375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,55150025110,NDC,10,ML,37.85,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,33.3837,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Ig Paraprotein Qual Bld/UR,PX0077U90,CDM,300,RC,0077U,HCPCS,90,,,,,,,66,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,33.396,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
"Level III - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3933,CDM,310,RC,88304,CPT,TC,,,,,,,66,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,33.396,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
Ot Contracted Service/Msho/MA,PX120.178,CDM,431,RC,,,,,,,,,,66,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,33.396,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
Pt Contracted Service/Msho,PX120.176,CDM,421,RC,,,,,,,,,,66,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,33.396,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
Surg Pathology-Level 2-Tc,PX3932,CDM,310,RC,88302,CPT,TC,,,,,,,66,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,33.396,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.01,64.68
Xray Orbits Optic Foramina,PX7019001,CDM,320,RC,70190,CPT,TC,,,,,,,66,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,33.396,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,79.39
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707426,NDC,100,ML,39.29,,First Health,Commercial,both,85,,999999999,percent of total billed charges,33.3965,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331601,NDC,10,ML,77.86,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,33.40194,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
ESOPHAGEAL BALLOON INFLATION DEVICE 60ML,27200000,CDM,272,RC,C1726,HCPCS,,11326-MAIN,LOCAL,,,,,80.41,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,33.402314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338080304,NDC,1000,ML,69.59,,Health Partners,Health Partners Care Plans,both,48,,6.034333333,percent of total billed charges,33.4032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338080304,NDC,1000,ML,69.59,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,33.4032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990710709,NDC,1000,ML,69.59,,Health Partners,Health Partners Care Plans,both,48,,6.034333333,percent of total billed charges,33.4032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990710709,NDC,1000,ML,69.59,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,33.4032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004824,NDC,150,ML,69.59,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,33.4032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004824,NDC,150,ML,69.59,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,33.4032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018200,NDC,10,ML,68.21,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.4229,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.24,991.564
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018200,NDC,10,ML,68.21,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.4229,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.24,991.564
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018200,NDC,10,ML,68.21,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,33.4229,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.24,991.564
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018210,NDC,10,ML,68.21,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.4229,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.24,991.564
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018210,NDC,10,ML,68.21,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.4229,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.24,991.564
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018210,NDC,10,ML,68.21,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,33.4229,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.24,991.564
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409493311,NDC,10,ML,66.06,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,33.42636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409317801,NDC,20,ML,34.11,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,33.4278,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409317816,NDC,20,ML,34.11,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,33.4278,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189001,NDC,1,ML,34.11,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,33.4278,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189003,NDC,1,ML,34.11,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,33.4278,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143978410,NDC,2,ML,37.91,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,33.43662,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036001,NDC,10,ML,80.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,33.4397,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,84.5054
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,58602060407,NDC,100,GR,67.56,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,33.4422,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
DULoxetine 20 MG Capsule Delayed Release Particles 60 Each Bottle,63700001,CDM,250,RC,,,,,,57237001760,NDC,1,EA,37.58,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,33.4462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,574722612,NDC,1,EA,67.57,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,33.44715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.345782,66.2186
Ceruloplasmin - Ref,PX8239090,CDM,300,RC,82390,CPT,90,,,,,,,78,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,33.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,76.44
Chemiluminescent Assay - Ref,PX8239790,CDM,300,RC,82397,CPT,90,,,,,,,78,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,33.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.95,76.44
VISUALIZATION SYSTEM CLEARIFY LAPAROSCOPE STERILE,27200000,CDM,272,RC,,,,11875-MAIN,LOCAL,,,,,78,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,33.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078121,NDC,0.5,EA,36.75,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,33.47925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078141,NDC,0.5,EA,36.75,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,33.47925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050601,NDC,1,ML,68.33,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1.136465517,percent of total billed charges,33.4817,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050601,NDC,1,ML,68.33,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.4817,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050601,NDC,1,ML,68.33,,United Healthcare,All Medicare advantage plans,outpatient,49,,1.675,percent of total billed charges,33.4817,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010520,NDC,1,EA,68.33,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,12.3175,percent of total billed charges,33.4817,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010520,NDC,1,EA,68.33,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.4817,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010520,NDC,1,EA,68.33,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,33.4817,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010541,NDC,1,EA,68.33,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,12.3175,percent of total billed charges,33.4817,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010541,NDC,1,EA,68.33,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.4817,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010541,NDC,1,EA,68.33,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,33.4817,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
pioglitazone 15 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342005410,NDC,1,EA,37.62,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,33.4818,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"dextrose 5% and sodium chloride 0.45% with potassium chloride 10 mEq in 1000 mL 10-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,338066904,NDC,1000,ML,80.61,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,33.485394,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,264957710,NDC,500,ML,80.61,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,33.485394,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052201,NDC,500,ML,80.61,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,33.485394,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052277,NDC,500,ML,80.61,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,33.485394,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
pramox-PE-glycerin-petrolatum 1-0.25-14.4-15 % Cream 51 g Tube,63700001,CDM,250,RC,,,,,,573286898,NDC,51,GR,68.34,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.4866,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramox-PE-glycerin-petrolatum 1-0.25-14.4-15 % Cream 51 g Tube,63700001,CDM,250,RC,,,,,,573286898,NDC,51,GR,68.34,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.4866,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pramox-PE-glycerin-petrolatum 1-0.25-14.4-15 % Cream 51 g Tube,63700001,CDM,250,RC,,,,,,573286898,NDC,51,GR,68.34,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,33.4866,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Flex Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707526,NDC,100,ML,37.63,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,33.4907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,641601301,NDC,5,ML,34.41,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,33.491253,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
aspirin-dipyridamole 25-200 MG Capsule Extended Release 12 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687030533,NDC,1,EA,67.66,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,33.4917,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin-dipyridamole 25-200 MG Capsule Extended Release 12 Hour 20 Each Box,63700001,CDM,250,RC,,,,,,60687030532,NDC,1,EA,67.66,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,33.4917,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
famciclovir 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714030401,NDC,1,EA,34.42,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,33.500986,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457000100,NDC,10,ML,68.38,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,12.9192,percent of total billed charges,33.5062,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457000100,NDC,10,ML,68.38,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.5062,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457000100,NDC,10,ML,68.38,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,33.5062,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
atropine 1 mg/mL Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100101,NDC,0.2,ML,39.42,,First Health,Commercial,both,85,,999999999,percent of total billed charges,33.507,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
"Chlamydia Trachomatis Dna, Amp Probe",PX87491,CDM,300,RC,87491,CPT,,,,,,,,157,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,33.51,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.51,35.09
"Chlamydia Trachomatis Dna, Amp Probe",PX87491,CDM,300,RC,87491,CPT,,,,,,,,157,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,33.51,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.51,35.09
Detect Agent Nos Dna Amp,PX87798,CDM,300,RC,87798,CPT,,,,,,,,176,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,33.51,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.51,35.09
Detect Agent Nos Dna Amp,PX87798,CDM,300,RC,87798,CPT,,,,,,,,176,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,33.51,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.51,35.09
"Infect Ea Organ, Amp Prob - Ref",PX8779890,CDM,300,RC,87798,CPT,90,,,,,,,180,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,33.51,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.51,35.09
"Infect Ea Organ, Amp Prob - Ref",PX8779890,CDM,300,RC,87798,CPT,90,,,,,,,180,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,33.51,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.51,35.09
"Neisseria Gonorrhoeae Dna, Amp Probe",PX87591,CDM,300,RC,87591,CPT,,,,,,,,157,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,33.51,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.51,35.09
"Neisseria Gonorrhoeae Dna, Amp Probe",PX87591,CDM,300,RC,87591,CPT,,,,,,,,157,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,33.51,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.51,35.09
8MM-12MM CANNULA SEAL 5-8MM,27200000,CDM,272,RC,,,,11921-MAIN,LOCAL,,,,,38,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,33.516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRAPE COLUMN 470341,27200000,CDM,272,RC,,,,12013-MAIN,LOCAL,,,,,38,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,33.516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HH Hha Visit,PXG0156,CDM,571,RC,G0156,HCPCS,,,,,,,,38,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,33.516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
Mitochondrial Antibody Each,PX8638190,CDM,300,RC,86381,CPT,90,,,,,,,38,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,33.516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
Nasal Sm for Eos,PX89190,CDM,300,RC,89190,CPT,,,,,,,,38,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,33.516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.31,37.24
NEEDLE IV 19GA X .75IN HUBER POWERLOC SAFETY 0651934,120.85,CDM,272,RC,A4215,HCPCS,,12701-MAIN,LOCAL,,,,,38,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,33.516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
NEEDLE IV 19GA X 1 IN HUBER POWERLOC SAFETY 0651910,120.85,CDM,272,RC,A4215,HCPCS,,12702-MAIN,LOCAL,,,,,38,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,33.516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
NEEDLE IV 19GA X 1.5 IN HUBER POWERLOC SAFETY 0651915,120.85,CDM,272,RC,A4215,HCPCS,,12703-MAIN,LOCAL,,,,,38,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,33.516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
PEZZER CATHETER DRAIN LATEX 14FR,27200000,CDM,272,RC,,,,12053-MAIN,LOCAL,,,,,38,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,33.516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PEZZER LATEX CATHETER DRAIN 10FR,27200000,CDM,272,RC,,,,12646-MAIN,LOCAL,,,,,38,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,33.516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PNEUVIEW SMOKE ELIMINATOR,27200000,CDM,272,RC,,,,11884-MAIN,LOCAL,,,,,38,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,33.516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Psa, Free - Ref",PX8415490,CDM,300,RC,84154,CPT,90,,,,,,,38,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,33.516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
"Psa, Total - Ref",PX8415390,CDM,300,RC,84153,CPT,90,,,,,,,38,,United Healthcare,All Payer,outpatient,88.2,,83.21,percent of total billed charges,33.516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
SPECULUM VAGINAL WITH BUILT IN LIGHT LARGE,120.133,CDM,272,RC,,,,8251-MAIN,LOCAL,,,,,38,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,33.516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
SPECULUM VAGINAL WITH BUILT IN LIGHT MEDIUM,120.133,CDM,272,RC,,,,8250-MAIN,LOCAL,,,,,38,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,33.516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
SPECULUM VAGINAL WITH BUILT IN LIGHT SMALL,120.133,CDM,272,RC,,,,8249-MAIN,LOCAL,,,,,38,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,33.516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
TROCAR KII FIOS SYSTEM BLADELSS Z-THREAD 5MMX100MM,27200000,CDM,272,RC,,,,12003-MAIN,LOCAL,,,,,38,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,33.516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Bone Age Studies Tc,PX7707201,CDM,320,RC,77072,CPT,TC,,,,,,,211,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,33.53,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.12,33.53
Bone Age Studies Tc,PX7707201,CDM,320,RC,77072,CPT,TC,,,,,,,211,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,33.53,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.12,33.53
GASTRONOMY FEEDING TUBE MIC BALLOONED 20FR 7-10ML 0112-20,27200000,CDM,272,RC,B4087,HCPCS,,13098-MAIN,LOCAL,,,,,45,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,33.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TUBE GASTROSTOMY 18FR REPLACEMENT DYND70318,120.256,CDM,271,RC,B4087,HCPCS,,407-MAIN,LOCAL,,,,,179,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,33.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.53,175.42
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120301,NDC,0.5,ML,34.45,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,33.530185,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120311,NDC,0.5,ML,34.45,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,33.530185,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,25021011487,NDC,200,ML,66.28,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,33.53768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.20921,64.9544
ursodiol 300 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,591315901,NDC,1,EA,39.47,,First Health,Commercial,both,85,,999999999,percent of total billed charges,33.5495,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,55150023501,NDC,0.5,EA,37.72,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,33.5708,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037604,NDC,0.75,ML,36.86,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,33.57946,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
LAP KIT BASIC,27200000,CDM,272,RC,,,,4829-MAIN,LOCAL,,,,,78.29,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,33.58641,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Removal of Nail Plate,PX11730F,CDM,510,RC,11730,CPT,,,,,,,,229,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,33.59,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.37,239.36
Removal of Nail Plate,PX11730F,CDM,510,RC,11730,CPT,,,,,,,,229,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,33.59,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.37,239.36
SCAR GEL SHEET,120.458,CDM,273,RC,A6025,HCPCS,,5796-MAIN,LOCAL,,,,,51,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,33.59,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.79,33.59
SCAR GEL SHEET,120.458,CDM,273,RC,A6025,HCPCS,,5796-MAIN,LOCAL,,,,,51,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,33.59,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.79,33.59
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323031119,NDC,10,ML,66.39,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,33.59334,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,84.5054
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039801,NDC,1,EA,67.88,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,33.6006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039810,NDC,1,EA,67.88,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,33.6006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409751766,NDC,50,ML,80.89,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,33.601706,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
neomycin-bacitracin-polymyxin 3.5-400-5000 Ointment 28 g Tube,25000000,CDM,250,RC,,,,,,45802014303,NDC,28,GR,37.76,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,33.6064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
US Pregnancy Tc Limited,PX7681501,CDM,402,RC,76815,CPT,TC,,,,,,,438,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,33.61,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.61,99.92
"BUPivacaine 0.25%-EPINEPHrine 1:200,000 0.25% -1:200000 Solution 50 mL Vial",25000000,CDM,250,RC,,,,,,409175250,NDC,30,ML,68.6,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.614,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.25%-EPINEPHrine 1:200,000 0.25% -1:200000 Solution 50 mL Vial",25000000,CDM,250,RC,,,,,,409175250,NDC,30,ML,68.6,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.614,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.25%-EPINEPHrine 1:200,000 0.25% -1:200000 Solution 50 mL Vial",25000000,CDM,250,RC,,,,,,409175250,NDC,30,ML,68.6,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,33.614,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016501,NDC,1,ML,34.55,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1.579660194,percent of total billed charges,33.627515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049226,NDC,30,ML,34.55,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,33.627515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049245,NDC,30,ML,34.55,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,33.627515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,23155024031,NDC,2,ML,34.55,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1.12,percent of total billed charges,33.627515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.859
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,69543025204,NDC,118,ML,78.39,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,33.62931,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253022233,NDC,3,ML,38.13,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,33.63066,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
bisoprolol-hydroCHLOROthiazide 5-6.25 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,42799092102,NDC,1,EA,39.57,,First Health,Commercial,both,85,,999999999,percent of total billed charges,33.6345,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 1 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409128303,NDC,1,ML,36.93,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,33.64323,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
CAPTIFLEX SNARE SINGLE USE EXTRA SMALL 11MM,27200000,CDM,272,RC,,,,12378-MAIN,LOCAL,,,,,81,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,33.6474,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Smear Special Stain,PX87207,CDM,300,RC,87207,CPT,,,,,,,,81,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,33.6474,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.49,79.38
Tacrolimus - Ref,PX8019790,CDM,300,RC,80197,CPT,90,,,,,,,81,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,33.6474,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,79.38
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,63739003807,NDC,1,EA,66.51,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,33.65406,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143966001,NDC,5,ML,37.82,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,33.6598,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143966010,NDC,5,ML,37.82,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,33.6598,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Flour. Afstain , Micro - Ref",PX8720690,CDM,300,RC,87206,CPT,90,,,,,,,68,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,33.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.94,66.64
Hemoglobin,PX85018,CDM,300,RC,85018,CPT,,,,,,,,68,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,33.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.17,66.64
Thyroglobulin - Ref,PX8443290,CDM,300,RC,84432,CPT,90,,,,,,,68,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,33.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.73,66.64
Thyroglobulin Antibody,PX8680090,CDM,300,RC,86800,CPT,90,,,,,,,68,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,33.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.59,66.64
Apply Lower Leg Splint,PX29515F,CDM,510,RC,29515,CPT,,,,,,,,296,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,33.66,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.54,152.89
Apply Lower Leg Splint,PX29515P,CDM,983,RC,29515,CPT,,,,,,,,311,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,33.66,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.54,304.78
cyclopentolate 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,17478010002,NDC,2,ML,66.55,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,33.6743,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
HYDROmorphone 2 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409131203,NDC,1,ML,38.18,,United Healthcare,All Payer,outpatient,88.2,,34.74,percent of total billed charges,33.67476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
terbinafine 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714079501,NDC,1,EA,68.03,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,33.67485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terbinafine 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714050101,NDC,1,EA,68.04,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,33.6798,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,55150025110,NDC,10,ML,37.85,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,33.6865,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608201,NDC,1,ML,66.6,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,33.6996,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084243,NDC,0.5,ML,202.42,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,33.7,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.7,39.08
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084252,NDC,0.5,ML,207.65,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,33.7,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.7,39.08
COLLAR CERVICAL LARGE WITH TRACH 2 PIECE PHP-T4L,120.184,CDM,274,RC,L0172,HCPCS,,10142-MAIN,LOCAL,,,,,37,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,33.707,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.3698,152.79
COLLAR CERVICAL MEDIUM WITH TRACH 2 PIECE PHP-T4M,120.183,CDM,274,RC,L0172,HCPCS,,10141-MAIN,LOCAL,,,,,37,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,33.707,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.3698,152.79
COLLAR CERVICAL SMALL WITH TRACH 2 PIECE PHP-T4S,120.182,CDM,274,RC,L0172,HCPCS,,10140-MAIN,LOCAL,,,,,37,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,33.707,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.3698,152.79
SUTURE TICRON 0 36IN BRAIDED DYED 1/2 CIRCLE DBLE ARM 25MM CV-305 BLUE STERILE,27200000,CDM,272,RC,,,,11956-MAIN,LOCAL,,,,,37,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,33.707,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Drain/Inject Medium Joint/Bursa,PX20605F,CDM,510,RC,20605,CPT,,,,,,,,247,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,33.7155,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.47,114.84
Drain/Inject Medium Joint/Bursa,PX20605P,CDM,983,RC,20605,CPT,,,,,,,,318,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,33.7155,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.47,311.64
"Inject Trigger Point, 1 or 2",PX20552F,CDM,510,RC,20552,CPT,,,,,,,,252,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,33.7155,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.9,109.3
"Inject Trigger Point, 1 or 2",PX20552P,CDM,983,RC,20552,CPT,,,,,,,,210,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,33.7155,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.9,205.8
"Remv F.B.,Eye,Embed Conjunc",PX65210F,CDM,510,RC,65210,CPT,,,,,,,,325,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,33.7155,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.69,78.87
"Remv F.B.,Eye,Embed Conjunc",PX65210P,CDM,983,RC,65210,CPT,,,,,,,,216,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,33.7155,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.69,211.68
belimumab (400v) 400 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010201,NDC,1,EA,3523.71,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,33.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.72,3453.2358
belimumab 120 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010101,NDC,1,EA,1015.95,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,33.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.72,3453.2358
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,641601301,NDC,5,ML,34.41,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,33.7218,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
famciclovir 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714030401,NDC,1,EA,34.42,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,33.7316,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BIOPSY FORCEPS HOT,27200000,CDM,272,RC,,,,4353-MAIN,LOCAL,,,,,38.25,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,33.7365,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRESSING GEL FOAM SIZE 100SPONGE STERILE 00009034201,27200000,CDM,272,RC,A6248,HCPCS,,3378-MAIN,LOCAL,,,,,38.25,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,33.7365,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFFLATION TUBING SET,27200000,CDM,272,RC,,,,4686-MAIN,LOCAL,,,,,38.25,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,33.7365,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143978410,NDC,2,ML,37.91,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,33.7399,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Spirometry,PX9401001,CDM,460,RC,94010,CPT,TC,,,,,,,281,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,33.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.21,33.74
Spirometry,PX9401001,CDM,460,RC,94010,CPT,TC,,,,,,,281,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,33.74,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.21,33.74
Spirometry Incl Graph Rec Tc,PX9401002,CDM,460,RC,94010,CPT,TC,,,,,,,288,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,33.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.21,33.74
Spirometry Incl Graph Rec Tc,PX9401002,CDM,460,RC,94010,CPT,TC,,,,,,,288,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,33.74,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.21,33.74
Fetal Profile W/O Stress,PX7681901,CDM,402,RC,76819,CPT,TC,,,,,,,248,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,33.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.86,97.95
Fetal Profile W/O Stress,PX7681901,CDM,402,RC,76819,CPT,TC,,,,,,,248,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,33.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.86,97.95
Canalith Repositioning,PX95992,CDM,420,RC,95992,CPT,,,,,,,,128,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,33.7575,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.69,73.88
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120301,NDC,0.5,ML,34.45,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,33.761,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120311,NDC,0.5,ML,34.45,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,33.761,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018200,NDC,10,ML,68.21,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,33.76395,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.24,991.564
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018210,NDC,10,ML,68.21,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,33.76395,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.24,991.564
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600701,NDC,10,ML,39.73,,First Health,Commercial,both,85,,999999999,percent of total billed charges,33.7705,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,38.9354
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,17478081725,NDC,25,ML,81.3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,33.77202,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
brimonidine 0.2 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,70069023101,NDC,5,ML,70.38,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,33.7824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
brimonidine 0.2 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,70069023101,NDC,5,ML,70.38,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,33.7824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032056,NDC,1,EA,68.97,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,14.99111111,percent of total billed charges,33.7953,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032056,NDC,1,EA,68.97,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.7953,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032056,NDC,1,EA,68.97,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,33.7953,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078110,NDC,0.5,EA,38.33,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,33.80706,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Apply Short Leg Cast,Walker",PX29425F,CDM,510,RC,29425,CPT,,,,,,,,179,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,33.81,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.81,159.11
"Apply Short Leg Cast,Walker",PX29425P,CDM,983,RC,29425,CPT,,,,,,,,119,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,33.81,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.81,159.11
Assay Bld/Serum Cholesterol,PX82465,CDM,300,RC,82465,CPT,,,,,,,,69,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.99,67.62
Assay Bld/Serum Cholesterol,PX82465,CDM,300,RC,82465,CPT,,,,,,,,69,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.99,67.62
Assay Bld/Serum Cholesterol,PX82465,CDM,300,RC,82465,CPT,,,,,,,,69,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,33.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.99,67.62
"Astrazeneca Covid-19 Vaccine, Administration, 1st Dose",PX0021A,CDM,771,RC,,,,,,,,,,69,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Astrazeneca Covid-19 Vaccine, Administration, 1st Dose",PX0021A,CDM,771,RC,,,,,,,,,,69,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Astrazeneca Covid-19 Vaccine, Administration, 1st Dose",PX0021A,CDM,771,RC,,,,,,,,,,69,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,33.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Astrazeneca Covid-19 Vaccine, Adminstration, 2nd Dose",PX0022A,CDM,771,RC,,,,,,,,,,69,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Astrazeneca Covid-19 Vaccine, Adminstration, 2nd Dose",PX0022A,CDM,771,RC,,,,,,,,,,69,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Astrazeneca Covid-19 Vaccine, Adminstration, 2nd Dose",PX0022A,CDM,771,RC,,,,,,,,,,69,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,33.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Janssen Covid-19 Vaccine, Administration",PX0031A,CDM,771,RC,0031A,HCPCS,,,,,,,,69,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Janssen Covid-19 Vaccine, Administration",PX0031A,CDM,771,RC,0031A,HCPCS,,,,,,,,69,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Janssen Covid-19 Vaccine, Administration",PX0031A,CDM,771,RC,0031A,HCPCS,,,,,,,,69,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,33.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 1st Dose",PX0011A,CDM,771,RC,0011A,HCPCS,,,,,,,,69,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 1st Dose",PX0011A,CDM,771,RC,0011A,HCPCS,,,,,,,,69,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 1st Dose",PX0011A,CDM,771,RC,0011A,HCPCS,,,,,,,,69,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,33.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 2nd Dose",PX0012A,CDM,771,RC,0012A,HCPCS,,,,,,,,69,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 2nd Dose",PX0012A,CDM,771,RC,0012A,HCPCS,,,,,,,,69,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 2nd Dose",PX0012A,CDM,771,RC,0012A,HCPCS,,,,,,,,69,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,33.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 3rd Dose",PX0013A,CDM,771,RC,0013A,HCPCS,,,,,,,,69,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 3rd Dose",PX0013A,CDM,771,RC,0013A,HCPCS,,,,,,,,69,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 3rd Dose",PX0013A,CDM,771,RC,0013A,HCPCS,,,,,,,,69,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,33.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
Novavax Covid-19 Vaccine Administration 1st Dose,PX0041A,CDM,771,RC,0041A,HCPCS,,,,,,,,69,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
Novavax Covid-19 Vaccine Administration 1st Dose,PX0041A,CDM,771,RC,0041A,HCPCS,,,,,,,,69,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
Novavax Covid-19 Vaccine Administration 1st Dose,PX0041A,CDM,771,RC,0041A,HCPCS,,,,,,,,69,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,33.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
Novavax Covid-19 Vaccine Administration 2nd Dose,PX0042A,CDM,771,RC,0042A,HCPCS,,,,,,,,69,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
Novavax Covid-19 Vaccine Administration 2nd Dose,PX0042A,CDM,771,RC,0042A,HCPCS,,,,,,,,69,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
Novavax Covid-19 Vaccine Administration 2nd Dose,PX0042A,CDM,771,RC,0042A,HCPCS,,,,,,,,69,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,33.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Pfizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 2nd Dose",PX0002A,CDM,771,RC,0002A,HCPCS,,,,,,,,69,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Pfizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 2nd Dose",PX0002A,CDM,771,RC,0002A,HCPCS,,,,,,,,69,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Pfizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 2nd Dose",PX0002A,CDM,771,RC,0002A,HCPCS,,,,,,,,69,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,33.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Pfizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 3rd Dose",PX0003A,CDM,771,RC,0003A,HCPCS,,,,,,,,69,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Pfizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 3rd Dose",PX0003A,CDM,771,RC,0003A,HCPCS,,,,,,,,69,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Pfizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 3rd Dose",PX0003A,CDM,771,RC,0003A,HCPCS,,,,,,,,69,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,33.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Pifizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 1st Dose",PX0001A,CDM,771,RC,0001A,HCPCS,,,,,,,,69,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Pifizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 1st Dose",PX0001A,CDM,771,RC,0001A,HCPCS,,,,,,,,69,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Pifizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 1st Dose",PX0001A,CDM,771,RC,0001A,HCPCS,,,,,,,,69,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,33.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
Tap Block Unilateral by Injection(S),PX64486F,CDM,510,RC,64486,CPT,,,,,,,,253,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,33.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.81,231.06
Tap Block Unilateral by Injection(S),PX64486F,CDM,510,RC,64486,CPT,,,,,,,,253,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,33.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.81,231.06
Tap Block Unilateral by Injection(S),PX64486P,CDM,983,RC,64486,CPT,,,,,,,,169,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,33.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.81,231.06
Tap Block Unilateral by Injection(S),PX64486P,CDM,983,RC,64486,CPT,,,,,,,,169,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,33.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.81,231.06
lidocaine 1% PF 1 % Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,63323049227,NDC,2,ML,34.74,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,33.812442,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323048201,NDC,10,ML,39.78,,First Health,Commercial,both,85,,999999999,percent of total billed charges,33.813,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323048217,NDC,10,ML,39.78,,First Health,Commercial,both,85,,999999999,percent of total billed charges,33.813,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
8MM-12MM CANNULA SEAL 5-8MM,27200000,CDM,272,RC,,,,11921-MAIN,LOCAL,,,,,38,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,33.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRAPE COLUMN 470341,27200000,CDM,272,RC,,,,12013-MAIN,LOCAL,,,,,38,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,33.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HH Hha Visit,PXG0156,CDM,571,RC,G0156,HCPCS,,,,,,,,38,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,33.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
Mitochondrial Antibody Each,PX8638190,CDM,300,RC,86381,CPT,90,,,,,,,38,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,33.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
Nasal Sm for Eos,PX89190,CDM,300,RC,89190,CPT,,,,,,,,38,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,33.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.31,37.24
NEEDLE IV 19GA X .75IN HUBER POWERLOC SAFETY 0651934,120.85,CDM,272,RC,A4215,HCPCS,,12701-MAIN,LOCAL,,,,,38,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,33.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
NEEDLE IV 19GA X 1 IN HUBER POWERLOC SAFETY 0651910,120.85,CDM,272,RC,A4215,HCPCS,,12702-MAIN,LOCAL,,,,,38,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,33.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
NEEDLE IV 19GA X 1.5 IN HUBER POWERLOC SAFETY 0651915,120.85,CDM,272,RC,A4215,HCPCS,,12703-MAIN,LOCAL,,,,,38,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,33.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
PEZZER CATHETER DRAIN LATEX 14FR,27200000,CDM,272,RC,,,,12053-MAIN,LOCAL,,,,,38,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,33.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PEZZER LATEX CATHETER DRAIN 10FR,27200000,CDM,272,RC,,,,12646-MAIN,LOCAL,,,,,38,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,33.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PNEUVIEW SMOKE ELIMINATOR,27200000,CDM,272,RC,,,,11884-MAIN,LOCAL,,,,,38,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,33.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Psa, Free - Ref",PX8415490,CDM,300,RC,84154,CPT,90,,,,,,,38,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,33.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
"Psa, Total - Ref",PX8415390,CDM,300,RC,84153,CPT,90,,,,,,,38,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,33.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
SPECULUM VAGINAL WITH BUILT IN LIGHT LARGE,120.133,CDM,272,RC,,,,8251-MAIN,LOCAL,,,,,38,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,33.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
SPECULUM VAGINAL WITH BUILT IN LIGHT MEDIUM,120.133,CDM,272,RC,,,,8250-MAIN,LOCAL,,,,,38,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,33.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
SPECULUM VAGINAL WITH BUILT IN LIGHT SMALL,120.133,CDM,272,RC,,,,8249-MAIN,LOCAL,,,,,38,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,33.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
TROCAR KII FIOS SYSTEM BLADELSS Z-THREAD 5MMX100MM,27200000,CDM,272,RC,,,,12003-MAIN,LOCAL,,,,,38,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,33.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050601,NDC,1,ML,68.33,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,33.82335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010520,NDC,1,EA,68.33,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,33.82335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010541,NDC,1,EA,68.33,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,33.82335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
pramox-PE-glycerin-petrolatum 1-0.25-14.4-15 % Cream 51 g Tube,63700001,CDM,250,RC,,,,,,573286898,NDC,51,GR,68.34,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,33.8283,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
charcoal activated Liquid 240 mL Bottle,63700001,CDM,250,RC,,,,,,574012108,NDC,120,ML,66.88,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,33.84128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457000100,NDC,10,ML,68.38,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,33.8481,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
dabigatran 75 MG capsule 60 Each Box,63700001,CDM,250,RC,,,,,,597014960,NDC,1,EA,39.83,,First Health,Commercial,both,85,,999999999,percent of total billed charges,33.8555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016501,NDC,1,ML,34.55,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,33.859,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049226,NDC,30,ML,34.55,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,33.859,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049245,NDC,30,ML,34.55,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,33.859,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,23155024031,NDC,2,ML,34.55,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,33.859,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,33.859
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039814,NDC,1,EA,39.84,,First Health,Commercial,both,85,,999999999,percent of total billed charges,33.864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
BUPivacaine PF 0.5 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,55150016910,NDC,10,ML,39.84,,First Health,Commercial,both,85,,999999999,percent of total billed charges,33.864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
enalaprilat 1.25 MG/ML Injectable 1 mL Vial,25000000,CDM,250,RC,,,,,,143978710,NDC,1,ML,39.84,,First Health,Commercial,both,85,,999999999,percent of total billed charges,33.864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098141,NDC,1,EA,39.84,,First Health,Commercial,both,85,,999999999,percent of total billed charges,33.864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098153,NDC,1,EA,39.84,,First Health,Commercial,both,85,,999999999,percent of total billed charges,33.864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,47781059807,NDC,1,EA,39.84,,First Health,Commercial,both,85,,999999999,percent of total billed charges,33.864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
betamethasone acetate-betamethasone sodium phosphate 6 (3-3) MG/ML Suspension 5 mL Vial,J0702.01,CDM,636,RC,J0702,HCPCS,,,,517072001,NDC,1,ML,78.96,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,33.87384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.799984,77.3808
miconazole 2 % Powder 71 g Bottle,25000000,CDM,250,RC,,,,,,316023125,NDC,71,GR,34.82,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,33.890306,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Everolimus,PX8016990,CDM,300,RC,80169,CPT,,,,,,,,79,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,33.891,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,77.42
Group Therapeutic Procedures,PX97150,CDM,420,RC,97150,CPT,,,,,,,,67,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,33.902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.82,65.66
"Hydroxyprogesterone, 17-D - Ref",PX8349890,CDM,300,RC,83498,CPT,90,,,,,,,67,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,33.902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.91,65.66
Lab Org ID Anaerobic-Each,PX87076,CDM,300,RC,87076,CPT,,,,,,,,67,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,33.902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,65.66
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,517095501,NDC,0.25,EA,69.19,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.9031,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86,213.6008
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,517095501,NDC,0.25,EA,69.19,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.9031,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86,213.6008
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,517095501,NDC,0.25,EA,69.19,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,33.9031,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86,213.6008
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409427602,NDC,50,ML,38.46,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,33.92172,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
levoFLOXacin 250 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635161,NDC,1,EA,79.08,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,33.92532,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ampicillin-sulbactam 1.5 (1-0.5) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001381,NDC,1,EA,69.24,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.9276,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
ampicillin-sulbactam 1.5 (1-0.5) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001381,NDC,1,EA,69.24,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,33.9276,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
ampicillin-sulbactam 1.5 (1-0.5) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001381,NDC,1,EA,69.24,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,33.9276,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253022233,NDC,3,ML,38.13,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,33.9357,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
morphine 1 MG/ML Solution 50 mL Syringe,J2270.01,CDM,636,RC,J2270,HCPCS,,,,61553064975,NDC,50,ML,81.71,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,33.942334,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
sterile water (preservative free) Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409488724,NDC,50,ML,34.88,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,33.948704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409488750,NDC,50,ML,34.88,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,33.948704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.25%-EPINEPHrine 1:200,000 0.25% -1:200000 Solution 50 mL Vial",25000000,CDM,250,RC,,,,,,409175250,NDC,30,ML,68.6,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,33.957,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
HYDROmorphone 2 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409131203,NDC,1,ML,38.18,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,33.9802,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
urea 20 % Cream 85 g Tube,63700001,CDM,250,RC,,,,,,536110945,NDC,85,GR,81.83,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,33.992182,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
8MM-12MM TIP COVER ACCESSORY,27200000,CDM,272,RC,,,,11918-MAIN,LOCAL,,,,,40,,First Health,Commercial,both,85,,999999999,percent of total billed charges,34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CATHETER URETERAL  5FR TIGERTAIL OPEN TIP FLEXIBLE 139005,27200000,CDM,272,RC,A4340,HCPCS,,12302-MAIN,LOCAL,,,,,40,,First Health,Commercial,both,85,,999999999,percent of total billed charges,34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NEEDLE BIOPSY 14GAX4 1/2 2N2702X,120.211,CDM,272,RC,,,,724-MAIN,LOCAL,,,,,40,,First Health,Commercial,both,85,,999999999,percent of total billed charges,34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.616,39.2
STAPLER CANNULA SEAL 12 mm 470380,27200000,CDM,272,RC,,,,11962-MAIN,LOCAL,,,,,40,,First Health,Commercial,both,85,,999999999,percent of total billed charges,34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"SUTURE V-LOC 22G NEEDLE 9"" 180 GREEN VLOCL2145",27200000,CDM,272,RC,,,,11930-MAIN,LOCAL,,,,,40,,First Health,Commercial,both,85,,999999999,percent of total billed charges,34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"SUTURE V-LOC SZ 0.9"" 180 GREEN GS-21 NEEDLE VLOCL0346",27200000,CDM,272,RC,,,,11933-MAIN,LOCAL,,,,,40,,First Health,Commercial,both,85,,999999999,percent of total billed charges,34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Telehealth Origin Site Fac Fee,PXQ3014,CDM,780,RC,Q3014,HCPCS,,,,,,,,40,,First Health,Commercial,both,85,,999999999,percent of total billed charges,34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.616,39.2
valACYclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069801,NDC,1,EA,38.55,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,34.0011,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915850,NDC,0.2,ML,69.44,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,34.0256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915850,NDC,0.2,ML,69.44,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,34.0256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915850,NDC,0.2,ML,69.44,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,34.0256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
"Ctrl Nosebleed,Anter,Simple",PX30901F,CDM,510,RC,30901,CPT,,,,,,,,342,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,34.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.03,325.15
"Ctrl Nosebleed,Anter,Simple",PX30901F,CDM,510,RC,30901,CPT,,,,,,,,342,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,34.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.03,325.15
"Ctrl Nosebleed,Anter,Simple",PX30901F,CDM,510,RC,30901,CPT,,,,,,,,342,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,34.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.03,325.15
"Ctrl Nosebleed,Anter,Simple",PX30901P,CDM,983,RC,30901,CPT,,,,,,,,229,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,34.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.03,325.15
"Ctrl Nosebleed,Anter,Simple",PX30901P,CDM,983,RC,30901,CPT,,,,,,,,229,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,34.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.03,325.15
"Ctrl Nosebleed,Anter,Simple",PX30901P,CDM,983,RC,30901,CPT,,,,,,,,229,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,34.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.03,325.15
Repr Superf Wnd Face 2.6-5,PX12013F,CDM,510,RC,12013,CPT,,,,,,,,375,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,34.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.03,243.51
Repr Superf Wnd Face 2.6-5,PX12013F,CDM,510,RC,12013,CPT,,,,,,,,375,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,34.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.03,243.51
Repr Superf Wnd Face 2.6-5,PX12013P,CDM,983,RC,12013,CPT,,,,,,,,681,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,34.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.03,667.38
Repr Superf Wnd Face 2.6-5,PX12013P,CDM,983,RC,12013,CPT,,,,,,,,681,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,34.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.03,667.38
Tap Block Unilateral by Injection(S),PX64486F,CDM,510,RC,64486,CPT,,,,,,,,253,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,34.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.81,231.06
Tap Block Unilateral by Injection(S),PX64486P,CDM,983,RC,64486,CPT,,,,,,,,169,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,34.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.81,231.06
Declot Vascular Access Device,PX36593F,CDM,510,RC,36593,CPT,,,,,,,,358,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,34.0366,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.6,71.95
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046203,NDC,30,ML,70.91,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,34.0368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046203,NDC,30,ML,70.91,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,34.0368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"B.Burgdorferi, Amp Probe - Ref",PX8747690,CDM,300,RC,87476,CPT,90,,,,,,,72,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,34.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
"B.Burgdorferi, Amp Probe - Ref",PX8747690,CDM,300,RC,87476,CPT,90,,,,,,,72,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,34.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
"B.Burgdorferi, Amp Probe - Ref",PX8747690,CDM,300,RC,87476,CPT,90,,,,,,,72,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,34.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
"Chlamydia Trachomatis Dna, Amp Probe",PX87491,CDM,300,RC,87491,CPT,,,,,,,,157,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,34.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.51,35.09
"Cmv Detect, Amplifi Probe - Ref",PX8749690,CDM,300,RC,87496,CPT,90,,,,,,,147,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,34.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
"Cmv Detect, Amplifi Probe - Ref",PX8749690,CDM,300,RC,87496,CPT,90,,,,,,,147,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,34.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
"Cmv Detect, Amplifi Probe - Ref",PX8749690,CDM,300,RC,87496,CPT,90,,,,,,,147,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,34.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
Detect Agent Nos Dna Amp,PX87798,CDM,300,RC,87798,CPT,,,,,,,,176,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,34.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.51,35.09
Detection of Anaplasma Phagocytophilum by Amplified Nucleic Acid Probe Technique,PX8746890,CDM,300,RC,87468,CPT,90,,,,,,,41,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,34.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
Detection of Anaplasma Phagocytophilum by Amplified Nucleic Acid Probe Technique,PX8746890,CDM,300,RC,87468,CPT,90,,,,,,,41,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,34.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
Detection of Anaplasma Phagocytophilum by Amplified Nucleic Acid Probe Technique,PX8746890,CDM,300,RC,87468,CPT,90,,,,,,,41,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,34.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
Detection of Babesia Borrelia Miyamotoi by Amplified Nucleic Acid Probe Technique,PX8747890,CDM,300,RC,87478,CPT,90,,,,,,,23,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,34.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
Detection of Babesia Borrelia Miyamotoi by Amplified Nucleic Acid Probe Technique,PX8747890,CDM,300,RC,87478,CPT,90,,,,,,,23,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,34.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
Detection of Babesia Borrelia Miyamotoi by Amplified Nucleic Acid Probe Technique,PX8747890,CDM,300,RC,87478,CPT,90,,,,,,,23,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,34.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
Detection of Babesia Microtim by Amplified Nucleic Acid Probe Technique,PX8746990,CDM,300,RC,87469,CPT,90,,,,,,,23,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,34.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
Detection of Babesia Microtim by Amplified Nucleic Acid Probe Technique,PX8746990,CDM,300,RC,87469,CPT,90,,,,,,,23,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,34.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
Detection of Babesia Microtim by Amplified Nucleic Acid Probe Technique,PX8746990,CDM,300,RC,87469,CPT,90,,,,,,,23,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,34.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
Detection of Ehrlichia Chaffeensis by Amplified Nucleic Acid Probe Technique,PX8748490,CDM,300,RC,87484,CPT,90,,,,,,,41,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,34.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
Detection of Ehrlichia Chaffeensis by Amplified Nucleic Acid Probe Technique,PX8748490,CDM,300,RC,87484,CPT,90,,,,,,,41,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,34.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
Detection of Ehrlichia Chaffeensis by Amplified Nucleic Acid Probe Technique,PX8748490,CDM,300,RC,87484,CPT,90,,,,,,,41,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,34.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
"Hsv Detect, Amplif Probe - Ref",PX8752990,CDM,300,RC,87529,CPT,90,,,,,,,150,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,34.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
"Hsv Detect, Amplif Probe - Ref",PX8752990,CDM,300,RC,87529,CPT,90,,,,,,,150,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,34.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
"Hsv Detect, Amplif Probe - Ref",PX8752990,CDM,300,RC,87529,CPT,90,,,,,,,150,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,34.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
Hsv Dna Amp Probe,PX87529,CDM,300,RC,87529,CPT,,,,,,,,145,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,34.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
Hsv Dna Amp Probe,PX87529,CDM,300,RC,87529,CPT,,,,,,,,145,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,34.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
Hsv Dna Amp Probe,PX87529,CDM,300,RC,87529,CPT,,,,,,,,145,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,34.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
Iadna Streptococcus Group a Amplified Probe Tq,PX87651,CDM,300,RC,87651,CPT,,,,,,,,113,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,34.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
Iadna Streptococcus Group a Amplified Probe Tq,PX87651,CDM,300,RC,87651,CPT,,,,,,,,113,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,34.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
Iadna Streptococcus Group a Amplified Probe Tq,PX87651,CDM,300,RC,87651,CPT,,,,,,,,113,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,34.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
"Infect Ea Organ, Amp Prob - Ref",PX8779890,CDM,300,RC,87798,CPT,90,,,,,,,180,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,34.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.51,35.09
Mrsa by Amplification Na,PX87641,CDM,300,RC,87641,CPT,,,,,,,,180,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,34.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
Mrsa by Amplification Na,PX87641,CDM,300,RC,87641,CPT,,,,,,,,180,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,34.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
Mrsa by Amplification Na,PX87641,CDM,300,RC,87641,CPT,,,,,,,,180,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,34.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
"Neisseria Gonorrhoeae Dna, Amp Probe",PX87591,CDM,300,RC,87591,CPT,,,,,,,,157,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,34.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.51,35.09
BIOPSY FORCEPS HOT,27200000,CDM,272,RC,,,,4353-MAIN,LOCAL,,,,,38.25,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,34.0425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRESSING GEL FOAM SIZE 100SPONGE STERILE 00009034201,27200000,CDM,272,RC,A6248,HCPCS,,3378-MAIN,LOCAL,,,,,38.25,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,34.0425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFFLATION TUBING SET,27200000,CDM,272,RC,,,,4686-MAIN,LOCAL,,,,,38.25,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,34.0425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
lidocaine 1% PF 1 % Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,63323049227,NDC,2,ML,34.74,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,34.0452,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,60432006547,NDC,10,ML,34.98,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,34.046034,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781910572,NDC,0.25,EA,69.49,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,34.0501,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86,213.6008
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781910572,NDC,0.25,EA,69.49,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,34.0501,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86,213.6008
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781910572,NDC,0.25,EA,69.49,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,34.0501,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86,213.6008
rivaroxaban 15 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50458057830,NDC,0.666666667,EA,67.3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,34.0538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,17478081705,NDC,5,ML,34.99,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,34.055767,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Level IV - Surgical Pathology, Gross and Microscopic Examination , Tech",PX3934,CDM,310,RC,88305,CPT,TC,,,,,,,185,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,34.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.06,58.096
"Level IV - Surgical Pathology, Gross and Microscopic Examination , Tech",PX3934,CDM,310,RC,88305,CPT,TC,,,,,,,185,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,34.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.06,58.096
Ace - Ref,PX8216490,CDM,300,RC,82164,CPT,90,,,,,,,82,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,34.0628,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.39,80.36
Anca Screen Each Antibody,PX8603690,CDM,300,RC,86036,CPT,90,,,,,,,82,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,34.0628,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.0628,80.36
"Cognitive Funct Ther Interv, Ea Addl 15 Min",PX97130,CDM,420,RC,97130,CPT,,,,,,,,82,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,34.0628,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31,80.36
"Cortisol, Free - Ref",PX8253090,CDM,300,RC,82530,CPT,90,,,,,,,82,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,34.0628,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.32,80.36
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209F,CDM,510,RC,69209,CPT,,,,,,,,35,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,34.0655,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,53.44
SHOE POST OP X-LARGE MALE DS1016-16,120.237,CDM,274,RC,L3260,HCPCS,,6337-MAIN,LOCAL,,,,,35,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,34.0655,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
"Trimming of Dystrophic Nails, Any Number",PXG0127P,CDM,983,RC,G0127,HCPCS,,,,,,,,35,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,34.0655,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,53.44
Gabapentin - Ref,PX8017190,CDM,300,RC,80171,CPT,90,,,,,,,71,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,34.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.87,69.58
Gabapentin - Ref,PX8017190,CDM,300,RC,80171,CPT,90,,,,,,,71,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,34.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.87,69.58
Histoplasma Antibody - Ref,PX8669890,CDM,300,RC,86698,CPT,90,,,,,,,71,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,34.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.64,69.58
Histoplasma Antibody - Ref,PX8669890,CDM,300,RC,86698,CPT,90,,,,,,,71,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,34.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.64,69.58
Legionella Antibody - Ref,PX8671390,CDM,300,RC,86713,CPT,90,,,,,,,71,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,34.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.03,69.58
Legionella Antibody - Ref,PX8671390,CDM,300,RC,86713,CPT,90,,,,,,,71,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,34.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.03,69.58
pancrelipase (lip-prot-amyl) 24000-76000 units Capsule Delayed Release Particles 100 Each Bottle,63700001,CDM,250,RC,,,,,,32122401,NDC,1,EA,37.41,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,34.08051,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338080304,NDC,1000,ML,69.59,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1.633818182,percent of total billed charges,34.0991,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338080304,NDC,1000,ML,69.59,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,34.0991,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338080304,NDC,1000,ML,69.59,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,34.0991,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990710709,NDC,1000,ML,69.59,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1.633818182,percent of total billed charges,34.0991,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990710709,NDC,1000,ML,69.59,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,34.0991,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990710709,NDC,1000,ML,69.59,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,34.0991,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004824,NDC,150,ML,69.59,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,4.651111111,percent of total billed charges,34.0991,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004824,NDC,150,ML,69.59,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,34.0991,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004824,NDC,150,ML,69.59,,United Healthcare,All Medicare advantage plans,outpatient,49,,17.13,percent of total billed charges,34.0991,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329333901,NDC,10,ML,79.51,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,34.10979,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
calcium CHLORIDE 10 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,76329330401,NDC,10,ML,79.51,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,34.10979,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,25021018482,NDC,100,ML,79.51,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,34.10979,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.786918,140.5516
leucovorin 10 mg/mL Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,25021081467,NDC,1,EA,40.13,,First Health,Commercial,both,85,,999999999,percent of total billed charges,34.1105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.670002,84.6818
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078110,NDC,0.5,EA,38.33,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,34.1137,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
menthol-zinc oxide Paste 113 g Tube,63700001,CDM,250,RC,,,,,,53329016544,NDC,113,GR,79.52,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,34.11408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
miconazole 2 % Powder 71 g Bottle,25000000,CDM,250,RC,,,,,,316023125,NDC,71,GR,34.82,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,34.1236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032056,NDC,1,EA,68.97,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,34.14015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001001,NDC,1.5,ML,40.17,,First Health,Commercial,both,85,,999999999,percent of total billed charges,34.1445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,42.5516
Assay Bld/Serum Cholesterol,PX82465,CDM,300,RC,82465,CPT,,,,,,,,69,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,34.155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.99,67.62
"Astrazeneca Covid-19 Vaccine, Administration, 1st Dose",PX0021A,CDM,771,RC,,,,,,,,,,69,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,34.155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Astrazeneca Covid-19 Vaccine, Adminstration, 2nd Dose",PX0022A,CDM,771,RC,,,,,,,,,,69,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,34.155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Janssen Covid-19 Vaccine, Administration",PX0031A,CDM,771,RC,0031A,HCPCS,,,,,,,,69,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,34.155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 1st Dose",PX0011A,CDM,771,RC,0011A,HCPCS,,,,,,,,69,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,34.155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 2nd Dose",PX0012A,CDM,771,RC,0012A,HCPCS,,,,,,,,69,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,34.155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 3rd Dose",PX0013A,CDM,771,RC,0013A,HCPCS,,,,,,,,69,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,34.155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
Novavax Covid-19 Vaccine Administration 1st Dose,PX0041A,CDM,771,RC,0041A,HCPCS,,,,,,,,69,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,34.155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
Novavax Covid-19 Vaccine Administration 2nd Dose,PX0042A,CDM,771,RC,0042A,HCPCS,,,,,,,,69,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,34.155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Pfizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 2nd Dose",PX0002A,CDM,771,RC,0002A,HCPCS,,,,,,,,69,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,34.155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Pfizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 3rd Dose",PX0003A,CDM,771,RC,0003A,HCPCS,,,,,,,,69,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,34.155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Pifizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 1st Dose",PX0001A,CDM,771,RC,0001A,HCPCS,,,,,,,,69,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,34.155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"CUFF STERILE DISPOSABLE SPSB 24""",27200000,CDM,272,RC,,,,7437-MAIN,LOCAL,,,,,37.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,34.1625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ENDOCAVITY NEEDLE GUIDE,27200000,CDM,272,RC,,,,11134-MAIN,LOCAL,,,,,37.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,34.1625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR KII BALOON 5X100MM STERILE,27200000,CDM,272,RC,,,,11701-MAIN,LOCAL,,,,,37.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,34.1625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
C Diff Amplified Probe,PX87493,CDM,300,RC,87493,CPT,,,,,,,,179,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,34.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.17,175.42
CISplatin 50 MG/50ML Solution 50 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010351,NDC,50,ML,82.27,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,34.174958,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.174958,180.2416
X-Ray Exam Chest 1 View,PX7104501,CDM,320,RC,71045,CPT,TC,,,,,,,357,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,34.18,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.34,34.18
X-Ray Exam Chest 1 View,PX7104501,CDM,320,RC,71045,CPT,TC,,,,,,,357,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,34.18,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.34,34.18
sterile water (preservative free) Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409488724,NDC,50,ML,34.88,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,34.1824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409488750,NDC,50,ML,34.88,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,34.1824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,58602060407,NDC,100,GR,67.56,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,34.18536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,36000014801,NDC,2,ML,38.76,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,34.18632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,574722612,NDC,1,EA,67.57,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,34.19042,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.345782,66.2186
valACYclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,31722070430,NDC,1,EA,38.79,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,34.21278,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409427602,NDC,50,ML,38.46,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,34.2294,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
DULoxetine 20 MG Capsule Delayed Release Particles 60 Each Bottle,63700001,CDM,250,RC,,,,,,57237001760,NDC,1,EA,37.58,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,34.23538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin-dipyridamole 25-200 MG Capsule Extended Release 12 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687030533,NDC,1,EA,67.66,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,34.23596,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin-dipyridamole 25-200 MG Capsule Extended Release 12 Hour 20 Each Box,63700001,CDM,250,RC,,,,,,60687030532,NDC,1,EA,67.66,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,34.23596,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,517095501,NDC,0.25,EA,69.19,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,34.24905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86,213.6008
"Apply Short Leg Cast,Walker",PX29425F,CDM,510,RC,29425,CPT,,,,,,,,179,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,34.25,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.81,159.11
"Apply Short Leg Cast,Walker",PX29425F,CDM,510,RC,29425,CPT,,,,,,,,179,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,34.25,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.81,159.11
"Apply Short Leg Cast,Walker",PX29425P,CDM,983,RC,29425,CPT,,,,,,,,119,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,34.25,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.81,159.11
"Apply Short Leg Cast,Walker",PX29425P,CDM,983,RC,29425,CPT,,,,,,,,119,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,34.25,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.81,159.11
Repr Superf Wnd Face 2.6-5,PX12013F,CDM,510,RC,12013,CPT,,,,,,,,375,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,34.25,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.03,243.51
Repr Superf Wnd Face 2.6-5,PX12013P,CDM,983,RC,12013,CPT,,,,,,,,681,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,34.25,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.03,667.38
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046201,NDC,30,ML,79.84,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,34.25136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,703291401,NDC,0.5,EA,40.3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,34.255,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Iaad Ia Severe Aqt Respir Synd Coronavirus,PX87426,CDM,300,RC,87426,CPT,,,,,,,,159,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,34.27,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.27,35.33
pioglitazone 15 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342005410,NDC,1,EA,37.62,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,34.27182,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ampicillin-sulbactam 1.5 (1-0.5) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001381,NDC,1,EA,69.24,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,34.2738,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,60432006547,NDC,10,ML,34.98,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,34.2804,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Flex Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707526,NDC,100,ML,37.63,,Medica,Commercial,both,91.1,,1.111818182,percent of total billed charges,34.28093,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
fluticasone-salmeterol 100-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069500,NDC,1,EA,38.87,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,34.28334,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,17478081705,NDC,5,ML,34.99,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,34.2902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
anastrozole 1 MG Tablet 30 Each Bottle,25000000,CDM,250,RC,,,,,,16729003510,NDC,1,EA,71.44,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,34.2912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
anastrozole 1 MG Tablet 30 Each Bottle,25000000,CDM,250,RC,,,,,,16729003510,NDC,1,EA,71.44,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,34.2912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209F,CDM,510,RC,69209,CPT,,,,,,,,35,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,34.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,53.44
SHOE POST OP X-LARGE MALE DS1016-16,120.237,CDM,274,RC,L3260,HCPCS,,6337-MAIN,LOCAL,,,,,35,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,34.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
"Trimming of Dystrophic Nails, Any Number",PXG0127P,CDM,983,RC,G0127,HCPCS,,,,,,,,35,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,34.3,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.58,41.88
valACYclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069801,NDC,1,EA,38.55,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,34.3095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Alpha-Fetoprotein, Serum - Ref",PX8210590,CDM,300,RC,82105,CPT,90,,,,,,,80,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,34.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.38,78.4
Concurrent Infusion,PX96368,CDM,260,RC,96368,CPT,,,,,,,,102,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,34.32,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.87,34.32
Concurrent Infusion,PX96368,CDM,260,RC,96368,CPT,,,,,,,,102,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,34.32,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.87,34.32
Prealubimin,PX84134,CDM,300,RC,84134,CPT,,,,,,,,80,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,34.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.38,78.4
enalaprilat 1.25 MG/ML Injectable 1 mL Vial,25000000,CDM,250,RC,,,,,,143978701,NDC,1,ML,40.39,,First Health,Commercial,both,85,,999999999,percent of total billed charges,34.3315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"B.Burgdorferi, Amp Probe - Ref",PX8747690,CDM,300,RC,87476,CPT,90,,,,,,,72,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,34.3363,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
"Chlamydia Trachomatis Dna, Amp Probe",PX87491,CDM,300,RC,87491,CPT,,,,,,,,157,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,34.3363,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.51,35.09
"Cmv Detect, Amplifi Probe - Ref",PX8749690,CDM,300,RC,87496,CPT,90,,,,,,,147,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,34.3363,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
Detect Agent Nos Dna Amp,PX87798,CDM,300,RC,87798,CPT,,,,,,,,176,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,34.3363,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.51,35.09
Detection of Anaplasma Phagocytophilum by Amplified Nucleic Acid Probe Technique,PX8746890,CDM,300,RC,87468,CPT,90,,,,,,,41,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,34.3363,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
Detection of Babesia Borrelia Miyamotoi by Amplified Nucleic Acid Probe Technique,PX8747890,CDM,300,RC,87478,CPT,90,,,,,,,23,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,34.3363,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
Detection of Babesia Microtim by Amplified Nucleic Acid Probe Technique,PX8746990,CDM,300,RC,87469,CPT,90,,,,,,,23,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,34.3363,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
Detection of Ehrlichia Chaffeensis by Amplified Nucleic Acid Probe Technique,PX8748490,CDM,300,RC,87484,CPT,90,,,,,,,41,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,34.3363,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
"Hsv Detect, Amplif Probe - Ref",PX8752990,CDM,300,RC,87529,CPT,90,,,,,,,150,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,34.3363,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
Hsv Dna Amp Probe,PX87529,CDM,300,RC,87529,CPT,,,,,,,,145,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,34.3363,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
Iadna Streptococcus Group a Amplified Probe Tq,PX87651,CDM,300,RC,87651,CPT,,,,,,,,113,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,34.3363,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
"Infect Ea Organ, Amp Prob - Ref",PX8779890,CDM,300,RC,87798,CPT,90,,,,,,,180,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,34.3363,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.51,35.09
Mrsa by Amplification Na,PX87641,CDM,300,RC,87641,CPT,,,,,,,,180,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,34.3363,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
"Neisseria Gonorrhoeae Dna, Amp Probe",PX87591,CDM,300,RC,87591,CPT,,,,,,,,157,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,34.3363,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.51,35.09
atropine (PF) 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517040125,NDC,1,ML,71.55,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,34.344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
atropine (PF) 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517040125,NDC,1,ML,71.55,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,34.344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
tetracaine 0.5 % Solution 4 mL Plas Cont,25000000,CDM,250,RC,,,,,,65074114,NDC,4,ML,71.55,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,34.344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tetracaine 0.5 % Solution 4 mL Plas Cont,25000000,CDM,250,RC,,,,,,65074114,NDC,4,ML,71.55,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,34.344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Chemo Ad Sq/Im Hormnl Anti-Neo,PX96402,CDM,335,RC,96402,CPT,,,,,,,,130,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,34.347,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.03,61.66
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039801,NDC,1,EA,67.88,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,34.34728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039810,NDC,1,EA,67.88,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,34.34728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,55150023501,NDC,0.5,EA,37.72,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,34.36292,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028002,NDC,1,ML,40.43,,First Health,Commercial,both,85,,999999999,percent of total billed charges,34.3655,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915850,NDC,0.2,ML,69.44,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,34.3728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253033335,NDC,5,ML,40.44,,First Health,Commercial,both,85,,999999999,percent of total billed charges,34.374,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,45802095301,NDC,100,GR,82.76,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,34.378504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
morphine 2 MG/ML Solution 1 mL Syringe,J2272.01,CDM,636,RC,J2272,HCPCS,,,,76045000401,NDC,1,ML,38.98,,United Healthcare,All Payer,outpatient,88.2,,19.11,percent of total billed charges,34.38036,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.192292,38.2004
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781910572,NDC,0.25,EA,69.49,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,34.39755,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86,213.6008
CLOSED WOUND ROUND CHANNEL DRAIN WITH TROCAR 15FR FULL FLUTED,27200000,CDM,272,RC,,,,12223-MAIN,LOCAL,,,,,39,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,34.398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
fluorouracil 500 MG/10ML Solution 10 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,63323011710,NDC,10,ML,39,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,34.398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,256.2112
gemcitabine 200 MG Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323010294,NDC,1,EA,39,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,34.398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
Lab Wbc and Differential,PX85004,CDM,300,RC,85004,CPT,,,,,,,,39,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,34.398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,38.22
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003928,NDC,1,EA,39,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,34.398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
methylPREDNISolone sod succ 500 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9075801,NDC,0.25,EA,39,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,34.398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
NEEDLE JAMSHIDI 11G X 101MM BIOPSY DJ4011X,27200000,CDM,272,RC,,,,12798-MAIN,LOCAL,,,,,39,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,34.398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
O2 SENSOR ADULT ADHESIVE SINGLE PATIENT 040-003382-00,120.576,CDM,272,RC,,,,12930-MAIN,LOCAL,,,,,39,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,34.398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
O2 SENSOR INFANT ADHESIVE SINGLE PATIENT 040-003384-00,120.576,CDM,272,RC,,,,12932-MAIN,LOCAL,,,,,39,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,34.398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
O2 SENSOR PEDIATRIC ADHESIVE SINGLE PATIENT 040-003383-00,120.576,CDM,272,RC,,,,12931-MAIN,LOCAL,,,,,39,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,34.398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
SLEEVE ACHILLES LG/XL PROTECTION 92437145348,120.422,CDM,271,RC,,,,11378-MAIN,LOCAL,,,,,39,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,34.398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
SLEEVE ACHILLES SM/MED PROTECTION 92437145324,120.422,CDM,271,RC,,,,11377-MAIN,LOCAL,,,,,39,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,34.398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
Treponema Pallidum - Ref,PX8678090,CDM,300,RC,86780,CPT,90,,,,,,,39,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,34.398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.14,38.22
TROCAR KII FIOS SYSTEM BLADELSS Z-THREAD 5MMX150MM,27200000,CDM,272,RC,,,,12827-MAIN,LOCAL,,,,,39,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,34.398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
neomycin-bacitracin-polymyxin 3.5-400-5000 Ointment 28 g Tube,25000000,CDM,250,RC,,,,,,45802014303,NDC,28,GR,37.76,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,34.39936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Cpap/Bipap Mgmnt-Pt Own Equipment,PX94660.02F,CDM,410,RC,94660,CPT,,,,,,,,497,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,34.4005,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.9,112.85
"POS Airway Pressure, Bipap",PX94660.01F,CDM,410,RC,94660,CPT,,,,,,,,468,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,34.4005,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.9,112.85
"POS Airway Pressure, Cpap",PX94660F,CDM,410,RC,94660,CPT,,,,,,,,498,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,34.4005,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.9,112.85
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409427617,NDC,50,ML,39.01,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,34.40682,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Flour. Afstain , Micro - Ref",PX8720690,CDM,300,RC,87206,CPT,90,,,,,,,68,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,34.408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.94,66.64
Hemoglobin,PX85018,CDM,300,RC,85018,CPT,,,,,,,,68,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,34.408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.17,66.64
Thyroglobulin - Ref,PX8443290,CDM,300,RC,84432,CPT,90,,,,,,,68,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,34.408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.73,66.64
Thyroglobulin Antibody,PX8680090,CDM,300,RC,86800,CPT,90,,,,,,,68,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,34.408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.59,66.64
terbinafine 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714079501,NDC,1,EA,68.03,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,34.42318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terbinafine 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714050101,NDC,1,EA,68.04,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,34.42824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
X-Ray Abdomen 2+ Views W/ Single Vw Chest (Tc),PX7402201,CDM,320,RC,74022,CPT,TC,,,,,,,334,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,34.4326,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.9,69.03
benzocaine-menthol 20-0.5 % Aerosol 78 g Can,63700001,CDM,250,RC,,,,,,75137085520,NDC,78,GR,35.38,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,34.435354,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tiotropium 18 MCG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,597007541,NDC,1,EA,82.92,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,34.444968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338080304,NDC,1000,ML,69.59,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,34.44705,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990710709,NDC,1000,ML,69.59,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,34.44705,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004824,NDC,150,ML,69.59,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,34.44705,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143966001,NDC,5,ML,37.82,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,34.45402,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143966010,NDC,5,ML,37.82,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,34.45402,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Dress/Debrid Small Burn No Anes,PX16020F,CDM,510,RC,16020,CPT,,,,,,,,313,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,34.46,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.46,179.18
Fac/Ther Injection Carpal Tunnel,PX20526F,CDM,510,RC,20526,CPT,,,,,,,,191,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,34.46,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.46,171.57
Ther Injection Carpal Tunnel,PX20526P,CDM,983,RC,20526,CPT,,,,,,,,248,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,34.46,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.46,243.04
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,25021012867,NDC,1,EA,82.96,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,34.461584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,55150020830,NDC,1,EA,82.96,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,34.461584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.461584,189.875
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457033900,NDC,1,EA,71.82,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,34.4736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457033900,NDC,1,EA,71.82,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,34.4736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,47781047013,NDC,1,EA,83,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,34.4782,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,64380079901,NDC,1,EA,83,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,34.4782,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,69238126601,NDC,1,EA,83,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,34.4782,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SLING ARM CHILD PAD CANVAS NAVY 8004-02,120.54,CDM,273,RC,A4565,HCPCS,,878-MAIN,LOCAL,,,,,83,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,34.4782,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM LARGE PAD CANVAS NAVY ORT11300L,120.54,CDM,273,RC,A4565,HCPCS,,870-MAIN,LOCAL,,,,,83,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,34.4782,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM MEDIUM PAD CANVAS NAVY ORT11300M,120.54,CDM,273,RC,A4565,HCPCS,,872-MAIN,LOCAL,,,,,83,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,34.4782,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM SMALL PAD CANVAS NAVY ORT11300S,120.54,CDM,273,RC,A4565,HCPCS,,874-MAIN,LOCAL,,,,,83,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,34.4782,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM X-LARGE PAD ENVELOPE ORT11300XL,120.54,CDM,273,RC,A4565,HCPCS,,876-MAIN,LOCAL,,,,,83,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,34.4782,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,55150025110,NDC,10,ML,37.85,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,34.48135,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
miconazole 2 % Powder 85 g Bottle,25000000,CDM,250,RC,,,,,,67094930,NDC,85,GR,35.43,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,34.484019,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
brimonidine 0.2 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,70069023101,NDC,5,ML,70.38,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,34.4862,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
brimonidine 0.2 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,70069023101,NDC,5,ML,70.38,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,34.4862,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
brimonidine 0.2 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,70069023101,NDC,5,ML,70.38,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,34.4862,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,641601310,NDC,5,ML,40.58,,First Health,Commercial,both,85,,999999999,percent of total billed charges,34.493,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ESOPHAGEAL BALLOON INFLATION DEVICE 60ML,27200000,CDM,272,RC,C1726,HCPCS,,11326-MAIN,LOCAL,,,,,80.41,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,34.49589,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,36000014801,NDC,2,ML,38.76,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,34.4964,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733513,NDC,1,EA,39.12,,United Healthcare,All Payer,outpatient,88.2,,201.07,percent of total billed charges,34.50384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018200,NDC,10,ML,68.21,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,34.51426,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.24,991.564
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018210,NDC,10,ML,68.21,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,34.51426,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.24,991.564
levOCARNitine 200 MG/ML Solution 5 mL Vial,J1955.01,CDM,636,RC,J1955,HCPCS,,,,517104501,NDC,5,ML,249.86,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,34.51841,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.08,35.32
skin oil Oil 236.6 mL Bottle,63700001,CDM,250,RC,,,,,,67211008,NDC,236.6,ML,40.61,,First Health,Commercial,both,85,,999999999,percent of total billed charges,34.5185,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levoFLOXacin 750 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635361,NDC,0.333333333,EA,39.14,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,34.52148,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
valACYclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,31722070430,NDC,1,EA,38.79,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,34.5231,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036001,NDC,10,ML,80.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,34.5345,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,84.5054
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143978410,NDC,2,ML,37.91,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,34.53601,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
DRAPE SHEET LAP T-DRAPE WITH INSTRUMENT PAD DYNJP3003,27200000,CDM,272,RC,,,,10913-MAIN,LOCAL,,,,,35.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,34.55215,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"B.Burgdorferi, Amp Probe - Ref",PX8747690,CDM,300,RC,87476,CPT,90,,,,,,,72,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,34.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.9088,70.56
"B.Burgdorferi, Amp Probe - Ref",PX8747690,CDM,300,RC,87476,CPT,90,,,,,,,72,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,34.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.9088,70.56
"Blood, Occult, Other Sources",PX82271,CDM,300,RC,82271,CPT,,,,,,,,72,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,34.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.88,70.56
"Blood, Occult, Other Sources",PX82271,CDM,300,RC,82271,CPT,,,,,,,,72,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,34.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.88,70.56
Epstein-barr antibody,PX86664,CDM,300,RC,86664,CPT,,,,,,,,72,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,34.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.02,70.56
Epstein-barr antibody,PX86664,CDM,300,RC,86664,CPT,,,,,,,,72,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,34.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.02,70.56
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050601,NDC,1,ML,68.33,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,34.57498,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010520,NDC,1,EA,68.33,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,34.57498,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010541,NDC,1,EA,68.33,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,34.57498,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
pramox-PE-glycerin-petrolatum 1-0.25-14.4-15 % Cream 51 g Tube,63700001,CDM,250,RC,,,,,,573286898,NDC,51,GR,68.34,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,34.58004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"dextrose 5% and sodium chloride 0.45% with potassium chloride 10 mEq in 1000 mL 10-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,338066904,NDC,1000,ML,80.61,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,34.58169,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,264957710,NDC,500,ML,80.61,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,34.58169,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052201,NDC,500,ML,80.61,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,34.58169,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052277,NDC,500,ML,80.61,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,34.58169,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143998391,NDC,1,EA,83.25,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,34.58205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
"B Cells, Total Count",PX86355,CDM,300,RC,86355,CPT,,,,,,,,56,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,34.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.2624,54.88
Remove Additional Nail Plate,PX11732F,CDM,510,RC,11732,CPT,,,,,,,,77,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,34.59,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.46,68.49
fluticasone-salmeterol 100-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069500,NDC,1,EA,38.87,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,34.5943,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Level IV - Surgical Pathology, Gross and Microscopic Examination , Tech",PX3934,CDM,310,RC,88305,CPT,TC,,,,,,,185,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,34.6,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.06,58.096
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457000100,NDC,10,ML,68.38,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,34.60028,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
penicillin v potassium 250 MG/5ML Recon Soln 200 mL Bottle,63700001,CDM,250,RC,,,,,,93412774,NDC,200,ML,83.32,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,34.611128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
8MM-12MM CANNULA SEAL 5-8MM,27200000,CDM,272,RC,,,,11921-MAIN,LOCAL,,,,,38,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,34.618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRAPE COLUMN 470341,27200000,CDM,272,RC,,,,12013-MAIN,LOCAL,,,,,38,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,34.618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HH Hha Visit,PXG0156,CDM,571,RC,G0156,HCPCS,,,,,,,,38,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,34.618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
Mitochondrial Antibody Each,PX8638190,CDM,300,RC,86381,CPT,90,,,,,,,38,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,34.618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
Nasal Sm for Eos,PX89190,CDM,300,RC,89190,CPT,,,,,,,,38,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,34.618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.31,37.24
NEEDLE IV 19GA X .75IN HUBER POWERLOC SAFETY 0651934,120.85,CDM,272,RC,A4215,HCPCS,,12701-MAIN,LOCAL,,,,,38,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,34.618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
NEEDLE IV 19GA X 1 IN HUBER POWERLOC SAFETY 0651910,120.85,CDM,272,RC,A4215,HCPCS,,12702-MAIN,LOCAL,,,,,38,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,34.618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
NEEDLE IV 19GA X 1.5 IN HUBER POWERLOC SAFETY 0651915,120.85,CDM,272,RC,A4215,HCPCS,,12703-MAIN,LOCAL,,,,,38,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,34.618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
PEZZER CATHETER DRAIN LATEX 14FR,27200000,CDM,272,RC,,,,12053-MAIN,LOCAL,,,,,38,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,34.618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PEZZER LATEX CATHETER DRAIN 10FR,27200000,CDM,272,RC,,,,12646-MAIN,LOCAL,,,,,38,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,34.618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PNEUVIEW SMOKE ELIMINATOR,27200000,CDM,272,RC,,,,11884-MAIN,LOCAL,,,,,38,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,34.618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Psa, Free - Ref",PX8415490,CDM,300,RC,84154,CPT,90,,,,,,,38,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,34.618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
"Psa, Total - Ref",PX8415390,CDM,300,RC,84153,CPT,90,,,,,,,38,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,34.618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
SPECULUM VAGINAL WITH BUILT IN LIGHT LARGE,120.133,CDM,272,RC,,,,8251-MAIN,LOCAL,,,,,38,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,34.618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
SPECULUM VAGINAL WITH BUILT IN LIGHT MEDIUM,120.133,CDM,272,RC,,,,8250-MAIN,LOCAL,,,,,38,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,34.618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
SPECULUM VAGINAL WITH BUILT IN LIGHT SMALL,120.133,CDM,272,RC,,,,8249-MAIN,LOCAL,,,,,38,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,34.618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
TROCAR KII FIOS SYSTEM BLADELSS Z-THREAD 5MMX100MM,27200000,CDM,272,RC,,,,12003-MAIN,LOCAL,,,,,38,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,34.618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Iaad Ia Severe Aqt Respir Synd Coronavirus,PX87426,CDM,300,RC,87426,CPT,,,,,,,,159,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,34.62511,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.27,35.33
gemcitabine 200 MG/5.26ML Solution 5.26 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018301,NDC,5.26,ML,40.74,,First Health,Commercial,both,85,,999999999,percent of total billed charges,34.629,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
US Pregnancy Tc Limited,PX7681501,CDM,402,RC,76815,CPT,TC,,,,,,,438,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,34.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.61,99.92
US Pregnancy Tc Limited,PX7681501,CDM,402,RC,76815,CPT,TC,,,,,,,438,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,34.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.61,99.92
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707426,NDC,100,ML,39.29,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,34.65378,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
benzocaine-menthol 20-0.5 % Aerosol 78 g Can,63700001,CDM,250,RC,,,,,,75137085520,NDC,78,GR,35.38,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,34.6724,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Chem Cautery Granulatn Tissue,PX17250F,CDM,510,RC,17250,CPT,,,,,,,,170,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,34.6788,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.12,181.25
Chem Cautery Granulatn Tissue,PX17250P,CDM,983,RC,17250,CPT,,,,,,,,402,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,34.6788,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.12,393.96
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102F,CDM,510,RC,11102,CPT,,,,,,,,171,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,34.6788,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.56,208.92
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102P,CDM,983,RC,11102,CPT,,,,,,,,465,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,34.6788,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.56,455.7
Fac/Ther Injection Carpal Tunnel,PX20526F,CDM,510,RC,20526,CPT,,,,,,,,191,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,34.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.46,171.57
Fac/Ther Injection Carpal Tunnel,PX20526F,CDM,510,RC,20526,CPT,,,,,,,,191,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,34.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.46,171.57
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106F,CDM,510,RC,11106,CPT,,,,,,,,255,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,34.68,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.68,323.07
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106P,CDM,983,RC,11106,CPT,,,,,,,,204,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,34.68,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.68,323.07
"Sigmoidoscopy,Diagnostic",PX45330F,CDM,510,RC,45330,CPT,,,,,,,,720,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,34.68,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.68,386.72
"Sigmoidoscopy,Diagnostic",PX45330P,CDM,983,RC,45330,CPT,,,,,,,,480,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,34.68,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.68,470.4
"Sigmoidoscopy,Screen Prev",PX2001F,CDM,750,RC,45330,CPT,,,,,,,,843,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,34.68,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.68,386.72
Ther Injection Carpal Tunnel,PX20526P,CDM,983,RC,20526,CPT,,,,,,,,248,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,34.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.46,243.04
Ther Injection Carpal Tunnel,PX20526P,CDM,983,RC,20526,CPT,,,,,,,,248,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,34.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.46,243.04
FLEXITIP APPLICATOR 38CM,27200000,CDM,272,RC,,,,10200-MAIN,LOCAL,,,,,40.8,,First Health,Commercial,both,85,,999999999,percent of total billed charges,34.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TRAY IV SURGICAL EXTREMITY DYNJS0804,27200000,CDM,272,RC,,,,10919-MAIN,LOCAL,,,,,83.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,34.6859,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
morphine 2 MG/ML Solution 1 mL Syringe,J2272.01,CDM,636,RC,J2272,HCPCS,,,,76045000401,NDC,1,ML,38.98,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,34.6922,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.192292,38.2004
dextrose 25% Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409177510,NDC,10,ML,83.53,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,34.698362,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
bezlotoxumab 1000 MG/40ML Solution 40 mL Vial,J0565.01,CDM,636,RC,J0565,HCPCS,,,,6302500,NDC,40,ML,7752,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,34.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.7,7596.96
Neg Pressure Wound Therapy Dme >50 Sq Cm,PX97606F,CDM,761,RC,97606,CPT,,,,,,,,404,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,34.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.75,67.21
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409751766,NDC,50,ML,80.89,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,34.70181,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
CLOSED WOUND ROUND CHANNEL DRAIN WITH TROCAR 15FR FULL FLUTED,27200000,CDM,272,RC,,,,12223-MAIN,LOCAL,,,,,39,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,34.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
fluorouracil 500 MG/10ML Solution 10 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,63323011710,NDC,10,ML,39,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,34.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,256.2112
gemcitabine 200 MG Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323010294,NDC,1,EA,39,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,34.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
Lab Wbc and Differential,PX85004,CDM,300,RC,85004,CPT,,,,,,,,39,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,34.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,38.22
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003928,NDC,1,EA,39,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,34.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
methylPREDNISolone sod succ 500 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9075801,NDC,0.25,EA,39,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,34.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
NEEDLE JAMSHIDI 11G X 101MM BIOPSY DJ4011X,27200000,CDM,272,RC,,,,12798-MAIN,LOCAL,,,,,39,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,34.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
O2 SENSOR ADULT ADHESIVE SINGLE PATIENT 040-003382-00,120.576,CDM,272,RC,,,,12930-MAIN,LOCAL,,,,,39,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,34.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
O2 SENSOR INFANT ADHESIVE SINGLE PATIENT 040-003384-00,120.576,CDM,272,RC,,,,12932-MAIN,LOCAL,,,,,39,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,34.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
O2 SENSOR PEDIATRIC ADHESIVE SINGLE PATIENT 040-003383-00,120.576,CDM,272,RC,,,,12931-MAIN,LOCAL,,,,,39,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,34.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
SLEEVE ACHILLES LG/XL PROTECTION 92437145348,120.422,CDM,271,RC,,,,11378-MAIN,LOCAL,,,,,39,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,34.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
SLEEVE ACHILLES SM/MED PROTECTION 92437145324,120.422,CDM,271,RC,,,,11377-MAIN,LOCAL,,,,,39,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,34.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
Treponema Pallidum - Ref,PX8678090,CDM,300,RC,86780,CPT,90,,,,,,,39,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,34.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.14,38.22
TROCAR KII FIOS SYSTEM BLADELSS Z-THREAD 5MMX150MM,27200000,CDM,272,RC,,,,12827-MAIN,LOCAL,,,,,39,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,34.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"BUPivacaine 0.25%-EPINEPHrine 1:200,000 0.25% -1:200000 Solution 50 mL Vial",25000000,CDM,250,RC,,,,,,409175250,NDC,30,ML,68.6,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,34.7116,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409427617,NDC,50,ML,39.01,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,34.7189,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
miconazole 2 % Powder 85 g Bottle,25000000,CDM,250,RC,,,,,,67094930,NDC,85,GR,35.43,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,34.7214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
buprenorphine 75 MCG FILM 1 Each Package,63700001,CDM,250,RC,,,,,,59385002101,NDC,1,EA,35.68,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,34.727344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253022233,NDC,3,ML,38.13,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,34.73643,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046203,NDC,30,ML,70.91,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,34.7459,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046203,NDC,30,ML,70.91,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,34.7459,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046203,NDC,30,ML,70.91,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,34.7459,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
CAPTIFLEX SNARE SINGLE USE EXTRA SMALL 11MM,27200000,CDM,272,RC,,,,12378-MAIN,LOCAL,,,,,81,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,34.749,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Smear Special Stain,PX87207,CDM,300,RC,87207,CPT,,,,,,,,81,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,34.749,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.49,79.38
Tacrolimus - Ref,PX8019790,CDM,300,RC,80197,CPT,90,,,,,,,81,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,34.749,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,79.38
Xray Facial Bones Minimum 3 Vws,PX7015001,CDM,320,RC,70150,CPT,TC,,,,,,,551,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,34.7544,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.9,69.03
hydrOXYzine 50 MG/ML Solution 1 mL Vial,J3410.01,CDM,636,RC,J3410,HCPCS,,,,517560125,NDC,0.5,ML,83.68,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,34.760672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.760672,82.0064
atropine 1 mg/mL Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100101,NDC,0.2,ML,39.42,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,34.76844,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,17478070311,NDC,10,ML,72.46,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,34.7808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,17478070311,NDC,10,ML,72.46,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,34.7808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
HYDROmorphone 2 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409131203,NDC,1,ML,38.18,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,34.78198,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
DRAPE SHEET LAP T-DRAPE WITH INSTRUMENT PAD DYNJP3003,27200000,CDM,272,RC,,,,10913-MAIN,LOCAL,,,,,35.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,34.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Gabapentin - Ref,PX8017190,CDM,300,RC,80171,CPT,90,,,,,,,71,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,34.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.87,69.58
Gabapentin - Ref,PX8017190,CDM,300,RC,80171,CPT,90,,,,,,,71,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,34.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.87,69.58
Gabapentin - Ref,PX8017190,CDM,300,RC,80171,CPT,90,,,,,,,71,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,34.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.87,69.58
Histoplasma Antibody - Ref,PX8669890,CDM,300,RC,86698,CPT,90,,,,,,,71,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,34.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.64,69.58
Histoplasma Antibody - Ref,PX8669890,CDM,300,RC,86698,CPT,90,,,,,,,71,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,34.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.64,69.58
Histoplasma Antibody - Ref,PX8669890,CDM,300,RC,86698,CPT,90,,,,,,,71,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,34.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.64,69.58
Legionella Antibody - Ref,PX8671390,CDM,300,RC,86713,CPT,90,,,,,,,71,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,34.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.03,69.58
Legionella Antibody - Ref,PX8671390,CDM,300,RC,86713,CPT,90,,,,,,,71,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,34.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.03,69.58
Legionella Antibody - Ref,PX8671390,CDM,300,RC,86713,CPT,90,,,,,,,71,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,34.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.03,69.58
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070548,NDC,100,ML,40.94,,First Health,Commercial,both,85,,999999999,percent of total billed charges,34.799,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
ursodiol 300 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,591315901,NDC,1,EA,39.47,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,34.81254,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733513,NDC,1,EA,39.12,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,34.8168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
levoFLOXacin 750 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635361,NDC,0.333333333,EA,39.14,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,34.8346,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
brimonidine 0.2 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,70069023101,NDC,5,ML,70.38,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,34.8381,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BIOPSY FORCEPS HOT,27200000,CDM,272,RC,,,,4353-MAIN,LOCAL,,,,,38.25,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,34.84575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRESSING GEL FOAM SIZE 100SPONGE STERILE 00009034201,27200000,CDM,272,RC,A6248,HCPCS,,3378-MAIN,LOCAL,,,,,38.25,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,34.84575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFFLATION TUBING SET,27200000,CDM,272,RC,,,,4686-MAIN,LOCAL,,,,,38.25,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,34.84575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
silver sulfADIAZINE 1 % Cream 50 g Jar,25000000,CDM,250,RC,,,,,,43598021055,NDC,50,GR,83.89,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,34.847906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
CANNULA SEAL 5-12MM UNIVERSAL 470500,27200000,CDM,272,RC,,,,12885-MAIN,LOCAL,,,,,41,,First Health,Commercial,both,85,,999999999,percent of total billed charges,34.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CUP HEEL LARGE WONDERSPUR 4502,120.43,CDM,274,RC,L3485,HCPCS,,11385-MAIN,LOCAL,,,,,41,,First Health,Commercial,both,85,,999999999,percent of total billed charges,34.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL MEDIUM WONDERSPUR 4501,120.43,CDM,274,RC,L3485,HCPCS,,11384-MAIN,LOCAL,,,,,41,,First Health,Commercial,both,85,,999999999,percent of total billed charges,34.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL SMALL WONDERSPUR 4500,120.43,CDM,274,RC,L3485,HCPCS,,11383-MAIN,LOCAL,,,,,41,,First Health,Commercial,both,85,,999999999,percent of total billed charges,34.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL XL WONDERSPUR 4503,120.43,CDM,274,RC,L3485,HCPCS,,11386-MAIN,LOCAL,,,,,41,,First Health,Commercial,both,85,,999999999,percent of total billed charges,34.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
Detection of Anaplasma Phagocytophilum by Amplified Nucleic Acid Probe Technique,PX8746890,CDM,300,RC,87468,CPT,90,,,,,,,41,,First Health,Commercial,both,85,,999999999,percent of total billed charges,34.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
Detection of Ehrlichia Chaffeensis by Amplified Nucleic Acid Probe Technique,PX8748490,CDM,300,RC,87484,CPT,90,,,,,,,41,,First Health,Commercial,both,85,,999999999,percent of total billed charges,34.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 21G 110MM SONOTAP II WITH FACET TIP 1285-3F110,120.483,CDM,271,RC,A4215,HCPCS,,12201-MAIN,LOCAL,,,,,41,,First Health,Commercial,both,85,,999999999,percent of total billed charges,34.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 21G X 4IN (100MM) SONOBLOCK II NERVE BLOCK WITH FACET S TIP 001281-77,120.483,CDM,271,RC,A4215,HCPCS,,12761-MAIN,LOCAL,,,,,41,,First Health,Commercial,both,85,,999999999,percent of total billed charges,34.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 22G 80MM SONOTAP II WITH FACET TIP 1285-3E080,120.483,CDM,271,RC,A4215,HCPCS,,12103-MAIN,LOCAL,,,,,41,,First Health,Commercial,both,85,,999999999,percent of total billed charges,34.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 22G X 3.25IN (80MM) SONOBLOCK II  NERVE BLOCK WITH FACET S TIP 001281-71,120.483,CDM,271,RC,A4215,HCPCS,,12760-MAIN,LOCAL,,,,,41,,First Health,Commercial,both,85,,999999999,percent of total billed charges,34.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 22GX2 SONOPLEX II WITH FACET S TIP 001287-74,120.483,CDM,271,RC,A4215,HCPCS,,13110-MAIN,LOCAL,,,,,41,,First Health,Commercial,both,85,,999999999,percent of total billed charges,34.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE NON-STIMULATING 22GX2 SONOBLOCK II WITH FACET S TIP 001281-74,120.483,CDM,271,RC,A4215,HCPCS,,11459-MAIN,LOCAL,,,,,41,,First Health,Commercial,both,85,,999999999,percent of total billed charges,34.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE SONOPLEX II STIMULATING WITH FACET S TIP 22GX3-1/4,120.483,CDM,271,RC,A4215,HCPCS,,11457-MAIN,LOCAL,,,,,41,,First Health,Commercial,both,85,,999999999,percent of total billed charges,34.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE STIMULATING 21GX4  SONOPLEX II  WITH FACET S TIP 001287-77,120.483,CDM,271,RC,A4215,HCPCS,,11458-MAIN,LOCAL,,,,,41,,First Health,Commercial,both,85,,999999999,percent of total billed charges,34.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
STRAP FOOT LG/XL GEL UNIVERSAL 10165,120.428,CDM,271,RC,,,,11382-MAIN,LOCAL,,,,,41,,First Health,Commercial,both,85,,999999999,percent of total billed charges,34.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
STRAP FOOT SM/MED GEL UNIVERSAL 10155,120.428,CDM,271,RC,,,,11381-MAIN,LOCAL,,,,,41,,First Health,Commercial,both,85,,999999999,percent of total billed charges,34.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
SUTURE V-LOC SZ 1/2 180 GREEN GS-21 VLOCL0316,27200000,CDM,272,RC,,,,11932-MAIN,LOCAL,,,,,41,,First Health,Commercial,both,85,,999999999,percent of total billed charges,34.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
URGOK2 DUAL COMPRESSION SYSTEM LARGE,120.491,CDM,271,RC,A6452,HCPCS,,11871-MAIN,LOCAL,,,,,41,,First Health,Commercial,both,85,,999999999,percent of total billed charges,34.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
URGOK2 DUAL COMPRESSION SYSTEM REGULAR,120.491,CDM,271,RC,A6452,HCPCS,,11870-MAIN,LOCAL,,,,,41,,First Health,Commercial,both,85,,999999999,percent of total billed charges,34.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
Ex for Speech Device Rx Addl,PX92608,CDM,444,RC,92608,CPT,,,,,,,,160,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,34.86,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.86,84.93
triamcinolone acetonide 40 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029320,NDC,1,ML,72.65,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,34.872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,72.0986
triamcinolone acetonide 40 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029320,NDC,1,ML,72.65,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,34.872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,72.0986
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,17478081725,NDC,25,ML,81.3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,34.8777,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
CANNULA OPTIFLOW JUNIOR2+ XXL OJR520,120.494,CDM,271,RC,A4615,HCPCS,,11619-MAIN,LOCAL,,,,,84,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,34.8936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.8936,82.32
Hiaa - Ref,PX8349790,CDM,300,RC,83497,CPT,90,,,,,,,84,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,34.8936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.83,82.32
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032056,NDC,1,EA,68.97,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,34.89882,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106F,CDM,510,RC,11106,CPT,,,,,,,,255,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,34.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.68,323.07
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106F,CDM,510,RC,11106,CPT,,,,,,,,255,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,34.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.68,323.07
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106P,CDM,983,RC,11106,CPT,,,,,,,,204,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,34.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.68,323.07
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106P,CDM,983,RC,11106,CPT,,,,,,,,204,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,34.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.68,323.07
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002F,CDM,510,RC,12002,CPT,,,,,,,,343,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,34.9,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.9,237.98
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002P,CDM,983,RC,12002,CPT,,,,,,,,486,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,34.9,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.9,476.28
"Thrombolysis,Coronary,IV Infusn",PX92977F,CDM,480,RC,92977,CPT,,,,,,,,595,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,34.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.16,96.56
"Thrombolysis,Coronary,IV Infusn",PX92977F,CDM,480,RC,92977,CPT,,,,,,,,595,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,34.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.16,96.56
bisoprolol-hydroCHLOROthiazide 5-6.25 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,42799092102,NDC,1,EA,39.57,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,34.90074,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026994,NDC,20,ML,35.87,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1.094496241,percent of total billed charges,34.912271,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
Assay Bld/Serum Cholesterol,PX82465,CDM,300,RC,82465,CPT,,,,,,,,69,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,34.914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.99,67.62
"Astrazeneca Covid-19 Vaccine, Administration, 1st Dose",PX0021A,CDM,771,RC,,,,,,,,,,69,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,34.914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Astrazeneca Covid-19 Vaccine, Adminstration, 2nd Dose",PX0022A,CDM,771,RC,,,,,,,,,,69,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,34.914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Janssen Covid-19 Vaccine, Administration",PX0031A,CDM,771,RC,0031A,HCPCS,,,,,,,,69,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,34.914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 1st Dose",PX0011A,CDM,771,RC,0011A,HCPCS,,,,,,,,69,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,34.914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 2nd Dose",PX0012A,CDM,771,RC,0012A,HCPCS,,,,,,,,69,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,34.914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 3rd Dose",PX0013A,CDM,771,RC,0013A,HCPCS,,,,,,,,69,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,34.914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
Novavax Covid-19 Vaccine Administration 1st Dose,PX0041A,CDM,771,RC,0041A,HCPCS,,,,,,,,69,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,34.914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
Novavax Covid-19 Vaccine Administration 2nd Dose,PX0042A,CDM,771,RC,0042A,HCPCS,,,,,,,,69,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,34.914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Pfizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 2nd Dose",PX0002A,CDM,771,RC,0002A,HCPCS,,,,,,,,69,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,34.914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Pfizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 3rd Dose",PX0003A,CDM,771,RC,0003A,HCPCS,,,,,,,,69,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,34.914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Pifizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 1st Dose",PX0001A,CDM,771,RC,0001A,HCPCS,,,,,,,,69,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,34.914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078110,NDC,0.5,EA,38.33,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,34.91863,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"CUFF STERILE DISPOSABLE SPSB  STERILE 18""",27200000,CDM,272,RC,,,,7436-MAIN,LOCAL,,,,,35.89,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,34.931737,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094310,NDC,10,ML,72.79,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,34.9392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.236966,143.9032
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094310,NDC,10,ML,72.79,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,34.9392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.236966,143.9032
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094321,NDC,10,ML,72.79,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,34.9392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.236966,143.9032
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094321,NDC,10,ML,72.79,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,34.9392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.236966,143.9032
buprenorphine 75 MCG FILM 1 Each Package,63700001,CDM,250,RC,,,,,,59385002101,NDC,1,EA,35.68,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,34.9664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707426,NDC,100,ML,39.29,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,34.9681,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
TROCAR KII BALLOON 12MM STERILE,27200000,CDM,272,RC,,,,11703-MAIN,LOCAL,,,,,41.14,,First Health,Commercial,both,85,,999999999,percent of total billed charges,34.969,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR KII BALLOON BLUNT 12MM STERILE,27200000,CDM,272,RC,,,,11702-MAIN,LOCAL,,,,,41.14,,First Health,Commercial,both,85,,999999999,percent of total billed charges,34.969,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Level IV - Surgical Pathology, Gross and Microscopic Examination , Tech",PX3934,CDM,310,RC,88305,CPT,TC,,,,,,,185,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,34.9781,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.06,58.096
CATHETER TEMP-SENSING 8FR LUBRISIL PEDS DYND110508,120.363,CDM,272,RC,A4340,HCPCS,,12777-MAIN,LOCAL,,,,,45,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,34.98,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.98,36.82
CATHETER TEMP-SENSING 12FR LUBRISIL 119212M,120.363,CDM,272,RC,A4340,HCPCS,,10750-MAIN,LOCAL,,,,,45,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,34.98,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.98,36.82
CATHETER TEMP-SENSING 14FR LUBRISIL 119214M,120.363,CDM,272,RC,A4340,HCPCS,,10751-MAIN,LOCAL,,,,,45,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,34.98,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.98,36.82
CATHETER TEMP-SENSING 16FR LUBRISIL 119216M,120.363,CDM,272,RC,A4340,HCPCS,,10752-MAIN,LOCAL,,,,,45,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,34.98,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.98,36.82
CATHETER URETERAL  5FR TIGERTAIL OPEN TIP FLEXIBLE 139005,27200000,CDM,272,RC,A4340,HCPCS,,12302-MAIN,LOCAL,,,,,40,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,34.98,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641622901,NDC,1,ML,41.16,,First Health,Commercial,both,85,,999999999,percent of total billed charges,34.986,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.097864,86.9162
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409751716,NDC,50,ML,72.9,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,34.992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409751716,NDC,50,ML,72.9,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,34.992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
anastrozole 1 MG Tablet 30 Each Bottle,25000000,CDM,250,RC,,,,,,16729003510,NDC,1,EA,71.44,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,35.0056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
anastrozole 1 MG Tablet 30 Each Bottle,25000000,CDM,250,RC,,,,,,16729003510,NDC,1,EA,71.44,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,35.0056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
anastrozole 1 MG Tablet 30 Each Bottle,25000000,CDM,250,RC,,,,,,16729003510,NDC,1,EA,71.44,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,35.0056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,517095501,NDC,0.25,EA,69.19,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,35.01014,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86,213.6008
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098121,NDC,1,EA,72.95,,Health Partners,Health Partners Care Plans,both,48,,6.796666667,percent of total billed charges,35.016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098121,NDC,1,EA,72.95,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,35.016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
Blood Typing Rh (D),PX86901,CDM,300,RC,86901,CPT,,,,,,,,92,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,35.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.03,90.16
"Blood Typing, Rh Phenotype",PX86906,CDM,300,RC,86906,CPT,,,,,,,,115,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,35.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.03,112.7
"Long Term Holter, 48 Hrs Up to 7 Days, Recording",PX93242,CDM,731,RC,93242,CPT,,,,,,,,58,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,35.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.0932,56.84
"Long Term Holter, More Than 7 Days Up to 15 Days, Recording",PX93246,CDM,731,RC,93246,CPT,,,,,,,,58,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,35.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.0932,56.84
fluconazole 150 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,16714069210,NDC,1,EA,72.98,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,35.0304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluconazole 150 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,16714069210,NDC,1,EA,72.98,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,35.0304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ampicillin-sulbactam 1.5 (1-0.5) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001381,NDC,1,EA,69.24,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,35.03544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409427602,NDC,50,ML,38.46,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,35.03706,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Anes Dx Shoulder Arthroscopy,PX01622.01,CDM,964,RC,1622,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Lower Intestinal Endoscopic Px Nos,PX00811.01,CDM,964,RC,811,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,22.41053227,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Lower Intestinal Screening Colonoscopy,PX00812.01,CDM,964,RC,812,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,19.91708333,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Spine Transthor W/Vent,PX00626.01,CDM,964,RC,626,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Spine Tranthor W/O Vent,PX00625.01,CDM,964,RC,625,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Ther Interven Rad Art,PX01924.01,CDM,964,RC,1924,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Ther Interven Rad Car,PX01925.01,CDM,964,RC,1925,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Ther Interven Rad Tip,PX01931.01,CDM,964,RC,1931,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Ther Interven Rad Vei,PX01930.01,CDM,964,RC,1930,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Tx Interv Rad Cran V,PX01933.01,CDM,964,RC,1933,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Tx Interv Rad Hrt/Cran,PX01926.01,CDM,964,RC,1926,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Tx Interv Rad Th Vein,PX01932.01,CDM,964,RC,1932,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Upper GI Endoscopic Px Ercp,PX00732.01,CDM,964,RC,732,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Upper GI Endoscopic Px Nos,PX00731.01,CDM,964,RC,731,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,21.84629213,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes Upper/Lower GI Endoscopic Px,PX00813.01,CDM,964,RC,813,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,5.3652,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anes/Analg Cs Deliver Add-On,PX01968.01,CDM,964,RC,1968,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Abdomen Vessel Surg,PX00880.01,CDM,964,RC,880,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Abdominal Wall Surg,PX00700.01,CDM,964,RC,700,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Abdominal Wall Surg,PX00730.01,CDM,964,RC,730,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Abdominal Wall Surg,PX00800.01,CDM,964,RC,800,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Abdominal Wall Surg,PX00820.01,CDM,964,RC,820,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Achilles Tendon Surg,PX01472.01,CDM,964,RC,1472,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Airplane Cast,PX01682.01,CDM,964,RC,1682,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Amniocentesis,PX00842.01,CDM,964,RC,842,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Amputation at Knee,PX01404.01,CDM,964,RC,1404,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Amputation at Pelvis,PX01140.01,CDM,964,RC,1140,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Amputation of Femur,PX01232.01,CDM,964,RC,1232,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Amputation of Penis,PX00932.01,CDM,964,RC,932,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Ankle Replacement,PX01486.01,CDM,964,RC,1486,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Ankle/Ft Arthroscopy,PX01464.01,CDM,964,RC,1464,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Anorectal Surgery,PX00902.01,CDM,964,RC,902,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,27.53555556,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Antepartum Manipul,PX01958.01,CDM,964,RC,1958,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Arm-Leg Vessel Surg,PX01656.01,CDM,964,RC,1656,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Arthroscopy of Hip,PX01202.01,CDM,964,RC,1202,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Biceps Tendon Repair,PX01716.01,CDM,964,RC,1716,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Biopsy of Nose,PX00164.01,CDM,964,RC,164,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Biopsy of Thyroid,PX00322.01,CDM,964,RC,322,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Bladder Stone Surg,PX00870.01,CDM,964,RC,870,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Bladder Surgery,PX00910.01,CDM,964,RC,910,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Bladder Tumor Surg,PX00912.01,CDM,964,RC,912,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Bleeding Control,PX00916.01,CDM,964,RC,916,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Blepharoplasty,PX00103.01,CDM,964,RC,103,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Blood Vessel Repair,PX00770.01,CDM,964,RC,770,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Body Cast Procedure,PX01130.01,CDM,964,RC,1130,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Bone Aspirate/Bx,PX01112.01,CDM,964,RC,1112,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Burn 4-9 Percent,PX01952.01,CDM,964,RC,1952,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Burn Each 9 Percent,PX01953.01,CDM,964,RC,1953,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Burn Less 4 Percent,PX01951.01,CDM,964,RC,1951,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cabg W/O Pump,PX00566.01,CDM,964,RC,566,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cabg W/Pump,PX00567.01,CDM,964,RC,567,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cardiac Electrophys,PX00537.01,CDM,964,RC,537,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cardioverter/Defib,PX00534.01,CDM,964,RC,534,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cat or MRI Scan,PX01922.01,CDM,964,RC,1922,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Catheterize Heart,PX01920.01,CDM,964,RC,1920,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Drainage,PX00524.01,CDM,964,RC,524,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Lining Biopsy,PX00522.01,CDM,964,RC,522,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Partition View,PX00528.01,CDM,964,RC,528,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Partition View,PX00529.01,CDM,964,RC,529,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Procedure,PX00520.01,CDM,964,RC,520,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Surgery,PX00540.01,CDM,964,RC,540,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Chest Wall Repair,PX00472.01,CDM,964,RC,472,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cleft Palate Repair,PX00172.01,CDM,964,RC,172,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Collar Bone Biopsy,PX00454.01,CDM,964,RC,454,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Corneal Transplant,PX00144.01,CDM,964,RC,144,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Correct Heart Rhythm,PX00410.01,CDM,964,RC,410,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cran Surg Hemotoma,PX00211.01,CDM,964,RC,211,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cranial Surg Nos,PX00210.01,CDM,964,RC,210,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cs Delivery,PX01961.01,CDM,964,RC,1961,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Cs Hysterectomy,PX01963.01,CDM,964,RC,1963,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Dx Arteriography,PX01916.01,CDM,964,RC,1916,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Dx Elbow Arthroscopy,PX01732.01,CDM,964,RC,1732,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Dx Knee Arthroscopy,PX01382.01,CDM,964,RC,1382,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Dx Wrist Arthroscopy,PX01829.01,CDM,964,RC,1829,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Ear Exam,PX00124.01,CDM,964,RC,124,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Ear Surgery,PX00120.01,CDM,964,RC,120,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Elbow Area Surgery,PX01710.01,CDM,964,RC,1710,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Elbow Replacement,PX01760.01,CDM,964,RC,1760,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Electroshock,PX00104.01,CDM,964,RC,104,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Emer Hysterectomy,PX01962.01,CDM,964,RC,1962,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Esophageal Surgery,PX00500.01,CDM,964,RC,500,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Eye Exam,PX00148.01,CDM,964,RC,148,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Face/Skull Bone Surg,PX00190.01,CDM,964,RC,190,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Facial Bone Surgery,PX00192.01,CDM,964,RC,192,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Fat Layer Removal,PX00802.01,CDM,964,RC,802,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Femoral Artery Surg,PX01272.01,CDM,964,RC,1272,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Femoral Embolectomy,PX01274.01,CDM,964,RC,1274,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth for Chemonucleolysis,PX00634.01,CDM,964,RC,634,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth for Liver Biopsy,PX00702.01,CDM,964,RC,702,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth for Liver Transplant,PX00796.01,CDM,964,RC,796,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Forequarter Amput,PX01636.01,CDM,964,RC,1636,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Fx Repair Pelvis,PX01173.01,CDM,964,RC,1173,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Genitalia Surgery,PX00920.01,CDM,964,RC,920,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Head Nerve Surgery,PX00222.01,CDM,964,RC,222,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Head Vessel Surgery,PX00216.01,CDM,964,RC,216,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Head/Neck/Ptrunk,PX00300.01,CDM,964,RC,300,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,15.31146154,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Heart Surg < 1 Yr,PX00561.01,CDM,964,RC,561,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Heart Surg W/Arrest,PX00563.01,CDM,964,RC,563,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Heart Surg W/O Pump,PX00560.01,CDM,964,RC,560,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Heart/Lung Transplnt,PX00580.01,CDM,964,RC,580,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hemorr/Excise Liver,PX00792.01,CDM,964,RC,792,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hernia Repair < 1 Yr,PX00834.01,CDM,964,RC,834,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hernia Repair Preemie,PX00836.01,CDM,964,RC,836,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hip Arthroplasty,PX01214.01,CDM,964,RC,1214,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hip Disarticulation,PX01212.01,CDM,964,RC,1212,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hip Joint Procedure,PX01200.01,CDM,964,RC,1200,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hip Joint Surgery,PX01210.01,CDM,964,RC,1210,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hrt Surg W/Pmp Age 1+,PX00562.01,CDM,964,RC,562,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Humeral Lesion Surg,PX01758.01,CDM,964,RC,1758,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Humerus Repair,PX01744.01,CDM,964,RC,1744,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Humerus Surgery,PX01742.01,CDM,964,RC,1742,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hysterectomy,PX00846.01,CDM,964,RC,846,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Hysteroscope/Graph,PX00952.01,CDM,964,RC,952,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Inc/Missed Ab Proc,PX01965.01,CDM,964,RC,1965,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Induced Ab Procedure,PX01966.01,CDM,964,RC,1966,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Insert Penis Device,PX00938.01,CDM,964,RC,938,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Intrcrn Nerve,PX00220.01,CDM,964,RC,220,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Iridectomy,PX00147.01,CDM,964,RC,147,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Kidney Stone Destruct,PX00872.01,CDM,964,RC,872,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Kidney Stone Destruct,PX00873.01,CDM,964,RC,873,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Kidney Transplant,PX00868.01,CDM,964,RC,868,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Kidney/Ureter Surg,PX00862.01,CDM,964,RC,862,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Area Procedure,PX01340.01,CDM,964,RC,1340,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Area Procedure,PX01390.01,CDM,964,RC,1390,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Area Surgery,PX01320.01,CDM,964,RC,1320,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Area Surgery,PX01360.01,CDM,964,RC,1360,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Area Surgery,PX01392.01,CDM,964,RC,1392,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Arteries Surg,PX01440.01,CDM,964,RC,1440,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Artery Repair,PX01444.01,CDM,964,RC,1444,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Artery Surg,PX01442.01,CDM,964,RC,1442,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Arthroplasty,PX01402.01,CDM,964,RC,1402,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Joint Casting,PX01420.01,CDM,964,RC,1420,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Joint Procedure,PX01380.01,CDM,964,RC,1380,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Joint Surgery,PX01400.01,CDM,964,RC,1400,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Veins Surgery,PX01430.01,CDM,964,RC,1430,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Knee Vessel Surg,PX01432.01,CDM,964,RC,1432,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Larynx/Trach < 1 Yr,PX00326.01,CDM,964,RC,326,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Leg Arteries Surg,PX01500.01,CDM,964,RC,1500,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lens Surgery,PX00142.01,CDM,964,RC,142,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Low Intestine Scope,PX00810.01,CDM,964,RC,810,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Arm Casting,PX01860.01,CDM,964,RC,1860,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Arm Procedure,PX01820.01,CDM,964,RC,1820,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Arm Surgery,PX01810.01,CDM,964,RC,1810,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Arm Surgery,PX01830.01,CDM,964,RC,1830,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Arm Vein Surg,PX01850.01,CDM,964,RC,1850,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Bone Surg,PX01480.01,CDM,964,RC,1480,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,7.2,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Casting,PX01490.01,CDM,964,RC,1490,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Procedure,PX01462.01,CDM,964,RC,1462,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Revision,PX01484.01,CDM,964,RC,1484,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Surgery,PX01470.01,CDM,964,RC,1470,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Surgery,PX01474.01,CDM,964,RC,1474,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Vein Surg,PX01520.01,CDM,964,RC,1520,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lower Leg Vein Surg,PX01522.01,CDM,964,RC,1522,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lumbar Puncture,PX00635.01,CDM,964,RC,635,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lung Chest Wall Surg,PX00546.01,CDM,964,RC,546,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lwr Arm Artery Surg,PX01840.01,CDM,964,RC,1840,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lwr Arm Embolectomy,PX01842.01,CDM,964,RC,1842,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lwr Arm Vein Repair,PX01852.01,CDM,964,RC,1852,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Lwr Leg Embolectomy,PX01502.01,CDM,964,RC,1502,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Major Vein Ligation,PX00882.01,CDM,964,RC,882,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth N Block/Inj Prone,PX01992.01,CDM,964,RC,1992,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Neck Organ 1 & Over,PX00320.01,CDM,964,RC,320,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Neck Vessel Surgery,PX00350.01,CDM,964,RC,350,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Neck Vessel Surgery,PX00352.01,CDM,964,RC,352,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Nerve Block/Inj,PX01991.01,CDM,964,RC,1991,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Nose/Sinus Surgery,PX00160.01,CDM,964,RC,160,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Nose/Sinus Surgery,PX00162.01,CDM,964,RC,162,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth One Lung Ventilation,PX00541.01,CDM,964,RC,541,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pacemaker Insertion,PX00530.01,CDM,964,RC,530,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pancreas Removal,PX00794.01,CDM,964,RC,794,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvic Organ Surg,PX00848.01,CDM,964,RC,848,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvic Tumor Surgery,PX01150.01,CDM,964,RC,1150,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvis Nerve Removal,PX01180.01,CDM,964,RC,1180,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvis Nerve Removal,PX01190.01,CDM,964,RC,1190,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvis Procedure,PX01160.01,CDM,964,RC,1160,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvis Surgery,PX00844.01,CDM,964,RC,844,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvis Surgery,PX01120.01,CDM,964,RC,1120,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pelvis Surgery,PX01170.01,CDM,964,RC,1170,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Penis Nodes Removal,PX00934.01,CDM,964,RC,934,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Penis Nodes Removal,PX00936.01,CDM,964,RC,936,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Perc Img Dx Sp Proc,PX01935.01,CDM,964,RC,1935,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Perc Img Tx Sp Proc,PX01936.01,CDM,964,RC,1936,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Perineal Surgery,PX00904.01,CDM,964,RC,904,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pharyngeal Surgery,PX00174.01,CDM,964,RC,174,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Pharyngeal Surgery,PX00176.01,CDM,964,RC,176,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Procedure on Femur,PX01220.01,CDM,964,RC,1220,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Procedure on Mouth,PX00170.01,CDM,964,RC,170,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Procedures on Eye,PX00140.01,CDM,964,RC,140,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Radical Femur Surg,PX01234.01,CDM,964,RC,1234,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Radical Humerus Surg,PX01756.01,CDM,964,RC,1756,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Radical Leg Surgery,PX01482.01,CDM,964,RC,1482,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Release of Lung,PX00542.01,CDM,964,RC,542,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Adrenal,PX00866.01,CDM,964,RC,866,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Bladder,PX00864.01,CDM,964,RC,864,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Nerves,PX00622.01,CDM,964,RC,622,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Nerves,PX00632.01,CDM,964,RC,632,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Prostate,PX00865.01,CDM,964,RC,865,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Prostate,PX00908.01,CDM,964,RC,908,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Rib,PX00470.01,CDM,964,RC,470,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Testis,PX00926.01,CDM,964,RC,926,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Testis,PX00928.01,CDM,964,RC,928,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Removal of Vulva,PX00906.01,CDM,964,RC,906,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Cervix,PX00948.01,CDM,964,RC,948,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Cleft Lip,PX00102.01,CDM,964,RC,102,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Hernia,PX00750.01,CDM,964,RC,750,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Hernia,PX00752.01,CDM,964,RC,752,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,30.05076923,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Hernia,PX00754.01,CDM,964,RC,754,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Hernia,PX00756.01,CDM,964,RC,756,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Hernia,PX00830.01,CDM,964,RC,830,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Repair of Hernia,PX00832.01,CDM,964,RC,832,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,35.30246377,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Revise Hip Repair,PX01215.01,CDM,964,RC,1215,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Salivary Gland,PX00100.01,CDM,964,RC,100,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Artery Surg,PX01650.01,CDM,964,RC,1650,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Casting,PX01680.01,CDM,964,RC,1680,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Joint Amput,PX01634.01,CDM,964,RC,1634,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Procedure,PX01620.01,CDM,964,RC,1620,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Replacement,PX01638.01,CDM,964,RC,1638,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Vein Surg,PX01670.01,CDM,964,RC,1670,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Vessel Surg,PX01652.01,CDM,964,RC,1652,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Shoulder Vessel Surg,PX01654.01,CDM,964,RC,1654,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Sitting Procedure,PX00604.01,CDM,964,RC,604,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Skin Ext/per/Atrunk,PX00400.01,CDM,964,RC,400,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Skull Drainage,PX00212.01,CDM,964,RC,212,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Skull Drainage,PX00214.01,CDM,964,RC,214,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Skull Repair/Fract,PX00215.01,CDM,964,RC,215,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Special Head Surgery,PX00218.01,CDM,964,RC,218,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Sperm Duct Surgery,PX00922.01,CDM,964,RC,922,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Spine Cord Surgery,PX00600.01,CDM,964,RC,600,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Spine Cord Surgery,PX00620.01,CDM,964,RC,620,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Spine Cord Surgery,PX00630.01,CDM,964,RC,630,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Spine Cord Surgery,PX00670.01,CDM,964,RC,670,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Spine Manipulation,PX00640.01,CDM,964,RC,640,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Sternal Debridement,PX00550.01,CDM,964,RC,550,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Stone Removal,PX00918.01,CDM,964,RC,918,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surg Lower Abdomen,PX00840.01,CDM,964,RC,840,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,24.41112903,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surg on Vag/Urethral,PX00942.01,CDM,964,RC,942,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surg Upper Abdomen,PX00790.01,CDM,964,RC,790,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,22.57655235,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery for Obesity,PX00797.01,CDM,964,RC,797,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Abdomen,PX00860.01,CDM,964,RC,860,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Breast,PX00402.01,CDM,964,RC,402,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Breast,PX00404.01,CDM,964,RC,404,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Breast,PX00406.01,CDM,964,RC,406,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Femur,PX01230.01,CDM,964,RC,1230,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Rib(S),PX00474.01,CDM,964,RC,474,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Shoulder,PX00450.01,CDM,964,RC,450,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Shoulder,PX00452.01,CDM,964,RC,452,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Shoulder,PX01610.01,CDM,964,RC,1610,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Surgery of Shoulder,PX01630.01,CDM,964,RC,1630,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Testis Exploration,PX00924.01,CDM,964,RC,924,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Testis Suspension,PX00930.01,CDM,964,RC,930,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Thigh Arteries Surg,PX01270.01,CDM,964,RC,1270,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Trach-Bronch Reconst,PX00539.01,CDM,964,RC,539,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Trachea Bronchi Surg,PX00548.01,CDM,964,RC,548,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Trans Resect of Prostate,PX00914.01,CDM,964,RC,914,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Tubal Ligation,PX00851.01,CDM,964,RC,851,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Tympanotomy,PX00126.01,CDM,964,RC,126,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Upper Arm Surgery,PX01740.01,CDM,964,RC,1740,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Upper Arm Vein Surg,PX01780.01,CDM,964,RC,1780,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Upper GI Visualize,PX00740.01,CDM,964,RC,740,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Upper Leg Surgery,PX01250.01,CDM,964,RC,1250,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Upper Leg Veins Surg,PX01260.01,CDM,964,RC,1260,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Uppr Arm Artery Surg,PX01770.01,CDM,964,RC,1770,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Uppr Arm Embolectomy,PX01772.01,CDM,964,RC,1772,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Uppr Arm Procedure,PX01730.01,CDM,964,RC,1730,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Uppr Arm Tendon Surg,PX01712.01,CDM,964,RC,1712,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Uppr Arm Tendon Surg,PX01714.01,CDM,964,RC,1714,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Uppr Arm Vein Repair,PX01782.01,CDM,964,RC,1782,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vaginal Delivery,PX01960.01,CDM,964,RC,1960,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vaginal Endoscopy,PX00950.01,CDM,964,RC,950,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vaginal Hysterectomy,PX00944.01,CDM,964,RC,944,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vaginal Procedures,PX00940.01,CDM,964,RC,940,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vascular Access,PX00532.01,CDM,964,RC,532,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vascular Shunt Surg,PX01844.01,CDM,964,RC,1844,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vasectomy,PX00921.01,CDM,964,RC,921,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Vitreoretinal Surg,PX00145.01,CDM,964,RC,145,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth Wrist Replacement,PX01832.01,CDM,964,RC,1832,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth/Analg Cs Hyst Add-On,PX01969.01,CDM,964,RC,1969,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Anesth/Analg Vag Delivery,PX01967.01,CDM,964,RC,1967,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Hosp Manage Cont Drug Admin,PX01996.01,CDM,964,RC,1996,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
IMMOBILIZER SHOULDER LARGE 9008-03,120.38,CDM,274,RC,L3650,HCPCS,,906-MAIN,LOCAL,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER LARGE STRAP OSG3033,120.38,CDM,274,RC,L3650,HCPCS,,2910-MAIN,LOCAL,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER MEDIUM 9008-02,120.38,CDM,274,RC,L3650,HCPCS,,912-MAIN,LOCAL,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER MEDIUM OSG3032,120.38,CDM,274,RC,L3650,HCPCS,,915-MAIN,LOCAL,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER SMALL 9008-01,120.38,CDM,274,RC,L3650,HCPCS,,913-MAIN,LOCAL,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER SMALL WITH CLOTH 9001-02,120.38,CDM,274,RC,L3650,HCPCS,,914-MAIN,LOCAL,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER X-LARGE CLOTH 9001-05,120.38,CDM,274,RC,L3650,HCPCS,,917-MAIN,LOCAL,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER X-LARGE ORT16100XL,120.38,CDM,274,RC,L3650,HCPCS,,904-MAIN,LOCAL,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
Support for Organ Donor,PX01990.01,CDM,964,RC,1990,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
Treponema Pallidum,PX86780,CDM,300,RC,86780,CPT,,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,59.02,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.14,35.28
Unlisted Anesth Procedure,PX01999.01,CDM,964,RC,1999,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405P,CDM,983,RC,36405,CPT,,,,,,,,36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.9544,35.0388
BALLOON EXTRACTOR PEDS,120.358,CDM,272,RC,,,,10771-MAIN,LOCAL,,,,,73,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,35.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.3242,71.54
BALLOON EXTRACTOR PEDS,120.358,CDM,272,RC,,,,10771-MAIN,LOCAL,,,,,73,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,35.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.3242,71.54
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600701,NDC,10,ML,39.73,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,35.04186,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,38.9354
morphine 1 MG/ML Solution 50 mL Syringe,J2270.01,CDM,636,RC,J2270,HCPCS,,,,61553064975,NDC,50,ML,81.71,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,35.05359,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
atropine (PF) 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517040125,NDC,1,ML,71.55,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,35.0595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
atropine (PF) 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517040125,NDC,1,ML,71.55,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,35.0595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
atropine (PF) 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517040125,NDC,1,ML,71.55,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,35.0595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
tetracaine 0.5 % Solution 4 mL Plas Cont,25000000,CDM,250,RC,,,,,,65074114,NDC,4,ML,71.55,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,35.0595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tetracaine 0.5 % Solution 4 mL Plas Cont,25000000,CDM,250,RC,,,,,,65074114,NDC,4,ML,71.55,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,35.0595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tetracaine 0.5 % Solution 4 mL Plas Cont,25000000,CDM,250,RC,,,,,,65074114,NDC,4,ML,71.55,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,35.0595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
timolol 0.25 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314022605,NDC,5,ML,84.45,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,35.08053,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
atropine 1 mg/mL Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100101,NDC,0.2,ML,39.42,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,35.0838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323048201,NDC,10,ML,39.78,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,35.08596,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323048217,NDC,10,ML,39.78,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,35.08596,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,70860030143,NDC,25,ML,84.47,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,35.088838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010626,NDC,50,ML,84.47,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,35.088838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
sodium bicarbonate 8.4 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409662502,NDC,50,ML,84.47,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,35.088838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"B.Burgdorferi, Amp Probe - Ref",PX8747690,CDM,300,RC,87476,CPT,90,,,,,,,72,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,35.09,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
"Chlamydia Trachomatis Dna, Amp Probe",PX87491,CDM,300,RC,87491,CPT,,,,,,,,157,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,35.09,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.51,35.09
"Cmv Detect, Amplifi Probe - Ref",PX8749690,CDM,300,RC,87496,CPT,90,,,,,,,147,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,35.09,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
Detect Agent Nos Dna Amp,PX87798,CDM,300,RC,87798,CPT,,,,,,,,176,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,35.09,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.51,35.09
Detection of Anaplasma Phagocytophilum by Amplified Nucleic Acid Probe Technique,PX8746890,CDM,300,RC,87468,CPT,90,,,,,,,41,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,35.09,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
Detection of Babesia Borrelia Miyamotoi by Amplified Nucleic Acid Probe Technique,PX8747890,CDM,300,RC,87478,CPT,90,,,,,,,23,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,35.09,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
Detection of Babesia Microtim by Amplified Nucleic Acid Probe Technique,PX8746990,CDM,300,RC,87469,CPT,90,,,,,,,23,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,35.09,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
Detection of Ehrlichia Chaffeensis by Amplified Nucleic Acid Probe Technique,PX8748490,CDM,300,RC,87484,CPT,90,,,,,,,41,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,35.09,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
"Hsv Detect, Amplif Probe - Ref",PX8752990,CDM,300,RC,87529,CPT,90,,,,,,,150,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,35.09,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
Hsv Dna Amp Probe,PX87529,CDM,300,RC,87529,CPT,,,,,,,,145,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,35.09,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
Iadna Streptococcus Group a Amplified Probe Tq,PX87651,CDM,300,RC,87651,CPT,,,,,,,,113,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,35.09,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
"Infect Ea Organ, Amp Prob - Ref",PX8779890,CDM,300,RC,87798,CPT,90,,,,,,,180,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,35.09,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.51,35.09
Mrsa by Amplification Na,PX87641,CDM,300,RC,87641,CPT,,,,,,,,180,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,35.09,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.04,35.09
"Neisseria Gonorrhoeae Dna, Amp Probe",PX87591,CDM,300,RC,87591,CPT,,,,,,,,157,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,35.09,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.51,35.09
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028016,NDC,2,ML,41.29,,First Health,Commercial,both,85,,999999999,percent of total billed charges,35.0965,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760,CDM,420,RC,97760,CPT,,,,,,,,142,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,35.1,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.1,62.82
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760F,CDM,510,RC,97760,CPT,,,,,,,,142,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,35.1,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.1,62.82
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046203,NDC,30,ML,70.91,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,35.10045,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
methylPREDNISolone acetate 20 MG/ML Suspension 5 mL Vial,J1010.01,CDM,636,RC,J1010,HCPCS,,,,9027401,NDC,0.5,ML,41.3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,35.105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.15602,40.474
urea 20 % Cream 85 g Tube,63700001,CDM,250,RC,,,,,,536110945,NDC,85,GR,81.83,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,35.10507,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
FORCEPS SERRATED WITH SPIKE JUMBO 230CM,27200000,CDM,272,RC,,,,7416-MAIN,LOCAL,,,,,41.31,,First Health,Commercial,both,85,,999999999,percent of total billed charges,35.1135,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
valACYclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069801,NDC,1,EA,38.55,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,35.11905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Dress/Debrid Small Burn No Anes,PX16020F,CDM,510,RC,16020,CPT,,,,,,,,313,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,35.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.46,179.18
Dress/Debrid Small Burn No Anes,PX16020F,CDM,510,RC,16020,CPT,,,,,,,,313,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,35.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.46,179.18
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002F,CDM,510,RC,12002,CPT,,,,,,,,343,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,35.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.9,237.98
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002F,CDM,510,RC,12002,CPT,,,,,,,,343,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,35.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.9,237.98
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002P,CDM,983,RC,12002,CPT,,,,,,,,486,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,35.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.9,476.28
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002P,CDM,983,RC,12002,CPT,,,,,,,,486,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,35.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.9,476.28
"Ileoscopy Thru Stoma,Diagnostic",PX44380F,CDM,750,RC,44380,CPT,,,,,,,,245,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,35.12,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.12,408.85
"Ileoscopy Thru Stoma,Diagnostic",PX44380P,CDM,983,RC,44380,CPT,,,,,,,,455,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,35.12,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.12,445.9
"Insert Needle,Intraosseous Infusn",PX36680F,CDM,510,RC,36680,CPT,,,,,,,,659,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,35.12,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.12,122.45
Ultrasound Breast Limited,PX7664201,CDM,402,RC,76642,CPT,TC,,,,,,,342,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,35.12,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.12,104.53
ursodiol 300 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,591315901,NDC,1,EA,39.47,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,35.1283,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levOCARNitine 200 MG/ML Solution 5 mL Vial,J1955.01,CDM,636,RC,J1955,HCPCS,,,,517104501,NDC,5,ML,249.86,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,35.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.08,35.32
levOCARNitine 200 MG/ML Solution 5 mL Vial,J1955.01,CDM,636,RC,J1955,HCPCS,,,,517104501,NDC,5,ML,249.86,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,35.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.08,35.32
dabigatran 75 MG capsule 60 Each Box,63700001,CDM,250,RC,,,,,,597014960,NDC,1,EA,39.83,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,35.13006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915850,NDC,0.2,ML,69.44,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,35.13664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039814,NDC,1,EA,39.84,,United Healthcare,All Payer,outpatient,88.2,,23.68,percent of total billed charges,35.13888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
BUPivacaine PF 0.5 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,55150016910,NDC,10,ML,39.84,,United Healthcare,All Payer,outpatient,88.2,,12.82416667,percent of total billed charges,35.13888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
enalaprilat 1.25 MG/ML Injectable 1 mL Vial,25000000,CDM,250,RC,,,,,,143978710,NDC,1,ML,39.84,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,35.13888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098141,NDC,1,EA,39.84,,United Healthcare,All Payer,outpatient,88.2,,49.96,percent of total billed charges,35.13888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098153,NDC,1,EA,39.84,,United Healthcare,All Payer,outpatient,88.2,,49.96,percent of total billed charges,35.13888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,47781059807,NDC,1,EA,39.84,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,35.13888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
Gabapentin - Ref,PX8017190,CDM,300,RC,80171,CPT,90,,,,,,,71,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,35.145,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.87,69.58
Histoplasma Antibody - Ref,PX8669890,CDM,300,RC,86698,CPT,90,,,,,,,71,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,35.145,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.64,69.58
Legionella Antibody - Ref,PX8671390,CDM,300,RC,86713,CPT,90,,,,,,,71,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,35.145,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.03,69.58
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,67457043800,NDC,0.5,EA,36.11,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.145863,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,67457043810,NDC,0.5,EA,36.11,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.145863,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409132305,NDC,5,ML,41.35,,First Health,Commercial,both,85,,999999999,percent of total billed charges,35.1475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026994,NDC,20,ML,35.87,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.1526,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028036,NDC,2,ML,36.12,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,4.556666667,percent of total billed charges,35.155596,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781910572,NDC,0.25,EA,69.49,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,35.16194,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86,213.6008
"CUFF STERILE DISPOSABLE SPSB  STERILE 18""",27200000,CDM,272,RC,,,,7436-MAIN,LOCAL,,,,,35.89,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.1722,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323020103,NDC,10,ML,36.14,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.175062,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Ace - Ref,PX8216490,CDM,300,RC,82164,CPT,90,,,,,,,82,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,35.178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.39,80.36
Anca Screen Each Antibody,PX8603690,CDM,300,RC,86036,CPT,90,,,,,,,82,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,35.178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.0628,80.36
"Cognitive Funct Ther Interv, Ea Addl 15 Min",PX97130,CDM,420,RC,97130,CPT,,,,,,,,82,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,35.178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31,80.36
"Cortisol, Free - Ref",PX8253090,CDM,300,RC,82530,CPT,90,,,,,,,82,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,35.178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.32,80.36
TRAY SURGICAL PODIATRY II EXTREMITY DYNJS0803,27200000,CDM,272,RC,,,,10920-MAIN,LOCAL,,,,,73.29,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,35.1792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TRAY SURGICAL PODIATRY II EXTREMITY DYNJS0803,27200000,CDM,272,RC,,,,10920-MAIN,LOCAL,,,,,73.29,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,35.1792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457033900,NDC,1,EA,71.82,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,12.3175,percent of total billed charges,35.1918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457033900,NDC,1,EA,71.82,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,35.1918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457033900,NDC,1,EA,71.82,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,35.1918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
protamine 10 MG/ML Solution 5 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022994,NDC,5,ML,84.74,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,35.200996,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.431298,83.0452
colchicine 0.6 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,49884017111,NDC,1,EA,36.17,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.204261,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028026,NDC,2,ML,41.42,,First Health,Commercial,both,85,,999999999,percent of total billed charges,35.207,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,63739005007,NDC,1,EA,73.35,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,35.208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,63739005007,NDC,1,EA,73.35,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,35.208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338080304,NDC,1000,ML,69.59,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,35.21254,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990710709,NDC,1000,ML,69.59,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,35.21254,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004824,NDC,150,ML,69.59,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,35.21254,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
bisoprolol-hydroCHLOROthiazide 5-6.25 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,42799092102,NDC,1,EA,39.57,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,35.2173,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
8MM-12MM TIP COVER ACCESSORY,27200000,CDM,272,RC,,,,11918-MAIN,LOCAL,,,,,40,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,35.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Anes Dx Shoulder Arthroscopy,PX01622.01,CDM,964,RC,1622,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anes Lower Intestinal Endoscopic Px Nos,PX00811.01,CDM,964,RC,811,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anes Lower Intestinal Screening Colonoscopy,PX00812.01,CDM,964,RC,812,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anes Spine Transthor W/Vent,PX00626.01,CDM,964,RC,626,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anes Spine Tranthor W/O Vent,PX00625.01,CDM,964,RC,625,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anes Ther Interven Rad Art,PX01924.01,CDM,964,RC,1924,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anes Ther Interven Rad Car,PX01925.01,CDM,964,RC,1925,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anes Ther Interven Rad Tip,PX01931.01,CDM,964,RC,1931,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anes Ther Interven Rad Vei,PX01930.01,CDM,964,RC,1930,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anes Tx Interv Rad Cran V,PX01933.01,CDM,964,RC,1933,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anes Tx Interv Rad Hrt/Cran,PX01926.01,CDM,964,RC,1926,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anes Tx Interv Rad Th Vein,PX01932.01,CDM,964,RC,1932,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anes Upper GI Endoscopic Px Ercp,PX00732.01,CDM,964,RC,732,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anes Upper GI Endoscopic Px Nos,PX00731.01,CDM,964,RC,731,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anes Upper/Lower GI Endoscopic Px,PX00813.01,CDM,964,RC,813,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anes/Analg Cs Deliver Add-On,PX01968.01,CDM,964,RC,1968,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Abdomen Vessel Surg,PX00880.01,CDM,964,RC,880,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Abdominal Wall Surg,PX00700.01,CDM,964,RC,700,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Abdominal Wall Surg,PX00730.01,CDM,964,RC,730,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Abdominal Wall Surg,PX00800.01,CDM,964,RC,800,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Abdominal Wall Surg,PX00820.01,CDM,964,RC,820,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Achilles Tendon Surg,PX01472.01,CDM,964,RC,1472,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Airplane Cast,PX01682.01,CDM,964,RC,1682,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Amniocentesis,PX00842.01,CDM,964,RC,842,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Amputation at Knee,PX01404.01,CDM,964,RC,1404,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Amputation at Pelvis,PX01140.01,CDM,964,RC,1140,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Amputation of Femur,PX01232.01,CDM,964,RC,1232,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Amputation of Penis,PX00932.01,CDM,964,RC,932,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Ankle Replacement,PX01486.01,CDM,964,RC,1486,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Ankle/Ft Arthroscopy,PX01464.01,CDM,964,RC,1464,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Anorectal Surgery,PX00902.01,CDM,964,RC,902,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Antepartum Manipul,PX01958.01,CDM,964,RC,1958,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Arm-Leg Vessel Surg,PX01656.01,CDM,964,RC,1656,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Arthroscopy of Hip,PX01202.01,CDM,964,RC,1202,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Biceps Tendon Repair,PX01716.01,CDM,964,RC,1716,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Biopsy of Nose,PX00164.01,CDM,964,RC,164,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Biopsy of Thyroid,PX00322.01,CDM,964,RC,322,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Bladder Stone Surg,PX00870.01,CDM,964,RC,870,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Bladder Surgery,PX00910.01,CDM,964,RC,910,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Bladder Tumor Surg,PX00912.01,CDM,964,RC,912,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Bleeding Control,PX00916.01,CDM,964,RC,916,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Blepharoplasty,PX00103.01,CDM,964,RC,103,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Blood Vessel Repair,PX00770.01,CDM,964,RC,770,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Body Cast Procedure,PX01130.01,CDM,964,RC,1130,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Bone Aspirate/Bx,PX01112.01,CDM,964,RC,1112,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Burn 4-9 Percent,PX01952.01,CDM,964,RC,1952,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Burn Each 9 Percent,PX01953.01,CDM,964,RC,1953,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Burn Less 4 Percent,PX01951.01,CDM,964,RC,1951,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Cabg W/O Pump,PX00566.01,CDM,964,RC,566,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Cabg W/Pump,PX00567.01,CDM,964,RC,567,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Cardiac Electrophys,PX00537.01,CDM,964,RC,537,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Cardioverter/Defib,PX00534.01,CDM,964,RC,534,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Cat or MRI Scan,PX01922.01,CDM,964,RC,1922,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Catheterize Heart,PX01920.01,CDM,964,RC,1920,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Chest Drainage,PX00524.01,CDM,964,RC,524,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Chest Lining Biopsy,PX00522.01,CDM,964,RC,522,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Chest Partition View,PX00528.01,CDM,964,RC,528,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Chest Partition View,PX00529.01,CDM,964,RC,529,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Chest Procedure,PX00520.01,CDM,964,RC,520,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Chest Surgery,PX00540.01,CDM,964,RC,540,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Chest Wall Repair,PX00472.01,CDM,964,RC,472,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Cleft Palate Repair,PX00172.01,CDM,964,RC,172,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Collar Bone Biopsy,PX00454.01,CDM,964,RC,454,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Corneal Transplant,PX00144.01,CDM,964,RC,144,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Correct Heart Rhythm,PX00410.01,CDM,964,RC,410,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Cran Surg Hemotoma,PX00211.01,CDM,964,RC,211,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Cranial Surg Nos,PX00210.01,CDM,964,RC,210,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Cs Delivery,PX01961.01,CDM,964,RC,1961,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Cs Hysterectomy,PX01963.01,CDM,964,RC,1963,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Dx Arteriography,PX01916.01,CDM,964,RC,1916,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Dx Elbow Arthroscopy,PX01732.01,CDM,964,RC,1732,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Dx Knee Arthroscopy,PX01382.01,CDM,964,RC,1382,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Dx Wrist Arthroscopy,PX01829.01,CDM,964,RC,1829,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Ear Exam,PX00124.01,CDM,964,RC,124,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Ear Surgery,PX00120.01,CDM,964,RC,120,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Elbow Area Surgery,PX01710.01,CDM,964,RC,1710,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Elbow Replacement,PX01760.01,CDM,964,RC,1760,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Electroshock,PX00104.01,CDM,964,RC,104,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Emer Hysterectomy,PX01962.01,CDM,964,RC,1962,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Esophageal Surgery,PX00500.01,CDM,964,RC,500,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Eye Exam,PX00148.01,CDM,964,RC,148,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Face/Skull Bone Surg,PX00190.01,CDM,964,RC,190,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Facial Bone Surgery,PX00192.01,CDM,964,RC,192,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Fat Layer Removal,PX00802.01,CDM,964,RC,802,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Femoral Artery Surg,PX01272.01,CDM,964,RC,1272,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Femoral Embolectomy,PX01274.01,CDM,964,RC,1274,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth for Chemonucleolysis,PX00634.01,CDM,964,RC,634,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth for Liver Biopsy,PX00702.01,CDM,964,RC,702,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth for Liver Transplant,PX00796.01,CDM,964,RC,796,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Forequarter Amput,PX01636.01,CDM,964,RC,1636,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Fx Repair Pelvis,PX01173.01,CDM,964,RC,1173,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Genitalia Surgery,PX00920.01,CDM,964,RC,920,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Head Nerve Surgery,PX00222.01,CDM,964,RC,222,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Head Vessel Surgery,PX00216.01,CDM,964,RC,216,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Head/Neck/Ptrunk,PX00300.01,CDM,964,RC,300,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Heart Surg < 1 Yr,PX00561.01,CDM,964,RC,561,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Heart Surg W/Arrest,PX00563.01,CDM,964,RC,563,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Heart Surg W/O Pump,PX00560.01,CDM,964,RC,560,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Heart/Lung Transplnt,PX00580.01,CDM,964,RC,580,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Hemorr/Excise Liver,PX00792.01,CDM,964,RC,792,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Hernia Repair < 1 Yr,PX00834.01,CDM,964,RC,834,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Hernia Repair Preemie,PX00836.01,CDM,964,RC,836,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Hip Arthroplasty,PX01214.01,CDM,964,RC,1214,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Hip Disarticulation,PX01212.01,CDM,964,RC,1212,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Hip Joint Procedure,PX01200.01,CDM,964,RC,1200,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Hip Joint Surgery,PX01210.01,CDM,964,RC,1210,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Hrt Surg W/Pmp Age 1+,PX00562.01,CDM,964,RC,562,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Humeral Lesion Surg,PX01758.01,CDM,964,RC,1758,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Humerus Repair,PX01744.01,CDM,964,RC,1744,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Humerus Surgery,PX01742.01,CDM,964,RC,1742,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Hysterectomy,PX00846.01,CDM,964,RC,846,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Hysteroscope/Graph,PX00952.01,CDM,964,RC,952,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Inc/Missed Ab Proc,PX01965.01,CDM,964,RC,1965,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Induced Ab Procedure,PX01966.01,CDM,964,RC,1966,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Insert Penis Device,PX00938.01,CDM,964,RC,938,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Intrcrn Nerve,PX00220.01,CDM,964,RC,220,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Iridectomy,PX00147.01,CDM,964,RC,147,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Kidney Stone Destruct,PX00872.01,CDM,964,RC,872,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Kidney Stone Destruct,PX00873.01,CDM,964,RC,873,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Kidney Transplant,PX00868.01,CDM,964,RC,868,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Kidney/Ureter Surg,PX00862.01,CDM,964,RC,862,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Knee Area Procedure,PX01340.01,CDM,964,RC,1340,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Knee Area Procedure,PX01390.01,CDM,964,RC,1390,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Knee Area Surgery,PX01320.01,CDM,964,RC,1320,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Knee Area Surgery,PX01360.01,CDM,964,RC,1360,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Knee Area Surgery,PX01392.01,CDM,964,RC,1392,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Knee Arteries Surg,PX01440.01,CDM,964,RC,1440,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Knee Artery Repair,PX01444.01,CDM,964,RC,1444,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Knee Artery Surg,PX01442.01,CDM,964,RC,1442,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Knee Arthroplasty,PX01402.01,CDM,964,RC,1402,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Knee Joint Casting,PX01420.01,CDM,964,RC,1420,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Knee Joint Procedure,PX01380.01,CDM,964,RC,1380,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Knee Joint Surgery,PX01400.01,CDM,964,RC,1400,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Knee Veins Surgery,PX01430.01,CDM,964,RC,1430,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Knee Vessel Surg,PX01432.01,CDM,964,RC,1432,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Larynx/Trach < 1 Yr,PX00326.01,CDM,964,RC,326,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Leg Arteries Surg,PX01500.01,CDM,964,RC,1500,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Lens Surgery,PX00142.01,CDM,964,RC,142,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Low Intestine Scope,PX00810.01,CDM,964,RC,810,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Lower Arm Casting,PX01860.01,CDM,964,RC,1860,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Lower Arm Procedure,PX01820.01,CDM,964,RC,1820,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Lower Arm Surgery,PX01810.01,CDM,964,RC,1810,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Lower Arm Surgery,PX01830.01,CDM,964,RC,1830,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Lower Arm Vein Surg,PX01850.01,CDM,964,RC,1850,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Lower Leg Bone Surg,PX01480.01,CDM,964,RC,1480,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Lower Leg Casting,PX01490.01,CDM,964,RC,1490,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Lower Leg Procedure,PX01462.01,CDM,964,RC,1462,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Lower Leg Revision,PX01484.01,CDM,964,RC,1484,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Lower Leg Surgery,PX01470.01,CDM,964,RC,1470,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Lower Leg Surgery,PX01474.01,CDM,964,RC,1474,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Lower Leg Vein Surg,PX01520.01,CDM,964,RC,1520,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Lower Leg Vein Surg,PX01522.01,CDM,964,RC,1522,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Lumbar Puncture,PX00635.01,CDM,964,RC,635,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Lung Chest Wall Surg,PX00546.01,CDM,964,RC,546,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Lwr Arm Artery Surg,PX01840.01,CDM,964,RC,1840,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Lwr Arm Embolectomy,PX01842.01,CDM,964,RC,1842,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Lwr Arm Vein Repair,PX01852.01,CDM,964,RC,1852,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Lwr Leg Embolectomy,PX01502.01,CDM,964,RC,1502,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Major Vein Ligation,PX00882.01,CDM,964,RC,882,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth N Block/Inj Prone,PX01992.01,CDM,964,RC,1992,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Neck Organ 1 & Over,PX00320.01,CDM,964,RC,320,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Neck Vessel Surgery,PX00350.01,CDM,964,RC,350,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Neck Vessel Surgery,PX00352.01,CDM,964,RC,352,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Nerve Block/Inj,PX01991.01,CDM,964,RC,1991,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Nose/Sinus Surgery,PX00160.01,CDM,964,RC,160,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Nose/Sinus Surgery,PX00162.01,CDM,964,RC,162,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth One Lung Ventilation,PX00541.01,CDM,964,RC,541,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Pacemaker Insertion,PX00530.01,CDM,964,RC,530,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Pancreas Removal,PX00794.01,CDM,964,RC,794,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Pelvic Organ Surg,PX00848.01,CDM,964,RC,848,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Pelvic Tumor Surgery,PX01150.01,CDM,964,RC,1150,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Pelvis Nerve Removal,PX01180.01,CDM,964,RC,1180,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Pelvis Nerve Removal,PX01190.01,CDM,964,RC,1190,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Pelvis Procedure,PX01160.01,CDM,964,RC,1160,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Pelvis Surgery,PX00844.01,CDM,964,RC,844,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Pelvis Surgery,PX01120.01,CDM,964,RC,1120,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Pelvis Surgery,PX01170.01,CDM,964,RC,1170,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Penis Nodes Removal,PX00934.01,CDM,964,RC,934,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Penis Nodes Removal,PX00936.01,CDM,964,RC,936,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Perc Img Dx Sp Proc,PX01935.01,CDM,964,RC,1935,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Perc Img Tx Sp Proc,PX01936.01,CDM,964,RC,1936,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Perineal Surgery,PX00904.01,CDM,964,RC,904,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Pharyngeal Surgery,PX00174.01,CDM,964,RC,174,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Pharyngeal Surgery,PX00176.01,CDM,964,RC,176,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Procedure on Femur,PX01220.01,CDM,964,RC,1220,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Procedure on Mouth,PX00170.01,CDM,964,RC,170,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Procedures on Eye,PX00140.01,CDM,964,RC,140,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Radical Femur Surg,PX01234.01,CDM,964,RC,1234,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Radical Humerus Surg,PX01756.01,CDM,964,RC,1756,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Radical Leg Surgery,PX01482.01,CDM,964,RC,1482,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Release of Lung,PX00542.01,CDM,964,RC,542,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Removal of Adrenal,PX00866.01,CDM,964,RC,866,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Removal of Bladder,PX00864.01,CDM,964,RC,864,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Removal of Nerves,PX00622.01,CDM,964,RC,622,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Removal of Nerves,PX00632.01,CDM,964,RC,632,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Removal of Prostate,PX00865.01,CDM,964,RC,865,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Removal of Prostate,PX00908.01,CDM,964,RC,908,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Removal of Rib,PX00470.01,CDM,964,RC,470,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Removal of Testis,PX00926.01,CDM,964,RC,926,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Removal of Testis,PX00928.01,CDM,964,RC,928,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Removal of Vulva,PX00906.01,CDM,964,RC,906,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Repair of Cervix,PX00948.01,CDM,964,RC,948,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Repair of Cleft Lip,PX00102.01,CDM,964,RC,102,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Repair of Hernia,PX00750.01,CDM,964,RC,750,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Repair of Hernia,PX00752.01,CDM,964,RC,752,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Repair of Hernia,PX00754.01,CDM,964,RC,754,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Repair of Hernia,PX00756.01,CDM,964,RC,756,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Repair of Hernia,PX00830.01,CDM,964,RC,830,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Repair of Hernia,PX00832.01,CDM,964,RC,832,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Revise Hip Repair,PX01215.01,CDM,964,RC,1215,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Salivary Gland,PX00100.01,CDM,964,RC,100,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Shoulder Artery Surg,PX01650.01,CDM,964,RC,1650,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Shoulder Casting,PX01680.01,CDM,964,RC,1680,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Shoulder Joint Amput,PX01634.01,CDM,964,RC,1634,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Shoulder Procedure,PX01620.01,CDM,964,RC,1620,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Shoulder Replacement,PX01638.01,CDM,964,RC,1638,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Shoulder Vein Surg,PX01670.01,CDM,964,RC,1670,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Shoulder Vessel Surg,PX01652.01,CDM,964,RC,1652,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Shoulder Vessel Surg,PX01654.01,CDM,964,RC,1654,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Sitting Procedure,PX00604.01,CDM,964,RC,604,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Skin Ext/per/Atrunk,PX00400.01,CDM,964,RC,400,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Skull Drainage,PX00212.01,CDM,964,RC,212,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Skull Drainage,PX00214.01,CDM,964,RC,214,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Skull Repair/Fract,PX00215.01,CDM,964,RC,215,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Special Head Surgery,PX00218.01,CDM,964,RC,218,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Sperm Duct Surgery,PX00922.01,CDM,964,RC,922,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Spine Cord Surgery,PX00600.01,CDM,964,RC,600,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Spine Cord Surgery,PX00620.01,CDM,964,RC,620,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Spine Cord Surgery,PX00630.01,CDM,964,RC,630,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Spine Cord Surgery,PX00670.01,CDM,964,RC,670,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Spine Manipulation,PX00640.01,CDM,964,RC,640,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Sternal Debridement,PX00550.01,CDM,964,RC,550,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Stone Removal,PX00918.01,CDM,964,RC,918,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Surg Lower Abdomen,PX00840.01,CDM,964,RC,840,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Surg on Vag/Urethral,PX00942.01,CDM,964,RC,942,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Surg Upper Abdomen,PX00790.01,CDM,964,RC,790,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Surgery for Obesity,PX00797.01,CDM,964,RC,797,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Surgery of Abdomen,PX00860.01,CDM,964,RC,860,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Surgery of Breast,PX00402.01,CDM,964,RC,402,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Surgery of Breast,PX00404.01,CDM,964,RC,404,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Surgery of Breast,PX00406.01,CDM,964,RC,406,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Surgery of Femur,PX01230.01,CDM,964,RC,1230,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Surgery of Rib(S),PX00474.01,CDM,964,RC,474,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Surgery of Shoulder,PX00450.01,CDM,964,RC,450,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Surgery of Shoulder,PX00452.01,CDM,964,RC,452,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Surgery of Shoulder,PX01610.01,CDM,964,RC,1610,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Surgery of Shoulder,PX01630.01,CDM,964,RC,1630,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Testis Exploration,PX00924.01,CDM,964,RC,924,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Testis Suspension,PX00930.01,CDM,964,RC,930,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Thigh Arteries Surg,PX01270.01,CDM,964,RC,1270,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Trach-Bronch Reconst,PX00539.01,CDM,964,RC,539,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Trachea Bronchi Surg,PX00548.01,CDM,964,RC,548,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Trans Resect of Prostate,PX00914.01,CDM,964,RC,914,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Tubal Ligation,PX00851.01,CDM,964,RC,851,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Tympanotomy,PX00126.01,CDM,964,RC,126,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Upper Arm Surgery,PX01740.01,CDM,964,RC,1740,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Upper Arm Vein Surg,PX01780.01,CDM,964,RC,1780,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Upper GI Visualize,PX00740.01,CDM,964,RC,740,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Upper Leg Surgery,PX01250.01,CDM,964,RC,1250,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Upper Leg Veins Surg,PX01260.01,CDM,964,RC,1260,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Uppr Arm Artery Surg,PX01770.01,CDM,964,RC,1770,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Uppr Arm Embolectomy,PX01772.01,CDM,964,RC,1772,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Uppr Arm Procedure,PX01730.01,CDM,964,RC,1730,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Uppr Arm Tendon Surg,PX01712.01,CDM,964,RC,1712,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Uppr Arm Tendon Surg,PX01714.01,CDM,964,RC,1714,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Uppr Arm Vein Repair,PX01782.01,CDM,964,RC,1782,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Vaginal Delivery,PX01960.01,CDM,964,RC,1960,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Vaginal Endoscopy,PX00950.01,CDM,964,RC,950,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Vaginal Hysterectomy,PX00944.01,CDM,964,RC,944,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Vaginal Procedures,PX00940.01,CDM,964,RC,940,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Vascular Access,PX00532.01,CDM,964,RC,532,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Vascular Shunt Surg,PX01844.01,CDM,964,RC,1844,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Vasectomy,PX00921.01,CDM,964,RC,921,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Vitreoretinal Surg,PX00145.01,CDM,964,RC,145,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth Wrist Replacement,PX01832.01,CDM,964,RC,1832,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth/Analg Cs Hyst Add-On,PX01969.01,CDM,964,RC,1969,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
Anesth/Analg Vag Delivery,PX01967.01,CDM,964,RC,1967,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
"B.Burgdorferi, Amp Probe - Ref",PX8747690,CDM,300,RC,87476,CPT,90,,,,,,,72,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,35.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.9088,70.56
"B.Burgdorferi, Amp Probe - Ref",PX8747690,CDM,300,RC,87476,CPT,90,,,,,,,72,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,35.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.9088,70.56
"B.Burgdorferi, Amp Probe - Ref",PX8747690,CDM,300,RC,87476,CPT,90,,,,,,,72,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,35.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.9088,70.56
"Blood, Occult, Other Sources",PX82271,CDM,300,RC,82271,CPT,,,,,,,,72,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,35.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.88,70.56
"Blood, Occult, Other Sources",PX82271,CDM,300,RC,82271,CPT,,,,,,,,72,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,35.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.88,70.56
"Blood, Occult, Other Sources",PX82271,CDM,300,RC,82271,CPT,,,,,,,,72,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,35.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.88,70.56
CATHETER URETERAL  5FR TIGERTAIL OPEN TIP FLEXIBLE 139005,27200000,CDM,272,RC,A4340,HCPCS,,12302-MAIN,LOCAL,,,,,40,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,35.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Epstein-barr antibody,PX86664,CDM,300,RC,86664,CPT,,,,,,,,72,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,35.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.02,70.56
Epstein-barr antibody,PX86664,CDM,300,RC,86664,CPT,,,,,,,,72,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,35.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.02,70.56
Epstein-barr antibody,PX86664,CDM,300,RC,86664,CPT,,,,,,,,72,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,35.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.02,70.56
Hosp Manage Cont Drug Admin,PX01996.01,CDM,964,RC,1996,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.69,107.06
IMMOBILIZER SHOULDER LARGE 9008-03,120.38,CDM,274,RC,L3650,HCPCS,,906-MAIN,LOCAL,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER LARGE STRAP OSG3033,120.38,CDM,274,RC,L3650,HCPCS,,2910-MAIN,LOCAL,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER MEDIUM 9008-02,120.38,CDM,274,RC,L3650,HCPCS,,912-MAIN,LOCAL,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER MEDIUM OSG3032,120.38,CDM,274,RC,L3650,HCPCS,,915-MAIN,LOCAL,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER SMALL 9008-01,120.38,CDM,274,RC,L3650,HCPCS,,913-MAIN,LOCAL,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER SMALL WITH CLOTH 9001-02,120.38,CDM,274,RC,L3650,HCPCS,,914-MAIN,LOCAL,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER X-LARGE CLOTH 9001-05,120.38,CDM,274,RC,L3650,HCPCS,,917-MAIN,LOCAL,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER X-LARGE ORT16100XL,120.38,CDM,274,RC,L3650,HCPCS,,904-MAIN,LOCAL,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
NEEDLE BIOPSY 14GAX4 1/2 2N2702X,120.211,CDM,272,RC,,,,724-MAIN,LOCAL,,,,,40,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,35.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.616,39.2
STAPLER CANNULA SEAL 12 mm 470380,27200000,CDM,272,RC,,,,11962-MAIN,LOCAL,,,,,40,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,35.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Strapping of Ankle,PX29540F,CDM,420,RC,29540,CPT,,,,,,,,271,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,35.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.68,58.11
Support for Organ Donor,PX01990.01,CDM,964,RC,1990,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
"SUTURE V-LOC 22G NEEDLE 9"" 180 GREEN VLOCL2145",27200000,CDM,272,RC,,,,11930-MAIN,LOCAL,,,,,40,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,35.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"SUTURE V-LOC SZ 0.9"" 180 GREEN GS-21 NEEDLE VLOCL0346",27200000,CDM,272,RC,,,,11933-MAIN,LOCAL,,,,,40,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,35.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Telehealth Origin Site Fac Fee,PXQ3014,CDM,780,RC,Q3014,HCPCS,,,,,,,,40,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,35.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.616,39.2
Treponema Pallidum,PX86780,CDM,300,RC,86780,CPT,,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.14,35.28
Unlisted Anesth Procedure,PX01999.01,CDM,964,RC,1999,CPT,QZ,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.28,35.28
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405P,CDM,983,RC,36405,CPT,,,,,,,,36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.16,49.81
CISplatin 50 MG/50ML Solution 50 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010351,NDC,50,ML,82.27,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,35.29383,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.174958,180.2416
ceFAZolin in D4W 1 g / 50 mL 1-4 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0690.01,CDM,636,RC,J0690,HCPCS,,,,264310311,NDC,1,EA,84.97,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,35.296538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
Dihydroxyvitamin D - Ref,PX8265290,CDM,300,RC,82652,CPT,90,,,,,,,165,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,35.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.3,161.7
Vit D 1 25-Dihydroxy,PX82652,CDM,300,RC,82652,CPT,,,,,,,,154,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,35.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.3,150.92
"Cognitive Funct Ther Interv, Initial 15 Min",PX97129,CDM,420,RC,97129,CPT,,,,,,,,85,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,35.309,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15,83.3
"Exam,Synovial Fluid Crystals",PX89060,CDM,300,RC,89060,CPT,,,,,,,,85,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,35.309,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.72,83.3
GLIDESCOPE QC MAC S3 SINGLE USE 0270-1083,120.579,CDM,272,RC,,,,13046-MAIN,LOCAL,,,,,85,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,35.309,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.309,83.3
GLIDESCOPE QC MAC S3 SINGLE USE 0270-1085,120.579,CDM,272,RC,,,,13022-MAIN,LOCAL,,,,,85,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,35.309,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.309,83.3
GLIDESCOPE QC MAC S4 SINGLE USE 0270-1086,120.579,CDM,272,RC,,,,13023-MAIN,LOCAL,,,,,85,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,35.309,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.309,83.3
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,36000014801,NDC,2,ML,38.76,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,35.31036,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
triamcinolone acetonide 40 MG/ML Suspension 1 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029305,NDC,1,ML,73.57,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,35.3136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,72.0986
triamcinolone acetonide 40 MG/ML Suspension 1 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029305,NDC,1,ML,73.57,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,35.3136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,72.0986
sodium bicarbonate 8.4 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409662522,NDC,50,ML,85.02,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,35.317308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
levOCARNitine 200 MG/ML Solution 5 mL Vial,J1955.01,CDM,636,RC,J1955,HCPCS,,,,517104501,NDC,5,ML,249.86,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,35.32,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.08,35.32
Inj Tendon/Ligament/Cyst,PX20550F,CDM,510,RC,20550,CPT,,,,,,,,177,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,35.321,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.78,120.37
Inj Tendon/Ligament/Cyst,PX20550P,CDM,983,RC,20550,CPT,,,,,,,,264,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,35.321,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.78,258.72
buprenorphine 8 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,54017713,NDC,1,EA,41.56,,First Health,Commercial,both,85,,999999999,percent of total billed charges,35.326,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.14,40.7288
Iaad Ia Severe Aqt Respir Synd Coronavirus,PX87426,CDM,300,RC,87426,CPT,,,,,,,,159,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,35.33,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.27,35.33
Iaad Ia Severe Aqt Respir Synd Coronavirus,PX87426,CDM,300,RC,87426,CPT,,,,,,,,159,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,35.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.27,35.33
Iaad Ia Severe Aqt Respir Synd Coronavirus,PX87426,CDM,300,RC,87426,CPT,,,,,,,,159,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,35.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.27,35.33
"Insert Needle,Intraosseous Infusn",PX36680F,CDM,510,RC,36680,CPT,,,,,,,,659,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,35.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.12,122.45
"Insert Needle,Intraosseous Infusn",PX36680F,CDM,510,RC,36680,CPT,,,,,,,,659,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,35.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.12,122.45
"Sigmoidoscopy,Diagnostic",PX45330F,CDM,510,RC,45330,CPT,,,,,,,,720,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,35.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.68,386.72
"Sigmoidoscopy,Diagnostic",PX45330F,CDM,510,RC,45330,CPT,,,,,,,,720,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,35.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.68,386.72
"Sigmoidoscopy,Diagnostic",PX45330P,CDM,983,RC,45330,CPT,,,,,,,,480,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,35.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.68,470.4
"Sigmoidoscopy,Diagnostic",PX45330P,CDM,983,RC,45330,CPT,,,,,,,,480,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,35.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.68,470.4
"Sigmoidoscopy,Screen Prev",PX2001F,CDM,750,RC,45330,CPT,,,,,,,,843,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,35.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.68,386.72
"Sigmoidoscopy,Screen Prev",PX2001F,CDM,750,RC,45330,CPT,,,,,,,,843,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,35.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.68,386.72
Ultrasound Breast Limited,PX7664201,CDM,402,RC,76642,CPT,TC,,,,,,,342,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,35.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.12,104.53
Ultrasound Breast Limited,PX7664201,CDM,402,RC,76642,CPT,TC,,,,,,,342,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,35.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.12,104.53
valACYclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,31722070430,NDC,1,EA,38.79,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,35.33769,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022143,NDC,1,EA,36.31,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,12.385,percent of total billed charges,35.340523,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600701,NDC,10,ML,39.73,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,35.3597,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,38.9354
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022116,NDC,1,EA,36.33,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,12.385,percent of total billed charges,35.359989,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022141,NDC,1,EA,36.33,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,12.385,percent of total billed charges,35.359989,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
Infliximab - Ref,PX8023090,CDM,300,RC,80230,CPT,90,,,,,,,343,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,35.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.36,336.14
Vedolizumab - Ref,PX8028090,CDM,300,RC,80280,CPT,90,,,,,,,468,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,35.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.36,458.64
anastrozole 1 MG Tablet 30 Each Bottle,25000000,CDM,250,RC,,,,,,16729003510,NDC,1,EA,71.44,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,35.3628,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
magnesium sulfate 4 GM/50ML Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010701,NDC,50,ML,73.72,,Health Partners,Health Partners Care Plans,both,48,,14.6175,percent of total billed charges,35.3856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
magnesium sulfate 4 GM/50ML Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010701,NDC,50,ML,73.72,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,35.3856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,67457043800,NDC,0.5,EA,36.11,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.3878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,67457043810,NDC,0.5,EA,36.11,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.3878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
leucovorin 10 mg/mL Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,25021081467,NDC,1,EA,40.13,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,35.39466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.670002,84.6818
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028036,NDC,2,ML,36.12,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.3976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323048201,NDC,10,ML,39.78,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,35.4042,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323048217,NDC,10,ML,39.78,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,35.4042,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Acth - Ref,PX8202490,CDM,300,RC,82024,CPT,90,,,,,,,259,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,35.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.41,253.82
fluticasone-salmeterol 100-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069500,NDC,1,EA,38.87,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,35.41057,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323020103,NDC,10,ML,36.14,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.4172,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
atropine (PF) 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517040125,NDC,1,ML,71.55,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,35.41725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
tetracaine 0.5 % Solution 4 mL Plas Cont,25000000,CDM,250,RC,,,,,,65074114,NDC,4,ML,71.55,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,35.41725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001001,NDC,1.5,ML,40.17,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,35.42994,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,42.5516
caffeine citrate 60 MG/3ML Solution 3 mL Vial,J0706.01,CDM,636,RC,J0706,HCPCS,,,,63323040704,NDC,3,ML,73.84,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,35.4432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.673136,72.3632
caffeine citrate 60 MG/3ML Solution 3 mL Vial,J0706.01,CDM,636,RC,J0706,HCPCS,,,,63323040704,NDC,3,ML,73.84,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,35.4432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.673136,72.3632
colchicine 0.6 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,49884017111,NDC,1,EA,36.17,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.4466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dabigatran 75 MG capsule 60 Each Box,63700001,CDM,250,RC,,,,,,597014960,NDC,1,EA,39.83,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,35.4487,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,409508411,NDC,1,EA,73.86,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,35.4528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,409508411,NDC,1,EA,73.86,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,35.4528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039814,NDC,1,EA,39.84,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,35.4576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
BUPivacaine PF 0.5 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,55150016910,NDC,10,ML,39.84,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,35.4576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
enalaprilat 1.25 MG/ML Injectable 1 mL Vial,25000000,CDM,250,RC,,,,,,143978710,NDC,1,ML,39.84,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,35.4576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098141,NDC,1,EA,39.84,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,35.4576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098153,NDC,1,EA,39.84,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,35.4576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,47781059807,NDC,1,EA,39.84,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,35.4576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
azithromycin 250 MG Tablet 6 Each Box,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096104,NDC,1,EA,41.72,,First Health,Commercial,both,85,,999999999,percent of total billed charges,35.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096105,NDC,1,EA,41.73,,First Health,Commercial,both,85,,999999999,percent of total billed charges,35.4705,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
Each Add'l Hour IV Infusion <8 Hour,PX96366,CDM,260,RC,96366,CPT,,,,,,,,161,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,35.48,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.31,35.48
Each Add'l Hour IV Infusion <8 Hour,PX96366,CDM,260,RC,96366,CPT,,,,,,,,161,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,35.48,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.31,35.48
DULoxetine 20 MG Capsule Delayed Release Particles 60 Each Bottle,63700001,CDM,250,RC,,,,,,2323560,NDC,1,EA,41.76,,First Health,Commercial,both,85,,999999999,percent of total billed charges,35.496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,487960130,NDC,2,ML,36.47,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.496251,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
B-Scan Global,PX7651201,CDM,402,RC,76512,CPT,TC,,,,,,,127,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,35.5,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.55,35.5
B-Scan Global,PX7651201,CDM,402,RC,76512,CPT,TC,,,,,,,127,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,35.5,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.55,35.5
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,45802095301,NDC,100,GR,82.76,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,35.50404,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,17478070311,NDC,10,ML,72.46,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,35.5054,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,17478070311,NDC,10,ML,72.46,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,35.5054,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,17478070311,NDC,10,ML,72.46,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,35.5054,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
morphine 2 MG/ML Solution 1 mL Syringe,J2272.01,CDM,636,RC,J2272,HCPCS,,,,76045000401,NDC,1,ML,38.98,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,35.51078,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.192292,38.2004
Glucose Test,PX82950,CDM,300,RC,82950,CPT,,,,,,,,74,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,35.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.36,72.52
Glucose Test,PX82950,CDM,300,RC,82950,CPT,,,,,,,,74,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,35.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.36,72.52
KIT EMERGENCY BIRTH DYNJS0600,120.317,CDM,272,RC,,,,8344-MAIN,LOCAL,,,,,74,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,35.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.7396,72.52
KIT EMERGENCY BIRTH DYNJS0600,120.317,CDM,272,RC,,,,8344-MAIN,LOCAL,,,,,74,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,35.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.7396,72.52
Rubeola Antibody,PX86765,CDM,300,RC,86765,CPT,,,,,,,,74,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,35.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.81,72.52
Rubeola Antibody,PX86765,CDM,300,RC,86765,CPT,,,,,,,,74,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,35.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.81,72.52
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,50111078751,NDC,1,EA,41.79,,First Health,Commercial,both,85,,999999999,percent of total billed charges,35.5215,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
donepezil 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904640861,NDC,1,EA,41.79,,First Health,Commercial,both,85,,999999999,percent of total billed charges,35.5215,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CLOSED WOUND ROUND CHANNEL DRAIN WITH TROCAR 15FR FULL FLUTED,27200000,CDM,272,RC,,,,12223-MAIN,LOCAL,,,,,39,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,35.529,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
fluorouracil 500 MG/10ML Solution 10 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,63323011710,NDC,10,ML,39,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,35.529,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,256.2112
gemcitabine 200 MG Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323010294,NDC,1,EA,39,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,35.529,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
Lab Wbc and Differential,PX85004,CDM,300,RC,85004,CPT,,,,,,,,39,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,35.529,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,38.22
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003928,NDC,1,EA,39,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,35.529,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
methylPREDNISolone sod succ 500 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9075801,NDC,0.25,EA,39,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,35.529,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
NEEDLE JAMSHIDI 11G X 101MM BIOPSY DJ4011X,27200000,CDM,272,RC,,,,12798-MAIN,LOCAL,,,,,39,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,35.529,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
O2 SENSOR ADULT ADHESIVE SINGLE PATIENT 040-003382-00,120.576,CDM,272,RC,,,,12930-MAIN,LOCAL,,,,,39,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,35.529,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
O2 SENSOR INFANT ADHESIVE SINGLE PATIENT 040-003384-00,120.576,CDM,272,RC,,,,12932-MAIN,LOCAL,,,,,39,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,35.529,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
O2 SENSOR PEDIATRIC ADHESIVE SINGLE PATIENT 040-003383-00,120.576,CDM,272,RC,,,,12931-MAIN,LOCAL,,,,,39,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,35.529,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
SLEEVE ACHILLES LG/XL PROTECTION 92437145348,120.422,CDM,271,RC,,,,11378-MAIN,LOCAL,,,,,39,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,35.529,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
SLEEVE ACHILLES SM/MED PROTECTION 92437145324,120.422,CDM,271,RC,,,,11377-MAIN,LOCAL,,,,,39,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,35.529,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
Treponema Pallidum - Ref,PX8678090,CDM,300,RC,86780,CPT,90,,,,,,,39,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,35.529,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.14,38.22
TROCAR KII FIOS SYSTEM BLADELSS Z-THREAD 5MMX150MM,27200000,CDM,272,RC,,,,12827-MAIN,LOCAL,,,,,39,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,35.529,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409427617,NDC,50,ML,39.01,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,35.53811,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,703291401,NDC,0.5,EA,40.3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,35.5446,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Needle Biopsy,Muscle",PX20206F,CDM,510,RC,20206,CPT,,,,,,,,258,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,35.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.55,453.13
"Needle Biopsy,Muscle",PX20206F,CDM,510,RC,20206,CPT,,,,,,,,258,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,35.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.55,453.13
"Needle Biopsy,Muscle",PX20206P,CDM,983,RC,20206,CPT,,,,,,,,1028,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,35.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.55,1007.44
"Needle Biopsy,Muscle",PX20206P,CDM,983,RC,20206,CPT,,,,,,,,1028,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,35.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.55,1007.44
"Needle Biopsy,Muscle",PX20206F,CDM,510,RC,20206,CPT,,,,,,,,258,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,35.55,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.55,453.13
"Needle Biopsy,Muscle",PX20206P,CDM,983,RC,20206,CPT,,,,,,,,1028,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,35.55,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.55,1007.44
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457033900,NDC,1,EA,71.82,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,35.5509,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,409710709,NDC,1000,ML,36.53,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,4.559571429,percent of total billed charges,35.554649,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5% and sodium chloride 0.45% with potassium chloride 10 mEq in 1000 mL 10-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,264763400,NDC,1000,ML,36.53,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.554649,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409338513,NDC,1,EA,74.09,,Health Partners,Health Partners Care Plans,both,48,,6.796666667,percent of total billed charges,35.5632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409338513,NDC,1,EA,74.09,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,35.5632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
tiotropium 18 MCG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,597007541,NDC,1,EA,82.92,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,35.57268,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Apply Long Leg Splint,PX29505F,CDM,510,RC,29505,CPT,,,,,,,,320,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,35.58,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.28,190.25
Apply Long Leg Splint,PX29505P,CDM,983,RC,29505,CPT,,,,,,,,385,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,35.58,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.28,377.3
"Manual Ther Tech,1+Regions,Ea 15 Min",PX97140,CDM,420,RC,97140,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,35.58,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.47,35.58
"Manual Ther Tech,1+Regions,Ea 15 Min",PX97140,CDM,420,RC,97140,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,35.58,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.47,35.58
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022143,NDC,1,EA,36.31,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.5838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,25021012867,NDC,1,EA,82.96,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,35.58984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,55150020830,NDC,1,EA,82.96,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,35.58984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.461584,189.875
triamcinolone acetonide 40 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029320,NDC,1,ML,72.65,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,3.733333333,percent of total billed charges,35.5985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,72.0986
triamcinolone acetonide 40 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029320,NDC,1,ML,72.65,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,35.5985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,72.0986
triamcinolone acetonide 40 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029320,NDC,1,ML,72.65,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,35.5985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,72.0986
8MM-12MM TIP COVER ACCESSORY,27200000,CDM,272,RC,,,,11918-MAIN,LOCAL,,,,,40,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,35.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CATHETER URETERAL  5FR TIGERTAIL OPEN TIP FLEXIBLE 139005,27200000,CDM,272,RC,A4340,HCPCS,,12302-MAIN,LOCAL,,,,,40,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,35.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NEEDLE BIOPSY 14GAX4 1/2 2N2702X,120.211,CDM,272,RC,,,,724-MAIN,LOCAL,,,,,40,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,35.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.616,39.2
STAPLER CANNULA SEAL 12 mm 470380,27200000,CDM,272,RC,,,,11962-MAIN,LOCAL,,,,,40,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,35.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"SUTURE V-LOC 22G NEEDLE 9"" 180 GREEN VLOCL2145",27200000,CDM,272,RC,,,,11930-MAIN,LOCAL,,,,,40,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,35.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"SUTURE V-LOC SZ 0.9"" 180 GREEN GS-21 NEEDLE VLOCL0346",27200000,CDM,272,RC,,,,11933-MAIN,LOCAL,,,,,40,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,35.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Telehealth Origin Site Fac Fee,PXQ3014,CDM,780,RC,Q3014,HCPCS,,,,,,,,40,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,35.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.616,39.2
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022116,NDC,1,EA,36.33,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.6034,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022141,NDC,1,EA,36.33,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.6034,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,47781047013,NDC,1,EA,83,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,35.607,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,64380079901,NDC,1,EA,83,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,35.607,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,69238126601,NDC,1,EA,83,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,35.607,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SLING ARM CHILD PAD CANVAS NAVY 8004-02,120.54,CDM,273,RC,A4565,HCPCS,,878-MAIN,LOCAL,,,,,83,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,35.607,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM LARGE PAD CANVAS NAVY ORT11300L,120.54,CDM,273,RC,A4565,HCPCS,,870-MAIN,LOCAL,,,,,83,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,35.607,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM MEDIUM PAD CANVAS NAVY ORT11300M,120.54,CDM,273,RC,A4565,HCPCS,,872-MAIN,LOCAL,,,,,83,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,35.607,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM SMALL PAD CANVAS NAVY ORT11300S,120.54,CDM,273,RC,A4565,HCPCS,,874-MAIN,LOCAL,,,,,83,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,35.607,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM X-LARGE PAD ENVELOPE ORT11300XL,120.54,CDM,273,RC,A4565,HCPCS,,876-MAIN,LOCAL,,,,,83,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,35.607,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
brimonidine 0.2 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,70069023101,NDC,5,ML,70.38,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,35.61228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
enalaprilat 1.25 MG/ML Injectable 1 mL Vial,25000000,CDM,250,RC,,,,,,143978701,NDC,1,ML,40.39,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,35.62398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"IV Push, Single/1st Drug",PX96374,CDM,260,RC,96374,CPT,,,,,,,,259,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,35.631,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.21,63.99
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733513,NDC,1,EA,39.12,,Medica,Commercial,both,91.1,,6.892980769,percent of total billed charges,35.63832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
"B.Burgdorferi, Amp Probe - Ref",PX8747690,CDM,300,RC,87476,CPT,90,,,,,,,72,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,35.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.9088,70.56
"Blood, Occult, Other Sources",PX82271,CDM,300,RC,82271,CPT,,,,,,,,72,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,35.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.88,70.56
Epstein-barr antibody,PX86664,CDM,300,RC,86664,CPT,,,,,,,,72,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,35.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.02,70.56
ePHEDrine sulfate 50 MG/ML Solution 1 mL Vial,25000000,CDM,250,RC,,,,,,42023021689,NDC,0.1,ML,36.62,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.642246,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
levoFLOXacin 750 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635361,NDC,0.333333333,EA,39.14,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,35.65654,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028002,NDC,1,ML,40.43,,United Healthcare,All Payer,outpatient,88.2,,8.0425,percent of total billed charges,35.65926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094310,NDC,10,ML,72.79,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1.188333333,percent of total billed charges,35.6671,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.236966,143.9032
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094310,NDC,10,ML,72.79,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,35.6671,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.236966,143.9032
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094310,NDC,10,ML,72.79,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,35.6671,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.236966,143.9032
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094321,NDC,10,ML,72.79,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1.188333333,percent of total billed charges,35.6671,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.236966,143.9032
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094321,NDC,10,ML,72.79,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,35.6671,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.236966,143.9032
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094321,NDC,10,ML,72.79,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,35.6671,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.236966,143.9032
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253033335,NDC,5,ML,40.44,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,35.66808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
"SUTURE ETHIBOND #0 CT-1 CR 8-18"" CX21D",27200000,CDM,272,RC,,,,6415-MAIN,LOCAL,,,,,41.97,,First Health,Commercial,both,85,,999999999,percent of total billed charges,35.6745,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760,CDM,420,RC,97760,CPT,,,,,,,,142,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,35.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.1,62.82
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760,CDM,420,RC,97760,CPT,,,,,,,,142,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,35.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.1,62.82
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760F,CDM,510,RC,97760,CPT,,,,,,,,142,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,35.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.1,62.82
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760F,CDM,510,RC,97760,CPT,,,,,,,,142,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,35.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.1,62.82
Actin Antibody Each,PX8601590,CDM,300,RC,86015,CPT,90,,,,,,,42,,First Health,Commercial,both,85,,999999999,percent of total billed charges,35.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.05,41.16
Assay Vitamin B-6,PX84207,CDM,300,RC,84207,CPT,90,,,,,,,42,,First Health,Commercial,both,85,,999999999,percent of total billed charges,35.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
"BOUGIE TRACH 10FR 70CM COUDE 	9-0211-70",120.199,CDM,272,RC,A7520,HCPCS,,11112-MAIN,LOCAL,,,,,42,,First Health,Commercial,both,85,,999999999,percent of total billed charges,35.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
BOUGIE TRACHEAL TUBE & GUIDE 100123515,120.199,CDM,272,RC,A7520,HCPCS,,8950-MAIN,LOCAL,,,,,42,,First Health,Commercial,both,85,,999999999,percent of total billed charges,35.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
CATHETER PUREWICK FEMALE EXTERNAL PWF030K,120.414,CDM,272,RC,A6590,HCPCS,,11836-MAIN,LOCAL,,,,,42,,First Health,Commercial,both,85,,999999999,percent of total billed charges,35.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
Culture Type Immunologic,PX87147,CDM,300,RC,87147,CPT,,,,,,,,42,,First Health,Commercial,both,85,,999999999,percent of total billed charges,35.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,41.16
EZ-STABILIZER DRESSING,120.415,CDM,272,RC,,,,9058-MAIN,LOCAL,,,,,42,,First Health,Commercial,both,85,,999999999,percent of total billed charges,35.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
MEPILEX AG FOAM 4X4,120.192,CDM,272,RC,A6213,HCPCS,,8480-MAIN,LOCAL,,,,,42,,First Health,Commercial,both,85,,999999999,percent of total billed charges,35.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
MEPILEX AG FOAM 4X8,120.192,CDM,272,RC,A6213,HCPCS,,8479-MAIN,LOCAL,,,,,42,,First Health,Commercial,both,85,,999999999,percent of total billed charges,35.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY CENTRAL LINE DRESSING WITH CHLORAPREP DYND75234,120.68,CDM,272,RC,,,,10923-MAIN,LOCAL,,,,,42,,First Health,Commercial,both,85,,999999999,percent of total billed charges,35.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY FOLEY 14FR CATHETER A300414A,120.414,CDM,272,RC,A4344,HCPCS,,11281-MAIN,LOCAL,,,,,42,,First Health,Commercial,both,85,,999999999,percent of total billed charges,35.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY FOLEY 16FR CATHETER 300416A,120.414,CDM,272,RC,A4344,HCPCS,,11774-MAIN,LOCAL,,,,,42,,First Health,Commercial,both,85,,999999999,percent of total billed charges,35.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
"TRAY SPINAL  25GX3.5"" WITH WHITEACRE 405671",120.275,CDM,272,RC,,,,3284-MAIN,LOCAL,,,,,42,,First Health,Commercial,both,85,,999999999,percent of total billed charges,35.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY SPINAL 25G ANESTH SADDLE BLOCK NLD-4795-20,120.275,CDM,272,RC,,,,935-MAIN,LOCAL,,,,,42,,First Health,Commercial,both,85,,999999999,percent of total billed charges,35.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143998391,NDC,1,EA,83.25,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,35.71425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
leucovorin 10 mg/mL Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,25021081467,NDC,1,EA,40.13,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,35.7157,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.670002,84.6818
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409751716,NDC,50,ML,72.9,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,35.721,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409751716,NDC,50,ML,72.9,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,35.721,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409751716,NDC,50,ML,72.9,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,35.721,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Aldosterone - Ref,PX8208890,CDM,300,RC,82088,CPT,90,,,,,,,86,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,35.7244,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.7244,84.28
Epstein-barr antibody,PX86665,CDM,300,RC,86665,CPT,,,,,,,,86,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,35.7244,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.63,84.28
SAWBLADE SAGITAL STERILE 25MM LENGTH 5.5MM WIDTH 0.60MM THICKNESS,27200000,CDM,272,RC,,,,11623-MAIN,LOCAL,,,,,86.02,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,35.732708,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,487960130,NDC,2,ML,36.47,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.7406,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
penicillin v potassium 250 MG/5ML Recon Soln 200 mL Bottle,63700001,CDM,250,RC,,,,,,93412774,NDC,200,ML,83.32,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,35.74428,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098121,NDC,1,EA,72.95,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,14.99111111,percent of total billed charges,35.7455,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098121,NDC,1,EA,72.95,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,35.7455,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098121,NDC,1,EA,72.95,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,35.7455,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001001,NDC,1.5,ML,40.17,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,35.7513,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,42.5516
fluconazole 150 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,16714069210,NDC,1,EA,72.98,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,35.7602,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluconazole 150 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,16714069210,NDC,1,EA,72.98,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,35.7602,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluconazole 150 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,16714069210,NDC,1,EA,72.98,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,35.7602,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078121,NDC,0.5,EA,36.75,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.768775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078141,NDC,0.5,EA,36.75,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.768775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
solifenacin 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50228042730,NDC,1,EA,74.52,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,35.7696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
solifenacin 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50228042730,NDC,1,EA,74.52,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,35.7696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BALLOON EXTRACTOR PEDS,120.358,CDM,272,RC,,,,10771-MAIN,LOCAL,,,,,73,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,35.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.3242,71.54
BALLOON EXTRACTOR PEDS,120.358,CDM,272,RC,,,,10771-MAIN,LOCAL,,,,,73,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,35.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.3242,71.54
BALLOON EXTRACTOR PEDS,120.358,CDM,272,RC,,,,10771-MAIN,LOCAL,,,,,73,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,35.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.3242,71.54
"Chemotherapy, IV Push, Additional Drug",PX96411,CDM,335,RC,96411,CPT,,,,,,,,87,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,35.77,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.77,94.82
"Chemotherapy, IV Push, Additional Drug",PX96411,CDM,335,RC,96411,CPT,,,,,,,,87,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,35.77,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.77,94.82
"Chemotherapy, IV Push, Additional Drug",PX96411,CDM,335,RC,96411,CPT,,,,,,,,87,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,35.77,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.77,94.82
Therapeutic Activities,PX97530,CDM,420,RC,97530,CPT,,,,,,,,135,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,35.7864,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.68,48.32
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,641601310,NDC,5,ML,40.58,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,35.79156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707426,NDC,100,ML,39.29,,Medica,Commercial,both,91.1,,1.111818182,percent of total billed charges,35.79319,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,409710709,NDC,1000,ML,36.53,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.7994,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5% and sodium chloride 0.45% with potassium chloride 10 mEq in 1000 mL 10-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,264763400,NDC,1000,ML,36.53,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.7994,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
skin oil Oil 236.6 mL Bottle,63700001,CDM,250,RC,,,,,,67211008,NDC,236.6,ML,40.61,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,35.81802,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036019,NDC,10,ML,86.23,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,35.819942,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,84.5054
TRAY IV SURGICAL EXTREMITY DYNJS0804,27200000,CDM,272,RC,,,,10919-MAIN,LOCAL,,,,,83.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,35.8215,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Syringe,J7040.01,CDM,636,RC,J7040,HCPCS,,,,64253020230,NDC,10,ML,42.15,,First Health,Commercial,both,85,,999999999,percent of total billed charges,35.8275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028426,NDC,1,EA,42.15,,First Health,Commercial,both,85,,999999999,percent of total billed charges,35.8275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
dextrose 25% Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409177510,NDC,10,ML,83.53,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,35.83437,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
DULoxetine 30 MG Capsule Delayed Release Particles 90 Each Bottle,63700001,CDM,250,RC,,,,,,57237001890,NDC,1,EA,42.17,,First Health,Commercial,both,85,,999999999,percent of total billed charges,35.8445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,703291401,NDC,0.5,EA,40.3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,35.867,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,17478070311,NDC,10,ML,72.46,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,35.8677,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037604,NDC,0.75,ML,36.86,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,35.875838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046203,NDC,30,ML,70.91,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,35.88046,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ePHEDrine sulfate 50 MG/ML Solution 1 mL Vial,25000000,CDM,250,RC,,,,,,42023021689,NDC,0.1,ML,36.62,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,35.8876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
riTUXimab-abbs 500 MG/50ML Solution 50 mL Vial,Q5115.01,CDM,636,RC,Q5115,HCPCS,,,,63459010450,NDC,50,ML,8624.61,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,35.89,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.4,35.89
leucovorin 350 MG Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,703514501,NDC,1,EA,86.41,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,35.894714,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.670002,84.6818
hydrOXYzine 50 MG/ML Solution 1 mL Vial,J3410.01,CDM,636,RC,J3410,HCPCS,,,,517560125,NDC,0.5,ML,83.68,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,35.89872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.760672,82.0064
RETRIEVAL BAG 10MM,27200000,CDM,272,RC,,,,11707-MAIN,LOCAL,,,,,74.8,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,35.904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RETRIEVAL BAG 10MM,27200000,CDM,272,RC,,,,11707-MAIN,LOCAL,,,,,74.8,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,35.904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
atropine 1 mg/mL Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100101,NDC,0.2,ML,39.42,,Medica,Commercial,both,91.1,,1.63075,percent of total billed charges,35.91162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
TRAY SURGICAL PODIATRY II EXTREMITY DYNJS0803,27200000,CDM,272,RC,,,,10920-MAIN,LOCAL,,,,,73.29,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,35.9121,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TRAY SURGICAL PODIATRY II EXTREMITY DYNJS0803,27200000,CDM,272,RC,,,,10920-MAIN,LOCAL,,,,,73.29,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,35.9121,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TRAY SURGICAL PODIATRY II EXTREMITY DYNJS0803,27200000,CDM,272,RC,,,,10920-MAIN,LOCAL,,,,,73.29,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,35.9121,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Gabapentin - Ref,PX8017190,CDM,300,RC,80171,CPT,90,,,,,,,71,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,35.926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.87,69.58
Histoplasma Antibody - Ref,PX8669890,CDM,300,RC,86698,CPT,90,,,,,,,71,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,35.926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.64,69.58
Legionella Antibody - Ref,PX8671390,CDM,300,RC,86713,CPT,90,,,,,,,71,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,35.926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.03,69.58
gemcitabine 200 MG/5.26ML Solution 5.26 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018301,NDC,5.26,ML,40.74,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,35.93268,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
SUCTION TIP POOLE STERILE 35040,27200000,CDM,272,RC,,,,977-MAIN,LOCAL,,,,,42.28,,First Health,Commercial,both,85,,999999999,percent of total billed charges,35.938,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,63739005007,NDC,1,EA,73.35,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,35.9415,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,63739005007,NDC,1,EA,73.35,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,35.9415,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,63739005007,NDC,1,EA,73.35,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,35.9415,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 1 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409128303,NDC,1,ML,36.93,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,15.571,percent of total billed charges,35.943969,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490334,NDC,5,ML,42.29,,First Health,Commercial,both,85,,999999999,percent of total billed charges,35.9465,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
tetracycline 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,51991090701,NDC,0.5,EA,42.29,,First Health,Commercial,both,85,,999999999,percent of total billed charges,35.9465,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
enalaprilat 1.25 MG/ML Injectable 1 mL Vial,25000000,CDM,250,RC,,,,,,143978701,NDC,1,ML,40.39,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,35.9471,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
HH Pta Routine Visit,PXG0157,CDM,421,RC,G0157,HCPCS,,,,,,,,,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,35.95,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.95,35.95
ursodiol 300 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,591315901,NDC,1,EA,39.47,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,35.95717,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
triamcinolone acetonide 40 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029320,NDC,1,ML,72.65,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,35.96175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,72.0986
Naso/Orogastric Tube,PX43752F,CDM,510,RC,43752,CPT,,,,,,,,464,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,35.9632,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.21,81.63
Naso/Orogastric Tube,PX43752P,CDM,983,RC,43752,CPT,,,,,,,,309,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,35.9632,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.21,302.82
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,55150016205,NDC,5,ML,42.32,,First Health,Commercial,both,85,,999999999,percent of total billed charges,35.972,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028002,NDC,1,ML,40.43,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,35.9827,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
FLEXITIP APPLICATOR 38CM,27200000,CDM,272,RC,,,,10200-MAIN,LOCAL,,,,,40.8,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,35.9856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
silver sulfADIAZINE 1 % Cream 50 g Jar,25000000,CDM,250,RC,,,,,,43598021055,NDC,50,GR,83.89,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,35.98881,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Biopsy Vulva/Perineum,One Lesn",PX56605F,CDM,510,RC,56605,CPT,,,,,,,,236,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,35.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.99,201.31
"Biopsy Vulva/Perineum,One Lesn",PX56605F,CDM,510,RC,56605,CPT,,,,,,,,236,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,35.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.99,201.31
"Biopsy Vulva/Perineum,One Lesn",PX56605F,CDM,510,RC,56605,CPT,,,,,,,,236,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,35.99,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.99,201.31
"Biopsy Vulva/Perineum,One Lesn",PX56605P,CDM,983,RC,56605,CPT,,,,,,,,142,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,35.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.99,201.31
"Biopsy Vulva/Perineum,One Lesn",PX56605P,CDM,983,RC,56605,CPT,,,,,,,,142,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,35.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.99,201.31
"Biopsy Vulva/Perineum,One Lesn",PX56605P,CDM,983,RC,56605,CPT,,,,,,,,142,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,35.99,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.99,201.31
"Ileoscopy Thru Stoma,Diagnostic",PX44380F,CDM,750,RC,44380,CPT,,,,,,,,245,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,35.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.12,408.85
"Ileoscopy Thru Stoma,Diagnostic",PX44380F,CDM,750,RC,44380,CPT,,,,,,,,245,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,35.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.12,408.85
"Ileoscopy Thru Stoma,Diagnostic",PX44380P,CDM,983,RC,44380,CPT,,,,,,,,455,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,35.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.12,445.9
"Ileoscopy Thru Stoma,Diagnostic",PX44380P,CDM,983,RC,44380,CPT,,,,,,,,455,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,35.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.12,445.9
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253033335,NDC,5,ML,40.44,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,35.9916,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
Assay Cryofibrinogen,PX82585,CDM,300,RC,82585,CPT,,,,,,,,75,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.96,73.5
Assay Cryofibrinogen,PX82585,CDM,300,RC,82585,CPT,,,,,,,,75,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.96,73.5
Assay Cryoglobulin,PX82595,CDM,300,RC,82595,CPT,,,,,,,,75,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,73.5
Assay Cryoglobulin,PX82595,CDM,300,RC,82595,CPT,,,,,,,,75,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,73.5
Assay of Natriuretic Peptide,PX83880,CDM,300,RC,83880,CPT,,,,,,,,290,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36,284.2
BINDER ABDOMINAL 9 INCH 46 TO 62 INCH XL ORT21100LXL,120.238,CDM,271,RC,A4467,HCPCS,,2989-MAIN,LOCAL,,,,,75,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL 9 INCH 46 TO 62 INCH XL ORT21100LXL,120.238,CDM,271,RC,A4467,HCPCS,,2989-MAIN,LOCAL,,,,,75,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL 9 INCH 63 TO 74 INCH 3- PANEL ORT211002XL,120.238,CDM,271,RC,A4467,HCPCS,,37-MAIN,LOCAL,,,,,75,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL 9 INCH 63 TO 74 INCH 3- PANEL ORT211002XL,120.238,CDM,271,RC,A4467,HCPCS,,37-MAIN,LOCAL,,,,,75,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL 10 INCH 26 TO 50 INCHES ABB1050,120.238,CDM,271,RC,A4467,HCPCS,,52-MAIN,LOCAL,,,,,75,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL 10 INCH 26 TO 50 INCHES ABB1050,120.238,CDM,271,RC,A4467,HCPCS,,52-MAIN,LOCAL,,,,,75,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
"BINDER ABDOMINAL 12"" HIGH 2XL 60-75INCH 4 PANEL ORT213002XL",120.238,CDM,271,RC,A4467,HCPCS,,12536-MAIN,LOCAL,,,,,75,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
"BINDER ABDOMINAL 12"" HIGH 2XL 60-75INCH 4 PANEL ORT213002XL",120.238,CDM,271,RC,A4467,HCPCS,,12536-MAIN,LOCAL,,,,,75,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL UNISIZE 46-62IN 9 IN MDS169024,120.238,CDM,271,RC,A4467,HCPCS,,63-MAIN,LOCAL,,,,,75,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL UNISIZE 46-62IN 9 IN MDS169024,120.238,CDM,271,RC,A4467,HCPCS,,63-MAIN,LOCAL,,,,,75,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
"Direct skilled nursing services of a license practical nurse (lpn) in the home health or hospice setting, each 15 minutes",PXG0300,CDM,551,RC,G0300,HCPCS,,,,,,,,75,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
"Direct skilled nursing services of a license practical nurse (lpn) in the home health or hospice setting, each 15 minutes",PXG0300,CDM,551,RC,G0300,HCPCS,,,,,,,,75,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
HH Rn Initial Visit,PXG0154,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
HH Rn Initial Visit,PXG0154,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
HH Rn Routine Visit,PXG0154.01,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
HH Rn Routine Visit,PXG0154.01,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
Skilled Srvc of a Lpn in Training and/or Education of Pt or Fam Ea 15 Min,PXG0496,CDM,551,RC,G0496,HCPCS,,,,,,,,75,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
Skilled Srvc of a Lpn in Training and/or Education of Pt or Fam Ea 15 Min,PXG0496,CDM,551,RC,G0496,HCPCS,,,,,,,,75,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
Skilled srvc of an RN in training and/or education of pt or fam ea 15 min,PXG0495,CDM,551,RC,G0495,HCPCS,,,,,,,,75,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
Skilled srvc of an RN in training and/or education of pt or fam ea 15 min,PXG0495,CDM,551,RC,G0495,HCPCS,,,,,,,,75,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
COLLAR CERVICAL LARGE WITH TRACH 2 PIECE PHP-T4L,120.184,CDM,274,RC,L0172,HCPCS,,10142-MAIN,LOCAL,,,,,37,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,7,percent of total billed charges,36.0121,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.3698,152.79
COLLAR CERVICAL MEDIUM WITH TRACH 2 PIECE PHP-T4M,120.183,CDM,274,RC,L0172,HCPCS,,10141-MAIN,LOCAL,,,,,37,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,7,percent of total billed charges,36.0121,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.3698,152.79
COLLAR CERVICAL SMALL WITH TRACH 2 PIECE PHP-T4S,120.182,CDM,274,RC,L0172,HCPCS,,10140-MAIN,LOCAL,,,,,37,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,7,percent of total billed charges,36.0121,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.3698,152.79
SUTURE TICRON 0 36IN BRAIDED DYED 1/2 CIRCLE DBLE ARM 25MM CV-305 BLUE STERILE,27200000,CDM,272,RC,,,,11956-MAIN,LOCAL,,,,,37,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,36.0121,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078121,NDC,0.5,EA,36.75,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,36.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078141,NDC,0.5,EA,36.75,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,36.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
CATHETER TEMP-SENSING 8FR LUBRISIL PEDS DYND110508,120.363,CDM,272,RC,A4340,HCPCS,,12777-MAIN,LOCAL,,,,,45,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,36.0304,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.98,36.82
CATHETER TEMP-SENSING 12FR LUBRISIL 119212M,120.363,CDM,272,RC,A4340,HCPCS,,10750-MAIN,LOCAL,,,,,45,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,36.0304,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.98,36.82
CATHETER TEMP-SENSING 14FR LUBRISIL 119214M,120.363,CDM,272,RC,A4340,HCPCS,,10751-MAIN,LOCAL,,,,,45,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,36.0304,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.98,36.82
CATHETER TEMP-SENSING 16FR LUBRISIL 119216M,120.363,CDM,272,RC,A4340,HCPCS,,10752-MAIN,LOCAL,,,,,45,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,36.0304,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.98,36.82
CATHETER URETERAL  5FR TIGERTAIL OPEN TIP FLEXIBLE 139005,27200000,CDM,272,RC,A4340,HCPCS,,12302-MAIN,LOCAL,,,,,40,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,36.0304,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094310,NDC,10,ML,72.79,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,36.03105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.236966,143.9032
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094321,NDC,10,ML,72.79,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,36.03105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.236966,143.9032
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,17478004001,NDC,1,ML,42.39,,First Health,Commercial,both,85,,999999999,percent of total billed charges,36.0315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
CANNULA OPTIFLOW JUNIOR2+ XXL OJR520,120.494,CDM,271,RC,A4615,HCPCS,,11619-MAIN,LOCAL,,,,,84,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,36.036,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.8936,82.32
Hiaa - Ref,PX8349790,CDM,300,RC,83497,CPT,90,,,,,,,84,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,36.036,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.83,82.32
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505615204,NDC,0.5,EA,86.76,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,36.040104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
Xray Knee 4 or More Vws,PX7356401,CDM,320,RC,73564,CPT,TC,,,,,,,490,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,36.0416,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.56,71.66
bisoprolol-hydroCHLOROthiazide 5-6.25 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,42799092102,NDC,1,EA,39.57,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,36.04827,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
triamcinolone acetonide 40 MG/ML Suspension 1 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029305,NDC,1,ML,73.57,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,3.733333333,percent of total billed charges,36.0493,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,72.0986
triamcinolone acetonide 40 MG/ML Suspension 1 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029305,NDC,1,ML,73.57,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,36.0493,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,72.0986
triamcinolone acetonide 40 MG/ML Suspension 1 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029305,NDC,1,ML,73.57,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,36.0493,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,72.0986
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001302,NDC,2,ML,86.79,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,36.052566,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049257,NDC,5,ML,42.43,,First Health,Commercial,both,85,,999999999,percent of total billed charges,36.0655,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Admin Hep B,Adult 19+",PX3242,CDM,771,RC,90471,CPT,,,,,,,,48,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,36.07,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.09,36.07
"Admin Hep B,Adult 19+",PX3242,CDM,771,RC,90471,CPT,,,,,,,,48,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,36.07,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.09,36.07
Immunization Admin - Influenza,PX3241,CDM,771,RC,90471,CPT,,,,,,,,48,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,36.07,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.09,36.07
Immunization Admin - Influenza,PX3241,CDM,771,RC,90471,CPT,,,,,,,,48,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,36.07,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.09,36.07
Immunization Administration; One Vaccine (Single or Combination Vaccine/To*,PX90471,CDM,771,RC,90471,CPT,,,,,,,,130,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,36.07,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.09,36.07
Immunization Administration; One Vaccine (Single or Combination Vaccine/To*,PX90471,CDM,771,RC,90471,CPT,,,,,,,,130,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,36.07,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.09,36.07
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409751716,NDC,50,ML,72.9,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,36.0855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
infuvite adult Injectable 10 mL Vial,J3490.99,CDM,636,RC,J3490,HCPCS,,,,54643564901,NDC,10,ML,86.89,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,36.094106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.094106,85.1522
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070548,NDC,100,ML,40.94,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,36.10908,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098121,NDC,1,EA,72.95,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,36.11025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,641601310,NDC,5,ML,40.58,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,36.1162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
magnesium sulfate 4 GM/50ML Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010701,NDC,50,ML,73.72,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,5.851071429,percent of total billed charges,36.1228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
magnesium sulfate 4 GM/50ML Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010701,NDC,50,ML,73.72,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,36.1228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
magnesium sulfate 4 GM/50ML Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010701,NDC,50,ML,73.72,,United Healthcare,All Medicare advantage plans,outpatient,49,,13.925,percent of total billed charges,36.1228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037604,NDC,0.75,ML,36.86,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,36.1228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
ketorolac 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314012605,NDC,5,ML,42.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,36.125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fluconazole 150 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,16714069210,NDC,1,EA,72.98,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,36.1251,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Lab Antibody ID,RBC",PX7605,CDM,300,RC,86870,CPT,,,,,,,,155,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,36.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.13,60.672
"Lab Antibody ID,RBC",PX7605,CDM,300,RC,86870,CPT,,,,,,,,155,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,36.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.13,60.672
"Lab Antibody ID,RBC",PX7605,CDM,300,RC,86870,CPT,,,,,,,,155,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,36.13,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.13,60.672
BALLOON EXTRACTOR PEDS,120.358,CDM,272,RC,,,,10771-MAIN,LOCAL,,,,,73,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,36.135,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.3242,71.54
"Chemotherapy, IV Push, Additional Drug",PX96411,CDM,335,RC,96411,CPT,,,,,,,,87,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,36.1398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.1398,85.26
skin oil Oil 236.6 mL Bottle,63700001,CDM,250,RC,,,,,,67211008,NDC,236.6,ML,40.61,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,36.1429,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
anastrozole 1 MG Tablet 30 Each Bottle,25000000,CDM,250,RC,,,,,,16729003510,NDC,1,EA,71.44,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,36.14864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
C Diff Amplified Probe,PX87493,CDM,300,RC,87493,CPT,,,,,,,,179,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,36.15,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.15,37.27
C Diff Amplified Probe,PX87493,CDM,300,RC,87493,CPT,,,,,,,,179,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,36.15,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.15,37.27
C Diff Amplified Probe,PX87493,CDM,300,RC,87493,CPT,,,,,,,,179,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,36.15,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.15,37.27
omalizumab 150 MG Recon Soln 1 Each Vial,J2357.01,CDM,636,RC,J2357,HCPCS,,,,50242004062,NDC,1,EA,2212.7,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,36.15908,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.18,39.46
CANNULA SEAL 5-12MM UNIVERSAL 470500,27200000,CDM,272,RC,,,,12885-MAIN,LOCAL,,,,,41,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,36.162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CUP HEEL LARGE WONDERSPUR 4502,120.43,CDM,274,RC,L3485,HCPCS,,11385-MAIN,LOCAL,,,,,41,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,36.162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL MEDIUM WONDERSPUR 4501,120.43,CDM,274,RC,L3485,HCPCS,,11384-MAIN,LOCAL,,,,,41,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,36.162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL SMALL WONDERSPUR 4500,120.43,CDM,274,RC,L3485,HCPCS,,11383-MAIN,LOCAL,,,,,41,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,36.162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL XL WONDERSPUR 4503,120.43,CDM,274,RC,L3485,HCPCS,,11386-MAIN,LOCAL,,,,,41,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,36.162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
Detection of Anaplasma Phagocytophilum by Amplified Nucleic Acid Probe Technique,PX8746890,CDM,300,RC,87468,CPT,90,,,,,,,41,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,36.162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
Detection of Ehrlichia Chaffeensis by Amplified Nucleic Acid Probe Technique,PX8748490,CDM,300,RC,87484,CPT,90,,,,,,,41,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,36.162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 21G 110MM SONOTAP II WITH FACET TIP 1285-3F110,120.483,CDM,271,RC,A4215,HCPCS,,12201-MAIN,LOCAL,,,,,41,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,36.162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 21G X 4IN (100MM) SONOBLOCK II NERVE BLOCK WITH FACET S TIP 001281-77,120.483,CDM,271,RC,A4215,HCPCS,,12761-MAIN,LOCAL,,,,,41,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,36.162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 22G 80MM SONOTAP II WITH FACET TIP 1285-3E080,120.483,CDM,271,RC,A4215,HCPCS,,12103-MAIN,LOCAL,,,,,41,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,36.162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 22G X 3.25IN (80MM) SONOBLOCK II  NERVE BLOCK WITH FACET S TIP 001281-71,120.483,CDM,271,RC,A4215,HCPCS,,12760-MAIN,LOCAL,,,,,41,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,36.162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 22GX2 SONOPLEX II WITH FACET S TIP 001287-74,120.483,CDM,271,RC,A4215,HCPCS,,13110-MAIN,LOCAL,,,,,41,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,36.162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE NON-STIMULATING 22GX2 SONOBLOCK II WITH FACET S TIP 001281-74,120.483,CDM,271,RC,A4215,HCPCS,,11459-MAIN,LOCAL,,,,,41,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,36.162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE SONOPLEX II STIMULATING WITH FACET S TIP 22GX3-1/4,120.483,CDM,271,RC,A4215,HCPCS,,11457-MAIN,LOCAL,,,,,41,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,36.162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE STIMULATING 21GX4  SONOPLEX II  WITH FACET S TIP 001287-77,120.483,CDM,271,RC,A4215,HCPCS,,11458-MAIN,LOCAL,,,,,41,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,36.162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
STRAP FOOT LG/XL GEL UNIVERSAL 10165,120.428,CDM,271,RC,,,,11382-MAIN,LOCAL,,,,,41,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,36.162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
STRAP FOOT SM/MED GEL UNIVERSAL 10155,120.428,CDM,271,RC,,,,11381-MAIN,LOCAL,,,,,41,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,36.162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
SUTURE V-LOC SZ 1/2 180 GREEN GS-21 VLOCL0316,27200000,CDM,272,RC,,,,11932-MAIN,LOCAL,,,,,41,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,36.162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
URGOK2 DUAL COMPRESSION SYSTEM LARGE,120.491,CDM,271,RC,A6452,HCPCS,,11871-MAIN,LOCAL,,,,,41,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,36.162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
URGOK2 DUAL COMPRESSION SYSTEM REGULAR,120.491,CDM,271,RC,A6452,HCPCS,,11870-MAIN,LOCAL,,,,,41,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,36.162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
mycophenolate 500 MG Tablet 100 Each Bottle,J7517.01,CDM,637,RC,J7517,HCPCS,,,,64380072506,NDC,1,EA,42.56,,First Health,Commercial,both,85,,999999999,percent of total billed charges,36.176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.679424,41.7088
caffeine citrate 60 MG/3ML Solution 3 mL Vial,J0706.01,CDM,636,RC,J0706,HCPCS,,,,63323040704,NDC,3,ML,73.84,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,36.1816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.673136,72.3632
caffeine citrate 60 MG/3ML Solution 3 mL Vial,J0706.01,CDM,636,RC,J0706,HCPCS,,,,63323040704,NDC,3,ML,73.84,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,36.1816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.673136,72.3632
caffeine citrate 60 MG/3ML Solution 3 mL Vial,J0706.01,CDM,636,RC,J0706,HCPCS,,,,63323040704,NDC,3,ML,73.84,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,36.1816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.673136,72.3632
Ex for Speech Device Rx Addl,PX92608,CDM,444,RC,92608,CPT,,,,,,,,160,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,36.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.86,84.93
Ex for Speech Device Rx Addl,PX92608,CDM,444,RC,92608,CPT,,,,,,,,160,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,36.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.86,84.93
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,409508411,NDC,1,EA,73.86,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,36.1914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,409508411,NDC,1,EA,73.86,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,36.1914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,409508411,NDC,1,EA,73.86,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,36.1914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
HYDROmorphone 1 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409128303,NDC,1,ML,36.93,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,36.1914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600701,NDC,10,ML,39.73,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,36.19403,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,38.9354
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070948,NDC,100,ML,42.59,,First Health,Commercial,both,85,,999999999,percent of total billed charges,36.2015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
atropine (PF) 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517040125,NDC,1,ML,71.55,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,36.2043,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
tetracaine 0.5 % Solution 4 mL Plas Cont,25000000,CDM,250,RC,,,,,,65074114,NDC,4,ML,71.55,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,36.2043,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611F,CDM,510,RC,20611,CPT,,,,,,,,456,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,36.21,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.21,206.85
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611F,CDM,510,RC,20611,CPT,,,,,,,,456,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,36.21,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.21,206.85
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611P,CDM,983,RC,20611,CPT,,,,,,,,272,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,36.21,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.21,266.56
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611P,CDM,983,RC,20611,CPT,,,,,,,,272,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,36.21,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.21,266.56
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004703,NDC,1,EA,75.45,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,36.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004703,NDC,1,EA,75.45,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,36.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
droPERidol 2.5 MG/ML Solution 2 mL Vial,J1790.01,CDM,636,RC,J1790,HCPCS,,,,517970201,NDC,2,ML,75.47,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,36.2256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.350238,73.9606
droPERidol 2.5 MG/ML Solution 2 mL Vial,J1790.01,CDM,636,RC,J1790,HCPCS,,,,517970201,NDC,2,ML,75.47,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,36.2256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.350238,73.9606
timolol 0.25 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314022605,NDC,5,ML,84.45,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,36.22905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,70860030143,NDC,25,ML,84.47,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,36.23763,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010626,NDC,50,ML,84.47,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,36.23763,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
sodium bicarbonate 8.4 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409662502,NDC,50,ML,84.47,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,36.23763,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323048201,NDC,10,ML,39.78,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,36.23958,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323048217,NDC,10,ML,39.78,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,36.23958,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
gemcitabine 200 MG/5.26ML Solution 5.26 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018301,NDC,5.26,ML,40.74,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,36.2586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046837,NDC,30,ML,75.54,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,36.2592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046837,NDC,30,ML,75.54,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,36.2592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
COLLAR CERVICAL LARGE WITH TRACH 2 PIECE PHP-T4L,120.184,CDM,274,RC,L0172,HCPCS,,10142-MAIN,LOCAL,,,,,37,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,36.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.3698,152.79
COLLAR CERVICAL MEDIUM WITH TRACH 2 PIECE PHP-T4M,120.183,CDM,274,RC,L0172,HCPCS,,10141-MAIN,LOCAL,,,,,37,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,36.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.3698,152.79
COLLAR CERVICAL SMALL WITH TRACH 2 PIECE PHP-T4S,120.182,CDM,274,RC,L0172,HCPCS,,10140-MAIN,LOCAL,,,,,37,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,36.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.3698,152.79
Glucose Test,PX82950,CDM,300,RC,82950,CPT,,,,,,,,74,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,36.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.36,72.52
Glucose Test,PX82950,CDM,300,RC,82950,CPT,,,,,,,,74,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,36.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.36,72.52
Glucose Test,PX82950,CDM,300,RC,82950,CPT,,,,,,,,74,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,36.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.36,72.52
KIT EMERGENCY BIRTH DYNJS0600,120.317,CDM,272,RC,,,,8344-MAIN,LOCAL,,,,,74,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,36.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.7396,72.52
KIT EMERGENCY BIRTH DYNJS0600,120.317,CDM,272,RC,,,,8344-MAIN,LOCAL,,,,,74,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,36.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.7396,72.52
KIT EMERGENCY BIRTH DYNJS0600,120.317,CDM,272,RC,,,,8344-MAIN,LOCAL,,,,,74,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,36.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.7396,72.52
Rubeola Antibody,PX86765,CDM,300,RC,86765,CPT,,,,,,,,74,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,36.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.81,72.52
Rubeola Antibody,PX86765,CDM,300,RC,86765,CPT,,,,,,,,74,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,36.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.81,72.52
Rubeola Antibody,PX86765,CDM,300,RC,86765,CPT,,,,,,,,74,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,36.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.81,72.52
SUTURE TICRON 0 36IN BRAIDED DYED 1/2 CIRCLE DBLE ARM 25MM CV-305 BLUE STERILE,27200000,CDM,272,RC,,,,11956-MAIN,LOCAL,,,,,37,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,36.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TRAY SURGICAL PODIATRY II EXTREMITY DYNJS0803,27200000,CDM,272,RC,,,,10920-MAIN,LOCAL,,,,,73.29,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,36.27855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
dabigatran 75 MG capsule 60 Each Box,63700001,CDM,250,RC,,,,,,597014960,NDC,1,EA,39.83,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,36.28513,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
TROCAR KII BALLOON 12MM STERILE,27200000,CDM,272,RC,,,,11703-MAIN,LOCAL,,,,,41.14,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,36.28548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR KII BALLOON BLUNT 12MM STERILE,27200000,CDM,272,RC,,,,11702-MAIN,LOCAL,,,,,41.14,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,36.28548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039814,NDC,1,EA,39.84,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,36.29424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
BUPivacaine PF 0.5 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,55150016910,NDC,10,ML,39.84,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,36.29424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
enalaprilat 1.25 MG/ML Injectable 1 mL Vial,25000000,CDM,250,RC,,,,,,143978710,NDC,1,ML,39.84,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,36.29424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098141,NDC,1,EA,39.84,,Medica,Commercial,both,91.1,,5.442333333,percent of total billed charges,36.29424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098153,NDC,1,EA,39.84,,Medica,Commercial,both,91.1,,5.442333333,percent of total billed charges,36.29424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,47781059807,NDC,1,EA,39.84,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,36.29424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
enalaprilat 1.25 MG/ML Injectable 2 mL Vial,25000000,CDM,250,RC,,,,,,143978601,NDC,2,ML,75.63,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,36.3024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
enalaprilat 1.25 MG/ML Injectable 2 mL Vial,25000000,CDM,250,RC,,,,,,143978601,NDC,2,ML,75.63,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,36.3024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641622901,NDC,1,ML,41.16,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,36.30312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.097864,86.9162
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409338513,NDC,1,EA,74.09,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,14.99111111,percent of total billed charges,36.3041,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409338513,NDC,1,EA,74.09,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,36.3041,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409338513,NDC,1,EA,74.09,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,36.3041,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,63739005007,NDC,1,EA,73.35,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,36.30825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
FLEXITIP APPLICATOR 38CM,27200000,CDM,272,RC,,,,10200-MAIN,LOCAL,,,,,40.8,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,36.312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,24208031510,NDC,10,ML,75.67,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,36.3216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,24208031510,NDC,10,ML,75.67,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,36.3216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457033900,NDC,1,EA,71.82,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,36.34092,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
protamine 10 MG/ML Solution 5 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022994,NDC,5,ML,84.74,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,36.35346,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.431298,83.0452
levothyroxine Sodium 200 MCG Recon Soln 1 Each Vial,J0650.01,CDM,636,RC,J0650,HCPCS,,,,63323064710,NDC,0.0625,EA,75.75,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,36.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.46655,74.235
levothyroxine Sodium 200 MCG Recon Soln 1 Each Vial,J0650.01,CDM,636,RC,J0650,HCPCS,,,,63323064710,NDC,0.0625,EA,75.75,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,36.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.46655,74.235
"Manage/Train Orthotic/Prosthetic, per 15 Min",PX97763,CDM,420,RC,97763,CPT,,,,,,,,121,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,36.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.36,118.58
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,16714081701,NDC,1,EA,75.78,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,36.3744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,16714081701,NDC,1,EA,75.78,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,36.3744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pancrelipase (lip-prot-amyl) 24000-76000 units Capsule Delayed Release Particles 100 Each Bottle,63700001,CDM,250,RC,,,,,,32122401,NDC,1,EA,37.41,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,36.411153,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
triamcinolone acetonide 40 MG/ML Suspension 1 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029305,NDC,1,ML,73.57,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,36.41715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,72.0986
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028016,NDC,2,ML,41.29,,United Healthcare,All Payer,outpatient,88.2,,8.0425,percent of total billed charges,36.41778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611F,CDM,510,RC,20611,CPT,,,,,,,,456,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,36.42,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.21,206.85
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611P,CDM,983,RC,20611,CPT,,,,,,,,272,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,36.42,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.21,266.56
methylPREDNISolone acetate 20 MG/ML Suspension 5 mL Vial,J1010.01,CDM,636,RC,J1010,HCPCS,,,,9027401,NDC,0.5,ML,41.3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,36.4266,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.15602,40.474
"B.Burgdorferi, Amp Probe - Ref",PX8747690,CDM,300,RC,87476,CPT,90,,,,,,,72,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,36.432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.9088,70.56
"Blood, Occult, Other Sources",PX82271,CDM,300,RC,82271,CPT,,,,,,,,72,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,36.432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.88,70.56
Epstein-barr antibody,PX86664,CDM,300,RC,86664,CPT,,,,,,,,72,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,36.432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.02,70.56
FORCEPS SERRATED WITH SPIKE JUMBO 230CM,27200000,CDM,272,RC,,,,7416-MAIN,LOCAL,,,,,41.31,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,36.43542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070548,NDC,100,ML,40.94,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,36.4366,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
8MM-12MM TIP COVER ACCESSORY,27200000,CDM,272,RC,,,,11918-MAIN,LOCAL,,,,,40,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,36.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CATHETER URETERAL  5FR TIGERTAIL OPEN TIP FLEXIBLE 139005,27200000,CDM,272,RC,A4340,HCPCS,,12302-MAIN,LOCAL,,,,,40,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,36.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NEEDLE BIOPSY 14GAX4 1/2 2N2702X,120.211,CDM,272,RC,,,,724-MAIN,LOCAL,,,,,40,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,36.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.616,39.2
STAPLER CANNULA SEAL 12 mm 470380,27200000,CDM,272,RC,,,,11962-MAIN,LOCAL,,,,,40,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,36.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"SUTURE V-LOC 22G NEEDLE 9"" 180 GREEN VLOCL2145",27200000,CDM,272,RC,,,,11930-MAIN,LOCAL,,,,,40,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,36.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"SUTURE V-LOC SZ 0.9"" 180 GREEN GS-21 NEEDLE VLOCL0346",27200000,CDM,272,RC,,,,11933-MAIN,LOCAL,,,,,40,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,36.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Telehealth Origin Site Fac Fee,PXQ3014,CDM,780,RC,Q3014,HCPCS,,,,,,,,40,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,36.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.616,39.2
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001326,NDC,1,ML,42.88,,First Health,Commercial,both,85,,999999999,percent of total billed charges,36.448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001341,NDC,1,ML,42.88,,First Health,Commercial,both,85,,999999999,percent of total billed charges,36.448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
ceFAZolin in D4W 1 g / 50 mL 1-4 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0690.01,CDM,636,RC,J0690,HCPCS,,,,264310311,NDC,1,EA,84.97,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,36.45213,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049237,NDC,30,ML,87.77,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,36.459658,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Cognitive Funct Ther Interv, Initial 15 Min",PX97129,CDM,420,RC,97129,CPT,,,,,,,,85,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,36.465,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15,83.3
"Exam,Synovial Fluid Crystals",PX89060,CDM,300,RC,89060,CPT,,,,,,,,85,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,36.465,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.72,83.3
GLIDESCOPE QC MAC S3 SINGLE USE 0270-1083,120.579,CDM,272,RC,,,,13046-MAIN,LOCAL,,,,,85,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,36.465,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.309,83.3
GLIDESCOPE QC MAC S3 SINGLE USE 0270-1085,120.579,CDM,272,RC,,,,13022-MAIN,LOCAL,,,,,85,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,36.465,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.309,83.3
GLIDESCOPE QC MAC S4 SINGLE USE 0270-1086,120.579,CDM,272,RC,,,,13023-MAIN,LOCAL,,,,,85,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,36.465,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.309,83.3
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409132305,NDC,5,ML,41.35,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,36.4707,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
sodium bicarbonate 8.4 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409662522,NDC,50,ML,85.02,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,36.47358,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Assay of Blood Lipoprotein,PX83721,CDM,300,RC,83721,CPT,,,,,,,,76,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,36.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.63,74.48
Assay of Blood Lipoprotein,PX83721,CDM,300,RC,83721,CPT,,,,,,,,76,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,36.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.63,74.48
Lab Direct Coombs,PX86880,CDM,300,RC,86880,CPT,,,,,,,,76,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,36.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.5704,74.48
Lab Direct Coombs,PX86880,CDM,300,RC,86880,CPT,,,,,,,,76,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,36.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.5704,74.48
PRONEVIEW CUSHION INSERTS LARGE,120.557,CDM,272,RC,E0190,HCPCS,,12500-MAIN,LOCAL,,,,,76,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,36.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.5704,74.48
PRONEVIEW CUSHION INSERTS LARGE,120.557,CDM,272,RC,E0190,HCPCS,,12500-MAIN,LOCAL,,,,,76,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,36.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.5704,74.48
SHOE POST OP LARGE MALE MQM3B,120.237,CDM,274,RC,L3260,HCPCS,,794-MAIN,LOCAL,,,,,76,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,36.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP LARGE MALE MQM3B,120.237,CDM,274,RC,L3260,HCPCS,,794-MAIN,LOCAL,,,,,76,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,36.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP LARGE SQUARE TOE WOMENS ORT30300WL,120.237,CDM,274,RC,L3260,HCPCS,,10606-MAIN,LOCAL,,,,,76,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,36.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP LARGE SQUARE TOE WOMENS ORT30300WL,120.237,CDM,274,RC,L3260,HCPCS,,10606-MAIN,LOCAL,,,,,76,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,36.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP MEDIUM SQUARE TOE MALE ORT30300MM,120.237,CDM,274,RC,L3260,HCPCS,,10603-MAIN,LOCAL,,,,,76,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,36.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP MEDIUM SQUARE TOE MALE ORT30300MM,120.237,CDM,274,RC,L3260,HCPCS,,10603-MAIN,LOCAL,,,,,76,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,36.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP MEDIUM SQUARE TOE WOMENS ORT30300WM,120.237,CDM,274,RC,L3260,HCPCS,,10605-MAIN,LOCAL,,,,,76,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,36.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP MEDIUM SQUARE TOE WOMENS ORT30300WM,120.237,CDM,274,RC,L3260,HCPCS,,10605-MAIN,LOCAL,,,,,76,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,36.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP SMALL MALE 0814-1192,120.237,CDM,274,RC,L3260,HCPCS,,803-MAIN,LOCAL,,,,,76,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,36.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP SMALL MALE 0814-1192,120.237,CDM,274,RC,L3260,HCPCS,,803-MAIN,LOCAL,,,,,76,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,36.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP SMALL SQUARE TOE WOMENS MQW1B,120.237,CDM,274,RC,L3260,HCPCS,,10604-MAIN,LOCAL,,,,,76,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,36.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP SMALL SQUARE TOE WOMENS MQW1B,120.237,CDM,274,RC,L3260,HCPCS,,10604-MAIN,LOCAL,,,,,76,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,36.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041100,NDC,0.5,ML,196.94,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,36.48078,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.48078,42.34
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041105,NDC,1,ML,419.67,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,36.48078,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.48078,42.34
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041110,NDC,0.5,ML,196.94,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,36.48078,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.48078,42.34
CANNULA SEAL 5-12MM UNIVERSAL 470500,27200000,CDM,272,RC,,,,12885-MAIN,LOCAL,,,,,41,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,36.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CUP HEEL LARGE WONDERSPUR 4502,120.43,CDM,274,RC,L3485,HCPCS,,11385-MAIN,LOCAL,,,,,41,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,36.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL MEDIUM WONDERSPUR 4501,120.43,CDM,274,RC,L3485,HCPCS,,11384-MAIN,LOCAL,,,,,41,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,36.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL SMALL WONDERSPUR 4500,120.43,CDM,274,RC,L3485,HCPCS,,11383-MAIN,LOCAL,,,,,41,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,36.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL XL WONDERSPUR 4503,120.43,CDM,274,RC,L3485,HCPCS,,11386-MAIN,LOCAL,,,,,41,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,36.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
Detection of Anaplasma Phagocytophilum by Amplified Nucleic Acid Probe Technique,PX8746890,CDM,300,RC,87468,CPT,90,,,,,,,41,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,36.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
Detection of Ehrlichia Chaffeensis by Amplified Nucleic Acid Probe Technique,PX8748490,CDM,300,RC,87484,CPT,90,,,,,,,41,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,36.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 21G 110MM SONOTAP II WITH FACET TIP 1285-3F110,120.483,CDM,271,RC,A4215,HCPCS,,12201-MAIN,LOCAL,,,,,41,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,36.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 21G X 4IN (100MM) SONOBLOCK II NERVE BLOCK WITH FACET S TIP 001281-77,120.483,CDM,271,RC,A4215,HCPCS,,12761-MAIN,LOCAL,,,,,41,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,36.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 22G 80MM SONOTAP II WITH FACET TIP 1285-3E080,120.483,CDM,271,RC,A4215,HCPCS,,12103-MAIN,LOCAL,,,,,41,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,36.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 22G X 3.25IN (80MM) SONOBLOCK II  NERVE BLOCK WITH FACET S TIP 001281-71,120.483,CDM,271,RC,A4215,HCPCS,,12760-MAIN,LOCAL,,,,,41,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,36.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 22GX2 SONOPLEX II WITH FACET S TIP 001287-74,120.483,CDM,271,RC,A4215,HCPCS,,13110-MAIN,LOCAL,,,,,41,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,36.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE NON-STIMULATING 22GX2 SONOBLOCK II WITH FACET S TIP 001281-74,120.483,CDM,271,RC,A4215,HCPCS,,11459-MAIN,LOCAL,,,,,41,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,36.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE SONOPLEX II STIMULATING WITH FACET S TIP 22GX3-1/4,120.483,CDM,271,RC,A4215,HCPCS,,11457-MAIN,LOCAL,,,,,41,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,36.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE STIMULATING 21GX4  SONOPLEX II  WITH FACET S TIP 001287-77,120.483,CDM,271,RC,A4215,HCPCS,,11458-MAIN,LOCAL,,,,,41,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,36.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
STRAP FOOT LG/XL GEL UNIVERSAL 10165,120.428,CDM,271,RC,,,,11382-MAIN,LOCAL,,,,,41,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,36.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
STRAP FOOT SM/MED GEL UNIVERSAL 10155,120.428,CDM,271,RC,,,,11381-MAIN,LOCAL,,,,,41,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,36.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
SUTURE V-LOC SZ 1/2 180 GREEN GS-21 VLOCL0316,27200000,CDM,272,RC,,,,11932-MAIN,LOCAL,,,,,41,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,36.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
URGOK2 DUAL COMPRESSION SYSTEM LARGE,120.491,CDM,271,RC,A6452,HCPCS,,11871-MAIN,LOCAL,,,,,41,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,36.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
URGOK2 DUAL COMPRESSION SYSTEM REGULAR,120.491,CDM,271,RC,A6452,HCPCS,,11870-MAIN,LOCAL,,,,,41,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,36.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
magnesium sulfate 4 GM/50ML Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010701,NDC,50,ML,73.72,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,36.4914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
"CUFF STERILE DISPOSABLE SPSB 24""",27200000,CDM,272,RC,,,,7437-MAIN,LOCAL,,,,,37.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,36.49875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ENDOCAVITY NEEDLE GUIDE,27200000,CDM,272,RC,,,,11134-MAIN,LOCAL,,,,,37.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,36.49875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR KII BALOON 5X100MM STERILE,27200000,CDM,272,RC,,,,11701-MAIN,LOCAL,,,,,37.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,36.49875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
solifenacin 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50228042730,NDC,1,EA,74.52,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,36.5148,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
solifenacin 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50228042730,NDC,1,EA,74.52,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,36.5148,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
solifenacin 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50228042730,NDC,1,EA,74.52,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,36.5148,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium polystyrene sulfonate Powder 15 g Bottle,25000000,CDM,250,RC,,,,,,10702003615,NDC,15,GR,76.09,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,36.5232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium polystyrene sulfonate Powder 15 g Bottle,25000000,CDM,250,RC,,,,,,10702003615,NDC,15,GR,76.09,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,36.5232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024110,NDC,1,EA,76.1,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,36.528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024110,NDC,1,EA,76.1,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,36.528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028026,NDC,2,ML,41.42,,United Healthcare,All Payer,outpatient,88.2,,8.0425,percent of total billed charges,36.53244,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
Antinuclear Antibodiesana - Ref,PX8603890,CDM,300,RC,86038,CPT,90,,,,,,,43,,First Health,Commercial,both,85,,999999999,percent of total billed charges,36.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.09,42.14
Blood Type Antigen Donor Ea,PX86902,CDM,300,RC,86902,CPT,,,,,,,,43,,First Health,Commercial,both,85,,999999999,percent of total billed charges,36.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.8622,314.02
ETRAP POLYP TRAP,27200000,CDM,272,RC,,,,11282-MAIN,LOCAL,,,,,43,,First Health,Commercial,both,85,,999999999,percent of total billed charges,36.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Smking Cess 4-10 Min,PX99406P,CDM,983,RC,99406,CPT,,,,,,,,43,,First Health,Commercial,both,85,,999999999,percent of total billed charges,36.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.8622,41.8519
"Testosterone, Total - Ref",PX8440390,CDM,300,RC,84403,CPT,90,,,,,,,43,,First Health,Commercial,both,85,,999999999,percent of total billed charges,36.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.8622,42.14
caffeine citrate 60 MG/3ML Solution 3 mL Vial,J0706.01,CDM,636,RC,J0706,HCPCS,,,,63323040704,NDC,3,ML,73.84,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,36.5508,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.673136,72.3632
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,47781046813,NDC,1,EA,76.15,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,36.552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,47781046813,NDC,1,EA,76.15,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,36.552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,64380079701,NDC,1,EA,76.15,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,36.552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,64380079701,NDC,1,EA,76.15,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,36.552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Apply of Paste Boot,PX29580P,CDM,983,RC,29580,CPT,,,,,,,,88,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,36.5552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.5552,137.65
POSITIONING KIT TRENDELENBURG NUBLUE TP 3000-NB,27100000,CDM,271,RC,,,,12992-MAIN,LOCAL,,,,,88,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,36.5552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
SPLINT ANKLE GEL BRACE UNIVERSAL AIRFORM 70351,120.61,CDM,274,RC,L4350,HCPCS,,12342-MAIN,LOCAL,,,,,88,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,36.5552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.5552,104.38
SUCTION IRRIGATOR 2 0250070500,27200000,CDM,272,RC,,,,12262-MAIN,LOCAL,,,,,88,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,36.5552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
leucovorin 10 mg/mL Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,25021081467,NDC,1,EA,40.13,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,36.55843,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.670002,84.6818
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,409508411,NDC,1,EA,73.86,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,36.5607,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
GASTRONOMY FEEDING TUBE MIC BALLOONED 20FR 7-10ML 0112-20,27200000,CDM,272,RC,B4087,HCPCS,,13098-MAIN,LOCAL,,,,,45,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,36.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
GASTRONOMY FEEDING TUBE MIC BALLOONED 20FR 7-10ML 0112-20,27200000,CDM,272,RC,B4087,HCPCS,,13098-MAIN,LOCAL,,,,,45,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,36.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
GASTRONOMY FEEDING TUBE MIC BALLOONED 20FR 7-10ML 0112-20,27200000,CDM,272,RC,B4087,HCPCS,,13098-MAIN,LOCAL,,,,,45,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,36.57,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
TUBE GASTROSTOMY 18FR REPLACEMENT DYND70318,120.256,CDM,271,RC,B4087,HCPCS,,407-MAIN,LOCAL,,,,,179,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,36.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.9181,38.26
TUBE GASTROSTOMY 18FR REPLACEMENT DYND70318,120.256,CDM,271,RC,B4087,HCPCS,,407-MAIN,LOCAL,,,,,179,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,36.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.9181,38.26
TUBE GASTROSTOMY 18FR REPLACEMENT DYND70318,120.256,CDM,271,RC,B4087,HCPCS,,407-MAIN,LOCAL,,,,,179,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,36.57,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.9181,38.26
DULoxetine 20 MG Capsule Delayed Release Particles 60 Each Bottle,63700001,CDM,250,RC,,,,,,57237001760,NDC,1,EA,37.58,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,36.576614,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
C Diff Amplified Probe,PX87493,CDM,300,RC,87493,CPT,,,,,,,,179,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,36.5826,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.15,37.27
leflunomide 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,62332006130,NDC,1,EA,88.09,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,36.592586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001001,NDC,1.5,ML,40.17,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,36.59487,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,42.5516
"B Cells, Total Count",PX86355,CDM,300,RC,86355,CPT,,,,,,,,56,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,36.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.6,37.73
"B Cells, Total Count",PX86355,CDM,300,RC,86355,CPT,,,,,,,,56,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,36.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.6,37.73
"B Cells, Total Count",PX86355,CDM,300,RC,86355,CPT,,,,,,,,56,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,36.6,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.6,37.73
TROCAR KII BALLOON 12MM STERILE,27200000,CDM,272,RC,,,,11703-MAIN,LOCAL,,,,,41.14,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,36.6146,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR KII BALLOON BLUNT 12MM STERILE,27200000,CDM,272,RC,,,,11702-MAIN,LOCAL,,,,,41.14,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,36.6146,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
pioglitazone 15 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342005410,NDC,1,EA,37.62,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,36.615546,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Flex Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707526,NDC,100,ML,37.63,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,4.559571429,percent of total billed charges,36.625279,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323018507,NDC,10,ML,43.09,,First Health,Commercial,both,85,,999999999,percent of total billed charges,36.6265,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Glucose Test,PX82950,CDM,300,RC,82950,CPT,,,,,,,,74,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,36.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.36,72.52
KIT EMERGENCY BIRTH DYNJS0600,120.317,CDM,272,RC,,,,8344-MAIN,LOCAL,,,,,74,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,36.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.7396,72.52
Rubeola Antibody,PX86765,CDM,300,RC,86765,CPT,,,,,,,,74,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,36.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.81,72.52
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641622901,NDC,1,ML,41.16,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,36.6324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.097864,86.9162
X-Ray Exam Entire Spine 2-3 Vws,PX7208201,CDM,320,RC,72082,CPT,TC,,,,,,,454,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,36.64,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.64,109.13
RETRIEVAL BAG 10MM,27200000,CDM,272,RC,,,,11707-MAIN,LOCAL,,,,,74.8,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,36.652,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RETRIEVAL BAG 10MM,27200000,CDM,272,RC,,,,11707-MAIN,LOCAL,,,,,74.8,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,36.652,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RETRIEVAL BAG 10MM,27200000,CDM,272,RC,,,,11707-MAIN,LOCAL,,,,,74.8,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,36.652,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
buprenorphine 8 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,54017713,NDC,1,EA,41.56,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,36.65592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.14,40.7288
pancrelipase (lip-prot-amyl) 24000-76000 units Capsule Delayed Release Particles 100 Each Bottle,63700001,CDM,250,RC,,,,,,32122401,NDC,1,EA,37.41,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,36.6618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,17478070311,NDC,10,ML,72.46,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,36.66476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039841,NDC,1,EA,43.14,,First Health,Commercial,both,85,,999999999,percent of total billed charges,36.669,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
HH Pt Initial Visit,PXG0151,CDM,421,RC,G0151,HCPCS,GP,,,,,,,,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,36.67,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.67,36.67
HH Pt Routine Visit,PXG0151.01,CDM,421,RC,G0151,HCPCS,GP,,,,,,,,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,36.67,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.67,36.67
Strapping of Knee,PX29530F,CDM,420,RC,29530,CPT,,,,,,,,303,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,36.67,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.12,60.88
Strapping of Shoulder,PX29240F,CDM,420,RC,29240,CPT,,,,,,,,165,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,36.67,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.12,61.57
Strapping of Shoulder,PX29240P,CDM,983,RC,29240,CPT,,,,,,,,110,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,36.67,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.12,107.8
"Venipunc Need Phys Skill,Dx or Rx",PX36410,CDM,983,RC,36410,CPT,,,,,,,,132,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,36.67,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.45,129.36
"Venipunc Need Phys Skill,Dx or Rx",PX36410F,CDM,510,RC,36410,CPT,,,,,,,,34,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,36.67,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.45,36.67
"Venipunc Need Phys Skill,Dx or Rx",PX36410P,CDM,983,RC,36410,CPT,,,,,,,,129,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,36.67,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.45,126.42
"Venipuncture by Physician, Other Vein, Under Age 3 Years",PX36406,CDM,983,RC,36406,CPT,,,,,,,,45,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,36.67,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.45,44.1
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409338513,NDC,1,EA,74.09,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,36.67455,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
tolterodine ER 2 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,43975032203,NDC,1,EA,43.15,,First Health,Commercial,both,85,,999999999,percent of total billed charges,36.6775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"X-Ray Exam Hip,Unilat W/Pelvis 2-3 Vws",PX7350201,CDM,320,RC,73502,CPT,TC,,,,,,,436,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,36.6852,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.99,72.97
Xray Ribs Bilat 3 Vws With Pa Chest,PX7111101,CDM,320,RC,71111,CPT,TC,,,,,,,417,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,36.6852,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.65,73.63
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004722,NDC,2,ML,88.35,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,36.70059,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
ampicillin 1 GM Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781926185,NDC,0.5,EA,43.18,,First Health,Commercial,both,85,,999999999,percent of total billed charges,36.703,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,55150023501,NDC,0.5,EA,37.72,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,36.712876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,703291401,NDC,0.5,EA,40.3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,36.7133,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Etoposide 100 MG/5ML Solution 5 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,16729011431,NDC,5,ML,43.21,,First Health,Commercial,both,85,,999999999,percent of total billed charges,36.7285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.949434,169.8144
amoxicillin 250 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,93415580,NDC,150,ML,43.22,,First Health,Commercial,both,85,,999999999,percent of total billed charges,36.737,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028016,NDC,2,ML,41.29,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,36.7481,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
Assay Cryofibrinogen,PX82585,CDM,300,RC,82585,CPT,,,,,,,,75,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,36.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.96,73.5
Assay Cryofibrinogen,PX82585,CDM,300,RC,82585,CPT,,,,,,,,75,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,36.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.96,73.5
Assay Cryofibrinogen,PX82585,CDM,300,RC,82585,CPT,,,,,,,,75,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,36.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.96,73.5
Assay Cryoglobulin,PX82595,CDM,300,RC,82595,CPT,,,,,,,,75,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,36.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,73.5
Assay Cryoglobulin,PX82595,CDM,300,RC,82595,CPT,,,,,,,,75,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,36.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,73.5
Assay Cryoglobulin,PX82595,CDM,300,RC,82595,CPT,,,,,,,,75,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,36.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,73.5
BINDER ABDOMINAL 9 INCH 46 TO 62 INCH XL ORT21100LXL,120.238,CDM,271,RC,A4467,HCPCS,,2989-MAIN,LOCAL,,,,,75,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,36.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL 9 INCH 46 TO 62 INCH XL ORT21100LXL,120.238,CDM,271,RC,A4467,HCPCS,,2989-MAIN,LOCAL,,,,,75,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,36.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL 9 INCH 46 TO 62 INCH XL ORT21100LXL,120.238,CDM,271,RC,A4467,HCPCS,,2989-MAIN,LOCAL,,,,,75,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,36.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL 9 INCH 63 TO 74 INCH 3- PANEL ORT211002XL,120.238,CDM,271,RC,A4467,HCPCS,,37-MAIN,LOCAL,,,,,75,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,36.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL 9 INCH 63 TO 74 INCH 3- PANEL ORT211002XL,120.238,CDM,271,RC,A4467,HCPCS,,37-MAIN,LOCAL,,,,,75,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,36.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL 9 INCH 63 TO 74 INCH 3- PANEL ORT211002XL,120.238,CDM,271,RC,A4467,HCPCS,,37-MAIN,LOCAL,,,,,75,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,36.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL 10 INCH 26 TO 50 INCHES ABB1050,120.238,CDM,271,RC,A4467,HCPCS,,52-MAIN,LOCAL,,,,,75,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,36.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL 10 INCH 26 TO 50 INCHES ABB1050,120.238,CDM,271,RC,A4467,HCPCS,,52-MAIN,LOCAL,,,,,75,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,36.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL 10 INCH 26 TO 50 INCHES ABB1050,120.238,CDM,271,RC,A4467,HCPCS,,52-MAIN,LOCAL,,,,,75,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,36.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
"BINDER ABDOMINAL 12"" HIGH 2XL 60-75INCH 4 PANEL ORT213002XL",120.238,CDM,271,RC,A4467,HCPCS,,12536-MAIN,LOCAL,,,,,75,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,36.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
"BINDER ABDOMINAL 12"" HIGH 2XL 60-75INCH 4 PANEL ORT213002XL",120.238,CDM,271,RC,A4467,HCPCS,,12536-MAIN,LOCAL,,,,,75,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,36.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
"BINDER ABDOMINAL 12"" HIGH 2XL 60-75INCH 4 PANEL ORT213002XL",120.238,CDM,271,RC,A4467,HCPCS,,12536-MAIN,LOCAL,,,,,75,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,36.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL UNISIZE 46-62IN 9 IN MDS169024,120.238,CDM,271,RC,A4467,HCPCS,,63-MAIN,LOCAL,,,,,75,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,36.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL UNISIZE 46-62IN 9 IN MDS169024,120.238,CDM,271,RC,A4467,HCPCS,,63-MAIN,LOCAL,,,,,75,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,36.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL UNISIZE 46-62IN 9 IN MDS169024,120.238,CDM,271,RC,A4467,HCPCS,,63-MAIN,LOCAL,,,,,75,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,36.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
"CUFF STERILE DISPOSABLE SPSB 24""",27200000,CDM,272,RC,,,,7437-MAIN,LOCAL,,,,,37.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,36.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Direct skilled nursing services of a license practical nurse (lpn) in the home health or hospice setting, each 15 minutes",PXG0300,CDM,551,RC,G0300,HCPCS,,,,,,,,75,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,36.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
"Direct skilled nursing services of a license practical nurse (lpn) in the home health or hospice setting, each 15 minutes",PXG0300,CDM,551,RC,G0300,HCPCS,,,,,,,,75,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,36.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
"Direct skilled nursing services of a license practical nurse (lpn) in the home health or hospice setting, each 15 minutes",PXG0300,CDM,551,RC,G0300,HCPCS,,,,,,,,75,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,36.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
ENDOCAVITY NEEDLE GUIDE,27200000,CDM,272,RC,,,,11134-MAIN,LOCAL,,,,,37.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,36.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HH Rn Initial Visit,PXG0154,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,36.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
HH Rn Initial Visit,PXG0154,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,36.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
HH Rn Initial Visit,PXG0154,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,36.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
HH Rn Routine Visit,PXG0154.01,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,36.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
HH Rn Routine Visit,PXG0154.01,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,36.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
HH Rn Routine Visit,PXG0154.01,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,36.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
Skilled Srvc of a Lpn in Training and/or Education of Pt or Fam Ea 15 Min,PXG0496,CDM,551,RC,G0496,HCPCS,,,,,,,,75,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,36.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
Skilled Srvc of a Lpn in Training and/or Education of Pt or Fam Ea 15 Min,PXG0496,CDM,551,RC,G0496,HCPCS,,,,,,,,75,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,36.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
Skilled Srvc of a Lpn in Training and/or Education of Pt or Fam Ea 15 Min,PXG0496,CDM,551,RC,G0496,HCPCS,,,,,,,,75,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,36.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
Skilled srvc of an RN in training and/or education of pt or fam ea 15 min,PXG0495,CDM,551,RC,G0495,HCPCS,,,,,,,,75,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,36.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
Skilled srvc of an RN in training and/or education of pt or fam ea 15 min,PXG0495,CDM,551,RC,G0495,HCPCS,,,,,,,,75,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,36.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
Skilled srvc of an RN in training and/or education of pt or fam ea 15 min,PXG0495,CDM,551,RC,G0495,HCPCS,,,,,,,,75,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,36.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
TROCAR KII BALOON 5X100MM STERILE,27200000,CDM,272,RC,,,,11701-MAIN,LOCAL,,,,,37.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,36.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
neomycin-bacitracin-polymyxin 3.5-400-5000 Ointment 28 g Tube,25000000,CDM,250,RC,,,,,,45802014303,NDC,28,GR,37.76,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,36.751808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
methylPREDNISolone acetate 20 MG/ML Suspension 5 mL Vial,J1010.01,CDM,636,RC,J1010,HCPCS,,,,9027401,NDC,0.5,ML,41.3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,36.757,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.15602,40.474
triamcinolone acetonide 40 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029320,NDC,1,ML,72.65,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,36.7609,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,72.0986
FORCEPS SERRATED WITH SPIKE JUMBO 230CM,27200000,CDM,272,RC,,,,7416-MAIN,LOCAL,,,,,41.31,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,36.7659,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
belimumab (400v) 400 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010201,NDC,1,EA,3523.71,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,36.78,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.37,53.14484
belimumab (400v) 400 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010201,NDC,1,EA,3523.71,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,36.78,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.37,53.14484
belimumab 120 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010101,NDC,1,EA,1015.95,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,36.78,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.37,53.14484
belimumab 120 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010101,NDC,1,EA,1015.95,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,36.78,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.37,53.14484
enalaprilat 1.25 MG/ML Injectable 1 mL Vial,25000000,CDM,250,RC,,,,,,143978701,NDC,1,ML,40.39,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,36.79529,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
azithromycin 250 MG Tablet 6 Each Box,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096104,NDC,1,EA,41.72,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,36.79704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409132305,NDC,5,ML,41.35,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,36.8015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034020,NDC,1,EA,76.67,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,36.8016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034020,NDC,1,EA,76.67,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,36.8016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034021,NDC,1,EA,76.67,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,36.8016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034021,NDC,1,EA,76.67,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,36.8016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096105,NDC,1,EA,41.73,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,36.80586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143966001,NDC,5,ML,37.82,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,36.810206,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143966010,NDC,5,ML,37.82,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,36.810206,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"CUFF STERILE DISPOSABLE SPSB 12""",27200000,CDM,272,RC,,,,7435-MAIN,LOCAL,,,,,43.31,,First Health,Commercial,both,85,,999999999,percent of total billed charges,36.8135,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CATHETER TEMP-SENSING 8FR LUBRISIL PEDS DYND110508,120.363,CDM,272,RC,A4340,HCPCS,,12777-MAIN,LOCAL,,,,,45,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,36.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.98,36.82
CATHETER TEMP-SENSING 8FR LUBRISIL PEDS DYND110508,120.363,CDM,272,RC,A4340,HCPCS,,12777-MAIN,LOCAL,,,,,45,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,36.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.98,36.82
CATHETER TEMP-SENSING 8FR LUBRISIL PEDS DYND110508,120.363,CDM,272,RC,A4340,HCPCS,,12777-MAIN,LOCAL,,,,,45,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,36.82,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.98,36.82
CATHETER TEMP-SENSING 12FR LUBRISIL 119212M,120.363,CDM,272,RC,A4340,HCPCS,,10750-MAIN,LOCAL,,,,,45,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,36.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.98,36.82
CATHETER TEMP-SENSING 12FR LUBRISIL 119212M,120.363,CDM,272,RC,A4340,HCPCS,,10750-MAIN,LOCAL,,,,,45,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,36.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.98,36.82
CATHETER TEMP-SENSING 12FR LUBRISIL 119212M,120.363,CDM,272,RC,A4340,HCPCS,,10750-MAIN,LOCAL,,,,,45,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,36.82,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.98,36.82
CATHETER TEMP-SENSING 14FR LUBRISIL 119214M,120.363,CDM,272,RC,A4340,HCPCS,,10751-MAIN,LOCAL,,,,,45,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,36.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.98,36.82
CATHETER TEMP-SENSING 14FR LUBRISIL 119214M,120.363,CDM,272,RC,A4340,HCPCS,,10751-MAIN,LOCAL,,,,,45,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,36.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.98,36.82
CATHETER TEMP-SENSING 14FR LUBRISIL 119214M,120.363,CDM,272,RC,A4340,HCPCS,,10751-MAIN,LOCAL,,,,,45,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,36.82,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.98,36.82
CATHETER TEMP-SENSING 16FR LUBRISIL 119216M,120.363,CDM,272,RC,A4340,HCPCS,,10752-MAIN,LOCAL,,,,,45,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,36.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.98,36.82
CATHETER TEMP-SENSING 16FR LUBRISIL 119216M,120.363,CDM,272,RC,A4340,HCPCS,,10752-MAIN,LOCAL,,,,,45,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,36.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.98,36.82
CATHETER TEMP-SENSING 16FR LUBRISIL 119216M,120.363,CDM,272,RC,A4340,HCPCS,,10752-MAIN,LOCAL,,,,,45,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,36.82,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.98,36.82
CATHETER URETERAL  5FR TIGERTAIL OPEN TIP FLEXIBLE 139005,27200000,CDM,272,RC,A4340,HCPCS,,12302-MAIN,LOCAL,,,,,40,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,36.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
CATHETER URETERAL  5FR TIGERTAIL OPEN TIP FLEXIBLE 139005,27200000,CDM,272,RC,A4340,HCPCS,,12302-MAIN,LOCAL,,,,,40,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,36.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
CATHETER URETERAL  5FR TIGERTAIL OPEN TIP FLEXIBLE 139005,27200000,CDM,272,RC,A4340,HCPCS,,12302-MAIN,LOCAL,,,,,40,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,36.82,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
prasugrel 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862083030,NDC,1,EA,88.64,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,36.821056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DULoxetine 20 MG Capsule Delayed Release Particles 60 Each Bottle,63700001,CDM,250,RC,,,,,,57237001760,NDC,1,EA,37.58,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,36.8284,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028002,NDC,1,ML,40.43,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,36.83173,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094310,NDC,10,ML,72.79,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,36.83174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.236966,143.9032
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094321,NDC,10,ML,72.79,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,36.83174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.236966,143.9032
DULoxetine 20 MG Capsule Delayed Release Particles 60 Each Bottle,63700001,CDM,250,RC,,,,,,2323560,NDC,1,EA,41.76,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,36.83232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,55150025110,NDC,10,ML,37.85,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,36.839405,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253033335,NDC,5,ML,40.44,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,36.84084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010269,NDC,1,EA,88.69,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,36.841826,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010299,NDC,1,EA,88.69,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,36.841826,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614201,NDC,1,ML,88.69,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,36.841826,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.097864,86.9162
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614225,NDC,1,ML,88.69,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,36.841826,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.097864,86.9162
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963801,NDC,0.5,ML,88.69,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,36.841826,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,50111078751,NDC,1,EA,41.79,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,36.85878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
donepezil 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904640861,NDC,1,EA,41.79,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,36.85878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157F,CDM,370,RC,99157,CPT,,,,,,,,270,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,36.86,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.86,102.38
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157F,CDM,370,RC,99157,CPT,,,,,,,,270,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,36.86,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.86,102.38
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157P,CDM,983,RC,99157,CPT,,,,,,,,270,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,36.86,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.86,264.6
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157P,CDM,983,RC,99157,CPT,,,,,,,,270,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,36.86,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.86,264.6
X-Ray Exam Entire Spine 2-3 Vws,PX7208201,CDM,320,RC,72082,CPT,TC,,,,,,,454,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,36.86,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.64,109.13
X-Ray Exam Entire Spine 2-3 Vws,PX7208201,CDM,320,RC,72082,CPT,TC,,,,,,,454,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,36.86,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.64,109.13
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028026,NDC,2,ML,41.42,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,36.8638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
pioglitazone 15 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342005410,NDC,1,EA,37.62,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,36.8676,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Flex Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707526,NDC,100,ML,37.63,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,36.8774,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490311,NDC,5,ML,43.39,,First Health,Commercial,both,85,,999999999,percent of total billed charges,36.8815,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
solifenacin 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50228042730,NDC,1,EA,74.52,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,36.8874,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409751716,NDC,50,ML,72.9,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,36.8874,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Dimethicone 1.5 % Cream 118 mL Tube,800000,CDM,,,,,,,,53329016104,NDC,118,ML,43.4,,First Health,Commercial,both,85,,999999999,percent of total billed charges,36.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
acyclovir 50 MG/ML Solution 20 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,63323032524,NDC,20,ML,76.86,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,36.8928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.927644,105.9968
acyclovir 50 MG/ML Solution 20 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,63323032524,NDC,20,ML,76.86,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,36.8928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.927644,105.9968
Aldosterone - Ref,PX8208890,CDM,300,RC,82088,CPT,90,,,,,,,86,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,36.894,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.7244,84.28
Epstein-barr antibody,PX86665,CDM,300,RC,86665,CPT,,,,,,,,86,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,36.894,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.63,84.28
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143978410,NDC,2,ML,37.91,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,36.897803,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
SAWBLADE SAGITAL STERILE 25MM LENGTH 5.5MM WIDTH 0.60MM THICKNESS,27200000,CDM,272,RC,,,,11623-MAIN,LOCAL,,,,,86.02,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,36.90258,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"B Cells, Total Count",PX86355,CDM,300,RC,86355,CPT,,,,,,,,56,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,36.9035,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.6,37.73
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001002,NDC,2,ML,43.42,,First Health,Commercial,both,85,,999999999,percent of total billed charges,36.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,42.5516
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037601,NDC,1,ML,76.9,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,36.912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037601,NDC,1,ML,76.9,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,36.912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098121,NDC,1,EA,72.95,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,36.9127,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329334001,NDC,10,ML,88.88,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,36.920752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
Apply Long Arm Splint,PX29105F,CDM,510,RC,29105,CPT,,,,,,,,290,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,36.9265,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.87,175.72
Apply Long Arm Splint,PX29105P,CDM,983,RC,29105,CPT,,,,,,,,385,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,36.9265,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.87,377.3
fluconazole 150 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,16714069210,NDC,1,EA,72.98,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,36.92788,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BALLOON EXTRACTOR PEDS,120.358,CDM,272,RC,,,,10771-MAIN,LOCAL,,,,,73,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,36.938,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.3242,71.54
Alpha-Fetoprotein Serum,PX82105,CDM,300,RC,82105,CPT,,,,,,,,77,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,36.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.38,75.46
Alpha-Fetoprotein Serum,PX82105,CDM,300,RC,82105,CPT,,,,,,,,77,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,36.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.38,75.46
BRACE WRIST HAND THUMB LEFT 455-LT,120.315,CDM,274,RC,L3809,HCPCS,,8283-MAIN,LOCAL,,,,,77,,Health Partners,Health Partners Care Plans,both,48,,34.92,percent of total billed charges,36.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.9858,245.51
BRACE WRIST HAND THUMB LEFT 455-LT,120.315,CDM,274,RC,L3809,HCPCS,,8283-MAIN,LOCAL,,,,,77,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,36.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.9858,245.51
BRACE WRIST HAND THUMB RIGHT 455-RT,120.315,CDM,274,RC,L3809,HCPCS,,8284-MAIN,LOCAL,,,,,77,,Health Partners,Health Partners Care Plans,both,48,,34.92,percent of total billed charges,36.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.9858,245.51
BRACE WRIST HAND THUMB RIGHT 455-RT,120.315,CDM,274,RC,L3809,HCPCS,,8284-MAIN,LOCAL,,,,,77,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,36.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.9858,245.51
CAUTERY HIGH TEMP LOOP TIP,120.21,CDM,272,RC,,,,332-MAIN,LOCAL,,,,,77,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,36.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
CAUTERY HIGH TEMP LOOP TIP,120.21,CDM,272,RC,,,,332-MAIN,LOCAL,,,,,77,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,36.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
NEEDLE ACUJECT 25GA VARIABLE INJECTION VIN-25,27200000,CDM,272,RC,,,,7412-MAIN,LOCAL,,,,,77,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,36.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NEEDLE ACUJECT 25GA VARIABLE INJECTION VIN-25,27200000,CDM,272,RC,,,,7412-MAIN,LOCAL,,,,,77,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,36.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Remove Additional Nail Plate,PX11732F,CDM,510,RC,11732,CPT,,,,,,,,77,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,36.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.9858,75.46
Remove Additional Nail Plate,PX11732F,CDM,510,RC,11732,CPT,,,,,,,,77,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,36.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.9858,75.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,55150023501,NDC,0.5,EA,37.72,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,36.9656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,641601310,NDC,5,ML,40.58,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,36.96838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004703,NDC,1,EA,75.45,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,36.9705,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004703,NDC,1,EA,75.45,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,36.9705,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004703,NDC,1,EA,75.45,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,36.9705,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
Aldolase - Ref,PX8208590,CDM,300,RC,82085,CPT,90,,,,,,,89,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,36.9706,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.9,87.22
Assay of Ggt,PX82977,CDM,300,RC,82977,CPT,,,,,,,,89,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,36.9706,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6,87.22
"Debridement of Nail(S), 1-5",PX11720F,CDM,510,RC,11720,CPT,,,,,,,,89,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,36.9706,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.9706,87.22
"Hla a, B or C, Single Ag - Ref",PX8681290,CDM,300,RC,86812,CPT,90,,,,,,,89,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,36.9706,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.67,87.22
KIT INTRODUCER 8.5FR AK-09803-CDC,120.128,CDM,272,RC,,,,8826-MAIN,LOCAL,,,,,89,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,36.9706,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.9706,87.22
dextrose 5 % 5 % Solution 50 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338055111,NDC,50,ML,43.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,36.975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 100 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001748,NDC,100,ML,43.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,36.975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,264763500,NDC,1000,ML,43.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,36.975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5% lactated ringers 5 % Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012504,NDC,1000,ML,43.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,36.975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329330201,NDC,25,ML,43.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,36.975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9 % 0.9 % Solution 50 mL Flex Cont,J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004941,NDC,50,ML,43.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,36.975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004941,NDC,250,ML,43.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,36.975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055311,NDC,250,ML,43.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,36.975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004948,NDC,300,ML,43.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,36.975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055318,NDC,300,ML,43.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,36.975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 150 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,409798361,NDC,300,ML,43.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,36.975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9% irrigation 0.9 % Solution 3,000 mL Plas Cont",25000000,CDM,250,RC,,,,,,338004727,NDC,3000,ML,43.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,36.975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9% IV LINE FLUSH 0.9% Solution 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,338004948,NDC,100,ML,43.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,36.975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
droPERidol 2.5 MG/ML Solution 2 mL Vial,J1790.01,CDM,636,RC,J1790,HCPCS,,,,517970201,NDC,2,ML,75.47,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,15.1,percent of total billed charges,36.9803,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.350238,73.9606
droPERidol 2.5 MG/ML Solution 2 mL Vial,J1790.01,CDM,636,RC,J1790,HCPCS,,,,517970201,NDC,2,ML,75.47,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,36.9803,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.350238,73.9606
droPERidol 2.5 MG/ML Solution 2 mL Vial,J1790.01,CDM,636,RC,J1790,HCPCS,,,,517970201,NDC,2,ML,75.47,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,36.9803,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.350238,73.9606
"Cardiac Stress Tst,Tracing Only",PX93017,CDM,482,RC,93017,CPT,,,,,,,,1959,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,36.984,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.34,65.73
8MM-12MM CANNULA SEAL 5-8MM,27200000,CDM,272,RC,,,,11921-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,36.9854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRAPE COLUMN 470341,27200000,CDM,272,RC,,,,12013-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,36.9854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HH Hha Visit,PXG0156,CDM,571,RC,G0156,HCPCS,,,,,,,,38,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,36.9854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
Mitochondrial Antibody Each,PX8638190,CDM,300,RC,86381,CPT,90,,,,,,,38,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,36.9854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
Nasal Sm for Eos,PX89190,CDM,300,RC,89190,CPT,,,,,,,,38,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,36.9854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.31,37.24
NEEDLE IV 19GA X .75IN HUBER POWERLOC SAFETY 0651934,120.85,CDM,272,RC,A4215,HCPCS,,12701-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,36.9854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
NEEDLE IV 19GA X 1 IN HUBER POWERLOC SAFETY 0651910,120.85,CDM,272,RC,A4215,HCPCS,,12702-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,36.9854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
NEEDLE IV 19GA X 1.5 IN HUBER POWERLOC SAFETY 0651915,120.85,CDM,272,RC,A4215,HCPCS,,12703-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,36.9854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
PEZZER CATHETER DRAIN LATEX 14FR,27200000,CDM,272,RC,,,,12053-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,36.9854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PEZZER LATEX CATHETER DRAIN 10FR,27200000,CDM,272,RC,,,,12646-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,36.9854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PNEUVIEW SMOKE ELIMINATOR,27200000,CDM,272,RC,,,,11884-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,36.9854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Psa, Free - Ref",PX8415490,CDM,300,RC,84154,CPT,90,,,,,,,38,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,36.9854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
"Psa, Total - Ref",PX8415390,CDM,300,RC,84153,CPT,90,,,,,,,38,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,36.9854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
SPECULUM VAGINAL WITH BUILT IN LIGHT LARGE,120.133,CDM,272,RC,,,,8251-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,36.9854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
SPECULUM VAGINAL WITH BUILT IN LIGHT MEDIUM,120.133,CDM,272,RC,,,,8250-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,36.9854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
SPECULUM VAGINAL WITH BUILT IN LIGHT SMALL,120.133,CDM,272,RC,,,,8249-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,36.9854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
TROCAR KII FIOS SYSTEM BLADELSS Z-THREAD 5MMX100MM,27200000,CDM,272,RC,,,,12003-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,36.9854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
buprenorphine 8 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,54017713,NDC,1,EA,41.56,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,36.9884,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.14,40.7288
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036019,NDC,10,ML,86.23,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,36.99267,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,84.5054
skin oil Oil 236.6 mL Bottle,63700001,CDM,250,RC,,,,,,67211008,NDC,236.6,ML,40.61,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,36.99571,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
neomycin-bacitracin-polymyxin 3.5-400-5000 Ointment 28 g Tube,25000000,CDM,250,RC,,,,,,45802014303,NDC,28,GR,37.76,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,37.0048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
empagliflozin 25 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,597015330,NDC,0.4,EA,43.54,,First Health,Commercial,both,85,,999999999,percent of total billed charges,37.009,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
empagliflozin 25 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,597015337,NDC,0.4,EA,43.54,,First Health,Commercial,both,85,,999999999,percent of total billed charges,37.009,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046837,NDC,30,ML,75.54,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.0146,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046837,NDC,30,ML,75.54,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.0146,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046837,NDC,30,ML,75.54,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,37.0146,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"SUTURE ETHIBOND #0 CT-1 CR 8-18"" CX21D",27200000,CDM,272,RC,,,,6415-MAIN,LOCAL,,,,,41.97,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,37.01754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RETRIEVAL BAG 10MM,27200000,CDM,272,RC,,,,11707-MAIN,LOCAL,,,,,74.8,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,37.026,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
nafcillin 1 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,55150012215,NDC,1,EA,89.17,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,37.041218,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Actin Antibody Each,PX8601590,CDM,300,RC,86015,CPT,90,,,,,,,42,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,37.044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.05,41.16
Assay Vitamin B-6,PX84207,CDM,300,RC,84207,CPT,90,,,,,,,42,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,37.044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
"BOUGIE TRACH 10FR 70CM COUDE 	9-0211-70",120.199,CDM,272,RC,A7520,HCPCS,,11112-MAIN,LOCAL,,,,,42,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,37.044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
BOUGIE TRACHEAL TUBE & GUIDE 100123515,120.199,CDM,272,RC,A7520,HCPCS,,8950-MAIN,LOCAL,,,,,42,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,37.044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
CATHETER PUREWICK FEMALE EXTERNAL PWF030K,120.414,CDM,272,RC,A6590,HCPCS,,11836-MAIN,LOCAL,,,,,42,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,37.044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
Culture Type Immunologic,PX87147,CDM,300,RC,87147,CPT,,,,,,,,42,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,37.044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,41.16
EZ-STABILIZER DRESSING,120.415,CDM,272,RC,,,,9058-MAIN,LOCAL,,,,,42,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,37.044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
MEPILEX AG FOAM 4X4,120.192,CDM,272,RC,A6213,HCPCS,,8480-MAIN,LOCAL,,,,,42,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,37.044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
MEPILEX AG FOAM 4X8,120.192,CDM,272,RC,A6213,HCPCS,,8479-MAIN,LOCAL,,,,,42,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,37.044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY CENTRAL LINE DRESSING WITH CHLORAPREP DYND75234,120.68,CDM,272,RC,,,,10923-MAIN,LOCAL,,,,,42,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,37.044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY FOLEY 14FR CATHETER A300414A,120.414,CDM,272,RC,A4344,HCPCS,,11281-MAIN,LOCAL,,,,,42,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,37.044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY FOLEY 16FR CATHETER 300416A,120.414,CDM,272,RC,A4344,HCPCS,,11774-MAIN,LOCAL,,,,,42,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,37.044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
"TRAY SPINAL  25GX3.5"" WITH WHITEACRE 405671",120.275,CDM,272,RC,,,,3284-MAIN,LOCAL,,,,,42,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,37.044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY SPINAL 25G ANESTH SADDLE BLOCK NLD-4795-20,120.275,CDM,272,RC,,,,935-MAIN,LOCAL,,,,,42,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,37.044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
enalaprilat 1.25 MG/ML Injectable 2 mL Vial,25000000,CDM,250,RC,,,,,,143978601,NDC,2,ML,75.63,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.0587,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
enalaprilat 1.25 MG/ML Injectable 2 mL Vial,25000000,CDM,250,RC,,,,,,143978601,NDC,2,ML,75.63,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.0587,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
enalaprilat 1.25 MG/ML Injectable 2 mL Vial,25000000,CDM,250,RC,,,,,,143978601,NDC,2,ML,75.63,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,37.0587,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143966001,NDC,5,ML,37.82,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,37.0636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143966010,NDC,5,ML,37.82,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,37.0636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
leucovorin 350 MG Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,703514501,NDC,1,EA,86.41,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,37.06989,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.670002,84.6818
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,436067216,NDC,473,ML,77.23,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,37.0704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,436067216,NDC,473,ML,77.23,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,37.0704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,39328006412,NDC,473,ML,77.23,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,37.0704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,39328006412,NDC,473,ML,77.23,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,37.0704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012250,NDC,1,EA,77.24,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,37.0752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012250,NDC,1,EA,77.24,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,37.0752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012267,NDC,1,EA,77.24,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,37.0752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012267,NDC,1,EA,77.24,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,37.0752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
cefOXitin 2 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021011020,NDC,1,EA,77.24,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,37.0752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.367364,75.6952
cefOXitin 2 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021011020,NDC,1,EA,77.24,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,37.0752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.367364,75.6952
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023610,NDC,1,EA,77.24,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,37.0752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023610,NDC,1,EA,77.24,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,37.0752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,24208031510,NDC,10,ML,75.67,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.0783,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,24208031510,NDC,10,ML,75.67,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.0783,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,24208031510,NDC,10,ML,75.67,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,37.0783,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Debride Skin/Tissue,PX11042F,CDM,510,RC,11042,CPT,,,,,,,,1067,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,37.08,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.08,269.8
Debride Skin/Tissue,PX11042P,CDM,983,RC,11042,CPT,,,,,,,,995,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,37.08,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.08,975.1
TRAY SURGICAL PODIATRY II EXTREMITY DYNJS0803,27200000,CDM,272,RC,,,,10920-MAIN,LOCAL,,,,,73.29,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,37.08474,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,55150025110,NDC,10,ML,37.85,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,37.093,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019602,NDC,2,ML,77.29,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,37.0992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019602,NDC,2,ML,77.29,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,37.0992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,409163221,NDC,0.5,EA,43.65,,First Health,Commercial,both,85,,999999999,percent of total billed charges,37.1025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041100,NDC,0.5,ML,196.94,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,37.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.48078,42.34
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041100,NDC,0.5,ML,196.94,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,37.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.48078,42.34
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041105,NDC,1,ML,419.67,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,37.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.48078,42.34
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041105,NDC,1,ML,419.67,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,37.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.48078,42.34
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041110,NDC,0.5,ML,196.94,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,37.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.48078,42.34
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041110,NDC,0.5,ML,196.94,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,37.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.48078,42.34
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253022233,NDC,3,ML,38.13,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.46575,percent of total billed charges,37.111929,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
gemcitabine 200 MG/5.26ML Solution 5.26 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018301,NDC,5.26,ML,40.74,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,37.11414,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,63739005007,NDC,1,EA,73.35,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,37.1151,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine Sodium 200 MCG Recon Soln 1 Each Vial,J0650.01,CDM,636,RC,J0650,HCPCS,,,,63323064710,NDC,0.0625,EA,75.75,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.1175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.46655,74.235
levothyroxine Sodium 200 MCG Recon Soln 1 Each Vial,J0650.01,CDM,636,RC,J0650,HCPCS,,,,63323064710,NDC,0.0625,EA,75.75,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.1175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.46655,74.235
levothyroxine Sodium 200 MCG Recon Soln 1 Each Vial,J0650.01,CDM,636,RC,J0650,HCPCS,,,,63323064710,NDC,0.0625,EA,75.75,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,37.1175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.46655,74.235
Assay Cryofibrinogen,PX82585,CDM,300,RC,82585,CPT,,,,,,,,75,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,37.125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.96,73.5
Assay Cryoglobulin,PX82595,CDM,300,RC,82595,CPT,,,,,,,,75,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,37.125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,73.5
BINDER ABDOMINAL 9 INCH 46 TO 62 INCH XL ORT21100LXL,120.238,CDM,271,RC,A4467,HCPCS,,2989-MAIN,LOCAL,,,,,75,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,37.125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL 9 INCH 63 TO 74 INCH 3- PANEL ORT211002XL,120.238,CDM,271,RC,A4467,HCPCS,,37-MAIN,LOCAL,,,,,75,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,37.125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL 10 INCH 26 TO 50 INCHES ABB1050,120.238,CDM,271,RC,A4467,HCPCS,,52-MAIN,LOCAL,,,,,75,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,37.125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
"BINDER ABDOMINAL 12"" HIGH 2XL 60-75INCH 4 PANEL ORT213002XL",120.238,CDM,271,RC,A4467,HCPCS,,12536-MAIN,LOCAL,,,,,75,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,37.125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL UNISIZE 46-62IN 9 IN MDS169024,120.238,CDM,271,RC,A4467,HCPCS,,63-MAIN,LOCAL,,,,,75,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,37.125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
"Direct skilled nursing services of a license practical nurse (lpn) in the home health or hospice setting, each 15 minutes",PXG0300,CDM,551,RC,G0300,HCPCS,,,,,,,,75,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,37.125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
HH Rn Initial Visit,PXG0154,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,37.125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
HH Rn Routine Visit,PXG0154.01,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,37.125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
Skilled Srvc of a Lpn in Training and/or Education of Pt or Fam Ea 15 Min,PXG0496,CDM,551,RC,G0496,HCPCS,,,,,,,,75,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,37.125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
Skilled srvc of an RN in training and/or education of pt or fam ea 15 min,PXG0495,CDM,551,RC,G0495,HCPCS,,,,,,,,75,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,37.125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
azithromycin 250 MG Tablet 6 Each Box,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096104,NDC,1,EA,41.72,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,37.1308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,16714081701,NDC,1,EA,75.78,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.1322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,16714081701,NDC,1,EA,75.78,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.1322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,16714081701,NDC,1,EA,75.78,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,37.1322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096105,NDC,1,EA,41.73,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,37.1397,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,63323094004,NDC,4,ML,89.43,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,37.149222,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,63323094021,NDC,4,ML,89.43,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,37.149222,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143978410,NDC,2,ML,37.91,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,37.1518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
HYDROmorphone 2 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409131203,NDC,1,ML,38.18,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,15.571,percent of total billed charges,37.160594,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
DULoxetine 20 MG Capsule Delayed Release Particles 60 Each Bottle,63700001,CDM,250,RC,,,,,,2323560,NDC,1,EA,41.76,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,37.1664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
FLEXITIP APPLICATOR 38CM,27200000,CDM,272,RC,,,,10200-MAIN,LOCAL,,,,,40.8,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,37.1688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Syringe,J7040.01,CDM,636,RC,J7040,HCPCS,,,,64253020230,NDC,10,ML,42.15,,United Healthcare,All Payer,outpatient,88.2,,0.191910792,percent of total billed charges,37.1763,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028426,NDC,1,EA,42.15,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,37.1763,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,50111078751,NDC,1,EA,41.79,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,37.1931,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
donepezil 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904640861,NDC,1,EA,41.79,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,37.1931,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DULoxetine 30 MG Capsule Delayed Release Particles 90 Each Bottle,63700001,CDM,250,RC,,,,,,57237001890,NDC,1,EA,42.17,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,37.19394,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 25 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,591319872,NDC,1,EA,77.51,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,37.2048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 25 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,591319872,NDC,1,EA,77.51,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,37.2048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505615204,NDC,0.5,EA,86.76,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,37.22004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
triamcinolone acetonide 40 MG/ML Suspension 1 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029305,NDC,1,ML,73.57,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,37.22642,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,72.0986
BIOPSY FORCEPS HOT,27200000,CDM,272,RC,,,,4353-MAIN,LOCAL,,,,,38.25,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,37.228725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRESSING GEL FOAM SIZE 100SPONGE STERILE 00009034201,27200000,CDM,272,RC,A6248,HCPCS,,3378-MAIN,LOCAL,,,,,38.25,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,37.228725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFFLATION TUBING SET,27200000,CDM,272,RC,,,,4686-MAIN,LOCAL,,,,,38.25,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,37.228725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
oxytocin 10 UNIT/ML Solution 1 mL Vial,J2590.01,CDM,636,RC,J2590,HCPCS,,,,42023011625,NDC,1,ML,43.8,,First Health,Commercial,both,85,,999999999,percent of total billed charges,37.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.19452,42.924
PRONEVIEW CUSHION INSERTS LARGE,120.557,CDM,272,RC,E0190,HCPCS,,12500-MAIN,LOCAL,,,,,76,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,37.23,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.72,37.23
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001302,NDC,2,ML,86.79,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,37.23291,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011701,NDC,1,EA,89.64,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,37.236456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011710,NDC,1,EA,89.64,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,37.236456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
8MM-12MM CANNULA SEAL 5-8MM,27200000,CDM,272,RC,,,,11921-MAIN,LOCAL,,,,,38,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,37.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Assay of Blood Lipoprotein,PX83721,CDM,300,RC,83721,CPT,,,,,,,,76,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.63,74.48
Assay of Blood Lipoprotein,PX83721,CDM,300,RC,83721,CPT,,,,,,,,76,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.63,74.48
Assay of Blood Lipoprotein,PX83721,CDM,300,RC,83721,CPT,,,,,,,,76,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,37.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.63,74.48
DRAPE COLUMN 470341,27200000,CDM,272,RC,,,,12013-MAIN,LOCAL,,,,,38,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,37.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HH Hha Visit,PXG0156,CDM,571,RC,G0156,HCPCS,,,,,,,,38,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,37.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
Lab Direct Coombs,PX86880,CDM,300,RC,86880,CPT,,,,,,,,76,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.5704,74.48
Lab Direct Coombs,PX86880,CDM,300,RC,86880,CPT,,,,,,,,76,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.5704,74.48
Lab Direct Coombs,PX86880,CDM,300,RC,86880,CPT,,,,,,,,76,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,37.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.5704,74.48
Mitochondrial Antibody Each,PX8638190,CDM,300,RC,86381,CPT,90,,,,,,,38,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,37.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
Nasal Sm for Eos,PX89190,CDM,300,RC,89190,CPT,,,,,,,,38,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,37.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.31,37.24
NEEDLE IV 19GA X .75IN HUBER POWERLOC SAFETY 0651934,120.85,CDM,272,RC,A4215,HCPCS,,12701-MAIN,LOCAL,,,,,38,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,37.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
NEEDLE IV 19GA X 1 IN HUBER POWERLOC SAFETY 0651910,120.85,CDM,272,RC,A4215,HCPCS,,12702-MAIN,LOCAL,,,,,38,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,37.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
NEEDLE IV 19GA X 1.5 IN HUBER POWERLOC SAFETY 0651915,120.85,CDM,272,RC,A4215,HCPCS,,12703-MAIN,LOCAL,,,,,38,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,37.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
PEZZER CATHETER DRAIN LATEX 14FR,27200000,CDM,272,RC,,,,12053-MAIN,LOCAL,,,,,38,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,37.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PEZZER LATEX CATHETER DRAIN 10FR,27200000,CDM,272,RC,,,,12646-MAIN,LOCAL,,,,,38,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,37.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PNEUVIEW SMOKE ELIMINATOR,27200000,CDM,272,RC,,,,11884-MAIN,LOCAL,,,,,38,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,37.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PRONEVIEW CUSHION INSERTS LARGE,120.557,CDM,272,RC,E0190,HCPCS,,12500-MAIN,LOCAL,,,,,76,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.5704,74.48
PRONEVIEW CUSHION INSERTS LARGE,120.557,CDM,272,RC,E0190,HCPCS,,12500-MAIN,LOCAL,,,,,76,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.5704,74.48
PRONEVIEW CUSHION INSERTS LARGE,120.557,CDM,272,RC,E0190,HCPCS,,12500-MAIN,LOCAL,,,,,76,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,37.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.5704,74.48
"Psa, Free - Ref",PX8415490,CDM,300,RC,84154,CPT,90,,,,,,,38,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,37.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
"Psa, Total - Ref",PX8415390,CDM,300,RC,84153,CPT,90,,,,,,,38,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,37.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
SHOE POST OP LARGE MALE MQM3B,120.237,CDM,274,RC,L3260,HCPCS,,794-MAIN,LOCAL,,,,,76,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP LARGE MALE MQM3B,120.237,CDM,274,RC,L3260,HCPCS,,794-MAIN,LOCAL,,,,,76,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP LARGE MALE MQM3B,120.237,CDM,274,RC,L3260,HCPCS,,794-MAIN,LOCAL,,,,,76,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,37.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP LARGE SQUARE TOE WOMENS ORT30300WL,120.237,CDM,274,RC,L3260,HCPCS,,10606-MAIN,LOCAL,,,,,76,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP LARGE SQUARE TOE WOMENS ORT30300WL,120.237,CDM,274,RC,L3260,HCPCS,,10606-MAIN,LOCAL,,,,,76,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP LARGE SQUARE TOE WOMENS ORT30300WL,120.237,CDM,274,RC,L3260,HCPCS,,10606-MAIN,LOCAL,,,,,76,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,37.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP MEDIUM SQUARE TOE MALE ORT30300MM,120.237,CDM,274,RC,L3260,HCPCS,,10603-MAIN,LOCAL,,,,,76,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP MEDIUM SQUARE TOE MALE ORT30300MM,120.237,CDM,274,RC,L3260,HCPCS,,10603-MAIN,LOCAL,,,,,76,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP MEDIUM SQUARE TOE MALE ORT30300MM,120.237,CDM,274,RC,L3260,HCPCS,,10603-MAIN,LOCAL,,,,,76,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,37.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP MEDIUM SQUARE TOE WOMENS ORT30300WM,120.237,CDM,274,RC,L3260,HCPCS,,10605-MAIN,LOCAL,,,,,76,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP MEDIUM SQUARE TOE WOMENS ORT30300WM,120.237,CDM,274,RC,L3260,HCPCS,,10605-MAIN,LOCAL,,,,,76,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP MEDIUM SQUARE TOE WOMENS ORT30300WM,120.237,CDM,274,RC,L3260,HCPCS,,10605-MAIN,LOCAL,,,,,76,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,37.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP SMALL MALE 0814-1192,120.237,CDM,274,RC,L3260,HCPCS,,803-MAIN,LOCAL,,,,,76,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP SMALL MALE 0814-1192,120.237,CDM,274,RC,L3260,HCPCS,,803-MAIN,LOCAL,,,,,76,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP SMALL MALE 0814-1192,120.237,CDM,274,RC,L3260,HCPCS,,803-MAIN,LOCAL,,,,,76,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,37.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP SMALL SQUARE TOE WOMENS MQW1B,120.237,CDM,274,RC,L3260,HCPCS,,10604-MAIN,LOCAL,,,,,76,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP SMALL SQUARE TOE WOMENS MQW1B,120.237,CDM,274,RC,L3260,HCPCS,,10604-MAIN,LOCAL,,,,,76,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP SMALL SQUARE TOE WOMENS MQW1B,120.237,CDM,274,RC,L3260,HCPCS,,10604-MAIN,LOCAL,,,,,76,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,37.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SPECULUM VAGINAL WITH BUILT IN LIGHT LARGE,120.133,CDM,272,RC,,,,8251-MAIN,LOCAL,,,,,38,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,37.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
SPECULUM VAGINAL WITH BUILT IN LIGHT MEDIUM,120.133,CDM,272,RC,,,,8250-MAIN,LOCAL,,,,,38,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,37.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
SPECULUM VAGINAL WITH BUILT IN LIGHT SMALL,120.133,CDM,272,RC,,,,8249-MAIN,LOCAL,,,,,38,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,37.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7852,37.24
TROCAR KII FIOS SYSTEM BLADELSS Z-THREAD 5MMX100MM,27200000,CDM,272,RC,,,,12003-MAIN,LOCAL,,,,,38,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,37.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Lab Antibody ID,RBC",PX7605,CDM,300,RC,86870,CPT,,,,,,,,155,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,37.25,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.13,60.672
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041100,NDC,0.5,ML,196.94,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,37.26,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.48078,42.34
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041105,NDC,1,ML,419.67,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,37.26,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.48078,42.34
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041110,NDC,0.5,ML,196.94,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,37.26,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.48078,42.34
HYDROmorphone 0.1 MG/ML Solution 55 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,61553067976,NDC,55,ML,89.7,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,37.26138,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409663734,NDC,50,ML,89.7,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,37.26138,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Apply Short Leg Cast,Walker",PX29425F,CDM,510,RC,29425,CPT,,,,,,,,179,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,37.27,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.81,159.11
"Apply Short Leg Cast,Walker",PX29425P,CDM,983,RC,29425,CPT,,,,,,,,119,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,37.27,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.81,159.11
C Diff Amplified Probe,PX87493,CDM,300,RC,87493,CPT,,,,,,,,179,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,37.27,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.15,37.27
infuvite adult Injectable 10 mL Vial,J3490.99,CDM,636,RC,J3490,HCPCS,,,,54643564901,NDC,10,ML,86.89,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,37.27581,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.094106,85.1522
sodium polystyrene sulfonate Powder 15 g Bottle,25000000,CDM,250,RC,,,,,,10702003615,NDC,15,GR,76.09,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.2841,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium polystyrene sulfonate Powder 15 g Bottle,25000000,CDM,250,RC,,,,,,10702003615,NDC,15,GR,76.09,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.2841,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium polystyrene sulfonate Powder 15 g Bottle,25000000,CDM,250,RC,,,,,,10702003615,NDC,15,GR,76.09,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,37.2841,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024110,NDC,1,EA,76.1,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.289,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024110,NDC,1,EA,76.1,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.289,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024110,NDC,1,EA,76.1,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,37.289,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
SUCTION TIP POOLE STERILE 35040,27200000,CDM,272,RC,,,,977-MAIN,LOCAL,,,,,42.28,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,37.29096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070548,NDC,100,ML,40.94,,Medica,Commercial,both,91.1,,1.111818182,percent of total billed charges,37.29634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,4080285,NDC,1,EA,89.79,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,37.298766,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490334,NDC,5,ML,42.29,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,37.29978,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
tetracycline 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,51991090701,NDC,0.5,EA,42.29,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,37.29978,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Spinal Puncture,Lumbar,Diagnostic",PX62270F,CDM,510,RC,62270,CPT,,,,,,,,684,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,37.3,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.3,303.7
"Spinal Puncture,Lumbar,Diagnostic",PX62270P,CDM,983,RC,62270,CPT,,,,,,,,705,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,37.3,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.3,690.9
magnesium sulfate 4 GM/50ML Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010701,NDC,50,ML,73.72,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,37.30232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078110,NDC,0.5,EA,38.33,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,37.306589,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,47781046813,NDC,1,EA,76.15,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.3135,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,47781046813,NDC,1,EA,76.15,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.3135,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,47781046813,NDC,1,EA,76.15,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,37.3135,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,64380079701,NDC,1,EA,76.15,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.3135,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,64380079701,NDC,1,EA,76.15,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.3135,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,64380079701,NDC,1,EA,76.15,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,37.3135,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Chemotherapy, IV Push, Additional Drug",PX96411,CDM,335,RC,96411,CPT,,,,,,,,87,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,37.323,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.1398,85.26
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,55150016205,NDC,5,ML,42.32,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,37.32624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004703,NDC,1,EA,75.45,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,37.34775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
Dihydroxyvitamin D - Ref,PX8265290,CDM,300,RC,82652,CPT,90,,,,,,,165,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,37.35,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.35,38.5
Vit D 1 25-Dihydroxy,PX82652,CDM,300,RC,82652,CPT,,,,,,,,154,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,37.35,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.35,38.5
Dihydroxyvitamin D - Ref,PX8265290,CDM,300,RC,82652,CPT,90,,,,,,,165,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,37.35,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.35,38.5
Dihydroxyvitamin D - Ref,PX8265290,CDM,300,RC,82652,CPT,90,,,,,,,165,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,37.35,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.35,38.5
Vit D 1 25-Dihydroxy,PX82652,CDM,300,RC,82652,CPT,,,,,,,,154,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,37.35,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.35,38.5
Vit D 1 25-Dihydroxy,PX82652,CDM,300,RC,82652,CPT,,,,,,,,154,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,37.35,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.35,38.5
CANNULA SEAL 5-12MM UNIVERSAL 470500,27200000,CDM,272,RC,,,,12885-MAIN,LOCAL,,,,,41,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,37.351,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CUP HEEL LARGE WONDERSPUR 4502,120.43,CDM,274,RC,L3485,HCPCS,,11385-MAIN,LOCAL,,,,,41,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,37.351,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL MEDIUM WONDERSPUR 4501,120.43,CDM,274,RC,L3485,HCPCS,,11384-MAIN,LOCAL,,,,,41,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,37.351,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL SMALL WONDERSPUR 4500,120.43,CDM,274,RC,L3485,HCPCS,,11383-MAIN,LOCAL,,,,,41,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,37.351,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL XL WONDERSPUR 4503,120.43,CDM,274,RC,L3485,HCPCS,,11386-MAIN,LOCAL,,,,,41,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,37.351,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
Detection of Anaplasma Phagocytophilum by Amplified Nucleic Acid Probe Technique,PX8746890,CDM,300,RC,87468,CPT,90,,,,,,,41,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,37.351,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
Detection of Ehrlichia Chaffeensis by Amplified Nucleic Acid Probe Technique,PX8748490,CDM,300,RC,87484,CPT,90,,,,,,,41,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,37.351,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 21G 110MM SONOTAP II WITH FACET TIP 1285-3F110,120.483,CDM,271,RC,A4215,HCPCS,,12201-MAIN,LOCAL,,,,,41,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,37.351,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 21G X 4IN (100MM) SONOBLOCK II NERVE BLOCK WITH FACET S TIP 001281-77,120.483,CDM,271,RC,A4215,HCPCS,,12761-MAIN,LOCAL,,,,,41,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,37.351,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 22G 80MM SONOTAP II WITH FACET TIP 1285-3E080,120.483,CDM,271,RC,A4215,HCPCS,,12103-MAIN,LOCAL,,,,,41,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,37.351,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 22G X 3.25IN (80MM) SONOBLOCK II  NERVE BLOCK WITH FACET S TIP 001281-71,120.483,CDM,271,RC,A4215,HCPCS,,12760-MAIN,LOCAL,,,,,41,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,37.351,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 22GX2 SONOPLEX II WITH FACET S TIP 001287-74,120.483,CDM,271,RC,A4215,HCPCS,,13110-MAIN,LOCAL,,,,,41,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,37.351,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE NON-STIMULATING 22GX2 SONOBLOCK II WITH FACET S TIP 001281-74,120.483,CDM,271,RC,A4215,HCPCS,,11459-MAIN,LOCAL,,,,,41,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,37.351,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE SONOPLEX II STIMULATING WITH FACET S TIP 22GX3-1/4,120.483,CDM,271,RC,A4215,HCPCS,,11457-MAIN,LOCAL,,,,,41,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,37.351,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE STIMULATING 21GX4  SONOPLEX II  WITH FACET S TIP 001287-77,120.483,CDM,271,RC,A4215,HCPCS,,11458-MAIN,LOCAL,,,,,41,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,37.351,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
STRAP FOOT LG/XL GEL UNIVERSAL 10165,120.428,CDM,271,RC,,,,11382-MAIN,LOCAL,,,,,41,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,37.351,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
STRAP FOOT SM/MED GEL UNIVERSAL 10155,120.428,CDM,271,RC,,,,11381-MAIN,LOCAL,,,,,41,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,37.351,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
SUTURE V-LOC SZ 1/2 180 GREEN GS-21 VLOCL0316,27200000,CDM,272,RC,,,,11932-MAIN,LOCAL,,,,,41,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,37.351,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
URGOK2 DUAL COMPRESSION SYSTEM LARGE,120.491,CDM,271,RC,A6452,HCPCS,,11871-MAIN,LOCAL,,,,,41,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,37.351,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
URGOK2 DUAL COMPRESSION SYSTEM REGULAR,120.491,CDM,271,RC,A6452,HCPCS,,11870-MAIN,LOCAL,,,,,41,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,37.351,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
"SUTURE ETHIBOND #0 CT-1 CR 8-18"" CX21D",27200000,CDM,272,RC,,,,6415-MAIN,LOCAL,,,,,41.97,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,37.3533,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
droPERidol 2.5 MG/ML Solution 2 mL Vial,J1790.01,CDM,636,RC,J1790,HCPCS,,,,517970201,NDC,2,ML,75.47,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,37.35765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.350238,73.9606
Aldosterone - Ref,PX8208890,CDM,300,RC,82088,CPT,90,,,,,,,86,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,37.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.7244,84.28
Flow Cyto Ea Addtl Marker - Ref,PX8818590,CDM,310,RC,88185,CPT,90,,,,,,,165,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,37.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.12,38.816
Flow Cyto Ea Addtl Marker - Ref,PX8818590,CDM,310,RC,88185,CPT,90,,,,,,,165,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,37.36,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.12,38.816
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; Add'l",PX88185,CDM,310,RC,88185,CPT,,,,,,,,96,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,37.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.12,38.816
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; Add'l",PX88185,CDM,310,RC,88185,CPT,,,,,,,,96,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,37.36,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.12,38.816
caffeine citrate 60 MG/3ML Solution 3 mL Vial,J0706.01,CDM,636,RC,J0706,HCPCS,,,,63323040704,NDC,3,ML,73.84,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,37.36304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.673136,72.3632
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253022233,NDC,3,ML,38.13,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,37.3674,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331601,NDC,10,ML,77.86,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,37.3728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331601,NDC,10,ML,77.86,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,37.3728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,409508411,NDC,1,EA,73.86,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,37.37316,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
Actin Antibody Each,PX8601590,CDM,300,RC,86015,CPT,90,,,,,,,42,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,37.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.05,41.16
Assay Vitamin B-6,PX84207,CDM,300,RC,84207,CPT,90,,,,,,,42,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,37.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
"BOUGIE TRACH 10FR 70CM COUDE 	9-0211-70",120.199,CDM,272,RC,A7520,HCPCS,,11112-MAIN,LOCAL,,,,,42,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,37.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
BOUGIE TRACHEAL TUBE & GUIDE 100123515,120.199,CDM,272,RC,A7520,HCPCS,,8950-MAIN,LOCAL,,,,,42,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,37.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
CATHETER PUREWICK FEMALE EXTERNAL PWF030K,120.414,CDM,272,RC,A6590,HCPCS,,11836-MAIN,LOCAL,,,,,42,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,37.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
Culture Type Immunologic,PX87147,CDM,300,RC,87147,CPT,,,,,,,,42,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,37.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,41.16
EZ-STABILIZER DRESSING,120.415,CDM,272,RC,,,,9058-MAIN,LOCAL,,,,,42,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,37.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
MEPILEX AG FOAM 4X4,120.192,CDM,272,RC,A6213,HCPCS,,8480-MAIN,LOCAL,,,,,42,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,37.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
MEPILEX AG FOAM 4X8,120.192,CDM,272,RC,A6213,HCPCS,,8479-MAIN,LOCAL,,,,,42,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,37.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY CENTRAL LINE DRESSING WITH CHLORAPREP DYND75234,120.68,CDM,272,RC,,,,10923-MAIN,LOCAL,,,,,42,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,37.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY FOLEY 14FR CATHETER A300414A,120.414,CDM,272,RC,A4344,HCPCS,,11281-MAIN,LOCAL,,,,,42,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,37.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY FOLEY 16FR CATHETER 300416A,120.414,CDM,272,RC,A4344,HCPCS,,11774-MAIN,LOCAL,,,,,42,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,37.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
"TRAY SPINAL  25GX3.5"" WITH WHITEACRE 405671",120.275,CDM,272,RC,,,,3284-MAIN,LOCAL,,,,,42,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,37.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY SPINAL 25G ANESTH SADDLE BLOCK NLD-4795-20,120.275,CDM,272,RC,,,,935-MAIN,LOCAL,,,,,42,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,37.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
"Gammaglobulin; Iga, Dg,M - Ref",PX8278490,CDM,300,RC,82784,CPT,90,,,,,,,90,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,37.386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.53,88.2
"Misc Virus Antibody, Nos - Ref",PX8679090,CDM,300,RC,86790,CPT,90,,,,,,,90,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,37.386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.81,88.2
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152P,CDM,983,RC,99152,CPT,,,,,,,,90,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,37.386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.386,87.597
Mycobacteria Culture - Ref,PX8711690,CDM,300,RC,87116,CPT,90,,,,,,,90,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,37.386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9,88.2
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,17478004001,NDC,1,ML,42.39,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,37.38798,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046837,NDC,30,ML,75.54,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,37.3923,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
CANNULA ADULT LARGE OPTIFLOW OPT946,120.495,CDM,271,RC,A4615,HCPCS,,11622-MAIN,LOCAL,,,,,44,,First Health,Commercial,both,85,,999999999,percent of total billed charges,37.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
CANNULA ADULT MEDIUM OPTIFLOW OPT944,120.495,CDM,271,RC,A4615,HCPCS,,11621-MAIN,LOCAL,,,,,44,,First Health,Commercial,both,85,,999999999,percent of total billed charges,37.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
CANNULA ADULT SMALL OPTIFLOW OPT942,120.495,CDM,271,RC,A4615,HCPCS,,11620-MAIN,LOCAL,,,,,44,,First Health,Commercial,both,85,,999999999,percent of total billed charges,37.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
Homocysteine,PX83090,CDM,300,RC,83090,CPT,,,,,,,,44,,First Health,Commercial,both,85,,999999999,percent of total billed charges,37.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.43,43.12
KIT GASTRIC LAVAGE 2075,120.257,CDM,272,RC,C7510,HCPCS,,410-MAIN,LOCAL,,,,,44,,First Health,Commercial,both,85,,999999999,percent of total billed charges,37.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
SUTURE V-LOC 1/2 CIRCLE NEEDLE WOUND CLOSURE DEVICE VLOCN0306,27200000,CDM,272,RC,,,,11931-MAIN,LOCAL,,,,,44,,First Health,Commercial,both,85,,999999999,percent of total billed charges,37.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE V-LOC SZ 3-0 180 GREEN V-20 9 INCH VLOCL0644,27200000,CDM,272,RC,,,,13056-SURG,LOCAL,,,,,44,,First Health,Commercial,both,85,,999999999,percent of total billed charges,37.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Infliximab - Ref,PX8023090,CDM,300,RC,80230,CPT,90,,,,,,,343,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,37.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.41,38.57
Infliximab - Ref,PX8023090,CDM,300,RC,80230,CPT,90,,,,,,,343,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,37.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.41,38.57
Vedolizumab - Ref,PX8028090,CDM,300,RC,80280,CPT,90,,,,,,,468,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,37.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.41,38.57
Vedolizumab - Ref,PX8028090,CDM,300,RC,80280,CPT,90,,,,,,,468,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,37.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.41,38.57
Infliximab - Ref,PX8023090,CDM,300,RC,80230,CPT,90,,,,,,,343,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,37.41,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.41,38.57
Vedolizumab - Ref,PX8028090,CDM,300,RC,80280,CPT,90,,,,,,,468,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,37.41,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.41,38.57
HYDROmorphone 2 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409131203,NDC,1,ML,38.18,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,37.4164,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049257,NDC,5,ML,42.43,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,37.42326,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409427602,NDC,50,ML,38.46,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,37.433118,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
enalaprilat 1.25 MG/ML Injectable 2 mL Vial,25000000,CDM,250,RC,,,,,,143978601,NDC,2,ML,75.63,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,37.43685,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Ceruloplasmin - Ref,PX8239090,CDM,300,RC,82390,CPT,90,,,,,,,78,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,37.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,76.44
Ceruloplasmin - Ref,PX8239090,CDM,300,RC,82390,CPT,90,,,,,,,78,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,37.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,76.44
Chemiluminescent Assay - Ref,PX8239790,CDM,300,RC,82397,CPT,90,,,,,,,78,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,37.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.95,76.44
Chemiluminescent Assay - Ref,PX8239790,CDM,300,RC,82397,CPT,90,,,,,,,78,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,37.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.95,76.44
VISUALIZATION SYSTEM CLEARIFY LAPAROSCOPE STERILE,27200000,CDM,272,RC,,,,11875-MAIN,LOCAL,,,,,78,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,37.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
VISUALIZATION SYSTEM CLEARIFY LAPAROSCOPE STERILE,27200000,CDM,272,RC,,,,11875-MAIN,LOCAL,,,,,78,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,37.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,63323041536,NDC,0.5,ML,44.05,,First Health,Commercial,both,85,,999999999,percent of total billed charges,37.4425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
Glucose Test,PX82950,CDM,300,RC,82950,CPT,,,,,,,,74,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,37.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.36,72.52
KIT EMERGENCY BIRTH DYNJS0600,120.317,CDM,272,RC,,,,8344-MAIN,LOCAL,,,,,74,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,37.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.7396,72.52
Rubeola Antibody,PX86765,CDM,300,RC,86765,CPT,,,,,,,,74,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,37.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.81,72.52
HH Ot Initial Visit,PXG0152,CDM,431,RC,G0152,HCPCS,GO,,,,,,,,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,37.45,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.45,37.45
HH Ot Routine Visit,PXG0152.01,CDM,431,RC,G0152,HCPCS,GO,,,,,,,,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,37.45,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.45,37.45
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,24208031510,NDC,10,ML,75.67,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,37.45665,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Acth - Ref,PX8202490,CDM,300,RC,82024,CPT,90,,,,,,,259,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,37.46,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.46,38.62
Acth - Ref,PX8202490,CDM,300,RC,82024,CPT,90,,,,,,,259,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,37.46,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.46,38.62
Acth - Ref,PX8202490,CDM,300,RC,82024,CPT,90,,,,,,,259,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,37.46,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.46,38.62
TROCAR KII BALLOON 12MM STERILE,27200000,CDM,272,RC,,,,11703-MAIN,LOCAL,,,,,41.14,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,37.47854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR KII BALLOON BLUNT 12MM STERILE,27200000,CDM,272,RC,,,,11702-MAIN,LOCAL,,,,,41.14,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,37.47854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
BIOPSY FORCEPS HOT,27200000,CDM,272,RC,,,,4353-MAIN,LOCAL,,,,,38.25,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,37.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRESSING GEL FOAM SIZE 100SPONGE STERILE 00009034201,27200000,CDM,272,RC,A6248,HCPCS,,3378-MAIN,LOCAL,,,,,38.25,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,37.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFFLATION TUBING SET,27200000,CDM,272,RC,,,,4686-MAIN,LOCAL,,,,,38.25,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,37.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ketorolac 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314012605,NDC,5,ML,42.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,37.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
leflunomide 20 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,70748013006,NDC,0.5,EA,44.1,,First Health,Commercial,both,85,,999999999,percent of total billed charges,37.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409338513,NDC,1,EA,74.09,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,37.48954,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
levothyroxine Sodium 200 MCG Recon Soln 1 Each Vial,J0650.01,CDM,636,RC,J0650,HCPCS,,,,63323064710,NDC,0.0625,EA,75.75,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,37.49625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.46655,74.235
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641622901,NDC,1,ML,41.16,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,37.49676,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.097864,86.9162
DIMETHICONE (TOPICAL) 5 % Cream 118 mL Tube,800000,CDM,,,,,,,,53329015104,NDC,118,ML,44.12,,First Health,Commercial,both,85,,999999999,percent of total billed charges,37.502,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
phenol-glycerin 1.5-33 % Liquid 118 mL Bottle,25000000,CDM,250,RC,,,,,,78112000068,NDC,118,ML,44.12,,First Health,Commercial,both,85,,999999999,percent of total billed charges,37.502,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Spinal Puncture,Lumbar,Diagnostic",PX62270F,CDM,510,RC,62270,CPT,,,,,,,,684,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,37.51,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.3,303.7
"Spinal Puncture,Lumbar,Diagnostic",PX62270F,CDM,510,RC,62270,CPT,,,,,,,,684,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,37.51,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.3,303.7
"Spinal Puncture,Lumbar,Diagnostic",PX62270P,CDM,983,RC,62270,CPT,,,,,,,,705,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,37.51,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.3,690.9
"Spinal Puncture,Lumbar,Diagnostic",PX62270P,CDM,983,RC,62270,CPT,,,,,,,,705,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,37.51,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.3,690.9
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,16714081701,NDC,1,EA,75.78,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,37.5111,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Syringe,J7040.01,CDM,636,RC,J7040,HCPCS,,,,64253020230,NDC,10,ML,42.15,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,37.5135,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028426,NDC,1,EA,42.15,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,37.5135,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
"dextran 70, glycerin, hypromellose 0.1-0.2-0.3 % Solution 15 mL Bottle",63700001,CDM,250,RC,,,,,,65042636,NDC,15,ML,44.14,,First Health,Commercial,both,85,,999999999,percent of total billed charges,37.519,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
valACYclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069801,NDC,1,EA,38.55,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,37.520715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DULoxetine 30 MG Capsule Delayed Release Particles 90 Each Bottle,63700001,CDM,250,RC,,,,,,57237001890,NDC,1,EA,42.17,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,37.5313,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
mycophenolate 500 MG Tablet 100 Each Bottle,J7517.01,CDM,637,RC,J7517,HCPCS,,,,64380072506,NDC,1,EA,42.56,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,37.53792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.679424,41.7088
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078110,NDC,0.5,EA,38.33,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,37.5634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070948,NDC,100,ML,42.59,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,37.56438,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034020,NDC,1,EA,76.67,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.5683,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034020,NDC,1,EA,76.67,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.5683,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034020,NDC,1,EA,76.67,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,37.5683,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034021,NDC,1,EA,76.67,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.5683,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034021,NDC,1,EA,76.67,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.5683,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034021,NDC,1,EA,76.67,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,37.5683,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
LAP KIT BASIC,27200000,CDM,272,RC,,,,4829-MAIN,LOCAL,,,,,78.29,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,37.5792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LAP KIT BASIC,27200000,CDM,272,RC,,,,4829-MAIN,LOCAL,,,,,78.29,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,37.5792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,143957501,NDC,50,ML,44.24,,First Health,Commercial,both,85,,999999999,percent of total billed charges,37.604,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,143957510,NDC,50,ML,44.24,,First Health,Commercial,both,85,,999999999,percent of total billed charges,37.604,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361250,NDC,50,ML,90.53,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,37.606162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361650,NDC,50,ML,90.53,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,37.606162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028016,NDC,2,ML,41.29,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,37.61519,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
Assay of Blood Lipoprotein,PX83721,CDM,300,RC,83721,CPT,,,,,,,,76,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,37.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.63,74.48
Lab Direct Coombs,PX86880,CDM,300,RC,86880,CPT,,,,,,,,76,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,37.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.5704,74.48
PRONEVIEW CUSHION INSERTS LARGE,120.557,CDM,272,RC,E0190,HCPCS,,12500-MAIN,LOCAL,,,,,76,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,37.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.5704,74.48
SHOE POST OP LARGE MALE MQM3B,120.237,CDM,274,RC,L3260,HCPCS,,794-MAIN,LOCAL,,,,,76,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,37.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP LARGE SQUARE TOE WOMENS ORT30300WL,120.237,CDM,274,RC,L3260,HCPCS,,10606-MAIN,LOCAL,,,,,76,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,37.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP MEDIUM SQUARE TOE MALE ORT30300MM,120.237,CDM,274,RC,L3260,HCPCS,,10603-MAIN,LOCAL,,,,,76,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,37.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP MEDIUM SQUARE TOE WOMENS ORT30300WM,120.237,CDM,274,RC,L3260,HCPCS,,10605-MAIN,LOCAL,,,,,76,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,37.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP SMALL MALE 0814-1192,120.237,CDM,274,RC,L3260,HCPCS,,803-MAIN,LOCAL,,,,,76,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,37.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP SMALL SQUARE TOE WOMENS MQW1B,120.237,CDM,274,RC,L3260,HCPCS,,10604-MAIN,LOCAL,,,,,76,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,37.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
methylPREDNISolone acetate 20 MG/ML Suspension 5 mL Vial,J1010.01,CDM,636,RC,J1010,HCPCS,,,,9027401,NDC,0.5,ML,41.3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,37.6243,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.15602,40.474
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,69543025204,NDC,118,ML,78.39,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,37.6272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,69543025204,NDC,118,ML,78.39,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,37.6272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SUCTION TIP POOLE STERILE 35040,27200000,CDM,272,RC,,,,977-MAIN,LOCAL,,,,,42.28,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,37.6292,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
FORCEPS SERRATED WITH SPIKE JUMBO 230CM,27200000,CDM,272,RC,,,,7416-MAIN,LOCAL,,,,,41.31,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,37.63341,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ampicillin 500 MG Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781925078,NDC,1,EA,44.28,,First Health,Commercial,both,85,,999999999,percent of total billed charges,37.638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490334,NDC,5,ML,42.29,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,37.6381,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
tetracycline 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,51991090701,NDC,0.5,EA,42.29,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,37.6381,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nafcillin 2 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,S0032,HCPCS,,,,63323032820,NDC,1,EA,185.37,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,37.648,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.38,37.648
nafcillin 2 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,S0032,HCPCS,,,,63323032820,NDC,1,EA,185.37,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,37.648,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.38,37.648
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049237,NDC,30,ML,87.77,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,37.65333,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
acyclovir 50 MG/ML Solution 20 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,63323032524,NDC,20,ML,76.86,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.6614,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.927644,105.9968
acyclovir 50 MG/ML Solution 20 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,63323032524,NDC,20,ML,76.86,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.6614,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.927644,105.9968
acyclovir 50 MG/ML Solution 20 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,63323032524,NDC,20,ML,76.86,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,37.6614,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.927644,105.9968
sodium polystyrene sulfonate Powder 15 g Bottle,25000000,CDM,250,RC,,,,,,10702003615,NDC,15,GR,76.09,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,37.66455,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,55150016205,NDC,5,ML,42.32,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,37.6648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024110,NDC,1,EA,76.1,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,37.6695,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409132305,NDC,5,ML,41.35,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,37.66985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915701,NDC,0.5,ML,44.33,,First Health,Commercial,both,85,,999999999,percent of total billed charges,37.6805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915731,NDC,0.5,ML,44.33,,First Health,Commercial,both,85,,999999999,percent of total billed charges,37.6805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,47335093140,NDC,0.5,EA,44.33,,First Health,Commercial,both,85,,999999999,percent of total billed charges,37.6805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,47335093144,NDC,0.5,EA,44.33,,First Health,Commercial,both,85,,999999999,percent of total billed charges,37.6805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037601,NDC,1,ML,76.9,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,12.26041667,percent of total billed charges,37.681,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037601,NDC,1,ML,76.9,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.681,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037601,NDC,1,ML,76.9,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,37.681,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409427602,NDC,50,ML,38.46,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,37.6908,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,47781046813,NDC,1,EA,76.15,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,37.69425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,64380079701,NDC,1,EA,76.15,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,37.69425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ticagrelor 90 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,186077739,NDC,1,EA,44.35,,First Health,Commercial,both,85,,999999999,percent of total billed charges,37.6975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
solifenacin 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50228042730,NDC,1,EA,74.52,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,37.70712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
protamine 10 MG/ML Solution 25 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022930,NDC,2.5,ML,44.37,,First Health,Commercial,both,85,,999999999,percent of total billed charges,37.7145,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.431298,83.0452
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,36000014801,NDC,2,ML,38.76,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,37.725108,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,17478004001,NDC,1,ML,42.39,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,37.7271,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
Alpha-Fetoprotein Serum,PX82105,CDM,300,RC,82105,CPT,,,,,,,,77,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.38,75.46
Alpha-Fetoprotein Serum,PX82105,CDM,300,RC,82105,CPT,,,,,,,,77,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.38,75.46
Alpha-Fetoprotein Serum,PX82105,CDM,300,RC,82105,CPT,,,,,,,,77,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,37.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.38,75.46
BRACE WRIST HAND THUMB LEFT 455-LT,120.315,CDM,274,RC,L3809,HCPCS,,8283-MAIN,LOCAL,,,,,77,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,6.8,percent of total billed charges,37.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.9858,245.51
BRACE WRIST HAND THUMB LEFT 455-LT,120.315,CDM,274,RC,L3809,HCPCS,,8283-MAIN,LOCAL,,,,,77,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.9858,245.51
BRACE WRIST HAND THUMB LEFT 455-LT,120.315,CDM,274,RC,L3809,HCPCS,,8283-MAIN,LOCAL,,,,,77,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,37.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.9858,245.51
BRACE WRIST HAND THUMB RIGHT 455-RT,120.315,CDM,274,RC,L3809,HCPCS,,8284-MAIN,LOCAL,,,,,77,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,6.8,percent of total billed charges,37.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.9858,245.51
BRACE WRIST HAND THUMB RIGHT 455-RT,120.315,CDM,274,RC,L3809,HCPCS,,8284-MAIN,LOCAL,,,,,77,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.9858,245.51
BRACE WRIST HAND THUMB RIGHT 455-RT,120.315,CDM,274,RC,L3809,HCPCS,,8284-MAIN,LOCAL,,,,,77,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,37.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.9858,245.51
CAUTERY HIGH TEMP LOOP TIP,120.21,CDM,272,RC,,,,332-MAIN,LOCAL,,,,,77,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
CAUTERY HIGH TEMP LOOP TIP,120.21,CDM,272,RC,,,,332-MAIN,LOCAL,,,,,77,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
CAUTERY HIGH TEMP LOOP TIP,120.21,CDM,272,RC,,,,332-MAIN,LOCAL,,,,,77,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,37.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
Debride Skin/Tissue,PX11042F,CDM,510,RC,11042,CPT,,,,,,,,1067,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,37.73,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.08,269.8
Debride Skin/Tissue,PX11042F,CDM,510,RC,11042,CPT,,,,,,,,1067,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,37.73,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.08,269.8
Debride Skin/Tissue,PX11042P,CDM,983,RC,11042,CPT,,,,,,,,995,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,37.73,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.08,975.1
Debride Skin/Tissue,PX11042P,CDM,983,RC,11042,CPT,,,,,,,,995,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,37.73,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.08,975.1
NEEDLE ACUJECT 25GA VARIABLE INJECTION VIN-25,27200000,CDM,272,RC,,,,7412-MAIN,LOCAL,,,,,77,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NEEDLE ACUJECT 25GA VARIABLE INJECTION VIN-25,27200000,CDM,272,RC,,,,7412-MAIN,LOCAL,,,,,77,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NEEDLE ACUJECT 25GA VARIABLE INJECTION VIN-25,27200000,CDM,272,RC,,,,7412-MAIN,LOCAL,,,,,77,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,37.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Remove Additional Nail Plate,PX11732F,CDM,510,RC,11732,CPT,,,,,,,,77,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.9858,75.46
Remove Additional Nail Plate,PX11732F,CDM,510,RC,11732,CPT,,,,,,,,77,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.9858,75.46
Remove Additional Nail Plate,PX11732F,CDM,510,RC,11732,CPT,,,,,,,,77,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,37.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.9858,75.46
"B Cells, Total Count",PX86355,CDM,300,RC,86355,CPT,,,,,,,,56,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,37.73,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.6,37.73
"Biopsy, Nail Unit",PX11755F,CDM,510,RC,11755,CPT,,,,,,,,1490,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,37.73,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.73,253.89
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028026,NDC,2,ML,41.42,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,37.73362,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
venetoclax 100 MG Tablet 1 Each Box,25000000,CDM,250,RC,,,,,,74057611,NDC,0.2,EA,90.87,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,37.747398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Apply of Paste Boot,PX29580P,CDM,983,RC,29580,CPT,,,,,,,,88,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,37.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.5552,137.65
POSITIONING KIT TRENDELENBURG NUBLUE TP 3000-NB,27100000,CDM,271,RC,,,,12992-MAIN,LOCAL,,,,,88,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,37.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
SPLINT ANKLE GEL BRACE UNIVERSAL AIRFORM 70351,120.61,CDM,274,RC,L4350,HCPCS,,12342-MAIN,LOCAL,,,,,88,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,37.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.5552,104.38
SUCTION IRRIGATOR 2 0250070500,27200000,CDM,272,RC,,,,12262-MAIN,LOCAL,,,,,88,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,37.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
valACYclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,31722070430,NDC,1,EA,38.79,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,37.754307,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049257,NDC,5,ML,42.43,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,37.7627,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
valACYclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069801,NDC,1,EA,38.55,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,37.779,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
leflunomide 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,62332006130,NDC,1,EA,88.09,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,37.79061,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,703903201,NDC,2,ML,44.46,,First Health,Commercial,both,85,,999999999,percent of total billed charges,37.791,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,97.0102
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2021301,NDC,3,ML,44.46,,First Health,Commercial,both,85,,999999999,percent of total billed charges,37.791,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001326,NDC,1,ML,42.88,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,37.82016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001341,NDC,1,ML,42.88,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,37.82016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
ketorolac 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314012605,NDC,5,ML,42.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,37.825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fluticasone-salmeterol 100-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069500,NDC,1,EA,38.87,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,37.832171,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049209,NDC,5,ML,44.52,,First Health,Commercial,both,85,,999999999,percent of total billed charges,37.842,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,436067216,NDC,473,ML,77.23,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.8427,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,436067216,NDC,473,ML,77.23,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.8427,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,436067216,NDC,473,ML,77.23,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,37.8427,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,39328006412,NDC,473,ML,77.23,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.8427,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,39328006412,NDC,473,ML,77.23,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.8427,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,39328006412,NDC,473,ML,77.23,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,37.8427,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012250,NDC,1,EA,77.24,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.8476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012250,NDC,1,EA,77.24,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.8476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012250,NDC,1,EA,77.24,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,37.8476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012267,NDC,1,EA,77.24,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.8476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012267,NDC,1,EA,77.24,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.8476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012267,NDC,1,EA,77.24,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,37.8476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
cefOXitin 2 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021011020,NDC,1,EA,77.24,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.8476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.367364,75.6952
cefOXitin 2 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021011020,NDC,1,EA,77.24,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.8476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.367364,75.6952
cefOXitin 2 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021011020,NDC,1,EA,77.24,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,37.8476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.367364,75.6952
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023610,NDC,1,EA,77.24,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.8476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023610,NDC,1,EA,77.24,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.8476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023610,NDC,1,EA,77.24,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,37.8476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
RETRIEVAL BAG 10MM,27200000,CDM,272,RC,,,,11707-MAIN,LOCAL,,,,,74.8,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,37.8488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Lab Pth Immunoch Part 1,PX83970,CDM,300,RC,83970,CPT,,,,,,,,128,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,37.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.85,125.44
bezlotoxumab 1000 MG/40ML Solution 40 mL Vial,J0565.01,CDM,636,RC,J0565,HCPCS,,,,6302500,NDC,40,ML,7752,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,37.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.31,39.86
bezlotoxumab 1000 MG/40ML Solution 40 mL Vial,J0565.01,CDM,636,RC,J0565,HCPCS,,,,6302500,NDC,40,ML,7752,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,37.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.31,39.86
buprenorphine 8 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,54017713,NDC,1,EA,41.56,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,37.86116,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.14,40.7288
Acth - Ref,PX8202490,CDM,300,RC,82024,CPT,90,,,,,,,259,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,37.8662,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.46,38.62
Dihydroxyvitamin D - Ref,PX8265290,CDM,300,RC,82652,CPT,90,,,,,,,165,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,37.8662,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.35,38.5
Infliximab - Ref,PX8023090,CDM,300,RC,80230,CPT,90,,,,,,,343,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,37.8662,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.41,38.57
Vedolizumab - Ref,PX8028090,CDM,300,RC,80280,CPT,90,,,,,,,468,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,37.8662,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.41,38.57
Vit D 1 25-Dihydroxy,PX82652,CDM,300,RC,82652,CPT,,,,,,,,154,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,37.8662,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.35,38.5
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019602,NDC,2,ML,77.29,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.8721,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019602,NDC,2,ML,77.29,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.8721,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019602,NDC,2,ML,77.29,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,37.8721,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
mycophenolate 500 MG Tablet 100 Each Bottle,J7517.01,CDM,637,RC,J7517,HCPCS,,,,64380072506,NDC,1,EA,42.56,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,37.8784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.679424,41.7088
"Apply Forearm Splint,Static",PX29125F,CDM,510,RC,29125,CPT,,,,,,,,223,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,37.8898,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.08,141.82
"Apply Forearm Splint,Static",PX29125P,CDM,983,RC,29125,CPT,,,,,,,,296,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,37.8898,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.08,290.08
"Remv F.B.,Eye,Cornea,No Slit",PX65220F,CDM,510,RC,65220,CPT,,,,,,,,334,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,37.8898,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.52,125.91
"Remv F.B.,Eye,Cornea,No Slit",PX65220P,CDM,983,RC,65220,CPT,,,,,,,,318,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,37.8898,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.52,311.64
betamethasone acetate-betamethasone sodium phosphate 6 (3-3) MG/ML Suspension 5 mL Vial,J0702.01,CDM,636,RC,J0702,HCPCS,,,,517072001,NDC,1,ML,78.96,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,37.9008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.799984,77.3808
betamethasone acetate-betamethasone sodium phosphate 6 (3-3) MG/ML Suspension 5 mL Vial,J0702.01,CDM,636,RC,J0702,HCPCS,,,,517072001,NDC,1,ML,78.96,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,37.9008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.799984,77.3808
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004722,NDC,2,ML,88.35,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,37.90215,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070948,NDC,100,ML,42.59,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,37.9051,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
Everolimus,PX8016990,CDM,300,RC,80169,CPT,,,,,,,,79,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,37.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,77.42
Everolimus,PX8016990,CDM,300,RC,80169,CPT,,,,,,,,79,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,37.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,77.42
Antinuclear Antibodiesana - Ref,PX8603890,CDM,300,RC,86038,CPT,90,,,,,,,43,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,37.926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.09,42.14
Blood Type Antigen Donor Ea,PX86902,CDM,300,RC,86902,CPT,,,,,,,,43,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,37.926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.8622,314.02
ETRAP POLYP TRAP,27200000,CDM,272,RC,,,,11282-MAIN,LOCAL,,,,,43,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,37.926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Smking Cess 4-10 Min,PX99406P,CDM,983,RC,99406,CPT,,,,,,,,43,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,37.926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.8622,41.8519
"Testosterone, Total - Ref",PX8440390,CDM,300,RC,84403,CPT,90,,,,,,,43,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,37.926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.8622,42.14
Eval of Bronchospasm,PX94060,CDM,983,RC,94060,CPT,,,,,,,,176,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,37.937,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.08,172.48
morphine 2 MG/ML Solution 1 mL Syringe,J2272.01,CDM,636,RC,J2272,HCPCS,,,,76045000401,NDC,1,ML,38.98,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,18.01923077,percent of total billed charges,37.939234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.192292,38.2004
Infectious Agent Antigen Detection by Immunoassay With Direct Visual Observation.,PX87811,CDM,300,RC,87811,CPT,,,,,,,,192,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,37.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.94,188.16
Emergency Level II Visit,PX99282P,CDM,981,RC,99282,CPT,,,,,,,,337,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,37.9488,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.53,330.26
Facility Emergency Level II Visit,PX99282F,CDM,450,RC,99282,CPT,,,,,,,,387,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,37.9488,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.53,74.15
Assay Cryofibrinogen,PX82585,CDM,300,RC,82585,CPT,,,,,,,,75,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,37.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.96,73.5
Assay Cryoglobulin,PX82595,CDM,300,RC,82595,CPT,,,,,,,,75,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,37.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,73.5
BINDER ABDOMINAL 9 INCH 46 TO 62 INCH XL ORT21100LXL,120.238,CDM,271,RC,A4467,HCPCS,,2989-MAIN,LOCAL,,,,,75,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,37.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL 9 INCH 63 TO 74 INCH 3- PANEL ORT211002XL,120.238,CDM,271,RC,A4467,HCPCS,,37-MAIN,LOCAL,,,,,75,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,37.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL 10 INCH 26 TO 50 INCHES ABB1050,120.238,CDM,271,RC,A4467,HCPCS,,52-MAIN,LOCAL,,,,,75,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,37.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
"BINDER ABDOMINAL 12"" HIGH 2XL 60-75INCH 4 PANEL ORT213002XL",120.238,CDM,271,RC,A4467,HCPCS,,12536-MAIN,LOCAL,,,,,75,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,37.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL UNISIZE 46-62IN 9 IN MDS169024,120.238,CDM,271,RC,A4467,HCPCS,,63-MAIN,LOCAL,,,,,75,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,37.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
"Biopsy, Nail Unit",PX11755F,CDM,510,RC,11755,CPT,,,,,,,,1490,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,37.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.73,253.89
"Biopsy, Nail Unit",PX11755F,CDM,510,RC,11755,CPT,,,,,,,,1490,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,37.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.73,253.89
"Direct skilled nursing services of a license practical nurse (lpn) in the home health or hospice setting, each 15 minutes",PXG0300,CDM,551,RC,G0300,HCPCS,,,,,,,,75,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,37.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
HH Rn Initial Visit,PXG0154,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,37.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
HH Rn Routine Visit,PXG0154.01,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,37.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
Skilled Srvc of a Lpn in Training and/or Education of Pt or Fam Ea 15 Min,PXG0496,CDM,551,RC,G0496,HCPCS,,,,,,,,75,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,37.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
Skilled srvc of an RN in training and/or education of pt or fam ea 15 min,PXG0495,CDM,551,RC,G0495,HCPCS,,,,,,,,75,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,37.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034020,NDC,1,EA,76.67,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,37.95165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034021,NDC,1,EA,76.67,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,37.95165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
levoFLOXacin 250 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635161,NDC,1,EA,79.08,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,37.9584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levoFLOXacin 250 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635161,NDC,1,EA,79.08,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,37.9584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CLOSED WOUND ROUND CHANNEL DRAIN WITH TROCAR 15FR FULL FLUTED,27200000,CDM,272,RC,,,,12223-MAIN,LOCAL,,,,,39,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,37.9587,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
fluorouracil 500 MG/10ML Solution 10 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,63323011710,NDC,10,ML,39,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,37.9587,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,256.2112
gemcitabine 200 MG Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323010294,NDC,1,EA,39,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,37.9587,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
Lab Wbc and Differential,PX85004,CDM,300,RC,85004,CPT,,,,,,,,39,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,37.9587,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,38.22
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003928,NDC,1,EA,39,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,37.9587,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
methylPREDNISolone sod succ 500 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9075801,NDC,0.25,EA,39,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,37.9587,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
NEEDLE JAMSHIDI 11G X 101MM BIOPSY DJ4011X,27200000,CDM,272,RC,,,,12798-MAIN,LOCAL,,,,,39,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,37.9587,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
O2 SENSOR ADULT ADHESIVE SINGLE PATIENT 040-003382-00,120.576,CDM,272,RC,,,,12930-MAIN,LOCAL,,,,,39,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,37.9587,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
O2 SENSOR INFANT ADHESIVE SINGLE PATIENT 040-003384-00,120.576,CDM,272,RC,,,,12932-MAIN,LOCAL,,,,,39,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,37.9587,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
O2 SENSOR PEDIATRIC ADHESIVE SINGLE PATIENT 040-003383-00,120.576,CDM,272,RC,,,,12931-MAIN,LOCAL,,,,,39,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,37.9587,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
SLEEVE ACHILLES LG/XL PROTECTION 92437145348,120.422,CDM,271,RC,,,,11378-MAIN,LOCAL,,,,,39,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,37.9587,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
SLEEVE ACHILLES SM/MED PROTECTION 92437145324,120.422,CDM,271,RC,,,,11377-MAIN,LOCAL,,,,,39,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,37.9587,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
Treponema Pallidum - Ref,PX8678090,CDM,300,RC,86780,CPT,90,,,,,,,39,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,59.02,percent of total billed charges,37.9587,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.14,38.22
TROCAR KII FIOS SYSTEM BLADELSS Z-THREAD 5MMX150MM,27200000,CDM,272,RC,,,,12827-MAIN,LOCAL,,,,,39,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,37.9587,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409427617,NDC,50,ML,39.01,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,37.968433,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Transvaginal US, Obstetric",PX7681701,CDM,402,RC,76817,CPT,TC,,,,,,,460,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,37.97,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.97,113.07
fentaNYL 25 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,591319872,NDC,1,EA,77.51,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.9799,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 25 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,591319872,NDC,1,EA,77.51,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,37.9799,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 25 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,591319872,NDC,1,EA,77.51,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,37.9799,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218710,NDC,2,EA,5662.72,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,37.98,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.98,43.16
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218713,NDC,2,EA,6875.36,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,37.98,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.98,43.16
pembrolizumab 100 MG/4ML Solution 4 mL Vial,J9271.01,CDM,636,RC,J9271,HCPCS,,,,6302602,NDC,4,ML,9627.58,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,37.98,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.98,58.52
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,36000014801,NDC,2,ML,38.76,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,37.9848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium bicarbonate 4.2 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409553434,NDC,10,ML,91.46,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,37.992484,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323018507,NDC,10,ML,43.09,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,38.00538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
azithromycin 250 MG Tablet 6 Each Box,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096104,NDC,1,EA,41.72,,Medica,Commercial,both,91.1,,28.105,percent of total billed charges,38.00692,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
valACYclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,31722070430,NDC,1,EA,38.79,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,38.0142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096105,NDC,1,EA,41.73,,Medica,Commercial,both,91.1,,28.105,percent of total billed charges,38.01603,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
prasugrel 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862083030,NDC,1,EA,88.64,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,38.02656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
imipenem-cilastatin 250 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323034925,NDC,1,EA,91.55,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,38.02987,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,173.1856
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032294,NDC,1,EA,91.55,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,38.02987,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,173.1856
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234001,NDC,1.25,ML,91.55,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,38.02987,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
DULoxetine 20 MG Capsule Delayed Release Particles 60 Each Bottle,63700001,CDM,250,RC,,,,,,2323560,NDC,1,EA,41.76,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,38.04336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acyclovir 50 MG/ML Solution 20 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,63323032524,NDC,20,ML,76.86,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,38.0457,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.927644,105.9968
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010269,NDC,1,EA,88.69,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,38.04801,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010299,NDC,1,EA,88.69,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,38.04801,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614201,NDC,1,ML,88.69,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,38.04801,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.097864,86.9162
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614225,NDC,1,ML,88.69,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,38.04801,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.097864,86.9162
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963801,NDC,0.5,ML,88.69,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,38.04801,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039841,NDC,1,EA,43.14,,United Healthcare,All Payer,outpatient,88.2,,23.68,percent of total billed charges,38.04948,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
tolterodine ER 2 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,43975032203,NDC,1,EA,43.15,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,38.0583,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037601,NDC,1,ML,76.9,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,38.0655,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,50111078751,NDC,1,EA,41.79,,Medica,Commercial,both,91.1,,28.105,percent of total billed charges,38.07069,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
donepezil 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904640861,NDC,1,EA,41.79,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,38.07069,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733513,NDC,1,EA,39.12,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,18.43861111,percent of total billed charges,38.075496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
Assay of Natriuretic Peptide,PX83880,CDM,300,RC,83880,CPT,,,,,,,,290,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,38.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.08,39.26
Assay of Natriuretic Peptide,PX83880,CDM,300,RC,83880,CPT,,,,,,,,290,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,38.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.08,39.26
Assay of Natriuretic Peptide,PX83880,CDM,300,RC,83880,CPT,,,,,,,,290,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,38.08,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.08,39.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048203,NDC,20,ML,44.8,,First Health,Commercial,both,85,,999999999,percent of total billed charges,38.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048227,NDC,20,ML,44.8,,First Health,Commercial,both,85,,999999999,percent of total billed charges,38.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ampicillin 1 GM Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781926185,NDC,0.5,EA,43.18,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,38.08476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
fluticasone-salmeterol 100-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069500,NDC,1,EA,38.87,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,38.0926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levoFLOXacin 750 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635361,NDC,0.333333333,EA,39.14,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,38.094962,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Etoposide 100 MG/5ML Solution 5 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,16729011431,NDC,5,ML,43.21,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,38.11122,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.949434,169.8144
Alpha-Fetoprotein Serum,PX82105,CDM,300,RC,82105,CPT,,,,,,,,77,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,38.115,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.38,75.46
BRACE WRIST HAND THUMB LEFT 455-LT,120.315,CDM,274,RC,L3809,HCPCS,,8283-MAIN,LOCAL,,,,,77,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,38.115,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.9858,245.51
BRACE WRIST HAND THUMB RIGHT 455-RT,120.315,CDM,274,RC,L3809,HCPCS,,8284-MAIN,LOCAL,,,,,77,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,38.115,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.9858,245.51
CAUTERY HIGH TEMP LOOP TIP,120.21,CDM,272,RC,,,,332-MAIN,LOCAL,,,,,77,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,38.115,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
NEEDLE ACUJECT 25GA VARIABLE INJECTION VIN-25,27200000,CDM,272,RC,,,,7412-MAIN,LOCAL,,,,,77,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,38.115,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Remove Additional Nail Plate,PX11732F,CDM,510,RC,11732,CPT,,,,,,,,77,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,38.115,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.9858,75.46
amoxicillin 250 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,93415580,NDC,150,ML,43.22,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,38.12004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,67815203,NDC,100,GR,91.77,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,38.121258,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329334001,NDC,10,ML,88.88,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,38.12952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331601,NDC,10,ML,77.86,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,150.5666667,percent of total billed charges,38.1514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331601,NDC,10,ML,77.86,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,38.1514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331601,NDC,10,ML,77.86,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,38.1514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001326,NDC,1,ML,42.88,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,38.1632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001341,NDC,1,ML,42.88,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,38.1632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329333901,NDC,10,ML,79.51,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,38.1648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329333901,NDC,10,ML,79.51,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,38.1648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
calcium CHLORIDE 10 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,76329330401,NDC,10,ML,79.51,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,38.1648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
calcium CHLORIDE 10 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,76329330401,NDC,10,ML,79.51,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,38.1648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,25021018482,NDC,100,ML,79.51,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,38.1648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.786918,140.5516
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,25021018482,NDC,100,ML,79.51,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,38.1648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.786918,140.5516
menthol-zinc oxide Paste 113 g Tube,63700001,CDM,250,RC,,,,,,53329016544,NDC,113,GR,79.52,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,38.1696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
menthol-zinc oxide Paste 113 g Tube,63700001,CDM,250,RC,,,,,,53329016544,NDC,113,GR,79.52,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,38.1696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atropine (PF) 1 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517101025,NDC,1,ML,91.89,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,38.171106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
ezetimibe 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714081301,NDC,1,EA,44.91,,First Health,Commercial,both,85,,999999999,percent of total billed charges,38.1735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004703,NDC,1,EA,75.45,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,38.1777,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
Aldolase - Ref,PX8208590,CDM,300,RC,82085,CPT,90,,,,,,,89,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,38.181,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.9,87.22
Assay of Ggt,PX82977,CDM,300,RC,82977,CPT,,,,,,,,89,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,38.181,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6,87.22
"Debridement of Nail(S), 1-5",PX11720F,CDM,510,RC,11720,CPT,,,,,,,,89,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,38.181,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.9706,87.22
"Hla a, B or C, Single Ag - Ref",PX8681290,CDM,300,RC,86812,CPT,90,,,,,,,89,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,38.181,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.67,87.22
KIT INTRODUCER 8.5FR AK-09803-CDC,120.128,CDM,272,RC,,,,8826-MAIN,LOCAL,,,,,89,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,38.181,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.9706,87.22
droPERidol 2.5 MG/ML Solution 2 mL Vial,J1790.01,CDM,636,RC,J1790,HCPCS,,,,517970201,NDC,2,ML,75.47,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,38.18782,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.350238,73.9606
"CUFF STERILE DISPOSABLE SPSB 12""",27200000,CDM,272,RC,,,,7435-MAIN,LOCAL,,,,,43.31,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,38.19942,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
morphine 2 MG/ML Solution 1 mL Syringe,J2272.01,CDM,636,RC,J2272,HCPCS,,,,76045000401,NDC,1,ML,38.98,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,38.2004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.192292,38.2004
Blood Typing Abo,PX86900,CDM,300,RC,86900,CPT,,,,,,,,92,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,38.2168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.2168,111.6
Blood Typing Rh (D),PX86901,CDM,300,RC,86901,CPT,,,,,,,,92,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,38.2168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.03,90.16
Parvovirus Antibody - Ref,PX8674790,CDM,300,RC,86747,CPT,90,,,,,,,92,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,38.2168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.78,90.16
"Reticulocyte Count,Flow Cyto",PX85045,CDM,300,RC,85045,CPT,,,,,,,,92,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,38.2168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.66,90.16
Ceruloplasmin - Ref,PX8239090,CDM,300,RC,82390,CPT,90,,,,,,,78,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,38.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,76.44
Ceruloplasmin - Ref,PX8239090,CDM,300,RC,82390,CPT,90,,,,,,,78,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,38.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,76.44
Ceruloplasmin - Ref,PX8239090,CDM,300,RC,82390,CPT,90,,,,,,,78,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,38.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,76.44
Chemiluminescent Assay - Ref,PX8239790,CDM,300,RC,82397,CPT,90,,,,,,,78,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,38.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.95,76.44
Chemiluminescent Assay - Ref,PX8239790,CDM,300,RC,82397,CPT,90,,,,,,,78,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,38.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.95,76.44
Chemiluminescent Assay - Ref,PX8239790,CDM,300,RC,82397,CPT,90,,,,,,,78,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,38.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.95,76.44
CLOSED WOUND ROUND CHANNEL DRAIN WITH TROCAR 15FR FULL FLUTED,27200000,CDM,272,RC,,,,12223-MAIN,LOCAL,,,,,39,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,38.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
fluorouracil 500 MG/10ML Solution 10 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,63323011710,NDC,10,ML,39,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,38.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,256.2112
gemcitabine 200 MG Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323010294,NDC,1,EA,39,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,38.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
Lab Wbc and Differential,PX85004,CDM,300,RC,85004,CPT,,,,,,,,39,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,38.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,38.22
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003928,NDC,1,EA,39,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,38.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
methylPREDNISolone sod succ 500 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9075801,NDC,0.25,EA,39,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,38.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
NEEDLE JAMSHIDI 11G X 101MM BIOPSY DJ4011X,27200000,CDM,272,RC,,,,12798-MAIN,LOCAL,,,,,39,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,38.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
O2 SENSOR ADULT ADHESIVE SINGLE PATIENT 040-003382-00,120.576,CDM,272,RC,,,,12930-MAIN,LOCAL,,,,,39,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,38.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
O2 SENSOR INFANT ADHESIVE SINGLE PATIENT 040-003384-00,120.576,CDM,272,RC,,,,12932-MAIN,LOCAL,,,,,39,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,38.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
O2 SENSOR PEDIATRIC ADHESIVE SINGLE PATIENT 040-003383-00,120.576,CDM,272,RC,,,,12931-MAIN,LOCAL,,,,,39,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,38.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
SLEEVE ACHILLES LG/XL PROTECTION 92437145348,120.422,CDM,271,RC,,,,11378-MAIN,LOCAL,,,,,39,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,38.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
SLEEVE ACHILLES SM/MED PROTECTION 92437145324,120.422,CDM,271,RC,,,,11377-MAIN,LOCAL,,,,,39,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,38.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,38.22
Treponema Pallidum - Ref,PX8678090,CDM,300,RC,86780,CPT,90,,,,,,,39,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,38.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.14,38.22
TROCAR KII FIOS SYSTEM BLADELSS Z-THREAD 5MMX150MM,27200000,CDM,272,RC,,,,12827-MAIN,LOCAL,,,,,39,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,38.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
VISUALIZATION SYSTEM CLEARIFY LAPAROSCOPE STERILE,27200000,CDM,272,RC,,,,11875-MAIN,LOCAL,,,,,78,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,38.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
VISUALIZATION SYSTEM CLEARIFY LAPAROSCOPE STERILE,27200000,CDM,272,RC,,,,11875-MAIN,LOCAL,,,,,78,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,38.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
VISUALIZATION SYSTEM CLEARIFY LAPAROSCOPE STERILE,27200000,CDM,272,RC,,,,11875-MAIN,LOCAL,,,,,78,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,38.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046837,NDC,30,ML,75.54,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,38.22324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,436067216,NDC,473,ML,77.23,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,38.22885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,39328006412,NDC,473,ML,77.23,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,38.22885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409427617,NDC,50,ML,39.01,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,38.2298,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012250,NDC,1,EA,77.24,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,38.2338,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012267,NDC,1,EA,77.24,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,38.2338,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
cefOXitin 2 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021011020,NDC,1,EA,77.24,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,38.2338,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.367364,75.6952
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023610,NDC,1,EA,77.24,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,38.2338,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
"SUTURE ETHIBOND #0 CT-1 CR 8-18"" CX21D",27200000,CDM,272,RC,,,,6415-MAIN,LOCAL,,,,,41.97,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,38.23467,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707426,NDC,100,ML,39.29,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,4.559571429,percent of total billed charges,38.240957,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
Cardiac Rehab,PX93797F,CDM,943,RC,93797,CPT,,,,,,,,45,,First Health,Commercial,both,85,,999999999,percent of total billed charges,38.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,115.44
CATHETER TEMP-SENSING 8FR LUBRISIL PEDS DYND110508,120.363,CDM,272,RC,A4340,HCPCS,,12777-MAIN,LOCAL,,,,,45,,First Health,Commercial,both,85,,999999999,percent of total billed charges,38.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
CATHETER TEMP-SENSING 12FR LUBRISIL 119212M,120.363,CDM,272,RC,A4340,HCPCS,,10750-MAIN,LOCAL,,,,,45,,First Health,Commercial,both,85,,999999999,percent of total billed charges,38.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
CATHETER TEMP-SENSING 14FR LUBRISIL 119214M,120.363,CDM,272,RC,A4340,HCPCS,,10751-MAIN,LOCAL,,,,,45,,First Health,Commercial,both,85,,999999999,percent of total billed charges,38.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
CATHETER TEMP-SENSING 16FR LUBRISIL 119216M,120.363,CDM,272,RC,A4340,HCPCS,,10752-MAIN,LOCAL,,,,,45,,First Health,Commercial,both,85,,999999999,percent of total billed charges,38.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
Cryptococcus Neoformans,PX87327,CDM,300,RC,87327,CPT,,,,,,,,45,,First Health,Commercial,both,85,,999999999,percent of total billed charges,38.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.3,44.1
Gammaglobulin; Ige - Ref,PX8278590,CDM,300,RC,82785,CPT,90,,,,,,,45,,First Health,Commercial,both,85,,999999999,percent of total billed charges,38.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.09,44.1
GASTRONOMY FEEDING TUBE MIC BALLOONED 20FR 7-10ML 0112-20,27200000,CDM,272,RC,B4087,HCPCS,,13098-MAIN,LOCAL,,,,,45,,First Health,Commercial,both,85,,999999999,percent of total billed charges,38.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRES 1.6MM,27200000,CDM,272,RC,C1769,HCPCS,,11852-MAIN,LOCAL,,,,,45,,First Health,Commercial,both,85,,999999999,percent of total billed charges,38.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"La Crosse, Antibody - Ref",PX8665190,CDM,300,RC,86651,CPT,90,,,,,,,45,,First Health,Commercial,both,85,,999999999,percent of total billed charges,38.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.09,44.1
MELGISORB AG SILVER CALCIUM STERILE 6X6,120.502,CDM,272,RC,A6197,HCPCS,,11844-MAIN,LOCAL,,,,,45,,First Health,Commercial,both,85,,999999999,percent of total billed charges,38.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
"St Louis, Antibody - Ref",PX8665390,CDM,300,RC,86653,CPT,90,,,,,,,45,,First Health,Commercial,both,85,,999999999,percent of total billed charges,38.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.09,44.1
"Sugars, Qual, Ea Spec - Ref",PX8437690,CDM,300,RC,84376,CPT,90,,,,,,,45,,First Health,Commercial,both,85,,999999999,percent of total billed charges,38.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.04,44.1
"Venipuncture by Physician, Other Vein, Under Age 3 Years",PX36406,CDM,983,RC,36406,CPT,,,,,,,,45,,First Health,Commercial,both,85,,999999999,percent of total billed charges,38.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,43.7985
"Western Equine, Ab - Ref",PX8665490,CDM,300,RC,86654,CPT,90,,,,,,,45,,First Health,Commercial,both,85,,999999999,percent of total billed charges,38.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.09,44.1
nafcillin 1 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,55150012215,NDC,1,EA,89.17,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,38.25393,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Chest Wall Manipulation,Subsequent",PX94668F,CDM,410,RC,94668,CPT,,,,,,,,192,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,38.2585,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.78,68.64
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019602,NDC,2,ML,77.29,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,38.25855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
GASTRONOMY FEEDING TUBE MIC BALLOONED 20FR 7-10ML 0112-20,27200000,CDM,272,RC,B4087,HCPCS,,13098-MAIN,LOCAL,,,,,45,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,38.26,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
TUBE GASTROSTOMY 18FR REPLACEMENT DYND70318,120.256,CDM,271,RC,B4087,HCPCS,,407-MAIN,LOCAL,,,,,179,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,38.26,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.9181,38.26
Actin Antibody Each,PX8601590,CDM,300,RC,86015,CPT,90,,,,,,,42,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,38.262,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.05,41.16
Assay Vitamin B-6,PX84207,CDM,300,RC,84207,CPT,90,,,,,,,42,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,38.262,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
"BOUGIE TRACH 10FR 70CM COUDE 	9-0211-70",120.199,CDM,272,RC,A7520,HCPCS,,11112-MAIN,LOCAL,,,,,42,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,38.262,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
BOUGIE TRACHEAL TUBE & GUIDE 100123515,120.199,CDM,272,RC,A7520,HCPCS,,8950-MAIN,LOCAL,,,,,42,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,38.262,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
CATHETER PUREWICK FEMALE EXTERNAL PWF030K,120.414,CDM,272,RC,A6590,HCPCS,,11836-MAIN,LOCAL,,,,,42,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,38.262,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
Culture Type Immunologic,PX87147,CDM,300,RC,87147,CPT,,,,,,,,42,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,38.262,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,41.16
EZ-STABILIZER DRESSING,120.415,CDM,272,RC,,,,9058-MAIN,LOCAL,,,,,42,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,38.262,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
MEPILEX AG FOAM 4X4,120.192,CDM,272,RC,A6213,HCPCS,,8480-MAIN,LOCAL,,,,,42,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,38.262,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
MEPILEX AG FOAM 4X8,120.192,CDM,272,RC,A6213,HCPCS,,8479-MAIN,LOCAL,,,,,42,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,38.262,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY CENTRAL LINE DRESSING WITH CHLORAPREP DYND75234,120.68,CDM,272,RC,,,,10923-MAIN,LOCAL,,,,,42,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,38.262,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY FOLEY 14FR CATHETER A300414A,120.414,CDM,272,RC,A4344,HCPCS,,11281-MAIN,LOCAL,,,,,42,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,38.262,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY FOLEY 16FR CATHETER 300416A,120.414,CDM,272,RC,A4344,HCPCS,,11774-MAIN,LOCAL,,,,,42,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,38.262,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
"TRAY SPINAL  25GX3.5"" WITH WHITEACRE 405671",120.275,CDM,272,RC,,,,3284-MAIN,LOCAL,,,,,42,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,38.262,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY SPINAL 25G ANESTH SADDLE BLOCK NLD-4795-20,120.275,CDM,272,RC,,,,935-MAIN,LOCAL,,,,,42,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,38.262,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
enalaprilat 1.25 MG/ML Injectable 2 mL Vial,25000000,CDM,250,RC,,,,,,143978601,NDC,2,ML,75.63,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,38.26878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490311,NDC,5,ML,43.39,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,38.26998,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
Antinuclear Antibodiesana - Ref,PX8603890,CDM,300,RC,86038,CPT,90,,,,,,,43,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,38.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.09,42.14
Blood Type Antigen Donor Ea,PX86902,CDM,300,RC,86902,CPT,,,,,,,,43,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,38.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.8622,314.02
ETRAP POLYP TRAP,27200000,CDM,272,RC,,,,11282-MAIN,LOCAL,,,,,43,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,38.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Smking Cess 4-10 Min,PX99406P,CDM,983,RC,99406,CPT,,,,,,,,43,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,38.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.8622,41.8519
"Testosterone, Total - Ref",PX8440390,CDM,300,RC,84403,CPT,90,,,,,,,43,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,38.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.8622,42.14
Dimethicone 1.5 % Cream 118 mL Tube,800000,CDM,,,,,,,,53329016104,NDC,118,ML,43.4,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,38.2788,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010301,NDC,0.3,ML,45.04,,First Health,Commercial,both,85,,999999999,percent of total billed charges,38.284,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,24208031510,NDC,10,ML,75.67,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,38.28902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001002,NDC,2,ML,43.42,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,38.29644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,42.5516
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084243,NDC,0.5,ML,202.42,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,38.31,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.7,39.08
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084252,NDC,0.5,ML,207.65,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,38.31,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.7,39.08
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084243,NDC,0.5,ML,202.42,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,38.31546,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.7,39.08
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084252,NDC,0.5,ML,207.65,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,38.31546,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.7,39.08
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046201,NDC,30,ML,79.84,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,38.3232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046201,NDC,30,ML,79.84,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,38.3232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
levothyroxine Sodium 200 MCG Recon Soln 1 Each Vial,J0650.01,CDM,636,RC,J0650,HCPCS,,,,63323064710,NDC,0.0625,EA,75.75,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,38.3295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.46655,74.235
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733513,NDC,1,EA,39.12,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,38.3376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,16714081701,NDC,1,EA,75.78,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,38.34468,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323018507,NDC,10,ML,43.09,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,38.3501,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
levoFLOXacin 750 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635361,NDC,0.333333333,EA,39.14,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,38.3572,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LAP KIT BASIC,27200000,CDM,272,RC,,,,4829-MAIN,LOCAL,,,,,78.29,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,38.3621,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LAP KIT BASIC,27200000,CDM,272,RC,,,,4829-MAIN,LOCAL,,,,,78.29,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,38.3621,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LAP KIT BASIC,27200000,CDM,272,RC,,,,4829-MAIN,LOCAL,,,,,78.29,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,38.3621,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,63323094004,NDC,4,ML,89.43,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,38.36547,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,63323094021,NDC,4,ML,89.43,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,38.36547,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dextrose 5 % 5 % Solution 50 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338055111,NDC,50,ML,43.5,,United Healthcare,All Payer,outpatient,88.2,,4.9575,percent of total billed charges,38.367,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 100 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001748,NDC,100,ML,43.5,,United Healthcare,All Payer,outpatient,88.2,,4.9575,percent of total billed charges,38.367,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,264763500,NDC,1000,ML,43.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,38.367,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5% lactated ringers 5 % Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012504,NDC,1000,ML,43.5,,United Healthcare,All Payer,outpatient,88.2,,0.063571088,percent of total billed charges,38.367,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329330201,NDC,25,ML,43.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,38.367,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9 % 0.9 % Solution 50 mL Flex Cont,J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004941,NDC,50,ML,43.5,,United Healthcare,All Payer,outpatient,88.2,,0.191910792,percent of total billed charges,38.367,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004941,NDC,250,ML,43.5,,United Healthcare,All Payer,outpatient,88.2,,0.092261369,percent of total billed charges,38.367,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055311,NDC,250,ML,43.5,,United Healthcare,All Payer,outpatient,88.2,,0.092261369,percent of total billed charges,38.367,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004948,NDC,300,ML,43.5,,United Healthcare,All Payer,outpatient,88.2,,0.092261369,percent of total billed charges,38.367,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055318,NDC,300,ML,43.5,,United Healthcare,All Payer,outpatient,88.2,,0.092261369,percent of total billed charges,38.367,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 150 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,409798361,NDC,300,ML,43.5,,United Healthcare,All Payer,outpatient,88.2,,0.092261369,percent of total billed charges,38.367,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9% irrigation 0.9 % Solution 3,000 mL Plas Cont",25000000,CDM,250,RC,,,,,,338004727,NDC,3000,ML,43.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,38.367,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9% IV LINE FLUSH 0.9% Solution 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,338004948,NDC,100,ML,43.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,38.367,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fentaNYL 25 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,591319872,NDC,1,EA,77.51,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,38.36745,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atropine 1 mg/mL Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100101,NDC,0.2,ML,39.42,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1.253,percent of total billed charges,38.367486,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
levoFLOXacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635261,NDC,0.5,EA,45.16,,First Health,Commercial,both,85,,999999999,percent of total billed charges,38.386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157F,CDM,370,RC,99157,CPT,,,,,,,,270,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,38.39,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.86,102.38
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157P,CDM,983,RC,99157,CPT,,,,,,,,270,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,38.39,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.86,264.6
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039841,NDC,1,EA,43.14,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,38.3946,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Syringe,J7040.01,CDM,636,RC,J7040,HCPCS,,,,64253020230,NDC,10,ML,42.15,,Medica,Commercial,both,91.1,,7.872391304,percent of total billed charges,38.39865,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028426,NDC,1,EA,42.15,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,38.39865,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
"Alpha-Fetoprotein, Serum - Ref",PX8210590,CDM,300,RC,82105,CPT,90,,,,,,,80,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,38.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.38,78.4
"Alpha-Fetoprotein, Serum - Ref",PX8210590,CDM,300,RC,82105,CPT,90,,,,,,,80,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,38.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.38,78.4
Prealubimin,PX84134,CDM,300,RC,84134,CPT,,,,,,,,80,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,38.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.38,78.4
Prealubimin,PX84134,CDM,300,RC,84134,CPT,,,,,,,,80,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,38.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.38,78.4
empagliflozin 25 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,597015330,NDC,0.4,EA,43.54,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,38.40228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
empagliflozin 25 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,597015337,NDC,0.4,EA,43.54,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,38.40228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tolterodine ER 2 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,43975032203,NDC,1,EA,43.15,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,38.4035,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052084,NDC,1,EA,92.46,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,38.407884,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.407884,90.9538
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,69543025204,NDC,118,ML,78.39,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,38.4111,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,69543025204,NDC,118,ML,78.39,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,38.4111,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,69543025204,NDC,118,ML,78.39,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,38.4111,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
empagliflozin 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,597015230,NDC,1,EA,92.47,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,38.412038,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ursodiol 300 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,591315901,NDC,1,EA,39.47,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,38.416151,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DULoxetine 30 MG Capsule Delayed Release Particles 90 Each Bottle,63700001,CDM,250,RC,,,,,,57237001890,NDC,1,EA,42.17,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,38.41687,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ampicillin 1 GM Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781926185,NDC,0.5,EA,43.18,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,38.4302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011701,NDC,1,EA,89.64,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,38.45556,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011710,NDC,1,EA,89.64,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,38.45556,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
Assay of Blood Lipoprotein,PX83721,CDM,300,RC,83721,CPT,,,,,,,,76,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,38.456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.63,74.48
Lab Direct Coombs,PX86880,CDM,300,RC,86880,CPT,,,,,,,,76,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,38.456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.5704,74.48
PRONEVIEW CUSHION INSERTS LARGE,120.557,CDM,272,RC,E0190,HCPCS,,12500-MAIN,LOCAL,,,,,76,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,38.456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.5704,74.48
SHOE POST OP LARGE MALE MQM3B,120.237,CDM,274,RC,L3260,HCPCS,,794-MAIN,LOCAL,,,,,76,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,38.456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP LARGE SQUARE TOE WOMENS ORT30300WL,120.237,CDM,274,RC,L3260,HCPCS,,10606-MAIN,LOCAL,,,,,76,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,38.456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP MEDIUM SQUARE TOE MALE ORT30300MM,120.237,CDM,274,RC,L3260,HCPCS,,10603-MAIN,LOCAL,,,,,76,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,38.456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP MEDIUM SQUARE TOE WOMENS ORT30300WM,120.237,CDM,274,RC,L3260,HCPCS,,10605-MAIN,LOCAL,,,,,76,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,38.456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP SMALL MALE 0814-1192,120.237,CDM,274,RC,L3260,HCPCS,,803-MAIN,LOCAL,,,,,76,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,38.456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP SMALL SQUARE TOE WOMENS MQW1B,120.237,CDM,274,RC,L3260,HCPCS,,10604-MAIN,LOCAL,,,,,76,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,38.456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
Etoposide 100 MG/5ML Solution 5 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,16729011431,NDC,5,ML,43.21,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,38.4569,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.949434,169.8144
amoxicillin 250 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,93415580,NDC,150,ML,43.22,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,38.4658,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Manage/Train Orthotic/Prosthetic, per 15 Min",PX97763,CDM,420,RC,97763,CPT,,,,,,,,121,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,38.47,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.47,68.97
HYDROmorphone 0.1 MG/ML Solution 55 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,61553067976,NDC,55,ML,89.7,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,38.4813,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409663734,NDC,50,ML,89.7,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,38.4813,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,409163221,NDC,0.5,EA,43.65,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,38.4993,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Dihydroxyvitamin D - Ref,PX8265290,CDM,300,RC,82652,CPT,90,,,,,,,165,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,38.5,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.35,38.5
Glycosylated Hemoglobin Test,PX83036,CDM,300,RC,83036,CPT,,,,,,,,110,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,38.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.9,130.9
Vit D 1 25-Dihydroxy,PX82652,CDM,300,RC,82652,CPT,,,,,,,,154,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,38.5,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.35,38.5
sodium polystyrene sulfonate Powder 15 g Bottle,25000000,CDM,250,RC,,,,,,10702003615,NDC,15,GR,76.09,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,38.50154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707426,NDC,100,ML,39.29,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,38.5042,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024110,NDC,1,EA,76.1,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,38.5066,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
Assay of Natriuretic Peptide,PX83880,CDM,300,RC,83880,CPT,,,,,,,,290,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,38.508,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.08,39.26
bisoprolol-hydroCHLOROthiazide 5-6.25 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,42799092102,NDC,1,EA,39.57,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,38.513481,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SUCTION TIP POOLE STERILE 35040,27200000,CDM,272,RC,,,,977-MAIN,LOCAL,,,,,42.28,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,38.51708,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,4080285,NDC,1,EA,89.79,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,38.51991,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490334,NDC,5,ML,42.29,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,38.52619,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
tetracycline 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,51991090701,NDC,0.5,EA,42.29,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,38.52619,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,47781046813,NDC,1,EA,76.15,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,38.5319,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,64380079701,NDC,1,EA,76.15,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,38.5319,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Diagnostic Anoscopy,PX46600F,CDM,510,RC,46600,CPT,,,,,,,,505,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,38.532,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.52,244.9
Diagnostic Anoscopy,PX46600P,CDM,983,RC,46600,CPT,,,,,,,,405,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,38.532,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.52,396.9
"Inject Nerv Blck,Othr Periph Nerv",PX64450F,CDM,510,RC,64450,CPT,,,,,,,,757,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,38.532,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.96,156.35
"Inject Nerv Blck,Othr Periph Nerv",PX64450P,CDM,983,RC,64450,CPT,,,,,,,,904,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,38.532,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.96,885.92
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331601,NDC,10,ML,77.86,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,38.5407,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
"CUFF STERILE DISPOSABLE SPSB 12""",27200000,CDM,272,RC,,,,7435-MAIN,LOCAL,,,,,43.31,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,38.5459,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052083,NDC,1,EA,92.81,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,38.553274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.407884,90.9538
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,55150016205,NDC,5,ML,42.32,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,38.55352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Infliximab - Ref,PX8023090,CDM,300,RC,80230,CPT,90,,,,,,,343,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,38.57,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.41,38.57
Vedolizumab - Ref,PX8028090,CDM,300,RC,80280,CPT,90,,,,,,,468,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,38.57,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.41,38.57
ESOPHAGEAL BALLOON INFLATION DEVICE 60ML,27200000,CDM,272,RC,C1726,HCPCS,,11326-MAIN,LOCAL,,,,,80.41,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,38.5968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ESOPHAGEAL BALLOON INFLATION DEVICE 60ML,27200000,CDM,272,RC,C1726,HCPCS,,11326-MAIN,LOCAL,,,,,80.41,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,38.5968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
polyvinyl alcohol 1.4 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,50268067815,NDC,15,ML,45.42,,First Health,Commercial,both,85,,999999999,percent of total billed charges,38.607,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Ceruloplasmin - Ref,PX8239090,CDM,300,RC,82390,CPT,90,,,,,,,78,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,38.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,76.44
Chemiluminescent Assay - Ref,PX8239790,CDM,300,RC,82397,CPT,90,,,,,,,78,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,38.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.95,76.44
"Gammaglobulin; Iga, Dg,M - Ref",PX8278490,CDM,300,RC,82784,CPT,90,,,,,,,90,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,38.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.53,88.2
"Misc Virus Antibody, Nos - Ref",PX8679090,CDM,300,RC,86790,CPT,90,,,,,,,90,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,38.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.81,88.2
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152P,CDM,983,RC,99152,CPT,,,,,,,,90,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,38.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.386,87.597
Mycobacteria Culture - Ref,PX8711690,CDM,300,RC,87116,CPT,90,,,,,,,90,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,38.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9,88.2
VISUALIZATION SYSTEM CLEARIFY LAPAROSCOPE STERILE,27200000,CDM,272,RC,,,,11875-MAIN,LOCAL,,,,,78,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,38.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490311,NDC,5,ML,43.39,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,38.6171,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,17478004001,NDC,1,ML,42.39,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,38.61729,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
Acth - Ref,PX8202490,CDM,300,RC,82024,CPT,90,,,,,,,259,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,38.62,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.46,38.62
Dimethicone 1.5 % Cream 118 mL Tube,800000,CDM,,,,,,,,53329016104,NDC,118,ML,43.4,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,38.626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Sars-Cov-2 Covid-19 Antibody,PX86769,CDM,300,RC,86769,CPT,,,,,,,,340,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,38.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.63,333.2
Sars-Cov-2 Covid-19 Antibody,PX8676990,CDM,300,RC,86769,CPT,90,,,,,,,100,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,38.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.63,98
atropine 1 mg/mL Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100101,NDC,0.2,ML,39.42,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,38.6316,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
oxytocin 10 UNIT/ML Solution 1 mL Vial,J2590.01,CDM,636,RC,J2590,HCPCS,,,,42023011625,NDC,1,ML,43.8,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,38.6316,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.19452,42.924
BOOT AIRSELECT SHORT LARGE 01ES-L,120.45,CDM,274,RC,L4360,HCPCS,,11890-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,38.6322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT MEDIUM 01ES-M,120.45,CDM,274,RC,L4360,HCPCS,,11889-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,38.6322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT SMALL 01ES-S,120.45,CDM,274,RC,L4360,HCPCS,,11888-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,38.6322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT X-LARGE 01ES-XL,120.45,CDM,274,RC,L4360,HCPCS,,11891-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,38.6322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT X-SMALL 01ES-XS,120.45,CDM,274,RC,L4360,HCPCS,,11887-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,38.6322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD LARGE 01EF-L,120.45,CDM,274,RC,L4360,HCPCS,,11697-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,38.6322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD MEDIUM 01EF-M,120.45,CDM,274,RC,L4360,HCPCS,,11696-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,38.6322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD SMALL 01EF-S,120.45,CDM,274,RC,L4360,HCPCS,,11695-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,38.6322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD X-LARGE 01EF-XL,120.45,CDM,274,RC,L4360,HCPCS,,11698-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,38.6322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD X-SMALL 01EF-XS,120.45,CDM,274,RC,L4360,HCPCS,,11694-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,38.6322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
Russell Viper Venom - Ref,PX8561390,CDM,300,RC,85613,CPT,90,,,,,,,93,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,38.6322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.78,91.14
SPLINT FOOT SMALL STRUT WALK 11-1383-2-00000,120.45,CDM,274,RC,L4360,HCPCS,,1205-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,38.6322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036001,NDC,10,ML,80.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,38.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,84.5054
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036001,NDC,10,ML,80.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,38.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,84.5054
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188602,NDC,5,ML,45.46,,First Health,Commercial,both,85,,999999999,percent of total billed charges,38.641,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.884084,44.5508
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188622,NDC,5,ML,45.46,,First Health,Commercial,both,85,,999999999,percent of total billed charges,38.641,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.884084,44.5508
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001002,NDC,2,ML,43.42,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,38.6438,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,42.5516
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049257,NDC,5,ML,42.43,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,38.65373,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Gait Training Therapy,PX97116,CDM,420,RC,97116,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,38.66,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.16,38.66
Gait Training Therapy,PX97116,CDM,420,RC,97116,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,38.66,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.16,38.66
Therapeutic Exercises,PX97110,CDM,420,RC,97110,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,38.66,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.16,38.66
Therapeutic Exercises,PX97110,CDM,420,RC,97110,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,38.66,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.16,38.66
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600701,NDC,10,ML,39.73,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,38.669209,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,38.9354
ursodiol 300 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,591315901,NDC,1,EA,39.47,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,38.6806,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
betamethasone acetate-betamethasone sodium phosphate 6 (3-3) MG/ML Suspension 5 mL Vial,J0702.01,CDM,636,RC,J0702,HCPCS,,,,517072001,NDC,1,ML,78.96,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,38.6904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.799984,77.3808
betamethasone acetate-betamethasone sodium phosphate 6 (3-3) MG/ML Suspension 5 mL Vial,J0702.01,CDM,636,RC,J0702,HCPCS,,,,517072001,NDC,1,ML,78.96,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,38.6904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.799984,77.3808
betamethasone acetate-betamethasone sodium phosphate 6 (3-3) MG/ML Suspension 5 mL Vial,J0702.01,CDM,636,RC,J0702,HCPCS,,,,517072001,NDC,1,ML,78.96,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,38.6904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.799984,77.3808
"dextrose 5% and sodium chloride 0.45% with potassium chloride 10 mEq in 1000 mL 10-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,338066904,NDC,1000,ML,80.61,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,38.6928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"dextrose 5% and sodium chloride 0.45% with potassium chloride 10 mEq in 1000 mL 10-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,338066904,NDC,1000,ML,80.61,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,38.6928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,264957710,NDC,500,ML,80.61,,Health Partners,Health Partners Care Plans,both,48,,1.83137931,percent of total billed charges,38.6928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,264957710,NDC,500,ML,80.61,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,38.6928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052201,NDC,500,ML,80.61,,Health Partners,Health Partners Care Plans,both,48,,1.83137931,percent of total billed charges,38.6928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052201,NDC,500,ML,80.61,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,38.6928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052277,NDC,500,ML,80.61,,Health Partners,Health Partners Care Plans,both,48,,1.83137931,percent of total billed charges,38.6928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052277,NDC,500,ML,80.61,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,38.6928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
Everolimus,PX8016990,CDM,300,RC,80169,CPT,,,,,,,,79,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,38.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,77.42
Everolimus,PX8016990,CDM,300,RC,80169,CPT,,,,,,,,79,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,38.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,77.42
Everolimus,PX8016990,CDM,300,RC,80169,CPT,,,,,,,,79,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,38.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,77.42
dextrose 5 % 5 % Solution 50 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338055111,NDC,50,ML,43.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,38.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 100 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001748,NDC,100,ML,43.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,38.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,264763500,NDC,1000,ML,43.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,38.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5% lactated ringers 5 % Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012504,NDC,1000,ML,43.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,38.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329330201,NDC,25,ML,43.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,38.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9 % 0.9 % Solution 50 mL Flex Cont,J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004941,NDC,50,ML,43.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,38.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004941,NDC,250,ML,43.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,38.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055311,NDC,250,ML,43.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,38.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004948,NDC,300,ML,43.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,38.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055318,NDC,300,ML,43.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,38.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 150 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,409798361,NDC,300,ML,43.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,38.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9% irrigation 0.9 % Solution 3,000 mL Plas Cont",25000000,CDM,250,RC,,,,,,338004727,NDC,3000,ML,43.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,38.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9% IV LINE FLUSH 0.9% Solution 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,338004948,NDC,100,ML,43.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,38.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ketorolac 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314012605,NDC,5,ML,42.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,38.7175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323048201,NDC,10,ML,39.78,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,38.717874,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323048217,NDC,10,ML,39.78,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,38.717874,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Strapping of Elbow or Wrist,PX29260F,CDM,420,RC,29260,CPT,,,,,,,,64,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,38.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.77,60.19
levoFLOXacin 250 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635161,NDC,1,EA,79.08,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,38.7492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levoFLOXacin 250 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635161,NDC,1,EA,79.08,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,38.7492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levoFLOXacin 250 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635161,NDC,1,EA,79.08,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,38.7492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
empagliflozin 25 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,597015330,NDC,0.4,EA,43.54,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,38.7506,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
empagliflozin 25 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,597015337,NDC,0.4,EA,43.54,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,38.7506,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LAP KIT BASIC,27200000,CDM,272,RC,,,,4829-MAIN,LOCAL,,,,,78.29,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,38.75355,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
dabigatran 75 MG capsule 60 Each Box,63700001,CDM,250,RC,,,,,,597014960,NDC,1,EA,39.83,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,38.766539,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
mycophenolate 500 MG Tablet 100 Each Bottle,J7517.01,CDM,637,RC,J7517,HCPCS,,,,64380072506,NDC,1,EA,42.56,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,38.77216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.679424,41.7088
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039814,NDC,1,EA,39.84,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,11.23,percent of total billed charges,38.776272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
BUPivacaine PF 0.5 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,55150016910,NDC,10,ML,39.84,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.296682081,percent of total billed charges,38.776272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
enalaprilat 1.25 MG/ML Injectable 1 mL Vial,25000000,CDM,250,RC,,,,,,143978710,NDC,1,ML,39.84,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,38.776272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098141,NDC,1,EA,39.84,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,13.11107143,percent of total billed charges,38.776272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098153,NDC,1,EA,39.84,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,13.11107143,percent of total billed charges,38.776272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,47781059807,NDC,1,EA,39.84,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,12.385,percent of total billed charges,38.776272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
bisoprolol-hydroCHLOROthiazide 5-6.25 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,42799092102,NDC,1,EA,39.57,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,38.7786,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Xray Pelvis 1 or 2 Vws,PX7217001,CDM,320,RC,72170,CPT,TC,,,,,,,279,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,38.79,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.87,38.79
Xray Pelvis 1 or 2 Vws,PX7217001,CDM,320,RC,72170,CPT,TC,,,,,,,279,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,38.79,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.87,38.79
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034020,NDC,1,EA,76.67,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,38.79502,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034021,NDC,1,EA,76.67,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,38.79502,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070948,NDC,100,ML,42.59,,Medica,Commercial,both,91.1,,1.111818182,percent of total billed charges,38.79949,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,69543025204,NDC,118,ML,78.39,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,38.80305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CANNULA ADULT LARGE OPTIFLOW OPT946,120.495,CDM,271,RC,A4615,HCPCS,,11622-MAIN,LOCAL,,,,,44,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,38.808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
CANNULA ADULT MEDIUM OPTIFLOW OPT944,120.495,CDM,271,RC,A4615,HCPCS,,11621-MAIN,LOCAL,,,,,44,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,38.808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
CANNULA ADULT SMALL OPTIFLOW OPT942,120.495,CDM,271,RC,A4615,HCPCS,,11620-MAIN,LOCAL,,,,,44,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,38.808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
Homocysteine,PX83090,CDM,300,RC,83090,CPT,,,,,,,,44,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,38.808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.43,43.12
KIT GASTRIC LAVAGE 2075,120.257,CDM,272,RC,C7510,HCPCS,,410-MAIN,LOCAL,,,,,44,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,38.808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
SUTURE V-LOC 1/2 CIRCLE NEEDLE WOUND CLOSURE DEVICE VLOCN0306,27200000,CDM,272,RC,,,,11931-MAIN,LOCAL,,,,,44,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,38.808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE V-LOC SZ 3-0 180 GREEN V-20 9 INCH VLOCL0644,27200000,CDM,272,RC,,,,13056-SURG,LOCAL,,,,,44,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,38.808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Flow Cyto Ea Addtl Marker - Ref,PX8818590,CDM,310,RC,88185,CPT,90,,,,,,,165,,UCare,Individual and Family Plans,both,,,48.304,fee schedule,38.816,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.12,38.816
Flow Cyto Ea Addtl Marker - Ref,PX8818590,CDM,310,RC,88185,CPT,90,,,,,,,165,,UCare,Individual and Family Plans,both,,,48.304,fee schedule,38.816,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.12,38.816
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; Add'l",PX88185,CDM,310,RC,88185,CPT,,,,,,,,96,,UCare,Individual and Family Plans,both,,,48.304,fee schedule,38.816,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.12,38.816
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; Add'l",PX88185,CDM,310,RC,88185,CPT,,,,,,,,96,,UCare,Individual and Family Plans,both,,,48.304,fee schedule,38.816,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.12,38.816
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409751766,NDC,50,ML,80.89,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,38.8272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409751766,NDC,50,ML,80.89,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,38.8272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Apply Forearm Cast,PX29075F,CDM,510,RC,29075,CPT,,,,,,,,210,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,38.83,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.83,186.09
Apply Forearm Cast,PX29075P,CDM,983,RC,29075,CPT,,,,,,,,140,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,38.83,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.83,186.09
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015901,NDC,0.3,ML,45.69,,First Health,Commercial,both,85,,999999999,percent of total billed charges,38.8365,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015925,NDC,0.3,ML,45.69,,First Health,Commercial,both,85,,999999999,percent of total billed charges,38.8365,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361250,NDC,50,ML,90.53,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,38.83737,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361650,NDC,50,ML,90.53,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,38.83737,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,409163221,NDC,0.5,EA,43.65,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,38.8485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270004,NDC,100,ML,2827.78,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,38.85,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.85,44.15
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270010,NDC,100,ML,3458.14,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,38.85,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.85,44.15
immune globulin (Human) 10 GM/100ML Solution 100 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270005,NDC,100,ML,2827.78,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,38.85,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.85,44.15
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270006,NDC,100,ML,2912.78,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,38.85,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.85,44.15
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270012,NDC,100,ML,3293.58,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,38.85,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.85,44.15
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270007,NDC,100,ML,2827.78,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,38.85,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.85,44.15
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270013,NDC,100,ML,2827.78,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,38.85,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.85,44.15
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,63323041536,NDC,0.5,ML,44.05,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,38.8521,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066501,NDC,0.25,ML,45.74,,First Health,Commercial,both,85,,999999999,percent of total billed charges,38.879,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.000396,47.2262
CAPTIFLEX SNARE SINGLE USE EXTRA SMALL 11MM,27200000,CDM,272,RC,,,,12378-MAIN,LOCAL,,,,,81,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,38.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CAPTIFLEX SNARE SINGLE USE EXTRA SMALL 11MM,27200000,CDM,272,RC,,,,12378-MAIN,LOCAL,,,,,81,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,38.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Smear Special Stain,PX87207,CDM,300,RC,87207,CPT,,,,,,,,81,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,38.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.49,79.38
Smear Special Stain,PX87207,CDM,300,RC,87207,CPT,,,,,,,,81,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,38.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.49,79.38
Tacrolimus - Ref,PX8019790,CDM,300,RC,80197,CPT,90,,,,,,,81,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,38.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,79.38
Tacrolimus - Ref,PX8019790,CDM,300,RC,80197,CPT,90,,,,,,,81,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,38.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,79.38
ACUSNARE POLYPECTOMY SNARE,27200000,CDM,272,RC,,,,7733-MAIN,LOCAL,,,,,45.75,,First Health,Commercial,both,85,,999999999,percent of total billed charges,38.8875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
acyclovir 50 MG/ML Solution 20 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,63323032524,NDC,20,ML,76.86,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,38.89116,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.927644,105.9968
leflunomide 20 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,70748013006,NDC,0.5,EA,44.1,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,38.8962,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037601,NDC,1,ML,76.9,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,38.9114,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
DIMETHICONE (TOPICAL) 5 % Cream 118 mL Tube,800000,CDM,,,,,,,,53329015104,NDC,118,ML,44.12,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,38.91384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
phenol-glycerin 1.5-33 % Liquid 118 mL Bottle,25000000,CDM,250,RC,,,,,,78112000068,NDC,118,ML,44.12,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,38.91384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"dextran 70, glycerin, hypromellose 0.1-0.2-0.3 % Solution 15 mL Bottle",63700001,CDM,250,RC,,,,,,65042636,NDC,15,ML,44.14,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,38.93148,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
8MM-12MM TIP COVER ACCESSORY,27200000,CDM,272,RC,,,,11918-MAIN,LOCAL,,,,,40,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,38.932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CATHETER URETERAL  5FR TIGERTAIL OPEN TIP FLEXIBLE 139005,27200000,CDM,272,RC,A4340,HCPCS,,12302-MAIN,LOCAL,,,,,40,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,38.932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NEEDLE BIOPSY 14GAX4 1/2 2N2702X,120.211,CDM,272,RC,,,,724-MAIN,LOCAL,,,,,40,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,38.932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.616,39.2
STAPLER CANNULA SEAL 12 mm 470380,27200000,CDM,272,RC,,,,11962-MAIN,LOCAL,,,,,40,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,38.932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"SUTURE V-LOC 22G NEEDLE 9"" 180 GREEN VLOCL2145",27200000,CDM,272,RC,,,,11930-MAIN,LOCAL,,,,,40,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,38.932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"SUTURE V-LOC SZ 0.9"" 180 GREEN GS-21 NEEDLE VLOCL0346",27200000,CDM,272,RC,,,,11933-MAIN,LOCAL,,,,,40,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,38.932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Telehealth Origin Site Fac Fee,PXQ3014,CDM,780,RC,Q3014,HCPCS,,,,,,,,40,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,38.932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.616,39.2
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600701,NDC,10,ML,39.73,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,38.9354,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,38.9354
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329333901,NDC,10,ML,79.51,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,38.9599,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329333901,NDC,10,ML,79.51,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,38.9599,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329333901,NDC,10,ML,79.51,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,38.9599,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
calcium CHLORIDE 10 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,76329330401,NDC,10,ML,79.51,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,38.9599,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
calcium CHLORIDE 10 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,76329330401,NDC,10,ML,79.51,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,38.9599,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
calcium CHLORIDE 10 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,76329330401,NDC,10,ML,79.51,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,38.9599,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,25021018482,NDC,100,ML,79.51,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,38.9599,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.786918,140.5516
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,25021018482,NDC,100,ML,79.51,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,38.9599,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.786918,140.5516
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,25021018482,NDC,100,ML,79.51,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,38.9599,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.786918,140.5516
Alpha-Fetoprotein Serum,PX82105,CDM,300,RC,82105,CPT,,,,,,,,77,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,38.962,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.38,75.46
BRACE WRIST HAND THUMB LEFT 455-LT,120.315,CDM,274,RC,L3809,HCPCS,,8283-MAIN,LOCAL,,,,,77,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,38.962,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.9858,245.51
BRACE WRIST HAND THUMB RIGHT 455-RT,120.315,CDM,274,RC,L3809,HCPCS,,8284-MAIN,LOCAL,,,,,77,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,38.962,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.9858,245.51
CAUTERY HIGH TEMP LOOP TIP,120.21,CDM,272,RC,,,,332-MAIN,LOCAL,,,,,77,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,38.962,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
NEEDLE ACUJECT 25GA VARIABLE INJECTION VIN-25,27200000,CDM,272,RC,,,,7412-MAIN,LOCAL,,,,,77,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,38.962,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Remove Additional Nail Plate,PX11732F,CDM,510,RC,11732,CPT,,,,,,,,77,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,38.962,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.9858,75.46
menthol-zinc oxide Paste 113 g Tube,63700001,CDM,250,RC,,,,,,53329016544,NDC,113,GR,79.52,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,38.9648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
menthol-zinc oxide Paste 113 g Tube,63700001,CDM,250,RC,,,,,,53329016544,NDC,113,GR,79.52,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,38.9648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
menthol-zinc oxide Paste 113 g Tube,63700001,CDM,250,RC,,,,,,53329016544,NDC,113,GR,79.52,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,38.9648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxytocin 10 UNIT/ML Solution 1 mL Vial,J2590.01,CDM,636,RC,J2590,HCPCS,,,,42023011625,NDC,1,ML,43.8,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,38.982,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.19452,42.924
venetoclax 100 MG Tablet 1 Each Box,25000000,CDM,250,RC,,,,,,74057611,NDC,0.2,EA,90.87,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,38.98323,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323048201,NDC,10,ML,39.78,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,38.9844,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323048217,NDC,10,ML,39.78,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,38.9844,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fluticasone-salmeterol 250-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,54032756,NDC,1,EA,45.88,,First Health,Commercial,both,85,,999999999,percent of total billed charges,38.998,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine urethral/mucosal 2 % Gel 30 mL Tube,25000000,CDM,250,RC,,,,,,17478084030,NDC,30,ML,93.91,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,39.010214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,143957501,NDC,50,ML,44.24,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,39.01968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,143957510,NDC,50,ML,44.24,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,39.01968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,17478081725,NDC,25,ML,81.3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,39.024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,17478081725,NDC,25,ML,81.3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,39.024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dabigatran 75 MG capsule 60 Each Box,63700001,CDM,250,RC,,,,,,597014960,NDC,1,EA,39.83,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,39.0334,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzoin Tincture 59 mL Bottle,25000000,CDM,250,RC,,,,,,49348080130,NDC,59,ML,45.93,,First Health,Commercial,both,85,,999999999,percent of total billed charges,39.0405,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039814,NDC,1,EA,39.84,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,39.0432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
BUPivacaine PF 0.5 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,55150016910,NDC,10,ML,39.84,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,39.0432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
enalaprilat 1.25 MG/ML Injectable 1 mL Vial,25000000,CDM,250,RC,,,,,,143978710,NDC,1,ML,39.84,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,39.0432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098141,NDC,1,EA,39.84,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,39.0432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098153,NDC,1,EA,39.84,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,39.0432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,47781059807,NDC,1,EA,39.84,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,39.0432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
Coccidioides Antibody - Ref,PX8663590,CDM,300,RC,86635,CPT,90,,,,,,,94,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,39.0476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.52,92.12
Copper - Ref,PX8252590,CDM,300,RC,82525,CPT,90,,,,,,,94,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,39.0476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.38,92.12
DEFIBRILLATION PAD MULTI FUNCTION ADULT,120.58,CDM,271,RC,A0392,HCPCS,,1320-MAIN,LOCAL,,,,,94,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,39.0476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
DEFIBRILLATION PAD PEDI PADZ PEDS,120.58,CDM,271,RC,A0392,HCPCS,,1322-MAIN,LOCAL,,,,,94,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,39.0476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
DRESSING NASAL 4.5CM NON-INFLATABLE RAPID RHINO RR450,120.97,CDM,272,RC,A6407,HCPCS,,616-MAIN,LOCAL,,,,,94,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,39.0476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
DRESSING NASAL 5.5CM INFLATABLE RAPID RHINO RR550,120.97,CDM,272,RC,A6407,HCPCS,,606-MAIN,LOCAL,,,,,94,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,39.0476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
DRESSING NASAL 7.5CM INFLATABLE RAPID RHINO RR750,120.97,CDM,272,RC,A6407,HCPCS,,611-MAIN,LOCAL,,,,,94,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,39.0476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
DRESSING NASAL 8CM LONGX1.5CM THICK X3CM HIGH ANATOMICAL 34-105,120.97,CDM,272,RC,A6407,HCPCS,,613-MAIN,LOCAL,,,,,94,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,39.0476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
Tissue Exam for Fungi,PX87220,CDM,300,RC,87220,CPT,,,,,,,,94,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,39.0476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,92.12
TUBING IRRIGATION F SET STERILE MXB-T,27200000,CDM,272,RC,,,,11693-MAIN,LOCAL,,,,,94,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,39.0476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Injection for Nerve Block,PX64447F,CDM,510,RC,64447,CPT,,,,,,,,3023,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,39.05,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.05,240.75
Injection for Nerve Block,PX64447P,CDM,983,RC,64447,CPT,,,,,,,,3892,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,39.05,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.05,3814.16
ampicillin 500 MG Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781925078,NDC,1,EA,44.28,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,39.05496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
leucovorin 10 mg/mL Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,25021081467,NDC,1,EA,40.13,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,39.058529,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.670002,84.6818
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001326,NDC,1,ML,42.88,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,39.06368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001341,NDC,1,ML,42.88,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,39.06368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,436067216,NDC,473,ML,77.23,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,39.07838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,39328006412,NDC,473,ML,77.23,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,39.07838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084243,NDC,0.5,ML,202.42,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,39.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.7,39.08
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084243,NDC,0.5,ML,202.42,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,39.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.7,39.08
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084252,NDC,0.5,ML,207.65,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,39.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.7,39.08
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084252,NDC,0.5,ML,207.65,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,39.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.7,39.08
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012250,NDC,1,EA,77.24,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,39.08344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012267,NDC,1,EA,77.24,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,39.08344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
cefOXitin 2 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021011020,NDC,1,EA,77.24,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,39.08344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.367364,75.6952
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023610,NDC,1,EA,77.24,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,39.08344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
betamethasone acetate-betamethasone sodium phosphate 6 (3-3) MG/ML Suspension 5 mL Vial,J0702.01,CDM,636,RC,J0702,HCPCS,,,,517072001,NDC,1,ML,78.96,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,39.0852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.799984,77.3808
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001001,NDC,1.5,ML,40.17,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,39.097461,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,42.5516
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915701,NDC,0.5,ML,44.33,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,39.09906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915731,NDC,0.5,ML,44.33,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,39.09906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,47335093140,NDC,0.5,EA,44.33,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,39.09906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,47335093144,NDC,0.5,EA,44.33,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,39.09906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
DERMABOND ADVANCED TOPICAL SKIN ADHESIVE,120.198,CDM,272,RC,,,,9101-MAIN,LOCAL,,,,,46,,First Health,Commercial,both,85,,999999999,percent of total billed charges,39.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.1084,45.08
Pinworm Exam,PX87172,CDM,300,RC,87172,CPT,,,,,,,,46,,First Health,Commercial,both,85,,999999999,percent of total billed charges,39.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,45.08
Everolimus,PX8016990,CDM,300,RC,80169,CPT,,,,,,,,79,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,39.105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,77.42
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019602,NDC,2,ML,77.29,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,39.10874,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
ticagrelor 90 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,186077739,NDC,1,EA,44.35,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,39.1167,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Transvaginal US, Obstetric",PX7681701,CDM,402,RC,76817,CPT,TC,,,,,,,460,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,39.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.97,113.07
"Transvaginal US, Obstetric",PX7681701,CDM,402,RC,76817,CPT,TC,,,,,,,460,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,39.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.97,113.07
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046201,NDC,30,ML,79.84,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,39.1216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046201,NDC,30,ML,79.84,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,39.1216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046201,NDC,30,ML,79.84,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,39.1216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
protamine 10 MG/ML Solution 25 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022930,NDC,2.5,ML,44.37,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,39.13434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.431298,83.0452
levoFLOXacin 250 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635161,NDC,1,EA,79.08,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,39.1446,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CANNULA ADULT LARGE OPTIFLOW OPT946,120.495,CDM,271,RC,A4615,HCPCS,,11622-MAIN,LOCAL,,,,,44,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,39.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
CANNULA ADULT MEDIUM OPTIFLOW OPT944,120.495,CDM,271,RC,A4615,HCPCS,,11621-MAIN,LOCAL,,,,,44,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,39.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
CANNULA ADULT SMALL OPTIFLOW OPT942,120.495,CDM,271,RC,A4615,HCPCS,,11620-MAIN,LOCAL,,,,,44,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,39.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
Homocysteine,PX83090,CDM,300,RC,83090,CPT,,,,,,,,44,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,39.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.43,43.12
KIT GASTRIC LAVAGE 2075,120.257,CDM,272,RC,C7510,HCPCS,,410-MAIN,LOCAL,,,,,44,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,39.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
SUTURE V-LOC 1/2 CIRCLE NEEDLE WOUND CLOSURE DEVICE VLOCN0306,27200000,CDM,272,RC,,,,11931-MAIN,LOCAL,,,,,44,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,39.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE V-LOC SZ 3-0 180 GREEN V-20 9 INCH VLOCL0644,27200000,CDM,272,RC,,,,13056-SURG,LOCAL,,,,,44,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,39.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Antinuclear Antibodiesana - Ref,PX8603890,CDM,300,RC,86038,CPT,90,,,,,,,43,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,39.173,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.09,42.14
Blood Type Antigen Donor Ea,PX86902,CDM,300,RC,86902,CPT,,,,,,,,43,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,39.173,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.8622,314.02
ETRAP POLYP TRAP,27200000,CDM,272,RC,,,,11282-MAIN,LOCAL,,,,,43,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,39.173,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Smking Cess 4-10 Min,PX99406P,CDM,983,RC,99406,CPT,,,,,,,,43,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,39.173,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.8622,41.8519
"Testosterone, Total - Ref",PX8440390,CDM,300,RC,84403,CPT,90,,,,,,,43,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,39.173,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.8622,42.14
bezlotoxumab 1000 MG/40ML Solution 40 mL Vial,J0565.01,CDM,636,RC,J0565,HCPCS,,,,6302500,NDC,40,ML,7752,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,39.18306,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.31,39.86
8MM-12MM TIP COVER ACCESSORY,27200000,CDM,272,RC,,,,11918-MAIN,LOCAL,,,,,40,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,39.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Alpha-Fetoprotein, Serum - Ref",PX8210590,CDM,300,RC,82105,CPT,90,,,,,,,80,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,39.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.38,78.4
"Alpha-Fetoprotein, Serum - Ref",PX8210590,CDM,300,RC,82105,CPT,90,,,,,,,80,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,39.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.38,78.4
"Alpha-Fetoprotein, Serum - Ref",PX8210590,CDM,300,RC,82105,CPT,90,,,,,,,80,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,39.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.38,78.4
CATHETER URETERAL  5FR TIGERTAIL OPEN TIP FLEXIBLE 139005,27200000,CDM,272,RC,A4340,HCPCS,,12302-MAIN,LOCAL,,,,,40,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,39.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NEEDLE BIOPSY 14GAX4 1/2 2N2702X,120.211,CDM,272,RC,,,,724-MAIN,LOCAL,,,,,40,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,39.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.616,39.2
Prealubimin,PX84134,CDM,300,RC,84134,CPT,,,,,,,,80,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,39.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.38,78.4
Prealubimin,PX84134,CDM,300,RC,84134,CPT,,,,,,,,80,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,39.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.38,78.4
Prealubimin,PX84134,CDM,300,RC,84134,CPT,,,,,,,,80,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,39.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.38,78.4
STAPLER CANNULA SEAL 12 mm 470380,27200000,CDM,272,RC,,,,11962-MAIN,LOCAL,,,,,40,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,39.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"SUTURE V-LOC 22G NEEDLE 9"" 180 GREEN VLOCL2145",27200000,CDM,272,RC,,,,11930-MAIN,LOCAL,,,,,40,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,39.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"SUTURE V-LOC SZ 0.9"" 180 GREEN GS-21 NEEDLE VLOCL0346",27200000,CDM,272,RC,,,,11933-MAIN,LOCAL,,,,,40,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,39.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Telehealth Origin Site Fac Fee,PXQ3014,CDM,780,RC,Q3014,HCPCS,,,,,,,,40,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,39.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.616,39.2
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,63323041536,NDC,0.5,ML,44.05,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,39.2045,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
"Janssen Covid-19 Vaccine, Administration",PX0031A,CDM,771,RC,0031A,HCPCS,,,,,,,,69,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,39.21,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.21,39.21398
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 1st Dose",PX0011A,CDM,771,RC,0011A,HCPCS,,,,,,,,69,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,39.21,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.21,39.21398
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 2nd Dose",PX0012A,CDM,771,RC,0012A,HCPCS,,,,,,,,69,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,39.21,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.21,39.21398
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 3rd Dose",PX0013A,CDM,771,RC,0013A,HCPCS,,,,,,,,69,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,39.21,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.21,39.21398
Novavax Covid-19 Vaccine Administration 1st Dose,PX0041A,CDM,771,RC,0041A,HCPCS,,,,,,,,69,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,39.21,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.21,39.21398
Novavax Covid-19 Vaccine Administration 2nd Dose,PX0042A,CDM,771,RC,0042A,HCPCS,,,,,,,,69,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,39.21,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.21,39.21398
"Pfizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 2nd Dose",PX0002A,CDM,771,RC,0002A,HCPCS,,,,,,,,69,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,39.21,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.21,39.21398
"Pfizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 3rd Dose",PX0003A,CDM,771,RC,0003A,HCPCS,,,,,,,,69,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,39.21,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.21,39.21398
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,703903201,NDC,2,ML,44.46,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,39.21372,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,97.0102
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2021301,NDC,3,ML,44.46,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,39.21372,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
"Janssen Covid-19 Vaccine, Administration",PX0031A,CDM,771,RC,0031A,HCPCS,,,,,,,,69,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,39.21398,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.21,39.21398
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 1st Dose",PX0011A,CDM,771,RC,0011A,HCPCS,,,,,,,,69,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,39.21398,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.21,39.21398
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 2nd Dose",PX0012A,CDM,771,RC,0012A,HCPCS,,,,,,,,69,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,39.21398,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.21,39.21398
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 3rd Dose",PX0013A,CDM,771,RC,0013A,HCPCS,,,,,,,,69,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,39.21398,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.21,39.21398
Novavax Covid-19 Vaccine Administration 1st Dose,PX0041A,CDM,771,RC,0041A,HCPCS,,,,,,,,69,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,39.21398,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.21,39.21398
Novavax Covid-19 Vaccine Administration 2nd Dose,PX0042A,CDM,771,RC,0042A,HCPCS,,,,,,,,69,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,39.21398,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.21,39.21398
"Pfizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 2nd Dose",PX0002A,CDM,771,RC,0002A,HCPCS,,,,,,,,69,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,39.21398,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.21,39.21398
"Pfizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 3rd Dose",PX0003A,CDM,771,RC,0003A,HCPCS,,,,,,,,69,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,39.21398,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.21,39.21398
fentaNYL 25 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,591319872,NDC,1,EA,77.51,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,39.22006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine 1 MG/ML Solution 50 mL Syringe,J2270.01,CDM,636,RC,J2270,HCPCS,,,,61553064975,NDC,50,ML,81.71,,Health Partners,Health Partners Care Plans,both,48,,31.91333333,percent of total billed charges,39.2208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
morphine 1 MG/ML Solution 50 mL Syringe,J2270.01,CDM,636,RC,J2270,HCPCS,,,,61553064975,NDC,50,ML,81.71,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,39.2208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,703291401,NDC,0.5,EA,40.3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,39.22399,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium bicarbonate 4.2 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409553434,NDC,10,ML,91.46,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,39.23634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
leflunomide 20 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,70748013006,NDC,0.5,EA,44.1,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,39.249,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16714098801,NDC,1,EA,46.18,,First Health,Commercial,both,85,,999999999,percent of total billed charges,39.253,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323018507,NDC,10,ML,43.09,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,39.25499,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Xray Lumbosacral Minimum 4 Vws,PX7211001,CDM,320,RC,72110,CPT,TC,,,,,,,565,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,39.2596,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.74,78.23
Assay of Natriuretic Peptide,PX83880,CDM,300,RC,83880,CPT,,,,,,,,290,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,39.26,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.08,39.26
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049209,NDC,5,ML,44.52,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,39.26664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
DIMETHICONE (TOPICAL) 5 % Cream 118 mL Tube,800000,CDM,,,,,,,,53329015104,NDC,118,ML,44.12,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,39.2668,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
phenol-glycerin 1.5-33 % Liquid 118 mL Bottle,25000000,CDM,250,RC,,,,,,78112000068,NDC,118,ML,44.12,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,39.2668,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Apply Forearm Cast,PX29075F,CDM,510,RC,29075,CPT,,,,,,,,210,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,39.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.83,186.09
Apply Forearm Cast,PX29075F,CDM,510,RC,29075,CPT,,,,,,,,210,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,39.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.83,186.09
Apply Forearm Cast,PX29075P,CDM,983,RC,29075,CPT,,,,,,,,140,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,39.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.83,186.09
Apply Forearm Cast,PX29075P,CDM,983,RC,29075,CPT,,,,,,,,140,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,39.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.83,186.09
Injection for Nerve Block,PX64447F,CDM,510,RC,64447,CPT,,,,,,,,3023,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,39.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.05,240.75
Injection for Nerve Block,PX64447F,CDM,510,RC,64447,CPT,,,,,,,,3023,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,39.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.05,240.75
Injection for Nerve Block,PX64447P,CDM,983,RC,64447,CPT,,,,,,,,3892,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,39.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.05,3814.16
Injection for Nerve Block,PX64447P,CDM,983,RC,64447,CPT,,,,,,,,3892,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,39.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.05,3814.16
imipenem-cilastatin 250 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323034925,NDC,1,EA,91.55,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,39.27495,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,173.1856
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032294,NDC,1,EA,91.55,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,39.27495,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,173.1856
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234001,NDC,1.25,ML,91.55,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,39.27495,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
urea 20 % Cream 85 g Tube,63700001,CDM,250,RC,,,,,,536110945,NDC,85,GR,81.83,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,39.2784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
urea 20 % Cream 85 g Tube,63700001,CDM,250,RC,,,,,,536110945,NDC,85,GR,81.83,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,39.2784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Cmv, Quant - Ref",PX8749790,CDM,300,RC,87497,CPT,90,,,,,,,194,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,39.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.28,190.12
Hepatitis C Rna Quant,PX87522,CDM,300,RC,87522,CPT,,,,,,,,185,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,39.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.28,181.3
Infec Agent Direct Probe - Ref,PX8779990,CDM,300,RC,87799,CPT,90,,,,,,,182,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,39.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.28,178.36
"dextran 70, glycerin, hypromellose 0.1-0.2-0.3 % Solution 15 mL Bottle",63700001,CDM,250,RC,,,,,,65042636,NDC,15,ML,44.14,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,39.2846,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclopentolate 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,61314039601,NDC,2,ML,94.58,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,39.288532,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039841,NDC,1,EA,43.14,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,39.30054,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
tolterodine ER 2 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,43975032203,NDC,1,EA,43.15,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,39.30965,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
enalaprilat 1.25 MG/ML Injectable 1 mL Vial,25000000,CDM,250,RC,,,,,,143978701,NDC,1,ML,40.39,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,39.311587,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
leucovorin 10 mg/mL Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,25021081467,NDC,1,EA,40.13,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,39.3274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.670002,84.6818
ampicillin 1 GM Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781926185,NDC,0.5,EA,43.18,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,39.33698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028002,NDC,1,ML,40.43,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,4.556666667,percent of total billed charges,39.350519,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329333901,NDC,10,ML,79.51,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,39.35745,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
calcium CHLORIDE 10 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,76329330401,NDC,10,ML,79.51,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,39.35745,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,25021018482,NDC,100,ML,79.51,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,39.35745,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.786918,140.5516
Ace - Ref,PX8216490,CDM,300,RC,82164,CPT,90,,,,,,,82,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,39.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.39,80.36
Ace - Ref,PX8216490,CDM,300,RC,82164,CPT,90,,,,,,,82,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,39.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.39,80.36
Anca Screen Each Antibody,PX8603690,CDM,300,RC,86036,CPT,90,,,,,,,82,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,39.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.0628,80.36
Anca Screen Each Antibody,PX8603690,CDM,300,RC,86036,CPT,90,,,,,,,82,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,39.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.0628,80.36
"Cognitive Funct Ther Interv, Ea Addl 15 Min",PX97130,CDM,420,RC,97130,CPT,,,,,,,,82,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,39.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31,80.36
"Cognitive Funct Ther Interv, Ea Addl 15 Min",PX97130,CDM,420,RC,97130,CPT,,,,,,,,82,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,39.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31,80.36
"Cortisol, Free - Ref",PX8253090,CDM,300,RC,82530,CPT,90,,,,,,,82,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,39.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.32,80.36
"Cortisol, Free - Ref",PX8253090,CDM,300,RC,82530,CPT,90,,,,,,,82,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,39.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.32,80.36
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253033335,NDC,5,ML,40.44,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.46575,percent of total billed charges,39.360252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
menthol-zinc oxide Paste 113 g Tube,63700001,CDM,250,RC,,,,,,53329016544,NDC,113,GR,79.52,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,39.3624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Etoposide 100 MG/5ML Solution 5 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,16729011431,NDC,5,ML,43.21,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,39.36431,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.949434,169.8144
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001001,NDC,1.5,ML,40.17,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,39.3666,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,42.5516
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,67815203,NDC,100,GR,91.77,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,39.36933,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
amoxicillin 250 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,93415580,NDC,150,ML,43.22,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,39.37342,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,143957501,NDC,50,ML,44.24,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,39.3736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,143957510,NDC,50,ML,44.24,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,39.3736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331601,NDC,10,ML,77.86,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,39.39716,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
ESOPHAGEAL BALLOON INFLATION DEVICE 60ML,27200000,CDM,272,RC,C1726,HCPCS,,11326-MAIN,LOCAL,,,,,80.41,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,39.4009,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ESOPHAGEAL BALLOON INFLATION DEVICE 60ML,27200000,CDM,272,RC,C1726,HCPCS,,11326-MAIN,LOCAL,,,,,80.41,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,39.4009,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ESOPHAGEAL BALLOON INFLATION DEVICE 60ML,27200000,CDM,272,RC,C1726,HCPCS,,11326-MAIN,LOCAL,,,,,80.41,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,39.4009,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061401,NDC,1,ML,94.87,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,39.408998,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.114178,99.911
ampicillin 500 MG Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781925078,NDC,1,EA,44.28,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,39.4092,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
atropine (PF) 1 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517101025,NDC,1,ML,91.89,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,39.42081,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
Xray Ac Joints(Bilateral),PX7305001,CDM,320,RC,73050,CPT,TC,,,,,,,519,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,39.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.87,39.44
Xray Ac Joints(Bilateral),PX7305001,CDM,320,RC,73050,CPT,TC,,,,,,,519,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,39.44,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.87,39.44
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036001,NDC,10,ML,80.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.141,percent of total billed charges,39.445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,84.5054
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036001,NDC,10,ML,80.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,39.445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,84.5054
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036001,NDC,10,ML,80.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,39.445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,84.5054
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915701,NDC,0.5,ML,44.33,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,39.4537,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915731,NDC,0.5,ML,44.33,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,39.4537,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,47335093140,NDC,0.5,EA,44.33,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,39.4537,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,47335093144,NDC,0.5,EA,44.33,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,39.4537,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"CUFF STERILE DISPOSABLE SPSB 12""",27200000,CDM,272,RC,,,,7435-MAIN,LOCAL,,,,,43.31,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,39.45541,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
omalizumab 150 MG Recon Soln 1 Each Vial,J2357.01,CDM,636,RC,J2357,HCPCS,,,,50242004062,NDC,1,EA,2212.7,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,39.46,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.18,39.46
Assay Blood Carbon Dioxide,PX82374,CDM,300,RC,82374,CPT,,,,,,,,95,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,39.463,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.47,93.1
Blood Viscosity Examination,PX85810,CDM,300,RC,85810,CPT,,,,,,,,95,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,39.463,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.7,93.1
Cyclosporine - Ref,PX8015890,CDM,300,RC,80158,CPT,90,,,,,,,95,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,39.463,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.55,93.1
"Fac/Debridement of Nails, 6 or Mor",PX11721F,CDM,510,RC,11721,CPT,,,,,,,,95,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,39.463,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.463,93.1
"Fat/Lipids, Feces, Quant - Ref",PX8271090,CDM,300,RC,82710,CPT,90,,,,,,,95,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,39.463,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.4,93.1
KIT EPIDURAL 19GA FLEXTIP PLUS AK-05502,120.305,CDM,272,RC,,,,11413-MAIN,LOCAL,,,,,95,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,39.463,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.463,93.1
"Lyme Disease, Confirm Tst - Ref",PX8661790,CDM,300,RC,86617,CPT,90,,,,,,,95,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,39.463,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.2,93.1
"Organism ID, Anaerobic - Ref",PX8707690,CDM,300,RC,87076,CPT,90,,,,,,,95,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,39.463,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,93.1
Strep a Assay W/Optic,PX87880,CDM,300,RC,87880,CPT,,,,,,,,95,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,39.463,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.16,93.1
"Thyroxine, Total - Ref",PX8443690,CDM,300,RC,84436,CPT,90,,,,,,,95,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,39.463,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.3,93.1
TRAY FACIAL LACERATION PACK STERILE 96-1707,120.12,CDM,272,RC,,,,406-MAIN,LOCAL,,,,,95,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,39.463,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.463,93.1
Varicella-Zoster Antibody,PX86787,CDM,300,RC,86787,CPT,,,,,,,,95,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,39.463,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.81,93.1
Blood Typing Abo,PX86900,CDM,300,RC,86900,CPT,,,,,,,,92,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,39.468,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.2168,111.6
Blood Typing Rh (D),PX86901,CDM,300,RC,86901,CPT,,,,,,,,92,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,39.468,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.03,90.16
Parvovirus Antibody - Ref,PX8674790,CDM,300,RC,86747,CPT,90,,,,,,,92,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,39.468,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.78,90.16
"Reticulocyte Count,Flow Cyto",PX85045,CDM,300,RC,85045,CPT,,,,,,,,92,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,39.468,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.66,90.16
Ceruloplasmin - Ref,PX8239090,CDM,300,RC,82390,CPT,90,,,,,,,78,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,39.468,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,76.44
Chemiluminescent Assay - Ref,PX8239790,CDM,300,RC,82397,CPT,90,,,,,,,78,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,39.468,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.95,76.44
VISUALIZATION SYSTEM CLEARIFY LAPAROSCOPE STERILE,27200000,CDM,272,RC,,,,11875-MAIN,LOCAL,,,,,78,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,39.468,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ticagrelor 90 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,186077739,NDC,1,EA,44.35,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,39.4715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
protamine 10 MG/ML Solution 25 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022930,NDC,2.5,ML,44.37,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,39.4893,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.431298,83.0452
CISplatin 50 MG/50ML Solution 50 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010351,NDC,50,ML,82.27,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,39.4896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.174958,180.2416
CISplatin 50 MG/50ML Solution 50 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010351,NDC,50,ML,82.27,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,39.4896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.174958,180.2416
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,703291401,NDC,0.5,EA,40.3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,39.494,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,641601310,NDC,5,ML,40.58,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,39.496514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"dextrose 5% and sodium chloride 0.45% with potassium chloride 10 mEq in 1000 mL 10-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,338066904,NDC,1000,ML,80.61,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,39.4989,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"dextrose 5% and sodium chloride 0.45% with potassium chloride 10 mEq in 1000 mL 10-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,338066904,NDC,1000,ML,80.61,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,39.4989,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"dextrose 5% and sodium chloride 0.45% with potassium chloride 10 mEq in 1000 mL 10-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,338066904,NDC,1000,ML,80.61,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,39.4989,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,264957710,NDC,500,ML,80.61,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.717962963,percent of total billed charges,39.4989,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,264957710,NDC,500,ML,80.61,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,39.4989,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,264957710,NDC,500,ML,80.61,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,39.4989,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052201,NDC,500,ML,80.61,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.717962963,percent of total billed charges,39.4989,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052201,NDC,500,ML,80.61,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,39.4989,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052201,NDC,500,ML,80.61,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,39.4989,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052277,NDC,500,ML,80.61,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.717962963,percent of total billed charges,39.4989,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052277,NDC,500,ML,80.61,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,39.4989,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052277,NDC,500,ML,80.61,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,39.4989,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048203,NDC,20,ML,44.8,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,39.5136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048227,NDC,20,ML,44.8,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,39.5136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046201,NDC,30,ML,79.84,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,39.5208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
skin oil Oil 236.6 mL Bottle,63700001,CDM,250,RC,,,,,,67211008,NDC,236.6,ML,40.61,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,39.525713,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490311,NDC,5,ML,43.39,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,39.52829,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
Aldosterone - Ref,PX8208890,CDM,300,RC,82088,CPT,90,,,,,,,86,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,39.53,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.53,40.75
Aldosterone - Ref,PX8208890,CDM,300,RC,82088,CPT,90,,,,,,,86,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,39.53,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.53,40.75
Aldosterone - Ref,PX8208890,CDM,300,RC,82088,CPT,90,,,,,,,86,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,39.53,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.53,40.75
Dimethicone 1.5 % Cream 118 mL Tube,800000,CDM,,,,,,,,53329016104,NDC,118,ML,43.4,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,39.5374,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001002,NDC,2,ML,43.42,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,39.55562,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,42.5516
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,703903201,NDC,2,ML,44.46,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,39.5694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,97.0102
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2021301,NDC,3,ML,44.46,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,39.5694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218710,NDC,2,EA,5662.72,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,39.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.57,6737.8528
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218713,NDC,2,EA,6875.36,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,39.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.57,6737.8528
pembrolizumab 100 MG/4ML Solution 4 mL Vial,J9271.01,CDM,636,RC,J9271,HCPCS,,,,6302602,NDC,4,ML,9627.58,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,39.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.57,9435.0284
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,50383058766,NDC,60,ML,95.26,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,39.571004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,60432053760,NDC,60,ML,95.26,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,39.571004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"X-Ray Exam Hip,Bilat W/Pelvis 3-4 Vws",PX7352201,CDM,320,RC,73522,CPT,TC,,,,,,,382,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,39.58,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.58,78.89
"X-Ray Exam Hip,Bilat W/Pelvis 3-4 Vws",PX7352201,CDM,320,RC,73522,CPT,TC,,,,,,,382,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,39.5814,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.58,78.89
enalaprilat 1.25 MG/ML Injectable 1 mL Vial,25000000,CDM,250,RC,,,,,,143978701,NDC,1,ML,40.39,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,39.5822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089901,NDC,0.25,ML,95.31,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,39.591774,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.79,93.4038
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089910,NDC,0.25,ML,95.31,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,39.591774,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.79,93.4038
"Alpha-Fetoprotein, Serum - Ref",PX8210590,CDM,300,RC,82105,CPT,90,,,,,,,80,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,39.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.38,78.4
Prealubimin,PX84134,CDM,300,RC,84134,CPT,,,,,,,,80,,Humana Choice Care,All Medicare plans,outpatient,49.5,,62.72,percent of total billed charges,39.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.38,78.4
ezetimibe 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714081301,NDC,1,EA,44.91,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,39.61062,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LAP KIT BASIC,27200000,CDM,272,RC,,,,4829-MAIN,LOCAL,,,,,78.29,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,39.61474,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028002,NDC,1,ML,40.43,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,39.6214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049209,NDC,5,ML,44.52,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,39.6228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dextrose 5 % 5 % Solution 50 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338055111,NDC,50,ML,43.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,39.6285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 100 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001748,NDC,100,ML,43.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,39.6285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,264763500,NDC,1000,ML,43.5,,Medica,Commercial,both,91.1,,1.111818182,percent of total billed charges,39.6285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5% lactated ringers 5 % Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012504,NDC,1000,ML,43.5,,Medica,Commercial,both,91.1,,15.33309859,percent of total billed charges,39.6285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329330201,NDC,25,ML,43.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,39.6285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9 % 0.9 % Solution 50 mL Flex Cont,J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004941,NDC,50,ML,43.5,,Medica,Commercial,both,91.1,,7.872391304,percent of total billed charges,39.6285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004941,NDC,250,ML,43.5,,Medica,Commercial,both,91.1,,13.59421053,percent of total billed charges,39.6285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055311,NDC,250,ML,43.5,,Medica,Commercial,both,91.1,,13.59421053,percent of total billed charges,39.6285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004948,NDC,300,ML,43.5,,Medica,Commercial,both,91.1,,13.59421053,percent of total billed charges,39.6285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055318,NDC,300,ML,43.5,,Medica,Commercial,both,91.1,,13.59421053,percent of total billed charges,39.6285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 150 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,409798361,NDC,300,ML,43.5,,Medica,Commercial,both,91.1,,13.59421053,percent of total billed charges,39.6285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9% irrigation 0.9 % Solution 3,000 mL Plas Cont",25000000,CDM,250,RC,,,,,,338004727,NDC,3000,ML,43.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,39.6285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9% IV LINE FLUSH 0.9% Solution 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,338004948,NDC,100,ML,43.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,39.6285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253033335,NDC,5,ML,40.44,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,39.6312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,39.6312
sildenafil citrate 20 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,65162035109,NDC,1,EA,95.41,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,39.633314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409751766,NDC,50,ML,80.89,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,39.6361,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409751766,NDC,50,ML,80.89,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,39.6361,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409751766,NDC,50,ML,80.89,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,39.6361,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
gemcitabine 200 MG/5.26ML Solution 5.26 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018301,NDC,5.26,ML,40.74,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,39.652242,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
"Manage/Train Orthotic/Prosthetic, per 15 Min",PX97763,CDM,420,RC,97763,CPT,,,,,,,,121,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,39.66,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.47,68.97
"Manage/Train Orthotic/Prosthetic, per 15 Min",PX97763,CDM,420,RC,97763,CPT,,,,,,,,121,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,39.66,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.47,68.97
empagliflozin 25 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,597015330,NDC,0.4,EA,43.54,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,39.66494,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
empagliflozin 25 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,597015337,NDC,0.4,EA,43.54,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,39.66494,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,69543025204,NDC,118,ML,78.39,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,39.66534,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052084,NDC,1,EA,92.46,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,39.66534,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.407884,90.9538
methylPREDNISolone sod succ 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,63323025803,NDC,0.4,EA,46.67,,First Health,Commercial,both,85,,999999999,percent of total billed charges,39.6695,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
empagliflozin 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,597015230,NDC,1,EA,92.47,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,39.66963,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CAPTIFLEX SNARE SINGLE USE EXTRA SMALL 11MM,27200000,CDM,272,RC,,,,12378-MAIN,LOCAL,,,,,81,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,39.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CAPTIFLEX SNARE SINGLE USE EXTRA SMALL 11MM,27200000,CDM,272,RC,,,,12378-MAIN,LOCAL,,,,,81,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,39.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CAPTIFLEX SNARE SINGLE USE EXTRA SMALL 11MM,27200000,CDM,272,RC,,,,12378-MAIN,LOCAL,,,,,81,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,39.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Cardiac Rehab,PX93797F,CDM,943,RC,93797,CPT,,,,,,,,45,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,39.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,115.44
CATHETER TEMP-SENSING 8FR LUBRISIL PEDS DYND110508,120.363,CDM,272,RC,A4340,HCPCS,,12777-MAIN,LOCAL,,,,,45,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,39.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
CATHETER TEMP-SENSING 12FR LUBRISIL 119212M,120.363,CDM,272,RC,A4340,HCPCS,,10750-MAIN,LOCAL,,,,,45,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,39.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
CATHETER TEMP-SENSING 14FR LUBRISIL 119214M,120.363,CDM,272,RC,A4340,HCPCS,,10751-MAIN,LOCAL,,,,,45,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,39.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
CATHETER TEMP-SENSING 16FR LUBRISIL 119216M,120.363,CDM,272,RC,A4340,HCPCS,,10752-MAIN,LOCAL,,,,,45,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,39.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
Cryptococcus Neoformans,PX87327,CDM,300,RC,87327,CPT,,,,,,,,45,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,39.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.3,44.1
Gammaglobulin; Ige - Ref,PX8278590,CDM,300,RC,82785,CPT,90,,,,,,,45,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,39.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.09,44.1
GASTRONOMY FEEDING TUBE MIC BALLOONED 20FR 7-10ML 0112-20,27200000,CDM,272,RC,B4087,HCPCS,,13098-MAIN,LOCAL,,,,,45,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,39.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRES 1.6MM,27200000,CDM,272,RC,C1769,HCPCS,,11852-MAIN,LOCAL,,,,,45,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,39.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"La Crosse, Antibody - Ref",PX8665190,CDM,300,RC,86651,CPT,90,,,,,,,45,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,39.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.09,44.1
MELGISORB AG SILVER CALCIUM STERILE 6X6,120.502,CDM,272,RC,A6197,HCPCS,,11844-MAIN,LOCAL,,,,,45,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,39.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
Smear Special Stain,PX87207,CDM,300,RC,87207,CPT,,,,,,,,81,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,39.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.49,79.38
Smear Special Stain,PX87207,CDM,300,RC,87207,CPT,,,,,,,,81,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,39.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.49,79.38
Smear Special Stain,PX87207,CDM,300,RC,87207,CPT,,,,,,,,81,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,39.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.49,79.38
"St Louis, Antibody - Ref",PX8665390,CDM,300,RC,86653,CPT,90,,,,,,,45,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,39.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.09,44.1
"Sugars, Qual, Ea Spec - Ref",PX8437690,CDM,300,RC,84376,CPT,90,,,,,,,45,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,39.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.04,44.1
Tacrolimus - Ref,PX8019790,CDM,300,RC,80197,CPT,90,,,,,,,81,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,39.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,79.38
Tacrolimus - Ref,PX8019790,CDM,300,RC,80197,CPT,90,,,,,,,81,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,39.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,79.38
Tacrolimus - Ref,PX8019790,CDM,300,RC,80197,CPT,90,,,,,,,81,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,39.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,79.38
"Venipuncture by Physician, Other Vein, Under Age 3 Years",PX36406,CDM,983,RC,36406,CPT,,,,,,,,45,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,39.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,43.7985
"Western Equine, Ab - Ref",PX8665490,CDM,300,RC,86654,CPT,90,,,,,,,45,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,39.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.09,44.1
US Abdomen Limited Tc,PX7670501,CDM,402,RC,76705,CPT,TC,,,,,,,425,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,39.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.7,117.67
US Abdomen Limited Tc,PX7670501,CDM,402,RC,76705,CPT,TC,,,,,,,425,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,39.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.7,117.67
Ventilator Mgmt.Subsequent Days,PX94003F,CDM,410,RC,94003,CPT,,,,,,,,1686,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,39.7,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.7,110.52
FLEXITIP APPLICATOR 38CM,27200000,CDM,272,RC,,,,10200-MAIN,LOCAL,,,,,40.8,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,39.71064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,45802095301,NDC,100,GR,82.76,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,39.7248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,45802095301,NDC,100,GR,82.76,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,39.7248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010301,NDC,0.3,ML,45.04,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,39.72528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
SAW BLADE 300 SAGITTAL 25X9.4X0.7,27200000,CDM,272,RC,,,,11592-MAIN,LOCAL,,,,,46.75,,First Health,Commercial,both,85,,999999999,percent of total billed charges,39.7375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SAW BLADE 300 SAGITTAL 40X14X0.6MM,27200000,CDM,272,RC,,,,11591-MAIN,LOCAL,,,,,46.75,,First Health,Commercial,both,85,,999999999,percent of total billed charges,39.7375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,17478028810,NDC,5,ML,95.71,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,39.757934,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314022705,NDC,5,ML,95.71,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,39.757934,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,64980051405,NDC,5,ML,95.71,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,39.757934,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,409163221,NDC,0.5,EA,43.65,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,39.76515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,641601310,NDC,5,ML,40.58,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,39.7684,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424601,NDC,15,ML,95.76,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,39.778704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.778704,295.3916
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424681,NDC,15,ML,95.76,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,39.778704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.778704,295.3916
Aldosterone - Ref,PX8208890,CDM,300,RC,82088,CPT,90,,,,,,,86,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,39.7916,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.53,40.75
skin oil Oil 236.6 mL Bottle,63700001,CDM,250,RC,,,,,,67211008,NDC,236.6,ML,40.61,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,39.7978,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tiotropium 18 MCG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,597007541,NDC,1,EA,82.92,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,39.8016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tiotropium 18 MCG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,597007541,NDC,1,EA,82.92,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,39.8016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ESOPHAGEAL BALLOON INFLATION DEVICE 60ML,27200000,CDM,272,RC,C1726,HCPCS,,11326-MAIN,LOCAL,,,,,80.41,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,39.80295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052083,NDC,1,EA,92.81,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,39.81549,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.407884,90.9538
Repr Superf Wnd Body <2.5cm,PX12001F,CDM,510,RC,12001,CPT,,,,,,,,311,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,39.8164,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.83,196.47
Repr Superf Wnd Body <2.5cm,PX12001P,CDM,983,RC,12001,CPT,,,,,,,,293,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,39.8164,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.83,287.14
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,25021012867,NDC,1,EA,82.96,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,39.8208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,25021012867,NDC,1,EA,82.96,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,39.8208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,55150020830,NDC,1,EA,82.96,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,39.8208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.461584,189.875
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,55150020830,NDC,1,EA,82.96,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,39.8208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.461584,189.875
sod citrate-citric acid 500-334 MG/5ML Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,121059516,NDC,473,ML,95.87,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,39.824398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levoFLOXacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635261,NDC,0.5,EA,45.16,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,39.83112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,17478081725,NDC,25,ML,81.3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,39.837,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,17478081725,NDC,25,ML,81.3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,39.837,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,17478081725,NDC,25,ML,81.3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,39.837,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,47781047013,NDC,1,EA,83,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,39.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,47781047013,NDC,1,EA,83,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,39.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,64380079901,NDC,1,EA,83,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,39.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,64380079901,NDC,1,EA,83,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,39.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,69238126601,NDC,1,EA,83,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,39.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,69238126601,NDC,1,EA,83,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,39.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SLING ARM CHILD PAD CANVAS NAVY 8004-02,120.54,CDM,273,RC,A4565,HCPCS,,878-MAIN,LOCAL,,,,,83,,Health Partners,Health Partners Care Plans,both,48,,80.51,percent of total billed charges,39.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM CHILD PAD CANVAS NAVY 8004-02,120.54,CDM,273,RC,A4565,HCPCS,,878-MAIN,LOCAL,,,,,83,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,39.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM LARGE PAD CANVAS NAVY ORT11300L,120.54,CDM,273,RC,A4565,HCPCS,,870-MAIN,LOCAL,,,,,83,,Health Partners,Health Partners Care Plans,both,48,,80.51,percent of total billed charges,39.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM LARGE PAD CANVAS NAVY ORT11300L,120.54,CDM,273,RC,A4565,HCPCS,,870-MAIN,LOCAL,,,,,83,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,39.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM MEDIUM PAD CANVAS NAVY ORT11300M,120.54,CDM,273,RC,A4565,HCPCS,,872-MAIN,LOCAL,,,,,83,,Health Partners,Health Partners Care Plans,both,48,,80.51,percent of total billed charges,39.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM MEDIUM PAD CANVAS NAVY ORT11300M,120.54,CDM,273,RC,A4565,HCPCS,,872-MAIN,LOCAL,,,,,83,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,39.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM SMALL PAD CANVAS NAVY ORT11300S,120.54,CDM,273,RC,A4565,HCPCS,,874-MAIN,LOCAL,,,,,83,,Health Partners,Health Partners Care Plans,both,48,,80.51,percent of total billed charges,39.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM SMALL PAD CANVAS NAVY ORT11300S,120.54,CDM,273,RC,A4565,HCPCS,,874-MAIN,LOCAL,,,,,83,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,39.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM X-LARGE PAD ENVELOPE ORT11300XL,120.54,CDM,273,RC,A4565,HCPCS,,876-MAIN,LOCAL,,,,,83,,Health Partners,Health Partners Care Plans,both,48,,80.51,percent of total billed charges,39.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM X-LARGE PAD ENVELOPE ORT11300XL,120.54,CDM,273,RC,A4565,HCPCS,,876-MAIN,LOCAL,,,,,83,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,39.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070548,NDC,100,ML,40.94,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,4.559571429,percent of total billed charges,39.846902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036001,NDC,10,ML,80.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,39.8475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,84.5054
bezlotoxumab 1000 MG/40ML Solution 40 mL Vial,J0565.01,CDM,636,RC,J0565,HCPCS,,,,6302500,NDC,40,ML,7752,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,39.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.31,39.86
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048203,NDC,20,ML,44.8,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,39.872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048227,NDC,20,ML,44.8,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,39.872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; 1st",PX88184,CDM,310,RC,88184,CPT,,,,,,,,96,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,39.8784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.8784,314.02
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; Add'l",PX88185,CDM,310,RC,88185,CPT,,,,,,,,96,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,39.8784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.8784,94.08
US Urine Capacity Measure,PX51798F,CDM,510,RC,51798,CPT,,,,,,,,96,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,39.8784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.8784,94.08
BOOT AIRSELECT SHORT LARGE 01ES-L,120.45,CDM,274,RC,L4360,HCPCS,,11890-MAIN,LOCAL,,,,,93,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,39.897,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT MEDIUM 01ES-M,120.45,CDM,274,RC,L4360,HCPCS,,11889-MAIN,LOCAL,,,,,93,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,39.897,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT SMALL 01ES-S,120.45,CDM,274,RC,L4360,HCPCS,,11888-MAIN,LOCAL,,,,,93,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,39.897,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT X-LARGE 01ES-XL,120.45,CDM,274,RC,L4360,HCPCS,,11891-MAIN,LOCAL,,,,,93,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,39.897,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT X-SMALL 01ES-XS,120.45,CDM,274,RC,L4360,HCPCS,,11887-MAIN,LOCAL,,,,,93,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,39.897,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD LARGE 01EF-L,120.45,CDM,274,RC,L4360,HCPCS,,11697-MAIN,LOCAL,,,,,93,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,39.897,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD MEDIUM 01EF-M,120.45,CDM,274,RC,L4360,HCPCS,,11696-MAIN,LOCAL,,,,,93,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,39.897,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD SMALL 01EF-S,120.45,CDM,274,RC,L4360,HCPCS,,11695-MAIN,LOCAL,,,,,93,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,39.897,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD X-LARGE 01EF-XL,120.45,CDM,274,RC,L4360,HCPCS,,11698-MAIN,LOCAL,,,,,93,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,39.897,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD X-SMALL 01EF-XS,120.45,CDM,274,RC,L4360,HCPCS,,11694-MAIN,LOCAL,,,,,93,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,39.897,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
Russell Viper Venom - Ref,PX8561390,CDM,300,RC,85613,CPT,90,,,,,,,93,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,39.897,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.78,91.14
SPLINT FOOT SMALL STRUT WALK 11-1383-2-00000,120.45,CDM,274,RC,L4360,HCPCS,,1205-MAIN,LOCAL,,,,,93,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,39.897,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
oxytocin 10 UNIT/ML Solution 1 mL Vial,J2590.01,CDM,636,RC,J2590,HCPCS,,,,42023011625,NDC,1,ML,43.8,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,39.9018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.19452,42.924
"dextrose 5% and sodium chloride 0.45% with potassium chloride 10 mEq in 1000 mL 10-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,338066904,NDC,1000,ML,80.61,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,39.90195,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,264957710,NDC,500,ML,80.61,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,39.90195,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052201,NDC,500,ML,80.61,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,39.90195,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052277,NDC,500,ML,80.61,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,39.90195,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
CANNULA SEAL 5-12MM UNIVERSAL 470500,27200000,CDM,272,RC,,,,12885-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,39.9053,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CUP HEEL LARGE WONDERSPUR 4502,120.43,CDM,274,RC,L3485,HCPCS,,11385-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,39.9053,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL MEDIUM WONDERSPUR 4501,120.43,CDM,274,RC,L3485,HCPCS,,11384-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,39.9053,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL SMALL WONDERSPUR 4500,120.43,CDM,274,RC,L3485,HCPCS,,11383-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,39.9053,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL XL WONDERSPUR 4503,120.43,CDM,274,RC,L3485,HCPCS,,11386-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,39.9053,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
Detection of Anaplasma Phagocytophilum by Amplified Nucleic Acid Probe Technique,PX8746890,CDM,300,RC,87468,CPT,90,,,,,,,41,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,39.9053,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
Detection of Ehrlichia Chaffeensis by Amplified Nucleic Acid Probe Technique,PX8748490,CDM,300,RC,87484,CPT,90,,,,,,,41,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,39.9053,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 21G 110MM SONOTAP II WITH FACET TIP 1285-3F110,120.483,CDM,271,RC,A4215,HCPCS,,12201-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,39.9053,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 21G X 4IN (100MM) SONOBLOCK II NERVE BLOCK WITH FACET S TIP 001281-77,120.483,CDM,271,RC,A4215,HCPCS,,12761-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,39.9053,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 22G 80MM SONOTAP II WITH FACET TIP 1285-3E080,120.483,CDM,271,RC,A4215,HCPCS,,12103-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,39.9053,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 22G X 3.25IN (80MM) SONOBLOCK II  NERVE BLOCK WITH FACET S TIP 001281-71,120.483,CDM,271,RC,A4215,HCPCS,,12760-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,39.9053,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 22GX2 SONOPLEX II WITH FACET S TIP 001287-74,120.483,CDM,271,RC,A4215,HCPCS,,13110-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,39.9053,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE NON-STIMULATING 22GX2 SONOBLOCK II WITH FACET S TIP 001281-74,120.483,CDM,271,RC,A4215,HCPCS,,11459-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,39.9053,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE SONOPLEX II STIMULATING WITH FACET S TIP 22GX3-1/4,120.483,CDM,271,RC,A4215,HCPCS,,11457-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,39.9053,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE STIMULATING 21GX4  SONOPLEX II  WITH FACET S TIP 001287-77,120.483,CDM,271,RC,A4215,HCPCS,,11458-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,39.9053,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
STRAP FOOT LG/XL GEL UNIVERSAL 10165,120.428,CDM,271,RC,,,,11382-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,39.9053,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
STRAP FOOT SM/MED GEL UNIVERSAL 10155,120.428,CDM,271,RC,,,,11381-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,39.9053,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
SUTURE V-LOC SZ 1/2 180 GREEN GS-21 VLOCL0316,27200000,CDM,272,RC,,,,11932-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,39.9053,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
URGOK2 DUAL COMPRESSION SYSTEM LARGE,120.491,CDM,271,RC,A6452,HCPCS,,11871-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,39.9053,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
URGOK2 DUAL COMPRESSION SYSTEM REGULAR,120.491,CDM,271,RC,A6452,HCPCS,,11870-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,39.9053,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
US Abdomen Limited Tc,PX7670501,CDM,402,RC,76705,CPT,TC,,,,,,,425,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,39.92,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.7,117.67
Ventilator Mgmt.Subsequent Days,PX94003F,CDM,410,RC,94003,CPT,,,,,,,,1686,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,39.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.7,110.52
Ventilator Mgmt.Subsequent Days,PX94003F,CDM,410,RC,94003,CPT,,,,,,,,1686,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,39.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.7,110.52
gemcitabine 200 MG/5.26ML Solution 5.26 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018301,NDC,5.26,ML,40.74,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,39.9252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
Blood Count Reticulocytes Auto 1/> Cell Meas,PX85046,CDM,300,RC,85046,CPT,,,,,,,,47,,First Health,Commercial,both,85,,999999999,percent of total billed charges,39.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.11,46.06
"PAD BED SENSOR 10X28"" P-107517",120.124,CDM,271,RC,,,,8377-MAIN,LOCAL,,,,,47,,First Health,Commercial,both,85,,999999999,percent of total billed charges,39.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.5238,46.06
"PAD CHAIR SENSOR 10x15"" 106380",120.124,CDM,271,RC,,,,8378-MAIN,LOCAL,,,,,47,,First Health,Commercial,both,85,,999999999,percent of total billed charges,39.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.5238,46.06
"Protein S, Free - Ref",PX8530690,CDM,300,RC,85306,CPT,90,,,,,,,47,,First Health,Commercial,both,85,,999999999,percent of total billed charges,39.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.05,46.06
REDUCER 12 - 8MM,27200000,CDM,272,RC,,,,11961-MAIN,LOCAL,,,,,47,,First Health,Commercial,both,85,,999999999,percent of total billed charges,39.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
betamethasone acetate-betamethasone sodium phosphate 6 (3-3) MG/ML Suspension 5 mL Vial,J0702.01,CDM,636,RC,J0702,HCPCS,,,,517072001,NDC,1,ML,78.96,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,39.95376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.799984,77.3808
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143998391,NDC,1,EA,83.25,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,39.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143998391,NDC,1,EA,83.25,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,39.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ezetimibe 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714081301,NDC,1,EA,44.91,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,39.9699,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Everolimus,PX8016990,CDM,300,RC,80169,CPT,,,,,,,,79,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,39.974,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,77.42
FLEXITIP APPLICATOR 38CM,27200000,CDM,272,RC,,,,10200-MAIN,LOCAL,,,,,40.8,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,39.984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
penicillin v potassium 250 MG/5ML Recon Soln 200 mL Bottle,63700001,CDM,250,RC,,,,,,93412774,NDC,200,ML,83.32,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,39.9936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
penicillin v potassium 250 MG/5ML Recon Soln 200 mL Bottle,63700001,CDM,250,RC,,,,,,93412774,NDC,200,ML,83.32,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,39.9936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levoFLOXacin 250 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635161,NDC,1,EA,79.08,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,40.01448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine 1 MG/ML Solution 50 mL Syringe,J2270.01,CDM,636,RC,J2270,HCPCS,,,,61553064975,NDC,50,ML,81.71,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,4.09125,percent of total billed charges,40.0379,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
morphine 1 MG/ML Solution 50 mL Syringe,J2270.01,CDM,636,RC,J2270,HCPCS,,,,61553064975,NDC,50,ML,81.71,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,40.0379,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
morphine 1 MG/ML Solution 50 mL Syringe,J2270.01,CDM,636,RC,J2270,HCPCS,,,,61553064975,NDC,50,ML,81.71,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,40.0379,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
Lab Pth Immunoch Part 1,PX83970,CDM,300,RC,83970,CPT,,,,,,,,128,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,40.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.04,41.28
Lab Pth Immunoch Part 1,PX83970,CDM,300,RC,83970,CPT,,,,,,,,128,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,40.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.04,41.28
Lab Pth Immunoch Part 1,PX83970,CDM,300,RC,83970,CPT,,,,,,,,128,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,40.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.04,41.28
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409751766,NDC,50,ML,80.89,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,40.04055,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
TROCAR KII BALLOON 12MM STERILE,27200000,CDM,272,RC,,,,11703-MAIN,LOCAL,,,,,41.14,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,40.041562,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR KII BALLOON BLUNT 12MM STERILE,27200000,CDM,272,RC,,,,11702-MAIN,LOCAL,,,,,41.14,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,40.041562,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Cardiac Rehab,PX93797F,CDM,943,RC,93797,CPT,,,,,,,,45,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,40.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,115.44
CATHETER TEMP-SENSING 8FR LUBRISIL PEDS DYND110508,120.363,CDM,272,RC,A4340,HCPCS,,12777-MAIN,LOCAL,,,,,45,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,40.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
CATHETER TEMP-SENSING 12FR LUBRISIL 119212M,120.363,CDM,272,RC,A4340,HCPCS,,10750-MAIN,LOCAL,,,,,45,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,40.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
CATHETER TEMP-SENSING 14FR LUBRISIL 119214M,120.363,CDM,272,RC,A4340,HCPCS,,10751-MAIN,LOCAL,,,,,45,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,40.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
CATHETER TEMP-SENSING 16FR LUBRISIL 119216M,120.363,CDM,272,RC,A4340,HCPCS,,10752-MAIN,LOCAL,,,,,45,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,40.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
Cryptococcus Neoformans,PX87327,CDM,300,RC,87327,CPT,,,,,,,,45,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,40.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.3,44.1
Gammaglobulin; Ige - Ref,PX8278590,CDM,300,RC,82785,CPT,90,,,,,,,45,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,40.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.09,44.1
GASTRONOMY FEEDING TUBE MIC BALLOONED 20FR 7-10ML 0112-20,27200000,CDM,272,RC,B4087,HCPCS,,13098-MAIN,LOCAL,,,,,45,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,40.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRES 1.6MM,27200000,CDM,272,RC,C1769,HCPCS,,11852-MAIN,LOCAL,,,,,45,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,40.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"La Crosse, Antibody - Ref",PX8665190,CDM,300,RC,86651,CPT,90,,,,,,,45,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,40.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.09,44.1
MELGISORB AG SILVER CALCIUM STERILE 6X6,120.502,CDM,272,RC,A6197,HCPCS,,11844-MAIN,LOCAL,,,,,45,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,40.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
"St Louis, Antibody - Ref",PX8665390,CDM,300,RC,86653,CPT,90,,,,,,,45,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,40.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.09,44.1
"Sugars, Qual, Ea Spec - Ref",PX8437690,CDM,300,RC,84376,CPT,90,,,,,,,45,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,40.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.04,44.1
"Venipuncture by Physician, Other Vein, Under Age 3 Years",PX36406,CDM,983,RC,36406,CPT,,,,,,,,45,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,40.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,43.7985
"Western Equine, Ab - Ref",PX8665490,CDM,300,RC,86654,CPT,90,,,,,,,45,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,40.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.09,44.1
polyvinyl alcohol 1.4 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,50268067815,NDC,15,ML,45.42,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,40.06044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641622901,NDC,1,ML,41.16,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,40.061028,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.097864,86.9162
TRAY IV SURGICAL EXTREMITY DYNJS0804,27200000,CDM,272,RC,,,,10919-MAIN,LOCAL,,,,,83.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,40.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TRAY IV SURGICAL EXTREMITY DYNJS0804,27200000,CDM,272,RC,,,,10919-MAIN,LOCAL,,,,,83.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,40.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CANNULA ADULT LARGE OPTIFLOW OPT946,120.495,CDM,271,RC,A4615,HCPCS,,11622-MAIN,LOCAL,,,,,44,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,40.084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
CANNULA ADULT MEDIUM OPTIFLOW OPT944,120.495,CDM,271,RC,A4615,HCPCS,,11621-MAIN,LOCAL,,,,,44,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,40.084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
CANNULA ADULT SMALL OPTIFLOW OPT942,120.495,CDM,271,RC,A4615,HCPCS,,11620-MAIN,LOCAL,,,,,44,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,40.084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
Homocysteine,PX83090,CDM,300,RC,83090,CPT,,,,,,,,44,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,40.084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.43,43.12
KIT GASTRIC LAVAGE 2075,120.257,CDM,272,RC,C7510,HCPCS,,410-MAIN,LOCAL,,,,,44,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,40.084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
SUTURE V-LOC 1/2 CIRCLE NEEDLE WOUND CLOSURE DEVICE VLOCN0306,27200000,CDM,272,RC,,,,11931-MAIN,LOCAL,,,,,44,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,40.084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE V-LOC SZ 3-0 180 GREEN V-20 9 INCH VLOCL0644,27200000,CDM,272,RC,,,,13056-SURG,LOCAL,,,,,44,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,40.084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010301,NDC,0.3,ML,45.04,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,40.0856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
dextrose 25% Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409177510,NDC,10,ML,83.53,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,40.0944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dextrose 25% Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409177510,NDC,10,ML,83.53,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,40.0944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
CAPTIFLEX SNARE SINGLE USE EXTRA SMALL 11MM,27200000,CDM,272,RC,,,,12378-MAIN,LOCAL,,,,,81,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,40.095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Smear Special Stain,PX87207,CDM,300,RC,87207,CPT,,,,,,,,81,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,40.095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.49,79.38
Tacrolimus - Ref,PX8019790,CDM,300,RC,80197,CPT,90,,,,,,,81,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,40.095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,79.38
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188602,NDC,5,ML,45.46,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,40.09572,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.884084,44.5508
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188622,NDC,5,ML,45.46,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,40.09572,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.884084,44.5508
urea 20 % Cream 85 g Tube,63700001,CDM,250,RC,,,,,,536110945,NDC,85,GR,81.83,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,40.0967,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
urea 20 % Cream 85 g Tube,63700001,CDM,250,RC,,,,,,536110945,NDC,85,GR,81.83,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,40.0967,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
urea 20 % Cream 85 g Tube,63700001,CDM,250,RC,,,,,,536110945,NDC,85,GR,81.83,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,40.0967,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Strapping of Toes,PX29550F,CDM,510,RC,29550,CPT,,,,,,,,113,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,40.12,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.76,40.12
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070548,NDC,100,ML,40.94,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,40.1212,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,63323041536,NDC,0.5,ML,44.05,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,40.12955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
Cyto Non Gyn,PX8811201,CDM,310,RC,88112,CPT,TC,,,,,,,372,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,40.14,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.14,67.392
Cyto Non Gyn,PX8811201,CDM,310,RC,88112,CPT,TC,,,,,,,372,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,40.14,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.14,67.392
Cyto Non Gyn,PX8811201,CDM,310,RC,88112,CPT,TC,,,,,,,372,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,40.14,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.14,67.392
Infectious Agent Antigen Detection by Immunoassay With Direct Visual Observation.,PX87811,CDM,300,RC,87811,CPT,,,,,,,,192,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,40.14,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.14,41.38
Remove Intrauterine Device,PX58301,CDM,983,RC,58301,CPT,,,,,,,,357,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,40.14,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.14,349.86
hydrOXYzine 50 MG/ML Solution 1 mL Vial,J3410.01,CDM,636,RC,J3410,HCPCS,,,,517560125,NDC,0.5,ML,83.68,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,40.1664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.760672,82.0064
hydrOXYzine 50 MG/ML Solution 1 mL Vial,J3410.01,CDM,636,RC,J3410,HCPCS,,,,517560125,NDC,0.5,ML,83.68,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,40.1664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.760672,82.0064
leflunomide 20 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,70748013006,NDC,0.5,EA,44.1,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,40.1751,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Ace - Ref,PX8216490,CDM,300,RC,82164,CPT,90,,,,,,,82,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,40.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.39,80.36
Ace - Ref,PX8216490,CDM,300,RC,82164,CPT,90,,,,,,,82,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,40.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.39,80.36
Ace - Ref,PX8216490,CDM,300,RC,82164,CPT,90,,,,,,,82,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,40.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.39,80.36
Anca Screen Each Antibody,PX8603690,CDM,300,RC,86036,CPT,90,,,,,,,82,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,40.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.0628,80.36
Anca Screen Each Antibody,PX8603690,CDM,300,RC,86036,CPT,90,,,,,,,82,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,40.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.0628,80.36
Anca Screen Each Antibody,PX8603690,CDM,300,RC,86036,CPT,90,,,,,,,82,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,40.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.0628,80.36
CANNULA SEAL 5-12MM UNIVERSAL 470500,27200000,CDM,272,RC,,,,12885-MAIN,LOCAL,,,,,41,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,40.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Cognitive Funct Ther Interv, Ea Addl 15 Min",PX97130,CDM,420,RC,97130,CPT,,,,,,,,82,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,8.14,percent of total billed charges,40.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31,80.36
"Cognitive Funct Ther Interv, Ea Addl 15 Min",PX97130,CDM,420,RC,97130,CPT,,,,,,,,82,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,40.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31,80.36
"Cognitive Funct Ther Interv, Ea Addl 15 Min",PX97130,CDM,420,RC,97130,CPT,,,,,,,,82,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,40.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31,80.36
"Cortisol, Free - Ref",PX8253090,CDM,300,RC,82530,CPT,90,,,,,,,82,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,40.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.32,80.36
"Cortisol, Free - Ref",PX8253090,CDM,300,RC,82530,CPT,90,,,,,,,82,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,40.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.32,80.36
"Cortisol, Free - Ref",PX8253090,CDM,300,RC,82530,CPT,90,,,,,,,82,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,40.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.32,80.36
CUP HEEL LARGE WONDERSPUR 4502,120.43,CDM,274,RC,L3485,HCPCS,,11385-MAIN,LOCAL,,,,,41,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,40.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL MEDIUM WONDERSPUR 4501,120.43,CDM,274,RC,L3485,HCPCS,,11384-MAIN,LOCAL,,,,,41,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,40.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL SMALL WONDERSPUR 4500,120.43,CDM,274,RC,L3485,HCPCS,,11383-MAIN,LOCAL,,,,,41,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,40.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
CUP HEEL XL WONDERSPUR 4503,120.43,CDM,274,RC,L3485,HCPCS,,11386-MAIN,LOCAL,,,,,41,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,40.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.64,40.18
Detection of Anaplasma Phagocytophilum by Amplified Nucleic Acid Probe Technique,PX8746890,CDM,300,RC,87468,CPT,90,,,,,,,41,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,40.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
Detection of Ehrlichia Chaffeensis by Amplified Nucleic Acid Probe Technique,PX8748490,CDM,300,RC,87484,CPT,90,,,,,,,41,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,40.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 21G 110MM SONOTAP II WITH FACET TIP 1285-3F110,120.483,CDM,271,RC,A4215,HCPCS,,12201-MAIN,LOCAL,,,,,41,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,40.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 21G X 4IN (100MM) SONOBLOCK II NERVE BLOCK WITH FACET S TIP 001281-77,120.483,CDM,271,RC,A4215,HCPCS,,12761-MAIN,LOCAL,,,,,41,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,40.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 22G 80MM SONOTAP II WITH FACET TIP 1285-3E080,120.483,CDM,271,RC,A4215,HCPCS,,12103-MAIN,LOCAL,,,,,41,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,40.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 22G X 3.25IN (80MM) SONOBLOCK II  NERVE BLOCK WITH FACET S TIP 001281-71,120.483,CDM,271,RC,A4215,HCPCS,,12760-MAIN,LOCAL,,,,,41,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,40.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE ECHOGENIC 22GX2 SONOPLEX II WITH FACET S TIP 001287-74,120.483,CDM,271,RC,A4215,HCPCS,,13110-MAIN,LOCAL,,,,,41,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,40.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE NON-STIMULATING 22GX2 SONOBLOCK II WITH FACET S TIP 001281-74,120.483,CDM,271,RC,A4215,HCPCS,,11459-MAIN,LOCAL,,,,,41,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,40.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE SONOPLEX II STIMULATING WITH FACET S TIP 22GX3-1/4,120.483,CDM,271,RC,A4215,HCPCS,,11457-MAIN,LOCAL,,,,,41,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,40.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
NEEDLE STIMULATING 21GX4  SONOPLEX II  WITH FACET S TIP 001287-77,120.483,CDM,271,RC,A4215,HCPCS,,11458-MAIN,LOCAL,,,,,41,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,40.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
STRAP FOOT LG/XL GEL UNIVERSAL 10165,120.428,CDM,271,RC,,,,11382-MAIN,LOCAL,,,,,41,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,40.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
STRAP FOOT SM/MED GEL UNIVERSAL 10155,120.428,CDM,271,RC,,,,11381-MAIN,LOCAL,,,,,41,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,40.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
SUTURE V-LOC SZ 1/2 180 GREEN GS-21 VLOCL0316,27200000,CDM,272,RC,,,,11932-MAIN,LOCAL,,,,,41,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,40.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
URGOK2 DUAL COMPRESSION SYSTEM LARGE,120.491,CDM,271,RC,A6452,HCPCS,,11871-MAIN,LOCAL,,,,,41,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,40.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
URGOK2 DUAL COMPRESSION SYSTEM REGULAR,120.491,CDM,271,RC,A6452,HCPCS,,11870-MAIN,LOCAL,,,,,41,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,40.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.0314,40.18
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028016,NDC,2,ML,41.29,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,4.556666667,percent of total billed charges,40.187557,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
levoFLOXacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635261,NDC,0.5,EA,45.16,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,40.1924,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DIMETHICONE (TOPICAL) 5 % Cream 118 mL Tube,800000,CDM,,,,,,,,53329015104,NDC,118,ML,44.12,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,40.19332,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
phenol-glycerin 1.5-33 % Liquid 118 mL Bottle,25000000,CDM,250,RC,,,,,,78112000068,NDC,118,ML,44.12,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,40.19332,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
methylPREDNISolone acetate 20 MG/ML Suspension 5 mL Vial,J1010.01,CDM,636,RC,J1010,HCPCS,,,,9027401,NDC,0.5,ML,41.3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,40.19729,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.15602,40.474
inFLIXimab 100 MG Recon Soln 1 Each Vial,J1745.01,CDM,636,RC,J1745,HCPCS,,,,57894003001,NDC,1,EA,2382.35,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,40.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.49,2334.703
FORCEPS SERRATED WITH SPIKE JUMBO 230CM,27200000,CDM,272,RC,,,,7416-MAIN,LOCAL,,,,,41.31,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,40.207023,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"dextran 70, glycerin, hypromellose 0.1-0.2-0.3 % Solution 15 mL Bottle",63700001,CDM,250,RC,,,,,,65042636,NDC,15,ML,44.14,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,40.21154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 12 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,378911916,NDC,1,EA,96.83,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,40.223182,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 12 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505708000,NDC,1,EA,96.83,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,40.223182,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 12 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,378911998,NDC,1,EA,96.84,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,40.227336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 12 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,60505708002,NDC,1,EA,96.84,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,40.227336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329333901,NDC,10,ML,79.51,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,40.23206,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
calcium CHLORIDE 10 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,76329330401,NDC,10,ML,79.51,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,40.23206,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,25021018482,NDC,100,ML,79.51,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,40.23206,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.786918,140.5516
menthol-zinc oxide Paste 113 g Tube,63700001,CDM,250,RC,,,,,,53329016544,NDC,113,GR,79.52,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,40.23712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,17478081725,NDC,25,ML,81.3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,40.2435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409132305,NDC,5,ML,41.35,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,40.245955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
silver sulfADIAZINE 1 % Cream 50 g Jar,25000000,CDM,250,RC,,,,,,43598021055,NDC,50,GR,83.89,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,40.2672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
silver sulfADIAZINE 1 % Cream 50 g Jar,25000000,CDM,250,RC,,,,,,43598021055,NDC,50,GR,83.89,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,40.2672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 4 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,536128128,NDC,30,GR,96.95,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,40.27303,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine urethral/mucosal 2 % Gel 30 mL Tube,25000000,CDM,250,RC,,,,,,17478084030,NDC,30,ML,93.91,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,40.28739,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Blastomyces Antibody - Ref,PX8661290,CDM,300,RC,86612,CPT,90,,,,,,,97,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,40.2938,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.83,95.06
Contrast Bath Therapy,PX97034,CDM,420,RC,97034,CPT,,,,,,,,97,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,40.2938,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,95.06
DRAPE INSTRUMENT ARM 470015,27200000,CDM,272,RC,,,,11925-MAIN,LOCAL,,,,,97,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,40.2938,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
High Sens Crp,PX86141,CDM,300,RC,86141,CPT,,,,,,,,97,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,40.2938,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,95.06
Rheumatoid Factor Quant,PX86431,CDM,300,RC,86431,CPT,,,,,,,,97,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,40.2938,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.2,95.06
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015901,NDC,0.3,ML,45.69,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,40.29858,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015925,NDC,0.3,ML,45.69,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,40.29858,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,143957501,NDC,50,ML,44.24,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,40.30264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,143957510,NDC,50,ML,44.24,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,40.30264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
CISplatin 50 MG/50ML Solution 50 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010351,NDC,50,ML,82.27,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,40.3123,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.174958,180.2416
CISplatin 50 MG/50ML Solution 50 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010351,NDC,50,ML,82.27,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,40.3123,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.174958,180.2416
CISplatin 50 MG/50ML Solution 50 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010351,NDC,50,ML,82.27,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,40.3123,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.174958,180.2416
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028026,NDC,2,ML,41.42,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,4.556666667,percent of total billed charges,40.314086,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
TROCAR KII BALLOON 12MM STERILE,27200000,CDM,272,RC,,,,11703-MAIN,LOCAL,,,,,41.14,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,40.3172,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR KII BALLOON BLUNT 12MM STERILE,27200000,CDM,272,RC,,,,11702-MAIN,LOCAL,,,,,41.14,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,40.3172,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CANNULA OPTIFLOW JUNIOR2+ XXL OJR520,120.494,CDM,271,RC,A4615,HCPCS,,11619-MAIN,LOCAL,,,,,84,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,40.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.8936,82.32
CANNULA OPTIFLOW JUNIOR2+ XXL OJR520,120.494,CDM,271,RC,A4615,HCPCS,,11619-MAIN,LOCAL,,,,,84,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,40.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.8936,82.32
Hiaa - Ref,PX8349790,CDM,300,RC,83497,CPT,90,,,,,,,84,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,40.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.83,82.32
Hiaa - Ref,PX8349790,CDM,300,RC,83497,CPT,90,,,,,,,84,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,40.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.83,82.32
Coccidioides Antibody - Ref,PX8663590,CDM,300,RC,86635,CPT,90,,,,,,,94,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,40.326,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.52,92.12
Copper - Ref,PX8252590,CDM,300,RC,82525,CPT,90,,,,,,,94,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,40.326,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.38,92.12
DEFIBRILLATION PAD MULTI FUNCTION ADULT,120.58,CDM,271,RC,A0392,HCPCS,,1320-MAIN,LOCAL,,,,,94,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,40.326,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
DEFIBRILLATION PAD PEDI PADZ PEDS,120.58,CDM,271,RC,A0392,HCPCS,,1322-MAIN,LOCAL,,,,,94,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,40.326,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
DRESSING NASAL 4.5CM NON-INFLATABLE RAPID RHINO RR450,120.97,CDM,272,RC,A6407,HCPCS,,616-MAIN,LOCAL,,,,,94,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,40.326,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
DRESSING NASAL 5.5CM INFLATABLE RAPID RHINO RR550,120.97,CDM,272,RC,A6407,HCPCS,,606-MAIN,LOCAL,,,,,94,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,40.326,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
DRESSING NASAL 7.5CM INFLATABLE RAPID RHINO RR750,120.97,CDM,272,RC,A6407,HCPCS,,611-MAIN,LOCAL,,,,,94,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,40.326,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
DRESSING NASAL 8CM LONGX1.5CM THICK X3CM HIGH ANATOMICAL 34-105,120.97,CDM,272,RC,A6407,HCPCS,,613-MAIN,LOCAL,,,,,94,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,40.326,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
Tissue Exam for Fungi,PX87220,CDM,300,RC,87220,CPT,,,,,,,,94,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,40.326,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,92.12
TUBING IRRIGATION F SET STERILE MXB-T,27200000,CDM,272,RC,,,,11693-MAIN,LOCAL,,,,,94,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,40.326,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641622901,NDC,1,ML,41.16,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,40.3368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.097864,86.9162
ampicillin 500 MG Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781925078,NDC,1,EA,44.28,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,40.33908,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066501,NDC,0.25,ML,45.74,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,40.34268,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.000396,47.2262
ACUSNARE POLYPECTOMY SNARE,27200000,CDM,272,RC,,,,7733-MAIN,LOCAL,,,,,45.75,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,40.3515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915701,NDC,0.5,ML,44.33,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,40.38463,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915731,NDC,0.5,ML,44.33,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,40.38463,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,47335093140,NDC,0.5,EA,44.33,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,40.38463,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,47335093144,NDC,0.5,EA,44.33,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,40.38463,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046201,NDC,30,ML,79.84,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,40.39904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ticagrelor 90 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,186077739,NDC,1,EA,44.35,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,40.40285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
promethazine 25 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802075930,NDC,0.5,EA,47.54,,First Health,Commercial,both,85,,999999999,percent of total billed charges,40.409,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
promethazine 25 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,45802075900,NDC,0.5,EA,47.55,,First Health,Commercial,both,85,,999999999,percent of total billed charges,40.4175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
protamine 10 MG/ML Solution 25 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022930,NDC,2.5,ML,44.37,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,40.42107,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.431298,83.0452
polyvinyl alcohol 1.4 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,50268067815,NDC,15,ML,45.42,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,40.4238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Lab Pth Immunoch Part 1,PX83970,CDM,300,RC,83970,CPT,,,,,,,,128,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,40.4334,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.04,41.28
morphine 1 MG/ML Solution 50 mL Syringe,J2270.01,CDM,636,RC,J2270,HCPCS,,,,61553064975,NDC,50,ML,81.71,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,40.44645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
alendronate 70 MG Tablet 4 Each Box,63700001,CDM,250,RC,,,,,,16714063301,NDC,1,EA,97.37,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,40.447498,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buprenorphine 8 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,54017713,NDC,1,EA,41.56,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,40.450348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.14,40.7288
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188602,NDC,5,ML,45.46,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,40.4594,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.884084,44.5508
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188622,NDC,5,ML,45.46,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,40.4594,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.884084,44.5508
SCISSORS ENDOSCOPIC 5MM STANDARD STERILE,27200000,CDM,272,RC,,,,11706-MAIN,LOCAL,,,,,47.6,,First Health,Commercial,both,85,,999999999,percent of total billed charges,40.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028016,NDC,2,ML,41.29,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,40.4642,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
fluticasone-salmeterol 250-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,54032756,NDC,1,EA,45.88,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,40.46616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone acetate 20 MG/ML Suspension 5 mL Vial,J1010.01,CDM,636,RC,J1010,HCPCS,,,,9027401,NDC,0.5,ML,41.3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,40.474,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.15602,40.474
"Alpha-Fetoprotein, Serum - Ref",PX8210590,CDM,300,RC,82105,CPT,90,,,,,,,80,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,40.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.38,78.4
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270004,NDC,100,ML,2827.78,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,40.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270010,NDC,100,ML,3458.14,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,40.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 10 GM/100ML Solution 100 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270005,NDC,100,ML,2827.78,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,40.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270006,NDC,100,ML,2912.78,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,40.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270012,NDC,100,ML,3293.58,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,40.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270007,NDC,100,ML,2827.78,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,40.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270013,NDC,100,ML,2827.78,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,40.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
Prealubimin,PX84134,CDM,300,RC,84134,CPT,,,,,,,,80,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,40.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.38,78.4
CARTER THOMASON CLOSURE 5MM,27200000,CDM,272,RC,,,,10278-MAIN,LOCAL,,,,,97.45,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,40.48073,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
FORCEPS SERRATED WITH SPIKE JUMBO 230CM,27200000,CDM,272,RC,,,,7416-MAIN,LOCAL,,,,,41.31,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,40.4838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,703903201,NDC,2,ML,44.46,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,40.50306,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,97.0102
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2021301,NDC,3,ML,44.46,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,40.50306,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
urea 20 % Cream 85 g Tube,63700001,CDM,250,RC,,,,,,536110945,NDC,85,GR,81.83,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,40.50585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzoin Tincture 59 mL Bottle,25000000,CDM,250,RC,,,,,,49348080130,NDC,59,ML,45.93,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,40.51026,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409132305,NDC,5,ML,41.35,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,40.523,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
timolol 0.25 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314022605,NDC,5,ML,84.45,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,40.536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
timolol 0.25 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314022605,NDC,5,ML,84.45,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,40.536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,70860030143,NDC,25,ML,84.47,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,40.5456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,70860030143,NDC,25,ML,84.47,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,40.5456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010626,NDC,50,ML,84.47,,Health Partners,Health Partners Care Plans,both,48,,14.6175,percent of total billed charges,40.5456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010626,NDC,50,ML,84.47,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,40.5456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
sodium bicarbonate 8.4 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409662502,NDC,50,ML,84.47,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,40.5456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium bicarbonate 8.4 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409662502,NDC,50,ML,84.47,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,40.5456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Xray Cervical Spine 4 or 5 Vws,PX7205001,CDM,320,RC,72050,CPT,TC,,,,,,,664,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,40.5468,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.61,80.86
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,45802095301,NDC,100,GR,82.76,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,40.5524,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,45802095301,NDC,100,GR,82.76,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,40.5524,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,45802095301,NDC,100,GR,82.76,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,40.5524,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028442,NDC,1,EA,47.71,,First Health,Commercial,both,85,,999999999,percent of total billed charges,40.5535,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049209,NDC,5,ML,44.52,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,40.55772,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Infectious Agent Antigen Detection by Immunoassay With Direct Visual Observation.,PX87811,CDM,300,RC,87811,CPT,,,,,,,,192,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,40.56176,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.14,41.38
DERMABOND ADVANCED TOPICAL SKIN ADHESIVE,120.198,CDM,272,RC,,,,9101-MAIN,LOCAL,,,,,46,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,40.572,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.1084,45.08
Pinworm Exam,PX87172,CDM,300,RC,87172,CPT,,,,,,,,46,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,40.572,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,45.08
cyclopentolate 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,61314039601,NDC,2,ML,94.58,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,40.57482,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Ace - Ref,PX8216490,CDM,300,RC,82164,CPT,90,,,,,,,82,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,40.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.39,80.36
Anca Screen Each Antibody,PX8603690,CDM,300,RC,86036,CPT,90,,,,,,,82,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,40.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.0628,80.36
"Cognitive Funct Ther Interv, Ea Addl 15 Min",PX97130,CDM,420,RC,97130,CPT,,,,,,,,82,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,40.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31,80.36
"Cortisol, Free - Ref",PX8253090,CDM,300,RC,82530,CPT,90,,,,,,,82,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,40.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.32,80.36
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028026,NDC,2,ML,41.42,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,40.5916,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,40.5916
azithromycin 250 MG Tablet 6 Each Box,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096104,NDC,1,EA,41.72,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,16.7575,percent of total billed charges,40.606076,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096105,NDC,1,EA,41.73,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,16.7575,percent of total billed charges,40.615809,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
"Prosthetic Training, Initial, Each 15 Mins",PX97761,CDM,420,RC,97761,CPT,,,,,,,,121,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,40.6224,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.05,54.91
tiotropium 18 MCG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,597007541,NDC,1,EA,82.92,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,40.6308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tiotropium 18 MCG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,597007541,NDC,1,EA,82.92,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,40.6308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tiotropium 18 MCG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,597007541,NDC,1,EA,82.92,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,40.6308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DULoxetine 20 MG Capsule Delayed Release Particles 60 Each Bottle,63700001,CDM,250,RC,,,,,,2323560,NDC,1,EA,41.76,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,40.645008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,25021012867,NDC,1,EA,82.96,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,40.6504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,25021012867,NDC,1,EA,82.96,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,40.6504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,25021012867,NDC,1,EA,82.96,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,40.6504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,55150020830,NDC,1,EA,82.96,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,3.99575,percent of total billed charges,40.6504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.461584,189.875
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,55150020830,NDC,1,EA,82.96,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,40.6504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.461584,189.875
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,55150020830,NDC,1,EA,82.96,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,40.6504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.461584,189.875
oseltamivir 75 MG capsule 10 Each Disp Pack,63700001,CDM,250,RC,,,,,,4080085,NDC,1,EA,97.87,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,40.655198,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015901,NDC,0.3,ML,45.69,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,40.6641,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015925,NDC,0.3,ML,45.69,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,40.6641,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,47781047013,NDC,1,EA,83,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,40.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,47781047013,NDC,1,EA,83,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,40.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,47781047013,NDC,1,EA,83,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,40.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,64380079901,NDC,1,EA,83,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,40.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,64380079901,NDC,1,EA,83,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,40.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,64380079901,NDC,1,EA,83,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,40.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,69238126601,NDC,1,EA,83,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,40.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,69238126601,NDC,1,EA,83,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,40.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,69238126601,NDC,1,EA,83,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,40.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SLING ARM CHILD PAD CANVAS NAVY 8004-02,120.54,CDM,273,RC,A4565,HCPCS,,878-MAIN,LOCAL,,,,,83,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,40.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM CHILD PAD CANVAS NAVY 8004-02,120.54,CDM,273,RC,A4565,HCPCS,,878-MAIN,LOCAL,,,,,83,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,40.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM CHILD PAD CANVAS NAVY 8004-02,120.54,CDM,273,RC,A4565,HCPCS,,878-MAIN,LOCAL,,,,,83,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,40.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM LARGE PAD CANVAS NAVY ORT11300L,120.54,CDM,273,RC,A4565,HCPCS,,870-MAIN,LOCAL,,,,,83,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,40.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM LARGE PAD CANVAS NAVY ORT11300L,120.54,CDM,273,RC,A4565,HCPCS,,870-MAIN,LOCAL,,,,,83,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,40.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM LARGE PAD CANVAS NAVY ORT11300L,120.54,CDM,273,RC,A4565,HCPCS,,870-MAIN,LOCAL,,,,,83,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,40.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM MEDIUM PAD CANVAS NAVY ORT11300M,120.54,CDM,273,RC,A4565,HCPCS,,872-MAIN,LOCAL,,,,,83,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,40.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM MEDIUM PAD CANVAS NAVY ORT11300M,120.54,CDM,273,RC,A4565,HCPCS,,872-MAIN,LOCAL,,,,,83,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,40.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM MEDIUM PAD CANVAS NAVY ORT11300M,120.54,CDM,273,RC,A4565,HCPCS,,872-MAIN,LOCAL,,,,,83,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,40.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM SMALL PAD CANVAS NAVY ORT11300S,120.54,CDM,273,RC,A4565,HCPCS,,874-MAIN,LOCAL,,,,,83,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,40.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM SMALL PAD CANVAS NAVY ORT11300S,120.54,CDM,273,RC,A4565,HCPCS,,874-MAIN,LOCAL,,,,,83,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,40.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM SMALL PAD CANVAS NAVY ORT11300S,120.54,CDM,273,RC,A4565,HCPCS,,874-MAIN,LOCAL,,,,,83,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,40.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM X-LARGE PAD ENVELOPE ORT11300XL,120.54,CDM,273,RC,A4565,HCPCS,,876-MAIN,LOCAL,,,,,83,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,40.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM X-LARGE PAD ENVELOPE ORT11300XL,120.54,CDM,273,RC,A4565,HCPCS,,876-MAIN,LOCAL,,,,,83,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,40.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM X-LARGE PAD ENVELOPE ORT11300XL,120.54,CDM,273,RC,A4565,HCPCS,,876-MAIN,LOCAL,,,,,83,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,40.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,50111078751,NDC,1,EA,41.79,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,16.7575,percent of total billed charges,40.674207,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
donepezil 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904640861,NDC,1,EA,41.79,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,40.674207,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
protamine 10 MG/ML Solution 5 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022994,NDC,5,ML,84.74,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,40.6752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.431298,83.0452
protamine 10 MG/ML Solution 5 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022994,NDC,5,ML,84.74,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,40.6752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.431298,83.0452
ESOPHAGEAL BALLOON INFLATION DEVICE 60ML,27200000,CDM,272,RC,C1726,HCPCS,,11326-MAIN,LOCAL,,,,,80.41,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,40.68746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061401,NDC,1,ML,94.87,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,40.69923,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.114178,99.911
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066501,NDC,0.25,ML,45.74,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,40.7086,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.000396,47.2262
BLADE LARYNGOSCOPE MAC #3 SINGLE USE350-005-000,120.121,CDM,272,RC,,,,8320-MAIN,LOCAL,,,,,98,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,40.7092,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
BLADE LARYNGOSCOPE MAC #4 SINGLE USE 350-012-000,120.121,CDM,272,RC,,,,8321-MAIN,LOCAL,,,,,98,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,40.7092,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
BLADE LARYNGOSCOPE MAC #X3 SINGLE USE X3-003-000,120.121,CDM,272,RC,,,,8322-MAIN,LOCAL,,,,,98,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,40.7092,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
CANNULA JUNIOR 2 LARGE OPTIFLOW OJR416VT,120.561,CDM,272,RC,A4615,HCPCS,,12645-MAIN,LOCAL,,,,,98,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,40.7092,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
CANNULA JUNIOR 2 MEDIUM OPTIFLOW OJR414VT,120.561,CDM,272,RC,A4615,HCPCS,,12644-MAIN,LOCAL,,,,,98,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,40.7092,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
CANNULA OPTIFLOW JUNIOR 2 SMALL OJR412VT,120.561,CDM,272,RC,A4615,HCPCS,,12643-MAIN,LOCAL,,,,,98,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,40.7092,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
Hepatitis B Surface Antigen,PX87340,CDM,300,RC,87340,CPT,,,,,,,,98,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,40.7092,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.47,96.04
Ot Contracted Service/MCR,PX120.177,CDM,431,RC,,,,,,,,,,98,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,40.7092,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
Pt Contracted Services/MCR,PX120.175,CDM,421,RC,,,,,,,,,,98,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,40.7092,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
bicalutamide 50 MG Tablet 30 Each Bottle,25000000,CDM,250,RC,,,,,,16714081601,NDC,1,EA,98.01,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,40.713354,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ACUSNARE POLYPECTOMY SNARE,27200000,CDM,272,RC,,,,7733-MAIN,LOCAL,,,,,45.75,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,40.7175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CISplatin 50 MG/50ML Solution 50 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010351,NDC,50,ML,82.27,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,40.72365,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.174958,180.2416
buprenorphine 8 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,54017713,NDC,1,EA,41.56,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,40.7288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.14,40.7288
rosuvastatin 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16714098801,NDC,1,EA,46.18,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,40.73076,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036001,NDC,10,ML,80.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,40.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,84.5054
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,61314062810,NDC,10,ML,98.07,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,40.738278,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Aldosterone - Ref,PX8208890,CDM,300,RC,82088,CPT,90,,,,,,,86,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,40.75,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.53,40.75
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Box,25000000,CDM,250,RC,,,,,,67434509,NDC,1,EA,98.1,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,40.75074,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Cyto Non Gyn,PX8811201,CDM,310,RC,88112,CPT,TC,,,,,,,372,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,40.7543,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.14,67.392
Assay Blood Carbon Dioxide,PX82374,CDM,300,RC,82374,CPT,,,,,,,,95,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,40.755,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.47,93.1
Blood Viscosity Examination,PX85810,CDM,300,RC,85810,CPT,,,,,,,,95,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,40.755,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.7,93.1
Cyclosporine - Ref,PX8015890,CDM,300,RC,80158,CPT,90,,,,,,,95,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,40.755,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.55,93.1
"Fac/Debridement of Nails, 6 or Mor",PX11721F,CDM,510,RC,11721,CPT,,,,,,,,95,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,40.755,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.463,93.1
"Fat/Lipids, Feces, Quant - Ref",PX8271090,CDM,300,RC,82710,CPT,90,,,,,,,95,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,40.755,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.4,93.1
KIT EPIDURAL 19GA FLEXTIP PLUS AK-05502,120.305,CDM,272,RC,,,,11413-MAIN,LOCAL,,,,,95,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,40.755,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.463,93.1
"Lyme Disease, Confirm Tst - Ref",PX8661790,CDM,300,RC,86617,CPT,90,,,,,,,95,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,40.755,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.2,93.1
"Organism ID, Anaerobic - Ref",PX8707690,CDM,300,RC,87076,CPT,90,,,,,,,95,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,40.755,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,93.1
Strep a Assay W/Optic,PX87880,CDM,300,RC,87880,CPT,,,,,,,,95,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,40.755,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.16,93.1
"Thyroxine, Total - Ref",PX8443690,CDM,300,RC,84436,CPT,90,,,,,,,95,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,40.755,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.3,93.1
TRAY FACIAL LACERATION PACK STERILE 96-1707,120.12,CDM,272,RC,,,,406-MAIN,LOCAL,,,,,95,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,40.755,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.463,93.1
Varicella-Zoster Antibody,PX86787,CDM,300,RC,86787,CPT,,,,,,,,95,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,40.755,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.81,93.1
Initial Rx Burn(S) 1st Degree,PX16000F,CDM,510,RC,16000,CPT,,,,,,,,338,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,40.7797,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.7,166.03
ceFAZolin in D4W 1 g / 50 mL 1-4 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0690.01,CDM,636,RC,J0690,HCPCS,,,,264310311,NDC,1,EA,84.97,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,40.7856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin in D4W 1 g / 50 mL 1-4 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0690.01,CDM,636,RC,J0690,HCPCS,,,,264310311,NDC,1,EA,84.97,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,40.7856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
"dextrose 5% and sodium chloride 0.45% with potassium chloride 10 mEq in 1000 mL 10-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,338066904,NDC,1000,ML,80.61,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,40.78866,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,264957710,NDC,500,ML,80.61,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,40.78866,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052201,NDC,500,ML,80.61,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,40.78866,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052277,NDC,500,ML,80.61,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,40.78866,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143998391,NDC,1,EA,83.25,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,7.351730769,percent of total billed charges,40.7925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143998391,NDC,1,EA,83.25,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,40.7925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143998391,NDC,1,EA,83.25,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,40.7925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
"Admin Hep B,Adult 19+",PX3242,CDM,771,RC,90471,CPT,,,,,,,,48,,First Health,Commercial,both,85,,999999999,percent of total billed charges,40.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,61.54
Amphetamines; 3 or 4,PX8032590,CDM,300,RC,80325,CPT,90,,,,,,,48,,First Health,Commercial,both,85,,999999999,percent of total billed charges,40.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,47.04
"Cognitive Funct Ther Interv, Initial 15 Min",PX97129,CDM,420,RC,97129,CPT,,,,,,,,85,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,40.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15,83.3
"Cognitive Funct Ther Interv, Initial 15 Min",PX97129,CDM,420,RC,97129,CPT,,,,,,,,85,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,40.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15,83.3
"Exam,Synovial Fluid Crystals",PX89060,CDM,300,RC,89060,CPT,,,,,,,,85,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,40.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.72,83.3
"Exam,Synovial Fluid Crystals",PX89060,CDM,300,RC,89060,CPT,,,,,,,,85,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,40.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.72,83.3
GLIDESCOPE QC MAC S3 SINGLE USE 0270-1083,120.579,CDM,272,RC,,,,13046-MAIN,LOCAL,,,,,85,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,40.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.309,83.3
GLIDESCOPE QC MAC S3 SINGLE USE 0270-1083,120.579,CDM,272,RC,,,,13046-MAIN,LOCAL,,,,,85,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,40.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.309,83.3
GLIDESCOPE QC MAC S3 SINGLE USE 0270-1085,120.579,CDM,272,RC,,,,13022-MAIN,LOCAL,,,,,85,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,40.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.309,83.3
GLIDESCOPE QC MAC S3 SINGLE USE 0270-1085,120.579,CDM,272,RC,,,,13022-MAIN,LOCAL,,,,,85,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,40.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.309,83.3
GLIDESCOPE QC MAC S4 SINGLE USE 0270-1086,120.579,CDM,272,RC,,,,13023-MAIN,LOCAL,,,,,85,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,40.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.309,83.3
GLIDESCOPE QC MAC S4 SINGLE USE 0270-1086,120.579,CDM,272,RC,,,,13023-MAIN,LOCAL,,,,,85,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,40.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.309,83.3
Immunization Admin - Influenza,PX3241,CDM,771,RC,90471,CPT,,,,,,,,48,,First Health,Commercial,both,85,,999999999,percent of total billed charges,40.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,61.54
Immunization Administration; Each Add'l Vaccine (Single or Combo Vaccine/T*,PX90472,CDM,771,RC,90472,CPT,,,,,,,,48,,First Health,Commercial,both,85,,999999999,percent of total billed charges,40.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,47.04
sodium bicarbonate 8.4 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409662522,NDC,50,ML,85.02,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,40.8096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium bicarbonate 8.4 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409662522,NDC,50,ML,85.02,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,40.8096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048203,NDC,20,ML,44.8,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,40.8128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048227,NDC,20,ML,44.8,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,40.8128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
penicillin v potassium 250 MG/5ML Recon Soln 200 mL Bottle,63700001,CDM,250,RC,,,,,,93412774,NDC,200,ML,83.32,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,40.8268,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
penicillin v potassium 250 MG/5ML Recon Soln 200 mL Bottle,63700001,CDM,250,RC,,,,,,93412774,NDC,200,ML,83.32,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,40.8268,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
penicillin v potassium 250 MG/5ML Recon Soln 200 mL Bottle,63700001,CDM,250,RC,,,,,,93412774,NDC,200,ML,83.32,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,40.8268,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone-salmeterol 250-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,54032756,NDC,1,EA,45.88,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,40.8332,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"SUTURE ETHIBOND #0 CT-1 CR 8-18"" CX21D",27200000,CDM,272,RC,,,,6415-MAIN,LOCAL,,,,,41.97,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,40.849401,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,50383058766,NDC,60,ML,95.26,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,40.86654,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,60432053760,NDC,60,ML,95.26,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,40.86654,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Sars-Cov-2 Covid-19 Antibody,PX86769,CDM,300,RC,86769,CPT,,,,,,,,340,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,40.87,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.87,42.13
Sars-Cov-2 Covid-19 Antibody,PX8676990,CDM,300,RC,86769,CPT,90,,,,,,,100,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,40.87,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.87,42.13
benzoin Tincture 59 mL Bottle,25000000,CDM,250,RC,,,,,,49348080130,NDC,59,ML,45.93,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,40.8777,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Actin Antibody Each,PX8601590,CDM,300,RC,86015,CPT,90,,,,,,,42,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,40.8786,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.05,41.16
Assay Vitamin B-6,PX84207,CDM,300,RC,84207,CPT,90,,,,,,,42,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,40.8786,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
"BOUGIE TRACH 10FR 70CM COUDE 	9-0211-70",120.199,CDM,272,RC,A7520,HCPCS,,11112-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,40.8786,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
BOUGIE TRACHEAL TUBE & GUIDE 100123515,120.199,CDM,272,RC,A7520,HCPCS,,8950-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,40.8786,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
CATHETER PUREWICK FEMALE EXTERNAL PWF030K,120.414,CDM,272,RC,A6590,HCPCS,,11836-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,40.8786,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
Culture Type Immunologic,PX87147,CDM,300,RC,87147,CPT,,,,,,,,42,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,40.8786,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,41.16
EZ-STABILIZER DRESSING,120.415,CDM,272,RC,,,,9058-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,40.8786,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
MEPILEX AG FOAM 4X4,120.192,CDM,272,RC,A6213,HCPCS,,8480-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,40.8786,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
MEPILEX AG FOAM 4X8,120.192,CDM,272,RC,A6213,HCPCS,,8479-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,40.8786,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY CENTRAL LINE DRESSING WITH CHLORAPREP DYND75234,120.68,CDM,272,RC,,,,10923-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,40.8786,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY FOLEY 14FR CATHETER A300414A,120.414,CDM,272,RC,A4344,HCPCS,,11281-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,40.8786,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY FOLEY 16FR CATHETER 300416A,120.414,CDM,272,RC,A4344,HCPCS,,11774-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,40.8786,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
"TRAY SPINAL  25GX3.5"" WITH WHITEACRE 405671",120.275,CDM,272,RC,,,,3284-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,40.8786,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY SPINAL 25G ANESTH SADDLE BLOCK NLD-4795-20,120.275,CDM,272,RC,,,,935-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,40.8786,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
azithromycin 250 MG Tablet 6 Each Box,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096104,NDC,1,EA,41.72,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,40.8856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089901,NDC,0.25,ML,95.31,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,40.88799,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.79,93.4038
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089910,NDC,0.25,ML,95.31,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,40.88799,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.79,93.4038
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096105,NDC,1,EA,41.73,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,40.8954,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
Infec Agent Direct Probe - Ref,PX8779990,CDM,300,RC,87799,CPT,90,,,,,,,182,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,40.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.91,42.84
Infec Agent Direct Probe - Ref,PX8779990,CDM,300,RC,87799,CPT,90,,,,,,,182,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,40.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.91,42.84
ezetimibe 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714081301,NDC,1,EA,44.91,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,40.91301,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
TRAY IV SURGICAL EXTREMITY DYNJS0804,27200000,CDM,272,RC,,,,10919-MAIN,LOCAL,,,,,83.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,40.915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TRAY IV SURGICAL EXTREMITY DYNJS0804,27200000,CDM,272,RC,,,,10919-MAIN,LOCAL,,,,,83.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,40.915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TRAY IV SURGICAL EXTREMITY DYNJS0804,27200000,CDM,272,RC,,,,10919-MAIN,LOCAL,,,,,83.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,40.915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DULoxetine 20 MG Capsule Delayed Release Particles 60 Each Bottle,63700001,CDM,250,RC,,,,,,2323560,NDC,1,EA,41.76,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,40.9248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dextrose 25% Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409177510,NDC,10,ML,83.53,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,40.9297,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dextrose 25% Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409177510,NDC,10,ML,83.53,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,40.9297,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dextrose 25% Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409177510,NDC,10,ML,83.53,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,40.9297,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409751766,NDC,50,ML,80.89,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,40.93034,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sildenafil citrate 20 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,65162035109,NDC,1,EA,95.41,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,40.93089,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DERMABOND ADVANCED TOPICAL SKIN ADHESIVE,120.198,CDM,272,RC,,,,9101-MAIN,LOCAL,,,,,46,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,40.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.1084,45.08
Pinworm Exam,PX87172,CDM,300,RC,87172,CPT,,,,,,,,46,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,40.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,45.08
rivaroxaban 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50458058030,NDC,1,EA,98.57,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,40.945978,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,50111078751,NDC,1,EA,41.79,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,40.9542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
donepezil 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904640861,NDC,1,EA,41.79,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,40.9542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066500,NDC,0.25,ML,48.19,,First Health,Commercial,both,85,,999999999,percent of total billed charges,40.9615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.000396,47.2262
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409339004,NDC,1,EA,98.61,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,40.962594,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,45802095301,NDC,100,GR,82.76,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,40.9662,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
CAPTIFLEX SNARE SINGLE USE EXTRA SMALL 11MM,27200000,CDM,272,RC,,,,12378-MAIN,LOCAL,,,,,81,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,40.986,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Smear Special Stain,PX87207,CDM,300,RC,87207,CPT,,,,,,,,81,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,40.986,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.49,79.38
Tacrolimus - Ref,PX8019790,CDM,300,RC,80197,CPT,90,,,,,,,81,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,40.986,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,79.38
Cardiac Rehab,PX93797F,CDM,943,RC,93797,CPT,,,,,,,,45,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,40.995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,115.44
CATHETER TEMP-SENSING 8FR LUBRISIL PEDS DYND110508,120.363,CDM,272,RC,A4340,HCPCS,,12777-MAIN,LOCAL,,,,,45,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,40.995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
CATHETER TEMP-SENSING 12FR LUBRISIL 119212M,120.363,CDM,272,RC,A4340,HCPCS,,10750-MAIN,LOCAL,,,,,45,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,40.995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
CATHETER TEMP-SENSING 14FR LUBRISIL 119214M,120.363,CDM,272,RC,A4340,HCPCS,,10751-MAIN,LOCAL,,,,,45,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,40.995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
CATHETER TEMP-SENSING 16FR LUBRISIL 119216M,120.363,CDM,272,RC,A4340,HCPCS,,10752-MAIN,LOCAL,,,,,45,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,40.995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
Cryptococcus Neoformans,PX87327,CDM,300,RC,87327,CPT,,,,,,,,45,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,40.995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.3,44.1
Gammaglobulin; Ige - Ref,PX8278590,CDM,300,RC,82785,CPT,90,,,,,,,45,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,40.995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.09,44.1
GASTRONOMY FEEDING TUBE MIC BALLOONED 20FR 7-10ML 0112-20,27200000,CDM,272,RC,B4087,HCPCS,,13098-MAIN,LOCAL,,,,,45,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,40.995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRES 1.6MM,27200000,CDM,272,RC,C1769,HCPCS,,11852-MAIN,LOCAL,,,,,45,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,40.995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"La Crosse, Antibody - Ref",PX8665190,CDM,300,RC,86651,CPT,90,,,,,,,45,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,40.995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.09,44.1
MELGISORB AG SILVER CALCIUM STERILE 6X6,120.502,CDM,272,RC,A6197,HCPCS,,11844-MAIN,LOCAL,,,,,45,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,40.995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
"St Louis, Antibody - Ref",PX8665390,CDM,300,RC,86653,CPT,90,,,,,,,45,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,40.995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.09,44.1
"Sugars, Qual, Ea Spec - Ref",PX8437690,CDM,300,RC,84376,CPT,90,,,,,,,45,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,40.995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.04,44.1
"Venipuncture by Physician, Other Vein, Under Age 3 Years",PX36406,CDM,983,RC,36406,CPT,,,,,,,,45,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,40.995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,43.7985
"Western Equine, Ab - Ref",PX8665490,CDM,300,RC,86654,CPT,90,,,,,,,45,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,40.995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.09,44.1
hydrOXYzine 50 MG/ML Solution 1 mL Vial,J3410.01,CDM,636,RC,J3410,HCPCS,,,,517560125,NDC,0.5,ML,83.68,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,41.0032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.760672,82.0064
hydrOXYzine 50 MG/ML Solution 1 mL Vial,J3410.01,CDM,636,RC,J3410,HCPCS,,,,517560125,NDC,0.5,ML,83.68,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,41.0032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.760672,82.0064
hydrOXYzine 50 MG/ML Solution 1 mL Vial,J3410.01,CDM,636,RC,J3410,HCPCS,,,,517560125,NDC,0.5,ML,83.68,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,41.0032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.760672,82.0064
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Syringe,J7040.01,CDM,636,RC,J7040,HCPCS,,,,64253020230,NDC,10,ML,42.15,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,26.00411043,percent of total billed charges,41.024595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028426,NDC,1,EA,42.15,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,12.385,percent of total billed charges,41.024595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010301,NDC,0.3,ML,45.04,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,41.03144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
DULoxetine 30 MG Capsule Delayed Release Particles 90 Each Bottle,63700001,CDM,250,RC,,,,,,57237001890,NDC,1,EA,42.17,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,41.044061,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tiotropium 18 MCG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,597007541,NDC,1,EA,82.92,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,41.0454,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,17478028810,NDC,5,ML,95.71,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,41.05959,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314022705,NDC,5,ML,95.71,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,41.05959,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,64980051405,NDC,5,ML,95.71,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,41.05959,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,25021012867,NDC,1,EA,82.96,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,41.0652,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,55150020830,NDC,1,EA,82.96,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,41.0652,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.461584,189.875
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424601,NDC,15,ML,95.76,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,41.08104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.778704,295.3916
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424681,NDC,15,ML,95.76,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,41.08104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.778704,295.3916
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,47781047013,NDC,1,EA,83,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,41.085,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,64380079901,NDC,1,EA,83,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,41.085,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,69238126601,NDC,1,EA,83,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,41.085,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SLING ARM CHILD PAD CANVAS NAVY 8004-02,120.54,CDM,273,RC,A4565,HCPCS,,878-MAIN,LOCAL,,,,,83,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,41.085,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM LARGE PAD CANVAS NAVY ORT11300L,120.54,CDM,273,RC,A4565,HCPCS,,870-MAIN,LOCAL,,,,,83,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,41.085,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM MEDIUM PAD CANVAS NAVY ORT11300M,120.54,CDM,273,RC,A4565,HCPCS,,872-MAIN,LOCAL,,,,,83,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,41.085,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM SMALL PAD CANVAS NAVY ORT11300S,120.54,CDM,273,RC,A4565,HCPCS,,874-MAIN,LOCAL,,,,,83,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,41.085,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM X-LARGE PAD ENVELOPE ORT11300XL,120.54,CDM,273,RC,A4565,HCPCS,,876-MAIN,LOCAL,,,,,83,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,41.085,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
ondansetron 4 MG/5ML Solution 50 mL Bottle,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714067102,NDC,5,ML,98.91,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.087214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,25021010720,NDC,1,EA,48.35,,First Health,Commercial,both,85,,999999999,percent of total billed charges,41.0975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
rosuvastatin 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16714098801,NDC,1,EA,46.18,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,41.1002,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Blood Transfusion Service,PX36430,CDM,391,RC,36430,CPT,,,,,,,,839,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,41.1008,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.52,87.86
Drain/Inject Large Joint/Bursa,PX20610F,CDM,510,RC,20610,CPT,,,,,,,,364,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,41.1008,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.48,135.59
Drain/Inject Large Joint/Bursa,PX20610P,CDM,983,RC,20610,CPT,,,,,,,,291,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,41.1008,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.48,285.18
silver sulfADIAZINE 1 % Cream 50 g Jar,25000000,CDM,250,RC,,,,,,43598021055,NDC,50,GR,83.89,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,41.1061,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
silver sulfADIAZINE 1 % Cream 50 g Jar,25000000,CDM,250,RC,,,,,,43598021055,NDC,50,GR,83.89,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,41.1061,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
silver sulfADIAZINE 1 % Cream 50 g Jar,25000000,CDM,250,RC,,,,,,43598021055,NDC,50,GR,83.89,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,41.1061,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,23155029031,NDC,2,ML,98.99,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.120446,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,97.0102
"Clostridium Ag, Eia",PX87324,CDM,300,RC,87324,CPT,,,,,,,,99,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.1246,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,97.02
Deoxyribonuclease Ab,PX86215,CDM,300,RC,86215,CPT,,,,,,,,99,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.1246,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,97.02
"Extractable Nuclear Antigen, Each Antigen",PX86235,CDM,300,RC,86235,CPT,90,,,,,,,99,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.1246,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.44,97.02
"Fungus Antibody, Nos - Ref",PX8667190,CDM,300,RC,86671,CPT,90,,,,,,,99,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.1246,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.23,97.02
"Lab Immunoassay, Non Antibody",PX83516,CDM,300,RC,83516,CPT,,,,,,,,99,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.1246,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.57,97.02
"Protozoa Antibody, Nos - Ref",PX8675390,CDM,300,RC,86753,CPT,90,,,,,,,99,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.1246,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.36,97.02
sod citrate-citric acid 500-334 MG/5ML Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,121059516,NDC,473,ML,95.87,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,41.12823,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"SUTURE ETHIBOND #0 CT-1 CR 8-18"" CX21D",27200000,CDM,272,RC,,,,6415-MAIN,LOCAL,,,,,41.97,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,41.1306,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,17478081725,NDC,25,ML,81.3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,41.1378,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
levoFLOXacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635261,NDC,0.5,EA,45.16,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,41.14076,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SUCTION TIP POOLE STERILE 35040,27200000,CDM,272,RC,,,,977-MAIN,LOCAL,,,,,42.28,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,41.151124,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Actin Antibody Each,PX8601590,CDM,300,RC,86015,CPT,90,,,,,,,42,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,41.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.05,41.16
Assay Vitamin B-6,PX84207,CDM,300,RC,84207,CPT,90,,,,,,,42,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,41.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
"BOUGIE TRACH 10FR 70CM COUDE 	9-0211-70",120.199,CDM,272,RC,A7520,HCPCS,,11112-MAIN,LOCAL,,,,,42,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,41.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
BOUGIE TRACHEAL TUBE & GUIDE 100123515,120.199,CDM,272,RC,A7520,HCPCS,,8950-MAIN,LOCAL,,,,,42,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,41.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
CANNULA OPTIFLOW JUNIOR2+ XXL OJR520,120.494,CDM,271,RC,A4615,HCPCS,,11619-MAIN,LOCAL,,,,,84,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,41.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.8936,82.32
CANNULA OPTIFLOW JUNIOR2+ XXL OJR520,120.494,CDM,271,RC,A4615,HCPCS,,11619-MAIN,LOCAL,,,,,84,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,41.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.8936,82.32
CANNULA OPTIFLOW JUNIOR2+ XXL OJR520,120.494,CDM,271,RC,A4615,HCPCS,,11619-MAIN,LOCAL,,,,,84,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,41.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.8936,82.32
CATHETER PUREWICK FEMALE EXTERNAL PWF030K,120.414,CDM,272,RC,A6590,HCPCS,,11836-MAIN,LOCAL,,,,,42,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,41.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
Culture Type Immunologic,PX87147,CDM,300,RC,87147,CPT,,,,,,,,42,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,41.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,41.16
EZ-STABILIZER DRESSING,120.415,CDM,272,RC,,,,9058-MAIN,LOCAL,,,,,42,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,41.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
Hiaa - Ref,PX8349790,CDM,300,RC,83497,CPT,90,,,,,,,84,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,41.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.83,82.32
Hiaa - Ref,PX8349790,CDM,300,RC,83497,CPT,90,,,,,,,84,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,41.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.83,82.32
Hiaa - Ref,PX8349790,CDM,300,RC,83497,CPT,90,,,,,,,84,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,41.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.83,82.32
MEPILEX AG FOAM 4X4,120.192,CDM,272,RC,A6213,HCPCS,,8480-MAIN,LOCAL,,,,,42,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,41.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
MEPILEX AG FOAM 4X8,120.192,CDM,272,RC,A6213,HCPCS,,8479-MAIN,LOCAL,,,,,42,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,41.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY CENTRAL LINE DRESSING WITH CHLORAPREP DYND75234,120.68,CDM,272,RC,,,,10923-MAIN,LOCAL,,,,,42,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,41.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY FOLEY 14FR CATHETER A300414A,120.414,CDM,272,RC,A4344,HCPCS,,11281-MAIN,LOCAL,,,,,42,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,41.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY FOLEY 16FR CATHETER 300416A,120.414,CDM,272,RC,A4344,HCPCS,,11774-MAIN,LOCAL,,,,,42,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,41.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
"TRAY SPINAL  25GX3.5"" WITH WHITEACRE 405671",120.275,CDM,272,RC,,,,3284-MAIN,LOCAL,,,,,42,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,41.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
TRAY SPINAL 25G ANESTH SADDLE BLOCK NLD-4795-20,120.275,CDM,272,RC,,,,935-MAIN,LOCAL,,,,,42,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,41.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.4468,41.16
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490334,NDC,5,ML,42.29,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,41.160857,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
tetracycline 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,51991090701,NDC,0.5,EA,42.29,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,41.160857,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone sod succ 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,63323025803,NDC,0.4,EA,46.67,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,41.16294,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
"dextrose 5 % 5 % Solution 1,000 mL Flex Cont",J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001704,NDC,1000,ML,99.12,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.174448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001702,NDC,250,ML,99.12,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.174448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338634602,NDC,250,ML,99.12,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.174448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 500 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001703,NDC,500,ML,99.12,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.174448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % Non-DEHP bag 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,264751020,NDC,250,ML,99.12,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.174448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"dextrose 5% and sodium chloride 0.2% 5-0.2 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338007704,NDC,1000,ML,99.12,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.174448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
"dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008904,NDC,1000,ML,99.12,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.174448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 500 mL Flex Cont,J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008903,NDC,500,ML,99.12,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.174448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
"dextrose 5% and sodium chloride 0.45% 5-0.45 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008504,NDC,1000,ML,99.12,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.174448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
dextrose 5% lactated ringers 5 % Solution 500 mL Flex Cont,J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012503,NDC,500,ML,99.12,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.174448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 10% 10 % Solution 500 mL Flex Cont,25000000,CDM,250,RC,,,,,,338002303,NDC,500,ML,99.12,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.174448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lactated ringers Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338011704,NDC,1000,ML,99.12,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.174448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338069104,NDC,1000,ML,99.12,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.174448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004904,NDC,1000,ML,99.12,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.174448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954306,NDC,1000,ML,99.12,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.174448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004902,NDC,250,ML,99.12,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.174448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954302,NDC,250,ML,99.12,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.174448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 500 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004903,NDC,500,ML,99.12,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.174448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9% 0.9% Solution 1,000 mL Flex Cont",J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004904,NDC,1000,ML,99.12,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.174448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9% IV LINE FLUSH 0.9% Solution 250 mL Flex Cont,25000000,CDM,250,RC,,,,,,338004902,NDC,250,ML,99.12,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.174448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"sodium chloride 0.45 % 0.45 % Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,338004304,NDC,1000,ML,99.12,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.174448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 3 % 3 % Solution 500 mL Flex Cont,J7131.01,CDM,636,RC,J7131,HCPCS,,,,338005403,NDC,500,ML,99.12,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.174448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; 1st",PX88184,CDM,310,RC,88184,CPT,,,,,,,,96,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,41.184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.8784,314.02
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; Add'l",PX88185,CDM,310,RC,88185,CPT,,,,,,,,96,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,41.184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.8784,94.08
US Urine Capacity Measure,PX51798F,CDM,510,RC,51798,CPT,,,,,,,,96,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,41.184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.8784,94.08
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,55150016205,NDC,5,ML,42.32,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,41.190056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143998391,NDC,1,EA,83.25,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,41.20875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
"IV Infusion Therapy, 1 Hour",PX96365,CDM,260,RC,96365,CPT,,,,,,,,327,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,41.23,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.23,109.36
"IV Infusion Therapy, 1 Hour",PX96365,CDM,260,RC,96365,CPT,,,,,,,,327,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,41.23,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.23,109.36
Sigmoidoscope W/Submuc Inj,PX45335F,CDM,750,RC,45335,CPT,,,,,,,,750,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,41.23,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.23,602.56
Sigmoidoscope W/Submuc Inj,PX45335P,CDM,983,RC,45335,CPT,,,,,,,,500,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,41.23,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.23,602.56
SAW BLADE 300 SAGITTAL 25X9.4X0.7,27200000,CDM,272,RC,,,,11592-MAIN,LOCAL,,,,,46.75,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,41.2335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SAW BLADE 300 SAGITTAL 40X14X0.6MM,27200000,CDM,272,RC,,,,11591-MAIN,LOCAL,,,,,46.75,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,41.2335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
penicillin v potassium 250 MG/5ML Recon Soln 200 mL Bottle,63700001,CDM,250,RC,,,,,,93412774,NDC,200,ML,83.32,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,41.2434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Complete Cbc W/Auto Diff Wbc,PX85025,CDM,300,RC,85025,CPT,,,,,,,,168,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,41.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.12,164.64
"Fac/Office Consultation,Level III",PX99243F,CDM,510,RC,99213,CPT,,,,,,,,374,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,41.25,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.25,163.25
"Office/Outpt Visit,Est,Levl III",PX99213F,CDM,510,RC,99213,CPT,,,,,,,,185,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,41.25,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.25,163.25
"Office/Outpt Visit,Est,Levl III",PX99213P,CDM,983,RC,99213,CPT,,,,,,,,185,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,41.25,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.25,181.3
levothyroxine 100 MCG/5ML Solution 5 mL Vial,J0651.01,CDM,636,RC,J0651,HCPCS,,,,63323088510,NDC,0.625,ML,99.32,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.257528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.257528,97.3336
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,17478004001,NDC,1,ML,42.39,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,10.90473684,percent of total billed charges,41.258187,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,409469930,NDC,20,ML,48.54,,First Health,Commercial,both,85,,999999999,percent of total billed charges,41.259,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026969,NDC,100,ML,99.34,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.265836,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
Aldosterone - Ref,PX8208890,CDM,300,RC,82088,CPT,90,,,,,,,86,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,41.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.7244,84.28
Aldosterone - Ref,PX8208890,CDM,300,RC,82088,CPT,90,,,,,,,86,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,41.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.7244,84.28
Epstein-barr antibody,PX86665,CDM,300,RC,86665,CPT,,,,,,,,86,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,41.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.63,84.28
Epstein-barr antibody,PX86665,CDM,300,RC,86665,CPT,,,,,,,,86,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,41.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.63,84.28
Lab Pth Immunoch Part 1,PX83970,CDM,300,RC,83970,CPT,,,,,,,,128,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,41.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.04,41.28
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098321,NDC,1,EA,99.39,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.286606,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098323,NDC,1,EA,99.39,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.286606,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052200,NDC,1,EA,99.39,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.286606,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052237,NDC,1,EA,99.39,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.286606,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
SAWBLADE SAGITAL STERILE 25MM LENGTH 5.5MM WIDTH 0.60MM THICKNESS,27200000,CDM,272,RC,,,,11623-MAIN,LOCAL,,,,,86.02,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,41.2896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SAWBLADE SAGITAL STERILE 25MM LENGTH 5.5MM WIDTH 0.60MM THICKNESS,27200000,CDM,272,RC,,,,11623-MAIN,LOCAL,,,,,86.02,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,41.2896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049257,NDC,5,ML,42.43,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,41.297119,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Sars-Cov-2 Covid-19 Antibody,PX86769,CDM,300,RC,86769,CPT,,,,,,,,340,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,41.29983,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.87,42.13
Sars-Cov-2 Covid-19 Antibody,PX8676990,CDM,300,RC,86769,CPT,90,,,,,,,100,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,41.29983,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.87,42.13
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151F,CDM,370,RC,99151,CPT,,,,,,,,176,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,41.3,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.05,105.87
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151P,CDM,983,RC,99151,CPT,,,,,,,,275,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,41.3,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.05,269.5
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Syringe,J7040.01,CDM,636,RC,J7040,HCPCS,,,,64253020230,NDC,10,ML,42.15,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,41.307,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028426,NDC,1,EA,42.15,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,41.307,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
DULoxetine 30 MG Capsule Delayed Release Particles 90 Each Bottle,63700001,CDM,250,RC,,,,,,57237001890,NDC,1,EA,42.17,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,41.3266,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine (preservative free) 4 % Solution 5 mL Ampule,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409428325,NDC,5,ML,48.62,,First Health,Commercial,both,85,,999999999,percent of total billed charges,41.327,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
TRAY IV SURGICAL EXTREMITY DYNJS0804,27200000,CDM,272,RC,,,,10919-MAIN,LOCAL,,,,,83.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,41.3325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019600,NDC,1,ML,48.64,,First Health,Commercial,both,85,,999999999,percent of total billed charges,41.344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
morphine 1 MG/ML Solution 50 mL Syringe,J2270.01,CDM,636,RC,J2270,HCPCS,,,,61553064975,NDC,50,ML,81.71,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,41.34526,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
dextrose 25% Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409177510,NDC,10,ML,83.53,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,41.34735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,36000000924,NDC,200,ML,48.65,,First Health,Commercial,both,85,,999999999,percent of total billed charges,41.3525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.20921,64.9544
ketorolac 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314012605,NDC,5,ML,42.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,41.36525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
polyvinyl alcohol 1.4 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,50268067815,NDC,15,ML,45.42,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,41.37762,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Infectious Agent Antigen Detection by Immunoassay With Direct Visual Observation.,PX87811,CDM,300,RC,87811,CPT,,,,,,,,192,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,41.38,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.14,41.38
Infectious Agent Antigen Detection by Immunoassay With Direct Visual Observation.,PX87811,CDM,300,RC,87811,CPT,,,,,,,,192,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,41.38,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.14,41.38
Infectious Agent Antigen Detection by Immunoassay With Direct Visual Observation.,PX87811,CDM,300,RC,87811,CPT,,,,,,,,192,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,41.38,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.14,41.38
timolol 0.25 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314022605,NDC,5,ML,84.45,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,41.3805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
timolol 0.25 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314022605,NDC,5,ML,84.45,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,41.3805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
timolol 0.25 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314022605,NDC,5,ML,84.45,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,41.3805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,70860030143,NDC,25,ML,84.47,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,41.3903,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,70860030143,NDC,25,ML,84.47,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,41.3903,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,70860030143,NDC,25,ML,84.47,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,41.3903,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010626,NDC,50,ML,84.47,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,5.851071429,percent of total billed charges,41.3903,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010626,NDC,50,ML,84.47,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,41.3903,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010626,NDC,50,ML,84.47,,United Healthcare,All Medicare advantage plans,outpatient,49,,13.925,percent of total billed charges,41.3903,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
sodium bicarbonate 8.4 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409662502,NDC,50,ML,84.47,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,41.3903,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium bicarbonate 8.4 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409662502,NDC,50,ML,84.47,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,41.3903,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium bicarbonate 8.4 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409662502,NDC,50,ML,84.47,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,41.3903,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036019,NDC,10,ML,86.23,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,41.3904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,84.5054
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036019,NDC,10,ML,86.23,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,41.3904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,84.5054
urea 20 % Cream 85 g Tube,63700001,CDM,250,RC,,,,,,536110945,NDC,85,GR,81.83,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,41.40598,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vinCRIStine 1 MG/ML Solution 2 mL Vial,J9370.01,CDM,636,RC,J9370,HCPCS,,,,61703030916,NDC,2,ML,48.72,,First Health,Commercial,both,85,,999999999,percent of total billed charges,41.412,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.238288,47.7456
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188602,NDC,5,ML,45.46,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,41.41406,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.884084,44.5508
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188622,NDC,5,ML,45.46,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,41.41406,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.884084,44.5508
Xray Calcaneus Minimum 2 Vws,PX7365001,CDM,320,RC,73650,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,41.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.74,41.42
Xray Calcaneus Minimum 2 Vws,PX7365001,CDM,320,RC,73650,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,41.42,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.74,41.42
hydrOXYzine 50 MG/ML Solution 1 mL Vial,J3410.01,CDM,636,RC,J3410,HCPCS,,,,517560125,NDC,0.5,ML,83.68,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,41.4216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.760672,82.0064
mycophenolate 500 MG Tablet 100 Each Bottle,J7517.01,CDM,637,RC,J7517,HCPCS,,,,64380072506,NDC,1,EA,42.56,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,41.423648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.679424,41.7088
SUCTION TIP POOLE STERILE 35040,27200000,CDM,272,RC,,,,977-MAIN,LOCAL,,,,,42.28,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,41.4344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490334,NDC,5,ML,42.29,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,41.4442,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
tetracycline 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,51991090701,NDC,0.5,EA,42.29,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,41.4442,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070948,NDC,100,ML,42.59,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,4.559571429,percent of total billed charges,41.452847,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
Blood Count Reticulocytes Auto 1/> Cell Meas,PX85046,CDM,300,RC,85046,CPT,,,,,,,,47,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,41.454,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.11,46.06
"PAD BED SENSOR 10X28"" P-107517",120.124,CDM,271,RC,,,,8377-MAIN,LOCAL,,,,,47,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,41.454,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.5238,46.06
"PAD CHAIR SENSOR 10x15"" 106380",120.124,CDM,271,RC,,,,8378-MAIN,LOCAL,,,,,47,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,41.454,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.5238,46.06
"Protein S, Free - Ref",PX8530690,CDM,300,RC,85306,CPT,90,,,,,,,47,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,41.454,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.05,46.06
REDUCER 12 - 8MM,27200000,CDM,272,RC,,,,11961-MAIN,LOCAL,,,,,47,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,41.454,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,55150016205,NDC,5,ML,42.32,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,41.4736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
leucovorin 350 MG Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,703514501,NDC,1,EA,86.41,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,41.4768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.670002,84.6818
leucovorin 350 MG Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,703514501,NDC,1,EA,86.41,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,41.4768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.670002,84.6818
Ace - Ref,PX8216490,CDM,300,RC,82164,CPT,90,,,,,,,82,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,41.492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.39,80.36
Anca Screen Each Antibody,PX8603690,CDM,300,RC,86036,CPT,90,,,,,,,82,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,41.492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.0628,80.36
"Cognitive Funct Ther Interv, Ea Addl 15 Min",PX97130,CDM,420,RC,97130,CPT,,,,,,,,82,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,41.492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31,80.36
"Cortisol, Free - Ref",PX8253090,CDM,300,RC,82530,CPT,90,,,,,,,82,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,41.492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.32,80.36
DOPamine 1600 mcg/mL in dextrose 5% 250 mL premix 1600 mcg/mL Solution 250 mL Plas Cont,J1265.01,CDM,636,RC,J1265,HCPCS,,,,338100702,NDC,250,ML,99.9,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.49846,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.49846,97.902
Appl on-Body Injector for Timed Subq Injection,PX96377,CDM,260,RC,96377,CPT,,,,,,,,13093,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,41.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,12831.14
Each Add'l Hour IV Hydration,PX96361,CDM,260,RC,96361,CPT,,,,,,,,123,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,41.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,120.54
Each Add'l Hour IV Infusion <8 Hour,PX96366,CDM,260,RC,96366,CPT,,,,,,,,161,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,41.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,157.78
Each Add'l Sequential Push New Drug,PX96375,CDM,260,RC,96375,CPT,,,,,,,,130,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,41.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,127.4
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927380,NDC,1,EA,99.91,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.502614,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927395,NDC,1,EA,99.91,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.502614,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
Strapping of Hand or Finger,PX29280F,CDM,420,RC,29280,CPT,,,,,,,,64,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,41.51,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.21,62.26
protamine 10 MG/ML Solution 5 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022994,NDC,5,ML,84.74,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,41.5226,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.431298,83.0452
protamine 10 MG/ML Solution 5 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022994,NDC,5,ML,84.74,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,41.5226,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.431298,83.0452
protamine 10 MG/ML Solution 5 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022994,NDC,5,ML,84.74,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,41.5226,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.431298,83.0452
silver sulfADIAZINE 1 % Cream 50 g Jar,25000000,CDM,250,RC,,,,,,43598021055,NDC,50,GR,83.89,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,41.52555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
methylPREDNISolone sod succ 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,63323025803,NDC,0.4,EA,46.67,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,41.5363,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
gadoteridol 279.3 MG/ML Solution 5 mL Vial,A9576,CDM,636,RC,A9576,HCPCS,,,,270111104,NDC,10,ML,100,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.54,166.6
Sars-Cov-2 Covid-19 Antibody,PX8676990,CDM,300,RC,86769,CPT,90,,,,,,,100,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.63,98
fentaNYL 12 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,378911916,NDC,1,EA,96.83,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,41.54007,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 12 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505708000,NDC,1,EA,96.83,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,41.54007,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,17478004001,NDC,1,ML,42.39,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,41.5422,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,41.5422
fentaNYL 12 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,378911998,NDC,1,EA,96.84,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,41.54436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 12 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,60505708002,NDC,1,EA,96.84,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,41.54436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Cmv, Quant - Ref",PX8749790,CDM,300,RC,87497,CPT,90,,,,,,,194,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,41.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.55,42.84
"Cmv, Quant - Ref",PX8749790,CDM,300,RC,87497,CPT,90,,,,,,,194,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,41.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.55,42.84
"Cmv, Quant - Ref",PX8749790,CDM,300,RC,87497,CPT,90,,,,,,,194,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,41.55,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.55,42.84
Hepatitis C Rna Quant,PX87522,CDM,300,RC,87522,CPT,,,,,,,,185,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,41.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.55,42.84
Hepatitis C Rna Quant,PX87522,CDM,300,RC,87522,CPT,,,,,,,,185,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,41.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.55,42.84
Hepatitis C Rna Quant,PX87522,CDM,300,RC,87522,CPT,,,,,,,,185,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,41.55,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.55,42.84
Infec Agent Direct Probe - Ref,PX8779990,CDM,300,RC,87799,CPT,90,,,,,,,182,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,41.55,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.91,42.84
CANNULA OPTIFLOW JUNIOR2+ XXL OJR520,120.494,CDM,271,RC,A4615,HCPCS,,11619-MAIN,LOCAL,,,,,84,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,41.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.8936,82.32
Hiaa - Ref,PX8349790,CDM,300,RC,83497,CPT,90,,,,,,,84,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,41.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.83,82.32
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049257,NDC,5,ML,42.43,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,41.5814,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 4 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,536128128,NDC,30,GR,96.95,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,41.59155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SAW BLADE 300 SAGITTAL 25X9.4X0.7,27200000,CDM,272,RC,,,,11592-MAIN,LOCAL,,,,,46.75,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,41.6075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SAW BLADE 300 SAGITTAL 40X14X0.6MM,27200000,CDM,272,RC,,,,11591-MAIN,LOCAL,,,,,46.75,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,41.6075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Blastomyces Antibody - Ref,PX8661290,CDM,300,RC,86612,CPT,90,,,,,,,97,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,41.613,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.83,95.06
Contrast Bath Therapy,PX97034,CDM,420,RC,97034,CPT,,,,,,,,97,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,41.613,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,95.06
DRAPE INSTRUMENT ARM 470015,27200000,CDM,272,RC,,,,11925-MAIN,LOCAL,,,,,97,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,41.613,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
High Sens Crp,PX86141,CDM,300,RC,86141,CPT,,,,,,,,97,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,41.613,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,95.06
Rheumatoid Factor Quant,PX86431,CDM,300,RC,86431,CPT,,,,,,,,97,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,41.613,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.2,95.06
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015901,NDC,0.3,ML,45.69,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,41.62359,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015925,NDC,0.3,ML,45.69,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,41.62359,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
CISplatin 50 MG/50ML Solution 50 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010351,NDC,50,ML,82.27,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,41.62862,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.174958,180.2416
ceFAZolin in D4W 1 g / 50 mL 1-4 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0690.01,CDM,636,RC,J0690,HCPCS,,,,264310311,NDC,1,EA,84.97,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,7.351730769,percent of total billed charges,41.6353,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin in D4W 1 g / 50 mL 1-4 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0690.01,CDM,636,RC,J0690,HCPCS,,,,264310311,NDC,1,EA,84.97,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,41.6353,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin in D4W 1 g / 50 mL 1-4 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0690.01,CDM,636,RC,J0690,HCPCS,,,,264310311,NDC,1,EA,84.97,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,41.6353,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505615204,NDC,0.5,EA,86.76,,Health Partners,Health Partners Care Plans,both,48,,26.64321429,percent of total billed charges,41.6448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505615204,NDC,0.5,EA,86.76,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,41.6448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
Beta-2-Microglobulin - Ref,PX8223290,CDM,300,RC,82232,CPT,90,,,,,,,49,,First Health,Commercial,both,85,,999999999,percent of total billed charges,41.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.84,48.02
"Cannabinoids, Natural - Ref",PX8034990,CDM,300,RC,80349,CPT,90,,,,,,,49,,First Health,Commercial,both,85,,999999999,percent of total billed charges,41.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,48.02
cefTAZidime 1 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023525,NDC,1,EA,49,,First Health,Commercial,both,85,,999999999,percent of total billed charges,41.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
"Cognitive Funct Ther Interv, Initial 15 Min",PX97129,CDM,420,RC,97129,CPT,,,,,,,,85,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,19.93,percent of total billed charges,41.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15,83.3
"Cognitive Funct Ther Interv, Initial 15 Min",PX97129,CDM,420,RC,97129,CPT,,,,,,,,85,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,41.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15,83.3
"Cognitive Funct Ther Interv, Initial 15 Min",PX97129,CDM,420,RC,97129,CPT,,,,,,,,85,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,41.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15,83.3
COLLAR CERVICAL X-LARGE WITH TRACH 2 PIECE OSG2404,120.185,CDM,274,RC,L0172,HCPCS,,10143-MAIN,LOCAL,,,,,49,,First Health,Commercial,both,85,,999999999,percent of total billed charges,41.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,152.79
"Exam,Synovial Fluid Crystals",PX89060,CDM,300,RC,89060,CPT,,,,,,,,85,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,41.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.72,83.3
"Exam,Synovial Fluid Crystals",PX89060,CDM,300,RC,89060,CPT,,,,,,,,85,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,41.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.72,83.3
"Exam,Synovial Fluid Crystals",PX89060,CDM,300,RC,89060,CPT,,,,,,,,85,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,41.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.72,83.3
GLIDESCOPE QC MAC S3 SINGLE USE 0270-1083,120.579,CDM,272,RC,,,,13046-MAIN,LOCAL,,,,,85,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,41.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.309,83.3
GLIDESCOPE QC MAC S3 SINGLE USE 0270-1083,120.579,CDM,272,RC,,,,13046-MAIN,LOCAL,,,,,85,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,41.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.309,83.3
GLIDESCOPE QC MAC S3 SINGLE USE 0270-1083,120.579,CDM,272,RC,,,,13046-MAIN,LOCAL,,,,,85,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,41.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.309,83.3
GLIDESCOPE QC MAC S3 SINGLE USE 0270-1085,120.579,CDM,272,RC,,,,13022-MAIN,LOCAL,,,,,85,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,41.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.309,83.3
GLIDESCOPE QC MAC S3 SINGLE USE 0270-1085,120.579,CDM,272,RC,,,,13022-MAIN,LOCAL,,,,,85,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,41.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.309,83.3
GLIDESCOPE QC MAC S3 SINGLE USE 0270-1085,120.579,CDM,272,RC,,,,13022-MAIN,LOCAL,,,,,85,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,41.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.309,83.3
GLIDESCOPE QC MAC S4 SINGLE USE 0270-1086,120.579,CDM,272,RC,,,,13023-MAIN,LOCAL,,,,,85,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,41.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.309,83.3
GLIDESCOPE QC MAC S4 SINGLE USE 0270-1086,120.579,CDM,272,RC,,,,13023-MAIN,LOCAL,,,,,85,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,41.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.309,83.3
GLIDESCOPE QC MAC S4 SINGLE USE 0270-1086,120.579,CDM,272,RC,,,,13023-MAIN,LOCAL,,,,,85,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,41.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.309,83.3
Glycated Protein - Ref,PX8298590,CDM,300,RC,82985,CPT,90,,,,,,,49,,First Health,Commercial,both,85,,999999999,percent of total billed charges,41.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.37,48.02
ketorolac 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314012605,NDC,5,ML,42.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,41.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"SUTURE V-LOC SZ 0 180 GREEN GS21 NEEDLE 18"" VLOCL0326",27200000,CDM,272,RC,,,,12218-MAIN,LOCAL,,,,,49,,First Health,Commercial,both,85,,999999999,percent of total billed charges,41.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001302,NDC,2,ML,86.79,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,41.6592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001302,NDC,2,ML,86.79,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,41.6592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
sodium bicarbonate 8.4 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409662522,NDC,50,ML,85.02,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,41.6598,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium bicarbonate 8.4 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409662522,NDC,50,ML,85.02,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,41.6598,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium bicarbonate 8.4 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409662522,NDC,50,ML,85.02,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,41.6598,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Injection Hip Arthrogram,PX27093F,CDM,510,RC,27093,CPT,,,,,,,,654,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,41.66,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.66,477.34
Injection Hip Arthrogram,PX27093F,CDM,510,RC,27093,CPT,,,,,,,,654,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,41.66,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.66,477.34
Sigmoidoscope W/Submuc Inj,PX45335F,CDM,750,RC,45335,CPT,,,,,,,,750,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,41.66,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.23,602.56
Sigmoidoscope W/Submuc Inj,PX45335F,CDM,750,RC,45335,CPT,,,,,,,,750,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,41.66,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.23,602.56
Sigmoidoscope W/Submuc Inj,PX45335P,CDM,983,RC,45335,CPT,,,,,,,,500,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,41.66,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.23,602.56
Sigmoidoscope W/Submuc Inj,PX45335P,CDM,983,RC,45335,CPT,,,,,,,,500,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,41.66,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.23,602.56
"IV Infusion Therapy, 1 Hour",PX96365,CDM,260,RC,96365,CPT,,,,,,,,327,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,41.66,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.23,109.36
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066501,NDC,0.25,ML,45.74,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,41.66914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.000396,47.2262
ACUSNARE POLYPECTOMY SNARE,27200000,CDM,272,RC,,,,7733-MAIN,LOCAL,,,,,45.75,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,41.67825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
infuvite adult Injectable 10 mL Vial,J3490.99,CDM,636,RC,J3490,HCPCS,,,,54643564901,NDC,10,ML,86.89,,Health Partners,Health Partners Care Plans,both,48,,31.91277778,percent of total billed charges,41.7072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.094106,85.1522
infuvite adult Injectable 10 mL Vial,J3490.99,CDM,636,RC,J3490,HCPCS,,,,54643564901,NDC,10,ML,86.89,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,41.7072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.094106,85.1522
mycophenolate 500 MG Tablet 100 Each Bottle,J7517.01,CDM,637,RC,J7517,HCPCS,,,,64380072506,NDC,1,EA,42.56,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,41.7088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.679424,41.7088
Wheelchair Mngement Training,PX97542,CDM,420,RC,97542,CPT,,,,,,,,145,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,41.73,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.84,41.73
Wheelchair Mngement Training,PX97542,CDM,420,RC,97542,CPT,,,,,,,,145,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,41.73,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.84,41.73
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001326,NDC,1,ML,42.88,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,42.99521739,percent of total billed charges,41.735104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001341,NDC,1,ML,42.88,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,42.99521739,percent of total billed charges,41.735104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714001601,NDC,0.4,ML,100.47,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.735238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070948,NDC,100,ML,42.59,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,41.7382,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604F,CDM,510,RC,20604,CPT,,,,,,,,344,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,41.743,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.13,172.26
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604P,CDM,983,RC,20604,CPT,,,,,,,,229,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,41.743,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.13,224.42
"Chemotherapy, IV Push, Additional Drug",PX96411,CDM,335,RC,96411,CPT,,,,,,,,87,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,41.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.1398,85.26
"Chemotherapy, IV Push, Additional Drug",PX96411,CDM,335,RC,96411,CPT,,,,,,,,87,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,41.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.1398,85.26
alendronate 70 MG Tablet 4 Each Box,63700001,CDM,250,RC,,,,,,16714063301,NDC,1,EA,97.37,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,41.77173,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone-salmeterol 250-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,54032756,NDC,1,EA,45.88,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,41.79668,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
timolol 0.25 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314022605,NDC,5,ML,84.45,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,41.80275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
CARTER THOMASON CLOSURE 5MM,27200000,CDM,272,RC,,,,10278-MAIN,LOCAL,,,,,97.45,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,41.80605,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,70860030143,NDC,25,ML,84.47,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,41.81265,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010626,NDC,50,ML,84.47,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,41.81265,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
sodium bicarbonate 8.4 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409662502,NDC,50,ML,84.47,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,41.81265,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Blood Count Reticulocytes Auto 1/> Cell Meas,PX85046,CDM,300,RC,85046,CPT,,,,,,,,47,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,41.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.11,46.06
"PAD BED SENSOR 10X28"" P-107517",120.124,CDM,271,RC,,,,8377-MAIN,LOCAL,,,,,47,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,41.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.5238,46.06
"PAD CHAIR SENSOR 10x15"" 106380",120.124,CDM,271,RC,,,,8378-MAIN,LOCAL,,,,,47,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,41.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.5238,46.06
"Protein S, Free - Ref",PX8530690,CDM,300,RC,85306,CPT,90,,,,,,,47,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,41.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.05,46.06
REDUCER 12 - 8MM,27200000,CDM,272,RC,,,,11961-MAIN,LOCAL,,,,,47,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,41.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
benzoin Tincture 59 mL Bottle,25000000,CDM,250,RC,,,,,,49348080130,NDC,59,ML,45.93,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,41.84223,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Antinuclear Antibodiesana - Ref,PX8603890,CDM,300,RC,86038,CPT,90,,,,,,,43,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,41.8519,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.09,42.14
Blood Type Antigen Donor Ea,PX86902,CDM,300,RC,86902,CPT,,,,,,,,43,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,41.8519,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.8622,314.02
ETRAP POLYP TRAP,27200000,CDM,272,RC,,,,11282-MAIN,LOCAL,,,,,43,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,41.8519,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Smking Cess 4-10 Min,PX99406P,CDM,983,RC,99406,CPT,,,,,,,,43,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,41.8519,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.8622,41.8519
"Testosterone, Total - Ref",PX8440390,CDM,300,RC,84403,CPT,90,,,,,,,43,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,36.47,percent of total billed charges,41.8519,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.8622,42.14
Office/Outpt Visit Est Level I,PX99211F,CDM,510,RC,99211,CPT,,,,,,,,119,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,41.86,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.46,41.86
Office/Outpt Visit Est Level I,PX99211P,CDM,983,RC,99211,CPT,,,,,,,,119,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,41.86,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.46,116.62
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,45802095301,NDC,100,GR,82.76,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,41.87656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Chemotherapy, IV Infusion, Each Add'l Sequential Infusion",PX96417,CDM,335,RC,96417,CPT,,,,,,,,328,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,41.88,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.88,111.1
Dystrophic Nail Trimming Any Number,PXG0127F,CDM,940,RC,G0127,HCPCS,,,,,,,,53,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,41.88,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.58,41.88
Injection Hip Arthrogram,PX27093F,CDM,510,RC,27093,CPT,,,,,,,,654,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,41.88,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.66,477.34
"N Block Inj, Common Digit",PX64632F,CDM,510,RC,64632,CPT,,,,,,,,190,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,41.88,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.88,188.86
"N Block Inj, Common Digit",PX64632P,CDM,983,RC,64632,CPT,,,,,,,,128,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,41.88,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.88,188.86
"Trimming of Dystrophic Nails, Any Number",PXG0127P,CDM,983,RC,G0127,HCPCS,,,,,,,,35,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,41.88,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.58,41.88
"Chemotherapy, IV Infusion, Each Add'l Sequential Infusion",PX96417,CDM,335,RC,96417,CPT,,,,,,,,328,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,41.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.88,111.1
"Chemotherapy, IV Infusion, Each Add'l Sequential Infusion",PX96417,CDM,335,RC,96417,CPT,,,,,,,,328,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,41.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.88,111.1
DERMABOND ADVANCED TOPICAL SKIN ADHESIVE,120.198,CDM,272,RC,,,,9101-MAIN,LOCAL,,,,,46,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,41.906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.1084,45.08
Pinworm Exam,PX87172,CDM,300,RC,87172,CPT,,,,,,,,46,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,41.906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,45.08
promethazine 25 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802075930,NDC,0.5,EA,47.54,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,41.93028,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
promethazine 25 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,45802075900,NDC,0.5,EA,47.55,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,41.9391,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323018507,NDC,10,ML,43.09,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,41.939497,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
protamine 10 MG/ML Solution 5 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022994,NDC,5,ML,84.74,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,41.9463,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.431298,83.0452
BRACE KNEE LARGE SHORTRUNNER 21754,120.387,CDM,274,RC,L1833,HCPCS,,10044-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.9554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE MEDIUM SHORTRUNNER 21753,120.387,CDM,274,RC,L1833,HCPCS,,10126-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.9554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE SMALL SHORTRUNNER 21752,120.387,CDM,274,RC,L1833,HCPCS,,10900-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.9554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE X-LARGE SHORTRUNNER 21755,120.387,CDM,274,RC,L1833,HCPCS,,3444-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.9554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE XX-LARGE SHORTRUNNER 21756,120.387,CDM,274,RC,L1833,HCPCS,,10615-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.9554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
"COLLAR CERVICAL 2"" SMALL UNIVERSAL 08140039",120.249,CDM,274,RC,L0120,HCPCS,,270-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.9554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 2X20"" SMALL 1003-02",120.249,CDM,274,RC,L0120,HCPCS,,272-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.9554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 2X23.5"" MEDIUM XNARROW 1003-04",120.249,CDM,274,RC,L0120,HCPCS,,273-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.9554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 10-15"" SMALL XLONG 1005-06",120.249,CDM,274,RC,L0120,HCPCS,,267-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.9554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL LARGE 21.5""X5"" 1005-04",120.249,CDM,274,RC,L0120,HCPCS,,268-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.9554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL MEDIUM 20-1/2X4"" 1005-03",120.249,CDM,274,RC,L0120,HCPCS,,269-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.9554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
COLLAR CERVICAL SMALL 1005-02,120.249,CDM,274,RC,L0120,HCPCS,,266-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,41.9554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
tiotropium 18 MCG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,597007541,NDC,1,EA,82.92,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,41.95752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,25021012867,NDC,1,EA,82.96,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,41.97776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,55150020830,NDC,1,EA,82.96,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,41.97776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.461584,189.875
SCISSORS ENDOSCOPIC 5MM STANDARD STERILE,27200000,CDM,272,RC,,,,11706-MAIN,LOCAL,,,,,47.6,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,41.9832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
oseltamivir 75 MG capsule 10 Each Disp Pack,63700001,CDM,250,RC,,,,,,4080085,NDC,1,EA,97.87,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,41.98623,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039841,NDC,1,EA,43.14,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,11.23,percent of total billed charges,41.988162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
tolterodine ER 2 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,43975032203,NDC,1,EA,43.15,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,41.997895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,47781047013,NDC,1,EA,83,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,41.998,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,64380079901,NDC,1,EA,83,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,41.998,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,69238126601,NDC,1,EA,83,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,41.998,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SLING ARM CHILD PAD CANVAS NAVY 8004-02,120.54,CDM,273,RC,A4565,HCPCS,,878-MAIN,LOCAL,,,,,83,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,41.998,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM LARGE PAD CANVAS NAVY ORT11300L,120.54,CDM,273,RC,A4565,HCPCS,,870-MAIN,LOCAL,,,,,83,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,41.998,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM MEDIUM PAD CANVAS NAVY ORT11300M,120.54,CDM,273,RC,A4565,HCPCS,,872-MAIN,LOCAL,,,,,83,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,41.998,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM SMALL PAD CANVAS NAVY ORT11300S,120.54,CDM,273,RC,A4565,HCPCS,,874-MAIN,LOCAL,,,,,83,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,41.998,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM X-LARGE PAD ENVELOPE ORT11300XL,120.54,CDM,273,RC,A4565,HCPCS,,876-MAIN,LOCAL,,,,,83,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,41.998,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,574402435,NDC,3.5,GR,101.11,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,42.001094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001326,NDC,1,ML,42.88,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,42.0224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001341,NDC,1,ML,42.88,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,42.0224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
ampicillin 1 GM Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781926185,NDC,0.5,EA,43.18,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,42.027094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
"Cmv, Quant - Ref",PX8749790,CDM,300,RC,87497,CPT,90,,,,,,,194,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,42.0379,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.55,42.84
Hepatitis C Rna Quant,PX87522,CDM,300,RC,87522,CPT,,,,,,,,185,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,42.0379,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.55,42.84
Infec Agent Direct Probe - Ref,PX8779990,CDM,300,RC,87799,CPT,90,,,,,,,182,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,42.0379,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.91,42.84
BLADE LARYNGOSCOPE MAC #3 SINGLE USE350-005-000,120.121,CDM,272,RC,,,,8320-MAIN,LOCAL,,,,,98,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.042,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
BLADE LARYNGOSCOPE MAC #4 SINGLE USE 350-012-000,120.121,CDM,272,RC,,,,8321-MAIN,LOCAL,,,,,98,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.042,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
BLADE LARYNGOSCOPE MAC #X3 SINGLE USE X3-003-000,120.121,CDM,272,RC,,,,8322-MAIN,LOCAL,,,,,98,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.042,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
CANNULA JUNIOR 2 LARGE OPTIFLOW OJR416VT,120.561,CDM,272,RC,A4615,HCPCS,,12645-MAIN,LOCAL,,,,,98,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.042,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
CANNULA JUNIOR 2 MEDIUM OPTIFLOW OJR414VT,120.561,CDM,272,RC,A4615,HCPCS,,12644-MAIN,LOCAL,,,,,98,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.042,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
CANNULA OPTIFLOW JUNIOR 2 SMALL OJR412VT,120.561,CDM,272,RC,A4615,HCPCS,,12643-MAIN,LOCAL,,,,,98,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.042,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
Hepatitis B Surface Antigen,PX87340,CDM,300,RC,87340,CPT,,,,,,,,98,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.042,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.47,96.04
Ot Contracted Service/MCR,PX120.177,CDM,431,RC,,,,,,,,,,98,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.042,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
Pt Contracted Services/MCR,PX120.175,CDM,421,RC,,,,,,,,,,98,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.042,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
bicalutamide 50 MG Tablet 30 Each Bottle,25000000,CDM,250,RC,,,,,,16714081601,NDC,1,EA,98.01,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.04629,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Etoposide 100 MG/5ML Solution 5 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,16729011431,NDC,5,ML,43.21,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,42.056293,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.949434,169.8144
ceFAZolin in D4W 1 g / 50 mL 1-4 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0690.01,CDM,636,RC,J0690,HCPCS,,,,264310311,NDC,1,EA,84.97,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,42.06015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
amoxicillin 250 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,93415580,NDC,150,ML,43.22,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,42.066026,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rosuvastatin 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16714098801,NDC,1,EA,46.18,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,42.06998,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
X-Ray Exam Femur 1 Vw,PX7355101,CDM,320,RC,73551,CPT,TC,,,,,,,142,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,42.07,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.96,42.07
X-Ray Exam Femur 1 Vw,PX7355101,CDM,320,RC,73551,CPT,TC,,,,,,,142,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,42.07,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.96,42.07
Xray Elbow 2 Vws,PX7307001,CDM,320,RC,73070,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,42.07,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.96,42.07
Xray Elbow 2 Vws,PX7307001,CDM,320,RC,73070,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,42.07,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.96,42.07
Xray Foot 2 Vws,PX7362001,CDM,320,RC,73620,CPT,TC,,,,,,,367,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,42.07,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.74,42.07
Xray Foot 2 Vws,PX7362001,CDM,320,RC,73620,CPT,TC,,,,,,,367,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,42.07,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.74,42.07
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,61314062810,NDC,10,ML,98.07,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.07203,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Cognitive Funct Ther Interv, Initial 15 Min",PX97129,CDM,420,RC,97129,CPT,,,,,,,,85,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,42.075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15,83.3
"Exam,Synovial Fluid Crystals",PX89060,CDM,300,RC,89060,CPT,,,,,,,,85,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,42.075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.72,83.3
GLIDESCOPE QC MAC S3 SINGLE USE 0270-1083,120.579,CDM,272,RC,,,,13046-MAIN,LOCAL,,,,,85,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,42.075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.309,83.3
GLIDESCOPE QC MAC S3 SINGLE USE 0270-1085,120.579,CDM,272,RC,,,,13022-MAIN,LOCAL,,,,,85,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,42.075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.309,83.3
GLIDESCOPE QC MAC S4 SINGLE USE 0270-1086,120.579,CDM,272,RC,,,,13023-MAIN,LOCAL,,,,,85,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,42.075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.309,83.3
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218710,NDC,2,EA,5662.72,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,42.07836,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.98,43.16
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218713,NDC,2,EA,6875.36,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,42.07836,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.98,43.16
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028442,NDC,1,EA,47.71,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,42.08022,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Box,25000000,CDM,250,RC,,,,,,67434509,NDC,1,EA,98.1,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.0849,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium bicarbonate 8.4 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409662522,NDC,50,ML,85.02,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,42.0849,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Bone Marrow Aspiration(S),Diag",PX38220F,CDM,510,RC,38220,CPT,,,,,,,,305,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,42.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.1,326.53
"Bone Marrow Aspiration(S),Diag",PX38220F,CDM,510,RC,38220,CPT,,,,,,,,305,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,42.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.1,326.53
"Bone Marrow Aspiration(S),Diag",PX38220P,CDM,983,RC,38220,CPT,,,,,,,,244,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,42.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.1,326.53
"Bone Marrow Aspiration(S),Diag",PX38220P,CDM,983,RC,38220,CPT,,,,,,,,244,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,42.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.1,326.53
Surg Pathology-Level 2-Tc,PX3932,CDM,310,RC,88302,CPT,TC,,,,,,,66,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,42.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.41,43.344
Surg Pathology-Level 2-Tc,PX3932,CDM,310,RC,88302,CPT,TC,,,,,,,66,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,42.1,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.41,43.344
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143998391,NDC,1,EA,83.25,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,42.1245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049237,NDC,30,ML,87.77,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,42.1296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049237,NDC,30,ML,87.77,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,42.1296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Sars-Cov-2 Covid-19 Antibody,PX86769,CDM,300,RC,86769,CPT,,,,,,,,340,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,42.13,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.87,42.13
Sars-Cov-2 Covid-19 Antibody,PX86769,CDM,300,RC,86769,CPT,,,,,,,,340,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,42.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.87,42.13
Sars-Cov-2 Covid-19 Antibody,PX86769,CDM,300,RC,86769,CPT,,,,,,,,340,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,42.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.87,42.13
Sars-Cov-2 Covid-19 Antibody,PX8676990,CDM,300,RC,86769,CPT,90,,,,,,,100,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,42.13,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.87,42.13
Sars-Cov-2 Covid-19 Antibody,PX8676990,CDM,300,RC,86769,CPT,90,,,,,,,100,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,42.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.87,42.13
Sars-Cov-2 Covid-19 Antibody,PX8676990,CDM,300,RC,86769,CPT,90,,,,,,,100,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,42.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.87,42.13
fentaNYL 25 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,47781042411,NDC,1,EA,101.44,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,42.138176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Aldosterone - Ref,PX8208890,CDM,300,RC,82088,CPT,90,,,,,,,86,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,42.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.7244,84.28
Aldosterone - Ref,PX8208890,CDM,300,RC,82088,CPT,90,,,,,,,86,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,42.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.7244,84.28
Aldosterone - Ref,PX8208890,CDM,300,RC,82088,CPT,90,,,,,,,86,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,42.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.7244,84.28
Antinuclear Antibodiesana - Ref,PX8603890,CDM,300,RC,86038,CPT,90,,,,,,,43,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,42.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.09,42.14
Blood Type Antigen Donor Ea,PX86902,CDM,300,RC,86902,CPT,,,,,,,,43,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,42.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.8622,314.02
Epstein-barr antibody,PX86665,CDM,300,RC,86665,CPT,,,,,,,,86,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,42.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.63,84.28
Epstein-barr antibody,PX86665,CDM,300,RC,86665,CPT,,,,,,,,86,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,42.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.63,84.28
Epstein-barr antibody,PX86665,CDM,300,RC,86665,CPT,,,,,,,,86,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,42.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.63,84.28
ETRAP POLYP TRAP,27200000,CDM,272,RC,,,,11282-MAIN,LOCAL,,,,,43,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,42.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Smking Cess 4-10 Min,PX99406P,CDM,983,RC,99406,CPT,,,,,,,,43,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,42.14,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.2,42.14
"Testosterone, Total - Ref",PX8440390,CDM,300,RC,84403,CPT,90,,,,,,,43,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,42.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.8622,42.14
fentaNYL 25 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505700600,NDC,1,EA,101.46,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,42.146484,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SAWBLADE SAGITAL STERILE 25MM LENGTH 5.5MM WIDTH 0.60MM THICKNESS,27200000,CDM,272,RC,,,,11623-MAIN,LOCAL,,,,,86.02,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,42.1498,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SAWBLADE SAGITAL STERILE 25MM LENGTH 5.5MM WIDTH 0.60MM THICKNESS,27200000,CDM,272,RC,,,,11623-MAIN,LOCAL,,,,,86.02,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,42.1498,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SAWBLADE SAGITAL STERILE 25MM LENGTH 5.5MM WIDTH 0.60MM THICKNESS,27200000,CDM,272,RC,,,,11623-MAIN,LOCAL,,,,,86.02,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,42.1498,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"CUFF STERILE DISPOSABLE SPSB 12""",27200000,CDM,272,RC,,,,7435-MAIN,LOCAL,,,,,43.31,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,42.153623,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
penicillin v potassium 250 MG/5ML Recon Soln 200 mL Bottle,63700001,CDM,250,RC,,,,,,93412774,NDC,200,ML,83.32,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,42.15992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
perflutren lipid microsphere 6.52 MG/ML Suspension 2 mL Vial,Q9957,CDM,636,RC,Q9957,HCPCS,,,,11994001101,NDC,2,ML,751.71,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,42.16,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.16,48.69
perflutren protein A microsphere Suspension 3 mL Vial,Q9956,CDM,636,RC,Q9956,HCPCS,,,,407270703,NDC,3,ML,739.41,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,42.16,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.56,43.68686
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323018507,NDC,10,ML,43.09,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,42.2282,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490311,NDC,5,ML,43.39,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,42.231487,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
POSITIONING KIT TRENDELENBURG NUBLUE TP 3000-NB,27100000,CDM,271,RC,,,,12992-MAIN,LOCAL,,,,,88,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,42.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
POSITIONING KIT TRENDELENBURG NUBLUE TP 3000-NB,27100000,CDM,271,RC,,,,12992-MAIN,LOCAL,,,,,88,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,42.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
SPLINT ANKLE GEL BRACE UNIVERSAL AIRFORM 70351,120.61,CDM,274,RC,L4350,HCPCS,,12342-MAIN,LOCAL,,,,,88,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,42.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.5552,104.38
SPLINT ANKLE GEL BRACE UNIVERSAL AIRFORM 70351,120.61,CDM,274,RC,L4350,HCPCS,,12342-MAIN,LOCAL,,,,,88,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,42.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.5552,104.38
SUCTION IRRIGATOR 2 0250070500,27200000,CDM,272,RC,,,,12262-MAIN,LOCAL,,,,,88,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,42.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUCTION IRRIGATOR 2 0250070500,27200000,CDM,272,RC,,,,12262-MAIN,LOCAL,,,,,88,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,42.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Dimethicone 1.5 % Cream 118 mL Tube,800000,CDM,,,,,,,,53329016104,NDC,118,ML,43.4,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,42.24122,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
TRAY IV SURGICAL EXTREMITY DYNJS0804,27200000,CDM,272,RC,,,,10919-MAIN,LOCAL,,,,,83.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,42.251,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036019,NDC,10,ML,86.23,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.141,percent of total billed charges,42.2527,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,84.5054
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036019,NDC,10,ML,86.23,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,42.2527,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,84.5054
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036019,NDC,10,ML,86.23,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,42.2527,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,84.5054
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001002,NDC,2,ML,43.42,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,42.260686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,42.5516
dextrose 25% Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409177510,NDC,10,ML,83.53,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,42.26618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039841,NDC,1,EA,43.14,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,42.2772,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
leflunomide 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,62332006130,NDC,1,EA,88.09,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,42.2832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
leflunomide 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,62332006130,NDC,1,EA,88.09,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,42.2832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rivaroxaban 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50458058030,NDC,1,EA,98.57,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.28653,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tolterodine ER 2 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,43975032203,NDC,1,EA,43.15,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,42.287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409339004,NDC,1,EA,98.61,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.30369,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
promethazine 25 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802075930,NDC,0.5,EA,47.54,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,42.3106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ampicillin 1 GM Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781926185,NDC,0.5,EA,43.18,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,42.3164,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
promethazine 25 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,45802075900,NDC,0.5,EA,47.55,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,42.3195,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Bone Marrow Aspiration(S),Diag",PX38220F,CDM,510,RC,38220,CPT,,,,,,,,305,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,42.32,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.1,326.53
"Bone Marrow Aspiration(S),Diag",PX38220P,CDM,983,RC,38220,CPT,,,,,,,,244,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,42.32,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.1,326.53
Tap Block Bilateral by Injection(S),PX64488F,CDM,510,RC,64488,CPT,,,,,,,,393,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,42.32,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.32,285.02
Tap Block Bilateral by Injection(S),PX64488F,CDM,510,RC,64488,CPT,,,,,,,,393,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,42.32,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.32,285.02
Tap Block Bilateral by Injection(S),PX64488F,CDM,510,RC,64488,CPT,,,,,,,,393,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,42.32,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.32,285.02
Tap Block Bilateral by Injection(S),PX64488P,CDM,983,RC,64488,CPT,,,,,,,,262,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,42.32,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.32,285.02
Tap Block Bilateral by Injection(S),PX64488P,CDM,983,RC,64488,CPT,,,,,,,,262,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,42.32,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.32,285.02
Tap Block Bilateral by Injection(S),PX64488P,CDM,983,RC,64488,CPT,,,,,,,,262,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,42.32,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.32,285.02
"Admin Hep B,Adult 19+",PX3242,CDM,771,RC,90471,CPT,,,,,,,,48,,United Healthcare,All Payer,outpatient,88.2,,89.69,percent of total billed charges,42.336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,61.54
Amphetamines; 3 or 4,PX8032590,CDM,300,RC,80325,CPT,90,,,,,,,48,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,42.336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,47.04
Immunization Admin - Influenza,PX3241,CDM,771,RC,90471,CPT,,,,,,,,48,,United Healthcare,All Payer,outpatient,88.2,,89.69,percent of total billed charges,42.336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,61.54
Immunization Administration; Each Add'l Vaccine (Single or Combo Vaccine/T*,PX90472,CDM,771,RC,90472,CPT,,,,,,,,48,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,42.336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,47.04
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615704,NDC,1,EA,101.92,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,42.337568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
dextrose 5 % 5 % Solution 50 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338055111,NDC,50,ML,43.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,42.33855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 100 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001748,NDC,100,ML,43.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,42.33855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,264763500,NDC,1000,ML,43.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,4.559571429,percent of total billed charges,42.33855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5% lactated ringers 5 % Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012504,NDC,1000,ML,43.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,51.5301,percent of total billed charges,42.33855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329330201,NDC,25,ML,43.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,42.33855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9 % 0.9 % Solution 50 mL Flex Cont,J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004941,NDC,50,ML,43.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,26.00411043,percent of total billed charges,42.33855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004941,NDC,250,ML,43.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,47.90196078,percent of total billed charges,42.33855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055311,NDC,250,ML,43.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,47.90196078,percent of total billed charges,42.33855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004948,NDC,300,ML,43.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,47.90196078,percent of total billed charges,42.33855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055318,NDC,300,ML,43.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,47.90196078,percent of total billed charges,42.33855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 150 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,409798361,NDC,300,ML,43.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,47.90196078,percent of total billed charges,42.33855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9% irrigation 0.9 % Solution 3,000 mL Plas Cont",25000000,CDM,250,RC,,,,,,338004727,NDC,3000,ML,43.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,42.33855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9% IV LINE FLUSH 0.9% Solution 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,338004948,NDC,100,ML,43.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,42.33855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041100,NDC,0.5,ML,196.94,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,42.34,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.48078,42.34
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041105,NDC,1,ML,419.67,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,42.34,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.48078,42.34
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041110,NDC,0.5,ML,196.94,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,42.34,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.48078,42.34
leucovorin 350 MG Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,703514501,NDC,1,EA,86.41,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,42.3409,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.670002,84.6818
leucovorin 350 MG Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,703514501,NDC,1,EA,86.41,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,42.3409,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.670002,84.6818
leucovorin 350 MG Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,703514501,NDC,1,EA,86.41,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,42.3409,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.670002,84.6818
hydrOXYzine 50 MG/ML Solution 1 mL Vial,J3410.01,CDM,636,RC,J3410,HCPCS,,,,517560125,NDC,0.5,ML,83.68,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,42.34208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.760672,82.0064
Etoposide 100 MG/5ML Solution 5 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,16729011431,NDC,5,ML,43.21,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,42.3458,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.949434,169.8144
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061400,NDC,1,ML,101.95,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,42.35003,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.114178,99.911
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615700,NDC,1,EA,101.95,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,42.35003,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
amoxicillin 250 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,93415580,NDC,150,ML,43.22,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,42.3556,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SCISSORS ENDOSCOPIC 5MM STANDARD STERILE,27200000,CDM,272,RC,,,,11706-MAIN,LOCAL,,,,,47.6,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,42.364,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Concurrent Infusion,PX96368,CDM,260,RC,96368,CPT,,,,,,,,102,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,42.3708,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.3708,99.96
Immunohisto Antibody Slide Ea Addl,PX8834101,CDM,310,RC,88341,CPT,TC,,,,,,,102,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,42.3708,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.3708,99.96
Reptilase Test - Ref,PX8563590,CDM,300,RC,85635,CPT,90,,,,,,,102,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,42.3708,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.03,99.96
empagliflozin 25 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,597015330,NDC,0.4,EA,43.54,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,42.377482,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
empagliflozin 25 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,597015337,NDC,0.4,EA,43.54,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,42.377482,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"lidocaine 2% -EPINEPHRine 1:200,000 2 %-1:200000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409318301,NDC,20,ML,49.86,,First Health,Commercial,both,85,,999999999,percent of total billed charges,42.381,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Package,25000000,CDM,250,RC,,,,,,66758020858,NDC,1,EA,102.08,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,42.404032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004722,NDC,2,ML,88.35,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,42.408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004722,NDC,2,ML,88.35,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,42.408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001481,NDC,1,EA,102.12,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,42.420648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
ondansetron 4 MG/5ML Solution 50 mL Bottle,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714067102,NDC,5,ML,98.91,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.43239,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
"CUFF STERILE DISPOSABLE SPSB 12""",27200000,CDM,272,RC,,,,7435-MAIN,LOCAL,,,,,43.31,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,42.4438,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
silver sulfADIAZINE 1 % Cream 50 g Jar,25000000,CDM,250,RC,,,,,,43598021055,NDC,50,GR,83.89,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,42.44834,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028442,NDC,1,EA,47.71,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,42.4619,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270004,NDC,100,ML,2827.78,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,42.4644,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.85,44.15
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270010,NDC,100,ML,3458.14,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,42.4644,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.85,44.15
immune globulin (Human) 10 GM/100ML Solution 100 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270005,NDC,100,ML,2827.78,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,42.4644,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.85,44.15
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270006,NDC,100,ML,2912.78,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,42.4644,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.85,44.15
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270012,NDC,100,ML,3293.58,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,42.4644,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.85,44.15
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270007,NDC,100,ML,2827.78,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,42.4644,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.85,44.15
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270013,NDC,100,ML,2827.78,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,42.4644,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.85,44.15
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,23155029031,NDC,2,ML,98.99,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.46671,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,97.0102
"Clostridium Ag, Eia",PX87324,CDM,300,RC,87324,CPT,,,,,,,,99,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.471,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,97.02
Deoxyribonuclease Ab,PX86215,CDM,300,RC,86215,CPT,,,,,,,,99,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.471,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,97.02
"Extractable Nuclear Antigen, Each Antigen",PX86235,CDM,300,RC,86235,CPT,90,,,,,,,99,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.471,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.44,97.02
"Fungus Antibody, Nos - Ref",PX8667190,CDM,300,RC,86671,CPT,90,,,,,,,99,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.471,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.23,97.02
"Lab Immunoassay, Non Antibody",PX83516,CDM,300,RC,83516,CPT,,,,,,,,99,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.471,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.57,97.02
"Protozoa Antibody, Nos - Ref",PX8675390,CDM,300,RC,86753,CPT,90,,,,,,,99,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.471,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.36,97.02
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665305,NDC,20,ML,49.97,,First Health,Commercial,both,85,,999999999,percent of total billed charges,42.4745,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,409163221,NDC,0.5,EA,43.65,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,42.484545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ERBEFLO CLEVERCAP CO2 TUBING CAP SET,27200000,CDM,272,RC,,,,11831-MAIN,LOCAL,,,,,50,,First Health,Commercial,both,85,,999999999,percent of total billed charges,42.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
G6pd; Quant Screen - Ref,PX8295590,CDM,300,RC,82955,CPT,90,,,,,,,50,,First Health,Commercial,both,85,,999999999,percent of total billed charges,42.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.89,49
"Homogenization, Tissue for Culture",PX87176,CDM,300,RC,87176,CPT,,,,,,,,50,,First Health,Commercial,both,85,,999999999,percent of total billed charges,42.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.39,49
"NEEDLE ASP 16GX3/16"" 1-7/8"" ILLINOIS STERNAL 8881245164",120.8,CDM,272,RC,G0364,HCPCS,,5730-MAIN,LOCAL,,,,,50,,First Health,Commercial,both,85,,999999999,percent of total billed charges,42.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,49
"NEEDLE BONE MARROW 8G X 4"" BIOPSY/ASPIRATION 8881247087",120.8,CDM,272,RC,G0364,HCPCS,,166-MAIN,LOCAL,,,,,50,,First Health,Commercial,both,85,,999999999,percent of total billed charges,42.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,49
"NEEDLE BONE MARROW 11G X 4"" 8881247111",120.8,CDM,272,RC,G0364,HCPCS,,162-MAIN,LOCAL,,,,,50,,First Health,Commercial,both,85,,999999999,percent of total billed charges,42.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,49
Potassium; Urine,PX84133,CDM,300,RC,84133,CPT,,,,,,,,50,,First Health,Commercial,both,85,,999999999,percent of total billed charges,42.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.34,49
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066500,NDC,0.25,ML,48.19,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,42.50358,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.000396,47.2262
CANNULA OPTIFLOW JUNIOR2+ XXL OJR520,120.494,CDM,271,RC,A4615,HCPCS,,11619-MAIN,LOCAL,,,,,84,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,42.504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.8936,82.32
Hiaa - Ref,PX8349790,CDM,300,RC,83497,CPT,90,,,,,,,84,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,42.504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.83,82.32
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505615204,NDC,0.5,EA,86.76,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,9.983703704,percent of total billed charges,42.5124,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505615204,NDC,0.5,EA,86.76,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,42.5124,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505615204,NDC,0.5,EA,86.76,,United Healthcare,All Medicare advantage plans,outpatient,49,,3.9675,percent of total billed charges,42.5124,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
methylPREDNISolone sod succ 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,63323025803,NDC,0.4,EA,46.67,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,42.51637,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490311,NDC,5,ML,43.39,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,42.5222,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
"dextrose 5 % 5 % Solution 1,000 mL Flex Cont",J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001704,NDC,1000,ML,99.12,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.52248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001702,NDC,250,ML,99.12,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.52248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338634602,NDC,250,ML,99.12,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.52248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 500 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001703,NDC,500,ML,99.12,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.52248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % Non-DEHP bag 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,264751020,NDC,250,ML,99.12,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.52248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"dextrose 5% and sodium chloride 0.2% 5-0.2 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338007704,NDC,1000,ML,99.12,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.52248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
"dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008904,NDC,1000,ML,99.12,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.52248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 500 mL Flex Cont,J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008903,NDC,500,ML,99.12,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.52248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
"dextrose 5% and sodium chloride 0.45% 5-0.45 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008504,NDC,1000,ML,99.12,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.52248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
dextrose 5% lactated ringers 5 % Solution 500 mL Flex Cont,J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012503,NDC,500,ML,99.12,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.52248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 10% 10 % Solution 500 mL Flex Cont,25000000,CDM,250,RC,,,,,,338002303,NDC,500,ML,99.12,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.52248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lactated ringers Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338011704,NDC,1000,ML,99.12,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.52248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338069104,NDC,1000,ML,99.12,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.52248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004904,NDC,1000,ML,99.12,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.52248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954306,NDC,1000,ML,99.12,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.52248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004902,NDC,250,ML,99.12,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.52248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954302,NDC,250,ML,99.12,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.52248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 500 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004903,NDC,500,ML,99.12,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.52248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9% 0.9% Solution 1,000 mL Flex Cont",J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004904,NDC,1000,ML,99.12,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.52248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9% IV LINE FLUSH 0.9% Solution 250 mL Flex Cont,25000000,CDM,250,RC,,,,,,338004902,NDC,250,ML,99.12,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.52248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"sodium chloride 0.45 % 0.45 % Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,338004304,NDC,1000,ML,99.12,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.52248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 3 % 3 % Solution 500 mL Flex Cont,J7131.01,CDM,636,RC,J7131,HCPCS,,,,338005403,NDC,500,ML,99.12,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.52248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001302,NDC,2,ML,86.79,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,42.5271,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001302,NDC,2,ML,86.79,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,42.5271,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001302,NDC,2,ML,86.79,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,42.5271,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
Dimethicone 1.5 % Cream 118 mL Tube,800000,CDM,,,,,,,,53329016104,NDC,118,ML,43.4,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,42.532,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
"N Block Inj, Common Digit",PX64632F,CDM,510,RC,64632,CPT,,,,,,,,190,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,42.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.88,188.86
"N Block Inj, Common Digit",PX64632F,CDM,510,RC,64632,CPT,,,,,,,,190,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,42.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.88,188.86
"N Block Inj, Common Digit",PX64632P,CDM,983,RC,64632,CPT,,,,,,,,128,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,42.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.88,188.86
"N Block Inj, Common Digit",PX64632P,CDM,983,RC,64632,CPT,,,,,,,,128,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,42.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.88,188.86
prasugrel 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862083030,NDC,1,EA,88.64,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,42.5472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prasugrel 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862083030,NDC,1,EA,88.64,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,42.5472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001002,NDC,2,ML,43.42,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,42.5516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,42.5516
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665318,NDC,20,ML,50.08,,First Health,Commercial,both,85,,999999999,percent of total billed charges,42.568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
sterile water (preservative free) Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323018520,NDC,20,ML,50.08,,First Health,Commercial,both,85,,999999999,percent of total billed charges,42.568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Aldosterone - Ref,PX8208890,CDM,300,RC,82088,CPT,90,,,,,,,86,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,42.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.7244,84.28
Epstein-barr antibody,PX86665,CDM,300,RC,86665,CPT,,,,,,,,86,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,42.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.63,84.28
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010269,NDC,1,EA,88.69,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,42.5712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010269,NDC,1,EA,88.69,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,42.5712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010299,NDC,1,EA,88.69,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,42.5712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010299,NDC,1,EA,88.69,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,42.5712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614201,NDC,1,ML,88.69,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,42.5712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.097864,86.9162
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614201,NDC,1,ML,88.69,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,42.5712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.097864,86.9162
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614225,NDC,1,ML,88.69,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,42.5712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.097864,86.9162
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614225,NDC,1,ML,88.69,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,42.5712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.097864,86.9162
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963801,NDC,0.5,ML,88.69,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,42.5712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963801,NDC,0.5,ML,88.69,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,42.5712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
infuvite adult Injectable 10 mL Vial,J3490.99,CDM,636,RC,J3490,HCPCS,,,,54643564901,NDC,10,ML,86.89,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,12.9192,percent of total billed charges,42.5761,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.094106,85.1522
infuvite adult Injectable 10 mL Vial,J3490.99,CDM,636,RC,J3490,HCPCS,,,,54643564901,NDC,10,ML,86.89,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,42.5761,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.094106,85.1522
infuvite adult Injectable 10 mL Vial,J3490.99,CDM,636,RC,J3490,HCPCS,,,,54643564901,NDC,10,ML,86.89,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,42.5761,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.094106,85.1522
SAWBLADE SAGITAL STERILE 25MM LENGTH 5.5MM WIDTH 0.60MM THICKNESS,27200000,CDM,272,RC,,,,11623-MAIN,LOCAL,,,,,86.02,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,42.5799,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SAW BLADE 300 SAGITTAL 25X9.4X0.7,27200000,CDM,272,RC,,,,11592-MAIN,LOCAL,,,,,46.75,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,42.58925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SAW BLADE 300 SAGITTAL 40X14X0.6MM,27200000,CDM,272,RC,,,,11591-MAIN,LOCAL,,,,,46.75,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,42.58925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
levothyroxine 100 MCG/5ML Solution 5 mL Vial,J0651.01,CDM,636,RC,J0651,HCPCS,,,,63323088510,NDC,0.625,ML,99.32,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.60828,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.257528,97.3336
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026969,NDC,100,ML,99.34,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.61686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
artificial tears Ointment 3.5 g Tube,63700001,CDM,250,RC,,,,,,10119002239,NDC,3.5,GR,50.14,,First Health,Commercial,both,85,,999999999,percent of total billed charges,42.619,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Chemotherapy, IV Push, Additional Drug",PX96411,CDM,335,RC,96411,CPT,,,,,,,,87,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,42.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.1398,85.26
"Chemotherapy, IV Push, Additional Drug",PX96411,CDM,335,RC,96411,CPT,,,,,,,,87,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,42.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.1398,85.26
"Chemotherapy, IV Push, Additional Drug",PX96411,CDM,335,RC,96411,CPT,,,,,,,,87,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,42.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.1398,85.26
dextrose 5 % 5 % Solution 50 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338055111,NDC,50,ML,43.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,42.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 100 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001748,NDC,100,ML,43.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,42.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,264763500,NDC,1000,ML,43.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,42.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5% lactated ringers 5 % Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012504,NDC,1000,ML,43.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,42.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329330201,NDC,25,ML,43.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,42.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9 % 0.9 % Solution 50 mL Flex Cont,J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004941,NDC,50,ML,43.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,42.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004941,NDC,250,ML,43.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,42.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055311,NDC,250,ML,43.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,42.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004948,NDC,300,ML,43.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,42.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055318,NDC,300,ML,43.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,42.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 150 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,409798361,NDC,300,ML,43.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,42.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9% irrigation 0.9 % Solution 3,000 mL Plas Cont",25000000,CDM,250,RC,,,,,,338004727,NDC,3000,ML,43.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,42.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9% IV LINE FLUSH 0.9% Solution 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,338004948,NDC,100,ML,43.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,42.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
oxytocin 10 UNIT/ML Solution 1 mL Vial,J2590.01,CDM,636,RC,J2590,HCPCS,,,,42023011625,NDC,1,ML,43.8,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,42.63054,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.19452,42.924
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098321,NDC,1,EA,99.39,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.63831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098323,NDC,1,EA,99.39,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.63831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052200,NDC,1,EA,99.39,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.63831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052237,NDC,1,EA,99.39,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.63831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331801,NDC,10,ML,102.65,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,42.64081,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,25021010720,NDC,1,EA,48.35,,United Healthcare,All Payer,outpatient,88.2,,201.07,percent of total billed charges,42.6447,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329334001,NDC,10,ML,88.88,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,42.6624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329334001,NDC,10,ML,88.88,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,42.6624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
empagliflozin 25 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,597015330,NDC,0.4,EA,43.54,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,42.6692,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
empagliflozin 25 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,597015337,NDC,0.4,EA,43.54,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,42.6692,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Ig Paraprotein Qual Bld/UR,PX0077U90,CDM,300,RC,0077U,HCPCS,90,,,,,,,66,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,42.6797,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.6797,43.43
Ig Paraprotein Qual Bld/UR,PX0077U90,CDM,300,RC,0077U,HCPCS,90,,,,,,,66,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,42.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.6797,43.43
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036019,NDC,10,ML,86.23,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,42.68385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,84.5054
"Admin Hep B,Adult 19+",PX3242,CDM,771,RC,90471,CPT,,,,,,,,48,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,42.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,61.54
Aldolase - Ref,PX8208590,CDM,300,RC,82085,CPT,90,,,,,,,89,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,42.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.9,87.22
Aldolase - Ref,PX8208590,CDM,300,RC,82085,CPT,90,,,,,,,89,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,42.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.9,87.22
Amphetamines; 3 or 4,PX8032590,CDM,300,RC,80325,CPT,90,,,,,,,48,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,42.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,47.04
Assay of Ggt,PX82977,CDM,300,RC,82977,CPT,,,,,,,,89,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,42.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6,87.22
Assay of Ggt,PX82977,CDM,300,RC,82977,CPT,,,,,,,,89,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,42.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6,87.22
"Debridement of Nail(S), 1-5",PX11720F,CDM,510,RC,11720,CPT,,,,,,,,89,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,42.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.9706,87.22
"Debridement of Nail(S), 1-5",PX11720F,CDM,510,RC,11720,CPT,,,,,,,,89,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,42.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.9706,87.22
"Hla a, B or C, Single Ag - Ref",PX8681290,CDM,300,RC,86812,CPT,90,,,,,,,89,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,42.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.67,87.22
"Hla a, B or C, Single Ag - Ref",PX8681290,CDM,300,RC,86812,CPT,90,,,,,,,89,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,42.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.67,87.22
Immunization Admin - Influenza,PX3241,CDM,771,RC,90471,CPT,,,,,,,,48,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,42.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,61.54
Immunization Administration; Each Add'l Vaccine (Single or Combo Vaccine/T*,PX90472,CDM,771,RC,90472,CPT,,,,,,,,48,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,42.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,47.04
KIT INTRODUCER 8.5FR AK-09803-CDC,120.128,CDM,272,RC,,,,8826-MAIN,LOCAL,,,,,89,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,42.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.9706,87.22
KIT INTRODUCER 8.5FR AK-09803-CDC,120.128,CDM,272,RC,,,,8826-MAIN,LOCAL,,,,,89,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,42.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.9706,87.22
lidocaine 5 % Patch 1 Each Box,63700001,CDM,250,RC,,,,,,591352511,NDC,1,EA,50.26,,First Health,Commercial,both,85,,999999999,percent of total billed charges,42.721,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 5 % Patch 30 Each Box,63700001,CDM,250,RC,,,,,,591352530,NDC,1,EA,50.26,,First Health,Commercial,both,85,,999999999,percent of total billed charges,42.721,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALEXIS 0 LARGE STERILE,27200000,CDM,272,RC,,,,11765-MAIN,LOCAL,,,,,102.85,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,42.72389,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
X-Ray Exam Abdomen 1 View,PX7401801,CDM,320,RC,74018,CPT,TC,,,,,,,358,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,42.73,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.96,42.73
X-Ray Exam Abdomen 1 View,PX7401801,CDM,320,RC,74018,CPT,TC,,,,,,,358,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,42.73,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.96,42.73
Xray Forearm 2 Vws,PX7309001,CDM,320,RC,73090,CPT,TC,,,,,,,364,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,42.73,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.18,42.73
Xray Forearm 2 Vws,PX7309001,CDM,320,RC,73090,CPT,TC,,,,,,,364,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,42.73,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.18,42.73
timolol 0.25 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314022605,NDC,5,ML,84.45,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,42.7317,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,70860030143,NDC,25,ML,84.47,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,42.74182,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010626,NDC,50,ML,84.47,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,42.74182,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
sodium bicarbonate 8.4 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409662502,NDC,50,ML,84.47,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,42.74182,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sulfamethoxazole-trimethoprim 400-80 MG/5ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,703951403,NDC,10,ML,102.93,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,42.757122,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
leucovorin 350 MG Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,703514501,NDC,1,EA,86.41,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,42.77295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.670002,84.6818
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,409163221,NDC,0.5,EA,43.65,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,42.777,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Assay of Transferrin,PX84466,CDM,300,RC,84466,CPT,,,,,,,,103,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,42.7862,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.7,100.94
"Lactoferrin, Fecal; Qual",PX83630,CDM,300,RC,83630,CPT,,,,,,,,103,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,42.7862,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.06,100.94
"Molecyto Insitu, 100-300cl - Ref",PX8827590,CDM,310,RC,88275,CPT,90,,,,,,,103,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,42.7862,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.7862,100.94
"Tiss Cult,Non-Neop Lymph - Ref",PX8823090,CDM,310,RC,88230,CPT,90,,,,,,,103,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,42.7862,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.7862,106.81
Apply Forearm Cast,PX29075F,CDM,510,RC,29075,CPT,,,,,,,,210,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,42.8,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.83,186.09
Apply Forearm Cast,PX29075P,CDM,983,RC,29075,CPT,,,,,,,,140,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,42.8,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.83,186.09
nafcillin 1 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,55150012215,NDC,1,EA,89.17,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,42.8016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
nafcillin 1 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,55150012215,NDC,1,EA,89.17,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,42.8016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,409469930,NDC,20,ML,48.54,,United Healthcare,All Payer,outpatient,88.2,,1.151420557,percent of total billed charges,42.81228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
Blood Count Reticulocytes Auto 1/> Cell Meas,PX85046,CDM,300,RC,85046,CPT,,,,,,,,47,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,42.817,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.11,46.06
"PAD BED SENSOR 10X28"" P-107517",120.124,CDM,271,RC,,,,8377-MAIN,LOCAL,,,,,47,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,42.817,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.5238,46.06
"PAD CHAIR SENSOR 10x15"" 106380",120.124,CDM,271,RC,,,,8378-MAIN,LOCAL,,,,,47,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,42.817,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.5238,46.06
"Protein S, Free - Ref",PX8530690,CDM,300,RC,85306,CPT,90,,,,,,,47,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,42.817,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.05,46.06
REDUCER 12 - 8MM,27200000,CDM,272,RC,,,,11961-MAIN,LOCAL,,,,,47,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,42.817,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CANNULA ADULT LARGE OPTIFLOW OPT946,120.495,CDM,271,RC,A4615,HCPCS,,11622-MAIN,LOCAL,,,,,44,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,42.8252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
CANNULA ADULT MEDIUM OPTIFLOW OPT944,120.495,CDM,271,RC,A4615,HCPCS,,11621-MAIN,LOCAL,,,,,44,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,42.8252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
CANNULA ADULT SMALL OPTIFLOW OPT942,120.495,CDM,271,RC,A4615,HCPCS,,11620-MAIN,LOCAL,,,,,44,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,42.8252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
Homocysteine,PX83090,CDM,300,RC,83090,CPT,,,,,,,,44,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,42.8252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.43,43.12
KIT GASTRIC LAVAGE 2075,120.257,CDM,272,RC,C7510,HCPCS,,410-MAIN,LOCAL,,,,,44,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,42.8252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
SUTURE V-LOC 1/2 CIRCLE NEEDLE WOUND CLOSURE DEVICE VLOCN0306,27200000,CDM,272,RC,,,,11931-MAIN,LOCAL,,,,,44,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,42.8252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE V-LOC SZ 3-0 180 GREEN V-20 9 INCH VLOCL0644,27200000,CDM,272,RC,,,,13056-SURG,LOCAL,,,,,44,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,42.8252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Cmv, Quant - Ref",PX8749790,CDM,300,RC,87497,CPT,90,,,,,,,194,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,42.84,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.55,42.84
Hepatitis C Rna Quant,PX87522,CDM,300,RC,87522,CPT,,,,,,,,185,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,42.84,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.55,42.84
Infec Agent Direct Probe - Ref,PX8779990,CDM,300,RC,87799,CPT,90,,,,,,,182,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,42.84,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.91,42.84
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218710,NDC,2,EA,5662.72,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,42.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.98,43.16
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218710,NDC,2,EA,5662.72,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,42.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.98,43.16
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218713,NDC,2,EA,6875.36,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,42.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.98,43.16
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218713,NDC,2,EA,6875.36,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,42.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.98,43.16
perflutren lipid microsphere 6.52 MG/ML Suspension 2 mL Vial,Q9957,CDM,636,RC,Q9957,HCPCS,,,,11994001101,NDC,2,ML,751.71,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,42.85,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.16,48.69
DOPamine 1600 mcg/mL in dextrose 5% 250 mL premix 1600 mcg/mL Solution 250 mL Plas Cont,J1265.01,CDM,636,RC,J1265,HCPCS,,,,338100702,NDC,250,ML,99.9,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.8571,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.49846,97.902
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927380,NDC,1,EA,99.91,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.86139,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927395,NDC,1,EA,99.91,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.86139,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
lidocaine 0.5 % PF 0.5 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323049101,NDC,50,ML,103.2,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,42.86928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,63323041536,NDC,0.5,ML,44.05,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,42.873865,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
protamine 10 MG/ML Solution 5 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022994,NDC,5,ML,84.74,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,42.87844,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.431298,83.0452
lidocaine (preservative free) 4 % Solution 5 mL Ampule,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409428325,NDC,5,ML,48.62,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,42.88284,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066500,NDC,0.25,ML,48.19,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,42.8891,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.000396,47.2262
gadoteridol 279.3 MG/ML Solution 5 mL Vial,A9576,CDM,636,RC,A9576,HCPCS,,,,270111104,NDC,10,ML,100,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.54,166.6
Sars-Cov-2 Covid-19 Antibody,PX8676990,CDM,300,RC,86769,CPT,90,,,,,,,100,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,42.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.63,98
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019600,NDC,1,ML,48.64,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,42.90048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,36000000924,NDC,200,ML,48.65,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,42.9093,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.20921,64.9544
leflunomide 20 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,70748013006,NDC,0.5,EA,44.1,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,42.92253,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxytocin 10 UNIT/ML Solution 1 mL Vial,J2590.01,CDM,636,RC,J2590,HCPCS,,,,42023011625,NDC,1,ML,43.8,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,42.924,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.19452,42.924
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,63323094004,NDC,4,ML,89.43,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,42.9264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,63323094004,NDC,4,ML,89.43,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,42.9264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,63323094021,NDC,4,ML,89.43,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,42.9264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,63323094021,NDC,4,ML,89.43,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,42.9264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
DIMETHICONE (TOPICAL) 5 % Cream 118 mL Tube,800000,CDM,,,,,,,,53329015104,NDC,118,ML,44.12,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,42.941996,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
phenol-glycerin 1.5-33 % Liquid 118 mL Bottle,25000000,CDM,250,RC,,,,,,78112000068,NDC,118,ML,44.12,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,42.941996,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505615204,NDC,0.5,EA,86.76,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,42.9462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001302,NDC,2,ML,86.79,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,42.96105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
"dextran 70, glycerin, hypromellose 0.1-0.2-0.3 % Solution 15 mL Bottle",63700001,CDM,250,RC,,,,,,65042636,NDC,15,ML,44.14,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,42.961462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
scopolamine 1 MG/3DAYS Patch 72 Hour 4 Each Box,25000000,CDM,250,RC,,,,,,45802058084,NDC,1,EA,103.43,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,42.964822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Destruct Benign Lesion, 1-14",PX17110F,CDM,510,RC,17110,CPT,,,,,,,,302,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,42.97,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.97,237.29
"Destruct Benign Lesion, 1-14",PX17110P,CDM,983,RC,17110,CPT,,,,,,,,521,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,42.97,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.97,510.58
vinCRIStine 1 MG/ML Solution 2 mL Vial,J9370.01,CDM,636,RC,J9370,HCPCS,,,,61703030916,NDC,2,ML,48.72,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,42.97104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.238288,47.7456
apixaban 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,3089331,NDC,1,EA,50.57,,First Health,Commercial,both,85,,999999999,percent of total billed charges,42.9845,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010310,NDC,1,ML,103.48,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,42.985592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
etomidate 2 MG/ML Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,55150022220,NDC,10,ML,50.58,,First Health,Commercial,both,85,,999999999,percent of total billed charges,42.993,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004624,NDC,50,ML,50.58,,First Health,Commercial,both,85,,999999999,percent of total billed charges,42.993,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
ceFAZolin in D4W 1 g / 50 mL 1-4 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0690.01,CDM,636,RC,J0690,HCPCS,,,,264310311,NDC,1,EA,84.97,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,42.99482,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049237,NDC,30,ML,87.77,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,43.0073,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049237,NDC,30,ML,87.77,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,43.0073,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049237,NDC,30,ML,87.77,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,43.0073,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Cognitive Funct Ther Interv, Initial 15 Min",PX97129,CDM,420,RC,97129,CPT,,,,,,,,85,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,43.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15,83.3
"Exam,Synovial Fluid Crystals",PX89060,CDM,300,RC,89060,CPT,,,,,,,,85,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,43.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.72,83.3
GLIDESCOPE QC MAC S3 SINGLE USE 0270-1083,120.579,CDM,272,RC,,,,13046-MAIN,LOCAL,,,,,85,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,43.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.309,83.3
GLIDESCOPE QC MAC S3 SINGLE USE 0270-1085,120.579,CDM,272,RC,,,,13022-MAIN,LOCAL,,,,,85,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,43.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.309,83.3
GLIDESCOPE QC MAC S4 SINGLE USE 0270-1086,120.579,CDM,272,RC,,,,13023-MAIN,LOCAL,,,,,85,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,43.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.309,83.3
infuvite adult Injectable 10 mL Vial,J3490.99,CDM,636,RC,J3490,HCPCS,,,,54643564901,NDC,10,ML,86.89,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,43.01055,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.094106,85.1522
sodium bicarbonate 8.4 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409662522,NDC,50,ML,85.02,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,43.02012,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011701,NDC,1,EA,89.64,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,43.0272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011701,NDC,1,EA,89.64,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,43.0272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011710,NDC,1,EA,89.64,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,43.0272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011710,NDC,1,EA,89.64,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,43.0272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,25021010720,NDC,1,EA,48.35,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,43.0315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
Self Care Mngment Training,PX97535,CDM,420,RC,97535,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,43.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.56,43.05
Self Care Mngment Training,PX97535,CDM,420,RC,97535,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,43.05,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.56,43.05
HYDROmorphone 0.1 MG/ML Solution 55 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,61553067976,NDC,55,ML,89.7,,Health Partners,Health Partners Care Plans,both,48,,25.36411765,percent of total billed charges,43.056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
HYDROmorphone 0.1 MG/ML Solution 55 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,61553067976,NDC,55,ML,89.7,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,43.056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409663734,NDC,50,ML,89.7,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,43.056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409663734,NDC,50,ML,89.7,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,43.056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,143957501,NDC,50,ML,44.24,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,43.058792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,143957510,NDC,50,ML,44.24,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,43.058792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Chemotherapy, IV Push, Additional Drug",PX96411,CDM,335,RC,96411,CPT,,,,,,,,87,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,43.065,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.1398,85.26
ampicillin 500 MG Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781925078,NDC,1,EA,44.28,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,43.097724,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,4080285,NDC,1,EA,89.79,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,43.0992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,4080285,NDC,1,EA,89.79,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,43.0992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714001601,NDC,0.4,ML,100.47,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,43.10163,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
Apply of Paste Boot,PX29580P,CDM,983,RC,29580,CPT,,,,,,,,88,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,43.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.5552,137.65
Apply of Paste Boot,PX29580P,CDM,983,RC,29580,CPT,,,,,,,,88,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,43.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.5552,137.65
Apply of Paste Boot,PX29580P,CDM,983,RC,29580,CPT,,,,,,,,88,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,43.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.5552,137.65
CANNULA ADULT LARGE OPTIFLOW OPT946,120.495,CDM,271,RC,A4615,HCPCS,,11622-MAIN,LOCAL,,,,,44,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,43.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
CANNULA ADULT MEDIUM OPTIFLOW OPT944,120.495,CDM,271,RC,A4615,HCPCS,,11621-MAIN,LOCAL,,,,,44,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,43.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
CANNULA ADULT SMALL OPTIFLOW OPT942,120.495,CDM,271,RC,A4615,HCPCS,,11620-MAIN,LOCAL,,,,,44,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,43.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
Homocysteine,PX83090,CDM,300,RC,83090,CPT,,,,,,,,44,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,43.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.43,43.12
KIT GASTRIC LAVAGE 2075,120.257,CDM,272,RC,C7510,HCPCS,,410-MAIN,LOCAL,,,,,44,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,43.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.2776,43.12
POSITIONING KIT TRENDELENBURG NUBLUE TP 3000-NB,27100000,CDM,271,RC,,,,12992-MAIN,LOCAL,,,,,88,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,43.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
POSITIONING KIT TRENDELENBURG NUBLUE TP 3000-NB,27100000,CDM,271,RC,,,,12992-MAIN,LOCAL,,,,,88,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,43.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
POSITIONING KIT TRENDELENBURG NUBLUE TP 3000-NB,27100000,CDM,271,RC,,,,12992-MAIN,LOCAL,,,,,88,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,43.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
SPLINT ANKLE GEL BRACE UNIVERSAL AIRFORM 70351,120.61,CDM,274,RC,L4350,HCPCS,,12342-MAIN,LOCAL,,,,,88,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,74.63,percent of total billed charges,43.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.5552,104.38
SPLINT ANKLE GEL BRACE UNIVERSAL AIRFORM 70351,120.61,CDM,274,RC,L4350,HCPCS,,12342-MAIN,LOCAL,,,,,88,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,43.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.5552,104.38
SPLINT ANKLE GEL BRACE UNIVERSAL AIRFORM 70351,120.61,CDM,274,RC,L4350,HCPCS,,12342-MAIN,LOCAL,,,,,88,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,43.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.5552,104.38
SUCTION IRRIGATOR 2 0250070500,27200000,CDM,272,RC,,,,12262-MAIN,LOCAL,,,,,88,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,43.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUCTION IRRIGATOR 2 0250070500,27200000,CDM,272,RC,,,,12262-MAIN,LOCAL,,,,,88,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,43.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUCTION IRRIGATOR 2 0250070500,27200000,CDM,272,RC,,,,12262-MAIN,LOCAL,,,,,88,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,43.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE V-LOC 1/2 CIRCLE NEEDLE WOUND CLOSURE DEVICE VLOCN0306,27200000,CDM,272,RC,,,,11931-MAIN,LOCAL,,,,,44,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,43.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE V-LOC SZ 3-0 180 GREEN V-20 9 INCH VLOCL0644,27200000,CDM,272,RC,,,,13056-SURG,LOCAL,,,,,44,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,43.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
clotrimazole 1 % Cream 28.35 g Tube,25000000,CDM,250,RC,,,,,,904782231,NDC,28.35,GR,50.75,,First Health,Commercial,both,85,,999999999,percent of total billed charges,43.1375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915701,NDC,0.5,ML,44.33,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,43.146389,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915731,NDC,0.5,ML,44.33,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,43.146389,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,47335093140,NDC,0.5,EA,44.33,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,43.146389,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,47335093144,NDC,0.5,EA,44.33,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,43.146389,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pembrolizumab 100 MG/4ML Solution 4 mL Vial,J9271.01,CDM,636,RC,J9271,HCPCS,,,,6302602,NDC,4,ML,9627.58,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,43.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.98,58.52
pembrolizumab 100 MG/4ML Solution 4 mL Vial,J9271.01,CDM,636,RC,J9271,HCPCS,,,,6302602,NDC,4,ML,9627.58,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,43.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.98,58.52
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218710,NDC,2,EA,5662.72,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,43.16,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.98,43.16
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218713,NDC,2,EA,6875.36,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,43.16,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.98,43.16
leflunomide 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,62332006130,NDC,1,EA,88.09,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,43.1641,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
leflunomide 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,62332006130,NDC,1,EA,88.09,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,43.1641,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
leflunomide 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,62332006130,NDC,1,EA,88.09,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,43.1641,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ticagrelor 90 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,186077739,NDC,1,EA,44.35,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,43.165855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,63323041536,NDC,0.5,ML,44.05,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,43.169,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,43.169
protamine 10 MG/ML Solution 25 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022930,NDC,2.5,ML,44.37,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,43.185321,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.431298,83.0452
"Gammaglobulin; Iga, Dg,M - Ref",PX8278490,CDM,300,RC,82784,CPT,90,,,,,,,90,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,43.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.53,88.2
"Gammaglobulin; Iga, Dg,M - Ref",PX8278490,CDM,300,RC,82784,CPT,90,,,,,,,90,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,43.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.53,88.2
"Misc Virus Antibody, Nos - Ref",PX8679090,CDM,300,RC,86790,CPT,90,,,,,,,90,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,43.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.81,88.2
"Misc Virus Antibody, Nos - Ref",PX8679090,CDM,300,RC,86790,CPT,90,,,,,,,90,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,43.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.81,88.2
Mycobacteria Culture - Ref,PX8711690,CDM,300,RC,87116,CPT,90,,,,,,,90,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,43.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9,88.2
Mycobacteria Culture - Ref,PX8711690,CDM,300,RC,87116,CPT,90,,,,,,,90,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,43.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9,88.2
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,409469930,NDC,20,ML,48.54,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,43.2006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
Carnitine - Ref,PX8237990,CDM,300,RC,82379,CPT,90,,,,,,,104,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,43.2016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.47,101.92
Cmv Antibody - Ref,PX8664490,CDM,300,RC,86644,CPT,90,,,,,,,104,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,43.2016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,101.92
Beta-2-Microglobulin - Ref,PX8223290,CDM,300,RC,82232,CPT,90,,,,,,,49,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,43.218,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.84,48.02
"Cannabinoids, Natural - Ref",PX8034990,CDM,300,RC,80349,CPT,90,,,,,,,49,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,43.218,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,48.02
cefTAZidime 1 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023525,NDC,1,EA,49,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,43.218,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
COLLAR CERVICAL X-LARGE WITH TRACH 2 PIECE OSG2404,120.185,CDM,274,RC,L0172,HCPCS,,10143-MAIN,LOCAL,,,,,49,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,43.218,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,152.79
Glycated Protein - Ref,PX8298590,CDM,300,RC,82985,CPT,90,,,,,,,49,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,43.218,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.37,48.02
leflunomide 20 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,70748013006,NDC,0.5,EA,44.1,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,43.218,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"SUTURE V-LOC SZ 0 180 GREEN GS21 NEEDLE 18"" VLOCL0326",27200000,CDM,272,RC,,,,12218-MAIN,LOCAL,,,,,49,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,43.218,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270004,NDC,100,ML,2827.78,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,43.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.85,44.15
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270004,NDC,100,ML,2827.78,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,43.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.85,44.15
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270010,NDC,100,ML,3458.14,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,43.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.85,44.15
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270010,NDC,100,ML,3458.14,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,43.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.85,44.15
immune globulin (Human) 10 GM/100ML Solution 100 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270005,NDC,100,ML,2827.78,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,43.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.85,44.15
immune globulin (Human) 10 GM/100ML Solution 100 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270005,NDC,100,ML,2827.78,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,43.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.85,44.15
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270006,NDC,100,ML,2912.78,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,43.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.85,44.15
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270006,NDC,100,ML,2912.78,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,43.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.85,44.15
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270012,NDC,100,ML,3293.58,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,43.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.85,44.15
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270012,NDC,100,ML,3293.58,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,43.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.85,44.15
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270007,NDC,100,ML,2827.78,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,43.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.85,44.15
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270007,NDC,100,ML,2827.78,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,43.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.85,44.15
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270013,NDC,100,ML,2827.78,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,43.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.85,44.15
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270013,NDC,100,ML,2827.78,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,43.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.85,44.15
DIMETHICONE (TOPICAL) 5 % Cream 118 mL Tube,800000,CDM,,,,,,,,53329015104,NDC,118,ML,44.12,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,43.2376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
phenol-glycerin 1.5-33 % Liquid 118 mL Bottle,25000000,CDM,250,RC,,,,,,78112000068,NDC,118,ML,44.12,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,43.2376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"dextran 70, glycerin, hypromellose 0.1-0.2-0.3 % Solution 15 mL Bottle",63700001,CDM,250,RC,,,,,,65042636,NDC,15,ML,44.14,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,43.2572,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine (preservative free) 4 % Solution 5 mL Ampule,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409428325,NDC,5,ML,48.62,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,43.2718,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,703903201,NDC,2,ML,44.46,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,43.272918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,97.0102
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2021301,NDC,3,ML,44.46,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,4.0055,percent of total billed charges,43.272918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
atropine 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100401,NDC,0.5,ML,50.91,,First Health,Commercial,both,85,,999999999,percent of total billed charges,43.2735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019600,NDC,1,ML,48.64,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,43.2896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004722,NDC,2,ML,88.35,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,43.2915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004722,NDC,2,ML,88.35,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,43.2915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004722,NDC,2,ML,88.35,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,43.2915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,36000000924,NDC,200,ML,48.65,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,43.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.20921,64.9544
promethazine 25 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802075930,NDC,0.5,EA,47.54,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,43.30894,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
promethazine 25 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,45802075900,NDC,0.5,EA,47.55,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,43.31805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BRACE KNEE LARGE SHORTRUNNER 21754,120.387,CDM,274,RC,L1833,HCPCS,,10044-MAIN,LOCAL,,,,,101,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,43.329,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE MEDIUM SHORTRUNNER 21753,120.387,CDM,274,RC,L1833,HCPCS,,10126-MAIN,LOCAL,,,,,101,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,43.329,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE SMALL SHORTRUNNER 21752,120.387,CDM,274,RC,L1833,HCPCS,,10900-MAIN,LOCAL,,,,,101,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,43.329,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE X-LARGE SHORTRUNNER 21755,120.387,CDM,274,RC,L1833,HCPCS,,3444-MAIN,LOCAL,,,,,101,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,43.329,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE XX-LARGE SHORTRUNNER 21756,120.387,CDM,274,RC,L1833,HCPCS,,10615-MAIN,LOCAL,,,,,101,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,43.329,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
"COLLAR CERVICAL 2"" SMALL UNIVERSAL 08140039",120.249,CDM,274,RC,L0120,HCPCS,,270-MAIN,LOCAL,,,,,101,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,43.329,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 2X20"" SMALL 1003-02",120.249,CDM,274,RC,L0120,HCPCS,,272-MAIN,LOCAL,,,,,101,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,43.329,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 2X23.5"" MEDIUM XNARROW 1003-04",120.249,CDM,274,RC,L0120,HCPCS,,273-MAIN,LOCAL,,,,,101,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,43.329,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 10-15"" SMALL XLONG 1005-06",120.249,CDM,274,RC,L0120,HCPCS,,267-MAIN,LOCAL,,,,,101,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,43.329,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL LARGE 21.5""X5"" 1005-04",120.249,CDM,274,RC,L0120,HCPCS,,268-MAIN,LOCAL,,,,,101,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,43.329,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL MEDIUM 20-1/2X4"" 1005-03",120.249,CDM,274,RC,L0120,HCPCS,,269-MAIN,LOCAL,,,,,101,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,43.329,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
COLLAR CERVICAL SMALL 1005-02,120.249,CDM,274,RC,L0120,HCPCS,,266-MAIN,LOCAL,,,,,101,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,43.329,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049209,NDC,5,ML,44.52,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,43.331316,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Surg Pathology-Level 2-Tc,PX3932,CDM,310,RC,88302,CPT,TC,,,,,,,66,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,43.344,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.41,43.344
Surg Pathology-Level 2-Tc,PX3932,CDM,310,RC,88302,CPT,TC,,,,,,,66,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,43.344,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.41,43.344
Remv Ext Canal Foreign Body,PX69200F,CDM,510,RC,69200,CPT,,,,,,,,235,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,43.3485,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.22,167.42
Remv Ext Canal Foreign Body,PX69200P,CDM,983,RC,69200,CPT,,,,,,,,157,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,43.3485,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.22,167.42
DRAPE STERILE 109X100X110 ROBOTIC DYNJP9108,27200000,CDM,272,RC,,,,12020-MAIN,LOCAL,,,,,51,,First Health,Commercial,both,85,,999999999,percent of total billed charges,43.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Immunohisto Antibody Slide Ea Multiplex,PX8834401,CDM,310,RC,88344,CPT,TC,,,,,,,51,,First Health,Commercial,both,85,,999999999,percent of total billed charges,43.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,314.02
RANGER UNIT TUBING FLUID WARMING,120.229,CDM,272,RC,,,,10612-MAIN,LOCAL,,,,,51,,First Health,Commercial,both,85,,999999999,percent of total billed charges,43.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,49.98
SCAR GEL SHEET,120.458,CDM,273,RC,A6025,HCPCS,,5796-MAIN,LOCAL,,,,,51,,First Health,Commercial,both,85,,999999999,percent of total billed charges,43.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,49.98
TUBE FEEDING DECLOGGING SYSTEM CLOG ZAPPER 20-0002,120.277,CDM,272,RC,,,,4226-MAIN,LOCAL,,,,,51,,First Health,Commercial,both,85,,999999999,percent of total billed charges,43.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,49.98
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,143957501,NDC,50,ML,44.24,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,43.3552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,143957510,NDC,50,ML,44.24,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,43.3552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vinCRIStine 1 MG/ML Solution 2 mL Vial,J9370.01,CDM,636,RC,J9370,HCPCS,,,,61703030916,NDC,2,ML,48.72,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,43.3608,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.238288,47.7456
SCISSORS ENDOSCOPIC 5MM STANDARD STERILE,27200000,CDM,272,RC,,,,11706-MAIN,LOCAL,,,,,47.6,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,43.3636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,574402435,NDC,3.5,GR,101.11,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,43.37619,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ampicillin 500 MG Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781925078,NDC,1,EA,44.28,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,43.3944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
Repr Superf Wnd Body 7.6-12.5,PX12004F,CDM,510,RC,12004,CPT,,,,,,,,453,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,43.41,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,43.41,277.41
Repr Superf Wnd Body 7.6-12.5,PX12004P,CDM,983,RC,12004,CPT,,,,,,,,614,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,43.41,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,43.41,601.72
Ig Paraprotein Qual Bld/UR,PX0077U90,CDM,300,RC,0077U,HCPCS,90,,,,,,,66,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,43.43,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.6797,43.43
prasugrel 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862083030,NDC,1,EA,88.64,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,43.4336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prasugrel 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862083030,NDC,1,EA,88.64,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,43.4336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prasugrel 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862083030,NDC,1,EA,88.64,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,43.4336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915701,NDC,0.5,ML,44.33,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,43.4434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915731,NDC,0.5,ML,44.33,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,43.4434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,47335093140,NDC,0.5,EA,44.33,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,43.4434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,47335093144,NDC,0.5,EA,44.33,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,43.4434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049237,NDC,30,ML,87.77,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,43.44615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361250,NDC,50,ML,90.53,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,43.4544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361250,NDC,50,ML,90.53,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,43.4544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361650,NDC,50,ML,90.53,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,43.4544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361650,NDC,50,ML,90.53,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,43.4544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010269,NDC,1,EA,88.69,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,7.351730769,percent of total billed charges,43.4581,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010269,NDC,1,EA,88.69,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,43.4581,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010269,NDC,1,EA,88.69,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,43.4581,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010299,NDC,1,EA,88.69,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,7.351730769,percent of total billed charges,43.4581,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010299,NDC,1,EA,88.69,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,43.4581,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010299,NDC,1,EA,88.69,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,43.4581,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614201,NDC,1,ML,88.69,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,43.4581,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.097864,86.9162
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614201,NDC,1,ML,88.69,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,43.4581,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.097864,86.9162
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614201,NDC,1,ML,88.69,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,43.4581,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.097864,86.9162
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614225,NDC,1,ML,88.69,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,43.4581,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.097864,86.9162
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614225,NDC,1,ML,88.69,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,43.4581,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.097864,86.9162
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614225,NDC,1,ML,88.69,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,43.4581,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.097864,86.9162
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963801,NDC,0.5,ML,88.69,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,43.4581,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963801,NDC,0.5,ML,88.69,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,43.4581,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963801,NDC,0.5,ML,88.69,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,43.4581,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
ticagrelor 90 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,186077739,NDC,1,EA,44.35,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,43.463,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028442,NDC,1,EA,47.71,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,43.46381,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
empagliflozin 10 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,597015237,NDC,1,EA,104.66,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,43.475764,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
protamine 10 MG/ML Solution 25 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022930,NDC,2.5,ML,44.37,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,43.4826,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.431298,83.0452
Aldosterone - Ref,PX8208890,CDM,300,RC,82088,CPT,90,,,,,,,86,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,43.516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.7244,84.28
Epstein-barr antibody,PX86665,CDM,300,RC,86665,CPT,,,,,,,,86,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,43.516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.63,84.28
fentaNYL 25 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,47781042411,NDC,1,EA,101.44,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,43.51776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SAWBLADE SAGITAL STERILE 25MM LENGTH 5.5MM WIDTH 0.60MM THICKNESS,27200000,CDM,272,RC,,,,11623-MAIN,LOCAL,,,,,86.02,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,43.52612,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
fentaNYL 25 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505700600,NDC,1,EA,101.46,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,43.52634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329334001,NDC,10,ML,88.88,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,43.5512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329334001,NDC,10,ML,88.88,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,43.5512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329334001,NDC,10,ML,88.88,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,43.5512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
Apply of Paste Boot,PX29580P,CDM,983,RC,29580,CPT,,,,,,,,88,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,43.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.5552,137.65
POSITIONING KIT TRENDELENBURG NUBLUE TP 3000-NB,27100000,CDM,271,RC,,,,12992-MAIN,LOCAL,,,,,88,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,43.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
Remove Intrauterine Device,PX58301,CDM,983,RC,58301,CPT,,,,,,,,357,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,43.56,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.14,349.86
Remove Intrauterine Device,PX58301,CDM,983,RC,58301,CPT,,,,,,,,357,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,43.56,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.14,349.86
SPLINT ANKLE GEL BRACE UNIVERSAL AIRFORM 70351,120.61,CDM,274,RC,L4350,HCPCS,,12342-MAIN,LOCAL,,,,,88,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,43.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.5552,104.38
SUCTION IRRIGATOR 2 0250070500,27200000,CDM,272,RC,,,,12262-MAIN,LOCAL,,,,,88,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,43.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,703903201,NDC,2,ML,44.46,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,43.5708,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,97.0102
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2021301,NDC,3,ML,44.46,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,43.5708,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048203,NDC,20,ML,44.8,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,43.60384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048227,NDC,20,ML,44.8,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,43.60384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
leflunomide 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,62332006130,NDC,1,EA,88.09,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,43.60455,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Aldolase - Ref,PX8208590,CDM,300,RC,82085,CPT,90,,,,,,,89,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,43.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.9,87.22
Aldolase - Ref,PX8208590,CDM,300,RC,82085,CPT,90,,,,,,,89,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,43.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.9,87.22
Aldolase - Ref,PX8208590,CDM,300,RC,82085,CPT,90,,,,,,,89,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,43.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.9,87.22
Assay of Ggt,PX82977,CDM,300,RC,82977,CPT,,,,,,,,89,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,43.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6,87.22
Assay of Ggt,PX82977,CDM,300,RC,82977,CPT,,,,,,,,89,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,43.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6,87.22
Assay of Ggt,PX82977,CDM,300,RC,82977,CPT,,,,,,,,89,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,43.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6,87.22
Beta-2-Microglobulin - Ref,PX8223290,CDM,300,RC,82232,CPT,90,,,,,,,49,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,43.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.84,48.02
"Cannabinoids, Natural - Ref",PX8034990,CDM,300,RC,80349,CPT,90,,,,,,,49,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,43.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,48.02
cefTAZidime 1 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023525,NDC,1,EA,49,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,43.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
COLLAR CERVICAL X-LARGE WITH TRACH 2 PIECE OSG2404,120.185,CDM,274,RC,L0172,HCPCS,,10143-MAIN,LOCAL,,,,,49,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,43.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,152.79
"Debridement of Nail(S), 1-5",PX11720F,CDM,510,RC,11720,CPT,,,,,,,,89,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,17.8,percent of total billed charges,43.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.9706,87.22
"Debridement of Nail(S), 1-5",PX11720F,CDM,510,RC,11720,CPT,,,,,,,,89,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,43.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.9706,87.22
"Debridement of Nail(S), 1-5",PX11720F,CDM,510,RC,11720,CPT,,,,,,,,89,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,43.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.9706,87.22
Glycated Protein - Ref,PX8298590,CDM,300,RC,82985,CPT,90,,,,,,,49,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,43.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.37,48.02
"Hla a, B or C, Single Ag - Ref",PX8681290,CDM,300,RC,86812,CPT,90,,,,,,,89,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,43.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.67,87.22
"Hla a, B or C, Single Ag - Ref",PX8681290,CDM,300,RC,86812,CPT,90,,,,,,,89,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,43.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.67,87.22
"Hla a, B or C, Single Ag - Ref",PX8681290,CDM,300,RC,86812,CPT,90,,,,,,,89,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,43.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.67,87.22
KIT INTRODUCER 8.5FR AK-09803-CDC,120.128,CDM,272,RC,,,,8826-MAIN,LOCAL,,,,,89,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,43.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.9706,87.22
KIT INTRODUCER 8.5FR AK-09803-CDC,120.128,CDM,272,RC,,,,8826-MAIN,LOCAL,,,,,89,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,43.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.9706,87.22
KIT INTRODUCER 8.5FR AK-09803-CDC,120.128,CDM,272,RC,,,,8826-MAIN,LOCAL,,,,,89,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,43.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.9706,87.22
"SUTURE V-LOC SZ 0 180 GREEN GS21 NEEDLE 18"" VLOCL0326",27200000,CDM,272,RC,,,,12218-MAIN,LOCAL,,,,,49,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,43.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Dx Occult Blood Immunoassay,PX82274,CDM,300,RC,82274,CPT,,,,,,,,105,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,43.617,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.6,102.9
Specimen Concentration - Ref,PX8701590,CDM,300,RC,87015,CPT,90,,,,,,,105,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,43.617,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.12,102.9
venetoclax 100 MG Tablet 1 Each Box,25000000,CDM,250,RC,,,,,,74057611,NDC,0.2,EA,90.87,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,43.6176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
venetoclax 100 MG Tablet 1 Each Box,25000000,CDM,250,RC,,,,,,74057611,NDC,0.2,EA,90.87,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,43.6176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,17478007035,NDC,3.5,GR,105.01,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,43.621154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049209,NDC,5,ML,44.52,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,43.6296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Chest Wall Manipulation,Initial",PX94667,CDM,410,RC,94667,CPT,,,,,,,,121,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,43.63,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.05,43.63
"Chest Wall Manipulation,Initial",PX94667,CDM,410,RC,94667,CPT,,,,,,,,121,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,43.63,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.05,43.63
Irri Implted Drug Dlvr Device,PX96523,CDM,260,RC,96523,CPT,,,,,,,,119,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,43.63,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.58,43.63
Irri Implted Drug Dlvr Device,PX96523,CDM,260,RC,96523,CPT,,,,,,,,119,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,43.63,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.58,43.63
Repr Superf Wnd Body 7.6-12.5,PX12004F,CDM,510,RC,12004,CPT,,,,,,,,453,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,43.63,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,43.41,277.41
Repr Superf Wnd Body 7.6-12.5,PX12004F,CDM,510,RC,12004,CPT,,,,,,,,453,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,43.63,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,43.41,277.41
Repr Superf Wnd Body 7.6-12.5,PX12004P,CDM,983,RC,12004,CPT,,,,,,,,614,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,43.63,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,43.41,601.72
Repr Superf Wnd Body 7.6-12.5,PX12004P,CDM,983,RC,12004,CPT,,,,,,,,614,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,43.63,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,43.41,601.72
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036019,NDC,10,ML,86.23,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,43.63238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,84.5054
Acute Hepatitis Panel,PX80074,CDM,300,RC,80074,CPT,,,,,,,,509,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,43.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,43.67,498.82
perflutren lipid microsphere 6.52 MG/ML Suspension 2 mL Vial,Q9957,CDM,636,RC,Q9957,HCPCS,,,,11994001101,NDC,2,ML,751.71,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,43.68686,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.16,48.69
perflutren protein A microsphere Suspension 3 mL Vial,Q9956,CDM,636,RC,Q9956,HCPCS,,,,407270703,NDC,3,ML,739.41,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,43.68686,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.56,43.68686
nafcillin 1 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,55150012215,NDC,1,EA,89.17,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,43.6933,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
nafcillin 1 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,55150012215,NDC,1,EA,89.17,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,43.6933,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
nafcillin 1 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,55150012215,NDC,1,EA,89.17,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,43.6933,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703331101,NDC,0.75,ML,51.41,,First Health,Commercial,both,85,,999999999,percent of total billed charges,43.6985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
ezetimibe 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714081301,NDC,1,EA,44.91,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,43.710903,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
leucovorin 350 MG Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,703514501,NDC,1,EA,86.41,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,43.72346,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.670002,84.6818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615704,NDC,1,EA,101.92,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,43.72368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
"Admin Hep B,Adult 19+",PX3242,CDM,771,RC,90471,CPT,,,,,,,,48,,Medica,Commercial,both,91.1,,20.9825,percent of total billed charges,43.728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,61.54
Amphetamines; 3 or 4,PX8032590,CDM,300,RC,80325,CPT,90,,,,,,,48,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,43.728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,47.04
Immunization Admin - Influenza,PX3241,CDM,771,RC,90471,CPT,,,,,,,,48,,Medica,Commercial,both,91.1,,20.9825,percent of total billed charges,43.728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,61.54
Immunization Administration; Each Add'l Vaccine (Single or Combo Vaccine/T*,PX90472,CDM,771,RC,90472,CPT,,,,,,,,48,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,43.728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,47.04
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004722,NDC,2,ML,88.35,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,43.73325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061400,NDC,1,ML,101.95,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,43.73655,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.114178,99.911
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615700,NDC,1,EA,101.95,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,43.73655,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
"Office/Outpt Visit,New,Levl II",PX99202F,CDM,510,RC,99202,CPT,,,,,,,,123,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,43.7376,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.89,129.77
"Office/Outpt Visit,New,Levl II",PX99202P,CDM,983,RC,99202,CPT,,,,,,,,123,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,43.7376,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.89,129.77
Concurrent Infusion,PX96368,CDM,260,RC,96368,CPT,,,,,,,,102,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,43.758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.3708,99.96
Immunohisto Antibody Slide Ea Addl,PX8834101,CDM,310,RC,88341,CPT,TC,,,,,,,102,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,43.758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.3708,99.96
Reptilase Test - Ref,PX8563590,CDM,300,RC,85635,CPT,90,,,,,,,102,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,43.758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.03,99.96
lidocaine 4 % Cream 5 g Tube,63700001,CDM,250,RC,,,,,,496088205,NDC,5,GR,51.49,,First Health,Commercial,both,85,,999999999,percent of total billed charges,43.7665,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Package,25000000,CDM,250,RC,,,,,,66758020858,NDC,1,EA,102.08,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,43.79232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Cardiac Rehab,PX93797F,CDM,943,RC,93797,CPT,,,,,,,,45,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,43.7985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,115.44
CATHETER TEMP-SENSING 8FR LUBRISIL PEDS DYND110508,120.363,CDM,272,RC,A4340,HCPCS,,12777-MAIN,LOCAL,,,,,45,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,43.7985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
CATHETER TEMP-SENSING 12FR LUBRISIL 119212M,120.363,CDM,272,RC,A4340,HCPCS,,10750-MAIN,LOCAL,,,,,45,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,43.7985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
CATHETER TEMP-SENSING 14FR LUBRISIL 119214M,120.363,CDM,272,RC,A4340,HCPCS,,10751-MAIN,LOCAL,,,,,45,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,43.7985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
CATHETER TEMP-SENSING 16FR LUBRISIL 119216M,120.363,CDM,272,RC,A4340,HCPCS,,10752-MAIN,LOCAL,,,,,45,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,43.7985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
Cryptococcus Neoformans,PX87327,CDM,300,RC,87327,CPT,,,,,,,,45,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,43.7985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.3,44.1
Gammaglobulin; Ige - Ref,PX8278590,CDM,300,RC,82785,CPT,90,,,,,,,45,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,43.7985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.09,44.1
GASTRONOMY FEEDING TUBE MIC BALLOONED 20FR 7-10ML 0112-20,27200000,CDM,272,RC,B4087,HCPCS,,13098-MAIN,LOCAL,,,,,45,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,43.7985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRES 1.6MM,27200000,CDM,272,RC,C1769,HCPCS,,11852-MAIN,LOCAL,,,,,45,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,43.7985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"La Crosse, Antibody - Ref",PX8665190,CDM,300,RC,86651,CPT,90,,,,,,,45,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,43.7985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.09,44.1
MELGISORB AG SILVER CALCIUM STERILE 6X6,120.502,CDM,272,RC,A6197,HCPCS,,11844-MAIN,LOCAL,,,,,45,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,43.7985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
"St Louis, Antibody - Ref",PX8665390,CDM,300,RC,86653,CPT,90,,,,,,,45,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,43.7985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.09,44.1
"Sugars, Qual, Ea Spec - Ref",PX8437690,CDM,300,RC,84376,CPT,90,,,,,,,45,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,43.7985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.04,44.1
"Venipuncture by Physician, Other Vein, Under Age 3 Years",PX36406,CDM,983,RC,36406,CPT,,,,,,,,45,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,43.7985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,43.7985
"Western Equine, Ab - Ref",PX8665490,CDM,300,RC,86654,CPT,90,,,,,,,45,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,43.7985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.09,44.1
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001481,NDC,1,EA,102.12,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,43.80948,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,63323094004,NDC,4,ML,89.43,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,43.8207,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,63323094004,NDC,4,ML,89.43,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,43.8207,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,63323094004,NDC,4,ML,89.43,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,43.8207,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,63323094021,NDC,4,ML,89.43,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,43.8207,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,63323094021,NDC,4,ML,89.43,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,43.8207,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,63323094021,NDC,4,ML,89.43,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,43.8207,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 2%-EPINEPHrine 1:100,000 2 %-1:100000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,409318221,NDC,30,ML,51.57,,First Health,Commercial,both,85,,999999999,percent of total billed charges,43.8345,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010301,NDC,0.3,ML,45.04,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,229.0777778,percent of total billed charges,43.837432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
Bone Marrow Biopsy(Ies),PX38221F,CDM,510,RC,38221,CPT,,,,,,,,1221,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,43.84,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,43.84,337.6
Emergency Level III Visit,PX99283P,CDM,981,RC,99283,CPT,,,,,,,,568,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,43.86,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,43.86,556.64
Facility Emergency Level III Visit,PX99283F,CDM,450,RC,99283,CPT,,,,,,,,587,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,43.86,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,43.86,126.18
prasugrel 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862083030,NDC,1,EA,88.64,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,43.8768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505615204,NDC,0.5,EA,86.76,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,43.90056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
sodium bicarbonate 4.2 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409553434,NDC,10,ML,91.46,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,43.9008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium bicarbonate 4.2 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409553434,NDC,10,ML,91.46,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,43.9008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066500,NDC,0.25,ML,48.19,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,43.90109,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.000396,47.2262
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010269,NDC,1,EA,88.69,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,43.90155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010299,NDC,1,EA,88.69,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,43.90155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614201,NDC,1,ML,88.69,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,43.90155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.097864,86.9162
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614225,NDC,1,ML,88.69,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,43.90155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.097864,86.9162
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963801,NDC,0.5,ML,88.69,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,43.90155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048203,NDC,20,ML,44.8,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,43.904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048227,NDC,20,ML,44.8,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,43.904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001302,NDC,2,ML,86.79,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,43.91574,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011701,NDC,1,EA,89.64,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,43.9236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011701,NDC,1,EA,89.64,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,43.9236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011701,NDC,1,EA,89.64,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,43.9236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011710,NDC,1,EA,89.64,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,43.9236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011710,NDC,1,EA,89.64,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,43.9236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011710,NDC,1,EA,89.64,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,43.9236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
imipenem-cilastatin 250 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323034925,NDC,1,EA,91.55,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,43.944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,173.1856
imipenem-cilastatin 250 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323034925,NDC,1,EA,91.55,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,43.944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,173.1856
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032294,NDC,1,EA,91.55,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,43.944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,173.1856
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032294,NDC,1,EA,91.55,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,43.944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,173.1856
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234001,NDC,1.25,ML,91.55,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,43.944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234001,NDC,1.25,ML,91.55,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,43.944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
HYDROmorphone 0.1 MG/ML Solution 55 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,61553067976,NDC,55,ML,89.7,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,10.0725,percent of total billed charges,43.953,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
HYDROmorphone 0.1 MG/ML Solution 55 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,61553067976,NDC,55,ML,89.7,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,43.953,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
HYDROmorphone 0.1 MG/ML Solution 55 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,61553067976,NDC,55,ML,89.7,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,43.953,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409663734,NDC,50,ML,89.7,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,43.953,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409663734,NDC,50,ML,89.7,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,43.953,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409663734,NDC,50,ML,89.7,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,43.953,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
levoFLOXacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635261,NDC,0.5,EA,45.16,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,43.954228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
infuvite adult Injectable 10 mL Vial,J3490.99,CDM,636,RC,J3490,HCPCS,,,,54643564901,NDC,10,ML,86.89,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,43.96634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.094106,85.1522
"lidocaine 2% -EPINEPHRine 1:200,000 2 %-1:200000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409318301,NDC,20,ML,49.86,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,43.97652,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329334001,NDC,10,ML,88.88,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,43.9956,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,4080285,NDC,1,EA,89.79,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,43.9971,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,4080285,NDC,1,EA,89.79,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,43.9971,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,4080285,NDC,1,EA,89.79,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,43.9971,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Sulfur Colloid per Dose,PXA9541,CDM,343,RC,A9541,HCPCS,,,,,,,,295,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,44,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44,701.306
ezetimibe 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714081301,NDC,1,EA,44.91,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,44.0118,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Chemotherapy, IV Push, Additional Drug",PX96411,CDM,335,RC,96411,CPT,,,,,,,,87,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,44.022,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.1398,85.26
GLIDESCOPE QC MILLER S0 SINGLE USE 0270-1087,120.58,CDM,272,RC,,,,13024-MAIN,LOCAL,,,,,106,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,44.0324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
GLIDESCOPE QC MILLER S1 SINGLE USE 0270-1088,120.58,CDM,272,RC,,,,13025-MAIN,LOCAL,,,,,106,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,44.0324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331801,NDC,10,ML,102.65,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,44.03685,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
cefTRIAXone in dextrose 1 g / 50 mL 1-3.74 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0696.01,CDM,636,RC,J0696,HCPCS,,,,264315311,NDC,1,EA,106.03,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,44.044862,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,25021010720,NDC,1,EA,48.35,,Medica,Commercial,both,91.1,,6.892980769,percent of total billed charges,44.04685,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,67815203,NDC,100,GR,91.77,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,44.0496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,67815203,NDC,100,GR,91.77,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,44.0496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"DXA, Bone Density Study, Radius/Wrist/Heel",PX7708101,CDM,320,RC,77081,CPT,TC,,,,,,,460,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,44.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.18,44.05
"DXA, Bone Density Study, Radius/Wrist/Heel",PX7708101,CDM,320,RC,77081,CPT,TC,,,,,,,460,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,44.05,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.18,44.05
Aldolase - Ref,PX8208590,CDM,300,RC,82085,CPT,90,,,,,,,89,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,44.055,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.9,87.22
Assay of Ggt,PX82977,CDM,300,RC,82977,CPT,,,,,,,,89,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,44.055,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6,87.22
"Debridement of Nail(S), 1-5",PX11720F,CDM,510,RC,11720,CPT,,,,,,,,89,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,44.055,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.9706,87.22
"Hla a, B or C, Single Ag - Ref",PX8681290,CDM,300,RC,86812,CPT,90,,,,,,,89,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,44.055,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.67,87.22
KIT INTRODUCER 8.5FR AK-09803-CDC,120.128,CDM,272,RC,,,,8826-MAIN,LOCAL,,,,,89,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,44.055,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.9706,87.22
Bone Marrow Biopsy(Ies),PX38221F,CDM,510,RC,38221,CPT,,,,,,,,1221,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,44.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,43.84,337.6
Bone Marrow Biopsy(Ies),PX38221F,CDM,510,RC,38221,CPT,,,,,,,,1221,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,44.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,43.84,337.6
Repr Superf Wnd Face 5.1-7.5,PX12014F,CDM,510,RC,12014,CPT,,,,,,,,453,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,44.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.06,297.47
Repr Superf Wnd Face 5.1-7.5,PX12014F,CDM,510,RC,12014,CPT,,,,,,,,453,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,44.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.06,297.47
Repr Superf Wnd Face 5.1-7.5,PX12014F,CDM,510,RC,12014,CPT,,,,,,,,453,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,44.06,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.06,297.47
Repr Superf Wnd Face 5.1-7.5,PX12014P,CDM,983,RC,12014,CPT,,,,,,,,819,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,44.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.06,802.62
Repr Superf Wnd Face 5.1-7.5,PX12014P,CDM,983,RC,12014,CPT,,,,,,,,819,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,44.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.06,802.62
Repr Superf Wnd Face 5.1-7.5,PX12014P,CDM,983,RC,12014,CPT,,,,,,,,819,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,44.06,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.06,802.62
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665305,NDC,20,ML,49.97,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,44.07354,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
BAG LEG URINARY STND 32OZ,120.33,CDM,272,RC,A5112,HCPCS,,4433-MAIN,LOCAL,,,,,121,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,44.08,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,46.4
BAG URINARY LEG PACK 9349,120.33,CDM,272,RC,A5112,HCPCS,,623-MAIN,LOCAL,,,,,121,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,44.08,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,46.4
Cardiac Rehab,PX93797F,CDM,943,RC,93797,CPT,,,,,,,,45,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,44.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,115.44
CATHETER TEMP-SENSING 8FR LUBRISIL PEDS DYND110508,120.363,CDM,272,RC,A4340,HCPCS,,12777-MAIN,LOCAL,,,,,45,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,44.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
CATHETER TEMP-SENSING 12FR LUBRISIL 119212M,120.363,CDM,272,RC,A4340,HCPCS,,10750-MAIN,LOCAL,,,,,45,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,44.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
CATHETER TEMP-SENSING 14FR LUBRISIL 119214M,120.363,CDM,272,RC,A4340,HCPCS,,10751-MAIN,LOCAL,,,,,45,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,44.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
CATHETER TEMP-SENSING 16FR LUBRISIL 119216M,120.363,CDM,272,RC,A4340,HCPCS,,10752-MAIN,LOCAL,,,,,45,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,44.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
Cryptococcus Neoformans,PX87327,CDM,300,RC,87327,CPT,,,,,,,,45,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,44.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.3,44.1
ERBEFLO CLEVERCAP CO2 TUBING CAP SET,27200000,CDM,272,RC,,,,11831-MAIN,LOCAL,,,,,50,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,44.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
G6pd; Quant Screen - Ref,PX8295590,CDM,300,RC,82955,CPT,90,,,,,,,50,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,44.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.89,49
"Gammaglobulin; Iga, Dg,M - Ref",PX8278490,CDM,300,RC,82784,CPT,90,,,,,,,90,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,44.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.53,88.2
"Gammaglobulin; Iga, Dg,M - Ref",PX8278490,CDM,300,RC,82784,CPT,90,,,,,,,90,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,44.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.53,88.2
"Gammaglobulin; Iga, Dg,M - Ref",PX8278490,CDM,300,RC,82784,CPT,90,,,,,,,90,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,44.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.53,88.2
Gammaglobulin; Ige - Ref,PX8278590,CDM,300,RC,82785,CPT,90,,,,,,,45,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,44.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.09,44.1
GASTRONOMY FEEDING TUBE MIC BALLOONED 20FR 7-10ML 0112-20,27200000,CDM,272,RC,B4087,HCPCS,,13098-MAIN,LOCAL,,,,,45,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,44.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Homogenization, Tissue for Culture",PX87176,CDM,300,RC,87176,CPT,,,,,,,,50,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,44.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.39,49
K-WIRES 1.6MM,27200000,CDM,272,RC,C1769,HCPCS,,11852-MAIN,LOCAL,,,,,45,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,44.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"La Crosse, Antibody - Ref",PX8665190,CDM,300,RC,86651,CPT,90,,,,,,,45,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,44.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.09,44.1
MELGISORB AG SILVER CALCIUM STERILE 6X6,120.502,CDM,272,RC,A6197,HCPCS,,11844-MAIN,LOCAL,,,,,45,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,44.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,44.1
"Misc Virus Antibody, Nos - Ref",PX8679090,CDM,300,RC,86790,CPT,90,,,,,,,90,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,44.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.81,88.2
"Misc Virus Antibody, Nos - Ref",PX8679090,CDM,300,RC,86790,CPT,90,,,,,,,90,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,44.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.81,88.2
"Misc Virus Antibody, Nos - Ref",PX8679090,CDM,300,RC,86790,CPT,90,,,,,,,90,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,44.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.81,88.2
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152P,CDM,983,RC,99152,CPT,,,,,,,,90,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,44.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.386,87.597
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152P,CDM,983,RC,99152,CPT,,,,,,,,90,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,44.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.386,87.597
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152P,CDM,983,RC,99152,CPT,,,,,,,,90,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,44.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.386,87.597
Mycobacteria Culture - Ref,PX8711690,CDM,300,RC,87116,CPT,90,,,,,,,90,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,44.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9,88.2
Mycobacteria Culture - Ref,PX8711690,CDM,300,RC,87116,CPT,90,,,,,,,90,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,44.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9,88.2
Mycobacteria Culture - Ref,PX8711690,CDM,300,RC,87116,CPT,90,,,,,,,90,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,44.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9,88.2
"NEEDLE ASP 16GX3/16"" 1-7/8"" ILLINOIS STERNAL 8881245164",120.8,CDM,272,RC,G0364,HCPCS,,5730-MAIN,LOCAL,,,,,50,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,44.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,49
"NEEDLE BONE MARROW 8G X 4"" BIOPSY/ASPIRATION 8881247087",120.8,CDM,272,RC,G0364,HCPCS,,166-MAIN,LOCAL,,,,,50,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,44.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,49
"NEEDLE BONE MARROW 11G X 4"" 8881247111",120.8,CDM,272,RC,G0364,HCPCS,,162-MAIN,LOCAL,,,,,50,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,44.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,49
Potassium; Urine,PX84133,CDM,300,RC,84133,CPT,,,,,,,,50,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,44.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.34,49
"St Louis, Antibody - Ref",PX8665390,CDM,300,RC,86653,CPT,90,,,,,,,45,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,44.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.09,44.1
"Sugars, Qual, Ea Spec - Ref",PX8437690,CDM,300,RC,84376,CPT,90,,,,,,,45,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,44.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.04,44.1
"Venipuncture by Physician, Other Vein, Under Age 3 Years",PX36406,CDM,983,RC,36406,CPT,,,,,,,,45,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,44.1,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.45,44.1
"Western Equine, Ab - Ref",PX8665490,CDM,300,RC,86654,CPT,90,,,,,,,45,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,44.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.09,44.1
atropine (PF) 1 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517101025,NDC,1,ML,91.89,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,44.1072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
atropine (PF) 1 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517101025,NDC,1,ML,91.89,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,44.1072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
ALEXIS 0 LARGE STERILE,27200000,CDM,272,RC,,,,11765-MAIN,LOCAL,,,,,102.85,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,44.12265,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338411450,NDC,50,ML,106.23,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,44.127942,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
nafcillin 1 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,55150012215,NDC,1,EA,89.17,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,44.13915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010301,NDC,0.3,ML,45.04,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,44.1392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270004,NDC,100,ML,2827.78,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,44.15,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.85,44.15
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270010,NDC,100,ML,3458.14,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,44.15,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.85,44.15
immune globulin (Human) 10 GM/100ML Solution 100 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270005,NDC,100,ML,2827.78,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,44.15,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.85,44.15
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270006,NDC,100,ML,2912.78,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,44.15,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.85,44.15
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270012,NDC,100,ML,3293.58,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,44.15,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.85,44.15
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270007,NDC,100,ML,2827.78,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,44.15,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.85,44.15
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270013,NDC,100,ML,2827.78,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,44.15,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.85,44.15
sulfamethoxazole-trimethoprim 400-80 MG/5ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,703951403,NDC,10,ML,102.93,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,44.15697,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Blood Typing Abo,PX86900,CDM,300,RC,86900,CPT,,,,,,,,92,,Health Partners,Health Partners Care Plans,both,48,,44.86,percent of total billed charges,44.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.2168,111.6
Blood Typing Abo,PX86900,CDM,300,RC,86900,CPT,,,,,,,,92,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,44.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.2168,111.6
Blood Typing Rh (D),PX86901,CDM,300,RC,86901,CPT,,,,,,,,92,,Health Partners,Health Partners Care Plans,both,48,,44.86,percent of total billed charges,44.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.03,90.16
Blood Typing Rh (D),PX86901,CDM,300,RC,86901,CPT,,,,,,,,92,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,44.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.03,90.16
Parvovirus Antibody - Ref,PX8674790,CDM,300,RC,86747,CPT,90,,,,,,,92,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,44.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.78,90.16
Parvovirus Antibody - Ref,PX8674790,CDM,300,RC,86747,CPT,90,,,,,,,92,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,44.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.78,90.16
"Reticulocyte Count,Flow Cyto",PX85045,CDM,300,RC,85045,CPT,,,,,,,,92,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,44.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.66,90.16
"Reticulocyte Count,Flow Cyto",PX85045,CDM,300,RC,85045,CPT,,,,,,,,92,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,44.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.66,90.16
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665318,NDC,20,ML,50.08,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,44.17056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
sterile water (preservative free) Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323018520,NDC,20,ML,50.08,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,44.17056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,781523806,NDC,1,EA,106.34,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,44.173636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,781523864,NDC,1,EA,106.34,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,44.173636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,65862039010,NDC,1,EA,106.34,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,44.173636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
Assay of Transferrin,PX84466,CDM,300,RC,84466,CPT,,,,,,,,103,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,44.187,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.7,100.94
"Lactoferrin, Fecal; Qual",PX83630,CDM,300,RC,83630,CPT,,,,,,,,103,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,44.187,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.06,100.94
"Molecyto Insitu, 100-300cl - Ref",PX8827590,CDM,310,RC,88275,CPT,90,,,,,,,103,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,44.187,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.7862,100.94
"Tiss Cult,Non-Neop Lymph - Ref",PX8823090,CDM,310,RC,88230,CPT,90,,,,,,,103,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,44.187,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.7862,106.81
Antinuclear Ab(Ana) Titer - Ref,PX8603990,CDM,300,RC,86039,CPT,90,,,,,,,52,,First Health,Commercial,both,85,,999999999,percent of total billed charges,44.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.23,50.96
Assay Biovlbl Testosterone Direct Measurement - Ref,PX8441090,CDM,300,RC,84410,CPT,90,,,,,,,52,,First Health,Commercial,both,85,,999999999,percent of total billed charges,44.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.6008,50.96
"Beta 2 Glycoprot 1 Ab,Ea - Ref",PX8614690,CDM,300,RC,86146,CPT,90,,,,,,,52,,First Health,Commercial,both,85,,999999999,percent of total billed charges,44.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.6008,50.96
Iron - Ref,PX8354090,CDM,300,RC,83540,CPT,90,,,,,,,52,,First Health,Commercial,both,85,,999999999,percent of total billed charges,44.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,50.96
Rickettsia Antibody - Ref,PX8675790,CDM,300,RC,86757,CPT,90,,,,,,,52,,First Health,Commercial,both,85,,999999999,percent of total billed charges,44.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.74,50.96
Uric Acid; Blood,PX84550,CDM,300,RC,84550,CPT,,,,,,,,52,,First Health,Commercial,both,85,,999999999,percent of total billed charges,44.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.14,50.96
polyvinyl alcohol 1.4 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,50268067815,NDC,15,ML,45.42,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,44.207286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ROPivacaine 2 MG/ML Solution 10 mL Vial,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028513,NDC,10,ML,52.01,,First Health,Commercial,both,85,,999999999,percent of total billed charges,44.2085,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.604954,269.6078
"Noninvasv Oxygen Satut,Continuous",PX94762,CDM,460,RC,94762,CPT,,,,,,,,242,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,44.21,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.58,44.21
"Noninvasv Oxygen Satut,Continuous",PX94762,CDM,460,RC,94762,CPT,,,,,,,,242,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,44.21,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.58,44.21
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,409469930,NDC,20,ML,48.54,,Medica,Commercial,both,91.1,,0.687108295,percent of total billed charges,44.21994,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
artificial tears Ointment 3.5 g Tube,63700001,CDM,250,RC,,,,,,10119002239,NDC,3.5,GR,50.14,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,44.22348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188602,NDC,5,ML,45.46,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.66212,percent of total billed charges,44.246218,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.884084,44.5508
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188622,NDC,5,ML,45.46,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.66212,percent of total billed charges,44.246218,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.884084,44.5508
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,25021050002,NDC,1,ML,52.06,,First Health,Commercial,both,85,,999999999,percent of total billed charges,44.251,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
levoFLOXacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635261,NDC,0.5,EA,45.16,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,44.2568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,63323094004,NDC,4,ML,89.43,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,44.26785,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,63323094021,NDC,4,ML,89.43,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,44.26785,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 0.5 % PF 0.5 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323049101,NDC,50,ML,103.2,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,44.2728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
oxyCODONE CR 20 MG Tablet ER 12 hour Abuse-Deterrent 20 Each Box,63700001,CDM,250,RC,,,,,,59011042020,NDC,1,EA,52.09,,First Health,Commercial,both,85,,999999999,percent of total billed charges,44.2765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Gastric Intubation Treatment,PX43753F,CDM,510,RC,43753,CPT,,,,,,,,441,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,44.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.65,44.28
Gastric Intubation Treatment,PX43753F,CDM,510,RC,43753,CPT,,,,,,,,441,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,44.28,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.65,44.28
Gastric Intubation Treatment,PX43753P,CDM,983,RC,43753,CPT,,,,,,,,498,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,44.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.65,488.04
Gastric Intubation Treatment,PX43753P,CDM,983,RC,43753,CPT,,,,,,,,498,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,44.28,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.65,488.04
Injection for Nerve Block,PX64448F,CDM,510,RC,64448,CPT,,,,,,,,873,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,44.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.28,147.35
Injection for Nerve Block,PX64448F,CDM,510,RC,64448,CPT,,,,,,,,873,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,44.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.28,147.35
lidocaine (preservative free) 4 % Solution 5 mL Ampule,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409428325,NDC,5,ML,48.62,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,44.29282,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019600,NDC,1,ML,48.64,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,44.31104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,36000000924,NDC,200,ML,48.65,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,44.32015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.20921,64.9544
lidocaine 5 % Patch 1 Each Box,63700001,CDM,250,RC,,,,,,591352511,NDC,1,EA,50.26,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,44.32932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 5 % Patch 30 Each Box,63700001,CDM,250,RC,,,,,,591352530,NDC,1,EA,50.26,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,44.32932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361250,NDC,50,ML,90.53,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,7.983333333,percent of total billed charges,44.3597,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361250,NDC,50,ML,90.53,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,44.3597,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361250,NDC,50,ML,90.53,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,44.3597,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361650,NDC,50,ML,90.53,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,7.983333333,percent of total billed charges,44.3597,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361650,NDC,50,ML,90.53,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,44.3597,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361650,NDC,50,ML,90.53,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,44.3597,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
Neuromuscular Re-Education,PX97112,CDM,420,RC,97112,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,44.37,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.28,44.37
Neuromuscular Re-Education,PX97112,CDM,420,RC,97112,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,44.37,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.28,44.37
scopolamine 1 MG/3DAYS Patch 72 Hour 4 Each Box,25000000,CDM,250,RC,,,,,,45802058084,NDC,1,EA,103.43,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,44.37147,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011701,NDC,1,EA,89.64,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,44.3718,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011710,NDC,1,EA,89.64,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,44.3718,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
"lidocaine 2% -EPINEPHRine 1:200,000 2 %-1:200000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409318301,NDC,20,ML,49.86,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,44.3754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052084,NDC,1,EA,92.46,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,44.3808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.407884,90.9538
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052084,NDC,1,EA,92.46,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,44.3808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.407884,90.9538
vinCRIStine 1 MG/ML Solution 2 mL Vial,J9370.01,CDM,636,RC,J9370,HCPCS,,,,61703030916,NDC,2,ML,48.72,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,44.38392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.238288,47.7456
empagliflozin 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,597015230,NDC,1,EA,92.47,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,44.3856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
empagliflozin 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,597015230,NDC,1,EA,92.47,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,44.3856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016200,NDC,1,ML,52.22,,First Health,Commercial,both,85,,999999999,percent of total billed charges,44.387,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8092351,NDC,1,EA,52.22,,First Health,Commercial,both,85,,999999999,percent of total billed charges,44.387,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400101,NDC,1,EA,52.22,,First Health,Commercial,both,85,,999999999,percent of total billed charges,44.387,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400125,NDC,1,EA,52.22,,First Health,Commercial,both,85,,999999999,percent of total billed charges,44.387,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010310,NDC,1,ML,103.48,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,44.39292,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
HYDROmorphone 0.1 MG/ML Solution 55 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,61553067976,NDC,55,ML,89.7,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,44.4015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409663734,NDC,50,ML,89.7,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,44.4015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049237,NDC,30,ML,87.77,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,44.41162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,24208091055,NDC,3.5,GR,106.98,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,44.439492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,4080285,NDC,1,EA,89.79,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,44.44605,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
3.0MM NON-THREADED K WIRE,27200000,CDM,272,RC,C1769,HCPCS,,12658-MAIN,LOCAL,,,,,107,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,44.4478,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Androsetenedione - Ref,PX8215790,CDM,300,RC,82157,CPT,90,,,,,,,107,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,44.4478,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.85,104.86
Decalcify Tc,PX8831101,CDM,310,RC,88311,CPT,TC,,,,,,,107,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,44.4478,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
Fac/Trim Nail(S),PX11719F,CDM,510,RC,11719,CPT,,,,,,,,107,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,44.4478,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
Path Special Stains II,PX3979,CDM,310,RC,88313,CPT,TC,,,,,,,107,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,44.4478,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
"Special Stains,Group I",PX3978,CDM,310,RC,88312,CPT,TC,,,,,,,107,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,44.4478,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015901,NDC,0.3,ML,45.69,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,229.0777778,percent of total billed charges,44.470077,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015925,NDC,0.3,ML,45.69,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,229.0777778,percent of total billed charges,44.470077,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665305,NDC,20,ML,49.97,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,44.4733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
Emergency Level III Visit,PX99283P,CDM,981,RC,99283,CPT,,,,,,,,568,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,44.48,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,43.86,556.64
Emergency Level III Visit,PX99283P,CDM,981,RC,99283,CPT,,,,,,,,568,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,44.48,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,43.86,556.64
Facility Emergency Level III Visit,PX99283F,CDM,450,RC,99283,CPT,,,,,,,,587,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,44.48,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,43.86,126.18
Facility Emergency Level III Visit,PX99283F,CDM,450,RC,99283,CPT,,,,,,,,587,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,44.48,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,43.86,126.18
Abd Paracentesis,PX49082F,CDM,510,RC,49082,CPT,,,,,,,,884,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,44.5,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.5,439.29
ERBEFLO CLEVERCAP CO2 TUBING CAP SET,27200000,CDM,272,RC,,,,11831-MAIN,LOCAL,,,,,50,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,44.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
G6pd; Quant Screen - Ref,PX8295590,CDM,300,RC,82955,CPT,90,,,,,,,50,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,44.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.89,49
"Homogenization, Tissue for Culture",PX87176,CDM,300,RC,87176,CPT,,,,,,,,50,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,44.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.39,49
Injection for Nerve Block,PX64448F,CDM,510,RC,64448,CPT,,,,,,,,873,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,44.5,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.28,147.35
"NEEDLE ASP 16GX3/16"" 1-7/8"" ILLINOIS STERNAL 8881245164",120.8,CDM,272,RC,G0364,HCPCS,,5730-MAIN,LOCAL,,,,,50,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,44.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,49
"NEEDLE BONE MARROW 8G X 4"" BIOPSY/ASPIRATION 8881247087",120.8,CDM,272,RC,G0364,HCPCS,,166-MAIN,LOCAL,,,,,50,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,44.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,49
"NEEDLE BONE MARROW 11G X 4"" 8881247111",120.8,CDM,272,RC,G0364,HCPCS,,162-MAIN,LOCAL,,,,,50,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,44.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,49
Potassium; Urine,PX84133,CDM,300,RC,84133,CPT,,,,,,,,50,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,44.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.34,49
"Sigmoidoscopy,Biopsy",PX45331F,CDM,750,RC,45331,CPT,,,,,,,,1776,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,44.5,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.5,593.56
"Sigmoidoscopy,Biopsy",PX45331P,CDM,983,RC,45331,CPT,,,,,,,,1316,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,44.5,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.5,1289.68
polyvinyl alcohol 1.4 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,50268067815,NDC,15,ML,45.42,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,44.5116,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066501,NDC,0.25,ML,45.74,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,44.518742,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.000396,47.2262
venetoclax 100 MG Tablet 1 Each Box,25000000,CDM,250,RC,,,,,,74057611,NDC,0.2,EA,90.87,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,44.5263,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
venetoclax 100 MG Tablet 1 Each Box,25000000,CDM,250,RC,,,,,,74057611,NDC,0.2,EA,90.87,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,44.5263,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
venetoclax 100 MG Tablet 1 Each Box,25000000,CDM,250,RC,,,,,,74057611,NDC,0.2,EA,90.87,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,44.5263,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Apply of Paste Boot,PX29580P,CDM,983,RC,29580,CPT,,,,,,,,88,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,44.528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.5552,137.65
POSITIONING KIT TRENDELENBURG NUBLUE TP 3000-NB,27100000,CDM,271,RC,,,,12992-MAIN,LOCAL,,,,,88,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,44.528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
SPLINT ANKLE GEL BRACE UNIVERSAL AIRFORM 70351,120.61,CDM,274,RC,L4350,HCPCS,,12342-MAIN,LOCAL,,,,,88,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,44.528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.5552,104.38
SUCTION IRRIGATOR 2 0250070500,27200000,CDM,272,RC,,,,12262-MAIN,LOCAL,,,,,88,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,44.528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ACUSNARE POLYPECTOMY SNARE,27200000,CDM,272,RC,,,,7733-MAIN,LOCAL,,,,,45.75,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,44.528475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052083,NDC,1,EA,92.81,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,44.5488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.407884,90.9538
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052083,NDC,1,EA,92.81,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,44.5488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.407884,90.9538
"Gammaglobulin; Iga, Dg,M - Ref",PX8278490,CDM,300,RC,82784,CPT,90,,,,,,,90,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,44.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.53,88.2
"Misc Virus Antibody, Nos - Ref",PX8679090,CDM,300,RC,86790,CPT,90,,,,,,,90,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,44.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.81,88.2
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152P,CDM,983,RC,99152,CPT,,,,,,,,90,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,44.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.386,87.597
Mycobacteria Culture - Ref,PX8711690,CDM,300,RC,87116,CPT,90,,,,,,,90,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,44.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9,88.2
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188602,NDC,5,ML,45.46,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,44.5508,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.884084,44.5508
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188622,NDC,5,ML,45.46,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,44.5508,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.884084,44.5508
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665318,NDC,20,ML,50.08,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,44.5712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
sterile water (preservative free) Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323018520,NDC,20,ML,50.08,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,44.5712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
leflunomide 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,62332006130,NDC,1,EA,88.09,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,44.57354,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pegfilgrastim 6 MG/0.6ML Prefilled Syringe Kit 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019201,NDC,0.6,ML,13092.7,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,44.59,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.59,109.75
pegfilgrastim 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019001,NDC,0.6,ML,12711.36,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,44.59,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.59,109.75
apixaban 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,3089331,NDC,1,EA,50.57,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,44.60274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
etomidate 2 MG/ML Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,55150022220,NDC,10,ML,50.58,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,44.61156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004624,NDC,50,ML,50.58,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,44.61156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
Carnitine - Ref,PX8237990,CDM,300,RC,82379,CPT,90,,,,,,,104,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,44.616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.47,101.92
Cmv Antibody - Ref,PX8664490,CDM,300,RC,86644,CPT,90,,,,,,,104,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,44.616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,101.92
artificial tears Ointment 3.5 g Tube,63700001,CDM,250,RC,,,,,,10119002239,NDC,3.5,GR,50.14,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,44.6246,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
magnesium sulfate 1 g in 100 ml D5W (premix) 1-5 GM/100ML-% Solution 100 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010802,NDC,100,ML,52.51,,First Health,Commercial,both,85,,999999999,percent of total billed charges,44.6335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
Beta-2-Microglobulin - Ref,PX8223290,CDM,300,RC,82232,CPT,90,,,,,,,49,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,44.639,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.84,48.02
"Cannabinoids, Natural - Ref",PX8034990,CDM,300,RC,80349,CPT,90,,,,,,,49,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,44.639,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,48.02
cefTAZidime 1 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023525,NDC,1,EA,49,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,44.639,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
COLLAR CERVICAL X-LARGE WITH TRACH 2 PIECE OSG2404,120.185,CDM,274,RC,L0172,HCPCS,,10143-MAIN,LOCAL,,,,,49,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,44.639,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,152.79
Glycated Protein - Ref,PX8298590,CDM,300,RC,82985,CPT,90,,,,,,,49,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,44.639,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.37,48.02
"SUTURE V-LOC SZ 0 180 GREEN GS21 NEEDLE 18"" VLOCL0326",27200000,CDM,272,RC,,,,12218-MAIN,LOCAL,,,,,49,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,44.639,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
BOOT AIRSELECT SHORT LARGE 01ES-L,120.45,CDM,274,RC,L4360,HCPCS,,11890-MAIN,LOCAL,,,,,93,,Health Partners,Health Partners Care Plans,both,48,,69.84,percent of total billed charges,44.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT LARGE 01ES-L,120.45,CDM,274,RC,L4360,HCPCS,,11890-MAIN,LOCAL,,,,,93,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,44.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT MEDIUM 01ES-M,120.45,CDM,274,RC,L4360,HCPCS,,11889-MAIN,LOCAL,,,,,93,,Health Partners,Health Partners Care Plans,both,48,,69.84,percent of total billed charges,44.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT MEDIUM 01ES-M,120.45,CDM,274,RC,L4360,HCPCS,,11889-MAIN,LOCAL,,,,,93,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,44.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT SMALL 01ES-S,120.45,CDM,274,RC,L4360,HCPCS,,11888-MAIN,LOCAL,,,,,93,,Health Partners,Health Partners Care Plans,both,48,,69.84,percent of total billed charges,44.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT SMALL 01ES-S,120.45,CDM,274,RC,L4360,HCPCS,,11888-MAIN,LOCAL,,,,,93,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,44.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT X-LARGE 01ES-XL,120.45,CDM,274,RC,L4360,HCPCS,,11891-MAIN,LOCAL,,,,,93,,Health Partners,Health Partners Care Plans,both,48,,69.84,percent of total billed charges,44.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT X-LARGE 01ES-XL,120.45,CDM,274,RC,L4360,HCPCS,,11891-MAIN,LOCAL,,,,,93,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,44.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT X-SMALL 01ES-XS,120.45,CDM,274,RC,L4360,HCPCS,,11887-MAIN,LOCAL,,,,,93,,Health Partners,Health Partners Care Plans,both,48,,69.84,percent of total billed charges,44.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT X-SMALL 01ES-XS,120.45,CDM,274,RC,L4360,HCPCS,,11887-MAIN,LOCAL,,,,,93,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,44.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD LARGE 01EF-L,120.45,CDM,274,RC,L4360,HCPCS,,11697-MAIN,LOCAL,,,,,93,,Health Partners,Health Partners Care Plans,both,48,,69.84,percent of total billed charges,44.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD LARGE 01EF-L,120.45,CDM,274,RC,L4360,HCPCS,,11697-MAIN,LOCAL,,,,,93,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,44.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD MEDIUM 01EF-M,120.45,CDM,274,RC,L4360,HCPCS,,11696-MAIN,LOCAL,,,,,93,,Health Partners,Health Partners Care Plans,both,48,,69.84,percent of total billed charges,44.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD MEDIUM 01EF-M,120.45,CDM,274,RC,L4360,HCPCS,,11696-MAIN,LOCAL,,,,,93,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,44.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD SMALL 01EF-S,120.45,CDM,274,RC,L4360,HCPCS,,11695-MAIN,LOCAL,,,,,93,,Health Partners,Health Partners Care Plans,both,48,,69.84,percent of total billed charges,44.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD SMALL 01EF-S,120.45,CDM,274,RC,L4360,HCPCS,,11695-MAIN,LOCAL,,,,,93,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,44.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD X-LARGE 01EF-XL,120.45,CDM,274,RC,L4360,HCPCS,,11698-MAIN,LOCAL,,,,,93,,Health Partners,Health Partners Care Plans,both,48,,69.84,percent of total billed charges,44.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD X-LARGE 01EF-XL,120.45,CDM,274,RC,L4360,HCPCS,,11698-MAIN,LOCAL,,,,,93,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,44.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD X-SMALL 01EF-XS,120.45,CDM,274,RC,L4360,HCPCS,,11694-MAIN,LOCAL,,,,,93,,Health Partners,Health Partners Care Plans,both,48,,69.84,percent of total billed charges,44.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD X-SMALL 01EF-XS,120.45,CDM,274,RC,L4360,HCPCS,,11694-MAIN,LOCAL,,,,,93,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,44.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
Russell Viper Venom - Ref,PX8561390,CDM,300,RC,85613,CPT,90,,,,,,,93,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,44.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.78,91.14
Russell Viper Venom - Ref,PX8561390,CDM,300,RC,85613,CPT,90,,,,,,,93,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,44.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.78,91.14
SPLINT FOOT SMALL STRUT WALK 11-1383-2-00000,120.45,CDM,274,RC,L4360,HCPCS,,1205-MAIN,LOCAL,,,,,93,,Health Partners,Health Partners Care Plans,both,48,,69.84,percent of total billed charges,44.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
SPLINT FOOT SMALL STRUT WALK 11-1383-2-00000,120.45,CDM,274,RC,L4360,HCPCS,,1205-MAIN,LOCAL,,,,,93,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,44.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
fluticasone-salmeterol 250-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,54032756,NDC,1,EA,45.88,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,44.655004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ramuCIRumab 100 MG/10ML Solution 10 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2766901,NDC,10,ML,2463.3,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,44.7,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.7,73.76
ramuCIRumab 500 MG/50ML Solution 50 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2767801,NDC,50,ML,12316.5,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,44.7,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.7,73.76
Xray Facial Bones Less Than 3 Vws,PX7014001,CDM,320,RC,70140,CPT,TC,,,,,,,301,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,44.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.83,44.7
Xray Facial Bones Less Than 3 Vws,PX7014001,CDM,320,RC,70140,CPT,TC,,,,,,,301,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,44.7,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.83,44.7
"Xray Neck, Soft Tissue",PX7036001,CDM,320,RC,70360,CPT,TC,,,,,,,277,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,44.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.83,44.7
"Xray Neck, Soft Tissue",PX7036001,CDM,320,RC,70360,CPT,TC,,,,,,,277,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,44.7,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.83,44.7
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329330101,NDC,50,ML,107.61,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,44.701194,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
benzoin Tincture 59 mL Bottle,25000000,CDM,250,RC,,,,,,49348080130,NDC,59,ML,45.93,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,44.703669,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004722,NDC,2,ML,88.35,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,44.7051,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
Injection for Nerve Block,PX64445F,CDM,510,RC,64445,CPT,,,,,,,,385,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,44.71,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.71,329.3
Injection for Nerve Block,PX64445F,CDM,510,RC,64445,CPT,,,,,,,,385,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,44.71,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.71,329.3
Injection for Nerve Block,PX64445P,CDM,983,RC,64445,CPT,,,,,,,,385,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,44.71,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.71,377.3
Injection for Nerve Block,PX64445P,CDM,983,RC,64445,CPT,,,,,,,,385,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,44.71,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.71,377.3
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714020010,NDC,1,EA,107.64,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,44.713656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714020030,NDC,1,EA,107.64,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,44.713656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
lidocaine 5 % Patch 1 Each Box,63700001,CDM,250,RC,,,,,,591352511,NDC,1,EA,50.26,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,44.7314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 5 % Patch 30 Each Box,63700001,CDM,250,RC,,,,,,591352530,NDC,1,EA,50.26,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,44.7314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011801,NDC,0.5,ML,52.63,,First Health,Commercial,both,85,,999999999,percent of total billed charges,44.7355,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011805,NDC,0.5,ML,52.63,,First Health,Commercial,both,85,,999999999,percent of total billed charges,44.7355,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
clotrimazole 1 % Cream 28.35 g Tube,25000000,CDM,250,RC,,,,,,904782231,NDC,28.35,GR,50.75,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,44.7615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
DERMABOND ADVANCED TOPICAL SKIN ADHESIVE,120.198,CDM,272,RC,,,,9101-MAIN,LOCAL,,,,,46,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,44.7718,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.1084,45.08
Pinworm Exam,PX87172,CDM,300,RC,87172,CPT,,,,,,,,46,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,44.7718,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,45.08
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015901,NDC,0.3,ML,45.69,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,44.7762,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015925,NDC,0.3,ML,45.69,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,44.7762,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
Cardiac Rehab II Eval,PX93798.05,CDM,943,RC,93798,CPT,,,,,,,,364,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,44.79,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.29,44.79
Cardiac Rehab II W/ Monitor,PX93798.02,CDM,943,RC,93798,CPT,,,,,,,,338,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,44.79,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.29,44.79
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361250,NDC,50,ML,90.53,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,44.81235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361650,NDC,50,ML,90.53,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,44.81235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
sodium bicarbonate 4.2 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409553434,NDC,10,ML,91.46,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,44.8154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium bicarbonate 4.2 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409553434,NDC,10,ML,91.46,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,44.8154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium bicarbonate 4.2 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409553434,NDC,10,ML,91.46,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,44.8154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066501,NDC,0.25,ML,45.74,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,44.8252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.000396,47.2262
ACUSNARE POLYPECTOMY SNARE,27200000,CDM,272,RC,,,,7733-MAIN,LOCAL,,,,,45.75,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,44.835,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
prasugrel 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862083030,NDC,1,EA,88.64,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,44.85184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gentamicin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,60758018805,NDC,5,ML,107.98,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,44.854892,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
imipenem-cilastatin 250 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323034925,NDC,1,EA,91.55,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,44.8595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,173.1856
imipenem-cilastatin 250 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323034925,NDC,1,EA,91.55,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,44.8595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,173.1856
imipenem-cilastatin 250 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323034925,NDC,1,EA,91.55,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,44.8595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,173.1856
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032294,NDC,1,EA,91.55,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,44.8595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,173.1856
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032294,NDC,1,EA,91.55,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,44.8595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,173.1856
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032294,NDC,1,EA,91.55,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,44.8595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,173.1856
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234001,NDC,1.25,ML,91.55,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,44.8595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234001,NDC,1.25,ML,91.55,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,44.8595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234001,NDC,1.25,ML,91.55,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,44.8595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048557,NDC,50,ML,52.78,,First Health,Commercial,both,85,,999999999,percent of total billed charges,44.863,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Erythropietin - Ref,PX8266890,CDM,300,RC,82668,CPT,90,,,,,,,108,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,44.8632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,105.84
Levetiracetam - Ref,PX8017790,CDM,300,RC,80177,CPT,90,,,,,,,108,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,44.8632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,105.84
Oxcarbazepine - Ref,PX8018390,CDM,300,RC,80183,CPT,90,,,,,,,108,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,44.8632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,105.84
hydrocortisone 25 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,713050306,NDC,1,EA,108.03,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,44.875662,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 25 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713050312,NDC,1,EA,108.03,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,44.875662,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010269,NDC,1,EA,88.69,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,44.87714,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010299,NDC,1,EA,88.69,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,44.87714,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614201,NDC,1,ML,88.69,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,44.87714,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.097864,86.9162
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614225,NDC,1,ML,88.69,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,44.87714,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.097864,86.9162
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963801,NDC,0.5,ML,88.69,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,44.87714,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
empagliflozin 10 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,597015237,NDC,1,EA,104.66,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,44.89914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atropine 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100401,NDC,0.5,ML,50.91,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,44.90262,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
acyclovir 50 MG/ML Solution 10 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,55150015410,NDC,10,ML,108.16,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,44.929664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.927644,105.9968
Abd Paracentesis,PX49082F,CDM,510,RC,49082,CPT,,,,,,,,884,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,44.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.5,439.29
Abd Paracentesis,PX49082F,CDM,510,RC,49082,CPT,,,,,,,,884,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,44.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.5,439.29
"Fna Biopsy, W/US Guidance; First Lesion",PX10005F,CDM,510,RC,10005,CPT,,,,,,,,333,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,44.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.93,278.8
"Fna Biopsy, W/US Guidance; First Lesion",PX10005F,CDM,510,RC,10005,CPT,,,,,,,,333,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,44.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.93,278.8
"Fna Biopsy, W/US Guidance; First Lesion",PX10005P,CDM,983,RC,10005,CPT,,,,,,,,621,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,44.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.93,608.58
"Fna Biopsy, W/US Guidance; First Lesion",PX10005P,CDM,983,RC,10005,CPT,,,,,,,,621,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,44.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.93,608.58
Injection for Nerve Block,PX64445F,CDM,510,RC,64445,CPT,,,,,,,,385,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,44.93,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.71,329.3
Injection for Nerve Block,PX64445P,CDM,983,RC,64445,CPT,,,,,,,,385,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,44.93,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.71,377.3
"Sigmoidoscopy,Biopsy",PX45331F,CDM,750,RC,45331,CPT,,,,,,,,1776,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,44.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.5,593.56
"Sigmoidoscopy,Biopsy",PX45331F,CDM,750,RC,45331,CPT,,,,,,,,1776,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,44.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.5,593.56
"Sigmoidoscopy,Biopsy",PX45331P,CDM,983,RC,45331,CPT,,,,,,,,1316,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,44.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.5,1289.68
"Sigmoidoscopy,Biopsy",PX45331P,CDM,983,RC,45331,CPT,,,,,,,,1316,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,44.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.5,1289.68
rosuvastatin 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16714098801,NDC,1,EA,46.18,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,44.946994,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,781323294,NDC,1,EA,52.89,,First Health,Commercial,both,85,,999999999,percent of total billed charges,44.9565,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
fluticasone-salmeterol 250-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,54032756,NDC,1,EA,45.88,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,44.9624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,67815203,NDC,100,GR,91.77,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,44.9673,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,67815203,NDC,100,GR,91.77,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,44.9673,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,67815203,NDC,100,GR,91.77,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,44.9673,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Fac/Trm Hyperkeratotic Skn Lesn2-4,PX11056F,CDM,510,RC,11056,CPT,,,,,,,,158,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,44.97,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.52,171.57
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329334001,NDC,10,ML,88.88,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,44.97328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
venetoclax 100 MG Tablet 1 Each Box,25000000,CDM,250,RC,,,,,,74057611,NDC,0.2,EA,90.87,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,44.98065,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
DRAPE STERILE 109X100X110 ROBOTIC DYNJP9108,27200000,CDM,272,RC,,,,12020-MAIN,LOCAL,,,,,51,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,44.982,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Immunohisto Antibody Slide Ea Multiplex,PX8834401,CDM,310,RC,88344,CPT,TC,,,,,,,51,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,44.982,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,314.02
RANGER UNIT TUBING FLUID WARMING,120.229,CDM,272,RC,,,,10612-MAIN,LOCAL,,,,,51,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,44.982,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,49.98
SCAR GEL SHEET,120.458,CDM,273,RC,A6025,HCPCS,,5796-MAIN,LOCAL,,,,,51,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,44.982,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,49.98
TUBE FEEDING DECLOGGING SYSTEM CLOG ZAPPER 20-0002,120.277,CDM,272,RC,,,,4226-MAIN,LOCAL,,,,,51,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,44.982,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,49.98
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001104,NDC,1,EA,108.29,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,44.983666,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001103,NDC,1,EA,108.34,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,45.004436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
apixaban 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,3089331,NDC,1,EA,50.57,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,45.0073,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
benzoin Tincture 59 mL Bottle,25000000,CDM,250,RC,,,,,,49348080130,NDC,59,ML,45.93,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,45.0114,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
etomidate 2 MG/ML Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,55150022220,NDC,10,ML,50.58,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,45.0162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004624,NDC,50,ML,50.58,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,45.0162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
atropine (PF) 1 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517101025,NDC,1,ML,91.89,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,45.0261,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
atropine (PF) 1 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517101025,NDC,1,ML,91.89,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,45.0261,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
atropine (PF) 1 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517101025,NDC,1,ML,91.89,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,45.0261,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
Aldolase - Ref,PX8208590,CDM,300,RC,82085,CPT,90,,,,,,,89,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,45.034,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.9,87.22
Assay of Ggt,PX82977,CDM,300,RC,82977,CPT,,,,,,,,89,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,45.034,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6,87.22
"Debridement of Nail(S), 1-5",PX11720F,CDM,510,RC,11720,CPT,,,,,,,,89,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,45.034,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.9706,87.22
"Hla a, B or C, Single Ag - Ref",PX8681290,CDM,300,RC,86812,CPT,90,,,,,,,89,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,45.034,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.67,87.22
KIT INTRODUCER 8.5FR AK-09803-CDC,120.128,CDM,272,RC,,,,8826-MAIN,LOCAL,,,,,89,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,45.034,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.9706,87.22
lidocaine HCl 4 % Cream 133 g Tube,63700001,CDM,250,RC,,,,,,41167005828,NDC,133,GR,52.99,,First Health,Commercial,both,85,,999999999,percent of total billed charges,45.0415,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Dx Occult Blood Immunoassay,PX82274,CDM,300,RC,82274,CPT,,,,,,,,105,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,45.045,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.6,102.9
Specimen Concentration - Ref,PX8701590,CDM,300,RC,87015,CPT,90,,,,,,,105,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,45.045,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.12,102.9
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,17478007035,NDC,3.5,GR,105.01,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,45.04929,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Dystrophic Nail Trimming Any Number,PXG0127F,CDM,940,RC,G0127,HCPCS,,,,,,,,53,,First Health,Commercial,both,85,,999999999,percent of total billed charges,45.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.0162,53.44
Renin - Ref,PX8424490,CDM,300,RC,84244,CPT,90,,,,,,,53,,First Health,Commercial,both,85,,999999999,percent of total billed charges,45.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.16,51.94
lidocaine urethral/mucosal 2 % Gel 30 mL Tube,25000000,CDM,250,RC,,,,,,17478084030,NDC,30,ML,93.91,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,45.0768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine urethral/mucosal 2 % Gel 30 mL Tube,25000000,CDM,250,RC,,,,,,17478084030,NDC,30,ML,93.91,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,45.0768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Blood Typing Abo,PX86900,CDM,300,RC,86900,CPT,,,,,,,,92,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,8.386666667,percent of total billed charges,45.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.2168,111.6
Blood Typing Abo,PX86900,CDM,300,RC,86900,CPT,,,,,,,,92,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,45.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.2168,111.6
Blood Typing Abo,PX86900,CDM,300,RC,86900,CPT,,,,,,,,92,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,45.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.2168,111.6
Blood Typing Rh (D),PX86901,CDM,300,RC,86901,CPT,,,,,,,,92,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,8.386666667,percent of total billed charges,45.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.03,90.16
Blood Typing Rh (D),PX86901,CDM,300,RC,86901,CPT,,,,,,,,92,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,45.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.03,90.16
Blood Typing Rh (D),PX86901,CDM,300,RC,86901,CPT,,,,,,,,92,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,45.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.03,90.16
DERMABOND ADVANCED TOPICAL SKIN ADHESIVE,120.198,CDM,272,RC,,,,9101-MAIN,LOCAL,,,,,46,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,45.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.1084,45.08
Parvovirus Antibody - Ref,PX8674790,CDM,300,RC,86747,CPT,90,,,,,,,92,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,45.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.78,90.16
Parvovirus Antibody - Ref,PX8674790,CDM,300,RC,86747,CPT,90,,,,,,,92,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,45.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.78,90.16
Parvovirus Antibody - Ref,PX8674790,CDM,300,RC,86747,CPT,90,,,,,,,92,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,45.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.78,90.16
Pinworm Exam,PX87172,CDM,300,RC,87172,CPT,,,,,,,,46,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,45.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,45.08
"Reticulocyte Count,Flow Cyto",PX85045,CDM,300,RC,85045,CPT,,,,,,,,92,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,45.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.66,90.16
"Reticulocyte Count,Flow Cyto",PX85045,CDM,300,RC,85045,CPT,,,,,,,,92,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,45.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.66,90.16
"Reticulocyte Count,Flow Cyto",PX85045,CDM,300,RC,85045,CPT,,,,,,,,92,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,45.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.66,90.16
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338067104,NDC,1000,ML,53.06,,First Health,Commercial,both,85,,999999999,percent of total billed charges,45.101,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
Coccidioides Antibody - Ref,PX8663590,CDM,300,RC,86635,CPT,90,,,,,,,94,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,45.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.52,92.12
Coccidioides Antibody - Ref,PX8663590,CDM,300,RC,86635,CPT,90,,,,,,,94,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,45.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.52,92.12
Copper - Ref,PX8252590,CDM,300,RC,82525,CPT,90,,,,,,,94,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,45.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.38,92.12
Copper - Ref,PX8252590,CDM,300,RC,82525,CPT,90,,,,,,,94,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,45.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.38,92.12
DEFIBRILLATION PAD MULTI FUNCTION ADULT,120.58,CDM,271,RC,A0392,HCPCS,,1320-MAIN,LOCAL,,,,,94,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,45.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
DEFIBRILLATION PAD MULTI FUNCTION ADULT,120.58,CDM,271,RC,A0392,HCPCS,,1320-MAIN,LOCAL,,,,,94,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,45.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
DEFIBRILLATION PAD PEDI PADZ PEDS,120.58,CDM,271,RC,A0392,HCPCS,,1322-MAIN,LOCAL,,,,,94,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,45.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
DEFIBRILLATION PAD PEDI PADZ PEDS,120.58,CDM,271,RC,A0392,HCPCS,,1322-MAIN,LOCAL,,,,,94,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,45.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
DRESSING NASAL 4.5CM NON-INFLATABLE RAPID RHINO RR450,120.97,CDM,272,RC,A6407,HCPCS,,616-MAIN,LOCAL,,,,,94,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,45.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
DRESSING NASAL 4.5CM NON-INFLATABLE RAPID RHINO RR450,120.97,CDM,272,RC,A6407,HCPCS,,616-MAIN,LOCAL,,,,,94,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,45.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
DRESSING NASAL 5.5CM INFLATABLE RAPID RHINO RR550,120.97,CDM,272,RC,A6407,HCPCS,,606-MAIN,LOCAL,,,,,94,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,45.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
DRESSING NASAL 5.5CM INFLATABLE RAPID RHINO RR550,120.97,CDM,272,RC,A6407,HCPCS,,606-MAIN,LOCAL,,,,,94,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,45.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
DRESSING NASAL 7.5CM INFLATABLE RAPID RHINO RR750,120.97,CDM,272,RC,A6407,HCPCS,,611-MAIN,LOCAL,,,,,94,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,45.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
DRESSING NASAL 7.5CM INFLATABLE RAPID RHINO RR750,120.97,CDM,272,RC,A6407,HCPCS,,611-MAIN,LOCAL,,,,,94,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,45.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
DRESSING NASAL 8CM LONGX1.5CM THICK X3CM HIGH ANATOMICAL 34-105,120.97,CDM,272,RC,A6407,HCPCS,,613-MAIN,LOCAL,,,,,94,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,45.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
DRESSING NASAL 8CM LONGX1.5CM THICK X3CM HIGH ANATOMICAL 34-105,120.97,CDM,272,RC,A6407,HCPCS,,613-MAIN,LOCAL,,,,,94,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,45.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
Tissue Exam for Fungi,PX87220,CDM,300,RC,87220,CPT,,,,,,,,94,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,45.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,92.12
Tissue Exam for Fungi,PX87220,CDM,300,RC,87220,CPT,,,,,,,,94,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,45.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,92.12
TUBING IRRIGATION F SET STERILE MXB-T,27200000,CDM,272,RC,,,,11693-MAIN,LOCAL,,,,,94,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,45.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TUBING IRRIGATION F SET STERILE MXB-T,27200000,CDM,272,RC,,,,11693-MAIN,LOCAL,,,,,94,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,45.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
nafcillin 1 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,55150012215,NDC,1,EA,89.17,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,45.12002,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Fna Biopsy, W/US Guidance; First Lesion",PX10005F,CDM,510,RC,10005,CPT,,,,,,,,333,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,45.15,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.93,278.8
"Fna Biopsy, W/US Guidance; First Lesion",PX10005P,CDM,983,RC,10005,CPT,,,,,,,,621,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,45.15,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.93,608.58
clotrimazole 1 % Cream 28.35 g Tube,25000000,CDM,250,RC,,,,,,904782231,NDC,28.35,GR,50.75,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,45.1675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
OBINutuzumab 1000 MG/40ML Solution 40 mL Vial,J9301.01,CDM,636,RC,J9301,HCPCS,,,,50242007001,NDC,4,ML,1397.15,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,45.22,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.22,73.86
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,63323094004,NDC,4,ML,89.43,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,45.25158,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,63323094021,NDC,4,ML,89.43,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,45.25158,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
rosuvastatin 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16714098801,NDC,1,EA,46.18,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,45.2564,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium bicarbonate 4.2 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409553434,NDC,10,ML,91.46,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,45.2727,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Inject Nerv Blck,Trigeminal",PX64400F,CDM,510,RC,64400,CPT,,,,,,,,255,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,45.2751,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.1,236.6
"Inject Nerv Blck,Trigeminal",PX64400P,CDM,983,RC,64400,CPT,,,,,,,,170,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,45.2751,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.1,236.6
Injection for Shoulder Arthrogram,PX23350F,CDM,510,RC,23350,CPT,,,,,,,,675,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,45.2751,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.54,335.52
"RBC Sed Rate, Auto",PX85652,CDM,300,RC,85652,CPT,,,,,,,,109,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,45.2786,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.48,106.82
Smear Gram Stain,PX87205,CDM,300,RC,87205,CPT,,,,,,,,109,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,45.2786,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,106.82
Smear Wet Mount Saline/Ink,PX87210,CDM,300,RC,87210,CPT,,,,,,,,109,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,45.2786,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.34,106.82
"West Nile Ab, Igm - Ref",PX8678890,CDM,300,RC,86788,CPT,90,,,,,,,109,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,45.2786,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.45,106.82
dabigatran 75 MG capsule 60 Each Box,63700001,CDM,250,RC,,,,,,597035556,NDC,1,EA,53.27,,First Health,Commercial,both,85,,999999999,percent of total billed charges,45.2795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052084,NDC,1,EA,92.46,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,45.3054,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.407884,90.9538
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052084,NDC,1,EA,92.46,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,45.3054,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.407884,90.9538
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052084,NDC,1,EA,92.46,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,45.3054,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.407884,90.9538
atropine 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100401,NDC,0.5,ML,50.91,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,45.3099,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
empagliflozin 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,597015230,NDC,1,EA,92.47,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,45.3103,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
empagliflozin 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,597015230,NDC,1,EA,92.47,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,45.3103,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
empagliflozin 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,597015230,NDC,1,EA,92.47,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,45.3103,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
imipenem-cilastatin 250 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323034925,NDC,1,EA,91.55,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,45.31725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,173.1856
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032294,NDC,1,EA,91.55,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,45.31725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,173.1856
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234001,NDC,1.25,ML,91.55,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,45.31725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703331101,NDC,0.75,ML,51.41,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,45.34362,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011701,NDC,1,EA,89.64,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,45.35784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011710,NDC,1,EA,89.64,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,45.35784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
Xray Toe(S) Tc,PX7366001,CDM,320,RC,73660,CPT,TC,,,,,,,282,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,45.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.05,45.36
Xray Toe(S) Tc,PX7366001,CDM,320,RC,73660,CPT,TC,,,,,,,282,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,45.36,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.05,45.36
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714000601,NDC,0.3,ML,53.39,,First Health,Commercial,both,85,,999999999,percent of total billed charges,45.3815,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329335201,NDC,50,ML,109.26,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,45.386604,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
HYDROmorphone 0.1 MG/ML Solution 55 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,61553067976,NDC,55,ML,89.7,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,45.3882,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409663734,NDC,50,ML,89.7,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,45.3882,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
DRAPE STERILE 109X100X110 ROBOTIC DYNJP9108,27200000,CDM,272,RC,,,,12020-MAIN,LOCAL,,,,,51,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,45.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Immunohisto Antibody Slide Ea Multiplex,PX8834401,CDM,310,RC,88344,CPT,TC,,,,,,,51,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,45.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,314.02
RANGER UNIT TUBING FLUID WARMING,120.229,CDM,272,RC,,,,10612-MAIN,LOCAL,,,,,51,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,45.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,49.98
SCAR GEL SHEET,120.458,CDM,273,RC,A6025,HCPCS,,5796-MAIN,LOCAL,,,,,51,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,45.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,49.98
TUBE FEEDING DECLOGGING SYSTEM CLOG ZAPPER 20-0002,120.277,CDM,272,RC,,,,4226-MAIN,LOCAL,,,,,51,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,45.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,49.98
cyclopentolate 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,61314039601,NDC,2,ML,94.58,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,45.3984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
cyclopentolate 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,61314039601,NDC,2,ML,94.58,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,45.3984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,67457022800,NDC,5,ML,53.42,,First Health,Commercial,both,85,,999999999,percent of total billed charges,45.407,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,67457057305,NDC,5,ML,53.42,,First Health,Commercial,both,85,,999999999,percent of total billed charges,45.407,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 4 % Cream 5 g Tube,63700001,CDM,250,RC,,,,,,496088205,NDC,5,GR,51.49,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,45.41418,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"lidocaine 2% -EPINEPHRine 1:200,000 2 %-1:200000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409318301,NDC,20,ML,49.86,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,45.42246,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
methylPREDNISolone sod succ 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,63323025803,NDC,0.4,EA,46.67,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,45.423911,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,67815203,NDC,100,GR,91.77,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,45.42615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,4080285,NDC,1,EA,89.79,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,45.43374,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,17478062512,NDC,2.5,ML,109.45,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,45.46553,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
GLIDESCOPE QC MILLER S0 SINGLE USE 0270-1087,120.58,CDM,272,RC,,,,13024-MAIN,LOCAL,,,,,106,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,45.474,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
GLIDESCOPE QC MILLER S1 SINGLE USE 0270-1088,120.58,CDM,272,RC,,,,13025-MAIN,LOCAL,,,,,106,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,45.474,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052083,NDC,1,EA,92.81,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,45.4769,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.407884,90.9538
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052083,NDC,1,EA,92.81,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,45.4769,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.407884,90.9538
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052083,NDC,1,EA,92.81,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,45.4769,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.407884,90.9538
"lidocaine 2%-EPINEPHrine 1:100,000 2 %-1:100000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,409318221,NDC,30,ML,51.57,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,45.48474,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
atropine (PF) 1 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517101025,NDC,1,ML,91.89,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,45.48555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
cefTRIAXone in dextrose 1 g / 50 mL 1-3.74 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0696.01,CDM,636,RC,J0696,HCPCS,,,,264315311,NDC,1,EA,106.03,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,45.48687,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
SAW BLADE 300 SAGITTAL 25X9.4X0.7,27200000,CDM,272,RC,,,,11592-MAIN,LOCAL,,,,,46.75,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,45.501775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SAW BLADE 300 SAGITTAL 40X14X0.6MM,27200000,CDM,272,RC,,,,11591-MAIN,LOCAL,,,,,46.75,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,45.501775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665305,NDC,20,ML,49.97,,Medica,Commercial,both,91.1,,1.111818182,percent of total billed charges,45.52267,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
scopolamine 1 MG/3DAYS Patch 72 Hour 24 Each Box,25000000,CDM,250,RC,,,,,,50742050524,NDC,1,EA,109.59,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,45.523686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061401,NDC,1,ML,94.87,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,45.5376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.114178,99.911
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061401,NDC,1,ML,94.87,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,45.5376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.114178,99.911
Blood Typing Abo,PX86900,CDM,300,RC,86900,CPT,,,,,,,,92,,Humana Choice Care,All Medicare plans,outpatient,49.5,,45.08,percent of total billed charges,45.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.2168,111.6
Blood Typing Rh (D),PX86901,CDM,300,RC,86901,CPT,,,,,,,,92,,Humana Choice Care,All Medicare plans,outpatient,49.5,,45.08,percent of total billed charges,45.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.03,90.16
"Gammaglobulin; Iga, Dg,M - Ref",PX8278490,CDM,300,RC,82784,CPT,90,,,,,,,90,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,45.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.53,88.2
"Misc Virus Antibody, Nos - Ref",PX8679090,CDM,300,RC,86790,CPT,90,,,,,,,90,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,45.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.81,88.2
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152P,CDM,983,RC,99152,CPT,,,,,,,,90,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,45.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.386,87.597
Mycobacteria Culture - Ref,PX8711690,CDM,300,RC,87116,CPT,90,,,,,,,90,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,45.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9,88.2
Parvovirus Antibody - Ref,PX8674790,CDM,300,RC,86747,CPT,90,,,,,,,92,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,45.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.78,90.16
"Reticulocyte Count,Flow Cyto",PX85045,CDM,300,RC,85045,CPT,,,,,,,,92,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,45.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.66,90.16
ERBEFLO CLEVERCAP CO2 TUBING CAP SET,27200000,CDM,272,RC,,,,11831-MAIN,LOCAL,,,,,50,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,45.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
G6pd; Quant Screen - Ref,PX8295590,CDM,300,RC,82955,CPT,90,,,,,,,50,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,45.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.89,49
"Homogenization, Tissue for Culture",PX87176,CDM,300,RC,87176,CPT,,,,,,,,50,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,45.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.39,49
"NEEDLE ASP 16GX3/16"" 1-7/8"" ILLINOIS STERNAL 8881245164",120.8,CDM,272,RC,G0364,HCPCS,,5730-MAIN,LOCAL,,,,,50,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,45.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,49
"NEEDLE BONE MARROW 8G X 4"" BIOPSY/ASPIRATION 8881247087",120.8,CDM,272,RC,G0364,HCPCS,,166-MAIN,LOCAL,,,,,50,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,45.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,49
"NEEDLE BONE MARROW 11G X 4"" 8881247111",120.8,CDM,272,RC,G0364,HCPCS,,162-MAIN,LOCAL,,,,,50,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,45.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,49
Potassium; Urine,PX84133,CDM,300,RC,84133,CPT,,,,,,,,50,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,45.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.34,49
BOOT AIRSELECT SHORT LARGE 01ES-L,120.45,CDM,274,RC,L4360,HCPCS,,11890-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,45.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT LARGE 01ES-L,120.45,CDM,274,RC,L4360,HCPCS,,11890-MAIN,LOCAL,,,,,93,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,45.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT LARGE 01ES-L,120.45,CDM,274,RC,L4360,HCPCS,,11890-MAIN,LOCAL,,,,,93,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,45.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT MEDIUM 01ES-M,120.45,CDM,274,RC,L4360,HCPCS,,11889-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,45.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT MEDIUM 01ES-M,120.45,CDM,274,RC,L4360,HCPCS,,11889-MAIN,LOCAL,,,,,93,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,45.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT MEDIUM 01ES-M,120.45,CDM,274,RC,L4360,HCPCS,,11889-MAIN,LOCAL,,,,,93,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,45.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT SMALL 01ES-S,120.45,CDM,274,RC,L4360,HCPCS,,11888-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,45.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT SMALL 01ES-S,120.45,CDM,274,RC,L4360,HCPCS,,11888-MAIN,LOCAL,,,,,93,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,45.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT SMALL 01ES-S,120.45,CDM,274,RC,L4360,HCPCS,,11888-MAIN,LOCAL,,,,,93,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,45.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT X-LARGE 01ES-XL,120.45,CDM,274,RC,L4360,HCPCS,,11891-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,45.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT X-LARGE 01ES-XL,120.45,CDM,274,RC,L4360,HCPCS,,11891-MAIN,LOCAL,,,,,93,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,45.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT X-LARGE 01ES-XL,120.45,CDM,274,RC,L4360,HCPCS,,11891-MAIN,LOCAL,,,,,93,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,45.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT X-SMALL 01ES-XS,120.45,CDM,274,RC,L4360,HCPCS,,11887-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,45.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT X-SMALL 01ES-XS,120.45,CDM,274,RC,L4360,HCPCS,,11887-MAIN,LOCAL,,,,,93,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,45.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT X-SMALL 01ES-XS,120.45,CDM,274,RC,L4360,HCPCS,,11887-MAIN,LOCAL,,,,,93,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,45.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD LARGE 01EF-L,120.45,CDM,274,RC,L4360,HCPCS,,11697-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,45.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD LARGE 01EF-L,120.45,CDM,274,RC,L4360,HCPCS,,11697-MAIN,LOCAL,,,,,93,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,45.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD LARGE 01EF-L,120.45,CDM,274,RC,L4360,HCPCS,,11697-MAIN,LOCAL,,,,,93,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,45.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD MEDIUM 01EF-M,120.45,CDM,274,RC,L4360,HCPCS,,11696-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,45.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD MEDIUM 01EF-M,120.45,CDM,274,RC,L4360,HCPCS,,11696-MAIN,LOCAL,,,,,93,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,45.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD MEDIUM 01EF-M,120.45,CDM,274,RC,L4360,HCPCS,,11696-MAIN,LOCAL,,,,,93,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,45.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD SMALL 01EF-S,120.45,CDM,274,RC,L4360,HCPCS,,11695-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,45.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD SMALL 01EF-S,120.45,CDM,274,RC,L4360,HCPCS,,11695-MAIN,LOCAL,,,,,93,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,45.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD SMALL 01EF-S,120.45,CDM,274,RC,L4360,HCPCS,,11695-MAIN,LOCAL,,,,,93,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,45.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD X-LARGE 01EF-XL,120.45,CDM,274,RC,L4360,HCPCS,,11698-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,45.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD X-LARGE 01EF-XL,120.45,CDM,274,RC,L4360,HCPCS,,11698-MAIN,LOCAL,,,,,93,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,45.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD X-LARGE 01EF-XL,120.45,CDM,274,RC,L4360,HCPCS,,11698-MAIN,LOCAL,,,,,93,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,45.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD X-SMALL 01EF-XS,120.45,CDM,274,RC,L4360,HCPCS,,11694-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,45.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD X-SMALL 01EF-XS,120.45,CDM,274,RC,L4360,HCPCS,,11694-MAIN,LOCAL,,,,,93,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,45.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD X-SMALL 01EF-XS,120.45,CDM,274,RC,L4360,HCPCS,,11694-MAIN,LOCAL,,,,,93,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,45.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
Russell Viper Venom - Ref,PX8561390,CDM,300,RC,85613,CPT,90,,,,,,,93,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,45.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.78,91.14
Russell Viper Venom - Ref,PX8561390,CDM,300,RC,85613,CPT,90,,,,,,,93,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,45.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.78,91.14
Russell Viper Venom - Ref,PX8561390,CDM,300,RC,85613,CPT,90,,,,,,,93,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,45.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.78,91.14
SPLINT FOOT SMALL STRUT WALK 11-1383-2-00000,120.45,CDM,274,RC,L4360,HCPCS,,1205-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,45.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
SPLINT FOOT SMALL STRUT WALK 11-1383-2-00000,120.45,CDM,274,RC,L4360,HCPCS,,1205-MAIN,LOCAL,,,,,93,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,45.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
SPLINT FOOT SMALL STRUT WALK 11-1383-2-00000,120.45,CDM,274,RC,L4360,HCPCS,,1205-MAIN,LOCAL,,,,,93,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,45.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338411450,NDC,50,ML,106.23,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,45.57267,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
Ultrasound Breast Complete,PX7664101,CDM,402,RC,76641,CPT,TC,,,,,,,333,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,45.59,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.59,134.77
Ultrasound Breast Complete,PX7664101,CDM,402,RC,76641,CPT,TC,,,,,,,333,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,45.59,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.59,134.77
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006F,CDM,510,RC,10006,CPT,,,,,,,,213,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,45.5962,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.76,124.52
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006P,CDM,983,RC,10006,CPT,,,,,,,,142,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,45.5962,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.76,139.16
Assay Blood Carbon Dioxide,PX82374,CDM,300,RC,82374,CPT,,,,,,,,95,,Health Partners,Health Partners Care Plans,both,48,,45.43,percent of total billed charges,45.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.47,93.1
Assay Blood Carbon Dioxide,PX82374,CDM,300,RC,82374,CPT,,,,,,,,95,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,45.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.47,93.1
Blood Viscosity Examination,PX85810,CDM,300,RC,85810,CPT,,,,,,,,95,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,45.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.7,93.1
Blood Viscosity Examination,PX85810,CDM,300,RC,85810,CPT,,,,,,,,95,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,45.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.7,93.1
Cyclosporine - Ref,PX8015890,CDM,300,RC,80158,CPT,90,,,,,,,95,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,45.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.55,93.1
Cyclosporine - Ref,PX8015890,CDM,300,RC,80158,CPT,90,,,,,,,95,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,45.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.55,93.1
"Fac/Debridement of Nails, 6 or Mor",PX11721F,CDM,510,RC,11721,CPT,,,,,,,,95,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,45.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.463,93.1
"Fac/Debridement of Nails, 6 or Mor",PX11721F,CDM,510,RC,11721,CPT,,,,,,,,95,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,45.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.463,93.1
"Fat/Lipids, Feces, Quant - Ref",PX8271090,CDM,300,RC,82710,CPT,90,,,,,,,95,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,45.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.4,93.1
"Fat/Lipids, Feces, Quant - Ref",PX8271090,CDM,300,RC,82710,CPT,90,,,,,,,95,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,45.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.4,93.1
KIT EPIDURAL 19GA FLEXTIP PLUS AK-05502,120.305,CDM,272,RC,,,,11413-MAIN,LOCAL,,,,,95,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,45.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.463,93.1
KIT EPIDURAL 19GA FLEXTIP PLUS AK-05502,120.305,CDM,272,RC,,,,11413-MAIN,LOCAL,,,,,95,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,45.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.463,93.1
"Lyme Disease, Confirm Tst - Ref",PX8661790,CDM,300,RC,86617,CPT,90,,,,,,,95,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,45.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.2,93.1
"Lyme Disease, Confirm Tst - Ref",PX8661790,CDM,300,RC,86617,CPT,90,,,,,,,95,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,45.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.2,93.1
"Organism ID, Anaerobic - Ref",PX8707690,CDM,300,RC,87076,CPT,90,,,,,,,95,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,45.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,93.1
"Organism ID, Anaerobic - Ref",PX8707690,CDM,300,RC,87076,CPT,90,,,,,,,95,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,45.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,93.1
Strep a Assay W/Optic,PX87880,CDM,300,RC,87880,CPT,,,,,,,,95,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,45.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.16,93.1
Strep a Assay W/Optic,PX87880,CDM,300,RC,87880,CPT,,,,,,,,95,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,45.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.16,93.1
"Thyroxine, Total - Ref",PX8443690,CDM,300,RC,84436,CPT,90,,,,,,,95,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,45.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.3,93.1
"Thyroxine, Total - Ref",PX8443690,CDM,300,RC,84436,CPT,90,,,,,,,95,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,45.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.3,93.1
TRAY FACIAL LACERATION PACK STERILE 96-1707,120.12,CDM,272,RC,,,,406-MAIN,LOCAL,,,,,95,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,45.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.463,93.1
TRAY FACIAL LACERATION PACK STERILE 96-1707,120.12,CDM,272,RC,,,,406-MAIN,LOCAL,,,,,95,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,45.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.463,93.1
Varicella-Zoster Antibody,PX86787,CDM,300,RC,86787,CPT,,,,,,,,95,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,45.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.81,93.1
Varicella-Zoster Antibody,PX86787,CDM,300,RC,86787,CPT,,,,,,,,95,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,45.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.81,93.1
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,781523806,NDC,1,EA,106.34,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,45.61986,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,781523864,NDC,1,EA,106.34,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,45.61986,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,65862039010,NDC,1,EA,106.34,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,45.61986,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665318,NDC,20,ML,50.08,,Medica,Commercial,both,91.1,,1.111818182,percent of total billed charges,45.62288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
sterile water (preservative free) Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323018520,NDC,20,ML,50.08,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,45.62288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963801,NDC,0.5,ML,88.69,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,45.65,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.65,84.496
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963805,NDC,0.5,ML,142.98,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,45.65,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.65,84.496
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,55150017301,NDC,0.5,ML,319.2,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,45.65,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.65,84.496
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,63323027301,NDC,0.5,ML,235.6,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,45.65,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.65,84.496
Needle Insertion W/O Injection 3 or More Muscles,PX20561,CDM,420,RC,20561,CPT,,,,,,,,10,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,45.66,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.87,76.79
Lvl 1 Sub Hosp Low Mdm or 25 Minutes,PX99231,CDM,982,RC,99231,CPT,,,,,,,,133,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,45.6672,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.55,130.34
artificial tears Ointment 3.5 g Tube,63700001,CDM,250,RC,,,,,,10119002239,NDC,3.5,GR,50.14,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,45.67754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BAG LEG URINARY STND 32OZ,120.33,CDM,272,RC,A5112,HCPCS,,4433-MAIN,LOCAL,,,,,121,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,45.6814,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,46.4
BAG URINARY LEG PACK 9349,120.33,CDM,272,RC,A5112,HCPCS,,623-MAIN,LOCAL,,,,,121,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,45.6814,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,46.4
BURETROL ADD ON SET 150ML,120.38,CDM,272,RC,A4222,HCPCS,,11118-MAIN,LOCAL,,,,,18,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,45.6814,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,77.17
TUBE AIRSPIRAL BREATHING AND CHAMBER 900PT561,120.493,CDM,271,RC,A4604,HCPCS,,11618-MAIN,LOCAL,,,,,112,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,45.6814,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,75.92
"Acylcarnitines, Quant - Ref",PX8201790,CDM,300,RC,82017,CPT,90,,,,,,,110,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,45.694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.47,107.8
"Assay Calcium, Ionized",PX82330,CDM,300,RC,82330,CPT,,,,,,,,110,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,45.694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.54,107.8
BONE MARROW BIOPSY ASPIRATION NEEDLE 11G X 4 IN,120.562,CDM,272,RC,C1830,HCPCS,,12677-MAIN,LOCAL,,,,,110,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,45.694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.694,107.8
K-WIRE 0.9X150MM BLUNT/TROCAR DART-FIRE STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12449-MAIN,LOCAL,,,,,110,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,45.694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRE 0.9X150MM BLUNT/TROCAR STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12452-MAIN,LOCAL,,,,,110,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,45.694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRE 1.4X150MM BLUNT/TROCAR DART-FIRE STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12450-MAIN,LOCAL,,,,,110,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,45.694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRE 1.4X150MM BLUNT/TROCAR STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12451-MAIN,LOCAL,,,,,110,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,45.694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA 2.0MM TARGETING GUIDE PIN,27200000,CDM,272,RC,,,,12436-MAIN,LOCAL,,,,,110,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,45.694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Strapping of Shoulder,PX29240P,CDM,983,RC,29240,CPT,,,,,,,,110,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,45.694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.694,111.6
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,50383058766,NDC,60,ML,95.26,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,45.7248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,50383058766,NDC,60,ML,95.26,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,45.7248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,60432053760,NDC,60,ML,95.26,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,45.7248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,60432053760,NDC,60,ML,95.26,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,45.7248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone sod succ 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,63323025803,NDC,0.4,EA,46.67,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,45.7366,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
Blood Count Reticulocytes Auto 1/> Cell Meas,PX85046,CDM,300,RC,85046,CPT,,,,,,,,47,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,45.7451,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.11,46.06
"PAD BED SENSOR 10X28"" P-107517",120.124,CDM,271,RC,,,,8377-MAIN,LOCAL,,,,,47,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,45.7451,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.5238,46.06
"PAD CHAIR SENSOR 10x15"" 106380",120.124,CDM,271,RC,,,,8378-MAIN,LOCAL,,,,,47,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,45.7451,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.5238,46.06
"Protein S, Free - Ref",PX8530690,CDM,300,RC,85306,CPT,90,,,,,,,47,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,45.7451,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.05,46.06
REDUCER 12 - 8MM,27200000,CDM,272,RC,,,,11961-MAIN,LOCAL,,,,,47,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,45.7451,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089901,NDC,0.25,ML,95.31,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,45.7488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.79,93.4038
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089901,NDC,0.25,ML,95.31,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,45.7488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.79,93.4038
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089910,NDC,0.25,ML,95.31,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,45.7488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.79,93.4038
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089910,NDC,0.25,ML,95.31,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,45.7488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.79,93.4038
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703331101,NDC,0.75,ML,51.41,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,45.7549,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
DERMABOND MINI SKIN ADHESIVE,27200000,CDM,272,RC,,,,8532-MAIN,LOCAL,,,,,110.16,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,45.760464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052084,NDC,1,EA,92.46,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,45.7677,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.407884,90.9538
empagliflozin 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,597015230,NDC,1,EA,92.47,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,45.77265,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 5 % Patch 1 Each Box,63700001,CDM,250,RC,,,,,,591352511,NDC,1,EA,50.26,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,45.78686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 5 % Patch 30 Each Box,63700001,CDM,250,RC,,,,,,591352530,NDC,1,EA,50.26,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,45.78686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sildenafil citrate 20 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,65162035109,NDC,1,EA,95.41,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,45.7968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sildenafil citrate 20 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,65162035109,NDC,1,EA,95.41,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,45.7968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,68462015740,NDC,1,EA,110.25,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,45.79785,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,68462015713,NDC,1,EA,110.25,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,45.79785,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
Ultrasound Breast Complete,PX7664101,CDM,402,RC,76641,CPT,TC,,,,,,,333,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,45.8,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.59,134.77
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361250,NDC,50,ML,90.53,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,45.80818,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361650,NDC,50,ML,90.53,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,45.80818,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
SAW BLADE 300 SAGITTAL 25X9.4X0.7,27200000,CDM,272,RC,,,,11592-MAIN,LOCAL,,,,,46.75,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,45.815,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SAW BLADE 300 SAGITTAL 40X14X0.6MM,27200000,CDM,272,RC,,,,11591-MAIN,LOCAL,,,,,46.75,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,45.815,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
lidocaine 4 % Cream 5 g Tube,63700001,CDM,250,RC,,,,,,496088205,NDC,5,GR,51.49,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,45.8261,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Antinuclear Ab(Ana) Titer - Ref,PX8603990,CDM,300,RC,86039,CPT,90,,,,,,,52,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,45.864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.23,50.96
Assay Biovlbl Testosterone Direct Measurement - Ref,PX8441090,CDM,300,RC,84410,CPT,90,,,,,,,52,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,45.864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.6008,50.96
"Beta 2 Glycoprot 1 Ab,Ea - Ref",PX8614690,CDM,300,RC,86146,CPT,90,,,,,,,52,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,45.864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.6008,50.96
Iron - Ref,PX8354090,CDM,300,RC,83540,CPT,90,,,,,,,52,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,45.864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,50.96
Rickettsia Antibody - Ref,PX8675790,CDM,300,RC,86757,CPT,90,,,,,,,52,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,45.864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.74,50.96
Uric Acid; Blood,PX84550,CDM,300,RC,84550,CPT,,,,,,,,52,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,45.864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.14,50.96
ROPivacaine 2 MG/ML Solution 10 mL Vial,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028513,NDC,10,ML,52.01,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,45.87282,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.604954,269.6078
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,24208091055,NDC,3.5,GR,106.98,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,45.89442,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 2%-EPINEPHrine 1:100,000 2 %-1:100000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,409318221,NDC,30,ML,51.57,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,45.8973,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405F,CDM,510,RC,36405,CPT,,,,,,,,54,,First Health,Commercial,both,85,,999999999,percent of total billed charges,45.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.4316,52.92
3.0MM NON-THREADED K WIRE,27200000,CDM,272,RC,C1769,HCPCS,,12658-MAIN,LOCAL,,,,,107,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,45.903,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Androsetenedione - Ref,PX8215790,CDM,300,RC,82157,CPT,90,,,,,,,107,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,45.903,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.85,104.86
Decalcify Tc,PX8831101,CDM,310,RC,88311,CPT,TC,,,,,,,107,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,45.903,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
Fac/Trim Nail(S),PX11719F,CDM,510,RC,11719,CPT,,,,,,,,107,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,45.903,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
Path Special Stains II,PX3979,CDM,310,RC,88313,CPT,TC,,,,,,,107,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,45.903,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
"Special Stains,Group I",PX3978,CDM,310,RC,88312,CPT,TC,,,,,,,107,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,45.903,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,25021050002,NDC,1,ML,52.06,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,45.91692,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,17478028810,NDC,5,ML,95.71,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,45.9408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,17478028810,NDC,5,ML,95.71,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,45.9408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314022705,NDC,5,ML,95.71,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,45.9408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314022705,NDC,5,ML,95.71,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,45.9408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,64980051405,NDC,5,ML,95.71,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,45.9408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,64980051405,NDC,5,ML,95.71,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,45.9408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052083,NDC,1,EA,92.81,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,45.94095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.407884,90.9538
oxyCODONE CR 20 MG Tablet ER 12 hour Abuse-Deterrent 20 Each Box,63700001,CDM,250,RC,,,,,,59011042020,NDC,1,EA,52.09,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,45.94338,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424601,NDC,15,ML,95.76,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,45.9648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.778704,295.3916
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424601,NDC,15,ML,95.76,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,45.9648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.778704,295.3916
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424681,NDC,15,ML,95.76,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,45.9648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.778704,295.3916
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424681,NDC,15,ML,95.76,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,45.9648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.778704,295.3916
venetoclax 100 MG Tablet 1 Each Box,25000000,CDM,250,RC,,,,,,74057611,NDC,0.2,EA,90.87,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,45.98022,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine urethral/mucosal 2 % Gel 30 mL Tube,25000000,CDM,250,RC,,,,,,17478084030,NDC,30,ML,93.91,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.0159,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine urethral/mucosal 2 % Gel 30 mL Tube,25000000,CDM,250,RC,,,,,,17478084030,NDC,30,ML,93.91,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.0159,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine urethral/mucosal 2 % Gel 30 mL Tube,25000000,CDM,250,RC,,,,,,17478084030,NDC,30,ML,93.91,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,46.0159,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sod citrate-citric acid 500-334 MG/5ML Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,121059516,NDC,473,ML,95.87,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,46.0176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sod citrate-citric acid 500-334 MG/5ML Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,121059516,NDC,473,ML,95.87,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,46.0176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CT Head/Brain W/O Dye,PX7045001,CDM,350,RC,70450,CPT,TC,,,,,,,2757,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,46.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.02,136.08
CT Head/Brain W/O Dye,PX7045001,CDM,350,RC,70450,CPT,TC,,,,,,,2757,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,46.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.02,136.08
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156F,CDM,370,RC,99156,CPT,,,,,,,,325,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,46.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.02,129.14
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156F,CDM,370,RC,99156,CPT,,,,,,,,325,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,46.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.02,129.14
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156P,CDM,983,RC,99156,CPT,,,,,,,,325,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,46.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.02,318.5
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156P,CDM,983,RC,99156,CPT,,,,,,,,325,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,46.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.02,318.5
X-Ray Exam Chest 2 Views,PX7104601,CDM,320,RC,71046,CPT,TC,,,,,,,556,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,46.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.27,46.02
X-Ray Exam Chest 2 Views,PX7104601,CDM,320,RC,71046,CPT,TC,,,,,,,556,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,46.02,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.27,46.02
Xray Thoracic Spine 2 Vws,PX7207001,CDM,320,RC,72070,CPT,TC,,,,,,,428,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,46.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.27,46.02
Xray Thoracic Spine 2 Vws,PX7207001,CDM,320,RC,72070,CPT,TC,,,,,,,428,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,46.02,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.27,46.02
BOOT AIRSELECT SHORT LARGE 01ES-L,120.45,CDM,274,RC,L4360,HCPCS,,11890-MAIN,LOCAL,,,,,93,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,46.035,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT MEDIUM 01ES-M,120.45,CDM,274,RC,L4360,HCPCS,,11889-MAIN,LOCAL,,,,,93,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,46.035,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT SMALL 01ES-S,120.45,CDM,274,RC,L4360,HCPCS,,11888-MAIN,LOCAL,,,,,93,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,46.035,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT X-LARGE 01ES-XL,120.45,CDM,274,RC,L4360,HCPCS,,11891-MAIN,LOCAL,,,,,93,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,46.035,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT X-SMALL 01ES-XS,120.45,CDM,274,RC,L4360,HCPCS,,11887-MAIN,LOCAL,,,,,93,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,46.035,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD LARGE 01EF-L,120.45,CDM,274,RC,L4360,HCPCS,,11697-MAIN,LOCAL,,,,,93,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,46.035,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD MEDIUM 01EF-M,120.45,CDM,274,RC,L4360,HCPCS,,11696-MAIN,LOCAL,,,,,93,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,46.035,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD SMALL 01EF-S,120.45,CDM,274,RC,L4360,HCPCS,,11695-MAIN,LOCAL,,,,,93,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,46.035,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD X-LARGE 01EF-XL,120.45,CDM,274,RC,L4360,HCPCS,,11698-MAIN,LOCAL,,,,,93,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,46.035,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD X-SMALL 01EF-XS,120.45,CDM,274,RC,L4360,HCPCS,,11694-MAIN,LOCAL,,,,,93,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,46.035,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
Russell Viper Venom - Ref,PX8561390,CDM,300,RC,85613,CPT,90,,,,,,,93,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,46.035,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.78,91.14
SPLINT FOOT SMALL STRUT WALK 11-1383-2-00000,120.45,CDM,274,RC,L4360,HCPCS,,1205-MAIN,LOCAL,,,,,93,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,46.035,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016200,NDC,1,ML,52.22,,United Healthcare,All Payer,outpatient,88.2,,12.05571429,percent of total billed charges,46.05804,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8092351,NDC,1,EA,52.22,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,46.05804,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400101,NDC,1,EA,52.22,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,46.05804,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400125,NDC,1,EA,52.22,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,46.05804,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
Blood Count Reticulocytes Auto 1/> Cell Meas,PX85046,CDM,300,RC,85046,CPT,,,,,,,,47,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,46.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.11,46.06
Coccidioides Antibody - Ref,PX8663590,CDM,300,RC,86635,CPT,90,,,,,,,94,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.52,92.12
Coccidioides Antibody - Ref,PX8663590,CDM,300,RC,86635,CPT,90,,,,,,,94,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.52,92.12
Coccidioides Antibody - Ref,PX8663590,CDM,300,RC,86635,CPT,90,,,,,,,94,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,46.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.52,92.12
Copper - Ref,PX8252590,CDM,300,RC,82525,CPT,90,,,,,,,94,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.38,92.12
Copper - Ref,PX8252590,CDM,300,RC,82525,CPT,90,,,,,,,94,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.38,92.12
Copper - Ref,PX8252590,CDM,300,RC,82525,CPT,90,,,,,,,94,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,46.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.38,92.12
DEFIBRILLATION PAD MULTI FUNCTION ADULT,120.58,CDM,271,RC,A0392,HCPCS,,1320-MAIN,LOCAL,,,,,94,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
DEFIBRILLATION PAD MULTI FUNCTION ADULT,120.58,CDM,271,RC,A0392,HCPCS,,1320-MAIN,LOCAL,,,,,94,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
DEFIBRILLATION PAD MULTI FUNCTION ADULT,120.58,CDM,271,RC,A0392,HCPCS,,1320-MAIN,LOCAL,,,,,94,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,46.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
DEFIBRILLATION PAD PEDI PADZ PEDS,120.58,CDM,271,RC,A0392,HCPCS,,1322-MAIN,LOCAL,,,,,94,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
DEFIBRILLATION PAD PEDI PADZ PEDS,120.58,CDM,271,RC,A0392,HCPCS,,1322-MAIN,LOCAL,,,,,94,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
DEFIBRILLATION PAD PEDI PADZ PEDS,120.58,CDM,271,RC,A0392,HCPCS,,1322-MAIN,LOCAL,,,,,94,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,46.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
DRESSING NASAL 4.5CM NON-INFLATABLE RAPID RHINO RR450,120.97,CDM,272,RC,A6407,HCPCS,,616-MAIN,LOCAL,,,,,94,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
DRESSING NASAL 4.5CM NON-INFLATABLE RAPID RHINO RR450,120.97,CDM,272,RC,A6407,HCPCS,,616-MAIN,LOCAL,,,,,94,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
DRESSING NASAL 4.5CM NON-INFLATABLE RAPID RHINO RR450,120.97,CDM,272,RC,A6407,HCPCS,,616-MAIN,LOCAL,,,,,94,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,46.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
DRESSING NASAL 5.5CM INFLATABLE RAPID RHINO RR550,120.97,CDM,272,RC,A6407,HCPCS,,606-MAIN,LOCAL,,,,,94,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
DRESSING NASAL 5.5CM INFLATABLE RAPID RHINO RR550,120.97,CDM,272,RC,A6407,HCPCS,,606-MAIN,LOCAL,,,,,94,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
DRESSING NASAL 5.5CM INFLATABLE RAPID RHINO RR550,120.97,CDM,272,RC,A6407,HCPCS,,606-MAIN,LOCAL,,,,,94,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,46.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
DRESSING NASAL 7.5CM INFLATABLE RAPID RHINO RR750,120.97,CDM,272,RC,A6407,HCPCS,,611-MAIN,LOCAL,,,,,94,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
DRESSING NASAL 7.5CM INFLATABLE RAPID RHINO RR750,120.97,CDM,272,RC,A6407,HCPCS,,611-MAIN,LOCAL,,,,,94,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
DRESSING NASAL 7.5CM INFLATABLE RAPID RHINO RR750,120.97,CDM,272,RC,A6407,HCPCS,,611-MAIN,LOCAL,,,,,94,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,46.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
DRESSING NASAL 8CM LONGX1.5CM THICK X3CM HIGH ANATOMICAL 34-105,120.97,CDM,272,RC,A6407,HCPCS,,613-MAIN,LOCAL,,,,,94,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
DRESSING NASAL 8CM LONGX1.5CM THICK X3CM HIGH ANATOMICAL 34-105,120.97,CDM,272,RC,A6407,HCPCS,,613-MAIN,LOCAL,,,,,94,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
DRESSING NASAL 8CM LONGX1.5CM THICK X3CM HIGH ANATOMICAL 34-105,120.97,CDM,272,RC,A6407,HCPCS,,613-MAIN,LOCAL,,,,,94,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,46.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
"PAD BED SENSOR 10X28"" P-107517",120.124,CDM,271,RC,,,,8377-MAIN,LOCAL,,,,,47,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,46.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.5238,46.06
"PAD CHAIR SENSOR 10x15"" 106380",120.124,CDM,271,RC,,,,8378-MAIN,LOCAL,,,,,47,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,46.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.5238,46.06
"Protein S, Free - Ref",PX8530690,CDM,300,RC,85306,CPT,90,,,,,,,47,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,46.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.05,46.06
REDUCER 12 - 8MM,27200000,CDM,272,RC,,,,11961-MAIN,LOCAL,,,,,47,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,46.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Tissue Exam for Fungi,PX87220,CDM,300,RC,87220,CPT,,,,,,,,94,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,92.12
Tissue Exam for Fungi,PX87220,CDM,300,RC,87220,CPT,,,,,,,,94,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,92.12
Tissue Exam for Fungi,PX87220,CDM,300,RC,87220,CPT,,,,,,,,94,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,46.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,92.12
TUBING IRRIGATION F SET STERILE MXB-T,27200000,CDM,272,RC,,,,11693-MAIN,LOCAL,,,,,94,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TUBING IRRIGATION F SET STERILE MXB-T,27200000,CDM,272,RC,,,,11693-MAIN,LOCAL,,,,,94,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TUBING IRRIGATION F SET STERILE MXB-T,27200000,CDM,272,RC,,,,11693-MAIN,LOCAL,,,,,94,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,46.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
apixaban 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,3089331,NDC,1,EA,50.57,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,46.06927,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
etomidate 2 MG/ML Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,55150022220,NDC,10,ML,50.58,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,46.07838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004624,NDC,50,ML,50.58,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,46.07838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; 1st",PX88184,CDM,310,RC,88184,CPT,,,,,,,,96,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,46.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.8784,314.02
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; 1st",PX88184,CDM,310,RC,88184,CPT,,,,,,,,96,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,46.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.8784,314.02
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; Add'l",PX88185,CDM,310,RC,88185,CPT,,,,,,,,96,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,46.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.8784,94.08
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; Add'l",PX88185,CDM,310,RC,88185,CPT,,,,,,,,96,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,46.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.8784,94.08
US Urine Capacity Measure,PX51798F,CDM,510,RC,51798,CPT,,,,,,,,96,,Health Partners,Health Partners Care Plans,both,48,,90.21,percent of total billed charges,46.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.8784,94.08
US Urine Capacity Measure,PX51798F,CDM,510,RC,51798,CPT,,,,,,,,96,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,46.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.8784,94.08
"Fac/Office Consultation,Level III",PX99243F,CDM,510,RC,99213,CPT,,,,,,,,374,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,46.09,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.25,163.25
"Fac/Office Consultation,Level III",PX99243F,CDM,510,RC,99213,CPT,,,,,,,,374,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,46.09,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.25,163.25
"Office/Outpt Visit,Est,Levl III",PX99213F,CDM,510,RC,99213,CPT,,,,,,,,185,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,46.09,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.25,163.25
"Office/Outpt Visit,Est,Levl III",PX99213F,CDM,510,RC,99213,CPT,,,,,,,,185,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,46.09,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.25,163.25
"Office/Outpt Visit,Est,Levl III",PX99213P,CDM,983,RC,99213,CPT,,,,,,,,185,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,46.09,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.25,181.3
"Office/Outpt Visit,Est,Levl III",PX99213P,CDM,983,RC,99213,CPT,,,,,,,,185,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,46.09,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.25,181.3
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028401,NDC,1,EA,111.01,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,46.113554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028420,NDC,1,EA,111.01,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,46.113554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597F,CDM,510,RC,97597,CPT,,,,,,,,266,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,46.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.28,133.11
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597P,CDM,983,RC,97597,CPT,,,,,,,,274,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,46.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.28,268.52
albumin human 25% 25 % Solution 50 mL Flex Cont,P9047,CDM,636,RC,P9047,HCPCS,,,,944049301,NDC,50,ML,402.67,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,46.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.16,53.08
albumin human 25% 25 % Solution 50 mL Flex Cont,P9047,CDM,636,RC,P9047,HCPCS,,,,944049301,NDC,50,ML,402.67,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,46.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.16,53.08
albumin human 25% 25 % Solution 50 mL Flex Cont,P9047,CDM,636,RC,P9047,HCPCS,,,,944049301,NDC,50,ML,402.67,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,46.16,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.16,53.08
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329330101,NDC,50,ML,107.61,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,46.16469,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714020010,NDC,1,EA,107.64,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,46.17756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714020030,NDC,1,EA,107.64,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,46.17756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
Acute Hepatitis Panel,PX80074,CDM,300,RC,80074,CPT,,,,,,,,509,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,46.2,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.2,47.63
Acute Hepatitis Panel,PX80074,CDM,300,RC,80074,CPT,,,,,,,,509,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,46.2,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.2,47.63
Acute Hepatitis Panel,PX80074,CDM,300,RC,80074,CPT,,,,,,,,509,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,46.2,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.2,47.63
clotrimazole 1 % Cream 28.35 g Tube,25000000,CDM,250,RC,,,,,,904782231,NDC,28.35,GR,50.75,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,46.23325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Apply Lower Leg Splint,PX29515F,CDM,510,RC,29515,CPT,,,,,,,,296,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,46.2384,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.54,152.89
Apply Lower Leg Splint,PX29515P,CDM,983,RC,29515,CPT,,,,,,,,311,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,46.2384,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.54,304.78
CT Head/Brain W/O Dye,PX7045001,CDM,350,RC,70450,CPT,TC,,,,,,,2757,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,46.24,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.02,136.08
Extremity Study - Vascular Diagnostics,PX9392201,CDM,921,RC,93922,CPT,TC,,,,,,,600,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,46.24,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.24,123.32
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156F,CDM,370,RC,99156,CPT,,,,,,,,325,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,46.24,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.02,129.14
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156P,CDM,983,RC,99156,CPT,,,,,,,,325,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,46.24,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.02,318.5
US Pregnancy Tc Follow-Up,PX7681601,CDM,402,RC,76816,CPT,TC,,,,,,,362,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,46.26,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.26,138.05
promethazine 25 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802075930,NDC,0.5,EA,47.54,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,46.270682,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium bicarbonate 4.2 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409553434,NDC,10,ML,91.46,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,46.27876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Antinuclear Ab(Ana) Titer - Ref,PX8603990,CDM,300,RC,86039,CPT,90,,,,,,,52,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,46.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.23,50.96
Assay Biovlbl Testosterone Direct Measurement - Ref,PX8441090,CDM,300,RC,84410,CPT,90,,,,,,,52,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,46.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.6008,50.96
"Beta 2 Glycoprot 1 Ab,Ea - Ref",PX8614690,CDM,300,RC,86146,CPT,90,,,,,,,52,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,46.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.6008,50.96
Iron - Ref,PX8354090,CDM,300,RC,83540,CPT,90,,,,,,,52,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,46.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,50.96
Rickettsia Antibody - Ref,PX8675790,CDM,300,RC,86757,CPT,90,,,,,,,52,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,46.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.74,50.96
Uric Acid; Blood,PX84550,CDM,300,RC,84550,CPT,,,,,,,,52,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,46.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.14,50.96
promethazine 25 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,45802075900,NDC,0.5,EA,47.55,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,46.280415,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ROPivacaine 2 MG/ML Solution 10 mL Vial,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028513,NDC,10,ML,52.01,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,46.2889,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.604954,269.6078
magnesium sulfate 1 g in 100 ml D5W (premix) 1-5 GM/100ML-% Solution 100 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010802,NDC,100,ML,52.51,,United Healthcare,All Payer,outpatient,88.2,,13.925,percent of total billed charges,46.31382,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
gentamicin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,60758018805,NDC,5,ML,107.98,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,46.32342,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
imipenem-cilastatin 250 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323034925,NDC,1,EA,91.55,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,46.3243,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,173.1856
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032294,NDC,1,EA,91.55,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,46.3243,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,173.1856
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234001,NDC,1.25,ML,91.55,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,46.3243,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
SCISSORS ENDOSCOPIC 5MM STANDARD STERILE,27200000,CDM,272,RC,,,,11706-MAIN,LOCAL,,,,,47.6,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,46.32908,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Erythropietin - Ref,PX8266890,CDM,300,RC,82668,CPT,90,,,,,,,108,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,46.332,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,105.84
Levetiracetam - Ref,PX8017790,CDM,300,RC,80177,CPT,90,,,,,,,108,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,46.332,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,105.84
Oxcarbazepine - Ref,PX8018390,CDM,300,RC,80183,CPT,90,,,,,,,108,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,46.332,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,105.84
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,25021050002,NDC,1,ML,52.06,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,46.3334,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
cyclopentolate 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,61314039601,NDC,2,ML,94.58,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.3442,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
cyclopentolate 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,61314039601,NDC,2,ML,94.58,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.3442,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
cyclopentolate 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,61314039601,NDC,2,ML,94.58,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,46.3442,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
hydrocortisone 25 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,713050306,NDC,1,EA,108.03,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,46.34487,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 25 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713050312,NDC,1,EA,108.03,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,46.34487,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047625,NDC,0.769230769,ML,111.59,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,46.354486,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.354486,332.1514
carfilzomib 30 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010201,NDC,1,EA,2785.91,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,46.35697,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.22,49.44
carfilzomib 60 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010101,NDC,1,EA,5571.82,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,46.35697,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.22,49.44
oxyCODONE CR 20 MG Tablet ER 12 hour Abuse-Deterrent 20 Each Box,63700001,CDM,250,RC,,,,,,59011042020,NDC,1,EA,52.09,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,46.3601,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atropine 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100401,NDC,0.5,ML,50.91,,Medica,Commercial,both,91.1,,1.63075,percent of total billed charges,46.37901,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
BURETROL ADD ON SET 150ML,120.38,CDM,272,RC,A4222,HCPCS,,11118-MAIN,LOCAL,,,,,18,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,46.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,77.17
BURETROL ADD ON SET 150ML,120.38,CDM,272,RC,A4222,HCPCS,,11118-MAIN,LOCAL,,,,,18,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,46.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,77.17
BURETROL ADD ON SET 150ML,120.38,CDM,272,RC,A4222,HCPCS,,11118-MAIN,LOCAL,,,,,18,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,46.39,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,77.17
BAG LEG URINARY STND 32OZ,120.33,CDM,272,RC,A5112,HCPCS,,4433-MAIN,LOCAL,,,,,121,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,46.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,46.4
BAG LEG URINARY STND 32OZ,120.33,CDM,272,RC,A5112,HCPCS,,4433-MAIN,LOCAL,,,,,121,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,46.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,46.4
BAG LEG URINARY STND 32OZ,120.33,CDM,272,RC,A5112,HCPCS,,4433-MAIN,LOCAL,,,,,121,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,46.4,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,46.4
BAG URINARY LEG PACK 9349,120.33,CDM,272,RC,A5112,HCPCS,,623-MAIN,LOCAL,,,,,121,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,46.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,46.4
BAG URINARY LEG PACK 9349,120.33,CDM,272,RC,A5112,HCPCS,,623-MAIN,LOCAL,,,,,121,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,46.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,46.4
BAG URINARY LEG PACK 9349,120.33,CDM,272,RC,A5112,HCPCS,,623-MAIN,LOCAL,,,,,121,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,46.4,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,46.4
acyclovir 50 MG/ML Solution 10 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,55150015410,NDC,10,ML,108.16,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,46.40064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.927644,105.9968
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046417,NDC,10,ML,54.6,,First Health,Commercial,both,85,,999999999,percent of total billed charges,46.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011801,NDC,0.5,ML,52.63,,United Healthcare,All Payer,outpatient,88.2,,0.211744841,percent of total billed charges,46.41966,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011805,NDC,0.5,ML,52.63,,United Healthcare,All Payer,outpatient,88.2,,0.211744841,percent of total billed charges,46.41966,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760,CDM,420,RC,97760,CPT,,,,,,,,142,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,46.4256,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.1,62.82
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760F,CDM,510,RC,97760,CPT,,,,,,,,142,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,46.4256,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.1,62.82
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,67815203,NDC,100,GR,91.77,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,46.43562,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028442,NDC,1,EA,47.71,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,12.385,percent of total billed charges,46.436143,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034001,NDC,1,EA,111.81,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,46.445874,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034000,NDC,1,EA,111.82,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,46.450028,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001104,NDC,1,EA,108.29,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,46.45641,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
"Ctrl Nosebleed,Anter,Complex",PX30903F,CDM,510,RC,30903,CPT,,,,,,,,456,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,46.46,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.46,506.4
"Ctrl Nosebleed,Anter,Complex",PX30903F,CDM,510,RC,30903,CPT,,,,,,,,456,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,46.46,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.46,506.4
"Ctrl Nosebleed,Anter,Complex",PX30903P,CDM,983,RC,30903,CPT,,,,,,,,304,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,46.46,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.46,506.4
"Ctrl Nosebleed,Anter,Complex",PX30903P,CDM,983,RC,30903,CPT,,,,,,,,304,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,46.46,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.46,506.4
pegfilgrastim 6 MG/0.6ML Prefilled Syringe Kit 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019201,NDC,0.6,ML,13092.7,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,46.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.46,12830.846
pegfilgrastim 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019001,NDC,0.6,ML,12711.36,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,46.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.46,12830.846
DRAPE STERILE 109X100X110 ROBOTIC DYNJP9108,27200000,CDM,272,RC,,,,12020-MAIN,LOCAL,,,,,51,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,46.461,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409492120,NDC,10,ML,54.66,,First Health,Commercial,both,85,,999999999,percent of total billed charges,46.461,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
Immunohisto Antibody Slide Ea Multiplex,PX8834401,CDM,310,RC,88344,CPT,TC,,,,,,,51,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,46.461,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,314.02
RANGER UNIT TUBING FLUID WARMING,120.229,CDM,272,RC,,,,10612-MAIN,LOCAL,,,,,51,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,46.461,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,49.98
SCAR GEL SHEET,120.458,CDM,273,RC,A6025,HCPCS,,5796-MAIN,LOCAL,,,,,51,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,46.461,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,49.98
TUBE FEEDING DECLOGGING SYSTEM CLOG ZAPPER 20-0002,120.277,CDM,272,RC,,,,4226-MAIN,LOCAL,,,,,51,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,46.461,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,49.98
ketamine 100 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,55150044001,NDC,10,ML,111.85,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,46.46249,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016200,NDC,1,ML,52.22,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,46.4758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8092351,NDC,1,EA,52.22,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,46.4758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400101,NDC,1,EA,52.22,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,46.4758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400125,NDC,1,EA,52.22,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,46.4758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001103,NDC,1,EA,108.34,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,46.47786,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
fentaNYL 12 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,378911916,NDC,1,EA,96.83,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,46.4784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 12 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,378911916,NDC,1,EA,96.83,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,46.4784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 12 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505708000,NDC,1,EA,96.83,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,46.4784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 12 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505708000,NDC,1,EA,96.83,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,46.4784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 12 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,378911998,NDC,1,EA,96.84,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,46.4832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 12 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,378911998,NDC,1,EA,96.84,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,46.4832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 12 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,60505708002,NDC,1,EA,96.84,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,46.4832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 12 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,60505708002,NDC,1,EA,96.84,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,46.4832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine urethral/mucosal 2 % Gel 30 mL Tube,25000000,CDM,250,RC,,,,,,17478084030,NDC,30,ML,93.91,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,46.48545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061401,NDC,1,ML,94.87,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.4863,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.114178,99.911
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061401,NDC,1,ML,94.87,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.4863,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.114178,99.911
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061401,NDC,1,ML,94.87,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,46.4863,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.114178,99.911
atropine (PF) 1 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517101025,NDC,1,ML,91.89,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,46.49634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
ELECTRODE PEDS ONESTEP SINGLE,120.343,CDM,272,RC,A4556,HCPCS,,10296-MAIN,LOCAL,,,,,112,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,46.5248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
EYE IRRIGATION SYSTEM MT2000,120.318,CDM,272,RC,,,,8718-MAIN,LOCAL,,,,,112,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,46.5248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
F5 Gene - Ref,PX8124190,CDM,300,RC,81241,CPT,90,,,,,,,112,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,46.5248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
Immunofluorescence per Spec Add Singl Antb Stain - Ref,PX8835090,CDM,310,RC,88350,CPT,90,,,,,,,112,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,46.5248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
Osmolality; Urine,PX83935,CDM,300,RC,83935,CPT,,,,,,,,112,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,46.5248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.25,109.76
Prolactin,PX84146,CDM,300,RC,84146,CPT,,,,,,,,112,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,46.5248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.77,109.76
Quantitation Drug Nos - Ref,PX8029990,CDM,300,RC,80299,CPT,90,,,,,,,112,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,46.5248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.09,109.76
TUBE AIRSPIRAL BREATHING AND CHAMBER 900PT561,120.493,CDM,271,RC,A4604,HCPCS,,11618-MAIN,LOCAL,,,,,112,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,46.5248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
verapamil 2.5 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,51754020401,NDC,1,ML,112.01,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,46.528954,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Coccidioides Antibody - Ref,PX8663590,CDM,300,RC,86635,CPT,90,,,,,,,94,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,46.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.52,92.12
Copper - Ref,PX8252590,CDM,300,RC,82525,CPT,90,,,,,,,94,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,46.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.38,92.12
DEFIBRILLATION PAD MULTI FUNCTION ADULT,120.58,CDM,271,RC,A0392,HCPCS,,1320-MAIN,LOCAL,,,,,94,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,46.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
DEFIBRILLATION PAD PEDI PADZ PEDS,120.58,CDM,271,RC,A0392,HCPCS,,1322-MAIN,LOCAL,,,,,94,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,46.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
DRESSING NASAL 4.5CM NON-INFLATABLE RAPID RHINO RR450,120.97,CDM,272,RC,A6407,HCPCS,,616-MAIN,LOCAL,,,,,94,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,46.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
DRESSING NASAL 5.5CM INFLATABLE RAPID RHINO RR550,120.97,CDM,272,RC,A6407,HCPCS,,606-MAIN,LOCAL,,,,,94,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,46.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
DRESSING NASAL 7.5CM INFLATABLE RAPID RHINO RR750,120.97,CDM,272,RC,A6407,HCPCS,,611-MAIN,LOCAL,,,,,94,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,46.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
DRESSING NASAL 8CM LONGX1.5CM THICK X3CM HIGH ANATOMICAL 34-105,120.97,CDM,272,RC,A6407,HCPCS,,613-MAIN,LOCAL,,,,,94,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,46.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
Tissue Exam for Fungi,PX87220,CDM,300,RC,87220,CPT,,,,,,,,94,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,46.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,92.12
TUBING IRRIGATION F SET STERILE MXB-T,27200000,CDM,272,RC,,,,11693-MAIN,LOCAL,,,,,94,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,46.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Acute Hepatitis Panel,PX80074,CDM,300,RC,80074,CPT,,,,,,,,509,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,46.5305,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.2,47.63
lidocaine 4 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,536128128,NDC,30,GR,96.95,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,46.536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 4 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,536128128,NDC,30,GR,96.95,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,46.536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay Blood Carbon Dioxide,PX82374,CDM,300,RC,82374,CPT,,,,,,,,95,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.47,93.1
Assay Blood Carbon Dioxide,PX82374,CDM,300,RC,82374,CPT,,,,,,,,95,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.47,93.1
Assay Blood Carbon Dioxide,PX82374,CDM,300,RC,82374,CPT,,,,,,,,95,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,46.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.47,93.1
Blood Viscosity Examination,PX85810,CDM,300,RC,85810,CPT,,,,,,,,95,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.7,93.1
Blood Viscosity Examination,PX85810,CDM,300,RC,85810,CPT,,,,,,,,95,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.7,93.1
Blood Viscosity Examination,PX85810,CDM,300,RC,85810,CPT,,,,,,,,95,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,46.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.7,93.1
Cyclosporine - Ref,PX8015890,CDM,300,RC,80158,CPT,90,,,,,,,95,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.55,93.1
Cyclosporine - Ref,PX8015890,CDM,300,RC,80158,CPT,90,,,,,,,95,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.55,93.1
Cyclosporine - Ref,PX8015890,CDM,300,RC,80158,CPT,90,,,,,,,95,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,46.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.55,93.1
"Fac/Debridement of Nails, 6 or Mor",PX11721F,CDM,510,RC,11721,CPT,,,,,,,,95,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,22.38333333,percent of total billed charges,46.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.463,93.1
"Fac/Debridement of Nails, 6 or Mor",PX11721F,CDM,510,RC,11721,CPT,,,,,,,,95,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.463,93.1
"Fac/Debridement of Nails, 6 or Mor",PX11721F,CDM,510,RC,11721,CPT,,,,,,,,95,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,46.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.463,93.1
"Fat/Lipids, Feces, Quant - Ref",PX8271090,CDM,300,RC,82710,CPT,90,,,,,,,95,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.4,93.1
"Fat/Lipids, Feces, Quant - Ref",PX8271090,CDM,300,RC,82710,CPT,90,,,,,,,95,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.4,93.1
"Fat/Lipids, Feces, Quant - Ref",PX8271090,CDM,300,RC,82710,CPT,90,,,,,,,95,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,46.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.4,93.1
KIT EPIDURAL 19GA FLEXTIP PLUS AK-05502,120.305,CDM,272,RC,,,,11413-MAIN,LOCAL,,,,,95,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.463,93.1
KIT EPIDURAL 19GA FLEXTIP PLUS AK-05502,120.305,CDM,272,RC,,,,11413-MAIN,LOCAL,,,,,95,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.463,93.1
KIT EPIDURAL 19GA FLEXTIP PLUS AK-05502,120.305,CDM,272,RC,,,,11413-MAIN,LOCAL,,,,,95,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,46.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.463,93.1
"Lyme Disease, Confirm Tst - Ref",PX8661790,CDM,300,RC,86617,CPT,90,,,,,,,95,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.2,93.1
"Lyme Disease, Confirm Tst - Ref",PX8661790,CDM,300,RC,86617,CPT,90,,,,,,,95,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.2,93.1
"Lyme Disease, Confirm Tst - Ref",PX8661790,CDM,300,RC,86617,CPT,90,,,,,,,95,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,46.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.2,93.1
"Organism ID, Anaerobic - Ref",PX8707690,CDM,300,RC,87076,CPT,90,,,,,,,95,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,93.1
"Organism ID, Anaerobic - Ref",PX8707690,CDM,300,RC,87076,CPT,90,,,,,,,95,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,93.1
"Organism ID, Anaerobic - Ref",PX8707690,CDM,300,RC,87076,CPT,90,,,,,,,95,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,46.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,93.1
Strep a Assay W/Optic,PX87880,CDM,300,RC,87880,CPT,,,,,,,,95,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.16,93.1
Strep a Assay W/Optic,PX87880,CDM,300,RC,87880,CPT,,,,,,,,95,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.16,93.1
Strep a Assay W/Optic,PX87880,CDM,300,RC,87880,CPT,,,,,,,,95,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,46.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.16,93.1
"Thyroxine, Total - Ref",PX8443690,CDM,300,RC,84436,CPT,90,,,,,,,95,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.3,93.1
"Thyroxine, Total - Ref",PX8443690,CDM,300,RC,84436,CPT,90,,,,,,,95,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.3,93.1
"Thyroxine, Total - Ref",PX8443690,CDM,300,RC,84436,CPT,90,,,,,,,95,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,46.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.3,93.1
TRAY FACIAL LACERATION PACK STERILE 96-1707,120.12,CDM,272,RC,,,,406-MAIN,LOCAL,,,,,95,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.463,93.1
TRAY FACIAL LACERATION PACK STERILE 96-1707,120.12,CDM,272,RC,,,,406-MAIN,LOCAL,,,,,95,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.463,93.1
TRAY FACIAL LACERATION PACK STERILE 96-1707,120.12,CDM,272,RC,,,,406-MAIN,LOCAL,,,,,95,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,46.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.463,93.1
Varicella-Zoster Antibody,PX86787,CDM,300,RC,86787,CPT,,,,,,,,95,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.81,93.1
Varicella-Zoster Antibody,PX86787,CDM,300,RC,86787,CPT,,,,,,,,95,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.81,93.1
Varicella-Zoster Antibody,PX86787,CDM,300,RC,86787,CPT,,,,,,,,95,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,46.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.81,93.1
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048557,NDC,50,ML,52.78,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,46.55196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Blood Typing Abo,PX86900,CDM,300,RC,86900,CPT,,,,,,,,92,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,46.552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.2168,111.6
Blood Typing Rh (D),PX86901,CDM,300,RC,86901,CPT,,,,,,,,92,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,46.552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.03,90.16
Parvovirus Antibody - Ref,PX8674790,CDM,300,RC,86747,CPT,90,,,,,,,92,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,46.552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.78,90.16
"Reticulocyte Count,Flow Cyto",PX85045,CDM,300,RC,85045,CPT,,,,,,,,92,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,46.552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.66,90.16
Blastomyces Antibody - Ref,PX8661290,CDM,300,RC,86612,CPT,90,,,,,,,97,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,46.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.83,95.06
Blastomyces Antibody - Ref,PX8661290,CDM,300,RC,86612,CPT,90,,,,,,,97,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,46.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.83,95.06
Contrast Bath Therapy,PX97034,CDM,420,RC,97034,CPT,,,,,,,,97,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,46.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,95.06
Contrast Bath Therapy,PX97034,CDM,420,RC,97034,CPT,,,,,,,,97,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,46.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,95.06
DRAPE INSTRUMENT ARM 470015,27200000,CDM,272,RC,,,,11925-MAIN,LOCAL,,,,,97,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,46.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRAPE INSTRUMENT ARM 470015,27200000,CDM,272,RC,,,,11925-MAIN,LOCAL,,,,,97,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,46.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
High Sens Crp,PX86141,CDM,300,RC,86141,CPT,,,,,,,,97,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,46.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,95.06
High Sens Crp,PX86141,CDM,300,RC,86141,CPT,,,,,,,,97,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,46.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,95.06
Rheumatoid Factor Quant,PX86431,CDM,300,RC,86431,CPT,,,,,,,,97,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,46.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.2,95.06
Rheumatoid Factor Quant,PX86431,CDM,300,RC,86431,CPT,,,,,,,,97,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,46.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.2,95.06
ramuCIRumab 100 MG/10ML Solution 10 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2766901,NDC,10,ML,2463.3,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,46.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.57,12070.17
ramuCIRumab 500 MG/50ML Solution 50 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2767801,NDC,50,ML,12316.5,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,46.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.57,12070.17
promethazine 25 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802075930,NDC,0.5,EA,47.54,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,46.5892,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
promethazine 25 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,45802075900,NDC,0.5,EA,47.55,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,46.599,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
TUBE AIRSPIRAL BREATHING AND CHAMBER 900PT561,120.493,CDM,271,RC,A4604,HCPCS,,11618-MAIN,LOCAL,,,,,112,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,46.61,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,75.92
TUBE AIRSPIRAL BREATHING AND CHAMBER 900PT561,120.493,CDM,271,RC,A4604,HCPCS,,11618-MAIN,LOCAL,,,,,112,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,46.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,75.92
TUBE AIRSPIRAL BREATHING AND CHAMBER 900PT561,120.493,CDM,271,RC,A4604,HCPCS,,11618-MAIN,LOCAL,,,,,112,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,46.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,75.92
TUBE AIRSPIRAL BREATHING AND CHAMBER 900PT561,120.493,CDM,271,RC,A4604,HCPCS,,11618-MAIN,LOCAL,,,,,112,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,46.61,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,75.92
Thyrstim Immun Glob (Tsi) - Ref,PX8444590,CDM,300,RC,84445,CPT,90,,,,,,,254,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,46.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.63,248.92
SCISSORS ENDOSCOPIC 5MM STANDARD STERILE,27200000,CDM,272,RC,,,,11706-MAIN,LOCAL,,,,,47.6,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,46.648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,781323294,NDC,1,EA,52.89,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,46.64898,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,50383058766,NDC,60,ML,95.26,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.6774,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,50383058766,NDC,60,ML,95.26,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.6774,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,50383058766,NDC,60,ML,95.26,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,46.6774,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,60432053760,NDC,60,ML,95.26,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.6774,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,60432053760,NDC,60,ML,95.26,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.6774,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,60432053760,NDC,60,ML,95.26,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,46.6774,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Ctrl Nosebleed,Anter,Complex",PX30903F,CDM,510,RC,30903,CPT,,,,,,,,456,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,46.68,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.46,506.4
"Ctrl Nosebleed,Anter,Complex",PX30903P,CDM,983,RC,30903,CPT,,,,,,,,304,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,46.68,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.46,506.4
Xray Hand 2vws Tc,PX7312001,CDM,320,RC,73120,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,46.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.27,46.68
Xray Hand 2vws Tc,PX7312001,CDM,320,RC,73120,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,46.68,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.27,46.68
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089901,NDC,0.25,ML,95.31,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.7019,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.79,93.4038
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089901,NDC,0.25,ML,95.31,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.7019,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.79,93.4038
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089901,NDC,0.25,ML,95.31,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,46.7019,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.79,93.4038
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089910,NDC,0.25,ML,95.31,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.7019,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.79,93.4038
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089910,NDC,0.25,ML,95.31,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.7019,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.79,93.4038
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089910,NDC,0.25,ML,95.31,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,46.7019,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.79,93.4038
"Admin Hep B,Adult 19+",PX3242,CDM,771,RC,90471,CPT,,,,,,,,48,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,39.605,percent of total billed charges,46.7184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,61.54
Amphetamines; 3 or 4,PX8032590,CDM,300,RC,80325,CPT,90,,,,,,,48,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,46.7184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,47.04
Immunization Admin - Influenza,PX3241,CDM,771,RC,90471,CPT,,,,,,,,48,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,39.605,percent of total billed charges,46.7184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,61.54
Immunization Administration; Each Add'l Vaccine (Single or Combo Vaccine/T*,PX90472,CDM,771,RC,90472,CPT,,,,,,,,48,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,46.7184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,47.04
ibuprofen 100 MG/5ML Suspension 118 mL Bottle,63700001,CDM,250,RC,,,,,,45802089726,NDC,118,ML,54.97,,First Health,Commercial,both,85,,999999999,percent of total billed charges,46.7245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Tc99 Mebrofenin to 15 Mci,PXA9537,CDM,343,RC,A9537,HCPCS,,,,,,,,495,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,46.73,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.73,58.5494
magnesium sulfate 1 g in 100 ml D5W (premix) 1-5 GM/100ML-% Solution 100 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010802,NDC,100,ML,52.51,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,46.7339,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
lidocaine HCl 4 % Cream 133 g Tube,63700001,CDM,250,RC,,,,,,41167005828,NDC,133,GR,52.99,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,46.73718,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
alendronate 70 MG Tablet 4 Each Box,63700001,CDM,250,RC,,,,,,16714063301,NDC,1,EA,97.37,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,46.7376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
alendronate 70 MG Tablet 4 Each Box,63700001,CDM,250,RC,,,,,,16714063301,NDC,1,EA,97.37,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,46.7376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lopinavir-ritonavir 200-50 MG Tablet 120 Each Bottle,63700001,CDM,250,RC,,,,,,74679922,NDC,1,EA,54.99,,First Health,Commercial,both,85,,999999999,percent of total billed charges,46.7415,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Dystrophic Nail Trimming Any Number,PXG0127F,CDM,940,RC,G0127,HCPCS,,,,,,,,53,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,46.746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.0162,53.44
Renin - Ref,PX8424490,CDM,300,RC,84244,CPT,90,,,,,,,53,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,46.746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.16,51.94
Endocrine E2,PX82670,CDM,300,RC,82670,CPT,90,,,,,,,55,,First Health,Commercial,both,85,,999999999,percent of total billed charges,46.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,53.9
"Immunofluo Direct, Ea Ab - Ref",PX8834690,CDM,310,RC,88346,CPT,90,,,,,,,55,,First Health,Commercial,both,85,,999999999,percent of total billed charges,46.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,149.22
Lipid Profile,PX80061,CDM,300,RC,80061,CPT,,,,,,,,245,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,46.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.28,240.1
Lipoprotein (a) - Ref,PX8369590,CDM,300,RC,83695,CPT,90,,,,,,,55,,First Health,Commercial,both,85,,999999999,percent of total billed charges,46.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.13,53.9
MEPILEX BORDER AG POST OP 4X10,120.368,CDM,272,RC,A6212,HCPCS,,10839-MAIN,LOCAL,,,,,55,,First Health,Commercial,both,85,,999999999,percent of total billed charges,46.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,53.9
SURGIFOAM ABSORBABLE GELATIN SPONGE 3.1 IN X 4.9IN X 10MM,120.371,CDM,272,RC,A4649,HCPCS,,10864-MAIN,LOCAL,,,,,55,,First Health,Commercial,both,85,,999999999,percent of total billed charges,46.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,53.9
sildenafil citrate 20 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,65162035109,NDC,1,EA,95.41,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.7509,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sildenafil citrate 20 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,65162035109,NDC,1,EA,95.41,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.7509,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sildenafil citrate 20 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,65162035109,NDC,1,EA,95.41,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,46.7509,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028442,NDC,1,EA,47.71,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,46.7558,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
"RBC Sed Rate, Auto",PX85652,CDM,300,RC,85652,CPT,,,,,,,,109,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,46.761,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.48,106.82
Smear Gram Stain,PX87205,CDM,300,RC,87205,CPT,,,,,,,,109,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,46.761,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,106.82
Smear Wet Mount Saline/Ink,PX87210,CDM,300,RC,87210,CPT,,,,,,,,109,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,46.761,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.34,106.82
"West Nile Ab, Igm - Ref",PX8678890,CDM,300,RC,86788,CPT,90,,,,,,,109,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,46.761,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.45,106.82
"polyethylene glycol 236 g Recon Soln 4,000 mL Bottle",63700001,CDM,250,RC,,,,,,43386009019,NDC,4000,ML,112.6,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,46.77404,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CARTER THOMASON CLOSURE 5MM,27200000,CDM,272,RC,,,,10278-MAIN,LOCAL,,,,,97.45,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,46.776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CARTER THOMASON CLOSURE 5MM,27200000,CDM,272,RC,,,,10278-MAIN,LOCAL,,,,,97.45,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,46.776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052084,NDC,1,EA,92.46,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,46.78476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.407884,90.9538
empagliflozin 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,597015230,NDC,1,EA,92.47,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,46.78982,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338067104,NDC,1000,ML,53.06,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,46.79892,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
cyclopentolate 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,61314039601,NDC,2,ML,94.58,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,46.8171,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703331101,NDC,0.75,ML,51.41,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,46.83451,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011801,NDC,0.5,ML,52.63,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,46.8407,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011805,NDC,0.5,ML,52.63,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,46.8407,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329335201,NDC,50,ML,109.26,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,46.87254,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,17478028810,NDC,5,ML,95.71,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.8979,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,17478028810,NDC,5,ML,95.71,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.8979,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,17478028810,NDC,5,ML,95.71,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,46.8979,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314022705,NDC,5,ML,95.71,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.8979,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314022705,NDC,5,ML,95.71,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.8979,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314022705,NDC,5,ML,95.71,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,46.8979,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,64980051405,NDC,5,ML,95.71,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.8979,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,64980051405,NDC,5,ML,95.71,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.8979,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,64980051405,NDC,5,ML,95.71,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,46.8979,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Diagnostic Bone Marrow, Biopsy and Aspiration",PX38222F,CDM,761,RC,38222,CPT,,,,,,,,1748,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,46.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9,363.89
"Diagnostic Bone Marrow, Biopsy and Aspiration",PX38222F,CDM,761,RC,38222,CPT,,,,,,,,1748,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,46.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9,363.89
Extremity Study - Vascular Diagnostics,PX9392201,CDM,921,RC,93922,CPT,TC,,,,,,,600,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,46.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.24,123.32
Extremity Study - Vascular Diagnostics,PX9392201,CDM,921,RC,93922,CPT,TC,,,,,,,600,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,46.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.24,123.32
lidocaine 5 % Patch 30 Each Box,63700001,CDM,250,RC,,,,,,603188016,NDC,1,EA,55.18,,First Health,Commercial,both,85,,999999999,percent of total billed charges,46.903,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066500,NDC,0.25,ML,48.19,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,46.903327,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.000396,47.2262
lidocaine 4 % Cream 5 g Tube,63700001,CDM,250,RC,,,,,,496088205,NDC,5,GR,51.49,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,46.90739,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 5 % Patch 1 Each Box,63700001,CDM,250,RC,,,,,,603188010,NDC,1,EA,55.2,,First Health,Commercial,both,85,,999999999,percent of total billed charges,46.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424601,NDC,15,ML,95.76,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.9224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.778704,295.3916
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424601,NDC,15,ML,95.76,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.9224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.778704,295.3916
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424601,NDC,15,ML,95.76,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,46.9224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.778704,295.3916
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424681,NDC,15,ML,95.76,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.9224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.778704,295.3916
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424681,NDC,15,ML,95.76,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.9224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.778704,295.3916
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424681,NDC,15,ML,95.76,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,46.9224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.778704,295.3916
"Molecyto Insitu, 100-300cl - Ref",PX8827590,CDM,310,RC,88275,CPT,90,,,,,,,103,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,46.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.7862,100.94
Iadna Streptococcus Group a Amplified Probe Tq,PX87651,CDM,300,RC,87651,CPT,,,,,,,,113,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,46.9402,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,110.74
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209P,CDM,982,RC,69209,CPT,,,,,,,,113,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,46.9402,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9402,109.9829
Strapping of Toes,PX29550F,CDM,510,RC,29550,CPT,,,,,,,,113,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,46.9402,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9402,110.74
Xray Spine Single Tc,PX7202001,CDM,320,RC,72020,CPT,TC,,,,,,,113,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,46.9402,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9402,110.74
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,17478062512,NDC,2.5,ML,109.45,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,46.95405,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061401,NDC,1,ML,94.87,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,46.96065,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.114178,99.911
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052083,NDC,1,EA,92.81,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,46.96186,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.407884,90.9538
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048557,NDC,50,ML,52.78,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,46.9742,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sod citrate-citric acid 500-334 MG/5ML Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,121059516,NDC,473,ML,95.87,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.9763,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sod citrate-citric acid 500-334 MG/5ML Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,121059516,NDC,473,ML,95.87,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,46.9763,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sod citrate-citric acid 500-334 MG/5ML Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,121059516,NDC,473,ML,95.87,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,46.9763,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 75 MG capsule 10 Each Disp Pack,63700001,CDM,250,RC,,,,,,4080085,NDC,1,EA,97.87,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,46.9776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 75 MG capsule 10 Each Disp Pack,63700001,CDM,250,RC,,,,,,4080085,NDC,1,EA,97.87,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,46.9776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"lidocaine 2%-EPINEPHrine 1:100,000 2 %-1:100000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,409318221,NDC,30,ML,51.57,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,46.98027,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dabigatran 75 MG capsule 60 Each Box,63700001,CDM,250,RC,,,,,,597035556,NDC,1,EA,53.27,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,46.98414,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
scopolamine 1 MG/3DAYS Patch 72 Hour 24 Each Box,25000000,CDM,250,RC,,,,,,50742050524,NDC,1,EA,109.59,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,47.01411,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Assay Biovlbl Testosterone Direct Measurement - Ref,PX8441090,CDM,300,RC,84410,CPT,90,,,,,,,52,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,47.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.6008,50.96
Assay Blood Carbon Dioxide,PX82374,CDM,300,RC,82374,CPT,,,,,,,,95,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,47.025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.47,93.1
Blood Viscosity Examination,PX85810,CDM,300,RC,85810,CPT,,,,,,,,95,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,47.025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.7,93.1
Cyclosporine - Ref,PX8015890,CDM,300,RC,80158,CPT,90,,,,,,,95,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,47.025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.55,93.1
"Fac/Debridement of Nails, 6 or Mor",PX11721F,CDM,510,RC,11721,CPT,,,,,,,,95,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,47.025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.463,93.1
"Fat/Lipids, Feces, Quant - Ref",PX8271090,CDM,300,RC,82710,CPT,90,,,,,,,95,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,47.025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.4,93.1
KIT EPIDURAL 19GA FLEXTIP PLUS AK-05502,120.305,CDM,272,RC,,,,11413-MAIN,LOCAL,,,,,95,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,47.025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.463,93.1
"Lyme Disease, Confirm Tst - Ref",PX8661790,CDM,300,RC,86617,CPT,90,,,,,,,95,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,47.025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.2,93.1
"Organism ID, Anaerobic - Ref",PX8707690,CDM,300,RC,87076,CPT,90,,,,,,,95,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,47.025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,93.1
Strep a Assay W/Optic,PX87880,CDM,300,RC,87880,CPT,,,,,,,,95,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,47.025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.16,93.1
"Thyroxine, Total - Ref",PX8443690,CDM,300,RC,84436,CPT,90,,,,,,,95,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,47.025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.3,93.1
TRAY FACIAL LACERATION PACK STERILE 96-1707,120.12,CDM,272,RC,,,,406-MAIN,LOCAL,,,,,95,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,47.025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.463,93.1
Varicella-Zoster Antibody,PX86787,CDM,300,RC,86787,CPT,,,,,,,,95,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,47.025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.81,93.1
pregabalin 25 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,71101268,NDC,1,EA,55.33,,First Health,Commercial,both,85,,999999999,percent of total billed charges,47.0305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Admin Hep B,Adult 19+",PX3242,CDM,771,RC,90471,CPT,,,,,,,,48,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,47.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,61.54
Amphetamines; 3 or 4,PX8032590,CDM,300,RC,80325,CPT,90,,,,,,,48,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,47.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,47.04
BLADE LARYNGOSCOPE MAC #3 SINGLE USE350-005-000,120.121,CDM,272,RC,,,,8320-MAIN,LOCAL,,,,,98,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,47.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
BLADE LARYNGOSCOPE MAC #3 SINGLE USE350-005-000,120.121,CDM,272,RC,,,,8320-MAIN,LOCAL,,,,,98,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
BLADE LARYNGOSCOPE MAC #4 SINGLE USE 350-012-000,120.121,CDM,272,RC,,,,8321-MAIN,LOCAL,,,,,98,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,47.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
BLADE LARYNGOSCOPE MAC #4 SINGLE USE 350-012-000,120.121,CDM,272,RC,,,,8321-MAIN,LOCAL,,,,,98,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
BLADE LARYNGOSCOPE MAC #X3 SINGLE USE X3-003-000,120.121,CDM,272,RC,,,,8322-MAIN,LOCAL,,,,,98,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,47.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
BLADE LARYNGOSCOPE MAC #X3 SINGLE USE X3-003-000,120.121,CDM,272,RC,,,,8322-MAIN,LOCAL,,,,,98,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
CANNULA JUNIOR 2 LARGE OPTIFLOW OJR416VT,120.561,CDM,272,RC,A4615,HCPCS,,12645-MAIN,LOCAL,,,,,98,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,47.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
CANNULA JUNIOR 2 LARGE OPTIFLOW OJR416VT,120.561,CDM,272,RC,A4615,HCPCS,,12645-MAIN,LOCAL,,,,,98,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
CANNULA JUNIOR 2 MEDIUM OPTIFLOW OJR414VT,120.561,CDM,272,RC,A4615,HCPCS,,12644-MAIN,LOCAL,,,,,98,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,47.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
CANNULA JUNIOR 2 MEDIUM OPTIFLOW OJR414VT,120.561,CDM,272,RC,A4615,HCPCS,,12644-MAIN,LOCAL,,,,,98,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
CANNULA OPTIFLOW JUNIOR 2 SMALL OJR412VT,120.561,CDM,272,RC,A4615,HCPCS,,12643-MAIN,LOCAL,,,,,98,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,47.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
CANNULA OPTIFLOW JUNIOR 2 SMALL OJR412VT,120.561,CDM,272,RC,A4615,HCPCS,,12643-MAIN,LOCAL,,,,,98,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; 1st",PX88184,CDM,310,RC,88184,CPT,,,,,,,,96,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,36.16,percent of total billed charges,47.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.8784,314.02
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; 1st",PX88184,CDM,310,RC,88184,CPT,,,,,,,,96,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,47.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.8784,314.02
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; 1st",PX88184,CDM,310,RC,88184,CPT,,,,,,,,96,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,47.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.8784,314.02
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; Add'l",PX88185,CDM,310,RC,88185,CPT,,,,,,,,96,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,37.45071429,percent of total billed charges,47.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.8784,94.08
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; Add'l",PX88185,CDM,310,RC,88185,CPT,,,,,,,,96,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,47.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.8784,94.08
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; Add'l",PX88185,CDM,310,RC,88185,CPT,,,,,,,,96,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,47.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.8784,94.08
Hepatitis B Surface Antigen,PX87340,CDM,300,RC,87340,CPT,,,,,,,,98,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,47.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.47,96.04
Hepatitis B Surface Antigen,PX87340,CDM,300,RC,87340,CPT,,,,,,,,98,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.47,96.04
Immunization Admin - Influenza,PX3241,CDM,771,RC,90471,CPT,,,,,,,,48,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,47.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,61.54
Immunization Administration; Each Add'l Vaccine (Single or Combo Vaccine/T*,PX90472,CDM,771,RC,90472,CPT,,,,,,,,48,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,47.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,47.04
Ot Contracted Service/MCR,PX120.177,CDM,431,RC,,,,,,,,,,98,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,47.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
Ot Contracted Service/MCR,PX120.177,CDM,431,RC,,,,,,,,,,98,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
Pt Contracted Services/MCR,PX120.175,CDM,421,RC,,,,,,,,,,98,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,47.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
Pt Contracted Services/MCR,PX120.175,CDM,421,RC,,,,,,,,,,98,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
US Urine Capacity Measure,PX51798F,CDM,510,RC,51798,CPT,,,,,,,,96,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,47.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.8784,94.08
US Urine Capacity Measure,PX51798F,CDM,510,RC,51798,CPT,,,,,,,,96,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,47.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.8784,94.08
US Urine Capacity Measure,PX51798F,CDM,510,RC,51798,CPT,,,,,,,,96,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,47.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.8784,94.08
bicalutamide 50 MG Tablet 30 Each Bottle,25000000,CDM,250,RC,,,,,,16714081601,NDC,1,EA,98.01,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,47.0448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
bicalutamide 50 MG Tablet 30 Each Bottle,25000000,CDM,250,RC,,,,,,16714081601,NDC,1,EA,98.01,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.0448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"2019-Ncov Coronavirus, Sars-Cov-2/2019-Ncov (Covid-19)",PXU000290,CDM,300,RC,U0002,HCPCS,90,,,,,,,365,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,47.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,357.7
Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq,PX87635,CDM,300,RC,87635,CPT,,,,,,,,166,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,47.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,224.4
Physical Therapy Re-Eval Est Plan Care 20 Mins,PX97164,CDM,424,RC,97164,CPT,,,,,,,,239,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,47.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,234.22
Sars-Cov-2 Covid-19 Amp Prb,PX8763590,CDM,300,RC,87635,CPT,90,,,,,,,365,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,47.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,357.7
BOOT AIRSELECT SHORT LARGE 01ES-L,120.45,CDM,274,RC,L4360,HCPCS,,11890-MAIN,LOCAL,,,,,93,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,47.058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT MEDIUM 01ES-M,120.45,CDM,274,RC,L4360,HCPCS,,11889-MAIN,LOCAL,,,,,93,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,47.058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT SMALL 01ES-S,120.45,CDM,274,RC,L4360,HCPCS,,11888-MAIN,LOCAL,,,,,93,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,47.058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT X-LARGE 01ES-XL,120.45,CDM,274,RC,L4360,HCPCS,,11891-MAIN,LOCAL,,,,,93,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,47.058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT X-SMALL 01ES-XS,120.45,CDM,274,RC,L4360,HCPCS,,11887-MAIN,LOCAL,,,,,93,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,47.058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD LARGE 01EF-L,120.45,CDM,274,RC,L4360,HCPCS,,11697-MAIN,LOCAL,,,,,93,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,47.058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD MEDIUM 01EF-M,120.45,CDM,274,RC,L4360,HCPCS,,11696-MAIN,LOCAL,,,,,93,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,47.058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD SMALL 01EF-S,120.45,CDM,274,RC,L4360,HCPCS,,11695-MAIN,LOCAL,,,,,93,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,47.058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD X-LARGE 01EF-XL,120.45,CDM,274,RC,L4360,HCPCS,,11698-MAIN,LOCAL,,,,,93,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,47.058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD X-SMALL 01EF-XS,120.45,CDM,274,RC,L4360,HCPCS,,11694-MAIN,LOCAL,,,,,93,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,47.058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
Russell Viper Venom - Ref,PX8561390,CDM,300,RC,85613,CPT,90,,,,,,,93,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,47.058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.78,91.14
SPLINT FOOT SMALL STRUT WALK 11-1383-2-00000,120.45,CDM,274,RC,L4360,HCPCS,,1205-MAIN,LOCAL,,,,,93,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,47.058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,25021010720,NDC,1,EA,48.35,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,18.43861111,percent of total billed charges,47.059055,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,781323294,NDC,1,EA,52.89,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,47.0721,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,61314062810,NDC,10,ML,98.07,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,47.0736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,61314062810,NDC,10,ML,98.07,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.0736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Box,25000000,CDM,250,RC,,,,,,67434509,NDC,1,EA,98.1,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,47.088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Box,25000000,CDM,250,RC,,,,,,67434509,NDC,1,EA,98.1,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714000601,NDC,0.3,ML,53.39,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,47.08998,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,67457022800,NDC,5,ML,53.42,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,47.11644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,67457057305,NDC,5,ML,53.42,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,47.11644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Chemotherapy Administration, Subq/Im Non-Hormonal Anti-Neoplastic",PX96401,CDM,335,RC,96401,CPT,,,,,,,,170,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,47.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.12,125.07
"Chemotherapy Administration, Subq/Im Non-Hormonal Anti-Neoplastic",PX96401,CDM,335,RC,96401,CPT,,,,,,,,170,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,47.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.12,125.07
"Diagnostic Bone Marrow, Biopsy and Aspiration",PX38222F,CDM,761,RC,38222,CPT,,,,,,,,1748,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,47.12,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9,363.89
OBINutuzumab 1000 MG/40ML Solution 40 mL Vial,J9301.01,CDM,636,RC,J9301,HCPCS,,,,50242007001,NDC,4,ML,1397.15,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,47.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.12,1369.207
US Scrotum & Contents Tc,PX7687001,CDM,402,RC,76870,CPT,TC,,,,,,,457,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,47.12,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.12,138.71
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030926,NDC,1,EA,55.44,,First Health,Commercial,both,85,,999999999,percent of total billed charges,47.124,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,50383058766,NDC,60,ML,95.26,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,47.1537,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,60432053760,NDC,60,ML,95.26,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,47.1537,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine HCl 4 % Cream 133 g Tube,63700001,CDM,250,RC,,,,,,41167005828,NDC,133,GR,52.99,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,47.1611,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Dystrophic Nail Trimming Any Number,PXG0127F,CDM,940,RC,G0127,HCPCS,,,,,,,,53,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,47.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.0162,53.44
Renin - Ref,PX8424490,CDM,300,RC,84244,CPT,90,,,,,,,53,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,47.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.16,51.94
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089901,NDC,0.25,ML,95.31,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,47.17845,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.79,93.4038
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089910,NDC,0.25,ML,95.31,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,47.17845,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.79,93.4038
"Acylcarnitines, Quant - Ref",PX8201790,CDM,300,RC,82017,CPT,90,,,,,,,110,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,47.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.47,107.8
"Assay Calcium, Ionized",PX82330,CDM,300,RC,82330,CPT,,,,,,,,110,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,47.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.54,107.8
BONE MARROW BIOPSY ASPIRATION NEEDLE 11G X 4 IN,120.562,CDM,272,RC,C1830,HCPCS,,12677-MAIN,LOCAL,,,,,110,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,47.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.694,107.8
Glycosylated Hemoglobin Test,PX83036,CDM,300,RC,83036,CPT,,,,,,,,110,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,47.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.9,130.9
K-WIRE 0.9X150MM BLUNT/TROCAR DART-FIRE STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12449-MAIN,LOCAL,,,,,110,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,47.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRE 0.9X150MM BLUNT/TROCAR STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12452-MAIN,LOCAL,,,,,110,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,47.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRE 1.4X150MM BLUNT/TROCAR DART-FIRE STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12450-MAIN,LOCAL,,,,,110,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,47.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRE 1.4X150MM BLUNT/TROCAR STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12451-MAIN,LOCAL,,,,,110,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,47.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA 2.0MM TARGETING GUIDE PIN,27200000,CDM,272,RC,,,,12436-MAIN,LOCAL,,,,,110,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,47.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Strapping of Shoulder,PX29240P,CDM,983,RC,29240,CPT,,,,,,,,110,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,47.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.694,111.6
Drain/Inject Med Joint/Brusa W/US Guide,PX20606F,CDM,510,RC,20606,CPT,,,,,,,,387,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,47.2017,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.85,187.48
Drain/Inject Med Joint/Brusa W/US Guide,PX20606P,CDM,983,RC,20606,CPT,,,,,,,,309,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,47.2017,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.85,302.82
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338067104,NDC,1000,ML,53.06,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,47.2234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066500,NDC,0.25,ML,48.19,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,47.2262,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.000396,47.2262
sildenafil citrate 20 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,65162035109,NDC,1,EA,95.41,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,47.22795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 900 MG/18ML Solution 18 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,67457015318,NDC,18,ML,113.73,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,47.243442,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,409469930,NDC,20,ML,48.54,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1.094496241,percent of total billed charges,47.243982,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
DERMABOND MINI SKIN ADHESIVE,27200000,CDM,272,RC,,,,8532-MAIN,LOCAL,,,,,110.16,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,47.25864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Ex for Speech Device Rx Addl,PX92608,CDM,444,RC,92608,CPT,,,,,,,,160,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,47.2605,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.86,84.93
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,68462015740,NDC,1,EA,110.25,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,47.29725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,68462015713,NDC,1,EA,110.25,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,47.29725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
rivaroxaban 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50458058030,NDC,1,EA,98.57,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,47.3136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rivaroxaban 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50458058030,NDC,1,EA,98.57,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.3136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine (preservative free) 4 % Solution 5 mL Ampule,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409428325,NDC,5,ML,48.62,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,47.321846,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
"Breast Tomosynthesis,Screen Tc",PX7706301,CDM,403,RC,77063,CPT,TC,,,,,,,166,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,47.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,47.33
"Breast Tomosynthesis,Screen Tc",PX7706301,CDM,403,RC,77063,CPT,TC,,,,,,,166,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,47.33,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,47.33
"X-Ray Exam Hip,Unilat W/Pelvis 1vw",PX7350101,CDM,320,RC,73501,CPT,TC,,,,,,,263,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,47.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,47.33
"X-Ray Exam Hip,Unilat W/Pelvis 1vw",PX7350101,CDM,320,RC,73501,CPT,TC,,,,,,,263,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,47.33,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,47.33
Xray Sinuses Less Than 3 Vws,PX7021001,CDM,320,RC,70210,CPT,TC,,,,,,,486,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,47.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,47.33
Xray Sinuses Less Than 3 Vws,PX7021001,CDM,320,RC,70210,CPT,TC,,,,,,,486,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,47.33,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,47.33
Xray Tibia & Fibula 2 Vws,PX7359001,CDM,320,RC,73590,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,47.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,47.33
Xray Tibia & Fibula 2 Vws,PX7359001,CDM,320,RC,73590,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,47.33,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,47.33
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409339004,NDC,1,EA,98.61,,Health Partners,Health Partners Care Plans,both,48,,6.796666667,percent of total billed charges,47.3328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409339004,NDC,1,EA,98.61,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.3328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
"Chemotherapy Administration, Subq/Im Non-Hormonal Anti-Neoplastic",PX96401,CDM,335,RC,96401,CPT,,,,,,,,170,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,47.34,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.12,125.07
Cyto Non Gyn,PX8811201,CDM,310,RC,88112,CPT,TC,,,,,,,372,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,47.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,364.56
"Cytoflo, Cell or Dna Anal - Ref",PX8818290,CDM,310,RC,88182,CPT,90,,,,,,,225,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,47.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,220.5
"Level III - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3933,CDM,310,RC,88304,CPT,TC,,,,,,,66,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,47.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
"Level IV - Surgical Pathology, Gross and Microscopic Examination , Tech",PX3934,CDM,310,RC,88305,CPT,TC,,,,,,,185,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,47.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,271.15
RBC Antibody Screen,PX86850,CDM,300,RC,86850,CPT,,,,,,,,173,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,47.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,169.54
"Special Stains,Group I",PX3978,CDM,310,RC,88312,CPT,TC,,,,,,,107,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,47.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
"Tech-Cytopath Eval, Fna, Rep",PX8817301,CDM,310,RC,88173,CPT,TC,,,,,,,379,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,47.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,371.42
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019600,NDC,1,ML,48.64,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,42.99521739,percent of total billed charges,47.341312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
"OB US < 14 Wks, Single Fetus - Radiology, Tech",PX7680101,CDM,402,RC,76801,CPT,TC,,,,,,,472,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,47.35,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.35,140.03
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,36000000924,NDC,200,ML,48.65,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,47.351045,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.20921,64.9544
Assay of Erythropoietin,PX82668,CDM,300,RC,82668,CPT,,,,,,,,114,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,47.3556,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,111.72
Antinuclear Ab(Ana) Titer - Ref,PX8603990,CDM,300,RC,86039,CPT,90,,,,,,,52,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,47.372,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.23,50.96
Assay Biovlbl Testosterone Direct Measurement - Ref,PX8441090,CDM,300,RC,84410,CPT,90,,,,,,,52,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,47.372,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.6008,50.96
"Beta 2 Glycoprot 1 Ab,Ea - Ref",PX8614690,CDM,300,RC,86146,CPT,90,,,,,,,52,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,47.372,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.6008,50.96
Iron - Ref,PX8354090,CDM,300,RC,83540,CPT,90,,,,,,,52,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,47.372,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,50.96
Rickettsia Antibody - Ref,PX8675790,CDM,300,RC,86757,CPT,90,,,,,,,52,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,47.372,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.74,50.96
Uric Acid; Blood,PX84550,CDM,300,RC,84550,CPT,,,,,,,,52,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,47.372,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.14,50.96
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,17478028810,NDC,5,ML,95.71,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,47.37645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314022705,NDC,5,ML,95.71,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,47.37645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,64980051405,NDC,5,ML,95.71,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,47.37645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ROPivacaine 2 MG/ML Solution 10 mL Vial,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028513,NDC,10,ML,52.01,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,47.38111,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.604954,269.6078
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,25021010720,NDC,1,EA,48.35,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,47.383,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424601,NDC,15,ML,95.76,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,47.4012,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.778704,295.3916
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424681,NDC,15,ML,95.76,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,47.4012,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.778704,295.3916
dabigatran 75 MG capsule 60 Each Box,63700001,CDM,250,RC,,,,,,597035556,NDC,1,EA,53.27,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,47.4103,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vinCRIStine 1 MG/ML Solution 2 mL Vial,J9370.01,CDM,636,RC,J9370,HCPCS,,,,61703030916,NDC,2,ML,48.72,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,47.419176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.238288,47.7456
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,25021050002,NDC,1,ML,52.06,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,47.42666,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
fentaNYL 12 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,378911916,NDC,1,EA,96.83,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,47.4467,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 12 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,378911916,NDC,1,EA,96.83,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,47.4467,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 12 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,378911916,NDC,1,EA,96.83,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,47.4467,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 12 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505708000,NDC,1,EA,96.83,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,47.4467,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 12 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505708000,NDC,1,EA,96.83,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,47.4467,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 12 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505708000,NDC,1,EA,96.83,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,47.4467,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexmedeTOMIDine 200 MCG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,70860060541,NDC,2,ML,55.82,,First Health,Commercial,both,85,,999999999,percent of total billed charges,47.447,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 4-5 MG/ML-% Solution 500 mL Flex Cont,J2001.01,CDM,636,RC,J2001,HCPCS,,,,338040903,NDC,500,ML,55.82,,First Health,Commercial,both,85,,999999999,percent of total billed charges,47.447,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
fentaNYL 12 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,378911998,NDC,1,EA,96.84,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,47.4516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 12 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,378911998,NDC,1,EA,96.84,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,47.4516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 12 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,378911998,NDC,1,EA,96.84,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,47.4516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 12 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,60505708002,NDC,1,EA,96.84,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,47.4516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 12 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,60505708002,NDC,1,EA,96.84,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,47.4516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 12 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,60505708002,NDC,1,EA,96.84,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,47.4516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oxyCODONE CR 20 MG Tablet ER 12 hour Abuse-Deterrent 20 Each Box,63700001,CDM,250,RC,,,,,,59011042020,NDC,1,EA,52.09,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,47.45399,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sod citrate-citric acid 500-334 MG/5ML Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,121059516,NDC,473,ML,95.87,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,47.45565,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ondansetron 4 MG/5ML Solution 50 mL Bottle,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714067102,NDC,5,ML,98.91,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,47.4768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG/5ML Solution 50 mL Bottle,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714067102,NDC,5,ML,98.91,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.4768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ocrelizumab 300 MG/10ML Solution 10 mL Vial,J2350.01,CDM,636,RC,J2350,HCPCS,,,,50242015001,NDC,10,ML,33150,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,47.48,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.48,59.75
lidocaine 4 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,536128128,NDC,30,GR,96.95,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,47.5055,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 4 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,536128128,NDC,30,GR,96.95,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,47.5055,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 4 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,536128128,NDC,30,GR,96.95,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,47.5055,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,23155029031,NDC,2,ML,98.99,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,47.5152,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,97.0102
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,23155029031,NDC,2,ML,98.99,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.5152,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,97.0102
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714000601,NDC,0.3,ML,53.39,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,47.5171,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
lidocaine urethral/mucosal 2 % Gel 30 mL Tube,25000000,CDM,250,RC,,,,,,17478084030,NDC,30,ML,93.91,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,47.51846,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Clostridium Ag, Eia",PX87324,CDM,300,RC,87324,CPT,,,,,,,,99,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,47.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,97.02
"Clostridium Ag, Eia",PX87324,CDM,300,RC,87324,CPT,,,,,,,,99,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,97.02
Deoxyribonuclease Ab,PX86215,CDM,300,RC,86215,CPT,,,,,,,,99,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,47.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,97.02
Deoxyribonuclease Ab,PX86215,CDM,300,RC,86215,CPT,,,,,,,,99,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,97.02
"Extractable Nuclear Antigen, Each Antigen",PX86235,CDM,300,RC,86235,CPT,90,,,,,,,99,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,47.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.44,97.02
"Extractable Nuclear Antigen, Each Antigen",PX86235,CDM,300,RC,86235,CPT,90,,,,,,,99,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.44,97.02
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; 1st",PX88184,CDM,310,RC,88184,CPT,,,,,,,,96,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,47.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.8784,314.02
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; Add'l",PX88185,CDM,310,RC,88185,CPT,,,,,,,,96,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,47.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.8784,94.08
"Fungus Antibody, Nos - Ref",PX8667190,CDM,300,RC,86671,CPT,90,,,,,,,99,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,47.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.23,97.02
"Fungus Antibody, Nos - Ref",PX8667190,CDM,300,RC,86671,CPT,90,,,,,,,99,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.23,97.02
"Lab Immunoassay, Non Antibody",PX83516,CDM,300,RC,83516,CPT,,,,,,,,99,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,47.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.57,97.02
"Lab Immunoassay, Non Antibody",PX83516,CDM,300,RC,83516,CPT,,,,,,,,99,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.57,97.02
"Protozoa Antibody, Nos - Ref",PX8675390,CDM,300,RC,86753,CPT,90,,,,,,,99,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,47.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.36,97.02
"Protozoa Antibody, Nos - Ref",PX8675390,CDM,300,RC,86753,CPT,90,,,,,,,99,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.36,97.02
US Urine Capacity Measure,PX51798F,CDM,510,RC,51798,CPT,,,,,,,,96,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,47.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.8784,94.08
Blastomyces Antibody - Ref,PX8661290,CDM,300,RC,86612,CPT,90,,,,,,,97,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,47.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.83,95.06
Blastomyces Antibody - Ref,PX8661290,CDM,300,RC,86612,CPT,90,,,,,,,97,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,47.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.83,95.06
Blastomyces Antibody - Ref,PX8661290,CDM,300,RC,86612,CPT,90,,,,,,,97,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,47.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.83,95.06
Contrast Bath Therapy,PX97034,CDM,420,RC,97034,CPT,,,,,,,,97,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,47.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,95.06
Contrast Bath Therapy,PX97034,CDM,420,RC,97034,CPT,,,,,,,,97,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,47.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,95.06
Contrast Bath Therapy,PX97034,CDM,420,RC,97034,CPT,,,,,,,,97,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,47.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,95.06
DRAPE INSTRUMENT ARM 470015,27200000,CDM,272,RC,,,,11925-MAIN,LOCAL,,,,,97,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,47.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRAPE INSTRUMENT ARM 470015,27200000,CDM,272,RC,,,,11925-MAIN,LOCAL,,,,,97,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,47.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRAPE INSTRUMENT ARM 470015,27200000,CDM,272,RC,,,,11925-MAIN,LOCAL,,,,,97,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,47.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
High Sens Crp,PX86141,CDM,300,RC,86141,CPT,,,,,,,,97,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,47.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,95.06
High Sens Crp,PX86141,CDM,300,RC,86141,CPT,,,,,,,,97,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,47.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,95.06
High Sens Crp,PX86141,CDM,300,RC,86141,CPT,,,,,,,,97,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,47.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,95.06
Rheumatoid Factor Quant,PX86431,CDM,300,RC,86431,CPT,,,,,,,,97,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,47.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.2,95.06
Rheumatoid Factor Quant,PX86431,CDM,300,RC,86431,CPT,,,,,,,,97,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,47.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.2,95.06
Rheumatoid Factor Quant,PX86431,CDM,300,RC,86431,CPT,,,,,,,,97,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,47.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.2,95.06
naloxone 2 MG/2ML solution prefilled syringe 2 mL Syringe,J2310.01,CDM,636,RC,J2310,HCPCS,,,,76329346901,NDC,1,ML,114.45,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,47.54253,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.54253,130.4968
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,67457022800,NDC,5,ML,53.42,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,47.5438,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,67457057305,NDC,5,ML,53.42,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,47.5438,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
levonorgestrel 1.5 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,62756071860,NDC,1,EA,114.48,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,47.554992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Coccidioides Antibody - Ref,PX8663590,CDM,300,RC,86635,CPT,90,,,,,,,94,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,47.564,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.52,92.12
Copper - Ref,PX8252590,CDM,300,RC,82525,CPT,90,,,,,,,94,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,47.564,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.38,92.12
DEFIBRILLATION PAD MULTI FUNCTION ADULT,120.58,CDM,271,RC,A0392,HCPCS,,1320-MAIN,LOCAL,,,,,94,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,47.564,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
DEFIBRILLATION PAD PEDI PADZ PEDS,120.58,CDM,271,RC,A0392,HCPCS,,1322-MAIN,LOCAL,,,,,94,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,47.564,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
DRESSING NASAL 4.5CM NON-INFLATABLE RAPID RHINO RR450,120.97,CDM,272,RC,A6407,HCPCS,,616-MAIN,LOCAL,,,,,94,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,47.564,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
DRESSING NASAL 5.5CM INFLATABLE RAPID RHINO RR550,120.97,CDM,272,RC,A6407,HCPCS,,606-MAIN,LOCAL,,,,,94,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,47.564,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
DRESSING NASAL 7.5CM INFLATABLE RAPID RHINO RR750,120.97,CDM,272,RC,A6407,HCPCS,,611-MAIN,LOCAL,,,,,94,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,47.564,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
DRESSING NASAL 8CM LONGX1.5CM THICK X3CM HIGH ANATOMICAL 34-105,120.97,CDM,272,RC,A6407,HCPCS,,613-MAIN,LOCAL,,,,,94,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,47.564,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
Tissue Exam for Fungi,PX87220,CDM,300,RC,87220,CPT,,,,,,,,94,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,47.564,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,92.12
TUBING IRRIGATION F SET STERILE MXB-T,27200000,CDM,272,RC,,,,11693-MAIN,LOCAL,,,,,94,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,47.564,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,409469930,NDC,20,ML,48.54,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,47.5692,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016200,NDC,1,ML,52.22,,Medica,Commercial,both,91.1,,3.497586207,percent of total billed charges,47.57242,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8092351,NDC,1,EA,52.22,,Medica,Commercial,both,91.1,,23.075,percent of total billed charges,47.57242,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400101,NDC,1,EA,52.22,,Medica,Commercial,both,91.1,,23.075,percent of total billed charges,47.57242,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400125,NDC,1,EA,52.22,,Medica,Commercial,both,91.1,,23.075,percent of total billed charges,47.57242,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
"dextrose 5 % 5 % Solution 1,000 mL Flex Cont",J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001704,NDC,1000,ML,99.12,,Health Partners,Health Partners Care Plans,both,48,,43.88894737,percent of total billed charges,47.5776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"dextrose 5 % 5 % Solution 1,000 mL Flex Cont",J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001704,NDC,1000,ML,99.12,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.5776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001702,NDC,250,ML,99.12,,Health Partners,Health Partners Care Plans,both,48,,43.88894737,percent of total billed charges,47.5776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001702,NDC,250,ML,99.12,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.5776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338634602,NDC,250,ML,99.12,,Health Partners,Health Partners Care Plans,both,48,,43.88894737,percent of total billed charges,47.5776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338634602,NDC,250,ML,99.12,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.5776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 500 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001703,NDC,500,ML,99.12,,Health Partners,Health Partners Care Plans,both,48,,43.88894737,percent of total billed charges,47.5776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 500 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001703,NDC,500,ML,99.12,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.5776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % Non-DEHP bag 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,264751020,NDC,250,ML,99.12,,Health Partners,Health Partners Care Plans,both,48,,43.88894737,percent of total billed charges,47.5776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % Non-DEHP bag 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,264751020,NDC,250,ML,99.12,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.5776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"dextrose 5% and sodium chloride 0.2% 5-0.2 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338007704,NDC,1000,ML,99.12,,Health Partners,Health Partners Care Plans,both,48,,22.98666667,percent of total billed charges,47.5776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
"dextrose 5% and sodium chloride 0.2% 5-0.2 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338007704,NDC,1000,ML,99.12,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.5776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
"dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008904,NDC,1000,ML,99.12,,Health Partners,Health Partners Care Plans,both,48,,22.98666667,percent of total billed charges,47.5776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
"dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008904,NDC,1000,ML,99.12,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.5776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 500 mL Flex Cont,J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008903,NDC,500,ML,99.12,,Health Partners,Health Partners Care Plans,both,48,,22.98666667,percent of total billed charges,47.5776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 500 mL Flex Cont,J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008903,NDC,500,ML,99.12,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.5776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
"dextrose 5% and sodium chloride 0.45% 5-0.45 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008504,NDC,1000,ML,99.12,,Health Partners,Health Partners Care Plans,both,48,,22.98666667,percent of total billed charges,47.5776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
"dextrose 5% and sodium chloride 0.45% 5-0.45 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008504,NDC,1000,ML,99.12,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.5776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
dextrose 5% lactated ringers 5 % Solution 500 mL Flex Cont,J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012503,NDC,500,ML,99.12,,Health Partners,Health Partners Care Plans,both,48,,62.59384615,percent of total billed charges,47.5776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5% lactated ringers 5 % Solution 500 mL Flex Cont,J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012503,NDC,500,ML,99.12,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.5776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 10% 10 % Solution 500 mL Flex Cont,25000000,CDM,250,RC,,,,,,338002303,NDC,500,ML,99.12,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,47.5776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dextrose 10% 10 % Solution 500 mL Flex Cont,25000000,CDM,250,RC,,,,,,338002303,NDC,500,ML,99.12,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.5776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lactated ringers Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338011704,NDC,1000,ML,99.12,,Health Partners,Health Partners Care Plans,both,48,,62.59384615,percent of total billed charges,47.5776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"lactated ringers Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338011704,NDC,1000,ML,99.12,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.5776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338069104,NDC,1000,ML,99.12,,Health Partners,Health Partners Care Plans,both,48,,6.034333333,percent of total billed charges,47.5776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338069104,NDC,1000,ML,99.12,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.5776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004904,NDC,1000,ML,99.12,,Health Partners,Health Partners Care Plans,both,48,,38.34875,percent of total billed charges,47.5776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004904,NDC,1000,ML,99.12,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.5776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954306,NDC,1000,ML,99.12,,Health Partners,Health Partners Care Plans,both,48,,38.34875,percent of total billed charges,47.5776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954306,NDC,1000,ML,99.12,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.5776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004902,NDC,250,ML,99.12,,Health Partners,Health Partners Care Plans,both,48,,38.34875,percent of total billed charges,47.5776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004902,NDC,250,ML,99.12,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.5776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954302,NDC,250,ML,99.12,,Health Partners,Health Partners Care Plans,both,48,,38.34875,percent of total billed charges,47.5776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954302,NDC,250,ML,99.12,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.5776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 500 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004903,NDC,500,ML,99.12,,Health Partners,Health Partners Care Plans,both,48,,38.34875,percent of total billed charges,47.5776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 500 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004903,NDC,500,ML,99.12,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.5776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9% 0.9% Solution 1,000 mL Flex Cont",J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004904,NDC,1000,ML,99.12,,Health Partners,Health Partners Care Plans,both,48,,36.618125,percent of total billed charges,47.5776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
"sodium chloride 0.9% 0.9% Solution 1,000 mL Flex Cont",J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004904,NDC,1000,ML,99.12,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.5776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9% IV LINE FLUSH 0.9% Solution 250 mL Flex Cont,25000000,CDM,250,RC,,,,,,338004902,NDC,250,ML,99.12,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,47.5776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9% IV LINE FLUSH 0.9% Solution 250 mL Flex Cont,25000000,CDM,250,RC,,,,,,338004902,NDC,250,ML,99.12,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.5776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"sodium chloride 0.45 % 0.45 % Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,338004304,NDC,1000,ML,99.12,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,47.5776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"sodium chloride 0.45 % 0.45 % Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,338004304,NDC,1000,ML,99.12,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.5776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 3 % 3 % Solution 500 mL Flex Cont,J7131.01,CDM,636,RC,J7131,HCPCS,,,,338005403,NDC,500,ML,99.12,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,47.5776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
sodium chloride 3 % 3 % Solution 500 mL Flex Cont,J7131.01,CDM,636,RC,J7131,HCPCS,,,,338005403,NDC,500,ML,99.12,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.5776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
8MM-12MM BLADELESS OBTURATOR 8MM,27200000,CDM,272,RC,,,,11919-MAIN,LOCAL,,,,,56,,First Health,Commercial,both,85,,999999999,percent of total billed charges,47.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM-12MM BLADELESS OBTURATOR 8MM LONG,27200000,CDM,272,RC,,,,11920-MAIN,LOCAL,,,,,56,,First Health,Commercial,both,85,,999999999,percent of total billed charges,47.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"B Cells, Total Count",PX86355,CDM,300,RC,86355,CPT,,,,,,,,56,,First Health,Commercial,both,85,,999999999,percent of total billed charges,47.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.2624,54.88
Citrate - Ref,PX8250790,CDM,300,RC,82507,CPT,90,,,,,,,56,,First Health,Commercial,both,85,,999999999,percent of total billed charges,47.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.2624,54.88
"Folic Acid (Folate), Serum",PX82746,CDM,300,RC,82746,CPT,,,,,,,,56,,First Health,Commercial,both,85,,999999999,percent of total billed charges,47.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.48,54.88
Lab Platelet Count,PX85049,CDM,300,RC,85049,CPT,,,,,,,,56,,First Health,Commercial,both,85,,999999999,percent of total billed charges,47.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.11,54.88
Mycophenolate Mycophenolicacid - Ref,PX8018090,CDM,300,RC,80180,CPT,90,,,,,,,56,,First Health,Commercial,both,85,,999999999,percent of total billed charges,47.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.55,54.88
Progesterone,PX84144,CDM,300,RC,84144,CPT,,,,,,,,56,,First Health,Commercial,both,85,,999999999,percent of total billed charges,47.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.13,54.88
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028401,NDC,1,EA,111.01,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,47.62329,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028420,NDC,1,EA,111.01,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,47.62329,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
Xray Cervical Spine 6 or More Vws,PX7205201,CDM,320,RC,72052,CPT,TC,,,,,,,664,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,47.6264,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.85,95.32
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405F,CDM,510,RC,36405,CPT,,,,,,,,54,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,47.628,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.4316,52.92
Acute Hepatitis Panel,PX80074,CDM,300,RC,80074,CPT,,,,,,,,509,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,47.63,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.2,47.63
rosuvastatin 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,310075430,NDC,1,EA,56.04,,First Health,Commercial,both,85,,999999999,percent of total billed charges,47.634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine (preservative free) 4 % Solution 5 mL Ampule,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409428325,NDC,5,ML,48.62,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,47.6476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019600,NDC,1,ML,48.64,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,47.6672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
levothyroxine 100 MCG/5ML Solution 5 mL Vial,J0651.01,CDM,636,RC,J0651,HCPCS,,,,63323088510,NDC,0.625,ML,99.32,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,47.6736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.257528,97.3336
levothyroxine 100 MCG/5ML Solution 5 mL Vial,J0651.01,CDM,636,RC,J0651,HCPCS,,,,63323088510,NDC,0.625,ML,99.32,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.6736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.257528,97.3336
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,36000000924,NDC,200,ML,48.65,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,47.677,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.20921,64.9544
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026969,NDC,100,ML,99.34,,Health Partners,Health Partners Care Plans,both,48,,1.259785714,percent of total billed charges,47.6832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026969,NDC,100,ML,99.34,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.6832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
Beta-2-Microglobulin - Ref,PX8223290,CDM,300,RC,82232,CPT,90,,,,,,,49,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,47.6917,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.84,48.02
"Cannabinoids, Natural - Ref",PX8034990,CDM,300,RC,80349,CPT,90,,,,,,,49,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,47.6917,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,48.02
cefTAZidime 1 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023525,NDC,1,EA,49,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,47.6917,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
COLLAR CERVICAL X-LARGE WITH TRACH 2 PIECE OSG2404,120.185,CDM,274,RC,L0172,HCPCS,,10143-MAIN,LOCAL,,,,,49,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,7,percent of total billed charges,47.6917,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,152.79
Glycated Protein - Ref,PX8298590,CDM,300,RC,82985,CPT,90,,,,,,,49,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,47.6917,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.37,48.02
"SUTURE V-LOC SZ 0 180 GREEN GS21 NEEDLE 18"" VLOCL0326",27200000,CDM,272,RC,,,,12218-MAIN,LOCAL,,,,,49,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,47.6917,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098321,NDC,1,EA,99.39,,Health Partners,Health Partners Care Plans,both,48,,6.796666667,percent of total billed charges,47.7072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098321,NDC,1,EA,99.39,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.7072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098323,NDC,1,EA,99.39,,Health Partners,Health Partners Care Plans,both,48,,6.796666667,percent of total billed charges,47.7072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098323,NDC,1,EA,99.39,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.7072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052200,NDC,1,EA,99.39,,Health Partners,Health Partners Care Plans,both,48,,6.796666667,percent of total billed charges,47.7072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052200,NDC,1,EA,99.39,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.7072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052237,NDC,1,EA,99.39,,Health Partners,Health Partners Care Plans,both,48,,6.796666667,percent of total billed charges,47.7072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052237,NDC,1,EA,99.39,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.7072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
alendronate 70 MG Tablet 4 Each Box,63700001,CDM,250,RC,,,,,,16714063301,NDC,1,EA,97.37,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,47.7113,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
alendronate 70 MG Tablet 4 Each Box,63700001,CDM,250,RC,,,,,,16714063301,NDC,1,EA,97.37,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,47.7113,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
alendronate 70 MG Tablet 4 Each Box,63700001,CDM,250,RC,,,,,,16714063301,NDC,1,EA,97.37,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,47.7113,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vinCRIStine 1 MG/ML Solution 2 mL Vial,J9370.01,CDM,636,RC,J9370,HCPCS,,,,61703030916,NDC,2,ML,48.72,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,47.7456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.238288,47.7456
CARTER THOMASON CLOSURE 5MM,27200000,CDM,272,RC,,,,10278-MAIN,LOCAL,,,,,97.45,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,47.7505,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CARTER THOMASON CLOSURE 5MM,27200000,CDM,272,RC,,,,10278-MAIN,LOCAL,,,,,97.45,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,47.7505,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CARTER THOMASON CLOSURE 5MM,27200000,CDM,272,RC,,,,10278-MAIN,LOCAL,,,,,97.45,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,47.7505,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Assay of Triglycerides,PX84478,CDM,300,RC,84478,CPT,,,,,,,,115,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,47.771,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.26,112.7
"Blood Typing, Rh Phenotype",PX86906,CDM,300,RC,86906,CPT,,,,,,,,115,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,47.771,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.03,112.7
BRACE ANKLE LARGE 264015,120.51,CDM,274,RC,L1902,HCPCS,,4-MAIN,LOCAL,,,,,115,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,47.771,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE MEDIUM 264014,120.51,CDM,274,RC,L1902,HCPCS,,7-MAIN,LOCAL,,,,,115,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,47.771,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE SMALL 264012,120.51,CDM,274,RC,L1902,HCPCS,,12-MAIN,LOCAL,,,,,115,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,47.771,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE X-LARGE 264016,120.51,CDM,274,RC,L1902,HCPCS,,14-MAIN,LOCAL,,,,,115,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,47.771,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE X-SMALL 264011,120.51,CDM,274,RC,L1902,HCPCS,,1-MAIN,LOCAL,,,,,115,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,47.771,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
Debride Skin/Subq Ea Ad 20sqcm,PX11045F,CDM,510,RC,11045,CPT,,,,,,,,115,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,47.771,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
Glucagon - Ref,PX8294390,CDM,300,RC,82943,CPT,90,,,,,,,115,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,47.771,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.1,112.7
"Immuno for Tumor Ag, Qn - Ref",PX8631690,CDM,300,RC,86316,CPT,90,,,,,,,115,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,47.771,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,112.7
Microsomal Antibody,PX7893,CDM,300,RC,86376,CPT,,,,,,,,115,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,47.771,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.34,112.7
US Pregnancy Tc Follow-Up,PX7681601,CDM,402,RC,76816,CPT,TC,,,,,,,362,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,47.83,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.26,138.05
US Pregnancy Tc Follow-Up,PX7681601,CDM,402,RC,76816,CPT,TC,,,,,,,362,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,47.83,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.26,138.05
magnesium sulfate 1 g in 100 ml D5W (premix) 1-5 GM/100ML-% Solution 100 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010802,NDC,100,ML,52.51,,Medica,Commercial,both,91.1,,6.305,percent of total billed charges,47.83661,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
cyclopentolate 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,61314039601,NDC,2,ML,94.58,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,47.85748,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047625,NDC,0.769230769,ML,111.59,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,47.87211,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.354486,332.1514
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409663724,NDC,50,ML,115.32,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,47.903928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141035,NDC,2,ML,56.37,,First Health,Commercial,both,85,,999999999,percent of total billed charges,47.9145,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,65219044501,NDC,10,ML,56.37,,First Health,Commercial,both,85,,999999999,percent of total billed charges,47.9145,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,65219044510,NDC,10,ML,56.37,,First Health,Commercial,both,85,,999999999,percent of total billed charges,47.9145,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fentaNYL 12 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,378911916,NDC,1,EA,96.83,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,47.93085,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 12 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505708000,NDC,1,EA,96.83,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,47.93085,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 12 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,378911998,NDC,1,EA,96.84,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,47.9358,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 12 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,60505708002,NDC,1,EA,96.84,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,47.9358,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011801,NDC,0.5,ML,52.63,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,47.94593,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011805,NDC,0.5,ML,52.63,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,47.94593,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
DOPamine 1600 mcg/mL in dextrose 5% 250 mL premix 1600 mcg/mL Solution 250 mL Plas Cont,J1265.01,CDM,636,RC,J1265,HCPCS,,,,338100702,NDC,250,ML,99.9,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,47.952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.49846,97.902
DOPamine 1600 mcg/mL in dextrose 5% 250 mL premix 1600 mcg/mL Solution 250 mL Plas Cont,J1265.01,CDM,636,RC,J1265,HCPCS,,,,338100702,NDC,250,ML,99.9,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.49846,97.902
oseltamivir 75 MG capsule 10 Each Disp Pack,63700001,CDM,250,RC,,,,,,4080085,NDC,1,EA,97.87,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,47.9563,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 75 MG capsule 10 Each Disp Pack,63700001,CDM,250,RC,,,,,,4080085,NDC,1,EA,97.87,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,47.9563,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 75 MG capsule 10 Each Disp Pack,63700001,CDM,250,RC,,,,,,4080085,NDC,1,EA,97.87,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,47.9563,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927380,NDC,1,EA,99.91,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,47.9568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927380,NDC,1,EA,99.91,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.9568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927395,NDC,1,EA,99.91,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,47.9568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927395,NDC,1,EA,99.91,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,47.9568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034001,NDC,1,EA,111.81,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,47.96649,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034000,NDC,1,EA,111.82,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,47.97078,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
ketamine 100 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,55150044001,NDC,10,ML,111.85,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,47.98365,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
Pvb Thoracic Single Injection Site W/Img Gid,PX64461F,CDM,510,RC,64461,CPT,,,,,,,,353,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,47.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.99,278.1
Pvb Thoracic Single Injection Site W/Img Gid,PX64461F,CDM,510,RC,64461,CPT,,,,,,,,353,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,47.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.99,278.1
Pvb Thoracic Single Injection Site W/Img Gid,PX64461F,CDM,510,RC,64461,CPT,,,,,,,,353,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,47.99,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.99,278.1
Pvb Thoracic Single Injection Site W/Img Gid,PX64461P,CDM,983,RC,64461,CPT,,,,,,,,616,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,47.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.99,603.68
Pvb Thoracic Single Injection Site W/Img Gid,PX64461P,CDM,983,RC,64461,CPT,,,,,,,,616,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,47.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.99,603.68
Pvb Thoracic Single Injection Site W/Img Gid,PX64461P,CDM,983,RC,64461,CPT,,,,,,,,616,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,47.99,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.99,603.68
Xray Eye Foreign Body,PX7003001,CDM,320,RC,70030,CPT,TC,,,,,,,432,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,47.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,47.99
Xray Eye Foreign Body,PX7003001,CDM,320,RC,70030,CPT,TC,,,,,,,432,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,47.99,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,47.99
Xray Humerus Minimum 2 Vws,PX7306001,CDM,320,RC,73060,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,47.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,47.99
Xray Humerus Minimum 2 Vws,PX7306001,CDM,320,RC,73060,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,47.99,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,47.99
Xray Sacrum/ Coccyx Minimum 2 Vws,PX7222001,CDM,320,RC,72220,CPT,TC,,,,,,,540,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,47.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,47.99
Xray Sacrum/ Coccyx Minimum 2 Vws,PX7222001,CDM,320,RC,72220,CPT,TC,,,,,,,540,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,47.99,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,47.99
Xray Sternum 2vws Tc,PX7112001,CDM,320,RC,71120,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,47.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,47.99
Xray Sternum 2vws Tc,PX7112001,CDM,320,RC,71120,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,47.99,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,47.99
lidocaine 4 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,536128128,NDC,30,GR,96.95,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,47.99025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gadoteridol 279.3 MG/ML Solution 5 mL Vial,A9576,CDM,636,RC,A9576,HCPCS,,,,270111104,NDC,10,ML,100,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.54,166.6
gadoteridol 279.3 MG/ML Solution 5 mL Vial,A9576,CDM,636,RC,A9576,HCPCS,,,,270111104,NDC,10,ML,100,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.54,166.6
Sars-Cov-2 Covid-19 Antibody,PX8676990,CDM,300,RC,86769,CPT,90,,,,,,,100,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.63,98
Sars-Cov-2 Covid-19 Antibody,PX8676990,CDM,300,RC,86769,CPT,90,,,,,,,100,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.63,98
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061401,NDC,1,ML,94.87,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,48.00422,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.114178,99.911
Blastomyces Antibody - Ref,PX8661290,CDM,300,RC,86612,CPT,90,,,,,,,97,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,48.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.83,95.06
Contrast Bath Therapy,PX97034,CDM,420,RC,97034,CPT,,,,,,,,97,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,48.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,95.06
DRAPE INSTRUMENT ARM 470015,27200000,CDM,272,RC,,,,11925-MAIN,LOCAL,,,,,97,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,48.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
High Sens Crp,PX86141,CDM,300,RC,86141,CPT,,,,,,,,97,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,48.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,95.06
Rheumatoid Factor Quant,PX86431,CDM,300,RC,86431,CPT,,,,,,,,97,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,48.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.2,95.06
Beta-2-Microglobulin - Ref,PX8223290,CDM,300,RC,82232,CPT,90,,,,,,,49,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,48.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.84,48.02
BLADE LARYNGOSCOPE MAC #3 SINGLE USE350-005-000,120.121,CDM,272,RC,,,,8320-MAIN,LOCAL,,,,,98,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
BLADE LARYNGOSCOPE MAC #3 SINGLE USE350-005-000,120.121,CDM,272,RC,,,,8320-MAIN,LOCAL,,,,,98,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
BLADE LARYNGOSCOPE MAC #3 SINGLE USE350-005-000,120.121,CDM,272,RC,,,,8320-MAIN,LOCAL,,,,,98,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
BLADE LARYNGOSCOPE MAC #4 SINGLE USE 350-012-000,120.121,CDM,272,RC,,,,8321-MAIN,LOCAL,,,,,98,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
BLADE LARYNGOSCOPE MAC #4 SINGLE USE 350-012-000,120.121,CDM,272,RC,,,,8321-MAIN,LOCAL,,,,,98,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
BLADE LARYNGOSCOPE MAC #4 SINGLE USE 350-012-000,120.121,CDM,272,RC,,,,8321-MAIN,LOCAL,,,,,98,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
BLADE LARYNGOSCOPE MAC #X3 SINGLE USE X3-003-000,120.121,CDM,272,RC,,,,8322-MAIN,LOCAL,,,,,98,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
BLADE LARYNGOSCOPE MAC #X3 SINGLE USE X3-003-000,120.121,CDM,272,RC,,,,8322-MAIN,LOCAL,,,,,98,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
BLADE LARYNGOSCOPE MAC #X3 SINGLE USE X3-003-000,120.121,CDM,272,RC,,,,8322-MAIN,LOCAL,,,,,98,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
"Cannabinoids, Natural - Ref",PX8034990,CDM,300,RC,80349,CPT,90,,,,,,,49,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,48.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,48.02
CANNULA JUNIOR 2 LARGE OPTIFLOW OJR416VT,120.561,CDM,272,RC,A4615,HCPCS,,12645-MAIN,LOCAL,,,,,98,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
CANNULA JUNIOR 2 LARGE OPTIFLOW OJR416VT,120.561,CDM,272,RC,A4615,HCPCS,,12645-MAIN,LOCAL,,,,,98,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
CANNULA JUNIOR 2 LARGE OPTIFLOW OJR416VT,120.561,CDM,272,RC,A4615,HCPCS,,12645-MAIN,LOCAL,,,,,98,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
CANNULA JUNIOR 2 MEDIUM OPTIFLOW OJR414VT,120.561,CDM,272,RC,A4615,HCPCS,,12644-MAIN,LOCAL,,,,,98,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
CANNULA JUNIOR 2 MEDIUM OPTIFLOW OJR414VT,120.561,CDM,272,RC,A4615,HCPCS,,12644-MAIN,LOCAL,,,,,98,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
CANNULA JUNIOR 2 MEDIUM OPTIFLOW OJR414VT,120.561,CDM,272,RC,A4615,HCPCS,,12644-MAIN,LOCAL,,,,,98,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
CANNULA OPTIFLOW JUNIOR 2 SMALL OJR412VT,120.561,CDM,272,RC,A4615,HCPCS,,12643-MAIN,LOCAL,,,,,98,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
CANNULA OPTIFLOW JUNIOR 2 SMALL OJR412VT,120.561,CDM,272,RC,A4615,HCPCS,,12643-MAIN,LOCAL,,,,,98,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
CANNULA OPTIFLOW JUNIOR 2 SMALL OJR412VT,120.561,CDM,272,RC,A4615,HCPCS,,12643-MAIN,LOCAL,,,,,98,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
cefTAZidime 1 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023525,NDC,1,EA,49,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,48.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
COLLAR CERVICAL X-LARGE WITH TRACH 2 PIECE OSG2404,120.185,CDM,274,RC,L0172,HCPCS,,10143-MAIN,LOCAL,,,,,49,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,48.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,152.79
Glycated Protein - Ref,PX8298590,CDM,300,RC,82985,CPT,90,,,,,,,49,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,48.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.37,48.02
Hepatitis B Surface Antigen,PX87340,CDM,300,RC,87340,CPT,,,,,,,,98,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.47,96.04
Hepatitis B Surface Antigen,PX87340,CDM,300,RC,87340,CPT,,,,,,,,98,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.47,96.04
Hepatitis B Surface Antigen,PX87340,CDM,300,RC,87340,CPT,,,,,,,,98,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.47,96.04
Ot Contracted Service/MCR,PX120.177,CDM,431,RC,,,,,,,,,,98,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
Ot Contracted Service/MCR,PX120.177,CDM,431,RC,,,,,,,,,,98,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
Ot Contracted Service/MCR,PX120.177,CDM,431,RC,,,,,,,,,,98,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
Pt Contracted Services/MCR,PX120.175,CDM,421,RC,,,,,,,,,,98,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
Pt Contracted Services/MCR,PX120.175,CDM,421,RC,,,,,,,,,,98,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
Pt Contracted Services/MCR,PX120.175,CDM,421,RC,,,,,,,,,,98,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
"SUTURE V-LOC SZ 0 180 GREEN GS21 NEEDLE 18"" VLOCL0326",27200000,CDM,272,RC,,,,12218-MAIN,LOCAL,,,,,49,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,48.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
bicalutamide 50 MG Tablet 30 Each Bottle,25000000,CDM,250,RC,,,,,,16714081601,NDC,1,EA,98.01,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.0249,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
bicalutamide 50 MG Tablet 30 Each Bottle,25000000,CDM,250,RC,,,,,,16714081601,NDC,1,EA,98.01,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.0249,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
bicalutamide 50 MG Tablet 30 Each Bottle,25000000,CDM,250,RC,,,,,,16714081601,NDC,1,EA,98.01,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.0249,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,990771512,NDC,62.5,ML,56.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,48.025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.4701,303.0944
BMWD 2X2,27200000,CDM,272,RC,Q4104,HCPCS,,12134-MAIN,LOCAL,,,,,8016,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,48.02981,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
ELECTRODE PEDS ONESTEP SINGLE,120.343,CDM,272,RC,A4556,HCPCS,,10296-MAIN,LOCAL,,,,,112,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,48.048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
EYE IRRIGATION SYSTEM MT2000,120.318,CDM,272,RC,,,,8718-MAIN,LOCAL,,,,,112,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,48.048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
F5 Gene - Ref,PX8124190,CDM,300,RC,81241,CPT,90,,,,,,,112,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,48.048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
Immunofluorescence per Spec Add Singl Antb Stain - Ref,PX8835090,CDM,310,RC,88350,CPT,90,,,,,,,112,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,48.048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
Osmolality; Urine,PX83935,CDM,300,RC,83935,CPT,,,,,,,,112,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,48.048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.25,109.76
Prolactin,PX84146,CDM,300,RC,84146,CPT,,,,,,,,112,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,48.048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.77,109.76
Quantitation Drug Nos - Ref,PX8029990,CDM,300,RC,80299,CPT,90,,,,,,,112,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,48.048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.09,109.76
TUBE AIRSPIRAL BREATHING AND CHAMBER 900PT561,120.493,CDM,271,RC,A4604,HCPCS,,11618-MAIN,LOCAL,,,,,112,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,48.048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
verapamil 2.5 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,51754020401,NDC,1,ML,112.01,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,48.05229,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,61314062810,NDC,10,ML,98.07,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.0543,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,61314062810,NDC,10,ML,98.07,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.0543,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,61314062810,NDC,10,ML,98.07,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.0543,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405F,CDM,510,RC,36405,CPT,,,,,,,,54,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,48.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.4316,52.92
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Box,25000000,CDM,250,RC,,,,,,67434509,NDC,1,EA,98.1,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.069,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Box,25000000,CDM,250,RC,,,,,,67434509,NDC,1,EA,98.1,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.069,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Box,25000000,CDM,250,RC,,,,,,67434509,NDC,1,EA,98.1,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.069,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Assay Blood Carbon Dioxide,PX82374,CDM,300,RC,82374,CPT,,,,,,,,95,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,48.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.47,93.1
Blood Viscosity Examination,PX85810,CDM,300,RC,85810,CPT,,,,,,,,95,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,48.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.7,93.1
Cyclosporine - Ref,PX8015890,CDM,300,RC,80158,CPT,90,,,,,,,95,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,48.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.55,93.1
"Fac/Debridement of Nails, 6 or Mor",PX11721F,CDM,510,RC,11721,CPT,,,,,,,,95,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,48.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.463,93.1
"Fat/Lipids, Feces, Quant - Ref",PX8271090,CDM,300,RC,82710,CPT,90,,,,,,,95,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,48.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.4,93.1
KIT EPIDURAL 19GA FLEXTIP PLUS AK-05502,120.305,CDM,272,RC,,,,11413-MAIN,LOCAL,,,,,95,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,48.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.463,93.1
"Lyme Disease, Confirm Tst - Ref",PX8661790,CDM,300,RC,86617,CPT,90,,,,,,,95,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,48.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.2,93.1
"Organism ID, Anaerobic - Ref",PX8707690,CDM,300,RC,87076,CPT,90,,,,,,,95,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,48.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,93.1
Strep a Assay W/Optic,PX87880,CDM,300,RC,87880,CPT,,,,,,,,95,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,48.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.16,93.1
"Thyroxine, Total - Ref",PX8443690,CDM,300,RC,84436,CPT,90,,,,,,,95,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,48.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.3,93.1
TRAY FACIAL LACERATION PACK STERILE 96-1707,120.12,CDM,272,RC,,,,406-MAIN,LOCAL,,,,,95,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,48.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.463,93.1
Varicella-Zoster Antibody,PX86787,CDM,300,RC,86787,CPT,,,,,,,,95,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,48.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.81,93.1
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048557,NDC,50,ML,52.78,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,48.08258,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046417,NDC,10,ML,54.6,,United Healthcare,All Payer,outpatient,88.2,,12.82416667,percent of total billed charges,48.1572,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,781323294,NDC,1,EA,52.89,,Medica,Commercial,both,91.1,,23.075,percent of total billed charges,48.18279,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
Antithrombin III Ag Assay - Ref,PX8530190,CDM,300,RC,85301,CPT,90,,,,,,,116,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,48.1864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.91,113.68
Ca 19-9,PX86301,CDM,300,RC,86301,CPT,,,,,,,,116,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,48.1864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,113.68
alendronate 70 MG Tablet 4 Each Box,63700001,CDM,250,RC,,,,,,16714063301,NDC,1,EA,97.37,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,48.19815,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,50383058766,NDC,60,ML,95.26,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,48.20156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,60432053760,NDC,60,ML,95.26,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,48.20156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409492120,NDC,10,ML,54.66,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,48.21012,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024010,NDC,1,EA,56.73,,First Health,Commercial,both,85,,999999999,percent of total billed charges,48.2205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030036,NDC,1,EA,56.73,,First Health,Commercial,both,85,,999999999,percent of total billed charges,48.2205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098341,NDC,1,EA,56.73,,First Health,Commercial,both,85,,999999999,percent of total billed charges,48.2205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714001601,NDC,0.4,ML,100.47,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,48.2256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714001601,NDC,0.4,ML,100.47,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,48.2256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089901,NDC,0.25,ML,95.31,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,48.22686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.79,93.4038
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089910,NDC,0.25,ML,95.31,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,48.22686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.79,93.4038
CARTER THOMASON CLOSURE 5MM,27200000,CDM,272,RC,,,,10278-MAIN,LOCAL,,,,,97.45,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,48.23775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Fetal Profile W/O Stress,PX7681901,CDM,402,RC,76819,CPT,TC,,,,,,,248,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,48.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.86,97.95
lidocaine HCl 4 % Cream 133 g Tube,63700001,CDM,250,RC,,,,,,41167005828,NDC,133,GR,52.99,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,48.27389,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sildenafil citrate 20 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,65162035109,NDC,1,EA,95.41,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,48.27746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Chemotherapy, IV Infusion, Add'l Hour",PX96415,CDM,335,RC,96415,CPT,,,,,,,,191,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,48.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.1,48.28
"Chemotherapy, IV Infusion, Add'l Hour",PX96415,CDM,335,RC,96415,CPT,,,,,,,,191,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,48.28,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.1,48.28
Dystrophic Nail Trimming Any Number,PXG0127F,CDM,940,RC,G0127,HCPCS,,,,,,,,53,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,48.283,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.0162,53.44
Renin - Ref,PX8424490,CDM,300,RC,84244,CPT,90,,,,,,,53,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,48.283,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.16,51.94
rivaroxaban 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50458058030,NDC,1,EA,98.57,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.2993,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rivaroxaban 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50458058030,NDC,1,EA,98.57,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.2993,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rivaroxaban 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50458058030,NDC,1,EA,98.57,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.2993,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"polyethylene glycol 236 g Recon Soln 4,000 mL Bottle",63700001,CDM,250,RC,,,,,,43386009019,NDC,4000,ML,112.6,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,48.3054,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409339004,NDC,1,EA,98.61,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,14.99111111,percent of total billed charges,48.3189,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409339004,NDC,1,EA,98.61,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.3189,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409339004,NDC,1,EA,98.61,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.3189,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
Therapeutic Activities,PX97530,CDM,420,RC,97530,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,48.32,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.68,48.32
Therapeutic Activities,PX97530,CDM,420,RC,97530,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,48.32,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.68,48.32
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338067104,NDC,1000,ML,53.06,,Medica,Commercial,both,91.1,,1.111818182,percent of total billed charges,48.33766,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
TRUMPET SUCTION IRRIGATION,27100000,CDM,271,RC,,,,4577-MAIN,LOCAL,,,,,116.4,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,48.35256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,409672924,NDC,50,ML,116.43,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,48.365022,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
"PDS II ENDOLOOP LIGATURE SIZE 0 18""",27200000,CDM,272,RC,,,,11700-MAIN,LOCAL,,,,,56.96,,First Health,Commercial,both,85,,999999999,percent of total billed charges,48.416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409669501,NDC,10,ML,56.97,,First Health,Commercial,both,85,,999999999,percent of total billed charges,48.4245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,17478028810,NDC,5,ML,95.71,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,48.42926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314022705,NDC,5,ML,95.71,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,48.42926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,64980051405,NDC,5,ML,95.71,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,48.42926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Fac/Debridement of Nails, 6 or Mor",PX11721F,CDM,510,RC,11721,CPT,,,,,,,,95,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,48.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.61,92.7
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006111,NDC,0.5,EA,56.98,,First Health,Commercial,both,85,,999999999,percent of total billed charges,48.433,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.669492,55.8404
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006158,NDC,0.5,EA,56.98,,First Health,Commercial,both,85,,999999999,percent of total billed charges,48.433,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.669492,55.8404
oseltamivir 75 MG capsule 10 Each Disp Pack,63700001,CDM,250,RC,,,,,,4080085,NDC,1,EA,97.87,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,48.44565,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Albumin, Othr Source - Ref",PX8204290,CDM,300,RC,82042,CPT,90,,,,,,,57,,First Health,Commercial,both,85,,999999999,percent of total billed charges,48.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.13,55.86
"Albumin, Serum - Ref",PX8204090,CDM,300,RC,82040,CPT,90,,,,,,,57,,First Health,Commercial,both,85,,999999999,percent of total billed charges,48.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.54,55.86
Assay Alkaline Phosphatase,PX84075,CDM,300,RC,84075,CPT,,,,,,,,57,,First Health,Commercial,both,85,,999999999,percent of total billed charges,48.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,55.86
Calcium Total,PX82310,CDM,300,RC,82310,CPT,,,,,,,,57,,First Health,Commercial,both,85,,999999999,percent of total billed charges,48.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.73,55.86
Dhea-S - Ref,PX8262790,CDM,300,RC,82627,CPT,90,,,,,,,57,,First Health,Commercial,both,85,,999999999,percent of total billed charges,48.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.38,55.86
Tiss Trnsgltmnase Ea Ig Clas,PX86364,CDM,300,RC,86364,CPT,,,,,,,,57,,First Health,Commercial,both,85,,999999999,percent of total billed charges,48.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.6778,55.86
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424601,NDC,15,ML,95.76,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,48.45456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.778704,295.3916
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424681,NDC,15,ML,95.76,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,48.45456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.778704,295.3916
ondansetron 4 MG/5ML Solution 50 mL Bottle,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714067102,NDC,5,ML,98.91,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.4659,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG/5ML Solution 50 mL Bottle,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714067102,NDC,5,ML,98.91,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.4659,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG/5ML Solution 50 mL Bottle,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714067102,NDC,5,ML,98.91,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.4659,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
Iadna Streptococcus Group a Amplified Probe Tq,PX87651,CDM,300,RC,87651,CPT,,,,,,,,113,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,48.477,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,110.74
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209P,CDM,982,RC,69209,CPT,,,,,,,,113,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,48.477,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9402,109.9829
Strapping of Toes,PX29550F,CDM,510,RC,29550,CPT,,,,,,,,113,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,48.477,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9402,110.74
Xray Spine Single Tc,PX7202001,CDM,320,RC,72020,CPT,TC,,,,,,,113,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,48.477,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9402,110.74
BRACE KNEE LARGE SHORTRUNNER 21754,120.387,CDM,274,RC,L1833,HCPCS,,10044-MAIN,LOCAL,,,,,101,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,48.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE LARGE SHORTRUNNER 21754,120.387,CDM,274,RC,L1833,HCPCS,,10044-MAIN,LOCAL,,,,,101,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,48.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE MEDIUM SHORTRUNNER 21753,120.387,CDM,274,RC,L1833,HCPCS,,10126-MAIN,LOCAL,,,,,101,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,48.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE MEDIUM SHORTRUNNER 21753,120.387,CDM,274,RC,L1833,HCPCS,,10126-MAIN,LOCAL,,,,,101,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,48.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE SMALL SHORTRUNNER 21752,120.387,CDM,274,RC,L1833,HCPCS,,10900-MAIN,LOCAL,,,,,101,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,48.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE SMALL SHORTRUNNER 21752,120.387,CDM,274,RC,L1833,HCPCS,,10900-MAIN,LOCAL,,,,,101,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,48.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE X-LARGE SHORTRUNNER 21755,120.387,CDM,274,RC,L1833,HCPCS,,3444-MAIN,LOCAL,,,,,101,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,48.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE X-LARGE SHORTRUNNER 21755,120.387,CDM,274,RC,L1833,HCPCS,,3444-MAIN,LOCAL,,,,,101,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,48.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE XX-LARGE SHORTRUNNER 21756,120.387,CDM,274,RC,L1833,HCPCS,,10615-MAIN,LOCAL,,,,,101,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,48.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE XX-LARGE SHORTRUNNER 21756,120.387,CDM,274,RC,L1833,HCPCS,,10615-MAIN,LOCAL,,,,,101,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,48.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
"COLLAR CERVICAL 2"" SMALL UNIVERSAL 08140039",120.249,CDM,274,RC,L0120,HCPCS,,270-MAIN,LOCAL,,,,,101,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,48.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 2"" SMALL UNIVERSAL 08140039",120.249,CDM,274,RC,L0120,HCPCS,,270-MAIN,LOCAL,,,,,101,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,48.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 2X20"" SMALL 1003-02",120.249,CDM,274,RC,L0120,HCPCS,,272-MAIN,LOCAL,,,,,101,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,48.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 2X20"" SMALL 1003-02",120.249,CDM,274,RC,L0120,HCPCS,,272-MAIN,LOCAL,,,,,101,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,48.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 2X23.5"" MEDIUM XNARROW 1003-04",120.249,CDM,274,RC,L0120,HCPCS,,273-MAIN,LOCAL,,,,,101,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,48.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 2X23.5"" MEDIUM XNARROW 1003-04",120.249,CDM,274,RC,L0120,HCPCS,,273-MAIN,LOCAL,,,,,101,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,48.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 10-15"" SMALL XLONG 1005-06",120.249,CDM,274,RC,L0120,HCPCS,,267-MAIN,LOCAL,,,,,101,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,48.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 10-15"" SMALL XLONG 1005-06",120.249,CDM,274,RC,L0120,HCPCS,,267-MAIN,LOCAL,,,,,101,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,48.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL LARGE 21.5""X5"" 1005-04",120.249,CDM,274,RC,L0120,HCPCS,,268-MAIN,LOCAL,,,,,101,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,48.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL LARGE 21.5""X5"" 1005-04",120.249,CDM,274,RC,L0120,HCPCS,,268-MAIN,LOCAL,,,,,101,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,48.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL MEDIUM 20-1/2X4"" 1005-03",120.249,CDM,274,RC,L0120,HCPCS,,269-MAIN,LOCAL,,,,,101,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,48.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL MEDIUM 20-1/2X4"" 1005-03",120.249,CDM,274,RC,L0120,HCPCS,,269-MAIN,LOCAL,,,,,101,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,48.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
COLLAR CERVICAL SMALL 1005-02,120.249,CDM,274,RC,L0120,HCPCS,,266-MAIN,LOCAL,,,,,101,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,48.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
COLLAR CERVICAL SMALL 1005-02,120.249,CDM,274,RC,L0120,HCPCS,,266-MAIN,LOCAL,,,,,101,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,48.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
ibuprofen 100 MG/5ML Suspension 118 mL Bottle,63700001,CDM,250,RC,,,,,,45802089726,NDC,118,ML,54.97,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,48.48354,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Debride Muscle Ea Add 20 Sqcm,PX11046F,CDM,510,RC,11046,CPT,,,,,,,,248,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,48.4861,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.5,151.5
Debride Muscle Ea Add 20 Sqcm,PX11046P,CDM,983,RC,11046,CPT,,,,,,,,198,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,48.4861,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.5,194.04
"OB US < 14 Wks, Single Fetus - Radiology, Tech",PX7680101,CDM,402,RC,76801,CPT,TC,,,,,,,472,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,48.5,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.35,140.03
"OB US < 14 Wks, Single Fetus - Radiology, Tech",PX7680101,CDM,402,RC,76801,CPT,TC,,,,,,,472,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,48.5,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.35,140.03
lopinavir-ritonavir 200-50 MG Tablet 120 Each Bottle,63700001,CDM,250,RC,,,,,,74679922,NDC,1,EA,54.99,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,48.50118,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,23155029031,NDC,2,ML,98.99,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.5051,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,97.0102
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,23155029031,NDC,2,ML,98.99,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.5051,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,97.0102
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,23155029031,NDC,2,ML,98.99,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.5051,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,97.0102
BLADE LARYNGOSCOPE MAC #3 SINGLE USE350-005-000,120.121,CDM,272,RC,,,,8320-MAIN,LOCAL,,,,,98,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,48.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
BLADE LARYNGOSCOPE MAC #4 SINGLE USE 350-012-000,120.121,CDM,272,RC,,,,8321-MAIN,LOCAL,,,,,98,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,48.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
BLADE LARYNGOSCOPE MAC #X3 SINGLE USE X3-003-000,120.121,CDM,272,RC,,,,8322-MAIN,LOCAL,,,,,98,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,48.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
CANNULA JUNIOR 2 LARGE OPTIFLOW OJR416VT,120.561,CDM,272,RC,A4615,HCPCS,,12645-MAIN,LOCAL,,,,,98,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,48.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
CANNULA JUNIOR 2 MEDIUM OPTIFLOW OJR414VT,120.561,CDM,272,RC,A4615,HCPCS,,12644-MAIN,LOCAL,,,,,98,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,48.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
CANNULA OPTIFLOW JUNIOR 2 SMALL OJR412VT,120.561,CDM,272,RC,A4615,HCPCS,,12643-MAIN,LOCAL,,,,,98,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,48.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
"Clostridium Ag, Eia",PX87324,CDM,300,RC,87324,CPT,,,,,,,,99,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,97.02
"Clostridium Ag, Eia",PX87324,CDM,300,RC,87324,CPT,,,,,,,,99,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,97.02
"Clostridium Ag, Eia",PX87324,CDM,300,RC,87324,CPT,,,,,,,,99,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,97.02
Deoxyribonuclease Ab,PX86215,CDM,300,RC,86215,CPT,,,,,,,,99,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,97.02
Deoxyribonuclease Ab,PX86215,CDM,300,RC,86215,CPT,,,,,,,,99,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,97.02
Deoxyribonuclease Ab,PX86215,CDM,300,RC,86215,CPT,,,,,,,,99,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,97.02
Endocrine E2,PX82670,CDM,300,RC,82670,CPT,90,,,,,,,55,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,48.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,53.9
"Extractable Nuclear Antigen, Each Antigen",PX86235,CDM,300,RC,86235,CPT,90,,,,,,,99,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.44,97.02
"Extractable Nuclear Antigen, Each Antigen",PX86235,CDM,300,RC,86235,CPT,90,,,,,,,99,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.44,97.02
"Extractable Nuclear Antigen, Each Antigen",PX86235,CDM,300,RC,86235,CPT,90,,,,,,,99,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.44,97.02
"Fungus Antibody, Nos - Ref",PX8667190,CDM,300,RC,86671,CPT,90,,,,,,,99,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.23,97.02
"Fungus Antibody, Nos - Ref",PX8667190,CDM,300,RC,86671,CPT,90,,,,,,,99,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.23,97.02
"Fungus Antibody, Nos - Ref",PX8667190,CDM,300,RC,86671,CPT,90,,,,,,,99,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.23,97.02
Hepatitis B Surface Antigen,PX87340,CDM,300,RC,87340,CPT,,,,,,,,98,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,48.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.47,96.04
"Immunofluo Direct, Ea Ab - Ref",PX8834690,CDM,310,RC,88346,CPT,90,,,,,,,55,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,48.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,149.22
"Lab Immunoassay, Non Antibody",PX83516,CDM,300,RC,83516,CPT,,,,,,,,99,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.57,97.02
"Lab Immunoassay, Non Antibody",PX83516,CDM,300,RC,83516,CPT,,,,,,,,99,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.57,97.02
"Lab Immunoassay, Non Antibody",PX83516,CDM,300,RC,83516,CPT,,,,,,,,99,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.57,97.02
Lipoprotein (a) - Ref,PX8369590,CDM,300,RC,83695,CPT,90,,,,,,,55,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,48.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.13,53.9
MEPILEX BORDER AG POST OP 4X10,120.368,CDM,272,RC,A6212,HCPCS,,10839-MAIN,LOCAL,,,,,55,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,48.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,53.9
Ot Contracted Service/MCR,PX120.177,CDM,431,RC,,,,,,,,,,98,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,48.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
"Protozoa Antibody, Nos - Ref",PX8675390,CDM,300,RC,86753,CPT,90,,,,,,,99,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.36,97.02
"Protozoa Antibody, Nos - Ref",PX8675390,CDM,300,RC,86753,CPT,90,,,,,,,99,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.36,97.02
"Protozoa Antibody, Nos - Ref",PX8675390,CDM,300,RC,86753,CPT,90,,,,,,,99,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.36,97.02
Pt Contracted Services/MCR,PX120.175,CDM,421,RC,,,,,,,,,,98,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,48.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
SURGIFOAM ABSORBABLE GELATIN SPONGE 3.1 IN X 4.9IN X 10MM,120.371,CDM,272,RC,A4649,HCPCS,,10864-MAIN,LOCAL,,,,,55,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,48.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,53.9
sod citrate-citric acid 500-334 MG/5ML Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,121059516,NDC,473,ML,95.87,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,48.51022,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bicalutamide 50 MG Tablet 30 Each Bottle,25000000,CDM,250,RC,,,,,,16714081601,NDC,1,EA,98.01,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,48.51495,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Destruct Benign Lesion, 1-14",PX17110F,CDM,510,RC,17110,CPT,,,,,,,,302,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,48.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.97,237.29
"Destruct Benign Lesion, 1-14",PX17110F,CDM,510,RC,17110,CPT,,,,,,,,302,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,48.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.97,237.29
"Destruct Benign Lesion, 1-14",PX17110P,CDM,983,RC,17110,CPT,,,,,,,,521,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,48.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.97,510.58
"Destruct Benign Lesion, 1-14",PX17110P,CDM,983,RC,17110,CPT,,,,,,,,521,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,48.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.97,510.58
"lidocaine 2% -EPINEPHRine 1:200,000 2 %-1:200000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409318301,NDC,20,ML,49.86,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,48.528738,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dabigatran 75 MG capsule 60 Each Box,63700001,CDM,250,RC,,,,,,597035556,NDC,1,EA,53.27,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,48.52897,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,574402435,NDC,3.5,GR,101.11,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,48.5328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,574402435,NDC,3.5,GR,101.11,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,48.5328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,61314062810,NDC,10,ML,98.07,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,48.54465,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Box,25000000,CDM,250,RC,,,,,,67434509,NDC,1,EA,98.1,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,48.5595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"dextrose 5 % 5 % Solution 1,000 mL Flex Cont",J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001704,NDC,1000,ML,99.12,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,58.38,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"dextrose 5 % 5 % Solution 1,000 mL Flex Cont",J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001704,NDC,1000,ML,99.12,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"dextrose 5 % 5 % Solution 1,000 mL Flex Cont",J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001704,NDC,1000,ML,99.12,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001702,NDC,250,ML,99.12,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,58.38,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001702,NDC,250,ML,99.12,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001702,NDC,250,ML,99.12,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338634602,NDC,250,ML,99.12,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,58.38,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338634602,NDC,250,ML,99.12,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338634602,NDC,250,ML,99.12,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 500 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001703,NDC,500,ML,99.12,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,58.38,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 500 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001703,NDC,500,ML,99.12,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 500 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001703,NDC,500,ML,99.12,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % Non-DEHP bag 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,264751020,NDC,250,ML,99.12,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,58.38,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % Non-DEHP bag 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,264751020,NDC,250,ML,99.12,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % Non-DEHP bag 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,264751020,NDC,250,ML,99.12,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"dextrose 5% and sodium chloride 0.2% 5-0.2 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338007704,NDC,1000,ML,99.12,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
"dextrose 5% and sodium chloride 0.2% 5-0.2 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338007704,NDC,1000,ML,99.12,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
"dextrose 5% and sodium chloride 0.2% 5-0.2 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338007704,NDC,1000,ML,99.12,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
"dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008904,NDC,1000,ML,99.12,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
"dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008904,NDC,1000,ML,99.12,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
"dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008904,NDC,1000,ML,99.12,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 500 mL Flex Cont,J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008903,NDC,500,ML,99.12,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 500 mL Flex Cont,J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008903,NDC,500,ML,99.12,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 500 mL Flex Cont,J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008903,NDC,500,ML,99.12,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
"dextrose 5% and sodium chloride 0.45% 5-0.45 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008504,NDC,1000,ML,99.12,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
"dextrose 5% and sodium chloride 0.45% 5-0.45 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008504,NDC,1000,ML,99.12,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
"dextrose 5% and sodium chloride 0.45% 5-0.45 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008504,NDC,1000,ML,99.12,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
dextrose 5% lactated ringers 5 % Solution 500 mL Flex Cont,J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012503,NDC,500,ML,99.12,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,30.11839286,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5% lactated ringers 5 % Solution 500 mL Flex Cont,J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012503,NDC,500,ML,99.12,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5% lactated ringers 5 % Solution 500 mL Flex Cont,J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012503,NDC,500,ML,99.12,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 10% 10 % Solution 500 mL Flex Cont,25000000,CDM,250,RC,,,,,,338002303,NDC,500,ML,99.12,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dextrose 10% 10 % Solution 500 mL Flex Cont,25000000,CDM,250,RC,,,,,,338002303,NDC,500,ML,99.12,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dextrose 10% 10 % Solution 500 mL Flex Cont,25000000,CDM,250,RC,,,,,,338002303,NDC,500,ML,99.12,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lactated ringers Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338011704,NDC,1000,ML,99.12,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,30.11839286,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"lactated ringers Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338011704,NDC,1000,ML,99.12,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"lactated ringers Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338011704,NDC,1000,ML,99.12,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338069104,NDC,1000,ML,99.12,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1.633818182,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338069104,NDC,1000,ML,99.12,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338069104,NDC,1000,ML,99.12,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004904,NDC,1000,ML,99.12,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,21.61375,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004904,NDC,1000,ML,99.12,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004904,NDC,1000,ML,99.12,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954306,NDC,1000,ML,99.12,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,21.61375,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954306,NDC,1000,ML,99.12,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954306,NDC,1000,ML,99.12,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004902,NDC,250,ML,99.12,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,21.61375,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004902,NDC,250,ML,99.12,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004902,NDC,250,ML,99.12,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954302,NDC,250,ML,99.12,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,21.61375,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954302,NDC,250,ML,99.12,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954302,NDC,250,ML,99.12,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 500 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004903,NDC,500,ML,99.12,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,21.61375,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 500 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004903,NDC,500,ML,99.12,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 500 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004903,NDC,500,ML,99.12,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9% 0.9% Solution 1,000 mL Flex Cont",J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004904,NDC,1000,ML,99.12,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,14.79337121,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
"sodium chloride 0.9% 0.9% Solution 1,000 mL Flex Cont",J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004904,NDC,1000,ML,99.12,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
"sodium chloride 0.9% 0.9% Solution 1,000 mL Flex Cont",J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004904,NDC,1000,ML,99.12,,United Healthcare,All Medicare advantage plans,outpatient,49,,25.20333333,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9% IV LINE FLUSH 0.9% Solution 250 mL Flex Cont,25000000,CDM,250,RC,,,,,,338004902,NDC,250,ML,99.12,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9% IV LINE FLUSH 0.9% Solution 250 mL Flex Cont,25000000,CDM,250,RC,,,,,,338004902,NDC,250,ML,99.12,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 0.9% IV LINE FLUSH 0.9% Solution 250 mL Flex Cont,25000000,CDM,250,RC,,,,,,338004902,NDC,250,ML,99.12,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"sodium chloride 0.45 % 0.45 % Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,338004304,NDC,1000,ML,99.12,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"sodium chloride 0.45 % 0.45 % Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,338004304,NDC,1000,ML,99.12,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"sodium chloride 0.45 % 0.45 % Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,338004304,NDC,1000,ML,99.12,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 3 % 3 % Solution 500 mL Flex Cont,J7131.01,CDM,636,RC,J7131,HCPCS,,,,338005403,NDC,500,ML,99.12,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
sodium chloride 3 % 3 % Solution 500 mL Flex Cont,J7131.01,CDM,636,RC,J7131,HCPCS,,,,338005403,NDC,500,ML,99.12,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
sodium chloride 3 % 3 % Solution 500 mL Flex Cont,J7131.01,CDM,636,RC,J7131,HCPCS,,,,338005403,NDC,500,ML,99.12,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.5688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; 1st",PX88184,CDM,310,RC,88184,CPT,,,,,,,,96,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,48.576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.8784,314.02
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; Add'l",PX88185,CDM,310,RC,88185,CPT,,,,,,,,96,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,48.576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.8784,94.08
US Urine Capacity Measure,PX51798F,CDM,510,RC,51798,CPT,,,,,,,,96,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,48.576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.8784,94.08
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046417,NDC,10,ML,54.6,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,48.594,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505624500,NDC,1,EA,116.99,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,48.597646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
Cryptosporidum,PX87328,CDM,300,RC,87328,CPT,,,,,,,,117,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,48.6018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.67,114.66
Drain Blood From Under Nail,PX11740F,CDM,510,RC,11740,CPT,,,,,,,,117,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,48.6018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.6018,114.66
Giardia,PX87329,CDM,300,RC,87329,CPT,,,,,,,,117,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,48.6018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,114.66
"In Situ Hybridization (Eg, Fish), Each Probe, Tech",PX8836501,CDM,310,RC,88365,CPT,TC,,,,,,,117,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,48.6018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.6018,149.22
RBC Pretreatment,PX8697002,CDM,300,RC,86970,CPT,,,,,,,,117,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,48.6018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.6018,114.66
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665305,NDC,20,ML,49.97,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,4.559571429,percent of total billed charges,48.635801,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714000601,NDC,0.3,ML,53.39,,Medica,Commercial,both,91.1,,7.8,percent of total billed charges,48.63829,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409492120,NDC,10,ML,54.66,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,48.6474,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
"Echo Heart Xthoracic,Limited",PX9330801,CDM,480,RC,93308,CPT,TC,,,,,,,349,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,48.65,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.65,129.72
Fac/Removal of Skin Tags,PX11200F,CDM,510,RC,11200,CPT,,,,,,,,348,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,48.65,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.65,193.01
Removal of Skin Tags,PX11200P,CDM,983,RC,11200,CPT,,,,,,,,418,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,48.65,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.65,409.64
"US Guide, Vascular Access",PX7693701,CDM,402,RC,76937,CPT,TC,,,,,,,760,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,48.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.36,48.65
"US Guide, Vascular Access",PX7693701,CDM,402,RC,76937,CPT,TC,,,,,,,760,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,48.65,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.36,48.65
US Pelvic Tc Complete,PX7685601,CDM,402,RC,76856,CPT,TC,,,,,,,472,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,48.65,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.65,144.63
Xray Ankle 2 Vws,PX7360001,CDM,320,RC,73600,CPT,TC,,,,,,,163,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,48.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.14,48.65
Xray Ankle 2 Vws,PX7360001,CDM,320,RC,73600,CPT,TC,,,,,,,163,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,48.65,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.14,48.65
Xray Clavicle Complete,PX7300001,CDM,320,RC,73000,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,48.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,48.65
Xray Clavicle Complete,PX7300001,CDM,320,RC,73000,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,48.65,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,48.65
Xray Elbow 3+Vws Tc,PX7308001,CDM,320,RC,73080,CPT,TC,,,,,,,370,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,48.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,48.65
Xray Elbow 3+Vws Tc,PX7308001,CDM,320,RC,73080,CPT,TC,,,,,,,370,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,48.65,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,48.65
Xray Thoracolumbar 2 Vws,PX7208001,CDM,320,RC,72080,CPT,TC,,,,,,,306,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,48.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.14,48.65
Xray Thoracolumbar 2 Vws,PX7208001,CDM,320,RC,72080,CPT,TC,,,,,,,306,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,48.65,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.14,48.65
albumin human 25% 25 % Solution 50 mL Flex Cont,P9047,CDM,636,RC,P9047,HCPCS,,,,944049301,NDC,50,ML,402.67,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,48.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.66,394.6166
ERBEFLO CLEVERCAP CO2 TUBING CAP SET,27200000,CDM,272,RC,,,,11831-MAIN,LOCAL,,,,,50,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,48.665,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
G6pd; Quant Screen - Ref,PX8295590,CDM,300,RC,82955,CPT,90,,,,,,,50,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,48.665,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.89,49
"Homogenization, Tissue for Culture",PX87176,CDM,300,RC,87176,CPT,,,,,,,,50,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,48.665,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.39,49
"NEEDLE ASP 16GX3/16"" 1-7/8"" ILLINOIS STERNAL 8881245164",120.8,CDM,272,RC,G0364,HCPCS,,5730-MAIN,LOCAL,,,,,50,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,48.665,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,49
"NEEDLE BONE MARROW 8G X 4"" BIOPSY/ASPIRATION 8881247087",120.8,CDM,272,RC,G0364,HCPCS,,166-MAIN,LOCAL,,,,,50,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,48.665,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,49
"NEEDLE BONE MARROW 11G X 4"" 8881247111",120.8,CDM,272,RC,G0364,HCPCS,,162-MAIN,LOCAL,,,,,50,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,48.665,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,49
Potassium; Urine,PX84133,CDM,300,RC,84133,CPT,,,,,,,,50,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,48.665,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.34,49
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,67457022800,NDC,5,ML,53.42,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,48.66562,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,67457057305,NDC,5,ML,53.42,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,48.66562,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
levothyroxine 100 MCG/5ML Solution 5 mL Vial,J0651.01,CDM,636,RC,J0651,HCPCS,,,,63323088510,NDC,0.625,ML,99.32,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.6668,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.257528,97.3336
levothyroxine 100 MCG/5ML Solution 5 mL Vial,J0651.01,CDM,636,RC,J0651,HCPCS,,,,63323088510,NDC,0.625,ML,99.32,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.6668,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.257528,97.3336
levothyroxine 100 MCG/5ML Solution 5 mL Vial,J0651.01,CDM,636,RC,J0651,HCPCS,,,,63323088510,NDC,0.625,ML,99.32,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.6668,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.257528,97.3336
lidocaine 5 % Patch 30 Each Box,63700001,CDM,250,RC,,,,,,603188016,NDC,1,EA,55.18,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,48.66876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026969,NDC,100,ML,99.34,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.619455696,percent of total billed charges,48.6766,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026969,NDC,100,ML,99.34,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.6766,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026969,NDC,100,ML,99.34,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.6766,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
lidocaine 5 % Patch 1 Each Box,63700001,CDM,250,RC,,,,,,603188010,NDC,1,EA,55.2,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,48.6864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
perflutren lipid microsphere 6.52 MG/ML Suspension 2 mL Vial,Q9957,CDM,636,RC,Q9957,HCPCS,,,,11994001101,NDC,2,ML,751.71,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,48.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.16,48.69
perflutren lipid microsphere 6.52 MG/ML Suspension 2 mL Vial,Q9957,CDM,636,RC,Q9957,HCPCS,,,,11994001101,NDC,2,ML,751.71,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,48.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.16,48.69
fentaNYL 25 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,47781042411,NDC,1,EA,101.44,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,48.6912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 25 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,47781042411,NDC,1,EA,101.44,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,48.6912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 25 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505700600,NDC,1,EA,101.46,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,48.7008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 25 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505700600,NDC,1,EA,101.46,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,48.7008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098321,NDC,1,EA,99.39,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,14.99111111,percent of total billed charges,48.7011,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098321,NDC,1,EA,99.39,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.7011,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098321,NDC,1,EA,99.39,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.7011,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098323,NDC,1,EA,99.39,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,14.99111111,percent of total billed charges,48.7011,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098323,NDC,1,EA,99.39,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.7011,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098323,NDC,1,EA,99.39,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.7011,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052200,NDC,1,EA,99.39,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,14.99111111,percent of total billed charges,48.7011,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052200,NDC,1,EA,99.39,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.7011,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052200,NDC,1,EA,99.39,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.7011,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052237,NDC,1,EA,99.39,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,14.99111111,percent of total billed charges,48.7011,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052237,NDC,1,EA,99.39,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.7011,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052237,NDC,1,EA,99.39,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.7011,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665318,NDC,20,ML,50.08,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,4.559571429,percent of total billed charges,48.742864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
sterile water (preservative free) Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323018520,NDC,20,ML,50.08,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,48.742864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
amiodarone 900 MG/18ML Solution 18 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,67457015318,NDC,18,ML,113.73,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,48.79017,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
rivaroxaban 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50458058030,NDC,1,EA,98.57,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,48.79215,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Telehealth Origin Site Fac Fee,PXQ3014,CDM,780,RC,Q3014,HCPCS,,,,,,,,40,,UCare,Individual and Family Plans,both,,,28.07,fee schedule,48.8,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.65,48.8
Telehealth Origin Site Fac Fee,PXQ3014,CDM,780,RC,Q3014,HCPCS,,,,,,,,40,,UCare,Individual and Family Plans,both,,,28.07,fee schedule,48.8,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.65,48.8
pregabalin 25 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,71101268,NDC,1,EA,55.33,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,48.80106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
artificial tears Ointment 3.5 g Tube,63700001,CDM,250,RC,,,,,,10119002239,NDC,3.5,GR,50.14,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,48.801262,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Apply Long Leg Splint,PX29505F,CDM,510,RC,29505,CPT,,,,,,,,320,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,48.8072,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.28,190.25
Apply Long Leg Splint,PX29505P,CDM,983,RC,29505,CPT,,,,,,,,385,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,48.8072,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.28,377.3
Repr Superf Wnd Face <2.5cm,PX12011F,CDM,510,RC,12011,CPT,,,,,,,,335,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,48.8072,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.94,233.83
Repr Superf Wnd Face <2.5cm,PX12011P,CDM,983,RC,12011,CPT,,,,,,,,461,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,48.8072,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.94,451.78
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409339004,NDC,1,EA,98.61,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,48.81195,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
Fac/Cystourethroscopy,PX52000F,CDM,761,RC,52000,CPT,,,,,,,,1601,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,48.86,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.86,497.4
"lidocaine 2% -EPINEPHRine 1:200,000 2 %-1:200000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409318301,NDC,20,ML,49.86,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,48.8628,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BMWD 2X2,27200000,CDM,272,RC,Q4104,HCPCS,,12134-MAIN,LOCAL,,,,,8016,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,48.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
BMWD 2X2,27200000,CDM,272,RC,Q4104,HCPCS,,12134-MAIN,LOCAL,,,,,8016,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,48.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030926,NDC,1,EA,55.44,,United Healthcare,All Payer,outpatient,88.2,,49.96,percent of total billed charges,48.89808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963801,NDC,0.5,ML,88.69,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,48.8984,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.65,84.496
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963805,NDC,0.5,ML,142.98,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,48.8984,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.65,84.496
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,55150017301,NDC,0.5,ML,319.2,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,48.8984,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.65,84.496
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,63323027301,NDC,0.5,ML,235.6,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,48.8984,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.65,84.496
Assay of Erythropoietin,PX82668,CDM,300,RC,82668,CPT,,,,,,,,114,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,48.906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,111.72
lidocaine 5 % Patch 1 Each Box,63700001,CDM,250,RC,,,,,,591352511,NDC,1,EA,50.26,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,48.918058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 5 % Patch 30 Each Box,63700001,CDM,250,RC,,,,,,591352530,NDC,1,EA,50.26,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,48.918058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615704,NDC,1,EA,101.92,,Health Partners,Health Partners Care Plans,both,48,,6.796666667,percent of total billed charges,48.9216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615704,NDC,1,EA,101.92,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,48.9216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
ibuprofen 100 MG/5ML Suspension 118 mL Bottle,63700001,CDM,250,RC,,,,,,45802089726,NDC,118,ML,54.97,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,48.9233,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061400,NDC,1,ML,101.95,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,48.936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.114178,99.911
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061400,NDC,1,ML,101.95,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,48.936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.114178,99.911
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615700,NDC,1,EA,101.95,,Health Partners,Health Partners Care Plans,both,48,,6.796666667,percent of total billed charges,48.936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615700,NDC,1,EA,101.95,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,48.936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
lopinavir-ritonavir 200-50 MG Tablet 120 Each Bottle,63700001,CDM,250,RC,,,,,,74679922,NDC,1,EA,54.99,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,48.9411,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Endocrine E2,PX82670,CDM,300,RC,82670,CPT,90,,,,,,,55,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,48.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,53.9
"Immunofluo Direct, Ea Ab - Ref",PX8834690,CDM,310,RC,88346,CPT,90,,,,,,,55,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,48.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,149.22
Lipoprotein (a) - Ref,PX8369590,CDM,300,RC,83695,CPT,90,,,,,,,55,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,48.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.13,53.9
MEPILEX BORDER AG POST OP 4X10,120.368,CDM,272,RC,A6212,HCPCS,,10839-MAIN,LOCAL,,,,,55,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,48.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,53.9
SURGIFOAM ABSORBABLE GELATIN SPONGE 3.1 IN X 4.9IN X 10MM,120.371,CDM,272,RC,A4649,HCPCS,,10864-MAIN,LOCAL,,,,,55,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,48.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,53.9
DOPamine 1600 mcg/mL in dextrose 5% 250 mL premix 1600 mcg/mL Solution 250 mL Plas Cont,J1265.01,CDM,636,RC,J1265,HCPCS,,,,338100702,NDC,250,ML,99.9,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1.998,percent of total billed charges,48.951,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.49846,97.902
DOPamine 1600 mcg/mL in dextrose 5% 250 mL premix 1600 mcg/mL Solution 250 mL Plas Cont,J1265.01,CDM,636,RC,J1265,HCPCS,,,,338100702,NDC,250,ML,99.9,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.951,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.49846,97.902
DOPamine 1600 mcg/mL in dextrose 5% 250 mL premix 1600 mcg/mL Solution 250 mL Plas Cont,J1265.01,CDM,636,RC,J1265,HCPCS,,,,338100702,NDC,250,ML,99.9,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.951,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.49846,97.902
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093107,NDC,1,ML,57.59,,First Health,Commercial,both,85,,999999999,percent of total billed charges,48.9515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927380,NDC,1,EA,99.91,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.9559,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927380,NDC,1,EA,99.91,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.9559,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927380,NDC,1,EA,99.91,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.9559,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927395,NDC,1,EA,99.91,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.9559,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927395,NDC,1,EA,99.91,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,48.9559,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927395,NDC,1,EA,99.91,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,48.9559,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
Concurrent Infusion,PX96368,CDM,260,RC,96368,CPT,,,,,,,,102,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,48.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.3708,99.96
Concurrent Infusion,PX96368,CDM,260,RC,96368,CPT,,,,,,,,102,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,48.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.3708,99.96
Immunohisto Antibody Slide Ea Addl,PX8834101,CDM,310,RC,88341,CPT,TC,,,,,,,102,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,48.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.3708,99.96
Immunohisto Antibody Slide Ea Addl,PX8834101,CDM,310,RC,88341,CPT,TC,,,,,,,102,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,48.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.3708,99.96
Reptilase Test - Ref,PX8563590,CDM,300,RC,85635,CPT,90,,,,,,,102,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,48.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.03,99.96
Reptilase Test - Ref,PX8563590,CDM,300,RC,85635,CPT,90,,,,,,,102,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,48.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.03,99.96
ondansetron 4 MG/5ML Solution 50 mL Bottle,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714067102,NDC,5,ML,98.91,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,48.96045,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665305,NDC,20,ML,49.97,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,48.9706,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
ofloxacin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,17478071310,NDC,5,ML,117.89,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,48.971506,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,72603012801,NDC,1,EA,57.64,,First Health,Commercial,both,85,,999999999,percent of total billed charges,48.994,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
fentaNYL 12 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,378911916,NDC,1,EA,96.83,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,48.99598,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 12 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505708000,NDC,1,EA,96.83,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,48.99598,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Package,25000000,CDM,250,RC,,,,,,66758020858,NDC,1,EA,102.08,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,48.9984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Package,25000000,CDM,250,RC,,,,,,66758020858,NDC,1,EA,102.08,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,48.9984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ERBEFLO CLEVERCAP CO2 TUBING CAP SET,27200000,CDM,272,RC,,,,11831-MAIN,LOCAL,,,,,50,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
G6pd; Quant Screen - Ref,PX8295590,CDM,300,RC,82955,CPT,90,,,,,,,50,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.89,49
gadoteridol 279.3 MG/ML Solution 5 mL Vial,A9576,CDM,636,RC,A9576,HCPCS,,,,270111104,NDC,10,ML,100,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.54,166.6
gadoteridol 279.3 MG/ML Solution 5 mL Vial,A9576,CDM,636,RC,A9576,HCPCS,,,,270111104,NDC,10,ML,100,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.54,166.6
gadoteridol 279.3 MG/ML Solution 5 mL Vial,A9576,CDM,636,RC,A9576,HCPCS,,,,270111104,NDC,10,ML,100,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.54,166.6
"Homogenization, Tissue for Culture",PX87176,CDM,300,RC,87176,CPT,,,,,,,,50,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.39,49
"NEEDLE ASP 16GX3/16"" 1-7/8"" ILLINOIS STERNAL 8881245164",120.8,CDM,272,RC,G0364,HCPCS,,5730-MAIN,LOCAL,,,,,50,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,49
"NEEDLE BONE MARROW 8G X 4"" BIOPSY/ASPIRATION 8881247087",120.8,CDM,272,RC,G0364,HCPCS,,166-MAIN,LOCAL,,,,,50,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,49
"NEEDLE BONE MARROW 11G X 4"" 8881247111",120.8,CDM,272,RC,G0364,HCPCS,,162-MAIN,LOCAL,,,,,50,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.77,49
Potassium; Urine,PX84133,CDM,300,RC,84133,CPT,,,,,,,,50,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.34,49
Sars-Cov-2 Covid-19 Antibody,PX8676990,CDM,300,RC,86769,CPT,90,,,,,,,100,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.63,98
Sars-Cov-2 Covid-19 Antibody,PX8676990,CDM,300,RC,86769,CPT,90,,,,,,,100,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.63,98
Sars-Cov-2 Covid-19 Antibody,PX8676990,CDM,300,RC,86769,CPT,90,,,,,,,100,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.63,98
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,23155029031,NDC,2,ML,98.99,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.00005,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,97.0102
fentaNYL 12 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,378911998,NDC,1,EA,96.84,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,49.00104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 12 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,60505708002,NDC,1,EA,96.84,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,49.00104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Clostridium Ag, Eia",PX87324,CDM,300,RC,87324,CPT,,,,,,,,99,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.005,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,97.02
Deoxyribonuclease Ab,PX86215,CDM,300,RC,86215,CPT,,,,,,,,99,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.005,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,97.02
"Extractable Nuclear Antigen, Each Antigen",PX86235,CDM,300,RC,86235,CPT,90,,,,,,,99,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.005,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.44,97.02
"Fungus Antibody, Nos - Ref",PX8667190,CDM,300,RC,86671,CPT,90,,,,,,,99,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.005,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.23,97.02
"Lab Immunoassay, Non Antibody",PX83516,CDM,300,RC,83516,CPT,,,,,,,,99,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.005,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.57,97.02
"Protozoa Antibody, Nos - Ref",PX8675390,CDM,300,RC,86753,CPT,90,,,,,,,99,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.005,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.36,97.02
Fibrinolysins Screen - Ref,PX8539090,CDM,300,RC,85390,CPT,90,,,,,,,118,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,49.0172,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.19,115.64
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001481,NDC,1,EA,102.12,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,49.0176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001481,NDC,1,EA,102.12,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,49.0176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
potassium chloride 20 MEQ Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,245036089,NDC,1,EA,57.67,,First Health,Commercial,both,85,,999999999,percent of total billed charges,49.0195,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,93681545,NDC,2,ML,57.71,,First Health,Commercial,both,85,,999999999,percent of total billed charges,49.0535,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,93681573,NDC,2,ML,57.71,,First Health,Commercial,both,85,,999999999,percent of total billed charges,49.0535,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 4 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,536128128,NDC,30,GR,96.95,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,49.0567,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"dextrose 5 % 5 % Solution 1,000 mL Flex Cont",J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001704,NDC,1000,ML,99.12,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.0644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001702,NDC,250,ML,99.12,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.0644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338634602,NDC,250,ML,99.12,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.0644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 500 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001703,NDC,500,ML,99.12,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.0644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % Non-DEHP bag 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,264751020,NDC,250,ML,99.12,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.0644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"dextrose 5% and sodium chloride 0.2% 5-0.2 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338007704,NDC,1000,ML,99.12,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.0644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
"dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008904,NDC,1000,ML,99.12,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.0644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 500 mL Flex Cont,J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008903,NDC,500,ML,99.12,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.0644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
"dextrose 5% and sodium chloride 0.45% 5-0.45 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008504,NDC,1000,ML,99.12,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.0644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
dextrose 5% lactated ringers 5 % Solution 500 mL Flex Cont,J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012503,NDC,500,ML,99.12,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.0644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 10% 10 % Solution 500 mL Flex Cont,25000000,CDM,250,RC,,,,,,338002303,NDC,500,ML,99.12,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.0644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lactated ringers Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338011704,NDC,1000,ML,99.12,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.0644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338069104,NDC,1000,ML,99.12,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.0644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004904,NDC,1000,ML,99.12,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.0644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954306,NDC,1000,ML,99.12,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.0644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004902,NDC,250,ML,99.12,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.0644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954302,NDC,250,ML,99.12,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.0644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 500 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004903,NDC,500,ML,99.12,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.0644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9% 0.9% Solution 1,000 mL Flex Cont",J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004904,NDC,1000,ML,99.12,,Humana Choice Care,All Medicare plans,outpatient,49.5,,2.714444444,percent of total billed charges,49.0644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9% IV LINE FLUSH 0.9% Solution 250 mL Flex Cont,25000000,CDM,250,RC,,,,,,338004902,NDC,250,ML,99.12,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.0644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"sodium chloride 0.45 % 0.45 % Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,338004304,NDC,1000,ML,99.12,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.0644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 3 % 3 % Solution 500 mL Flex Cont,J7131.01,CDM,636,RC,J7131,HCPCS,,,,338005403,NDC,500,ML,99.12,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.0644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665318,NDC,20,ML,50.08,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,49.0784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
sterile water (preservative free) Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323018520,NDC,20,ML,50.08,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,49.0784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048503,NDC,50,ML,57.74,,First Health,Commercial,both,85,,999999999,percent of total billed charges,49.079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
US Retroperitoneal Tc,PX7677001,CDM,402,RC,76770,CPT,TC,,,,,,,566,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,49.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.08,145.29
US Retroperitoneal Tc,PX7677001,CDM,402,RC,76770,CPT,TC,,,,,,,566,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,49.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.08,145.29
US Retroperitoneal Tc,PX7677001,CDM,402,RC,76770,CPT,TC,,,,,,,566,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,49.08,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.08,145.29
Blastomyces Antibody - Ref,PX8661290,CDM,300,RC,86612,CPT,90,,,,,,,97,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,49.082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.83,95.06
Contrast Bath Therapy,PX97034,CDM,420,RC,97034,CPT,,,,,,,,97,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,49.082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,95.06
DRAPE INSTRUMENT ARM 470015,27200000,CDM,272,RC,,,,11925-MAIN,LOCAL,,,,,97,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,49.082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
High Sens Crp,PX86141,CDM,300,RC,86141,CPT,,,,,,,,97,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,49.082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,95.06
Rheumatoid Factor Quant,PX86431,CDM,300,RC,86431,CPT,,,,,,,,97,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,49.082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.2,95.06
naloxone 2 MG/2ML solution prefilled syringe 2 mL Syringe,J2310.01,CDM,636,RC,J2310,HCPCS,,,,76329346901,NDC,1,ML,114.45,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,49.09905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.54253,130.4968
lidocaine 5 % Patch 30 Each Box,63700001,CDM,250,RC,,,,,,603188016,NDC,1,EA,55.18,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,49.1102,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levonorgestrel 1.5 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,62756071860,NDC,1,EA,114.48,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,49.11192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 5 % Patch 1 Each Box,63700001,CDM,250,RC,,,,,,603188010,NDC,1,EA,55.2,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,49.128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
artificial tears Ointment 3.5 g Tube,63700001,CDM,250,RC,,,,,,10119002239,NDC,3.5,GR,50.14,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,49.1372,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tuberculin 5 UNIT/0.1ML Solution 1 mL Vial,25000000,CDM,250,RC,,,,,,42023010401,NDC,0.1,ML,57.82,,First Health,Commercial,both,85,,999999999,percent of total billed charges,49.147,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
levothyroxine 100 MCG/5ML Solution 5 mL Vial,J0651.01,CDM,636,RC,J0651,HCPCS,,,,63323088510,NDC,0.625,ML,99.32,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.1634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.257528,97.3336
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026969,NDC,100,ML,99.34,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.1733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405F,CDM,510,RC,36405,CPT,,,,,,,,54,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,49.194,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.4316,52.92
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098321,NDC,1,EA,99.39,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.19805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098323,NDC,1,EA,99.39,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.19805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052200,NDC,1,EA,99.39,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.19805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052237,NDC,1,EA,99.39,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.19805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
apixaban 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,3089331,NDC,1,EA,50.57,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,49.219781,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
etomidate 2 MG/ML Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,55150022220,NDC,10,ML,50.58,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,49.229514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004624,NDC,50,ML,50.58,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,2.672307692,percent of total billed charges,49.229514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714001601,NDC,0.4,ML,100.47,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,9.81,percent of total billed charges,49.2303,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714001601,NDC,0.4,ML,100.47,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,49.2303,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714001601,NDC,0.4,ML,100.47,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,49.2303,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
dexmedeTOMIDine 200 MCG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,70860060541,NDC,2,ML,55.82,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,49.23324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 4-5 MG/ML-% Solution 500 mL Flex Cont,J2001.01,CDM,636,RC,J2001,HCPCS,,,,338040903,NDC,500,ML,55.82,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,49.23324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
pregabalin 25 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,71101268,NDC,1,EA,55.33,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,49.2437,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 5 % Patch 1 Each Box,63700001,CDM,250,RC,,,,,,591352511,NDC,1,EA,50.26,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,49.2548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 5 % Patch 30 Each Box,63700001,CDM,250,RC,,,,,,591352530,NDC,1,EA,50.26,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,49.2548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
alendronate 70 MG Tablet 4 Each Box,63700001,CDM,250,RC,,,,,,16714063301,NDC,1,EA,97.37,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,49.26922,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331801,NDC,10,ML,102.65,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,49.272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331801,NDC,10,ML,102.65,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,49.272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
"Albumin, Blood",PX82040,CDM,300,RC,82040,CPT,90,,,,,,,58,,First Health,Commercial,both,85,,999999999,percent of total billed charges,49.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.54,56.84
Assay of creatinine,PX82565,CDM,300,RC,82565,CPT,,,,,,,,58,,First Health,Commercial,both,85,,999999999,percent of total billed charges,49.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.69,56.84
Assay of Urea Nitrogen,PX84520,CDM,300,RC,84520,CPT,,,,,,,,58,,First Health,Commercial,both,85,,999999999,percent of total billed charges,49.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.62,56.84
"Assay, Glucose, Blood Quant",PX82947,CDM,300,RC,82947,CPT,,,,,,,,58,,First Health,Commercial,both,85,,999999999,percent of total billed charges,49.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.6,56.84
Automated Leukocyte Count,PX85048,CDM,300,RC,85048,CPT,,,,,,,,58,,First Health,Commercial,both,85,,999999999,percent of total billed charges,49.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.33,56.84
DEFIBRILLATION PAD BIPHASIC ADULT,120.96,CDM,271,RC,A0392,HCPCS,,1321-MAIN,LOCAL,,,,,58,,First Health,Commercial,both,85,,999999999,percent of total billed charges,49.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.0932,56.84
"Ebv, Nuclear Antigen - Ref",PX8666490,CDM,300,RC,86664,CPT,90,,,,,,,58,,First Health,Commercial,both,85,,999999999,percent of total billed charges,49.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.02,56.84
"Ebv, Viral Capsid Ab - Ref",PX8666590,CDM,300,RC,86665,CPT,90,,,,,,,58,,First Health,Commercial,both,85,,999999999,percent of total billed charges,49.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.63,56.84
Fac/Cystourethroscopy,PX52000F,CDM,761,RC,52000,CPT,,,,,,,,1601,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,49.3,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.86,497.4
Fac/Cystourethroscopy,PX52000F,CDM,761,RC,52000,CPT,,,,,,,,1601,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,49.3,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.86,497.4
Hematocrit,PX85014,CDM,300,RC,85014,CPT,,,,,,,,58,,First Health,Commercial,both,85,,999999999,percent of total billed charges,49.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.17,56.84
"Long Term Holter, 48 Hrs Up to 7 Days, Recording",PX93242,CDM,731,RC,93242,CPT,,,,,,,,58,,First Health,Commercial,both,85,,999999999,percent of total billed charges,49.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.0932,56.84
"Long Term Holter, More Than 7 Days Up to 15 Days, Recording",PX93246,CDM,731,RC,93246,CPT,,,,,,,,58,,First Health,Commercial,both,85,,999999999,percent of total billed charges,49.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.0932,56.84
"Sodium; Serum, Plasma or Whole Blood",PX84295,CDM,300,RC,84295,CPT,,,,,,,,58,,First Health,Commercial,both,85,,999999999,percent of total billed charges,49.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.41,56.84
SUTURE V-LOC SZ 1 PBT WOUND CLOSURE DEVICE BLUE 18 IN GS 21 NEEDLE VLOCN0327,27200000,CDM,272,RC,,,,12828-MAIN,LOCAL,,,,,58,,First Health,Commercial,both,85,,999999999,percent of total billed charges,49.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Transferase; Alanine Amino (Alt) (Sgpt),PX84460,CDM,300,RC,84460,CPT,,,,,,,,58,,First Health,Commercial,both,85,,999999999,percent of total billed charges,49.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.86,56.84
Transferase; Aspartate Amino (Ast) (Sgot),PX84450,CDM,300,RC,84450,CPT,,,,,,,,58,,First Health,Commercial,both,85,,999999999,percent of total billed charges,49.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,56.84
CARTER THOMASON CLOSURE 5MM,27200000,CDM,272,RC,,,,10278-MAIN,LOCAL,,,,,97.45,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,49.3097,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Thyrstim Immun Glob (Tsi) - Ref,PX8444590,CDM,300,RC,84445,CPT,90,,,,,,,254,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,49.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.33,50.86
Thyrstim Immun Glob (Tsi) - Ref,PX8444590,CDM,300,RC,84445,CPT,90,,,,,,,254,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,49.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.33,50.86
Thyrstim Immun Glob (Tsi) - Ref,PX8444590,CDM,300,RC,84445,CPT,90,,,,,,,254,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,49.33,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.33,50.86
Assay of Triglycerides,PX84478,CDM,300,RC,84478,CPT,,,,,,,,115,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,49.335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.26,112.7
"Blood Typing, Rh Phenotype",PX86906,CDM,300,RC,86906,CPT,,,,,,,,115,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,49.335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.03,112.7
BRACE ANKLE LARGE 264015,120.51,CDM,274,RC,L1902,HCPCS,,4-MAIN,LOCAL,,,,,115,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,49.335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE MEDIUM 264014,120.51,CDM,274,RC,L1902,HCPCS,,7-MAIN,LOCAL,,,,,115,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,49.335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE SMALL 264012,120.51,CDM,274,RC,L1902,HCPCS,,12-MAIN,LOCAL,,,,,115,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,49.335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE X-LARGE 264016,120.51,CDM,274,RC,L1902,HCPCS,,14-MAIN,LOCAL,,,,,115,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,49.335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE X-SMALL 264011,120.51,CDM,274,RC,L1902,HCPCS,,1-MAIN,LOCAL,,,,,115,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,49.335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
Debride Skin/Subq Ea Ad 20sqcm,PX11045F,CDM,510,RC,11045,CPT,,,,,,,,115,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,49.335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
Glucagon - Ref,PX8294390,CDM,300,RC,82943,CPT,90,,,,,,,115,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,49.335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.1,112.7
"Immuno for Tumor Ag, Qn - Ref",PX8631690,CDM,300,RC,86316,CPT,90,,,,,,,115,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,49.335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,112.7
Microsomal Antibody,PX7893,CDM,300,RC,86376,CPT,,,,,,,,115,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,49.335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.34,112.7
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030926,NDC,1,EA,55.44,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,49.3416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
ALEXIS 0 LARGE STERILE,27200000,CDM,272,RC,,,,11765-MAIN,LOCAL,,,,,102.85,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,49.368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ALEXIS 0 LARGE STERILE,27200000,CDM,272,RC,,,,11765-MAIN,LOCAL,,,,,102.85,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,49.368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM-12MM BLADELESS OBTURATOR 8MM,27200000,CDM,272,RC,,,,11919-MAIN,LOCAL,,,,,56,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,49.392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM-12MM BLADELESS OBTURATOR 8MM LONG,27200000,CDM,272,RC,,,,11920-MAIN,LOCAL,,,,,56,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,49.392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"B Cells, Total Count",PX86355,CDM,300,RC,86355,CPT,,,,,,,,56,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,49.392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.2624,54.88
Citrate - Ref,PX8250790,CDM,300,RC,82507,CPT,90,,,,,,,56,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,49.392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.2624,54.88
"Folic Acid (Folate), Serum",PX82746,CDM,300,RC,82746,CPT,,,,,,,,56,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,49.392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.48,54.88
Lab Platelet Count,PX85049,CDM,300,RC,85049,CPT,,,,,,,,56,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,49.392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.11,54.88
Mycophenolate Mycophenolicacid - Ref,PX8018090,CDM,300,RC,80180,CPT,90,,,,,,,56,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,49.392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.55,54.88
Progesterone,PX84144,CDM,300,RC,84144,CPT,,,,,,,,56,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,49.392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.13,54.88
clotrimazole 1 % Cream 28.35 g Tube,25000000,CDM,250,RC,,,,,,904782231,NDC,28.35,GR,50.75,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,49.394975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sulfamethoxazole-trimethoprim 400-80 MG/5ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,703951403,NDC,10,ML,102.93,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,49.4064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sulfamethoxazole-trimethoprim 400-80 MG/5ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,703951403,NDC,10,ML,102.93,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,49.4064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
rosuvastatin 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,310075430,NDC,1,EA,56.04,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,49.42728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Apply Short Leg Cast,Walker",PX29425P,CDM,983,RC,29425,CPT,,,,,,,,119,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,49.4326,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,234.62
Creatinine; Other Source - Ref,PX82570,CDM,300,RC,82570,CPT,90,,,,,,,119,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,49.4326,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,116.62
FLAT DRAIN HEMADUCT 7MM FULL DUCT WITH TROCAR SILICONE,27200000,CDM,272,RC,,,,12464-MAIN,LOCAL,,,,,119,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,49.4326,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Injection, Subq/Im",PX96372,CDM,260,RC,96372,CPT,,,,,,,,119,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,49.4326,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,116.62
Irri Implted Drug Dlvr Device,PX96523,CDM,260,RC,96523,CPT,,,,,,,,119,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,49.4326,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,116.62
"Morphometric Analysis,Tumor Immunohistochemistry, Ea Antibody Manual , Tech",PX8836001,CDM,310,RC,88360,CPT,TC,,,,,,,119,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,49.4326,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,149.22
Office/Outpt Visit Est Level I,PX99211F,CDM,510,RC,99211,CPT,,,,,,,,119,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,49.4326,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,116.62
Office/Outpt Visit Est Level I,PX99211P,CDM,983,RC,99211,CPT,,,,,,,,119,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,49.4326,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,115.8227
Sodium; Urine,PX84300,CDM,300,RC,84300,CPT,,,,,,,,119,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,49.4326,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.64,116.62
STIFNECK ADULT,120.77,CDM,274,RC,L0180,HCPCS,,991-MAIN,LOCAL,,,,,119,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,49.4326,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,486.73
STIFNECK PEDIATRIC,120.77,CDM,274,RC,L0180,HCPCS,,998-MAIN,LOCAL,,,,,119,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,49.4326,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,486.73
Assay of Transferrin,PX84466,CDM,300,RC,84466,CPT,,,,,,,,103,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,49.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.7,100.94
Assay of Transferrin,PX84466,CDM,300,RC,84466,CPT,,,,,,,,103,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,49.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.7,100.94
carfilzomib 30 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010201,NDC,1,EA,2785.91,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,49.44,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.22,49.44
carfilzomib 60 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010101,NDC,1,EA,5571.82,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,49.44,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.22,49.44
Each Add'l Sequential IV Infusion <1 Hour,PX96367,CDM,260,RC,96367,CPT,,,,,,,,190,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,49.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.54,49.44
Each Add'l Sequential IV Infusion <1 Hour,PX96367,CDM,260,RC,96367,CPT,,,,,,,,190,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,49.44,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.54,49.44
"Lactoferrin, Fecal; Qual",PX83630,CDM,300,RC,83630,CPT,,,,,,,,103,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,49.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.06,100.94
"Lactoferrin, Fecal; Qual",PX83630,CDM,300,RC,83630,CPT,,,,,,,,103,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,49.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.06,100.94
"Molecyto Insitu, 100-300cl - Ref",PX8827590,CDM,310,RC,88275,CPT,90,,,,,,,103,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,49.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.7862,100.94
"Molecyto Insitu, 100-300cl - Ref",PX8827590,CDM,310,RC,88275,CPT,90,,,,,,,103,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,49.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.7862,100.94
"Tiss Cult,Non-Neop Lymph - Ref",PX8823090,CDM,310,RC,88230,CPT,90,,,,,,,103,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,49.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.7862,106.81
"Tiss Cult,Non-Neop Lymph - Ref",PX8823090,CDM,310,RC,88230,CPT,90,,,,,,,103,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,49.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.7862,106.81
DOPamine 1600 mcg/mL in dextrose 5% 250 mL premix 1600 mcg/mL Solution 250 mL Plas Cont,J1265.01,CDM,636,RC,J1265,HCPCS,,,,338100702,NDC,250,ML,99.9,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.4505,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.49846,97.902
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927380,NDC,1,EA,99.91,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.45545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927395,NDC,1,EA,99.91,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.45545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
ocrelizumab 300 MG/10ML Solution 10 mL Vial,J2350.01,CDM,636,RC,J2350,HCPCS,,,,50242015001,NDC,10,ML,33150,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,49.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.47,32487
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409663724,NDC,50,ML,115.32,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,49.47228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BRACE KNEE LARGE SHORTRUNNER 21754,120.387,CDM,274,RC,L1833,HCPCS,,10044-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,49.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE LARGE SHORTRUNNER 21754,120.387,CDM,274,RC,L1833,HCPCS,,10044-MAIN,LOCAL,,,,,101,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,49.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE LARGE SHORTRUNNER 21754,120.387,CDM,274,RC,L1833,HCPCS,,10044-MAIN,LOCAL,,,,,101,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,49.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE MEDIUM SHORTRUNNER 21753,120.387,CDM,274,RC,L1833,HCPCS,,10126-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,49.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE MEDIUM SHORTRUNNER 21753,120.387,CDM,274,RC,L1833,HCPCS,,10126-MAIN,LOCAL,,,,,101,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,49.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE MEDIUM SHORTRUNNER 21753,120.387,CDM,274,RC,L1833,HCPCS,,10126-MAIN,LOCAL,,,,,101,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,49.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE SMALL SHORTRUNNER 21752,120.387,CDM,274,RC,L1833,HCPCS,,10900-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,49.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE SMALL SHORTRUNNER 21752,120.387,CDM,274,RC,L1833,HCPCS,,10900-MAIN,LOCAL,,,,,101,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,49.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE SMALL SHORTRUNNER 21752,120.387,CDM,274,RC,L1833,HCPCS,,10900-MAIN,LOCAL,,,,,101,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,49.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE X-LARGE SHORTRUNNER 21755,120.387,CDM,274,RC,L1833,HCPCS,,3444-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,49.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE X-LARGE SHORTRUNNER 21755,120.387,CDM,274,RC,L1833,HCPCS,,3444-MAIN,LOCAL,,,,,101,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,49.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE X-LARGE SHORTRUNNER 21755,120.387,CDM,274,RC,L1833,HCPCS,,3444-MAIN,LOCAL,,,,,101,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,49.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE XX-LARGE SHORTRUNNER 21756,120.387,CDM,274,RC,L1833,HCPCS,,10615-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,49.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE XX-LARGE SHORTRUNNER 21756,120.387,CDM,274,RC,L1833,HCPCS,,10615-MAIN,LOCAL,,,,,101,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,49.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE XX-LARGE SHORTRUNNER 21756,120.387,CDM,274,RC,L1833,HCPCS,,10615-MAIN,LOCAL,,,,,101,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,49.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
"COLLAR CERVICAL 2"" SMALL UNIVERSAL 08140039",120.249,CDM,274,RC,L0120,HCPCS,,270-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,49.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 2"" SMALL UNIVERSAL 08140039",120.249,CDM,274,RC,L0120,HCPCS,,270-MAIN,LOCAL,,,,,101,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,49.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 2"" SMALL UNIVERSAL 08140039",120.249,CDM,274,RC,L0120,HCPCS,,270-MAIN,LOCAL,,,,,101,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,49.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 2X20"" SMALL 1003-02",120.249,CDM,274,RC,L0120,HCPCS,,272-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,49.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 2X20"" SMALL 1003-02",120.249,CDM,274,RC,L0120,HCPCS,,272-MAIN,LOCAL,,,,,101,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,49.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 2X20"" SMALL 1003-02",120.249,CDM,274,RC,L0120,HCPCS,,272-MAIN,LOCAL,,,,,101,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,49.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 2X23.5"" MEDIUM XNARROW 1003-04",120.249,CDM,274,RC,L0120,HCPCS,,273-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,49.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 2X23.5"" MEDIUM XNARROW 1003-04",120.249,CDM,274,RC,L0120,HCPCS,,273-MAIN,LOCAL,,,,,101,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,49.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 2X23.5"" MEDIUM XNARROW 1003-04",120.249,CDM,274,RC,L0120,HCPCS,,273-MAIN,LOCAL,,,,,101,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,49.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 10-15"" SMALL XLONG 1005-06",120.249,CDM,274,RC,L0120,HCPCS,,267-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,49.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 10-15"" SMALL XLONG 1005-06",120.249,CDM,274,RC,L0120,HCPCS,,267-MAIN,LOCAL,,,,,101,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,49.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 10-15"" SMALL XLONG 1005-06",120.249,CDM,274,RC,L0120,HCPCS,,267-MAIN,LOCAL,,,,,101,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,49.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL LARGE 21.5""X5"" 1005-04",120.249,CDM,274,RC,L0120,HCPCS,,268-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,49.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL LARGE 21.5""X5"" 1005-04",120.249,CDM,274,RC,L0120,HCPCS,,268-MAIN,LOCAL,,,,,101,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,49.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL LARGE 21.5""X5"" 1005-04",120.249,CDM,274,RC,L0120,HCPCS,,268-MAIN,LOCAL,,,,,101,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,49.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL MEDIUM 20-1/2X4"" 1005-03",120.249,CDM,274,RC,L0120,HCPCS,,269-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,49.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL MEDIUM 20-1/2X4"" 1005-03",120.249,CDM,274,RC,L0120,HCPCS,,269-MAIN,LOCAL,,,,,101,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,49.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL MEDIUM 20-1/2X4"" 1005-03",120.249,CDM,274,RC,L0120,HCPCS,,269-MAIN,LOCAL,,,,,101,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,49.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
COLLAR CERVICAL SMALL 1005-02,120.249,CDM,274,RC,L0120,HCPCS,,266-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,49.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
COLLAR CERVICAL SMALL 1005-02,120.249,CDM,274,RC,L0120,HCPCS,,266-MAIN,LOCAL,,,,,101,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,49.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
COLLAR CERVICAL SMALL 1005-02,120.249,CDM,274,RC,L0120,HCPCS,,266-MAIN,LOCAL,,,,,101,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,49.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
Assay Thyroid Stim Hormone,PX84443,CDM,300,RC,84443,CPT,,,,,,,,294,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,49.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.4,288.12
gadoteridol 279.3 MG/ML Solution 5 mL Vial,A9576,CDM,636,RC,A9576,HCPCS,,,,270111104,NDC,10,ML,100,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.54,166.6
Sars-Cov-2 Covid-19 Antibody,PX8676990,CDM,300,RC,86769,CPT,90,,,,,,,100,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.63,98
"Echo Heart Xthoracic,Limited",PX9330801,CDM,480,RC,93308,CPT,TC,,,,,,,349,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,49.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.65,129.72
"Echo Heart Xthoracic,Limited",PX9330801,CDM,480,RC,93308,CPT,TC,,,,,,,349,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,49.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.65,129.72
oseltamivir 75 MG capsule 10 Each Disp Pack,63700001,CDM,250,RC,,,,,,4080085,NDC,1,EA,97.87,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,49.52222,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BMWD 2X2,27200000,CDM,272,RC,Q4104,HCPCS,,12134-MAIN,LOCAL,,,,,8016,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,49.53,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
BMWD 2X2,27200000,CDM,272,RC,Q4104,HCPCS,,12134-MAIN,LOCAL,,,,,8016,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,49.53,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
lidocaine 0.5 % PF 0.5 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323049101,NDC,50,ML,103.2,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,49.536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 0.5 % PF 0.5 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323049101,NDC,50,ML,103.2,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,49.536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Lvl 2 Sub Hosp Mod Mdm or 35 Minute,PX99232,CDM,982,RC,99232,CPT,,,,,,,,253,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,49.54,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.54,247.94
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,574402435,NDC,3.5,GR,101.11,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,49.5439,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,574402435,NDC,3.5,GR,101.11,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,49.5439,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,574402435,NDC,3.5,GR,101.11,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,49.5439,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,641601501,NDC,25,ML,58.29,,First Health,Commercial,both,85,,999999999,percent of total billed charges,49.5465,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
atropine 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100401,NDC,0.5,ML,50.91,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1.253,percent of total billed charges,49.550703,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
US Pregnancy Tc Limited,PX7681501,CDM,402,RC,76815,CPT,TC,,,,,,,438,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,49.5572,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.61,99.92
apixaban 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,3089331,NDC,1,EA,50.57,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,49.5586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
etomidate 2 MG/ML Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,55150022220,NDC,10,ML,50.58,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,49.5684,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004624,NDC,50,ML,50.58,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,49.5684,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
BLADE LARYNGOSCOPE MAC #3 SINGLE USE350-005-000,120.121,CDM,272,RC,,,,8320-MAIN,LOCAL,,,,,98,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,49.588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
BLADE LARYNGOSCOPE MAC #4 SINGLE USE 350-012-000,120.121,CDM,272,RC,,,,8321-MAIN,LOCAL,,,,,98,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,49.588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
BLADE LARYNGOSCOPE MAC #X3 SINGLE USE X3-003-000,120.121,CDM,272,RC,,,,8322-MAIN,LOCAL,,,,,98,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,49.588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
CANNULA JUNIOR 2 LARGE OPTIFLOW OJR416VT,120.561,CDM,272,RC,A4615,HCPCS,,12645-MAIN,LOCAL,,,,,98,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,49.588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
CANNULA JUNIOR 2 MEDIUM OPTIFLOW OJR414VT,120.561,CDM,272,RC,A4615,HCPCS,,12644-MAIN,LOCAL,,,,,98,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,49.588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
CANNULA OPTIFLOW JUNIOR 2 SMALL OJR412VT,120.561,CDM,272,RC,A4615,HCPCS,,12643-MAIN,LOCAL,,,,,98,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,49.588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
Hepatitis B Surface Antigen,PX87340,CDM,300,RC,87340,CPT,,,,,,,,98,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,49.588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.47,96.04
Ot Contracted Service/MCR,PX120.177,CDM,431,RC,,,,,,,,,,98,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,49.588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
Pt Contracted Services/MCR,PX120.175,CDM,421,RC,,,,,,,,,,98,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,49.588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117630,NDC,1,ML,58.34,,First Health,Commercial,both,85,,999999999,percent of total billed charges,49.589,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
bicalutamide 50 MG Tablet 30 Each Bottle,25000000,CDM,250,RC,,,,,,16714081601,NDC,1,EA,98.01,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,49.59306,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
PACLitaxel 30 MG/5ML Concentrate 5 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476401,NDC,5,ML,58.37,,First Health,Commercial,both,85,,999999999,percent of total billed charges,49.6145,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,61314062810,NDC,10,ML,98.07,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,49.62342,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
DRAPE STERILE 109X100X110 ROBOTIC DYNJP9108,27200000,CDM,272,RC,,,,12020-MAIN,LOCAL,,,,,51,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,49.6383,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Immunohisto Antibody Slide Ea Multiplex,PX8834401,CDM,310,RC,88344,CPT,TC,,,,,,,51,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,49.6383,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,314.02
RANGER UNIT TUBING FLUID WARMING,120.229,CDM,272,RC,,,,10612-MAIN,LOCAL,,,,,51,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,49.6383,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,49.98
SCAR GEL SHEET,120.458,CDM,273,RC,A6025,HCPCS,,5796-MAIN,LOCAL,,,,,51,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,49.6383,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,49.98
TUBE FEEDING DECLOGGING SYSTEM CLOG ZAPPER 20-0002,120.277,CDM,272,RC,,,,4226-MAIN,LOCAL,,,,,51,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,49.6383,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,49.98
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Box,25000000,CDM,250,RC,,,,,,67434509,NDC,1,EA,98.1,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,49.6386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
scopolamine 1 MG/3DAYS Patch 72 Hour 4 Each Box,25000000,CDM,250,RC,,,,,,45802058084,NDC,1,EA,103.43,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,49.6464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
scopolamine 1 MG/3DAYS Patch 72 Hour 4 Each Box,25000000,CDM,250,RC,,,,,,45802058084,NDC,1,EA,103.43,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,49.6464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Molecyto Insitu, 100-300cl - Ref",PX8827590,CDM,310,RC,88275,CPT,90,,,,,,,103,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,49.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.65,51.19
"Molecyto Insitu, 100-300cl - Ref",PX8827590,CDM,310,RC,88275,CPT,90,,,,,,,103,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,49.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.65,51.19
"Molecyto Insitu, 100-300cl - Ref",PX8827590,CDM,310,RC,88275,CPT,90,,,,,,,103,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,49.65,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.65,51.19
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010310,NDC,1,ML,103.48,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,49.6704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010310,NDC,1,ML,103.48,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,49.6704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
dexmedeTOMIDine 200 MCG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,70860060541,NDC,2,ML,55.82,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,49.6798,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 4-5 MG/ML-% Solution 500 mL Flex Cont,J2001.01,CDM,636,RC,J2001,HCPCS,,,,338040903,NDC,500,ML,55.82,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,49.6798,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,143950801,NDC,10,ML,58.46,,First Health,Commercial,both,85,,999999999,percent of total billed charges,49.691,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
fentaNYL 25 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,47781042411,NDC,1,EA,101.44,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,49.7056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 25 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,47781042411,NDC,1,EA,101.44,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,49.7056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 25 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,47781042411,NDC,1,EA,101.44,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,49.7056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 25 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505700600,NDC,1,EA,101.46,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,49.7154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 25 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505700600,NDC,1,EA,101.46,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,49.7154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 25 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505700600,NDC,1,EA,101.46,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,49.7154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141035,NDC,2,ML,56.37,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,49.71834,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,65219044501,NDC,10,ML,56.37,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,49.71834,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,65219044510,NDC,10,ML,56.37,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,49.71834,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714001601,NDC,0.4,ML,100.47,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.73265,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,143950810,NDC,10,ML,58.51,,First Health,Commercial,both,85,,999999999,percent of total billed charges,49.7335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
Sacubitril-Valsartan 49-51 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,78077720,NDC,1,EA,58.51,,First Health,Commercial,both,85,,999999999,percent of total billed charges,49.7335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clotrimazole 1 % Cream 28.35 g Tube,25000000,CDM,250,RC,,,,,,904782231,NDC,28.35,GR,50.75,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,49.735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,781329091,NDC,50,ML,119.73,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,49.735842,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
Thyrstim Immun Glob (Tsi) - Ref,PX8444590,CDM,300,RC,84445,CPT,90,,,,,,,254,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,49.7395,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.33,50.86
Assay Biovlbl Testosterone Direct Measurement - Ref,PX8441090,CDM,300,RC,84410,CPT,90,,,,,,,52,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,49.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.74,51.28
Assay Biovlbl Testosterone Direct Measurement - Ref,PX8441090,CDM,300,RC,84410,CPT,90,,,,,,,52,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,49.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.74,51.28
Assay Biovlbl Testosterone Direct Measurement - Ref,PX8441090,CDM,300,RC,84410,CPT,90,,,,,,,52,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,49.74,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.74,51.28
Fac/Removal of Skin Tags,PX11200F,CDM,510,RC,11200,CPT,,,,,,,,348,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,49.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.65,193.01
Fac/Removal of Skin Tags,PX11200F,CDM,510,RC,11200,CPT,,,,,,,,348,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,49.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.65,193.01
Removal of Skin Tags,PX11200P,CDM,983,RC,11200,CPT,,,,,,,,418,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,49.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.65,409.64
Removal of Skin Tags,PX11200P,CDM,983,RC,11200,CPT,,,,,,,,418,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,49.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.65,409.64
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046417,NDC,10,ML,54.6,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,49.7406,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
Antithrombin III Ag Assay - Ref,PX8530190,CDM,300,RC,85301,CPT,90,,,,,,,116,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,49.764,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.91,113.68
Ca 19-9,PX86301,CDM,300,RC,86301,CPT,,,,,,,,116,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,49.764,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,113.68
"2019-Ncov Coronavirus, Sars-Cov-2/2019-Ncov (Covid-19)",PXU000290,CDM,300,RC,U0002,HCPCS,90,,,,,,,365,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,49.77,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.77,51.31
Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq,PX87635,CDM,300,RC,87635,CPT,,,,,,,,166,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,49.77,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.77,51.31
Physical Therapy Re-Eval Est Plan Care 20 Mins,PX97164,CDM,424,RC,97164,CPT,,,,,,,,239,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,49.77,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.77,91.81
Sars-Cov-2 Covid-19 Amp Prb,PX8763590,CDM,300,RC,87635,CPT,90,,,,,,,365,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,49.77,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.77,51.31
Removal of Nail Plate,PX11730F,CDM,510,RC,11730,CPT,,,,,,,,229,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,49.7705,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.37,239.36
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060820,NDC,20,ML,58.57,,First Health,Commercial,both,85,,999999999,percent of total billed charges,49.7845,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
"sodium chloride 0.45 % 1,000 mL with potassium chloride 20 mEq 20-0.45 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070434,NDC,1000,ML,58.57,,First Health,Commercial,both,85,,999999999,percent of total billed charges,49.7845,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409492120,NDC,10,ML,54.66,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,49.79526,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405F,CDM,510,RC,36405,CPT,,,,,,,,54,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,49.81,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.16,49.81
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405P,CDM,983,RC,36405,CPT,,,,,,,,36,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,49.81,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.16,49.81
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,63323047401,NDC,1,ML,58.6,,First Health,Commercial,both,85,,999999999,percent of total billed charges,49.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.428
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076501,NDC,1,EA,58.6,,First Health,Commercial,both,85,,999999999,percent of total billed charges,49.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076510,NDC,1,EA,58.6,,First Health,Commercial,both,85,,999999999,percent of total billed charges,49.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,990771512,NDC,62.5,ML,56.5,,United Healthcare,All Payer,outpatient,88.2,,7.6225,percent of total billed charges,49.833,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.4701,303.0944
8MM-12MM BLADELESS OBTURATOR 8MM,27200000,CDM,272,RC,,,,11919-MAIN,LOCAL,,,,,56,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,49.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM-12MM BLADELESS OBTURATOR 8MM LONG,27200000,CDM,272,RC,,,,11920-MAIN,LOCAL,,,,,56,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,49.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"B Cells, Total Count",PX86355,CDM,300,RC,86355,CPT,,,,,,,,56,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,49.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.2624,54.88
Citrate - Ref,PX8250790,CDM,300,RC,82507,CPT,90,,,,,,,56,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,49.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.2624,54.88
"Folic Acid (Folate), Serum",PX82746,CDM,300,RC,82746,CPT,,,,,,,,56,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,49.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.48,54.88
Lab Platelet Count,PX85049,CDM,300,RC,85049,CPT,,,,,,,,56,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,49.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.11,54.88
Mycophenolate Mycophenolicacid - Ref,PX8018090,CDM,300,RC,80180,CPT,90,,,,,,,56,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,49.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.55,54.88
Progesterone,PX84144,CDM,300,RC,84144,CPT,,,,,,,,56,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,49.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.13,54.88
"Compatibility Test,Antiglob Tech",PX86922,CDM,300,RC,86922,CPT,,,,,,,,120,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,49.848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.848,149.22
KIWI OMNICUP VACUUM DELIVERY SYSTEM,120.225,CDM,272,RC,,,,11608-MAIN,LOCAL,,,,,120,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,49.848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.848,117.6
VACUUM KIWI W/PALM PUMP,120.225,CDM,272,RC,,,,10028-MAIN,LOCAL,,,,,120,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,49.848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.848,117.6
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086000,NDC,1,EA,58.66,,First Health,Commercial,both,85,,999999999,percent of total billed charges,49.861,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086050,NDC,1,EA,58.66,,First Health,Commercial,both,85,,999999999,percent of total billed charges,49.861,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012166,NDC,1,EA,58.66,,First Health,Commercial,both,85,,999999999,percent of total billed charges,49.861,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
cefOXitin 1 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021010910,NDC,1,EA,58.66,,First Health,Commercial,both,85,,999999999,percent of total billed charges,49.861,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.367364,75.6952
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,65219025915,NDC,1,EA,58.66,,First Health,Commercial,both,85,,999999999,percent of total billed charges,49.861,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
rosuvastatin 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,310075430,NDC,1,EA,56.04,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,49.8756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rivaroxaban 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50458058030,NDC,1,EA,98.57,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,49.87642,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atropine 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100401,NDC,0.5,ML,50.91,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,49.8918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409339004,NDC,1,EA,98.61,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,49.89666,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
Carnitine - Ref,PX8237990,CDM,300,RC,82379,CPT,90,,,,,,,104,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,49.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.47,101.92
Carnitine - Ref,PX8237990,CDM,300,RC,82379,CPT,90,,,,,,,104,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,49.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.47,101.92
Cmv Antibody - Ref,PX8664490,CDM,300,RC,86644,CPT,90,,,,,,,104,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,49.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,101.92
Cmv Antibody - Ref,PX8664490,CDM,300,RC,86644,CPT,90,,,,,,,104,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,49.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,101.92
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,43598020453,NDC,10,ML,58.73,,First Health,Commercial,both,85,,999999999,percent of total billed charges,49.9205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,72508020415,NDC,10,ML,58.73,,First Health,Commercial,both,85,,999999999,percent of total billed charges,49.9205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
TRUMPET SUCTION IRRIGATION,27100000,CDM,271,RC,,,,4577-MAIN,LOCAL,,,,,116.4,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,49.9356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615704,NDC,1,EA,101.92,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,14.99111111,percent of total billed charges,49.9408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615704,NDC,1,EA,101.92,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,49.9408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615704,NDC,1,EA,101.92,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,49.9408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,517460125,NDC,0.5,ML,58.76,,First Health,Commercial,both,85,,999999999,percent of total billed charges,49.946,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,409672924,NDC,50,ML,116.43,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,49.94847,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
"Injection Hip Arthrogram,Anesth",PX27095F,CDM,510,RC,27095,CPT,,,,,,,,425,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,49.95,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.95,633.69
"Injection Hip Arthrogram,Anesth",PX27095P,CDM,983,RC,27095,CPT,,,,,,,,425,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,49.95,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.95,633.69
"Injection Hip Arthrogram,Anesth",PX27095F,CDM,510,RC,27095,CPT,,,,,,,,425,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,49.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.95,633.69
"Injection Hip Arthrogram,Anesth",PX27095F,CDM,510,RC,27095,CPT,,,,,,,,425,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,49.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.95,633.69
"Injection Hip Arthrogram,Anesth",PX27095P,CDM,983,RC,27095,CPT,,,,,,,,425,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,49.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.95,633.69
"Injection Hip Arthrogram,Anesth",PX27095P,CDM,983,RC,27095,CPT,,,,,,,,425,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,49.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.95,633.69
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003905,NDC,1,EA,58.77,,First Health,Commercial,both,85,,999999999,percent of total billed charges,49.9545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061400,NDC,1,ML,101.95,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,49.9555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.114178,99.911
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061400,NDC,1,ML,101.95,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,49.9555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.114178,99.911
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061400,NDC,1,ML,101.95,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,49.9555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.114178,99.911
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615700,NDC,1,EA,101.95,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,14.99111111,percent of total billed charges,49.9555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615700,NDC,1,EA,101.95,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,49.9555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615700,NDC,1,EA,101.95,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,49.9555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
Xray Sacroiliac Jnts Less Than 3 Vws,PX7220001,CDM,320,RC,72200,CPT,TC,,,,,,,555,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,49.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.36,49.96
Xray Sacroiliac Jnts Less Than 3 Vws,PX7220001,CDM,320,RC,72200,CPT,TC,,,,,,,555,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,49.96,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.36,49.96
Concurrent Infusion,PX96368,CDM,260,RC,96368,CPT,,,,,,,,102,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,30.69166667,percent of total billed charges,49.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.3708,99.96
Concurrent Infusion,PX96368,CDM,260,RC,96368,CPT,,,,,,,,102,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,49.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.3708,99.96
Concurrent Infusion,PX96368,CDM,260,RC,96368,CPT,,,,,,,,102,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,49.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.3708,99.96
DRAPE STERILE 109X100X110 ROBOTIC DYNJP9108,27200000,CDM,272,RC,,,,12020-MAIN,LOCAL,,,,,51,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,49.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Immunohisto Antibody Slide Ea Addl,PX8834101,CDM,310,RC,88341,CPT,TC,,,,,,,102,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,19.31111111,percent of total billed charges,49.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.3708,99.96
Immunohisto Antibody Slide Ea Addl,PX8834101,CDM,310,RC,88341,CPT,TC,,,,,,,102,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,49.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.3708,99.96
Immunohisto Antibody Slide Ea Addl,PX8834101,CDM,310,RC,88341,CPT,TC,,,,,,,102,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,49.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.3708,99.96
Immunohisto Antibody Slide Ea Multiplex,PX8834401,CDM,310,RC,88344,CPT,TC,,,,,,,51,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,49.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,314.02
RANGER UNIT TUBING FLUID WARMING,120.229,CDM,272,RC,,,,10612-MAIN,LOCAL,,,,,51,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,49.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,49.98
Reptilase Test - Ref,PX8563590,CDM,300,RC,85635,CPT,90,,,,,,,102,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,49.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.03,99.96
Reptilase Test - Ref,PX8563590,CDM,300,RC,85635,CPT,90,,,,,,,102,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,49.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.03,99.96
Reptilase Test - Ref,PX8563590,CDM,300,RC,85635,CPT,90,,,,,,,102,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,49.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.03,99.96
SCAR GEL SHEET,120.458,CDM,273,RC,A6025,HCPCS,,5796-MAIN,LOCAL,,,,,51,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,49.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,49.98
TUBE FEEDING DECLOGGING SYSTEM CLOG ZAPPER 20-0002,120.277,CDM,272,RC,,,,4226-MAIN,LOCAL,,,,,51,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,49.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,49.98
BRACE KNEE LARGE SHORTRUNNER 21754,120.387,CDM,274,RC,L1833,HCPCS,,10044-MAIN,LOCAL,,,,,101,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE MEDIUM SHORTRUNNER 21753,120.387,CDM,274,RC,L1833,HCPCS,,10126-MAIN,LOCAL,,,,,101,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE SMALL SHORTRUNNER 21752,120.387,CDM,274,RC,L1833,HCPCS,,10900-MAIN,LOCAL,,,,,101,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE X-LARGE SHORTRUNNER 21755,120.387,CDM,274,RC,L1833,HCPCS,,3444-MAIN,LOCAL,,,,,101,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE XX-LARGE SHORTRUNNER 21756,120.387,CDM,274,RC,L1833,HCPCS,,10615-MAIN,LOCAL,,,,,101,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
"COLLAR CERVICAL 2"" SMALL UNIVERSAL 08140039",120.249,CDM,274,RC,L0120,HCPCS,,270-MAIN,LOCAL,,,,,101,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 2X20"" SMALL 1003-02",120.249,CDM,274,RC,L0120,HCPCS,,272-MAIN,LOCAL,,,,,101,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 2X23.5"" MEDIUM XNARROW 1003-04",120.249,CDM,274,RC,L0120,HCPCS,,273-MAIN,LOCAL,,,,,101,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 10-15"" SMALL XLONG 1005-06",120.249,CDM,274,RC,L0120,HCPCS,,267-MAIN,LOCAL,,,,,101,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL LARGE 21.5""X5"" 1005-04",120.249,CDM,274,RC,L0120,HCPCS,,268-MAIN,LOCAL,,,,,101,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL MEDIUM 20-1/2X4"" 1005-03",120.249,CDM,274,RC,L0120,HCPCS,,269-MAIN,LOCAL,,,,,101,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
COLLAR CERVICAL SMALL 1005-02,120.249,CDM,274,RC,L0120,HCPCS,,266-MAIN,LOCAL,,,,,101,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,49.995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
Sulfur Colloid per Dose,PXA9541,CDM,343,RC,A9541,HCPCS,,,,,,,,295,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,50,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44,701.306
Sulfur Colloid per Dose,PXA9541,CDM,343,RC,A9541,HCPCS,,,,,,,,295,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,50,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44,701.306
Sulfur Colloid per Dose,PXA9541,CDM,343,RC,A9541,HCPCS,,,,,,,,295,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,50,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44,701.306
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Package,25000000,CDM,250,RC,,,,,,66758020858,NDC,1,EA,102.08,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,50.0192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Package,25000000,CDM,250,RC,,,,,,66758020858,NDC,1,EA,102.08,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,50.0192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Package,25000000,CDM,250,RC,,,,,,66758020858,NDC,1,EA,102.08,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,50.0192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024010,NDC,1,EA,56.73,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,50.03586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030036,NDC,1,EA,56.73,,United Healthcare,All Payer,outpatient,88.2,,49.96,percent of total billed charges,50.03586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098341,NDC,1,EA,56.73,,United Healthcare,All Payer,outpatient,88.2,,49.96,percent of total billed charges,50.03586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703331101,NDC,0.75,ML,51.41,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,50.037353,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001481,NDC,1,EA,102.12,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,50.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001481,NDC,1,EA,102.12,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,50.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001481,NDC,1,EA,102.12,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,50.0388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
ondansetron 4 MG/5ML Solution 50 mL Bottle,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714067102,NDC,5,ML,98.91,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,50.04846,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,574402435,NDC,3.5,GR,101.11,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,50.04945,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032050,NDC,1,EA,120.51,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,50.059854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
"Molecyto Insitu, 100-300cl - Ref",PX8827590,CDM,310,RC,88275,CPT,90,,,,,,,103,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,50.0604,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.65,51.19
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618201,NDC,2,ML,120.53,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,50.068162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.068162,123.3918
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618210,NDC,2,ML,120.53,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,50.068162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.068162,123.3918
ibuprofen 100 MG/5ML Suspension 118 mL Bottle,63700001,CDM,250,RC,,,,,,45802089726,NDC,118,ML,54.97,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,50.07767,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,23155029031,NDC,2,ML,98.99,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,50.08894,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,97.0102
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117603,NDC,1,ML,58.93,,First Health,Commercial,both,85,,999999999,percent of total billed charges,50.0905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
Tap Block Unilateral by Injection(S),PX64486F,CDM,510,RC,64486,CPT,,,,,,,,253,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,50.0916,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.81,231.06
Tap Block Unilateral by Injection(S),PX64486P,CDM,983,RC,64486,CPT,,,,,,,,169,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,50.0916,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.81,231.06
"Clostridium Ag, Eia",PX87324,CDM,300,RC,87324,CPT,,,,,,,,99,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,50.094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,97.02
Deoxyribonuclease Ab,PX86215,CDM,300,RC,86215,CPT,,,,,,,,99,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,50.094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,97.02
"Extractable Nuclear Antigen, Each Antigen",PX86235,CDM,300,RC,86235,CPT,90,,,,,,,99,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,50.094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.44,97.02
"Fungus Antibody, Nos - Ref",PX8667190,CDM,300,RC,86671,CPT,90,,,,,,,99,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,50.094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.23,97.02
"Lab Immunoassay, Non Antibody",PX83516,CDM,300,RC,83516,CPT,,,,,,,,99,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,50.094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.57,97.02
"Protozoa Antibody, Nos - Ref",PX8675390,CDM,300,RC,86753,CPT,90,,,,,,,99,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,50.094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.36,97.02
lopinavir-ritonavir 200-50 MG Tablet 120 Each Bottle,63700001,CDM,250,RC,,,,,,74679922,NDC,1,EA,54.99,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,50.09589,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Endocrine E2,PX82670,CDM,300,RC,82670,CPT,90,,,,,,,55,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,50.105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,53.9
"Immunofluo Direct, Ea Ab - Ref",PX8834690,CDM,310,RC,88346,CPT,90,,,,,,,55,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,50.105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,149.22
Lipoprotein (a) - Ref,PX8369590,CDM,300,RC,83695,CPT,90,,,,,,,55,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,50.105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.13,53.9
MEPILEX BORDER AG POST OP 4X10,120.368,CDM,272,RC,A6212,HCPCS,,10839-MAIN,LOCAL,,,,,55,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,50.105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,53.9
SURGIFOAM ABSORBABLE GELATIN SPONGE 3.1 IN X 4.9IN X 10MM,120.371,CDM,272,RC,A4649,HCPCS,,10864-MAIN,LOCAL,,,,,55,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,50.105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,53.9
lidocaine 4 % Cream 5 g Tube,63700001,CDM,250,RC,,,,,,496088205,NDC,5,GR,51.49,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,50.115217,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003930,NDC,1,EA,58.99,,First Health,Commercial,both,85,,999999999,percent of total billed charges,50.1415,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
DRAWTEX HYDROCONDUCTIVE NONADHERENT DRESSING,120.508,CDM,271,RC,A6199,HCPCS,,12022-MAIN,LOCAL,,,,,59,,First Health,Commercial,both,85,,999999999,percent of total billed charges,50.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.5086,57.82
"Potassium; Serum, Plasma or Whole Blood",PX84132,CDM,300,RC,84132,CPT,,,,,,,,59,,First Health,Commercial,both,85,,999999999,percent of total billed charges,50.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.36,57.82
"dextrose 5 % 5 % Solution 1,000 mL Flex Cont",J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001704,NDC,1000,ML,99.12,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,50.15472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001702,NDC,250,ML,99.12,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,50.15472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338634602,NDC,250,ML,99.12,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,50.15472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 500 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001703,NDC,500,ML,99.12,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,50.15472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % Non-DEHP bag 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,264751020,NDC,250,ML,99.12,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,50.15472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"dextrose 5% and sodium chloride 0.2% 5-0.2 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338007704,NDC,1000,ML,99.12,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,50.15472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
"dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008904,NDC,1000,ML,99.12,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,50.15472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 500 mL Flex Cont,J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008903,NDC,500,ML,99.12,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,50.15472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
"dextrose 5% and sodium chloride 0.45% 5-0.45 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008504,NDC,1000,ML,99.12,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,50.15472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
dextrose 5% lactated ringers 5 % Solution 500 mL Flex Cont,J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012503,NDC,500,ML,99.12,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,50.15472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 10% 10 % Solution 500 mL Flex Cont,25000000,CDM,250,RC,,,,,,338002303,NDC,500,ML,99.12,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,50.15472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lactated ringers Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338011704,NDC,1000,ML,99.12,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,50.15472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338069104,NDC,1000,ML,99.12,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,50.15472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004904,NDC,1000,ML,99.12,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,50.15472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954306,NDC,1000,ML,99.12,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,50.15472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004902,NDC,250,ML,99.12,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,50.15472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954302,NDC,250,ML,99.12,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,50.15472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 500 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004903,NDC,500,ML,99.12,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,50.15472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9% 0.9% Solution 1,000 mL Flex Cont",J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004904,NDC,1000,ML,99.12,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,50.15472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9% IV LINE FLUSH 0.9% Solution 250 mL Flex Cont,25000000,CDM,250,RC,,,,,,338004902,NDC,250,ML,99.12,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,50.15472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"sodium chloride 0.45 % 0.45 % Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,338004304,NDC,1000,ML,99.12,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,50.15472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 3 % 3 % Solution 500 mL Flex Cont,J7131.01,CDM,636,RC,J7131,HCPCS,,,,338005403,NDC,500,ML,99.12,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,50.15472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141035,NDC,2,ML,56.37,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,50.1693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,65219044501,NDC,10,ML,56.37,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,50.1693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,65219044510,NDC,10,ML,56.37,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,50.1693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505624500,NDC,1,EA,116.99,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,50.18871,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
Cryptosporidum,PX87328,CDM,300,RC,87328,CPT,,,,,,,,117,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,50.193,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.67,114.66
Drain Blood From Under Nail,PX11740F,CDM,510,RC,11740,CPT,,,,,,,,117,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,50.193,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.6018,114.66
Giardia,PX87329,CDM,300,RC,87329,CPT,,,,,,,,117,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,50.193,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,114.66
"In Situ Hybridization (Eg, Fish), Each Probe, Tech",PX8836501,CDM,310,RC,88365,CPT,TC,,,,,,,117,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,50.193,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.6018,149.22
RBC Pretreatment,PX8697002,CDM,300,RC,86970,CPT,,,,,,,,117,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,50.193,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.6018,114.66
"lidocaine 2%-EPINEPHrine 1:100,000 2 %-1:100000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,409318221,NDC,30,ML,51.57,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,50.193081,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fentaNYL 25 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,47781042411,NDC,1,EA,101.44,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,50.2128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 25 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505700600,NDC,1,EA,101.46,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,50.2227,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
empagliflozin 10 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,597015237,NDC,1,EA,104.66,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,50.2368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
empagliflozin 10 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,597015237,NDC,1,EA,104.66,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,50.2368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"PDS II ENDOLOOP LIGATURE SIZE 0 18""",27200000,CDM,272,RC,,,,11700-MAIN,LOCAL,,,,,56.96,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,50.23872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409669501,NDC,10,ML,56.97,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,50.24754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
levothyroxine 100 MCG/5ML Solution 5 mL Vial,J0651.01,CDM,636,RC,J0651,HCPCS,,,,63323088510,NDC,0.625,ML,99.32,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,50.25592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.257528,97.3336
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006111,NDC,0.5,EA,56.98,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,50.25636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.669492,55.8404
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006158,NDC,0.5,EA,56.98,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,50.25636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.669492,55.8404
BAG LEG URINARY STND 32OZ,120.33,CDM,272,RC,A5112,HCPCS,,4433-MAIN,LOCAL,,,,,121,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,50.2634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
BAG URINARY DRAINAGE 2000ML 6300,120.33,CDM,274,RC,A4357,HCPCS,,1283-MAIN,LOCAL,,,,,121,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,50.2634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
BAG URINARY LEG PACK 9349,120.33,CDM,272,RC,A5112,HCPCS,,623-MAIN,LOCAL,,,,,121,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,50.2634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
"Chest Wall Manipulation,Initial",PX94667,CDM,410,RC,94667,CPT,,,,,,,,121,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,50.2634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.2634,118.58
"Fluor Noninfect Ab Sc, Ea - Ref",PX8625590,CDM,300,RC,86255,CPT,90,,,,,,,121,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,50.2634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.05,118.58
"Manage/Train Orthotic/Prosthetic, per 15 Min",PX97763,CDM,420,RC,97763,CPT,,,,,,,,121,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,50.2634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.36,118.58
"Prosthetic Training, Initial, Each 15 Mins",PX97761,CDM,420,RC,97761,CPT,,,,,,,,121,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,50.2634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.41,118.58
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026969,NDC,100,ML,99.34,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,50.26604,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
lidocaine 5 % Patch 30 Each Box,63700001,CDM,250,RC,,,,,,603188016,NDC,1,EA,55.18,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,50.26898,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Albumin, Othr Source - Ref",PX8204290,CDM,300,RC,82042,CPT,90,,,,,,,57,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,50.274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.13,55.86
"Albumin, Serum - Ref",PX8204090,CDM,300,RC,82040,CPT,90,,,,,,,57,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,50.274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.54,55.86
Assay Alkaline Phosphatase,PX84075,CDM,300,RC,84075,CPT,,,,,,,,57,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,50.274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,55.86
Calcium Total,PX82310,CDM,300,RC,82310,CPT,,,,,,,,57,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,50.274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.73,55.86
Dhea-S - Ref,PX8262790,CDM,300,RC,82627,CPT,90,,,,,,,57,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,50.274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.38,55.86
Tiss Trnsgltmnase Ea Ig Clas,PX86364,CDM,300,RC,86364,CPT,,,,,,,,57,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,50.274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.6778,55.86
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,990771512,NDC,62.5,ML,56.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,50.285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.4701,303.0944
Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq,PX87635,CDM,300,RC,87635,CPT,,,,,,,,166,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,50.28503,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.77,51.31
Sars-Cov-2 Covid-19 Amp Prb,PX8763590,CDM,300,RC,87635,CPT,90,,,,,,,365,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,50.28503,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.77,51.31
lidocaine 5 % Patch 1 Each Box,63700001,CDM,250,RC,,,,,,603188010,NDC,1,EA,55.2,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,50.2872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098321,NDC,1,EA,99.39,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,50.29134,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098323,NDC,1,EA,99.39,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,50.29134,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052200,NDC,1,EA,99.39,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,50.29134,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052237,NDC,1,EA,99.39,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,50.29134,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331801,NDC,10,ML,102.65,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,150.5666667,percent of total billed charges,50.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331801,NDC,10,ML,102.65,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,50.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331801,NDC,10,ML,102.65,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,50.2985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
triamcinolone acetonide 0.1 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,16714098602,NDC,30,GR,59.22,,First Health,Commercial,both,85,,999999999,percent of total billed charges,50.337,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine-epinephrine-tetracaine Gel 3 mL Syringe,J3490.160,CDM,636,RC,J3490,HCPCS,,,,88888800028,NDC,3,ML,121.19,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,50.342326,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.342326,118.7662
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623100,NDC,1,EA,59.25,,First Health,Commercial,both,85,,999999999,percent of total billed charges,50.3625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623105,NDC,1,EA,59.27,,First Health,Commercial,both,85,,999999999,percent of total billed charges,50.3795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
Assay Biovlbl Testosterone Direct Measurement - Ref,PX8441090,CDM,300,RC,84410,CPT,90,,,,,,,52,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,50.3813,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.74,51.28
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703331101,NDC,0.75,ML,51.41,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,50.3818,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155F,CDM,370,RC,99155,CPT,,,,,,,,353,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,50.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.39,142.52
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155F,CDM,370,RC,99155,CPT,,,,,,,,353,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,50.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.39,142.52
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155F,CDM,370,RC,99155,CPT,,,,,,,,353,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,50.39,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.39,142.52
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155P,CDM,983,RC,99155,CPT,,,,,,,,353,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,50.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.39,345.94
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155P,CDM,983,RC,99155,CPT,,,,,,,,353,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,50.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.39,345.94
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155P,CDM,983,RC,99155,CPT,,,,,,,,353,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,50.39,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.39,345.94
"Percut Biopsy, Abdominal Mass",PX49180F,CDM,510,RC,49180,CPT,,,,,,,,2084,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,50.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.39,359.04
"Percut Biopsy, Abdominal Mass",PX49180F,CDM,510,RC,49180,CPT,,,,,,,,2084,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,50.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.39,359.04
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122F,CDM,510,RC,13122,CPT,,,,,,,,788,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,50.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.39,262.88
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122F,CDM,510,RC,13122,CPT,,,,,,,,788,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,50.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.39,262.88
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122F,CDM,510,RC,13122,CPT,,,,,,,,788,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,50.39,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.39,262.88
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122P,CDM,983,RC,13122,CPT,,,,,,,,301,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,50.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.39,294.98
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122P,CDM,983,RC,13122,CPT,,,,,,,,301,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,50.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.39,294.98
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122P,CDM,983,RC,13122,CPT,,,,,,,,301,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,50.39,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.39,294.98
ALEXIS 0 LARGE STERILE,27200000,CDM,272,RC,,,,11765-MAIN,LOCAL,,,,,102.85,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,50.3965,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ALEXIS 0 LARGE STERILE,27200000,CDM,272,RC,,,,11765-MAIN,LOCAL,,,,,102.85,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,50.3965,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ALEXIS 0 LARGE STERILE,27200000,CDM,272,RC,,,,11765-MAIN,LOCAL,,,,,102.85,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,50.3965,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Dx Occult Blood Immunoassay,PX82274,CDM,300,RC,82274,CPT,,,,,,,,105,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,50.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.6,102.9
Dx Occult Blood Immunoassay,PX82274,CDM,300,RC,82274,CPT,,,,,,,,105,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,50.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.6,102.9
Specimen Concentration - Ref,PX8701590,CDM,300,RC,87015,CPT,90,,,,,,,105,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,50.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.12,102.9
Specimen Concentration - Ref,PX8701590,CDM,300,RC,87015,CPT,90,,,,,,,105,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,50.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.12,102.9
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,17478007035,NDC,3.5,GR,105.01,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,50.4048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,17478007035,NDC,3.5,GR,105.01,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,50.4048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pregabalin 25 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,71101268,NDC,1,EA,55.33,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,50.40563,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"2019-Ncov Coronavirus, Sars-Cov-2/2019-Ncov (Covid-19)",PXU000290,CDM,300,RC,U0002,HCPCS,90,,,,,,,365,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,50.41039,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.77,51.31
"Ctrl Nosebleed,Anter,Simple",PX30901F,CDM,510,RC,30901,CPT,,,,,,,,342,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,50.4127,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.03,325.15
"Ctrl Nosebleed,Anter,Simple",PX30901P,CDM,983,RC,30901,CPT,,,,,,,,229,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,50.4127,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.03,325.15
Repr Superf Wnd Face 2.6-5,PX12013F,CDM,510,RC,12013,CPT,,,,,,,,375,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,50.4127,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.03,243.51
Repr Superf Wnd Face 2.6-5,PX12013P,CDM,983,RC,12013,CPT,,,,,,,,681,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,50.4127,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.03,667.38
sulfamethoxazole-trimethoprim 400-80 MG/5ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,703951403,NDC,10,ML,102.93,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,50.4357,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sulfamethoxazole-trimethoprim 400-80 MG/5ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,703951403,NDC,10,ML,102.93,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,50.4357,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sulfamethoxazole-trimethoprim 400-80 MG/5ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,703951403,NDC,10,ML,102.93,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,50.4357,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615704,NDC,1,EA,101.92,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,50.4504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
lidocaine 4 % Cream 5 g Tube,63700001,CDM,250,RC,,,,,,496088205,NDC,5,GR,51.49,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,50.4602,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061400,NDC,1,ML,101.95,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,50.46525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.114178,99.911
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615700,NDC,1,EA,101.95,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,50.46525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
Assay of Transferrin,PX84466,CDM,300,RC,84466,CPT,,,,,,,,103,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,50.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.7,100.94
Assay of Transferrin,PX84466,CDM,300,RC,84466,CPT,,,,,,,,103,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,50.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.7,100.94
Assay of Transferrin,PX84466,CDM,300,RC,84466,CPT,,,,,,,,103,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,50.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.7,100.94
"Lactoferrin, Fecal; Qual",PX83630,CDM,300,RC,83630,CPT,,,,,,,,103,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,50.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.06,100.94
"Lactoferrin, Fecal; Qual",PX83630,CDM,300,RC,83630,CPT,,,,,,,,103,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,50.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.06,100.94
"Lactoferrin, Fecal; Qual",PX83630,CDM,300,RC,83630,CPT,,,,,,,,103,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,50.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.06,100.94
"Molecyto Insitu, 100-300cl - Ref",PX8827590,CDM,310,RC,88275,CPT,90,,,,,,,103,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,50.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.7862,100.94
"Molecyto Insitu, 100-300cl - Ref",PX8827590,CDM,310,RC,88275,CPT,90,,,,,,,103,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,50.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.7862,100.94
"Molecyto Insitu, 100-300cl - Ref",PX8827590,CDM,310,RC,88275,CPT,90,,,,,,,103,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,50.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.7862,100.94
"Tiss Cult,Non-Neop Lymph - Ref",PX8823090,CDM,310,RC,88230,CPT,90,,,,,,,103,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,50.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.7862,106.81
"Tiss Cult,Non-Neop Lymph - Ref",PX8823090,CDM,310,RC,88230,CPT,90,,,,,,,103,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,50.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.7862,106.81
"Tiss Cult,Non-Neop Lymph - Ref",PX8823090,CDM,310,RC,88230,CPT,90,,,,,,,103,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,50.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.7862,106.81
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024010,NDC,1,EA,56.73,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,50.4897,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030036,NDC,1,EA,56.73,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,50.4897,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098341,NDC,1,EA,56.73,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,50.4897,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
Concurrent Infusion,PX96368,CDM,260,RC,96368,CPT,,,,,,,,102,,Humana Choice Care,All Medicare plans,outpatient,49.5,,99.96,percent of total billed charges,50.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.3708,99.96
Immunohisto Antibody Slide Ea Addl,PX8834101,CDM,310,RC,88341,CPT,TC,,,,,,,102,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,50.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.3708,99.96
Reptilase Test - Ref,PX8563590,CDM,300,RC,85635,CPT,90,,,,,,,102,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,50.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.03,99.96
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030926,NDC,1,EA,55.44,,Medica,Commercial,both,91.1,,5.442333333,percent of total billed charges,50.50584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
"Level III - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3933,CDM,310,RC,88304,CPT,TC,,,,,,,66,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,50.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.02,52.096
"Level III - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3933,CDM,310,RC,88304,CPT,TC,,,,,,,66,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,50.52,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.02,52.096
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Package,25000000,CDM,250,RC,,,,,,66758020858,NDC,1,EA,102.08,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,50.5296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lidocaine 2%-EPINEPHrine 1:100,000 2 %-1:100000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,409318221,NDC,30,ML,51.57,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,50.5386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001481,NDC,1,EA,102.12,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,50.5494,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
DOPamine 1600 mcg/mL in dextrose 5% 250 mL premix 1600 mcg/mL Solution 250 mL Plas Cont,J1265.01,CDM,636,RC,J1265,HCPCS,,,,338100702,NDC,250,ML,99.9,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,50.5494,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.49846,97.902
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927380,NDC,1,EA,99.91,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,50.55446,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927395,NDC,1,EA,99.91,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,50.55446,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
lidocaine 0.5 % PF 0.5 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323049101,NDC,50,ML,103.2,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,50.568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 0.5 % PF 0.5 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323049101,NDC,50,ML,103.2,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,50.568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 0.5 % PF 0.5 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323049101,NDC,50,ML,103.2,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,50.568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ofloxacin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,17478071310,NDC,5,ML,117.89,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,50.57481,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
gadoteridol 279.3 MG/ML Solution 5 mL Vial,A9576,CDM,636,RC,A9576,HCPCS,,,,270111104,NDC,10,ML,100,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,50.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.54,166.6
Sars-Cov-2 Covid-19 Antibody,PX8676990,CDM,300,RC,86769,CPT,90,,,,,,,100,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,50.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.63,98
Antinuclear Ab(Ana) Titer - Ref,PX8603990,CDM,300,RC,86039,CPT,90,,,,,,,52,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,50.6116,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.23,50.96
Assay Biovlbl Testosterone Direct Measurement - Ref,PX8441090,CDM,300,RC,84410,CPT,90,,,,,,,52,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,50.6116,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.6008,50.96
"Beta 2 Glycoprot 1 Ab,Ea - Ref",PX8614690,CDM,300,RC,86146,CPT,90,,,,,,,52,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,50.6116,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.6008,50.96
Iron - Ref,PX8354090,CDM,300,RC,83540,CPT,90,,,,,,,52,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,29.64,percent of total billed charges,50.6116,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,50.96
Rickettsia Antibody - Ref,PX8675790,CDM,300,RC,86757,CPT,90,,,,,,,52,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,50.6116,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.74,50.96
Uric Acid; Blood,PX84550,CDM,300,RC,84550,CPT,,,,,,,,52,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,42.41,percent of total billed charges,50.6116,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.14,50.96
ROPivacaine 2 MG/ML Solution 10 mL Vial,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028513,NDC,10,ML,52.01,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,50.621333,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.604954,269.6078
Fibrinolysins Screen - Ref,PX8539090,CDM,300,RC,85390,CPT,90,,,,,,,118,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,50.622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.19,115.64
IV 0.9% NS 1000ML 2B1324X,27200000,CDM,272,RC,,,,538-MAIN,LOCAL,,,,,121.89,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,50.633106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Package,25000000,CDM,250,RC,,,,,,10019055390,NDC,1,EA,121.9,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,50.63726,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Place Needle in Vein,PX36000P,CDM,983,RC,36000,CPT,,,,,,,,1034,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,50.656,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.45,1013.32
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,25021050002,NDC,1,ML,52.06,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,42.99521739,percent of total billed charges,50.669998,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
Assay of Iron,PX83540,CDM,300,RC,83540,CPT,,,,,,,,122,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,50.6788,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,119.56
"Compliment, Total (Ch50) - Ref",PX8616290,CDM,300,RC,86162,CPT,90,,,,,,,122,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,50.6788,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.63,119.56
Vitamin B-12,PX82607,CDM,300,RC,82607,CPT,,,,,,,,122,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,50.6788,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.83,119.56
pegfilgrastim 6 MG/0.6ML Prefilled Syringe Kit 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019201,NDC,0.6,ML,13092.7,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,50.68,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.59,109.75
pegfilgrastim 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019001,NDC,0.6,ML,12711.36,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,50.68,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.59,109.75
scopolamine 1 MG/3DAYS Patch 72 Hour 4 Each Box,25000000,CDM,250,RC,,,,,,45802058084,NDC,1,EA,103.43,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,50.6807,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
scopolamine 1 MG/3DAYS Patch 72 Hour 4 Each Box,25000000,CDM,250,RC,,,,,,45802058084,NDC,1,EA,103.43,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,50.6807,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
scopolamine 1 MG/3DAYS Patch 72 Hour 4 Each Box,25000000,CDM,250,RC,,,,,,45802058084,NDC,1,EA,103.43,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,50.6807,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"PDS II ENDOLOOP LIGATURE SIZE 0 18""",27200000,CDM,272,RC,,,,11700-MAIN,LOCAL,,,,,56.96,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,50.6944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
oxyCODONE CR 20 MG Tablet ER 12 hour Abuse-Deterrent 20 Each Box,63700001,CDM,250,RC,,,,,,59011042020,NDC,1,EA,52.09,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,50.699197,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409669501,NDC,10,ML,56.97,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,50.7033,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010310,NDC,1,ML,103.48,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,150.5666667,percent of total billed charges,50.7052,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010310,NDC,1,ML,103.48,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,50.7052,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010310,NDC,1,ML,103.48,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,50.7052,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006111,NDC,0.5,EA,56.98,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,50.7122,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.669492,55.8404
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006158,NDC,0.5,EA,56.98,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,50.7122,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.669492,55.8404
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,70655000206,NDC,100,ML,59.67,,First Health,Commercial,both,85,,999999999,percent of total billed charges,50.7195,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.786918,140.5516
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457000110,NDC,10,ML,59.67,,First Health,Commercial,both,85,,999999999,percent of total billed charges,50.7195,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013266,NDC,50,ML,59.67,,First Health,Commercial,both,85,,999999999,percent of total billed charges,50.7195,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013268,NDC,150,ML,59.67,,First Health,Commercial,both,85,,999999999,percent of total billed charges,50.7195,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
Lvl 2 Sub Hosp Mod Mdm or 35 Minute,PX99232,CDM,982,RC,99232,CPT,,,,,,,,253,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,50.73,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.54,247.94
Lvl 2 Sub Hosp Mod Mdm or 35 Minute,PX99232,CDM,982,RC,99232,CPT,,,,,,,,253,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,50.73,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.54,247.94
"Albumin, Othr Source - Ref",PX8204290,CDM,300,RC,82042,CPT,90,,,,,,,57,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,50.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.13,55.86
"Albumin, Serum - Ref",PX8204090,CDM,300,RC,82040,CPT,90,,,,,,,57,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,50.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.54,55.86
Assay Alkaline Phosphatase,PX84075,CDM,300,RC,84075,CPT,,,,,,,,57,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,50.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,55.86
Calcium Total,PX82310,CDM,300,RC,82310,CPT,,,,,,,,57,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,50.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.73,55.86
Dhea-S - Ref,PX8262790,CDM,300,RC,82627,CPT,90,,,,,,,57,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,50.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.38,55.86
Tiss Trnsgltmnase Ea Ig Clas,PX86364,CDM,300,RC,86364,CPT,,,,,,,,57,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,50.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.6778,55.86
"Apply Short Leg Cast,Walker",PX29425F,CDM,510,RC,29425,CPT,,,,,,,,179,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,50.7338,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.81,159.11
"Apply Short Leg Cast,Walker",PX29425P,CDM,983,RC,29425,CPT,,,,,,,,119,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,50.7338,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.81,159.11
gentamicin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063305,NDC,5,ML,122.17,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,50.749418,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ramuCIRumab 100 MG/10ML Solution 10 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2766901,NDC,10,ML,2463.3,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,50.79,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.7,73.76
ramuCIRumab 100 MG/10ML Solution 10 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2766901,NDC,10,ML,2463.3,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,50.79,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.7,73.76
ramuCIRumab 500 MG/50ML Solution 50 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2767801,NDC,50,ML,12316.5,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,50.79,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.7,73.76
ramuCIRumab 500 MG/50ML Solution 50 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2767801,NDC,50,ML,12316.5,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,50.79,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.7,73.76
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093107,NDC,1,ML,57.59,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,50.79438,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331801,NDC,10,ML,102.65,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,50.81175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016200,NDC,1,ML,52.22,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,6.156509434,percent of total billed charges,50.825726,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8092351,NDC,1,EA,52.22,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,23.41888889,percent of total billed charges,50.825726,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400101,NDC,1,EA,52.22,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,23.41888889,percent of total billed charges,50.825726,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400125,NDC,1,EA,52.22,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,23.41888889,percent of total billed charges,50.825726,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573F,CDM,761,RC,36573,CPT,,,,,,,,1529,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,50.83,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.83,778.97
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573F,CDM,761,RC,36573,CPT,,,,,,,,1529,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,50.83,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.83,778.97
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573P,CDM,983,RC,36573,CPT,,,,,,,,1721,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,50.83,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.83,1686.58
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573P,CDM,983,RC,36573,CPT,,,,,,,,1721,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,50.83,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.83,1686.58
"Percut Biopsy, Abdominal Mass",PX49180F,CDM,510,RC,49180,CPT,,,,,,,,2084,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,50.83,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.39,359.04
Skin Sub Graft Trnk/Arm/Leg,PX15271F,CDM,510,RC,15271,CPT,,,,,,,,862,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,50.83,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.83,320.3
Skin Sub Graft Trnk/Arm/Leg,PX15271P,CDM,983,RC,15271,CPT,,,,,,,,705,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,50.83,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.83,690.9
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714001601,NDC,0.4,ML,100.47,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,50.83782,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,72603012801,NDC,1,EA,57.64,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,50.83848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
Inpt or Obs Disch Day Mngmt <=30 Minutes,PX99238,CDM,982,RC,99238,CPT,,,,,,,,199,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,50.85,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.85,195.02
dexmedeTOMIDine 200 MCG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,70860060541,NDC,2,ML,55.82,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,50.85202,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 4-5 MG/ML-% Solution 500 mL Flex Cont,J2001.01,CDM,636,RC,J2001,HCPCS,,,,338040903,NDC,500,ML,55.82,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,50.85202,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
Thyrstim Immun Glob (Tsi) - Ref,PX8444590,CDM,300,RC,84445,CPT,90,,,,,,,254,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,50.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.33,50.86
BUPivacaine 0.25 % Solution 50 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046557,NDC,30,ML,59.84,,First Health,Commercial,both,85,,999999999,percent of total billed charges,50.864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
potassium chloride 20 MEQ Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,245036089,NDC,1,EA,57.67,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,50.86494,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
GLIDESCOPE QC MILLER S0 SINGLE USE 0270-1087,120.58,CDM,272,RC,,,,13024-MAIN,LOCAL,,,,,106,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,50.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
GLIDESCOPE QC MILLER S0 SINGLE USE 0270-1087,120.58,CDM,272,RC,,,,13024-MAIN,LOCAL,,,,,106,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,50.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
GLIDESCOPE QC MILLER S1 SINGLE USE 0270-1088,120.58,CDM,272,RC,,,,13025-MAIN,LOCAL,,,,,106,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,50.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
GLIDESCOPE QC MILLER S1 SINGLE USE 0270-1088,120.58,CDM,272,RC,,,,13025-MAIN,LOCAL,,,,,106,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,50.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
US Scrotum & Contents Tc,PX7687001,CDM,402,RC,76870,CPT,TC,,,,,,,457,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,50.89,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.12,138.71
US Scrotum & Contents Tc,PX7687001,CDM,402,RC,76870,CPT,TC,,,,,,,457,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,50.89,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.12,138.71
cefTRIAXone in dextrose 1 g / 50 mL 1-3.74 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0696.01,CDM,636,RC,J0696,HCPCS,,,,264315311,NDC,1,EA,106.03,,Health Partners,Health Partners Care Plans,both,48,,26.64321429,percent of total billed charges,50.8944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone in dextrose 1 g / 50 mL 1-3.74 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0696.01,CDM,636,RC,J0696,HCPCS,,,,264315311,NDC,1,EA,106.03,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,50.8944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,93681545,NDC,2,ML,57.71,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,50.90022,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,93681573,NDC,2,ML,57.71,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,50.90022,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ALEXIS 0 LARGE STERILE,27200000,CDM,272,RC,,,,11765-MAIN,LOCAL,,,,,102.85,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,50.91075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048503,NDC,50,ML,57.74,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,50.92668,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sulfamethoxazole-trimethoprim 400-80 MG/5ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,703951403,NDC,10,ML,102.93,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,50.95035,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Antinuclear Ab(Ana) Titer - Ref,PX8603990,CDM,300,RC,86039,CPT,90,,,,,,,52,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,50.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.23,50.96
Assay Biovlbl Testosterone Direct Measurement - Ref,PX8441090,CDM,300,RC,84410,CPT,90,,,,,,,52,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,50.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.6008,50.96
"Beta 2 Glycoprot 1 Ab,Ea - Ref",PX8614690,CDM,300,RC,86146,CPT,90,,,,,,,52,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,50.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.6008,50.96
Carnitine - Ref,PX8237990,CDM,300,RC,82379,CPT,90,,,,,,,104,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,50.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.47,101.92
Carnitine - Ref,PX8237990,CDM,300,RC,82379,CPT,90,,,,,,,104,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,50.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.47,101.92
Carnitine - Ref,PX8237990,CDM,300,RC,82379,CPT,90,,,,,,,104,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,50.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.47,101.92
Cmv Antibody - Ref,PX8664490,CDM,300,RC,86644,CPT,90,,,,,,,104,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,50.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,101.92
Cmv Antibody - Ref,PX8664490,CDM,300,RC,86644,CPT,90,,,,,,,104,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,50.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,101.92
Cmv Antibody - Ref,PX8664490,CDM,300,RC,86644,CPT,90,,,,,,,104,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,50.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,101.92
Iron - Ref,PX8354090,CDM,300,RC,83540,CPT,90,,,,,,,52,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,50.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,50.96
Rickettsia Antibody - Ref,PX8675790,CDM,300,RC,86757,CPT,90,,,,,,,52,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,50.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.74,50.96
Uric Acid; Blood,PX84550,CDM,300,RC,84550,CPT,,,,,,,,52,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,50.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.14,50.96
ROPivacaine 2 MG/ML Solution 10 mL Vial,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028513,NDC,10,ML,52.01,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,50.9698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.604954,269.6078
Assay of Transferrin,PX84466,CDM,300,RC,84466,CPT,,,,,,,,103,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,50.985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.7,100.94
"Lactoferrin, Fecal; Qual",PX83630,CDM,300,RC,83630,CPT,,,,,,,,103,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,50.985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.06,100.94
"Molecyto Insitu, 100-300cl - Ref",PX8827590,CDM,310,RC,88275,CPT,90,,,,,,,103,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,50.985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.7862,100.94
"Tiss Cult,Non-Neop Lymph - Ref",PX8823090,CDM,310,RC,88230,CPT,90,,,,,,,103,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,50.985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.7862,106.81
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338411450,NDC,50,ML,106.23,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,50.9904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338411450,NDC,50,ML,106.23,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,50.9904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
tuberculin 5 UNIT/0.1ML Solution 1 mL Vial,25000000,CDM,250,RC,,,,,,42023010401,NDC,0.1,ML,57.82,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,50.99724,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Capillary Blood Collection,PX36416,CDM,300,RC,36416,CPT,,,,,,,,60,,First Health,Commercial,both,85,,999999999,percent of total billed charges,51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,58.8
HERNIA BELT MENS TRUSS LARGE,120.526,CDM,274,RC,L8310,HCPCS,,12221-MAIN,LOCAL,,,,,60,,First Health,Commercial,both,85,,999999999,percent of total billed charges,51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,160.6
HERNIA BELT MENS TRUSS MEDIUM,120.526,CDM,274,RC,L8310,HCPCS,,12220-MAIN,LOCAL,,,,,60,,First Health,Commercial,both,85,,999999999,percent of total billed charges,51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,160.6
HERNIA BELT MENS TRUSS XLARGE,120.526,CDM,274,RC,L8310,HCPCS,,12222-MAIN,LOCAL,,,,,60,,First Health,Commercial,both,85,,999999999,percent of total billed charges,51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,160.6
"IMMOBILIZER KNEE  24"" 7041-44",120.22,CDM,274,RC,L1830,HCPCS,,595-MAIN,LOCAL,,,,,60,,First Health,Commercial,both,85,,999999999,percent of total billed charges,51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE 16"" UNIVERSAL 7088-04",120.22,CDM,274,RC,L1830,HCPCS,,589-MAIN,LOCAL,,,,,60,,First Health,Commercial,both,85,,999999999,percent of total billed charges,51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
IMMOBILIZER KNEE 20 INCH ORT2420019,120.22,CDM,274,RC,L1830,HCPCS,,587-MAIN,LOCAL,,,,,60,,First Health,Commercial,both,85,,999999999,percent of total billed charges,51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE 20"" LARGE FOAM COUNTOURED STAYS 7062-03",120.22,CDM,274,RC,L1830,HCPCS,,593-MAIN,LOCAL,,,,,60,,First Health,Commercial,both,85,,999999999,percent of total billed charges,51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE 20"" QUICK-WRAP ORT2440020S",120.22,CDM,274,RC,L1830,HCPCS,,591-MAIN,LOCAL,,,,,60,,First Health,Commercial,both,85,,999999999,percent of total billed charges,51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
IMMOBILIZER KNEE CUTAWAY STRAIGHT 2 7041-05,120.22,CDM,274,RC,L1830,HCPCS,,596-MAIN,LOCAL,,,,,60,,First Health,Commercial,both,85,,999999999,percent of total billed charges,51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
8MM-12MM BLADELESS OBTURATOR 8MM,27200000,CDM,272,RC,,,,11919-MAIN,LOCAL,,,,,56,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,51.016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM-12MM BLADELESS OBTURATOR 8MM LONG,27200000,CDM,272,RC,,,,11920-MAIN,LOCAL,,,,,56,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,51.016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"B Cells, Total Count",PX86355,CDM,300,RC,86355,CPT,,,,,,,,56,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,51.016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.2624,54.88
Citrate - Ref,PX8250790,CDM,300,RC,82507,CPT,90,,,,,,,56,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,51.016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.2624,54.88
"Folic Acid (Folate), Serum",PX82746,CDM,300,RC,82746,CPT,,,,,,,,56,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,51.016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.48,54.88
Lab Platelet Count,PX85049,CDM,300,RC,85049,CPT,,,,,,,,56,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,51.016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.11,54.88
Mycophenolate Mycophenolicacid - Ref,PX8018090,CDM,300,RC,80180,CPT,90,,,,,,,56,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,51.016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.55,54.88
Progesterone,PX84144,CDM,300,RC,84144,CPT,,,,,,,,56,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,51.016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.13,54.88
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,25021050002,NDC,1,ML,52.06,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,51.0188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
"Closed Rx Radial Head Disloc,Child",PX24640F,CDM,510,RC,24640,CPT,,,,,,,,270,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,51.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.04,218.61
"Closed Rx Radial Head Disloc,Child",PX24640P,CDM,983,RC,24640,CPT,,,,,,,,180,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,51.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.04,218.61
Insert Non-Tunnel Cv Catheter >5 Years,PX36556F,CDM,510,RC,36556,CPT,,,,,,,,1025,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,51.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.04,439.29
Insert Non-Tunnel Cv Catheter >5 Years,PX36556F,CDM,510,RC,36556,CPT,,,,,,,,1025,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,51.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.04,439.29
Insert Non-Tunnel Cv Catheter >5 Years,PX36556F,CDM,510,RC,36556,CPT,,,,,,,,1025,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,51.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.04,439.29
Insert Non-Tunnel Cv Catheter >5 Years,PX36556P,CDM,983,RC,36556,CPT,,,,,,,,1274,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,51.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.04,1248.52
Insert Non-Tunnel Cv Catheter >5 Years,PX36556P,CDM,983,RC,36556,CPT,,,,,,,,1274,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,51.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.04,1248.52
Insert Non-Tunnel Cv Catheter >5 Years,PX36556P,CDM,983,RC,36556,CPT,,,,,,,,1274,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,51.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.04,1248.52
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,781523806,NDC,1,EA,106.34,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,51.0432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,781523806,NDC,1,EA,106.34,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,51.0432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,781523864,NDC,1,EA,106.34,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,51.0432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,781523864,NDC,1,EA,106.34,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,51.0432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,65862039010,NDC,1,EA,106.34,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,51.0432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,65862039010,NDC,1,EA,106.34,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,51.0432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
oxyCODONE CR 20 MG Tablet ER 12 hour Abuse-Deterrent 20 Each Box,63700001,CDM,250,RC,,,,,,59011042020,NDC,1,EA,52.09,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,51.0482,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Apply Short Leg Cast,Walker",PX29425P,CDM,983,RC,29425,CPT,,,,,,,,119,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,51.051,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,234.62
Creatinine; Other Source - Ref,PX82570,CDM,300,RC,82570,CPT,90,,,,,,,119,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,51.051,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,116.62
FLAT DRAIN HEMADUCT 7MM FULL DUCT WITH TROCAR SILICONE,27200000,CDM,272,RC,,,,12464-MAIN,LOCAL,,,,,119,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,51.051,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Injection, Subq/Im",PX96372,CDM,260,RC,96372,CPT,,,,,,,,119,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,51.051,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,116.62
Irri Implted Drug Dlvr Device,PX96523,CDM,260,RC,96523,CPT,,,,,,,,119,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,51.051,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,116.62
"Morphometric Analysis,Tumor Immunohistochemistry, Ea Antibody Manual , Tech",PX8836001,CDM,310,RC,88360,CPT,TC,,,,,,,119,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,51.051,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,149.22
Office/Outpt Visit Est Level I,PX99211F,CDM,510,RC,99211,CPT,,,,,,,,119,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,51.051,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,116.62
Office/Outpt Visit Est Level I,PX99211P,CDM,983,RC,99211,CPT,,,,,,,,119,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,51.051,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,115.8227
Sodium; Urine,PX84300,CDM,300,RC,84300,CPT,,,,,,,,119,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,51.051,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.64,116.62
STIFNECK ADULT,120.77,CDM,274,RC,L0180,HCPCS,,991-MAIN,LOCAL,,,,,119,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,51.051,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,486.73
STIFNECK PEDIATRIC,120.77,CDM,274,RC,L0180,HCPCS,,998-MAIN,LOCAL,,,,,119,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,51.051,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,486.73
rosuvastatin 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,310075430,NDC,1,EA,56.04,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,51.05244,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Fac/Ther Injection Carpal Tunnel,PX20526F,CDM,510,RC,20526,CPT,,,,,,,,191,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,51.0549,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.46,171.57
Ther Injection Carpal Tunnel,PX20526P,CDM,983,RC,20526,CPT,,,,,,,,248,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,51.0549,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.46,243.04
"Off/Outpt Visit,New,Levl III",PX99203P,CDM,983,RC,99203,CPT,,,,,,,,252,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,51.07,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.07,246.96
"Office/Outpt Visit,New,Levl III",PX99203F,CDM,510,RC,99203,CPT,,,,,,,,252,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,51.07,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.07,200.33
lidocaine 0.5 % PF 0.5 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323049101,NDC,50,ML,103.2,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,51.084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Each Add'l Hour IV Hydration,PX96361,CDM,260,RC,96361,CPT,,,,,,,,123,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,51.0942,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,120.54
FLAT WOUND DRAIN WITH TROCAR 4 CHANNEL FULL FLUTED 7FR SILICONE,27200000,CDM,272,RC,,,,12473-MAIN,LOCAL,,,,,123,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,51.0942,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Office/Outpt Visit,New,Levl II",PX99202F,CDM,510,RC,99202,CPT,,,,,,,,123,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,51.0942,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.0942,120.54
"Office/Outpt Visit,New,Levl II",PX99202P,CDM,983,RC,99202,CPT,,,,,,,,123,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,51.0942,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.0942,119.7159
BRACE KNEE LARGE SHORTRUNNER 21754,120.387,CDM,274,RC,L1833,HCPCS,,10044-MAIN,LOCAL,,,,,101,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,51.106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE MEDIUM SHORTRUNNER 21753,120.387,CDM,274,RC,L1833,HCPCS,,10126-MAIN,LOCAL,,,,,101,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,51.106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE SMALL SHORTRUNNER 21752,120.387,CDM,274,RC,L1833,HCPCS,,10900-MAIN,LOCAL,,,,,101,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,51.106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE X-LARGE SHORTRUNNER 21755,120.387,CDM,274,RC,L1833,HCPCS,,3444-MAIN,LOCAL,,,,,101,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,51.106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE XX-LARGE SHORTRUNNER 21756,120.387,CDM,274,RC,L1833,HCPCS,,10615-MAIN,LOCAL,,,,,101,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,51.106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
"COLLAR CERVICAL 2"" SMALL UNIVERSAL 08140039",120.249,CDM,274,RC,L0120,HCPCS,,270-MAIN,LOCAL,,,,,101,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,51.106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 2X20"" SMALL 1003-02",120.249,CDM,274,RC,L0120,HCPCS,,272-MAIN,LOCAL,,,,,101,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,51.106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 2X23.5"" MEDIUM XNARROW 1003-04",120.249,CDM,274,RC,L0120,HCPCS,,273-MAIN,LOCAL,,,,,101,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,51.106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 10-15"" SMALL XLONG 1005-06",120.249,CDM,274,RC,L0120,HCPCS,,267-MAIN,LOCAL,,,,,101,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,51.106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL LARGE 21.5""X5"" 1005-04",120.249,CDM,274,RC,L0120,HCPCS,,268-MAIN,LOCAL,,,,,101,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,51.106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL MEDIUM 20-1/2X4"" 1005-03",120.249,CDM,274,RC,L0120,HCPCS,,269-MAIN,LOCAL,,,,,101,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,51.106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
COLLAR CERVICAL SMALL 1005-02,120.249,CDM,274,RC,L0120,HCPCS,,266-MAIN,LOCAL,,,,,101,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,51.106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
magnesium sulfate 1 g in 100 ml D5W (premix) 1-5 GM/100ML-% Solution 100 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010802,NDC,100,ML,52.51,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,14.23621053,percent of total billed charges,51.107983,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
OLANZapine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60505311000,NDC,1,EA,60.13,,First Health,Commercial,both,85,,999999999,percent of total billed charges,51.1105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
adenosine 6 MG/2ML Solution 2 mL Syringe,J0153.01,CDM,636,RC,J0153,HCPCS,,,,25021030167,NDC,2,ML,123.1,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,51.13574,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.13574,120.638
"Albumin, Blood",PX82040,CDM,300,RC,82040,CPT,90,,,,,,,58,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,51.156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.54,56.84
Assay of creatinine,PX82565,CDM,300,RC,82565,CPT,,,,,,,,58,,United Healthcare,All Payer,outpatient,88.2,,31.92714286,percent of total billed charges,51.156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.69,56.84
Assay of Urea Nitrogen,PX84520,CDM,300,RC,84520,CPT,,,,,,,,58,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,51.156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.62,56.84
"Assay, Glucose, Blood Quant",PX82947,CDM,300,RC,82947,CPT,,,,,,,,58,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,51.156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.6,56.84
Automated Leukocyte Count,PX85048,CDM,300,RC,85048,CPT,,,,,,,,58,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,51.156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.33,56.84
DEFIBRILLATION PAD BIPHASIC ADULT,120.96,CDM,271,RC,A0392,HCPCS,,1321-MAIN,LOCAL,,,,,58,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,51.156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.0932,56.84
"Ebv, Nuclear Antigen - Ref",PX8666490,CDM,300,RC,86664,CPT,90,,,,,,,58,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,51.156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.02,56.84
"Ebv, Viral Capsid Ab - Ref",PX8666590,CDM,300,RC,86665,CPT,90,,,,,,,58,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,51.156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.63,56.84
Hematocrit,PX85014,CDM,300,RC,85014,CPT,,,,,,,,58,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,51.156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.17,56.84
"Long Term Holter, 48 Hrs Up to 7 Days, Recording",PX93242,CDM,731,RC,93242,CPT,,,,,,,,58,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,51.156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.0932,56.84
"Long Term Holter, More Than 7 Days Up to 15 Days, Recording",PX93246,CDM,731,RC,93246,CPT,,,,,,,,58,,United Healthcare,All Payer,outpatient,88.2,,34.62,percent of total billed charges,51.156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.0932,56.84
"Sodium; Serum, Plasma or Whole Blood",PX84295,CDM,300,RC,84295,CPT,,,,,,,,58,,United Healthcare,All Payer,outpatient,88.2,,49.39,percent of total billed charges,51.156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.41,56.84
SUTURE V-LOC SZ 1 PBT WOUND CLOSURE DEVICE BLUE 18 IN GS 21 NEEDLE VLOCN0327,27200000,CDM,272,RC,,,,12828-MAIN,LOCAL,,,,,58,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,51.156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Transferase; Alanine Amino (Alt) (Sgpt),PX84460,CDM,300,RC,84460,CPT,,,,,,,,58,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,51.156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.86,56.84
Transferase; Aspartate Amino (Ast) (Sgot),PX84450,CDM,300,RC,84450,CPT,,,,,,,,58,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,51.156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,56.84
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,574402435,NDC,3.5,GR,101.11,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,51.16166,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016200,NDC,1,ML,52.22,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,51.1756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,51.1756
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8092351,NDC,1,EA,52.22,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,51.1756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400101,NDC,1,EA,52.22,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,51.1756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400125,NDC,1,EA,52.22,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,51.1756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
"Molecyto Insitu, 100-300cl - Ref",PX8827590,CDM,310,RC,88275,CPT,90,,,,,,,103,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,51.19,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.65,51.19
scopolamine 1 MG/3DAYS Patch 72 Hour 4 Each Box,25000000,CDM,250,RC,,,,,,45802058084,NDC,1,EA,103.43,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,51.19785,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium polystyrene sulfonate 15 GM/60ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,46287000660,NDC,60,ML,123.3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,51.21882,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010310,NDC,1,ML,103.48,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,51.2226,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011801,NDC,0.5,ML,52.63,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.983043478,percent of total billed charges,51.224779,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011805,NDC,0.5,ML,52.63,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.983043478,percent of total billed charges,51.224779,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093107,NDC,1,ML,57.59,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,51.2551,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573F,CDM,761,RC,36573,CPT,,,,,,,,1529,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,51.26,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.83,778.97
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573P,CDM,983,RC,36573,CPT,,,,,,,,1721,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,51.26,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.83,1686.58
"Manage/Train Orthotic/Prosthetic, per 15 Min",PX97763,CDM,420,RC,97763,CPT,,,,,,,,121,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,51.2616,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.47,68.97
Assay Biovlbl Testosterone Direct Measurement - Ref,PX8441090,CDM,300,RC,84410,CPT,90,,,,,,,52,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,51.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.74,51.28
X-Ray Exam Abdomen 2 Views,PX7401901,CDM,320,RC,74019,CPT,TC,,,,,,,436,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,51.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.01,51.28
X-Ray Exam Abdomen 2 Views,PX7401901,CDM,320,RC,74019,CPT,TC,,,,,,,436,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,51.28,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.01,51.28
Xray Shoulder Minimum 2 Vws,PX7303001,CDM,320,RC,73030,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,51.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.79,51.28
Xray Shoulder Minimum 2 Vws,PX7303001,CDM,320,RC,73030,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,51.28,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.79,51.28
Xray Temporomandib Jnt Unilat,PX7032801,CDM,320,RC,70328,CPT,TC,,,,,,,385,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,51.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.01,51.28
Xray Temporomandib Jnt Unilat,PX7032801,CDM,320,RC,70328,CPT,TC,,,,,,,385,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,51.28,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.01,51.28
Xray Wrist 2 Vws,PX7310001,CDM,320,RC,73100,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,51.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.01,51.28
Xray Wrist 2 Vws,PX7310001,CDM,320,RC,73100,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,51.28,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.01,51.28
empagliflozin 10 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,597015237,NDC,1,EA,104.66,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,51.2834,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
empagliflozin 10 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,597015237,NDC,1,EA,104.66,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,51.2834,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
empagliflozin 10 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,597015237,NDC,1,EA,104.66,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,51.2834,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Lvl 1 Init Hosp Low Mdm or 40 Minutes,PX99221,CDM,982,RC,99221,CPT,,,,,,,,400,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,51.29,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.29,392
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,72603012801,NDC,1,EA,57.64,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,51.2996,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
LAPAROTOMY MAJOR I,27200000,CDM,272,RC,,,,4828-MAIN,LOCAL,,,,,123.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,51.3019,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"2019-Ncov Coronavirus, Sars-Cov-2/2019-Ncov (Covid-19)",PXU000290,CDM,300,RC,U0002,HCPCS,90,,,,,,,365,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,51.31,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.77,51.31
Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq,PX87635,CDM,300,RC,87635,CPT,,,,,,,,166,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,51.31,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.77,51.31
Sars-Cov-2 Covid-19 Amp Prb,PX8763590,CDM,300,RC,87635,CPT,90,,,,,,,365,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,51.31,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.77,51.31
"2019-Ncov Coronavirus, Sars-Cov-2/2019-Ncov (Covid-19)",PXU000290,CDM,300,RC,U0002,HCPCS,90,,,,,,,365,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,51.31,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.77,51.31
"2019-Ncov Coronavirus, Sars-Cov-2/2019-Ncov (Covid-19)",PXU000290,CDM,300,RC,U0002,HCPCS,90,,,,,,,365,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,51.31,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.77,51.31
Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq,PX87635,CDM,300,RC,87635,CPT,,,,,,,,166,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,51.31,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.77,51.31
Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq,PX87635,CDM,300,RC,87635,CPT,,,,,,,,166,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,51.31,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.77,51.31
Sars-Cov-2 Covid-19 Amp Prb,PX8763590,CDM,300,RC,87635,CPT,90,,,,,,,365,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,51.31,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.77,51.31
Sars-Cov-2 Covid-19 Amp Prb,PX8763590,CDM,300,RC,87635,CPT,90,,,,,,,365,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,51.31,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.77,51.31
potassium chloride 20 MEQ Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,245036089,NDC,1,EA,57.67,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,51.3263,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 25 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,47781042411,NDC,1,EA,101.44,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,51.32864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 25 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505700600,NDC,1,EA,101.46,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,51.33876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,24208091055,NDC,3.5,GR,106.98,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,51.3504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,24208091055,NDC,3.5,GR,106.98,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,51.3504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141035,NDC,2,ML,56.37,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,51.35307,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,65219044501,NDC,10,ML,56.37,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,51.35307,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,65219044510,NDC,10,ML,56.37,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,51.35307,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
3.0MM NON-THREADED K WIRE,27200000,CDM,272,RC,C1769,HCPCS,,12658-MAIN,LOCAL,,,,,107,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,51.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
3.0MM NON-THREADED K WIRE,27200000,CDM,272,RC,C1769,HCPCS,,12658-MAIN,LOCAL,,,,,107,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,51.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Androsetenedione - Ref,PX8215790,CDM,300,RC,82157,CPT,90,,,,,,,107,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,51.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.85,104.86
Androsetenedione - Ref,PX8215790,CDM,300,RC,82157,CPT,90,,,,,,,107,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,51.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.85,104.86
Decalcify Tc,PX8831101,CDM,310,RC,88311,CPT,TC,,,,,,,107,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,51.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
Decalcify Tc,PX8831101,CDM,310,RC,88311,CPT,TC,,,,,,,107,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,51.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
Fac/Trim Nail(S),PX11719F,CDM,510,RC,11719,CPT,,,,,,,,107,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,51.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
Fac/Trim Nail(S),PX11719F,CDM,510,RC,11719,CPT,,,,,,,,107,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,51.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
Path Special Stains II,PX3979,CDM,310,RC,88313,CPT,TC,,,,,,,107,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,51.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
Path Special Stains II,PX3979,CDM,310,RC,88313,CPT,TC,,,,,,,107,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,51.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
"Special Stains,Group I",PX3978,CDM,310,RC,88312,CPT,TC,,,,,,,107,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,51.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
"Special Stains,Group I",PX3978,CDM,310,RC,88312,CPT,TC,,,,,,,107,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,51.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,93681545,NDC,2,ML,57.71,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,51.3619,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,93681573,NDC,2,ML,57.71,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,51.3619,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,781329091,NDC,50,ML,119.73,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,51.36417,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048557,NDC,50,ML,52.78,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,51.370774,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106F,CDM,510,RC,11106,CPT,,,,,,,,255,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,51.376,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.68,323.07
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106P,CDM,983,RC,11106,CPT,,,,,,,,204,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,51.376,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.68,323.07
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048503,NDC,50,ML,57.74,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,51.3886,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
OBINutuzumab 1000 MG/40ML Solution 40 mL Vial,J9301.01,CDM,636,RC,J9301,HCPCS,,,,50242007001,NDC,4,ML,1397.15,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,51.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.22,73.86
OBINutuzumab 1000 MG/40ML Solution 40 mL Vial,J9301.01,CDM,636,RC,J9301,HCPCS,,,,50242007001,NDC,4,ML,1397.15,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,51.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.22,73.86
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093102,NDC,1,ML,60.47,,First Health,Commercial,both,85,,999999999,percent of total billed charges,51.3995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615900,NDC,1,EA,123.75,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,51.40575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615904,NDC,1,EA,123.75,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,51.40575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,641601501,NDC,25,ML,58.29,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,51.41178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Thrombolysis,Coronary,IV Infusn",PX92977F,CDM,480,RC,92977,CPT,,,,,,,,595,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,51.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.16,96.56
Dx Occult Blood Immunoassay,PX82274,CDM,300,RC,82274,CPT,,,,,,,,105,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,51.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.6,102.9
Dx Occult Blood Immunoassay,PX82274,CDM,300,RC,82274,CPT,,,,,,,,105,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,51.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.6,102.9
Dx Occult Blood Immunoassay,PX82274,CDM,300,RC,82274,CPT,,,,,,,,105,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,51.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.6,102.9
Specimen Concentration - Ref,PX8701590,CDM,300,RC,87015,CPT,90,,,,,,,105,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,51.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.12,102.9
Specimen Concentration - Ref,PX8701590,CDM,300,RC,87015,CPT,90,,,,,,,105,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,51.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.12,102.9
Specimen Concentration - Ref,PX8701590,CDM,300,RC,87015,CPT,90,,,,,,,105,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,51.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.12,102.9
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,17478007035,NDC,3.5,GR,105.01,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,51.4549,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,17478007035,NDC,3.5,GR,105.01,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,51.4549,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,17478007035,NDC,3.5,GR,105.01,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,51.4549,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117630,NDC,1,ML,58.34,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,51.45588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
magnesium sulfate 1 g in 100 ml D5W (premix) 1-5 GM/100ML-% Solution 100 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010802,NDC,100,ML,52.51,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,51.4598,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
tuberculin 5 UNIT/0.1ML Solution 1 mL Vial,25000000,CDM,250,RC,,,,,,42023010401,NDC,0.1,ML,57.82,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,51.4598,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,990771512,NDC,62.5,ML,56.5,,Medica,Commercial,both,91.1,,7.37,percent of total billed charges,51.4715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.4701,303.0944
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,781323294,NDC,1,EA,52.89,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,23.41888889,percent of total billed charges,51.477837,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
Carnitine - Ref,PX8237990,CDM,300,RC,82379,CPT,90,,,,,,,104,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,51.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.47,101.92
Cmv Antibody - Ref,PX8664490,CDM,300,RC,86644,CPT,90,,,,,,,104,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,51.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,101.92
"Compatibility Test,Antiglob Tech",PX86922,CDM,300,RC,86922,CPT,,,,,,,,120,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,51.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.848,149.22
KIWI OMNICUP VACUUM DELIVERY SYSTEM,120.225,CDM,272,RC,,,,11608-MAIN,LOCAL,,,,,120,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,51.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.848,117.6
Skin Sub Graft Trnk/Arm/Leg,PX15271F,CDM,510,RC,15271,CPT,,,,,,,,862,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,51.48,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.83,320.3
Skin Sub Graft Trnk/Arm/Leg,PX15271F,CDM,510,RC,15271,CPT,,,,,,,,862,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,51.48,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.83,320.3
Skin Sub Graft Trnk/Arm/Leg,PX15271P,CDM,983,RC,15271,CPT,,,,,,,,705,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,51.48,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.83,690.9
Skin Sub Graft Trnk/Arm/Leg,PX15271P,CDM,983,RC,15271,CPT,,,,,,,,705,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,51.48,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.83,690.9
VACUUM KIWI W/PALM PUMP,120.225,CDM,272,RC,,,,10028-MAIN,LOCAL,,,,,120,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,51.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.848,117.6
PACLitaxel 30 MG/5ML Concentrate 5 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476401,NDC,5,ML,58.37,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,51.48234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
Assay of Lithium,PX80178,CDM,300,RC,80178,CPT,,,,,,,,124,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,51.5096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.06,121.52
"Complement; Antigen, Each Component",PX86160,CDM,300,RC,86160,CPT,,,,,,,,124,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,51.5096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11,121.52
"Immunoassay,Ca15-3(27.29) - Ref",PX8630090,CDM,300,RC,86300,CPT,90,,,,,,,124,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,51.5096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,121.52
Itraconazole,PX8018990,CDM,300,RC,80189,CPT,90,,,,,,,124,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,51.5096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.86,121.52
Microbe Susceptible Mic,PX87186,CDM,300,RC,87186,CPT,,,,,,,,124,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,51.5096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.93,121.52
Nocardia Susceptibility - Ref,PX8718690,CDM,300,RC,87186,CPT,90,,,,,,,124,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,51.5096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.93,121.52
Oligoclonal Bands - Ref,PX8391690,CDM,300,RC,83916,CPT,90,,,,,,,124,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,51.5096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.11,121.52
UMBILICAL VESSEL CATHETER INSERTION TRAY POLY SINGLE LUMEN 3.5/5FR,120.573,CDM,272,RC,,,,12857-MAIN,LOCAL,,,,,124,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,51.5096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.5096,121.52
LAP SPONGES 18x18 7INCH LOOP,27200000,CDM,272,RC,,,,604-MAIN,LOCAL,,,,,60.64,,First Health,Commercial,both,85,,999999999,percent of total billed charges,51.544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ezetimibe 10 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,16729043316,NDC,1,EA,60.66,,First Health,Commercial,both,85,,999999999,percent of total billed charges,51.561,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,143950801,NDC,10,ML,58.46,,United Healthcare,All Payer,outpatient,88.2,,7.6225,percent of total billed charges,51.56172,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615704,NDC,1,EA,101.92,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,51.57152,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
lidocaine HCl 4 % Cream 133 g Tube,63700001,CDM,250,RC,,,,,,41167005828,NDC,133,GR,52.99,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,51.575167,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011801,NDC,0.5,ML,52.63,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,51.5774,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011805,NDC,0.5,ML,52.63,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,51.5774,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
Dystrophic Nail Trimming Any Number,PXG0127F,CDM,940,RC,G0127,HCPCS,,,,,,,,53,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,51.5849,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.0162,53.44
Renin - Ref,PX8424490,CDM,300,RC,84244,CPT,90,,,,,,,53,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,51.5849,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.16,51.94
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061400,NDC,1,ML,101.95,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,51.5867,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.114178,99.911
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615700,NDC,1,EA,101.95,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,51.5867,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,143950810,NDC,10,ML,58.51,,United Healthcare,All Payer,outpatient,88.2,,7.6225,percent of total billed charges,51.60582,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
Sacubitril-Valsartan 49-51 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,78077720,NDC,1,EA,58.51,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,51.60582,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714078401,NDC,0.4,EA,60.72,,First Health,Commercial,both,85,,999999999,percent of total billed charges,51.612,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Concurrent Infusion,PX96368,CDM,260,RC,96368,CPT,,,,,,,,102,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,51.612,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.3708,99.96
Immunohisto Antibody Slide Ea Addl,PX8834101,CDM,310,RC,88341,CPT,TC,,,,,,,102,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,51.612,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.3708,99.96
Reptilase Test - Ref,PX8563590,CDM,300,RC,85635,CPT,90,,,,,,,102,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,51.612,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.03,99.96
"Albumin, Blood",PX82040,CDM,300,RC,82040,CPT,90,,,,,,,58,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,51.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.54,56.84
Assay of creatinine,PX82565,CDM,300,RC,82565,CPT,,,,,,,,58,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,51.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.69,56.84
Assay of Urea Nitrogen,PX84520,CDM,300,RC,84520,CPT,,,,,,,,58,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,51.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.62,56.84
"Assay, Glucose, Blood Quant",PX82947,CDM,300,RC,82947,CPT,,,,,,,,58,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,51.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.6,56.84
Automated Leukocyte Count,PX85048,CDM,300,RC,85048,CPT,,,,,,,,58,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,51.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.33,56.84
DEFIBRILLATION PAD BIPHASIC ADULT,120.96,CDM,271,RC,A0392,HCPCS,,1321-MAIN,LOCAL,,,,,58,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,51.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.0932,56.84
"Ebv, Nuclear Antigen - Ref",PX8666490,CDM,300,RC,86664,CPT,90,,,,,,,58,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,51.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.02,56.84
"Ebv, Viral Capsid Ab - Ref",PX8666590,CDM,300,RC,86665,CPT,90,,,,,,,58,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,51.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.63,56.84
Hematocrit,PX85014,CDM,300,RC,85014,CPT,,,,,,,,58,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,51.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.17,56.84
"Long Term Holter, 48 Hrs Up to 7 Days, Recording",PX93242,CDM,731,RC,93242,CPT,,,,,,,,58,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,51.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.0932,56.84
"Long Term Holter, More Than 7 Days Up to 15 Days, Recording",PX93246,CDM,731,RC,93246,CPT,,,,,,,,58,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,51.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.0932,56.84
"Sodium; Serum, Plasma or Whole Blood",PX84295,CDM,300,RC,84295,CPT,,,,,,,,58,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,51.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.41,56.84
SUTURE V-LOC SZ 1 PBT WOUND CLOSURE DEVICE BLUE 18 IN GS 21 NEEDLE VLOCN0327,27200000,CDM,272,RC,,,,12828-MAIN,LOCAL,,,,,58,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,51.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Transferase; Alanine Amino (Alt) (Sgpt),PX84460,CDM,300,RC,84460,CPT,,,,,,,,58,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,51.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.86,56.84
Transferase; Aspartate Amino (Ast) (Sgot),PX84450,CDM,300,RC,84450,CPT,,,,,,,,58,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,51.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,56.84
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338067104,NDC,1000,ML,53.06,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,4.559571429,percent of total billed charges,51.643298,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Package,25000000,CDM,250,RC,,,,,,66758020858,NDC,1,EA,102.08,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,51.65248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329330101,NDC,50,ML,107.61,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,51.6528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329330101,NDC,50,ML,107.61,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,51.6528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060820,NDC,20,ML,58.57,,United Healthcare,All Payer,outpatient,88.2,,1.151420557,percent of total billed charges,51.65874,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
"sodium chloride 0.45 % 1,000 mL with potassium chloride 20 mEq 20-0.45 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070434,NDC,1000,ML,58.57,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,51.65874,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714020010,NDC,1,EA,107.64,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,51.6672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714020010,NDC,1,EA,107.64,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,51.6672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714020030,NDC,1,EA,107.64,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,51.6672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714020030,NDC,1,EA,107.64,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,51.6672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001481,NDC,1,EA,102.12,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,51.67272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024010,NDC,1,EA,56.73,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,51.68103,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030036,NDC,1,EA,56.73,,Medica,Commercial,both,91.1,,5.442333333,percent of total billed charges,51.68103,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098341,NDC,1,EA,56.73,,Medica,Commercial,both,91.1,,5.442333333,percent of total billed charges,51.68103,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,63323047401,NDC,1,ML,58.6,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,51.6852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.428
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076501,NDC,1,EA,58.6,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,51.6852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076510,NDC,1,EA,58.6,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,51.6852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032050,NDC,1,EA,120.51,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,51.69879,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
"Injection,Sacroiliac Joint(T)",PX27096F,CDM,510,RC,27096,CPT,,,,,,,,881,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,51.7,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.7,341.06
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618201,NDC,2,ML,120.53,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,51.70737,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.068162,123.3918
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618210,NDC,2,ML,120.53,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,51.70737,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.068162,123.3918
hydrocortisone 2.5 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,45802000403,NDC,28,GR,60.85,,First Health,Commercial,both,85,,999999999,percent of total billed charges,51.7225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048557,NDC,50,ML,52.78,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,51.7244,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086000,NDC,1,EA,58.66,,United Healthcare,All Payer,outpatient,88.2,,23.68,percent of total billed charges,51.73812,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086050,NDC,1,EA,58.66,,United Healthcare,All Payer,outpatient,88.2,,23.68,percent of total billed charges,51.73812,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012166,NDC,1,EA,58.66,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,51.73812,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
cefOXitin 1 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021010910,NDC,1,EA,58.66,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,51.73812,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.367364,75.6952
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,65219025915,NDC,1,EA,58.66,,United Healthcare,All Payer,outpatient,88.2,,49.96,percent of total billed charges,51.73812,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
sucralfate 1 GM/10ML Suspension 10 mL Cup,63700001,CDM,250,RC,,,,,,68094004359,NDC,10,ML,60.92,,First Health,Commercial,both,85,,999999999,percent of total billed charges,51.782,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,43598020453,NDC,10,ML,58.73,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,51.79986,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,72508020415,NDC,10,ML,58.73,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,51.79986,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
empagliflozin 10 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,597015237,NDC,1,EA,104.66,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,51.8067,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Physical Therapy Re-Eval Est Plan Care 20 Mins,PX97164,CDM,424,RC,97164,CPT,,,,,,,,239,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,51.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.77,91.81
Physical Therapy Re-Eval Est Plan Care 20 Mins,PX97164,CDM,424,RC,97164,CPT,,,,,,,,239,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,51.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.77,91.81
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,517460125,NDC,0.5,ML,58.76,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,51.82632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
gentamicin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,60758018805,NDC,5,ML,107.98,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,51.8304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
gentamicin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,60758018805,NDC,5,ML,107.98,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,51.8304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,781323294,NDC,1,EA,52.89,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,51.8322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003905,NDC,1,EA,58.77,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,51.83514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
Erythropietin - Ref,PX8266890,CDM,300,RC,82668,CPT,90,,,,,,,108,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,51.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,105.84
Erythropietin - Ref,PX8266890,CDM,300,RC,82668,CPT,90,,,,,,,108,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,51.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,105.84
Levetiracetam - Ref,PX8017790,CDM,300,RC,80177,CPT,90,,,,,,,108,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,51.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,105.84
Levetiracetam - Ref,PX8017790,CDM,300,RC,80177,CPT,90,,,,,,,108,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,51.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,105.84
Oxcarbazepine - Ref,PX8018390,CDM,300,RC,80183,CPT,90,,,,,,,108,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,51.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,105.84
Oxcarbazepine - Ref,PX8018390,CDM,300,RC,80183,CPT,90,,,,,,,108,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,51.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,105.84
dabigatran 75 MG capsule 60 Each Box,63700001,CDM,250,RC,,,,,,597035556,NDC,1,EA,53.27,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,51.847691,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Protoporphyrin, RBC, Qnt - Ref",PX8420290,CDM,300,RC,84202,CPT,90,,,,,,,61,,First Health,Commercial,both,85,,999999999,percent of total billed charges,51.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.16,59.78
"Venipuncture, Lab",PX3641502,CDM,300,RC,36415,CPT,,,,,,,,61,,First Health,Commercial,both,85,,999999999,percent of total billed charges,51.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.1,65.45
hydrocortisone 25 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,713050306,NDC,1,EA,108.03,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,51.8544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 25 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,713050306,NDC,1,EA,108.03,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,51.8544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 25 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713050312,NDC,1,EA,108.03,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,51.8544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 25 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713050312,NDC,1,EA,108.03,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,51.8544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,641601501,NDC,25,ML,58.29,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,51.8781,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963801,NDC,0.5,ML,88.69,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,51.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.65,84.496
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963801,NDC,0.5,ML,88.69,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,51.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.65,84.496
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963805,NDC,0.5,ML,142.98,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,51.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.65,84.496
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963805,NDC,0.5,ML,142.98,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,51.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.65,84.496
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,55150017301,NDC,0.5,ML,319.2,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,51.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.65,84.496
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,55150017301,NDC,0.5,ML,319.2,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,51.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.65,84.496
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,63323027301,NDC,0.5,ML,235.6,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,51.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.65,84.496
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,63323027301,NDC,0.5,ML,235.6,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,51.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.65,84.496
Debride Skin/Subq Ea Ad 20sqcm,PX11045F,CDM,510,RC,11045,CPT,,,,,,,,115,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,51.89,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.05,83.02
Debride Skin/Subq Ea Ad 20sqcm,PX11045P,CDM,983,RC,11045,CPT,,,,,,,,182,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,51.89,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.05,178.36
Insert Simple Cath Foley,PX51702F,CDM,510,RC,51702,CPT,,,,,,,,198,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,51.89,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.27,129.37
"PDS II ENDOLOOP LIGATURE SIZE 0 18""",27200000,CDM,272,RC,,,,11700-MAIN,LOCAL,,,,,56.96,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,51.89056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048657,NDC,50,ML,61.05,,First Health,Commercial,both,85,,999999999,percent of total billed charges,51.8925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409669501,NDC,10,ML,56.97,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,51.89967,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006111,NDC,0.5,EA,56.98,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,51.90878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.669492,55.8404
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006158,NDC,0.5,EA,56.98,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,51.90878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.669492,55.8404
BAG LEG URINARY STND 32OZ,120.33,CDM,272,RC,A5112,HCPCS,,4433-MAIN,LOCAL,,,,,121,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,51.909,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
BAG URINARY DRAINAGE 2000ML 6300,120.33,CDM,274,RC,A4357,HCPCS,,1283-MAIN,LOCAL,,,,,121,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,51.909,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
BAG URINARY LEG PACK 9349,120.33,CDM,272,RC,A5112,HCPCS,,623-MAIN,LOCAL,,,,,121,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,51.909,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
"Chest Wall Manipulation,Initial",PX94667,CDM,410,RC,94667,CPT,,,,,,,,121,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,51.909,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.2634,118.58
"Fluor Noninfect Ab Sc, Ea - Ref",PX8625590,CDM,300,RC,86255,CPT,90,,,,,,,121,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,51.909,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.05,118.58
"Manage/Train Orthotic/Prosthetic, per 15 Min",PX97763,CDM,420,RC,97763,CPT,,,,,,,,121,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,51.909,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.36,118.58
"Prosthetic Training, Initial, Each 15 Mins",PX97761,CDM,420,RC,97761,CPT,,,,,,,,121,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,51.909,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.41,118.58
acyclovir 50 MG/ML Solution 10 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,55150015410,NDC,10,ML,108.16,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,51.9168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.927644,105.9968
acyclovir 50 MG/ML Solution 10 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,55150015410,NDC,10,ML,108.16,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,51.9168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.927644,105.9968
"Closed Rx Radial Head Disloc,Child",PX24640F,CDM,510,RC,24640,CPT,,,,,,,,270,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,51.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.04,218.61
"Closed Rx Radial Head Disloc,Child",PX24640F,CDM,510,RC,24640,CPT,,,,,,,,270,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,51.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.04,218.61
"Closed Rx Radial Head Disloc,Child",PX24640P,CDM,983,RC,24640,CPT,,,,,,,,180,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,51.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.04,218.61
"Closed Rx Radial Head Disloc,Child",PX24640P,CDM,983,RC,24640,CPT,,,,,,,,180,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,51.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.04,218.61
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117630,NDC,1,ML,58.34,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,51.9226,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
Cmv Igm Antibody - Ref,PX8664590,CDM,300,RC,86645,CPT,90,,,,,,,125,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,51.925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.45,122.5
DRESSING SURGICEL HEMOSTAT 4X8 ABSORBABLE 1952,120.123,CDM,272,RC,A6252,HCPCS,,1002-MAIN,LOCAL,,,,,125,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,51.925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.925,122.5
Factor VII - Ref,PX8523090,CDM,300,RC,85230,CPT,90,,,,,,,125,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,51.925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.41,122.5
"Albumin, Othr Source - Ref",PX8204290,CDM,300,RC,82042,CPT,90,,,,,,,57,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,51.927,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.13,55.86
"Albumin, Serum - Ref",PX8204090,CDM,300,RC,82040,CPT,90,,,,,,,57,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,51.927,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.54,55.86
Assay Alkaline Phosphatase,PX84075,CDM,300,RC,84075,CPT,,,,,,,,57,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,51.927,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,55.86
Calcium Total,PX82310,CDM,300,RC,82310,CPT,,,,,,,,57,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,51.927,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.73,55.86
Dhea-S - Ref,PX8262790,CDM,300,RC,82627,CPT,90,,,,,,,57,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,51.927,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.38,55.86
Tiss Trnsgltmnase Ea Ig Clas,PX86364,CDM,300,RC,86364,CPT,,,,,,,,57,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,51.927,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.6778,55.86
US Follicles-Limited Tc,PX7685701,CDM,402,RC,76857,CPT,TC,,,,,,,300,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,51.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.58,51.93
US Follicles-Limited Tc,PX7685701,CDM,402,RC,76857,CPT,TC,,,,,,,300,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,51.93,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.58,51.93
Xray Foot Minimum 3 Vws,PX7363001,CDM,320,RC,73630,CPT,TC,,,,,,,404,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,51.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,51.93
Xray Foot Minimum 3 Vws,PX7363001,CDM,320,RC,73630,CPT,TC,,,,,,,404,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,51.93,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,51.93
Xray Knee 1 or 2 Vws,PX7356001,CDM,320,RC,73560,CPT,TC,,,,,,,303,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,51.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,51.93
Xray Knee 1 or 2 Vws,PX7356001,CDM,320,RC,73560,CPT,TC,,,,,,,303,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,51.93,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,51.93
Xray Ribs Unilat 2 Vws,PX7110001,CDM,320,RC,71100,CPT,TC,,,,,,,437,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,51.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,51.93
Xray Ribs Unilat 2 Vws,PX7110001,CDM,320,RC,71100,CPT,TC,,,,,,,437,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,51.93,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,51.93
lidocaine HCl 4 % Cream 133 g Tube,63700001,CDM,250,RC,,,,,,41167005828,NDC,133,GR,52.99,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,51.9302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,143950601,NDC,10,ML,61.1,,First Health,Commercial,both,85,,999999999,percent of total billed charges,51.935,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,143950610,NDC,10,ML,61.1,,First Health,Commercial,both,85,,999999999,percent of total billed charges,51.935,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Dystrophic Nail Trimming Any Number,PXG0127F,CDM,940,RC,G0127,HCPCS,,,,,,,,53,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,51.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.0162,53.44
GLIDESCOPE QC MILLER S0 SINGLE USE 0270-1087,120.58,CDM,272,RC,,,,13024-MAIN,LOCAL,,,,,106,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,51.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
GLIDESCOPE QC MILLER S0 SINGLE USE 0270-1087,120.58,CDM,272,RC,,,,13024-MAIN,LOCAL,,,,,106,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,51.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
GLIDESCOPE QC MILLER S0 SINGLE USE 0270-1087,120.58,CDM,272,RC,,,,13024-MAIN,LOCAL,,,,,106,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,51.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
GLIDESCOPE QC MILLER S1 SINGLE USE 0270-1088,120.58,CDM,272,RC,,,,13025-MAIN,LOCAL,,,,,106,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,51.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
GLIDESCOPE QC MILLER S1 SINGLE USE 0270-1088,120.58,CDM,272,RC,,,,13025-MAIN,LOCAL,,,,,106,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,51.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
GLIDESCOPE QC MILLER S1 SINGLE USE 0270-1088,120.58,CDM,272,RC,,,,13025-MAIN,LOCAL,,,,,106,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,51.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
Renin - Ref,PX8424490,CDM,300,RC,84244,CPT,90,,,,,,,53,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,51.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.16,51.94
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331801,NDC,10,ML,102.65,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,51.9409,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
PACLitaxel 30 MG/5ML Concentrate 5 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476401,NDC,5,ML,58.37,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,51.9493,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
cefTRIAXone in dextrose 1 g / 50 mL 1-3.74 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0696.01,CDM,636,RC,J0696,HCPCS,,,,264315311,NDC,1,EA,106.03,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,9.983703704,percent of total billed charges,51.9547,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone in dextrose 1 g / 50 mL 1-3.74 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0696.01,CDM,636,RC,J0696,HCPCS,,,,264315311,NDC,1,EA,106.03,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,51.9547,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone in dextrose 1 g / 50 mL 1-3.74 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0696.01,CDM,636,RC,J0696,HCPCS,,,,264315311,NDC,1,EA,106.03,,United Healthcare,All Medicare advantage plans,outpatient,49,,3.9675,percent of total billed charges,51.9547,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714000601,NDC,0.3,ML,53.39,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,25.0327027,percent of total billed charges,51.964487,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
Dx Occult Blood Immunoassay,PX82274,CDM,300,RC,82274,CPT,,,,,,,,105,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,51.975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.6,102.9
Specimen Concentration - Ref,PX8701590,CDM,300,RC,87015,CPT,90,,,,,,,105,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,51.975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.12,102.9
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117603,NDC,1,ML,58.93,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,51.97626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001104,NDC,1,EA,108.29,,Health Partners,Health Partners Care Plans,both,48,,50.24,percent of total billed charges,51.9792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001104,NDC,1,EA,108.29,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,51.9792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,17478007035,NDC,3.5,GR,105.01,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,51.97995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine-epinephrine-tetracaine Gel 3 mL Syringe,J3490.160,CDM,636,RC,J3490,HCPCS,,,,88888800028,NDC,3,ML,121.19,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,51.99051,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.342326,118.7662
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,67457022800,NDC,5,ML,53.42,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,51.993686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,67457057305,NDC,5,ML,53.42,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,51.993686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338067104,NDC,1000,ML,53.06,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,51.9988,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
belimumab (400v) 400 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010201,NDC,1,EA,3523.71,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,52,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.37,53.14484
belimumab 120 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010101,NDC,1,EA,1015.95,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,52,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.37,53.14484
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001103,NDC,1,EA,108.34,,Health Partners,Health Partners Care Plans,both,48,,50.24,percent of total billed charges,52.0032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001103,NDC,1,EA,108.34,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,52.0032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305972,NDC,2,ML,61.19,,First Health,Commercial,both,85,,999999999,percent of total billed charges,52.0115,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305995,NDC,2,ML,61.19,,First Health,Commercial,both,85,,999999999,percent of total billed charges,52.0115,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
Dress/Debrid Small Burn No Anes,PX16020F,CDM,510,RC,16020,CPT,,,,,,,,313,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,52.0182,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.46,179.18
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002F,CDM,510,RC,12002,CPT,,,,,,,,343,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,52.0182,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.9,237.98
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002P,CDM,983,RC,12002,CPT,,,,,,,,486,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,52.0182,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.9,476.28
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003930,NDC,1,EA,58.99,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,52.02918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,143950801,NDC,10,ML,58.46,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,52.0294,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
DRAWTEX HYDROCONDUCTIVE NONADHERENT DRESSING,120.508,CDM,271,RC,A6199,HCPCS,,12022-MAIN,LOCAL,,,,,59,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,52.038,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.5086,57.82
"Potassium; Serum, Plasma or Whole Blood",PX84132,CDM,300,RC,84132,CPT,,,,,,,,59,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,52.038,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.36,57.82
ALEXIS 0 LARGE STERILE,27200000,CDM,272,RC,,,,11765-MAIN,LOCAL,,,,,102.85,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,52.0421,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338411450,NDC,50,ML,106.23,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,7.983333333,percent of total billed charges,52.0527,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338411450,NDC,50,ML,106.23,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,52.0527,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338411450,NDC,50,ML,106.23,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,52.0527,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43598055530,NDC,0.4,EA,61.26,,First Health,Commercial,both,85,,999999999,percent of total billed charges,52.071,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43598096630,NDC,0.4,EA,61.26,,First Health,Commercial,both,85,,999999999,percent of total billed charges,52.071,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,143950810,NDC,10,ML,58.51,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,52.0739,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
Sacubitril-Valsartan 49-51 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,78077720,NDC,1,EA,58.51,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,52.0739,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfamethoxazole-trimethoprim 400-80 MG/5ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,703951403,NDC,10,ML,102.93,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,52.08258,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Level III - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3933,CDM,310,RC,88304,CPT,TC,,,,,,,66,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,52.096,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.02,52.096
"Level III - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3933,CDM,310,RC,88304,CPT,TC,,,,,,,66,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,52.096,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.02,52.096
tropicamide 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,24208058559,NDC,2,ML,61.3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,52.105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,781523806,NDC,1,EA,106.34,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,52.1066,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,781523806,NDC,1,EA,106.34,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,52.1066,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,781523806,NDC,1,EA,106.34,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,52.1066,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,781523864,NDC,1,EA,106.34,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,52.1066,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,781523864,NDC,1,EA,106.34,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,52.1066,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,781523864,NDC,1,EA,106.34,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,52.1066,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,65862039010,NDC,1,EA,106.34,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,52.1066,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,65862039010,NDC,1,EA,106.34,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,52.1066,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,65862039010,NDC,1,EA,106.34,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,52.1066,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
Assay of Transferrin,PX84466,CDM,300,RC,84466,CPT,,,,,,,,103,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,52.118,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.7,100.94
"Lactoferrin, Fecal; Qual",PX83630,CDM,300,RC,83630,CPT,,,,,,,,103,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,52.118,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.06,100.94
"Molecyto Insitu, 100-300cl - Ref",PX8827590,CDM,310,RC,88275,CPT,90,,,,,,,103,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,52.118,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.7862,100.94
"Tiss Cult,Non-Neop Lymph - Ref",PX8823090,CDM,310,RC,88230,CPT,90,,,,,,,103,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,52.118,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.7862,106.81
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060820,NDC,20,ML,58.57,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,52.1273,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
"sodium chloride 0.45 % 1,000 mL with potassium chloride 20 mEq 20-0.45 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070434,NDC,1000,ML,58.57,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,52.1273,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"Injection,Sacroiliac Joint(T)",PX27096F,CDM,510,RC,27096,CPT,,,,,,,,881,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,52.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.7,341.06
"Injection,Sacroiliac Joint(T)",PX27096F,CDM,510,RC,27096,CPT,,,,,,,,881,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,52.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.7,341.06
albumin human 25% 25 % Solution 50 mL Flex Cont,P9047,CDM,636,RC,P9047,HCPCS,,,,944049301,NDC,50,ML,402.67,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,52.14757,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.16,53.08
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,63323047401,NDC,1,ML,58.6,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,52.154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.428
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076501,NDC,1,EA,58.6,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,52.154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076510,NDC,1,EA,58.6,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,52.154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
dabigatran 75 MG capsule 60 Each Box,63700001,CDM,250,RC,,,,,,597035556,NDC,1,EA,53.27,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,52.2046,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086000,NDC,1,EA,58.66,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,52.2074,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086050,NDC,1,EA,58.66,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,52.2074,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012166,NDC,1,EA,58.66,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,52.2074,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
cefOXitin 1 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021010910,NDC,1,EA,58.66,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,52.2074,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.367364,75.6952
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,65219025915,NDC,1,EA,58.66,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,52.2074,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
lidocaine 0.5 % PF 0.5 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323049101,NDC,50,ML,103.2,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,52.2192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
triamcinolone acetonide 0.1 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,16714098602,NDC,30,GR,59.22,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,52.23204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 50 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,406905076,NDC,1,EA,125.74,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,52.232396,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623100,NDC,1,EA,59.25,,United Healthcare,All Payer,outpatient,88.2,,20.73428571,percent of total billed charges,52.2585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,43598020453,NDC,10,ML,58.73,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,52.2697,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,72508020415,NDC,10,ML,58.73,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,52.2697,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623105,NDC,1,EA,59.27,,United Healthcare,All Payer,outpatient,88.2,,20.73428571,percent of total billed charges,52.27614,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
IV 0.9% NS 1000ML 2B1324X,27200000,CDM,272,RC,,,,538-MAIN,LOCAL,,,,,121.89,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,52.29081,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052331,NDC,2,ML,125.89,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,52.294706,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.294706,123.3722
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052341,NDC,2,ML,125.89,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,52.294706,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.294706,123.3722
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Package,25000000,CDM,250,RC,,,,,,10019055390,NDC,1,EA,121.9,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,52.2951,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,517460125,NDC,0.5,ML,58.76,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,52.2964,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,17478053802,NDC,2,ML,125.91,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,52.303014,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.068162,123.3918
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003905,NDC,1,EA,58.77,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,52.3053,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
"RBC Sed Rate, Auto",PX85652,CDM,300,RC,85652,CPT,,,,,,,,109,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,52.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.48,106.82
"RBC Sed Rate, Auto",PX85652,CDM,300,RC,85652,CPT,,,,,,,,109,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,52.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.48,106.82
Smear Gram Stain,PX87205,CDM,300,RC,87205,CPT,,,,,,,,109,,Health Partners,Health Partners Care Plans,both,48,,105.73,percent of total billed charges,52.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,106.82
Smear Gram Stain,PX87205,CDM,300,RC,87205,CPT,,,,,,,,109,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,52.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,106.82
Smear Wet Mount Saline/Ink,PX87210,CDM,300,RC,87210,CPT,,,,,,,,109,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,52.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.34,106.82
Smear Wet Mount Saline/Ink,PX87210,CDM,300,RC,87210,CPT,,,,,,,,109,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,52.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.34,106.82
"West Nile Ab, Igm - Ref",PX8678890,CDM,300,RC,86788,CPT,90,,,,,,,109,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,52.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.45,106.82
"West Nile Ab, Igm - Ref",PX8678890,CDM,300,RC,86788,CPT,90,,,,,,,109,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,52.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.45,106.82
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714000601,NDC,0.3,ML,53.39,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,52.3222,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
BURETROL ADD ON SET 150ML,120.38,CDM,272,RC,A4222,HCPCS,,11118-MAIN,LOCAL,,,,,18,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,52.33,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,77.17
scopolamine 1 MG/3DAYS Patch 72 Hour 4 Each Box,25000000,CDM,250,RC,,,,,,45802058084,NDC,1,EA,103.43,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,52.33558,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Assay of Iron,PX83540,CDM,300,RC,83540,CPT,,,,,,,,122,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,52.338,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,119.56
"Compliment, Total (Ch50) - Ref",PX8616290,CDM,300,RC,86162,CPT,90,,,,,,,122,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,52.338,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.63,119.56
Vitamin B-12,PX82607,CDM,300,RC,82607,CPT,,,,,,,,122,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,52.338,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.83,119.56
"Insert Needle,Intraosseous Infusn",PX36680F,CDM,510,RC,36680,CPT,,,,,,,,659,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,52.3393,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.12,122.45
"Sigmoidoscopy,Diagnostic",PX45330F,CDM,510,RC,45330,CPT,,,,,,,,720,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,52.3393,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.68,386.72
"Sigmoidoscopy,Diagnostic",PX45330P,CDM,983,RC,45330,CPT,,,,,,,,480,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,52.3393,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.68,470.4
"Sigmoidoscopy,Screen Prev",PX2001F,CDM,750,RC,45330,CPT,,,,,,,,843,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,52.3393,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.68,386.72
Thrombin Time Plasma,PX85670,CDM,300,RC,85670,CPT,,,,,,,,126,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,52.3404,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.29,123.48
"Destruct Benign Lesion, 15+",PX17111F,CDM,510,RC,17111,CPT,,,,,,,,303,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,52.35,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.35,277.41
Exc Skin Benig <5mm Remaindr Body,PX11420P,CDM,983,RC,11420,CPT,,,,,,,,299,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,52.35,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.35,293.02
Fac/Exc Skin Benig<5mm Remaind Bod,PX11420F,CDM,510,RC,11420,CPT,,,,,,,,374,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,52.35,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.35,264.27
US Abdomen Tc,PX7670001,CDM,402,RC,76700,CPT,TC,,,,,,,586,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,52.35,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.35,155.15
US Abdomen Tc,PX7670001,CDM,402,RC,76700,CPT,TC,,,,,,,586,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,52.35,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.35,155.15
US Abdomen Tc,PX7670001,CDM,402,RC,76700,CPT,TC,,,,,,,586,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,52.35,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.35,155.15
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,67457022800,NDC,5,ML,53.42,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,52.3516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,67457057305,NDC,5,ML,53.42,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,52.3516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010310,NDC,1,ML,103.48,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,52.36088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010602,NDC,50,ML,126.07,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,52.369478,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010605,NDC,50,ML,126.07,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,52.369478,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
nitroglycerin in dextrose 5% 100-5 MCG/ML-% Solution 250 mL Glass Cont,J2305.01,CDM,636,RC,J2305,HCPCS,,,,338104702,NDC,250,ML,126.07,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,52.369478,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.17,123.5486
gentamicin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063305,NDC,5,ML,122.17,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,52.41093,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,24208091055,NDC,3.5,GR,106.98,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,52.4202,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,24208091055,NDC,3.5,GR,106.98,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,52.4202,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,24208091055,NDC,3.5,GR,106.98,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,52.4202,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
3.0MM NON-THREADED K WIRE,27200000,CDM,272,RC,C1769,HCPCS,,12658-MAIN,LOCAL,,,,,107,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,52.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
3.0MM NON-THREADED K WIRE,27200000,CDM,272,RC,C1769,HCPCS,,12658-MAIN,LOCAL,,,,,107,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,52.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
3.0MM NON-THREADED K WIRE,27200000,CDM,272,RC,C1769,HCPCS,,12658-MAIN,LOCAL,,,,,107,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,52.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Androsetenedione - Ref,PX8215790,CDM,300,RC,82157,CPT,90,,,,,,,107,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,52.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.85,104.86
Androsetenedione - Ref,PX8215790,CDM,300,RC,82157,CPT,90,,,,,,,107,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,52.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.85,104.86
Androsetenedione - Ref,PX8215790,CDM,300,RC,82157,CPT,90,,,,,,,107,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,52.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.85,104.86
Decalcify Tc,PX8831101,CDM,310,RC,88311,CPT,TC,,,,,,,107,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,11.03,percent of total billed charges,52.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
Decalcify Tc,PX8831101,CDM,310,RC,88311,CPT,TC,,,,,,,107,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,52.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
Decalcify Tc,PX8831101,CDM,310,RC,88311,CPT,TC,,,,,,,107,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,52.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
Fac/Trim Nail(S),PX11719F,CDM,510,RC,11719,CPT,,,,,,,,107,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,52.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
Fac/Trim Nail(S),PX11719F,CDM,510,RC,11719,CPT,,,,,,,,107,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,52.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
Fac/Trim Nail(S),PX11719F,CDM,510,RC,11719,CPT,,,,,,,,107,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,52.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
Path Special Stains II,PX3979,CDM,310,RC,88313,CPT,TC,,,,,,,107,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,11.03,percent of total billed charges,52.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
Path Special Stains II,PX3979,CDM,310,RC,88313,CPT,TC,,,,,,,107,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,52.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
Path Special Stains II,PX3979,CDM,310,RC,88313,CPT,TC,,,,,,,107,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,52.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
"Special Stains,Group I",PX3978,CDM,310,RC,88312,CPT,TC,,,,,,,107,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,52.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
"Special Stains,Group I",PX3978,CDM,310,RC,88312,CPT,TC,,,,,,,107,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,52.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
"Special Stains,Group I",PX3978,CDM,310,RC,88312,CPT,TC,,,,,,,107,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,52.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329335201,NDC,50,ML,109.26,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,52.4448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329335201,NDC,50,ML,109.26,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,52.4448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117603,NDC,1,ML,58.93,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,52.4477,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
Ultrasound Breast Limited,PX7664201,CDM,402,RC,76642,CPT,TC,,,,,,,342,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,52.4534,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.12,104.53
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093107,NDC,1,ML,57.59,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,52.46449,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
GLIDESCOPE QC MILLER S0 SINGLE USE 0270-1087,120.58,CDM,272,RC,,,,13024-MAIN,LOCAL,,,,,106,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,52.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
GLIDESCOPE QC MILLER S1 SINGLE USE 0270-1088,120.58,CDM,272,RC,,,,13025-MAIN,LOCAL,,,,,106,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,52.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
cefTRIAXone in dextrose 1 g / 50 mL 1-3.74 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0696.01,CDM,636,RC,J0696,HCPCS,,,,264315311,NDC,1,EA,106.03,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,52.48485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003930,NDC,1,EA,58.99,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,52.5011,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
DRAWTEX HYDROCONDUCTIVE NONADHERENT DRESSING,120.508,CDM,271,RC,A6199,HCPCS,,12022-MAIN,LOCAL,,,,,59,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,52.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.5086,57.82
"Potassium; Serum, Plasma or Whole Blood",PX84132,CDM,300,RC,84132,CPT,,,,,,,,59,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,52.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.36,57.82
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,72603012801,NDC,1,EA,57.64,,Medica,Commercial,both,91.1,,23.075,percent of total billed charges,52.51004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
Inpt or Obs Disch Day Mngmt <=30 Minutes,PX99238,CDM,982,RC,99238,CPT,,,,,,,,199,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,52.53,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.85,195.02
Inpt or Obs Disch Day Mngmt <=30 Minutes,PX99238,CDM,982,RC,99238,CPT,,,,,,,,199,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,52.53,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.85,195.02
Lvl 1 Init Hosp Low Mdm or 40 Minutes,PX99221,CDM,982,RC,99221,CPT,,,,,,,,400,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,52.53,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.29,392
Lvl 1 Init Hosp Low Mdm or 40 Minutes,PX99221,CDM,982,RC,99221,CPT,,,,,,,,400,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,52.53,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.29,392
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,17478062512,NDC,2.5,ML,109.45,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,52.536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,17478062512,NDC,2.5,ML,109.45,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,52.536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
potassium chloride 20 MEQ Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,245036089,NDC,1,EA,57.67,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,52.53737,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405F,CDM,510,RC,36405,CPT,,,,,,,,54,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,52.5582,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.4316,52.92
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,93681545,NDC,2,ML,57.71,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,52.57381,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,93681573,NDC,2,ML,57.71,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,52.57381,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Insert Straight Catheter,PX51701F,CDM,510,RC,51701,CPT,,,,,,,,168,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,52.58,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.27,92.7
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105F,CDM,510,RC,11105,CPT,,,,,,,,171,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,52.58,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,123.83
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105P,CDM,983,RC,11105,CPT,,,,,,,,171,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,52.58,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,167.58
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338411450,NDC,50,ML,106.23,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,52.58385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
LIGACLIP APPLIER CLIP STERILE SIZE MEDIUM LARGE,27200000,CDM,272,RC,,,,11699-MAIN,LOCAL,,,,,126.62,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,52.597948,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048503,NDC,50,ML,57.74,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,52.60114,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
scopolamine 1 MG/3DAYS Patch 72 Hour 24 Each Box,25000000,CDM,250,RC,,,,,,50742050524,NDC,1,EA,109.59,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,52.6032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
scopolamine 1 MG/3DAYS Patch 72 Hour 24 Each Box,25000000,CDM,250,RC,,,,,,50742050524,NDC,1,EA,109.59,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,52.6032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Cytogen, Interp/Report - Ref",PX8829190,CDM,310,RC,88291,CPT,90,,,,,,,2874,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,52.62,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.68,53.2
"Cytogen, Interp/Report - Ref",PX8829190,CDM,310,RC,88291,CPT,90,,,,,,,2874,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,52.62,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.68,53.2
Carnitine - Ref,PX8237990,CDM,300,RC,82379,CPT,90,,,,,,,104,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,52.624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.47,101.92
Cmv Antibody - Ref,PX8664490,CDM,300,RC,86644,CPT,90,,,,,,,104,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,52.624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,101.92
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,70655000206,NDC,100,ML,59.67,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,52.62894,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.786918,140.5516
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457000110,NDC,10,ML,59.67,,United Healthcare,All Payer,outpatient,88.2,,7.6225,percent of total billed charges,52.62894,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013266,NDC,50,ML,59.67,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,52.62894,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013268,NDC,150,ML,59.67,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,52.62894,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,781523806,NDC,1,EA,106.34,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,52.6383,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,781523864,NDC,1,EA,106.34,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,52.6383,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,65862039010,NDC,1,EA,106.34,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,52.6383,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
"Needle Biopsy,Muscle",PX20206F,CDM,510,RC,20206,CPT,,,,,,,,258,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,52.6604,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.55,453.13
"Needle Biopsy,Muscle",PX20206P,CDM,983,RC,20206,CPT,,,,,,,,1028,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,52.6604,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.55,1007.44
tuberculin 5 UNIT/0.1ML Solution 1 mL Vial,25000000,CDM,250,RC,,,,,,42023010401,NDC,0.1,ML,57.82,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,52.67402,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
hydrocortisone 2.5 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,168008031,NDC,30,GR,61.99,,First Health,Commercial,both,85,,999999999,percent of total billed charges,52.6915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
triamcinolone acetonide 0.1 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,16714098602,NDC,30,GR,59.22,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,52.7058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329330101,NDC,50,ML,107.61,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,52.7289,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329330101,NDC,50,ML,107.61,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,52.7289,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329330101,NDC,50,ML,107.61,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,52.7289,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623100,NDC,1,EA,59.25,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,52.7325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714020010,NDC,1,EA,107.64,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,52.7436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714020010,NDC,1,EA,107.64,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,52.7436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714020010,NDC,1,EA,107.64,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,52.7436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714020030,NDC,1,EA,107.64,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,52.7436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714020030,NDC,1,EA,107.64,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,52.7436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714020030,NDC,1,EA,107.64,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,52.7436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623105,NDC,1,EA,59.27,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,52.7503,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
B-Scan Global,PX7651201,CDM,402,RC,76512,CPT,TC,,,,,,,127,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,52.7558,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.7558,124.46
Candida Dna Dir Probe,PX87480,CDM,300,RC,87480,CPT,,,,,,,,127,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,52.7558,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.38,124.46
Gardner Vag Dna Dir Probe,PX87510,CDM,300,RC,87510,CPT,,,,,,,,127,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,52.7558,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.38,124.46
Influenza Assay W/Optic,PX87804,CDM,300,RC,87804,CPT,,,,,,,,127,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,52.7558,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.17,124.46
Trichomonas Vagin Dir Probe,PX87660,CDM,300,RC,87660,CPT,,,,,,,,127,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,52.7558,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.38,124.46
Each Add'l Hour IV Hydration,PX96361,CDM,260,RC,96361,CPT,,,,,,,,123,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,52.767,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,120.54
FLAT WOUND DRAIN WITH TROCAR 4 CHANNEL FULL FLUTED 7FR SILICONE,27200000,CDM,272,RC,,,,12473-MAIN,LOCAL,,,,,123,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,52.767,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Office/Outpt Visit,New,Levl II",PX99202F,CDM,510,RC,99202,CPT,,,,,,,,123,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,52.767,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.0942,120.54
"Office/Outpt Visit,New,Levl II",PX99202P,CDM,983,RC,99202,CPT,,,,,,,,123,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,52.767,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.0942,119.7159
BUPivacaine 0.25 % Solution 50 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046557,NDC,30,ML,59.84,,United Healthcare,All Payer,outpatient,88.2,,12.82416667,percent of total billed charges,52.77888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
"Spinal Punc,Drain,Theraputic",PX62272F,CDM,510,RC,62272,CPT,,,,,,,,450,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,52.79,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.79,384.64
"Spinal Punc,Drain,Theraputic",PX62272P,CDM,983,RC,62272,CPT,,,,,,,,300,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,52.79,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.79,384.64
"Acylcarnitines, Quant - Ref",PX8201790,CDM,300,RC,82017,CPT,90,,,,,,,110,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,52.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.47,107.8
"Acylcarnitines, Quant - Ref",PX8201790,CDM,300,RC,82017,CPT,90,,,,,,,110,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,52.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.47,107.8
"Assay Calcium, Ionized",PX82330,CDM,300,RC,82330,CPT,,,,,,,,110,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,52.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.54,107.8
"Assay Calcium, Ionized",PX82330,CDM,300,RC,82330,CPT,,,,,,,,110,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,52.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.54,107.8
BONE MARROW BIOPSY ASPIRATION NEEDLE 11G X 4 IN,120.562,CDM,272,RC,C1830,HCPCS,,12677-MAIN,LOCAL,,,,,110,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,52.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.694,107.8
BONE MARROW BIOPSY ASPIRATION NEEDLE 11G X 4 IN,120.562,CDM,272,RC,C1830,HCPCS,,12677-MAIN,LOCAL,,,,,110,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,52.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.694,107.8
Glycosylated Hemoglobin Test,PX83036,CDM,300,RC,83036,CPT,,,,,,,,110,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,52.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.9,130.9
Glycosylated Hemoglobin Test,PX83036,CDM,300,RC,83036,CPT,,,,,,,,110,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,52.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.9,130.9
K-WIRE 0.9X150MM BLUNT/TROCAR DART-FIRE STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12449-MAIN,LOCAL,,,,,110,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,52.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRE 0.9X150MM BLUNT/TROCAR DART-FIRE STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12449-MAIN,LOCAL,,,,,110,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,52.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRE 0.9X150MM BLUNT/TROCAR STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12452-MAIN,LOCAL,,,,,110,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,52.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRE 0.9X150MM BLUNT/TROCAR STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12452-MAIN,LOCAL,,,,,110,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,52.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRE 1.4X150MM BLUNT/TROCAR DART-FIRE STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12450-MAIN,LOCAL,,,,,110,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,52.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRE 1.4X150MM BLUNT/TROCAR DART-FIRE STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12450-MAIN,LOCAL,,,,,110,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,52.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRE 1.4X150MM BLUNT/TROCAR STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12451-MAIN,LOCAL,,,,,110,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,52.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRE 1.4X150MM BLUNT/TROCAR STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12451-MAIN,LOCAL,,,,,110,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,52.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA 2.0MM TARGETING GUIDE PIN,27200000,CDM,272,RC,,,,12436-MAIN,LOCAL,,,,,110,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,52.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA 2.0MM TARGETING GUIDE PIN,27200000,CDM,272,RC,,,,12436-MAIN,LOCAL,,,,,110,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,52.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
adenosine 6 MG/2ML Solution 2 mL Syringe,J0153.01,CDM,636,RC,J0153,HCPCS,,,,25021030167,NDC,2,ML,123.1,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,52.8099,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.13574,120.638
"Albumin, Blood",PX82040,CDM,300,RC,82040,CPT,90,,,,,,,58,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,52.838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.54,56.84
Assay of creatinine,PX82565,CDM,300,RC,82565,CPT,,,,,,,,58,,Medica,Commercial,both,91.1,,13.21,percent of total billed charges,52.838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.69,56.84
Assay of Urea Nitrogen,PX84520,CDM,300,RC,84520,CPT,,,,,,,,58,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,52.838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.62,56.84
"Assay, Glucose, Blood Quant",PX82947,CDM,300,RC,82947,CPT,,,,,,,,58,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,52.838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.6,56.84
Automated Leukocyte Count,PX85048,CDM,300,RC,85048,CPT,,,,,,,,58,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,52.838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.33,56.84
DEFIBRILLATION PAD BIPHASIC ADULT,120.96,CDM,271,RC,A0392,HCPCS,,1321-MAIN,LOCAL,,,,,58,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,52.838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.0932,56.84
"Ebv, Nuclear Antigen - Ref",PX8666490,CDM,300,RC,86664,CPT,90,,,,,,,58,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,52.838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.02,56.84
"Ebv, Viral Capsid Ab - Ref",PX8666590,CDM,300,RC,86665,CPT,90,,,,,,,58,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,52.838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.63,56.84
Hematocrit,PX85014,CDM,300,RC,85014,CPT,,,,,,,,58,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,52.838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.17,56.84
"Long Term Holter, 48 Hrs Up to 7 Days, Recording",PX93242,CDM,731,RC,93242,CPT,,,,,,,,58,,Medica,Commercial,both,91.1,,52.95,percent of total billed charges,52.838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.0932,56.84
"Long Term Holter, More Than 7 Days Up to 15 Days, Recording",PX93246,CDM,731,RC,93246,CPT,,,,,,,,58,,Medica,Commercial,both,91.1,,21.77,percent of total billed charges,52.838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.0932,56.84
"Sodium; Serum, Plasma or Whole Blood",PX84295,CDM,300,RC,84295,CPT,,,,,,,,58,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,52.838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.41,56.84
SUTURE V-LOC SZ 1 PBT WOUND CLOSURE DEVICE BLUE 18 IN GS 21 NEEDLE VLOCN0327,27200000,CDM,272,RC,,,,12828-MAIN,LOCAL,,,,,58,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,52.838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Transferase; Alanine Amino (Alt) (Sgpt),PX84460,CDM,300,RC,84460,CPT,,,,,,,,58,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,52.838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.86,56.84
Transferase; Aspartate Amino (Ast) (Sgot),PX84450,CDM,300,RC,84450,CPT,,,,,,,,58,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,52.838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,56.84
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,16714001905,NDC,2,ML,62.17,,First Health,Commercial,both,85,,999999999,percent of total billed charges,52.8445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,16714001930,NDC,2,ML,62.17,,First Health,Commercial,both,85,,999999999,percent of total billed charges,52.8445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
DERMABOND MINI SKIN ADHESIVE,27200000,CDM,272,RC,,,,8532-MAIN,LOCAL,,,,,110.16,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,52.8768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DERMABOND MINI SKIN ADHESIVE,27200000,CDM,272,RC,,,,8532-MAIN,LOCAL,,,,,110.16,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,52.8768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
sodium polystyrene sulfonate 15 GM/60ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,46287000660,NDC,60,ML,123.3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,52.8957,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gentamicin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,60758018805,NDC,5,ML,107.98,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,52.9102,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
gentamicin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,60758018805,NDC,5,ML,107.98,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,52.9102,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
gentamicin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,60758018805,NDC,5,ML,107.98,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,52.9102,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,68462015740,NDC,1,EA,110.25,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,52.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,68462015740,NDC,1,EA,110.25,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,52.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,68462015713,NDC,1,EA,110.25,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,52.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,68462015713,NDC,1,EA,110.25,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,52.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
Capillary Blood Collection,PX36416,CDM,300,RC,36416,CPT,,,,,,,,60,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,52.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,58.8
Erythropietin - Ref,PX8266890,CDM,300,RC,82668,CPT,90,,,,,,,108,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,52.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,105.84
Erythropietin - Ref,PX8266890,CDM,300,RC,82668,CPT,90,,,,,,,108,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,52.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,105.84
Erythropietin - Ref,PX8266890,CDM,300,RC,82668,CPT,90,,,,,,,108,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,52.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,105.84
HERNIA BELT MENS TRUSS LARGE,120.526,CDM,274,RC,L8310,HCPCS,,12221-MAIN,LOCAL,,,,,60,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,52.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,160.6
HERNIA BELT MENS TRUSS MEDIUM,120.526,CDM,274,RC,L8310,HCPCS,,12220-MAIN,LOCAL,,,,,60,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,52.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,160.6
HERNIA BELT MENS TRUSS XLARGE,120.526,CDM,274,RC,L8310,HCPCS,,12222-MAIN,LOCAL,,,,,60,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,52.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,160.6
"IMMOBILIZER KNEE  24"" 7041-44",120.22,CDM,274,RC,L1830,HCPCS,,595-MAIN,LOCAL,,,,,60,,United Healthcare,All Payer,outpatient,88.2,,56.4,percent of total billed charges,52.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE 16"" UNIVERSAL 7088-04",120.22,CDM,274,RC,L1830,HCPCS,,589-MAIN,LOCAL,,,,,60,,United Healthcare,All Payer,outpatient,88.2,,56.4,percent of total billed charges,52.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
IMMOBILIZER KNEE 20 INCH ORT2420019,120.22,CDM,274,RC,L1830,HCPCS,,587-MAIN,LOCAL,,,,,60,,United Healthcare,All Payer,outpatient,88.2,,56.4,percent of total billed charges,52.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE 20"" LARGE FOAM COUNTOURED STAYS 7062-03",120.22,CDM,274,RC,L1830,HCPCS,,593-MAIN,LOCAL,,,,,60,,United Healthcare,All Payer,outpatient,88.2,,56.4,percent of total billed charges,52.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE 20"" QUICK-WRAP ORT2440020S",120.22,CDM,274,RC,L1830,HCPCS,,591-MAIN,LOCAL,,,,,60,,United Healthcare,All Payer,outpatient,88.2,,56.4,percent of total billed charges,52.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
IMMOBILIZER KNEE CUTAWAY STRAIGHT 2 7041-05,120.22,CDM,274,RC,L1830,HCPCS,,596-MAIN,LOCAL,,,,,60,,United Healthcare,All Payer,outpatient,88.2,,56.4,percent of total billed charges,52.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
Levetiracetam - Ref,PX8017790,CDM,300,RC,80177,CPT,90,,,,,,,108,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,52.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,105.84
Levetiracetam - Ref,PX8017790,CDM,300,RC,80177,CPT,90,,,,,,,108,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,52.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,105.84
Levetiracetam - Ref,PX8017790,CDM,300,RC,80177,CPT,90,,,,,,,108,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,52.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,105.84
Oxcarbazepine - Ref,PX8018390,CDM,300,RC,80183,CPT,90,,,,,,,108,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,52.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,105.84
Oxcarbazepine - Ref,PX8018390,CDM,300,RC,80183,CPT,90,,,,,,,108,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,52.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,105.84
Oxcarbazepine - Ref,PX8018390,CDM,300,RC,80183,CPT,90,,,,,,,108,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,52.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,105.84
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405F,CDM,510,RC,36405,CPT,,,,,,,,54,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,52.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.4316,52.92
hydrocortisone 25 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,713050306,NDC,1,EA,108.03,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,52.9347,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 25 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,713050306,NDC,1,EA,108.03,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,52.9347,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 25 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,713050306,NDC,1,EA,108.03,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,52.9347,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 25 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713050312,NDC,1,EA,108.03,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,52.9347,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 25 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713050312,NDC,1,EA,108.03,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,52.9347,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 25 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713050312,NDC,1,EA,108.03,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,52.9347,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,24208091055,NDC,3.5,GR,106.98,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,52.9551,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
empagliflozin 10 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,597015237,NDC,1,EA,104.66,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,52.95796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
3.0MM NON-THREADED K WIRE,27200000,CDM,272,RC,C1769,HCPCS,,12658-MAIN,LOCAL,,,,,107,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,52.965,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Androsetenedione - Ref,PX8215790,CDM,300,RC,82157,CPT,90,,,,,,,107,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,52.965,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.85,104.86
Decalcify Tc,PX8831101,CDM,310,RC,88311,CPT,TC,,,,,,,107,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,52.965,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
Fac/Trim Nail(S),PX11719F,CDM,510,RC,11719,CPT,,,,,,,,107,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,52.965,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
Path Special Stains II,PX3979,CDM,310,RC,88313,CPT,TC,,,,,,,107,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,52.965,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
"Special Stains,Group I",PX3978,CDM,310,RC,88312,CPT,TC,,,,,,,107,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,52.965,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
"Chemotherapy, IV Push, Additional Drug",PX96411,CDM,335,RC,96411,CPT,,,,,,,,87,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,52.965,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.77,94.82
"Biopsy Vulva/Perineum,One Lesn",PX56605F,CDM,510,RC,56605,CPT,,,,,,,,236,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,52.9815,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.99,201.31
"Biopsy Vulva/Perineum,One Lesn",PX56605P,CDM,983,RC,56605,CPT,,,,,,,,142,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,52.9815,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.99,201.31
"Ileoscopy Thru Stoma,Diagnostic",PX44380F,CDM,750,RC,44380,CPT,,,,,,,,245,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,52.9815,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.12,408.85
"Ileoscopy Thru Stoma,Diagnostic",PX44380P,CDM,983,RC,44380,CPT,,,,,,,,455,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,52.9815,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.12,445.9
LAPAROTOMY MAJOR I,27200000,CDM,272,RC,,,,4828-MAIN,LOCAL,,,,,123.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,52.9815,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
acyclovir 50 MG/ML Solution 10 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,55150015410,NDC,10,ML,108.16,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,52.9984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.927644,105.9968
acyclovir 50 MG/ML Solution 10 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,55150015410,NDC,10,ML,108.16,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,52.9984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.927644,105.9968
acyclovir 50 MG/ML Solution 10 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,55150015410,NDC,10,ML,108.16,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,52.9984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.927644,105.9968
"Needle Biopsy, Lymph Node(S)",PX38505F,CDM,510,RC,38505,CPT,,,,,,,,667,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,53,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53,360.43
"Needle Biopsy, Lymph Node(S)",PX38505F,CDM,510,RC,38505,CPT,,,,,,,,667,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,53,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53,360.43
US Pelvic Tc Complete,PX7685601,CDM,402,RC,76856,CPT,TC,,,,,,,472,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,53.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.65,144.63
US Pelvic Tc Complete,PX7685601,CDM,402,RC,76856,CPT,TC,,,,,,,472,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,53.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.65,144.63
budesonide 0.5 MG/2ML Suspension 2 mL Ampule,25000000,CDM,250,RC,,,,,,68180098405,NDC,2,ML,62.38,,First Health,Commercial,both,85,,999999999,percent of total billed charges,53.023,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,781751614,NDC,2,ML,62.38,,First Health,Commercial,both,85,,999999999,percent of total billed charges,53.023,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,781751687,NDC,2,ML,62.38,,First Health,Commercial,both,85,,999999999,percent of total billed charges,53.023,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097031986,NDC,2,ML,62.38,,First Health,Commercial,both,85,,999999999,percent of total billed charges,53.023,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
OLANZapine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60505311000,NDC,1,EA,60.13,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,53.03466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001104,NDC,1,EA,108.29,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,53.0621,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001104,NDC,1,EA,108.29,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,53.0621,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001104,NDC,1,EA,108.29,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,53.0621,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
albumin human 25% 25 % Solution 50 mL Flex Cont,P9047,CDM,636,RC,P9047,HCPCS,,,,944049301,NDC,50,ML,402.67,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,53.08,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.16,53.08
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001103,NDC,1,EA,108.34,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,53.0866,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001103,NDC,1,EA,108.34,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,53.0866,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001103,NDC,1,EA,108.34,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,53.0866,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615900,NDC,1,EA,123.75,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,53.08875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615904,NDC,1,EA,123.75,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,53.08875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
Tc99 Mebrofenin to 15 Mci,PXA9537,CDM,343,RC,A9537,HCPCS,,,,,,,,495,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,53.1,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.73,58.5494
Tc99 Mebrofenin to 15 Mci,PXA9537,CDM,343,RC,A9537,HCPCS,,,,,,,,495,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,53.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.73,58.5494
Tc99 Mebrofenin to 15 Mci,PXA9537,CDM,343,RC,A9537,HCPCS,,,,,,,,495,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,53.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.73,58.5494
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,641601501,NDC,25,ML,58.29,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,53.10219,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,70655000206,NDC,100,ML,59.67,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,53.1063,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.786918,140.5516
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457000110,NDC,10,ML,59.67,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,53.1063,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013266,NDC,50,ML,59.67,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,53.1063,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013268,NDC,150,ML,59.67,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,53.1063,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
Dx Occult Blood Immunoassay,PX82274,CDM,300,RC,82274,CPT,,,,,,,,105,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,53.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.6,102.9
Specimen Concentration - Ref,PX8701590,CDM,300,RC,87015,CPT,90,,,,,,,105,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,53.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.12,102.9
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,17478007035,NDC,3.5,GR,105.01,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,53.13506,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046417,NDC,10,ML,54.6,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.296682081,percent of total billed charges,53.14218,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
belimumab (400v) 400 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010201,NDC,1,EA,3523.71,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,53.14484,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.37,53.14484
belimumab 120 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010101,NDC,1,EA,1015.95,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,53.14484,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.37,53.14484
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046204,NDC,30,ML,127.94,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,53.146276,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117630,NDC,1,ML,58.34,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,53.14774,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
Canalith Repositioning,PX95992,CDM,420,RC,95992,CPT,,,,,,,,128,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,53.1712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.86,125.44
Heparin Xa,PX85520,CDM,300,RC,85520,CPT,,,,,,,,128,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,53.1712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12,125.44
Lab Pth Immunoch Part 1,PX83970,CDM,300,RC,83970,CPT,,,,,,,,128,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,53.1712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.85,125.44
"N Block Inj, Common Digit",PX64632P,CDM,983,RC,64632,CPT,,,,,,,,128,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,53.1712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.1712,258.75
PACLitaxel 30 MG/5ML Concentrate 5 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476401,NDC,5,ML,58.37,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,53.17507,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
Assay of Lithium,PX80178,CDM,300,RC,80178,CPT,,,,,,,,124,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,53.196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.06,121.52
"Complement; Antigen, Each Component",PX86160,CDM,300,RC,86160,CPT,,,,,,,,124,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,53.196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11,121.52
"Immunoassay,Ca15-3(27.29) - Ref",PX8630090,CDM,300,RC,86300,CPT,90,,,,,,,124,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,53.196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,121.52
Itraconazole,PX8018990,CDM,300,RC,80189,CPT,90,,,,,,,124,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,53.196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.86,121.52
Microbe Susceptible Mic,PX87186,CDM,300,RC,87186,CPT,,,,,,,,124,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,53.196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.93,121.52
Nocardia Susceptibility - Ref,PX8718690,CDM,300,RC,87186,CPT,90,,,,,,,124,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,53.196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.93,121.52
Oligoclonal Bands - Ref,PX8391690,CDM,300,RC,83916,CPT,90,,,,,,,124,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,53.196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.11,121.52
UMBILICAL VESSEL CATHETER INSERTION TRAY POLY SINGLE LUMEN 3.5/5FR,120.573,CDM,272,RC,,,,12857-MAIN,LOCAL,,,,,124,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,53.196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.5096,121.52
"Cytogen, Interp/Report - Ref",PX8829190,CDM,310,RC,88291,CPT,90,,,,,,,2874,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,53.2,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.68,53.2
"Cytogen, Interp/Report - Ref",PX8829190,CDM,310,RC,88291,CPT,90,,,,,,,2874,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,53.2,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.68,53.2
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409492120,NDC,10,ML,54.66,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,229.0777778,percent of total billed charges,53.200578,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
sacubitril-valsartan 24-26 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,78065920,NDC,1,EA,62.6,,First Health,Commercial,both,85,,999999999,percent of total billed charges,53.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Exc Skin Benig <5mm Remaindr Body,PX11420P,CDM,983,RC,11420,CPT,,,,,,,,299,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,53.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.35,293.02
Exc Skin Benig <5mm Remaindr Body,PX11420P,CDM,983,RC,11420,CPT,,,,,,,,299,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,53.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.35,293.02
Fac/Exc Skin Benig<5mm Remaind Bod,PX11420F,CDM,510,RC,11420,CPT,,,,,,,,374,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,53.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.35,264.27
Fac/Exc Skin Benig<5mm Remaind Bod,PX11420F,CDM,510,RC,11420,CPT,,,,,,,,374,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,53.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.35,264.27
"Spinal Punc,Drain,Theraputic",PX62272F,CDM,510,RC,62272,CPT,,,,,,,,450,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,53.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.79,384.64
"Spinal Punc,Drain,Theraputic",PX62272F,CDM,510,RC,62272,CPT,,,,,,,,450,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,53.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.79,384.64
"Spinal Punc,Drain,Theraputic",PX62272P,CDM,983,RC,62272,CPT,,,,,,,,300,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,53.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.79,384.64
"Spinal Punc,Drain,Theraputic",PX62272P,CDM,983,RC,62272,CPT,,,,,,,,300,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,53.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.79,384.64
"Needle Biopsy, Lymph Node(S)",PX38505F,CDM,510,RC,38505,CPT,,,,,,,,667,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,53.22,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53,360.43
X-Ray Exam Femur Min 2 Vws,PX7355201,CDM,320,RC,73552,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,53.25,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.66,53.25
X-Ray Exam Femur Min 2 Vws,PX7355201,CDM,320,RC,73552,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,53.25,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.66,53.25
Xray Orbits Optic Foramina,PX7019001,CDM,320,RC,70190,CPT,TC,,,,,,,66,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,53.25,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.66,53.25
Xray Orbits Optic Foramina,PX7019001,CDM,320,RC,70190,CPT,TC,,,,,,,66,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,53.25,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.66,53.25
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,143950801,NDC,10,ML,58.46,,Medica,Commercial,both,91.1,,7.37,percent of total billed charges,53.25706,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
BUPivacaine 0.25 % Solution 50 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046557,NDC,30,ML,59.84,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,53.2576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329330101,NDC,50,ML,107.61,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,53.26695,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Needle Insertion W/O Injection 1 or 2 Muscles,PX20560,CDM,420,RC,20560,CPT,,,,,,,,10,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,53.27,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.8073,53.27
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714020010,NDC,1,EA,107.64,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,53.2818,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714020030,NDC,1,EA,107.64,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,53.2818,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028401,NDC,1,EA,111.01,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,53.2848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028401,NDC,1,EA,111.01,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,53.2848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028420,NDC,1,EA,111.01,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,53.2848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028420,NDC,1,EA,111.01,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,53.2848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,143950810,NDC,10,ML,58.51,,Medica,Commercial,both,91.1,,7.37,percent of total billed charges,53.30261,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
Sacubitril-Valsartan 49-51 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,78077720,NDC,1,EA,58.51,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,53.30261,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093102,NDC,1,ML,60.47,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,53.33454,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060820,NDC,20,ML,58.57,,Medica,Commercial,both,91.1,,0.687108295,percent of total billed charges,53.35727,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
"sodium chloride 0.45 % 1,000 mL with potassium chloride 20 mEq 20-0.45 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070434,NDC,1000,ML,58.57,,Medica,Commercial,both,91.1,,1.111818182,percent of total billed charges,53.35727,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,63323047401,NDC,1,ML,58.6,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,53.3846,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.428
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076501,NDC,1,EA,58.6,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,53.3846,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076510,NDC,1,EA,58.6,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,53.3846,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
Capillary Blood Collection,PX36416,CDM,300,RC,36416,CPT,,,,,,,,60,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,53.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,58.8
HERNIA BELT MENS TRUSS LARGE,120.526,CDM,274,RC,L8310,HCPCS,,12221-MAIN,LOCAL,,,,,60,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,53.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,160.6
HERNIA BELT MENS TRUSS MEDIUM,120.526,CDM,274,RC,L8310,HCPCS,,12220-MAIN,LOCAL,,,,,60,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,53.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,160.6
HERNIA BELT MENS TRUSS XLARGE,120.526,CDM,274,RC,L8310,HCPCS,,12222-MAIN,LOCAL,,,,,60,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,53.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,160.6
"IMMOBILIZER KNEE  24"" 7041-44",120.22,CDM,274,RC,L1830,HCPCS,,595-MAIN,LOCAL,,,,,60,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,53.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE 16"" UNIVERSAL 7088-04",120.22,CDM,274,RC,L1830,HCPCS,,589-MAIN,LOCAL,,,,,60,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,53.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
IMMOBILIZER KNEE 20 INCH ORT2420019,120.22,CDM,274,RC,L1830,HCPCS,,587-MAIN,LOCAL,,,,,60,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,53.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE 20"" LARGE FOAM COUNTOURED STAYS 7062-03",120.22,CDM,274,RC,L1830,HCPCS,,593-MAIN,LOCAL,,,,,60,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,53.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE 20"" QUICK-WRAP ORT2440020S",120.22,CDM,274,RC,L1830,HCPCS,,591-MAIN,LOCAL,,,,,60,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,53.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
IMMOBILIZER KNEE CUTAWAY STRAIGHT 2 7041-05,120.22,CDM,274,RC,L1830,HCPCS,,596-MAIN,LOCAL,,,,,60,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,53.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"RBC Sed Rate, Auto",PX85652,CDM,300,RC,85652,CPT,,,,,,,,109,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,77.25,percent of total billed charges,53.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.48,106.82
"RBC Sed Rate, Auto",PX85652,CDM,300,RC,85652,CPT,,,,,,,,109,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,53.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.48,106.82
"RBC Sed Rate, Auto",PX85652,CDM,300,RC,85652,CPT,,,,,,,,109,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,53.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.48,106.82
Smear Gram Stain,PX87205,CDM,300,RC,87205,CPT,,,,,,,,109,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,53.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,106.82
Smear Gram Stain,PX87205,CDM,300,RC,87205,CPT,,,,,,,,109,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,53.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,106.82
Smear Gram Stain,PX87205,CDM,300,RC,87205,CPT,,,,,,,,109,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,53.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,106.82
Smear Wet Mount Saline/Ink,PX87210,CDM,300,RC,87210,CPT,,,,,,,,109,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,53.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.34,106.82
Smear Wet Mount Saline/Ink,PX87210,CDM,300,RC,87210,CPT,,,,,,,,109,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,53.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.34,106.82
Smear Wet Mount Saline/Ink,PX87210,CDM,300,RC,87210,CPT,,,,,,,,109,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,53.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.34,106.82
"West Nile Ab, Igm - Ref",PX8678890,CDM,300,RC,86788,CPT,90,,,,,,,109,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,53.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.45,106.82
"West Nile Ab, Igm - Ref",PX8678890,CDM,300,RC,86788,CPT,90,,,,,,,109,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,53.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.45,106.82
"West Nile Ab, Igm - Ref",PX8678890,CDM,300,RC,86788,CPT,90,,,,,,,109,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,53.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.45,106.82
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086000,NDC,1,EA,58.66,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,53.43926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086050,NDC,1,EA,58.66,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,53.43926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012166,NDC,1,EA,58.66,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,53.43926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
cefOXitin 1 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021010910,NDC,1,EA,58.66,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,53.43926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.367364,75.6952
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,65219025915,NDC,1,EA,58.66,,Medica,Commercial,both,91.1,,5.442333333,percent of total billed charges,53.43926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
"Debridement of Nail(S), 1-5",PX11720F,CDM,510,RC,11720,CPT,,,,,,,,89,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,53.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.9706,87.22
Dystrophic Nail Trimming Any Number,PXG0127F,CDM,940,RC,G0127,HCPCS,,,,,,,,53,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,53.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.0162,53.44
"Ecg 12 Lead, Tracing Only",PX93005,CDM,730,RC,93005,CPT,,,,,,,,298,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,53.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.44,292.04
"Fac/Debridement of Nails, 6 or Mor",PX11721F,CDM,510,RC,11721,CPT,,,,,,,,95,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,53.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.463,93.1
Fac/Trim Nail(S),PX11719F,CDM,510,RC,11719,CPT,,,,,,,,107,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,53.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
Irri Implted Drug Dlvr Device,PX96523,CDM,260,RC,96523,CPT,,,,,,,,119,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,53.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,116.62
Lab Direct Coombs,PX86880,CDM,300,RC,86880,CPT,,,,,,,,76,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,53.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.5704,74.48
Path Special Stains II,PX3979,CDM,310,RC,88313,CPT,TC,,,,,,,107,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,53.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
RBC Pretreatment,PX8697002,CDM,300,RC,86970,CPT,,,,,,,,117,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,53.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.6018,114.66
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209F,CDM,510,RC,69209,CPT,,,,,,,,35,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,53.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,53.44
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209P,CDM,982,RC,69209,CPT,,,,,,,,113,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,53.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9402,109.9829
Remove Impacted Ear Wax,PX69210F,CDM,510,RC,69210,CPT,,,,,,,,213,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,53.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.44,208.74
Remove Impacted Ear Wax,PX69210P,CDM,983,RC,69210,CPT,,,,,,,,221,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,53.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.44,215.0993
Strapping of Elbow or Wrist,PX29260F,CDM,420,RC,29260,CPT,,,,,,,,64,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,53.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.5856,62.72
Strapping of Hand or Finger,PX29280F,CDM,420,RC,29280,CPT,,,,,,,,64,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,53.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.5856,62.72
Strapping of Toes,PX29550F,CDM,510,RC,29550,CPT,,,,,,,,113,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,53.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9402,110.74
"Trimming of Dystrophic Nails, Any Number",PXG0127P,CDM,983,RC,G0127,HCPCS,,,,,,,,35,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,53.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,53.44
US Urine Capacity Measure,PX51798F,CDM,510,RC,51798,CPT,,,,,,,,96,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,53.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.8784,94.08
gentamicin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,60758018805,NDC,5,ML,107.98,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,53.4501,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Erythropietin - Ref,PX8266890,CDM,300,RC,82668,CPT,90,,,,,,,108,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,53.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,105.84
Levetiracetam - Ref,PX8017790,CDM,300,RC,80177,CPT,90,,,,,,,108,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,53.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,105.84
Oxcarbazepine - Ref,PX8018390,CDM,300,RC,80183,CPT,90,,,,,,,108,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,53.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,105.84
hydrocortisone 25 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,713050306,NDC,1,EA,108.03,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,53.47485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 25 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713050312,NDC,1,EA,108.03,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,53.47485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LAP SPONGES 18x18 7INCH LOOP,27200000,CDM,272,RC,,,,604-MAIN,LOCAL,,,,,60.64,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,53.48448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ezetimibe 10 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,16729043316,NDC,1,EA,60.66,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,53.50212,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 100 MG/5ML Suspension 118 mL Bottle,63700001,CDM,250,RC,,,,,,45802089726,NDC,118,ML,54.97,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,53.502301,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,43598020453,NDC,10,ML,58.73,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,53.50303,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,72508020415,NDC,10,ML,58.73,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,53.50303,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046417,NDC,10,ML,54.6,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,53.508,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
OLANZapine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60505311000,NDC,1,EA,60.13,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,53.5157,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lopinavir-ritonavir 200-50 MG Tablet 120 Each Bottle,63700001,CDM,250,RC,,,,,,74679922,NDC,1,EA,54.99,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,53.521767,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,517460125,NDC,0.5,ML,58.76,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,53.53036,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
Endocrine E2,PX82670,CDM,300,RC,82670,CPT,90,,,,,,,55,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,53.5315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,53.9
"Immunofluo Direct, Ea Ab - Ref",PX8834690,CDM,310,RC,88346,CPT,90,,,,,,,55,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,53.5315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,149.22
Lipoprotein (a) - Ref,PX8369590,CDM,300,RC,83695,CPT,90,,,,,,,55,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,53.5315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.13,53.9
MEPILEX BORDER AG POST OP 4X10,120.368,CDM,272,RC,A6212,HCPCS,,10839-MAIN,LOCAL,,,,,55,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,53.5315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,53.9
SURGIFOAM ABSORBABLE GELATIN SPONGE 3.1 IN X 4.9IN X 10MM,120.371,CDM,272,RC,A4649,HCPCS,,10864-MAIN,LOCAL,,,,,55,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,53.5315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,53.9
dexmedeTOMIDine 200 MCG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,143953201,NDC,2,ML,62.98,,First Health,Commercial,both,85,,999999999,percent of total billed charges,53.533,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329335201,NDC,50,ML,109.26,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,53.5374,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329335201,NDC,50,ML,109.26,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,53.5374,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329335201,NDC,50,ML,109.26,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,53.5374,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
acyclovir 50 MG/ML Solution 10 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,55150015410,NDC,10,ML,108.16,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,53.5392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.927644,105.9968
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003905,NDC,1,EA,58.77,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,53.53947,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
K-WIRE SMOOTH 1.4MM X 100MM,C1713,CDM,272,RC,C1713,HCPCS,,12634-MAIN,LOCAL,,,,,63,,First Health,Commercial,both,85,,999999999,percent of total billed charges,53.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
SUTURE MAXON MONOFILAMENT ABSORBABLE GREEN SIZE 1 96IN WITH 1/2 CIRCLE TAPER POINT 65MM NEEDLE,27200000,CDM,272,RC,,,,11986-MAIN,LOCAL,,,,,63,,First Health,Commercial,both,85,,999999999,percent of total billed charges,53.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Vitamin a - Ref,PX8459090,CDM,300,RC,84590,CPT,90,,,,,,,63,,First Health,Commercial,both,85,,999999999,percent of total billed charges,53.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.65,61.74
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714078401,NDC,0.4,EA,60.72,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,53.55504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047625,NDC,0.769230769,ML,111.59,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,53.5632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.354486,332.1514
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047625,NDC,0.769230769,ML,111.59,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,53.5632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.354486,332.1514
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409492120,NDC,10,ML,54.66,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,53.5668,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
Complete Cbc Automated,PX85027,CDM,300,RC,85027,CPT,,,,,,,,129,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,53.5866,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,126.42
"Venipunc Need Phys Skill,Dx or Rx",PX36410P,CDM,983,RC,36410,CPT,,,,,,,,129,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,53.5866,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.5866,125.5557
SUMAtriptan 25 MG Tablet 9 Each Box,63700001,CDM,250,RC,,,,,,65862014636,NDC,1,EA,129.04,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,53.603216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001104,NDC,1,EA,108.29,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,53.60355,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611F,CDM,510,RC,20611,CPT,,,,,,,,456,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,53.6237,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.21,206.85
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611P,CDM,983,RC,20611,CPT,,,,,,,,272,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,53.6237,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.21,266.56
Cmv Igm Antibody - Ref,PX8664590,CDM,300,RC,86645,CPT,90,,,,,,,125,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,53.625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.45,122.5
DRESSING SURGICEL HEMOSTAT 4X8 ABSORBABLE 1952,120.123,CDM,272,RC,A6252,HCPCS,,1002-MAIN,LOCAL,,,,,125,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,53.625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.925,122.5
Factor VII - Ref,PX8523090,CDM,300,RC,85230,CPT,90,,,,,,,125,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,53.625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.41,122.5
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001103,NDC,1,EA,108.34,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,53.6283,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,17478062512,NDC,2.5,ML,109.45,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,53.6305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,17478062512,NDC,2.5,ML,109.45,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,53.6305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,17478062512,NDC,2.5,ML,109.45,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,53.6305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
GLIDESCOPE QC MILLER S0 SINGLE USE 0270-1087,120.58,CDM,272,RC,,,,13024-MAIN,LOCAL,,,,,106,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,53.636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
GLIDESCOPE QC MILLER S1 SINGLE USE 0270-1088,120.58,CDM,272,RC,,,,13025-MAIN,LOCAL,,,,,106,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,53.636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
KUMAR CHOLANGIOGRAPHY CATHETER,27200000,CDM,272,RC,,,,10230-MAIN,LOCAL,,,,,63.11,,First Health,Commercial,both,85,,999999999,percent of total billed charges,53.6435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
cefTRIAXone in dextrose 1 g / 50 mL 1-3.74 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0696.01,CDM,636,RC,J0696,HCPCS,,,,264315311,NDC,1,EA,106.03,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,53.65118,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
Aaa US Screen Tc,PX7670601,CDM,402,RC,76706,CPT,TC,,,,,,,554,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,53.66,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.66,159.75
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034001,NDC,1,EA,111.81,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,53.6688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034001,NDC,1,EA,111.81,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,53.6688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
hydrocortisone 2.5 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,45802000403,NDC,28,GR,60.85,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,53.6697,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034000,NDC,1,EA,111.82,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,53.6736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034000,NDC,1,EA,111.82,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,53.6736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117603,NDC,1,ML,58.93,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,53.68523,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
ketamine 100 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,55150044001,NDC,10,ML,111.85,,Health Partners,Health Partners Care Plans,both,48,,31.91277778,percent of total billed charges,53.688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
ketamine 100 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,55150044001,NDC,10,ML,111.85,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,53.688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
scopolamine 1 MG/3DAYS Patch 72 Hour 24 Each Box,25000000,CDM,250,RC,,,,,,50742050524,NDC,1,EA,109.59,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,53.6991,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
scopolamine 1 MG/3DAYS Patch 72 Hour 24 Each Box,25000000,CDM,250,RC,,,,,,50742050524,NDC,1,EA,109.59,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,53.6991,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
scopolamine 1 MG/3DAYS Patch 72 Hour 24 Each Box,25000000,CDM,250,RC,,,,,,50742050524,NDC,1,EA,109.59,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,53.6991,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 5 % Patch 30 Each Box,63700001,CDM,250,RC,,,,,,603188016,NDC,1,EA,55.18,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,53.706694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 5 % Patch 1 Each Box,63700001,CDM,250,RC,,,,,,603188010,NDC,1,EA,55.2,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,53.72616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sucralfate 1 GM/10ML Suspension 10 mL Cup,63700001,CDM,250,RC,,,,,,68094004359,NDC,10,ML,60.92,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,53.73144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003930,NDC,1,EA,58.99,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,53.73989,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
DRAWTEX HYDROCONDUCTIVE NONADHERENT DRESSING,120.508,CDM,271,RC,A6199,HCPCS,,12022-MAIN,LOCAL,,,,,59,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,53.749,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.5086,57.82
"Potassium; Serum, Plasma or Whole Blood",PX84132,CDM,300,RC,84132,CPT,,,,,,,,59,,Medica,Commercial,both,91.1,,4.695,percent of total billed charges,53.749,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.36,57.82
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338411450,NDC,50,ML,106.23,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,53.75238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
ELECTRODE PEDS ONESTEP SINGLE,120.343,CDM,272,RC,A4556,HCPCS,,10296-MAIN,LOCAL,,,,,112,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,53.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
ELECTRODE PEDS ONESTEP SINGLE,120.343,CDM,272,RC,A4556,HCPCS,,10296-MAIN,LOCAL,,,,,112,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,53.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
EYE IRRIGATION SYSTEM MT2000,120.318,CDM,272,RC,,,,8718-MAIN,LOCAL,,,,,112,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,53.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
EYE IRRIGATION SYSTEM MT2000,120.318,CDM,272,RC,,,,8718-MAIN,LOCAL,,,,,112,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,53.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
F5 Gene - Ref,PX8124190,CDM,300,RC,81241,CPT,90,,,,,,,112,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,53.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
F5 Gene - Ref,PX8124190,CDM,300,RC,81241,CPT,90,,,,,,,112,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,53.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
Immunofluorescence per Spec Add Singl Antb Stain - Ref,PX8835090,CDM,310,RC,88350,CPT,90,,,,,,,112,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,53.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
Immunofluorescence per Spec Add Singl Antb Stain - Ref,PX8835090,CDM,310,RC,88350,CPT,90,,,,,,,112,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,53.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
Osmolality; Urine,PX83935,CDM,300,RC,83935,CPT,,,,,,,,112,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,53.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.25,109.76
Osmolality; Urine,PX83935,CDM,300,RC,83935,CPT,,,,,,,,112,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,53.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.25,109.76
Prolactin,PX84146,CDM,300,RC,84146,CPT,,,,,,,,112,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,53.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.77,109.76
Prolactin,PX84146,CDM,300,RC,84146,CPT,,,,,,,,112,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,53.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.77,109.76
Quantitation Drug Nos - Ref,PX8029990,CDM,300,RC,80299,CPT,90,,,,,,,112,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,53.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.09,109.76
Quantitation Drug Nos - Ref,PX8029990,CDM,300,RC,80299,CPT,90,,,,,,,112,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,53.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.09,109.76
TUBE AIRSPIRAL BREATHING AND CHAMBER 900PT561,120.493,CDM,271,RC,A4604,HCPCS,,11618-MAIN,LOCAL,,,,,112,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,53.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
TUBE AIRSPIRAL BREATHING AND CHAMBER 900PT561,120.493,CDM,271,RC,A4604,HCPCS,,11618-MAIN,LOCAL,,,,,112,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,53.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
verapamil 2.5 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,51754020401,NDC,1,ML,112.01,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,53.7648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
verapamil 2.5 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,51754020401,NDC,1,ML,112.01,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,53.7648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,45802011222,NDC,22,GR,63.29,,First Health,Commercial,both,85,,999999999,percent of total billed charges,53.7965,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Protoporphyrin, RBC, Qnt - Ref",PX8420290,CDM,300,RC,84202,CPT,90,,,,,,,61,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,53.802,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.16,59.78
"Venipuncture, Lab",PX3641502,CDM,300,RC,36415,CPT,,,,,,,,61,,United Healthcare,All Payer,outpatient,88.2,,34.11894737,percent of total billed charges,53.802,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.1,65.45
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,781523806,NDC,1,EA,106.34,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,53.80804,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,781523864,NDC,1,EA,106.34,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,53.80804,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,65862039010,NDC,1,EA,106.34,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,53.80804,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093102,NDC,1,ML,60.47,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,53.8183,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048657,NDC,50,ML,61.05,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,53.8461,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pregabalin 25 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,71101268,NDC,1,EA,55.33,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,53.852689,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ibuprofen 100 MG/5ML Suspension 118 mL Bottle,63700001,CDM,250,RC,,,,,,45802089726,NDC,118,ML,54.97,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,53.8706,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Aspirate Pleura W/O Imaging,PX32554F,CDM,510,RC,32554,CPT,,,,,,,,795,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,53.88,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.88,484.95
Aspirate Pleura W/O Imaging,PX32554F,CDM,510,RC,32554,CPT,,,,,,,,795,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,53.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.88,484.95
Aspirate Pleura W/O Imaging,PX32554F,CDM,510,RC,32554,CPT,,,,,,,,795,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,53.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.88,484.95
"Destruct Benign Lesion, 15+",PX17111F,CDM,510,RC,17111,CPT,,,,,,,,303,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,53.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.35,277.41
"Destruct Benign Lesion, 15+",PX17111F,CDM,510,RC,17111,CPT,,,,,,,,303,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,53.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.35,277.41
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320885,NDC,0.5,EA,129.71,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,53.881534,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320895,NDC,0.5,EA,129.71,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,53.881534,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,143950601,NDC,10,ML,61.1,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,53.8902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,143950610,NDC,10,ML,61.1,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,53.8902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lopinavir-ritonavir 200-50 MG Tablet 120 Each Bottle,63700001,CDM,250,RC,,,,,,74679922,NDC,1,EA,54.99,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,53.8902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Acylcarnitines, Quant - Ref",PX8201790,CDM,300,RC,82017,CPT,90,,,,,,,110,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,53.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.47,107.8
"Acylcarnitines, Quant - Ref",PX8201790,CDM,300,RC,82017,CPT,90,,,,,,,110,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,53.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.47,107.8
"Acylcarnitines, Quant - Ref",PX8201790,CDM,300,RC,82017,CPT,90,,,,,,,110,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,53.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.47,107.8
"Assay Calcium, Ionized",PX82330,CDM,300,RC,82330,CPT,,,,,,,,110,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,53.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.54,107.8
"Assay Calcium, Ionized",PX82330,CDM,300,RC,82330,CPT,,,,,,,,110,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,53.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.54,107.8
"Assay Calcium, Ionized",PX82330,CDM,300,RC,82330,CPT,,,,,,,,110,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,53.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.54,107.8
BONE MARROW BIOPSY ASPIRATION NEEDLE 11G X 4 IN,120.562,CDM,272,RC,C1830,HCPCS,,12677-MAIN,LOCAL,,,,,110,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,53.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.694,107.8
BONE MARROW BIOPSY ASPIRATION NEEDLE 11G X 4 IN,120.562,CDM,272,RC,C1830,HCPCS,,12677-MAIN,LOCAL,,,,,110,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,53.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.694,107.8
BONE MARROW BIOPSY ASPIRATION NEEDLE 11G X 4 IN,120.562,CDM,272,RC,C1830,HCPCS,,12677-MAIN,LOCAL,,,,,110,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,53.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.694,107.8
Endocrine E2,PX82670,CDM,300,RC,82670,CPT,90,,,,,,,55,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,53.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,53.9
Glycosylated Hemoglobin Test,PX83036,CDM,300,RC,83036,CPT,,,,,,,,110,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,9.456,percent of total billed charges,53.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.9,130.9
Glycosylated Hemoglobin Test,PX83036,CDM,300,RC,83036,CPT,,,,,,,,110,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,53.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.9,130.9
Glycosylated Hemoglobin Test,PX83036,CDM,300,RC,83036,CPT,,,,,,,,110,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,53.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.9,130.9
"Immunofluo Direct, Ea Ab - Ref",PX8834690,CDM,310,RC,88346,CPT,90,,,,,,,55,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,53.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,149.22
K-WIRE 0.9X150MM BLUNT/TROCAR DART-FIRE STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12449-MAIN,LOCAL,,,,,110,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,53.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRE 0.9X150MM BLUNT/TROCAR DART-FIRE STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12449-MAIN,LOCAL,,,,,110,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,53.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRE 0.9X150MM BLUNT/TROCAR DART-FIRE STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12449-MAIN,LOCAL,,,,,110,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,53.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRE 0.9X150MM BLUNT/TROCAR STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12452-MAIN,LOCAL,,,,,110,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,53.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRE 0.9X150MM BLUNT/TROCAR STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12452-MAIN,LOCAL,,,,,110,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,53.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRE 0.9X150MM BLUNT/TROCAR STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12452-MAIN,LOCAL,,,,,110,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,53.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRE 1.4X150MM BLUNT/TROCAR DART-FIRE STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12450-MAIN,LOCAL,,,,,110,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,53.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRE 1.4X150MM BLUNT/TROCAR DART-FIRE STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12450-MAIN,LOCAL,,,,,110,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,53.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRE 1.4X150MM BLUNT/TROCAR DART-FIRE STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12450-MAIN,LOCAL,,,,,110,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,53.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRE 1.4X150MM BLUNT/TROCAR STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12451-MAIN,LOCAL,,,,,110,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,53.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRE 1.4X150MM BLUNT/TROCAR STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12451-MAIN,LOCAL,,,,,110,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,53.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRE 1.4X150MM BLUNT/TROCAR STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12451-MAIN,LOCAL,,,,,110,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,53.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Lipoprotein (a) - Ref,PX8369590,CDM,300,RC,83695,CPT,90,,,,,,,55,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,53.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.13,53.9
MEPILEX BORDER AG POST OP 4X10,120.368,CDM,272,RC,A6212,HCPCS,,10839-MAIN,LOCAL,,,,,55,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,53.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,53.9
MICA 2.0MM TARGETING GUIDE PIN,27200000,CDM,272,RC,,,,12436-MAIN,LOCAL,,,,,110,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,53.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA 2.0MM TARGETING GUIDE PIN,27200000,CDM,272,RC,,,,12436-MAIN,LOCAL,,,,,110,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,53.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA 2.0MM TARGETING GUIDE PIN,27200000,CDM,272,RC,,,,12436-MAIN,LOCAL,,,,,110,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,53.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Strapping of Shoulder,PX29240P,CDM,983,RC,29240,CPT,,,,,,,,110,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,53.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.694,111.6
Strapping of Shoulder,PX29240P,CDM,983,RC,29240,CPT,,,,,,,,110,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,53.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.694,111.6
Strapping of Shoulder,PX29240P,CDM,983,RC,29240,CPT,,,,,,,,110,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,53.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.694,111.6
SURGIFOAM ABSORBABLE GELATIN SPONGE 3.1 IN X 4.9IN X 10MM,120.371,CDM,272,RC,A4649,HCPCS,,10864-MAIN,LOCAL,,,,,55,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,53.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,53.9
Xray Sinuses Minimum 3 Vws,PX7022001,CDM,320,RC,70220,CPT,TC,,,,,,,354,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,53.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.88,53.91
Xray Sinuses Minimum 3 Vws,PX7022001,CDM,320,RC,70220,CPT,TC,,,,,,,354,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,53.91,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.88,53.91
Xray Skull Less Than 4 Vws,PX7025001,CDM,320,RC,70250,CPT,TC,,,,,,,311,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,53.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.88,53.91
Xray Skull Less Than 4 Vws,PX7025001,CDM,320,RC,70250,CPT,TC,,,,,,,311,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,53.91,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.88,53.91
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608210,NDC,1,ML,63.43,,First Health,Commercial,both,85,,999999999,percent of total billed charges,53.9155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
fentaNYL 50 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,406905076,NDC,1,EA,125.74,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,53.94246,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
triamcinolone acetonide 0.1 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,16714098602,NDC,30,GR,59.22,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,53.94942,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ocrelizumab 300 MG/10ML Solution 10 mL Vial,J2350.01,CDM,636,RC,J2350,HCPCS,,,,50242015001,NDC,10,ML,33150,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,53.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.48,59.75
ocrelizumab 300 MG/10ML Solution 10 mL Vial,J2350.01,CDM,636,RC,J2350,HCPCS,,,,50242015001,NDC,10,ML,33150,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,53.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.48,59.75
"RBC Sed Rate, Auto",PX85652,CDM,300,RC,85652,CPT,,,,,,,,109,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,53.955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.48,106.82
Smear Gram Stain,PX87205,CDM,300,RC,87205,CPT,,,,,,,,109,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,53.955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,106.82
Smear Wet Mount Saline/Ink,PX87210,CDM,300,RC,87210,CPT,,,,,,,,109,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,53.955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.34,106.82
"West Nile Ab, Igm - Ref",PX8678890,CDM,300,RC,86788,CPT,90,,,,,,,109,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,53.955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.45,106.82
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030926,NDC,1,EA,55.44,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,13.11107143,percent of total billed charges,53.959752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
Apply of Paste Boot,PX29580F,CDM,510,RC,29580,CPT,,,,,,,,132,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,53.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,132.83
Apply of Paste Boot,PX29580P,CDM,983,RC,29580,CPT,,,,,,,,88,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,53.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,132.83
DAPTOmycin 500 MG Recon Soln 1 Each Vial,J0878.01,CDM,636,RC,J0878,HCPCS,,,,70594003402,NDC,1,EA,129.9,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,53.96046,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.96046,127.302
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305972,NDC,2,ML,61.19,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,53.96958,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305995,NDC,2,ML,61.19,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,53.96958,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
LAP SPONGES 18x18 7INCH LOOP,27200000,CDM,272,RC,,,,604-MAIN,LOCAL,,,,,60.64,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,53.9696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623100,NDC,1,EA,59.25,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,53.97675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
DERMABOND MINI SKIN ADHESIVE,27200000,CDM,272,RC,,,,8532-MAIN,LOCAL,,,,,110.16,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,53.9784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DERMABOND MINI SKIN ADHESIVE,27200000,CDM,272,RC,,,,8532-MAIN,LOCAL,,,,,110.16,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,53.9784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DERMABOND MINI SKIN ADHESIVE,27200000,CDM,272,RC,,,,8532-MAIN,LOCAL,,,,,110.16,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,53.9784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ezetimibe 10 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,16729043316,NDC,1,EA,60.66,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,53.9874,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623105,NDC,1,EA,59.27,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,53.99497,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
Chemo Ad Sq/Im Hormnl Anti-Neo,PX96402,CDM,335,RC,96402,CPT,,,,,,,,130,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,54.002,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,127.4
Cystatin C - Ref,PX8261090,CDM,300,RC,82610,CPT,90,,,,,,,130,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,54.002,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.98,127.4
Each Add'l Sequential Push New Drug,PX96375,CDM,260,RC,96375,CPT,,,,,,,,130,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,54.002,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,127.4
Immunization Administration; One Vaccine (Single or Combination Vaccine/To*,PX90471,CDM,771,RC,90471,CPT,,,,,,,,130,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,54.002,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,127.4
Prothrombin Time (Pt/Inr),PX85610,CDM,300,RC,85610,CPT,,,,,,,,130,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,54.002,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.93,127.4
SPLINT WRIST LARGE ALUMINUM FOREARM LEFT 9101-06,120.87,CDM,274,RC,L3809,HCPCS,,1265-MAIN,LOCAL,,,,,130,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,54.002,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST LARGE ALUMINUM FOREARM RIGHT 9101-03,120.87,CDM,274,RC,L3809,HCPCS,,1263-MAIN,LOCAL,,,,,130,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,54.002,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST MEDIUM ALUMINUM FOREARM LEFT 9101-05,120.87,CDM,274,RC,L3809,HCPCS,,1264-MAIN,LOCAL,,,,,130,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,54.002,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST MEDIUM ALUMINUM FOREARM RIGHT 9101-02,120.87,CDM,274,RC,L3809,HCPCS,,1262-MAIN,LOCAL,,,,,130,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,54.002,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
Vitamin B-1 - Ref,PX8442590,CDM,300,RC,84425,CPT,90,,,,,,,130,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,54.002,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.47,127.4
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052331,NDC,2,ML,125.89,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,54.00681,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.294706,123.3722
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052341,NDC,2,ML,125.89,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,54.00681,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.294706,123.3722
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,17478053802,NDC,2,ML,125.91,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,54.01539,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.068162,123.3918
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,68462015740,NDC,1,EA,110.25,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,54.0225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,68462015740,NDC,1,EA,110.25,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,54.0225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,68462015740,NDC,1,EA,110.25,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,54.0225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,68462015713,NDC,1,EA,110.25,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,54.0225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,68462015713,NDC,1,EA,110.25,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,54.0225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,68462015713,NDC,1,EA,110.25,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,54.0225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43598055530,NDC,0.4,EA,61.26,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,54.03132,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43598096630,NDC,0.4,EA,61.26,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,54.03132,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714078401,NDC,0.4,EA,60.72,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,54.0408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"polyethylene glycol 236 g Recon Soln 4,000 mL Bottle",63700001,CDM,250,RC,,,,,,43386009019,NDC,4000,ML,112.6,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,54.048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"polyethylene glycol 236 g Recon Soln 4,000 mL Bottle",63700001,CDM,250,RC,,,,,,43386009019,NDC,4000,ML,112.6,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,54.048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Thrombin Time Plasma,PX85670,CDM,300,RC,85670,CPT,,,,,,,,126,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,54.054,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.29,123.48
tropicamide 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,24208058559,NDC,2,ML,61.3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,54.0666,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 5 % Patch 30 Each Box,63700001,CDM,250,RC,,,,,,603188016,NDC,1,EA,55.18,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,54.0764,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329335201,NDC,50,ML,109.26,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,54.0837,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010602,NDC,50,ML,126.07,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,54.08403,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010605,NDC,50,ML,126.07,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,54.08403,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
nitroglycerin in dextrose 5% 100-5 MCG/ML-% Solution 250 mL Glass Cont,J2305.01,CDM,636,RC,J2305,HCPCS,,,,338104702,NDC,250,ML,126.07,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,54.08403,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.17,123.5486
Aaa US Screen Tc,PX7670601,CDM,402,RC,76706,CPT,TC,,,,,,,554,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,54.09,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.66,159.75
Aaa US Screen Tc,PX7670601,CDM,402,RC,76706,CPT,TC,,,,,,,554,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,54.09,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.66,159.75
lidocaine 5 % Patch 1 Each Box,63700001,CDM,250,RC,,,,,,603188010,NDC,1,EA,55.2,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,54.096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,24208091055,NDC,3.5,GR,106.98,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,54.13188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
3.0MM NON-THREADED K WIRE,27200000,CDM,272,RC,C1769,HCPCS,,12658-MAIN,LOCAL,,,,,107,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,54.142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Androsetenedione - Ref,PX8215790,CDM,300,RC,82157,CPT,90,,,,,,,107,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,54.142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.85,104.86
Decalcify Tc,PX8831101,CDM,310,RC,88311,CPT,TC,,,,,,,107,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,54.142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
Fac/Trim Nail(S),PX11719F,CDM,510,RC,11719,CPT,,,,,,,,107,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,54.142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
Path Special Stains II,PX3979,CDM,310,RC,88313,CPT,TC,,,,,,,107,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,54.142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
"Special Stains,Group I",PX3978,CDM,310,RC,88312,CPT,TC,,,,,,,107,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,54.142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
triamcinolone acetonide 0.1 % Cream 454 g Jar,63700001,CDM,250,RC,,,,,,45802006405,NDC,454,GR,130.36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,54.151544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 2.5 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,45802000403,NDC,28,GR,60.85,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,54.1565,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,17478062512,NDC,2.5,ML,109.45,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,54.17775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sucralfate 1 GM/10ML Suspension 10 mL Cup,63700001,CDM,250,RC,,,,,,68094004359,NDC,10,ML,60.92,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,54.2188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pregabalin 25 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,71101268,NDC,1,EA,55.33,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,54.2234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Iadna Streptococcus Group a Amplified Probe Tq,PX87651,CDM,300,RC,87651,CPT,,,,,,,,113,,Health Partners,Health Partners Care Plans,both,48,,109.61,percent of total billed charges,54.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,110.74
Iadna Streptococcus Group a Amplified Probe Tq,PX87651,CDM,300,RC,87651,CPT,,,,,,,,113,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,54.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,110.74
Strapping of Toes,PX29550F,CDM,510,RC,29550,CPT,,,,,,,,113,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,54.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9402,110.74
Strapping of Toes,PX29550F,CDM,510,RC,29550,CPT,,,,,,,,113,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,54.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9402,110.74
Xray Spine Single Tc,PX7202001,CDM,320,RC,72020,CPT,TC,,,,,,,113,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,54.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9402,110.74
Xray Spine Single Tc,PX7202001,CDM,320,RC,72020,CPT,TC,,,,,,,113,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,54.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9402,110.74
scopolamine 1 MG/3DAYS Patch 72 Hour 24 Each Box,25000000,CDM,250,RC,,,,,,50742050524,NDC,1,EA,109.59,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,54.24705,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,43598040516,NDC,0.2,ML,63.83,,First Health,Commercial,both,85,,999999999,percent of total billed charges,54.2555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
apixaban 2.5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,3089321,NDC,1,EA,63.84,,First Health,Commercial,both,85,,999999999,percent of total billed charges,54.264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Protoporphyrin, RBC, Qnt - Ref",PX8420290,CDM,300,RC,84202,CPT,90,,,,,,,61,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,54.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.16,59.78
"Venipuncture, Lab",PX3641502,CDM,300,RC,36415,CPT,,,,,,,,61,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,54.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.1,65.45
LIGACLIP APPLIER CLIP STERILE SIZE MEDIUM LARGE,27200000,CDM,272,RC,,,,11699-MAIN,LOCAL,,,,,126.62,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,54.31998,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Alkaloids, Not Otherwise Specified - Ref",PX8032390,CDM,300,RC,80323,CPT,90,,,,,,,65,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,54.32,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.32,54.32
dexmedeTOMIDine 200 MCG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,70860060541,NDC,2,ML,55.82,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,54.329606,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 4-5 MG/ML-% Solution 500 mL Flex Cont,J2001.01,CDM,636,RC,J2001,HCPCS,,,,338040903,NDC,500,ML,55.82,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,54.329606,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030926,NDC,1,EA,55.44,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,54.3312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157F,CDM,370,RC,99157,CPT,,,,,,,,270,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,54.3335,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.86,102.38
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157P,CDM,983,RC,99157,CPT,,,,,,,,270,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,54.3335,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.86,264.6
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048657,NDC,50,ML,61.05,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,54.3345,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,70655000206,NDC,100,ML,59.67,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,54.35937,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.786918,140.5516
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457000110,NDC,10,ML,59.67,,Medica,Commercial,both,91.1,,7.37,percent of total billed charges,54.35937,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013266,NDC,50,ML,59.67,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,54.35937,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013268,NDC,150,ML,59.67,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,54.35937,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,143950601,NDC,10,ML,61.1,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,54.379,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,143950610,NDC,10,ML,61.1,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,54.379,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
X-Ray Exam Entire Spine 2-3 Vws,PX7208201,CDM,320,RC,72082,CPT,TC,,,,,,,454,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,54.3842,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.64,109.13
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028401,NDC,1,EA,111.01,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,12.3175,percent of total billed charges,54.3949,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028401,NDC,1,EA,111.01,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,54.3949,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028401,NDC,1,EA,111.01,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,54.3949,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028420,NDC,1,EA,111.01,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,12.3175,percent of total billed charges,54.3949,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028420,NDC,1,EA,111.01,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,54.3949,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028420,NDC,1,EA,111.01,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,54.3949,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
Blood Occult Peroxidase,PX82272,CDM,300,RC,82272,CPT,,,,,,,,64,,First Health,Commercial,both,85,,999999999,percent of total billed charges,54.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.88,62.72
Strapping of Elbow or Wrist,PX29260F,CDM,420,RC,29260,CPT,,,,,,,,64,,First Health,Commercial,both,85,,999999999,percent of total billed charges,54.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.5856,62.72
Strapping of Hand or Finger,PX29280F,CDM,420,RC,29280,CPT,,,,,,,,64,,First Health,Commercial,both,85,,999999999,percent of total billed charges,54.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.5856,62.72
Noninvasv Oxygen Satur;Single,PX94760,CDM,460,RC,94760,CPT,,,,,,,,131,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,54.4174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.4174,128.38
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,69315030615,NDC,15,GR,131.07,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,54.446478,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Acylcarnitines, Quant - Ref",PX8201790,CDM,300,RC,82017,CPT,90,,,,,,,110,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,54.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.47,107.8
"Assay Calcium, Ionized",PX82330,CDM,300,RC,82330,CPT,,,,,,,,110,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,54.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.54,107.8
BONE MARROW BIOPSY ASPIRATION NEEDLE 11G X 4 IN,120.562,CDM,272,RC,C1830,HCPCS,,12677-MAIN,LOCAL,,,,,110,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,54.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.694,107.8
Glycosylated Hemoglobin Test,PX83036,CDM,300,RC,83036,CPT,,,,,,,,110,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,54.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.9,130.9
K-WIRE 0.9X150MM BLUNT/TROCAR DART-FIRE STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12449-MAIN,LOCAL,,,,,110,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,54.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRE 0.9X150MM BLUNT/TROCAR STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12452-MAIN,LOCAL,,,,,110,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,54.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRE 1.4X150MM BLUNT/TROCAR DART-FIRE STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12450-MAIN,LOCAL,,,,,110,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,54.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRE 1.4X150MM BLUNT/TROCAR STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12451-MAIN,LOCAL,,,,,110,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,54.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA 2.0MM TARGETING GUIDE PIN,27200000,CDM,272,RC,,,,12436-MAIN,LOCAL,,,,,110,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,54.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Strapping of Shoulder,PX29240P,CDM,983,RC,29240,CPT,,,,,,,,110,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,54.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.694,111.6
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329330101,NDC,50,ML,107.61,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,54.45066,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305972,NDC,2,ML,61.19,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,54.4591,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305995,NDC,2,ML,61.19,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,54.4591,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714020010,NDC,1,EA,107.64,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,54.46584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714020030,NDC,1,EA,107.64,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,54.46584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990711509,NDC,1000,ML,64.08,,First Health,Commercial,both,85,,999999999,percent of total billed charges,54.468,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
B-Scan Global,PX7651201,CDM,402,RC,76512,CPT,TC,,,,,,,127,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,54.483,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.7558,124.46
Candida Dna Dir Probe,PX87480,CDM,300,RC,87480,CPT,,,,,,,,127,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,54.483,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.38,124.46
Gardner Vag Dna Dir Probe,PX87510,CDM,300,RC,87510,CPT,,,,,,,,127,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,54.483,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.38,124.46
Influenza Assay W/Optic,PX87804,CDM,300,RC,87804,CPT,,,,,,,,127,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,54.483,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.17,124.46
Trichomonas Vagin Dir Probe,PX87660,CDM,300,RC,87660,CPT,,,,,,,,127,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,54.483,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.38,124.46
8MM-12MM BLADELESS OBTURATOR 8MM,27200000,CDM,272,RC,,,,11919-MAIN,LOCAL,,,,,56,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,54.5048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM-12MM BLADELESS OBTURATOR 8MM LONG,27200000,CDM,272,RC,,,,11920-MAIN,LOCAL,,,,,56,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,54.5048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"B Cells, Total Count",PX86355,CDM,300,RC,86355,CPT,,,,,,,,56,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,54.5048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.2624,54.88
Citrate - Ref,PX8250790,CDM,300,RC,82507,CPT,90,,,,,,,56,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,54.5048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.2624,54.88
"Folic Acid (Folate), Serum",PX82746,CDM,300,RC,82746,CPT,,,,,,,,56,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,54.5048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.48,54.88
Lab Platelet Count,PX85049,CDM,300,RC,85049,CPT,,,,,,,,56,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,54.5048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.11,54.88
Mycophenolate Mycophenolicacid - Ref,PX8018090,CDM,300,RC,80180,CPT,90,,,,,,,56,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,54.5048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.55,54.88
Progesterone,PX84144,CDM,300,RC,84144,CPT,,,,,,,,56,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,23.75,percent of total billed charges,54.5048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.13,54.88
BUPivacaine 0.25 % Solution 50 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046557,NDC,30,ML,59.84,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,54.51424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43598055530,NDC,0.4,EA,61.26,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,54.5214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43598096630,NDC,0.4,EA,61.26,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,54.5214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DERMABOND MINI SKIN ADHESIVE,27200000,CDM,272,RC,,,,8532-MAIN,LOCAL,,,,,110.16,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,54.5292,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
rosuvastatin 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,310075430,NDC,1,EA,56.04,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,54.543732,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tropicamide 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,24208058559,NDC,2,ML,61.3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,54.557,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,68462015740,NDC,1,EA,110.25,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,54.57375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,68462015713,NDC,1,EA,110.25,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,54.57375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
amiodarone 900 MG/18ML Solution 18 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,67457015318,NDC,18,ML,113.73,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,54.5904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
amiodarone 900 MG/18ML Solution 18 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,67457015318,NDC,18,ML,113.73,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,54.5904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004725,NDC,2,ML,131.52,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,54.633408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
gentamicin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,60758018805,NDC,5,ML,107.98,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,54.63788,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Erythropietin - Ref,PX8266890,CDM,300,RC,82668,CPT,90,,,,,,,108,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,54.648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,105.84
Levetiracetam - Ref,PX8017790,CDM,300,RC,80177,CPT,90,,,,,,,108,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,54.648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,105.84
Oxcarbazepine - Ref,PX8018390,CDM,300,RC,80183,CPT,90,,,,,,,108,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,54.648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,105.84
Apply Multlay Comprs Lwr Leg,PX29581F,CDM,510,RC,29581,CPT,,,,,,,,213,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,54.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.01,182.64
Apply Multlay Comprs Lwr Leg,PX29581P,CDM,983,RC,29581,CPT,,,,,,,,142,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,54.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.01,182.64
Capillary Blood Collection,PX36416,CDM,300,RC,36416,CPT,,,,,,,,60,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,54.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,58.8
HERNIA BELT MENS TRUSS LARGE,120.526,CDM,274,RC,L8310,HCPCS,,12221-MAIN,LOCAL,,,,,60,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,54.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,160.6
HERNIA BELT MENS TRUSS MEDIUM,120.526,CDM,274,RC,L8310,HCPCS,,12220-MAIN,LOCAL,,,,,60,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,54.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,160.6
HERNIA BELT MENS TRUSS XLARGE,120.526,CDM,274,RC,L8310,HCPCS,,12222-MAIN,LOCAL,,,,,60,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,54.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,160.6
"IMMOBILIZER KNEE  24"" 7041-44",120.22,CDM,274,RC,L1830,HCPCS,,595-MAIN,LOCAL,,,,,60,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,54.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE 16"" UNIVERSAL 7088-04",120.22,CDM,274,RC,L1830,HCPCS,,589-MAIN,LOCAL,,,,,60,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,54.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
IMMOBILIZER KNEE 20 INCH ORT2420019,120.22,CDM,274,RC,L1830,HCPCS,,587-MAIN,LOCAL,,,,,60,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,54.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE 20"" LARGE FOAM COUNTOURED STAYS 7062-03",120.22,CDM,274,RC,L1830,HCPCS,,593-MAIN,LOCAL,,,,,60,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,54.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE 20"" QUICK-WRAP ORT2440020S",120.22,CDM,274,RC,L1830,HCPCS,,591-MAIN,LOCAL,,,,,60,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,54.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
IMMOBILIZER KNEE CUTAWAY STRAIGHT 2 7041-05,120.22,CDM,274,RC,L1830,HCPCS,,596-MAIN,LOCAL,,,,,60,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,54.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
hydrocortisone 25 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,713050306,NDC,1,EA,108.03,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,54.66318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 25 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713050312,NDC,1,EA,108.03,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,54.66318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 2.5 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,168008031,NDC,30,GR,61.99,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,54.67518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047625,NDC,0.769230769,ML,111.59,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,54.6791,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.354486,332.1514
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047625,NDC,0.769230769,ML,111.59,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,54.6791,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.354486,332.1514
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047625,NDC,0.769230769,ML,111.59,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,54.6791,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.354486,332.1514
dexmedeTOMIDine 200 MCG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,70860060541,NDC,2,ML,55.82,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,54.7036,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 4-5 MG/ML-% Solution 500 mL Flex Cont,J2001.01,CDM,636,RC,J2001,HCPCS,,,,338040903,NDC,500,ML,55.82,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,54.7036,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
Assay of Erythropoietin,PX82668,CDM,300,RC,82668,CPT,,,,,,,,114,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,54.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,111.72
Assay of Erythropoietin,PX82668,CDM,300,RC,82668,CPT,,,,,,,,114,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,54.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,111.72
acyclovir 50 MG/ML Solution 10 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,55150015410,NDC,10,ML,108.16,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,54.72896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.927644,105.9968
OLANZapine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60505311000,NDC,1,EA,60.13,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,54.77843,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034001,NDC,1,EA,111.81,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,12.3175,percent of total billed charges,54.7869,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034001,NDC,1,EA,111.81,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,54.7869,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034001,NDC,1,EA,111.81,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,54.7869,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034000,NDC,1,EA,111.82,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,12.3175,percent of total billed charges,54.7918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034000,NDC,1,EA,111.82,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,54.7918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034000,NDC,1,EA,111.82,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,54.7918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001104,NDC,1,EA,108.29,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,54.79474,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
ketamine 100 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,55150044001,NDC,10,ML,111.85,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,12.9192,percent of total billed charges,54.8065,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
ketamine 100 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,55150044001,NDC,10,ML,111.85,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,54.8065,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
ketamine 100 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,55150044001,NDC,10,ML,111.85,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,54.8065,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001103,NDC,1,EA,108.34,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,54.82004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
Apply of Paste Boot,PX29580F,CDM,510,RC,29580,CPT,,,,,,,,132,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,54.8328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,137.65
Assay Dipropylacetic Acid,PX80164,CDM,300,RC,80164,CPT,,,,,,,,132,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,54.8328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.41,129.36
Assay of Lipase,PX83690,CDM,300,RC,83690,CPT,,,,,,,,132,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,54.8328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.32,129.36
"Remv F.B.,Eye,Superf Conjunc",PX65205F,CDM,510,RC,65205,CPT,,,,,,,,132,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,54.8328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,129.36
"Remv F.B.,Eye,Superf Conjunc",PX65205P,CDM,983,RC,65205,CPT,,,,,,,,132,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,54.8328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,128.4756
"Venipunc Need Phys Skill,Dx or Rx",PX36410,CDM,983,RC,36410,CPT,,,,,,,,132,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,54.8328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,128.4756
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,16714001905,NDC,2,ML,62.17,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,54.83394,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,16714001930,NDC,2,ML,62.17,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,54.83394,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,63323004401,NDC,1,ML,64.53,,First Health,Commercial,both,85,,999999999,percent of total billed charges,54.8505,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,63.2394
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141035,NDC,2,ML,56.37,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,54.864921,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,65219044501,NDC,10,ML,56.37,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,54.864921,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,65219044510,NDC,10,ML,56.37,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,54.864921,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
8MM-12MM BLADELESS OBTURATOR 8MM,27200000,CDM,272,RC,,,,11919-MAIN,LOCAL,,,,,56,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,54.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM-12MM BLADELESS OBTURATOR 8MM LONG,27200000,CDM,272,RC,,,,11920-MAIN,LOCAL,,,,,56,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,54.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"B Cells, Total Count",PX86355,CDM,300,RC,86355,CPT,,,,,,,,56,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,54.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.2624,54.88
Citrate - Ref,PX8250790,CDM,300,RC,82507,CPT,90,,,,,,,56,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,54.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.2624,54.88
ELECTRODE PEDS ONESTEP SINGLE,120.343,CDM,272,RC,A4556,HCPCS,,10296-MAIN,LOCAL,,,,,112,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,54.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
ELECTRODE PEDS ONESTEP SINGLE,120.343,CDM,272,RC,A4556,HCPCS,,10296-MAIN,LOCAL,,,,,112,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,54.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
ELECTRODE PEDS ONESTEP SINGLE,120.343,CDM,272,RC,A4556,HCPCS,,10296-MAIN,LOCAL,,,,,112,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,54.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
EYE IRRIGATION SYSTEM MT2000,120.318,CDM,272,RC,,,,8718-MAIN,LOCAL,,,,,112,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,54.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
EYE IRRIGATION SYSTEM MT2000,120.318,CDM,272,RC,,,,8718-MAIN,LOCAL,,,,,112,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,54.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
EYE IRRIGATION SYSTEM MT2000,120.318,CDM,272,RC,,,,8718-MAIN,LOCAL,,,,,112,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,54.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
F5 Gene - Ref,PX8124190,CDM,300,RC,81241,CPT,90,,,,,,,112,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,54.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
F5 Gene - Ref,PX8124190,CDM,300,RC,81241,CPT,90,,,,,,,112,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,54.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
F5 Gene - Ref,PX8124190,CDM,300,RC,81241,CPT,90,,,,,,,112,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,54.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
"Folic Acid (Folate), Serum",PX82746,CDM,300,RC,82746,CPT,,,,,,,,56,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,54.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.48,54.88
Immunofluorescence per Spec Add Singl Antb Stain - Ref,PX8835090,CDM,310,RC,88350,CPT,90,,,,,,,112,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,54.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
Immunofluorescence per Spec Add Singl Antb Stain - Ref,PX8835090,CDM,310,RC,88350,CPT,90,,,,,,,112,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,54.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
Immunofluorescence per Spec Add Singl Antb Stain - Ref,PX8835090,CDM,310,RC,88350,CPT,90,,,,,,,112,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,54.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
Lab Platelet Count,PX85049,CDM,300,RC,85049,CPT,,,,,,,,56,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,54.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.11,54.88
Mycophenolate Mycophenolicacid - Ref,PX8018090,CDM,300,RC,80180,CPT,90,,,,,,,56,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,54.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.55,54.88
Osmolality; Urine,PX83935,CDM,300,RC,83935,CPT,,,,,,,,112,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,54.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.25,109.76
Osmolality; Urine,PX83935,CDM,300,RC,83935,CPT,,,,,,,,112,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,54.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.25,109.76
Osmolality; Urine,PX83935,CDM,300,RC,83935,CPT,,,,,,,,112,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,54.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.25,109.76
Progesterone,PX84144,CDM,300,RC,84144,CPT,,,,,,,,56,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,54.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.13,54.88
Prolactin,PX84146,CDM,300,RC,84146,CPT,,,,,,,,112,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,54.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.77,109.76
Prolactin,PX84146,CDM,300,RC,84146,CPT,,,,,,,,112,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,54.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.77,109.76
Prolactin,PX84146,CDM,300,RC,84146,CPT,,,,,,,,112,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,54.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.77,109.76
Quantitation Drug Nos - Ref,PX8029990,CDM,300,RC,80299,CPT,90,,,,,,,112,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,54.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.09,109.76
Quantitation Drug Nos - Ref,PX8029990,CDM,300,RC,80299,CPT,90,,,,,,,112,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,54.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.09,109.76
Quantitation Drug Nos - Ref,PX8029990,CDM,300,RC,80299,CPT,90,,,,,,,112,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,54.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.09,109.76
TUBE AIRSPIRAL BREATHING AND CHAMBER 900PT561,120.493,CDM,271,RC,A4604,HCPCS,,11618-MAIN,LOCAL,,,,,112,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,54.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
TUBE AIRSPIRAL BREATHING AND CHAMBER 900PT561,120.493,CDM,271,RC,A4604,HCPCS,,11618-MAIN,LOCAL,,,,,112,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,54.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
TUBE AIRSPIRAL BREATHING AND CHAMBER 900PT561,120.493,CDM,271,RC,A4604,HCPCS,,11618-MAIN,LOCAL,,,,,112,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,54.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
verapamil 2.5 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,51754020401,NDC,1,ML,112.01,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,54.8849,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
verapamil 2.5 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,51754020401,NDC,1,ML,112.01,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,54.8849,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
verapamil 2.5 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,51754020401,NDC,1,ML,112.01,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,54.8849,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046204,NDC,30,ML,127.94,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,54.88626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Prosthetic Training, Initial, Each 15 Mins",PX97761,CDM,420,RC,97761,CPT,,,,,,,,121,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,54.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.05,54.91
"Prosthetic Training, Initial, Each 15 Mins",PX97761,CDM,420,RC,97761,CPT,,,,,,,,121,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,54.91,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.05,54.91
Canalith Repositioning,PX95992,CDM,420,RC,95992,CPT,,,,,,,,128,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,54.912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.86,125.44
Heparin Xa,PX85520,CDM,300,RC,85520,CPT,,,,,,,,128,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,54.912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12,125.44
Lab Pth Immunoch Part 1,PX83970,CDM,300,RC,83970,CPT,,,,,,,,128,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,54.912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.85,125.44
"N Block Inj, Common Digit",PX64632P,CDM,983,RC,64632,CPT,,,,,,,,128,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,54.912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.1712,258.75
rosuvastatin 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,310075430,NDC,1,EA,56.04,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,54.9192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
TRAY HAND SURGICAL II DYNJS0806,27200000,CDM,272,RC,,,,11024-MAIN,LOCAL,,,,,64.62,,First Health,Commercial,both,85,,999999999,percent of total billed charges,54.927,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
levoFLOXacin in dextrose 5% 500 MG/100ML Solution 100 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004724,NDC,100,ML,64.63,,First Health,Commercial,both,85,,999999999,percent of total billed charges,54.9355,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,76329339001,NDC,5,ML,64.63,,First Health,Commercial,both,85,,999999999,percent of total billed charges,54.9355,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
naloxone 2 MG/2ML solution prefilled syringe 2 mL Syringe,J2310.01,CDM,636,RC,J2310,HCPCS,,,,76329346901,NDC,1,ML,114.45,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,54.936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.54253,130.4968
naloxone 2 MG/2ML solution prefilled syringe 2 mL Syringe,J2310.01,CDM,636,RC,J2310,HCPCS,,,,76329346901,NDC,1,ML,114.45,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,54.936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.54253,130.4968
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028401,NDC,1,EA,111.01,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,54.94995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028420,NDC,1,EA,111.01,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,54.94995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
levonorgestrel 1.5 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,62756071860,NDC,1,EA,114.48,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,54.9504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levonorgestrel 1.5 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,62756071860,NDC,1,EA,114.48,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,54.9504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Hosp Manage Cont Drug Admin,PX01996.01,CDM,964,RC,1996,CPT,QZ,,,,,,,36,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,54.96,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.69,107.06
Hosp Manage Cont Drug Admin,PX01996.01,CDM,964,RC,1996,CPT,QZ,,,,,,,36,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,54.96,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.69,107.06
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042350,NDC,0.5,ML,132.37,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,54.986498,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.49,129.7226
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042388,NDC,0.5,ML,132.37,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,54.986498,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.49,129.7226
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,990771512,NDC,62.5,ML,56.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,11.07921788,percent of total billed charges,54.99145,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.4701,303.0944
budesonide 0.5 MG/2ML Suspension 2 mL Ampule,25000000,CDM,250,RC,,,,,,68180098405,NDC,2,ML,62.38,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,55.01916,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,781751614,NDC,2,ML,62.38,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,55.01916,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,781751687,NDC,2,ML,62.38,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,55.01916,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097031986,NDC,2,ML,62.38,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,55.01916,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323042605,NDC,5,ML,64.8,,First Health,Commercial,both,85,,999999999,percent of total billed charges,55.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium phosphate 15 MMOLE/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323088401,NDC,5,ML,132.6,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,55.08204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium phosphate 15 MMOLE/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323088406,NDC,5,ML,132.6,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,55.08204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093102,NDC,1,ML,60.47,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,55.08817,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323042405,NDC,5,ML,64.82,,First Health,Commercial,both,85,,999999999,percent of total billed charges,55.097,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
calcium CHLORIDE 10 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409163140,NDC,10,ML,64.85,,First Health,Commercial,both,85,,999999999,percent of total billed charges,55.1225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"RBC Sed Rate, Auto",PX85652,CDM,300,RC,85652,CPT,,,,,,,,109,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,55.154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.48,106.82
Smear Gram Stain,PX87205,CDM,300,RC,87205,CPT,,,,,,,,109,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,55.154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,106.82
Smear Wet Mount Saline/Ink,PX87210,CDM,300,RC,87210,CPT,,,,,,,,109,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,55.154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.34,106.82
"West Nile Ab, Igm - Ref",PX8678890,CDM,300,RC,86788,CPT,90,,,,,,,109,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,55.154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.45,106.82
hydrocortisone 2.5 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,168008031,NDC,30,GR,61.99,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,55.1711,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"polyethylene glycol 236 g Recon Soln 4,000 mL Bottle",63700001,CDM,250,RC,,,,,,43386009019,NDC,4000,ML,112.6,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,55.174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"polyethylene glycol 236 g Recon Soln 4,000 mL Bottle",63700001,CDM,250,RC,,,,,,43386009019,NDC,4000,ML,112.6,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,55.174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"polyethylene glycol 236 g Recon Soln 4,000 mL Bottle",63700001,CDM,250,RC,,,,,,43386009019,NDC,4000,ML,112.6,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,55.174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270004,NDC,100,ML,2827.78,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,55.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270010,NDC,100,ML,3458.14,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,55.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 10 GM/100ML Solution 100 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270005,NDC,100,ML,2827.78,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,55.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270006,NDC,100,ML,2912.78,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,55.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270012,NDC,100,ML,3293.58,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,55.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270007,NDC,100,ML,2827.78,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,55.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270013,NDC,100,ML,2827.78,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,55.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
Assay of Triglycerides,PX84478,CDM,300,RC,84478,CPT,,,,,,,,115,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,55.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.26,112.7
Assay of Triglycerides,PX84478,CDM,300,RC,84478,CPT,,,,,,,,115,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,55.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.26,112.7
"Blood Typing, Rh Phenotype",PX86906,CDM,300,RC,86906,CPT,,,,,,,,115,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,55.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.03,112.7
"Blood Typing, Rh Phenotype",PX86906,CDM,300,RC,86906,CPT,,,,,,,,115,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,55.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.03,112.7
BRACE ANKLE LARGE 264015,120.51,CDM,274,RC,L1902,HCPCS,,4-MAIN,LOCAL,,,,,115,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,55.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE LARGE 264015,120.51,CDM,274,RC,L1902,HCPCS,,4-MAIN,LOCAL,,,,,115,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,55.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE MEDIUM 264014,120.51,CDM,274,RC,L1902,HCPCS,,7-MAIN,LOCAL,,,,,115,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,55.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE MEDIUM 264014,120.51,CDM,274,RC,L1902,HCPCS,,7-MAIN,LOCAL,,,,,115,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,55.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE SMALL 264012,120.51,CDM,274,RC,L1902,HCPCS,,12-MAIN,LOCAL,,,,,115,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,55.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE SMALL 264012,120.51,CDM,274,RC,L1902,HCPCS,,12-MAIN,LOCAL,,,,,115,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,55.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE X-LARGE 264016,120.51,CDM,274,RC,L1902,HCPCS,,14-MAIN,LOCAL,,,,,115,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,55.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE X-LARGE 264016,120.51,CDM,274,RC,L1902,HCPCS,,14-MAIN,LOCAL,,,,,115,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,55.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE X-SMALL 264011,120.51,CDM,274,RC,L1902,HCPCS,,1-MAIN,LOCAL,,,,,115,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,55.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE X-SMALL 264011,120.51,CDM,274,RC,L1902,HCPCS,,1-MAIN,LOCAL,,,,,115,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,55.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
Debride Skin/Subq Ea Ad 20sqcm,PX11045F,CDM,510,RC,11045,CPT,,,,,,,,115,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,55.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
Debride Skin/Subq Ea Ad 20sqcm,PX11045F,CDM,510,RC,11045,CPT,,,,,,,,115,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,55.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
Glucagon - Ref,PX8294390,CDM,300,RC,82943,CPT,90,,,,,,,115,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,55.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.1,112.7
Glucagon - Ref,PX8294390,CDM,300,RC,82943,CPT,90,,,,,,,115,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,55.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.1,112.7
"Immuno for Tumor Ag, Qn - Ref",PX8631690,CDM,300,RC,86316,CPT,90,,,,,,,115,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,55.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,112.7
"Immuno for Tumor Ag, Qn - Ref",PX8631690,CDM,300,RC,86316,CPT,90,,,,,,,115,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,55.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,112.7
Microsomal Antibody,PX7893,CDM,300,RC,86376,CPT,,,,,,,,115,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,55.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.34,112.7
Microsomal Antibody,PX7893,CDM,300,RC,86376,CPT,,,,,,,,115,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,55.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.34,112.7
sacubitril-valsartan 24-26 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,78065920,NDC,1,EA,62.6,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,55.2132,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024010,NDC,1,EA,56.73,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,18.705,percent of total billed charges,55.215309,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030036,NDC,1,EA,56.73,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,13.11107143,percent of total billed charges,55.215309,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098341,NDC,1,EA,56.73,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,13.11107143,percent of total billed charges,55.215309,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
Fluoroscope Examination Tc,PX7600001,CDM,320,RC,76000,CPT,TC,,,,,,,597,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,55.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.32,55.22
Fluoroscope Examination Tc,PX7600001,CDM,320,RC,76000,CPT,TC,,,,,,,597,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,55.22,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.32,55.22
budesonide 1 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097032187,NDC,1,ML,64.97,,First Health,Commercial,both,85,,999999999,percent of total billed charges,55.2245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Spinal Puncture,Lumbar,Diagnostic",PX62270F,CDM,510,RC,62270,CPT,,,,,,,,684,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,55.2292,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.3,303.7
"Spinal Puncture,Lumbar,Diagnostic",PX62270P,CDM,983,RC,62270,CPT,,,,,,,,705,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,55.2292,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.3,690.9
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047625,NDC,0.769230769,ML,111.59,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,55.23705,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.354486,332.1514
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141035,NDC,2,ML,56.37,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,55.2426,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,65219044501,NDC,10,ML,56.37,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,55.2426,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,65219044510,NDC,10,ML,56.37,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,55.2426,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
LAP SPONGES 18x18 7INCH LOOP,27200000,CDM,272,RC,,,,604-MAIN,LOCAL,,,,,60.64,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,55.24304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Flow Interp,2-8 Markers - Ref",PX8818790,CDM,310,RC,88187,CPT,90,,,,,,,162,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,55.248,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.9,55.25
"Flow Interp,2-8 Markers - Ref",PX8818790,CDM,310,RC,88187,CPT,90,,,,,,,162,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,55.248,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.9,55.25
"Cardiolipin Ab, Ea Lg - Ref",PX8614790,CDM,300,RC,86147,CPT,90,,,,,,,133,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,55.2482,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.34,130.34
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU0003,CDM,300,RC,U0003,HCPCS,,,,,,,,133,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,55.2482,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.2482,130.34
Lvl 1 Sub Hosp Low Mdm or 25 Minutes,PX99231,CDM,982,RC,99231,CPT,,,,,,,,133,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,55.2482,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.2482,129.4489
"Alkaloids, Not Otherwise Specified - Ref",PX8032390,CDM,300,RC,80323,CPT,90,,,,,,,65,,First Health,Commercial,both,85,,999999999,percent of total billed charges,55.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.001,63.7
Anesthesia Level 3,PX37000017,CDM,370,RC,,,,,,,,,,65,,First Health,Commercial,both,85,,999999999,percent of total billed charges,55.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.001,63.7
Clozapine - Ref,PX8015990,CDM,300,RC,80159,CPT,90,,,,,,,65,,First Health,Commercial,both,85,,999999999,percent of total billed charges,55.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.48,63.7
"Flow Interp,2-8 Markers - Ref",PX8818790,CDM,310,RC,88187,CPT,90,,,,,,,162,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,55.25,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.9,55.25
"Flow Interp,2-8 Markers - Ref",PX8818790,CDM,310,RC,88187,CPT,90,,,,,,,162,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,55.25,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.9,55.25
Gastrin - Ref,PX8294190,CDM,300,RC,82941,CPT,90,,,,,,,65,,First Health,Commercial,both,85,,999999999,percent of total billed charges,55.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.16,63.7
Insulin Ab - Ref,PX8633790,CDM,300,RC,86337,CPT,90,,,,,,,65,,First Health,Commercial,both,85,,999999999,percent of total billed charges,55.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.63,63.7
Resp Muscles 1:1 per 15 Min,PXG0237,CDM,948,RC,G0237,HCPCS,,,,,,,,65,,First Health,Commercial,both,85,,999999999,percent of total billed charges,55.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.01,63.7
Smking Cess 4-10 Min,PX99406F,CDM,942,RC,99406,CPT,,,,,,,,65,,First Health,Commercial,both,85,,999999999,percent of total billed charges,55.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.07,63.7
ezetimibe 10 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,16729043316,NDC,1,EA,60.66,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,55.26126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329335201,NDC,50,ML,109.26,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,55.28556,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
methylergonovine 0.2 MG/ML Solution 1 mL Ampule,J2210.01,CDM,636,RC,J2210,HCPCS,,,,51991014417,NDC,1,ML,133.11,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,55.293894,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.293894,130.4478
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059900,NDC,1,ML,133.16,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,55.314664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.54253,130.4968
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059902,NDC,1,ML,133.16,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,55.314664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.54253,130.4968
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714078401,NDC,0.4,EA,60.72,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,55.31592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,16714001905,NDC,2,ML,62.17,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,55.3313,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,16714001930,NDC,2,ML,62.17,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,55.3313,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Complete Cbc Automated,PX85027,CDM,300,RC,85027,CPT,,,,,,,,129,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,55.341,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,126.42
"Venipunc Need Phys Skill,Dx or Rx",PX36410P,CDM,983,RC,36410,CPT,,,,,,,,129,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,55.341,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.5866,125.5557
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034001,NDC,1,EA,111.81,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,55.34595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034000,NDC,1,EA,111.82,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,55.3509,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409663724,NDC,50,ML,115.32,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,55.3536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409663724,NDC,50,ML,115.32,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,55.3536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
SUMAtriptan 25 MG Tablet 9 Each Box,63700001,CDM,250,RC,,,,,,65862014636,NDC,1,EA,129.04,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,55.35816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ketamine 100 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,55150044001,NDC,10,ML,111.85,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,55.36575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
Iadna Streptococcus Group a Amplified Probe Tq,PX87651,CDM,300,RC,87651,CPT,,,,,,,,113,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,55.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,110.74
Iadna Streptococcus Group a Amplified Probe Tq,PX87651,CDM,300,RC,87651,CPT,,,,,,,,113,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,55.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,110.74
Iadna Streptococcus Group a Amplified Probe Tq,PX87651,CDM,300,RC,87651,CPT,,,,,,,,113,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,55.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,110.74
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,990771512,NDC,62.5,ML,56.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,55.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.4701,303.0944
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209P,CDM,982,RC,69209,CPT,,,,,,,,113,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,55.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9402,109.9829
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209P,CDM,982,RC,69209,CPT,,,,,,,,113,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,55.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9402,109.9829
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209P,CDM,982,RC,69209,CPT,,,,,,,,113,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,55.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9402,109.9829
Strapping of Toes,PX29550F,CDM,510,RC,29550,CPT,,,,,,,,113,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,55.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9402,110.74
Strapping of Toes,PX29550F,CDM,510,RC,29550,CPT,,,,,,,,113,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,55.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9402,110.74
Strapping of Toes,PX29550F,CDM,510,RC,29550,CPT,,,,,,,,113,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,55.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9402,110.74
Xray Spine Single Tc,PX7202001,CDM,320,RC,72020,CPT,TC,,,,,,,113,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,55.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9402,110.74
Xray Spine Single Tc,PX7202001,CDM,320,RC,72020,CPT,TC,,,,,,,113,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,55.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9402,110.74
Xray Spine Single Tc,PX7202001,CDM,320,RC,72020,CPT,TC,,,,,,,113,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,55.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9402,110.74
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,17478062512,NDC,2.5,ML,109.45,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,55.3817,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
hydrocortisone 2.5 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,45802000403,NDC,28,GR,60.85,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,55.43435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"PDS II ENDOLOOP LIGATURE SIZE 0 18""",27200000,CDM,272,RC,,,,11700-MAIN,LOCAL,,,,,56.96,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,55.439168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ELECTRODE PEDS ONESTEP SINGLE,120.343,CDM,272,RC,A4556,HCPCS,,10296-MAIN,LOCAL,,,,,112,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,55.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
EYE IRRIGATION SYSTEM MT2000,120.318,CDM,272,RC,,,,8718-MAIN,LOCAL,,,,,112,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,55.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
F5 Gene - Ref,PX8124190,CDM,300,RC,81241,CPT,90,,,,,,,112,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,55.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
Immunofluorescence per Spec Add Singl Antb Stain - Ref,PX8835090,CDM,310,RC,88350,CPT,90,,,,,,,112,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,55.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
Osmolality; Urine,PX83935,CDM,300,RC,83935,CPT,,,,,,,,112,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,55.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.25,109.76
Prolactin,PX84146,CDM,300,RC,84146,CPT,,,,,,,,112,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,55.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.77,109.76
Quantitation Drug Nos - Ref,PX8029990,CDM,300,RC,80299,CPT,90,,,,,,,112,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,55.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.09,109.76
TUBE AIRSPIRAL BREATHING AND CHAMBER 900PT561,120.493,CDM,271,RC,A4604,HCPCS,,11618-MAIN,LOCAL,,,,,112,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,55.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
verapamil 2.5 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,51754020401,NDC,1,ML,112.01,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,55.44495,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409669501,NDC,10,ML,56.97,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,55.448901,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
scopolamine 1 MG/3DAYS Patch 72 Hour 24 Each Box,25000000,CDM,250,RC,,,,,,50742050524,NDC,1,EA,109.59,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,55.45254,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006111,NDC,0.5,EA,56.98,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,55.458634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.669492,55.8404
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006158,NDC,0.5,EA,56.98,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,55.458634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.669492,55.8404
"Albumin, Othr Source - Ref",PX8204290,CDM,300,RC,82042,CPT,90,,,,,,,57,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,55.4781,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.13,55.86
"Albumin, Serum - Ref",PX8204090,CDM,300,RC,82040,CPT,90,,,,,,,57,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,55.4781,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.54,55.86
Assay Alkaline Phosphatase,PX84075,CDM,300,RC,84075,CPT,,,,,,,,57,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,55.4781,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,55.86
Calcium Total,PX82310,CDM,300,RC,82310,CPT,,,,,,,,57,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,55.4781,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.73,55.86
Dhea-S - Ref,PX8262790,CDM,300,RC,82627,CPT,90,,,,,,,57,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,55.4781,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.38,55.86
Tiss Trnsgltmnase Ea Ig Clas,PX86364,CDM,300,RC,86364,CPT,,,,,,,,57,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,55.4781,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.6778,55.86
sucralfate 1 GM/10ML Suspension 10 mL Cup,63700001,CDM,250,RC,,,,,,68094004359,NDC,10,ML,60.92,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,55.49812,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
budesonide 0.5 MG/2ML Suspension 2 mL Ampule,25000000,CDM,250,RC,,,,,,68180098405,NDC,2,ML,62.38,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,55.5182,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,781751614,NDC,2,ML,62.38,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,55.5182,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,781751687,NDC,2,ML,62.38,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,55.5182,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097031986,NDC,2,ML,62.38,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,55.5182,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dexmedeTOMIDine 200 MCG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,143953201,NDC,2,ML,62.98,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,55.54836,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
K-WIRE SMOOTH 1.4MM X 100MM,C1713,CDM,272,RC,C1713,HCPCS,,12634-MAIN,LOCAL,,,,,63,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,55.566,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
SUTURE MAXON MONOFILAMENT ABSORBABLE GREEN SIZE 1 96IN WITH 1/2 CIRCLE TAPER POINT 65MM NEEDLE,27200000,CDM,272,RC,,,,11986-MAIN,LOCAL,,,,,63,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,55.566,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Vitamin a - Ref,PX8459090,CDM,300,RC,84590,CPT,90,,,,,,,63,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,55.566,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.65,61.74
octreotide 200 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037805,NDC,1,ML,133.77,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,55.568058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
"Protoporphyrin, RBC, Qnt - Ref",PX8420290,CDM,300,RC,84202,CPT,90,,,,,,,61,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,55.571,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.16,59.78
"Venipuncture, Lab",PX3641502,CDM,300,RC,36415,CPT,,,,,,,,61,,Medica,Commercial,both,91.1,,19.05351648,percent of total billed charges,55.571,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.1,65.45
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024010,NDC,1,EA,56.73,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,55.5954,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030036,NDC,1,EA,56.73,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,55.5954,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098341,NDC,1,EA,56.73,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,55.5954,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048657,NDC,50,ML,61.05,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,55.61655,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320885,NDC,0.5,EA,129.71,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,55.64559,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320895,NDC,0.5,EA,129.71,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,55.64559,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
"Office Consultation,Level III",PX99243P,CDM,983,RC,99243,CPT,,,,,,,,374,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,55.65,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.65,366.52
"Acylcarnitines, Quant - Ref",PX8201790,CDM,300,RC,82017,CPT,90,,,,,,,110,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,55.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.47,107.8
"Assay Calcium, Ionized",PX82330,CDM,300,RC,82330,CPT,,,,,,,,110,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,55.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.54,107.8
BONE MARROW BIOPSY ASPIRATION NEEDLE 11G X 4 IN,120.562,CDM,272,RC,C1830,HCPCS,,12677-MAIN,LOCAL,,,,,110,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,55.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.694,107.8
Glycosylated Hemoglobin Test,PX83036,CDM,300,RC,83036,CPT,,,,,,,,110,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,55.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.9,130.9
K-WIRE 0.9X150MM BLUNT/TROCAR DART-FIRE STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12449-MAIN,LOCAL,,,,,110,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,55.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRE 0.9X150MM BLUNT/TROCAR STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12452-MAIN,LOCAL,,,,,110,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,55.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRE 1.4X150MM BLUNT/TROCAR DART-FIRE STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12450-MAIN,LOCAL,,,,,110,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,55.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRE 1.4X150MM BLUNT/TROCAR STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12451-MAIN,LOCAL,,,,,110,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,55.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA 2.0MM TARGETING GUIDE PIN,27200000,CDM,272,RC,,,,12436-MAIN,LOCAL,,,,,110,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,55.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Strapping of Shoulder,PX29240P,CDM,983,RC,29240,CPT,,,,,,,,110,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,55.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.694,111.6
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,143950601,NDC,10,ML,61.1,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,55.6621,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,143950610,NDC,10,ML,61.1,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,55.6621,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
KUMAR CHOLANGIOGRAPHY CATHETER,27200000,CDM,272,RC,,,,10230-MAIN,LOCAL,,,,,63.11,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,55.66302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Antithrombin III Ag Assay - Ref,PX8530190,CDM,300,RC,85301,CPT,90,,,,,,,116,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,55.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.91,113.68
Antithrombin III Ag Assay - Ref,PX8530190,CDM,300,RC,85301,CPT,90,,,,,,,116,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,55.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.91,113.68
Ca 19-9,PX86301,CDM,300,RC,86301,CPT,,,,,,,,116,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,55.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,113.68
Ca 19-9,PX86301,CDM,300,RC,86301,CPT,,,,,,,,116,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,55.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,113.68
sacubitril-valsartan 24-26 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,78065920,NDC,1,EA,62.6,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,55.714,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DAPTOmycin 500 MG Recon Soln 1 Each Vial,J0878.01,CDM,636,RC,J0878,HCPCS,,,,70594003402,NDC,1,EA,129.9,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,55.7271,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.96046,127.302
amiodarone 900 MG/18ML Solution 18 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,67457015318,NDC,18,ML,113.73,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,55.7277,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
amiodarone 900 MG/18ML Solution 18 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,67457015318,NDC,18,ML,113.73,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,55.7277,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
amiodarone 900 MG/18ML Solution 18 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,67457015318,NDC,18,ML,113.73,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,55.7277,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
"polyethylene glycol 236 g Recon Soln 4,000 mL Bottle",63700001,CDM,250,RC,,,,,,43386009019,NDC,4000,ML,112.6,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,55.737,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DERMABOND MINI SKIN ADHESIVE,27200000,CDM,272,RC,,,,8532-MAIN,LOCAL,,,,,110.16,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,55.74096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305972,NDC,2,ML,61.19,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,55.74409,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305995,NDC,2,ML,61.19,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,55.74409,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
Chemo Ad Sq/Im Hormnl Anti-Neo,PX96402,CDM,335,RC,96402,CPT,,,,,,,,130,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,55.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,127.4
Cystatin C - Ref,PX8261090,CDM,300,RC,82610,CPT,90,,,,,,,130,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,55.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.98,127.4
Each Add'l Sequential Push New Drug,PX96375,CDM,260,RC,96375,CPT,,,,,,,,130,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,55.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,127.4
Immunization Administration; One Vaccine (Single or Combination Vaccine/To*,PX90471,CDM,771,RC,90471,CPT,,,,,,,,130,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,55.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,127.4
Prothrombin Time (Pt/Inr),PX85610,CDM,300,RC,85610,CPT,,,,,,,,130,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,55.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.93,127.4
SPLINT WRIST LARGE ALUMINUM FOREARM LEFT 9101-06,120.87,CDM,274,RC,L3809,HCPCS,,1265-MAIN,LOCAL,,,,,130,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,55.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST LARGE ALUMINUM FOREARM RIGHT 9101-03,120.87,CDM,274,RC,L3809,HCPCS,,1263-MAIN,LOCAL,,,,,130,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,55.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST MEDIUM ALUMINUM FOREARM LEFT 9101-05,120.87,CDM,274,RC,L3809,HCPCS,,1264-MAIN,LOCAL,,,,,130,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,55.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST MEDIUM ALUMINUM FOREARM RIGHT 9101-02,120.87,CDM,274,RC,L3809,HCPCS,,1262-MAIN,LOCAL,,,,,130,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,55.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
Vitamin B-1 - Ref,PX8442590,CDM,300,RC,84425,CPT,90,,,,,,,130,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,55.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.47,127.4
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606001,NDC,10,ML,65.62,,First Health,Commercial,both,85,,999999999,percent of total billed charges,55.777,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606010,NDC,10,ML,65.62,,First Health,Commercial,both,85,,999999999,percent of total billed charges,55.777,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
Fibrinolysins Screen - Ref,PX8539090,CDM,300,RC,85390,CPT,90,,,,,,,118,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,55.78,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.02,55.78
Fibrinolysins Screen - Ref,PX8539090,CDM,300,RC,85390,CPT,90,,,,,,,118,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,55.78,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.02,55.78
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,68462015740,NDC,1,EA,110.25,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,55.7865,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,68462015713,NDC,1,EA,110.25,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,55.7865,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,55150020200,NDC,1,EA,65.65,,First Health,Commercial,both,85,,999999999,percent of total billed charges,55.8025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43598055530,NDC,0.4,EA,61.26,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,55.80786,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43598096630,NDC,0.4,EA,61.26,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,55.80786,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"PDS II ENDOLOOP LIGATURE SIZE 0 18""",27200000,CDM,272,RC,,,,11700-MAIN,LOCAL,,,,,56.96,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,55.8208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,45802011222,NDC,22,GR,63.29,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,55.82178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409669501,NDC,10,ML,56.97,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,55.8306,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Repr Superf Wnd Body 12.6-20,PX12005F,CDM,510,RC,12005,CPT,,,,,,,,565,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,55.84,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.84,369.42
Repr Superf Wnd Body 12.6-20,PX12005P,CDM,983,RC,12005,CPT,,,,,,,,377,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,55.84,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.84,369.46
Repr Superf Wnd Body 12.6-20,PX12005F,CDM,510,RC,12005,CPT,,,,,,,,565,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,55.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.84,369.42
Repr Superf Wnd Body 12.6-20,PX12005F,CDM,510,RC,12005,CPT,,,,,,,,565,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,55.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.84,369.42
Repr Superf Wnd Body 12.6-20,PX12005P,CDM,983,RC,12005,CPT,,,,,,,,377,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,55.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.84,369.46
Repr Superf Wnd Body 12.6-20,PX12005P,CDM,983,RC,12005,CPT,,,,,,,,377,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,55.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.84,369.46
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006111,NDC,0.5,EA,56.98,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,55.8404,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.669492,55.8404
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006158,NDC,0.5,EA,56.98,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,55.8404,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.669492,55.8404
tropicamide 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,24208058559,NDC,2,ML,61.3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,55.8443,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Albumin, Othr Source - Ref",PX8204290,CDM,300,RC,82042,CPT,90,,,,,,,57,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,55.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.13,55.86
"Albumin, Serum - Ref",PX8204090,CDM,300,RC,82040,CPT,90,,,,,,,57,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,55.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.54,55.86
Assay Alkaline Phosphatase,PX84075,CDM,300,RC,84075,CPT,,,,,,,,57,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,55.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,55.86
Assay of Erythropoietin,PX82668,CDM,300,RC,82668,CPT,,,,,,,,114,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,55.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,111.72
Assay of Erythropoietin,PX82668,CDM,300,RC,82668,CPT,,,,,,,,114,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,55.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,111.72
Assay of Erythropoietin,PX82668,CDM,300,RC,82668,CPT,,,,,,,,114,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,55.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,111.72
Calcium Total,PX82310,CDM,300,RC,82310,CPT,,,,,,,,57,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,55.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.73,55.86
Dhea-S - Ref,PX8262790,CDM,300,RC,82627,CPT,90,,,,,,,57,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,55.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.38,55.86
Tiss Trnsgltmnase Ea Ig Clas,PX86364,CDM,300,RC,86364,CPT,,,,,,,,57,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,55.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.6778,55.86
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,63323050830,NDC,1,EA,134.48,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,55.862992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.461584,189.875
"Biopsy, Nail Unit",PX11755F,CDM,510,RC,11755,CPT,,,,,,,,1490,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,55.8714,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.73,253.89
Debride Skin/Tissue,PX11042F,CDM,510,RC,11042,CPT,,,,,,,,1067,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,55.8714,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.08,269.8
Debride Skin/Tissue,PX11042P,CDM,983,RC,11042,CPT,,,,,,,,995,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,55.8714,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.08,975.1
TRUMPET SUCTION IRRIGATION,27100000,CDM,271,RC,,,,4577-MAIN,LOCAL,,,,,116.4,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,55.872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
TRUMPET SUCTION IRRIGATION,27100000,CDM,271,RC,,,,4577-MAIN,LOCAL,,,,,116.4,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,55.872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
US Guide Needle Bx S&I,PX7694201,CDM,402,RC,76942,CPT,TC,,,,,,,747,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,55.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.32,55.88
US Guide Needle Bx S&I,PX7694201,CDM,402,RC,76942,CPT,TC,,,,,,,747,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,55.88,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.32,55.88
Xray Ankle Minimum 3 Vws,PX7361001,CDM,320,RC,73610,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,55.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.75,55.88
Xray Ankle Minimum 3 Vws,PX7361001,CDM,320,RC,73610,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,55.88,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.75,55.88
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,409672924,NDC,50,ML,116.43,,Health Partners,Health Partners Care Plans,both,48,,14.6175,percent of total billed charges,55.8864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,409672924,NDC,50,ML,116.43,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,55.8864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
triamcinolone acetonide 0.1 % Cream 80 g Tube,63700001,CDM,250,RC,,,,,,16714098603,NDC,80,GR,65.76,,First Health,Commercial,both,85,,999999999,percent of total billed charges,55.896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
triamcinolone acetonide 0.1 % Cream 454 g Jar,63700001,CDM,250,RC,,,,,,45802006405,NDC,454,GR,130.36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,55.92444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Iadna Streptococcus Group a Amplified Probe Tq,PX87651,CDM,300,RC,87651,CPT,,,,,,,,113,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,55.935,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,110.74
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209P,CDM,982,RC,69209,CPT,,,,,,,,113,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,55.935,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9402,109.9829
Strapping of Toes,PX29550F,CDM,510,RC,29550,CPT,,,,,,,,113,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,55.935,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9402,110.74
Xray Spine Single Tc,PX7202001,CDM,320,RC,72020,CPT,TC,,,,,,,113,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,55.935,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9402,110.74
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608210,NDC,1,ML,63.43,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,55.94526,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,713013512,NDC,1,EA,65.83,,First Health,Commercial,both,85,,999999999,percent of total billed charges,55.9555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.345782,66.2186
dexmedeTOMIDine 200 MCG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,143953201,NDC,2,ML,62.98,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,56.0522,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093107,NDC,1,ML,57.59,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,13.01809524,percent of total billed charges,56.052347,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
US Head/Neck Tc,PX7653601,CDM,402,RC,76536,CPT,TC,,,,,,,416,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,56.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.06,165.66
US Head/Neck Tc,PX7653601,CDM,402,RC,76536,CPT,TC,,,,,,,416,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,56.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.06,165.66
K-WIRE SMOOTH 1.4MM X 100MM,C1713,CDM,272,RC,C1713,HCPCS,,12634-MAIN,LOCAL,,,,,63,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,56.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
SUTURE MAXON MONOFILAMENT ABSORBABLE GREEN SIZE 1 96IN WITH 1/2 CIRCLE TAPER POINT 65MM NEEDLE,27200000,CDM,272,RC,,,,11986-MAIN,LOCAL,,,,,63,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,56.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Vitamin a - Ref,PX8459090,CDM,300,RC,84590,CPT,90,,,,,,,63,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,56.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.65,61.74
"Cognitive Funct Ther Interv, per Day",PX97127,CDM,420,RC,97127,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,56.079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.079,132.3
Electric Stimulation Therapy,PX97014,CDM,420,RC,97014,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,56.079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.18,132.3
Electrical Stimulation,PX97032,CDM,420,RC,97032,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,56.079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,132.3
Gait Training Therapy,PX97116,CDM,420,RC,97116,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,56.079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20,132.3
Mechanical Traction Therapy,PX97012,CDM,420,RC,97012,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,56.079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,132.3
Self Care Mngment Training,PX97535,CDM,420,RC,97535,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,56.079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.27,132.3
Ultrasound Therapy,PX97035,CDM,420,RC,97035,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,56.079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,132.3
naloxone 2 MG/2ML solution prefilled syringe 2 mL Syringe,J2310.01,CDM,636,RC,J2310,HCPCS,,,,76329346901,NDC,1,ML,114.45,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,56.0805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.54253,130.4968
naloxone 2 MG/2ML solution prefilled syringe 2 mL Syringe,J2310.01,CDM,636,RC,J2310,HCPCS,,,,76329346901,NDC,1,ML,114.45,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,56.0805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.54253,130.4968
naloxone 2 MG/2ML solution prefilled syringe 2 mL Syringe,J2310.01,CDM,636,RC,J2310,HCPCS,,,,76329346901,NDC,1,ML,114.45,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,56.0805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.54253,130.4968
levonorgestrel 1.5 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,62756071860,NDC,1,EA,114.48,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,56.0952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levonorgestrel 1.5 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,62756071860,NDC,1,EA,114.48,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,56.0952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levonorgestrel 1.5 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,62756071860,NDC,1,EA,114.48,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,56.0952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Ig Paraprotein Qual Bld/UR,PX0077U90,CDM,300,RC,0077U,HCPCS,90,,,,,,,66,,First Health,Commercial,both,85,,999999999,percent of total billed charges,56.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
"Level III - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3933,CDM,310,RC,88304,CPT,TC,,,,,,,66,,First Health,Commercial,both,85,,999999999,percent of total billed charges,56.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
Ot Contracted Service/Msho/MA,PX120.178,CDM,431,RC,,,,,,,,,,66,,First Health,Commercial,both,85,,999999999,percent of total billed charges,56.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
Pt Contracted Service/Msho,PX120.176,CDM,421,RC,,,,,,,,,,66,,First Health,Commercial,both,85,,999999999,percent of total billed charges,56.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
Surg Pathology-Level 2-Tc,PX3932,CDM,310,RC,88302,CPT,TC,,,,,,,66,,First Health,Commercial,both,85,,999999999,percent of total billed charges,56.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.01,64.68
Xray Orbits Optic Foramina,PX7019001,CDM,320,RC,70190,CPT,TC,,,,,,,66,,First Health,Commercial,both,85,,999999999,percent of total billed charges,56.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,79.39
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,72603012801,NDC,1,EA,57.64,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,23.41888889,percent of total billed charges,56.101012,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
potassium chloride 20 MEQ Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,245036089,NDC,1,EA,57.67,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,56.130211,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409493311,NDC,10,ML,66.06,,First Health,Commercial,both,85,,999999999,percent of total billed charges,56.151,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505624500,NDC,1,EA,116.99,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,56.1552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505624500,NDC,1,EA,116.99,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,56.1552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
Cryptosporidum,PX87328,CDM,300,RC,87328,CPT,,,,,,,,117,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,56.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.67,114.66
Cryptosporidum,PX87328,CDM,300,RC,87328,CPT,,,,,,,,117,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,56.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.67,114.66
Drain Blood From Under Nail,PX11740F,CDM,510,RC,11740,CPT,,,,,,,,117,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,56.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.6018,114.66
Drain Blood From Under Nail,PX11740F,CDM,510,RC,11740,CPT,,,,,,,,117,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,56.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.6018,114.66
Giardia,PX87329,CDM,300,RC,87329,CPT,,,,,,,,117,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,56.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,114.66
Giardia,PX87329,CDM,300,RC,87329,CPT,,,,,,,,117,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,56.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,114.66
"In Situ Hybridization (Eg, Fish), Each Probe, Tech",PX8836501,CDM,310,RC,88365,CPT,TC,,,,,,,117,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,56.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.6018,149.22
"In Situ Hybridization (Eg, Fish), Each Probe, Tech",PX8836501,CDM,310,RC,88365,CPT,TC,,,,,,,117,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,56.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.6018,149.22
RBC Pretreatment,PX8697002,CDM,300,RC,86970,CPT,,,,,,,,117,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,56.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.6018,114.66
RBC Pretreatment,PX8697002,CDM,300,RC,86970,CPT,,,,,,,,117,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,56.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.6018,114.66
KUMAR CHOLANGIOGRAPHY CATHETER,27200000,CDM,272,RC,,,,10230-MAIN,LOCAL,,,,,63.11,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,56.1679,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,93681545,NDC,2,ML,57.71,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,56.169143,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,93681573,NDC,2,ML,57.71,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,56.169143,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028401,NDC,1,EA,111.01,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,56.17106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028420,NDC,1,EA,111.01,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,56.17106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048503,NDC,50,ML,57.74,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,56.198342,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Noninvasv Oxygen Satur;Single,PX94760,CDM,460,RC,94760,CPT,,,,,,,,131,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,56.199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.4174,128.38
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,69315030615,NDC,15,GR,131.07,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,56.22903,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337501,NDC,50,ML,135.43,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,56.257622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337502,NDC,50,ML,135.43,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,56.257622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9678001,NDC,50,ML,135.43,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,56.257622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
tuberculin 5 UNIT/0.1ML Solution 1 mL Vial,25000000,CDM,250,RC,,,,,,42023010401,NDC,0.1,ML,57.82,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,56.276206,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
CT Abdomen W/O Dye,PX7415001,CDM,350,RC,74150,CPT,TC,,,,,,,2757,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,56.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.28,166.32
CT Abdomen W/O Dye,PX7415001,CDM,350,RC,74150,CPT,TC,,,,,,,2757,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,56.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.28,166.32
"Non-Select. Wound Debride., W/O Anesth.; Top. Appl./Wound Assess./Instruct., per Sess.",PX97602,CDM,761,RC,97602,CPT,,,,,,,,212,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,56.28,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.28,104.16
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569F,CDM,510,RC,36569,CPT,,,,,,,,1217,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,56.28,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.28,193.01
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569P,CDM,983,RC,36569,CPT,,,,,,,,1825,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,56.28,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.28,1788.5
US Head/Neck Tc,PX7653601,CDM,402,RC,76536,CPT,TC,,,,,,,416,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,56.28,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.06,165.66
amiodarone 900 MG/18ML Solution 18 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,67457015318,NDC,18,ML,113.73,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,56.29635,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
pembrolizumab 100 MG/4ML Solution 4 mL Vial,J9271.01,CDM,636,RC,J9271,HCPCS,,,,6302602,NDC,4,ML,9627.58,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,56.2975,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.98,58.52
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,43598040516,NDC,0.2,ML,63.83,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,56.29806,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
"Level IV - Surgical Pathology, Gross and Microscopic Examination , Tech",PX3934,CDM,310,RC,88305,CPT,TC,,,,,,,185,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,56.3,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.06,58.096
"Level IV - Surgical Pathology, Gross and Microscopic Examination , Tech",PX3934,CDM,310,RC,88305,CPT,TC,,,,,,,185,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,56.3,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.06,58.096
apixaban 2.5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,3089321,NDC,1,EA,63.84,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,56.30688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Transvaginal US, Obstetric",PX7681701,CDM,402,RC,76817,CPT,TC,,,,,,,460,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,56.315,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.97,113.07
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,45802011222,NDC,22,GR,63.29,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,56.3281,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,25021011487,NDC,200,ML,66.28,,First Health,Commercial,both,85,,999999999,percent of total billed charges,56.338,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.20921,64.9544
Assay of Triglycerides,PX84478,CDM,300,RC,84478,CPT,,,,,,,,115,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,56.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.26,112.7
Assay of Triglycerides,PX84478,CDM,300,RC,84478,CPT,,,,,,,,115,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,56.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.26,112.7
Assay of Triglycerides,PX84478,CDM,300,RC,84478,CPT,,,,,,,,115,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,56.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.26,112.7
"Blood Typing, Rh Phenotype",PX86906,CDM,300,RC,86906,CPT,,,,,,,,115,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,56.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.03,112.7
"Blood Typing, Rh Phenotype",PX86906,CDM,300,RC,86906,CPT,,,,,,,,115,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,56.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.03,112.7
"Blood Typing, Rh Phenotype",PX86906,CDM,300,RC,86906,CPT,,,,,,,,115,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,56.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.03,112.7
BRACE ANKLE LARGE 264015,120.51,CDM,274,RC,L1902,HCPCS,,4-MAIN,LOCAL,,,,,115,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,56.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE LARGE 264015,120.51,CDM,274,RC,L1902,HCPCS,,4-MAIN,LOCAL,,,,,115,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,56.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE LARGE 264015,120.51,CDM,274,RC,L1902,HCPCS,,4-MAIN,LOCAL,,,,,115,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,56.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE MEDIUM 264014,120.51,CDM,274,RC,L1902,HCPCS,,7-MAIN,LOCAL,,,,,115,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,56.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE MEDIUM 264014,120.51,CDM,274,RC,L1902,HCPCS,,7-MAIN,LOCAL,,,,,115,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,56.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE MEDIUM 264014,120.51,CDM,274,RC,L1902,HCPCS,,7-MAIN,LOCAL,,,,,115,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,56.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE SMALL 264012,120.51,CDM,274,RC,L1902,HCPCS,,12-MAIN,LOCAL,,,,,115,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,56.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE SMALL 264012,120.51,CDM,274,RC,L1902,HCPCS,,12-MAIN,LOCAL,,,,,115,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,56.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE SMALL 264012,120.51,CDM,274,RC,L1902,HCPCS,,12-MAIN,LOCAL,,,,,115,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,56.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE X-LARGE 264016,120.51,CDM,274,RC,L1902,HCPCS,,14-MAIN,LOCAL,,,,,115,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,56.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE X-LARGE 264016,120.51,CDM,274,RC,L1902,HCPCS,,14-MAIN,LOCAL,,,,,115,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,56.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE X-LARGE 264016,120.51,CDM,274,RC,L1902,HCPCS,,14-MAIN,LOCAL,,,,,115,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,56.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE X-SMALL 264011,120.51,CDM,274,RC,L1902,HCPCS,,1-MAIN,LOCAL,,,,,115,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,56.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE X-SMALL 264011,120.51,CDM,274,RC,L1902,HCPCS,,1-MAIN,LOCAL,,,,,115,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,56.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE X-SMALL 264011,120.51,CDM,274,RC,L1902,HCPCS,,1-MAIN,LOCAL,,,,,115,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,56.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
Debride Skin/Subq Ea Ad 20sqcm,PX11045F,CDM,510,RC,11045,CPT,,,,,,,,115,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,56.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
Debride Skin/Subq Ea Ad 20sqcm,PX11045F,CDM,510,RC,11045,CPT,,,,,,,,115,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,56.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
Debride Skin/Subq Ea Ad 20sqcm,PX11045F,CDM,510,RC,11045,CPT,,,,,,,,115,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,56.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
Glucagon - Ref,PX8294390,CDM,300,RC,82943,CPT,90,,,,,,,115,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,56.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.1,112.7
Glucagon - Ref,PX8294390,CDM,300,RC,82943,CPT,90,,,,,,,115,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,56.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.1,112.7
Glucagon - Ref,PX8294390,CDM,300,RC,82943,CPT,90,,,,,,,115,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,56.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.1,112.7
"Immuno for Tumor Ag, Qn - Ref",PX8631690,CDM,300,RC,86316,CPT,90,,,,,,,115,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,56.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,112.7
"Immuno for Tumor Ag, Qn - Ref",PX8631690,CDM,300,RC,86316,CPT,90,,,,,,,115,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,56.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,112.7
"Immuno for Tumor Ag, Qn - Ref",PX8631690,CDM,300,RC,86316,CPT,90,,,,,,,115,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,56.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,112.7
Microsomal Antibody,PX7893,CDM,300,RC,86376,CPT,,,,,,,,115,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,56.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.34,112.7
Microsomal Antibody,PX7893,CDM,300,RC,86376,CPT,,,,,,,,115,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,56.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.34,112.7
Microsomal Antibody,PX7893,CDM,300,RC,86376,CPT,,,,,,,,115,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,56.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.34,112.7
First Hour IV Hydration <1 Hour,PX96360,CDM,260,RC,96360,CPT,,,,,,,,260,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,56.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.16,56.42
First Hour IV Hydration <1 Hour,PX96360,CDM,260,RC,96360,CPT,,,,,,,,260,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,56.42,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.16,56.42
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004725,NDC,2,ML,131.52,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,56.42208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
Assay of Erythropoietin,PX82668,CDM,300,RC,82668,CPT,,,,,,,,114,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,56.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,111.72
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323031119,NDC,10,ML,66.39,,First Health,Commercial,both,85,,999999999,percent of total billed charges,56.4315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,84.5054
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093107,NDC,1,ML,57.59,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,56.4382,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
Blood Occult Peroxidase,PX82272,CDM,300,RC,82272,CPT,,,,,,,,64,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,56.448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.88,62.72
Strapping of Elbow or Wrist,PX29260F,CDM,420,RC,29260,CPT,,,,,,,,64,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,56.448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.5856,62.72
Strapping of Hand or Finger,PX29280F,CDM,420,RC,29280,CPT,,,,,,,,64,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,56.448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.5856,62.72
"Albumin, Blood",PX82040,CDM,300,RC,82040,CPT,90,,,,,,,58,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,56.4514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.54,56.84
Assay of creatinine,PX82565,CDM,300,RC,82565,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,17.72392857,percent of total billed charges,56.4514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.69,56.84
Assay of Urea Nitrogen,PX84520,CDM,300,RC,84520,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,56.4514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.62,56.84
"Assay, Glucose, Blood Quant",PX82947,CDM,300,RC,82947,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,56.4514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.6,56.84
Automated Leukocyte Count,PX85048,CDM,300,RC,85048,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,56.4514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.33,56.84
DEFIBRILLATION PAD BIPHASIC ADULT,120.96,CDM,271,RC,A0392,HCPCS,,1321-MAIN,LOCAL,,,,,58,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,56.4514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.0932,56.84
"Ebv, Nuclear Antigen - Ref",PX8666490,CDM,300,RC,86664,CPT,90,,,,,,,58,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,56.4514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.02,56.84
"Ebv, Viral Capsid Ab - Ref",PX8666590,CDM,300,RC,86665,CPT,90,,,,,,,58,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,56.4514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.63,56.84
Hematocrit,PX85014,CDM,300,RC,85014,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,24.93,percent of total billed charges,56.4514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.17,56.84
"Long Term Holter, 48 Hrs Up to 7 Days, Recording",PX93242,CDM,731,RC,93242,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,446.32,percent of total billed charges,56.4514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.0932,56.84
"Long Term Holter, More Than 7 Days Up to 15 Days, Recording",PX93246,CDM,731,RC,93246,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,32.48,percent of total billed charges,56.4514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.0932,56.84
"Sodium; Serum, Plasma or Whole Blood",PX84295,CDM,300,RC,84295,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,56.4514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.41,56.84
SUTURE V-LOC SZ 1 PBT WOUND CLOSURE DEVICE BLUE 18 IN GS 21 NEEDLE VLOCN0327,27200000,CDM,272,RC,,,,12828-MAIN,LOCAL,,,,,58,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,56.4514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Transferase; Alanine Amino (Alt) (Sgpt),PX84460,CDM,300,RC,84460,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,56.4514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.86,56.84
Transferase; Aspartate Amino (Ast) (Sgot),PX84450,CDM,300,RC,84450,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,6.14875,percent of total billed charges,56.4514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,56.84
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608210,NDC,1,ML,63.43,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,56.4527,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047625,NDC,0.769230769,ML,111.59,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,56.46454,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.354486,332.1514
hydrocortisone 2.5 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,168008031,NDC,30,GR,61.99,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,56.47289,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,72603012801,NDC,1,EA,57.64,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,56.4872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
CT Abdomen W/O Dye,PX7415001,CDM,350,RC,74150,CPT,TC,,,,,,,2757,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,56.5,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.28,166.32
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409663724,NDC,50,ML,115.32,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,56.5068,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409663724,NDC,50,ML,115.32,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,56.5068,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409663724,NDC,50,ML,115.32,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,56.5068,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
potassium chloride 20 MEQ Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,245036089,NDC,1,EA,57.67,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,56.5166,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990711509,NDC,1000,ML,64.08,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,56.51856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,63739003807,NDC,1,EA,66.51,,First Health,Commercial,both,85,,999999999,percent of total billed charges,56.5335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,703115301,NDC,4,ML,136.1,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,56.53594,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Xray Sacroiliac Jnts 3 or More Vws,PX7220201,CDM,320,RC,72202,CPT,TC,,,,,,,285,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,56.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.75,56.54
Xray Sacroiliac Jnts 3 or More Vws,PX7220201,CDM,320,RC,72202,CPT,TC,,,,,,,285,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,56.54,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.75,56.54
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,93681545,NDC,2,ML,57.71,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,56.5558,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,93681573,NDC,2,ML,57.71,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,56.5558,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
cyclopentolate 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,17478010002,NDC,2,ML,66.55,,First Health,Commercial,both,85,,999999999,percent of total billed charges,56.5675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034001,NDC,1,EA,111.81,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,56.57586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034000,NDC,1,EA,111.82,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,56.58092,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048503,NDC,50,ML,57.74,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,56.5852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ofloxacin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,17478071310,NDC,5,ML,117.89,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,56.5872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ofloxacin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,17478071310,NDC,5,ML,117.89,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,56.5872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ketamine 100 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,55150044001,NDC,10,ML,111.85,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,56.5961,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608201,NDC,1,ML,66.6,,First Health,Commercial,both,85,,999999999,percent of total billed charges,56.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
Apply of Paste Boot,PX29580F,CDM,510,RC,29580,CPT,,,,,,,,132,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,56.628,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,137.65
Assay Dipropylacetic Acid,PX80164,CDM,300,RC,80164,CPT,,,,,,,,132,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,56.628,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.41,129.36
Assay of Lipase,PX83690,CDM,300,RC,83690,CPT,,,,,,,,132,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,56.628,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.32,129.36
"Remv F.B.,Eye,Superf Conjunc",PX65205F,CDM,510,RC,65205,CPT,,,,,,,,132,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,56.628,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,129.36
"Remv F.B.,Eye,Superf Conjunc",PX65205P,CDM,983,RC,65205,CPT,,,,,,,,132,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,56.628,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,128.4756
"Venipunc Need Phys Skill,Dx or Rx",PX36410,CDM,983,RC,36410,CPT,,,,,,,,132,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,56.628,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,128.4756
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,16714001905,NDC,2,ML,62.17,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,56.63687,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,16714001930,NDC,2,ML,62.17,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,56.63687,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Fibrinolysins Screen - Ref,PX8539090,CDM,300,RC,85390,CPT,90,,,,,,,118,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,56.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.19,115.64
Fibrinolysins Screen - Ref,PX8539090,CDM,300,RC,85390,CPT,90,,,,,,,118,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,56.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.19,115.64
naloxone 2 MG/2ML solution prefilled syringe 2 mL Syringe,J2310.01,CDM,636,RC,J2310,HCPCS,,,,76329346901,NDC,1,ML,114.45,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,56.65275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.54253,130.4968
tuberculin 5 UNIT/0.1ML Solution 1 mL Vial,25000000,CDM,250,RC,,,,,,42023010401,NDC,0.1,ML,57.82,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,56.6636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
levonorgestrel 1.5 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,62756071860,NDC,1,EA,114.48,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,56.6676,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Neg Pressure Wound Therapy Dme </=50 Sq Cm,PX97605F,CDM,510,RC,97605,CPT,,,,,,,,396,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,56.67,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.3,56.67
ELECTRODE PEDS ONESTEP SINGLE,120.343,CDM,272,RC,A4556,HCPCS,,10296-MAIN,LOCAL,,,,,112,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,56.672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
EYE IRRIGATION SYSTEM MT2000,120.318,CDM,272,RC,,,,8718-MAIN,LOCAL,,,,,112,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,56.672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
F5 Gene - Ref,PX8124190,CDM,300,RC,81241,CPT,90,,,,,,,112,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,56.672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
Immunofluorescence per Spec Add Singl Antb Stain - Ref,PX8835090,CDM,310,RC,88350,CPT,90,,,,,,,112,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,56.672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
Osmolality; Urine,PX83935,CDM,300,RC,83935,CPT,,,,,,,,112,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,56.672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.25,109.76
Prolactin,PX84146,CDM,300,RC,84146,CPT,,,,,,,,112,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,56.672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.77,109.76
Quantitation Drug Nos - Ref,PX8029990,CDM,300,RC,80299,CPT,90,,,,,,,112,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,56.672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.09,109.76
TUBE AIRSPIRAL BREATHING AND CHAMBER 900PT561,120.493,CDM,271,RC,A4604,HCPCS,,11618-MAIN,LOCAL,,,,,112,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,56.672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
verapamil 2.5 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,51754020401,NDC,1,ML,112.01,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,56.67706,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569F,CDM,510,RC,36569,CPT,,,,,,,,1217,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,56.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.28,193.01
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569F,CDM,510,RC,36569,CPT,,,,,,,,1217,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,56.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.28,193.01
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569P,CDM,983,RC,36569,CPT,,,,,,,,1825,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,56.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.28,1788.5
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569P,CDM,983,RC,36569,CPT,,,,,,,,1825,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,56.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.28,1788.5
Surgical Cleansing of Skin,PX11000P,CDM,983,RC,11000,CPT,,,,,,,,145,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,56.73,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.79,142.1
Withdrawal of Arterial Blood,PX36600F,CDM,510,RC,36600,CPT,,,,,,,,250,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,56.73,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.16,56.73
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,641601501,NDC,25,ML,58.29,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,56.733657,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Off/Outpt Visit,New,Levl III",PX99203P,CDM,983,RC,99203,CPT,,,,,,,,252,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,56.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.07,246.96
"Off/Outpt Visit,New,Levl III",PX99203P,CDM,983,RC,99203,CPT,,,,,,,,252,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,56.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.07,246.96
"Office/Outpt Visit,New,Levl III",PX99203F,CDM,510,RC,99203,CPT,,,,,,,,252,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,56.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.07,200.33
"Office/Outpt Visit,New,Levl III",PX99203F,CDM,510,RC,99203,CPT,,,,,,,,252,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,56.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.07,200.33
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117630,NDC,1,ML,58.34,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,56.782322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042350,NDC,0.5,ML,132.37,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,56.78673,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.49,129.7226
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042388,NDC,0.5,ML,132.37,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,56.78673,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.49,129.7226
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,43598040516,NDC,0.2,ML,63.83,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,56.8087,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
PACLitaxel 30 MG/5ML Concentrate 5 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476401,NDC,5,ML,58.37,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,56.811521,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
apixaban 2.5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,3089321,NDC,1,EA,63.84,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,56.8176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
budesonide 0.5 MG/2ML Suspension 2 mL Ampule,25000000,CDM,250,RC,,,,,,68180098405,NDC,2,ML,62.38,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,56.82818,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,781751614,NDC,2,ML,62.38,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,56.82818,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,781751687,NDC,2,ML,62.38,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,56.82818,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097031986,NDC,2,ML,62.38,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,56.82818,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"TB Test, Cell Immunity Measure",PX86480,CDM,300,RC,86480,CPT,,,,,,,,186,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,56.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.83,182.28
"Albumin, Blood",PX82040,CDM,300,RC,82040,CPT,90,,,,,,,58,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,56.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.54,56.84
Antithrombin III Ag Assay - Ref,PX8530190,CDM,300,RC,85301,CPT,90,,,,,,,116,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,56.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.91,113.68
Antithrombin III Ag Assay - Ref,PX8530190,CDM,300,RC,85301,CPT,90,,,,,,,116,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,56.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.91,113.68
Antithrombin III Ag Assay - Ref,PX8530190,CDM,300,RC,85301,CPT,90,,,,,,,116,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,56.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.91,113.68
Assay of creatinine,PX82565,CDM,300,RC,82565,CPT,,,,,,,,58,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,56.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.69,56.84
Assay of Urea Nitrogen,PX84520,CDM,300,RC,84520,CPT,,,,,,,,58,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,56.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.62,56.84
"Assay, Glucose, Blood Quant",PX82947,CDM,300,RC,82947,CPT,,,,,,,,58,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,56.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.6,56.84
Automated Leukocyte Count,PX85048,CDM,300,RC,85048,CPT,,,,,,,,58,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,56.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.33,56.84
Ca 19-9,PX86301,CDM,300,RC,86301,CPT,,,,,,,,116,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,56.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,113.68
Ca 19-9,PX86301,CDM,300,RC,86301,CPT,,,,,,,,116,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,56.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,113.68
Ca 19-9,PX86301,CDM,300,RC,86301,CPT,,,,,,,,116,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,56.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,113.68
DEFIBRILLATION PAD BIPHASIC ADULT,120.96,CDM,271,RC,A0392,HCPCS,,1321-MAIN,LOCAL,,,,,58,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,56.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.0932,56.84
"Ebv, Nuclear Antigen - Ref",PX8666490,CDM,300,RC,86664,CPT,90,,,,,,,58,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,56.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.02,56.84
"Ebv, Viral Capsid Ab - Ref",PX8666590,CDM,300,RC,86665,CPT,90,,,,,,,58,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,56.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.63,56.84
Hematocrit,PX85014,CDM,300,RC,85014,CPT,,,,,,,,58,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,56.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.17,56.84
"Long Term Holter, 48 Hrs Up to 7 Days, Recording",PX93242,CDM,731,RC,93242,CPT,,,,,,,,58,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,56.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.0932,56.84
"Long Term Holter, More Than 7 Days Up to 15 Days, Recording",PX93246,CDM,731,RC,93246,CPT,,,,,,,,58,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,56.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.0932,56.84
"Sodium; Serum, Plasma or Whole Blood",PX84295,CDM,300,RC,84295,CPT,,,,,,,,58,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,56.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.41,56.84
SUTURE V-LOC SZ 1 PBT WOUND CLOSURE DEVICE BLUE 18 IN GS 21 NEEDLE VLOCN0327,27200000,CDM,272,RC,,,,12828-MAIN,LOCAL,,,,,58,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,56.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Transferase; Alanine Amino (Alt) (Sgpt),PX84460,CDM,300,RC,84460,CPT,,,,,,,,58,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,56.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.86,56.84
Transferase; Aspartate Amino (Ast) (Sgot),PX84450,CDM,300,RC,84450,CPT,,,,,,,,58,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,56.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,56.84
charcoal activated Liquid 240 mL Bottle,63700001,CDM,250,RC,,,,,,574012108,NDC,120,ML,66.88,,First Health,Commercial,both,85,,999999999,percent of total billed charges,56.848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium phosphate 15 MMOLE/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323088401,NDC,5,ML,132.6,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,56.8854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium phosphate 15 MMOLE/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323088406,NDC,5,ML,132.6,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,56.8854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,143950801,NDC,10,ML,58.46,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,11.07921788,percent of total billed charges,56.899118,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
Total Cortisol,PX82533,CDM,300,RC,82533,CPT,,,,,,,,137,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,56.9098,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.95,134.26
"Triiodothyronine T3, Free (Free T3)",PX84481,CDM,300,RC,84481,CPT,,,,,,,,137,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,56.9098,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.53,134.26
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,63323004401,NDC,1,ML,64.53,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,56.91546,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,63.2394
Assay of Triglycerides,PX84478,CDM,300,RC,84478,CPT,,,,,,,,115,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,56.925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.26,112.7
"Blood Typing, Rh Phenotype",PX86906,CDM,300,RC,86906,CPT,,,,,,,,115,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,56.925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.03,112.7
BRACE ANKLE LARGE 264015,120.51,CDM,274,RC,L1902,HCPCS,,4-MAIN,LOCAL,,,,,115,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,56.925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE MEDIUM 264014,120.51,CDM,274,RC,L1902,HCPCS,,7-MAIN,LOCAL,,,,,115,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,56.925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE SMALL 264012,120.51,CDM,274,RC,L1902,HCPCS,,12-MAIN,LOCAL,,,,,115,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,56.925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE X-LARGE 264016,120.51,CDM,274,RC,L1902,HCPCS,,14-MAIN,LOCAL,,,,,115,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,56.925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE X-SMALL 264011,120.51,CDM,274,RC,L1902,HCPCS,,1-MAIN,LOCAL,,,,,115,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,56.925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
Debride Skin/Subq Ea Ad 20sqcm,PX11045F,CDM,510,RC,11045,CPT,,,,,,,,115,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,56.925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
Glucagon - Ref,PX8294390,CDM,300,RC,82943,CPT,90,,,,,,,115,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,56.925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.1,112.7
"Immuno for Tumor Ag, Qn - Ref",PX8631690,CDM,300,RC,86316,CPT,90,,,,,,,115,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,56.925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,112.7
Microsomal Antibody,PX7893,CDM,300,RC,86376,CPT,,,,,,,,115,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,56.925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.34,112.7
CT Pelvis W/O Dye,PX7219201,CDM,350,RC,72192,CPT,TC,,,,,,,2744,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,56.94,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.94,168.29
CT Pelvis W/O Dye,PX7219201,CDM,350,RC,72192,CPT,TC,,,,,,,2744,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,56.94,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.94,168.29
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,143950810,NDC,10,ML,58.51,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,11.07921788,percent of total billed charges,56.947783,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
Sacubitril-Valsartan 49-51 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,78077720,NDC,1,EA,58.51,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,56.947783,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Group Therapeutic Procedures,PX97150,CDM,420,RC,97150,CPT,,,,,,,,67,,First Health,Commercial,both,85,,999999999,percent of total billed charges,56.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.82,65.66
"Hydroxyprogesterone, 17-D - Ref",PX8349890,CDM,300,RC,83498,CPT,90,,,,,,,67,,First Health,Commercial,both,85,,999999999,percent of total billed charges,56.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.91,65.66
Lab Org ID Anaerobic-Each,PX87076,CDM,300,RC,87076,CPT,,,,,,,,67,,First Health,Commercial,both,85,,999999999,percent of total billed charges,56.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,65.66
Blood Occult Peroxidase,PX82272,CDM,300,RC,82272,CPT,,,,,,,,64,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,56.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.88,62.72
Strapping of Elbow or Wrist,PX29260F,CDM,420,RC,29260,CPT,,,,,,,,64,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,56.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.5856,62.72
Strapping of Hand or Finger,PX29280F,CDM,420,RC,29280,CPT,,,,,,,,64,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,56.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.5856,62.72
"polyethylene glycol 236 g Recon Soln 4,000 mL Bottle",63700001,CDM,250,RC,,,,,,43386009019,NDC,4000,ML,112.6,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,56.9756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Acetaminophen,PX80307E,CDM,300,RC,80307,CPT,,,,,,,,370,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,56.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Alcohol,PX80307A,CDM,300,RC,80307,CPT,,,,,,,,370,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,56.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Salicylate,PX80307D,CDM,300,RC,80307,CPT,,,,,,,,370,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,56.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Urine Drug Screen,PX80307B,CDM,300,RC,80307,CPT,,,,,,,,370,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,56.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
TRAY HAND SURGICAL II DYNJS0806,27200000,CDM,272,RC,,,,11024-MAIN,LOCAL,,,,,64.62,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,56.99484,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
levoFLOXacin in dextrose 5% 500 MG/100ML Solution 100 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004724,NDC,100,ML,64.63,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,57.00366,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,76329339001,NDC,5,ML,64.63,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,57.00366,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060820,NDC,20,ML,58.57,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1.094496241,percent of total billed charges,57.006181,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
"sodium chloride 0.45 % 1,000 mL with potassium chloride 20 mEq 20-0.45 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070434,NDC,1000,ML,58.57,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,4.559571429,percent of total billed charges,57.006181,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,24208046325,NDC,2.5,ML,137.26,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,57.017804,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sacubitril-valsartan 24-26 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,78065920,NDC,1,EA,62.6,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,57.0286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990711509,NDC,1000,ML,64.08,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,57.0312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,63323047401,NDC,1,ML,58.6,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,57.03538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.428
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076501,NDC,1,EA,58.6,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,12.385,percent of total billed charges,57.03538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076510,NDC,1,EA,58.6,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,12.385,percent of total billed charges,57.03538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
TRUMPET SUCTION IRRIGATION,27100000,CDM,271,RC,,,,4577-MAIN,LOCAL,,,,,116.4,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,57.036,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
TRUMPET SUCTION IRRIGATION,27100000,CDM,271,RC,,,,4577-MAIN,LOCAL,,,,,116.4,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,57.036,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
TRUMPET SUCTION IRRIGATION,27100000,CDM,271,RC,,,,4577-MAIN,LOCAL,,,,,116.4,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,57.036,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,409672924,NDC,50,ML,116.43,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,5.851071429,percent of total billed charges,57.0507,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,409672924,NDC,50,ML,116.43,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,57.0507,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,409672924,NDC,50,ML,116.43,,United Healthcare,All Medicare advantage plans,outpatient,49,,13.925,percent of total billed charges,57.0507,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
"Cardiolipin Ab, Ea Lg - Ref",PX8614790,CDM,300,RC,86147,CPT,90,,,,,,,133,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,57.057,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.34,130.34
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU0003,CDM,300,RC,U0003,HCPCS,,,,,,,,133,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,57.057,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.2482,130.34
Lvl 1 Sub Hosp Low Mdm or 25 Minutes,PX99231,CDM,982,RC,99231,CPT,,,,,,,,133,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,57.057,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.2482,129.4489
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409663724,NDC,50,ML,115.32,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,57.0834,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086000,NDC,1,EA,58.66,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,11.23,percent of total billed charges,57.093778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086050,NDC,1,EA,58.66,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,11.23,percent of total billed charges,57.093778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012166,NDC,1,EA,58.66,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,18.705,percent of total billed charges,57.093778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
cefOXitin 1 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021010910,NDC,1,EA,58.66,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,57.093778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.367364,75.6952
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,65219025915,NDC,1,EA,58.66,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,13.11107143,percent of total billed charges,57.093778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
methylergonovine 0.2 MG/ML Solution 1 mL Ampule,J2210.01,CDM,636,RC,J2210,HCPCS,,,,51991014417,NDC,1,ML,133.11,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,57.10419,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.293894,130.4478
hepatitis b recomb vaccine 10 MCG/0.5ML suspension prefilled syringe 0.5 mL Syringe,90743,CDM,636,RC,90743,CPT,,,,58160082052,NDC,0.5,ML,137.47,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,57.105038,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.105038,134.7206
Creatinine; Other Source - Ref,PX82570,CDM,300,RC,82570,CPT,90,,,,,,,119,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,57.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,116.62
Creatinine; Other Source - Ref,PX82570,CDM,300,RC,82570,CPT,90,,,,,,,119,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,57.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,116.62
FLAT DRAIN HEMADUCT 7MM FULL DUCT WITH TROCAR SILICONE,27200000,CDM,272,RC,,,,12464-MAIN,LOCAL,,,,,119,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,57.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
FLAT DRAIN HEMADUCT 7MM FULL DUCT WITH TROCAR SILICONE,27200000,CDM,272,RC,,,,12464-MAIN,LOCAL,,,,,119,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,57.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Injection, Subq/Im",PX96372,CDM,260,RC,96372,CPT,,,,,,,,119,,Health Partners,Health Partners Care Plans,both,48,,76.11039216,percent of total billed charges,57.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,116.62
"Injection, Subq/Im",PX96372,CDM,260,RC,96372,CPT,,,,,,,,119,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,57.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,116.62
Irri Implted Drug Dlvr Device,PX96523,CDM,260,RC,96523,CPT,,,,,,,,119,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,57.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,116.62
Irri Implted Drug Dlvr Device,PX96523,CDM,260,RC,96523,CPT,,,,,,,,119,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,57.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,116.62
"Morphometric Analysis,Tumor Immunohistochemistry, Ea Antibody Manual , Tech",PX8836001,CDM,310,RC,88360,CPT,TC,,,,,,,119,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,57.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,149.22
"Morphometric Analysis,Tumor Immunohistochemistry, Ea Antibody Manual , Tech",PX8836001,CDM,310,RC,88360,CPT,TC,,,,,,,119,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,57.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,149.22
Office/Outpt Visit Est Level I,PX99211F,CDM,510,RC,99211,CPT,,,,,,,,119,,Health Partners,Health Partners Care Plans,both,48,,115.44,percent of total billed charges,57.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,116.62
Office/Outpt Visit Est Level I,PX99211F,CDM,510,RC,99211,CPT,,,,,,,,119,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,57.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,116.62
Sodium; Urine,PX84300,CDM,300,RC,84300,CPT,,,,,,,,119,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,57.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.64,116.62
Sodium; Urine,PX84300,CDM,300,RC,84300,CPT,,,,,,,,119,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,57.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.64,116.62
STIFNECK ADULT,120.77,CDM,274,RC,L0180,HCPCS,,991-MAIN,LOCAL,,,,,119,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,57.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,486.73
STIFNECK ADULT,120.77,CDM,274,RC,L0180,HCPCS,,991-MAIN,LOCAL,,,,,119,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,57.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,486.73
STIFNECK PEDIATRIC,120.77,CDM,274,RC,L0180,HCPCS,,998-MAIN,LOCAL,,,,,119,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,57.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,486.73
STIFNECK PEDIATRIC,120.77,CDM,274,RC,L0180,HCPCS,,998-MAIN,LOCAL,,,,,119,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,57.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,486.73
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,641601501,NDC,25,ML,58.29,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,57.1242,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059900,NDC,1,ML,133.16,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,57.12564,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.54253,130.4968
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059902,NDC,1,ML,133.16,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,57.12564,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.54253,130.4968
CT Lumbar Spine W/O Dye,PX7213101,CDM,350,RC,72131,CPT,TC,,,,,,,2757,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,57.15,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.15,168.95
CT Lumbar Spine W/O Dye,PX7213101,CDM,350,RC,72131,CPT,TC,,,,,,,2757,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,57.15,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.15,168.95
Diagnostic CT Thorax W/O Contrast,PX7125001,CDM,350,RC,71250,CPT,TC,,,,,,,2757,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,57.15,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.15,168.95
Diagnostic CT Thorax W/O Contrast,PX7125001,CDM,350,RC,71250,CPT,TC,,,,,,,2757,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,57.15,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.15,168.95
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323042605,NDC,5,ML,64.8,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,57.1536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,43598020453,NDC,10,ML,58.73,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,57.161909,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,72508020415,NDC,10,ML,58.73,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,57.161909,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323042405,NDC,5,ML,64.82,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,57.17124,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117630,NDC,1,ML,58.34,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,57.1732,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
Iadna Streptococcus Group a Amplified Probe Tq,PX87651,CDM,300,RC,87651,CPT,,,,,,,,113,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,57.178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,110.74
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209P,CDM,982,RC,69209,CPT,,,,,,,,113,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,57.178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9402,109.9829
Strapping of Toes,PX29550F,CDM,510,RC,29550,CPT,,,,,,,,113,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,57.178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9402,110.74
Xray Spine Single Tc,PX7202001,CDM,320,RC,72020,CPT,TC,,,,,,,113,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,57.178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9402,110.74
Xray Cervical Spine 2 or 3 Vws,PX7204001,CDM,320,RC,72040,CPT,TC,,,,,,,436,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,57.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.97,57.19
Xray Cervical Spine 2 or 3 Vws,PX7204001,CDM,320,RC,72040,CPT,TC,,,,,,,436,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,57.19,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.97,57.19
Xray Hand 3vws Tc,PX7313001,CDM,320,RC,73130,CPT,TC,,,,,,,374,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,57.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.75,57.19
Xray Hand 3vws Tc,PX7313001,CDM,320,RC,73130,CPT,TC,,,,,,,374,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,57.19,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.75,57.19
Xray Thoracic Spine 3 Vws,PX7207201,CDM,320,RC,72072,CPT,TC,,,,,,,522,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,57.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.75,57.19
Xray Thoracic Spine 3 Vws,PX7207201,CDM,320,RC,72072,CPT,TC,,,,,,,522,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,57.19,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.75,57.19
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,517460125,NDC,0.5,ML,58.76,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,57.191108,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
calcium CHLORIDE 10 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409163140,NDC,10,ML,64.85,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,57.1977,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003905,NDC,1,EA,58.77,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,57.200841,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
PACLitaxel 30 MG/5ML Concentrate 5 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476401,NDC,5,ML,58.37,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,57.2026,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
rivaroxaban 15 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50458057830,NDC,0.666666667,EA,67.3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,57.205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,143950801,NDC,10,ML,58.46,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,57.2908,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
budesonide 1 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097032187,NDC,1,ML,64.97,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,57.30354,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,16714076901,NDC,15,GR,137.99,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,57.321046,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505624500,NDC,1,EA,116.99,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,57.3251,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505624500,NDC,1,EA,116.99,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,57.3251,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505624500,NDC,1,EA,116.99,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,57.3251,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
"Alkaloids, Not Otherwise Specified - Ref",PX8032390,CDM,300,RC,80323,CPT,90,,,,,,,65,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,57.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.001,63.7
Anesthesia Level 3,PX37000017,CDM,370,RC,,,,,,,,,,65,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,57.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.001,63.7
Clozapine - Ref,PX8015990,CDM,300,RC,80159,CPT,90,,,,,,,65,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,57.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.48,63.7
Cryptosporidum,PX87328,CDM,300,RC,87328,CPT,,,,,,,,117,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,57.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.67,114.66
Cryptosporidum,PX87328,CDM,300,RC,87328,CPT,,,,,,,,117,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,57.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.67,114.66
Cryptosporidum,PX87328,CDM,300,RC,87328,CPT,,,,,,,,117,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,57.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.67,114.66
Drain Blood From Under Nail,PX11740F,CDM,510,RC,11740,CPT,,,,,,,,117,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,57.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.6018,114.66
Drain Blood From Under Nail,PX11740F,CDM,510,RC,11740,CPT,,,,,,,,117,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,57.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.6018,114.66
Drain Blood From Under Nail,PX11740F,CDM,510,RC,11740,CPT,,,,,,,,117,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,57.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.6018,114.66
Gastrin - Ref,PX8294190,CDM,300,RC,82941,CPT,90,,,,,,,65,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,57.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.16,63.7
Giardia,PX87329,CDM,300,RC,87329,CPT,,,,,,,,117,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,57.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,114.66
Giardia,PX87329,CDM,300,RC,87329,CPT,,,,,,,,117,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,57.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,114.66
Giardia,PX87329,CDM,300,RC,87329,CPT,,,,,,,,117,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,57.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,114.66
"In Situ Hybridization (Eg, Fish), Each Probe, Tech",PX8836501,CDM,310,RC,88365,CPT,TC,,,,,,,117,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,12.1,percent of total billed charges,57.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.6018,149.22
"In Situ Hybridization (Eg, Fish), Each Probe, Tech",PX8836501,CDM,310,RC,88365,CPT,TC,,,,,,,117,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,57.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.6018,149.22
"In Situ Hybridization (Eg, Fish), Each Probe, Tech",PX8836501,CDM,310,RC,88365,CPT,TC,,,,,,,117,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,57.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.6018,149.22
Insulin Ab - Ref,PX8633790,CDM,300,RC,86337,CPT,90,,,,,,,65,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,57.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.63,63.7
RBC Pretreatment,PX8697002,CDM,300,RC,86970,CPT,,,,,,,,117,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,57.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.6018,114.66
RBC Pretreatment,PX8697002,CDM,300,RC,86970,CPT,,,,,,,,117,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,57.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.6018,114.66
RBC Pretreatment,PX8697002,CDM,300,RC,86970,CPT,,,,,,,,117,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,57.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.6018,114.66
Resp Muscles 1:1 per 15 Min,PXG0237,CDM,948,RC,G0237,HCPCS,,,,,,,,65,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,57.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.01,63.7
Smking Cess 4-10 Min,PX99406F,CDM,942,RC,99406,CPT,,,,,,,,65,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,57.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.07,63.7
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,143950810,NDC,10,ML,58.51,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,57.3398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
Sacubitril-Valsartan 49-51 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,78077720,NDC,1,EA,58.51,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,57.3398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117603,NDC,1,ML,58.93,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,57.356569,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
CT Lower Extremity W/O Dye,PX7370001,CDM,350,RC,73700,CPT,TC,,,,,,,2757,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,57.37,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.37,169.61
CT Lower Extremity W/O Dye,PX7370001,CDM,350,RC,73700,CPT,TC,,,,,,,2757,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,57.37,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.37,169.61
CT Pelvis W/O Dye,PX7219201,CDM,350,RC,72192,CPT,TC,,,,,,,2744,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,57.37,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.94,168.29
dexmedeTOMIDine 200 MCG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,143953201,NDC,2,ML,62.98,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,57.37478,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
octreotide 200 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037805,NDC,1,ML,133.77,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,57.38733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
K-WIRE SMOOTH 1.4MM X 100MM,C1713,CDM,272,RC,C1713,HCPCS,,12634-MAIN,LOCAL,,,,,63,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,57.393,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
SUTURE MAXON MONOFILAMENT ABSORBABLE GREEN SIZE 1 96IN WITH 1/2 CIRCLE TAPER POINT 65MM NEEDLE,27200000,CDM,272,RC,,,,11986-MAIN,LOCAL,,,,,63,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,57.393,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Vitamin a - Ref,PX8459090,CDM,300,RC,84590,CPT,90,,,,,,,63,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,57.393,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.65,61.74
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060820,NDC,20,ML,58.57,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,57.3986,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
"sodium chloride 0.45 % 1,000 mL with potassium chloride 20 mEq 20-0.45 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070434,NDC,1000,ML,58.57,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,57.3986,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003930,NDC,1,EA,58.99,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,57.414967,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
Antithrombin III Ag Assay - Ref,PX8530190,CDM,300,RC,85301,CPT,90,,,,,,,116,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,57.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.91,113.68
Ca 19-9,PX86301,CDM,300,RC,86301,CPT,,,,,,,,116,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,57.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,113.68
Draw Blood Off Venous Device,PX36591F,CDM,510,RC,36591,CPT,,,,,,,,211,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,57.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.45,57.42
Draw Blood Off Venous Device,PX36591F,CDM,510,RC,36591,CPT,,,,,,,,211,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,57.42,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.45,57.42
DRAWTEX HYDROCONDUCTIVE NONADHERENT DRESSING,120.508,CDM,271,RC,A6199,HCPCS,,12022-MAIN,LOCAL,,,,,59,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,57.4247,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.5086,57.82
"Potassium; Serum, Plasma or Whole Blood",PX84132,CDM,300,RC,84132,CPT,,,,,,,,59,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,10.29571429,percent of total billed charges,57.4247,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.36,57.82
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,58602060407,NDC,100,GR,67.56,,First Health,Commercial,both,85,,999999999,percent of total billed charges,57.426,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,63323047401,NDC,1,ML,58.6,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,57.428,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.428
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076501,NDC,1,EA,58.6,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,57.428,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076510,NDC,1,EA,58.6,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,57.428,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,63323004401,NDC,1,ML,64.53,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,57.4317,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,63.2394
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,574722612,NDC,1,EA,67.57,,First Health,Commercial,both,85,,999999999,percent of total billed charges,57.4345,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.345782,66.2186
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,781329091,NDC,50,ML,119.73,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,57.4704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,781329091,NDC,50,ML,119.73,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,57.4704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086000,NDC,1,EA,58.66,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,57.4868,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086050,NDC,1,EA,58.66,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,57.4868,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012166,NDC,1,EA,58.66,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,57.4868,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
cefOXitin 1 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021010910,NDC,1,EA,58.66,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,57.4868,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.367364,75.6952
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,65219025915,NDC,1,EA,58.66,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,57.4868,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
KUMAR CHOLANGIOGRAPHY CATHETER,27200000,CDM,272,RC,,,,10230-MAIN,LOCAL,,,,,63.11,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,57.49321,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
aspirin-dipyridamole 25-200 MG Capsule Extended Release 12 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687030533,NDC,1,EA,67.66,,First Health,Commercial,both,85,,999999999,percent of total billed charges,57.511,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin-dipyridamole 25-200 MG Capsule Extended Release 12 Hour 20 Each Box,63700001,CDM,250,RC,,,,,,60687030532,NDC,1,EA,67.66,,First Health,Commercial,both,85,,999999999,percent of total billed charges,57.511,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
TRAY HAND SURGICAL II DYNJS0806,27200000,CDM,272,RC,,,,11024-MAIN,LOCAL,,,,,64.62,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,57.5118,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
levoFLOXacin in dextrose 5% 500 MG/100ML Solution 100 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004724,NDC,100,ML,64.63,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,57.5207,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,76329339001,NDC,5,ML,64.63,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,57.5207,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
amiodarone 900 MG/18ML Solution 18 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,67457015318,NDC,18,ML,113.73,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,57.54738,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,43598020453,NDC,10,ML,58.73,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,57.5554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,72508020415,NDC,10,ML,58.73,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,57.5554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,517460125,NDC,0.5,ML,58.76,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,57.5848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,57.5848
CT Lumbar Spine W/O Dye,PX7213101,CDM,350,RC,72131,CPT,TC,,,,,,,2757,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,57.59,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.15,168.95
Debride Bone Ea Add 20 Sqcm,PX11047F,CDM,510,RC,11047,CPT,,,,,,,,438,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,57.59,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.59,250.43
Debride Bone Ea Add 20 Sqcm,PX11047P,CDM,983,RC,11047,CPT,,,,,,,,351,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,57.59,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.59,343.98
Diagnostic CT Thorax W/O Contrast,PX7125001,CDM,350,RC,71250,CPT,TC,,,,,,,2757,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,57.59,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.15,168.95
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003905,NDC,1,EA,58.77,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,57.5946,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
"Compatibility Test,Antiglob Tech",PX86922,CDM,300,RC,86922,CPT,,,,,,,,120,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,57.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.848,149.22
"Compatibility Test,Antiglob Tech",PX86922,CDM,300,RC,86922,CPT,,,,,,,,120,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,57.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.848,149.22
KIWI OMNICUP VACUUM DELIVERY SYSTEM,120.225,CDM,272,RC,,,,11608-MAIN,LOCAL,,,,,120,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,57.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.848,117.6
KIWI OMNICUP VACUUM DELIVERY SYSTEM,120.225,CDM,272,RC,,,,11608-MAIN,LOCAL,,,,,120,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,57.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.848,117.6
VACUUM KIWI W/PALM PUMP,120.225,CDM,272,RC,,,,10028-MAIN,LOCAL,,,,,120,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,57.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.848,117.6
VACUUM KIWI W/PALM PUMP,120.225,CDM,272,RC,,,,10028-MAIN,LOCAL,,,,,120,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,57.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.848,117.6
TRUMPET SUCTION IRRIGATION,27100000,CDM,271,RC,,,,4577-MAIN,LOCAL,,,,,116.4,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,57.618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,409672924,NDC,50,ML,116.43,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,57.63285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
triamcinolone acetonide 0.1 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,16714098602,NDC,30,GR,59.22,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,57.638826,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,45802011222,NDC,22,GR,63.29,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,57.65719,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623100,NDC,1,EA,59.25,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,23.54375,percent of total billed charges,57.668025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323042605,NDC,5,ML,64.8,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,57.672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Assay of Erythropoietin,PX82668,CDM,300,RC,82668,CPT,,,,,,,,114,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,57.684,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,111.72
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623105,NDC,1,EA,59.27,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,23.54375,percent of total billed charges,57.687491,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323042405,NDC,5,ML,64.82,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,57.6898,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,63323050830,NDC,1,EA,134.48,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,57.69192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.461584,189.875
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039801,NDC,1,EA,67.88,,First Health,Commercial,both,85,,999999999,percent of total billed charges,57.698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039810,NDC,1,EA,67.88,,First Health,Commercial,both,85,,999999999,percent of total billed charges,57.698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
ocrelizumab 300 MG/10ML Solution 10 mL Vial,J2350.01,CDM,636,RC,J2350,HCPCS,,,,50242015001,NDC,10,ML,33150,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,57.71298,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.48,59.75
calcium CHLORIDE 10 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409163140,NDC,10,ML,64.85,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,57.7165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Lab Basic Metabolic Panel,PX80048,CDM,300,RC,80048,CPT,,,,,,,,236,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,57.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.76,231.28
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117603,NDC,1,ML,58.93,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,57.7514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31053,57.7514
ofloxacin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,17478071310,NDC,5,ML,117.89,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,57.7661,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ofloxacin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,17478071310,NDC,5,ML,117.89,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,57.7661,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ofloxacin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,17478071310,NDC,5,ML,117.89,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,57.7661,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608210,NDC,1,ML,63.43,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,57.78473,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
Injection for Nerve Block,PX64447F,CDM,510,RC,64447,CPT,,,,,,,,3023,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,57.798,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.05,240.75
Injection for Nerve Block,PX64447P,CDM,983,RC,64447,CPT,,,,,,,,3892,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,57.798,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.05,3814.16
"Flour. Afstain , Micro - Ref",PX8720690,CDM,300,RC,87206,CPT,90,,,,,,,68,,First Health,Commercial,both,85,,999999999,percent of total billed charges,57.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.94,66.64
Hemoglobin,PX85018,CDM,300,RC,85018,CPT,,,,,,,,68,,First Health,Commercial,both,85,,999999999,percent of total billed charges,57.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.17,66.64
Thyroglobulin - Ref,PX8443290,CDM,300,RC,84432,CPT,90,,,,,,,68,,First Health,Commercial,both,85,,999999999,percent of total billed charges,57.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.73,66.64
Thyroglobulin Antibody,PX8680090,CDM,300,RC,86800,CPT,90,,,,,,,68,,First Health,Commercial,both,85,,999999999,percent of total billed charges,57.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.59,66.64
CT Lower Extremity W/O Dye,PX7370001,CDM,350,RC,73700,CPT,TC,,,,,,,2757,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,57.81,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.37,169.61
CT Neck Spine W/O Dye,PX7212501,CDM,350,RC,72125,CPT,TC,,,,,,,2757,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,57.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.81,170.92
CT Neck Spine W/O Dye,PX7212501,CDM,350,RC,72125,CPT,TC,,,,,,,2757,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,57.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.81,170.92
Debride Bone Ea Add 20 Sqcm,PX11047F,CDM,510,RC,11047,CPT,,,,,,,,438,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,57.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.59,250.43
Debride Bone Ea Add 20 Sqcm,PX11047F,CDM,510,RC,11047,CPT,,,,,,,,438,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,57.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.59,250.43
Debride Bone Ea Add 20 Sqcm,PX11047P,CDM,983,RC,11047,CPT,,,,,,,,351,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,57.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.59,343.98
Debride Bone Ea Add 20 Sqcm,PX11047P,CDM,983,RC,11047,CPT,,,,,,,,351,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,57.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.59,343.98
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003930,NDC,1,EA,58.99,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,57.8102,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
DRAWTEX HYDROCONDUCTIVE NONADHERENT DRESSING,120.508,CDM,271,RC,A6199,HCPCS,,12022-MAIN,LOCAL,,,,,59,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,57.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.5086,57.82
Fibrinolysins Screen - Ref,PX8539090,CDM,300,RC,85390,CPT,90,,,,,,,118,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,57.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.19,115.64
Fibrinolysins Screen - Ref,PX8539090,CDM,300,RC,85390,CPT,90,,,,,,,118,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,57.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.19,115.64
Fibrinolysins Screen - Ref,PX8539090,CDM,300,RC,85390,CPT,90,,,,,,,118,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,57.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.19,115.64
"Potassium; Serum, Plasma or Whole Blood",PX84132,CDM,300,RC,84132,CPT,,,,,,,,59,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,57.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.36,57.82
budesonide 1 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097032187,NDC,1,ML,64.97,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,57.8233,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
terbinafine 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714079501,NDC,1,EA,68.03,,First Health,Commercial,both,85,,999999999,percent of total billed charges,57.8255,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terbinafine 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714050101,NDC,1,EA,68.04,,First Health,Commercial,both,85,,999999999,percent of total billed charges,57.834,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylene blue 1 % Solution 10 mL Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,54288014701,NDC,1,ML,139.25,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,57.84445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.29,1354.4776
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032050,NDC,1,EA,120.51,,Health Partners,Health Partners Care Plans,both,48,,6.796666667,percent of total billed charges,57.8448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032050,NDC,1,EA,120.51,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,57.8448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
X-Ray Exam Chest 3 Views,PX7104701,CDM,320,RC,71047,CPT,TC,,,,,,,340,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,57.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.19,57.85
X-Ray Exam Chest 3 Views,PX7104701,CDM,320,RC,71047,CPT,TC,,,,,,,340,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,57.85,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.19,57.85
Xray Lumbosacral 2 or 3 Vws,PX7210001,CDM,320,RC,72100,CPT,TC,,,,,,,399,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,57.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.19,57.85
Xray Lumbosacral 2 or 3 Vws,PX7210001,CDM,320,RC,72100,CPT,TC,,,,,,,399,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,57.85,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.19,57.85
"Alkaloids, Not Otherwise Specified - Ref",PX8032390,CDM,300,RC,80323,CPT,90,,,,,,,65,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,57.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.001,63.7
Anesthesia Level 3,PX37000017,CDM,370,RC,,,,,,,,,,65,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,57.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.001,63.7
Clozapine - Ref,PX8015990,CDM,300,RC,80159,CPT,90,,,,,,,65,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,57.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.48,63.7
Gastrin - Ref,PX8294190,CDM,300,RC,82941,CPT,90,,,,,,,65,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,57.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.16,63.7
Insulin Ab - Ref,PX8633790,CDM,300,RC,86337,CPT,90,,,,,,,65,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,57.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.63,63.7
Resp Muscles 1:1 per 15 Min,PXG0237,CDM,948,RC,G0237,HCPCS,,,,,,,,65,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,57.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.01,63.7
Smking Cess 4-10 Min,PX99406F,CDM,942,RC,99406,CPT,,,,,,,,65,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,57.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.07,63.7
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618201,NDC,2,ML,120.53,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,57.8544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.068162,123.3918
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618201,NDC,2,ML,120.53,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,57.8544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.068162,123.3918
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618210,NDC,2,ML,120.53,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,57.8544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.068162,123.3918
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618210,NDC,2,ML,120.53,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,57.8544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.068162,123.3918
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606001,NDC,10,ML,65.62,,United Healthcare,All Payer,outpatient,88.2,,25.35,percent of total billed charges,57.87684,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606010,NDC,10,ML,65.62,,United Healthcare,All Payer,outpatient,88.2,,25.35,percent of total billed charges,57.87684,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
Observation Initial,PXG0378.03,CDM,762,RC,G0378,HCPCS,,,,,,,,680,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,57.9,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.9,57.9
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,55150020200,NDC,1,EA,65.65,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,57.9033,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505624500,NDC,1,EA,116.99,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,57.91005,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
naloxone 2 MG/2ML solution prefilled syringe 2 mL Syringe,J2310.01,CDM,636,RC,J2310,HCPCS,,,,76329346901,NDC,1,ML,114.45,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,57.9117,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.54253,130.4968
"Cognitive Funct Ther Interv, per Day",PX97127,CDM,420,RC,97127,CPT,,,,,,,,135,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,57.915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.079,132.3
Cryptosporidum,PX87328,CDM,300,RC,87328,CPT,,,,,,,,117,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,57.915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.67,114.66
Drain Blood From Under Nail,PX11740F,CDM,510,RC,11740,CPT,,,,,,,,117,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,57.915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.6018,114.66
Electric Stimulation Therapy,PX97014,CDM,420,RC,97014,CPT,,,,,,,,135,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,57.915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.18,132.3
Electrical Stimulation,PX97032,CDM,420,RC,97032,CPT,,,,,,,,135,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,57.915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,132.3
Gait Training Therapy,PX97116,CDM,420,RC,97116,CPT,,,,,,,,135,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,57.915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20,132.3
Giardia,PX87329,CDM,300,RC,87329,CPT,,,,,,,,117,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,57.915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,114.66
"In Situ Hybridization (Eg, Fish), Each Probe, Tech",PX8836501,CDM,310,RC,88365,CPT,TC,,,,,,,117,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,57.915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.6018,149.22
"Manual Ther Tech,1+Regions,Ea 15 Min",PX97140,CDM,420,RC,97140,CPT,,,,,,,,135,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,57.915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.4,215.05
Mechanical Traction Therapy,PX97012,CDM,420,RC,97012,CPT,,,,,,,,135,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,57.915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,132.3
Neuromuscular Re-Education,PX97112,CDM,420,RC,97112,CPT,,,,,,,,135,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,57.915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.95,215.05
RBC Pretreatment,PX8697002,CDM,300,RC,86970,CPT,,,,,,,,117,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,57.915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.6018,114.66
Self Care Mngment Training,PX97535,CDM,420,RC,97535,CPT,,,,,,,,135,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,57.915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.27,132.3
Therapeutic Activities,PX97530,CDM,420,RC,97530,CPT,,,,,,,,135,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,57.915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.22,205.7
Therapeutic Exercises,PX97110,CDM,420,RC,97110,CPT,,,,,,,,135,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,57.915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20,215.05
Ultrasound Therapy,PX97035,CDM,420,RC,97035,CPT,,,,,,,,135,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,57.915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,132.3
levonorgestrel 1.5 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,62756071860,NDC,1,EA,114.48,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,57.92688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018200,NDC,10,ML,68.21,,First Health,Commercial,both,85,,999999999,percent of total billed charges,57.9785,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.24,991.564
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018210,NDC,10,ML,68.21,,First Health,Commercial,both,85,,999999999,percent of total billed charges,57.9785,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.24,991.564
triamcinolone acetonide 0.1 % Cream 80 g Tube,63700001,CDM,250,RC,,,,,,16714098603,NDC,80,GR,65.76,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,58.00032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CT Neck Spine W/O Dye,PX7212501,CDM,350,RC,72125,CPT,TC,,,,,,,2757,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,58.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.81,170.92
"Digital Mamm, Diag, Unilat, Tc W/Cad Perf",PX7706501,CDM,401,RC,77065,CPT,TC,,,,,,,293,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,58.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.03,172.24
US Transvaginal Tc,PX7683001,CDM,402,RC,76830,CPT,TC,,,,,,,472,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,58.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.03,171.58
US Transvaginal Tc,PX7683001,CDM,402,RC,76830,CPT,TC,,,,,,,472,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,58.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.03,171.58
US Transvaginal Tc,PX7683001,CDM,402,RC,76830,CPT,TC,,,,,,,472,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,58.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.03,171.58
triamcinolone acetonide 0.1 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,16714098602,NDC,30,GR,59.22,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,58.0356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,713013512,NDC,1,EA,65.83,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,58.06206,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.345782,66.2186
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623100,NDC,1,EA,59.25,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,58.065,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,70655000206,NDC,100,ML,59.67,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,58.076811,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.786918,140.5516
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457000110,NDC,10,ML,59.67,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,11.07921788,percent of total billed charges,58.076811,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013266,NDC,50,ML,59.67,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,2.672307692,percent of total billed charges,58.076811,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013268,NDC,150,ML,59.67,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,2.672307692,percent of total billed charges,58.076811,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
BAG LEG URINARY STND 32OZ,120.33,CDM,272,RC,A5112,HCPCS,,4433-MAIN,LOCAL,,,,,121,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,58.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
BAG LEG URINARY STND 32OZ,120.33,CDM,272,RC,A5112,HCPCS,,4433-MAIN,LOCAL,,,,,121,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,58.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
BAG URINARY DRAINAGE 2000ML 6300,120.33,CDM,274,RC,A4357,HCPCS,,1283-MAIN,LOCAL,,,,,121,,Health Partners,Health Partners Care Plans,both,48,,6.98,percent of total billed charges,58.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
BAG URINARY DRAINAGE 2000ML 6300,120.33,CDM,274,RC,A4357,HCPCS,,1283-MAIN,LOCAL,,,,,121,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,58.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
BAG URINARY LEG PACK 9349,120.33,CDM,272,RC,A5112,HCPCS,,623-MAIN,LOCAL,,,,,121,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,58.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
BAG URINARY LEG PACK 9349,120.33,CDM,272,RC,A5112,HCPCS,,623-MAIN,LOCAL,,,,,121,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,58.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
"Chest Wall Manipulation,Initial",PX94667,CDM,410,RC,94667,CPT,,,,,,,,121,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,58.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.2634,118.58
"Chest Wall Manipulation,Initial",PX94667,CDM,410,RC,94667,CPT,,,,,,,,121,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,58.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.2634,118.58
"Fluor Noninfect Ab Sc, Ea - Ref",PX8625590,CDM,300,RC,86255,CPT,90,,,,,,,121,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,58.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.05,118.58
"Fluor Noninfect Ab Sc, Ea - Ref",PX8625590,CDM,300,RC,86255,CPT,90,,,,,,,121,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,58.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.05,118.58
"Manage/Train Orthotic/Prosthetic, per 15 Min",PX97763,CDM,420,RC,97763,CPT,,,,,,,,121,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,58.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.36,118.58
"Manage/Train Orthotic/Prosthetic, per 15 Min",PX97763,CDM,420,RC,97763,CPT,,,,,,,,121,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,58.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.36,118.58
"Prosthetic Training, Initial, Each 15 Mins",PX97761,CDM,420,RC,97761,CPT,,,,,,,,121,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,58.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.41,118.58
"Prosthetic Training, Initial, Each 15 Mins",PX97761,CDM,420,RC,97761,CPT,,,,,,,,121,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,58.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.41,118.58
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050601,NDC,1,ML,68.33,,First Health,Commercial,both,85,,999999999,percent of total billed charges,58.0805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010520,NDC,1,EA,68.33,,First Health,Commercial,both,85,,999999999,percent of total billed charges,58.0805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010541,NDC,1,EA,68.33,,First Health,Commercial,both,85,,999999999,percent of total billed charges,58.0805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623105,NDC,1,EA,59.27,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,58.0846,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
pramox-PE-glycerin-petrolatum 1-0.25-14.4-15 % Cream 51 g Tube,63700001,CDM,250,RC,,,,,,573286898,NDC,51,GR,68.34,,First Health,Commercial,both,85,,999999999,percent of total billed charges,58.089,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Level IV - Surgical Pathology, Gross and Microscopic Examination , Tech",PX3934,CDM,310,RC,88305,CPT,TC,,,,,,,185,,UCare,Individual and Family Plans,both,,,94.17257143,fee schedule,58.096,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.06,58.096
"Level IV - Surgical Pathology, Gross and Microscopic Examination , Tech",PX3934,CDM,310,RC,88305,CPT,TC,,,,,,,185,,UCare,Individual and Family Plans,both,,,94.17257143,fee schedule,58.096,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.06,58.096
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337501,NDC,50,ML,135.43,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,58.09947,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337502,NDC,50,ML,135.43,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,58.09947,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9678001,NDC,50,ML,135.43,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,58.09947,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
Strapping of Ankle,PX29540F,CDM,420,RC,29540,CPT,,,,,,,,271,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,58.11,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.68,58.11
Apply Forearm Cast,PX29075F,CDM,510,RC,29075,CPT,,,,,,,,210,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,58.1191,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.83,186.09
Apply Forearm Cast,PX29075P,CDM,983,RC,29075,CPT,,,,,,,,140,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,58.1191,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.83,186.09
Fna W/Image,PX10022F,CDM,510,RC,10022,CPT,,,,,,,,742,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,58.1191,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.1191,58.12
Fna W/Image,PX10022F,CDM,510,RC,10022,CPT,,,,,,,,742,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,58.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.1191,58.12
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457000100,NDC,10,ML,68.38,,First Health,Commercial,both,85,,999999999,percent of total billed charges,58.123,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
TISSUE RETRIEVAL SYSTEM,27200000,CDM,272,RC,,,,10233-MAIN,LOCAL,,,,,139.98,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,58.147692,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,43598040516,NDC,0.2,ML,63.83,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,58.14913,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
Apply Forearm Cast,PX29075P,CDM,983,RC,29075,CPT,,,,,,,,140,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,58.156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.156,234.62
Hospital Discharge Day>30 Min,PX99239P,CDM,982,RC,99239,CPT,,,,,,,,140,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,58.156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.156,136.262
apixaban 2.5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,3089321,NDC,1,EA,63.84,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,58.15824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine-epinephrine-tetracaine Gel 3 mL Syringe,J3490.160,CDM,636,RC,J3490,HCPCS,,,,88888800028,NDC,3,ML,121.19,,Health Partners,Health Partners Care Plans,both,48,,31.91277778,percent of total billed charges,58.1712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.342326,118.7662
lidocaine-epinephrine-tetracaine Gel 3 mL Syringe,J3490.160,CDM,636,RC,J3490,HCPCS,,,,88888800028,NDC,3,ML,121.19,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,58.1712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.342326,118.7662
Assay of Triglycerides,PX84478,CDM,300,RC,84478,CPT,,,,,,,,115,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,58.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.26,112.7
"Blood Typing, Rh Phenotype",PX86906,CDM,300,RC,86906,CPT,,,,,,,,115,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,58.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.03,112.7
BRACE ANKLE LARGE 264015,120.51,CDM,274,RC,L1902,HCPCS,,4-MAIN,LOCAL,,,,,115,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,58.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE MEDIUM 264014,120.51,CDM,274,RC,L1902,HCPCS,,7-MAIN,LOCAL,,,,,115,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,58.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE SMALL 264012,120.51,CDM,274,RC,L1902,HCPCS,,12-MAIN,LOCAL,,,,,115,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,58.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE X-LARGE 264016,120.51,CDM,274,RC,L1902,HCPCS,,14-MAIN,LOCAL,,,,,115,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,58.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE X-SMALL 264011,120.51,CDM,274,RC,L1902,HCPCS,,1-MAIN,LOCAL,,,,,115,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,58.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
Debride Skin/Subq Ea Ad 20sqcm,PX11045F,CDM,510,RC,11045,CPT,,,,,,,,115,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,58.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
Glucagon - Ref,PX8294390,CDM,300,RC,82943,CPT,90,,,,,,,115,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,58.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.1,112.7
"Immuno for Tumor Ag, Qn - Ref",PX8631690,CDM,300,RC,86316,CPT,90,,,,,,,115,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,58.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,112.7
Microsomal Antibody,PX7893,CDM,300,RC,86376,CPT,,,,,,,,115,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,58.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.34,112.7
Ig Paraprotein Qual Bld/UR,PX0077U90,CDM,300,RC,0077U,HCPCS,90,,,,,,,66,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,58.212,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
"Level III - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3933,CDM,310,RC,88304,CPT,TC,,,,,,,66,,United Healthcare,All Payer,outpatient,88.2,,34.98,percent of total billed charges,58.212,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
Ot Contracted Service/Msho/MA,PX120.178,CDM,431,RC,,,,,,,,,,66,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,58.212,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
Pt Contracted Service/Msho,PX120.176,CDM,421,RC,,,,,,,,,,66,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,58.212,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
Surg Pathology-Level 2-Tc,PX3932,CDM,310,RC,88302,CPT,TC,,,,,,,66,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,58.212,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.01,64.68
Xray Orbits Optic Foramina,PX7019001,CDM,320,RC,70190,CPT,TC,,,,,,,66,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,58.212,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,79.39
doxycycline 100 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323013041,NDC,1,EA,140.2,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,58.23908,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Closed Rx I-P Jt,Toe Dislocation",PX28660F,CDM,510,RC,28660,CPT,,,,,,,,335,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,58.24,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.24,267.03
"Closed Rx I-P Jt,Toe Dislocation",PX28660P,CDM,983,RC,28660,CPT,,,,,,,,628,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,58.24,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.24,615.44
"Digital Mamm, Diag, Unilat, Tc W/Cad Perf",PX7706501,CDM,401,RC,77065,CPT,TC,,,,,,,293,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,58.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.03,172.24
"Digital Mamm, Diag, Unilat, Tc W/Cad Perf",PX7706501,CDM,401,RC,77065,CPT,TC,,,,,,,293,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,58.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.03,172.24
BUPivacaine 0.25 % Solution 50 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046557,NDC,30,ML,59.84,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.296682081,percent of total billed charges,58.242272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409493311,NDC,10,ML,66.06,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,58.26492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
Blood Occult Peroxidase,PX82272,CDM,300,RC,82272,CPT,,,,,,,,64,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,58.304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.88,62.72
Strapping of Elbow or Wrist,PX29260F,CDM,420,RC,29260,CPT,,,,,,,,64,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,58.304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.5856,62.72
Strapping of Hand or Finger,PX29280F,CDM,420,RC,29280,CPT,,,,,,,,64,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,58.304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.5856,62.72
"BUPivacaine 0.25%-EPINEPHrine 1:200,000 0.25% -1:200000 Solution 50 mL Vial",25000000,CDM,250,RC,,,,,,409175250,NDC,30,ML,68.6,,First Health,Commercial,both,85,,999999999,percent of total billed charges,58.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Apply Short Leg Cast,Walker",PX29425P,CDM,983,RC,29425,CPT,,,,,,,,119,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,58.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,234.62
"Apply Short Leg Cast,Walker",PX29425P,CDM,983,RC,29425,CPT,,,,,,,,119,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,58.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,234.62
"Apply Short Leg Cast,Walker",PX29425P,CDM,983,RC,29425,CPT,,,,,,,,119,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,58.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,234.62
Creatinine; Other Source - Ref,PX82570,CDM,300,RC,82570,CPT,90,,,,,,,119,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,58.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,116.62
Creatinine; Other Source - Ref,PX82570,CDM,300,RC,82570,CPT,90,,,,,,,119,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,58.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,116.62
Creatinine; Other Source - Ref,PX82570,CDM,300,RC,82570,CPT,90,,,,,,,119,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,58.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,116.62
FLAT DRAIN HEMADUCT 7MM FULL DUCT WITH TROCAR SILICONE,27200000,CDM,272,RC,,,,12464-MAIN,LOCAL,,,,,119,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,58.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
FLAT DRAIN HEMADUCT 7MM FULL DUCT WITH TROCAR SILICONE,27200000,CDM,272,RC,,,,12464-MAIN,LOCAL,,,,,119,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,58.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
FLAT DRAIN HEMADUCT 7MM FULL DUCT WITH TROCAR SILICONE,27200000,CDM,272,RC,,,,12464-MAIN,LOCAL,,,,,119,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,58.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Injection, Subq/Im",PX96372,CDM,260,RC,96372,CPT,,,,,,,,119,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,32.52085714,percent of total billed charges,58.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,116.62
"Injection, Subq/Im",PX96372,CDM,260,RC,96372,CPT,,,,,,,,119,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,58.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,116.62
"Injection, Subq/Im",PX96372,CDM,260,RC,96372,CPT,,,,,,,,119,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,58.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,116.62
Irri Implted Drug Dlvr Device,PX96523,CDM,260,RC,96523,CPT,,,,,,,,119,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,58.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,116.62
Irri Implted Drug Dlvr Device,PX96523,CDM,260,RC,96523,CPT,,,,,,,,119,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,58.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,116.62
Irri Implted Drug Dlvr Device,PX96523,CDM,260,RC,96523,CPT,,,,,,,,119,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,58.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,116.62
"Morphometric Analysis,Tumor Immunohistochemistry, Ea Antibody Manual , Tech",PX8836001,CDM,310,RC,88360,CPT,TC,,,,,,,119,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,58.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,149.22
"Morphometric Analysis,Tumor Immunohistochemistry, Ea Antibody Manual , Tech",PX8836001,CDM,310,RC,88360,CPT,TC,,,,,,,119,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,58.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,149.22
"Morphometric Analysis,Tumor Immunohistochemistry, Ea Antibody Manual , Tech",PX8836001,CDM,310,RC,88360,CPT,TC,,,,,,,119,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,58.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,149.22
Office/Outpt Visit Est Level I,PX99211F,CDM,510,RC,99211,CPT,,,,,,,,119,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,119,percent of total billed charges,58.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,116.62
Office/Outpt Visit Est Level I,PX99211F,CDM,510,RC,99211,CPT,,,,,,,,119,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,58.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,116.62
Office/Outpt Visit Est Level I,PX99211F,CDM,510,RC,99211,CPT,,,,,,,,119,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,58.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,116.62
Office/Outpt Visit Est Level I,PX99211P,CDM,983,RC,99211,CPT,,,,,,,,119,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,119,percent of total billed charges,58.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,115.8227
Office/Outpt Visit Est Level I,PX99211P,CDM,983,RC,99211,CPT,,,,,,,,119,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,58.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,115.8227
Office/Outpt Visit Est Level I,PX99211P,CDM,983,RC,99211,CPT,,,,,,,,119,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,58.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,115.8227
Sodium; Urine,PX84300,CDM,300,RC,84300,CPT,,,,,,,,119,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,58.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.64,116.62
Sodium; Urine,PX84300,CDM,300,RC,84300,CPT,,,,,,,,119,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,58.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.64,116.62
Sodium; Urine,PX84300,CDM,300,RC,84300,CPT,,,,,,,,119,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,58.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.64,116.62
STIFNECK ADULT,120.77,CDM,274,RC,L0180,HCPCS,,991-MAIN,LOCAL,,,,,119,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,23.53333333,percent of total billed charges,58.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,486.73
STIFNECK ADULT,120.77,CDM,274,RC,L0180,HCPCS,,991-MAIN,LOCAL,,,,,119,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,58.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,486.73
STIFNECK ADULT,120.77,CDM,274,RC,L0180,HCPCS,,991-MAIN,LOCAL,,,,,119,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,58.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,486.73
STIFNECK PEDIATRIC,120.77,CDM,274,RC,L0180,HCPCS,,998-MAIN,LOCAL,,,,,119,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,23.53333333,percent of total billed charges,58.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,486.73
STIFNECK PEDIATRIC,120.77,CDM,274,RC,L0180,HCPCS,,998-MAIN,LOCAL,,,,,119,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,58.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,486.73
STIFNECK PEDIATRIC,120.77,CDM,274,RC,L0180,HCPCS,,998-MAIN,LOCAL,,,,,119,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,58.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,486.73
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409663724,NDC,50,ML,115.32,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,58.35192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ofloxacin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,17478071310,NDC,5,ML,117.89,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,58.35555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990711509,NDC,1000,ML,64.08,,Medica,Commercial,both,91.1,,1.111818182,percent of total billed charges,58.37688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,703115301,NDC,4,ML,136.1,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,58.3869,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Capillary Blood Collection,PX36416,CDM,300,RC,36416,CPT,,,,,,,,60,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,58.398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,58.8
HERNIA BELT MENS TRUSS LARGE,120.526,CDM,274,RC,L8310,HCPCS,,12221-MAIN,LOCAL,,,,,60,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,58.398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,160.6
HERNIA BELT MENS TRUSS MEDIUM,120.526,CDM,274,RC,L8310,HCPCS,,12220-MAIN,LOCAL,,,,,60,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,58.398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,160.6
HERNIA BELT MENS TRUSS XLARGE,120.526,CDM,274,RC,L8310,HCPCS,,12222-MAIN,LOCAL,,,,,60,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,58.398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,160.6
"IMMOBILIZER KNEE  24"" 7041-44",120.22,CDM,274,RC,L1830,HCPCS,,595-MAIN,LOCAL,,,,,60,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,12,percent of total billed charges,58.398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE 16"" UNIVERSAL 7088-04",120.22,CDM,274,RC,L1830,HCPCS,,589-MAIN,LOCAL,,,,,60,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,12,percent of total billed charges,58.398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
IMMOBILIZER KNEE 20 INCH ORT2420019,120.22,CDM,274,RC,L1830,HCPCS,,587-MAIN,LOCAL,,,,,60,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,12,percent of total billed charges,58.398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE 20"" LARGE FOAM COUNTOURED STAYS 7062-03",120.22,CDM,274,RC,L1830,HCPCS,,593-MAIN,LOCAL,,,,,60,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,12,percent of total billed charges,58.398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE 20"" QUICK-WRAP ORT2440020S",120.22,CDM,274,RC,L1830,HCPCS,,591-MAIN,LOCAL,,,,,60,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,12,percent of total billed charges,58.398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
IMMOBILIZER KNEE CUTAWAY STRAIGHT 2 7041-05,120.22,CDM,274,RC,L1830,HCPCS,,596-MAIN,LOCAL,,,,,60,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,12,percent of total billed charges,58.398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606001,NDC,10,ML,65.62,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,58.4018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606010,NDC,10,ML,65.62,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,58.4018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
Fibrinolysins Screen - Ref,PX8539090,CDM,300,RC,85390,CPT,90,,,,,,,118,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,58.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.19,115.64
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,55150020200,NDC,1,EA,65.65,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,58.4285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,51672131200,NDC,22,GR,140.7,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,58.44678,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,25021011487,NDC,200,ML,66.28,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,58.45896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.20921,64.9544
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,70655000206,NDC,100,ML,59.67,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,58.4766,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.786918,140.5516
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457000110,NDC,10,ML,59.67,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,58.4766,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013266,NDC,50,ML,59.67,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,58.4766,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013268,NDC,150,ML,59.67,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,58.4766,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
IV 0.9% NS 1000ML 2B1324X,27200000,CDM,272,RC,,,,538-MAIN,LOCAL,,,,,121.89,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,58.5072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
IV 0.9% NS 1000ML 2B1324X,27200000,CDM,272,RC,,,,538-MAIN,LOCAL,,,,,121.89,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,58.5072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"DXA, Bone Density Study, Hips/Pelv/Spine",PX7708001,CDM,320,RC,77080,CPT,TC,,,,,,,575,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,58.51,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.75,58.51
"DXA, Bone Density Study, Hips/Pelv/Spine",PX7708001,CDM,320,RC,77080,CPT,TC,,,,,,,575,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,58.51,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.75,58.51
US Guide Needle Bx S&I,PX7694226,CDM,982,RC,76942,CPT,26,,,,,,,148,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,58.51,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.97,145.04
US Guide Needle Bx S&I,PX7694226,CDM,982,RC,76942,CPT,26,,,,,,,148,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,58.51,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.97,145.04
Xray Nasal Bones Minimum 3 Vws,PX7016001,CDM,320,RC,70160,CPT,TC,,,,,,,456,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,58.51,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.63,58.51
Xray Nasal Bones Minimum 3 Vws,PX7016001,CDM,320,RC,70160,CPT,TC,,,,,,,456,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,58.51,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.63,58.51
Xray Ribs Unilat 2 Vws With Pa Chest,PX7110101,CDM,320,RC,71101,CPT,TC,,,,,,,792,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,58.51,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.41,58.51
Xray Ribs Unilat 2 Vws With Pa Chest,PX7110101,CDM,320,RC,71101,CPT,TC,,,,,,,792,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,58.51,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.41,58.51
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Package,25000000,CDM,250,RC,,,,,,10019055390,NDC,1,EA,121.9,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,58.512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Package,25000000,CDM,250,RC,,,,,,10019055390,NDC,1,EA,121.9,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,58.512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pembrolizumab 100 MG/4ML Solution 4 mL Vial,J9271.01,CDM,636,RC,J9271,HCPCS,,,,6302602,NDC,4,ML,9627.58,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,58.52,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.98,58.52
pembrolizumab 100 MG/4ML Solution 4 mL Vial,J9271.01,CDM,636,RC,J9271,HCPCS,,,,6302602,NDC,4,ML,9627.58,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,58.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.57,9435.0284
OLANZapine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60505311000,NDC,1,EA,60.13,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,58.524529,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
triamcinolone acetonide 0.1 % Cream 80 g Tube,63700001,CDM,250,RC,,,,,,16714098603,NDC,80,GR,65.76,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,58.5264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 0.3 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,61314065625,NDC,2.5,ML,140.92,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,58.538168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Tc99 Mebrofenin to 15 Mci,PXA9537,CDM,343,RC,A9537,HCPCS,,,,,,,,495,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,58.5494,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.73,58.5494
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323031119,NDC,10,ML,66.39,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,58.55598,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,84.5054
Assay of Iron,PX83540,CDM,300,RC,83540,CPT,,,,,,,,122,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,58.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,119.56
Assay of Iron,PX83540,CDM,300,RC,83540,CPT,,,,,,,,122,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,58.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,119.56
"Compliment, Total (Ch50) - Ref",PX8616290,CDM,300,RC,86162,CPT,90,,,,,,,122,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,58.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.63,119.56
"Compliment, Total (Ch50) - Ref",PX8616290,CDM,300,RC,86162,CPT,90,,,,,,,122,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,58.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.63,119.56
Vitamin B-12,PX82607,CDM,300,RC,82607,CPT,,,,,,,,122,,Health Partners,Health Partners Care Plans,both,48,,56.57,percent of total billed charges,58.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.83,119.56
Vitamin B-12,PX82607,CDM,300,RC,82607,CPT,,,,,,,,122,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,58.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.83,119.56
US Abdomen Limited Tc,PX7670501,CDM,402,RC,76705,CPT,TC,,,,,,,425,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,58.5676,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.7,117.67
Aspergillus Ag - Ref,PX8730590,CDM,300,RC,87305,CPT,90,,,,,,,141,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,58.5714,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,138.18
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,713013512,NDC,1,EA,65.83,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,58.5887,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.345782,66.2186
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032056,NDC,1,EA,68.97,,First Health,Commercial,both,85,,999999999,percent of total billed charges,58.6245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
gentamicin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063305,NDC,5,ML,122.17,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,58.6416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
gentamicin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063305,NDC,5,ML,122.17,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,58.6416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BUPivacaine 0.25 % Solution 50 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046557,NDC,30,ML,59.84,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,58.6432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.01,58.6432
Assay Bld/Serum Cholesterol,PX82465,CDM,300,RC,82465,CPT,,,,,,,,69,,First Health,Commercial,both,85,,999999999,percent of total billed charges,58.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.99,67.62
"Astrazeneca Covid-19 Vaccine, Administration, 1st Dose",PX0021A,CDM,771,RC,,,,,,,,,,69,,First Health,Commercial,both,85,,999999999,percent of total billed charges,58.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Astrazeneca Covid-19 Vaccine, Adminstration, 2nd Dose",PX0022A,CDM,771,RC,,,,,,,,,,69,,First Health,Commercial,both,85,,999999999,percent of total billed charges,58.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Janssen Covid-19 Vaccine, Administration",PX0031A,CDM,771,RC,0031A,HCPCS,,,,,,,,69,,First Health,Commercial,both,85,,999999999,percent of total billed charges,58.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 1st Dose",PX0011A,CDM,771,RC,0011A,HCPCS,,,,,,,,69,,First Health,Commercial,both,85,,999999999,percent of total billed charges,58.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 2nd Dose",PX0012A,CDM,771,RC,0012A,HCPCS,,,,,,,,69,,First Health,Commercial,both,85,,999999999,percent of total billed charges,58.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 3rd Dose",PX0013A,CDM,771,RC,0013A,HCPCS,,,,,,,,69,,First Health,Commercial,both,85,,999999999,percent of total billed charges,58.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
Novavax Covid-19 Vaccine Administration 1st Dose,PX0041A,CDM,771,RC,0041A,HCPCS,,,,,,,,69,,First Health,Commercial,both,85,,999999999,percent of total billed charges,58.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
Novavax Covid-19 Vaccine Administration 2nd Dose,PX0042A,CDM,771,RC,0042A,HCPCS,,,,,,,,69,,First Health,Commercial,both,85,,999999999,percent of total billed charges,58.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Pfizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 2nd Dose",PX0002A,CDM,771,RC,0002A,HCPCS,,,,,,,,69,,First Health,Commercial,both,85,,999999999,percent of total billed charges,58.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Pfizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 3rd Dose",PX0003A,CDM,771,RC,0003A,HCPCS,,,,,,,,69,,First Health,Commercial,both,85,,999999999,percent of total billed charges,58.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Pifizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 1st Dose",PX0001A,CDM,771,RC,0001A,HCPCS,,,,,,,,69,,First Health,Commercial,both,85,,999999999,percent of total billed charges,58.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,63739003807,NDC,1,EA,66.51,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,58.66182,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,781329091,NDC,50,ML,119.73,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,7.983333333,percent of total billed charges,58.6677,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,781329091,NDC,50,ML,119.73,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,58.6677,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,781329091,NDC,50,ML,119.73,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,58.6677,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
"Excision of Nail Fold, Toe",PX11765F,CDM,510,RC,11765,CPT,,,,,,,,210,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,58.68,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.68,345.9
Antithrombin III Ag Assay - Ref,PX8530190,CDM,300,RC,85301,CPT,90,,,,,,,116,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,58.696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.91,113.68
Ca 19-9,PX86301,CDM,300,RC,86301,CPT,,,,,,,,116,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,58.696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,113.68
cyclopentolate 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,17478010002,NDC,2,ML,66.55,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,58.6971,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Ig Paraprotein Qual Bld/UR,PX0077U90,CDM,300,RC,0077U,HCPCS,90,,,,,,,66,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,58.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
"Level III - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3933,CDM,310,RC,88304,CPT,TC,,,,,,,66,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,58.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
Ot Contracted Service/Msho/MA,PX120.178,CDM,431,RC,,,,,,,,,,66,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,58.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
Pt Contracted Service/Msho,PX120.176,CDM,421,RC,,,,,,,,,,66,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,58.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
Surg Pathology-Level 2-Tc,PX3932,CDM,310,RC,88302,CPT,TC,,,,,,,66,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,58.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.01,64.68
Xray Orbits Optic Foramina,PX7019001,CDM,320,RC,70190,CPT,TC,,,,,,,66,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,58.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,79.39
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608201,NDC,1,ML,66.6,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,58.7412,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
Total Cortisol,PX82533,CDM,300,RC,82533,CPT,,,,,,,,137,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,58.773,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.95,134.26
"Triiodothyronine T3, Free (Free T3)",PX84481,CDM,300,RC,84481,CPT,,,,,,,,137,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,58.773,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.53,134.26
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,63323004401,NDC,1,ML,64.53,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,58.78683,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,63.2394
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409493311,NDC,10,ML,66.06,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,58.7934,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
Capillary Blood Collection,PX36416,CDM,300,RC,36416,CPT,,,,,,,,60,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,58.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,58.8
"Compatibility Test,Antiglob Tech",PX86922,CDM,300,RC,86922,CPT,,,,,,,,120,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,23.2,percent of total billed charges,58.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.848,149.22
"Compatibility Test,Antiglob Tech",PX86922,CDM,300,RC,86922,CPT,,,,,,,,120,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,58.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.848,149.22
"Compatibility Test,Antiglob Tech",PX86922,CDM,300,RC,86922,CPT,,,,,,,,120,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,58.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.848,149.22
"Fac/Trm Hyperkeratotic Skn Lesn,>4",PX11057F,CDM,510,RC,11057,CPT,,,,,,,,175,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,58.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.66,187.48
HERNIA BELT MENS TRUSS LARGE,120.526,CDM,274,RC,L8310,HCPCS,,12221-MAIN,LOCAL,,,,,60,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,58.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,160.6
HERNIA BELT MENS TRUSS MEDIUM,120.526,CDM,274,RC,L8310,HCPCS,,12220-MAIN,LOCAL,,,,,60,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,58.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,160.6
HERNIA BELT MENS TRUSS XLARGE,120.526,CDM,274,RC,L8310,HCPCS,,12222-MAIN,LOCAL,,,,,60,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,58.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,160.6
"IMMOBILIZER KNEE  24"" 7041-44",120.22,CDM,274,RC,L1830,HCPCS,,595-MAIN,LOCAL,,,,,60,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,58.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE 16"" UNIVERSAL 7088-04",120.22,CDM,274,RC,L1830,HCPCS,,589-MAIN,LOCAL,,,,,60,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,58.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
IMMOBILIZER KNEE 20 INCH ORT2420019,120.22,CDM,274,RC,L1830,HCPCS,,587-MAIN,LOCAL,,,,,60,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,58.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE 20"" LARGE FOAM COUNTOURED STAYS 7062-03",120.22,CDM,274,RC,L1830,HCPCS,,593-MAIN,LOCAL,,,,,60,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,58.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE 20"" QUICK-WRAP ORT2440020S",120.22,CDM,274,RC,L1830,HCPCS,,591-MAIN,LOCAL,,,,,60,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,58.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
IMMOBILIZER KNEE CUTAWAY STRAIGHT 2 7041-05,120.22,CDM,274,RC,L1830,HCPCS,,596-MAIN,LOCAL,,,,,60,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,58.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
KIWI OMNICUP VACUUM DELIVERY SYSTEM,120.225,CDM,272,RC,,,,11608-MAIN,LOCAL,,,,,120,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,58.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.848,117.6
KIWI OMNICUP VACUUM DELIVERY SYSTEM,120.225,CDM,272,RC,,,,11608-MAIN,LOCAL,,,,,120,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,58.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.848,117.6
KIWI OMNICUP VACUUM DELIVERY SYSTEM,120.225,CDM,272,RC,,,,11608-MAIN,LOCAL,,,,,120,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,58.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.848,117.6
"Remv F.B.,Eye,Superf Conjunc",PX65205F,CDM,510,RC,65205,CPT,,,,,,,,132,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,58.8,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.1,59.49
"Remv F.B.,Eye,Superf Conjunc",PX65205P,CDM,983,RC,65205,CPT,,,,,,,,132,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,58.8,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.1,129.36
VACUUM KIWI W/PALM PUMP,120.225,CDM,272,RC,,,,10028-MAIN,LOCAL,,,,,120,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,58.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.848,117.6
VACUUM KIWI W/PALM PUMP,120.225,CDM,272,RC,,,,10028-MAIN,LOCAL,,,,,120,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,58.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.848,117.6
VACUUM KIWI W/PALM PUMP,120.225,CDM,272,RC,,,,10028-MAIN,LOCAL,,,,,120,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,58.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.848,117.6
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,517095501,NDC,0.25,EA,69.19,,First Health,Commercial,both,85,,999999999,percent of total billed charges,58.8115,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86,213.6008
Ventilator Mgmt.Subsequent Days,PX94003F,CDM,410,RC,94003,CPT,,,,,,,,1686,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,58.8345,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.7,110.52
ampicillin-sulbactam 1.5 (1-0.5) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001381,NDC,1,EA,69.24,,First Health,Commercial,both,85,,999999999,percent of total billed charges,58.854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093102,NDC,1,ML,60.47,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,13.01809524,percent of total billed charges,58.855451,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
TRAY HAND SURGICAL II DYNJS0806,27200000,CDM,272,RC,,,,11024-MAIN,LOCAL,,,,,64.62,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,58.86882,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
levoFLOXacin in dextrose 5% 500 MG/100ML Solution 100 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004724,NDC,100,ML,64.63,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,58.87793,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,76329339001,NDC,5,ML,64.63,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,58.87793,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,24208046325,NDC,2.5,ML,137.26,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,58.88454,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
TRUMPET SUCTION IRRIGATION,27100000,CDM,271,RC,,,,4577-MAIN,LOCAL,,,,,116.4,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,58.8984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
"Apply Short Leg Cast,Walker",PX29425P,CDM,983,RC,29425,CPT,,,,,,,,119,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,58.905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,234.62
Creatinine; Other Source - Ref,PX82570,CDM,300,RC,82570,CPT,90,,,,,,,119,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,58.905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,116.62
FLAT DRAIN HEMADUCT 7MM FULL DUCT WITH TROCAR SILICONE,27200000,CDM,272,RC,,,,12464-MAIN,LOCAL,,,,,119,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,58.905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Injection, Subq/Im",PX96372,CDM,260,RC,96372,CPT,,,,,,,,119,,Humana Choice Care,All Medicare plans,outpatient,49.5,,87.465,percent of total billed charges,58.905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,116.62
Irri Implted Drug Dlvr Device,PX96523,CDM,260,RC,96523,CPT,,,,,,,,119,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,58.905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,116.62
"Morphometric Analysis,Tumor Immunohistochemistry, Ea Antibody Manual , Tech",PX8836001,CDM,310,RC,88360,CPT,TC,,,,,,,119,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,58.905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,149.22
Office/Outpt Visit Est Level I,PX99211F,CDM,510,RC,99211,CPT,,,,,,,,119,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,58.905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,116.62
Office/Outpt Visit Est Level I,PX99211P,CDM,983,RC,99211,CPT,,,,,,,,119,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,58.905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,115.8227
Sodium; Urine,PX84300,CDM,300,RC,84300,CPT,,,,,,,,119,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,58.905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.64,116.62
STIFNECK ADULT,120.77,CDM,274,RC,L0180,HCPCS,,991-MAIN,LOCAL,,,,,119,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,58.905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,486.73
STIFNECK PEDIATRIC,120.77,CDM,274,RC,L0180,HCPCS,,998-MAIN,LOCAL,,,,,119,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,58.905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,486.73
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,409672924,NDC,50,ML,116.43,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,58.91358,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
"US,Preg. Uterus,Fetal/Mat.Eval.,>1st Trim.(>/= 14 Wks 0 Dys),Transabd;Single/First Gest., Tech",PX7680501,CDM,402,RC,76805,CPT,TC,,,,,,,562,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,58.92,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.92,175.53
OLANZapine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60505311000,NDC,1,EA,60.13,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,58.9274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine 20 mg/mL Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,54040444,NDC,30,ML,141.88,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,58.936952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hepatitis b recomb vaccine 10 MCG/0.5ML suspension prefilled syringe 0.5 mL Syringe,90743,CDM,636,RC,90743,CPT,,,,58160082052,NDC,0.5,ML,137.47,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,58.97463,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.105038,134.7206
Apply Multlay Comprs Lwr Leg,PX29581P,CDM,983,RC,29581,CPT,,,,,,,,142,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,58.9868,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,138.2086
"Biopsy Vulva/Perineum,One Lesn",PX56605P,CDM,983,RC,56605,CPT,,,,,,,,142,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,58.9868,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,702.31
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006P,CDM,983,RC,10006,CPT,,,,,,,,142,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,58.9868,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,138.2086
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760,CDM,420,RC,97760,CPT,,,,,,,,142,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,58.9868,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.18,139.16
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760F,CDM,510,RC,97760,CPT,,,,,,,,142,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,58.9868,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.18,139.16
Oximetry;Mult Determine,PX610,CDM,460,RC,94761,CPT,,,,,,,,142,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,58.9868,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,139.16
Thromboplastin Time Partial,PX85730,CDM,300,RC,85730,CPT,,,,,,,,142,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,58.9868,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.51,139.16
X-Ray Exam Femur 1 Vw,PX7355101,CDM,320,RC,73551,CPT,TC,,,,,,,142,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,58.9868,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,139.16
charcoal activated Liquid 240 mL Bottle,63700001,CDM,250,RC,,,,,,574012108,NDC,120,ML,66.88,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,58.98816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,25021011487,NDC,200,ML,66.28,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,58.9892,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.20921,64.9544
LAP SPONGES 18x18 7INCH LOOP,27200000,CDM,272,RC,,,,604-MAIN,LOCAL,,,,,60.64,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,59.020912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915850,NDC,0.2,ML,69.44,,First Health,Commercial,both,85,,999999999,percent of total billed charges,59.024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323042605,NDC,5,ML,64.8,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,59.0328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Each Add'l Hour IV Hydration,PX96361,CDM,260,RC,96361,CPT,,,,,,,,123,,Health Partners,Health Partners Care Plans,both,48,,61.61352941,percent of total billed charges,59.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,120.54
Each Add'l Hour IV Hydration,PX96361,CDM,260,RC,96361,CPT,,,,,,,,123,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,59.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,120.54
FLAT WOUND DRAIN WITH TROCAR 4 CHANNEL FULL FLUTED 7FR SILICONE,27200000,CDM,272,RC,,,,12473-MAIN,LOCAL,,,,,123,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,59.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
FLAT WOUND DRAIN WITH TROCAR 4 CHANNEL FULL FLUTED 7FR SILICONE,27200000,CDM,272,RC,,,,12473-MAIN,LOCAL,,,,,123,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,59.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Office/Outpt Visit,New,Levl II",PX99202F,CDM,510,RC,99202,CPT,,,,,,,,123,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,59.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.0942,120.54
"Office/Outpt Visit,New,Levl II",PX99202F,CDM,510,RC,99202,CPT,,,,,,,,123,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,59.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.0942,120.54
ezetimibe 10 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,16729043316,NDC,1,EA,60.66,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,59.040378,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032050,NDC,1,EA,120.51,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,14.99111111,percent of total billed charges,59.0499,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032050,NDC,1,EA,120.51,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,59.0499,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032050,NDC,1,EA,120.51,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,59.0499,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323042405,NDC,5,ML,64.82,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,59.05102,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618201,NDC,2,ML,120.53,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,59.0597,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.068162,123.3918
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618201,NDC,2,ML,120.53,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,59.0597,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.068162,123.3918
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618201,NDC,2,ML,120.53,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,59.0597,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.068162,123.3918
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618210,NDC,2,ML,120.53,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,59.0597,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.068162,123.3918
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618210,NDC,2,ML,120.53,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,59.0597,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.068162,123.3918
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618210,NDC,2,ML,120.53,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,59.0597,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.068162,123.3918
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781910572,NDC,0.25,EA,69.49,,First Health,Commercial,both,85,,999999999,percent of total billed charges,59.0665,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86,213.6008
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,781375575,NDC,4,ML,142.22,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,59.078188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
calcium CHLORIDE 10 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409163140,NDC,10,ML,64.85,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,59.07835,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Remove Intrauterine Device,PX58301,CDM,983,RC,58301,CPT,,,,,,,,357,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,59.0824,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.14,349.86
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323031119,NDC,10,ML,66.39,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,59.0871,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,84.5054
adenosine 6 MG/2ML Solution 2 mL Syringe,J0153.01,CDM,636,RC,J0153,HCPCS,,,,25021030167,NDC,2,ML,123.1,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,59.088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.13574,120.638
adenosine 6 MG/2ML Solution 2 mL Syringe,J0153.01,CDM,636,RC,J0153,HCPCS,,,,25021030167,NDC,2,ML,123.1,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,59.088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.13574,120.638
Group Therapeutic Procedures,PX97150,CDM,420,RC,97150,CPT,,,,,,,,67,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,59.094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.82,65.66
"Hydroxyprogesterone, 17-D - Ref",PX8349890,CDM,300,RC,83498,CPT,90,,,,,,,67,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,59.094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.91,65.66
Lab Org ID Anaerobic-Each,PX87076,CDM,300,RC,87076,CPT,,,,,,,,67,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,59.094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,65.66
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714078401,NDC,0.4,EA,60.72,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,59.098776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338080304,NDC,1000,ML,69.59,,First Health,Commercial,both,85,,999999999,percent of total billed charges,59.1515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990710709,NDC,1000,ML,69.59,,First Health,Commercial,both,85,,999999999,percent of total billed charges,59.1515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004824,NDC,150,ML,69.59,,First Health,Commercial,both,85,,999999999,percent of total billed charges,59.1515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
Xray Ls Spine Bend Tc,PX7212001,CDM,320,RC,72120,CPT,TC,,,,,,,323,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,59.17,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.84,59.17
Xray Ls Spine Bend Tc,PX7212001,CDM,320,RC,72120,CPT,TC,,,,,,,323,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,59.17,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.84,59.17
sodium polystyrene sulfonate 15 GM/60ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,46287000660,NDC,60,ML,123.3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,59.184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium polystyrene sulfonate 15 GM/60ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,46287000660,NDC,60,ML,123.3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,59.184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
budesonide 1 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097032187,NDC,1,ML,64.97,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,59.18767,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,63739003807,NDC,1,EA,66.51,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,59.1939,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505624500,NDC,1,EA,116.99,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,59.19694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,16714076901,NDC,15,GR,137.99,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,59.19771,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Cryptosporidum,PX87328,CDM,300,RC,87328,CPT,,,,,,,,117,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,59.202,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.67,114.66
Drain Blood From Under Nail,PX11740F,CDM,510,RC,11740,CPT,,,,,,,,117,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,59.202,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.6018,114.66
Giardia,PX87329,CDM,300,RC,87329,CPT,,,,,,,,117,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,59.202,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,114.66
"In Situ Hybridization (Eg, Fish), Each Probe, Tech",PX8836501,CDM,310,RC,88365,CPT,TC,,,,,,,117,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,59.202,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.6018,149.22
RBC Pretreatment,PX8697002,CDM,300,RC,86970,CPT,,,,,,,,117,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,59.202,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.6018,114.66
"Alkaloids, Not Otherwise Specified - Ref",PX8032390,CDM,300,RC,80323,CPT,90,,,,,,,65,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,59.215,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.001,63.7
Anesthesia Level 3,PX37000017,CDM,370,RC,,,,,,,,,,65,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,59.215,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.001,63.7
Clozapine - Ref,PX8015990,CDM,300,RC,80159,CPT,90,,,,,,,65,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,59.215,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.48,63.7
Gastrin - Ref,PX8294190,CDM,300,RC,82941,CPT,90,,,,,,,65,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,59.215,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.16,63.7
Insulin Ab - Ref,PX8633790,CDM,300,RC,86337,CPT,90,,,,,,,65,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,59.215,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.63,63.7
Resp Muscles 1:1 per 15 Min,PXG0237,CDM,948,RC,G0237,HCPCS,,,,,,,,65,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,59.215,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.01,63.7
Smking Cess 4-10 Min,PX99406F,CDM,942,RC,99406,CPT,,,,,,,,65,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,59.215,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.07,63.7
hydrocortisone 2.5 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,45802000403,NDC,28,GR,60.85,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,59.225305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclopentolate 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,17478010002,NDC,2,ML,66.55,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,59.2295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093102,NDC,1,ML,60.47,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,59.2606,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,781329091,NDC,50,ML,119.73,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,59.26635,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608201,NDC,1,ML,66.6,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,59.274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
LAPAROTOMY MAJOR I,27200000,CDM,272,RC,,,,4828-MAIN,LOCAL,,,,,123.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,59.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LAPAROTOMY MAJOR I,27200000,CDM,272,RC,,,,4828-MAIN,LOCAL,,,,,123.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,59.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
BAG LEG URINARY STND 32OZ,120.33,CDM,272,RC,A5112,HCPCS,,4433-MAIN,LOCAL,,,,,121,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,59.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
BAG LEG URINARY STND 32OZ,120.33,CDM,272,RC,A5112,HCPCS,,4433-MAIN,LOCAL,,,,,121,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,59.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
BAG LEG URINARY STND 32OZ,120.33,CDM,272,RC,A5112,HCPCS,,4433-MAIN,LOCAL,,,,,121,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,59.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
BAG URINARY DRAINAGE 2000ML 6300,120.33,CDM,274,RC,A4357,HCPCS,,1283-MAIN,LOCAL,,,,,121,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,2.446666667,percent of total billed charges,59.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
BAG URINARY DRAINAGE 2000ML 6300,120.33,CDM,274,RC,A4357,HCPCS,,1283-MAIN,LOCAL,,,,,121,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,59.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
BAG URINARY DRAINAGE 2000ML 6300,120.33,CDM,274,RC,A4357,HCPCS,,1283-MAIN,LOCAL,,,,,121,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,59.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
BAG URINARY LEG PACK 9349,120.33,CDM,272,RC,A5112,HCPCS,,623-MAIN,LOCAL,,,,,121,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,59.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
BAG URINARY LEG PACK 9349,120.33,CDM,272,RC,A5112,HCPCS,,623-MAIN,LOCAL,,,,,121,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,59.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
BAG URINARY LEG PACK 9349,120.33,CDM,272,RC,A5112,HCPCS,,623-MAIN,LOCAL,,,,,121,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,59.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
"Chest Wall Manipulation,Initial",PX94667,CDM,410,RC,94667,CPT,,,,,,,,121,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,59.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.2634,118.58
"Chest Wall Manipulation,Initial",PX94667,CDM,410,RC,94667,CPT,,,,,,,,121,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,59.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.2634,118.58
"Chest Wall Manipulation,Initial",PX94667,CDM,410,RC,94667,CPT,,,,,,,,121,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,59.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.2634,118.58
"Fluor Noninfect Ab Sc, Ea - Ref",PX8625590,CDM,300,RC,86255,CPT,90,,,,,,,121,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,59.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.05,118.58
"Fluor Noninfect Ab Sc, Ea - Ref",PX8625590,CDM,300,RC,86255,CPT,90,,,,,,,121,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,59.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.05,118.58
"Fluor Noninfect Ab Sc, Ea - Ref",PX8625590,CDM,300,RC,86255,CPT,90,,,,,,,121,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,59.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.05,118.58
"Manage/Train Orthotic/Prosthetic, per 15 Min",PX97763,CDM,420,RC,97763,CPT,,,,,,,,121,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,59.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.36,118.58
"Manage/Train Orthotic/Prosthetic, per 15 Min",PX97763,CDM,420,RC,97763,CPT,,,,,,,,121,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,59.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.36,118.58
"Manage/Train Orthotic/Prosthetic, per 15 Min",PX97763,CDM,420,RC,97763,CPT,,,,,,,,121,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,59.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.36,118.58
"Prosthetic Training, Initial, Each 15 Mins",PX97761,CDM,420,RC,97761,CPT,,,,,,,,121,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,24.2,percent of total billed charges,59.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.41,118.58
"Prosthetic Training, Initial, Each 15 Mins",PX97761,CDM,420,RC,97761,CPT,,,,,,,,121,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,59.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.41,118.58
"Prosthetic Training, Initial, Each 15 Mins",PX97761,CDM,420,RC,97761,CPT,,,,,,,,121,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,59.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.41,118.58
sucralfate 1 GM/10ML Suspension 10 mL Cup,63700001,CDM,250,RC,,,,,,68094004359,NDC,10,ML,60.92,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,59.293436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598F,CDM,510,RC,97598,CPT,,,,,,,,406,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,59.31,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.59,59.31
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598P,CDM,982,RC,97598,CPT,,,,,,,,325,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,59.31,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.59,318.5
Pulmonary Stress Test,PX94618,CDM,976,RC,94618,CPT,,,,,,,,153,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,59.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.38,149.94
Pulmonary Stress Test,PX94618,CDM,976,RC,94618,CPT,,,,,,,,153,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,59.33,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.38,149.94
rivaroxaban 15 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50458057830,NDC,0.666666667,EA,67.3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,59.3586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Protoporphyrin, RBC, Qnt - Ref",PX8420290,CDM,300,RC,84202,CPT,90,,,,,,,61,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,59.3713,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.16,59.78
lidocaine-epinephrine-tetracaine Gel 3 mL Syringe,J3490.160,CDM,636,RC,J3490,HCPCS,,,,88888800028,NDC,3,ML,121.19,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,12.9192,percent of total billed charges,59.3831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.342326,118.7662
lidocaine-epinephrine-tetracaine Gel 3 mL Syringe,J3490.160,CDM,636,RC,J3490,HCPCS,,,,88888800028,NDC,3,ML,121.19,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,59.3831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.342326,118.7662
lidocaine-epinephrine-tetracaine Gel 3 mL Syringe,J3490.160,CDM,636,RC,J3490,HCPCS,,,,88888800028,NDC,3,ML,121.19,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,59.3831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.342326,118.7662
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703334301,NDC,0.5,ML,142.98,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,59.393892,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963805,NDC,0.5,ML,142.98,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,59.393892,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
"Compatibility Test,Antiglob Tech",PX86922,CDM,300,RC,86922,CPT,,,,,,,,120,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,59.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.848,149.22
KIWI OMNICUP VACUUM DELIVERY SYSTEM,120.225,CDM,272,RC,,,,11608-MAIN,LOCAL,,,,,120,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,59.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.848,117.6
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615900,NDC,1,EA,123.75,,Health Partners,Health Partners Care Plans,both,48,,6.796666667,percent of total billed charges,59.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615900,NDC,1,EA,123.75,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,59.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615904,NDC,1,EA,123.75,,Health Partners,Health Partners Care Plans,both,48,,6.796666667,percent of total billed charges,59.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615904,NDC,1,EA,123.75,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,59.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
VACUUM KIWI W/PALM PUMP,120.225,CDM,272,RC,,,,10028-MAIN,LOCAL,,,,,120,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,59.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.848,117.6
phytonadione 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714097302,NDC,0.5,EA,143.02,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,59.410508,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phytonadione 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,69238105103,NDC,0.5,EA,143.02,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,59.410508,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048657,NDC,50,ML,61.05,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,59.419965,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
LAP SPONGES 18x18 7INCH LOOP,27200000,CDM,272,RC,,,,604-MAIN,LOCAL,,,,,60.64,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,59.4272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ezetimibe 10 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,16729043316,NDC,1,EA,60.66,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,59.4468,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,143950601,NDC,10,ML,61.1,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,59.46863,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,143950610,NDC,10,ML,61.1,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,59.46863,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Remv F.B.,Eye,Superf Conjunc",PX65205F,CDM,510,RC,65205,CPT,,,,,,,,132,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,59.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.1,59.49
"Remv F.B.,Eye,Superf Conjunc",PX65205P,CDM,983,RC,65205,CPT,,,,,,,,132,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,59.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.1,129.36
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714078401,NDC,0.4,EA,60.72,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,59.5056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of Lithium,PX80178,CDM,300,RC,80178,CPT,,,,,,,,124,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,59.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.06,121.52
Assay of Lithium,PX80178,CDM,300,RC,80178,CPT,,,,,,,,124,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,59.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.06,121.52
"Complement; Antigen, Each Component",PX86160,CDM,300,RC,86160,CPT,,,,,,,,124,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,59.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11,121.52
"Complement; Antigen, Each Component",PX86160,CDM,300,RC,86160,CPT,,,,,,,,124,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,59.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11,121.52
"Immunoassay,Ca15-3(27.29) - Ref",PX8630090,CDM,300,RC,86300,CPT,90,,,,,,,124,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,59.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,121.52
"Immunoassay,Ca15-3(27.29) - Ref",PX8630090,CDM,300,RC,86300,CPT,90,,,,,,,124,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,59.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,121.52
Itraconazole,PX8018990,CDM,300,RC,80189,CPT,90,,,,,,,124,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,59.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.86,121.52
Itraconazole,PX8018990,CDM,300,RC,80189,CPT,90,,,,,,,124,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,59.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.86,121.52
Microbe Susceptible Mic,PX87186,CDM,300,RC,87186,CPT,,,,,,,,124,,Health Partners,Health Partners Care Plans,both,48,,78.45666667,percent of total billed charges,59.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.93,121.52
Microbe Susceptible Mic,PX87186,CDM,300,RC,87186,CPT,,,,,,,,124,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,59.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.93,121.52
Nocardia Susceptibility - Ref,PX8718690,CDM,300,RC,87186,CPT,90,,,,,,,124,,Health Partners,Health Partners Care Plans,both,48,,78.45666667,percent of total billed charges,59.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.93,121.52
Nocardia Susceptibility - Ref,PX8718690,CDM,300,RC,87186,CPT,90,,,,,,,124,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,59.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.93,121.52
Oligoclonal Bands - Ref,PX8391690,CDM,300,RC,83916,CPT,90,,,,,,,124,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,59.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.11,121.52
Oligoclonal Bands - Ref,PX8391690,CDM,300,RC,83916,CPT,90,,,,,,,124,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,59.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.11,121.52
UMBILICAL VESSEL CATHETER INSERTION TRAY POLY SINGLE LUMEN 3.5/5FR,120.573,CDM,272,RC,,,,12857-MAIN,LOCAL,,,,,124,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,59.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.5096,121.52
UMBILICAL VESSEL CATHETER INSERTION TRAY POLY SINGLE LUMEN 3.5/5FR,120.573,CDM,272,RC,,,,12857-MAIN,LOCAL,,,,,124,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,59.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.5096,121.52
charcoal activated Liquid 240 mL Bottle,63700001,CDM,250,RC,,,,,,574012108,NDC,120,ML,66.88,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,59.5232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305972,NDC,2,ML,61.19,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,59.556227,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305995,NDC,2,ML,61.19,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,59.556227,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Plas Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,338604648,NDC,100,ML,143.42,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,59.576668,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.786918,140.5516
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,58602060407,NDC,100,GR,67.56,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,59.58792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,574722612,NDC,1,EA,67.57,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,59.59674,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.345782,66.2186
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43598055530,NDC,0.4,EA,61.26,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,59.624358,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43598096630,NDC,0.4,EA,61.26,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,59.624358,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Group Therapeutic Procedures,PX97150,CDM,420,RC,97150,CPT,,,,,,,,67,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,59.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.82,65.66
"Hydroxyprogesterone, 17-D - Ref",PX8349890,CDM,300,RC,83498,CPT,90,,,,,,,67,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,59.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.91,65.66
Lab Org ID Anaerobic-Each,PX87076,CDM,300,RC,87076,CPT,,,,,,,,67,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,59.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,65.66
hydrocortisone 2.5 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,45802000403,NDC,28,GR,60.85,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,59.633,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ENDOLOOP COATED VICRYL 0 18,27200000,CDM,272,RC,,,,10228-MAIN,LOCAL,,,,,143.6,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,59.65144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ofloxacin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,17478071310,NDC,5,ML,117.89,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,59.65234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032050,NDC,1,EA,120.51,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,59.65245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618201,NDC,2,ML,120.53,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,59.66235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.068162,123.3918
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618210,NDC,2,ML,120.53,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,59.66235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.068162,123.3918
tropicamide 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,24208058559,NDC,2,ML,61.3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,59.66329,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
aspirin-dipyridamole 25-200 MG Capsule Extended Release 12 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687030533,NDC,1,EA,67.66,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,59.67612,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin-dipyridamole 25-200 MG Capsule Extended Release 12 Hour 20 Each Box,63700001,CDM,250,RC,,,,,,60687030532,NDC,1,EA,67.66,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,59.67612,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sucralfate 1 GM/10ML Suspension 10 mL Cup,63700001,CDM,250,RC,,,,,,68094004359,NDC,10,ML,60.92,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,59.7016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Fibrinolysins Screen - Ref,PX8539090,CDM,300,RC,85390,CPT,90,,,,,,,118,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,59.708,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.19,115.64
IV 0.9% NS 1000ML 2B1324X,27200000,CDM,272,RC,,,,538-MAIN,LOCAL,,,,,121.89,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,59.7261,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
IV 0.9% NS 1000ML 2B1324X,27200000,CDM,272,RC,,,,538-MAIN,LOCAL,,,,,121.89,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,59.7261,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
IV 0.9% NS 1000ML 2B1324X,27200000,CDM,272,RC,,,,538-MAIN,LOCAL,,,,,121.89,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,59.7261,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Package,25000000,CDM,250,RC,,,,,,10019055390,NDC,1,EA,121.9,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,59.731,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Package,25000000,CDM,250,RC,,,,,,10019055390,NDC,1,EA,121.9,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,59.731,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Package,25000000,CDM,250,RC,,,,,,10019055390,NDC,1,EA,121.9,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,59.731,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
methylene blue 1 % Solution 10 mL Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,54288014701,NDC,1,ML,139.25,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,59.73825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.29,1354.4776
ocrelizumab 300 MG/10ML Solution 10 mL Vial,J2350.01,CDM,636,RC,J2350,HCPCS,,,,50242015001,NDC,10,ML,33150,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,59.75,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.48,59.75
"Closed Rx I-P Jt,Toe Dislocation",PX28660F,CDM,510,RC,28660,CPT,,,,,,,,335,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,59.77,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.24,267.03
"Closed Rx I-P Jt,Toe Dislocation",PX28660F,CDM,510,RC,28660,CPT,,,,,,,,335,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,59.77,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.24,267.03
"Closed Rx I-P Jt,Toe Dislocation",PX28660P,CDM,983,RC,28660,CPT,,,,,,,,628,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,59.77,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.24,615.44
"Closed Rx I-P Jt,Toe Dislocation",PX28660P,CDM,983,RC,28660,CPT,,,,,,,,628,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,59.77,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.24,615.44
Fluoroscopy Guid Needle Plcmt Tc,PX7700201,CDM,320,RC,77002,CPT,TC,,,,,,,662,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,59.77,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,59.77,176.84
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606001,NDC,10,ML,65.62,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,59.77982,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606010,NDC,10,ML,65.62,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,59.77982,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
Assay of Iron,PX83540,CDM,300,RC,83540,CPT,,,,,,,,122,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,59.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,119.56
Assay of Iron,PX83540,CDM,300,RC,83540,CPT,,,,,,,,122,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,59.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,119.56
Assay of Iron,PX83540,CDM,300,RC,83540,CPT,,,,,,,,122,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,59.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,119.56
"Compliment, Total (Ch50) - Ref",PX8616290,CDM,300,RC,86162,CPT,90,,,,,,,122,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,59.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.63,119.56
"Compliment, Total (Ch50) - Ref",PX8616290,CDM,300,RC,86162,CPT,90,,,,,,,122,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,59.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.63,119.56
"Compliment, Total (Ch50) - Ref",PX8616290,CDM,300,RC,86162,CPT,90,,,,,,,122,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,59.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.63,119.56
"Protoporphyrin, RBC, Qnt - Ref",PX8420290,CDM,300,RC,84202,CPT,90,,,,,,,61,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,59.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.16,59.78
"Venipuncture, Lab",PX3641502,CDM,300,RC,36415,CPT,,,,,,,,61,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,59.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.1,65.45
Vitamin B-12,PX82607,CDM,300,RC,82607,CPT,,,,,,,,122,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,13.24125,percent of total billed charges,59.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.83,119.56
Vitamin B-12,PX82607,CDM,300,RC,82607,CPT,,,,,,,,122,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,59.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.83,119.56
Vitamin B-12,PX82607,CDM,300,RC,82607,CPT,,,,,,,,122,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,59.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.83,119.56
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,55150020200,NDC,1,EA,65.65,,Medica,Commercial,both,91.1,,23.075,percent of total billed charges,59.80715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
Hepatitis C Antibody,PX86803,CDM,300,RC,86803,CPT,,,,,,,,144,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,59.8176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.08,141.12
US Chest Tc,PX7660401,CDM,402,RC,76604,CPT,TC,,,,,,,248,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,59.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.19,59.82
US Chest Tc,PX7660401,CDM,402,RC,76604,CPT,TC,,,,,,,248,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,59.82,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.19,59.82
X-Ray Exam Entire Spine 1vw,PX7208101,CDM,320,RC,72081,CPT,TC,,,,,,,414,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,59.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.06,59.82
X-Ray Exam Entire Spine 1vw,PX7208101,CDM,320,RC,72081,CPT,TC,,,,,,,414,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,59.82,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.06,59.82
Xray Mandible Partial Less Than 4 Vws,PX7010001,CDM,320,RC,70100,CPT,TC,,,,,,,347,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,59.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.84,59.82
Xray Mandible Partial Less Than 4 Vws,PX7010001,CDM,320,RC,70100,CPT,TC,,,,,,,347,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,59.82,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.84,59.82
Xray Pelvis Compl 3+ Tc,PX7219001,CDM,320,RC,72190,CPT,TC,,,,,,,563,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,59.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.06,59.82
Xray Pelvis Compl 3+ Tc,PX7219001,CDM,320,RC,72190,CPT,TC,,,,,,,563,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,59.82,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.06,59.82
Xray Ribs Bil 3vws Tc,PX7111001,CDM,320,RC,71110,CPT,TC,,,,,,,533,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,59.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.06,59.82
Xray Ribs Bil 3vws Tc,PX7111001,CDM,320,RC,71110,CPT,TC,,,,,,,533,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,59.82,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.06,59.82
brimonidine 0.2 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,70069023101,NDC,5,ML,70.38,,First Health,Commercial,both,85,,999999999,percent of total billed charges,59.823,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048657,NDC,50,ML,61.05,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,59.829,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
gentamicin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063305,NDC,5,ML,122.17,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,59.8633,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
gentamicin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063305,NDC,5,ML,122.17,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,59.8633,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
gentamicin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063305,NDC,5,ML,122.17,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,59.8633,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039801,NDC,1,EA,67.88,,United Healthcare,All Payer,outpatient,88.2,,23.68,percent of total billed charges,59.87016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039810,NDC,1,EA,67.88,,United Healthcare,All Payer,outpatient,88.2,,23.68,percent of total billed charges,59.87016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,143950601,NDC,10,ML,61.1,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,59.878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,143950610,NDC,10,ML,61.1,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,59.878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BAG LEG URINARY STND 32OZ,120.33,CDM,272,RC,A5112,HCPCS,,4433-MAIN,LOCAL,,,,,121,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,59.895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
BAG URINARY DRAINAGE 2000ML 6300,120.33,CDM,274,RC,A4357,HCPCS,,1283-MAIN,LOCAL,,,,,121,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,59.895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
BAG URINARY LEG PACK 9349,120.33,CDM,272,RC,A5112,HCPCS,,623-MAIN,LOCAL,,,,,121,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,59.895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
"Chest Wall Manipulation,Initial",PX94667,CDM,410,RC,94667,CPT,,,,,,,,121,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,59.895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.2634,118.58
"Fluor Noninfect Ab Sc, Ea - Ref",PX8625590,CDM,300,RC,86255,CPT,90,,,,,,,121,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,59.895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.05,118.58
"Manage/Train Orthotic/Prosthetic, per 15 Min",PX97763,CDM,420,RC,97763,CPT,,,,,,,,121,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,59.895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.36,118.58
"Prosthetic Training, Initial, Each 15 Mins",PX97761,CDM,420,RC,97761,CPT,,,,,,,,121,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,59.895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.41,118.58
rivaroxaban 15 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50458057830,NDC,0.666666667,EA,67.3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,59.897,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
triamcinolone acetonide 0.1 % Cream 80 g Tube,63700001,CDM,250,RC,,,,,,16714098603,NDC,80,GR,65.76,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,59.90736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Hfe Gene - Ref,PX8125690,CDM,300,RC,81256,CPT,90,,,,,,,526,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,59.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,59.93,515.48
durvalumab 120 MG/2.4ML Solution 2.4 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310450012,NDC,30,ML,21771.9,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,59.96,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,59.96,84.74
durvalumab 500 MG/10ML Solution 10 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310461150,NDC,10,ML,7588.77,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,59.96,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,59.96,84.74
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305972,NDC,2,ML,61.19,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,59.9662,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305995,NDC,2,ML,61.19,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,59.9662,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,59.9662
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,713013512,NDC,1,EA,65.83,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,59.97113,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.345782,66.2186
"Flour. Afstain , Micro - Ref",PX8720690,CDM,300,RC,87206,CPT,90,,,,,,,68,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,59.976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.94,66.64
Hemoglobin,PX85018,CDM,300,RC,85018,CPT,,,,,,,,68,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,59.976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.17,66.64
Thyroglobulin - Ref,PX8443290,CDM,300,RC,84432,CPT,90,,,,,,,68,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,59.976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.73,66.64
Thyroglobulin Antibody,PX8680090,CDM,300,RC,86800,CPT,90,,,,,,,68,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,59.976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.59,66.64
lidocaine-epinephrine-tetracaine Gel 3 mL Syringe,J3490.160,CDM,636,RC,J3490,HCPCS,,,,88888800028,NDC,3,ML,121.19,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,59.98905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.342326,118.7662
Fluoroscopy Guid Needle Plcmt Tc,PX7700201,CDM,320,RC,77002,CPT,TC,,,,,,,662,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,59.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,59.77,176.84
Fluoroscopy Guid Needle Plcmt Tc,PX7700201,CDM,320,RC,77002,CPT,TC,,,,,,,662,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,59.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,59.77,176.84
Cmv Igm Antibody - Ref,PX8664590,CDM,300,RC,86645,CPT,90,,,,,,,125,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,60,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.45,122.5
Cmv Igm Antibody - Ref,PX8664590,CDM,300,RC,86645,CPT,90,,,,,,,125,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,60,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.45,122.5
DRESSING SURGICEL HEMOSTAT 4X8 ABSORBABLE 1952,120.123,CDM,272,RC,A6252,HCPCS,,1002-MAIN,LOCAL,,,,,125,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,60,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.925,122.5
DRESSING SURGICEL HEMOSTAT 4X8 ABSORBABLE 1952,120.123,CDM,272,RC,A6252,HCPCS,,1002-MAIN,LOCAL,,,,,125,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,60,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.925,122.5
Factor VII - Ref,PX8523090,CDM,300,RC,85230,CPT,90,,,,,,,125,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,60,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.41,122.5
Factor VII - Ref,PX8523090,CDM,300,RC,85230,CPT,90,,,,,,,125,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,60,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.41,122.5
terbinafine 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714079501,NDC,1,EA,68.03,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,60.00246,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terbinafine 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714050101,NDC,1,EA,68.04,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,60.01128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43598055530,NDC,0.4,EA,61.26,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,60.0348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43598096630,NDC,0.4,EA,61.26,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,60.0348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
TISSUE RETRIEVAL SYSTEM,27200000,CDM,272,RC,,,,10233-MAIN,LOCAL,,,,,139.98,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,60.05142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Apply Forearm Cast,PX29075P,CDM,983,RC,29075,CPT,,,,,,,,140,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,60.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.156,234.62
Hospital Discharge Day>30 Min,PX99239P,CDM,982,RC,99239,CPT,,,,,,,,140,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,60.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.156,136.262
tropicamide 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,24208058559,NDC,2,ML,61.3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,60.074,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"TB Test, Cell Immunity Measure",PX86480,CDM,300,RC,86480,CPT,,,,,,,,186,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,60.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.12,61.98
"TB Test, Cell Immunity Measure",PX86480,CDM,300,RC,86480,CPT,,,,,,,,186,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,60.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.12,61.98
"TB Test, Cell Immunity Measure",PX86480,CDM,300,RC,86480,CPT,,,,,,,,186,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,60.12,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.12,61.98
Ig Paraprotein Qual Bld/UR,PX0077U90,CDM,300,RC,0077U,HCPCS,90,,,,,,,66,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,60.126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
"Level III - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3933,CDM,310,RC,88304,CPT,TC,,,,,,,66,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,60.126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
Ot Contracted Service/Msho/MA,PX120.178,CDM,431,RC,,,,,,,,,,66,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,60.126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
Pt Contracted Service/Msho,PX120.176,CDM,421,RC,,,,,,,,,,66,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,60.126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
Surg Pathology-Level 2-Tc,PX3932,CDM,310,RC,88302,CPT,TC,,,,,,,66,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,60.126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.01,64.68
Xray Orbits Optic Foramina,PX7019001,CDM,320,RC,70190,CPT,TC,,,,,,,66,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,60.126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,79.39
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,58602060407,NDC,100,GR,67.56,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,60.1284,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,574722612,NDC,1,EA,67.57,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,60.1373,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.345782,66.2186
doxycycline 100 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323013041,NDC,1,EA,140.2,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,60.1458,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018200,NDC,10,ML,68.21,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,60.16122,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.24,991.564
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018210,NDC,10,ML,68.21,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,60.16122,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.24,991.564
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409493311,NDC,10,ML,66.06,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,60.18066,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
"Apply Finger Splint,Static",PX29130F,CDM,420,RC,29130,CPT,,,,,,,,196,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,60.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.66,88.55
"Apply Finger Splint,Static",PX29130P,CDM,983,RC,29130,CPT,,,,,,,,223,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,60.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.66,218.54
Strapping of Elbow or Wrist,PX29260F,CDM,420,RC,29260,CPT,,,,,,,,64,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,60.19,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.77,60.19
"Excision of Nail Fold, Toe",PX11765F,CDM,510,RC,11765,CPT,,,,,,,,210,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,60.21,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.68,345.9
"Excision of Nail Fold, Toe",PX11765F,CDM,510,RC,11765,CPT,,,,,,,,210,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,60.21,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.68,345.9
Low Dose CT Lung Ca Screen WO Contrast,PX7127101,CDM,350,RC,71271,CPT,TC,,,,,,,1286,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,60.21,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.21,178.16
Low Dose CT Lung Ca Screen WO Contrast,PX7127101,CDM,350,RC,71271,CPT,TC,,,,,,,1286,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,60.21,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.21,178.16
"Apply Short Leg Cast,Walker",PX29425P,CDM,983,RC,29425,CPT,,,,,,,,119,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,60.214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,234.62
Creatinine; Other Source - Ref,PX82570,CDM,300,RC,82570,CPT,90,,,,,,,119,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,60.214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,116.62
FLAT DRAIN HEMADUCT 7MM FULL DUCT WITH TROCAR SILICONE,27200000,CDM,272,RC,,,,12464-MAIN,LOCAL,,,,,119,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,60.214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Injection, Subq/Im",PX96372,CDM,260,RC,96372,CPT,,,,,,,,119,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,60.214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,116.62
Irri Implted Drug Dlvr Device,PX96523,CDM,260,RC,96523,CPT,,,,,,,,119,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,60.214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,116.62
"Morphometric Analysis,Tumor Immunohistochemistry, Ea Antibody Manual , Tech",PX8836001,CDM,310,RC,88360,CPT,TC,,,,,,,119,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,60.214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,149.22
Office/Outpt Visit Est Level I,PX99211F,CDM,510,RC,99211,CPT,,,,,,,,119,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,60.214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,116.62
Office/Outpt Visit Est Level I,PX99211P,CDM,983,RC,99211,CPT,,,,,,,,119,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,60.214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,115.8227
Sodium; Urine,PX84300,CDM,300,RC,84300,CPT,,,,,,,,119,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,60.214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.64,116.62
STIFNECK ADULT,120.77,CDM,274,RC,L0180,HCPCS,,991-MAIN,LOCAL,,,,,119,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,60.214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,486.73
STIFNECK PEDIATRIC,120.77,CDM,274,RC,L0180,HCPCS,,998-MAIN,LOCAL,,,,,119,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,60.214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,486.73
aspirin-dipyridamole 25-200 MG Capsule Extended Release 12 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687030533,NDC,1,EA,67.66,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,60.2174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin-dipyridamole 25-200 MG Capsule Extended Release 12 Hour 20 Each Box,63700001,CDM,250,RC,,,,,,60687030532,NDC,1,EA,67.66,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,60.2174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay Carbamazepine Total,PX80156,CDM,300,RC,80156,CPT,,,,,,,,145,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,60.233,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.36,142.1
"Calculus, Infrared Spec - Ref",PX8236590,CDM,300,RC,82365,CPT,90,,,,,,,145,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,60.233,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.83,142.1
"Catecholamines, Fraction - Ref",PX8238490,CDM,300,RC,82384,CPT,90,,,,,,,145,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,60.233,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.15,142.1
Hsv Dna Amp Probe,PX87529,CDM,300,RC,87529,CPT,,,,,,,,145,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,60.233,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,142.1
Immunofixation Electrophoresis; Serum,PX86334,CDM,300,RC,86334,CPT,,,,,,,,145,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,60.233,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.48,142.1
LEGGING COMPRESSION JUXTALITE LONG LG 33CM,120.369,CDM,271,RC,A6545,HCPCS,,10840-MAIN,LOCAL,,,,,145,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,60.233,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.233,142.1
"Pare/Cut Hyperkeratotic Skin Lesion, Single",PX11055F,CDM,510,RC,11055,CPT,,,,,,,,145,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,60.233,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.233,174.9
Surgical Cleansing of Skin,PX11000P,CDM,983,RC,11000,CPT,,,,,,,,145,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,60.233,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.233,548.67
Wheelchair Mngement Training,PX97542,CDM,420,RC,97542,CPT,,,,,,,,145,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,60.233,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.59,142.1
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050601,NDC,1,ML,68.33,,United Healthcare,All Payer,outpatient,88.2,,23.48,percent of total billed charges,60.26706,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010520,NDC,1,EA,68.33,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,60.26706,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010541,NDC,1,EA,68.33,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,60.26706,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
Each Add'l Hour IV Hydration,PX96361,CDM,260,RC,96361,CPT,,,,,,,,123,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,28.98387097,percent of total billed charges,60.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,120.54
Each Add'l Hour IV Hydration,PX96361,CDM,260,RC,96361,CPT,,,,,,,,123,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,60.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,120.54
Each Add'l Hour IV Hydration,PX96361,CDM,260,RC,96361,CPT,,,,,,,,123,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,60.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,120.54
FLAT WOUND DRAIN WITH TROCAR 4 CHANNEL FULL FLUTED 7FR SILICONE,27200000,CDM,272,RC,,,,12473-MAIN,LOCAL,,,,,123,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,60.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
FLAT WOUND DRAIN WITH TROCAR 4 CHANNEL FULL FLUTED 7FR SILICONE,27200000,CDM,272,RC,,,,12473-MAIN,LOCAL,,,,,123,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,60.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
FLAT WOUND DRAIN WITH TROCAR 4 CHANNEL FULL FLUTED 7FR SILICONE,27200000,CDM,272,RC,,,,12473-MAIN,LOCAL,,,,,123,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,60.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Office/Outpt Visit,New,Levl II",PX99202F,CDM,510,RC,99202,CPT,,,,,,,,123,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,43.89,percent of total billed charges,60.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.0942,120.54
"Office/Outpt Visit,New,Levl II",PX99202F,CDM,510,RC,99202,CPT,,,,,,,,123,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,60.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.0942,120.54
"Office/Outpt Visit,New,Levl II",PX99202F,CDM,510,RC,99202,CPT,,,,,,,,123,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,60.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.0942,120.54
"Office/Outpt Visit,New,Levl II",PX99202P,CDM,983,RC,99202,CPT,,,,,,,,123,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,43.89,percent of total billed charges,60.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.0942,119.7159
"Office/Outpt Visit,New,Levl II",PX99202P,CDM,983,RC,99202,CPT,,,,,,,,123,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,60.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.0942,119.7159
"Office/Outpt Visit,New,Levl II",PX99202P,CDM,983,RC,99202,CPT,,,,,,,,123,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,60.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.0942,119.7159
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046203,NDC,30,ML,70.91,,First Health,Commercial,both,85,,999999999,percent of total billed charges,60.2735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pramox-PE-glycerin-petrolatum 1-0.25-14.4-15 % Cream 51 g Tube,63700001,CDM,250,RC,,,,,,573286898,NDC,51,GR,68.34,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,60.27588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Acetaminophen,PX80307E,CDM,300,RC,80307,CPT,,,,,,,,370,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,60.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.28,62.14
Acetaminophen,PX80307E,CDM,300,RC,80307,CPT,,,,,,,,370,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,60.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.28,62.14
Acetaminophen,PX80307E,CDM,300,RC,80307,CPT,,,,,,,,370,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,60.28,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.28,62.14
Alcohol,PX80307A,CDM,300,RC,80307,CPT,,,,,,,,370,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,60.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.28,62.14
Alcohol,PX80307A,CDM,300,RC,80307,CPT,,,,,,,,370,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,60.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.28,62.14
Alcohol,PX80307A,CDM,300,RC,80307,CPT,,,,,,,,370,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,60.28,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.28,62.14
Salicylate,PX80307D,CDM,300,RC,80307,CPT,,,,,,,,370,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,60.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.28,62.14
Salicylate,PX80307D,CDM,300,RC,80307,CPT,,,,,,,,370,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,60.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.28,62.14
Salicylate,PX80307D,CDM,300,RC,80307,CPT,,,,,,,,370,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,60.28,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.28,62.14
Urine Drug Screen,PX80307B,CDM,300,RC,80307,CPT,,,,,,,,370,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,60.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.28,62.14
Urine Drug Screen,PX80307B,CDM,300,RC,80307,CPT,,,,,,,,370,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,60.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.28,62.14
Urine Drug Screen,PX80307B,CDM,300,RC,80307,CPT,,,,,,,,370,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,60.28,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.28,62.14
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457000100,NDC,10,ML,68.38,,United Healthcare,All Payer,outpatient,88.2,,7.6225,percent of total billed charges,60.31116,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
adenosine 6 MG/2ML Solution 2 mL Syringe,J0153.01,CDM,636,RC,J0153,HCPCS,,,,25021030167,NDC,2,ML,123.1,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.528333333,percent of total billed charges,60.319,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.13574,120.638
adenosine 6 MG/2ML Solution 2 mL Syringe,J0153.01,CDM,636,RC,J0153,HCPCS,,,,25021030167,NDC,2,ML,123.1,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,60.319,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.13574,120.638
adenosine 6 MG/2ML Solution 2 mL Syringe,J0153.01,CDM,636,RC,J0153,HCPCS,,,,25021030167,NDC,2,ML,123.1,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,60.319,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.13574,120.638
hydrocortisone 2.5 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,168008031,NDC,30,GR,61.99,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,60.334867,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
IV 0.9% NS 1000ML 2B1324X,27200000,CDM,272,RC,,,,538-MAIN,LOCAL,,,,,121.89,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,60.33555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Package,25000000,CDM,250,RC,,,,,,10019055390,NDC,1,EA,121.9,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,60.3405,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Gabapentin - Ref,PX8017190,CDM,300,RC,80171,CPT,90,,,,,,,71,,First Health,Commercial,both,85,,999999999,percent of total billed charges,60.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.87,69.58
Histoplasma Antibody - Ref,PX8669890,CDM,300,RC,86698,CPT,90,,,,,,,71,,First Health,Commercial,both,85,,999999999,percent of total billed charges,60.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.64,69.58
Legionella Antibody - Ref,PX8671390,CDM,300,RC,86713,CPT,90,,,,,,,71,,First Health,Commercial,both,85,,999999999,percent of total billed charges,60.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.03,69.58
fentaNYL 50 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,406905076,NDC,1,EA,125.74,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,60.3552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 50 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,406905076,NDC,1,EA,125.74,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,60.3552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,51672131200,NDC,22,GR,140.7,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,60.3603,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,25021011487,NDC,200,ML,66.28,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,60.38108,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.20921,64.9544
Assay of Iron,PX83540,CDM,300,RC,83540,CPT,,,,,,,,122,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,60.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,119.56
"Compliment, Total (Ch50) - Ref",PX8616290,CDM,300,RC,86162,CPT,90,,,,,,,122,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,60.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.63,119.56
Vitamin B-12,PX82607,CDM,300,RC,82607,CPT,,,,,,,,122,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,60.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.83,119.56
"IMMOBILIZER KNEE  24"" 7041-44",120.22,CDM,274,RC,L1830,HCPCS,,595-MAIN,LOCAL,,,,,60,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,60.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE 16"" UNIVERSAL 7088-04",120.22,CDM,274,RC,L1830,HCPCS,,589-MAIN,LOCAL,,,,,60,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,60.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
IMMOBILIZER KNEE 20 INCH ORT2420019,120.22,CDM,274,RC,L1830,HCPCS,,587-MAIN,LOCAL,,,,,60,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,60.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE 20"" LARGE FOAM COUNTOURED STAYS 7062-03",120.22,CDM,274,RC,L1830,HCPCS,,593-MAIN,LOCAL,,,,,60,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,60.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
"IMMOBILIZER KNEE 20"" QUICK-WRAP ORT2440020S",120.22,CDM,274,RC,L1830,HCPCS,,591-MAIN,LOCAL,,,,,60,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,60.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
IMMOBILIZER KNEE CUTAWAY STRAIGHT 2 7041-05,120.22,CDM,274,RC,L1830,HCPCS,,596-MAIN,LOCAL,,,,,60,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,60.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,60.41
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039801,NDC,1,EA,67.88,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,60.4132,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039810,NDC,1,EA,67.88,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,60.4132,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
sodium polystyrene sulfonate 15 GM/60ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,46287000660,NDC,60,ML,123.3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,60.417,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium polystyrene sulfonate 15 GM/60ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,46287000660,NDC,60,ML,123.3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,60.417,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium polystyrene sulfonate 15 GM/60ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,46287000660,NDC,60,ML,123.3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,60.417,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052331,NDC,2,ML,125.89,,Health Partners,Health Partners Care Plans,both,48,,85.485,percent of total billed charges,60.4272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.294706,123.3722
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052331,NDC,2,ML,125.89,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,60.4272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.294706,123.3722
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052341,NDC,2,ML,125.89,,Health Partners,Health Partners Care Plans,both,48,,85.485,percent of total billed charges,60.4272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.294706,123.3722
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052341,NDC,2,ML,125.89,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,60.4272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.294706,123.3722
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,17478053802,NDC,2,ML,125.91,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,60.4368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.068162,123.3918
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,17478053802,NDC,2,ML,125.91,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,60.4368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.068162,123.3918
ciprofloxacin 0.3 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,61314065625,NDC,2.5,ML,140.92,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,60.45468,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Digital Mamm, Diag, Unilat, Tc W/Cad Perf",PX7706501,CDM,401,RC,77065,CPT,TC,,,,,,,293,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,60.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.46,287.14
gentamicin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063305,NDC,5,ML,122.17,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,60.47415,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Joint Survey Tc,PX7707701,CDM,320,RC,77077,CPT,TC,,,,,,,304,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,60.48,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.28,60.48
Joint Survey Tc,PX7707701,CDM,320,RC,77077,CPT,TC,,,,,,,304,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,60.48,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.28,60.48
Thrombin Time Plasma,PX85670,CDM,300,RC,85670,CPT,,,,,,,,126,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,60.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.29,123.48
Thrombin Time Plasma,PX85670,CDM,300,RC,85670,CPT,,,,,,,,126,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,60.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.29,123.48
"X-Ray Exam Hip,Bilat W/Pelvis 2 Vws",PX7352101,CDM,320,RC,73521,CPT,TC,,,,,,,399,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,60.48,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.28,60.48
"X-Ray Exam Hip,Bilat W/Pelvis 2 Vws",PX7352101,CDM,320,RC,73521,CPT,TC,,,,,,,399,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,60.48,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.28,60.48
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323031119,NDC,10,ML,66.39,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,60.48129,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,84.5054
Aspergillus Ag - Ref,PX8730590,CDM,300,RC,87305,CPT,90,,,,,,,141,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,60.489,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,138.18
Therapeutic Activities,PX97530,CDM,420,RC,97530,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,60.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.22,205.7
"BUPivacaine 0.25%-EPINEPHrine 1:200,000 0.25% -1:200000 Solution 50 mL Vial",25000000,CDM,250,RC,,,,,,409175250,NDC,30,ML,68.6,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,60.5052,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,16714001905,NDC,2,ML,62.17,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,60.510061,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,16714001930,NDC,2,ML,62.17,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,60.510061,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010602,NDC,50,ML,126.07,,Health Partners,Health Partners Care Plans,both,48,,14.6175,percent of total billed charges,60.5136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010602,NDC,50,ML,126.07,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,60.5136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010605,NDC,50,ML,126.07,,Health Partners,Health Partners Care Plans,both,48,,14.6175,percent of total billed charges,60.5136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010605,NDC,50,ML,126.07,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,60.5136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
nitroglycerin in dextrose 5% 100-5 MCG/ML-% Solution 250 mL Glass Cont,J2305.01,CDM,636,RC,J2305,HCPCS,,,,338104702,NDC,250,ML,126.07,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,60.5136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.17,123.5486
nitroglycerin in dextrose 5% 100-5 MCG/ML-% Solution 250 mL Glass Cont,J2305.01,CDM,636,RC,J2305,HCPCS,,,,338104702,NDC,250,ML,126.07,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,60.5136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.17,123.5486
LAPAROTOMY MAJOR I,27200000,CDM,272,RC,,,,4828-MAIN,LOCAL,,,,,123.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,60.515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LAPAROTOMY MAJOR I,27200000,CDM,272,RC,,,,4828-MAIN,LOCAL,,,,,123.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,60.515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LAPAROTOMY MAJOR I,27200000,CDM,272,RC,,,,4828-MAIN,LOCAL,,,,,123.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,60.515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Flour. Afstain , Micro - Ref",PX8720690,CDM,300,RC,87206,CPT,90,,,,,,,68,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,60.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.94,66.64
Hemoglobin,PX85018,CDM,300,RC,85018,CPT,,,,,,,,68,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,60.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.17,66.64
Thyroglobulin - Ref,PX8443290,CDM,300,RC,84432,CPT,90,,,,,,,68,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,60.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.73,66.64
Thyroglobulin Antibody,PX8680090,CDM,300,RC,86800,CPT,90,,,,,,,68,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,60.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.59,66.64
terbinafine 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714079501,NDC,1,EA,68.03,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,60.5467,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terbinafine 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714050101,NDC,1,EA,68.04,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,60.5556,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,781329091,NDC,50,ML,119.73,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,60.58338,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,63739003807,NDC,1,EA,66.51,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,60.59061,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclopentolate 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,17478010002,NDC,2,ML,66.55,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,60.62705,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615900,NDC,1,EA,123.75,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,14.99111111,percent of total billed charges,60.6375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615900,NDC,1,EA,123.75,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,60.6375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615900,NDC,1,EA,123.75,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,60.6375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615904,NDC,1,EA,123.75,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,14.99111111,percent of total billed charges,60.6375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615904,NDC,1,EA,123.75,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,60.6375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615904,NDC,1,EA,123.75,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,60.6375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
Low Dose CT Lung Ca Screen WO Contrast,PX7127101,CDM,350,RC,71271,CPT,TC,,,,,,,1286,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,60.64,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.21,178.16
Islet Cell Antibody - Ref,PX8634190,CDM,300,RC,86341,CPT,90,,,,,,,146,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,60.6484,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.61,143.08
"TB Test, Cell Immunity Measure",PX86480,CDM,300,RC,86480,CPT,,,,,,,,186,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,60.6501,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.12,61.98
"IV Infusion Therapy, 1 Hour",PX96365,CDM,260,RC,96365,CPT,,,,,,,,327,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,60.669,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.23,109.36
"Lab Antibody ID,RBC",PX7605,CDM,300,RC,86870,CPT,,,,,,,,155,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,60.672,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.13,60.672
"Lab Antibody ID,RBC",PX7605,CDM,300,RC,86870,CPT,,,,,,,,155,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,60.672,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.13,60.672
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608201,NDC,1,ML,66.6,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,60.6726,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018200,NDC,10,ML,68.21,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,60.7069,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.24,991.564
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018210,NDC,10,ML,68.21,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,60.7069,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.24,991.564
budesonide 0.5 MG/2ML Suspension 2 mL Ampule,25000000,CDM,250,RC,,,,,,68180098405,NDC,2,ML,62.38,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,60.714454,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,781751614,NDC,2,ML,62.38,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,60.714454,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,781751687,NDC,2,ML,62.38,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,60.714454,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097031986,NDC,2,ML,62.38,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,60.714454,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Compatibility Test,Antiglob Tech",PX86922,CDM,300,RC,86922,CPT,,,,,,,,120,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,60.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.848,149.22
KIWI OMNICUP VACUUM DELIVERY SYSTEM,120.225,CDM,272,RC,,,,11608-MAIN,LOCAL,,,,,120,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,60.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.848,117.6
VACUUM KIWI W/PALM PUMP,120.225,CDM,272,RC,,,,10028-MAIN,LOCAL,,,,,120,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,60.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.848,117.6
anastrozole 1 MG Tablet 30 Each Bottle,25000000,CDM,250,RC,,,,,,16729003510,NDC,1,EA,71.44,,First Health,Commercial,both,85,,999999999,percent of total billed charges,60.724,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
hydrocortisone 2.5 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,168008031,NDC,30,GR,61.99,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,60.7502,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of Lithium,PX80178,CDM,300,RC,80178,CPT,,,,,,,,124,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,60.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.06,121.52
Assay of Lithium,PX80178,CDM,300,RC,80178,CPT,,,,,,,,124,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,60.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.06,121.52
Assay of Lithium,PX80178,CDM,300,RC,80178,CPT,,,,,,,,124,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,60.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.06,121.52
"Complement; Antigen, Each Component",PX86160,CDM,300,RC,86160,CPT,,,,,,,,124,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,60.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11,121.52
"Complement; Antigen, Each Component",PX86160,CDM,300,RC,86160,CPT,,,,,,,,124,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,60.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11,121.52
"Complement; Antigen, Each Component",PX86160,CDM,300,RC,86160,CPT,,,,,,,,124,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,60.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11,121.52
"Immunoassay,Ca15-3(27.29) - Ref",PX8630090,CDM,300,RC,86300,CPT,90,,,,,,,124,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,60.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,121.52
"Immunoassay,Ca15-3(27.29) - Ref",PX8630090,CDM,300,RC,86300,CPT,90,,,,,,,124,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,60.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,121.52
"Immunoassay,Ca15-3(27.29) - Ref",PX8630090,CDM,300,RC,86300,CPT,90,,,,,,,124,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,60.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,121.52
Itraconazole,PX8018990,CDM,300,RC,80189,CPT,90,,,,,,,124,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,60.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.86,121.52
Itraconazole,PX8018990,CDM,300,RC,80189,CPT,90,,,,,,,124,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,60.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.86,121.52
Itraconazole,PX8018990,CDM,300,RC,80189,CPT,90,,,,,,,124,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,60.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.86,121.52
Microbe Susceptible Mic,PX87186,CDM,300,RC,87186,CPT,,,,,,,,124,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,60.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.93,121.52
Microbe Susceptible Mic,PX87186,CDM,300,RC,87186,CPT,,,,,,,,124,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,60.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.93,121.52
Microbe Susceptible Mic,PX87186,CDM,300,RC,87186,CPT,,,,,,,,124,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,60.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.93,121.52
Nocardia Susceptibility - Ref,PX8718690,CDM,300,RC,87186,CPT,90,,,,,,,124,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,60.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.93,121.52
Nocardia Susceptibility - Ref,PX8718690,CDM,300,RC,87186,CPT,90,,,,,,,124,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,60.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.93,121.52
Nocardia Susceptibility - Ref,PX8718690,CDM,300,RC,87186,CPT,90,,,,,,,124,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,60.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.93,121.52
Oligoclonal Bands - Ref,PX8391690,CDM,300,RC,83916,CPT,90,,,,,,,124,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,60.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.11,121.52
Oligoclonal Bands - Ref,PX8391690,CDM,300,RC,83916,CPT,90,,,,,,,124,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,60.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.11,121.52
Oligoclonal Bands - Ref,PX8391690,CDM,300,RC,83916,CPT,90,,,,,,,124,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,60.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.11,121.52
UMBILICAL VESSEL CATHETER INSERTION TRAY POLY SINGLE LUMEN 3.5/5FR,120.573,CDM,272,RC,,,,12857-MAIN,LOCAL,,,,,124,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,60.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.5096,121.52
UMBILICAL VESSEL CATHETER INSERTION TRAY POLY SINGLE LUMEN 3.5/5FR,120.573,CDM,272,RC,,,,12857-MAIN,LOCAL,,,,,124,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,60.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.5096,121.52
UMBILICAL VESSEL CATHETER INSERTION TRAY POLY SINGLE LUMEN 3.5/5FR,120.573,CDM,272,RC,,,,12857-MAIN,LOCAL,,,,,124,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,60.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.5096,121.52
LIGACLIP APPLIER CLIP STERILE SIZE MEDIUM LARGE,27200000,CDM,272,RC,,,,11699-MAIN,LOCAL,,,,,126.62,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,60.7776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LIGACLIP APPLIER CLIP STERILE SIZE MEDIUM LARGE,27200000,CDM,272,RC,,,,11699-MAIN,LOCAL,,,,,126.62,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,60.7776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"US,Preg. Uterus,Fetal/Mat.Eval.,>1st Trim.(>/= 14 Wks 0 Dys),Transabd;Single/First Gest., Tech",PX7680501,CDM,402,RC,76805,CPT,TC,,,,,,,562,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,60.79,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.92,175.53
"US,Preg. Uterus,Fetal/Mat.Eval.,>1st Trim.(>/= 14 Wks 0 Dys),Transabd;Single/First Gest., Tech",PX7680501,CDM,402,RC,76805,CPT,TC,,,,,,,562,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,60.79,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.92,175.53
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050601,NDC,1,ML,68.33,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,60.8137,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010520,NDC,1,EA,68.33,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,60.8137,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010541,NDC,1,EA,68.33,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,60.8137,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
atropine (PF) 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517040125,NDC,1,ML,71.55,,First Health,Commercial,both,85,,999999999,percent of total billed charges,60.8175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
tetracaine 0.5 % Solution 4 mL Plas Cont,25000000,CDM,250,RC,,,,,,65074114,NDC,4,ML,71.55,,First Health,Commercial,both,85,,999999999,percent of total billed charges,60.8175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pramox-PE-glycerin-petrolatum 1-0.25-14.4-15 % Cream 51 g Tube,63700001,CDM,250,RC,,,,,,573286898,NDC,51,GR,68.34,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,60.8226,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032056,NDC,1,EA,68.97,,United Healthcare,All Payer,outpatient,88.2,,49.96,percent of total billed charges,60.83154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
Assay Bld/Serum Cholesterol,PX82465,CDM,300,RC,82465,CPT,,,,,,,,69,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,60.858,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.99,67.62
"Astrazeneca Covid-19 Vaccine, Administration, 1st Dose",PX0021A,CDM,771,RC,,,,,,,,,,69,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,60.858,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Astrazeneca Covid-19 Vaccine, Adminstration, 2nd Dose",PX0022A,CDM,771,RC,,,,,,,,,,69,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,60.858,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Janssen Covid-19 Vaccine, Administration",PX0031A,CDM,771,RC,0031A,HCPCS,,,,,,,,69,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,60.858,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 1st Dose",PX0011A,CDM,771,RC,0011A,HCPCS,,,,,,,,69,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,60.858,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 2nd Dose",PX0012A,CDM,771,RC,0012A,HCPCS,,,,,,,,69,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,60.858,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 3rd Dose",PX0013A,CDM,771,RC,0013A,HCPCS,,,,,,,,69,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,60.858,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
Novavax Covid-19 Vaccine Administration 1st Dose,PX0041A,CDM,771,RC,0041A,HCPCS,,,,,,,,69,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,60.858,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
Novavax Covid-19 Vaccine Administration 2nd Dose,PX0042A,CDM,771,RC,0042A,HCPCS,,,,,,,,69,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,60.858,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Pfizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 2nd Dose",PX0002A,CDM,771,RC,0002A,HCPCS,,,,,,,,69,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,60.858,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Pfizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 3rd Dose",PX0003A,CDM,771,RC,0003A,HCPCS,,,,,,,,69,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,60.858,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Pifizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 1st Dose",PX0001A,CDM,771,RC,0001A,HCPCS,,,,,,,,69,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,60.858,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457000100,NDC,10,ML,68.38,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,60.8582,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
Puncture Drainage of Lesion,PX10160F,CDM,510,RC,10160,CPT,,,,,,,,279,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,60.86,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.86,270.49
Puncture Drainage of Lesion,PX10160P,CDM,983,RC,10160,CPT,,,,,,,,186,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,60.86,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.86,270.49
morphine 20 mg/mL Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,54040444,NDC,30,ML,141.88,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,60.86652,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Strapping of Knee,PX29530F,CDM,420,RC,29530,CPT,,,,,,,,303,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,60.88,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.12,60.88
Each Add'l Hour IV Hydration,PX96361,CDM,260,RC,96361,CPT,,,,,,,,123,,Humana Choice Care,All Medicare plans,outpatient,49.5,,34.025,percent of total billed charges,60.885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,120.54
FLAT WOUND DRAIN WITH TROCAR 4 CHANNEL FULL FLUTED 7FR SILICONE,27200000,CDM,272,RC,,,,12473-MAIN,LOCAL,,,,,123,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,60.885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Office/Outpt Visit,New,Levl II",PX99202F,CDM,510,RC,99202,CPT,,,,,,,,123,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,60.885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.0942,120.54
"Office/Outpt Visit,New,Levl II",PX99202P,CDM,983,RC,99202,CPT,,,,,,,,123,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,60.885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.0942,119.7159
Apply Multlay Comprs Lwr Leg,PX29581P,CDM,983,RC,29581,CPT,,,,,,,,142,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,60.918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,138.2086
"Biopsy Vulva/Perineum,One Lesn",PX56605P,CDM,983,RC,56605,CPT,,,,,,,,142,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,60.918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,702.31
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006P,CDM,983,RC,10006,CPT,,,,,,,,142,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,60.918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,138.2086
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760,CDM,420,RC,97760,CPT,,,,,,,,142,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,60.918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.18,139.16
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760F,CDM,510,RC,97760,CPT,,,,,,,,142,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,60.918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.18,139.16
Oximetry;Mult Determine,PX610,CDM,460,RC,94761,CPT,,,,,,,,142,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,60.918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,139.16
Thromboplastin Time Partial,PX85730,CDM,300,RC,85730,CPT,,,,,,,,142,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,60.918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.51,139.16
X-Ray Exam Femur 1 Vw,PX7355101,CDM,320,RC,73551,CPT,TC,,,,,,,142,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,60.918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,139.16
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,16714001905,NDC,2,ML,62.17,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,60.9266,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,16714001930,NDC,2,ML,62.17,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,60.9266,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
charcoal activated Liquid 240 mL Bottle,63700001,CDM,250,RC,,,,,,574012108,NDC,120,ML,66.88,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,60.92768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sacubitril-valsartan 24-26 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,78065920,NDC,1,EA,62.6,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,60.92858,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
adenosine 6 MG/2ML Solution 2 mL Syringe,J0153.01,CDM,636,RC,J0153,HCPCS,,,,25021030167,NDC,2,ML,123.1,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,60.9345,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.13574,120.638
DOBUTamine 1000 mcg/mL in dextrose 5% 250 mL premix 1000 mcg/ml Solution 250 mL Flex Cont,J1250.01,CDM,636,RC,J1250,HCPCS,,,,338107302,NDC,250,ML,146.73,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,60.951642,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.951642,143.7954
B-Scan Global,PX7651201,CDM,402,RC,76512,CPT,TC,,,,,,,127,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,60.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.7558,124.46
B-Scan Global,PX7651201,CDM,402,RC,76512,CPT,TC,,,,,,,127,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,60.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.7558,124.46
Candida Dna Dir Probe,PX87480,CDM,300,RC,87480,CPT,,,,,,,,127,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,60.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.38,124.46
Candida Dna Dir Probe,PX87480,CDM,300,RC,87480,CPT,,,,,,,,127,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,60.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.38,124.46
Gardner Vag Dna Dir Probe,PX87510,CDM,300,RC,87510,CPT,,,,,,,,127,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,60.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.38,124.46
Gardner Vag Dna Dir Probe,PX87510,CDM,300,RC,87510,CPT,,,,,,,,127,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,60.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.38,124.46
Influenza Assay W/Optic,PX87804,CDM,300,RC,87804,CPT,,,,,,,,127,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,60.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.17,124.46
Influenza Assay W/Optic,PX87804,CDM,300,RC,87804,CPT,,,,,,,,127,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,60.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.17,124.46
Trichomonas Vagin Dir Probe,PX87660,CDM,300,RC,87660,CPT,,,,,,,,127,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,60.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.38,124.46
Trichomonas Vagin Dir Probe,PX87660,CDM,300,RC,87660,CPT,,,,,,,,127,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,60.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.38,124.46
Acetaminophen,PX80307E,CDM,300,RC,80307,CPT,,,,,,,,370,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,60.971,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.28,62.14
Alcohol,PX80307A,CDM,300,RC,80307,CPT,,,,,,,,370,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,60.971,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.28,62.14
Salicylate,PX80307D,CDM,300,RC,80307,CPT,,,,,,,,370,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,60.971,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.28,62.14
Urine Drug Screen,PX80307B,CDM,300,RC,80307,CPT,,,,,,,,370,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,60.971,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.28,62.14
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032050,NDC,1,EA,120.51,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,60.97806,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
TUBE TRACH SIZE 5 7.0MM ID 10.1MM OD SHILEY CUFFED 5CN70H,120.287,CDM,272,RC,A7521,HCPCS,,10350-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,60.98,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 6 6.0MM ID 8.3MM OD SHILEY CUFFED 6SCT,120.287,CDM,272,RC,A7521,HCPCS,,8812-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,60.98,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 6 6.4MM ID 10.8MM OD SHILEY CUFFED 6DCT,120.287,CDM,272,RC,A7521,HCPCS,,1190-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,60.98,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 7.5MM ID 10.8MM OD SHILEY CUFFED 6CN75H,120.287,CDM,272,RC,A7521,HCPCS,,8488-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,60.98,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 8 7.6MM ID 12.2MM OD SHILEY 8DCT,120.287,CDM,272,RC,A7521,HCPCS,,1192-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,60.98,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 8 7.6MM ID 12.22MM OD SHILEY CUFFED 8LPC,120.287,CDM,272,RC,A7521,HCPCS,,8815-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,60.98,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 8.0MM ID 10.9MM OD SHILEY CUFFED 8SCT,120.287,CDM,272,RC,A7521,HCPCS,,8811-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,60.98,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 10 SHILEY 10LPC,120.287,CDM,272,RC,A7521,HCPCS,,1181-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,60.98,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618201,NDC,2,ML,120.53,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,60.98818,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.068162,123.3918
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618210,NDC,2,ML,120.53,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,60.98818,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.068162,123.3918
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,409662902,NDC,10,ML,146.84,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,60.997336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.236966,143.9032
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,781375575,NDC,4,ML,142.22,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,61.01238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,517095501,NDC,0.25,EA,69.19,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,61.02558,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86,213.6008
sodium polystyrene sulfonate 15 GM/60ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,46287000660,NDC,60,ML,123.3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,61.0335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Group Therapeutic Procedures,PX97150,CDM,420,RC,97150,CPT,,,,,,,,67,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,61.037,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.82,65.66
"Hydroxyprogesterone, 17-D - Ref",PX8349890,CDM,300,RC,83498,CPT,90,,,,,,,67,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,61.037,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.91,65.66
Lab Org ID Anaerobic-Each,PX87076,CDM,300,RC,87076,CPT,,,,,,,,67,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,61.037,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,65.66
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457033900,NDC,1,EA,71.82,,First Health,Commercial,both,85,,999999999,percent of total billed charges,61.047,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
"BUPivacaine 0.25%-EPINEPHrine 1:200,000 0.25% -1:200000 Solution 50 mL Vial",25000000,CDM,250,RC,,,,,,409175250,NDC,30,ML,68.6,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,61.054,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Amphetamines; 1 or 2 - Ref,PX8032490,CDM,300,RC,80324,CPT,90,,,,,,,147,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,61.0638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.0638,144.06
Assay Ph Body Fluids Nos,PX83986,CDM,300,RC,83986,CPT,,,,,,,,147,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,61.0638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.28,144.06
"Cmv Detect, Amplifi Probe - Ref",PX8749690,CDM,300,RC,87496,CPT,90,,,,,,,147,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,61.0638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,144.06
"Methlenedioxyamphetamines (Mda, Mdea, Mdma) - Ref",PX8035990,CDM,300,RC,80359,CPT,90,,,,,,,147,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,61.0638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.0638,144.06
Ph Venous Blood,PX82800,CDM,300,RC,82800,CPT,,,,,,,,147,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,61.0638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.09,144.06
ampicillin-sulbactam 1.5 (1-0.5) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001381,NDC,1,EA,69.24,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,61.06968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
CT Maxillofacialw/O Dye,PX7048601,CDM,350,RC,70486,CPT,TC,,,,,,,2757,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,61.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.08,180.13
CT Maxillofacialw/O Dye,PX7048601,CDM,350,RC,70486,CPT,TC,,,,,,,2757,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,61.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.08,180.13
"Fac/Office Consultation,Level III",PX99243F,CDM,510,RC,99213,CPT,,,,,,,,374,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,61.104,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.25,163.25
"Office/Outpt Visit,Est,Levl III",PX99213F,CDM,510,RC,99213,CPT,,,,,,,,185,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,61.104,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.25,163.25
"Office/Outpt Visit,Est,Levl III",PX99213P,CDM,983,RC,99213,CPT,,,,,,,,185,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,61.104,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.25,181.3
"Office/Outpt Visit,Est,Levl IV",PX99214F,CDM,510,RC,99214,CPT,,,,,,,,256,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,61.11,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.11,230.23
"Office/Outpt Visit,Est,Levl IV",PX99214P,CDM,983,RC,99214,CPT,,,,,,,,256,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,61.11,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.11,250.88
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062430,NDC,0.3,ML,147.12,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,61.113648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801301,NDC,0.3,ML,147.12,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,61.113648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801310,NDC,0.3,ML,147.12,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,61.113648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
"Non-Select. Wound Debride., W/O Anesth.; Top. Appl./Wound Assess./Instruct., per Sess.",PX97602,CDM,761,RC,97602,CPT,,,,,,,,212,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,61.13,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.28,104.16
budesonide 0.5 MG/2ML Suspension 2 mL Ampule,25000000,CDM,250,RC,,,,,,68180098405,NDC,2,ML,62.38,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,61.1324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,781751614,NDC,2,ML,62.38,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,61.1324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,781751687,NDC,2,ML,62.38,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,61.1324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097031986,NDC,2,ML,62.38,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,61.1324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
LAPAROTOMY MAJOR I,27200000,CDM,272,RC,,,,4828-MAIN,LOCAL,,,,,123.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,61.1325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
US Ext Non-Vasc Img Lmtd,PX7688201,CDM,402,RC,76882,CPT,TC,,,,,,,425,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,61.14,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.5,61.14
US Ext Non-Vasc Img Lmtd,PX7688201,CDM,402,RC,76882,CPT,TC,,,,,,,425,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,61.14,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.5,61.14
"B.Burgdorferi, Amp Probe - Ref",PX8747690,CDM,300,RC,87476,CPT,90,,,,,,,72,,First Health,Commercial,both,85,,999999999,percent of total billed charges,61.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.9088,70.56
"Blood, Occult, Other Sources",PX82271,CDM,300,RC,82271,CPT,,,,,,,,72,,First Health,Commercial,both,85,,999999999,percent of total billed charges,61.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.88,70.56
Epstein-barr antibody,PX86664,CDM,300,RC,86664,CPT,,,,,,,,72,,First Health,Commercial,both,85,,999999999,percent of total billed charges,61.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.02,70.56
BAG LEG URINARY STND 32OZ,120.33,CDM,272,RC,A5112,HCPCS,,4433-MAIN,LOCAL,,,,,121,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,61.226,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
BAG URINARY DRAINAGE 2000ML 6300,120.33,CDM,274,RC,A4357,HCPCS,,1283-MAIN,LOCAL,,,,,121,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,61.226,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
BAG URINARY LEG PACK 9349,120.33,CDM,272,RC,A5112,HCPCS,,623-MAIN,LOCAL,,,,,121,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,61.226,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
"Chest Wall Manipulation,Initial",PX94667,CDM,410,RC,94667,CPT,,,,,,,,121,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,61.226,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.2634,118.58
"Fluor Noninfect Ab Sc, Ea - Ref",PX8625590,CDM,300,RC,86255,CPT,90,,,,,,,121,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,61.226,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.05,118.58
"Manage/Train Orthotic/Prosthetic, per 15 Min",PX97763,CDM,420,RC,97763,CPT,,,,,,,,121,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,61.226,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.36,118.58
"Prosthetic Training, Initial, Each 15 Mins",PX97761,CDM,420,RC,97761,CPT,,,,,,,,121,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,61.226,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.41,118.58
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915850,NDC,0.2,ML,69.44,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,61.24608,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
Cmv Igm Antibody - Ref,PX8664590,CDM,300,RC,86645,CPT,90,,,,,,,125,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,61.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.45,122.5
Cmv Igm Antibody - Ref,PX8664590,CDM,300,RC,86645,CPT,90,,,,,,,125,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,61.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.45,122.5
Cmv Igm Antibody - Ref,PX8664590,CDM,300,RC,86645,CPT,90,,,,,,,125,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,61.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.45,122.5
DRESSING SURGICEL HEMOSTAT 4X8 ABSORBABLE 1952,120.123,CDM,272,RC,A6252,HCPCS,,1002-MAIN,LOCAL,,,,,125,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,61.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.925,122.5
DRESSING SURGICEL HEMOSTAT 4X8 ABSORBABLE 1952,120.123,CDM,272,RC,A6252,HCPCS,,1002-MAIN,LOCAL,,,,,125,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,61.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.925,122.5
DRESSING SURGICEL HEMOSTAT 4X8 ABSORBABLE 1952,120.123,CDM,272,RC,A6252,HCPCS,,1002-MAIN,LOCAL,,,,,125,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,61.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.925,122.5
Factor VII - Ref,PX8523090,CDM,300,RC,85230,CPT,90,,,,,,,125,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,61.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.41,122.5
Factor VII - Ref,PX8523090,CDM,300,RC,85230,CPT,90,,,,,,,125,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,61.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.41,122.5
Factor VII - Ref,PX8523090,CDM,300,RC,85230,CPT,90,,,,,,,125,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,61.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.41,122.5
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615900,NDC,1,EA,123.75,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,61.25625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615904,NDC,1,EA,123.75,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,61.25625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
Apply Long Leg Cast,PX29345F,CDM,510,RC,29345,CPT,,,,,,,,912,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,61.29,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.29,285.71
CT Maxillofacialw/O Dye,PX7048601,CDM,350,RC,70486,CPT,TC,,,,,,,2757,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,61.29,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.08,180.13
"Digital Mammogram, Screen Bil, Tc W/Cad Perf",PX7706701,CDM,403,RC,77067,CPT,TC,,,,,,,375,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,61.29,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.29,182.1
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781910572,NDC,0.25,EA,69.49,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,61.29018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86,213.6008
dexmedeTOMIDine 200 MCG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,143953201,NDC,2,ML,62.98,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,61.298434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
rivaroxaban 15 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50458057830,NDC,0.666666667,EA,67.3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,61.3103,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
K-WIRE SMOOTH 1.4MM X 100MM,C1713,CDM,272,RC,C1713,HCPCS,,12634-MAIN,LOCAL,,,,,63,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,61.3179,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
SUTURE MAXON MONOFILAMENT ABSORBABLE GREEN SIZE 1 96IN WITH 1/2 CIRCLE TAPER POINT 65MM NEEDLE,27200000,CDM,272,RC,,,,11986-MAIN,LOCAL,,,,,63,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,61.3179,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Vitamin a - Ref,PX8459090,CDM,300,RC,84590,CPT,90,,,,,,,63,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,61.3179,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.65,61.74
"Hospital Inpt or Obs Care, Admin/Disch Same Date Straightforward or Low Level Mdm >= 45 Minutes",PX99234,CDM,982,RC,99234,CPT,,,,,,,,464,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,61.32,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.32,454.72
lidocaine-epinephrine-tetracaine Gel 3 mL Syringe,J3490.160,CDM,636,RC,J3490,HCPCS,,,,88888800028,NDC,3,ML,121.19,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,61.32214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.342326,118.7662
Sigmoidoscope W/Submuc Inj,PX45335F,CDM,750,RC,45335,CPT,,,,,,,,750,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,61.3301,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.23,602.56
Sigmoidoscope W/Submuc Inj,PX45335P,CDM,983,RC,45335,CPT,,,,,,,,500,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,61.3301,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.23,602.56
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703334301,NDC,0.5,ML,142.98,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,61.33842,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963805,NDC,0.5,ML,142.98,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,61.33842,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
sacubitril-valsartan 24-26 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,78065920,NDC,1,EA,62.6,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,61.348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phytonadione 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714097302,NDC,0.5,EA,143.02,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,61.35558,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phytonadione 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,69238105103,NDC,0.5,EA,143.02,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,61.35558,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338080304,NDC,1000,ML,69.59,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,61.37838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990710709,NDC,1000,ML,69.59,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,61.37838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004824,NDC,150,ML,69.59,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,61.37838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
Assay of Lithium,PX80178,CDM,300,RC,80178,CPT,,,,,,,,124,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,61.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.06,121.52
"Complement; Antigen, Each Component",PX86160,CDM,300,RC,86160,CPT,,,,,,,,124,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,61.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11,121.52
"Immunoassay,Ca15-3(27.29) - Ref",PX8630090,CDM,300,RC,86300,CPT,90,,,,,,,124,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,61.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,121.52
Itraconazole,PX8018990,CDM,300,RC,80189,CPT,90,,,,,,,124,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,61.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.86,121.52
Microbe Susceptible Mic,PX87186,CDM,300,RC,87186,CPT,,,,,,,,124,,Humana Choice Care,All Medicare plans,outpatient,49.5,,30.38,percent of total billed charges,61.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.93,121.52
Nocardia Susceptibility - Ref,PX8718690,CDM,300,RC,87186,CPT,90,,,,,,,124,,Humana Choice Care,All Medicare plans,outpatient,49.5,,30.38,percent of total billed charges,61.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.93,121.52
Oligoclonal Bands - Ref,PX8391690,CDM,300,RC,83916,CPT,90,,,,,,,124,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,61.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.11,121.52
UMBILICAL VESSEL CATHETER INSERTION TRAY POLY SINGLE LUMEN 3.5/5FR,120.573,CDM,272,RC,,,,12857-MAIN,LOCAL,,,,,124,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,61.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.5096,121.52
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032056,NDC,1,EA,68.97,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,61.3833,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
nystatin 100000 UNIT/GM Cream 30 g Tube,25000000,CDM,250,RC,,,,,,168005430,NDC,30,GR,147.79,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,61.391966,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Assay Bld/Serum Cholesterol,PX82465,CDM,300,RC,82465,CPT,,,,,,,,69,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,61.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.99,67.62
"Astrazeneca Covid-19 Vaccine, Administration, 1st Dose",PX0021A,CDM,771,RC,,,,,,,,,,69,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,61.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Astrazeneca Covid-19 Vaccine, Adminstration, 2nd Dose",PX0022A,CDM,771,RC,,,,,,,,,,69,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,61.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Janssen Covid-19 Vaccine, Administration",PX0031A,CDM,771,RC,0031A,HCPCS,,,,,,,,69,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,61.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 1st Dose",PX0011A,CDM,771,RC,0011A,HCPCS,,,,,,,,69,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,61.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 2nd Dose",PX0012A,CDM,771,RC,0012A,HCPCS,,,,,,,,69,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,61.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 3rd Dose",PX0013A,CDM,771,RC,0013A,HCPCS,,,,,,,,69,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,61.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
Novavax Covid-19 Vaccine Administration 1st Dose,PX0041A,CDM,771,RC,0041A,HCPCS,,,,,,,,69,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,61.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
Novavax Covid-19 Vaccine Administration 2nd Dose,PX0042A,CDM,771,RC,0042A,HCPCS,,,,,,,,69,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,61.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Pfizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 2nd Dose",PX0002A,CDM,771,RC,0002A,HCPCS,,,,,,,,69,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,61.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Pfizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 3rd Dose",PX0003A,CDM,771,RC,0003A,HCPCS,,,,,,,,69,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,61.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Pifizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 1st Dose",PX0001A,CDM,771,RC,0001A,HCPCS,,,,,,,,69,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,61.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046204,NDC,30,ML,127.94,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,61.4112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046204,NDC,30,ML,127.94,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,61.4112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
KUMAR CHOLANGIOGRAPHY CATHETER,27200000,CDM,272,RC,,,,10230-MAIN,LOCAL,,,,,63.11,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,61.424963,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Canalith Repositioning,PX95992,CDM,420,RC,95992,CPT,,,,,,,,128,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,61.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.86,125.44
Canalith Repositioning,PX95992,CDM,420,RC,95992,CPT,,,,,,,,128,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,61.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.86,125.44
Heparin Xa,PX85520,CDM,300,RC,85520,CPT,,,,,,,,128,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,61.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12,125.44
Heparin Xa,PX85520,CDM,300,RC,85520,CPT,,,,,,,,128,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,61.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12,125.44
Lab Pth Immunoch Part 1,PX83970,CDM,300,RC,83970,CPT,,,,,,,,128,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,61.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.85,125.44
Lab Pth Immunoch Part 1,PX83970,CDM,300,RC,83970,CPT,,,,,,,,128,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,61.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.85,125.44
BLUE EYE SUBMUCOSAL LIFTING AGENT 5ML,27200000,CDM,272,RC,,,,12684-MAIN,LOCAL,,,,,148,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,61.4792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Mumps,PX86735,CDM,300,RC,86735,CPT,,,,,,,,148,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,61.4792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.97,145.04
US Guide Needle Bx S&I,PX7694226,CDM,982,RC,76942,CPT,26,,,,,,,148,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,61.4792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.4792,144.0484
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Plas Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,338604648,NDC,100,ML,143.42,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,61.52718,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.786918,140.5516
"Admin Hep B,Adult 19+",PX3242,CDM,771,RC,90471,CPT,,,,,,,,48,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,61.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,61.54
"BOUGIE TRACH 10FR 70CM COUDE 	9-0211-70",120.199,CDM,272,RC,A7520,HCPCS,,11112-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,61.54,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,64.78
BOUGIE TRACHEAL TUBE & GUIDE 100123515,120.199,CDM,272,RC,A7520,HCPCS,,8950-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,61.54,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,64.78
Chemo Ad Sq/Im Hormnl Anti-Neo,PX96402,CDM,335,RC,96402,CPT,,,,,,,,130,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,61.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,127.4
"Chemotherapy Administration, Subq/Im Non-Hormonal Anti-Neoplastic",PX96401,CDM,335,RC,96401,CPT,,,,,,,,170,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,61.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,166.6
"Chemotherapy, IV Infusion, Add'l Hour",PX96415,CDM,335,RC,96415,CPT,,,,,,,,191,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,61.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,187.18
"Chemotherapy, IV Infusion, Each Add'l Sequential Infusion",PX96417,CDM,335,RC,96417,CPT,,,,,,,,328,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,61.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,321.44
"Chemotherapy, IV Push, Additional Drug",PX96411,CDM,335,RC,96411,CPT,,,,,,,,87,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,61.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.1398,85.26
CRICOTHROTOMY QUICKTRACH 4MM,120.228,CDM,272,RC,A7520,HCPCS,,8868-MAIN,LOCAL,,,,,494,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,61.54,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,64.78
Each Add'l Sequential IV Infusion <1 Hour,PX96367,CDM,260,RC,96367,CPT,,,,,,,,190,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,61.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,186.2
Immunization Admin - Influenza,PX3241,CDM,771,RC,90471,CPT,,,,,,,,48,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,61.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.9392,61.54
Immunization Administration; One Vaccine (Single or Combination Vaccine/To*,PX90471,CDM,771,RC,90471,CPT,,,,,,,,130,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,61.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,127.4
"Injection, Subq/Im",PX96372,CDM,260,RC,96372,CPT,,,,,,,,119,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,61.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,116.62
TUBE TRACH SIZE 3.0MM ID 4.5MM OD SHILEY PEDIATRIC 3.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1185-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,61.54,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 3.5MM ID 5.2MM OD SHILEY PEDIATRIC,120.287,CDM,272,RC,A7520,HCPCS,,8813-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,61.54,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 4.0MM ID 5.9MM OD SHILEY PEDIATRIC 4.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1187-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,61.54,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 5.0MM ID 7.1MM OD SHILEY PEDIATRIC 5.0PED,120.287,CDM,272,RC,A7520,HCPCS,,8814-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,61.54,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,58602060407,NDC,100,GR,67.56,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,61.54716,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,574722612,NDC,1,EA,67.57,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,61.55627,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.345782,66.2186
Fac/Irrigation of Bladder,PX51700F,CDM,510,RC,51700,CPT,,,,,,,,358,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,61.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.1,159.11
Strapping of Shoulder,PX29240F,CDM,420,RC,29240,CPT,,,,,,,,165,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,61.57,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.12,61.57
Strapping of Shoulder,PX29240P,CDM,983,RC,29240,CPT,,,,,,,,110,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,61.57,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.12,107.8
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,517095501,NDC,0.25,EA,69.19,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,61.5791,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86,213.6008
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,17478070311,NDC,10,ML,72.46,,First Health,Commercial,both,85,,999999999,percent of total billed charges,61.591,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
nystatin 100000 UNIT/GM Cream 30 g Tube,25000000,CDM,250,RC,,,,,,51672128902,NDC,30,GR,148.29,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,61.599666,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,45802011222,NDC,22,GR,63.29,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,61.600157,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ENDOLOOP COATED VICRYL 0 18,27200000,CDM,272,RC,,,,10228-MAIN,LOCAL,,,,,143.6,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,61.6044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
fentaNYL 50 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,406905076,NDC,1,EA,125.74,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,61.6126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 50 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,406905076,NDC,1,EA,125.74,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,61.6126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 50 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,406905076,NDC,1,EA,125.74,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,61.6126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ampicillin-sulbactam 1.5 (1-0.5) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001381,NDC,1,EA,69.24,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,61.6236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
"Chemotherapy, IV Infusion, Each Add'l Sequential Infusion",PX96417,CDM,335,RC,96417,CPT,,,,,,,,328,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,61.632,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.88,111.1
aspirin-dipyridamole 25-200 MG Capsule Extended Release 12 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687030533,NDC,1,EA,67.66,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,61.63826,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin-dipyridamole 25-200 MG Capsule Extended Release 12 Hour 20 Each Box,63700001,CDM,250,RC,,,,,,60687030532,NDC,1,EA,67.66,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,61.63826,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Injection Hip Arthrogram,PX27093F,CDM,510,RC,27093,CPT,,,,,,,,654,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,61.6512,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.66,477.34
Canalith Repositioning,PX95992,CDM,420,RC,95992,CPT,,,,,,,,128,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,61.66,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.69,73.88
Chemo Ad Sq/Im Hormnl Anti-Neo,PX96402,CDM,335,RC,96402,CPT,,,,,,,,130,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,61.66,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.03,61.66
Chemo Ad Sq/Im Hormnl Anti-Neo,PX96402,CDM,335,RC,96402,CPT,,,,,,,,130,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,61.66,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.03,61.66
IV 0.9% NS 1000ML 2B1324X,27200000,CDM,272,RC,,,,538-MAIN,LOCAL,,,,,121.89,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,61.67634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Package,25000000,CDM,250,RC,,,,,,10019055390,NDC,1,EA,121.9,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,61.6814,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052331,NDC,2,ML,125.89,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,20.95,percent of total billed charges,61.6861,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.294706,123.3722
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052331,NDC,2,ML,125.89,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,61.6861,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.294706,123.3722
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052331,NDC,2,ML,125.89,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,61.6861,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.294706,123.3722
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052341,NDC,2,ML,125.89,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,20.95,percent of total billed charges,61.6861,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.294706,123.3722
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052341,NDC,2,ML,125.89,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,61.6861,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.294706,123.3722
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052341,NDC,2,ML,125.89,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,61.6861,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.294706,123.3722
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,17478053802,NDC,2,ML,125.91,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,61.6959,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.068162,123.3918
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,17478053802,NDC,2,ML,125.91,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,61.6959,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.068162,123.3918
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,17478053802,NDC,2,ML,125.91,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,61.6959,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.068162,123.3918
dexmedeTOMIDine 200 MCG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,143953201,NDC,2,ML,62.98,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,61.7204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Apply Long Leg Cast,PX29345F,CDM,510,RC,29345,CPT,,,,,,,,912,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,61.73,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.29,285.71
Apply Long Leg Cast,PX29345F,CDM,510,RC,29345,CPT,,,,,,,,912,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,61.73,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.29,285.71
"Digital Mammogram, Screen Bil, Tc W/Cad Perf",PX7706701,CDM,403,RC,77067,CPT,TC,,,,,,,375,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,61.73,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.29,182.1
"Digital Mammogram, Screen Bil, Tc W/Cad Perf",PX7706701,CDM,403,RC,77067,CPT,TC,,,,,,,375,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,61.73,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.29,182.1
Puncture Drainage of Lesion,PX10160F,CDM,510,RC,10160,CPT,,,,,,,,279,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,61.73,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.86,270.49
Puncture Drainage of Lesion,PX10160F,CDM,510,RC,10160,CPT,,,,,,,,279,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,61.73,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.86,270.49
Puncture Drainage of Lesion,PX10160P,CDM,983,RC,10160,CPT,,,,,,,,186,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,61.73,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.86,270.49
Puncture Drainage of Lesion,PX10160P,CDM,983,RC,10160,CPT,,,,,,,,186,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,61.73,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.86,270.49
Assay of Iron,PX83540,CDM,300,RC,83540,CPT,,,,,,,,122,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,61.732,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,119.56
"Compliment, Total (Ch50) - Ref",PX8616290,CDM,300,RC,86162,CPT,90,,,,,,,122,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,61.732,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.63,119.56
Vitamin B-12,PX82607,CDM,300,RC,82607,CPT,,,,,,,,122,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,61.732,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.83,119.56
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608210,NDC,1,ML,63.43,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,13.01809524,percent of total billed charges,61.736419,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
K-WIRE SMOOTH 1.4MM X 100MM,C1713,CDM,272,RC,C1713,HCPCS,,12634-MAIN,LOCAL,,,,,63,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,61.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
SUTURE MAXON MONOFILAMENT ABSORBABLE GREEN SIZE 1 96IN WITH 1/2 CIRCLE TAPER POINT 65MM NEEDLE,27200000,CDM,272,RC,,,,11986-MAIN,LOCAL,,,,,63,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,61.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Thrombin Time Plasma,PX85670,CDM,300,RC,85670,CPT,,,,,,,,126,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,61.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.29,123.48
Thrombin Time Plasma,PX85670,CDM,300,RC,85670,CPT,,,,,,,,126,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,61.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.29,123.48
Thrombin Time Plasma,PX85670,CDM,300,RC,85670,CPT,,,,,,,,126,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,61.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.29,123.48
Vitamin a - Ref,PX8459090,CDM,300,RC,84590,CPT,90,,,,,,,63,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,61.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.65,61.74
triamcinolone acetonide 40 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029320,NDC,1,ML,72.65,,First Health,Commercial,both,85,,999999999,percent of total billed charges,61.7525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,72.0986
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010602,NDC,50,ML,126.07,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,5.851071429,percent of total billed charges,61.7743,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010602,NDC,50,ML,126.07,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,61.7743,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010602,NDC,50,ML,126.07,,United Healthcare,All Medicare advantage plans,outpatient,49,,13.925,percent of total billed charges,61.7743,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010605,NDC,50,ML,126.07,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,5.851071429,percent of total billed charges,61.7743,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010605,NDC,50,ML,126.07,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,61.7743,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010605,NDC,50,ML,126.07,,United Healthcare,All Medicare advantage plans,outpatient,49,,13.925,percent of total billed charges,61.7743,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
nitroglycerin in dextrose 5% 100-5 MCG/ML-% Solution 250 mL Glass Cont,J2305.01,CDM,636,RC,J2305,HCPCS,,,,338104702,NDC,250,ML,126.07,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,61.7743,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.17,123.5486
nitroglycerin in dextrose 5% 100-5 MCG/ML-% Solution 250 mL Glass Cont,J2305.01,CDM,636,RC,J2305,HCPCS,,,,338104702,NDC,250,ML,126.07,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,61.7743,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.17,123.5486
nitroglycerin in dextrose 5% 100-5 MCG/ML-% Solution 250 mL Glass Cont,J2305.01,CDM,636,RC,J2305,HCPCS,,,,338104702,NDC,250,ML,126.07,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,61.7743,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.17,123.5486
Hepatitis C Antibody,PX86803,CDM,300,RC,86803,CPT,,,,,,,,144,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,61.776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.08,141.12
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915850,NDC,0.2,ML,69.44,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,61.8016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
gentamicin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063305,NDC,5,ML,122.17,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,61.81802,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
hepatitis A vaccine 1440 EL U/ML Suspension 1 mL Syringe,90632,CDM,636,RC,90632,CPT,,,,58160082652,NDC,1,ML,375.78,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,61.83,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.83,70.54
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039801,NDC,1,EA,67.88,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,61.83868,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039810,NDC,1,EA,67.88,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,61.83868,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781910572,NDC,0.25,EA,69.49,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,61.8461,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86,213.6008
KUMAR CHOLANGIOGRAPHY CATHETER,27200000,CDM,272,RC,,,,10230-MAIN,LOCAL,,,,,63.11,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,61.8478,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094310,NDC,10,ML,72.79,,First Health,Commercial,both,85,,999999999,percent of total billed charges,61.8715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.236966,143.9032
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094321,NDC,10,ML,72.79,,First Health,Commercial,both,85,,999999999,percent of total billed charges,61.8715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.236966,143.9032
Cmv Igm Antibody - Ref,PX8664590,CDM,300,RC,86645,CPT,90,,,,,,,125,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,61.875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.45,122.5
DRESSING SURGICEL HEMOSTAT 4X8 ABSORBABLE 1952,120.123,CDM,272,RC,A6252,HCPCS,,1002-MAIN,LOCAL,,,,,125,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,61.875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.925,122.5
Factor VII - Ref,PX8523090,CDM,300,RC,85230,CPT,90,,,,,,,125,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,61.875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.41,122.5
"Urinalysis, Auto W/O Scope",PX81003,CDM,300,RC,81003,CPT,,,,,,,,149,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,61.8946,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.06,146.02
albuterol HFA 108 (90 Base) MCG/ACT Aerosol Solution 8 g Inhaler,25000000,CDM,250,RC,,,,,,173068224,NDC,8,GR,149.04,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,61.911216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Complete Cbc Automated,PX85027,CDM,300,RC,85027,CPT,,,,,,,,129,,Health Partners,Health Partners Care Plans,both,48,,52.87318182,percent of total billed charges,61.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,126.42
Complete Cbc Automated,PX85027,CDM,300,RC,85027,CPT,,,,,,,,129,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,61.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,126.42
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338080304,NDC,1000,ML,69.59,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,61.9351,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990710709,NDC,1000,ML,69.59,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,61.9351,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004824,NDC,150,ML,69.59,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,61.9351,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
SUMAtriptan 25 MG Tablet 9 Each Box,63700001,CDM,250,RC,,,,,,65862014636,NDC,1,EA,129.04,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,61.9392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SUMAtriptan 25 MG Tablet 9 Each Box,63700001,CDM,250,RC,,,,,,65862014636,NDC,1,EA,129.04,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,61.9392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Flour. Afstain , Micro - Ref",PX8720690,CDM,300,RC,87206,CPT,90,,,,,,,68,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,61.948,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.94,66.64
Hemoglobin,PX85018,CDM,300,RC,85018,CPT,,,,,,,,68,,Medica,Commercial,both,91.1,,30.935,percent of total billed charges,61.948,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.17,66.64
Thyroglobulin - Ref,PX8443290,CDM,300,RC,84432,CPT,90,,,,,,,68,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,61.948,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.73,66.64
Thyroglobulin Antibody,PX8680090,CDM,300,RC,86800,CPT,90,,,,,,,68,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,61.948,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.59,66.64
Echo Tt 2d Complete,PX9330701,CDM,480,RC,93307,CPT,TC,,,,,,,2303,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,61.95,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.95,164.04
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409751716,NDC,50,ML,72.9,,First Health,Commercial,both,85,,999999999,percent of total billed charges,61.965,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
terbinafine 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714079501,NDC,1,EA,68.03,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,61.97533,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"TB Test, Cell Immunity Measure",PX86480,CDM,300,RC,86480,CPT,,,,,,,,186,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,61.98,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.12,61.98
terbinafine 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714050101,NDC,1,EA,68.04,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,61.98444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098121,NDC,1,EA,72.95,,First Health,Commercial,both,85,,999999999,percent of total billed charges,62.0075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,45802011222,NDC,22,GR,63.29,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,62.0242,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vancomycin 125 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68180016611,NDC,1,EA,149.33,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,62.031682,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 125 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,47781072902,NDC,1,EA,149.33,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,62.031682,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 125 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,62559039020,NDC,1,EA,149.33,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,62.031682,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluconazole 150 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,16714069210,NDC,1,EA,72.98,,First Health,Commercial,both,85,,999999999,percent of total billed charges,62.033,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LIGACLIP APPLIER CLIP STERILE SIZE MEDIUM LARGE,27200000,CDM,272,RC,,,,11699-MAIN,LOCAL,,,,,126.62,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,62.0438,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LIGACLIP APPLIER CLIP STERILE SIZE MEDIUM LARGE,27200000,CDM,272,RC,,,,11699-MAIN,LOCAL,,,,,126.62,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,62.0438,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LIGACLIP APPLIER CLIP STERILE SIZE MEDIUM LARGE,27200000,CDM,272,RC,,,,11699-MAIN,LOCAL,,,,,126.62,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,62.0438,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
BALLOON EXTRACTOR PEDS,120.358,CDM,272,RC,,,,10771-MAIN,LOCAL,,,,,73,,First Health,Commercial,both,85,,999999999,percent of total billed charges,62.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.3242,71.54
brimonidine 0.2 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,70069023101,NDC,5,ML,70.38,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,62.07516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Office Consultation,Level III",PX99243P,CDM,983,RC,99243,CPT,,,,,,,,374,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,62.09,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.65,366.52
"Office Consultation,Level III",PX99243P,CDM,983,RC,99243,CPT,,,,,,,,374,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,62.09,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.65,366.52
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,43598040516,NDC,0.2,ML,63.83,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,62.125739,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
apixaban 2.5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,3089321,NDC,1,EA,63.84,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,62.135472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018200,NDC,10,ML,68.21,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,62.13931,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.24,991.564
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018210,NDC,10,ML,68.21,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,62.13931,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.24,991.564
Acetaminophen,PX80307E,CDM,300,RC,80307,CPT,,,,,,,,370,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,62.14,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.28,62.14
Alcohol,PX80307A,CDM,300,RC,80307,CPT,,,,,,,,370,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,62.14,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.28,62.14
Salicylate,PX80307D,CDM,300,RC,80307,CPT,,,,,,,,370,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,62.14,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.28,62.14
Urine Drug Screen,PX80307B,CDM,300,RC,80307,CPT,,,,,,,,370,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,62.14,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.28,62.14
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608210,NDC,1,ML,63.43,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,62.1614,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
fluticasone 110 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173071920,NDC,12,GR,149.67,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,62.172918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Immunohisto Antibody Slide Ea Addl,PX8834101,CDM,310,RC,88341,CPT,TC,,,,,,,102,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,62.18,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.18,104.4
Immunohisto Antibody Slide Ea Addl,PX8834101,CDM,310,RC,88341,CPT,TC,,,,,,,102,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,62.18,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.18,104.4
Immunohisto Antibody Slide Ea Addl,PX8834101,CDM,310,RC,88341,CPT,TC,,,,,,,102,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,62.18,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.18,104.4
Assay Carbamazepine Total,PX80156,CDM,300,RC,80156,CPT,,,,,,,,145,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,62.205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.36,142.1
"Calculus, Infrared Spec - Ref",PX8236590,CDM,300,RC,82365,CPT,90,,,,,,,145,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,62.205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.83,142.1
"Catecholamines, Fraction - Ref",PX8238490,CDM,300,RC,82384,CPT,90,,,,,,,145,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,62.205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.15,142.1
Hsv Dna Amp Probe,PX87529,CDM,300,RC,87529,CPT,,,,,,,,145,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,62.205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,142.1
Immunofixation Electrophoresis; Serum,PX86334,CDM,300,RC,86334,CPT,,,,,,,,145,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,62.205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.48,142.1
LEGGING COMPRESSION JUXTALITE LONG LG 33CM,120.369,CDM,271,RC,A6545,HCPCS,,10840-MAIN,LOCAL,,,,,145,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,62.205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.233,142.1
"Pare/Cut Hyperkeratotic Skin Lesion, Single",PX11055F,CDM,510,RC,11055,CPT,,,,,,,,145,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,62.205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.233,174.9
Surgical Cleansing of Skin,PX11000P,CDM,983,RC,11000,CPT,,,,,,,,145,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,62.205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.233,548.67
Wheelchair Mngement Training,PX97542,CDM,420,RC,97542,CPT,,,,,,,,145,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,62.205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.59,142.1
B-Scan Global,PX7651201,CDM,402,RC,76512,CPT,TC,,,,,,,127,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,62.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.7558,124.46
B-Scan Global,PX7651201,CDM,402,RC,76512,CPT,TC,,,,,,,127,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,62.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.7558,124.46
B-Scan Global,PX7651201,CDM,402,RC,76512,CPT,TC,,,,,,,127,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,62.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.7558,124.46
Candida Dna Dir Probe,PX87480,CDM,300,RC,87480,CPT,,,,,,,,127,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,62.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.38,124.46
Candida Dna Dir Probe,PX87480,CDM,300,RC,87480,CPT,,,,,,,,127,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,62.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.38,124.46
Candida Dna Dir Probe,PX87480,CDM,300,RC,87480,CPT,,,,,,,,127,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,62.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.38,124.46
Gardner Vag Dna Dir Probe,PX87510,CDM,300,RC,87510,CPT,,,,,,,,127,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,62.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.38,124.46
Gardner Vag Dna Dir Probe,PX87510,CDM,300,RC,87510,CPT,,,,,,,,127,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,62.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.38,124.46
Gardner Vag Dna Dir Probe,PX87510,CDM,300,RC,87510,CPT,,,,,,,,127,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,62.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.38,124.46
Influenza Assay W/Optic,PX87804,CDM,300,RC,87804,CPT,,,,,,,,127,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,62.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.17,124.46
Influenza Assay W/Optic,PX87804,CDM,300,RC,87804,CPT,,,,,,,,127,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,62.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.17,124.46
Influenza Assay W/Optic,PX87804,CDM,300,RC,87804,CPT,,,,,,,,127,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,62.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.17,124.46
Trichomonas Vagin Dir Probe,PX87660,CDM,300,RC,87660,CPT,,,,,,,,127,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,62.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.38,124.46
Trichomonas Vagin Dir Probe,PX87660,CDM,300,RC,87660,CPT,,,,,,,,127,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,62.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.38,124.46
Trichomonas Vagin Dir Probe,PX87660,CDM,300,RC,87660,CPT,,,,,,,,127,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,62.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.38,124.46
Each Add'l Hour IV Hydration,PX96361,CDM,260,RC,96361,CPT,,,,,,,,123,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,62.238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,120.54
FLAT WOUND DRAIN WITH TROCAR 4 CHANNEL FULL FLUTED 7FR SILICONE,27200000,CDM,272,RC,,,,12473-MAIN,LOCAL,,,,,123,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,62.238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Office/Outpt Visit,New,Levl II",PX99202F,CDM,510,RC,99202,CPT,,,,,,,,123,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,62.238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.0942,120.54
"Office/Outpt Visit,New,Levl II",PX99202P,CDM,983,RC,99202,CPT,,,,,,,,123,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,62.238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.0942,119.7159
fentaNYL 50 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,406905076,NDC,1,EA,125.74,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,62.2413,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050601,NDC,1,ML,68.33,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,62.24863,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010520,NDC,1,EA,68.33,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,62.24863,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010541,NDC,1,EA,68.33,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,62.24863,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
pramox-PE-glycerin-petrolatum 1-0.25-14.4-15 % Cream 51 g Tube,63700001,CDM,250,RC,,,,,,573286898,NDC,51,GR,68.34,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,62.25774,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Collect Blood From Picc,PX36592,CDM,949,RC,36592,CPT,,,,,,,,198,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,62.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.97,62.26
Collect Blood From Picc,PX36592,CDM,949,RC,36592,CPT,,,,,,,,198,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,62.26,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.97,62.26
Collect Blood From Picc,PX36592F,CDM,510,RC,36592,CPT,,,,,,,,211,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,62.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.97,62.26
Collect Blood From Picc,PX36592F,CDM,510,RC,36592,CPT,,,,,,,,211,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,62.26,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.97,62.26
Strapping of Hand or Finger,PX29280F,CDM,420,RC,29280,CPT,,,,,,,,64,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,62.26,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.21,62.26
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320885,NDC,0.5,EA,129.71,,Health Partners,Health Partners Care Plans,both,48,,26.64321429,percent of total billed charges,62.2608,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320885,NDC,0.5,EA,129.71,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,62.2608,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320895,NDC,0.5,EA,129.71,,Health Partners,Health Partners Care Plans,both,48,,26.64321429,percent of total billed charges,62.2608,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320895,NDC,0.5,EA,129.71,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,62.2608,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
adenosine 6 MG/2ML Solution 2 mL Syringe,J0153.01,CDM,636,RC,J0153,HCPCS,,,,25021030167,NDC,2,ML,123.1,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,62.2886,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.13574,120.638
Blood Occult Peroxidase,PX82272,CDM,300,RC,82272,CPT,,,,,,,,64,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,30.27333333,percent of total billed charges,62.2912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.88,62.72
Strapping of Elbow or Wrist,PX29260F,CDM,420,RC,29260,CPT,,,,,,,,64,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,62.2912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.5856,62.72
Strapping of Hand or Finger,PX29280F,CDM,420,RC,29280,CPT,,,,,,,,64,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,62.2912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.5856,62.72
"Bone Marrow Aspiration(S),Diag",PX38220F,CDM,510,RC,38220,CPT,,,,,,,,305,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,62.2934,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.1,326.53
"Bone Marrow Aspiration(S),Diag",PX38220P,CDM,983,RC,38220,CPT,,,,,,,,244,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,62.2934,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.1,326.53
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457000100,NDC,10,ML,68.38,,Medica,Commercial,both,91.1,,7.37,percent of total billed charges,62.29418,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
TRAY SURGICAL PODIATRY II EXTREMITY DYNJS0803,27200000,CDM,272,RC,,,,10920-MAIN,LOCAL,,,,,73.29,,First Health,Commercial,both,85,,999999999,percent of total billed charges,62.2965,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Assay of CK (Cpk),PX82550,CDM,300,RC,82550,CPT,,,,,,,,150,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,62.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.97,147
Assay of Lactic Acid,PX83605,CDM,300,RC,83605,CPT,,,,,,,,150,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,62.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.61,147
Assay of Phosphorus,PX84100,CDM,300,RC,84100,CPT,,,,,,,,150,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,62.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.35,147
Bilirubin Direct,PX82248,CDM,300,RC,82248,CPT,,,,,,,,150,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,62.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.6,147
Bilirubin Total,PX82247,CDM,300,RC,82247,CPT,,,,,,,,150,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,62.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.6,147
"Drug(S) or Substance(S), Definitive, Qualitative or Quantitative, Not Otherwise Specified; 1-3 - Ref",PX8037590,CDM,300,RC,80375,CPT,90,,,,,,,150,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,62.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.31,147
"Hsv Detect, Amplif Probe - Ref",PX8752990,CDM,300,RC,87529,CPT,90,,,,,,,150,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,62.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,147
Magnesium,PX83735,CDM,300,RC,83735,CPT,,,,,,,,150,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,62.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.14,147
Magnesium - Ref,PX8373590,CDM,300,RC,83735,CPT,90,,,,,,,150,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,62.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.14,147
Po4 Inorganic (Phosphate) - Ref,PX8410090,CDM,300,RC,84100,CPT,90,,,,,,,150,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,62.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.35,147
TB Antigen Response Gamma Interferon T-Cell Susp,PX86481,CDM,300,RC,86481,CPT,,,,,,,,150,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,62.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.31,147
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052331,NDC,2,ML,125.89,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,62.31555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.294706,123.3722
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052341,NDC,2,ML,125.89,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,62.31555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.294706,123.3722
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,17478053802,NDC,2,ML,125.91,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,62.32545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.068162,123.3918
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,63739005007,NDC,1,EA,73.35,,First Health,Commercial,both,85,,999999999,percent of total billed charges,62.3475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DAPTOmycin 500 MG Recon Soln 1 Each Vial,J0878.01,CDM,636,RC,J0878,HCPCS,,,,70594003402,NDC,1,EA,129.9,,Health Partners,Health Partners Care Plans,both,48,,0.245566667,percent of total billed charges,62.352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.96046,127.302
DAPTOmycin 500 MG Recon Soln 1 Each Vial,J0878.01,CDM,636,RC,J0878,HCPCS,,,,70594003402,NDC,1,EA,129.9,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,62.352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.96046,127.302
"Hospital Inpt or Obs Care, Admin/Disch Same Date Straightforward or Low Level Mdm >= 45 Minutes",PX99234,CDM,982,RC,99234,CPT,,,,,,,,464,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,62.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.32,454.72
"Hospital Inpt or Obs Care, Admin/Disch Same Date Straightforward or Low Level Mdm >= 45 Minutes",PX99234,CDM,982,RC,99234,CPT,,,,,,,,464,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,62.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.32,454.72
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990711509,NDC,1000,ML,64.08,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,4.559571429,percent of total billed charges,62.369064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
Thrombin Time Plasma,PX85670,CDM,300,RC,85670,CPT,,,,,,,,126,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,62.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.29,123.48
sodium polystyrene sulfonate 15 GM/60ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,46287000660,NDC,60,ML,123.3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,62.3898,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Raltegravir 400 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,6022761,NDC,1,EA,150.2,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,62.39308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Chemo Ad Sq/Im Hormnl Anti-Neo,PX96402,CDM,335,RC,96402,CPT,,,,,,,,130,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,62.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,127.4
Chemo Ad Sq/Im Hormnl Anti-Neo,PX96402,CDM,335,RC,96402,CPT,,,,,,,,130,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,62.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,127.4
Cystatin C - Ref,PX8261090,CDM,300,RC,82610,CPT,90,,,,,,,130,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,62.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.98,127.4
Cystatin C - Ref,PX8261090,CDM,300,RC,82610,CPT,90,,,,,,,130,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,62.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.98,127.4
Each Add'l Sequential Push New Drug,PX96375,CDM,260,RC,96375,CPT,,,,,,,,130,,Health Partners,Health Partners Care Plans,both,48,,59.63690476,percent of total billed charges,62.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,127.4
Each Add'l Sequential Push New Drug,PX96375,CDM,260,RC,96375,CPT,,,,,,,,130,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,62.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,127.4
Immunization Administration; One Vaccine (Single or Combination Vaccine/To*,PX90471,CDM,771,RC,90471,CPT,,,,,,,,130,,Health Partners,Health Partners Care Plans,both,48,,73.38285714,percent of total billed charges,62.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,127.4
Immunization Administration; One Vaccine (Single or Combination Vaccine/To*,PX90471,CDM,771,RC,90471,CPT,,,,,,,,130,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,62.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,127.4
Prothrombin Time (Pt/Inr),PX85610,CDM,300,RC,85610,CPT,,,,,,,,130,,Health Partners,Health Partners Care Plans,both,48,,84.5025,percent of total billed charges,62.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.93,127.4
Prothrombin Time (Pt/Inr),PX85610,CDM,300,RC,85610,CPT,,,,,,,,130,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,62.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.93,127.4
SPLINT WRIST LARGE ALUMINUM FOREARM LEFT 9101-06,120.87,CDM,274,RC,L3809,HCPCS,,1265-MAIN,LOCAL,,,,,130,,Health Partners,Health Partners Care Plans,both,48,,34.92,percent of total billed charges,62.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST LARGE ALUMINUM FOREARM LEFT 9101-06,120.87,CDM,274,RC,L3809,HCPCS,,1265-MAIN,LOCAL,,,,,130,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,62.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST LARGE ALUMINUM FOREARM RIGHT 9101-03,120.87,CDM,274,RC,L3809,HCPCS,,1263-MAIN,LOCAL,,,,,130,,Health Partners,Health Partners Care Plans,both,48,,34.92,percent of total billed charges,62.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST LARGE ALUMINUM FOREARM RIGHT 9101-03,120.87,CDM,274,RC,L3809,HCPCS,,1263-MAIN,LOCAL,,,,,130,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,62.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST MEDIUM ALUMINUM FOREARM LEFT 9101-05,120.87,CDM,274,RC,L3809,HCPCS,,1264-MAIN,LOCAL,,,,,130,,Health Partners,Health Partners Care Plans,both,48,,34.92,percent of total billed charges,62.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST MEDIUM ALUMINUM FOREARM LEFT 9101-05,120.87,CDM,274,RC,L3809,HCPCS,,1264-MAIN,LOCAL,,,,,130,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,62.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST MEDIUM ALUMINUM FOREARM RIGHT 9101-02,120.87,CDM,274,RC,L3809,HCPCS,,1262-MAIN,LOCAL,,,,,130,,Health Partners,Health Partners Care Plans,both,48,,34.92,percent of total billed charges,62.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST MEDIUM ALUMINUM FOREARM RIGHT 9101-02,120.87,CDM,274,RC,L3809,HCPCS,,1262-MAIN,LOCAL,,,,,130,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,62.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
Vitamin B-1 - Ref,PX8442590,CDM,300,RC,84425,CPT,90,,,,,,,130,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,62.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.47,127.4
Vitamin B-1 - Ref,PX8442590,CDM,300,RC,84425,CPT,90,,,,,,,130,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,62.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.47,127.4
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010602,NDC,50,ML,126.07,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,62.40465,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010605,NDC,50,ML,126.07,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,62.40465,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
nitroglycerin in dextrose 5% 100-5 MCG/ML-% Solution 250 mL Glass Cont,J2305.01,CDM,636,RC,J2305,HCPCS,,,,338104702,NDC,250,ML,126.07,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,62.40465,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.17,123.5486
Xray Finger(S) Tc,PX7314001,CDM,320,RC,73140,CPT,TC,,,,,,,282,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,62.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.72,62.45
Xray Finger(S) Tc,PX7314001,CDM,320,RC,73140,CPT,TC,,,,,,,282,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,62.45,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.72,62.45
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,409337504,NDC,4,ML,150.36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,62.459544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
durvalumab 120 MG/2.4ML Solution 2.4 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310450012,NDC,30,ML,21771.9,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,62.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.48,21336.462
durvalumab 500 MG/10ML Solution 10 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310461150,NDC,10,ML,7588.77,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,62.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.48,21336.462
LAPAROTOMY MAJOR I,27200000,CDM,272,RC,,,,4828-MAIN,LOCAL,,,,,123.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,62.491,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"BUPivacaine 0.25%-EPINEPHrine 1:200,000 0.25% -1:200000 Solution 50 mL Vial",25000000,CDM,250,RC,,,,,,409175250,NDC,30,ML,68.6,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,62.4946,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
triamcinolone acetonide 40 MG/ML Suspension 1 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029305,NDC,1,ML,73.57,,First Health,Commercial,both,85,,999999999,percent of total billed charges,62.5345,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,72.0986
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046203,NDC,30,ML,70.91,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,62.54262,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,43598040516,NDC,0.2,ML,63.83,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,62.5534,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
apixaban 2.5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,3089321,NDC,1,EA,63.84,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,62.5632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
triamcinolone acetonide 0.1 % Cream 454 g Jar,63700001,CDM,250,RC,,,,,,45802006405,NDC,454,GR,130.36,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,62.5728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
triamcinolone acetonide 0.1 % Cream 454 g Jar,63700001,CDM,250,RC,,,,,,45802006405,NDC,454,GR,130.36,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,62.5728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Immunohisto Antibody Slide Ea Addl,PX8834101,CDM,310,RC,88341,CPT,TC,,,,,,,102,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,62.5755,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.18,104.4
CT Soft Tissue Neck W/O Dye,PX7049001,CDM,350,RC,70490,CPT,TC,,,,,,,711,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,62.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.6,184.73
CT Soft Tissue Neck W/O Dye,PX7049001,CDM,350,RC,70490,CPT,TC,,,,,,,711,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,62.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.6,184.73
Echo Tt 2d Complete,PX9330701,CDM,480,RC,93307,CPT,TC,,,,,,,2303,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,62.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.95,164.04
Echo Tt 2d Complete,PX9330701,CDM,480,RC,93307,CPT,TC,,,,,,,2303,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,62.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.95,164.04
Tap Block Bilateral by Injection(S),PX64488F,CDM,510,RC,64488,CPT,,,,,,,,393,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,62.6145,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.32,285.02
Tap Block Bilateral by Injection(S),PX64488P,CDM,983,RC,64488,CPT,,,,,,,,262,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,62.6145,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.32,285.02
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615900,NDC,1,EA,123.75,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,62.6175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615904,NDC,1,EA,123.75,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,62.6175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
Gabapentin - Ref,PX8017190,CDM,300,RC,80171,CPT,90,,,,,,,71,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,62.622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.87,69.58
Histoplasma Antibody - Ref,PX8669890,CDM,300,RC,86698,CPT,90,,,,,,,71,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,62.622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.64,69.58
Legionella Antibody - Ref,PX8671390,CDM,300,RC,86713,CPT,90,,,,,,,71,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,62.622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.03,69.58
Islet Cell Antibody - Ref,PX8634190,CDM,300,RC,86341,CPT,90,,,,,,,146,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,62.634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.61,143.08
brimonidine 0.2 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,70069023101,NDC,5,ML,70.38,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,62.6382,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
magnesium sulfate 4 GM/50ML Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010701,NDC,50,ML,73.72,,First Health,Commercial,both,85,,999999999,percent of total billed charges,62.662,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
LIGACLIP APPLIER CLIP STERILE SIZE MEDIUM LARGE,27200000,CDM,272,RC,,,,11699-MAIN,LOCAL,,,,,126.62,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,62.6769,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046204,NDC,30,ML,127.94,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,62.6906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046204,NDC,30,ML,127.94,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,62.6906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046204,NDC,30,ML,127.94,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,62.6906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Non-Select. Wound Debride., W/O Anesth.; Top. Appl./Wound Assess./Instruct., per Sess.",PX97602,CDM,761,RC,97602,CPT,,,,,,,,212,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,62.71,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.28,104.16
"Non-Select. Wound Debride., W/O Anesth.; Top. Appl./Wound Assess./Instruct., per Sess.",PX97602,CDM,761,RC,97602,CPT,,,,,,,,212,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,62.71,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.28,104.16
Blood Occult Peroxidase,PX82272,CDM,300,RC,82272,CPT,,,,,,,,64,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,62.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.88,62.72
Canalith Repositioning,PX95992,CDM,420,RC,95992,CPT,,,,,,,,128,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,120.4,percent of total billed charges,62.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.86,125.44
Canalith Repositioning,PX95992,CDM,420,RC,95992,CPT,,,,,,,,128,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,62.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.86,125.44
Canalith Repositioning,PX95992,CDM,420,RC,95992,CPT,,,,,,,,128,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,62.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.86,125.44
Heparin Xa,PX85520,CDM,300,RC,85520,CPT,,,,,,,,128,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,62.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12,125.44
Heparin Xa,PX85520,CDM,300,RC,85520,CPT,,,,,,,,128,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,62.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12,125.44
Heparin Xa,PX85520,CDM,300,RC,85520,CPT,,,,,,,,128,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,62.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12,125.44
Lab Pth Immunoch Part 1,PX83970,CDM,300,RC,83970,CPT,,,,,,,,128,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,62.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.85,125.44
Lab Pth Immunoch Part 1,PX83970,CDM,300,RC,83970,CPT,,,,,,,,128,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,62.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.85,125.44
Lab Pth Immunoch Part 1,PX83970,CDM,300,RC,83970,CPT,,,,,,,,128,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,62.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.85,125.44
"N Block Inj, Common Digit",PX64632P,CDM,983,RC,64632,CPT,,,,,,,,128,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,62.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.1712,258.75
"N Block Inj, Common Digit",PX64632P,CDM,983,RC,64632,CPT,,,,,,,,128,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,62.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.1712,258.75
"N Block Inj, Common Digit",PX64632P,CDM,983,RC,64632,CPT,,,,,,,,128,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,62.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.1712,258.75
Strapping of Elbow or Wrist,PX29260F,CDM,420,RC,29260,CPT,,,,,,,,64,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,62.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.5856,62.72
Strapping of Hand or Finger,PX29280F,CDM,420,RC,29280,CPT,,,,,,,,64,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,62.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.5856,62.72
Assay of Lithium,PX80178,CDM,300,RC,80178,CPT,,,,,,,,124,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,62.744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.06,121.52
"Complement; Antigen, Each Component",PX86160,CDM,300,RC,86160,CPT,,,,,,,,124,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,62.744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11,121.52
"Immunoassay,Ca15-3(27.29) - Ref",PX8630090,CDM,300,RC,86300,CPT,90,,,,,,,124,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,62.744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,121.52
Itraconazole,PX8018990,CDM,300,RC,80189,CPT,90,,,,,,,124,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,62.744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.86,121.52
Microbe Susceptible Mic,PX87186,CDM,300,RC,87186,CPT,,,,,,,,124,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,62.744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.93,121.52
Nocardia Susceptibility - Ref,PX8718690,CDM,300,RC,87186,CPT,90,,,,,,,124,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,62.744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.93,121.52
Oligoclonal Bands - Ref,PX8391690,CDM,300,RC,83916,CPT,90,,,,,,,124,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,62.744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.11,121.52
UMBILICAL VESSEL CATHETER INSERTION TRAY POLY SINGLE LUMEN 3.5/5FR,120.573,CDM,272,RC,,,,12857-MAIN,LOCAL,,,,,124,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,62.744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.5096,121.52
caffeine citrate 60 MG/3ML Solution 3 mL Vial,J0706.01,CDM,636,RC,J0706,HCPCS,,,,63323040704,NDC,3,ML,73.84,,First Health,Commercial,both,85,,999999999,percent of total billed charges,62.764,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.673136,72.3632
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,409508411,NDC,1,EA,73.86,,First Health,Commercial,both,85,,999999999,percent of total billed charges,62.781,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
"Office/Outpt Visit,Est,Levl II",PX99212F,CDM,510,RC,99212,CPT,,,,,,,,155,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,62.79,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.04,101.66
"Office/Outpt Visit,Est,Levl II",PX99212P,CDM,983,RC,99212,CPT,,,,,,,,155,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,62.79,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.04,151.9
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990711509,NDC,1000,ML,64.08,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,62.7984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,63323004401,NDC,1,ML,64.53,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,62.807049,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,63.2394
CT Soft Tissue Neck W/O Dye,PX7049001,CDM,350,RC,70490,CPT,TC,,,,,,,711,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,62.82,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.6,184.73
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760,CDM,420,RC,97760,CPT,,,,,,,,142,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,62.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.1,62.82
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760,CDM,420,RC,97760,CPT,,,,,,,,142,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,62.82,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.1,62.82
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760F,CDM,510,RC,97760,CPT,,,,,,,,142,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,62.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.1,62.82
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760F,CDM,510,RC,97760,CPT,,,,,,,,142,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,62.82,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.1,62.82
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032056,NDC,1,EA,68.97,,Medica,Commercial,both,91.1,,5.442333333,percent of total billed charges,62.83167,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
Assay Bld/Serum Cholesterol,PX82465,CDM,300,RC,82465,CPT,,,,,,,,69,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,62.859,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.99,67.62
"Astrazeneca Covid-19 Vaccine, Administration, 1st Dose",PX0021A,CDM,771,RC,,,,,,,,,,69,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,62.859,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Astrazeneca Covid-19 Vaccine, Adminstration, 2nd Dose",PX0022A,CDM,771,RC,,,,,,,,,,69,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,62.859,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Janssen Covid-19 Vaccine, Administration",PX0031A,CDM,771,RC,0031A,HCPCS,,,,,,,,69,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,62.859,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 1st Dose",PX0011A,CDM,771,RC,0011A,HCPCS,,,,,,,,69,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,62.859,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 2nd Dose",PX0012A,CDM,771,RC,0012A,HCPCS,,,,,,,,69,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,62.859,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 3rd Dose",PX0013A,CDM,771,RC,0013A,HCPCS,,,,,,,,69,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,62.859,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
Novavax Covid-19 Vaccine Administration 1st Dose,PX0041A,CDM,771,RC,0041A,HCPCS,,,,,,,,69,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,62.859,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
Novavax Covid-19 Vaccine Administration 2nd Dose,PX0042A,CDM,771,RC,0042A,HCPCS,,,,,,,,69,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,62.859,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Pfizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 2nd Dose",PX0002A,CDM,771,RC,0002A,HCPCS,,,,,,,,69,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,62.859,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Pfizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 3rd Dose",PX0003A,CDM,771,RC,0003A,HCPCS,,,,,,,,69,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,62.859,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Pifizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 1st Dose",PX0001A,CDM,771,RC,0001A,HCPCS,,,,,,,,69,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,62.859,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
B-Scan Global,PX7651201,CDM,402,RC,76512,CPT,TC,,,,,,,127,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,62.865,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.7558,124.46
Candida Dna Dir Probe,PX87480,CDM,300,RC,87480,CPT,,,,,,,,127,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,62.865,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.38,124.46
Gardner Vag Dna Dir Probe,PX87510,CDM,300,RC,87510,CPT,,,,,,,,127,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,62.865,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.38,124.46
Influenza Assay W/Optic,PX87804,CDM,300,RC,87804,CPT,,,,,,,,127,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,62.865,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.17,124.46
Trichomonas Vagin Dir Probe,PX87660,CDM,300,RC,87660,CPT,,,,,,,,127,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,62.865,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.38,124.46
ARIPiprazole 2 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714014101,NDC,1,EA,151.35,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,62.87079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Noninvasv Oxygen Satur;Single,PX94760,CDM,460,RC,94760,CPT,,,,,,,,131,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,62.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.4174,128.38
Noninvasv Oxygen Satur;Single,PX94760,CDM,460,RC,94760,CPT,,,,,,,,131,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,62.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.4174,128.38
TRAY HAND SURGICAL II DYNJS0806,27200000,CDM,272,RC,,,,11024-MAIN,LOCAL,,,,,64.62,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,62.894646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,55150012150,NDC,1,EA,151.41,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,62.895714,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
Glucose Test,PX82950,CDM,300,RC,82950,CPT,,,,,,,,74,,First Health,Commercial,both,85,,999999999,percent of total billed charges,62.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.36,72.52
KIT EMERGENCY BIRTH DYNJS0600,120.317,CDM,272,RC,,,,8344-MAIN,LOCAL,,,,,74,,First Health,Commercial,both,85,,999999999,percent of total billed charges,62.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.7396,72.52
Rubeola Antibody,PX86765,CDM,300,RC,86765,CPT,,,,,,,,74,,First Health,Commercial,both,85,,999999999,percent of total billed charges,62.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.81,72.52
levoFLOXacin in dextrose 5% 500 MG/100ML Solution 100 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004724,NDC,100,ML,64.63,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,2.672307692,percent of total billed charges,62.904379,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,76329339001,NDC,5,ML,64.63,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,62.904379,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,69315030615,NDC,15,GR,131.07,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,62.9136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,69315030615,NDC,15,GR,131.07,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,62.9136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"N Block Inj, Common Digit",PX64632F,CDM,510,RC,64632,CPT,,,,,,,,190,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,62.9356,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.88,188.86
"N Block Inj, Common Digit",PX64632P,CDM,983,RC,64632,CPT,,,,,,,,128,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,62.9356,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.88,188.86
DOBUTamine 1000 mcg/mL in dextrose 5% 250 mL premix 1000 mcg/ml Solution 250 mL Flex Cont,J1250.01,CDM,636,RC,J1250,HCPCS,,,,338107302,NDC,250,ML,146.73,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,62.94717,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.951642,143.7954
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409338513,NDC,1,EA,74.09,,First Health,Commercial,both,85,,999999999,percent of total billed charges,62.9765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,409662902,NDC,10,ML,146.84,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,62.99436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.236966,143.9032
anastrozole 1 MG Tablet 30 Each Bottle,25000000,CDM,250,RC,,,,,,16729003510,NDC,1,EA,71.44,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,63.01008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,517095501,NDC,0.25,EA,69.19,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,63.03209,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86,213.6008
TUBE TRACH SIZE 5 7.0MM ID 10.1MM OD SHILEY CUFFED 5CN70H,120.287,CDM,272,RC,A7521,HCPCS,,10350-MAIN,LOCAL,,,,,184,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,63.0532,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 6 6.0MM ID 8.3MM OD SHILEY CUFFED 6SCT,120.287,CDM,272,RC,A7521,HCPCS,,8812-MAIN,LOCAL,,,,,184,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,63.0532,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 6 6.4MM ID 10.8MM OD SHILEY CUFFED 6DCT,120.287,CDM,272,RC,A7521,HCPCS,,1190-MAIN,LOCAL,,,,,184,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,63.0532,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 7.5MM ID 10.8MM OD SHILEY CUFFED 6CN75H,120.287,CDM,272,RC,A7521,HCPCS,,8488-MAIN,LOCAL,,,,,184,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,63.0532,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 8 7.6MM ID 12.2MM OD SHILEY 8DCT,120.287,CDM,272,RC,A7521,HCPCS,,1192-MAIN,LOCAL,,,,,184,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,63.0532,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 8 7.6MM ID 12.22MM OD SHILEY CUFFED 8LPC,120.287,CDM,272,RC,A7521,HCPCS,,8815-MAIN,LOCAL,,,,,184,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,63.0532,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 8.0MM ID 10.9MM OD SHILEY CUFFED 8SCT,120.287,CDM,272,RC,A7521,HCPCS,,8811-MAIN,LOCAL,,,,,184,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,63.0532,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 10 SHILEY 10LPC,120.287,CDM,272,RC,A7521,HCPCS,,1181-MAIN,LOCAL,,,,,184,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,63.0532,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
Amphetamines; 1 or 2 - Ref,PX8032490,CDM,300,RC,80324,CPT,90,,,,,,,147,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,63.063,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.0638,144.06
Assay Ph Body Fluids Nos,PX83986,CDM,300,RC,83986,CPT,,,,,,,,147,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,63.063,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.28,144.06
"Cmv Detect, Amplifi Probe - Ref",PX8749690,CDM,300,RC,87496,CPT,90,,,,,,,147,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,63.063,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,144.06
"Methlenedioxyamphetamines (Mda, Mdea, Mdma) - Ref",PX8035990,CDM,300,RC,80359,CPT,90,,,,,,,147,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,63.063,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.0638,144.06
Ph Venous Blood,PX82800,CDM,300,RC,82800,CPT,,,,,,,,147,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,63.063,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.09,144.06
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323042605,NDC,5,ML,64.8,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,63.06984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Inpatient Consult, Level III",PX99253,CDM,983,RC,99253,CPT,,,,,,,,374,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,63.07,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.07,366.52
ampicillin-sulbactam 1.5 (1-0.5) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001381,NDC,1,EA,69.24,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,63.07764,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323042405,NDC,5,ML,64.82,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,63.089306,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
atropine (PF) 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517040125,NDC,1,ML,71.55,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,63.1071,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
tetracaine 0.5 % Solution 4 mL Plas Cont,25000000,CDM,250,RC,,,,,,65074114,NDC,4,ML,71.55,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,63.1071,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046203,NDC,30,ML,70.91,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,63.1099,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Xray Knee (Both) Ap Stand,PX7356501,CDM,320,RC,73565,CPT,TC,,,,,,,543,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,63.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.94,63.11
Xray Knee (Both) Ap Stand,PX7356501,CDM,320,RC,73565,CPT,TC,,,,,,,543,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,63.11,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.94,63.11
Xray Knee 3 Vws,PX7356201,CDM,320,RC,73562,CPT,TC,,,,,,,404,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,63.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.94,63.11
Xray Knee 3 Vws,PX7356201,CDM,320,RC,73562,CPT,TC,,,,,,,404,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,63.11,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.94,63.11
"Xray Mandible Compl, Min 4 Vws",PX7011001,CDM,320,RC,70110,CPT,TC,,,,,,,381,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,63.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.94,63.11
"Xray Mandible Compl, Min 4 Vws",PX7011001,CDM,320,RC,70110,CPT,TC,,,,,,,381,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,63.11,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.94,63.11
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062430,NDC,0.3,ML,147.12,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,63.11448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801301,NDC,0.3,ML,147.12,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,63.11448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801310,NDC,0.3,ML,147.12,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,63.11448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
calcium CHLORIDE 10 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409163140,NDC,10,ML,64.85,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,63.118505,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium zirconium cyclosilicate 5 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,310110501,NDC,1,EA,151.95,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,63.12003,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004725,NDC,2,ML,131.52,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,63.1296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004725,NDC,2,ML,131.52,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,63.1296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
"Antipsychotics, Not Otherwise Specified; 1-3 - Ref",PX8034290,CDM,300,RC,80342,CPT,90,,,,,,,152,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,63.1408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.1408,148.96
Body Fluid Cell Count,PX89050,CDM,300,RC,89050,CPT,,,,,,,,152,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,63.1408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.33,148.96
Gabapentin - Ref,PX8017190,CDM,300,RC,80171,CPT,90,,,,,,,71,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,63.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.87,69.58
Histoplasma Antibody - Ref,PX8669890,CDM,300,RC,86698,CPT,90,,,,,,,71,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,63.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.64,69.58
Legionella Antibody - Ref,PX8671390,CDM,300,RC,86713,CPT,90,,,,,,,71,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,63.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.03,69.58
Complete Cbc Automated,PX85027,CDM,300,RC,85027,CPT,,,,,,,,129,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,6.424264706,percent of total billed charges,63.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,126.42
Complete Cbc Automated,PX85027,CDM,300,RC,85027,CPT,,,,,,,,129,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,63.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,126.42
Complete Cbc Automated,PX85027,CDM,300,RC,85027,CPT,,,,,,,,129,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,63.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,126.42
"Venipunc Need Phys Skill,Dx or Rx",PX36410P,CDM,983,RC,36410,CPT,,,,,,,,129,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,2.85,percent of total billed charges,63.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.5866,125.5557
"Venipunc Need Phys Skill,Dx or Rx",PX36410P,CDM,983,RC,36410,CPT,,,,,,,,129,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,63.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.5866,125.5557
"Venipunc Need Phys Skill,Dx or Rx",PX36410P,CDM,983,RC,36410,CPT,,,,,,,,129,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,63.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.5866,125.5557
SUMAtriptan 25 MG Tablet 9 Each Box,63700001,CDM,250,RC,,,,,,65862014636,NDC,1,EA,129.04,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,63.2296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SUMAtriptan 25 MG Tablet 9 Each Box,63700001,CDM,250,RC,,,,,,65862014636,NDC,1,EA,129.04,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,63.2296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SUMAtriptan 25 MG Tablet 9 Each Box,63700001,CDM,250,RC,,,,,,65862014636,NDC,1,EA,129.04,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,63.2296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
budesonide 1 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097032187,NDC,1,ML,64.97,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,63.235301,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,63323004401,NDC,1,ML,64.53,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,63.2394,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,63.2394
Cmv Igm Antibody - Ref,PX8664590,CDM,300,RC,86645,CPT,90,,,,,,,125,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,63.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.45,122.5
DRESSING SURGICEL HEMOSTAT 4X8 ABSORBABLE 1952,120.123,CDM,272,RC,A6252,HCPCS,,1002-MAIN,LOCAL,,,,,125,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,63.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.925,122.5
Factor VII - Ref,PX8523090,CDM,300,RC,85230,CPT,90,,,,,,,125,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,63.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.41,122.5
"Manual Ther Tech,1+Regions,Ea 15 Min",PX97140,CDM,420,RC,97140,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,63.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.4,215.05
Neuromuscular Re-Education,PX97112,CDM,420,RC,97112,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,63.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.95,215.05
Therapeutic Exercises,PX97110,CDM,420,RC,97110,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,63.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20,215.05
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915850,NDC,0.2,ML,69.44,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,63.25984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
"I&D Perianal Abscess,Superficial",PX46050,CDM,983,RC,46050,CPT,,,,,,,,1096,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,63.26,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.26,1074.08
"I&D Perianal Abscess,Superficial",PX46050F,CDM,510,RC,46050,CPT,,,,,,,,1463,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,63.26,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.26,492.56
"I&D Perianal Abscess,Superficial",PX46050P,CDM,983,RC,46050,CPT,,,,,,,,993,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,63.26,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.26,973.14
"Alkaloids, Not Otherwise Specified - Ref",PX8032390,CDM,300,RC,80323,CPT,90,,,,,,,65,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,63.2645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.001,63.7
Anesthesia Level 3,PX37000017,CDM,370,RC,,,,,,,,,,65,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,63.2645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.001,63.7
Clozapine - Ref,PX8015990,CDM,300,RC,80159,CPT,90,,,,,,,65,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,63.2645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.48,63.7
Gastrin - Ref,PX8294190,CDM,300,RC,82941,CPT,90,,,,,,,65,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,63.2645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.16,63.7
Insulin Ab - Ref,PX8633790,CDM,300,RC,86337,CPT,90,,,,,,,65,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,63.2645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.63,63.7
Resp Muscles 1:1 per 15 Min,PXG0237,CDM,948,RC,G0237,HCPCS,,,,,,,,65,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,63.2645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.01,63.7
Smking Cess 4-10 Min,PX99406F,CDM,942,RC,99406,CPT,,,,,,,,65,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,63.2645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.07,63.7
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781910572,NDC,0.25,EA,69.49,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,63.30539,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86,213.6008
TRAY HAND SURGICAL II DYNJS0806,27200000,CDM,272,RC,,,,11024-MAIN,LOCAL,,,,,64.62,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,63.3276,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046204,NDC,30,ML,127.94,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,63.3303,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
levoFLOXacin in dextrose 5% 500 MG/100ML Solution 100 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004724,NDC,100,ML,64.63,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,63.3374,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,76329339001,NDC,5,ML,64.63,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,63.3374,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.17679,63.3374
solifenacin 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50228042730,NDC,1,EA,74.52,,First Health,Commercial,both,85,,999999999,percent of total billed charges,63.342,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457033900,NDC,1,EA,71.82,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,63.34524,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
Apply of Paste Boot,PX29580F,CDM,510,RC,29580,CPT,,,,,,,,132,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,63.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,137.65
Apply of Paste Boot,PX29580F,CDM,510,RC,29580,CPT,,,,,,,,132,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,63.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,137.65
Assay Dipropylacetic Acid,PX80164,CDM,300,RC,80164,CPT,,,,,,,,132,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,63.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.41,129.36
Assay Dipropylacetic Acid,PX80164,CDM,300,RC,80164,CPT,,,,,,,,132,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,63.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.41,129.36
Assay of Lipase,PX83690,CDM,300,RC,83690,CPT,,,,,,,,132,,Health Partners,Health Partners Care Plans,both,48,,69.34142857,percent of total billed charges,63.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.32,129.36
Assay of Lipase,PX83690,CDM,300,RC,83690,CPT,,,,,,,,132,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,63.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.32,129.36
Canalith Repositioning,PX95992,CDM,420,RC,95992,CPT,,,,,,,,128,,Humana Choice Care,All Medicare plans,outpatient,49.5,,14.74,percent of total billed charges,63.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.86,125.44
Heparin Xa,PX85520,CDM,300,RC,85520,CPT,,,,,,,,128,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,63.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12,125.44
Lab Pth Immunoch Part 1,PX83970,CDM,300,RC,83970,CPT,,,,,,,,128,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,63.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.85,125.44
"N Block Inj, Common Digit",PX64632P,CDM,983,RC,64632,CPT,,,,,,,,128,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,63.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.1712,258.75
"Remv F.B.,Eye,Superf Conjunc",PX65205F,CDM,510,RC,65205,CPT,,,,,,,,132,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,63.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,129.36
"Remv F.B.,Eye,Superf Conjunc",PX65205F,CDM,510,RC,65205,CPT,,,,,,,,132,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,63.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,129.36
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338080304,NDC,1000,ML,69.59,,Medica,Commercial,both,91.1,,1.111818182,percent of total billed charges,63.39649,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990710709,NDC,1000,ML,69.59,,Medica,Commercial,both,91.1,,1.111818182,percent of total billed charges,63.39649,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004824,NDC,150,ML,69.59,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,63.39649,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
Hfe Gene - Ref,PX8125690,CDM,300,RC,81256,CPT,90,,,,,,,526,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,63.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.4,65.36
Hfe Gene - Ref,PX8125690,CDM,300,RC,81256,CPT,90,,,,,,,526,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,63.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.4,65.36
Hfe Gene - Ref,PX8125690,CDM,300,RC,81256,CPT,90,,,,,,,526,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,63.4,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.4,65.36
nystatin 100000 UNIT/GM Cream 30 g Tube,25000000,CDM,250,RC,,,,,,168005430,NDC,30,GR,147.79,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,63.40191,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127303,NDC,2,ML,152.7,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,63.43158,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.43158,173.019
BLUE EYE SUBMUCOSAL LIFTING AGENT 5ML,27200000,CDM,272,RC,,,,12684-MAIN,LOCAL,,,,,148,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,63.492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Mumps,PX86735,CDM,300,RC,86735,CPT,,,,,,,,148,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,63.492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.97,145.04
US Guide Needle Bx S&I,PX7694226,CDM,982,RC,76942,CPT,26,,,,,,,148,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,63.492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.4792,144.0484
"B.Burgdorferi, Amp Probe - Ref",PX8747690,CDM,300,RC,87476,CPT,90,,,,,,,72,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,63.504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.9088,70.56
"Blood, Occult, Other Sources",PX82271,CDM,300,RC,82271,CPT,,,,,,,,72,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,63.504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.88,70.56
Epstein-barr antibody,PX86664,CDM,300,RC,86664,CPT,,,,,,,,72,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,63.504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.02,70.56
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323042605,NDC,5,ML,64.8,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,63.504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,55150043801,NDC,20,ML,152.9,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,63.51466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457018120,NDC,20,ML,152.9,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,63.51466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323042405,NDC,5,ML,64.82,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,63.5236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042350,NDC,0.5,ML,132.37,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,63.5376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.49,129.7226
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042350,NDC,0.5,ML,132.37,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,63.5376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.49,129.7226
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042388,NDC,0.5,ML,132.37,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,63.5376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.49,129.7226
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042388,NDC,0.5,ML,132.37,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,63.5376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.49,129.7226
calcium CHLORIDE 10 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409163140,NDC,10,ML,64.85,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,63.553,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ELECTRODE ADULT PACING ONESTEP,120.214,CDM,272,RC,A4556,HCPCS,,10242-MAIN,LOCAL,,,,,153,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,63.5562,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.5562,149.94
"Protein, Total; Other Source",PX84157,CDM,300,RC,84157,CPT,,,,,,,,153,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,63.5562,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.67,149.94
Pulmonary Stress Test,PX94618,CDM,976,RC,94618,CPT,,,,,,,,153,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,63.5562,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.5562,148.9149
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320885,NDC,0.5,EA,129.71,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,9.983703704,percent of total billed charges,63.5579,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320885,NDC,0.5,EA,129.71,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,63.5579,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320885,NDC,0.5,EA,129.71,,United Healthcare,All Medicare advantage plans,outpatient,49,,3.9675,percent of total billed charges,63.5579,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320895,NDC,0.5,EA,129.71,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,9.983703704,percent of total billed charges,63.5579,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320895,NDC,0.5,EA,129.71,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,63.5579,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320895,NDC,0.5,EA,129.71,,United Healthcare,All Medicare advantage plans,outpatient,49,,3.9675,percent of total billed charges,63.5579,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457018100,NDC,20,ML,153.01,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,63.560354,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
RETRIEVAL BAG 10MM,27200000,CDM,272,RC,,,,11707-MAIN,LOCAL,,,,,74.8,,First Health,Commercial,both,85,,999999999,percent of total billed charges,63.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
anastrozole 1 MG Tablet 30 Each Bottle,25000000,CDM,250,RC,,,,,,16729003510,NDC,1,EA,71.44,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,63.5816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
nystatin 100000 UNIT/GM Cream 30 g Tube,25000000,CDM,250,RC,,,,,,51672128902,NDC,30,GR,148.29,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,63.61641,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fentaNYL 50 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,406905076,NDC,1,EA,125.74,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,63.62444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862066230,NDC,1,EA,153.17,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,63.626818,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954201,NDC,10,ML,153.18,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,63.630972,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.630972,150.1164
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954210,NDC,10,ML,153.18,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,63.630972,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.630972,150.1164
sodium phosphate 15 MMOLE/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323088401,NDC,5,ML,132.6,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,63.648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium phosphate 15 MMOLE/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323088401,NDC,5,ML,132.6,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,63.648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium phosphate 15 MMOLE/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323088406,NDC,5,ML,132.6,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,63.648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium phosphate 15 MMOLE/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323088406,NDC,5,ML,132.6,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,63.648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
DAPTOmycin 500 MG Recon Soln 1 Each Vial,J0878.01,CDM,636,RC,J0878,HCPCS,,,,70594003402,NDC,1,EA,129.9,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.053975,percent of total billed charges,63.651,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.96046,127.302
DAPTOmycin 500 MG Recon Soln 1 Each Vial,J0878.01,CDM,636,RC,J0878,HCPCS,,,,70594003402,NDC,1,EA,129.9,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,63.651,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.96046,127.302
DAPTOmycin 500 MG Recon Soln 1 Each Vial,J0878.01,CDM,636,RC,J0878,HCPCS,,,,70594003402,NDC,1,EA,129.9,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,63.651,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.96046,127.302
budesonide 1 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097032187,NDC,1,ML,64.97,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,63.6706,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
atropine (PF) 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517040125,NDC,1,ML,71.55,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,63.6795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
tetracaine 0.5 % Solution 4 mL Plas Cont,25000000,CDM,250,RC,,,,,,65074114,NDC,4,ML,71.55,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,63.6795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Surgical Diagnostic Exam, Anorectal",PX45990P,CDM,983,RC,45990,CPT,,,,,,,,409,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,63.69,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.69,400.82
"BOUGIE TRACH 10FR 70CM COUDE 	9-0211-70",120.199,CDM,272,RC,A7520,HCPCS,,11112-MAIN,LOCAL,,,,,42,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,63.6966,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,64.78
BOUGIE TRACHEAL TUBE & GUIDE 100123515,120.199,CDM,272,RC,A7520,HCPCS,,8950-MAIN,LOCAL,,,,,42,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,63.6966,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,64.78
CRICOTHROTOMY QUICKTRACH 4MM,120.228,CDM,272,RC,A7520,HCPCS,,8868-MAIN,LOCAL,,,,,494,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,63.6966,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,64.78
TUBE TRACH SIZE 3.0MM ID 4.5MM OD SHILEY PEDIATRIC 3.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1185-MAIN,LOCAL,,,,,184,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,63.6966,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 3.5MM ID 5.2MM OD SHILEY PEDIATRIC,120.287,CDM,272,RC,A7520,HCPCS,,8813-MAIN,LOCAL,,,,,184,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,63.6966,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 4.0MM ID 5.9MM OD SHILEY PEDIATRIC 4.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1187-MAIN,LOCAL,,,,,184,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,63.6966,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 5.0MM ID 7.1MM OD SHILEY PEDIATRIC 5.0PED,120.287,CDM,272,RC,A7520,HCPCS,,8814-MAIN,LOCAL,,,,,184,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,63.6966,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
"Alkaloids, Not Otherwise Specified - Ref",PX8032390,CDM,300,RC,80323,CPT,90,,,,,,,65,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,63.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.001,63.7
Anesthesia Level 3,PX37000017,CDM,370,RC,,,,,,,,,,65,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,63.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.001,63.7
Chemo Ad Sq/Im Hormnl Anti-Neo,PX96402,CDM,335,RC,96402,CPT,,,,,,,,130,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,26,percent of total billed charges,63.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,127.4
Chemo Ad Sq/Im Hormnl Anti-Neo,PX96402,CDM,335,RC,96402,CPT,,,,,,,,130,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,63.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,127.4
Chemo Ad Sq/Im Hormnl Anti-Neo,PX96402,CDM,335,RC,96402,CPT,,,,,,,,130,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,63.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,127.4
Clozapine - Ref,PX8015990,CDM,300,RC,80159,CPT,90,,,,,,,65,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,63.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.48,63.7
Cystatin C - Ref,PX8261090,CDM,300,RC,82610,CPT,90,,,,,,,130,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,63.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.98,127.4
Cystatin C - Ref,PX8261090,CDM,300,RC,82610,CPT,90,,,,,,,130,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,63.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.98,127.4
Cystatin C - Ref,PX8261090,CDM,300,RC,82610,CPT,90,,,,,,,130,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,63.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.98,127.4
Each Add'l Sequential Push New Drug,PX96375,CDM,260,RC,96375,CPT,,,,,,,,130,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,35.85407407,percent of total billed charges,63.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,127.4
Each Add'l Sequential Push New Drug,PX96375,CDM,260,RC,96375,CPT,,,,,,,,130,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,63.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,127.4
Each Add'l Sequential Push New Drug,PX96375,CDM,260,RC,96375,CPT,,,,,,,,130,,United Healthcare,All Medicare advantage plans,outpatient,49,,66.78,percent of total billed charges,63.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,127.4
Gastrin - Ref,PX8294190,CDM,300,RC,82941,CPT,90,,,,,,,65,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,63.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.16,63.7
Immunization Administration; One Vaccine (Single or Combination Vaccine/To*,PX90471,CDM,771,RC,90471,CPT,,,,,,,,130,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,88.75,percent of total billed charges,63.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,127.4
Immunization Administration; One Vaccine (Single or Combination Vaccine/To*,PX90471,CDM,771,RC,90471,CPT,,,,,,,,130,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,63.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,127.4
Immunization Administration; One Vaccine (Single or Combination Vaccine/To*,PX90471,CDM,771,RC,90471,CPT,,,,,,,,130,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,63.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,127.4
Insulin Ab - Ref,PX8633790,CDM,300,RC,86337,CPT,90,,,,,,,65,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,63.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.63,63.7
Prothrombin Time (Pt/Inr),PX85610,CDM,300,RC,85610,CPT,,,,,,,,130,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,7.853265306,percent of total billed charges,63.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.93,127.4
Prothrombin Time (Pt/Inr),PX85610,CDM,300,RC,85610,CPT,,,,,,,,130,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,63.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.93,127.4
Prothrombin Time (Pt/Inr),PX85610,CDM,300,RC,85610,CPT,,,,,,,,130,,United Healthcare,All Medicare advantage plans,outpatient,49,,68.9,percent of total billed charges,63.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.93,127.4
Resp Muscles 1:1 per 15 Min,PXG0237,CDM,948,RC,G0237,HCPCS,,,,,,,,65,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,63.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.01,63.7
Smking Cess 4-10 Min,PX99406F,CDM,942,RC,99406,CPT,,,,,,,,65,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,63.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.07,63.7
SPLINT WRIST LARGE ALUMINUM FOREARM LEFT 9101-06,120.87,CDM,274,RC,L3809,HCPCS,,1265-MAIN,LOCAL,,,,,130,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,6.8,percent of total billed charges,63.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST LARGE ALUMINUM FOREARM LEFT 9101-06,120.87,CDM,274,RC,L3809,HCPCS,,1265-MAIN,LOCAL,,,,,130,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,63.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST LARGE ALUMINUM FOREARM LEFT 9101-06,120.87,CDM,274,RC,L3809,HCPCS,,1265-MAIN,LOCAL,,,,,130,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,63.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST LARGE ALUMINUM FOREARM RIGHT 9101-03,120.87,CDM,274,RC,L3809,HCPCS,,1263-MAIN,LOCAL,,,,,130,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,6.8,percent of total billed charges,63.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST LARGE ALUMINUM FOREARM RIGHT 9101-03,120.87,CDM,274,RC,L3809,HCPCS,,1263-MAIN,LOCAL,,,,,130,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,63.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST LARGE ALUMINUM FOREARM RIGHT 9101-03,120.87,CDM,274,RC,L3809,HCPCS,,1263-MAIN,LOCAL,,,,,130,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,63.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST MEDIUM ALUMINUM FOREARM LEFT 9101-05,120.87,CDM,274,RC,L3809,HCPCS,,1264-MAIN,LOCAL,,,,,130,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,6.8,percent of total billed charges,63.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST MEDIUM ALUMINUM FOREARM LEFT 9101-05,120.87,CDM,274,RC,L3809,HCPCS,,1264-MAIN,LOCAL,,,,,130,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,63.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST MEDIUM ALUMINUM FOREARM LEFT 9101-05,120.87,CDM,274,RC,L3809,HCPCS,,1264-MAIN,LOCAL,,,,,130,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,63.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST MEDIUM ALUMINUM FOREARM RIGHT 9101-02,120.87,CDM,274,RC,L3809,HCPCS,,1262-MAIN,LOCAL,,,,,130,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,6.8,percent of total billed charges,63.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST MEDIUM ALUMINUM FOREARM RIGHT 9101-02,120.87,CDM,274,RC,L3809,HCPCS,,1262-MAIN,LOCAL,,,,,130,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,63.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST MEDIUM ALUMINUM FOREARM RIGHT 9101-02,120.87,CDM,274,RC,L3809,HCPCS,,1262-MAIN,LOCAL,,,,,130,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,63.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
Vitamin B-1 - Ref,PX8442590,CDM,300,RC,84425,CPT,90,,,,,,,130,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,63.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.47,127.4
Vitamin B-1 - Ref,PX8442590,CDM,300,RC,84425,CPT,90,,,,,,,130,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,63.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.47,127.4
Vitamin B-1 - Ref,PX8442590,CDM,300,RC,84425,CPT,90,,,,,,,130,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,63.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.47,127.4
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052331,NDC,2,ML,125.89,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,63.70034,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.294706,123.3722
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052341,NDC,2,ML,125.89,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,63.70034,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.294706,123.3722
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,17478053802,NDC,2,ML,125.91,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,63.71046,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.068162,123.3918
Assay Cryofibrinogen,PX82585,CDM,300,RC,82585,CPT,,,,,,,,75,,First Health,Commercial,both,85,,999999999,percent of total billed charges,63.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.96,73.5
Assay Cryoglobulin,PX82595,CDM,300,RC,82595,CPT,,,,,,,,75,,First Health,Commercial,both,85,,999999999,percent of total billed charges,63.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,73.5
BINDER ABDOMINAL 9 INCH 46 TO 62 INCH XL ORT21100LXL,120.238,CDM,271,RC,A4467,HCPCS,,2989-MAIN,LOCAL,,,,,75,,First Health,Commercial,both,85,,999999999,percent of total billed charges,63.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL 9 INCH 63 TO 74 INCH 3- PANEL ORT211002XL,120.238,CDM,271,RC,A4467,HCPCS,,37-MAIN,LOCAL,,,,,75,,First Health,Commercial,both,85,,999999999,percent of total billed charges,63.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL 10 INCH 26 TO 50 INCHES ABB1050,120.238,CDM,271,RC,A4467,HCPCS,,52-MAIN,LOCAL,,,,,75,,First Health,Commercial,both,85,,999999999,percent of total billed charges,63.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
"BINDER ABDOMINAL 12"" HIGH 2XL 60-75INCH 4 PANEL ORT213002XL",120.238,CDM,271,RC,A4467,HCPCS,,12536-MAIN,LOCAL,,,,,75,,First Health,Commercial,both,85,,999999999,percent of total billed charges,63.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL UNISIZE 46-62IN 9 IN MDS169024,120.238,CDM,271,RC,A4467,HCPCS,,63-MAIN,LOCAL,,,,,75,,First Health,Commercial,both,85,,999999999,percent of total billed charges,63.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
"Direct skilled nursing services of a license practical nurse (lpn) in the home health or hospice setting, each 15 minutes",PXG0300,CDM,551,RC,G0300,HCPCS,,,,,,,,75,,First Health,Commercial,both,85,,999999999,percent of total billed charges,63.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
HH Rn Initial Visit,PXG0154,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,First Health,Commercial,both,85,,999999999,percent of total billed charges,63.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
HH Rn Routine Visit,PXG0154.01,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,First Health,Commercial,both,85,,999999999,percent of total billed charges,63.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
Skilled Srvc of a Lpn in Training and/or Education of Pt or Fam Ea 15 Min,PXG0496,CDM,551,RC,G0496,HCPCS,,,,,,,,75,,First Health,Commercial,both,85,,999999999,percent of total billed charges,63.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
Skilled srvc of an RN in training and/or education of pt or fam ea 15 min,PXG0495,CDM,551,RC,G0495,HCPCS,,,,,,,,75,,First Health,Commercial,both,85,,999999999,percent of total billed charges,63.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
Thrombin Time Plasma,PX85670,CDM,300,RC,85670,CPT,,,,,,,,126,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,63.756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.29,123.48
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010602,NDC,50,ML,126.07,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,63.79142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010605,NDC,50,ML,126.07,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,63.79142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
nitroglycerin in dextrose 5% 100-5 MCG/ML-% Solution 250 mL Glass Cont,J2305.01,CDM,636,RC,J2305,HCPCS,,,,338104702,NDC,250,ML,126.07,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,63.79142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.17,123.5486
"Cardiolipin Ab, Ea Lg - Ref",PX8614790,CDM,300,RC,86147,CPT,90,,,,,,,133,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,63.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.34,130.34
"Cardiolipin Ab, Ea Lg - Ref",PX8614790,CDM,300,RC,86147,CPT,90,,,,,,,133,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,63.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.34,130.34
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU0003,CDM,300,RC,U0003,HCPCS,,,,,,,,133,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,63.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.2482,130.34
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU0003,CDM,300,RC,U0003,HCPCS,,,,,,,,133,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,63.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.2482,130.34
Complete Cbc Automated,PX85027,CDM,300,RC,85027,CPT,,,,,,,,129,,Humana Choice Care,All Medicare plans,outpatient,49.5,,50.5725,percent of total billed charges,63.855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,126.42
"Venipunc Need Phys Skill,Dx or Rx",PX36410P,CDM,983,RC,36410,CPT,,,,,,,,129,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,63.855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.5866,125.5557
"Digital Mammogram, Screen Bil, Tc W/Cad Perf",PX7706701,CDM,403,RC,77067,CPT,TC,,,,,,,375,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,63.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.86,561
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606001,NDC,10,ML,65.62,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,6.89375,percent of total billed charges,63.867946,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606010,NDC,10,ML,65.62,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,6.89375,percent of total billed charges,63.867946,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
SUMAtriptan 25 MG Tablet 9 Each Box,63700001,CDM,250,RC,,,,,,65862014636,NDC,1,EA,129.04,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,63.8748,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
triamcinolone acetonide 0.1 % Cream 454 g Jar,63700001,CDM,250,RC,,,,,,45802006405,NDC,454,GR,130.36,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,63.8764,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
triamcinolone acetonide 0.1 % Cream 454 g Jar,63700001,CDM,250,RC,,,,,,45802006405,NDC,454,GR,130.36,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,63.8764,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
triamcinolone acetonide 0.1 % Cream 454 g Jar,63700001,CDM,250,RC,,,,,,45802006405,NDC,454,GR,130.36,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,63.8764,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylergonovine 0.2 MG/ML Solution 1 mL Ampule,J2210.01,CDM,636,RC,J2210,HCPCS,,,,51991014417,NDC,1,ML,133.11,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,63.8928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.293894,130.4478
methylergonovine 0.2 MG/ML Solution 1 mL Ampule,J2210.01,CDM,636,RC,J2210,HCPCS,,,,51991014417,NDC,1,ML,133.11,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,63.8928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.293894,130.4478
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,55150020200,NDC,1,EA,65.65,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,23.41888889,percent of total billed charges,63.897145,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,17478070311,NDC,10,ML,72.46,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,63.90972,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Removal of Nail Bed,PX11750F,CDM,510,RC,11750,CPT,,,,,,,,629,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,63.91,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.91,334.83
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059900,NDC,1,ML,133.16,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,63.9168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.54253,130.4968
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059900,NDC,1,ML,133.16,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,63.9168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.54253,130.4968
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059902,NDC,1,ML,133.16,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,63.9168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.54253,130.4968
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059902,NDC,1,ML,133.16,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,63.9168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.54253,130.4968
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457033900,NDC,1,EA,71.82,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,63.9198,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
"Urinalysis, Auto W/O Scope",PX81003,CDM,300,RC,81003,CPT,,,,,,,,149,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,63.921,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.06,146.02
albuterol HFA 108 (90 Base) MCG/ACT Aerosol Solution 8 g Inhaler,25000000,CDM,250,RC,,,,,,173068224,NDC,8,GR,149.04,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,63.93816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
PROSTEP 0.9MM ANTI SKIVE PIN,27200000,CDM,272,RC,,,,12950-MAIN,LOCAL,,,,,154,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,63.9716,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PROSTEP 1.4MM ANTI SKIVE PIN,27200000,CDM,272,RC,,,,12949-MAIN,LOCAL,,,,,154,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,63.9716,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Vit D 1 25-Dihydroxy,PX82652,CDM,300,RC,82652,CPT,,,,,,,,154,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,63.9716,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.3,150.92
Cpap/Bipap Mgmnt-Pt Own Equipment,PX94660.02F,CDM,410,RC,94660,CPT,,,,,,,,497,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,63.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.9,112.85
"IV Push, Single/1st Drug",PX96374,CDM,260,RC,96374,CPT,,,,,,,,259,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,63.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.21,63.99
"IV Push, Single/1st Drug",PX96374,CDM,260,RC,96374,CPT,,,,,,,,259,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,63.99,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.21,63.99
"POS Airway Pressure, Bipap",PX94660.01F,CDM,410,RC,94660,CPT,,,,,,,,468,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,63.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.9,112.85
"POS Airway Pressure, Cpap",PX94660F,CDM,410,RC,94660,CPT,,,,,,,,498,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,63.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.9,112.85
triamcinolone acetonide 0.1 % Cream 80 g Tube,63700001,CDM,250,RC,,,,,,16714098603,NDC,80,GR,65.76,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,64.004208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 125 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68180016611,NDC,1,EA,149.33,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,64.06257,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 125 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,47781072902,NDC,1,EA,149.33,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,64.06257,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 125 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,62559039020,NDC,1,EA,149.33,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,64.06257,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LIGACLIP APPLIER CLIP STERILE SIZE MEDIUM LARGE,27200000,CDM,272,RC,,,,11699-MAIN,LOCAL,,,,,126.62,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,64.06972,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,713013512,NDC,1,EA,65.83,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,64.072339,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.345782,66.2186
triamcinolone acetonide 40 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029320,NDC,1,ML,72.65,,United Healthcare,All Payer,outpatient,88.2,,39.2,percent of total billed charges,64.0773,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,72.0986
"B.Burgdorferi, Amp Probe - Ref",PX8747690,CDM,300,RC,87476,CPT,90,,,,,,,72,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,64.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.9088,70.56
"Blood, Occult, Other Sources",PX82271,CDM,300,RC,82271,CPT,,,,,,,,72,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,64.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.88,70.56
Epstein-barr antibody,PX86664,CDM,300,RC,86664,CPT,,,,,,,,72,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,64.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.02,70.56
brimonidine 0.2 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,70069023101,NDC,5,ML,70.38,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,64.11618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"I&D Perianal Abscess,Superficial",PX46050,CDM,983,RC,46050,CPT,,,,,,,,1096,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,64.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.26,1074.08
"I&D Perianal Abscess,Superficial",PX46050,CDM,983,RC,46050,CPT,,,,,,,,1096,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,64.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.26,1074.08
"I&D Perianal Abscess,Superficial",PX46050F,CDM,510,RC,46050,CPT,,,,,,,,1463,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,64.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.26,492.56
"I&D Perianal Abscess,Superficial",PX46050F,CDM,510,RC,46050,CPT,,,,,,,,1463,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,64.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.26,492.56
"I&D Perianal Abscess,Superficial",PX46050P,CDM,983,RC,46050,CPT,,,,,,,,993,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,64.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.26,973.14
"I&D Perianal Abscess,Superficial",PX46050P,CDM,983,RC,46050,CPT,,,,,,,,993,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,64.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.26,973.14
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004703,NDC,1,EA,75.45,,First Health,Commercial,both,85,,999999999,percent of total billed charges,64.1325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
droPERidol 2.5 MG/ML Solution 2 mL Vial,J1790.01,CDM,636,RC,J1790,HCPCS,,,,517970201,NDC,2,ML,75.47,,First Health,Commercial,both,85,,999999999,percent of total billed charges,64.1495,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.350238,73.9606
Hfe Gene - Ref,PX8125690,CDM,300,RC,81256,CPT,90,,,,,,,526,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,64.18,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.4,65.36
Noninvasv Oxygen Satur;Single,PX94760,CDM,460,RC,94760,CPT,,,,,,,,131,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,64.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.4174,128.38
Noninvasv Oxygen Satur;Single,PX94760,CDM,460,RC,94760,CPT,,,,,,,,131,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,64.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.4174,128.38
Noninvasv Oxygen Satur;Single,PX94760,CDM,460,RC,94760,CPT,,,,,,,,131,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,64.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.4174,128.38
TUBE TRACH SIZE 5 7.0MM ID 10.1MM OD SHILEY CUFFED 5CN70H,120.287,CDM,272,RC,A7521,HCPCS,,10350-MAIN,LOCAL,,,,,184,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,64.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 5 7.0MM ID 10.1MM OD SHILEY CUFFED 5CN70H,120.287,CDM,272,RC,A7521,HCPCS,,10350-MAIN,LOCAL,,,,,184,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,64.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 5 7.0MM ID 10.1MM OD SHILEY CUFFED 5CN70H,120.287,CDM,272,RC,A7521,HCPCS,,10350-MAIN,LOCAL,,,,,184,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,64.19,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 6 6.0MM ID 8.3MM OD SHILEY CUFFED 6SCT,120.287,CDM,272,RC,A7521,HCPCS,,8812-MAIN,LOCAL,,,,,184,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,64.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 6 6.0MM ID 8.3MM OD SHILEY CUFFED 6SCT,120.287,CDM,272,RC,A7521,HCPCS,,8812-MAIN,LOCAL,,,,,184,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,64.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 6 6.0MM ID 8.3MM OD SHILEY CUFFED 6SCT,120.287,CDM,272,RC,A7521,HCPCS,,8812-MAIN,LOCAL,,,,,184,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,64.19,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 6 6.4MM ID 10.8MM OD SHILEY CUFFED 6DCT,120.287,CDM,272,RC,A7521,HCPCS,,1190-MAIN,LOCAL,,,,,184,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,64.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 6 6.4MM ID 10.8MM OD SHILEY CUFFED 6DCT,120.287,CDM,272,RC,A7521,HCPCS,,1190-MAIN,LOCAL,,,,,184,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,64.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 6 6.4MM ID 10.8MM OD SHILEY CUFFED 6DCT,120.287,CDM,272,RC,A7521,HCPCS,,1190-MAIN,LOCAL,,,,,184,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,64.19,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 7.5MM ID 10.8MM OD SHILEY CUFFED 6CN75H,120.287,CDM,272,RC,A7521,HCPCS,,8488-MAIN,LOCAL,,,,,184,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,64.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 7.5MM ID 10.8MM OD SHILEY CUFFED 6CN75H,120.287,CDM,272,RC,A7521,HCPCS,,8488-MAIN,LOCAL,,,,,184,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,64.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 7.5MM ID 10.8MM OD SHILEY CUFFED 6CN75H,120.287,CDM,272,RC,A7521,HCPCS,,8488-MAIN,LOCAL,,,,,184,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,64.19,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 8 7.6MM ID 12.2MM OD SHILEY 8DCT,120.287,CDM,272,RC,A7521,HCPCS,,1192-MAIN,LOCAL,,,,,184,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,64.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 8 7.6MM ID 12.2MM OD SHILEY 8DCT,120.287,CDM,272,RC,A7521,HCPCS,,1192-MAIN,LOCAL,,,,,184,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,64.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 8 7.6MM ID 12.2MM OD SHILEY 8DCT,120.287,CDM,272,RC,A7521,HCPCS,,1192-MAIN,LOCAL,,,,,184,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,64.19,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 8 7.6MM ID 12.22MM OD SHILEY CUFFED 8LPC,120.287,CDM,272,RC,A7521,HCPCS,,8815-MAIN,LOCAL,,,,,184,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,64.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 8 7.6MM ID 12.22MM OD SHILEY CUFFED 8LPC,120.287,CDM,272,RC,A7521,HCPCS,,8815-MAIN,LOCAL,,,,,184,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,64.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 8 7.6MM ID 12.22MM OD SHILEY CUFFED 8LPC,120.287,CDM,272,RC,A7521,HCPCS,,8815-MAIN,LOCAL,,,,,184,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,64.19,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 8.0MM ID 10.9MM OD SHILEY CUFFED 8SCT,120.287,CDM,272,RC,A7521,HCPCS,,8811-MAIN,LOCAL,,,,,184,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,64.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 8.0MM ID 10.9MM OD SHILEY CUFFED 8SCT,120.287,CDM,272,RC,A7521,HCPCS,,8811-MAIN,LOCAL,,,,,184,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,64.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 8.0MM ID 10.9MM OD SHILEY CUFFED 8SCT,120.287,CDM,272,RC,A7521,HCPCS,,8811-MAIN,LOCAL,,,,,184,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,64.19,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 10 SHILEY 10LPC,120.287,CDM,272,RC,A7521,HCPCS,,1181-MAIN,LOCAL,,,,,184,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,64.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 10 SHILEY 10LPC,120.287,CDM,272,RC,A7521,HCPCS,,1181-MAIN,LOCAL,,,,,184,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,64.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 10 SHILEY 10LPC,120.287,CDM,272,RC,A7521,HCPCS,,1181-MAIN,LOCAL,,,,,184,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,64.19,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094310,NDC,10,ML,72.79,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,64.20078,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.236966,143.9032
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094321,NDC,10,ML,72.79,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,64.20078,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.236966,143.9032
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320885,NDC,0.5,EA,129.71,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,64.20645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320895,NDC,0.5,EA,129.71,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,64.20645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
fluticasone 110 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173071920,NDC,12,GR,149.67,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,64.20843,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046837,NDC,30,ML,75.54,,First Health,Commercial,both,85,,999999999,percent of total billed charges,64.209,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
octreotide 200 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037805,NDC,1,ML,133.77,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,64.2096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
octreotide 200 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037805,NDC,1,ML,133.77,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,64.2096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,69315030615,NDC,15,GR,131.07,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,64.2243,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,69315030615,NDC,15,GR,131.07,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,64.2243,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,69315030615,NDC,15,GR,131.07,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,64.2243,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,574200815,NDC,15,GR,154.63,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,64.233302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Ig Paraprotein Qual Bld/UR,PX0077U90,CDM,300,RC,0077U,HCPCS,90,,,,,,,66,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,64.2378,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
"Level III - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3933,CDM,310,RC,88304,CPT,TC,,,,,,,66,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,36.67909091,percent of total billed charges,64.2378,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
Ot Contracted Service/Msho/MA,PX120.178,CDM,431,RC,,,,,,,,,,66,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,64.2378,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
Pt Contracted Service/Msho,PX120.176,CDM,421,RC,,,,,,,,,,66,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,64.2378,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
Surg Pathology-Level 2-Tc,PX3932,CDM,310,RC,88302,CPT,TC,,,,,,,66,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,55.98,percent of total billed charges,64.2378,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.01,64.68
Xray Orbits Optic Foramina,PX7019001,CDM,320,RC,70190,CPT,TC,,,,,,,66,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,64.2378,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,79.39
B-Scan Global,PX7651201,CDM,402,RC,76512,CPT,TC,,,,,,,127,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,64.262,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.7558,124.46
Candida Dna Dir Probe,PX87480,CDM,300,RC,87480,CPT,,,,,,,,127,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,64.262,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.38,124.46
Gardner Vag Dna Dir Probe,PX87510,CDM,300,RC,87510,CPT,,,,,,,,127,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,64.262,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.38,124.46
Influenza Assay W/Optic,PX87804,CDM,300,RC,87804,CPT,,,,,,,,127,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,64.262,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.17,124.46
Trichomonas Vagin Dir Probe,PX87660,CDM,300,RC,87660,CPT,,,,,,,,127,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,64.262,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.38,124.46
enalaprilat 1.25 MG/ML Injectable 2 mL Vial,25000000,CDM,250,RC,,,,,,143978601,NDC,2,ML,75.63,,First Health,Commercial,both,85,,999999999,percent of total billed charges,64.2855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409493311,NDC,10,ML,66.06,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,229.0777778,percent of total billed charges,64.296198,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409751716,NDC,50,ML,72.9,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,64.2978,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
DAPTOmycin 500 MG Recon Soln 1 Each Vial,J0878.01,CDM,636,RC,J0878,HCPCS,,,,70594003402,NDC,1,EA,129.9,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,64.3005,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.96046,127.302
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606001,NDC,10,ML,65.62,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,64.3076,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606010,NDC,10,ML,65.62,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,64.3076,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,64.3076
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,24208031510,NDC,10,ML,75.67,,First Health,Commercial,both,85,,999999999,percent of total billed charges,64.3195,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Emergency Level III Visit,PX99283P,CDM,981,RC,99283,CPT,,,,,,,,568,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,64.32,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,43.86,556.64
Facility Emergency Level III Visit,PX99283F,CDM,450,RC,99283,CPT,,,,,,,,587,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,64.32,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,43.86,126.18
Subsequent Observation Care,PX99225,CDM,982,RC,99225,CPT,,,,,,,,253,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,64.32,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.32,247.94
Subsequent Observation Care,PX99225,CDM,982,RC,99225,CPT,,,,,,,,253,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,64.32,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.32,247.94
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,55150020200,NDC,1,EA,65.65,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,64.337,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.692188,64.337
Place Needle in Vein,PX36000P,CDM,983,RC,36000,CPT,,,,,,,,1034,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,64.34,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.45,1013.32
Reduce Temporomandibl Disloc,PX21480F,CDM,510,RC,21480,CPT,,,,,,,,335,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,64.34,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.54,294.02
Reduce Temporomandibl Disloc,PX21480P,CDM,983,RC,21480,CPT,,,,,,,,223,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,64.34,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.54,294.02
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098121,NDC,1,EA,72.95,,United Healthcare,All Payer,outpatient,88.2,,49.96,percent of total billed charges,64.3419,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
Assay of CK (Cpk),PX82550,CDM,300,RC,82550,CPT,,,,,,,,150,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,64.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.97,147
Assay of Lactic Acid,PX83605,CDM,300,RC,83605,CPT,,,,,,,,150,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,64.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.61,147
Assay of Phosphorus,PX84100,CDM,300,RC,84100,CPT,,,,,,,,150,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,64.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.35,147
Bilirubin Direct,PX82248,CDM,300,RC,82248,CPT,,,,,,,,150,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,64.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.6,147
Bilirubin Total,PX82247,CDM,300,RC,82247,CPT,,,,,,,,150,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,64.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.6,147
Chemo Ad Sq/Im Hormnl Anti-Neo,PX96402,CDM,335,RC,96402,CPT,,,,,,,,130,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,64.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,127.4
Cystatin C - Ref,PX8261090,CDM,300,RC,82610,CPT,90,,,,,,,130,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,64.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.98,127.4
"Drug(S) or Substance(S), Definitive, Qualitative or Quantitative, Not Otherwise Specified; 1-3 - Ref",PX8037590,CDM,300,RC,80375,CPT,90,,,,,,,150,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,64.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.31,147
Each Add'l Sequential Push New Drug,PX96375,CDM,260,RC,96375,CPT,,,,,,,,130,,Humana Choice Care,All Medicare plans,outpatient,49.5,,66.73333333,percent of total billed charges,64.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,127.4
"Hsv Detect, Amplif Probe - Ref",PX8752990,CDM,300,RC,87529,CPT,90,,,,,,,150,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,64.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,147
Immunization Administration; One Vaccine (Single or Combination Vaccine/To*,PX90471,CDM,771,RC,90471,CPT,,,,,,,,130,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,64.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,127.4
Magnesium,PX83735,CDM,300,RC,83735,CPT,,,,,,,,150,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,64.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.14,147
Magnesium - Ref,PX8373590,CDM,300,RC,83735,CPT,90,,,,,,,150,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,64.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.14,147
Po4 Inorganic (Phosphate) - Ref,PX8410090,CDM,300,RC,84100,CPT,90,,,,,,,150,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,64.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.35,147
Prothrombin Time (Pt/Inr),PX85610,CDM,300,RC,85610,CPT,,,,,,,,130,,Humana Choice Care,All Medicare plans,outpatient,49.5,,21.23333333,percent of total billed charges,64.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.93,127.4
SPLINT WRIST LARGE ALUMINUM FOREARM LEFT 9101-06,120.87,CDM,274,RC,L3809,HCPCS,,1265-MAIN,LOCAL,,,,,130,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,64.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST LARGE ALUMINUM FOREARM RIGHT 9101-03,120.87,CDM,274,RC,L3809,HCPCS,,1263-MAIN,LOCAL,,,,,130,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,64.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST MEDIUM ALUMINUM FOREARM LEFT 9101-05,120.87,CDM,274,RC,L3809,HCPCS,,1264-MAIN,LOCAL,,,,,130,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,64.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST MEDIUM ALUMINUM FOREARM RIGHT 9101-02,120.87,CDM,274,RC,L3809,HCPCS,,1262-MAIN,LOCAL,,,,,130,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,64.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
TB Antigen Response Gamma Interferon T-Cell Susp,PX86481,CDM,300,RC,86481,CPT,,,,,,,,150,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,64.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.31,147
Vitamin B-1 - Ref,PX8442590,CDM,300,RC,84425,CPT,90,,,,,,,130,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,64.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.47,127.4
fluconazole 150 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,16714069210,NDC,1,EA,72.98,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,64.36836,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Infect, Organ, Amp Probe - Ref",PX8780190,CDM,300,RC,87801,CPT,90,,,,,,,630,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,64.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.37,617.4
BALLOON EXTRACTOR PEDS,120.358,CDM,272,RC,,,,10771-MAIN,LOCAL,,,,,73,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,64.386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.3242,71.54
CYSTOSCOPY PACK I STERILE,120.505,CDM,272,RC,,,,4527-MAIN,LOCAL,,,,,155,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,64.387,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,151.9
"Lab Antibody ID,RBC",PX7605,CDM,300,RC,86870,CPT,,,,,,,,155,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,64.387,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,314.02
"Office/Outpt Visit,Est,Levl II",PX99212F,CDM,510,RC,99212,CPT,,,,,,,,155,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,64.387,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,151.9
"Office/Outpt Visit,Est,Levl II",PX99212P,CDM,983,RC,99212,CPT,,,,,,,,155,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,64.387,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,150.8615
Smear Fluorescent/Acid Stai,PX87206,CDM,300,RC,87206,CPT,,,,,,,,155,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,64.387,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.94,151.9
TB Test Enumeration of T-Cells - Ref,PX8648190,CDM,300,RC,86481,CPT,90,,,,,,,155,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,64.387,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,151.9
levothyroxine Sodium 200 MCG Recon Soln 1 Each Vial,J0650.01,CDM,636,RC,J0650,HCPCS,,,,63323064710,NDC,0.0625,EA,75.75,,First Health,Commercial,both,85,,999999999,percent of total billed charges,64.3875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.46655,74.235
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,16714081701,NDC,1,EA,75.78,,First Health,Commercial,both,85,,999999999,percent of total billed charges,64.413,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
US Renal Retroperit Ltd,PX7677501,CDM,402,RC,76775,CPT,TC,,,,,,,566,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,64.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.94,64.43
US Renal Retroperit Ltd,PX7677501,CDM,402,RC,76775,CPT,TC,,,,,,,566,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,64.43,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.94,64.43
Raltegravir 400 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,6022761,NDC,1,EA,150.2,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,64.4358,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004725,NDC,2,ML,131.52,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,64.4448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004725,NDC,2,ML,131.52,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,64.4448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004725,NDC,2,ML,131.52,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,64.4448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
triamcinolone acetonide 0.1 % Cream 80 g Tube,63700001,CDM,250,RC,,,,,,16714098603,NDC,80,GR,65.76,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,64.4448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,17478070311,NDC,10,ML,72.46,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,64.4894,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,409337504,NDC,4,ML,150.36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,64.50444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,25021011487,NDC,200,ML,66.28,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,64.510324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.20921,64.9544
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,713013512,NDC,1,EA,65.83,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,64.5134,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.345782,66.2186
triamcinolone acetonide 0.1 % Cream 454 g Jar,63700001,CDM,250,RC,,,,,,45802006405,NDC,454,GR,130.36,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,64.5282,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Repr Superf Wnd Body 7.6-12.5,PX12004F,CDM,510,RC,12004,CPT,,,,,,,,453,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,64.5411,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,43.41,277.41
Repr Superf Wnd Body 7.6-12.5,PX12004P,CDM,983,RC,12004,CPT,,,,,,,,614,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,64.5411,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,43.41,601.72
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,63323050830,NDC,1,EA,134.48,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,64.5504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.461584,189.875
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,63323050830,NDC,1,EA,134.48,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,64.5504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.461584,189.875
"Surgical Diagnostic Exam, Anorectal",PX45990P,CDM,983,RC,45990,CPT,,,,,,,,409,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,64.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.69,400.82
"Surgical Diagnostic Exam, Anorectal",PX45990P,CDM,983,RC,45990,CPT,,,,,,,,409,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,64.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.69,400.82
C-COLLAR ASPEN REGULAR 79-83365,120.25,CDM,274,RC,L0140,HCPCS,,167-MAIN,LOCAL,,,,,216,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,64.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.58,211.68
C-COLLAR ASPEN TALL 79-83367,120.25,CDM,274,RC,L0140,HCPCS,,164-MAIN,LOCAL,,,,,216,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,64.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.58,211.68
C-COLLAR ASPEN X-TALL 79-83368,120.25,CDM,274,RC,L0140,HCPCS,,168-MAIN,LOCAL,,,,,216,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,64.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.58,211.68
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012365,NDC,0.7,ML,291.98,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,64.59,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.59,73.4
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012388,NDC,0.7,ML,291.98,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,64.59,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.59,73.4
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072310,NDC,0.5,ML,291.98,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,64.59,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.59,73.4
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072388,NDC,0.5,ML,291.98,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,64.59,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.59,73.4
"Inpatient Consult, Level III",PX99253,CDM,983,RC,99253,CPT,,,,,,,,374,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,64.59,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.07,366.52
"Inpatient Consult, Level III",PX99253,CDM,983,RC,99253,CPT,,,,,,,,374,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,64.59,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.07,366.52
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046203,NDC,30,ML,70.91,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,64.59901,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Assay of Blood Lipoprotein,PX83721,CDM,300,RC,83721,CPT,,,,,,,,76,,First Health,Commercial,both,85,,999999999,percent of total billed charges,64.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.63,74.48
Lab Direct Coombs,PX86880,CDM,300,RC,86880,CPT,,,,,,,,76,,First Health,Commercial,both,85,,999999999,percent of total billed charges,64.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.5704,74.48
PRONEVIEW CUSHION INSERTS LARGE,120.557,CDM,272,RC,E0190,HCPCS,,12500-MAIN,LOCAL,,,,,76,,First Health,Commercial,both,85,,999999999,percent of total billed charges,64.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.5704,74.48
SHOE POST OP LARGE MALE MQM3B,120.237,CDM,274,RC,L3260,HCPCS,,794-MAIN,LOCAL,,,,,76,,First Health,Commercial,both,85,,999999999,percent of total billed charges,64.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP LARGE SQUARE TOE WOMENS ORT30300WL,120.237,CDM,274,RC,L3260,HCPCS,,10606-MAIN,LOCAL,,,,,76,,First Health,Commercial,both,85,,999999999,percent of total billed charges,64.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP MEDIUM SQUARE TOE MALE ORT30300MM,120.237,CDM,274,RC,L3260,HCPCS,,10603-MAIN,LOCAL,,,,,76,,First Health,Commercial,both,85,,999999999,percent of total billed charges,64.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP MEDIUM SQUARE TOE WOMENS ORT30300WM,120.237,CDM,274,RC,L3260,HCPCS,,10605-MAIN,LOCAL,,,,,76,,First Health,Commercial,both,85,,999999999,percent of total billed charges,64.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP SMALL MALE 0814-1192,120.237,CDM,274,RC,L3260,HCPCS,,803-MAIN,LOCAL,,,,,76,,First Health,Commercial,both,85,,999999999,percent of total billed charges,64.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP SMALL SQUARE TOE WOMENS MQW1B,120.237,CDM,274,RC,L3260,HCPCS,,10604-MAIN,LOCAL,,,,,76,,First Health,Commercial,both,85,,999999999,percent of total billed charges,64.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
tranexamic acid 1000 mg in 100 mL 0.7% sodium chloride (premix) 1000-0.7 MG/100ML-% Solution 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,80830232901,NDC,100,ML,155.55,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,64.61547,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323031119,NDC,10,ML,66.39,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.161,percent of total billed charges,64.617387,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,84.5054
TRAY SURGICAL PODIATRY II EXTREMITY DYNJS0803,27200000,CDM,272,RC,,,,10920-MAIN,LOCAL,,,,,73.29,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,64.64178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
triamcinolone acetonide 40 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029320,NDC,1,ML,72.65,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,64.6585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,72.0986
"IMMOBILIZER KNEE  24"" 7041-44",120.22,CDM,274,RC,L1830,HCPCS,,595-MAIN,LOCAL,,,,,60,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,64.6617,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.6617,81.17
"IMMOBILIZER KNEE 16"" UNIVERSAL 7088-04",120.22,CDM,274,RC,L1830,HCPCS,,589-MAIN,LOCAL,,,,,60,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,64.6617,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.6617,81.17
IMMOBILIZER KNEE 20 INCH ORT2420019,120.22,CDM,274,RC,L1830,HCPCS,,587-MAIN,LOCAL,,,,,60,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,64.6617,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.6617,81.17
"IMMOBILIZER KNEE 20"" LARGE FOAM COUNTOURED STAYS 7062-03",120.22,CDM,274,RC,L1830,HCPCS,,593-MAIN,LOCAL,,,,,60,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,64.6617,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.6617,81.17
"IMMOBILIZER KNEE 20"" QUICK-WRAP ORT2440020S",120.22,CDM,274,RC,L1830,HCPCS,,591-MAIN,LOCAL,,,,,60,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,64.6617,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.6617,81.17
IMMOBILIZER KNEE CUTAWAY STRAIGHT 2 7041-05,120.22,CDM,274,RC,L1830,HCPCS,,596-MAIN,LOCAL,,,,,60,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,64.6617,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.6617,81.17
sodium polystyrene sulfonate Powder 15 g Bottle,25000000,CDM,250,RC,,,,,,10702003615,NDC,15,GR,76.09,,First Health,Commercial,both,85,,999999999,percent of total billed charges,64.6765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Apply of Paste Boot,PX29580F,CDM,510,RC,29580,CPT,,,,,,,,132,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,64.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,137.65
Apply of Paste Boot,PX29580F,CDM,510,RC,29580,CPT,,,,,,,,132,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,64.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,137.65
Apply of Paste Boot,PX29580F,CDM,510,RC,29580,CPT,,,,,,,,132,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,64.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,137.65
Assay Dipropylacetic Acid,PX80164,CDM,300,RC,80164,CPT,,,,,,,,132,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,64.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.41,129.36
Assay Dipropylacetic Acid,PX80164,CDM,300,RC,80164,CPT,,,,,,,,132,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,64.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.41,129.36
Assay Dipropylacetic Acid,PX80164,CDM,300,RC,80164,CPT,,,,,,,,132,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,64.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.41,129.36
Assay of Lipase,PX83690,CDM,300,RC,83690,CPT,,,,,,,,132,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,42.34,percent of total billed charges,64.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.32,129.36
Assay of Lipase,PX83690,CDM,300,RC,83690,CPT,,,,,,,,132,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,64.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.32,129.36
Assay of Lipase,PX83690,CDM,300,RC,83690,CPT,,,,,,,,132,,United Healthcare,All Medicare advantage plans,outpatient,49,,69.96,percent of total billed charges,64.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.32,129.36
Ig Paraprotein Qual Bld/UR,PX0077U90,CDM,300,RC,0077U,HCPCS,90,,,,,,,66,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,64.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
"Level III - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3933,CDM,310,RC,88304,CPT,TC,,,,,,,66,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,64.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
Ot Contracted Service/Msho/MA,PX120.178,CDM,431,RC,,,,,,,,,,66,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,64.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
Pt Contracted Service/Msho,PX120.176,CDM,421,RC,,,,,,,,,,66,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,64.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,64.68
"Remv F.B.,Eye,Superf Conjunc",PX65205F,CDM,510,RC,65205,CPT,,,,,,,,132,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,44.715,percent of total billed charges,64.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,129.36
"Remv F.B.,Eye,Superf Conjunc",PX65205F,CDM,510,RC,65205,CPT,,,,,,,,132,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,64.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,129.36
"Remv F.B.,Eye,Superf Conjunc",PX65205F,CDM,510,RC,65205,CPT,,,,,,,,132,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,64.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,129.36
"Remv F.B.,Eye,Superf Conjunc",PX65205P,CDM,983,RC,65205,CPT,,,,,,,,132,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,44.715,percent of total billed charges,64.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,128.4756
"Remv F.B.,Eye,Superf Conjunc",PX65205P,CDM,983,RC,65205,CPT,,,,,,,,132,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,64.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,128.4756
"Remv F.B.,Eye,Superf Conjunc",PX65205P,CDM,983,RC,65205,CPT,,,,,,,,132,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,64.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,128.4756
Surg Pathology-Level 2-Tc,PX3932,CDM,310,RC,88302,CPT,TC,,,,,,,66,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,64.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.01,64.68
"Venipunc Need Phys Skill,Dx or Rx",PX36410,CDM,983,RC,36410,CPT,,,,,,,,132,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,2.85,percent of total billed charges,64.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,128.4756
"Venipunc Need Phys Skill,Dx or Rx",PX36410,CDM,983,RC,36410,CPT,,,,,,,,132,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,64.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,128.4756
"Venipunc Need Phys Skill,Dx or Rx",PX36410,CDM,983,RC,36410,CPT,,,,,,,,132,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,64.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,128.4756
Xray Orbits Optic Foramina,PX7019001,CDM,320,RC,70190,CPT,TC,,,,,,,66,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,64.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,79.39
Gabapentin - Ref,PX8017190,CDM,300,RC,80171,CPT,90,,,,,,,71,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,64.681,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.87,69.58
Histoplasma Antibody - Ref,PX8669890,CDM,300,RC,86698,CPT,90,,,,,,,71,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,64.681,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.64,69.58
Legionella Antibody - Ref,PX8671390,CDM,300,RC,86713,CPT,90,,,,,,,71,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,64.681,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.03,69.58
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024110,NDC,1,EA,76.1,,First Health,Commercial,both,85,,999999999,percent of total billed charges,64.685,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,63739005007,NDC,1,EA,73.35,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,64.6947,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,47781046813,NDC,1,EA,76.15,,First Health,Commercial,both,85,,999999999,percent of total billed charges,64.7275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,64380079701,NDC,1,EA,76.15,,First Health,Commercial,both,85,,999999999,percent of total billed charges,64.7275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,63739003807,NDC,1,EA,66.51,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,64.734183,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046204,NDC,30,ML,127.94,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,64.73764,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409493311,NDC,10,ML,66.06,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,64.7388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
Canalith Repositioning,PX95992,CDM,420,RC,95992,CPT,,,,,,,,128,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,64.768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.86,125.44
Heparin Xa,PX85520,CDM,300,RC,85520,CPT,,,,,,,,128,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,64.768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12,125.44
Lab Pth Immunoch Part 1,PX83970,CDM,300,RC,83970,CPT,,,,,,,,128,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,64.768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.85,125.44
"N Block Inj, Common Digit",PX64632P,CDM,983,RC,64632,CPT,,,,,,,,128,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,64.768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.1712,258.75
cyclopentolate 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,17478010002,NDC,2,ML,66.55,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,64.773115,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BOUGIE TRACH 10FR 70CM COUDE 	9-0211-70",120.199,CDM,272,RC,A7520,HCPCS,,11112-MAIN,LOCAL,,,,,42,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,64.78,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,64.78
"BOUGIE TRACH 10FR 70CM COUDE 	9-0211-70",120.199,CDM,272,RC,A7520,HCPCS,,11112-MAIN,LOCAL,,,,,42,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,64.78,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,64.78
"BOUGIE TRACH 10FR 70CM COUDE 	9-0211-70",120.199,CDM,272,RC,A7520,HCPCS,,11112-MAIN,LOCAL,,,,,42,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,64.78,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,64.78
BOUGIE TRACHEAL TUBE & GUIDE 100123515,120.199,CDM,272,RC,A7520,HCPCS,,8950-MAIN,LOCAL,,,,,42,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,64.78,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,64.78
BOUGIE TRACHEAL TUBE & GUIDE 100123515,120.199,CDM,272,RC,A7520,HCPCS,,8950-MAIN,LOCAL,,,,,42,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,64.78,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,64.78
BOUGIE TRACHEAL TUBE & GUIDE 100123515,120.199,CDM,272,RC,A7520,HCPCS,,8950-MAIN,LOCAL,,,,,42,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,64.78,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,64.78
CRICOTHROTOMY QUICKTRACH 4MM,120.228,CDM,272,RC,A7520,HCPCS,,8868-MAIN,LOCAL,,,,,494,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,64.78,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,64.78
CRICOTHROTOMY QUICKTRACH 4MM,120.228,CDM,272,RC,A7520,HCPCS,,8868-MAIN,LOCAL,,,,,494,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,64.78,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,64.78
CRICOTHROTOMY QUICKTRACH 4MM,120.228,CDM,272,RC,A7520,HCPCS,,8868-MAIN,LOCAL,,,,,494,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,64.78,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,64.78
TUBE TRACH SIZE 3.0MM ID 4.5MM OD SHILEY PEDIATRIC 3.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1185-MAIN,LOCAL,,,,,184,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,64.78,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 3.0MM ID 4.5MM OD SHILEY PEDIATRIC 3.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1185-MAIN,LOCAL,,,,,184,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,64.78,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 3.0MM ID 4.5MM OD SHILEY PEDIATRIC 3.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1185-MAIN,LOCAL,,,,,184,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,64.78,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 3.5MM ID 5.2MM OD SHILEY PEDIATRIC,120.287,CDM,272,RC,A7520,HCPCS,,8813-MAIN,LOCAL,,,,,184,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,64.78,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 3.5MM ID 5.2MM OD SHILEY PEDIATRIC,120.287,CDM,272,RC,A7520,HCPCS,,8813-MAIN,LOCAL,,,,,184,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,64.78,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 3.5MM ID 5.2MM OD SHILEY PEDIATRIC,120.287,CDM,272,RC,A7520,HCPCS,,8813-MAIN,LOCAL,,,,,184,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,64.78,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 4.0MM ID 5.9MM OD SHILEY PEDIATRIC 4.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1187-MAIN,LOCAL,,,,,184,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,64.78,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 4.0MM ID 5.9MM OD SHILEY PEDIATRIC 4.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1187-MAIN,LOCAL,,,,,184,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,64.78,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 4.0MM ID 5.9MM OD SHILEY PEDIATRIC 4.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1187-MAIN,LOCAL,,,,,184,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,64.78,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 5.0MM ID 7.1MM OD SHILEY PEDIATRIC 5.0PED,120.287,CDM,272,RC,A7520,HCPCS,,8814-MAIN,LOCAL,,,,,184,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,64.78,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 5.0MM ID 7.1MM OD SHILEY PEDIATRIC 5.0PED,120.287,CDM,272,RC,A7520,HCPCS,,8814-MAIN,LOCAL,,,,,184,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,64.78,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
TUBE TRACH SIZE 5.0MM ID 7.1MM OD SHILEY PEDIATRIC 5.0PED,120.287,CDM,272,RC,A7520,HCPCS,,8814-MAIN,LOCAL,,,,,184,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,64.78,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.98,64.78
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094310,NDC,10,ML,72.79,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,64.7831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.236966,143.9032
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094321,NDC,10,ML,72.79,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,64.7831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.236966,143.9032
"Cognitive Funct Ther Interv, per Day",PX97127,CDM,420,RC,97127,CPT,,,,,,,,135,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,64.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.079,132.3
"Cognitive Funct Ther Interv, per Day",PX97127,CDM,420,RC,97127,CPT,,,,,,,,135,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,64.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.079,132.3
Electric Stimulation Therapy,PX97014,CDM,420,RC,97014,CPT,,,,,,,,135,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,64.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.18,132.3
Electric Stimulation Therapy,PX97014,CDM,420,RC,97014,CPT,,,,,,,,135,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,64.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.18,132.3
Electrical Stimulation,PX97032,CDM,420,RC,97032,CPT,,,,,,,,135,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,64.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,132.3
Electrical Stimulation,PX97032,CDM,420,RC,97032,CPT,,,,,,,,135,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,64.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,132.3
Gait Training Therapy,PX97116,CDM,420,RC,97116,CPT,,,,,,,,135,,Health Partners,Health Partners Care Plans,both,48,,26.2,percent of total billed charges,64.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20,132.3
Gait Training Therapy,PX97116,CDM,420,RC,97116,CPT,,,,,,,,135,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,64.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20,132.3
"Manual Ther Tech,1+Regions,Ea 15 Min",PX97140,CDM,420,RC,97140,CPT,,,,,,,,135,,Health Partners,Health Partners Care Plans,both,48,,95.36080808,percent of total billed charges,64.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.4,215.05
"Manual Ther Tech,1+Regions,Ea 15 Min",PX97140,CDM,420,RC,97140,CPT,,,,,,,,135,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,64.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.4,215.05
Mechanical Traction Therapy,PX97012,CDM,420,RC,97012,CPT,,,,,,,,135,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,64.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,132.3
Mechanical Traction Therapy,PX97012,CDM,420,RC,97012,CPT,,,,,,,,135,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,64.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,132.3
Neuromuscular Re-Education,PX97112,CDM,420,RC,97112,CPT,,,,,,,,135,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,64.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.95,215.05
Neuromuscular Re-Education,PX97112,CDM,420,RC,97112,CPT,,,,,,,,135,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,64.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.95,215.05
Self Care Mngment Training,PX97535,CDM,420,RC,97535,CPT,,,,,,,,135,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,64.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.27,132.3
Self Care Mngment Training,PX97535,CDM,420,RC,97535,CPT,,,,,,,,135,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,64.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.27,132.3
Therapeutic Activities,PX97530,CDM,420,RC,97530,CPT,,,,,,,,135,,Health Partners,Health Partners Care Plans,both,48,,26.2,percent of total billed charges,64.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.22,205.7
Therapeutic Activities,PX97530,CDM,420,RC,97530,CPT,,,,,,,,135,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,64.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.22,205.7
Therapeutic Exercises,PX97110,CDM,420,RC,97110,CPT,,,,,,,,135,,Health Partners,Health Partners Care Plans,both,48,,86.56828767,percent of total billed charges,64.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20,215.05
Therapeutic Exercises,PX97110,CDM,420,RC,97110,CPT,,,,,,,,135,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,64.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20,215.05
Ultrasound Therapy,PX97035,CDM,420,RC,97035,CPT,,,,,,,,135,,Health Partners,Health Partners Care Plans,both,48,,60.74,percent of total billed charges,64.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,132.3
Ultrasound Therapy,PX97035,CDM,420,RC,97035,CPT,,,,,,,,135,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,64.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,132.3
Assay Blood Carbon Monoxide,PX82375,CDM,300,RC,82375,CPT,,,,,,,,156,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,64.8024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.3,152.88
"Cortisol, Am",PX7152,CDM,300,RC,82533,CPT,,,,,,,,156,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,64.8024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.95,152.88
DERMABOND PRINEO SKIN CLOSURE SYSTEM 22CM,27200000,CDM,272,RC,,,,12324-MAIN,LOCAL,,,,,156,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,64.8024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608201,NDC,1,ML,66.6,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,13.01809524,percent of total billed charges,64.82178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
Noninvasv Oxygen Satur;Single,PX94760,CDM,460,RC,94760,CPT,,,,,,,,131,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,64.845,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.4174,128.38
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042350,NDC,0.5,ML,132.37,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,64.8613,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.49,129.7226
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042350,NDC,0.5,ML,132.37,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,64.8613,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.49,129.7226
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042350,NDC,0.5,ML,132.37,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,64.8613,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.49,129.7226
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042388,NDC,0.5,ML,132.37,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,64.8613,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.49,129.7226
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042388,NDC,0.5,ML,132.37,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,64.8613,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.49,129.7226
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042388,NDC,0.5,ML,132.37,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,64.8613,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.49,129.7226
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,69315030615,NDC,15,GR,131.07,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,64.87965,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409751716,NDC,50,ML,72.9,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,64.881,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
triamcinolone acetonide 40 MG/ML Suspension 1 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029305,NDC,1,ML,73.57,,United Healthcare,All Payer,outpatient,88.2,,39.2,percent of total billed charges,64.88874,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,72.0986
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098121,NDC,1,EA,72.95,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,64.9255,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
ARIPiprazole 2 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714014101,NDC,1,EA,151.35,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,64.92915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluconazole 150 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,16714069210,NDC,1,EA,72.98,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,64.9522,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,25021011487,NDC,200,ML,66.28,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,64.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.20921,64.9544
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,55150012150,NDC,1,EA,151.41,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,64.95489,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
Observation Care Discharge,PX99217,CDM,982,RC,99217,CPT,,,,,,,,222,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,64.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.96,217.56
Observation Care Discharge,PX99217,CDM,982,RC,99217,CPT,,,,,,,,222,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,64.9632,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.96,217.56
BALLOON EXTRACTOR PEDS,120.358,CDM,272,RC,,,,10771-MAIN,LOCAL,,,,,73,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,64.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.3242,71.54
sodium phosphate 15 MMOLE/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323088401,NDC,5,ML,132.6,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,64.974,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium phosphate 15 MMOLE/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323088401,NDC,5,ML,132.6,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,64.974,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium phosphate 15 MMOLE/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323088401,NDC,5,ML,132.6,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,64.974,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium phosphate 15 MMOLE/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323088406,NDC,5,ML,132.6,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,64.974,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium phosphate 15 MMOLE/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323088406,NDC,5,ML,132.6,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,64.974,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium phosphate 15 MMOLE/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323088406,NDC,5,ML,132.6,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,64.974,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337501,NDC,50,ML,135.43,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,65.0064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337501,NDC,50,ML,135.43,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,65.0064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337502,NDC,50,ML,135.43,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,65.0064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337502,NDC,50,ML,135.43,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,65.0064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9678001,NDC,50,ML,135.43,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,65.0064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9678001,NDC,50,ML,135.43,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,65.0064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
magnesium sulfate 4 GM/50ML Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010701,NDC,50,ML,73.72,,United Healthcare,All Payer,outpatient,88.2,,13.925,percent of total billed charges,65.02104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323031119,NDC,10,ML,66.39,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,65.0622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,84.5054
Xray Wrist Minimum 3 Vws,PX7311001,CDM,320,RC,73110,CPT,TC,,,,,,,375,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,65.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.6,65.08
Xray Wrist Minimum 3 Vws,PX7311001,CDM,320,RC,73110,CPT,TC,,,,,,,375,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,65.08,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.6,65.08
anastrozole 1 MG Tablet 30 Each Bottle,25000000,CDM,250,RC,,,,,,16729003510,NDC,1,EA,71.44,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,65.08184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
charcoal activated Liquid 240 mL Bottle,63700001,CDM,250,RC,,,,,,574012108,NDC,120,ML,66.88,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,65.094304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004725,NDC,2,ML,131.52,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,65.1024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
caffeine citrate 60 MG/3ML Solution 3 mL Vial,J0706.01,CDM,636,RC,J0706,HCPCS,,,,63323040704,NDC,3,ML,73.84,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,65.12688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.673136,72.3632
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,409508411,NDC,1,EA,73.86,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,65.14452,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034020,NDC,1,EA,76.67,,First Health,Commercial,both,85,,999999999,percent of total billed charges,65.1695,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034021,NDC,1,EA,76.67,,First Health,Commercial,both,85,,999999999,percent of total billed charges,65.1695,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
"Cardiolipin Ab, Ea Lg - Ref",PX8614790,CDM,300,RC,86147,CPT,90,,,,,,,133,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,65.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.34,130.34
"Cardiolipin Ab, Ea Lg - Ref",PX8614790,CDM,300,RC,86147,CPT,90,,,,,,,133,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,65.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.34,130.34
"Cardiolipin Ab, Ea Lg - Ref",PX8614790,CDM,300,RC,86147,CPT,90,,,,,,,133,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,65.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.34,130.34
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU0003,CDM,300,RC,U0003,HCPCS,,,,,,,,133,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,65.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.2482,130.34
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU0003,CDM,300,RC,U0003,HCPCS,,,,,,,,133,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,65.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.2482,130.34
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU0003,CDM,300,RC,U0003,HCPCS,,,,,,,,133,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,65.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.2482,130.34
Lvl 1 Sub Hosp Low Mdm or 25 Minutes,PX99231,CDM,982,RC,99231,CPT,,,,,,,,133,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,65.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.2482,129.4489
Lvl 1 Sub Hosp Low Mdm or 25 Minutes,PX99231,CDM,982,RC,99231,CPT,,,,,,,,133,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,65.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.2482,129.4489
Lvl 1 Sub Hosp Low Mdm or 25 Minutes,PX99231,CDM,982,RC,99231,CPT,,,,,,,,133,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,65.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.2482,129.4489
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,63739003807,NDC,1,EA,66.51,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,65.1798,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atropine (PF) 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517040125,NDC,1,ML,71.55,,Medica,Commercial,both,91.1,,1.63075,percent of total billed charges,65.18205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
tetracaine 0.5 % Solution 4 mL Plas Cont,25000000,CDM,250,RC,,,,,,65074114,NDC,4,ML,71.55,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,65.18205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Bone Marrow Biopsy(Ies),PX38221F,CDM,510,RC,38221,CPT,,,,,,,,1221,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,65.1833,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,43.84,337.6
Repr Superf Wnd Face 5.1-7.5,PX12014F,CDM,510,RC,12014,CPT,,,,,,,,453,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,65.1833,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.06,297.47
Repr Superf Wnd Face 5.1-7.5,PX12014P,CDM,983,RC,12014,CPT,,,,,,,,819,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,65.1833,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.06,802.62
sodium zirconium cyclosilicate 5 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,310110501,NDC,1,EA,151.95,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,65.18655,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Antipsychotics, Not Otherwise Specified; 1-3 - Ref",PX8034290,CDM,300,RC,80342,CPT,90,,,,,,,152,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,65.208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.1408,148.96
Body Fluid Cell Count,PX89050,CDM,300,RC,89050,CPT,,,,,,,,152,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,65.208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.33,148.96
Group Therapeutic Procedures,PX97150,CDM,420,RC,97150,CPT,,,,,,,,67,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,65.2111,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.82,65.66
"Hydroxyprogesterone, 17-D - Ref",PX8349890,CDM,300,RC,83498,CPT,90,,,,,,,67,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,65.2111,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.91,65.66
Lab Org ID Anaerobic-Each,PX87076,CDM,300,RC,87076,CPT,,,,,,,,67,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,65.2111,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,65.66
Assay of Psa Total,PX84153,CDM,300,RC,84153,CPT,,,,,,,,157,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,65.2178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.86,153.86
"Chlamydia Trachomatis Dna, Amp Probe",PX87491,CDM,300,RC,87491,CPT,,,,,,,,157,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,65.2178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,153.86
"Cognitive Skill Dev, Ea 15 Min",PX97532,CDM,420,RC,97532,CPT,,,,,,,,157,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,65.2178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.2178,153.86
"Fungal Culture, Other Source - Ref",PX8710290,CDM,300,RC,87102,CPT,90,,,,,,,157,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,65.2178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.71,153.86
Lactate (Ld) (Ldh) Enzyme,PX83615,CDM,300,RC,83615,CPT,,,,,,,,157,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,65.2178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.54,153.86
"Neisseria Gonorrhoeae Dna, Amp Probe",PX87591,CDM,300,RC,87591,CPT,,,,,,,,157,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,65.2178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,153.86
Psa Screening,PXG0103,CDM,300,RC,G0103,HCPCS,,,,,,,,157,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,65.2178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.71,153.86
Remv Ext Canal Foreign Body,PX69200P,CDM,983,RC,69200,CPT,,,,,,,,157,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,65.2178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.2178,152.8081
cyclopentolate 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,17478010002,NDC,2,ML,66.55,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,65.219,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
methylergonovine 0.2 MG/ML Solution 1 mL Ampule,J2210.01,CDM,636,RC,J2210,HCPCS,,,,51991014417,NDC,1,ML,133.11,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,65.2239,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.293894,130.4478
methylergonovine 0.2 MG/ML Solution 1 mL Ampule,J2210.01,CDM,636,RC,J2210,HCPCS,,,,51991014417,NDC,1,ML,133.11,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,65.2239,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.293894,130.4478
methylergonovine 0.2 MG/ML Solution 1 mL Ampule,J2210.01,CDM,636,RC,J2210,HCPCS,,,,51991014417,NDC,1,ML,133.11,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,65.2239,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.293894,130.4478
TRAY SURGICAL PODIATRY II EXTREMITY DYNJS0803,27200000,CDM,272,RC,,,,10920-MAIN,LOCAL,,,,,73.29,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,65.2281,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Venous Duplex Scan Uni,PX9397101,CDM,921,RC,93971,CPT,TC,,,,,,,809,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,65.23,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.23,171.6
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059900,NDC,1,ML,133.16,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,65.2484,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.54253,130.4968
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059900,NDC,1,ML,133.16,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,65.2484,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.54253,130.4968
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059900,NDC,1,ML,133.16,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,65.2484,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.54253,130.4968
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059902,NDC,1,ML,133.16,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,65.2484,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.54253,130.4968
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059902,NDC,1,ML,133.16,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,65.2484,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.54253,130.4968
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059902,NDC,1,ML,133.16,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,65.2484,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.54253,130.4968
Cyto Non Gyn,PX8811201,CDM,310,RC,88112,CPT,TC,,,,,,,372,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,65.25,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.14,67.392
Cyto Non Gyn,PX8811201,CDM,310,RC,88112,CPT,TC,,,,,,,372,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,65.25,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.14,67.392
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608201,NDC,1,ML,66.6,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,65.268,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.88,65.268
Glucose Test,PX82950,CDM,300,RC,82950,CPT,,,,,,,,74,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,65.268,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.36,72.52
KIT EMERGENCY BIRTH DYNJS0600,120.317,CDM,272,RC,,,,8344-MAIN,LOCAL,,,,,74,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,65.268,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.7396,72.52
Rubeola Antibody,PX86765,CDM,300,RC,86765,CPT,,,,,,,,74,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,65.268,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.81,72.52
Complete Cbc Automated,PX85027,CDM,300,RC,85027,CPT,,,,,,,,129,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,65.274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,126.42
"Venipunc Need Phys Skill,Dx or Rx",PX36410P,CDM,983,RC,36410,CPT,,,,,,,,129,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,65.274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.5866,125.5557
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,63739005007,NDC,1,EA,73.35,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,65.2815,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SUMAtriptan 25 MG Tablet 9 Each Box,63700001,CDM,250,RC,,,,,,65862014636,NDC,1,EA,129.04,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,65.29424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,703115301,NDC,4,ML,136.1,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,65.328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,703115301,NDC,4,ML,136.1,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,65.328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
acyclovir 50 MG/ML Solution 20 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,63323032524,NDC,20,ML,76.86,,First Health,Commercial,both,85,,999999999,percent of total billed charges,65.331,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.927644,105.9968
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047621,NDC,1,ML,157.28,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,65.334112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.354486,332.1514
Apply of Paste Boot,PX29580F,CDM,510,RC,29580,CPT,,,,,,,,132,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,65.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,137.65
Assay Dipropylacetic Acid,PX80164,CDM,300,RC,80164,CPT,,,,,,,,132,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,65.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.41,129.36
Assay of Lipase,PX83690,CDM,300,RC,83690,CPT,,,,,,,,132,,Humana Choice Care,All Medicare plans,outpatient,49.5,,32.34,percent of total billed charges,65.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.32,129.36
"Remv F.B.,Eye,Superf Conjunc",PX65205F,CDM,510,RC,65205,CPT,,,,,,,,132,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,65.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,129.36
"Remv F.B.,Eye,Superf Conjunc",PX65205P,CDM,983,RC,65205,CPT,,,,,,,,132,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,65.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,128.4756
"Venipunc Need Phys Skill,Dx or Rx",PX36410,CDM,983,RC,36410,CPT,,,,,,,,132,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,65.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,128.4756
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409338513,NDC,1,EA,74.09,,United Healthcare,All Payer,outpatient,88.2,,49.96,percent of total billed charges,65.34738,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
Hfe Gene - Ref,PX8125690,CDM,300,RC,81256,CPT,90,,,,,,,526,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,65.36,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.4,65.36
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037601,NDC,1,ML,76.9,,First Health,Commercial,both,85,,999999999,percent of total billed charges,65.365,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457033900,NDC,1,EA,71.82,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,65.42802,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
Abd Paracentesis W/Imaging(P),PX49083P,CDM,983,RC,49083,CPT,,,,,,,,696,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,65.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.45,682.08
Abd Paracentesis W/Imaging(P),PX49083P,CDM,983,RC,49083,CPT,,,,,,,,696,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,65.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.45,682.08
Abd Paracentesis W/Imaging(P),PX49083P,CDM,983,RC,49083,CPT,,,,,,,,696,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,65.45,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.45,682.08
Abd Paracentesis W/Imaging(T),PX49083F,CDM,510,RC,49083,CPT,,,,,,,,1006,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,65.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.45,602.56
Abd Paracentesis W/Imaging(T),PX49083F,CDM,510,RC,49083,CPT,,,,,,,,1006,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,65.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.45,602.56
Abd Paracentesis W/Imaging(T),PX49083F,CDM,510,RC,49083,CPT,,,,,,,,1006,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,65.45,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.45,602.56
Alpha-Fetoprotein Serum,PX82105,CDM,300,RC,82105,CPT,,,,,,,,77,,First Health,Commercial,both,85,,999999999,percent of total billed charges,65.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.38,75.46
BRACE WRIST HAND THUMB LEFT 455-LT,120.315,CDM,274,RC,L3809,HCPCS,,8283-MAIN,LOCAL,,,,,77,,First Health,Commercial,both,85,,999999999,percent of total billed charges,65.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.9858,245.51
BRACE WRIST HAND THUMB RIGHT 455-RT,120.315,CDM,274,RC,L3809,HCPCS,,8284-MAIN,LOCAL,,,,,77,,First Health,Commercial,both,85,,999999999,percent of total billed charges,65.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.9858,245.51
CAUTERY HIGH TEMP LOOP TIP,120.21,CDM,272,RC,,,,332-MAIN,LOCAL,,,,,77,,First Health,Commercial,both,85,,999999999,percent of total billed charges,65.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
NEEDLE ACUJECT 25GA VARIABLE INJECTION VIN-25,27200000,CDM,272,RC,,,,7412-MAIN,LOCAL,,,,,77,,First Health,Commercial,both,85,,999999999,percent of total billed charges,65.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Removal of Nail Bed,PX11750F,CDM,510,RC,11750,CPT,,,,,,,,629,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,65.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.91,334.83
Removal of Nail Bed,PX11750F,CDM,510,RC,11750,CPT,,,,,,,,629,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,65.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.91,334.83
Remove Additional Nail Plate,PX11732F,CDM,510,RC,11732,CPT,,,,,,,,77,,First Health,Commercial,both,85,,999999999,percent of total billed charges,65.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.9858,75.46
"Venipuncture, Lab",PX3641502,CDM,300,RC,36415,CPT,,,,,,,,61,,Blue Cross Blue Shield of MN,All commercial plans,both,,,24.25728448,fee schedule,65.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.1,65.45
Venous Duplex Scan Uni,PX9397101,CDM,921,RC,93971,CPT,TC,,,,,,,809,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,65.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.23,171.6
Venous Duplex Scan Uni,PX9397101,CDM,921,RC,93971,CPT,TC,,,,,,,809,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,65.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.23,171.6
triamcinolone acetonide 40 MG/ML Suspension 1 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029305,NDC,1,ML,73.57,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,65.4773,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,72.0986
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,517096010,NDC,10,ML,157.64,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,65.483656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
rivaroxaban 15 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50458057830,NDC,0.666666667,EA,67.3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,65.50309,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Injection for Nerve Block,PX64448F,CDM,510,RC,64448,CPT,,,,,,,,873,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,65.5044,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.28,147.35
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127303,NDC,2,ML,152.7,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,65.5083,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.43158,173.019
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042350,NDC,0.5,ML,132.37,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,65.52315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.49,129.7226
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042388,NDC,0.5,ML,132.37,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,65.52315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.49,129.7226
charcoal activated Liquid 240 mL Bottle,63700001,CDM,250,RC,,,,,,574012108,NDC,120,ML,66.88,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,65.5424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
octreotide 200 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037805,NDC,1,ML,133.77,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,12.26041667,percent of total billed charges,65.5473,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
octreotide 200 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037805,NDC,1,ML,133.77,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,65.5473,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
octreotide 200 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037805,NDC,1,ML,133.77,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,65.5473,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
"B.Burgdorferi, Amp Probe - Ref",PX8747690,CDM,300,RC,87476,CPT,90,,,,,,,72,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,65.592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.9088,70.56
"Blood, Occult, Other Sources",PX82271,CDM,300,RC,82271,CPT,,,,,,,,72,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,65.592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.88,70.56
Epstein-barr antibody,PX86664,CDM,300,RC,86664,CPT,,,,,,,,72,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,65.592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.02,70.56
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,55150043801,NDC,20,ML,152.9,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,65.5941,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457018120,NDC,20,ML,152.9,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,65.5941,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
magnesium sulfate 4 GM/50ML Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010701,NDC,50,ML,73.72,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,65.6108,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
Antithrombin III Activity - Ref,PX8530090,CDM,300,RC,85300,CPT,90,,,,,,,158,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,65.6332,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.87,154.84
Fac/Trm Hyperkeratotic Skn Lesn2-4,PX11056F,CDM,510,RC,11056,CPT,,,,,,,,158,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,65.6332,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.6332,174.9
"Glucose, Body Fluid Other Than Blood",PX82945,CDM,300,RC,82945,CPT,,,,,,,,158,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,65.6332,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.6,154.84
Protein C Activity - Ref,PX8530390,CDM,300,RC,85303,CPT,90,,,,,,,158,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,65.6332,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.69,154.84
"Triiodothyronine T3, Tot - Ref",PX8448090,CDM,300,RC,84480,CPT,90,,,,,,,158,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,65.6332,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13,154.84
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320885,NDC,0.5,EA,129.71,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,65.63326,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320895,NDC,0.5,EA,129.71,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,65.63326,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
ELECTRODE ADULT PACING ONESTEP,120.214,CDM,272,RC,A4556,HCPCS,,10242-MAIN,LOCAL,,,,,153,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,65.637,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.5562,149.94
"Protein, Total; Other Source",PX84157,CDM,300,RC,84157,CPT,,,,,,,,153,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,65.637,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.67,149.94
Pulmonary Stress Test,PX94618,CDM,976,RC,94618,CPT,,,,,,,,153,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,65.637,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.5562,148.9149
sodium phosphate 15 MMOLE/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323088401,NDC,5,ML,132.6,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,65.637,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium phosphate 15 MMOLE/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323088406,NDC,5,ML,132.6,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,65.637,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457018100,NDC,20,ML,153.01,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,65.64129,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,436067216,NDC,473,ML,77.23,,First Health,Commercial,both,85,,999999999,percent of total billed charges,65.6455,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,39328006412,NDC,473,ML,77.23,,First Health,Commercial,both,85,,999999999,percent of total billed charges,65.6455,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012250,NDC,1,EA,77.24,,First Health,Commercial,both,85,,999999999,percent of total billed charges,65.654,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012267,NDC,1,EA,77.24,,First Health,Commercial,both,85,,999999999,percent of total billed charges,65.654,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
cefOXitin 2 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021011020,NDC,1,EA,77.24,,First Health,Commercial,both,85,,999999999,percent of total billed charges,65.654,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.367364,75.6952
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023610,NDC,1,EA,77.24,,First Health,Commercial,both,85,,999999999,percent of total billed charges,65.654,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
Group Therapeutic Procedures,PX97150,CDM,420,RC,97150,CPT,,,,,,,,67,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,65.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.82,65.66
"Hydroxyprogesterone, 17-D - Ref",PX8349890,CDM,300,RC,83498,CPT,90,,,,,,,67,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,65.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.91,65.66
Lab Org ID Anaerobic-Each,PX87076,CDM,300,RC,87076,CPT,,,,,,,,67,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,65.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,65.66
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019602,NDC,2,ML,77.29,,First Health,Commercial,both,85,,999999999,percent of total billed charges,65.6965,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
cloNIDine 0.1 MG/24HR PATCH WEEKLY 4 Each Box,63700001,CDM,250,RC,,,,,,51862045304,NDC,1,EA,158.16,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,65.699664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862066230,NDC,1,EA,153.17,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,65.70993,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954201,NDC,10,ML,153.18,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,65.71422,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.630972,150.1164
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954210,NDC,10,ML,153.18,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,65.71422,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.630972,150.1164
caffeine citrate 60 MG/3ML Solution 3 mL Vial,J0706.01,CDM,636,RC,J0706,HCPCS,,,,63323040704,NDC,3,ML,73.84,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,65.7176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.673136,72.3632
solifenacin 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50228042730,NDC,1,EA,74.52,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,65.72664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DAPTOmycin 500 MG Recon Soln 1 Each Vial,J0878.01,CDM,636,RC,J0878,HCPCS,,,,70594003402,NDC,1,EA,129.9,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,65.7294,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.96046,127.302
"Cardiac Stress Tst,Tracing Only",PX93017,CDM,482,RC,93017,CPT,,,,,,,,1959,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,65.73,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.34,65.73
"Cardiac Stress Tst,Tracing Only",PX93017,CDM,482,RC,93017,CPT,,,,,,,,1959,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,65.73,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.34,65.73
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,409508411,NDC,1,EA,73.86,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,65.7354,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,58602060407,NDC,100,GR,67.56,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,65.756148,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Total Cortisol,PX82533,CDM,300,RC,82533,CPT,,,,,,,,137,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,65.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.95,134.26
Total Cortisol,PX82533,CDM,300,RC,82533,CPT,,,,,,,,137,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,65.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.95,134.26
"Triiodothyronine T3, Free (Free T3)",PX84481,CDM,300,RC,84481,CPT,,,,,,,,137,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,65.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.53,134.26
"Triiodothyronine T3, Free (Free T3)",PX84481,CDM,300,RC,84481,CPT,,,,,,,,137,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,65.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.53,134.26
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,574722612,NDC,1,EA,67.57,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,65.765881,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.345782,66.2186
Chemo Ad Sq/Im Hormnl Anti-Neo,PX96402,CDM,335,RC,96402,CPT,,,,,,,,130,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,65.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,127.4
Cystatin C - Ref,PX8261090,CDM,300,RC,82610,CPT,90,,,,,,,130,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,65.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.98,127.4
Each Add'l Sequential Push New Drug,PX96375,CDM,260,RC,96375,CPT,,,,,,,,130,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,65.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,127.4
Immunization Administration; One Vaccine (Single or Combination Vaccine/To*,PX90471,CDM,771,RC,90471,CPT,,,,,,,,130,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,65.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,127.4
Prothrombin Time (Pt/Inr),PX85610,CDM,300,RC,85610,CPT,,,,,,,,130,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,65.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.93,127.4
SPLINT WRIST LARGE ALUMINUM FOREARM LEFT 9101-06,120.87,CDM,274,RC,L3809,HCPCS,,1265-MAIN,LOCAL,,,,,130,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,65.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST LARGE ALUMINUM FOREARM RIGHT 9101-03,120.87,CDM,274,RC,L3809,HCPCS,,1263-MAIN,LOCAL,,,,,130,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,65.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST MEDIUM ALUMINUM FOREARM LEFT 9101-05,120.87,CDM,274,RC,L3809,HCPCS,,1264-MAIN,LOCAL,,,,,130,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,65.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST MEDIUM ALUMINUM FOREARM RIGHT 9101-02,120.87,CDM,274,RC,L3809,HCPCS,,1262-MAIN,LOCAL,,,,,130,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,65.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
Vitamin B-1 - Ref,PX8442590,CDM,300,RC,84425,CPT,90,,,,,,,130,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,65.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.47,127.4
"Destruct Benign Lesion, 1-14",PX17110F,CDM,510,RC,17110,CPT,,,,,,,,302,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,65.8255,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.97,237.29
"Destruct Benign Lesion, 1-14",PX17110P,CDM,983,RC,17110,CPT,,,,,,,,521,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,65.8255,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.97,510.58
"Cardiolipin Ab, Ea Lg - Ref",PX8614790,CDM,300,RC,86147,CPT,90,,,,,,,133,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,65.835,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.34,130.34
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU0003,CDM,300,RC,U0003,HCPCS,,,,,,,,133,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,65.835,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.2482,130.34
Lvl 1 Sub Hosp Low Mdm or 25 Minutes,PX99231,CDM,982,RC,99231,CPT,,,,,,,,133,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,65.835,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.2482,129.4489
aspirin-dipyridamole 25-200 MG Capsule Extended Release 12 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687030533,NDC,1,EA,67.66,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,65.853478,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin-dipyridamole 25-200 MG Capsule Extended Release 12 Hour 20 Each Box,63700001,CDM,250,RC,,,,,,60687030532,NDC,1,EA,67.66,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,65.853478,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Glucose Test,PX82950,CDM,300,RC,82950,CPT,,,,,,,,74,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,65.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.36,72.52
KIT EMERGENCY BIRTH DYNJS0600,120.317,CDM,272,RC,,,,8344-MAIN,LOCAL,,,,,74,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,65.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.7396,72.52
Rubeola Antibody,PX86765,CDM,300,RC,86765,CPT,,,,,,,,74,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,65.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.81,72.52
"Chemotherapy, IV Push, Single Drug",PX96409,CDM,335,RC,96409,CPT,,,,,,,,502,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,65.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.88,174.51
"Chemotherapy, IV Push, Single Drug",PX96409,CDM,335,RC,96409,CPT,,,,,,,,502,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,65.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.88,174.51
"Chemotherapy, IV Push, Single Drug",PX96409,CDM,335,RC,96409,CPT,,,,,,,,502,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,65.88,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.88,174.51
Drain Pilonidal Cyst Simpl,PX10080F,CDM,510,RC,10080,CPT,,,,,,,,742,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,65.88,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.88,521.62
"IMMOBILIZER KNEE  24"" 7041-44",120.22,CDM,274,RC,L1830,HCPCS,,595-MAIN,LOCAL,,,,,60,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,65.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.6617,81.17
"IMMOBILIZER KNEE  24"" 7041-44",120.22,CDM,274,RC,L1830,HCPCS,,595-MAIN,LOCAL,,,,,60,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,65.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.6617,81.17
"IMMOBILIZER KNEE  24"" 7041-44",120.22,CDM,274,RC,L1830,HCPCS,,595-MAIN,LOCAL,,,,,60,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,65.88,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.6617,81.17
"IMMOBILIZER KNEE 16"" UNIVERSAL 7088-04",120.22,CDM,274,RC,L1830,HCPCS,,589-MAIN,LOCAL,,,,,60,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,65.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.6617,81.17
"IMMOBILIZER KNEE 16"" UNIVERSAL 7088-04",120.22,CDM,274,RC,L1830,HCPCS,,589-MAIN,LOCAL,,,,,60,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,65.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.6617,81.17
"IMMOBILIZER KNEE 16"" UNIVERSAL 7088-04",120.22,CDM,274,RC,L1830,HCPCS,,589-MAIN,LOCAL,,,,,60,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,65.88,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.6617,81.17
IMMOBILIZER KNEE 20 INCH ORT2420019,120.22,CDM,274,RC,L1830,HCPCS,,587-MAIN,LOCAL,,,,,60,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,65.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.6617,81.17
IMMOBILIZER KNEE 20 INCH ORT2420019,120.22,CDM,274,RC,L1830,HCPCS,,587-MAIN,LOCAL,,,,,60,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,65.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.6617,81.17
IMMOBILIZER KNEE 20 INCH ORT2420019,120.22,CDM,274,RC,L1830,HCPCS,,587-MAIN,LOCAL,,,,,60,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,65.88,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.6617,81.17
"IMMOBILIZER KNEE 20"" LARGE FOAM COUNTOURED STAYS 7062-03",120.22,CDM,274,RC,L1830,HCPCS,,593-MAIN,LOCAL,,,,,60,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,65.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.6617,81.17
"IMMOBILIZER KNEE 20"" LARGE FOAM COUNTOURED STAYS 7062-03",120.22,CDM,274,RC,L1830,HCPCS,,593-MAIN,LOCAL,,,,,60,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,65.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.6617,81.17
"IMMOBILIZER KNEE 20"" LARGE FOAM COUNTOURED STAYS 7062-03",120.22,CDM,274,RC,L1830,HCPCS,,593-MAIN,LOCAL,,,,,60,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,65.88,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.6617,81.17
"IMMOBILIZER KNEE 20"" QUICK-WRAP ORT2440020S",120.22,CDM,274,RC,L1830,HCPCS,,591-MAIN,LOCAL,,,,,60,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,65.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.6617,81.17
"IMMOBILIZER KNEE 20"" QUICK-WRAP ORT2440020S",120.22,CDM,274,RC,L1830,HCPCS,,591-MAIN,LOCAL,,,,,60,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,65.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.6617,81.17
"IMMOBILIZER KNEE 20"" QUICK-WRAP ORT2440020S",120.22,CDM,274,RC,L1830,HCPCS,,591-MAIN,LOCAL,,,,,60,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,65.88,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.6617,81.17
IMMOBILIZER KNEE CUTAWAY STRAIGHT 2 7041-05,120.22,CDM,274,RC,L1830,HCPCS,,596-MAIN,LOCAL,,,,,60,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,65.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.6617,81.17
IMMOBILIZER KNEE CUTAWAY STRAIGHT 2 7041-05,120.22,CDM,274,RC,L1830,HCPCS,,596-MAIN,LOCAL,,,,,60,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,65.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.6617,81.17
IMMOBILIZER KNEE CUTAWAY STRAIGHT 2 7041-05,120.22,CDM,274,RC,L1830,HCPCS,,596-MAIN,LOCAL,,,,,60,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,65.88,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.6617,81.17
fentaNYL 25 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,591319872,NDC,1,EA,77.51,,First Health,Commercial,both,85,,999999999,percent of total billed charges,65.8835,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,24208046325,NDC,2.5,ML,137.26,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,65.8848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,24208046325,NDC,2.5,ML,137.26,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,65.8848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
methylergonovine 0.2 MG/ML Solution 1 mL Ampule,J2210.01,CDM,636,RC,J2210,HCPCS,,,,51991014417,NDC,1,ML,133.11,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,65.88945,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.293894,130.4478
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,63323050830,NDC,1,EA,134.48,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,3.99575,percent of total billed charges,65.8952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.461584,189.875
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,63323050830,NDC,1,EA,134.48,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,65.8952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.461584,189.875
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,63323050830,NDC,1,EA,134.48,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,65.8952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.461584,189.875
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059900,NDC,1,ML,133.16,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,65.9142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.54253,130.4968
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059902,NDC,1,ML,133.16,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,65.9142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.54253,130.4968
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409338513,NDC,1,EA,74.09,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,65.9401,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
rivaroxaban 15 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50458057830,NDC,0.666666667,EA,67.3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,65.954,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
triamcinolone acetonide 0.1 % Cream 454 g Jar,63700001,CDM,250,RC,,,,,,45802006405,NDC,454,GR,130.36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,65.96216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
RETRIEVAL BAG 10MM,27200000,CDM,272,RC,,,,11707-MAIN,LOCAL,,,,,74.8,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,65.9736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
hepatitis b recomb vaccine 10 MCG/0.5ML suspension prefilled syringe 0.5 mL Syringe,90743,CDM,636,RC,90743,CPT,,,,58160082052,NDC,0.5,ML,137.47,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,65.9856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.105038,134.7206
hepatitis b recomb vaccine 10 MCG/0.5ML suspension prefilled syringe 0.5 mL Syringe,90743,CDM,636,RC,90743,CPT,,,,58160082052,NDC,0.5,ML,137.47,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,65.9856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.105038,134.7206
Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq,PX87635,CDM,300,RC,87635,CPT,,,,,,,,166,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,224.4
Sars-Cov-2 Covid-19 Amp Prb,PX8763590,CDM,300,RC,87635,CPT,90,,,,,,,365,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,357.7
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,17478070311,NDC,10,ML,72.46,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,66.01106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
EPIX UNIVERSAL CLIP APPLIER,27200000,CDM,272,RC,,,,11708-MAIN,LOCAL,,,,,158.95,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,66.02783,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Iaad Ia Severe Aqt Respir Synd Coronavirus,PX87426,CDM,300,RC,87426,CPT,,,,,,,,159,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,66.0486,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.39,155.82
PROSTEP 0.9MM ANTI SKIVE PIN,27200000,CDM,272,RC,,,,12950-MAIN,LOCAL,,,,,154,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,66.066,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PROSTEP 1.4MM ANTI SKIVE PIN,27200000,CDM,272,RC,,,,12949-MAIN,LOCAL,,,,,154,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,66.066,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Vit D 1 25-Dihydroxy,PX82652,CDM,300,RC,82652,CPT,,,,,,,,154,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,66.066,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.3,150.92
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039801,NDC,1,EA,67.88,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,11.23,percent of total billed charges,66.067604,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039810,NDC,1,EA,67.88,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,11.23,percent of total billed charges,66.067604,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
CT Head/Brain W/Dye,PX7046001,CDM,350,RC,70460,CPT,TC,,,,,,,3398,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,66.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.1,195.25
CT Head/Brain W/Dye,PX7046001,CDM,350,RC,70460,CPT,TC,,,,,,,3398,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,66.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.1,195.25
CT Head/Brain W/Dye,PX7046001,CDM,350,RC,70460,CPT,TC,,,,,,,3398,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,66.1,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.1,195.25
"Critical Care, Addl 30 Min",PX99292P,CDM,983,RC,99292,CPT,,,,,,,,542,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,66.12,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.12,531.16
"Facility Critical Care, Addl 30 Min",PX99292F,CDM,510,RC,99292,CPT,,,,,,,,484,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,66.12,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.12,214.08
"Fna Biopsy, W/US Guidance; First Lesion",PX10005F,CDM,510,RC,10005,CPT,,,,,,,,333,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,66.1466,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.93,278.8
"Fna Biopsy, W/US Guidance; First Lesion",PX10005P,CDM,983,RC,10005,CPT,,,,,,,,621,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,66.1466,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.93,608.58
Injection for Nerve Block,PX64445F,CDM,510,RC,64445,CPT,,,,,,,,385,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,66.1466,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.71,329.3
Injection for Nerve Block,PX64445P,CDM,983,RC,64445,CPT,,,,,,,,385,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,66.1466,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.71,377.3
Assay Cryofibrinogen,PX82585,CDM,300,RC,82585,CPT,,,,,,,,75,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,66.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.96,73.5
Assay Cryoglobulin,PX82595,CDM,300,RC,82595,CPT,,,,,,,,75,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,66.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,73.5
BINDER ABDOMINAL 9 INCH 46 TO 62 INCH XL ORT21100LXL,120.238,CDM,271,RC,A4467,HCPCS,,2989-MAIN,LOCAL,,,,,75,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,66.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL 9 INCH 63 TO 74 INCH 3- PANEL ORT211002XL,120.238,CDM,271,RC,A4467,HCPCS,,37-MAIN,LOCAL,,,,,75,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,66.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL 10 INCH 26 TO 50 INCHES ABB1050,120.238,CDM,271,RC,A4467,HCPCS,,52-MAIN,LOCAL,,,,,75,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,66.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
"BINDER ABDOMINAL 12"" HIGH 2XL 60-75INCH 4 PANEL ORT213002XL",120.238,CDM,271,RC,A4467,HCPCS,,12536-MAIN,LOCAL,,,,,75,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,66.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL UNISIZE 46-62IN 9 IN MDS169024,120.238,CDM,271,RC,A4467,HCPCS,,63-MAIN,LOCAL,,,,,75,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,66.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
"Cognitive Funct Ther Interv, per Day",PX97127,CDM,420,RC,97127,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,66.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.079,132.3
"Cognitive Funct Ther Interv, per Day",PX97127,CDM,420,RC,97127,CPT,,,,,,,,135,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,66.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.079,132.3
"Cognitive Funct Ther Interv, per Day",PX97127,CDM,420,RC,97127,CPT,,,,,,,,135,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,66.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.079,132.3
"Direct skilled nursing services of a license practical nurse (lpn) in the home health or hospice setting, each 15 minutes",PXG0300,CDM,551,RC,G0300,HCPCS,,,,,,,,75,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,66.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
Electric Stimulation Therapy,PX97014,CDM,420,RC,97014,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,131,percent of total billed charges,66.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.18,132.3
Electric Stimulation Therapy,PX97014,CDM,420,RC,97014,CPT,,,,,,,,135,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,66.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.18,132.3
Electric Stimulation Therapy,PX97014,CDM,420,RC,97014,CPT,,,,,,,,135,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,66.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.18,132.3
Electrical Stimulation,PX97032,CDM,420,RC,97032,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,131,percent of total billed charges,66.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,132.3
Electrical Stimulation,PX97032,CDM,420,RC,97032,CPT,,,,,,,,135,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,66.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,132.3
Electrical Stimulation,PX97032,CDM,420,RC,97032,CPT,,,,,,,,135,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,66.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,132.3
Gait Training Therapy,PX97116,CDM,420,RC,97116,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,24.09902439,percent of total billed charges,66.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20,132.3
Gait Training Therapy,PX97116,CDM,420,RC,97116,CPT,,,,,,,,135,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,66.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20,132.3
Gait Training Therapy,PX97116,CDM,420,RC,97116,CPT,,,,,,,,135,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,66.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20,132.3
HH Rn Initial Visit,PXG0154,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,66.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
HH Rn Routine Visit,PXG0154.01,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,66.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
"Manual Ther Tech,1+Regions,Ea 15 Min",PX97140,CDM,420,RC,97140,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,31.62525597,percent of total billed charges,66.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.4,215.05
"Manual Ther Tech,1+Regions,Ea 15 Min",PX97140,CDM,420,RC,97140,CPT,,,,,,,,135,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,66.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.4,215.05
"Manual Ther Tech,1+Regions,Ea 15 Min",PX97140,CDM,420,RC,97140,CPT,,,,,,,,135,,United Healthcare,All Medicare advantage plans,outpatient,49,,70.84333333,percent of total billed charges,66.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.4,215.05
Mechanical Traction Therapy,PX97012,CDM,420,RC,97012,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,26.50769231,percent of total billed charges,66.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,132.3
Mechanical Traction Therapy,PX97012,CDM,420,RC,97012,CPT,,,,,,,,135,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,66.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,132.3
Mechanical Traction Therapy,PX97012,CDM,420,RC,97012,CPT,,,,,,,,135,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,66.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,132.3
Neuromuscular Re-Education,PX97112,CDM,420,RC,97112,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,26.52,percent of total billed charges,66.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.95,215.05
Neuromuscular Re-Education,PX97112,CDM,420,RC,97112,CPT,,,,,,,,135,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,66.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.95,215.05
Neuromuscular Re-Education,PX97112,CDM,420,RC,97112,CPT,,,,,,,,135,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,66.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.95,215.05
Self Care Mngment Training,PX97535,CDM,420,RC,97535,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,66.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.27,132.3
Self Care Mngment Training,PX97535,CDM,420,RC,97535,CPT,,,,,,,,135,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,66.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.27,132.3
Self Care Mngment Training,PX97535,CDM,420,RC,97535,CPT,,,,,,,,135,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,66.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.27,132.3
Skilled Srvc of a Lpn in Training and/or Education of Pt or Fam Ea 15 Min,PXG0496,CDM,551,RC,G0496,HCPCS,,,,,,,,75,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,66.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
Skilled srvc of an RN in training and/or education of pt or fam ea 15 min,PXG0495,CDM,551,RC,G0495,HCPCS,,,,,,,,75,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,66.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
Therapeutic Activities,PX97530,CDM,420,RC,97530,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,27.93740741,percent of total billed charges,66.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.22,205.7
Therapeutic Activities,PX97530,CDM,420,RC,97530,CPT,,,,,,,,135,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,66.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.22,205.7
Therapeutic Activities,PX97530,CDM,420,RC,97530,CPT,,,,,,,,135,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,66.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.22,205.7
Therapeutic Exercises,PX97110,CDM,420,RC,97110,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,30.00714854,percent of total billed charges,66.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20,215.05
Therapeutic Exercises,PX97110,CDM,420,RC,97110,CPT,,,,,,,,135,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,66.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20,215.05
Therapeutic Exercises,PX97110,CDM,420,RC,97110,CPT,,,,,,,,135,,United Healthcare,All Medicare advantage plans,outpatient,49,,58.08348837,percent of total billed charges,66.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20,215.05
Ultrasound Therapy,PX97035,CDM,420,RC,97035,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,32.28717949,percent of total billed charges,66.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,132.3
Ultrasound Therapy,PX97035,CDM,420,RC,97035,CPT,,,,,,,,135,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,66.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,132.3
Ultrasound Therapy,PX97035,CDM,420,RC,97035,CPT,,,,,,,,135,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,66.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,132.3
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331601,NDC,10,ML,77.86,,First Health,Commercial,both,85,,999999999,percent of total billed charges,66.181,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
triamcinolone acetonide 40 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029320,NDC,1,ML,72.65,,Medica,Commercial,both,91.1,,1.066666667,percent of total billed charges,66.18415,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,72.0986
"Flour. Afstain , Micro - Ref",PX8720690,CDM,300,RC,87206,CPT,90,,,,,,,68,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,66.1844,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.94,66.64
Hemoglobin,PX85018,CDM,300,RC,85018,CPT,,,,,,,,68,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,31.9925,percent of total billed charges,66.1844,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.17,66.64
Thyroglobulin - Ref,PX8443290,CDM,300,RC,84432,CPT,90,,,,,,,68,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,66.1844,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.73,66.64
Thyroglobulin Antibody,PX8680090,CDM,300,RC,86800,CPT,90,,,,,,,68,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,66.1844,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.59,66.64
"Infectious Disease,Chronic Hep C Virus,Six Assays, Utilizing Serum",PX8159690,CDM,300,RC,81596,CPT,90,,,,,,,609,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,66.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.19,596.82
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,58602060407,NDC,100,GR,67.56,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,66.2088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
terbinafine 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714079501,NDC,1,EA,68.03,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,66.213599,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
octreotide 200 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037805,NDC,1,ML,133.77,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,66.21615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,574722612,NDC,1,EA,67.57,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,66.2186,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.345782,66.2186
terbinafine 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714050101,NDC,1,EA,68.04,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,66.223332,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,16714076901,NDC,15,GR,137.99,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,66.2352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,16714076901,NDC,15,GR,137.99,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,66.2352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Noninvasv Oxygen Satur;Single,PX94760,CDM,460,RC,94760,CPT,,,,,,,,131,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,66.286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.4174,128.38
Ceruloplasmin - Ref,PX8239090,CDM,300,RC,82390,CPT,90,,,,,,,78,,First Health,Commercial,both,85,,999999999,percent of total billed charges,66.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,76.44
Chemiluminescent Assay - Ref,PX8239790,CDM,300,RC,82397,CPT,90,,,,,,,78,,First Health,Commercial,both,85,,999999999,percent of total billed charges,66.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.95,76.44
VISUALIZATION SYSTEM CLEARIFY LAPAROSCOPE STERILE,27200000,CDM,272,RC,,,,11875-MAIN,LOCAL,,,,,78,,First Health,Commercial,both,85,,999999999,percent of total billed charges,66.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
aspirin-dipyridamole 25-200 MG Capsule Extended Release 12 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687030533,NDC,1,EA,67.66,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,66.3068,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
aspirin-dipyridamole 25-200 MG Capsule Extended Release 12 Hour 20 Each Box,63700001,CDM,250,RC,,,,,,60687030532,NDC,1,EA,67.66,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,66.3068,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094310,NDC,10,ML,72.79,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,66.31169,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.236966,143.9032
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094321,NDC,10,ML,72.79,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,66.31169,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.236966,143.9032
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,69315030615,NDC,15,GR,131.07,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,66.32142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
solifenacin 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50228042730,NDC,1,EA,74.52,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,66.3228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,574200815,NDC,15,GR,154.63,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,66.33627,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337501,NDC,50,ML,135.43,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,7.983333333,percent of total billed charges,66.3607,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337501,NDC,50,ML,135.43,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,66.3607,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337501,NDC,50,ML,135.43,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,66.3607,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337502,NDC,50,ML,135.43,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,7.983333333,percent of total billed charges,66.3607,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337502,NDC,50,ML,135.43,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,66.3607,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337502,NDC,50,ML,135.43,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,66.3607,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9678001,NDC,50,ML,135.43,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,7.983333333,percent of total billed charges,66.3607,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9678001,NDC,50,ML,135.43,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,66.3607,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9678001,NDC,50,ML,135.43,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,66.3607,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018200,NDC,10,ML,68.21,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,66.388793,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.24,991.564
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018210,NDC,10,ML,68.21,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,66.388793,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.24,991.564
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409751716,NDC,50,ML,72.9,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,66.4119,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098121,NDC,1,EA,72.95,,Medica,Commercial,both,91.1,,5.442333333,percent of total billed charges,66.45745,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
Ex for Speech Device Rx Addl,PX92608,CDM,444,RC,92608,CPT,,,,,,,,160,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,66.464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.95,156.8
Abd Paracentesis,PX49082F,CDM,510,RC,49082,CPT,,,,,,,,884,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,66.4677,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.5,439.29
"Sigmoidoscopy,Biopsy",PX45331F,CDM,750,RC,45331,CPT,,,,,,,,1776,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,66.4677,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.5,593.56
"Sigmoidoscopy,Biopsy",PX45331P,CDM,983,RC,45331,CPT,,,,,,,,1316,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,66.4677,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.5,1289.68
fluconazole 150 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,16714069210,NDC,1,EA,72.98,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,66.48478,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CYSTOSCOPY PACK I STERILE,120.505,CDM,272,RC,,,,4527-MAIN,LOCAL,,,,,155,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,66.495,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,151.9
"Lab Antibody ID,RBC",PX7605,CDM,300,RC,86870,CPT,,,,,,,,155,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,66.495,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,314.02
"Office/Outpt Visit,Est,Levl II",PX99212F,CDM,510,RC,99212,CPT,,,,,,,,155,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,66.495,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,151.9
"Office/Outpt Visit,Est,Levl II",PX99212P,CDM,983,RC,99212,CPT,,,,,,,,155,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,66.495,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,150.8615
Smear Fluorescent/Acid Stai,PX87206,CDM,300,RC,87206,CPT,,,,,,,,155,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,66.495,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.94,151.9
TB Test Enumeration of T-Cells - Ref,PX8648190,CDM,300,RC,86481,CPT,90,,,,,,,155,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,66.495,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,151.9
BALLOON EXTRACTOR PEDS,120.358,CDM,272,RC,,,,10771-MAIN,LOCAL,,,,,73,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,66.503,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.3242,71.54
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050601,NDC,1,ML,68.33,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1.579660194,percent of total billed charges,66.505589,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010520,NDC,1,EA,68.33,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,12.385,percent of total billed charges,66.505589,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010541,NDC,1,EA,68.33,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,12.385,percent of total billed charges,66.505589,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
pramox-PE-glycerin-petrolatum 1-0.25-14.4-15 % Cream 51 g Tube,63700001,CDM,250,RC,,,,,,573286898,NDC,51,GR,68.34,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,66.515322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039801,NDC,1,EA,67.88,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,66.5224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039810,NDC,1,EA,67.88,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,66.5224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,66.5224
Remove Foreign Body Simple,PX10120F,CDM,510,RC,10120,CPT,,,,,,,,404,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,66.53,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.53,317.54
Remove Foreign Body Simple,PX10120P,CDM,983,RC,10120,CPT,,,,,,,,404,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,66.53,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.53,395.92
LAP KIT BASIC,27200000,CDM,272,RC,,,,4829-MAIN,LOCAL,,,,,78.29,,First Health,Commercial,both,85,,999999999,percent of total billed charges,66.5465,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004703,NDC,1,EA,75.45,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,66.5469,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004725,NDC,2,ML,131.52,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,66.54912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457000100,NDC,10,ML,68.38,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,11.07921788,percent of total billed charges,66.554254,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
droPERidol 2.5 MG/ML Solution 2 mL Vial,J1790.01,CDM,636,RC,J1790,HCPCS,,,,517970201,NDC,2,ML,75.47,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,66.56454,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.350238,73.9606
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,63323050830,NDC,1,EA,134.48,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,66.5676,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.461584,189.875
RETRIEVAL BAG 10MM,27200000,CDM,272,RC,,,,11707-MAIN,LOCAL,,,,,74.8,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,66.572,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046837,NDC,30,ML,75.54,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,66.62628,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,69543025204,NDC,118,ML,78.39,,First Health,Commercial,both,85,,999999999,percent of total billed charges,66.6315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Flour. Afstain , Micro - Ref",PX8720690,CDM,300,RC,87206,CPT,90,,,,,,,68,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,66.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.94,66.64
Hemoglobin,PX85018,CDM,300,RC,85018,CPT,,,,,,,,68,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,66.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.17,66.64
Thyroglobulin - Ref,PX8443290,CDM,300,RC,84432,CPT,90,,,,,,,68,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,66.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.73,66.64
Thyroglobulin Antibody,PX8680090,CDM,300,RC,86800,CPT,90,,,,,,,68,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,66.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.59,66.64
terbinafine 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714079501,NDC,1,EA,68.03,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,66.6694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
terbinafine 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714050101,NDC,1,EA,68.04,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,66.6792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,703115301,NDC,4,ML,136.1,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,66.689,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,703115301,NDC,4,ML,136.1,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,66.689,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,703115301,NDC,4,ML,136.1,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,66.689,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
enalaprilat 1.25 MG/ML Injectable 2 mL Vial,25000000,CDM,250,RC,,,,,,143978601,NDC,2,ML,75.63,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,66.70566,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tranexamic acid 1000 mg in 100 mL 0.7% sodium chloride (premix) 1000-0.7 MG/100ML-% Solution 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,80830232901,NDC,100,ML,155.55,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,66.73095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,24208031510,NDC,10,ML,75.67,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,66.74094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Art Upper Extremity-Ltd,PX9393101,CDM,921,RC,93931,CPT,TC,,,,,,,718,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,66.75,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.75,175.67
Aspirate Pleura W/ Imaging,PX32555F,CDM,761,RC,32555,CPT,,,,,,,,795,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,66.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.75,646.83
Aspirate Pleura W/ Imaging,PX32555F,CDM,761,RC,32555,CPT,,,,,,,,795,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,66.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.75,646.83
Aspirate Pleura W/ Imaging,PX32555P,CDM,983,RC,32555,CPT,,,,,,,,536,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,66.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.75,646.83
Aspirate Pleura W/ Imaging,PX32555P,CDM,983,RC,32555,CPT,,,,,,,,536,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,66.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.75,646.83
Assay Cryofibrinogen,PX82585,CDM,300,RC,82585,CPT,,,,,,,,75,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,66.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.96,73.5
Assay Cryoglobulin,PX82595,CDM,300,RC,82595,CPT,,,,,,,,75,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,66.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,73.5
BINDER ABDOMINAL 9 INCH 46 TO 62 INCH XL ORT21100LXL,120.238,CDM,271,RC,A4467,HCPCS,,2989-MAIN,LOCAL,,,,,75,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,66.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL 9 INCH 63 TO 74 INCH 3- PANEL ORT211002XL,120.238,CDM,271,RC,A4467,HCPCS,,37-MAIN,LOCAL,,,,,75,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,66.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL 10 INCH 26 TO 50 INCHES ABB1050,120.238,CDM,271,RC,A4467,HCPCS,,52-MAIN,LOCAL,,,,,75,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,66.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
"BINDER ABDOMINAL 12"" HIGH 2XL 60-75INCH 4 PANEL ORT213002XL",120.238,CDM,271,RC,A4467,HCPCS,,12536-MAIN,LOCAL,,,,,75,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,66.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL UNISIZE 46-62IN 9 IN MDS169024,120.238,CDM,271,RC,A4467,HCPCS,,63-MAIN,LOCAL,,,,,75,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,66.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
"Direct skilled nursing services of a license practical nurse (lpn) in the home health or hospice setting, each 15 minutes",PXG0300,CDM,551,RC,G0300,HCPCS,,,,,,,,75,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,66.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
HH Rn Initial Visit,PXG0154,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,66.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
HH Rn Routine Visit,PXG0154.01,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,66.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
Skilled Srvc of a Lpn in Training and/or Education of Pt or Fam Ea 15 Min,PXG0496,CDM,551,RC,G0496,HCPCS,,,,,,,,75,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,66.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
Skilled srvc of an RN in training and/or education of pt or fam ea 15 min,PXG0495,CDM,551,RC,G0495,HCPCS,,,,,,,,75,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,66.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
TRAY SURGICAL PODIATRY II EXTREMITY DYNJS0803,27200000,CDM,272,RC,,,,10920-MAIN,LOCAL,,,,,73.29,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,66.76719,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"BUPivacaine 0.25%-EPINEPHrine 1:200,000 0.25% -1:200000 Solution 50 mL Vial",25000000,CDM,250,RC,,,,,,409175250,NDC,30,ML,68.6,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,66.76838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989001,NDC,50,ML,160.78,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,66.788012,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989002,NDC,50,ML,160.78,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,66.788012,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
Apply of Paste Boot,PX29580F,CDM,510,RC,29580,CPT,,,,,,,,132,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,66.792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,137.65
Assay Dipropylacetic Acid,PX80164,CDM,300,RC,80164,CPT,,,,,,,,132,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,66.792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.41,129.36
Assay of Lipase,PX83690,CDM,300,RC,83690,CPT,,,,,,,,132,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,66.792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.32,129.36
"Remv F.B.,Eye,Superf Conjunc",PX65205F,CDM,510,RC,65205,CPT,,,,,,,,132,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,66.792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,129.36
"Remv F.B.,Eye,Superf Conjunc",PX65205P,CDM,983,RC,65205,CPT,,,,,,,,132,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,66.792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,128.4756
"Venipunc Need Phys Skill,Dx or Rx",PX36410,CDM,983,RC,36410,CPT,,,,,,,,132,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,66.792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,128.4756
levothyroxine Sodium 200 MCG Recon Soln 1 Each Vial,J0650.01,CDM,636,RC,J0650,HCPCS,,,,63323064710,NDC,0.0625,EA,75.75,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,66.8115,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.46655,74.235
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,63739005007,NDC,1,EA,73.35,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,66.82185,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Cognitive Funct Ther Interv, per Day",PX97127,CDM,420,RC,97127,CPT,,,,,,,,135,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,66.825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.079,132.3
Electric Stimulation Therapy,PX97014,CDM,420,RC,97014,CPT,,,,,,,,135,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,66.825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.18,132.3
Electrical Stimulation,PX97032,CDM,420,RC,97032,CPT,,,,,,,,135,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,66.825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,132.3
Gait Training Therapy,PX97116,CDM,420,RC,97116,CPT,,,,,,,,135,,Humana Choice Care,All Medicare plans,outpatient,49.5,,56.89,percent of total billed charges,66.825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20,132.3
"Manual Ther Tech,1+Regions,Ea 15 Min",PX97140,CDM,420,RC,97140,CPT,,,,,,,,135,,Humana Choice Care,All Medicare plans,outpatient,49.5,,40.9647541,percent of total billed charges,66.825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.4,215.05
Mechanical Traction Therapy,PX97012,CDM,420,RC,97012,CPT,,,,,,,,135,,Humana Choice Care,All Medicare plans,outpatient,49.5,,27.072,percent of total billed charges,66.825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,132.3
Neuromuscular Re-Education,PX97112,CDM,420,RC,97112,CPT,,,,,,,,135,,Humana Choice Care,All Medicare plans,outpatient,49.5,,56.89,percent of total billed charges,66.825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.95,215.05
Self Care Mngment Training,PX97535,CDM,420,RC,97535,CPT,,,,,,,,135,,Humana Choice Care,All Medicare plans,outpatient,49.5,,55.373,percent of total billed charges,66.825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.27,132.3
Therapeutic Activities,PX97530,CDM,420,RC,97530,CPT,,,,,,,,135,,Humana Choice Care,All Medicare plans,outpatient,49.5,,42.21714286,percent of total billed charges,66.825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.22,205.7
Therapeutic Exercises,PX97110,CDM,420,RC,97110,CPT,,,,,,,,135,,Humana Choice Care,All Medicare plans,outpatient,49.5,,42.65327731,percent of total billed charges,66.825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20,215.05
Ultrasound Therapy,PX97035,CDM,420,RC,97035,CPT,,,,,,,,135,,Humana Choice Care,All Medicare plans,outpatient,49.5,,17.69,percent of total billed charges,66.825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,132.3
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,16714081701,NDC,1,EA,75.78,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,66.83796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylene blue 1 % Solution 10 mL Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,54288014701,NDC,1,ML,139.25,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,66.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.29,1354.4776
methylene blue 1 % Solution 10 mL Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,54288014701,NDC,1,ML,139.25,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,66.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.29,1354.4776
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018200,NDC,10,ML,68.21,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,66.8458,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.24,991.564
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018210,NDC,10,ML,68.21,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,66.8458,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.24,991.564
Catheterize for Urine Spec,PXP9612,CDM,300,RC,P9612,HCPCS,,,,,,,,161,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,66.8794,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.1,157.78
Drain/Inject Small Joint/Bursa,PX20600F,CDM,510,RC,20600,CPT,,,,,,,,161,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,66.8794,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.8794,258.75
Drain/Inject Small Joint/Bursa,PX20600P,CDM,983,RC,20600,CPT,,,,,,,,161,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,66.8794,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.8794,258.75
Each Add'l Hour IV Infusion <8 Hour,PX96366,CDM,260,RC,96366,CPT,,,,,,,,161,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,66.8794,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,157.78
C-COLLAR ASPEN REGULAR 79-83365,120.25,CDM,274,RC,L0140,HCPCS,,167-MAIN,LOCAL,,,,,216,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,66.91,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.91,70.43
C-COLLAR ASPEN TALL 79-83367,120.25,CDM,274,RC,L0140,HCPCS,,164-MAIN,LOCAL,,,,,216,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,66.91,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.91,70.43
C-COLLAR ASPEN X-TALL 79-83368,120.25,CDM,274,RC,L0140,HCPCS,,168-MAIN,LOCAL,,,,,216,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,66.91,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.91,70.43
Assay Blood Carbon Monoxide,PX82375,CDM,300,RC,82375,CPT,,,,,,,,156,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,66.924,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.3,152.88
"Cortisol, Am",PX7152,CDM,300,RC,82533,CPT,,,,,,,,156,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,66.924,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.95,152.88
DERMABOND PRINEO SKIN CLOSURE SYSTEM 22CM,27200000,CDM,272,RC,,,,12324-MAIN,LOCAL,,,,,156,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,66.924,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050601,NDC,1,ML,68.33,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,66.9634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,66.9634
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010520,NDC,1,EA,68.33,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,66.9634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010541,NDC,1,EA,68.33,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,66.9634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
pramox-PE-glycerin-petrolatum 1-0.25-14.4-15 % Cream 51 g Tube,63700001,CDM,250,RC,,,,,,573286898,NDC,51,GR,68.34,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,66.9732,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042350,NDC,0.5,ML,132.37,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,66.97922,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.49,129.7226
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042388,NDC,0.5,ML,132.37,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,66.97922,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.49,129.7226
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457000100,NDC,10,ML,68.38,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,67.0124,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
triamcinolone acetonide 40 MG/ML Suspension 1 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029305,NDC,1,ML,73.57,,Medica,Commercial,both,91.1,,1.066666667,percent of total billed charges,67.02227,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,72.0986
Assay of Blood Lipoprotein,PX83721,CDM,300,RC,83721,CPT,,,,,,,,76,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,67.032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.63,74.48
Lab Direct Coombs,PX86880,CDM,300,RC,86880,CPT,,,,,,,,76,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,67.032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.5704,74.48
PRONEVIEW CUSHION INSERTS LARGE,120.557,CDM,272,RC,E0190,HCPCS,,12500-MAIN,LOCAL,,,,,76,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,67.032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.5704,74.48
SHOE POST OP LARGE MALE MQM3B,120.237,CDM,274,RC,L3260,HCPCS,,794-MAIN,LOCAL,,,,,76,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,67.032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP LARGE SQUARE TOE WOMENS ORT30300WL,120.237,CDM,274,RC,L3260,HCPCS,,10606-MAIN,LOCAL,,,,,76,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,67.032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP MEDIUM SQUARE TOE MALE ORT30300MM,120.237,CDM,274,RC,L3260,HCPCS,,10603-MAIN,LOCAL,,,,,76,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,67.032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP MEDIUM SQUARE TOE WOMENS ORT30300WM,120.237,CDM,274,RC,L3260,HCPCS,,10605-MAIN,LOCAL,,,,,76,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,67.032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP SMALL MALE 0814-1192,120.237,CDM,274,RC,L3260,HCPCS,,803-MAIN,LOCAL,,,,,76,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,67.032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP SMALL SQUARE TOE WOMENS MQW1B,120.237,CDM,274,RC,L3260,HCPCS,,10604-MAIN,LOCAL,,,,,76,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,67.032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337501,NDC,50,ML,135.43,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,67.03785,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337502,NDC,50,ML,135.43,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,67.03785,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9678001,NDC,50,ML,135.43,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,67.03785,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
sodium phosphate 15 MMOLE/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323088401,NDC,5,ML,132.6,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,67.0956,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium phosphate 15 MMOLE/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323088406,NDC,5,ML,132.6,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,67.0956,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Drain Blood From Under Nail,PX11740F,CDM,510,RC,11740,CPT,,,,,,,,117,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,67.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.28,120.37
Remove Impacted Ear Wax,PX69210F,CDM,510,RC,69210,CPT,,,,,,,,213,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,67.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.06,99.62
Remove Impacted Ear Wax,PX69210P,CDM,983,RC,69210,CPT,,,,,,,,221,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,67.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.06,216.58
sodium polystyrene sulfonate Powder 15 g Bottle,25000000,CDM,250,RC,,,,,,10702003615,NDC,15,GR,76.09,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,67.11138,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
betamethasone acetate-betamethasone sodium phosphate 6 (3-3) MG/ML Suspension 5 mL Vial,J0702.01,CDM,636,RC,J0702,HCPCS,,,,517072001,NDC,1,ML,78.96,,First Health,Commercial,both,85,,999999999,percent of total billed charges,67.116,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.799984,77.3808
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024110,NDC,1,EA,76.1,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,67.1202,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032056,NDC,1,EA,68.97,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,13.11107143,percent of total billed charges,67.128501,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
Total Cortisol,PX82533,CDM,300,RC,82533,CPT,,,,,,,,137,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,67.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.95,134.26
Total Cortisol,PX82533,CDM,300,RC,82533,CPT,,,,,,,,137,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,67.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.95,134.26
Total Cortisol,PX82533,CDM,300,RC,82533,CPT,,,,,,,,137,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,67.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.95,134.26
"Triiodothyronine T3, Free (Free T3)",PX84481,CDM,300,RC,84481,CPT,,,,,,,,137,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,67.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.53,134.26
"Triiodothyronine T3, Free (Free T3)",PX84481,CDM,300,RC,84481,CPT,,,,,,,,137,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,67.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.53,134.26
"Triiodothyronine T3, Free (Free T3)",PX84481,CDM,300,RC,84481,CPT,,,,,,,,137,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,67.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.53,134.26
Everolimus,PX8016990,CDM,300,RC,80169,CPT,,,,,,,,79,,First Health,Commercial,both,85,,999999999,percent of total billed charges,67.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,77.42
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004703,NDC,1,EA,75.45,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,67.1505,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
Assay Bld/Serum Cholesterol,PX82465,CDM,300,RC,82465,CPT,,,,,,,,69,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,67.1577,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.99,67.62
"Astrazeneca Covid-19 Vaccine, Administration, 1st Dose",PX0021A,CDM,771,RC,,,,,,,,,,69,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,67.1577,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Astrazeneca Covid-19 Vaccine, Adminstration, 2nd Dose",PX0022A,CDM,771,RC,,,,,,,,,,69,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,67.1577,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Janssen Covid-19 Vaccine, Administration",PX0031A,CDM,771,RC,0031A,HCPCS,,,,,,,,69,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,67.1577,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 1st Dose",PX0011A,CDM,771,RC,0011A,HCPCS,,,,,,,,69,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,67.1577,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 2nd Dose",PX0012A,CDM,771,RC,0012A,HCPCS,,,,,,,,69,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,67.1577,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 3rd Dose",PX0013A,CDM,771,RC,0013A,HCPCS,,,,,,,,69,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,67.1577,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
Novavax Covid-19 Vaccine Administration 1st Dose,PX0041A,CDM,771,RC,0041A,HCPCS,,,,,,,,69,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,67.1577,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
Novavax Covid-19 Vaccine Administration 2nd Dose,PX0042A,CDM,771,RC,0042A,HCPCS,,,,,,,,69,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,67.1577,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Pfizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 2nd Dose",PX0002A,CDM,771,RC,0002A,HCPCS,,,,,,,,69,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,67.1577,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Pfizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 3rd Dose",PX0003A,CDM,771,RC,0003A,HCPCS,,,,,,,,69,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,67.1577,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Pifizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 1st Dose",PX0001A,CDM,771,RC,0001A,HCPCS,,,,,,,,69,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,67.1577,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
magnesium sulfate 4 GM/50ML Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010701,NDC,50,ML,73.72,,Medica,Commercial,both,91.1,,6.305,percent of total billed charges,67.15892,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,47781046813,NDC,1,EA,76.15,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,67.1643,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,64380079701,NDC,1,EA,76.15,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,67.1643,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
droPERidol 2.5 MG/ML Solution 2 mL Vial,J1790.01,CDM,636,RC,J1790,HCPCS,,,,517970201,NDC,2,ML,75.47,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,67.1683,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.350238,73.9606
Art Upper Extremity-Ltd,PX9393101,CDM,921,RC,93931,CPT,TC,,,,,,,718,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,67.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.75,175.67
Art Upper Extremity-Ltd,PX9393101,CDM,921,RC,93931,CPT,TC,,,,,,,718,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,67.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.75,175.67
Aspirate Pleura W/ Imaging,PX32555F,CDM,761,RC,32555,CPT,,,,,,,,795,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,67.19,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.75,646.83
Aspirate Pleura W/ Imaging,PX32555P,CDM,983,RC,32555,CPT,,,,,,,,536,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,67.19,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.75,646.83
Drain Pilonidal Cyst Simpl,PX10080F,CDM,510,RC,10080,CPT,,,,,,,,742,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,67.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.88,521.62
Drain Pilonidal Cyst Simpl,PX10080F,CDM,510,RC,10080,CPT,,,,,,,,742,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,67.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.88,521.62
"Ex Sknbngn0.6-1cmtrnk,Arm,Lg",PX11401P,CDM,983,RC,11401,CPT,,,,,,,,387,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,67.19,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.19,379.26
"Fac/Ex Skinbngn0.6-1cmtrnk,Arm,Lg",PX11401F,CDM,510,RC,11401,CPT,,,,,,,,484,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,67.19,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.19,325.84
TISSUE RETRIEVAL SYSTEM,27200000,CDM,272,RC,,,,10233-MAIN,LOCAL,,,,,139.98,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,67.1904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TISSUE RETRIEVAL SYSTEM,27200000,CDM,272,RC,,,,10233-MAIN,LOCAL,,,,,139.98,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,67.1904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Neg Pressure Wound Therapy Dme >50 Sq Cm,PX97606F,CDM,761,RC,97606,CPT,,,,,,,,404,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,67.21,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.75,67.21
levoFLOXacin 250 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635161,NDC,1,EA,79.08,,First Health,Commercial,both,85,,999999999,percent of total billed charges,67.218,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"BUPivacaine 0.25%-EPINEPHrine 1:200,000 0.25% -1:200000 Solution 50 mL Vial",25000000,CDM,250,RC,,,,,,409175250,NDC,30,ML,68.6,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,67.228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046837,NDC,30,ML,75.54,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,67.2306,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,24208046325,NDC,2.5,ML,137.26,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,67.2574,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,24208046325,NDC,2.5,ML,137.26,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,67.2574,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,24208046325,NDC,2.5,ML,137.26,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,67.2574,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
caffeine citrate 60 MG/3ML Solution 3 mL Vial,J0706.01,CDM,636,RC,J0706,HCPCS,,,,63323040704,NDC,3,ML,73.84,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,67.26824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.673136,72.3632
F5 Gene - Ref,PX8124190,CDM,300,RC,81241,CPT,90,,,,,,,112,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,67.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,409508411,NDC,1,EA,73.86,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,67.28646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
Acetone Assay,PX82010,CDM,300,RC,82010,CPT,,,,,,,,162,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,67.2948,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.49,158.76
"Flow Interp,2-8 Markers - Ref",PX8818790,CDM,310,RC,88187,CPT,90,,,,,,,162,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,67.2948,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.1,158.76
KIT THORACENTESIS PLEURA SEAL AK-01000-T,120.24,CDM,272,RC,,,,1147-MAIN,LOCAL,,,,,162,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,67.2948,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.2948,158.76
doxycycline 100 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323013041,NDC,1,EA,140.2,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,67.296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
doxycycline 100 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323013041,NDC,1,EA,140.2,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,67.296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Cardiolipin Ab, Ea Lg - Ref",PX8614790,CDM,300,RC,86147,CPT,90,,,,,,,133,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,67.298,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.34,130.34
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU0003,CDM,300,RC,U0003,HCPCS,,,,,,,,133,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,67.298,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.2482,130.34
Lvl 1 Sub Hosp Low Mdm or 25 Minutes,PX99231,CDM,982,RC,99231,CPT,,,,,,,,133,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,67.298,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.2482,129.4489
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012365,NDC,0.7,ML,291.98,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,67.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012388,NDC,0.7,ML,291.98,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,67.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072310,NDC,0.5,ML,291.98,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,67.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072388,NDC,0.5,ML,291.98,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,67.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
isatuximab-irfc 500 MG/25ML Solution 25 mL Vial,J9227.01,CDM,636,RC,J9227,HCPCS,,,,24065601,NDC,25,ML,7876.36,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,67.31,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.31,80.32
enalaprilat 1.25 MG/ML Injectable 2 mL Vial,25000000,CDM,250,RC,,,,,,143978601,NDC,2,ML,75.63,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,67.3107,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,517095501,NDC,0.25,EA,69.19,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,67.342627,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86,213.6008
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,24208031510,NDC,10,ML,75.67,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,67.3463,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Assay of Psa Total,PX84153,CDM,300,RC,84153,CPT,,,,,,,,157,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,67.353,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.86,153.86
"Chlamydia Trachomatis Dna, Amp Probe",PX87491,CDM,300,RC,87491,CPT,,,,,,,,157,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,67.353,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,153.86
"Cognitive Skill Dev, Ea 15 Min",PX97532,CDM,420,RC,97532,CPT,,,,,,,,157,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,67.353,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.2178,153.86
"Fungal Culture, Other Source - Ref",PX8710290,CDM,300,RC,87102,CPT,90,,,,,,,157,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,67.353,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.71,153.86
Lactate (Ld) (Ldh) Enzyme,PX83615,CDM,300,RC,83615,CPT,,,,,,,,157,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,67.353,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.54,153.86
"Neisseria Gonorrhoeae Dna, Amp Probe",PX87591,CDM,300,RC,87591,CPT,,,,,,,,157,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,67.353,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,153.86
Psa Screening,PXG0103,CDM,300,RC,G0103,HCPCS,,,,,,,,157,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,67.353,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.71,153.86
Remv Ext Canal Foreign Body,PX69200P,CDM,983,RC,69200,CPT,,,,,,,,157,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,67.353,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.2178,152.8081
methylergonovine 0.2 MG/ML Solution 1 mL Ampule,J2210.01,CDM,636,RC,J2210,HCPCS,,,,51991014417,NDC,1,ML,133.11,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,67.35366,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.293894,130.4478
hepatitis b recomb vaccine 10 MCG/0.5ML suspension prefilled syringe 0.5 mL Syringe,90743,CDM,636,RC,90743,CPT,,,,58160082052,NDC,0.5,ML,137.47,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,67.3603,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.105038,134.7206
hepatitis b recomb vaccine 10 MCG/0.5ML suspension prefilled syringe 0.5 mL Syringe,90743,CDM,636,RC,90743,CPT,,,,58160082052,NDC,0.5,ML,137.47,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,67.3603,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.105038,134.7206
hepatitis b recomb vaccine 10 MCG/0.5ML suspension prefilled syringe 0.5 mL Syringe,90743,CDM,636,RC,90743,CPT,,,,58160082052,NDC,0.5,ML,137.47,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,67.3603,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.105038,134.7206
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,703115301,NDC,4,ML,136.1,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,67.3695,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059900,NDC,1,ML,133.16,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,67.37896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.54253,130.4968
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059902,NDC,1,ML,133.16,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,67.37896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.54253,130.4968
ampicillin-sulbactam 1.5 (1-0.5) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001381,NDC,1,EA,69.24,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,58.74,percent of total billed charges,67.391292,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
Cyto Non Gyn,PX8811201,CDM,310,RC,88112,CPT,TC,,,,,,,372,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,67.392,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.14,67.392
Cyto Non Gyn,PX8811201,CDM,310,RC,88112,CPT,TC,,,,,,,372,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,67.392,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.14,67.392
"Cardioversion, Elective;Extern",PX92960F,CDM,480,RC,92960,CPT,,,,,,,,402,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,67.41,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.41,267
"Cardioversion, Elective;Extern",PX92960P,CDM,983,RC,92960,CPT,,,,,,,,688,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,67.41,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.41,674.24
Drain Skin Abscess Simple,PX10060F,CDM,510,RC,10060,CPT,,,,,,,,296,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,67.41,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.41,264.96
Drain Skin Abscess Simple,PX10060P,CDM,983,RC,10060,CPT,,,,,,,,293,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,67.41,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.41,287.14
Glucose Test,PX82950,CDM,300,RC,82950,CPT,,,,,,,,74,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,67.414,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.36,72.52
KIT EMERGENCY BIRTH DYNJS0600,120.317,CDM,272,RC,,,,8344-MAIN,LOCAL,,,,,74,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,67.414,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.7396,72.52
Rubeola Antibody,PX86765,CDM,300,RC,86765,CPT,,,,,,,,74,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,67.414,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.81,72.52
levothyroxine Sodium 200 MCG Recon Soln 1 Each Vial,J0650.01,CDM,636,RC,J0650,HCPCS,,,,63323064710,NDC,0.0625,EA,75.75,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,67.4175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.46655,74.235
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,16714081701,NDC,1,EA,75.78,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,67.4442,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047621,NDC,1,ML,157.28,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,67.47312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.354486,332.1514
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409338513,NDC,1,EA,74.09,,Medica,Commercial,both,91.1,,5.442333333,percent of total billed charges,67.49599,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,51672131200,NDC,22,GR,140.7,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,67.536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,51672131200,NDC,22,GR,140.7,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,67.536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Apply Long Leg Cast,PX29345F,CDM,510,RC,29345,CPT,,,,,,,,912,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,67.56,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.29,285.71
Ultrasound Breast Complete,PX7664101,CDM,402,RC,76641,CPT,TC,,,,,,,333,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,67.578,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.59,134.77
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329333901,NDC,10,ML,79.51,,First Health,Commercial,both,85,,999999999,percent of total billed charges,67.5835,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
calcium CHLORIDE 10 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,76329330401,NDC,10,ML,79.51,,First Health,Commercial,both,85,,999999999,percent of total billed charges,67.5835,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,25021018482,NDC,100,ML,79.51,,First Health,Commercial,both,85,,999999999,percent of total billed charges,67.5835,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.786918,140.5516
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915850,NDC,0.2,ML,69.44,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,67.585952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032056,NDC,1,EA,68.97,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,67.5906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
menthol-zinc oxide Paste 113 g Tube,63700001,CDM,250,RC,,,,,,53329016544,NDC,113,GR,79.52,,First Health,Commercial,both,85,,999999999,percent of total billed charges,67.592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
alteplase 1 MG/ML Solution 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,8888800497,NDC,1,EA,21140.86,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,67.6,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.6,88.97
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004110,NDC,1,EA,666.53,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,67.6,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.6,88.97
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004164,NDC,1,EA,666.52,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,67.6,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.6,88.97
alteplase 100 MG Recon Soln 1 Each Syringe,J2997.01,CDM,636,RC,J2997,HCPCS,,,,88888800475,NDC,0.09,EA,1920.88,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,67.6,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.6,88.97
alteplase 100 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242008527,NDC,1,EA,21140.86,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,67.6,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.6,88.97
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,16714076901,NDC,15,GR,137.99,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,67.6151,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,16714076901,NDC,15,GR,137.99,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,67.6151,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,16714076901,NDC,15,GR,137.99,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,67.6151,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay Bld/Serum Cholesterol,PX82465,CDM,300,RC,82465,CPT,,,,,,,,69,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,67.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.99,67.62
"Astrazeneca Covid-19 Vaccine, Administration, 1st Dose",PX0021A,CDM,771,RC,,,,,,,,,,69,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,67.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Astrazeneca Covid-19 Vaccine, Adminstration, 2nd Dose",PX0022A,CDM,771,RC,,,,,,,,,,69,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,67.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Cardioversion, Elective;Extern",PX92960F,CDM,480,RC,92960,CPT,,,,,,,,402,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,67.62,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.41,267
"Cardioversion, Elective;Extern",PX92960F,CDM,480,RC,92960,CPT,,,,,,,,402,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,67.62,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.41,267
"Cardioversion, Elective;Extern",PX92960P,CDM,983,RC,92960,CPT,,,,,,,,688,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,67.62,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.41,674.24
"Cardioversion, Elective;Extern",PX92960P,CDM,983,RC,92960,CPT,,,,,,,,688,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,67.62,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.41,674.24
"Janssen Covid-19 Vaccine, Administration",PX0031A,CDM,771,RC,0031A,HCPCS,,,,,,,,69,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,67.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 1st Dose",PX0011A,CDM,771,RC,0011A,HCPCS,,,,,,,,69,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,67.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 2nd Dose",PX0012A,CDM,771,RC,0012A,HCPCS,,,,,,,,69,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,67.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 3rd Dose",PX0013A,CDM,771,RC,0013A,HCPCS,,,,,,,,69,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,67.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
Novavax Covid-19 Vaccine Administration 1st Dose,PX0041A,CDM,771,RC,0041A,HCPCS,,,,,,,,69,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,67.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
Novavax Covid-19 Vaccine Administration 2nd Dose,PX0042A,CDM,771,RC,0042A,HCPCS,,,,,,,,69,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,67.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Pfizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 2nd Dose",PX0002A,CDM,771,RC,0002A,HCPCS,,,,,,,,69,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,67.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Pfizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 3rd Dose",PX0003A,CDM,771,RC,0003A,HCPCS,,,,,,,,69,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,67.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
"Pifizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 1st Dose",PX0001A,CDM,771,RC,0001A,HCPCS,,,,,,,,69,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,67.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.6626,67.62
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034020,NDC,1,EA,76.67,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,67.62294,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034021,NDC,1,EA,76.67,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,67.62294,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,517096010,NDC,10,ML,157.64,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,67.62756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781910572,NDC,0.25,EA,69.49,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,67.634617,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86,213.6008
Assay of Blood Lipoprotein,PX83721,CDM,300,RC,83721,CPT,,,,,,,,76,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,67.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.63,74.48
Lab Direct Coombs,PX86880,CDM,300,RC,86880,CPT,,,,,,,,76,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,67.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.5704,74.48
PRONEVIEW CUSHION INSERTS LARGE,120.557,CDM,272,RC,E0190,HCPCS,,12500-MAIN,LOCAL,,,,,76,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,67.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.5704,74.48
SHOE POST OP LARGE MALE MQM3B,120.237,CDM,274,RC,L3260,HCPCS,,794-MAIN,LOCAL,,,,,76,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,67.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP LARGE SQUARE TOE WOMENS ORT30300WL,120.237,CDM,274,RC,L3260,HCPCS,,10606-MAIN,LOCAL,,,,,76,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,67.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP MEDIUM SQUARE TOE MALE ORT30300MM,120.237,CDM,274,RC,L3260,HCPCS,,10603-MAIN,LOCAL,,,,,76,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,67.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP MEDIUM SQUARE TOE WOMENS ORT30300WM,120.237,CDM,274,RC,L3260,HCPCS,,10605-MAIN,LOCAL,,,,,76,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,67.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP SMALL MALE 0814-1192,120.237,CDM,274,RC,L3260,HCPCS,,803-MAIN,LOCAL,,,,,76,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,67.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP SMALL SQUARE TOE WOMENS MQW1B,120.237,CDM,274,RC,L3260,HCPCS,,10604-MAIN,LOCAL,,,,,76,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,67.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
ciprofloxacin 0.3 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,61314065625,NDC,2.5,ML,140.92,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,67.6416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ciprofloxacin 0.3 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,61314065625,NDC,2.5,ML,140.92,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,67.6416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Aspergillus Ag - Ref,PX8730590,CDM,300,RC,87305,CPT,90,,,,,,,141,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,67.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,138.18
Aspergillus Ag - Ref,PX8730590,CDM,300,RC,87305,CPT,90,,,,,,,141,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,67.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,138.18
octreotide 200 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037805,NDC,1,ML,133.77,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,67.68762,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
Physical Therapy Re-Eval Est Plan Care 20 Mins,PX97164,CDM,424,RC,97164,CPT,,,,,,,,239,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,67.704,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.77,91.81
Ehrlichia (Anaplasma) Ab - Ref,PX8666690,CDM,300,RC,86666,CPT,90,,,,,,,163,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,67.7102,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.33,159.74
Xray Ankle 2 Vws,PX7360001,CDM,320,RC,73600,CPT,TC,,,,,,,163,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,67.7102,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.7102,159.74
"Critical Care, Addl 30 Min",PX99292P,CDM,983,RC,99292,CPT,,,,,,,,542,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,67.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.12,531.16
"Critical Care, Addl 30 Min",PX99292P,CDM,983,RC,99292,CPT,,,,,,,,542,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,67.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.12,531.16
"Facility Critical Care, Addl 30 Min",PX99292F,CDM,510,RC,99292,CPT,,,,,,,,484,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,67.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.12,214.08
"Facility Critical Care, Addl 30 Min",PX99292F,CDM,510,RC,99292,CPT,,,,,,,,484,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,67.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.12,214.08
sodium polystyrene sulfonate Powder 15 g Bottle,25000000,CDM,250,RC,,,,,,10702003615,NDC,15,GR,76.09,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,67.7201,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024110,NDC,1,EA,76.1,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,67.729,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338080304,NDC,1000,ML,69.59,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,4.559571429,percent of total billed charges,67.731947,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990710709,NDC,1000,ML,69.59,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,4.559571429,percent of total billed charges,67.731947,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004824,NDC,150,ML,69.59,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,2.672307692,percent of total billed charges,67.731947,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,47781046813,NDC,1,EA,76.15,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,67.7735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,64380079701,NDC,1,EA,76.15,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,67.7735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Antithrombin III Activity - Ref,PX8530090,CDM,300,RC,85300,CPT,90,,,,,,,158,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,67.782,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.87,154.84
Fac/Trm Hyperkeratotic Skn Lesn2-4,PX11056F,CDM,510,RC,11056,CPT,,,,,,,,158,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,67.782,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.6332,174.9
"Glucose, Body Fluid Other Than Blood",PX82945,CDM,300,RC,82945,CPT,,,,,,,,158,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,67.782,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.6,154.84
Protein C Activity - Ref,PX8530390,CDM,300,RC,85303,CPT,90,,,,,,,158,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,67.782,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.69,154.84
"Triiodothyronine T3, Tot - Ref",PX8448090,CDM,300,RC,84480,CPT,90,,,,,,,158,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,67.782,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13,154.84
acyclovir 50 MG/ML Solution 20 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,63323032524,NDC,20,ML,76.86,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,67.79052,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.927644,105.9968
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,517095501,NDC,0.25,EA,69.19,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,67.8062,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86,213.6008
Total Cortisol,PX82533,CDM,300,RC,82533,CPT,,,,,,,,137,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,67.815,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.95,134.26
"Triiodothyronine T3, Free (Free T3)",PX84481,CDM,300,RC,84481,CPT,,,,,,,,137,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,67.815,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.53,134.26
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037601,NDC,1,ML,76.9,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,67.8258,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156F,CDM,370,RC,99156,CPT,,,,,,,,325,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,67.8365,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.02,129.14
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156P,CDM,983,RC,99156,CPT,,,,,,,,325,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,67.8365,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.02,318.5
cloNIDine 0.1 MG/24HR PATCH WEEKLY 4 Each Box,63700001,CDM,250,RC,,,,,,51862045304,NDC,1,EA,158.16,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,67.85064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ampicillin-sulbactam 1.5 (1-0.5) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001381,NDC,1,EA,69.24,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,67.8552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046201,NDC,30,ML,79.84,,First Health,Commercial,both,85,,999999999,percent of total billed charges,67.864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
solifenacin 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50228042730,NDC,1,EA,74.52,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,67.88772,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Alpha-Fetoprotein Serum,PX82105,CDM,300,RC,82105,CPT,,,,,,,,77,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,67.914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.38,75.46
BRACE WRIST HAND THUMB LEFT 455-LT,120.315,CDM,274,RC,L3809,HCPCS,,8283-MAIN,LOCAL,,,,,77,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,67.914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.9858,245.51
BRACE WRIST HAND THUMB RIGHT 455-RT,120.315,CDM,274,RC,L3809,HCPCS,,8284-MAIN,LOCAL,,,,,77,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,67.914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.9858,245.51
CAUTERY HIGH TEMP LOOP TIP,120.21,CDM,272,RC,,,,332-MAIN,LOCAL,,,,,77,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,67.914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
NEEDLE ACUJECT 25GA VARIABLE INJECTION VIN-25,27200000,CDM,272,RC,,,,7412-MAIN,LOCAL,,,,,77,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,67.914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Remove Additional Nail Plate,PX11732F,CDM,510,RC,11732,CPT,,,,,,,,77,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,67.914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.9858,75.46
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,24208046325,NDC,2.5,ML,137.26,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,67.9437,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Alpha-Fetoprotein, Serum - Ref",PX8210590,CDM,300,RC,82105,CPT,90,,,,,,,80,,First Health,Commercial,both,85,,999999999,percent of total billed charges,68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.38,78.4
Prealubimin,PX84134,CDM,300,RC,84134,CPT,,,,,,,,80,,First Health,Commercial,both,85,,999999999,percent of total billed charges,68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.38,78.4
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,63323050830,NDC,1,EA,134.48,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,68.04688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.461584,189.875
hepatitis b recomb vaccine 10 MCG/0.5ML suspension prefilled syringe 0.5 mL Syringe,90743,CDM,636,RC,90743,CPT,,,,58160082052,NDC,0.5,ML,137.47,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,68.04765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.105038,134.7206
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915850,NDC,0.2,ML,69.44,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,68.0512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
Dress/Debrid Med Burn No Anesth,PX16025F,CDM,510,RC,16025,CPT,,,,,,,,366,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,68.06,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.06,327.91
Dress/Debrid Med Burn No Anesth,PX16025P,CDM,983,RC,16025,CPT,,,,,,,,244,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,68.06,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.06,327.91
Eval of Bronchospasm,PX94060,CDM,983,RC,94060,CPT,,,,,,,,176,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,68.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.08,172.48
Eval of Bronchospasm,PX94060,CDM,983,RC,94060,CPT,,,,,,,,176,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,68.06,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.08,172.48
"Ex Sknbngn0.6-1cmtrnk,Arm,Lg",PX11401P,CDM,983,RC,11401,CPT,,,,,,,,387,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,68.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.19,379.26
"Ex Sknbngn0.6-1cmtrnk,Arm,Lg",PX11401P,CDM,983,RC,11401,CPT,,,,,,,,387,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,68.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.19,379.26
"Fac/Ex Skinbngn0.6-1cmtrnk,Arm,Lg",PX11401F,CDM,510,RC,11401,CPT,,,,,,,,484,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,68.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.19,325.84
"Fac/Ex Skinbngn0.6-1cmtrnk,Arm,Lg",PX11401F,CDM,510,RC,11401,CPT,,,,,,,,484,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,68.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.19,325.84
"Infect, Organ, Amp Probe - Ref",PX8780190,CDM,300,RC,87801,CPT,90,,,,,,,630,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,68.09,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.09,70.2
"Infect, Organ, Amp Probe - Ref",PX8780190,CDM,300,RC,87801,CPT,90,,,,,,,630,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,68.09,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.09,70.2
"Infect, Organ, Amp Probe - Ref",PX8780190,CDM,300,RC,87801,CPT,90,,,,,,,630,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,68.09,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.09,70.2
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781910572,NDC,0.25,EA,69.49,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,68.1002,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86,213.6008
morphine 20 mg/mL Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,54040444,NDC,30,ML,141.88,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,68.1024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine 20 mg/mL Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,54040444,NDC,30,ML,141.88,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,68.1024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,436067216,NDC,473,ML,77.23,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,68.11686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,39328006412,NDC,473,ML,77.23,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,68.11686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Tx/Pro/Dx Inj Same Drug Adon,PX96376,CDM,260,RC,96376,CPT,,,,,,,,164,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,68.1256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.1256,160.72
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012250,NDC,1,EA,77.24,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,68.12568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012267,NDC,1,EA,77.24,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,68.12568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
cefOXitin 2 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021011020,NDC,1,EA,77.24,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,68.12568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.367364,75.6952
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023610,NDC,1,EA,77.24,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,68.12568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
durvalumab 120 MG/2.4ML Solution 2.4 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310450012,NDC,30,ML,21771.9,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,68.14,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,59.96,84.74
durvalumab 120 MG/2.4ML Solution 2.4 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310450012,NDC,30,ML,21771.9,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,68.14,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,59.96,84.74
durvalumab 500 MG/10ML Solution 10 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310461150,NDC,10,ML,7588.77,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,68.14,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,59.96,84.74
durvalumab 500 MG/10ML Solution 10 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310461150,NDC,10,ML,7588.77,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,68.14,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,59.96,84.74
RETRIEVAL BAG 10MM,27200000,CDM,272,RC,,,,11707-MAIN,LOCAL,,,,,74.8,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,68.1428,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Office/Outpt Visit,Est,Levl IV",PX99214F,CDM,510,RC,99214,CPT,,,,,,,,256,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,68.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.11,230.23
"Office/Outpt Visit,Est,Levl IV",PX99214F,CDM,510,RC,99214,CPT,,,,,,,,256,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,68.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.11,230.23
"Office/Outpt Visit,Est,Levl IV",PX99214P,CDM,983,RC,99214,CPT,,,,,,,,256,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,68.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.11,250.88
"Office/Outpt Visit,Est,Levl IV",PX99214P,CDM,983,RC,99214,CPT,,,,,,,,256,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,68.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.11,250.88
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760,CDM,420,RC,97760,CPT,,,,,,,,142,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,68.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.18,139.16
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760,CDM,420,RC,97760,CPT,,,,,,,,142,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,68.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.18,139.16
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760F,CDM,510,RC,97760,CPT,,,,,,,,142,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,68.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.18,139.16
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760F,CDM,510,RC,97760,CPT,,,,,,,,142,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,68.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.18,139.16
Oximetry;Mult Determine,PX610,CDM,460,RC,94761,CPT,,,,,,,,142,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,68.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,139.16
Oximetry;Mult Determine,PX610,CDM,460,RC,94761,CPT,,,,,,,,142,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,68.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,139.16
Thromboplastin Time Partial,PX85730,CDM,300,RC,85730,CPT,,,,,,,,142,,Health Partners,Health Partners Care Plans,both,48,,89.78333333,percent of total billed charges,68.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.51,139.16
Thromboplastin Time Partial,PX85730,CDM,300,RC,85730,CPT,,,,,,,,142,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,68.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.51,139.16
X-Ray Exam Femur 1 Vw,PX7355101,CDM,320,RC,73551,CPT,TC,,,,,,,142,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,68.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,139.16
X-Ray Exam Femur 1 Vw,PX7355101,CDM,320,RC,73551,CPT,TC,,,,,,,142,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,68.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,139.16
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019602,NDC,2,ML,77.29,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,68.16978,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
EPIX UNIVERSAL CLIP APPLIER,27200000,CDM,272,RC,,,,11708-MAIN,LOCAL,,,,,158.95,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,68.18955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Occupational Therapy Eval High Complex,PX97167,CDM,434,RC,97167,CPT,,,,,,,,289,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,68.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,283.22
Occupational Therapy Eval Low Complex,PX97165,CDM,434,RC,97165,CPT,,,,,,,,235,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,68.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,230.3
Occupational Therapy Eval Mod Complex,PX97166,CDM,434,RC,97166,CPT,,,,,,,,264,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,68.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,258.72
Physical Therapy Evaluation High Complex,PX97163,CDM,424,RC,97163,CPT,,,,,,,,294,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,68.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,288.12
Physical Therapy Evaluation Low Complex,PX97161,CDM,424,RC,97161,CPT,,,,,,,,235,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,68.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,392.7
Physical Therapy Evaluation Mod Complex,PX97162,CDM,424,RC,97162,CPT,,,,,,,,264,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,68.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,258.72
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338080304,NDC,1000,ML,69.59,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,68.1982,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990710709,NDC,1000,ML,69.59,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,68.1982,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004824,NDC,150,ML,69.59,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,68.1982,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.010932,68.1982
Iaad Ia Severe Aqt Respir Synd Coronavirus,PX87426,CDM,300,RC,87426,CPT,,,,,,,,159,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,68.211,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.39,155.82
CT Head/Brain W/O Dye,PX7045001,CDM,350,RC,70450,CPT,TC,,,,,,,2757,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,68.2216,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.02,136.08
methylene blue 1 % Solution 10 mL Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,54288014701,NDC,1,ML,139.25,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,4.176666667,percent of total billed charges,68.2325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.29,1354.4776
methylene blue 1 % Solution 10 mL Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,54288014701,NDC,1,ML,139.25,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,68.2325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.29,1354.4776
methylene blue 1 % Solution 10 mL Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,54288014701,NDC,1,ML,139.25,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,68.2325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.29,1354.4776
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034020,NDC,1,EA,76.67,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,68.2363,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034021,NDC,1,EA,76.67,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,68.2363,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,781375575,NDC,4,ML,142.22,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,68.2656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,781375575,NDC,4,ML,142.22,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,68.2656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Exc Skn Benig<5mm Face,Facial",PX11440P,CDM,983,RC,11440,CPT,,,,,,,,387,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,68.28,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.28,379.26
"Fac/Exc Skn Benig<5mm Face,Facial",PX11440F,CDM,510,RC,11440,CPT,,,,,,,,484,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,68.28,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.28,299.55
Incise External Hemorrhoid,PX46083F,CDM,510,RC,46083,CPT,,,,,,,,502,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,68.28,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.28,433.76
Incise External Hemorrhoid,PX46083P,CDM,983,RC,46083,CPT,,,,,,,,956,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,68.28,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.28,936.88
Remove Foreign Body Simple,PX10120F,CDM,510,RC,10120,CPT,,,,,,,,404,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,68.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.53,317.54
Remove Foreign Body Simple,PX10120F,CDM,510,RC,10120,CPT,,,,,,,,404,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,68.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.53,317.54
Remove Foreign Body Simple,PX10120P,CDM,983,RC,10120,CPT,,,,,,,,404,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,68.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.53,395.92
Remove Foreign Body Simple,PX10120P,CDM,983,RC,10120,CPT,,,,,,,,404,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,68.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.53,395.92
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,16714076901,NDC,15,GR,137.99,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,68.30505,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Cognitive Funct Ther Interv, per Day",PX97127,CDM,420,RC,97127,CPT,,,,,,,,135,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,68.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.079,132.3
Electric Stimulation Therapy,PX97014,CDM,420,RC,97014,CPT,,,,,,,,135,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,68.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.18,132.3
Electrical Stimulation,PX97032,CDM,420,RC,97032,CPT,,,,,,,,135,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,68.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,132.3
Gait Training Therapy,PX97116,CDM,420,RC,97116,CPT,,,,,,,,135,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,68.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20,132.3
"Manual Ther Tech,1+Regions,Ea 15 Min",PX97140,CDM,420,RC,97140,CPT,,,,,,,,135,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,68.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.4,215.05
Mechanical Traction Therapy,PX97012,CDM,420,RC,97012,CPT,,,,,,,,135,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,68.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,132.3
Neuromuscular Re-Education,PX97112,CDM,420,RC,97112,CPT,,,,,,,,135,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,68.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.95,215.05
Self Care Mngment Training,PX97535,CDM,420,RC,97535,CPT,,,,,,,,135,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,68.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.27,132.3
Therapeutic Activities,PX97530,CDM,420,RC,97530,CPT,,,,,,,,135,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,68.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.22,205.7
Therapeutic Exercises,PX97110,CDM,420,RC,97110,CPT,,,,,,,,135,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,68.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20,215.05
Ultrasound Therapy,PX97035,CDM,420,RC,97035,CPT,,,,,,,,135,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,68.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,132.3
Assay Cryofibrinogen,PX82585,CDM,300,RC,82585,CPT,,,,,,,,75,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,68.325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.96,73.5
Assay Cryoglobulin,PX82595,CDM,300,RC,82595,CPT,,,,,,,,75,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,68.325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,73.5
BINDER ABDOMINAL 9 INCH 46 TO 62 INCH XL ORT21100LXL,120.238,CDM,271,RC,A4467,HCPCS,,2989-MAIN,LOCAL,,,,,75,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,68.325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL 9 INCH 63 TO 74 INCH 3- PANEL ORT211002XL,120.238,CDM,271,RC,A4467,HCPCS,,37-MAIN,LOCAL,,,,,75,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,68.325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL 10 INCH 26 TO 50 INCHES ABB1050,120.238,CDM,271,RC,A4467,HCPCS,,52-MAIN,LOCAL,,,,,75,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,68.325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
"BINDER ABDOMINAL 12"" HIGH 2XL 60-75INCH 4 PANEL ORT213002XL",120.238,CDM,271,RC,A4467,HCPCS,,12536-MAIN,LOCAL,,,,,75,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,68.325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL UNISIZE 46-62IN 9 IN MDS169024,120.238,CDM,271,RC,A4467,HCPCS,,63-MAIN,LOCAL,,,,,75,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,68.325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
"Direct skilled nursing services of a license practical nurse (lpn) in the home health or hospice setting, each 15 minutes",PXG0300,CDM,551,RC,G0300,HCPCS,,,,,,,,75,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,68.325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
HH Rn Initial Visit,PXG0154,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,68.325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
HH Rn Routine Visit,PXG0154.01,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,68.325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
Skilled Srvc of a Lpn in Training and/or Education of Pt or Fam Ea 15 Min,PXG0496,CDM,551,RC,G0496,HCPCS,,,,,,,,75,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,68.325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
Skilled srvc of an RN in training and/or education of pt or fam ea 15 min,PXG0495,CDM,551,RC,G0495,HCPCS,,,,,,,,75,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,68.325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
ESOPHAGEAL BALLOON INFLATION DEVICE 60ML,27200000,CDM,272,RC,C1726,HCPCS,,11326-MAIN,LOCAL,,,,,80.41,,First Health,Commercial,both,85,,999999999,percent of total billed charges,68.3485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010365,NDC,100,ML,164.54,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,68.349916,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.174958,180.2416
fentaNYL 25 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,591319872,NDC,1,EA,77.51,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,68.36382,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Ctrl Nosebleed,Anter,Complex",PX30903F,CDM,510,RC,30903,CPT,,,,,,,,456,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,68.3943,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.46,506.4
"Ctrl Nosebleed,Anter,Complex",PX30903P,CDM,983,RC,30903,CPT,,,,,,,,304,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,68.3943,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.46,506.4
acyclovir 50 MG/ML Solution 20 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,63323032524,NDC,20,ML,76.86,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,68.4054,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.927644,105.9968
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036001,NDC,10,ML,80.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,68.425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,84.5054
ramuCIRumab 100 MG/10ML Solution 10 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2766901,NDC,10,ML,2463.3,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,68.42559,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.7,73.76
ramuCIRumab 500 MG/50ML Solution 50 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2767801,NDC,50,ML,12316.5,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,68.42559,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.7,73.76
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037601,NDC,1,ML,76.9,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,68.441,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
"Debridement of Nail(S), 1-5",PX11720F,CDM,510,RC,11720,CPT,,,,,,,,89,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,68.49,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.72,68.49
"N Block Inj, Plantar Digit",PX64455F,CDM,510,RC,64455,CPT,,,,,,,,385,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,68.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.72,103.77
"N Block Inj, Plantar Digit",PX64455P,CDM,983,RC,64455,CPT,,,,,,,,385,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,68.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.72,377.3
Remove Additional Nail Plate,PX11732F,CDM,510,RC,11732,CPT,,,,,,,,77,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,68.49,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.46,68.49
CT Orbit/Ear/Fosa W/O Dye,PX7048001,CDM,350,RC,70480,CPT,TC,,,,,,,2757,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,68.5,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.5,202.48
CT Orbit/Ear/Fosa W/O Dye,PX7048001,CDM,350,RC,70480,CPT,TC,,,,,,,2757,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,68.5,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.5,202.48
brimonidine 0.2 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,70069023101,NDC,5,ML,70.38,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,68.500854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"dextrose 5% and sodium chloride 0.45% with potassium chloride 10 mEq in 1000 mL 10-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,338066904,NDC,1000,ML,80.61,,First Health,Commercial,both,85,,999999999,percent of total billed charges,68.5185,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,264957710,NDC,500,ML,80.61,,First Health,Commercial,both,85,,999999999,percent of total billed charges,68.5185,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052201,NDC,500,ML,80.61,,First Health,Commercial,both,85,,999999999,percent of total billed charges,68.5185,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052277,NDC,500,ML,80.61,,First Health,Commercial,both,85,,999999999,percent of total billed charges,68.5185,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337501,NDC,50,ML,135.43,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,68.52758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337502,NDC,50,ML,135.43,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,68.52758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9678001,NDC,50,ML,135.43,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,68.52758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
Alpha-Fetoprotein Serum,PX82105,CDM,300,RC,82105,CPT,,,,,,,,77,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,68.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.38,75.46
BRACE WRIST HAND THUMB LEFT 455-LT,120.315,CDM,274,RC,L3809,HCPCS,,8283-MAIN,LOCAL,,,,,77,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,68.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.9858,245.51
BRACE WRIST HAND THUMB RIGHT 455-RT,120.315,CDM,274,RC,L3809,HCPCS,,8284-MAIN,LOCAL,,,,,77,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,68.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.9858,245.51
CAUTERY HIGH TEMP LOOP TIP,120.21,CDM,272,RC,,,,332-MAIN,LOCAL,,,,,77,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,68.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
NEEDLE ACUJECT 25GA VARIABLE INJECTION VIN-25,27200000,CDM,272,RC,,,,7412-MAIN,LOCAL,,,,,77,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,68.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Remove Additional Nail Plate,PX11732F,CDM,510,RC,11732,CPT,,,,,,,,77,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,68.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.9858,75.46
Dihydroxyvitamin D - Ref,PX8265290,CDM,300,RC,82652,CPT,90,,,,,,,165,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,68.541,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.3,161.7
Flow Cyto Ea Addtl Marker - Ref,PX8818590,CDM,310,RC,88185,CPT,90,,,,,,,165,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,68.541,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.541,161.7
Strapping of Shoulder,PX29240F,CDM,420,RC,29240,CPT,,,,,,,,165,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,68.541,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.541,161.7
TISSUE RETRIEVAL SYSTEM,27200000,CDM,272,RC,,,,10233-MAIN,LOCAL,,,,,139.98,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,68.5902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TISSUE RETRIEVAL SYSTEM,27200000,CDM,272,RC,,,,10233-MAIN,LOCAL,,,,,139.98,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,68.5902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TISSUE RETRIEVAL SYSTEM,27200000,CDM,272,RC,,,,10233-MAIN,LOCAL,,,,,139.98,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,68.5902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Apply Forearm Cast,PX29075P,CDM,983,RC,29075,CPT,,,,,,,,140,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,68.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.156,234.62
Apply Forearm Cast,PX29075P,CDM,983,RC,29075,CPT,,,,,,,,140,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,68.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.156,234.62
Apply Forearm Cast,PX29075P,CDM,983,RC,29075,CPT,,,,,,,,140,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,68.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.156,234.62
Hospital Discharge Day>30 Min,PX99239P,CDM,982,RC,99239,CPT,,,,,,,,140,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,68.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.156,136.262
Hospital Discharge Day>30 Min,PX99239P,CDM,982,RC,99239,CPT,,,,,,,,140,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,68.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.156,136.262
Hospital Discharge Day>30 Min,PX99239P,CDM,982,RC,99239,CPT,,,,,,,,140,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,68.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.156,136.262
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703334301,NDC,0.5,ML,142.98,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,68.6304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703334301,NDC,0.5,ML,142.98,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,68.6304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963805,NDC,0.5,ML,142.98,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,68.6304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963805,NDC,0.5,ML,142.98,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,68.6304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
"Chest Wall Manipulation,Subsequent",PX94668F,CDM,410,RC,94668,CPT,,,,,,,,192,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,68.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.78,68.64
"Chest Wall Manipulation,Subsequent",PX94668F,CDM,410,RC,94668,CPT,,,,,,,,192,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,68.64,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.78,68.64
Ex for Speech Device Rx Addl,PX92608,CDM,444,RC,92608,CPT,,,,,,,,160,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,68.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.95,156.8
phytonadione 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714097302,NDC,0.5,EA,143.02,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,68.6496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phytonadione 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714097302,NDC,0.5,EA,143.02,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,68.6496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phytonadione 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,69238105103,NDC,0.5,EA,143.02,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,68.6496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phytonadione 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,69238105103,NDC,0.5,EA,143.02,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,68.6496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331601,NDC,10,ML,77.86,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,68.67252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
"Infect, Organ, Amp Probe - Ref",PX8780190,CDM,300,RC,87801,CPT,90,,,,,,,630,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,68.6726,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.09,70.2
doxycycline 100 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323013041,NDC,1,EA,140.2,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,68.698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
doxycycline 100 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323013041,NDC,1,EA,140.2,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,68.698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
doxycycline 100 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323013041,NDC,1,EA,140.2,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,68.698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
CT Orbit/Ear/Fosa W/O Dye,PX7048001,CDM,350,RC,70480,CPT,TC,,,,,,,2757,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,68.71,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.5,202.48
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,436067216,NDC,473,ML,77.23,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,68.7347,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,39328006412,NDC,473,ML,77.23,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,68.7347,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004703,NDC,1,EA,75.45,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,68.73495,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012250,NDC,1,EA,77.24,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,68.7436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012267,NDC,1,EA,77.24,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,68.7436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
cefOXitin 2 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021011020,NDC,1,EA,77.24,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,68.7436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.367364,75.6952
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023610,NDC,1,EA,77.24,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,68.7436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
droPERidol 2.5 MG/ML Solution 2 mL Vial,J1790.01,CDM,636,RC,J1790,HCPCS,,,,517970201,NDC,2,ML,75.47,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,68.75317,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.350238,73.9606
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409751766,NDC,50,ML,80.89,,First Health,Commercial,both,85,,999999999,percent of total billed charges,68.7565,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019602,NDC,2,ML,77.29,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,68.7881,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
Ceruloplasmin - Ref,PX8239090,CDM,300,RC,82390,CPT,90,,,,,,,78,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,68.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,76.44
Chemiluminescent Assay - Ref,PX8239790,CDM,300,RC,82397,CPT,90,,,,,,,78,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,68.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.95,76.44
VISUALIZATION SYSTEM CLEARIFY LAPAROSCOPE STERILE,27200000,CDM,272,RC,,,,11875-MAIN,LOCAL,,,,,78,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,68.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046837,NDC,30,ML,75.54,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,68.81694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Plas Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,338604648,NDC,100,ML,143.42,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,68.8416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.786918,140.5516
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Plas Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,338604648,NDC,100,ML,143.42,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,68.8416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.786918,140.5516
CAPTIFLEX SNARE SINGLE USE EXTRA SMALL 11MM,27200000,CDM,272,RC,,,,12378-MAIN,LOCAL,,,,,81,,First Health,Commercial,both,85,,999999999,percent of total billed charges,68.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Smear Special Stain,PX87207,CDM,300,RC,87207,CPT,,,,,,,,81,,First Health,Commercial,both,85,,999999999,percent of total billed charges,68.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.49,79.38
Tacrolimus - Ref,PX8019790,CDM,300,RC,80197,CPT,90,,,,,,,81,,First Health,Commercial,both,85,,999999999,percent of total billed charges,68.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,79.38
US Pregnancy Tc Follow-Up,PX7681601,CDM,402,RC,76816,CPT,TC,,,,,,,362,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,68.8652,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.26,138.05
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,703115301,NDC,4,ML,136.1,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,68.8666,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
enalaprilat 1.25 MG/ML Injectable 2 mL Vial,25000000,CDM,250,RC,,,,,,143978601,NDC,2,ML,75.63,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,68.89893,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ENDOLOOP COATED VICRYL 0 18,27200000,CDM,272,RC,,,,10228-MAIN,LOCAL,,,,,143.6,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,68.928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ENDOLOOP COATED VICRYL 0 18,27200000,CDM,272,RC,,,,10228-MAIN,LOCAL,,,,,143.6,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,68.928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
methylene blue 1 % Solution 10 mL Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,54288014701,NDC,1,ML,139.25,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,68.92875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.29,1354.4776
Closed Rx Mt-Phal Toe Dislocation,PX28630F,CDM,510,RC,28630,CPT,,,,,,,,360,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,68.93,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.93,327.22
Closed Rx Mt-Phal Toe Dislocation,PX28630P,CDM,983,RC,28630,CPT,,,,,,,,248,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,68.93,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.93,327.22
CT Maxillofacial W/Dye,PX7048701,CDM,350,RC,70487,CPT,TC,,,,,,,3332,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,68.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.93,203.79
CT Maxillofacial W/Dye,PX7048701,CDM,350,RC,70487,CPT,TC,,,,,,,3332,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,68.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.93,203.79
Dress/Debrid Med Burn No Anesth,PX16025F,CDM,510,RC,16025,CPT,,,,,,,,366,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,68.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.06,327.91
Dress/Debrid Med Burn No Anesth,PX16025F,CDM,510,RC,16025,CPT,,,,,,,,366,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,68.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.06,327.91
Dress/Debrid Med Burn No Anesth,PX16025P,CDM,983,RC,16025,CPT,,,,,,,,244,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,68.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.06,327.91
Dress/Debrid Med Burn No Anesth,PX16025P,CDM,983,RC,16025,CPT,,,,,,,,244,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,68.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.06,327.91
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,24208031510,NDC,10,ML,75.67,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,68.93537,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,51672131200,NDC,22,GR,140.7,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,68.943,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,51672131200,NDC,22,GR,140.7,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,68.943,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,51672131200,NDC,22,GR,140.7,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,68.943,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Breast Tomosynthesis,Dx Tc Bilat",PX7706201,CDM,401,RC,77062,CPT,TC,,,,,,,166,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,68.9564,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.9564,162.68
"Breast Tomosynthesis,Dx Tc Unilat",PX7706101,CDM,401,RC,77061,CPT,TC,,,,,,,166,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,68.9564,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.9564,162.68
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,990771502,NDC,250,ML,166.02,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,68.964708,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.4701,303.0944
"Manage/Train Orthotic/Prosthetic, per 15 Min",PX97763,CDM,420,RC,97763,CPT,,,,,,,,121,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,68.97,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.47,68.97
"Manage/Train Orthotic/Prosthetic, per 15 Min",PX97763,CDM,420,RC,97763,CPT,,,,,,,,121,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,68.97,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.47,68.97
brimonidine 0.2 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,70069023101,NDC,5,ML,70.38,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,68.9724,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
OBINutuzumab 1000 MG/40ML Solution 40 mL Vial,J9301.01,CDM,636,RC,J9301,HCPCS,,,,50242007001,NDC,4,ML,1397.15,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,68.97248,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.22,73.86
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989001,NDC,50,ML,160.78,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,68.97462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989002,NDC,50,ML,160.78,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,68.97462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
fentaNYL 25 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,591319872,NDC,1,EA,77.51,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,68.9839,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine Sodium 200 MCG Recon Soln 1 Each Vial,J0650.01,CDM,636,RC,J0650,HCPCS,,,,63323064710,NDC,0.0625,EA,75.75,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,69.00825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.46655,74.235
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046203,NDC,30,ML,70.91,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,69.016703,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
X-Ray Abdomen 2+ Views W/ Single Vw Chest (Tc),PX7402201,CDM,320,RC,74022,CPT,TC,,,,,,,334,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,69.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.9,69.03
X-Ray Abdomen 2+ Views W/ Single Vw Chest (Tc),PX7402201,CDM,320,RC,74022,CPT,TC,,,,,,,334,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,69.03,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.9,69.03
Xray Facial Bones Minimum 3 Vws,PX7015001,CDM,320,RC,70150,CPT,TC,,,,,,,551,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,69.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.9,69.03
Xray Facial Bones Minimum 3 Vws,PX7015001,CDM,320,RC,70150,CPT,TC,,,,,,,551,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,69.03,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.9,69.03
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,16714081701,NDC,1,EA,75.78,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,69.03558,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 0.3 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,61314065625,NDC,2.5,ML,140.92,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,69.0508,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ciprofloxacin 0.3 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,61314065625,NDC,2.5,ML,140.92,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,69.0508,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ciprofloxacin 0.3 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,61314065625,NDC,2.5,ML,140.92,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,69.0508,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
LAP KIT BASIC,27200000,CDM,272,RC,,,,4829-MAIN,LOCAL,,,,,78.29,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,69.05178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Catheterize for Urine Spec,PXP9612,CDM,300,RC,P9612,HCPCS,,,,,,,,161,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,69.069,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.1,157.78
Drain/Inject Small Joint/Bursa,PX20600F,CDM,510,RC,20600,CPT,,,,,,,,161,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,69.069,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.8794,258.75
Drain/Inject Small Joint/Bursa,PX20600P,CDM,983,RC,20600,CPT,,,,,,,,161,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,69.069,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.8794,258.75
Each Add'l Hour IV Infusion <8 Hour,PX96366,CDM,260,RC,96366,CPT,,,,,,,,161,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,69.069,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,157.78
Aspergillus Ag - Ref,PX8730590,CDM,300,RC,87305,CPT,90,,,,,,,141,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,69.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,138.18
Aspergillus Ag - Ref,PX8730590,CDM,300,RC,87305,CPT,90,,,,,,,141,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,69.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,138.18
Aspergillus Ag - Ref,PX8730590,CDM,300,RC,87305,CPT,90,,,,,,,141,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,69.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,138.18
Gabapentin - Ref,PX8017190,CDM,300,RC,80171,CPT,90,,,,,,,71,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,69.1043,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.87,69.58
Histoplasma Antibody - Ref,PX8669890,CDM,300,RC,86698,CPT,90,,,,,,,71,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,69.1043,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.64,69.58
Legionella Antibody - Ref,PX8671390,CDM,300,RC,86713,CPT,90,,,,,,,71,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,69.1043,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.03,69.58
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,17478081725,NDC,25,ML,81.3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,69.105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Hepatitis C Antibody,PX86803,CDM,300,RC,86803,CPT,,,,,,,,144,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,69.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.08,141.12
Hepatitis C Antibody,PX86803,CDM,300,RC,86803,CPT,,,,,,,,144,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,69.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.08,141.12
hepatitis A vaccine 1440 EL U/ML Suspension 1 mL Syringe,90632,CDM,636,RC,90632,CPT,,,,58160082652,NDC,1,ML,375.78,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,69.12186,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.83,70.54
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,69543025204,NDC,118,ML,78.39,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,69.13998,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CT Maxillofacial W/Dye,PX7048701,CDM,350,RC,70487,CPT,TC,,,,,,,3332,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,69.15,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.93,203.79
Exc Skn Bnig0.6-1cm Remain Bdy,PX11421P,CDM,983,RC,11421,CPT,,,,,,,,345,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,69.15,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.15,338.1
Fac/Exc Skn Beni 0.6-1cm Remain Bdy,PX11421F,CDM,510,RC,11421,CPT,,,,,,,,931,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,69.15,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.15,333.45
C-COLLAR ASPEN REGULAR 79-83365,120.25,CDM,274,RC,L0140,HCPCS,,167-MAIN,LOCAL,,,,,216,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,69.1655,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.91,70.43
C-COLLAR ASPEN TALL 79-83367,120.25,CDM,274,RC,L0140,HCPCS,,164-MAIN,LOCAL,,,,,216,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,69.1655,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.91,70.43
C-COLLAR ASPEN X-TALL 79-83368,120.25,CDM,274,RC,L0140,HCPCS,,168-MAIN,LOCAL,,,,,216,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,69.1655,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.91,70.43
US Scrotum & Contents Tc,PX7687001,CDM,402,RC,76870,CPT,TC,,,,,,,457,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,69.187,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.12,138.71
Assay of Blood Lipoprotein,PX83721,CDM,300,RC,83721,CPT,,,,,,,,76,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,69.236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.63,74.48
Lab Direct Coombs,PX86880,CDM,300,RC,86880,CPT,,,,,,,,76,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,69.236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.5704,74.48
PRONEVIEW CUSHION INSERTS LARGE,120.557,CDM,272,RC,E0190,HCPCS,,12500-MAIN,LOCAL,,,,,76,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,69.236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.5704,74.48
SHOE POST OP LARGE MALE MQM3B,120.237,CDM,274,RC,L3260,HCPCS,,794-MAIN,LOCAL,,,,,76,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,69.236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP LARGE SQUARE TOE WOMENS ORT30300WL,120.237,CDM,274,RC,L3260,HCPCS,,10606-MAIN,LOCAL,,,,,76,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,69.236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP MEDIUM SQUARE TOE MALE ORT30300MM,120.237,CDM,274,RC,L3260,HCPCS,,10603-MAIN,LOCAL,,,,,76,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,69.236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP MEDIUM SQUARE TOE WOMENS ORT30300WM,120.237,CDM,274,RC,L3260,HCPCS,,10605-MAIN,LOCAL,,,,,76,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,69.236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP SMALL MALE 0814-1192,120.237,CDM,274,RC,L3260,HCPCS,,803-MAIN,LOCAL,,,,,76,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,69.236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP SMALL SQUARE TOE WOMENS MQW1B,120.237,CDM,274,RC,L3260,HCPCS,,10604-MAIN,LOCAL,,,,,76,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,69.236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
TISSUE RETRIEVAL SYSTEM,27200000,CDM,272,RC,,,,10233-MAIN,LOCAL,,,,,139.98,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,69.2901,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331601,NDC,10,ML,77.86,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,69.2954,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
Apply Forearm Cast,PX29075P,CDM,983,RC,29075,CPT,,,,,,,,140,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,69.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.156,234.62
Hospital Discharge Day>30 Min,PX99239P,CDM,982,RC,99239,CPT,,,,,,,,140,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,69.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.156,136.262
sodium polystyrene sulfonate Powder 15 g Bottle,25000000,CDM,250,RC,,,,,,10702003615,NDC,15,GR,76.09,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,69.31799,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Total Cortisol,PX82533,CDM,300,RC,82533,CPT,,,,,,,,137,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,69.322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.95,134.26
"Triiodothyronine T3, Free (Free T3)",PX84481,CDM,300,RC,84481,CPT,,,,,,,,137,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,69.322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.53,134.26
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024110,NDC,1,EA,76.1,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,69.3271,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
"Diagnostic Bone Marrow, Biopsy and Aspiration",PX38222F,CDM,761,RC,38222,CPT,,,,,,,,1748,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,69.3576,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9,363.89
Reconstruc of Nail Bed,PX11760F,CDM,510,RC,11760,CPT,,,,,,,,1162,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,69.37,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.37,384.64
Reconstruc of Nail Bed,PX11760P,CDM,983,RC,11760,CPT,,,,,,,,903,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,69.37,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.37,884.94
Incise External Hemorrhoid,PX46083F,CDM,510,RC,46083,CPT,,,,,,,,502,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,69.37,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.28,433.76
Incise External Hemorrhoid,PX46083F,CDM,510,RC,46083,CPT,,,,,,,,502,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,69.37,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.28,433.76
Incise External Hemorrhoid,PX46083P,CDM,983,RC,46083,CPT,,,,,,,,956,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,69.37,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.28,936.88
Incise External Hemorrhoid,PX46083P,CDM,983,RC,46083,CPT,,,,,,,,956,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,69.37,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.28,936.88
Fungus Isolation Culture,PX87102,CDM,300,RC,87102,CPT,,,,,,,,167,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,69.3718,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.71,163.66
Microalbumin Quantitative,PX82043,CDM,300,RC,82043,CPT,,,,,,,,167,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,69.3718,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.3,163.66
Wound Cult/Afb,PX87116,CDM,300,RC,87116,CPT,,,,,,,,167,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,69.3718,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9,163.66
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,47781046813,NDC,1,EA,76.15,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,69.37265,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,64380079701,NDC,1,EA,76.15,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,69.37265,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
doxycycline 100 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323013041,NDC,1,EA,140.2,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,69.399,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Ceruloplasmin - Ref,PX8239090,CDM,300,RC,82390,CPT,90,,,,,,,78,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,69.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,76.44
Chemiluminescent Assay - Ref,PX8239790,CDM,300,RC,82397,CPT,90,,,,,,,78,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,69.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.95,76.44
VISUALIZATION SYSTEM CLEARIFY LAPAROSCOPE STERILE,27200000,CDM,272,RC,,,,11875-MAIN,LOCAL,,,,,78,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,69.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Path Special Stains II,PX3979,CDM,310,RC,88313,CPT,TC,,,,,,,107,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,69.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.44,116.608
Path Special Stains II,PX3979,CDM,310,RC,88313,CPT,TC,,,,,,,107,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,69.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.44,116.608
Path Special Stains II,PX3979,CDM,310,RC,88313,CPT,TC,,,,,,,107,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,69.44,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.44,116.608
Extremity Study - Vascular Diagnostics,PX9392201,CDM,921,RC,93922,CPT,TC,,,,,,,600,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,69.444,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.24,123.32
morphine 1 MG/ML Solution 50 mL Syringe,J2270.01,CDM,636,RC,J2270,HCPCS,,,,61553064975,NDC,50,ML,81.71,,First Health,Commercial,both,85,,999999999,percent of total billed charges,69.4535,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,24208046325,NDC,2.5,ML,137.26,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,69.45356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Phlebotomy,PX99195,CDM,940,RC,99195,CPT,,,,,,,,238,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,69.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.49,166.95
Phlebotomy,PX99195,CDM,940,RC,99195,CPT,,,,,,,,238,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,69.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.49,166.95
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046203,NDC,30,ML,70.91,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,69.4918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Acetone Assay,PX82010,CDM,300,RC,82010,CPT,,,,,,,,162,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,69.498,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.49,158.76
"Flow Interp,2-8 Markers - Ref",PX8818790,CDM,310,RC,88187,CPT,90,,,,,,,162,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,69.498,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.1,158.76
KIT THORACENTESIS PLEURA SEAL AK-01000-T,120.24,CDM,272,RC,,,,1147-MAIN,LOCAL,,,,,162,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,69.498,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.2948,158.76
morphine 20 mg/mL Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,54040444,NDC,30,ML,141.88,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,69.5212,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine 20 mg/mL Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,54040444,NDC,30,ML,141.88,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,69.5212,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine 20 mg/mL Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,54040444,NDC,30,ML,141.88,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,69.5212,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
anastrozole 1 MG Tablet 30 Each Bottle,25000000,CDM,250,RC,,,,,,16729003510,NDC,1,EA,71.44,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,69.532552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
urea 20 % Cream 85 g Tube,63700001,CDM,250,RC,,,,,,536110945,NDC,85,GR,81.83,,First Health,Commercial,both,85,,999999999,percent of total billed charges,69.5555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hepatitis b recomb vaccine 10 MCG/0.5ML suspension prefilled syringe 0.5 mL Syringe,90743,CDM,636,RC,90743,CPT,,,,58160082052,NDC,0.5,ML,137.47,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,69.55982,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.105038,134.7206
Apply Multlay Comprs Lwr Leg,PX29581P,CDM,983,RC,29581,CPT,,,,,,,,142,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,69.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,138.2086
Apply Multlay Comprs Lwr Leg,PX29581P,CDM,983,RC,29581,CPT,,,,,,,,142,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,69.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,138.2086
Apply Multlay Comprs Lwr Leg,PX29581P,CDM,983,RC,29581,CPT,,,,,,,,142,,United Healthcare,All Medicare advantage plans,outpatient,49,,112.89,percent of total billed charges,69.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,138.2086
"Biopsy Vulva/Perineum,One Lesn",PX56605P,CDM,983,RC,56605,CPT,,,,,,,,142,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,69.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,702.31
"Biopsy Vulva/Perineum,One Lesn",PX56605P,CDM,983,RC,56605,CPT,,,,,,,,142,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,69.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,702.31
"Biopsy Vulva/Perineum,One Lesn",PX56605P,CDM,983,RC,56605,CPT,,,,,,,,142,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,69.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,702.31
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006P,CDM,983,RC,10006,CPT,,,,,,,,142,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,69.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,138.2086
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006P,CDM,983,RC,10006,CPT,,,,,,,,142,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,69.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,138.2086
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006P,CDM,983,RC,10006,CPT,,,,,,,,142,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,69.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,138.2086
Gabapentin - Ref,PX8017190,CDM,300,RC,80171,CPT,90,,,,,,,71,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,69.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.87,69.58
Histoplasma Antibody - Ref,PX8669890,CDM,300,RC,86698,CPT,90,,,,,,,71,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,69.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.64,69.58
Legionella Antibody - Ref,PX8671390,CDM,300,RC,86713,CPT,90,,,,,,,71,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,69.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.03,69.58
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760,CDM,420,RC,97760,CPT,,,,,,,,142,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,28.4,percent of total billed charges,69.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.18,139.16
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760,CDM,420,RC,97760,CPT,,,,,,,,142,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,69.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.18,139.16
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760,CDM,420,RC,97760,CPT,,,,,,,,142,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,69.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.18,139.16
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760F,CDM,510,RC,97760,CPT,,,,,,,,142,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,28.4,percent of total billed charges,69.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.18,139.16
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760F,CDM,510,RC,97760,CPT,,,,,,,,142,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,69.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.18,139.16
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760F,CDM,510,RC,97760,CPT,,,,,,,,142,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,69.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.18,139.16
Oximetry;Mult Determine,PX610,CDM,460,RC,94761,CPT,,,,,,,,142,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,69.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,139.16
Oximetry;Mult Determine,PX610,CDM,460,RC,94761,CPT,,,,,,,,142,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,69.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,139.16
Oximetry;Mult Determine,PX610,CDM,460,RC,94761,CPT,,,,,,,,142,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,69.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,139.16
Thromboplastin Time Partial,PX85730,CDM,300,RC,85730,CPT,,,,,,,,142,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,3.663529412,percent of total billed charges,69.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.51,139.16
Thromboplastin Time Partial,PX85730,CDM,300,RC,85730,CPT,,,,,,,,142,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,69.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.51,139.16
Thromboplastin Time Partial,PX85730,CDM,300,RC,85730,CPT,,,,,,,,142,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,69.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.51,139.16
X-Ray Exam Femur 1 Vw,PX7355101,CDM,320,RC,73551,CPT,TC,,,,,,,142,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,69.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,139.16
X-Ray Exam Femur 1 Vw,PX7355101,CDM,320,RC,73551,CPT,TC,,,,,,,142,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,69.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,139.16
X-Ray Exam Femur 1 Vw,PX7355101,CDM,320,RC,73551,CPT,TC,,,,,,,142,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,69.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,139.16
Reconstruc of Nail Bed,PX11760F,CDM,510,RC,11760,CPT,,,,,,,,1162,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,69.59,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.37,384.64
Reconstruc of Nail Bed,PX11760F,CDM,510,RC,11760,CPT,,,,,,,,1162,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,69.59,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.37,384.64
Reconstruc of Nail Bed,PX11760P,CDM,983,RC,11760,CPT,,,,,,,,903,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,69.59,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.37,884.94
Reconstruc of Nail Bed,PX11760P,CDM,983,RC,11760,CPT,,,,,,,,903,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,69.59,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.37,884.94
Assay Carbamazepine Total,PX80156,CDM,300,RC,80156,CPT,,,,,,,,145,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,69.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.36,142.1
Assay Carbamazepine Total,PX80156,CDM,300,RC,80156,CPT,,,,,,,,145,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,69.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.36,142.1
"Calculus, Infrared Spec - Ref",PX8236590,CDM,300,RC,82365,CPT,90,,,,,,,145,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,69.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.83,142.1
"Calculus, Infrared Spec - Ref",PX8236590,CDM,300,RC,82365,CPT,90,,,,,,,145,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,69.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.83,142.1
"Catecholamines, Fraction - Ref",PX8238490,CDM,300,RC,82384,CPT,90,,,,,,,145,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,69.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.15,142.1
"Catecholamines, Fraction - Ref",PX8238490,CDM,300,RC,82384,CPT,90,,,,,,,145,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,69.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.15,142.1
Hsv Dna Amp Probe,PX87529,CDM,300,RC,87529,CPT,,,,,,,,145,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,69.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,142.1
Hsv Dna Amp Probe,PX87529,CDM,300,RC,87529,CPT,,,,,,,,145,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,69.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,142.1
Immunofixation Electrophoresis; Serum,PX86334,CDM,300,RC,86334,CPT,,,,,,,,145,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,69.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.48,142.1
Immunofixation Electrophoresis; Serum,PX86334,CDM,300,RC,86334,CPT,,,,,,,,145,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,69.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.48,142.1
LEGGING COMPRESSION JUXTALITE LONG LG 33CM,120.369,CDM,271,RC,A6545,HCPCS,,10840-MAIN,LOCAL,,,,,145,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,69.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.233,142.1
LEGGING COMPRESSION JUXTALITE LONG LG 33CM,120.369,CDM,271,RC,A6545,HCPCS,,10840-MAIN,LOCAL,,,,,145,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,69.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.233,142.1
"Pare/Cut Hyperkeratotic Skin Lesion, Single",PX11055F,CDM,510,RC,11055,CPT,,,,,,,,145,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,69.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.233,174.9
"Pare/Cut Hyperkeratotic Skin Lesion, Single",PX11055F,CDM,510,RC,11055,CPT,,,,,,,,145,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,69.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.233,174.9
Wheelchair Mngement Training,PX97542,CDM,420,RC,97542,CPT,,,,,,,,145,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,69.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.59,142.1
Wheelchair Mngement Training,PX97542,CDM,420,RC,97542,CPT,,,,,,,,145,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,69.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.59,142.1
atropine (PF) 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517040125,NDC,1,ML,71.55,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1.253,percent of total billed charges,69.639615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
tetracaine 0.5 % Solution 4 mL Plas Cont,25000000,CDM,250,RC,,,,,,65074114,NDC,4,ML,71.55,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,69.639615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
betamethasone acetate-betamethasone sodium phosphate 6 (3-3) MG/ML Suspension 5 mL Vial,J0702.01,CDM,636,RC,J0702,HCPCS,,,,517072001,NDC,1,ML,78.96,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,69.64272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.799984,77.3808
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,51672131200,NDC,22,GR,140.7,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,69.6465,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Chemotherapy Administration, Subq/Im Non-Hormonal Anti-Neoplastic",PX96401,CDM,335,RC,96401,CPT,,,,,,,,170,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,69.657,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.12,125.07
Everolimus,PX8016990,CDM,300,RC,80169,CPT,,,,,,,,79,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,69.678,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,77.42
LAP KIT BASIC,27200000,CDM,272,RC,,,,4829-MAIN,LOCAL,,,,,78.29,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,69.6781,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,781375575,NDC,4,ML,142.22,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,69.6878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,781375575,NDC,4,ML,142.22,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,69.6878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,781375575,NDC,4,ML,142.22,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,69.6878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
riTUXimab 100 MG/10ML Solution 10 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005121,NDC,10,ML,1916.61,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,69.69,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.69,83.16
riTUXimab 500 MG/50ML Solution 50 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005306,NDC,50,ML,8860.06,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,69.69,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.69,83.16
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,39328006712,NDC,473,ML,167.77,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,69.691658,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Ace - Ref,PX8216490,CDM,300,RC,82164,CPT,90,,,,,,,82,,First Health,Commercial,both,85,,999999999,percent of total billed charges,69.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.39,80.36
Anca Screen Each Antibody,PX8603690,CDM,300,RC,86036,CPT,90,,,,,,,82,,First Health,Commercial,both,85,,999999999,percent of total billed charges,69.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.0628,80.36
"Cognitive Funct Ther Interv, Ea Addl 15 Min",PX97130,CDM,420,RC,97130,CPT,,,,,,,,82,,First Health,Commercial,both,85,,999999999,percent of total billed charges,69.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31,80.36
"Cortisol, Free - Ref",PX8253090,CDM,300,RC,82530,CPT,90,,,,,,,82,,First Health,Commercial,both,85,,999999999,percent of total billed charges,69.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.32,80.36
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU0003,CDM,300,RC,U0003,HCPCS,,,,,,,,133,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,69.71239,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.71239,75
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU000390,CDM,300,RC,U0003,HCPCS,90,,,,,,,222,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,69.71239,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.71239,75
levoFLOXacin 250 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635161,NDC,1,EA,79.08,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,69.74856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 0.3 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,61314065625,NDC,2.5,ML,140.92,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,69.7554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,69543025204,NDC,118,ML,78.39,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,69.7671,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Aerobic Isolate - Ref,PX8707790,CDM,300,RC,87077,CPT,90,,,,,,,168,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,69.7872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,164.64
Insert Straight Catheter,PX51701F,CDM,510,RC,51701,CPT,,,,,,,,168,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,69.7872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.7872,164.64
Org ID Aerobic-Each,PX87077,CDM,300,RC,87077,CPT,,,,,,,,168,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,69.7872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,164.64
Aspergillus Ag - Ref,PX8730590,CDM,300,RC,87305,CPT,90,,,,,,,141,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,69.795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,138.18
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,16714076901,NDC,15,GR,137.99,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,69.82294,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034020,NDC,1,EA,76.67,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,69.84637,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034021,NDC,1,EA,76.67,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,69.84637,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457033900,NDC,1,EA,71.82,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,12.385,percent of total billed charges,69.902406,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
Ehrlichia (Anaplasma) Ab - Ref,PX8666690,CDM,300,RC,86666,CPT,90,,,,,,,163,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,69.927,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.33,159.74
Xray Ankle 2 Vws,PX7360001,CDM,320,RC,73600,CPT,TC,,,,,,,163,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,69.927,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.7102,159.74
CISplatin 50 MG/50ML Solution 50 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010351,NDC,50,ML,82.27,,First Health,Commercial,both,85,,999999999,percent of total billed charges,69.9295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.174958,180.2416
Phlebotomy,PX99195,CDM,940,RC,99195,CPT,,,,,,,,238,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,69.97,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.49,166.95
anastrozole 1 MG Tablet 30 Each Bottle,25000000,CDM,250,RC,,,,,,16729003510,NDC,1,EA,71.44,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,70.0112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
acyclovir 50 MG/ML Solution 20 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,63323032524,NDC,20,ML,76.86,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,70.01946,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.927644,105.9968
Closed Rx Mt-Phal Toe Dislocation,PX28630F,CDM,510,RC,28630,CPT,,,,,,,,360,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,70.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.93,327.22
Closed Rx Mt-Phal Toe Dislocation,PX28630F,CDM,510,RC,28630,CPT,,,,,,,,360,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,70.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.93,327.22
Closed Rx Mt-Phal Toe Dislocation,PX28630P,CDM,983,RC,28630,CPT,,,,,,,,248,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,70.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.93,327.22
Closed Rx Mt-Phal Toe Dislocation,PX28630P,CDM,983,RC,28630,CPT,,,,,,,,248,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,70.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.93,327.22
"Exc Skn Benig<5mm Face,Facial",PX11440P,CDM,983,RC,11440,CPT,,,,,,,,387,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,70.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.28,379.26
"Exc Skn Benig<5mm Face,Facial",PX11440P,CDM,983,RC,11440,CPT,,,,,,,,387,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,70.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.28,379.26
Exc Skn Bnig0.6-1cm Remain Bdy,PX11421P,CDM,983,RC,11421,CPT,,,,,,,,345,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,70.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.15,338.1
Exc Skn Bnig0.6-1cm Remain Bdy,PX11421P,CDM,983,RC,11421,CPT,,,,,,,,345,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,70.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.15,338.1
Fac/Exc Skn Beni 0.6-1cm Remain Bdy,PX11421F,CDM,510,RC,11421,CPT,,,,,,,,931,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,70.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.15,333.45
Fac/Exc Skn Beni 0.6-1cm Remain Bdy,PX11421F,CDM,510,RC,11421,CPT,,,,,,,,931,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,70.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.15,333.45
"Fac/Exc Skn Benig<5mm Face,Facial",PX11440F,CDM,510,RC,11440,CPT,,,,,,,,484,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,70.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.28,299.55
"Fac/Exc Skn Benig<5mm Face,Facial",PX11440F,CDM,510,RC,11440,CPT,,,,,,,,484,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,70.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.28,299.55
I&D Bartholin Gland Abscess,PX56420F,CDM,510,RC,56420,CPT,,,,,,,,429,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,70.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.02,389.48
I&D Bartholin Gland Abscess,PX56420P,CDM,983,RC,56420,CPT,,,,,,,,286,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,70.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.02,389.48
"Infectious Disease,Chronic Hep C Virus,Six Assays, Utilizing Serum",PX8159690,CDM,300,RC,81596,CPT,90,,,,,,,609,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,70.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.02,72.19
"Infectious Disease,Chronic Hep C Virus,Six Assays, Utilizing Serum",PX8159690,CDM,300,RC,81596,CPT,90,,,,,,,609,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,70.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.02,72.19
"Infectious Disease,Chronic Hep C Virus,Six Assays, Utilizing Serum",PX8159690,CDM,300,RC,81596,CPT,90,,,,,,,609,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,70.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.02,72.19
"Inj,Lumb Epidur,Blood/Clot Patch",PX62273P,CDM,983,RC,62273,CPT,,,,,,,,552,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,70.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.02,540.96
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037601,NDC,1,ML,76.9,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,70.0559,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703334301,NDC,0.5,ML,142.98,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,12.26041667,percent of total billed charges,70.0602,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703334301,NDC,0.5,ML,142.98,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,70.0602,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703334301,NDC,0.5,ML,142.98,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,70.0602,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963805,NDC,0.5,ML,142.98,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,70.0602,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963805,NDC,0.5,ML,142.98,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,70.0602,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963805,NDC,0.5,ML,142.98,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,70.0602,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
"B.Burgdorferi, Amp Probe - Ref",PX8747690,CDM,300,RC,87476,CPT,90,,,,,,,72,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,70.0776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.9088,70.56
"Blood, Occult, Other Sources",PX82271,CDM,300,RC,82271,CPT,,,,,,,,72,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,70.0776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.88,70.56
Epstein-barr antibody,PX86664,CDM,300,RC,86664,CPT,,,,,,,,72,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,70.0776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.02,70.56
phytonadione 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714097302,NDC,0.5,EA,143.02,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,70.0798,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phytonadione 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714097302,NDC,0.5,EA,143.02,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,70.0798,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phytonadione 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714097302,NDC,0.5,EA,143.02,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,70.0798,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phytonadione 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,69238105103,NDC,0.5,EA,143.02,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,70.0798,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phytonadione 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,69238105103,NDC,0.5,EA,143.02,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,70.0798,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phytonadione 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,69238105103,NDC,0.5,EA,143.02,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,70.0798,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Islet Cell Antibody - Ref,PX8634190,CDM,300,RC,86341,CPT,90,,,,,,,146,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,70.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.61,143.08
Islet Cell Antibody - Ref,PX8634190,CDM,300,RC,86341,CPT,90,,,,,,,146,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,70.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.61,143.08
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040304,NDC,10,ML,168.77,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,70.107058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040310,NDC,10,ML,168.77,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,70.107058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
atropine (PF) 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517040125,NDC,1,ML,71.55,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,70.119,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
tetracaine 0.5 % Solution 4 mL Plas Cont,25000000,CDM,250,RC,,,,,,65074114,NDC,4,ML,71.55,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,70.119,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329333901,NDC,10,ML,79.51,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,70.12782,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
calcium CHLORIDE 10 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,76329330401,NDC,10,ML,79.51,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,70.12782,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,25021018482,NDC,100,ML,79.51,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,70.12782,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.786918,140.5516
isatuximab-irfc 500 MG/25ML Solution 25 mL Vial,J9227.01,CDM,636,RC,J9227,HCPCS,,,,24065601,NDC,25,ML,7876.36,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,70.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.13,7718.8328
menthol-zinc oxide Paste 113 g Tube,63700001,CDM,250,RC,,,,,,53329016544,NDC,113,GR,79.52,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,70.13664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Alpha-Fetoprotein Serum,PX82105,CDM,300,RC,82105,CPT,,,,,,,,77,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,70.147,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.38,75.46
BRACE WRIST HAND THUMB LEFT 455-LT,120.315,CDM,274,RC,L3809,HCPCS,,8283-MAIN,LOCAL,,,,,77,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,70.147,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.9858,245.51
BRACE WRIST HAND THUMB RIGHT 455-RT,120.315,CDM,274,RC,L3809,HCPCS,,8284-MAIN,LOCAL,,,,,77,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,70.147,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.9858,245.51
CAUTERY HIGH TEMP LOOP TIP,120.21,CDM,272,RC,,,,332-MAIN,LOCAL,,,,,77,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,70.147,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
NEEDLE ACUJECT 25GA VARIABLE INJECTION VIN-25,27200000,CDM,272,RC,,,,7412-MAIN,LOCAL,,,,,77,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,70.147,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Remove Additional Nail Plate,PX11732F,CDM,510,RC,11732,CPT,,,,,,,,77,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,70.147,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.9858,75.46
"OB US < 14 Wks, Single Fetus - Radiology, Tech",PX7680101,CDM,402,RC,76801,CPT,TC,,,,,,,472,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,70.1524,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.35,140.03
"Infect, Organ, Amp Probe - Ref",PX8780190,CDM,300,RC,87801,CPT,90,,,,,,,630,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,70.2,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.09,70.2
Blood Clot Factor VIII Test,PX85247,CDM,300,RC,85247,CPT,,,,,,,,169,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,70.2026,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.03,165.62
Tap Block Unilateral by Injection(S),PX64486P,CDM,983,RC,64486,CPT,,,,,,,,169,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,70.2026,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.2026,164.4877
morphine 20 mg/mL Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,54040444,NDC,30,ML,141.88,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,70.2306,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
I&D Bartholin Gland Abscess,PX56420F,CDM,510,RC,56420,CPT,,,,,,,,429,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,70.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.02,389.48
I&D Bartholin Gland Abscess,PX56420F,CDM,510,RC,56420,CPT,,,,,,,,429,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,70.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.02,389.48
I&D Bartholin Gland Abscess,PX56420P,CDM,983,RC,56420,CPT,,,,,,,,286,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,70.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.02,389.48
I&D Bartholin Gland Abscess,PX56420P,CDM,983,RC,56420,CPT,,,,,,,,286,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,70.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.02,389.48
Removal of Hemorrhoid Clot,PX46320F,CDM,510,RC,46320,CPT,,,,,,,,2027,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,70.24,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.24,445.52
Removal of Hemorrhoid Clot,PX46320P,CDM,983,RC,46320,CPT,,,,,,,,374,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,70.24,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.24,445.52
hepatitis A vaccine 1440 EL U/ML Suspension 1 mL Syringe,90632,CDM,636,RC,90632,CPT,,,,58160082652,NDC,1,ML,375.78,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,70.26,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.83,70.54
betamethasone acetate-betamethasone sodium phosphate 6 (3-3) MG/ML Suspension 5 mL Vial,J0702.01,CDM,636,RC,J0702,HCPCS,,,,517072001,NDC,1,ML,78.96,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,70.2744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.799984,77.3808
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Plas Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,338604648,NDC,100,ML,143.42,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,70.2758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.786918,140.5516
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Plas Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,338604648,NDC,100,ML,143.42,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,70.2758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.786918,140.5516
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Plas Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,338604648,NDC,100,ML,143.42,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,70.2758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.786918,140.5516
Apply Multlay Comprs Lwr Leg,PX29581P,CDM,983,RC,29581,CPT,,,,,,,,142,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,70.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,138.2086
"Biopsy Vulva/Perineum,One Lesn",PX56605P,CDM,983,RC,56605,CPT,,,,,,,,142,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,70.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,702.31
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006P,CDM,983,RC,10006,CPT,,,,,,,,142,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,70.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,138.2086
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760,CDM,420,RC,97760,CPT,,,,,,,,142,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,70.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.18,139.16
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760F,CDM,510,RC,97760,CPT,,,,,,,,142,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,70.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.18,139.16
Oximetry;Mult Determine,PX610,CDM,460,RC,94761,CPT,,,,,,,,142,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,70.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,139.16
Thromboplastin Time Partial,PX85730,CDM,300,RC,85730,CPT,,,,,,,,142,,Humana Choice Care,All Medicare plans,outpatient,49.5,,55.664,percent of total billed charges,70.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.51,139.16
X-Ray Exam Femur 1 Vw,PX7355101,CDM,320,RC,73551,CPT,TC,,,,,,,142,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,70.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,139.16
Everolimus,PX8016990,CDM,300,RC,80169,CPT,,,,,,,,79,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,70.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,77.42
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,45802095301,NDC,100,GR,82.76,,First Health,Commercial,both,85,,999999999,percent of total billed charges,70.346,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Tx/Pro/Dx Inj Same Drug Adon,PX96376,CDM,260,RC,96376,CPT,,,,,,,,164,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,70.356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.1256,160.72
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,436067216,NDC,473,ML,77.23,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,70.35653,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,39328006412,NDC,473,ML,77.23,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,70.35653,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ENDOLOOP COATED VICRYL 0 18,27200000,CDM,272,RC,,,,10228-MAIN,LOCAL,,,,,143.6,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,70.364,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ENDOLOOP COATED VICRYL 0 18,27200000,CDM,272,RC,,,,10228-MAIN,LOCAL,,,,,143.6,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,70.364,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ENDOLOOP COATED VICRYL 0 18,27200000,CDM,272,RC,,,,10228-MAIN,LOCAL,,,,,143.6,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,70.364,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012250,NDC,1,EA,77.24,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,70.36564,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012267,NDC,1,EA,77.24,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,70.36564,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
cefOXitin 2 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021011020,NDC,1,EA,77.24,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,70.36564,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.367364,75.6952
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023610,NDC,1,EA,77.24,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,70.36564,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
levoFLOXacin 250 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635161,NDC,1,EA,79.08,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,70.3812,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457033900,NDC,1,EA,71.82,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,70.3836,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,781375575,NDC,4,ML,142.22,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,70.3989,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Immunocytochemistry,PX3993,CDM,310,RC,88342,CPT,TC,,,,,,,182,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,70.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.41,118.24
Immunocytochemistry,PX3993,CDM,310,RC,88342,CPT,TC,,,,,,,182,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,70.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.41,118.24
Immunocytochemistry,PX3993,CDM,310,RC,88342,CPT,TC,,,,,,,182,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,70.41,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.41,118.24
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019602,NDC,2,ML,77.29,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,70.41119,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046201,NDC,30,ML,79.84,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,70.41888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
C-COLLAR ASPEN REGULAR 79-83365,120.25,CDM,274,RC,L0140,HCPCS,,167-MAIN,LOCAL,,,,,216,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,70.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.91,70.43
C-COLLAR ASPEN REGULAR 79-83365,120.25,CDM,274,RC,L0140,HCPCS,,167-MAIN,LOCAL,,,,,216,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,70.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.91,70.43
C-COLLAR ASPEN REGULAR 79-83365,120.25,CDM,274,RC,L0140,HCPCS,,167-MAIN,LOCAL,,,,,216,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,70.43,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.91,70.43
C-COLLAR ASPEN TALL 79-83367,120.25,CDM,274,RC,L0140,HCPCS,,164-MAIN,LOCAL,,,,,216,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,70.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.91,70.43
C-COLLAR ASPEN TALL 79-83367,120.25,CDM,274,RC,L0140,HCPCS,,164-MAIN,LOCAL,,,,,216,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,70.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.91,70.43
C-COLLAR ASPEN TALL 79-83367,120.25,CDM,274,RC,L0140,HCPCS,,164-MAIN,LOCAL,,,,,216,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,70.43,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.91,70.43
C-COLLAR ASPEN X-TALL 79-83368,120.25,CDM,274,RC,L0140,HCPCS,,168-MAIN,LOCAL,,,,,216,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,70.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.91,70.43
C-COLLAR ASPEN X-TALL 79-83368,120.25,CDM,274,RC,L0140,HCPCS,,168-MAIN,LOCAL,,,,,216,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,70.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.91,70.43
C-COLLAR ASPEN X-TALL 79-83368,120.25,CDM,274,RC,L0140,HCPCS,,168-MAIN,LOCAL,,,,,216,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,70.43,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.91,70.43
DOBUTamine 1000 mcg/mL in dextrose 5% 250 mL premix 1000 mcg/ml Solution 250 mL Flex Cont,J1250.01,CDM,636,RC,J1250,HCPCS,,,,338107302,NDC,250,ML,146.73,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,70.4304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.951642,143.7954
DOBUTamine 1000 mcg/mL in dextrose 5% 250 mL premix 1000 mcg/ml Solution 250 mL Flex Cont,J1250.01,CDM,636,RC,J1250,HCPCS,,,,338107302,NDC,250,ML,146.73,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,70.4304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.951642,143.7954
alteplase 1 MG/ML Solution 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,8888800497,NDC,1,EA,21140.86,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,70.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004110,NDC,1,EA,666.53,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,70.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004164,NDC,1,EA,666.52,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,70.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
alteplase 100 MG Recon Soln 1 Each Syringe,J2997.01,CDM,636,RC,J2997,HCPCS,,,,88888800475,NDC,0.09,EA,1920.88,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,70.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
alteplase 100 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242008527,NDC,1,EA,21140.86,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,70.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
methylene blue 1 % Solution 10 mL Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,54288014701,NDC,1,ML,139.25,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,70.4605,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.29,1354.4776
tiotropium 18 MCG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,597007541,NDC,1,EA,82.92,,First Health,Commercial,both,85,,999999999,percent of total billed charges,70.482,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,409662902,NDC,10,ML,146.84,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,70.4832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.236966,143.9032
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,409662902,NDC,10,ML,146.84,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,70.4832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.236966,143.9032
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,25021012867,NDC,1,EA,82.96,,First Health,Commercial,both,85,,999999999,percent of total billed charges,70.516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,55150020830,NDC,1,EA,82.96,,First Health,Commercial,both,85,,999999999,percent of total billed charges,70.516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.461584,189.875
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,17478070311,NDC,10,ML,72.46,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,70.525318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
hepatitis A vaccine 1440 EL U/ML Suspension 1 mL Syringe,90632,CDM,636,RC,90632,CPT,,,,58160082652,NDC,1,ML,375.78,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,70.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.83,70.54
hepatitis A vaccine 1440 EL U/ML Suspension 1 mL Syringe,90632,CDM,636,RC,90632,CPT,,,,58160082652,NDC,1,ML,375.78,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,70.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.83,70.54
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,47781047013,NDC,1,EA,83,,First Health,Commercial,both,85,,999999999,percent of total billed charges,70.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,64380079901,NDC,1,EA,83,,First Health,Commercial,both,85,,999999999,percent of total billed charges,70.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,69238126601,NDC,1,EA,83,,First Health,Commercial,both,85,,999999999,percent of total billed charges,70.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SLING ARM CHILD PAD CANVAS NAVY 8004-02,120.54,CDM,273,RC,A4565,HCPCS,,878-MAIN,LOCAL,,,,,83,,First Health,Commercial,both,85,,999999999,percent of total billed charges,70.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM LARGE PAD CANVAS NAVY ORT11300L,120.54,CDM,273,RC,A4565,HCPCS,,870-MAIN,LOCAL,,,,,83,,First Health,Commercial,both,85,,999999999,percent of total billed charges,70.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM MEDIUM PAD CANVAS NAVY ORT11300M,120.54,CDM,273,RC,A4565,HCPCS,,872-MAIN,LOCAL,,,,,83,,First Health,Commercial,both,85,,999999999,percent of total billed charges,70.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM SMALL PAD CANVAS NAVY ORT11300S,120.54,CDM,273,RC,A4565,HCPCS,,874-MAIN,LOCAL,,,,,83,,First Health,Commercial,both,85,,999999999,percent of total billed charges,70.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM X-LARGE PAD ENVELOPE ORT11300XL,120.54,CDM,273,RC,A4565,HCPCS,,876-MAIN,LOCAL,,,,,83,,First Health,Commercial,both,85,,999999999,percent of total billed charges,70.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
"Alpha-Fetoprotein, Serum - Ref",PX8210590,CDM,300,RC,82105,CPT,90,,,,,,,80,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,70.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.38,78.4
Amphetamines; 1 or 2 - Ref,PX8032490,CDM,300,RC,80324,CPT,90,,,,,,,147,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,70.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.0638,144.06
Amphetamines; 1 or 2 - Ref,PX8032490,CDM,300,RC,80324,CPT,90,,,,,,,147,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,70.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.0638,144.06
Assay Ph Body Fluids Nos,PX83986,CDM,300,RC,83986,CPT,,,,,,,,147,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,70.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.28,144.06
Assay Ph Body Fluids Nos,PX83986,CDM,300,RC,83986,CPT,,,,,,,,147,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,70.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.28,144.06
"B.Burgdorferi, Amp Probe - Ref",PX8747690,CDM,300,RC,87476,CPT,90,,,,,,,72,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,70.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.9088,70.56
"Blood, Occult, Other Sources",PX82271,CDM,300,RC,82271,CPT,,,,,,,,72,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,70.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.88,70.56
"Cmv Detect, Amplifi Probe - Ref",PX8749690,CDM,300,RC,87496,CPT,90,,,,,,,147,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,70.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,144.06
"Cmv Detect, Amplifi Probe - Ref",PX8749690,CDM,300,RC,87496,CPT,90,,,,,,,147,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,70.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,144.06
Epstein-barr antibody,PX86664,CDM,300,RC,86664,CPT,,,,,,,,72,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,70.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.02,70.56
Hepatitis C Antibody,PX86803,CDM,300,RC,86803,CPT,,,,,,,,144,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,70.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.08,141.12
Hepatitis C Antibody,PX86803,CDM,300,RC,86803,CPT,,,,,,,,144,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,70.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.08,141.12
Hepatitis C Antibody,PX86803,CDM,300,RC,86803,CPT,,,,,,,,144,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,70.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.08,141.12
"Methlenedioxyamphetamines (Mda, Mdea, Mdma) - Ref",PX8035990,CDM,300,RC,80359,CPT,90,,,,,,,147,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,70.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.0638,144.06
"Methlenedioxyamphetamines (Mda, Mdea, Mdma) - Ref",PX8035990,CDM,300,RC,80359,CPT,90,,,,,,,147,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,70.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.0638,144.06
Ph Venous Blood,PX82800,CDM,300,RC,82800,CPT,,,,,,,,147,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,70.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.09,144.06
Ph Venous Blood,PX82800,CDM,300,RC,82800,CPT,,,,,,,,147,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,70.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.09,144.06
Prealubimin,PX84134,CDM,300,RC,84134,CPT,,,,,,,,80,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,70.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.38,78.4
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010365,NDC,100,ML,164.54,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,70.58766,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.174958,180.2416
"Infectious Disease,Chronic Hep C Virus,Six Assays, Utilizing Serum",PX8159690,CDM,300,RC,81596,CPT,90,,,,,,,609,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,70.598,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.02,72.19
Path Special Stains II,PX3979,CDM,310,RC,88313,CPT,TC,,,,,,,107,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,70.598,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.44,116.608
fentaNYL 25 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,591319872,NDC,1,EA,77.51,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,70.61161,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062430,NDC,0.3,ML,147.12,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,70.6176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062430,NDC,0.3,ML,147.12,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,70.6176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801301,NDC,0.3,ML,147.12,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,70.6176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801301,NDC,0.3,ML,147.12,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,70.6176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801310,NDC,0.3,ML,147.12,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,70.6176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801310,NDC,0.3,ML,147.12,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,70.6176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
Asay of Interleukin-6 (Il-6),PX8352990,CDM,300,RC,83529,CPT,90,,,,,,,170,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,70.618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,166.6
Chem Cautery Granulatn Tissue,PX17250F,CDM,510,RC,17250,CPT,,,,,,,,170,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,70.618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,174.9
"Chemotherapy Administration, Subq/Im Non-Hormonal Anti-Neoplastic",PX96401,CDM,335,RC,96401,CPT,,,,,,,,170,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,70.618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,166.6
Collagen Cross Links - Ref,PX8252390,CDM,300,RC,82523,CPT,90,,,,,,,170,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,70.618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.13,166.6
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800P,CDM,983,RC,40800,CPT,,,,,,,,170,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,70.618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,614.65
gadoteridol 279.3 MG/ML Solution 17 mL Syringe,A9576,CDM,636,RC,A9576,HCPCS,,,,270111145,NDC,17,ML,170,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,70.618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.54,166.6
"Inject Nerv Blck,Trigeminal",PX64400P,CDM,983,RC,64400,CPT,,,,,,,,170,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,70.618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,258.75
"Protein, Total; Serum, Plasma or Whole Blood",PX84155,CDM,300,RC,84155,CPT,,,,,,,,170,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,70.618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.37,166.6
Art Lower Extremity+Upper,PX9392301,CDM,921,RC,93923,CPT,TC,,,,,,,784,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,70.67,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.67,190.22
"Inj,Lumb Epidur,Blood/Clot Patch",PX62273P,CDM,983,RC,62273,CPT,,,,,,,,552,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,70.67,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.02,540.96
"Inj,Lumb Epidur,Blood/Clot Patch",PX62273P,CDM,983,RC,62273,CPT,,,,,,,,552,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,70.67,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.02,540.96
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,59148000713,NDC,1,EA,170.19,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,70.696926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
triamcinolone acetonide 40 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029320,NDC,1,ML,72.65,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,6.011428571,percent of total billed charges,70.710245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,72.0986
IMMOBILIZER SHOULDER LARGE 9008-03,120.38,CDM,274,RC,L3650,HCPCS,,906-MAIN,LOCAL,,,,,36,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,70.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER LARGE STRAP OSG3033,120.38,CDM,274,RC,L3650,HCPCS,,2910-MAIN,LOCAL,,,,,36,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,70.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER MEDIUM 9008-02,120.38,CDM,274,RC,L3650,HCPCS,,912-MAIN,LOCAL,,,,,36,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,70.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER MEDIUM OSG3032,120.38,CDM,274,RC,L3650,HCPCS,,915-MAIN,LOCAL,,,,,36,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,70.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER SMALL 9008-01,120.38,CDM,274,RC,L3650,HCPCS,,913-MAIN,LOCAL,,,,,36,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,70.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER SMALL WITH CLOTH 9001-02,120.38,CDM,274,RC,L3650,HCPCS,,914-MAIN,LOCAL,,,,,36,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,70.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER X-LARGE CLOTH 9001-05,120.38,CDM,274,RC,L3650,HCPCS,,917-MAIN,LOCAL,,,,,36,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,70.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
IMMOBILIZER SHOULDER X-LARGE ORT16100XL,120.38,CDM,274,RC,L3650,HCPCS,,904-MAIN,LOCAL,,,,,36,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,70.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4772,70.76
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143998391,NDC,1,EA,83.25,,First Health,Commercial,both,85,,999999999,percent of total billed charges,70.7625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329333901,NDC,10,ML,79.51,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,70.7639,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
calcium CHLORIDE 10 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,76329330401,NDC,10,ML,79.51,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,70.7639,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,25021018482,NDC,100,ML,79.51,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,70.7639,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.786918,140.5516
menthol-zinc oxide Paste 113 g Tube,63700001,CDM,250,RC,,,,,,53329016544,NDC,113,GR,79.52,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,70.7728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703334301,NDC,0.5,ML,142.98,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,70.7751,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963805,NDC,0.5,ML,142.98,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,70.7751,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
Dihydroxyvitamin D - Ref,PX8265290,CDM,300,RC,82652,CPT,90,,,,,,,165,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,70.785,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.3,161.7
Flow Cyto Ea Addtl Marker - Ref,PX8818590,CDM,310,RC,88185,CPT,90,,,,,,,165,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,70.785,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.541,161.7
Strapping of Shoulder,PX29240F,CDM,420,RC,29240,CPT,,,,,,,,165,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,70.785,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.541,161.7
phytonadione 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714097302,NDC,0.5,EA,143.02,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,70.7949,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phytonadione 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,69238105103,NDC,0.5,EA,143.02,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,70.7949,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
trastuzumab 150 MG Recon Soln 1 Each Vial,J9355.01,CDM,636,RC,J9355,HCPCS,,,,50242013201,NDC,1,EA,3179.17,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,70.8,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.8,84.49
penicillin v potassium 250 MG/5ML Recon Soln 200 mL Bottle,63700001,CDM,250,RC,,,,,,93412774,NDC,200,ML,83.32,,First Health,Commercial,both,85,,999999999,percent of total billed charges,70.822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
TISSUE RETRIEVAL SYSTEM,27200000,CDM,272,RC,,,,10233-MAIN,LOCAL,,,,,139.98,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,70.82988,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Apply Forearm Cast,PX29075P,CDM,983,RC,29075,CPT,,,,,,,,140,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,70.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.156,234.62
Hospital Discharge Day>30 Min,PX99239P,CDM,982,RC,99239,CPT,,,,,,,,140,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,70.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.156,136.262
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094310,NDC,10,ML,72.79,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,14.281,percent of total billed charges,70.846507,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.236966,143.9032
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094321,NDC,10,ML,72.79,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,14.281,percent of total billed charges,70.846507,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.236966,143.9032
CT Abd & Pelvis W/O Contrast,PX7417601,CDM,350,RC,74176,CPT,TC,,,,,,,4288,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,70.89,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.89,209.71
CT Abd & Pelvis W/O Contrast,PX7417601,CDM,350,RC,74176,CPT,TC,,,,,,,4288,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,70.89,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.89,209.71
CT Abd & Pelvis W/O Contrast,PX7417601,CDM,350,RC,74176,CPT,TC,,,,,,,4288,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,70.89,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.89,209.71
US Doppler Lw Ext Art Tc,PX9392601,CDM,921,RC,93926,CPT,TC,,,,,,,740,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,70.89,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.89,211.74
US Doppler Lw Ext Art Tc,PX9392601,CDM,921,RC,93926,CPT,TC,,,,,,,740,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,70.89,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.89,211.74
ESOPHAGEAL BALLOON INFLATION DEVICE 60ML,27200000,CDM,272,RC,C1726,HCPCS,,11326-MAIN,LOCAL,,,,,80.41,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,70.92162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331601,NDC,10,ML,77.86,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,70.93046,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
nystatin 100000 UNIT/GM Cream 30 g Tube,25000000,CDM,250,RC,,,,,,168005430,NDC,30,GR,147.79,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,70.9392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
nystatin 100000 UNIT/GM Cream 30 g Tube,25000000,CDM,250,RC,,,,,,168005430,NDC,30,GR,147.79,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,70.9392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
doxycycline 100 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323013041,NDC,1,EA,140.2,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,70.9412,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409751716,NDC,50,ML,72.9,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,70.95357,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Pvb Thoracic Single Injection Site W/Img Gid,PX64461F,CDM,510,RC,64461,CPT,,,,,,,,353,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,70.9631,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.99,278.1
Pvb Thoracic Single Injection Site W/Img Gid,PX64461P,CDM,983,RC,64461,CPT,,,,,,,,616,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,70.9631,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.99,603.68
TRAY IV SURGICAL EXTREMITY DYNJS0804,27200000,CDM,272,RC,,,,10919-MAIN,LOCAL,,,,,83.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,70.975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Plas Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,338604648,NDC,100,ML,143.42,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,70.9929,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.786918,140.5516
dextrose 25% Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409177510,NDC,10,ML,83.53,,First Health,Commercial,both,85,,999999999,percent of total billed charges,71.0005,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036001,NDC,10,ML,80.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,71.001,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,84.5054
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098121,NDC,1,EA,72.95,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,13.11107143,percent of total billed charges,71.002235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,17478070311,NDC,10,ML,72.46,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,71.0108,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fluconazole 150 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,16714069210,NDC,1,EA,72.98,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,71.031434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"CCP, Antibody - Ref",PX8620090,CDM,300,RC,86200,CPT,90,,,,,,,171,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,71.0334,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,167.58
Hepatic Function Panel,PX80076,CDM,300,RC,80076,CPT,,,,,,,,171,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,71.0334,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.49,167.58
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105F,CDM,510,RC,11105,CPT,,,,,,,,171,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,71.0334,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.0334,167.58
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105P,CDM,983,RC,11105,CPT,,,,,,,,171,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,71.0334,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.0334,166.4343
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102F,CDM,510,RC,11102,CPT,,,,,,,,171,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,71.0334,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.0334,174.9
BLUE EYE SUBMUCOSAL LIFTING AGENT 5ML,27200000,CDM,272,RC,,,,12684-MAIN,LOCAL,,,,,148,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,71.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
BLUE EYE SUBMUCOSAL LIFTING AGENT 5ML,27200000,CDM,272,RC,,,,12684-MAIN,LOCAL,,,,,148,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,71.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Mumps,PX86735,CDM,300,RC,86735,CPT,,,,,,,,148,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,71.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.97,145.04
Mumps,PX86735,CDM,300,RC,86735,CPT,,,,,,,,148,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,71.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.97,145.04
Assay Carbamazepine Total,PX80156,CDM,300,RC,80156,CPT,,,,,,,,145,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,71.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.36,142.1
Assay Carbamazepine Total,PX80156,CDM,300,RC,80156,CPT,,,,,,,,145,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,71.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.36,142.1
Assay Carbamazepine Total,PX80156,CDM,300,RC,80156,CPT,,,,,,,,145,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,71.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.36,142.1
"Calculus, Infrared Spec - Ref",PX8236590,CDM,300,RC,82365,CPT,90,,,,,,,145,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,71.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.83,142.1
"Calculus, Infrared Spec - Ref",PX8236590,CDM,300,RC,82365,CPT,90,,,,,,,145,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,71.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.83,142.1
"Calculus, Infrared Spec - Ref",PX8236590,CDM,300,RC,82365,CPT,90,,,,,,,145,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,71.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.83,142.1
"Catecholamines, Fraction - Ref",PX8238490,CDM,300,RC,82384,CPT,90,,,,,,,145,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,71.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.15,142.1
"Catecholamines, Fraction - Ref",PX8238490,CDM,300,RC,82384,CPT,90,,,,,,,145,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,71.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.15,142.1
"Catecholamines, Fraction - Ref",PX8238490,CDM,300,RC,82384,CPT,90,,,,,,,145,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,71.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.15,142.1
Hsv Dna Amp Probe,PX87529,CDM,300,RC,87529,CPT,,,,,,,,145,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,71.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,142.1
Hsv Dna Amp Probe,PX87529,CDM,300,RC,87529,CPT,,,,,,,,145,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,71.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,142.1
Hsv Dna Amp Probe,PX87529,CDM,300,RC,87529,CPT,,,,,,,,145,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,71.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,142.1
Immunofixation Electrophoresis; Serum,PX86334,CDM,300,RC,86334,CPT,,,,,,,,145,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,71.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.48,142.1
Immunofixation Electrophoresis; Serum,PX86334,CDM,300,RC,86334,CPT,,,,,,,,145,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,71.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.48,142.1
Immunofixation Electrophoresis; Serum,PX86334,CDM,300,RC,86334,CPT,,,,,,,,145,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,71.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.48,142.1
LEGGING COMPRESSION JUXTALITE LONG LG 33CM,120.369,CDM,271,RC,A6545,HCPCS,,10840-MAIN,LOCAL,,,,,145,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,71.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.233,142.1
LEGGING COMPRESSION JUXTALITE LONG LG 33CM,120.369,CDM,271,RC,A6545,HCPCS,,10840-MAIN,LOCAL,,,,,145,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,71.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.233,142.1
LEGGING COMPRESSION JUXTALITE LONG LG 33CM,120.369,CDM,271,RC,A6545,HCPCS,,10840-MAIN,LOCAL,,,,,145,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,71.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.233,142.1
"Pare/Cut Hyperkeratotic Skin Lesion, Single",PX11055F,CDM,510,RC,11055,CPT,,,,,,,,145,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,28,percent of total billed charges,71.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.233,174.9
"Pare/Cut Hyperkeratotic Skin Lesion, Single",PX11055F,CDM,510,RC,11055,CPT,,,,,,,,145,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,71.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.233,174.9
"Pare/Cut Hyperkeratotic Skin Lesion, Single",PX11055F,CDM,510,RC,11055,CPT,,,,,,,,145,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,71.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.233,174.9
Surgical Cleansing of Skin,PX11000P,CDM,983,RC,11000,CPT,,,,,,,,145,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,71.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.233,548.67
Surgical Cleansing of Skin,PX11000P,CDM,983,RC,11000,CPT,,,,,,,,145,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,71.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.233,548.67
Surgical Cleansing of Skin,PX11000P,CDM,983,RC,11000,CPT,,,,,,,,145,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,71.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.233,548.67
Wheelchair Mngement Training,PX97542,CDM,420,RC,97542,CPT,,,,,,,,145,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,71.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.59,142.1
Wheelchair Mngement Training,PX97542,CDM,420,RC,97542,CPT,,,,,,,,145,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,71.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.59,142.1
Wheelchair Mngement Training,PX97542,CDM,420,RC,97542,CPT,,,,,,,,145,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,71.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.59,142.1
BALLOON EXTRACTOR PEDS,120.358,CDM,272,RC,,,,10771-MAIN,LOCAL,,,,,73,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,71.0509,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.3242,71.54
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046201,NDC,30,ML,79.84,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,71.0576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Ceruloplasmin - Ref,PX8239090,CDM,300,RC,82390,CPT,90,,,,,,,78,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,71.058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,76.44
Chemiluminescent Assay - Ref,PX8239790,CDM,300,RC,82397,CPT,90,,,,,,,78,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,71.058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.95,76.44
VISUALIZATION SYSTEM CLEARIFY LAPAROSCOPE STERILE,27200000,CDM,272,RC,,,,11875-MAIN,LOCAL,,,,,78,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,71.058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
erythromycin lactobionate 500 MG Recon Soln 1 Each Vial,J1364.01,CDM,636,RC,J1364,HCPCS,,,,409648211,NDC,1,EA,437.09,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,71.08,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.08,80.78
ENDOLOOP COATED VICRYL 0 18,27200000,CDM,272,RC,,,,10228-MAIN,LOCAL,,,,,143.6,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,71.082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"dextrose 5% and sodium chloride 0.45% with potassium chloride 10 mEq in 1000 mL 10-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,338066904,NDC,1000,ML,80.61,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,71.09802,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,264957710,NDC,500,ML,80.61,,United Healthcare,All Payer,outpatient,88.2,,0.211744841,percent of total billed charges,71.09802,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052201,NDC,500,ML,80.61,,United Healthcare,All Payer,outpatient,88.2,,0.211744841,percent of total billed charges,71.09802,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052277,NDC,500,ML,80.61,,United Healthcare,All Payer,outpatient,88.2,,0.211744841,percent of total billed charges,71.09802,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
Removal of Hemorrhoid Clot,PX46320F,CDM,510,RC,46320,CPT,,,,,,,,2027,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,71.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.24,445.52
Removal of Hemorrhoid Clot,PX46320F,CDM,510,RC,46320,CPT,,,,,,,,2027,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,71.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.24,445.52
Removal of Hemorrhoid Clot,PX46320P,CDM,983,RC,46320,CPT,,,,,,,,374,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,71.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.24,445.52
Removal of Hemorrhoid Clot,PX46320P,CDM,983,RC,46320,CPT,,,,,,,,374,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,71.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.24,445.52
hydrOXYzine 50 MG/ML Solution 1 mL Vial,J3410.01,CDM,636,RC,J3410,HCPCS,,,,517560125,NDC,0.5,ML,83.68,,First Health,Commercial,both,85,,999999999,percent of total billed charges,71.128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.760672,82.0064
F5 Gene - Ref,PX8124190,CDM,300,RC,81241,CPT,90,,,,,,,112,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,71.17,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.17,73.37
F5 Gene - Ref,PX8124190,CDM,300,RC,81241,CPT,90,,,,,,,112,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,71.17,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.17,73.37
F5 Gene - Ref,PX8124190,CDM,300,RC,81241,CPT,90,,,,,,,112,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,71.17,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.17,73.37
nystatin 100000 UNIT/GM Cream 30 g Tube,25000000,CDM,250,RC,,,,,,51672128902,NDC,30,GR,148.29,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,71.1792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
nystatin 100000 UNIT/GM Cream 30 g Tube,25000000,CDM,250,RC,,,,,,51672128902,NDC,30,GR,148.29,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,71.1792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,51672131200,NDC,22,GR,140.7,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,71.1942,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
triamcinolone acetonide 40 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029320,NDC,1,ML,72.65,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,71.197,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,72.0986
"Alpha-Fetoprotein, Serum - Ref",PX8210590,CDM,300,RC,82105,CPT,90,,,,,,,80,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,71.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.38,78.4
Prealubimin,PX84134,CDM,300,RC,84134,CPT,,,,,,,,80,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,71.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.38,78.4
"Breast Tomosynthesis,Dx Tc Bilat",PX7706201,CDM,401,RC,77062,CPT,TC,,,,,,,166,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,71.214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.9564,162.68
"Breast Tomosynthesis,Dx Tc Unilat",PX7706101,CDM,401,RC,77061,CPT,TC,,,,,,,166,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,71.214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.9564,162.68
"Breast Tomosynthesis,Screen Tc",PX7706301,CDM,403,RC,77063,CPT,TC,,,,,,,166,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,71.214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.59,280.5
Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq,PX87635,CDM,300,RC,87635,CPT,,,,,,,,166,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,71.214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,224.4
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,990771502,NDC,250,ML,166.02,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,71.22258,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.4701,303.0944
Immunocytochemistry,PX3993,CDM,310,RC,88342,CPT,TC,,,,,,,182,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,71.2398,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.41,118.24
Hepatitis C Antibody,PX86803,CDM,300,RC,86803,CPT,,,,,,,,144,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,71.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.08,141.12
ciprofloxacin 0.3 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,61314065625,NDC,2.5,ML,140.92,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,71.30552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
silver sulfADIAZINE 1 % Cream 50 g Jar,25000000,CDM,250,RC,,,,,,43598021055,NDC,50,GR,83.89,,First Health,Commercial,both,85,,999999999,percent of total billed charges,71.3065,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
LAP KIT BASIC,27200000,CDM,272,RC,,,,4829-MAIN,LOCAL,,,,,78.29,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,71.32219,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CT Upper Extremity W/O Dye,PX7320001,CDM,350,RC,73200,CPT,TC,,,,,,,2757,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,71.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.33,234.03
CT Upper Extremity W/O Dye,PX7320001,CDM,350,RC,73200,CPT,TC,,,,,,,2757,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,71.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.33,234.03
TRAY SURGICAL PODIATRY II EXTREMITY DYNJS0803,27200000,CDM,272,RC,,,,10920-MAIN,LOCAL,,,,,73.29,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,71.333157,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094310,NDC,10,ML,72.79,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,71.3342,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.236966,143.9032
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094321,NDC,10,ML,72.79,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,71.3342,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.236966,143.9032
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409751766,NDC,50,ML,80.89,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,71.34498,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Aspergillus Ag - Ref,PX8730590,CDM,300,RC,87305,CPT,90,,,,,,,141,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,71.346,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,138.18
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,63739005007,NDC,1,EA,73.35,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,71.391555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CANNULA OPTIFLOW JUNIOR2+ XXL OJR520,120.494,CDM,271,RC,A4615,HCPCS,,11619-MAIN,LOCAL,,,,,84,,First Health,Commercial,both,85,,999999999,percent of total billed charges,71.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.8936,82.32
Hiaa - Ref,PX8349790,CDM,300,RC,83497,CPT,90,,,,,,,84,,First Health,Commercial,both,85,,999999999,percent of total billed charges,71.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.83,82.32
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,69543025204,NDC,118,ML,78.39,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,71.41329,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rho d immune globulin human 1500 units solution prefilled syringe 1 Each Syringe,J2790.01,CDM,636,RC,J2790,HCPCS,,,,562780500,NDC,1,EA,464.01,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,71.42,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.42,81.16
CAPTIFLEX SNARE SINGLE USE EXTRA SMALL 11MM,27200000,CDM,272,RC,,,,12378-MAIN,LOCAL,,,,,81,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,71.442,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409751716,NDC,50,ML,72.9,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,71.442,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Smear Special Stain,PX87207,CDM,300,RC,87207,CPT,,,,,,,,81,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,71.442,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.49,79.38
Tacrolimus - Ref,PX8019790,CDM,300,RC,80197,CPT,90,,,,,,,81,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,71.442,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,79.38
AIRSEAL 12MM ACCESS PORT AND PALM GRIP OBTURATOR BLADELESS OPTICAL TIP 120MM,27200000,CDM,272,RC,,,,12207-MAIN,LOCAL,,,,,172,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,71.4488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
AIRSEAL TUBE SET TRI LUMEN FILTERED WITH ACTIVATED CHARCOAL,27200000,CDM,272,RC,,,,12206-MAIN,LOCAL,,,,,172,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,71.4488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098121,NDC,1,EA,72.95,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,71.491,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
"Urinalysis, Auto W/O Scope",PX81003,CDM,300,RC,81003,CPT,,,,,,,,149,,Health Partners,Health Partners Care Plans,both,48,,70.095,percent of total billed charges,71.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.06,146.02
"Urinalysis, Auto W/O Scope",PX81003,CDM,300,RC,81003,CPT,,,,,,,,149,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,71.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.06,146.02
fluconazole 150 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,16714069210,NDC,1,EA,72.98,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,71.5204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
albuterol HFA 108 (90 Base) MCG/ACT Aerosol Solution 8 g Inhaler,25000000,CDM,250,RC,,,,,,173068224,NDC,8,GR,149.04,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,71.5392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
albuterol HFA 108 (90 Base) MCG/ACT Aerosol Solution 8 g Inhaler,25000000,CDM,250,RC,,,,,,173068224,NDC,8,GR,149.04,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,71.5392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BALLOON EXTRACTOR PEDS,120.358,CDM,272,RC,,,,10771-MAIN,LOCAL,,,,,73,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,71.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.3242,71.54
Islet Cell Antibody - Ref,PX8634190,CDM,300,RC,86341,CPT,90,,,,,,,146,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,71.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.61,143.08
Islet Cell Antibody - Ref,PX8634190,CDM,300,RC,86341,CPT,90,,,,,,,146,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,71.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.61,143.08
Islet Cell Antibody - Ref,PX8634190,CDM,300,RC,86341,CPT,90,,,,,,,146,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,71.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.61,143.08
Abd Duplex Abd -Follow Up,PX9397602,CDM,921,RC,93976,CPT,TC,,,,,,,784,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,71.55,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.55,211.74
Abd Duplex Abd-Follow Up(T),PX9397601,CDM,921,RC,93976,CPT,TC,,,,,,,809,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,71.55,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.55,211.74
CT Upper Extremity W/O Dye,PX7320001,CDM,350,RC,73200,CPT,TC,,,,,,,2757,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,71.55,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.33,234.03
US Doppler Lw Ext Art Tc,PX9392601,CDM,921,RC,93926,CPT,TC,,,,,,,740,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,71.55,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.89,211.74
ESOPHAGEAL BALLOON INFLATION DEVICE 60ML,27200000,CDM,272,RC,C1726,HCPCS,,11326-MAIN,LOCAL,,,,,80.41,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,71.5649,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
triamcinolone acetonide 40 MG/ML Suspension 1 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029305,NDC,1,ML,73.57,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,6.011428571,percent of total billed charges,71.605681,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,72.0986
Fungus Isolation Culture,PX87102,CDM,300,RC,87102,CPT,,,,,,,,167,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,71.643,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.71,163.66
Microalbumin Quantitative,PX82043,CDM,300,RC,82043,CPT,,,,,,,,167,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,71.643,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.3,163.66
Wound Cult/Afb,PX87116,CDM,300,RC,87116,CPT,,,,,,,,167,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,71.643,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9,163.66
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036001,NDC,10,ML,80.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,71.645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,84.5054
Xray Knee 4 or More Vws,PX7356401,CDM,320,RC,73564,CPT,TC,,,,,,,490,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,71.66,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.56,71.66
Xray Knee 4 or More Vws,PX7356401,CDM,320,RC,73564,CPT,TC,,,,,,,490,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,71.66,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.56,71.66
vancomycin 125 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68180016611,NDC,1,EA,149.33,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,71.6784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 125 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68180016611,NDC,1,EA,149.33,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,71.6784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 125 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,47781072902,NDC,1,EA,149.33,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,71.6784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 125 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,47781072902,NDC,1,EA,149.33,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,71.6784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 125 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,62559039020,NDC,1,EA,149.33,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,71.6784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 125 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,62559039020,NDC,1,EA,149.33,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,71.6784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium zirconium cyclosilicate 10 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,310111001,NDC,1,EA,172.56,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,71.681424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,17478081725,NDC,25,ML,81.3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,71.7066,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"dextrose 5% and sodium chloride 0.45% with potassium chloride 10 mEq in 1000 mL 10-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,338066904,NDC,1000,ML,80.61,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,71.7429,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,264957710,NDC,500,ML,80.61,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,71.7429,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052201,NDC,500,ML,80.61,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,71.7429,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052277,NDC,500,ML,80.61,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,71.7429,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
magnesium sulfate 4 GM/50ML Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010701,NDC,50,ML,73.72,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,14.23621053,percent of total billed charges,71.751676,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
Assay Carbamazepine Total,PX80156,CDM,300,RC,80156,CPT,,,,,,,,145,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,71.775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.36,142.1
"Calculus, Infrared Spec - Ref",PX8236590,CDM,300,RC,82365,CPT,90,,,,,,,145,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,71.775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.83,142.1
"Catecholamines, Fraction - Ref",PX8238490,CDM,300,RC,82384,CPT,90,,,,,,,145,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,71.775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.15,142.1
Hsv Dna Amp Probe,PX87529,CDM,300,RC,87529,CPT,,,,,,,,145,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,71.775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,142.1
Immunofixation Electrophoresis; Serum,PX86334,CDM,300,RC,86334,CPT,,,,,,,,145,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,71.775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.48,142.1
LEGGING COMPRESSION JUXTALITE LONG LG 33CM,120.369,CDM,271,RC,A6545,HCPCS,,10840-MAIN,LOCAL,,,,,145,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,71.775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.233,142.1
"Pare/Cut Hyperkeratotic Skin Lesion, Single",PX11055F,CDM,510,RC,11055,CPT,,,,,,,,145,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,71.775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.233,174.9
Surgical Cleansing of Skin,PX11000P,CDM,983,RC,11000,CPT,,,,,,,,145,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,71.775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.233,548.67
Wheelchair Mngement Training,PX97542,CDM,420,RC,97542,CPT,,,,,,,,145,,Humana Choice Care,All Medicare plans,outpatient,49.5,,20.36666667,percent of total billed charges,71.775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.59,142.1
timolol 0.25 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314022605,NDC,5,ML,84.45,,First Health,Commercial,both,85,,999999999,percent of total billed charges,71.7825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
morphine 20 mg/mL Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,54040444,NDC,30,ML,141.88,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,71.79128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,70860030143,NDC,25,ML,84.47,,First Health,Commercial,both,85,,999999999,percent of total billed charges,71.7995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010626,NDC,50,ML,84.47,,First Health,Commercial,both,85,,999999999,percent of total billed charges,71.7995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
sodium bicarbonate 8.4 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409662502,NDC,50,ML,84.47,,First Health,Commercial,both,85,,999999999,percent of total billed charges,71.7995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Fac/Hospital Discharge Day>30 Min,PX99239F,CDM,510,RC,99239,CPT,,,,,,,,210,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,71.8,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.8,203.32
Hospital Discharge Day>30 Min,PX99239P,CDM,982,RC,99239,CPT,,,,,,,,140,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,71.8,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.8,203.32
TRAY SURGICAL PODIATRY II EXTREMITY DYNJS0803,27200000,CDM,272,RC,,,,10920-MAIN,LOCAL,,,,,73.29,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,71.8242,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
fluticasone 110 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173071920,NDC,12,GR,149.67,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,71.8416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone 110 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173071920,NDC,12,GR,149.67,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,71.8416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clotrimazole-betamethasone 1-0.05 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,51672404801,NDC,15,GR,172.95,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,71.84343,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Apply Multlay Comprs Lwr Leg,PX29581P,CDM,983,RC,29581,CPT,,,,,,,,142,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,71.852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,138.2086
"Biopsy Vulva/Perineum,One Lesn",PX56605P,CDM,983,RC,56605,CPT,,,,,,,,142,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,71.852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,702.31
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006P,CDM,983,RC,10006,CPT,,,,,,,,142,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,71.852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,138.2086
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760,CDM,420,RC,97760,CPT,,,,,,,,142,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,71.852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.18,139.16
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760F,CDM,510,RC,97760,CPT,,,,,,,,142,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,71.852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.18,139.16
Oximetry;Mult Determine,PX610,CDM,460,RC,94761,CPT,,,,,,,,142,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,71.852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,139.16
Thromboplastin Time Partial,PX85730,CDM,300,RC,85730,CPT,,,,,,,,142,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,71.852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.51,139.16
X-Ray Exam Femur 1 Vw,PX7355101,CDM,320,RC,73551,CPT,TC,,,,,,,142,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,71.852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,139.16
RBC Antibody Screen,PX86850,CDM,300,RC,86850,CPT,,,,,,,,173,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,71.8642,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,169.54
"Thyroxin, Free (Free T4)",PX84439,CDM,300,RC,84439,CPT,,,,,,,,173,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,71.8642,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.27,169.54
caffeine citrate 60 MG/3ML Solution 3 mL Vial,J0706.01,CDM,636,RC,J0706,HCPCS,,,,63323040704,NDC,3,ML,73.84,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,71.868472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.673136,72.3632
F5 Gene - Ref,PX8124190,CDM,300,RC,81241,CPT,90,,,,,,,112,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,71.8816,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.17,73.37
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,63739005007,NDC,1,EA,73.35,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,71.883,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,409508411,NDC,1,EA,73.86,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,71.887938,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
DOBUTamine 1000 mcg/mL in dextrose 5% 250 mL premix 1000 mcg/ml Solution 250 mL Flex Cont,J1250.01,CDM,636,RC,J1250,HCPCS,,,,338107302,NDC,250,ML,146.73,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,71.8977,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.951642,143.7954
DOBUTamine 1000 mcg/mL in dextrose 5% 250 mL premix 1000 mcg/ml Solution 250 mL Flex Cont,J1250.01,CDM,636,RC,J1250,HCPCS,,,,338107302,NDC,250,ML,146.73,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,71.8977,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.951642,143.7954
DOBUTamine 1000 mcg/mL in dextrose 5% 250 mL premix 1000 mcg/ml Solution 250 mL Flex Cont,J1250.01,CDM,636,RC,J1250,HCPCS,,,,338107302,NDC,250,ML,146.73,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,71.8977,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.951642,143.7954
betamethasone acetate-betamethasone sodium phosphate 6 (3-3) MG/ML Suspension 5 mL Vial,J0702.01,CDM,636,RC,J0702,HCPCS,,,,517072001,NDC,1,ML,78.96,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,71.93256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.799984,77.3808
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012365,NDC,0.7,ML,291.98,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,71.94578,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.59,73.4
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012388,NDC,0.7,ML,291.98,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,71.94578,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.59,73.4
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072310,NDC,0.5,ML,291.98,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,71.94578,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.59,73.4
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072388,NDC,0.5,ML,291.98,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,71.94578,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.59,73.4
Declot Vascular Access Device,PX36593F,CDM,510,RC,36593,CPT,,,,,,,,358,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,71.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.6,71.95
Declot Vascular Access Device,PX36593F,CDM,510,RC,36593,CPT,,,,,,,,358,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,71.95,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.6,71.95
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,409662902,NDC,10,ML,146.84,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1.188333333,percent of total billed charges,71.9516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.236966,143.9032
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,409662902,NDC,10,ML,146.84,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,71.9516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.236966,143.9032
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,409662902,NDC,10,ML,146.84,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,71.9516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.236966,143.9032
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,781375575,NDC,4,ML,142.22,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,71.96332,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Everolimus,PX8016990,CDM,300,RC,80169,CPT,,,,,,,,79,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,71.969,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,77.42
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,39328006712,NDC,473,ML,167.77,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,71.97333,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
etoposide 500 MG/25ML Solution 25 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,703565601,NDC,25,ML,173.28,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,71.980512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.949434,169.8144
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409751766,NDC,50,ML,80.89,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,71.9921,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Assay of CK (Cpk),PX82550,CDM,300,RC,82550,CPT,,,,,,,,150,,Health Partners,Health Partners Care Plans,both,48,,108.5916667,percent of total billed charges,72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.97,147
Assay of CK (Cpk),PX82550,CDM,300,RC,82550,CPT,,,,,,,,150,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.97,147
Assay of Lactic Acid,PX83605,CDM,300,RC,83605,CPT,,,,,,,,150,,Health Partners,Health Partners Care Plans,both,48,,63.49555556,percent of total billed charges,72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.61,147
Assay of Lactic Acid,PX83605,CDM,300,RC,83605,CPT,,,,,,,,150,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.61,147
Assay of Phosphorus,PX84100,CDM,300,RC,84100,CPT,,,,,,,,150,,Health Partners,Health Partners Care Plans,both,48,,130.96,percent of total billed charges,72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.35,147
Assay of Phosphorus,PX84100,CDM,300,RC,84100,CPT,,,,,,,,150,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.35,147
Bilirubin Direct,PX82248,CDM,300,RC,82248,CPT,,,,,,,,150,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.6,147
Bilirubin Direct,PX82248,CDM,300,RC,82248,CPT,,,,,,,,150,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.6,147
Bilirubin Total,PX82247,CDM,300,RC,82247,CPT,,,,,,,,150,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.6,147
Bilirubin Total,PX82247,CDM,300,RC,82247,CPT,,,,,,,,150,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.6,147
"Drug(S) or Substance(S), Definitive, Qualitative or Quantitative, Not Otherwise Specified; 1-3 - Ref",PX8037590,CDM,300,RC,80375,CPT,90,,,,,,,150,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.31,147
"Drug(S) or Substance(S), Definitive, Qualitative or Quantitative, Not Otherwise Specified; 1-3 - Ref",PX8037590,CDM,300,RC,80375,CPT,90,,,,,,,150,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.31,147
"Hsv Detect, Amplif Probe - Ref",PX8752990,CDM,300,RC,87529,CPT,90,,,,,,,150,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,147
"Hsv Detect, Amplif Probe - Ref",PX8752990,CDM,300,RC,87529,CPT,90,,,,,,,150,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,147
Magnesium,PX83735,CDM,300,RC,83735,CPT,,,,,,,,150,,Health Partners,Health Partners Care Plans,both,48,,86.5025,percent of total billed charges,72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.14,147
Magnesium,PX83735,CDM,300,RC,83735,CPT,,,,,,,,150,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.14,147
Magnesium - Ref,PX8373590,CDM,300,RC,83735,CPT,90,,,,,,,150,,Health Partners,Health Partners Care Plans,both,48,,86.5025,percent of total billed charges,72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.14,147
Magnesium - Ref,PX8373590,CDM,300,RC,83735,CPT,90,,,,,,,150,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.14,147
Po4 Inorganic (Phosphate) - Ref,PX8410090,CDM,300,RC,84100,CPT,90,,,,,,,150,,Health Partners,Health Partners Care Plans,both,48,,130.96,percent of total billed charges,72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.35,147
Po4 Inorganic (Phosphate) - Ref,PX8410090,CDM,300,RC,84100,CPT,90,,,,,,,150,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.35,147
TB Antigen Response Gamma Interferon T-Cell Susp,PX86481,CDM,300,RC,86481,CPT,,,,,,,,150,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.31,147
TB Antigen Response Gamma Interferon T-Cell Susp,PX86481,CDM,300,RC,86481,CPT,,,,,,,,150,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.31,147
Glucose Test,PX82950,CDM,300,RC,82950,CPT,,,,,,,,74,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,72.0242,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.36,72.52
KIT EMERGENCY BIRTH DYNJS0600,120.317,CDM,272,RC,,,,8344-MAIN,LOCAL,,,,,74,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,72.0242,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.7396,72.52
Rubeola Antibody,PX86765,CDM,300,RC,86765,CPT,,,,,,,,74,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,72.0242,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.81,72.52
protamine 10 MG/ML Solution 5 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022994,NDC,5,ML,84.74,,First Health,Commercial,both,85,,999999999,percent of total billed charges,72.029,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.431298,83.0452
Amphetamines; 1 or 2 - Ref,PX8032490,CDM,300,RC,80324,CPT,90,,,,,,,147,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,72.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.0638,144.06
Amphetamines; 1 or 2 - Ref,PX8032490,CDM,300,RC,80324,CPT,90,,,,,,,147,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,72.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.0638,144.06
Amphetamines; 1 or 2 - Ref,PX8032490,CDM,300,RC,80324,CPT,90,,,,,,,147,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,72.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.0638,144.06
Assay Ph Body Fluids Nos,PX83986,CDM,300,RC,83986,CPT,,,,,,,,147,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,72.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.28,144.06
Assay Ph Body Fluids Nos,PX83986,CDM,300,RC,83986,CPT,,,,,,,,147,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,72.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.28,144.06
Assay Ph Body Fluids Nos,PX83986,CDM,300,RC,83986,CPT,,,,,,,,147,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,72.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.28,144.06
"Cmv Detect, Amplifi Probe - Ref",PX8749690,CDM,300,RC,87496,CPT,90,,,,,,,147,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,72.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,144.06
"Cmv Detect, Amplifi Probe - Ref",PX8749690,CDM,300,RC,87496,CPT,90,,,,,,,147,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,72.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,144.06
"Cmv Detect, Amplifi Probe - Ref",PX8749690,CDM,300,RC,87496,CPT,90,,,,,,,147,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,72.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,144.06
"Methlenedioxyamphetamines (Mda, Mdea, Mdma) - Ref",PX8035990,CDM,300,RC,80359,CPT,90,,,,,,,147,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,72.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.0638,144.06
"Methlenedioxyamphetamines (Mda, Mdea, Mdma) - Ref",PX8035990,CDM,300,RC,80359,CPT,90,,,,,,,147,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,72.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.0638,144.06
"Methlenedioxyamphetamines (Mda, Mdea, Mdma) - Ref",PX8035990,CDM,300,RC,80359,CPT,90,,,,,,,147,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,72.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.0638,144.06
Ph Venous Blood,PX82800,CDM,300,RC,82800,CPT,,,,,,,,147,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,72.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.09,144.06
Ph Venous Blood,PX82800,CDM,300,RC,82800,CPT,,,,,,,,147,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,72.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.09,144.06
Ph Venous Blood,PX82800,CDM,300,RC,82800,CPT,,,,,,,,147,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,72.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.09,144.06
levoFLOXacin 250 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635161,NDC,1,EA,79.08,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,72.04188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine 1 MG/ML Solution 50 mL Syringe,J2270.01,CDM,636,RC,J2270,HCPCS,,,,61553064975,NDC,50,ML,81.71,,United Healthcare,All Payer,outpatient,88.2,,16.488,percent of total billed charges,72.06822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
Aerobic Isolate - Ref,PX8707790,CDM,300,RC,87077,CPT,90,,,,,,,168,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,72.072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,164.64
Complete Cbc W/Auto Diff Wbc,PX85025,CDM,300,RC,85025,CPT,,,,,,,,168,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,72.072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.12,164.64
Insert Straight Catheter,PX51701F,CDM,510,RC,51701,CPT,,,,,,,,168,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,72.072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.7872,164.64
Org ID Aerobic-Each,PX87077,CDM,300,RC,87077,CPT,,,,,,,,168,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,72.072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,164.64
US Pelvic Tc Complete,PX7685601,CDM,402,RC,76856,CPT,TC,,,,,,,472,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,72.0832,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.65,144.63
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062430,NDC,0.3,ML,147.12,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,9.81,percent of total billed charges,72.0888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062430,NDC,0.3,ML,147.12,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,72.0888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062430,NDC,0.3,ML,147.12,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,72.0888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801301,NDC,0.3,ML,147.12,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,9.81,percent of total billed charges,72.0888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801301,NDC,0.3,ML,147.12,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,72.0888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801301,NDC,0.3,ML,147.12,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,72.0888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801310,NDC,0.3,ML,147.12,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,9.81,percent of total billed charges,72.0888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801310,NDC,0.3,ML,147.12,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,72.0888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801310,NDC,0.3,ML,147.12,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,72.0888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
CAPTIFLEX SNARE SINGLE USE EXTRA SMALL 11MM,27200000,CDM,272,RC,,,,12378-MAIN,LOCAL,,,,,81,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,72.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Smear Special Stain,PX87207,CDM,300,RC,87207,CPT,,,,,,,,81,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,72.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.49,79.38
Tacrolimus - Ref,PX8019790,CDM,300,RC,80197,CPT,90,,,,,,,81,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,72.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,79.38
Raltegravir 400 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,6022761,NDC,1,EA,150.2,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,72.096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Raltegravir 400 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,6022761,NDC,1,EA,150.2,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,72.096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
triamcinolone acetonide 40 MG/ML Suspension 1 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029305,NDC,1,ML,73.57,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,72.0986,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,72.0986
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409338513,NDC,1,EA,74.09,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,13.11107143,percent of total billed charges,72.111797,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
Occupational Therapy Eval High Complex,PX97167,CDM,434,RC,97167,CPT,,,,,,,,289,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,72.14,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.14,133.55
Occupational Therapy Eval Low Complex,PX97165,CDM,434,RC,97165,CPT,,,,,,,,235,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,72.14,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.14,133.55
Occupational Therapy Eval Mod Complex,PX97166,CDM,434,RC,97166,CPT,,,,,,,,264,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,72.14,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.14,133.55
Physical Therapy Evaluation High Complex,PX97163,CDM,424,RC,97163,CPT,,,,,,,,294,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,72.14,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.14,132.23
Physical Therapy Evaluation Low Complex,PX97161,CDM,424,RC,97161,CPT,,,,,,,,235,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,72.14,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.14,132.23
Physical Therapy Evaluation Mod Complex,PX97162,CDM,424,RC,97162,CPT,,,,,,,,264,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,72.14,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.14,132.23
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,409337504,NDC,4,ML,150.36,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,72.1728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,409337504,NDC,4,ML,150.36,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,72.1728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
urea 20 % Cream 85 g Tube,63700001,CDM,250,RC,,,,,,536110945,NDC,85,GR,81.83,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,72.17406,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Infectious Disease,Chronic Hep C Virus,Six Assays, Utilizing Serum",PX8159690,CDM,300,RC,81596,CPT,90,,,,,,,609,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,72.19,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.02,72.19
ceFAZolin in D4W 1 g / 50 mL 1-4 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0690.01,CDM,636,RC,J0690,HCPCS,,,,264310311,NDC,1,EA,84.97,,First Health,Commercial,both,85,,999999999,percent of total billed charges,72.2245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
magnesium sulfate 4 GM/50ML Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010701,NDC,50,ML,73.72,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,72.2456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
"Cognitive Funct Ther Interv, Initial 15 Min",PX97129,CDM,420,RC,97129,CPT,,,,,,,,85,,First Health,Commercial,both,85,,999999999,percent of total billed charges,72.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15,83.3
"Exam,Synovial Fluid Crystals",PX89060,CDM,300,RC,89060,CPT,,,,,,,,85,,First Health,Commercial,both,85,,999999999,percent of total billed charges,72.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.72,83.3
GLIDESCOPE QC MAC S3 SINGLE USE 0270-1083,120.579,CDM,272,RC,,,,13046-MAIN,LOCAL,,,,,85,,First Health,Commercial,both,85,,999999999,percent of total billed charges,72.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.309,83.3
GLIDESCOPE QC MAC S3 SINGLE USE 0270-1085,120.579,CDM,272,RC,,,,13022-MAIN,LOCAL,,,,,85,,First Health,Commercial,both,85,,999999999,percent of total billed charges,72.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.309,83.3
GLIDESCOPE QC MAC S4 SINGLE USE 0270-1086,120.579,CDM,272,RC,,,,13023-MAIN,LOCAL,,,,,85,,First Health,Commercial,both,85,,999999999,percent of total billed charges,72.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.309,83.3
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963801,NDC,0.5,ML,88.69,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,72.25,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.65,84.496
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963805,NDC,0.5,ML,142.98,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,72.25,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.65,84.496
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,55150017301,NDC,0.5,ML,319.2,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,72.25,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.65,84.496
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,63323027301,NDC,0.5,ML,235.6,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,72.25,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.65,84.496
sodium bicarbonate 8.4 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409662522,NDC,50,ML,85.02,,First Health,Commercial,both,85,,999999999,percent of total billed charges,72.267,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ketoconazole 2 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,168009915,NDC,15,GR,173.97,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,72.267138,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Islet Cell Antibody - Ref,PX8634190,CDM,300,RC,86341,CPT,90,,,,,,,146,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,72.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.61,143.08
Ace - Ref,PX8216490,CDM,300,RC,82164,CPT,90,,,,,,,82,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,72.324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.39,80.36
Anca Screen Each Antibody,PX8603690,CDM,300,RC,86036,CPT,90,,,,,,,82,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,72.324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.0628,80.36
"Cognitive Funct Ther Interv, Ea Addl 15 Min",PX97130,CDM,420,RC,97130,CPT,,,,,,,,82,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,72.324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31,80.36
"Cortisol, Free - Ref",PX8253090,CDM,300,RC,82530,CPT,90,,,,,,,82,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,72.324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.32,80.36
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703334301,NDC,0.5,ML,142.98,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,72.34788,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963805,NDC,0.5,ML,142.98,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,72.34788,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,17478081725,NDC,25,ML,81.3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,72.357,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
caffeine citrate 60 MG/3ML Solution 3 mL Vial,J0706.01,CDM,636,RC,J0706,HCPCS,,,,63323040704,NDC,3,ML,73.84,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,72.3632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.673136,72.3632
phytonadione 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714097302,NDC,0.5,EA,143.02,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,72.36812,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phytonadione 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,69238105103,NDC,0.5,EA,143.02,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,72.36812,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,409508411,NDC,1,EA,73.86,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,72.3828,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040304,NDC,10,ML,168.77,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,72.40233,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040310,NDC,10,ML,168.77,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,72.40233,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
nystatin 100000 UNIT/GM Cream 30 g Tube,25000000,CDM,250,RC,,,,,,168005430,NDC,30,GR,147.79,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,72.4171,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
nystatin 100000 UNIT/GM Cream 30 g Tube,25000000,CDM,250,RC,,,,,,168005430,NDC,30,GR,147.79,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,72.4171,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
nystatin 100000 UNIT/GM Cream 30 g Tube,25000000,CDM,250,RC,,,,,,168005430,NDC,30,GR,147.79,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,72.4171,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329333901,NDC,10,ML,79.51,,Medica,Commercial,both,91.1,,1.63075,percent of total billed charges,72.43361,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
calcium CHLORIDE 10 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,76329330401,NDC,10,ML,79.51,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,72.43361,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,25021018482,NDC,100,ML,79.51,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,72.43361,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.786918,140.5516
levonorgestrel 1.5 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,68180085211,NDC,1,EA,174.39,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,72.441606,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
menthol-zinc oxide Paste 113 g Tube,63700001,CDM,250,RC,,,,,,53329016544,NDC,113,GR,79.52,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,72.44272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Blood Clot Factor VIII Test,PX85247,CDM,300,RC,85247,CPT,,,,,,,,169,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,72.501,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.03,165.62
Tap Block Unilateral by Injection(S),PX64486P,CDM,983,RC,64486,CPT,,,,,,,,169,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,72.501,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.2026,164.4877
BLUE EYE SUBMUCOSAL LIFTING AGENT 5ML,27200000,CDM,272,RC,,,,12684-MAIN,LOCAL,,,,,148,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,72.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
BLUE EYE SUBMUCOSAL LIFTING AGENT 5ML,27200000,CDM,272,RC,,,,12684-MAIN,LOCAL,,,,,148,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,72.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
BLUE EYE SUBMUCOSAL LIFTING AGENT 5ML,27200000,CDM,272,RC,,,,12684-MAIN,LOCAL,,,,,148,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,72.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Glucose Test,PX82950,CDM,300,RC,82950,CPT,,,,,,,,74,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,72.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.36,72.52
KIT EMERGENCY BIRTH DYNJS0600,120.317,CDM,272,RC,,,,8344-MAIN,LOCAL,,,,,74,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,72.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.7396,72.52
Mumps,PX86735,CDM,300,RC,86735,CPT,,,,,,,,148,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,72.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.97,145.04
Mumps,PX86735,CDM,300,RC,86735,CPT,,,,,,,,148,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,72.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.97,145.04
Mumps,PX86735,CDM,300,RC,86735,CPT,,,,,,,,148,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,72.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.97,145.04
Rubeola Antibody,PX86765,CDM,300,RC,86765,CPT,,,,,,,,74,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,72.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.81,72.52
US Guide Needle Bx S&I,PX7694226,CDM,982,RC,76942,CPT,26,,,,,,,148,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,149.4,percent of total billed charges,72.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.4792,144.0484
US Guide Needle Bx S&I,PX7694226,CDM,982,RC,76942,CPT,26,,,,,,,148,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,72.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.4792,144.0484
US Guide Needle Bx S&I,PX7694226,CDM,982,RC,76942,CPT,26,,,,,,,148,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,72.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.4792,144.0484
solifenacin 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50228042730,NDC,1,EA,74.52,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,72.530316,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CISplatin 50 MG/50ML Solution 50 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010351,NDC,50,ML,82.27,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,72.56214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.174958,180.2416
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Plas Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,338604648,NDC,100,ML,143.42,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,72.57052,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.786918,140.5516
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409338513,NDC,1,EA,74.09,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,72.6082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
riTUXimab 100 MG/10ML Solution 10 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005121,NDC,10,ML,1916.61,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,72.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.61,8682.8588
riTUXimab 500 MG/50ML Solution 50 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005306,NDC,50,ML,8860.06,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,72.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.61,8682.8588
DOBUTamine 1000 mcg/mL in dextrose 5% 250 mL premix 1000 mcg/ml Solution 250 mL Flex Cont,J1250.01,CDM,636,RC,J1250,HCPCS,,,,338107302,NDC,250,ML,146.73,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,72.63135,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.951642,143.7954
Art Lower Extremity+Upper,PX9392301,CDM,921,RC,93923,CPT,TC,,,,,,,784,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,72.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.67,190.22
Art Lower Extremity+Upper,PX9392301,CDM,921,RC,93923,CPT,TC,,,,,,,784,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,72.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.67,190.22
ARIPiprazole 2 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714014101,NDC,1,EA,151.35,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,72.648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ARIPiprazole 2 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714014101,NDC,1,EA,151.35,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,72.648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ENDOLOOP COATED VICRYL 0 18,27200000,CDM,272,RC,,,,10228-MAIN,LOCAL,,,,,143.6,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,72.6616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
nystatin 100000 UNIT/GM Cream 30 g Tube,25000000,CDM,250,RC,,,,,,51672128902,NDC,30,GR,148.29,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,72.6621,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
nystatin 100000 UNIT/GM Cream 30 g Tube,25000000,CDM,250,RC,,,,,,51672128902,NDC,30,GR,148.29,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,72.6621,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
nystatin 100000 UNIT/GM Cream 30 g Tube,25000000,CDM,250,RC,,,,,,51672128902,NDC,30,GR,148.29,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,72.6621,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,55150012150,NDC,1,EA,151.41,,Health Partners,Health Partners Care Plans,both,48,,6.796666667,percent of total billed charges,72.6768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,55150012150,NDC,1,EA,151.41,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,72.6768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,409662902,NDC,10,ML,146.84,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,72.6858,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.236966,143.9032
Electrolyte Panel,PX80051,CDM,300,RC,80051,CPT,,,,,,,,175,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,72.695,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.43,171.5
"Fac/Trm Hyperkeratotic Skn Lesn,>4",PX11057F,CDM,510,RC,11057,CPT,,,,,,,,175,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,72.695,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.695,174.9
"Gonadotropin, Chorionic (Hcg), Qualitative",PX84703,CDM,300,RC,84703,CPT,,,,,,,,175,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,72.695,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.9,171.5
Protein E-Phoresis Serum,PX84165,CDM,300,RC,84165,CPT,,,,,,,,175,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,72.695,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,171.5
Protein Elp Interp,PX8416526,CDM,300,RC,84165,CPT,26,,,,,,,175,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,72.695,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,171.5
morphine 1 MG/ML Solution 50 mL Syringe,J2270.01,CDM,636,RC,J2270,HCPCS,,,,61553064975,NDC,50,ML,81.71,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,72.7219,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
US Retroperitoneal Tc,PX7677001,CDM,402,RC,76770,CPT,TC,,,,,,,566,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,72.7268,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.08,145.29
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046201,NDC,30,ML,79.84,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,72.73424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Amphetamines; 1 or 2 - Ref,PX8032490,CDM,300,RC,80324,CPT,90,,,,,,,147,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,72.765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.0638,144.06
Assay Ph Body Fluids Nos,PX83986,CDM,300,RC,83986,CPT,,,,,,,,147,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,72.765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.28,144.06
"Cmv Detect, Amplifi Probe - Ref",PX8749690,CDM,300,RC,87496,CPT,90,,,,,,,147,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,72.765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,144.06
"Methlenedioxyamphetamines (Mda, Mdea, Mdma) - Ref",PX8035990,CDM,300,RC,80359,CPT,90,,,,,,,147,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,72.765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.0638,144.06
Ph Venous Blood,PX82800,CDM,300,RC,82800,CPT,,,,,,,,147,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,72.765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.09,144.06
RETRIEVAL BAG 10MM,27200000,CDM,272,RC,,,,11707-MAIN,LOCAL,,,,,74.8,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,72.80284,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062430,NDC,0.3,ML,147.12,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,72.8244,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801301,NDC,0.3,ML,147.12,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,72.8244,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801310,NDC,0.3,ML,147.12,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,72.8244,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
urea 20 % Cream 85 g Tube,63700001,CDM,250,RC,,,,,,536110945,NDC,85,GR,81.83,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,72.8287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Hepatitis C Antibody,PX86803,CDM,300,RC,86803,CPT,,,,,,,,144,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,72.864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.08,141.12
"Alpha-Fetoprotein, Serum - Ref",PX8210590,CDM,300,RC,82105,CPT,90,,,,,,,80,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,72.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.38,78.4
Prealubimin,PX84134,CDM,300,RC,84134,CPT,,,,,,,,80,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,72.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.38,78.4
Fac/Cystourethroscopy,PX52000F,CDM,761,RC,52000,CPT,,,,,,,,1601,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,72.8897,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.86,497.4
Asay of Interleukin-6 (Il-6),PX8352990,CDM,300,RC,83529,CPT,90,,,,,,,170,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,72.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,166.6
Chem Cautery Granulatn Tissue,PX17250F,CDM,510,RC,17250,CPT,,,,,,,,170,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,72.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,174.9
"Chemotherapy Administration, Subq/Im Non-Hormonal Anti-Neoplastic",PX96401,CDM,335,RC,96401,CPT,,,,,,,,170,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,72.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,166.6
Collagen Cross Links - Ref,PX8252390,CDM,300,RC,82523,CPT,90,,,,,,,170,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,72.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.13,166.6
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800P,CDM,983,RC,40800,CPT,,,,,,,,170,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,72.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,614.65
gadoteridol 279.3 MG/ML Solution 17 mL Syringe,A9576,CDM,636,RC,A9576,HCPCS,,,,270111145,NDC,17,ML,170,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,72.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.54,166.6
"Inject Nerv Blck,Trigeminal",PX64400P,CDM,983,RC,64400,CPT,,,,,,,,170,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,72.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,258.75
"Protein, Total; Serum, Plasma or Whole Blood",PX84155,CDM,300,RC,84155,CPT,,,,,,,,170,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,72.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.37,166.6
sodium zirconium cyclosilicate 5 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,310110501,NDC,1,EA,151.95,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,72.936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium zirconium cyclosilicate 5 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,310110501,NDC,1,EA,151.95,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,72.936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Antipsychotics, Not Otherwise Specified; 1-3 - Ref",PX8034290,CDM,300,RC,80342,CPT,90,,,,,,,152,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,72.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.1408,148.96
"Antipsychotics, Not Otherwise Specified; 1-3 - Ref",PX8034290,CDM,300,RC,80342,CPT,90,,,,,,,152,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,72.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.1408,148.96
Body Fluid Cell Count,PX89050,CDM,300,RC,89050,CPT,,,,,,,,152,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,72.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.33,148.96
Body Fluid Cell Count,PX89050,CDM,300,RC,89050,CPT,,,,,,,,152,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,72.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.33,148.96
"X-Ray Exam Hip,Unilat W/Pelvis 2-3 Vws",PX7350201,CDM,320,RC,73502,CPT,TC,,,,,,,436,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,72.97,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.99,72.97
"X-Ray Exam Hip,Unilat W/Pelvis 2-3 Vws",PX7350201,CDM,320,RC,73502,CPT,TC,,,,,,,436,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,72.97,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.99,72.97
Ace - Ref,PX8216490,CDM,300,RC,82164,CPT,90,,,,,,,82,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,72.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.39,80.36
Anca Screen Each Antibody,PX8603690,CDM,300,RC,86036,CPT,90,,,,,,,82,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,72.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.0628,80.36
"Cognitive Funct Ther Interv, Ea Addl 15 Min",PX97130,CDM,420,RC,97130,CPT,,,,,,,,82,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,72.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31,80.36
"Cortisol, Free - Ref",PX8253090,CDM,300,RC,82530,CPT,90,,,,,,,82,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,72.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.32,80.36
"Echo Heart Xthoracic,Limited",PX9330801,CDM,480,RC,93308,CPT,TC,,,,,,,349,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,72.9805,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.65,129.72
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,45802095301,NDC,100,GR,82.76,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,72.99432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Assay Cryofibrinogen,PX82585,CDM,300,RC,82585,CPT,,,,,,,,75,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,72.9975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.96,73.5
Assay Cryoglobulin,PX82595,CDM,300,RC,82595,CPT,,,,,,,,75,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,72.9975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,73.5
BINDER ABDOMINAL 9 INCH 46 TO 62 INCH XL ORT21100LXL,120.238,CDM,271,RC,A4467,HCPCS,,2989-MAIN,LOCAL,,,,,75,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,72.9975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL 9 INCH 63 TO 74 INCH 3- PANEL ORT211002XL,120.238,CDM,271,RC,A4467,HCPCS,,37-MAIN,LOCAL,,,,,75,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,72.9975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL 10 INCH 26 TO 50 INCHES ABB1050,120.238,CDM,271,RC,A4467,HCPCS,,52-MAIN,LOCAL,,,,,75,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,72.9975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
"BINDER ABDOMINAL 12"" HIGH 2XL 60-75INCH 4 PANEL ORT213002XL",120.238,CDM,271,RC,A4467,HCPCS,,12536-MAIN,LOCAL,,,,,75,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,72.9975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL UNISIZE 46-62IN 9 IN MDS169024,120.238,CDM,271,RC,A4467,HCPCS,,63-MAIN,LOCAL,,,,,75,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,72.9975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
"Direct skilled nursing services of a license practical nurse (lpn) in the home health or hospice setting, each 15 minutes",PXG0300,CDM,551,RC,G0300,HCPCS,,,,,,,,75,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,72.9975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
HH Rn Initial Visit,PXG0154,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,72.9975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
HH Rn Routine Visit,PXG0154.01,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,72.9975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
Skilled Srvc of a Lpn in Training and/or Education of Pt or Fam Ea 15 Min,PXG0496,CDM,551,RC,G0496,HCPCS,,,,,,,,75,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,72.9975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
Skilled srvc of an RN in training and/or education of pt or fam ea 15 min,PXG0495,CDM,551,RC,G0495,HCPCS,,,,,,,,75,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,72.9975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
"Urinalysis, Auto W/O Scope",PX81003,CDM,300,RC,81003,CPT,,,,,,,,149,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,21.18619048,percent of total billed charges,73.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.06,146.02
"Urinalysis, Auto W/O Scope",PX81003,CDM,300,RC,81003,CPT,,,,,,,,149,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,73.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.06,146.02
"Urinalysis, Auto W/O Scope",PX81003,CDM,300,RC,81003,CPT,,,,,,,,149,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,73.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.06,146.02
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,59148000713,NDC,1,EA,170.19,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,73.01151,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
albuterol HFA 108 (90 Base) MCG/ACT Aerosol Solution 8 g Inhaler,25000000,CDM,250,RC,,,,,,173068224,NDC,8,GR,149.04,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,73.0296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
albuterol HFA 108 (90 Base) MCG/ACT Aerosol Solution 8 g Inhaler,25000000,CDM,250,RC,,,,,,173068224,NDC,8,GR,149.04,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,73.0296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
albuterol HFA 108 (90 Base) MCG/ACT Aerosol Solution 8 g Inhaler,25000000,CDM,250,RC,,,,,,173068224,NDC,8,GR,149.04,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,73.0296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
solifenacin 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50228042730,NDC,1,EA,74.52,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,73.0296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402F,CDM,510,RC,11402,CPT,,,,,,,,424,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,73.08,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.08,359.04
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402P,CDM,983,RC,11402,CPT,,,,,,,,424,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,73.08,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.08,415.52
Aldosterone - Ref,PX8208890,CDM,300,RC,82088,CPT,90,,,,,,,86,,First Health,Commercial,both,85,,999999999,percent of total billed charges,73.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.7244,84.28
Epstein-barr antibody,PX86665,CDM,300,RC,86665,CPT,,,,,,,,86,,First Health,Commercial,both,85,,999999999,percent of total billed charges,73.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.63,84.28
CCP Antibody,PX86200,CDM,300,RC,86200,CPT,,,,,,,,176,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,73.1104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,172.48
Detect Agent Nos Dna Amp,PX87798,CDM,300,RC,87798,CPT,,,,,,,,176,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,73.1104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,172.48
Eval of Bronchospasm,PX94060,CDM,983,RC,94060,CPT,,,,,,,,176,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,73.1104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.1104,274.21
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151F,CDM,370,RC,99151,CPT,,,,,,,,176,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,73.1104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.1104,172.48
SAWBLADE SAGITAL STERILE 25MM LENGTH 5.5MM WIDTH 0.60MM THICKNESS,27200000,CDM,272,RC,,,,11623-MAIN,LOCAL,,,,,86.02,,First Health,Commercial,both,85,,999999999,percent of total billed charges,73.117,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
tiotropium 18 MCG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,597007541,NDC,1,EA,82.92,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,73.13544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/GM Cream 30 g Tube,25000000,CDM,250,RC,,,,,,168005430,NDC,30,GR,147.79,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,73.15605,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,25021012867,NDC,1,EA,82.96,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,73.17072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,55150020830,NDC,1,EA,82.96,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,73.17072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.461584,189.875
vancomycin 125 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68180016611,NDC,1,EA,149.33,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,73.1717,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 125 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68180016611,NDC,1,EA,149.33,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,73.1717,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 125 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68180016611,NDC,1,EA,149.33,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,73.1717,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 125 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,47781072902,NDC,1,EA,149.33,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,73.1717,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 125 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,47781072902,NDC,1,EA,149.33,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,73.1717,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 125 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,47781072902,NDC,1,EA,149.33,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,73.1717,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 125 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,62559039020,NDC,1,EA,149.33,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,73.1717,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 125 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,62559039020,NDC,1,EA,149.33,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,73.1717,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 125 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,62559039020,NDC,1,EA,149.33,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,73.1717,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,47781047013,NDC,1,EA,83,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,73.206,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,64380079901,NDC,1,EA,83,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,73.206,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,69238126601,NDC,1,EA,83,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,73.206,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SLING ARM CHILD PAD CANVAS NAVY 8004-02,120.54,CDM,273,RC,A4565,HCPCS,,878-MAIN,LOCAL,,,,,83,,United Healthcare,All Payer,outpatient,88.2,,166,percent of total billed charges,73.206,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM LARGE PAD CANVAS NAVY ORT11300L,120.54,CDM,273,RC,A4565,HCPCS,,870-MAIN,LOCAL,,,,,83,,United Healthcare,All Payer,outpatient,88.2,,166,percent of total billed charges,73.206,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM MEDIUM PAD CANVAS NAVY ORT11300M,120.54,CDM,273,RC,A4565,HCPCS,,872-MAIN,LOCAL,,,,,83,,United Healthcare,All Payer,outpatient,88.2,,166,percent of total billed charges,73.206,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM SMALL PAD CANVAS NAVY ORT11300S,120.54,CDM,273,RC,A4565,HCPCS,,874-MAIN,LOCAL,,,,,83,,United Healthcare,All Payer,outpatient,88.2,,166,percent of total billed charges,73.206,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM X-LARGE PAD ENVELOPE ORT11300XL,120.54,CDM,273,RC,A4565,HCPCS,,876-MAIN,LOCAL,,,,,83,,United Healthcare,All Payer,outpatient,88.2,,166,percent of total billed charges,73.206,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
CISplatin 50 MG/50ML Solution 50 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010351,NDC,50,ML,82.27,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,73.2203,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.174958,180.2416
aztreonam 1 g Recon Soln 1 Each Vial,J0457.01,CDM,636,RC,J0457,HCPCS,,,,63323040124,NDC,1,EA,176.32,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,73.243328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.32,172.7936
ESOPHAGEAL BALLOON INFLATION DEVICE 60ML,27200000,CDM,272,RC,C1726,HCPCS,,11326-MAIN,LOCAL,,,,,80.41,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,73.25351,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
BLUE EYE SUBMUCOSAL LIFTING AGENT 5ML,27200000,CDM,272,RC,,,,12684-MAIN,LOCAL,,,,,148,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,73.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Mumps,PX86735,CDM,300,RC,86735,CPT,,,,,,,,148,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,73.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.97,145.04
US Guide Needle Bx S&I,PX7694226,CDM,982,RC,76942,CPT,26,,,,,,,148,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,73.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.4792,144.0484
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036019,NDC,10,ML,86.23,,First Health,Commercial,both,85,,999999999,percent of total billed charges,73.2955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,84.5054
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127303,NDC,2,ML,152.7,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,73.296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.43158,173.019
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127303,NDC,2,ML,152.7,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,73.296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.43158,173.019
RETRIEVAL BAG 10MM,27200000,CDM,272,RC,,,,11707-MAIN,LOCAL,,,,,74.8,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,73.304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
IMMOBILIZER SHOULDER LARGE 9008-03,120.38,CDM,274,RC,L3650,HCPCS,,906-MAIN,LOCAL,,,,,36,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,73.31,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,77.17
IMMOBILIZER SHOULDER LARGE STRAP OSG3033,120.38,CDM,274,RC,L3650,HCPCS,,2910-MAIN,LOCAL,,,,,36,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,73.31,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,77.17
IMMOBILIZER SHOULDER MEDIUM 9008-02,120.38,CDM,274,RC,L3650,HCPCS,,912-MAIN,LOCAL,,,,,36,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,73.31,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,77.17
IMMOBILIZER SHOULDER MEDIUM OSG3032,120.38,CDM,274,RC,L3650,HCPCS,,915-MAIN,LOCAL,,,,,36,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,73.31,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,77.17
IMMOBILIZER SHOULDER SMALL 9008-01,120.38,CDM,274,RC,L3650,HCPCS,,913-MAIN,LOCAL,,,,,36,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,73.31,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,77.17
IMMOBILIZER SHOULDER SMALL WITH CLOTH 9001-02,120.38,CDM,274,RC,L3650,HCPCS,,914-MAIN,LOCAL,,,,,36,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,73.31,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,77.17
IMMOBILIZER SHOULDER X-LARGE CLOTH 9001-05,120.38,CDM,274,RC,L3650,HCPCS,,917-MAIN,LOCAL,,,,,36,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,73.31,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,77.17
IMMOBILIZER SHOULDER X-LARGE ORT16100XL,120.38,CDM,274,RC,L3650,HCPCS,,904-MAIN,LOCAL,,,,,36,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,73.31,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,77.17
Fresh Frozen Plasma,PXP9017,CDM,390,RC,P9017,HCPCS,,,,,,,,319,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,73.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.32,312.62
Lvl 2 Sub Hosp Mod Mdm or 35 Minute,PX99232,CDM,982,RC,99232,CPT,,,,,,,,253,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,73.3248,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.54,247.94
"Remv F.B.,Eye,Embed Conjunc",PX65210F,CDM,510,RC,65210,CPT,,,,,,,,325,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,73.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.69,78.87
"Remv F.B.,Eye,Embed Conjunc",PX65210P,CDM,983,RC,65210,CPT,,,,,,,,216,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,73.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.69,211.68
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036001,NDC,10,ML,80.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,73.3355,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,84.5054
fluticasone 110 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173071920,NDC,12,GR,149.67,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,73.3383,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone 110 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173071920,NDC,12,GR,149.67,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,73.3383,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone 110 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173071920,NDC,12,GR,149.67,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,73.3383,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127332,NDC,2,ML,176.55,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,73.33887,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.43158,173.019
"CCP, Antibody - Ref",PX8620090,CDM,300,RC,86200,CPT,90,,,,,,,171,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,73.359,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,167.58
Hepatic Function Panel,PX80076,CDM,300,RC,80076,CPT,,,,,,,,171,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,73.359,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.49,167.58
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105F,CDM,510,RC,11105,CPT,,,,,,,,171,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,73.359,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.0334,167.58
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105P,CDM,983,RC,11105,CPT,,,,,,,,171,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,73.359,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.0334,166.4343
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102F,CDM,510,RC,11102,CPT,,,,,,,,171,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,73.359,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.0334,174.9
F5 Gene - Ref,PX8124190,CDM,300,RC,81241,CPT,90,,,,,,,112,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,73.37,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.17,73.37
Assay Carbamazepine Total,PX80156,CDM,300,RC,80156,CPT,,,,,,,,145,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,73.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.36,142.1
"Calculus, Infrared Spec - Ref",PX8236590,CDM,300,RC,82365,CPT,90,,,,,,,145,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,73.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.83,142.1
"Catecholamines, Fraction - Ref",PX8238490,CDM,300,RC,82384,CPT,90,,,,,,,145,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,73.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.15,142.1
Hsv Dna Amp Probe,PX87529,CDM,300,RC,87529,CPT,,,,,,,,145,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,73.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,142.1
Immunofixation Electrophoresis; Serum,PX86334,CDM,300,RC,86334,CPT,,,,,,,,145,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,73.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.48,142.1
LEGGING COMPRESSION JUXTALITE LONG LG 33CM,120.369,CDM,271,RC,A6545,HCPCS,,10840-MAIN,LOCAL,,,,,145,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,73.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.233,142.1
"Pare/Cut Hyperkeratotic Skin Lesion, Single",PX11055F,CDM,510,RC,11055,CPT,,,,,,,,145,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,73.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.233,174.9
Surgical Cleansing of Skin,PX11000P,CDM,983,RC,11000,CPT,,,,,,,,145,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,73.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.233,548.67
Wheelchair Mngement Training,PX97542,CDM,420,RC,97542,CPT,,,,,,,,145,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,73.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.59,142.1
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,55150043801,NDC,20,ML,152.9,,Health Partners,Health Partners Care Plans,both,48,,31.91277778,percent of total billed charges,73.392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,55150043801,NDC,20,ML,152.9,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,73.392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457018120,NDC,20,ML,152.9,,Health Partners,Health Partners Care Plans,both,48,,31.91277778,percent of total billed charges,73.392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457018120,NDC,20,ML,152.9,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,73.392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012365,NDC,0.7,ML,291.98,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,73.4,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.59,73.4
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012365,NDC,0.7,ML,291.98,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,73.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.59,73.4
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012365,NDC,0.7,ML,291.98,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,73.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.59,73.4
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012388,NDC,0.7,ML,291.98,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,73.4,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.59,73.4
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012388,NDC,0.7,ML,291.98,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,73.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.59,73.4
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012388,NDC,0.7,ML,291.98,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,73.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.59,73.4
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072310,NDC,0.5,ML,291.98,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,73.4,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.59,73.4
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072310,NDC,0.5,ML,291.98,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,73.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.59,73.4
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072310,NDC,0.5,ML,291.98,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,73.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.59,73.4
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072388,NDC,0.5,ML,291.98,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,73.4,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.59,73.4
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072388,NDC,0.5,ML,291.98,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,73.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.59,73.4
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072388,NDC,0.5,ML,291.98,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,73.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.59,73.4
nystatin 100000 UNIT/GM Cream 30 g Tube,25000000,CDM,250,RC,,,,,,51672128902,NDC,30,GR,148.29,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,73.40355,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032225,NDC,1,EA,176.72,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,73.409488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,173.1856
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143998391,NDC,1,EA,83.25,,United Healthcare,All Payer,outpatient,88.2,,20.73428571,percent of total billed charges,73.4265,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004703,NDC,1,EA,75.45,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,73.435485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
"dextrose 5% and sodium chloride 0.45% with potassium chloride 10 mEq in 1000 mL 10-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,338066904,NDC,1000,ML,80.61,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,73.43571,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,264957710,NDC,500,ML,80.61,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,73.43571,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052201,NDC,500,ML,80.61,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,73.43571,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052277,NDC,500,ML,80.61,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,73.43571,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
ELECTRODE ADULT PACING ONESTEP,120.214,CDM,272,RC,A4556,HCPCS,,10242-MAIN,LOCAL,,,,,153,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,73.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.5562,149.94
ELECTRODE ADULT PACING ONESTEP,120.214,CDM,272,RC,A4556,HCPCS,,10242-MAIN,LOCAL,,,,,153,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,73.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.5562,149.94
"Protein, Total; Other Source",PX84157,CDM,300,RC,84157,CPT,,,,,,,,153,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,73.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.67,149.94
"Protein, Total; Other Source",PX84157,CDM,300,RC,84157,CPT,,,,,,,,153,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,73.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.67,149.94
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457018100,NDC,20,ML,153.01,,Health Partners,Health Partners Care Plans,both,48,,31.91277778,percent of total billed charges,73.4448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457018100,NDC,20,ML,153.01,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,73.4448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
leucovorin 350 MG Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,703514501,NDC,1,EA,86.41,,First Health,Commercial,both,85,,999999999,percent of total billed charges,73.4485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.670002,84.6818
droPERidol 2.5 MG/ML Solution 2 mL Vial,J1790.01,CDM,636,RC,J1790,HCPCS,,,,517970201,NDC,2,ML,75.47,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,15.1,percent of total billed charges,73.454951,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.350238,73.9606
penicillin v potassium 250 MG/5ML Recon Soln 200 mL Bottle,63700001,CDM,250,RC,,,,,,93412774,NDC,200,ML,83.32,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,73.48824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay Cryofibrinogen,PX82585,CDM,300,RC,82585,CPT,,,,,,,,75,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,73.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.96,73.5
Assay Cryoglobulin,PX82595,CDM,300,RC,82595,CPT,,,,,,,,75,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,73.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,73.5
Assay of CK (Cpk),PX82550,CDM,300,RC,82550,CPT,,,,,,,,150,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,36.59857143,percent of total billed charges,73.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.97,147
Assay of CK (Cpk),PX82550,CDM,300,RC,82550,CPT,,,,,,,,150,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,73.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.97,147
Assay of CK (Cpk),PX82550,CDM,300,RC,82550,CPT,,,,,,,,150,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,73.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.97,147
Assay of Lactic Acid,PX83605,CDM,300,RC,83605,CPT,,,,,,,,150,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,17.32,percent of total billed charges,73.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.61,147
Assay of Lactic Acid,PX83605,CDM,300,RC,83605,CPT,,,,,,,,150,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,73.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.61,147
Assay of Lactic Acid,PX83605,CDM,300,RC,83605,CPT,,,,,,,,150,,United Healthcare,All Medicare advantage plans,outpatient,49,,78.175,percent of total billed charges,73.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.61,147
Assay of Phosphorus,PX84100,CDM,300,RC,84100,CPT,,,,,,,,150,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,127.21,percent of total billed charges,73.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.35,147
Assay of Phosphorus,PX84100,CDM,300,RC,84100,CPT,,,,,,,,150,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,73.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.35,147
Assay of Phosphorus,PX84100,CDM,300,RC,84100,CPT,,,,,,,,150,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,73.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.35,147
Bilirubin Direct,PX82248,CDM,300,RC,82248,CPT,,,,,,,,150,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,73.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.6,147
Bilirubin Direct,PX82248,CDM,300,RC,82248,CPT,,,,,,,,150,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,73.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.6,147
Bilirubin Direct,PX82248,CDM,300,RC,82248,CPT,,,,,,,,150,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,73.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.6,147
Bilirubin Total,PX82247,CDM,300,RC,82247,CPT,,,,,,,,150,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,73.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.6,147
Bilirubin Total,PX82247,CDM,300,RC,82247,CPT,,,,,,,,150,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,73.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.6,147
Bilirubin Total,PX82247,CDM,300,RC,82247,CPT,,,,,,,,150,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,73.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.6,147
BINDER ABDOMINAL 9 INCH 46 TO 62 INCH XL ORT21100LXL,120.238,CDM,271,RC,A4467,HCPCS,,2989-MAIN,LOCAL,,,,,75,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,73.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL 9 INCH 63 TO 74 INCH 3- PANEL ORT211002XL,120.238,CDM,271,RC,A4467,HCPCS,,37-MAIN,LOCAL,,,,,75,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,73.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL 10 INCH 26 TO 50 INCHES ABB1050,120.238,CDM,271,RC,A4467,HCPCS,,52-MAIN,LOCAL,,,,,75,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,73.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
"BINDER ABDOMINAL 12"" HIGH 2XL 60-75INCH 4 PANEL ORT213002XL",120.238,CDM,271,RC,A4467,HCPCS,,12536-MAIN,LOCAL,,,,,75,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,73.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
BINDER ABDOMINAL UNISIZE 46-62IN 9 IN MDS169024,120.238,CDM,271,RC,A4467,HCPCS,,63-MAIN,LOCAL,,,,,75,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,73.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6464,73.5
"Direct skilled nursing services of a license practical nurse (lpn) in the home health or hospice setting, each 15 minutes",PXG0300,CDM,551,RC,G0300,HCPCS,,,,,,,,75,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,73.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
"Drug(S) or Substance(S), Definitive, Qualitative or Quantitative, Not Otherwise Specified; 1-3 - Ref",PX8037590,CDM,300,RC,80375,CPT,90,,,,,,,150,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,73.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.31,147
"Drug(S) or Substance(S), Definitive, Qualitative or Quantitative, Not Otherwise Specified; 1-3 - Ref",PX8037590,CDM,300,RC,80375,CPT,90,,,,,,,150,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,73.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.31,147
"Drug(S) or Substance(S), Definitive, Qualitative or Quantitative, Not Otherwise Specified; 1-3 - Ref",PX8037590,CDM,300,RC,80375,CPT,90,,,,,,,150,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,73.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.31,147
HH Rn Initial Visit,PXG0154,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,73.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
HH Rn Routine Visit,PXG0154.01,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,73.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
"Hsv Detect, Amplif Probe - Ref",PX8752990,CDM,300,RC,87529,CPT,90,,,,,,,150,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,73.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,147
"Hsv Detect, Amplif Probe - Ref",PX8752990,CDM,300,RC,87529,CPT,90,,,,,,,150,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,73.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,147
"Hsv Detect, Amplif Probe - Ref",PX8752990,CDM,300,RC,87529,CPT,90,,,,,,,150,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,73.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,147
Magnesium,PX83735,CDM,300,RC,83735,CPT,,,,,,,,150,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,11.71705882,percent of total billed charges,73.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.14,147
Magnesium,PX83735,CDM,300,RC,83735,CPT,,,,,,,,150,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,73.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.14,147
Magnesium,PX83735,CDM,300,RC,83735,CPT,,,,,,,,150,,United Healthcare,All Medicare advantage plans,outpatient,49,,79.5,percent of total billed charges,73.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.14,147
Magnesium - Ref,PX8373590,CDM,300,RC,83735,CPT,90,,,,,,,150,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,11.71705882,percent of total billed charges,73.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.14,147
Magnesium - Ref,PX8373590,CDM,300,RC,83735,CPT,90,,,,,,,150,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,73.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.14,147
Magnesium - Ref,PX8373590,CDM,300,RC,83735,CPT,90,,,,,,,150,,United Healthcare,All Medicare advantage plans,outpatient,49,,79.5,percent of total billed charges,73.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.14,147
Po4 Inorganic (Phosphate) - Ref,PX8410090,CDM,300,RC,84100,CPT,90,,,,,,,150,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,127.21,percent of total billed charges,73.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.35,147
Po4 Inorganic (Phosphate) - Ref,PX8410090,CDM,300,RC,84100,CPT,90,,,,,,,150,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,73.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.35,147
Po4 Inorganic (Phosphate) - Ref,PX8410090,CDM,300,RC,84100,CPT,90,,,,,,,150,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,73.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.35,147
Skilled Srvc of a Lpn in Training and/or Education of Pt or Fam Ea 15 Min,PXG0496,CDM,551,RC,G0496,HCPCS,,,,,,,,75,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,73.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
Skilled srvc of an RN in training and/or education of pt or fam ea 15 min,PXG0495,CDM,551,RC,G0495,HCPCS,,,,,,,,75,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,73.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.155,73.5
TB Antigen Response Gamma Interferon T-Cell Susp,PX86481,CDM,300,RC,86481,CPT,,,,,,,,150,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,73.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.31,147
TB Antigen Response Gamma Interferon T-Cell Susp,PX86481,CDM,300,RC,86481,CPT,,,,,,,,150,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,73.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.31,147
TB Antigen Response Gamma Interferon T-Cell Susp,PX86481,CDM,300,RC,86481,CPT,,,,,,,,150,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,73.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.31,147
"Sigmoidoscopy,Remv Lesn,Snare",PX45338F,CDM,510,RC,45338,CPT,,,,,,,,2137,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,73.52,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.52,620.54
"Sigmoidoscopy,Remv Lesn,Snare",PX45338P,CDM,983,RC,45338,CPT,,,,,,,,1710,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,73.52,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.52,1675.8
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862066230,NDC,1,EA,153.17,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,73.5216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862066230,NDC,1,EA,153.17,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,73.5216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046837,NDC,30,ML,75.54,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,73.523082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Assay of Ferritin,PX82728,CDM,300,RC,82728,CPT,,,,,,,,177,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,73.5258,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.5,173.46
"D-Dimer, Quantitative - Ref",PX8537990,CDM,300,RC,85379,CPT,90,,,,,,,177,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,73.5258,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.33,173.46
Fibrin Degradation Quant,PX85379,CDM,300,RC,85379,CPT,,,,,,,,177,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,73.5258,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.33,173.46
Inj Tendon/Ligament/Cyst,PX20550F,CDM,510,RC,20550,CPT,,,,,,,,177,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,73.5258,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.5258,258.75
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954201,NDC,10,ML,153.18,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,73.5264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.630972,150.1164
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954201,NDC,10,ML,153.18,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,73.5264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.630972,150.1164
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954210,NDC,10,ML,153.18,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,73.5264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.630972,150.1164
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954210,NDC,10,ML,153.18,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,73.5264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.630972,150.1164
Fac/Removal of Skin Tags,PX11200F,CDM,510,RC,11200,CPT,,,,,,,,348,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,73.5319,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.65,193.01
Removal of Skin Tags,PX11200P,CDM,983,RC,11200,CPT,,,,,,,,418,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,73.5319,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.65,409.64
Raltegravir 400 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,6022761,NDC,1,EA,150.2,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,73.598,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Raltegravir 400 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,6022761,NDC,1,EA,150.2,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,73.598,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Raltegravir 400 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,6022761,NDC,1,EA,150.2,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,73.598,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
enalaprilat 1.25 MG/ML Injectable 2 mL Vial,25000000,CDM,250,RC,,,,,,143978601,NDC,2,ML,75.63,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,73.610679,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Xray Ribs Bilat 3 Vws With Pa Chest,PX7111101,CDM,320,RC,71111,CPT,TC,,,,,,,417,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,73.63,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.65,73.63
Xray Ribs Bilat 3 Vws With Pa Chest,PX7111101,CDM,320,RC,71111,CPT,TC,,,,,,,417,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,73.63,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.65,73.63
hepatitis b recomb vaccine 10 MCG/0.5ML suspension prefilled syringe 0.5 mL Syringe,90743,CDM,636,RC,90743,CPT,,,,58160082052,NDC,0.5,ML,137.47,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,73.64655,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.64655,75.15
TRAY IV SURGICAL EXTREMITY DYNJS0804,27200000,CDM,272,RC,,,,10919-MAIN,LOCAL,,,,,83.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,73.647,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,24208031510,NDC,10,ML,75.67,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,73.649611,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
hepatitis b recomb vaccine 10 MCG/0.5ML suspension prefilled syringe 0.5 mL Syringe,90743,CDM,636,RC,90743,CPT,,,,58160082052,NDC,0.5,ML,137.47,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,73.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.64655,75.15
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,45802095301,NDC,100,GR,82.76,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,73.6564,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dextrose 25% Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409177510,NDC,10,ML,83.53,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,73.67346,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,409337504,NDC,4,ML,150.36,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,73.6764,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,409337504,NDC,4,ML,150.36,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,73.6764,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,409337504,NDC,4,ML,150.36,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,73.6764,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409751766,NDC,50,ML,80.89,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,73.69079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
levothyroxine Sodium 200 MCG Recon Soln 1 Each Vial,J0650.01,CDM,636,RC,J0650,HCPCS,,,,63323064710,NDC,0.0625,EA,75.75,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,73.727475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.46655,74.235
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505615204,NDC,0.5,EA,86.76,,First Health,Commercial,both,85,,999999999,percent of total billed charges,73.746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
"Urinalysis, Auto W/O Scope",PX81003,CDM,300,RC,81003,CPT,,,,,,,,149,,Humana Choice Care,All Medicare plans,outpatient,49.5,,73.01,percent of total billed charges,73.755,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.06,146.02
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,16714081701,NDC,1,EA,75.78,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,73.756674,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ramuCIRumab 100 MG/10ML Solution 10 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2766901,NDC,10,ML,2463.3,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,73.76,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.7,73.76
ramuCIRumab 500 MG/50ML Solution 50 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2767801,NDC,50,ML,12316.5,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,73.76,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.7,73.76
Fibrinogen Test - Ref,PX8536690,CDM,300,RC,85366,CPT,90,,,,,,,179,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,73.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.77,175.42
trastuzumab 150 MG Recon Soln 1 Each Vial,J9355.01,CDM,636,RC,J9355,HCPCS,,,,50242013201,NDC,1,EA,3179.17,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,73.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.77,3115.5866
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001302,NDC,2,ML,86.79,,First Health,Commercial,both,85,,999999999,percent of total billed charges,73.7715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
albuterol HFA 108 (90 Base) MCG/ACT Aerosol Solution 8 g Inhaler,25000000,CDM,250,RC,,,,,,173068224,NDC,8,GR,149.04,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,73.7748,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
AIRSEAL 12MM ACCESS PORT AND PALM GRIP OBTURATOR BLADELESS OPTICAL TIP 120MM,27200000,CDM,272,RC,,,,12207-MAIN,LOCAL,,,,,172,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,73.788,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
AIRSEAL TUBE SET TRI LUMEN FILTERED WITH ACTIVATED CHARCOAL,27200000,CDM,272,RC,,,,12206-MAIN,LOCAL,,,,,172,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,73.788,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CAPTIFLEX SNARE SINGLE USE EXTRA SMALL 11MM,27200000,CDM,272,RC,,,,12378-MAIN,LOCAL,,,,,81,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,73.791,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Smear Special Stain,PX87207,CDM,300,RC,87207,CPT,,,,,,,,81,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,73.791,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.49,79.38
Tacrolimus - Ref,PX8019790,CDM,300,RC,80197,CPT,90,,,,,,,81,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,73.791,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,79.38
tiotropium 18 MCG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,597007541,NDC,1,EA,82.92,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,73.7988,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine 50 MG/ML Solution 1 mL Vial,J3410.01,CDM,636,RC,J3410,HCPCS,,,,517560125,NDC,0.5,ML,83.68,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,73.80576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.760672,82.0064
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,25021012867,NDC,1,EA,82.96,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,73.8344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,55150020830,NDC,1,EA,82.96,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,73.8344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.461584,189.875
"Injection Hip Arthrogram,Anesth",PX27095F,CDM,510,RC,27095,CPT,,,,,,,,425,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,73.853,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.95,633.69
"Injection Hip Arthrogram,Anesth",PX27095P,CDM,983,RC,27095,CPT,,,,,,,,425,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,73.853,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.95,633.69
infuvite adult Injectable 10 mL Vial,J3490.99,CDM,636,RC,J3490,HCPCS,,,,54643564901,NDC,10,ML,86.89,,First Health,Commercial,both,85,,999999999,percent of total billed charges,73.8565,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.094106,85.1522
OBINutuzumab 1000 MG/40ML Solution 40 mL Vial,J9301.01,CDM,636,RC,J9301,HCPCS,,,,50242007001,NDC,4,ML,1397.15,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,73.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.22,73.86
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,47781047013,NDC,1,EA,83,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,73.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,64380079901,NDC,1,EA,83,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,73.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,69238126601,NDC,1,EA,83,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,73.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SLING ARM CHILD PAD CANVAS NAVY 8004-02,120.54,CDM,273,RC,A4565,HCPCS,,878-MAIN,LOCAL,,,,,83,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,73.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM LARGE PAD CANVAS NAVY ORT11300L,120.54,CDM,273,RC,A4565,HCPCS,,870-MAIN,LOCAL,,,,,83,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,73.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM MEDIUM PAD CANVAS NAVY ORT11300M,120.54,CDM,273,RC,A4565,HCPCS,,872-MAIN,LOCAL,,,,,83,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,73.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM SMALL PAD CANVAS NAVY ORT11300S,120.54,CDM,273,RC,A4565,HCPCS,,874-MAIN,LOCAL,,,,,83,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,73.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM X-LARGE PAD ENVELOPE ORT11300XL,120.54,CDM,273,RC,A4565,HCPCS,,876-MAIN,LOCAL,,,,,83,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,73.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
Islet Cell Antibody - Ref,PX8634190,CDM,300,RC,86341,CPT,90,,,,,,,146,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,73.876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.61,143.08
Canalith Repositioning,PX95992,CDM,420,RC,95992,CPT,,,,,,,,128,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,73.88,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.69,73.88
vancomycin 125 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68180016611,NDC,1,EA,149.33,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,73.91835,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 125 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,47781072902,NDC,1,EA,149.33,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,73.91835,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 125 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,62559039020,NDC,1,EA,149.33,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,73.91835,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PROSTEP 0.9MM ANTI SKIVE PIN,27200000,CDM,272,RC,,,,12950-MAIN,LOCAL,,,,,154,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,73.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PROSTEP 0.9MM ANTI SKIVE PIN,27200000,CDM,272,RC,,,,12950-MAIN,LOCAL,,,,,154,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,73.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PROSTEP 1.4MM ANTI SKIVE PIN,27200000,CDM,272,RC,,,,12949-MAIN,LOCAL,,,,,154,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,73.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PROSTEP 1.4MM ANTI SKIVE PIN,27200000,CDM,272,RC,,,,12949-MAIN,LOCAL,,,,,154,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,73.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Vit D 1 25-Dihydroxy,PX82652,CDM,300,RC,82652,CPT,,,,,,,,154,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,73.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.3,150.92
Vit D 1 25-Dihydroxy,PX82652,CDM,300,RC,82652,CPT,,,,,,,,154,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,73.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.3,150.92
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004703,NDC,1,EA,75.45,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,73.941,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
"Chemotherapy, IV Push, Additional Drug",PX96411,CDM,335,RC,96411,CPT,,,,,,,,87,,First Health,Commercial,both,85,,999999999,percent of total billed charges,73.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.1398,85.26
"Digital Mamm, Diag, Bilat, Tc W/Cad Perf",PX7706601,CDM,401,RC,77066,CPT,TC,,,,,,,375,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,73.95,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.95,220.89
droPERidol 2.5 MG/ML Solution 2 mL Vial,J1790.01,CDM,636,RC,J1790,HCPCS,,,,517970201,NDC,2,ML,75.47,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,73.9606,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.350238,73.9606
Assay of Blood Lipoprotein,PX83721,CDM,300,RC,83721,CPT,,,,,,,,76,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,73.9708,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.63,74.48
Lab Direct Coombs,PX86880,CDM,300,RC,86880,CPT,,,,,,,,76,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,73.9708,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.5704,74.48
PRONEVIEW CUSHION INSERTS LARGE,120.557,CDM,272,RC,E0190,HCPCS,,12500-MAIN,LOCAL,,,,,76,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,73.9708,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.5704,74.48
SHOE POST OP LARGE MALE MQM3B,120.237,CDM,274,RC,L3260,HCPCS,,794-MAIN,LOCAL,,,,,76,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,73.9708,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP LARGE SQUARE TOE WOMENS ORT30300WL,120.237,CDM,274,RC,L3260,HCPCS,,10606-MAIN,LOCAL,,,,,76,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,73.9708,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP MEDIUM SQUARE TOE MALE ORT30300MM,120.237,CDM,274,RC,L3260,HCPCS,,10603-MAIN,LOCAL,,,,,76,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,73.9708,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP MEDIUM SQUARE TOE WOMENS ORT30300WM,120.237,CDM,274,RC,L3260,HCPCS,,10605-MAIN,LOCAL,,,,,76,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,73.9708,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP SMALL MALE 0814-1192,120.237,CDM,274,RC,L3260,HCPCS,,803-MAIN,LOCAL,,,,,76,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,73.9708,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP SMALL SQUARE TOE WOMENS MQW1B,120.237,CDM,274,RC,L3260,HCPCS,,10604-MAIN,LOCAL,,,,,76,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,73.9708,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
silver sulfADIAZINE 1 % Cream 50 g Jar,25000000,CDM,250,RC,,,,,,43598021055,NDC,50,GR,83.89,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,73.99098,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Drain/Inject Small Joint/Bursa,PX20600F,CDM,510,RC,20600,CPT,,,,,,,,161,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,74.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.82,112.07
Drain/Inject Small Joint/Bursa,PX20600P,CDM,983,RC,20600,CPT,,,,,,,,161,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,74.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.82,157.78
sodium zirconium cyclosilicate 10 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,310111001,NDC,1,EA,172.56,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,74.02824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046837,NDC,30,ML,75.54,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,74.0292,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium polystyrene sulfonate Powder 15 g Bottle,25000000,CDM,250,RC,,,,,,10702003615,NDC,15,GR,76.09,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,74.058397,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
erythromycin lactobionate 500 MG Recon Soln 1 Each Vial,J1364.01,CDM,636,RC,J1364,HCPCS,,,,409648211,NDC,1,EA,437.09,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,74.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.06,428.3482
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,17478081725,NDC,25,ML,81.3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,74.0643,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024110,NDC,1,EA,76.1,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,18.705,percent of total billed charges,74.06813,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
fluticasone 110 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173071920,NDC,12,GR,149.67,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,74.08665,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CANNULA OPTIFLOW JUNIOR2+ XXL OJR520,120.494,CDM,271,RC,A4615,HCPCS,,11619-MAIN,LOCAL,,,,,84,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,74.088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.8936,82.32
Hiaa - Ref,PX8349790,CDM,300,RC,83497,CPT,90,,,,,,,84,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,74.088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.83,82.32
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143998391,NDC,1,EA,83.25,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,74.0925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,47781046813,NDC,1,EA,76.15,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,74.116795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,64380079701,NDC,1,EA,76.15,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,74.116795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
enalaprilat 1.25 MG/ML Injectable 2 mL Vial,25000000,CDM,250,RC,,,,,,143978601,NDC,2,ML,75.63,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,74.1174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Emergency Level II Visit,PX99282P,CDM,981,RC,99282,CPT,,,,,,,,337,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,74.15,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.53,330.26
Emergency Level II Visit,PX99282P,CDM,981,RC,99282,CPT,,,,,,,,337,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,74.15,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.53,330.26
Facility Emergency Level II Visit,PX99282F,CDM,450,RC,99282,CPT,,,,,,,,387,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,74.15,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.53,74.15
Facility Emergency Level II Visit,PX99282F,CDM,450,RC,99282,CPT,,,,,,,,387,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,74.15,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.53,74.15
penicillin v potassium 250 MG/5ML Recon Soln 200 mL Bottle,63700001,CDM,250,RC,,,,,,93412774,NDC,200,ML,83.32,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,74.1548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,24208031510,NDC,10,ML,75.67,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,74.1566,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ARIPiprazole 2 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714014101,NDC,1,EA,151.35,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,74.1615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ARIPiprazole 2 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714014101,NDC,1,EA,151.35,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,74.1615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ARIPiprazole 2 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714014101,NDC,1,EA,151.35,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,74.1615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Drainage of Hematoma/Fluid (P),PX10140P,CDM,983,RC,10140,CPT,,,,,,,,465,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,74.17,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.17,455.7
Drainage of Hematoma/Fluid (T),PX10140F,CDM,510,RC,10140,CPT,,,,,,,,341,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,74.17,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.17,354.2
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402F,CDM,510,RC,11402,CPT,,,,,,,,424,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,74.17,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.08,359.04
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402F,CDM,510,RC,11402,CPT,,,,,,,,424,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,74.17,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.08,359.04
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402P,CDM,983,RC,11402,CPT,,,,,,,,424,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,74.17,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.08,415.52
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402P,CDM,983,RC,11402,CPT,,,,,,,,424,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,74.17,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.08,415.52
"Sigmoidoscopy,Remv Lesn,Snare",PX45338F,CDM,510,RC,45338,CPT,,,,,,,,2137,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,74.17,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.52,620.54
"Sigmoidoscopy,Remv Lesn,Snare",PX45338F,CDM,510,RC,45338,CPT,,,,,,,,2137,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,74.17,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.52,620.54
"Sigmoidoscopy,Remv Lesn,Snare",PX45338P,CDM,983,RC,45338,CPT,,,,,,,,1710,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,74.17,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.52,1675.8
"Sigmoidoscopy,Remv Lesn,Snare",PX45338P,CDM,983,RC,45338,CPT,,,,,,,,1710,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,74.17,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.52,1675.8
"Percut Biopsy, Abdominal Mass",PX49180F,CDM,510,RC,49180,CPT,,,,,,,,2084,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,74.1741,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.39,359.04
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,55150012150,NDC,1,EA,151.41,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,14.99111111,percent of total billed charges,74.1909,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,55150012150,NDC,1,EA,151.41,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,74.1909,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,55150012150,NDC,1,EA,151.41,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,74.1909,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
clotrimazole-betamethasone 1-0.05 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,51672404801,NDC,15,GR,172.95,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,74.19555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Emergency Level IV Visit,PX99284P,CDM,981,RC,99284,CPT,,,,,,,,914,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,74.2,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.2,895.72
Fac/Hospital Discharge Day>30 Min,PX99239F,CDM,510,RC,99239,CPT,,,,,,,,210,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,74.2,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.8,203.32
Fac/Hospital Discharge Day>30 Min,PX99239F,CDM,510,RC,99239,CPT,,,,,,,,210,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,74.2,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.8,203.32
Facility Emergency Level IV Visit,PX99284F,CDM,450,RC,99284,CPT,,,,,,,,1054,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,74.2,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.2,214.68
Hospital Discharge Day>30 Min,PX99239P,CDM,982,RC,99239,CPT,,,,,,,,140,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,74.2,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.8,203.32
Hospital Discharge Day>30 Min,PX99239P,CDM,982,RC,99239,CPT,,,,,,,,140,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,74.2,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.8,203.32
RBC Antibody Screen,PX86850,CDM,300,RC,86850,CPT,,,,,,,,173,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,74.217,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,169.54
"Thyroxin, Free (Free T4)",PX84439,CDM,300,RC,84439,CPT,,,,,,,,173,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,74.217,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.27,169.54
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,574200815,NDC,15,GR,154.63,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,74.2224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,574200815,NDC,15,GR,154.63,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,74.2224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levothyroxine Sodium 200 MCG Recon Soln 1 Each Vial,J0650.01,CDM,636,RC,J0650,HCPCS,,,,63323064710,NDC,0.0625,EA,75.75,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,74.235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.46655,74.235
DOBUTamine 1000 mcg/mL in dextrose 5% 250 mL premix 1000 mcg/ml Solution 250 mL Flex Cont,J1250.01,CDM,636,RC,J1250,HCPCS,,,,338107302,NDC,250,ML,146.73,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,74.24538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.951642,143.7954
Assay of CK (Cpk),PX82550,CDM,300,RC,82550,CPT,,,,,,,,150,,Humana Choice Care,All Medicare plans,outpatient,49.5,,98,percent of total billed charges,74.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.97,147
Assay of Lactic Acid,PX83605,CDM,300,RC,83605,CPT,,,,,,,,150,,Humana Choice Care,All Medicare plans,outpatient,49.5,,79.73636364,percent of total billed charges,74.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.61,147
Assay of Phosphorus,PX84100,CDM,300,RC,84100,CPT,,,,,,,,150,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,74.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.35,147
Bilirubin Direct,PX82248,CDM,300,RC,82248,CPT,,,,,,,,150,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,74.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.6,147
Bilirubin Total,PX82247,CDM,300,RC,82247,CPT,,,,,,,,150,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,74.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.6,147
Comprehensive Metabolic Panel,PX80053,CDM,300,RC,80053,CPT,,,,,,,,396,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,74.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.68,388.08
"Drug(S) or Substance(S), Definitive, Qualitative or Quantitative, Not Otherwise Specified; 1-3 - Ref",PX8037590,CDM,300,RC,80375,CPT,90,,,,,,,150,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,74.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.31,147
"Hsv Detect, Amplif Probe - Ref",PX8752990,CDM,300,RC,87529,CPT,90,,,,,,,150,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,74.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,147
Magnesium,PX83735,CDM,300,RC,83735,CPT,,,,,,,,150,,Humana Choice Care,All Medicare plans,outpatient,49.5,,60.52941176,percent of total billed charges,74.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.14,147
Magnesium - Ref,PX8373590,CDM,300,RC,83735,CPT,90,,,,,,,150,,Humana Choice Care,All Medicare plans,outpatient,49.5,,60.52941176,percent of total billed charges,74.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.14,147
Po4 Inorganic (Phosphate) - Ref,PX8410090,CDM,300,RC,84100,CPT,90,,,,,,,150,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,74.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.35,147
TB Antigen Response Gamma Interferon T-Cell Susp,PX86481,CDM,300,RC,86481,CPT,,,,,,,,150,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,74.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.31,147
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,16714081701,NDC,1,EA,75.78,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,74.2644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155F,CDM,370,RC,99155,CPT,,,,,,,,353,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,74.2665,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.39,142.52
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155P,CDM,983,RC,99155,CPT,,,,,,,,353,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,74.2665,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.39,345.94
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,409662902,NDC,10,ML,146.84,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,74.30104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.236966,143.9032
TRAY IV SURGICAL EXTREMITY DYNJS0804,27200000,CDM,272,RC,,,,10919-MAIN,LOCAL,,,,,83.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,74.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
etoposide 500 MG/25ML Solution 25 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,703565601,NDC,25,ML,173.28,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,74.33712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.949434,169.8144
dextrose 25% Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409177510,NDC,10,ML,83.53,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,74.3417,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Raltegravir 400 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,6022761,NDC,1,EA,150.2,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,74.349,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Apply Short Leg Cast,Walker",PX29425F,CDM,510,RC,29425,CPT,,,,,,,,179,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,74.3566,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.3566,234.62
C Diff Amplified Probe,PX87493,CDM,300,RC,87493,CPT,,,,,,,,179,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,74.3566,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.17,175.42
Fibrinogen Test - Ref,PX8536690,CDM,300,RC,85366,CPT,90,,,,,,,179,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,74.3566,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.77,175.42
TUBE GASTROSTOMY 18FR REPLACEMENT DYND70318,120.256,CDM,271,RC,B4087,HCPCS,,407-MAIN,LOCAL,,,,,179,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,74.3566,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.53,175.42
Amphetamines; 1 or 2 - Ref,PX8032490,CDM,300,RC,80324,CPT,90,,,,,,,147,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,74.382,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.0638,144.06
Assay Ph Body Fluids Nos,PX83986,CDM,300,RC,83986,CPT,,,,,,,,147,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,74.382,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.28,144.06
"Cmv Detect, Amplifi Probe - Ref",PX8749690,CDM,300,RC,87496,CPT,90,,,,,,,147,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,74.382,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,144.06
"Methlenedioxyamphetamines (Mda, Mdea, Mdma) - Ref",PX8035990,CDM,300,RC,80359,CPT,90,,,,,,,147,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,74.382,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.0638,144.06
Ph Venous Blood,PX82800,CDM,300,RC,82800,CPT,,,,,,,,147,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,74.382,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.09,144.06
CYSTOSCOPY PACK I STERILE,120.505,CDM,272,RC,,,,4527-MAIN,LOCAL,,,,,155,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,74.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,151.9
CYSTOSCOPY PACK I STERILE,120.505,CDM,272,RC,,,,4527-MAIN,LOCAL,,,,,155,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,74.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,151.9
"Lab Antibody ID,RBC",PX7605,CDM,300,RC,86870,CPT,,,,,,,,155,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,74.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,314.02
"Lab Antibody ID,RBC",PX7605,CDM,300,RC,86870,CPT,,,,,,,,155,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,74.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,314.02
"Office/Outpt Visit,Est,Levl II",PX99212F,CDM,510,RC,99212,CPT,,,,,,,,155,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,74.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,151.9
"Office/Outpt Visit,Est,Levl II",PX99212F,CDM,510,RC,99212,CPT,,,,,,,,155,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,74.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,151.9
Smear Fluorescent/Acid Stai,PX87206,CDM,300,RC,87206,CPT,,,,,,,,155,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,74.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.94,151.9
Smear Fluorescent/Acid Stai,PX87206,CDM,300,RC,87206,CPT,,,,,,,,155,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,74.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.94,151.9
TB Test Enumeration of T-Cells - Ref,PX8648190,CDM,300,RC,86481,CPT,90,,,,,,,155,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,74.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,151.9
TB Test Enumeration of T-Cells - Ref,PX8648190,CDM,300,RC,86481,CPT,90,,,,,,,155,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,74.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,151.9
Lvl 3 Sub Hosp High Mdm or 50 Minutes,PX99233,CDM,982,RC,99233,CPT,,,,,,,,384,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,74.41,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.41,376.32
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,409337504,NDC,4,ML,150.36,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,74.4282,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
morphine 1 MG/ML Solution 50 mL Syringe,J2270.01,CDM,636,RC,J2270,HCPCS,,,,61553064975,NDC,50,ML,81.71,,Medica,Commercial,both,91.1,,7.3275,percent of total billed charges,74.43781,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062430,NDC,0.3,ML,147.12,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,74.44272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801301,NDC,0.3,ML,147.12,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,74.44272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801310,NDC,0.3,ML,147.12,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,74.44272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
sodium zirconium cyclosilicate 5 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,310110501,NDC,1,EA,151.95,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,74.4555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium zirconium cyclosilicate 5 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,310110501,NDC,1,EA,151.95,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,74.4555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium zirconium cyclosilicate 5 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,310110501,NDC,1,EA,151.95,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,74.4555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrOXYzine 50 MG/ML Solution 1 mL Vial,J3410.01,CDM,636,RC,J3410,HCPCS,,,,517560125,NDC,0.5,ML,83.68,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,74.4752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.760672,82.0064
"Antipsychotics, Not Otherwise Specified; 1-3 - Ref",PX8034290,CDM,300,RC,80342,CPT,90,,,,,,,152,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,74.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.1408,148.96
"Antipsychotics, Not Otherwise Specified; 1-3 - Ref",PX8034290,CDM,300,RC,80342,CPT,90,,,,,,,152,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,74.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.1408,148.96
"Antipsychotics, Not Otherwise Specified; 1-3 - Ref",PX8034290,CDM,300,RC,80342,CPT,90,,,,,,,152,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,74.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.1408,148.96
Assay of Blood Lipoprotein,PX83721,CDM,300,RC,83721,CPT,,,,,,,,76,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,74.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.63,74.48
Body Fluid Cell Count,PX89050,CDM,300,RC,89050,CPT,,,,,,,,152,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,74.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.33,148.96
Body Fluid Cell Count,PX89050,CDM,300,RC,89050,CPT,,,,,,,,152,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,74.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.33,148.96
Body Fluid Cell Count,PX89050,CDM,300,RC,89050,CPT,,,,,,,,152,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,74.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.33,148.96
Lab Direct Coombs,PX86880,CDM,300,RC,86880,CPT,,,,,,,,76,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,74.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.5704,74.48
PRONEVIEW CUSHION INSERTS LARGE,120.557,CDM,272,RC,E0190,HCPCS,,12500-MAIN,LOCAL,,,,,76,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,74.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.5704,74.48
SHOE POST OP LARGE MALE MQM3B,120.237,CDM,274,RC,L3260,HCPCS,,794-MAIN,LOCAL,,,,,76,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,74.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP LARGE SQUARE TOE WOMENS ORT30300WL,120.237,CDM,274,RC,L3260,HCPCS,,10606-MAIN,LOCAL,,,,,76,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,74.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP MEDIUM SQUARE TOE MALE ORT30300MM,120.237,CDM,274,RC,L3260,HCPCS,,10603-MAIN,LOCAL,,,,,76,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,74.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP MEDIUM SQUARE TOE WOMENS ORT30300WM,120.237,CDM,274,RC,L3260,HCPCS,,10605-MAIN,LOCAL,,,,,76,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,74.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP SMALL MALE 0814-1192,120.237,CDM,274,RC,L3260,HCPCS,,803-MAIN,LOCAL,,,,,76,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,74.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
SHOE POST OP SMALL SQUARE TOE WOMENS MQW1B,120.237,CDM,274,RC,L3260,HCPCS,,10604-MAIN,LOCAL,,,,,76,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,74.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.539,74.48
timolol 0.25 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314022605,NDC,5,ML,84.45,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,74.4849,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122F,CDM,510,RC,13122,CPT,,,,,,,,788,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,74.4952,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.39,262.88
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122P,CDM,983,RC,13122,CPT,,,,,,,,301,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,74.4952,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.39,294.98
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,70860030143,NDC,25,ML,84.47,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,74.50254,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010626,NDC,50,ML,84.47,,United Healthcare,All Payer,outpatient,88.2,,13.925,percent of total billed charges,74.50254,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
sodium bicarbonate 8.4 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409662502,NDC,50,ML,84.47,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,74.50254,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
urea 20 % Cream 85 g Tube,63700001,CDM,250,RC,,,,,,536110945,NDC,85,GR,81.83,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,74.54713,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium polystyrene sulfonate Powder 15 g Bottle,25000000,CDM,250,RC,,,,,,10702003615,NDC,15,GR,76.09,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,74.5682,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024110,NDC,1,EA,76.1,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,74.578,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049237,NDC,30,ML,87.77,,First Health,Commercial,both,85,,999999999,percent of total billed charges,74.6045,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Digital Mamm, Diag, Bilat, Tc W/Cad Perf",PX7706601,CDM,401,RC,77066,CPT,TC,,,,,,,375,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,74.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.95,220.89
"Digital Mamm, Diag, Bilat, Tc W/Cad Perf",PX7706601,CDM,401,RC,77066,CPT,TC,,,,,,,375,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,74.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.95,220.89
Physical Therapy Evaluation High Complex,PX97163,CDM,424,RC,97163,CPT,,,,,,,,294,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,74.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.14,132.23
Physical Therapy Evaluation High Complex,PX97163,CDM,424,RC,97163,CPT,,,,,,,,294,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,74.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.14,132.23
Physical Therapy Evaluation Low Complex,PX97161,CDM,424,RC,97161,CPT,,,,,,,,235,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,74.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.14,132.23
Physical Therapy Evaluation Low Complex,PX97161,CDM,424,RC,97161,CPT,,,,,,,,235,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,74.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.14,132.23
Physical Therapy Evaluation Mod Complex,PX97162,CDM,424,RC,97162,CPT,,,,,,,,264,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,74.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.14,132.23
Physical Therapy Evaluation Mod Complex,PX97162,CDM,424,RC,97162,CPT,,,,,,,,264,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,74.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.14,132.23
US Kidney Transplt Untrsd,PX7677601,CDM,402,RC,76776,CPT,TC,,,,,,,554,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,74.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.61,220.89
US Kidney Transplt Untrsd,PX7677601,CDM,402,RC,76776,CPT,TC,,,,,,,554,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,74.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.61,220.89
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034020,NDC,1,EA,76.67,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,18.705,percent of total billed charges,74.622911,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034021,NDC,1,EA,76.67,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,18.705,percent of total billed charges,74.622911,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,47781046813,NDC,1,EA,76.15,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,74.627,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,64380079701,NDC,1,EA,76.15,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,74.627,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ketoconazole 2 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,168009915,NDC,15,GR,173.97,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,74.63313,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
silver sulfADIAZINE 1 % Cream 50 g Jar,25000000,CDM,250,RC,,,,,,43598021055,NDC,50,GR,83.89,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,74.6621,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tranexamic acid 1000 mg in 100 mL 0.7% sodium chloride (premix) 1000-0.7 MG/100ML-% Solution 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,80830232901,NDC,100,ML,155.55,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,74.664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tranexamic acid 1000 mg in 100 mL 0.7% sodium chloride (premix) 1000-0.7 MG/100ML-% Solution 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,80830232901,NDC,100,ML,155.55,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,74.664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ocrelizumab 300 MG/10ML Solution 10 mL Vial,J2350.01,CDM,636,RC,J2350,HCPCS,,,,50242015001,NDC,10,ML,33150,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,74.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.47,32487
Ace - Ref,PX8216490,CDM,300,RC,82164,CPT,90,,,,,,,82,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,74.702,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.39,80.36
Anca Screen Each Antibody,PX8603690,CDM,300,RC,86036,CPT,90,,,,,,,82,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,74.702,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.0628,80.36
"Cognitive Funct Ther Interv, Ea Addl 15 Min",PX97130,CDM,420,RC,97130,CPT,,,,,,,,82,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,74.702,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31,80.36
"Cortisol, Free - Ref",PX8253090,CDM,300,RC,82530,CPT,90,,,,,,,82,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,74.702,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.32,80.36
protamine 10 MG/ML Solution 5 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022994,NDC,5,ML,84.74,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,74.74068,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.431298,83.0452
CANNULA OPTIFLOW JUNIOR2+ XXL OJR520,120.494,CDM,271,RC,A4615,HCPCS,,11619-MAIN,LOCAL,,,,,84,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,74.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.8936,82.32
Hiaa - Ref,PX8349790,CDM,300,RC,83497,CPT,90,,,,,,,84,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,74.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.83,82.32
C-Peptide - Ref,PX8468190,CDM,300,RC,84681,CPT,90,,,,,,,180,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,74.772,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,176.4
"Closed Rx Radial Head Disloc,Child",PX24640P,CDM,983,RC,24640,CPT,,,,,,,,180,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,74.772,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.772,206.02
"Infect Ea Organ, Amp Prob - Ref",PX8779890,CDM,300,RC,87798,CPT,90,,,,,,,180,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,74.772,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,176.4
Mrsa by Amplification Na,PX87641,CDM,300,RC,87641,CPT,,,,,,,,180,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,74.772,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,176.4
Protein Elp,PX84166,CDM,300,RC,84166,CPT,,,,,,,,180,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,74.772,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.35,176.4
nystatin 100000 UNIT/GM Cream 30 g Tube,25000000,CDM,250,RC,,,,,,168005430,NDC,30,GR,147.79,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,74.78174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Apply of Paste Boot,PX29580P,CDM,983,RC,29580,CPT,,,,,,,,88,,First Health,Commercial,both,85,,999999999,percent of total billed charges,74.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.5552,137.65
POSITIONING KIT TRENDELENBURG NUBLUE TP 3000-NB,27100000,CDM,271,RC,,,,12992-MAIN,LOCAL,,,,,88,,First Health,Commercial,both,85,,999999999,percent of total billed charges,74.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
SPLINT ANKLE GEL BRACE UNIVERSAL AIRFORM 70351,120.61,CDM,274,RC,L4350,HCPCS,,12342-MAIN,LOCAL,,,,,88,,First Health,Commercial,both,85,,999999999,percent of total billed charges,74.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.5552,104.38
SUCTION IRRIGATOR 2 0250070500,27200000,CDM,272,RC,,,,12262-MAIN,LOCAL,,,,,88,,First Health,Commercial,both,85,,999999999,percent of total billed charges,74.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
acyclovir 50 MG/ML Solution 20 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,63323032524,NDC,20,ML,76.86,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,74.807838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.927644,105.9968
levonorgestrel 1.5 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,68180085211,NDC,1,EA,174.39,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,74.81331,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573F,CDM,761,RC,36573,CPT,,,,,,,,1529,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,74.8163,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.83,778.97
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573P,CDM,983,RC,36573,CPT,,,,,,,,1721,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,74.8163,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.83,1686.58
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127303,NDC,2,ML,152.7,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,15.275,percent of total billed charges,74.823,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.43158,173.019
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127303,NDC,2,ML,152.7,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,74.823,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.43158,173.019
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127303,NDC,2,ML,152.7,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,74.823,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.43158,173.019
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037601,NDC,1,ML,76.9,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,74.84677,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
leflunomide 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,62332006130,NDC,1,EA,88.09,,First Health,Commercial,both,85,,999999999,percent of total billed charges,74.8765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay Blood Carbon Monoxide,PX82375,CDM,300,RC,82375,CPT,,,,,,,,156,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,74.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.3,152.88
Assay Blood Carbon Monoxide,PX82375,CDM,300,RC,82375,CPT,,,,,,,,156,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,74.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.3,152.88
"Cortisol, Am",PX7152,CDM,300,RC,82533,CPT,,,,,,,,156,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,74.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.95,152.88
"Cortisol, Am",PX7152,CDM,300,RC,82533,CPT,,,,,,,,156,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,74.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.95,152.88
DERMABOND PRINEO SKIN CLOSURE SYSTEM 22CM,27200000,CDM,272,RC,,,,12324-MAIN,LOCAL,,,,,156,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,74.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DERMABOND PRINEO SKIN CLOSURE SYSTEM 22CM,27200000,CDM,272,RC,,,,12324-MAIN,LOCAL,,,,,156,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,74.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
BLUE EYE SUBMUCOSAL LIFTING AGENT 5ML,27200000,CDM,272,RC,,,,12684-MAIN,LOCAL,,,,,148,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,74.888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Mumps,PX86735,CDM,300,RC,86735,CPT,,,,,,,,148,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,74.888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.97,145.04
US Guide Needle Bx S&I,PX7694226,CDM,982,RC,76942,CPT,26,,,,,,,148,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,74.888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.4792,144.0484
ARIPiprazole 2 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714014101,NDC,1,EA,151.35,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,74.91825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,55150043801,NDC,20,ML,152.9,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,12.9192,percent of total billed charges,74.921,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,55150043801,NDC,20,ML,152.9,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,74.921,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,55150043801,NDC,20,ML,152.9,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,74.921,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457018120,NDC,20,ML,152.9,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,12.9192,percent of total billed charges,74.921,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457018120,NDC,20,ML,152.9,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,74.921,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457018120,NDC,20,ML,152.9,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,74.921,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
ceFAZolin in D4W 1 g / 50 mL 1-4 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0690.01,CDM,636,RC,J0690,HCPCS,,,,264310311,NDC,1,EA,84.97,,United Healthcare,All Payer,outpatient,88.2,,20.73428571,percent of total billed charges,74.94354,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
Alpha-Fetoprotein Serum,PX82105,CDM,300,RC,82105,CPT,,,,,,,,77,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,74.9441,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.38,75.46
BRACE WRIST HAND THUMB LEFT 455-LT,120.315,CDM,274,RC,L3809,HCPCS,,8283-MAIN,LOCAL,,,,,77,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,74.9441,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.9858,245.51
BRACE WRIST HAND THUMB RIGHT 455-RT,120.315,CDM,274,RC,L3809,HCPCS,,8284-MAIN,LOCAL,,,,,77,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,74.9441,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.9858,245.51
CAUTERY HIGH TEMP LOOP TIP,120.21,CDM,272,RC,,,,332-MAIN,LOCAL,,,,,77,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,74.9441,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
NEEDLE ACUJECT 25GA VARIABLE INJECTION VIN-25,27200000,CDM,272,RC,,,,7412-MAIN,LOCAL,,,,,77,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,74.9441,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Remove Additional Nail Plate,PX11732F,CDM,510,RC,11732,CPT,,,,,,,,77,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,74.9441,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.9858,75.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,55150012150,NDC,1,EA,151.41,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,74.94795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
CISplatin 50 MG/50ML Solution 50 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010351,NDC,50,ML,82.27,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,74.94797,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.174958,180.2416
"Cognitive Funct Ther Interv, Initial 15 Min",PX97129,CDM,420,RC,97129,CPT,,,,,,,,85,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,74.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15,83.3
ELECTRODE ADULT PACING ONESTEP,120.214,CDM,272,RC,A4556,HCPCS,,10242-MAIN,LOCAL,,,,,153,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,74.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.5562,149.94
ELECTRODE ADULT PACING ONESTEP,120.214,CDM,272,RC,A4556,HCPCS,,10242-MAIN,LOCAL,,,,,153,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,74.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.5562,149.94
ELECTRODE ADULT PACING ONESTEP,120.214,CDM,272,RC,A4556,HCPCS,,10242-MAIN,LOCAL,,,,,153,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,74.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.5562,149.94
"Exam,Synovial Fluid Crystals",PX89060,CDM,300,RC,89060,CPT,,,,,,,,85,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,74.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.72,83.3
GLIDESCOPE QC MAC S3 SINGLE USE 0270-1083,120.579,CDM,272,RC,,,,13046-MAIN,LOCAL,,,,,85,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,74.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.309,83.3
GLIDESCOPE QC MAC S3 SINGLE USE 0270-1085,120.579,CDM,272,RC,,,,13022-MAIN,LOCAL,,,,,85,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,74.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.309,83.3
GLIDESCOPE QC MAC S4 SINGLE USE 0270-1086,120.579,CDM,272,RC,,,,13023-MAIN,LOCAL,,,,,85,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,74.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.309,83.3
"Protein, Total; Other Source",PX84157,CDM,300,RC,84157,CPT,,,,,,,,153,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,74.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.67,149.94
"Protein, Total; Other Source",PX84157,CDM,300,RC,84157,CPT,,,,,,,,153,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,74.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.67,149.94
"Protein, Total; Other Source",PX84157,CDM,300,RC,84157,CPT,,,,,,,,153,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,74.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.67,149.94
Pulmonary Stress Test,PX94618,CDM,976,RC,94618,CPT,,,,,,,,153,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,74.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.5562,148.9149
Pulmonary Stress Test,PX94618,CDM,976,RC,94618,CPT,,,,,,,,153,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,74.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.5562,148.9149
Pulmonary Stress Test,PX94618,CDM,976,RC,94618,CPT,,,,,,,,153,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,74.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.5562,148.9149
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457018100,NDC,20,ML,153.01,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,12.9192,percent of total billed charges,74.9749,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457018100,NDC,20,ML,153.01,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,74.9749,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457018100,NDC,20,ML,153.01,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,74.9749,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
sodium bicarbonate 8.4 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409662522,NDC,50,ML,85.02,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,74.98764,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU0003,CDM,300,RC,U0003,HCPCS,,,,,,,,133,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.71239,75
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU0003,CDM,300,RC,U0003,HCPCS,,,,,,,,133,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.71239,75
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU000390,CDM,300,RC,U0003,HCPCS,90,,,,,,,222,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.71239,75
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU000390,CDM,300,RC,U0003,HCPCS,90,,,,,,,222,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.71239,75
nystatin 100000 UNIT/GM Cream 30 g Tube,25000000,CDM,250,RC,,,,,,51672128902,NDC,30,GR,148.29,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,75.03474,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Drain Skin Abscess Simple,PX10060F,CDM,510,RC,10060,CPT,,,,,,,,296,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,75.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.41,264.96
Drain Skin Abscess Simple,PX10060F,CDM,510,RC,10060,CPT,,,,,,,,296,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,75.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.41,264.96
Drain Skin Abscess Simple,PX10060P,CDM,983,RC,10060,CPT,,,,,,,,293,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,75.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.41,287.14
Drain Skin Abscess Simple,PX10060P,CDM,983,RC,10060,CPT,,,,,,,,293,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,75.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.41,287.14
"Upper GI Endoscopy,Diagnosis",PX43235F,CDM,750,RC,43235,CPT,,,,,,,,2539,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,75.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.04,597.02
"Upper GI Endoscopy,Diagnosis",PX43235P,CDM,983,RC,43235,CPT,,,,,,,,1406,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,75.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.04,1377.88
US Kidney Transplt Untrsd,PX7677601,CDM,402,RC,76776,CPT,TC,,,,,,,554,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,75.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.61,220.89
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862066230,NDC,1,EA,153.17,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,75.0533,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862066230,NDC,1,EA,153.17,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,75.0533,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862066230,NDC,1,EA,153.17,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,75.0533,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954201,NDC,10,ML,153.18,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,75.0582,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.630972,150.1164
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954201,NDC,10,ML,153.18,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,75.0582,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.630972,150.1164
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954201,NDC,10,ML,153.18,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,75.0582,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.630972,150.1164
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954210,NDC,10,ML,153.18,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,75.0582,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.630972,150.1164
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954210,NDC,10,ML,153.18,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,75.0582,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.630972,150.1164
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954210,NDC,10,ML,153.18,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,75.0582,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.630972,150.1164
Electrolyte Panel,PX80051,CDM,300,RC,80051,CPT,,,,,,,,175,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,75.075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.43,171.5
"Fac/Trm Hyperkeratotic Skn Lesn,>4",PX11057F,CDM,510,RC,11057,CPT,,,,,,,,175,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,75.075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.695,174.9
"Gonadotropin, Chorionic (Hcg), Qualitative",PX84703,CDM,300,RC,84703,CPT,,,,,,,,175,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,75.075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.9,171.5
Protein E-Phoresis Serum,PX84165,CDM,300,RC,84165,CPT,,,,,,,,175,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,75.075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,171.5
Protein Elp Interp,PX8416526,CDM,300,RC,84165,CPT,26,,,,,,,175,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,75.075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,171.5
isatuximab-irfc 500 MG/25ML Solution 25 mL Vial,J9227.01,CDM,636,RC,J9227,HCPCS,,,,24065601,NDC,25,ML,7876.36,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,75.08478,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.31,80.32
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004722,NDC,2,ML,88.35,,First Health,Commercial,both,85,,999999999,percent of total billed charges,75.0975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034020,NDC,1,EA,76.67,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,75.1366,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034021,NDC,1,EA,76.67,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,75.1366,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
Insert Non-Tunnel Cv Catheter >5 Years,PX36556F,CDM,510,RC,36556,CPT,,,,,,,,1025,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,75.1374,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.04,439.29
Insert Non-Tunnel Cv Catheter >5 Years,PX36556P,CDM,983,RC,36556,CPT,,,,,,,,1274,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,75.1374,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.04,1248.52
hepatitis b recomb vaccine 10 MCG/0.5ML suspension prefilled syringe 0.5 mL Syringe,90743,CDM,636,RC,90743,CPT,,,,58160082052,NDC,0.5,ML,137.47,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,75.15,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.64655,75.15
timolol 0.25 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314022605,NDC,5,ML,84.45,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,75.1605,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,436067216,NDC,473,ML,77.23,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,75.167959,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,39328006412,NDC,473,ML,77.23,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,75.167959,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012250,NDC,1,EA,77.24,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,18.705,percent of total billed charges,75.177692,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012267,NDC,1,EA,77.24,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,18.705,percent of total billed charges,75.177692,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
cefOXitin 2 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021011020,NDC,1,EA,77.24,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,75.177692,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.367364,75.6952
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023610,NDC,1,EA,77.24,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,75.177692,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,70860030143,NDC,25,ML,84.47,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,75.1783,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010626,NDC,50,ML,84.47,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,75.1783,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
sodium bicarbonate 8.4 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409662502,NDC,50,ML,84.47,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,75.1783,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Alcohol Biomarkers; 1 or 2 - Ref,PX8032190,CDM,300,RC,80321,CPT,90,,,,,,,181,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,75.1874,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.1874,177.38
"Lyme Disease, Antibody - Ref",PX8661890,CDM,300,RC,86618,CPT,90,,,,,,,181,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,75.1874,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.61,177.38
PHALINX STERILE TRIAL SIZER 45A00000,27200000,CDM,272,RC,,,,12959-MAIN,LOCAL,,,,,181,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,75.1874,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
sodium zirconium cyclosilicate 5 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,310110501,NDC,1,EA,151.95,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,75.21525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019602,NDC,2,ML,77.29,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,42.99521739,percent of total billed charges,75.226357,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
"Antipsychotics, Not Otherwise Specified; 1-3 - Ref",PX8034290,CDM,300,RC,80342,CPT,90,,,,,,,152,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,75.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.1408,148.96
Body Fluid Cell Count,PX89050,CDM,300,RC,89050,CPT,,,,,,,,152,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,75.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.33,148.96
acyclovir 50 MG/ML Solution 20 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,63323032524,NDC,20,ML,76.86,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,75.3228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.927644,105.9968
prasugrel 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862083030,NDC,1,EA,88.64,,First Health,Commercial,both,85,,999999999,percent of total billed charges,75.344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of Psa Total,PX84153,CDM,300,RC,84153,CPT,,,,,,,,157,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,75.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.86,153.86
Assay of Psa Total,PX84153,CDM,300,RC,84153,CPT,,,,,,,,157,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,75.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.86,153.86
"Chlamydia Trachomatis Dna, Amp Probe",PX87491,CDM,300,RC,87491,CPT,,,,,,,,157,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,75.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,153.86
"Chlamydia Trachomatis Dna, Amp Probe",PX87491,CDM,300,RC,87491,CPT,,,,,,,,157,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,75.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,153.86
"Cognitive Skill Dev, Ea 15 Min",PX97532,CDM,420,RC,97532,CPT,,,,,,,,157,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,75.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.2178,153.86
"Cognitive Skill Dev, Ea 15 Min",PX97532,CDM,420,RC,97532,CPT,,,,,,,,157,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,75.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.2178,153.86
"Fungal Culture, Other Source - Ref",PX8710290,CDM,300,RC,87102,CPT,90,,,,,,,157,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,75.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.71,153.86
"Fungal Culture, Other Source - Ref",PX8710290,CDM,300,RC,87102,CPT,90,,,,,,,157,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,75.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.71,153.86
Lactate (Ld) (Ldh) Enzyme,PX83615,CDM,300,RC,83615,CPT,,,,,,,,157,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,75.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.54,153.86
Lactate (Ld) (Ldh) Enzyme,PX83615,CDM,300,RC,83615,CPT,,,,,,,,157,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,75.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.54,153.86
"Neisseria Gonorrhoeae Dna, Amp Probe",PX87591,CDM,300,RC,87591,CPT,,,,,,,,157,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,75.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,153.86
"Neisseria Gonorrhoeae Dna, Amp Probe",PX87591,CDM,300,RC,87591,CPT,,,,,,,,157,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,75.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,153.86
Occupational Therapy Eval High Complex,PX97167,CDM,434,RC,97167,CPT,,,,,,,,289,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,75.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.14,133.55
Occupational Therapy Eval High Complex,PX97167,CDM,434,RC,97167,CPT,,,,,,,,289,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,75.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.14,133.55
Occupational Therapy Eval Low Complex,PX97165,CDM,434,RC,97165,CPT,,,,,,,,235,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,75.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.14,133.55
Occupational Therapy Eval Low Complex,PX97165,CDM,434,RC,97165,CPT,,,,,,,,235,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,75.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.14,133.55
Occupational Therapy Eval Mod Complex,PX97166,CDM,434,RC,97166,CPT,,,,,,,,264,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,75.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.14,133.55
Occupational Therapy Eval Mod Complex,PX97166,CDM,434,RC,97166,CPT,,,,,,,,264,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,75.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.14,133.55
Psa Screening,PXG0103,CDM,300,RC,G0103,HCPCS,,,,,,,,157,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,75.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.71,153.86
Psa Screening,PXG0103,CDM,300,RC,G0103,HCPCS,,,,,,,,157,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,75.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.71,153.86
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037601,NDC,1,ML,76.9,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,75.362,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010269,NDC,1,EA,88.69,,First Health,Commercial,both,85,,999999999,percent of total billed charges,75.3865,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010299,NDC,1,EA,88.69,,First Health,Commercial,both,85,,999999999,percent of total billed charges,75.3865,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614201,NDC,1,ML,88.69,,First Health,Commercial,both,85,,999999999,percent of total billed charges,75.3865,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.097864,86.9162
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614225,NDC,1,ML,88.69,,First Health,Commercial,both,85,,999999999,percent of total billed charges,75.3865,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.097864,86.9162
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963801,NDC,0.5,ML,88.69,,First Health,Commercial,both,85,,999999999,percent of total billed charges,75.3865,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
"Urinalysis, Auto W/O Scope",PX81003,CDM,300,RC,81003,CPT,,,,,,,,149,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,75.394,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.06,146.02
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,45802095301,NDC,100,GR,82.76,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,75.39436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
albuterol HFA 108 (90 Base) MCG/ACT Aerosol Solution 8 g Inhaler,25000000,CDM,250,RC,,,,,,173068224,NDC,8,GR,149.04,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,75.41424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
protamine 10 MG/ML Solution 5 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022994,NDC,5,ML,84.74,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,75.4186,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.431298,83.0452
fentaNYL 25 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,591319872,NDC,1,EA,77.51,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,75.440483,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Alpha-Fetoprotein Serum,PX82105,CDM,300,RC,82105,CPT,,,,,,,,77,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,75.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.38,75.46
BRACE WRIST HAND THUMB LEFT 455-LT,120.315,CDM,274,RC,L3809,HCPCS,,8283-MAIN,LOCAL,,,,,77,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,75.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.9858,245.51
BRACE WRIST HAND THUMB RIGHT 455-RT,120.315,CDM,274,RC,L3809,HCPCS,,8284-MAIN,LOCAL,,,,,77,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,75.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.9858,245.51
CAUTERY HIGH TEMP LOOP TIP,120.21,CDM,272,RC,,,,332-MAIN,LOCAL,,,,,77,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,75.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.7082,75.46
NEEDLE ACUJECT 25GA VARIABLE INJECTION VIN-25,27200000,CDM,272,RC,,,,7412-MAIN,LOCAL,,,,,77,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,75.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PROSTEP 0.9MM ANTI SKIVE PIN,27200000,CDM,272,RC,,,,12950-MAIN,LOCAL,,,,,154,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,75.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PROSTEP 0.9MM ANTI SKIVE PIN,27200000,CDM,272,RC,,,,12950-MAIN,LOCAL,,,,,154,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,75.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PROSTEP 0.9MM ANTI SKIVE PIN,27200000,CDM,272,RC,,,,12950-MAIN,LOCAL,,,,,154,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,75.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PROSTEP 1.4MM ANTI SKIVE PIN,27200000,CDM,272,RC,,,,12949-MAIN,LOCAL,,,,,154,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,75.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PROSTEP 1.4MM ANTI SKIVE PIN,27200000,CDM,272,RC,,,,12949-MAIN,LOCAL,,,,,154,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,75.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PROSTEP 1.4MM ANTI SKIVE PIN,27200000,CDM,272,RC,,,,12949-MAIN,LOCAL,,,,,154,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,75.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Remove Additional Nail Plate,PX11732F,CDM,510,RC,11732,CPT,,,,,,,,77,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,75.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.9858,75.46
Vit D 1 25-Dihydroxy,PX82652,CDM,300,RC,82652,CPT,,,,,,,,154,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,75.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.3,150.92
Vit D 1 25-Dihydroxy,PX82652,CDM,300,RC,82652,CPT,,,,,,,,154,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,75.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.3,150.92
Vit D 1 25-Dihydroxy,PX82652,CDM,300,RC,82652,CPT,,,,,,,,154,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,75.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.3,150.92
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047621,NDC,1,ML,157.28,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,75.4944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.354486,332.1514
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047621,NDC,1,ML,157.28,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,75.4944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.354486,332.1514
CCP Antibody,PX86200,CDM,300,RC,86200,CPT,,,,,,,,176,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,75.504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,172.48
Detect Agent Nos Dna Amp,PX87798,CDM,300,RC,87798,CPT,,,,,,,,176,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,75.504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,172.48
Eval of Bronchospasm,PX94060,CDM,983,RC,94060,CPT,,,,,,,,176,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,75.504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.1104,274.21
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151F,CDM,370,RC,99151,CPT,,,,,,,,176,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,75.504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.1104,172.48
tiotropium 18 MCG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,597007541,NDC,1,EA,82.92,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,75.54012,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329334001,NDC,10,ML,88.88,,First Health,Commercial,both,85,,999999999,percent of total billed charges,75.548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
vancomycin 125 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68180016611,NDC,1,EA,149.33,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,75.56098,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 125 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,47781072902,NDC,1,EA,149.33,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,75.56098,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 125 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,62559039020,NDC,1,EA,149.33,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,75.56098,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Inpt or Obs Disch Day Mngmt <=30 Minutes,PX99238,CDM,982,RC,99238,CPT,,,,,,,,199,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,75.576,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.85,195.02
Lvl 1 Init Hosp Low Mdm or 40 Minutes,PX99221,CDM,982,RC,99221,CPT,,,,,,,,400,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,75.576,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.29,392
"Off/Outpt Visit,New,Levl III",PX99203P,CDM,983,RC,99203,CPT,,,,,,,,252,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,75.576,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.07,246.96
"Office/Outpt Visit,New,Levl III",PX99203F,CDM,510,RC,99203,CPT,,,,,,,,252,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,75.576,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.07,200.33
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,25021012867,NDC,1,EA,82.96,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,75.57656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,55150020830,NDC,1,EA,82.96,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,75.57656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.461584,189.875
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127303,NDC,2,ML,152.7,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,75.5865,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.43158,173.019
Debride Skin/Subq Ea Ad 20sqcm,PX11045P,CDM,983,RC,11045,CPT,,,,,,,,182,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,75.6028,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.6028,177.1406
Immunocytochemistry,PX3993,CDM,310,RC,88342,CPT,TC,,,,,,,182,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,75.6028,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.6028,178.36
Infec Agent Direct Probe - Ref,PX8779990,CDM,300,RC,87799,CPT,90,,,,,,,182,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,75.6028,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.28,178.36
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,47781047013,NDC,1,EA,83,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,75.613,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,64380079901,NDC,1,EA,83,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,75.613,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,69238126601,NDC,1,EA,83,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,75.613,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SLING ARM CHILD PAD CANVAS NAVY 8004-02,120.54,CDM,273,RC,A4565,HCPCS,,878-MAIN,LOCAL,,,,,83,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,75.613,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM LARGE PAD CANVAS NAVY ORT11300L,120.54,CDM,273,RC,A4565,HCPCS,,870-MAIN,LOCAL,,,,,83,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,75.613,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM MEDIUM PAD CANVAS NAVY ORT11300M,120.54,CDM,273,RC,A4565,HCPCS,,872-MAIN,LOCAL,,,,,83,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,75.613,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM SMALL PAD CANVAS NAVY ORT11300S,120.54,CDM,273,RC,A4565,HCPCS,,874-MAIN,LOCAL,,,,,83,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,75.613,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM X-LARGE PAD ENVELOPE ORT11300XL,120.54,CDM,273,RC,A4565,HCPCS,,876-MAIN,LOCAL,,,,,83,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,75.613,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
ceFAZolin in D4W 1 g / 50 mL 1-4 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0690.01,CDM,636,RC,J0690,HCPCS,,,,264310311,NDC,1,EA,84.97,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,75.6233,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
aztreonam 1 g Recon Soln 1 Each Vial,J0457.01,CDM,636,RC,J0457,HCPCS,,,,63323040124,NDC,1,EA,176.32,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,75.64128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.32,172.7936
Aldolase - Ref,PX8208590,CDM,300,RC,82085,CPT,90,,,,,,,89,,First Health,Commercial,both,85,,999999999,percent of total billed charges,75.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.9,87.22
Assay of Ggt,PX82977,CDM,300,RC,82977,CPT,,,,,,,,89,,First Health,Commercial,both,85,,999999999,percent of total billed charges,75.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6,87.22
"Debridement of Nail(S), 1-5",PX11720F,CDM,510,RC,11720,CPT,,,,,,,,89,,First Health,Commercial,both,85,,999999999,percent of total billed charges,75.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.9706,87.22
"Hla a, B or C, Single Ag - Ref",PX8681290,CDM,300,RC,86812,CPT,90,,,,,,,89,,First Health,Commercial,both,85,,999999999,percent of total billed charges,75.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.67,87.22
KIT INTRODUCER 8.5FR AK-09803-CDC,120.128,CDM,272,RC,,,,8826-MAIN,LOCAL,,,,,89,,First Health,Commercial,both,85,,999999999,percent of total billed charges,75.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.9706,87.22
"Cognitive Funct Ther Interv, Initial 15 Min",PX97129,CDM,420,RC,97129,CPT,,,,,,,,85,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,75.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15,83.3
"Exam,Synovial Fluid Crystals",PX89060,CDM,300,RC,89060,CPT,,,,,,,,85,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,75.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.72,83.3
GLIDESCOPE QC MAC S3 SINGLE USE 0270-1083,120.579,CDM,272,RC,,,,13046-MAIN,LOCAL,,,,,85,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,75.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.309,83.3
GLIDESCOPE QC MAC S3 SINGLE USE 0270-1085,120.579,CDM,272,RC,,,,13022-MAIN,LOCAL,,,,,85,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,75.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.309,83.3
GLIDESCOPE QC MAC S4 SINGLE USE 0270-1086,120.579,CDM,272,RC,,,,13023-MAIN,LOCAL,,,,,85,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,75.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.309,83.3
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,517096010,NDC,10,ML,157.64,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,75.6672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,517096010,NDC,10,ML,157.64,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,75.6672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium bicarbonate 8.4 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409662522,NDC,50,ML,85.02,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,75.6678,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,436067216,NDC,473,ML,77.23,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,75.6854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,39328006412,NDC,473,ML,77.23,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,75.6854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,55150043801,NDC,20,ML,152.9,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,75.6855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457018120,NDC,20,ML,152.9,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,75.6855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012250,NDC,1,EA,77.24,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,75.6952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012267,NDC,1,EA,77.24,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,75.6952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
cefOXitin 2 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021011020,NDC,1,EA,77.24,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,75.6952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.367364,75.6952
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023610,NDC,1,EA,77.24,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,75.6952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
"Flow Cyto, Tech, 1st Mrkr - Ref",PX8818490,CDM,310,RC,88184,CPT,90,,,,,,,223,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,75.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.72,127.152
"Flow Cyto, Tech, 1st Mrkr - Ref",PX8818490,CDM,310,RC,88184,CPT,90,,,,,,,223,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,75.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.72,127.152
"Flow Cyto, Tech, 1st Mrkr - Ref",PX8818490,CDM,310,RC,88184,CPT,90,,,,,,,223,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,75.72,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.72,127.152
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; 1st",PX88184,CDM,310,RC,88184,CPT,,,,,,,,96,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,75.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.72,127.152
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; 1st",PX88184,CDM,310,RC,88184,CPT,,,,,,,,96,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,75.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.72,127.152
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; 1st",PX88184,CDM,310,RC,88184,CPT,,,,,,,,96,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,75.72,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.72,127.152
fluticasone 110 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173071920,NDC,12,GR,149.67,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,75.73302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ELECTRODE ADULT PACING ONESTEP,120.214,CDM,272,RC,A4556,HCPCS,,10242-MAIN,LOCAL,,,,,153,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,75.735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.5562,149.94
"Protein, Total; Other Source",PX84157,CDM,300,RC,84157,CPT,,,,,,,,153,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,75.735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.67,149.94
Pulmonary Stress Test,PX94618,CDM,976,RC,94618,CPT,,,,,,,,153,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,75.735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.5562,148.9149
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457018100,NDC,20,ML,153.01,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,75.73995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127332,NDC,2,ML,176.55,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,75.73995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.43158,173.019
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019602,NDC,2,ML,77.29,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,75.7442,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,574200815,NDC,15,GR,154.63,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,75.7687,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,574200815,NDC,15,GR,154.63,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,75.7687,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,574200815,NDC,15,GR,154.63,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,75.7687,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331601,NDC,10,ML,77.86,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,229.0777778,percent of total billed charges,75.781138,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
nafcillin 1 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,55150012215,NDC,1,EA,89.17,,First Health,Commercial,both,85,,999999999,percent of total billed charges,75.7945,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032225,NDC,1,EA,176.72,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,75.81288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,173.1856
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862066230,NDC,1,EA,153.17,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,75.81915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954201,NDC,10,ML,153.18,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,75.8241,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.630972,150.1164
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954210,NDC,10,ML,153.18,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,75.8241,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.630972,150.1164
Antithrombin III Activity - Ref,PX8530090,CDM,300,RC,85300,CPT,90,,,,,,,158,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,75.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.87,154.84
Antithrombin III Activity - Ref,PX8530090,CDM,300,RC,85300,CPT,90,,,,,,,158,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,75.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.87,154.84
Fac/Trm Hyperkeratotic Skn Lesn2-4,PX11056F,CDM,510,RC,11056,CPT,,,,,,,,158,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,75.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.6332,174.9
Fac/Trm Hyperkeratotic Skn Lesn2-4,PX11056F,CDM,510,RC,11056,CPT,,,,,,,,158,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,75.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.6332,174.9
"Glucose, Body Fluid Other Than Blood",PX82945,CDM,300,RC,82945,CPT,,,,,,,,158,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,75.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.6,154.84
"Glucose, Body Fluid Other Than Blood",PX82945,CDM,300,RC,82945,CPT,,,,,,,,158,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,75.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.6,154.84
Protein C Activity - Ref,PX8530390,CDM,300,RC,85303,CPT,90,,,,,,,158,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,75.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.69,154.84
Protein C Activity - Ref,PX8530390,CDM,300,RC,85303,CPT,90,,,,,,,158,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,75.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.69,154.84
"Triiodothyronine T3, Tot - Ref",PX8448090,CDM,300,RC,84480,CPT,90,,,,,,,158,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,75.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13,154.84
"Triiodothyronine T3, Tot - Ref",PX8448090,CDM,300,RC,84480,CPT,90,,,,,,,158,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,75.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13,154.84
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143998391,NDC,1,EA,83.25,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,75.84075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
Aldosterone - Ref,PX8208890,CDM,300,RC,82088,CPT,90,,,,,,,86,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,75.852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.7244,84.28
Epstein-barr antibody,PX86665,CDM,300,RC,86665,CPT,,,,,,,,86,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,75.852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.63,84.28
SAWBLADE SAGITAL STERILE 25MM LENGTH 5.5MM WIDTH 0.60MM THICKNESS,27200000,CDM,272,RC,,,,11623-MAIN,LOCAL,,,,,86.02,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,75.86964,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Assay of CK (Cpk),PX82550,CDM,300,RC,82550,CPT,,,,,,,,150,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,75.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.97,147
Assay of Lactic Acid,PX83605,CDM,300,RC,83605,CPT,,,,,,,,150,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,75.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.61,147
Assay of Phosphorus,PX84100,CDM,300,RC,84100,CPT,,,,,,,,150,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,75.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.35,147
Bilirubin Direct,PX82248,CDM,300,RC,82248,CPT,,,,,,,,150,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,75.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.6,147
Bilirubin Total,PX82247,CDM,300,RC,82247,CPT,,,,,,,,150,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,75.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.6,147
"Drug(S) or Substance(S), Definitive, Qualitative or Quantitative, Not Otherwise Specified; 1-3 - Ref",PX8037590,CDM,300,RC,80375,CPT,90,,,,,,,150,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,75.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.31,147
"Hsv Detect, Amplif Probe - Ref",PX8752990,CDM,300,RC,87529,CPT,90,,,,,,,150,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,75.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,147
Magnesium,PX83735,CDM,300,RC,83735,CPT,,,,,,,,150,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,75.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.14,147
Magnesium - Ref,PX8373590,CDM,300,RC,83735,CPT,90,,,,,,,150,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,75.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.14,147
Po4 Inorganic (Phosphate) - Ref,PX8410090,CDM,300,RC,84100,CPT,90,,,,,,,150,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,75.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.35,147
TB Antigen Response Gamma Interferon T-Cell Susp,PX86481,CDM,300,RC,86481,CPT,,,,,,,,150,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,75.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.31,147
penicillin v potassium 250 MG/5ML Recon Soln 200 mL Bottle,63700001,CDM,250,RC,,,,,,93412774,NDC,200,ML,83.32,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,75.90452,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Upper GI Endoscopy,Diagnosis",PX43235F,CDM,750,RC,43235,CPT,,,,,,,,2539,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,75.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.04,597.02
"Upper GI Endoscopy,Diagnosis",PX43235F,CDM,750,RC,43235,CPT,,,,,,,,2539,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,75.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.04,597.02
"Upper GI Endoscopy,Diagnosis",PX43235P,CDM,983,RC,43235,CPT,,,,,,,,1406,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,75.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.04,1377.88
"Upper GI Endoscopy,Diagnosis",PX43235P,CDM,983,RC,43235,CPT,,,,,,,,1406,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,75.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.04,1377.88
cloNIDine 0.1 MG/24HR PATCH WEEKLY 4 Each Box,63700001,CDM,250,RC,,,,,,51862045304,NDC,1,EA,158.16,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,75.9168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloNIDine 0.1 MG/24HR PATCH WEEKLY 4 Each Box,63700001,CDM,250,RC,,,,,,51862045304,NDC,1,EA,158.16,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,75.9168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Ceruloplasmin - Ref,PX8239090,CDM,300,RC,82390,CPT,90,,,,,,,78,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,75.9174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,76.44
Chemiluminescent Assay - Ref,PX8239790,CDM,300,RC,82397,CPT,90,,,,,,,78,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,75.9174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.95,76.44
VISUALIZATION SYSTEM CLEARIFY LAPAROSCOPE STERILE,27200000,CDM,272,RC,,,,11875-MAIN,LOCAL,,,,,78,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,75.9174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TUBE AIRSPIRAL BREATHING AND CHAMBER 900PT561,120.493,CDM,271,RC,A4604,HCPCS,,11618-MAIN,LOCAL,,,,,112,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,75.92,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,75.92
TUBE AIRSPIRAL BREATHING AND CHAMBER 900PT561,120.493,CDM,271,RC,A4604,HCPCS,,11618-MAIN,LOCAL,,,,,112,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,75.92,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,75.92
IMMOBILIZER SHOULDER LARGE 9008-03,120.38,CDM,274,RC,L3650,HCPCS,,906-MAIN,LOCAL,,,,,36,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,75.9212,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,77.17
IMMOBILIZER SHOULDER LARGE STRAP OSG3033,120.38,CDM,274,RC,L3650,HCPCS,,2910-MAIN,LOCAL,,,,,36,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,75.9212,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,77.17
IMMOBILIZER SHOULDER MEDIUM 9008-02,120.38,CDM,274,RC,L3650,HCPCS,,912-MAIN,LOCAL,,,,,36,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,75.9212,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,77.17
IMMOBILIZER SHOULDER MEDIUM OSG3032,120.38,CDM,274,RC,L3650,HCPCS,,915-MAIN,LOCAL,,,,,36,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,75.9212,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,77.17
IMMOBILIZER SHOULDER SMALL 9008-01,120.38,CDM,274,RC,L3650,HCPCS,,913-MAIN,LOCAL,,,,,36,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,75.9212,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,77.17
IMMOBILIZER SHOULDER SMALL WITH CLOTH 9001-02,120.38,CDM,274,RC,L3650,HCPCS,,914-MAIN,LOCAL,,,,,36,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,75.9212,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,77.17
IMMOBILIZER SHOULDER X-LARGE CLOTH 9001-05,120.38,CDM,274,RC,L3650,HCPCS,,917-MAIN,LOCAL,,,,,36,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,75.9212,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,77.17
IMMOBILIZER SHOULDER X-LARGE ORT16100XL,120.38,CDM,274,RC,L3650,HCPCS,,904-MAIN,LOCAL,,,,,36,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,75.9212,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,77.17
Assay of Ferritin,PX82728,CDM,300,RC,82728,CPT,,,,,,,,177,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,75.933,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.5,173.46
"D-Dimer, Quantitative - Ref",PX8537990,CDM,300,RC,85379,CPT,90,,,,,,,177,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,75.933,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.33,173.46
Fibrin Degradation Quant,PX85379,CDM,300,RC,85379,CPT,,,,,,,,177,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,75.933,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.33,173.46
Inj Tendon/Ligament/Cyst,PX20550F,CDM,510,RC,20550,CPT,,,,,,,,177,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,75.933,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.5258,258.75
CYSTOSCOPY PACK I STERILE,120.505,CDM,272,RC,,,,4527-MAIN,LOCAL,,,,,155,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,75.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,151.9
CYSTOSCOPY PACK I STERILE,120.505,CDM,272,RC,,,,4527-MAIN,LOCAL,,,,,155,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,75.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,151.9
CYSTOSCOPY PACK I STERILE,120.505,CDM,272,RC,,,,4527-MAIN,LOCAL,,,,,155,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,75.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,151.9
"Lab Antibody ID,RBC",PX7605,CDM,300,RC,86870,CPT,,,,,,,,155,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,75.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,314.02
"Lab Antibody ID,RBC",PX7605,CDM,300,RC,86870,CPT,,,,,,,,155,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,75.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,314.02
"Lab Antibody ID,RBC",PX7605,CDM,300,RC,86870,CPT,,,,,,,,155,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,75.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,314.02
"Office/Outpt Visit,Est,Levl II",PX99212F,CDM,510,RC,99212,CPT,,,,,,,,155,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,73,percent of total billed charges,75.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,151.9
"Office/Outpt Visit,Est,Levl II",PX99212F,CDM,510,RC,99212,CPT,,,,,,,,155,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,75.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,151.9
"Office/Outpt Visit,Est,Levl II",PX99212F,CDM,510,RC,99212,CPT,,,,,,,,155,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,75.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,151.9
"Office/Outpt Visit,Est,Levl II",PX99212P,CDM,983,RC,99212,CPT,,,,,,,,155,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,73,percent of total billed charges,75.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,150.8615
"Office/Outpt Visit,Est,Levl II",PX99212P,CDM,983,RC,99212,CPT,,,,,,,,155,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,75.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,150.8615
"Office/Outpt Visit,Est,Levl II",PX99212P,CDM,983,RC,99212,CPT,,,,,,,,155,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,75.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,150.8615
Smear Fluorescent/Acid Stai,PX87206,CDM,300,RC,87206,CPT,,,,,,,,155,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,75.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.94,151.9
Smear Fluorescent/Acid Stai,PX87206,CDM,300,RC,87206,CPT,,,,,,,,155,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,75.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.94,151.9
Smear Fluorescent/Acid Stai,PX87206,CDM,300,RC,87206,CPT,,,,,,,,155,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,75.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.94,151.9
TB Test Enumeration of T-Cells - Ref,PX8648190,CDM,300,RC,86481,CPT,90,,,,,,,155,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,75.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,151.9
TB Test Enumeration of T-Cells - Ref,PX8648190,CDM,300,RC,86481,CPT,90,,,,,,,155,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,75.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,151.9
TB Test Enumeration of T-Cells - Ref,PX8648190,CDM,300,RC,86481,CPT,90,,,,,,,155,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,75.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,151.9
fentaNYL 25 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,591319872,NDC,1,EA,77.51,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,75.9598,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Emergency Level IV Visit,PX99284P,CDM,981,RC,99284,CPT,,,,,,,,914,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.2,895.72
Emergency Level IV Visit,PX99284P,CDM,981,RC,99284,CPT,,,,,,,,914,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.2,895.72
Facility Emergency Level IV Visit,PX99284F,CDM,450,RC,99284,CPT,,,,,,,,1054,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.2,214.68
Facility Emergency Level IV Visit,PX99284F,CDM,450,RC,99284,CPT,,,,,,,,1054,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.2,214.68
Raltegravir 400 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,6022761,NDC,1,EA,150.2,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,76.0012,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,63323094004,NDC,4,ML,89.43,,First Health,Commercial,both,85,,999999999,percent of total billed charges,76.0155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,63323094021,NDC,4,ML,89.43,,First Health,Commercial,both,85,,999999999,percent of total billed charges,76.0155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Voriconazole - Ref,PX8028590,CDM,300,RC,80285,CPT,90,,,,,,,183,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,76.0182,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.86,179.34
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036019,NDC,10,ML,86.23,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,76.05486,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,84.5054
TRAY IV SURGICAL EXTREMITY DYNJS0804,27200000,CDM,272,RC,,,,10919-MAIN,LOCAL,,,,,83.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,76.0685,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,409337504,NDC,4,ML,150.36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,76.08216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dextrose 25% Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409177510,NDC,10,ML,83.53,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,76.09583,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Drain/Inject Medium Joint/Bursa,PX20605F,CDM,510,RC,20605,CPT,,,,,,,,247,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,76.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.47,114.84
Drain/Inject Medium Joint/Bursa,PX20605P,CDM,983,RC,20605,CPT,,,,,,,,318,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,76.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.47,311.64
"Inject Trigger Point, 1 or 2",PX20552F,CDM,510,RC,20552,CPT,,,,,,,,252,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,76.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.9,109.3
"Inject Trigger Point, 1 or 2",PX20552P,CDM,983,RC,20552,CPT,,,,,,,,210,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,76.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.9,205.8
Skin Sub Graft Trnk/Arm/Leg,PX15271F,CDM,510,RC,15271,CPT,,,,,,,,862,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,76.1007,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.83,320.3
Skin Sub Graft Trnk/Arm/Leg,PX15271P,CDM,983,RC,15271,CPT,,,,,,,,705,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,76.1007,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.83,690.9
hydrocortisone sodium succinate (preservative free) 250 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001305,NDC,1,EA,183.32,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,76.151128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011701,NDC,1,EA,89.64,,First Health,Commercial,both,85,,999999999,percent of total billed charges,76.194,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011710,NDC,1,EA,89.64,,First Health,Commercial,both,85,,999999999,percent of total billed charges,76.194,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
LAP KIT BASIC,27200000,CDM,272,RC,,,,4829-MAIN,LOCAL,,,,,78.29,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,76.199657,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
leucovorin 350 MG Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,703514501,NDC,1,EA,86.41,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,76.21362,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.670002,84.6818
tranexamic acid 1000 mg in 100 mL 0.7% sodium chloride (premix) 1000-0.7 MG/100ML-% Solution 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,80830232901,NDC,100,ML,155.55,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,76.2195,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tranexamic acid 1000 mg in 100 mL 0.7% sodium chloride (premix) 1000-0.7 MG/100ML-% Solution 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,80830232901,NDC,100,ML,155.55,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,76.2195,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tranexamic acid 1000 mg in 100 mL 0.7% sodium chloride (premix) 1000-0.7 MG/100ML-% Solution 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,80830232901,NDC,100,ML,155.55,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,76.2195,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Lvl 3 Sub Hosp High Mdm or 50 Minutes,PX99233,CDM,982,RC,99233,CPT,,,,,,,,384,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,76.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.41,376.32
Lvl 3 Sub Hosp High Mdm or 50 Minutes,PX99233,CDM,982,RC,99233,CPT,,,,,,,,384,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,76.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.41,376.32
PROSTEP 0.9MM ANTI SKIVE PIN,27200000,CDM,272,RC,,,,12950-MAIN,LOCAL,,,,,154,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,76.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PROSTEP 1.4MM ANTI SKIVE PIN,27200000,CDM,272,RC,,,,12949-MAIN,LOCAL,,,,,154,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,76.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Vit D 1 25-Dihydroxy,PX82652,CDM,300,RC,82652,CPT,,,,,,,,154,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,76.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.3,150.92
hydrOXYzine 50 MG/ML Solution 1 mL Vial,J3410.01,CDM,636,RC,J3410,HCPCS,,,,517560125,NDC,0.5,ML,83.68,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,76.23248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.760672,82.0064
HYDROmorphone 0.1 MG/ML Solution 55 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,61553067976,NDC,55,ML,89.7,,First Health,Commercial,both,85,,999999999,percent of total billed charges,76.245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409663734,NDC,50,ML,89.7,,First Health,Commercial,both,85,,999999999,percent of total billed charges,76.245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
EPIX UNIVERSAL CLIP APPLIER,27200000,CDM,272,RC,,,,11708-MAIN,LOCAL,,,,,158.95,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,76.296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
EPIX UNIVERSAL CLIP APPLIER,27200000,CDM,272,RC,,,,11708-MAIN,LOCAL,,,,,158.95,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,76.296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,69543025204,NDC,118,ML,78.39,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,76.296987,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331601,NDC,10,ML,77.86,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,76.3028,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
Iaad Ia Severe Aqt Respir Synd Coronavirus,PX87426,CDM,300,RC,87426,CPT,,,,,,,,159,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,76.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.39,155.82
Iaad Ia Severe Aqt Respir Synd Coronavirus,PX87426,CDM,300,RC,87426,CPT,,,,,,,,159,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,76.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.39,155.82
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,4080285,NDC,1,EA,89.79,,First Health,Commercial,both,85,,999999999,percent of total billed charges,76.3215,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800F,CDM,510,RC,40800,CPT,,,,,,,,255,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,76.35,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.35,420.61
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800P,CDM,983,RC,40800,CPT,,,,,,,,170,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,76.35,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.35,420.61
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,703574811,NDC,100,ML,183.92,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,76.400368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.174958,180.2416
isatuximab-irfc 500 MG/25ML Solution 25 mL Vial,J9227.01,CDM,636,RC,J9227,HCPCS,,,,24065601,NDC,25,ML,7876.36,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,76.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.31,80.32
isatuximab-irfc 500 MG/25ML Solution 25 mL Vial,J9227.01,CDM,636,RC,J9227,HCPCS,,,,24065601,NDC,25,ML,7876.36,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,76.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.31,80.32
silver sulfADIAZINE 1 % Cream 50 g Jar,25000000,CDM,250,RC,,,,,,43598021055,NDC,50,GR,83.89,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,76.42379,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
TUBE TRACH SIZE 3.0MM ID 4.5MM OD SHILEY PEDIATRIC 3.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1185-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,76.4336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 3.5MM ID 5.2MM OD SHILEY PEDIATRIC,120.287,CDM,272,RC,A7520,HCPCS,,8813-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,76.4336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 4.0MM ID 5.9MM OD SHILEY PEDIATRIC 4.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1187-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,76.4336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 5 7.0MM ID 10.1MM OD SHILEY CUFFED 5CN70H,120.287,CDM,272,RC,A7521,HCPCS,,10350-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,76.4336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 5.0MM ID 7.1MM OD SHILEY PEDIATRIC 5.0PED,120.287,CDM,272,RC,A7520,HCPCS,,8814-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,76.4336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 6 6.0MM ID 8.3MM OD SHILEY CUFFED 6SCT,120.287,CDM,272,RC,A7521,HCPCS,,8812-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,76.4336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 6 6.4MM ID 10.8MM OD SHILEY CUFFED 6DCT,120.287,CDM,272,RC,A7521,HCPCS,,1190-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,76.4336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 7.5MM ID 10.8MM OD SHILEY CUFFED 6CN75H,120.287,CDM,272,RC,A7521,HCPCS,,8488-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,76.4336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 8 7.6MM ID 12.2MM OD SHILEY 8DCT,120.287,CDM,272,RC,A7521,HCPCS,,1192-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,76.4336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 8 7.6MM ID 12.22MM OD SHILEY CUFFED 8LPC,120.287,CDM,272,RC,A7521,HCPCS,,8815-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,76.4336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 8.0MM ID 10.9MM OD SHILEY CUFFED 8SCT,120.287,CDM,272,RC,A7521,HCPCS,,8811-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,76.4336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 10 SHILEY 10LPC,120.287,CDM,272,RC,A7521,HCPCS,,1181-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,76.4336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
Assay Blood Carbon Monoxide,PX82375,CDM,300,RC,82375,CPT,,,,,,,,156,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,76.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.3,152.88
Assay Blood Carbon Monoxide,PX82375,CDM,300,RC,82375,CPT,,,,,,,,156,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,76.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.3,152.88
Assay Blood Carbon Monoxide,PX82375,CDM,300,RC,82375,CPT,,,,,,,,156,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,76.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.3,152.88
Ceruloplasmin - Ref,PX8239090,CDM,300,RC,82390,CPT,90,,,,,,,78,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,76.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,76.44
Chemiluminescent Assay - Ref,PX8239790,CDM,300,RC,82397,CPT,90,,,,,,,78,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,76.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.95,76.44
"Cortisol, Am",PX7152,CDM,300,RC,82533,CPT,,,,,,,,156,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,76.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.95,152.88
"Cortisol, Am",PX7152,CDM,300,RC,82533,CPT,,,,,,,,156,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,76.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.95,152.88
"Cortisol, Am",PX7152,CDM,300,RC,82533,CPT,,,,,,,,156,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,76.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.95,152.88
DERMABOND PRINEO SKIN CLOSURE SYSTEM 22CM,27200000,CDM,272,RC,,,,12324-MAIN,LOCAL,,,,,156,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,76.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DERMABOND PRINEO SKIN CLOSURE SYSTEM 22CM,27200000,CDM,272,RC,,,,12324-MAIN,LOCAL,,,,,156,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,76.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DERMABOND PRINEO SKIN CLOSURE SYSTEM 22CM,27200000,CDM,272,RC,,,,12324-MAIN,LOCAL,,,,,156,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,76.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
VISUALIZATION SYSTEM CLEARIFY LAPAROSCOPE STERILE,27200000,CDM,272,RC,,,,11875-MAIN,LOCAL,,,,,78,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,76.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Gammaglobulin; Iga, Dg,M - Ref",PX8278490,CDM,300,RC,82784,CPT,90,,,,,,,90,,First Health,Commercial,both,85,,999999999,percent of total billed charges,76.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.53,88.2
"Misc Virus Antibody, Nos - Ref",PX8679090,CDM,300,RC,86790,CPT,90,,,,,,,90,,First Health,Commercial,both,85,,999999999,percent of total billed charges,76.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.81,88.2
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152P,CDM,983,RC,99152,CPT,,,,,,,,90,,First Health,Commercial,both,85,,999999999,percent of total billed charges,76.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.386,87.597
Mycobacteria Culture - Ref,PX8711690,CDM,300,RC,87116,CPT,90,,,,,,,90,,First Health,Commercial,both,85,,999999999,percent of total billed charges,76.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9,88.2
erythromycin lactobionate 500 MG Recon Soln 1 Each Vial,J1364.01,CDM,636,RC,J1364,HCPCS,,,,409648211,NDC,1,EA,437.09,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,76.50026,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.08,80.78
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505615204,NDC,0.5,EA,86.76,,United Healthcare,All Payer,outpatient,88.2,,201.07,percent of total billed charges,76.52232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
CANNULA OPTIFLOW JUNIOR2+ XXL OJR520,120.494,CDM,271,RC,A4615,HCPCS,,11619-MAIN,LOCAL,,,,,84,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,76.524,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.8936,82.32
Hiaa - Ref,PX8349790,CDM,300,RC,83497,CPT,90,,,,,,,84,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,76.524,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.83,82.32
Aldosterone - Ref,PX8208890,CDM,300,RC,82088,CPT,90,,,,,,,86,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,76.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.7244,84.28
Epstein-barr antibody,PX86665,CDM,300,RC,86665,CPT,,,,,,,,86,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,76.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.63,84.28
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,574200815,NDC,15,GR,154.63,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,76.54185,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001302,NDC,2,ML,86.79,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,76.54878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
SAWBLADE SAGITAL STERILE 25MM LENGTH 5.5MM WIDTH 0.60MM THICKNESS,27200000,CDM,272,RC,,,,11623-MAIN,LOCAL,,,,,86.02,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,76.5578,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ARIPiprazole 2 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714014101,NDC,1,EA,151.35,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,76.5831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,55150012150,NDC,1,EA,151.41,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,76.61346,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
infuvite adult Injectable 10 mL Vial,J3490.99,CDM,636,RC,J3490,HCPCS,,,,54643564901,NDC,10,ML,86.89,,United Healthcare,All Payer,outpatient,88.2,,7.6225,percent of total billed charges,76.63698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.094106,85.1522
"Flow Cyto, Tech, 1st Mrkr - Ref",PX8818490,CDM,310,RC,88184,CPT,90,,,,,,,223,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,76.6951,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.72,127.152
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; 1st",PX88184,CDM,310,RC,88184,CPT,,,,,,,,96,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,76.6951,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.72,127.152
LAP KIT BASIC,27200000,CDM,272,RC,,,,4829-MAIN,LOCAL,,,,,78.29,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,76.7242,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CYSTOSCOPY PACK I STERILE,120.505,CDM,272,RC,,,,4527-MAIN,LOCAL,,,,,155,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,76.725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,151.9
"Lab Antibody ID,RBC",PX7605,CDM,300,RC,86870,CPT,,,,,,,,155,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,76.725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,314.02
"Office/Outpt Visit,Est,Levl II",PX99212F,CDM,510,RC,99212,CPT,,,,,,,,155,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,76.725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,151.9
"Office/Outpt Visit,Est,Levl II",PX99212P,CDM,983,RC,99212,CPT,,,,,,,,155,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,76.725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,150.8615
Smear Fluorescent/Acid Stai,PX87206,CDM,300,RC,87206,CPT,,,,,,,,155,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,76.725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.94,151.9
TB Test Enumeration of T-Cells - Ref,PX8648190,CDM,300,RC,86481,CPT,90,,,,,,,155,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,76.725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,151.9
"Chemotherapy, IV Push, Additional Drug",PX96411,CDM,335,RC,96411,CPT,,,,,,,,87,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,76.734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.1398,85.26
"Closed Rx Radial Head Disloc,Child",PX24640F,CDM,510,RC,24640,CPT,,,,,,,,270,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,76.7429,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.04,218.61
"Closed Rx Radial Head Disloc,Child",PX24640P,CDM,983,RC,24640,CPT,,,,,,,,180,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,76.7429,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.04,218.61
"Injection,Sacroiliac Joint(T)",PX27096F,CDM,510,RC,27096,CPT,,,,,,,,881,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,76.7429,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.7,341.06
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036019,NDC,10,ML,86.23,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,76.7447,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,84.5054
Needle Insertion W/O Injection 3 or More Muscles,PX20561,CDM,420,RC,20561,CPT,,,,,,,,10,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,76.79,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.87,76.79
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762F,CDM,510,RC,43762,CPT,,,,,,,,492,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,76.79,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.03,467.66
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762P,CDM,983,RC,43762,CPT,,,,,,,,328,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,76.79,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.03,467.66
"Apply Short Leg Cast,Walker",PX29425F,CDM,510,RC,29425,CPT,,,,,,,,179,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,76.791,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.3566,234.62
C Diff Amplified Probe,PX87493,CDM,300,RC,87493,CPT,,,,,,,,179,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,76.791,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.17,175.42
Fibrinogen Test - Ref,PX8536690,CDM,300,RC,85366,CPT,90,,,,,,,179,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,76.791,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.77,175.42
TUBE GASTROSTOMY 18FR REPLACEMENT DYND70318,120.256,CDM,271,RC,B4087,HCPCS,,407-MAIN,LOCAL,,,,,179,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,76.791,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.53,175.42
Ex for Speech Device Rx Addl,PX92608,CDM,444,RC,92608,CPT,,,,,,,,160,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,76.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.95,156.8
Ex for Speech Device Rx Addl,PX92608,CDM,444,RC,92608,CPT,,,,,,,,160,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,76.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.95,156.8
alteplase 1 MG/ML Solution 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,8888800497,NDC,1,EA,21140.86,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,76.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.6,88.97
alteplase 1 MG/ML Solution 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,8888800497,NDC,1,EA,21140.86,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,76.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.6,88.97
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004110,NDC,1,EA,666.53,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,76.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.6,88.97
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004110,NDC,1,EA,666.53,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,76.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.6,88.97
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004164,NDC,1,EA,666.52,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,76.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.6,88.97
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004164,NDC,1,EA,666.52,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,76.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.6,88.97
alteplase 100 MG Recon Soln 1 Each Syringe,J2997.01,CDM,636,RC,J2997,HCPCS,,,,88888800475,NDC,0.09,EA,1920.88,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,76.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.6,88.97
alteplase 100 MG Recon Soln 1 Each Syringe,J2997.01,CDM,636,RC,J2997,HCPCS,,,,88888800475,NDC,0.09,EA,1920.88,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,76.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.6,88.97
alteplase 100 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242008527,NDC,1,EA,21140.86,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,76.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.6,88.97
alteplase 100 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242008527,NDC,1,EA,21140.86,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,76.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.6,88.97
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,69543025204,NDC,118,ML,78.39,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,76.8222,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Amylase - Ref,PX8215090,CDM,300,RC,82150,CPT,90,,,,,,,185,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,76.849,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.94,181.3
Hepatitis C Rna Quant,PX87522,CDM,300,RC,87522,CPT,,,,,,,,185,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,76.849,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.28,181.3
"Office/Outpt Visit,Est,Levl III",PX99213F,CDM,510,RC,99213,CPT,,,,,,,,185,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,76.849,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.849,181.3
"Office/Outpt Visit,Est,Levl III",PX99213P,CDM,983,RC,99213,CPT,,,,,,,,185,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,76.849,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.849,180.0605
betamethasone acetate-betamethasone sodium phosphate 6 (3-3) MG/ML Suspension 5 mL Vial,J0702.01,CDM,636,RC,J0702,HCPCS,,,,517072001,NDC,1,ML,78.96,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,76.851768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.799984,77.3808
sodium zirconium cyclosilicate 5 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,310110501,NDC,1,EA,151.95,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,76.8867,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Everolimus,PX8016990,CDM,300,RC,80169,CPT,,,,,,,,79,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,76.8907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,77.42
leucovorin 350 MG Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,703514501,NDC,1,EA,86.41,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,76.9049,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.670002,84.6818
"Antipsychotics, Not Otherwise Specified; 1-3 - Ref",PX8034290,CDM,300,RC,80342,CPT,90,,,,,,,152,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,76.912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.1408,148.96
Body Fluid Cell Count,PX89050,CDM,300,RC,89050,CPT,,,,,,,,152,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,76.912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.33,148.96
Assay of Psa Total,PX84153,CDM,300,RC,84153,CPT,,,,,,,,157,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,76.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.86,153.86
Assay of Psa Total,PX84153,CDM,300,RC,84153,CPT,,,,,,,,157,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,76.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.86,153.86
Assay of Psa Total,PX84153,CDM,300,RC,84153,CPT,,,,,,,,157,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,76.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.86,153.86
"Chlamydia Trachomatis Dna, Amp Probe",PX87491,CDM,300,RC,87491,CPT,,,,,,,,157,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,76.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,153.86
"Chlamydia Trachomatis Dna, Amp Probe",PX87491,CDM,300,RC,87491,CPT,,,,,,,,157,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,76.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,153.86
"Chlamydia Trachomatis Dna, Amp Probe",PX87491,CDM,300,RC,87491,CPT,,,,,,,,157,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,76.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,153.86
"Cognitive Skill Dev, Ea 15 Min",PX97532,CDM,420,RC,97532,CPT,,,,,,,,157,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,76.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.2178,153.86
"Cognitive Skill Dev, Ea 15 Min",PX97532,CDM,420,RC,97532,CPT,,,,,,,,157,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,76.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.2178,153.86
"Cognitive Skill Dev, Ea 15 Min",PX97532,CDM,420,RC,97532,CPT,,,,,,,,157,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,76.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.2178,153.86
"Fungal Culture, Other Source - Ref",PX8710290,CDM,300,RC,87102,CPT,90,,,,,,,157,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,76.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.71,153.86
"Fungal Culture, Other Source - Ref",PX8710290,CDM,300,RC,87102,CPT,90,,,,,,,157,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,76.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.71,153.86
"Fungal Culture, Other Source - Ref",PX8710290,CDM,300,RC,87102,CPT,90,,,,,,,157,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,76.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.71,153.86
Lactate (Ld) (Ldh) Enzyme,PX83615,CDM,300,RC,83615,CPT,,,,,,,,157,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,76.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.54,153.86
Lactate (Ld) (Ldh) Enzyme,PX83615,CDM,300,RC,83615,CPT,,,,,,,,157,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,76.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.54,153.86
Lactate (Ld) (Ldh) Enzyme,PX83615,CDM,300,RC,83615,CPT,,,,,,,,157,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,76.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.54,153.86
"Neisseria Gonorrhoeae Dna, Amp Probe",PX87591,CDM,300,RC,87591,CPT,,,,,,,,157,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,76.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,153.86
"Neisseria Gonorrhoeae Dna, Amp Probe",PX87591,CDM,300,RC,87591,CPT,,,,,,,,157,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,76.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,153.86
"Neisseria Gonorrhoeae Dna, Amp Probe",PX87591,CDM,300,RC,87591,CPT,,,,,,,,157,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,76.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,153.86
Psa Screening,PXG0103,CDM,300,RC,G0103,HCPCS,,,,,,,,157,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,76.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.71,153.86
Psa Screening,PXG0103,CDM,300,RC,G0103,HCPCS,,,,,,,,157,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,76.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.71,153.86
Psa Screening,PXG0103,CDM,300,RC,G0103,HCPCS,,,,,,,,157,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,76.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.71,153.86
Remv Ext Canal Foreign Body,PX69200P,CDM,983,RC,69200,CPT,,,,,,,,157,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,76.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.2178,152.8081
Remv Ext Canal Foreign Body,PX69200P,CDM,983,RC,69200,CPT,,,,,,,,157,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,76.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.2178,152.8081
Remv Ext Canal Foreign Body,PX69200P,CDM,983,RC,69200,CPT,,,,,,,,157,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,76.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.2178,152.8081
timolol 0.25 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314022605,NDC,5,ML,84.45,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,76.93395,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361250,NDC,50,ML,90.53,,First Health,Commercial,both,85,,999999999,percent of total billed charges,76.9505,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361650,NDC,50,ML,90.53,,First Health,Commercial,both,85,,999999999,percent of total billed charges,76.9505,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,70860030143,NDC,25,ML,84.47,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,76.95217,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010626,NDC,50,ML,84.47,,Medica,Commercial,both,91.1,,6.305,percent of total billed charges,76.95217,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
sodium bicarbonate 8.4 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409662502,NDC,50,ML,84.47,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,76.95217,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
levoFLOXacin 250 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635161,NDC,1,EA,79.08,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,76.968564,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tranexamic acid 1000 mg in 100 mL 0.7% sodium chloride (premix) 1000-0.7 MG/100ML-% Solution 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,80830232901,NDC,100,ML,155.55,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,76.99725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133F,CDM,510,RC,13133,CPT,,,,,,,,595,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,77,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77,348.67
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133P,CDM,983,RC,13133,CPT,,,,,,,,256,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,77,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77,348.67
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031801,NDC,1,ML,185.37,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,77.002698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.002698,181.6626
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031825,NDC,1,ML,185.37,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,77.002698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.002698,181.6626
nafcillin 2 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,S0032,HCPCS,,,,63323032820,NDC,1,EA,185.37,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,77.002698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fentaNYL 50 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,47781042611,NDC,1,EA,185.47,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,77.044238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 50 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,47781042647,NDC,1,EA,185.47,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,77.044238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Digital Mamm, Diag, Bilat, Tc W/Cad Perf",PX7706601,CDM,401,RC,77066,CPT,TC,,,,,,,375,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,77.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.05,367.5
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047621,NDC,1,ML,157.28,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,77.0672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.354486,332.1514
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047621,NDC,1,ML,157.28,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,77.0672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.354486,332.1514
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047621,NDC,1,ML,157.28,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,77.0672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.354486,332.1514
verapamil 2.5 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,409114405,NDC,2,ML,185.65,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,77.11901,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
IMMOBILIZER SHOULDER LARGE 9008-03,120.38,CDM,274,RC,L3650,HCPCS,,906-MAIN,LOCAL,,,,,36,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,77.17,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,77.17
IMMOBILIZER SHOULDER LARGE STRAP OSG3033,120.38,CDM,274,RC,L3650,HCPCS,,2910-MAIN,LOCAL,,,,,36,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,77.17,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,77.17
IMMOBILIZER SHOULDER MEDIUM 9008-02,120.38,CDM,274,RC,L3650,HCPCS,,912-MAIN,LOCAL,,,,,36,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,77.17,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,77.17
IMMOBILIZER SHOULDER MEDIUM OSG3032,120.38,CDM,274,RC,L3650,HCPCS,,915-MAIN,LOCAL,,,,,36,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,77.17,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,77.17
IMMOBILIZER SHOULDER SMALL 9008-01,120.38,CDM,274,RC,L3650,HCPCS,,913-MAIN,LOCAL,,,,,36,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,77.17,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,77.17
IMMOBILIZER SHOULDER SMALL WITH CLOTH 9001-02,120.38,CDM,274,RC,L3650,HCPCS,,914-MAIN,LOCAL,,,,,36,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,77.17,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,77.17
IMMOBILIZER SHOULDER X-LARGE CLOTH 9001-05,120.38,CDM,274,RC,L3650,HCPCS,,917-MAIN,LOCAL,,,,,36,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,77.17,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,77.17
IMMOBILIZER SHOULDER X-LARGE ORT16100XL,120.38,CDM,274,RC,L3650,HCPCS,,904-MAIN,LOCAL,,,,,36,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,77.17,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,77.17
Abd Duplex Abd -Follow Up,PX9397602,CDM,921,RC,93976,CPT,TC,,,,,,,784,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,77.17,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.55,211.74
Abd Duplex Abd -Follow Up,PX9397602,CDM,921,RC,93976,CPT,TC,,,,,,,784,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,77.17,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.55,211.74
Abd Duplex Abd-Follow Up(T),PX9397601,CDM,921,RC,93976,CPT,TC,,,,,,,809,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,77.17,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.55,211.74
Abd Duplex Abd-Follow Up(T),PX9397601,CDM,921,RC,93976,CPT,TC,,,,,,,809,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,77.17,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.55,211.74
IMMOBILIZER SHOULDER LARGE 9008-03,120.38,CDM,274,RC,L3650,HCPCS,,906-MAIN,LOCAL,,,,,36,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,77.17,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,77.17
IMMOBILIZER SHOULDER LARGE 9008-03,120.38,CDM,274,RC,L3650,HCPCS,,906-MAIN,LOCAL,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,77.17,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,77.17
IMMOBILIZER SHOULDER LARGE STRAP OSG3033,120.38,CDM,274,RC,L3650,HCPCS,,2910-MAIN,LOCAL,,,,,36,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,77.17,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,77.17
IMMOBILIZER SHOULDER LARGE STRAP OSG3033,120.38,CDM,274,RC,L3650,HCPCS,,2910-MAIN,LOCAL,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,77.17,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,77.17
IMMOBILIZER SHOULDER MEDIUM 9008-02,120.38,CDM,274,RC,L3650,HCPCS,,912-MAIN,LOCAL,,,,,36,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,77.17,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,77.17
IMMOBILIZER SHOULDER MEDIUM 9008-02,120.38,CDM,274,RC,L3650,HCPCS,,912-MAIN,LOCAL,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,77.17,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,77.17
IMMOBILIZER SHOULDER MEDIUM OSG3032,120.38,CDM,274,RC,L3650,HCPCS,,915-MAIN,LOCAL,,,,,36,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,77.17,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,77.17
IMMOBILIZER SHOULDER MEDIUM OSG3032,120.38,CDM,274,RC,L3650,HCPCS,,915-MAIN,LOCAL,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,77.17,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,77.17
IMMOBILIZER SHOULDER SMALL 9008-01,120.38,CDM,274,RC,L3650,HCPCS,,913-MAIN,LOCAL,,,,,36,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,77.17,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,77.17
IMMOBILIZER SHOULDER SMALL 9008-01,120.38,CDM,274,RC,L3650,HCPCS,,913-MAIN,LOCAL,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,77.17,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,77.17
IMMOBILIZER SHOULDER SMALL WITH CLOTH 9001-02,120.38,CDM,274,RC,L3650,HCPCS,,914-MAIN,LOCAL,,,,,36,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,77.17,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,77.17
IMMOBILIZER SHOULDER SMALL WITH CLOTH 9001-02,120.38,CDM,274,RC,L3650,HCPCS,,914-MAIN,LOCAL,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,77.17,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,77.17
IMMOBILIZER SHOULDER X-LARGE CLOTH 9001-05,120.38,CDM,274,RC,L3650,HCPCS,,917-MAIN,LOCAL,,,,,36,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,77.17,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,77.17
IMMOBILIZER SHOULDER X-LARGE CLOTH 9001-05,120.38,CDM,274,RC,L3650,HCPCS,,917-MAIN,LOCAL,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,77.17,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,77.17
IMMOBILIZER SHOULDER X-LARGE ORT16100XL,120.38,CDM,274,RC,L3650,HCPCS,,904-MAIN,LOCAL,,,,,36,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,77.17,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,77.17
IMMOBILIZER SHOULDER X-LARGE ORT16100XL,120.38,CDM,274,RC,L3650,HCPCS,,904-MAIN,LOCAL,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,77.17,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.6814,77.17
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989001,NDC,50,ML,160.78,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,77.1744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989001,NDC,50,ML,160.78,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,77.1744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989002,NDC,50,ML,160.78,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,77.1744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989002,NDC,50,ML,160.78,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,77.1744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
protamine 10 MG/ML Solution 5 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022994,NDC,5,ML,84.74,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,77.19814,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.431298,83.0452
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505615204,NDC,0.5,EA,86.76,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,77.2164,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
Assay Blood Carbon Monoxide,PX82375,CDM,300,RC,82375,CPT,,,,,,,,156,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,77.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.3,152.88
C-Peptide - Ref,PX8468190,CDM,300,RC,84681,CPT,90,,,,,,,180,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,77.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,176.4
"Closed Rx Radial Head Disloc,Child",PX24640P,CDM,983,RC,24640,CPT,,,,,,,,180,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,77.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.772,206.02
"Cortisol, Am",PX7152,CDM,300,RC,82533,CPT,,,,,,,,156,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,77.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.95,152.88
DERMABOND PRINEO SKIN CLOSURE SYSTEM 22CM,27200000,CDM,272,RC,,,,12324-MAIN,LOCAL,,,,,156,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,77.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800F,CDM,510,RC,40800,CPT,,,,,,,,255,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,77.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.35,420.61
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800F,CDM,510,RC,40800,CPT,,,,,,,,255,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,77.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.35,420.61
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800P,CDM,983,RC,40800,CPT,,,,,,,,170,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,77.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.35,420.61
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800P,CDM,983,RC,40800,CPT,,,,,,,,170,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,77.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.35,420.61
"Infect Ea Organ, Amp Prob - Ref",PX8779890,CDM,300,RC,87798,CPT,90,,,,,,,180,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,77.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,176.4
Mrsa by Amplification Na,PX87641,CDM,300,RC,87641,CPT,,,,,,,,180,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,77.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,176.4
Protein Elp,PX84166,CDM,300,RC,84166,CPT,,,,,,,,180,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,77.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.35,176.4
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133F,CDM,510,RC,13133,CPT,,,,,,,,595,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,77.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77,348.67
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133F,CDM,510,RC,13133,CPT,,,,,,,,595,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,77.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77,348.67
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133P,CDM,983,RC,13133,CPT,,,,,,,,256,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,77.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77,348.67
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133P,CDM,983,RC,13133,CPT,,,,,,,,256,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,77.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77,348.67
Sleep Staging 4 + Pap,PX9581126,CDM,982,RC,95811,CPT,26,,,,,,,1850,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,77.22,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.22,1813
venetoclax 100 MG Tablet 1 Each Box,25000000,CDM,250,RC,,,,,,74057611,NDC,0.2,EA,90.87,,First Health,Commercial,both,85,,999999999,percent of total billed charges,77.2395,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001302,NDC,2,ML,86.79,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,77.2431,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,517096010,NDC,10,ML,157.64,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,77.2436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,517096010,NDC,10,ML,157.64,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,77.2436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,517096010,NDC,10,ML,157.64,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,77.2436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
nitroPRUSSide 25 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,72485010501,NDC,2,ML,186,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,77.2644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Puncture Drainage of Lesion,PX10160P,CDM,983,RC,10160,CPT,,,,,,,,186,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,77.2644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.2644,348.35
"TB Test, Cell Immunity Measure",PX86480,CDM,300,RC,86480,CPT,,,,,,,,186,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,77.2644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.83,182.28
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127303,NDC,2,ML,152.7,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,77.2662,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.43158,173.019
Catheterize for Urine Spec,PXP9612,CDM,300,RC,P9612,HCPCS,,,,,,,,161,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,77.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.1,157.78
Catheterize for Urine Spec,PXP9612,CDM,300,RC,P9612,HCPCS,,,,,,,,161,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,77.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.1,157.78
Drain/Inject Small Joint/Bursa,PX20600F,CDM,510,RC,20600,CPT,,,,,,,,161,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,77.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.8794,258.75
Drain/Inject Small Joint/Bursa,PX20600F,CDM,510,RC,20600,CPT,,,,,,,,161,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,77.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.8794,258.75
Each Add'l Hour IV Infusion <8 Hour,PX96366,CDM,260,RC,96366,CPT,,,,,,,,161,,Health Partners,Health Partners Care Plans,both,48,,85.41296296,percent of total billed charges,77.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,157.78
Each Add'l Hour IV Infusion <8 Hour,PX96366,CDM,260,RC,96366,CPT,,,,,,,,161,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,77.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,157.78
infuvite adult Injectable 10 mL Vial,J3490.99,CDM,636,RC,J3490,HCPCS,,,,54643564901,NDC,10,ML,86.89,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,77.3321,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.094106,85.1522
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,55150043801,NDC,20,ML,152.9,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,77.3674,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457018120,NDC,20,ML,152.9,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,77.3674,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
betamethasone acetate-betamethasone sodium phosphate 6 (3-3) MG/ML Suspension 5 mL Vial,J0702.01,CDM,636,RC,J0702,HCPCS,,,,517072001,NDC,1,ML,78.96,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,77.3808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.799984,77.3808
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329333901,NDC,10,ML,79.51,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1.253,percent of total billed charges,77.387083,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
calcium CHLORIDE 10 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,76329330401,NDC,10,ML,79.51,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,77.387083,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,25021018482,NDC,100,ML,79.51,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,77.387083,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.786918,140.5516
menthol-zinc oxide Paste 113 g Tube,63700001,CDM,250,RC,,,,,,53329016544,NDC,113,GR,79.52,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,77.396816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ceFAZolin in D4W 1 g / 50 mL 1-4 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0690.01,CDM,636,RC,J0690,HCPCS,,,,264310311,NDC,1,EA,84.97,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,77.40767,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049237,NDC,30,ML,87.77,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,77.41314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ELECTRODE ADULT PACING ONESTEP,120.214,CDM,272,RC,A4556,HCPCS,,10242-MAIN,LOCAL,,,,,153,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,77.418,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.5562,149.94
"Protein, Total; Other Source",PX84157,CDM,300,RC,84157,CPT,,,,,,,,153,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,77.418,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.67,149.94
Pulmonary Stress Test,PX94618,CDM,976,RC,94618,CPT,,,,,,,,153,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,77.418,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.5562,148.9149
Antithrombin III Activity - Ref,PX8530090,CDM,300,RC,85300,CPT,90,,,,,,,158,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,77.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.87,154.84
Antithrombin III Activity - Ref,PX8530090,CDM,300,RC,85300,CPT,90,,,,,,,158,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,77.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.87,154.84
Antithrombin III Activity - Ref,PX8530090,CDM,300,RC,85300,CPT,90,,,,,,,158,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,77.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.87,154.84
Everolimus,PX8016990,CDM,300,RC,80169,CPT,,,,,,,,79,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,77.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,77.42
Fac/Trm Hyperkeratotic Skn Lesn2-4,PX11056F,CDM,510,RC,11056,CPT,,,,,,,,158,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,30.6,percent of total billed charges,77.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.6332,174.9
Fac/Trm Hyperkeratotic Skn Lesn2-4,PX11056F,CDM,510,RC,11056,CPT,,,,,,,,158,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,77.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.6332,174.9
Fac/Trm Hyperkeratotic Skn Lesn2-4,PX11056F,CDM,510,RC,11056,CPT,,,,,,,,158,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,77.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.6332,174.9
"Glucose, Body Fluid Other Than Blood",PX82945,CDM,300,RC,82945,CPT,,,,,,,,158,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,77.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.6,154.84
"Glucose, Body Fluid Other Than Blood",PX82945,CDM,300,RC,82945,CPT,,,,,,,,158,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,77.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.6,154.84
"Glucose, Body Fluid Other Than Blood",PX82945,CDM,300,RC,82945,CPT,,,,,,,,158,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,77.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.6,154.84
Protein C Activity - Ref,PX8530390,CDM,300,RC,85303,CPT,90,,,,,,,158,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,77.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.69,154.84
Protein C Activity - Ref,PX8530390,CDM,300,RC,85303,CPT,90,,,,,,,158,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,77.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.69,154.84
Protein C Activity - Ref,PX8530390,CDM,300,RC,85303,CPT,90,,,,,,,158,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,77.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.69,154.84
"Triiodothyronine T3, Tot - Ref",PX8448090,CDM,300,RC,84480,CPT,90,,,,,,,158,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,77.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13,154.84
"Triiodothyronine T3, Tot - Ref",PX8448090,CDM,300,RC,84480,CPT,90,,,,,,,158,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,77.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13,154.84
"Triiodothyronine T3, Tot - Ref",PX8448090,CDM,300,RC,84480,CPT,90,,,,,,,158,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,77.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13,154.84
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457018100,NDC,20,ML,153.01,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,77.42306,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
"Chemotherapy, IV Push, Additional Drug",PX96411,CDM,335,RC,96411,CPT,,,,,,,,87,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,77.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.1398,85.26
"Cognitive Funct Ther Interv, Initial 15 Min",PX97129,CDM,420,RC,97129,CPT,,,,,,,,85,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,77.435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15,83.3
"Exam,Synovial Fluid Crystals",PX89060,CDM,300,RC,89060,CPT,,,,,,,,85,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,77.435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.72,83.3
GLIDESCOPE QC MAC S3 SINGLE USE 0270-1083,120.579,CDM,272,RC,,,,13046-MAIN,LOCAL,,,,,85,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,77.435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.309,83.3
GLIDESCOPE QC MAC S3 SINGLE USE 0270-1085,120.579,CDM,272,RC,,,,13022-MAIN,LOCAL,,,,,85,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,77.435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.309,83.3
GLIDESCOPE QC MAC S4 SINGLE USE 0270-1086,120.579,CDM,272,RC,,,,13023-MAIN,LOCAL,,,,,85,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,77.435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.309,83.3
sodium bicarbonate 8.4 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409662522,NDC,50,ML,85.02,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,77.45322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
predniSONE 5 mg/5 mL 5 MG/5ML Solution 120 mL Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54372250,NDC,120,ML,186.47,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,77.459638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102F,CDM,510,RC,11102,CPT,,,,,,,,171,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,77.48,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.56,208.92
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102P,CDM,983,RC,11102,CPT,,,,,,,,465,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,77.48,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.56,455.7
riTUXimab 100 MG/10ML Solution 10 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005121,NDC,10,ML,1916.61,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,77.49753,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.69,83.16
riTUXimab 500 MG/50ML Solution 50 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005306,NDC,50,ML,8860.06,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,77.49753,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.69,83.16
cloNIDine 0.1 MG/24HR PATCH WEEKLY 4 Each Box,63700001,CDM,250,RC,,,,,,51862045304,NDC,1,EA,158.16,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,77.4984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloNIDine 0.1 MG/24HR PATCH WEEKLY 4 Each Box,63700001,CDM,250,RC,,,,,,51862045304,NDC,1,EA,158.16,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,77.4984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cloNIDine 0.1 MG/24HR PATCH WEEKLY 4 Each Box,63700001,CDM,250,RC,,,,,,51862045304,NDC,1,EA,158.16,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,77.4984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levoFLOXacin 250 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635161,NDC,1,EA,79.08,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,77.4984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862066230,NDC,1,EA,153.17,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,77.50402,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954201,NDC,10,ML,153.18,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,77.50908,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.630972,150.1164
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954210,NDC,10,ML,153.18,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,77.50908,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.630972,150.1164
US Abdomen Tc,PX7670001,CDM,402,RC,76700,CPT,TC,,,,,,,586,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,77.5538,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.35,155.15
Emergency Level I Visit,PX99281P,CDM,981,RC,99281,CPT,,,,,,,,224,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,77.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.56,218.0192
Facility Emergency Level 1 Visit,PX99281F,CDM,450,RC,99281,CPT,,,,,,,,329,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,77.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.56,322.42
Apply of Paste Boot,PX29580P,CDM,983,RC,29580,CPT,,,,,,,,88,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,77.616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.5552,137.65
POSITIONING KIT TRENDELENBURG NUBLUE TP 3000-NB,27100000,CDM,271,RC,,,,12992-MAIN,LOCAL,,,,,88,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,77.616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
SPLINT ANKLE GEL BRACE UNIVERSAL AIRFORM 70351,120.61,CDM,274,RC,L4350,HCPCS,,12342-MAIN,LOCAL,,,,,88,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,77.616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.5552,104.38
SUCTION IRRIGATOR 2 0250070500,27200000,CDM,272,RC,,,,12262-MAIN,LOCAL,,,,,88,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,77.616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Alcohol Biomarkers; 1 or 2 - Ref,PX8032190,CDM,300,RC,80321,CPT,90,,,,,,,181,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,77.649,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.1874,177.38
"Lyme Disease, Antibody - Ref",PX8661890,CDM,300,RC,86618,CPT,90,,,,,,,181,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,77.649,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.61,177.38
PHALINX STERILE TRIAL SIZER 45A00000,27200000,CDM,272,RC,,,,12959-MAIN,LOCAL,,,,,181,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,77.649,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Sleep Staging 4 + Pap,PX9581126,CDM,982,RC,95811,CPT,26,,,,,,,1850,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,77.66,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.22,1813
Sleep Staging 4 + Pap,PX9581126,CDM,982,RC,95811,CPT,26,,,,,,,1850,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,77.66,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.22,1813
Fac/Initial Hospital Care Levl II,PX99222F,CDM,510,RC,99222,CPT,,,,,,,,187,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,77.6798,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.6798,183.26
"Infect Ag,Eia, Nos, Ea - Ref",PX8744990,CDM,300,RC,87449,CPT,90,,,,,,,187,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,77.6798,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,183.26
Initial Hospital Care Levl II,PX99222P,CDM,982,RC,99222,CPT,,,,,,,,187,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,77.6798,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.6798,182.0071
RETRIEVAL BAG 12/15MM,27200000,CDM,272,RC,,,,12660-MAIN,LOCAL,,,,,187,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,77.6798,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
leflunomide 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,62332006130,NDC,1,EA,88.09,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,77.69538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046201,NDC,30,ML,79.84,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,77.708272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Assay of Psa Total,PX84153,CDM,300,RC,84153,CPT,,,,,,,,157,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,77.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.86,153.86
"Chlamydia Trachomatis Dna, Amp Probe",PX87491,CDM,300,RC,87491,CPT,,,,,,,,157,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,77.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,153.86
"Cognitive Skill Dev, Ea 15 Min",PX97532,CDM,420,RC,97532,CPT,,,,,,,,157,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,77.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.2178,153.86
"Fungal Culture, Other Source - Ref",PX8710290,CDM,300,RC,87102,CPT,90,,,,,,,157,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,77.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.71,153.86
Lactate (Ld) (Ldh) Enzyme,PX83615,CDM,300,RC,83615,CPT,,,,,,,,157,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,77.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.54,153.86
"Neisseria Gonorrhoeae Dna, Amp Probe",PX87591,CDM,300,RC,87591,CPT,,,,,,,,157,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,77.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,153.86
Psa Screening,PXG0103,CDM,300,RC,G0103,HCPCS,,,,,,,,157,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,77.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.71,153.86
Remv Ext Canal Foreign Body,PX69200P,CDM,983,RC,69200,CPT,,,,,,,,157,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,77.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.2178,152.8081
sodium bicarbonate 4.2 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409553434,NDC,10,ML,91.46,,First Health,Commercial,both,85,,999999999,percent of total billed charges,77.741,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Acetone Assay,PX82010,CDM,300,RC,82010,CPT,,,,,,,,162,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,77.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.49,158.76
Acetone Assay,PX82010,CDM,300,RC,82010,CPT,,,,,,,,162,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,77.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.49,158.76
"Flow Interp,2-8 Markers - Ref",PX8818790,CDM,310,RC,88187,CPT,90,,,,,,,162,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,77.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.1,158.76
"Flow Interp,2-8 Markers - Ref",PX8818790,CDM,310,RC,88187,CPT,90,,,,,,,162,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,77.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.1,158.76
KIT THORACENTESIS PLEURA SEAL AK-01000-T,120.24,CDM,272,RC,,,,1147-MAIN,LOCAL,,,,,162,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,77.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.2948,158.76
KIT THORACENTESIS PLEURA SEAL AK-01000-T,120.24,CDM,272,RC,,,,1147-MAIN,LOCAL,,,,,162,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,77.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.2948,158.76
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021515,NDC,0.5,ML,187.24,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,77.779496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.779496,199.7926
imipenem-cilastatin 250 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323034925,NDC,1,EA,91.55,,First Health,Commercial,both,85,,999999999,percent of total billed charges,77.8175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,173.1856
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032294,NDC,1,EA,91.55,,First Health,Commercial,both,85,,999999999,percent of total billed charges,77.8175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,173.1856
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234001,NDC,1.25,ML,91.55,,First Health,Commercial,both,85,,999999999,percent of total billed charges,77.8175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
erythromycin lactobionate 500 MG Recon Soln 1 Each Vial,J1364.01,CDM,636,RC,J1364,HCPCS,,,,409648211,NDC,1,EA,437.09,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,77.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.08,80.78
erythromycin lactobionate 500 MG Recon Soln 1 Each Vial,J1364.01,CDM,636,RC,J1364,HCPCS,,,,409648211,NDC,1,EA,437.09,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,77.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.08,80.78
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047621,NDC,1,ML,157.28,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,77.8536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.354486,332.1514
"Alpha-Fetoprotein, Serum - Ref",PX8210590,CDM,300,RC,82105,CPT,90,,,,,,,80,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,77.864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.38,78.4
Prealubimin,PX84134,CDM,300,RC,84134,CPT,,,,,,,,80,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,77.864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.38,78.4
CT Lower Extremity W/Dye,PX7370101,CDM,350,RC,73701,CPT,TC,,,,,,,2690,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,77.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.88,230.09
CT Lower Extremity W/Dye,PX7370101,CDM,350,RC,73701,CPT,TC,,,,,,,2690,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,77.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.88,230.09
Diagnostic CT Thorax W/ Contrast,PX7126001,CDM,350,RC,71260,CPT,TC,,,,,,,3415,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,77.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.88,230.09
Diagnostic CT Thorax W/ Contrast,PX7126001,CDM,350,RC,71260,CPT,TC,,,,,,,3415,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,77.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.88,230.09
EPIX UNIVERSAL CLIP APPLIER,27200000,CDM,272,RC,,,,11708-MAIN,LOCAL,,,,,158.95,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,77.8855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
EPIX UNIVERSAL CLIP APPLIER,27200000,CDM,272,RC,,,,11708-MAIN,LOCAL,,,,,158.95,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,77.8855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
EPIX UNIVERSAL CLIP APPLIER,27200000,CDM,272,RC,,,,11708-MAIN,LOCAL,,,,,158.95,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,77.8855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Iaad Ia Severe Aqt Respir Synd Coronavirus,PX87426,CDM,300,RC,87426,CPT,,,,,,,,159,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,77.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.39,155.82
Iaad Ia Severe Aqt Respir Synd Coronavirus,PX87426,CDM,300,RC,87426,CPT,,,,,,,,159,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,77.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.39,155.82
Iaad Ia Severe Aqt Respir Synd Coronavirus,PX87426,CDM,300,RC,87426,CPT,,,,,,,,159,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,77.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.39,155.82
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329333901,NDC,10,ML,79.51,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,77.9198,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
calcium CHLORIDE 10 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,76329330401,NDC,10,ML,79.51,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,77.9198,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,25021018482,NDC,100,ML,79.51,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,77.9198,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.786918,140.5516
PROSTEP 0.9MM ANTI SKIVE PIN,27200000,CDM,272,RC,,,,12950-MAIN,LOCAL,,,,,154,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,77.924,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PROSTEP 1.4MM ANTI SKIVE PIN,27200000,CDM,272,RC,,,,12949-MAIN,LOCAL,,,,,154,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,77.924,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Vit D 1 25-Dihydroxy,PX82652,CDM,300,RC,82652,CPT,,,,,,,,154,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,77.924,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.3,150.92
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004722,NDC,2,ML,88.35,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,77.9247,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
menthol-zinc oxide Paste 113 g Tube,63700001,CDM,250,RC,,,,,,53329016544,NDC,113,GR,79.52,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,77.9296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,67815203,NDC,100,GR,91.77,,First Health,Commercial,both,85,,999999999,percent of total billed charges,78.0045,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Hiv-1, Quantification - Ref",PX8753690,CDM,300,RC,87536,CPT,90,,,,,,,220,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,78.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.03,215.6
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,517096010,NDC,10,ML,157.64,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,78.0318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Fibrinogen Test - Ref,PX8536690,CDM,300,RC,85366,CPT,90,,,,,,,179,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,78.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.05,80.46
Fibrinogen Test - Ref,PX8536690,CDM,300,RC,85366,CPT,90,,,,,,,179,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,78.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.05,80.46
Fibrinogen Test - Ref,PX8536690,CDM,300,RC,85366,CPT,90,,,,,,,179,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,78.05,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.05,80.46
Debride Skin/Subq Ea Ad 20sqcm,PX11045P,CDM,983,RC,11045,CPT,,,,,,,,182,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,78.078,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.6028,177.1406
Immunocytochemistry,PX3993,CDM,310,RC,88342,CPT,TC,,,,,,,182,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,78.078,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.6028,178.36
Infec Agent Direct Probe - Ref,PX8779990,CDM,300,RC,87799,CPT,90,,,,,,,182,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,78.078,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.28,178.36
CT Chest Spine W/Dye,PX7212901,CDM,350,RC,72129,CPT,TC,,,,,,,2096,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,78.09,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.09,230.75
CT Chest Spine W/Dye,PX7212901,CDM,350,RC,72129,CPT,TC,,,,,,,2096,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,78.09,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.09,230.75
Diagnostic CT Thorax W/ Contrast,PX7126001,CDM,350,RC,71260,CPT,TC,,,,,,,3415,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,78.09,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.88,230.09
atropine (PF) 1 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517101025,NDC,1,ML,91.89,,First Health,Commercial,both,85,,999999999,percent of total billed charges,78.1065,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049237,NDC,30,ML,87.77,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,78.1153,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Chem Cautery Granulatn Tissue,PX17250F,CDM,510,RC,17250,CPT,,,,,,,,170,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,78.17,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.12,181.25
Chem Cautery Granulatn Tissue,PX17250P,CDM,983,RC,17250,CPT,,,,,,,,402,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,78.17,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.12,393.96
prasugrel 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862083030,NDC,1,EA,88.64,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,78.18048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Blood Typing Abo,PX86900,CDM,300,RC,86900,CPT,,,,,,,,92,,First Health,Commercial,both,85,,999999999,percent of total billed charges,78.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.2168,111.6
Blood Typing Rh (D),PX86901,CDM,300,RC,86901,CPT,,,,,,,,92,,First Health,Commercial,both,85,,999999999,percent of total billed charges,78.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.03,90.16
Parvovirus Antibody - Ref,PX8674790,CDM,300,RC,86747,CPT,90,,,,,,,92,,First Health,Commercial,both,85,,999999999,percent of total billed charges,78.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.78,90.16
"Reticulocyte Count,Flow Cyto",PX85045,CDM,300,RC,85045,CPT,,,,,,,,92,,First Health,Commercial,both,85,,999999999,percent of total billed charges,78.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.66,90.16
Antithrombin III Activity - Ref,PX8530090,CDM,300,RC,85300,CPT,90,,,,,,,158,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,78.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.87,154.84
Fac/Trm Hyperkeratotic Skn Lesn2-4,PX11056F,CDM,510,RC,11056,CPT,,,,,,,,158,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,78.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.6332,174.9
"Glucose, Body Fluid Other Than Blood",PX82945,CDM,300,RC,82945,CPT,,,,,,,,158,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,78.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.6,154.84
Protein C Activity - Ref,PX8530390,CDM,300,RC,85303,CPT,90,,,,,,,158,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,78.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.69,154.84
"Triiodothyronine T3, Tot - Ref",PX8448090,CDM,300,RC,84480,CPT,90,,,,,,,158,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,78.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13,154.84
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010269,NDC,1,EA,88.69,,United Healthcare,All Payer,outpatient,88.2,,20.73428571,percent of total billed charges,78.22458,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010299,NDC,1,EA,88.69,,United Healthcare,All Payer,outpatient,88.2,,20.73428571,percent of total billed charges,78.22458,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614201,NDC,1,ML,88.69,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,78.22458,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.097864,86.9162
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614225,NDC,1,ML,88.69,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,78.22458,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.097864,86.9162
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963801,NDC,0.5,ML,88.69,,United Healthcare,All Payer,outpatient,88.2,,225.03,percent of total billed charges,78.22458,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
"Morphometric Analysis,Tumor Immunohistochemistry, Ea Antibody Manual , Tech",PX8836001,CDM,310,RC,88360,CPT,TC,,,,,,,119,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,78.23,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.23,131.36
"Morphometric Analysis,Tumor Immunohistochemistry, Ea Antibody Manual , Tech",PX8836001,CDM,310,RC,88360,CPT,TC,,,,,,,119,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,78.23,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.23,131.36
"Morphometric Analysis,Tumor Immunohistochemistry, Ea Antibody Manual , Tech",PX8836001,CDM,310,RC,88360,CPT,TC,,,,,,,119,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,78.23,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.23,131.36
Xray Lumbosacral Minimum 4 Vws,PX7211001,CDM,320,RC,72110,CPT,TC,,,,,,,565,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,78.23,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.74,78.23
Xray Lumbosacral Minimum 4 Vws,PX7211001,CDM,320,RC,72110,CPT,TC,,,,,,,565,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,78.23,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.74,78.23
Ehrlichia (Anaplasma) Ab - Ref,PX8666690,CDM,300,RC,86666,CPT,90,,,,,,,163,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,78.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.33,159.74
Ehrlichia (Anaplasma) Ab - Ref,PX8666690,CDM,300,RC,86666,CPT,90,,,,,,,163,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,78.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.33,159.74
Xray Ankle 2 Vws,PX7360001,CDM,320,RC,73600,CPT,TC,,,,,,,163,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,78.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.7102,159.74
Xray Ankle 2 Vws,PX7360001,CDM,320,RC,73600,CPT,TC,,,,,,,163,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,78.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.7102,159.74
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,574200815,NDC,15,GR,154.63,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,78.24278,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046201,NDC,30,ML,79.84,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,78.2432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ESOPHAGEAL BALLOON INFLATION DEVICE 60ML,27200000,CDM,272,RC,C1726,HCPCS,,11326-MAIN,LOCAL,,,,,80.41,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,78.263053,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
cloNIDine 0.1 MG/24HR PATCH WEEKLY 4 Each Box,63700001,CDM,250,RC,,,,,,51862045304,NDC,1,EA,158.16,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,78.2892,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CT Lower Extremity W/Dye,PX7370101,CDM,350,RC,73701,CPT,TC,,,,,,,2690,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,78.31,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.88,230.09
Apply of Paste Boot,PX29580P,CDM,983,RC,29580,CPT,,,,,,,,88,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,78.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.5552,137.65
POSITIONING KIT TRENDELENBURG NUBLUE TP 3000-NB,27100000,CDM,271,RC,,,,12992-MAIN,LOCAL,,,,,88,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,78.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
SPLINT ANKLE GEL BRACE UNIVERSAL AIRFORM 70351,120.61,CDM,274,RC,L4350,HCPCS,,12342-MAIN,LOCAL,,,,,88,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,78.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.5552,104.38
SUCTION IRRIGATOR 2 0250070500,27200000,CDM,272,RC,,,,12262-MAIN,LOCAL,,,,,88,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,78.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Aldosterone - Ref,PX8208890,CDM,300,RC,82088,CPT,90,,,,,,,86,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,78.346,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.7244,84.28
Epstein-barr antibody,PX86665,CDM,300,RC,86665,CPT,,,,,,,,86,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,78.346,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.63,84.28
Exc Skin Benig <5mm Remaindr Body,PX11420P,CDM,983,RC,11420,CPT,,,,,,,,299,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,78.3484,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.35,293.02
Fac/Exc Skin Benig<5mm Remaind Bod,PX11420F,CDM,510,RC,11420,CPT,,,,,,,,374,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,78.3484,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.35,264.27
"Needle Biopsy, Lymph Node(S)",PX38505F,CDM,510,RC,38505,CPT,,,,,,,,667,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,78.3484,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53,360.43
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036001,NDC,10,ML,80.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.161,percent of total billed charges,78.35065,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,84.5054
SAWBLADE SAGITAL STERILE 25MM LENGTH 5.5MM WIDTH 0.60MM THICKNESS,27200000,CDM,272,RC,,,,11623-MAIN,LOCAL,,,,,86.02,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,78.36422,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329334001,NDC,10,ML,88.88,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,78.39216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
"Alpha-Fetoprotein, Serum - Ref",PX8210590,CDM,300,RC,82105,CPT,90,,,,,,,80,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,78.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.38,78.4
Ex for Speech Device Rx Addl,PX92608,CDM,444,RC,92608,CPT,,,,,,,,160,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,78.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.95,156.8
Ex for Speech Device Rx Addl,PX92608,CDM,444,RC,92608,CPT,,,,,,,,160,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,78.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.95,156.8
Ex for Speech Device Rx Addl,PX92608,CDM,444,RC,92608,CPT,,,,,,,,160,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,78.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.95,156.8
Prealubimin,PX84134,CDM,300,RC,84134,CPT,,,,,,,,80,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,78.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.38,78.4
leflunomide 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,62332006130,NDC,1,EA,88.09,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,78.4001,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CYSTOSCOPY PACK I STERILE,120.505,CDM,272,RC,,,,4527-MAIN,LOCAL,,,,,155,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,78.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,151.9
"Lab Antibody ID,RBC",PX7605,CDM,300,RC,86870,CPT,,,,,,,,155,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,78.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,314.02
"Office/Outpt Visit,Est,Levl II",PX99212F,CDM,510,RC,99212,CPT,,,,,,,,155,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,78.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,151.9
"Office/Outpt Visit,Est,Levl II",PX99212P,CDM,983,RC,99212,CPT,,,,,,,,155,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,78.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,150.8615
Smear Fluorescent/Acid Stai,PX87206,CDM,300,RC,87206,CPT,,,,,,,,155,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,78.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.94,151.9
TB Test Enumeration of T-Cells - Ref,PX8648190,CDM,300,RC,86481,CPT,90,,,,,,,155,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,78.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,151.9
"dextrose 5% and sodium chloride 0.45% with potassium chloride 10 mEq in 1000 mL 10-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,338066904,NDC,1000,ML,80.61,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,78.457713,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,264957710,NDC,500,ML,80.61,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.983043478,percent of total billed charges,78.457713,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052201,NDC,500,ML,80.61,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.983043478,percent of total billed charges,78.457713,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052277,NDC,500,ML,80.61,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.983043478,percent of total billed charges,78.457713,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
Aldolase - Ref,PX8208590,CDM,300,RC,82085,CPT,90,,,,,,,89,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,78.498,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.9,87.22
Assay of Ggt,PX82977,CDM,300,RC,82977,CPT,,,,,,,,89,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,78.498,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6,87.22
"Debridement of Nail(S), 1-5",PX11720F,CDM,510,RC,11720,CPT,,,,,,,,89,,United Healthcare,All Payer,outpatient,88.2,,42.14,percent of total billed charges,78.498,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.9706,87.22
"Hla a, B or C, Single Ag - Ref",PX8681290,CDM,300,RC,86812,CPT,90,,,,,,,89,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,78.498,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.67,87.22
KIT INTRODUCER 8.5FR AK-09803-CDC,120.128,CDM,272,RC,,,,8826-MAIN,LOCAL,,,,,89,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,78.498,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.9706,87.22
Voriconazole - Ref,PX8028590,CDM,300,RC,80285,CPT,90,,,,,,,183,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,78.507,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.86,179.34
Alcohols - Ref,PX8032090,CDM,300,RC,80320,CPT,90,,,,,,,189,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,78.5106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.5106,185.22
CT Chest Spine W/Dye,PX7212901,CDM,350,RC,72129,CPT,TC,,,,,,,2096,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,78.53,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.09,230.75
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036019,NDC,10,ML,86.23,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,78.55553,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,84.5054
rho d immune globulin human 1500 units solution prefilled syringe 1 Each Syringe,J2790.01,CDM,636,RC,J2790,HCPCS,,,,562780500,NDC,1,EA,464.01,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,78.55914,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.42,81.16
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052084,NDC,1,EA,92.46,,First Health,Commercial,both,85,,999999999,percent of total billed charges,78.591,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.407884,90.9538
empagliflozin 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,597015230,NDC,1,EA,92.47,,First Health,Commercial,both,85,,999999999,percent of total billed charges,78.5995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004722,NDC,2,ML,88.35,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,78.6315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
hydrocortisone sodium succinate (preservative free) 250 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001305,NDC,1,EA,183.32,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,78.64428,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
nafcillin 1 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,55150012215,NDC,1,EA,89.17,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,78.64794,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
trastuzumab 150 MG Recon Soln 1 Each Vial,J9355.01,CDM,636,RC,J9355,HCPCS,,,,50242013201,NDC,1,EA,3179.17,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,78.65565,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.8,84.49
"Spinal Punc,Drain,Theraputic",PX62272F,CDM,510,RC,62272,CPT,,,,,,,,450,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,78.6695,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.79,384.64
"Spinal Punc,Drain,Theraputic",PX62272P,CDM,983,RC,62272,CPT,,,,,,,,300,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,78.6695,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.79,384.64
EPIX UNIVERSAL CLIP APPLIER,27200000,CDM,272,RC,,,,11708-MAIN,LOCAL,,,,,158.95,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,78.68025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Iaad Ia Severe Aqt Respir Synd Coronavirus,PX87426,CDM,300,RC,87426,CPT,,,,,,,,159,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,78.705,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.39,155.82
tranexamic acid 1000 mg in 100 mL 0.7% sodium chloride (premix) 1000-0.7 MG/100ML-% Solution 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,80830232901,NDC,100,ML,155.55,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,78.7083,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062001,NDC,0.4,ML,189.48,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,78.709992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062040,NDC,0.4,ML,189.48,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,78.709992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801401,NDC,0.4,ML,189.48,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,78.709992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801410,NDC,0.4,ML,189.48,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,78.709992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
leucovorin 350 MG Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,703514501,NDC,1,EA,86.41,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,78.71951,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.670002,84.6818
Tx/Pro/Dx Inj Same Drug Adon,PX96376,CDM,260,RC,96376,CPT,,,,,,,,164,,Health Partners,Health Partners Care Plans,both,48,,112.9872727,percent of total billed charges,78.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.1256,160.72
Tx/Pro/Dx Inj Same Drug Adon,PX96376,CDM,260,RC,96376,CPT,,,,,,,,164,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,78.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.1256,160.72
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409751766,NDC,50,ML,80.89,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,78.730237,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989001,NDC,50,ML,160.78,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,7.983333333,percent of total billed charges,78.7822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989001,NDC,50,ML,160.78,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,78.7822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989001,NDC,50,ML,160.78,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,78.7822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989002,NDC,50,ML,160.78,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,7.983333333,percent of total billed charges,78.7822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989002,NDC,50,ML,160.78,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,78.7822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989002,NDC,50,ML,160.78,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,78.7822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
ESOPHAGEAL BALLOON INFLATION DEVICE 60ML,27200000,CDM,272,RC,C1726,HCPCS,,11326-MAIN,LOCAL,,,,,80.41,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,78.8018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CAPTIFLEX SNARE SINGLE USE EXTRA SMALL 11MM,27200000,CDM,272,RC,,,,12378-MAIN,LOCAL,,,,,81,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,78.8373,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Smear Special Stain,PX87207,CDM,300,RC,87207,CPT,,,,,,,,81,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,78.8373,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.49,79.38
Tacrolimus - Ref,PX8019790,CDM,300,RC,80197,CPT,90,,,,,,,81,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,78.8373,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,79.38
"Remv F.B.,Eye,Embed Conjunc",PX65210F,CDM,510,RC,65210,CPT,,,,,,,,325,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,78.87,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.69,78.87
"Remv F.B.,Eye,Embed Conjunc",PX65210P,CDM,983,RC,65210,CPT,,,,,,,,216,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,78.87,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.69,211.68
riTUXimab 100 MG/10ML Solution 10 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005121,NDC,10,ML,1916.61,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,78.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.69,83.16
riTUXimab 100 MG/10ML Solution 10 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005121,NDC,10,ML,1916.61,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,78.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.69,83.16
riTUXimab 500 MG/50ML Solution 50 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005306,NDC,50,ML,8860.06,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,78.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.69,83.16
riTUXimab 500 MG/50ML Solution 50 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005306,NDC,50,ML,8860.06,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,78.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.69,83.16
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,63323094004,NDC,4,ML,89.43,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,78.87726,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,63323094021,NDC,4,ML,89.43,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,78.87726,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052083,NDC,1,EA,92.81,,First Health,Commercial,both,85,,999999999,percent of total billed charges,78.8885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.407884,90.9538
prasugrel 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862083030,NDC,1,EA,88.64,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,78.8896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036001,NDC,10,ML,80.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,78.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,84.5054
Catheterize for Urine Spec,PXP9612,CDM,300,RC,P9612,HCPCS,,,,,,,,161,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,78.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.1,157.78
Catheterize for Urine Spec,PXP9612,CDM,300,RC,P9612,HCPCS,,,,,,,,161,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,78.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.1,157.78
Catheterize for Urine Spec,PXP9612,CDM,300,RC,P9612,HCPCS,,,,,,,,161,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,78.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.1,157.78
Drain/Inject Small Joint/Bursa,PX20600F,CDM,510,RC,20600,CPT,,,,,,,,161,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,19.495,percent of total billed charges,78.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.8794,258.75
Drain/Inject Small Joint/Bursa,PX20600F,CDM,510,RC,20600,CPT,,,,,,,,161,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,78.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.8794,258.75
Drain/Inject Small Joint/Bursa,PX20600F,CDM,510,RC,20600,CPT,,,,,,,,161,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,78.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.8794,258.75
Drain/Inject Small Joint/Bursa,PX20600P,CDM,983,RC,20600,CPT,,,,,,,,161,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,19.495,percent of total billed charges,78.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.8794,258.75
Drain/Inject Small Joint/Bursa,PX20600P,CDM,983,RC,20600,CPT,,,,,,,,161,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,78.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.8794,258.75
Drain/Inject Small Joint/Bursa,PX20600P,CDM,983,RC,20600,CPT,,,,,,,,161,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,78.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.8794,258.75
Each Add'l Hour IV Infusion <8 Hour,PX96366,CDM,260,RC,96366,CPT,,,,,,,,161,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,43.71470588,percent of total billed charges,78.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,157.78
Each Add'l Hour IV Infusion <8 Hour,PX96366,CDM,260,RC,96366,CPT,,,,,,,,161,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,78.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,157.78
Each Add'l Hour IV Infusion <8 Hour,PX96366,CDM,260,RC,96366,CPT,,,,,,,,161,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,78.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,157.78
"X-Ray Exam Hip,Bilat W/Pelvis 3-4 Vws",PX7352201,CDM,320,RC,73522,CPT,TC,,,,,,,382,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,78.89,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.58,78.89
"X-Ray Exam Hip,Bilat W/Pelvis 3-4 Vws",PX7352201,CDM,320,RC,73522,CPT,TC,,,,,,,382,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,78.89,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.58,78.89
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,703574811,NDC,100,ML,183.92,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,78.90168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.174958,180.2416
Assay of ammonia,PX82140,CDM,300,RC,82140,CPT,,,,,,,,190,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,78.926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.36,186.2
Assay of protein urine,PX84156,CDM,300,RC,84156,CPT,,,,,,,,190,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,78.926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.37,186.2
Each Add'l Sequential IV Infusion <1 Hour,PX96367,CDM,260,RC,96367,CPT,,,,,,,,190,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,78.926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,186.2
"N Block Inj, Common Digit",PX64632F,CDM,510,RC,64632,CPT,,,,,,,,190,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,78.926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.926,258.75
"Tumor Antigen, Ca-125",PX86304,CDM,300,RC,86304,CPT,,,,,,,,190,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,78.926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,186.2
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010269,NDC,1,EA,88.69,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,78.9341,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010299,NDC,1,EA,88.69,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,78.9341,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614201,NDC,1,ML,88.69,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,78.9341,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.097864,86.9162
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614225,NDC,1,ML,88.69,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,78.9341,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.097864,86.9162
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963801,NDC,0.5,ML,88.69,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,78.9341,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
TUBE TRACH SIZE 3.0MM ID 4.5MM OD SHILEY PEDIATRIC 3.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1185-MAIN,LOCAL,,,,,184,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,78.936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 3.5MM ID 5.2MM OD SHILEY PEDIATRIC,120.287,CDM,272,RC,A7520,HCPCS,,8813-MAIN,LOCAL,,,,,184,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,78.936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 4.0MM ID 5.9MM OD SHILEY PEDIATRIC 4.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1187-MAIN,LOCAL,,,,,184,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,78.936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 5 7.0MM ID 10.1MM OD SHILEY CUFFED 5CN70H,120.287,CDM,272,RC,A7521,HCPCS,,10350-MAIN,LOCAL,,,,,184,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,78.936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 5.0MM ID 7.1MM OD SHILEY PEDIATRIC 5.0PED,120.287,CDM,272,RC,A7520,HCPCS,,8814-MAIN,LOCAL,,,,,184,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,78.936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 6 6.0MM ID 8.3MM OD SHILEY CUFFED 6SCT,120.287,CDM,272,RC,A7521,HCPCS,,8812-MAIN,LOCAL,,,,,184,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,78.936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 6 6.4MM ID 10.8MM OD SHILEY CUFFED 6DCT,120.287,CDM,272,RC,A7521,HCPCS,,1190-MAIN,LOCAL,,,,,184,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,78.936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 7.5MM ID 10.8MM OD SHILEY CUFFED 6CN75H,120.287,CDM,272,RC,A7521,HCPCS,,8488-MAIN,LOCAL,,,,,184,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,78.936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 8 7.6MM ID 12.2MM OD SHILEY 8DCT,120.287,CDM,272,RC,A7521,HCPCS,,1192-MAIN,LOCAL,,,,,184,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,78.936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 8 7.6MM ID 12.22MM OD SHILEY CUFFED 8LPC,120.287,CDM,272,RC,A7521,HCPCS,,8815-MAIN,LOCAL,,,,,184,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,78.936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 8.0MM ID 10.9MM OD SHILEY CUFFED 8SCT,120.287,CDM,272,RC,A7521,HCPCS,,8811-MAIN,LOCAL,,,,,184,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,78.936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 10 SHILEY 10LPC,120.287,CDM,272,RC,A7521,HCPCS,,1181-MAIN,LOCAL,,,,,184,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,78.936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
Assay Blood Carbon Monoxide,PX82375,CDM,300,RC,82375,CPT,,,,,,,,156,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,78.936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.3,152.88
"Cortisol, Am",PX7152,CDM,300,RC,82533,CPT,,,,,,,,156,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,78.936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.95,152.88
DERMABOND PRINEO SKIN CLOSURE SYSTEM 22CM,27200000,CDM,272,RC,,,,12324-MAIN,LOCAL,,,,,156,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,78.936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Fibrinogen Test - Ref,PX8536690,CDM,300,RC,85366,CPT,90,,,,,,,179,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,78.9414,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.05,80.46
"Biopsy of Prostate,Needle/Punch",PX55700F,CDM,510,RC,55700,CPT,,,,,,,,2039,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,78.96,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.96,500.17
CT Head/Brain W/O & W/Dye,PX7047001,CDM,350,RC,70470,CPT,TC,,,,,,,3671,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,78.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.96,233.38
CT Head/Brain W/O & W/Dye,PX7047001,CDM,350,RC,70470,CPT,TC,,,,,,,3671,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,78.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.96,233.38
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010365,NDC,100,ML,164.54,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,78.9792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.174958,180.2416
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010365,NDC,100,ML,164.54,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,78.9792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.174958,180.2416
"dextrose 5% and sodium chloride 0.45% with potassium chloride 10 mEq in 1000 mL 10-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,338066904,NDC,1000,ML,80.61,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,78.9978,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,264957710,NDC,500,ML,80.61,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,78.9978,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052201,NDC,500,ML,80.61,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,78.9978,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052277,NDC,500,ML,80.61,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,78.9978,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,78.9978
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505615204,NDC,0.5,EA,86.76,,Medica,Commercial,both,91.1,,6.892980769,percent of total billed charges,79.03836,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
BOOT AIRSELECT SHORT LARGE 01ES-L,120.45,CDM,274,RC,L4360,HCPCS,,11890-MAIN,LOCAL,,,,,93,,First Health,Commercial,both,85,,999999999,percent of total billed charges,79.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT MEDIUM 01ES-M,120.45,CDM,274,RC,L4360,HCPCS,,11889-MAIN,LOCAL,,,,,93,,First Health,Commercial,both,85,,999999999,percent of total billed charges,79.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT SMALL 01ES-S,120.45,CDM,274,RC,L4360,HCPCS,,11888-MAIN,LOCAL,,,,,93,,First Health,Commercial,both,85,,999999999,percent of total billed charges,79.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT X-LARGE 01ES-XL,120.45,CDM,274,RC,L4360,HCPCS,,11891-MAIN,LOCAL,,,,,93,,First Health,Commercial,both,85,,999999999,percent of total billed charges,79.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT X-SMALL 01ES-XS,120.45,CDM,274,RC,L4360,HCPCS,,11887-MAIN,LOCAL,,,,,93,,First Health,Commercial,both,85,,999999999,percent of total billed charges,79.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD LARGE 01EF-L,120.45,CDM,274,RC,L4360,HCPCS,,11697-MAIN,LOCAL,,,,,93,,First Health,Commercial,both,85,,999999999,percent of total billed charges,79.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD MEDIUM 01EF-M,120.45,CDM,274,RC,L4360,HCPCS,,11696-MAIN,LOCAL,,,,,93,,First Health,Commercial,both,85,,999999999,percent of total billed charges,79.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD SMALL 01EF-S,120.45,CDM,274,RC,L4360,HCPCS,,11695-MAIN,LOCAL,,,,,93,,First Health,Commercial,both,85,,999999999,percent of total billed charges,79.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD X-LARGE 01EF-XL,120.45,CDM,274,RC,L4360,HCPCS,,11698-MAIN,LOCAL,,,,,93,,First Health,Commercial,both,85,,999999999,percent of total billed charges,79.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD X-SMALL 01EF-XS,120.45,CDM,274,RC,L4360,HCPCS,,11694-MAIN,LOCAL,,,,,93,,First Health,Commercial,both,85,,999999999,percent of total billed charges,79.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
Russell Viper Venom - Ref,PX8561390,CDM,300,RC,85613,CPT,90,,,,,,,93,,First Health,Commercial,both,85,,999999999,percent of total billed charges,79.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.78,91.14
SPLINT FOOT SMALL STRUT WALK 11-1383-2-00000,120.45,CDM,274,RC,L4360,HCPCS,,1205-MAIN,LOCAL,,,,,93,,First Health,Commercial,both,85,,999999999,percent of total billed charges,79.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011701,NDC,1,EA,89.64,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,79.06248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011710,NDC,1,EA,89.64,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,79.06248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001302,NDC,2,ML,86.79,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,79.06569,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
"measles, mumps & rubella vaccine Recon Soln 1 Each Vial",90707,CDM,636,RC,90707,CPT,,,,6468100,NDC,1,EA,381.47,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,79.09,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.09,146.384
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329334001,NDC,10,ML,88.88,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,79.1032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
durvalumab 120 MG/2.4ML Solution 2.4 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310450012,NDC,30,ML,21771.9,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,79.10603,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,59.96,84.74
durvalumab 500 MG/10ML Solution 10 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310461150,NDC,10,ML,7588.77,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,79.10603,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,59.96,84.74
HYDROmorphone 0.1 MG/ML Solution 55 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,61553067976,NDC,55,ML,89.7,,United Healthcare,All Payer,outpatient,88.2,,34.74,percent of total billed charges,79.1154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409663734,NDC,50,ML,89.7,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,79.1154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,17478081725,NDC,25,ML,81.3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,79.12929,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
infuvite adult Injectable 10 mL Vial,J3490.99,CDM,636,RC,J3490,HCPCS,,,,54643564901,NDC,10,ML,86.89,,Medica,Commercial,both,91.1,,7.37,percent of total billed charges,79.15679,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.094106,85.1522
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,4080285,NDC,1,EA,89.79,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,79.19478,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Dihydroxyvitamin D - Ref,PX8265290,CDM,300,RC,82652,CPT,90,,,,,,,165,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,79.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.3,161.7
Dihydroxyvitamin D - Ref,PX8265290,CDM,300,RC,82652,CPT,90,,,,,,,165,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,79.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.3,161.7
Ex for Speech Device Rx Addl,PX92608,CDM,444,RC,92608,CPT,,,,,,,,160,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,79.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.95,156.8
Flow Cyto Ea Addtl Marker - Ref,PX8818590,CDM,310,RC,88185,CPT,90,,,,,,,165,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,79.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.541,161.7
Flow Cyto Ea Addtl Marker - Ref,PX8818590,CDM,310,RC,88185,CPT,90,,,,,,,165,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,79.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.541,161.7
Strapping of Shoulder,PX29240F,CDM,420,RC,29240,CPT,,,,,,,,165,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,79.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.541,161.7
Strapping of Shoulder,PX29240F,CDM,420,RC,29240,CPT,,,,,,,,165,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,79.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.541,161.7
Aldolase - Ref,PX8208590,CDM,300,RC,82085,CPT,90,,,,,,,89,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,79.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.9,87.22
Assay of Ggt,PX82977,CDM,300,RC,82977,CPT,,,,,,,,89,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,79.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6,87.22
"Debridement of Nail(S), 1-5",PX11720F,CDM,510,RC,11720,CPT,,,,,,,,89,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,79.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.9706,87.22
"Hla a, B or C, Single Ag - Ref",PX8681290,CDM,300,RC,86812,CPT,90,,,,,,,89,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,79.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.67,87.22
KIT INTRODUCER 8.5FR AK-09803-CDC,120.128,CDM,272,RC,,,,8826-MAIN,LOCAL,,,,,89,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,79.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.9706,87.22
"Chemotherapy, IV Push, Additional Drug",PX96411,CDM,335,RC,96411,CPT,,,,,,,,87,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,79.257,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.1398,85.26
"Morphometric Analysis,Tumor Immunohistochemistry, Ea Antibody Manual , Tech",PX8836001,CDM,310,RC,88360,CPT,TC,,,,,,,119,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,79.2623,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.23,131.36
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409751766,NDC,50,ML,80.89,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,79.2722,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Aspirate Pleura W/O Imaging,PX32554F,CDM,510,RC,32554,CPT,,,,,,,,795,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,79.3117,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.88,484.95
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323012594,NDC,1,EA,190.99,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,79.337246,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
Assay of Amylase,PX82150,CDM,300,RC,82150,CPT,,,,,,,,191,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,79.3414,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.94,187.18
C-Reactive Protein,PX86140,CDM,300,RC,86140,CPT,,,,,,,,191,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,79.3414,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,187.18
"Chemotherapy, IV Infusion, Add'l Hour",PX96415,CDM,335,RC,96415,CPT,,,,,,,,191,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,79.3414,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,187.18
Fac/Ther Injection Carpal Tunnel,PX20526F,CDM,510,RC,20526,CPT,,,,,,,,191,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,79.3414,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.3414,258.75
Urine Pregnancy Test,PX81025,CDM,300,RC,81025,CPT,,,,,,,,191,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,79.3414,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.89,187.18
nafcillin 1 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,55150012215,NDC,1,EA,89.17,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,79.3613,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Amylase - Ref,PX8215090,CDM,300,RC,82150,CPT,90,,,,,,,185,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,79.365,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.94,181.3
Hepatitis C Rna Quant,PX87522,CDM,300,RC,87522,CPT,,,,,,,,185,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,79.365,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.28,181.3
"Level IV - Surgical Pathology, Gross and Microscopic Examination , Tech",PX3934,CDM,310,RC,88305,CPT,TC,,,,,,,185,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,79.365,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,271.15
"Office/Outpt Visit,Est,Levl III",PX99213F,CDM,510,RC,99213,CPT,,,,,,,,185,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,79.365,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.849,181.3
"Office/Outpt Visit,Est,Levl III",PX99213P,CDM,983,RC,99213,CPT,,,,,,,,185,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,79.365,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.849,180.0605
Acetone Assay,PX82010,CDM,300,RC,82010,CPT,,,,,,,,162,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,68.69,percent of total billed charges,79.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.49,158.76
Acetone Assay,PX82010,CDM,300,RC,82010,CPT,,,,,,,,162,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,79.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.49,158.76
Acetone Assay,PX82010,CDM,300,RC,82010,CPT,,,,,,,,162,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,79.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.49,158.76
CAPTIFLEX SNARE SINGLE USE EXTRA SMALL 11MM,27200000,CDM,272,RC,,,,12378-MAIN,LOCAL,,,,,81,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,79.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Flow Interp,2-8 Markers - Ref",PX8818790,CDM,310,RC,88187,CPT,90,,,,,,,162,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,79.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.1,158.76
"Flow Interp,2-8 Markers - Ref",PX8818790,CDM,310,RC,88187,CPT,90,,,,,,,162,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,79.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.1,158.76
"Flow Interp,2-8 Markers - Ref",PX8818790,CDM,310,RC,88187,CPT,90,,,,,,,162,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,79.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.1,158.76
"Gammaglobulin; Iga, Dg,M - Ref",PX8278490,CDM,300,RC,82784,CPT,90,,,,,,,90,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,79.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.53,88.2
KIT THORACENTESIS PLEURA SEAL AK-01000-T,120.24,CDM,272,RC,,,,1147-MAIN,LOCAL,,,,,162,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,79.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.2948,158.76
KIT THORACENTESIS PLEURA SEAL AK-01000-T,120.24,CDM,272,RC,,,,1147-MAIN,LOCAL,,,,,162,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,79.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.2948,158.76
KIT THORACENTESIS PLEURA SEAL AK-01000-T,120.24,CDM,272,RC,,,,1147-MAIN,LOCAL,,,,,162,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,79.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.2948,158.76
"Misc Virus Antibody, Nos - Ref",PX8679090,CDM,300,RC,86790,CPT,90,,,,,,,90,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,79.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.81,88.2
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152P,CDM,983,RC,99152,CPT,,,,,,,,90,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,79.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.386,87.597
Mycobacteria Culture - Ref,PX8711690,CDM,300,RC,87116,CPT,90,,,,,,,90,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,79.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9,88.2
Smear Special Stain,PX87207,CDM,300,RC,87207,CPT,,,,,,,,81,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,79.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.49,79.38
Tacrolimus - Ref,PX8019790,CDM,300,RC,80197,CPT,90,,,,,,,81,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,79.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.59,79.38
"DXA, Bone Density Study, Radius/Wrist/Heel",PX7708101,CDM,320,RC,77081,CPT,TC,,,,,,,460,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,79.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,450.8
Ultrasound Breast Limited,PX7664201,CDM,402,RC,76642,CPT,TC,,,,,,,342,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,79.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,335.16
X-Ray Exam Abdomen 1 View,PX7401801,CDM,320,RC,74018,CPT,TC,,,,,,,358,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,79.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,350.84
X-Ray Exam Chest 1 View,PX7104501,CDM,320,RC,71045,CPT,TC,,,,,,,357,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,79.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,349.86
X-Ray Exam Chest 2 Views,PX7104601,CDM,320,RC,71046,CPT,TC,,,,,,,556,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,79.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,544.88
X-Ray Exam Chest 3 Views,PX7104701,CDM,320,RC,71047,CPT,TC,,,,,,,340,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,79.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,333.2
X-Ray Exam Entire Spine 1vw,PX7208101,CDM,320,RC,72081,CPT,TC,,,,,,,414,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,79.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,405.72
X-Ray Exam Femur 1 Vw,PX7355101,CDM,320,RC,73551,CPT,TC,,,,,,,142,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,79.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,139.16
X-Ray Exam Femur Min 2 Vws,PX7355201,CDM,320,RC,73552,CPT,TC,,,,,,,365,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,79.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
"X-Ray Exam Hip,Unilat W/Pelvis 1vw",PX7350101,CDM,320,RC,73501,CPT,TC,,,,,,,263,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,79.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,257.74
"X-Ray Exam Hip,Unilat W/Pelvis 2-3 Vws",PX7350201,CDM,320,RC,73502,CPT,TC,,,,,,,436,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,79.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,427.28
Xray Ac Joints(Bilateral),PX7305001,CDM,320,RC,73050,CPT,TC,,,,,,,519,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,79.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,508.62
Xray Ankle 2 Vws,PX7360001,CDM,320,RC,73600,CPT,TC,,,,,,,163,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,79.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.7102,159.74
Xray Ankle Minimum 3 Vws,PX7361001,CDM,320,RC,73610,CPT,TC,,,,,,,365,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,79.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Calcaneus Minimum 2 Vws,PX7365001,CDM,320,RC,73650,CPT,TC,,,,,,,365,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,79.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Cervical Spine 2 or 3 Vws,PX7204001,CDM,320,RC,72040,CPT,TC,,,,,,,436,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,79.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,427.28
Xray Clavicle Complete,PX7300001,CDM,320,RC,73000,CPT,TC,,,,,,,365,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,79.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Elbow 2 Vws,PX7307001,CDM,320,RC,73070,CPT,TC,,,,,,,365,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,79.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Elbow 3+Vws Tc,PX7308001,CDM,320,RC,73080,CPT,TC,,,,,,,370,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,79.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,362.6
Xray Eye Foreign Body,PX7003001,CDM,320,RC,70030,CPT,TC,,,,,,,432,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,79.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,423.36
Xray Facial Bones Less Than 3 Vws,PX7014001,CDM,320,RC,70140,CPT,TC,,,,,,,301,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,79.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,294.98
Xray Finger(S) Tc,PX7314001,CDM,320,RC,73140,CPT,TC,,,,,,,282,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,79.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,276.36
Xray Foot 2 Vws,PX7362001,CDM,320,RC,73620,CPT,TC,,,,,,,367,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,79.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,359.66
Xray Foot Minimum 3 Vws,PX7363001,CDM,320,RC,73630,CPT,TC,,,,,,,404,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,79.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,395.92
Xray Forearm 2 Vws,PX7309001,CDM,320,RC,73090,CPT,TC,,,,,,,364,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,79.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,356.72
Xray Hand 3vws Tc,PX7313001,CDM,320,RC,73130,CPT,TC,,,,,,,374,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,79.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,366.52
Xray Humerus Minimum 2 Vws,PX7306001,CDM,320,RC,73060,CPT,TC,,,,,,,365,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,79.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Knee (Both) Ap Stand,PX7356501,CDM,320,RC,73565,CPT,TC,,,,,,,543,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,79.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,532.14
Xray Knee 1 or 2 Vws,PX7356001,CDM,320,RC,73560,CPT,TC,,,,,,,303,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,79.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,296.94
Xray Knee 3 Vws,PX7356201,CDM,320,RC,73562,CPT,TC,,,,,,,404,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,79.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,395.92
Xray Mandible Partial Less Than 4 Vws,PX7010001,CDM,320,RC,70100,CPT,TC,,,,,,,347,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,79.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,340.06
Xray Nasal Bones Minimum 3 Vws,PX7016001,CDM,320,RC,70160,CPT,TC,,,,,,,456,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,79.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,446.88
"Xray Neck, Soft Tissue",PX7036001,CDM,320,RC,70360,CPT,TC,,,,,,,277,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,79.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,271.46
Xray Orbits Optic Foramina,PX7019001,CDM,320,RC,70190,CPT,TC,,,,,,,66,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,79.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.4164,79.39
Xray Ribs Unilat 2 Vws,PX7110001,CDM,320,RC,71100,CPT,TC,,,,,,,437,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,79.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,428.26
Xray Sacrum/ Coccyx Minimum 2 Vws,PX7222001,CDM,320,RC,72220,CPT,TC,,,,,,,540,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,79.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,529.2
Xray Shoulder 1 Vw,PX7302001,CDM,320,RC,73020,CPT,TC,,,,,,,267,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,79.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,261.66
Xray Shoulder Minimum 2 Vws,PX7303001,CDM,320,RC,73030,CPT,TC,,,,,,,365,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,79.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Sinuses Less Than 3 Vws,PX7021001,CDM,320,RC,70210,CPT,TC,,,,,,,486,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,79.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,476.28
Xray Sinuses Minimum 3 Vws,PX7022001,CDM,320,RC,70220,CPT,TC,,,,,,,354,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,79.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,346.92
Xray Spine Single Tc,PX7202001,CDM,320,RC,72020,CPT,TC,,,,,,,113,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,79.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9402,110.74
Xray Sternum 2vws Tc,PX7112001,CDM,320,RC,71120,CPT,TC,,,,,,,365,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,79.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Temporomandib Jnt Unilat,PX7032801,CDM,320,RC,70328,CPT,TC,,,,,,,385,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,79.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,377.3
Xray Thoracolumbar 2 Vws,PX7208001,CDM,320,RC,72080,CPT,TC,,,,,,,306,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,79.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,299.88
Xray Tibia & Fibula 2 Vws,PX7359001,CDM,320,RC,73590,CPT,TC,,,,,,,365,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,79.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Toe(S) Tc,PX7366001,CDM,320,RC,73660,CPT,TC,,,,,,,282,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,79.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,276.36
Xray Wrist 2 Vws,PX7310001,CDM,320,RC,73100,CPT,TC,,,,,,,365,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,79.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Wrist Minimum 3 Vws,PX7311001,CDM,320,RC,73110,CPT,TC,,,,,,,375,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,79.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,367.5
CT Head/Brain W/O & W/Dye,PX7047001,CDM,350,RC,70470,CPT,TC,,,,,,,3671,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,79.4,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.96,233.38
Assay of Psa Total,PX84153,CDM,300,RC,84153,CPT,,,,,,,,157,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,79.442,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.86,153.86
"Chlamydia Trachomatis Dna, Amp Probe",PX87491,CDM,300,RC,87491,CPT,,,,,,,,157,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,79.442,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,153.86
"Cognitive Skill Dev, Ea 15 Min",PX97532,CDM,420,RC,97532,CPT,,,,,,,,157,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,79.442,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.2178,153.86
"Fungal Culture, Other Source - Ref",PX8710290,CDM,300,RC,87102,CPT,90,,,,,,,157,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,79.442,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.71,153.86
Lactate (Ld) (Ldh) Enzyme,PX83615,CDM,300,RC,83615,CPT,,,,,,,,157,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,79.442,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.54,153.86
"Neisseria Gonorrhoeae Dna, Amp Probe",PX87591,CDM,300,RC,87591,CPT,,,,,,,,157,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,79.442,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,153.86
Psa Screening,PXG0103,CDM,300,RC,G0103,HCPCS,,,,,,,,157,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,79.442,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.71,153.86
Remv Ext Canal Foreign Body,PX69200P,CDM,983,RC,69200,CPT,,,,,,,,157,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,79.442,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.2178,152.8081
tobramycin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314064305,NDC,5,ML,191.42,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,79.515868,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031801,NDC,1,ML,185.37,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,79.52373,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.002698,181.6626
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031825,NDC,1,ML,185.37,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,79.52373,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.002698,181.6626
nafcillin 2 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,S0032,HCPCS,,,,63323032820,NDC,1,EA,185.37,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,79.52373,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
morphine 1 MG/ML Solution 50 mL Syringe,J2270.01,CDM,636,RC,J2270,HCPCS,,,,61553064975,NDC,50,ML,81.71,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,10.32421053,percent of total billed charges,79.528343,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
fentaNYL 50 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,47781042611,NDC,1,EA,185.47,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,79.56663,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 50 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,47781042647,NDC,1,EA,185.47,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,79.56663,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047621,NDC,1,ML,157.28,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,79.58368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.354486,332.1514
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989001,NDC,50,ML,160.78,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,79.5861,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989002,NDC,50,ML,160.78,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,79.5861,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,63323094004,NDC,4,ML,89.43,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,79.5927,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,63323094021,NDC,4,ML,89.43,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,79.5927,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Destruct Benign Lesion, 15+",PX17111F,CDM,510,RC,17111,CPT,,,,,,,,303,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,79.6328,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.35,277.41
verapamil 2.5 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,409114405,NDC,2,ML,185.65,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,79.64385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
urea 20 % Cream 85 g Tube,63700001,CDM,250,RC,,,,,,536110945,NDC,85,GR,81.83,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,79.645139,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,17478081725,NDC,25,ML,81.3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,79.674,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Breast Tomosynthesis,Dx Tc Bilat",PX7706201,CDM,401,RC,77062,CPT,TC,,,,,,,166,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,79.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.9564,162.68
"Breast Tomosynthesis,Dx Tc Bilat",PX7706201,CDM,401,RC,77062,CPT,TC,,,,,,,166,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,79.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.9564,162.68
"Breast Tomosynthesis,Dx Tc Unilat",PX7706101,CDM,401,RC,77061,CPT,TC,,,,,,,166,,Health Partners,Health Partners Care Plans,both,48,,144.915,percent of total billed charges,79.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.9564,162.68
"Breast Tomosynthesis,Dx Tc Unilat",PX7706101,CDM,401,RC,77061,CPT,TC,,,,,,,166,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,79.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.9564,162.68
"Breast Tomosynthesis,Screen Tc",PX7706301,CDM,403,RC,77063,CPT,TC,,,,,,,166,,Health Partners,Health Partners Care Plans,both,48,,152.335,percent of total billed charges,79.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.59,280.5
"Breast Tomosynthesis,Screen Tc",PX7706301,CDM,403,RC,77063,CPT,TC,,,,,,,166,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,79.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.59,280.5
Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq,PX87635,CDM,300,RC,87635,CPT,,,,,,,,166,,Health Partners,Health Partners Care Plans,both,48,,52.13,percent of total billed charges,79.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,224.4
Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq,PX87635,CDM,300,RC,87635,CPT,,,,,,,,166,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,79.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,224.4
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,990771502,NDC,250,ML,166.02,,Health Partners,Health Partners Care Plans,both,48,,31.91277778,percent of total billed charges,79.6896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.4701,303.0944
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,990771502,NDC,250,ML,166.02,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,79.6896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.4701,303.0944
Catheterize for Urine Spec,PXP9612,CDM,300,RC,P9612,HCPCS,,,,,,,,161,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,79.695,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.1,157.78
Drain/Inject Small Joint/Bursa,PX20600F,CDM,510,RC,20600,CPT,,,,,,,,161,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,79.695,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.8794,258.75
Drain/Inject Small Joint/Bursa,PX20600P,CDM,983,RC,20600,CPT,,,,,,,,161,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,79.695,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.8794,258.75
Each Add'l Hour IV Infusion <8 Hour,PX96366,CDM,260,RC,96366,CPT,,,,,,,,161,,Humana Choice Care,All Medicare plans,outpatient,49.5,,12.13692308,percent of total billed charges,79.695,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,157.78
"Ecg 12 Lead, Tracing Only",PX93005,CDM,730,RC,93005,CPT,,,,,,,,298,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,79.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.44,292.04
"Level IV - Surgical Pathology, Gross and Microscopic Examination , Tech",PX3934,CDM,310,RC,88305,CPT,TC,,,,,,,185,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,79.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,271.15
"Chest Wall Manipulation,Subsequent",PX94668F,CDM,410,RC,94668,CPT,,,,,,,,192,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,79.7568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.7568,188.16
Hepatitis Be Antibody - Ref,PX8670790,CDM,300,RC,86707,CPT,90,,,,,,,192,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,79.7568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.61,188.16
Infectious Agent Antigen Detection by Immunoassay With Direct Visual Observation.,PX87811,CDM,300,RC,87811,CPT,,,,,,,,192,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,79.7568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.94,188.16
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,517096010,NDC,10,ML,157.64,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,79.76584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011701,NDC,1,EA,89.64,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,79.7796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011710,NDC,1,EA,89.64,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,79.7796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
nitroPRUSSide 25 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,72485010501,NDC,2,ML,186,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,79.794,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Puncture Drainage of Lesion,PX10160P,CDM,983,RC,10160,CPT,,,,,,,,186,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,79.794,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.2644,348.35
"TB Test, Cell Immunity Measure",PX86480,CDM,300,RC,86480,CPT,,,,,,,,186,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,79.794,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.83,182.28
Ace - Ref,PX8216490,CDM,300,RC,82164,CPT,90,,,,,,,82,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,79.8106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.39,80.36
Anca Screen Each Antibody,PX8603690,CDM,300,RC,86036,CPT,90,,,,,,,82,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,79.8106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.0628,80.36
"Cognitive Funct Ther Interv, Ea Addl 15 Min",PX97130,CDM,420,RC,97130,CPT,,,,,,,,82,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,15.8,percent of total billed charges,79.8106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31,80.36
"Cortisol, Free - Ref",PX8253090,CDM,300,RC,82530,CPT,90,,,,,,,82,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,79.8106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.32,80.36
lidocaine urethral/mucosal 2 % Gel 30 mL Tube,25000000,CDM,250,RC,,,,,,17478084030,NDC,30,ML,93.91,,First Health,Commercial,both,85,,999999999,percent of total billed charges,79.8235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
HYDROmorphone 0.1 MG/ML Solution 55 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,61553067976,NDC,55,ML,89.7,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,79.833,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409663734,NDC,50,ML,89.7,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,79.833,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Biopsy of Prostate,Needle/Punch",PX55700F,CDM,510,RC,55700,CPT,,,,,,,,2039,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,79.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.96,500.17
"Biopsy of Prostate,Needle/Punch",PX55700F,CDM,510,RC,55700,CPT,,,,,,,,2039,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,79.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.96,500.17
Dress/Debrid Large Burn No Anesth,PX16030F,CDM,510,RC,16030,CPT,,,,,,,,399,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,79.84,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.84,410.93
Remove Nasal Foreign Body,PX30300F,CDM,510,RC,30300,CPT,,,,,,,,972,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,79.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.84,438.6
Remove Nasal Foreign Body,PX30300F,CDM,510,RC,30300,CPT,,,,,,,,972,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,79.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.84,438.6
Remove Nasal Foreign Body,PX30300P,CDM,983,RC,30300,CPT,,,,,,,,572,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,79.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.84,560.56
Remove Nasal Foreign Body,PX30300P,CDM,983,RC,30300,CPT,,,,,,,,572,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,79.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.84,560.56
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361250,NDC,50,ML,90.53,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,79.84746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361650,NDC,50,ML,90.53,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,79.84746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
Ehrlichia (Anaplasma) Ab - Ref,PX8666690,CDM,300,RC,86666,CPT,90,,,,,,,163,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,79.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.33,159.74
Ehrlichia (Anaplasma) Ab - Ref,PX8666690,CDM,300,RC,86666,CPT,90,,,,,,,163,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,79.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.33,159.74
Ehrlichia (Anaplasma) Ab - Ref,PX8666690,CDM,300,RC,86666,CPT,90,,,,,,,163,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,79.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.33,159.74
Xray Ankle 2 Vws,PX7360001,CDM,320,RC,73600,CPT,TC,,,,,,,163,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,79.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.7102,159.74
Xray Ankle 2 Vws,PX7360001,CDM,320,RC,73600,CPT,TC,,,,,,,163,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,79.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.7102,159.74
Xray Ankle 2 Vws,PX7360001,CDM,320,RC,73600,CPT,TC,,,,,,,163,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,79.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.7102,159.74
Coccidioides Antibody - Ref,PX8663590,CDM,300,RC,86635,CPT,90,,,,,,,94,,First Health,Commercial,both,85,,999999999,percent of total billed charges,79.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.52,92.12
Copper - Ref,PX8252590,CDM,300,RC,82525,CPT,90,,,,,,,94,,First Health,Commercial,both,85,,999999999,percent of total billed charges,79.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.38,92.12
DEFIBRILLATION PAD MULTI FUNCTION ADULT,120.58,CDM,271,RC,A0392,HCPCS,,1320-MAIN,LOCAL,,,,,94,,First Health,Commercial,both,85,,999999999,percent of total billed charges,79.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
DEFIBRILLATION PAD PEDI PADZ PEDS,120.58,CDM,271,RC,A0392,HCPCS,,1322-MAIN,LOCAL,,,,,94,,First Health,Commercial,both,85,,999999999,percent of total billed charges,79.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
DRESSING NASAL 4.5CM NON-INFLATABLE RAPID RHINO RR450,120.97,CDM,272,RC,A6407,HCPCS,,616-MAIN,LOCAL,,,,,94,,First Health,Commercial,both,85,,999999999,percent of total billed charges,79.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
DRESSING NASAL 5.5CM INFLATABLE RAPID RHINO RR550,120.97,CDM,272,RC,A6407,HCPCS,,606-MAIN,LOCAL,,,,,94,,First Health,Commercial,both,85,,999999999,percent of total billed charges,79.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
DRESSING NASAL 7.5CM INFLATABLE RAPID RHINO RR750,120.97,CDM,272,RC,A6407,HCPCS,,611-MAIN,LOCAL,,,,,94,,First Health,Commercial,both,85,,999999999,percent of total billed charges,79.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
DRESSING NASAL 8CM LONGX1.5CM THICK X3CM HIGH ANATOMICAL 34-105,120.97,CDM,272,RC,A6407,HCPCS,,613-MAIN,LOCAL,,,,,94,,First Health,Commercial,both,85,,999999999,percent of total billed charges,79.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
Tissue Exam for Fungi,PX87220,CDM,300,RC,87220,CPT,,,,,,,,94,,First Health,Commercial,both,85,,999999999,percent of total billed charges,79.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,92.12
TUBING IRRIGATION F SET STERILE MXB-T,27200000,CDM,272,RC,,,,11693-MAIN,LOCAL,,,,,94,,First Health,Commercial,both,85,,999999999,percent of total billed charges,79.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,4080285,NDC,1,EA,89.79,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,79.9131,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Antithrombin III Activity - Ref,PX8530090,CDM,300,RC,85300,CPT,90,,,,,,,158,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,79.948,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.87,154.84
Fac/Trm Hyperkeratotic Skn Lesn2-4,PX11056F,CDM,510,RC,11056,CPT,,,,,,,,158,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,79.948,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.6332,174.9
"Glucose, Body Fluid Other Than Blood",PX82945,CDM,300,RC,82945,CPT,,,,,,,,158,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,79.948,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.6,154.84
Protein C Activity - Ref,PX8530390,CDM,300,RC,85303,CPT,90,,,,,,,158,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,79.948,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.69,154.84
"Triiodothyronine T3, Tot - Ref",PX8448090,CDM,300,RC,84480,CPT,90,,,,,,,158,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,79.948,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13,154.84
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049237,NDC,30,ML,87.77,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,79.95847,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
rho d immune globulin human 1500 units solution prefilled syringe 1 Each Syringe,J2790.01,CDM,636,RC,J2790,HCPCS,,,,562780500,NDC,1,EA,464.01,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,79.97,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.42,81.16
rho d immune globulin human 1500 units solution prefilled syringe 1 Each Syringe,J2790.01,CDM,636,RC,J2790,HCPCS,,,,562780500,NDC,1,EA,464.01,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,79.97,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.42,81.16
clotrimazole-betamethasone 1-0.05 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,66993089815,NDC,15,GR,192.55,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,79.98527,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
predniSONE 5 mg/5 mL 5 MG/5ML Solution 120 mL Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54372250,NDC,120,ML,186.47,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,79.99563,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
cloNIDine 0.1 MG/24HR PATCH WEEKLY 4 Each Box,63700001,CDM,250,RC,,,,,,51862045304,NDC,1,EA,158.16,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,80.02896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
trastuzumab 150 MG Recon Soln 1 Each Vial,J9355.01,CDM,636,RC,J9355,HCPCS,,,,50242013201,NDC,1,EA,3179.17,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,80.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.8,84.49
trastuzumab 150 MG Recon Soln 1 Each Vial,J9355.01,CDM,636,RC,J9355,HCPCS,,,,50242013201,NDC,1,EA,3179.17,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,80.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.8,84.49
CISplatin 50 MG/50ML Solution 50 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010351,NDC,50,ML,82.27,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,80.073391,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.174958,180.2416
morphine 1 MG/ML Solution 50 mL Syringe,J2270.01,CDM,636,RC,J2270,HCPCS,,,,61553064975,NDC,50,ML,81.71,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,80.0758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.471422,80.0758
"Gammaglobulin; Iga, Dg,M - Ref",PX8278490,CDM,300,RC,82784,CPT,90,,,,,,,90,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,80.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.53,88.2
"Misc Virus Antibody, Nos - Ref",PX8679090,CDM,300,RC,86790,CPT,90,,,,,,,90,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,80.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.81,88.2
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152P,CDM,983,RC,99152,CPT,,,,,,,,90,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,80.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.386,87.597
Mycobacteria Culture - Ref,PX8711690,CDM,300,RC,87116,CPT,90,,,,,,,90,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,80.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9,88.2
Aaa US Screen Tc,PX7670601,CDM,402,RC,76706,CPT,TC,,,,,,,554,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,80.1282,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.66,159.75
venetoclax 100 MG Tablet 1 Each Box,25000000,CDM,250,RC,,,,,,74057611,NDC,0.2,EA,90.87,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,80.14734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Fungus Isolation Culture,PX87102,CDM,300,RC,87102,CPT,,,,,,,,167,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,80.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.71,163.66
Fungus Isolation Culture,PX87102,CDM,300,RC,87102,CPT,,,,,,,,167,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,80.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.71,163.66
Microalbumin Quantitative,PX82043,CDM,300,RC,82043,CPT,,,,,,,,167,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,80.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.3,163.66
Microalbumin Quantitative,PX82043,CDM,300,RC,82043,CPT,,,,,,,,167,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,80.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.3,163.66
Wound Cult/Afb,PX87116,CDM,300,RC,87116,CPT,,,,,,,,167,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,80.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9,163.66
Wound Cult/Afb,PX87116,CDM,300,RC,87116,CPT,,,,,,,,167,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,80.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9,163.66
Apply of Paste Boot,PX29580P,CDM,983,RC,29580,CPT,,,,,,,,88,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,80.168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.5552,137.65
POSITIONING KIT TRENDELENBURG NUBLUE TP 3000-NB,27100000,CDM,271,RC,,,,12992-MAIN,LOCAL,,,,,88,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,80.168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
SPLINT ANKLE GEL BRACE UNIVERSAL AIRFORM 70351,120.61,CDM,274,RC,L4350,HCPCS,,12342-MAIN,LOCAL,,,,,88,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,80.168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.5552,104.38
SUCTION IRRIGATOR 2 0250070500,27200000,CDM,272,RC,,,,12262-MAIN,LOCAL,,,,,88,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,80.168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Ag Detect Nos Eia Mult,PX87449,CDM,300,RC,87449,CPT,,,,,,,,193,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,80.1722,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,189.14
Acetone Assay,PX82010,CDM,300,RC,82010,CPT,,,,,,,,162,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,80.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.49,158.76
"Flow Interp,2-8 Markers - Ref",PX8818790,CDM,310,RC,88187,CPT,90,,,,,,,162,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,80.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.1,158.76
KIT THORACENTESIS PLEURA SEAL AK-01000-T,120.24,CDM,272,RC,,,,1147-MAIN,LOCAL,,,,,162,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,80.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.2948,158.76
urea 20 % Cream 85 g Tube,63700001,CDM,250,RC,,,,,,536110945,NDC,85,GR,81.83,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,80.1934,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Fac/Initial Hospital Care Levl II,PX99222F,CDM,510,RC,99222,CPT,,,,,,,,187,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,80.223,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.6798,183.26
"Infect Ag,Eia, Nos, Ea - Ref",PX8744990,CDM,300,RC,87449,CPT,90,,,,,,,187,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,80.223,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,183.26
Initial Hospital Care Levl II,PX99222P,CDM,982,RC,99222,CPT,,,,,,,,187,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,80.223,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.6798,182.0071
RETRIEVAL BAG 12/15MM,27200000,CDM,272,RC,,,,12660-MAIN,LOCAL,,,,,187,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,80.223,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
leflunomide 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,62332006130,NDC,1,EA,88.09,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,80.24999,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Inj Tendon/Ligament/Cyst,PX20550F,CDM,510,RC,20550,CPT,,,,,,,,177,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,80.25,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.78,120.37
Inj Tendon/Ligament/Cyst,PX20550P,CDM,983,RC,20550,CPT,,,,,,,,264,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,80.25,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.78,258.72
Remove Nasal Foreign Body,PX30300F,CDM,510,RC,30300,CPT,,,,,,,,972,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,80.27,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.84,438.6
Remove Nasal Foreign Body,PX30300P,CDM,983,RC,30300,CPT,,,,,,,,572,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,80.27,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.84,560.56
isatuximab-irfc 500 MG/25ML Solution 25 mL Vial,J9227.01,CDM,636,RC,J9227,HCPCS,,,,24065601,NDC,25,ML,7876.36,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,80.32,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.31,80.32
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021515,NDC,0.5,ML,187.24,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,80.32596,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.779496,199.7926
Ace - Ref,PX8216490,CDM,300,RC,82164,CPT,90,,,,,,,82,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,80.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.39,80.36
Anca Screen Each Antibody,PX8603690,CDM,300,RC,86036,CPT,90,,,,,,,82,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,80.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.0628,80.36
"Cognitive Funct Ther Interv, Ea Addl 15 Min",PX97130,CDM,420,RC,97130,CPT,,,,,,,,82,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,80.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.31,80.36
"Cortisol, Free - Ref",PX8253090,CDM,300,RC,82530,CPT,90,,,,,,,82,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,80.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.32,80.36
Tx/Pro/Dx Inj Same Drug Adon,PX96376,CDM,260,RC,96376,CPT,,,,,,,,164,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,31.71607143,percent of total billed charges,80.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.1256,160.72
Tx/Pro/Dx Inj Same Drug Adon,PX96376,CDM,260,RC,96376,CPT,,,,,,,,164,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,80.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.1256,160.72
Tx/Pro/Dx Inj Same Drug Adon,PX96376,CDM,260,RC,96376,CPT,,,,,,,,164,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,80.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.1256,160.72
cyclopentolate 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,61314039601,NDC,2,ML,94.58,,First Health,Commercial,both,85,,999999999,percent of total billed charges,80.393,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
EPIX UNIVERSAL CLIP APPLIER,27200000,CDM,272,RC,,,,11708-MAIN,LOCAL,,,,,158.95,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,80.4287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Iaad Ia Severe Aqt Respir Synd Coronavirus,PX87426,CDM,300,RC,87426,CPT,,,,,,,,159,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,80.454,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.39,155.82
Fibrinogen Test - Ref,PX8536690,CDM,300,RC,85366,CPT,90,,,,,,,179,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,80.46,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.05,80.46
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,781309894,NDC,1,EA,193.75,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,80.48375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.461584,189.875
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004722,NDC,2,ML,88.35,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,80.48685,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
Dress/Debrid Large Burn No Anesth,PX16030F,CDM,510,RC,16030,CPT,,,,,,,,399,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,80.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.84,410.93
Dress/Debrid Large Burn No Anesth,PX16030F,CDM,510,RC,16030,CPT,,,,,,,,399,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,80.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.84,410.93
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,39328006712,NDC,473,ML,167.77,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,80.5296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,39328006712,NDC,473,ML,167.77,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,80.5296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BRACE ANKLE LARGE 264015,120.51,CDM,274,RC,L1902,HCPCS,,4-MAIN,LOCAL,,,,,115,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,80.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE MEDIUM 264014,120.51,CDM,274,RC,L1902,HCPCS,,7-MAIN,LOCAL,,,,,115,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,80.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE SMALL 264012,120.51,CDM,274,RC,L1902,HCPCS,,12-MAIN,LOCAL,,,,,115,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,80.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE X-LARGE 264016,120.51,CDM,274,RC,L1902,HCPCS,,14-MAIN,LOCAL,,,,,115,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,80.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE X-SMALL 264011,120.51,CDM,274,RC,L1902,HCPCS,,1-MAIN,LOCAL,,,,,115,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,80.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,45802095301,NDC,100,GR,82.76,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,80.550308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361250,NDC,50,ML,90.53,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,80.5717,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361650,NDC,50,ML,90.53,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,80.5717,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
"Cmv, Quant - Ref",PX8749790,CDM,300,RC,87497,CPT,90,,,,,,,194,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,80.5876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.28,190.12
Hiv-1 Antigens W/Hiv 1/2 Antib,PX87389,CDM,300,RC,87389,CPT,,,,,,,,194,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,80.5876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.08,190.12
Lyme Disease Antibody,PX86618,CDM,300,RC,86618,CPT,,,,,,,,194,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,80.5876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.61,190.12
CISplatin 50 MG/50ML Solution 50 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010351,NDC,50,ML,82.27,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,80.6246,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.174958,180.2416
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010365,NDC,100,ML,164.54,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,80.6246,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.174958,180.2416
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010365,NDC,100,ML,164.54,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,80.6246,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.174958,180.2416
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010365,NDC,100,ML,164.54,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,80.6246,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.174958,180.2416
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061401,NDC,1,ML,94.87,,First Health,Commercial,both,85,,999999999,percent of total billed charges,80.6395,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.114178,99.911
Aerobic Isolate - Ref,PX8707790,CDM,300,RC,87077,CPT,90,,,,,,,168,,Health Partners,Health Partners Care Plans,both,48,,120.515,percent of total billed charges,80.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,164.64
Aerobic Isolate - Ref,PX8707790,CDM,300,RC,87077,CPT,90,,,,,,,168,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,80.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,164.64
Complete Cbc W/Auto Diff Wbc,PX85025,CDM,300,RC,85025,CPT,,,,,,,,168,,Health Partners,Health Partners Care Plans,both,48,,91.42880952,percent of total billed charges,80.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.12,164.64
Complete Cbc W/Auto Diff Wbc,PX85025,CDM,300,RC,85025,CPT,,,,,,,,168,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,80.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.12,164.64
Insert Straight Catheter,PX51701F,CDM,510,RC,51701,CPT,,,,,,,,168,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,80.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.7872,164.64
Insert Straight Catheter,PX51701F,CDM,510,RC,51701,CPT,,,,,,,,168,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,80.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.7872,164.64
Org ID Aerobic-Each,PX87077,CDM,300,RC,87077,CPT,,,,,,,,168,,Health Partners,Health Partners Care Plans,both,48,,120.515,percent of total billed charges,80.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,164.64
Org ID Aerobic-Each,PX87077,CDM,300,RC,87077,CPT,,,,,,,,168,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,80.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,164.64
sodium bicarbonate 4.2 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409553434,NDC,10,ML,91.46,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,80.66772,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Ehrlichia (Anaplasma) Ab - Ref,PX8666690,CDM,300,RC,86666,CPT,90,,,,,,,163,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,80.685,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.33,159.74
Xray Ankle 2 Vws,PX7360001,CDM,320,RC,73600,CPT,TC,,,,,,,163,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,80.685,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.7102,159.74
ON Q PAIN BUSTER,27100000,CDM,271,RC,A4305,HCPCS,,6751-MAIN,LOCAL,,,,,194.26,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,80.695604,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
tiotropium 18 MCG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,597007541,NDC,1,EA,82.92,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,80.706036,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Repeat Control of Nosebleed,PX30906F,CDM,510,RC,30906,CPT,,,,,,,,334,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,80.71,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,80.71,780.35
Repeat Control of Nosebleed,PX30906F,CDM,510,RC,30906,CPT,,,,,,,,334,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,80.71,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,80.71,780.35
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,25021012867,NDC,1,EA,82.96,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,80.744968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,55150020830,NDC,1,EA,82.96,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,80.744968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.461584,189.875
imipenem-cilastatin 250 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323034925,NDC,1,EA,91.55,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,80.7471,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,173.1856
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032294,NDC,1,EA,91.55,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,80.7471,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,173.1856
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234001,NDC,1.25,ML,91.55,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,80.7471,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
Assay Blood Carbon Dioxide,PX82374,CDM,300,RC,82374,CPT,,,,,,,,95,,First Health,Commercial,both,85,,999999999,percent of total billed charges,80.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.47,93.1
Blood Viscosity Examination,PX85810,CDM,300,RC,85810,CPT,,,,,,,,95,,First Health,Commercial,both,85,,999999999,percent of total billed charges,80.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.7,93.1
Cyclosporine - Ref,PX8015890,CDM,300,RC,80158,CPT,90,,,,,,,95,,First Health,Commercial,both,85,,999999999,percent of total billed charges,80.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.55,93.1
"Fac/Debridement of Nails, 6 or Mor",PX11721F,CDM,510,RC,11721,CPT,,,,,,,,95,,First Health,Commercial,both,85,,999999999,percent of total billed charges,80.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.463,93.1
"Fat/Lipids, Feces, Quant - Ref",PX8271090,CDM,300,RC,82710,CPT,90,,,,,,,95,,First Health,Commercial,both,85,,999999999,percent of total billed charges,80.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.4,93.1
KIT EPIDURAL 19GA FLEXTIP PLUS AK-05502,120.305,CDM,272,RC,,,,11413-MAIN,LOCAL,,,,,95,,First Health,Commercial,both,85,,999999999,percent of total billed charges,80.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.463,93.1
"Lyme Disease, Confirm Tst - Ref",PX8661790,CDM,300,RC,86617,CPT,90,,,,,,,95,,First Health,Commercial,both,85,,999999999,percent of total billed charges,80.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.2,93.1
"Organism ID, Anaerobic - Ref",PX8707690,CDM,300,RC,87076,CPT,90,,,,,,,95,,First Health,Commercial,both,85,,999999999,percent of total billed charges,80.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,93.1
Strep a Assay W/Optic,PX87880,CDM,300,RC,87880,CPT,,,,,,,,95,,First Health,Commercial,both,85,,999999999,percent of total billed charges,80.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.16,93.1
"Thyroxine, Total - Ref",PX8443690,CDM,300,RC,84436,CPT,90,,,,,,,95,,First Health,Commercial,both,85,,999999999,percent of total billed charges,80.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.3,93.1
TRAY FACIAL LACERATION PACK STERILE 96-1707,120.12,CDM,272,RC,,,,406-MAIN,LOCAL,,,,,95,,First Health,Commercial,both,85,,999999999,percent of total billed charges,80.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.463,93.1
Varicella-Zoster Antibody,PX86787,CDM,300,RC,86787,CPT,,,,,,,,95,,First Health,Commercial,both,85,,999999999,percent of total billed charges,80.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.81,93.1
prasugrel 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862083030,NDC,1,EA,88.64,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,80.75104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
erythromycin lactobionate 500 MG Recon Soln 1 Each Vial,J1364.01,CDM,636,RC,J1364,HCPCS,,,,409648211,NDC,1,EA,437.09,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,80.78,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.08,80.78
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,47781047013,NDC,1,EA,83,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,80.7839,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,64380079901,NDC,1,EA,83,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,80.7839,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,69238126601,NDC,1,EA,83,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,80.7839,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SLING ARM CHILD PAD CANVAS NAVY 8004-02,120.54,CDM,273,RC,A4565,HCPCS,,878-MAIN,LOCAL,,,,,83,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,81.69,percent of total billed charges,80.7839,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM LARGE PAD CANVAS NAVY ORT11300L,120.54,CDM,273,RC,A4565,HCPCS,,870-MAIN,LOCAL,,,,,83,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,81.69,percent of total billed charges,80.7839,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM MEDIUM PAD CANVAS NAVY ORT11300M,120.54,CDM,273,RC,A4565,HCPCS,,872-MAIN,LOCAL,,,,,83,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,81.69,percent of total billed charges,80.7839,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM SMALL PAD CANVAS NAVY ORT11300S,120.54,CDM,273,RC,A4565,HCPCS,,874-MAIN,LOCAL,,,,,83,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,81.69,percent of total billed charges,80.7839,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM X-LARGE PAD ENVELOPE ORT11300XL,120.54,CDM,273,RC,A4565,HCPCS,,876-MAIN,LOCAL,,,,,83,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,81.69,percent of total billed charges,80.7839,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010269,NDC,1,EA,88.69,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,80.79659,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010299,NDC,1,EA,88.69,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,80.79659,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614201,NDC,1,ML,88.69,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,80.79659,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.097864,86.9162
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614225,NDC,1,ML,88.69,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,80.79659,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.097864,86.9162
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963801,NDC,0.5,ML,88.69,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,80.79659,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
Dihydroxyvitamin D - Ref,PX8265290,CDM,300,RC,82652,CPT,90,,,,,,,165,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,80.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.3,161.7
Dihydroxyvitamin D - Ref,PX8265290,CDM,300,RC,82652,CPT,90,,,,,,,165,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,80.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.3,161.7
Dihydroxyvitamin D - Ref,PX8265290,CDM,300,RC,82652,CPT,90,,,,,,,165,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,80.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.3,161.7
Flow Cyto Ea Addtl Marker - Ref,PX8818590,CDM,310,RC,88185,CPT,90,,,,,,,165,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,37.45071429,percent of total billed charges,80.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.541,161.7
Flow Cyto Ea Addtl Marker - Ref,PX8818590,CDM,310,RC,88185,CPT,90,,,,,,,165,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,80.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.541,161.7
Flow Cyto Ea Addtl Marker - Ref,PX8818590,CDM,310,RC,88185,CPT,90,,,,,,,165,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,80.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.541,161.7
Strapping of Shoulder,PX29240F,CDM,420,RC,29240,CPT,,,,,,,,165,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,80.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.541,161.7
Strapping of Shoulder,PX29240F,CDM,420,RC,29240,CPT,,,,,,,,165,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,80.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.541,161.7
Strapping of Shoulder,PX29240F,CDM,420,RC,29240,CPT,,,,,,,,165,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,80.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.541,161.7
Xray Cervical Spine 4 or 5 Vws,PX7205001,CDM,320,RC,72050,CPT,TC,,,,,,,664,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,80.86,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.61,80.86
Xray Cervical Spine 4 or 5 Vws,PX7205001,CDM,320,RC,72050,CPT,TC,,,,,,,664,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,80.86,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.61,80.86
venetoclax 100 MG Tablet 1 Each Box,25000000,CDM,250,RC,,,,,,74057611,NDC,0.2,EA,90.87,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,80.8743,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,67815203,NDC,100,GR,91.77,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,80.94114,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Ex for Speech Device Rx Addl,PX92608,CDM,444,RC,92608,CPT,,,,,,,,160,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,80.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.95,156.8
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329334001,NDC,10,ML,88.88,,Medica,Commercial,both,91.1,,1.63075,percent of total billed charges,80.96968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,50383058766,NDC,60,ML,95.26,,First Health,Commercial,both,85,,999999999,percent of total billed charges,80.971,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,60432053760,NDC,60,ML,95.26,,First Health,Commercial,both,85,,999999999,percent of total billed charges,80.971,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Topiramate - Ref,PX8020190,CDM,300,RC,80201,CPT,90,,,,,,,195,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,81.003,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.93,191.1
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040304,NDC,10,ML,168.77,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,81.0096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040304,NDC,10,ML,168.77,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,81.0096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040310,NDC,10,ML,168.77,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,81.0096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040310,NDC,10,ML,168.77,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,81.0096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089901,NDC,0.25,ML,95.31,,First Health,Commercial,both,85,,999999999,percent of total billed charges,81.0135,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.79,93.4038
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089910,NDC,0.25,ML,95.31,,First Health,Commercial,both,85,,999999999,percent of total billed charges,81.0135,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.79,93.4038
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143998391,NDC,1,EA,83.25,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,23.54375,percent of total billed charges,81.027225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
atropine (PF) 1 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517101025,NDC,1,ML,91.89,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,81.04698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
Aldolase - Ref,PX8208590,CDM,300,RC,82085,CPT,90,,,,,,,89,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,81.079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.9,87.22
Assay of Ggt,PX82977,CDM,300,RC,82977,CPT,,,,,,,,89,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,81.079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6,87.22
"Debridement of Nail(S), 1-5",PX11720F,CDM,510,RC,11720,CPT,,,,,,,,89,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,81.079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.9706,87.22
"Hla a, B or C, Single Ag - Ref",PX8681290,CDM,300,RC,86812,CPT,90,,,,,,,89,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,81.079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.67,87.22
KIT INTRODUCER 8.5FR AK-09803-CDC,120.128,CDM,272,RC,,,,8826-MAIN,LOCAL,,,,,89,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,81.079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.9706,87.22
Alcohols - Ref,PX8032090,CDM,300,RC,80320,CPT,90,,,,,,,189,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,81.081,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.5106,185.22
penicillin v potassium 250 MG/5ML Recon Soln 200 mL Bottle,63700001,CDM,250,RC,,,,,,93412774,NDC,200,ML,83.32,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,81.095356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sildenafil citrate 20 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,65162035109,NDC,1,EA,95.41,,First Health,Commercial,both,85,,999999999,percent of total billed charges,81.0985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,45802095301,NDC,100,GR,82.76,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,81.1048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Blood Clot Factor VIII Test,PX85247,CDM,300,RC,85247,CPT,,,,,,,,169,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,81.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.03,165.62
Blood Clot Factor VIII Test,PX85247,CDM,300,RC,85247,CPT,,,,,,,,169,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,81.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.03,165.62
Blood Typing Abo,PX86900,CDM,300,RC,86900,CPT,,,,,,,,92,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,81.144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.2168,111.6
Blood Typing Rh (D),PX86901,CDM,300,RC,86901,CPT,,,,,,,,92,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,81.144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.03,90.16
Parvovirus Antibody - Ref,PX8674790,CDM,300,RC,86747,CPT,90,,,,,,,92,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,81.144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.78,90.16
"Reticulocyte Count,Flow Cyto",PX85045,CDM,300,RC,85045,CPT,,,,,,,,92,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,81.144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.66,90.16
rho d immune globulin human 1500 units solution prefilled syringe 1 Each Syringe,J2790.01,CDM,636,RC,J2790,HCPCS,,,,562780500,NDC,1,EA,464.01,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,81.16,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.42,81.16
"IMMOBILIZER KNEE  24"" 7041-44",120.22,CDM,274,RC,L1830,HCPCS,,595-MAIN,LOCAL,,,,,60,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,81.17,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.6617,81.17
"IMMOBILIZER KNEE 16"" UNIVERSAL 7088-04",120.22,CDM,274,RC,L1830,HCPCS,,589-MAIN,LOCAL,,,,,60,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,81.17,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.6617,81.17
IMMOBILIZER KNEE 20 INCH ORT2420019,120.22,CDM,274,RC,L1830,HCPCS,,587-MAIN,LOCAL,,,,,60,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,81.17,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.6617,81.17
"IMMOBILIZER KNEE 20"" LARGE FOAM COUNTOURED STAYS 7062-03",120.22,CDM,274,RC,L1830,HCPCS,,593-MAIN,LOCAL,,,,,60,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,81.17,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.6617,81.17
"IMMOBILIZER KNEE 20"" QUICK-WRAP ORT2440020S",120.22,CDM,274,RC,L1830,HCPCS,,591-MAIN,LOCAL,,,,,60,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,81.17,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.6617,81.17
IMMOBILIZER KNEE CUTAWAY STRAIGHT 2 7041-05,120.22,CDM,274,RC,L1830,HCPCS,,596-MAIN,LOCAL,,,,,60,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,81.17,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.6617,81.17
Fac/Initial Hospital Care Levl II,PX99222F,CDM,510,RC,99222,CPT,,,,,,,,187,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,81.18,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.18,232.02
Initial Hospital Care Levl II,PX99222P,CDM,982,RC,99222,CPT,,,,,,,,187,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,81.18,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.18,232.02
Lvl 2 Init Hosp Mod Mdm or 55 Minutes,PX99222,CDM,982,RC,99222,CPT,,,,,,,,508,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,81.18,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.18,497.84
Tx/Pro/Dx Inj Same Drug Adon,PX96376,CDM,260,RC,96376,CPT,,,,,,,,164,,Humana Choice Care,All Medicare plans,outpatient,49.5,,140.63,percent of total billed charges,81.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.1256,160.72
nafcillin 1 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,55150012215,NDC,1,EA,89.17,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,81.23387,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tiotropium 18 MCG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,597007541,NDC,1,EA,82.92,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,81.2616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Hiv-1, Quantification - Ref",PX8753690,CDM,300,RC,87536,CPT,90,,,,,,,220,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,81.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.27,85.1
"Hiv-1, Quantification - Ref",PX8753690,CDM,300,RC,87536,CPT,90,,,,,,,220,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,81.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.27,85.1
TRAY IV SURGICAL EXTREMITY DYNJS0804,27200000,CDM,272,RC,,,,10919-MAIN,LOCAL,,,,,83.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,81.27055,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062001,NDC,0.4,ML,189.48,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,81.28692,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062040,NDC,0.4,ML,189.48,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,81.28692,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801401,NDC,0.4,ML,189.48,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,81.28692,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801410,NDC,0.4,ML,189.48,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,81.28692,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
dextrose 25% Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409177510,NDC,10,ML,83.53,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,81.299749,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,25021012867,NDC,1,EA,82.96,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,81.3008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,81.3008
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,55150020830,NDC,1,EA,82.96,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,81.3008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.461584,189.875
"Breast Tomosynthesis,Dx Tc Bilat",PX7706201,CDM,401,RC,77062,CPT,TC,,,,,,,166,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,81.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.9564,162.68
"Breast Tomosynthesis,Dx Tc Bilat",PX7706201,CDM,401,RC,77062,CPT,TC,,,,,,,166,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,81.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.9564,162.68
"Breast Tomosynthesis,Dx Tc Bilat",PX7706201,CDM,401,RC,77062,CPT,TC,,,,,,,166,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,81.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.9564,162.68
"Breast Tomosynthesis,Dx Tc Unilat",PX7706101,CDM,401,RC,77061,CPT,TC,,,,,,,166,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,81.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.9564,162.68
"Breast Tomosynthesis,Dx Tc Unilat",PX7706101,CDM,401,RC,77061,CPT,TC,,,,,,,166,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,81.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.9564,162.68
"Breast Tomosynthesis,Dx Tc Unilat",PX7706101,CDM,401,RC,77061,CPT,TC,,,,,,,166,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,81.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.9564,162.68
"Breast Tomosynthesis,Screen Tc",PX7706301,CDM,403,RC,77063,CPT,TC,,,,,,,166,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,279.8538462,percent of total billed charges,81.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.59,280.5
"Breast Tomosynthesis,Screen Tc",PX7706301,CDM,403,RC,77063,CPT,TC,,,,,,,166,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,81.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.59,280.5
"Breast Tomosynthesis,Screen Tc",PX7706301,CDM,403,RC,77063,CPT,TC,,,,,,,166,,United Healthcare,All Medicare advantage plans,outpatient,49,,23.48,percent of total billed charges,81.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.59,280.5
Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq,PX87635,CDM,300,RC,87635,CPT,,,,,,,,166,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,5.488461538,percent of total billed charges,81.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,224.4
Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq,PX87635,CDM,300,RC,87635,CPT,,,,,,,,166,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,81.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,224.4
Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq,PX87635,CDM,300,RC,87635,CPT,,,,,,,,166,,United Healthcare,All Medicare advantage plans,outpatient,49,,85.33,percent of total billed charges,81.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,224.4
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,47781047013,NDC,1,EA,83,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,81.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,64380079901,NDC,1,EA,83,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,81.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,69238126601,NDC,1,EA,83,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,81.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SLING ARM CHILD PAD CANVAS NAVY 8004-02,120.54,CDM,273,RC,A4565,HCPCS,,878-MAIN,LOCAL,,,,,83,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,81.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM LARGE PAD CANVAS NAVY ORT11300L,120.54,CDM,273,RC,A4565,HCPCS,,870-MAIN,LOCAL,,,,,83,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,81.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM MEDIUM PAD CANVAS NAVY ORT11300M,120.54,CDM,273,RC,A4565,HCPCS,,872-MAIN,LOCAL,,,,,83,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,81.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM SMALL PAD CANVAS NAVY ORT11300S,120.54,CDM,273,RC,A4565,HCPCS,,874-MAIN,LOCAL,,,,,83,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,81.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
SLING ARM X-LARGE PAD ENVELOPE ORT11300XL,120.54,CDM,273,RC,A4565,HCPCS,,876-MAIN,LOCAL,,,,,83,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,81.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.4782,81.34
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,990771502,NDC,250,ML,166.02,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,12.9192,percent of total billed charges,81.3498,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.4701,303.0944
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,990771502,NDC,250,ML,166.02,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,81.3498,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.4701,303.0944
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,990771502,NDC,250,ML,166.02,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,81.3498,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.4701,303.0944
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,17478028810,NDC,5,ML,95.71,,First Health,Commercial,both,85,,999999999,percent of total billed charges,81.3535,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314022705,NDC,5,ML,95.71,,First Health,Commercial,both,85,,999999999,percent of total billed charges,81.3535,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,64980051405,NDC,5,ML,95.71,,First Health,Commercial,both,85,,999999999,percent of total billed charges,81.3535,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989001,NDC,50,ML,160.78,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,81.35468,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989002,NDC,50,ML,160.78,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,81.35468,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
Repeat Control of Nosebleed,PX30906F,CDM,510,RC,30906,CPT,,,,,,,,334,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,81.36,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,80.71,780.35
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424601,NDC,15,ML,95.76,,First Health,Commercial,both,85,,999999999,percent of total billed charges,81.396,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.778704,295.3916
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424681,NDC,15,ML,95.76,,First Health,Commercial,both,85,,999999999,percent of total billed charges,81.396,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.778704,295.3916
sodium bicarbonate 4.2 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409553434,NDC,10,ML,91.46,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,81.3994,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Apply Finger Splint,Static",PX29130F,CDM,420,RC,29130,CPT,,,,,,,,196,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,81.4184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.4184,192.08
Heterophile Antibodies,PX86308,CDM,300,RC,86308,CPT,,,,,,,,196,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,81.4184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,192.08
hydrOXYzine 50 MG/ML Solution 1 mL Vial,J3410.01,CDM,636,RC,J3410,HCPCS,,,,517560125,NDC,0.5,ML,83.68,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,81.445744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.760672,82.0064
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010365,NDC,100,ML,164.54,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,81.4473,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.174958,180.2416
Catheterize for Urine Spec,PXP9612,CDM,300,RC,P9612,HCPCS,,,,,,,,161,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,81.466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.1,157.78
Drain/Inject Small Joint/Bursa,PX20600F,CDM,510,RC,20600,CPT,,,,,,,,161,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,81.466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.8794,258.75
Drain/Inject Small Joint/Bursa,PX20600P,CDM,983,RC,20600,CPT,,,,,,,,161,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,81.466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.8794,258.75
Each Add'l Hour IV Infusion <8 Hour,PX96366,CDM,260,RC,96366,CPT,,,,,,,,161,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,81.466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,157.78
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,63323094004,NDC,4,ML,89.43,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,81.47073,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,63323094021,NDC,4,ML,89.43,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,81.47073,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
imipenem-cilastatin 250 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323034925,NDC,1,EA,91.55,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,81.4795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,173.1856
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032294,NDC,1,EA,91.55,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,81.4795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,173.1856
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234001,NDC,1.25,ML,91.55,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,81.4795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
sod citrate-citric acid 500-334 MG/5ML Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,121059516,NDC,473,ML,95.87,,First Health,Commercial,both,85,,999999999,percent of total billed charges,81.4895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of ammonia,PX82140,CDM,300,RC,82140,CPT,,,,,,,,190,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,81.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.36,186.2
Assay of protein urine,PX84156,CDM,300,RC,84156,CPT,,,,,,,,190,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,81.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.37,186.2
Each Add'l Sequential IV Infusion <1 Hour,PX96367,CDM,260,RC,96367,CPT,,,,,,,,190,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,81.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,186.2
"N Block Inj, Common Digit",PX64632F,CDM,510,RC,64632,CPT,,,,,,,,190,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,81.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.926,258.75
"Tumor Antigen, Ca-125",PX86304,CDM,300,RC,86304,CPT,,,,,,,,190,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,81.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,186.2
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052084,NDC,1,EA,92.46,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,81.54972,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.407884,90.9538
empagliflozin 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,597015230,NDC,1,EA,92.47,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,81.55854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
azithromycin 200 MG/5ML Recon Susp 15 mL Bottle,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,59762312001,NDC,15,ML,196.35,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,81.56379,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
ROTH NET PLATINUM RETRIEVER,27200000,CDM,272,RC,,,,7518-MAIN,LOCAL,,,,,196.35,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,81.56379,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143998391,NDC,1,EA,83.25,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,81.585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
Asay of Interleukin-6 (Il-6),PX8352990,CDM,300,RC,83529,CPT,90,,,,,,,170,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,81.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,166.6
Asay of Interleukin-6 (Il-6),PX8352990,CDM,300,RC,83529,CPT,90,,,,,,,170,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,81.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,166.6
Chem Cautery Granulatn Tissue,PX17250F,CDM,510,RC,17250,CPT,,,,,,,,170,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,81.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,174.9
Chem Cautery Granulatn Tissue,PX17250F,CDM,510,RC,17250,CPT,,,,,,,,170,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,81.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,174.9
"Chemotherapy Administration, Subq/Im Non-Hormonal Anti-Neoplastic",PX96401,CDM,335,RC,96401,CPT,,,,,,,,170,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,81.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,166.6
"Chemotherapy Administration, Subq/Im Non-Hormonal Anti-Neoplastic",PX96401,CDM,335,RC,96401,CPT,,,,,,,,170,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,81.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,166.6
Collagen Cross Links - Ref,PX8252390,CDM,300,RC,82523,CPT,90,,,,,,,170,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,81.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.13,166.6
Collagen Cross Links - Ref,PX8252390,CDM,300,RC,82523,CPT,90,,,,,,,170,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,81.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.13,166.6
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; 1st",PX88184,CDM,310,RC,88184,CPT,,,,,,,,96,,First Health,Commercial,both,85,,999999999,percent of total billed charges,81.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.8784,314.02
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; Add'l",PX88185,CDM,310,RC,88185,CPT,,,,,,,,96,,First Health,Commercial,both,85,,999999999,percent of total billed charges,81.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.8784,94.08
gadoteridol 279.3 MG/ML Solution 17 mL Syringe,A9576,CDM,636,RC,A9576,HCPCS,,,,270111145,NDC,17,ML,170,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,81.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.54,166.6
gadoteridol 279.3 MG/ML Solution 17 mL Syringe,A9576,CDM,636,RC,A9576,HCPCS,,,,270111145,NDC,17,ML,170,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,81.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.54,166.6
"Protein, Total; Serum, Plasma or Whole Blood",PX84155,CDM,300,RC,84155,CPT,,,,,,,,170,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,81.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.37,166.6
"Protein, Total; Serum, Plasma or Whole Blood",PX84155,CDM,300,RC,84155,CPT,,,,,,,,170,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,81.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.37,166.6
US Urine Capacity Measure,PX51798F,CDM,510,RC,51798,CPT,,,,,,,,96,,First Health,Commercial,both,85,,999999999,percent of total billed charges,81.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.8784,94.08
Naso/Orogastric Tube,PX43752F,CDM,510,RC,43752,CPT,,,,,,,,464,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,81.63,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.21,81.63
Naso/Orogastric Tube,PX43752F,CDM,510,RC,43752,CPT,,,,,,,,464,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,81.63,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.21,81.63
Naso/Orogastric Tube,PX43752P,CDM,983,RC,43752,CPT,,,,,,,,309,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,81.63,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.21,302.82
Naso/Orogastric Tube,PX43752P,CDM,983,RC,43752,CPT,,,,,,,,309,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,81.63,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.21,302.82
silver sulfADIAZINE 1 % Cream 50 g Jar,25000000,CDM,250,RC,,,,,,43598021055,NDC,50,GR,83.89,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,81.650137,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
penicillin v potassium 250 MG/5ML Recon Soln 200 mL Bottle,63700001,CDM,250,RC,,,,,,93412774,NDC,200,ML,83.32,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,81.6536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011701,NDC,1,EA,89.64,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,81.66204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011710,NDC,1,EA,89.64,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,81.66204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
Dihydroxyvitamin D - Ref,PX8265290,CDM,300,RC,82652,CPT,90,,,,,,,165,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,81.675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.3,161.7
Flow Cyto Ea Addtl Marker - Ref,PX8818590,CDM,310,RC,88185,CPT,90,,,,,,,165,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,81.675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.541,161.7
Strapping of Shoulder,PX29240F,CDM,420,RC,29240,CPT,,,,,,,,165,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,81.675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.541,161.7
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,67815203,NDC,100,GR,91.77,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,81.6753,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,59148000713,NDC,1,EA,170.19,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,81.6912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,59148000713,NDC,1,EA,170.19,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,81.6912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HYDROmorphone 0.1 MG/ML Solution 55 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,61553067976,NDC,55,ML,89.7,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,81.7167,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409663734,NDC,50,ML,89.7,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,81.7167,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
CANNULA OPTIFLOW JUNIOR2+ XXL OJR520,120.494,CDM,271,RC,A4615,HCPCS,,11619-MAIN,LOCAL,,,,,84,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,81.7572,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.8936,82.32
Hiaa - Ref,PX8349790,CDM,300,RC,83497,CPT,90,,,,,,,84,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,81.7572,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.83,82.32
atropine (PF) 1 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517101025,NDC,1,ML,91.89,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,81.7821,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,4080285,NDC,1,EA,89.79,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,81.79869,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Refill/Maint Portable Pump,PX96521,CDM,260,RC,96521,CPT,,,,,,,,325,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,81.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.8,216.39
Refill/Maint Portable Pump,PX96521,CDM,260,RC,96521,CPT,,,,,,,,325,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,81.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.8,216.39
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041100,NDC,0.5,ML,196.94,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,81.808876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.808876,411.2766
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041110,NDC,0.5,ML,196.94,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,81.808876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.808876,411.2766
Fungus Isolation Culture,PX87102,CDM,300,RC,87102,CPT,,,,,,,,167,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,81.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.71,163.66
Fungus Isolation Culture,PX87102,CDM,300,RC,87102,CPT,,,,,,,,167,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,81.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.71,163.66
Fungus Isolation Culture,PX87102,CDM,300,RC,87102,CPT,,,,,,,,167,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,81.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.71,163.66
Microalbumin Quantitative,PX82043,CDM,300,RC,82043,CPT,,,,,,,,167,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,81.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.3,163.66
Microalbumin Quantitative,PX82043,CDM,300,RC,82043,CPT,,,,,,,,167,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,81.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.3,163.66
Microalbumin Quantitative,PX82043,CDM,300,RC,82043,CPT,,,,,,,,167,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,81.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.3,163.66
TRAY IV SURGICAL EXTREMITY DYNJS0804,27200000,CDM,272,RC,,,,10919-MAIN,LOCAL,,,,,83.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,81.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Wound Cult/Afb,PX87116,CDM,300,RC,87116,CPT,,,,,,,,167,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,81.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9,163.66
Wound Cult/Afb,PX87116,CDM,300,RC,87116,CPT,,,,,,,,167,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,81.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9,163.66
Wound Cult/Afb,PX87116,CDM,300,RC,87116,CPT,,,,,,,,167,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,81.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9,163.66
Assay Other Fluid Chlorides - Ref,PX8243890,CDM,300,RC,82438,CPT,90,,,,,,,197,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,81.8338,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.58,193.06
Tramadol - Ref,PX8037390,CDM,300,RC,80373,CPT,90,,,,,,,197,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,81.8338,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.8338,193.06
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052083,NDC,1,EA,92.81,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,81.85842,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.407884,90.9538
dextrose 25% Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409177510,NDC,10,ML,83.53,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,81.8594,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Blood Typing Abo,PX86900,CDM,300,RC,86900,CPT,,,,,,,,92,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,81.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.2168,111.6
Blood Typing Rh (D),PX86901,CDM,300,RC,86901,CPT,,,,,,,,92,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,81.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.03,90.16
Parvovirus Antibody - Ref,PX8674790,CDM,300,RC,86747,CPT,90,,,,,,,92,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,81.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.78,90.16
"Reticulocyte Count,Flow Cyto",PX85045,CDM,300,RC,85045,CPT,,,,,,,,92,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,81.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.66,90.16
Drainage of Hematoma/Fluid (P),PX10140P,CDM,983,RC,10140,CPT,,,,,,,,465,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,81.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.17,455.7
Drainage of Hematoma/Fluid (P),PX10140P,CDM,983,RC,10140,CPT,,,,,,,,465,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,81.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.17,455.7
Drainage of Hematoma/Fluid (T),PX10140F,CDM,510,RC,10140,CPT,,,,,,,,341,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,81.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.17,354.2
Drainage of Hematoma/Fluid (T),PX10140F,CDM,510,RC,10140,CPT,,,,,,,,341,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,81.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.17,354.2
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323012594,NDC,1,EA,190.99,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,81.93471,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
Assay of Amylase,PX82150,CDM,300,RC,82150,CPT,,,,,,,,191,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,81.939,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.94,187.18
C-Reactive Protein,PX86140,CDM,300,RC,86140,CPT,,,,,,,,191,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,81.939,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,187.18
"Chemotherapy, IV Infusion, Add'l Hour",PX96415,CDM,335,RC,96415,CPT,,,,,,,,191,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,81.939,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,187.18
Fac/Ther Injection Carpal Tunnel,PX20526F,CDM,510,RC,20526,CPT,,,,,,,,191,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,81.939,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.3414,258.75
Urine Pregnancy Test,PX81025,CDM,300,RC,81025,CPT,,,,,,,,191,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,81.939,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.89,187.18
Acetone Assay,PX82010,CDM,300,RC,82010,CPT,,,,,,,,162,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,81.972,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.49,158.76
"Flow Interp,2-8 Markers - Ref",PX8818790,CDM,310,RC,88187,CPT,90,,,,,,,162,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,81.972,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.1,158.76
KIT THORACENTESIS PLEURA SEAL AK-01000-T,120.24,CDM,272,RC,,,,1147-MAIN,LOCAL,,,,,162,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,81.972,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.2948,158.76
"Gammaglobulin; Iga, Dg,M - Ref",PX8278490,CDM,300,RC,82784,CPT,90,,,,,,,90,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,81.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.53,88.2
"Misc Virus Antibody, Nos - Ref",PX8679090,CDM,300,RC,86790,CPT,90,,,,,,,90,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,81.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.81,88.2
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152P,CDM,983,RC,99152,CPT,,,,,,,,90,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,81.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.386,87.597
Mycobacteria Culture - Ref,PX8711690,CDM,300,RC,87116,CPT,90,,,,,,,90,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,81.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9,88.2
hydrOXYzine 50 MG/ML Solution 1 mL Vial,J3410.01,CDM,636,RC,J3410,HCPCS,,,,517560125,NDC,0.5,ML,83.68,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,82.0064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.760672,82.0064
BOOT AIRSELECT SHORT LARGE 01ES-L,120.45,CDM,274,RC,L4360,HCPCS,,11890-MAIN,LOCAL,,,,,93,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,82.026,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT MEDIUM 01ES-M,120.45,CDM,274,RC,L4360,HCPCS,,11889-MAIN,LOCAL,,,,,93,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,82.026,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT SMALL 01ES-S,120.45,CDM,274,RC,L4360,HCPCS,,11888-MAIN,LOCAL,,,,,93,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,82.026,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT X-LARGE 01ES-XL,120.45,CDM,274,RC,L4360,HCPCS,,11891-MAIN,LOCAL,,,,,93,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,82.026,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT X-SMALL 01ES-XS,120.45,CDM,274,RC,L4360,HCPCS,,11887-MAIN,LOCAL,,,,,93,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,82.026,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD LARGE 01EF-L,120.45,CDM,274,RC,L4360,HCPCS,,11697-MAIN,LOCAL,,,,,93,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,82.026,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD MEDIUM 01EF-M,120.45,CDM,274,RC,L4360,HCPCS,,11696-MAIN,LOCAL,,,,,93,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,82.026,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD SMALL 01EF-S,120.45,CDM,274,RC,L4360,HCPCS,,11695-MAIN,LOCAL,,,,,93,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,82.026,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD X-LARGE 01EF-XL,120.45,CDM,274,RC,L4360,HCPCS,,11698-MAIN,LOCAL,,,,,93,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,82.026,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD X-SMALL 01EF-XS,120.45,CDM,274,RC,L4360,HCPCS,,11694-MAIN,LOCAL,,,,,93,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,82.026,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
Russell Viper Venom - Ref,PX8561390,CDM,300,RC,85613,CPT,90,,,,,,,93,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,82.026,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.78,91.14
SPLINT FOOT SMALL STRUT WALK 11-1383-2-00000,120.45,CDM,274,RC,L4360,HCPCS,,1205-MAIN,LOCAL,,,,,93,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,82.026,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
"CCP, Antibody - Ref",PX8620090,CDM,300,RC,86200,CPT,90,,,,,,,171,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,82.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,167.58
"CCP, Antibody - Ref",PX8620090,CDM,300,RC,86200,CPT,90,,,,,,,171,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,82.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,167.58
Hepatic Function Panel,PX80076,CDM,300,RC,80076,CPT,,,,,,,,171,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,82.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.49,167.58
Hepatic Function Panel,PX80076,CDM,300,RC,80076,CPT,,,,,,,,171,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,82.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.49,167.58
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105F,CDM,510,RC,11105,CPT,,,,,,,,171,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,82.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.0334,167.58
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105F,CDM,510,RC,11105,CPT,,,,,,,,171,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,82.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.0334,167.58
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102F,CDM,510,RC,11102,CPT,,,,,,,,171,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,82.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.0334,174.9
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102F,CDM,510,RC,11102,CPT,,,,,,,,171,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,82.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.0334,174.9
tobramycin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314064305,NDC,5,ML,191.42,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,82.11918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Breast Tomosynthesis,Dx Tc Bilat",PX7706201,CDM,401,RC,77062,CPT,TC,,,,,,,166,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,82.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.9564,162.68
"Breast Tomosynthesis,Dx Tc Unilat",PX7706101,CDM,401,RC,77061,CPT,TC,,,,,,,166,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,82.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.9564,162.68
"Breast Tomosynthesis,Screen Tc",PX7706301,CDM,403,RC,77063,CPT,TC,,,,,,,166,,Humana Choice Care,All Medicare plans,outpatient,49.5,,144.7727273,percent of total billed charges,82.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.59,280.5
Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq,PX87635,CDM,300,RC,87635,CPT,,,,,,,,166,,Humana Choice Care,All Medicare plans,outpatient,49.5,,18.07555556,percent of total billed charges,82.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,224.4
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,990771502,NDC,250,ML,166.02,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,82.1799,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.4701,303.0944
timolol 0.25 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314022605,NDC,5,ML,84.45,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,82.195185,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Repr Superf Wnd Body 12.6-20,PX12005F,CDM,510,RC,12005,CPT,,,,,,,,565,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,82.2016,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.84,369.42
Repr Superf Wnd Body 12.6-20,PX12005P,CDM,983,RC,12005,CPT,,,,,,,,377,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,82.2016,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.84,369.46
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,39328006712,NDC,473,ML,167.77,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,82.2073,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,39328006712,NDC,473,ML,167.77,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,82.2073,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,39328006712,NDC,473,ML,167.77,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,82.2073,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
silver sulfADIAZINE 1 % Cream 50 g Jar,25000000,CDM,250,RC,,,,,,43598021055,NDC,50,GR,83.89,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,82.2122,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,70860030143,NDC,25,ML,84.47,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,82.214651,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010626,NDC,50,ML,84.47,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,14.23621053,percent of total billed charges,82.214651,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
sodium bicarbonate 8.4 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409662502,NDC,50,ML,84.47,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,82.214651,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Collect Blood From Picc,PX36592,CDM,949,RC,36592,CPT,,,,,,,,198,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,82.2492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.2492,194.04
Debride Muscle Ea Add 20 Sqcm,PX11046P,CDM,983,RC,11046,CPT,,,,,,,,198,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,82.2492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.2492,192.7134
Insert Simple Cath Foley,PX51702F,CDM,510,RC,51702,CPT,,,,,,,,198,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,82.2492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.2492,194.04
KIT PLEUREVAC CHEST DRAIN S-1100-08LF,120.2,CDM,272,RC,,,,4190-MAIN,LOCAL,,,,,198,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,82.2492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.0466,194.04
Lyme Screen,PX7585,CDM,300,RC,86618,CPT,,,,,,,,198,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,82.2492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.61,194.04
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052084,NDC,1,EA,92.46,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,82.2894,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.407884,90.9538
empagliflozin 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,597015230,NDC,1,EA,92.47,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,82.2983,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 12 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,378911916,NDC,1,EA,96.83,,First Health,Commercial,both,85,,999999999,percent of total billed charges,82.3055,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 12 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505708000,NDC,1,EA,96.83,,First Health,Commercial,both,85,,999999999,percent of total billed charges,82.3055,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 12 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,378911998,NDC,1,EA,96.84,,First Health,Commercial,both,85,,999999999,percent of total billed charges,82.314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 12 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,60505708002,NDC,1,EA,96.84,,First Health,Commercial,both,85,,999999999,percent of total billed charges,82.314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Aerobic Isolate - Ref,PX8707790,CDM,300,RC,87077,CPT,90,,,,,,,168,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,10.17125,percent of total billed charges,82.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,164.64
Aerobic Isolate - Ref,PX8707790,CDM,300,RC,87077,CPT,90,,,,,,,168,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,82.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,164.64
Aerobic Isolate - Ref,PX8707790,CDM,300,RC,87077,CPT,90,,,,,,,168,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,82.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,164.64
CANNULA OPTIFLOW JUNIOR2+ XXL OJR520,120.494,CDM,271,RC,A4615,HCPCS,,11619-MAIN,LOCAL,,,,,84,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,82.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.8936,82.32
Complete Cbc W/Auto Diff Wbc,PX85025,CDM,300,RC,85025,CPT,,,,,,,,168,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,16.3056,percent of total billed charges,82.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.12,164.64
Complete Cbc W/Auto Diff Wbc,PX85025,CDM,300,RC,85025,CPT,,,,,,,,168,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,82.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.12,164.64
Complete Cbc W/Auto Diff Wbc,PX85025,CDM,300,RC,85025,CPT,,,,,,,,168,,United Healthcare,All Medicare advantage plans,outpatient,49,,87.715,percent of total billed charges,82.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.12,164.64
Hiaa - Ref,PX8349790,CDM,300,RC,83497,CPT,90,,,,,,,84,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,82.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.83,82.32
Insert Straight Catheter,PX51701F,CDM,510,RC,51701,CPT,,,,,,,,168,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,82.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.7872,164.64
Insert Straight Catheter,PX51701F,CDM,510,RC,51701,CPT,,,,,,,,168,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,82.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.7872,164.64
Insert Straight Catheter,PX51701F,CDM,510,RC,51701,CPT,,,,,,,,168,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,82.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.7872,164.64
Org ID Aerobic-Each,PX87077,CDM,300,RC,87077,CPT,,,,,,,,168,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,10.17125,percent of total billed charges,82.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,164.64
Org ID Aerobic-Each,PX87077,CDM,300,RC,87077,CPT,,,,,,,,168,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,82.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,164.64
Org ID Aerobic-Each,PX87077,CDM,300,RC,87077,CPT,,,,,,,,168,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,82.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,164.64
"Office Consultation,Level III",PX99243P,CDM,983,RC,99243,CPT,,,,,,,,374,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,82.3296,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.65,366.52
"Chest Wall Manipulation,Subsequent",PX94668F,CDM,410,RC,94668,CPT,,,,,,,,192,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,82.368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.7568,188.16
Hepatitis Be Antibody - Ref,PX8670790,CDM,300,RC,86707,CPT,90,,,,,,,192,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,82.368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.61,188.16
Infectious Agent Antigen Detection by Immunoassay With Direct Visual Observation.,PX87811,CDM,300,RC,87811,CPT,,,,,,,,192,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,82.368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.94,188.16
lidocaine 4 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,536128128,NDC,30,GR,96.95,,First Health,Commercial,both,85,,999999999,percent of total billed charges,82.4075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Blastomyces Antibody - Ref,PX8661290,CDM,300,RC,86612,CPT,90,,,,,,,97,,First Health,Commercial,both,85,,999999999,percent of total billed charges,82.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.83,95.06
Contrast Bath Therapy,PX97034,CDM,420,RC,97034,CPT,,,,,,,,97,,First Health,Commercial,both,85,,999999999,percent of total billed charges,82.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,95.06
DRAPE INSTRUMENT ARM 470015,27200000,CDM,272,RC,,,,11925-MAIN,LOCAL,,,,,97,,First Health,Commercial,both,85,,999999999,percent of total billed charges,82.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
High Sens Crp,PX86141,CDM,300,RC,86141,CPT,,,,,,,,97,,First Health,Commercial,both,85,,999999999,percent of total billed charges,82.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,95.06
Rheumatoid Factor Quant,PX86431,CDM,300,RC,86431,CPT,,,,,,,,97,,First Health,Commercial,both,85,,999999999,percent of total billed charges,82.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.2,95.06
Refill/Maint Portable Pump,PX96521,CDM,260,RC,96521,CPT,,,,,,,,325,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,82.46,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.8,216.39
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361250,NDC,50,ML,90.53,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,82.47283,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361650,NDC,50,ML,90.53,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,82.47283,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
protamine 10 MG/ML Solution 5 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022994,NDC,5,ML,84.74,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,82.477442,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.431298,83.0452
Ehrlichia (Anaplasma) Ab - Ref,PX8666690,CDM,300,RC,86666,CPT,90,,,,,,,163,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,82.478,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.33,159.74
Xray Ankle 2 Vws,PX7360001,CDM,320,RC,73600,CPT,TC,,,,,,,163,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,82.478,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.7102,159.74
"Breast Tomosynthesis,Screen Tc",PX7706301,CDM,403,RC,77063,CPT,TC,,,,,,,166,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,82.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.59,280.5
"Hiv-1, Quantification - Ref",PX8753690,CDM,300,RC,87536,CPT,90,,,,,,,220,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,82.55,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.27,85.1
AIRSEAL 12MM ACCESS PORT AND PALM GRIP OBTURATOR BLADELESS OPTICAL TIP 120MM,27200000,CDM,272,RC,,,,12207-MAIN,LOCAL,,,,,172,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,82.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
AIRSEAL 12MM ACCESS PORT AND PALM GRIP OBTURATOR BLADELESS OPTICAL TIP 120MM,27200000,CDM,272,RC,,,,12207-MAIN,LOCAL,,,,,172,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,82.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
AIRSEAL TUBE SET TRI LUMEN FILTERED WITH ACTIVATED CHARCOAL,27200000,CDM,272,RC,,,,12206-MAIN,LOCAL,,,,,172,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,82.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
AIRSEAL TUBE SET TRI LUMEN FILTERED WITH ACTIVATED CHARCOAL,27200000,CDM,272,RC,,,,12206-MAIN,LOCAL,,,,,172,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,82.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052083,NDC,1,EA,92.81,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,82.6009,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.407884,90.9538
clotrimazole-betamethasone 1-0.05 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,66993089815,NDC,15,GR,192.55,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,82.60395,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Inpt or Obs Disch Day Mngmt <=30 Minutes,PX99238,CDM,982,RC,99238,CPT,,,,,,,,199,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,82.6646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.6646,193.6867
Fungus Isolation Culture,PX87102,CDM,300,RC,87102,CPT,,,,,,,,167,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,82.665,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.71,163.66
Microalbumin Quantitative,PX82043,CDM,300,RC,82043,CPT,,,,,,,,167,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,82.665,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.3,163.66
Wound Cult/Afb,PX87116,CDM,300,RC,87116,CPT,,,,,,,,167,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,82.665,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9,163.66
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040304,NDC,10,ML,168.77,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,82.6973,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040304,NDC,10,ML,168.77,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,82.6973,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040304,NDC,10,ML,168.77,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,82.6973,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040310,NDC,10,ML,168.77,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,82.6973,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040310,NDC,10,ML,168.77,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,82.6973,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040310,NDC,10,ML,168.77,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,82.6973,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
ceFAZolin in D4W 1 g / 50 mL 1-4 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0690.01,CDM,636,RC,J0690,HCPCS,,,,264310311,NDC,1,EA,84.97,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,23.54375,percent of total billed charges,82.701301,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
US Head/Neck Tc,PX7653601,CDM,402,RC,76536,CPT,TC,,,,,,,416,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,82.7026,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.06,165.66
"Cognitive Funct Ther Interv, Initial 15 Min",PX97129,CDM,420,RC,97129,CPT,,,,,,,,85,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,16.4,percent of total billed charges,82.7305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15,83.3
"Exam,Synovial Fluid Crystals",PX89060,CDM,300,RC,89060,CPT,,,,,,,,85,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,82.7305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.72,83.3
GLIDESCOPE QC MAC S3 SINGLE USE 0270-1083,120.579,CDM,272,RC,,,,13046-MAIN,LOCAL,,,,,85,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,82.7305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.309,83.3
GLIDESCOPE QC MAC S3 SINGLE USE 0270-1085,120.579,CDM,272,RC,,,,13022-MAIN,LOCAL,,,,,85,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,82.7305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.309,83.3
GLIDESCOPE QC MAC S4 SINGLE USE 0270-1086,120.579,CDM,272,RC,,,,13023-MAIN,LOCAL,,,,,85,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,82.7305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.309,83.3
sodium bicarbonate 8.4 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409662522,NDC,50,ML,85.02,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,82.749966,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
timolol 0.25 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314022605,NDC,5,ML,84.45,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,82.761,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
alendronate 70 MG Tablet 4 Each Box,63700001,CDM,250,RC,,,,,,16714063301,NDC,1,EA,97.37,,First Health,Commercial,both,85,,999999999,percent of total billed charges,82.7645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BOOT AIRSELECT SHORT LARGE 01ES-L,120.45,CDM,274,RC,L4360,HCPCS,,11890-MAIN,LOCAL,,,,,93,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,82.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT MEDIUM 01ES-M,120.45,CDM,274,RC,L4360,HCPCS,,11889-MAIN,LOCAL,,,,,93,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,82.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT SMALL 01ES-S,120.45,CDM,274,RC,L4360,HCPCS,,11888-MAIN,LOCAL,,,,,93,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,82.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT X-LARGE 01ES-XL,120.45,CDM,274,RC,L4360,HCPCS,,11891-MAIN,LOCAL,,,,,93,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,82.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT X-SMALL 01ES-XS,120.45,CDM,274,RC,L4360,HCPCS,,11887-MAIN,LOCAL,,,,,93,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,82.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD LARGE 01EF-L,120.45,CDM,274,RC,L4360,HCPCS,,11697-MAIN,LOCAL,,,,,93,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,82.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD MEDIUM 01EF-M,120.45,CDM,274,RC,L4360,HCPCS,,11696-MAIN,LOCAL,,,,,93,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,82.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD SMALL 01EF-S,120.45,CDM,274,RC,L4360,HCPCS,,11695-MAIN,LOCAL,,,,,93,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,82.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD X-LARGE 01EF-XL,120.45,CDM,274,RC,L4360,HCPCS,,11698-MAIN,LOCAL,,,,,93,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,82.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD X-SMALL 01EF-XS,120.45,CDM,274,RC,L4360,HCPCS,,11694-MAIN,LOCAL,,,,,93,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,82.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
Russell Viper Venom - Ref,PX8561390,CDM,300,RC,85613,CPT,90,,,,,,,93,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,82.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.78,91.14
SPLINT FOOT SMALL STRUT WALK 11-1383-2-00000,120.45,CDM,274,RC,L4360,HCPCS,,1205-MAIN,LOCAL,,,,,93,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,82.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,70860030143,NDC,25,ML,84.47,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,82.7806,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010626,NDC,50,ML,84.47,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,82.7806,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
sodium bicarbonate 8.4 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409662502,NDC,50,ML,84.47,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,82.7806,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
venetoclax 100 MG Tablet 1 Each Box,25000000,CDM,250,RC,,,,,,74057611,NDC,0.2,EA,90.87,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,82.78257,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Ag Detect Nos Eia Mult,PX87449,CDM,300,RC,87449,CPT,,,,,,,,193,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,82.797,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,189.14
Blood Clot Factor VIII Test,PX85247,CDM,300,RC,85247,CPT,,,,,,,,169,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,82.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.03,165.62
Blood Clot Factor VIII Test,PX85247,CDM,300,RC,85247,CPT,,,,,,,,169,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,82.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.03,165.62
Blood Clot Factor VIII Test,PX85247,CDM,300,RC,85247,CPT,,,,,,,,169,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,82.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.03,165.62
Tap Block Unilateral by Injection(S),PX64486P,CDM,983,RC,64486,CPT,,,,,,,,169,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,33.8,percent of total billed charges,82.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.2026,164.4877
Tap Block Unilateral by Injection(S),PX64486P,CDM,983,RC,64486,CPT,,,,,,,,169,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,82.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.2026,164.4877
Tap Block Unilateral by Injection(S),PX64486P,CDM,983,RC,64486,CPT,,,,,,,,169,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,82.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.2026,164.4877
lidocaine urethral/mucosal 2 % Gel 30 mL Tube,25000000,CDM,250,RC,,,,,,17478084030,NDC,30,ML,93.91,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,82.82862,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium zirconium cyclosilicate 10 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,310111001,NDC,1,EA,172.56,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,82.8288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium zirconium cyclosilicate 10 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,310111001,NDC,1,EA,172.56,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,82.8288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CARTER THOMASON CLOSURE 5MM,27200000,CDM,272,RC,,,,10278-MAIN,LOCAL,,,,,97.45,,First Health,Commercial,both,85,,999999999,percent of total billed charges,82.8325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CT Soft Tissue Neck W/Dye,PX7049101,CDM,350,RC,70491,CPT,TC,,,,,,,3415,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,82.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.9,245.21
CT Soft Tissue Neck W/Dye,PX7049101,CDM,350,RC,70491,CPT,TC,,,,,,,3415,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,82.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.9,245.21
Coccidioides Antibody - Ref,PX8663590,CDM,300,RC,86635,CPT,90,,,,,,,94,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,82.908,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.52,92.12
Copper - Ref,PX8252590,CDM,300,RC,82525,CPT,90,,,,,,,94,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,82.908,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.38,92.12
DEFIBRILLATION PAD MULTI FUNCTION ADULT,120.58,CDM,271,RC,A0392,HCPCS,,1320-MAIN,LOCAL,,,,,94,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,82.908,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
DEFIBRILLATION PAD PEDI PADZ PEDS,120.58,CDM,271,RC,A0392,HCPCS,,1322-MAIN,LOCAL,,,,,94,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,82.908,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
DRESSING NASAL 4.5CM NON-INFLATABLE RAPID RHINO RR450,120.97,CDM,272,RC,A6407,HCPCS,,616-MAIN,LOCAL,,,,,94,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,82.908,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
DRESSING NASAL 5.5CM INFLATABLE RAPID RHINO RR550,120.97,CDM,272,RC,A6407,HCPCS,,606-MAIN,LOCAL,,,,,94,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,82.908,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
DRESSING NASAL 7.5CM INFLATABLE RAPID RHINO RR750,120.97,CDM,272,RC,A6407,HCPCS,,611-MAIN,LOCAL,,,,,94,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,82.908,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
DRESSING NASAL 8CM LONGX1.5CM THICK X3CM HIGH ANATOMICAL 34-105,120.97,CDM,272,RC,A6407,HCPCS,,613-MAIN,LOCAL,,,,,94,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,82.908,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
Tissue Exam for Fungi,PX87220,CDM,300,RC,87220,CPT,,,,,,,,94,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,82.908,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,92.12
TUBING IRRIGATION F SET STERILE MXB-T,27200000,CDM,272,RC,,,,11693-MAIN,LOCAL,,,,,94,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,82.908,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Office/Outpt Visit,New,Levl IV",PX99204F,CDM,510,RC,99204,CPT,,,,,,,,359,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,82.93,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.93,300.2
"Office/Outpt Visit,New,Levl IV",PX99204P,CDM,983,RC,99204,CPT,,,,,,,,359,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,82.93,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.93,351.82
Tx/Pro/Dx Inj Same Drug Adon,PX96376,CDM,260,RC,96376,CPT,,,,,,,,164,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,82.984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.1256,160.72
clotrimazole-betamethasone 1-0.05 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,51672404801,NDC,15,GR,172.95,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,83.016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
clotrimazole-betamethasone 1-0.05 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,51672404801,NDC,15,GR,172.95,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,83.016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Debride Skin/Subq Ea Ad 20sqcm,PX11045F,CDM,510,RC,11045,CPT,,,,,,,,115,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,83.02,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.05,83.02
Debride Skin/Subq Ea Ad 20sqcm,PX11045P,CDM,983,RC,11045,CPT,,,,,,,,182,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,83.02,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.05,178.36
CT Abdomen W/O Dye,PX7415001,CDM,350,RC,74150,CPT,TC,,,,,,,2757,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,83.0244,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.28,166.32
RBC Antibody Screen,PX86850,CDM,300,RC,86850,CPT,,,,,,,,173,,Health Partners,Health Partners Care Plans,both,48,,84.35,percent of total billed charges,83.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,169.54
RBC Antibody Screen,PX86850,CDM,300,RC,86850,CPT,,,,,,,,173,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,83.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,169.54
"Thyroxin, Free (Free T4)",PX84439,CDM,300,RC,84439,CPT,,,,,,,,173,,Health Partners,Health Partners Care Plans,both,48,,80.21,percent of total billed charges,83.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.27,169.54
"Thyroxin, Free (Free T4)",PX84439,CDM,300,RC,84439,CPT,,,,,,,,173,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,83.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.27,169.54
protamine 10 MG/ML Solution 5 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022994,NDC,5,ML,84.74,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,83.0452,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.431298,83.0452
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,39328006712,NDC,473,ML,167.77,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,83.04615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DERMABOND PRINEO SKIN CLOSURE SYSTEM 42CM,27200000,CDM,272,RC,,,,12323-MAIN,LOCAL,,,,,200,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,83.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
gadoxetate disodium 0.25 MOL/L Solution 10 mL Vial,A9581,CDM,636,RC,A9581,HCPCS,,,,50419032005,NDC,10,ML,200,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,83.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,196
iohexol 300 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141363,NDC,100,ML,200,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,83.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,294
iohexol 350 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141491,NDC,100,ML,200,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,83.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,294
Lacosamide - Ref,PX8023590,CDM,300,RC,80235,CPT,90,,,,,,,200,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,83.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.86,196
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059611,NDC,0.25,EA,200.05,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,83.10077,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.10077,725.3862
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059613,NDC,0.25,EA,200.05,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,83.10077,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.10077,725.3862
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,781309894,NDC,1,EA,193.75,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,83.11875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.461584,189.875
Aerobic Isolate - Ref,PX8707790,CDM,300,RC,87077,CPT,90,,,,,,,168,,Humana Choice Care,All Medicare plans,outpatient,49.5,,73.36142857,percent of total billed charges,83.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,164.64
Complete Cbc W/Auto Diff Wbc,PX85025,CDM,300,RC,85025,CPT,,,,,,,,168,,Humana Choice Care,All Medicare plans,outpatient,49.5,,62.44965517,percent of total billed charges,83.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.12,164.64
Insert Straight Catheter,PX51701F,CDM,510,RC,51701,CPT,,,,,,,,168,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,83.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.7872,164.64
Org ID Aerobic-Each,PX87077,CDM,300,RC,87077,CPT,,,,,,,,168,,Humana Choice Care,All Medicare plans,outpatient,49.5,,73.36142857,percent of total billed charges,83.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,164.64
riTUXimab 100 MG/10ML Solution 10 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005121,NDC,10,ML,1916.61,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,83.16,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.69,83.16
riTUXimab 500 MG/50ML Solution 50 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005306,NDC,50,ML,8860.06,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,83.16,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.69,83.16
etoposide 500 MG/25ML Solution 25 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,703565601,NDC,25,ML,173.28,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,83.1744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.949434,169.8144
etoposide 500 MG/25ML Solution 25 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,703565601,NDC,25,ML,173.28,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,83.1744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.949434,169.8144
oseltamivir 75 MG capsule 10 Each Disp Pack,63700001,CDM,250,RC,,,,,,4080085,NDC,1,EA,97.87,,First Health,Commercial,both,85,,999999999,percent of total billed charges,83.1895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Cmv, Quant - Ref",PX8749790,CDM,300,RC,87497,CPT,90,,,,,,,194,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,83.226,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.28,190.12
Hiv-1 Antigens W/Hiv 1/2 Antib,PX87389,CDM,300,RC,87389,CPT,,,,,,,,194,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,83.226,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.08,190.12
Lyme Disease Antibody,PX86618,CDM,300,RC,86618,CPT,,,,,,,,194,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,83.226,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.61,190.12
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010365,NDC,100,ML,164.54,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,83.25724,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.174958,180.2416
ceFAZolin in D4W 1 g / 50 mL 1-4 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0690.01,CDM,636,RC,J0690,HCPCS,,,,264310311,NDC,1,EA,84.97,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,83.2706,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
Asay of Interleukin-6 (Il-6),PX8352990,CDM,300,RC,83529,CPT,90,,,,,,,170,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,83.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,166.6
Asay of Interleukin-6 (Il-6),PX8352990,CDM,300,RC,83529,CPT,90,,,,,,,170,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,83.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,166.6
Asay of Interleukin-6 (Il-6),PX8352990,CDM,300,RC,83529,CPT,90,,,,,,,170,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,83.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,166.6
BLADE LARYNGOSCOPE MAC #3 SINGLE USE350-005-000,120.121,CDM,272,RC,,,,8320-MAIN,LOCAL,,,,,98,,First Health,Commercial,both,85,,999999999,percent of total billed charges,83.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
BLADE LARYNGOSCOPE MAC #4 SINGLE USE 350-012-000,120.121,CDM,272,RC,,,,8321-MAIN,LOCAL,,,,,98,,First Health,Commercial,both,85,,999999999,percent of total billed charges,83.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
BLADE LARYNGOSCOPE MAC #X3 SINGLE USE X3-003-000,120.121,CDM,272,RC,,,,8322-MAIN,LOCAL,,,,,98,,First Health,Commercial,both,85,,999999999,percent of total billed charges,83.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
CANNULA JUNIOR 2 LARGE OPTIFLOW OJR416VT,120.561,CDM,272,RC,A4615,HCPCS,,12645-MAIN,LOCAL,,,,,98,,First Health,Commercial,both,85,,999999999,percent of total billed charges,83.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
CANNULA JUNIOR 2 MEDIUM OPTIFLOW OJR414VT,120.561,CDM,272,RC,A4615,HCPCS,,12644-MAIN,LOCAL,,,,,98,,First Health,Commercial,both,85,,999999999,percent of total billed charges,83.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
CANNULA OPTIFLOW JUNIOR 2 SMALL OJR412VT,120.561,CDM,272,RC,A4615,HCPCS,,12643-MAIN,LOCAL,,,,,98,,First Health,Commercial,both,85,,999999999,percent of total billed charges,83.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
Chem Cautery Granulatn Tissue,PX17250F,CDM,510,RC,17250,CPT,,,,,,,,170,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,83.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,174.9
Chem Cautery Granulatn Tissue,PX17250F,CDM,510,RC,17250,CPT,,,,,,,,170,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,83.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,174.9
Chem Cautery Granulatn Tissue,PX17250F,CDM,510,RC,17250,CPT,,,,,,,,170,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,83.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,174.9
"Chemotherapy Administration, Subq/Im Non-Hormonal Anti-Neoplastic",PX96401,CDM,335,RC,96401,CPT,,,,,,,,170,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,34,percent of total billed charges,83.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,166.6
"Chemotherapy Administration, Subq/Im Non-Hormonal Anti-Neoplastic",PX96401,CDM,335,RC,96401,CPT,,,,,,,,170,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,83.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,166.6
"Chemotherapy Administration, Subq/Im Non-Hormonal Anti-Neoplastic",PX96401,CDM,335,RC,96401,CPT,,,,,,,,170,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,83.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,166.6
"Cognitive Funct Ther Interv, Initial 15 Min",PX97129,CDM,420,RC,97129,CPT,,,,,,,,85,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,83.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15,83.3
Collagen Cross Links - Ref,PX8252390,CDM,300,RC,82523,CPT,90,,,,,,,170,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,83.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.13,166.6
Collagen Cross Links - Ref,PX8252390,CDM,300,RC,82523,CPT,90,,,,,,,170,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,83.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.13,166.6
Collagen Cross Links - Ref,PX8252390,CDM,300,RC,82523,CPT,90,,,,,,,170,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,83.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.13,166.6
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800P,CDM,983,RC,40800,CPT,,,,,,,,170,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,83.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,614.65
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800P,CDM,983,RC,40800,CPT,,,,,,,,170,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,83.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,614.65
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800P,CDM,983,RC,40800,CPT,,,,,,,,170,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,83.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,614.65
"Exam,Synovial Fluid Crystals",PX89060,CDM,300,RC,89060,CPT,,,,,,,,85,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,83.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.72,83.3
gadoteridol 279.3 MG/ML Solution 17 mL Syringe,A9576,CDM,636,RC,A9576,HCPCS,,,,270111145,NDC,17,ML,170,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,83.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.54,166.6
gadoteridol 279.3 MG/ML Solution 17 mL Syringe,A9576,CDM,636,RC,A9576,HCPCS,,,,270111145,NDC,17,ML,170,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,83.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.54,166.6
gadoteridol 279.3 MG/ML Solution 17 mL Syringe,A9576,CDM,636,RC,A9576,HCPCS,,,,270111145,NDC,17,ML,170,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,83.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.54,166.6
GLIDESCOPE QC MAC S3 SINGLE USE 0270-1083,120.579,CDM,272,RC,,,,13046-MAIN,LOCAL,,,,,85,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,83.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.309,83.3
GLIDESCOPE QC MAC S3 SINGLE USE 0270-1085,120.579,CDM,272,RC,,,,13022-MAIN,LOCAL,,,,,85,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,83.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.309,83.3
GLIDESCOPE QC MAC S4 SINGLE USE 0270-1086,120.579,CDM,272,RC,,,,13023-MAIN,LOCAL,,,,,85,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,83.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.309,83.3
Hepatitis B Surface Antigen,PX87340,CDM,300,RC,87340,CPT,,,,,,,,98,,First Health,Commercial,both,85,,999999999,percent of total billed charges,83.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.47,96.04
"Inject Nerv Blck,Trigeminal",PX64400P,CDM,983,RC,64400,CPT,,,,,,,,170,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,83.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,258.75
"Inject Nerv Blck,Trigeminal",PX64400P,CDM,983,RC,64400,CPT,,,,,,,,170,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,83.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,258.75
"Inject Nerv Blck,Trigeminal",PX64400P,CDM,983,RC,64400,CPT,,,,,,,,170,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,83.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,258.75
Ot Contracted Service/MCR,PX120.177,CDM,431,RC,,,,,,,,,,98,,First Health,Commercial,both,85,,999999999,percent of total billed charges,83.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
"Protein, Total; Serum, Plasma or Whole Blood",PX84155,CDM,300,RC,84155,CPT,,,,,,,,170,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,83.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.37,166.6
"Protein, Total; Serum, Plasma or Whole Blood",PX84155,CDM,300,RC,84155,CPT,,,,,,,,170,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,83.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.37,166.6
"Protein, Total; Serum, Plasma or Whole Blood",PX84155,CDM,300,RC,84155,CPT,,,,,,,,170,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,83.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.37,166.6
Pt Contracted Services/MCR,PX120.175,CDM,421,RC,,,,,,,,,,98,,First Health,Commercial,both,85,,999999999,percent of total billed charges,83.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
bicalutamide 50 MG Tablet 30 Each Bottle,25000000,CDM,250,RC,,,,,,16714081601,NDC,1,EA,98.01,,First Health,Commercial,both,85,,999999999,percent of total billed charges,83.3085,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium bicarbonate 8.4 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409662522,NDC,50,ML,85.02,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,83.3196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium bicarbonate 4.2 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409553434,NDC,10,ML,91.46,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,83.32006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ON Q PAIN BUSTER,27100000,CDM,271,RC,A4305,HCPCS,,6751-MAIN,LOCAL,,,,,194.26,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,83.33754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,61314062810,NDC,10,ML,98.07,,First Health,Commercial,both,85,,999999999,percent of total billed charges,83.3595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Box,25000000,CDM,250,RC,,,,,,67434509,NDC,1,EA,98.1,,First Health,Commercial,both,85,,999999999,percent of total billed charges,83.385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,59148000713,NDC,1,EA,170.19,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,83.3931,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,59148000713,NDC,1,EA,170.19,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,83.3931,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,59148000713,NDC,1,EA,170.19,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,83.3931,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
imipenem-cilastatin 250 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323034925,NDC,1,EA,91.55,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,83.40205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,173.1856
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032294,NDC,1,EA,91.55,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,83.40205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,173.1856
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234001,NDC,1.25,ML,91.55,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,83.40205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
cyclopentolate 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,61314039601,NDC,2,ML,94.58,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,83.41956,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Hiv-1, Quantification - Ref",PX8753690,CDM,300,RC,87536,CPT,90,,,,,,,220,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,83.434,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.27,85.1
BRACE ANKLE LARGE 264015,120.51,CDM,274,RC,L1902,HCPCS,,4-MAIN,LOCAL,,,,,115,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,83.44,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.44,87.83
BRACE ANKLE MEDIUM 264014,120.51,CDM,274,RC,L1902,HCPCS,,7-MAIN,LOCAL,,,,,115,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,83.44,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.44,87.83
BRACE ANKLE SMALL 264012,120.51,CDM,274,RC,L1902,HCPCS,,12-MAIN,LOCAL,,,,,115,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,83.44,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.44,87.83
BRACE ANKLE X-LARGE 264016,120.51,CDM,274,RC,L1902,HCPCS,,14-MAIN,LOCAL,,,,,115,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,83.44,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.44,87.83
BRACE ANKLE X-SMALL 264011,120.51,CDM,274,RC,L1902,HCPCS,,1-MAIN,LOCAL,,,,,115,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,83.44,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.44,87.83
Dihydroxyvitamin D - Ref,PX8265290,CDM,300,RC,82652,CPT,90,,,,,,,165,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,83.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.3,161.7
Flow Cyto Ea Addtl Marker - Ref,PX8818590,CDM,310,RC,88185,CPT,90,,,,,,,165,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,83.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.541,161.7
Strapping of Shoulder,PX29240F,CDM,420,RC,29240,CPT,,,,,,,,165,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,83.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.541,161.7
"Hepatitis a Antibody, Tot - Ref",PX8670890,CDM,300,RC,86708,CPT,90,,,,,,,201,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,83.4954,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.36,196.98
Hepatitis B Surface Antibody,PX86706,CDM,300,RC,86706,CPT,,,,,,,,201,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,83.4954,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,196.98
KIT 3-LUMEN 7FR X 16CM CENTRALVENOUS CDC-42703-P1A,120.37,CDM,272,RC,C1751,HCPCS,,10707-MAIN,LOCAL,,,,,201,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,83.4954,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.4954,196.98
ketoconazole 2 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,168009915,NDC,15,GR,173.97,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,83.5056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ketoconazole 2 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,168009915,NDC,15,GR,173.97,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,83.5056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040304,NDC,10,ML,168.77,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,83.54115,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040310,NDC,10,ML,168.77,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,83.54115,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
CT Soft Tissue Neck W/Dye,PX7049101,CDM,350,RC,70491,CPT,TC,,,,,,,3415,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,83.55,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.9,245.21
"Remv Foot Foreign Body,Subcutaneous",PX28190F,CDM,510,RC,28190,CPT,,,,,,,,1025,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,83.55,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.55,499.48
"Remv Foot Foreign Body,Subcutaneous",PX28190P,CDM,983,RC,28190,CPT,,,,,,,,683,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,83.55,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.55,669.34
lidocaine urethral/mucosal 2 % Gel 30 mL Tube,25000000,CDM,250,RC,,,,,,17478084030,NDC,30,ML,93.91,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,83.5799,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Fac/Initial Hospital Care Levl II,PX99222F,CDM,510,RC,99222,CPT,,,,,,,,187,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,83.59,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.18,232.02
Fac/Initial Hospital Care Levl II,PX99222F,CDM,510,RC,99222,CPT,,,,,,,,187,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,83.59,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.18,232.02
Initial Hospital Care Levl II,PX99222P,CDM,982,RC,99222,CPT,,,,,,,,187,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,83.59,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.18,232.02
Initial Hospital Care Levl II,PX99222P,CDM,982,RC,99222,CPT,,,,,,,,187,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,83.59,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.18,232.02
Lvl 2 Init Hosp Mod Mdm or 55 Minutes,PX99222,CDM,982,RC,99222,CPT,,,,,,,,508,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,83.59,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.18,497.84
Lvl 2 Init Hosp Mod Mdm or 55 Minutes,PX99222,CDM,982,RC,99222,CPT,,,,,,,,508,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,83.59,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.18,497.84
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,67815203,NDC,100,GR,91.77,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,83.60247,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Blood Clot Factor VIII Test,PX85247,CDM,300,RC,85247,CPT,,,,,,,,169,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,83.655,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.03,165.62
Tap Block Unilateral by Injection(S),PX64486P,CDM,983,RC,64486,CPT,,,,,,,,169,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,83.655,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.2026,164.4877
Topiramate - Ref,PX8020190,CDM,300,RC,80201,CPT,90,,,,,,,195,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,83.655,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.93,191.1
Coccidioides Antibody - Ref,PX8663590,CDM,300,RC,86635,CPT,90,,,,,,,94,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,83.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.52,92.12
Copper - Ref,PX8252590,CDM,300,RC,82525,CPT,90,,,,,,,94,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,83.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.38,92.12
DEFIBRILLATION PAD MULTI FUNCTION ADULT,120.58,CDM,271,RC,A0392,HCPCS,,1320-MAIN,LOCAL,,,,,94,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,83.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
DEFIBRILLATION PAD PEDI PADZ PEDS,120.58,CDM,271,RC,A0392,HCPCS,,1322-MAIN,LOCAL,,,,,94,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,83.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
DRESSING NASAL 4.5CM NON-INFLATABLE RAPID RHINO RR450,120.97,CDM,272,RC,A6407,HCPCS,,616-MAIN,LOCAL,,,,,94,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,83.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
DRESSING NASAL 5.5CM INFLATABLE RAPID RHINO RR550,120.97,CDM,272,RC,A6407,HCPCS,,606-MAIN,LOCAL,,,,,94,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,83.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
DRESSING NASAL 7.5CM INFLATABLE RAPID RHINO RR750,120.97,CDM,272,RC,A6407,HCPCS,,611-MAIN,LOCAL,,,,,94,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,83.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
DRESSING NASAL 8CM LONGX1.5CM THICK X3CM HIGH ANATOMICAL 34-105,120.97,CDM,272,RC,A6407,HCPCS,,613-MAIN,LOCAL,,,,,94,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,83.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
Tissue Exam for Fungi,PX87220,CDM,300,RC,87220,CPT,,,,,,,,94,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,83.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,92.12
TUBING IRRIGATION F SET STERILE MXB-T,27200000,CDM,272,RC,,,,11693-MAIN,LOCAL,,,,,94,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,83.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061401,NDC,1,ML,94.87,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,83.67534,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.114178,99.911
Aldosterone - Ref,PX8208890,CDM,300,RC,82088,CPT,90,,,,,,,86,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,83.7038,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.7244,84.28
Epstein-barr antibody,PX86665,CDM,300,RC,86665,CPT,,,,,,,,86,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,83.7038,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.63,84.28
levonorgestrel 1.5 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,68180085211,NDC,1,EA,174.39,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,83.7072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levonorgestrel 1.5 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,68180085211,NDC,1,EA,174.39,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,83.7072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atropine (PF) 1 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517101025,NDC,1,ML,91.89,,Medica,Commercial,both,91.1,,1.63075,percent of total billed charges,83.71179,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
SAWBLADE SAGITAL STERILE 25MM LENGTH 5.5MM WIDTH 0.60MM THICKNESS,27200000,CDM,272,RC,,,,11623-MAIN,LOCAL,,,,,86.02,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,83.723266,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
rivaroxaban 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50458058030,NDC,1,EA,98.57,,First Health,Commercial,both,85,,999999999,percent of total billed charges,83.7845,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"CCP, Antibody - Ref",PX8620090,CDM,300,RC,86200,CPT,90,,,,,,,171,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,83.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,167.58
"CCP, Antibody - Ref",PX8620090,CDM,300,RC,86200,CPT,90,,,,,,,171,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,83.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,167.58
"CCP, Antibody - Ref",PX8620090,CDM,300,RC,86200,CPT,90,,,,,,,171,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,83.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,167.58
Hepatic Function Panel,PX80076,CDM,300,RC,80076,CPT,,,,,,,,171,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,72.65142857,percent of total billed charges,83.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.49,167.58
Hepatic Function Panel,PX80076,CDM,300,RC,80076,CPT,,,,,,,,171,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,83.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.49,167.58
Hepatic Function Panel,PX80076,CDM,300,RC,80076,CPT,,,,,,,,171,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,83.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.49,167.58
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105F,CDM,510,RC,11105,CPT,,,,,,,,171,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,83.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.0334,167.58
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105F,CDM,510,RC,11105,CPT,,,,,,,,171,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,83.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.0334,167.58
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105F,CDM,510,RC,11105,CPT,,,,,,,,171,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,83.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.0334,167.58
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105P,CDM,983,RC,11105,CPT,,,,,,,,171,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,83.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.0334,166.4343
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105P,CDM,983,RC,11105,CPT,,,,,,,,171,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,83.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.0334,166.4343
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105P,CDM,983,RC,11105,CPT,,,,,,,,171,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,83.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.0334,166.4343
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102F,CDM,510,RC,11102,CPT,,,,,,,,171,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,83.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.0334,174.9
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102F,CDM,510,RC,11102,CPT,,,,,,,,171,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,83.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.0334,174.9
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102F,CDM,510,RC,11102,CPT,,,,,,,,171,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,83.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.0334,174.9
Assay Blood Carbon Dioxide,PX82374,CDM,300,RC,82374,CPT,,,,,,,,95,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,83.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.47,93.1
Blood Viscosity Examination,PX85810,CDM,300,RC,85810,CPT,,,,,,,,95,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,83.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.7,93.1
Cyclosporine - Ref,PX8015890,CDM,300,RC,80158,CPT,90,,,,,,,95,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,83.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.55,93.1
"Fac/Debridement of Nails, 6 or Mor",PX11721F,CDM,510,RC,11721,CPT,,,,,,,,95,,United Healthcare,All Payer,outpatient,88.2,,46.722,percent of total billed charges,83.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.463,93.1
"Fat/Lipids, Feces, Quant - Ref",PX8271090,CDM,300,RC,82710,CPT,90,,,,,,,95,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,83.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.4,93.1
KIT EPIDURAL 19GA FLEXTIP PLUS AK-05502,120.305,CDM,272,RC,,,,11413-MAIN,LOCAL,,,,,95,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,83.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.463,93.1
"Lyme Disease, Confirm Tst - Ref",PX8661790,CDM,300,RC,86617,CPT,90,,,,,,,95,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,83.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.2,93.1
"Organism ID, Anaerobic - Ref",PX8707690,CDM,300,RC,87076,CPT,90,,,,,,,95,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,83.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,93.1
Strep a Assay W/Optic,PX87880,CDM,300,RC,87880,CPT,,,,,,,,95,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,83.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.16,93.1
"Thyroxine, Total - Ref",PX8443690,CDM,300,RC,84436,CPT,90,,,,,,,95,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,83.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.3,93.1
TRAY FACIAL LACERATION PACK STERILE 96-1707,120.12,CDM,272,RC,,,,406-MAIN,LOCAL,,,,,95,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,83.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.463,93.1
Varicella-Zoster Antibody,PX86787,CDM,300,RC,86787,CPT,,,,,,,,95,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,83.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.81,93.1
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569F,CDM,510,RC,36569,CPT,,,,,,,,1217,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,83.8071,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.28,193.01
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569P,CDM,983,RC,36569,CPT,,,,,,,,1825,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,83.8071,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.28,1788.5
Blood Typing Abo,PX86900,CDM,300,RC,86900,CPT,,,,,,,,92,,Medica,Commercial,both,91.1,,16.684,percent of total billed charges,83.812,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.2168,111.6
Blood Typing Rh (D),PX86901,CDM,300,RC,86901,CPT,,,,,,,,92,,Medica,Commercial,both,91.1,,16.684,percent of total billed charges,83.812,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.03,90.16
Parvovirus Antibody - Ref,PX8674790,CDM,300,RC,86747,CPT,90,,,,,,,92,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,83.812,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.78,90.16
"Reticulocyte Count,Flow Cyto",PX85045,CDM,300,RC,85045,CPT,,,,,,,,92,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,83.812,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.66,90.16
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409339004,NDC,1,EA,98.61,,First Health,Commercial,both,85,,999999999,percent of total billed charges,83.8185,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036019,NDC,10,ML,86.23,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.161,percent of total billed charges,83.927659,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,84.5054
CT Pelvis W/O Dye,PX7219201,CDM,350,RC,72192,CPT,TC,,,,,,,2744,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,83.9898,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.94,168.29
"Breast Tomosynthesis,Dx Tc Bilat",PX7706201,CDM,401,RC,77062,CPT,TC,,,,,,,166,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,83.996,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.9564,162.68
"Breast Tomosynthesis,Dx Tc Unilat",PX7706101,CDM,401,RC,77061,CPT,TC,,,,,,,166,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,83.996,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.9564,162.68
"Breast Tomosynthesis,Screen Tc",PX7706301,CDM,403,RC,77063,CPT,TC,,,,,,,166,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,83.996,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.59,280.5
Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq,PX87635,CDM,300,RC,87635,CPT,,,,,,,,166,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,83.996,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,224.4
Electrolyte Panel,PX80051,CDM,300,RC,80051,CPT,,,,,,,,175,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.43,171.5
Electrolyte Panel,PX80051,CDM,300,RC,80051,CPT,,,,,,,,175,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.43,171.5
"Fac/Trm Hyperkeratotic Skn Lesn,>4",PX11057F,CDM,510,RC,11057,CPT,,,,,,,,175,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.695,174.9
"Fac/Trm Hyperkeratotic Skn Lesn,>4",PX11057F,CDM,510,RC,11057,CPT,,,,,,,,175,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.695,174.9
"Gonadotropin, Chorionic (Hcg), Qualitative",PX84703,CDM,300,RC,84703,CPT,,,,,,,,175,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.9,171.5
"Gonadotropin, Chorionic (Hcg), Qualitative",PX84703,CDM,300,RC,84703,CPT,,,,,,,,175,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.9,171.5
Protein E-Phoresis Serum,PX84165,CDM,300,RC,84165,CPT,,,,,,,,175,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,171.5
Protein E-Phoresis Serum,PX84165,CDM,300,RC,84165,CPT,,,,,,,,175,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,171.5
Protein Elp Interp,PX8416526,CDM,300,RC,84165,CPT,26,,,,,,,175,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,171.5
Protein Elp Interp,PX8416526,CDM,300,RC,84165,CPT,26,,,,,,,175,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,171.5
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,990771502,NDC,250,ML,166.02,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,84.00612,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.4701,303.0944
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,50383058766,NDC,60,ML,95.26,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,84.01932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,60432053760,NDC,60,ML,95.26,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,84.01932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Jak2 Gene - Ref,PX8127090,CDM,300,RC,81270,CPT,90,,,,,,,734,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,84.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.04,719.32
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089901,NDC,0.25,ML,95.31,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,84.06342,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.79,93.4038
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089910,NDC,0.25,ML,95.31,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,84.06342,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.79,93.4038
ondansetron 4 MG/5ML Solution 50 mL Bottle,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714067102,NDC,5,ML,98.91,,First Health,Commercial,both,85,,999999999,percent of total billed charges,84.0735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
"Apply Finger Splint,Static",PX29130F,CDM,420,RC,29130,CPT,,,,,,,,196,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,84.084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.4184,192.08
Heterophile Antibodies,PX86308,CDM,300,RC,86308,CPT,,,,,,,,196,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,84.084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,192.08
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084243,NDC,0.5,ML,202.42,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,84.085268,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.085268,203.497
leucovorin 350 MG Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,703514501,NDC,1,EA,86.41,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,84.102853,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.670002,84.6818
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,23155029031,NDC,2,ML,98.99,,First Health,Commercial,both,85,,999999999,percent of total billed charges,84.1415,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,97.0102
"Clostridium Ag, Eia",PX87324,CDM,300,RC,87324,CPT,,,,,,,,99,,First Health,Commercial,both,85,,999999999,percent of total billed charges,84.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,97.02
Deoxyribonuclease Ab,PX86215,CDM,300,RC,86215,CPT,,,,,,,,99,,First Health,Commercial,both,85,,999999999,percent of total billed charges,84.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,97.02
"Extractable Nuclear Antigen, Each Antigen",PX86235,CDM,300,RC,86235,CPT,90,,,,,,,99,,First Health,Commercial,both,85,,999999999,percent of total billed charges,84.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.44,97.02
"Fungus Antibody, Nos - Ref",PX8667190,CDM,300,RC,86671,CPT,90,,,,,,,99,,First Health,Commercial,both,85,,999999999,percent of total billed charges,84.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.23,97.02
"Lab Immunoassay, Non Antibody",PX83516,CDM,300,RC,83516,CPT,,,,,,,,99,,First Health,Commercial,both,85,,999999999,percent of total billed charges,84.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.57,97.02
"Protozoa Antibody, Nos - Ref",PX8675390,CDM,300,RC,86753,CPT,90,,,,,,,99,,First Health,Commercial,both,85,,999999999,percent of total billed charges,84.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.36,97.02
Asay of Interleukin-6 (Il-6),PX8352990,CDM,300,RC,83529,CPT,90,,,,,,,170,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,84.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,166.6
Chem Cautery Granulatn Tissue,PX17250F,CDM,510,RC,17250,CPT,,,,,,,,170,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,84.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,174.9
"Chemotherapy Administration, Subq/Im Non-Hormonal Anti-Neoplastic",PX96401,CDM,335,RC,96401,CPT,,,,,,,,170,,Humana Choice Care,All Medicare plans,outpatient,49.5,,39.31,percent of total billed charges,84.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,166.6
Collagen Cross Links - Ref,PX8252390,CDM,300,RC,82523,CPT,90,,,,,,,170,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,84.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.13,166.6
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800P,CDM,983,RC,40800,CPT,,,,,,,,170,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,84.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,614.65
gadoteridol 279.3 MG/ML Solution 17 mL Syringe,A9576,CDM,636,RC,A9576,HCPCS,,,,270111145,NDC,17,ML,170,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,84.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.54,166.6
"Inject Nerv Blck,Trigeminal",PX64400P,CDM,983,RC,64400,CPT,,,,,,,,170,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,84.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,258.75
"Protein, Total; Serum, Plasma or Whole Blood",PX84155,CDM,300,RC,84155,CPT,,,,,,,,170,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,84.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.37,166.6
sildenafil citrate 20 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,65162035109,NDC,1,EA,95.41,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,84.15162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclopentolate 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,61314039601,NDC,2,ML,94.58,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,84.1762,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052084,NDC,1,EA,92.46,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,84.23106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.407884,90.9538
azithromycin 200 MG/5ML Recon Susp 15 mL Bottle,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,59762312001,NDC,15,ML,196.35,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,84.23415,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
ROTH NET PLATINUM RETRIEVER,27200000,CDM,272,RC,,,,7518-MAIN,LOCAL,,,,,196.35,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,84.23415,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
empagliflozin 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,597015230,NDC,1,EA,92.47,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,84.24017,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,59148000713,NDC,1,EA,170.19,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,84.24405,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"dextrose 5 % 5 % Solution 1,000 mL Flex Cont",J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001704,NDC,1000,ML,99.12,,First Health,Commercial,both,85,,999999999,percent of total billed charges,84.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001702,NDC,250,ML,99.12,,First Health,Commercial,both,85,,999999999,percent of total billed charges,84.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338634602,NDC,250,ML,99.12,,First Health,Commercial,both,85,,999999999,percent of total billed charges,84.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 500 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001703,NDC,500,ML,99.12,,First Health,Commercial,both,85,,999999999,percent of total billed charges,84.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % Non-DEHP bag 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,264751020,NDC,250,ML,99.12,,First Health,Commercial,both,85,,999999999,percent of total billed charges,84.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"dextrose 5% and sodium chloride 0.2% 5-0.2 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338007704,NDC,1000,ML,99.12,,First Health,Commercial,both,85,,999999999,percent of total billed charges,84.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
"dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008904,NDC,1000,ML,99.12,,First Health,Commercial,both,85,,999999999,percent of total billed charges,84.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 500 mL Flex Cont,J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008903,NDC,500,ML,99.12,,First Health,Commercial,both,85,,999999999,percent of total billed charges,84.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
"dextrose 5% and sodium chloride 0.45% 5-0.45 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008504,NDC,1000,ML,99.12,,First Health,Commercial,both,85,,999999999,percent of total billed charges,84.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
dextrose 5% lactated ringers 5 % Solution 500 mL Flex Cont,J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012503,NDC,500,ML,99.12,,First Health,Commercial,both,85,,999999999,percent of total billed charges,84.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 10% 10 % Solution 500 mL Flex Cont,25000000,CDM,250,RC,,,,,,338002303,NDC,500,ML,99.12,,First Health,Commercial,both,85,,999999999,percent of total billed charges,84.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lactated ringers Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338011704,NDC,1000,ML,99.12,,First Health,Commercial,both,85,,999999999,percent of total billed charges,84.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338069104,NDC,1000,ML,99.12,,First Health,Commercial,both,85,,999999999,percent of total billed charges,84.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004904,NDC,1000,ML,99.12,,First Health,Commercial,both,85,,999999999,percent of total billed charges,84.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954306,NDC,1000,ML,99.12,,First Health,Commercial,both,85,,999999999,percent of total billed charges,84.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004902,NDC,250,ML,99.12,,First Health,Commercial,both,85,,999999999,percent of total billed charges,84.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954302,NDC,250,ML,99.12,,First Health,Commercial,both,85,,999999999,percent of total billed charges,84.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 500 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004903,NDC,500,ML,99.12,,First Health,Commercial,both,85,,999999999,percent of total billed charges,84.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9% 0.9% Solution 1,000 mL Flex Cont",J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004904,NDC,1000,ML,99.12,,First Health,Commercial,both,85,,999999999,percent of total billed charges,84.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9% IV LINE FLUSH 0.9% Solution 250 mL Flex Cont,25000000,CDM,250,RC,,,,,,338004902,NDC,250,ML,99.12,,First Health,Commercial,both,85,,999999999,percent of total billed charges,84.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"sodium chloride 0.45 % 0.45 % Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,338004304,NDC,1000,ML,99.12,,First Health,Commercial,both,85,,999999999,percent of total billed charges,84.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 3 % 3 % Solution 500 mL Flex Cont,J7131.01,CDM,636,RC,J7131,HCPCS,,,,338005403,NDC,500,ML,99.12,,First Health,Commercial,both,85,,999999999,percent of total billed charges,84.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
AIRSEAL 12MM ACCESS PORT AND PALM GRIP OBTURATOR BLADELESS OPTICAL TIP 120MM,27200000,CDM,272,RC,,,,12207-MAIN,LOCAL,,,,,172,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,84.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
AIRSEAL 12MM ACCESS PORT AND PALM GRIP OBTURATOR BLADELESS OPTICAL TIP 120MM,27200000,CDM,272,RC,,,,12207-MAIN,LOCAL,,,,,172,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,84.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
AIRSEAL 12MM ACCESS PORT AND PALM GRIP OBTURATOR BLADELESS OPTICAL TIP 120MM,27200000,CDM,272,RC,,,,12207-MAIN,LOCAL,,,,,172,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,84.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
AIRSEAL TUBE SET TRI LUMEN FILTERED WITH ACTIVATED CHARCOAL,27200000,CDM,272,RC,,,,12206-MAIN,LOCAL,,,,,172,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,84.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
AIRSEAL TUBE SET TRI LUMEN FILTERED WITH ACTIVATED CHARCOAL,27200000,CDM,272,RC,,,,12206-MAIN,LOCAL,,,,,172,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,84.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
AIRSEAL TUBE SET TRI LUMEN FILTERED WITH ACTIVATED CHARCOAL,27200000,CDM,272,RC,,,,12206-MAIN,LOCAL,,,,,172,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,84.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Aldosterone - Ref,PX8208890,CDM,300,RC,82088,CPT,90,,,,,,,86,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,84.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.7244,84.28
Epstein-barr antibody,PX86665,CDM,300,RC,86665,CPT,,,,,,,,86,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,84.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.63,84.28
SAWBLADE SAGITAL STERILE 25MM LENGTH 5.5MM WIDTH 0.60MM THICKNESS,27200000,CDM,272,RC,,,,11623-MAIN,LOCAL,,,,,86.02,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,84.2996,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CT Lumbar Spine W/O Dye,PX7213101,CDM,350,RC,72131,CPT,TC,,,,,,,2757,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,84.3116,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.15,168.95
Diagnostic CT Thorax W/O Contrast,PX7125001,CDM,350,RC,71250,CPT,TC,,,,,,,2757,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,84.3116,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.15,168.95
"Office/Outpt Visit,New,Levl II",PX99202F,CDM,510,RC,99202,CPT,,,,,,,,123,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,84.32,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.89,129.77
"Office/Outpt Visit,New,Levl II",PX99202P,CDM,983,RC,99202,CPT,,,,,,,,123,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,84.32,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.89,129.77
baricitinib 2 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,2418230,NDC,0.5,EA,203.12,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,84.376048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pyRIDostigmine bromide 10 MG/2ML Solution 2 mL Ampule,25000000,CDM,250,RC,,,,,,781304095,NDC,2,ML,203.16,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,84.392664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Apply Forearm Splint,Static",PX29125F,CDM,510,RC,29125,CPT,,,,,,,,223,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,84.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.08,141.82
"Apply Forearm Splint,Static",PX29125P,CDM,983,RC,29125,CPT,,,,,,,,296,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,84.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.08,290.08
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,17478028810,NDC,5,ML,95.71,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,84.41622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314022705,NDC,5,ML,95.71,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,84.41622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,64980051405,NDC,5,ML,95.71,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,84.41622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
MRI T Spine WO Contrast,PX7214601,CDM,610,RC,72146,CPT,TC,,,,,,,3267,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,84.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.42,249.15
MRI T Spine WO Contrast,PX7214601,CDM,610,RC,72146,CPT,TC,,,,,,,3267,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,84.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.42,249.15
levothyroxine 100 MCG/5ML Solution 5 mL Vial,J0651.01,CDM,636,RC,J0651,HCPCS,,,,63323088510,NDC,0.625,ML,99.32,,First Health,Commercial,both,85,,999999999,percent of total billed charges,84.422,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.257528,97.3336
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061401,NDC,1,ML,94.87,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,84.4343,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.114178,99.911
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026969,NDC,100,ML,99.34,,First Health,Commercial,both,85,,999999999,percent of total billed charges,84.439,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505615204,NDC,0.5,EA,86.76,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,18.43861111,percent of total billed charges,84.443508,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424601,NDC,15,ML,95.76,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,84.46032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.778704,295.3916
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424681,NDC,15,ML,95.76,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,84.46032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.778704,295.3916
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001302,NDC,2,ML,86.79,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,42.99521739,percent of total billed charges,84.472707,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
CCP Antibody,PX86200,CDM,300,RC,86200,CPT,,,,,,,,176,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,84.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,172.48
CCP Antibody,PX86200,CDM,300,RC,86200,CPT,,,,,,,,176,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,84.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,172.48
Detect Agent Nos Dna Amp,PX87798,CDM,300,RC,87798,CPT,,,,,,,,176,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,84.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,172.48
Detect Agent Nos Dna Amp,PX87798,CDM,300,RC,87798,CPT,,,,,,,,176,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,84.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,172.48
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151F,CDM,370,RC,99151,CPT,,,,,,,,176,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,84.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.1104,172.48
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151F,CDM,370,RC,99151,CPT,,,,,,,,176,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,84.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.1104,172.48
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098321,NDC,1,EA,99.39,,First Health,Commercial,both,85,,999999999,percent of total billed charges,84.4815,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098323,NDC,1,EA,99.39,,First Health,Commercial,both,85,,999999999,percent of total billed charges,84.4815,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052200,NDC,1,EA,99.39,,First Health,Commercial,both,85,,999999999,percent of total billed charges,84.4815,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052237,NDC,1,EA,99.39,,First Health,Commercial,both,85,,999999999,percent of total billed charges,84.4815,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041100,NDC,0.5,ML,196.94,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,84.48726,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.808876,411.2766
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041110,NDC,0.5,ML,196.94,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,84.48726,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.808876,411.2766
trastuzumab 150 MG Recon Soln 1 Each Vial,J9355.01,CDM,636,RC,J9355,HCPCS,,,,50242013201,NDC,1,EA,3179.17,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,84.49,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.8,84.49
trastuzumab 150 MG Recon Soln 1 Each Vial,J9355.01,CDM,636,RC,J9355,HCPCS,,,,50242013201,NDC,1,EA,3179.17,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,84.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.77,3115.5866
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963801,NDC,0.5,ML,88.69,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,84.496,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.65,84.496
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963801,NDC,0.5,ML,88.69,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,84.496,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.65,84.496
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963805,NDC,0.5,ML,142.98,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,84.496,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.65,84.496
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963805,NDC,0.5,ML,142.98,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,84.496,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.65,84.496
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,55150017301,NDC,0.5,ML,319.2,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,84.496,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.65,84.496
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,55150017301,NDC,0.5,ML,319.2,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,84.496,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.65,84.496
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,63323027301,NDC,0.5,ML,235.6,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,84.496,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.65,84.496
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,63323027301,NDC,0.5,ML,235.6,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,84.496,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.65,84.496
romiPLOStim 250 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022101,NDC,1,EA,3791.51,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,84.5,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.5,96.38
RomiPLOStim 500 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022201,NDC,1,EA,7018.25,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,84.5,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.5,96.38
Fungus Isolation Culture,PX87102,CDM,300,RC,87102,CPT,,,,,,,,167,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,84.502,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.71,163.66
Microalbumin Quantitative,PX82043,CDM,300,RC,82043,CPT,,,,,,,,167,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,84.502,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.3,163.66
Wound Cult/Afb,PX87116,CDM,300,RC,87116,CPT,,,,,,,,167,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,84.502,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9,163.66
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036019,NDC,10,ML,86.23,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,84.5054,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.05,84.5054
Assay Other Fluid Chlorides - Ref,PX8243890,CDM,300,RC,82438,CPT,90,,,,,,,197,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,84.513,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.58,193.06
Tramadol - Ref,PX8037390,CDM,300,RC,80373,CPT,90,,,,,,,197,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,84.513,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.8338,193.06
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052083,NDC,1,EA,92.81,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,84.54991,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.407884,90.9538
Assay Blood Carbon Dioxide,PX82374,CDM,300,RC,82374,CPT,,,,,,,,95,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,84.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.47,93.1
Blood Viscosity Examination,PX85810,CDM,300,RC,85810,CPT,,,,,,,,95,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,84.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.7,93.1
Cyclosporine - Ref,PX8015890,CDM,300,RC,80158,CPT,90,,,,,,,95,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,84.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.55,93.1
"Fac/Debridement of Nails, 6 or Mor",PX11721F,CDM,510,RC,11721,CPT,,,,,,,,95,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,84.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.463,93.1
"Fat/Lipids, Feces, Quant - Ref",PX8271090,CDM,300,RC,82710,CPT,90,,,,,,,95,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,84.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.4,93.1
KIT EPIDURAL 19GA FLEXTIP PLUS AK-05502,120.305,CDM,272,RC,,,,11413-MAIN,LOCAL,,,,,95,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,84.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.463,93.1
"Lyme Disease, Confirm Tst - Ref",PX8661790,CDM,300,RC,86617,CPT,90,,,,,,,95,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,84.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.2,93.1
"Organism ID, Anaerobic - Ref",PX8707690,CDM,300,RC,87076,CPT,90,,,,,,,95,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,84.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,93.1
Strep a Assay W/Optic,PX87880,CDM,300,RC,87880,CPT,,,,,,,,95,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,84.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.16,93.1
"Thyroxine, Total - Ref",PX8443690,CDM,300,RC,84436,CPT,90,,,,,,,95,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,84.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.3,93.1
TRAY FACIAL LACERATION PACK STERILE 96-1707,120.12,CDM,272,RC,,,,406-MAIN,LOCAL,,,,,95,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,84.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.463,93.1
Varicella-Zoster Antibody,PX86787,CDM,300,RC,86787,CPT,,,,,,,,95,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,84.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.81,93.1
sodium zirconium cyclosilicate 10 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,310111001,NDC,1,EA,172.56,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,84.5544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium zirconium cyclosilicate 10 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,310111001,NDC,1,EA,172.56,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,84.5544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium zirconium cyclosilicate 10 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,310111001,NDC,1,EA,172.56,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,84.5544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sod citrate-citric acid 500-334 MG/5ML Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,121059516,NDC,473,ML,95.87,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,84.55734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gemcitabine 1 GM/26.3ML Solution 26.3 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018101,NDC,26.3,ML,203.58,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,84.567132,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
infuvite adult Injectable 10 mL Vial,J3490.99,CDM,636,RC,J3490,HCPCS,,,,54643564901,NDC,10,ML,86.89,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,11.07921788,percent of total billed charges,84.570037,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.094106,85.1522
CT Lower Extremity W/O Dye,PX7370001,CDM,350,RC,73700,CPT,TC,,,,,,,2757,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,84.6334,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.37,169.61
aztreonam 1 g Recon Soln 1 Each Vial,J0457.01,CDM,636,RC,J0457,HCPCS,,,,63323040124,NDC,1,EA,176.32,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,84.6336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.32,172.7936
aztreonam 1 g Recon Soln 1 Each Vial,J0457.01,CDM,636,RC,J0457,HCPCS,,,,63323040124,NDC,1,EA,176.32,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,84.6336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.32,172.7936
Exc Skn Beni 0.6-1cm Fcefacial,PX11441P,CDM,983,RC,11441,CPT,,,,,,,,485,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,84.64,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.64,475.3
"Fac/Exc Skn Bnig0.6-1cm Fae,Facial",PX11441F,CDM,510,RC,11441,CPT,,,,,,,,606,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,84.64,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.64,363.89
Insert Emergency Endotrach Airway,PX31500F,CDM,510,RC,31500,CPT,,,,,,,,637,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,84.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.64,288.48
Insert Emergency Endotrach Airway,PX31500F,CDM,510,RC,31500,CPT,,,,,,,,637,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,84.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.64,288.48
Insert Emergency Endotrach Airway,PX31500P,CDM,983,RC,31500,CPT,,,,,,,,657,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,84.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.64,643.86
Insert Emergency Endotrach Airway,PX31500P,CDM,983,RC,31500,CPT,,,,,,,,657,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,84.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.64,643.86
MRI C-Spine WO Contrast,PX7214101,CDM,610,RC,72141,CPT,TC,,,,,,,3541,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,84.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.64,249.81
MRI C-Spine WO Contrast,PX7214101,CDM,610,RC,72141,CPT,TC,,,,,,,3541,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,84.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.64,249.81
"CCP, Antibody - Ref",PX8620090,CDM,300,RC,86200,CPT,90,,,,,,,171,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,84.645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,167.58
Hepatic Function Panel,PX80076,CDM,300,RC,80076,CPT,,,,,,,,171,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,84.645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.49,167.58
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105F,CDM,510,RC,11105,CPT,,,,,,,,171,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,84.645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.0334,167.58
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105P,CDM,983,RC,11105,CPT,,,,,,,,171,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,84.645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.0334,166.4343
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102F,CDM,510,RC,11102,CPT,,,,,,,,171,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,84.645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.0334,174.9
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; 1st",PX88184,CDM,310,RC,88184,CPT,,,,,,,,96,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,84.672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.8784,314.02
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; Add'l",PX88185,CDM,310,RC,88185,CPT,,,,,,,,96,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,84.672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.8784,94.08
US Urine Capacity Measure,PX51798F,CDM,510,RC,51798,CPT,,,,,,,,96,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,84.672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.8784,94.08
"Chemotherapy, IV Push, Additional Drug",PX96411,CDM,335,RC,96411,CPT,,,,,,,,87,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,84.6771,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.1398,85.26
leucovorin 350 MG Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,703514501,NDC,1,EA,86.41,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,84.6818,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.670002,84.6818
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021588,NDC,0.5,ML,203.87,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,84.687598,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.779496,199.7926
BOOT AIRSELECT SHORT LARGE 01ES-L,120.45,CDM,274,RC,L4360,HCPCS,,11890-MAIN,LOCAL,,,,,93,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,84.723,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT MEDIUM 01ES-M,120.45,CDM,274,RC,L4360,HCPCS,,11889-MAIN,LOCAL,,,,,93,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,84.723,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT SMALL 01ES-S,120.45,CDM,274,RC,L4360,HCPCS,,11888-MAIN,LOCAL,,,,,93,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,84.723,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT X-LARGE 01ES-XL,120.45,CDM,274,RC,L4360,HCPCS,,11891-MAIN,LOCAL,,,,,93,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,84.723,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT X-SMALL 01ES-XS,120.45,CDM,274,RC,L4360,HCPCS,,11887-MAIN,LOCAL,,,,,93,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,84.723,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD LARGE 01EF-L,120.45,CDM,274,RC,L4360,HCPCS,,11697-MAIN,LOCAL,,,,,93,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,84.723,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD MEDIUM 01EF-M,120.45,CDM,274,RC,L4360,HCPCS,,11696-MAIN,LOCAL,,,,,93,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,84.723,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD SMALL 01EF-S,120.45,CDM,274,RC,L4360,HCPCS,,11695-MAIN,LOCAL,,,,,93,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,84.723,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD X-LARGE 01EF-XL,120.45,CDM,274,RC,L4360,HCPCS,,11698-MAIN,LOCAL,,,,,93,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,84.723,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD X-SMALL 01EF-XS,120.45,CDM,274,RC,L4360,HCPCS,,11694-MAIN,LOCAL,,,,,93,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,84.723,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
Russell Viper Venom - Ref,PX8561390,CDM,300,RC,85613,CPT,90,,,,,,,93,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,84.723,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.78,91.14
SPLINT FOOT SMALL STRUT WALK 11-1383-2-00000,120.45,CDM,274,RC,L4360,HCPCS,,1205-MAIN,LOCAL,,,,,93,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,84.723,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
"Special Stains,Group I",PX3978,CDM,310,RC,88312,CPT,TC,,,,,,,107,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,84.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.74,142.288
"Special Stains,Group I",PX3978,CDM,310,RC,88312,CPT,TC,,,,,,,107,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,84.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.74,142.288
durvalumab 120 MG/2.4ML Solution 2.4 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310450012,NDC,30,ML,21771.9,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,84.74,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,59.96,84.74
durvalumab 500 MG/10ML Solution 10 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310461150,NDC,10,ML,7588.77,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,84.74,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,59.96,84.74
"Special Stains,Group I",PX3978,CDM,310,RC,88312,CPT,TC,,,,,,,107,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,84.74,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.74,142.288
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106P,CDM,983,RC,11106,CPT,,,,,,,,204,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,84.7416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.7416,548.67
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127332,NDC,2,ML,176.55,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,84.744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.43158,173.019
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127332,NDC,2,ML,176.55,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,84.744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.43158,173.019
clotrimazole-betamethasone 1-0.05 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,51672404801,NDC,15,GR,172.95,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,84.7455,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
clotrimazole-betamethasone 1-0.05 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,51672404801,NDC,15,GR,172.95,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,84.7455,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
clotrimazole-betamethasone 1-0.05 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,51672404801,NDC,15,GR,172.95,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,84.7455,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
RBC Antibody Screen,PX86850,CDM,300,RC,86850,CPT,,,,,,,,173,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,15.73666667,percent of total billed charges,84.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,169.54
RBC Antibody Screen,PX86850,CDM,300,RC,86850,CPT,,,,,,,,173,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,84.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,169.54
RBC Antibody Screen,PX86850,CDM,300,RC,86850,CPT,,,,,,,,173,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,84.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,169.54
"Thyroxin, Free (Free T4)",PX84439,CDM,300,RC,84439,CPT,,,,,,,,173,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,84.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.27,169.54
"Thyroxin, Free (Free T4)",PX84439,CDM,300,RC,84439,CPT,,,,,,,,173,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,84.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.27,169.54
"Thyroxin, Free (Free T4)",PX84439,CDM,300,RC,84439,CPT,,,,,,,,173,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,84.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.27,169.54
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,50383058766,NDC,60,ML,95.26,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,84.7814,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,60432053760,NDC,60,ML,95.26,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,84.7814,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032225,NDC,1,EA,176.72,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,84.8256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,173.1856
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032225,NDC,1,EA,176.72,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,84.8256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,173.1856
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089901,NDC,0.25,ML,95.31,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,84.8259,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.79,93.4038
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089910,NDC,0.25,ML,95.31,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,84.8259,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.79,93.4038
Insert Emergency Endotrach Airway,PX31500F,CDM,510,RC,31500,CPT,,,,,,,,637,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,84.86,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.64,288.48
Insert Emergency Endotrach Airway,PX31500P,CDM,983,RC,31500,CPT,,,,,,,,657,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,84.86,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.64,643.86
MRI C-Spine WO Contrast,PX7214101,CDM,610,RC,72141,CPT,TC,,,,,,,3541,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,84.86,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.64,249.81
MRI L Spine WO Contrast,PX7214801,CDM,610,RC,72148,CPT,TC,,,,,,,3541,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,84.86,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.86,250.47
MRI L Spine WO Contrast,PX7214801,CDM,610,RC,72148,CPT,TC,,,,,,,3541,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,84.86,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.86,250.47
MRI T Spine WO Contrast,PX7214601,CDM,610,RC,72146,CPT,TC,,,,,,,3267,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,84.86,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.42,249.15
"Upper GI Endoscopy,Biopsy",PX43239F,CDM,750,RC,43239,CPT,,,,,,,,2364,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,84.86,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.86,780.35
"Upper GI Endoscopy,Biopsy",PX43239P,CDM,983,RC,43239,CPT,,,,,,,,2458,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,84.86,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.86,2408.84
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,39328006712,NDC,473,ML,167.77,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,84.89162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
etoposide 500 MG/25ML Solution 25 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,703565601,NDC,25,ML,173.28,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,84.9072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.949434,169.8144
etoposide 500 MG/25ML Solution 25 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,703565601,NDC,25,ML,173.28,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,84.9072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.949434,169.8144
etoposide 500 MG/25ML Solution 25 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,703565601,NDC,25,ML,173.28,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,84.9072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.949434,169.8144
sildenafil citrate 20 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,65162035109,NDC,1,EA,95.41,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,84.9149,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DOPamine 1600 mcg/mL in dextrose 5% 250 mL premix 1600 mcg/mL Solution 250 mL Plas Cont,J1265.01,CDM,636,RC,J1265,HCPCS,,,,338100702,NDC,250,ML,99.9,,First Health,Commercial,both,85,,999999999,percent of total billed charges,84.915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.49846,97.902
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927380,NDC,1,EA,99.91,,First Health,Commercial,both,85,,999999999,percent of total billed charges,84.9235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927395,NDC,1,EA,99.91,,First Health,Commercial,both,85,,999999999,percent of total billed charges,84.9235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
Ex for Speech Device Rx Addl,PX92608,CDM,444,RC,92608,CPT,,,,,,,,160,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,84.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.86,84.93
Ex for Speech Device Rx Addl,PX92608,CDM,444,RC,92608,CPT,,,,,,,,160,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,84.93,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.86,84.93
Collect Blood From Picc,PX36592,CDM,949,RC,36592,CPT,,,,,,,,198,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,84.942,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.2492,194.04
Debride Muscle Ea Add 20 Sqcm,PX11046P,CDM,983,RC,11046,CPT,,,,,,,,198,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,84.942,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.2492,192.7134
Insert Simple Cath Foley,PX51702F,CDM,510,RC,51702,CPT,,,,,,,,198,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,84.942,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.2492,194.04
KIT PLEUREVAC CHEST DRAIN S-1100-08LF,120.2,CDM,272,RC,,,,4190-MAIN,LOCAL,,,,,198,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,84.942,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.0466,194.04
Lyme Screen,PX7585,CDM,300,RC,86618,CPT,,,,,,,,198,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,84.942,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.61,194.04
CT Chest Spine W/O Dye,PX7212801,CDM,350,RC,72128,CPT,TC,,,,,,,2757,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,84.9552,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.9552,170.27
Assay of Ferritin,PX82728,CDM,300,RC,82728,CPT,,,,,,,,177,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,84.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.5,173.46
Assay of Ferritin,PX82728,CDM,300,RC,82728,CPT,,,,,,,,177,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,84.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.5,173.46
CT Chest Spine W/O Dye,PX7212801,CDM,350,RC,72128,CPT,TC,,,,,,,2757,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,84.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.9552,170.27
"D-Dimer, Quantitative - Ref",PX8537990,CDM,300,RC,85379,CPT,90,,,,,,,177,,Health Partners,Health Partners Care Plans,both,48,,121.8766667,percent of total billed charges,84.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.33,173.46
"D-Dimer, Quantitative - Ref",PX8537990,CDM,300,RC,85379,CPT,90,,,,,,,177,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,84.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.33,173.46
Fibrin Degradation Quant,PX85379,CDM,300,RC,85379,CPT,,,,,,,,177,,Health Partners,Health Partners Care Plans,both,48,,121.8766667,percent of total billed charges,84.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.33,173.46
Fibrin Degradation Quant,PX85379,CDM,300,RC,85379,CPT,,,,,,,,177,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,84.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.33,173.46
Inj Tendon/Ligament/Cyst,PX20550F,CDM,510,RC,20550,CPT,,,,,,,,177,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,84.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.5258,258.75
Inj Tendon/Ligament/Cyst,PX20550F,CDM,510,RC,20550,CPT,,,,,,,,177,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,84.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.5258,258.75
gadoteridol 279.3 MG/ML Solution 5 mL Vial,A9576,CDM,636,RC,A9576,HCPCS,,,,270111104,NDC,10,ML,100,,First Health,Commercial,both,85,,999999999,percent of total billed charges,85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.54,166.6
Sars-Cov-2 Covid-19 Antibody,PX8676990,CDM,300,RC,86769,CPT,90,,,,,,,100,,First Health,Commercial,both,85,,999999999,percent of total billed charges,85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.63,98
Aerobic Isolate - Ref,PX8707790,CDM,300,RC,87077,CPT,90,,,,,,,168,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,85.008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,164.64
Complete Cbc W/Auto Diff Wbc,PX85025,CDM,300,RC,85025,CPT,,,,,,,,168,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,85.008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.12,164.64
Insert Straight Catheter,PX51701F,CDM,510,RC,51701,CPT,,,,,,,,168,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,85.008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.7872,164.64
Org ID Aerobic-Each,PX87077,CDM,300,RC,87077,CPT,,,,,,,,168,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,85.008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,164.64
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505615204,NDC,0.5,EA,86.76,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,85.0248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001302,NDC,2,ML,86.79,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,85.0542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.812352,85.0542
MRI L Spine WO Contrast,PX7214801,CDM,610,RC,72148,CPT,TC,,,,,,,3541,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,85.08,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.86,250.47
"Remv Foot Foreign Body,Subcutaneous",PX28190F,CDM,510,RC,28190,CPT,,,,,,,,1025,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,85.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.55,499.48
"Remv Foot Foreign Body,Subcutaneous",PX28190F,CDM,510,RC,28190,CPT,,,,,,,,1025,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,85.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.55,499.48
"Remv Foot Foreign Body,Subcutaneous",PX28190P,CDM,983,RC,28190,CPT,,,,,,,,683,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,85.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.55,669.34
"Remv Foot Foreign Body,Subcutaneous",PX28190P,CDM,983,RC,28190,CPT,,,,,,,,683,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,85.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.55,669.34
"Tte W/Doppler, Complete",PX9330601,CDM,483,RC,93306,CPT,TC,,,,,,,2191,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,85.08,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.08,225.12
"Remv F.B.,Eye,Cornea,No Slit",PX65220F,CDM,510,RC,65220,CPT,,,,,,,,334,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,85.09,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.52,125.91
"Remv F.B.,Eye,Cornea,No Slit",PX65220P,CDM,983,RC,65220,CPT,,,,,,,,318,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,85.09,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.52,311.64
"Hiv-1, Quantification - Ref",PX8753690,CDM,300,RC,87536,CPT,90,,,,,,,220,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,85.1,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.27,85.1
"Fac/Office Consultation,Level IV",PX99244F,CDM,510,RC,99244,CPT,,,,,,,,441,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,85.11,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.11,287.64
"Office Consultation,Level IV",PX99244P,CDM,983,RC,99244,CPT,,,,,,,,441,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,85.11,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.11,432.18
AIRSEAL 12MM ACCESS PORT AND PALM GRIP OBTURATOR BLADELESS OPTICAL TIP 120MM,27200000,CDM,272,RC,,,,12207-MAIN,LOCAL,,,,,172,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,85.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
AIRSEAL TUBE SET TRI LUMEN FILTERED WITH ACTIVATED CHARCOAL,27200000,CDM,272,RC,,,,12206-MAIN,LOCAL,,,,,172,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,85.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
infuvite adult Injectable 10 mL Vial,J3490.99,CDM,636,RC,J3490,HCPCS,,,,54643564901,NDC,10,ML,86.89,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,85.1522,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.094106,85.1522
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,17478028810,NDC,5,ML,95.71,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,85.1819,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314022705,NDC,5,ML,95.71,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,85.1819,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,64980051405,NDC,5,ML,95.71,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,85.1819,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,43598054910,NDC,100,ML,205.14,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,85.215156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424601,NDC,15,ML,95.76,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,85.2264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.778704,295.3916
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424681,NDC,15,ML,95.76,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,85.2264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.778704,295.3916
ketoconazole 2 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,168009915,NDC,15,GR,173.97,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,85.2453,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ketoconazole 2 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,168009915,NDC,15,GR,173.97,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,85.2453,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ketoconazole 2 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,168009915,NDC,15,GR,173.97,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,85.2453,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Chemotherapy, IV Push, Additional Drug",PX96411,CDM,335,RC,96411,CPT,,,,,,,,87,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,85.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.1398,85.26
CT Neck Spine W/O Dye,PX7212501,CDM,350,RC,72125,CPT,TC,,,,,,,2757,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,85.277,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.81,170.92
"Chemotherapy, IV Infusion, 1 Hour",PX96413,CDM,335,RC,96413,CPT,,,,,,,,614,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,85.29,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.29,225.7
"Chemotherapy, IV Infusion, 1 Hour",PX96413,CDM,335,RC,96413,CPT,,,,,,,,614,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,85.29,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.29,225.7
sod citrate-citric acid 500-334 MG/5ML Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,121059516,NDC,473,ML,95.87,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,85.3243,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Inpt or Obs Disch Day Mngmt <=30 Minutes,PX99238,CDM,982,RC,99238,CPT,,,,,,,,199,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,85.371,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.6646,193.6867
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040304,NDC,10,ML,168.77,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,85.39762,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040310,NDC,10,ML,168.77,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,85.39762,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714001601,NDC,0.4,ML,100.47,,First Health,Commercial,both,85,,999999999,percent of total billed charges,85.3995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
fentaNYL 12 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,378911916,NDC,1,EA,96.83,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,85.40406,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 12 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505708000,NDC,1,EA,96.83,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,85.40406,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Debride Bone Ea Add 20 Sqcm,PX11047F,CDM,510,RC,11047,CPT,,,,,,,,438,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,85.4126,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.59,250.43
Debride Bone Ea Add 20 Sqcm,PX11047P,CDM,983,RC,11047,CPT,,,,,,,,351,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,85.4126,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.59,343.98
fentaNYL 12 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,378911998,NDC,1,EA,96.84,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,85.41288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 12 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,60505708002,NDC,1,EA,96.84,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,85.41288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium zirconium cyclosilicate 10 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,310111001,NDC,1,EA,172.56,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,85.4172,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049237,NDC,30,ML,87.77,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,85.426541,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; 1st",PX88184,CDM,310,RC,88184,CPT,,,,,,,,96,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,85.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.8784,314.02
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; Add'l",PX88185,CDM,310,RC,88185,CPT,,,,,,,,96,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,85.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.8784,94.08
US Urine Capacity Measure,PX51798F,CDM,510,RC,51798,CPT,,,,,,,,96,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,85.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.8784,94.08
levonorgestrel 1.5 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,68180085211,NDC,1,EA,174.39,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,85.4511,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levonorgestrel 1.5 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,68180085211,NDC,1,EA,174.39,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,85.4511,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levonorgestrel 1.5 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,68180085211,NDC,1,EA,174.39,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,85.4511,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 4 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,536128128,NDC,30,GR,96.95,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,85.5099,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Chemotherapy, IV Infusion, 1 Hour",PX96413,CDM,335,RC,96413,CPT,,,,,,,,614,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,85.51,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.29,225.7
"Upper GI Endoscopy,Biopsy",PX43239F,CDM,750,RC,43239,CPT,,,,,,,,2364,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,85.51,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.86,780.35
"Upper GI Endoscopy,Biopsy",PX43239F,CDM,750,RC,43239,CPT,,,,,,,,2364,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,85.51,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.86,780.35
"Upper GI Endoscopy,Biopsy",PX43239P,CDM,983,RC,43239,CPT,,,,,,,,2458,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,85.51,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.86,2408.84
"Upper GI Endoscopy,Biopsy",PX43239P,CDM,983,RC,43239,CPT,,,,,,,,2458,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,85.51,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.86,2408.84
Blood Clot Factor VIII Test,PX85247,CDM,300,RC,85247,CPT,,,,,,,,169,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,85.514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.03,165.62
Tap Block Unilateral by Injection(S),PX64486P,CDM,983,RC,64486,CPT,,,,,,,,169,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,85.514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.2026,164.4877
lidocaine urethral/mucosal 2 % Gel 30 mL Tube,25000000,CDM,250,RC,,,,,,17478084030,NDC,30,ML,93.91,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,85.55201,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Blastomyces Antibody - Ref,PX8661290,CDM,300,RC,86612,CPT,90,,,,,,,97,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,85.554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.83,95.06
Contrast Bath Therapy,PX97034,CDM,420,RC,97034,CPT,,,,,,,,97,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,85.554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,95.06
DRAPE INSTRUMENT ARM 470015,27200000,CDM,272,RC,,,,11925-MAIN,LOCAL,,,,,97,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,85.554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
High Sens Crp,PX86141,CDM,300,RC,86141,CPT,,,,,,,,97,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,85.554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,95.06
Rheumatoid Factor Quant,PX86431,CDM,300,RC,86431,CPT,,,,,,,,97,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,85.554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.2,95.06
US Transvaginal Tc,PX7683001,CDM,402,RC,76830,CPT,TC,,,,,,,472,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,85.5988,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.03,171.58
clotrimazole-betamethasone 1-0.05 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,51672404801,NDC,15,GR,172.95,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,85.61025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Coccidioides Antibody - Ref,PX8663590,CDM,300,RC,86635,CPT,90,,,,,,,94,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,85.634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.52,92.12
Copper - Ref,PX8252590,CDM,300,RC,82525,CPT,90,,,,,,,94,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,85.634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.38,92.12
DEFIBRILLATION PAD MULTI FUNCTION ADULT,120.58,CDM,271,RC,A0392,HCPCS,,1320-MAIN,LOCAL,,,,,94,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,85.634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
DEFIBRILLATION PAD PEDI PADZ PEDS,120.58,CDM,271,RC,A0392,HCPCS,,1322-MAIN,LOCAL,,,,,94,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,85.634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
DRESSING NASAL 4.5CM NON-INFLATABLE RAPID RHINO RR450,120.97,CDM,272,RC,A6407,HCPCS,,616-MAIN,LOCAL,,,,,94,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,85.634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
DRESSING NASAL 5.5CM INFLATABLE RAPID RHINO RR550,120.97,CDM,272,RC,A6407,HCPCS,,606-MAIN,LOCAL,,,,,94,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,85.634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
DRESSING NASAL 7.5CM INFLATABLE RAPID RHINO RR750,120.97,CDM,272,RC,A6407,HCPCS,,611-MAIN,LOCAL,,,,,94,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,85.634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
DRESSING NASAL 8CM LONGX1.5CM THICK X3CM HIGH ANATOMICAL 34-105,120.97,CDM,272,RC,A6407,HCPCS,,613-MAIN,LOCAL,,,,,94,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,85.634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
Tissue Exam for Fungi,PX87220,CDM,300,RC,87220,CPT,,,,,,,,94,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,85.634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,92.12
TUBING IRRIGATION F SET STERILE MXB-T,27200000,CDM,272,RC,,,,11693-MAIN,LOCAL,,,,,94,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,85.634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RBC Antibody Screen,PX86850,CDM,300,RC,86850,CPT,,,,,,,,173,,Humana Choice Care,All Medicare plans,outpatient,49.5,,84.77,percent of total billed charges,85.635,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,169.54
"Thyroxin, Free (Free T4)",PX84439,CDM,300,RC,84439,CPT,,,,,,,,173,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,85.635,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.27,169.54
Apply of Paste Boot,PX29580P,CDM,983,RC,29580,CPT,,,,,,,,88,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,85.6504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.5552,137.65
POSITIONING KIT TRENDELENBURG NUBLUE TP 3000-NB,27100000,CDM,271,RC,,,,12992-MAIN,LOCAL,,,,,88,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,85.6504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
SPLINT ANKLE GEL BRACE UNIVERSAL AIRFORM 70351,120.61,CDM,274,RC,L4350,HCPCS,,12342-MAIN,LOCAL,,,,,88,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,62.44,percent of total billed charges,85.6504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.5552,104.38
SUCTION IRRIGATOR 2 0250070500,27200000,CDM,272,RC,,,,12262-MAIN,LOCAL,,,,,88,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,85.6504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Special Stains,Group I",PX3978,CDM,310,RC,88312,CPT,TC,,,,,,,107,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,85.6803,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.74,142.288
leflunomide 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,62332006130,NDC,1,EA,88.09,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,85.737997,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Electrolyte Panel,PX80051,CDM,300,RC,80051,CPT,,,,,,,,175,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,85.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.43,171.5
Electrolyte Panel,PX80051,CDM,300,RC,80051,CPT,,,,,,,,175,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,85.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.43,171.5
Electrolyte Panel,PX80051,CDM,300,RC,80051,CPT,,,,,,,,175,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,85.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.43,171.5
"Fac/Trm Hyperkeratotic Skn Lesn,>4",PX11057F,CDM,510,RC,11057,CPT,,,,,,,,175,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,85.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.695,174.9
"Fac/Trm Hyperkeratotic Skn Lesn,>4",PX11057F,CDM,510,RC,11057,CPT,,,,,,,,175,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,85.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.695,174.9
"Fac/Trm Hyperkeratotic Skn Lesn,>4",PX11057F,CDM,510,RC,11057,CPT,,,,,,,,175,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,85.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.695,174.9
"Gonadotropin, Chorionic (Hcg), Qualitative",PX84703,CDM,300,RC,84703,CPT,,,,,,,,175,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,85.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.9,171.5
"Gonadotropin, Chorionic (Hcg), Qualitative",PX84703,CDM,300,RC,84703,CPT,,,,,,,,175,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,85.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.9,171.5
"Gonadotropin, Chorionic (Hcg), Qualitative",PX84703,CDM,300,RC,84703,CPT,,,,,,,,175,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,85.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.9,171.5
Protein E-Phoresis Serum,PX84165,CDM,300,RC,84165,CPT,,,,,,,,175,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,85.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,171.5
Protein E-Phoresis Serum,PX84165,CDM,300,RC,84165,CPT,,,,,,,,175,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,85.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,171.5
Protein E-Phoresis Serum,PX84165,CDM,300,RC,84165,CPT,,,,,,,,175,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,85.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,171.5
Protein Elp Interp,PX8416526,CDM,300,RC,84165,CPT,26,,,,,,,175,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,85.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,171.5
Protein Elp Interp,PX8416526,CDM,300,RC,84165,CPT,26,,,,,,,175,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,85.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,171.5
Protein Elp Interp,PX8416526,CDM,300,RC,84165,CPT,26,,,,,,,175,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,85.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,171.5
etoposide 500 MG/25ML Solution 25 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,703565601,NDC,25,ML,173.28,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,85.7736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.949434,169.8144
Diagnostic Anoscopy,PX46600F,CDM,510,RC,46600,CPT,,,,,,,,505,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,85.78,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.52,244.9
Diagnostic Anoscopy,PX46600P,CDM,983,RC,46600,CPT,,,,,,,,405,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,85.78,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.52,396.9
DERMABOND PRINEO SKIN CLOSURE SYSTEM 42CM,27200000,CDM,272,RC,,,,12323-MAIN,LOCAL,,,,,200,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,85.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
gadoxetate disodium 0.25 MOL/L Solution 10 mL Vial,A9581,CDM,636,RC,A9581,HCPCS,,,,50419032005,NDC,10,ML,200,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,85.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,196
iohexol 300 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141363,NDC,100,ML,200,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,85.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,294
iohexol 350 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141491,NDC,100,ML,200,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,85.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,294
Lacosamide - Ref,PX8023590,CDM,300,RC,80235,CPT,90,,,,,,,200,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,85.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.86,196
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059611,NDC,0.25,EA,200.05,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,85.82145,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.10077,725.3862
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059613,NDC,0.25,EA,200.05,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,85.82145,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.10077,725.3862
BRACE KNEE LARGE SHORTRUNNER 21754,120.387,CDM,274,RC,L1833,HCPCS,,10044-MAIN,LOCAL,,,,,101,,First Health,Commercial,both,85,,999999999,percent of total billed charges,85.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE MEDIUM SHORTRUNNER 21753,120.387,CDM,274,RC,L1833,HCPCS,,10126-MAIN,LOCAL,,,,,101,,First Health,Commercial,both,85,,999999999,percent of total billed charges,85.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE SMALL SHORTRUNNER 21752,120.387,CDM,274,RC,L1833,HCPCS,,10900-MAIN,LOCAL,,,,,101,,First Health,Commercial,both,85,,999999999,percent of total billed charges,85.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE X-LARGE SHORTRUNNER 21755,120.387,CDM,274,RC,L1833,HCPCS,,3444-MAIN,LOCAL,,,,,101,,First Health,Commercial,both,85,,999999999,percent of total billed charges,85.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE XX-LARGE SHORTRUNNER 21756,120.387,CDM,274,RC,L1833,HCPCS,,10615-MAIN,LOCAL,,,,,101,,First Health,Commercial,both,85,,999999999,percent of total billed charges,85.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
"COLLAR CERVICAL 2"" SMALL UNIVERSAL 08140039",120.249,CDM,274,RC,L0120,HCPCS,,270-MAIN,LOCAL,,,,,101,,First Health,Commercial,both,85,,999999999,percent of total billed charges,85.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 2X20"" SMALL 1003-02",120.249,CDM,274,RC,L0120,HCPCS,,272-MAIN,LOCAL,,,,,101,,First Health,Commercial,both,85,,999999999,percent of total billed charges,85.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 2X23.5"" MEDIUM XNARROW 1003-04",120.249,CDM,274,RC,L0120,HCPCS,,273-MAIN,LOCAL,,,,,101,,First Health,Commercial,both,85,,999999999,percent of total billed charges,85.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 10-15"" SMALL XLONG 1005-06",120.249,CDM,274,RC,L0120,HCPCS,,267-MAIN,LOCAL,,,,,101,,First Health,Commercial,both,85,,999999999,percent of total billed charges,85.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL LARGE 21.5""X5"" 1005-04",120.249,CDM,274,RC,L0120,HCPCS,,268-MAIN,LOCAL,,,,,101,,First Health,Commercial,both,85,,999999999,percent of total billed charges,85.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL MEDIUM 20-1/2X4"" 1005-03",120.249,CDM,274,RC,L0120,HCPCS,,269-MAIN,LOCAL,,,,,101,,First Health,Commercial,both,85,,999999999,percent of total billed charges,85.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
COLLAR CERVICAL SMALL 1005-02,120.249,CDM,274,RC,L0120,HCPCS,,266-MAIN,LOCAL,,,,,101,,First Health,Commercial,both,85,,999999999,percent of total billed charges,85.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
alendronate 70 MG Tablet 4 Each Box,63700001,CDM,250,RC,,,,,,16714063301,NDC,1,EA,97.37,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,85.88034,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Apply Short Leg Cast,Walker",PX29425F,CDM,510,RC,29425,CPT,,,,,,,,179,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,85.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.3566,234.62
"Apply Short Leg Cast,Walker",PX29425F,CDM,510,RC,29425,CPT,,,,,,,,179,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,85.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.3566,234.62
C Diff Amplified Probe,PX87493,CDM,300,RC,87493,CPT,,,,,,,,179,,Health Partners,Health Partners Care Plans,both,48,,173.63,percent of total billed charges,85.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.17,175.42
C Diff Amplified Probe,PX87493,CDM,300,RC,87493,CPT,,,,,,,,179,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,85.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.17,175.42
Fibrinogen Test - Ref,PX8536690,CDM,300,RC,85366,CPT,90,,,,,,,179,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,85.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.77,175.42
Fibrinogen Test - Ref,PX8536690,CDM,300,RC,85366,CPT,90,,,,,,,179,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,85.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.77,175.42
TUBE GASTROSTOMY 18FR REPLACEMENT DYND70318,120.256,CDM,271,RC,B4087,HCPCS,,407-MAIN,LOCAL,,,,,179,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,85.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.53,175.42
TUBE GASTROSTOMY 18FR REPLACEMENT DYND70318,120.256,CDM,271,RC,B4087,HCPCS,,407-MAIN,LOCAL,,,,,179,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,85.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.53,175.42
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,574402435,NDC,3.5,GR,101.11,,First Health,Commercial,both,85,,999999999,percent of total billed charges,85.9435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Exc Skn Beni 0.6-1cm Fcefacial,PX11441P,CDM,983,RC,11441,CPT,,,,,,,,485,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,85.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.64,475.3
Exc Skn Beni 0.6-1cm Fcefacial,PX11441P,CDM,983,RC,11441,CPT,,,,,,,,485,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,85.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.64,475.3
Exc Skn Bngn1.1-2cm Remain Bdy,PX11422P,CDM,983,RC,11422,CPT,,,,,,,,822,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,85.95,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.95,805.56
Fac/Exc Skn Bngn1.1-2cm Remain Bdy,PX11422F,CDM,510,RC,11422,CPT,,,,,,,,618,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,85.95,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.95,374.26
"Fac/Exc Skn Bnig0.6-1cm Fae,Facial",PX11441F,CDM,510,RC,11441,CPT,,,,,,,,606,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,85.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.64,363.89
"Fac/Exc Skn Bnig0.6-1cm Fae,Facial",PX11441F,CDM,510,RC,11441,CPT,,,,,,,,606,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,85.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.64,363.89
"Tte W/Doppler, Complete",PX9330601,CDM,483,RC,93306,CPT,TC,,,,,,,2191,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,85.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.08,225.12
"Tte W/Doppler, Complete",PX9330601,CDM,483,RC,93306,CPT,TC,,,,,,,2191,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,85.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.08,225.12
CARTER THOMASON CLOSURE 5MM,27200000,CDM,272,RC,,,,10278-MAIN,LOCAL,,,,,97.45,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,85.9509,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Drain Finger Abscess,Simple",PX26010P,CDM,983,RC,26010,CPT,,,,,,,,207,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,85.9878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.9878,201.4731
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004722,NDC,2,ML,88.35,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,85.991055,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049237,NDC,30,ML,87.77,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,86.0146,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Asay of Interleukin-6 (Il-6),PX8352990,CDM,300,RC,83529,CPT,90,,,,,,,170,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,86.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,166.6
Chem Cautery Granulatn Tissue,PX17250F,CDM,510,RC,17250,CPT,,,,,,,,170,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,86.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,174.9
"Chemotherapy Administration, Subq/Im Non-Hormonal Anti-Neoplastic",PX96401,CDM,335,RC,96401,CPT,,,,,,,,170,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,86.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,166.6
Collagen Cross Links - Ref,PX8252390,CDM,300,RC,82523,CPT,90,,,,,,,170,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,86.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.13,166.6
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800P,CDM,983,RC,40800,CPT,,,,,,,,170,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,86.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,614.65
gadoteridol 279.3 MG/ML Solution 17 mL Syringe,A9576,CDM,636,RC,A9576,HCPCS,,,,270111145,NDC,17,ML,170,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,86.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.54,166.6
"Inject Nerv Blck,Trigeminal",PX64400P,CDM,983,RC,64400,CPT,,,,,,,,170,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,86.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,258.75
"Protein, Total; Serum, Plasma or Whole Blood",PX84155,CDM,300,RC,84155,CPT,,,,,,,,170,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,86.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.37,166.6
ketoconazole 2 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,168009915,NDC,15,GR,173.97,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,86.11515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,59148000713,NDC,1,EA,170.19,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,86.11614,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cyclopentolate 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,61314039601,NDC,2,ML,94.58,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,86.16238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fentaNYL 12 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,378911916,NDC,1,EA,96.83,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,86.1787,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 12 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505708000,NDC,1,EA,96.83,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,86.1787,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 12 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,378911998,NDC,1,EA,96.84,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,86.1876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 12 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,60505708002,NDC,1,EA,96.84,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,86.1876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BRACE ANKLE LARGE 264015,120.51,CDM,274,RC,L1902,HCPCS,,4-MAIN,LOCAL,,,,,115,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,86.2156,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.44,87.83
BRACE ANKLE MEDIUM 264014,120.51,CDM,274,RC,L1902,HCPCS,,7-MAIN,LOCAL,,,,,115,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,86.2156,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.44,87.83
BRACE ANKLE SMALL 264012,120.51,CDM,274,RC,L1902,HCPCS,,12-MAIN,LOCAL,,,,,115,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,86.2156,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.44,87.83
BRACE ANKLE X-LARGE 264016,120.51,CDM,274,RC,L1902,HCPCS,,14-MAIN,LOCAL,,,,,115,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,86.2156,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.44,87.83
BRACE ANKLE X-SMALL 264011,120.51,CDM,274,RC,L1902,HCPCS,,1-MAIN,LOCAL,,,,,115,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,86.2156,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.44,87.83
fentaNYL 25 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,47781042411,NDC,1,EA,101.44,,First Health,Commercial,both,85,,999999999,percent of total billed charges,86.224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Hepatitis a Antibody, Tot - Ref",PX8670890,CDM,300,RC,86708,CPT,90,,,,,,,201,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,86.229,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.36,196.98
Hepatitis B Surface Antibody,PX86706,CDM,300,RC,86706,CPT,,,,,,,,201,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,86.229,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,196.98
KIT 3-LUMEN 7FR X 16CM CENTRALVENOUS CDC-42703-P1A,120.37,CDM,272,RC,C1751,HCPCS,,10707-MAIN,LOCAL,,,,,201,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,86.229,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.4954,196.98
Apply of Paste Boot,PX29580P,CDM,983,RC,29580,CPT,,,,,,,,88,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,86.24,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,132.83
CCP Antibody,PX86200,CDM,300,RC,86200,CPT,,,,,,,,176,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,86.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,172.48
CCP Antibody,PX86200,CDM,300,RC,86200,CPT,,,,,,,,176,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,86.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,172.48
CCP Antibody,PX86200,CDM,300,RC,86200,CPT,,,,,,,,176,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,86.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,172.48
Detect Agent Nos Dna Amp,PX87798,CDM,300,RC,87798,CPT,,,,,,,,176,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,86.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,172.48
Detect Agent Nos Dna Amp,PX87798,CDM,300,RC,87798,CPT,,,,,,,,176,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,86.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,172.48
Detect Agent Nos Dna Amp,PX87798,CDM,300,RC,87798,CPT,,,,,,,,176,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,86.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,172.48
Eval of Bronchospasm,PX94060,CDM,983,RC,94060,CPT,,,,,,,,176,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,86.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.1104,274.21
Eval of Bronchospasm,PX94060,CDM,983,RC,94060,CPT,,,,,,,,176,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,86.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.1104,274.21
Eval of Bronchospasm,PX94060,CDM,983,RC,94060,CPT,,,,,,,,176,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,86.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.1104,274.21
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151F,CDM,370,RC,99151,CPT,,,,,,,,176,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,86.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.1104,172.48
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151F,CDM,370,RC,99151,CPT,,,,,,,,176,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,86.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.1104,172.48
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151F,CDM,370,RC,99151,CPT,,,,,,,,176,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,86.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.1104,172.48
POSITIONING KIT TRENDELENBURG NUBLUE TP 3000-NB,27100000,CDM,271,RC,,,,12992-MAIN,LOCAL,,,,,88,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,86.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
SPLINT ANKLE GEL BRACE UNIVERSAL AIRFORM 70351,120.61,CDM,274,RC,L4350,HCPCS,,12342-MAIN,LOCAL,,,,,88,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,86.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.5552,104.38
SUCTION IRRIGATOR 2 0250070500,27200000,CDM,272,RC,,,,12262-MAIN,LOCAL,,,,,88,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,86.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
fentaNYL 25 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505700600,NDC,1,EA,101.46,,First Health,Commercial,both,85,,999999999,percent of total billed charges,86.241,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Digital Mamm, Diag, Unilat, Tc W/Cad Perf",PX7706501,CDM,401,RC,77065,CPT,TC,,,,,,,293,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,86.2424,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.03,172.24
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084252,NDC,0.5,ML,207.65,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,86.25781,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.085268,203.497
prasugrel 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862083030,NDC,1,EA,88.64,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,86.273312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 4 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,536128128,NDC,30,GR,96.95,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,86.2855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 75 MG capsule 10 Each Disp Pack,63700001,CDM,250,RC,,,,,,4080085,NDC,1,EA,97.87,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,86.32134,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010269,NDC,1,EA,88.69,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,23.54375,percent of total billed charges,86.321977,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010299,NDC,1,EA,88.69,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,23.54375,percent of total billed charges,86.321977,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614201,NDC,1,ML,88.69,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,86.321977,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.097864,86.9162
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614225,NDC,1,ML,88.69,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,86.321977,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.097864,86.9162
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963801,NDC,0.5,ML,88.69,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,86.321977,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
levonorgestrel 1.5 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,68180085211,NDC,1,EA,174.39,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,86.32305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
leflunomide 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,62332006130,NDC,1,EA,88.09,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,86.3282,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Blastomyces Antibody - Ref,PX8661290,CDM,300,RC,86612,CPT,90,,,,,,,97,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,86.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.83,95.06
Contrast Bath Therapy,PX97034,CDM,420,RC,97034,CPT,,,,,,,,97,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,86.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,95.06
DRAPE INSTRUMENT ARM 470015,27200000,CDM,272,RC,,,,11925-MAIN,LOCAL,,,,,97,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,86.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
High Sens Crp,PX86141,CDM,300,RC,86141,CPT,,,,,,,,97,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,86.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,95.06
Rheumatoid Factor Quant,PX86431,CDM,300,RC,86431,CPT,,,,,,,,97,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,86.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.2,95.06
acetaZOLAMIDE 500 MG Recon Soln 1 Each Vial,J1120.01,CDM,636,RC,J1120,HCPCS,,,,39822019001,NDC,1,EA,207.84,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,86.336736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.336736,203.6832
Inc/Drain Peritonsil Abscess,PX42700F,CDM,510,RC,42700,CPT,,,,,,,,624,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,86.38,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.38,402.63
Inc/Drain Peritonsil Abscess,PX42700P,CDM,983,RC,42700,CPT,,,,,,,,889,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,86.38,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.38,871.22
aztreonam 1 g Recon Soln 1 Each Vial,J0457.01,CDM,636,RC,J0457,HCPCS,,,,63323040124,NDC,1,EA,176.32,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,86.3968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.32,172.7936
aztreonam 1 g Recon Soln 1 Each Vial,J0457.01,CDM,636,RC,J0457,HCPCS,,,,63323040124,NDC,1,EA,176.32,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,86.3968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.32,172.7936
aztreonam 1 g Recon Soln 1 Each Vial,J0457.01,CDM,636,RC,J0457,HCPCS,,,,63323040124,NDC,1,EA,176.32,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,86.3968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.32,172.7936
C-Peptide - Ref,PX8468190,CDM,300,RC,84681,CPT,90,,,,,,,180,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,86.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,176.4
C-Peptide - Ref,PX8468190,CDM,300,RC,84681,CPT,90,,,,,,,180,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,86.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,176.4
"Infect Ea Organ, Amp Prob - Ref",PX8779890,CDM,300,RC,87798,CPT,90,,,,,,,180,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,86.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,176.4
"Infect Ea Organ, Amp Prob - Ref",PX8779890,CDM,300,RC,87798,CPT,90,,,,,,,180,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,86.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,176.4
Mrsa by Amplification Na,PX87641,CDM,300,RC,87641,CPT,,,,,,,,180,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,86.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,176.4
Mrsa by Amplification Na,PX87641,CDM,300,RC,87641,CPT,,,,,,,,180,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,86.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,176.4
Protein Elp,PX84166,CDM,300,RC,84166,CPT,,,,,,,,180,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,86.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.35,176.4
Protein Elp,PX84166,CDM,300,RC,84166,CPT,,,,,,,,180,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,86.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.35,176.4
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061401,NDC,1,ML,94.87,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,86.42657,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.114178,99.911
BLADE LARYNGOSCOPE MAC #3 SINGLE USE350-005-000,120.121,CDM,272,RC,,,,8320-MAIN,LOCAL,,,,,98,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,86.436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
BLADE LARYNGOSCOPE MAC #4 SINGLE USE 350-012-000,120.121,CDM,272,RC,,,,8321-MAIN,LOCAL,,,,,98,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,86.436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
BLADE LARYNGOSCOPE MAC #X3 SINGLE USE X3-003-000,120.121,CDM,272,RC,,,,8322-MAIN,LOCAL,,,,,98,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,86.436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
CANNULA JUNIOR 2 LARGE OPTIFLOW OJR416VT,120.561,CDM,272,RC,A4615,HCPCS,,12645-MAIN,LOCAL,,,,,98,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,86.436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
CANNULA JUNIOR 2 MEDIUM OPTIFLOW OJR414VT,120.561,CDM,272,RC,A4615,HCPCS,,12644-MAIN,LOCAL,,,,,98,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,86.436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
CANNULA OPTIFLOW JUNIOR 2 SMALL OJR412VT,120.561,CDM,272,RC,A4615,HCPCS,,12643-MAIN,LOCAL,,,,,98,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,86.436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
Hepatitis B Surface Antigen,PX87340,CDM,300,RC,87340,CPT,,,,,,,,98,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,86.436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.47,96.04
Ot Contracted Service/MCR,PX120.177,CDM,431,RC,,,,,,,,,,98,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,86.436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
Pt Contracted Services/MCR,PX120.175,CDM,421,RC,,,,,,,,,,98,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,86.436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
bicalutamide 50 MG Tablet 30 Each Bottle,25000000,CDM,250,RC,,,,,,16714081601,NDC,1,EA,98.01,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,86.44482,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Apply Long Arm Splint,PX29105F,CDM,510,RC,29105,CPT,,,,,,,,290,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,86.48,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.87,175.72
Apply Long Arm Splint,PX29105P,CDM,983,RC,29105,CPT,,,,,,,,385,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,86.48,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.87,377.3
"Inject Nerv Blck,Othr Periph Nerv",PX64450F,CDM,510,RC,64450,CPT,,,,,,,,757,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,86.48,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.96,156.35
"Inject Nerv Blck,Othr Periph Nerv",PX64450P,CDM,983,RC,64450,CPT,,,,,,,,904,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,86.48,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.96,885.92
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,61314062810,NDC,10,ML,98.07,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,86.49774,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329334001,NDC,10,ML,88.88,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1.253,percent of total billed charges,86.506904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127332,NDC,2,ML,176.55,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,15.275,percent of total billed charges,86.5095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.43158,173.019
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127332,NDC,2,ML,176.55,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,86.5095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.43158,173.019
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127332,NDC,2,ML,176.55,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,86.5095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.43158,173.019
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Box,25000000,CDM,250,RC,,,,,,67434509,NDC,1,EA,98.1,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,86.5242,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"CCP, Antibody - Ref",PX8620090,CDM,300,RC,86200,CPT,90,,,,,,,171,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,86.526,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,167.58
Hepatic Function Panel,PX80076,CDM,300,RC,80076,CPT,,,,,,,,171,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,86.526,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.49,167.58
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105F,CDM,510,RC,11105,CPT,,,,,,,,171,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,86.526,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.0334,167.58
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105P,CDM,983,RC,11105,CPT,,,,,,,,171,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,86.526,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.0334,166.4343
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102F,CDM,510,RC,11102,CPT,,,,,,,,171,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,86.526,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.0334,174.9
Assay Blood Carbon Dioxide,PX82374,CDM,300,RC,82374,CPT,,,,,,,,95,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,86.545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.47,93.1
Blood Viscosity Examination,PX85810,CDM,300,RC,85810,CPT,,,,,,,,95,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,86.545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.7,93.1
Cyclosporine - Ref,PX8015890,CDM,300,RC,80158,CPT,90,,,,,,,95,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,86.545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.55,93.1
"Fac/Debridement of Nails, 6 or Mor",PX11721F,CDM,510,RC,11721,CPT,,,,,,,,95,,Medica,Commercial,both,91.1,,42.36666667,percent of total billed charges,86.545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.463,93.1
"Fat/Lipids, Feces, Quant - Ref",PX8271090,CDM,300,RC,82710,CPT,90,,,,,,,95,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,86.545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.4,93.1
KIT EPIDURAL 19GA FLEXTIP PLUS AK-05502,120.305,CDM,272,RC,,,,11413-MAIN,LOCAL,,,,,95,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,86.545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.463,93.1
"Lyme Disease, Confirm Tst - Ref",PX8661790,CDM,300,RC,86617,CPT,90,,,,,,,95,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,86.545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.2,93.1
"Organism ID, Anaerobic - Ref",PX8707690,CDM,300,RC,87076,CPT,90,,,,,,,95,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,86.545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,93.1
Strep a Assay W/Optic,PX87880,CDM,300,RC,87880,CPT,,,,,,,,95,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,86.545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.16,93.1
"Thyroxine, Total - Ref",PX8443690,CDM,300,RC,84436,CPT,90,,,,,,,95,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,86.545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.3,93.1
TRAY FACIAL LACERATION PACK STERILE 96-1707,120.12,CDM,272,RC,,,,406-MAIN,LOCAL,,,,,95,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,86.545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.463,93.1
Varicella-Zoster Antibody,PX86787,CDM,300,RC,86787,CPT,,,,,,,,95,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,86.545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.81,93.1
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004722,NDC,2,ML,88.35,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,86.583,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032225,NDC,1,EA,176.72,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,86.5928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,173.1856
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032225,NDC,1,EA,176.72,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,86.5928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,173.1856
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032225,NDC,1,EA,176.72,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,86.5928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,173.1856
Aldolase - Ref,PX8208590,CDM,300,RC,82085,CPT,90,,,,,,,89,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,86.6237,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.9,87.22
Assay of Ggt,PX82977,CDM,300,RC,82977,CPT,,,,,,,,89,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,86.6237,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6,87.22
"Debridement of Nail(S), 1-5",PX11720F,CDM,510,RC,11720,CPT,,,,,,,,89,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,17.8,percent of total billed charges,86.6237,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.9706,87.22
"Hla a, B or C, Single Ag - Ref",PX8681290,CDM,300,RC,86812,CPT,90,,,,,,,89,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,86.6237,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.67,87.22
KIT INTRODUCER 8.5FR AK-09803-CDC,120.128,CDM,272,RC,,,,8826-MAIN,LOCAL,,,,,89,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,86.6237,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.9706,87.22
Electrolyte Panel,PX80051,CDM,300,RC,80051,CPT,,,,,,,,175,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,86.625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.43,171.5
"Fac/Trm Hyperkeratotic Skn Lesn,>4",PX11057F,CDM,510,RC,11057,CPT,,,,,,,,175,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,86.625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.695,174.9
"Gonadotropin, Chorionic (Hcg), Qualitative",PX84703,CDM,300,RC,84703,CPT,,,,,,,,175,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,86.625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.9,171.5
Protein E-Phoresis Serum,PX84165,CDM,300,RC,84165,CPT,,,,,,,,175,,Humana Choice Care,All Medicare plans,outpatient,49.5,,86.64,percent of total billed charges,86.625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,171.5
Protein Elp Interp,PX8416526,CDM,300,RC,84165,CPT,26,,,,,,,175,,Humana Choice Care,All Medicare plans,outpatient,49.5,,86.64,percent of total billed charges,86.625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,171.5
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615704,NDC,1,EA,101.92,,First Health,Commercial,both,85,,999999999,percent of total billed charges,86.632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061400,NDC,1,ML,101.95,,First Health,Commercial,both,85,,999999999,percent of total billed charges,86.6575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.114178,99.911
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615700,NDC,1,EA,101.95,,First Health,Commercial,both,85,,999999999,percent of total billed charges,86.6575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
alendronate 70 MG Tablet 4 Each Box,63700001,CDM,250,RC,,,,,,16714063301,NDC,1,EA,97.37,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,86.6593,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Concurrent Infusion,PX96368,CDM,260,RC,96368,CPT,,,,,,,,102,,First Health,Commercial,both,85,,999999999,percent of total billed charges,86.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.3708,99.96
Immunohisto Antibody Slide Ea Addl,PX8834101,CDM,310,RC,88341,CPT,TC,,,,,,,102,,First Health,Commercial,both,85,,999999999,percent of total billed charges,86.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.3708,99.96
Reptilase Test - Ref,PX8563590,CDM,300,RC,85635,CPT,90,,,,,,,102,,First Health,Commercial,both,85,,999999999,percent of total billed charges,86.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.03,99.96
Assay of Ferritin,PX82728,CDM,300,RC,82728,CPT,,,,,,,,177,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,15.216,percent of total billed charges,86.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.5,173.46
Assay of Ferritin,PX82728,CDM,300,RC,82728,CPT,,,,,,,,177,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,86.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.5,173.46
Assay of Ferritin,PX82728,CDM,300,RC,82728,CPT,,,,,,,,177,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,86.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.5,173.46
"D-Dimer, Quantitative - Ref",PX8537990,CDM,300,RC,85379,CPT,90,,,,,,,177,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,34.11333333,percent of total billed charges,86.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.33,173.46
"D-Dimer, Quantitative - Ref",PX8537990,CDM,300,RC,85379,CPT,90,,,,,,,177,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,86.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.33,173.46
"D-Dimer, Quantitative - Ref",PX8537990,CDM,300,RC,85379,CPT,90,,,,,,,177,,United Healthcare,All Medicare advantage plans,outpatient,49,,90.63,percent of total billed charges,86.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.33,173.46
Fibrin Degradation Quant,PX85379,CDM,300,RC,85379,CPT,,,,,,,,177,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,34.11333333,percent of total billed charges,86.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.33,173.46
Fibrin Degradation Quant,PX85379,CDM,300,RC,85379,CPT,,,,,,,,177,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,86.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.33,173.46
Fibrin Degradation Quant,PX85379,CDM,300,RC,85379,CPT,,,,,,,,177,,United Healthcare,All Medicare advantage plans,outpatient,49,,90.63,percent of total billed charges,86.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.33,173.46
Inj Tendon/Ligament/Cyst,PX20550F,CDM,510,RC,20550,CPT,,,,,,,,177,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,86.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.5258,258.75
Inj Tendon/Ligament/Cyst,PX20550F,CDM,510,RC,20550,CPT,,,,,,,,177,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,86.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.5258,258.75
Inj Tendon/Ligament/Cyst,PX20550F,CDM,510,RC,20550,CPT,,,,,,,,177,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,86.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.5258,258.75
CARTER THOMASON CLOSURE 5MM,27200000,CDM,272,RC,,,,10278-MAIN,LOCAL,,,,,97.45,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,86.7305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Package,25000000,CDM,250,RC,,,,,,66758020858,NDC,1,EA,102.08,,First Health,Commercial,both,85,,999999999,percent of total billed charges,86.768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,50383058766,NDC,60,ML,95.26,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,86.78186,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,60432053760,NDC,60,ML,95.26,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,86.78186,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nafcillin 1 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,55150012215,NDC,1,EA,89.17,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,86.789161,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001481,NDC,1,EA,102.12,,First Health,Commercial,both,85,,999999999,percent of total billed charges,86.802,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
ACCESSORY KIT FOR GROSHONG 16GA,120.46,CDM,272,RC,C1751,HCPCS,,2967-MAIN,LOCAL,,,,,209,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,86.8186,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.8186,204.82
Infection Agent Detect Dna/Rna Probe Tq 12-25,PX87507,CDM,300,RC,87507,CPT,,,,,,,,209,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,86.8186,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.8186,382.15
"Organic Acid, Single, Qnt - Ref",PX8392190,CDM,300,RC,83921,CPT,90,,,,,,,209,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,86.8186,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.45,204.82
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089901,NDC,0.25,ML,95.31,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,86.82741,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.79,93.4038
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089910,NDC,0.25,ML,95.31,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,86.82741,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.79,93.4038
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084243,NDC,0.5,ML,202.42,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,86.83818,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.085268,203.497
prasugrel 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862083030,NDC,1,EA,88.64,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,86.8672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Alcohol Biomarkers; 1 or 2 - Ref,PX8032190,CDM,300,RC,80321,CPT,90,,,,,,,181,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,86.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.1874,177.38
Alcohol Biomarkers; 1 or 2 - Ref,PX8032190,CDM,300,RC,80321,CPT,90,,,,,,,181,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,86.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.1874,177.38
"Lyme Disease, Antibody - Ref",PX8661890,CDM,300,RC,86618,CPT,90,,,,,,,181,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,86.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.61,177.38
"Lyme Disease, Antibody - Ref",PX8661890,CDM,300,RC,86618,CPT,90,,,,,,,181,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,86.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.61,177.38
PHALINX STERILE TRIAL SIZER 45A00000,27200000,CDM,272,RC,,,,12959-MAIN,LOCAL,,,,,181,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,86.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PHALINX STERILE TRIAL SIZER 45A00000,27200000,CDM,272,RC,,,,12959-MAIN,LOCAL,,,,,181,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,86.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010269,NDC,1,EA,88.69,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,86.9162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010299,NDC,1,EA,88.69,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,86.9162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,86.9162
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614201,NDC,1,ML,88.69,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,86.9162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.097864,86.9162
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614225,NDC,1,ML,88.69,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,86.9162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.097864,86.9162
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963801,NDC,0.5,ML,88.69,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,86.9162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
sildenafil citrate 20 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,65162035109,NDC,1,EA,95.41,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,86.91851,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rivaroxaban 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50458058030,NDC,1,EA,98.57,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,86.93874,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409339004,NDC,1,EA,98.61,,United Healthcare,All Payer,outpatient,88.2,,49.96,percent of total billed charges,86.97402,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
AIRSEAL 12MM ACCESS PORT AND PALM GRIP OBTURATOR BLADELESS OPTICAL TIP 120MM,27200000,CDM,272,RC,,,,12207-MAIN,LOCAL,,,,,172,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,87.032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
AIRSEAL TUBE SET TRI LUMEN FILTERED WITH ACTIVATED CHARCOAL,27200000,CDM,272,RC,,,,12206-MAIN,LOCAL,,,,,172,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,87.032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,63323094004,NDC,4,ML,89.43,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,87.042219,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,63323094021,NDC,4,ML,89.43,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,87.042219,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329334001,NDC,10,ML,88.88,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,87.1024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
oseltamivir 75 MG capsule 10 Each Disp Pack,63700001,CDM,250,RC,,,,,,4080085,NDC,1,EA,97.87,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,87.1043,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CCP Antibody,PX86200,CDM,300,RC,86200,CPT,,,,,,,,176,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,87.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,172.48
Detect Agent Nos Dna Amp,PX87798,CDM,300,RC,87798,CPT,,,,,,,,176,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,87.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,172.48
Eval of Bronchospasm,PX94060,CDM,983,RC,94060,CPT,,,,,,,,176,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,87.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.1104,274.21
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151F,CDM,370,RC,99151,CPT,,,,,,,,176,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,87.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.1104,172.48
baricitinib 2 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,2418230,NDC,0.5,EA,203.12,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,87.13848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pyRIDostigmine bromide 10 MG/2ML Solution 2 mL Ampule,25000000,CDM,250,RC,,,,,,781304095,NDC,2,ML,203.16,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,87.15564,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,17478028810,NDC,5,ML,95.71,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,87.19181,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314022705,NDC,5,ML,95.71,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,87.19181,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,64980051405,NDC,5,ML,95.71,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,87.19181,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Aldolase - Ref,PX8208590,CDM,300,RC,82085,CPT,90,,,,,,,89,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,87.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.9,87.22
Assay of Ggt,PX82977,CDM,300,RC,82977,CPT,,,,,,,,89,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,87.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.6,87.22
BLADE LARYNGOSCOPE MAC #3 SINGLE USE350-005-000,120.121,CDM,272,RC,,,,8320-MAIN,LOCAL,,,,,98,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,87.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
BLADE LARYNGOSCOPE MAC #4 SINGLE USE 350-012-000,120.121,CDM,272,RC,,,,8321-MAIN,LOCAL,,,,,98,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,87.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
BLADE LARYNGOSCOPE MAC #X3 SINGLE USE X3-003-000,120.121,CDM,272,RC,,,,8322-MAIN,LOCAL,,,,,98,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,87.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
CANNULA JUNIOR 2 LARGE OPTIFLOW OJR416VT,120.561,CDM,272,RC,A4615,HCPCS,,12645-MAIN,LOCAL,,,,,98,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,87.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
CANNULA JUNIOR 2 MEDIUM OPTIFLOW OJR414VT,120.561,CDM,272,RC,A4615,HCPCS,,12644-MAIN,LOCAL,,,,,98,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,87.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
CANNULA OPTIFLOW JUNIOR 2 SMALL OJR412VT,120.561,CDM,272,RC,A4615,HCPCS,,12643-MAIN,LOCAL,,,,,98,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,87.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
"Debridement of Nail(S), 1-5",PX11720F,CDM,510,RC,11720,CPT,,,,,,,,89,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,87.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.9706,87.22
Hepatitis B Surface Antigen,PX87340,CDM,300,RC,87340,CPT,,,,,,,,98,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,87.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.47,96.04
"Hla a, B or C, Single Ag - Ref",PX8681290,CDM,300,RC,86812,CPT,90,,,,,,,89,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,87.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.67,87.22
KIT INTRODUCER 8.5FR AK-09803-CDC,120.128,CDM,272,RC,,,,8826-MAIN,LOCAL,,,,,89,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,87.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.9706,87.22
Ot Contracted Service/MCR,PX120.177,CDM,431,RC,,,,,,,,,,98,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,87.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
Pt Contracted Services/MCR,PX120.175,CDM,421,RC,,,,,,,,,,98,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,87.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
bicalutamide 50 MG Tablet 30 Each Bottle,25000000,CDM,250,RC,,,,,,16714081601,NDC,1,EA,98.01,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,87.2289,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
AIRSEAL ROBOTIC Xi CAP AND OBTURATOR WITH BLADELESS OPTICAL TIP,27200000,CDM,272,RC,,,,12208-MAIN,LOCAL,,,,,210,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,87.234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
AIRSEAL ROBOTIC Xi TRI LUMEN FILTERED TUBE SET WITH ACTIVATED CHARCOAL,27200000,CDM,272,RC,,,,12209-MAIN,LOCAL,,,,,210,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,87.234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Apply Forearm Cast,PX29075F,CDM,510,RC,29075,CPT,,,,,,,,210,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,87.234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,234.62
Chorionic gonadotropin test,PX84702,CDM,300,RC,84702,CPT,,,,,,,,210,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,87.234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.8,205.8
"Excision of Nail Fold, Toe",PX11765F,CDM,510,RC,11765,CPT,,,,,,,,210,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,87.234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,348.35
Fac/Hospital Discharge Day>30 Min,PX99239F,CDM,510,RC,99239,CPT,,,,,,,,210,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,87.234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,205.8
"Inject Trigger Point, 1 or 2",PX20552P,CDM,983,RC,20552,CPT,,,,,,,,210,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,87.234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,258.75
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424601,NDC,15,ML,95.76,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,87.23736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.778704,295.3916
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424681,NDC,15,ML,95.76,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,87.23736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.778704,295.3916
ondansetron 4 MG/5ML Solution 50 mL Bottle,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714067102,NDC,5,ML,98.91,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,87.23862,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011701,NDC,1,EA,89.64,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,58.74,percent of total billed charges,87.246612,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011710,NDC,1,EA,89.64,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,58.74,percent of total billed charges,87.246612,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331801,NDC,10,ML,102.65,,First Health,Commercial,both,85,,999999999,percent of total billed charges,87.2525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
Exc Skn Bngn1.1-2cm Remain Bdy,PX11422P,CDM,983,RC,11422,CPT,,,,,,,,822,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,87.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.95,805.56
Exc Skn Bngn1.1-2cm Remain Bdy,PX11422P,CDM,983,RC,11422,CPT,,,,,,,,822,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,87.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.95,805.56
Fac/Exc Skn Bngn1.1-2cm Remain Bdy,PX11422F,CDM,510,RC,11422,CPT,,,,,,,,618,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,87.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.95,374.26
Fac/Exc Skn Bngn1.1-2cm Remain Bdy,PX11422F,CDM,510,RC,11422,CPT,,,,,,,,618,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,87.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.95,374.26
Inc/Drain Peritonsil Abscess,PX42700F,CDM,510,RC,42700,CPT,,,,,,,,624,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,87.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.38,402.63
Inc/Drain Peritonsil Abscess,PX42700F,CDM,510,RC,42700,CPT,,,,,,,,624,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,87.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.38,402.63
Inc/Drain Peritonsil Abscess,PX42700P,CDM,983,RC,42700,CPT,,,,,,,,889,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,87.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.38,871.22
Inc/Drain Peritonsil Abscess,PX42700P,CDM,983,RC,42700,CPT,,,,,,,,889,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,87.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.38,871.22
alteplase 1 MG/ML Solution 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,8888800497,NDC,1,EA,21140.86,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,87.27721,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.6,88.97
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004110,NDC,1,EA,666.53,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,87.27721,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.6,88.97
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004164,NDC,1,EA,666.52,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,87.27721,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.6,88.97
alteplase 100 MG Recon Soln 1 Each Syringe,J2997.01,CDM,636,RC,J2997,HCPCS,,,,88888800475,NDC,0.09,EA,1920.88,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,87.27721,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.6,88.97
alteplase 100 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242008527,NDC,1,EA,21140.86,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,87.27721,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.6,88.97
aztreonam 1 g Recon Soln 1 Each Vial,J0457.01,CDM,636,RC,J0457,HCPCS,,,,63323040124,NDC,1,EA,176.32,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,87.2784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.32,172.7936
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,61314062810,NDC,10,ML,98.07,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,87.2823,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
HYDROmorphone 0.1 MG/ML Solution 55 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,61553067976,NDC,55,ML,89.7,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,15.571,percent of total billed charges,87.30501,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409663734,NDC,50,ML,89.7,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,87.30501,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Box,25000000,CDM,250,RC,,,,,,67434509,NDC,1,EA,98.1,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,87.309,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,23155029031,NDC,2,ML,98.99,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,87.30918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,97.0102
sodium zirconium cyclosilicate 10 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,310111001,NDC,1,EA,172.56,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,87.31536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Clostridium Ag, Eia",PX87324,CDM,300,RC,87324,CPT,,,,,,,,99,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,87.318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,97.02
Deoxyribonuclease Ab,PX86215,CDM,300,RC,86215,CPT,,,,,,,,99,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,87.318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,97.02
"Extractable Nuclear Antigen, Each Antigen",PX86235,CDM,300,RC,86235,CPT,90,,,,,,,99,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,87.318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.44,97.02
"Fungus Antibody, Nos - Ref",PX8667190,CDM,300,RC,86671,CPT,90,,,,,,,99,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,87.318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.23,97.02
"Lab Immunoassay, Non Antibody",PX83516,CDM,300,RC,83516,CPT,,,,,,,,99,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,87.318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.57,97.02
"Protozoa Antibody, Nos - Ref",PX8675390,CDM,300,RC,86753,CPT,90,,,,,,,99,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,87.318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.36,97.02
gemcitabine 1 GM/26.3ML Solution 26.3 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018101,NDC,26.3,ML,203.58,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,87.33582,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
sod citrate-citric acid 500-334 MG/5ML Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,121059516,NDC,473,ML,95.87,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,87.33757,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Immunocytochemistry,PX3993,CDM,310,RC,88342,CPT,TC,,,,,,,182,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,87.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.6028,178.36
Immunocytochemistry,PX3993,CDM,310,RC,88342,CPT,TC,,,,,,,182,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,87.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.6028,178.36
Infec Agent Direct Probe - Ref,PX8779990,CDM,300,RC,87799,CPT,90,,,,,,,182,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,87.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.28,178.36
Infec Agent Direct Probe - Ref,PX8779990,CDM,300,RC,87799,CPT,90,,,,,,,182,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,87.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.28,178.36
nafcillin 1 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,55150012215,NDC,1,EA,89.17,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,87.3866,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127332,NDC,2,ML,176.55,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,87.39225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.43158,173.019
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,4080285,NDC,1,EA,89.79,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,87.392607,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ALEXIS 0 LARGE STERILE,27200000,CDM,272,RC,,,,11765-MAIN,LOCAL,,,,,102.85,,First Health,Commercial,both,85,,999999999,percent of total billed charges,87.4225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"dextrose 5 % 5 % Solution 1,000 mL Flex Cont",J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001704,NDC,1000,ML,99.12,,United Healthcare,All Payer,outpatient,88.2,,4.9575,percent of total billed charges,87.42384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001702,NDC,250,ML,99.12,,United Healthcare,All Payer,outpatient,88.2,,4.9575,percent of total billed charges,87.42384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338634602,NDC,250,ML,99.12,,United Healthcare,All Payer,outpatient,88.2,,4.9575,percent of total billed charges,87.42384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 500 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001703,NDC,500,ML,99.12,,United Healthcare,All Payer,outpatient,88.2,,4.9575,percent of total billed charges,87.42384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % Non-DEHP bag 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,264751020,NDC,250,ML,99.12,,United Healthcare,All Payer,outpatient,88.2,,4.9575,percent of total billed charges,87.42384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"dextrose 5% and sodium chloride 0.2% 5-0.2 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338007704,NDC,1000,ML,99.12,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,87.42384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
"dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008904,NDC,1000,ML,99.12,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,87.42384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 500 mL Flex Cont,J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008903,NDC,500,ML,99.12,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,87.42384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
"dextrose 5% and sodium chloride 0.45% 5-0.45 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008504,NDC,1000,ML,99.12,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,87.42384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
dextrose 5% lactated ringers 5 % Solution 500 mL Flex Cont,J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012503,NDC,500,ML,99.12,,United Healthcare,All Payer,outpatient,88.2,,0.063571088,percent of total billed charges,87.42384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 10% 10 % Solution 500 mL Flex Cont,25000000,CDM,250,RC,,,,,,338002303,NDC,500,ML,99.12,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,87.42384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lactated ringers Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338011704,NDC,1000,ML,99.12,,United Healthcare,All Payer,outpatient,88.2,,0.063571088,percent of total billed charges,87.42384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338069104,NDC,1000,ML,99.12,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,87.42384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004904,NDC,1000,ML,99.12,,United Healthcare,All Payer,outpatient,88.2,,0.092261369,percent of total billed charges,87.42384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954306,NDC,1000,ML,99.12,,United Healthcare,All Payer,outpatient,88.2,,0.092261369,percent of total billed charges,87.42384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004902,NDC,250,ML,99.12,,United Healthcare,All Payer,outpatient,88.2,,0.092261369,percent of total billed charges,87.42384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954302,NDC,250,ML,99.12,,United Healthcare,All Payer,outpatient,88.2,,0.092261369,percent of total billed charges,87.42384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 500 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004903,NDC,500,ML,99.12,,United Healthcare,All Payer,outpatient,88.2,,0.092261369,percent of total billed charges,87.42384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9% 0.9% Solution 1,000 mL Flex Cont",J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004904,NDC,1000,ML,99.12,,United Healthcare,All Payer,outpatient,88.2,,0.191910792,percent of total billed charges,87.42384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9% IV LINE FLUSH 0.9% Solution 250 mL Flex Cont,25000000,CDM,250,RC,,,,,,338004902,NDC,250,ML,99.12,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,87.42384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"sodium chloride 0.45 % 0.45 % Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,338004304,NDC,1000,ML,99.12,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,87.42384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 3 % 3 % Solution 500 mL Flex Cont,J7131.01,CDM,636,RC,J7131,HCPCS,,,,338005403,NDC,500,ML,99.12,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,87.42384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; 1st",PX88184,CDM,310,RC,88184,CPT,,,,,,,,96,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,87.456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.8784,314.02
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; Add'l",PX88185,CDM,310,RC,88185,CPT,,,,,,,,96,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,87.456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.8784,94.08
US Urine Capacity Measure,PX51798F,CDM,510,RC,51798,CPT,,,,,,,,96,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,87.456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.8784,94.08
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021588,NDC,0.5,ML,203.87,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,87.46023,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.779496,199.7926
"Initial Observation Care,Levl I",PX99218,CDM,982,RC,99218,CPT,,,,,,,,266,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,87.4752,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.4752,260.68
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032225,NDC,1,EA,176.72,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,87.4764,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,173.1856
"Initial Observation Care,Levl I",PX99218,CDM,982,RC,99218,CPT,,,,,,,,266,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,87.48,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.4752,260.68
sulfamethoxazole-trimethoprim 400-80 MG/5ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,703951403,NDC,10,ML,102.93,,First Health,Commercial,both,85,,999999999,percent of total billed charges,87.4905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
clotrimazole-betamethasone 1-0.05 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,51672404801,NDC,15,GR,172.95,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,87.5127,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106P,CDM,983,RC,11106,CPT,,,,,,,,204,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,87.516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.7416,548.67
RBC Antibody Screen,PX86850,CDM,300,RC,86850,CPT,,,,,,,,173,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,87.538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,169.54
"Thyroxin, Free (Free T4)",PX84439,CDM,300,RC,84439,CPT,,,,,,,,173,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,87.538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.27,169.54
Assay of Transferrin,PX84466,CDM,300,RC,84466,CPT,,,,,,,,103,,First Health,Commercial,both,85,,999999999,percent of total billed charges,87.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.7,100.94
"Lactoferrin, Fecal; Qual",PX83630,CDM,300,RC,83630,CPT,,,,,,,,103,,First Health,Commercial,both,85,,999999999,percent of total billed charges,87.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.06,100.94
"Molecyto Insitu, 100-300cl - Ref",PX8827590,CDM,310,RC,88275,CPT,90,,,,,,,103,,First Health,Commercial,both,85,,999999999,percent of total billed charges,87.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.7862,100.94
"Tiss Cult,Non-Neop Lymph - Ref",PX8823090,CDM,310,RC,88230,CPT,90,,,,,,,103,,First Health,Commercial,both,85,,999999999,percent of total billed charges,87.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.7862,106.81
"Gammaglobulin; Iga, Dg,M - Ref",PX8278490,CDM,300,RC,82784,CPT,90,,,,,,,90,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,87.597,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.53,88.2
"Misc Virus Antibody, Nos - Ref",PX8679090,CDM,300,RC,86790,CPT,90,,,,,,,90,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,87.597,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.81,88.2
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152P,CDM,983,RC,99152,CPT,,,,,,,,90,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,87.597,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.386,87.597
Mycobacteria Culture - Ref,PX8711690,CDM,300,RC,87116,CPT,90,,,,,,,90,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,87.597,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9,88.2
levothyroxine 100 MCG/5ML Solution 5 mL Vial,J0651.01,CDM,636,RC,J0651,HCPCS,,,,63323088510,NDC,0.625,ML,99.32,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,87.60024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.257528,97.3336
Assay of Ferritin,PX82728,CDM,300,RC,82728,CPT,,,,,,,,177,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,87.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.5,173.46
"D-Dimer, Quantitative - Ref",PX8537990,CDM,300,RC,85379,CPT,90,,,,,,,177,,Humana Choice Care,All Medicare plans,outpatient,49.5,,104.076,percent of total billed charges,87.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.33,173.46
Fibrin Degradation Quant,PX85379,CDM,300,RC,85379,CPT,,,,,,,,177,,Humana Choice Care,All Medicare plans,outpatient,49.5,,104.076,percent of total billed charges,87.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.33,173.46
Inj Tendon/Ligament/Cyst,PX20550F,CDM,510,RC,20550,CPT,,,,,,,,177,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,87.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.5258,258.75
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026969,NDC,100,ML,99.34,,United Healthcare,All Payer,outpatient,88.2,,1.151420557,percent of total billed charges,87.61788,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,63323094004,NDC,4,ML,89.43,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,87.6414,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,63323094021,NDC,4,ML,89.43,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,87.6414,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Bone Age Studies Tc,PX7707201,CDM,320,RC,77072,CPT,TC,,,,,,,211,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,87.6494,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.6494,206.78
Collect Blood From Picc,PX36592F,CDM,510,RC,36592,CPT,,,,,,,,211,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,87.6494,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.6494,206.78
Draw Blood Off Venous Device,PX36591F,CDM,510,RC,36591,CPT,,,,,,,,211,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,87.6494,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.6494,206.78
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098321,NDC,1,EA,99.39,,United Healthcare,All Payer,outpatient,88.2,,49.96,percent of total billed charges,87.66198,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098323,NDC,1,EA,99.39,,United Healthcare,All Payer,outpatient,88.2,,49.96,percent of total billed charges,87.66198,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052200,NDC,1,EA,99.39,,United Healthcare,All Payer,outpatient,88.2,,49.96,percent of total billed charges,87.66198,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052237,NDC,1,EA,99.39,,United Healthcare,All Payer,outpatient,88.2,,49.96,percent of total billed charges,87.66198,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
etoposide 500 MG/25ML Solution 25 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,703565601,NDC,25,ML,173.28,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,87.67968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.949434,169.8144
"Apply Short Leg Cast,Walker",PX29425F,CDM,510,RC,29425,CPT,,,,,,,,179,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,87.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.3566,234.62
"Apply Short Leg Cast,Walker",PX29425F,CDM,510,RC,29425,CPT,,,,,,,,179,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,87.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.3566,234.62
"Apply Short Leg Cast,Walker",PX29425F,CDM,510,RC,29425,CPT,,,,,,,,179,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,87.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.3566,234.62
C Diff Amplified Probe,PX87493,CDM,300,RC,87493,CPT,,,,,,,,179,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,38.485,percent of total billed charges,87.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.17,175.42
C Diff Amplified Probe,PX87493,CDM,300,RC,87493,CPT,,,,,,,,179,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,87.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.17,175.42
C Diff Amplified Probe,PX87493,CDM,300,RC,87493,CPT,,,,,,,,179,,United Healthcare,All Medicare advantage plans,outpatient,49,,94.87,percent of total billed charges,87.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.17,175.42
Fibrinogen Test - Ref,PX8536690,CDM,300,RC,85366,CPT,90,,,,,,,179,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,87.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.77,175.42
Fibrinogen Test - Ref,PX8536690,CDM,300,RC,85366,CPT,90,,,,,,,179,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,87.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.77,175.42
Fibrinogen Test - Ref,PX8536690,CDM,300,RC,85366,CPT,90,,,,,,,179,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,87.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.77,175.42
TUBE GASTROSTOMY 18FR REPLACEMENT DYND70318,120.256,CDM,271,RC,B4087,HCPCS,,407-MAIN,LOCAL,,,,,179,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,87.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.53,175.42
TUBE GASTROSTOMY 18FR REPLACEMENT DYND70318,120.256,CDM,271,RC,B4087,HCPCS,,407-MAIN,LOCAL,,,,,179,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,87.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.53,175.42
TUBE GASTROSTOMY 18FR REPLACEMENT DYND70318,120.256,CDM,271,RC,B4087,HCPCS,,407-MAIN,LOCAL,,,,,179,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,87.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.53,175.42
lidocaine 0.5 % PF 0.5 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323049101,NDC,50,ML,103.2,,First Health,Commercial,both,85,,999999999,percent of total billed charges,87.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
rivaroxaban 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50458058030,NDC,1,EA,98.57,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,87.7273,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Inpatient Consult, Level IV",PX99254,CDM,983,RC,99254,CPT,,,,,,,,508,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,87.73,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.73,497.84
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409339004,NDC,1,EA,98.61,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,87.7629,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
BRACE ANKLE LARGE 264015,120.51,CDM,274,RC,L1902,HCPCS,,4-MAIN,LOCAL,,,,,115,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,87.83,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.44,87.83
BRACE ANKLE LARGE 264015,120.51,CDM,274,RC,L1902,HCPCS,,4-MAIN,LOCAL,,,,,115,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,87.83,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.44,87.83
BRACE ANKLE LARGE 264015,120.51,CDM,274,RC,L1902,HCPCS,,4-MAIN,LOCAL,,,,,115,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,87.83,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.44,87.83
BRACE ANKLE MEDIUM 264014,120.51,CDM,274,RC,L1902,HCPCS,,7-MAIN,LOCAL,,,,,115,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,87.83,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.44,87.83
BRACE ANKLE MEDIUM 264014,120.51,CDM,274,RC,L1902,HCPCS,,7-MAIN,LOCAL,,,,,115,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,87.83,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.44,87.83
BRACE ANKLE MEDIUM 264014,120.51,CDM,274,RC,L1902,HCPCS,,7-MAIN,LOCAL,,,,,115,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,87.83,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.44,87.83
BRACE ANKLE SMALL 264012,120.51,CDM,274,RC,L1902,HCPCS,,12-MAIN,LOCAL,,,,,115,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,87.83,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.44,87.83
BRACE ANKLE SMALL 264012,120.51,CDM,274,RC,L1902,HCPCS,,12-MAIN,LOCAL,,,,,115,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,87.83,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.44,87.83
BRACE ANKLE SMALL 264012,120.51,CDM,274,RC,L1902,HCPCS,,12-MAIN,LOCAL,,,,,115,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,87.83,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.44,87.83
BRACE ANKLE X-LARGE 264016,120.51,CDM,274,RC,L1902,HCPCS,,14-MAIN,LOCAL,,,,,115,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,87.83,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.44,87.83
BRACE ANKLE X-LARGE 264016,120.51,CDM,274,RC,L1902,HCPCS,,14-MAIN,LOCAL,,,,,115,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,87.83,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.44,87.83
BRACE ANKLE X-LARGE 264016,120.51,CDM,274,RC,L1902,HCPCS,,14-MAIN,LOCAL,,,,,115,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,87.83,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.44,87.83
BRACE ANKLE X-SMALL 264011,120.51,CDM,274,RC,L1902,HCPCS,,1-MAIN,LOCAL,,,,,115,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,87.83,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.44,87.83
BRACE ANKLE X-SMALL 264011,120.51,CDM,274,RC,L1902,HCPCS,,1-MAIN,LOCAL,,,,,115,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,87.83,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.44,87.83
BRACE ANKLE X-SMALL 264011,120.51,CDM,274,RC,L1902,HCPCS,,1-MAIN,LOCAL,,,,,115,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,87.83,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.44,87.83
Flu Dna Amp Probe 1st 2 Types,PX87502,CDM,300,RC,87502,CPT,,,,,,,,350,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,87.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.84,343
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152F,CDM,370,RC,99152,CPT,,,,,,,,235,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,87.84,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,87.84
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152P,CDM,983,RC,99152,CPT,,,,,,,,90,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,87.84,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,88.2
Voriconazole - Ref,PX8028590,CDM,300,RC,80285,CPT,90,,,,,,,183,,Health Partners,Health Partners Care Plans,both,48,,84.84,percent of total billed charges,87.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.86,179.34
Voriconazole - Ref,PX8028590,CDM,300,RC,80285,CPT,90,,,,,,,183,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,87.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.86,179.34
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601901,NDC,10,ML,211.47,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,87.844638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.844638,207.2406
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601910,NDC,10,ML,211.47,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,87.844638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.844638,207.2406
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011701,NDC,1,EA,89.64,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,87.8472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011710,NDC,1,EA,89.64,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,87.8472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
"US,Preg. Uterus,Fetal/Mat.Eval.,>1st Trim.(>/= 14 Wks 0 Dys),Transabd;Single/First Gest., Tech",PX7680501,CDM,402,RC,76805,CPT,TC,,,,,,,562,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,87.8514,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.92,175.53
Blood Transfusion Service,PX36430,CDM,391,RC,36430,CPT,,,,,,,,839,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,87.86,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.52,87.86
Blood Transfusion Service,PX36430,CDM,391,RC,36430,CPT,,,,,,,,839,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,87.86,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.52,87.86
HYDROmorphone 0.1 MG/ML Solution 55 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,61553067976,NDC,55,ML,89.7,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,87.906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,87.906
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409663734,NDC,50,ML,89.7,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,87.906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Lvl 1 Sub Hosp Low Mdm or 25 Minutes,PX99231,CDM,982,RC,99231,CPT,,,,,,,,133,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,87.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.55,130.34
Lvl 1 Sub Hosp Low Mdm or 25 Minutes,PX99231,CDM,982,RC,99231,CPT,,,,,,,,133,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,87.91,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.55,130.34
scopolamine 1 MG/3DAYS Patch 72 Hour 4 Each Box,25000000,CDM,250,RC,,,,,,45802058084,NDC,1,EA,103.43,,First Health,Commercial,both,85,,999999999,percent of total billed charges,87.9155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010310,NDC,1,ML,103.48,,First Health,Commercial,both,85,,999999999,percent of total billed charges,87.958,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
"Closed Rx I-P Jt,Toe Dislocation",PX28660F,CDM,510,RC,28660,CPT,,,,,,,,335,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,87.9814,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.24,267.03
"Closed Rx I-P Jt,Toe Dislocation",PX28660P,CDM,983,RC,28660,CPT,,,,,,,,628,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,87.9814,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.24,615.44
hydrocortisone sodium succinate (preservative free) 250 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001305,NDC,1,EA,183.32,,Health Partners,Health Partners Care Plans,both,48,,50.24,percent of total billed charges,87.9936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
hydrocortisone sodium succinate (preservative free) 250 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001305,NDC,1,EA,183.32,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,87.9936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,4080285,NDC,1,EA,89.79,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,87.9942,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,43598054910,NDC,100,ML,205.14,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,88.00506,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
ketoconazole 2 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,168009915,NDC,15,GR,173.97,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,88.02882,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ondansetron 4 MG/5ML Solution 50 mL Bottle,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714067102,NDC,5,ML,98.91,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,88.0299,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
romiPLOStim 250 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022101,NDC,1,EA,3791.51,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,88.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.04,6877.885
RomiPLOStim 500 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022201,NDC,1,EA,7018.25,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,88.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.04,6877.885
"Non-Select. Wound Debride., W/O Anesth.; Top. Appl./Wound Assess./Instruct., per Sess.",PX97602,CDM,761,RC,97602,CPT,,,,,,,,212,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,88.0648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.0648,207.76
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,23155029031,NDC,2,ML,98.99,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,88.1011,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,97.0102
"Clostridium Ag, Eia",PX87324,CDM,300,RC,87324,CPT,,,,,,,,99,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,88.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,97.02
Deoxyribonuclease Ab,PX86215,CDM,300,RC,86215,CPT,,,,,,,,99,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,88.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,97.02
"Extractable Nuclear Antigen, Each Antigen",PX86235,CDM,300,RC,86235,CPT,90,,,,,,,99,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,88.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.44,97.02
"Fungus Antibody, Nos - Ref",PX8667190,CDM,300,RC,86671,CPT,90,,,,,,,99,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,88.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.23,97.02
"Lab Immunoassay, Non Antibody",PX83516,CDM,300,RC,83516,CPT,,,,,,,,99,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,88.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.57,97.02
"Protozoa Antibody, Nos - Ref",PX8675390,CDM,300,RC,86753,CPT,90,,,,,,,99,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,88.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.36,97.02
DOPamine 1600 mcg/mL in dextrose 5% 250 mL premix 1600 mcg/mL Solution 250 mL Plas Cont,J1265.01,CDM,636,RC,J1265,HCPCS,,,,338100702,NDC,250,ML,99.9,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,88.1118,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.49846,97.902
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361250,NDC,50,ML,90.53,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1.636666667,percent of total billed charges,88.112849,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361650,NDC,50,ML,90.53,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1.636666667,percent of total billed charges,88.112849,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927380,NDC,1,EA,99.91,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,88.12062,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927395,NDC,1,EA,99.91,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,88.12062,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
Fluoroscopy Guid Needle Plcmt Tc,PX7700201,CDM,320,RC,77002,CPT,TC,,,,,,,662,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,88.1732,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,59.77,176.84
C-Peptide - Ref,PX8468190,CDM,300,RC,84681,CPT,90,,,,,,,180,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,88.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,176.4
C-Peptide - Ref,PX8468190,CDM,300,RC,84681,CPT,90,,,,,,,180,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,88.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,176.4
C-Peptide - Ref,PX8468190,CDM,300,RC,84681,CPT,90,,,,,,,180,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,88.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,176.4
"Closed Rx Radial Head Disloc,Child",PX24640P,CDM,983,RC,24640,CPT,,,,,,,,180,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,216,percent of total billed charges,88.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.772,206.02
"Closed Rx Radial Head Disloc,Child",PX24640P,CDM,983,RC,24640,CPT,,,,,,,,180,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,88.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.772,206.02
"Closed Rx Radial Head Disloc,Child",PX24640P,CDM,983,RC,24640,CPT,,,,,,,,180,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,88.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.772,206.02
gadoteridol 279.3 MG/ML Solution 5 mL Vial,A9576,CDM,636,RC,A9576,HCPCS,,,,270111104,NDC,10,ML,100,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,88.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.54,166.6
"Gammaglobulin; Iga, Dg,M - Ref",PX8278490,CDM,300,RC,82784,CPT,90,,,,,,,90,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,88.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.53,88.2
"Infect Ea Organ, Amp Prob - Ref",PX8779890,CDM,300,RC,87798,CPT,90,,,,,,,180,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,88.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,176.4
"Infect Ea Organ, Amp Prob - Ref",PX8779890,CDM,300,RC,87798,CPT,90,,,,,,,180,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,88.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,176.4
"Infect Ea Organ, Amp Prob - Ref",PX8779890,CDM,300,RC,87798,CPT,90,,,,,,,180,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,88.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,176.4
"Misc Virus Antibody, Nos - Ref",PX8679090,CDM,300,RC,86790,CPT,90,,,,,,,90,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,88.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.81,88.2
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152P,CDM,983,RC,99152,CPT,,,,,,,,90,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,88.2,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,88.2
Mrsa by Amplification Na,PX87641,CDM,300,RC,87641,CPT,,,,,,,,180,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,88.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,176.4
Mrsa by Amplification Na,PX87641,CDM,300,RC,87641,CPT,,,,,,,,180,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,88.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,176.4
Mrsa by Amplification Na,PX87641,CDM,300,RC,87641,CPT,,,,,,,,180,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,88.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,176.4
Mycobacteria Culture - Ref,PX8711690,CDM,300,RC,87116,CPT,90,,,,,,,90,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,88.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9,88.2
Protein Elp,PX84166,CDM,300,RC,84166,CPT,,,,,,,,180,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,88.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.35,176.4
Protein Elp,PX84166,CDM,300,RC,84166,CPT,,,,,,,,180,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,88.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.35,176.4
Protein Elp,PX84166,CDM,300,RC,84166,CPT,,,,,,,,180,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,88.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.35,176.4
Sars-Cov-2 Covid-19 Antibody,PX8676990,CDM,300,RC,86769,CPT,90,,,,,,,100,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,88.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.63,98
fentaNYL 12 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,378911916,NDC,1,EA,96.83,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,88.21213,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 12 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505708000,NDC,1,EA,96.83,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,88.21213,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"dextrose 5 % 5 % Solution 1,000 mL Flex Cont",J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001704,NDC,1000,ML,99.12,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,88.2168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001702,NDC,250,ML,99.12,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,88.2168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338634602,NDC,250,ML,99.12,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,88.2168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 500 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001703,NDC,500,ML,99.12,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,88.2168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % Non-DEHP bag 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,264751020,NDC,250,ML,99.12,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,88.2168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"dextrose 5% and sodium chloride 0.2% 5-0.2 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338007704,NDC,1000,ML,99.12,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,88.2168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
"dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008904,NDC,1000,ML,99.12,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,88.2168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 500 mL Flex Cont,J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008903,NDC,500,ML,99.12,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,88.2168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
"dextrose 5% and sodium chloride 0.45% 5-0.45 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008504,NDC,1000,ML,99.12,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,88.2168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
dextrose 5% lactated ringers 5 % Solution 500 mL Flex Cont,J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012503,NDC,500,ML,99.12,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,88.2168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 10% 10 % Solution 500 mL Flex Cont,25000000,CDM,250,RC,,,,,,338002303,NDC,500,ML,99.12,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,88.2168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lactated ringers Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338011704,NDC,1000,ML,99.12,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,88.2168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338069104,NDC,1000,ML,99.12,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,88.2168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004904,NDC,1000,ML,99.12,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,88.2168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954306,NDC,1000,ML,99.12,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,88.2168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004902,NDC,250,ML,99.12,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,88.2168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954302,NDC,250,ML,99.12,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,88.2168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 500 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004903,NDC,500,ML,99.12,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,88.2168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9% 0.9% Solution 1,000 mL Flex Cont",J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004904,NDC,1000,ML,99.12,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,88.2168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9% IV LINE FLUSH 0.9% Solution 250 mL Flex Cont,25000000,CDM,250,RC,,,,,,338004902,NDC,250,ML,99.12,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,88.2168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"sodium chloride 0.45 % 0.45 % Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,338004304,NDC,1000,ML,99.12,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,88.2168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 3 % 3 % Solution 500 mL Flex Cont,J7131.01,CDM,636,RC,J7131,HCPCS,,,,338005403,NDC,500,ML,99.12,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,88.2168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
fentaNYL 12 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,378911998,NDC,1,EA,96.84,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,88.22124,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 12 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,60505708002,NDC,1,EA,96.84,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,88.22124,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levonorgestrel 1.5 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,68180085211,NDC,1,EA,174.39,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,88.24134,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505614700,NDC,1,EA,212.52,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,88.280808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,703574811,NDC,100,ML,183.92,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,88.2816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.174958,180.2416
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,703574811,NDC,100,ML,183.92,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,88.2816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.174958,180.2416
TUBE TRACH SIZE 3.0MM ID 4.5MM OD SHILEY PEDIATRIC 3.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1185-MAIN,LOCAL,,,,,184,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,88.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 3.0MM ID 4.5MM OD SHILEY PEDIATRIC 3.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1185-MAIN,LOCAL,,,,,184,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,88.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 3.5MM ID 5.2MM OD SHILEY PEDIATRIC,120.287,CDM,272,RC,A7520,HCPCS,,8813-MAIN,LOCAL,,,,,184,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,88.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 3.5MM ID 5.2MM OD SHILEY PEDIATRIC,120.287,CDM,272,RC,A7520,HCPCS,,8813-MAIN,LOCAL,,,,,184,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,88.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 4.0MM ID 5.9MM OD SHILEY PEDIATRIC 4.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1187-MAIN,LOCAL,,,,,184,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,88.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 4.0MM ID 5.9MM OD SHILEY PEDIATRIC 4.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1187-MAIN,LOCAL,,,,,184,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,88.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 5 7.0MM ID 10.1MM OD SHILEY CUFFED 5CN70H,120.287,CDM,272,RC,A7521,HCPCS,,10350-MAIN,LOCAL,,,,,184,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,88.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 5 7.0MM ID 10.1MM OD SHILEY CUFFED 5CN70H,120.287,CDM,272,RC,A7521,HCPCS,,10350-MAIN,LOCAL,,,,,184,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,88.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 5.0MM ID 7.1MM OD SHILEY PEDIATRIC 5.0PED,120.287,CDM,272,RC,A7520,HCPCS,,8814-MAIN,LOCAL,,,,,184,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,88.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 5.0MM ID 7.1MM OD SHILEY PEDIATRIC 5.0PED,120.287,CDM,272,RC,A7520,HCPCS,,8814-MAIN,LOCAL,,,,,184,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,88.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 6 6.0MM ID 8.3MM OD SHILEY CUFFED 6SCT,120.287,CDM,272,RC,A7521,HCPCS,,8812-MAIN,LOCAL,,,,,184,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,88.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 6 6.0MM ID 8.3MM OD SHILEY CUFFED 6SCT,120.287,CDM,272,RC,A7521,HCPCS,,8812-MAIN,LOCAL,,,,,184,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,88.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 6 6.4MM ID 10.8MM OD SHILEY CUFFED 6DCT,120.287,CDM,272,RC,A7521,HCPCS,,1190-MAIN,LOCAL,,,,,184,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,88.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 6 6.4MM ID 10.8MM OD SHILEY CUFFED 6DCT,120.287,CDM,272,RC,A7521,HCPCS,,1190-MAIN,LOCAL,,,,,184,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,88.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 7.5MM ID 10.8MM OD SHILEY CUFFED 6CN75H,120.287,CDM,272,RC,A7521,HCPCS,,8488-MAIN,LOCAL,,,,,184,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,88.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 7.5MM ID 10.8MM OD SHILEY CUFFED 6CN75H,120.287,CDM,272,RC,A7521,HCPCS,,8488-MAIN,LOCAL,,,,,184,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,88.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 8 7.6MM ID 12.2MM OD SHILEY 8DCT,120.287,CDM,272,RC,A7521,HCPCS,,1192-MAIN,LOCAL,,,,,184,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,88.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 8 7.6MM ID 12.2MM OD SHILEY 8DCT,120.287,CDM,272,RC,A7521,HCPCS,,1192-MAIN,LOCAL,,,,,184,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,88.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 8 7.6MM ID 12.22MM OD SHILEY CUFFED 8LPC,120.287,CDM,272,RC,A7521,HCPCS,,8815-MAIN,LOCAL,,,,,184,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,88.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 8 7.6MM ID 12.22MM OD SHILEY CUFFED 8LPC,120.287,CDM,272,RC,A7521,HCPCS,,8815-MAIN,LOCAL,,,,,184,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,88.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 8.0MM ID 10.9MM OD SHILEY CUFFED 8SCT,120.287,CDM,272,RC,A7521,HCPCS,,8811-MAIN,LOCAL,,,,,184,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,88.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 8.0MM ID 10.9MM OD SHILEY CUFFED 8SCT,120.287,CDM,272,RC,A7521,HCPCS,,8811-MAIN,LOCAL,,,,,184,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,88.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 10 SHILEY 10LPC,120.287,CDM,272,RC,A7521,HCPCS,,1181-MAIN,LOCAL,,,,,184,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,88.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 10 SHILEY 10LPC,120.287,CDM,272,RC,A7521,HCPCS,,1181-MAIN,LOCAL,,,,,184,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,88.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
lidocaine 4 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,536128128,NDC,30,GR,96.95,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,88.32145,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
MRI Brain WO Contrast Tc,PX7055101,CDM,610,RC,70551,CPT,TC,,,,,,,3335,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,88.34,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.34,260.99
MRI Brain WO Contrast Tc,PX7055101,CDM,610,RC,70551,CPT,TC,,,,,,,3335,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,88.34,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.34,260.99
Noninvasv Lo Extrem Art Stress/Rest,PX9392401,CDM,921,RC,93924,CPT,TC,,,,,,,810,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,88.34,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.34,238.5
Blastomyces Antibody - Ref,PX8661290,CDM,300,RC,86612,CPT,90,,,,,,,97,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,88.367,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.83,95.06
Contrast Bath Therapy,PX97034,CDM,420,RC,97034,CPT,,,,,,,,97,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,88.367,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,95.06
DRAPE INSTRUMENT ARM 470015,27200000,CDM,272,RC,,,,11925-MAIN,LOCAL,,,,,97,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,88.367,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
High Sens Crp,PX86141,CDM,300,RC,86141,CPT,,,,,,,,97,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,88.367,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,95.06
Rheumatoid Factor Quant,PX86431,CDM,300,RC,86431,CPT,,,,,,,,97,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,88.367,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.2,95.06
levothyroxine 100 MCG/5ML Solution 5 mL Vial,J0651.01,CDM,636,RC,J0651,HCPCS,,,,63323088510,NDC,0.625,ML,99.32,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,88.3948,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.257528,97.3336
Carnitine - Ref,PX8237990,CDM,300,RC,82379,CPT,90,,,,,,,104,,First Health,Commercial,both,85,,999999999,percent of total billed charges,88.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.47,101.92
Cmv Antibody - Ref,PX8664490,CDM,300,RC,86644,CPT,90,,,,,,,104,,First Health,Commercial,both,85,,999999999,percent of total billed charges,88.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,101.92
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026969,NDC,100,ML,99.34,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,88.4126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
venetoclax 100 MG Tablet 1 Each Box,25000000,CDM,250,RC,,,,,,74057611,NDC,0.2,EA,90.87,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,88.443771,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098321,NDC,1,EA,99.39,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,88.4571,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098323,NDC,1,EA,99.39,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,88.4571,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052200,NDC,1,EA,99.39,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,88.4571,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052237,NDC,1,EA,99.39,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,88.4571,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
Apply Multlay Comprs Lwr Leg,PX29581F,CDM,510,RC,29581,CPT,,,,,,,,213,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,88.4802,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.4802,208.74
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006F,CDM,510,RC,10006,CPT,,,,,,,,213,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,88.4802,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.4802,208.74
"GI Pathogen Panel, Pcr - Ref",PX8750790,CDM,300,RC,87507,CPT,90,,,,,,,213,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,88.4802,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.4802,382.15
Remove Impacted Ear Wax,PX69210F,CDM,510,RC,69210,CPT,,,,,,,,213,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,88.4802,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.44,208.74
"Apply Finger Splint,Static",PX29130F,CDM,420,RC,29130,CPT,,,,,,,,196,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,88.55,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.66,88.55
"Apply Finger Splint,Static",PX29130P,CDM,983,RC,29130,CPT,,,,,,,,223,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,88.55,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.66,218.54
Electrolyte Panel,PX80051,CDM,300,RC,80051,CPT,,,,,,,,175,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,88.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.43,171.5
"Fac/Trm Hyperkeratotic Skn Lesn,>4",PX11057F,CDM,510,RC,11057,CPT,,,,,,,,175,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,88.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.695,174.9
"Gonadotropin, Chorionic (Hcg), Qualitative",PX84703,CDM,300,RC,84703,CPT,,,,,,,,175,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,88.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.9,171.5
Protein E-Phoresis Serum,PX84165,CDM,300,RC,84165,CPT,,,,,,,,175,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,88.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,171.5
Protein Elp Interp,PX8416526,CDM,300,RC,84165,CPT,26,,,,,,,175,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,88.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,171.5
"Apply Short Leg Cast,Walker",PX29425F,CDM,510,RC,29425,CPT,,,,,,,,179,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,88.605,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.3566,234.62
C Diff Amplified Probe,PX87493,CDM,300,RC,87493,CPT,,,,,,,,179,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,88.605,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.17,175.42
Fibrinogen Test - Ref,PX8536690,CDM,300,RC,85366,CPT,90,,,,,,,179,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,88.605,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.77,175.42
TUBE GASTROSTOMY 18FR REPLACEMENT DYND70318,120.256,CDM,271,RC,B4087,HCPCS,,407-MAIN,LOCAL,,,,,179,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,88.605,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.53,175.42
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714001601,NDC,0.4,ML,100.47,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,88.61454,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060851,NDC,100,ML,213.4,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,88.64636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
"MESH PROLENE 3X6""",C1781,CDM,278,RC,C1781,HCPCS,,688-MAIN,LOCAL,,,,,213.49,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,88.683746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Alcohol Biomarkers; 1 or 2 - Ref,PX8032190,CDM,300,RC,80321,CPT,90,,,,,,,181,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,88.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.1874,177.38
Alcohol Biomarkers; 1 or 2 - Ref,PX8032190,CDM,300,RC,80321,CPT,90,,,,,,,181,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,88.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.1874,177.38
Alcohol Biomarkers; 1 or 2 - Ref,PX8032190,CDM,300,RC,80321,CPT,90,,,,,,,181,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,88.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.1874,177.38
"Lyme Disease, Antibody - Ref",PX8661890,CDM,300,RC,86618,CPT,90,,,,,,,181,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,88.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.61,177.38
"Lyme Disease, Antibody - Ref",PX8661890,CDM,300,RC,86618,CPT,90,,,,,,,181,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,88.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.61,177.38
"Lyme Disease, Antibody - Ref",PX8661890,CDM,300,RC,86618,CPT,90,,,,,,,181,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,88.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.61,177.38
PHALINX STERILE TRIAL SIZER 45A00000,27200000,CDM,272,RC,,,,12959-MAIN,LOCAL,,,,,181,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,88.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PHALINX STERILE TRIAL SIZER 45A00000,27200000,CDM,272,RC,,,,12959-MAIN,LOCAL,,,,,181,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,88.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PHALINX STERILE TRIAL SIZER 45A00000,27200000,CDM,272,RC,,,,12959-MAIN,LOCAL,,,,,181,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,88.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
alendronate 70 MG Tablet 4 Each Box,63700001,CDM,250,RC,,,,,,16714063301,NDC,1,EA,97.37,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,88.70407,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361250,NDC,50,ML,90.53,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,88.7194,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361650,NDC,50,ML,90.53,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,88.7194,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
CARTER THOMASON CLOSURE 5MM,27200000,CDM,272,RC,,,,10278-MAIN,LOCAL,,,,,97.45,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,88.77695,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MRI Abdomen W/O Tc,PX7418101,CDM,610,RC,74181,CPT,TC,,,,,,,2655,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,88.78,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.78,262.3
MRI Abdomen W/O Tc,PX7418101,CDM,610,RC,74181,CPT,TC,,,,,,,2655,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,88.78,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.78,262.3
MRI Brain WO Contrast Tc,PX7055101,CDM,610,RC,70551,CPT,TC,,,,,,,3335,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,88.78,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.34,260.99
Amylase - Ref,PX8215090,CDM,300,RC,82150,CPT,90,,,,,,,185,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,88.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.94,181.3
Amylase - Ref,PX8215090,CDM,300,RC,82150,CPT,90,,,,,,,185,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,88.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.94,181.3
Hepatitis C Rna Quant,PX87522,CDM,300,RC,87522,CPT,,,,,,,,185,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,88.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.28,181.3
Hepatitis C Rna Quant,PX87522,CDM,300,RC,87522,CPT,,,,,,,,185,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,88.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.28,181.3
"Level IV - Surgical Pathology, Gross and Microscopic Examination , Tech",PX3934,CDM,310,RC,88305,CPT,TC,,,,,,,185,,Health Partners,Health Partners Care Plans,both,48,,155.339,percent of total billed charges,88.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,271.15
"Level IV - Surgical Pathology, Gross and Microscopic Examination , Tech",PX3934,CDM,310,RC,88305,CPT,TC,,,,,,,185,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,88.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,271.15
"Office/Outpt Visit,Est,Levl III",PX99213F,CDM,510,RC,99213,CPT,,,,,,,,185,,Health Partners,Health Partners Care Plans,both,48,,173.62,percent of total billed charges,88.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.849,181.3
"Office/Outpt Visit,Est,Levl III",PX99213F,CDM,510,RC,99213,CPT,,,,,,,,185,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,88.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.849,181.3
"Drain Finger Abscess,Simple",PX26010P,CDM,983,RC,26010,CPT,,,,,,,,207,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,88.803,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.9878,201.4731
Low Dose CT Lung Ca Screen WO Contrast,PX7127101,CDM,350,RC,71271,CPT,TC,,,,,,,1286,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,88.8168,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.21,178.16
Immunofix Elp,PX86335,CDM,300,RC,86335,CPT,,,,,,,,214,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,88.8956,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.91,209.72
Jak2 Gene - Ref,PX8127090,CDM,300,RC,81270,CPT,90,,,,,,,734,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,88.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.91,91.66
Jak2 Gene - Ref,PX8127090,CDM,300,RC,81270,CPT,90,,,,,,,734,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,88.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.91,91.66
Jak2 Gene - Ref,PX8127090,CDM,300,RC,81270,CPT,90,,,,,,,734,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,88.91,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.91,91.66
DOPamine 1600 mcg/mL in dextrose 5% 250 mL premix 1600 mcg/mL Solution 250 mL Plas Cont,J1265.01,CDM,636,RC,J1265,HCPCS,,,,338100702,NDC,250,ML,99.9,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,88.911,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.49846,97.902
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927380,NDC,1,EA,99.91,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,88.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927395,NDC,1,EA,99.91,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,88.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
"Excision of Nail Fold, Toe",PX11765F,CDM,510,RC,11765,CPT,,,,,,,,210,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,88.9447,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.68,345.9
empagliflozin 10 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,597015237,NDC,1,EA,104.66,,First Health,Commercial,both,85,,999999999,percent of total billed charges,88.961,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
alteplase 1 MG/ML Solution 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,8888800497,NDC,1,EA,21140.86,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,88.97,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.6,88.97
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004110,NDC,1,EA,666.53,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,88.97,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.6,88.97
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004164,NDC,1,EA,666.52,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,88.97,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.6,88.97
alteplase 100 MG Recon Soln 1 Each Syringe,J2997.01,CDM,636,RC,J2997,HCPCS,,,,88888800475,NDC,0.09,EA,1920.88,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,88.97,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.6,88.97
alteplase 100 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242008527,NDC,1,EA,21140.86,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,88.97,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.6,88.97
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031801,NDC,1,ML,185.37,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,88.9776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.002698,181.6626
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031801,NDC,1,ML,185.37,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,88.9776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.002698,181.6626
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031825,NDC,1,ML,185.37,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,88.9776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.002698,181.6626
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031825,NDC,1,ML,185.37,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,88.9776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.002698,181.6626
nafcillin 2 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,S0032,HCPCS,,,,63323032820,NDC,1,EA,185.37,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,88.9776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
nafcillin 2 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,S0032,HCPCS,,,,63323032820,NDC,1,EA,185.37,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,88.9776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
gadoteridol 279.3 MG/ML Solution 5 mL Vial,A9576,CDM,636,RC,A9576,HCPCS,,,,270111104,NDC,10,ML,100,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.54,166.6
Sars-Cov-2 Covid-19 Antibody,PX8676990,CDM,300,RC,86769,CPT,90,,,,,,,100,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.63,98
sodium bicarbonate 4.2 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409553434,NDC,10,ML,91.46,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,89.018018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fentaNYL 50 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,47781042611,NDC,1,EA,185.47,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,89.0256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 50 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,47781042611,NDC,1,EA,185.47,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,89.0256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 50 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,47781042647,NDC,1,EA,185.47,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,89.0256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 50 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,47781042647,NDC,1,EA,185.47,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,89.0256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
venetoclax 100 MG Tablet 1 Each Box,25000000,CDM,250,RC,,,,,,74057611,NDC,0.2,EA,90.87,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,89.0526,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
CCP Antibody,PX86200,CDM,300,RC,86200,CPT,,,,,,,,176,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,89.056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,172.48
Detect Agent Nos Dna Amp,PX87798,CDM,300,RC,87798,CPT,,,,,,,,176,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,89.056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,172.48
Eval of Bronchospasm,PX94060,CDM,983,RC,94060,CPT,,,,,,,,176,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,89.056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.1104,274.21
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151F,CDM,370,RC,99151,CPT,,,,,,,,176,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,89.056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.1104,172.48
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084252,NDC,0.5,ML,207.65,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,89.08185,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.085268,203.497
BRACE KNEE LARGE SHORTRUNNER 21754,120.387,CDM,274,RC,L1833,HCPCS,,10044-MAIN,LOCAL,,,,,101,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,89.082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE MEDIUM SHORTRUNNER 21753,120.387,CDM,274,RC,L1833,HCPCS,,10126-MAIN,LOCAL,,,,,101,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,89.082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE SMALL SHORTRUNNER 21752,120.387,CDM,274,RC,L1833,HCPCS,,10900-MAIN,LOCAL,,,,,101,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,89.082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE X-LARGE SHORTRUNNER 21755,120.387,CDM,274,RC,L1833,HCPCS,,3444-MAIN,LOCAL,,,,,101,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,89.082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE XX-LARGE SHORTRUNNER 21756,120.387,CDM,274,RC,L1833,HCPCS,,10615-MAIN,LOCAL,,,,,101,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,89.082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
"COLLAR CERVICAL 2"" SMALL UNIVERSAL 08140039",120.249,CDM,274,RC,L0120,HCPCS,,270-MAIN,LOCAL,,,,,101,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,89.082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 2X20"" SMALL 1003-02",120.249,CDM,274,RC,L0120,HCPCS,,272-MAIN,LOCAL,,,,,101,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,89.082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 2X23.5"" MEDIUM XNARROW 1003-04",120.249,CDM,274,RC,L0120,HCPCS,,273-MAIN,LOCAL,,,,,101,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,89.082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 10-15"" SMALL XLONG 1005-06",120.249,CDM,274,RC,L0120,HCPCS,,267-MAIN,LOCAL,,,,,101,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,89.082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL LARGE 21.5""X5"" 1005-04",120.249,CDM,274,RC,L0120,HCPCS,,268-MAIN,LOCAL,,,,,101,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,89.082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL MEDIUM 20-1/2X4"" 1005-03",120.249,CDM,274,RC,L0120,HCPCS,,269-MAIN,LOCAL,,,,,101,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,89.082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
COLLAR CERVICAL SMALL 1005-02,120.249,CDM,274,RC,L0120,HCPCS,,266-MAIN,LOCAL,,,,,101,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,89.082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
C-Peptide - Ref,PX8468190,CDM,300,RC,84681,CPT,90,,,,,,,180,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,89.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,176.4
"Closed Rx Radial Head Disloc,Child",PX24640P,CDM,983,RC,24640,CPT,,,,,,,,180,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,89.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.772,206.02
"Infect Ea Organ, Amp Prob - Ref",PX8779890,CDM,300,RC,87798,CPT,90,,,,,,,180,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,89.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,176.4
Mrsa by Amplification Na,PX87641,CDM,300,RC,87641,CPT,,,,,,,,180,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,89.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,176.4
Protein Elp,PX84166,CDM,300,RC,84166,CPT,,,,,,,,180,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,89.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.35,176.4
imipenem-cilastatin 250 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323034925,NDC,1,EA,91.55,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,89.105615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,173.1856
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032294,NDC,1,EA,91.55,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,89.105615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,173.1856
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234001,NDC,1.25,ML,91.55,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.5924,percent of total billed charges,89.105615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
verapamil 2.5 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,409114405,NDC,2,ML,185.65,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,89.112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
verapamil 2.5 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,409114405,NDC,2,ML,185.65,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,89.112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
oseltamivir 75 MG capsule 10 Each Disp Pack,63700001,CDM,250,RC,,,,,,4080085,NDC,1,EA,97.87,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,89.15957,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaZOLAMIDE 500 MG Recon Soln 1 Each Vial,J1120.01,CDM,636,RC,J1120,HCPCS,,,,39822019001,NDC,1,EA,207.84,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,89.16336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.336736,203.6832
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,574402435,NDC,3.5,GR,101.11,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,89.17902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Debride Skin/Subq Ea Ad 20sqcm,PX11045P,CDM,983,RC,11045,CPT,,,,,,,,182,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,89.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.6028,177.1406
Debride Skin/Subq Ea Ad 20sqcm,PX11045P,CDM,983,RC,11045,CPT,,,,,,,,182,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,89.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.6028,177.1406
Debride Skin/Subq Ea Ad 20sqcm,PX11045P,CDM,983,RC,11045,CPT,,,,,,,,182,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,89.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.6028,177.1406
Immunocytochemistry,PX3993,CDM,310,RC,88342,CPT,TC,,,,,,,182,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,27.625,percent of total billed charges,89.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.6028,178.36
Immunocytochemistry,PX3993,CDM,310,RC,88342,CPT,TC,,,,,,,182,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,89.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.6028,178.36
Immunocytochemistry,PX3993,CDM,310,RC,88342,CPT,TC,,,,,,,182,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,89.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.6028,178.36
Infec Agent Direct Probe - Ref,PX8779990,CDM,300,RC,87799,CPT,90,,,,,,,182,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,89.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.28,178.36
Infec Agent Direct Probe - Ref,PX8779990,CDM,300,RC,87799,CPT,90,,,,,,,182,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,89.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.28,178.36
Infec Agent Direct Probe - Ref,PX8779990,CDM,300,RC,87799,CPT,90,,,,,,,182,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,89.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.28,178.36
aztreonam 1 g Recon Soln 1 Each Vial,J0457.01,CDM,636,RC,J0457,HCPCS,,,,63323040124,NDC,1,EA,176.32,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,89.21792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.32,172.7936
Dx Occult Blood Immunoassay,PX82274,CDM,300,RC,82274,CPT,,,,,,,,105,,First Health,Commercial,both,85,,999999999,percent of total billed charges,89.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.6,102.9
Specimen Concentration - Ref,PX8701590,CDM,300,RC,87015,CPT,90,,,,,,,105,,First Health,Commercial,both,85,,999999999,percent of total billed charges,89.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.12,102.9
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,17478007035,NDC,3.5,GR,105.01,,First Health,Commercial,both,85,,999999999,percent of total billed charges,89.2585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BLADE LARYNGOSCOPE MAC #3 SINGLE USE350-005-000,120.121,CDM,272,RC,,,,8320-MAIN,LOCAL,,,,,98,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,89.278,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
BLADE LARYNGOSCOPE MAC #4 SINGLE USE 350-012-000,120.121,CDM,272,RC,,,,8321-MAIN,LOCAL,,,,,98,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,89.278,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
BLADE LARYNGOSCOPE MAC #X3 SINGLE USE X3-003-000,120.121,CDM,272,RC,,,,8322-MAIN,LOCAL,,,,,98,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,89.278,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
CANNULA JUNIOR 2 LARGE OPTIFLOW OJR416VT,120.561,CDM,272,RC,A4615,HCPCS,,12645-MAIN,LOCAL,,,,,98,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,89.278,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
CANNULA JUNIOR 2 MEDIUM OPTIFLOW OJR414VT,120.561,CDM,272,RC,A4615,HCPCS,,12644-MAIN,LOCAL,,,,,98,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,89.278,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
CANNULA OPTIFLOW JUNIOR 2 SMALL OJR412VT,120.561,CDM,272,RC,A4615,HCPCS,,12643-MAIN,LOCAL,,,,,98,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,89.278,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
Hepatitis B Surface Antigen,PX87340,CDM,300,RC,87340,CPT,,,,,,,,98,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,89.278,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.47,96.04
Ot Contracted Service/MCR,PX120.177,CDM,431,RC,,,,,,,,,,98,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,89.278,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
Pt Contracted Services/MCR,PX120.175,CDM,421,RC,,,,,,,,,,98,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,89.278,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
nitroPRUSSide 25 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,72485010501,NDC,2,ML,186,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,89.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
nitroPRUSSide 25 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,72485010501,NDC,2,ML,186,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,89.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"TB Test, Cell Immunity Measure",PX86480,CDM,300,RC,86480,CPT,,,,,,,,186,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,89.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.83,182.28
"TB Test, Cell Immunity Measure",PX86480,CDM,300,RC,86480,CPT,,,,,,,,186,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,89.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.83,182.28
bicalutamide 50 MG Tablet 30 Each Bottle,25000000,CDM,250,RC,,,,,,16714081601,NDC,1,EA,98.01,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,89.28711,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Immunoglobulin Subclasses - Ref,PX8278790,CDM,300,RC,82787,CPT,90,,,,,,,215,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,89.311,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.35,210.7
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,67815203,NDC,100,GR,91.77,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,89.319741,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127332,NDC,2,ML,176.55,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,89.3343,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.43158,173.019
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,61314062810,NDC,10,ML,98.07,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,89.34177,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Box,25000000,CDM,250,RC,,,,,,67434509,NDC,1,EA,98.1,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,89.3691,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714001601,NDC,0.4,ML,100.47,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,89.4183,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032225,NDC,1,EA,176.72,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,89.42032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,173.1856
atropine (PF) 1 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517101025,NDC,1,ML,91.89,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1.253,percent of total billed charges,89.436537,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
fentaNYL 25 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,47781042411,NDC,1,EA,101.44,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,89.47008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 25 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505700600,NDC,1,EA,101.46,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,89.48772,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
predniSONE 5 mg/5 mL 5 MG/5ML Solution 120 mL Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54372250,NDC,120,ML,186.47,,Health Partners,Health Partners Care Plans,both,48,,0.129529412,percent of total billed charges,89.5056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 5 mg/5 mL 5 MG/5ML Solution 120 mL Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54372250,NDC,120,ML,186.47,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,89.5056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
Blood Typing Abo,PX86900,CDM,300,RC,86900,CPT,,,,,,,,92,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,35.03555556,percent of total billed charges,89.5436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.2168,111.6
Blood Typing Rh (D),PX86901,CDM,300,RC,86901,CPT,,,,,,,,92,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,35.03555556,percent of total billed charges,89.5436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.03,90.16
Parvovirus Antibody - Ref,PX8674790,CDM,300,RC,86747,CPT,90,,,,,,,92,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,89.5436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.78,90.16
"Reticulocyte Count,Flow Cyto",PX85045,CDM,300,RC,85045,CPT,,,,,,,,92,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,89.5436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.66,90.16
Assay of Ferritin,PX82728,CDM,300,RC,82728,CPT,,,,,,,,177,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,89.562,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.5,173.46
"D-Dimer, Quantitative - Ref",PX8537990,CDM,300,RC,85379,CPT,90,,,,,,,177,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,89.562,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.33,173.46
Fibrin Degradation Quant,PX85379,CDM,300,RC,85379,CPT,,,,,,,,177,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,89.562,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.33,173.46
Inj Tendon/Ligament/Cyst,PX20550F,CDM,510,RC,20550,CPT,,,,,,,,177,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,89.562,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.5258,258.75
Alcohol Biomarkers; 1 or 2 - Ref,PX8032190,CDM,300,RC,80321,CPT,90,,,,,,,181,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,89.595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.1874,177.38
"Lyme Disease, Antibody - Ref",PX8661890,CDM,300,RC,86618,CPT,90,,,,,,,181,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,89.595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.61,177.38
PHALINX STERILE TRIAL SIZER 45A00000,27200000,CDM,272,RC,,,,12959-MAIN,LOCAL,,,,,181,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,89.595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
sodium bicarbonate 4.2 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409553434,NDC,10,ML,91.46,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,89.6308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Drain Finger Abscess,Simple",PX26010F,CDM,510,RC,26010,CPT,,,,,,,,310,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,89.65,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,89.65,716.7
"Drain Finger Abscess,Simple",PX26010P,CDM,983,RC,26010,CPT,,,,,,,,207,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,89.65,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,89.65,716.7
MRI Abdomen W/O Tc,PX7418101,CDM,610,RC,74181,CPT,TC,,,,,,,2655,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,89.65,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.78,262.3
ACCESSORY KIT FOR GROSHONG 16GA,120.46,CDM,272,RC,C1751,HCPCS,,2967-MAIN,LOCAL,,,,,209,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,89.661,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.8186,204.82
Infection Agent Detect Dna/Rna Probe Tq 12-25,PX87507,CDM,300,RC,87507,CPT,,,,,,,,209,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,89.661,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.8186,382.15
"Organic Acid, Single, Qnt - Ref",PX8392190,CDM,300,RC,83921,CPT,90,,,,,,,209,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,89.661,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.45,204.82
Voriconazole - Ref,PX8028590,CDM,300,RC,80285,CPT,90,,,,,,,183,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,89.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.86,179.34
Voriconazole - Ref,PX8028590,CDM,300,RC,80285,CPT,90,,,,,,,183,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,89.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.86,179.34
Voriconazole - Ref,PX8028590,CDM,300,RC,80285,CPT,90,,,,,,,183,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,89.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.86,179.34
"Office/Outpt Visit,Est,Levl V",PX99215F,CDM,510,RC,99215,CPT,,,,,,,,318,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,89.69,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,89.69,324.12
"Office/Outpt Visit,Est,Levl V",PX99215P,CDM,983,RC,99215,CPT,,,,,,,,318,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,89.69,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,89.69,324.12
imipenem-cilastatin 250 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323034925,NDC,1,EA,91.55,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,89.719,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,173.1856
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032294,NDC,1,EA,91.55,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,89.719,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,173.1856
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234001,NDC,1.25,ML,91.55,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,89.719,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
C-COLLAR ASPEN REGULAR 79-83365,120.25,CDM,274,RC,L0140,HCPCS,,167-MAIN,LOCAL,,,,,216,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,89.7264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.58,211.68
C-COLLAR ASPEN TALL 79-83367,120.25,CDM,274,RC,L0140,HCPCS,,164-MAIN,LOCAL,,,,,216,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,89.7264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.58,211.68
C-COLLAR ASPEN X-TALL 79-83368,120.25,CDM,274,RC,L0140,HCPCS,,168-MAIN,LOCAL,,,,,216,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,89.7264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.58,211.68
"Remv F.B.,Eye,Embed Conjunc",PX65210P,CDM,983,RC,65210,CPT,,,,,,,,216,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,89.7264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,89.7264,348.08
Fac/Initial Hospital Care Levl II,PX99222F,CDM,510,RC,99222,CPT,,,,,,,,187,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,89.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.6798,183.26
Fac/Initial Hospital Care Levl II,PX99222F,CDM,510,RC,99222,CPT,,,,,,,,187,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,89.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.6798,183.26
"Infect Ag,Eia, Nos, Ea - Ref",PX8744990,CDM,300,RC,87449,CPT,90,,,,,,,187,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,89.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,183.26
"Infect Ag,Eia, Nos, Ea - Ref",PX8744990,CDM,300,RC,87449,CPT,90,,,,,,,187,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,89.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,183.26
RETRIEVAL BAG 12/15MM,27200000,CDM,272,RC,,,,12660-MAIN,LOCAL,,,,,187,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,89.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RETRIEVAL BAG 12/15MM,27200000,CDM,272,RC,,,,12660-MAIN,LOCAL,,,,,187,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,89.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
rivaroxaban 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50458058030,NDC,1,EA,98.57,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,89.79727,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone sodium succinate (preservative free) 250 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001305,NDC,1,EA,183.32,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,89.8268,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
hydrocortisone sodium succinate (preservative free) 250 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001305,NDC,1,EA,183.32,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,89.8268,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
hydrocortisone sodium succinate (preservative free) 250 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001305,NDC,1,EA,183.32,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,89.8268,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409339004,NDC,1,EA,98.61,,Medica,Commercial,both,91.1,,5.442333333,percent of total billed charges,89.83371,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
"Inpatient Consult, Level IV",PX99254,CDM,983,RC,99254,CPT,,,,,,,,508,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,89.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.73,497.84
"Inpatient Consult, Level IV",PX99254,CDM,983,RC,99254,CPT,,,,,,,,508,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,89.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.73,497.84
Jak2 Gene - Ref,PX8127090,CDM,300,RC,81270,CPT,90,,,,,,,734,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,89.852,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.91,91.66
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021515,NDC,0.5,ML,187.24,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,89.8752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.779496,199.7926
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021515,NDC,0.5,ML,187.24,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,89.8752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.779496,199.7926
BRACE KNEE LARGE SHORTRUNNER 21754,120.387,CDM,274,RC,L1833,HCPCS,,10044-MAIN,LOCAL,,,,,101,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,89.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE MEDIUM SHORTRUNNER 21753,120.387,CDM,274,RC,L1833,HCPCS,,10126-MAIN,LOCAL,,,,,101,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,89.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE SMALL SHORTRUNNER 21752,120.387,CDM,274,RC,L1833,HCPCS,,10900-MAIN,LOCAL,,,,,101,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,89.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE X-LARGE SHORTRUNNER 21755,120.387,CDM,274,RC,L1833,HCPCS,,3444-MAIN,LOCAL,,,,,101,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,89.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE XX-LARGE SHORTRUNNER 21756,120.387,CDM,274,RC,L1833,HCPCS,,10615-MAIN,LOCAL,,,,,101,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,89.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
"COLLAR CERVICAL 2"" SMALL UNIVERSAL 08140039",120.249,CDM,274,RC,L0120,HCPCS,,270-MAIN,LOCAL,,,,,101,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,89.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 2X20"" SMALL 1003-02",120.249,CDM,274,RC,L0120,HCPCS,,272-MAIN,LOCAL,,,,,101,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,89.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 2X23.5"" MEDIUM XNARROW 1003-04",120.249,CDM,274,RC,L0120,HCPCS,,273-MAIN,LOCAL,,,,,101,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,89.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 10-15"" SMALL XLONG 1005-06",120.249,CDM,274,RC,L0120,HCPCS,,267-MAIN,LOCAL,,,,,101,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,89.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL LARGE 21.5""X5"" 1005-04",120.249,CDM,274,RC,L0120,HCPCS,,268-MAIN,LOCAL,,,,,101,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,89.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL MEDIUM 20-1/2X4"" 1005-03",120.249,CDM,274,RC,L0120,HCPCS,,269-MAIN,LOCAL,,,,,101,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,89.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
COLLAR CERVICAL SMALL 1005-02,120.249,CDM,274,RC,L0120,HCPCS,,266-MAIN,LOCAL,,,,,101,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,89.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615704,NDC,1,EA,101.92,,United Healthcare,All Payer,outpatient,88.2,,49.96,percent of total billed charges,89.89344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061400,NDC,1,ML,101.95,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,89.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.114178,99.911
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615700,NDC,1,EA,101.95,,United Healthcare,All Payer,outpatient,88.2,,49.96,percent of total billed charges,89.9199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,67815203,NDC,100,GR,91.77,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,89.9346,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Concurrent Infusion,PX96368,CDM,260,RC,96368,CPT,,,,,,,,102,,United Healthcare,All Payer,outpatient,88.2,,54.06,percent of total billed charges,89.964,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.3708,99.96
Immunohisto Antibody Slide Ea Addl,PX8834101,CDM,310,RC,88341,CPT,TC,,,,,,,102,,United Healthcare,All Payer,outpatient,88.2,,48.51,percent of total billed charges,89.964,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.3708,99.96
Reptilase Test - Ref,PX8563590,CDM,300,RC,85635,CPT,90,,,,,,,102,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,89.964,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.03,99.96
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,574402435,NDC,3.5,GR,101.11,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,89.9879,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052084,NDC,1,EA,92.46,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,89.991318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.407884,90.9538
empagliflozin 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,597015230,NDC,1,EA,92.47,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,90.001051,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Package,25000000,CDM,250,RC,,,,,,66758020858,NDC,1,EA,102.08,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,90.03456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Hospital Inpt or Obs Care, Admin/Disch Same Date Straightforward or Low Level Mdm >= 45 Minutes",PX99234,CDM,982,RC,99234,CPT,,,,,,,,464,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,90.048,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.32,454.72
atropine (PF) 1 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517101025,NDC,1,ML,91.89,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,90.0522,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,90.0522
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001481,NDC,1,EA,102.12,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,90.06984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
AIRSEAL ROBOTIC Xi CAP AND OBTURATOR WITH BLADELESS OPTICAL TIP,27200000,CDM,272,RC,,,,12208-MAIN,LOCAL,,,,,210,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,90.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
AIRSEAL ROBOTIC Xi TRI LUMEN FILTERED TUBE SET WITH ACTIVATED CHARCOAL,27200000,CDM,272,RC,,,,12209-MAIN,LOCAL,,,,,210,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,90.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Apply Forearm Cast,PX29075F,CDM,510,RC,29075,CPT,,,,,,,,210,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,90.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,234.62
Chorionic gonadotropin test,PX84702,CDM,300,RC,84702,CPT,,,,,,,,210,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,90.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.8,205.8
Debride Skin/Subq Ea Ad 20sqcm,PX11045P,CDM,983,RC,11045,CPT,,,,,,,,182,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,90.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.6028,177.1406
"Excision of Nail Fold, Toe",PX11765F,CDM,510,RC,11765,CPT,,,,,,,,210,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,90.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,348.35
Fac/Hospital Discharge Day>30 Min,PX99239F,CDM,510,RC,99239,CPT,,,,,,,,210,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,90.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,205.8
Immunocytochemistry,PX3993,CDM,310,RC,88342,CPT,TC,,,,,,,182,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,90.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.6028,178.36
Infec Agent Direct Probe - Ref,PX8779990,CDM,300,RC,87799,CPT,90,,,,,,,182,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,90.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.28,178.36
"Inject Trigger Point, 1 or 2",PX20552P,CDM,983,RC,20552,CPT,,,,,,,,210,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,90.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,258.75
GLIDESCOPE QC MILLER S0 SINGLE USE 0270-1087,120.58,CDM,272,RC,,,,13024-MAIN,LOCAL,,,,,106,,First Health,Commercial,both,85,,999999999,percent of total billed charges,90.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
GLIDESCOPE QC MILLER S1 SINGLE USE 0270-1088,120.58,CDM,272,RC,,,,13025-MAIN,LOCAL,,,,,106,,First Health,Commercial,both,85,,999999999,percent of total billed charges,90.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
ondansetron 4 MG/5ML Solution 50 mL Bottle,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714067102,NDC,5,ML,98.91,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,90.10701,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,703574811,NDC,100,ML,183.92,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,90.1208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.174958,180.2416
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,703574811,NDC,100,ML,183.92,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,90.1208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.174958,180.2416
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,703574811,NDC,100,ML,183.92,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,90.1208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.174958,180.2416
cefTRIAXone in dextrose 1 g / 50 mL 1-3.74 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0696.01,CDM,636,RC,J0696,HCPCS,,,,264315311,NDC,1,EA,106.03,,First Health,Commercial,both,85,,999999999,percent of total billed charges,90.1255,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
Procalcitonin,PX84145,CDM,300,RC,84145,CPT,,,,,,,,217,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,90.1418,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.96,212.66
TRAY 8 FR 5IN CENTESIS WITH TURKEL  30-CE1CO,120.303,CDM,272,RC,,,,11503-MAIN,LOCAL,,,,,217,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,90.1418,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,90.1418,212.66
Blood Typing Abo,PX86900,CDM,300,RC,86900,CPT,,,,,,,,92,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,90.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.2168,111.6
Blood Typing Rh (D),PX86901,CDM,300,RC,86901,CPT,,,,,,,,92,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,90.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.03,90.16
Parvovirus Antibody - Ref,PX8674790,CDM,300,RC,86747,CPT,90,,,,,,,92,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,90.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.78,90.16
"Reticulocyte Count,Flow Cyto",PX85045,CDM,300,RC,85045,CPT,,,,,,,,92,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,90.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.66,90.16
TUBE TRACH SIZE 3.0MM ID 4.5MM OD SHILEY PEDIATRIC 3.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1185-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,90.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 3.0MM ID 4.5MM OD SHILEY PEDIATRIC 3.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1185-MAIN,LOCAL,,,,,184,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,90.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 3.0MM ID 4.5MM OD SHILEY PEDIATRIC 3.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1185-MAIN,LOCAL,,,,,184,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,90.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 3.5MM ID 5.2MM OD SHILEY PEDIATRIC,120.287,CDM,272,RC,A7520,HCPCS,,8813-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,90.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 3.5MM ID 5.2MM OD SHILEY PEDIATRIC,120.287,CDM,272,RC,A7520,HCPCS,,8813-MAIN,LOCAL,,,,,184,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,90.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 3.5MM ID 5.2MM OD SHILEY PEDIATRIC,120.287,CDM,272,RC,A7520,HCPCS,,8813-MAIN,LOCAL,,,,,184,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,90.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 4.0MM ID 5.9MM OD SHILEY PEDIATRIC 4.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1187-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,90.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 4.0MM ID 5.9MM OD SHILEY PEDIATRIC 4.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1187-MAIN,LOCAL,,,,,184,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,90.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 4.0MM ID 5.9MM OD SHILEY PEDIATRIC 4.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1187-MAIN,LOCAL,,,,,184,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,90.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 5 7.0MM ID 10.1MM OD SHILEY CUFFED 5CN70H,120.287,CDM,272,RC,A7521,HCPCS,,10350-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,90.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 5 7.0MM ID 10.1MM OD SHILEY CUFFED 5CN70H,120.287,CDM,272,RC,A7521,HCPCS,,10350-MAIN,LOCAL,,,,,184,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,90.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 5 7.0MM ID 10.1MM OD SHILEY CUFFED 5CN70H,120.287,CDM,272,RC,A7521,HCPCS,,10350-MAIN,LOCAL,,,,,184,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,90.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 5.0MM ID 7.1MM OD SHILEY PEDIATRIC 5.0PED,120.287,CDM,272,RC,A7520,HCPCS,,8814-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,90.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 5.0MM ID 7.1MM OD SHILEY PEDIATRIC 5.0PED,120.287,CDM,272,RC,A7520,HCPCS,,8814-MAIN,LOCAL,,,,,184,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,90.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 5.0MM ID 7.1MM OD SHILEY PEDIATRIC 5.0PED,120.287,CDM,272,RC,A7520,HCPCS,,8814-MAIN,LOCAL,,,,,184,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,90.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 6 6.0MM ID 8.3MM OD SHILEY CUFFED 6SCT,120.287,CDM,272,RC,A7521,HCPCS,,8812-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,90.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 6 6.0MM ID 8.3MM OD SHILEY CUFFED 6SCT,120.287,CDM,272,RC,A7521,HCPCS,,8812-MAIN,LOCAL,,,,,184,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,90.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 6 6.0MM ID 8.3MM OD SHILEY CUFFED 6SCT,120.287,CDM,272,RC,A7521,HCPCS,,8812-MAIN,LOCAL,,,,,184,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,90.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 6 6.4MM ID 10.8MM OD SHILEY CUFFED 6DCT,120.287,CDM,272,RC,A7521,HCPCS,,1190-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,90.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 6 6.4MM ID 10.8MM OD SHILEY CUFFED 6DCT,120.287,CDM,272,RC,A7521,HCPCS,,1190-MAIN,LOCAL,,,,,184,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,90.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 6 6.4MM ID 10.8MM OD SHILEY CUFFED 6DCT,120.287,CDM,272,RC,A7521,HCPCS,,1190-MAIN,LOCAL,,,,,184,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,90.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 7.5MM ID 10.8MM OD SHILEY CUFFED 6CN75H,120.287,CDM,272,RC,A7521,HCPCS,,8488-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,90.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 7.5MM ID 10.8MM OD SHILEY CUFFED 6CN75H,120.287,CDM,272,RC,A7521,HCPCS,,8488-MAIN,LOCAL,,,,,184,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,90.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 7.5MM ID 10.8MM OD SHILEY CUFFED 6CN75H,120.287,CDM,272,RC,A7521,HCPCS,,8488-MAIN,LOCAL,,,,,184,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,90.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 8 7.6MM ID 12.2MM OD SHILEY 8DCT,120.287,CDM,272,RC,A7521,HCPCS,,1192-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,90.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 8 7.6MM ID 12.2MM OD SHILEY 8DCT,120.287,CDM,272,RC,A7521,HCPCS,,1192-MAIN,LOCAL,,,,,184,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,90.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 8 7.6MM ID 12.2MM OD SHILEY 8DCT,120.287,CDM,272,RC,A7521,HCPCS,,1192-MAIN,LOCAL,,,,,184,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,90.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 8 7.6MM ID 12.22MM OD SHILEY CUFFED 8LPC,120.287,CDM,272,RC,A7521,HCPCS,,8815-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,90.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 8 7.6MM ID 12.22MM OD SHILEY CUFFED 8LPC,120.287,CDM,272,RC,A7521,HCPCS,,8815-MAIN,LOCAL,,,,,184,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,90.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 8 7.6MM ID 12.22MM OD SHILEY CUFFED 8LPC,120.287,CDM,272,RC,A7521,HCPCS,,8815-MAIN,LOCAL,,,,,184,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,90.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 8.0MM ID 10.9MM OD SHILEY CUFFED 8SCT,120.287,CDM,272,RC,A7521,HCPCS,,8811-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,90.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 8.0MM ID 10.9MM OD SHILEY CUFFED 8SCT,120.287,CDM,272,RC,A7521,HCPCS,,8811-MAIN,LOCAL,,,,,184,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,90.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 8.0MM ID 10.9MM OD SHILEY CUFFED 8SCT,120.287,CDM,272,RC,A7521,HCPCS,,8811-MAIN,LOCAL,,,,,184,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,90.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 10 SHILEY 10LPC,120.287,CDM,272,RC,A7521,HCPCS,,1181-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,90.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 10 SHILEY 10LPC,120.287,CDM,272,RC,A7521,HCPCS,,1181-MAIN,LOCAL,,,,,184,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,90.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 10 SHILEY 10LPC,120.287,CDM,272,RC,A7521,HCPCS,,1181-MAIN,LOCAL,,,,,184,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,90.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,23155029031,NDC,2,ML,98.99,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,90.17989,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,97.0102
"Clostridium Ag, Eia",PX87324,CDM,300,RC,87324,CPT,,,,,,,,99,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,90.189,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,97.02
Deoxyribonuclease Ab,PX86215,CDM,300,RC,86215,CPT,,,,,,,,99,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,90.189,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,97.02
"Extractable Nuclear Antigen, Each Antigen",PX86235,CDM,300,RC,86235,CPT,90,,,,,,,99,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,90.189,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.44,97.02
"Fungus Antibody, Nos - Ref",PX8667190,CDM,300,RC,86671,CPT,90,,,,,,,99,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,90.189,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.23,97.02
"Lab Immunoassay, Non Antibody",PX83516,CDM,300,RC,83516,CPT,,,,,,,,99,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,90.189,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.57,97.02
"Protozoa Antibody, Nos - Ref",PX8675390,CDM,300,RC,86753,CPT,90,,,,,,,99,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,90.189,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.36,97.02
fentaNYL 25 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,47781042411,NDC,1,EA,101.44,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,90.2816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338411450,NDC,50,ML,106.23,,First Health,Commercial,both,85,,999999999,percent of total billed charges,90.2955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
"dextrose 5 % 5 % Solution 1,000 mL Flex Cont",J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001704,NDC,1000,ML,99.12,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,90.29832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001702,NDC,250,ML,99.12,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,90.29832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338634602,NDC,250,ML,99.12,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,90.29832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 500 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001703,NDC,500,ML,99.12,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,90.29832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % Non-DEHP bag 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,264751020,NDC,250,ML,99.12,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,90.29832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"dextrose 5% and sodium chloride 0.2% 5-0.2 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338007704,NDC,1000,ML,99.12,,Medica,Commercial,both,91.1,,12.792,percent of total billed charges,90.29832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
"dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008904,NDC,1000,ML,99.12,,Medica,Commercial,both,91.1,,12.792,percent of total billed charges,90.29832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 500 mL Flex Cont,J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008903,NDC,500,ML,99.12,,Medica,Commercial,both,91.1,,12.792,percent of total billed charges,90.29832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
"dextrose 5% and sodium chloride 0.45% 5-0.45 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008504,NDC,1000,ML,99.12,,Medica,Commercial,both,91.1,,12.792,percent of total billed charges,90.29832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
dextrose 5% lactated ringers 5 % Solution 500 mL Flex Cont,J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012503,NDC,500,ML,99.12,,Medica,Commercial,both,91.1,,15.33309859,percent of total billed charges,90.29832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 10% 10 % Solution 500 mL Flex Cont,25000000,CDM,250,RC,,,,,,338002303,NDC,500,ML,99.12,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,90.29832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lactated ringers Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338011704,NDC,1000,ML,99.12,,Medica,Commercial,both,91.1,,15.33309859,percent of total billed charges,90.29832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338069104,NDC,1000,ML,99.12,,Medica,Commercial,both,91.1,,1.111818182,percent of total billed charges,90.29832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004904,NDC,1000,ML,99.12,,Medica,Commercial,both,91.1,,13.59421053,percent of total billed charges,90.29832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954306,NDC,1000,ML,99.12,,Medica,Commercial,both,91.1,,13.59421053,percent of total billed charges,90.29832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004902,NDC,250,ML,99.12,,Medica,Commercial,both,91.1,,13.59421053,percent of total billed charges,90.29832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954302,NDC,250,ML,99.12,,Medica,Commercial,both,91.1,,13.59421053,percent of total billed charges,90.29832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 500 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004903,NDC,500,ML,99.12,,Medica,Commercial,both,91.1,,13.59421053,percent of total billed charges,90.29832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9% 0.9% Solution 1,000 mL Flex Cont",J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004904,NDC,1000,ML,99.12,,Medica,Commercial,both,91.1,,7.872391304,percent of total billed charges,90.29832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9% IV LINE FLUSH 0.9% Solution 250 mL Flex Cont,25000000,CDM,250,RC,,,,,,338004902,NDC,250,ML,99.12,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,90.29832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"sodium chloride 0.45 % 0.45 % Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,338004304,NDC,1000,ML,99.12,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,90.29832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 3 % 3 % Solution 500 mL Flex Cont,J7131.01,CDM,636,RC,J7131,HCPCS,,,,338005403,NDC,500,ML,99.12,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,90.29832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
fentaNYL 25 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505700600,NDC,1,EA,101.46,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,90.2994,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052083,NDC,1,EA,92.81,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,90.331973,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.407884,90.9538
"Office/Outpt Visit,Est,Levl IV",PX99214F,CDM,510,RC,99214,CPT,,,,,,,,256,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,90.3696,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.11,230.23
"Office/Outpt Visit,Est,Levl IV",PX99214P,CDM,983,RC,99214,CPT,,,,,,,,256,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,90.3696,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.11,250.88
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,781523806,NDC,1,EA,106.34,,First Health,Commercial,both,85,,999999999,percent of total billed charges,90.389,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,781523864,NDC,1,EA,106.34,,First Health,Commercial,both,85,,999999999,percent of total billed charges,90.389,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,65862039010,NDC,1,EA,106.34,,First Health,Commercial,both,85,,999999999,percent of total billed charges,90.389,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
CT Maxillofacialw/O Dye,PX7048601,CDM,350,RC,70486,CPT,TC,,,,,,,2757,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,90.4258,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.08,180.13
levothyroxine 100 MCG/5ML Solution 5 mL Vial,J0651.01,CDM,636,RC,J0651,HCPCS,,,,63323088510,NDC,0.625,ML,99.32,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,90.48052,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.257528,97.3336
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026969,NDC,100,ML,99.34,,Medica,Commercial,both,91.1,,0.687108295,percent of total billed charges,90.49874,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
BOOT AIRSELECT SHORT LARGE 01ES-L,120.45,CDM,274,RC,L4360,HCPCS,,11890-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,74.22,percent of total billed charges,90.5169,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT MEDIUM 01ES-M,120.45,CDM,274,RC,L4360,HCPCS,,11889-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,74.22,percent of total billed charges,90.5169,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT SMALL 01ES-S,120.45,CDM,274,RC,L4360,HCPCS,,11888-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,74.22,percent of total billed charges,90.5169,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT X-LARGE 01ES-XL,120.45,CDM,274,RC,L4360,HCPCS,,11891-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,74.22,percent of total billed charges,90.5169,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT X-SMALL 01ES-XS,120.45,CDM,274,RC,L4360,HCPCS,,11887-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,74.22,percent of total billed charges,90.5169,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD LARGE 01EF-L,120.45,CDM,274,RC,L4360,HCPCS,,11697-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,74.22,percent of total billed charges,90.5169,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD MEDIUM 01EF-M,120.45,CDM,274,RC,L4360,HCPCS,,11696-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,74.22,percent of total billed charges,90.5169,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD SMALL 01EF-S,120.45,CDM,274,RC,L4360,HCPCS,,11695-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,74.22,percent of total billed charges,90.5169,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD X-LARGE 01EF-XL,120.45,CDM,274,RC,L4360,HCPCS,,11698-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,74.22,percent of total billed charges,90.5169,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD X-SMALL 01EF-XS,120.45,CDM,274,RC,L4360,HCPCS,,11694-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,74.22,percent of total billed charges,90.5169,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
Russell Viper Venom - Ref,PX8561390,CDM,300,RC,85613,CPT,90,,,,,,,93,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,90.5169,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.78,91.14
SPLINT FOOT SMALL STRUT WALK 11-1383-2-00000,120.45,CDM,274,RC,L4360,HCPCS,,1205-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,74.22,percent of total billed charges,90.5169,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
Bone Age Studies Tc,PX7707201,CDM,320,RC,77072,CPT,TC,,,,,,,211,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,90.519,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.6494,206.78
Collect Blood From Picc,PX36592F,CDM,510,RC,36592,CPT,,,,,,,,211,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,90.519,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.6494,206.78
Draw Blood Off Venous Device,PX36591F,CDM,510,RC,36591,CPT,,,,,,,,211,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,90.519,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.6494,206.78
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331801,NDC,10,ML,102.65,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,90.5373,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781315972,NDC,1,EA,217.96,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,90.540584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86,213.6008
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098321,NDC,1,EA,99.39,,Medica,Commercial,both,91.1,,5.442333333,percent of total billed charges,90.54429,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098323,NDC,1,EA,99.39,,Medica,Commercial,both,91.1,,5.442333333,percent of total billed charges,90.54429,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052200,NDC,1,EA,99.39,,Medica,Commercial,both,91.1,,5.442333333,percent of total billed charges,90.54429,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052237,NDC,1,EA,99.39,,Medica,Commercial,both,91.1,,5.442333333,percent of total billed charges,90.54429,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
"Apply Short Leg Cast,Walker",PX29425F,CDM,510,RC,29425,CPT,,,,,,,,179,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,90.574,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.3566,234.62
C Diff Amplified Probe,PX87493,CDM,300,RC,87493,CPT,,,,,,,,179,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,90.574,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.17,175.42
Fibrinogen Test - Ref,PX8536690,CDM,300,RC,85366,CPT,90,,,,,,,179,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,90.574,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.77,175.42
TUBE GASTROSTOMY 18FR REPLACEMENT DYND70318,120.256,CDM,271,RC,B4087,HCPCS,,407-MAIN,LOCAL,,,,,179,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,90.574,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.53,175.42
Voriconazole - Ref,PX8028590,CDM,300,RC,80285,CPT,90,,,,,,,183,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,90.585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.86,179.34
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052084,NDC,1,EA,92.46,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,90.6108,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.407884,90.9538
empagliflozin 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,597015230,NDC,1,EA,92.47,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,90.6206,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Amylase - Ref,PX8215090,CDM,300,RC,82150,CPT,90,,,,,,,185,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,90.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.94,181.3
Amylase - Ref,PX8215090,CDM,300,RC,82150,CPT,90,,,,,,,185,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,90.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.94,181.3
Amylase - Ref,PX8215090,CDM,300,RC,82150,CPT,90,,,,,,,185,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,90.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.94,181.3
Hepatitis C Rna Quant,PX87522,CDM,300,RC,87522,CPT,,,,,,,,185,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,90.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.28,181.3
Hepatitis C Rna Quant,PX87522,CDM,300,RC,87522,CPT,,,,,,,,185,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,90.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.28,181.3
Hepatitis C Rna Quant,PX87522,CDM,300,RC,87522,CPT,,,,,,,,185,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,90.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.28,181.3
"Level IV - Surgical Pathology, Gross and Microscopic Examination , Tech",PX3934,CDM,310,RC,88305,CPT,TC,,,,,,,185,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,53.92052632,percent of total billed charges,90.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,271.15
"Level IV - Surgical Pathology, Gross and Microscopic Examination , Tech",PX3934,CDM,310,RC,88305,CPT,TC,,,,,,,185,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,90.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,271.15
"Level IV - Surgical Pathology, Gross and Microscopic Examination , Tech",PX3934,CDM,310,RC,88305,CPT,TC,,,,,,,185,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,90.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,271.15
"Office/Outpt Visit,Est,Levl III",PX99213F,CDM,510,RC,99213,CPT,,,,,,,,185,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,27.725,percent of total billed charges,90.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.849,181.3
"Office/Outpt Visit,Est,Levl III",PX99213F,CDM,510,RC,99213,CPT,,,,,,,,185,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,90.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.849,181.3
"Office/Outpt Visit,Est,Levl III",PX99213F,CDM,510,RC,99213,CPT,,,,,,,,185,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,90.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.849,181.3
"Office/Outpt Visit,Est,Levl III",PX99213P,CDM,983,RC,99213,CPT,,,,,,,,185,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,27.725,percent of total billed charges,90.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.849,180.0605
"Office/Outpt Visit,Est,Levl III",PX99213P,CDM,983,RC,99213,CPT,,,,,,,,185,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,90.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.849,180.0605
"Office/Outpt Visit,Est,Levl III",PX99213P,CDM,983,RC,99213,CPT,,,,,,,,185,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,90.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.849,180.0605
rifAXIMin 550 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,65649030302,NDC,1,EA,218.25,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,90.66105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rifAXIMin 550 MG Tablet 60 Each Box,63700001,CDM,250,RC,,,,,,65649030303,NDC,1,EA,218.25,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,90.66105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615704,NDC,1,EA,101.92,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,90.7088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
ALEXIS 0 LARGE STERILE,27200000,CDM,272,RC,,,,11765-MAIN,LOCAL,,,,,102.85,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,90.7137,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Alcohols - Ref,PX8032090,CDM,300,RC,80320,CPT,90,,,,,,,189,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,90.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.5106,185.22
Alcohols - Ref,PX8032090,CDM,300,RC,80320,CPT,90,,,,,,,189,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,90.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.5106,185.22
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601901,NDC,10,ML,211.47,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,90.72063,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.844638,207.2406
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601910,NDC,10,ML,211.47,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,90.72063,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.844638,207.2406
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061400,NDC,1,ML,101.95,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,90.7355,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.114178,99.911
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615700,NDC,1,EA,101.95,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,90.7355,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
hydrocortisone sodium succinate (preservative free) 250 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001305,NDC,1,EA,183.32,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,90.7434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
Concurrent Infusion,PX96368,CDM,260,RC,96368,CPT,,,,,,,,102,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,90.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.3708,99.96
Immunohisto Antibody Slide Ea Addl,PX8834101,CDM,310,RC,88341,CPT,TC,,,,,,,102,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,90.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.3708,99.96
Reptilase Test - Ref,PX8563590,CDM,300,RC,85635,CPT,90,,,,,,,102,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,90.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.03,99.96
sulfamethoxazole-trimethoprim 400-80 MG/5ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,703951403,NDC,10,ML,102.93,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,90.78426,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031801,NDC,1,ML,185.37,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,90.8313,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.002698,181.6626
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031801,NDC,1,ML,185.37,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,90.8313,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.002698,181.6626
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031801,NDC,1,ML,185.37,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,90.8313,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.002698,181.6626
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031825,NDC,1,ML,185.37,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,90.8313,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.002698,181.6626
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031825,NDC,1,ML,185.37,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,90.8313,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.002698,181.6626
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031825,NDC,1,ML,185.37,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,90.8313,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.002698,181.6626
nafcillin 2 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,S0032,HCPCS,,,,63323032820,NDC,1,EA,185.37,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,90.8313,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
nafcillin 2 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,S0032,HCPCS,,,,63323032820,NDC,1,EA,185.37,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,90.8313,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
nafcillin 2 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,S0032,HCPCS,,,,63323032820,NDC,1,EA,185.37,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,90.8313,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Assay of Transferrin,PX84466,CDM,300,RC,84466,CPT,,,,,,,,103,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,90.846,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.7,100.94
"Lactoferrin, Fecal; Qual",PX83630,CDM,300,RC,83630,CPT,,,,,,,,103,,United Healthcare,All Payer,outpatient,88.2,,50.47,percent of total billed charges,90.846,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.06,100.94
"Molecyto Insitu, 100-300cl - Ref",PX8827590,CDM,310,RC,88275,CPT,90,,,,,,,103,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,90.846,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.7862,100.94
"Tiss Cult,Non-Neop Lymph - Ref",PX8823090,CDM,310,RC,88230,CPT,90,,,,,,,103,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,90.846,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.7862,106.81
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Package,25000000,CDM,250,RC,,,,,,66758020858,NDC,1,EA,102.08,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,90.8512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Apply Long Leg Cast,PX29345F,CDM,510,RC,29345,CPT,,,,,,,,912,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,90.8713,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.29,285.71
fentaNYL 50 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,47781042611,NDC,1,EA,185.47,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,90.8803,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 50 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,47781042611,NDC,1,EA,185.47,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,90.8803,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 50 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,47781042611,NDC,1,EA,185.47,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,90.8803,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 50 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,47781042647,NDC,1,EA,185.47,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,90.8803,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 50 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,47781042647,NDC,1,EA,185.47,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,90.8803,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 50 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,47781042647,NDC,1,EA,185.47,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,90.8803,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001481,NDC,1,EA,102.12,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,90.8868,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,24208091055,NDC,3.5,GR,106.98,,First Health,Commercial,both,85,,999999999,percent of total billed charges,90.933,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Non-Select. Wound Debride., W/O Anesth.; Top. Appl./Wound Assess./Instruct., per Sess.",PX97602,CDM,761,RC,97602,CPT,,,,,,,,212,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,90.948,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.0648,207.76
3.0MM NON-THREADED K WIRE,27200000,CDM,272,RC,C1769,HCPCS,,12658-MAIN,LOCAL,,,,,107,,First Health,Commercial,both,85,,999999999,percent of total billed charges,90.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Androsetenedione - Ref,PX8215790,CDM,300,RC,82157,CPT,90,,,,,,,107,,First Health,Commercial,both,85,,999999999,percent of total billed charges,90.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.85,104.86
Decalcify Tc,PX8831101,CDM,310,RC,88311,CPT,TC,,,,,,,107,,First Health,Commercial,both,85,,999999999,percent of total billed charges,90.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
Fac/Trim Nail(S),PX11719F,CDM,510,RC,11719,CPT,,,,,,,,107,,First Health,Commercial,both,85,,999999999,percent of total billed charges,90.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
Path Special Stains II,PX3979,CDM,310,RC,88313,CPT,TC,,,,,,,107,,First Health,Commercial,both,85,,999999999,percent of total billed charges,90.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
"Special Stains,Group I",PX3978,CDM,310,RC,88312,CPT,TC,,,,,,,107,,First Health,Commercial,both,85,,999999999,percent of total billed charges,90.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062001,NDC,0.4,ML,189.48,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,90.9504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062001,NDC,0.4,ML,189.48,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,90.9504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062040,NDC,0.4,ML,189.48,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,90.9504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062040,NDC,0.4,ML,189.48,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,90.9504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801401,NDC,0.4,ML,189.48,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,90.9504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801401,NDC,0.4,ML,189.48,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,90.9504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801410,NDC,0.4,ML,189.48,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,90.9504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801410,NDC,0.4,ML,189.48,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,90.9504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052083,NDC,1,EA,92.81,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,90.9538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.407884,90.9538
verapamil 2.5 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,409114405,NDC,2,ML,185.65,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,90.9685,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
verapamil 2.5 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,409114405,NDC,2,ML,185.65,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,90.9685,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
verapamil 2.5 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,409114405,NDC,2,ML,185.65,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,90.9685,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Drain Finger Abscess,Simple",PX26010F,CDM,510,RC,26010,CPT,,,,,,,,310,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,90.97,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,89.65,716.7
"Drain Finger Abscess,Simple",PX26010F,CDM,510,RC,26010,CPT,,,,,,,,310,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,90.97,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,89.65,716.7
"Drain Finger Abscess,Simple",PX26010P,CDM,983,RC,26010,CPT,,,,,,,,207,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,90.97,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,89.65,716.7
"Drain Finger Abscess,Simple",PX26010P,CDM,983,RC,26010,CPT,,,,,,,,207,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,90.97,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,89.65,716.7
CANNULATED AO HANDLE STERILE MICA SCREW SYSTEM 57S1HNDL,27200000,CDM,272,RC,,,,12446-MAIN,LOCAL,,,,,219,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,90.9726,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TUBE SURGICAL IRRIGATION 1PK PD-IT,27200000,CDM,272,RC,,,,12433-MAIN,LOCAL,,,,,219,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,90.9726,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DOPamine 1600 mcg/mL in dextrose 5% 250 mL premix 1600 mcg/mL Solution 250 mL Plas Cont,J1265.01,CDM,636,RC,J1265,HCPCS,,,,338100702,NDC,250,ML,99.9,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,91.0089,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.49846,97.902
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927380,NDC,1,EA,99.91,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,91.01801,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927395,NDC,1,EA,99.91,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,91.01801,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
lidocaine 0.5 % PF 0.5 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323049101,NDC,50,ML,103.2,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,91.0224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,703574811,NDC,100,ML,183.92,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,91.0404,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.174958,180.2416
C-Peptide - Ref,PX8468190,CDM,300,RC,84681,CPT,90,,,,,,,180,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,91.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,176.4
"Closed Rx Radial Head Disloc,Child",PX24640P,CDM,983,RC,24640,CPT,,,,,,,,180,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,91.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.772,206.02
"Infect Ea Organ, Amp Prob - Ref",PX8779890,CDM,300,RC,87798,CPT,90,,,,,,,180,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,91.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,176.4
Mrsa by Amplification Na,PX87641,CDM,300,RC,87641,CPT,,,,,,,,180,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,91.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,176.4
Protein Elp,PX84166,CDM,300,RC,84166,CPT,,,,,,,,180,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,91.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.35,176.4
TUBE TRACH SIZE 3.0MM ID 4.5MM OD SHILEY PEDIATRIC 3.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1185-MAIN,LOCAL,,,,,184,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,91.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 3.5MM ID 5.2MM OD SHILEY PEDIATRIC,120.287,CDM,272,RC,A7520,HCPCS,,8813-MAIN,LOCAL,,,,,184,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,91.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 4.0MM ID 5.9MM OD SHILEY PEDIATRIC 4.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1187-MAIN,LOCAL,,,,,184,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,91.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 5 7.0MM ID 10.1MM OD SHILEY CUFFED 5CN70H,120.287,CDM,272,RC,A7521,HCPCS,,10350-MAIN,LOCAL,,,,,184,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,91.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 5.0MM ID 7.1MM OD SHILEY PEDIATRIC 5.0PED,120.287,CDM,272,RC,A7520,HCPCS,,8814-MAIN,LOCAL,,,,,184,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,91.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 6 6.0MM ID 8.3MM OD SHILEY CUFFED 6SCT,120.287,CDM,272,RC,A7521,HCPCS,,8812-MAIN,LOCAL,,,,,184,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,91.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 6 6.4MM ID 10.8MM OD SHILEY CUFFED 6DCT,120.287,CDM,272,RC,A7521,HCPCS,,1190-MAIN,LOCAL,,,,,184,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,91.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 7.5MM ID 10.8MM OD SHILEY CUFFED 6CN75H,120.287,CDM,272,RC,A7521,HCPCS,,8488-MAIN,LOCAL,,,,,184,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,91.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 8 7.6MM ID 12.2MM OD SHILEY 8DCT,120.287,CDM,272,RC,A7521,HCPCS,,1192-MAIN,LOCAL,,,,,184,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,91.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 8 7.6MM ID 12.22MM OD SHILEY CUFFED 8LPC,120.287,CDM,272,RC,A7521,HCPCS,,8815-MAIN,LOCAL,,,,,184,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,91.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 8.0MM ID 10.9MM OD SHILEY CUFFED 8SCT,120.287,CDM,272,RC,A7521,HCPCS,,8811-MAIN,LOCAL,,,,,184,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,91.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 10 SHILEY 10LPC,120.287,CDM,272,RC,A7521,HCPCS,,1181-MAIN,LOCAL,,,,,184,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,91.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
gentamicin 0.3 % Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,17478028435,NDC,3.5,GR,219.3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,91.09722,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
gadoteridol 279.3 MG/ML Solution 5 mL Vial,A9576,CDM,636,RC,A9576,HCPCS,,,,270111104,NDC,10,ML,100,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,91.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.54,166.6
Sars-Cov-2 Covid-19 Antibody,PX8676990,CDM,300,RC,86769,CPT,90,,,,,,,100,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,91.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.63,98
BOOT AIRSELECT SHORT LARGE 01ES-L,120.45,CDM,274,RC,L4360,HCPCS,,11890-MAIN,LOCAL,,,,,93,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,91.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT MEDIUM 01ES-M,120.45,CDM,274,RC,L4360,HCPCS,,11889-MAIN,LOCAL,,,,,93,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,91.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT SMALL 01ES-S,120.45,CDM,274,RC,L4360,HCPCS,,11888-MAIN,LOCAL,,,,,93,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,91.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT X-LARGE 01ES-XL,120.45,CDM,274,RC,L4360,HCPCS,,11891-MAIN,LOCAL,,,,,93,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,91.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT X-SMALL 01ES-XS,120.45,CDM,274,RC,L4360,HCPCS,,11887-MAIN,LOCAL,,,,,93,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,91.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD LARGE 01EF-L,120.45,CDM,274,RC,L4360,HCPCS,,11697-MAIN,LOCAL,,,,,93,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,91.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD MEDIUM 01EF-M,120.45,CDM,274,RC,L4360,HCPCS,,11696-MAIN,LOCAL,,,,,93,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,91.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD SMALL 01EF-S,120.45,CDM,274,RC,L4360,HCPCS,,11695-MAIN,LOCAL,,,,,93,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,91.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD X-LARGE 01EF-XL,120.45,CDM,274,RC,L4360,HCPCS,,11698-MAIN,LOCAL,,,,,93,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,91.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD X-SMALL 01EF-XS,120.45,CDM,274,RC,L4360,HCPCS,,11694-MAIN,LOCAL,,,,,93,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,91.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
nitroPRUSSide 25 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,72485010501,NDC,2,ML,186,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,91.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
nitroPRUSSide 25 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,72485010501,NDC,2,ML,186,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,91.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
nitroPRUSSide 25 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,72485010501,NDC,2,ML,186,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,91.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Puncture Drainage of Lesion,PX10160P,CDM,983,RC,10160,CPT,,,,,,,,186,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,91.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.2644,348.35
Puncture Drainage of Lesion,PX10160P,CDM,983,RC,10160,CPT,,,,,,,,186,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,91.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.2644,348.35
Puncture Drainage of Lesion,PX10160P,CDM,983,RC,10160,CPT,,,,,,,,186,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,91.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.2644,348.35
Russell Viper Venom - Ref,PX8561390,CDM,300,RC,85613,CPT,90,,,,,,,93,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,91.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.78,91.14
SPLINT FOOT SMALL STRUT WALK 11-1383-2-00000,120.45,CDM,274,RC,L4360,HCPCS,,1205-MAIN,LOCAL,,,,,93,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,91.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
"TB Test, Cell Immunity Measure",PX86480,CDM,300,RC,86480,CPT,,,,,,,,186,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,91.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.83,182.28
"TB Test, Cell Immunity Measure",PX86480,CDM,300,RC,86480,CPT,,,,,,,,186,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,91.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.83,182.28
"TB Test, Cell Immunity Measure",PX86480,CDM,300,RC,86480,CPT,,,,,,,,186,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,91.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.83,182.28
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505614700,NDC,1,EA,212.52,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,91.17108,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
Noninvasv Lo Extrem Art Stress/Rest,PX9392401,CDM,921,RC,93924,CPT,TC,,,,,,,810,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,91.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.34,238.5
Noninvasv Lo Extrem Art Stress/Rest,PX9392401,CDM,921,RC,93924,CPT,TC,,,,,,,810,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,91.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.34,238.5
Puncture Drainage of Lesion,PX10160F,CDM,510,RC,10160,CPT,,,,,,,,279,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,91.1924,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.86,270.49
Puncture Drainage of Lesion,PX10160P,CDM,983,RC,10160,CPT,,,,,,,,186,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,91.1924,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.86,270.49
Assay of ammonia,PX82140,CDM,300,RC,82140,CPT,,,,,,,,190,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,91.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.36,186.2
Assay of ammonia,PX82140,CDM,300,RC,82140,CPT,,,,,,,,190,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,91.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.36,186.2
Assay of protein urine,PX84156,CDM,300,RC,84156,CPT,,,,,,,,190,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,91.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.37,186.2
Assay of protein urine,PX84156,CDM,300,RC,84156,CPT,,,,,,,,190,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,91.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.37,186.2
Each Add'l Sequential IV Infusion <1 Hour,PX96367,CDM,260,RC,96367,CPT,,,,,,,,190,,Health Partners,Health Partners Care Plans,both,48,,88.0975,percent of total billed charges,91.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,186.2
Each Add'l Sequential IV Infusion <1 Hour,PX96367,CDM,260,RC,96367,CPT,,,,,,,,190,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,91.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,186.2
"N Block Inj, Common Digit",PX64632F,CDM,510,RC,64632,CPT,,,,,,,,190,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,91.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.926,258.75
"N Block Inj, Common Digit",PX64632F,CDM,510,RC,64632,CPT,,,,,,,,190,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,91.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.926,258.75
"Tumor Antigen, Ca-125",PX86304,CDM,300,RC,86304,CPT,,,,,,,,190,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,91.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,186.2
"Tumor Antigen, Ca-125",PX86304,CDM,300,RC,86304,CPT,,,,,,,,190,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,91.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,186.2
scopolamine 1 MG/3DAYS Patch 72 Hour 4 Each Box,25000000,CDM,250,RC,,,,,,45802058084,NDC,1,EA,103.43,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,91.22526,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010310,NDC,1,ML,103.48,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,91.26936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331801,NDC,10,ML,102.65,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,91.3585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
predniSONE 5 mg/5 mL 5 MG/5ML Solution 120 mL Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54372250,NDC,120,ML,186.47,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.016111111,percent of total billed charges,91.3703,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 5 mg/5 mL 5 MG/5ML Solution 120 mL Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54372250,NDC,120,ML,186.47,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,91.3703,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
predniSONE 5 mg/5 mL 5 MG/5ML Solution 120 mL Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54372250,NDC,120,ML,186.47,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,91.3703,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
Apply Multlay Comprs Lwr Leg,PX29581F,CDM,510,RC,29581,CPT,,,,,,,,213,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,91.377,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.4802,208.74
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006F,CDM,510,RC,10006,CPT,,,,,,,,213,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,91.377,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.4802,208.74
"GI Pathogen Panel, Pcr - Ref",PX8750790,CDM,300,RC,87507,CPT,90,,,,,,,213,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,91.377,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.4802,382.15
Remove Impacted Ear Wax,PX69210F,CDM,510,RC,69210,CPT,,,,,,,,213,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,91.377,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.44,208.74
Hepatitis a Igm Antibody,PX86709,CDM,300,RC,86709,CPT,,,,,,,,220,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,91.388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.32,215.6
"Hiv-1, Quantification - Ref",PX8753690,CDM,300,RC,87536,CPT,90,,,,,,,220,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,91.388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.03,215.6
Immunoassay Nos - Ref,PX8352090,CDM,300,RC,83520,CPT,90,,,,,,,220,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,91.388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.83,215.6
Leptospira Antibody - Ref,PX8672090,CDM,300,RC,86720,CPT,90,,,,,,,220,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,91.388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.85,215.6
"Digital Mammogram, Screen Bil, Tc W/Cad Perf",PX7706701,CDM,403,RC,77067,CPT,TC,,,,,,,375,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,91.3912,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.29,182.1
lidocaine urethral/mucosal 2 % Gel 30 mL Tube,25000000,CDM,250,RC,,,,,,17478084030,NDC,30,ML,93.91,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,91.402603,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329330101,NDC,50,ML,107.61,,First Health,Commercial,both,85,,999999999,percent of total billed charges,91.4685,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Coccidioides Antibody - Ref,PX8663590,CDM,300,RC,86635,CPT,90,,,,,,,94,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,91.4902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.52,92.12
Copper - Ref,PX8252590,CDM,300,RC,82525,CPT,90,,,,,,,94,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,91.4902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.38,92.12
DEFIBRILLATION PAD MULTI FUNCTION ADULT,120.58,CDM,271,RC,A0392,HCPCS,,1320-MAIN,LOCAL,,,,,94,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,91.4902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
DEFIBRILLATION PAD PEDI PADZ PEDS,120.58,CDM,271,RC,A0392,HCPCS,,1322-MAIN,LOCAL,,,,,94,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,91.4902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
DRESSING NASAL 4.5CM NON-INFLATABLE RAPID RHINO RR450,120.97,CDM,272,RC,A6407,HCPCS,,616-MAIN,LOCAL,,,,,94,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,91.4902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
DRESSING NASAL 5.5CM INFLATABLE RAPID RHINO RR550,120.97,CDM,272,RC,A6407,HCPCS,,606-MAIN,LOCAL,,,,,94,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,91.4902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
DRESSING NASAL 7.5CM INFLATABLE RAPID RHINO RR750,120.97,CDM,272,RC,A6407,HCPCS,,611-MAIN,LOCAL,,,,,94,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,91.4902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
DRESSING NASAL 8CM LONGX1.5CM THICK X3CM HIGH ANATOMICAL 34-105,120.97,CDM,272,RC,A6407,HCPCS,,613-MAIN,LOCAL,,,,,94,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,91.4902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
Tissue Exam for Fungi,PX87220,CDM,300,RC,87220,CPT,,,,,,,,94,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,91.4902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,92.12
TUBING IRRIGATION F SET STERILE MXB-T,27200000,CDM,272,RC,,,,11693-MAIN,LOCAL,,,,,94,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,91.4902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714020010,NDC,1,EA,107.64,,First Health,Commercial,both,85,,999999999,percent of total billed charges,91.494,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714020030,NDC,1,EA,107.64,,First Health,Commercial,both,85,,999999999,percent of total billed charges,91.494,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714001601,NDC,0.4,ML,100.47,,Medica,Commercial,both,91.1,,7.8,percent of total billed charges,91.52817,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
ALEXIS 0 LARGE STERILE,27200000,CDM,272,RC,,,,11765-MAIN,LOCAL,,,,,102.85,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,91.5365,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060851,NDC,100,ML,213.4,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,91.5486,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
Amylase - Ref,PX8215090,CDM,300,RC,82150,CPT,90,,,,,,,185,,Humana Choice Care,All Medicare plans,outpatient,49.5,,187.18,percent of total billed charges,91.575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.94,181.3
Hepatitis C Rna Quant,PX87522,CDM,300,RC,87522,CPT,,,,,,,,185,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,91.575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.28,181.3
"Level IV - Surgical Pathology, Gross and Microscopic Examination , Tech",PX3934,CDM,310,RC,88305,CPT,TC,,,,,,,185,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,91.575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,271.15
"Office/Outpt Visit,Est,Levl III",PX99213F,CDM,510,RC,99213,CPT,,,,,,,,185,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,91.575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.849,181.3
"Office/Outpt Visit,Est,Levl III",PX99213P,CDM,983,RC,99213,CPT,,,,,,,,185,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,91.575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.849,180.0605
Alcohol Biomarkers; 1 or 2 - Ref,PX8032190,CDM,300,RC,80321,CPT,90,,,,,,,181,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,91.586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.1874,177.38
"Lyme Disease, Antibody - Ref",PX8661890,CDM,300,RC,86618,CPT,90,,,,,,,181,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,91.586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.61,177.38
PHALINX STERILE TRIAL SIZER 45A00000,27200000,CDM,272,RC,,,,12959-MAIN,LOCAL,,,,,181,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,91.586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"MESH PROLENE 3X6""",C1781,CDM,278,RC,C1781,HCPCS,,688-MAIN,LOCAL,,,,,213.49,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,91.58721,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
sulfamethoxazole-trimethoprim 400-80 MG/5ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,703951403,NDC,10,ML,102.93,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,91.6077,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Fac/Initial Hospital Care Levl II,PX99222F,CDM,510,RC,99222,CPT,,,,,,,,187,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,91.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.6798,183.26
Fac/Initial Hospital Care Levl II,PX99222F,CDM,510,RC,99222,CPT,,,,,,,,187,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,91.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.6798,183.26
Fac/Initial Hospital Care Levl II,PX99222F,CDM,510,RC,99222,CPT,,,,,,,,187,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,91.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.6798,183.26
"Infect Ag,Eia, Nos, Ea - Ref",PX8744990,CDM,300,RC,87449,CPT,90,,,,,,,187,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,91.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,183.26
"Infect Ag,Eia, Nos, Ea - Ref",PX8744990,CDM,300,RC,87449,CPT,90,,,,,,,187,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,91.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,183.26
"Infect Ag,Eia, Nos, Ea - Ref",PX8744990,CDM,300,RC,87449,CPT,90,,,,,,,187,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,91.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,183.26
Initial Hospital Care Levl II,PX99222P,CDM,982,RC,99222,CPT,,,,,,,,187,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,91.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.6798,182.0071
Initial Hospital Care Levl II,PX99222P,CDM,982,RC,99222,CPT,,,,,,,,187,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,91.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.6798,182.0071
Initial Hospital Care Levl II,PX99222P,CDM,982,RC,99222,CPT,,,,,,,,187,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,91.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.6798,182.0071
RETRIEVAL BAG 12/15MM,27200000,CDM,272,RC,,,,12660-MAIN,LOCAL,,,,,187,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,91.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RETRIEVAL BAG 12/15MM,27200000,CDM,272,RC,,,,12660-MAIN,LOCAL,,,,,187,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,91.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RETRIEVAL BAG 12/15MM,27200000,CDM,272,RC,,,,12660-MAIN,LOCAL,,,,,187,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,91.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Jak2 Gene - Ref,PX8127090,CDM,300,RC,81270,CPT,90,,,,,,,734,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,91.66,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.91,91.66
Assay of Transferrin,PX84466,CDM,300,RC,84466,CPT,,,,,,,,103,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,91.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.7,100.94
"Lactoferrin, Fecal; Qual",PX83630,CDM,300,RC,83630,CPT,,,,,,,,103,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,91.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.06,100.94
"Molecyto Insitu, 100-300cl - Ref",PX8827590,CDM,310,RC,88275,CPT,90,,,,,,,103,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,91.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.7862,100.94
"Tiss Cult,Non-Neop Lymph - Ref",PX8823090,CDM,310,RC,88230,CPT,90,,,,,,,103,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,91.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.7862,106.81
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323012594,NDC,1,EA,190.99,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,91.6752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323012594,NDC,1,EA,190.99,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,91.6752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
Assay of Amylase,PX82150,CDM,300,RC,82150,CPT,,,,,,,,191,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,91.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.94,187.18
Assay of Amylase,PX82150,CDM,300,RC,82150,CPT,,,,,,,,191,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,91.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.94,187.18
C-Reactive Protein,PX86140,CDM,300,RC,86140,CPT,,,,,,,,191,,Health Partners,Health Partners Care Plans,both,48,,117.685,percent of total billed charges,91.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,187.18
C-Reactive Protein,PX86140,CDM,300,RC,86140,CPT,,,,,,,,191,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,91.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,187.18
"Chemotherapy, IV Infusion, Add'l Hour",PX96415,CDM,335,RC,96415,CPT,,,,,,,,191,,Health Partners,Health Partners Care Plans,both,48,,88.56,percent of total billed charges,91.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,187.18
"Chemotherapy, IV Infusion, Add'l Hour",PX96415,CDM,335,RC,96415,CPT,,,,,,,,191,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,91.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,187.18
Fac/Ther Injection Carpal Tunnel,PX20526F,CDM,510,RC,20526,CPT,,,,,,,,191,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,91.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.3414,258.75
Fac/Ther Injection Carpal Tunnel,PX20526F,CDM,510,RC,20526,CPT,,,,,,,,191,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,91.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.3414,258.75
Urine Pregnancy Test,PX81025,CDM,300,RC,81025,CPT,,,,,,,,191,,Health Partners,Health Partners Care Plans,both,48,,32.50666667,percent of total billed charges,91.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.89,187.18
Urine Pregnancy Test,PX81025,CDM,300,RC,81025,CPT,,,,,,,,191,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,91.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.89,187.18
"Supply Technetium Medronate,to 30 MC",PXA9503,CDM,343,RC,A9503,HCPCS,,,,,,,,531,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,91.6845,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.41,91.6845
TB Antigen Response Gamma Interferon T-Cell Susp,PX86481,CDM,300,RC,86481,CPT,,,,,,,,150,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,91.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.31,147
TB Test Enumeration of T-Cells - Ref,PX8648190,CDM,300,RC,86481,CPT,90,,,,,,,155,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,91.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,151.9
Carnitine - Ref,PX8237990,CDM,300,RC,82379,CPT,90,,,,,,,104,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,91.728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.47,101.92
Cmv Antibody - Ref,PX8664490,CDM,300,RC,86644,CPT,90,,,,,,,104,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,91.728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,101.92
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021515,NDC,0.5,ML,187.24,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,91.7476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.779496,199.7926
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021515,NDC,0.5,ML,187.24,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,91.7476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.779496,199.7926
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021515,NDC,0.5,ML,187.24,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,91.7476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.779496,199.7926
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031801,NDC,1,ML,185.37,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,91.75815,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.002698,181.6626
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031825,NDC,1,ML,185.37,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,91.75815,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.002698,181.6626
nafcillin 2 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,S0032,HCPCS,,,,63323032820,NDC,1,EA,185.37,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,91.75815,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
gentamicin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,60758018805,NDC,5,ML,107.98,,First Health,Commercial,both,85,,999999999,percent of total billed charges,91.783,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Erythropietin - Ref,PX8266890,CDM,300,RC,82668,CPT,90,,,,,,,108,,First Health,Commercial,both,85,,999999999,percent of total billed charges,91.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,105.84
Levetiracetam - Ref,PX8017790,CDM,300,RC,80177,CPT,90,,,,,,,108,,First Health,Commercial,both,85,,999999999,percent of total billed charges,91.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,105.84
Oxcarbazepine - Ref,PX8018390,CDM,300,RC,80183,CPT,90,,,,,,,108,,First Health,Commercial,both,85,,999999999,percent of total billed charges,91.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,105.84
Remove Impacted Ear Wax,PX69210P,CDM,983,RC,69210,CPT,,,,,,,,221,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,91.8034,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.44,215.0993
Immunofix Elp,PX86335,CDM,300,RC,86335,CPT,,,,,,,,214,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,91.806,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.91,209.72
fentaNYL 50 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,47781042611,NDC,1,EA,185.47,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,91.80765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 50 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,47781042647,NDC,1,EA,185.47,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,91.80765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Physical Therapy Re-Eval Est Plan Care 20 Mins,PX97164,CDM,424,RC,97164,CPT,,,,,,,,239,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,91.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.77,91.81
Physical Therapy Re-Eval Est Plan Care 20 Mins,PX97164,CDM,424,RC,97164,CPT,,,,,,,,239,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,91.81,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.77,91.81
hydrocortisone 25 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,713050306,NDC,1,EA,108.03,,First Health,Commercial,both,85,,999999999,percent of total billed charges,91.8255,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 25 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713050312,NDC,1,EA,108.03,,First Health,Commercial,both,85,,999999999,percent of total billed charges,91.8255,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine 0.5 % PF 0.5 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323049101,NDC,50,ML,103.2,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,91.848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tobramycin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314064305,NDC,5,ML,191.42,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,91.8816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tobramycin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314064305,NDC,5,ML,191.42,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,91.8816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
verapamil 2.5 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,409114405,NDC,2,ML,185.65,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,91.89675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
acyclovir 50 MG/ML Solution 10 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,55150015410,NDC,10,ML,108.16,,First Health,Commercial,both,85,,999999999,percent of total billed charges,91.936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.927644,105.9968
BRACE KNEE LARGE SHORTRUNNER 21754,120.387,CDM,274,RC,L1833,HCPCS,,10044-MAIN,LOCAL,,,,,101,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,92.011,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE MEDIUM SHORTRUNNER 21753,120.387,CDM,274,RC,L1833,HCPCS,,10126-MAIN,LOCAL,,,,,101,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,92.011,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE SMALL SHORTRUNNER 21752,120.387,CDM,274,RC,L1833,HCPCS,,10900-MAIN,LOCAL,,,,,101,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,92.011,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE X-LARGE SHORTRUNNER 21755,120.387,CDM,274,RC,L1833,HCPCS,,3444-MAIN,LOCAL,,,,,101,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,92.011,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE XX-LARGE SHORTRUNNER 21756,120.387,CDM,274,RC,L1833,HCPCS,,10615-MAIN,LOCAL,,,,,101,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,92.011,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
"COLLAR CERVICAL 2"" SMALL UNIVERSAL 08140039",120.249,CDM,274,RC,L0120,HCPCS,,270-MAIN,LOCAL,,,,,101,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,92.011,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 2X20"" SMALL 1003-02",120.249,CDM,274,RC,L0120,HCPCS,,272-MAIN,LOCAL,,,,,101,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,92.011,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 2X23.5"" MEDIUM XNARROW 1003-04",120.249,CDM,274,RC,L0120,HCPCS,,273-MAIN,LOCAL,,,,,101,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,92.011,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 10-15"" SMALL XLONG 1005-06",120.249,CDM,274,RC,L0120,HCPCS,,267-MAIN,LOCAL,,,,,101,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,92.011,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL LARGE 21.5""X5"" 1005-04",120.249,CDM,274,RC,L0120,HCPCS,,268-MAIN,LOCAL,,,,,101,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,92.011,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL MEDIUM 20-1/2X4"" 1005-03",120.249,CDM,274,RC,L0120,HCPCS,,269-MAIN,LOCAL,,,,,101,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,92.011,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
COLLAR CERVICAL SMALL 1005-02,120.249,CDM,274,RC,L0120,HCPCS,,266-MAIN,LOCAL,,,,,101,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,92.011,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
lidocaine urethral/mucosal 2 % Gel 30 mL Tube,25000000,CDM,250,RC,,,,,,17478084030,NDC,30,ML,93.91,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,92.0318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001104,NDC,1,EA,108.29,,First Health,Commercial,both,85,,999999999,percent of total billed charges,92.0465,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
scopolamine 1 MG/3DAYS Patch 72 Hour 4 Each Box,25000000,CDM,250,RC,,,,,,45802058084,NDC,1,EA,103.43,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,92.0527,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
cyclopentolate 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,61314039601,NDC,2,ML,94.58,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,92.054714,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
nitroPRUSSide 25 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,72485010501,NDC,2,ML,186,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,92.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Puncture Drainage of Lesion,PX10160P,CDM,983,RC,10160,CPT,,,,,,,,186,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,92.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.2644,348.35
"TB Test, Cell Immunity Measure",PX86480,CDM,300,RC,86480,CPT,,,,,,,,186,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,92.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.83,182.28
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001103,NDC,1,EA,108.34,,First Health,Commercial,both,85,,999999999,percent of total billed charges,92.089,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
Debride Skin/Subq Ea Ad 20sqcm,PX11045P,CDM,983,RC,11045,CPT,,,,,,,,182,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,92.092,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.6028,177.1406
Immunocytochemistry,PX3993,CDM,310,RC,88342,CPT,TC,,,,,,,182,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,92.092,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.6028,178.36
Infec Agent Direct Probe - Ref,PX8779990,CDM,300,RC,87799,CPT,90,,,,,,,182,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,92.092,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.28,178.36
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010310,NDC,1,ML,103.48,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,92.0972,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,574402435,NDC,3.5,GR,101.11,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,92.11121,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Coccidioides Antibody - Ref,PX8663590,CDM,300,RC,86635,CPT,90,,,,,,,94,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,92.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.52,92.12
Copper - Ref,PX8252590,CDM,300,RC,82525,CPT,90,,,,,,,94,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,92.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.38,92.12
DEFIBRILLATION PAD MULTI FUNCTION ADULT,120.58,CDM,271,RC,A0392,HCPCS,,1320-MAIN,LOCAL,,,,,94,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,92.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
DEFIBRILLATION PAD PEDI PADZ PEDS,120.58,CDM,271,RC,A0392,HCPCS,,1322-MAIN,LOCAL,,,,,94,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,92.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
DRESSING NASAL 4.5CM NON-INFLATABLE RAPID RHINO RR450,120.97,CDM,272,RC,A6407,HCPCS,,616-MAIN,LOCAL,,,,,94,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,92.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
DRESSING NASAL 5.5CM INFLATABLE RAPID RHINO RR550,120.97,CDM,272,RC,A6407,HCPCS,,606-MAIN,LOCAL,,,,,94,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,92.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
DRESSING NASAL 7.5CM INFLATABLE RAPID RHINO RR750,120.97,CDM,272,RC,A6407,HCPCS,,611-MAIN,LOCAL,,,,,94,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,92.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
DRESSING NASAL 8CM LONGX1.5CM THICK X3CM HIGH ANATOMICAL 34-105,120.97,CDM,272,RC,A6407,HCPCS,,613-MAIN,LOCAL,,,,,94,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,92.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,92.12
Tissue Exam for Fungi,PX87220,CDM,300,RC,87220,CPT,,,,,,,,94,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,92.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,92.12
TUBING IRRIGATION F SET STERILE MXB-T,27200000,CDM,272,RC,,,,11693-MAIN,LOCAL,,,,,94,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,92.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Chest Wall Manipulation,Subsequent",PX94668F,CDM,410,RC,94668,CPT,,,,,,,,192,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,92.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.7568,188.16
"Chest Wall Manipulation,Subsequent",PX94668F,CDM,410,RC,94668,CPT,,,,,,,,192,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,92.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.7568,188.16
Hepatitis Be Antibody - Ref,PX8670790,CDM,300,RC,86707,CPT,90,,,,,,,192,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,92.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.61,188.16
Hepatitis Be Antibody - Ref,PX8670790,CDM,300,RC,86707,CPT,90,,,,,,,192,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,92.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.61,188.16
Infectious Agent Antigen Detection by Immunoassay With Direct Visual Observation.,PX87811,CDM,300,RC,87811,CPT,,,,,,,,192,,Health Partners,Health Partners Care Plans,both,48,,8.408,percent of total billed charges,92.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.94,188.16
Infectious Agent Antigen Detection by Immunoassay With Direct Visual Observation.,PX87811,CDM,300,RC,87811,CPT,,,,,,,,192,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,92.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.94,188.16
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU000390,CDM,300,RC,U0003,HCPCS,90,,,,,,,222,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,92.2188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.2188,217.56
Nfct Ds Bct/Vir Respir Dna/Rna 22 Trgt Sarscov2,PX0202U,CDM,300,RC,0202U,HCPCS,,,,,,,,222,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,92.2188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.2188,382.15
Observation Care Discharge,PX99217,CDM,982,RC,99217,CPT,,,,,,,,222,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,92.2188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.2188,216.0726
Immunoglobulin Subclasses - Ref,PX8278790,CDM,300,RC,82787,CPT,90,,,,,,,215,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,92.235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.35,210.7
predniSONE 5 mg/5 mL 5 MG/5ML Solution 120 mL Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54372250,NDC,120,ML,186.47,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,92.30265,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
empagliflozin 10 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,597015237,NDC,1,EA,104.66,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,92.31012,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061401,NDC,1,ML,94.87,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,92.336971,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.114178,99.911
CT Soft Tissue Neck W/O Dye,PX7049001,CDM,350,RC,70490,CPT,TC,,,,,,,711,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,92.3566,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.6,184.73
fentaNYL 25 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,47781042411,NDC,1,EA,101.44,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,92.41184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clotrimazole-betamethasone 1-0.05 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,66993089815,NDC,15,GR,192.55,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,92.424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
clotrimazole-betamethasone 1-0.05 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,66993089815,NDC,15,GR,192.55,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,92.424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fentaNYL 25 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505700600,NDC,1,EA,101.46,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,92.43006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay Blood Carbon Dioxide,PX82374,CDM,300,RC,82374,CPT,,,,,,,,95,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,92.4635,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.47,93.1
Blood Viscosity Examination,PX85810,CDM,300,RC,85810,CPT,,,,,,,,95,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,92.4635,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.7,93.1
Cyclosporine - Ref,PX8015890,CDM,300,RC,80158,CPT,90,,,,,,,95,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,92.4635,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.55,93.1
"Fac/Debridement of Nails, 6 or Mor",PX11721F,CDM,510,RC,11721,CPT,,,,,,,,95,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,32.48571429,percent of total billed charges,92.4635,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.463,93.1
"Fat/Lipids, Feces, Quant - Ref",PX8271090,CDM,300,RC,82710,CPT,90,,,,,,,95,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,92.4635,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.4,93.1
KIT EPIDURAL 19GA FLEXTIP PLUS AK-05502,120.305,CDM,272,RC,,,,11413-MAIN,LOCAL,,,,,95,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,92.4635,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.463,93.1
"Lyme Disease, Confirm Tst - Ref",PX8661790,CDM,300,RC,86617,CPT,90,,,,,,,95,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,92.4635,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.2,93.1
"Organism ID, Anaerobic - Ref",PX8707690,CDM,300,RC,87076,CPT,90,,,,,,,95,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,92.4635,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,93.1
Strep a Assay W/Optic,PX87880,CDM,300,RC,87880,CPT,,,,,,,,95,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,92.4635,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.16,93.1
"Thyroxine, Total - Ref",PX8443690,CDM,300,RC,84436,CPT,90,,,,,,,95,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,92.4635,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.3,93.1
TRAY FACIAL LACERATION PACK STERILE 96-1707,120.12,CDM,272,RC,,,,406-MAIN,LOCAL,,,,,95,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,92.4635,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.463,93.1
Varicella-Zoster Antibody,PX86787,CDM,300,RC,86787,CPT,,,,,,,,95,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,92.4635,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.81,93.1
"measles, mumps & rubella vaccine Recon Soln 1 Each Vial",90707,CDM,636,RC,90707,CPT,,,,6468100,NDC,1,EA,381.47,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,92.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.09,146.384
"measles, mumps & rubella vaccine Recon Soln 1 Each Vial",90707,CDM,636,RC,90707,CPT,,,,6468100,NDC,1,EA,381.47,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,92.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.09,146.384
Tube Thoracostomy Inc Wtr Seal,PX32551F,CDM,510,RC,32551,CPT,,,,,,,,989,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,92.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.49,317.54
Tube Thoracostomy Inc Wtr Seal,PX32551F,CDM,510,RC,32551,CPT,,,,,,,,989,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,92.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.49,317.54
Tube Thoracostomy Inc Wtr Seal,PX32551P,CDM,983,RC,32551,CPT,,,,,,,,1236,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,92.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.49,1211.28
Tube Thoracostomy Inc Wtr Seal,PX32551P,CDM,983,RC,32551,CPT,,,,,,,,1236,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,92.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.49,1211.28
Tube Thoracostomy Inc Wtr Seal,PX32551F,CDM,510,RC,32551,CPT,,,,,,,,989,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,92.49,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.49,317.54
Tube Thoracostomy Inc Wtr Seal,PX32551P,CDM,983,RC,32551,CPT,,,,,,,,1236,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,92.49,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.49,1211.28
Carnitine - Ref,PX8237990,CDM,300,RC,82379,CPT,90,,,,,,,104,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,92.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.47,101.92
Cmv Antibody - Ref,PX8664490,CDM,300,RC,86644,CPT,90,,,,,,,104,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,92.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,101.92
Fac/Initial Hospital Care Levl II,PX99222F,CDM,510,RC,99222,CPT,,,,,,,,187,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,92.565,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.6798,183.26
"Infect Ag,Eia, Nos, Ea - Ref",PX8744990,CDM,300,RC,87449,CPT,90,,,,,,,187,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,92.565,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,183.26
Initial Hospital Care Levl II,PX99222P,CDM,982,RC,99222,CPT,,,,,,,,187,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,92.565,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.6798,182.0071
RETRIEVAL BAG 12/15MM,27200000,CDM,272,RC,,,,12660-MAIN,LOCAL,,,,,187,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,92.565,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Echo Tt 2d Complete,PX9330701,CDM,480,RC,93307,CPT,TC,,,,,,,2303,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,92.592,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.95,164.04
Voriconazole - Ref,PX8028590,CDM,300,RC,80285,CPT,90,,,,,,,183,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,92.598,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.86,179.34
Alcohols - Ref,PX8032090,CDM,300,RC,80320,CPT,90,,,,,,,189,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,92.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.5106,185.22
Alcohols - Ref,PX8032090,CDM,300,RC,80320,CPT,90,,,,,,,189,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,92.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.5106,185.22
Alcohols - Ref,PX8032090,CDM,300,RC,80320,CPT,90,,,,,,,189,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,92.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.5106,185.22
Dx Occult Blood Immunoassay,PX82274,CDM,300,RC,82274,CPT,,,,,,,,105,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,92.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.6,102.9
Specimen Concentration - Ref,PX8701590,CDM,300,RC,87015,CPT,90,,,,,,,105,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,92.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.12,102.9
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,17478007035,NDC,3.5,GR,105.01,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,92.61882,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Apply Finger Splint,Static",PX29130P,CDM,983,RC,29130,CPT,,,,,,,,223,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,92.6342,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,217.0459
"Apply Forearm Splint,Static",PX29125F,CDM,510,RC,29125,CPT,,,,,,,,223,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,92.6342,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,218.54
"Flow Cyto, Tech, 1st Mrkr - Ref",PX8818490,CDM,310,RC,88184,CPT,90,,,,,,,223,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,92.6342,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,314.02
"Nephelometry, Each, Nos - Ref",PX8388390,CDM,300,RC,83883,CPT,90,,,,,,,223,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,92.6342,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.47,218.54
Reduce Temporomandibl Disloc,PX21480P,CDM,983,RC,21480,CPT,,,,,,,,223,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,92.6342,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,217.0459
Ag Detect Nos Eia Mult,PX87449,CDM,300,RC,87449,CPT,,,,,,,,193,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,92.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,189.14
Ag Detect Nos Eia Mult,PX87449,CDM,300,RC,87449,CPT,,,,,,,,193,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,92.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,189.14
"RBC Sed Rate, Auto",PX85652,CDM,300,RC,85652,CPT,,,,,,,,109,,First Health,Commercial,both,85,,999999999,percent of total billed charges,92.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.48,106.82
Smear Gram Stain,PX87205,CDM,300,RC,87205,CPT,,,,,,,,109,,First Health,Commercial,both,85,,999999999,percent of total billed charges,92.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,106.82
Smear Wet Mount Saline/Ink,PX87210,CDM,300,RC,87210,CPT,,,,,,,,109,,First Health,Commercial,both,85,,999999999,percent of total billed charges,92.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.34,106.82
"West Nile Ab, Igm - Ref",PX8678890,CDM,300,RC,86788,CPT,90,,,,,,,109,,First Health,Commercial,both,85,,999999999,percent of total billed charges,92.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.45,106.82
C-COLLAR ASPEN REGULAR 79-83365,120.25,CDM,274,RC,L0140,HCPCS,,167-MAIN,LOCAL,,,,,216,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,92.664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.58,211.68
C-COLLAR ASPEN TALL 79-83367,120.25,CDM,274,RC,L0140,HCPCS,,164-MAIN,LOCAL,,,,,216,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,92.664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.58,211.68
C-COLLAR ASPEN X-TALL 79-83368,120.25,CDM,274,RC,L0140,HCPCS,,168-MAIN,LOCAL,,,,,216,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,92.664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.58,211.68
"Remv F.B.,Eye,Embed Conjunc",PX65210P,CDM,983,RC,65210,CPT,,,,,,,,216,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,92.664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,89.7264,348.08
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021515,NDC,0.5,ML,187.24,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,92.6838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.779496,199.7926
cyclopentolate 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,61314039601,NDC,2,ML,94.58,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,92.6884,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Fac/Debridement of Nails, 6 or Mor",PX11721F,CDM,510,RC,11721,CPT,,,,,,,,95,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,92.7,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.61,92.7
Insert Straight Catheter,PX51701F,CDM,510,RC,51701,CPT,,,,,,,,168,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,92.7,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.27,92.7
Repr Superf Wnd Body <2.5cm,PX12001F,CDM,510,RC,12001,CPT,,,,,,,,311,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,92.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.83,196.47
Repr Superf Wnd Body <2.5cm,PX12001P,CDM,983,RC,12001,CPT,,,,,,,,293,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,92.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.83,287.14
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,50383058766,NDC,60,ML,95.26,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,92.716558,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,60432053760,NDC,60,ML,95.26,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,92.716558,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone sodium succinate (preservative free) 250 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001305,NDC,1,EA,183.32,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,92.75992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089901,NDC,0.25,ML,95.31,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,92.765223,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.79,93.4038
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089910,NDC,0.25,ML,95.31,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,92.765223,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.79,93.4038
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062001,NDC,0.4,ML,189.48,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,9.81,percent of total billed charges,92.8452,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062001,NDC,0.4,ML,189.48,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,92.8452,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062001,NDC,0.4,ML,189.48,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,92.8452,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062040,NDC,0.4,ML,189.48,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,9.81,percent of total billed charges,92.8452,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062040,NDC,0.4,ML,189.48,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,92.8452,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062040,NDC,0.4,ML,189.48,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,92.8452,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801401,NDC,0.4,ML,189.48,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,9.81,percent of total billed charges,92.8452,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801401,NDC,0.4,ML,189.48,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,92.8452,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801401,NDC,0.4,ML,189.48,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,92.8452,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801410,NDC,0.4,ML,189.48,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,9.81,percent of total billed charges,92.8452,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801410,NDC,0.4,ML,189.48,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,92.8452,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801410,NDC,0.4,ML,189.48,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,92.8452,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615704,NDC,1,EA,101.92,,Medica,Commercial,both,91.1,,5.442333333,percent of total billed charges,92.84912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
sildenafil citrate 20 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,65162035109,NDC,1,EA,95.41,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,92.862553,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329335201,NDC,50,ML,109.26,,First Health,Commercial,both,85,,999999999,percent of total billed charges,92.871,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061400,NDC,1,ML,101.95,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,92.87645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.114178,99.911
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615700,NDC,1,EA,101.95,,Medica,Commercial,both,91.1,,5.442333333,percent of total billed charges,92.87645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
"Office/Outpt Visit,New,Levl IV",PX99204F,CDM,510,RC,99204,CPT,,,,,,,,359,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,92.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.93,300.2
"Office/Outpt Visit,New,Levl IV",PX99204F,CDM,510,RC,99204,CPT,,,,,,,,359,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,92.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.93,300.2
"Office/Outpt Visit,New,Levl IV",PX99204P,CDM,983,RC,99204,CPT,,,,,,,,359,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,92.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.93,351.82
"Office/Outpt Visit,New,Levl IV",PX99204P,CDM,983,RC,99204,CPT,,,,,,,,359,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,92.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.93,351.82
Concurrent Infusion,PX96368,CDM,260,RC,96368,CPT,,,,,,,,102,,Medica,Commercial,both,91.1,,20.4,percent of total billed charges,92.922,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.3708,99.96
Immunohisto Antibody Slide Ea Addl,PX8834101,CDM,310,RC,88341,CPT,TC,,,,,,,102,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,92.922,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.3708,99.96
Reptilase Test - Ref,PX8563590,CDM,300,RC,85635,CPT,90,,,,,,,102,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,92.922,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.03,99.96
"Closed Rx Toe Fx,Manipulatn",PX28515F,CDM,510,RC,28515,CPT,,,,,,,,390,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,92.93,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.93,352.82
"Closed Rx Toe Fx,Manipulatn",PX28515P,CDM,983,RC,28515,CPT,,,,,,,,260,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,92.93,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.93,352.82
Flu Dna Amp Probe 1st 2 Types,PX87502,CDM,300,RC,87502,CPT,,,,,,,,350,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,92.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.93,95.8
Flu Dna Amp Probe 1st 2 Types,PX87502,CDM,300,RC,87502,CPT,,,,,,,,350,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,92.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.93,95.8
Flu Dna Amp Probe 1st 2 Types,PX87502,CDM,300,RC,87502,CPT,,,,,,,,350,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,92.93,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.93,95.8
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061401,NDC,1,ML,94.87,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,92.9726,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.114178,99.911
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Package,25000000,CDM,250,RC,,,,,,66758020858,NDC,1,EA,102.08,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,92.99488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,781309894,NDC,1,EA,193.75,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.461584,189.875
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,781309894,NDC,1,EA,193.75,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.461584,189.875
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001481,NDC,1,EA,102.12,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,93.03132,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,17478062512,NDC,2.5,ML,109.45,,First Health,Commercial,both,85,,999999999,percent of total billed charges,93.0325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Body Fluid Cell Count W Diff,PX89051,CDM,300,RC,89051,CPT,,,,,,,,224,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,93.0496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.13,219.52
Emergency Level I Visit,PX99281P,CDM,981,RC,99281,CPT,,,,,,,,224,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,93.0496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.56,218.0192
ENDOWRIST INSTRUMENTS PERMANENT CAUTERY HOOK 8MM,27200000,CDM,272,RC,,,,12050-MAIN,LOCAL,,,,,224,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,93.0496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Helicobacter Pylori Ab,PX86677,CDM,300,RC,86677,CPT,,,,,,,,224,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,93.0496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.45,219.52
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,703574811,NDC,100,ML,183.92,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,93.06352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.174958,180.2416
Procalcitonin,PX84145,CDM,300,RC,84145,CPT,,,,,,,,217,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,93.093,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.96,212.66
TRAY 8 FR 5IN CENTESIS WITH TURKEL  30-CE1CO,120.303,CDM,272,RC,,,,11503-MAIN,LOCAL,,,,,217,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,93.093,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,90.1418,212.66
Assay Blood Carbon Dioxide,PX82374,CDM,300,RC,82374,CPT,,,,,,,,95,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,93.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.47,93.1
Assay of ammonia,PX82140,CDM,300,RC,82140,CPT,,,,,,,,190,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,78.025,percent of total billed charges,93.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.36,186.2
Assay of ammonia,PX82140,CDM,300,RC,82140,CPT,,,,,,,,190,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,93.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.36,186.2
Assay of ammonia,PX82140,CDM,300,RC,82140,CPT,,,,,,,,190,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,93.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.36,186.2
Assay of protein urine,PX84156,CDM,300,RC,84156,CPT,,,,,,,,190,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,93.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.37,186.2
Assay of protein urine,PX84156,CDM,300,RC,84156,CPT,,,,,,,,190,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,93.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.37,186.2
Assay of protein urine,PX84156,CDM,300,RC,84156,CPT,,,,,,,,190,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,93.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.37,186.2
Blood Viscosity Examination,PX85810,CDM,300,RC,85810,CPT,,,,,,,,95,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,93.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.7,93.1
Cyclosporine - Ref,PX8015890,CDM,300,RC,80158,CPT,90,,,,,,,95,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,93.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.55,93.1
Each Add'l Sequential IV Infusion <1 Hour,PX96367,CDM,260,RC,96367,CPT,,,,,,,,190,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,49.25428571,percent of total billed charges,93.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,186.2
Each Add'l Sequential IV Infusion <1 Hour,PX96367,CDM,260,RC,96367,CPT,,,,,,,,190,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,93.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,186.2
Each Add'l Sequential IV Infusion <1 Hour,PX96367,CDM,260,RC,96367,CPT,,,,,,,,190,,United Healthcare,All Medicare advantage plans,outpatient,49,,100.7,percent of total billed charges,93.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,186.2
"Fac/Debridement of Nails, 6 or Mor",PX11721F,CDM,510,RC,11721,CPT,,,,,,,,95,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,93.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.463,93.1
"Fat/Lipids, Feces, Quant - Ref",PX8271090,CDM,300,RC,82710,CPT,90,,,,,,,95,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,93.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.4,93.1
KIT EPIDURAL 19GA FLEXTIP PLUS AK-05502,120.305,CDM,272,RC,,,,11413-MAIN,LOCAL,,,,,95,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,93.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.463,93.1
"Lyme Disease, Confirm Tst - Ref",PX8661790,CDM,300,RC,86617,CPT,90,,,,,,,95,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,93.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.2,93.1
"N Block Inj, Common Digit",PX64632F,CDM,510,RC,64632,CPT,,,,,,,,190,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,93.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.926,258.75
"N Block Inj, Common Digit",PX64632F,CDM,510,RC,64632,CPT,,,,,,,,190,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,93.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.926,258.75
"N Block Inj, Common Digit",PX64632F,CDM,510,RC,64632,CPT,,,,,,,,190,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,93.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.926,258.75
"Organism ID, Anaerobic - Ref",PX8707690,CDM,300,RC,87076,CPT,90,,,,,,,95,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,93.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,93.1
Strep a Assay W/Optic,PX87880,CDM,300,RC,87880,CPT,,,,,,,,95,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,93.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.16,93.1
"Thyroxine, Total - Ref",PX8443690,CDM,300,RC,84436,CPT,90,,,,,,,95,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,93.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.3,93.1
TRAY FACIAL LACERATION PACK STERILE 96-1707,120.12,CDM,272,RC,,,,406-MAIN,LOCAL,,,,,95,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,93.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.463,93.1
"Tumor Antigen, Ca-125",PX86304,CDM,300,RC,86304,CPT,,,,,,,,190,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,93.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,186.2
"Tumor Antigen, Ca-125",PX86304,CDM,300,RC,86304,CPT,,,,,,,,190,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,93.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,186.2
"Tumor Antigen, Ca-125",PX86304,CDM,300,RC,86304,CPT,,,,,,,,190,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,93.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,186.2
Varicella-Zoster Antibody,PX86787,CDM,300,RC,86787,CPT,,,,,,,,95,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,93.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.81,93.1
TUBE TRACH SIZE 3.0MM ID 4.5MM OD SHILEY PEDIATRIC 3.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1185-MAIN,LOCAL,,,,,184,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,93.104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 3.5MM ID 5.2MM OD SHILEY PEDIATRIC,120.287,CDM,272,RC,A7520,HCPCS,,8813-MAIN,LOCAL,,,,,184,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,93.104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 4.0MM ID 5.9MM OD SHILEY PEDIATRIC 4.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1187-MAIN,LOCAL,,,,,184,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,93.104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 5 7.0MM ID 10.1MM OD SHILEY CUFFED 5CN70H,120.287,CDM,272,RC,A7521,HCPCS,,10350-MAIN,LOCAL,,,,,184,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,93.104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 5.0MM ID 7.1MM OD SHILEY PEDIATRIC 5.0PED,120.287,CDM,272,RC,A7520,HCPCS,,8814-MAIN,LOCAL,,,,,184,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,93.104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 6 6.0MM ID 8.3MM OD SHILEY CUFFED 6SCT,120.287,CDM,272,RC,A7521,HCPCS,,8812-MAIN,LOCAL,,,,,184,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,93.104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 6 6.4MM ID 10.8MM OD SHILEY CUFFED 6DCT,120.287,CDM,272,RC,A7521,HCPCS,,1190-MAIN,LOCAL,,,,,184,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,93.104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 7.5MM ID 10.8MM OD SHILEY CUFFED 6CN75H,120.287,CDM,272,RC,A7521,HCPCS,,8488-MAIN,LOCAL,,,,,184,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,93.104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 8 7.6MM ID 12.2MM OD SHILEY 8DCT,120.287,CDM,272,RC,A7521,HCPCS,,1192-MAIN,LOCAL,,,,,184,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,93.104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 8 7.6MM ID 12.22MM OD SHILEY CUFFED 8LPC,120.287,CDM,272,RC,A7521,HCPCS,,8815-MAIN,LOCAL,,,,,184,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,93.104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 8.0MM ID 10.9MM OD SHILEY CUFFED 8SCT,120.287,CDM,272,RC,A7521,HCPCS,,8811-MAIN,LOCAL,,,,,184,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,93.104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 10 SHILEY 10LPC,120.287,CDM,272,RC,A7521,HCPCS,,1181-MAIN,LOCAL,,,,,184,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,93.104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
"Cmv, Quant - Ref",PX8749790,CDM,300,RC,87497,CPT,90,,,,,,,194,,Health Partners,Health Partners Care Plans,both,48,,89.95,percent of total billed charges,93.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.28,190.12
"Cmv, Quant - Ref",PX8749790,CDM,300,RC,87497,CPT,90,,,,,,,194,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,93.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.28,190.12
Hiv-1 Antigens W/Hiv 1/2 Antib,PX87389,CDM,300,RC,87389,CPT,,,,,,,,194,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,93.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.08,190.12
Hiv-1 Antigens W/Hiv 1/2 Antib,PX87389,CDM,300,RC,87389,CPT,,,,,,,,194,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,93.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.08,190.12
Lyme Disease Antibody,PX86618,CDM,300,RC,86618,CPT,,,,,,,,194,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,93.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.61,190.12
Lyme Disease Antibody,PX86618,CDM,300,RC,86618,CPT,,,,,,,,194,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,93.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.61,190.12
empagliflozin 10 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,597015237,NDC,1,EA,104.66,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,93.1474,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Exc Skn Beig1.1-2cm Face,Facil",PX11442P,CDM,983,RC,11442,CPT,,,,,,,,886,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,93.15,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.15,868.28
"Fac/Exc Skn Beni1.1-2cm Fce,Facial",PX11442F,CDM,510,RC,11442,CPT,,,,,,,,668,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,93.15,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.15,404.01
scopolamine 1 MG/3DAYS Patch 72 Hour 24 Each Box,25000000,CDM,250,RC,,,,,,50742050524,NDC,1,EA,109.59,,First Health,Commercial,both,85,,999999999,percent of total billed charges,93.1515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,17478028810,NDC,5,ML,95.71,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,93.154543,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314022705,NDC,5,ML,95.71,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,93.154543,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,64980051405,NDC,5,ML,95.71,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,93.154543,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424601,NDC,15,ML,95.76,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,93.203208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.778704,295.3916
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424681,NDC,15,ML,95.76,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,93.203208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.778704,295.3916
Phlebotomy,PX99195,CDM,940,RC,99195,CPT,,,,,,,,238,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,93.235,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.49,166.95
ON Q PAIN BUSTER,27100000,CDM,271,RC,A4305,HCPCS,,6751-MAIN,LOCAL,,,,,194.26,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,93.2448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
ON Q PAIN BUSTER,27100000,CDM,271,RC,A4305,HCPCS,,6751-MAIN,LOCAL,,,,,194.26,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,93.2448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
"Inpatient Consult, Level III",PX99253,CDM,983,RC,99253,CPT,,,,,,,,374,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,93.264,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.07,366.52
sod citrate-citric acid 500-334 MG/5ML Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,121059516,NDC,473,ML,95.87,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,93.310271,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,50383058766,NDC,60,ML,95.26,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,93.3548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,60432053760,NDC,60,ML,95.26,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,93.3548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601P,CDM,983,RC,11601,CPT,,,,,,,,1046,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,93.37,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.37,1025.08
"Fac/Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601F,CDM,510,RC,11601,CPT,,,,,,,,673,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,93.37,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.37,476.65
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089901,NDC,0.25,ML,95.31,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,93.4038,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.79,93.4038
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089910,NDC,0.25,ML,95.31,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,93.4038,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.79,93.4038
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; 1st",PX88184,CDM,310,RC,88184,CPT,,,,,,,,96,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,93.4368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.8784,314.02
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; Add'l",PX88185,CDM,310,RC,88185,CPT,,,,,,,,96,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,93.4368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.8784,94.08
US Urine Capacity Measure,PX51798F,CDM,510,RC,51798,CPT,,,,,,,,96,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,93.4368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.8784,94.08
Dx Occult Blood Immunoassay,PX82274,CDM,300,RC,82274,CPT,,,,,,,,105,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,93.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.6,102.9
Specimen Concentration - Ref,PX8701590,CDM,300,RC,87015,CPT,90,,,,,,,105,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,93.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.12,102.9
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,17478007035,NDC,3.5,GR,105.01,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,93.4589,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Cytoflo, Cell or Dna Anal - Ref",PX8818290,CDM,310,RC,88182,CPT,90,,,,,,,225,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,93.465,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,220.5
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153F,CDM,370,RC,99153,CPT,,,,,,,,225,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,93.465,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.465,220.5
GLIDESCOPE QC MILLER S0 SINGLE USE 0270-1087,120.58,CDM,272,RC,,,,13024-MAIN,LOCAL,,,,,106,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,93.492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
GLIDESCOPE QC MILLER S1 SINGLE USE 0270-1088,120.58,CDM,272,RC,,,,13025-MAIN,LOCAL,,,,,106,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,93.492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
"Acylcarnitines, Quant - Ref",PX8201790,CDM,300,RC,82017,CPT,90,,,,,,,110,,First Health,Commercial,both,85,,999999999,percent of total billed charges,93.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.47,107.8
"Assay Calcium, Ionized",PX82330,CDM,300,RC,82330,CPT,,,,,,,,110,,First Health,Commercial,both,85,,999999999,percent of total billed charges,93.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.54,107.8
BONE MARROW BIOPSY ASPIRATION NEEDLE 11G X 4 IN,120.562,CDM,272,RC,C1830,HCPCS,,12677-MAIN,LOCAL,,,,,110,,First Health,Commercial,both,85,,999999999,percent of total billed charges,93.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.694,107.8
Glycosylated Hemoglobin Test,PX83036,CDM,300,RC,83036,CPT,,,,,,,,110,,First Health,Commercial,both,85,,999999999,percent of total billed charges,93.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.9,130.9
K-WIRE 0.9X150MM BLUNT/TROCAR DART-FIRE STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12449-MAIN,LOCAL,,,,,110,,First Health,Commercial,both,85,,999999999,percent of total billed charges,93.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRE 0.9X150MM BLUNT/TROCAR STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12452-MAIN,LOCAL,,,,,110,,First Health,Commercial,both,85,,999999999,percent of total billed charges,93.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRE 1.4X150MM BLUNT/TROCAR DART-FIRE STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12450-MAIN,LOCAL,,,,,110,,First Health,Commercial,both,85,,999999999,percent of total billed charges,93.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRE 1.4X150MM BLUNT/TROCAR STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12451-MAIN,LOCAL,,,,,110,,First Health,Commercial,both,85,,999999999,percent of total billed charges,93.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA 2.0MM TARGETING GUIDE PIN,27200000,CDM,272,RC,,,,12436-MAIN,LOCAL,,,,,110,,First Health,Commercial,both,85,,999999999,percent of total billed charges,93.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Strapping of Shoulder,PX29240P,CDM,983,RC,29240,CPT,,,,,,,,110,,First Health,Commercial,both,85,,999999999,percent of total billed charges,93.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.694,111.6
sildenafil citrate 20 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,65162035109,NDC,1,EA,95.41,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,93.5018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781315972,NDC,1,EA,217.96,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,93.50484,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86,213.6008
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331801,NDC,10,ML,102.65,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,93.51415,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
cefTRIAXone in dextrose 1 g / 50 mL 1-3.74 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0696.01,CDM,636,RC,J0696,HCPCS,,,,264315311,NDC,1,EA,106.03,,United Healthcare,All Payer,outpatient,88.2,,201.07,percent of total billed charges,93.51846,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
albuterol (5 MG/ML) 0.5% Nebulization Solution 20 mL Bottle,J7611.01,CDM,250,RC,,,,,,50383074120,NDC,20,ML,225.2,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,93.54808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.54808,220.696
Alcohols - Ref,PX8032090,CDM,300,RC,80320,CPT,90,,,,,,,189,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,93.555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.5106,185.22
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323012594,NDC,1,EA,190.99,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,93.5851,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323012594,NDC,1,EA,190.99,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,93.5851,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323012594,NDC,1,EA,190.99,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,93.5851,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
Assay of Amylase,PX82150,CDM,300,RC,82150,CPT,,,,,,,,191,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,93.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.94,187.18
Assay of Amylase,PX82150,CDM,300,RC,82150,CPT,,,,,,,,191,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,93.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.94,187.18
Assay of Amylase,PX82150,CDM,300,RC,82150,CPT,,,,,,,,191,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,93.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.94,187.18
C-Reactive Protein,PX86140,CDM,300,RC,86140,CPT,,,,,,,,191,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,17.01102041,percent of total billed charges,93.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,187.18
C-Reactive Protein,PX86140,CDM,300,RC,86140,CPT,,,,,,,,191,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,93.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,187.18
C-Reactive Protein,PX86140,CDM,300,RC,86140,CPT,,,,,,,,191,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,93.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,187.18
"Chemotherapy, IV Infusion, Add'l Hour",PX96415,CDM,335,RC,96415,CPT,,,,,,,,191,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,161.98,percent of total billed charges,93.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,187.18
"Chemotherapy, IV Infusion, Add'l Hour",PX96415,CDM,335,RC,96415,CPT,,,,,,,,191,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,93.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,187.18
"Chemotherapy, IV Infusion, Add'l Hour",PX96415,CDM,335,RC,96415,CPT,,,,,,,,191,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,93.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,187.18
Fac/Ther Injection Carpal Tunnel,PX20526F,CDM,510,RC,20526,CPT,,,,,,,,191,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,93.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.3414,258.75
Fac/Ther Injection Carpal Tunnel,PX20526F,CDM,510,RC,20526,CPT,,,,,,,,191,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,93.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.3414,258.75
Fac/Ther Injection Carpal Tunnel,PX20526F,CDM,510,RC,20526,CPT,,,,,,,,191,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,93.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.3414,258.75
Urine Pregnancy Test,PX81025,CDM,300,RC,81025,CPT,,,,,,,,191,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,173.495,percent of total billed charges,93.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.89,187.18
Urine Pregnancy Test,PX81025,CDM,300,RC,81025,CPT,,,,,,,,191,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,93.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.89,187.18
Urine Pregnancy Test,PX81025,CDM,300,RC,81025,CPT,,,,,,,,191,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,93.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.89,187.18
Topiramate - Ref,PX8020190,CDM,300,RC,80201,CPT,90,,,,,,,195,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,93.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.93,191.1
Topiramate - Ref,PX8020190,CDM,300,RC,80201,CPT,90,,,,,,,195,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,93.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.93,191.1
Amylase - Ref,PX8215090,CDM,300,RC,82150,CPT,90,,,,,,,185,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,93.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.94,181.3
Hepatitis C Rna Quant,PX87522,CDM,300,RC,87522,CPT,,,,,,,,185,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,93.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.28,181.3
"Level IV - Surgical Pathology, Gross and Microscopic Examination , Tech",PX3934,CDM,310,RC,88305,CPT,TC,,,,,,,185,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,93.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,271.15
"Office/Outpt Visit,Est,Levl III",PX99213F,CDM,510,RC,99213,CPT,,,,,,,,185,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,93.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.849,181.3
"Office/Outpt Visit,Est,Levl III",PX99213P,CDM,983,RC,99213,CPT,,,,,,,,185,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,93.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.849,180.0605
rifAXIMin 550 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,65649030302,NDC,1,EA,218.25,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,93.62925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rifAXIMin 550 MG Tablet 60 Each Box,63700001,CDM,250,RC,,,,,,65649030303,NDC,1,EA,218.25,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,93.62925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DERMABOND MINI SKIN ADHESIVE,27200000,CDM,272,RC,,,,8532-MAIN,LOCAL,,,,,110.16,,First Health,Commercial,both,85,,999999999,percent of total billed charges,93.636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338411450,NDC,50,ML,106.23,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,93.69486,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
ALEXIS 0 LARGE STERILE,27200000,CDM,272,RC,,,,11765-MAIN,LOCAL,,,,,102.85,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,93.69635,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,68462015740,NDC,1,EA,110.25,,First Health,Commercial,both,85,,999999999,percent of total billed charges,93.7125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,68462015713,NDC,1,EA,110.25,,First Health,Commercial,both,85,,999999999,percent of total billed charges,93.7125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
sulfamethoxazole-trimethoprim 400-80 MG/5ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,703951403,NDC,10,ML,102.93,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,93.76923,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vedolizumab 300 MG Recon Soln 1 Each Vial,J3380.01,CDM,636,RC,J3380,HCPCS,,,,64764030020,NDC,1,EA,12439.04,,Blue Cross Blue Shield of MN,All commercial plans,both,,,8.2927,fee schedule,93.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.66,12190.2592
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,781523806,NDC,1,EA,106.34,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,93.79188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,781523864,NDC,1,EA,106.34,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,93.79188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,65862039010,NDC,1,EA,106.34,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,93.79188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062001,NDC,0.4,ML,189.48,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,93.7926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062040,NDC,0.4,ML,189.48,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,93.7926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801401,NDC,0.4,ML,189.48,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,93.7926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801410,NDC,0.4,ML,189.48,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,93.7926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,17478028810,NDC,5,ML,95.71,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,93.7958,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314022705,NDC,5,ML,95.71,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,93.7958,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,64980051405,NDC,5,ML,95.71,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,93.7958,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tobramycin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314064305,NDC,5,ML,191.42,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,93.7958,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tobramycin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314064305,NDC,5,ML,191.42,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,93.7958,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tobramycin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314064305,NDC,5,ML,191.42,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,93.7958,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031801,NDC,1,ML,185.37,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,93.79722,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.002698,181.6626
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031825,NDC,1,ML,185.37,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,93.79722,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.002698,181.6626
nafcillin 2 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,S0032,HCPCS,,,,63323032820,NDC,1,EA,185.37,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,93.79722,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Debride Tissue/Muscle,PX11043F,CDM,510,RC,11043,CPT,,,,,,,,526,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,93.8,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.8,483.57
Debride Tissue/Muscle,PX11043P,CDM,983,RC,11043,CPT,,,,,,,,351,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,93.8,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.8,483.57
"Up GI Endoscopy,Ball Dil,30mm",PX43249F,CDM,750,RC,43249,CPT,,,,,,,,2596,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,93.8,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.8,2216.53
"Up GI Endoscopy,Ball Dil,30mm",PX43249P,CDM,983,RC,43249,CPT,,,,,,,,1731,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,93.8,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.8,2216.53
Assay of Transferrin,PX84466,CDM,300,RC,84466,CPT,,,,,,,,103,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,93.833,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.7,100.94
"Lactoferrin, Fecal; Qual",PX83630,CDM,300,RC,83630,CPT,,,,,,,,103,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,93.833,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.06,100.94
"Molecyto Insitu, 100-300cl - Ref",PX8827590,CDM,310,RC,88275,CPT,90,,,,,,,103,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,93.833,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.7862,100.94
"Tiss Cult,Non-Neop Lymph - Ref",PX8823090,CDM,310,RC,88230,CPT,90,,,,,,,103,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,93.833,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.7862,106.81
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424601,NDC,15,ML,95.76,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,93.8448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.778704,295.3916
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424681,NDC,15,ML,95.76,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,93.8448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.778704,295.3916
fentaNYL 50 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,47781042611,NDC,1,EA,185.47,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,93.84782,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 50 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,47781042647,NDC,1,EA,185.47,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,93.84782,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
verapamil 2.5 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,409114405,NDC,2,ML,185.65,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,93.9389,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
CANNULATED AO HANDLE STERILE MICA SCREW SYSTEM 57S1HNDL,27200000,CDM,272,RC,,,,12446-MAIN,LOCAL,,,,,219,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,93.951,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TUBE SURGICAL IRRIGATION 1PK PD-IT,27200000,CDM,272,RC,,,,12433-MAIN,LOCAL,,,,,219,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,93.951,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
sod citrate-citric acid 500-334 MG/5ML Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,121059516,NDC,473,ML,95.87,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,93.9526,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"measles, mumps & rubella vaccine Recon Soln 1 Each Vial",90707,CDM,636,RC,90707,CPT,,,,6468100,NDC,1,EA,381.47,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,93.96,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.09,146.384
lidocaine 0.5 % PF 0.5 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323049101,NDC,50,ML,103.2,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,94.0152,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Exc Skn Bngn2.1-3cmtrnk,Arm,Lg",PX11403P,CDM,983,RC,11403,CPT,,,,,,,,543,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,94.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.02,532.14
"Fac/Ex Skn Bngn2.1-3cm Trnk,Arm,Lg",PX11403F,CDM,510,RC,11403,CPT,,,,,,,,679,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,94.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.02,413.7
Flu Dna Amp Probe 1st 2 Types,PX87502,CDM,300,RC,87502,CPT,,,,,,,,350,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,94.0237,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.93,95.8
Assay of ammonia,PX82140,CDM,300,RC,82140,CPT,,,,,,,,190,,Humana Choice Care,All Medicare plans,outpatient,49.5,,23.275,percent of total billed charges,94.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.36,186.2
Assay of protein urine,PX84156,CDM,300,RC,84156,CPT,,,,,,,,190,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,94.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.37,186.2
Each Add'l Sequential IV Infusion <1 Hour,PX96367,CDM,260,RC,96367,CPT,,,,,,,,190,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,94.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,186.2
"N Block Inj, Common Digit",PX64632F,CDM,510,RC,64632,CPT,,,,,,,,190,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,94.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.926,258.75
"Tumor Antigen, Ca-125",PX86304,CDM,300,RC,86304,CPT,,,,,,,,190,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,94.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,186.2
gentamicin 0.3 % Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,17478028435,NDC,3.5,GR,219.3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,94.0797,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Apply Finger Splint,Static",PX29130F,CDM,420,RC,29130,CPT,,,,,,,,196,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,94.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.4184,192.08
"Apply Finger Splint,Static",PX29130F,CDM,420,RC,29130,CPT,,,,,,,,196,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,94.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.4184,192.08
"Chest Wall Manipulation,Subsequent",PX94668F,CDM,410,RC,94668,CPT,,,,,,,,192,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,94.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.7568,188.16
"Chest Wall Manipulation,Subsequent",PX94668F,CDM,410,RC,94668,CPT,,,,,,,,192,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,94.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.7568,188.16
"Chest Wall Manipulation,Subsequent",PX94668F,CDM,410,RC,94668,CPT,,,,,,,,192,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,94.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.7568,188.16
Drain/Inject Large Joint/Bursa,PX20610F,CDM,510,RC,20610,CPT,,,,,,,,364,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,94.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.48,135.59
Drain/Inject Large Joint/Bursa,PX20610P,CDM,983,RC,20610,CPT,,,,,,,,291,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,94.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.48,285.18
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604F,CDM,510,RC,20604,CPT,,,,,,,,344,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,94.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.13,172.26
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604P,CDM,983,RC,20604,CPT,,,,,,,,229,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,94.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.13,224.42
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; 1st",PX88184,CDM,310,RC,88184,CPT,,,,,,,,96,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,94.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.8784,314.02
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; Add'l",PX88185,CDM,310,RC,88185,CPT,,,,,,,,96,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,94.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.8784,94.08
Hepatitis Be Antibody - Ref,PX8670790,CDM,300,RC,86707,CPT,90,,,,,,,192,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,94.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.61,188.16
Hepatitis Be Antibody - Ref,PX8670790,CDM,300,RC,86707,CPT,90,,,,,,,192,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,94.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.61,188.16
Hepatitis Be Antibody - Ref,PX8670790,CDM,300,RC,86707,CPT,90,,,,,,,192,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,94.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.61,188.16
Heterophile Antibodies,PX86308,CDM,300,RC,86308,CPT,,,,,,,,196,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,94.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,192.08
Heterophile Antibodies,PX86308,CDM,300,RC,86308,CPT,,,,,,,,196,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,94.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,192.08
Infectious Agent Antigen Detection by Immunoassay With Direct Visual Observation.,PX87811,CDM,300,RC,87811,CPT,,,,,,,,192,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,94.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.94,188.16
Infectious Agent Antigen Detection by Immunoassay With Direct Visual Observation.,PX87811,CDM,300,RC,87811,CPT,,,,,,,,192,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,94.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.94,188.16
Infectious Agent Antigen Detection by Immunoassay With Direct Visual Observation.,PX87811,CDM,300,RC,87811,CPT,,,,,,,,192,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,94.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.94,188.16
Initial Rx Burn(S) 1st Degree,PX16000F,CDM,510,RC,16000,CPT,,,,,,,,338,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,94.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.7,166.03
US Urine Capacity Measure,PX51798F,CDM,510,RC,51798,CPT,,,,,,,,96,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,94.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.8784,94.08
nitroPRUSSide 25 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,72485010501,NDC,2,ML,186,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,94.116,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Puncture Drainage of Lesion,PX10160P,CDM,983,RC,10160,CPT,,,,,,,,186,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,94.116,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.2644,348.35
"TB Test, Cell Immunity Measure",PX86480,CDM,300,RC,86480,CPT,,,,,,,,186,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,94.116,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.83,182.28
scopolamine 1 MG/3DAYS Patch 72 Hour 4 Each Box,25000000,CDM,250,RC,,,,,,45802058084,NDC,1,EA,103.43,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,94.22473,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601P,CDM,983,RC,11601,CPT,,,,,,,,1046,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,94.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.37,1025.08
"Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601P,CDM,983,RC,11601,CPT,,,,,,,,1046,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,94.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.37,1025.08
"Fac/Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601F,CDM,510,RC,11601,CPT,,,,,,,,673,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,94.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.37,476.65
"Fac/Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601F,CDM,510,RC,11601,CPT,,,,,,,,673,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,94.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.37,476.65
fentaNYL 12 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,378911916,NDC,1,EA,96.83,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,94.244639,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 12 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505708000,NDC,1,EA,96.83,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,94.244639,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
azithromycin 200 MG/5ML Recon Susp 15 mL Bottle,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,59762312001,NDC,15,ML,196.35,,Health Partners,Health Partners Care Plans,both,48,,29.925,percent of total billed charges,94.248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
azithromycin 200 MG/5ML Recon Susp 15 mL Bottle,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,59762312001,NDC,15,ML,196.35,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,94.248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
ROTH NET PLATINUM RETRIEVER,27200000,CDM,272,RC,,,,7518-MAIN,LOCAL,,,,,196.35,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,94.248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ROTH NET PLATINUM RETRIEVER,27200000,CDM,272,RC,,,,7518-MAIN,LOCAL,,,,,196.35,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,94.248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
fentaNYL 12 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,378911998,NDC,1,EA,96.84,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,94.254372,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 12 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,60505708002,NDC,1,EA,96.84,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,94.254372,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010310,NDC,1,ML,103.48,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,94.27028,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
SET SP TUBE INTRODUCER  14CM 8-14FR G15469,120.377,CDM,272,RC,,,,7147-MAIN,LOCAL,,,,,227,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,94.2958,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.2958,222.46
Sp Stn for Inclusn Bodies - Ref,PX8720790,CDM,300,RC,87207,CPT,90,,,,,,,227,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,94.2958,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.49,222.46
GLIDESCOPE QC MILLER S0 SINGLE USE 0270-1087,120.58,CDM,272,RC,,,,13024-MAIN,LOCAL,,,,,106,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,94.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
GLIDESCOPE QC MILLER S1 SINGLE USE 0270-1088,120.58,CDM,272,RC,,,,13025-MAIN,LOCAL,,,,,106,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,94.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
clotrimazole-betamethasone 1-0.05 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,66993089815,NDC,15,GR,192.55,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,94.3495,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
clotrimazole-betamethasone 1-0.05 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,66993089815,NDC,15,GR,192.55,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,94.3495,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
clotrimazole-betamethasone 1-0.05 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,66993089815,NDC,15,GR,192.55,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,94.3495,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
predniSONE 5 mg/5 mL 5 MG/5ML Solution 120 mL Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54372250,NDC,120,ML,186.47,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,94.35382,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,24208091055,NDC,3.5,GR,106.98,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,94.35636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028401,NDC,1,EA,111.01,,First Health,Commercial,both,85,,999999999,percent of total billed charges,94.3585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028420,NDC,1,EA,111.01,,First Health,Commercial,both,85,,999999999,percent of total billed charges,94.3585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
lidocaine 4 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,536128128,NDC,30,GR,96.95,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,94.361435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cefTRIAXone in dextrose 1 g / 50 mL 1-3.74 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0696.01,CDM,636,RC,J0696,HCPCS,,,,264315311,NDC,1,EA,106.03,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,94.3667,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
3.0MM NON-THREADED K WIRE,27200000,CDM,272,RC,C1769,HCPCS,,12658-MAIN,LOCAL,,,,,107,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,94.374,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Androsetenedione - Ref,PX8215790,CDM,300,RC,82157,CPT,90,,,,,,,107,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,94.374,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.85,104.86
Decalcify Tc,PX8831101,CDM,310,RC,88311,CPT,TC,,,,,,,107,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,94.374,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
Fac/Trim Nail(S),PX11719F,CDM,510,RC,11719,CPT,,,,,,,,107,,United Healthcare,All Payer,outpatient,88.2,,50.47,percent of total billed charges,94.374,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
Path Special Stains II,PX3979,CDM,310,RC,88313,CPT,TC,,,,,,,107,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,94.374,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
"Special Stains,Group I",PX3978,CDM,310,RC,88312,CPT,TC,,,,,,,107,,United Healthcare,All Payer,outpatient,88.2,,50.47,percent of total billed charges,94.374,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
Hepatitis a Igm Antibody,PX86709,CDM,300,RC,86709,CPT,,,,,,,,220,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,94.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.32,215.6
"Hiv-1, Quantification - Ref",PX8753690,CDM,300,RC,87536,CPT,90,,,,,,,220,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,94.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.03,215.6
Immunoassay Nos - Ref,PX8352090,CDM,300,RC,83520,CPT,90,,,,,,,220,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,94.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.83,215.6
Leptospira Antibody - Ref,PX8672090,CDM,300,RC,86720,CPT,90,,,,,,,220,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,94.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.85,215.6
"I&D Perianal Abscess,Superficial",PX46050,CDM,983,RC,46050,CPT,,,,,,,,1096,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,94.4034,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.26,1074.08
"I&D Perianal Abscess,Superficial",PX46050F,CDM,510,RC,46050,CPT,,,,,,,,1463,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,94.4034,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.26,492.56
"I&D Perianal Abscess,Superficial",PX46050P,CDM,983,RC,46050,CPT,,,,,,,,993,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,94.4034,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.26,973.14
Blastomyces Antibody - Ref,PX8661290,CDM,300,RC,86612,CPT,90,,,,,,,97,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,94.4101,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.83,95.06
Contrast Bath Therapy,PX97034,CDM,420,RC,97034,CPT,,,,,,,,97,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,94.4101,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,95.06
DRAPE INSTRUMENT ARM 470015,27200000,CDM,272,RC,,,,11925-MAIN,LOCAL,,,,,97,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,94.4101,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
High Sens Crp,PX86141,CDM,300,RC,86141,CPT,,,,,,,,97,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,94.4101,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,95.06
Rheumatoid Factor Quant,PX86431,CDM,300,RC,86431,CPT,,,,,,,,97,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,94.4101,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.2,95.06
Debride Tissue/Muscle,PX11043F,CDM,510,RC,11043,CPT,,,,,,,,526,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,94.46,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.8,483.57
Debride Tissue/Muscle,PX11043F,CDM,510,RC,11043,CPT,,,,,,,,526,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,94.46,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.8,483.57
Debride Tissue/Muscle,PX11043P,CDM,983,RC,11043,CPT,,,,,,,,351,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,94.46,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.8,483.57
Debride Tissue/Muscle,PX11043P,CDM,983,RC,11043,CPT,,,,,,,,351,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,94.46,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.8,483.57
"Exc Skn Beig1.1-2cm Face,Facil",PX11442P,CDM,983,RC,11442,CPT,,,,,,,,886,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,94.46,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.15,868.28
"Exc Skn Beig1.1-2cm Face,Facil",PX11442P,CDM,983,RC,11442,CPT,,,,,,,,886,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,94.46,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.15,868.28
"Fac/Exc Skn Beni1.1-2cm Fce,Facial",PX11442F,CDM,510,RC,11442,CPT,,,,,,,,668,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,94.46,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.15,404.01
"Fac/Exc Skn Beni1.1-2cm Fce,Facial",PX11442F,CDM,510,RC,11442,CPT,,,,,,,,668,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,94.46,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.15,404.01
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041100,NDC,0.5,ML,196.94,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,94.5312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.808876,411.2766
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041100,NDC,0.5,ML,196.94,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,94.5312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.808876,411.2766
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041110,NDC,0.5,ML,196.94,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,94.5312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.808876,411.2766
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041110,NDC,0.5,ML,196.94,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,94.5312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.808876,411.2766
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323012594,NDC,1,EA,190.99,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,94.54005,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338411450,NDC,50,ML,106.23,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,94.5447,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
Assay of Amylase,PX82150,CDM,300,RC,82150,CPT,,,,,,,,191,,Humana Choice Care,All Medicare plans,outpatient,49.5,,187.18,percent of total billed charges,94.545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.94,187.18
C-Reactive Protein,PX86140,CDM,300,RC,86140,CPT,,,,,,,,191,,Humana Choice Care,All Medicare plans,outpatient,49.5,,112.3075,percent of total billed charges,94.545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,187.18
"Chemotherapy, IV Infusion, Add'l Hour",PX96415,CDM,335,RC,96415,CPT,,,,,,,,191,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,94.545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,187.18
Fac/Ther Injection Carpal Tunnel,PX20526F,CDM,510,RC,20526,CPT,,,,,,,,191,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,94.545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.3414,258.75
Urine Pregnancy Test,PX81025,CDM,300,RC,81025,CPT,,,,,,,,191,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,94.545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.89,187.18
Assay Other Fluid Chlorides - Ref,PX8243890,CDM,300,RC,82438,CPT,90,,,,,,,197,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,94.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.58,193.06
Assay Other Fluid Chlorides - Ref,PX8243890,CDM,300,RC,82438,CPT,90,,,,,,,197,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,94.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.58,193.06
Tramadol - Ref,PX8037390,CDM,300,RC,80373,CPT,90,,,,,,,197,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,94.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.8338,193.06
Tramadol - Ref,PX8037390,CDM,300,RC,80373,CPT,90,,,,,,,197,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,94.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.8338,193.06
Ag Detect Nos Eia Mult,PX87449,CDM,300,RC,87449,CPT,,,,,,,,193,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,94.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,189.14
Ag Detect Nos Eia Mult,PX87449,CDM,300,RC,87449,CPT,,,,,,,,193,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,94.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,189.14
Ag Detect Nos Eia Mult,PX87449,CDM,300,RC,87449,CPT,,,,,,,,193,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,94.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,189.14
"Fac/Office Consultation,Level IV",PX99244F,CDM,510,RC,99244,CPT,,,,,,,,441,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,94.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.11,287.64
"Fac/Office Consultation,Level IV",PX99244F,CDM,510,RC,99244,CPT,,,,,,,,441,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,94.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.11,287.64
"Office Consultation,Level IV",PX99244P,CDM,983,RC,99244,CPT,,,,,,,,441,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,94.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.11,432.18
"Office Consultation,Level IV",PX99244P,CDM,983,RC,99244,CPT,,,,,,,,441,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,94.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.11,432.18
Fac/Initial Hospital Care Levl II,PX99222F,CDM,510,RC,99222,CPT,,,,,,,,187,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,94.622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.6798,183.26
"Infect Ag,Eia, Nos, Ea - Ref",PX8744990,CDM,300,RC,87449,CPT,90,,,,,,,187,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,94.622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,183.26
Initial Hospital Care Levl II,PX99222P,CDM,982,RC,99222,CPT,,,,,,,,187,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,94.622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.6798,182.0071
RETRIEVAL BAG 12/15MM,27200000,CDM,272,RC,,,,12660-MAIN,LOCAL,,,,,187,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,94.622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,781523806,NDC,1,EA,106.34,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,94.6426,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,781523864,NDC,1,EA,106.34,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,94.6426,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,65862039010,NDC,1,EA,106.34,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,94.6426,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
"Up GI Endoscopy,Ball Dil,30mm",PX43249F,CDM,750,RC,43249,CPT,,,,,,,,2596,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,94.67,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.8,2216.53
"Up GI Endoscopy,Ball Dil,30mm",PX43249F,CDM,750,RC,43249,CPT,,,,,,,,2596,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,94.67,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.8,2216.53
"Up GI Endoscopy,Ball Dil,30mm",PX43249P,CDM,983,RC,43249,CPT,,,,,,,,1731,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,94.67,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.8,2216.53
"Up GI Endoscopy,Ball Dil,30mm",PX43249P,CDM,983,RC,43249,CPT,,,,,,,,1731,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,94.67,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.8,2216.53
romiPLOStim 250 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022101,NDC,1,EA,3791.51,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,94.67631,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.5,96.38
RomiPLOStim 500 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022201,NDC,1,EA,7018.25,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,94.67631,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.5,96.38
OXALiplatin 50 MG/10ML Solution 10 mL Vial,J9263.01,CDM,636,RC,J9263,HCPCS,,,,955173110,NDC,10,ML,228,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,94.7112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.7112,223.44
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021515,NDC,0.5,ML,187.24,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,94.74344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.779496,199.7926
Carnitine - Ref,PX8237990,CDM,300,RC,82379,CPT,90,,,,,,,104,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,94.744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.47,101.92
Cmv Antibody - Ref,PX8664490,CDM,300,RC,86644,CPT,90,,,,,,,104,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,94.744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,101.92
tobramycin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314064305,NDC,5,ML,191.42,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,94.7529,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
alendronate 70 MG Tablet 4 Each Box,63700001,CDM,250,RC,,,,,,16714063301,NDC,1,EA,97.37,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,94.770221,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Remove Impacted Ear Wax,PX69210P,CDM,983,RC,69210,CPT,,,,,,,,221,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,94.809,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.44,215.0993
"Chemotherapy, IV Push, Additional Drug",PX96411,CDM,335,RC,96411,CPT,,,,,,,,87,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,94.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.77,94.82
"Chemotherapy, IV Push, Additional Drug",PX96411,CDM,335,RC,96411,CPT,,,,,,,,87,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,94.82,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.77,94.82
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,409277602,NDC,200,ML,228.28,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,94.827512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.827512,225.8704
CARTER THOMASON CLOSURE 5MM,27200000,CDM,272,RC,,,,10278-MAIN,LOCAL,,,,,97.45,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,94.848085,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047625,NDC,0.769230769,ML,111.59,,First Health,Commercial,both,85,,999999999,percent of total billed charges,94.8515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.354486,332.1514
Colonoscopy,PX44388F,CDM,750,RC,44388,CPT,,,,,,,,930,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,94.89,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.89,655.83
Colonoscopy,PX44388P,CDM,983,RC,44388,CPT,,,,,,,,620,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,94.89,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.89,655.83
fentaNYL 12 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,378911916,NDC,1,EA,96.83,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,94.8934,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 12 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505708000,NDC,1,EA,96.83,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,94.8934,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 12 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,378911998,NDC,1,EA,96.84,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,94.9032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 12 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,60505708002,NDC,1,EA,96.84,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,94.9032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329330101,NDC,50,ML,107.61,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,94.91202,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,781309894,NDC,1,EA,193.75,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,3.99575,percent of total billed charges,94.9375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.461584,189.875
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,781309894,NDC,1,EA,193.75,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,94.9375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.461584,189.875
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,781309894,NDC,1,EA,193.75,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,94.9375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.461584,189.875
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714020010,NDC,1,EA,107.64,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,94.93848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714020030,NDC,1,EA,107.64,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,94.93848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
lidocaine 4 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,536128128,NDC,30,GR,96.95,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,95.011,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034001,NDC,1,EA,111.81,,First Health,Commercial,both,85,,999999999,percent of total billed charges,95.0385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
"Chest Wall Manipulation,Subsequent",PX94668F,CDM,410,RC,94668,CPT,,,,,,,,192,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,95.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.7568,188.16
Collect Blood From Picc,PX36592,CDM,949,RC,36592,CPT,,,,,,,,198,,Health Partners,Health Partners Care Plans,both,48,,97.84,percent of total billed charges,95.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.2492,194.04
Collect Blood From Picc,PX36592,CDM,949,RC,36592,CPT,,,,,,,,198,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,95.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.2492,194.04
Hepatitis Be Antibody - Ref,PX8670790,CDM,300,RC,86707,CPT,90,,,,,,,192,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,95.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.61,188.16
Infectious Agent Antigen Detection by Immunoassay With Direct Visual Observation.,PX87811,CDM,300,RC,87811,CPT,,,,,,,,192,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,95.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.94,188.16
Insert Simple Cath Foley,PX51702F,CDM,510,RC,51702,CPT,,,,,,,,198,,Health Partners,Health Partners Care Plans,both,48,,186.24,percent of total billed charges,95.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.2492,194.04
Insert Simple Cath Foley,PX51702F,CDM,510,RC,51702,CPT,,,,,,,,198,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,95.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.2492,194.04
KIT PLEUREVAC CHEST DRAIN S-1100-08LF,120.2,CDM,272,RC,,,,4190-MAIN,LOCAL,,,,,198,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,95.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.0466,194.04
KIT PLEUREVAC CHEST DRAIN S-1100-08LF,120.2,CDM,272,RC,,,,4190-MAIN,LOCAL,,,,,198,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,95.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.0466,194.04
Lyme Screen,PX7585,CDM,300,RC,86618,CPT,,,,,,,,198,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,95.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.61,194.04
Lyme Screen,PX7585,CDM,300,RC,86618,CPT,,,,,,,,198,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,95.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.61,194.04
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034000,NDC,1,EA,111.82,,First Health,Commercial,both,85,,999999999,percent of total billed charges,95.047,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
Blastomyces Antibody - Ref,PX8661290,CDM,300,RC,86612,CPT,90,,,,,,,97,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,95.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.83,95.06
"Cmv, Quant - Ref",PX8749790,CDM,300,RC,87497,CPT,90,,,,,,,194,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,95.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.28,190.12
"Cmv, Quant - Ref",PX8749790,CDM,300,RC,87497,CPT,90,,,,,,,194,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,95.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.28,190.12
"Cmv, Quant - Ref",PX8749790,CDM,300,RC,87497,CPT,90,,,,,,,194,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,95.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.28,190.12
Contrast Bath Therapy,PX97034,CDM,420,RC,97034,CPT,,,,,,,,97,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,95.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,95.06
DRAPE INSTRUMENT ARM 470015,27200000,CDM,272,RC,,,,11925-MAIN,LOCAL,,,,,97,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,95.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
High Sens Crp,PX86141,CDM,300,RC,86141,CPT,,,,,,,,97,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,95.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,95.06
Hiv-1 Antigens W/Hiv 1/2 Antib,PX87389,CDM,300,RC,87389,CPT,,,,,,,,194,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,95.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.08,190.12
Hiv-1 Antigens W/Hiv 1/2 Antib,PX87389,CDM,300,RC,87389,CPT,,,,,,,,194,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,95.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.08,190.12
Hiv-1 Antigens W/Hiv 1/2 Antib,PX87389,CDM,300,RC,87389,CPT,,,,,,,,194,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,95.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.08,190.12
Lyme Disease Antibody,PX86618,CDM,300,RC,86618,CPT,,,,,,,,194,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,95.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.61,190.12
Lyme Disease Antibody,PX86618,CDM,300,RC,86618,CPT,,,,,,,,194,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,95.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.61,190.12
Lyme Disease Antibody,PX86618,CDM,300,RC,86618,CPT,,,,,,,,194,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,95.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.61,190.12
Rheumatoid Factor Quant,PX86431,CDM,300,RC,86431,CPT,,,,,,,,97,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,95.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.2,95.06
ketamine 100 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,55150044001,NDC,10,ML,111.85,,First Health,Commercial,both,85,,999999999,percent of total billed charges,95.0725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
patiromer sorbitex calcium 8.4 g Packet 4 Each Box,63700001,CDM,250,RC,,,,,,53436008404,NDC,1,EA,228.96,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,95.109984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Ctrl Nosebleed,Anter,Simple",PX30901P,CDM,983,RC,30901,CPT,,,,,,,,229,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,95.1266,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.1266,222.8857
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604P,CDM,983,RC,20604,CPT,,,,,,,,229,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,95.1266,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.1266,258.75
Removal of Nail Plate,PX11730F,CDM,510,RC,11730,CPT,,,,,,,,229,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,95.1266,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.1266,224.42
ON Q PAIN BUSTER,27100000,CDM,271,RC,A4305,HCPCS,,6751-MAIN,LOCAL,,,,,194.26,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,95.1874,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
ON Q PAIN BUSTER,27100000,CDM,271,RC,A4305,HCPCS,,6751-MAIN,LOCAL,,,,,194.26,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,95.1874,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
ON Q PAIN BUSTER,27100000,CDM,271,RC,A4305,HCPCS,,6751-MAIN,LOCAL,,,,,194.26,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,95.1874,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
ELECTRODE PEDS ONESTEP SINGLE,120.343,CDM,272,RC,A4556,HCPCS,,10296-MAIN,LOCAL,,,,,112,,First Health,Commercial,both,85,,999999999,percent of total billed charges,95.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
EYE IRRIGATION SYSTEM MT2000,120.318,CDM,272,RC,,,,8718-MAIN,LOCAL,,,,,112,,First Health,Commercial,both,85,,999999999,percent of total billed charges,95.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
F5 Gene - Ref,PX8124190,CDM,300,RC,81241,CPT,90,,,,,,,112,,First Health,Commercial,both,85,,999999999,percent of total billed charges,95.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
Immunofluorescence per Spec Add Singl Antb Stain - Ref,PX8835090,CDM,310,RC,88350,CPT,90,,,,,,,112,,First Health,Commercial,both,85,,999999999,percent of total billed charges,95.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
Osmolality; Urine,PX83935,CDM,300,RC,83935,CPT,,,,,,,,112,,First Health,Commercial,both,85,,999999999,percent of total billed charges,95.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.25,109.76
Prolactin,PX84146,CDM,300,RC,84146,CPT,,,,,,,,112,,First Health,Commercial,both,85,,999999999,percent of total billed charges,95.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.77,109.76
Quantitation Drug Nos - Ref,PX8029990,CDM,300,RC,80299,CPT,90,,,,,,,112,,First Health,Commercial,both,85,,999999999,percent of total billed charges,95.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.09,109.76
TUBE AIRSPIRAL BREATHING AND CHAMBER 900PT561,120.493,CDM,271,RC,A4604,HCPCS,,11618-MAIN,LOCAL,,,,,112,,First Health,Commercial,both,85,,999999999,percent of total billed charges,95.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
verapamil 2.5 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,51754020401,NDC,1,ML,112.01,,First Health,Commercial,both,85,,999999999,percent of total billed charges,95.2085,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,24208091055,NDC,3.5,GR,106.98,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,95.2122,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
3.0MM NON-THREADED K WIRE,27200000,CDM,272,RC,C1769,HCPCS,,12658-MAIN,LOCAL,,,,,107,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,95.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Androsetenedione - Ref,PX8215790,CDM,300,RC,82157,CPT,90,,,,,,,107,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,95.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.85,104.86
Decalcify Tc,PX8831101,CDM,310,RC,88311,CPT,TC,,,,,,,107,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,95.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
Fac/Trim Nail(S),PX11719F,CDM,510,RC,11719,CPT,,,,,,,,107,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,95.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
Path Special Stains II,PX3979,CDM,310,RC,88313,CPT,TC,,,,,,,107,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,95.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
"Special Stains,Group I",PX3978,CDM,310,RC,88312,CPT,TC,,,,,,,107,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,95.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU000390,CDM,300,RC,U0003,HCPCS,90,,,,,,,222,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,95.238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.2188,217.56
Nfct Ds Bct/Vir Respir Dna/Rna 22 Trgt Sarscov2,PX0202U,CDM,300,RC,0202U,HCPCS,,,,,,,,222,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,95.238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.2188,382.15
Observation Care Discharge,PX99217,CDM,982,RC,99217,CPT,,,,,,,,222,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,95.238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.2188,216.0726
gentamicin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,60758018805,NDC,5,ML,107.98,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,95.23836,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Erythropietin - Ref,PX8266890,CDM,300,RC,82668,CPT,90,,,,,,,108,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,95.256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,105.84
Levetiracetam - Ref,PX8017790,CDM,300,RC,80177,CPT,90,,,,,,,108,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,95.256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,105.84
Oxcarbazepine - Ref,PX8018390,CDM,300,RC,80183,CPT,90,,,,,,,108,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,95.256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,105.84
oseltamivir 75 MG capsule 10 Each Disp Pack,63700001,CDM,250,RC,,,,,,4080085,NDC,1,EA,97.87,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,95.256871,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 25 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,713050306,NDC,1,EA,108.03,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,95.28246,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 25 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713050312,NDC,1,EA,108.03,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,95.28246,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clotrimazole-betamethasone 1-0.05 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,66993089815,NDC,15,GR,192.55,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,95.31225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Xray Cervical Spine 6 or More Vws,PX7205201,CDM,320,RC,72052,CPT,TC,,,,,,,664,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,95.32,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.85,95.32
Xray Cervical Spine 6 or More Vws,PX7205201,CDM,320,RC,72052,CPT,TC,,,,,,,664,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,95.32,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.85,95.32
Colonoscopy,PX44388F,CDM,750,RC,44388,CPT,,,,,,,,930,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,95.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.89,655.83
Colonoscopy,PX44388F,CDM,750,RC,44388,CPT,,,,,,,,930,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,95.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.89,655.83
Colonoscopy,PX44388P,CDM,983,RC,44388,CPT,,,,,,,,620,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,95.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.89,655.83
Colonoscopy,PX44388P,CDM,983,RC,44388,CPT,,,,,,,,620,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,95.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.89,655.83
empagliflozin 10 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,597015237,NDC,1,EA,104.66,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,95.34526,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Surgical Diagnostic Exam, Anorectal",PX45990P,CDM,983,RC,45990,CPT,,,,,,,,409,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,95.3667,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.69,400.82
BLADE LARYNGOSCOPE MAC #3 SINGLE USE350-005-000,120.121,CDM,272,RC,,,,8320-MAIN,LOCAL,,,,,98,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,95.3834,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
BLADE LARYNGOSCOPE MAC #4 SINGLE USE 350-012-000,120.121,CDM,272,RC,,,,8321-MAIN,LOCAL,,,,,98,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,95.3834,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
BLADE LARYNGOSCOPE MAC #X3 SINGLE USE X3-003-000,120.121,CDM,272,RC,,,,8322-MAIN,LOCAL,,,,,98,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,95.3834,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
CANNULA JUNIOR 2 LARGE OPTIFLOW OJR416VT,120.561,CDM,272,RC,A4615,HCPCS,,12645-MAIN,LOCAL,,,,,98,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,95.3834,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
CANNULA JUNIOR 2 MEDIUM OPTIFLOW OJR414VT,120.561,CDM,272,RC,A4615,HCPCS,,12644-MAIN,LOCAL,,,,,98,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,95.3834,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
CANNULA OPTIFLOW JUNIOR 2 SMALL OJR412VT,120.561,CDM,272,RC,A4615,HCPCS,,12643-MAIN,LOCAL,,,,,98,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,95.3834,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
Hepatitis B Surface Antigen,PX87340,CDM,300,RC,87340,CPT,,,,,,,,98,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,95.3834,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.47,96.04
Ot Contracted Service/MCR,PX120.177,CDM,431,RC,,,,,,,,,,98,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,95.3834,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
Pt Contracted Services/MCR,PX120.175,CDM,421,RC,,,,,,,,,,98,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,95.3834,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
bicalutamide 50 MG Tablet 30 Each Bottle,25000000,CDM,250,RC,,,,,,16714081601,NDC,1,EA,98.01,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,95.393133,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
acyclovir 50 MG/ML Solution 10 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,55150015410,NDC,10,ML,108.16,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,95.39712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.927644,105.9968
alendronate 70 MG Tablet 4 Each Box,63700001,CDM,250,RC,,,,,,16714063301,NDC,1,EA,97.37,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,95.4226,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,61314062810,NDC,10,ML,98.07,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,95.451531,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Box,25000000,CDM,250,RC,,,,,,67434509,NDC,1,EA,98.1,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,95.48073,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037905,NDC,0.5,ML,229.88,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,95.492152,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
CARTER THOMASON CLOSURE 5MM,27200000,CDM,272,RC,,,,10278-MAIN,LOCAL,,,,,97.45,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,95.501,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001104,NDC,1,EA,108.29,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,95.51178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
Ag Detect Nos Eia Mult,PX87449,CDM,300,RC,87449,CPT,,,,,,,,193,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,95.535,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,189.14
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031F,CDM,510,RC,12031,CPT,,,,,,,,688,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,95.55,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.55,547.21
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031P,CDM,983,RC,12031,CPT,,,,,,,,551,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,95.55,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.55,547.21
Topiramate - Ref,PX8020190,CDM,300,RC,80201,CPT,90,,,,,,,195,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,95.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.93,191.1
Topiramate - Ref,PX8020190,CDM,300,RC,80201,CPT,90,,,,,,,195,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,95.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.93,191.1
Topiramate - Ref,PX8020190,CDM,300,RC,80201,CPT,90,,,,,,,195,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,95.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.93,191.1
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001103,NDC,1,EA,108.34,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,95.55588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
Alcohols - Ref,PX8032090,CDM,300,RC,80320,CPT,90,,,,,,,189,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,95.634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.5106,185.22
Dx Occult Blood Immunoassay,PX82274,CDM,300,RC,82274,CPT,,,,,,,,105,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,95.655,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.6,102.9
Specimen Concentration - Ref,PX8701590,CDM,300,RC,87015,CPT,90,,,,,,,105,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,95.655,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.12,102.9
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,17478007035,NDC,3.5,GR,105.01,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,95.66411,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Apply Finger Splint,Static",PX29130P,CDM,983,RC,29130,CPT,,,,,,,,223,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,95.667,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,217.0459
"Apply Forearm Splint,Static",PX29125F,CDM,510,RC,29125,CPT,,,,,,,,223,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,95.667,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,218.54
"Flow Cyto, Tech, 1st Mrkr - Ref",PX8818490,CDM,310,RC,88184,CPT,90,,,,,,,223,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,95.667,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,314.02
"Nephelometry, Each, Nos - Ref",PX8388390,CDM,300,RC,83883,CPT,90,,,,,,,223,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,95.667,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.47,218.54
Reduce Temporomandibl Disloc,PX21480P,CDM,983,RC,21480,CPT,,,,,,,,223,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,95.667,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,217.0459
"polyethylene glycol 236 g Recon Soln 4,000 mL Bottle",63700001,CDM,250,RC,,,,,,43386009019,NDC,4000,ML,112.6,,First Health,Commercial,both,85,,999999999,percent of total billed charges,95.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,143971801,NDC,200,ML,230.48,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,95.741392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.827512,225.8704
"Closed Rx Toe Fx,Manipulatn",PX28515F,CDM,510,RC,28515,CPT,,,,,,,,390,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,95.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.93,352.82
"Closed Rx Toe Fx,Manipulatn",PX28515F,CDM,510,RC,28515,CPT,,,,,,,,390,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,95.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.93,352.82
"Closed Rx Toe Fx,Manipulatn",PX28515P,CDM,983,RC,28515,CPT,,,,,,,,260,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,95.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.93,352.82
"Closed Rx Toe Fx,Manipulatn",PX28515P,CDM,983,RC,28515,CPT,,,,,,,,260,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,95.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.93,352.82
"Exc Skn Bngn2.1-3cmtrnk,Arm,Lg",PX11403P,CDM,983,RC,11403,CPT,,,,,,,,543,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,95.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.02,532.14
"Exc Skn Bngn2.1-3cmtrnk,Arm,Lg",PX11403P,CDM,983,RC,11403,CPT,,,,,,,,543,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,95.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.02,532.14
"Fac/Ex Skn Bngn2.1-3cm Trnk,Arm,Lg",PX11403F,CDM,510,RC,11403,CPT,,,,,,,,679,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,95.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.02,413.7
"Fac/Ex Skn Bngn2.1-3cm Trnk,Arm,Lg",PX11403F,CDM,510,RC,11403,CPT,,,,,,,,679,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,95.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.02,413.7
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329330101,NDC,50,ML,107.61,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,95.7729,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714020010,NDC,1,EA,107.64,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,95.7996,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714020030,NDC,1,EA,107.64,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,95.7996,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
Flu Dna Amp Probe 1st 2 Types,PX87502,CDM,300,RC,87502,CPT,,,,,,,,350,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,95.8,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.93,95.8
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062001,NDC,0.4,ML,189.48,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,95.87688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062040,NDC,0.4,ML,189.48,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,95.87688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801401,NDC,0.4,ML,189.48,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,95.87688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801410,NDC,0.4,ML,189.48,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,95.87688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,781309894,NDC,1,EA,193.75,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,95.90625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.461584,189.875
oseltamivir 75 MG capsule 10 Each Disp Pack,63700001,CDM,250,RC,,,,,,4080085,NDC,1,EA,97.87,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,95.9126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rivaroxaban 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50458058030,NDC,1,EA,98.57,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,95.938181,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409339004,NDC,1,EA,98.61,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,13.11107143,percent of total billed charges,95.977113,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
CT Lumbar Spine W/O & W/Dye,PX7213301,CDM,350,RC,72133,CPT,TC,,,,,,,4283,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,95.98,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.98,283.34
CT Lumbar Spine W/O & W/Dye,PX7213301,CDM,350,RC,72133,CPT,TC,,,,,,,4283,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,95.98,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.98,283.34
CT Lwr Extremity W/O&W/Dye,PX7370201,CDM,350,RC,73702,CPT,TC,,,,,,,1235,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,95.98,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.98,283.34
CT Lwr Extremity W/O&W/Dye,PX7370201,CDM,350,RC,73702,CPT,TC,,,,,,,1235,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,95.98,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.98,283.34
DERMABOND PRINEO SKIN CLOSURE SYSTEM 42CM,27200000,CDM,272,RC,,,,12323-MAIN,LOCAL,,,,,200,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DERMABOND PRINEO SKIN CLOSURE SYSTEM 42CM,27200000,CDM,272,RC,,,,12323-MAIN,LOCAL,,,,,200,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
gadoxetate disodium 0.25 MOL/L Solution 10 mL Vial,A9581,CDM,636,RC,A9581,HCPCS,,,,50419032005,NDC,10,ML,200,,Health Partners,Health Partners Care Plans,both,48,,19.4,percent of total billed charges,96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,196
gadoxetate disodium 0.25 MOL/L Solution 10 mL Vial,A9581,CDM,636,RC,A9581,HCPCS,,,,50419032005,NDC,10,ML,200,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,196
iohexol 300 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141363,NDC,100,ML,200,,Health Partners,Health Partners Care Plans,both,48,,1.954953846,percent of total billed charges,96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,294
iohexol 300 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141363,NDC,100,ML,200,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,294
iohexol 350 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141491,NDC,100,ML,200,,Health Partners,Health Partners Care Plans,both,48,,1.954953846,percent of total billed charges,96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,294
iohexol 350 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141491,NDC,100,ML,200,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,294
Lacosamide - Ref,PX8023590,CDM,300,RC,80235,CPT,90,,,,,,,200,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.86,196
Lacosamide - Ref,PX8023590,CDM,300,RC,80235,CPT,90,,,,,,,200,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.86,196
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059611,NDC,0.25,EA,200.05,,Health Partners,Health Partners Care Plans,both,48,,343.21,percent of total billed charges,96.024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.10077,725.3862
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059611,NDC,0.25,EA,200.05,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,96.024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.10077,725.3862
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059613,NDC,0.25,EA,200.05,,Health Partners,Health Partners Care Plans,both,48,,343.21,percent of total billed charges,96.024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.10077,725.3862
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059613,NDC,0.25,EA,200.05,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,96.024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.10077,725.3862
"Cmv, Quant - Ref",PX8749790,CDM,300,RC,87497,CPT,90,,,,,,,194,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,96.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.28,190.12
Hiv-1 Antigens W/Hiv 1/2 Antib,PX87389,CDM,300,RC,87389,CPT,,,,,,,,194,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,96.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.08,190.12
Lyme Disease Antibody,PX86618,CDM,300,RC,86618,CPT,,,,,,,,194,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,96.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.61,190.12
romiPLOStim 250 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022101,NDC,1,EA,3791.51,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,96.03,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.5,96.38
RomiPLOStim 500 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022201,NDC,1,EA,7018.25,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,96.03,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.5,96.38
"Apply Finger Splint,Static",PX29130F,CDM,420,RC,29130,CPT,,,,,,,,196,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,96.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.4184,192.08
"Apply Finger Splint,Static",PX29130F,CDM,420,RC,29130,CPT,,,,,,,,196,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,96.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.4184,192.08
"Apply Finger Splint,Static",PX29130F,CDM,420,RC,29130,CPT,,,,,,,,196,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,96.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.4184,192.08
BLADE LARYNGOSCOPE MAC #3 SINGLE USE350-005-000,120.121,CDM,272,RC,,,,8320-MAIN,LOCAL,,,,,98,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,96.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
BLADE LARYNGOSCOPE MAC #4 SINGLE USE 350-012-000,120.121,CDM,272,RC,,,,8321-MAIN,LOCAL,,,,,98,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,96.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
BLADE LARYNGOSCOPE MAC #X3 SINGLE USE X3-003-000,120.121,CDM,272,RC,,,,8322-MAIN,LOCAL,,,,,98,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,96.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
CANNULA JUNIOR 2 LARGE OPTIFLOW OJR416VT,120.561,CDM,272,RC,A4615,HCPCS,,12645-MAIN,LOCAL,,,,,98,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,96.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
CANNULA JUNIOR 2 MEDIUM OPTIFLOW OJR414VT,120.561,CDM,272,RC,A4615,HCPCS,,12644-MAIN,LOCAL,,,,,98,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,96.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
CANNULA OPTIFLOW JUNIOR 2 SMALL OJR412VT,120.561,CDM,272,RC,A4615,HCPCS,,12643-MAIN,LOCAL,,,,,98,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,96.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
Hepatitis B Surface Antigen,PX87340,CDM,300,RC,87340,CPT,,,,,,,,98,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,96.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.47,96.04
Heterophile Antibodies,PX86308,CDM,300,RC,86308,CPT,,,,,,,,196,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,96.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,192.08
Heterophile Antibodies,PX86308,CDM,300,RC,86308,CPT,,,,,,,,196,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,96.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,192.08
Heterophile Antibodies,PX86308,CDM,300,RC,86308,CPT,,,,,,,,196,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,96.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,192.08
Ot Contracted Service/MCR,PX120.177,CDM,431,RC,,,,,,,,,,98,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,96.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
Pt Contracted Services/MCR,PX120.175,CDM,421,RC,,,,,,,,,,98,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,96.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.7092,96.04
bicalutamide 50 MG Tablet 30 Each Bottle,25000000,CDM,250,RC,,,,,,16714081601,NDC,1,EA,98.01,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,96.0498,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Aaa US Screen Tc,PX7670601,CDM,402,RC,76706,CPT,TC,,,,,,,554,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,542.92
Abd Duplex Abd -Follow Up,PX9397602,CDM,921,RC,93976,CPT,TC,,,,,,,784,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,768.32
Abd Duplex Abd-Follow Up(T),PX9397601,CDM,921,RC,93976,CPT,TC,,,,,,,809,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,792.82
Art Upper Extremity-Ltd,PX9393101,CDM,921,RC,93931,CPT,TC,,,,,,,718,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,703.64
B-Scan Global,PX7651201,CDM,402,RC,76512,CPT,TC,,,,,,,127,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.7558,124.46
Bone Age Studies Tc,PX7707201,CDM,320,RC,77072,CPT,TC,,,,,,,211,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.6494,206.78
CT Abdomen W/O Dye,PX7415001,CDM,350,RC,74150,CPT,TC,,,,,,,2757,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Chest Spine W/O Dye,PX7212801,CDM,350,RC,72128,CPT,TC,,,,,,,2757,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Head/Brain W/O Dye,PX7045001,CDM,350,RC,70450,CPT,TC,,,,,,,2757,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Lower Extremity W/O Dye,PX7370001,CDM,350,RC,73700,CPT,TC,,,,,,,2757,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Lumbar Spine W/O Dye,PX7213101,CDM,350,RC,72131,CPT,TC,,,,,,,2757,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Maxillofacialw/O Dye,PX7048601,CDM,350,RC,70486,CPT,TC,,,,,,,2757,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Neck Spine W/O Dye,PX7212501,CDM,350,RC,72125,CPT,TC,,,,,,,2757,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Orbit/Ear/Fosa W/O Dye,PX7048001,CDM,350,RC,70480,CPT,TC,,,,,,,2757,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Pelvis W/O Dye,PX7219201,CDM,350,RC,72192,CPT,TC,,,,,,,2744,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2689.12
CT Soft Tissue Neck W/O Dye,PX7049001,CDM,350,RC,70490,CPT,TC,,,,,,,711,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,1198.67
CT Upper Extremity W/O Dye,PX7320001,CDM,350,RC,73200,CPT,TC,,,,,,,2757,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
Diagnostic CT Thorax W/O Contrast,PX7125001,CDM,350,RC,71250,CPT,TC,,,,,,,2757,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
"DXA, Bone Density Study, Hips/Pelv/Spine",PX7708001,CDM,320,RC,77080,CPT,TC,,,,,,,575,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,563.5
Fetal Profile W/O Stress,PX7681901,CDM,402,RC,76819,CPT,TC,,,,,,,248,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,243.04
Iadna Streptococcus Group a Amplified Probe Tq,PX87651,CDM,300,RC,87651,CPT,,,,,,,,113,,First Health,Commercial,both,85,,999999999,percent of total billed charges,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,110.74
Joint Survey,PX7707726,CDM,982,RC,77077,CPT,26,,,,,,,286,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,278.3638
Joint Survey Tc,PX7707701,CDM,320,RC,77077,CPT,TC,,,,,,,304,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,297.92
Low Dose CT Lung Ca Screen WO Contrast,PX7127101,CDM,350,RC,71271,CPT,TC,,,,,,,1286,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,1260.28
"OB US < 14 Wks, Single Fetus - Radiology, Tech",PX7680101,CDM,402,RC,76801,CPT,TC,,,,,,,472,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,462.56
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209P,CDM,982,RC,69209,CPT,,,,,,,,113,,First Health,Commercial,both,85,,999999999,percent of total billed charges,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9402,109.9829
Strapping of Toes,PX29550F,CDM,510,RC,29550,CPT,,,,,,,,113,,First Health,Commercial,both,85,,999999999,percent of total billed charges,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9402,110.74
"Transvaginal US, Obstetric",PX7681701,CDM,402,RC,76817,CPT,TC,,,,,,,460,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,450.8
Ultrasound Breast Complete,PX7664101,CDM,402,RC,76641,CPT,TC,,,,,,,333,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,326.34
US Abdomen Limited Tc,PX7670501,CDM,402,RC,76705,CPT,TC,,,,,,,425,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,416.5
US Abdomen Tc,PX7670001,CDM,402,RC,76700,CPT,TC,,,,,,,586,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,574.28
US Chest Tc,PX7660401,CDM,402,RC,76604,CPT,TC,,,,,,,248,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,243.04
"US Complete Joint, Realtime W/ Img Tc",PX7688101,CDM,402,RC,76881,CPT,TC,,,,,,,415,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,406.7
US Doppler Lw Ext Art Tc,PX9392601,CDM,921,RC,93926,CPT,TC,,,,,,,740,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,725.2
US Ext Non-Vasc Img Lmtd,PX7688201,CDM,402,RC,76882,CPT,TC,,,,,,,425,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,416.5
US Follicles-Limited Tc,PX7685701,CDM,402,RC,76857,CPT,TC,,,,,,,300,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,294
US Head/Neck Tc,PX7653601,CDM,402,RC,76536,CPT,TC,,,,,,,416,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,407.68
US Kidney Transplt Untrsd,PX7677601,CDM,402,RC,76776,CPT,TC,,,,,,,554,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,542.92
US Pelvic Tc Complete,PX7685601,CDM,402,RC,76856,CPT,TC,,,,,,,472,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,462.56
US Pregnancy Tc Follow-Up,PX7681601,CDM,402,RC,76816,CPT,TC,,,,,,,362,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,354.76
US Pregnancy Tc Limited,PX7681501,CDM,402,RC,76815,CPT,TC,,,,,,,438,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,429.24
US Renal Retroperit Ltd,PX7677501,CDM,402,RC,76775,CPT,TC,,,,,,,566,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,554.68
US Retroperitoneal Tc,PX7677001,CDM,402,RC,76770,CPT,TC,,,,,,,566,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,554.68
US Scrotum & Contents Tc,PX7687001,CDM,402,RC,76870,CPT,TC,,,,,,,457,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,447.86
US Transvaginal Tc,PX7683001,CDM,402,RC,76830,CPT,TC,,,,,,,472,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,462.56
"US,Preg. Uterus,Fetal/Mat.Eval.,>1st Trim.(>/= 14 Wks 0 Dys),Transabd;Single/First Gest., Tech",PX7680501,CDM,402,RC,76805,CPT,TC,,,,,,,562,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,550.76
Venous Duplex Scan Uni,PX9397101,CDM,921,RC,93971,CPT,TC,,,,,,,809,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,792.82
X-Ray Abdomen 2+ Views W/ Single Vw Chest (Tc),PX7402201,CDM,320,RC,74022,CPT,TC,,,,,,,334,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,327.32
X-Ray Exam Abdomen 2 Views,PX7401901,CDM,320,RC,74019,CPT,TC,,,,,,,436,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,427.28
X-Ray Exam Entire Spine 2-3 Vws,PX7208201,CDM,320,RC,72082,CPT,TC,,,,,,,454,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,444.92
"X-Ray Exam Hip,Bilat W/Pelvis 2 Vws",PX7352101,CDM,320,RC,73521,CPT,TC,,,,,,,399,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,391.02
"X-Ray Exam Hip,Bilat W/Pelvis 3-4 Vws",PX7352201,CDM,320,RC,73522,CPT,TC,,,,,,,382,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,374.36
Xray Cervical Spine 4 or 5 Vws,PX7205001,CDM,320,RC,72050,CPT,TC,,,,,,,664,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,650.72
Xray Cervical Spine 6 or More Vws,PX7205201,CDM,320,RC,72052,CPT,TC,,,,,,,664,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,650.72
Xray Facial Bones Minimum 3 Vws,PX7015001,CDM,320,RC,70150,CPT,TC,,,,,,,551,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,539.98
Xray Hand 2vws Tc,PX7312001,CDM,320,RC,73120,CPT,TC,,,,,,,365,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,357.7
Xray Knee 4 or More Vws,PX7356401,CDM,320,RC,73564,CPT,TC,,,,,,,490,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,480.2
Xray Ls Spine Bend Tc,PX7212001,CDM,320,RC,72120,CPT,TC,,,,,,,323,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,316.54
Xray Lumbosacral 2 or 3 Vws,PX7210001,CDM,320,RC,72100,CPT,TC,,,,,,,399,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,391.02
Xray Lumbosacral Minimum 4 Vws,PX7211001,CDM,320,RC,72110,CPT,TC,,,,,,,565,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,553.7
"Xray Mandible Compl, Min 4 Vws",PX7011001,CDM,320,RC,70110,CPT,TC,,,,,,,381,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,373.38
Xray Pelvis 1 or 2 Vws,PX7217001,CDM,320,RC,72170,CPT,TC,,,,,,,279,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,273.42
Xray Pelvis Compl 3+ Tc,PX7219001,CDM,320,RC,72190,CPT,TC,,,,,,,563,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,551.74
Xray Ribs Bil 3vws Tc,PX7111001,CDM,320,RC,71110,CPT,TC,,,,,,,533,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,522.34
Xray Ribs Bilat 3 Vws With Pa Chest,PX7111101,CDM,320,RC,71111,CPT,TC,,,,,,,417,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,408.66
Xray Ribs Unilat 2 Vws With Pa Chest,PX7110101,CDM,320,RC,71101,CPT,TC,,,,,,,792,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,776.16
Xray Sacroiliac Jnts 3 or More Vws,PX7220201,CDM,320,RC,72202,CPT,TC,,,,,,,285,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,279.3
Xray Sacroiliac Jnts Less Than 3 Vws,PX7220001,CDM,320,RC,72200,CPT,TC,,,,,,,555,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,543.9
Xray Scapula Complete,PX7301001,CDM,320,RC,73010,CPT,TC,,,,,,,357,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,349.86
Xray Skull Less Than 4 Vws,PX7025001,CDM,320,RC,70250,CPT,TC,,,,,,,311,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,304.78
Xray Spine Single Tc,PX7202001,CDM,320,RC,72020,CPT,TC,,,,,,,113,,First Health,Commercial,both,85,,999999999,percent of total billed charges,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9402,110.74
Xray Thoracic Spine 2 Vws,PX7207001,CDM,320,RC,72070,CPT,TC,,,,,,,428,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,419.44
Xray Thoracic Spine 3 Vws,PX7207201,CDM,320,RC,72072,CPT,TC,,,,,,,522,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,96.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,511.56
Body Fluid Cell Count W Diff,PX89051,CDM,300,RC,89051,CPT,,,,,,,,224,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,96.096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.13,219.52
Emergency Level I Visit,PX99281P,CDM,981,RC,99281,CPT,,,,,,,,224,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,96.096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.56,218.0192
ENDOWRIST INSTRUMENTS PERMANENT CAUTERY HOOK 8MM,27200000,CDM,272,RC,,,,12050-MAIN,LOCAL,,,,,224,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,96.096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Helicobacter Pylori Ab,PX86677,CDM,300,RC,86677,CPT,,,,,,,,224,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,96.096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.45,219.52
gentamicin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,60758018805,NDC,5,ML,107.98,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,96.1022,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,61314062810,NDC,10,ML,98.07,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,96.1086,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Erythropietin - Ref,PX8266890,CDM,300,RC,82668,CPT,90,,,,,,,108,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,96.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,105.84
Levetiracetam - Ref,PX8017790,CDM,300,RC,80177,CPT,90,,,,,,,108,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,96.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,105.84
Oxcarbazepine - Ref,PX8018390,CDM,300,RC,80183,CPT,90,,,,,,,108,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,96.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,105.84
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Box,25000000,CDM,250,RC,,,,,,67434509,NDC,1,EA,98.1,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,96.138,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"RBC Sed Rate, Auto",PX85652,CDM,300,RC,85652,CPT,,,,,,,,109,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,96.138,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.48,106.82
Smear Gram Stain,PX87205,CDM,300,RC,87205,CPT,,,,,,,,109,,United Healthcare,All Payer,outpatient,88.2,,51.45,percent of total billed charges,96.138,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,106.82
Smear Wet Mount Saline/Ink,PX87210,CDM,300,RC,87210,CPT,,,,,,,,109,,United Healthcare,All Payer,outpatient,88.2,,49.35,percent of total billed charges,96.138,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.34,106.82
"West Nile Ab, Igm - Ref",PX8678890,CDM,300,RC,86788,CPT,90,,,,,,,109,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,96.138,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.45,106.82
Assay of ammonia,PX82140,CDM,300,RC,82140,CPT,,,,,,,,190,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,96.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.36,186.2
Assay of protein urine,PX84156,CDM,300,RC,84156,CPT,,,,,,,,190,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,96.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.37,186.2
Each Add'l Sequential IV Infusion <1 Hour,PX96367,CDM,260,RC,96367,CPT,,,,,,,,190,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,96.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,186.2
"N Block Inj, Common Digit",PX64632F,CDM,510,RC,64632,CPT,,,,,,,,190,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,96.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.926,258.75
"Tumor Antigen, Ca-125",PX86304,CDM,300,RC,86304,CPT,,,,,,,,190,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,96.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,186.2
hydrocortisone 25 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,713050306,NDC,1,EA,108.03,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,96.1467,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 25 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713050312,NDC,1,EA,108.03,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,96.1467,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ON Q PAIN BUSTER,27100000,CDM,271,RC,A4305,HCPCS,,6751-MAIN,LOCAL,,,,,194.26,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,96.1587,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
azithromycin 200 MG/5ML Recon Susp 15 mL Bottle,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,59762312001,NDC,15,ML,196.35,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,96.2115,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
azithromycin 200 MG/5ML Recon Susp 15 mL Bottle,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,59762312001,NDC,15,ML,196.35,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,96.2115,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
azithromycin 200 MG/5ML Recon Susp 15 mL Bottle,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,59762312001,NDC,15,ML,196.35,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,96.2115,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
ROTH NET PLATINUM RETRIEVER,27200000,CDM,272,RC,,,,7518-MAIN,LOCAL,,,,,196.35,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,96.2115,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ROTH NET PLATINUM RETRIEVER,27200000,CDM,272,RC,,,,7518-MAIN,LOCAL,,,,,196.35,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,96.2115,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ROTH NET PLATINUM RETRIEVER,27200000,CDM,272,RC,,,,7518-MAIN,LOCAL,,,,,196.35,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,96.2115,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
acyclovir 50 MG/ML Solution 10 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,55150015410,NDC,10,ML,108.16,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,96.2624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.927644,105.9968
ondansetron 4 MG/5ML Solution 50 mL Bottle,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714067102,NDC,5,ML,98.91,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,96.269103,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
Abd Paracentesis W/Imaging(P),PX49083P,CDM,983,RC,49083,CPT,,,,,,,,696,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,96.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.45,682.08
Abd Paracentesis W/Imaging(T),PX49083F,CDM,510,RC,49083,CPT,,,,,,,,1006,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,96.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.45,602.56
Removal of Nail Bed,PX11750F,CDM,510,RC,11750,CPT,,,,,,,,629,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,96.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.91,334.83
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,23155029031,NDC,2,ML,98.99,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,96.346967,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,97.0102
"Clostridium Ag, Eia",PX87324,CDM,300,RC,87324,CPT,,,,,,,,99,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,96.3567,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,97.02
Deoxyribonuclease Ab,PX86215,CDM,300,RC,86215,CPT,,,,,,,,99,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,96.3567,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,97.02
"Extractable Nuclear Antigen, Each Antigen",PX86235,CDM,300,RC,86235,CPT,90,,,,,,,99,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,34.42833333,percent of total billed charges,96.3567,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.44,97.02
"Fungus Antibody, Nos - Ref",PX8667190,CDM,300,RC,86671,CPT,90,,,,,,,99,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,96.3567,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.23,97.02
"Lab Immunoassay, Non Antibody",PX83516,CDM,300,RC,83516,CPT,,,,,,,,99,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,96.3567,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.57,97.02
"Protozoa Antibody, Nos - Ref",PX8675390,CDM,300,RC,86753,CPT,90,,,,,,,99,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,96.3567,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.36,97.02
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329335201,NDC,50,ML,109.26,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,96.36732,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Bile Acids Total,PX8223990,CDM,300,RC,82239,CPT,90,,,,,,,232,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,96.3728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,227.36
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001104,NDC,1,EA,108.29,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,96.3781,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
romiPLOStim 250 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022101,NDC,1,EA,3791.51,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,96.38,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.5,96.38
romiPLOStim 250 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022101,NDC,1,EA,3791.51,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,96.38,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.5,96.38
RomiPLOStim 500 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022201,NDC,1,EA,7018.25,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,96.38,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.5,96.38
RomiPLOStim 500 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022201,NDC,1,EA,7018.25,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,96.38,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.5,96.38
"Closed Rx Big Toe Fx,Manip",PX28495F,CDM,510,RC,28495,CPT,,,,,,,,857,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,96.42,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.42,384.64
"Closed Rx Big Toe Fx,Manip",PX28495P,CDM,983,RC,28495,CPT,,,,,,,,412,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,96.42,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.42,403.76
CT Lumbar Spine W/O & W/Dye,PX7213301,CDM,350,RC,72133,CPT,TC,,,,,,,4283,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,96.42,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.98,283.34
CT Lwr Extremity W/O&W/Dye,PX7370201,CDM,350,RC,73702,CPT,TC,,,,,,,1235,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,96.42,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.98,283.34
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031F,CDM,510,RC,12031,CPT,,,,,,,,688,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,96.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.55,547.21
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031F,CDM,510,RC,12031,CPT,,,,,,,,688,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,96.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.55,547.21
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031P,CDM,983,RC,12031,CPT,,,,,,,,551,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,96.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.55,547.21
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031P,CDM,983,RC,12031,CPT,,,,,,,,551,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,96.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.55,547.21
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001103,NDC,1,EA,108.34,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,96.4226,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
"dextrose 5 % 5 % Solution 1,000 mL Flex Cont",J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001704,NDC,1000,ML,99.12,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,96.473496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001702,NDC,250,ML,99.12,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,96.473496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338634602,NDC,250,ML,99.12,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,96.473496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 500 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001703,NDC,500,ML,99.12,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,96.473496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % Non-DEHP bag 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,264751020,NDC,250,ML,99.12,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,96.473496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"dextrose 5% and sodium chloride 0.2% 5-0.2 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338007704,NDC,1000,ML,99.12,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1.076666667,percent of total billed charges,96.473496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
"dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008904,NDC,1000,ML,99.12,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1.076666667,percent of total billed charges,96.473496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 500 mL Flex Cont,J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008903,NDC,500,ML,99.12,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1.076666667,percent of total billed charges,96.473496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
"dextrose 5% and sodium chloride 0.45% 5-0.45 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008504,NDC,1000,ML,99.12,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1.076666667,percent of total billed charges,96.473496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
dextrose 5% lactated ringers 5 % Solution 500 mL Flex Cont,J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012503,NDC,500,ML,99.12,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,51.5301,percent of total billed charges,96.473496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 10% 10 % Solution 500 mL Flex Cont,25000000,CDM,250,RC,,,,,,338002303,NDC,500,ML,99.12,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,96.473496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lactated ringers Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338011704,NDC,1000,ML,99.12,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,51.5301,percent of total billed charges,96.473496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338069104,NDC,1000,ML,99.12,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,4.559571429,percent of total billed charges,96.473496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004904,NDC,1000,ML,99.12,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,47.90196078,percent of total billed charges,96.473496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954306,NDC,1000,ML,99.12,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,47.90196078,percent of total billed charges,96.473496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004902,NDC,250,ML,99.12,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,47.90196078,percent of total billed charges,96.473496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954302,NDC,250,ML,99.12,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,47.90196078,percent of total billed charges,96.473496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 500 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004903,NDC,500,ML,99.12,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,47.90196078,percent of total billed charges,96.473496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9% 0.9% Solution 1,000 mL Flex Cont",J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004904,NDC,1000,ML,99.12,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,26.00411043,percent of total billed charges,96.473496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9% IV LINE FLUSH 0.9% Solution 250 mL Flex Cont,25000000,CDM,250,RC,,,,,,338004902,NDC,250,ML,99.12,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,96.473496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"sodium chloride 0.45 % 0.45 % Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,338004304,NDC,1000,ML,99.12,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,96.473496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 3 % 3 % Solution 500 mL Flex Cont,J7131.01,CDM,636,RC,J7131,HCPCS,,,,338005403,NDC,500,ML,99.12,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,96.473496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
"Hepatitis a Antibody, Tot - Ref",PX8670890,CDM,300,RC,86708,CPT,90,,,,,,,201,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,96.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.36,196.98
"Hepatitis a Antibody, Tot - Ref",PX8670890,CDM,300,RC,86708,CPT,90,,,,,,,201,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,96.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.36,196.98
Hepatitis B Surface Antibody,PX86706,CDM,300,RC,86706,CPT,,,,,,,,201,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,96.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,196.98
Hepatitis B Surface Antibody,PX86706,CDM,300,RC,86706,CPT,,,,,,,,201,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,96.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,196.98
KIT 3-LUMEN 7FR X 16CM CENTRALVENOUS CDC-42703-P1A,120.37,CDM,272,RC,C1751,HCPCS,,10707-MAIN,LOCAL,,,,,201,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,96.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.4954,196.98
KIT 3-LUMEN 7FR X 16CM CENTRALVENOUS CDC-42703-P1A,120.37,CDM,272,RC,C1751,HCPCS,,10707-MAIN,LOCAL,,,,,201,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,96.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.4954,196.98
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041100,NDC,0.5,ML,196.94,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,96.5006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.808876,411.2766
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041100,NDC,0.5,ML,196.94,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,96.5006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.808876,411.2766
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041100,NDC,0.5,ML,196.94,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,96.5006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.808876,411.2766
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041110,NDC,0.5,ML,196.94,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,96.5006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.808876,411.2766
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041110,NDC,0.5,ML,196.94,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,96.5006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.808876,411.2766
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041110,NDC,0.5,ML,196.94,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,96.5006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.808876,411.2766
"Cytoflo, Cell or Dna Anal - Ref",PX8818290,CDM,310,RC,88182,CPT,90,,,,,,,225,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,96.525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,220.5
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153F,CDM,370,RC,99153,CPT,,,,,,,,225,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,96.525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.465,220.5
Topiramate - Ref,PX8020190,CDM,300,RC,80201,CPT,90,,,,,,,195,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,96.525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.93,191.1
Assay Other Fluid Chlorides - Ref,PX8243890,CDM,300,RC,82438,CPT,90,,,,,,,197,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,96.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.58,193.06
Assay Other Fluid Chlorides - Ref,PX8243890,CDM,300,RC,82438,CPT,90,,,,,,,197,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,96.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.58,193.06
Assay Other Fluid Chlorides - Ref,PX8243890,CDM,300,RC,82438,CPT,90,,,,,,,197,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,96.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.58,193.06
Tramadol - Ref,PX8037390,CDM,300,RC,80373,CPT,90,,,,,,,197,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,96.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.8338,193.06
Tramadol - Ref,PX8037390,CDM,300,RC,80373,CPT,90,,,,,,,197,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,96.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.8338,193.06
Tramadol - Ref,PX8037390,CDM,300,RC,80373,CPT,90,,,,,,,197,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,96.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.8338,193.06
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,17478062512,NDC,2.5,ML,109.45,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,96.5349,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Thrombolysis,Coronary,IV Infusn",PX92977F,CDM,480,RC,92977,CPT,,,,,,,,595,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,96.56,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.16,96.56
"Thrombolysis,Coronary,IV Infusn",PX92977F,CDM,480,RC,92977,CPT,,,,,,,,595,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,96.56,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.16,96.56
GLIDESCOPE QC MILLER S0 SINGLE USE 0270-1087,120.58,CDM,272,RC,,,,13024-MAIN,LOCAL,,,,,106,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,96.566,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
GLIDESCOPE QC MILLER S1 SINGLE USE 0270-1088,120.58,CDM,272,RC,,,,13025-MAIN,LOCAL,,,,,106,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,96.566,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
cefTRIAXone in dextrose 1 g / 50 mL 1-3.74 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0696.01,CDM,636,RC,J0696,HCPCS,,,,264315311,NDC,1,EA,106.03,,Medica,Commercial,both,91.1,,6.892980769,percent of total billed charges,96.59333,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
rivaroxaban 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50458058030,NDC,1,EA,98.57,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,96.5986,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
albuterol (5 MG/ML) 0.5% Nebulization Solution 20 mL Bottle,J7611.01,CDM,250,RC,,,,,,50383074120,NDC,20,ML,225.2,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,96.6108,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.54808,220.696
Anal Sphincterotomy,PX46080F,CDM,510,RC,46080,CPT,,,,,,,,607,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,96.63,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.63,598.41
Anal Sphincterotomy,PX46080P,CDM,983,RC,46080,CPT,,,,,,,,525,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,96.63,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.63,598.41
MRI Low Ext Jnt WO/Cont Tc,PX7372101,CDM,610,RC,73721,CPT,TC,,,,,,,3541,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,96.63,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.63,285.31
MRI Low Ext Jnt WO/Cont Tc,PX7372101,CDM,610,RC,73721,CPT,TC,,,,,,,3541,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,96.63,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.63,285.31
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409339004,NDC,1,EA,98.61,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,96.6378,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323012594,NDC,1,EA,190.99,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,96.64094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
Assay of Amylase,PX82150,CDM,300,RC,82150,CPT,,,,,,,,191,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,96.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.94,187.18
C-Reactive Protein,PX86140,CDM,300,RC,86140,CPT,,,,,,,,191,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,96.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,187.18
"Chemotherapy, IV Infusion, Add'l Hour",PX96415,CDM,335,RC,96415,CPT,,,,,,,,191,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,96.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,187.18
Fac/Ther Injection Carpal Tunnel,PX20526F,CDM,510,RC,20526,CPT,,,,,,,,191,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,96.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.3414,258.75
Urine Pregnancy Test,PX81025,CDM,300,RC,81025,CPT,,,,,,,,191,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,96.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.89,187.18
scopolamine 1 MG/3DAYS Patch 72 Hour 24 Each Box,25000000,CDM,250,RC,,,,,,50742050524,NDC,1,EA,109.59,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,96.65838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
levothyroxine 100 MCG/5ML Solution 5 mL Vial,J0651.01,CDM,636,RC,J0651,HCPCS,,,,63323088510,NDC,0.625,ML,99.32,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,96.668156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.257528,97.3336
amiodarone 900 MG/18ML Solution 18 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,67457015318,NDC,18,ML,113.73,,First Health,Commercial,both,85,,999999999,percent of total billed charges,96.6705,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026969,NDC,100,ML,99.34,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1.094496241,percent of total billed charges,96.687622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098321,NDC,1,EA,99.39,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,13.11107143,percent of total billed charges,96.736287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098323,NDC,1,EA,99.39,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,13.11107143,percent of total billed charges,96.736287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052200,NDC,1,EA,99.39,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,13.11107143,percent of total billed charges,96.736287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052237,NDC,1,EA,99.39,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,13.11107143,percent of total billed charges,96.736287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338411450,NDC,50,ML,106.23,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,96.77553,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
TRAY GROSHONG 4FR SAFETY PICC 7617407,120.26,CDM,272,RC,,,,500-MAIN,LOCAL,,,,,233,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,96.7882,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.7882,228.34
MRI Up Extremity Joint W/O Tc,PX7322101,CDM,610,RC,73221,CPT,TC,,,,,,,3319,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,96.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.85,285.97
MRI Up Extremity Joint W/O Tc,PX7322101,CDM,610,RC,73221,CPT,TC,,,,,,,3319,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,96.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.85,285.97
tobramycin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314064305,NDC,5,ML,191.42,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,96.85852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,781523806,NDC,1,EA,106.34,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,96.87574,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,781523864,NDC,1,EA,106.34,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,96.87574,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,65862039010,NDC,1,EA,106.34,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,96.87574,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
Assay of Erythropoietin,PX82668,CDM,300,RC,82668,CPT,,,,,,,,114,,First Health,Commercial,both,85,,999999999,percent of total billed charges,96.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,111.72
ondansetron 4 MG/5ML Solution 50 mL Bottle,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714067102,NDC,5,ML,98.91,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,96.9318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
"Tech-Cytopath Eval, Fna, Rep",PX8817301,CDM,310,RC,88173,CPT,TC,,,,,,,379,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,96.98,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.98,162.848
"Tech-Cytopath Eval, Fna, Rep",PX8817301,CDM,310,RC,88173,CPT,TC,,,,,,,379,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,96.98,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.98,162.848
"Tech-Cytopath Eval, Fna, Rep",PX8817301,CDM,310,RC,88173,CPT,TC,,,,,,,379,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,96.98,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.98,162.848
TB Antigen Response Gamma Interferon T-Cell Susp,PX86481,CDM,300,RC,86481,CPT,,,,,,,,150,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,97,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97,100
TB Antigen Response Gamma Interferon T-Cell Susp,PX86481,CDM,300,RC,86481,CPT,,,,,,,,150,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,97,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97,100
TB Antigen Response Gamma Interferon T-Cell Susp,PX86481,CDM,300,RC,86481,CPT,,,,,,,,150,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,97,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97,100
TB Test Enumeration of T-Cells - Ref,PX8648190,CDM,300,RC,86481,CPT,90,,,,,,,155,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,97,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97,100
TB Test Enumeration of T-Cells - Ref,PX8648190,CDM,300,RC,86481,CPT,90,,,,,,,155,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,97,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97,100
TB Test Enumeration of T-Cells - Ref,PX8648190,CDM,300,RC,86481,CPT,90,,,,,,,155,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,97,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97,100
"RBC Sed Rate, Auto",PX85652,CDM,300,RC,85652,CPT,,,,,,,,109,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,97.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.48,106.82
Smear Gram Stain,PX87205,CDM,300,RC,87205,CPT,,,,,,,,109,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,97.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,106.82
Smear Wet Mount Saline/Ink,PX87210,CDM,300,RC,87210,CPT,,,,,,,,109,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,97.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.34,106.82
"West Nile Ab, Igm - Ref",PX8678890,CDM,300,RC,86788,CPT,90,,,,,,,109,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,97.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.45,106.82
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,23155029031,NDC,2,ML,98.99,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,97.0102,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,97.0102
"Acylcarnitines, Quant - Ref",PX8201790,CDM,300,RC,82017,CPT,90,,,,,,,110,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,97.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.47,107.8
"Apply Finger Splint,Static",PX29130F,CDM,420,RC,29130,CPT,,,,,,,,196,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,97.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.4184,192.08
"Assay Calcium, Ionized",PX82330,CDM,300,RC,82330,CPT,,,,,,,,110,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,97.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.54,107.8
BONE MARROW BIOPSY ASPIRATION NEEDLE 11G X 4 IN,120.562,CDM,272,RC,C1830,HCPCS,,12677-MAIN,LOCAL,,,,,110,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,97.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.694,107.8
"Clostridium Ag, Eia",PX87324,CDM,300,RC,87324,CPT,,,,,,,,99,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,97.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,97.02
Collect Blood From Picc,PX36592,CDM,949,RC,36592,CPT,,,,,,,,198,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,42.2,percent of total billed charges,97.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.2492,194.04
Collect Blood From Picc,PX36592,CDM,949,RC,36592,CPT,,,,,,,,198,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,97.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.2492,194.04
Collect Blood From Picc,PX36592,CDM,949,RC,36592,CPT,,,,,,,,198,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,97.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.2492,194.04
Debride Muscle Ea Add 20 Sqcm,PX11046P,CDM,983,RC,11046,CPT,,,,,,,,198,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,97.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.2492,192.7134
Debride Muscle Ea Add 20 Sqcm,PX11046P,CDM,983,RC,11046,CPT,,,,,,,,198,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,97.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.2492,192.7134
Debride Muscle Ea Add 20 Sqcm,PX11046P,CDM,983,RC,11046,CPT,,,,,,,,198,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,97.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.2492,192.7134
Deoxyribonuclease Ab,PX86215,CDM,300,RC,86215,CPT,,,,,,,,99,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,97.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,97.02
"Extractable Nuclear Antigen, Each Antigen",PX86235,CDM,300,RC,86235,CPT,90,,,,,,,99,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,97.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.44,97.02
"Fungus Antibody, Nos - Ref",PX8667190,CDM,300,RC,86671,CPT,90,,,,,,,99,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,97.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.23,97.02
Glycosylated Hemoglobin Test,PX83036,CDM,300,RC,83036,CPT,,,,,,,,110,,United Healthcare,All Payer,outpatient,88.2,,58.3,percent of total billed charges,97.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.9,130.9
Heterophile Antibodies,PX86308,CDM,300,RC,86308,CPT,,,,,,,,196,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,97.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,192.08
Insert Simple Cath Foley,PX51702F,CDM,510,RC,51702,CPT,,,,,,,,198,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,97.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.2492,194.04
Insert Simple Cath Foley,PX51702F,CDM,510,RC,51702,CPT,,,,,,,,198,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,97.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.2492,194.04
Insert Simple Cath Foley,PX51702F,CDM,510,RC,51702,CPT,,,,,,,,198,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,97.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.2492,194.04
K-WIRE 0.9X150MM BLUNT/TROCAR DART-FIRE STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12449-MAIN,LOCAL,,,,,110,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,97.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRE 0.9X150MM BLUNT/TROCAR STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12452-MAIN,LOCAL,,,,,110,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,97.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRE 1.4X150MM BLUNT/TROCAR DART-FIRE STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12450-MAIN,LOCAL,,,,,110,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,97.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRE 1.4X150MM BLUNT/TROCAR STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12451-MAIN,LOCAL,,,,,110,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,97.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
KIT PLEUREVAC CHEST DRAIN S-1100-08LF,120.2,CDM,272,RC,,,,4190-MAIN,LOCAL,,,,,198,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,97.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.0466,194.04
KIT PLEUREVAC CHEST DRAIN S-1100-08LF,120.2,CDM,272,RC,,,,4190-MAIN,LOCAL,,,,,198,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,97.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.0466,194.04
KIT PLEUREVAC CHEST DRAIN S-1100-08LF,120.2,CDM,272,RC,,,,4190-MAIN,LOCAL,,,,,198,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,97.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.0466,194.04
"Lab Immunoassay, Non Antibody",PX83516,CDM,300,RC,83516,CPT,,,,,,,,99,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,97.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.57,97.02
Lyme Screen,PX7585,CDM,300,RC,86618,CPT,,,,,,,,198,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,97.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.61,194.04
Lyme Screen,PX7585,CDM,300,RC,86618,CPT,,,,,,,,198,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,97.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.61,194.04
Lyme Screen,PX7585,CDM,300,RC,86618,CPT,,,,,,,,198,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,97.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.61,194.04
MICA 2.0MM TARGETING GUIDE PIN,27200000,CDM,272,RC,,,,12436-MAIN,LOCAL,,,,,110,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,97.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Protozoa Antibody, Nos - Ref",PX8675390,CDM,300,RC,86753,CPT,90,,,,,,,99,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,97.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.36,97.02
Strapping of Shoulder,PX29240P,CDM,983,RC,29240,CPT,,,,,,,,110,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,97.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.694,111.6
Anal Sphincterotomy,PX46080F,CDM,510,RC,46080,CPT,,,,,,,,607,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,97.07,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.63,598.41
Anal Sphincterotomy,PX46080F,CDM,510,RC,46080,CPT,,,,,,,,607,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,97.07,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.63,598.41
Anal Sphincterotomy,PX46080P,CDM,983,RC,46080,CPT,,,,,,,,525,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,97.07,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.63,598.41
Anal Sphincterotomy,PX46080P,CDM,983,RC,46080,CPT,,,,,,,,525,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,97.07,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.63,598.41
MRI Low Ext Jnt WO/Cont Tc,PX7372101,CDM,610,RC,73721,CPT,TC,,,,,,,3541,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,97.07,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.63,285.31
MRI Up Extremity Joint W/O Tc,PX7322101,CDM,610,RC,73221,CPT,TC,,,,,,,3319,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,97.07,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.85,285.97
Venous Duplex Scan Uni,PX9397101,CDM,921,RC,93971,CPT,TC,,,,,,,809,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,97.093,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.23,171.6
"dextrose 5 % 5 % Solution 1,000 mL Flex Cont",J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001704,NDC,1000,ML,99.12,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,97.1376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001702,NDC,250,ML,99.12,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,97.1376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338634602,NDC,250,ML,99.12,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,97.1376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % 5 % Solution 500 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001703,NDC,500,ML,99.12,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,97.1376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 5 % Non-DEHP bag 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,264751020,NDC,250,ML,99.12,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,97.1376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"dextrose 5% and sodium chloride 0.2% 5-0.2 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338007704,NDC,1000,ML,99.12,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,97.1376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
"dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008904,NDC,1000,ML,99.12,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,97.1376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 500 mL Flex Cont,J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008903,NDC,500,ML,99.12,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,97.1376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
"dextrose 5% and sodium chloride 0.45% 5-0.45 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008504,NDC,1000,ML,99.12,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,97.1376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
dextrose 5% lactated ringers 5 % Solution 500 mL Flex Cont,J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012503,NDC,500,ML,99.12,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,97.1376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
dextrose 10% 10 % Solution 500 mL Flex Cont,25000000,CDM,250,RC,,,,,,338002303,NDC,500,ML,99.12,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,97.1376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"lactated ringers Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338011704,NDC,1000,ML,99.12,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,97.1376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338069104,NDC,1000,ML,99.12,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,97.1376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.174562,97.1376
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004904,NDC,1000,ML,99.12,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,97.1376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954306,NDC,1000,ML,99.12,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,97.1376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004902,NDC,250,ML,99.12,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,97.1376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954302,NDC,250,ML,99.12,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,97.1376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
sodium chloride 0.9% 0.9 % Solution 500 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004903,NDC,500,ML,99.12,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,97.1376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.0699,97.1376
"sodium chloride 0.9% 0.9% Solution 1,000 mL Flex Cont",J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004904,NDC,1000,ML,99.12,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,97.1376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,97.1376
sodium chloride 0.9% IV LINE FLUSH 0.9% Solution 250 mL Flex Cont,25000000,CDM,250,RC,,,,,,338004902,NDC,250,ML,99.12,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,97.1376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"sodium chloride 0.45 % 0.45 % Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,338004304,NDC,1000,ML,99.12,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,97.1376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium chloride 3 % 3 % Solution 500 mL Flex Cont,J7131.01,CDM,636,RC,J7131,HCPCS,,,,338005403,NDC,500,ML,99.12,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,97.1376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.174448,97.1376
"Chest Wall Manipulation,Subsequent",PX94668F,CDM,410,RC,94668,CPT,,,,,,,,192,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,97.152,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.7568,188.16
Hepatitis Be Antibody - Ref,PX8670790,CDM,300,RC,86707,CPT,90,,,,,,,192,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,97.152,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.61,188.16
Infectious Agent Antigen Detection by Immunoassay With Direct Visual Observation.,PX87811,CDM,300,RC,87811,CPT,,,,,,,,192,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,97.152,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.94,188.16
DERMABOND MINI SKIN ADHESIVE,27200000,CDM,272,RC,,,,8532-MAIN,LOCAL,,,,,110.16,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,97.16112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084243,NDC,0.5,ML,202.42,,Health Partners,Health Partners Care Plans,both,48,,125.6271429,percent of total billed charges,97.1616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.085268,203.497
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084243,NDC,0.5,ML,202.42,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,97.1616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.085268,203.497
azithromycin 200 MG/5ML Recon Susp 15 mL Bottle,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,59762312001,NDC,15,ML,196.35,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,97.19325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
ROTH NET PLATINUM RETRIEVER,27200000,CDM,272,RC,,,,7518-MAIN,LOCAL,,,,,196.35,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,97.19325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CANNULA FOR INJECTION 1.8MM WITH 3MM LUER CONNECTION 8383.65,27200000,CDM,272,RC,,,,12004-MAIN,LOCAL,,,,,234,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,97.2036,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Fibrinogen,PX7426,CDM,300,RC,85384,CPT,,,,,,,,234,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,97.2036,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.91,229.32
DOPamine 1600 mcg/mL in dextrose 5% 250 mL premix 1600 mcg/mL Solution 250 mL Plas Cont,J1265.01,CDM,636,RC,J1265,HCPCS,,,,338100702,NDC,250,ML,99.9,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,97.23267,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.49846,97.902
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,68462015740,NDC,1,EA,110.25,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,97.2405,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,68462015713,NDC,1,EA,110.25,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,97.2405,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329335201,NDC,50,ML,109.26,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,97.2414,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927380,NDC,1,EA,99.91,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,97.242403,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927395,NDC,1,EA,99.91,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,97.242403,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
"Chemotherapy, IV Push, Single Drug",PX96409,CDM,335,RC,96409,CPT,,,,,,,,502,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,97.263,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.88,174.51
naloxone 2 MG/2ML solution prefilled syringe 2 mL Syringe,J2310.01,CDM,636,RC,J2310,HCPCS,,,,76329346901,NDC,1,ML,114.45,,First Health,Commercial,both,85,,999999999,percent of total billed charges,97.2825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.54253,130.4968
levonorgestrel 1.5 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,62756071860,NDC,1,EA,114.48,,First Health,Commercial,both,85,,999999999,percent of total billed charges,97.308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gadoteridol 279.3 MG/ML Solution 5 mL Vial,A9576,CDM,636,RC,A9576,HCPCS,,,,270111104,NDC,10,ML,100,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,97.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.54,166.6
Sars-Cov-2 Covid-19 Antibody,PX8676990,CDM,300,RC,86769,CPT,90,,,,,,,100,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,97.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.63,98
levothyroxine 100 MCG/5ML Solution 5 mL Vial,J0651.01,CDM,636,RC,J0651,HCPCS,,,,63323088510,NDC,0.625,ML,99.32,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,97.3336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.257528,97.3336
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026969,NDC,100,ML,99.34,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,97.3532,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
Physical Therapy Evaluation High Complex,PX97163,CDM,424,RC,97163,CPT,,,,,,,,294,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,97.3648,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.14,132.23
Physical Therapy Evaluation Low Complex,PX97161,CDM,424,RC,97161,CPT,,,,,,,,235,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,97.3648,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.14,132.23
Physical Therapy Evaluation Mod Complex,PX97162,CDM,424,RC,97162,CPT,,,,,,,,264,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,97.3648,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.14,132.23
SET SP TUBE INTRODUCER  14CM 8-14FR G15469,120.377,CDM,272,RC,,,,7147-MAIN,LOCAL,,,,,227,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,97.383,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.2958,222.46
Sp Stn for Inclusn Bodies - Ref,PX8720790,CDM,300,RC,87207,CPT,90,,,,,,,227,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,97.383,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.49,222.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098321,NDC,1,EA,99.39,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,97.4022,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098323,NDC,1,EA,99.39,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,97.4022,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052200,NDC,1,EA,99.39,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,97.4022,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052237,NDC,1,EA,99.39,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,97.4022,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,17478062512,NDC,2.5,ML,109.45,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,97.4105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
clotrimazole-betamethasone 1-0.05 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,66993089815,NDC,15,GR,192.55,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,97.4303,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,24208091055,NDC,3.5,GR,106.98,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,97.45878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
3.0MM NON-THREADED K WIRE,27200000,CDM,272,RC,C1769,HCPCS,,12658-MAIN,LOCAL,,,,,107,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,97.477,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Androsetenedione - Ref,PX8215790,CDM,300,RC,82157,CPT,90,,,,,,,107,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,97.477,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.85,104.86
Decalcify Tc,PX8831101,CDM,310,RC,88311,CPT,TC,,,,,,,107,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,97.477,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
Fac/Trim Nail(S),PX11719F,CDM,510,RC,11719,CPT,,,,,,,,107,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,97.477,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
Path Special Stains II,PX3979,CDM,310,RC,88313,CPT,TC,,,,,,,107,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,97.477,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
"Special Stains,Group I",PX3978,CDM,310,RC,88312,CPT,TC,,,,,,,107,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,97.477,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041100,NDC,0.5,ML,196.94,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,97.4853,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.808876,411.2766
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041110,NDC,0.5,ML,196.94,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,97.4853,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.808876,411.2766
baricitinib 2 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,2418230,NDC,0.5,EA,203.12,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,97.4976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
baricitinib 2 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,2418230,NDC,0.5,EA,203.12,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,97.4976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CT Head/Brain W/Dye,PX7046001,CDM,350,RC,70460,CPT,TC,,,,,,,3398,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,97.5054,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.1,195.25
"Exc Skn Mal 0.6-1cm Fce,Facial",PX11641P,CDM,983,RC,11641,CPT,,,,,,,,453,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,97.51,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97.51,493.95
"Fac/Exc Skn Mal 0.6-1cm Fce,Facial",PX11641F,CDM,510,RC,11641,CPT,,,,,,,,680,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,97.51,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97.51,493.95
Inpt or Obs Disch Day Mngmt <=30 Minutes,PX99238,CDM,982,RC,99238,CPT,,,,,,,,199,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,97.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.6646,193.6867
Inpt or Obs Disch Day Mngmt <=30 Minutes,PX99238,CDM,982,RC,99238,CPT,,,,,,,,199,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,97.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.6646,193.6867
Inpt or Obs Disch Day Mngmt <=30 Minutes,PX99238,CDM,982,RC,99238,CPT,,,,,,,,199,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,97.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.6646,193.6867
Assay Other Fluid Chlorides - Ref,PX8243890,CDM,300,RC,82438,CPT,90,,,,,,,197,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,97.515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.58,193.06
Tramadol - Ref,PX8037390,CDM,300,RC,80373,CPT,90,,,,,,,197,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,97.515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.8338,193.06
pyRIDostigmine bromide 10 MG/2ML Solution 2 mL Ampule,25000000,CDM,250,RC,,,,,,781304095,NDC,2,ML,203.16,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,97.5168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pyRIDostigmine bromide 10 MG/2ML Solution 2 mL Ampule,25000000,CDM,250,RC,,,,,,781304095,NDC,2,ML,203.16,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,97.5168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
scopolamine 1 MG/3DAYS Patch 72 Hour 24 Each Box,25000000,CDM,250,RC,,,,,,50742050524,NDC,1,EA,109.59,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,97.5351,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152F,CDM,370,RC,99152,CPT,,,,,,,,235,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,97.619,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97.619,230.3
Occupational Therapy Eval Low Complex,PX97165,CDM,434,RC,97165,CPT,,,,,,,,235,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,97.619,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,230.3
Remv Ext Canal Foreign Body,PX69200F,CDM,510,RC,69200,CPT,,,,,,,,235,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,97.619,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97.619,230.3
"Vitamin D, 25 Hydroxy",PX82306,CDM,300,RC,82306,CPT,,,,,,,,235,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,97.619,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.14,230.3
Ag Detect Nos Eia Mult,PX87449,CDM,300,RC,87449,CPT,,,,,,,,193,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,97.658,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,189.14
gemcitabine 1 GM/26.3ML Solution 26.3 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018101,NDC,26.3,ML,203.58,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,97.7184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
gemcitabine 1 GM/26.3ML Solution 26.3 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018101,NDC,26.3,ML,203.58,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,97.7184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
Assay of Triglycerides,PX84478,CDM,300,RC,84478,CPT,,,,,,,,115,,First Health,Commercial,both,85,,999999999,percent of total billed charges,97.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.26,112.7
"Blood Typing, Rh Phenotype",PX86906,CDM,300,RC,86906,CPT,,,,,,,,115,,First Health,Commercial,both,85,,999999999,percent of total billed charges,97.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.03,112.7
BRACE ANKLE LARGE 264015,120.51,CDM,274,RC,L1902,HCPCS,,4-MAIN,LOCAL,,,,,115,,First Health,Commercial,both,85,,999999999,percent of total billed charges,97.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE MEDIUM 264014,120.51,CDM,274,RC,L1902,HCPCS,,7-MAIN,LOCAL,,,,,115,,First Health,Commercial,both,85,,999999999,percent of total billed charges,97.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE SMALL 264012,120.51,CDM,274,RC,L1902,HCPCS,,12-MAIN,LOCAL,,,,,115,,First Health,Commercial,both,85,,999999999,percent of total billed charges,97.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE X-LARGE 264016,120.51,CDM,274,RC,L1902,HCPCS,,14-MAIN,LOCAL,,,,,115,,First Health,Commercial,both,85,,999999999,percent of total billed charges,97.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE X-SMALL 264011,120.51,CDM,274,RC,L1902,HCPCS,,1-MAIN,LOCAL,,,,,115,,First Health,Commercial,both,85,,999999999,percent of total billed charges,97.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
Debride Skin/Subq Ea Ad 20sqcm,PX11045F,CDM,510,RC,11045,CPT,,,,,,,,115,,First Health,Commercial,both,85,,999999999,percent of total billed charges,97.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
Glucagon - Ref,PX8294390,CDM,300,RC,82943,CPT,90,,,,,,,115,,First Health,Commercial,both,85,,999999999,percent of total billed charges,97.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.1,112.7
"Immuno for Tumor Ag, Qn - Ref",PX8631690,CDM,300,RC,86316,CPT,90,,,,,,,115,,First Health,Commercial,both,85,,999999999,percent of total billed charges,97.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,112.7
Microsomal Antibody,PX7893,CDM,300,RC,86376,CPT,,,,,,,,115,,First Health,Commercial,both,85,,999999999,percent of total billed charges,97.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.34,112.7
"Critical Care, Addl 30 Min",PX99292P,CDM,983,RC,99292,CPT,,,,,,,,542,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,97.7664,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.12,531.16
"Facility Critical Care, Addl 30 Min",PX99292F,CDM,510,RC,99292,CPT,,,,,,,,484,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,97.7664,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.12,214.08
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714001601,NDC,0.4,ML,100.47,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,25.0327027,percent of total billed charges,97.787451,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
OXALiplatin 50 MG/10ML Solution 10 mL Vial,J9263.01,CDM,636,RC,J9263,HCPCS,,,,955173110,NDC,10,ML,228,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,97.812,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.7112,223.44
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021588,NDC,0.5,ML,203.87,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,97.8576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.779496,199.7926
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021588,NDC,0.5,ML,203.87,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,97.8576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.779496,199.7926
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,63323027301,NDC,0.5,ML,235.6,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,97.86824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
TB Antigen Response Gamma Interferon T-Cell Susp,PX86481,CDM,300,RC,86481,CPT,,,,,,,,150,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,97.8745,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97,100
TB Test Enumeration of T-Cells - Ref,PX8648190,CDM,300,RC,86481,CPT,90,,,,,,,155,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,97.8745,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97,100
"Tech-Cytopath Eval, Fna, Rep",PX8817301,CDM,310,RC,88173,CPT,TC,,,,,,,379,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,97.8745,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.98,162.848
"Acylcarnitines, Quant - Ref",PX8201790,CDM,300,RC,82017,CPT,90,,,,,,,110,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,97.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.47,107.8
"Assay Calcium, Ionized",PX82330,CDM,300,RC,82330,CPT,,,,,,,,110,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,97.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.54,107.8
BONE MARROW BIOPSY ASPIRATION NEEDLE 11G X 4 IN,120.562,CDM,272,RC,C1830,HCPCS,,12677-MAIN,LOCAL,,,,,110,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,97.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.694,107.8
Glycosylated Hemoglobin Test,PX83036,CDM,300,RC,83036,CPT,,,,,,,,110,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,97.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.9,130.9
K-WIRE 0.9X150MM BLUNT/TROCAR DART-FIRE STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12449-MAIN,LOCAL,,,,,110,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,97.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRE 0.9X150MM BLUNT/TROCAR STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12452-MAIN,LOCAL,,,,,110,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,97.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRE 1.4X150MM BLUNT/TROCAR DART-FIRE STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12450-MAIN,LOCAL,,,,,110,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,97.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRE 1.4X150MM BLUNT/TROCAR STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12451-MAIN,LOCAL,,,,,110,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,97.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA 2.0MM TARGETING GUIDE PIN,27200000,CDM,272,RC,,,,12436-MAIN,LOCAL,,,,,110,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,97.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Strapping of Shoulder,PX29240P,CDM,983,RC,29240,CPT,,,,,,,,110,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,97.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.694,111.6
DOPamine 1600 mcg/mL in dextrose 5% 250 mL premix 1600 mcg/mL Solution 250 mL Plas Cont,J1265.01,CDM,636,RC,J1265,HCPCS,,,,338100702,NDC,250,ML,99.9,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,97.902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.49846,97.902
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028401,NDC,1,EA,111.01,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,97.91082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028420,NDC,1,EA,111.01,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,97.91082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927380,NDC,1,EA,99.91,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,97.9118,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927395,NDC,1,EA,99.91,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,97.9118,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.936972,97.9118
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,409277602,NDC,200,ML,228.28,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,97.93212,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.827512,225.8704
Fetal Profile W/O Stress,PX7681901,CDM,402,RC,76819,CPT,TC,,,,,,,248,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,97.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.86,97.95
Fetal Profile W/O Stress,PX7681901,CDM,402,RC,76819,CPT,TC,,,,,,,248,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,97.95,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.86,97.95
DERMABOND PRINEO SKIN CLOSURE SYSTEM 42CM,27200000,CDM,272,RC,,,,12323-MAIN,LOCAL,,,,,200,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DERMABOND PRINEO SKIN CLOSURE SYSTEM 42CM,27200000,CDM,272,RC,,,,12323-MAIN,LOCAL,,,,,200,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DERMABOND PRINEO SKIN CLOSURE SYSTEM 42CM,27200000,CDM,272,RC,,,,12323-MAIN,LOCAL,,,,,200,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
gadoteridol 279.3 MG/ML Solution 5 mL Vial,A9576,CDM,636,RC,A9576,HCPCS,,,,270111104,NDC,10,ML,100,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.54,166.6
gadoxetate disodium 0.25 MOL/L Solution 10 mL Vial,A9581,CDM,636,RC,A9581,HCPCS,,,,50419032005,NDC,10,ML,200,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,196
gadoxetate disodium 0.25 MOL/L Solution 10 mL Vial,A9581,CDM,636,RC,A9581,HCPCS,,,,50419032005,NDC,10,ML,200,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,196
gadoxetate disodium 0.25 MOL/L Solution 10 mL Vial,A9581,CDM,636,RC,A9581,HCPCS,,,,50419032005,NDC,10,ML,200,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,196
iohexol 300 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141363,NDC,100,ML,200,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1.980701493,percent of total billed charges,98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,294
iohexol 300 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141363,NDC,100,ML,200,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,294
iohexol 300 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141363,NDC,100,ML,200,,United Healthcare,All Medicare advantage plans,outpatient,49,,1.11035,percent of total billed charges,98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,294
iohexol 350 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141491,NDC,100,ML,200,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1.980701493,percent of total billed charges,98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,294
iohexol 350 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141491,NDC,100,ML,200,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,294
iohexol 350 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141491,NDC,100,ML,200,,United Healthcare,All Medicare advantage plans,outpatient,49,,1.11035,percent of total billed charges,98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,294
Lacosamide - Ref,PX8023590,CDM,300,RC,80235,CPT,90,,,,,,,200,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.86,196
Lacosamide - Ref,PX8023590,CDM,300,RC,80235,CPT,90,,,,,,,200,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.86,196
Lacosamide - Ref,PX8023590,CDM,300,RC,80235,CPT,90,,,,,,,200,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.86,196
Sars-Cov-2 Covid-19 Antibody,PX8676990,CDM,300,RC,86769,CPT,90,,,,,,,100,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.63,98
Collect Blood From Picc,PX36592,CDM,949,RC,36592,CPT,,,,,,,,198,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,98.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.2492,194.04
Debride Muscle Ea Add 20 Sqcm,PX11046P,CDM,983,RC,11046,CPT,,,,,,,,198,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,98.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.2492,192.7134
Insert Simple Cath Foley,PX51702F,CDM,510,RC,51702,CPT,,,,,,,,198,,Humana Choice Care,All Medicare plans,outpatient,49.5,,86.24,percent of total billed charges,98.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.2492,194.04
KIT PLEUREVAC CHEST DRAIN S-1100-08LF,120.2,CDM,272,RC,,,,4190-MAIN,LOCAL,,,,,198,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,98.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.0466,194.04
Lyme Screen,PX7585,CDM,300,RC,86618,CPT,,,,,,,,198,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,98.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.61,194.04
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409663724,NDC,50,ML,115.32,,First Health,Commercial,both,85,,999999999,percent of total billed charges,98.022,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059611,NDC,0.25,EA,200.05,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,98.0245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.10077,725.3862
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059611,NDC,0.25,EA,200.05,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,98.0245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.10077,725.3862
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059611,NDC,0.25,EA,200.05,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,98.0245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.10077,725.3862
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059613,NDC,0.25,EA,200.05,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,98.0245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.10077,725.3862
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059613,NDC,0.25,EA,200.05,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,98.0245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.10077,725.3862
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059613,NDC,0.25,EA,200.05,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,98.0245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.10077,725.3862
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329330101,NDC,50,ML,107.61,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,98.03271,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Biopsy Vulva/Perineum,One Lesn",PX56605F,CDM,510,RC,56605,CPT,,,,,,,,236,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,98.0344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.0344,702.31
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,781309894,NDC,1,EA,193.75,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,98.0375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.461584,189.875
DERMABOND MINI SKIN ADHESIVE,27200000,CDM,272,RC,,,,8532-MAIN,LOCAL,,,,,110.16,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,98.0424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714020010,NDC,1,EA,107.64,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,98.06004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714020030,NDC,1,EA,107.64,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,98.06004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
Insitu Hybridization (Fish),PX8836401,CDM,310,RC,88364,CPT,TC,,,,,,,335,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,98.09,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.09,164.704
Insitu Hybridization (Fish),PX8836401,CDM,310,RC,88364,CPT,TC,,,,,,,335,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,98.09,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.09,164.704
Insitu Hybridization (Fish),PX8836401,CDM,310,RC,88364,CPT,TC,,,,,,,335,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,98.09,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.09,164.704
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,68462015740,NDC,1,EA,110.25,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,98.1225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,68462015713,NDC,1,EA,110.25,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,98.1225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
"Cmv, Quant - Ref",PX8749790,CDM,300,RC,87497,CPT,90,,,,,,,194,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,98.164,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.28,190.12
Hiv-1 Antigens W/Hiv 1/2 Antib,PX87389,CDM,300,RC,87389,CPT,,,,,,,,194,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,98.164,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.08,190.12
Lyme Disease Antibody,PX86618,CDM,300,RC,86618,CPT,,,,,,,,194,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,98.164,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.61,190.12
patiromer sorbitex calcium 8.4 g Packet 4 Each Box,63700001,CDM,250,RC,,,,,,53436008404,NDC,1,EA,228.96,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,98.22384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Remv Ext Canal Foreign Body,PX69200F,CDM,510,RC,69200,CPT,,,,,,,,235,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,98.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.22,167.42
Remv Ext Canal Foreign Body,PX69200P,CDM,983,RC,69200,CPT,,,,,,,,157,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,98.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.22,167.42
"Ctrl Nosebleed,Anter,Simple",PX30901P,CDM,983,RC,30901,CPT,,,,,,,,229,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,98.241,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.1266,222.8857
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604P,CDM,983,RC,20604,CPT,,,,,,,,229,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,98.241,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.1266,258.75
Removal of Nail Plate,PX11730F,CDM,510,RC,11730,CPT,,,,,,,,229,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,98.241,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.1266,224.42
Red Blood Cells Unit,PXP9021,CDM,390,RC,P9021,HCPCS,,,,,,,,1050,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,98.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.27,165.008
Red Blood Cells Unit,PXP9021,CDM,390,RC,P9021,HCPCS,,,,,,,,1050,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,98.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.27,165.008
Red Blood Cells Unit,PXP9021,CDM,390,RC,P9021,HCPCS,,,,,,,,1050,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,98.27,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.27,165.008
ON Q PAIN BUSTER,27100000,CDM,271,RC,A4305,HCPCS,,6751-MAIN,LOCAL,,,,,194.26,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,98.29556,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
BRACE KNEE LARGE SHORTRUNNER 21754,120.387,CDM,274,RC,L1833,HCPCS,,10044-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,98.3033,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE MEDIUM SHORTRUNNER 21753,120.387,CDM,274,RC,L1833,HCPCS,,10126-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,98.3033,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE SMALL SHORTRUNNER 21752,120.387,CDM,274,RC,L1833,HCPCS,,10900-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,98.3033,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE X-LARGE SHORTRUNNER 21755,120.387,CDM,274,RC,L1833,HCPCS,,3444-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,98.3033,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE XX-LARGE SHORTRUNNER 21756,120.387,CDM,274,RC,L1833,HCPCS,,10615-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,98.3033,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
"COLLAR CERVICAL 2"" SMALL UNIVERSAL 08140039",120.249,CDM,274,RC,L0120,HCPCS,,270-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,98.3033,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 2X20"" SMALL 1003-02",120.249,CDM,274,RC,L0120,HCPCS,,272-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,98.3033,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 2X23.5"" MEDIUM XNARROW 1003-04",120.249,CDM,274,RC,L0120,HCPCS,,273-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,98.3033,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 10-15"" SMALL XLONG 1005-06",120.249,CDM,274,RC,L0120,HCPCS,,267-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,98.3033,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL LARGE 21.5""X5"" 1005-04",120.249,CDM,274,RC,L0120,HCPCS,,268-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,98.3033,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL MEDIUM 20-1/2X4"" 1005-03",120.249,CDM,274,RC,L0120,HCPCS,,269-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,98.3033,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
COLLAR CERVICAL SMALL 1005-02,120.249,CDM,274,RC,L0120,HCPCS,,266-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,98.3033,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
Occupational Therapy Eval High Complex,PX97167,CDM,434,RC,97167,CPT,,,,,,,,289,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,98.332,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.14,133.55
Occupational Therapy Eval Low Complex,PX97165,CDM,434,RC,97165,CPT,,,,,,,,235,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,98.332,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.14,133.55
Occupational Therapy Eval Mod Complex,PX97166,CDM,434,RC,97166,CPT,,,,,,,,264,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,98.332,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.14,133.55
gentamicin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,60758018805,NDC,5,ML,107.98,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,98.36978,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Erythropietin - Ref,PX8266890,CDM,300,RC,82668,CPT,90,,,,,,,108,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,98.388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,105.84
Levetiracetam - Ref,PX8017790,CDM,300,RC,80177,CPT,90,,,,,,,108,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,98.388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,105.84
Oxcarbazepine - Ref,PX8018390,CDM,300,RC,80183,CPT,90,,,,,,,108,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,98.388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,105.84
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,574402435,NDC,3.5,GR,101.11,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,98.410363,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
hydrocortisone 25 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,713050306,NDC,1,EA,108.03,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,98.41533,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 25 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713050312,NDC,1,EA,108.03,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,98.41533,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047625,NDC,0.769230769,ML,111.59,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,98.42238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.354486,332.1514
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714001601,NDC,0.4,ML,100.47,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,98.4606,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,43598054910,NDC,100,ML,205.14,,Health Partners,Health Partners Care Plans,both,48,,1.259785714,percent of total billed charges,98.4672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,43598054910,NDC,100,ML,205.14,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,98.4672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
"Hepatitis a Antibody, Tot - Ref",PX8670890,CDM,300,RC,86708,CPT,90,,,,,,,201,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,98.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.36,196.98
"Hepatitis a Antibody, Tot - Ref",PX8670890,CDM,300,RC,86708,CPT,90,,,,,,,201,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,98.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.36,196.98
"Hepatitis a Antibody, Tot - Ref",PX8670890,CDM,300,RC,86708,CPT,90,,,,,,,201,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,98.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.36,196.98
Hepatitis B Surface Antibody,PX86706,CDM,300,RC,86706,CPT,,,,,,,,201,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,98.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,196.98
Hepatitis B Surface Antibody,PX86706,CDM,300,RC,86706,CPT,,,,,,,,201,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,98.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,196.98
Hepatitis B Surface Antibody,PX86706,CDM,300,RC,86706,CPT,,,,,,,,201,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,98.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,196.98
KIT 3-LUMEN 7FR X 16CM CENTRALVENOUS CDC-42703-P1A,120.37,CDM,272,RC,C1751,HCPCS,,10707-MAIN,LOCAL,,,,,201,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,98.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.4954,196.98
KIT 3-LUMEN 7FR X 16CM CENTRALVENOUS CDC-42703-P1A,120.37,CDM,272,RC,C1751,HCPCS,,10707-MAIN,LOCAL,,,,,201,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,98.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.4954,196.98
KIT 3-LUMEN 7FR X 16CM CENTRALVENOUS CDC-42703-P1A,120.37,CDM,272,RC,C1751,HCPCS,,10707-MAIN,LOCAL,,,,,201,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,98.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.4954,196.98
Inpt or Obs Disch Day Mngmt <=30 Minutes,PX99238,CDM,982,RC,99238,CPT,,,,,,,,199,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,98.505,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.6646,193.6867
acyclovir 50 MG/ML Solution 10 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,55150015410,NDC,10,ML,108.16,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,98.53376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.927644,105.9968
Aspirate Pleura W/ Imaging,PX32555F,CDM,761,RC,32555,CPT,,,,,,,,795,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,98.5777,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.75,646.83
Aspirate Pleura W/ Imaging,PX32555P,CDM,983,RC,32555,CPT,,,,,,,,536,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,98.5777,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.75,646.83
Antithrombin III Ag Assay - Ref,PX8530190,CDM,300,RC,85301,CPT,90,,,,,,,116,,First Health,Commercial,both,85,,999999999,percent of total billed charges,98.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.91,113.68
Ca 19-9,PX86301,CDM,300,RC,86301,CPT,,,,,,,,116,,First Health,Commercial,both,85,,999999999,percent of total billed charges,98.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,113.68
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423F,CDM,510,RC,11423,CPT,,,,,,,,711,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,98.6,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.6,428.92
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423P,CDM,983,RC,11423,CPT,,,,,,,,569,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,98.6,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.6,557.62
"Exc Skn Mal 0.6-1cm Fce,Facial",PX11641P,CDM,983,RC,11641,CPT,,,,,,,,453,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,98.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97.51,493.95
"Exc Skn Mal 0.6-1cm Fce,Facial",PX11641P,CDM,983,RC,11641,CPT,,,,,,,,453,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,98.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97.51,493.95
"Fac/Exc Skn Mal 0.6-1cm Fce,Facial",PX11641F,CDM,510,RC,11641,CPT,,,,,,,,680,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,98.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97.51,493.95
"Fac/Exc Skn Mal 0.6-1cm Fce,Facial",PX11641F,CDM,510,RC,11641,CPT,,,,,,,,680,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,98.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97.51,493.95
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034001,NDC,1,EA,111.81,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,98.61642,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037905,NDC,0.5,ML,229.88,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,98.61852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034000,NDC,1,EA,111.82,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,98.62524,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
ketamine 100 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,55150044001,NDC,10,ML,111.85,,United Healthcare,All Payer,outpatient,88.2,,7.6225,percent of total billed charges,98.6517,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001104,NDC,1,EA,108.29,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,98.65219,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
Topiramate - Ref,PX8020190,CDM,300,RC,80201,CPT,90,,,,,,,195,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,98.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.93,191.1
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001103,NDC,1,EA,108.34,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,98.69774,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
fentaNYL 25 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,47781042411,NDC,1,EA,101.44,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,98.731552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 25 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505700600,NDC,1,EA,101.46,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,98.751018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ELECTRODE PEDS ONESTEP SINGLE,120.343,CDM,272,RC,A4556,HCPCS,,10296-MAIN,LOCAL,,,,,112,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,98.784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
EYE IRRIGATION SYSTEM MT2000,120.318,CDM,272,RC,,,,8718-MAIN,LOCAL,,,,,112,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,98.784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
F5 Gene - Ref,PX8124190,CDM,300,RC,81241,CPT,90,,,,,,,112,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,98.784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
Immunofluorescence per Spec Add Singl Antb Stain - Ref,PX8835090,CDM,310,RC,88350,CPT,90,,,,,,,112,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,98.784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
Osmolality; Urine,PX83935,CDM,300,RC,83935,CPT,,,,,,,,112,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,98.784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.25,109.76
Prolactin,PX84146,CDM,300,RC,84146,CPT,,,,,,,,112,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,98.784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.77,109.76
Quantitation Drug Nos - Ref,PX8029990,CDM,300,RC,80299,CPT,90,,,,,,,112,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,98.784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.09,109.76
TUBE AIRSPIRAL BREATHING AND CHAMBER 900PT561,120.493,CDM,271,RC,A4604,HCPCS,,11618-MAIN,LOCAL,,,,,112,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,98.784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
verapamil 2.5 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,51754020401,NDC,1,ML,112.01,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,98.79282,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028401,NDC,1,EA,111.01,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,98.7989,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028420,NDC,1,EA,111.01,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,98.7989,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
Drainage of Gum Lesion,PX41800F,CDM,510,RC,41800,CPT,,,,,,,,395,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,98.82,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.82,606.02
Drainage of Gum Lesion,PX41800P,CDM,983,RC,41800,CPT,,,,,,,,839,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,98.82,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.82,822.22
Phlebotomy,PX99195,CDM,940,RC,99195,CPT,,,,,,,,238,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,98.8652,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.8652,233.24
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,143971801,NDC,200,ML,230.48,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,98.87592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.827512,225.8704
Drain Pilonidal Cyst Simpl,PX10080F,CDM,510,RC,10080,CPT,,,,,,,,742,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,98.8988,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.88,521.62
TRUMPET SUCTION IRRIGATION,27100000,CDM,271,RC,,,,4577-MAIN,LOCAL,,,,,116.4,,First Health,Commercial,both,85,,999999999,percent of total billed charges,98.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,409672924,NDC,50,ML,116.43,,First Health,Commercial,both,85,,999999999,percent of total billed charges,98.9655,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
BRACE KNEE LARGE SHORTRUNNER 21754,120.387,CDM,274,RC,L1833,HCPCS,,10044-MAIN,LOCAL,,,,,101,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,98.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE MEDIUM SHORTRUNNER 21753,120.387,CDM,274,RC,L1833,HCPCS,,10126-MAIN,LOCAL,,,,,101,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,98.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE SMALL SHORTRUNNER 21752,120.387,CDM,274,RC,L1833,HCPCS,,10900-MAIN,LOCAL,,,,,101,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,98.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE X-LARGE SHORTRUNNER 21755,120.387,CDM,274,RC,L1833,HCPCS,,3444-MAIN,LOCAL,,,,,101,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,98.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE XX-LARGE SHORTRUNNER 21756,120.387,CDM,274,RC,L1833,HCPCS,,10615-MAIN,LOCAL,,,,,101,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,98.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
"COLLAR CERVICAL 2"" SMALL UNIVERSAL 08140039",120.249,CDM,274,RC,L0120,HCPCS,,270-MAIN,LOCAL,,,,,101,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,98.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 2X20"" SMALL 1003-02",120.249,CDM,274,RC,L0120,HCPCS,,272-MAIN,LOCAL,,,,,101,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,98.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 2X23.5"" MEDIUM XNARROW 1003-04",120.249,CDM,274,RC,L0120,HCPCS,,273-MAIN,LOCAL,,,,,101,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,98.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL 10-15"" SMALL XLONG 1005-06",120.249,CDM,274,RC,L0120,HCPCS,,267-MAIN,LOCAL,,,,,101,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,98.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL LARGE 21.5""X5"" 1005-04",120.249,CDM,274,RC,L0120,HCPCS,,268-MAIN,LOCAL,,,,,101,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,98.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
"COLLAR CERVICAL MEDIUM 20-1/2X4"" 1005-03",120.249,CDM,274,RC,L0120,HCPCS,,269-MAIN,LOCAL,,,,,101,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,98.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
COLLAR CERVICAL SMALL 1005-02,120.249,CDM,274,RC,L0120,HCPCS,,266-MAIN,LOCAL,,,,,101,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,98.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.53,98.98
DERMABOND PRINEO SKIN CLOSURE SYSTEM 42CM,27200000,CDM,272,RC,,,,12323-MAIN,LOCAL,,,,,200,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
gadoxetate disodium 0.25 MOL/L Solution 10 mL Vial,A9581,CDM,636,RC,A9581,HCPCS,,,,50419032005,NDC,10,ML,200,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,196
iohexol 300 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141363,NDC,100,ML,200,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,294
iohexol 350 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141491,NDC,100,ML,200,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,294
Lacosamide - Ref,PX8023590,CDM,300,RC,80235,CPT,90,,,,,,,200,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.86,196
Art Upper Extremity-Ltd,PX9393101,CDM,921,RC,93931,CPT,TC,,,,,,,718,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,99.022,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.75,175.67
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059611,NDC,0.25,EA,200.05,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,99.02475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.10077,725.3862
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059613,NDC,0.25,EA,200.05,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,99.02475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.10077,725.3862
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,574402435,NDC,3.5,GR,101.11,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,99.0878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Insitu Hybridization (Fish),PX8836401,CDM,310,RC,88364,CPT,TC,,,,,,,335,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,99.1581,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.09,164.704
"Apply Finger Splint,Static",PX29130F,CDM,420,RC,29130,CPT,,,,,,,,196,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,99.176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.4184,192.08
Heterophile Antibodies,PX86308,CDM,300,RC,86308,CPT,,,,,,,,196,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,99.176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,192.08
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084243,NDC,0.5,ML,202.42,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,124.7133333,percent of total billed charges,99.1858,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.085268,203.497
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084243,NDC,0.5,ML,202.42,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,99.1858,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.085268,203.497
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084243,NDC,0.5,ML,202.42,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,99.1858,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.085268,203.497
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615704,NDC,1,EA,101.92,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,13.11107143,percent of total billed charges,99.198736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061400,NDC,1,ML,101.95,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,99.227935,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.114178,99.911
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615700,NDC,1,EA,101.95,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,13.11107143,percent of total billed charges,99.227935,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
"Closed Rx Big Toe Fx,Manip",PX28495F,CDM,510,RC,28495,CPT,,,,,,,,857,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,99.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.42,384.64
"Closed Rx Big Toe Fx,Manip",PX28495F,CDM,510,RC,28495,CPT,,,,,,,,857,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,99.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.42,384.64
"Closed Rx Big Toe Fx,Manip",PX28495P,CDM,983,RC,28495,CPT,,,,,,,,412,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,99.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.42,403.76
"Closed Rx Big Toe Fx,Manip",PX28495P,CDM,983,RC,28495,CPT,,,,,,,,412,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,99.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.42,403.76
Concurrent Infusion,PX96368,CDM,260,RC,96368,CPT,,,,,,,,102,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,69.07,percent of total billed charges,99.2766,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.3708,99.96
Immunohisto Antibody Slide Ea Addl,PX8834101,CDM,310,RC,88341,CPT,TC,,,,,,,102,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,85.30666667,percent of total billed charges,99.2766,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.3708,99.96
Reptilase Test - Ref,PX8563590,CDM,300,RC,85635,CPT,90,,,,,,,102,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,99.2766,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.03,99.96
Physical Therapy Re-Eval Est Plan Care 20 Mins,PX97164,CDM,424,RC,97164,CPT,,,,,,,,239,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,99.2806,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,234.22
"RBC Sed Rate, Auto",PX85652,CDM,300,RC,85652,CPT,,,,,,,,109,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,99.299,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.48,106.82
Smear Gram Stain,PX87205,CDM,300,RC,87205,CPT,,,,,,,,109,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,99.299,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,106.82
Smear Wet Mount Saline/Ink,PX87210,CDM,300,RC,87210,CPT,,,,,,,,109,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,99.299,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.34,106.82
"West Nile Ab, Igm - Ref",PX8678890,CDM,300,RC,86788,CPT,90,,,,,,,109,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,99.299,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.45,106.82
"polyethylene glycol 236 g Recon Soln 4,000 mL Bottle",63700001,CDM,250,RC,,,,,,43386009019,NDC,4000,ML,112.6,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,99.3132,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047625,NDC,0.769230769,ML,111.59,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,99.3151,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.354486,332.1514
DRAIN FLAT JACKSON PRATT 10MM,27100000,CDM,271,RC,,,,334-MAIN,LOCAL,,,,,239.09,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,99.317986,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
azithromycin 200 MG/5ML Recon Susp 15 mL Bottle,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,59762312001,NDC,15,ML,196.35,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,99.3531,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
ROTH NET PLATINUM RETRIEVER,27200000,CDM,272,RC,,,,7518-MAIN,LOCAL,,,,,196.35,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,99.3531,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Package,25000000,CDM,250,RC,,,,,,66758020858,NDC,1,EA,102.08,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,99.354464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614800,NDC,1,EA,239.18,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,99.355372,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001481,NDC,1,EA,102.12,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,58.74,percent of total billed charges,99.393396,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
fentaNYL 25 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,47781042411,NDC,1,EA,101.44,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,99.4112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 25 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505700600,NDC,1,EA,101.46,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,99.4308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505624500,NDC,1,EA,116.99,,First Health,Commercial,both,85,,999999999,percent of total billed charges,99.4415,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
Cryptosporidum,PX87328,CDM,300,RC,87328,CPT,,,,,,,,117,,First Health,Commercial,both,85,,999999999,percent of total billed charges,99.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.67,114.66
Drain Blood From Under Nail,PX11740F,CDM,510,RC,11740,CPT,,,,,,,,117,,First Health,Commercial,both,85,,999999999,percent of total billed charges,99.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.6018,114.66
Giardia,PX87329,CDM,300,RC,87329,CPT,,,,,,,,117,,First Health,Commercial,both,85,,999999999,percent of total billed charges,99.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,114.66
"In Situ Hybridization (Eg, Fish), Each Probe, Tech",PX8836501,CDM,310,RC,88365,CPT,TC,,,,,,,117,,First Health,Commercial,both,85,,999999999,percent of total billed charges,99.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.6018,149.22
RBC Pretreatment,PX8697002,CDM,300,RC,86970,CPT,,,,,,,,117,,First Health,Commercial,both,85,,999999999,percent of total billed charges,99.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.6018,114.66
"Hepatitis a Antibody, Tot - Ref",PX8670890,CDM,300,RC,86708,CPT,90,,,,,,,201,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,99.495,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.36,196.98
Hepatitis B Surface Antibody,PX86706,CDM,300,RC,86706,CPT,,,,,,,,201,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,99.495,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,196.98
KIT 3-LUMEN 7FR X 16CM CENTRALVENOUS CDC-42703-P1A,120.37,CDM,272,RC,C1751,HCPCS,,10707-MAIN,LOCAL,,,,,201,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,99.495,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.4954,196.98
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034001,NDC,1,EA,111.81,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,99.5109,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034000,NDC,1,EA,111.82,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,99.5198,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
Bile Acids Total,PX8223990,CDM,300,RC,82239,CPT,90,,,,,,,232,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,99.528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,227.36
baricitinib 2 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,2418230,NDC,0.5,EA,203.12,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,99.5288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
baricitinib 2 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,2418230,NDC,0.5,EA,203.12,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,99.5288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
baricitinib 2 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,2418230,NDC,0.5,EA,203.12,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,99.5288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329335201,NDC,50,ML,109.26,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,99.53586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ketamine 100 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,55150044001,NDC,10,ML,111.85,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,99.5465,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
pyRIDostigmine bromide 10 MG/2ML Solution 2 mL Ampule,25000000,CDM,250,RC,,,,,,781304095,NDC,2,ML,203.16,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,99.5484,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pyRIDostigmine bromide 10 MG/2ML Solution 2 mL Ampule,25000000,CDM,250,RC,,,,,,781304095,NDC,2,ML,203.16,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,99.5484,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pyRIDostigmine bromide 10 MG/2ML Solution 2 mL Ampule,25000000,CDM,250,RC,,,,,,781304095,NDC,2,ML,203.16,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,99.5484,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Remove Impacted Ear Wax,PX69210F,CDM,510,RC,69210,CPT,,,,,,,,213,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,99.62,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.06,99.62
Remove Impacted Ear Wax,PX69210P,CDM,983,RC,69210,CPT,,,,,,,,221,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,99.62,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.06,216.58
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041100,NDC,0.5,ML,196.94,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,99.65164,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.808876,411.2766
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041110,NDC,0.5,ML,196.94,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,99.65164,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.808876,411.2766
Iadna Streptococcus Group a Amplified Probe Tq,PX87651,CDM,300,RC,87651,CPT,,,,,,,,113,,United Healthcare,All Payer,outpatient,88.2,,55.37,percent of total billed charges,99.666,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,110.74
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209P,CDM,982,RC,69209,CPT,,,,,,,,113,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,99.666,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9402,109.9829
Strapping of Toes,PX29550F,CDM,510,RC,29550,CPT,,,,,,,,113,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,99.666,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9402,110.74
Xray Spine Single Tc,PX7202001,CDM,320,RC,72020,CPT,TC,,,,,,,113,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,99.666,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9402,110.74
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084252,NDC,0.5,ML,207.65,,Health Partners,Health Partners Care Plans,both,48,,125.6271429,percent of total billed charges,99.672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.085268,203.497
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084252,NDC,0.5,ML,207.65,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,99.672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.085268,203.497
ELECTRODE PEDS ONESTEP SINGLE,120.343,CDM,272,RC,A4556,HCPCS,,10296-MAIN,LOCAL,,,,,112,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,99.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
EYE IRRIGATION SYSTEM MT2000,120.318,CDM,272,RC,,,,8718-MAIN,LOCAL,,,,,112,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,99.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
F5 Gene - Ref,PX8124190,CDM,300,RC,81241,CPT,90,,,,,,,112,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,99.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
Immunofluorescence per Spec Add Singl Antb Stain - Ref,PX8835090,CDM,310,RC,88350,CPT,90,,,,,,,112,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,99.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
Osmolality; Urine,PX83935,CDM,300,RC,83935,CPT,,,,,,,,112,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,99.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.25,109.76
Prolactin,PX84146,CDM,300,RC,84146,CPT,,,,,,,,112,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,99.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.77,109.76
Quantitation Drug Nos - Ref,PX8029990,CDM,300,RC,80299,CPT,90,,,,,,,112,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,99.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.09,109.76
TUBE AIRSPIRAL BREATHING AND CHAMBER 900PT561,120.493,CDM,271,RC,A4604,HCPCS,,11618-MAIN,LOCAL,,,,,112,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,99.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
Assay Other Fluid Chlorides - Ref,PX8243890,CDM,300,RC,82438,CPT,90,,,,,,,197,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,99.682,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.58,193.06
Tramadol - Ref,PX8037390,CDM,300,RC,80373,CPT,90,,,,,,,197,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,99.682,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.8338,193.06
verapamil 2.5 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,51754020401,NDC,1,ML,112.01,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,99.6889,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,17478062512,NDC,2.5,ML,109.45,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,99.70895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Hospital Inpt or Obs Care, Admin/Disch Same Date, Moderate Level Mdm >= 70 Minutes",PX99235,CDM,982,RC,99235,CPT,,,,,,,,582,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,99.73,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,99.73,570.36
gemcitabine 1 GM/26.3ML Solution 26.3 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018101,NDC,26.3,ML,203.58,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,99.7542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
gemcitabine 1 GM/26.3ML Solution 26.3 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018101,NDC,26.3,ML,203.58,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,99.7542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
gemcitabine 1 GM/26.3ML Solution 26.3 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018101,NDC,26.3,ML,203.58,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,99.7542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
acetaZOLAMIDE 500 MG Recon Soln 1 Each Vial,J1120.01,CDM,636,RC,J1120,HCPCS,,,,39822019001,NDC,1,EA,207.84,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,99.7632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.336736,203.6832
acetaZOLAMIDE 500 MG Recon Soln 1 Each Vial,J1120.01,CDM,636,RC,J1120,HCPCS,,,,39822019001,NDC,1,EA,207.84,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,99.7632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.336736,203.6832
cefoTEtan 2 g Recon Soln 1 Each Vial,800000,CDM,,,S0074,HCPCS,,,,63323038620,NDC,1,EA,240.2,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,99.77908,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
scopolamine 1 MG/3DAYS Patch 72 Hour 24 Each Box,25000000,CDM,250,RC,,,,,,50742050524,NDC,1,EA,109.59,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,99.83649,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615704,NDC,1,EA,101.92,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,99.8816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021588,NDC,0.5,ML,203.87,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,99.8963,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.779496,199.7926
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021588,NDC,0.5,ML,203.87,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,99.8963,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.779496,199.7926
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021588,NDC,0.5,ML,203.87,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,99.8963,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.779496,199.7926
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331801,NDC,10,ML,102.65,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,229.0777778,percent of total billed charges,99.909245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
Drainage of Gum Lesion,PX41800F,CDM,510,RC,41800,CPT,,,,,,,,395,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,99.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.82,606.02
Drainage of Gum Lesion,PX41800F,CDM,510,RC,41800,CPT,,,,,,,,395,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,99.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.82,606.02
Drainage of Gum Lesion,PX41800P,CDM,983,RC,41800,CPT,,,,,,,,839,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,99.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.82,822.22
Drainage of Gum Lesion,PX41800P,CDM,983,RC,41800,CPT,,,,,,,,839,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,99.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.82,822.22
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061400,NDC,1,ML,101.95,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,99.911,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.114178,99.911
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615700,NDC,1,EA,101.95,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,99.911,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
US Pregnancy Tc Limited,PX7681501,CDM,402,RC,76815,CPT,TC,,,,,,,438,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,99.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.61,99.92
US Pregnancy Tc Limited,PX7681501,CDM,402,RC,76815,CPT,TC,,,,,,,438,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,99.92,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.61,99.92
TRAY GROSHONG 4FR SAFETY PICC 7617407,120.26,CDM,272,RC,,,,500-MAIN,LOCAL,,,,,233,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,99.957,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.7882,228.34
Concurrent Infusion,PX96368,CDM,260,RC,96368,CPT,,,,,,,,102,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,99.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.3708,99.96
Immunohisto Antibody Slide Ea Addl,PX8834101,CDM,310,RC,88341,CPT,TC,,,,,,,102,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,99.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.3708,99.96
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106P,CDM,983,RC,11106,CPT,,,,,,,,204,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,99.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.7416,548.67
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106P,CDM,983,RC,11106,CPT,,,,,,,,204,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,99.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.7416,548.67
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106P,CDM,983,RC,11106,CPT,,,,,,,,204,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,99.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.7416,548.67
Reptilase Test - Ref,PX8563590,CDM,300,RC,85635,CPT,90,,,,,,,102,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,99.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.03,99.96
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,68462018022,NDC,22,GR,240.66,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,99.970164,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Cardioversion, Elective;Extern",PX92960F,CDM,480,RC,92960,CPT,,,,,,,,402,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,99.9865,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.41,267
"Cardioversion, Elective;Extern",PX92960P,CDM,983,RC,92960,CPT,,,,,,,,688,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,99.9865,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.41,674.24
TB Antigen Response Gamma Interferon T-Cell Susp,PX86481,CDM,300,RC,86481,CPT,,,,,,,,150,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,100,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97,100
TB Test Enumeration of T-Cells - Ref,PX8648190,CDM,300,RC,86481,CPT,90,,,,,,,155,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,100,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97,100
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Package,25000000,CDM,250,RC,,,,,,66758020858,NDC,1,EA,102.08,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,100.0384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001481,NDC,1,EA,102.12,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,100.0776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.762296,100.0776
ALEXIS 0 LARGE STERILE,27200000,CDM,272,RC,,,,11765-MAIN,LOCAL,,,,,102.85,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,100.103905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
sulfamethoxazole-trimethoprim 400-80 MG/5ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,703951403,NDC,10,ML,102.93,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,100.181769,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Ex Sknbngn0.6-1cmtrnk,Arm,Lg",PX11401P,CDM,983,RC,11401,CPT,,,,,,,,387,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,100.1832,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.19,379.26
"Fac/Ex Skinbngn0.6-1cmtrnk,Arm,Lg",PX11401F,CDM,510,RC,11401,CPT,,,,,,,,484,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,100.1832,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.19,325.84
Collect Blood From Picc,PX36592,CDM,949,RC,36592,CPT,,,,,,,,198,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,100.188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.2492,194.04
Debride Muscle Ea Add 20 Sqcm,PX11046P,CDM,983,RC,11046,CPT,,,,,,,,198,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,100.188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.2492,192.7134
Insert Simple Cath Foley,PX51702F,CDM,510,RC,51702,CPT,,,,,,,,198,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,100.188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.2492,194.04
KIT PLEUREVAC CHEST DRAIN S-1100-08LF,120.2,CDM,272,RC,,,,4190-MAIN,LOCAL,,,,,198,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,100.188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.0466,194.04
Lyme Screen,PX7585,CDM,300,RC,86618,CPT,,,,,,,,198,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,100.188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.61,194.04
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084243,NDC,0.5,ML,202.42,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,100.1979,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.085268,203.497
ofloxacin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,17478071310,NDC,5,ML,117.89,,First Health,Commercial,both,85,,999999999,percent of total billed charges,100.2065,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Acylcarnitines, Quant - Ref",PX8201790,CDM,300,RC,82017,CPT,90,,,,,,,110,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,100.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.47,107.8
"Assay Calcium, Ionized",PX82330,CDM,300,RC,82330,CPT,,,,,,,,110,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,100.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.54,107.8
BONE MARROW BIOPSY ASPIRATION NEEDLE 11G X 4 IN,120.562,CDM,272,RC,C1830,HCPCS,,12677-MAIN,LOCAL,,,,,110,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,100.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.694,107.8
Glycosylated Hemoglobin Test,PX83036,CDM,300,RC,83036,CPT,,,,,,,,110,,Medica,Commercial,both,91.1,,96.57,percent of total billed charges,100.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.9,130.9
K-WIRE 0.9X150MM BLUNT/TROCAR DART-FIRE STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12449-MAIN,LOCAL,,,,,110,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,100.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRE 0.9X150MM BLUNT/TROCAR STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12452-MAIN,LOCAL,,,,,110,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,100.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRE 1.4X150MM BLUNT/TROCAR DART-FIRE STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12450-MAIN,LOCAL,,,,,110,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,100.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRE 1.4X150MM BLUNT/TROCAR STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12451-MAIN,LOCAL,,,,,110,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,100.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA 2.0MM TARGETING GUIDE PIN,27200000,CDM,272,RC,,,,12436-MAIN,LOCAL,,,,,110,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,100.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Strapping of Shoulder,PX29240P,CDM,983,RC,29240,CPT,,,,,,,,110,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,100.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.694,111.6
"polyethylene glycol 236 g Recon Soln 4,000 mL Bottle",63700001,CDM,250,RC,,,,,,43386009019,NDC,4000,ML,112.6,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,100.214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of Transferrin,PX84466,CDM,300,RC,84466,CPT,,,,,,,,103,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,25.015,percent of total billed charges,100.2499,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.7,100.94
"Lactoferrin, Fecal; Qual",PX83630,CDM,300,RC,83630,CPT,,,,,,,,103,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,100.2499,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.06,100.94
"Molecyto Insitu, 100-300cl - Ref",PX8827590,CDM,310,RC,88275,CPT,90,,,,,,,103,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,100.2499,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.7862,100.94
"Tiss Cult,Non-Neop Lymph - Ref",PX8823090,CDM,310,RC,88230,CPT,90,,,,,,,103,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,100.2499,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.7862,106.81
Fibrinolysins Screen - Ref,PX8539090,CDM,300,RC,85390,CPT,90,,,,,,,118,,First Health,Commercial,both,85,,999999999,percent of total billed charges,100.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.19,115.64
amiodarone 900 MG/18ML Solution 18 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,67457015318,NDC,18,ML,113.73,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,100.30986,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
ACCESSORY KIT FOR GROSHONG 16GA,120.46,CDM,272,RC,C1751,HCPCS,,2967-MAIN,LOCAL,,,,,209,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,100.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.8186,204.82
ACCESSORY KIT FOR GROSHONG 16GA,120.46,CDM,272,RC,C1751,HCPCS,,2967-MAIN,LOCAL,,,,,209,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,100.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.8186,204.82
Infection Agent Detect Dna/Rna Probe Tq 12-25,PX87507,CDM,300,RC,87507,CPT,,,,,,,,209,,Health Partners,Health Partners Care Plans,both,48,,202.72,percent of total billed charges,100.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.8186,382.15
Infection Agent Detect Dna/Rna Probe Tq 12-25,PX87507,CDM,300,RC,87507,CPT,,,,,,,,209,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,100.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.8186,382.15
"Organic Acid, Single, Qnt - Ref",PX8392190,CDM,300,RC,83921,CPT,90,,,,,,,209,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,100.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.45,204.82
"Organic Acid, Single, Qnt - Ref",PX8392190,CDM,300,RC,83921,CPT,90,,,,,,,209,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,100.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.45,204.82
DERMABOND MINI SKIN ADHESIVE,27200000,CDM,272,RC,,,,8532-MAIN,LOCAL,,,,,110.16,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,100.35576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CANNULA FOR INJECTION 1.8MM WITH 3MM LUER CONNECTION 8383.65,27200000,CDM,272,RC,,,,12004-MAIN,LOCAL,,,,,234,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,100.386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Fibrinogen,PX7426,CDM,300,RC,85384,CPT,,,,,,,,234,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,100.386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.91,229.32
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,68462015740,NDC,1,EA,110.25,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,100.43775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,68462015713,NDC,1,EA,110.25,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,100.43775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
lidocaine 0.5 % PF 0.5 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323049101,NDC,50,ML,103.2,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,100.44456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Immunohisto Antibody Slide Ea Addl,PX8834101,CDM,310,RC,88341,CPT,TC,,,,,,,102,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,100.5,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.18,104.4
Immunohisto Antibody Slide Ea Addl,PX8834101,CDM,310,RC,88341,CPT,TC,,,,,,,102,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,100.5,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.18,104.4
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,43598054910,NDC,100,ML,205.14,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.619455696,percent of total billed charges,100.5186,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,43598054910,NDC,100,ML,205.14,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,100.5186,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,43598054910,NDC,100,ML,205.14,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,100.5186,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
Airway Inhalation Treatment,PX94640F,CDM,410,RC,94640,CPT,,,,,,,,242,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,100.5268,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,100.5268,237.16
"Noninvasv Oxygen Satut,Continuous",PX94762,CDM,460,RC,94762,CPT,,,,,,,,242,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,100.5268,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,100.5268,237.16
baricitinib 2 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,2418230,NDC,0.5,EA,203.12,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,100.5444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of Erythropoietin,PX82668,CDM,300,RC,82668,CPT,,,,,,,,114,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,100.548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,111.72
pyRIDostigmine bromide 10 MG/2ML Solution 2 mL Ampule,25000000,CDM,250,RC,,,,,,781304095,NDC,2,ML,203.16,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,100.5642,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423F,CDM,510,RC,11423,CPT,,,,,,,,711,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,100.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.6,428.92
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423F,CDM,510,RC,11423,CPT,,,,,,,,711,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,100.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.6,428.92
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423P,CDM,983,RC,11423,CPT,,,,,,,,569,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,100.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.6,557.62
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423P,CDM,983,RC,11423,CPT,,,,,,,,569,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,100.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.6,557.62
Iadna Streptococcus Group a Amplified Probe Tq,PX87651,CDM,300,RC,87651,CPT,,,,,,,,113,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,100.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,110.74
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209P,CDM,982,RC,69209,CPT,,,,,,,,113,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,100.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9402,109.9829
Strapping of Toes,PX29550F,CDM,510,RC,29550,CPT,,,,,,,,113,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,100.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9402,110.74
Xray Spine Single Tc,PX7202001,CDM,320,RC,72020,CPT,TC,,,,,,,113,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,100.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9402,110.74
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331801,NDC,10,ML,102.65,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,100.597,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
scopolamine 1 MG/3DAYS Patch 72 Hour 4 Each Box,25000000,CDM,250,RC,,,,,,45802058084,NDC,1,EA,103.43,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,100.668419,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Inpt or Obs Disch Day Mngmt <=30 Minutes,PX99238,CDM,982,RC,99238,CPT,,,,,,,,199,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,100.694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.6646,193.6867
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010310,NDC,1,ML,103.48,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,229.0777778,percent of total billed charges,100.717084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
gemcitabine 1 GM/26.3ML Solution 26.3 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018101,NDC,26.3,ML,203.58,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,100.7721,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
ALEXIS 0 LARGE STERILE,27200000,CDM,272,RC,,,,11765-MAIN,LOCAL,,,,,102.85,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,100.793,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
AIRSEAL ROBOTIC Xi CAP AND OBTURATOR WITH BLADELESS OPTICAL TIP,27200000,CDM,272,RC,,,,12208-MAIN,LOCAL,,,,,210,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,100.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
AIRSEAL ROBOTIC Xi CAP AND OBTURATOR WITH BLADELESS OPTICAL TIP,27200000,CDM,272,RC,,,,12208-MAIN,LOCAL,,,,,210,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,100.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
AIRSEAL ROBOTIC Xi TRI LUMEN FILTERED TUBE SET WITH ACTIVATED CHARCOAL,27200000,CDM,272,RC,,,,12209-MAIN,LOCAL,,,,,210,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,100.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
AIRSEAL ROBOTIC Xi TRI LUMEN FILTERED TUBE SET WITH ACTIVATED CHARCOAL,27200000,CDM,272,RC,,,,12209-MAIN,LOCAL,,,,,210,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,100.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Apply Forearm Cast,PX29075F,CDM,510,RC,29075,CPT,,,,,,,,210,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,100.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,234.62
Apply Forearm Cast,PX29075F,CDM,510,RC,29075,CPT,,,,,,,,210,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,100.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,234.62
Chorionic gonadotropin test,PX84702,CDM,300,RC,84702,CPT,,,,,,,,210,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,100.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.8,205.8
Chorionic gonadotropin test,PX84702,CDM,300,RC,84702,CPT,,,,,,,,210,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,100.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.8,205.8
"Excision of Nail Fold, Toe",PX11765F,CDM,510,RC,11765,CPT,,,,,,,,210,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,100.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,348.35
"Excision of Nail Fold, Toe",PX11765F,CDM,510,RC,11765,CPT,,,,,,,,210,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,100.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,348.35
Fac/Hospital Discharge Day>30 Min,PX99239F,CDM,510,RC,99239,CPT,,,,,,,,210,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,100.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,205.8
Fac/Hospital Discharge Day>30 Min,PX99239F,CDM,510,RC,99239,CPT,,,,,,,,210,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,100.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,205.8
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152F,CDM,370,RC,99152,CPT,,,,,,,,235,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,100.815,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97.619,230.3
Occupational Therapy Eval Low Complex,PX97165,CDM,434,RC,97165,CPT,,,,,,,,235,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,100.815,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,230.3
Physical Therapy Evaluation Low Complex,PX97161,CDM,424,RC,97161,CPT,,,,,,,,235,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,100.815,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,392.7
Remv Ext Canal Foreign Body,PX69200F,CDM,510,RC,69200,CPT,,,,,,,,235,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,100.815,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97.619,230.3
"Vitamin D, 25 Hydroxy",PX82306,CDM,300,RC,82306,CPT,,,,,,,,235,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,100.815,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.14,230.3
Remove Foreign Body Simple,PX10120F,CDM,510,RC,10120,CPT,,,,,,,,404,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,100.8254,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.53,317.54
Remove Foreign Body Simple,PX10120P,CDM,983,RC,10120,CPT,,,,,,,,404,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,100.8254,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.53,395.92
sulfamethoxazole-trimethoprim 400-80 MG/5ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,703951403,NDC,10,ML,102.93,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,100.8714,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Office/Outpt Visit,Est,Levl V",PX99215F,CDM,510,RC,99215,CPT,,,,,,,,318,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,100.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,89.69,324.12
"Office/Outpt Visit,Est,Levl V",PX99215F,CDM,510,RC,99215,CPT,,,,,,,,318,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,100.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,89.69,324.12
"Office/Outpt Visit,Est,Levl V",PX99215P,CDM,983,RC,99215,CPT,,,,,,,,318,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,100.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,89.69,324.12
"Office/Outpt Visit,Est,Levl V",PX99215P,CDM,983,RC,99215,CPT,,,,,,,,318,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,100.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,89.69,324.12
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021588,NDC,0.5,ML,203.87,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,100.91565,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.779496,199.7926
Assay of Transferrin,PX84466,CDM,300,RC,84466,CPT,,,,,,,,103,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,100.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.7,100.94
"Lactoferrin, Fecal; Qual",PX83630,CDM,300,RC,83630,CPT,,,,,,,,103,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,100.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.06,100.94
"Molecyto Insitu, 100-300cl - Ref",PX8827590,CDM,310,RC,88275,CPT,90,,,,,,,103,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,100.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.7862,100.94
"Tiss Cult,Non-Neop Lymph - Ref",PX8823090,CDM,310,RC,88230,CPT,90,,,,,,,103,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,100.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.7862,106.81
naloxone 2 MG/2ML solution prefilled syringe 2 mL Syringe,J2310.01,CDM,636,RC,J2310,HCPCS,,,,76329346901,NDC,1,ML,114.45,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,100.9449,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.54253,130.4968
levonorgestrel 1.5 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,62756071860,NDC,1,EA,114.48,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,100.97136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106P,CDM,983,RC,11106,CPT,,,,,,,,204,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,100.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.7416,548.67
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,63323027301,NDC,0.5,ML,235.6,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,101.0724,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028401,NDC,1,EA,111.01,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,101.13011,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028420,NDC,1,EA,111.01,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,101.13011,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
lidocaine 0.5 % PF 0.5 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323049101,NDC,50,ML,103.2,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,101.136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Apply Short Leg Cast,Walker",PX29425P,CDM,983,RC,29425,CPT,,,,,,,,119,,First Health,Commercial,both,85,,999999999,percent of total billed charges,101.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,234.62
Creatinine; Other Source - Ref,PX82570,CDM,300,RC,82570,CPT,90,,,,,,,119,,First Health,Commercial,both,85,,999999999,percent of total billed charges,101.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,116.62
FLAT DRAIN HEMADUCT 7MM FULL DUCT WITH TROCAR SILICONE,27200000,CDM,272,RC,,,,12464-MAIN,LOCAL,,,,,119,,First Health,Commercial,both,85,,999999999,percent of total billed charges,101.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Injection, Subq/Im",PX96372,CDM,260,RC,96372,CPT,,,,,,,,119,,First Health,Commercial,both,85,,999999999,percent of total billed charges,101.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,116.62
Irri Implted Drug Dlvr Device,PX96523,CDM,260,RC,96523,CPT,,,,,,,,119,,First Health,Commercial,both,85,,999999999,percent of total billed charges,101.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,116.62
"Morphometric Analysis,Tumor Immunohistochemistry, Ea Antibody Manual , Tech",PX8836001,CDM,310,RC,88360,CPT,TC,,,,,,,119,,First Health,Commercial,both,85,,999999999,percent of total billed charges,101.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,149.22
Office/Outpt Visit Est Level I,PX99211F,CDM,510,RC,99211,CPT,,,,,,,,119,,First Health,Commercial,both,85,,999999999,percent of total billed charges,101.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,116.62
Office/Outpt Visit Est Level I,PX99211P,CDM,983,RC,99211,CPT,,,,,,,,119,,First Health,Commercial,both,85,,999999999,percent of total billed charges,101.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,115.8227
Sodium; Urine,PX84300,CDM,300,RC,84300,CPT,,,,,,,,119,,First Health,Commercial,both,85,,999999999,percent of total billed charges,101.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.64,116.62
STIFNECK ADULT,120.77,CDM,274,RC,L0180,HCPCS,,991-MAIN,LOCAL,,,,,119,,First Health,Commercial,both,85,,999999999,percent of total billed charges,101.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,486.73
STIFNECK PEDIATRIC,120.77,CDM,274,RC,L0180,HCPCS,,998-MAIN,LOCAL,,,,,119,,First Health,Commercial,both,85,,999999999,percent of total billed charges,101.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,486.73
DERMABOND PRINEO SKIN CLOSURE SYSTEM 42CM,27200000,CDM,272,RC,,,,12323-MAIN,LOCAL,,,,,200,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,101.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
gadoxetate disodium 0.25 MOL/L Solution 10 mL Vial,A9581,CDM,636,RC,A9581,HCPCS,,,,50419032005,NDC,10,ML,200,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,101.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,196
iohexol 300 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141363,NDC,100,ML,200,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,101.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,294
iohexol 350 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141491,NDC,100,ML,200,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,101.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,294
Lacosamide - Ref,PX8023590,CDM,300,RC,80235,CPT,90,,,,,,,200,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,101.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.86,196
amiodarone 900 MG/18ML Solution 18 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,67457015318,NDC,18,ML,113.73,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,101.2197,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
CT Upper Extremity W/Dye,PX7320101,CDM,350,RC,73201,CPT,TC,,,,,,,2757,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,101.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.22,299.12
CT Upper Extremity W/Dye,PX7320101,CDM,350,RC,73201,CPT,TC,,,,,,,2757,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,101.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.22,299.12
Carnitine - Ref,PX8237990,CDM,300,RC,82379,CPT,90,,,,,,,104,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,101.2232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.47,101.92
Cmv Antibody - Ref,PX8664490,CDM,300,RC,86644,CPT,90,,,,,,,104,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,101.2232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,101.92
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059611,NDC,0.25,EA,200.05,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,101.2253,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.10077,725.3862
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059613,NDC,0.25,EA,200.05,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,101.2253,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.10077,725.3862
"Biopsy Vulva/Perineum,One Lesn",PX56605F,CDM,510,RC,56605,CPT,,,,,,,,236,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,101.244,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.0344,702.31
Lab Basic Metabolic Panel,PX80048,CDM,300,RC,80048,CPT,,,,,,,,236,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,101.244,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.76,231.28
Bone Age Studies Tc,PX7707201,CDM,320,RC,77072,CPT,TC,,,,,,,211,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,101.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.6494,206.78
Bone Age Studies Tc,PX7707201,CDM,320,RC,77072,CPT,TC,,,,,,,211,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,101.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.6494,206.78
Collect Blood From Picc,PX36592F,CDM,510,RC,36592,CPT,,,,,,,,211,,Health Partners,Health Partners Care Plans,both,48,,97.84,percent of total billed charges,101.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.6494,206.78
Collect Blood From Picc,PX36592F,CDM,510,RC,36592,CPT,,,,,,,,211,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,101.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.6494,206.78
Draw Blood Off Venous Device,PX36591F,CDM,510,RC,36591,CPT,,,,,,,,211,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,101.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.6494,206.78
Draw Blood Off Venous Device,PX36591F,CDM,510,RC,36591,CPT,,,,,,,,211,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,101.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.6494,206.78
Red Blood Cells Unit,PXP9021,CDM,390,RC,P9021,HCPCS,,,,,,,,1050,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,101.31,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.27,165.008
BINDER PELVIC ADULT STABILIZATION T-PODR,120.357,CDM,271,RC,A4467,HCPCS,,10734-MAIN,LOCAL,,,,,244,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,101.3576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.3576,239.12
"Bone Marrow Aspiration(S),Diag",PX38220P,CDM,983,RC,38220,CPT,,,,,,,,244,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,101.3576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.3576,1416.38
Dress/Debrid Med Burn No Anesth,PX16025P,CDM,983,RC,16025,CPT,,,,,,,,244,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,101.3576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.3576,237.4852
scopolamine 1 MG/3DAYS Patch 72 Hour 4 Each Box,25000000,CDM,250,RC,,,,,,45802058084,NDC,1,EA,103.43,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,101.3614,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
CT Orbit/Ear/Fosa W/O Dye,PX7048001,CDM,350,RC,70480,CPT,TC,,,,,,,2757,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,101.367,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.5,202.48
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010310,NDC,1,ML,103.48,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,101.4104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
"Drain Finger Abscess,Simple",PX26010P,CDM,983,RC,26010,CPT,,,,,,,,207,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,101.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.9878,201.4731
"Drain Finger Abscess,Simple",PX26010P,CDM,983,RC,26010,CPT,,,,,,,,207,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,101.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.9878,201.4731
"Drain Finger Abscess,Simple",PX26010P,CDM,983,RC,26010,CPT,,,,,,,,207,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,101.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.9878,201.4731
Assay of Triglycerides,PX84478,CDM,300,RC,84478,CPT,,,,,,,,115,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,101.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.26,112.7
"Blood Typing, Rh Phenotype",PX86906,CDM,300,RC,86906,CPT,,,,,,,,115,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,101.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.03,112.7
BRACE ANKLE LARGE 264015,120.51,CDM,274,RC,L1902,HCPCS,,4-MAIN,LOCAL,,,,,115,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,101.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE MEDIUM 264014,120.51,CDM,274,RC,L1902,HCPCS,,7-MAIN,LOCAL,,,,,115,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,101.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE SMALL 264012,120.51,CDM,274,RC,L1902,HCPCS,,12-MAIN,LOCAL,,,,,115,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,101.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE X-LARGE 264016,120.51,CDM,274,RC,L1902,HCPCS,,14-MAIN,LOCAL,,,,,115,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,101.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE X-SMALL 264011,120.51,CDM,274,RC,L1902,HCPCS,,1-MAIN,LOCAL,,,,,115,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,101.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
Debride Skin/Subq Ea Ad 20sqcm,PX11045F,CDM,510,RC,11045,CPT,,,,,,,,115,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,101.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
Glucagon - Ref,PX8294390,CDM,300,RC,82943,CPT,90,,,,,,,115,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,101.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.1,112.7
"Immuno for Tumor Ag, Qn - Ref",PX8631690,CDM,300,RC,86316,CPT,90,,,,,,,115,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,101.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,112.7
Microsomal Antibody,PX7893,CDM,300,RC,86376,CPT,,,,,,,,115,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,101.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.34,112.7
Cv Carotid Imaging-Bilat,PX9388001,CDM,921,RC,93880,CPT,TC,,,,,,,1088,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,101.44,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.44,266.42
Assay of Erythropoietin,PX82668,CDM,300,RC,82668,CPT,,,,,,,,114,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,101.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,111.72
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601901,NDC,10,ML,211.47,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,101.5056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.844638,207.2406
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601901,NDC,10,ML,211.47,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,101.5056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.844638,207.2406
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601910,NDC,10,ML,211.47,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,101.5056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.844638,207.2406
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601910,NDC,10,ML,211.47,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,101.5056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.844638,207.2406
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,43598054910,NDC,100,ML,205.14,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,101.5443,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047625,NDC,0.769230769,ML,111.59,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,101.65849,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.354486,332.1514
"Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602P,CDM,983,RC,11602,CPT,,,,,,,,1120,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,101.66,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.66,1097.6
"Fac/Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602F,CDM,510,RC,11602,CPT,,,,,,,,731,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,101.66,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.66,509.86
"Office/Outpt Visit,Est,Levl II",PX99212F,CDM,510,RC,99212,CPT,,,,,,,,155,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,101.66,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.04,101.66
"Office/Outpt Visit,Est,Levl II",PX99212P,CDM,983,RC,99212,CPT,,,,,,,,155,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,101.66,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.04,151.9
Repr Superf Wnd Face >30cm,PX12018F,CDM,510,RC,12018,CPT,,,,,,,,713,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,101.66,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.66,358.35
Repr Superf Wnd Face >30cm,PX12018F,CDM,510,RC,12018,CPT,,,,,,,,713,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,101.66,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.66,358.35
Repr Superf Wnd Face >30cm,PX12018F,CDM,510,RC,12018,CPT,,,,,,,,713,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,101.66,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.66,358.35
"Up GI Endoscopy,Dilatn W Guide",PX43248F,CDM,750,RC,43248,CPT,,,,,,,,1995,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,101.66,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.66,856.45
CT Maxillofacial W/Dye,PX7048701,CDM,350,RC,70487,CPT,TC,,,,,,,3332,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,101.6888,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.93,203.79
Injection for Shoulder Arthrogram,PX23350F,CDM,510,RC,23350,CPT,,,,,,,,675,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,101.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.54,335.52
"Hepatitis a Antibody, Tot - Ref",PX8670890,CDM,300,RC,86708,CPT,90,,,,,,,201,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,101.706,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.36,196.98
Hepatitis B Surface Antibody,PX86706,CDM,300,RC,86706,CPT,,,,,,,,201,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,101.706,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,196.98
KIT 3-LUMEN 7FR X 16CM CENTRALVENOUS CDC-42703-P1A,120.37,CDM,272,RC,C1751,HCPCS,,10707-MAIN,LOCAL,,,,,201,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,101.706,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.4954,196.98
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409663724,NDC,50,ML,115.32,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,101.71224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084252,NDC,0.5,ML,207.65,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,124.7133333,percent of total billed charges,101.7485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.085268,203.497
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084252,NDC,0.5,ML,207.65,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,101.7485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.085268,203.497
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084252,NDC,0.5,ML,207.65,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,101.7485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.085268,203.497
"Non-Select. Wound Debride., W/O Anesth.; Top. Appl./Wound Assess./Instruct., per Sess.",PX97602,CDM,761,RC,97602,CPT,,,,,,,,212,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,101.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.0648,207.76
"Non-Select. Wound Debride., W/O Anesth.; Top. Appl./Wound Assess./Instruct., per Sess.",PX97602,CDM,761,RC,97602,CPT,,,,,,,,212,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,101.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.0648,207.76
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,781329091,NDC,50,ML,119.73,,First Health,Commercial,both,85,,999999999,percent of total billed charges,101.7705,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
Fibrinogen Activity - Ref,PX8538490,CDM,300,RC,85384,CPT,90,,,,,,,245,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,101.773,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.91,240.1
"Ileoscopy Thru Stoma,Diagnostic",PX44380F,CDM,750,RC,44380,CPT,,,,,,,,245,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,101.773,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.773,791.92
Platelet Antibodies - Ref,PX8602290,CDM,300,RC,86022,CPT,90,,,,,,,245,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,101.773,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.84,240.1
Dress/Debrid Med Burn No Anesth,PX16025F,CDM,510,RC,16025,CPT,,,,,,,,366,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,101.7887,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.06,327.91
Dress/Debrid Med Burn No Anesth,PX16025P,CDM,983,RC,16025,CPT,,,,,,,,244,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,101.7887,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.06,327.91
acetaZOLAMIDE 500 MG Recon Soln 1 Each Vial,J1120.01,CDM,636,RC,J1120,HCPCS,,,,39822019001,NDC,1,EA,207.84,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,101.8416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.336736,203.6832
acetaZOLAMIDE 500 MG Recon Soln 1 Each Vial,J1120.01,CDM,636,RC,J1120,HCPCS,,,,39822019001,NDC,1,EA,207.84,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,101.8416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.336736,203.6832
acetaZOLAMIDE 500 MG Recon Soln 1 Each Vial,J1120.01,CDM,636,RC,J1120,HCPCS,,,,39822019001,NDC,1,EA,207.84,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,101.8416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.336736,203.6832
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034001,NDC,1,EA,111.81,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,101.85891,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
naloxone 2 MG/2ML solution prefilled syringe 2 mL Syringe,J2310.01,CDM,636,RC,J2310,HCPCS,,,,76329346901,NDC,1,ML,114.45,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,101.8605,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.54253,130.4968
empagliflozin 10 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,597015237,NDC,1,EA,104.66,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,101.865578,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034000,NDC,1,EA,111.82,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,101.86802,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
Cv Carotid Imaging-Bilat,PX9388001,CDM,921,RC,93880,CPT,TC,,,,,,,1088,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,101.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.44,266.42
Cv Carotid Imaging-Bilat,PX9388001,CDM,921,RC,93880,CPT,TC,,,,,,,1088,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,101.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.44,266.42
levonorgestrel 1.5 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,62756071860,NDC,1,EA,114.48,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,101.8872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ketamine 100 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,55150044001,NDC,10,ML,111.85,,Medica,Commercial,both,91.1,,7.37,percent of total billed charges,101.89535,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
Carnitine - Ref,PX8237990,CDM,300,RC,82379,CPT,90,,,,,,,104,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,101.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.47,101.92
Cmv Antibody - Ref,PX8664490,CDM,300,RC,86644,CPT,90,,,,,,,104,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,101.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,101.92
"Compatibility Test,Antiglob Tech",PX86922,CDM,300,RC,86922,CPT,,,,,,,,120,,First Health,Commercial,both,85,,999999999,percent of total billed charges,102,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.848,149.22
KIWI OMNICUP VACUUM DELIVERY SYSTEM,120.225,CDM,272,RC,,,,11608-MAIN,LOCAL,,,,,120,,First Health,Commercial,both,85,,999999999,percent of total billed charges,102,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.848,117.6
VACUUM KIWI W/PALM PUMP,120.225,CDM,272,RC,,,,10028-MAIN,LOCAL,,,,,120,,First Health,Commercial,both,85,,999999999,percent of total billed charges,102,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.848,117.6
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505614700,NDC,1,EA,212.52,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,102.0096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505614700,NDC,1,EA,212.52,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,102.0096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ELECTRODE PEDS ONESTEP SINGLE,120.343,CDM,272,RC,A4556,HCPCS,,10296-MAIN,LOCAL,,,,,112,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,102.032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
EYE IRRIGATION SYSTEM MT2000,120.318,CDM,272,RC,,,,8718-MAIN,LOCAL,,,,,112,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,102.032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
F5 Gene - Ref,PX8124190,CDM,300,RC,81241,CPT,90,,,,,,,112,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,102.032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
Immunofluorescence per Spec Add Singl Antb Stain - Ref,PX8835090,CDM,310,RC,88350,CPT,90,,,,,,,112,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,102.032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
Osmolality; Urine,PX83935,CDM,300,RC,83935,CPT,,,,,,,,112,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,102.032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.25,109.76
Prolactin,PX84146,CDM,300,RC,84146,CPT,,,,,,,,112,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,102.032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.77,109.76
Quantitation Drug Nos - Ref,PX8029990,CDM,300,RC,80299,CPT,90,,,,,,,112,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,102.032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.09,109.76
TUBE AIRSPIRAL BREATHING AND CHAMBER 900PT561,120.493,CDM,271,RC,A4604,HCPCS,,11618-MAIN,LOCAL,,,,,112,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,102.032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
verapamil 2.5 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,51754020401,NDC,1,ML,112.01,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,102.04111,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Phlebotomy,PX99195,CDM,940,RC,99195,CPT,,,,,,,,238,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,102.102,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.8652,233.24
Drain Skin Abscess Simple,PX10060F,CDM,510,RC,10060,CPT,,,,,,,,296,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,102.1098,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.41,264.96
Drain Skin Abscess Simple,PX10060P,CDM,983,RC,10060,CPT,,,,,,,,293,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,102.1098,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.41,287.14
Incise External Hemorrhoid,PX46083F,CDM,510,RC,46083,CPT,,,,,,,,502,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,102.1098,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.28,433.76
Incise External Hemorrhoid,PX46083P,CDM,983,RC,46083,CPT,,,,,,,,956,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,102.1098,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.28,936.88
KATZ EXTRACTOR OTO-RHINO FOREIGN BODY REMOVER,120.568,CDM,272,RC,,,,12808-MAIN,LOCAL,,,,,246,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,102.1884,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.1884,241.08
Dx Occult Blood Immunoassay,PX82274,CDM,300,RC,82274,CPT,,,,,,,,105,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,102.1965,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.6,102.9
Specimen Concentration - Ref,PX8701590,CDM,300,RC,87015,CPT,90,,,,,,,105,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,102.1965,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.12,102.9
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,17478007035,NDC,3.5,GR,105.01,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,102.206233,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Apply Multlay Comprs Lwr Leg,PX29581F,CDM,510,RC,29581,CPT,,,,,,,,213,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,102.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.4802,208.74
Apply Multlay Comprs Lwr Leg,PX29581F,CDM,510,RC,29581,CPT,,,,,,,,213,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,102.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.4802,208.74
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006F,CDM,510,RC,10006,CPT,,,,,,,,213,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,102.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.4802,208.74
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006F,CDM,510,RC,10006,CPT,,,,,,,,213,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,102.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.4802,208.74
"GI Pathogen Panel, Pcr - Ref",PX8750790,CDM,300,RC,87507,CPT,90,,,,,,,213,,Health Partners,Health Partners Care Plans,both,48,,202.72,percent of total billed charges,102.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.4802,382.15
"GI Pathogen Panel, Pcr - Ref",PX8750790,CDM,300,RC,87507,CPT,90,,,,,,,213,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,102.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.4802,382.15
Remove Impacted Ear Wax,PX69210F,CDM,510,RC,69210,CPT,,,,,,,,213,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,102.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.44,208.74
Remove Impacted Ear Wax,PX69210F,CDM,510,RC,69210,CPT,,,,,,,,213,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,102.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.44,208.74
"Up GI Endoscopy,Dilatn W Guide",PX43248F,CDM,750,RC,43248,CPT,,,,,,,,1995,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,102.31,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.66,856.45
"Up GI Endoscopy,Dilatn W Guide",PX43248F,CDM,750,RC,43248,CPT,,,,,,,,1995,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,102.31,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.66,856.45
Antithrombin III Ag Assay - Ref,PX8530190,CDM,300,RC,85301,CPT,90,,,,,,,116,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,102.312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.91,113.68
Ca 19-9,PX86301,CDM,300,RC,86301,CPT,,,,,,,,116,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,102.312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,113.68
Assay of Triglycerides,PX84478,CDM,300,RC,84478,CPT,,,,,,,,115,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,102.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.26,112.7
"Blood Typing, Rh Phenotype",PX86906,CDM,300,RC,86906,CPT,,,,,,,,115,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,102.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.03,112.7
BRACE ANKLE LARGE 264015,120.51,CDM,274,RC,L1902,HCPCS,,4-MAIN,LOCAL,,,,,115,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,102.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE MEDIUM 264014,120.51,CDM,274,RC,L1902,HCPCS,,7-MAIN,LOCAL,,,,,115,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,102.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE SMALL 264012,120.51,CDM,274,RC,L1902,HCPCS,,12-MAIN,LOCAL,,,,,115,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,102.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE X-LARGE 264016,120.51,CDM,274,RC,L1902,HCPCS,,14-MAIN,LOCAL,,,,,115,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,102.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE X-SMALL 264011,120.51,CDM,274,RC,L1902,HCPCS,,1-MAIN,LOCAL,,,,,115,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,102.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
Debride Skin/Subq Ea Ad 20sqcm,PX11045F,CDM,510,RC,11045,CPT,,,,,,,,115,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,102.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
Glucagon - Ref,PX8294390,CDM,300,RC,82943,CPT,90,,,,,,,115,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,102.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.1,112.7
"Immuno for Tumor Ag, Qn - Ref",PX8631690,CDM,300,RC,86316,CPT,90,,,,,,,115,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,102.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,112.7
Microsomal Antibody,PX7893,CDM,300,RC,86376,CPT,,,,,,,,115,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,102.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.34,112.7
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157F,CDM,370,RC,99157,CPT,,,,,,,,270,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,102.38,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.86,102.38
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157F,CDM,370,RC,99157,CPT,,,,,,,,270,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,102.38,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.86,102.38
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157P,CDM,983,RC,99157,CPT,,,,,,,,270,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,102.38,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.86,264.6
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157P,CDM,983,RC,99157,CPT,,,,,,,,270,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,102.38,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.86,264.6
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006F,CDM,510,RC,10006,CPT,,,,,,,,213,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,102.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.76,124.52
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006P,CDM,983,RC,10006,CPT,,,,,,,,142,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,102.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.76,139.16
ACCESSORY KIT FOR GROSHONG 16GA,120.46,CDM,272,RC,C1751,HCPCS,,2967-MAIN,LOCAL,,,,,209,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,102.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.8186,204.82
ACCESSORY KIT FOR GROSHONG 16GA,120.46,CDM,272,RC,C1751,HCPCS,,2967-MAIN,LOCAL,,,,,209,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,102.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.8186,204.82
ACCESSORY KIT FOR GROSHONG 16GA,120.46,CDM,272,RC,C1751,HCPCS,,2967-MAIN,LOCAL,,,,,209,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,102.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.8186,204.82
Infection Agent Detect Dna/Rna Probe Tq 12-25,PX87507,CDM,300,RC,87507,CPT,,,,,,,,209,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,102.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.8186,382.15
Infection Agent Detect Dna/Rna Probe Tq 12-25,PX87507,CDM,300,RC,87507,CPT,,,,,,,,209,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,102.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.8186,382.15
Infection Agent Detect Dna/Rna Probe Tq 12-25,PX87507,CDM,300,RC,87507,CPT,,,,,,,,209,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,102.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.8186,382.15
"Organic Acid, Single, Qnt - Ref",PX8392190,CDM,300,RC,83921,CPT,90,,,,,,,209,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,102.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.45,204.82
"Organic Acid, Single, Qnt - Ref",PX8392190,CDM,300,RC,83921,CPT,90,,,,,,,209,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,102.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.45,204.82
"Organic Acid, Single, Qnt - Ref",PX8392190,CDM,300,RC,83921,CPT,90,,,,,,,209,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,102.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.45,204.82
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084243,NDC,0.5,ML,202.42,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,102.42452,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.085268,203.497
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060851,NDC,100,ML,213.4,,Health Partners,Health Partners Care Plans,both,48,,1.259785714,percent of total billed charges,102.432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060851,NDC,100,ML,213.4,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,102.432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032050,NDC,1,EA,120.51,,First Health,Commercial,both,85,,999999999,percent of total billed charges,102.4335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618201,NDC,2,ML,120.53,,First Health,Commercial,both,85,,999999999,percent of total billed charges,102.4505,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.068162,123.3918
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618210,NDC,2,ML,120.53,,First Health,Commercial,both,85,,999999999,percent of total billed charges,102.4505,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.068162,123.3918
"Drain Finger Abscess,Simple",PX26010P,CDM,983,RC,26010,CPT,,,,,,,,207,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,102.465,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.9878,201.4731
"MESH PROLENE 3X6""",C1781,CDM,278,RC,C1781,HCPCS,,688-MAIN,LOCAL,,,,,213.49,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,102.4752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"MESH PROLENE 3X6""",C1781,CDM,278,RC,C1781,HCPCS,,688-MAIN,LOCAL,,,,,213.49,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,102.4752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Cystourethroscopy, With Injection(S) for Chemodenervation of the Bladder",PX52287F,CDM,360,RC,52287,CPT,,,,,,,,2745,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,102.53,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.53,803.87
Physical Therapy Re-Eval Est Plan Care 20 Mins,PX97164,CDM,424,RC,97164,CPT,,,,,,,,239,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,102.531,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,234.22
empagliflozin 10 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,597015237,NDC,1,EA,104.66,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,102.5668,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DRAIN FLAT JACKSON PRATT 10MM,27100000,CDM,271,RC,,,,334-MAIN,LOCAL,,,,,239.09,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,102.56961,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
"polyethylene glycol 236 g Recon Soln 4,000 mL Bottle",63700001,CDM,250,RC,,,,,,43386009019,NDC,4000,ML,112.6,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,102.5786,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Hospital Inpt or Obs Care, Admin/Disch Same Date, Moderate Level Mdm >= 70 Minutes",PX99235,CDM,982,RC,99235,CPT,,,,,,,,582,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,102.59,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,99.73,570.36
"Hospital Inpt or Obs Care, Admin/Disch Same Date, Moderate Level Mdm >= 70 Minutes",PX99235,CDM,982,RC,99235,CPT,,,,,,,,582,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,102.59,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,99.73,570.36
Drain/Inject Medium Joint/Bursa,PX20605F,CDM,510,RC,20605,CPT,,,,,,,,247,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,102.6038,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.6038,258.75
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614800,NDC,1,EA,239.18,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,102.60822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409663724,NDC,50,ML,115.32,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,102.6348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
TRUMPET SUCTION IRRIGATION,27100000,CDM,271,RC,,,,4577-MAIN,LOCAL,,,,,116.4,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,102.6648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,409672924,NDC,50,ML,116.43,,United Healthcare,All Payer,outpatient,88.2,,13.925,percent of total billed charges,102.69126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
Immunofix Elp,PX86335,CDM,300,RC,86335,CPT,,,,,,,,214,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,102.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.91,209.72
Immunofix Elp,PX86335,CDM,300,RC,86335,CPT,,,,,,,,214,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,102.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.91,209.72
CT Upper Extremity W/Dye,PX7320101,CDM,350,RC,73201,CPT,TC,,,,,,,2757,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,102.75,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.22,299.12
"Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602P,CDM,983,RC,11602,CPT,,,,,,,,1120,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,102.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.66,1097.6
"Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602P,CDM,983,RC,11602,CPT,,,,,,,,1120,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,102.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.66,1097.6
"Fac/Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602F,CDM,510,RC,11602,CPT,,,,,,,,731,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,102.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.66,509.86
"Fac/Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602F,CDM,510,RC,11602,CPT,,,,,,,,731,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,102.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.66,509.86
Reconstruc of Nail Bed,PX11760F,CDM,510,RC,11760,CPT,,,,,,,,1162,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,102.752,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.37,384.64
Reconstruc of Nail Bed,PX11760P,CDM,983,RC,11760,CPT,,,,,,,,903,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,102.752,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.37,884.94
baricitinib 2 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,2418230,NDC,0.5,EA,203.12,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,102.77872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084252,NDC,0.5,ML,207.65,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,102.78675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.085268,203.497
pyRIDostigmine bromide 10 MG/2ML Solution 2 mL Ampule,25000000,CDM,250,RC,,,,,,781304095,NDC,2,ML,203.16,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,102.79896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BAG LEG URINARY STND 32OZ,120.33,CDM,272,RC,A5112,HCPCS,,4433-MAIN,LOCAL,,,,,121,,First Health,Commercial,both,85,,999999999,percent of total billed charges,102.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
BAG URINARY DRAINAGE 2000ML 6300,120.33,CDM,274,RC,A4357,HCPCS,,1283-MAIN,LOCAL,,,,,121,,First Health,Commercial,both,85,,999999999,percent of total billed charges,102.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
BAG URINARY LEG PACK 9349,120.33,CDM,272,RC,A5112,HCPCS,,623-MAIN,LOCAL,,,,,121,,First Health,Commercial,both,85,,999999999,percent of total billed charges,102.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
"Chest Wall Manipulation,Initial",PX94667,CDM,410,RC,94667,CPT,,,,,,,,121,,First Health,Commercial,both,85,,999999999,percent of total billed charges,102.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.2634,118.58
"Fluor Noninfect Ab Sc, Ea - Ref",PX8625590,CDM,300,RC,86255,CPT,90,,,,,,,121,,First Health,Commercial,both,85,,999999999,percent of total billed charges,102.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.05,118.58
"Manage/Train Orthotic/Prosthetic, per 15 Min",PX97763,CDM,420,RC,97763,CPT,,,,,,,,121,,First Health,Commercial,both,85,,999999999,percent of total billed charges,102.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.36,118.58
"Prosthetic Training, Initial, Each 15 Mins",PX97761,CDM,420,RC,97761,CPT,,,,,,,,121,,First Health,Commercial,both,85,,999999999,percent of total billed charges,102.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.41,118.58
acetaZOLAMIDE 500 MG Recon Soln 1 Each Vial,J1120.01,CDM,636,RC,J1120,HCPCS,,,,39822019001,NDC,1,EA,207.84,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,102.8808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.336736,203.6832
neomycin-polymyxin-dexamethasone 3.5-10000-0.1 Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,61314063136,NDC,3.5,GR,247.71,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,102.898734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
AIRSEAL ROBOTIC Xi CAP AND OBTURATOR WITH BLADELESS OPTICAL TIP,27200000,CDM,272,RC,,,,12208-MAIN,LOCAL,,,,,210,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,102.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
AIRSEAL ROBOTIC Xi CAP AND OBTURATOR WITH BLADELESS OPTICAL TIP,27200000,CDM,272,RC,,,,12208-MAIN,LOCAL,,,,,210,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,102.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
AIRSEAL ROBOTIC Xi CAP AND OBTURATOR WITH BLADELESS OPTICAL TIP,27200000,CDM,272,RC,,,,12208-MAIN,LOCAL,,,,,210,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,102.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
AIRSEAL ROBOTIC Xi TRI LUMEN FILTERED TUBE SET WITH ACTIVATED CHARCOAL,27200000,CDM,272,RC,,,,12209-MAIN,LOCAL,,,,,210,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,102.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
AIRSEAL ROBOTIC Xi TRI LUMEN FILTERED TUBE SET WITH ACTIVATED CHARCOAL,27200000,CDM,272,RC,,,,12209-MAIN,LOCAL,,,,,210,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,102.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
AIRSEAL ROBOTIC Xi TRI LUMEN FILTERED TUBE SET WITH ACTIVATED CHARCOAL,27200000,CDM,272,RC,,,,12209-MAIN,LOCAL,,,,,210,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,102.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Apply Forearm Cast,PX29075F,CDM,510,RC,29075,CPT,,,,,,,,210,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,102.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,234.62
Apply Forearm Cast,PX29075F,CDM,510,RC,29075,CPT,,,,,,,,210,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,102.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,234.62
Apply Forearm Cast,PX29075F,CDM,510,RC,29075,CPT,,,,,,,,210,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,102.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,234.62
Chorionic gonadotropin test,PX84702,CDM,300,RC,84702,CPT,,,,,,,,210,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,102.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.8,205.8
Chorionic gonadotropin test,PX84702,CDM,300,RC,84702,CPT,,,,,,,,210,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,102.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.8,205.8
Chorionic gonadotropin test,PX84702,CDM,300,RC,84702,CPT,,,,,,,,210,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,102.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.8,205.8
Dx Occult Blood Immunoassay,PX82274,CDM,300,RC,82274,CPT,,,,,,,,105,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,102.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.6,102.9
"Excision of Nail Fold, Toe",PX11765F,CDM,510,RC,11765,CPT,,,,,,,,210,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,102.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,348.35
"Excision of Nail Fold, Toe",PX11765F,CDM,510,RC,11765,CPT,,,,,,,,210,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,102.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,348.35
"Excision of Nail Fold, Toe",PX11765F,CDM,510,RC,11765,CPT,,,,,,,,210,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,102.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,348.35
Fac/Hospital Discharge Day>30 Min,PX99239F,CDM,510,RC,99239,CPT,,,,,,,,210,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,102.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,205.8
Fac/Hospital Discharge Day>30 Min,PX99239F,CDM,510,RC,99239,CPT,,,,,,,,210,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,102.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,205.8
Fac/Hospital Discharge Day>30 Min,PX99239F,CDM,510,RC,99239,CPT,,,,,,,,210,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,102.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,205.8
"Inject Trigger Point, 1 or 2",PX20552P,CDM,983,RC,20552,CPT,,,,,,,,210,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,102.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,258.75
"Inject Trigger Point, 1 or 2",PX20552P,CDM,983,RC,20552,CPT,,,,,,,,210,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,102.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,258.75
"Inject Trigger Point, 1 or 2",PX20552P,CDM,983,RC,20552,CPT,,,,,,,,210,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,102.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,258.75
Specimen Concentration - Ref,PX8701590,CDM,300,RC,87015,CPT,90,,,,,,,105,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,102.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.12,102.9
neomycin-polymyxin-dexameth 3.5-10000-0.1 Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063006,NDC,5,ML,247.72,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,102.902888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,17478007035,NDC,3.5,GR,105.01,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,102.9098,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Iadna Streptococcus Group a Amplified Probe Tq,PX87651,CDM,300,RC,87651,CPT,,,,,,,,113,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,102.943,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,110.74
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209P,CDM,982,RC,69209,CPT,,,,,,,,113,,Medica,Commercial,both,91.1,,49.65,percent of total billed charges,102.943,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9402,109.9829
Strapping of Toes,PX29550F,CDM,510,RC,29550,CPT,,,,,,,,113,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,102.943,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9402,110.74
Xray Spine Single Tc,PX7202001,CDM,320,RC,72020,CPT,TC,,,,,,,113,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,102.943,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9402,110.74
"Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404P,CDM,983,RC,11404,CPT,,,,,,,,600,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,102.96,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.96,588
"Fac/Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404F,CDM,510,RC,11404,CPT,,,,,,,,749,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,102.96,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.96,468.35
gemcitabine 1 GM/26.3ML Solution 26.3 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018101,NDC,26.3,ML,203.58,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,103.01148,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
lidocaine-epinephrine-tetracaine Gel 3 mL Syringe,J3490.160,CDM,636,RC,J3490,HCPCS,,,,88888800028,NDC,3,ML,121.19,,First Health,Commercial,both,85,,999999999,percent of total billed charges,103.0115,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.342326,118.7662
Closed Rx Mt-Phal Toe Dislocation,PX28630P,CDM,983,RC,28630,CPT,,,,,,,,248,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,103.0192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.0192,241.3784
Debride Muscle Ea Add 20 Sqcm,PX11046F,CDM,510,RC,11046,CPT,,,,,,,,248,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,103.0192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.0192,243.04
Fetal Profile W/O Stress,PX7681901,CDM,402,RC,76819,CPT,TC,,,,,,,248,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,103.0192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,243.04
Ther Injection Carpal Tunnel,PX20526P,CDM,983,RC,20526,CPT,,,,,,,,248,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,103.0192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.0192,258.75
US Chest Tc,PX7660401,CDM,402,RC,76604,CPT,TC,,,,,,,248,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,103.0192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,243.04
"West Nile Ab, Igg - Ref",PX8678990,CDM,300,RC,86789,CPT,90,,,,,,,248,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,103.0192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,243.04
cefoTEtan 2 g Recon Soln 1 Each Vial,800000,CDM,,,S0074,HCPCS,,,,63323038620,NDC,1,EA,240.2,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,103.0458,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Closed Rx Mt-Phal Toe Dislocation,PX28630F,CDM,510,RC,28630,CPT,,,,,,,,360,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,103.0731,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.93,327.22
Closed Rx Mt-Phal Toe Dislocation,PX28630P,CDM,983,RC,28630,CPT,,,,,,,,248,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,103.0731,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.93,327.22
"Exc Skn Benig<5mm Face,Facial",PX11440P,CDM,983,RC,11440,CPT,,,,,,,,387,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,103.0731,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.28,379.26
Exc Skn Bnig0.6-1cm Remain Bdy,PX11421P,CDM,983,RC,11421,CPT,,,,,,,,345,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,103.0731,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.15,338.1
Fac/Exc Skn Beni 0.6-1cm Remain Bdy,PX11421F,CDM,510,RC,11421,CPT,,,,,,,,931,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,103.0731,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.15,333.45
"Fac/Exc Skn Benig<5mm Face,Facial",PX11440F,CDM,510,RC,11440,CPT,,,,,,,,484,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,103.0731,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.28,299.55
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021588,NDC,0.5,ML,203.87,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,103.15822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.779496,199.7926
GLIDESCOPE QC MILLER S0 SINGLE USE 0270-1087,120.58,CDM,272,RC,,,,13024-MAIN,LOCAL,,,,,106,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,103.1698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
GLIDESCOPE QC MILLER S1 SINGLE USE 0270-1088,120.58,CDM,272,RC,,,,13025-MAIN,LOCAL,,,,,106,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,103.1698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
Ven Duplex Bilateral,PX9397001,CDM,921,RC,93970,CPT,TC,,,,,,,1189,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,103.18,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.18,269.91
"Cystourethroscopy, With Injection(S) for Chemodenervation of the Bladder",PX52287F,CDM,360,RC,52287,CPT,,,,,,,,2745,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,103.18,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.53,803.87
"Cystourethroscopy, With Injection(S) for Chemodenervation of the Bladder",PX52287F,CDM,360,RC,52287,CPT,,,,,,,,2745,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,103.18,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.53,803.87
Ven Duplex Bilateral,PX9397001,CDM,921,RC,93970,CPT,TC,,,,,,,1189,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,103.18,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.18,269.91
Ven Duplex Bilateral,PX9397001,CDM,921,RC,93970,CPT,TC,,,,,,,1189,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,103.18,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.18,269.91
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505624500,NDC,1,EA,116.99,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,103.18518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
Cryptosporidum,PX87328,CDM,300,RC,87328,CPT,,,,,,,,117,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,103.194,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.67,114.66
Drain Blood From Under Nail,PX11740F,CDM,510,RC,11740,CPT,,,,,,,,117,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,103.194,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.6018,114.66
Giardia,PX87329,CDM,300,RC,87329,CPT,,,,,,,,117,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,103.194,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,114.66
"In Situ Hybridization (Eg, Fish), Each Probe, Tech",PX8836501,CDM,310,RC,88365,CPT,TC,,,,,,,117,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,103.194,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.6018,149.22
RBC Pretreatment,PX8697002,CDM,300,RC,86970,CPT,,,,,,,,117,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,103.194,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.6018,114.66
cefTRIAXone in dextrose 1 g / 50 mL 1-3.74 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0696.01,CDM,636,RC,J0696,HCPCS,,,,264315311,NDC,1,EA,106.03,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,18.43861111,percent of total billed charges,103.198999,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
Immunoglobulin Subclasses - Ref,PX8278790,CDM,300,RC,82787,CPT,90,,,,,,,215,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,103.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.35,210.7
Immunoglobulin Subclasses - Ref,PX8278790,CDM,300,RC,82787,CPT,90,,,,,,,215,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,103.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.35,210.7
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106P,CDM,983,RC,11106,CPT,,,,,,,,204,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,103.224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.7416,548.67
Antithrombin III Ag Assay - Ref,PX8530190,CDM,300,RC,85301,CPT,90,,,,,,,116,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,103.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.91,113.68
Ca 19-9,PX86301,CDM,300,RC,86301,CPT,,,,,,,,116,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,103.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,113.68
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,68462018022,NDC,22,GR,240.66,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,103.24314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Bone Age Studies Tc,PX7707201,CDM,320,RC,77072,CPT,TC,,,,,,,211,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,103.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.6494,206.78
Bone Age Studies Tc,PX7707201,CDM,320,RC,77072,CPT,TC,,,,,,,211,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,103.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.6494,206.78
Bone Age Studies Tc,PX7707201,CDM,320,RC,77072,CPT,TC,,,,,,,211,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,103.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.6494,206.78
Collect Blood From Picc,PX36592F,CDM,510,RC,36592,CPT,,,,,,,,211,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,42.2,percent of total billed charges,103.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.6494,206.78
Collect Blood From Picc,PX36592F,CDM,510,RC,36592,CPT,,,,,,,,211,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,103.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.6494,206.78
Collect Blood From Picc,PX36592F,CDM,510,RC,36592,CPT,,,,,,,,211,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,103.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.6494,206.78
Draw Blood Off Venous Device,PX36591F,CDM,510,RC,36591,CPT,,,,,,,,211,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,41.4,percent of total billed charges,103.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.6494,206.78
Draw Blood Off Venous Device,PX36591F,CDM,510,RC,36591,CPT,,,,,,,,211,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,103.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.6494,206.78
Draw Blood Off Venous Device,PX36591F,CDM,510,RC,36591,CPT,,,,,,,,211,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,103.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.6494,206.78
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338411450,NDC,50,ML,106.23,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1.636666667,percent of total billed charges,103.393659,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
I&D Bartholin Gland Abscess,PX56420F,CDM,510,RC,56420,CPT,,,,,,,,429,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,103.3942,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.02,389.48
I&D Bartholin Gland Abscess,PX56420P,CDM,983,RC,56420,CPT,,,,,,,,286,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,103.3942,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.02,389.48
ACCESSORY KIT FOR GROSHONG 16GA,120.46,CDM,272,RC,C1751,HCPCS,,2967-MAIN,LOCAL,,,,,209,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,103.455,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.8186,204.82
Infection Agent Detect Dna/Rna Probe Tq 12-25,PX87507,CDM,300,RC,87507,CPT,,,,,,,,209,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,103.455,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.8186,382.15
"Organic Acid, Single, Qnt - Ref",PX8392190,CDM,300,RC,83921,CPT,90,,,,,,,209,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,103.455,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.45,204.82
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,781523806,NDC,1,EA,106.34,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,103.500722,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,781523864,NDC,1,EA,106.34,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,103.500722,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,65862039010,NDC,1,EA,106.34,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,103.500722,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
amiodarone 150-4.21 MG/100ML-% Solution 100 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066015010,NDC,100,ML,249.22,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,103.525988,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.35,318.745
TRUMPET SUCTION IRRIGATION,27100000,CDM,271,RC,,,,4577-MAIN,LOCAL,,,,,116.4,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,103.596,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
IV 0.9% NS 1000ML 2B1324X,27200000,CDM,272,RC,,,,538-MAIN,LOCAL,,,,,121.89,,First Health,Commercial,both,85,,999999999,percent of total billed charges,103.6065,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
amiodarone 900 MG/18ML Solution 18 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,67457015318,NDC,18,ML,113.73,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,103.60803,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Package,25000000,CDM,250,RC,,,,,,10019055390,NDC,1,EA,121.9,,First Health,Commercial,both,85,,999999999,percent of total billed charges,103.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601901,NDC,10,ML,211.47,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,103.6203,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.844638,207.2406
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601901,NDC,10,ML,211.47,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,103.6203,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.844638,207.2406
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601901,NDC,10,ML,211.47,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,103.6203,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.844638,207.2406
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601910,NDC,10,ML,211.47,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,103.6203,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.844638,207.2406
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601910,NDC,10,ML,211.47,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,103.6203,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.844638,207.2406
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601910,NDC,10,ML,211.47,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,103.6203,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.844638,207.2406
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,409672924,NDC,50,ML,116.43,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,103.6227,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
C-COLLAR ASPEN REGULAR 79-83365,120.25,CDM,274,RC,L0140,HCPCS,,167-MAIN,LOCAL,,,,,216,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,103.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.58,211.68
C-COLLAR ASPEN REGULAR 79-83365,120.25,CDM,274,RC,L0140,HCPCS,,167-MAIN,LOCAL,,,,,216,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,103.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.58,211.68
C-COLLAR ASPEN TALL 79-83367,120.25,CDM,274,RC,L0140,HCPCS,,164-MAIN,LOCAL,,,,,216,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,103.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.58,211.68
C-COLLAR ASPEN TALL 79-83367,120.25,CDM,274,RC,L0140,HCPCS,,164-MAIN,LOCAL,,,,,216,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,103.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.58,211.68
C-COLLAR ASPEN X-TALL 79-83368,120.25,CDM,274,RC,L0140,HCPCS,,168-MAIN,LOCAL,,,,,216,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,103.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.58,211.68
C-COLLAR ASPEN X-TALL 79-83368,120.25,CDM,274,RC,L0140,HCPCS,,168-MAIN,LOCAL,,,,,216,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,103.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.58,211.68
Assay of Iron,PX83540,CDM,300,RC,83540,CPT,,,,,,,,122,,First Health,Commercial,both,85,,999999999,percent of total billed charges,103.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,119.56
"Compliment, Total (Ch50) - Ref",PX8616290,CDM,300,RC,86162,CPT,90,,,,,,,122,,First Health,Commercial,both,85,,999999999,percent of total billed charges,103.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.63,119.56
Vitamin B-12,PX82607,CDM,300,RC,82607,CPT,,,,,,,,122,,First Health,Commercial,both,85,,999999999,percent of total billed charges,103.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.83,119.56
Apply Lower Leg Splint,PX29515F,CDM,510,RC,29515,CPT,,,,,,,,296,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,103.77,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.54,152.89
Apply Lower Leg Splint,PX29515P,CDM,983,RC,29515,CPT,,,,,,,,311,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,103.77,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.54,304.78
"N Block Inj, Plantar Digit",PX64455F,CDM,510,RC,64455,CPT,,,,,,,,385,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,103.77,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.72,103.77
"N Block Inj, Plantar Digit",PX64455P,CDM,983,RC,64455,CPT,,,,,,,,385,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,103.77,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.72,377.3
levOCARNitine 200 MG/ML Solution 5 mL Vial,J1955.01,CDM,636,RC,J1955,HCPCS,,,,517104501,NDC,5,ML,249.86,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,103.791844,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.791844,244.8628
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,43598054910,NDC,100,ML,205.14,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,103.80084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
Airway Inhalation Treatment,PX94640F,CDM,410,RC,94640,CPT,,,,,,,,242,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,103.818,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,100.5268,237.16
"Noninvasv Oxygen Satut,Continuous",PX94762,CDM,460,RC,94762,CPT,,,,,,,,242,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,103.818,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,100.5268,237.16
gentamicin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063305,NDC,5,ML,122.17,,First Health,Commercial,both,85,,999999999,percent of total billed charges,103.8445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153P,CDM,983,RC,99153,CPT,,,,,,,,250,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,103.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.85,243.325
sincalide 5 MCG Recon Soln 1 Each Vial,J2805.01,CDM,636,RC,J2805,HCPCS,,,,270055615,NDC,1,EA,250,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,103.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.85,245
Withdrawal of Arterial Blood,PX36600F,CDM,510,RC,36600,CPT,,,,,,,,250,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,103.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.85,245
Assay of Erythropoietin,PX82668,CDM,300,RC,82668,CPT,,,,,,,,114,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,103.854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,111.72
GLIDESCOPE QC MILLER S0 SINGLE USE 0270-1087,120.58,CDM,272,RC,,,,13024-MAIN,LOCAL,,,,,106,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,103.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
GLIDESCOPE QC MILLER S1 SINGLE USE 0270-1088,120.58,CDM,272,RC,,,,13025-MAIN,LOCAL,,,,,106,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,103.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.0476,103.88
"Non-Select. Wound Debride., W/O Anesth.; Top. Appl./Wound Assess./Instruct., per Sess.",PX97602,CDM,761,RC,97602,CPT,,,,,,,,212,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,103.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.0648,207.76
"Non-Select. Wound Debride., W/O Anesth.; Top. Appl./Wound Assess./Instruct., per Sess.",PX97602,CDM,761,RC,97602,CPT,,,,,,,,212,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,103.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.0648,207.76
"Non-Select. Wound Debride., W/O Anesth.; Top. Appl./Wound Assess./Instruct., per Sess.",PX97602,CDM,761,RC,97602,CPT,,,,,,,,212,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,103.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.0648,207.76
cefTRIAXone in dextrose 1 g / 50 mL 1-3.74 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0696.01,CDM,636,RC,J0696,HCPCS,,,,264315311,NDC,1,EA,106.03,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,103.9094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
AIRSEAL ROBOTIC Xi CAP AND OBTURATOR WITH BLADELESS OPTICAL TIP,27200000,CDM,272,RC,,,,12208-MAIN,LOCAL,,,,,210,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,103.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
AIRSEAL ROBOTIC Xi TRI LUMEN FILTERED TUBE SET WITH ACTIVATED CHARCOAL,27200000,CDM,272,RC,,,,12209-MAIN,LOCAL,,,,,210,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,103.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Apply Forearm Cast,PX29075F,CDM,510,RC,29075,CPT,,,,,,,,210,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,103.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,234.62
Chorionic gonadotropin test,PX84702,CDM,300,RC,84702,CPT,,,,,,,,210,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,103.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.8,205.8
"Excision of Nail Fold, Toe",PX11765F,CDM,510,RC,11765,CPT,,,,,,,,210,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,103.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,348.35
Fac/Hospital Discharge Day>30 Min,PX99239F,CDM,510,RC,99239,CPT,,,,,,,,210,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,103.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,205.8
"Inject Trigger Point, 1 or 2",PX20552P,CDM,983,RC,20552,CPT,,,,,,,,210,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,103.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,258.75
ofloxacin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,17478071310,NDC,5,ML,117.89,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,103.97898,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Fibrinolysins Screen - Ref,PX8539090,CDM,300,RC,85390,CPT,90,,,,,,,118,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,104.076,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.19,115.64
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338411450,NDC,50,ML,106.23,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,104.1054,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505624500,NDC,1,EA,116.99,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,104.1211,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,24208091055,NDC,3.5,GR,106.98,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,104.123634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Cryptosporidum,PX87328,CDM,300,RC,87328,CPT,,,,,,,,117,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,104.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.67,114.66
Drain Blood From Under Nail,PX11740F,CDM,510,RC,11740,CPT,,,,,,,,117,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,104.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.6018,114.66
Giardia,PX87329,CDM,300,RC,87329,CPT,,,,,,,,117,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,104.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,114.66
"In Situ Hybridization (Eg, Fish), Each Probe, Tech",PX8836501,CDM,310,RC,88365,CPT,TC,,,,,,,117,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,104.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.6018,149.22
RBC Pretreatment,PX8697002,CDM,300,RC,86970,CPT,,,,,,,,117,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,104.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.6018,114.66
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505614700,NDC,1,EA,212.52,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,104.1348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505614700,NDC,1,EA,212.52,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,104.1348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505614700,NDC,1,EA,212.52,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,104.1348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
3.0MM NON-THREADED K WIRE,27200000,CDM,272,RC,C1769,HCPCS,,12658-MAIN,LOCAL,,,,,107,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,104.1431,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Androsetenedione - Ref,PX8215790,CDM,300,RC,82157,CPT,90,,,,,,,107,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,104.1431,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.85,104.86
Decalcify Tc,PX8831101,CDM,310,RC,88311,CPT,TC,,,,,,,107,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,104.1431,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
Fac/Trim Nail(S),PX11719F,CDM,510,RC,11719,CPT,,,,,,,,107,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,21.4,percent of total billed charges,104.1431,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
Path Special Stains II,PX3979,CDM,310,RC,88313,CPT,TC,,,,,,,107,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,104.1431,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
"Special Stains,Group I",PX3978,CDM,310,RC,88312,CPT,TC,,,,,,,107,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,104.1431,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
"Non-Select. Wound Debride., W/O Anesth.; Top. Appl./Wound Assess./Instruct., per Sess.",PX97602,CDM,761,RC,97602,CPT,,,,,,,,212,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,104.16,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.28,104.16
"Non-Select. Wound Debride., W/O Anesth.; Top. Appl./Wound Assess./Instruct., per Sess.",PX97602,CDM,761,RC,97602,CPT,,,,,,,,212,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,104.16,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.28,104.16
Procalcitonin,PX84145,CDM,300,RC,84145,CPT,,,,,,,,217,,Health Partners,Health Partners Care Plans,both,48,,100.62,percent of total billed charges,104.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.96,212.66
Procalcitonin,PX84145,CDM,300,RC,84145,CPT,,,,,,,,217,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,104.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.96,212.66
TRAY 8 FR 5IN CENTESIS WITH TURKEL  30-CE1CO,120.303,CDM,272,RC,,,,11503-MAIN,LOCAL,,,,,217,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,104.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,90.1418,212.66
TRAY 8 FR 5IN CENTESIS WITH TURKEL  30-CE1CO,120.303,CDM,272,RC,,,,11503-MAIN,LOCAL,,,,,217,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,104.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,90.1418,212.66
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,781523806,NDC,1,EA,106.34,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,104.2132,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,781523864,NDC,1,EA,106.34,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,104.2132,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,65862039010,NDC,1,EA,106.34,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,104.2132,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
CT Abd & Pelvis W/O Contrast,PX7417601,CDM,350,RC,74176,CPT,TC,,,,,,,4288,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,104.2632,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.89,209.71
naloxone 2 MG/2ML solution prefilled syringe 2 mL Syringe,J2310.01,CDM,636,RC,J2310,HCPCS,,,,76329346901,NDC,1,ML,114.45,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,104.26395,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.54253,130.4968
Drainage Scrotal Wall Abscess,PX55100F,CDM,510,RC,55100,CPT,,,,,,,,634,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,104.27,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.27,482.88
Drainage Scrotal Wall Abscess,PX55100P,CDM,983,RC,55100,CPT,,,,,,,,341,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,104.27,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.27,482.88
"Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404P,CDM,983,RC,11404,CPT,,,,,,,,600,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,104.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.96,588
"Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404P,CDM,983,RC,11404,CPT,,,,,,,,600,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,104.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.96,588
"Fac/Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404F,CDM,510,RC,11404,CPT,,,,,,,,749,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,104.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.96,468.35
"Fac/Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404F,CDM,510,RC,11404,CPT,,,,,,,,749,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,104.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.96,468.35
levonorgestrel 1.5 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,62756071860,NDC,1,EA,114.48,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,104.29128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Inj,Lumb Epidur,Blood/Clot Patch",PX62273P,CDM,983,RC,62273,CPT,,,,,,,,552,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,104.3575,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.02,540.96
"Morphometric Analysis, in Situ Hybridization, Each Probe; Manual, Tech",PX8836801,CDM,310,RC,88368,CPT,TC,,,,,,,402,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,104.37,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.37,175.264
Apply Multlay Comprs Lwr Leg,PX29581F,CDM,510,RC,29581,CPT,,,,,,,,213,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,104.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.4802,208.74
Apply Multlay Comprs Lwr Leg,PX29581F,CDM,510,RC,29581,CPT,,,,,,,,213,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,104.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.4802,208.74
Apply Multlay Comprs Lwr Leg,PX29581F,CDM,510,RC,29581,CPT,,,,,,,,213,,United Healthcare,All Medicare advantage plans,outpatient,49,,112.89,percent of total billed charges,104.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.4802,208.74
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006F,CDM,510,RC,10006,CPT,,,,,,,,213,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,104.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.4802,208.74
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006F,CDM,510,RC,10006,CPT,,,,,,,,213,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,104.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.4802,208.74
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006F,CDM,510,RC,10006,CPT,,,,,,,,213,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,104.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.4802,208.74
"GI Pathogen Panel, Pcr - Ref",PX8750790,CDM,300,RC,87507,CPT,90,,,,,,,213,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,104.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.4802,382.15
"GI Pathogen Panel, Pcr - Ref",PX8750790,CDM,300,RC,87507,CPT,90,,,,,,,213,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,104.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.4802,382.15
"GI Pathogen Panel, Pcr - Ref",PX8750790,CDM,300,RC,87507,CPT,90,,,,,,,213,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,104.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.4802,382.15
"Morphometric Analysis, in Situ Hybridization, Each Probe; Manual, Tech",PX8836801,CDM,310,RC,88368,CPT,TC,,,,,,,402,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,104.37,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.37,175.264
"Morphometric Analysis, in Situ Hybridization, Each Probe; Manual, Tech",PX8836801,CDM,310,RC,88368,CPT,TC,,,,,,,402,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,104.37,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.37,175.264
Remove Impacted Ear Wax,PX69210F,CDM,510,RC,69210,CPT,,,,,,,,213,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,104.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.44,208.74
Remove Impacted Ear Wax,PX69210F,CDM,510,RC,69210,CPT,,,,,,,,213,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,104.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.44,208.74
Remove Impacted Ear Wax,PX69210F,CDM,510,RC,69210,CPT,,,,,,,,213,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,104.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.44,208.74
SPLINT ANKLE GEL BRACE UNIVERSAL AIRFORM 70351,120.61,CDM,274,RC,L4350,HCPCS,,12342-MAIN,LOCAL,,,,,88,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,104.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.5552,104.38
Immunohisto Antibody Slide Ea Addl,PX8834101,CDM,310,RC,88341,CPT,TC,,,,,,,102,,UCare,Individual and Family Plans,both,,,54.75333333,fee schedule,104.4,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.18,104.4
Immunohisto Antibody Slide Ea Addl,PX8834101,CDM,310,RC,88341,CPT,TC,,,,,,,102,,UCare,Individual and Family Plans,both,,,54.75333333,fee schedule,104.4,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.18,104.4
Bone Age Studies Tc,PX7707201,CDM,320,RC,77072,CPT,TC,,,,,,,211,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,104.445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.6494,206.78
Collect Blood From Picc,PX36592F,CDM,510,RC,36592,CPT,,,,,,,,211,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,104.445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.6494,206.78
Draw Blood Off Venous Device,PX36591F,CDM,510,RC,36591,CPT,,,,,,,,211,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,104.445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.6494,206.78
Ultrasound Breast Limited,PX7664201,CDM,402,RC,76642,CPT,TC,,,,,,,342,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,104.53,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.12,104.53
Ultrasound Breast Limited,PX7664201,CDM,402,RC,76642,CPT,TC,,,,,,,342,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,104.53,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.12,104.53
Each Add'l Hour IV Hydration,PX96361,CDM,260,RC,96361,CPT,,,,,,,,123,,First Health,Commercial,both,85,,999999999,percent of total billed charges,104.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,120.54
FLAT WOUND DRAIN WITH TROCAR 4 CHANNEL FULL FLUTED 7FR SILICONE,27200000,CDM,272,RC,,,,12473-MAIN,LOCAL,,,,,123,,First Health,Commercial,both,85,,999999999,percent of total billed charges,104.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Office/Outpt Visit,New,Levl II",PX99202F,CDM,510,RC,99202,CPT,,,,,,,,123,,First Health,Commercial,both,85,,999999999,percent of total billed charges,104.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.0942,120.54
"Office/Outpt Visit,New,Levl II",PX99202P,CDM,983,RC,99202,CPT,,,,,,,,123,,First Health,Commercial,both,85,,999999999,percent of total billed charges,104.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.0942,119.7159
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060851,NDC,100,ML,213.4,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.619455696,percent of total billed charges,104.566,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060851,NDC,100,ML,213.4,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,104.566,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060851,NDC,100,ML,213.4,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,104.566,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
"MESH PROLENE 3X6""",C1781,CDM,278,RC,C1781,HCPCS,,688-MAIN,LOCAL,,,,,213.49,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,196.035,percent of total billed charges,104.6101,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"MESH PROLENE 3X6""",C1781,CDM,278,RC,C1781,HCPCS,,688-MAIN,LOCAL,,,,,213.49,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,104.6101,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"MESH PROLENE 3X6""",C1781,CDM,278,RC,C1781,HCPCS,,688-MAIN,LOCAL,,,,,213.49,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,104.6101,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781315972,NDC,1,EA,217.96,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,104.6208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86,213.6008
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781315972,NDC,1,EA,217.96,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,104.6208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86,213.6008
adenosine 6 MG/2ML Solution 2 mL Syringe,J0153.01,CDM,636,RC,J0153,HCPCS,,,,25021030167,NDC,2,ML,123.1,,First Health,Commercial,both,85,,999999999,percent of total billed charges,104.635,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.13574,120.638
BINDER PELVIC ADULT STABILIZATION T-PODR,120.357,CDM,271,RC,A4467,HCPCS,,10734-MAIN,LOCAL,,,,,244,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,104.676,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.3576,239.12
"Bone Marrow Aspiration(S),Diag",PX38220P,CDM,983,RC,38220,CPT,,,,,,,,244,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,104.676,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.3576,1416.38
Dress/Debrid Med Burn No Anesth,PX16025P,CDM,983,RC,16025,CPT,,,,,,,,244,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,104.676,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.3576,237.4852
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601901,NDC,10,ML,211.47,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,104.67765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.844638,207.2406
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601910,NDC,10,ML,211.47,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,104.67765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.844638,207.2406
"Inject Trigger Point, 1 or 2",PX20552F,CDM,510,RC,20552,CPT,,,,,,,,252,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,104.6808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,258.75
"Level V - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3939,CDM,310,RC,88307,CPT,TC,,,,,,,252,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,104.6808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,314.02
"Off/Outpt Visit,New,Levl III",PX99203P,CDM,983,RC,99203,CPT,,,,,,,,252,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,104.6808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,245.2716
"Office/Outpt Visit,New,Levl III",PX99203F,CDM,510,RC,99203,CPT,,,,,,,,252,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,104.6808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,246.96
diclofenac 0.1 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,17478089225,NDC,2.5,ML,252.06,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,104.705724,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329330101,NDC,50,ML,107.61,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,104.736813,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Drain Finger Abscess,Simple",PX26010P,CDM,983,RC,26010,CPT,,,,,,,,207,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,104.742,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.9878,201.4731
rifAXIMin 550 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,65649030302,NDC,1,EA,218.25,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,104.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rifAXIMin 550 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,65649030302,NDC,1,EA,218.25,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,104.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rifAXIMin 550 MG Tablet 60 Each Box,63700001,CDM,250,RC,,,,,,65649030303,NDC,1,EA,218.25,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,104.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rifAXIMin 550 MG Tablet 60 Each Box,63700001,CDM,250,RC,,,,,,65649030303,NDC,1,EA,218.25,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,104.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of Triglycerides,PX84478,CDM,300,RC,84478,CPT,,,,,,,,115,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,104.765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.26,112.7
"Blood Typing, Rh Phenotype",PX86906,CDM,300,RC,86906,CPT,,,,,,,,115,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,104.765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.03,112.7
BRACE ANKLE LARGE 264015,120.51,CDM,274,RC,L1902,HCPCS,,4-MAIN,LOCAL,,,,,115,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,104.765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE MEDIUM 264014,120.51,CDM,274,RC,L1902,HCPCS,,7-MAIN,LOCAL,,,,,115,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,104.765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE SMALL 264012,120.51,CDM,274,RC,L1902,HCPCS,,12-MAIN,LOCAL,,,,,115,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,104.765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE X-LARGE 264016,120.51,CDM,274,RC,L1902,HCPCS,,14-MAIN,LOCAL,,,,,115,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,104.765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE X-SMALL 264011,120.51,CDM,274,RC,L1902,HCPCS,,1-MAIN,LOCAL,,,,,115,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,104.765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
Debride Skin/Subq Ea Ad 20sqcm,PX11045F,CDM,510,RC,11045,CPT,,,,,,,,115,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,104.765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
Glucagon - Ref,PX8294390,CDM,300,RC,82943,CPT,90,,,,,,,115,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,104.765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.1,112.7
"Immuno for Tumor Ag, Qn - Ref",PX8631690,CDM,300,RC,86316,CPT,90,,,,,,,115,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,104.765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,112.7
Microsomal Antibody,PX7893,CDM,300,RC,86376,CPT,,,,,,,,115,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,104.765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.34,112.7
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714020010,NDC,1,EA,107.64,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,104.766012,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714020030,NDC,1,EA,107.64,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,104.766012,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
sodium polystyrene sulfonate 15 GM/60ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,46287000660,NDC,60,ML,123.3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,104.805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,24208091055,NDC,3.5,GR,106.98,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,104.8404,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
3.0MM NON-THREADED K WIRE,27200000,CDM,272,RC,C1769,HCPCS,,12658-MAIN,LOCAL,,,,,107,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,104.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Androsetenedione - Ref,PX8215790,CDM,300,RC,82157,CPT,90,,,,,,,107,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,104.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.85,104.86
Decalcify Tc,PX8831101,CDM,310,RC,88311,CPT,TC,,,,,,,107,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,104.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
Fac/Trim Nail(S),PX11719F,CDM,510,RC,11719,CPT,,,,,,,,107,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,104.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
Immunofix Elp,PX86335,CDM,300,RC,86335,CPT,,,,,,,,214,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,104.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.91,209.72
Immunofix Elp,PX86335,CDM,300,RC,86335,CPT,,,,,,,,214,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,104.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.91,209.72
Immunofix Elp,PX86335,CDM,300,RC,86335,CPT,,,,,,,,214,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,104.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.91,209.72
Path Special Stains II,PX3979,CDM,310,RC,88313,CPT,TC,,,,,,,107,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,104.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
"Special Stains,Group I",PX3978,CDM,310,RC,88312,CPT,TC,,,,,,,107,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,104.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.4478,104.86
CT Orbit/Ear/Fossa W/O & W/Dye,PX7048201,CDM,350,RC,70482,CPT,TC,,,,,,,1400,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,104.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.92,309.64
CT Orbit/Ear/Fossa W/O & W/Dye,PX7048201,CDM,350,RC,70482,CPT,TC,,,,,,,1400,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,104.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.92,309.64
Duplex Up Extrem Art Bilat,PX9393001,CDM,921,RC,93930,CPT,TC,,,,,,,835,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,104.92,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.92,280.38
ofloxacin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,17478071310,NDC,5,ML,117.89,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,104.9221,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Non-Select. Wound Debride., W/O Anesth.; Top. Appl./Wound Assess./Instruct., per Sess.",PX97602,CDM,761,RC,97602,CPT,,,,,,,,212,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,104.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.0648,207.76
"Apply Short Leg Cast,Walker",PX29425P,CDM,983,RC,29425,CPT,,,,,,,,119,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,104.958,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,234.62
Creatinine; Other Source - Ref,PX82570,CDM,300,RC,82570,CPT,90,,,,,,,119,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,104.958,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,116.62
FLAT DRAIN HEMADUCT 7MM FULL DUCT WITH TROCAR SILICONE,27200000,CDM,272,RC,,,,12464-MAIN,LOCAL,,,,,119,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,104.958,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Injection, Subq/Im",PX96372,CDM,260,RC,96372,CPT,,,,,,,,119,,United Healthcare,All Payer,outpatient,88.2,,72.36391304,percent of total billed charges,104.958,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,116.62
Irri Implted Drug Dlvr Device,PX96523,CDM,260,RC,96523,CPT,,,,,,,,119,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,104.958,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,116.62
"Morphometric Analysis,Tumor Immunohistochemistry, Ea Antibody Manual , Tech",PX8836001,CDM,310,RC,88360,CPT,TC,,,,,,,119,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,104.958,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,149.22
Office/Outpt Visit Est Level I,PX99211F,CDM,510,RC,99211,CPT,,,,,,,,119,,United Healthcare,All Payer,outpatient,88.2,,104.96,percent of total billed charges,104.958,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,116.62
Office/Outpt Visit Est Level I,PX99211P,CDM,983,RC,99211,CPT,,,,,,,,119,,United Healthcare,All Payer,outpatient,88.2,,104.96,percent of total billed charges,104.958,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,115.8227
Sodium; Urine,PX84300,CDM,300,RC,84300,CPT,,,,,,,,119,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,104.958,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.64,116.62
STIFNECK ADULT,120.77,CDM,274,RC,L0180,HCPCS,,991-MAIN,LOCAL,,,,,119,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,104.958,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,486.73
STIFNECK PEDIATRIC,120.77,CDM,274,RC,L0180,HCPCS,,998-MAIN,LOCAL,,,,,119,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,104.958,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,486.73
LAPAROTOMY MAJOR I,27200000,CDM,272,RC,,,,4828-MAIN,LOCAL,,,,,123.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,104.975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Removal of Hemorrhoid Clot,PX46320F,CDM,510,RC,46320,CPT,,,,,,,,2027,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,104.9997,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.24,445.52
Removal of Hemorrhoid Clot,PX46320P,CDM,983,RC,46320,CPT,,,,,,,,374,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,104.9997,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.24,445.52
Fibrinolysins Screen - Ref,PX8539090,CDM,300,RC,85390,CPT,90,,,,,,,118,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,105.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.19,115.64
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409663724,NDC,50,ML,115.32,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,105.05652,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084252,NDC,0.5,ML,207.65,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,105.0709,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.085268,203.497
Lvl 2 Sub Hosp Mod Mdm or 35 Minute,PX99232,CDM,982,RC,99232,CPT,,,,,,,,253,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,105.0962,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.0962,246.2449
MESH FLAT SHEET SOFT 3X6 INCH,C1781,CDM,278,RC,C1781,HCPCS,,11773-MAIN,LOCAL,,,,,253,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,105.0962,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Subsequent Observation Care,PX99225,CDM,982,RC,99225,CPT,,,,,,,,253,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,105.0962,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.0962,246.2449
Tap Block Unilateral by Injection(S),PX64486F,CDM,510,RC,64486,CPT,,,,,,,,253,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,105.0962,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.0962,247.94
gentamicin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,60758018805,NDC,5,ML,107.98,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,105.096934,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Fibrinogen Activity - Ref,PX8538490,CDM,300,RC,85384,CPT,90,,,,,,,245,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,105.105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.91,240.1
"Ileoscopy Thru Stoma,Diagnostic",PX44380F,CDM,750,RC,44380,CPT,,,,,,,,245,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,105.105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.773,791.92
Lipid Profile,PX80061,CDM,300,RC,80061,CPT,,,,,,,,245,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,105.105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.28,240.1
Platelet Antibodies - Ref,PX8602290,CDM,300,RC,86022,CPT,90,,,,,,,245,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,105.105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.84,240.1
Erythropietin - Ref,PX8266890,CDM,300,RC,82668,CPT,90,,,,,,,108,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,105.1164,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,105.84
Levetiracetam - Ref,PX8017790,CDM,300,RC,80177,CPT,90,,,,,,,108,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,105.1164,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,105.84
Oxcarbazepine - Ref,PX8018390,CDM,300,RC,80183,CPT,90,,,,,,,108,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,105.1164,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,105.84
CANNULATED AO HANDLE STERILE MICA SCREW SYSTEM 57S1HNDL,27200000,CDM,272,RC,,,,12446-MAIN,LOCAL,,,,,219,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,105.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CANNULATED AO HANDLE STERILE MICA SCREW SYSTEM 57S1HNDL,27200000,CDM,272,RC,,,,12446-MAIN,LOCAL,,,,,219,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,105.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TUBE SURGICAL IRRIGATION 1PK PD-IT,27200000,CDM,272,RC,,,,12433-MAIN,LOCAL,,,,,219,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,105.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TUBE SURGICAL IRRIGATION 1PK PD-IT,27200000,CDM,272,RC,,,,12433-MAIN,LOCAL,,,,,219,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,105.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
hydrocortisone 25 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,713050306,NDC,1,EA,108.03,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,105.145599,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 25 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713050312,NDC,1,EA,108.03,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,105.145599,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
acetaZOLAMIDE 500 MG Recon Soln 1 Each Vial,J1120.01,CDM,636,RC,J1120,HCPCS,,,,39822019001,NDC,1,EA,207.84,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,105.16704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.336736,203.6832
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615900,NDC,1,EA,123.75,,First Health,Commercial,both,85,,999999999,percent of total billed charges,105.1875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615904,NDC,1,EA,123.75,,First Health,Commercial,both,85,,999999999,percent of total billed charges,105.1875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
hepatitis B immune globulin 312 UNIT/ML Solution 5 mL Vial,90371,CDM,636,RC,90371,CPT,,,,59730420301,NDC,5,ML,2851.63,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,105.19,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.19,138.3079
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505614700,NDC,1,EA,212.52,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,105.1974,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
gentamicin 0.3 % Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,17478028435,NDC,3.5,GR,219.3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,105.264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
gentamicin 0.3 % Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,17478028435,NDC,3.5,GR,219.3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,105.264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
acyclovir 50 MG/ML Solution 10 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,55150015410,NDC,10,ML,108.16,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,105.272128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.927644,105.9968
Immunoglobulin Subclasses - Ref,PX8278790,CDM,300,RC,82787,CPT,90,,,,,,,215,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,105.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.35,210.7
Immunoglobulin Subclasses - Ref,PX8278790,CDM,300,RC,82787,CPT,90,,,,,,,215,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,105.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.35,210.7
Immunoglobulin Subclasses - Ref,PX8278790,CDM,300,RC,82787,CPT,90,,,,,,,215,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,105.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.35,210.7
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001104,NDC,1,EA,108.29,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,105.398657,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
Assay of Lithium,PX80178,CDM,300,RC,80178,CPT,,,,,,,,124,,First Health,Commercial,both,85,,999999999,percent of total billed charges,105.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.06,121.52
"Complement; Antigen, Each Component",PX86160,CDM,300,RC,86160,CPT,,,,,,,,124,,First Health,Commercial,both,85,,999999999,percent of total billed charges,105.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11,121.52
"Immunoassay,Ca15-3(27.29) - Ref",PX8630090,CDM,300,RC,86300,CPT,90,,,,,,,124,,First Health,Commercial,both,85,,999999999,percent of total billed charges,105.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,121.52
Itraconazole,PX8018990,CDM,300,RC,80189,CPT,90,,,,,,,124,,First Health,Commercial,both,85,,999999999,percent of total billed charges,105.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.86,121.52
Microbe Susceptible Mic,PX87186,CDM,300,RC,87186,CPT,,,,,,,,124,,First Health,Commercial,both,85,,999999999,percent of total billed charges,105.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.93,121.52
Nocardia Susceptibility - Ref,PX8718690,CDM,300,RC,87186,CPT,90,,,,,,,124,,First Health,Commercial,both,85,,999999999,percent of total billed charges,105.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.93,121.52
Oligoclonal Bands - Ref,PX8391690,CDM,300,RC,83916,CPT,90,,,,,,,124,,First Health,Commercial,both,85,,999999999,percent of total billed charges,105.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.11,121.52
UMBILICAL VESSEL CATHETER INSERTION TRAY POLY SINGLE LUMEN 3.5/5FR,120.573,CDM,272,RC,,,,12857-MAIN,LOCAL,,,,,124,,First Health,Commercial,both,85,,999999999,percent of total billed charges,105.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.5096,121.52
Apply Multlay Comprs Lwr Leg,PX29581F,CDM,510,RC,29581,CPT,,,,,,,,213,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,105.435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.4802,208.74
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006F,CDM,510,RC,10006,CPT,,,,,,,,213,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,105.435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.4802,208.74
"GI Pathogen Panel, Pcr - Ref",PX8750790,CDM,300,RC,87507,CPT,90,,,,,,,213,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,105.435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.4802,382.15
Remove Impacted Ear Wax,PX69210F,CDM,510,RC,69210,CPT,,,,,,,,213,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,105.435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.44,208.74
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001103,NDC,1,EA,108.34,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,105.447322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329330101,NDC,50,ML,107.61,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,105.4578,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714020010,NDC,1,EA,107.64,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,105.4872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714020030,NDC,1,EA,107.64,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,105.4872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
Thyrstim Immun Glob (Tsi) - Ref,PX8444590,CDM,300,RC,84445,CPT,90,,,,,,,254,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,105.5116,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.63,248.92
KATZ EXTRACTOR OTO-RHINO FOREIGN BODY REMOVER,120.568,CDM,272,RC,,,,12808-MAIN,LOCAL,,,,,246,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,105.534,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.1884,241.08
"Morphometric Analysis, in Situ Hybridization, Each Probe; Manual, Tech",PX8836801,CDM,310,RC,88368,CPT,TC,,,,,,,402,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,105.5761,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.37,175.264
CT Orbit/Ear/Fossa W/O & W/Dye,PX7048201,CDM,350,RC,70482,CPT,TC,,,,,,,1400,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,105.58,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.92,309.64
Hepatitis a Igm Antibody,PX86709,CDM,300,RC,86709,CPT,,,,,,,,220,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,105.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.32,215.6
Hepatitis a Igm Antibody,PX86709,CDM,300,RC,86709,CPT,,,,,,,,220,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,105.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.32,215.6
"Hiv-1, Quantification - Ref",PX8753690,CDM,300,RC,87536,CPT,90,,,,,,,220,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,105.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.03,215.6
"Hiv-1, Quantification - Ref",PX8753690,CDM,300,RC,87536,CPT,90,,,,,,,220,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,105.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.03,215.6
Immunoassay Nos - Ref,PX8352090,CDM,300,RC,83520,CPT,90,,,,,,,220,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,105.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.83,215.6
Immunoassay Nos - Ref,PX8352090,CDM,300,RC,83520,CPT,90,,,,,,,220,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,105.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.83,215.6
Leptospira Antibody - Ref,PX8672090,CDM,300,RC,86720,CPT,90,,,,,,,220,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,105.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.85,215.6
Leptospira Antibody - Ref,PX8672090,CDM,300,RC,86720,CPT,90,,,,,,,220,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,105.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.85,215.6
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,781329091,NDC,50,ML,119.73,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,105.60186,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060851,NDC,100,ML,213.4,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,105.633,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
Antithrombin III Ag Assay - Ref,PX8530190,CDM,300,RC,85301,CPT,90,,,,,,,116,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,105.676,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.91,113.68
Ca 19-9,PX86301,CDM,300,RC,86301,CPT,,,,,,,,116,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,105.676,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,113.68
"MESH PROLENE 3X6""",C1781,CDM,278,RC,C1781,HCPCS,,688-MAIN,LOCAL,,,,,213.49,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,105.67755,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
ACCESSORY KIT FOR GROSHONG 16GA,120.46,CDM,272,RC,C1751,HCPCS,,2967-MAIN,LOCAL,,,,,209,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,105.754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.8186,204.82
Infection Agent Detect Dna/Rna Probe Tq 12-25,PX87507,CDM,300,RC,87507,CPT,,,,,,,,209,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,105.754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.8186,382.15
"Organic Acid, Single, Qnt - Ref",PX8392190,CDM,300,RC,83921,CPT,90,,,,,,,209,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,105.754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.45,204.82
ID Nucleic Acid Sequencing - Ref,PX8715390,CDM,300,RC,87153,CPT,90,,,,,,,265,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,105.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.77,259.7
gentamicin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,60758018805,NDC,5,ML,107.98,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,105.8204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
C-COLLAR ASPEN REGULAR 79-83365,120.25,CDM,274,RC,L0140,HCPCS,,167-MAIN,LOCAL,,,,,216,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,105.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.58,211.68
C-COLLAR ASPEN REGULAR 79-83365,120.25,CDM,274,RC,L0140,HCPCS,,167-MAIN,LOCAL,,,,,216,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,105.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.58,211.68
C-COLLAR ASPEN REGULAR 79-83365,120.25,CDM,274,RC,L0140,HCPCS,,167-MAIN,LOCAL,,,,,216,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,105.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.58,211.68
C-COLLAR ASPEN TALL 79-83367,120.25,CDM,274,RC,L0140,HCPCS,,164-MAIN,LOCAL,,,,,216,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,105.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.58,211.68
C-COLLAR ASPEN TALL 79-83367,120.25,CDM,274,RC,L0140,HCPCS,,164-MAIN,LOCAL,,,,,216,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,105.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.58,211.68
C-COLLAR ASPEN TALL 79-83367,120.25,CDM,274,RC,L0140,HCPCS,,164-MAIN,LOCAL,,,,,216,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,105.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.58,211.68
C-COLLAR ASPEN X-TALL 79-83368,120.25,CDM,274,RC,L0140,HCPCS,,168-MAIN,LOCAL,,,,,216,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,105.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.58,211.68
C-COLLAR ASPEN X-TALL 79-83368,120.25,CDM,274,RC,L0140,HCPCS,,168-MAIN,LOCAL,,,,,216,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,105.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.58,211.68
C-COLLAR ASPEN X-TALL 79-83368,120.25,CDM,274,RC,L0140,HCPCS,,168-MAIN,LOCAL,,,,,216,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,105.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.58,211.68
"Compatibility Test,Antiglob Tech",PX86922,CDM,300,RC,86922,CPT,,,,,,,,120,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,105.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.848,149.22
Erythropietin - Ref,PX8266890,CDM,300,RC,82668,CPT,90,,,,,,,108,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,105.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,105.84
KIWI OMNICUP VACUUM DELIVERY SYSTEM,120.225,CDM,272,RC,,,,11608-MAIN,LOCAL,,,,,120,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,105.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.848,117.6
Levetiracetam - Ref,PX8017790,CDM,300,RC,80177,CPT,90,,,,,,,108,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,105.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,105.84
Oxcarbazepine - Ref,PX8018390,CDM,300,RC,80183,CPT,90,,,,,,,108,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,105.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,105.84
"Remv F.B.,Eye,Embed Conjunc",PX65210P,CDM,983,RC,65210,CPT,,,,,,,,216,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,105.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,89.7264,348.08
"Remv F.B.,Eye,Embed Conjunc",PX65210P,CDM,983,RC,65210,CPT,,,,,,,,216,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,105.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,89.7264,348.08
"Remv F.B.,Eye,Embed Conjunc",PX65210P,CDM,983,RC,65210,CPT,,,,,,,,216,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,105.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,89.7264,348.08
VACUUM KIWI W/PALM PUMP,120.225,CDM,272,RC,,,,10028-MAIN,LOCAL,,,,,120,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,105.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.848,117.6
hydrocortisone 25 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,713050306,NDC,1,EA,108.03,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,105.8694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone 25 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713050312,NDC,1,EA,108.03,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,105.8694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151F,CDM,370,RC,99151,CPT,,,,,,,,176,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,105.87,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.05,105.87
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151P,CDM,983,RC,99151,CPT,,,,,,,,275,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,105.87,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.05,269.5
"Apply Short Leg Cast,Walker",PX29425P,CDM,983,RC,29425,CPT,,,,,,,,119,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,105.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,234.62
Creatinine; Other Source - Ref,PX82570,CDM,300,RC,82570,CPT,90,,,,,,,119,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,105.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,116.62
FLAT DRAIN HEMADUCT 7MM FULL DUCT WITH TROCAR SILICONE,27200000,CDM,272,RC,,,,12464-MAIN,LOCAL,,,,,119,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,105.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Injection, Subq/Im",PX96372,CDM,260,RC,96372,CPT,,,,,,,,119,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,105.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,116.62
Irri Implted Drug Dlvr Device,PX96523,CDM,260,RC,96523,CPT,,,,,,,,119,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,105.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,116.62
"Morphometric Analysis,Tumor Immunohistochemistry, Ea Antibody Manual , Tech",PX8836001,CDM,310,RC,88360,CPT,TC,,,,,,,119,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,105.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,149.22
Office/Outpt Visit Est Level I,PX99211F,CDM,510,RC,99211,CPT,,,,,,,,119,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,105.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,116.62
Office/Outpt Visit Est Level I,PX99211P,CDM,983,RC,99211,CPT,,,,,,,,119,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,105.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,115.8227
Sodium; Urine,PX84300,CDM,300,RC,84300,CPT,,,,,,,,119,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,105.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.64,116.62
STIFNECK ADULT,120.77,CDM,274,RC,L0180,HCPCS,,991-MAIN,LOCAL,,,,,119,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,105.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,486.73
STIFNECK PEDIATRIC,120.77,CDM,274,RC,L0180,HCPCS,,998-MAIN,LOCAL,,,,,119,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,105.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,486.73
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800F,CDM,510,RC,40800,CPT,,,,,,,,255,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,105.927,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.927,614.65
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106F,CDM,510,RC,11106,CPT,,,,,,,,255,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,105.927,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.927,548.67
"Inject Nerv Blck,Trigeminal",PX64400F,CDM,510,RC,64400,CPT,,,,,,,,255,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,105.927,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.927,258.75
"Urinalysis, Auto, W/Scope",PX81001,CDM,300,RC,81001,CPT,,,,,,,,255,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,105.927,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.91,249.9
Immunofix Elp,PX86335,CDM,300,RC,86335,CPT,,,,,,,,214,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,105.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.91,209.72
Drain/Inject Medium Joint/Bursa,PX20605F,CDM,510,RC,20605,CPT,,,,,,,,247,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,105.963,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.6038,258.75
acyclovir 50 MG/ML Solution 10 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,55150015410,NDC,10,ML,108.16,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,105.9968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.927644,105.9968
TRUMPET SUCTION IRRIGATION,27100000,CDM,271,RC,,,,4577-MAIN,LOCAL,,,,,116.4,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,106.0404,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,409672924,NDC,50,ML,116.43,,Medica,Commercial,both,91.1,,6.305,percent of total billed charges,106.06773,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
"RBC Sed Rate, Auto",PX85652,CDM,300,RC,85652,CPT,,,,,,,,109,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,29.69583333,percent of total billed charges,106.0897,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.48,106.82
Smear Gram Stain,PX87205,CDM,300,RC,87205,CPT,,,,,,,,109,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,89.765,percent of total billed charges,106.0897,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,106.82
Smear Wet Mount Saline/Ink,PX87210,CDM,300,RC,87210,CPT,,,,,,,,109,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,52.95,percent of total billed charges,106.0897,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.34,106.82
"West Nile Ab, Igm - Ref",PX8678890,CDM,300,RC,86788,CPT,90,,,,,,,109,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,106.0897,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.45,106.82
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001104,NDC,1,EA,108.29,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,106.1242,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001103,NDC,1,EA,108.34,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,106.1732,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
"Amputation Toe,I-P Jt",PX28825F,CDM,510,RC,28825,CPT,,,,,,,,1327,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,106.23,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.23,605.33
"Amputation Toe,I-P Jt",PX28825P,CDM,983,RC,28825,CPT,,,,,,,,780,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,106.23,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.23,764.4
Drainage Scrotal Wall Abscess,PX55100F,CDM,510,RC,55100,CPT,,,,,,,,634,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,106.23,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.27,482.88
Drainage Scrotal Wall Abscess,PX55100F,CDM,510,RC,55100,CPT,,,,,,,,634,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,106.23,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.27,482.88
Drainage Scrotal Wall Abscess,PX55100P,CDM,983,RC,55100,CPT,,,,,,,,341,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,106.23,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.27,482.88
Drainage Scrotal Wall Abscess,PX55100P,CDM,983,RC,55100,CPT,,,,,,,,341,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,106.23,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.27,482.88
Cmv Igm Antibody - Ref,PX8664590,CDM,300,RC,86645,CPT,90,,,,,,,125,,First Health,Commercial,both,85,,999999999,percent of total billed charges,106.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.45,122.5
DRESSING SURGICEL HEMOSTAT 4X8 ABSORBABLE 1952,120.123,CDM,272,RC,A6252,HCPCS,,1002-MAIN,LOCAL,,,,,125,,First Health,Commercial,both,85,,999999999,percent of total billed charges,106.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.925,122.5
Factor VII - Ref,PX8523090,CDM,300,RC,85230,CPT,90,,,,,,,125,,First Health,Commercial,both,85,,999999999,percent of total billed charges,106.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.41,122.5
AIRSEAL ROBOTIC Xi CAP AND OBTURATOR WITH BLADELESS OPTICAL TIP,27200000,CDM,272,RC,,,,12208-MAIN,LOCAL,,,,,210,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,106.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
AIRSEAL ROBOTIC Xi TRI LUMEN FILTERED TUBE SET WITH ACTIVATED CHARCOAL,27200000,CDM,272,RC,,,,12209-MAIN,LOCAL,,,,,210,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,106.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Apply Forearm Cast,PX29075F,CDM,510,RC,29075,CPT,,,,,,,,210,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,106.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,234.62
Chorionic gonadotropin test,PX84702,CDM,300,RC,84702,CPT,,,,,,,,210,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,106.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.8,205.8
"Excision of Nail Fold, Toe",PX11765F,CDM,510,RC,11765,CPT,,,,,,,,210,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,106.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,348.35
Fac/Hospital Discharge Day>30 Min,PX99239F,CDM,510,RC,99239,CPT,,,,,,,,210,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,106.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,205.8
"Inject Trigger Point, 1 or 2",PX20552P,CDM,983,RC,20552,CPT,,,,,,,,210,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,106.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,258.75
neomycin-polymyxin-dexamethasone 3.5-10000-0.1 Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,61314063136,NDC,3.5,GR,247.71,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,106.26759,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
neomycin-polymyxin-dexameth 3.5-10000-0.1 Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063006,NDC,5,ML,247.72,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,106.27188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032050,NDC,1,EA,120.51,,United Healthcare,All Payer,outpatient,88.2,,49.96,percent of total billed charges,106.28982,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618201,NDC,2,ML,120.53,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,106.30746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.068162,123.3918
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618210,NDC,2,ML,120.53,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,106.30746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.068162,123.3918
Procalcitonin,PX84145,CDM,300,RC,84145,CPT,,,,,,,,217,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,78.992,percent of total billed charges,106.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.96,212.66
Procalcitonin,PX84145,CDM,300,RC,84145,CPT,,,,,,,,217,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,106.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.96,212.66
Procalcitonin,PX84145,CDM,300,RC,84145,CPT,,,,,,,,217,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,106.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.96,212.66
TRAY 8 FR 5IN CENTESIS WITH TURKEL  30-CE1CO,120.303,CDM,272,RC,,,,11503-MAIN,LOCAL,,,,,217,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,106.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,90.1418,212.66
TRAY 8 FR 5IN CENTESIS WITH TURKEL  30-CE1CO,120.303,CDM,272,RC,,,,11503-MAIN,LOCAL,,,,,217,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,106.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,90.1418,212.66
TRAY 8 FR 5IN CENTESIS WITH TURKEL  30-CE1CO,120.303,CDM,272,RC,,,,11503-MAIN,LOCAL,,,,,217,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,106.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,90.1418,212.66
"Office/Outpt Visit,Est,Levl IV",PX99214F,CDM,510,RC,99214,CPT,,,,,,,,256,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,106.3424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.3424,250.88
"Office/Outpt Visit,Est,Levl IV",PX99214P,CDM,983,RC,99214,CPT,,,,,,,,256,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,106.3424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.3424,249.1648
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133P,CDM,983,RC,13133,CPT,,,,,,,,256,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,106.3424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.3424,249.1648
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329335201,NDC,50,ML,109.26,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,106.342758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Closed Rx Mt-Phal Toe Dislocation,PX28630P,CDM,983,RC,28630,CPT,,,,,,,,248,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,106.392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.0192,241.3784
Debride Muscle Ea Add 20 Sqcm,PX11046F,CDM,510,RC,11046,CPT,,,,,,,,248,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,106.392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.0192,243.04
Fetal Profile W/O Stress,PX7681901,CDM,402,RC,76819,CPT,TC,,,,,,,248,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,106.392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,243.04
Ther Injection Carpal Tunnel,PX20526P,CDM,983,RC,20526,CPT,,,,,,,,248,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,106.392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.0192,258.75
US Chest Tc,PX7660401,CDM,402,RC,76604,CPT,TC,,,,,,,248,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,106.392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,243.04
"West Nile Ab, Igg - Ref",PX8678990,CDM,300,RC,86789,CPT,90,,,,,,,248,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,106.392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,243.04
Immunoglobulin Subclasses - Ref,PX8278790,CDM,300,RC,82787,CPT,90,,,,,,,215,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,106.425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.35,210.7
"Layr Clos Wnd Face,Facial <2.5cm",PX12051F,CDM,510,RC,12051,CPT,,,,,,,,769,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,106.45,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.45,590.11
"Layr Clos Wnd Face,Facial <2.5cm",PX12051P,CDM,983,RC,12051,CPT,,,,,,,,615,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,106.45,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.45,602.7
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,17478062512,NDC,2.5,ML,109.45,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,106.527685,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,781329091,NDC,50,ML,119.73,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,106.5597,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU000390,CDM,300,RC,U0003,HCPCS,90,,,,,,,222,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,106.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.2188,217.56
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU000390,CDM,300,RC,U0003,HCPCS,90,,,,,,,222,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,106.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.2188,217.56
Nfct Ds Bct/Vir Respir Dna/Rna 22 Trgt Sarscov2,PX0202U,CDM,300,RC,0202U,HCPCS,,,,,,,,222,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,106.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.2188,382.15
Nfct Ds Bct/Vir Respir Dna/Rna 22 Trgt Sarscov2,PX0202U,CDM,300,RC,0202U,HCPCS,,,,,,,,222,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,106.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.2188,382.15
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505624500,NDC,1,EA,116.99,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,106.57789,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
LEGGING COMPRESSION JUXTALITE LONG LG 33CM,120.369,CDM,271,RC,A6545,HCPCS,,10840-MAIN,LOCAL,,,,,145,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,106.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.233,142.1
Cryptosporidum,PX87328,CDM,300,RC,87328,CPT,,,,,,,,117,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,106.587,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.67,114.66
Drain Blood From Under Nail,PX11740F,CDM,510,RC,11740,CPT,,,,,,,,117,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,106.587,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.6018,114.66
Giardia,PX87329,CDM,300,RC,87329,CPT,,,,,,,,117,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,106.587,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,114.66
"In Situ Hybridization (Eg, Fish), Each Probe, Tech",PX8836501,CDM,310,RC,88365,CPT,TC,,,,,,,117,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,106.587,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.6018,149.22
RBC Pretreatment,PX8697002,CDM,300,RC,86970,CPT,,,,,,,,117,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,106.587,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.6018,114.66
ammonium lactate 12 % Cream 385 g Tube,63700001,CDM,250,RC,,,,,,45802049326,NDC,385,GR,256.76,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,106.658104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
scopolamine 1 MG/3DAYS Patch 72 Hour 24 Each Box,25000000,CDM,250,RC,,,,,,50742050524,NDC,1,EA,109.59,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,106.663947,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ipratropium 0.03 % Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,24208039830,NDC,30,ML,256.9,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,106.71626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BAG LEG URINARY STND 32OZ,120.33,CDM,272,RC,A5112,HCPCS,,4433-MAIN,LOCAL,,,,,121,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,106.722,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
BAG URINARY DRAINAGE 2000ML 6300,120.33,CDM,274,RC,A4357,HCPCS,,1283-MAIN,LOCAL,,,,,121,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,106.722,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
BAG URINARY LEG PACK 9349,120.33,CDM,272,RC,A5112,HCPCS,,623-MAIN,LOCAL,,,,,121,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,106.722,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
"Chest Wall Manipulation,Initial",PX94667,CDM,410,RC,94667,CPT,,,,,,,,121,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,106.722,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.2634,118.58
"Fluor Noninfect Ab Sc, Ea - Ref",PX8625590,CDM,300,RC,86255,CPT,90,,,,,,,121,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,106.722,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.05,118.58
"Manage/Train Orthotic/Prosthetic, per 15 Min",PX97763,CDM,420,RC,97763,CPT,,,,,,,,121,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,106.722,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.36,118.58
"Prosthetic Training, Initial, Each 15 Mins",PX97761,CDM,420,RC,97761,CPT,,,,,,,,121,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,106.722,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.41,118.58
Bone Age Studies Tc,PX7707201,CDM,320,RC,77072,CPT,TC,,,,,,,211,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,106.766,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.6494,206.78
Collect Blood From Picc,PX36592F,CDM,510,RC,36592,CPT,,,,,,,,211,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,106.766,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.6494,206.78
Draw Blood Off Venous Device,PX36591F,CDM,510,RC,36591,CPT,,,,,,,,211,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,106.766,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.6494,206.78
"Compatibility Test,Antiglob Tech",PX86922,CDM,300,RC,86922,CPT,,,,,,,,120,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,106.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.848,149.22
KIWI OMNICUP VACUUM DELIVERY SYSTEM,120.225,CDM,272,RC,,,,11608-MAIN,LOCAL,,,,,120,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,106.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.848,117.6
VACUUM KIWI W/PALM PUMP,120.225,CDM,272,RC,,,,10028-MAIN,LOCAL,,,,,120,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,106.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.848,117.6
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781315972,NDC,1,EA,217.96,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,106.8004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86,213.6008
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781315972,NDC,1,EA,217.96,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,106.8004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86,213.6008
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781315972,NDC,1,EA,217.96,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,106.8004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86,213.6008
"Tiss Cult,Non-Neop Lymph - Ref",PX8823090,CDM,310,RC,88230,CPT,90,,,,,,,103,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,106.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.7862,106.81
"RBC Sed Rate, Auto",PX85652,CDM,300,RC,85652,CPT,,,,,,,,109,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,106.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.48,106.82
Smear Gram Stain,PX87205,CDM,300,RC,87205,CPT,,,,,,,,109,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,106.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.92,106.82
Smear Wet Mount Saline/Ink,PX87210,CDM,300,RC,87210,CPT,,,,,,,,109,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,106.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.34,106.82
"West Nile Ab, Igm - Ref",PX8678890,CDM,300,RC,86788,CPT,90,,,,,,,109,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,106.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.45,106.82
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081543,NDC,1,ML,479.89,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,106.83,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.83,197.744
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081552,NDC,1,ML,479.89,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,106.83,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.83,197.744
fentaNYL 50 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,406905076,NDC,1,EA,125.74,,First Health,Commercial,both,85,,999999999,percent of total billed charges,106.879,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine-epinephrine-tetracaine Gel 3 mL Syringe,J3490.160,CDM,636,RC,J3490,HCPCS,,,,88888800028,NDC,3,ML,121.19,,United Healthcare,All Payer,outpatient,88.2,,7.6225,percent of total billed charges,106.88958,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.342326,118.7662
amiodarone 150-4.21 MG/100ML-% Solution 100 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066015010,NDC,100,ML,249.22,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,106.91538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.35,318.745
C-COLLAR ASPEN REGULAR 79-83365,120.25,CDM,274,RC,L0140,HCPCS,,167-MAIN,LOCAL,,,,,216,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,106.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.58,211.68
C-COLLAR ASPEN TALL 79-83367,120.25,CDM,274,RC,L0140,HCPCS,,164-MAIN,LOCAL,,,,,216,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,106.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.58,211.68
C-COLLAR ASPEN X-TALL 79-83368,120.25,CDM,274,RC,L0140,HCPCS,,168-MAIN,LOCAL,,,,,216,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,106.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.58,211.68
"Remv F.B.,Eye,Embed Conjunc",PX65210P,CDM,983,RC,65210,CPT,,,,,,,,216,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,106.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,89.7264,348.08
rifAXIMin 550 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,65649030302,NDC,1,EA,218.25,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,106.9425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rifAXIMin 550 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,65649030302,NDC,1,EA,218.25,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,106.9425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rifAXIMin 550 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,65649030302,NDC,1,EA,218.25,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,106.9425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rifAXIMin 550 MG Tablet 60 Each Box,63700001,CDM,250,RC,,,,,,65649030303,NDC,1,EA,218.25,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,106.9425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rifAXIMin 550 MG Tablet 60 Each Box,63700001,CDM,250,RC,,,,,,65649030303,NDC,1,EA,218.25,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,106.9425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rifAXIMin 550 MG Tablet 60 Each Box,63700001,CDM,250,RC,,,,,,65649030303,NDC,1,EA,218.25,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,106.9425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601901,NDC,10,ML,211.47,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,107.00382,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.844638,207.2406
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601910,NDC,10,ML,211.47,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,107.00382,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.844638,207.2406
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052331,NDC,2,ML,125.89,,First Health,Commercial,both,85,,999999999,percent of total billed charges,107.0065,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.294706,123.3722
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052341,NDC,2,ML,125.89,,First Health,Commercial,both,85,,999999999,percent of total billed charges,107.0065,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.294706,123.3722
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,17478053802,NDC,2,ML,125.91,,First Health,Commercial,both,85,,999999999,percent of total billed charges,107.0235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.068162,123.3918
"Apply Forearm Splint,Static",PX29125F,CDM,510,RC,29125,CPT,,,,,,,,223,,Health Partners,Health Partners Care Plans,both,48,,251.72,percent of total billed charges,107.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,218.54
"Apply Forearm Splint,Static",PX29125F,CDM,510,RC,29125,CPT,,,,,,,,223,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,107.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,218.54
"Flow Cyto, Tech, 1st Mrkr - Ref",PX8818490,CDM,310,RC,88184,CPT,90,,,,,,,223,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,107.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,314.02
"Flow Cyto, Tech, 1st Mrkr - Ref",PX8818490,CDM,310,RC,88184,CPT,90,,,,,,,223,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,107.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,314.02
"Nephelometry, Each, Nos - Ref",PX8388390,CDM,300,RC,83883,CPT,90,,,,,,,223,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,107.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.47,218.54
"Nephelometry, Each, Nos - Ref",PX8388390,CDM,300,RC,83883,CPT,90,,,,,,,223,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,107.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.47,218.54
Art Lower Extremity+Upper,PX9392301,CDM,921,RC,93923,CPT,TC,,,,,,,784,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,107.0595,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.67,190.22
Hosp Manage Cont Drug Admin,PX01996.01,CDM,964,RC,1996,CPT,QZ,,,,,,,36,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,107.06,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.69,107.06
"Acylcarnitines, Quant - Ref",PX8201790,CDM,300,RC,82017,CPT,90,,,,,,,110,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,107.063,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.47,107.8
"Assay Calcium, Ionized",PX82330,CDM,300,RC,82330,CPT,,,,,,,,110,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,107.063,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.54,107.8
BONE MARROW BIOPSY ASPIRATION NEEDLE 11G X 4 IN,120.562,CDM,272,RC,C1830,HCPCS,,12677-MAIN,LOCAL,,,,,110,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,107.063,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.694,107.8
K-WIRE 0.9X150MM BLUNT/TROCAR DART-FIRE STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12449-MAIN,LOCAL,,,,,110,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,107.063,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRE 0.9X150MM BLUNT/TROCAR STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12452-MAIN,LOCAL,,,,,110,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,107.063,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRE 1.4X150MM BLUNT/TROCAR DART-FIRE STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12450-MAIN,LOCAL,,,,,110,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,107.063,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRE 1.4X150MM BLUNT/TROCAR STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12451-MAIN,LOCAL,,,,,110,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,107.063,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA 2.0MM TARGETING GUIDE PIN,27200000,CDM,272,RC,,,,12436-MAIN,LOCAL,,,,,110,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,107.063,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Strapping of Shoulder,PX29240P,CDM,983,RC,29240,CPT,,,,,,,,110,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,107.063,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.694,111.6
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329335201,NDC,50,ML,109.26,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,107.0748,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Fac/Hospital Discharge Day>30 Min,PX99239F,CDM,510,RC,99239,CPT,,,,,,,,210,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,107.0928,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.8,203.32
Hospital Discharge Day>30 Min,PX99239P,CDM,982,RC,99239,CPT,,,,,,,,140,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,107.0928,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.8,203.32
Duplex Up Extrem Art Bilat,PX9393001,CDM,921,RC,93930,CPT,TC,,,,,,,835,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,107.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.92,280.38
Duplex Up Extrem Art Bilat,PX9393001,CDM,921,RC,93930,CPT,TC,,,,,,,835,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,107.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.92,280.38
"Supply Technicium Sestamibi,per Dose",PXA9500,CDM,343,RC,A9500,HCPCS,,,,,,,,410,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,107.1,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.1,121.7
Thrombin Time Plasma,PX85670,CDM,300,RC,85670,CPT,,,,,,,,126,,First Health,Commercial,both,85,,999999999,percent of total billed charges,107.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.29,123.48
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010602,NDC,50,ML,126.07,,First Health,Commercial,both,85,,999999999,percent of total billed charges,107.1595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010605,NDC,50,ML,126.07,,First Health,Commercial,both,85,,999999999,percent of total billed charges,107.1595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
nitroglycerin in dextrose 5% 100-5 MCG/ML-% Solution 250 mL Glass Cont,J2305.01,CDM,636,RC,J2305,HCPCS,,,,338104702,NDC,250,ML,126.07,,First Health,Commercial,both,85,,999999999,percent of total billed charges,107.1595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.17,123.5486
"Needle Biopsy,Muscle",PX20206F,CDM,510,RC,20206,CPT,,,,,,,,258,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,107.1732,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.1732,1416.38
levOCARNitine 200 MG/ML Solution 5 mL Vial,J1955.01,CDM,636,RC,J1955,HCPCS,,,,517104501,NDC,5,ML,249.86,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,107.18994,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.791844,244.8628
DERMABOND MINI SKIN ADHESIVE,27200000,CDM,272,RC,,,,8532-MAIN,LOCAL,,,,,110.16,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,107.218728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Drain/Inject Med Joint/Brusa W/US Guide,PX20606F,CDM,510,RC,20606,CPT,,,,,,,,387,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,107.23,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.85,187.48
Drain/Inject Med Joint/Brusa W/US Guide,PX20606P,CDM,983,RC,20606,CPT,,,,,,,,309,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,107.23,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.85,302.82
"Inject Nerv Blck,Trigeminal",PX64400F,CDM,510,RC,64400,CPT,,,,,,,,255,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,107.23,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.1,236.6
"Inject Nerv Blck,Trigeminal",PX64400P,CDM,983,RC,64400,CPT,,,,,,,,170,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,107.23,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.1,236.6
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153P,CDM,983,RC,99153,CPT,,,,,,,,250,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,107.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.85,243.325
sincalide 5 MCG Recon Soln 1 Each Vial,J2805.01,CDM,636,RC,J2805,HCPCS,,,,270055615,NDC,1,EA,250,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,107.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.85,245
Withdrawal of Arterial Blood,PX36600F,CDM,510,RC,36600,CPT,,,,,,,,250,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,107.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.85,245
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032050,NDC,1,EA,120.51,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,107.2539,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,17478062512,NDC,2.5,ML,109.45,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,107.261,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618201,NDC,2,ML,120.53,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,107.2717,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.068162,123.3918
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618210,NDC,2,ML,120.53,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,107.2717,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.068162,123.3918
"Non-Select. Wound Debride., W/O Anesth.; Top. Appl./Wound Assess./Instruct., per Sess.",PX97602,CDM,761,RC,97602,CPT,,,,,,,,212,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,107.272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.0648,207.76
dexmedeTOMIDine in  dextrose 200MCG/50ML -5% Solution 50 mL Flex Cont,25000000,CDM,250,RC,,,,,,44567060224,NDC,50,ML,258.31,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,107.301974,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,68462015740,NDC,1,EA,110.25,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,107.306325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,68462015713,NDC,1,EA,110.25,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,107.306325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
CANNULATED AO HANDLE STERILE MICA SCREW SYSTEM 57S1HNDL,27200000,CDM,272,RC,,,,12446-MAIN,LOCAL,,,,,219,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,107.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CANNULATED AO HANDLE STERILE MICA SCREW SYSTEM 57S1HNDL,27200000,CDM,272,RC,,,,12446-MAIN,LOCAL,,,,,219,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,107.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CANNULATED AO HANDLE STERILE MICA SCREW SYSTEM 57S1HNDL,27200000,CDM,272,RC,,,,12446-MAIN,LOCAL,,,,,219,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,107.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TUBE SURGICAL IRRIGATION 1PK PD-IT,27200000,CDM,272,RC,,,,12433-MAIN,LOCAL,,,,,219,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,107.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TUBE SURGICAL IRRIGATION 1PK PD-IT,27200000,CDM,272,RC,,,,12433-MAIN,LOCAL,,,,,219,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,107.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TUBE SURGICAL IRRIGATION 1PK PD-IT,27200000,CDM,272,RC,,,,12433-MAIN,LOCAL,,,,,219,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,107.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Amputation Toe,I-P Jt",PX28825F,CDM,510,RC,28825,CPT,,,,,,,,1327,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,107.32,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.23,605.33
"Amputation Toe,I-P Jt",PX28825F,CDM,510,RC,28825,CPT,,,,,,,,1327,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,107.32,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.23,605.33
"Amputation Toe,I-P Jt",PX28825P,CDM,983,RC,28825,CPT,,,,,,,,780,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,107.32,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.23,764.4
"Amputation Toe,I-P Jt",PX28825P,CDM,983,RC,28825,CPT,,,,,,,,780,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,107.32,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.23,764.4
"Layr Clos Wnd Face,Facial <2.5cm",PX12051F,CDM,510,RC,12051,CPT,,,,,,,,769,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,107.32,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.45,590.11
"Layr Clos Wnd Face,Facial <2.5cm",PX12051F,CDM,510,RC,12051,CPT,,,,,,,,769,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,107.32,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.45,590.11
"Layr Clos Wnd Face,Facial <2.5cm",PX12051P,CDM,983,RC,12051,CPT,,,,,,,,615,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,107.32,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.45,602.7
"Layr Clos Wnd Face,Facial <2.5cm",PX12051P,CDM,983,RC,12051,CPT,,,,,,,,615,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,107.32,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.45,602.7
Removal of Anal Tabs,PX46230F,CDM,510,RC,46230,CPT,,,,,,,,790,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,107.32,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.32,652.37
Removal of Anal Tabs,PX46230P,CDM,983,RC,46230,CPT,,,,,,,,1435,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,107.32,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.32,1406.3
ofloxacin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,17478071310,NDC,5,ML,117.89,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,107.39779,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
scopolamine 1 MG/3DAYS Patch 72 Hour 24 Each Box,25000000,CDM,250,RC,,,,,,50742050524,NDC,1,EA,109.59,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,107.3982,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Procalcitonin,PX84145,CDM,300,RC,84145,CPT,,,,,,,,217,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,107.415,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.96,212.66
TRAY 8 FR 5IN CENTESIS WITH TURKEL  30-CE1CO,120.303,CDM,272,RC,,,,11503-MAIN,LOCAL,,,,,217,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,107.415,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,90.1418,212.66
pegfilgrastim-cbqv 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5111.01,CDM,636,RC,Q5111,HCPCS,,,,70114010101,NDC,0.6,ML,10040,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,107.45,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.45,135.48
gentamicin 0.3 % Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,17478028435,NDC,3.5,GR,219.3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,107.457,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
gentamicin 0.3 % Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,17478028435,NDC,3.5,GR,219.3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,107.457,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
gentamicin 0.3 % Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,17478028435,NDC,3.5,GR,219.3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,107.457,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Fibrinolysins Screen - Ref,PX8539090,CDM,300,RC,85390,CPT,90,,,,,,,118,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,107.498,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.19,115.64
IV 0.9% NS 1000ML 2B1324X,27200000,CDM,272,RC,,,,538-MAIN,LOCAL,,,,,121.89,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,107.50698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Package,25000000,CDM,250,RC,,,,,,10019055390,NDC,1,EA,121.9,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,107.5158,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Body Fluid Cell Count W Diff,PX89051,CDM,300,RC,89051,CPT,,,,,,,,224,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,107.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.13,219.52
Body Fluid Cell Count W Diff,PX89051,CDM,300,RC,89051,CPT,,,,,,,,224,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,107.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.13,219.52
ENDOWRIST INSTRUMENTS PERMANENT CAUTERY HOOK 8MM,27200000,CDM,272,RC,,,,12050-MAIN,LOCAL,,,,,224,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,107.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ENDOWRIST INSTRUMENTS PERMANENT CAUTERY HOOK 8MM,27200000,CDM,272,RC,,,,12050-MAIN,LOCAL,,,,,224,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,107.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Helicobacter Pylori Ab,PX86677,CDM,300,RC,86677,CPT,,,,,,,,224,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,107.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.45,219.52
Helicobacter Pylori Ab,PX86677,CDM,300,RC,86677,CPT,,,,,,,,224,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,107.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.45,219.52
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505614700,NDC,1,EA,212.52,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,107.53512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
Acth - Ref,PX8202490,CDM,300,RC,82024,CPT,90,,,,,,,259,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,107.5886,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.41,253.82
"IV Push, Single/1st Drug",PX96374,CDM,260,RC,96374,CPT,,,,,,,,259,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,107.5886,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.5886,253.82
Assay of Iron,PX83540,CDM,300,RC,83540,CPT,,,,,,,,122,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,107.604,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,119.56
"Compliment, Total (Ch50) - Ref",PX8616290,CDM,300,RC,86162,CPT,90,,,,,,,122,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,107.604,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.63,119.56
Vitamin B-12,PX82607,CDM,300,RC,82607,CPT,,,,,,,,122,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,107.604,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.83,119.56
LIGACLIP APPLIER CLIP STERILE SIZE MEDIUM LARGE,27200000,CDM,272,RC,,,,11699-MAIN,LOCAL,,,,,126.62,,First Health,Commercial,both,85,,999999999,percent of total billed charges,107.627,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
BAG LEG URINARY STND 32OZ,120.33,CDM,272,RC,A5112,HCPCS,,4433-MAIN,LOCAL,,,,,121,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,107.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
BAG URINARY DRAINAGE 2000ML 6300,120.33,CDM,274,RC,A4357,HCPCS,,1283-MAIN,LOCAL,,,,,121,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,107.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
BAG URINARY LEG PACK 9349,120.33,CDM,272,RC,A5112,HCPCS,,623-MAIN,LOCAL,,,,,121,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,107.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
"Chest Wall Manipulation,Initial",PX94667,CDM,410,RC,94667,CPT,,,,,,,,121,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,107.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.2634,118.58
"Fluor Noninfect Ab Sc, Ea - Ref",PX8625590,CDM,300,RC,86255,CPT,90,,,,,,,121,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,107.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.05,118.58
"Manage/Train Orthotic/Prosthetic, per 15 Min",PX97763,CDM,420,RC,97763,CPT,,,,,,,,121,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,107.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.36,118.58
"Prosthetic Training, Initial, Each 15 Mins",PX97761,CDM,420,RC,97761,CPT,,,,,,,,121,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,107.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.41,118.58
gentamicin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063305,NDC,5,ML,122.17,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,107.75394,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Apply Multlay Comprs Lwr Leg,PX29581F,CDM,510,RC,29581,CPT,,,,,,,,213,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,107.778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.4802,208.74
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006F,CDM,510,RC,10006,CPT,,,,,,,,213,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,107.778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.4802,208.74
"GI Pathogen Panel, Pcr - Ref",PX8750790,CDM,300,RC,87507,CPT,90,,,,,,,213,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,107.778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.4802,382.15
Remove Impacted Ear Wax,PX69210F,CDM,510,RC,69210,CPT,,,,,,,,213,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,107.778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.44,208.74
"Acylcarnitines, Quant - Ref",PX8201790,CDM,300,RC,82017,CPT,90,,,,,,,110,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,107.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.47,107.8
"Assay Calcium, Ionized",PX82330,CDM,300,RC,82330,CPT,,,,,,,,110,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,107.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.54,107.8
BONE MARROW BIOPSY ASPIRATION NEEDLE 11G X 4 IN,120.562,CDM,272,RC,C1830,HCPCS,,12677-MAIN,LOCAL,,,,,110,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,107.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.694,107.8
Glycosylated Hemoglobin Test,PX83036,CDM,300,RC,83036,CPT,,,,,,,,110,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,107.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.9,130.9
Hepatitis a Igm Antibody,PX86709,CDM,300,RC,86709,CPT,,,,,,,,220,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,107.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.32,215.6
Hepatitis a Igm Antibody,PX86709,CDM,300,RC,86709,CPT,,,,,,,,220,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,107.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.32,215.6
Hepatitis a Igm Antibody,PX86709,CDM,300,RC,86709,CPT,,,,,,,,220,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,107.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.32,215.6
"Hiv-1, Quantification - Ref",PX8753690,CDM,300,RC,87536,CPT,90,,,,,,,220,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,107.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.03,215.6
"Hiv-1, Quantification - Ref",PX8753690,CDM,300,RC,87536,CPT,90,,,,,,,220,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,107.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.03,215.6
"Hiv-1, Quantification - Ref",PX8753690,CDM,300,RC,87536,CPT,90,,,,,,,220,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,107.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.03,215.6
Immunoassay Nos - Ref,PX8352090,CDM,300,RC,83520,CPT,90,,,,,,,220,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,107.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.83,215.6
Immunoassay Nos - Ref,PX8352090,CDM,300,RC,83520,CPT,90,,,,,,,220,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,107.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.83,215.6
Immunoassay Nos - Ref,PX8352090,CDM,300,RC,83520,CPT,90,,,,,,,220,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,107.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.83,215.6
K-WIRE 0.9X150MM BLUNT/TROCAR DART-FIRE STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12449-MAIN,LOCAL,,,,,110,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,107.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRE 0.9X150MM BLUNT/TROCAR STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12452-MAIN,LOCAL,,,,,110,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,107.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRE 1.4X150MM BLUNT/TROCAR DART-FIRE STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12450-MAIN,LOCAL,,,,,110,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,107.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
K-WIRE 1.4X150MM BLUNT/TROCAR STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12451-MAIN,LOCAL,,,,,110,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,107.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Leptospira Antibody - Ref,PX8672090,CDM,300,RC,86720,CPT,90,,,,,,,220,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,107.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.85,215.6
Leptospira Antibody - Ref,PX8672090,CDM,300,RC,86720,CPT,90,,,,,,,220,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,107.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.85,215.6
Leptospira Antibody - Ref,PX8672090,CDM,300,RC,86720,CPT,90,,,,,,,220,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,107.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.85,215.6
MICA 2.0MM TARGETING GUIDE PIN,27200000,CDM,272,RC,,,,12436-MAIN,LOCAL,,,,,110,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,107.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Strapping of Shoulder,PX29240P,CDM,983,RC,29240,CPT,,,,,,,,110,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,107.8,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.12,107.8
Emergency Level V Visit,PX99285P,CDM,981,RC,99285,CPT,,,,,,,,1436,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,107.81,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.81,1407.28
Facility Emergency Level V Visit,PX99285F,CDM,450,RC,99285,CPT,,,,,,,,1464,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,107.81,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.81,310.96
pegfilgrastim 6 MG/0.6ML Prefilled Syringe Kit 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019201,NDC,0.6,ML,13092.7,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,107.83384,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.59,109.75
pegfilgrastim 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019001,NDC,0.6,ML,12711.36,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,107.83384,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.59,109.75
lidocaine-epinephrine-tetracaine Gel 3 mL Syringe,J3490.160,CDM,636,RC,J3490,HCPCS,,,,88888800028,NDC,3,ML,121.19,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,107.8591,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.342326,118.7662
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781315972,NDC,1,EA,217.96,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,107.8902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86,213.6008
B-Scan Global,PX7651201,CDM,402,RC,76512,CPT,TC,,,,,,,127,,First Health,Commercial,both,85,,999999999,percent of total billed charges,107.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.7558,124.46
Candida Dna Dir Probe,PX87480,CDM,300,RC,87480,CPT,,,,,,,,127,,First Health,Commercial,both,85,,999999999,percent of total billed charges,107.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.38,124.46
Gardner Vag Dna Dir Probe,PX87510,CDM,300,RC,87510,CPT,,,,,,,,127,,First Health,Commercial,both,85,,999999999,percent of total billed charges,107.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.38,124.46
Influenza Assay W/Optic,PX87804,CDM,300,RC,87804,CPT,,,,,,,,127,,First Health,Commercial,both,85,,999999999,percent of total billed charges,107.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.17,124.46
Trichomonas Vagin Dir Probe,PX87660,CDM,300,RC,87660,CPT,,,,,,,,127,,First Health,Commercial,both,85,,999999999,percent of total billed charges,107.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.38,124.46
DERMABOND MINI SKIN ADHESIVE,27200000,CDM,272,RC,,,,8532-MAIN,LOCAL,,,,,110.16,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,107.9568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060851,NDC,100,ML,213.4,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,107.9804,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
"Cytoflo, Cell or Dna Anal - Ref",PX8818290,CDM,310,RC,88182,CPT,90,,,,,,,225,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,108,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,220.5
"Cytoflo, Cell or Dna Anal - Ref",PX8818290,CDM,310,RC,88182,CPT,90,,,,,,,225,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,108,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,220.5
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153F,CDM,370,RC,99153,CPT,,,,,,,,225,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,108,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.465,220.5
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153F,CDM,370,RC,99153,CPT,,,,,,,,225,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,108,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.465,220.5
Blood Clot Factor V Test,PX85220,CDM,300,RC,85220,CPT,,,,,,,,260,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,108.004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.18,254.8
"Closed Rx Toe Fx,Manipulatn",PX28515P,CDM,983,RC,28515,CPT,,,,,,,,260,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,108.004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.004,253.058
First Hour IV Hydration <1 Hour,PX96360,CDM,260,RC,96360,CPT,,,,,,,,260,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,108.004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.004,254.8
"MESH PROLENE 3X6""",C1781,CDM,278,RC,C1781,HCPCS,,688-MAIN,LOCAL,,,,,213.49,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,108.02594,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
rifAXIMin 550 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,65649030302,NDC,1,EA,218.25,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,108.03375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rifAXIMin 550 MG Tablet 60 Each Box,63700001,CDM,250,RC,,,,,,65649030303,NDC,1,EA,218.25,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,108.03375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,68462015740,NDC,1,EA,110.25,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,108.045,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,68462015713,NDC,1,EA,110.25,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,108.045,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028401,NDC,1,EA,111.01,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,12.385,percent of total billed charges,108.046033,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028420,NDC,1,EA,111.01,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,12.385,percent of total billed charges,108.046033,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
albuterol (5 MG/ML) 0.5% Nebulization Solution 20 mL Bottle,J7611.01,CDM,250,RC,,,,,,50383074120,NDC,20,ML,225.2,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,108.096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.54808,220.696
albuterol (5 MG/ML) 0.5% Nebulization Solution 20 mL Bottle,J7611.01,CDM,250,RC,,,,,,50383074120,NDC,20,ML,225.2,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,108.096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.54808,220.696
"Inject Trigger Point, 1 or 2",PX20552F,CDM,510,RC,20552,CPT,,,,,,,,252,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,108.108,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,258.75
"Level V - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3939,CDM,310,RC,88307,CPT,TC,,,,,,,252,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,108.108,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,314.02
"Off/Outpt Visit,New,Levl III",PX99203P,CDM,983,RC,99203,CPT,,,,,,,,252,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,108.108,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,245.2716
"Office/Outpt Visit,New,Levl III",PX99203F,CDM,510,RC,99203,CPT,,,,,,,,252,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,108.108,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,246.96
diclofenac 0.1 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,17478089225,NDC,2.5,ML,252.06,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,108.13374,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
SPLINT ANKLE GEL BRACE UNIVERSAL AIRFORM 70351,120.61,CDM,274,RC,L4350,HCPCS,,12342-MAIN,LOCAL,,,,,88,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,108.15,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.15,113.84
Removal of Anal Tabs,PX46230F,CDM,510,RC,46230,CPT,,,,,,,,790,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,108.2,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.32,652.37
Removal of Anal Tabs,PX46230F,CDM,510,RC,46230,CPT,,,,,,,,790,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,108.2,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.32,652.37
Removal of Anal Tabs,PX46230P,CDM,983,RC,46230,CPT,,,,,,,,1435,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,108.2,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.32,1406.3
Removal of Anal Tabs,PX46230P,CDM,983,RC,46230,CPT,,,,,,,,1435,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,108.2,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.32,1406.3
Immunofix Elp,PX86335,CDM,300,RC,86335,CPT,,,,,,,,214,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,108.284,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.91,209.72
Remove Impacted Ear Wax,PX69210P,CDM,983,RC,69210,CPT,,,,,,,,221,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,108.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.44,215.0993
Remove Impacted Ear Wax,PX69210P,CDM,983,RC,69210,CPT,,,,,,,,221,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,108.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.44,215.0993
Remove Impacted Ear Wax,PX69210P,CDM,983,RC,69210,CPT,,,,,,,,221,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,108.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.44,215.0993
CANNULATED AO HANDLE STERILE MICA SCREW SYSTEM 57S1HNDL,27200000,CDM,272,RC,,,,12446-MAIN,LOCAL,,,,,219,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,108.405,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TUBE SURGICAL IRRIGATION 1PK PD-IT,27200000,CDM,272,RC,,,,12433-MAIN,LOCAL,,,,,219,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,108.405,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Apply Short Leg Cast,Walker",PX29425P,CDM,983,RC,29425,CPT,,,,,,,,119,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,108.409,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,234.62
Creatinine; Other Source - Ref,PX82570,CDM,300,RC,82570,CPT,90,,,,,,,119,,Medica,Commercial,both,91.1,,51.05,percent of total billed charges,108.409,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,116.62
FLAT DRAIN HEMADUCT 7MM FULL DUCT WITH TROCAR SILICONE,27200000,CDM,272,RC,,,,12464-MAIN,LOCAL,,,,,119,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,108.409,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Injection, Subq/Im",PX96372,CDM,260,RC,96372,CPT,,,,,,,,119,,Medica,Commercial,both,91.1,,17.036,percent of total billed charges,108.409,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,116.62
Irri Implted Drug Dlvr Device,PX96523,CDM,260,RC,96523,CPT,,,,,,,,119,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,108.409,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,116.62
"Morphometric Analysis,Tumor Immunohistochemistry, Ea Antibody Manual , Tech",PX8836001,CDM,310,RC,88360,CPT,TC,,,,,,,119,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,108.409,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,149.22
Office/Outpt Visit Est Level I,PX99211F,CDM,510,RC,99211,CPT,,,,,,,,119,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,108.409,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,116.62
Office/Outpt Visit Est Level I,PX99211P,CDM,983,RC,99211,CPT,,,,,,,,119,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,108.409,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,115.8227
Sodium; Urine,PX84300,CDM,300,RC,84300,CPT,,,,,,,,119,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,108.409,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.64,116.62
STIFNECK ADULT,120.77,CDM,274,RC,L0180,HCPCS,,991-MAIN,LOCAL,,,,,119,,Medica,Commercial,both,91.1,,1.01,percent of total billed charges,108.409,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,486.73
STIFNECK PEDIATRIC,120.77,CDM,274,RC,L0180,HCPCS,,998-MAIN,LOCAL,,,,,119,,Medica,Commercial,both,91.1,,1.01,percent of total billed charges,108.409,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,486.73
IV 0.9% NS 1000ML 2B1324X,27200000,CDM,272,RC,,,,538-MAIN,LOCAL,,,,,121.89,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,108.4821,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Each Add'l Hour IV Hydration,PX96361,CDM,260,RC,96361,CPT,,,,,,,,123,,United Healthcare,All Payer,outpatient,88.2,,79.726,percent of total billed charges,108.486,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,120.54
FLAT WOUND DRAIN WITH TROCAR 4 CHANNEL FULL FLUTED 7FR SILICONE,27200000,CDM,272,RC,,,,12473-MAIN,LOCAL,,,,,123,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,108.486,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Office/Outpt Visit,New,Levl II",PX99202F,CDM,510,RC,99202,CPT,,,,,,,,123,,United Healthcare,All Payer,outpatient,88.2,,53.025,percent of total billed charges,108.486,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.0942,120.54
"Office/Outpt Visit,New,Levl II",PX99202P,CDM,983,RC,99202,CPT,,,,,,,,123,,United Healthcare,All Payer,outpatient,88.2,,53.025,percent of total billed charges,108.486,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.0942,119.7159
Fresh Frozen Plasma,PXP9017,CDM,390,RC,P9017,HCPCS,,,,,,,,319,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,108.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.49,182.176
Fresh Frozen Plasma,PXP9017,CDM,390,RC,P9017,HCPCS,,,,,,,,319,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,108.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.49,182.176
Fresh Frozen Plasma,PXP9017,CDM,390,RC,P9017,HCPCS,,,,,,,,319,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,108.49,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.49,182.176
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Package,25000000,CDM,250,RC,,,,,,10019055390,NDC,1,EA,121.9,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,108.491,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Lvl 2 Sub Hosp Mod Mdm or 35 Minute,PX99232,CDM,982,RC,99232,CPT,,,,,,,,253,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,108.537,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.0962,246.2449
MESH FLAT SHEET SOFT 3X6 INCH,C1781,CDM,278,RC,C1781,HCPCS,,11773-MAIN,LOCAL,,,,,253,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,108.537,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Subsequent Observation Care,PX99225,CDM,982,RC,99225,CPT,,,,,,,,253,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,108.537,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.0962,246.2449
Tap Block Unilateral by Injection(S),PX64486F,CDM,510,RC,64486,CPT,,,,,,,,253,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,108.537,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.0962,247.94
gentamicin 0.3 % Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,17478028435,NDC,3.5,GR,219.3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,108.5535,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
adenosine 6 MG/2ML Solution 2 mL Syringe,J0153.01,CDM,636,RC,J0153,HCPCS,,,,25021030167,NDC,2,ML,123.1,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,108.5742,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.13574,120.638
Assay of Iron,PX83540,CDM,300,RC,83540,CPT,,,,,,,,122,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,108.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,119.56
"Compliment, Total (Ch50) - Ref",PX8616290,CDM,300,RC,86162,CPT,90,,,,,,,122,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,108.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.63,119.56
Vitamin B-12,PX82607,CDM,300,RC,82607,CPT,,,,,,,,122,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,108.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.83,119.56
fluorouracil 5 GM/100ML Solution 100 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,16729027638,NDC,100,ML,261.44,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,108.602176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,256.2112
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047625,NDC,0.769230769,ML,111.59,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,108.610547,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.354486,332.1514
Lvl 3 Init Hosp High Mdm or 75 Minutes,PX99223,CDM,982,RC,99223,CPT,,,,,,,,536,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,108.68,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.68,525.28
gentamicin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063305,NDC,5,ML,122.17,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,108.7313,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046204,NDC,30,ML,127.94,,First Health,Commercial,both,85,,999999999,percent of total billed charges,108.749,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium polystyrene sulfonate 15 GM/60ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,46287000660,NDC,60,ML,123.3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,108.7506,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU000390,CDM,300,RC,U0003,HCPCS,90,,,,,,,222,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,108.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.2188,217.56
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU000390,CDM,300,RC,U0003,HCPCS,90,,,,,,,222,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,108.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.2188,217.56
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU000390,CDM,300,RC,U0003,HCPCS,90,,,,,,,222,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,108.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.2188,217.56
Nfct Ds Bct/Vir Respir Dna/Rna 22 Trgt Sarscov2,PX0202U,CDM,300,RC,0202U,HCPCS,,,,,,,,222,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,108.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.2188,382.15
Nfct Ds Bct/Vir Respir Dna/Rna 22 Trgt Sarscov2,PX0202U,CDM,300,RC,0202U,HCPCS,,,,,,,,222,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,108.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.2188,382.15
Nfct Ds Bct/Vir Respir Dna/Rna 22 Trgt Sarscov2,PX0202U,CDM,300,RC,0202U,HCPCS,,,,,,,,222,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,108.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.2188,382.15
Observation Care Discharge,PX99217,CDM,982,RC,99217,CPT,,,,,,,,222,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,108.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.2188,216.0726
Observation Care Discharge,PX99217,CDM,982,RC,99217,CPT,,,,,,,,222,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,108.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.2188,216.0726
Observation Care Discharge,PX99217,CDM,982,RC,99217,CPT,,,,,,,,222,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,108.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.2188,216.0726
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028401,NDC,1,EA,111.01,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,108.7898,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028420,NDC,1,EA,111.01,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,108.7898,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
Immunoglobulin Subclasses - Ref,PX8278790,CDM,300,RC,82787,CPT,90,,,,,,,215,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,108.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.35,210.7
Canalith Repositioning,PX95992,CDM,420,RC,95992,CPT,,,,,,,,128,,First Health,Commercial,both,85,,999999999,percent of total billed charges,108.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.86,125.44
Heparin Xa,PX85520,CDM,300,RC,85520,CPT,,,,,,,,128,,First Health,Commercial,both,85,,999999999,percent of total billed charges,108.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12,125.44
Lab Pth Immunoch Part 1,PX83970,CDM,300,RC,83970,CPT,,,,,,,,128,,First Health,Commercial,both,85,,999999999,percent of total billed charges,108.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.85,125.44
"N Block Inj, Common Digit",PX64632P,CDM,983,RC,64632,CPT,,,,,,,,128,,First Health,Commercial,both,85,,999999999,percent of total billed charges,108.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.1712,258.75
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034001,NDC,1,EA,111.81,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,12.385,percent of total billed charges,108.824673,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034000,NDC,1,EA,111.82,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,12.385,percent of total billed charges,108.834406,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
Tap Block Bilateral by Injection(S),PX64488P,CDM,983,RC,64488,CPT,,,,,,,,262,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,108.8348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.8348,255.0046
ketamine 100 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,55150044001,NDC,10,ML,111.85,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,11.07921788,percent of total billed charges,108.863605,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
Hepatitis a Igm Antibody,PX86709,CDM,300,RC,86709,CPT,,,,,,,,220,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,108.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.32,215.6
"Hiv-1, Quantification - Ref",PX8753690,CDM,300,RC,87536,CPT,90,,,,,,,220,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,108.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.03,215.6
Immunoassay Nos - Ref,PX8352090,CDM,300,RC,83520,CPT,90,,,,,,,220,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,108.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.83,215.6
Leptospira Antibody - Ref,PX8672090,CDM,300,RC,86720,CPT,90,,,,,,,220,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,108.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.85,215.6
LAPAROTOMY MAJOR I,27200000,CDM,272,RC,,,,4828-MAIN,LOCAL,,,,,123.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,108.927,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SET SP TUBE INTRODUCER  14CM 8-14FR G15469,120.377,CDM,272,RC,,,,7147-MAIN,LOCAL,,,,,227,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,108.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.2958,222.46
SET SP TUBE INTRODUCER  14CM 8-14FR G15469,120.377,CDM,272,RC,,,,7147-MAIN,LOCAL,,,,,227,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,108.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.2958,222.46
Sp Stn for Inclusn Bodies - Ref,PX8720790,CDM,300,RC,87207,CPT,90,,,,,,,227,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,108.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.49,222.46
Sp Stn for Inclusn Bodies - Ref,PX8720790,CDM,300,RC,87207,CPT,90,,,,,,,227,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,108.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.49,222.46
ePHEDrine sulfate 50 MG/ML Solution 1 mL Ampule,25000000,CDM,250,RC,,,,,,17478041510,NDC,1,ML,262.31,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,108.963574,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Thyrstim Immun Glob (Tsi) - Ref,PX8444590,CDM,300,RC,84445,CPT,90,,,,,,,254,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,108.966,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.63,248.92
ELECTRODE PEDS ONESTEP SINGLE,120.343,CDM,272,RC,A4556,HCPCS,,10296-MAIN,LOCAL,,,,,112,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,109.0096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
EYE IRRIGATION SYSTEM MT2000,120.318,CDM,272,RC,,,,8718-MAIN,LOCAL,,,,,112,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,109.0096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
F5 Gene - Ref,PX8124190,CDM,300,RC,81241,CPT,90,,,,,,,112,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,109.0096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
Immunofluorescence per Spec Add Singl Antb Stain - Ref,PX8835090,CDM,310,RC,88350,CPT,90,,,,,,,112,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,109.0096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
Osmolality; Urine,PX83935,CDM,300,RC,83935,CPT,,,,,,,,112,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,109.0096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.25,109.76
Prolactin,PX84146,CDM,300,RC,84146,CPT,,,,,,,,112,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,109.0096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.77,109.76
Quantitation Drug Nos - Ref,PX8029990,CDM,300,RC,80299,CPT,90,,,,,,,112,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,109.0096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.09,109.76
TUBE AIRSPIRAL BREATHING AND CHAMBER 900PT561,120.493,CDM,271,RC,A4604,HCPCS,,11618-MAIN,LOCAL,,,,,112,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,109.0096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
verapamil 2.5 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,51754020401,NDC,1,ML,112.01,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,109.019333,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,781329091,NDC,50,ML,119.73,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,109.07403,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
X-Ray Exam Entire Spine 2-3 Vws,PX7208201,CDM,320,RC,72082,CPT,TC,,,,,,,454,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,109.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.64,109.13
X-Ray Exam Entire Spine 2-3 Vws,PX7208201,CDM,320,RC,72082,CPT,TC,,,,,,,454,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,109.13,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.64,109.13
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615900,NDC,1,EA,123.75,,United Healthcare,All Payer,outpatient,88.2,,49.96,percent of total billed charges,109.1475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615904,NDC,1,EA,123.75,,United Healthcare,All Payer,outpatient,88.2,,49.96,percent of total billed charges,109.1475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
"X-Ray Exam Hip,Unilat W/Pelvis 1vw",PX7350101,CDM,320,RC,73501,CPT,TC,,,,,,,263,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,109.2502,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,257.74
"Apply Finger Splint,Static",PX29130P,CDM,983,RC,29130,CPT,,,,,,,,223,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,109.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,217.0459
"Apply Finger Splint,Static",PX29130P,CDM,983,RC,29130,CPT,,,,,,,,223,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,109.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,217.0459
"Apply Finger Splint,Static",PX29130P,CDM,983,RC,29130,CPT,,,,,,,,223,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,109.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,217.0459
"Apply Forearm Splint,Static",PX29125F,CDM,510,RC,29125,CPT,,,,,,,,223,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,136.885,percent of total billed charges,109.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,218.54
"Apply Forearm Splint,Static",PX29125F,CDM,510,RC,29125,CPT,,,,,,,,223,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,109.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,218.54
"Apply Forearm Splint,Static",PX29125F,CDM,510,RC,29125,CPT,,,,,,,,223,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,109.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,218.54
"Flow Cyto, Tech, 1st Mrkr - Ref",PX8818490,CDM,310,RC,88184,CPT,90,,,,,,,223,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,36.16,percent of total billed charges,109.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,314.02
"Flow Cyto, Tech, 1st Mrkr - Ref",PX8818490,CDM,310,RC,88184,CPT,90,,,,,,,223,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,109.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,314.02
"Flow Cyto, Tech, 1st Mrkr - Ref",PX8818490,CDM,310,RC,88184,CPT,90,,,,,,,223,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,109.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,314.02
"Nephelometry, Each, Nos - Ref",PX8388390,CDM,300,RC,83883,CPT,90,,,,,,,223,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,109.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.47,218.54
"Nephelometry, Each, Nos - Ref",PX8388390,CDM,300,RC,83883,CPT,90,,,,,,,223,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,109.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.47,218.54
"Nephelometry, Each, Nos - Ref",PX8388390,CDM,300,RC,83883,CPT,90,,,,,,,223,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,109.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.47,218.54
Reduce Temporomandibl Disloc,PX21480P,CDM,983,RC,21480,CPT,,,,,,,,223,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,109.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,217.0459
Reduce Temporomandibl Disloc,PX21480P,CDM,983,RC,21480,CPT,,,,,,,,223,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,109.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,217.0459
Reduce Temporomandibl Disloc,PX21480P,CDM,983,RC,21480,CPT,,,,,,,,223,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,109.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,217.0459
C-COLLAR ASPEN REGULAR 79-83365,120.25,CDM,274,RC,L0140,HCPCS,,167-MAIN,LOCAL,,,,,216,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,109.296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.58,211.68
C-COLLAR ASPEN TALL 79-83367,120.25,CDM,274,RC,L0140,HCPCS,,164-MAIN,LOCAL,,,,,216,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,109.296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.58,211.68
C-COLLAR ASPEN X-TALL 79-83368,120.25,CDM,274,RC,L0140,HCPCS,,168-MAIN,LOCAL,,,,,216,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,109.296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.58,211.68
"Remv F.B.,Eye,Embed Conjunc",PX65210P,CDM,983,RC,65210,CPT,,,,,,,,216,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,109.296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,89.7264,348.08
Apply Long Leg Splint,PX29505F,CDM,510,RC,29505,CPT,,,,,,,,320,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,109.3,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.28,190.25
Apply Long Leg Splint,PX29505P,CDM,983,RC,29505,CPT,,,,,,,,385,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,109.3,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.28,377.3
"Inject Trigger Point, 1 or 2",PX20552F,CDM,510,RC,20552,CPT,,,,,,,,252,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,109.3,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.9,109.3
"Inject Trigger Point, 1 or 2",PX20552P,CDM,983,RC,20552,CPT,,,,,,,,210,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,109.3,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.9,205.8
"Compatibility Test,Antiglob Tech",PX86922,CDM,300,RC,86922,CPT,,,,,,,,120,,Medica,Commercial,both,91.1,,23.2,percent of total billed charges,109.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.848,149.22
KIWI OMNICUP VACUUM DELIVERY SYSTEM,120.225,CDM,272,RC,,,,11608-MAIN,LOCAL,,,,,120,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,109.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.848,117.6
VACUUM KIWI W/PALM PUMP,120.225,CDM,272,RC,,,,10028-MAIN,LOCAL,,,,,120,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,109.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.848,117.6
Emergency Level IV Visit,PX99284P,CDM,981,RC,99284,CPT,,,,,,,,914,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,109.344,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.2,895.72
Facility Emergency Level IV Visit,PX99284F,CDM,450,RC,99284,CPT,,,,,,,,1054,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,109.344,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.2,214.68
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047625,NDC,0.769230769,ML,111.59,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,109.3582,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.354486,332.1514
"IV Infusion Therapy, 1 Hour",PX96365,CDM,260,RC,96365,CPT,,,,,,,,327,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,109.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.23,109.36
"IV Infusion Therapy, 1 Hour",PX96365,CDM,260,RC,96365,CPT,,,,,,,,327,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,109.36,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.23,109.36
Assay of Lithium,PX80178,CDM,300,RC,80178,CPT,,,,,,,,124,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,109.368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.06,121.52
"Complement; Antigen, Each Component",PX86160,CDM,300,RC,86160,CPT,,,,,,,,124,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,109.368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11,121.52
"Immunoassay,Ca15-3(27.29) - Ref",PX8630090,CDM,300,RC,86300,CPT,90,,,,,,,124,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,109.368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,121.52
Itraconazole,PX8018990,CDM,300,RC,80189,CPT,90,,,,,,,124,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,109.368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.86,121.52
Microbe Susceptible Mic,PX87186,CDM,300,RC,87186,CPT,,,,,,,,124,,United Healthcare,All Payer,outpatient,88.2,,63.24,percent of total billed charges,109.368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.93,121.52
Nocardia Susceptibility - Ref,PX8718690,CDM,300,RC,87186,CPT,90,,,,,,,124,,United Healthcare,All Payer,outpatient,88.2,,63.24,percent of total billed charges,109.368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.93,121.52
Oligoclonal Bands - Ref,PX8391690,CDM,300,RC,83916,CPT,90,,,,,,,124,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,109.368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.11,121.52
UMBILICAL VESSEL CATHETER INSERTION TRAY POLY SINGLE LUMEN 3.5/5FR,120.573,CDM,272,RC,,,,12857-MAIN,LOCAL,,,,,124,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,109.368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.5096,121.52
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800F,CDM,510,RC,40800,CPT,,,,,,,,255,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,109.395,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.927,614.65
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106F,CDM,510,RC,11106,CPT,,,,,,,,255,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,109.395,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.927,548.67
"Inject Nerv Blck,Trigeminal",PX64400F,CDM,510,RC,64400,CPT,,,,,,,,255,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,109.395,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.927,258.75
Remove Impacted Ear Wax,PX69210P,CDM,983,RC,69210,CPT,,,,,,,,221,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,109.395,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.44,215.0993
"Urinalysis, Auto, W/Scope",PX81001,CDM,300,RC,81001,CPT,,,,,,,,255,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,109.395,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.91,249.9
OXALiplatin 50 MG/10ML Solution 10 mL Vial,J9263.01,CDM,636,RC,J9263,HCPCS,,,,955173110,NDC,10,ML,228,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,109.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.7112,223.44
OXALiplatin 50 MG/10ML Solution 10 mL Vial,J9263.01,CDM,636,RC,J9263,HCPCS,,,,955173110,NDC,10,ML,228,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,109.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.7112,223.44
Each Add'l Hour IV Hydration,PX96361,CDM,260,RC,96361,CPT,,,,,,,,123,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,109.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,120.54
FLAT WOUND DRAIN WITH TROCAR 4 CHANNEL FULL FLUTED 7FR SILICONE,27200000,CDM,272,RC,,,,12473-MAIN,LOCAL,,,,,123,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,109.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Office/Outpt Visit,New,Levl II",PX99202F,CDM,510,RC,99202,CPT,,,,,,,,123,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,109.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.0942,120.54
"Office/Outpt Visit,New,Levl II",PX99202P,CDM,983,RC,99202,CPT,,,,,,,,123,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,109.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.0942,119.7159
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402F,CDM,510,RC,11402,CPT,,,,,,,,424,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,109.4951,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.08,359.04
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402P,CDM,983,RC,11402,CPT,,,,,,,,424,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,109.4951,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.08,415.52
"Sigmoidoscopy,Remv Lesn,Snare",PX45338F,CDM,510,RC,45338,CPT,,,,,,,,2137,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,109.4951,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.52,620.54
"Sigmoidoscopy,Remv Lesn,Snare",PX45338P,CDM,983,RC,45338,CPT,,,,,,,,1710,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,109.4951,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.52,1675.8
"Amputation Toe,Mt-P Jt",PX28820F,CDM,510,RC,28820,CPT,,,,,,,,1950,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,109.51,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.51,615.01
"Amputation Toe,Mt-P Jt",PX28820P,CDM,983,RC,28820,CPT,,,,,,,,1300,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,109.51,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.51,1274
adenosine 6 MG/2ML Solution 2 mL Syringe,J0153.01,CDM,636,RC,J0153,HCPCS,,,,25021030167,NDC,2,ML,123.1,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,109.559,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.13574,120.638
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034001,NDC,1,EA,111.81,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,109.5738,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,409277602,NDC,200,ML,228.28,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,109.5744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.827512,225.8704
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,409277602,NDC,200,ML,228.28,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,109.5744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.827512,225.8704
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034000,NDC,1,EA,111.82,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,109.5836,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.083174,109.5836
"polyethylene glycol 236 g Recon Soln 4,000 mL Bottle",63700001,CDM,250,RC,,,,,,43386009019,NDC,4000,ML,112.6,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,109.59358,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hepatitis B immune globulin 312 UNIT/ML Solution 5 mL Vial,90371,CDM,636,RC,90371,CPT,,,,59730420301,NDC,5,ML,2851.63,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,109.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.6,2794.5974
ketamine 100 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,55150044001,NDC,10,ML,111.85,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,109.613,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
Complete Cbc Automated,PX85027,CDM,300,RC,85027,CPT,,,,,,,,129,,First Health,Commercial,both,85,,999999999,percent of total billed charges,109.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,126.42
"Venipunc Need Phys Skill,Dx or Rx",PX36410P,CDM,983,RC,36410,CPT,,,,,,,,129,,First Health,Commercial,both,85,,999999999,percent of total billed charges,109.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.5866,125.5557
Inj Tendon/Ligament/Cyst,PX20550P,CDM,983,RC,20550,CPT,,,,,,,,264,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,109.6656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.6656,258.75
Lvl 3 Sub Hosp High Mdm or 50 Minutes,PX99233,CDM,982,RC,99233,CPT,,,,,,,,384,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,109.6656,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.41,376.32
Occupational Therapy Eval Mod Complex,PX97166,CDM,434,RC,97166,CPT,,,,,,,,264,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,109.6656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,258.72
Physical Therapy Evaluation Mod Complex,PX97162,CDM,424,RC,97162,CPT,,,,,,,,264,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,109.6656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,258.72
Renal Function Panel,PX80069,CDM,300,RC,80069,CPT,,,,,,,,264,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,109.6656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.96,258.72
SUMAtriptan 25 MG Tablet 9 Each Box,63700001,CDM,250,RC,,,,,,65862014636,NDC,1,EA,129.04,,First Health,Commercial,both,85,,999999999,percent of total billed charges,109.684,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium polystyrene sulfonate 15 GM/60ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,46287000660,NDC,60,ML,123.3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,109.737,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pegfilgrastim 6 MG/0.6ML Prefilled Syringe Kit 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019201,NDC,0.6,ML,13092.7,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,109.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.59,109.75
pegfilgrastim 6 MG/0.6ML Prefilled Syringe Kit 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019201,NDC,0.6,ML,13092.7,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,109.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.59,109.75
pegfilgrastim 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019001,NDC,0.6,ML,12711.36,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,109.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.59,109.75
pegfilgrastim 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019001,NDC,0.6,ML,12711.36,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,109.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.59,109.75
Body Fluid Cell Count W Diff,PX89051,CDM,300,RC,89051,CPT,,,,,,,,224,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,109.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.13,219.52
Body Fluid Cell Count W Diff,PX89051,CDM,300,RC,89051,CPT,,,,,,,,224,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,109.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.13,219.52
Body Fluid Cell Count W Diff,PX89051,CDM,300,RC,89051,CPT,,,,,,,,224,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,109.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.13,219.52
ELECTRODE PEDS ONESTEP SINGLE,120.343,CDM,272,RC,A4556,HCPCS,,10296-MAIN,LOCAL,,,,,112,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,109.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
Emergency Level I Visit,PX99281P,CDM,981,RC,99281,CPT,,,,,,,,224,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,70.255,percent of total billed charges,109.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.56,218.0192
Emergency Level I Visit,PX99281P,CDM,981,RC,99281,CPT,,,,,,,,224,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,109.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.56,218.0192
Emergency Level I Visit,PX99281P,CDM,981,RC,99281,CPT,,,,,,,,224,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,109.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.56,218.0192
ENDOWRIST INSTRUMENTS PERMANENT CAUTERY HOOK 8MM,27200000,CDM,272,RC,,,,12050-MAIN,LOCAL,,,,,224,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,109.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ENDOWRIST INSTRUMENTS PERMANENT CAUTERY HOOK 8MM,27200000,CDM,272,RC,,,,12050-MAIN,LOCAL,,,,,224,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,109.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ENDOWRIST INSTRUMENTS PERMANENT CAUTERY HOOK 8MM,27200000,CDM,272,RC,,,,12050-MAIN,LOCAL,,,,,224,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,109.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
EYE IRRIGATION SYSTEM MT2000,120.318,CDM,272,RC,,,,8718-MAIN,LOCAL,,,,,112,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,109.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
F5 Gene - Ref,PX8124190,CDM,300,RC,81241,CPT,90,,,,,,,112,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,109.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
Helicobacter Pylori Ab,PX86677,CDM,300,RC,86677,CPT,,,,,,,,224,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,109.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.45,219.52
Helicobacter Pylori Ab,PX86677,CDM,300,RC,86677,CPT,,,,,,,,224,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,109.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.45,219.52
Helicobacter Pylori Ab,PX86677,CDM,300,RC,86677,CPT,,,,,,,,224,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,109.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.45,219.52
Immunofluorescence per Spec Add Singl Antb Stain - Ref,PX8835090,CDM,310,RC,88350,CPT,90,,,,,,,112,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,109.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
Osmolality; Urine,PX83935,CDM,300,RC,83935,CPT,,,,,,,,112,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,109.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.25,109.76
Prolactin,PX84146,CDM,300,RC,84146,CPT,,,,,,,,112,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,109.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.77,109.76
Quantitation Drug Nos - Ref,PX8029990,CDM,300,RC,80299,CPT,90,,,,,,,112,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,109.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.09,109.76
TUBE AIRSPIRAL BREATHING AND CHAMBER 900PT561,120.493,CDM,271,RC,A4604,HCPCS,,11618-MAIN,LOCAL,,,,,112,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,109.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.5248,109.76
verapamil 2.5 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,51754020401,NDC,1,ML,112.01,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,109.7698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032050,NDC,1,EA,120.51,,Medica,Commercial,both,91.1,,5.442333333,percent of total billed charges,109.78461,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
Procalcitonin,PX84145,CDM,300,RC,84145,CPT,,,,,,,,217,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,109.802,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.96,212.66
TRAY 8 FR 5IN CENTESIS WITH TURKEL  30-CE1CO,120.303,CDM,272,RC,,,,11503-MAIN,LOCAL,,,,,217,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,109.802,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,90.1418,212.66
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618201,NDC,2,ML,120.53,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,109.80283,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.068162,123.3918
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618210,NDC,2,ML,120.53,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,109.80283,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.068162,123.3918
"Office/Outpt Visit,Est,Levl IV",PX99214F,CDM,510,RC,99214,CPT,,,,,,,,256,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,109.824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.3424,250.88
"Office/Outpt Visit,Est,Levl IV",PX99214P,CDM,983,RC,99214,CPT,,,,,,,,256,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,109.824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.3424,249.1648
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133P,CDM,983,RC,13133,CPT,,,,,,,,256,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,109.824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.3424,249.1648
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU000390,CDM,300,RC,U0003,HCPCS,90,,,,,,,222,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,109.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.2188,217.56
Nfct Ds Bct/Vir Respir Dna/Rna 22 Trgt Sarscov2,PX0202U,CDM,300,RC,0202U,HCPCS,,,,,,,,222,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,109.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.2188,382.15
Observation Care Discharge,PX99217,CDM,982,RC,99217,CPT,,,,,,,,222,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,109.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.2188,216.0726
patiromer sorbitex calcium 8.4 g Packet 4 Each Box,63700001,CDM,250,RC,,,,,,53436008404,NDC,1,EA,228.96,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,109.9008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
patiromer sorbitex calcium 8.4 g Packet 4 Each Box,63700001,CDM,250,RC,,,,,,53436008404,NDC,1,EA,228.96,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,109.9008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LAPAROTOMY MAJOR I,27200000,CDM,272,RC,,,,4828-MAIN,LOCAL,,,,,123.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,109.915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Removal of Nail Plate,PX11730F,CDM,510,RC,11730,CPT,,,,,,,,229,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,109.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.1266,224.42
Removal of Nail Plate,PX11730F,CDM,510,RC,11730,CPT,,,,,,,,229,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,109.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.1266,224.42
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315606,NDC,100,ML,264.64,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,109.931456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.931456,259.3472
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315695,NDC,100,ML,264.64,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,109.931456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.931456,259.3472
"Amputation Toe,Mt-P Jt",PX28820F,CDM,510,RC,28820,CPT,,,,,,,,1950,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,109.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.51,615.01
"Amputation Toe,Mt-P Jt",PX28820F,CDM,510,RC,28820,CPT,,,,,,,,1950,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,109.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.51,615.01
"Amputation Toe,Mt-P Jt",PX28820P,CDM,983,RC,28820,CPT,,,,,,,,1300,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,109.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.51,1274
"Amputation Toe,Mt-P Jt",PX28820P,CDM,983,RC,28820,CPT,,,,,,,,1300,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,109.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.51,1274
"Complex Drainage, Wound",PX10180F,CDM,510,RC,10180,CPT,,,,,,,,1050,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,109.95,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.95,547.91
"Complex Drainage, Wound",PX10180P,CDM,983,RC,10180,CPT,,,,,,,,767,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,109.95,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.95,751.66
Emergency Level V Visit,PX99285P,CDM,981,RC,99285,CPT,,,,,,,,1436,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,109.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.81,1407.28
Emergency Level V Visit,PX99285P,CDM,981,RC,99285,CPT,,,,,,,,1436,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,109.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.81,1407.28
Facility Emergency Level V Visit,PX99285F,CDM,450,RC,99285,CPT,,,,,,,,1464,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,109.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.81,310.96
Facility Emergency Level V Visit,PX99285F,CDM,450,RC,99285,CPT,,,,,,,,1464,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,109.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.81,310.96
Iadna Streptococcus Group a Amplified Probe Tq,PX87651,CDM,300,RC,87651,CPT,,,,,,,,113,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,57.33695652,percent of total billed charges,109.9829,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,110.74
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209P,CDM,982,RC,69209,CPT,,,,,,,,113,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,109.9829,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9402,109.9829
Strapping of Toes,PX29550F,CDM,510,RC,29550,CPT,,,,,,,,113,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,109.9829,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9402,110.74
Xray Spine Single Tc,PX7202001,CDM,320,RC,72020,CPT,TC,,,,,,,113,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,109.9829,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9402,110.74
"Digital Mamm, Diag, Bilat, Tc W/Cad Perf",PX7706601,CDM,401,RC,77066,CPT,TC,,,,,,,375,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,110.0556,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.95,220.89
Haptoglobin; Quantitative,PX83010,CDM,300,RC,83010,CPT,,,,,,,,265,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,110.081,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.53,259.7
ID Nucleic Acid Sequencing - Ref,PX8715390,CDM,300,RC,87153,CPT,90,,,,,,,265,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,110.081,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.77,259.7
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615900,NDC,1,EA,123.75,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,110.1375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615904,NDC,1,EA,123.75,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,110.1375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
ammonium lactate 12 % Cream 385 g Tube,63700001,CDM,250,RC,,,,,,45802049326,NDC,385,GR,256.76,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,110.15004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ipratropium 0.03 % Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,24208039830,NDC,30,ML,256.9,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,110.2101,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BAG LEG URINARY STND 32OZ,120.33,CDM,272,RC,A5112,HCPCS,,4433-MAIN,LOCAL,,,,,121,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,110.231,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
BAG URINARY DRAINAGE 2000ML 6300,120.33,CDM,274,RC,A4357,HCPCS,,1283-MAIN,LOCAL,,,,,121,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,110.231,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
BAG URINARY LEG PACK 9349,120.33,CDM,272,RC,A5112,HCPCS,,623-MAIN,LOCAL,,,,,121,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,110.231,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
"Chest Wall Manipulation,Initial",PX94667,CDM,410,RC,94667,CPT,,,,,,,,121,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,110.231,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.2634,118.58
"Fluor Noninfect Ab Sc, Ea - Ref",PX8625590,CDM,300,RC,86255,CPT,90,,,,,,,121,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,110.231,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.05,118.58
"Manage/Train Orthotic/Prosthetic, per 15 Min",PX97763,CDM,420,RC,97763,CPT,,,,,,,,121,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,110.231,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.36,118.58
"Prosthetic Training, Initial, Each 15 Mins",PX97761,CDM,420,RC,97761,CPT,,,,,,,,121,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,110.231,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.41,118.58
Cmv Igm Antibody - Ref,PX8664590,CDM,300,RC,86645,CPT,90,,,,,,,125,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,110.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.45,122.5
"Cytoflo, Cell or Dna Anal - Ref",PX8818290,CDM,310,RC,88182,CPT,90,,,,,,,225,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,110.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,220.5
"Cytoflo, Cell or Dna Anal - Ref",PX8818290,CDM,310,RC,88182,CPT,90,,,,,,,225,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,110.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,220.5
"Cytoflo, Cell or Dna Anal - Ref",PX8818290,CDM,310,RC,88182,CPT,90,,,,,,,225,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,110.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,220.5
DRESSING SURGICEL HEMOSTAT 4X8 ABSORBABLE 1952,120.123,CDM,272,RC,A6252,HCPCS,,1002-MAIN,LOCAL,,,,,125,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,110.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.925,122.5
Factor VII - Ref,PX8523090,CDM,300,RC,85230,CPT,90,,,,,,,125,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,110.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.41,122.5
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153F,CDM,370,RC,99153,CPT,,,,,,,,225,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,110.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.465,220.5
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153F,CDM,370,RC,99153,CPT,,,,,,,,225,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,110.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.465,220.5
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153F,CDM,370,RC,99153,CPT,,,,,,,,225,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,110.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.465,220.5
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320885,NDC,0.5,EA,129.71,,First Health,Commercial,both,85,,999999999,percent of total billed charges,110.2535,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320895,NDC,0.5,EA,129.71,,First Health,Commercial,both,85,,999999999,percent of total billed charges,110.2535,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781315972,NDC,1,EA,217.96,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,110.28776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86,213.6008
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037905,NDC,0.5,ML,229.88,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,110.3424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037905,NDC,0.5,ML,229.88,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,110.3424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
albuterol (5 MG/ML) 0.5% Nebulization Solution 20 mL Bottle,J7611.01,CDM,250,RC,,,,,,50383074120,NDC,20,ML,225.2,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,110.348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.54808,220.696
albuterol (5 MG/ML) 0.5% Nebulization Solution 20 mL Bottle,J7611.01,CDM,250,RC,,,,,,50383074120,NDC,20,ML,225.2,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,110.348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.54808,220.696
albuterol (5 MG/ML) 0.5% Nebulization Solution 20 mL Bottle,J7611.01,CDM,250,RC,,,,,,50383074120,NDC,20,ML,225.2,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,110.348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.54808,220.696
"polyethylene glycol 236 g Recon Soln 4,000 mL Bottle",63700001,CDM,250,RC,,,,,,43386009019,NDC,4000,ML,112.6,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,110.348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of Lithium,PX80178,CDM,300,RC,80178,CPT,,,,,,,,124,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,110.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.06,121.52
"Complement; Antigen, Each Component",PX86160,CDM,300,RC,86160,CPT,,,,,,,,124,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,110.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11,121.52
"Immunoassay,Ca15-3(27.29) - Ref",PX8630090,CDM,300,RC,86300,CPT,90,,,,,,,124,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,110.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,121.52
Itraconazole,PX8018990,CDM,300,RC,80189,CPT,90,,,,,,,124,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,110.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.86,121.52
Microbe Susceptible Mic,PX87186,CDM,300,RC,87186,CPT,,,,,,,,124,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,110.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.93,121.52
Nocardia Susceptibility - Ref,PX8718690,CDM,300,RC,87186,CPT,90,,,,,,,124,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,110.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.93,121.52
Oligoclonal Bands - Ref,PX8391690,CDM,300,RC,83916,CPT,90,,,,,,,124,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,110.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.11,121.52
UMBILICAL VESSEL CATHETER INSERTION TRAY POLY SINGLE LUMEN 3.5/5FR,120.573,CDM,272,RC,,,,12857-MAIN,LOCAL,,,,,124,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,110.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.5096,121.52
US Kidney Transplt Untrsd,PX7677601,CDM,402,RC,76776,CPT,TC,,,,,,,554,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,110.3774,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.61,220.89
"Apply Finger Splint,Static",PX29130P,CDM,983,RC,29130,CPT,,,,,,,,223,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,110.385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,217.0459
"Apply Forearm Splint,Static",PX29125F,CDM,510,RC,29125,CPT,,,,,,,,223,,Humana Choice Care,All Medicare plans,outpatient,49.5,,55.37,percent of total billed charges,110.385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,218.54
"Flow Cyto, Tech, 1st Mrkr - Ref",PX8818490,CDM,310,RC,88184,CPT,90,,,,,,,223,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,110.385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,314.02
"Nephelometry, Each, Nos - Ref",PX8388390,CDM,300,RC,83883,CPT,90,,,,,,,223,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,110.385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.47,218.54
Reduce Temporomandibl Disloc,PX21480P,CDM,983,RC,21480,CPT,,,,,,,,223,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,110.385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,217.0459
lidocaine-epinephrine-tetracaine Gel 3 mL Syringe,J3490.160,CDM,636,RC,J3490,HCPCS,,,,88888800028,NDC,3,ML,121.19,,Medica,Commercial,both,91.1,,7.37,percent of total billed charges,110.40409,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.342326,118.7662
DAPTOmycin 500 MG Recon Soln 1 Each Vial,J0878.01,CDM,636,RC,J0878,HCPCS,,,,70594003402,NDC,1,EA,129.9,,First Health,Commercial,both,85,,999999999,percent of total billed charges,110.415,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.96046,127.302
Immunofluorescence per Spec Add Singl Antb Stain - Ref,PX8835090,CDM,310,RC,88350,CPT,90,,,,,,,112,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,110.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.42,185.408
Immunofluorescence per Spec Add Singl Antb Stain - Ref,PX8835090,CDM,310,RC,88350,CPT,90,,,,,,,112,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,110.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.42,185.408
Immunofluorescence per Spec Add Singl Antb Stain - Ref,PX8835090,CDM,310,RC,88350,CPT,90,,,,,,,112,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,110.42,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.42,185.408
LEGGING COMPRESSION JUXTALITE LONG LG 33CM,120.369,CDM,271,RC,A6545,HCPCS,,10840-MAIN,LOCAL,,,,,145,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,110.43,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.43,189.328
rifAXIMin 550 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,65649030302,NDC,1,EA,218.25,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,110.4345,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rifAXIMin 550 MG Tablet 60 Each Box,63700001,CDM,250,RC,,,,,,65649030303,NDC,1,EA,218.25,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,110.4345,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,63323072902,NDC,1,EA,265.95,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,110.47563,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.47563,793.6922
"Initial Observation Care,Levl I",PX99218,CDM,982,RC,99218,CPT,,,,,,,,266,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,110.4964,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.4964,258.8978
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597F,CDM,510,RC,97597,CPT,,,,,,,,266,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,110.4964,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.4964,260.68
Chemo Ad Sq/Im Hormnl Anti-Neo,PX96402,CDM,335,RC,96402,CPT,,,,,,,,130,,First Health,Commercial,both,85,,999999999,percent of total billed charges,110.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,127.4
Cystatin C - Ref,PX8261090,CDM,300,RC,82610,CPT,90,,,,,,,130,,First Health,Commercial,both,85,,999999999,percent of total billed charges,110.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.98,127.4
Each Add'l Sequential Push New Drug,PX96375,CDM,260,RC,96375,CPT,,,,,,,,130,,First Health,Commercial,both,85,,999999999,percent of total billed charges,110.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,127.4
Immunization Administration; One Vaccine (Single or Combination Vaccine/To*,PX90471,CDM,771,RC,90471,CPT,,,,,,,,130,,First Health,Commercial,both,85,,999999999,percent of total billed charges,110.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,127.4
Prothrombin Time (Pt/Inr),PX85610,CDM,300,RC,85610,CPT,,,,,,,,130,,First Health,Commercial,both,85,,999999999,percent of total billed charges,110.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.93,127.4
SPLINT WRIST LARGE ALUMINUM FOREARM LEFT 9101-06,120.87,CDM,274,RC,L3809,HCPCS,,1265-MAIN,LOCAL,,,,,130,,First Health,Commercial,both,85,,999999999,percent of total billed charges,110.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST LARGE ALUMINUM FOREARM RIGHT 9101-03,120.87,CDM,274,RC,L3809,HCPCS,,1263-MAIN,LOCAL,,,,,130,,First Health,Commercial,both,85,,999999999,percent of total billed charges,110.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST MEDIUM ALUMINUM FOREARM LEFT 9101-05,120.87,CDM,274,RC,L3809,HCPCS,,1264-MAIN,LOCAL,,,,,130,,First Health,Commercial,both,85,,999999999,percent of total billed charges,110.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST MEDIUM ALUMINUM FOREARM RIGHT 9101-02,120.87,CDM,274,RC,L3809,HCPCS,,1262-MAIN,LOCAL,,,,,130,,First Health,Commercial,both,85,,999999999,percent of total billed charges,110.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
Vitamin B-1 - Ref,PX8442590,CDM,300,RC,84425,CPT,90,,,,,,,130,,First Health,Commercial,both,85,,999999999,percent of total billed charges,110.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.47,127.4
Ventilator Mgmt.Subsequent Days,PX94003F,CDM,410,RC,94003,CPT,,,,,,,,1686,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,110.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.7,110.52
Ventilator Mgmt.Subsequent Days,PX94003F,CDM,410,RC,94003,CPT,,,,,,,,1686,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,110.52,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.7,110.52
"Mra, Head W/Out Contrast",PX7054401,CDM,610,RC,70544,CPT,TC,,,,,,,3541,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,110.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.6,326.73
"Mra, Head W/Out Contrast",PX7054401,CDM,610,RC,70544,CPT,TC,,,,,,,3541,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,110.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.6,326.73
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,49884093547,NDC,100,GR,266.25,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,110.60025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,143971801,NDC,200,ML,230.48,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,110.6304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.827512,225.8704
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,143971801,NDC,200,ML,230.48,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,110.6304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.827512,225.8704
"Needle Biopsy,Muscle",PX20206F,CDM,510,RC,20206,CPT,,,,,,,,258,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,110.682,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.1732,1416.38
Removal of Nail Plate,PX11730F,CDM,510,RC,11730,CPT,,,,,,,,229,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,110.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.37,239.36
amiodarone 900 MG/18ML Solution 18 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,67457015318,NDC,18,ML,113.73,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,110.693409,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
Iadna Streptococcus Group a Amplified Probe Tq,PX87651,CDM,300,RC,87651,CPT,,,,,,,,113,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,110.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,110.74
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209P,CDM,982,RC,69209,CPT,,,,,,,,113,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,110.74,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.03,110.74
Strapping of Toes,PX29550F,CDM,510,RC,29550,CPT,,,,,,,,113,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,110.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9402,110.74
Xray Spine Single Tc,PX7202001,CDM,320,RC,72020,CPT,TC,,,,,,,113,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,110.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9402,110.74
triamcinolone acetonide 0.1 % Cream 454 g Jar,63700001,CDM,250,RC,,,,,,45802006405,NDC,454,GR,130.36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,110.806,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CANNULATED AO HANDLE STERILE MICA SCREW SYSTEM 57S1HNDL,27200000,CDM,272,RC,,,,12446-MAIN,LOCAL,,,,,219,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,110.814,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TUBE SURGICAL IRRIGATION 1PK PD-IT,27200000,CDM,272,RC,,,,12433-MAIN,LOCAL,,,,,219,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,110.814,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
dexmedeTOMIDine in  dextrose 200MCG/50ML -5% Solution 50 mL Flex Cont,25000000,CDM,250,RC,,,,,,44567060224,NDC,50,ML,258.31,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,110.81499,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Body Fluid Cell Count W Diff,PX89051,CDM,300,RC,89051,CPT,,,,,,,,224,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,110.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.13,219.52
Emergency Level I Visit,PX99281P,CDM,981,RC,99281,CPT,,,,,,,,224,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,110.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.56,218.0192
ENDOWRIST INSTRUMENTS PERMANENT CAUTERY HOOK 8MM,27200000,CDM,272,RC,,,,12050-MAIN,LOCAL,,,,,224,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,110.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Helicobacter Pylori Ab,PX86677,CDM,300,RC,86677,CPT,,,,,,,,224,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,110.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.45,219.52
fentaNYL 50 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,406905076,NDC,1,EA,125.74,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,110.90268,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Xray Shoulder 1 Vw,PX7302001,CDM,320,RC,73020,CPT,TC,,,,,,,267,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,110.9118,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,261.66
Assay of Erythropoietin,PX82668,CDM,300,RC,82668,CPT,,,,,,,,114,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,110.9562,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,111.72
gentamicin 0.3 % Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,17478028435,NDC,3.5,GR,219.3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,110.9658,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915801,NDC,1,ML,267.19,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,110.990726,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052331,NDC,2,ML,125.89,,United Healthcare,All Payer,outpatient,88.2,,61.69,percent of total billed charges,111.03498,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.294706,123.3722
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052341,NDC,2,ML,125.89,,United Healthcare,All Payer,outpatient,88.2,,61.69,percent of total billed charges,111.03498,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.294706,123.3722
"Complex Drainage, Wound",PX10180F,CDM,510,RC,10180,CPT,,,,,,,,1050,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,111.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.95,547.91
"Complex Drainage, Wound",PX10180F,CDM,510,RC,10180,CPT,,,,,,,,1050,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,111.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.95,547.91
"Complex Drainage, Wound",PX10180P,CDM,983,RC,10180,CPT,,,,,,,,767,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,111.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.95,751.66
"Complex Drainage, Wound",PX10180P,CDM,983,RC,10180,CPT,,,,,,,,767,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,111.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.95,751.66
IV 0.9% NS 1000ML 2B1324X,27200000,CDM,272,RC,,,,538-MAIN,LOCAL,,,,,121.89,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,111.04179,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Package,25000000,CDM,250,RC,,,,,,10019055390,NDC,1,EA,121.9,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,111.0509,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,17478053802,NDC,2,ML,125.91,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,111.05262,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.068162,123.3918
"Chemotherapy, IV Infusion, Each Add'l Sequential Infusion",PX96417,CDM,335,RC,96417,CPT,,,,,,,,328,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,111.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.88,111.1
"Chemotherapy, IV Infusion, Each Add'l Sequential Infusion",PX96417,CDM,335,RC,96417,CPT,,,,,,,,328,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,111.1,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.88,111.1
Drainage of Hematoma/Fluid (P),PX10140P,CDM,983,RC,10140,CPT,,,,,,,,465,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,111.1006,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.17,455.7
Drainage of Hematoma/Fluid (T),PX10140F,CDM,510,RC,10140,CPT,,,,,,,,341,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,111.1006,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.17,354.2
Acth - Ref,PX8202490,CDM,300,RC,82024,CPT,90,,,,,,,259,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,111.111,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.41,253.82
"IV Push, Single/1st Drug",PX96374,CDM,260,RC,96374,CPT,,,,,,,,259,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,111.111,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.5886,253.82
Thrombin Time Plasma,PX85670,CDM,300,RC,85670,CPT,,,,,,,,126,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,111.132,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.29,123.48
Assay of Iron,PX83540,CDM,300,RC,83540,CPT,,,,,,,,122,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,111.142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,119.56
"Compliment, Total (Ch50) - Ref",PX8616290,CDM,300,RC,86162,CPT,90,,,,,,,122,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,111.142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.63,119.56
Vitamin B-12,PX82607,CDM,300,RC,82607,CPT,,,,,,,,122,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,111.142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.83,119.56
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010602,NDC,50,ML,126.07,,United Healthcare,All Payer,outpatient,88.2,,13.925,percent of total billed charges,111.19374,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010605,NDC,50,ML,126.07,,United Healthcare,All Payer,outpatient,88.2,,13.925,percent of total billed charges,111.19374,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
nitroglycerin in dextrose 5% 100-5 MCG/ML-% Solution 250 mL Glass Cont,J2305.01,CDM,636,RC,J2305,HCPCS,,,,338104702,NDC,250,ML,126.07,,United Healthcare,All Payer,outpatient,88.2,,0.24716,percent of total billed charges,111.19374,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.17,123.5486
SET SP TUBE INTRODUCER  14CM 8-14FR G15469,120.377,CDM,272,RC,,,,7147-MAIN,LOCAL,,,,,227,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,111.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.2958,222.46
SET SP TUBE INTRODUCER  14CM 8-14FR G15469,120.377,CDM,272,RC,,,,7147-MAIN,LOCAL,,,,,227,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,111.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.2958,222.46
SET SP TUBE INTRODUCER  14CM 8-14FR G15469,120.377,CDM,272,RC,,,,7147-MAIN,LOCAL,,,,,227,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,111.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.2958,222.46
Sp Stn for Inclusn Bodies - Ref,PX8720790,CDM,300,RC,87207,CPT,90,,,,,,,227,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,111.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.49,222.46
Sp Stn for Inclusn Bodies - Ref,PX8720790,CDM,300,RC,87207,CPT,90,,,,,,,227,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,111.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.49,222.46
Sp Stn for Inclusn Bodies - Ref,PX8720790,CDM,300,RC,87207,CPT,90,,,,,,,227,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,111.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.49,222.46
Cmv Igm Antibody - Ref,PX8664590,CDM,300,RC,86645,CPT,90,,,,,,,125,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,111.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.45,122.5
DRESSING SURGICEL HEMOSTAT 4X8 ABSORBABLE 1952,120.123,CDM,272,RC,A6252,HCPCS,,1002-MAIN,LOCAL,,,,,125,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,111.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.925,122.5
Factor VII - Ref,PX8523090,CDM,300,RC,85230,CPT,90,,,,,,,125,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,111.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.41,122.5
"Mra, Head W/Out Contrast",PX7054401,CDM,610,RC,70544,CPT,TC,,,,,,,3541,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,111.25,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.6,326.73
gentamicin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063305,NDC,5,ML,122.17,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,111.29687,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tropicamide 1 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,61314035502,NDC,15,ML,267.96,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,111.310584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Hepatitis a Igm Antibody,PX86709,CDM,300,RC,86709,CPT,,,,,,,,220,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,111.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.32,215.6
"Hiv-1, Quantification - Ref",PX8753690,CDM,300,RC,87536,CPT,90,,,,,,,220,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,111.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.03,215.6
Immunoassay Nos - Ref,PX8352090,CDM,300,RC,83520,CPT,90,,,,,,,220,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,111.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.83,215.6
Leptospira Antibody - Ref,PX8672090,CDM,300,RC,86720,CPT,90,,,,,,,220,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,111.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.85,215.6
Noninvasv Oxygen Satur;Single,PX94760,CDM,460,RC,94760,CPT,,,,,,,,131,,First Health,Commercial,both,85,,999999999,percent of total billed charges,111.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.4174,128.38
Bile Acids Total,PX8223990,CDM,300,RC,82239,CPT,90,,,,,,,232,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,111.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,227.36
Bile Acids Total,PX8223990,CDM,300,RC,82239,CPT,90,,,,,,,232,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,111.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,227.36
"Cytoflo, Cell or Dna Anal - Ref",PX8818290,CDM,310,RC,88182,CPT,90,,,,,,,225,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,111.375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,220.5
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153F,CDM,370,RC,99153,CPT,,,,,,,,225,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,111.375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.465,220.5
naloxone 2 MG/2ML solution prefilled syringe 2 mL Syringe,J2310.01,CDM,636,RC,J2310,HCPCS,,,,76329346901,NDC,1,ML,114.45,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,111.394185,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.54253,130.4968
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,69315030615,NDC,15,GR,131.07,,First Health,Commercial,both,85,,999999999,percent of total billed charges,111.4095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
levonorgestrel 1.5 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,62756071860,NDC,1,EA,114.48,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,111.423384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 900 MG/18ML Solution 18 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,67457015318,NDC,18,ML,113.73,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,111.4554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,111.4554
"MRI,Lwrext,No Jnt,No Cont",PX7371801,CDM,610,RC,73718,CPT,TC,,,,,,,3253,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,111.47,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.47,328.7
"MRI,Lwrext,No Jnt,No Cont",PX7371801,CDM,610,RC,73718,CPT,TC,,,,,,,3253,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,111.47,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.47,328.7
albuterol (5 MG/ML) 0.5% Nebulization Solution 20 mL Bottle,J7611.01,CDM,250,RC,,,,,,50383074120,NDC,20,ML,225.2,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,111.474,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.54808,220.696
Calr Gene Analysis Common Variants in Exon 9 - Ref,PX8121990,CDM,300,RC,81219,CPT,90,,,,,,,534,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,111.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.52,523.32
Lvl 3 Init Hosp High Mdm or 75 Minutes,PX99223,CDM,982,RC,99223,CPT,,,,,,,,536,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,111.53,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.68,525.28
Lvl 3 Init Hosp High Mdm or 75 Minutes,PX99223,CDM,982,RC,99223,CPT,,,,,,,,536,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,111.53,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.68,525.28
Blood Clot Factor V Test,PX85220,CDM,300,RC,85220,CPT,,,,,,,,260,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,111.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.18,254.8
"Closed Rx Toe Fx,Manipulatn",PX28515P,CDM,983,RC,28515,CPT,,,,,,,,260,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,111.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.004,253.058
First Hour IV Hydration <1 Hour,PX96360,CDM,260,RC,96360,CPT,,,,,,,,260,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,111.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.004,254.8
"Apply Finger Splint,Static",PX29130F,CDM,420,RC,29130,CPT,,,,,,,,196,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,111.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.4184,192.08
"Apply Finger Splint,Static",PX29130P,CDM,983,RC,29130,CPT,,,,,,,,223,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,111.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,217.0459
"Apply Forearm Splint,Static",PX29125F,CDM,510,RC,29125,CPT,,,,,,,,223,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,111.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,218.54
"Apply Forearm Splint,Static",PX29125P,CDM,983,RC,29125,CPT,,,,,,,,296,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,111.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,288.0968
Blood Typing Abo,PX86900,CDM,300,RC,86900,CPT,,,,,,,,92,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,111.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.2168,111.6
"Chest Wall Manipulation,Initial",PX94667,CDM,410,RC,94667,CPT,,,,,,,,121,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,111.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.2634,118.58
"Chest Wall Manipulation,Subsequent",PX94668F,CDM,410,RC,94668,CPT,,,,,,,,192,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,111.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.7568,188.16
Collect Blood From Picc,PX36592,CDM,949,RC,36592,CPT,,,,,,,,198,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,111.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.2492,194.04
Collect Blood From Picc,PX36592F,CDM,510,RC,36592,CPT,,,,,,,,211,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,111.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.6494,206.78
"Ctrl Nosebleed,Anter,Complex",PX30903F,CDM,510,RC,30903,CPT,,,,,,,,456,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,111.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,446.88
"Ctrl Nosebleed,Anter,Complex",PX30903P,CDM,983,RC,30903,CPT,,,,,,,,304,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,111.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,295.8832
"Ctrl Nosebleed,Anter,Simple",PX30901F,CDM,510,RC,30901,CPT,,,,,,,,342,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,111.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,335.16
"Ctrl Nosebleed,Anter,Simple",PX30901P,CDM,983,RC,30901,CPT,,,,,,,,229,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,111.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.1266,222.8857
Diagnostic Anoscopy,PX46600F,CDM,510,RC,46600,CPT,,,,,,,,505,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,111.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,494.9
Diagnostic Anoscopy,PX46600P,CDM,983,RC,46600,CPT,,,,,,,,405,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,111.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,394.1865
Drain Blood From Under Nail,PX11740F,CDM,510,RC,11740,CPT,,,,,,,,117,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,111.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.6018,114.66
Drainage of Gum Lesion,PX41800F,CDM,510,RC,41800,CPT,,,,,,,,395,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,111.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,387.1
Drainage of Gum Lesion,PX41800P,CDM,983,RC,41800,CPT,,,,,,,,839,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,111.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,816.5987
Draw Blood Off Venous Device,PX36591F,CDM,510,RC,36591,CPT,,,,,,,,211,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,111.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.6494,206.78
Extremity Study - Vascular Diagnostics,PX9392201,CDM,921,RC,93922,CPT,TC,,,,,,,600,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,111.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,588
Insert Simple Cath Foley,PX51702F,CDM,510,RC,51702,CPT,,,,,,,,198,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,111.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.2492,194.04
Insert Straight Catheter,PX51701F,CDM,510,RC,51701,CPT,,,,,,,,168,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,111.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.7872,164.64
Phlebotomy,PX99195,CDM,940,RC,99195,CPT,,,,,,,,238,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,111.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.8652,233.24
Pulmonary Stress Test,PX94618,CDM,976,RC,94618,CPT,,,,,,,,153,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,111.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.5562,148.9149
Remove Nasal Foreign Body,PX30300F,CDM,510,RC,30300,CPT,,,,,,,,972,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,111.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,952.56
Remove Nasal Foreign Body,PX30300P,CDM,983,RC,30300,CPT,,,,,,,,572,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,111.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,556.7276
Remv Ext Canal Foreign Body,PX69200F,CDM,510,RC,69200,CPT,,,,,,,,235,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,111.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97.619,230.3
Remv Ext Canal Foreign Body,PX69200P,CDM,983,RC,69200,CPT,,,,,,,,157,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,111.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.2178,152.8081
"Remv F.B.,Eye,Superf Conjunc",PX65205F,CDM,510,RC,65205,CPT,,,,,,,,132,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,111.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,129.36
"Remv F.B.,Eye,Superf Conjunc",PX65205P,CDM,983,RC,65205,CPT,,,,,,,,132,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,111.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,128.4756
Strapping of Knee,PX29530F,CDM,420,RC,29530,CPT,,,,,,,,303,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,111.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,296.94
Strapping of Shoulder,PX29240F,CDM,420,RC,29240,CPT,,,,,,,,165,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,111.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.541,161.7
Strapping of Shoulder,PX29240P,CDM,983,RC,29240,CPT,,,,,,,,110,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,111.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.694,111.6
Withdrawal of Arterial Blood,PX36600F,CDM,510,RC,36600,CPT,,,,,,,,250,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,111.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.85,245
STRAP CLAVICLE LARGE VP10123-040,120.191,CDM,274,RC,L3670,HCPCS,,12848-MAIN,LOCAL,,,,,24,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,111.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE MEDIUM VP10123-030,120.191,CDM,274,RC,L3670,HCPCS,,12847-MAIN,LOCAL,,,,,24,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,111.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE SMALL VP10123-020,120.191,CDM,274,RC,L3670,HCPCS,,12846-MAIN,LOCAL,,,,,24,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,111.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE XL 661 XL,120.191,CDM,274,RC,L3670,HCPCS,,12850-MAIN,LOCAL,,,,,24,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,111.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
STRAP CLAVICLE XSMALL CHILD ORT14100XS,120.191,CDM,274,RC,L3670,HCPCS,,12849-MAIN,LOCAL,,,,,24,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,111.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9696,111.62
Immunofluorescence per Spec Add Singl Antb Stain - Ref,PX8835090,CDM,310,RC,88350,CPT,90,,,,,,,112,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,111.6732,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.42,185.408
LIGACLIP APPLIER CLIP STERILE SIZE MEDIUM LARGE,27200000,CDM,272,RC,,,,11699-MAIN,LOCAL,,,,,126.62,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,111.67884,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"MRI,Pelvis W/Out Contrast",PX7219501,CDM,610,RC,72195,CPT,TC,,,,,,,3253,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,111.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.69,329.36
"MRI,Pelvis W/Out Contrast",PX7219501,CDM,610,RC,72195,CPT,TC,,,,,,,3253,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,111.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.69,329.36
Assay of Erythropoietin,PX82668,CDM,300,RC,82668,CPT,,,,,,,,114,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,111.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.23,111.72
OXALiplatin 50 MG/10ML Solution 10 mL Vial,J9263.01,CDM,636,RC,J9263,HCPCS,,,,955173110,NDC,10,ML,228,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,111.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.7112,223.44
OXALiplatin 50 MG/10ML Solution 10 mL Vial,J9263.01,CDM,636,RC,J9263,HCPCS,,,,955173110,NDC,10,ML,228,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,111.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.7112,223.44
OXALiplatin 50 MG/10ML Solution 10 mL Vial,J9263.01,CDM,636,RC,J9263,HCPCS,,,,955173110,NDC,10,ML,228,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,111.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.7112,223.44
NEEDLE INTRAOSSEOUS 15GA 15MM EZ-IO PEDS 9018,120.89,CDM,272,RC,A4215,HCPCS,,4964-MAIN,LOCAL,,,,,269,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,111.7426,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.7426,263.62
"Upper GI Endoscopy,Diagnosis",PX43235F,CDM,750,RC,43235,CPT,,,,,,,,2539,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,111.7428,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.04,597.02
"Upper GI Endoscopy,Diagnosis",PX43235P,CDM,983,RC,43235,CPT,,,,,,,,1406,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,111.7428,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.04,1377.88
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004725,NDC,2,ML,131.52,,First Health,Commercial,both,85,,999999999,percent of total billed charges,111.792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
Remove Impacted Ear Wax,PX69210P,CDM,983,RC,69210,CPT,,,,,,,,221,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,111.826,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.44,215.0993
TRAY GROSHONG 4FR SAFETY PICC 7617407,120.26,CDM,272,RC,,,,500-MAIN,LOCAL,,,,,233,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,111.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.7882,228.34
TRAY GROSHONG 4FR SAFETY PICC 7617407,120.26,CDM,272,RC,,,,500-MAIN,LOCAL,,,,,233,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,111.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.7882,228.34
Fresh Frozen Plasma,PXP9017,CDM,390,RC,P9017,HCPCS,,,,,,,,319,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,111.85,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.49,182.176
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,409277602,NDC,200,ML,228.28,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,111.8572,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.827512,225.8704
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,409277602,NDC,200,ML,228.28,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,111.8572,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.827512,225.8704
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,409277602,NDC,200,ML,228.28,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,111.8572,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.827512,225.8704
ID Nucleic Acid Sequencing - Ref,PX8715390,CDM,300,RC,87153,CPT,90,,,,,,,265,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,111.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.9,115.36
ID Nucleic Acid Sequencing - Ref,PX8715390,CDM,300,RC,87153,CPT,90,,,,,,,265,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,111.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.9,115.36
ID Nucleic Acid Sequencing - Ref,PX8715390,CDM,300,RC,87153,CPT,90,,,,,,,265,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,111.9,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.9,115.36
fentaNYL 50 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,406905076,NDC,1,EA,125.74,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,111.9086,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of Triglycerides,PX84478,CDM,300,RC,84478,CPT,,,,,,,,115,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,97.54,percent of total billed charges,111.9295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.26,112.7
"Blood Typing, Rh Phenotype",PX86906,CDM,300,RC,86906,CPT,,,,,,,,115,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,111.9295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.03,112.7
BRACE ANKLE LARGE 264015,120.51,CDM,274,RC,L1902,HCPCS,,4-MAIN,LOCAL,,,,,115,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,111.9295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE MEDIUM 264014,120.51,CDM,274,RC,L1902,HCPCS,,7-MAIN,LOCAL,,,,,115,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,111.9295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE SMALL 264012,120.51,CDM,274,RC,L1902,HCPCS,,12-MAIN,LOCAL,,,,,115,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,111.9295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE X-LARGE 264016,120.51,CDM,274,RC,L1902,HCPCS,,14-MAIN,LOCAL,,,,,115,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,111.9295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE X-SMALL 264011,120.51,CDM,274,RC,L1902,HCPCS,,1-MAIN,LOCAL,,,,,115,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,111.9295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
Debride Skin/Subq Ea Ad 20sqcm,PX11045F,CDM,510,RC,11045,CPT,,,,,,,,115,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,111.9295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
Glucagon - Ref,PX8294390,CDM,300,RC,82943,CPT,90,,,,,,,115,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,111.9295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.1,112.7
"Immuno for Tumor Ag, Qn - Ref",PX8631690,CDM,300,RC,86316,CPT,90,,,,,,,115,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,111.9295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,112.7
Microsomal Antibody,PX7893,CDM,300,RC,86376,CPT,,,,,,,,115,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,111.9295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.34,112.7
atropine 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,17478021502,NDC,2,ML,269.45,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,111.92953,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
atropine 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,60219174802,NDC,2,ML,269.45,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,111.92953,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pegfilgrastim-cbqv 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5111.01,CDM,636,RC,Q5111,HCPCS,,,,70114010101,NDC,0.6,ML,10040,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,111.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.95,9839.2
SPLINT ANKLE GEL BRACE UNIVERSAL AIRFORM 70351,120.61,CDM,274,RC,L4350,HCPCS,,12342-MAIN,LOCAL,,,,,88,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,111.9516,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.15,113.84
B-Scan Global,PX7651201,CDM,402,RC,76512,CPT,TC,,,,,,,127,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,112.014,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.7558,124.46
Candida Dna Dir Probe,PX87480,CDM,300,RC,87480,CPT,,,,,,,,127,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,112.014,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.38,124.46
Gardner Vag Dna Dir Probe,PX87510,CDM,300,RC,87510,CPT,,,,,,,,127,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,112.014,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.38,124.46
Influenza Assay W/Optic,PX87804,CDM,300,RC,87804,CPT,,,,,,,,127,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,112.014,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.17,124.46
Trichomonas Vagin Dir Probe,PX87660,CDM,300,RC,87660,CPT,,,,,,,,127,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,112.014,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.38,124.46
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052331,NDC,2,ML,125.89,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,112.0421,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.294706,123.3722
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052341,NDC,2,ML,125.89,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,112.0421,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.294706,123.3722
Each Add'l Hour IV Hydration,PX96361,CDM,260,RC,96361,CPT,,,,,,,,123,,Medica,Commercial,both,91.1,,17.64695652,percent of total billed charges,112.053,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,120.54
FLAT WOUND DRAIN WITH TROCAR 4 CHANNEL FULL FLUTED 7FR SILICONE,27200000,CDM,272,RC,,,,12473-MAIN,LOCAL,,,,,123,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,112.053,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Office/Outpt Visit,New,Levl II",PX99202F,CDM,510,RC,99202,CPT,,,,,,,,123,,Medica,Commercial,both,91.1,,9.12,percent of total billed charges,112.053,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.0942,120.54
"Office/Outpt Visit,New,Levl II",PX99202P,CDM,983,RC,99202,CPT,,,,,,,,123,,Medica,Commercial,both,91.1,,9.12,percent of total billed charges,112.053,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.0942,119.7159
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,17478053802,NDC,2,ML,125.91,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,112.0599,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.068162,123.3918
"Hla Class II Low Res, 1 Locus - Ref",PX8137690,CDM,310,RC,81376,CPT,90,,,,,,,279,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,112.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.06,273.42
Drain/Inject Small Joint/Bursa,PX20600F,CDM,510,RC,20600,CPT,,,,,,,,161,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,112.07,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.82,112.07
Drain/Inject Small Joint/Bursa,PX20600P,CDM,983,RC,20600,CPT,,,,,,,,161,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,112.07,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.82,157.78
Exc Skn Bngn3.1-4cm Remain Bdy,PX11424P,CDM,983,RC,11424,CPT,,,,,,,,562,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,112.13,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.13,550.76
Fac/Exc Skn Bngn3.1-4cm Remain Bdy,PX11424F,CDM,510,RC,11424,CPT,,,,,,,,931,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,112.13,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.13,496.71
Heart/Lung Resuscitation (Cpr),PX92950F,CDM,480,RC,92950,CPT,,,,,,,,1366,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,112.13,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.13,564.83
Heart/Lung Resuscitation (Cpr),PX92950P,CDM,983,RC,92950,CPT,,,,,,,,1023,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,112.13,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.13,1002.54
Thrombin Time Plasma,PX85670,CDM,300,RC,85670,CPT,,,,,,,,126,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,112.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.29,123.48
adenosine 6 MG/2ML Solution 2 mL Syringe,J0153.01,CDM,636,RC,J0153,HCPCS,,,,25021030167,NDC,2,ML,123.1,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,112.1441,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.13574,120.638
fluorouracil 5 GM/100ML Solution 100 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,16729027638,NDC,100,ML,261.44,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,112.15776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,256.2112
"Closed Rx Radial Head Disloc,Child",PX24640F,CDM,510,RC,24640,CPT,,,,,,,,270,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,112.158,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.158,264.6
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157F,CDM,370,RC,99157,CPT,,,,,,,,270,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,112.158,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.158,264.6
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157P,CDM,983,RC,99157,CPT,,,,,,,,270,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,112.158,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.158,262.791
Wound Culture Anaerobic,PX87075,CDM,300,RC,87075,CPT,,,,,,,,270,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,112.158,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.68,264.6
naloxone 2 MG/2ML solution prefilled syringe 2 mL Syringe,J2310.01,CDM,636,RC,J2310,HCPCS,,,,76329346901,NDC,1,ML,114.45,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,112.161,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.54253,130.4968
levonorgestrel 1.5 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,62756071860,NDC,1,EA,114.48,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,112.1904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
patiromer sorbitex calcium 8.4 g Packet 4 Each Box,63700001,CDM,250,RC,,,,,,53436008404,NDC,1,EA,228.96,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,112.1904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
patiromer sorbitex calcium 8.4 g Packet 4 Each Box,63700001,CDM,250,RC,,,,,,53436008404,NDC,1,EA,228.96,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,112.1904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
patiromer sorbitex calcium 8.4 g Packet 4 Each Box,63700001,CDM,250,RC,,,,,,53436008404,NDC,1,EA,228.96,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,112.1904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Apply of Paste Boot,PX29580F,CDM,510,RC,29580,CPT,,,,,,,,132,,First Health,Commercial,both,85,,999999999,percent of total billed charges,112.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,137.65
Assay Dipropylacetic Acid,PX80164,CDM,300,RC,80164,CPT,,,,,,,,132,,First Health,Commercial,both,85,,999999999,percent of total billed charges,112.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.41,129.36
Assay of Lipase,PX83690,CDM,300,RC,83690,CPT,,,,,,,,132,,First Health,Commercial,both,85,,999999999,percent of total billed charges,112.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.32,129.36
"Remv F.B.,Eye,Superf Conjunc",PX65205F,CDM,510,RC,65205,CPT,,,,,,,,132,,First Health,Commercial,both,85,,999999999,percent of total billed charges,112.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,129.36
"Remv F.B.,Eye,Superf Conjunc",PX65205P,CDM,983,RC,65205,CPT,,,,,,,,132,,First Health,Commercial,both,85,,999999999,percent of total billed charges,112.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,128.4756
"Venipunc Need Phys Skill,Dx or Rx",PX36410,CDM,983,RC,36410,CPT,,,,,,,,132,,First Health,Commercial,both,85,,999999999,percent of total billed charges,112.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,128.4756
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010602,NDC,50,ML,126.07,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,112.2023,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010605,NDC,50,ML,126.07,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,112.2023,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
nitroglycerin in dextrose 5% 100-5 MCG/ML-% Solution 250 mL Glass Cont,J2305.01,CDM,636,RC,J2305,HCPCS,,,,338104702,NDC,250,ML,126.07,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,112.2023,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.17,123.5486
"Ctrl Nosebleed,Anter,Simple",PX30901P,CDM,983,RC,30901,CPT,,,,,,,,229,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,83.63333333,percent of total billed charges,112.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.1266,222.8857
"Ctrl Nosebleed,Anter,Simple",PX30901P,CDM,983,RC,30901,CPT,,,,,,,,229,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,112.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.1266,222.8857
"Ctrl Nosebleed,Anter,Simple",PX30901P,CDM,983,RC,30901,CPT,,,,,,,,229,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,112.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.1266,222.8857
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604P,CDM,983,RC,20604,CPT,,,,,,,,229,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,112.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.1266,258.75
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604P,CDM,983,RC,20604,CPT,,,,,,,,229,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,112.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.1266,258.75
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604P,CDM,983,RC,20604,CPT,,,,,,,,229,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,112.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.1266,258.75
Removal of Nail Plate,PX11730F,CDM,510,RC,11730,CPT,,,,,,,,229,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,112.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.1266,224.42
Removal of Nail Plate,PX11730F,CDM,510,RC,11730,CPT,,,,,,,,229,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,112.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.1266,224.42
Removal of Nail Plate,PX11730F,CDM,510,RC,11730,CPT,,,,,,,,229,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,112.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.1266,224.42
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409663724,NDC,50,ML,115.32,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,112.240956,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
CANNULA FOR INJECTION 1.8MM WITH 3MM LUER CONNECTION 8383.65,27200000,CDM,272,RC,,,,12004-MAIN,LOCAL,,,,,234,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,112.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CANNULA FOR INJECTION 1.8MM WITH 3MM LUER CONNECTION 8383.65,27200000,CDM,272,RC,,,,12004-MAIN,LOCAL,,,,,234,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,112.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Fibrinogen,PX7426,CDM,300,RC,85384,CPT,,,,,,,,234,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,112.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.91,229.32
Fibrinogen,PX7426,CDM,300,RC,85384,CPT,,,,,,,,234,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,112.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.91,229.32
sodium polystyrene sulfonate 15 GM/60ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,46287000660,NDC,60,ML,123.3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,112.3263,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU000390,CDM,300,RC,U0003,HCPCS,90,,,,,,,222,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,112.332,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.2188,217.56
Nfct Ds Bct/Vir Respir Dna/Rna 22 Trgt Sarscov2,PX0202U,CDM,300,RC,0202U,HCPCS,,,,,,,,222,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,112.332,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.2188,382.15
Observation Care Discharge,PX99217,CDM,982,RC,99217,CPT,,,,,,,,222,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,112.332,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.2188,216.0726
Heart/Lung Resuscitation (Cpr),PX92950F,CDM,480,RC,92950,CPT,,,,,,,,1366,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,112.34,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.13,564.83
Heart/Lung Resuscitation (Cpr),PX92950F,CDM,480,RC,92950,CPT,,,,,,,,1366,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,112.34,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.13,564.83
Heart/Lung Resuscitation (Cpr),PX92950P,CDM,983,RC,92950,CPT,,,,,,,,1023,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,112.34,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.13,1002.54
Heart/Lung Resuscitation (Cpr),PX92950P,CDM,983,RC,92950,CPT,,,,,,,,1023,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,112.34,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.13,1002.54
pegfilgrastim-jmdb 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5108.01,CDM,636,RC,Q5108,HCPCS,,,,67457083306,NDC,0.6,ML,10040,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,112.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.36,9839.2
SET SP TUBE INTRODUCER  14CM 8-14FR G15469,120.377,CDM,272,RC,,,,7147-MAIN,LOCAL,,,,,227,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,112.365,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.2958,222.46
Sp Stn for Inclusn Bodies - Ref,PX8720790,CDM,300,RC,87207,CPT,90,,,,,,,227,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,112.365,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.49,222.46
Tap Block Bilateral by Injection(S),PX64488P,CDM,983,RC,64488,CPT,,,,,,,,262,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,112.398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.8348,255.0046
lidocaine - transparent dressing 4 % Kit 1 Each Box,63700001,CDM,250,RC,,,,,,496088207,NDC,1,EA,270.63,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,112.419702,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LAPAROTOMY MAJOR I,27200000,CDM,272,RC,,,,4828-MAIN,LOCAL,,,,,123.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,112.5085,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042350,NDC,0.5,ML,132.37,,First Health,Commercial,both,85,,999999999,percent of total billed charges,112.5145,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.49,129.7226
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042388,NDC,0.5,ML,132.37,,First Health,Commercial,both,85,,999999999,percent of total billed charges,112.5145,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.49,129.7226
ePHEDrine sulfate 50 MG/ML Solution 1 mL Ampule,25000000,CDM,250,RC,,,,,,17478041510,NDC,1,ML,262.31,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,112.53099,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Colonoscopy,Flex,Diagnostic",PX45378F,CDM,750,RC,45378,CPT,,,,,,,,1286,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,112.56,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.56,704.94
"Colonoscopy,Flex,Diagnostic",PX45378P,CDM,983,RC,45378,CPT,,,,,,,,1200,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,112.56,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.56,1176
"Colonoscopy,Flex,Screen",PX2002F,CDM,750,RC,G0105,HCPCS,,,,,,,,2539,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,112.56,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.56,592.75
Strapping of Ankle,PX29540F,CDM,420,RC,29540,CPT,,,,,,,,271,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,112.5734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.5734,265.58
Path Special Stains II,PX3979,CDM,310,RC,88313,CPT,TC,,,,,,,107,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,112.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.44,116.608
Path Special Stains II,PX3979,CDM,310,RC,88313,CPT,TC,,,,,,,107,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,112.61,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.44,116.608
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037905,NDC,0.5,ML,229.88,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,12.26041667,percent of total billed charges,112.6412,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037905,NDC,0.5,ML,229.88,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,112.6412,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037905,NDC,0.5,ML,229.88,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,112.6412,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
LIGACLIP APPLIER CLIP STERILE SIZE MEDIUM LARGE,27200000,CDM,272,RC,,,,11699-MAIN,LOCAL,,,,,126.62,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,112.6918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Assay of Triglycerides,PX84478,CDM,300,RC,84478,CPT,,,,,,,,115,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,112.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.26,112.7
"Blood Typing, Rh Phenotype",PX86906,CDM,300,RC,86906,CPT,,,,,,,,115,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,112.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.03,112.7
BRACE ANKLE LARGE 264015,120.51,CDM,274,RC,L1902,HCPCS,,4-MAIN,LOCAL,,,,,115,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,112.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE MEDIUM 264014,120.51,CDM,274,RC,L1902,HCPCS,,7-MAIN,LOCAL,,,,,115,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,112.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE SMALL 264012,120.51,CDM,274,RC,L1902,HCPCS,,12-MAIN,LOCAL,,,,,115,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,112.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE X-LARGE 264016,120.51,CDM,274,RC,L1902,HCPCS,,14-MAIN,LOCAL,,,,,115,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,112.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
BRACE ANKLE X-SMALL 264011,120.51,CDM,274,RC,L1902,HCPCS,,1-MAIN,LOCAL,,,,,115,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,112.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
Debride Skin/Subq Ea Ad 20sqcm,PX11045F,CDM,510,RC,11045,CPT,,,,,,,,115,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,112.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.771,112.7
Glucagon - Ref,PX8294390,CDM,300,RC,82943,CPT,90,,,,,,,115,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,112.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.1,112.7
"Immuno for Tumor Ag, Qn - Ref",PX8631690,CDM,300,RC,86316,CPT,90,,,,,,,115,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,112.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,112.7
Microsomal Antibody,PX7893,CDM,300,RC,86376,CPT,,,,,,,,115,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,112.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.34,112.7
sodium phosphate 15 MMOLE/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323088401,NDC,5,ML,132.6,,First Health,Commercial,both,85,,999999999,percent of total billed charges,112.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium phosphate 15 MMOLE/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323088406,NDC,5,ML,132.6,,First Health,Commercial,both,85,,999999999,percent of total billed charges,112.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615900,NDC,1,EA,123.75,,Medica,Commercial,both,91.1,,5.442333333,percent of total billed charges,112.73625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615904,NDC,1,EA,123.75,,Medica,Commercial,both,91.1,,5.442333333,percent of total billed charges,112.73625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
"Apply Short Leg Cast,Walker",PX29425F,CDM,510,RC,29425,CPT,,,,,,,,179,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,112.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.81,159.11
"Apply Short Leg Cast,Walker",PX29425P,CDM,983,RC,29425,CPT,,,,,,,,119,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,112.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.81,159.11
Debride Muscle Ea Add 20 Sqcm,PX11046F,CDM,510,RC,11046,CPT,,,,,,,,248,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,112.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.5,151.5
Debride Muscle Ea Add 20 Sqcm,PX11046P,CDM,983,RC,11046,CPT,,,,,,,,198,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,112.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.5,194.04
Tap Block Unilateral by Injection(S),PX64486F,CDM,510,RC,64486,CPT,,,,,,,,253,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,112.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.81,231.06
Tap Block Unilateral by Injection(S),PX64486P,CDM,983,RC,64486,CPT,,,,,,,,169,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,112.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.81,231.06
"Colonoscopy,Screen Prev",PX2004F,CDM,750,RC,G0121,HCPCS,,,,,,,,2502,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,112.78,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.78,593.33
"Exc Skn Bngn2.1-3cm Fce,Facial",PX11443P,CDM,983,RC,11443,CPT,,,,,,,,650,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,112.78,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.78,637
"Fac/Exc Skn Bngn 2.1-3cmfce,Facial",PX11443F,CDM,510,RC,11443,CPT,,,,,,,,813,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,112.78,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.78,475.96
"MRI,Lwrext,No Jnt,No Cont",PX7371801,CDM,610,RC,73718,CPT,TC,,,,,,,3253,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,112.78,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.47,328.7
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152F,CDM,370,RC,99152,CPT,,,,,,,,235,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,112.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97.619,230.3
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152F,CDM,370,RC,99152,CPT,,,,,,,,235,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,112.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97.619,230.3
Occupational Therapy Eval Low Complex,PX97165,CDM,434,RC,97165,CPT,,,,,,,,235,,Health Partners,Health Partners Care Plans,both,48,,163.9125,percent of total billed charges,112.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,230.3
Occupational Therapy Eval Low Complex,PX97165,CDM,434,RC,97165,CPT,,,,,,,,235,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,112.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,230.3
Physical Therapy Evaluation Low Complex,PX97161,CDM,424,RC,97161,CPT,,,,,,,,235,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,112.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,392.7
Physical Therapy Evaluation Low Complex,PX97161,CDM,424,RC,97161,CPT,,,,,,,,235,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,112.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,392.7
Remv Ext Canal Foreign Body,PX69200F,CDM,510,RC,69200,CPT,,,,,,,,235,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,112.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97.619,230.3
Remv Ext Canal Foreign Body,PX69200F,CDM,510,RC,69200,CPT,,,,,,,,235,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,112.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97.619,230.3
"Vitamin D, 25 Hydroxy",PX82306,CDM,300,RC,82306,CPT,,,,,,,,235,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,112.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.14,230.3
"Vitamin D, 25 Hydroxy",PX82306,CDM,300,RC,82306,CPT,,,,,,,,235,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,112.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.14,230.3
"Office/Outpt Visit,New,Levl V",PX99205F,CDM,510,RC,99205,CPT,,,,,,,,456,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,112.82,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.82,395.88
"Office/Outpt Visit,New,Levl V",PX99205P,CDM,983,RC,99205,CPT,,,,,,,,456,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,112.82,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.82,446.88
"X-Ray Exam Hip,Unilat W/Pelvis 1vw",PX7350101,CDM,320,RC,73501,CPT,TC,,,,,,,263,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,112.827,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,257.74
"Apply Finger Splint,Static",PX29130P,CDM,983,RC,29130,CPT,,,,,,,,223,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,112.838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,217.0459
"Apply Forearm Splint,Static",PX29125F,CDM,510,RC,29125,CPT,,,,,,,,223,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,112.838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,218.54
"Flow Cyto, Tech, 1st Mrkr - Ref",PX8818490,CDM,310,RC,88184,CPT,90,,,,,,,223,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,112.838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,314.02
"Nephelometry, Each, Nos - Ref",PX8388390,CDM,300,RC,83883,CPT,90,,,,,,,223,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,112.838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.47,218.54
Reduce Temporomandibl Disloc,PX21480P,CDM,983,RC,21480,CPT,,,,,,,,223,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,112.838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,217.0459
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046204,NDC,30,ML,127.94,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,112.84308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Cpap/Bipap Mgmnt-Pt Own Equipment,PX94660.02F,CDM,410,RC,94660,CPT,,,,,,,,497,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,112.85,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.9,112.85
"POS Airway Pressure, Bipap",PX94660.01F,CDM,410,RC,94660,CPT,,,,,,,,468,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,112.85,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.9,112.85
"POS Airway Pressure, Cpap",PX94660F,CDM,410,RC,94660,CPT,,,,,,,,498,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,112.85,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.9,112.85
OXALiplatin 50 MG/10ML Solution 10 mL Vial,J9263.01,CDM,636,RC,J9263,HCPCS,,,,955173110,NDC,10,ML,228,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,112.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.7112,223.44
Canalith Repositioning,PX95992,CDM,420,RC,95992,CPT,,,,,,,,128,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,112.896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.86,125.44
Heparin Xa,PX85520,CDM,300,RC,85520,CPT,,,,,,,,128,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,112.896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12,125.44
Lab Pth Immunoch Part 1,PX83970,CDM,300,RC,83970,CPT,,,,,,,,128,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,112.896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.85,125.44
"N Block Inj, Common Digit",PX64632P,CDM,983,RC,64632,CPT,,,,,,,,128,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,112.896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.1712,258.75
Antithrombin III Ag Assay - Ref,PX8530190,CDM,300,RC,85301,CPT,90,,,,,,,116,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,112.9028,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.91,113.68
Ca 19-9,PX86301,CDM,300,RC,86301,CPT,,,,,,,,116,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,112.9028,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,113.68
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409421505,NDC,5,ML,271.86,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,112.930644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,143971801,NDC,200,ML,230.48,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,112.9352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.827512,225.8704
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,143971801,NDC,200,ML,230.48,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,112.9352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.827512,225.8704
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,143971801,NDC,200,ML,230.48,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,112.9352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.827512,225.8704
ID Nucleic Acid Sequencing - Ref,PX8715390,CDM,300,RC,87153,CPT,90,,,,,,,265,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,112.9568,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.9,115.36
Assay of Lithium,PX80178,CDM,300,RC,80178,CPT,,,,,,,,124,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,112.964,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.06,121.52
"Complement; Antigen, Each Component",PX86160,CDM,300,RC,86160,CPT,,,,,,,,124,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,112.964,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11,121.52
"Immunoassay,Ca15-3(27.29) - Ref",PX8630090,CDM,300,RC,86300,CPT,90,,,,,,,124,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,112.964,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,121.52
Itraconazole,PX8018990,CDM,300,RC,80189,CPT,90,,,,,,,124,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,112.964,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.86,121.52
Microbe Susceptible Mic,PX87186,CDM,300,RC,87186,CPT,,,,,,,,124,,Medica,Commercial,both,91.1,,6.8325,percent of total billed charges,112.964,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.93,121.52
Nocardia Susceptibility - Ref,PX8718690,CDM,300,RC,87186,CPT,90,,,,,,,124,,Medica,Commercial,both,91.1,,6.8325,percent of total billed charges,112.964,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.93,121.52
Oligoclonal Bands - Ref,PX8391690,CDM,300,RC,83916,CPT,90,,,,,,,124,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,112.964,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.11,121.52
UMBILICAL VESSEL CATHETER INSERTION TRAY POLY SINGLE LUMEN 3.5/5FR,120.573,CDM,272,RC,,,,12857-MAIN,LOCAL,,,,,124,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,112.964,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.5096,121.52
methylPREDNISolone sod succ 1000 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9001820,NDC,1,EA,271.97,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,112.976338,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611P,CDM,983,RC,20611,CPT,,,,,,,,272,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,112.9888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.9888,264.7376
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,409277602,NDC,200,ML,228.28,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,112.9986,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.827512,225.8704
"MRI,Pelvis W/Out Contrast",PX7219501,CDM,610,RC,72195,CPT,TC,,,,,,,3253,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,113,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.69,329.36
"Tiss Cult,Non-Neop Lymph - Ref",PX8823090,CDM,310,RC,88230,CPT,90,,,,,,,103,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,113,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,113,116.49
"Tiss Cult,Non-Neop Lymph - Ref",PX8823090,CDM,310,RC,88230,CPT,90,,,,,,,103,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,113,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,113,116.49
"Tiss Cult,Non-Neop Lymph - Ref",PX8823090,CDM,310,RC,88230,CPT,90,,,,,,,103,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,113,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,113,116.49
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409663724,NDC,50,ML,115.32,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,113.0136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
B-Scan Global,PX7651201,CDM,402,RC,76512,CPT,TC,,,,,,,127,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,113.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.7558,124.46
Candida Dna Dir Probe,PX87480,CDM,300,RC,87480,CPT,,,,,,,,127,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,113.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.38,124.46
Gardner Vag Dna Dir Probe,PX87510,CDM,300,RC,87510,CPT,,,,,,,,127,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,113.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.38,124.46
Influenza Assay W/Optic,PX87804,CDM,300,RC,87804,CPT,,,,,,,,127,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,113.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.17,124.46
Trichomonas Vagin Dir Probe,PX87660,CDM,300,RC,87660,CPT,,,,,,,,127,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,113.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.38,124.46
"Cardiolipin Ab, Ea Lg - Ref",PX8614790,CDM,300,RC,86147,CPT,90,,,,,,,133,,First Health,Commercial,both,85,,999999999,percent of total billed charges,113.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.34,130.34
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU0003,CDM,300,RC,U0003,HCPCS,,,,,,,,133,,First Health,Commercial,both,85,,999999999,percent of total billed charges,113.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.2482,130.34
Lvl 1 Sub Hosp Low Mdm or 25 Minutes,PX99231,CDM,982,RC,99231,CPT,,,,,,,,133,,First Health,Commercial,both,85,,999999999,percent of total billed charges,113.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.2482,129.4489
"Transvaginal US, Obstetric",PX7681701,CDM,402,RC,76817,CPT,TC,,,,,,,460,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,113.07,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.97,113.07
"Transvaginal US, Obstetric",PX7681701,CDM,402,RC,76817,CPT,TC,,,,,,,460,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,113.07,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.97,113.07
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,63323027301,NDC,0.5,ML,235.6,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,113.088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,63323027301,NDC,0.5,ML,235.6,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,113.088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
methylergonovine 0.2 MG/ML Solution 1 mL Ampule,J2210.01,CDM,636,RC,J2210,HCPCS,,,,51991014417,NDC,1,ML,133.11,,First Health,Commercial,both,85,,999999999,percent of total billed charges,113.1435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.293894,130.4478
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059900,NDC,1,ML,133.16,,First Health,Commercial,both,85,,999999999,percent of total billed charges,113.186,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.54253,130.4968
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059902,NDC,1,ML,133.16,,First Health,Commercial,both,85,,999999999,percent of total billed charges,113.186,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.54253,130.4968
Inj Tendon/Ligament/Cyst,PX20550P,CDM,983,RC,20550,CPT,,,,,,,,264,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,113.256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.6656,258.75
Occupational Therapy Eval Mod Complex,PX97166,CDM,434,RC,97166,CPT,,,,,,,,264,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,113.256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,258.72
Physical Therapy Evaluation Mod Complex,PX97162,CDM,424,RC,97162,CPT,,,,,,,,264,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,113.256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,258.72
Renal Function Panel,PX80069,CDM,300,RC,80069,CPT,,,,,,,,264,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,113.256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.96,258.72
"Biopsy Vulva/Perineum,One Lesn",PX56605F,CDM,510,RC,56605,CPT,,,,,,,,236,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,113.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.0344,702.31
"Biopsy Vulva/Perineum,One Lesn",PX56605F,CDM,510,RC,56605,CPT,,,,,,,,236,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,113.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.0344,702.31
Lab Basic Metabolic Panel,PX80048,CDM,300,RC,80048,CPT,,,,,,,,236,,Health Partners,Health Partners Care Plans,both,48,,105.3263636,percent of total billed charges,113.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.76,231.28
Lab Basic Metabolic Panel,PX80048,CDM,300,RC,80048,CPT,,,,,,,,236,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,113.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.76,231.28
TRUMPET SUCTION IRRIGATION,27100000,CDM,271,RC,,,,4577-MAIN,LOCAL,,,,,116.4,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,113.29212,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,409672924,NDC,50,ML,116.43,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,14.23621053,percent of total billed charges,113.321319,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
patiromer sorbitex calcium 8.4 g Packet 4 Each Box,63700001,CDM,250,RC,,,,,,53436008404,NDC,1,EA,228.96,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,113.3352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Body Fluid Cell Count W Diff,PX89051,CDM,300,RC,89051,CPT,,,,,,,,224,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,113.344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.13,219.52
Emergency Level I Visit,PX99281P,CDM,981,RC,99281,CPT,,,,,,,,224,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,113.344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.56,218.0192
ENDOWRIST INSTRUMENTS PERMANENT CAUTERY HOOK 8MM,27200000,CDM,272,RC,,,,12050-MAIN,LOCAL,,,,,224,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,113.344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Helicobacter Pylori Ab,PX86677,CDM,300,RC,86677,CPT,,,,,,,,224,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,113.344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.45,219.52
"Ctrl Nosebleed,Anter,Simple",PX30901P,CDM,983,RC,30901,CPT,,,,,,,,229,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,113.355,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.1266,222.8857
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604P,CDM,983,RC,20604,CPT,,,,,,,,229,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,113.355,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.1266,258.75
Removal of Nail Plate,PX11730F,CDM,510,RC,11730,CPT,,,,,,,,229,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,113.355,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.1266,224.42
"Colonoscopy,Flex,Diagnostic",PX45378F,CDM,750,RC,45378,CPT,,,,,,,,1286,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,113.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.56,704.94
"Colonoscopy,Flex,Diagnostic",PX45378F,CDM,750,RC,45378,CPT,,,,,,,,1286,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,113.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.56,704.94
"Colonoscopy,Flex,Diagnostic",PX45378P,CDM,983,RC,45378,CPT,,,,,,,,1200,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,113.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.56,1176
"Colonoscopy,Flex,Diagnostic",PX45378P,CDM,983,RC,45378,CPT,,,,,,,,1200,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,113.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.56,1176
"Colonoscopy,Flex,Screen",PX2002F,CDM,750,RC,G0105,HCPCS,,,,,,,,2539,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,113.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.56,592.75
"Colonoscopy,Flex,Screen",PX2002F,CDM,750,RC,G0105,HCPCS,,,,,,,,2539,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,113.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.56,592.75
"Colonoscopy,Screen Prev",PX2004F,CDM,750,RC,G0121,HCPCS,,,,,,,,2502,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,113.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.78,593.33
"Colonoscopy,Screen Prev",PX2004F,CDM,750,RC,G0121,HCPCS,,,,,,,,2502,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,113.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.78,593.33
MRI Orbit/Face/Neck Tc,PX7054001,CDM,610,RC,70540,CPT,TC,,,,,,,3335,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,113.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,113.43,334.62
MRI Orbit/Face/Neck Tc,PX7054001,CDM,610,RC,70540,CPT,TC,,,,,,,3335,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,113.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,113.43,334.62
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315606,NDC,100,ML,264.64,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,113.53056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.931456,259.3472
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315695,NDC,100,ML,264.64,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,113.53056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.931456,259.3472
Antithrombin III Ag Assay - Ref,PX8530190,CDM,300,RC,85301,CPT,90,,,,,,,116,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,113.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.91,113.68
Bile Acids Total,PX8223990,CDM,300,RC,82239,CPT,90,,,,,,,232,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,113.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,227.36
Bile Acids Total,PX8223990,CDM,300,RC,82239,CPT,90,,,,,,,232,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,113.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,227.36
Bile Acids Total,PX8223990,CDM,300,RC,82239,CPT,90,,,,,,,232,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,113.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,227.36
Ca 19-9,PX86301,CDM,300,RC,86301,CPT,,,,,,,,116,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,113.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,113.68
Haptoglobin; Quantitative,PX83010,CDM,300,RC,83010,CPT,,,,,,,,265,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,113.685,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.53,259.7
ID Nucleic Acid Sequencing - Ref,PX8715390,CDM,300,RC,87153,CPT,90,,,,,,,265,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,113.685,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.77,259.7
octreotide 200 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037805,NDC,1,ML,133.77,,First Health,Commercial,both,85,,999999999,percent of total billed charges,113.7045,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
Complete Cbc Automated,PX85027,CDM,300,RC,85027,CPT,,,,,,,,129,,United Healthcare,All Payer,outpatient,88.2,,108.938,percent of total billed charges,113.778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,126.42
"Venipunc Need Phys Skill,Dx or Rx",PX36410P,CDM,983,RC,36410,CPT,,,,,,,,129,,United Healthcare,All Payer,outpatient,88.2,,8.745,percent of total billed charges,113.778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.5866,125.5557
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037905,NDC,0.5,ML,229.88,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,113.7906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
SUMAtriptan 25 MG Tablet 9 Each Box,63700001,CDM,250,RC,,,,,,65862014636,NDC,1,EA,129.04,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,113.81328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597P,CDM,983,RC,97597,CPT,,,,,,,,274,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,113.8196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,113.8196,266.6842
SPLINT ANKLE GEL BRACE UNIVERSAL AIRFORM 70351,120.61,CDM,274,RC,L4350,HCPCS,,12342-MAIN,LOCAL,,,,,88,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,113.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.15,113.84
SPLINT ANKLE GEL BRACE UNIVERSAL AIRFORM 70351,120.61,CDM,274,RC,L4350,HCPCS,,12342-MAIN,LOCAL,,,,,88,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,113.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.15,113.84
SPLINT ANKLE GEL BRACE UNIVERSAL AIRFORM 70351,120.61,CDM,274,RC,L4350,HCPCS,,12342-MAIN,LOCAL,,,,,88,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,113.84,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.15,113.84
"Cytoflo, Cell or Dna Anal - Ref",PX8818290,CDM,310,RC,88182,CPT,90,,,,,,,225,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,113.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,220.5
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153F,CDM,370,RC,99153,CPT,,,,,,,,225,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,113.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.465,220.5
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505624500,NDC,1,EA,116.99,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,18.705,percent of total billed charges,113.866367,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046204,NDC,30,ML,127.94,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,113.8666,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Exc Skn Malig1.1-2cm Fce,Facal",PX11642P,CDM,983,RC,11642,CPT,,,,,,,,466,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,113.87,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,113.87,558.97
"Fac/Exc Skn Malig .1-2cm Fce,Facal",PX11642F,CDM,510,RC,11642,CPT,,,,,,,,698,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,113.87,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,113.87,558.97
Cmv Igm Antibody - Ref,PX8664590,CDM,300,RC,86645,CPT,90,,,,,,,125,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,113.875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.45,122.5
DRESSING SURGICEL HEMOSTAT 4X8 ABSORBABLE 1952,120.123,CDM,272,RC,A6252,HCPCS,,1002-MAIN,LOCAL,,,,,125,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,113.875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.925,122.5
Factor VII - Ref,PX8523090,CDM,300,RC,85230,CPT,90,,,,,,,125,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,113.875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.41,122.5
Cryptosporidum,PX87328,CDM,300,RC,87328,CPT,,,,,,,,117,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,113.8761,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.67,114.66
Drain Blood From Under Nail,PX11740F,CDM,510,RC,11740,CPT,,,,,,,,117,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,89.735,percent of total billed charges,113.8761,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.6018,114.66
Giardia,PX87329,CDM,300,RC,87329,CPT,,,,,,,,117,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,113.8761,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,114.66
"In Situ Hybridization (Eg, Fish), Each Probe, Tech",PX8836501,CDM,310,RC,88365,CPT,TC,,,,,,,117,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,113.8761,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.6018,149.22
RBC Pretreatment,PX8697002,CDM,300,RC,86970,CPT,,,,,,,,117,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,113.8761,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.6018,114.66
Canalith Repositioning,PX95992,CDM,420,RC,95992,CPT,,,,,,,,128,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,113.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.86,125.44
Heparin Xa,PX85520,CDM,300,RC,85520,CPT,,,,,,,,128,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,113.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12,125.44
Lab Pth Immunoch Part 1,PX83970,CDM,300,RC,83970,CPT,,,,,,,,128,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,113.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.85,125.44
"N Block Inj, Common Digit",PX64632P,CDM,983,RC,64632,CPT,,,,,,,,128,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,113.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.1712,258.75
albuterol (5 MG/ML) 0.5% Nebulization Solution 20 mL Bottle,J7611.01,CDM,250,RC,,,,,,50383074120,NDC,20,ML,225.2,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,113.9512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.54808,220.696
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800F,CDM,510,RC,40800,CPT,,,,,,,,255,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,113.9905,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.35,420.61
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800P,CDM,983,RC,40800,CPT,,,,,,,,170,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,113.9905,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.35,420.61
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133F,CDM,510,RC,13133,CPT,,,,,,,,595,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,113.9905,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77,348.67
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133P,CDM,983,RC,13133,CPT,,,,,,,,256,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,113.9905,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77,348.67
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062160,NDC,0.6,ML,274.53,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,114.039762,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801601,NDC,0.6,ML,274.53,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,114.039762,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801610,NDC,0.6,ML,274.53,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,114.039762,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
TRUMPET SUCTION IRRIGATION,27100000,CDM,271,RC,,,,4577-MAIN,LOCAL,,,,,116.4,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,114.072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,143971801,NDC,200,ML,230.48,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,114.0876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.827512,225.8704
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,63323072902,NDC,1,EA,265.95,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,114.09255,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.47563,793.6922
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,409672924,NDC,50,ML,116.43,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,114.1014,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
"Initial Observation Care,Levl I",PX99218,CDM,982,RC,99218,CPT,,,,,,,,266,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,114.114,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.4964,258.8978
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597F,CDM,510,RC,97597,CPT,,,,,,,,266,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,114.114,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.4964,260.68
TRAY GROSHONG 4FR SAFETY PICC 7617407,120.26,CDM,272,RC,,,,500-MAIN,LOCAL,,,,,233,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,114.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.7882,228.34
TRAY GROSHONG 4FR SAFETY PICC 7617407,120.26,CDM,272,RC,,,,500-MAIN,LOCAL,,,,,233,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,114.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.7882,228.34
TRAY GROSHONG 4FR SAFETY PICC 7617407,120.26,CDM,272,RC,,,,500-MAIN,LOCAL,,,,,233,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,114.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.7882,228.34
Immunocytochemistry,PX3993,CDM,310,RC,88342,CPT,TC,,,,,,,182,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,114.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.41,118.24
Immunocytochemistry,PX3993,CDM,310,RC,88342,CPT,TC,,,,,,,182,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,114.19,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.41,118.24
LEGGING COMPRESSION JUXTALITE LONG LG 33CM,120.369,CDM,271,RC,A6545,HCPCS,,10840-MAIN,LOCAL,,,,,145,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,114.2,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.43,189.328
LEGGING COMPRESSION JUXTALITE LONG LG 33CM,120.369,CDM,271,RC,A6545,HCPCS,,10840-MAIN,LOCAL,,,,,145,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,114.2035,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.43,189.328
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,49884093547,NDC,100,GR,266.25,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,114.22125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151P,CDM,983,RC,99151,CPT,,,,,,,,275,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,114.235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,114.235,267.6575
Phlebotomy,PX99195,CDM,940,RC,99195,CPT,,,,,,,,238,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,114.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.8652,233.24
Phlebotomy,PX99195,CDM,940,RC,99195,CPT,,,,,,,,238,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,114.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.8652,233.24
"Tiss Cult,Non-Neop Lymph - Ref",PX8823090,CDM,310,RC,88230,CPT,90,,,,,,,103,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,114.2404,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,113,116.49
ROPivacaine 2 MG/ML Solution 100 mL Bottle,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028568,NDC,100,ML,275.11,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,114.280694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.604954,269.6078
"Exc Skn Bngn2.1-3cm Fce,Facial",PX11443P,CDM,983,RC,11443,CPT,,,,,,,,650,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,114.3,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.78,637
"Exc Skn Bngn2.1-3cm Fce,Facial",PX11443P,CDM,983,RC,11443,CPT,,,,,,,,650,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,114.3,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.78,637
"Fac/Exc Skn Bngn 2.1-3cmfce,Facial",PX11443F,CDM,510,RC,11443,CPT,,,,,,,,813,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,114.3,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.78,475.96
"Fac/Exc Skn Bngn 2.1-3cmfce,Facial",PX11443F,CDM,510,RC,11443,CPT,,,,,,,,813,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,114.3,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.78,475.96
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,63323050830,NDC,1,EA,134.48,,First Health,Commercial,both,85,,999999999,percent of total billed charges,114.308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.461584,189.875
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821517,NDC,3,ML,275.33,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,114.372082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
Sleep Staging 4 + Pap,PX9581126,CDM,982,RC,95811,CPT,26,,,,,,,1850,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,114.3828,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.22,1813
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320885,NDC,0.5,EA,129.71,,United Healthcare,All Payer,outpatient,88.2,,201.07,percent of total billed charges,114.40422,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320895,NDC,0.5,EA,129.71,,United Healthcare,All Payer,outpatient,88.2,,201.07,percent of total billed charges,114.40422,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
Kit Gene Analysis D816 Variant(S) - Ref,PX8127390,CDM,300,RC,81273,CPT,90,,,,,,,293,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,114.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,114.49,287.14
Remove Foreign Body Complic,PX10121F,CDM,510,RC,10121,CPT,,,,,,,,3575,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,114.52,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,114.52,551.36
Remove Foreign Body Complic,PX10121P,CDM,983,RC,10121,CPT,,,,,,,,651,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,114.52,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,114.52,637.98
Xray Shoulder 1 Vw,PX7302001,CDM,320,RC,73020,CPT,TC,,,,,,,267,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,114.543,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,261.66
fentaNYL 50 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,406905076,NDC,1,EA,125.74,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,114.54914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CT Lumbar Spine W/Dye,PX7213201,CDM,350,RC,72132,CPT,TC,,,,,,,3330,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,114.56,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,114.56,229.43
CT Lumbar Spine W/Dye,PX7213201,CDM,350,RC,72132,CPT,TC,,,,,,,3330,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,114.5608,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,114.56,229.43
DAPTOmycin 500 MG Recon Soln 1 Each Vial,J0878.01,CDM,636,RC,J0878,HCPCS,,,,70594003402,NDC,1,EA,129.9,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,114.5718,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.96046,127.302
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915801,NDC,1,ML,267.19,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,114.62451,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505624500,NDC,1,EA,116.99,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,114.6502,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
Culture Screen Only,PX87081,CDM,300,RC,87081,CPT,,,,,,,,276,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,114.6504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.08,270.48
CANNULA FOR INJECTION 1.8MM WITH 3MM LUER CONNECTION 8383.65,27200000,CDM,272,RC,,,,12004-MAIN,LOCAL,,,,,234,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,114.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CANNULA FOR INJECTION 1.8MM WITH 3MM LUER CONNECTION 8383.65,27200000,CDM,272,RC,,,,12004-MAIN,LOCAL,,,,,234,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,114.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CANNULA FOR INJECTION 1.8MM WITH 3MM LUER CONNECTION 8383.65,27200000,CDM,272,RC,,,,12004-MAIN,LOCAL,,,,,234,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,114.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Chemo Ad Sq/Im Hormnl Anti-Neo,PX96402,CDM,335,RC,96402,CPT,,,,,,,,130,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,114.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,127.4
Cryptosporidum,PX87328,CDM,300,RC,87328,CPT,,,,,,,,117,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,114.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.67,114.66
Cystatin C - Ref,PX8261090,CDM,300,RC,82610,CPT,90,,,,,,,130,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,114.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.98,127.4
Drain Blood From Under Nail,PX11740F,CDM,510,RC,11740,CPT,,,,,,,,117,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,114.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.6018,114.66
Each Add'l Sequential Push New Drug,PX96375,CDM,260,RC,96375,CPT,,,,,,,,130,,United Healthcare,All Payer,outpatient,88.2,,97.628,percent of total billed charges,114.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,127.4
Fibrinogen,PX7426,CDM,300,RC,85384,CPT,,,,,,,,234,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,114.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.91,229.32
Fibrinogen,PX7426,CDM,300,RC,85384,CPT,,,,,,,,234,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,114.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.91,229.32
Fibrinogen,PX7426,CDM,300,RC,85384,CPT,,,,,,,,234,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,114.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.91,229.32
Giardia,PX87329,CDM,300,RC,87329,CPT,,,,,,,,117,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,114.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,114.66
Immunization Administration; One Vaccine (Single or Combination Vaccine/To*,PX90471,CDM,771,RC,90471,CPT,,,,,,,,130,,United Healthcare,All Payer,outpatient,88.2,,89.69,percent of total billed charges,114.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,127.4
"In Situ Hybridization (Eg, Fish), Each Probe, Tech",PX8836501,CDM,310,RC,88365,CPT,TC,,,,,,,117,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,114.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.6018,149.22
Prothrombin Time (Pt/Inr),PX85610,CDM,300,RC,85610,CPT,,,,,,,,130,,United Healthcare,All Payer,outpatient,88.2,,95.69642857,percent of total billed charges,114.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.93,127.4
RBC Pretreatment,PX8697002,CDM,300,RC,86970,CPT,,,,,,,,117,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,114.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.6018,114.66
SPLINT WRIST LARGE ALUMINUM FOREARM LEFT 9101-06,120.87,CDM,274,RC,L3809,HCPCS,,1265-MAIN,LOCAL,,,,,130,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,114.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST LARGE ALUMINUM FOREARM RIGHT 9101-03,120.87,CDM,274,RC,L3809,HCPCS,,1263-MAIN,LOCAL,,,,,130,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,114.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST MEDIUM ALUMINUM FOREARM LEFT 9101-05,120.87,CDM,274,RC,L3809,HCPCS,,1264-MAIN,LOCAL,,,,,130,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,114.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST MEDIUM ALUMINUM FOREARM RIGHT 9101-02,120.87,CDM,274,RC,L3809,HCPCS,,1262-MAIN,LOCAL,,,,,130,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,114.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
Vitamin B-1 - Ref,PX8442590,CDM,300,RC,84425,CPT,90,,,,,,,130,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,114.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.47,127.4
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052331,NDC,2,ML,125.89,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,114.68579,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.294706,123.3722
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052341,NDC,2,ML,125.89,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,114.68579,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.294706,123.3722
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,17478053802,NDC,2,ML,125.91,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,114.70401,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.068162,123.3918
Physical Therapy Re-Eval Est Plan Care 20 Mins,PX97164,CDM,424,RC,97164,CPT,,,,,,,,239,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,114.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,234.22
Physical Therapy Re-Eval Est Plan Care 20 Mins,PX97164,CDM,424,RC,97164,CPT,,,,,,,,239,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,114.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,234.22
Exc Skn Bngn3.1-4cm Remain Bdy,PX11424P,CDM,983,RC,11424,CPT,,,,,,,,562,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,114.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.13,550.76
Exc Skn Bngn3.1-4cm Remain Bdy,PX11424P,CDM,983,RC,11424,CPT,,,,,,,,562,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,114.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.13,550.76
Fac/Exc Skn Bngn3.1-4cm Remain Bdy,PX11424F,CDM,510,RC,11424,CPT,,,,,,,,931,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,114.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.13,496.71
Fac/Exc Skn Bngn3.1-4cm Remain Bdy,PX11424F,CDM,510,RC,11424,CPT,,,,,,,,931,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,114.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.13,496.71
MRI Orbit/Face/Neck Tc,PX7054001,CDM,610,RC,70540,CPT,TC,,,,,,,3335,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,114.74,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,113.43,334.62
ofloxacin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,17478071310,NDC,5,ML,117.89,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,114.742337,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Cognitive Funct Ther Interv, per Day",PX97127,CDM,420,RC,97127,CPT,,,,,,,,135,,First Health,Commercial,both,85,,999999999,percent of total billed charges,114.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.079,132.3
Electric Stimulation Therapy,PX97014,CDM,420,RC,97014,CPT,,,,,,,,135,,First Health,Commercial,both,85,,999999999,percent of total billed charges,114.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.18,132.3
Electrical Stimulation,PX97032,CDM,420,RC,97032,CPT,,,,,,,,135,,First Health,Commercial,both,85,,999999999,percent of total billed charges,114.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,132.3
Gait Training Therapy,PX97116,CDM,420,RC,97116,CPT,,,,,,,,135,,First Health,Commercial,both,85,,999999999,percent of total billed charges,114.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20,132.3
"Manual Ther Tech,1+Regions,Ea 15 Min",PX97140,CDM,420,RC,97140,CPT,,,,,,,,135,,First Health,Commercial,both,85,,999999999,percent of total billed charges,114.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.4,215.05
Mechanical Traction Therapy,PX97012,CDM,420,RC,97012,CPT,,,,,,,,135,,First Health,Commercial,both,85,,999999999,percent of total billed charges,114.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,132.3
Neuromuscular Re-Education,PX97112,CDM,420,RC,97112,CPT,,,,,,,,135,,First Health,Commercial,both,85,,999999999,percent of total billed charges,114.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.95,215.05
Self Care Mngment Training,PX97535,CDM,420,RC,97535,CPT,,,,,,,,135,,First Health,Commercial,both,85,,999999999,percent of total billed charges,114.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.27,132.3
Therapeutic Activities,PX97530,CDM,420,RC,97530,CPT,,,,,,,,135,,First Health,Commercial,both,85,,999999999,percent of total billed charges,114.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.22,205.7
Therapeutic Exercises,PX97110,CDM,420,RC,97110,CPT,,,,,,,,135,,First Health,Commercial,both,85,,999999999,percent of total billed charges,114.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20,215.05
Ultrasound Therapy,PX97035,CDM,420,RC,97035,CPT,,,,,,,,135,,First Health,Commercial,both,85,,999999999,percent of total billed charges,114.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,132.3
DRAIN FLAT JACKSON PRATT 10MM,27100000,CDM,271,RC,,,,334-MAIN,LOCAL,,,,,239.09,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,114.7632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
DRAIN FLAT JACKSON PRATT 10MM,27100000,CDM,271,RC,,,,334-MAIN,LOCAL,,,,,239.09,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,114.7632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
Thrombin Time Plasma,PX85670,CDM,300,RC,85670,CPT,,,,,,,,126,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,114.786,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.29,123.48
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614800,NDC,1,EA,239.18,,Health Partners,Health Partners Care Plans,both,48,,26.64321429,percent of total billed charges,114.8064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614800,NDC,1,EA,239.18,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,114.8064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
Complete Cbc Automated,PX85027,CDM,300,RC,85027,CPT,,,,,,,,129,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,114.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,126.42
"Venipunc Need Phys Skill,Dx or Rx",PX36410P,CDM,983,RC,36410,CPT,,,,,,,,129,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,114.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.5866,125.5557
Bile Acids Total,PX8223990,CDM,300,RC,82239,CPT,90,,,,,,,232,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,114.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,227.36
Drain/Inject Medium Joint/Bursa,PX20605F,CDM,510,RC,20605,CPT,,,,,,,,247,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,114.84,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.47,114.84
Drain/Inject Medium Joint/Bursa,PX20605P,CDM,983,RC,20605,CPT,,,,,,,,318,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,114.84,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.47,311.64
Repr Superf Wnd Face <2.5cm,PX12011F,CDM,510,RC,12011,CPT,,,,,,,,335,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,114.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.94,233.83
Repr Superf Wnd Face <2.5cm,PX12011P,CDM,983,RC,12011,CPT,,,,,,,,461,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,114.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.94,451.78
SUMAtriptan 25 MG Tablet 9 Each Box,63700001,CDM,250,RC,,,,,,65862014636,NDC,1,EA,129.04,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,114.8456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Fibrinolysins Screen - Ref,PX8539090,CDM,300,RC,85390,CPT,90,,,,,,,118,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,114.8494,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.19,115.64
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010602,NDC,50,ML,126.07,,Medica,Commercial,both,91.1,,6.305,percent of total billed charges,114.84977,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010605,NDC,50,ML,126.07,,Medica,Commercial,both,91.1,,6.305,percent of total billed charges,114.84977,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
nitroglycerin in dextrose 5% 100-5 MCG/ML-% Solution 250 mL Glass Cont,J2305.01,CDM,636,RC,J2305,HCPCS,,,,338104702,NDC,250,ML,126.07,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,114.84977,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.17,123.5486
SET SP TUBE INTRODUCER  14CM 8-14FR G15469,120.377,CDM,272,RC,,,,7147-MAIN,LOCAL,,,,,227,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,114.862,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.2958,222.46
Sp Stn for Inclusn Bodies - Ref,PX8720790,CDM,300,RC,87207,CPT,90,,,,,,,227,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,114.862,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.49,222.46
CT Lower Extremity W/Dye,PX7370101,CDM,350,RC,73701,CPT,TC,,,,,,,2690,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,114.8826,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.88,230.09
Diagnostic CT Thorax W/ Contrast,PX7126001,CDM,350,RC,71260,CPT,TC,,,,,,,3415,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,114.8826,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.88,230.09
tropicamide 1 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,61314035502,NDC,15,ML,267.96,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,114.95484,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Exc Skn Malig1.1-2cm Fce,Facal",PX11642P,CDM,983,RC,11642,CPT,,,,,,,,466,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,114.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,113.87,558.97
"Exc Skn Malig1.1-2cm Fce,Facal",PX11642P,CDM,983,RC,11642,CPT,,,,,,,,466,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,114.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,113.87,558.97
"Fac/Exc Skn Malig .1-2cm Fce,Facal",PX11642F,CDM,510,RC,11642,CPT,,,,,,,,698,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,114.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,113.87,558.97
"Fac/Exc Skn Malig .1-2cm Fce,Facal",PX11642F,CDM,510,RC,11642,CPT,,,,,,,,698,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,114.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,113.87,558.97
triamcinolone acetonide 0.1 % Cream 454 g Jar,63700001,CDM,250,RC,,,,,,45802006405,NDC,454,GR,130.36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,114.97752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Chrom Anal 15-20 Cells - Ref,PX8826290,CDM,310,RC,88262,CPT,90,,,,,,,398,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,115.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.06,390.04
"Molecular Cytog, Ea Probe - Ref",PX8827190,CDM,310,RC,88271,CPT,90,,,,,,,277,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,115.0658,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.64,271.46
"Xray Neck, Soft Tissue",PX7036001,CDM,320,RC,70360,CPT,TC,,,,,,,277,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,115.0658,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,271.46
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337501,NDC,50,ML,135.43,,First Health,Commercial,both,85,,999999999,percent of total billed charges,115.1155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337502,NDC,50,ML,135.43,,First Health,Commercial,both,85,,999999999,percent of total billed charges,115.1155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9678001,NDC,50,ML,135.43,,First Health,Commercial,both,85,,999999999,percent of total billed charges,115.1155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152F,CDM,370,RC,99152,CPT,,,,,,,,235,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,115.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97.619,230.3
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152F,CDM,370,RC,99152,CPT,,,,,,,,235,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,115.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97.619,230.3
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152F,CDM,370,RC,99152,CPT,,,,,,,,235,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,115.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97.619,230.3
Occupational Therapy Eval Low Complex,PX97165,CDM,434,RC,97165,CPT,,,,,,,,235,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,54.4940625,percent of total billed charges,115.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,230.3
Occupational Therapy Eval Low Complex,PX97165,CDM,434,RC,97165,CPT,,,,,,,,235,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,115.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,230.3
Occupational Therapy Eval Low Complex,PX97165,CDM,434,RC,97165,CPT,,,,,,,,235,,United Healthcare,All Medicare advantage plans,outpatient,49,,120.84,percent of total billed charges,115.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,230.3
Physical Therapy Evaluation Low Complex,PX97161,CDM,424,RC,97161,CPT,,,,,,,,235,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,23.32,percent of total billed charges,115.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,392.7
Physical Therapy Evaluation Low Complex,PX97161,CDM,424,RC,97161,CPT,,,,,,,,235,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,115.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,392.7
Physical Therapy Evaluation Low Complex,PX97161,CDM,424,RC,97161,CPT,,,,,,,,235,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,115.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,392.7
Remv Ext Canal Foreign Body,PX69200F,CDM,510,RC,69200,CPT,,,,,,,,235,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,115.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97.619,230.3
Remv Ext Canal Foreign Body,PX69200F,CDM,510,RC,69200,CPT,,,,,,,,235,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,115.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97.619,230.3
Remv Ext Canal Foreign Body,PX69200F,CDM,510,RC,69200,CPT,,,,,,,,235,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,115.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97.619,230.3
"Vitamin D, 25 Hydroxy",PX82306,CDM,300,RC,82306,CPT,,,,,,,,235,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,115.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.14,230.3
"Vitamin D, 25 Hydroxy",PX82306,CDM,300,RC,82306,CPT,,,,,,,,235,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,115.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.14,230.3
"Vitamin D, 25 Hydroxy",PX82306,CDM,300,RC,82306,CPT,,,,,,,,235,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,115.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.14,230.3
cefoTEtan 2 g Recon Soln 1 Each Vial,800000,CDM,,,S0074,HCPCS,,,,63323038620,NDC,1,EA,240.2,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,115.296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
cefoTEtan 2 g Recon Soln 1 Each Vial,800000,CDM,,,S0074,HCPCS,,,,63323038620,NDC,1,EA,240.2,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,115.296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
TRAY GROSHONG 4FR SAFETY PICC 7617407,120.26,CDM,272,RC,,,,500-MAIN,LOCAL,,,,,233,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,115.335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.7882,228.34
LIGACLIP APPLIER CLIP STERILE SIZE MEDIUM LARGE,27200000,CDM,272,RC,,,,11699-MAIN,LOCAL,,,,,126.62,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,115.35082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ID Nucleic Acid Sequencing - Ref,PX8715390,CDM,300,RC,87153,CPT,90,,,,,,,265,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,115.36,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.9,115.36
OXALiplatin 50 MG/10ML Solution 10 mL Vial,J9263.01,CDM,636,RC,J9263,HCPCS,,,,955173110,NDC,10,ML,228,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,115.368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.7112,223.44
"Removal of Tunnel Cv Access Device, With Port/Pump",PX36590P,CDM,983,RC,36590,CPT,,,,,,,,1147,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,115.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.39,1124.06
"Removal of Tunnel Cv Access Device, With Port/Pump",PX36590P,CDM,983,RC,36590,CPT,,,,,,,,1147,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,115.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.39,1124.06
"Removal of Tunnel Cv Access Device, With Port/Pump",PX36590P,CDM,983,RC,36590,CPT,,,,,,,,1147,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,115.39,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.39,1124.06
Remove Foreign Body Complic,PX10121F,CDM,510,RC,10121,CPT,,,,,,,,3575,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,115.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,114.52,551.36
Remove Foreign Body Complic,PX10121F,CDM,510,RC,10121,CPT,,,,,,,,3575,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,115.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,114.52,551.36
Remove Foreign Body Complic,PX10121P,CDM,983,RC,10121,CPT,,,,,,,,651,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,115.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,114.52,637.98
Remove Foreign Body Complic,PX10121P,CDM,983,RC,10121,CPT,,,,,,,,651,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,115.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,114.52,637.98
NEEDLE INTRAOSSEOUS 15GA 15MM EZ-IO PEDS 9018,120.89,CDM,272,RC,A4215,HCPCS,,4964-MAIN,LOCAL,,,,,269,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,115.401,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.7426,263.62
Cardiac Rehab,PX93797F,CDM,943,RC,93797,CPT,,,,,,,,45,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,115.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.693,115.44
Cardiac Rehab II Eval,PX93798.05,CDM,943,RC,93798,CPT,,,,,,,,364,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,115.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.44,495.55
Cardiac Rehab II W/ Monitor,PX93798.02,CDM,943,RC,93798,CPT,,,,,,,,338,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,115.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.44,495.55
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320885,NDC,0.5,EA,129.71,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,115.4419,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320895,NDC,0.5,EA,129.71,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,115.4419,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,63323027301,NDC,0.5,ML,235.6,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,115.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,63323027301,NDC,0.5,ML,235.6,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,115.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,63323027301,NDC,0.5,ML,235.6,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,115.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
Physical Therapy Evaluation Low Complex,PX97161,CDM,424,RC,97161,CPT,,,,,,,,235,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,115.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,392.7
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,409277602,NDC,200,ML,228.28,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,115.50968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.827512,225.8704
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,68462018022,NDC,22,GR,240.66,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,115.5168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,68462018022,NDC,22,GR,240.66,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,115.5168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
CT Chest Spine W/Dye,PX7212901,CDM,350,RC,72129,CPT,TC,,,,,,,2096,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,115.5262,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.09,230.75
ofloxacin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,17478071310,NDC,5,ML,117.89,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,115.5322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Noninvasv Oxygen Satur;Single,PX94760,CDM,460,RC,94760,CPT,,,,,,,,131,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,115.542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.4174,128.38
atropine 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,17478021502,NDC,2,ML,269.45,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,115.59405,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
atropine 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,60219174802,NDC,2,ML,269.45,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,115.59405,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,69315030615,NDC,15,GR,131.07,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,115.60374,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DAPTOmycin 500 MG Recon Soln 1 Each Vial,J0878.01,CDM,636,RC,J0878,HCPCS,,,,70594003402,NDC,1,EA,129.9,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,115.611,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.96046,127.302
"Biopsy Vulva/Perineum,One Lesn",PX56605F,CDM,510,RC,56605,CPT,,,,,,,,236,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,115.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.0344,702.31
"Biopsy Vulva/Perineum,One Lesn",PX56605F,CDM,510,RC,56605,CPT,,,,,,,,236,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,115.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.0344,702.31
"Biopsy Vulva/Perineum,One Lesn",PX56605F,CDM,510,RC,56605,CPT,,,,,,,,236,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,115.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.0344,702.31
Fibrinolysins Screen - Ref,PX8539090,CDM,300,RC,85390,CPT,90,,,,,,,118,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,115.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.19,115.64
Lab Basic Metabolic Panel,PX80048,CDM,300,RC,80048,CPT,,,,,,,,236,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,7.364909091,percent of total billed charges,115.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.76,231.28
Lab Basic Metabolic Panel,PX80048,CDM,300,RC,80048,CPT,,,,,,,,236,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,115.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.76,231.28
Lab Basic Metabolic Panel,PX80048,CDM,300,RC,80048,CPT,,,,,,,,236,,United Healthcare,All Medicare advantage plans,outpatient,49,,121.37,percent of total billed charges,115.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.76,231.28
STRAP CLAVICLE LARGE VP10123-040,120.191,CDM,274,RC,L3670,HCPCS,,12848-MAIN,LOCAL,,,,,24,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,115.65,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.65,121.74
STRAP CLAVICLE MEDIUM VP10123-030,120.191,CDM,274,RC,L3670,HCPCS,,12847-MAIN,LOCAL,,,,,24,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,115.65,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.65,121.74
STRAP CLAVICLE SMALL VP10123-020,120.191,CDM,274,RC,L3670,HCPCS,,12846-MAIN,LOCAL,,,,,24,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,115.65,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.65,121.74
STRAP CLAVICLE XL 661 XL,120.191,CDM,274,RC,L3670,HCPCS,,12850-MAIN,LOCAL,,,,,24,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,115.65,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.65,121.74
STRAP CLAVICLE XSMALL CHILD ORT14100XS,120.191,CDM,274,RC,L3670,HCPCS,,12849-MAIN,LOCAL,,,,,24,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,115.65,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.65,121.74
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,703115301,NDC,4,ML,136.1,,First Health,Commercial,both,85,,999999999,percent of total billed charges,115.685,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
B-Scan Global,PX7651201,CDM,402,RC,76512,CPT,TC,,,,,,,127,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,115.697,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.7558,124.46
Candida Dna Dir Probe,PX87480,CDM,300,RC,87480,CPT,,,,,,,,127,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,115.697,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.38,124.46
Gardner Vag Dna Dir Probe,PX87510,CDM,300,RC,87510,CPT,,,,,,,,127,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,115.697,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.38,124.46
Influenza Assay W/Optic,PX87804,CDM,300,RC,87804,CPT,,,,,,,,127,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,115.697,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.17,124.46
Trichomonas Vagin Dir Probe,PX87660,CDM,300,RC,87660,CPT,,,,,,,,127,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,115.697,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.38,124.46
Chemo Ad Sq/Im Hormnl Anti-Neo,PX96402,CDM,335,RC,96402,CPT,,,,,,,,130,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,115.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,127.4
Cystatin C - Ref,PX8261090,CDM,300,RC,82610,CPT,90,,,,,,,130,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,115.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.98,127.4
Each Add'l Sequential Push New Drug,PX96375,CDM,260,RC,96375,CPT,,,,,,,,130,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,115.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,127.4
Immunization Administration; One Vaccine (Single or Combination Vaccine/To*,PX90471,CDM,771,RC,90471,CPT,,,,,,,,130,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,115.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,127.4
Prothrombin Time (Pt/Inr),PX85610,CDM,300,RC,85610,CPT,,,,,,,,130,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,115.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.93,127.4
SPLINT WRIST LARGE ALUMINUM FOREARM LEFT 9101-06,120.87,CDM,274,RC,L3809,HCPCS,,1265-MAIN,LOCAL,,,,,130,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,115.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST LARGE ALUMINUM FOREARM RIGHT 9101-03,120.87,CDM,274,RC,L3809,HCPCS,,1263-MAIN,LOCAL,,,,,130,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,115.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST MEDIUM ALUMINUM FOREARM LEFT 9101-05,120.87,CDM,274,RC,L3809,HCPCS,,1264-MAIN,LOCAL,,,,,130,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,115.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST MEDIUM ALUMINUM FOREARM RIGHT 9101-02,120.87,CDM,274,RC,L3809,HCPCS,,1262-MAIN,LOCAL,,,,,130,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,115.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
Vitamin B-1 - Ref,PX8442590,CDM,300,RC,84425,CPT,90,,,,,,,130,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,115.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.47,127.4
"Apply Short Leg Cast,Walker",PX29425P,CDM,983,RC,29425,CPT,,,,,,,,119,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,115.8227,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,234.62
Creatinine; Other Source - Ref,PX82570,CDM,300,RC,82570,CPT,90,,,,,,,119,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,115.8227,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,116.62
FLAT DRAIN HEMADUCT 7MM FULL DUCT WITH TROCAR SILICONE,27200000,CDM,272,RC,,,,12464-MAIN,LOCAL,,,,,119,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,115.8227,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Injection, Subq/Im",PX96372,CDM,260,RC,96372,CPT,,,,,,,,119,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,39.22196262,percent of total billed charges,115.8227,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,116.62
Irri Implted Drug Dlvr Device,PX96523,CDM,260,RC,96523,CPT,,,,,,,,119,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,115.8227,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,116.62
"Morphometric Analysis,Tumor Immunohistochemistry, Ea Antibody Manual , Tech",PX8836001,CDM,310,RC,88360,CPT,TC,,,,,,,119,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,115.8227,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,149.22
Office/Outpt Visit Est Level I,PX99211F,CDM,510,RC,99211,CPT,,,,,,,,119,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,136.6394118,percent of total billed charges,115.8227,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,116.62
Office/Outpt Visit Est Level I,PX99211P,CDM,983,RC,99211,CPT,,,,,,,,119,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,136.6394118,percent of total billed charges,115.8227,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,115.8227
Sodium; Urine,PX84300,CDM,300,RC,84300,CPT,,,,,,,,119,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,50.46,percent of total billed charges,115.8227,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.64,116.62
STIFNECK ADULT,120.77,CDM,274,RC,L0180,HCPCS,,991-MAIN,LOCAL,,,,,119,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,38.388,percent of total billed charges,115.8227,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,486.73
STIFNECK PEDIATRIC,120.77,CDM,274,RC,L0180,HCPCS,,998-MAIN,LOCAL,,,,,119,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,38.388,percent of total billed charges,115.8227,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,486.73
CANNULA FOR INJECTION 1.8MM WITH 3MM LUER CONNECTION 8383.65,27200000,CDM,272,RC,,,,12004-MAIN,LOCAL,,,,,234,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,115.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Closed Rx Radial Head Disloc,Child",PX24640F,CDM,510,RC,24640,CPT,,,,,,,,270,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,115.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.158,264.6
Drain Skin Abscess Complic,PX10061F,CDM,510,RC,10061,CPT,,,,,,,,889,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,115.83,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.83,447.59
Drain Skin Abscess Complic,PX10061P,CDM,983,RC,10061,CPT,,,,,,,,561,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,115.83,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.83,549.78
Fibrinogen,PX7426,CDM,300,RC,85384,CPT,,,,,,,,234,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,115.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.91,229.32
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157F,CDM,370,RC,99157,CPT,,,,,,,,270,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,115.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.158,264.6
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157P,CDM,983,RC,99157,CPT,,,,,,,,270,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,115.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.158,262.791
Wound Culture Anaerobic,PX87075,CDM,300,RC,87075,CPT,,,,,,,,270,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,115.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.68,264.6
patiromer sorbitex calcium 8.4 g Packet 4 Each Box,63700001,CDM,250,RC,,,,,,53436008404,NDC,1,EA,228.96,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,115.85376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Ctrl Nosebleed,Anter,Simple",PX30901P,CDM,983,RC,30901,CPT,,,,,,,,229,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,115.874,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.1266,222.8857
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604P,CDM,983,RC,20604,CPT,,,,,,,,229,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,115.874,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.1266,258.75
Removal of Nail Plate,PX11730F,CDM,510,RC,11730,CPT,,,,,,,,229,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,115.874,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.1266,224.42
"Hla Class II Low Res, 1 Locus - Ref",PX8137690,CDM,310,RC,81376,CPT,90,,,,,,,279,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,115.8966,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.06,273.42
INSUFLOWPORT & PNEUVIEW  XE SMOKE ELIMINATOR 5MM,27200000,CDM,272,RC,,,,11876-MAIN,LOCAL,,,,,279,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,115.8966,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 8MM,27200000,CDM,272,RC,,,,11877-MAIN,LOCAL,,,,,279,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,115.8966,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 10MM,27200000,CDM,272,RC,,,,11878-MAIN,LOCAL,,,,,279,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,115.8966,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 12MM,27200000,CDM,272,RC,,,,11879-MAIN,LOCAL,,,,,279,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,115.8966,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 5MM,27200000,CDM,272,RC,,,,11880-MAIN,LOCAL,,,,,279,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,115.8966,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 8MM,27200000,CDM,272,RC,,,,11881-MAIN,LOCAL,,,,,279,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,115.8966,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 10MM,27200000,CDM,272,RC,,,,11882-MAIN,LOCAL,,,,,279,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,115.8966,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 12MM,27200000,CDM,272,RC,,,,11883-MAIN,LOCAL,,,,,279,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,115.8966,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Puncture Drainage of Lesion,PX10160F,CDM,510,RC,10160,CPT,,,,,,,,279,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,115.8966,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.8966,348.35
Xray Pelvis 1 or 2 Vws,PX7217001,CDM,320,RC,72170,CPT,TC,,,,,,,279,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,115.8966,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,273.42
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004725,NDC,2,ML,131.52,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,116.00064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
triamcinolone acetonide 0.1 % Cream 454 g Jar,63700001,CDM,250,RC,,,,,,45802006405,NDC,454,GR,130.36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,116.0204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine - transparent dressing 4 % Kit 1 Each Box,63700001,CDM,250,RC,,,,,,496088207,NDC,1,EA,270.63,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,116.10027,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Airway Inhalation Treatment,PX94640F,CDM,410,RC,94640,CPT,,,,,,,,242,,Health Partners,Health Partners Care Plans,both,48,,461.72,percent of total billed charges,116.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,100.5268,237.16
Airway Inhalation Treatment,PX94640F,CDM,410,RC,94640,CPT,,,,,,,,242,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,116.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,100.5268,237.16
"Noninvasv Oxygen Satut,Continuous",PX94762,CDM,460,RC,94762,CPT,,,,,,,,242,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,116.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,100.5268,237.16
"Noninvasv Oxygen Satut,Continuous",PX94762,CDM,460,RC,94762,CPT,,,,,,,,242,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,116.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,100.5268,237.16
Dress/Debrid Small Burn No Anes,PX16020F,CDM,510,RC,16020,CPT,,,,,,,,313,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,116.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.46,179.18
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106F,CDM,510,RC,11106,CPT,,,,,,,,255,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,116.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.68,323.07
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106P,CDM,983,RC,11106,CPT,,,,,,,,204,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,116.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.68,323.07
LEGGING COMPRESSION JUXTALITE LONG LG 33CM,120.369,CDM,271,RC,A6545,HCPCS,,10840-MAIN,LOCAL,,,,,145,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,116.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.43,189.328
LEGGING COMPRESSION JUXTALITE LONG LG 33CM,120.369,CDM,271,RC,A6545,HCPCS,,10840-MAIN,LOCAL,,,,,145,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,116.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.43,189.328
LEGGING COMPRESSION JUXTALITE LONG LG 33CM,120.369,CDM,271,RC,A6545,HCPCS,,10840-MAIN,LOCAL,,,,,145,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,116.24,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.43,189.328
Strapping of Ankle,PX29540F,CDM,420,RC,29540,CPT,,,,,,,,271,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,116.259,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.5734,265.58
"Pertechnetate, Dia, per Mci",PXA9512,CDM,343,RC,A9512,HCPCS,,,,,,,,280,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,116.312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,116.312,274.4
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037905,NDC,0.5,ML,229.88,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,116.31928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152F,CDM,370,RC,99152,CPT,,,,,,,,235,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,116.325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97.619,230.3
Occupational Therapy Eval Low Complex,PX97165,CDM,434,RC,97165,CPT,,,,,,,,235,,Humana Choice Care,All Medicare plans,outpatient,49.5,,78.044,percent of total billed charges,116.325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,230.3
Physical Therapy Evaluation Low Complex,PX97161,CDM,424,RC,97161,CPT,,,,,,,,235,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,116.325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,392.7
Remv Ext Canal Foreign Body,PX69200F,CDM,510,RC,69200,CPT,,,,,,,,235,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,116.325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97.619,230.3
"Vitamin D, 25 Hydroxy",PX82306,CDM,300,RC,82306,CPT,,,,,,,,235,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,116.325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.14,230.3
"Morphometric Analysis, Tumor - Ref",PX8836090,CDM,310,RC,88360,CPT,90,,,,,,,349,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,116.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,116.39,195.44
"Morphometric Analysis, Tumor - Ref",PX8836090,CDM,310,RC,88360,CPT,90,,,,,,,349,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,116.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,116.39,195.44
"Morphometric Analysis, Tumor - Ref",PX8836090,CDM,310,RC,88360,CPT,90,,,,,,,349,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,116.39,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,116.39,195.44
Apply of Paste Boot,PX29580F,CDM,510,RC,29580,CPT,,,,,,,,132,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,116.424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,137.65
Assay Dipropylacetic Acid,PX80164,CDM,300,RC,80164,CPT,,,,,,,,132,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,116.424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.41,129.36
Assay of Lipase,PX83690,CDM,300,RC,83690,CPT,,,,,,,,132,,United Healthcare,All Payer,outpatient,88.2,,64.22666667,percent of total billed charges,116.424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.32,129.36
"Remv F.B.,Eye,Superf Conjunc",PX65205F,CDM,510,RC,65205,CPT,,,,,,,,132,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,116.424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,129.36
"Remv F.B.,Eye,Superf Conjunc",PX65205P,CDM,983,RC,65205,CPT,,,,,,,,132,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,116.424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,128.4756
"Venipunc Need Phys Skill,Dx or Rx",PX36410,CDM,983,RC,36410,CPT,,,,,,,,132,,United Healthcare,All Payer,outpatient,88.2,,8.745,percent of total billed charges,116.424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,128.4756
Total Cortisol,PX82533,CDM,300,RC,82533,CPT,,,,,,,,137,,First Health,Commercial,both,85,,999999999,percent of total billed charges,116.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.95,134.26
"Triiodothyronine T3, Free (Free T3)",PX84481,CDM,300,RC,84481,CPT,,,,,,,,137,,First Health,Commercial,both,85,,999999999,percent of total billed charges,116.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.53,134.26
"Tiss Cult,Non-Neop Lymph - Ref",PX8823090,CDM,310,RC,88230,CPT,90,,,,,,,103,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,116.49,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,113,116.49
MINIBUNION NON-LOCKING SCREW  2.7X18MM,C1713,CDM,278,RC,C1713,HCPCS,,11670-MAIN,LOCAL,,,,,280.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,116.5197,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,781329091,NDC,50,ML,119.73,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1.636666667,percent of total billed charges,116.533209,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046204,NDC,30,ML,127.94,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,116.55334,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Noninvasv Oxygen Satur;Single,PX94760,CDM,460,RC,94760,CPT,,,,,,,,131,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,116.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.4174,128.38
Canalith Repositioning,PX95992,CDM,420,RC,95992,CPT,,,,,,,,128,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,116.608,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.86,125.44
Heparin Xa,PX85520,CDM,300,RC,85520,CPT,,,,,,,,128,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,116.608,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12,125.44
Lab Pth Immunoch Part 1,PX83970,CDM,300,RC,83970,CPT,,,,,,,,128,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,116.608,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.85,125.44
"N Block Inj, Common Digit",PX64632P,CDM,983,RC,64632,CPT,,,,,,,,128,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,116.608,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.1712,258.75
Path Special Stains II,PX3979,CDM,310,RC,88313,CPT,TC,,,,,,,107,,UCare,Individual and Family Plans,both,,,53.5,fee schedule,116.608,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.44,116.608
Path Special Stains II,PX3979,CDM,310,RC,88313,CPT,TC,,,,,,,107,,UCare,Individual and Family Plans,both,,,53.5,fee schedule,116.608,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.44,116.608
"Apply Short Leg Cast,Walker",PX29425P,CDM,983,RC,29425,CPT,,,,,,,,119,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,116.62,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.81,159.11
Creatinine; Other Source - Ref,PX82570,CDM,300,RC,82570,CPT,90,,,,,,,119,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,116.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,116.62
FLAT DRAIN HEMADUCT 7MM FULL DUCT WITH TROCAR SILICONE,27200000,CDM,272,RC,,,,12464-MAIN,LOCAL,,,,,119,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,116.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Injection, Subq/Im",PX96372,CDM,260,RC,96372,CPT,,,,,,,,119,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,116.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,116.62
Irri Implted Drug Dlvr Device,PX96523,CDM,260,RC,96523,CPT,,,,,,,,119,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,116.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,116.62
"Morphometric Analysis,Tumor Immunohistochemistry, Ea Antibody Manual , Tech",PX8836001,CDM,310,RC,88360,CPT,TC,,,,,,,119,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,116.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,149.22
Office/Outpt Visit Est Level I,PX99211F,CDM,510,RC,99211,CPT,,,,,,,,119,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,116.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,116.62
Office/Outpt Visit Est Level I,PX99211P,CDM,983,RC,99211,CPT,,,,,,,,119,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,116.62,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.46,116.62
Phlebotomy,PX99195,CDM,940,RC,99195,CPT,,,,,,,,238,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,116.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.8652,233.24
Phlebotomy,PX99195,CDM,940,RC,99195,CPT,,,,,,,,238,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,116.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.8652,233.24
Phlebotomy,PX99195,CDM,940,RC,99195,CPT,,,,,,,,238,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,116.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.8652,233.24
Sodium; Urine,PX84300,CDM,300,RC,84300,CPT,,,,,,,,119,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,116.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.64,116.62
STIFNECK ADULT,120.77,CDM,274,RC,L0180,HCPCS,,991-MAIN,LOCAL,,,,,119,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,116.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,486.73
STIFNECK PEDIATRIC,120.77,CDM,274,RC,L0180,HCPCS,,998-MAIN,LOCAL,,,,,119,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,116.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,486.73
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,63323027301,NDC,0.5,ML,235.6,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,116.622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,143971801,NDC,200,ML,230.48,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,116.62288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.827512,225.8704
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409421505,NDC,5,ML,271.86,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,116.62794,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,69315030615,NDC,15,GR,131.07,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,116.6523,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,24208046325,NDC,2.5,ML,137.26,,First Health,Commercial,both,85,,999999999,percent of total billed charges,116.671,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
methylPREDNISolone sod succ 1000 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9001820,NDC,1,EA,271.97,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,116.67513,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611P,CDM,983,RC,20611,CPT,,,,,,,,272,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,116.688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.9888,264.7376
8MM ENDOWRIST INSTRUMENTS CADIERE FORCEPS,27200000,CDM,272,RC,,,,11913-MAIN,LOCAL,,,,,281,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,116.7274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
FORCEPS PROGRASP 8MM ENDOWRIST INSTRUMENTS,27200000,CDM,272,RC,,,,12062-MAIN,LOCAL,,,,,281,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,116.7274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Spirometry,PX9401001,CDM,460,RC,94010,CPT,TC,,,,,,,281,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,116.7274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,116.7274,275.38
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042350,NDC,0.5,ML,132.37,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,116.75034,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.49,129.7226
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042388,NDC,0.5,ML,132.37,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,116.75034,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.49,129.7226
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,65162083366,NDC,100,GR,281.12,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,116.777248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Compatibility Test,Antiglob Tech",PX86922,CDM,300,RC,86922,CPT,,,,,,,,120,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,116.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.848,149.22
KIWI OMNICUP VACUUM DELIVERY SYSTEM,120.225,CDM,272,RC,,,,11608-MAIN,LOCAL,,,,,120,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,116.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.848,117.6
VACUUM KIWI W/PALM PUMP,120.225,CDM,272,RC,,,,10028-MAIN,LOCAL,,,,,120,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,116.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.848,117.6
CT Head/Brain W/O & W/Dye,PX7047001,CDM,350,RC,70470,CPT,TC,,,,,,,3671,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,116.8134,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.96,233.38
"Biopsy Vulva/Perineum,One Lesn",PX56605F,CDM,510,RC,56605,CPT,,,,,,,,236,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,116.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.0344,702.31
Lab Basic Metabolic Panel,PX80048,CDM,300,RC,80048,CPT,,,,,,,,236,,Humana Choice Care,All Medicare plans,outpatient,49.5,,193.4175,percent of total billed charges,116.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.76,231.28
hepatitis b recomb vaccine 10 MCG/0.5ML suspension prefilled syringe 0.5 mL Syringe,90743,CDM,636,RC,90743,CPT,,,,58160082052,NDC,0.5,ML,137.47,,First Health,Commercial,both,85,,999999999,percent of total billed charges,116.8495,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.105038,134.7206
"Ctrl Nosebleed,Anter,Simple",PX30901F,CDM,510,RC,30901,CPT,,,,,,,,342,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,116.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.03,325.15
"Ctrl Nosebleed,Anter,Simple",PX30901P,CDM,983,RC,30901,CPT,,,,,,,,229,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,116.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.03,325.15
"Needle Biopsy,Muscle",PX20206F,CDM,510,RC,20206,CPT,,,,,,,,258,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,116.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.55,453.13
"Needle Biopsy,Muscle",PX20206P,CDM,983,RC,20206,CPT,,,,,,,,1028,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,116.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.55,1007.44
"Sigmoidoscopy,Diagnostic",PX45330F,CDM,510,RC,45330,CPT,,,,,,,,720,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,116.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.68,386.72
"Sigmoidoscopy,Diagnostic",PX45330P,CDM,983,RC,45330,CPT,,,,,,,,480,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,116.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.68,470.4
"Sigmoidoscopy,Screen Prev",PX2001F,CDM,750,RC,45330,CPT,,,,,,,,843,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,116.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.68,386.72
sodium phosphate 15 MMOLE/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323088401,NDC,5,ML,132.6,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,116.9532,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium phosphate 15 MMOLE/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323088406,NDC,5,ML,132.6,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,116.9532,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004725,NDC,2,ML,131.52,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,117.0528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
Physical Therapy Re-Eval Est Plan Care 20 Mins,PX97164,CDM,424,RC,97164,CPT,,,,,,,,239,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,117.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,234.22
Physical Therapy Re-Eval Est Plan Care 20 Mins,PX97164,CDM,424,RC,97164,CPT,,,,,,,,239,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,117.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,234.22
Physical Therapy Re-Eval Est Plan Care 20 Mins,PX97164,CDM,424,RC,97164,CPT,,,,,,,,239,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,117.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,234.22
BINDER PELVIC ADULT STABILIZATION T-PODR,120.357,CDM,271,RC,A4467,HCPCS,,10734-MAIN,LOCAL,,,,,244,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,117.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.3576,239.12
BINDER PELVIC ADULT STABILIZATION T-PODR,120.357,CDM,271,RC,A4467,HCPCS,,10734-MAIN,LOCAL,,,,,244,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,117.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.3576,239.12
sincalide 5 MCG Recon Soln 1 Each Vial,J2805.01,CDM,636,RC,J2805,HCPCS,,,,270055615,NDC,1,EA,250,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,117.12,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,117.12,133.1
CT Upper Extremity W/O Dye,PX7320001,CDM,350,RC,73200,CPT,TC,,,,,,,2757,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,117.1352,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.33,234.03
Xray Finger(S) Tc,PX7314001,CDM,320,RC,73140,CPT,TC,,,,,,,282,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,117.1428,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,276.36
Xray Toe(S) Tc,PX7366001,CDM,320,RC,73660,CPT,TC,,,,,,,282,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,117.1428,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,276.36
Closure Superf Wnd Dehis Simple,PX12020F,CDM,510,RC,12020,CPT,,,,,,,,632,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,117.15,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,117.15,624.7
Closure Superf Wnd Dehis Simple,PX12020P,CDM,983,RC,12020,CPT,,,,,,,,422,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,117.15,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,117.15,624.7
DRAIN FLAT JACKSON PRATT 10MM,27100000,CDM,271,RC,,,,334-MAIN,LOCAL,,,,,239.09,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,117.1541,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
DRAIN FLAT JACKSON PRATT 10MM,27100000,CDM,271,RC,,,,334-MAIN,LOCAL,,,,,239.09,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,117.1541,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
DRAIN FLAT JACKSON PRATT 10MM,27100000,CDM,271,RC,,,,334-MAIN,LOCAL,,,,,239.09,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,117.1541,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614800,NDC,1,EA,239.18,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,9.983703704,percent of total billed charges,117.1982,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614800,NDC,1,EA,239.18,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,117.1982,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614800,NDC,1,EA,239.18,,United Healthcare,All Medicare advantage plans,outpatient,49,,3.9675,percent of total billed charges,117.1982,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
"Fac/Office Consultation,Level III",PX99243F,CDM,510,RC,99213,CPT,,,,,,,,374,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,117.21,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.25,163.25
"Office/Outpt Visit,Est,Levl III",PX99213F,CDM,510,RC,99213,CPT,,,,,,,,185,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,117.21,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.25,163.25
"Office/Outpt Visit,Est,Levl III",PX99213P,CDM,983,RC,99213,CPT,,,,,,,,185,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,117.21,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.25,181.3
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,16714076901,NDC,15,GR,137.99,,First Health,Commercial,both,85,,999999999,percent of total billed charges,117.2915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032050,NDC,1,EA,120.51,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,13.11107143,percent of total billed charges,117.292383,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
"Cardiolipin Ab, Ea Lg - Ref",PX8614790,CDM,300,RC,86147,CPT,90,,,,,,,133,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,117.306,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.34,130.34
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU0003,CDM,300,RC,U0003,HCPCS,,,,,,,,133,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,117.306,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.2482,130.34
Lvl 1 Sub Hosp Low Mdm or 25 Minutes,PX99231,CDM,982,RC,99231,CPT,,,,,,,,133,,United Healthcare,All Payer,outpatient,88.2,,55.56,percent of total billed charges,117.306,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.2482,129.4489
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618201,NDC,2,ML,120.53,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,117.311849,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.068162,123.3918
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618210,NDC,2,ML,120.53,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,117.311849,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.068162,123.3918
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,781329091,NDC,50,ML,119.73,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,117.3354,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
Bile Acids Total,PX8223990,CDM,300,RC,82239,CPT,90,,,,,,,232,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,117.392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,227.36
methylergonovine 0.2 MG/ML Solution 1 mL Ampule,J2210.01,CDM,636,RC,J2210,HCPCS,,,,51991014417,NDC,1,ML,133.11,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,117.40302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.293894,130.4478
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059900,NDC,1,ML,133.16,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,117.44712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.54253,130.4968
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059902,NDC,1,ML,133.16,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,117.44712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.54253,130.4968
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494300,NDC,0.5,ML,419.23,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,117.45,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,117.45,133.47
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494301,NDC,0.5,ML,419.2,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,117.45,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,117.45,133.47
Apply of Paste Boot,PX29580F,CDM,510,RC,29580,CPT,,,,,,,,132,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,117.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,137.65
Assay Dipropylacetic Acid,PX80164,CDM,300,RC,80164,CPT,,,,,,,,132,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,117.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.41,129.36
Assay of Lipase,PX83690,CDM,300,RC,83690,CPT,,,,,,,,132,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,117.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.32,129.36
"Remv F.B.,Eye,Superf Conjunc",PX65205F,CDM,510,RC,65205,CPT,,,,,,,,132,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,117.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,129.36
"Remv F.B.,Eye,Superf Conjunc",PX65205P,CDM,983,RC,65205,CPT,,,,,,,,132,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,117.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,128.4756
"Venipunc Need Phys Skill,Dx or Rx",PX36410,CDM,983,RC,36410,CPT,,,,,,,,132,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,117.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,128.4756
Complete Cbc Automated,PX85027,CDM,300,RC,85027,CPT,,,,,,,,129,,Medica,Commercial,both,91.1,,9.468888889,percent of total billed charges,117.519,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,126.42
"Venipunc Need Phys Skill,Dx or Rx",PX36410P,CDM,983,RC,36410,CPT,,,,,,,,129,,Medica,Commercial,both,91.1,,14.27,percent of total billed charges,117.519,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.5866,125.5557
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597P,CDM,983,RC,97597,CPT,,,,,,,,274,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,117.546,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,113.8196,266.6842
SUMAtriptan 25 MG Tablet 9 Each Box,63700001,CDM,250,RC,,,,,,65862014636,NDC,1,EA,129.04,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,117.55544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
STAPLER RELOAD-CURVED CUTTER,27200000,CDM,272,RC,,,,12063-MAIN,LOCAL,,,,,283,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,117.5582,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Reconstruc of Nail Bed W Graft,PX11762F,CDM,510,RC,11762,CPT,,,,,,,,1901,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,117.58,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,117.58,599.1
"Compatibility Test,Antiglob Tech",PX86922,CDM,300,RC,86922,CPT,,,,,,,,120,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,117.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.848,149.22
Fibrinogen Activity - Ref,PX8538490,CDM,300,RC,85384,CPT,90,,,,,,,245,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,117.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.91,240.1
Fibrinogen Activity - Ref,PX8538490,CDM,300,RC,85384,CPT,90,,,,,,,245,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,117.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.91,240.1
"Ileoscopy Thru Stoma,Diagnostic",PX44380F,CDM,750,RC,44380,CPT,,,,,,,,245,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,117.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.773,791.92
"Ileoscopy Thru Stoma,Diagnostic",PX44380F,CDM,750,RC,44380,CPT,,,,,,,,245,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,117.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.773,791.92
KIWI OMNICUP VACUUM DELIVERY SYSTEM,120.225,CDM,272,RC,,,,11608-MAIN,LOCAL,,,,,120,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,117.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.848,117.6
Lipid Profile,PX80061,CDM,300,RC,80061,CPT,,,,,,,,245,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,117.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.28,240.1
Lipid Profile,PX80061,CDM,300,RC,80061,CPT,,,,,,,,245,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,117.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.28,240.1
Platelet Antibodies - Ref,PX8602290,CDM,300,RC,86022,CPT,90,,,,,,,245,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,117.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.84,240.1
Platelet Antibodies - Ref,PX8602290,CDM,300,RC,86022,CPT,90,,,,,,,245,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,117.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.84,240.1
VACUUM KIWI W/PALM PUMP,120.225,CDM,272,RC,,,,10028-MAIN,LOCAL,,,,,120,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,117.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.848,117.6
Fac/Ther Injection Carpal Tunnel,PX20526F,CDM,510,RC,20526,CPT,,,,,,,,191,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,117.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.46,171.57
Ther Injection Carpal Tunnel,PX20526P,CDM,983,RC,20526,CPT,,,,,,,,248,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,117.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.46,243.04
US Abdomen Limited Tc,PX7670501,CDM,402,RC,76705,CPT,TC,,,,,,,425,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,117.67,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.7,117.67
US Abdomen Limited Tc,PX7670501,CDM,402,RC,76705,CPT,TC,,,,,,,425,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,117.67,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.7,117.67
cefoTEtan 2 g Recon Soln 1 Each Vial,800000,CDM,,,S0074,HCPCS,,,,63323038620,NDC,1,EA,240.2,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,117.698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
cefoTEtan 2 g Recon Soln 1 Each Vial,800000,CDM,,,S0074,HCPCS,,,,63323038620,NDC,1,EA,240.2,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,117.698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
cefoTEtan 2 g Recon Soln 1 Each Vial,800000,CDM,,,S0074,HCPCS,,,,63323038620,NDC,1,EA,240.2,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,117.698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
BAG LEG URINARY STND 32OZ,120.33,CDM,272,RC,A5112,HCPCS,,4433-MAIN,LOCAL,,,,,121,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,117.7693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
BAG URINARY DRAINAGE 2000ML 6300,120.33,CDM,274,RC,A4357,HCPCS,,1283-MAIN,LOCAL,,,,,121,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,117.7693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
BAG URINARY LEG PACK 9349,120.33,CDM,272,RC,A5112,HCPCS,,623-MAIN,LOCAL,,,,,121,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,117.7693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
"Chest Wall Manipulation,Initial",PX94667,CDM,410,RC,94667,CPT,,,,,,,,121,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,117.7693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.2634,118.58
"Fluor Noninfect Ab Sc, Ea - Ref",PX8625590,CDM,300,RC,86255,CPT,90,,,,,,,121,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,117.7693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.05,118.58
"Manage/Train Orthotic/Prosthetic, per 15 Min",PX97763,CDM,420,RC,97763,CPT,,,,,,,,121,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,117.7693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.36,118.58
"Prosthetic Training, Initial, Each 15 Mins",PX97761,CDM,420,RC,97761,CPT,,,,,,,,121,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,117.7693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.41,118.58
"Morphometric Analysis, Tumor - Ref",PX8836090,CDM,310,RC,88360,CPT,90,,,,,,,349,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,117.7703,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,116.39,195.44
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062160,NDC,0.6,ML,274.53,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,117.77337,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801601,NDC,0.6,ML,274.53,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,117.77337,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801610,NDC,0.6,ML,274.53,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,117.77337,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
Drain Skin Abscess Complic,PX10061F,CDM,510,RC,10061,CPT,,,,,,,,889,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,117.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.83,447.59
Drain Skin Abscess Complic,PX10061F,CDM,510,RC,10061,CPT,,,,,,,,889,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,117.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.83,447.59
Drain Skin Abscess Complic,PX10061P,CDM,983,RC,10061,CPT,,,,,,,,561,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,117.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.83,549.78
Drain Skin Abscess Complic,PX10061P,CDM,983,RC,10061,CPT,,,,,,,,561,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,117.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.83,549.78
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042350,NDC,0.5,ML,132.37,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,117.8093,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.49,129.7226
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042388,NDC,0.5,ML,132.37,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,117.8093,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.49,129.7226
Phlebotomy,PX99195,CDM,940,RC,99195,CPT,,,,,,,,238,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,117.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.8652,233.24
"Biopsy of Prostate,Needle/Punch",PX55700F,CDM,510,RC,55700,CPT,,,,,,,,2039,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,117.8437,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.96,500.17
Remove Nasal Foreign Body,PX30300F,CDM,510,RC,30300,CPT,,,,,,,,972,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,117.8437,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.84,438.6
Remove Nasal Foreign Body,PX30300P,CDM,983,RC,30300,CPT,,,,,,,,572,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,117.8437,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.84,560.56
prednisoLONE acetate 1 % Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063705,NDC,5,ML,283.79,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,117.886366,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
TRAY GROSHONG 4FR SAFETY PICC 7617407,120.26,CDM,272,RC,,,,500-MAIN,LOCAL,,,,,233,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,117.898,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.7882,228.34
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,68462018022,NDC,22,GR,240.66,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,117.9234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,68462018022,NDC,22,GR,240.66,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,117.9234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,68462018022,NDC,22,GR,240.66,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,117.9234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
eriBULin 1 MG/2ML Solution 2 mL Vial,J9179.01,CDM,636,RC,J9179,HCPCS,,,,62856038901,NDC,2,ML,2321.52,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,117.93,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,117.93,140.72
lidocaine-epinephrine-tetracaine Gel 3 mL Syringe,J3490.160,CDM,636,RC,J3490,HCPCS,,,,88888800028,NDC,3,ML,121.19,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,11.07921788,percent of total billed charges,117.954227,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.342326,118.7662
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151P,CDM,983,RC,99151,CPT,,,,,,,,275,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,117.975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,114.235,267.6575
Calr Gene Analysis Common Variants in Exon 9 - Ref,PX8121990,CDM,300,RC,81219,CPT,90,,,,,,,534,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,117.98,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,117.98,121.63
Calr Gene Analysis Common Variants in Exon 9 - Ref,PX8121990,CDM,300,RC,81219,CPT,90,,,,,,,534,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,117.98,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,117.98,121.63
Calr Gene Analysis Common Variants in Exon 9 - Ref,PX8121990,CDM,300,RC,81219,CPT,90,,,,,,,534,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,117.98,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,117.98,121.63
octreotide 200 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037805,NDC,1,ML,133.77,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,117.98514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
sodium phosphate 15 MMOLE/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323088401,NDC,5,ML,132.6,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,118.014,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium phosphate 15 MMOLE/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323088406,NDC,5,ML,132.6,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,118.014,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ROPivacaine 2 MG/ML Solution 100 mL Bottle,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028568,NDC,100,ML,275.11,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,118.02219,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.604954,269.6078
KATZ EXTRACTOR OTO-RHINO FOREIGN BODY REMOVER,120.568,CDM,272,RC,,,,12808-MAIN,LOCAL,,,,,246,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,118.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.1884,241.08
KATZ EXTRACTOR OTO-RHINO FOREIGN BODY REMOVER,120.568,CDM,272,RC,,,,12808-MAIN,LOCAL,,,,,246,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,118.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.1884,241.08
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032050,NDC,1,EA,120.51,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,118.0998,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821517,NDC,3,ML,275.33,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,118.11657,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618201,NDC,2,ML,120.53,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,118.1194,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.068162,123.3918
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618210,NDC,2,ML,120.53,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,118.1194,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.068162,123.3918
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320885,NDC,0.5,EA,129.71,,Medica,Commercial,both,91.1,,6.892980769,percent of total billed charges,118.16581,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320895,NDC,0.5,EA,129.71,,Medica,Commercial,both,91.1,,6.892980769,percent of total billed charges,118.16581,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
Immunocytochemistry,PX3993,CDM,310,RC,88342,CPT,TC,,,,,,,182,,UCare,Individual and Family Plans,both,,,72.975,fee schedule,118.24,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.41,118.24
Immunocytochemistry,PX3993,CDM,310,RC,88342,CPT,TC,,,,,,,182,,UCare,Individual and Family Plans,both,,,72.975,fee schedule,118.24,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.41,118.24
X-Ray Exam Chest 2 Views,PX7104601,CDM,320,RC,71046,CPT,TC,,,,,,,556,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,118.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,544.88
"Ileoscopy Thru Stoma,Diagnostic",PX44380F,CDM,750,RC,44380,CPT,,,,,,,,245,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,118.3,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.12,408.85
"Ileoscopy Thru Stoma,Diagnostic",PX44380P,CDM,983,RC,44380,CPT,,,,,,,,455,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,118.3,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.12,445.9
Physical Therapy Re-Eval Est Plan Care 20 Mins,PX97164,CDM,424,RC,97164,CPT,,,,,,,,239,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,118.305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,234.22
DAPTOmycin 500 MG Recon Soln 1 Each Vial,J0878.01,CDM,636,RC,J0878,HCPCS,,,,70594003402,NDC,1,EA,129.9,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,118.3389,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.96046,127.302
DRAIN FLAT JACKSON PRATT 10MM,27100000,CDM,271,RC,,,,334-MAIN,LOCAL,,,,,239.09,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,118.34955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
methylene blue 1 % Solution 10 mL Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,54288014701,NDC,1,ML,139.25,,First Health,Commercial,both,85,,999999999,percent of total billed charges,118.3625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.29,1354.4776
"Cardiolipin Ab, Ea Lg - Ref",PX8614790,CDM,300,RC,86147,CPT,90,,,,,,,133,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,118.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.34,130.34
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU0003,CDM,300,RC,U0003,HCPCS,,,,,,,,133,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,118.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.2482,130.34
Lvl 1 Sub Hosp Low Mdm or 25 Minutes,PX99231,CDM,982,RC,99231,CPT,,,,,,,,133,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,118.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.2482,129.4489
Xray Sacroiliac Jnts 3 or More Vws,PX7220201,CDM,320,RC,72202,CPT,TC,,,,,,,285,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,118.389,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,279.3
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614800,NDC,1,EA,239.18,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,118.3941,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
CANNULA FOR INJECTION 1.8MM WITH 3MM LUER CONNECTION 8383.65,27200000,CDM,272,RC,,,,12004-MAIN,LOCAL,,,,,234,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,118.404,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Culture Screen Only,PX87081,CDM,300,RC,87081,CPT,,,,,,,,276,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,118.404,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.08,270.48
Fibrinogen,PX7426,CDM,300,RC,85384,CPT,,,,,,,,234,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,118.404,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.91,229.32
Chemo Ad Sq/Im Hormnl Anti-Neo,PX96402,CDM,335,RC,96402,CPT,,,,,,,,130,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,118.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,127.4
Cystatin C - Ref,PX8261090,CDM,300,RC,82610,CPT,90,,,,,,,130,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,118.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.98,127.4
Each Add'l Sequential Push New Drug,PX96375,CDM,260,RC,96375,CPT,,,,,,,,130,,Medica,Commercial,both,91.1,,7.541176471,percent of total billed charges,118.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,127.4
Immunization Administration; One Vaccine (Single or Combination Vaccine/To*,PX90471,CDM,771,RC,90471,CPT,,,,,,,,130,,Medica,Commercial,both,91.1,,20.9825,percent of total billed charges,118.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,127.4
Prothrombin Time (Pt/Inr),PX85610,CDM,300,RC,85610,CPT,,,,,,,,130,,Medica,Commercial,both,91.1,,20.91818182,percent of total billed charges,118.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.93,127.4
SPLINT WRIST LARGE ALUMINUM FOREARM LEFT 9101-06,120.87,CDM,274,RC,L3809,HCPCS,,1265-MAIN,LOCAL,,,,,130,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,118.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST LARGE ALUMINUM FOREARM RIGHT 9101-03,120.87,CDM,274,RC,L3809,HCPCS,,1263-MAIN,LOCAL,,,,,130,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,118.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST MEDIUM ALUMINUM FOREARM LEFT 9101-05,120.87,CDM,274,RC,L3809,HCPCS,,1264-MAIN,LOCAL,,,,,130,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,118.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST MEDIUM ALUMINUM FOREARM RIGHT 9101-02,120.87,CDM,274,RC,L3809,HCPCS,,1262-MAIN,LOCAL,,,,,130,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,118.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
Vitamin B-1 - Ref,PX8442590,CDM,300,RC,84425,CPT,90,,,,,,,130,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,118.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.47,127.4
Closure Superf Wnd Dehis Simple,PX12020F,CDM,510,RC,12020,CPT,,,,,,,,632,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,118.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,117.15,624.7
Closure Superf Wnd Dehis Simple,PX12020F,CDM,510,RC,12020,CPT,,,,,,,,632,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,118.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,117.15,624.7
Closure Superf Wnd Dehis Simple,PX12020P,CDM,983,RC,12020,CPT,,,,,,,,422,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,118.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,117.15,624.7
Closure Superf Wnd Dehis Simple,PX12020P,CDM,983,RC,12020,CPT,,,,,,,,422,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,118.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,117.15,624.7
Reconstruc of Nail Bed W Graft,PX11762F,CDM,510,RC,11762,CPT,,,,,,,,1901,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,118.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,117.58,599.1
Reconstruc of Nail Bed W Graft,PX11762F,CDM,510,RC,11762,CPT,,,,,,,,1901,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,118.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,117.58,599.1
methylergonovine 0.2 MG/ML Solution 1 mL Ampule,J2210.01,CDM,636,RC,J2210,HCPCS,,,,51991014417,NDC,1,ML,133.11,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,118.4679,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.293894,130.4478
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059900,NDC,1,ML,133.16,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,118.5124,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.54253,130.4968
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059902,NDC,1,ML,133.16,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,118.5124,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.54253,130.4968
"Hla Class II Low Res, 1 Locus - Ref",PX8137690,CDM,310,RC,81376,CPT,90,,,,,,,279,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,118.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,118.55,122.22
"Hla Class II Low Res, 1 Locus - Ref",PX8137690,CDM,310,RC,81376,CPT,90,,,,,,,279,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,118.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,118.55,122.22
"Hla Class II Low Res, 1 Locus - Ref",PX8137690,CDM,310,RC,81376,CPT,90,,,,,,,279,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,118.55,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,118.55,122.22
Drain/Inject Medium Joint/Bursa,PX20605F,CDM,510,RC,20605,CPT,,,,,,,,247,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,118.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.6038,258.75
Drain/Inject Medium Joint/Bursa,PX20605F,CDM,510,RC,20605,CPT,,,,,,,,247,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,118.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.6038,258.75
Airway Inhalation Treatment,PX94640F,CDM,410,RC,94640,CPT,,,,,,,,242,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,111.9008696,percent of total billed charges,118.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,100.5268,237.16
Airway Inhalation Treatment,PX94640F,CDM,410,RC,94640,CPT,,,,,,,,242,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,118.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,100.5268,237.16
Airway Inhalation Treatment,PX94640F,CDM,410,RC,94640,CPT,,,,,,,,242,,United Healthcare,All Medicare advantage plans,outpatient,49,,124.02,percent of total billed charges,118.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,100.5268,237.16
BAG LEG URINARY STND 32OZ,120.33,CDM,272,RC,A5112,HCPCS,,4433-MAIN,LOCAL,,,,,121,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,118.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
BAG URINARY DRAINAGE 2000ML 6300,120.33,CDM,274,RC,A4357,HCPCS,,1283-MAIN,LOCAL,,,,,121,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,118.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
BAG URINARY LEG PACK 9349,120.33,CDM,272,RC,A5112,HCPCS,,623-MAIN,LOCAL,,,,,121,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,118.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.9848,118.58
"Chest Wall Manipulation,Initial",PX94667,CDM,410,RC,94667,CPT,,,,,,,,121,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,118.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.2634,118.58
"Fluor Noninfect Ab Sc, Ea - Ref",PX8625590,CDM,300,RC,86255,CPT,90,,,,,,,121,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,118.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.05,118.58
"Manage/Train Orthotic/Prosthetic, per 15 Min",PX97763,CDM,420,RC,97763,CPT,,,,,,,,121,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,118.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.36,118.58
"Noninvasv Oxygen Satut,Continuous",PX94762,CDM,460,RC,94762,CPT,,,,,,,,242,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,118.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,100.5268,237.16
"Noninvasv Oxygen Satut,Continuous",PX94762,CDM,460,RC,94762,CPT,,,,,,,,242,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,118.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,100.5268,237.16
"Noninvasv Oxygen Satut,Continuous",PX94762,CDM,460,RC,94762,CPT,,,,,,,,242,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,118.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,100.5268,237.16
"Prosthetic Training, Initial, Each 15 Mins",PX97761,CDM,420,RC,97761,CPT,,,,,,,,121,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,118.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.41,118.58
sulfacetamide 10 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,61314070101,NDC,15,ML,285.48,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,118.588392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,63323050830,NDC,1,EA,134.48,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,118.61136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.461584,189.875
IV 0.9% NS 1000ML 2B1324X,27200000,CDM,272,RC,,,,538-MAIN,LOCAL,,,,,121.89,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,118.635537,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Package,25000000,CDM,250,RC,,,,,,10019055390,NDC,1,EA,121.9,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,118.64527,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Assay of Iron,PX83540,CDM,300,RC,83540,CPT,,,,,,,,122,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,29.64,percent of total billed charges,118.7426,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,119.56
"Compliment, Total (Ch50) - Ref",PX8616290,CDM,300,RC,86162,CPT,90,,,,,,,122,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,118.7426,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.63,119.56
Vitamin B-12,PX82607,CDM,300,RC,82607,CPT,,,,,,,,122,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,118.7426,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.83,119.56
triamcinolone acetonide 0.1 % Cream 454 g Jar,63700001,CDM,250,RC,,,,,,45802006405,NDC,454,GR,130.36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,118.75796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine-epinephrine-tetracaine Gel 3 mL Syringe,J3490.160,CDM,636,RC,J3490,HCPCS,,,,88888800028,NDC,3,ML,121.19,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,118.7662,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.342326,118.7662
Blood Culture for Bacteria,PX87040,CDM,300,RC,87040,CPT,,,,,,,,286,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,118.8044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.46,280.28
I&D Bartholin Gland Abscess,PX56420P,CDM,983,RC,56420,CPT,,,,,,,,286,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,118.8044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,118.8044,278.3638
Joint Survey,PX7707726,CDM,982,RC,77077,CPT,26,,,,,,,286,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,118.8044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,278.3638
Lab Culture Bacteria,PX87070,CDM,300,RC,87070,CPT,,,,,,,,286,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,118.8044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.9,280.28
Urine Culture/Colony Count,PX87086,CDM,300,RC,87086,CPT,,,,,,,,286,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,118.8044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4,280.28
Dress/Debrid Large Burn No Anesth,PX16030F,CDM,510,RC,16030,CPT,,,,,,,,399,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,118.807,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.84,410.93
"Molecular Cytog, Ea Probe - Ref",PX8827190,CDM,310,RC,88271,CPT,90,,,,,,,277,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,118.833,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.64,271.46
"Xray Neck, Soft Tissue",PX7036001,CDM,320,RC,70360,CPT,TC,,,,,,,277,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,118.833,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,271.46
CT Angio Abdom W/O & W/Dye,PX7417501,CDM,350,RC,74175,CPT,TC,,,,,,,4183,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,118.89,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,118.89,451.63
CT Angio Abdom W/O & W/Dye,PX7417501,CDM,350,RC,74175,CPT,TC,,,,,,,4183,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,118.89,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,118.89,451.63
CT Angio Upr Extrm W/O&W/Dye,PX7320601,CDM,350,RC,73206,CPT,TC,,,,,,,757,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,118.89,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,118.89,435.86
CT Angio Upr Extrm W/O&W/Dye,PX7320601,CDM,350,RC,73206,CPT,TC,,,,,,,757,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,118.89,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,118.89,435.86
CT Angiograph Pelv W/O&W/Dye,PX7219101,CDM,350,RC,72191,CPT,TC,,,,,,,1458,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,118.89,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,118.89,450.98
CT Angiograph Pelv W/O&W/Dye,PX7219101,CDM,350,RC,72191,CPT,TC,,,,,,,1458,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,118.89,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,118.89,450.98
Partial Bone Scan,PX7830001,CDM,341,RC,78300,CPT,TC,,,,,,,1391,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,118.89,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,118.89,351.05
Partial Bone Scan,PX7830001,CDM,341,RC,78300,CPT,TC,,,,,,,1391,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,118.89,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,118.89,351.05
cefoTEtan 2 g Recon Soln 1 Each Vial,800000,CDM,,,S0074,HCPCS,,,,63323038620,NDC,1,EA,240.2,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,118.899,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
neomycin-polymyxin-dexamethasone 3.5-10000-0.1 Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,61314063136,NDC,3.5,GR,247.71,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,118.9008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
neomycin-polymyxin-dexamethasone 3.5-10000-0.1 Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,61314063136,NDC,3.5,GR,247.71,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,118.9008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
neomycin-polymyxin-dexameth 3.5-10000-0.1 Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063006,NDC,5,ML,247.72,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,118.9056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
neomycin-polymyxin-dexameth 3.5-10000-0.1 Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063006,NDC,5,ML,247.72,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,118.9056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
gentamicin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063305,NDC,5,ML,122.17,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,118.908061,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152F,CDM,370,RC,99152,CPT,,,,,,,,235,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,118.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97.619,230.3
Occupational Therapy Eval Low Complex,PX97165,CDM,434,RC,97165,CPT,,,,,,,,235,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,118.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,230.3
Physical Therapy Evaluation Low Complex,PX97161,CDM,424,RC,97161,CPT,,,,,,,,235,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,118.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,392.7
Remv Ext Canal Foreign Body,PX69200F,CDM,510,RC,69200,CPT,,,,,,,,235,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,118.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97.619,230.3
"Vitamin D, 25 Hydroxy",PX82306,CDM,300,RC,82306,CPT,,,,,,,,235,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,118.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.14,230.3
US Doppler Lw Ext Art Tc,PX9392601,CDM,921,RC,93926,CPT,TC,,,,,,,740,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,118.955,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.89,211.74
TISSUE RETRIEVAL SYSTEM,27200000,CDM,272,RC,,,,10233-MAIN,LOCAL,,,,,139.98,,First Health,Commercial,both,85,,999999999,percent of total billed charges,118.983,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Apply Forearm Cast,PX29075P,CDM,983,RC,29075,CPT,,,,,,,,140,,First Health,Commercial,both,85,,999999999,percent of total billed charges,119,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.156,234.62
Hospital Discharge Day>30 Min,PX99239P,CDM,982,RC,99239,CPT,,,,,,,,140,,First Health,Commercial,both,85,,999999999,percent of total billed charges,119,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.156,136.262
Debride Muscle Ea Add 20 Sqcm,PX11046F,CDM,510,RC,11046,CPT,,,,,,,,248,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,119.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.0192,243.04
Debride Muscle Ea Add 20 Sqcm,PX11046F,CDM,510,RC,11046,CPT,,,,,,,,248,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,119.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.0192,243.04
Fetal Profile W/O Stress,PX7681901,CDM,402,RC,76819,CPT,TC,,,,,,,248,,Health Partners,Health Partners Care Plans,both,48,,240.56,percent of total billed charges,119.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,243.04
Fetal Profile W/O Stress,PX7681901,CDM,402,RC,76819,CPT,TC,,,,,,,248,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,119.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,243.04
US Chest Tc,PX7660401,CDM,402,RC,76604,CPT,TC,,,,,,,248,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,119.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,243.04
US Chest Tc,PX7660401,CDM,402,RC,76604,CPT,TC,,,,,,,248,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,119.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,243.04
"West Nile Ab, Igg - Ref",PX8678990,CDM,300,RC,86789,CPT,90,,,,,,,248,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,119.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,243.04
"West Nile Ab, Igg - Ref",PX8678990,CDM,300,RC,86789,CPT,90,,,,,,,248,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,119.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,243.04
Calr Gene Analysis Common Variants in Exon 9 - Ref,PX8121990,CDM,300,RC,81219,CPT,90,,,,,,,534,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,119.0539,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,117.98,121.63
octreotide 200 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037805,NDC,1,ML,133.77,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,119.0553,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
"Cognitive Funct Ther Interv, per Day",PX97127,CDM,420,RC,97127,CPT,,,,,,,,135,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,119.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.079,132.3
Electric Stimulation Therapy,PX97014,CDM,420,RC,97014,CPT,,,,,,,,135,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,119.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.18,132.3
Electrical Stimulation,PX97032,CDM,420,RC,97032,CPT,,,,,,,,135,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,119.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,132.3
Gait Training Therapy,PX97116,CDM,420,RC,97116,CPT,,,,,,,,135,,United Healthcare,All Payer,outpatient,88.2,,70.47,percent of total billed charges,119.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20,132.3
"Manual Ther Tech,1+Regions,Ea 15 Min",PX97140,CDM,420,RC,97140,CPT,,,,,,,,135,,United Healthcare,All Payer,outpatient,88.2,,98.31788732,percent of total billed charges,119.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.4,215.05
Mechanical Traction Therapy,PX97012,CDM,420,RC,97012,CPT,,,,,,,,135,,United Healthcare,All Payer,outpatient,88.2,,66.15,percent of total billed charges,119.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,132.3
Neuromuscular Re-Education,PX97112,CDM,420,RC,97112,CPT,,,,,,,,135,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,119.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.95,215.05
Self Care Mngment Training,PX97535,CDM,420,RC,97535,CPT,,,,,,,,135,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,119.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.27,132.3
Therapeutic Activities,PX97530,CDM,420,RC,97530,CPT,,,,,,,,135,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,119.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.22,205.7
Therapeutic Exercises,PX97110,CDM,420,RC,97110,CPT,,,,,,,,135,,United Healthcare,All Payer,outpatient,88.2,,80.64265625,percent of total billed charges,119.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20,215.05
Ultrasound Therapy,PX97035,CDM,420,RC,97035,CPT,,,,,,,,135,,United Healthcare,All Payer,outpatient,88.2,,81.61666667,percent of total billed charges,119.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,132.3
CT Abdomen W/Dye,PX7416001,CDM,350,RC,74160,CPT,TC,,,,,,,3413,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,119.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.11,354.34
CT Abdomen W/Dye,PX7416001,CDM,350,RC,74160,CPT,TC,,,,,,,3413,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,119.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.11,354.34
CT Abdomen W/O & W/Dye,PX7417001,CDM,350,RC,74170,CPT,TC,,,,,,,3689,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,119.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.11,401.67
CT Abdomen W/O & W/Dye,PX7417001,CDM,350,RC,74170,CPT,TC,,,,,,,3689,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,119.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.11,401.67
CT Angio Abdominal Arteries,PX7563501,CDM,350,RC,75635,CPT,TC,,,,,,,2936,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,119.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.11,612.7
CT Angio Abdominal Arteries,PX7563501,CDM,350,RC,75635,CPT,TC,,,,,,,2936,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,119.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.11,612.7
CT Angio Lwr Extr W/O&W/Dye,PX7370601,CDM,350,RC,73706,CPT,TC,,,,,,,1554,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,119.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.11,479.9
CT Angio Lwr Extr W/O&W/Dye,PX7370601,CDM,350,RC,73706,CPT,TC,,,,,,,1554,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,119.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.11,479.9
"CT Angiography, Chest",PX7127501,CDM,350,RC,71275,CPT,TC,,,,,,,3689,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,119.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.11,401.67
"CT Angiography, Chest",PX7127501,CDM,350,RC,71275,CPT,TC,,,,,,,3689,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,119.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.11,401.67
"CT Angiography, Head",PX7049601,CDM,350,RC,70496,CPT,TC,,,,,,,3690,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,119.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.11,397.07
"CT Angiography, Head",PX7049601,CDM,350,RC,70496,CPT,TC,,,,,,,3690,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,119.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.11,397.07
"CT Angiography, Neck",PX7049801,CDM,350,RC,70498,CPT,TC,,,,,,,3690,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,119.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.11,396.41
"CT Angiography, Neck",PX7049801,CDM,350,RC,70498,CPT,TC,,,,,,,3690,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,119.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.11,396.41
CT Pelvis W/Dye,PX7219301,CDM,350,RC,72193,CPT,TC,,,,,,,3330,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,119.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.11,356.31
CT Pelvis W/Dye,PX7219301,CDM,350,RC,72193,CPT,TC,,,,,,,3330,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,119.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.11,356.31
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,68462018022,NDC,22,GR,240.66,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,119.1267,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Repeat Control of Nosebleed,PX30906F,CDM,510,RC,30906,CPT,,,,,,,,334,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,119.1281,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,80.71,780.35
doxycycline 100 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323013041,NDC,1,EA,140.2,,First Health,Commercial,both,85,,999999999,percent of total billed charges,119.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,63323027301,NDC,0.5,ML,235.6,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,119.2136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
Abd Duplex Abd -Follow Up,PX9397602,CDM,921,RC,93976,CPT,TC,,,,,,,784,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,119.2765,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.55,211.74
Abd Duplex Abd-Follow Up(T),PX9397601,CDM,921,RC,93976,CPT,TC,,,,,,,809,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,119.2765,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.55,211.74
"Initial Observation Care,Levl II",PX99219,CDM,982,RC,99219,CPT,,,,,,,,391,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,119.31,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.31,383.18
"Initial Observation Care,Levl II",PX99219,CDM,982,RC,99219,CPT,,,,,,,,391,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,119.3136,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.31,383.18
Noninvasv Oxygen Satur;Single,PX94760,CDM,460,RC,94760,CPT,,,,,,,,131,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,119.341,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.4174,128.38
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,69315030615,NDC,15,GR,131.07,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,119.40477,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Biopsy Vulva/Perineum,One Lesn",PX56605F,CDM,510,RC,56605,CPT,,,,,,,,236,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,119.416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.0344,702.31
Lab Basic Metabolic Panel,PX80048,CDM,300,RC,80048,CPT,,,,,,,,236,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,119.416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.76,231.28
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337501,NDC,50,ML,135.43,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,119.44926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337502,NDC,50,ML,135.43,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,119.44926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9678001,NDC,50,ML,135.43,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,119.44926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
IV 0.9% NS 1000ML 2B1324X,27200000,CDM,272,RC,,,,538-MAIN,LOCAL,,,,,121.89,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,119.4522,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Package,25000000,CDM,250,RC,,,,,,10019055390,NDC,1,EA,121.9,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,119.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
PURAPLYAM XT-COM 4.91X4.91 EXTRA FENESTRATED 24.10 SQCM,120.567,CDM,272,RC,Q4197,HCPCS,,12806-MAIN,LOCAL,,,,,6562,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,119.47938,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.47938,122.98
PURAPLYAM XT-COM 4.91X4.91 EXTRA FENESTRATED 24.10 SQCM,120.567,CDM,272,RC,Q4197,HCPCS,,12806-MAIN,LOCAL,,,,,6562,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,119.48,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.47938,122.98
hepatitis B immune globulin 312 UNIT/ML Solution 5 mL Vial,90371,CDM,636,RC,90371,CPT,,,,59730420301,NDC,5,ML,2851.63,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,119.53,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.19,138.3079
hepatitis B immune globulin 312 UNIT/ML Solution 5 mL Vial,90371,CDM,636,RC,90371,CPT,,,,59730420301,NDC,5,ML,2851.63,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,119.53,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.19,138.3079
Assay of Iron,PX83540,CDM,300,RC,83540,CPT,,,,,,,,122,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,119.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,119.56
BINDER PELVIC ADULT STABILIZATION T-PODR,120.357,CDM,271,RC,A4467,HCPCS,,10734-MAIN,LOCAL,,,,,244,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,119.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.3576,239.12
BINDER PELVIC ADULT STABILIZATION T-PODR,120.357,CDM,271,RC,A4467,HCPCS,,10734-MAIN,LOCAL,,,,,244,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,119.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.3576,239.12
BINDER PELVIC ADULT STABILIZATION T-PODR,120.357,CDM,271,RC,A4467,HCPCS,,10734-MAIN,LOCAL,,,,,244,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,119.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.3576,239.12
"Bone Marrow Aspiration(S),Diag",PX38220P,CDM,983,RC,38220,CPT,,,,,,,,244,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,119.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.3576,1416.38
"Bone Marrow Aspiration(S),Diag",PX38220P,CDM,983,RC,38220,CPT,,,,,,,,244,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,119.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.3576,1416.38
"Bone Marrow Aspiration(S),Diag",PX38220P,CDM,983,RC,38220,CPT,,,,,,,,244,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,119.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.3576,1416.38
"Compliment, Total (Ch50) - Ref",PX8616290,CDM,300,RC,86162,CPT,90,,,,,,,122,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,119.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.63,119.56
Dress/Debrid Med Burn No Anesth,PX16025P,CDM,983,RC,16025,CPT,,,,,,,,244,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,119.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.3576,237.4852
Dress/Debrid Med Burn No Anesth,PX16025P,CDM,983,RC,16025,CPT,,,,,,,,244,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,119.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.3576,237.4852
Dress/Debrid Med Burn No Anesth,PX16025P,CDM,983,RC,16025,CPT,,,,,,,,244,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,119.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.3576,237.4852
Vitamin B-12,PX82607,CDM,300,RC,82607,CPT,,,,,,,,122,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,119.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.83,119.56
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,51672131200,NDC,22,GR,140.7,,First Health,Commercial,both,85,,999999999,percent of total billed charges,119.595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
amiodarone 150-4.21 MG/100ML-% Solution 100 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066015010,NDC,100,ML,249.22,,Health Partners,Health Partners Care Plans,both,48,,12.56916667,percent of total billed charges,119.6256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.35,318.745
amiodarone 150-4.21 MG/100ML-% Solution 100 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066015010,NDC,100,ML,249.22,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,119.6256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.35,318.745
CHOLANGIOGRAM CATHETER REDDICK,27200000,CDM,272,RC,,,,10232-MAIN,LOCAL,,,,,287.98,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,119.626892,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Spirometry Incl Graph Rec Tc,PX9401002,CDM,460,RC,94010,CPT,TC,,,,,,,288,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,119.6352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.6352,282.24
STRAP CLAVICLE LARGE VP10123-040,120.191,CDM,274,RC,L3670,HCPCS,,12848-MAIN,LOCAL,,,,,24,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,119.6724,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.65,121.74
STRAP CLAVICLE MEDIUM VP10123-030,120.191,CDM,274,RC,L3670,HCPCS,,12847-MAIN,LOCAL,,,,,24,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,119.6724,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.65,121.74
STRAP CLAVICLE SMALL VP10123-020,120.191,CDM,274,RC,L3670,HCPCS,,12846-MAIN,LOCAL,,,,,24,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,119.6724,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.65,121.74
STRAP CLAVICLE XL 661 XL,120.191,CDM,274,RC,L3670,HCPCS,,12850-MAIN,LOCAL,,,,,24,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,119.6724,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.65,121.74
STRAP CLAVICLE XSMALL CHILD ORT14100XS,120.191,CDM,274,RC,L3670,HCPCS,,12849-MAIN,LOCAL,,,,,24,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,119.6724,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.65,121.74
Repr Superf Wnd Face 2.6-5,PX12013F,CDM,510,RC,12013,CPT,,,,,,,,375,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,119.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.03,243.51
Repr Superf Wnd Face 2.6-5,PX12013P,CDM,983,RC,12013,CPT,,,,,,,,681,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,119.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.03,667.38
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,63323050830,NDC,1,EA,134.48,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,119.6872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.461584,189.875
"Hla Class II Low Res, 1 Locus - Ref",PX8137690,CDM,310,RC,81376,CPT,90,,,,,,,279,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,119.691,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.06,273.42
INSUFLOWPORT & PNEUVIEW  XE SMOKE ELIMINATOR 5MM,27200000,CDM,272,RC,,,,11876-MAIN,LOCAL,,,,,279,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,119.691,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 8MM,27200000,CDM,272,RC,,,,11877-MAIN,LOCAL,,,,,279,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,119.691,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 10MM,27200000,CDM,272,RC,,,,11878-MAIN,LOCAL,,,,,279,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,119.691,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 12MM,27200000,CDM,272,RC,,,,11879-MAIN,LOCAL,,,,,279,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,119.691,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 5MM,27200000,CDM,272,RC,,,,11880-MAIN,LOCAL,,,,,279,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,119.691,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 8MM,27200000,CDM,272,RC,,,,11881-MAIN,LOCAL,,,,,279,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,119.691,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 10MM,27200000,CDM,272,RC,,,,11882-MAIN,LOCAL,,,,,279,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,119.691,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 12MM,27200000,CDM,272,RC,,,,11883-MAIN,LOCAL,,,,,279,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,119.691,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Puncture Drainage of Lesion,PX10160F,CDM,510,RC,10160,CPT,,,,,,,,279,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,119.691,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.8966,348.35
Xray Pelvis 1 or 2 Vws,PX7217001,CDM,320,RC,72170,CPT,TC,,,,,,,279,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,119.691,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,273.42
"Hla Class II Low Res, 1 Locus - Ref",PX8137690,CDM,310,RC,81376,CPT,90,,,,,,,279,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,119.6957,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,118.55,122.22
Each Add'l Hour IV Hydration,PX96361,CDM,260,RC,96361,CPT,,,,,,,,123,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,98.97674419,percent of total billed charges,119.7159,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,120.54
FLAT WOUND DRAIN WITH TROCAR 4 CHANNEL FULL FLUTED 7FR SILICONE,27200000,CDM,272,RC,,,,12473-MAIN,LOCAL,,,,,123,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,119.7159,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Office/Outpt Visit,New,Levl II",PX99202F,CDM,510,RC,99202,CPT,,,,,,,,123,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,55.53,percent of total billed charges,119.7159,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.0942,120.54
"Office/Outpt Visit,New,Levl II",PX99202P,CDM,983,RC,99202,CPT,,,,,,,,123,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,55.53,percent of total billed charges,119.7159,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.0942,119.7159
gentamicin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063305,NDC,5,ML,122.17,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,119.7266,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032F,CDM,510,RC,12032,CPT,,,,,,,,386,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,119.76,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.76,632.31
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032P,CDM,983,RC,12032,CPT,,,,,,,,647,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,119.76,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.76,634.06
ciprofloxacin 0.3 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,61314065625,NDC,2.5,ML,140.92,,First Health,Commercial,both,85,,999999999,percent of total billed charges,119.782,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Airway Inhalation Treatment,PX94640F,CDM,410,RC,94640,CPT,,,,,,,,242,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,119.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,100.5268,237.16
"Noninvasv Oxygen Satut,Continuous",PX94762,CDM,460,RC,94762,CPT,,,,,,,,242,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,119.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,100.5268,237.16
adenosine 6 MG/2ML Solution 2 mL Syringe,J0153.01,CDM,636,RC,J0153,HCPCS,,,,25021030167,NDC,2,ML,123.1,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,2.535833333,percent of total billed charges,119.81323,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.13574,120.638
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004725,NDC,2,ML,131.52,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,119.81472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
Aspergillus Ag - Ref,PX8730590,CDM,300,RC,87305,CPT,90,,,,,,,141,,First Health,Commercial,both,85,,999999999,percent of total billed charges,119.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,138.18
levOCARNitine 200 MG/ML Solution 5 mL Vial,J1955.01,CDM,636,RC,J1955,HCPCS,,,,517104501,NDC,5,ML,249.86,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,119.9328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.791844,244.8628
levOCARNitine 200 MG/ML Solution 5 mL Vial,J1955.01,CDM,636,RC,J1955,HCPCS,,,,517104501,NDC,5,ML,249.86,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,119.9328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.791844,244.8628
sincalide 5 MCG Recon Soln 1 Each Vial,J2805.01,CDM,636,RC,J2805,HCPCS,,,,270055615,NDC,1,EA,250,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,120,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.85,245
sincalide 5 MCG Recon Soln 1 Each Vial,J2805.01,CDM,636,RC,J2805,HCPCS,,,,270055615,NDC,1,EA,250,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,120,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.85,245
Withdrawal of Arterial Blood,PX36600F,CDM,510,RC,36600,CPT,,,,,,,,250,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,120,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.85,245
Withdrawal of Arterial Blood,PX36600F,CDM,510,RC,36600,CPT,,,,,,,,250,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,120,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.85,245
sodium polystyrene sulfonate 15 GM/60ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,46287000660,NDC,60,ML,123.3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,120.00789,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,703115301,NDC,4,ML,136.1,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,120.0402,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Fibrinogen Activity - Ref,PX8538490,CDM,300,RC,85384,CPT,90,,,,,,,245,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,120.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.91,240.1
Fibrinogen Activity - Ref,PX8538490,CDM,300,RC,85384,CPT,90,,,,,,,245,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,120.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.91,240.1
Fibrinogen Activity - Ref,PX8538490,CDM,300,RC,85384,CPT,90,,,,,,,245,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,120.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.91,240.1
"Ileoscopy Thru Stoma,Diagnostic",PX44380F,CDM,750,RC,44380,CPT,,,,,,,,245,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,120.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.773,791.92
"Ileoscopy Thru Stoma,Diagnostic",PX44380F,CDM,750,RC,44380,CPT,,,,,,,,245,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,120.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.773,791.92
"Ileoscopy Thru Stoma,Diagnostic",PX44380F,CDM,750,RC,44380,CPT,,,,,,,,245,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,120.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.773,791.92
Lipid Profile,PX80061,CDM,300,RC,80061,CPT,,,,,,,,245,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,120.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.28,240.1
Lipid Profile,PX80061,CDM,300,RC,80061,CPT,,,,,,,,245,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,120.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.28,240.1
Lipid Profile,PX80061,CDM,300,RC,80061,CPT,,,,,,,,245,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,120.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.28,240.1
Platelet Antibodies - Ref,PX8602290,CDM,300,RC,86022,CPT,90,,,,,,,245,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,120.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.84,240.1
Platelet Antibodies - Ref,PX8602290,CDM,300,RC,86022,CPT,90,,,,,,,245,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,120.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.84,240.1
Platelet Antibodies - Ref,PX8602290,CDM,300,RC,86022,CPT,90,,,,,,,245,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,120.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.84,240.1
BONE SCREW T8 FULL THREAD 2.4MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12652-MAIN,LOCAL,,,,,289,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,120.0506,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
BONE SCREW T8 FULL THREAD 2.4MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12653-MAIN,LOCAL,,,,,289,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,120.0506,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
BONE SCREW T8 FULL THREAD 2.7MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12654-MAIN,LOCAL,,,,,289,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,120.0506,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Occupational Therapy Eval High Complex,PX97167,CDM,434,RC,97167,CPT,,,,,,,,289,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,120.0506,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,283.22
"Troponin, Quantitative",PX84484,CDM,300,RC,84484,CPT,,,,,,,,289,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,120.0506,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.43,283.22
"Pertechnetate, Dia, per Mci",PXA9512,CDM,343,RC,A9512,HCPCS,,,,,,,,280,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,120.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,116.312,274.4
"Cognitive Funct Ther Interv, per Day",PX97127,CDM,420,RC,97127,CPT,,,,,,,,135,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,120.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.079,132.3
Electric Stimulation Therapy,PX97014,CDM,420,RC,97014,CPT,,,,,,,,135,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,120.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.18,132.3
Electrical Stimulation,PX97032,CDM,420,RC,97032,CPT,,,,,,,,135,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,120.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,132.3
Gait Training Therapy,PX97116,CDM,420,RC,97116,CPT,,,,,,,,135,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,120.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20,132.3
"Manual Ther Tech,1+Regions,Ea 15 Min",PX97140,CDM,420,RC,97140,CPT,,,,,,,,135,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,120.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.4,215.05
Mechanical Traction Therapy,PX97012,CDM,420,RC,97012,CPT,,,,,,,,135,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,120.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,132.3
Neuromuscular Re-Education,PX97112,CDM,420,RC,97112,CPT,,,,,,,,135,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,120.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.95,215.05
Self Care Mngment Training,PX97535,CDM,420,RC,97535,CPT,,,,,,,,135,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,120.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.27,132.3
Therapeutic Activities,PX97530,CDM,420,RC,97530,CPT,,,,,,,,135,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,120.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.22,205.7
Therapeutic Exercises,PX97110,CDM,420,RC,97110,CPT,,,,,,,,135,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,120.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20,215.05
Ultrasound Therapy,PX97035,CDM,420,RC,97035,CPT,,,,,,,,135,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,120.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,132.3
LAPAROTOMY MAJOR I,27200000,CDM,272,RC,,,,4828-MAIN,LOCAL,,,,,123.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,120.20255,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Apply of Paste Boot,PX29580F,CDM,510,RC,29580,CPT,,,,,,,,132,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,120.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,137.65
Assay Dipropylacetic Acid,PX80164,CDM,300,RC,80164,CPT,,,,,,,,132,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,120.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.41,129.36
Assay of Lipase,PX83690,CDM,300,RC,83690,CPT,,,,,,,,132,,Medica,Commercial,both,91.1,,14.66,percent of total billed charges,120.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.32,129.36
"Remv F.B.,Eye,Superf Conjunc",PX65205F,CDM,510,RC,65205,CPT,,,,,,,,132,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,120.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,129.36
"Remv F.B.,Eye,Superf Conjunc",PX65205P,CDM,983,RC,65205,CPT,,,,,,,,132,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,120.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,128.4756
"Venipunc Need Phys Skill,Dx or Rx",PX36410,CDM,983,RC,36410,CPT,,,,,,,,132,,Medica,Commercial,both,91.1,,14.27,percent of total billed charges,120.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,128.4756
MINIBUNION NON-LOCKING SCREW  2.7X18MM,C1713,CDM,278,RC,C1713,HCPCS,,11670-MAIN,LOCAL,,,,,280.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,120.3345,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Drain Blood From Under Nail,PX11740F,CDM,510,RC,11740,CPT,,,,,,,,117,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,120.37,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.28,120.37
Inj Tendon/Ligament/Cyst,PX20550F,CDM,510,RC,20550,CPT,,,,,,,,177,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,120.37,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.78,120.37
Inj Tendon/Ligament/Cyst,PX20550P,CDM,983,RC,20550,CPT,,,,,,,,264,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,120.37,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.78,258.72
HERCULES 3 STAGE BALLOON ESOPHAGEAL 12-13.5-15::36-40.5-45MM,27200000,CDM,272,RC,C1726,HCPCS,,11329-MAIN,LOCAL,,,,,289.85,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,120.40369,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HERCULES 3 STAGE BALLOON ESOPHAGEAL 15-16.5-18:45-49.5-54MM,27200000,CDM,272,RC,C1726,HCPCS,,11328-MAIN,LOCAL,,,,,289.85,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,120.40369,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HERCULES 3 STAGE BALLOON ESOPHAGEAL 18-19-20::54-57-60MM,27200000,CDM,272,RC,C1726,HCPCS,,11330-MAIN,LOCAL,,,,,289.85,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,120.40369,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Phlebotomy,PX99195,CDM,940,RC,99195,CPT,,,,,,,,238,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,120.428,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.8652,233.24
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615900,NDC,1,EA,123.75,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,13.11107143,percent of total billed charges,120.445875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615904,NDC,1,EA,123.75,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,13.11107143,percent of total billed charges,120.445875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
Apply Long Arm Splint,PX29105F,CDM,510,RC,29105,CPT,,,,,,,,290,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,120.466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.466,284.2
Assay of Digoxin,PX80162,CDM,300,RC,80162,CPT,,,,,,,,290,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,120.466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.18,284.2
Assay of Natriuretic Peptide,PX83880,CDM,300,RC,83880,CPT,,,,,,,,290,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,120.466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36,284.2
NEEDLE INTRAOSSEOUS SET 15GA 25MM STABILIZER EZ-IO 9001P,120.216,CDM,272,RC,A4215,HCPCS,,10648-MAIN,LOCAL,,,,,290,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,120.466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.466,284.2
NEEDLE INTRAOSSEOUS SET 15GA 45MM STABILIZER EZ-IO 9079P,120.216,CDM,272,RC,A4215,HCPCS,,10297-MAIN,LOCAL,,,,,290,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,120.466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.466,284.2
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337501,NDC,50,ML,135.43,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,120.5327,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337502,NDC,50,ML,135.43,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,120.5327,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9678001,NDC,50,ML,135.43,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,120.5327,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
Each Add'l Hour IV Hydration,PX96361,CDM,260,RC,96361,CPT,,,,,,,,123,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,120.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,120.54
FLAT WOUND DRAIN WITH TROCAR 4 CHANNEL FULL FLUTED 7FR SILICONE,27200000,CDM,272,RC,,,,12473-MAIN,LOCAL,,,,,123,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,120.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
KATZ EXTRACTOR OTO-RHINO FOREIGN BODY REMOVER,120.568,CDM,272,RC,,,,12808-MAIN,LOCAL,,,,,246,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,120.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.1884,241.08
KATZ EXTRACTOR OTO-RHINO FOREIGN BODY REMOVER,120.568,CDM,272,RC,,,,12808-MAIN,LOCAL,,,,,246,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,120.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.1884,241.08
KATZ EXTRACTOR OTO-RHINO FOREIGN BODY REMOVER,120.568,CDM,272,RC,,,,12808-MAIN,LOCAL,,,,,246,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,120.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.1884,241.08
"Office/Outpt Visit,New,Levl II",PX99202F,CDM,510,RC,99202,CPT,,,,,,,,123,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,120.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.0942,120.54
"Office/Outpt Visit,New,Levl II",PX99202P,CDM,983,RC,99202,CPT,,,,,,,,123,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,120.54,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.89,129.77
8MM ENDOWRIST INSTRUMENTS CADIERE FORCEPS,27200000,CDM,272,RC,,,,11913-MAIN,LOCAL,,,,,281,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,120.549,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
FORCEPS PROGRASP 8MM ENDOWRIST INSTRUMENTS,27200000,CDM,272,RC,,,,12062-MAIN,LOCAL,,,,,281,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,120.549,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Spirometry,PX9401001,CDM,460,RC,94010,CPT,TC,,,,,,,281,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,120.549,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,116.7274,275.38
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042350,NDC,0.5,ML,132.37,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,120.58907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.49,129.7226
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042388,NDC,0.5,ML,132.37,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,120.58907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.49,129.7226
morphine 20 mg/mL Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,54040444,NDC,30,ML,141.88,,First Health,Commercial,both,85,,999999999,percent of total billed charges,120.598,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Fac/Initial Hospital Care Levl II,PX99222F,CDM,510,RC,99222,CPT,,,,,,,,187,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,120.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.18,232.02
Initial Hospital Care Levl II,PX99222P,CDM,982,RC,99222,CPT,,,,,,,,187,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,120.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.18,232.02
Lvl 2 Init Hosp Mod Mdm or 55 Minutes,PX99222,CDM,982,RC,99222,CPT,,,,,,,,508,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,120.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.18,497.84
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,65162083366,NDC,100,GR,281.12,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,120.60048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
CT Angio Abdom W/O & W/Dye,PX7417501,CDM,350,RC,74175,CPT,TC,,,,,,,4183,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,120.63,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,118.89,451.63
CT Angio Abdominal Arteries,PX7563501,CDM,350,RC,75635,CPT,TC,,,,,,,2936,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,120.63,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.11,612.7
CT Angio Upr Extrm W/O&W/Dye,PX7320601,CDM,350,RC,73206,CPT,TC,,,,,,,757,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,120.63,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,118.89,435.86
CT Angiograph Pelv W/O&W/Dye,PX7219101,CDM,350,RC,72191,CPT,TC,,,,,,,1458,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,120.63,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,118.89,450.98
"CT Angiography, Chest",PX7127501,CDM,350,RC,71275,CPT,TC,,,,,,,3689,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,120.63,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.11,401.67
"CT Angiography, Head",PX7049601,CDM,350,RC,70496,CPT,TC,,,,,,,3690,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,120.63,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.11,397.07
"CT Angiography, Neck",PX7049801,CDM,350,RC,70498,CPT,TC,,,,,,,3690,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,120.63,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.11,396.41
adenosine 6 MG/2ML Solution 2 mL Syringe,J0153.01,CDM,636,RC,J0153,HCPCS,,,,25021030167,NDC,2,ML,123.1,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,120.638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.13574,120.638
Assay of Lithium,PX80178,CDM,300,RC,80178,CPT,,,,,,,,124,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,120.6892,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.06,121.52
"Complement; Antigen, Each Component",PX86160,CDM,300,RC,86160,CPT,,,,,,,,124,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,120.6892,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11,121.52
"Immunoassay,Ca15-3(27.29) - Ref",PX8630090,CDM,300,RC,86300,CPT,90,,,,,,,124,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,120.6892,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,121.52
Itraconazole,PX8018990,CDM,300,RC,80189,CPT,90,,,,,,,124,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,120.6892,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.86,121.52
Microbe Susceptible Mic,PX87186,CDM,300,RC,87186,CPT,,,,,,,,124,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,25.60764706,percent of total billed charges,120.6892,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.93,121.52
Nocardia Susceptibility - Ref,PX8718690,CDM,300,RC,87186,CPT,90,,,,,,,124,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,25.60764706,percent of total billed charges,120.6892,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.93,121.52
Oligoclonal Bands - Ref,PX8391690,CDM,300,RC,83916,CPT,90,,,,,,,124,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,120.6892,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.11,121.52
UMBILICAL VESSEL CATHETER INSERTION TRAY POLY SINGLE LUMEN 3.5/5FR,120.573,CDM,272,RC,,,,12857-MAIN,LOCAL,,,,,124,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,120.6892,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.5096,121.52
Refill/Maint Portable Pump,PX96521,CDM,260,RC,96521,CPT,,,,,,,,325,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,120.696,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.8,216.39
Apply Multlay Comprs Lwr Leg,PX29581P,CDM,983,RC,29581,CPT,,,,,,,,142,,First Health,Commercial,both,85,,999999999,percent of total billed charges,120.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,138.2086
"Biopsy Vulva/Perineum,One Lesn",PX56605P,CDM,983,RC,56605,CPT,,,,,,,,142,,First Health,Commercial,both,85,,999999999,percent of total billed charges,120.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,702.31
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006P,CDM,983,RC,10006,CPT,,,,,,,,142,,First Health,Commercial,both,85,,999999999,percent of total billed charges,120.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,138.2086
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760,CDM,420,RC,97760,CPT,,,,,,,,142,,First Health,Commercial,both,85,,999999999,percent of total billed charges,120.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.18,139.16
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760F,CDM,510,RC,97760,CPT,,,,,,,,142,,First Health,Commercial,both,85,,999999999,percent of total billed charges,120.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.18,139.16
Oximetry;Mult Determine,PX610,CDM,460,RC,94761,CPT,,,,,,,,142,,First Health,Commercial,both,85,,999999999,percent of total billed charges,120.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,139.16
Thromboplastin Time Partial,PX85730,CDM,300,RC,85730,CPT,,,,,,,,142,,First Health,Commercial,both,85,,999999999,percent of total billed charges,120.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.51,139.16
X-Ray Exam Femur 1 Vw,PX7355101,CDM,320,RC,73551,CPT,TC,,,,,,,142,,First Health,Commercial,both,85,,999999999,percent of total billed charges,120.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,139.16
BINDER PELVIC ADULT STABILIZATION T-PODR,120.357,CDM,271,RC,A4467,HCPCS,,10734-MAIN,LOCAL,,,,,244,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,120.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.3576,239.12
"Bone Marrow Aspiration(S),Diag",PX38220P,CDM,983,RC,38220,CPT,,,,,,,,244,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,120.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.3576,1416.38
Dress/Debrid Med Burn No Anesth,PX16025P,CDM,983,RC,16025,CPT,,,,,,,,244,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,120.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.3576,237.4852
sodium phosphate 15 MMOLE/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323088401,NDC,5,ML,132.6,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,120.7986,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium phosphate 15 MMOLE/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323088406,NDC,5,ML,132.6,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,120.7986,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium polystyrene sulfonate 15 GM/60ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,46287000660,NDC,60,ML,123.3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,120.834,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Total Cortisol,PX82533,CDM,300,RC,82533,CPT,,,,,,,,137,,United Healthcare,All Payer,outpatient,88.2,,67.13,percent of total billed charges,120.834,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.95,134.26
"Triiodothyronine T3, Free (Free T3)",PX84481,CDM,300,RC,84481,CPT,,,,,,,,137,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,120.834,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.53,134.26
CT Abdomen W/Dye,PX7416001,CDM,350,RC,74160,CPT,TC,,,,,,,3413,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,120.85,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.11,354.34
CT Abdomen W/O & W/Dye,PX7417001,CDM,350,RC,74170,CPT,TC,,,,,,,3689,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,120.85,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.11,401.67
CT Angio Lwr Extr W/O&W/Dye,PX7370601,CDM,350,RC,73706,CPT,TC,,,,,,,1554,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,120.85,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.11,479.9
CT Pelvis W/Dye,PX7219301,CDM,350,RC,72193,CPT,TC,,,,,,,3330,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,120.85,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.11,356.31
Partial Bone Scan,PX7830001,CDM,341,RC,78300,CPT,TC,,,,,,,1391,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,120.85,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,118.89,351.05
Drain/Inject Large Joint/Bursa,PX20610P,CDM,983,RC,20610,CPT,,,,,,,,291,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,120.8814,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.8814,283.2303
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,781375575,NDC,4,ML,142.22,,First Health,Commercial,both,85,,999999999,percent of total billed charges,120.887,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Physical Therapy Re-Eval Est Plan Care 20 Mins,PX97164,CDM,424,RC,97164,CPT,,,,,,,,239,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,120.934,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,234.22
"Inject Trigger Point, 1 or 2",PX20552F,CDM,510,RC,20552,CPT,,,,,,,,252,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,120.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,258.75
"Inject Trigger Point, 1 or 2",PX20552F,CDM,510,RC,20552,CPT,,,,,,,,252,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,120.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,258.75
"Level V - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3939,CDM,310,RC,88307,CPT,TC,,,,,,,252,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,120.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,314.02
"Level V - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3939,CDM,310,RC,88307,CPT,TC,,,,,,,252,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,120.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,314.02
"Office/Outpt Visit,New,Levl III",PX99203F,CDM,510,RC,99203,CPT,,,,,,,,252,,Health Partners,Health Partners Care Plans,both,48,,208.93,percent of total billed charges,120.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,246.96
"Office/Outpt Visit,New,Levl III",PX99203F,CDM,510,RC,99203,CPT,,,,,,,,252,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,120.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,246.96
Xray Finger(S) Tc,PX7314001,CDM,320,RC,73140,CPT,TC,,,,,,,282,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,120.978,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,276.36
Xray Toe(S) Tc,PX7366001,CDM,320,RC,73660,CPT,TC,,,,,,,282,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,120.978,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,276.36
DRAIN FLAT JACKSON PRATT 10MM,27100000,CDM,271,RC,,,,334-MAIN,LOCAL,,,,,239.09,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,120.97954,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
diclofenac 0.1 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,17478089225,NDC,2.5,ML,252.06,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,120.9888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
diclofenac 0.1 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,17478089225,NDC,2.5,ML,252.06,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,120.9888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614800,NDC,1,EA,239.18,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,121.02508,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
Drain/Inject Medium Joint/Bursa,PX20605F,CDM,510,RC,20605,CPT,,,,,,,,247,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,121.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.6038,258.75
Drain/Inject Medium Joint/Bursa,PX20605F,CDM,510,RC,20605,CPT,,,,,,,,247,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,121.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.6038,258.75
Drain/Inject Medium Joint/Bursa,PX20605F,CDM,510,RC,20605,CPT,,,,,,,,247,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,121.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.6038,258.75
LAPAROTOMY MAJOR I,27200000,CDM,272,RC,,,,4828-MAIN,LOCAL,,,,,123.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,121.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,24208046325,NDC,2.5,ML,137.26,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,121.06332,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Exc Skn Mal 2.1-3cmtrnk,Arm,Lg",PX11603P,CDM,983,RC,11603,CPT,,,,,,,,1276,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,121.07,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.07,1250.48
"Fac/Exc Skn Mali2.1-3cmtrnk,Arm,Lg",PX11603F,CDM,510,RC,11603,CPT,,,,,,,,875,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,121.07,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.07,580.42
Kit Gene Analysis D816 Variant(S) - Ref,PX8127390,CDM,300,RC,81273,CPT,90,,,,,,,293,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,121.12,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.12,124.87
Kit Gene Analysis D816 Variant(S) - Ref,PX8127390,CDM,300,RC,81273,CPT,90,,,,,,,293,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,121.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.12,124.87
Kit Gene Analysis D816 Variant(S) - Ref,PX8127390,CDM,300,RC,81273,CPT,90,,,,,,,293,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,121.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.12,124.87
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,703115301,NDC,4,ML,136.1,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,121.129,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Cardiolipin Ab, Ea Lg - Ref",PX8614790,CDM,300,RC,86147,CPT,90,,,,,,,133,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,121.163,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.34,130.34
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU0003,CDM,300,RC,U0003,HCPCS,,,,,,,,133,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,121.163,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.2482,130.34
Lvl 1 Sub Hosp Low Mdm or 25 Minutes,PX99231,CDM,982,RC,99231,CPT,,,,,,,,133,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,121.163,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.2482,129.4489
hepatitis b recomb vaccine 10 MCG/0.5ML suspension prefilled syringe 0.5 mL Syringe,90743,CDM,636,RC,90743,CPT,,,,58160082052,NDC,0.5,ML,137.47,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,121.24854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.105038,134.7206
methylergonovine 0.2 MG/ML Solution 1 mL Ampule,J2210.01,CDM,636,RC,J2210,HCPCS,,,,51991014417,NDC,1,ML,133.11,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,121.26321,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.293894,130.4478
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615900,NDC,1,EA,123.75,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,121.275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615904,NDC,1,EA,123.75,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,121.275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
Fibrinogen Activity - Ref,PX8538490,CDM,300,RC,85384,CPT,90,,,,,,,245,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,121.275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.91,240.1
"Ileoscopy Thru Stoma,Diagnostic",PX44380F,CDM,750,RC,44380,CPT,,,,,,,,245,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,121.275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.773,791.92
Lipid Profile,PX80061,CDM,300,RC,80061,CPT,,,,,,,,245,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,121.275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.28,240.1
Platelet Antibodies - Ref,PX8602290,CDM,300,RC,86022,CPT,90,,,,,,,245,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,121.275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.84,240.1
"Supply Technicium Sestamibi,per Dose",PXA9500,CDM,343,RC,A9500,HCPCS,,,,,,,,410,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,121.2809,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.1,121.7
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012365,NDC,0.7,ML,291.98,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,121.288492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012388,NDC,0.7,ML,291.98,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,121.288492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072310,NDC,0.5,ML,291.98,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,121.288492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072388,NDC,0.5,ML,291.98,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,121.288492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032F,CDM,510,RC,12032,CPT,,,,,,,,386,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,121.29,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.76,632.31
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032F,CDM,510,RC,12032,CPT,,,,,,,,386,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,121.29,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.76,632.31
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032P,CDM,983,RC,12032,CPT,,,,,,,,647,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,121.29,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.76,634.06
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032P,CDM,983,RC,12032,CPT,,,,,,,,647,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,121.29,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.76,634.06
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059900,NDC,1,ML,133.16,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,121.30876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.54253,130.4968
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059902,NDC,1,ML,133.16,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,121.30876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.54253,130.4968
neomycin-polymyxin-dexamethasone 3.5-10000-0.1 Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,61314063136,NDC,3.5,GR,247.71,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,121.3779,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
neomycin-polymyxin-dexamethasone 3.5-10000-0.1 Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,61314063136,NDC,3.5,GR,247.71,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,121.3779,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
neomycin-polymyxin-dexamethasone 3.5-10000-0.1 Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,61314063136,NDC,3.5,GR,247.71,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,121.3779,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
neomycin-polymyxin-dexameth 3.5-10000-0.1 Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063006,NDC,5,ML,247.72,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,121.3828,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
neomycin-polymyxin-dexameth 3.5-10000-0.1 Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063006,NDC,5,ML,247.72,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,121.3828,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
neomycin-polymyxin-dexameth 3.5-10000-0.1 Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063006,NDC,5,ML,247.72,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,121.3828,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
STAPLER RELOAD-CURVED CUTTER,27200000,CDM,272,RC,,,,12063-MAIN,LOCAL,,,,,283,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,121.407,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MESH FLAT SHEET SOFT 3X6 INCH,C1781,CDM,278,RC,C1781,HCPCS,,11773-MAIN,LOCAL,,,,,253,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,121.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
MESH FLAT SHEET SOFT 3X6 INCH,C1781,CDM,278,RC,C1781,HCPCS,,11773-MAIN,LOCAL,,,,,253,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,121.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Tap Block Unilateral by Injection(S),PX64486F,CDM,510,RC,64486,CPT,,,,,,,,253,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,121.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.0962,247.94
Tap Block Unilateral by Injection(S),PX64486F,CDM,510,RC,64486,CPT,,,,,,,,253,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,121.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.0962,247.94
Assay of Lithium,PX80178,CDM,300,RC,80178,CPT,,,,,,,,124,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,121.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.06,121.52
Closed Rx Mt-Phal Toe Dislocation,PX28630P,CDM,983,RC,28630,CPT,,,,,,,,248,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,121.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.0192,241.3784
Closed Rx Mt-Phal Toe Dislocation,PX28630P,CDM,983,RC,28630,CPT,,,,,,,,248,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,121.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.0192,241.3784
Closed Rx Mt-Phal Toe Dislocation,PX28630P,CDM,983,RC,28630,CPT,,,,,,,,248,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,121.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.0192,241.3784
"Complement; Antigen, Each Component",PX86160,CDM,300,RC,86160,CPT,,,,,,,,124,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,121.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11,121.52
Debride Muscle Ea Add 20 Sqcm,PX11046F,CDM,510,RC,11046,CPT,,,,,,,,248,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,121.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.0192,243.04
Debride Muscle Ea Add 20 Sqcm,PX11046F,CDM,510,RC,11046,CPT,,,,,,,,248,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,121.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.0192,243.04
Debride Muscle Ea Add 20 Sqcm,PX11046F,CDM,510,RC,11046,CPT,,,,,,,,248,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,121.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.0192,243.04
Fetal Profile W/O Stress,PX7681901,CDM,402,RC,76819,CPT,TC,,,,,,,248,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,248,percent of total billed charges,121.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,243.04
Fetal Profile W/O Stress,PX7681901,CDM,402,RC,76819,CPT,TC,,,,,,,248,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,121.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,243.04
Fetal Profile W/O Stress,PX7681901,CDM,402,RC,76819,CPT,TC,,,,,,,248,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,121.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,243.04
"Immunoassay,Ca15-3(27.29) - Ref",PX8630090,CDM,300,RC,86300,CPT,90,,,,,,,124,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,121.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,121.52
Itraconazole,PX8018990,CDM,300,RC,80189,CPT,90,,,,,,,124,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,121.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.86,121.52
Microbe Susceptible Mic,PX87186,CDM,300,RC,87186,CPT,,,,,,,,124,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,121.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.93,121.52
Nocardia Susceptibility - Ref,PX8718690,CDM,300,RC,87186,CPT,90,,,,,,,124,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,121.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.93,121.52
Oligoclonal Bands - Ref,PX8391690,CDM,300,RC,83916,CPT,90,,,,,,,124,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,121.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.11,121.52
Ther Injection Carpal Tunnel,PX20526P,CDM,983,RC,20526,CPT,,,,,,,,248,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,121.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.0192,258.75
Ther Injection Carpal Tunnel,PX20526P,CDM,983,RC,20526,CPT,,,,,,,,248,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,121.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.0192,258.75
Ther Injection Carpal Tunnel,PX20526P,CDM,983,RC,20526,CPT,,,,,,,,248,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,121.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.0192,258.75
UMBILICAL VESSEL CATHETER INSERTION TRAY POLY SINGLE LUMEN 3.5/5FR,120.573,CDM,272,RC,,,,12857-MAIN,LOCAL,,,,,124,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,121.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.5096,121.52
US Chest Tc,PX7660401,CDM,402,RC,76604,CPT,TC,,,,,,,248,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,121.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,243.04
US Chest Tc,PX7660401,CDM,402,RC,76604,CPT,TC,,,,,,,248,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,121.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,243.04
US Chest Tc,PX7660401,CDM,402,RC,76604,CPT,TC,,,,,,,248,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,121.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,243.04
"West Nile Ab, Igg - Ref",PX8678990,CDM,300,RC,86789,CPT,90,,,,,,,248,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,121.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,243.04
"West Nile Ab, Igg - Ref",PX8678990,CDM,300,RC,86789,CPT,90,,,,,,,248,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,121.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,243.04
"West Nile Ab, Igg - Ref",PX8678990,CDM,300,RC,86789,CPT,90,,,,,,,248,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,121.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,243.04
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703334301,NDC,0.5,ML,142.98,,First Health,Commercial,both,85,,999999999,percent of total billed charges,121.533,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963805,NDC,0.5,ML,142.98,,First Health,Commercial,both,85,,999999999,percent of total billed charges,121.533,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
cefoTEtan 2 g Recon Soln 1 Each Vial,800000,CDM,,,S0074,HCPCS,,,,63323038620,NDC,1,EA,240.2,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,121.5412,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
phytonadione 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714097302,NDC,0.5,EA,143.02,,First Health,Commercial,both,85,,999999999,percent of total billed charges,121.567,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phytonadione 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,69238105103,NDC,0.5,EA,143.02,,First Health,Commercial,both,85,,999999999,percent of total billed charges,121.567,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fat emulsion 20 % Emulsion 250 mL Flex Cont,25000000,CDM,250,RC,,,,,,338051909,NDC,250,ML,292.75,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,121.60835,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Calr Gene Analysis Common Variants in Exon 9 - Ref,PX8121990,CDM,300,RC,81219,CPT,90,,,,,,,534,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,121.63,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,117.98,121.63
Cmv Igm Antibody - Ref,PX8664590,CDM,300,RC,86645,CPT,90,,,,,,,125,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,121.6625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.45,122.5
DRESSING SURGICEL HEMOSTAT 4X8 ABSORBABLE 1952,120.123,CDM,272,RC,A6252,HCPCS,,1002-MAIN,LOCAL,,,,,125,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,121.6625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.925,122.5
Factor VII - Ref,PX8523090,CDM,300,RC,85230,CPT,90,,,,,,,125,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,121.6625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.41,122.5
"Supply Technicium Sestamibi,per Dose",PXA9500,CDM,343,RC,A9500,HCPCS,,,,,,,,410,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,121.7,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.1,121.7
"Supply Technicium Sestamibi,per Dose",PXA9500,CDM,343,RC,A9500,HCPCS,,,,,,,,410,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,121.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.1,121.7
"Supply Technicium Sestamibi,per Dose",PXA9500,CDM,343,RC,A9500,HCPCS,,,,,,,,410,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,121.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.1,121.7
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,16714076901,NDC,15,GR,137.99,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,121.70718,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Digital Mamm, Diag, Unilat, Tc W/Cad Perf",PX7706501,CDM,401,RC,77065,CPT,TC,,,,,,,293,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,121.7122,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.46,287.14
Drain Skin Abscess Simple,PX10060P,CDM,983,RC,10060,CPT,,,,,,,,293,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,121.7122,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.7122,285.1769
Kit Gene Analysis D816 Variant(S) - Ref,PX8127390,CDM,300,RC,81273,CPT,90,,,,,,,293,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,121.7122,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,114.49,287.14
Repr Superf Wnd Body <2.5cm,PX12001P,CDM,983,RC,12001,CPT,,,,,,,,293,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,121.7122,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.7122,285.1769
Chrom Anal 15-20 Cells - Ref,PX8826290,CDM,310,RC,88262,CPT,90,,,,,,,398,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,121.73,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.73,125.49
Chrom Anal 15-20 Cells - Ref,PX8826290,CDM,310,RC,88262,CPT,90,,,,,,,398,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,121.73,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.73,125.49
Chrom Anal 15-20 Cells - Ref,PX8826290,CDM,310,RC,88262,CPT,90,,,,,,,398,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,121.73,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.73,125.49
STRAP CLAVICLE LARGE VP10123-040,120.191,CDM,274,RC,L3670,HCPCS,,12848-MAIN,LOCAL,,,,,24,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,121.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.65,121.74
STRAP CLAVICLE LARGE VP10123-040,120.191,CDM,274,RC,L3670,HCPCS,,12848-MAIN,LOCAL,,,,,24,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,121.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.65,121.74
STRAP CLAVICLE MEDIUM VP10123-030,120.191,CDM,274,RC,L3670,HCPCS,,12847-MAIN,LOCAL,,,,,24,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,121.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.65,121.74
STRAP CLAVICLE MEDIUM VP10123-030,120.191,CDM,274,RC,L3670,HCPCS,,12847-MAIN,LOCAL,,,,,24,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,121.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.65,121.74
STRAP CLAVICLE SMALL VP10123-020,120.191,CDM,274,RC,L3670,HCPCS,,12846-MAIN,LOCAL,,,,,24,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,121.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.65,121.74
STRAP CLAVICLE SMALL VP10123-020,120.191,CDM,274,RC,L3670,HCPCS,,12846-MAIN,LOCAL,,,,,24,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,121.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.65,121.74
STRAP CLAVICLE XL 661 XL,120.191,CDM,274,RC,L3670,HCPCS,,12850-MAIN,LOCAL,,,,,24,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,121.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.65,121.74
STRAP CLAVICLE XL 661 XL,120.191,CDM,274,RC,L3670,HCPCS,,12850-MAIN,LOCAL,,,,,24,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,121.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.65,121.74
STRAP CLAVICLE XSMALL CHILD ORT14100XS,120.191,CDM,274,RC,L3670,HCPCS,,12849-MAIN,LOCAL,,,,,24,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,121.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.65,121.74
STRAP CLAVICLE XSMALL CHILD ORT14100XS,120.191,CDM,274,RC,L3670,HCPCS,,12849-MAIN,LOCAL,,,,,24,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,121.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.65,121.74
STRAP CLAVICLE LARGE VP10123-040,120.191,CDM,274,RC,L3670,HCPCS,,12848-MAIN,LOCAL,,,,,24,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,121.74,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.65,121.74
STRAP CLAVICLE MEDIUM VP10123-030,120.191,CDM,274,RC,L3670,HCPCS,,12847-MAIN,LOCAL,,,,,24,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,121.74,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.65,121.74
STRAP CLAVICLE SMALL VP10123-020,120.191,CDM,274,RC,L3670,HCPCS,,12846-MAIN,LOCAL,,,,,24,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,121.74,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.65,121.74
STRAP CLAVICLE XL 661 XL,120.191,CDM,274,RC,L3670,HCPCS,,12850-MAIN,LOCAL,,,,,24,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,121.74,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.65,121.74
STRAP CLAVICLE XSMALL CHILD ORT14100XS,120.191,CDM,274,RC,L3670,HCPCS,,12849-MAIN,LOCAL,,,,,24,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,121.74,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.65,121.74
prednisoLONE acetate 1 % Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063705,NDC,5,ML,283.79,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,121.74591,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611F,CDM,510,RC,20611,CPT,,,,,,,,456,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,121.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.21,206.85
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611P,CDM,983,RC,20611,CPT,,,,,,,,272,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,121.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.21,266.56
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002F,CDM,510,RC,12002,CPT,,,,,,,,343,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,121.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.9,237.98
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002P,CDM,983,RC,12002,CPT,,,,,,,,486,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,121.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.9,476.28
KATZ EXTRACTOR OTO-RHINO FOREIGN BODY REMOVER,120.568,CDM,272,RC,,,,12808-MAIN,LOCAL,,,,,246,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,121.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.1884,241.08
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,68462018022,NDC,22,GR,240.66,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,121.77396,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
octreotide 200 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037805,NDC,1,ML,133.77,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,121.86447,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Plas Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,338604648,NDC,100,ML,143.42,,First Health,Commercial,both,85,,999999999,percent of total billed charges,121.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.786918,140.5516
Thyrstim Immun Glob (Tsi) - Ref,PX8444590,CDM,300,RC,84445,CPT,90,,,,,,,254,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,121.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.63,248.92
Thyrstim Immun Glob (Tsi) - Ref,PX8444590,CDM,300,RC,84445,CPT,90,,,,,,,254,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,121.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.63,248.92
Total Cortisol,PX82533,CDM,300,RC,82533,CPT,,,,,,,,137,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,121.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.95,134.26
"Triiodothyronine T3, Free (Free T3)",PX84481,CDM,300,RC,84481,CPT,,,,,,,,137,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,121.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.53,134.26
"Exc Skn Mal 2.1-3cmtrnk,Arm,Lg",PX11603P,CDM,983,RC,11603,CPT,,,,,,,,1276,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,121.94,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.07,1250.48
"Exc Skn Mal 2.1-3cmtrnk,Arm,Lg",PX11603P,CDM,983,RC,11603,CPT,,,,,,,,1276,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,121.94,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.07,1250.48
"Fac/Exc Skn Mali2.1-3cmtrnk,Arm,Lg",PX11603F,CDM,510,RC,11603,CPT,,,,,,,,875,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,121.94,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.07,580.42
"Fac/Exc Skn Mali2.1-3cmtrnk,Arm,Lg",PX11603F,CDM,510,RC,11603,CPT,,,,,,,,875,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,121.94,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.07,580.42
"Mra, Neck With Contrast",PX7054801,CDM,610,RC,70548,CPT,TC,,,,,,,3541,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,121.94,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.94,360.26
"Mra, Neck With Contrast",PX7054801,CDM,610,RC,70548,CPT,TC,,,,,,,3541,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,121.94,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.94,360.26
Fac/Ligation of Hemorrhoid(S),PX46221F,CDM,510,RC,46221,CPT,,,,,,,,1046,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,121.94,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.94,590.11
Ligation of Hemorrhoid(S),PX46221P,CDM,983,RC,46221,CPT,,,,,,,,697,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,121.94,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.94,683.06
ENDOLOOP COATED VICRYL 0 18,27200000,CDM,272,RC,,,,10228-MAIN,LOCAL,,,,,143.6,,First Health,Commercial,both,85,,999999999,percent of total billed charges,122.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
pegfilgrastim-cbqv 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5111.01,CDM,636,RC,Q5111,HCPCS,,,,70114010101,NDC,0.6,ML,10040,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,122.1,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.45,135.48
amiodarone 150-4.21 MG/100ML-% Solution 100 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066015010,NDC,100,ML,249.22,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,122.1178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.35,318.745
amiodarone 150-4.21 MG/100ML-% Solution 100 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066015010,NDC,100,ML,249.22,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,122.1178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.35,318.745
amiodarone 150-4.21 MG/100ML-% Solution 100 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066015010,NDC,100,ML,249.22,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,122.1178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.35,318.745
Francisella Tularensis Ab,PX8666890,CDM,300,RC,86668,CPT,90,,,,,,,294,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,122.1276,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.98,288.12
Physical Therapy Evaluation High Complex,PX97163,CDM,424,RC,97163,CPT,,,,,,,,294,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,122.1276,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,288.12
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,24208046325,NDC,2.5,ML,137.26,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,122.1614,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Hla Class II Low Res, 1 Locus - Ref",PX8137690,CDM,310,RC,81376,CPT,90,,,,,,,279,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,122.22,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,118.55,122.22
Kit Gene Analysis D816 Variant(S) - Ref,PX8127390,CDM,300,RC,81273,CPT,90,,,,,,,293,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,122.2629,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.12,124.87
Drain/Inject Medium Joint/Bursa,PX20605F,CDM,510,RC,20605,CPT,,,,,,,,247,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,122.265,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.6038,258.75
Xray Sacroiliac Jnts 3 or More Vws,PX7220201,CDM,320,RC,72202,CPT,TC,,,,,,,285,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,122.265,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,279.3
hepatitis b recomb vaccine 10 MCG/0.5ML suspension prefilled syringe 0.5 mL Syringe,90743,CDM,636,RC,90743,CPT,,,,58160082052,NDC,0.5,ML,137.47,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,122.3483,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.105038,134.7206
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494300,NDC,0.5,ML,419.23,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,122.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.38,410.8454
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494301,NDC,0.5,ML,419.2,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,122.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.38,410.8454
fentaNYL 50 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,406905076,NDC,1,EA,125.74,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,122.382742,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800F,CDM,510,RC,40800,CPT,,,,,,,,255,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,122.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.927,614.65
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800F,CDM,510,RC,40800,CPT,,,,,,,,255,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,122.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.927,614.65
Hepatitis C Antibody,PX86803,CDM,300,RC,86803,CPT,,,,,,,,144,,First Health,Commercial,both,85,,999999999,percent of total billed charges,122.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.08,141.12
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106F,CDM,510,RC,11106,CPT,,,,,,,,255,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,122.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.927,548.67
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106F,CDM,510,RC,11106,CPT,,,,,,,,255,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,122.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.927,548.67
"Inject Nerv Blck,Trigeminal",PX64400F,CDM,510,RC,64400,CPT,,,,,,,,255,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,122.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.927,258.75
"Inject Nerv Blck,Trigeminal",PX64400F,CDM,510,RC,64400,CPT,,,,,,,,255,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,122.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.927,258.75
"Urinalysis, Auto, W/Scope",PX81001,CDM,300,RC,81001,CPT,,,,,,,,255,,Health Partners,Health Partners Care Plans,both,48,,142.7590909,percent of total billed charges,122.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.91,249.9
"Urinalysis, Auto, W/Scope",PX81001,CDM,300,RC,81001,CPT,,,,,,,,255,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,122.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.91,249.9
levOCARNitine 200 MG/ML Solution 5 mL Vial,J1955.01,CDM,636,RC,J1955,HCPCS,,,,517104501,NDC,5,ML,249.86,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,122.4314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.791844,244.8628
levOCARNitine 200 MG/ML Solution 5 mL Vial,J1955.01,CDM,636,RC,J1955,HCPCS,,,,517104501,NDC,5,ML,249.86,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,122.4314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.791844,244.8628
levOCARNitine 200 MG/ML Solution 5 mL Vial,J1955.01,CDM,636,RC,J1955,HCPCS,,,,517104501,NDC,5,ML,249.86,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,122.4314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.791844,244.8628
"Biopsy Vulva/Perineum,One Lesn",PX56605F,CDM,510,RC,56605,CPT,,,,,,,,236,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,122.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.99,201.31
"Biopsy Vulva/Perineum,One Lesn",PX56605P,CDM,983,RC,56605,CPT,,,,,,,,142,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,122.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.99,201.31
"Insert Needle,Intraosseous Infusn",PX36680F,CDM,510,RC,36680,CPT,,,,,,,,659,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,122.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.12,122.45
"Insert Needle,Intraosseous Infusn",PX36680F,CDM,510,RC,36680,CPT,,,,,,,,659,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,122.45,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.12,122.45
Airway Inhalation Treatment,PX94640F,CDM,410,RC,94640,CPT,,,,,,,,242,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,122.452,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,100.5268,237.16
"Noninvasv Oxygen Satut,Continuous",PX94762,CDM,460,RC,94762,CPT,,,,,,,,242,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,122.452,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,100.5268,237.16
sulfacetamide 10 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,61314070101,NDC,15,ML,285.48,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,122.47092,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Cmv Igm Antibody - Ref,PX8664590,CDM,300,RC,86645,CPT,90,,,,,,,125,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,122.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.45,122.5
DRESSING SURGICEL HEMOSTAT 4X8 ABSORBABLE 1952,120.123,CDM,272,RC,A6252,HCPCS,,1002-MAIN,LOCAL,,,,,125,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,122.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.925,122.5
Factor VII - Ref,PX8523090,CDM,300,RC,85230,CPT,90,,,,,,,125,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,122.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.41,122.5
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153P,CDM,983,RC,99153,CPT,,,,,,,,250,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,122.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.85,243.325
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153P,CDM,983,RC,99153,CPT,,,,,,,,250,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,122.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.85,243.325
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153P,CDM,983,RC,99153,CPT,,,,,,,,250,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,122.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.85,243.325
sincalide 5 MCG Recon Soln 1 Each Vial,J2805.01,CDM,636,RC,J2805,HCPCS,,,,270055615,NDC,1,EA,250,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,24.81,percent of total billed charges,122.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.85,245
sincalide 5 MCG Recon Soln 1 Each Vial,J2805.01,CDM,636,RC,J2805,HCPCS,,,,270055615,NDC,1,EA,250,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,122.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.85,245
sincalide 5 MCG Recon Soln 1 Each Vial,J2805.01,CDM,636,RC,J2805,HCPCS,,,,270055615,NDC,1,EA,250,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,122.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.85,245
Withdrawal of Arterial Blood,PX36600F,CDM,510,RC,36600,CPT,,,,,,,,250,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,212.02,percent of total billed charges,122.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.85,245
Withdrawal of Arterial Blood,PX36600F,CDM,510,RC,36600,CPT,,,,,,,,250,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,122.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.85,245
Withdrawal of Arterial Blood,PX36600F,CDM,510,RC,36600,CPT,,,,,,,,250,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,122.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.85,245
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,63323050830,NDC,1,EA,134.48,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,122.51128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.461584,189.875
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052331,NDC,2,ML,125.89,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,73.565,percent of total billed charges,122.528737,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.294706,123.3722
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052341,NDC,2,ML,125.89,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,73.565,percent of total billed charges,122.528737,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.294706,123.3722
pegfilgrastim-jmdb 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5108.01,CDM,636,RC,Q5108,HCPCS,,,,67457083306,NDC,0.6,ML,10040,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,122.54,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.54,164.03
pegfilgrastim-jmdb 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5108.01,CDM,636,RC,Q5108,HCPCS,,,,67457083306,NDC,0.6,ML,10040,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,122.54,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.54,164.03
Closed Rx Metacarpal Fx,PX26600P,CDM,983,RC,26600,CPT,,,,,,,,295,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,122.543,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.543,287.1235
Sulfur Colloid per Dose,PXA9541,CDM,343,RC,A9541,HCPCS,,,,,,,,295,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,122.543,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.543,289.1
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,17478053802,NDC,2,ML,125.91,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,122.548203,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.068162,123.3918
"Colonoscope, Submucous Inj",PX45381F,CDM,750,RC,45381,CPT,,,,,,,,1179,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,122.59,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.59,917.33
"Colonoscope, Submucous Inj",PX45381P,CDM,983,RC,45381,CPT,,,,,,,,1215,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,122.59,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.59,1190.7
"Colonoscopy,Biopsy",PX45380F,CDM,750,RC,45380,CPT,,,,,,,,2465,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,122.59,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.59,898.65
"Colonoscopy,Biopsy",PX45380P,CDM,983,RC,45380,CPT,,,,,,,,2539,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,122.59,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.59,2488.22
"Upper GI Endoscopy,Ctrl Bleed",PX43255F,CDM,750,RC,43255,CPT,,,,,,,,1723,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,122.59,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.59,1292.28
"Upper GI Endoscopy,Ctrl Bleed",PX43255P,CDM,983,RC,43255,CPT,,,,,,,,1148,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,122.59,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.59,1292.28
neomycin-polymyxin-dexamethasone 3.5-10000-0.1 Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,61314063136,NDC,3.5,GR,247.71,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,122.61645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
neomycin-polymyxin-dexameth 3.5-10000-0.1 Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063006,NDC,5,ML,247.72,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,122.6214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Thrombin Time Plasma,PX85670,CDM,300,RC,85670,CPT,,,,,,,,126,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,122.6358,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.29,123.48
Blood Culture for Bacteria,PX87040,CDM,300,RC,87040,CPT,,,,,,,,286,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,122.694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.46,280.28
I&D Bartholin Gland Abscess,PX56420P,CDM,983,RC,56420,CPT,,,,,,,,286,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,122.694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,118.8044,278.3638
Joint Survey,PX7707726,CDM,982,RC,77077,CPT,26,,,,,,,286,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,122.694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,278.3638
Lab Culture Bacteria,PX87070,CDM,300,RC,87070,CPT,,,,,,,,286,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,122.694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.9,280.28
Urine Culture/Colony Count,PX87086,CDM,300,RC,87086,CPT,,,,,,,,286,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,122.694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4,280.28
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010602,NDC,50,ML,126.07,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,14.23621053,percent of total billed charges,122.703931,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010605,NDC,50,ML,126.07,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,14.23621053,percent of total billed charges,122.703931,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
nitroglycerin in dextrose 5% 100-5 MCG/ML-% Solution 250 mL Glass Cont,J2305.01,CDM,636,RC,J2305,HCPCS,,,,338104702,NDC,250,ML,126.07,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,21.3896,percent of total billed charges,122.703931,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.17,123.5486
Closed Rx Mt-Phal Toe Dislocation,PX28630P,CDM,983,RC,28630,CPT,,,,,,,,248,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,122.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.0192,241.3784
Debride Muscle Ea Add 20 Sqcm,PX11046F,CDM,510,RC,11046,CPT,,,,,,,,248,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,122.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.0192,243.04
Fetal Profile W/O Stress,PX7681901,CDM,402,RC,76819,CPT,TC,,,,,,,248,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,122.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,243.04
Ther Injection Carpal Tunnel,PX20526P,CDM,983,RC,20526,CPT,,,,,,,,248,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,122.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.0192,258.75
US Chest Tc,PX7660401,CDM,402,RC,76604,CPT,TC,,,,,,,248,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,122.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,243.04
"West Nile Ab, Igg - Ref",PX8678990,CDM,300,RC,86789,CPT,90,,,,,,,248,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,122.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,243.04
Fac/Ligation of Hemorrhoid(S),PX46221F,CDM,510,RC,46221,CPT,,,,,,,,1046,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,122.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.94,590.11
Fac/Ligation of Hemorrhoid(S),PX46221F,CDM,510,RC,46221,CPT,,,,,,,,1046,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,122.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.94,590.11
Ligation of Hemorrhoid(S),PX46221P,CDM,983,RC,46221,CPT,,,,,,,,697,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,122.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.94,683.06
Ligation of Hemorrhoid(S),PX46221P,CDM,983,RC,46221,CPT,,,,,,,,697,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,122.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.94,683.06
"Mra, Neck With Contrast",PX7054801,CDM,610,RC,70548,CPT,TC,,,,,,,3541,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,122.81,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.94,360.26
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,16714076901,NDC,15,GR,137.99,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,122.8111,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylene blue 1 % Solution 10 mL Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,54288014701,NDC,1,ML,139.25,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,122.8185,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.29,1354.4776
eriBULin 1 MG/2ML Solution 2 mL Vial,J9179.01,CDM,636,RC,J9179,HCPCS,,,,62856038901,NDC,2,ML,2321.52,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,122.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.87,2275.0896
"Office/Outpt Visit,Est,Levl IV",PX99214F,CDM,510,RC,99214,CPT,,,,,,,,256,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,122.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.3424,250.88
"Office/Outpt Visit,Est,Levl IV",PX99214F,CDM,510,RC,99214,CPT,,,,,,,,256,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,122.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.3424,250.88
Chrom Anal 15-20 Cells - Ref,PX8826290,CDM,310,RC,88262,CPT,90,,,,,,,398,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,122.9047,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.73,125.49
CT Soft Tissue Neck W/Dye,PX7049101,CDM,350,RC,70491,CPT,TC,,,,,,,3415,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,122.9276,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.9,245.21
"Apply Forearm Splint,Static",PX29125P,CDM,983,RC,29125,CPT,,,,,,,,296,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,122.9584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,288.0968
Apply Lower Leg Splint,PX29515F,CDM,510,RC,29515,CPT,,,,,,,,296,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,122.9584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.9584,290.08
Drain Skin Abscess Simple,PX10060F,CDM,510,RC,10060,CPT,,,,,,,,296,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,122.9584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.9584,290.08
PURAPLYAM XT-COM 4.91X4.91 EXTRA FENESTRATED 24.10 SQCM,120.567,CDM,272,RC,Q4197,HCPCS,,12806-MAIN,LOCAL,,,,,6562,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,122.98,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.47938,122.98
"Cognitive Funct Ther Interv, per Day",PX97127,CDM,420,RC,97127,CPT,,,,,,,,135,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,122.985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.079,132.3
Electric Stimulation Therapy,PX97014,CDM,420,RC,97014,CPT,,,,,,,,135,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,122.985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.18,132.3
Electrical Stimulation,PX97032,CDM,420,RC,97032,CPT,,,,,,,,135,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,122.985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,132.3
Gait Training Therapy,PX97116,CDM,420,RC,97116,CPT,,,,,,,,135,,Medica,Commercial,both,91.1,,70.455,percent of total billed charges,122.985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20,132.3
"Manual Ther Tech,1+Regions,Ea 15 Min",PX97140,CDM,420,RC,97140,CPT,,,,,,,,135,,Medica,Commercial,both,91.1,,28.9322276,percent of total billed charges,122.985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.4,215.05
Mechanical Traction Therapy,PX97012,CDM,420,RC,97012,CPT,,,,,,,,135,,Medica,Commercial,both,91.1,,37.46,percent of total billed charges,122.985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,132.3
Neuromuscular Re-Education,PX97112,CDM,420,RC,97112,CPT,,,,,,,,135,,Medica,Commercial,both,91.1,,23.66666667,percent of total billed charges,122.985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.95,215.05
Self Care Mngment Training,PX97535,CDM,420,RC,97535,CPT,,,,,,,,135,,Medica,Commercial,both,91.1,,27,percent of total billed charges,122.985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.27,132.3
Therapeutic Activities,PX97530,CDM,420,RC,97530,CPT,,,,,,,,135,,Medica,Commercial,both,91.1,,119.34,percent of total billed charges,122.985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.22,205.7
Therapeutic Exercises,PX97110,CDM,420,RC,97110,CPT,,,,,,,,135,,Medica,Commercial,both,91.1,,44.81708054,percent of total billed charges,122.985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20,215.05
Ultrasound Therapy,PX97035,CDM,420,RC,97035,CPT,,,,,,,,135,,Medica,Commercial,both,91.1,,102.99,percent of total billed charges,122.985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,132.3
"Colonoscope, Submucous Inj",PX45381F,CDM,750,RC,45381,CPT,,,,,,,,1179,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,123.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.59,917.33
"Colonoscope, Submucous Inj",PX45381F,CDM,750,RC,45381,CPT,,,,,,,,1179,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,123.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.59,917.33
"Colonoscope, Submucous Inj",PX45381P,CDM,983,RC,45381,CPT,,,,,,,,1215,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,123.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.59,1190.7
"Colonoscope, Submucous Inj",PX45381P,CDM,983,RC,45381,CPT,,,,,,,,1215,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,123.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.59,1190.7
Layr Clos Wnd Rest Body 2.6-7.5,PX12042F,CDM,510,RC,12042,CPT,,,,,,,,404,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,123.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,123.03,645.45
Layr Clos Wnd Rest Body 2.6-7.5,PX12042P,CDM,983,RC,12042,CPT,,,,,,,,777,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,123.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,123.03,761.46
"Flow Cyto, Tech, 1st Mrkr - Ref",PX8818490,CDM,310,RC,88184,CPT,90,,,,,,,223,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,123.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.72,127.152
"Flow Cyto, Tech, 1st Mrkr - Ref",PX8818490,CDM,310,RC,88184,CPT,90,,,,,,,223,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,123.13,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.72,127.152
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; 1st",PX88184,CDM,310,RC,88184,CPT,,,,,,,,96,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,123.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.72,127.152
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; 1st",PX88184,CDM,310,RC,88184,CPT,,,,,,,,96,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,123.13,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.72,127.152
Surgical Cleansing of Skin,PX11000P,CDM,983,RC,11000,CPT,,,,,,,,145,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,123.14,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.79,142.1
"Office/Outpt Visit,New,Levl IV",PX99204F,CDM,510,RC,99204,CPT,,,,,,,,359,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,123.1728,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.93,300.2
"Office/Outpt Visit,New,Levl IV",PX99204P,CDM,983,RC,99204,CPT,,,,,,,,359,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,123.1728,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.93,351.82
fentaNYL 50 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,406905076,NDC,1,EA,125.74,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,123.2252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
LIGACLIP APPLIER CLIP STERILE SIZE MEDIUM LARGE,27200000,CDM,272,RC,,,,11699-MAIN,LOCAL,,,,,126.62,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,123.239246,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ammonium lactate 12 % Cream 385 g Tube,63700001,CDM,250,RC,,,,,,45802049326,NDC,385,GR,256.76,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,123.2448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ammonium lactate 12 % Cream 385 g Tube,63700001,CDM,250,RC,,,,,,45802049326,NDC,385,GR,256.76,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,123.2448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay Carbamazepine Total,PX80156,CDM,300,RC,80156,CPT,,,,,,,,145,,First Health,Commercial,both,85,,999999999,percent of total billed charges,123.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.36,142.1
"Calculus, Infrared Spec - Ref",PX8236590,CDM,300,RC,82365,CPT,90,,,,,,,145,,First Health,Commercial,both,85,,999999999,percent of total billed charges,123.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.83,142.1
"Catecholamines, Fraction - Ref",PX8238490,CDM,300,RC,82384,CPT,90,,,,,,,145,,First Health,Commercial,both,85,,999999999,percent of total billed charges,123.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.15,142.1
Hsv Dna Amp Probe,PX87529,CDM,300,RC,87529,CPT,,,,,,,,145,,First Health,Commercial,both,85,,999999999,percent of total billed charges,123.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,142.1
Immunofixation Electrophoresis; Serum,PX86334,CDM,300,RC,86334,CPT,,,,,,,,145,,First Health,Commercial,both,85,,999999999,percent of total billed charges,123.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.48,142.1
LEGGING COMPRESSION JUXTALITE LONG LG 33CM,120.369,CDM,271,RC,A6545,HCPCS,,10840-MAIN,LOCAL,,,,,145,,First Health,Commercial,both,85,,999999999,percent of total billed charges,123.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.233,142.1
"Pare/Cut Hyperkeratotic Skin Lesion, Single",PX11055F,CDM,510,RC,11055,CPT,,,,,,,,145,,First Health,Commercial,both,85,,999999999,percent of total billed charges,123.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.233,174.9
Surgical Cleansing of Skin,PX11000P,CDM,983,RC,11000,CPT,,,,,,,,145,,First Health,Commercial,both,85,,999999999,percent of total billed charges,123.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.233,548.67
Wheelchair Mngement Training,PX97542,CDM,420,RC,97542,CPT,,,,,,,,145,,First Health,Commercial,both,85,,999999999,percent of total billed charges,123.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.59,142.1
ipratropium 0.03 % Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,24208039830,NDC,30,ML,256.9,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,123.312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ipratropium 0.03 % Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,24208039830,NDC,30,ML,256.9,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,123.312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Extremity Study - Vascular Diagnostics,PX9392201,CDM,921,RC,93922,CPT,TC,,,,,,,600,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,123.32,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.24,123.32
Extremity Study - Vascular Diagnostics,PX9392201,CDM,921,RC,93922,CPT,TC,,,,,,,600,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,123.32,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.24,123.32
amiodarone 150-4.21 MG/100ML-% Solution 100 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066015010,NDC,100,ML,249.22,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,123.3639,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.35,318.745
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052331,NDC,2,ML,125.89,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,123.3722,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.294706,123.3722
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052341,NDC,2,ML,125.89,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,123.3722,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.294706,123.3722
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337501,NDC,50,ML,135.43,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,123.37673,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337502,NDC,50,ML,135.43,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,123.37673,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9678001,NDC,50,ML,135.43,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,123.37673,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,17478053802,NDC,2,ML,125.91,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,123.3918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.068162,123.3918
TISSUE RETRIEVAL SYSTEM,27200000,CDM,272,RC,,,,10233-MAIN,LOCAL,,,,,139.98,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,123.46236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
BINDER PELVIC ADULT STABILIZATION T-PODR,120.357,CDM,271,RC,A4467,HCPCS,,10734-MAIN,LOCAL,,,,,244,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,123.464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.3576,239.12
"Bone Marrow Aspiration(S),Diag",PX38220P,CDM,983,RC,38220,CPT,,,,,,,,244,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,123.464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.3576,1416.38
Dress/Debrid Med Burn No Anesth,PX16025P,CDM,983,RC,16025,CPT,,,,,,,,244,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,123.464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.3576,237.4852
"Colonoscopy,Biopsy",PX45380F,CDM,750,RC,45380,CPT,,,,,,,,2465,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,123.47,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.59,898.65
"Colonoscopy,Biopsy",PX45380F,CDM,750,RC,45380,CPT,,,,,,,,2465,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,123.47,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.59,898.65
"Colonoscopy,Biopsy",PX45380P,CDM,983,RC,45380,CPT,,,,,,,,2539,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,123.47,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.59,2488.22
"Colonoscopy,Biopsy",PX45380P,CDM,983,RC,45380,CPT,,,,,,,,2539,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,123.47,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.59,2488.22
"Upper GI Endoscopy,Ctrl Bleed",PX43255F,CDM,750,RC,43255,CPT,,,,,,,,1723,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,123.47,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.59,1292.28
"Upper GI Endoscopy,Ctrl Bleed",PX43255F,CDM,750,RC,43255,CPT,,,,,,,,1723,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,123.47,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.59,1292.28
"Upper GI Endoscopy,Ctrl Bleed",PX43255P,CDM,983,RC,43255,CPT,,,,,,,,1148,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,123.47,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.59,1292.28
"Upper GI Endoscopy,Ctrl Bleed",PX43255P,CDM,983,RC,43255,CPT,,,,,,,,1148,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,123.47,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.59,1292.28
Apply Forearm Cast,PX29075P,CDM,983,RC,29075,CPT,,,,,,,,140,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,123.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.156,234.62
Hospital Discharge Day>30 Min,PX99239P,CDM,982,RC,99239,CPT,,,,,,,,140,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,123.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.156,136.262
"Inject Trigger Point, 1 or 2",PX20552F,CDM,510,RC,20552,CPT,,,,,,,,252,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,123.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,258.75
"Inject Trigger Point, 1 or 2",PX20552F,CDM,510,RC,20552,CPT,,,,,,,,252,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,123.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,258.75
"Inject Trigger Point, 1 or 2",PX20552F,CDM,510,RC,20552,CPT,,,,,,,,252,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,123.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,258.75
"Level V - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3939,CDM,310,RC,88307,CPT,TC,,,,,,,252,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,123.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,314.02
"Level V - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3939,CDM,310,RC,88307,CPT,TC,,,,,,,252,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,123.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,314.02
"Level V - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3939,CDM,310,RC,88307,CPT,TC,,,,,,,252,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,123.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,314.02
"Off/Outpt Visit,New,Levl III",PX99203P,CDM,983,RC,99203,CPT,,,,,,,,252,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,15.86909091,percent of total billed charges,123.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,245.2716
"Off/Outpt Visit,New,Levl III",PX99203P,CDM,983,RC,99203,CPT,,,,,,,,252,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,123.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,245.2716
"Off/Outpt Visit,New,Levl III",PX99203P,CDM,983,RC,99203,CPT,,,,,,,,252,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,123.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,245.2716
"Office/Outpt Visit,New,Levl III",PX99203F,CDM,510,RC,99203,CPT,,,,,,,,252,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,15.86909091,percent of total billed charges,123.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,246.96
"Office/Outpt Visit,New,Levl III",PX99203F,CDM,510,RC,99203,CPT,,,,,,,,252,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,123.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,246.96
"Office/Outpt Visit,New,Levl III",PX99203F,CDM,510,RC,99203,CPT,,,,,,,,252,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,123.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,246.96
Thrombin Time Plasma,PX85670,CDM,300,RC,85670,CPT,,,,,,,,126,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,123.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.29,123.48
diclofenac 0.1 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,17478089225,NDC,2.5,ML,252.06,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,123.5094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
diclofenac 0.1 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,17478089225,NDC,2.5,ML,252.06,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,123.5094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
diclofenac 0.1 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,17478089225,NDC,2.5,ML,252.06,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,123.5094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
CHOLANGIOGRAM CATHETER REDDICK,27200000,CDM,272,RC,,,,10232-MAIN,LOCAL,,,,,287.98,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,123.54342,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010602,NDC,50,ML,126.07,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,123.5486,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010605,NDC,50,ML,126.07,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,123.5486,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,123.5486
nitroglycerin in dextrose 5% 100-5 MCG/ML-% Solution 250 mL Glass Cont,J2305.01,CDM,636,RC,J2305,HCPCS,,,,338104702,NDC,250,ML,126.07,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,123.5486,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.17,123.5486
Spirometry Incl Graph Rec Tc,PX9401002,CDM,460,RC,94010,CPT,TC,,,,,,,288,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,123.552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.6352,282.24
B-Scan Global,PX7651201,CDM,402,RC,76512,CPT,TC,,,,,,,127,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,123.6091,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.7558,124.46
Candida Dna Dir Probe,PX87480,CDM,300,RC,87480,CPT,,,,,,,,127,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,123.6091,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.38,124.46
Gardner Vag Dna Dir Probe,PX87510,CDM,300,RC,87510,CPT,,,,,,,,127,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,123.6091,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.38,124.46
Influenza Assay W/Optic,PX87804,CDM,300,RC,87804,CPT,,,,,,,,127,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,123.6091,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.17,124.46
Trichomonas Vagin Dir Probe,PX87660,CDM,300,RC,87660,CPT,,,,,,,,127,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,123.6091,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.38,124.46
doxycycline 100 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323013041,NDC,1,EA,140.2,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,123.6564,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
levOCARNitine 200 MG/ML Solution 5 mL Vial,J1955.01,CDM,636,RC,J1955,HCPCS,,,,517104501,NDC,5,ML,249.86,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,123.6807,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.791844,244.8628
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153P,CDM,983,RC,99153,CPT,,,,,,,,250,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,123.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.85,243.325
sincalide 5 MCG Recon Soln 1 Each Vial,J2805.01,CDM,636,RC,J2805,HCPCS,,,,270055615,NDC,1,EA,250,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,123.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.85,245
Withdrawal of Arterial Blood,PX36600F,CDM,510,RC,36600,CPT,,,,,,,,250,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,123.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.85,245
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059303,NDC,1,EA,740.19,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,123.83,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,123.83,126.62112
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059611,NDC,0.25,EA,200.05,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,123.83,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,123.83,126.62112
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059613,NDC,0.25,EA,200.05,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,123.83,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,123.83,126.62112
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105F,CDM,510,RC,11105,CPT,,,,,,,,171,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,123.83,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,123.83
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105P,CDM,983,RC,11105,CPT,,,,,,,,171,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,123.83,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,167.58
"Needle Biopsy,Muscle",PX20206F,CDM,510,RC,20206,CPT,,,,,,,,258,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,123.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.1732,1416.38
"Needle Biopsy,Muscle",PX20206F,CDM,510,RC,20206,CPT,,,,,,,,258,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,123.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.1732,1416.38
methylene blue 1 % Solution 10 mL Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,54288014701,NDC,1,ML,139.25,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,123.9325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.29,1354.4776
Fibrinogen Activity - Ref,PX8538490,CDM,300,RC,85384,CPT,90,,,,,,,245,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,123.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.91,240.1
"Ileoscopy Thru Stoma,Diagnostic",PX44380F,CDM,750,RC,44380,CPT,,,,,,,,245,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,123.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.773,791.92
Lipid Profile,PX80061,CDM,300,RC,80061,CPT,,,,,,,,245,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,123.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.28,240.1
Lvl 2 Sub Hosp Mod Mdm or 35 Minute,PX99232,CDM,982,RC,99232,CPT,,,,,,,,253,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,123.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.0962,246.2449
Lvl 2 Sub Hosp Mod Mdm or 35 Minute,PX99232,CDM,982,RC,99232,CPT,,,,,,,,253,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,123.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.0962,246.2449
Lvl 2 Sub Hosp Mod Mdm or 35 Minute,PX99232,CDM,982,RC,99232,CPT,,,,,,,,253,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,123.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.0962,246.2449
MESH FLAT SHEET SOFT 3X6 INCH,C1781,CDM,278,RC,C1781,HCPCS,,11773-MAIN,LOCAL,,,,,253,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,196.035,percent of total billed charges,123.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
MESH FLAT SHEET SOFT 3X6 INCH,C1781,CDM,278,RC,C1781,HCPCS,,11773-MAIN,LOCAL,,,,,253,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,123.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
MESH FLAT SHEET SOFT 3X6 INCH,C1781,CDM,278,RC,C1781,HCPCS,,11773-MAIN,LOCAL,,,,,253,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,123.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Platelet Antibodies - Ref,PX8602290,CDM,300,RC,86022,CPT,90,,,,,,,245,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,123.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.84,240.1
Subsequent Observation Care,PX99225,CDM,982,RC,99225,CPT,,,,,,,,253,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,123.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.0962,246.2449
Subsequent Observation Care,PX99225,CDM,982,RC,99225,CPT,,,,,,,,253,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,123.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.0962,246.2449
Subsequent Observation Care,PX99225,CDM,982,RC,99225,CPT,,,,,,,,253,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,123.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.0962,246.2449
Tap Block Unilateral by Injection(S),PX64486F,CDM,510,RC,64486,CPT,,,,,,,,253,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,33.8,percent of total billed charges,123.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.0962,247.94
Tap Block Unilateral by Injection(S),PX64486F,CDM,510,RC,64486,CPT,,,,,,,,253,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,123.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.0962,247.94
Tap Block Unilateral by Injection(S),PX64486F,CDM,510,RC,64486,CPT,,,,,,,,253,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,123.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.0962,247.94
BONE SCREW T8 FULL THREAD 2.4MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12652-MAIN,LOCAL,,,,,289,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,123.981,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
BONE SCREW T8 FULL THREAD 2.4MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12653-MAIN,LOCAL,,,,,289,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,123.981,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
BONE SCREW T8 FULL THREAD 2.7MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12654-MAIN,LOCAL,,,,,289,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,123.981,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Occupational Therapy Eval High Complex,PX97167,CDM,434,RC,97167,CPT,,,,,,,,289,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,123.981,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,283.22
"Troponin, Quantitative",PX84484,CDM,300,RC,84484,CPT,,,,,,,,289,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,123.981,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.43,283.22
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,703115301,NDC,4,ML,136.1,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,123.9871,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dexmedeTOMIDine in  dextrose 200MCG/50ML -5% Solution 50 mL Flex Cont,25000000,CDM,250,RC,,,,,,44567060224,NDC,50,ML,258.31,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,123.9888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dexmedeTOMIDine in  dextrose 200MCG/50ML -5% Solution 50 mL Flex Cont,25000000,CDM,250,RC,,,,,,44567060224,NDC,50,ML,258.31,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,123.9888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
hydrocortisone sodium succinate (preservative free) 500 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001612,NDC,1,EA,298.53,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,124.009362,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
LIGACLIP APPLIER CLIP STERILE SIZE MEDIUM LARGE,27200000,CDM,272,RC,,,,11699-MAIN,LOCAL,,,,,126.62,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,124.0876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,51672131200,NDC,22,GR,140.7,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,124.0974,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Islet Cell Antibody - Ref,PX8634190,CDM,300,RC,86341,CPT,90,,,,,,,146,,First Health,Commercial,both,85,,999999999,percent of total billed charges,124.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.61,143.08
Layr Clos Wnd Rest Body 2.6-7.5,PX12042F,CDM,510,RC,12042,CPT,,,,,,,,404,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,124.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,123.03,645.45
Layr Clos Wnd Rest Body 2.6-7.5,PX12042F,CDM,510,RC,12042,CPT,,,,,,,,404,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,124.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,123.03,645.45
Layr Clos Wnd Rest Body 2.6-7.5,PX12042P,CDM,983,RC,12042,CPT,,,,,,,,777,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,124.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,123.03,761.46
Layr Clos Wnd Rest Body 2.6-7.5,PX12042P,CDM,983,RC,12042,CPT,,,,,,,,777,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,124.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,123.03,761.46
Exc Skin Benig <5mm Remaindr Body,PX11420P,CDM,983,RC,11420,CPT,,,,,,,,299,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,124.2046,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,124.2046,1416.38
ciprofloxacin 0.3 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,61314065625,NDC,2.5,ML,140.92,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,124.29144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Acth - Ref,PX8202490,CDM,300,RC,82024,CPT,90,,,,,,,259,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,124.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.41,253.82
Acth - Ref,PX8202490,CDM,300,RC,82024,CPT,90,,,,,,,259,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,124.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.41,253.82
"IV Push, Single/1st Drug",PX96374,CDM,260,RC,96374,CPT,,,,,,,,259,,Health Partners,Health Partners Care Plans,both,48,,85.26481481,percent of total billed charges,124.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.5886,253.82
"IV Push, Single/1st Drug",PX96374,CDM,260,RC,96374,CPT,,,,,,,,259,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,124.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.5886,253.82
Temporal Artery Ligatn or Bx,PX37609F,CDM,510,RC,37609,CPT,,,,,,,,705,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,124.34,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,124.34,645.45
Temporal Artery Ligatn or Bx,PX37609P,CDM,983,RC,37609,CPT,,,,,,,,965,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,124.34,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,124.34,945.7
HERCULES 3 STAGE BALLOON ESOPHAGEAL 12-13.5-15::36-40.5-45MM,27200000,CDM,272,RC,C1726,HCPCS,,11329-MAIN,LOCAL,,,,,289.85,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,124.34565,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HERCULES 3 STAGE BALLOON ESOPHAGEAL 15-16.5-18:45-49.5-54MM,27200000,CDM,272,RC,C1726,HCPCS,,11328-MAIN,LOCAL,,,,,289.85,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,124.34565,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HERCULES 3 STAGE BALLOON ESOPHAGEAL 18-19-20::54-57-60MM,27200000,CDM,272,RC,C1726,HCPCS,,11330-MAIN,LOCAL,,,,,289.85,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,124.34565,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Aspergillus Ag - Ref,PX8730590,CDM,300,RC,87305,CPT,90,,,,,,,141,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,124.362,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,138.18
atropine 1 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,60219174903,NDC,5,ML,299.49,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,124.408146,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Apply Long Arm Splint,PX29105F,CDM,510,RC,29105,CPT,,,,,,,,290,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,124.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.466,284.2
Assay of Digoxin,PX80162,CDM,300,RC,80162,CPT,,,,,,,,290,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,124.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.18,284.2
Assay of Natriuretic Peptide,PX83880,CDM,300,RC,83880,CPT,,,,,,,,290,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,124.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36,284.2
NEEDLE INTRAOSSEOUS SET 15GA 25MM STABILIZER EZ-IO 9001P,120.216,CDM,272,RC,A4215,HCPCS,,10648-MAIN,LOCAL,,,,,290,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,124.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.466,284.2
NEEDLE INTRAOSSEOUS SET 15GA 45MM STABILIZER EZ-IO 9079P,120.216,CDM,272,RC,A4215,HCPCS,,10297-MAIN,LOCAL,,,,,290,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,124.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.466,284.2
B-Scan Global,PX7651201,CDM,402,RC,76512,CPT,TC,,,,,,,127,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,124.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.7558,124.46
Candida Dna Dir Probe,PX87480,CDM,300,RC,87480,CPT,,,,,,,,127,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,124.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.38,124.46
Gardner Vag Dna Dir Probe,PX87510,CDM,300,RC,87510,CPT,,,,,,,,127,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,124.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.38,124.46
Influenza Assay W/Optic,PX87804,CDM,300,RC,87804,CPT,,,,,,,,127,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,124.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.17,124.46
Thyrstim Immun Glob (Tsi) - Ref,PX8444590,CDM,300,RC,84445,CPT,90,,,,,,,254,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,124.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.63,248.92
Thyrstim Immun Glob (Tsi) - Ref,PX8444590,CDM,300,RC,84445,CPT,90,,,,,,,254,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,124.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.63,248.92
Thyrstim Immun Glob (Tsi) - Ref,PX8444590,CDM,300,RC,84445,CPT,90,,,,,,,254,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,124.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.63,248.92
Trichomonas Vagin Dir Probe,PX87660,CDM,300,RC,87660,CPT,,,,,,,,127,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,124.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.38,124.46
KATZ EXTRACTOR OTO-RHINO FOREIGN BODY REMOVER,120.568,CDM,272,RC,,,,12808-MAIN,LOCAL,,,,,246,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,124.476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.1884,241.08
"Biopsy, Nail Unit",PX11755F,CDM,510,RC,11755,CPT,,,,,,,,1490,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,124.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.73,253.89
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006F,CDM,510,RC,10006,CPT,,,,,,,,213,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,124.52,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.76,124.52
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006P,CDM,983,RC,10006,CPT,,,,,,,,142,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,124.52,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.76,139.16
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046204,NDC,30,ML,127.94,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,124.524002,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
TISSUE RETRIEVAL SYSTEM,27200000,CDM,272,RC,,,,10233-MAIN,LOCAL,,,,,139.98,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,124.5822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Canalith Repositioning,PX95992,CDM,420,RC,95992,CPT,,,,,,,,128,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,25.6,percent of total billed charges,124.5824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.86,125.44
Heparin Xa,PX85520,CDM,300,RC,85520,CPT,,,,,,,,128,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,124.5824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12,125.44
Lab Pth Immunoch Part 1,PX83970,CDM,300,RC,83970,CPT,,,,,,,,128,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,124.5824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.85,125.44
"N Block Inj, Common Digit",PX64632P,CDM,983,RC,64632,CPT,,,,,,,,128,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,124.5824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.1712,258.75
Apply Forearm Cast,PX29075P,CDM,983,RC,29075,CPT,,,,,,,,140,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,124.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.156,234.62
Hospital Discharge Day>30 Min,PX99239P,CDM,982,RC,99239,CPT,,,,,,,,140,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,124.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.156,136.262
iohexol 300 MG/ML Solution 150 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141365,NDC,150,ML,300,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,124.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,294
"Spinal Punc,Drain,Theraputic",PX62272P,CDM,983,RC,62272,CPT,,,,,,,,300,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,124.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,124.62,604.15
US Follicles-Limited Tc,PX7685701,CDM,402,RC,76857,CPT,TC,,,,,,,300,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,124.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,294
DOBUTamine 1000 mcg/mL in dextrose 5% 250 mL premix 1000 mcg/ml Solution 250 mL Flex Cont,J1250.01,CDM,636,RC,J1250,HCPCS,,,,338107302,NDC,250,ML,146.73,,First Health,Commercial,both,85,,999999999,percent of total billed charges,124.7205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.951642,143.7954
"Inject Trigger Point, 1 or 2",PX20552F,CDM,510,RC,20552,CPT,,,,,,,,252,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,124.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,258.75
"Level V - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3939,CDM,310,RC,88307,CPT,TC,,,,,,,252,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,124.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,314.02
"Off/Outpt Visit,New,Levl III",PX99203P,CDM,983,RC,99203,CPT,,,,,,,,252,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,124.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,245.2716
"Office/Outpt Visit,New,Levl III",PX99203F,CDM,510,RC,99203,CPT,,,,,,,,252,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,124.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,246.96
diclofenac 0.1 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,17478089225,NDC,2.5,ML,252.06,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,124.7697,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
doxycycline 100 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323013041,NDC,1,EA,140.2,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,124.778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Temporal Artery Ligatn or Bx,PX37609F,CDM,510,RC,37609,CPT,,,,,,,,705,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,124.78,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,124.34,645.45
Temporal Artery Ligatn or Bx,PX37609F,CDM,510,RC,37609,CPT,,,,,,,,705,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,124.78,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,124.34,645.45
Temporal Artery Ligatn or Bx,PX37609P,CDM,983,RC,37609,CPT,,,,,,,,965,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,124.78,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,124.34,945.7
Temporal Artery Ligatn or Bx,PX37609P,CDM,983,RC,37609,CPT,,,,,,,,965,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,124.78,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,124.34,945.7
Blood Clot Factor V Test,PX85220,CDM,300,RC,85220,CPT,,,,,,,,260,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,124.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.18,254.8
Blood Clot Factor V Test,PX85220,CDM,300,RC,85220,CPT,,,,,,,,260,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,124.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.18,254.8
First Hour IV Hydration <1 Hour,PX96360,CDM,260,RC,96360,CPT,,,,,,,,260,,Health Partners,Health Partners Care Plans,both,48,,103.185,percent of total billed charges,124.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.004,254.8
First Hour IV Hydration <1 Hour,PX96360,CDM,260,RC,96360,CPT,,,,,,,,260,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,124.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.004,254.8
Total Cortisol,PX82533,CDM,300,RC,82533,CPT,,,,,,,,137,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,124.807,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.95,134.26
"Triiodothyronine T3, Free (Free T3)",PX84481,CDM,300,RC,84481,CPT,,,,,,,,137,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,124.807,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.53,134.26
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,409662902,NDC,10,ML,146.84,,First Health,Commercial,both,85,,999999999,percent of total billed charges,124.814,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.236966,143.9032
Drain/Inject Large Joint/Bursa,PX20610P,CDM,983,RC,20610,CPT,,,,,,,,291,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,124.839,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.8814,283.2303
MRI T Spine WO Contrast,PX7214601,CDM,610,RC,72146,CPT,TC,,,,,,,3267,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,124.8584,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.42,249.15
Kit Gene Analysis D816 Variant(S) - Ref,PX8127390,CDM,300,RC,81273,CPT,90,,,,,,,293,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,124.87,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.12,124.87
Insert Emergency Endotrach Airway,PX31500F,CDM,510,RC,31500,CPT,,,,,,,,637,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,124.9079,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.64,288.48
Insert Emergency Endotrach Airway,PX31500P,CDM,983,RC,31500,CPT,,,,,,,,657,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,124.9079,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.64,643.86
Amphetamines; 1 or 2 - Ref,PX8032490,CDM,300,RC,80324,CPT,90,,,,,,,147,,First Health,Commercial,both,85,,999999999,percent of total billed charges,124.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.0638,144.06
Assay Ph Body Fluids Nos,PX83986,CDM,300,RC,83986,CPT,,,,,,,,147,,First Health,Commercial,both,85,,999999999,percent of total billed charges,124.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.28,144.06
"Cmv Detect, Amplifi Probe - Ref",PX8749690,CDM,300,RC,87496,CPT,90,,,,,,,147,,First Health,Commercial,both,85,,999999999,percent of total billed charges,124.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,144.06
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800F,CDM,510,RC,40800,CPT,,,,,,,,255,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,124.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.927,614.65
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800F,CDM,510,RC,40800,CPT,,,,,,,,255,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,124.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.927,614.65
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800F,CDM,510,RC,40800,CPT,,,,,,,,255,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,124.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.927,614.65
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106F,CDM,510,RC,11106,CPT,,,,,,,,255,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,124.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.927,548.67
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106F,CDM,510,RC,11106,CPT,,,,,,,,255,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,124.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.927,548.67
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106F,CDM,510,RC,11106,CPT,,,,,,,,255,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,124.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.927,548.67
"Inject Nerv Blck,Trigeminal",PX64400F,CDM,510,RC,64400,CPT,,,,,,,,255,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,124.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.927,258.75
"Inject Nerv Blck,Trigeminal",PX64400F,CDM,510,RC,64400,CPT,,,,,,,,255,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,124.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.927,258.75
"Inject Nerv Blck,Trigeminal",PX64400F,CDM,510,RC,64400,CPT,,,,,,,,255,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,124.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.927,258.75
"Methlenedioxyamphetamines (Mda, Mdea, Mdma) - Ref",PX8035990,CDM,300,RC,80359,CPT,90,,,,,,,147,,First Health,Commercial,both,85,,999999999,percent of total billed charges,124.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.0638,144.06
Ph Venous Blood,PX82800,CDM,300,RC,82800,CPT,,,,,,,,147,,First Health,Commercial,both,85,,999999999,percent of total billed charges,124.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.09,144.06
"Urinalysis, Auto, W/Scope",PX81001,CDM,300,RC,81001,CPT,,,,,,,,255,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,30.37836364,percent of total billed charges,124.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.91,249.9
"Urinalysis, Auto, W/Scope",PX81001,CDM,300,RC,81001,CPT,,,,,,,,255,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,124.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.91,249.9
"Urinalysis, Auto, W/Scope",PX81001,CDM,300,RC,81001,CPT,,,,,,,,255,,United Healthcare,All Medicare advantage plans,outpatient,49,,135.15,percent of total billed charges,124.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.91,249.9
Drain/Inject Medium Joint/Bursa,PX20605F,CDM,510,RC,20605,CPT,,,,,,,,247,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,124.982,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.6038,258.75
PACLitaxel 150 MG/25ML Concentrate 25 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321701,NDC,25,ML,300.96,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,125.018784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122P,CDM,983,RC,13122,CPT,,,,,,,,301,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,125.0354,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.0354,292.9633
Xray Facial Bones Less Than 3 Vws,PX7014001,CDM,320,RC,70140,CPT,TC,,,,,,,301,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,125.0354,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,294.98
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,24208046325,NDC,2.5,ML,137.26,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,125.04386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062430,NDC,0.3,ML,147.12,,First Health,Commercial,both,85,,999999999,percent of total billed charges,125.052,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801301,NDC,0.3,ML,147.12,,First Health,Commercial,both,85,,999999999,percent of total billed charges,125.052,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801310,NDC,0.3,ML,147.12,,First Health,Commercial,both,85,,999999999,percent of total billed charges,125.052,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
"Chemotherapy Administration, Subq/Im Non-Hormonal Anti-Neoplastic",PX96401,CDM,335,RC,96401,CPT,,,,,,,,170,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,125.07,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.12,125.07
"Chemotherapy Administration, Subq/Im Non-Hormonal Anti-Neoplastic",PX96401,CDM,335,RC,96401,CPT,,,,,,,,170,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,125.07,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.12,125.07
morphine 20 mg/mL Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,54040444,NDC,30,ML,141.88,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,125.13816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Red Blood Cells Unit,PXP9021,CDM,390,RC,P9021,HCPCS,,,,,,,,1050,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,125.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.17,1029
MRI C-Spine WO Contrast,PX7214101,CDM,610,RC,72141,CPT,TC,,,,,,,3541,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,125.1802,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.64,249.81
CARBOplatin 600 MG/60ML Solution 60 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703423981,NDC,60,ML,301.42,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,125.209868,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.778704,295.3916
Debride Skin/Tissue,PX11042F,CDM,510,RC,11042,CPT,,,,,,,,1067,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,125.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.08,269.8
Debride Skin/Tissue,PX11042P,CDM,983,RC,11042,CPT,,,,,,,,995,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,125.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.08,975.1
"Layr Clos Wnd Face,Facial 2.5-5",PX12052F,CDM,510,RC,12052,CPT,,,,,,,,585,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,125.22,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.22,656.52
"Layr Clos Wnd Face,Facial 2.5-5",PX12052P,CDM,983,RC,12052,CPT,,,,,,,,776,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,125.22,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.22,760.48
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,51672131200,NDC,22,GR,140.7,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,125.223,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Remv Foot Foreign Body,Subcutaneous",PX28190F,CDM,510,RC,28190,CPT,,,,,,,,1025,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,125.229,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.55,499.48
"Remv Foot Foreign Body,Subcutaneous",PX28190P,CDM,983,RC,28190,CPT,,,,,,,,683,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,125.229,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.55,669.34
Lvl 2 Sub Hosp Mod Mdm or 35 Minute,PX99232,CDM,982,RC,99232,CPT,,,,,,,,253,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,125.235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.0962,246.2449
MESH FLAT SHEET SOFT 3X6 INCH,C1781,CDM,278,RC,C1781,HCPCS,,11773-MAIN,LOCAL,,,,,253,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,125.235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Subsequent Observation Care,PX99225,CDM,982,RC,99225,CPT,,,,,,,,253,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,125.235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.0962,246.2449
Tap Block Unilateral by Injection(S),PX64486F,CDM,510,RC,64486,CPT,,,,,,,,253,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,125.235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.0962,247.94
hepatitis b recomb vaccine 10 MCG/0.5ML suspension prefilled syringe 0.5 mL Syringe,90743,CDM,636,RC,90743,CPT,,,,58160082052,NDC,0.5,ML,137.47,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,125.23517,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.105038,134.7206
Apply Multlay Comprs Lwr Leg,PX29581P,CDM,983,RC,29581,CPT,,,,,,,,142,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,125.244,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,138.2086
"Biopsy Vulva/Perineum,One Lesn",PX56605P,CDM,983,RC,56605,CPT,,,,,,,,142,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,125.244,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,702.31
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006P,CDM,983,RC,10006,CPT,,,,,,,,142,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,125.244,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,138.2086
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760,CDM,420,RC,97760,CPT,,,,,,,,142,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,125.244,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.18,139.16
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760F,CDM,510,RC,97760,CPT,,,,,,,,142,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,125.244,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.18,139.16
Oximetry;Mult Determine,PX610,CDM,460,RC,94761,CPT,,,,,,,,142,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,125.244,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,139.16
Thromboplastin Time Partial,PX85730,CDM,300,RC,85730,CPT,,,,,,,,142,,United Healthcare,All Payer,outpatient,88.2,,112.4033333,percent of total billed charges,125.244,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.51,139.16
X-Ray Exam Femur 1 Vw,PX7355101,CDM,320,RC,73551,CPT,TC,,,,,,,142,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,125.244,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,139.16
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012365,NDC,0.7,ML,291.98,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,125.25942,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012388,NDC,0.7,ML,291.98,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,125.25942,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072310,NDC,0.5,ML,291.98,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,125.25942,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072388,NDC,0.5,ML,291.98,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,125.25942,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
neomycin-polymyxin-dexamethasone 3.5-10000-0.1 Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,61314063136,NDC,3.5,GR,247.71,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,125.34126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
neomycin-polymyxin-dexameth 3.5-10000-0.1 Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063006,NDC,5,ML,247.72,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,125.34632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046204,NDC,30,ML,127.94,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,125.3812,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ciprofloxacin 0.3 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,61314065625,NDC,2.5,ML,140.92,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,125.4188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,781375575,NDC,4,ML,142.22,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,125.43804,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Canalith Repositioning,PX95992,CDM,420,RC,95992,CPT,,,,,,,,128,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,125.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.86,125.44
Heparin Xa,PX85520,CDM,300,RC,85520,CPT,,,,,,,,128,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,125.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12,125.44
Lab Pth Immunoch Part 1,PX83970,CDM,300,RC,83970,CPT,,,,,,,,128,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,125.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.85,125.44
"N Block Inj, Common Digit",PX64632P,CDM,983,RC,64632,CPT,,,,,,,,128,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,125.44,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.88,188.86
"Office/Outpt Visit,Est,Levl IV",PX99214F,CDM,510,RC,99214,CPT,,,,,,,,256,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,74.66,percent of total billed charges,125.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.3424,250.88
"Office/Outpt Visit,Est,Levl IV",PX99214F,CDM,510,RC,99214,CPT,,,,,,,,256,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,125.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.3424,250.88
"Office/Outpt Visit,Est,Levl IV",PX99214F,CDM,510,RC,99214,CPT,,,,,,,,256,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,125.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.3424,250.88
"Office/Outpt Visit,Est,Levl IV",PX99214P,CDM,983,RC,99214,CPT,,,,,,,,256,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,74.66,percent of total billed charges,125.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.3424,249.1648
"Office/Outpt Visit,Est,Levl IV",PX99214P,CDM,983,RC,99214,CPT,,,,,,,,256,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,125.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.3424,249.1648
"Office/Outpt Visit,Est,Levl IV",PX99214P,CDM,983,RC,99214,CPT,,,,,,,,256,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,125.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.3424,249.1648
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133P,CDM,983,RC,13133,CPT,,,,,,,,256,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,125.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.3424,249.1648
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133P,CDM,983,RC,13133,CPT,,,,,,,,256,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,125.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.3424,249.1648
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133P,CDM,983,RC,13133,CPT,,,,,,,,256,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,125.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.3424,249.1648
"Destruct Benign Lesion, 1-14",PX17110F,CDM,510,RC,17110,CPT,,,,,,,,302,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,125.4508,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.4508,295.96
Closed Rx Mt-Phal Toe Dislocation,PX28630P,CDM,983,RC,28630,CPT,,,,,,,,248,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,125.488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.0192,241.3784
Debride Muscle Ea Add 20 Sqcm,PX11046F,CDM,510,RC,11046,CPT,,,,,,,,248,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,125.488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.0192,243.04
Fetal Profile W/O Stress,PX7681901,CDM,402,RC,76819,CPT,TC,,,,,,,248,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,125.488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,243.04
Ther Injection Carpal Tunnel,PX20526P,CDM,983,RC,20526,CPT,,,,,,,,248,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,125.488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.0192,258.75
US Chest Tc,PX7660401,CDM,402,RC,76604,CPT,TC,,,,,,,248,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,125.488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,243.04
"West Nile Ab, Igg - Ref",PX8678990,CDM,300,RC,86789,CPT,90,,,,,,,248,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,125.488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,243.04
Aspergillus Ag - Ref,PX8730590,CDM,300,RC,87305,CPT,90,,,,,,,141,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,125.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,138.18
Chrom Anal 15-20 Cells - Ref,PX8826290,CDM,310,RC,88262,CPT,90,,,,,,,398,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,125.49,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.73,125.49
fluorouracil 5 GM/100ML Solution 100 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,16729027638,NDC,100,ML,261.44,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,125.4912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,256.2112
fluorouracil 5 GM/100ML Solution 100 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,16729027638,NDC,100,ML,261.44,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,125.4912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,256.2112
MRI L Spine WO Contrast,PX7214801,CDM,610,RC,72148,CPT,TC,,,,,,,3541,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,125.502,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.86,250.47
Complete Cbc Automated,PX85027,CDM,300,RC,85027,CPT,,,,,,,,129,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,42.10535211,percent of total billed charges,125.5557,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,126.42
"Venipunc Need Phys Skill,Dx or Rx",PX36410P,CDM,983,RC,36410,CPT,,,,,,,,129,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,25.72625,percent of total billed charges,125.5557,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.5866,125.5557
fat emulsion 20 % Emulsion 250 mL Flex Cont,25000000,CDM,250,RC,,,,,,338051909,NDC,250,ML,292.75,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,125.58975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
SUMAtriptan 25 MG Tablet 9 Each Box,63700001,CDM,250,RC,,,,,,65862014636,NDC,1,EA,129.04,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,125.594632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Molecular Path Proc, Level 2 - Ref",PX8140190,CDM,310,RC,81401,CPT,90,,,,,,,672,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,125.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.62,658.56
nystatin 100000 UNIT/GM Cream 30 g Tube,25000000,CDM,250,RC,,,,,,168005430,NDC,30,GR,147.79,,First Health,Commercial,both,85,,999999999,percent of total billed charges,125.6215,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Digital Mamm, Diag, Unilat, Tc W/Cad Perf",PX7706501,CDM,401,RC,77065,CPT,TC,,,,,,,293,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,125.697,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.46,287.14
Drain Skin Abscess Simple,PX10060P,CDM,983,RC,10060,CPT,,,,,,,,293,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,125.697,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.7122,285.1769
Kit Gene Analysis D816 Variant(S) - Ref,PX8127390,CDM,300,RC,81273,CPT,90,,,,,,,293,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,125.697,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,114.49,287.14
Repr Superf Wnd Body <2.5cm,PX12001P,CDM,983,RC,12001,CPT,,,,,,,,293,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,125.697,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.7122,285.1769
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,16714076901,NDC,15,GR,137.99,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,125.70889,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Thyrstim Immun Glob (Tsi) - Ref,PX8444590,CDM,300,RC,84445,CPT,90,,,,,,,254,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,125.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.63,248.92
"Fac/Office Consultation,Level IV",PX99244F,CDM,510,RC,99244,CPT,,,,,,,,441,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,125.7456,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.11,287.64
"Office Consultation,Level IV",PX99244P,CDM,983,RC,99244,CPT,,,,,,,,441,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,125.7456,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.11,432.18
BLUE EYE SUBMUCOSAL LIFTING AGENT 5ML,27200000,CDM,272,RC,,,,12684-MAIN,LOCAL,,,,,148,,First Health,Commercial,both,85,,999999999,percent of total billed charges,125.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Mumps,PX86735,CDM,300,RC,86735,CPT,,,,,,,,148,,First Health,Commercial,both,85,,999999999,percent of total billed charges,125.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.97,145.04
US Guide Needle Bx S&I,PX7694226,CDM,982,RC,76942,CPT,26,,,,,,,148,,First Health,Commercial,both,85,,999999999,percent of total billed charges,125.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.4792,144.0484
ammonium lactate 12 % Cream 385 g Tube,63700001,CDM,250,RC,,,,,,45802049326,NDC,385,GR,256.76,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,125.8124,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ammonium lactate 12 % Cream 385 g Tube,63700001,CDM,250,RC,,,,,,45802049326,NDC,385,GR,256.76,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,125.8124,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ammonium lactate 12 % Cream 385 g Tube,63700001,CDM,250,RC,,,,,,45802049326,NDC,385,GR,256.76,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,125.8124,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Chemotherapy, IV Infusion, 1 Hour",PX96413,CDM,335,RC,96413,CPT,,,,,,,,614,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,125.832,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.29,225.7
"Destruct Benign Lesion, 15+",PX17111F,CDM,510,RC,17111,CPT,,,,,,,,303,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,125.8662,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.8662,296.94
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607P,CDM,983,RC,97607,CPT,,,,,,,,303,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,125.8662,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.8662,348.35
Strapping of Knee,PX29530F,CDM,420,RC,29530,CPT,,,,,,,,303,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,125.8662,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,296.94
Xray Knee 1 or 2 Vws,PX7356001,CDM,320,RC,73560,CPT,TC,,,,,,,303,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,125.8662,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,296.94
ipratropium 0.03 % Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,24208039830,NDC,30,ML,256.9,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,125.881,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ipratropium 0.03 % Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,24208039830,NDC,30,ML,256.9,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,125.881,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ipratropium 0.03 % Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,24208039830,NDC,30,ML,256.9,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,125.881,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ePHEDrine sulfate 50 MG/ML Solution 1 mL Ampule,25000000,CDM,250,RC,,,,,,17478041510,NDC,1,ML,262.31,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,125.9088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ePHEDrine sulfate 50 MG/ML Solution 1 mL Ampule,25000000,CDM,250,RC,,,,,,17478041510,NDC,1,ML,262.31,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,125.9088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Remv F.B.,Eye,Cornea,No Slit",PX65220F,CDM,510,RC,65220,CPT,,,,,,,,334,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,125.91,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.52,125.91
"Remv F.B.,Eye,Cornea,No Slit",PX65220P,CDM,983,RC,65220,CPT,,,,,,,,318,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,125.91,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.52,311.64
nystatin 100000 UNIT/GM Cream 30 g Tube,25000000,CDM,250,RC,,,,,,51672128902,NDC,30,GR,148.29,,First Health,Commercial,both,85,,999999999,percent of total billed charges,126.0465,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
amiodarone 150-4.21 MG/100ML-% Solution 100 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066015010,NDC,100,ML,249.22,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,126.10532,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.35,318.745
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703334301,NDC,0.5,ML,142.98,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,126.10836,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963805,NDC,0.5,ML,142.98,,United Healthcare,All Payer,outpatient,88.2,,225.03,percent of total billed charges,126.10836,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
Assay Thyroid Stim Hormone,PX84443,CDM,300,RC,84443,CPT,,,,,,,,294,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,126.126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.4,288.12
Francisella Tularensis Ab,PX8666890,CDM,300,RC,86668,CPT,90,,,,,,,294,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,126.126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.98,288.12
Physical Therapy Evaluation High Complex,PX97163,CDM,424,RC,97163,CPT,,,,,,,,294,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,126.126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,288.12
"Office/Outpt Visit,New,Levl V",PX99205F,CDM,510,RC,99205,CPT,,,,,,,,456,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,126.14,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.82,395.88
"Office/Outpt Visit,New,Levl V",PX99205F,CDM,510,RC,99205,CPT,,,,,,,,456,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,126.14,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.82,395.88
"Office/Outpt Visit,New,Levl V",PX99205P,CDM,983,RC,99205,CPT,,,,,,,,456,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,126.14,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.82,446.88
"Office/Outpt Visit,New,Levl V",PX99205P,CDM,983,RC,99205,CPT,,,,,,,,456,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,126.14,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.82,446.88
phytonadione 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714097302,NDC,0.5,EA,143.02,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,126.14364,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phytonadione 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,69238105103,NDC,0.5,EA,143.02,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,126.14364,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Emergency Level III Visit,PX99283P,CDM,981,RC,99283,CPT,,,,,,,,568,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,126.18,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,43.86,556.64
Emergency Level III Visit,PX99283P,CDM,981,RC,99283,CPT,,,,,,,,568,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,126.18,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,43.86,556.64
Facility Emergency Level III Visit,PX99283F,CDM,450,RC,99283,CPT,,,,,,,,587,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,126.18,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,43.86,126.18
Facility Emergency Level III Visit,PX99283F,CDM,450,RC,99283,CPT,,,,,,,,587,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,126.18,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,43.86,126.18
"Upper GI Endoscopy,Biopsy",PX43239F,CDM,750,RC,43239,CPT,,,,,,,,2364,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,126.1923,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.86,780.35
"Upper GI Endoscopy,Biopsy",PX43239P,CDM,983,RC,43239,CPT,,,,,,,,2458,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,126.1923,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.86,2408.84
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081543,NDC,1,ML,479.89,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,126.2,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.83,197.744
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081543,NDC,1,ML,479.89,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,126.2,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.83,197.744
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081552,NDC,1,ML,479.89,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,126.2,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.83,197.744
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081552,NDC,1,ML,479.89,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,126.2,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.83,197.744
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800F,CDM,510,RC,40800,CPT,,,,,,,,255,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,126.225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.927,614.65
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106F,CDM,510,RC,11106,CPT,,,,,,,,255,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,126.225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.927,548.67
"Inject Nerv Blck,Trigeminal",PX64400F,CDM,510,RC,64400,CPT,,,,,,,,255,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,126.225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.927,258.75
"Urinalysis, Auto, W/Scope",PX81001,CDM,300,RC,81001,CPT,,,,,,,,255,,Humana Choice Care,All Medicare plans,outpatient,49.5,,156.2023077,percent of total billed charges,126.225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.91,249.9
"X-Ray Exam Hip,Unilat W/Pelvis 1vw",PX7350101,CDM,320,RC,73501,CPT,TC,,,,,,,263,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,126.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,257.74
"X-Ray Exam Hip,Unilat W/Pelvis 1vw",PX7350101,CDM,320,RC,73501,CPT,TC,,,,,,,263,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,126.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,257.74
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320885,NDC,0.5,EA,129.71,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,18.43861111,percent of total billed charges,126.246743,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320895,NDC,0.5,EA,129.71,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,18.43861111,percent of total billed charges,126.246743,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
morphine 20 mg/mL Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,54040444,NDC,30,ML,141.88,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,126.2732,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Ctrl Nosebleed,Anter,Complex",PX30903P,CDM,983,RC,30903,CPT,,,,,,,,304,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,126.2816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,295.8832
Joint Survey Tc,PX7707701,CDM,320,RC,77077,CPT,TC,,,,,,,304,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,126.2816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,297.92
"Layr Clos Wnd Face,Facial 2.5-5",PX12052F,CDM,510,RC,12052,CPT,,,,,,,,585,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,126.31,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.22,656.52
"Layr Clos Wnd Face,Facial 2.5-5",PX12052F,CDM,510,RC,12052,CPT,,,,,,,,585,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,126.31,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.22,656.52
"Layr Clos Wnd Face,Facial 2.5-5",PX12052P,CDM,983,RC,12052,CPT,,,,,,,,776,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,126.31,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.22,760.48
"Layr Clos Wnd Face,Facial 2.5-5",PX12052P,CDM,983,RC,12052,CPT,,,,,,,,776,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,126.31,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.22,760.48
Apply Multlay Comprs Lwr Leg,PX29581P,CDM,983,RC,29581,CPT,,,,,,,,142,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,126.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,138.2086
"Biopsy Vulva/Perineum,One Lesn",PX56605P,CDM,983,RC,56605,CPT,,,,,,,,142,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,126.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,702.31
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006P,CDM,983,RC,10006,CPT,,,,,,,,142,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,126.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,138.2086
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760,CDM,420,RC,97760,CPT,,,,,,,,142,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,126.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.18,139.16
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760F,CDM,510,RC,97760,CPT,,,,,,,,142,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,126.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.18,139.16
Oximetry;Mult Determine,PX610,CDM,460,RC,94761,CPT,,,,,,,,142,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,126.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,139.16
Thromboplastin Time Partial,PX85730,CDM,300,RC,85730,CPT,,,,,,,,142,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,126.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.51,139.16
X-Ray Exam Femur 1 Vw,PX7355101,CDM,320,RC,73551,CPT,TC,,,,,,,142,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,126.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,139.16
dexmedeTOMIDine in sodium chloride 200 MCG/50ML Solution 50 mL Flex Cont,25000000,CDM,250,RC,,,,,,338955524,NDC,50,ML,304.32,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,126.414528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Complete Cbc Automated,PX85027,CDM,300,RC,85027,CPT,,,,,,,,129,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,126.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.93,126.42
"Needle Biopsy,Muscle",PX20206F,CDM,510,RC,20206,CPT,,,,,,,,258,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,126.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.1732,1416.38
"Needle Biopsy,Muscle",PX20206F,CDM,510,RC,20206,CPT,,,,,,,,258,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,126.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.1732,1416.38
"Needle Biopsy,Muscle",PX20206F,CDM,510,RC,20206,CPT,,,,,,,,258,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,126.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.1732,1416.38
"Venipunc Need Phys Skill,Dx or Rx",PX36410P,CDM,983,RC,36410,CPT,,,,,,,,129,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,126.42,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.45,126.42
levOCARNitine 200 MG/ML Solution 5 mL Vial,J1955.01,CDM,636,RC,J1955,HCPCS,,,,517104501,NDC,5,ML,249.86,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,126.42916,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.791844,244.8628
DAPTOmycin 500 MG Recon Soln 1 Each Vial,J0878.01,CDM,636,RC,J0878,HCPCS,,,,70594003402,NDC,1,EA,129.9,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,126.43167,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.96046,127.302
SUMAtriptan 25 MG Tablet 9 Each Box,63700001,CDM,250,RC,,,,,,65862014636,NDC,1,EA,129.04,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,126.4592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Plas Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,338604648,NDC,100,ML,143.42,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,126.49644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.786918,140.5516
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153P,CDM,983,RC,99153,CPT,,,,,,,,250,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,126.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.85,243.325
sincalide 5 MCG Recon Soln 1 Each Vial,J2805.01,CDM,636,RC,J2805,HCPCS,,,,270055615,NDC,1,EA,250,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,126.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.85,245
Withdrawal of Arterial Blood,PX36600F,CDM,510,RC,36600,CPT,,,,,,,,250,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,126.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.85,245
Chemo Ad Sq/Im Hormnl Anti-Neo,PX96402,CDM,335,RC,96402,CPT,,,,,,,,130,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,93.93,percent of total billed charges,126.529,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,127.4
Cystatin C - Ref,PX8261090,CDM,300,RC,82610,CPT,90,,,,,,,130,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,126.529,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.98,127.4
Each Add'l Sequential Push New Drug,PX96375,CDM,260,RC,96375,CPT,,,,,,,,130,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,63.99109756,percent of total billed charges,126.529,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,127.4
Immunization Administration; One Vaccine (Single or Combination Vaccine/To*,PX90471,CDM,771,RC,90471,CPT,,,,,,,,130,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,39.605,percent of total billed charges,126.529,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,127.4
Prothrombin Time (Pt/Inr),PX85610,CDM,300,RC,85610,CPT,,,,,,,,130,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,31.49926829,percent of total billed charges,126.529,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.93,127.4
SPLINT WRIST LARGE ALUMINUM FOREARM LEFT 9101-06,120.87,CDM,274,RC,L3809,HCPCS,,1265-MAIN,LOCAL,,,,,130,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,126.529,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST LARGE ALUMINUM FOREARM RIGHT 9101-03,120.87,CDM,274,RC,L3809,HCPCS,,1263-MAIN,LOCAL,,,,,130,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,126.529,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST MEDIUM ALUMINUM FOREARM LEFT 9101-05,120.87,CDM,274,RC,L3809,HCPCS,,1264-MAIN,LOCAL,,,,,130,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,126.529,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST MEDIUM ALUMINUM FOREARM RIGHT 9101-02,120.87,CDM,274,RC,L3809,HCPCS,,1262-MAIN,LOCAL,,,,,130,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,126.529,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
Vitamin B-1 - Ref,PX8442590,CDM,300,RC,84425,CPT,90,,,,,,,130,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,126.529,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.47,127.4
Closed Rx Metacarpal Fx,PX26600P,CDM,983,RC,26600,CPT,,,,,,,,295,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,126.555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.543,287.1235
Sulfur Colloid per Dose,PXA9541,CDM,343,RC,A9541,HCPCS,,,,,,,,295,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,126.555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.543,289.1
dexmedeTOMIDine in  dextrose 200MCG/50ML -5% Solution 50 mL Flex Cont,25000000,CDM,250,RC,,,,,,44567060224,NDC,50,ML,258.31,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,126.5719,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dexmedeTOMIDine in  dextrose 200MCG/50ML -5% Solution 50 mL Flex Cont,25000000,CDM,250,RC,,,,,,44567060224,NDC,50,ML,258.31,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,126.5719,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dexmedeTOMIDine in  dextrose 200MCG/50ML -5% Solution 50 mL Flex Cont,25000000,CDM,250,RC,,,,,,44567060224,NDC,50,ML,258.31,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,126.5719,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,781375575,NDC,4,ML,142.22,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,126.5758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059303,NDC,1,EA,740.19,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,126.62,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,123.83,126.62112
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059611,NDC,0.25,EA,200.05,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,126.62,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,123.83,126.62112
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059613,NDC,0.25,EA,200.05,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,126.62,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,123.83,126.62112
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059303,NDC,1,EA,740.19,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,126.62112,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,123.83,126.62112
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059611,NDC,0.25,EA,200.05,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,126.62112,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,123.83,126.62112
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059613,NDC,0.25,EA,200.05,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,126.62112,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,123.83,126.62112
"Urinalysis, Auto W/O Scope",PX81003,CDM,300,RC,81003,CPT,,,,,,,,149,,First Health,Commercial,both,85,,999999999,percent of total billed charges,126.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.06,146.02
ENDOLOOP COATED VICRYL 0 18,27200000,CDM,272,RC,,,,10228-MAIN,LOCAL,,,,,143.6,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,126.6552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Tte W/Doppler, Complete",PX9330601,CDM,483,RC,93306,CPT,TC,,,,,,,2191,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,126.671,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.08,225.12
albuterol HFA 108 (90 Base) MCG/ACT Aerosol Solution 8 g Inhaler,25000000,CDM,250,RC,,,,,,173068224,NDC,8,GR,149.04,,First Health,Commercial,both,85,,999999999,percent of total billed charges,126.684,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Bone Marrow Aspiration(S),Diag",PX38220F,CDM,510,RC,38220,CPT,,,,,,,,305,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,126.697,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,126.697,1416.38
Occupational Therapy Eval Mod Complex,PX97166,CDM,434,RC,97166,CPT,,,,,,,,264,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,126.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,258.72
Occupational Therapy Eval Mod Complex,PX97166,CDM,434,RC,97166,CPT,,,,,,,,264,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,126.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,258.72
"Office/Outpt Visit,Est,Levl IV",PX99214F,CDM,510,RC,99214,CPT,,,,,,,,256,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,126.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.3424,250.88
"Office/Outpt Visit,Est,Levl IV",PX99214P,CDM,983,RC,99214,CPT,,,,,,,,256,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,126.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.3424,249.1648
Physical Therapy Evaluation Mod Complex,PX97162,CDM,424,RC,97162,CPT,,,,,,,,264,,Health Partners,Health Partners Care Plans,both,48,,165.8771429,percent of total billed charges,126.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,258.72
Physical Therapy Evaluation Mod Complex,PX97162,CDM,424,RC,97162,CPT,,,,,,,,264,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,126.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,258.72
Renal Function Panel,PX80069,CDM,300,RC,80069,CPT,,,,,,,,264,,Health Partners,Health Partners Care Plans,both,48,,122.41,percent of total billed charges,126.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.96,258.72
Renal Function Panel,PX80069,CDM,300,RC,80069,CPT,,,,,,,,264,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,126.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.96,258.72
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133P,CDM,983,RC,13133,CPT,,,,,,,,256,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,126.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.3424,249.1648
"Morphometric Analysis,Tumor Immunohistochemistry, Ea Antibody Manual , Tech",PX8836001,CDM,310,RC,88360,CPT,TC,,,,,,,119,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,126.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.23,131.36
"Morphometric Analysis,Tumor Immunohistochemistry, Ea Antibody Manual , Tech",PX8836001,CDM,310,RC,88360,CPT,TC,,,,,,,119,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,126.81,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.23,131.36
Exc Skn Beni 0.6-1cm Fcefacial,PX11441P,CDM,983,RC,11441,CPT,,,,,,,,485,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,126.8345,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.64,475.3
"Fac/Exc Skn Bnig0.6-1cm Fae,Facial",PX11441F,CDM,510,RC,11441,CPT,,,,,,,,606,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,126.8345,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.64,363.89
methylene blue 1 % Solution 10 mL Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,54288014701,NDC,1,ML,139.25,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,126.85675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.29,1354.4776
triamcinolone acetonide 0.1 % Cream 454 g Jar,63700001,CDM,250,RC,,,,,,45802006405,NDC,454,GR,130.36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,126.879388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Acth - Ref,PX8202490,CDM,300,RC,82024,CPT,90,,,,,,,259,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,126.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.41,253.82
Acth - Ref,PX8202490,CDM,300,RC,82024,CPT,90,,,,,,,259,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,126.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.41,253.82
Acth - Ref,PX8202490,CDM,300,RC,82024,CPT,90,,,,,,,259,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,126.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.41,253.82
"IV Push, Single/1st Drug",PX96374,CDM,260,RC,96374,CPT,,,,,,,,259,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,70.51413793,percent of total billed charges,126.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.5886,253.82
"IV Push, Single/1st Drug",PX96374,CDM,260,RC,96374,CPT,,,,,,,,259,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,126.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.5886,253.82
"IV Push, Single/1st Drug",PX96374,CDM,260,RC,96374,CPT,,,,,,,,259,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,126.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.5886,253.82
vancomycin 125 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68180016611,NDC,1,EA,149.33,,First Health,Commercial,both,85,,999999999,percent of total billed charges,126.9305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 125 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,47781072902,NDC,1,EA,149.33,,First Health,Commercial,both,85,,999999999,percent of total billed charges,126.9305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 125 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,62559039020,NDC,1,EA,149.33,,First Health,Commercial,both,85,,999999999,percent of total billed charges,126.9305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Apply Forearm Splint,Static",PX29125P,CDM,983,RC,29125,CPT,,,,,,,,296,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,126.984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,288.0968
Apply Lower Leg Splint,PX29515F,CDM,510,RC,29515,CPT,,,,,,,,296,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,126.984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.9584,290.08
Drain Skin Abscess Simple,PX10060F,CDM,510,RC,10060,CPT,,,,,,,,296,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,126.984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.9584,290.08
Hepatitis C Antibody,PX86803,CDM,300,RC,86803,CPT,,,,,,,,144,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,127.008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.08,141.12
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315606,NDC,100,ML,264.64,,Health Partners,Health Partners Care Plans,both,48,,1.2271,percent of total billed charges,127.0272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.931456,259.3472
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315606,NDC,100,ML,264.64,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,127.0272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.931456,259.3472
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315695,NDC,100,ML,264.64,,Health Partners,Health Partners Care Plans,both,48,,1.2271,percent of total billed charges,127.0272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.931456,259.3472
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315695,NDC,100,ML,264.64,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,127.0272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.931456,259.3472
ammonium lactate 12 % Cream 385 g Tube,63700001,CDM,250,RC,,,,,,45802049326,NDC,385,GR,256.76,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,127.0962,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Xray Thoracolumbar 2 Vws,PX7208001,CDM,320,RC,72080,CPT,TC,,,,,,,306,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,127.1124,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,299.88
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320885,NDC,0.5,EA,129.71,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,127.1158,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320895,NDC,0.5,EA,129.71,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,127.1158,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
"Flow Cyto, Tech, 1st Mrkr - Ref",PX8818490,CDM,310,RC,88184,CPT,90,,,,,,,223,,UCare,Individual and Family Plans,both,,,48.3,fee schedule,127.152,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.72,127.152
"Flow Cyto, Tech, 1st Mrkr - Ref",PX8818490,CDM,310,RC,88184,CPT,90,,,,,,,223,,UCare,Individual and Family Plans,both,,,48.3,fee schedule,127.152,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.72,127.152
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; 1st",PX88184,CDM,310,RC,88184,CPT,,,,,,,,96,,UCare,Individual and Family Plans,both,,,48.3,fee schedule,127.152,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.72,127.152
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; 1st",PX88184,CDM,310,RC,88184,CPT,,,,,,,,96,,UCare,Individual and Family Plans,both,,,48.3,fee schedule,127.152,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.72,127.152
ipratropium 0.03 % Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,24208039830,NDC,30,ML,256.9,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,127.1655,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234010,NDC,5,ML,306.2,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,127.19548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234025,NDC,5,ML,306.2,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,127.19548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234099,NDC,5,ML,306.2,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,127.19548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
Haptoglobin; Quantitative,PX83010,CDM,300,RC,83010,CPT,,,,,,,,265,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,127.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.53,259.7
Haptoglobin; Quantitative,PX83010,CDM,300,RC,83010,CPT,,,,,,,,265,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,127.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.53,259.7
ID Nucleic Acid Sequencing - Ref,PX8715390,CDM,300,RC,87153,CPT,90,,,,,,,265,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,127.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.77,259.7
ID Nucleic Acid Sequencing - Ref,PX8715390,CDM,300,RC,87153,CPT,90,,,,,,,265,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,127.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.77,259.7
fluticasone 110 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173071920,NDC,12,GR,149.67,,First Health,Commercial,both,85,,999999999,percent of total billed charges,127.2195,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703334301,NDC,0.5,ML,142.98,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,127.2522,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963805,NDC,0.5,ML,142.98,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,127.2522,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
phytonadione 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714097302,NDC,0.5,EA,143.02,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,127.2878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phytonadione 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,69238105103,NDC,0.5,EA,143.02,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,127.2878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DAPTOmycin 500 MG Recon Soln 1 Each Vial,J0878.01,CDM,636,RC,J0878,HCPCS,,,,70594003402,NDC,1,EA,129.9,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,127.302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.96046,127.302
Blood Clot Factor V Test,PX85220,CDM,300,RC,85220,CPT,,,,,,,,260,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,127.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.18,254.8
Blood Clot Factor V Test,PX85220,CDM,300,RC,85220,CPT,,,,,,,,260,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,127.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.18,254.8
Blood Clot Factor V Test,PX85220,CDM,300,RC,85220,CPT,,,,,,,,260,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,127.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.18,254.8
Chemo Ad Sq/Im Hormnl Anti-Neo,PX96402,CDM,335,RC,96402,CPT,,,,,,,,130,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,127.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,127.4
"Closed Rx Toe Fx,Manipulatn",PX28515P,CDM,983,RC,28515,CPT,,,,,,,,260,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,127.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.004,253.058
"Closed Rx Toe Fx,Manipulatn",PX28515P,CDM,983,RC,28515,CPT,,,,,,,,260,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,127.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.004,253.058
"Closed Rx Toe Fx,Manipulatn",PX28515P,CDM,983,RC,28515,CPT,,,,,,,,260,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,127.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.004,253.058
Cystatin C - Ref,PX8261090,CDM,300,RC,82610,CPT,90,,,,,,,130,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,127.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.98,127.4
Each Add'l Sequential Push New Drug,PX96375,CDM,260,RC,96375,CPT,,,,,,,,130,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,127.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,127.4
First Hour IV Hydration <1 Hour,PX96360,CDM,260,RC,96360,CPT,,,,,,,,260,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,51.08571429,percent of total billed charges,127.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.004,254.8
First Hour IV Hydration <1 Hour,PX96360,CDM,260,RC,96360,CPT,,,,,,,,260,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,127.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.004,254.8
First Hour IV Hydration <1 Hour,PX96360,CDM,260,RC,96360,CPT,,,,,,,,260,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,127.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.004,254.8
Immunization Administration; One Vaccine (Single or Combination Vaccine/To*,PX90471,CDM,771,RC,90471,CPT,,,,,,,,130,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,127.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,127.4
Prothrombin Time (Pt/Inr),PX85610,CDM,300,RC,85610,CPT,,,,,,,,130,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,127.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.93,127.4
SPLINT WRIST LARGE ALUMINUM FOREARM LEFT 9101-06,120.87,CDM,274,RC,L3809,HCPCS,,1265-MAIN,LOCAL,,,,,130,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,127.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST LARGE ALUMINUM FOREARM RIGHT 9101-03,120.87,CDM,274,RC,L3809,HCPCS,,1263-MAIN,LOCAL,,,,,130,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,127.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST MEDIUM ALUMINUM FOREARM LEFT 9101-05,120.87,CDM,274,RC,L3809,HCPCS,,1264-MAIN,LOCAL,,,,,130,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,127.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST MEDIUM ALUMINUM FOREARM RIGHT 9101-02,120.87,CDM,274,RC,L3809,HCPCS,,1262-MAIN,LOCAL,,,,,130,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,127.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
Vitamin B-1 - Ref,PX8442590,CDM,300,RC,84425,CPT,90,,,,,,,130,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,127.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.47,127.4
sincalide 5 MCG Recon Soln 1 Each Vial,J2805.01,CDM,636,RC,J2805,HCPCS,,,,270055615,NDC,1,EA,250,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,127.45754,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,117.12,133.1
Assay of CK (Cpk),PX82550,CDM,300,RC,82550,CPT,,,,,,,,150,,First Health,Commercial,both,85,,999999999,percent of total billed charges,127.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.97,147
Assay of Lactic Acid,PX83605,CDM,300,RC,83605,CPT,,,,,,,,150,,First Health,Commercial,both,85,,999999999,percent of total billed charges,127.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.61,147
Assay of Phosphorus,PX84100,CDM,300,RC,84100,CPT,,,,,,,,150,,First Health,Commercial,both,85,,999999999,percent of total billed charges,127.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.35,147
Bilirubin Direct,PX82248,CDM,300,RC,82248,CPT,,,,,,,,150,,First Health,Commercial,both,85,,999999999,percent of total billed charges,127.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.6,147
Bilirubin Total,PX82247,CDM,300,RC,82247,CPT,,,,,,,,150,,First Health,Commercial,both,85,,999999999,percent of total billed charges,127.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.6,147
"Drug(S) or Substance(S), Definitive, Qualitative or Quantitative, Not Otherwise Specified; 1-3 - Ref",PX8037590,CDM,300,RC,80375,CPT,90,,,,,,,150,,First Health,Commercial,both,85,,999999999,percent of total billed charges,127.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.31,147
"Hsv Detect, Amplif Probe - Ref",PX8752990,CDM,300,RC,87529,CPT,90,,,,,,,150,,First Health,Commercial,both,85,,999999999,percent of total billed charges,127.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,147
Magnesium,PX83735,CDM,300,RC,83735,CPT,,,,,,,,150,,First Health,Commercial,both,85,,999999999,percent of total billed charges,127.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.14,147
Magnesium - Ref,PX8373590,CDM,300,RC,83735,CPT,90,,,,,,,150,,First Health,Commercial,both,85,,999999999,percent of total billed charges,127.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.14,147
Po4 Inorganic (Phosphate) - Ref,PX8410090,CDM,300,RC,84100,CPT,90,,,,,,,150,,First Health,Commercial,both,85,,999999999,percent of total billed charges,127.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.35,147
TB Antigen Response Gamma Interferon T-Cell Susp,PX86481,CDM,300,RC,86481,CPT,,,,,,,,150,,First Health,Commercial,both,85,,999999999,percent of total billed charges,127.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.31,147
Noninvasv Oxygen Satur;Single,PX94760,CDM,460,RC,94760,CPT,,,,,,,,131,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,127.5023,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.4174,128.38
"Inject Trigger Point, 1 or 2",PX20552F,CDM,510,RC,20552,CPT,,,,,,,,252,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,127.512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,258.75
"Level V - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3939,CDM,310,RC,88307,CPT,TC,,,,,,,252,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,127.512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,314.02
"Off/Outpt Visit,New,Levl III",PX99203P,CDM,983,RC,99203,CPT,,,,,,,,252,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,127.512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,245.2716
"Office/Outpt Visit,New,Levl III",PX99203F,CDM,510,RC,99203,CPT,,,,,,,,252,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,127.512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,246.96
TISSUE RETRIEVAL SYSTEM,27200000,CDM,272,RC,,,,10233-MAIN,LOCAL,,,,,139.98,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,127.52178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
COOK EMERGENCY PNEUMOTHORAX SET,120.559,CDM,272,RC,,,,12597-MAIN,LOCAL,,,,,307,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,127.5278,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,127.5278,300.86
Apply Forearm Cast,PX29075P,CDM,983,RC,29075,CPT,,,,,,,,140,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,127.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.156,234.62
Hospital Discharge Day>30 Min,PX99239P,CDM,982,RC,99239,CPT,,,,,,,,140,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,127.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.156,136.262
diclofenac 0.1 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,17478089225,NDC,2.5,ML,252.06,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,127.54236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,69315030615,NDC,15,GR,131.07,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,127.570431,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Plas Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,338604648,NDC,100,ML,143.42,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,127.6438,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.786918,140.5516
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,63323072902,NDC,1,EA,265.95,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,127.656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.47563,793.6922
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,63323072902,NDC,1,EA,265.95,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,127.656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.47563,793.6922
Raltegravir 400 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,6022761,NDC,1,EA,150.2,,First Health,Commercial,both,85,,999999999,percent of total billed charges,127.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597F,CDM,510,RC,97597,CPT,,,,,,,,266,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,127.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.4964,260.68
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597F,CDM,510,RC,97597,CPT,,,,,,,,266,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,127.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.4964,260.68
"Needle Biopsy,Muscle",PX20206F,CDM,510,RC,20206,CPT,,,,,,,,258,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,127.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.1732,1416.38
insulin regular 100 UNIT/ML Solution 10 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821501,NDC,10,ML,307.46,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,127.718884,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
doxycycline 100 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323013041,NDC,1,EA,140.2,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,127.7222,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
triamcinolone acetonide 0.1 % Cream 454 g Jar,63700001,CDM,250,RC,,,,,,45802006405,NDC,454,GR,130.36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,127.7528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,49884093547,NDC,100,GR,266.25,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,127.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,49884093547,NDC,100,GR,266.25,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,127.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ENDOLOOP COATED VICRYL 0 18,27200000,CDM,272,RC,,,,10228-MAIN,LOCAL,,,,,143.6,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,127.804,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,409337504,NDC,4,ML,150.36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,127.806,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Ecg 12 Lead, Tracing Only",PX93005,CDM,730,RC,93005,CPT,,,,,,,,298,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,127.842,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.44,292.04
dexmedeTOMIDine in  dextrose 200MCG/50ML -5% Solution 50 mL Flex Cont,25000000,CDM,250,RC,,,,,,44567060224,NDC,50,ML,258.31,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,127.86345,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Assay Carbamazepine Total,PX80156,CDM,300,RC,80156,CPT,,,,,,,,145,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,127.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.36,142.1
"Calculus, Infrared Spec - Ref",PX8236590,CDM,300,RC,82365,CPT,90,,,,,,,145,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,127.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.83,142.1
"Catecholamines, Fraction - Ref",PX8238490,CDM,300,RC,82384,CPT,90,,,,,,,145,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,127.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.15,142.1
Hsv Dna Amp Probe,PX87529,CDM,300,RC,87529,CPT,,,,,,,,145,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,127.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,142.1
Immunofixation Electrophoresis; Serum,PX86334,CDM,300,RC,86334,CPT,,,,,,,,145,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,127.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.48,142.1
LEGGING COMPRESSION JUXTALITE LONG LG 33CM,120.369,CDM,271,RC,A6545,HCPCS,,10840-MAIN,LOCAL,,,,,145,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,127.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.233,142.1
"Pare/Cut Hyperkeratotic Skin Lesion, Single",PX11055F,CDM,510,RC,11055,CPT,,,,,,,,145,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,127.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.233,174.9
Surgical Cleansing of Skin,PX11000P,CDM,983,RC,11000,CPT,,,,,,,,145,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,127.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.233,548.67
Wheelchair Mngement Training,PX97542,CDM,420,RC,97542,CPT,,,,,,,,145,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,127.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.59,142.1
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004725,NDC,2,ML,131.52,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,128.008416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
Lvl 2 Sub Hosp Mod Mdm or 35 Minute,PX99232,CDM,982,RC,99232,CPT,,,,,,,,253,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,128.018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.0962,246.2449
MESH FLAT SHEET SOFT 3X6 INCH,C1781,CDM,278,RC,C1781,HCPCS,,11773-MAIN,LOCAL,,,,,253,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,128.018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Subsequent Observation Care,PX99225,CDM,982,RC,99225,CPT,,,,,,,,253,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,128.018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.0962,246.2449
Tap Block Unilateral by Injection(S),PX64486F,CDM,510,RC,64486,CPT,,,,,,,,253,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,128.018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.0962,247.94
hydrocortisone sodium succinate (preservative free) 500 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001612,NDC,1,EA,298.53,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,128.06937,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
fluorouracil 5 GM/100ML Solution 100 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,16729027638,NDC,100,ML,261.44,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,128.1056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,256.2112
fluorouracil 5 GM/100ML Solution 100 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,16729027638,NDC,100,ML,261.44,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,128.1056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,256.2112
fluorouracil 5 GM/100ML Solution 100 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,16729027638,NDC,100,ML,261.44,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,128.1056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,256.2112
Hepatitis C Antibody,PX86803,CDM,300,RC,86803,CPT,,,,,,,,144,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,128.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.08,141.12
Xray Shoulder 1 Vw,PX7302001,CDM,320,RC,73020,CPT,TC,,,,,,,267,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,128.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,261.66
Xray Shoulder 1 Vw,PX7302001,CDM,320,RC,73020,CPT,TC,,,,,,,267,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,128.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,261.66
MINIBUNION LOCKING SCREW 3.0X24MM,C1713,CDM,278,RC,C1713,HCPCS,,11671-MAIN,LOCAL,,,,,308.55,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,128.17167,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,51672131200,NDC,22,GR,140.7,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,128.1777,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Acth - Ref,PX8202490,CDM,300,RC,82024,CPT,90,,,,,,,259,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,128.205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.41,253.82
"IV Push, Single/1st Drug",PX96374,CDM,260,RC,96374,CPT,,,,,,,,259,,Humana Choice Care,All Medicare plans,outpatient,49.5,,115.0653333,percent of total billed charges,128.205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.5886,253.82
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915801,NDC,1,ML,267.19,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,128.2512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915801,NDC,1,ML,267.19,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,128.2512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034F,CDM,510,RC,12034,CPT,,,,,,,,931,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,128.27,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.27,696.64
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034P,CDM,983,RC,12034,CPT,,,,,,,,1533,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,128.27,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.27,1502.34
Exc Skin Benig <5mm Remaindr Body,PX11420P,CDM,983,RC,11420,CPT,,,,,,,,299,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,128.271,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,124.2046,1416.38
Drain/Inject Med Joint/Brusa W/US Guide,PX20606P,CDM,983,RC,20606,CPT,,,,,,,,309,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,128.3586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.3586,604.15
LINNEAR CUTTER STAPLE RELOAD GST BLUE 60MM,27200000,CDM,272,RC,,,,12068-MAIN,LOCAL,,,,,309,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,128.3586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LINNEAR CUTTER STAPLE RELOAD GST GREEN 60MM,27200000,CDM,272,RC,,,,12069-MAIN,LOCAL,,,,,309,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,128.3586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LINNEAR CUTTER STAPLE RELOAD GST WHITE 60MM,27200000,CDM,272,RC,,,,12067-MAIN,LOCAL,,,,,309,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,128.3586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Naso/Orogastric Tube,PX43752P,CDM,983,RC,43752,CPT,,,,,,,,309,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,128.3586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.3586,348.08
ciprofloxacin 0.3 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,61314065625,NDC,2.5,ML,140.92,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,128.37812,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Noninvasv Oxygen Satur;Single,PX94760,CDM,460,RC,94760,CPT,,,,,,,,131,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,128.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.4174,128.38
Tap Block Bilateral by Injection(S),PX64488P,CDM,983,RC,64488,CPT,,,,,,,,262,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,128.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.8348,255.0046
Tap Block Bilateral by Injection(S),PX64488P,CDM,983,RC,64488,CPT,,,,,,,,262,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,128.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.8348,255.0046
Tap Block Bilateral by Injection(S),PX64488P,CDM,983,RC,64488,CPT,,,,,,,,262,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,128.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.8348,255.0046
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,69315030615,NDC,15,GR,131.07,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,128.4486,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Aspergillus Ag - Ref,PX8730590,CDM,300,RC,87305,CPT,90,,,,,,,141,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,128.451,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,138.18
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081543,NDC,1,ML,479.89,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,128.46,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.83,197.744
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081552,NDC,1,ML,479.89,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,128.46,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.83,197.744
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,338035702,NDC,250,ML,309.28,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,128.474912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.4701,303.0944
Apply of Paste Boot,PX29580F,CDM,510,RC,29580,CPT,,,,,,,,132,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,128.4756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,137.65
Assay Dipropylacetic Acid,PX80164,CDM,300,RC,80164,CPT,,,,,,,,132,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,128.4756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.41,129.36
Assay of Lipase,PX83690,CDM,300,RC,83690,CPT,,,,,,,,132,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,74.44074074,percent of total billed charges,128.4756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.32,129.36
"Remv F.B.,Eye,Superf Conjunc",PX65205F,CDM,510,RC,65205,CPT,,,,,,,,132,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,128.4756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,129.36
"Remv F.B.,Eye,Superf Conjunc",PX65205P,CDM,983,RC,65205,CPT,,,,,,,,132,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,128.4756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,128.4756
"Venipunc Need Phys Skill,Dx or Rx",PX36410,CDM,983,RC,36410,CPT,,,,,,,,132,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,25.72625,percent of total billed charges,128.4756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,128.4756
atropine 1 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,60219174903,NDC,5,ML,299.49,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,128.48121,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Thyrstim Immun Glob (Tsi) - Ref,PX8444590,CDM,300,RC,84445,CPT,90,,,,,,,254,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,128.524,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.63,248.92
ePHEDrine sulfate 50 MG/ML Solution 1 mL Ampule,25000000,CDM,250,RC,,,,,,17478041510,NDC,1,ML,262.31,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,128.5319,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ePHEDrine sulfate 50 MG/ML Solution 1 mL Ampule,25000000,CDM,250,RC,,,,,,17478041510,NDC,1,ML,262.31,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,128.5319,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ePHEDrine sulfate 50 MG/ML Solution 1 mL Ampule,25000000,CDM,250,RC,,,,,,17478041510,NDC,1,ML,262.31,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,128.5319,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tropicamide 1 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,61314035502,NDC,15,ML,267.96,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,128.6208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tropicamide 1 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,61314035502,NDC,15,ML,267.96,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,128.6208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ARIPiprazole 2 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714014101,NDC,1,EA,151.35,,First Health,Commercial,both,85,,999999999,percent of total billed charges,128.6475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,55150012150,NDC,1,EA,151.41,,First Health,Commercial,both,85,,999999999,percent of total billed charges,128.6985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
Blood Clot Factor V Test,PX85220,CDM,300,RC,85220,CPT,,,,,,,,260,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,128.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.18,254.8
"Closed Rx Toe Fx,Manipulatn",PX28515P,CDM,983,RC,28515,CPT,,,,,,,,260,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,128.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.004,253.058
First Hour IV Hydration <1 Hour,PX96360,CDM,260,RC,96360,CPT,,,,,,,,260,,Humana Choice Care,All Medicare plans,outpatient,49.5,,84.93333333,percent of total billed charges,128.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.004,254.8
iohexol 300 MG/ML Solution 150 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141365,NDC,150,ML,300,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,128.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,294
"Spinal Punc,Drain,Theraputic",PX62272P,CDM,983,RC,62272,CPT,,,,,,,,300,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,128.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,124.62,604.15
US Follicles-Limited Tc,PX7685701,CDM,402,RC,76857,CPT,TC,,,,,,,300,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,128.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,294
procainamide 500 MG/ML Solution 2 mL Vial,J2690.01,CDM,636,RC,J2690,HCPCS,,,,14789090002,NDC,2,ML,377.75,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,128.75,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.75,187.2
Exc Skn Bngn1.1-2cm Remain Bdy,PX11422P,CDM,983,RC,11422,CPT,,,,,,,,822,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,128.7611,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.95,805.56
Fac/Exc Skn Bngn1.1-2cm Remain Bdy,PX11422F,CDM,510,RC,11422,CPT,,,,,,,,618,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,128.7611,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.95,374.26
Inc/Drain Peritonsil Abscess,PX42700F,CDM,510,RC,42700,CPT,,,,,,,,624,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,128.7611,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.38,402.63
Inc/Drain Peritonsil Abscess,PX42700P,CDM,983,RC,42700,CPT,,,,,,,,889,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,128.7611,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.38,871.22
Islet Cell Antibody - Ref,PX8634190,CDM,300,RC,86341,CPT,90,,,,,,,146,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,128.772,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.61,143.08
"Drain Finger Abscess,Simple",PX26010F,CDM,510,RC,26010,CPT,,,,,,,,310,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,128.774,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.774,303.8
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042350,NDC,0.5,ML,132.37,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,128.835721,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.49,129.7226
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042388,NDC,0.5,ML,132.37,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,128.835721,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.49,129.7226
"X-Ray Exam Hip,Unilat W/Pelvis 1vw",PX7350101,CDM,320,RC,73501,CPT,TC,,,,,,,263,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,128.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,257.74
"X-Ray Exam Hip,Unilat W/Pelvis 1vw",PX7350101,CDM,320,RC,73501,CPT,TC,,,,,,,263,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,128.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,257.74
"X-Ray Exam Hip,Unilat W/Pelvis 1vw",PX7350101,CDM,320,RC,73501,CPT,TC,,,,,,,263,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,128.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,257.74
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004725,NDC,2,ML,131.52,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,128.8896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800F,CDM,510,RC,40800,CPT,,,,,,,,255,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,129.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.927,614.65
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106F,CDM,510,RC,11106,CPT,,,,,,,,255,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,129.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.927,548.67
"Inject Nerv Blck,Trigeminal",PX64400F,CDM,510,RC,64400,CPT,,,,,,,,255,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,129.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.927,258.75
"Urinalysis, Auto, W/Scope",PX81001,CDM,300,RC,81001,CPT,,,,,,,,255,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,129.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.91,249.9
Assay Carbamazepine Total,PX80156,CDM,300,RC,80156,CPT,,,,,,,,145,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,129.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.36,142.1
"Calculus, Infrared Spec - Ref",PX8236590,CDM,300,RC,82365,CPT,90,,,,,,,145,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,129.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.83,142.1
"Catecholamines, Fraction - Ref",PX8238490,CDM,300,RC,82384,CPT,90,,,,,,,145,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,129.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.15,142.1
Hsv Dna Amp Probe,PX87529,CDM,300,RC,87529,CPT,,,,,,,,145,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,129.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,142.1
Immunofixation Electrophoresis; Serum,PX86334,CDM,300,RC,86334,CPT,,,,,,,,145,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,129.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.48,142.1
LEGGING COMPRESSION JUXTALITE LONG LG 33CM,120.369,CDM,271,RC,A6545,HCPCS,,10840-MAIN,LOCAL,,,,,145,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,129.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.233,142.1
"Pare/Cut Hyperkeratotic Skin Lesion, Single",PX11055F,CDM,510,RC,11055,CPT,,,,,,,,145,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,129.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.233,174.9
Surgical Cleansing of Skin,PX11000P,CDM,983,RC,11000,CPT,,,,,,,,145,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,129.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.233,548.67
Wheelchair Mngement Training,PX97542,CDM,420,RC,97542,CPT,,,,,,,,145,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,129.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.59,142.1
sodium phosphate 15 MMOLE/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323088401,NDC,5,ML,132.6,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,129.05958,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium phosphate 15 MMOLE/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323088406,NDC,5,ML,132.6,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,129.05958,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
PACLitaxel 150 MG/25ML Concentrate 25 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321701,NDC,25,ML,300.96,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,129.11184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
NEEDLE INTRAOSSEOUS 15GA 15MM EZ-IO PEDS 9018,120.89,CDM,272,RC,A4215,HCPCS,,4964-MAIN,LOCAL,,,,,269,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,129.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.7426,263.62
NEEDLE INTRAOSSEOUS 15GA 15MM EZ-IO PEDS 9018,120.89,CDM,272,RC,A4215,HCPCS,,4964-MAIN,LOCAL,,,,,269,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,129.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.7426,263.62
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122P,CDM,983,RC,13122,CPT,,,,,,,,301,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,129.129,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.0354,292.9633
Xray Facial Bones Less Than 3 Vws,PX7014001,CDM,320,RC,70140,CPT,TC,,,,,,,301,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,129.129,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,294.98
Acellular Derm Matrix Implt,PX15777F,CDM,510,RC,15777,CPT,,,,,,,,650,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,129.14,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,129.14,440.68
Acellular Derm Matrix Implt,PX15777F,CDM,510,RC,15777,CPT,,,,,,,,650,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,129.14,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,129.14,440.68
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156F,CDM,370,RC,99156,CPT,,,,,,,,325,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,129.14,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.02,129.14
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156F,CDM,370,RC,99156,CPT,,,,,,,,325,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,129.14,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.02,129.14
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156P,CDM,983,RC,99156,CPT,,,,,,,,325,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,129.14,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.02,318.5
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156P,CDM,983,RC,99156,CPT,,,,,,,,325,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,129.14,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.02,318.5
sodium zirconium cyclosilicate 5 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,310110501,NDC,1,EA,151.95,,First Health,Commercial,both,85,,999999999,percent of total billed charges,129.1575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Apply Lower Leg Splint,PX29515P,CDM,983,RC,29515,CPT,,,,,,,,311,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,129.1894,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,129.1894,302.6963
Repr Superf Wnd Body <2.5cm,PX12001F,CDM,510,RC,12001,CPT,,,,,,,,311,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,129.1894,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,129.1894,304.78
Xray Skull Less Than 4 Vws,PX7025001,CDM,320,RC,70250,CPT,TC,,,,,,,311,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,129.1894,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,304.78
"Antipsychotics, Not Otherwise Specified; 1-3 - Ref",PX8034290,CDM,300,RC,80342,CPT,90,,,,,,,152,,First Health,Commercial,both,85,,999999999,percent of total billed charges,129.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.1408,148.96
Body Fluid Cell Count,PX89050,CDM,300,RC,89050,CPT,,,,,,,,152,,First Health,Commercial,both,85,,999999999,percent of total billed charges,129.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.33,148.96
morphine 20 mg/mL Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,54040444,NDC,30,ML,141.88,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,129.25268,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CARBOplatin 600 MG/60ML Solution 60 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703423981,NDC,60,ML,301.42,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,129.30918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.778704,295.3916
atropine 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,17478021502,NDC,2,ML,269.45,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,129.336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
atropine 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,17478021502,NDC,2,ML,269.45,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,129.336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
atropine 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,60219174802,NDC,2,ML,269.45,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,129.336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
atropine 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,60219174802,NDC,2,ML,269.45,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,129.336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Apply of Paste Boot,PX29580F,CDM,510,RC,29580,CPT,,,,,,,,132,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,129.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,137.65
Assay Dipropylacetic Acid,PX80164,CDM,300,RC,80164,CPT,,,,,,,,132,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,129.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.41,129.36
Assay of Lipase,PX83690,CDM,300,RC,83690,CPT,,,,,,,,132,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,129.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.32,129.36
Inj Tendon/Ligament/Cyst,PX20550P,CDM,983,RC,20550,CPT,,,,,,,,264,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,129.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.6656,258.75
Inj Tendon/Ligament/Cyst,PX20550P,CDM,983,RC,20550,CPT,,,,,,,,264,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,129.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.6656,258.75
Inj Tendon/Ligament/Cyst,PX20550P,CDM,983,RC,20550,CPT,,,,,,,,264,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,129.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.6656,258.75
Occupational Therapy Eval Mod Complex,PX97166,CDM,434,RC,97166,CPT,,,,,,,,264,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,216,percent of total billed charges,129.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,258.72
Occupational Therapy Eval Mod Complex,PX97166,CDM,434,RC,97166,CPT,,,,,,,,264,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,129.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,258.72
Occupational Therapy Eval Mod Complex,PX97166,CDM,434,RC,97166,CPT,,,,,,,,264,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,129.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,258.72
Physical Therapy Evaluation Mod Complex,PX97162,CDM,424,RC,97162,CPT,,,,,,,,264,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,63.72565217,percent of total billed charges,129.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,258.72
Physical Therapy Evaluation Mod Complex,PX97162,CDM,424,RC,97162,CPT,,,,,,,,264,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,129.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,258.72
Physical Therapy Evaluation Mod Complex,PX97162,CDM,424,RC,97162,CPT,,,,,,,,264,,United Healthcare,All Medicare advantage plans,outpatient,49,,139.92,percent of total billed charges,129.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,258.72
"Remv F.B.,Eye,Superf Conjunc",PX65205F,CDM,510,RC,65205,CPT,,,,,,,,132,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,129.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,129.36
"Remv F.B.,Eye,Superf Conjunc",PX65205P,CDM,983,RC,65205,CPT,,,,,,,,132,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,129.36,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.1,129.36
Renal Function Panel,PX80069,CDM,300,RC,80069,CPT,,,,,,,,264,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,129.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.96,258.72
Renal Function Panel,PX80069,CDM,300,RC,80069,CPT,,,,,,,,264,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,129.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.96,258.72
Renal Function Panel,PX80069,CDM,300,RC,80069,CPT,,,,,,,,264,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,129.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.96,258.72
"Venipunc Need Phys Skill,Dx or Rx",PX36410,CDM,983,RC,36410,CPT,,,,,,,,132,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,129.36,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.45,129.36
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034F,CDM,510,RC,12034,CPT,,,,,,,,931,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,129.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.27,696.64
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034F,CDM,510,RC,12034,CPT,,,,,,,,931,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,129.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.27,696.64
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034P,CDM,983,RC,12034,CPT,,,,,,,,1533,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,129.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.27,1502.34
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034P,CDM,983,RC,12034,CPT,,,,,,,,1533,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,129.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.27,1502.34
Apply Multlay Comprs Lwr Leg,PX29581P,CDM,983,RC,29581,CPT,,,,,,,,142,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,129.362,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,138.2086
"Biopsy Vulva/Perineum,One Lesn",PX56605P,CDM,983,RC,56605,CPT,,,,,,,,142,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,129.362,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,702.31
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006P,CDM,983,RC,10006,CPT,,,,,,,,142,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,129.362,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,138.2086
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760,CDM,420,RC,97760,CPT,,,,,,,,142,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,129.362,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.18,139.16
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760F,CDM,510,RC,97760,CPT,,,,,,,,142,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,129.362,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.18,139.16
Oximetry;Mult Determine,PX610,CDM,460,RC,94761,CPT,,,,,,,,142,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,129.362,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,139.16
Thromboplastin Time Partial,PX85730,CDM,300,RC,85730,CPT,,,,,,,,142,,Medica,Commercial,both,91.1,,60.21,percent of total billed charges,129.362,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.51,139.16
X-Ray Exam Femur 1 Vw,PX7355101,CDM,320,RC,73551,CPT,TC,,,,,,,142,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,129.362,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,139.16
Injection for Nerve Block,PX64447F,CDM,510,RC,64447,CPT,,,,,,,,3023,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,129.37,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.05,240.75
Injection for Nerve Block,PX64447P,CDM,983,RC,64447,CPT,,,,,,,,3892,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,129.37,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.05,3814.16
Insert Simple Cath Foley,PX51702F,CDM,510,RC,51702,CPT,,,,,,,,198,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,129.37,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.27,129.37
fluorouracil 5 GM/100ML Solution 100 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,16729027638,NDC,100,ML,261.44,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,129.4128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,256.2112
DOBUTamine 1000 mcg/mL in dextrose 5% 250 mL premix 1000 mcg/ml Solution 250 mL Flex Cont,J1250.01,CDM,636,RC,J1250,HCPCS,,,,338107302,NDC,250,ML,146.73,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,129.41586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.951642,143.7954
"Cardiolipin Ab, Ea Lg - Ref",PX8614790,CDM,300,RC,86147,CPT,90,,,,,,,133,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,51.6425,percent of total billed charges,129.4489,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.34,130.34
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU0003,CDM,300,RC,U0003,HCPCS,,,,,,,,133,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,129.4489,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.2482,130.34
Lvl 1 Sub Hosp Low Mdm or 25 Minutes,PX99231,CDM,982,RC,99231,CPT,,,,,,,,133,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,129.4489,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.2482,129.4489
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,409662902,NDC,10,ML,146.84,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,129.51288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.236966,143.9032
"Office/Outpt Visit,Est,Levl IV",PX99214F,CDM,510,RC,99214,CPT,,,,,,,,256,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,129.536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.3424,250.88
"Office/Outpt Visit,Est,Levl IV",PX99214P,CDM,983,RC,99214,CPT,,,,,,,,256,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,129.536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.3424,249.1648
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133P,CDM,983,RC,13133,CPT,,,,,,,,256,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,129.536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.3424,249.1648
methylergonovine 0.2 MG/ML Solution 1 mL Ampule,J2210.01,CDM,636,RC,J2210,HCPCS,,,,51991014417,NDC,1,ML,133.11,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,129.555963,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.293894,130.4478
"Destruct Benign Lesion, 1-14",PX17110F,CDM,510,RC,17110,CPT,,,,,,,,302,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,129.558,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.4508,295.96
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,781375575,NDC,4,ML,142.22,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,129.56242,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Acellular Derm Matrix Implt,PX15777F,CDM,510,RC,15777,CPT,,,,,,,,650,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,129.58,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,129.14,440.68
"Closed Rx Radial Head Disloc,Child",PX24640F,CDM,510,RC,24640,CPT,,,,,,,,270,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,129.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.158,264.6
"Closed Rx Radial Head Disloc,Child",PX24640F,CDM,510,RC,24640,CPT,,,,,,,,270,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,129.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.158,264.6
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157F,CDM,370,RC,99157,CPT,,,,,,,,270,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,129.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.158,264.6
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157F,CDM,370,RC,99157,CPT,,,,,,,,270,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,129.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.158,264.6
Wound Culture Anaerobic,PX87075,CDM,300,RC,87075,CPT,,,,,,,,270,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,129.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.68,264.6
Wound Culture Anaerobic,PX87075,CDM,300,RC,87075,CPT,,,,,,,,270,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,129.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.68,264.6
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059900,NDC,1,ML,133.16,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,129.604628,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.54253,130.4968
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059902,NDC,1,ML,133.16,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,129.604628,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.54253,130.4968
Closed Rx Kneecap Dislocatn,PX27560P,CDM,983,RC,27560,CPT,,,,,,,,312,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,129.6048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,129.6048,303.6696
"Inpatient Consult, Level IV",PX99254,CDM,983,RC,99254,CPT,,,,,,,,508,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,129.6048,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.73,497.84
Amphetamines; 1 or 2 - Ref,PX8032490,CDM,300,RC,80324,CPT,90,,,,,,,147,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,129.654,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.0638,144.06
Assay Ph Body Fluids Nos,PX83986,CDM,300,RC,83986,CPT,,,,,,,,147,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,129.654,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.28,144.06
"Cmv Detect, Amplifi Probe - Ref",PX8749690,CDM,300,RC,87496,CPT,90,,,,,,,147,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,129.654,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,144.06
"Methlenedioxyamphetamines (Mda, Mdea, Mdma) - Ref",PX8035990,CDM,300,RC,80359,CPT,90,,,,,,,147,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,129.654,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.0638,144.06
Ph Venous Blood,PX82800,CDM,300,RC,82800,CPT,,,,,,,,147,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,129.654,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.09,144.06
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315606,NDC,100,ML,264.64,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.5304,percent of total billed charges,129.6736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.931456,259.3472
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315606,NDC,100,ML,264.64,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,129.6736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.931456,259.3472
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315606,NDC,100,ML,264.64,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,129.6736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.931456,259.3472
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315695,NDC,100,ML,264.64,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.5304,percent of total billed charges,129.6736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.931456,259.3472
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315695,NDC,100,ML,264.64,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,129.6736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.931456,259.3472
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315695,NDC,100,ML,264.64,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,129.6736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.931456,259.3472
Tap Block Bilateral by Injection(S),PX64488P,CDM,983,RC,64488,CPT,,,,,,,,262,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,129.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.8348,255.0046
"Echo Heart Xthoracic,Limited",PX9330801,CDM,480,RC,93308,CPT,TC,,,,,,,349,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,129.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.65,129.72
"Echo Heart Xthoracic,Limited",PX9330801,CDM,480,RC,93308,CPT,TC,,,,,,,349,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,129.72,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.65,129.72
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042350,NDC,0.5,ML,132.37,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,129.7226,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.49,129.7226
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042388,NDC,0.5,ML,132.37,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,129.7226,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.49,129.7226
sincalide 5 MCG Recon Soln 1 Each Vial,J2805.01,CDM,636,RC,J2805,HCPCS,,,,270055615,NDC,1,EA,250,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,129.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,117.12,133.1
sincalide 5 MCG Recon Soln 1 Each Vial,J2805.01,CDM,636,RC,J2805,HCPCS,,,,270055615,NDC,1,EA,250,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,129.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,117.12,133.1
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062430,NDC,0.3,ML,147.12,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,129.75984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801301,NDC,0.3,ML,147.12,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,129.75984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801310,NDC,0.3,ML,147.12,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,129.75984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
"Office/Outpt Visit,New,Levl II",PX99202F,CDM,510,RC,99202,CPT,,,,,,,,123,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,129.77,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.89,129.77
"Office/Outpt Visit,New,Levl II",PX99202P,CDM,983,RC,99202,CPT,,,,,,,,123,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,129.77,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.89,129.77
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127303,NDC,2,ML,152.7,,First Health,Commercial,both,85,,999999999,percent of total billed charges,129.795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.43158,173.019
ePHEDrine sulfate 50 MG/ML Solution 1 mL Ampule,25000000,CDM,250,RC,,,,,,17478041510,NDC,1,ML,262.31,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,129.84345,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Haptoglobin; Quantitative,PX83010,CDM,300,RC,83010,CPT,,,,,,,,265,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,129.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.53,259.7
Haptoglobin; Quantitative,PX83010,CDM,300,RC,83010,CPT,,,,,,,,265,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,129.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.53,259.7
Haptoglobin; Quantitative,PX83010,CDM,300,RC,83010,CPT,,,,,,,,265,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,129.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.53,259.7
ID Nucleic Acid Sequencing - Ref,PX8715390,CDM,300,RC,87153,CPT,90,,,,,,,265,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,129.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.77,259.7
ID Nucleic Acid Sequencing - Ref,PX8715390,CDM,300,RC,87153,CPT,90,,,,,,,265,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,129.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.77,259.7
ID Nucleic Acid Sequencing - Ref,PX8715390,CDM,300,RC,87153,CPT,90,,,,,,,265,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,129.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.77,259.7
lidocaine - transparent dressing 4 % Kit 1 Each Box,63700001,CDM,250,RC,,,,,,496088207,NDC,1,EA,270.63,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,129.9024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine - transparent dressing 4 % Kit 1 Each Box,63700001,CDM,250,RC,,,,,,496088207,NDC,1,EA,270.63,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,129.9024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ammonium lactate 12 % Cream 385 g Tube,63700001,CDM,250,RC,,,,,,45802049326,NDC,385,GR,256.76,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,129.92056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Islet Cell Antibody - Ref,PX8634190,CDM,300,RC,86341,CPT,90,,,,,,,146,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,129.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.61,143.08
sodium phosphate 15 MMOLE/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323088401,NDC,5,ML,132.6,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,129.948,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium phosphate 15 MMOLE/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323088406,NDC,5,ML,132.6,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,129.948,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,55150043801,NDC,20,ML,152.9,,First Health,Commercial,both,85,,999999999,percent of total billed charges,129.965,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457018120,NDC,20,ML,152.9,,First Health,Commercial,both,85,,999999999,percent of total billed charges,129.965,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
"Destruct Benign Lesion, 15+",PX17111F,CDM,510,RC,17111,CPT,,,,,,,,303,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,129.987,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.8662,296.94
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607P,CDM,983,RC,97607,CPT,,,,,,,,303,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,129.987,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.8662,348.35
Strapping of Knee,PX29530F,CDM,420,RC,29530,CPT,,,,,,,,303,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,129.987,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,296.94
Xray Knee 1 or 2 Vws,PX7356001,CDM,320,RC,73560,CPT,TC,,,,,,,303,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,129.987,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,296.94
ipratropium 0.03 % Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,24208039830,NDC,30,ML,256.9,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,129.9914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfacetamide 10 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,24208067004,NDC,15,ML,312.96,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,130.003584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
MRI Brain W Contrast Tc,PX7055201,CDM,610,RC,70552,CPT,TC,,,,,,,2637,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,130.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.01,383.92
MRI Brain W Contrast Tc,PX7055201,CDM,610,RC,70552,CPT,TC,,,,,,,2637,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,130.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.01,383.92
MRI L Spine W Contrast Tc,PX7214901,CDM,610,RC,72149,CPT,TC,,,,,,,5136,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,130.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.01,383.92
MRI L Spine W Contrast Tc,PX7214901,CDM,610,RC,72149,CPT,TC,,,,,,,5136,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,130.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.01,383.92
Dress/Debrid Small Burn No Anes,PX16020F,CDM,510,RC,16020,CPT,,,,,,,,313,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,130.0202,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.0202,306.74
ELECTRODE ADULT PACING ONESTEP,120.214,CDM,272,RC,A4556,HCPCS,,10242-MAIN,LOCAL,,,,,153,,First Health,Commercial,both,85,,999999999,percent of total billed charges,130.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.5562,149.94
"Protein, Total; Other Source",PX84157,CDM,300,RC,84157,CPT,,,,,,,,153,,First Health,Commercial,both,85,,999999999,percent of total billed charges,130.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.67,149.94
Pulmonary Stress Test,PX94618,CDM,976,RC,94618,CPT,,,,,,,,153,,First Health,Commercial,both,85,,999999999,percent of total billed charges,130.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.5562,148.9149
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457018100,NDC,20,ML,153.01,,First Health,Commercial,both,85,,999999999,percent of total billed charges,130.0585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
Strapping of Ankle,PX29540F,CDM,420,RC,29540,CPT,,,,,,,,271,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,130.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.5734,265.58
Strapping of Ankle,PX29540F,CDM,420,RC,29540,CPT,,,,,,,,271,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,130.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.5734,265.58
"X-Ray Exam Hip,Unilat W/Pelvis 1vw",PX7350101,CDM,320,RC,73501,CPT,TC,,,,,,,263,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,130.185,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,257.74
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862066230,NDC,1,EA,153.17,,First Health,Commercial,both,85,,999999999,percent of total billed charges,130.1945,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
octreotide 200 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037805,NDC,1,ML,133.77,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,130.198341,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954201,NDC,10,ML,153.18,,First Health,Commercial,both,85,,999999999,percent of total billed charges,130.203,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.630972,150.1164
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954210,NDC,10,ML,153.18,,First Health,Commercial,both,85,,999999999,percent of total billed charges,130.203,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.630972,150.1164
"MRI,Lwrext,No Jnt, W/Cont",PX7371901,CDM,610,RC,73719,CPT,TC,,,,,,,3627,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,130.23,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.23,384.58
"MRI,Lwrext,No Jnt, W/Cont",PX7371901,CDM,610,RC,73719,CPT,TC,,,,,,,3627,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,130.23,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.23,384.58
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703334301,NDC,0.5,ML,142.98,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,130.25478,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963805,NDC,0.5,ML,142.98,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,130.25478,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
phytonadione 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714097302,NDC,0.5,EA,143.02,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,130.29122,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phytonadione 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,69238105103,NDC,0.5,EA,143.02,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,130.29122,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,63323072902,NDC,1,EA,265.95,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,130.3155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.47563,793.6922
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,63323072902,NDC,1,EA,265.95,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,130.3155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.47563,793.6922
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,63323072902,NDC,1,EA,265.95,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,130.3155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.47563,793.6922
"Cardiolipin Ab, Ea Lg - Ref",PX8614790,CDM,300,RC,86147,CPT,90,,,,,,,133,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,130.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.34,130.34
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU0003,CDM,300,RC,U0003,HCPCS,,,,,,,,133,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,130.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.2482,130.34
"Initial Observation Care,Levl I",PX99218,CDM,982,RC,99218,CPT,,,,,,,,266,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,130.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.4964,258.8978
"Initial Observation Care,Levl I",PX99218,CDM,982,RC,99218,CPT,,,,,,,,266,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,130.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.4964,258.8978
"Initial Observation Care,Levl I",PX99218,CDM,982,RC,99218,CPT,,,,,,,,266,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,130.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.4964,258.8978
Lvl 1 Sub Hosp Low Mdm or 25 Minutes,PX99231,CDM,982,RC,99231,CPT,,,,,,,,133,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,130.34,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.55,130.34
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597F,CDM,510,RC,97597,CPT,,,,,,,,266,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,53.2,percent of total billed charges,130.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.4964,260.68
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597F,CDM,510,RC,97597,CPT,,,,,,,,266,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,130.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.4964,260.68
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597F,CDM,510,RC,97597,CPT,,,,,,,,266,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,130.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.4964,260.68
nystatin 100000 UNIT/GM Cream 30 g Tube,25000000,CDM,250,RC,,,,,,168005430,NDC,30,GR,147.79,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,130.35078,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Ctrl Nosebleed,Anter,Complex",PX30903P,CDM,983,RC,30903,CPT,,,,,,,,304,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,130.416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,295.8832
Joint Survey Tc,PX7707701,CDM,320,RC,77077,CPT,TC,,,,,,,304,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,130.416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,297.92
Assay for Vancomycin,PX80202,CDM,300,RC,80202,CPT,,,,,,,,314,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,130.4356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.41,307.72
methylergonovine 0.2 MG/ML Solution 1 mL Ampule,J2210.01,CDM,636,RC,J2210,HCPCS,,,,51991014417,NDC,1,ML,133.11,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,130.4478,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.293894,130.4478
MRI Pelvis W/Contrast Tc,PX7219601,CDM,610,RC,72196,CPT,TC,,,,,,,3143,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,130.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.45,385.24
MRI Pelvis W/Contrast Tc,PX7219601,CDM,610,RC,72196,CPT,TC,,,,,,,3143,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,130.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.45,385.24
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,49884093547,NDC,100,GR,266.25,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,130.4625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,49884093547,NDC,100,GR,266.25,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,130.4625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,49884093547,NDC,100,GR,266.25,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,130.4625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409421505,NDC,5,ML,271.86,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,130.4928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409421505,NDC,5,ML,271.86,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,130.4928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059900,NDC,1,ML,133.16,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,130.4968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.54253,130.4968
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059902,NDC,1,ML,133.16,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,130.4968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.54253,130.4968
BLUE EYE SUBMUCOSAL LIFTING AGENT 5ML,27200000,CDM,272,RC,,,,12684-MAIN,LOCAL,,,,,148,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,130.536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Mumps,PX86735,CDM,300,RC,86735,CPT,,,,,,,,148,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,130.536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.97,145.04
US Guide Needle Bx S&I,PX7694226,CDM,982,RC,76942,CPT,26,,,,,,,148,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,130.536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.4792,144.0484
neomycin-polymyxin-gramicidin 1.75-10000-.025 Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,24208079062,NDC,10,ML,314.26,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,130.543604,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
methylPREDNISolone sod succ 1000 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9001820,NDC,1,EA,271.97,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,130.5456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
methylPREDNISolone sod succ 1000 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9001820,NDC,1,EA,271.97,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,130.5456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
"Needle Biopsy,Muscle",PX20206F,CDM,510,RC,20206,CPT,,,,,,,,258,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,130.548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.1732,1416.38
dexmedeTOMIDine in sodium chloride 200 MCG/50ML Solution 50 mL Flex Cont,25000000,CDM,250,RC,,,,,,338955524,NDC,50,ML,304.32,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,130.55328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
DOBUTamine 1000 mcg/mL in dextrose 5% 250 mL premix 1000 mcg/ml Solution 250 mL Flex Cont,J1250.01,CDM,636,RC,J1250,HCPCS,,,,338107302,NDC,250,ML,146.73,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,130.5897,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.951642,143.7954
MRI Brain WO Contrast Tc,PX7055101,CDM,610,RC,70551,CPT,TC,,,,,,,3335,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,130.6508,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.34,260.99
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Plas Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,338604648,NDC,100,ML,143.42,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,130.65562,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.786918,140.5516
Inj Tendon/Ligament/Cyst,PX20550P,CDM,983,RC,20550,CPT,,,,,,,,264,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,130.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.6656,258.75
Occupational Therapy Eval Mod Complex,PX97166,CDM,434,RC,97166,CPT,,,,,,,,264,,Humana Choice Care,All Medicare plans,outpatient,49.5,,111.25,percent of total billed charges,130.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,258.72
Physical Therapy Evaluation Mod Complex,PX97162,CDM,424,RC,97162,CPT,,,,,,,,264,,Humana Choice Care,All Medicare plans,outpatient,49.5,,109.565,percent of total billed charges,130.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,258.72
Renal Function Panel,PX80069,CDM,300,RC,80069,CPT,,,,,,,,264,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,130.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.96,258.72
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,409662902,NDC,10,ML,146.84,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,130.6876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.236966,143.9032
dexmedeTOMIDine in  dextrose 200MCG/50ML -5% Solution 50 mL Flex Cont,25000000,CDM,250,RC,,,,,,44567060224,NDC,50,ML,258.31,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,130.70486,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Apply Forearm Cast,PX29075F,CDM,510,RC,29075,CPT,,,,,,,,210,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,130.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.83,186.09
Apply Forearm Cast,PX29075P,CDM,983,RC,29075,CPT,,,,,,,,140,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,130.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.83,186.09
"Infectious Disease (Viral Respiratory Tract Infection),",PX0241U,CDM,300,RC,0241U,HCPCS,,,,,,,,457,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,130.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.78,447.86
Resp Virus 3-5 Targets,PX87631,CDM,300,RC,87631,CPT,,,,,,,,459,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,130.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.78,449.82
nystatin 100000 UNIT/GM Cream 30 g Tube,25000000,CDM,250,RC,,,,,,51672128902,NDC,30,GR,148.29,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,130.79178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494300,NDC,0.5,ML,419.23,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,130.79884,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,117.45,133.47
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494301,NDC,0.5,ML,419.2,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,130.79884,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,117.45,133.47
ENDOLOOP COATED VICRYL 0 18,27200000,CDM,272,RC,,,,10228-MAIN,LOCAL,,,,,143.6,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,130.8196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Xray Shoulder 1 Vw,PX7302001,CDM,320,RC,73020,CPT,TC,,,,,,,267,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,130.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,261.66
Xray Shoulder 1 Vw,PX7302001,CDM,320,RC,73020,CPT,TC,,,,,,,267,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,130.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,261.66
Xray Shoulder 1 Vw,PX7302001,CDM,320,RC,73020,CPT,TC,,,,,,,267,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,130.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,261.66
Amphetamines; 1 or 2 - Ref,PX8032490,CDM,300,RC,80324,CPT,90,,,,,,,147,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,130.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.0638,144.06
Assay Ph Body Fluids Nos,PX83986,CDM,300,RC,83986,CPT,,,,,,,,147,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,130.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.28,144.06
"Cmv Detect, Amplifi Probe - Ref",PX8749690,CDM,300,RC,87496,CPT,90,,,,,,,147,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,130.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,144.06
"Methlenedioxyamphetamines (Mda, Mdea, Mdma) - Ref",PX8035990,CDM,300,RC,80359,CPT,90,,,,,,,147,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,130.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.0638,144.06
Ph Venous Blood,PX82800,CDM,300,RC,82800,CPT,,,,,,,,147,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,130.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.09,144.06
"Bone Marrow Aspiration(S),Diag",PX38220F,CDM,510,RC,38220,CPT,,,,,,,,305,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,130.845,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,126.697,1416.38
Assay Iga/Igd/Igg/Igm Each,PX82784,CDM,300,RC,82784,CPT,,,,,,,,315,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,130.851,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.53,308.7
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,63323050830,NDC,1,EA,134.48,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,130.889384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.461584,189.875
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623F,CDM,510,RC,11623,CPT,,,,,,,,690,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,130.89,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.89,616.39
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623P,CDM,983,RC,11623,CPT,,,,,,,,460,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,130.89,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.89,616.39
Glycosylated Hemoglobin Test,PX83036,CDM,300,RC,83036,CPT,,,,,,,,110,,Blue Cross Blue Shield of MN,All commercial plans,both,,,91.69333333,fee schedule,130.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.9,130.9
PROSTEP 0.9MM ANTI SKIVE PIN,27200000,CDM,272,RC,,,,12950-MAIN,LOCAL,,,,,154,,First Health,Commercial,both,85,,999999999,percent of total billed charges,130.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PROSTEP 1.4MM ANTI SKIVE PIN,27200000,CDM,272,RC,,,,12949-MAIN,LOCAL,,,,,154,,First Health,Commercial,both,85,,999999999,percent of total billed charges,130.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Vit D 1 25-Dihydroxy,PX82652,CDM,300,RC,82652,CPT,,,,,,,,154,,First Health,Commercial,both,85,,999999999,percent of total billed charges,130.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.3,150.92
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915801,NDC,1,ML,267.19,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,130.9231,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915801,NDC,1,ML,267.19,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,130.9231,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915801,NDC,1,ML,267.19,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,130.9231,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062430,NDC,0.3,ML,147.12,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,130.9368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801301,NDC,0.3,ML,147.12,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,130.9368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801310,NDC,0.3,ML,147.12,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,130.9368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315606,NDC,100,ML,264.64,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,130.9968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.931456,259.3472
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315695,NDC,100,ML,264.64,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,130.9968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.931456,259.3472
Acth - Ref,PX8202490,CDM,300,RC,82024,CPT,90,,,,,,,259,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,131.054,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.41,253.82
"IV Push, Single/1st Drug",PX96374,CDM,260,RC,96374,CPT,,,,,,,,259,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,131.054,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.5886,253.82
octreotide 200 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037805,NDC,1,ML,133.77,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,131.0946,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
MRI Brain W Contrast Tc,PX7055201,CDM,610,RC,70552,CPT,TC,,,,,,,2637,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,131.1,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.01,383.92
"MRI,Lwrext,No Jnt, W/Cont",PX7371901,CDM,610,RC,73719,CPT,TC,,,,,,,3627,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,131.1,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.23,384.58
Haptoglobin; Quantitative,PX83010,CDM,300,RC,83010,CPT,,,,,,,,265,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,131.175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.53,259.7
ID Nucleic Acid Sequencing - Ref,PX8715390,CDM,300,RC,87153,CPT,90,,,,,,,265,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,131.175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.77,259.7
Hepatitis C Antibody,PX86803,CDM,300,RC,86803,CPT,,,,,,,,144,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,131.184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.08,141.12
Cast/Strap Procedure Unlisted,PX29799F,CDM,510,RC,29799,CPT,,,,,,,,316,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,131.2664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,131.2664,309.68
Xray Thoracolumbar 2 Vws,PX7208001,CDM,320,RC,72080,CPT,TC,,,,,,,306,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,131.274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,299.88
MRI Abdomen W/O Tc,PX7418101,CDM,610,RC,74181,CPT,TC,,,,,,,2655,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,131.2944,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.78,262.3
tropicamide 1 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,61314035502,NDC,15,ML,267.96,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,131.3004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tropicamide 1 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,61314035502,NDC,15,ML,267.96,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,131.3004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tropicamide 1 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,61314035502,NDC,15,ML,267.96,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,131.3004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
MRI L Spine W Contrast Tc,PX7214901,CDM,610,RC,72149,CPT,TC,,,,,,,5136,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,131.32,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.01,383.92
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234010,NDC,5,ML,306.2,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,131.3598,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234025,NDC,5,ML,306.2,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,131.3598,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234099,NDC,5,ML,306.2,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,131.3598,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
"Morphometric Analysis,Tumor Immunohistochemistry, Ea Antibody Manual , Tech",PX8836001,CDM,310,RC,88360,CPT,TC,,,,,,,119,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,131.36,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.23,131.36
"Morphometric Analysis,Tumor Immunohistochemistry, Ea Antibody Manual , Tech",PX8836001,CDM,310,RC,88360,CPT,TC,,,,,,,119,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,131.36,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.23,131.36
"Cognitive Funct Ther Interv, per Day",PX97127,CDM,420,RC,97127,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,131.3955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.079,132.3
Electric Stimulation Therapy,PX97014,CDM,420,RC,97014,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,115.5,percent of total billed charges,131.3955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.18,132.3
Electrical Stimulation,PX97032,CDM,420,RC,97032,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,131.3955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,132.3
Gait Training Therapy,PX97116,CDM,420,RC,97116,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,58.66666667,percent of total billed charges,131.3955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20,132.3
Mechanical Traction Therapy,PX97012,CDM,420,RC,97012,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,26.2,percent of total billed charges,131.3955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,132.3
Self Care Mngment Training,PX97535,CDM,420,RC,97535,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,107.3,percent of total billed charges,131.3955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.27,132.3
Ultrasound Therapy,PX97035,CDM,420,RC,97035,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,118.0588372,percent of total billed charges,131.3955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,132.3
"Urinalysis, Auto W/O Scope",PX81003,CDM,300,RC,81003,CPT,,,,,,,,149,,United Healthcare,All Payer,outpatient,88.2,,122.552,percent of total billed charges,131.418,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.06,146.02
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,574200815,NDC,15,GR,154.63,,First Health,Commercial,both,85,,999999999,percent of total billed charges,131.4355,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Spinal Puncture,Lumbar,Diagnostic",PX62270F,CDM,510,RC,62270,CPT,,,,,,,,684,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,131.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.3,303.7
"Spinal Puncture,Lumbar,Diagnostic",PX62270P,CDM,983,RC,62270,CPT,,,,,,,,705,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,131.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.3,690.9
albuterol HFA 108 (90 Base) MCG/ACT Aerosol Solution 8 g Inhaler,25000000,CDM,250,RC,,,,,,173068224,NDC,8,GR,149.04,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,131.45328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
nystatin 100000 UNIT/GM Cream 30 g Tube,25000000,CDM,250,RC,,,,,,168005430,NDC,30,GR,147.79,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,131.5331,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623F,CDM,510,RC,11623,CPT,,,,,,,,690,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,131.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.89,616.39
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623F,CDM,510,RC,11623,CPT,,,,,,,,690,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,131.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.89,616.39
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623P,CDM,983,RC,11623,CPT,,,,,,,,460,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,131.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.89,616.39
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623P,CDM,983,RC,11623,CPT,,,,,,,,460,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,131.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.89,616.39
Blood Clot Factor V Test,PX85220,CDM,300,RC,85220,CPT,,,,,,,,260,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,131.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.18,254.8
"Closed Rx Toe Fx,Manipulatn",PX28515P,CDM,983,RC,28515,CPT,,,,,,,,260,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,131.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.004,253.058
First Hour IV Hydration <1 Hour,PX96360,CDM,260,RC,96360,CPT,,,,,,,,260,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,131.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.004,254.8
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,63323072902,NDC,1,EA,265.95,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,131.64525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.47563,793.6922
"Initial Observation Care,Levl I",PX99218,CDM,982,RC,99218,CPT,,,,,,,,266,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,131.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.4964,258.8978
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597F,CDM,510,RC,97597,CPT,,,,,,,,266,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,131.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.4964,260.68
COOK EMERGENCY PNEUMOTHORAX SET,120.559,CDM,272,RC,,,,12597-MAIN,LOCAL,,,,,307,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,131.703,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,127.5278,300.86
vancomycin 125 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68180016611,NDC,1,EA,149.33,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,131.70906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 125 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,47781072902,NDC,1,EA,149.33,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,131.70906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 125 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,62559039020,NDC,1,EA,149.33,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,131.70906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BLUE EYE SUBMUCOSAL LIFTING AGENT 5ML,27200000,CDM,272,RC,,,,12684-MAIN,LOCAL,,,,,148,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,131.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Mumps,PX86735,CDM,300,RC,86735,CPT,,,,,,,,148,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,131.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.97,145.04
US Guide Needle Bx S&I,PX7694226,CDM,982,RC,76942,CPT,26,,,,,,,148,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,131.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.4792,144.0484
CYSTOSCOPY PACK I STERILE,120.505,CDM,272,RC,,,,4527-MAIN,LOCAL,,,,,155,,First Health,Commercial,both,85,,999999999,percent of total billed charges,131.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,151.9
"Lab Antibody ID,RBC",PX7605,CDM,300,RC,86870,CPT,,,,,,,,155,,First Health,Commercial,both,85,,999999999,percent of total billed charges,131.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,314.02
"Office/Outpt Visit,Est,Levl II",PX99212F,CDM,510,RC,99212,CPT,,,,,,,,155,,First Health,Commercial,both,85,,999999999,percent of total billed charges,131.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,151.9
"Office/Outpt Visit,Est,Levl II",PX99212P,CDM,983,RC,99212,CPT,,,,,,,,155,,First Health,Commercial,both,85,,999999999,percent of total billed charges,131.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,150.8615
Smear Fluorescent/Acid Stai,PX87206,CDM,300,RC,87206,CPT,,,,,,,,155,,First Health,Commercial,both,85,,999999999,percent of total billed charges,131.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.94,151.9
TB Test Enumeration of T-Cells - Ref,PX8648190,CDM,300,RC,86481,CPT,90,,,,,,,155,,First Health,Commercial,both,85,,999999999,percent of total billed charges,131.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,151.9
"Incis/Drain Scrotum/Testis,Epididym",PX54700F,CDM,510,RC,54700,CPT,,,,,,,,660,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,131.76,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,131.76,443.44
"Incis/Drain Scrotum/Testis,Epididym",PX54700P,CDM,983,RC,54700,CPT,,,,,,,,440,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,131.76,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,131.76,443.44
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062160,NDC,0.6,ML,274.53,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,131.7744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062160,NDC,0.6,ML,274.53,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,131.7744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801601,NDC,0.6,ML,274.53,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,131.7744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801601,NDC,0.6,ML,274.53,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,131.7744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801610,NDC,0.6,ML,274.53,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,131.7744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801610,NDC,0.6,ML,274.53,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,131.7744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,63323050830,NDC,1,EA,134.48,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,131.7904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.461584,189.875
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,49884093547,NDC,100,GR,266.25,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,131.79375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Tiss Cult, Neopl, Bm, Wb - Ref",PX8823790,CDM,310,RC,88237,CPT,90,,,,,,,3141,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,131.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,131.8,3078.18
NEEDLE INTRAOSSEOUS 15GA 15MM EZ-IO PEDS 9018,120.89,CDM,272,RC,A4215,HCPCS,,4964-MAIN,LOCAL,,,,,269,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,131.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.7426,263.62
NEEDLE INTRAOSSEOUS 15GA 15MM EZ-IO PEDS 9018,120.89,CDM,272,RC,A4215,HCPCS,,4964-MAIN,LOCAL,,,,,269,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,131.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.7426,263.62
NEEDLE INTRAOSSEOUS 15GA 15MM EZ-IO PEDS 9018,120.89,CDM,272,RC,A4215,HCPCS,,4964-MAIN,LOCAL,,,,,269,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,131.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.7426,263.62
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337501,NDC,50,ML,135.43,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1.636666667,percent of total billed charges,131.814019,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337502,NDC,50,ML,135.43,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1.636666667,percent of total billed charges,131.814019,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9678001,NDC,50,ML,135.43,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1.636666667,percent of total billed charges,131.814019,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
insulin regular 100 UNIT/ML Solution 10 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821501,NDC,10,ML,307.46,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,131.90034,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
MRI Pelvis W/Contrast Tc,PX7219601,CDM,610,RC,72196,CPT,TC,,,,,,,3143,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,131.97,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.45,385.24
nystatin 100000 UNIT/GM Cream 30 g Tube,25000000,CDM,250,RC,,,,,,51672128902,NDC,30,GR,148.29,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,131.9781,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fluticasone 110 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173071920,NDC,12,GR,149.67,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,132.00894,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atropine 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,17478021502,NDC,2,ML,269.45,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,132.0305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
atropine 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,17478021502,NDC,2,ML,269.45,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,132.0305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
atropine 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,17478021502,NDC,2,ML,269.45,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,132.0305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
atropine 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,60219174802,NDC,2,ML,269.45,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,132.0305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
atropine 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,60219174802,NDC,2,ML,269.45,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,132.0305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
atropine 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,60219174802,NDC,2,ML,269.45,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,132.0305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Critical Care, E/M 30-74 Minutes",PX99291P,CDM,983,RC,99291,CPT,,,,,,,,1061,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,132.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.04,1039.78
"Facility Critical Care, E/M 30-74 Minutes",PX99291F,CDM,510,RC,99291,CPT,,,,,,,,1264,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,132.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.04,489.16
ROPivacaine 2 MG/ML Solution 100 mL Bottle,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028568,NDC,100,ML,275.11,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,132.0528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.604954,269.6078
ROPivacaine 2 MG/ML Solution 100 mL Bottle,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028568,NDC,100,ML,275.11,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,132.0528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.604954,269.6078
Assay Carbamazepine Total,PX80156,CDM,300,RC,80156,CPT,,,,,,,,145,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,132.095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.36,142.1
"Calculus, Infrared Spec - Ref",PX8236590,CDM,300,RC,82365,CPT,90,,,,,,,145,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,132.095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.83,142.1
"Catecholamines, Fraction - Ref",PX8238490,CDM,300,RC,82384,CPT,90,,,,,,,145,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,132.095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.15,142.1
Hsv Dna Amp Probe,PX87529,CDM,300,RC,87529,CPT,,,,,,,,145,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,132.095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,142.1
Immunofixation Electrophoresis; Serum,PX86334,CDM,300,RC,86334,CPT,,,,,,,,145,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,132.095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.48,142.1
LEGGING COMPRESSION JUXTALITE LONG LG 33CM,120.369,CDM,271,RC,A6545,HCPCS,,10840-MAIN,LOCAL,,,,,145,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,132.095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.233,142.1
"Pare/Cut Hyperkeratotic Skin Lesion, Single",PX11055F,CDM,510,RC,11055,CPT,,,,,,,,145,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,132.095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.233,174.9
Surgical Cleansing of Skin,PX11000P,CDM,983,RC,11000,CPT,,,,,,,,145,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,132.095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.233,548.67
Wheelchair Mngement Training,PX97542,CDM,420,RC,97542,CPT,,,,,,,,145,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,132.095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.59,142.1
8MM ENDOWRIST INSTRUMENTS LARGE NEEDLE DRIVER,27200000,CDM,272,RC,,,,11912-MAIN,LOCAL,,,,,318,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,132.0972,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Drain/Inject Medium Joint/Bursa,PX20605P,CDM,983,RC,20605,CPT,,,,,,,,318,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,132.0972,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,309.5094
"Office/Outpt Visit,Est,Levl V",PX99215F,CDM,510,RC,99215,CPT,,,,,,,,318,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,132.0972,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,311.64
"Office/Outpt Visit,Est,Levl V",PX99215P,CDM,983,RC,99215,CPT,,,,,,,,318,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,132.0972,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,309.5094
"Remv F.B.,Eye,Cornea,No Slit",PX65220P,CDM,983,RC,65220,CPT,,,,,,,,318,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,132.0972,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,348.08
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821517,NDC,3,ML,275.33,,Health Partners,Health Partners Care Plans,both,48,,4.547805556,percent of total billed charges,132.1584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821517,NDC,3,ML,275.33,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,132.1584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
Xray Shoulder 1 Vw,PX7302001,CDM,320,RC,73020,CPT,TC,,,,,,,267,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,132.165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,261.66
tranexamic acid 1000 mg in 100 mL 0.7% sodium chloride (premix) 1000-0.7 MG/100ML-% Solution 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,80830232901,NDC,100,ML,155.55,,First Health,Commercial,both,85,,999999999,percent of total billed charges,132.2175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Physical Therapy Evaluation High Complex,PX97163,CDM,424,RC,97163,CPT,,,,,,,,294,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,132.23,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.14,132.23
Physical Therapy Evaluation High Complex,PX97163,CDM,424,RC,97163,CPT,,,,,,,,294,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,132.23,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.14,132.23
Physical Therapy Evaluation Low Complex,PX97161,CDM,424,RC,97161,CPT,,,,,,,,235,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,132.23,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.14,132.23
Physical Therapy Evaluation Low Complex,PX97161,CDM,424,RC,97161,CPT,,,,,,,,235,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,132.23,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.14,132.23
Physical Therapy Evaluation Mod Complex,PX97162,CDM,424,RC,97162,CPT,,,,,,,,264,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,132.23,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.14,132.23
Physical Therapy Evaluation Mod Complex,PX97162,CDM,424,RC,97162,CPT,,,,,,,,264,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,132.23,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.14,132.23
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915801,NDC,1,ML,267.19,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,132.25905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
fluorouracil 5 GM/100ML Solution 100 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,16729027638,NDC,100,ML,261.44,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,132.28864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,256.2112
Assay of CK (Cpk),PX82550,CDM,300,RC,82550,CPT,,,,,,,,150,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,132.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.97,147
Assay of Lactic Acid,PX83605,CDM,300,RC,83605,CPT,,,,,,,,150,,United Healthcare,All Payer,outpatient,88.2,,84.95909091,percent of total billed charges,132.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.61,147
Assay of Phosphorus,PX84100,CDM,300,RC,84100,CPT,,,,,,,,150,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,132.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.35,147
Bilirubin Direct,PX82248,CDM,300,RC,82248,CPT,,,,,,,,150,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,132.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.6,147
Bilirubin Total,PX82247,CDM,300,RC,82247,CPT,,,,,,,,150,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,132.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.6,147
"Closed Rx Radial Head Disloc,Child",PX24640F,CDM,510,RC,24640,CPT,,,,,,,,270,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,216,percent of total billed charges,132.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.158,264.6
"Closed Rx Radial Head Disloc,Child",PX24640F,CDM,510,RC,24640,CPT,,,,,,,,270,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,132.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.158,264.6
"Closed Rx Radial Head Disloc,Child",PX24640F,CDM,510,RC,24640,CPT,,,,,,,,270,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,132.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.158,264.6
"Cognitive Funct Ther Interv, per Day",PX97127,CDM,420,RC,97127,CPT,,,,,,,,135,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,132.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.079,132.3
"Drug(S) or Substance(S), Definitive, Qualitative or Quantitative, Not Otherwise Specified; 1-3 - Ref",PX8037590,CDM,300,RC,80375,CPT,90,,,,,,,150,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,132.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.31,147
Electric Stimulation Therapy,PX97014,CDM,420,RC,97014,CPT,,,,,,,,135,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,132.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.18,132.3
Electrical Stimulation,PX97032,CDM,420,RC,97032,CPT,,,,,,,,135,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,132.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,132.3
Gait Training Therapy,PX97116,CDM,420,RC,97116,CPT,,,,,,,,135,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,132.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20,132.3
"Hsv Detect, Amplif Probe - Ref",PX8752990,CDM,300,RC,87529,CPT,90,,,,,,,150,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,132.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,147
Magnesium,PX83735,CDM,300,RC,83735,CPT,,,,,,,,150,,United Healthcare,All Payer,outpatient,88.2,,105.9077778,percent of total billed charges,132.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.14,147
Magnesium - Ref,PX8373590,CDM,300,RC,83735,CPT,90,,,,,,,150,,United Healthcare,All Payer,outpatient,88.2,,105.9077778,percent of total billed charges,132.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.14,147
"Manual Ther Tech,1+Regions,Ea 15 Min",PX97140,CDM,420,RC,97140,CPT,,,,,,,,135,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,132.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.4,215.05
Mechanical Traction Therapy,PX97012,CDM,420,RC,97012,CPT,,,,,,,,135,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,132.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,132.3
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157F,CDM,370,RC,99157,CPT,,,,,,,,270,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,132.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.158,264.6
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157F,CDM,370,RC,99157,CPT,,,,,,,,270,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,132.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.158,264.6
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157F,CDM,370,RC,99157,CPT,,,,,,,,270,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,132.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.158,264.6
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157P,CDM,983,RC,99157,CPT,,,,,,,,270,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,132.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.158,262.791
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157P,CDM,983,RC,99157,CPT,,,,,,,,270,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,132.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.158,262.791
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157P,CDM,983,RC,99157,CPT,,,,,,,,270,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,132.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.158,262.791
Neuromuscular Re-Education,PX97112,CDM,420,RC,97112,CPT,,,,,,,,135,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,132.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.95,215.05
Po4 Inorganic (Phosphate) - Ref,PX8410090,CDM,300,RC,84100,CPT,90,,,,,,,150,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,132.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.35,147
Self Care Mngment Training,PX97535,CDM,420,RC,97535,CPT,,,,,,,,135,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,132.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.27,132.3
TB Antigen Response Gamma Interferon T-Cell Susp,PX86481,CDM,300,RC,86481,CPT,,,,,,,,150,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,132.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.31,147
Therapeutic Activities,PX97530,CDM,420,RC,97530,CPT,,,,,,,,135,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,132.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.22,205.7
Therapeutic Exercises,PX97110,CDM,420,RC,97110,CPT,,,,,,,,135,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,132.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20,215.05
Ultrasound Therapy,PX97035,CDM,420,RC,97035,CPT,,,,,,,,135,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,132.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.54,132.3
Wound Culture Anaerobic,PX87075,CDM,300,RC,87075,CPT,,,,,,,,270,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,132.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.68,264.6
Wound Culture Anaerobic,PX87075,CDM,300,RC,87075,CPT,,,,,,,,270,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,132.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.68,264.6
Wound Culture Anaerobic,PX87075,CDM,300,RC,87075,CPT,,,,,,,,270,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,132.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.68,264.6
MINIBUNION LOCKING SCREW 3.0X24MM,C1713,CDM,278,RC,C1713,HCPCS,,11671-MAIN,LOCAL,,,,,308.55,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,132.36795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"In Situ Hybridization (Eg, Fish), Each Probe, Tech",PX8836501,CDM,310,RC,88365,CPT,TC,,,,,,,117,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,132.37,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.37,222.272
"In Situ Hybridization (Eg, Fish), Each Probe, Tech",PX8836501,CDM,310,RC,88365,CPT,TC,,,,,,,117,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,132.37,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.37,222.272
"In Situ Hybridization (Eg, Fish), Each Probe, Tech",PX8836501,CDM,310,RC,88365,CPT,TC,,,,,,,117,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,132.37,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.37,222.272
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,703115301,NDC,4,ML,136.1,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,132.46613,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Raltegravir 400 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,6022761,NDC,1,EA,150.2,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,132.4764,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Culture Screen Only,PX87081,CDM,300,RC,87081,CPT,,,,,,,,276,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,132.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.08,270.48
Culture Screen Only,PX87081,CDM,300,RC,87081,CPT,,,,,,,,276,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,132.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.08,270.48
Fresh Frozen Plasma,PXP9017,CDM,390,RC,P9017,HCPCS,,,,,,,,319,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,132.5126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.32,312.62
Drain/Inject Med Joint/Brusa W/US Guide,PX20606P,CDM,983,RC,20606,CPT,,,,,,,,309,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,132.561,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.3586,604.15
LINNEAR CUTTER STAPLE RELOAD GST BLUE 60MM,27200000,CDM,272,RC,,,,12068-MAIN,LOCAL,,,,,309,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,132.561,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LINNEAR CUTTER STAPLE RELOAD GST GREEN 60MM,27200000,CDM,272,RC,,,,12069-MAIN,LOCAL,,,,,309,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,132.561,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LINNEAR CUTTER STAPLE RELOAD GST WHITE 60MM,27200000,CDM,272,RC,,,,12067-MAIN,LOCAL,,,,,309,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,132.561,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Naso/Orogastric Tube,PX43752P,CDM,983,RC,43752,CPT,,,,,,,,309,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,132.561,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.3586,348.08
Tap Block Bilateral by Injection(S),PX64488P,CDM,983,RC,64488,CPT,,,,,,,,262,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,132.572,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.8348,255.0046
"Chrom Anal, 20-25 Cells - Ref",PX8826490,CDM,310,RC,88264,CPT,90,,,,,,,3141,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,132.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.59,3078.18
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,55150017301,NDC,0.5,ML,319.2,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,132.59568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
Assay Blood Carbon Monoxide,PX82375,CDM,300,RC,82375,CPT,,,,,,,,156,,First Health,Commercial,both,85,,999999999,percent of total billed charges,132.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.3,152.88
"Cortisol, Am",PX7152,CDM,300,RC,82533,CPT,,,,,,,,156,,First Health,Commercial,both,85,,999999999,percent of total billed charges,132.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.95,152.88
DERMABOND PRINEO SKIN CLOSURE SYSTEM 22CM,27200000,CDM,272,RC,,,,12324-MAIN,LOCAL,,,,,156,,First Health,Commercial,both,85,,999999999,percent of total billed charges,132.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Immunohisto Antibody Slide Ea Multiplex,PX8834401,CDM,310,RC,88344,CPT,TC,,,,,,,51,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,132.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.6,222.656
Immunohisto Antibody Slide Ea Multiplex,PX8834401,CDM,310,RC,88344,CPT,TC,,,,,,,51,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,132.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.6,222.656
Immunohisto Antibody Slide Ea Multiplex,PX8834401,CDM,310,RC,88344,CPT,TC,,,,,,,51,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,132.6,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.6,222.656
lidocaine - transparent dressing 4 % Kit 1 Each Box,63700001,CDM,250,RC,,,,,,496088207,NDC,1,EA,270.63,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,132.6087,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine - transparent dressing 4 % Kit 1 Each Box,63700001,CDM,250,RC,,,,,,496088207,NDC,1,EA,270.63,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,132.6087,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
lidocaine - transparent dressing 4 % Kit 1 Each Box,63700001,CDM,250,RC,,,,,,496088207,NDC,1,EA,270.63,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,132.6087,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Urinalysis, Auto W/O Scope",PX81003,CDM,300,RC,81003,CPT,,,,,,,,149,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,132.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.06,146.02
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,409337504,NDC,4,ML,150.36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,132.61752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604F,CDM,510,RC,11604,CPT,,,,,,,,964,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,132.63,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.63,646.83
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604P,CDM,983,RC,11604,CPT,,,,,,,,1422,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,132.63,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.63,1393.56
tropicamide 1 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,61314035502,NDC,15,ML,267.96,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,132.6402,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
albuterol HFA 108 (90 Base) MCG/ACT Aerosol Solution 8 g Inhaler,25000000,CDM,250,RC,,,,,,173068224,NDC,8,GR,149.04,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,132.6456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,338035702,NDC,250,ML,309.28,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,132.68112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.4701,303.0944
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337501,NDC,50,ML,135.43,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,132.7214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337502,NDC,50,ML,135.43,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,132.7214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9678001,NDC,50,ML,135.43,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,132.7214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
ePHEDrine sulfate 50 MG/ML Solution 1 mL Ampule,25000000,CDM,250,RC,,,,,,17478041510,NDC,1,ML,262.31,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,132.72886,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Strapping of Ankle,PX29540F,CDM,420,RC,29540,CPT,,,,,,,,271,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,132.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.5734,265.58
Strapping of Ankle,PX29540F,CDM,420,RC,29540,CPT,,,,,,,,271,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,132.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.5734,265.58
Strapping of Ankle,PX29540F,CDM,420,RC,29540,CPT,,,,,,,,271,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,132.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.5734,265.58
Bcr/Abl1 Minor - Ref,PX8120790,CDM,310,RC,81207,CPT,90,,,,,,,1113,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,132.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.8,1090.74
Apply of Paste Boot,PX29580F,CDM,510,RC,29580,CPT,,,,,,,,132,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,132.83,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,132.83
Apply of Paste Boot,PX29580P,CDM,983,RC,29580,CPT,,,,,,,,88,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,132.83,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.92,132.83
"Molecular Path Proc, Level 2 - Ref",PX8140190,CDM,310,RC,81401,CPT,90,,,,,,,672,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,132.89,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.89,137
"Molecular Path Proc, Level 2 - Ref",PX8140190,CDM,310,RC,81401,CPT,90,,,,,,,672,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,132.89,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.89,137
"Molecular Path Proc, Level 2 - Ref",PX8140190,CDM,310,RC,81401,CPT,90,,,,,,,672,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,132.89,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.89,137
vancomycin 125 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68180016611,NDC,1,EA,149.33,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,132.9037,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 125 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,47781072902,NDC,1,EA,149.33,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,132.9037,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 125 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,62559039020,NDC,1,EA,149.33,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,132.9037,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Apply Long Leg Splint,PX29505F,CDM,510,RC,29505,CPT,,,,,,,,320,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,132.928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.928,313.6
"IV Infusion, Bamlanivimab, Infusion and Post Admin Monig",PXM0239,CDM,260,RC,M0239,HCPCS,,,,,,,,320,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,132.928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.928,313.6
"Molecular Cytog, Ea Probe - Ref",PX8827190,CDM,310,RC,88271,CPT,90,,,,,,,277,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,132.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.64,271.46
"Molecular Cytog, Ea Probe - Ref",PX8827190,CDM,310,RC,88271,CPT,90,,,,,,,277,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,132.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.64,271.46
"Xray Neck, Soft Tissue",PX7036001,CDM,320,RC,70360,CPT,TC,,,,,,,277,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,132.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,271.46
"Xray Neck, Soft Tissue",PX7036001,CDM,320,RC,70360,CPT,TC,,,,,,,277,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,132.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,271.46
"Drain Finger Abscess,Simple",PX26010F,CDM,510,RC,26010,CPT,,,,,,,,310,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,132.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.774,303.8
Bcr/Abl1 P210 - Ref,PX8120690,CDM,310,RC,81206,CPT,90,,,,,,,1144,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,133,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,133,160.7709
Islet Cell Antibody - Ref,PX8634190,CDM,300,RC,86341,CPT,90,,,,,,,146,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,133.006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.61,143.08
Layr Clos Wnd Rest Body 7.6-12.5,PX12044F,CDM,510,RC,12044,CPT,,,,,,,,785,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,133.06,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,133.06,796.26
Layr Clos Wnd Rest Body 7.6-12.5,PX12044P,CDM,983,RC,12044,CPT,,,,,,,,523,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,133.06,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,133.06,796.26
"X-Ray Exam Hip,Unilat W/Pelvis 1vw",PX7350101,CDM,320,RC,73501,CPT,TC,,,,,,,263,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,133.078,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,257.74
sincalide 5 MCG Recon Soln 1 Each Vial,J2805.01,CDM,636,RC,J2805,HCPCS,,,,270055615,NDC,1,EA,250,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,133.1,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,117.12,133.1
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597F,CDM,510,RC,97597,CPT,,,,,,,,266,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,133.11,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.28,133.11
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597P,CDM,983,RC,97597,CPT,,,,,,,,274,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,133.11,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.28,268.52
pegfilgrastim-cbqv 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5111.01,CDM,636,RC,Q5111,HCPCS,,,,70114010101,NDC,0.6,ML,10040,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,133.11946,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.45,135.48
NEEDLE INTRAOSSEOUS 15GA 15MM EZ-IO PEDS 9018,120.89,CDM,272,RC,A4215,HCPCS,,4964-MAIN,LOCAL,,,,,269,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,133.155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.7426,263.62
fluticasone 110 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173071920,NDC,12,GR,149.67,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,133.2063,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409421505,NDC,5,ML,271.86,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,57.34422222,percent of total billed charges,133.2114,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409421505,NDC,5,ML,271.86,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,133.2114,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409421505,NDC,5,ML,271.86,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,133.2114,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
methylPREDNISolone sod succ 1000 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9001820,NDC,1,EA,271.97,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,133.2653,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
methylPREDNISolone sod succ 1000 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9001820,NDC,1,EA,271.97,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,133.2653,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
methylPREDNISolone sod succ 1000 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9001820,NDC,1,EA,271.97,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,133.2653,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611P,CDM,983,RC,20611,CPT,,,,,,,,272,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,133.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.9888,264.7376
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611P,CDM,983,RC,20611,CPT,,,,,,,,272,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,133.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.9888,264.7376
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611P,CDM,983,RC,20611,CPT,,,,,,,,272,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,133.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.9888,264.7376
Total Cortisol,PX82533,CDM,300,RC,82533,CPT,,,,,,,,137,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,133.3421,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.95,134.26
"Triiodothyronine T3, Free (Free T3)",PX84481,CDM,300,RC,84481,CPT,,,,,,,,137,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,133.3421,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.53,134.26
atropine 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,17478021502,NDC,2,ML,269.45,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,133.37775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
atropine 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,60219174802,NDC,2,ML,269.45,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,133.37775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,703115301,NDC,4,ML,136.1,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,133.378,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Apply Lower Leg Splint,PX29515P,CDM,983,RC,29515,CPT,,,,,,,,311,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,133.419,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,129.1894,302.6963
Repr Superf Wnd Body <2.5cm,PX12001F,CDM,510,RC,12001,CPT,,,,,,,,311,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,133.419,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,129.1894,304.78
Xray Skull Less Than 4 Vws,PX7025001,CDM,320,RC,70250,CPT,TC,,,,,,,311,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,133.419,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,304.78
Assay of Psa Total,PX84153,CDM,300,RC,84153,CPT,,,,,,,,157,,First Health,Commercial,both,85,,999999999,percent of total billed charges,133.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.86,153.86
"Chlamydia Trachomatis Dna, Amp Probe",PX87491,CDM,300,RC,87491,CPT,,,,,,,,157,,First Health,Commercial,both,85,,999999999,percent of total billed charges,133.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,153.86
"Cognitive Skill Dev, Ea 15 Min",PX97532,CDM,420,RC,97532,CPT,,,,,,,,157,,First Health,Commercial,both,85,,999999999,percent of total billed charges,133.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.2178,153.86
"Fungal Culture, Other Source - Ref",PX8710290,CDM,300,RC,87102,CPT,90,,,,,,,157,,First Health,Commercial,both,85,,999999999,percent of total billed charges,133.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.71,153.86
Lactate (Ld) (Ldh) Enzyme,PX83615,CDM,300,RC,83615,CPT,,,,,,,,157,,First Health,Commercial,both,85,,999999999,percent of total billed charges,133.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.54,153.86
"Neisseria Gonorrhoeae Dna, Amp Probe",PX87591,CDM,300,RC,87591,CPT,,,,,,,,157,,First Health,Commercial,both,85,,999999999,percent of total billed charges,133.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,153.86
Psa Screening,PXG0103,CDM,300,RC,G0103,HCPCS,,,,,,,,157,,First Health,Commercial,both,85,,999999999,percent of total billed charges,133.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.71,153.86
Remv Ext Canal Foreign Body,PX69200P,CDM,983,RC,69200,CPT,,,,,,,,157,,First Health,Commercial,both,85,,999999999,percent of total billed charges,133.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.2178,152.8081
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494300,NDC,0.5,ML,419.23,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,133.47,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,117.45,133.47
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494300,NDC,0.5,ML,419.23,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,133.47,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,117.45,133.47
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494300,NDC,0.5,ML,419.23,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,133.47,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,117.45,133.47
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494301,NDC,0.5,ML,419.2,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,133.47,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,117.45,133.47
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494301,NDC,0.5,ML,419.2,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,133.47,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,117.45,133.47
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494301,NDC,0.5,ML,419.2,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,133.47,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,117.45,133.47
ARIPiprazole 2 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714014101,NDC,1,EA,151.35,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,133.4907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of CK (Cpk),PX82550,CDM,300,RC,82550,CPT,,,,,,,,150,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,133.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.97,147
Assay of Lactic Acid,PX83605,CDM,300,RC,83605,CPT,,,,,,,,150,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,133.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.61,147
Assay of Phosphorus,PX84100,CDM,300,RC,84100,CPT,,,,,,,,150,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,133.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.35,147
Bilirubin Direct,PX82248,CDM,300,RC,82248,CPT,,,,,,,,150,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,133.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.6,147
Bilirubin Total,PX82247,CDM,300,RC,82247,CPT,,,,,,,,150,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,133.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.6,147
"Drug(S) or Substance(S), Definitive, Qualitative or Quantitative, Not Otherwise Specified; 1-3 - Ref",PX8037590,CDM,300,RC,80375,CPT,90,,,,,,,150,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,133.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.31,147
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604F,CDM,510,RC,11604,CPT,,,,,,,,964,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,133.5,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.63,646.83
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604F,CDM,510,RC,11604,CPT,,,,,,,,964,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,133.5,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.63,646.83
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604P,CDM,983,RC,11604,CPT,,,,,,,,1422,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,133.5,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.63,1393.56
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604P,CDM,983,RC,11604,CPT,,,,,,,,1422,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,133.5,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.63,1393.56
"Hsv Detect, Amplif Probe - Ref",PX8752990,CDM,300,RC,87529,CPT,90,,,,,,,150,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,133.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,147
Magnesium,PX83735,CDM,300,RC,83735,CPT,,,,,,,,150,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,133.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.14,147
Magnesium - Ref,PX8373590,CDM,300,RC,83735,CPT,90,,,,,,,150,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,133.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.14,147
Po4 Inorganic (Phosphate) - Ref,PX8410090,CDM,300,RC,84100,CPT,90,,,,,,,150,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,133.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.35,147
TB Antigen Response Gamma Interferon T-Cell Susp,PX86481,CDM,300,RC,86481,CPT,,,,,,,,150,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,133.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.31,147
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,55150012150,NDC,1,EA,151.41,,United Healthcare,All Payer,outpatient,88.2,,49.96,percent of total billed charges,133.54362,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
Occupational Therapy Eval High Complex,PX97167,CDM,434,RC,97167,CPT,,,,,,,,289,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,133.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.14,133.55
Occupational Therapy Eval High Complex,PX97167,CDM,434,RC,97167,CPT,,,,,,,,289,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,133.55,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.14,133.55
Occupational Therapy Eval Low Complex,PX97165,CDM,434,RC,97165,CPT,,,,,,,,235,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,133.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.14,133.55
Occupational Therapy Eval Low Complex,PX97165,CDM,434,RC,97165,CPT,,,,,,,,235,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,133.55,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.14,133.55
Occupational Therapy Eval Mod Complex,PX97166,CDM,434,RC,97166,CPT,,,,,,,,264,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,133.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.14,133.55
Occupational Therapy Eval Mod Complex,PX97166,CDM,434,RC,97166,CPT,,,,,,,,264,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,133.55,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.14,133.55
Inj Tendon/Ligament/Cyst,PX20550P,CDM,983,RC,20550,CPT,,,,,,,,264,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,133.584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.6656,258.75
Occupational Therapy Eval Mod Complex,PX97166,CDM,434,RC,97166,CPT,,,,,,,,264,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,133.584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,258.72
Physical Therapy Evaluation Mod Complex,PX97162,CDM,424,RC,97162,CPT,,,,,,,,264,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,133.584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,258.72
Renal Function Panel,PX80069,CDM,300,RC,80069,CPT,,,,,,,,264,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,133.584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.96,258.72
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,24208046325,NDC,2.5,ML,137.26,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,133.595158,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Closed Rx Radial Head Disloc,Child",PX24640F,CDM,510,RC,24640,CPT,,,,,,,,270,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,133.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.158,264.6
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157F,CDM,370,RC,99157,CPT,,,,,,,,270,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,133.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.158,264.6
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157P,CDM,983,RC,99157,CPT,,,,,,,,270,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,133.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.158,262.791
Wound Culture Anaerobic,PX87075,CDM,300,RC,87075,CPT,,,,,,,,270,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,133.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.68,264.6
DOBUTamine 1000 mcg/mL in dextrose 5% 250 mL premix 1000 mcg/ml Solution 250 mL Flex Cont,J1250.01,CDM,636,RC,J1250,HCPCS,,,,338107302,NDC,250,ML,146.73,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,133.67103,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.951642,143.7954
Raltegravir 400 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,6022761,NDC,1,EA,150.2,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,133.678,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047621,NDC,1,ML,157.28,,First Health,Commercial,both,85,,999999999,percent of total billed charges,133.688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.354486,332.1514
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,409662902,NDC,10,ML,146.84,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,133.77124,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.236966,143.9032
hepatitis b recomb vaccine 10 MCG/0.5ML suspension prefilled syringe 0.5 mL Syringe,90743,CDM,636,RC,90743,CPT,,,,58160082052,NDC,0.5,ML,137.47,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,133.799551,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.105038,134.7206
"In Situ Hybridization (Eg, Fish), Each Probe, Tech",PX8836501,CDM,310,RC,88365,CPT,TC,,,,,,,117,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,133.8153,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.37,222.272
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,409337504,NDC,4,ML,150.36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,133.8204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Closed Rx Kneecap Dislocatn,PX27560P,CDM,983,RC,27560,CPT,,,,,,,,312,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,133.848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,129.6048,303.6696
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082143,NDC,1,ML,348.85,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,133.87,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,133.87,158.15
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082152,NDC,1,ML,375.43,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,133.87,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,133.87,158.15
"Drain Finger Abscess,Simple",PX26010F,CDM,510,RC,26010,CPT,,,,,,,,310,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,133.8987,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,89.65,716.7
"Drain Finger Abscess,Simple",PX26010P,CDM,983,RC,26010,CPT,,,,,,,,207,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,133.8987,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,89.65,716.7
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315606,NDC,100,ML,264.64,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,133.90784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.931456,259.3472
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315695,NDC,100,ML,264.64,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,133.90784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.931456,259.3472
Amphetamines; 1 or 2 - Ref,PX8032490,CDM,300,RC,80324,CPT,90,,,,,,,147,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,133.917,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.0638,144.06
Assay Ph Body Fluids Nos,PX83986,CDM,300,RC,83986,CPT,,,,,,,,147,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,133.917,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.28,144.06
"Cmv Detect, Amplifi Probe - Ref",PX8749690,CDM,300,RC,87496,CPT,90,,,,,,,147,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,133.917,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,144.06
"Methlenedioxyamphetamines (Mda, Mdea, Mdma) - Ref",PX8035990,CDM,300,RC,80359,CPT,90,,,,,,,147,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,133.917,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.0638,144.06
Ph Venous Blood,PX82800,CDM,300,RC,82800,CPT,,,,,,,,147,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,133.917,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.09,144.06
"Hla Class II Low Res, 1 Locus - Ref",PX8137690,CDM,310,RC,81376,CPT,90,,,,,,,279,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,133.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.06,273.42
"Hla Class II Low Res, 1 Locus - Ref",PX8137690,CDM,310,RC,81376,CPT,90,,,,,,,279,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,133.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.06,273.42
INSUFLOWPORT & PNEUVIEW  XE SMOKE ELIMINATOR 5MM,27200000,CDM,272,RC,,,,11876-MAIN,LOCAL,,,,,279,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,133.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT & PNEUVIEW  XE SMOKE ELIMINATOR 5MM,27200000,CDM,272,RC,,,,11876-MAIN,LOCAL,,,,,279,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,133.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 8MM,27200000,CDM,272,RC,,,,11877-MAIN,LOCAL,,,,,279,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,133.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 8MM,27200000,CDM,272,RC,,,,11877-MAIN,LOCAL,,,,,279,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,133.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 10MM,27200000,CDM,272,RC,,,,11878-MAIN,LOCAL,,,,,279,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,133.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 10MM,27200000,CDM,272,RC,,,,11878-MAIN,LOCAL,,,,,279,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,133.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 12MM,27200000,CDM,272,RC,,,,11879-MAIN,LOCAL,,,,,279,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,133.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 12MM,27200000,CDM,272,RC,,,,11879-MAIN,LOCAL,,,,,279,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,133.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 5MM,27200000,CDM,272,RC,,,,11880-MAIN,LOCAL,,,,,279,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,133.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 5MM,27200000,CDM,272,RC,,,,11880-MAIN,LOCAL,,,,,279,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,133.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 8MM,27200000,CDM,272,RC,,,,11881-MAIN,LOCAL,,,,,279,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,133.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 8MM,27200000,CDM,272,RC,,,,11881-MAIN,LOCAL,,,,,279,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,133.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 10MM,27200000,CDM,272,RC,,,,11882-MAIN,LOCAL,,,,,279,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,133.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 10MM,27200000,CDM,272,RC,,,,11882-MAIN,LOCAL,,,,,279,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,133.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 12MM,27200000,CDM,272,RC,,,,11883-MAIN,LOCAL,,,,,279,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,133.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 12MM,27200000,CDM,272,RC,,,,11883-MAIN,LOCAL,,,,,279,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,133.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Puncture Drainage of Lesion,PX10160F,CDM,510,RC,10160,CPT,,,,,,,,279,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,133.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.8966,348.35
Puncture Drainage of Lesion,PX10160F,CDM,510,RC,10160,CPT,,,,,,,,279,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,133.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.8966,348.35
Xray Pelvis 1 or 2 Vws,PX7217001,CDM,320,RC,72170,CPT,TC,,,,,,,279,,Health Partners,Health Partners Care Plans,both,48,,129.36,percent of total billed charges,133.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,273.42
Xray Pelvis 1 or 2 Vws,PX7217001,CDM,320,RC,72170,CPT,TC,,,,,,,279,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,133.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,273.42
ketoconazole 2 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,16714095501,NDC,15,GR,322.42,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,133.933268,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Incis/Drain Scrotum/Testis,Epididym",PX54700F,CDM,510,RC,54700,CPT,,,,,,,,660,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,133.94,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,131.76,443.44
"Incis/Drain Scrotum/Testis,Epididym",PX54700F,CDM,510,RC,54700,CPT,,,,,,,,660,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,133.94,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,131.76,443.44
"Incis/Drain Scrotum/Testis,Epididym",PX54700P,CDM,983,RC,54700,CPT,,,,,,,,440,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,133.94,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,131.76,443.44
"Incis/Drain Scrotum/Testis,Epididym",PX54700P,CDM,983,RC,54700,CPT,,,,,,,,440,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,133.94,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,131.76,443.44
lidocaine - transparent dressing 4 % Kit 1 Each Box,63700001,CDM,250,RC,,,,,,496088207,NDC,1,EA,270.63,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,133.96185,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,517096010,NDC,10,ML,157.64,,First Health,Commercial,both,85,,999999999,percent of total billed charges,133.994,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium zirconium cyclosilicate 5 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,310110501,NDC,1,EA,151.95,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,134.0199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062430,NDC,0.3,ML,147.12,,Medica,Commercial,both,91.1,,7.8,percent of total billed charges,134.02632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801301,NDC,0.3,ML,147.12,,Medica,Commercial,both,91.1,,7.8,percent of total billed charges,134.02632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801310,NDC,0.3,ML,147.12,,Medica,Commercial,both,91.1,,7.8,percent of total billed charges,134.02632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
"Antipsychotics, Not Otherwise Specified; 1-3 - Ref",PX8034290,CDM,300,RC,80342,CPT,90,,,,,,,152,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,134.064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.1408,148.96
Body Fluid Cell Count,PX89050,CDM,300,RC,89050,CPT,,,,,,,,152,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,134.064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.33,148.96
Haptoglobin; Quantitative,PX83010,CDM,300,RC,83010,CPT,,,,,,,,265,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,134.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.53,259.7
ID Nucleic Acid Sequencing - Ref,PX8715390,CDM,300,RC,87153,CPT,90,,,,,,,265,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,134.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.77,259.7
"Office/Outpt Visit,Est,Levl V",PX99215F,CDM,510,RC,99215,CPT,,,,,,,,318,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,134.1072,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,89.69,324.12
"Office/Outpt Visit,Est,Levl V",PX99215P,CDM,983,RC,99215,CPT,,,,,,,,318,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,134.1072,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,89.69,324.12
Immunohisto Antibody Slide Ea Multiplex,PX8834401,CDM,310,RC,88344,CPT,TC,,,,,,,51,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,134.1362,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.6,222.656
"Molecular Path Proc, Level 2 - Ref",PX8140190,CDM,310,RC,81401,CPT,90,,,,,,,672,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,134.1362,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.89,137
Strapping of Ankle,PX29540F,CDM,420,RC,29540,CPT,,,,,,,,271,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,134.145,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.5734,265.58
procainamide 500 MG/ML Solution 2 mL Vial,J2690.01,CDM,636,RC,J2690,HCPCS,,,,14789090002,NDC,2,ML,377.75,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,134.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,134.15,370.195
Xray Ls Spine Bend Tc,PX7212001,CDM,320,RC,72120,CPT,TC,,,,,,,323,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,134.1742,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,316.54
sulfacetamide 10 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,24208067004,NDC,15,ML,312.96,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,134.25984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597P,CDM,983,RC,97597,CPT,,,,,,,,274,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,53.2,percent of total billed charges,134.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,113.8196,266.6842
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597P,CDM,983,RC,97597,CPT,,,,,,,,274,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,134.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,113.8196,266.6842
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597P,CDM,983,RC,97597,CPT,,,,,,,,274,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,134.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,113.8196,266.6842
Total Cortisol,PX82533,CDM,300,RC,82533,CPT,,,,,,,,137,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,134.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.95,134.26
"Triiodothyronine T3, Free (Free T3)",PX84481,CDM,300,RC,84481,CPT,,,,,,,,137,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,134.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.53,134.26
Dress/Debrid Small Burn No Anes,PX16020F,CDM,510,RC,16020,CPT,,,,,,,,313,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,134.277,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.0202,306.74
Antithrombin III Activity - Ref,PX8530090,CDM,300,RC,85300,CPT,90,,,,,,,158,,First Health,Commercial,both,85,,999999999,percent of total billed charges,134.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.87,154.84
Fac/Trm Hyperkeratotic Skn Lesn2-4,PX11056F,CDM,510,RC,11056,CPT,,,,,,,,158,,First Health,Commercial,both,85,,999999999,percent of total billed charges,134.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.6332,174.9
"Glucose, Body Fluid Other Than Blood",PX82945,CDM,300,RC,82945,CPT,,,,,,,,158,,First Health,Commercial,both,85,,999999999,percent of total billed charges,134.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.6,154.84
Protein C Activity - Ref,PX8530390,CDM,300,RC,85303,CPT,90,,,,,,,158,,First Health,Commercial,both,85,,999999999,percent of total billed charges,134.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.69,154.84
"Triiodothyronine T3, Tot - Ref",PX8448090,CDM,300,RC,84480,CPT,90,,,,,,,158,,First Health,Commercial,both,85,,999999999,percent of total billed charges,134.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13,154.84
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,16714076901,NDC,15,GR,137.99,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,134.305667,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Pertechnetate, Dia, per Mci",PXA9512,CDM,343,RC,A9512,HCPCS,,,,,,,,280,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,134.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,116.312,274.4
"Pertechnetate, Dia, per Mci",PXA9512,CDM,343,RC,A9512,HCPCS,,,,,,,,280,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,134.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,116.312,274.4
cloNIDine 0.1 MG/24HR PATCH WEEKLY 4 Each Box,63700001,CDM,250,RC,,,,,,51862045304,NDC,1,EA,158.16,,First Health,Commercial,both,85,,999999999,percent of total billed charges,134.436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,24208046325,NDC,2.5,ML,137.26,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,134.5148,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062160,NDC,0.6,ML,274.53,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,9.81,percent of total billed charges,134.5197,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062160,NDC,0.6,ML,274.53,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,134.5197,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062160,NDC,0.6,ML,274.53,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,134.5197,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801601,NDC,0.6,ML,274.53,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,9.81,percent of total billed charges,134.5197,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801601,NDC,0.6,ML,274.53,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,134.5197,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801601,NDC,0.6,ML,274.53,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,134.5197,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801610,NDC,0.6,ML,274.53,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,9.81,percent of total billed charges,134.5197,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801610,NDC,0.6,ML,274.53,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,134.5197,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801610,NDC,0.6,ML,274.53,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,134.5197,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,63323072902,NDC,1,EA,265.95,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,134.5707,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.47563,793.6922
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409421505,NDC,5,ML,271.86,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,134.5707,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
"Initial Observation Care,Levl I",PX99218,CDM,982,RC,99218,CPT,,,,,,,,266,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,134.596,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.4964,258.8978
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597F,CDM,510,RC,97597,CPT,,,,,,,,266,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,134.596,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.4964,260.68
Layr Clos Wnd Rest Body 7.6-12.5,PX12044F,CDM,510,RC,12044,CPT,,,,,,,,785,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,134.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,133.06,796.26
Layr Clos Wnd Rest Body 7.6-12.5,PX12044F,CDM,510,RC,12044,CPT,,,,,,,,785,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,134.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,133.06,796.26
Layr Clos Wnd Rest Body 7.6-12.5,PX12044P,CDM,983,RC,12044,CPT,,,,,,,,523,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,134.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,133.06,796.26
Layr Clos Wnd Rest Body 7.6-12.5,PX12044P,CDM,983,RC,12044,CPT,,,,,,,,523,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,134.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,133.06,796.26
methylPREDNISolone sod succ 1000 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9001820,NDC,1,EA,271.97,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,134.62515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
nystatin 100000 UNIT/GM Cream 30 g Tube,25000000,CDM,250,RC,,,,,,168005430,NDC,30,GR,147.79,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,134.63669,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611P,CDM,983,RC,20611,CPT,,,,,,,,272,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,134.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.9888,264.7376
MINIBUNION NON-LOCKING SCREW  2.7X18MM,C1713,CDM,278,RC,C1713,HCPCS,,11670-MAIN,LOCAL,,,,,280.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,134.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
MINIBUNION NON-LOCKING SCREW  2.7X18MM,C1713,CDM,278,RC,C1713,HCPCS,,11670-MAIN,LOCAL,,,,,280.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,134.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127303,NDC,2,ML,152.7,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,134.6814,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.43158,173.019
ARIPiprazole 2 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714014101,NDC,1,EA,151.35,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,134.7015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay for Vancomycin,PX80202,CDM,300,RC,80202,CPT,,,,,,,,314,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,134.706,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.41,307.72
Noninvasv Lo Extrem Art Stress/Rest,PX9392401,CDM,921,RC,93924,CPT,TC,,,,,,,810,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,134.7085,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.34,238.5
hepatitis b recomb vaccine 10 MCG/0.5ML suspension prefilled syringe 0.5 mL Syringe,90743,CDM,636,RC,90743,CPT,,,,58160082052,NDC,0.5,ML,137.47,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,134.7206,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.105038,134.7206
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,49884093547,NDC,100,GR,266.25,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,134.7225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242003706,NDC,0.6,EA,8461.09,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,134.74,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,134.74,153.11
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012001,NDC,0.6,EA,7764.12,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,134.74,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,134.74,153.11
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012047,NDC,0.6,EA,10644.69,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,134.74,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,134.74,153.11
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151P,CDM,983,RC,99151,CPT,,,,,,,,275,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,134.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,114.235,267.6575
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151P,CDM,983,RC,99151,CPT,,,,,,,,275,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,134.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,114.235,267.6575
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151P,CDM,983,RC,99151,CPT,,,,,,,,275,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,134.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,114.235,267.6575
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,55150012150,NDC,1,EA,151.41,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,134.7549,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
Ultrasound Breast Complete,PX7664101,CDM,402,RC,76641,CPT,TC,,,,,,,333,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,134.77,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.59,134.77
Ultrasound Breast Complete,PX7664101,CDM,402,RC,76641,CPT,TC,,,,,,,333,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,134.77,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,45.59,134.77
ROPivacaine 2 MG/ML Solution 100 mL Bottle,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028568,NDC,100,ML,275.11,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,134.8039,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.604954,269.6078
ROPivacaine 2 MG/ML Solution 100 mL Bottle,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028568,NDC,100,ML,275.11,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,134.8039,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.604954,269.6078
ROPivacaine 2 MG/ML Solution 100 mL Bottle,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028568,NDC,100,ML,275.11,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,134.8039,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.604954,269.6078
neomycin-polymyxin-gramicidin 1.75-10000-.025 Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,24208079062,NDC,10,ML,314.26,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,134.81754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Art Lower Extremity-Bilat,PX9392501,CDM,921,RC,93925,CPT,TC,,,,,,,1188,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,134.82,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,134.82,354.84
BLUE EYE SUBMUCOSAL LIFTING AGENT 5ML,27200000,CDM,272,RC,,,,12684-MAIN,LOCAL,,,,,148,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,134.828,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Mumps,PX86735,CDM,300,RC,86735,CPT,,,,,,,,148,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,134.828,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.97,145.04
US Guide Needle Bx S&I,PX7694226,CDM,982,RC,76942,CPT,26,,,,,,,148,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,134.828,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.4792,144.0484
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,55150043801,NDC,20,ML,152.9,,United Healthcare,All Payer,outpatient,88.2,,7.6225,percent of total billed charges,134.8578,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457018120,NDC,20,ML,152.9,,United Healthcare,All Payer,outpatient,88.2,,7.6225,percent of total billed charges,134.8578,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
8MM ENDOWRIST INSTRUMENTS CADIERE FORCEPS,27200000,CDM,272,RC,,,,11913-MAIN,LOCAL,,,,,281,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,134.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM ENDOWRIST INSTRUMENTS CADIERE FORCEPS,27200000,CDM,272,RC,,,,11913-MAIN,LOCAL,,,,,281,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,134.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
FORCEPS PROGRASP 8MM ENDOWRIST INSTRUMENTS,27200000,CDM,272,RC,,,,12062-MAIN,LOCAL,,,,,281,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,134.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
FORCEPS PROGRASP 8MM ENDOWRIST INSTRUMENTS,27200000,CDM,272,RC,,,,12062-MAIN,LOCAL,,,,,281,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,134.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Spirometry,PX9401001,CDM,460,RC,94010,CPT,TC,,,,,,,281,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,134.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,116.7274,275.38
Spirometry,PX9401001,CDM,460,RC,94010,CPT,TC,,,,,,,281,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,134.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,116.7274,275.38
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821517,NDC,3,ML,275.33,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,3.1136,percent of total billed charges,134.9117,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821517,NDC,3,ML,275.33,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,134.9117,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821517,NDC,3,ML,275.33,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,134.9117,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,65162083366,NDC,100,GR,281.12,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,134.9376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,65162083366,NDC,100,GR,281.12,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,134.9376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ELECTRODE ADULT PACING ONESTEP,120.214,CDM,272,RC,A4556,HCPCS,,10242-MAIN,LOCAL,,,,,153,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,134.946,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.5562,149.94
"Protein, Total; Other Source",PX84157,CDM,300,RC,84157,CPT,,,,,,,,153,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,134.946,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.67,149.94
Pulmonary Stress Test,PX94618,CDM,976,RC,94618,CPT,,,,,,,,153,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,134.946,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.5562,148.9149
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457018100,NDC,20,ML,153.01,,United Healthcare,All Payer,outpatient,88.2,,7.6225,percent of total billed charges,134.95482,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156F,CDM,370,RC,99156,CPT,,,,,,,,325,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,135.005,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,318.5
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156P,CDM,983,RC,99156,CPT,,,,,,,,325,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,135.005,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,316.3225
Refill/Maint Portable Pump,PX96521,CDM,260,RC,96521,CPT,,,,,,,,325,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,135.005,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,318.5
"Remv F.B.,Eye,Embed Conjunc",PX65210F,CDM,510,RC,65210,CPT,,,,,,,,325,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,135.005,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,348.08
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598P,CDM,982,RC,97598,CPT,,,,,,,,325,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,135.005,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,316.3225
Somatostatin - Ref,PX8430790,CDM,300,RC,84307,CPT,90,,,,,,,325,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,135.005,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.76,318.5
nystatin 100000 UNIT/GM Cream 30 g Tube,25000000,CDM,250,RC,,,,,,51672128902,NDC,30,GR,148.29,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,135.09219,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862066230,NDC,1,EA,153.17,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,135.09594,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Xray Shoulder 1 Vw,PX7302001,CDM,320,RC,73020,CPT,TC,,,,,,,267,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,135.102,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,261.66
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954201,NDC,10,ML,153.18,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,135.10476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.630972,150.1164
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954210,NDC,10,ML,153.18,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,135.10476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.630972,150.1164
EPIX UNIVERSAL CLIP APPLIER,27200000,CDM,272,RC,,,,11708-MAIN,LOCAL,,,,,158.95,,First Health,Commercial,both,85,,999999999,percent of total billed charges,135.1075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
amiodarone 360-4.14 MG/200ML-% Solution 200 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066036020,NDC,200,ML,325.25,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,135.10885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.35,318.745
Assay Iga/Igd/Igg/Igm Each,PX82784,CDM,300,RC,82784,CPT,,,,,,,,315,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,135.135,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.53,308.7
Iaad Ia Severe Aqt Respir Synd Coronavirus,PX87426,CDM,300,RC,87426,CPT,,,,,,,,159,,First Health,Commercial,both,85,,999999999,percent of total billed charges,135.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.39,155.82
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915801,NDC,1,ML,267.19,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,135.19814,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
"Critical Care, E/M 30-74 Minutes",PX99291P,CDM,983,RC,99291,CPT,,,,,,,,1061,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,135.23,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.04,1039.78
"Critical Care, E/M 30-74 Minutes",PX99291P,CDM,983,RC,99291,CPT,,,,,,,,1061,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,135.23,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.04,1039.78
"Facility Critical Care, E/M 30-74 Minutes",PX99291F,CDM,510,RC,99291,CPT,,,,,,,,1264,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,135.23,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.04,489.16
"Facility Critical Care, E/M 30-74 Minutes",PX99291F,CDM,510,RC,99291,CPT,,,,,,,,1264,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,135.23,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.04,489.16
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,16714076901,NDC,15,GR,137.99,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,135.2302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium zirconium cyclosilicate 5 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,310110501,NDC,1,EA,151.95,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,135.2355,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Culture Screen Only,PX87081,CDM,300,RC,87081,CPT,,,,,,,,276,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,135.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.08,270.48
Culture Screen Only,PX87081,CDM,300,RC,87081,CPT,,,,,,,,276,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,135.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.08,270.48
Culture Screen Only,PX87081,CDM,300,RC,87081,CPT,,,,,,,,276,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,135.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.08,270.48
eriBULin 1 MG/2ML Solution 2 mL Vial,J9179.01,CDM,636,RC,J9179,HCPCS,,,,62856038901,NDC,2,ML,2321.52,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,135.24268,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,117.93,140.72
"Antipsychotics, Not Otherwise Specified; 1-3 - Ref",PX8034290,CDM,300,RC,80342,CPT,90,,,,,,,152,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,135.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.1408,148.96
Body Fluid Cell Count,PX89050,CDM,300,RC,89050,CPT,,,,,,,,152,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,135.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.33,148.96
Xray Finger(S) Tc,PX7314001,CDM,320,RC,73140,CPT,TC,,,,,,,282,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,135.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,276.36
Xray Finger(S) Tc,PX7314001,CDM,320,RC,73140,CPT,TC,,,,,,,282,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,135.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,276.36
Xray Toe(S) Tc,PX7366001,CDM,320,RC,73660,CPT,TC,,,,,,,282,,Health Partners,Health Partners Care Plans,both,48,,246.19,percent of total billed charges,135.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,276.36
Xray Toe(S) Tc,PX7366001,CDM,320,RC,73660,CPT,TC,,,,,,,282,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,135.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,276.36
pegfilgrastim-cbqv 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5111.01,CDM,636,RC,Q5111,HCPCS,,,,70114010101,NDC,0.6,ML,10040,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,135.48,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.45,135.48
pegfilgrastim-cbqv 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5111.01,CDM,636,RC,Q5111,HCPCS,,,,70114010101,NDC,0.6,ML,10040,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,135.48,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.45,135.48
methylene blue 1 % Solution 10 mL Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,54288014701,NDC,1,ML,139.25,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,15.50733333,percent of total billed charges,135.532025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.29,1354.4776
Cast/Strap Procedure Unlisted,PX29799F,CDM,510,RC,29799,CPT,,,,,,,,316,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,135.564,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,131.2664,309.68
tropicamide 1 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,61314035502,NDC,15,ML,267.96,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,135.58776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Drain/Inject Large Joint/Bursa,PX20610F,CDM,510,RC,20610,CPT,,,,,,,,364,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,135.59,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.48,135.59
Drain/Inject Large Joint/Bursa,PX20610P,CDM,983,RC,20610,CPT,,,,,,,,291,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,135.59,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.48,285.18
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597P,CDM,983,RC,97597,CPT,,,,,,,,274,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,135.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,113.8196,266.6842
Art Lower Extremity-Bilat,PX9392501,CDM,921,RC,93925,CPT,TC,,,,,,,1188,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,135.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,134.82,354.84
Art Lower Extremity-Bilat,PX9392501,CDM,921,RC,93925,CPT,TC,,,,,,,1188,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,135.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,134.82,354.84
"Molecular Cytog, Ea Probe - Ref",PX8827190,CDM,310,RC,88271,CPT,90,,,,,,,277,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,135.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.64,271.46
"Molecular Cytog, Ea Probe - Ref",PX8827190,CDM,310,RC,88271,CPT,90,,,,,,,277,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,135.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.64,271.46
"Molecular Cytog, Ea Probe - Ref",PX8827190,CDM,310,RC,88271,CPT,90,,,,,,,277,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,135.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.64,271.46
"Xray Neck, Soft Tissue",PX7036001,CDM,320,RC,70360,CPT,TC,,,,,,,277,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,135.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,271.46
"Xray Neck, Soft Tissue",PX7036001,CDM,320,RC,70360,CPT,TC,,,,,,,277,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,135.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,271.46
"Xray Neck, Soft Tissue",PX7036001,CDM,320,RC,70360,CPT,TC,,,,,,,277,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,135.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,271.46
"Urinalysis, Auto W/O Scope",PX81003,CDM,300,RC,81003,CPT,,,,,,,,149,,Medica,Commercial,both,91.1,,50.3325,percent of total billed charges,135.739,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.06,146.02
albuterol HFA 108 (90 Base) MCG/ACT Aerosol Solution 8 g Inhaler,25000000,CDM,250,RC,,,,,,173068224,NDC,8,GR,149.04,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,135.77544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
PROSTEP 0.9MM ANTI SKIVE PIN,27200000,CDM,272,RC,,,,12950-MAIN,LOCAL,,,,,154,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,135.828,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PROSTEP 1.4MM ANTI SKIVE PIN,27200000,CDM,272,RC,,,,12949-MAIN,LOCAL,,,,,154,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,135.828,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Vit D 1 25-Dihydroxy,PX82652,CDM,300,RC,82652,CPT,,,,,,,,154,,United Healthcare,All Payer,outpatient,88.2,,75.46,percent of total billed charges,135.828,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.3,150.92
8MM ENDOWRIST INSTRUMENTS MEGA SUTURE CUT NEEDLE DRIVER,27200000,CDM,272,RC,,,,11914-MAIN,LOCAL,,,,,327,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,135.8358,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"IV Infusion Therapy, 1 Hour",PX96365,CDM,260,RC,96365,CPT,,,,,,,,327,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,135.8358,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.8358,320.46
STAPLER RELOAD-CURVED CUTTER,27200000,CDM,272,RC,,,,12063-MAIN,LOCAL,,,,,283,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,135.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STAPLER RELOAD-CURVED CUTTER,27200000,CDM,272,RC,,,,12063-MAIN,LOCAL,,,,,283,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,135.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062160,NDC,0.6,ML,274.53,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,135.89235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801601,NDC,0.6,ML,274.53,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,135.89235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801610,NDC,0.6,ML,274.53,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,135.89235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127303,NDC,2,ML,152.7,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,135.903,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.43158,173.019
Ex for Speech Device Rx Addl,PX92608,CDM,444,RC,92608,CPT,,,,,,,,160,,First Health,Commercial,both,85,,999999999,percent of total billed charges,136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.95,156.8
vancomycin 125 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68180016611,NDC,1,EA,149.33,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,136.03963,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 125 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,47781072902,NDC,1,EA,149.33,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,136.03963,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 125 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,62559039020,NDC,1,EA,149.33,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,136.03963,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CT Head/Brain W/O Dye,PX7045001,CDM,350,RC,70450,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,136.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.02,136.08
CT Head/Brain W/O Dye,PX7045001,CDM,350,RC,70450,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,136.08,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.02,136.08
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,55150043801,NDC,20,ML,152.9,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,136.081,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457018120,NDC,20,ML,152.9,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,136.081,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
NEEDLE INTRAOSSEOUS 15GA 15MM EZ-IO PEDS 9018,120.89,CDM,272,RC,A4215,HCPCS,,4964-MAIN,LOCAL,,,,,269,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,136.114,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.7426,263.62
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151P,CDM,983,RC,99151,CPT,,,,,,,,275,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,136.125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,114.235,267.6575
Leukoreduced Rbc's,PXP9016,CDM,390,RC,P9016,HCPCS,,,,,,,,580,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,136.14,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.14,228.608
Leukoreduced Rbc's,PXP9016,CDM,390,RC,P9016,HCPCS,,,,,,,,580,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,136.14,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.14,228.608
Leukoreduced Rbc's,PXP9016,CDM,390,RC,P9016,HCPCS,,,,,,,,580,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,136.14,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.14,228.608
ELECTRODE ADULT PACING ONESTEP,120.214,CDM,272,RC,A4556,HCPCS,,10242-MAIN,LOCAL,,,,,153,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,136.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.5562,149.94
"Protein, Total; Other Source",PX84157,CDM,300,RC,84157,CPT,,,,,,,,153,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,136.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.67,149.94
Pulmonary Stress Test,PX94618,CDM,976,RC,94618,CPT,,,,,,,,153,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,136.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.5562,148.9149
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457018100,NDC,20,ML,153.01,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,136.1789,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
ROPivacaine 2 MG/ML Solution 100 mL Bottle,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028568,NDC,100,ML,275.11,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,136.17945,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.604954,269.6078
prednisoLONE acetate 1 % Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063705,NDC,5,ML,283.79,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,136.2192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
prednisoLONE acetate 1 % Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063705,NDC,5,ML,283.79,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,136.2192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
TISSUE RETRIEVAL SYSTEM,27200000,CDM,272,RC,,,,10233-MAIN,LOCAL,,,,,139.98,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,136.242534,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Chemotherapy, IV Infusion, Each Add'l Sequential Infusion",PX96417,CDM,335,RC,96417,CPT,,,,,,,,328,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,136.2512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,321.44
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762P,CDM,983,RC,43762,CPT,,,,,,,,328,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,136.2512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.2512,319.2424
Apply Forearm Cast,PX29075P,CDM,983,RC,29075,CPT,,,,,,,,140,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,136.262,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.156,234.62
Hospital Discharge Day>30 Min,PX99239P,CDM,982,RC,99239,CPT,,,,,,,,140,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,136.262,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.156,136.262
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821517,NDC,3,ML,275.33,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,136.28835,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
GRAFIXPL PRIME PLACENTAL MEMBRANE 1.5 x2CM 3SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12764-MAIN,LOCAL,,,,,1529,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,136.32,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.32,140.71158
GRAFIXPL PRIME PLACENTAL MEMBRANE 2x3CM 6SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12765-MAIN,LOCAL,,,,,1911,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,136.32,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.32,140.71158
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x3CM 9SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12766-MAIN,LOCAL,,,,,2171,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,136.32,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.32,140.71158
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x4CM 12SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12767-MAIN,LOCAL,,,,,2345,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,136.32,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.32,140.71158
GRAFIXPL PRIME PLACENTAL MEMBRANE 5x5CM 25SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12768-MAIN,LOCAL,,,,,5211,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,136.32,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.32,140.71158
GRAFIXPL PRIME PLACENTAL MEMBRANE 16MM DISC 2SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12763-MAIN,LOCAL,,,,,860,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,136.32,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.32,140.71158
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862066230,NDC,1,EA,153.17,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,136.3213,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954201,NDC,10,ML,153.18,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,136.3302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.630972,150.1164
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954210,NDC,10,ML,153.18,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,136.3302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.630972,150.1164
atropine 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,17478021502,NDC,2,ML,269.45,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,136.3417,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
atropine 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,60219174802,NDC,2,ML,269.45,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,136.3417,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fluticasone 110 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173071920,NDC,12,GR,149.67,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,136.34937,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,574200815,NDC,15,GR,154.63,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,136.38366,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
8MM ENDOWRIST INSTRUMENTS LARGE NEEDLE DRIVER,27200000,CDM,272,RC,,,,11912-MAIN,LOCAL,,,,,318,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,136.422,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Drain/Inject Medium Joint/Bursa,PX20605P,CDM,983,RC,20605,CPT,,,,,,,,318,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,136.422,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,309.5094
"Office/Outpt Visit,Est,Levl V",PX99215F,CDM,510,RC,99215,CPT,,,,,,,,318,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,136.422,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,311.64
"Office/Outpt Visit,Est,Levl V",PX99215P,CDM,983,RC,99215,CPT,,,,,,,,318,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,136.422,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,309.5094
"Remv F.B.,Eye,Cornea,No Slit",PX65220P,CDM,983,RC,65220,CPT,,,,,,,,318,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,136.422,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,348.08
doxycycline 100 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323013041,NDC,1,EA,140.2,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,136.45666,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Art Lower Extremity+Upper,PX9392301,CDM,921,RC,93923,CPT,TC,,,,,,,784,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,136.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.46,768.32
Noninvasv Lo Extrem Art Stress/Rest,PX9392401,CDM,921,RC,93924,CPT,TC,,,,,,,810,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,136.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.46,793.8
"Noninvasv Oxygen Satut,Continuous",PX94762,CDM,460,RC,94762,CPT,,,,,,,,242,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,136.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,100.5268,237.16
Spirometry,PX9401001,CDM,460,RC,94010,CPT,TC,,,,,,,281,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,136.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,116.7274,275.38
Spirometry Incl Graph Rec Tc,PX9401002,CDM,460,RC,94010,CPT,TC,,,,,,,288,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,136.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.6352,282.24
methylene blue 1 % Solution 10 mL Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,54288014701,NDC,1,ML,139.25,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,136.465,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.29,1354.4776
Tube Thoracostomy Inc Wtr Seal,PX32551F,CDM,510,RC,32551,CPT,,,,,,,,989,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,136.4675,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.49,317.54
Tube Thoracostomy Inc Wtr Seal,PX32551P,CDM,983,RC,32551,CPT,,,,,,,,1236,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,136.4675,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.49,1211.28
Debride Tissue/Muscle/Bone,PX11044F,CDM,510,RC,11044,CPT,,,,,,,,1082,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,136.56,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.56,646.83
Debride Tissue/Muscle/Bone,PX11044P,CDM,983,RC,11044,CPT,,,,,,,,866,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,136.56,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.56,848.68
"Closed Rx Radial Head Disloc,Child",PX24640F,CDM,510,RC,24640,CPT,,,,,,,,270,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,136.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.158,264.6
Culture Screen Only,PX87081,CDM,300,RC,87081,CPT,,,,,,,,276,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,136.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.08,270.48
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157F,CDM,370,RC,99157,CPT,,,,,,,,270,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,136.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.158,264.6
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157P,CDM,983,RC,99157,CPT,,,,,,,,270,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,136.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.158,262.791
Wound Culture Anaerobic,PX87075,CDM,300,RC,87075,CPT,,,,,,,,270,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,136.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.68,264.6
Assay of CK (Cpk),PX82550,CDM,300,RC,82550,CPT,,,,,,,,150,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,136.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.97,147
Assay of Lactic Acid,PX83605,CDM,300,RC,83605,CPT,,,,,,,,150,,Medica,Commercial,both,91.1,,14.92217391,percent of total billed charges,136.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.61,147
Assay of Phosphorus,PX84100,CDM,300,RC,84100,CPT,,,,,,,,150,,Medica,Commercial,both,91.1,,63.28,percent of total billed charges,136.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.35,147
Bilirubin Direct,PX82248,CDM,300,RC,82248,CPT,,,,,,,,150,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,136.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.6,147
Bilirubin Total,PX82247,CDM,300,RC,82247,CPT,,,,,,,,150,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,136.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.6,147
"Drug(S) or Substance(S), Definitive, Qualitative or Quantitative, Not Otherwise Specified; 1-3 - Ref",PX8037590,CDM,300,RC,80375,CPT,90,,,,,,,150,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,136.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.31,147
"Hsv Detect, Amplif Probe - Ref",PX8752990,CDM,300,RC,87529,CPT,90,,,,,,,150,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,136.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,147
Magnesium,PX83735,CDM,300,RC,83735,CPT,,,,,,,,150,,Medica,Commercial,both,91.1,,27.729375,percent of total billed charges,136.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.14,147
Magnesium - Ref,PX8373590,CDM,300,RC,83735,CPT,90,,,,,,,150,,Medica,Commercial,both,91.1,,27.729375,percent of total billed charges,136.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.14,147
Po4 Inorganic (Phosphate) - Ref,PX8410090,CDM,300,RC,84100,CPT,90,,,,,,,150,,Medica,Commercial,both,91.1,,63.28,percent of total billed charges,136.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.35,147
TB Antigen Response Gamma Interferon T-Cell Susp,PX86481,CDM,300,RC,86481,CPT,,,,,,,,150,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,136.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.31,147
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989001,NDC,50,ML,160.78,,First Health,Commercial,both,85,,999999999,percent of total billed charges,136.663,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989002,NDC,50,ML,160.78,,First Health,Commercial,both,85,,999999999,percent of total billed charges,136.663,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
Facility Emergency Level 1 Visit,PX99281F,CDM,450,RC,99281,CPT,,,,,,,,329,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,136.6666,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.56,322.42
inFLIXimab 100 MG Recon Soln 1 Each Vial,J1745.01,CDM,636,RC,J1745,HCPCS,,,,57894003001,NDC,1,EA,2382.35,,Blue Cross Blue Shield of MN,All commercial plans,both,,,124.100122,fee schedule,136.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.49,2334.703
CYSTOSCOPY PACK I STERILE,120.505,CDM,272,RC,,,,4527-MAIN,LOCAL,,,,,155,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,136.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,151.9
"Hla Class II Low Res, 1 Locus - Ref",PX8137690,CDM,310,RC,81376,CPT,90,,,,,,,279,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,136.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.06,273.42
"Hla Class II Low Res, 1 Locus - Ref",PX8137690,CDM,310,RC,81376,CPT,90,,,,,,,279,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,136.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.06,273.42
"Hla Class II Low Res, 1 Locus - Ref",PX8137690,CDM,310,RC,81376,CPT,90,,,,,,,279,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,136.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.06,273.42
INSUFLOWPORT & PNEUVIEW  XE SMOKE ELIMINATOR 5MM,27200000,CDM,272,RC,,,,11876-MAIN,LOCAL,,,,,279,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,136.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT & PNEUVIEW  XE SMOKE ELIMINATOR 5MM,27200000,CDM,272,RC,,,,11876-MAIN,LOCAL,,,,,279,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,136.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT & PNEUVIEW  XE SMOKE ELIMINATOR 5MM,27200000,CDM,272,RC,,,,11876-MAIN,LOCAL,,,,,279,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,136.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 8MM,27200000,CDM,272,RC,,,,11877-MAIN,LOCAL,,,,,279,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,136.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 8MM,27200000,CDM,272,RC,,,,11877-MAIN,LOCAL,,,,,279,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,136.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 8MM,27200000,CDM,272,RC,,,,11877-MAIN,LOCAL,,,,,279,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,136.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 10MM,27200000,CDM,272,RC,,,,11878-MAIN,LOCAL,,,,,279,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,136.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 10MM,27200000,CDM,272,RC,,,,11878-MAIN,LOCAL,,,,,279,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,136.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 10MM,27200000,CDM,272,RC,,,,11878-MAIN,LOCAL,,,,,279,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,136.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 12MM,27200000,CDM,272,RC,,,,11879-MAIN,LOCAL,,,,,279,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,136.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 12MM,27200000,CDM,272,RC,,,,11879-MAIN,LOCAL,,,,,279,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,136.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 12MM,27200000,CDM,272,RC,,,,11879-MAIN,LOCAL,,,,,279,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,136.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 5MM,27200000,CDM,272,RC,,,,11880-MAIN,LOCAL,,,,,279,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,136.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 5MM,27200000,CDM,272,RC,,,,11880-MAIN,LOCAL,,,,,279,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,136.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 5MM,27200000,CDM,272,RC,,,,11880-MAIN,LOCAL,,,,,279,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,136.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 8MM,27200000,CDM,272,RC,,,,11881-MAIN,LOCAL,,,,,279,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,136.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 8MM,27200000,CDM,272,RC,,,,11881-MAIN,LOCAL,,,,,279,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,136.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 8MM,27200000,CDM,272,RC,,,,11881-MAIN,LOCAL,,,,,279,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,136.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 10MM,27200000,CDM,272,RC,,,,11882-MAIN,LOCAL,,,,,279,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,136.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 10MM,27200000,CDM,272,RC,,,,11882-MAIN,LOCAL,,,,,279,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,136.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 10MM,27200000,CDM,272,RC,,,,11882-MAIN,LOCAL,,,,,279,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,136.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 12MM,27200000,CDM,272,RC,,,,11883-MAIN,LOCAL,,,,,279,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,136.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 12MM,27200000,CDM,272,RC,,,,11883-MAIN,LOCAL,,,,,279,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,136.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 12MM,27200000,CDM,272,RC,,,,11883-MAIN,LOCAL,,,,,279,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,136.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Lab Antibody ID,RBC",PX7605,CDM,300,RC,86870,CPT,,,,,,,,155,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,136.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,314.02
"Office/Outpt Visit,Est,Levl II",PX99212F,CDM,510,RC,99212,CPT,,,,,,,,155,,United Healthcare,All Payer,outpatient,88.2,,55.06,percent of total billed charges,136.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,151.9
"Office/Outpt Visit,Est,Levl II",PX99212P,CDM,983,RC,99212,CPT,,,,,,,,155,,United Healthcare,All Payer,outpatient,88.2,,55.06,percent of total billed charges,136.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,150.8615
Puncture Drainage of Lesion,PX10160F,CDM,510,RC,10160,CPT,,,,,,,,279,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,136.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.8966,348.35
Puncture Drainage of Lesion,PX10160F,CDM,510,RC,10160,CPT,,,,,,,,279,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,136.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.8966,348.35
Puncture Drainage of Lesion,PX10160F,CDM,510,RC,10160,CPT,,,,,,,,279,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,136.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.8966,348.35
Smear Fluorescent/Acid Stai,PX87206,CDM,300,RC,87206,CPT,,,,,,,,155,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,136.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.94,151.9
TB Test Enumeration of T-Cells - Ref,PX8648190,CDM,300,RC,86481,CPT,90,,,,,,,155,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,136.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,151.9
Xray Pelvis 1 or 2 Vws,PX7217001,CDM,320,RC,72170,CPT,TC,,,,,,,279,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,75.58555556,percent of total billed charges,136.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,273.42
Xray Pelvis 1 or 2 Vws,PX7217001,CDM,320,RC,72170,CPT,TC,,,,,,,279,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,136.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,273.42
Xray Pelvis 1 or 2 Vws,PX7217001,CDM,320,RC,72170,CPT,TC,,,,,,,279,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,136.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,273.42
Xray Sacroiliac Jnts 3 or More Vws,PX7220201,CDM,320,RC,72202,CPT,TC,,,,,,,285,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,136.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,279.3
Xray Sacroiliac Jnts 3 or More Vws,PX7220201,CDM,320,RC,72202,CPT,TC,,,,,,,285,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,136.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,279.3
Raltegravir 400 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,6022761,NDC,1,EA,150.2,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,136.8322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Catheterize for Urine Spec,PXP9612,CDM,300,RC,P9612,HCPCS,,,,,,,,161,,First Health,Commercial,both,85,,999999999,percent of total billed charges,136.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.1,157.78
Drain/Inject Small Joint/Bursa,PX20600F,CDM,510,RC,20600,CPT,,,,,,,,161,,First Health,Commercial,both,85,,999999999,percent of total billed charges,136.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.8794,258.75
Drain/Inject Small Joint/Bursa,PX20600P,CDM,983,RC,20600,CPT,,,,,,,,161,,First Health,Commercial,both,85,,999999999,percent of total billed charges,136.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.8794,258.75
Each Add'l Hour IV Infusion <8 Hour,PX96366,CDM,260,RC,96366,CPT,,,,,,,,161,,First Health,Commercial,both,85,,999999999,percent of total billed charges,136.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,157.78
Fresh Frozen Plasma,PXP9017,CDM,390,RC,P9017,HCPCS,,,,,,,,319,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,136.851,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.32,312.62
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,55150017301,NDC,0.5,ML,319.2,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,136.9368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
lidocaine - transparent dressing 4 % Kit 1 Each Box,63700001,CDM,250,RC,,,,,,496088207,NDC,1,EA,270.63,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,136.93878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,51672131200,NDC,22,GR,140.7,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,136.94331,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,409337504,NDC,4,ML,150.36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,136.97796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Remove Intrauterine Device,PX58301,CDM,983,RC,58301,CPT,,,,,,,,357,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,136.98,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.14,349.86
"Molecular Path Proc, Level 2 - Ref",PX8140190,CDM,310,RC,81401,CPT,90,,,,,,,672,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,137,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.89,137
sulfacetamide 10 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,61314070101,NDC,15,ML,285.48,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,137.0304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sulfacetamide 10 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,61314070101,NDC,15,ML,285.48,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,137.0304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
PROSTEP 0.9MM ANTI SKIVE PIN,27200000,CDM,272,RC,,,,12950-MAIN,LOCAL,,,,,154,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,137.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PROSTEP 1.4MM ANTI SKIVE PIN,27200000,CDM,272,RC,,,,12949-MAIN,LOCAL,,,,,154,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,137.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Vit D 1 25-Dihydroxy,PX82652,CDM,300,RC,82652,CPT,,,,,,,,154,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,137.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.3,150.92
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725P,CDM,983,RC,26725,CPT,,,,,,,,330,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,137.082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.082,321.189
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101P,CDM,983,RC,13101,CPT,,,,,,,,330,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,137.082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.082,548.67
"Molecular Cytog, Ea Probe - Ref",PX8827190,CDM,310,RC,88271,CPT,90,,,,,,,277,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,137.115,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.64,271.46
"Xray Neck, Soft Tissue",PX7036001,CDM,320,RC,70360,CPT,TC,,,,,,,277,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,137.115,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,271.46
Strapping of Ankle,PX29540F,CDM,420,RC,29540,CPT,,,,,,,,271,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,137.126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.5734,265.58
ciprofloxacin 0.3 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,61314065625,NDC,2.5,ML,140.92,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,137.157436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
TISSUE RETRIEVAL SYSTEM,27200000,CDM,272,RC,,,,10233-MAIN,LOCAL,,,,,139.98,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,137.1804,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
tranexamic acid 1000 mg in 100 mL 0.7% sodium chloride (premix) 1000-0.7 MG/100ML-% Solution 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,80830232901,NDC,100,ML,155.55,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,137.1951,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Apply Forearm Cast,PX29075P,CDM,983,RC,29075,CPT,,,,,,,,140,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,137.2,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.83,186.09
Hospital Discharge Day>30 Min,PX99239P,CDM,982,RC,99239,CPT,,,,,,,,140,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,137.2,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.8,203.32
"Pertechnetate, Dia, per Mci",PXA9512,CDM,343,RC,A9512,HCPCS,,,,,,,,280,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,137.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,116.312,274.4
"Pertechnetate, Dia, per Mci",PXA9512,CDM,343,RC,A9512,HCPCS,,,,,,,,280,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,137.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,116.312,274.4
"Pertechnetate, Dia, per Mci",PXA9512,CDM,343,RC,A9512,HCPCS,,,,,,,,280,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,137.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,116.312,274.4
Aspergillus Ag - Ref,PX8730590,CDM,300,RC,87305,CPT,90,,,,,,,141,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,137.2353,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,138.18
Apply Long Leg Splint,PX29505F,CDM,510,RC,29505,CPT,,,,,,,,320,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,137.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.928,313.6
Blood Culture for Bacteria,PX87040,CDM,300,RC,87040,CPT,,,,,,,,286,,Health Partners,Health Partners Care Plans,both,48,,209.2536364,percent of total billed charges,137.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.46,280.28
Blood Culture for Bacteria,PX87040,CDM,300,RC,87040,CPT,,,,,,,,286,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,137.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.46,280.28
"IV Infusion, Bamlanivimab, Infusion and Post Admin Monig",PXM0239,CDM,260,RC,M0239,HCPCS,,,,,,,,320,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,137.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.928,313.6
Lab Culture Bacteria,PX87070,CDM,300,RC,87070,CPT,,,,,,,,286,,Health Partners,Health Partners Care Plans,both,48,,152.42,percent of total billed charges,137.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.9,280.28
Lab Culture Bacteria,PX87070,CDM,300,RC,87070,CPT,,,,,,,,286,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,137.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.9,280.28
Urine Culture/Colony Count,PX87086,CDM,300,RC,87086,CPT,,,,,,,,286,,Health Partners,Health Partners Care Plans,both,48,,135.996,percent of total billed charges,137.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4,280.28
Urine Culture/Colony Count,PX87086,CDM,300,RC,87086,CPT,,,,,,,,286,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,137.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4,280.28
buprenorphine 5 MCG/HR PATCH WEEKLY 4 Each Box,63700001,CDM,250,RC,,,,,,42858075040,NDC,1,EA,330.52,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,137.298008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Special Stains,Group I",PX3978,CDM,310,RC,88312,CPT,TC,,,,,,,107,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,137.34,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.74,142.288
"Special Stains,Group I",PX3978,CDM,310,RC,88312,CPT,TC,,,,,,,107,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,137.34,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.74,142.288
doxycycline 100 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323013041,NDC,1,EA,140.2,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,137.396,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Debride Tissue/Muscle/Bone,PX11044F,CDM,510,RC,11044,CPT,,,,,,,,1082,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,137.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.56,646.83
Debride Tissue/Muscle/Bone,PX11044F,CDM,510,RC,11044,CPT,,,,,,,,1082,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,137.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.56,646.83
Debride Tissue/Muscle/Bone,PX11044P,CDM,983,RC,11044,CPT,,,,,,,,866,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,137.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.56,848.68
Debride Tissue/Muscle/Bone,PX11044P,CDM,983,RC,11044,CPT,,,,,,,,866,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,137.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.56,848.68
MINIBUNION NON-LOCKING SCREW  2.7X18MM,C1713,CDM,278,RC,C1713,HCPCS,,11670-MAIN,LOCAL,,,,,280.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,137.445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
MINIBUNION NON-LOCKING SCREW  2.7X18MM,C1713,CDM,278,RC,C1713,HCPCS,,11670-MAIN,LOCAL,,,,,280.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,137.445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
MINIBUNION NON-LOCKING SCREW  2.7X18MM,C1713,CDM,278,RC,C1713,HCPCS,,11670-MAIN,LOCAL,,,,,280.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,137.445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409421505,NDC,5,ML,271.86,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,137.56116,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
Assay Blood Carbon Monoxide,PX82375,CDM,300,RC,82375,CPT,,,,,,,,156,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,137.592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.3,152.88
"Cortisol, Am",PX7152,CDM,300,RC,82533,CPT,,,,,,,,156,,United Healthcare,All Payer,outpatient,88.2,,67.13,percent of total billed charges,137.592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.95,152.88
DERMABOND PRINEO SKIN CLOSURE SYSTEM 22CM,27200000,CDM,272,RC,,,,12324-MAIN,LOCAL,,,,,156,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,137.592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
methylPREDNISolone sod succ 1000 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9001820,NDC,1,EA,271.97,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,137.61682,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,574200815,NDC,15,GR,154.63,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,137.6207,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611P,CDM,983,RC,20611,CPT,,,,,,,,272,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,137.632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.9888,264.7376
Apply Long Arm Splint,PX29105F,CDM,510,RC,29105,CPT,,,,,,,,290,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,137.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.466,284.2
Apply Long Arm Splint,PX29105P,CDM,983,RC,29105,CPT,,,,,,,,385,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,137.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.65,374.7205
Apply Long Leg Splint,PX29505F,CDM,510,RC,29505,CPT,,,,,,,,320,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,137.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.928,313.6
Apply Long Leg Splint,PX29505P,CDM,983,RC,29505,CPT,,,,,,,,385,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,137.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.65,374.7205
Apply Lower Leg Splint,PX29515F,CDM,510,RC,29515,CPT,,,,,,,,296,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,137.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.9584,290.08
Apply Lower Leg Splint,PX29515P,CDM,983,RC,29515,CPT,,,,,,,,311,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,137.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,129.1894,302.6963
Apply Multlay Comprs Lwr Leg,PX29581F,CDM,510,RC,29581,CPT,,,,,,,,213,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,137.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.4802,208.74
Apply Multlay Comprs Lwr Leg,PX29581P,CDM,983,RC,29581,CPT,,,,,,,,142,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,137.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,138.2086
Apply of Paste Boot,PX29580F,CDM,510,RC,29580,CPT,,,,,,,,132,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,137.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.8328,137.65
Apply of Paste Boot,PX29580P,CDM,983,RC,29580,CPT,,,,,,,,88,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,137.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.5552,137.65
Cast/Strap Procedure Unlisted,PX29799F,CDM,510,RC,29799,CPT,,,,,,,,316,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,137.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,131.2664,309.68
Strapping of Ankle,PX29540F,CDM,420,RC,29540,CPT,,,,,,,,271,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,137.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.5734,265.58
eriBULin 1 MG/2ML Solution 2 mL Vial,J9179.01,CDM,636,RC,J9179,HCPCS,,,,62856038901,NDC,2,ML,2321.52,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,137.66,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,117.93,140.72
eriBULin 1 MG/2ML Solution 2 mL Vial,J9179.01,CDM,636,RC,J9179,HCPCS,,,,62856038901,NDC,2,ML,2321.52,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,137.66,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,117.93,140.72
"Bone Marrow Aspiration(S),Diag",PX38220F,CDM,510,RC,38220,CPT,,,,,,,,305,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,137.67,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.1,326.53
"Bone Marrow Aspiration(S),Diag",PX38220P,CDM,983,RC,38220,CPT,,,,,,,,244,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,137.67,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.1,326.53
Sigmoidoscope W/Submuc Inj,PX45335F,CDM,750,RC,45335,CPT,,,,,,,,750,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,137.67,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.23,602.56
Sigmoidoscope W/Submuc Inj,PX45335P,CDM,983,RC,45335,CPT,,,,,,,,500,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,137.67,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.23,602.56
8MM ENDOWRIST INSTRUMENTS CADIERE FORCEPS,27200000,CDM,272,RC,,,,11913-MAIN,LOCAL,,,,,281,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,137.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM ENDOWRIST INSTRUMENTS CADIERE FORCEPS,27200000,CDM,272,RC,,,,11913-MAIN,LOCAL,,,,,281,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,137.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM ENDOWRIST INSTRUMENTS CADIERE FORCEPS,27200000,CDM,272,RC,,,,11913-MAIN,LOCAL,,,,,281,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,137.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
FORCEPS PROGRASP 8MM ENDOWRIST INSTRUMENTS,27200000,CDM,272,RC,,,,12062-MAIN,LOCAL,,,,,281,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,137.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
FORCEPS PROGRASP 8MM ENDOWRIST INSTRUMENTS,27200000,CDM,272,RC,,,,12062-MAIN,LOCAL,,,,,281,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,137.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
FORCEPS PROGRASP 8MM ENDOWRIST INSTRUMENTS,27200000,CDM,272,RC,,,,12062-MAIN,LOCAL,,,,,281,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,137.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Spirometry,PX9401001,CDM,460,RC,94010,CPT,TC,,,,,,,281,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,137.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,116.7274,275.38
Spirometry,PX9401001,CDM,460,RC,94010,CPT,TC,,,,,,,281,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,137.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,116.7274,275.38
Spirometry,PX9401001,CDM,460,RC,94010,CPT,TC,,,,,,,281,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,137.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,116.7274,275.38
Acetone Assay,PX82010,CDM,300,RC,82010,CPT,,,,,,,,162,,First Health,Commercial,both,85,,999999999,percent of total billed charges,137.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.49,158.76
"Flow Interp,2-8 Markers - Ref",PX8818790,CDM,310,RC,88187,CPT,90,,,,,,,162,,First Health,Commercial,both,85,,999999999,percent of total billed charges,137.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.1,158.76
KIT THORACENTESIS PLEURA SEAL AK-01000-T,120.24,CDM,272,RC,,,,1147-MAIN,LOCAL,,,,,162,,First Health,Commercial,both,85,,999999999,percent of total billed charges,137.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.2948,158.76
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,65162083366,NDC,100,GR,281.12,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,137.7488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,65162083366,NDC,100,GR,281.12,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,137.7488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,65162083366,NDC,100,GR,281.12,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,137.7488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dexAMETHasone 0.1 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,24208072002,NDC,5,ML,331.81,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,137.833874,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ARIPiprazole 2 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714014101,NDC,1,EA,151.35,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,137.87985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,51672131200,NDC,22,GR,140.7,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,137.886,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
hepatitis B immune globulin 312 UNIT/ML Solution 5 mL Vial,90371,CDM,636,RC,90371,CPT,,,,59730420301,NDC,5,ML,2851.63,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,137.89,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.19,138.3079
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,55150012150,NDC,1,EA,151.41,,Medica,Commercial,both,91.1,,5.442333333,percent of total billed charges,137.93451,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
CYSTOSCOPY PACK I STERILE,120.505,CDM,272,RC,,,,4527-MAIN,LOCAL,,,,,155,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,137.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,151.9
"Lab Antibody ID,RBC",PX7605,CDM,300,RC,86870,CPT,,,,,,,,155,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,137.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,314.02
"Office/Outpt Visit,Est,Levl II",PX99212F,CDM,510,RC,99212,CPT,,,,,,,,155,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,137.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,151.9
"Office/Outpt Visit,Est,Levl II",PX99212P,CDM,983,RC,99212,CPT,,,,,,,,155,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,137.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,150.8615
Smear Fluorescent/Acid Stai,PX87206,CDM,300,RC,87206,CPT,,,,,,,,155,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,137.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.94,151.9
TB Test Enumeration of T-Cells - Ref,PX8648190,CDM,300,RC,86481,CPT,90,,,,,,,155,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,137.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,151.9
US Pregnancy Tc Follow-Up,PX7681601,CDM,402,RC,76816,CPT,TC,,,,,,,362,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,138.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.26,138.05
US Pregnancy Tc Follow-Up,PX7681601,CDM,402,RC,76816,CPT,TC,,,,,,,362,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,138.05,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.26,138.05
linezolid 600 MG/300ML Solution 300 mL Flex Cont,J2020.01,CDM,636,RC,J2020,HCPCS,,,,9514001,NDC,300,ML,332.42,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,138.087268,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.087268,325.7716
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384F,CDM,750,RC,45384,CPT,,,,,,,,2350,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,138.09,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.09,1011.41
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384P,CDM,983,RC,45384,CPT,,,,,,,,1436,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,138.09,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.09,1407.28
morphine 20 mg/mL Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,54040444,NDC,30,ML,141.88,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,138.091804,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin 0.3 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,61314065625,NDC,2.5,ML,140.92,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,138.1016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Hla Class II Low Res, 1 Locus - Ref",PX8137690,CDM,310,RC,81376,CPT,90,,,,,,,279,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,138.105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.06,273.42
INSUFLOWPORT & PNEUVIEW  XE SMOKE ELIMINATOR 5MM,27200000,CDM,272,RC,,,,11876-MAIN,LOCAL,,,,,279,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,138.105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 8MM,27200000,CDM,272,RC,,,,11877-MAIN,LOCAL,,,,,279,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,138.105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 10MM,27200000,CDM,272,RC,,,,11878-MAIN,LOCAL,,,,,279,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,138.105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 12MM,27200000,CDM,272,RC,,,,11879-MAIN,LOCAL,,,,,279,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,138.105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 5MM,27200000,CDM,272,RC,,,,11880-MAIN,LOCAL,,,,,279,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,138.105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 8MM,27200000,CDM,272,RC,,,,11881-MAIN,LOCAL,,,,,279,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,138.105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 10MM,27200000,CDM,272,RC,,,,11882-MAIN,LOCAL,,,,,279,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,138.105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 12MM,27200000,CDM,272,RC,,,,11883-MAIN,LOCAL,,,,,279,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,138.105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Puncture Drainage of Lesion,PX10160F,CDM,510,RC,10160,CPT,,,,,,,,279,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,138.105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.8966,348.35
Xray Pelvis 1 or 2 Vws,PX7217001,CDM,320,RC,72170,CPT,TC,,,,,,,279,,Humana Choice Care,All Medicare plans,outpatient,49.5,,273.42,percent of total billed charges,138.105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,273.42
Aspergillus Ag - Ref,PX8730590,CDM,300,RC,87305,CPT,90,,,,,,,141,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,138.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,138.18
Xray Finger(S) Tc,PX7314001,CDM,320,RC,73140,CPT,TC,,,,,,,282,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,163.8,percent of total billed charges,138.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,276.36
Xray Finger(S) Tc,PX7314001,CDM,320,RC,73140,CPT,TC,,,,,,,282,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,138.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,276.36
Xray Finger(S) Tc,PX7314001,CDM,320,RC,73140,CPT,TC,,,,,,,282,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,138.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,276.36
Xray Toe(S) Tc,PX7366001,CDM,320,RC,73660,CPT,TC,,,,,,,282,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,54.6,percent of total billed charges,138.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,276.36
Xray Toe(S) Tc,PX7366001,CDM,320,RC,73660,CPT,TC,,,,,,,282,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,138.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,276.36
Xray Toe(S) Tc,PX7366001,CDM,320,RC,73660,CPT,TC,,,,,,,282,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,138.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,276.36
Apply Multlay Comprs Lwr Leg,PX29581P,CDM,983,RC,29581,CPT,,,,,,,,142,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,138.2086,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,138.2086
"Biopsy Vulva/Perineum,One Lesn",PX56605P,CDM,983,RC,56605,CPT,,,,,,,,142,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,138.2086,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,702.31
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006P,CDM,983,RC,10006,CPT,,,,,,,,142,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,138.2086,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,138.2086
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760,CDM,420,RC,97760,CPT,,,,,,,,142,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,27,percent of total billed charges,138.2086,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.18,139.16
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760F,CDM,510,RC,97760,CPT,,,,,,,,142,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,27,percent of total billed charges,138.2086,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.18,139.16
Oximetry;Mult Determine,PX610,CDM,460,RC,94761,CPT,,,,,,,,142,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,138.2086,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,139.16
Thromboplastin Time Partial,PX85730,CDM,300,RC,85730,CPT,,,,,,,,142,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,37.81826087,percent of total billed charges,138.2086,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.51,139.16
X-Ray Exam Femur 1 Vw,PX7355101,CDM,320,RC,73551,CPT,TC,,,,,,,142,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,138.2086,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,139.16
CHOLANGIOGRAM CATHETER REDDICK,27200000,CDM,272,RC,,,,10232-MAIN,LOCAL,,,,,287.98,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,138.2304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CHOLANGIOGRAM CATHETER REDDICK,27200000,CDM,272,RC,,,,10232-MAIN,LOCAL,,,,,287.98,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,138.2304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Spirometry Incl Graph Rec Tc,PX9401002,CDM,460,RC,94010,CPT,TC,,,,,,,288,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,138.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.6352,282.24
Spirometry Incl Graph Rec Tc,PX9401002,CDM,460,RC,94010,CPT,TC,,,,,,,288,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,138.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.6352,282.24
hepatitis B immune globulin 312 UNIT/ML Solution 5 mL Vial,90371,CDM,636,RC,90371,CPT,,,,59730420301,NDC,5,ML,2851.63,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,138.3079,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.19,138.3079
ketoconazole 2 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,16714095501,NDC,15,GR,322.42,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,138.31818,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Fna Biopsy, W/US Guidance; First Lesion",PX10005F,CDM,510,RC,10005,CPT,,,,,,,,333,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,138.3282,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.3282,614.65
Ultrasound Breast Complete,PX7664101,CDM,402,RC,76641,CPT,TC,,,,,,,333,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,138.3282,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,326.34
Resp Virus 3-5 Targets,PX87631,CDM,300,RC,87631,CPT,,,,,,,,459,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,138.35,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.35,142.63
Resp Virus 3-5 Targets,PX87631,CDM,300,RC,87631,CPT,,,,,,,,459,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,138.35,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.35,142.63
"Infectious Disease (Viral Respiratory Tract Infection),",PX0241U,CDM,300,RC,0241U,HCPCS,,,,,,,,457,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,138.35,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.35,142.63
Resp Virus 3-5 Targets,PX87631,CDM,300,RC,87631,CPT,,,,,,,,459,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,138.35,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.35,142.63
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,781375575,NDC,4,ML,142.22,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,138.422726,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium zirconium cyclosilicate 5 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,310110501,NDC,1,EA,151.95,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,138.42645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tranexamic acid 1000 mg in 100 mL 0.7% sodium chloride (premix) 1000-0.7 MG/100ML-% Solution 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,80830232901,NDC,100,ML,155.55,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,138.4395,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Antipsychotics, Not Otherwise Specified; 1-3 - Ref",PX8034290,CDM,300,RC,80342,CPT,90,,,,,,,152,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,138.472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.1408,148.96
Body Fluid Cell Count,PX89050,CDM,300,RC,89050,CPT,,,,,,,,152,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,138.472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.33,148.96
Assay of Psa Total,PX84153,CDM,300,RC,84153,CPT,,,,,,,,157,,United Healthcare,All Payer,outpatient,88.2,,83.21,percent of total billed charges,138.474,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.86,153.86
"Chlamydia Trachomatis Dna, Amp Probe",PX87491,CDM,300,RC,87491,CPT,,,,,,,,157,,United Healthcare,All Payer,outpatient,88.2,,71.44,percent of total billed charges,138.474,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,153.86
"Cognitive Skill Dev, Ea 15 Min",PX97532,CDM,420,RC,97532,CPT,,,,,,,,157,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,138.474,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.2178,153.86
"Fungal Culture, Other Source - Ref",PX8710290,CDM,300,RC,87102,CPT,90,,,,,,,157,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,138.474,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.71,153.86
Lactate (Ld) (Ldh) Enzyme,PX83615,CDM,300,RC,83615,CPT,,,,,,,,157,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,138.474,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.54,153.86
"Neisseria Gonorrhoeae Dna, Amp Probe",PX87591,CDM,300,RC,87591,CPT,,,,,,,,157,,United Healthcare,All Payer,outpatient,88.2,,71.44,percent of total billed charges,138.474,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,153.86
Psa Screening,PXG0103,CDM,300,RC,G0103,HCPCS,,,,,,,,157,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,138.474,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.71,153.86
Remv Ext Canal Foreign Body,PX69200P,CDM,983,RC,69200,CPT,,,,,,,,157,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,138.474,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.2178,152.8081
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384F,CDM,750,RC,45384,CPT,,,,,,,,2350,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,138.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.09,1011.41
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384F,CDM,750,RC,45384,CPT,,,,,,,,2350,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,138.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.09,1011.41
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384P,CDM,983,RC,45384,CPT,,,,,,,,1436,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,138.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.09,1407.28
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384P,CDM,983,RC,45384,CPT,,,,,,,,1436,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,138.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.09,1407.28
Egd Balloon Dil Esoph30 Mm/>,PX43233F,CDM,750,RC,43233,CPT,,,,,,,,1120,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,138.52,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.52,468.35
Egd Balloon Dil Esoph30 Mm/>,PX43233P,CDM,983,RC,43233,CPT,,,,,,,,480,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,138.52,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.52,470.4
Ehrlichia (Anaplasma) Ab - Ref,PX8666690,CDM,300,RC,86666,CPT,90,,,,,,,163,,First Health,Commercial,both,85,,999999999,percent of total billed charges,138.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.33,159.74
Xray Ankle 2 Vws,PX7360001,CDM,320,RC,73600,CPT,TC,,,,,,,163,,First Health,Commercial,both,85,,999999999,percent of total billed charges,138.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.7102,159.74
Xray Ls Spine Bend Tc,PX7212001,CDM,320,RC,72120,CPT,TC,,,,,,,323,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,138.567,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,316.54
"Pertechnetate, Dia, per Mci",PXA9512,CDM,343,RC,A9512,HCPCS,,,,,,,,280,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,138.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,116.312,274.4
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597P,CDM,983,RC,97597,CPT,,,,,,,,274,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,138.644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,113.8196,266.6842
STAPLER RELOAD-CURVED CUTTER,27200000,CDM,272,RC,,,,12063-MAIN,LOCAL,,,,,283,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,138.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STAPLER RELOAD-CURVED CUTTER,27200000,CDM,272,RC,,,,12063-MAIN,LOCAL,,,,,283,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,138.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STAPLER RELOAD-CURVED CUTTER,27200000,CDM,272,RC,,,,12063-MAIN,LOCAL,,,,,283,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,138.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
cadexomer iodine 0.9 % Gel 40 g Tube,63700001,CDM,250,RC,,,,,,40565012249,NDC,40,GR,333.86,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,138.685444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
US Scrotum & Contents Tc,PX7687001,CDM,402,RC,76870,CPT,TC,,,,,,,457,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,138.71,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.12,138.71
US Scrotum & Contents Tc,PX7687001,CDM,402,RC,76870,CPT,TC,,,,,,,457,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,138.71,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.12,138.71
BONE SCREW T8 FULL THREAD 2.4MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12652-MAIN,LOCAL,,,,,289,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,138.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
BONE SCREW T8 FULL THREAD 2.4MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12652-MAIN,LOCAL,,,,,289,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,138.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
BONE SCREW T8 FULL THREAD 2.4MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12653-MAIN,LOCAL,,,,,289,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,138.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
BONE SCREW T8 FULL THREAD 2.4MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12653-MAIN,LOCAL,,,,,289,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,138.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
BONE SCREW T8 FULL THREAD 2.7MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12654-MAIN,LOCAL,,,,,289,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,138.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
BONE SCREW T8 FULL THREAD 2.7MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12654-MAIN,LOCAL,,,,,289,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,138.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Occupational Therapy Eval High Complex,PX97167,CDM,434,RC,97167,CPT,,,,,,,,289,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,138.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,283.22
Occupational Therapy Eval High Complex,PX97167,CDM,434,RC,97167,CPT,,,,,,,,289,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,138.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,283.22
"Troponin, Quantitative",PX84484,CDM,300,RC,84484,CPT,,,,,,,,289,,Health Partners,Health Partners Care Plans,both,48,,158.695,percent of total billed charges,138.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.43,283.22
"Troponin, Quantitative",PX84484,CDM,300,RC,84484,CPT,,,,,,,,289,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,138.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.43,283.22
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047621,NDC,1,ML,157.28,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,138.72096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.354486,332.1514
Clotting Function Activity - Ref,PX8539790,CDM,300,RC,85397,CPT,90,,,,,,,334,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,138.7436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.3,327.32
"Remv F.B.,Eye,Cornea,No Slit",PX65220F,CDM,510,RC,65220,CPT,,,,,,,,334,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,138.7436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.7436,348.08
Repeat Control of Nosebleed,PX30906F,CDM,510,RC,30906,CPT,,,,,,,,334,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,138.7436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.7436,327.32
X-Ray Abdomen 2+ Views W/ Single Vw Chest (Tc),PX7402201,CDM,320,RC,74022,CPT,TC,,,,,,,334,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,138.7436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,327.32
"Office Consultation,Level III",PX99243P,CDM,983,RC,99243,CPT,,,,,,,,374,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,138.832,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.65,366.52
Assay Blood Carbon Monoxide,PX82375,CDM,300,RC,82375,CPT,,,,,,,,156,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,138.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.3,152.88
"Cortisol, Am",PX7152,CDM,300,RC,82533,CPT,,,,,,,,156,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,138.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.95,152.88
DERMABOND PRINEO SKIN CLOSURE SYSTEM 22CM,27200000,CDM,272,RC,,,,12324-MAIN,LOCAL,,,,,156,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,138.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MINIBUNION NON-LOCKING SCREW  2.7X18MM,C1713,CDM,278,RC,C1713,HCPCS,,11670-MAIN,LOCAL,,,,,280.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,138.8475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062160,NDC,0.6,ML,274.53,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,138.91218,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801601,NDC,0.6,ML,274.53,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,138.91218,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801610,NDC,0.6,ML,274.53,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,138.91218,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
"Exc Skn Beig1.1-2cm Face,Facil",PX11442P,CDM,983,RC,11442,CPT,,,,,,,,886,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,139.0363,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.15,868.28
"Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601P,CDM,983,RC,11601,CPT,,,,,,,,1046,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,139.0363,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.37,1025.08
"Fac/Exc Skn Beni1.1-2cm Fce,Facial",PX11442F,CDM,510,RC,11442,CPT,,,,,,,,668,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,139.0363,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.15,404.01
"Fac/Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601F,CDM,510,RC,11601,CPT,,,,,,,,673,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,139.0363,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.37,476.65
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,517096010,NDC,10,ML,157.64,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,139.03848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
morphine 20 mg/mL Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,54040444,NDC,30,ML,141.88,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,139.0424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Injection Hip Arthrogram,PX27093F,CDM,510,RC,27093,CPT,,,,,,,,654,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,139.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.66,477.34
"N Block Inj, Common Digit",PX64632F,CDM,510,RC,64632,CPT,,,,,,,,190,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,139.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.88,188.86
"N Block Inj, Common Digit",PX64632P,CDM,983,RC,64632,CPT,,,,,,,,128,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,139.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.88,188.86
prednisoLONE acetate 1 % Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063705,NDC,5,ML,283.79,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,139.0571,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
prednisoLONE acetate 1 % Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063705,NDC,5,ML,283.79,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,139.0571,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
prednisoLONE acetate 1 % Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063705,NDC,5,ML,283.79,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,139.0571,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
8MM ENDOWRIST INSTRUMENTS CADIERE FORCEPS,27200000,CDM,272,RC,,,,11913-MAIN,LOCAL,,,,,281,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,139.095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
FORCEPS PROGRASP 8MM ENDOWRIST INSTRUMENTS,27200000,CDM,272,RC,,,,12062-MAIN,LOCAL,,,,,281,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,139.095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Spirometry,PX9401001,CDM,460,RC,94010,CPT,TC,,,,,,,281,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,139.095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,116.7274,275.38
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127303,NDC,2,ML,152.7,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,139.1097,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.43158,173.019
HERCULES 3 STAGE BALLOON ESOPHAGEAL 12-13.5-15::36-40.5-45MM,27200000,CDM,272,RC,C1726,HCPCS,,11329-MAIN,LOCAL,,,,,289.85,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,139.128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HERCULES 3 STAGE BALLOON ESOPHAGEAL 12-13.5-15::36-40.5-45MM,27200000,CDM,272,RC,C1726,HCPCS,,11329-MAIN,LOCAL,,,,,289.85,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,139.128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HERCULES 3 STAGE BALLOON ESOPHAGEAL 15-16.5-18:45-49.5-54MM,27200000,CDM,272,RC,C1726,HCPCS,,11328-MAIN,LOCAL,,,,,289.85,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,139.128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HERCULES 3 STAGE BALLOON ESOPHAGEAL 15-16.5-18:45-49.5-54MM,27200000,CDM,272,RC,C1726,HCPCS,,11328-MAIN,LOCAL,,,,,289.85,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,139.128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HERCULES 3 STAGE BALLOON ESOPHAGEAL 18-19-20::54-57-60MM,27200000,CDM,272,RC,C1726,HCPCS,,11330-MAIN,LOCAL,,,,,289.85,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,139.128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HERCULES 3 STAGE BALLOON ESOPHAGEAL 18-19-20::54-57-60MM,27200000,CDM,272,RC,C1726,HCPCS,,11330-MAIN,LOCAL,,,,,289.85,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,139.128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151P,CDM,983,RC,99151,CPT,,,,,,,,275,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,139.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,114.235,267.6575
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,65162083366,NDC,100,GR,281.12,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,139.1544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Close Rx Dist Fingr Fx,Manipulatn",PX26755F,CDM,510,RC,26755,CPT,,,,,,,,335,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,139.159,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
"Closed Rx I-P Jt,Toe Dislocation",PX28660F,CDM,510,RC,28660,CPT,,,,,,,,335,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,139.159,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Insitu Hybridization (Fish),PX8836401,CDM,310,RC,88364,CPT,TC,,,,,,,335,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,139.159,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Reduce Temporomandibl Disloc,PX21480F,CDM,510,RC,21480,CPT,,,,,,,,335,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,139.159,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Repr Superf Wnd Face <2.5cm,PX12011F,CDM,510,RC,12011,CPT,,,,,,,,335,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,139.159,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Apply Multlay Comprs Lwr Leg,PX29581P,CDM,983,RC,29581,CPT,,,,,,,,142,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,139.16,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.01,182.64
"Biopsy Vulva/Perineum,One Lesn",PX56605P,CDM,983,RC,56605,CPT,,,,,,,,142,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,139.16,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.99,201.31
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006P,CDM,983,RC,10006,CPT,,,,,,,,142,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,139.16,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.76,139.16
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760,CDM,420,RC,97760,CPT,,,,,,,,142,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,139.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.18,139.16
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760F,CDM,510,RC,97760,CPT,,,,,,,,142,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,139.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.18,139.16
Oximetry;Mult Determine,PX610,CDM,460,RC,94761,CPT,,,,,,,,142,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,139.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,139.16
Thromboplastin Time Partial,PX85730,CDM,300,RC,85730,CPT,,,,,,,,142,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,139.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.51,139.16
X-Ray Exam Femur 1 Vw,PX7355101,CDM,320,RC,73551,CPT,TC,,,,,,,142,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,139.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,139.16
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703334301,NDC,0.5,ML,142.98,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,139.162434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963805,NDC,0.5,ML,142.98,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,139.162434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
Egd Balloon Dil Esoph30 Mm/>,PX43233F,CDM,750,RC,43233,CPT,,,,,,,,1120,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,139.18,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.52,468.35
Egd Balloon Dil Esoph30 Mm/>,PX43233F,CDM,750,RC,43233,CPT,,,,,,,,1120,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,139.18,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.52,468.35
Egd Balloon Dil Esoph30 Mm/>,PX43233P,CDM,983,RC,43233,CPT,,,,,,,,480,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,139.18,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.52,470.4
Egd Balloon Dil Esoph30 Mm/>,PX43233P,CDM,983,RC,43233,CPT,,,,,,,,480,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,139.18,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.52,470.4
Apply Long Arm Splint,PX29105F,CDM,510,RC,29105,CPT,,,,,,,,290,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,139.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.466,284.2
Apply Long Arm Splint,PX29105F,CDM,510,RC,29105,CPT,,,,,,,,290,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,139.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.466,284.2
Assay of Digoxin,PX80162,CDM,300,RC,80162,CPT,,,,,,,,290,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,139.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.18,284.2
Assay of Digoxin,PX80162,CDM,300,RC,80162,CPT,,,,,,,,290,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,139.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.18,284.2
Assay of Natriuretic Peptide,PX83880,CDM,300,RC,83880,CPT,,,,,,,,290,,Health Partners,Health Partners Care Plans,both,48,,134.47,percent of total billed charges,139.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36,284.2
Assay of Natriuretic Peptide,PX83880,CDM,300,RC,83880,CPT,,,,,,,,290,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,139.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36,284.2
NEEDLE INTRAOSSEOUS SET 15GA 25MM STABILIZER EZ-IO 9001P,120.216,CDM,272,RC,A4215,HCPCS,,10648-MAIN,LOCAL,,,,,290,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,139.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.466,284.2
NEEDLE INTRAOSSEOUS SET 15GA 25MM STABILIZER EZ-IO 9001P,120.216,CDM,272,RC,A4215,HCPCS,,10648-MAIN,LOCAL,,,,,290,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,139.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.466,284.2
NEEDLE INTRAOSSEOUS SET 15GA 45MM STABILIZER EZ-IO 9079P,120.216,CDM,272,RC,A4215,HCPCS,,10297-MAIN,LOCAL,,,,,290,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,139.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.466,284.2
NEEDLE INTRAOSSEOUS SET 15GA 45MM STABILIZER EZ-IO 9079P,120.216,CDM,272,RC,A4215,HCPCS,,10297-MAIN,LOCAL,,,,,290,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,139.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.466,284.2
phytonadione 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714097302,NDC,0.5,EA,143.02,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,139.201366,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phytonadione 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,69238105103,NDC,0.5,EA,143.02,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,139.201366,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ROPivacaine 2 MG/ML Solution 100 mL Bottle,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028568,NDC,100,ML,275.11,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,139.20566,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.604954,269.6078
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,55150043801,NDC,20,ML,152.9,,Medica,Commercial,both,91.1,,7.37,percent of total billed charges,139.2919,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457018120,NDC,20,ML,152.9,,Medica,Commercial,both,91.1,,7.37,percent of total billed charges,139.2919,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821517,NDC,3,ML,275.33,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,139.31698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
Antithrombin III Activity - Ref,PX8530090,CDM,300,RC,85300,CPT,90,,,,,,,158,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,139.356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.87,154.84
Fac/Trm Hyperkeratotic Skn Lesn2-4,PX11056F,CDM,510,RC,11056,CPT,,,,,,,,158,,United Healthcare,All Payer,outpatient,88.2,,74.97,percent of total billed charges,139.356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.6332,174.9
"Glucose, Body Fluid Other Than Blood",PX82945,CDM,300,RC,82945,CPT,,,,,,,,158,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,139.356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.6,154.84
Protein C Activity - Ref,PX8530390,CDM,300,RC,85303,CPT,90,,,,,,,158,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,139.356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.69,154.84
"Triiodothyronine T3, Tot - Ref",PX8448090,CDM,300,RC,84480,CPT,90,,,,,,,158,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,139.356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13,154.84
Debride Tissue/Muscle,PX11043F,CDM,510,RC,11043,CPT,,,,,,,,526,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,139.3574,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.8,483.57
Debride Tissue/Muscle,PX11043P,CDM,983,RC,11043,CPT,,,,,,,,351,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,139.3574,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.8,483.57
"Up GI Endoscopy,Ball Dil,30mm",PX43249F,CDM,750,RC,43249,CPT,,,,,,,,2596,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,139.3574,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.8,2216.53
"Up GI Endoscopy,Ball Dil,30mm",PX43249P,CDM,983,RC,43249,CPT,,,,,,,,1731,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,139.3574,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.8,2216.53
nystatin 100000 UNIT/GM Powder 60 g Bottle,63700001,CDM,250,RC,,,,,,68308015260,NDC,60,GR,335.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,139.3667,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,781375575,NDC,4,ML,142.22,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,139.3756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ELECTRODE ADULT PACING ONESTEP,120.214,CDM,272,RC,A4556,HCPCS,,10242-MAIN,LOCAL,,,,,153,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,139.383,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.5562,149.94
"Protein, Total; Other Source",PX84157,CDM,300,RC,84157,CPT,,,,,,,,153,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,139.383,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.67,149.94
Pulmonary Stress Test,PX94618,CDM,976,RC,94618,CPT,,,,,,,,153,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,139.383,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.5562,148.9149
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457018100,NDC,20,ML,153.01,,Medica,Commercial,both,91.1,,7.37,percent of total billed charges,139.39211,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
Tx/Pro/Dx Inj Same Drug Adon,PX96376,CDM,260,RC,96376,CPT,,,,,,,,164,,First Health,Commercial,both,85,,999999999,percent of total billed charges,139.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.1256,160.72
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156F,CDM,370,RC,99156,CPT,,,,,,,,325,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,139.425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,318.5
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156P,CDM,983,RC,99156,CPT,,,,,,,,325,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,139.425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,316.3225
Refill/Maint Portable Pump,PX96521,CDM,260,RC,96521,CPT,,,,,,,,325,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,139.425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,318.5
"Remv F.B.,Eye,Embed Conjunc",PX65210F,CDM,510,RC,65210,CPT,,,,,,,,325,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,139.425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,348.08
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598P,CDM,982,RC,97598,CPT,,,,,,,,325,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,139.425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,316.3225
Somatostatin - Ref,PX8430790,CDM,300,RC,84307,CPT,90,,,,,,,325,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,139.425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.76,318.5
"Tiss Cult, Neopl, Bm, Wb - Ref",PX8823790,CDM,310,RC,88237,CPT,90,,,,,,,3141,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,139.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.44,143.75
"Tiss Cult, Neopl, Bm, Wb - Ref",PX8823790,CDM,310,RC,88237,CPT,90,,,,,,,3141,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,139.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.44,143.75
"Tiss Cult, Neopl, Bm, Wb - Ref",PX8823790,CDM,310,RC,88237,CPT,90,,,,,,,3141,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,139.44,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.44,143.75
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082143,NDC,1,ML,348.85,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,139.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.48,367.9214
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082152,NDC,1,ML,375.43,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,139.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.48,367.9214
cloNIDine 0.1 MG/24HR PATCH WEEKLY 4 Each Box,63700001,CDM,250,RC,,,,,,51862045304,NDC,1,EA,158.16,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,139.49712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 360-4.14 MG/200ML-% Solution 200 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066036020,NDC,200,ML,325.25,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,139.53225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.35,318.745
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862066230,NDC,1,EA,153.17,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,139.53787,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954201,NDC,10,ML,153.18,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,139.54698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.630972,150.1164
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954210,NDC,10,ML,153.18,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,139.54698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.630972,150.1164
Assay of Phenytoin Total,PX80185,CDM,300,RC,80185,CPT,,,,,,,,336,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,139.5744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,329.28
Xray Finger(S) Tc,PX7314001,CDM,320,RC,73140,CPT,TC,,,,,,,282,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,139.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,276.36
Xray Toe(S) Tc,PX7366001,CDM,320,RC,73660,CPT,TC,,,,,,,282,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,139.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,276.36
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Plas Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,338604648,NDC,100,ML,143.42,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,139.590686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.786918,140.5516
Xray Sacroiliac Jnts 3 or More Vws,PX7220201,CDM,320,RC,72202,CPT,TC,,,,,,,285,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,139.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,279.3
Xray Sacroiliac Jnts 3 or More Vws,PX7220201,CDM,320,RC,72202,CPT,TC,,,,,,,285,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,139.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,279.3
Xray Sacroiliac Jnts 3 or More Vws,PX7220201,CDM,320,RC,72202,CPT,TC,,,,,,,285,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,139.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,279.3
Culture Screen Only,PX87081,CDM,300,RC,87081,CPT,,,,,,,,276,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,139.656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.08,270.48
Assay of Psa Total,PX84153,CDM,300,RC,84153,CPT,,,,,,,,157,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,139.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.86,153.86
"Chlamydia Trachomatis Dna, Amp Probe",PX87491,CDM,300,RC,87491,CPT,,,,,,,,157,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,139.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,153.86
"Cognitive Skill Dev, Ea 15 Min",PX97532,CDM,420,RC,97532,CPT,,,,,,,,157,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,139.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.2178,153.86
"Fungal Culture, Other Source - Ref",PX8710290,CDM,300,RC,87102,CPT,90,,,,,,,157,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,139.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.71,153.86
Lactate (Ld) (Ldh) Enzyme,PX83615,CDM,300,RC,83615,CPT,,,,,,,,157,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,139.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.54,153.86
"Neisseria Gonorrhoeae Dna, Amp Probe",PX87591,CDM,300,RC,87591,CPT,,,,,,,,157,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,139.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,153.86
Psa Screening,PXG0103,CDM,300,RC,G0103,HCPCS,,,,,,,,157,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,139.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.71,153.86
Remv Ext Canal Foreign Body,PX69200P,CDM,983,RC,69200,CPT,,,,,,,,157,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,139.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.2178,152.8081
ENDOLOOP COATED VICRYL 0 18,27200000,CDM,272,RC,,,,10228-MAIN,LOCAL,,,,,143.6,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,139.76588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Infectious Disease (Viral Respiratory Tract Infection),",PX0241U,CDM,300,RC,0241U,HCPCS,,,,,,,,457,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,139.78404,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.35,142.63
Resp Virus 3-5 Targets,PX87631,CDM,300,RC,87631,CPT,,,,,,,,459,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,139.78404,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.35,142.63
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010365,NDC,100,ML,164.54,,First Health,Commercial,both,85,,999999999,percent of total billed charges,139.859,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.174958,180.2416
sulfacetamide 10 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,61314070101,NDC,15,ML,285.48,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,139.8852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sulfacetamide 10 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,61314070101,NDC,15,ML,285.48,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,139.8852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sulfacetamide 10 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,61314070101,NDC,15,ML,285.48,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,139.8852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Lvl 2 Sub Hosp Mod Mdm or 35 Minute,PX99232,CDM,982,RC,99232,CPT,,,,,,,,253,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,139.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.54,247.94
Lvl 2 Sub Hosp Mod Mdm or 35 Minute,PX99232,CDM,982,RC,99232,CPT,,,,,,,,253,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,139.93,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.54,247.94
folic acid 5 MG/ML Solution 10 mL Vial,J3490.94,CDM,636,RC,J3490,HCPCS,,,,63323018410,NDC,10,ML,336.94,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,139.964876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,330.2012
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047621,NDC,1,ML,157.28,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,139.9792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.354486,332.1514
Emergency Level II Visit,PX99282P,CDM,981,RC,99282,CPT,,,,,,,,337,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,139.9898,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.9898,328.0021
"OB US < 14 Wks, Single Fetus - Radiology, Tech",PX7680101,CDM,402,RC,76801,CPT,TC,,,,,,,472,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,140.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.35,140.03
"OB US < 14 Wks, Single Fetus - Radiology, Tech",PX7680101,CDM,402,RC,76801,CPT,TC,,,,,,,472,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,140.03,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.35,140.03
STAPLER RELOAD-CURVED CUTTER,27200000,CDM,272,RC,,,,12063-MAIN,LOCAL,,,,,283,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,140.085,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703334301,NDC,0.5,ML,142.98,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,140.1204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963805,NDC,0.5,ML,142.98,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,140.1204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
Blood Culture for Bacteria,PX87040,CDM,300,RC,87040,CPT,,,,,,,,286,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,13.79396226,percent of total billed charges,140.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.46,280.28
Blood Culture for Bacteria,PX87040,CDM,300,RC,87040,CPT,,,,,,,,286,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,140.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.46,280.28
Blood Culture for Bacteria,PX87040,CDM,300,RC,87040,CPT,,,,,,,,286,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,140.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.46,280.28
I&D Bartholin Gland Abscess,PX56420P,CDM,983,RC,56420,CPT,,,,,,,,286,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,140.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,118.8044,278.3638
I&D Bartholin Gland Abscess,PX56420P,CDM,983,RC,56420,CPT,,,,,,,,286,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,140.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,118.8044,278.3638
I&D Bartholin Gland Abscess,PX56420P,CDM,983,RC,56420,CPT,,,,,,,,286,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,140.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,118.8044,278.3638
Joint Survey,PX7707726,CDM,982,RC,77077,CPT,26,,,,,,,286,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,140.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,278.3638
Joint Survey,PX7707726,CDM,982,RC,77077,CPT,26,,,,,,,286,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,140.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,278.3638
Joint Survey,PX7707726,CDM,982,RC,77077,CPT,26,,,,,,,286,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,140.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,278.3638
Lab Culture Bacteria,PX87070,CDM,300,RC,87070,CPT,,,,,,,,286,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,140.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.9,280.28
Lab Culture Bacteria,PX87070,CDM,300,RC,87070,CPT,,,,,,,,286,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,140.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.9,280.28
Lab Culture Bacteria,PX87070,CDM,300,RC,87070,CPT,,,,,,,,286,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,140.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.9,280.28
Urine Culture/Colony Count,PX87086,CDM,300,RC,87086,CPT,,,,,,,,286,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,50.2232,percent of total billed charges,140.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4,280.28
Urine Culture/Colony Count,PX87086,CDM,300,RC,87086,CPT,,,,,,,,286,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,140.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4,280.28
Urine Culture/Colony Count,PX87086,CDM,300,RC,87086,CPT,,,,,,,,286,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,140.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4,280.28
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012365,NDC,0.7,ML,291.98,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,140.1504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012365,NDC,0.7,ML,291.98,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,140.1504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012388,NDC,0.7,ML,291.98,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,140.1504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012388,NDC,0.7,ML,291.98,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,140.1504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072310,NDC,0.5,ML,291.98,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,140.1504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072310,NDC,0.5,ML,291.98,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,140.1504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072388,NDC,0.5,ML,291.98,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,140.1504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072388,NDC,0.5,ML,291.98,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,140.1504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
Hepatitis C Antibody,PX86803,CDM,300,RC,86803,CPT,,,,,,,,144,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,140.1552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.08,141.12
phytonadione 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714097302,NDC,0.5,EA,143.02,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,140.1596,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phytonadione 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,69238105103,NDC,0.5,EA,143.02,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,140.1596,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Molecular Cytog, Ea Probe - Ref",PX8827190,CDM,310,RC,88271,CPT,90,,,,,,,277,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,140.162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.64,271.46
"Xray Neck, Soft Tissue",PX7036001,CDM,320,RC,70360,CPT,TC,,,,,,,277,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,140.162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,271.46
EPIX UNIVERSAL CLIP APPLIER,27200000,CDM,272,RC,,,,11708-MAIN,LOCAL,,,,,158.95,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,140.1939,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Iaad Ia Severe Aqt Respir Synd Coronavirus,PX87426,CDM,300,RC,87426,CPT,,,,,,,,159,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,140.238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.39,155.82
Complete Cbc W/Auto Diff Wbc,PX85025,CDM,300,RC,85025,CPT,,,,,,,,168,,Blue Cross Blue Shield of MN,All commercial plans,both,,,67.87282443,fee schedule,140.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.12,164.64
Dihydroxyvitamin D - Ref,PX8265290,CDM,300,RC,82652,CPT,90,,,,,,,165,,First Health,Commercial,both,85,,999999999,percent of total billed charges,140.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.3,161.7
Flow Cyto Ea Addtl Marker - Ref,PX8818590,CDM,310,RC,88185,CPT,90,,,,,,,165,,First Health,Commercial,both,85,,999999999,percent of total billed charges,140.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.541,161.7
Strapping of Shoulder,PX29240F,CDM,420,RC,29240,CPT,,,,,,,,165,,First Health,Commercial,both,85,,999999999,percent of total billed charges,140.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.541,161.7
Abd Duplex Abd-Full,PX9397501,CDM,921,RC,93975,CPT,TC,,,,,,,788,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,140.26,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.26,367.05
"Chrom Anal, 20-25 Cells - Ref",PX8826490,CDM,310,RC,88264,CPT,90,,,,,,,3141,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,140.27,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.27,144.61
"Chrom Anal, 20-25 Cells - Ref",PX8826490,CDM,310,RC,88264,CPT,90,,,,,,,3141,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,140.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.27,144.61
"Chrom Anal, 20-25 Cells - Ref",PX8826490,CDM,310,RC,88264,CPT,90,,,,,,,3141,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,140.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.27,144.61
8MM ENDOWRIST INSTRUMENTS MEGA SUTURE CUT NEEDLE DRIVER,27200000,CDM,272,RC,,,,11914-MAIN,LOCAL,,,,,327,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,140.283,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"IV Infusion Therapy, 1 Hour",PX96365,CDM,260,RC,96365,CPT,,,,,,,,327,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,140.283,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.8358,320.46
PROSTEP 0.9MM ANTI SKIVE PIN,27200000,CDM,272,RC,,,,12950-MAIN,LOCAL,,,,,154,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,140.294,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PROSTEP 1.4MM ANTI SKIVE PIN,27200000,CDM,272,RC,,,,12949-MAIN,LOCAL,,,,,154,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,140.294,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Vit D 1 25-Dihydroxy,PX82652,CDM,300,RC,82652,CPT,,,,,,,,154,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,140.294,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.3,150.92
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,517096010,NDC,10,ML,157.64,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,140.2996,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Colonoscopy,PX44388F,CDM,750,RC,44388,CPT,,,,,,,,930,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,140.3207,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.89,655.83
Colonoscopy,PX44388P,CDM,983,RC,44388,CPT,,,,,,,,620,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,140.3207,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.89,655.83
Leukoreduced Rbc's,PXP9016,CDM,390,RC,P9016,HCPCS,,,,,,,,580,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,140.35,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.14,228.608
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242003706,NDC,0.6,EA,8461.09,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,140.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.39,10431.7962
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012001,NDC,0.6,EA,7764.12,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,140.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.39,10431.7962
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012047,NDC,0.6,EA,10644.69,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,140.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.39,10431.7962
Initial Rx Burn(S) 1st Degree,PX16000F,CDM,510,RC,16000,CPT,,,,,,,,338,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,140.4052,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.4052,331.24
Tap Block Bilateral by Injection(S),PX64488F,CDM,510,RC,64488,CPT,,,,,,,,393,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,140.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.32,285.02
Tap Block Bilateral by Injection(S),PX64488P,CDM,983,RC,64488,CPT,,,,,,,,262,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,140.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.32,285.02
prednisoLONE acetate 1 % Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063705,NDC,5,ML,283.79,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,140.47605,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Bcr/Abl1 Minor - Ref,PX8120790,CDM,310,RC,81207,CPT,90,,,,,,,1113,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,140.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.49,144.84
Bcr/Abl1 Minor - Ref,PX8120790,CDM,310,RC,81207,CPT,90,,,,,,,1113,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,140.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.49,144.84
Bcr/Abl1 Minor - Ref,PX8120790,CDM,310,RC,81207,CPT,90,,,,,,,1113,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,140.49,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.49,144.84
fat emulsion 20 % Emulsion 250 mL Flex Cont,25000000,CDM,250,RC,,,,,,338051909,NDC,250,ML,292.75,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,140.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fat emulsion 20 % Emulsion 250 mL Flex Cont,25000000,CDM,250,RC,,,,,,338051909,NDC,250,ML,292.75,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,140.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Plas Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,338604648,NDC,100,ML,143.42,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,140.5516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.786918,140.5516
Antithrombin III Activity - Ref,PX8530090,CDM,300,RC,85300,CPT,90,,,,,,,158,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,140.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.87,154.84
Fac/Trm Hyperkeratotic Skn Lesn2-4,PX11056F,CDM,510,RC,11056,CPT,,,,,,,,158,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,140.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.6332,174.9
"Glucose, Body Fluid Other Than Blood",PX82945,CDM,300,RC,82945,CPT,,,,,,,,158,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,140.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.6,154.84
Protein C Activity - Ref,PX8530390,CDM,300,RC,85303,CPT,90,,,,,,,158,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,140.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.69,154.84
"Triiodothyronine T3, Tot - Ref",PX8448090,CDM,300,RC,84480,CPT,90,,,,,,,158,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,140.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13,154.84
"Digital Mamm, Diag, Unilat, Tc W/Cad Perf",PX7706501,CDM,401,RC,77065,CPT,TC,,,,,,,293,,Health Partners,Health Partners Care Plans,both,48,,255.795,percent of total billed charges,140.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.46,287.14
"Digital Mamm, Diag, Unilat, Tc W/Cad Perf",PX7706501,CDM,401,RC,77065,CPT,TC,,,,,,,293,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,140.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.46,287.14
Kit Gene Analysis D816 Variant(S) - Ref,PX8127390,CDM,300,RC,81273,CPT,90,,,,,,,293,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,140.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,114.49,287.14
Kit Gene Analysis D816 Variant(S) - Ref,PX8127390,CDM,300,RC,81273,CPT,90,,,,,,,293,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,140.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,114.49,287.14
GRAFIXPL PRIME PLACENTAL MEMBRANE 1.5 x2CM 3SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12764-MAIN,LOCAL,,,,,1529,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,140.71,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.32,140.71158
GRAFIXPL PRIME PLACENTAL MEMBRANE 2x3CM 6SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12765-MAIN,LOCAL,,,,,1911,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,140.71,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.32,140.71158
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x3CM 9SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12766-MAIN,LOCAL,,,,,2171,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,140.71,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.32,140.71158
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x4CM 12SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12767-MAIN,LOCAL,,,,,2345,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,140.71,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.32,140.71158
GRAFIXPL PRIME PLACENTAL MEMBRANE 5x5CM 25SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12768-MAIN,LOCAL,,,,,5211,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,140.71,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.32,140.71158
GRAFIXPL PRIME PLACENTAL MEMBRANE 16MM DISC 2SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12763-MAIN,LOCAL,,,,,860,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,140.71,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.32,140.71158
GRAFIXPL PRIME PLACENTAL MEMBRANE 1.5 x2CM 3SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12764-MAIN,LOCAL,,,,,1529,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,140.71158,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.32,140.71158
GRAFIXPL PRIME PLACENTAL MEMBRANE 2x3CM 6SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12765-MAIN,LOCAL,,,,,1911,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,140.71158,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.32,140.71158
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x3CM 9SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12766-MAIN,LOCAL,,,,,2171,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,140.71158,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.32,140.71158
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x4CM 12SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12767-MAIN,LOCAL,,,,,2345,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,140.71158,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.32,140.71158
GRAFIXPL PRIME PLACENTAL MEMBRANE 5x5CM 25SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12768-MAIN,LOCAL,,,,,5211,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,140.71158,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.32,140.71158
GRAFIXPL PRIME PLACENTAL MEMBRANE 16MM DISC 2SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12763-MAIN,LOCAL,,,,,860,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,140.71158,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.32,140.71158
"Chemotherapy, IV Infusion, Each Add'l Sequential Infusion",PX96417,CDM,335,RC,96417,CPT,,,,,,,,328,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,140.712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,321.44
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762P,CDM,983,RC,43762,CPT,,,,,,,,328,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,140.712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.2512,319.2424
eriBULin 1 MG/2ML Solution 2 mL Vial,J9179.01,CDM,636,RC,J9179,HCPCS,,,,62856038901,NDC,2,ML,2321.52,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,140.72,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,117.93,140.72
ENDOLOOP COATED VICRYL 0 18,27200000,CDM,272,RC,,,,10228-MAIN,LOCAL,,,,,143.6,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,140.728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
cloNIDine 0.1 MG/24HR PATCH WEEKLY 4 Each Box,63700001,CDM,250,RC,,,,,,51862045304,NDC,1,EA,158.16,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,140.7624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PHENobarbital 130 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047721,NDC,1,ML,338.93,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,140.791522,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.354486,332.1514
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,574200815,NDC,15,GR,154.63,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,140.86793,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Tiss Cult, Neopl, Bm, Wb - Ref",PX8823790,CDM,310,RC,88237,CPT,90,,,,,,,3141,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,140.8751,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.44,143.75
"Exc Skn Bngn2.1-3cmtrnk,Arm,Lg",PX11403P,CDM,983,RC,11403,CPT,,,,,,,,543,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,140.9629,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.02,532.14
"Fac/Ex Skn Bngn2.1-3cm Trnk,Arm,Lg",PX11403F,CDM,510,RC,11403,CPT,,,,,,,,679,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,140.9629,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.02,413.7
Xray Sacroiliac Jnts 3 or More Vws,PX7220201,CDM,320,RC,72202,CPT,TC,,,,,,,285,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,141.075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,279.3
"Breast Tomosynthesis,Dx Tc Bilat",PX7706201,CDM,401,RC,77062,CPT,TC,,,,,,,166,,First Health,Commercial,both,85,,999999999,percent of total billed charges,141.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.9564,162.68
"Breast Tomosynthesis,Dx Tc Unilat",PX7706101,CDM,401,RC,77061,CPT,TC,,,,,,,166,,First Health,Commercial,both,85,,999999999,percent of total billed charges,141.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.9564,162.68
"Breast Tomosynthesis,Screen Tc",PX7706301,CDM,403,RC,77063,CPT,TC,,,,,,,166,,First Health,Commercial,both,85,,999999999,percent of total billed charges,141.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.59,280.5
Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq,PX87635,CDM,300,RC,87635,CPT,,,,,,,,166,,First Health,Commercial,both,85,,999999999,percent of total billed charges,141.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,224.4
CHOLANGIOGRAM CATHETER REDDICK,27200000,CDM,272,RC,,,,10232-MAIN,LOCAL,,,,,287.98,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,141.1102,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CHOLANGIOGRAM CATHETER REDDICK,27200000,CDM,272,RC,,,,10232-MAIN,LOCAL,,,,,287.98,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,141.1102,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CHOLANGIOGRAM CATHETER REDDICK,27200000,CDM,272,RC,,,,10232-MAIN,LOCAL,,,,,287.98,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,141.1102,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,990771502,NDC,250,ML,166.02,,First Health,Commercial,both,85,,999999999,percent of total billed charges,141.117,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.4701,303.0944
Assay Thyroid Stim Hormone,PX84443,CDM,300,RC,84443,CPT,,,,,,,,294,,Health Partners,Health Partners Care Plans,both,48,,160.47,percent of total billed charges,141.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.4,288.12
Assay Thyroid Stim Hormone,PX84443,CDM,300,RC,84443,CPT,,,,,,,,294,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,141.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.4,288.12
Ex for Speech Device Rx Addl,PX92608,CDM,444,RC,92608,CPT,,,,,,,,160,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,141.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.95,156.8
Francisella Tularensis Ab,PX8666890,CDM,300,RC,86668,CPT,90,,,,,,,294,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,141.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.98,288.12
Francisella Tularensis Ab,PX8666890,CDM,300,RC,86668,CPT,90,,,,,,,294,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,141.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.98,288.12
Hepatitis C Antibody,PX86803,CDM,300,RC,86803,CPT,,,,,,,,144,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,141.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.08,141.12
Physical Therapy Evaluation High Complex,PX97163,CDM,424,RC,97163,CPT,,,,,,,,294,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,141.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,288.12
Physical Therapy Evaluation High Complex,PX97163,CDM,424,RC,97163,CPT,,,,,,,,294,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,141.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,288.12
Spirometry Incl Graph Rec Tc,PX9401002,CDM,460,RC,94010,CPT,TC,,,,,,,288,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,141.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.6352,282.24
Spirometry Incl Graph Rec Tc,PX9401002,CDM,460,RC,94010,CPT,TC,,,,,,,288,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,141.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.6352,282.24
Spirometry Incl Graph Rec Tc,PX9401002,CDM,460,RC,94010,CPT,TC,,,,,,,288,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,141.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.6352,282.24
Assay Carbamazepine Total,PX80156,CDM,300,RC,80156,CPT,,,,,,,,145,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,141.1285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.36,142.1
"Calculus, Infrared Spec - Ref",PX8236590,CDM,300,RC,82365,CPT,90,,,,,,,145,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,141.1285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.83,142.1
"Catecholamines, Fraction - Ref",PX8238490,CDM,300,RC,82384,CPT,90,,,,,,,145,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,141.1285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.15,142.1
Hsv Dna Amp Probe,PX87529,CDM,300,RC,87529,CPT,,,,,,,,145,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,141.1285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,142.1
Immunofixation Electrophoresis; Serum,PX86334,CDM,300,RC,86334,CPT,,,,,,,,145,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,141.1285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.48,142.1
LEGGING COMPRESSION JUXTALITE LONG LG 33CM,120.369,CDM,271,RC,A6545,HCPCS,,10840-MAIN,LOCAL,,,,,145,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,141.1285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.233,142.1
"Pare/Cut Hyperkeratotic Skin Lesion, Single",PX11055F,CDM,510,RC,11055,CPT,,,,,,,,145,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,141.1285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.233,174.9
Surgical Cleansing of Skin,PX11000P,CDM,983,RC,11000,CPT,,,,,,,,145,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,141.1285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.233,548.67
Wheelchair Mngement Training,PX97542,CDM,420,RC,97542,CPT,,,,,,,,145,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,141.1285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.59,142.1
"Hla Class II Low Res, 1 Locus - Ref",PX8137690,CDM,310,RC,81376,CPT,90,,,,,,,279,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,141.174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.06,273.42
INSUFLOWPORT & PNEUVIEW  XE SMOKE ELIMINATOR 5MM,27200000,CDM,272,RC,,,,11876-MAIN,LOCAL,,,,,279,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,141.174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 8MM,27200000,CDM,272,RC,,,,11877-MAIN,LOCAL,,,,,279,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,141.174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 10MM,27200000,CDM,272,RC,,,,11878-MAIN,LOCAL,,,,,279,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,141.174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 12MM,27200000,CDM,272,RC,,,,11879-MAIN,LOCAL,,,,,279,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,141.174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 5MM,27200000,CDM,272,RC,,,,11880-MAIN,LOCAL,,,,,279,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,141.174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 8MM,27200000,CDM,272,RC,,,,11881-MAIN,LOCAL,,,,,279,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,141.174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 10MM,27200000,CDM,272,RC,,,,11882-MAIN,LOCAL,,,,,279,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,141.174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 12MM,27200000,CDM,272,RC,,,,11883-MAIN,LOCAL,,,,,279,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,141.174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Puncture Drainage of Lesion,PX10160F,CDM,510,RC,10160,CPT,,,,,,,,279,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,141.174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.8966,348.35
Xray Pelvis 1 or 2 Vws,PX7217001,CDM,320,RC,72170,CPT,TC,,,,,,,279,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,141.174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,273.42
CYSTOSCOPY PACK I STERILE,120.505,CDM,272,RC,,,,4527-MAIN,LOCAL,,,,,155,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,141.205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,151.9
"Lab Antibody ID,RBC",PX7605,CDM,300,RC,86870,CPT,,,,,,,,155,,Medica,Commercial,both,91.1,,30,percent of total billed charges,141.205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,314.02
"Office/Outpt Visit,Est,Levl II",PX99212F,CDM,510,RC,99212,CPT,,,,,,,,155,,Medica,Commercial,both,91.1,,6.88,percent of total billed charges,141.205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,151.9
"Office/Outpt Visit,Est,Levl II",PX99212P,CDM,983,RC,99212,CPT,,,,,,,,155,,Medica,Commercial,both,91.1,,6.88,percent of total billed charges,141.205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,150.8615
Smear Fluorescent/Acid Stai,PX87206,CDM,300,RC,87206,CPT,,,,,,,,155,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,141.205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.94,151.9
TB Test Enumeration of T-Cells - Ref,PX8648190,CDM,300,RC,86481,CPT,90,,,,,,,155,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,141.205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,151.9
Sars-Cov-2 Covid-19 Antibody,PX86769,CDM,300,RC,86769,CPT,,,,,,,,340,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,141.236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.63,333.2
X-Ray Exam Chest 3 Views,PX7104701,CDM,320,RC,71047,CPT,TC,,,,,,,340,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,141.236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,333.2
"Closed Rx Toe Fx,Manipulatn",PX28515F,CDM,510,RC,28515,CPT,,,,,,,,390,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,141.284,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.93,352.82
"Closed Rx Toe Fx,Manipulatn",PX28515P,CDM,983,RC,28515,CPT,,,,,,,,260,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,141.284,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.93,352.82
sulfacetamide 10 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,61314070101,NDC,15,ML,285.48,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,141.3126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
EPIX UNIVERSAL CLIP APPLIER,27200000,CDM,272,RC,,,,11708-MAIN,LOCAL,,,,,158.95,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,141.4655,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Iaad Ia Severe Aqt Respir Synd Coronavirus,PX87426,CDM,300,RC,87426,CPT,,,,,,,,159,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,141.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.39,155.82
Blood Culture for Bacteria,PX87040,CDM,300,RC,87040,CPT,,,,,,,,286,,Humana Choice Care,All Medicare plans,outpatient,49.5,,112.112,percent of total billed charges,141.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.46,280.28
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725P,CDM,983,RC,26725,CPT,,,,,,,,330,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,141.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.082,321.189
I&D Bartholin Gland Abscess,PX56420P,CDM,983,RC,56420,CPT,,,,,,,,286,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,141.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,118.8044,278.3638
Joint Survey,PX7707726,CDM,982,RC,77077,CPT,26,,,,,,,286,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,141.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,278.3638
Lab Culture Bacteria,PX87070,CDM,300,RC,87070,CPT,,,,,,,,286,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,141.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.9,280.28
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101P,CDM,983,RC,13101,CPT,,,,,,,,330,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,141.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.082,548.67
Urine Culture/Colony Count,PX87086,CDM,300,RC,87086,CPT,,,,,,,,286,,Humana Choice Care,All Medicare plans,outpatient,49.5,,110.25875,percent of total billed charges,141.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4,280.28
CT Lwr Extremity W/O&W/Dye,PX7370201,CDM,350,RC,73702,CPT,TC,,,,,,,1235,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,141.592,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.98,283.34
Sulfur Colloid per Dose,PXA9541,CDM,343,RC,A9541,HCPCS,,,,,,,,295,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,141.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.543,289.1
Sulfur Colloid per Dose,PXA9541,CDM,343,RC,A9541,HCPCS,,,,,,,,295,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,141.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.543,289.1
BONE SCREW T8 FULL THREAD 2.4MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12652-MAIN,LOCAL,,,,,289,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,141.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
BONE SCREW T8 FULL THREAD 2.4MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12652-MAIN,LOCAL,,,,,289,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,141.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
BONE SCREW T8 FULL THREAD 2.4MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12652-MAIN,LOCAL,,,,,289,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,141.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
BONE SCREW T8 FULL THREAD 2.4MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12653-MAIN,LOCAL,,,,,289,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,141.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
BONE SCREW T8 FULL THREAD 2.4MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12653-MAIN,LOCAL,,,,,289,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,141.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
BONE SCREW T8 FULL THREAD 2.4MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12653-MAIN,LOCAL,,,,,289,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,141.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
BONE SCREW T8 FULL THREAD 2.7MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12654-MAIN,LOCAL,,,,,289,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,141.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
BONE SCREW T8 FULL THREAD 2.7MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12654-MAIN,LOCAL,,,,,289,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,141.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
BONE SCREW T8 FULL THREAD 2.7MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12654-MAIN,LOCAL,,,,,289,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,141.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Occupational Therapy Eval High Complex,PX97167,CDM,434,RC,97167,CPT,,,,,,,,289,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,141.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,283.22
Occupational Therapy Eval High Complex,PX97167,CDM,434,RC,97167,CPT,,,,,,,,289,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,141.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,283.22
Occupational Therapy Eval High Complex,PX97167,CDM,434,RC,97167,CPT,,,,,,,,289,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,141.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,283.22
"Troponin, Quantitative",PX84484,CDM,300,RC,84484,CPT,,,,,,,,289,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,33.764375,percent of total billed charges,141.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.43,283.22
"Troponin, Quantitative",PX84484,CDM,300,RC,84484,CPT,,,,,,,,289,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,141.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.43,283.22
"Troponin, Quantitative",PX84484,CDM,300,RC,84484,CPT,,,,,,,,289,,United Healthcare,All Medicare advantage plans,outpatient,49,,151.58,percent of total billed charges,141.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.43,283.22
Drainage of Hematoma/Fluid (T),PX10140F,CDM,510,RC,10140,CPT,,,,,,,,341,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,141.6514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,141.6514,1416.38
Drainage Scrotal Wall Abscess,PX55100P,CDM,983,RC,55100,CPT,,,,,,,,341,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,141.6514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,141.6514,1416.38
"Pertechnetate, Dia, per Mci",PXA9512,CDM,343,RC,A9512,HCPCS,,,,,,,,280,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,141.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,116.312,274.4
tranexamic acid 1000 mg in 100 mL 0.7% sodium chloride (premix) 1000-0.7 MG/100ML-% Solution 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,80830232901,NDC,100,ML,155.55,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,141.70605,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
buprenorphine 5 MCG/HR PATCH WEEKLY 4 Each Box,63700001,CDM,250,RC,,,,,,42858075040,NDC,1,EA,330.52,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,141.79308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989001,NDC,50,ML,160.78,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,141.80796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989002,NDC,50,ML,160.78,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,141.80796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
"Apply Forearm Splint,Static",PX29125F,CDM,510,RC,29125,CPT,,,,,,,,223,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,141.82,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.08,141.82
"Apply Forearm Splint,Static",PX29125P,CDM,983,RC,29125,CPT,,,,,,,,296,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,141.82,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.08,290.08
Bcr/Abl1 Minor - Ref,PX8120790,CDM,310,RC,81207,CPT,90,,,,,,,1113,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,141.8378,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.49,144.84
"Chrom Anal, 20-25 Cells - Ref",PX8826490,CDM,310,RC,88264,CPT,90,,,,,,,3141,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,141.8378,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.27,144.61
CT Lumbar Spine W/O & W/Dye,PX7213301,CDM,350,RC,72133,CPT,TC,,,,,,,4283,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,141.9138,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.98,283.34
MINIBUNION NON-LOCKING SCREW  2.7X18MM,C1713,CDM,278,RC,C1713,HCPCS,,11670-MAIN,LOCAL,,,,,280.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,141.933,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Fungus Isolation Culture,PX87102,CDM,300,RC,87102,CPT,,,,,,,,167,,First Health,Commercial,both,85,,999999999,percent of total billed charges,141.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.71,163.66
Microalbumin Quantitative,PX82043,CDM,300,RC,82043,CPT,,,,,,,,167,,First Health,Commercial,both,85,,999999999,percent of total billed charges,141.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.3,163.66
Wound Cult/Afb,PX87116,CDM,300,RC,87116,CPT,,,,,,,,167,,First Health,Commercial,both,85,,999999999,percent of total billed charges,141.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9,163.66
Catheterize for Urine Spec,PXP9612,CDM,300,RC,P9612,HCPCS,,,,,,,,161,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,142.002,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.1,157.78
Drain/Inject Small Joint/Bursa,PX20600F,CDM,510,RC,20600,CPT,,,,,,,,161,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,142.002,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.8794,258.75
Drain/Inject Small Joint/Bursa,PX20600P,CDM,983,RC,20600,CPT,,,,,,,,161,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,142.002,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.8794,258.75
Each Add'l Hour IV Infusion <8 Hour,PX96366,CDM,260,RC,96366,CPT,,,,,,,,161,,United Healthcare,All Payer,outpatient,88.2,,131.6545455,percent of total billed charges,142.002,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,157.78
HERCULES 3 STAGE BALLOON ESOPHAGEAL 12-13.5-15::36-40.5-45MM,27200000,CDM,272,RC,C1726,HCPCS,,11329-MAIN,LOCAL,,,,,289.85,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,142.0265,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HERCULES 3 STAGE BALLOON ESOPHAGEAL 12-13.5-15::36-40.5-45MM,27200000,CDM,272,RC,C1726,HCPCS,,11329-MAIN,LOCAL,,,,,289.85,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,142.0265,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HERCULES 3 STAGE BALLOON ESOPHAGEAL 12-13.5-15::36-40.5-45MM,27200000,CDM,272,RC,C1726,HCPCS,,11329-MAIN,LOCAL,,,,,289.85,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,142.0265,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HERCULES 3 STAGE BALLOON ESOPHAGEAL 15-16.5-18:45-49.5-54MM,27200000,CDM,272,RC,C1726,HCPCS,,11328-MAIN,LOCAL,,,,,289.85,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,142.0265,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HERCULES 3 STAGE BALLOON ESOPHAGEAL 15-16.5-18:45-49.5-54MM,27200000,CDM,272,RC,C1726,HCPCS,,11328-MAIN,LOCAL,,,,,289.85,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,142.0265,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HERCULES 3 STAGE BALLOON ESOPHAGEAL 15-16.5-18:45-49.5-54MM,27200000,CDM,272,RC,C1726,HCPCS,,11328-MAIN,LOCAL,,,,,289.85,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,142.0265,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HERCULES 3 STAGE BALLOON ESOPHAGEAL 18-19-20::54-57-60MM,27200000,CDM,272,RC,C1726,HCPCS,,11330-MAIN,LOCAL,,,,,289.85,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,142.0265,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HERCULES 3 STAGE BALLOON ESOPHAGEAL 18-19-20::54-57-60MM,27200000,CDM,272,RC,C1726,HCPCS,,11330-MAIN,LOCAL,,,,,289.85,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,142.0265,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HERCULES 3 STAGE BALLOON ESOPHAGEAL 18-19-20::54-57-60MM,27200000,CDM,272,RC,C1726,HCPCS,,11330-MAIN,LOCAL,,,,,289.85,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,142.0265,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Ctrl Nosebleed,Anter,Simple",PX30901F,CDM,510,RC,30901,CPT,,,,,,,,342,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,142.0668,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,335.16
Ultrasound Breast Limited,PX7664201,CDM,402,RC,76642,CPT,TC,,,,,,,342,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,142.0668,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,335.16
Apply Lower Leg Splint,PX29515F,CDM,510,RC,29515,CPT,,,,,,,,296,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,142.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.9584,290.08
Apply Lower Leg Splint,PX29515F,CDM,510,RC,29515,CPT,,,,,,,,296,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,142.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.9584,290.08
Drain Skin Abscess Simple,PX10060F,CDM,510,RC,10060,CPT,,,,,,,,296,,Health Partners,Health Partners Care Plans,both,48,,189.565,percent of total billed charges,142.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.9584,290.08
Drain Skin Abscess Simple,PX10060F,CDM,510,RC,10060,CPT,,,,,,,,296,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,142.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.9584,290.08
Apply Long Arm Splint,PX29105F,CDM,510,RC,29105,CPT,,,,,,,,290,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,142.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.466,284.2
Apply Long Arm Splint,PX29105F,CDM,510,RC,29105,CPT,,,,,,,,290,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,142.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.466,284.2
Apply Long Arm Splint,PX29105F,CDM,510,RC,29105,CPT,,,,,,,,290,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,142.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.466,284.2
Assay Carbamazepine Total,PX80156,CDM,300,RC,80156,CPT,,,,,,,,145,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,142.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.36,142.1
Assay of Digoxin,PX80162,CDM,300,RC,80162,CPT,,,,,,,,290,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,142.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.18,284.2
Assay of Digoxin,PX80162,CDM,300,RC,80162,CPT,,,,,,,,290,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,142.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.18,284.2
Assay of Digoxin,PX80162,CDM,300,RC,80162,CPT,,,,,,,,290,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,142.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.18,284.2
Assay of Natriuretic Peptide,PX83880,CDM,300,RC,83880,CPT,,,,,,,,290,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,5.781363636,percent of total billed charges,142.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36,284.2
Assay of Natriuretic Peptide,PX83880,CDM,300,RC,83880,CPT,,,,,,,,290,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,142.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36,284.2
Assay of Natriuretic Peptide,PX83880,CDM,300,RC,83880,CPT,,,,,,,,290,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,142.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36,284.2
"Calculus, Infrared Spec - Ref",PX8236590,CDM,300,RC,82365,CPT,90,,,,,,,145,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,142.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.83,142.1
"Catecholamines, Fraction - Ref",PX8238490,CDM,300,RC,82384,CPT,90,,,,,,,145,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,142.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.15,142.1
Hsv Dna Amp Probe,PX87529,CDM,300,RC,87529,CPT,,,,,,,,145,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,142.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,142.1
Immunofixation Electrophoresis; Serum,PX86334,CDM,300,RC,86334,CPT,,,,,,,,145,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,142.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.48,142.1
LEGGING COMPRESSION JUXTALITE LONG LG 33CM,120.369,CDM,271,RC,A6545,HCPCS,,10840-MAIN,LOCAL,,,,,145,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,142.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.233,142.1
NEEDLE INTRAOSSEOUS SET 15GA 25MM STABILIZER EZ-IO 9001P,120.216,CDM,272,RC,A4215,HCPCS,,10648-MAIN,LOCAL,,,,,290,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,142.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.466,284.2
NEEDLE INTRAOSSEOUS SET 15GA 25MM STABILIZER EZ-IO 9001P,120.216,CDM,272,RC,A4215,HCPCS,,10648-MAIN,LOCAL,,,,,290,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,142.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.466,284.2
NEEDLE INTRAOSSEOUS SET 15GA 25MM STABILIZER EZ-IO 9001P,120.216,CDM,272,RC,A4215,HCPCS,,10648-MAIN,LOCAL,,,,,290,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,142.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.466,284.2
NEEDLE INTRAOSSEOUS SET 15GA 45MM STABILIZER EZ-IO 9079P,120.216,CDM,272,RC,A4215,HCPCS,,10297-MAIN,LOCAL,,,,,290,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,142.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.466,284.2
NEEDLE INTRAOSSEOUS SET 15GA 45MM STABILIZER EZ-IO 9079P,120.216,CDM,272,RC,A4215,HCPCS,,10297-MAIN,LOCAL,,,,,290,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,142.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.466,284.2
NEEDLE INTRAOSSEOUS SET 15GA 45MM STABILIZER EZ-IO 9079P,120.216,CDM,272,RC,A4215,HCPCS,,10297-MAIN,LOCAL,,,,,290,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,142.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.466,284.2
"Pare/Cut Hyperkeratotic Skin Lesion, Single",PX11055F,CDM,510,RC,11055,CPT,,,,,,,,145,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,142.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.233,174.9
Surgical Cleansing of Skin,PX11000P,CDM,983,RC,11000,CPT,,,,,,,,145,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,142.1,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.79,142.1
Wheelchair Mngement Training,PX97542,CDM,420,RC,97542,CPT,,,,,,,,145,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,142.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.59,142.1
Islet Cell Antibody - Ref,PX8634190,CDM,300,RC,86341,CPT,90,,,,,,,146,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,142.1018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.61,143.08
Assay Blood Carbon Monoxide,PX82375,CDM,300,RC,82375,CPT,,,,,,,,156,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,142.116,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.3,152.88
"Cortisol, Am",PX7152,CDM,300,RC,82533,CPT,,,,,,,,156,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,142.116,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.95,152.88
DERMABOND PRINEO SKIN CLOSURE SYSTEM 22CM,27200000,CDM,272,RC,,,,12324-MAIN,LOCAL,,,,,156,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,142.116,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM ENDOWRIST INSTRUMENTS CADIERE FORCEPS,27200000,CDM,272,RC,,,,11913-MAIN,LOCAL,,,,,281,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,142.186,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
FORCEPS PROGRASP 8MM ENDOWRIST INSTRUMENTS,27200000,CDM,272,RC,,,,12062-MAIN,LOCAL,,,,,281,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,142.186,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Spirometry,PX9401001,CDM,460,RC,94010,CPT,TC,,,,,,,281,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,142.186,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,116.7274,275.38
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,65162083366,NDC,100,GR,281.12,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,142.24672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031F,CDM,510,RC,12031,CPT,,,,,,,,688,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,142.2473,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.55,547.21
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031P,CDM,983,RC,12031,CPT,,,,,,,,551,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,142.2473,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.55,547.21
"Special Stains,Group I",PX3978,CDM,310,RC,88312,CPT,TC,,,,,,,107,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,142.288,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.74,142.288
"Special Stains,Group I",PX3978,CDM,310,RC,88312,CPT,TC,,,,,,,107,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,142.288,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.74,142.288
dexAMETHasone 0.1 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,24208072002,NDC,5,ML,331.81,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,142.34649,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Ex for Speech Device Rx Addl,PX92608,CDM,444,RC,92608,CPT,,,,,,,,160,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,142.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.95,156.8
Infliximab - Ref,PX8023090,CDM,300,RC,80230,CPT,90,,,,,,,343,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,142.4822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.36,336.14
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002F,CDM,510,RC,12002,CPT,,,,,,,,343,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,142.4822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,142.4822,336.14
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155F,CDM,370,RC,99155,CPT,,,,,,,,353,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,142.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.39,142.52
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155F,CDM,370,RC,99155,CPT,,,,,,,,353,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,142.52,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.39,142.52
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155P,CDM,983,RC,99155,CPT,,,,,,,,353,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,142.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.39,345.94
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155P,CDM,983,RC,99155,CPT,,,,,,,,353,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,142.52,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.39,345.94
CHOLANGIOGRAM CATHETER REDDICK,27200000,CDM,272,RC,,,,10232-MAIN,LOCAL,,,,,287.98,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,142.5501,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Spirometry Incl Graph Rec Tc,PX9401002,CDM,460,RC,94010,CPT,TC,,,,,,,288,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,142.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.6352,282.24
Drain/Inject Large Joint/Bursa,PX20610P,CDM,983,RC,20610,CPT,,,,,,,,291,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,54.45428571,percent of total billed charges,142.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.8814,283.2303
Drain/Inject Large Joint/Bursa,PX20610P,CDM,983,RC,20610,CPT,,,,,,,,291,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,142.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.8814,283.2303
Drain/Inject Large Joint/Bursa,PX20610P,CDM,983,RC,20610,CPT,,,,,,,,291,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,142.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.8814,283.2303
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,39328006712,NDC,473,ML,167.77,,First Health,Commercial,both,85,,999999999,percent of total billed charges,142.6045,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
linezolid 600 MG/300ML Solution 300 mL Flex Cont,J2020.01,CDM,636,RC,J2020,HCPCS,,,,9514001,NDC,300,ML,332.42,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,142.60818,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.087268,325.7716
"Infectious Disease (Viral Respiratory Tract Infection),",PX0241U,CDM,300,RC,0241U,HCPCS,,,,,,,,457,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,142.63,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.35,142.63
"Infectious Disease (Viral Respiratory Tract Infection),",PX0241U,CDM,300,RC,0241U,HCPCS,,,,,,,,457,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,142.63,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.35,142.63
"Infectious Disease (Viral Respiratory Tract Infection),",PX0241U,CDM,300,RC,0241U,HCPCS,,,,,,,,457,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,142.63,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.35,142.63
Resp Virus 3-5 Targets,PX87631,CDM,300,RC,87631,CPT,,,,,,,,459,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,142.63,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.35,142.63
Xray Finger(S) Tc,PX7314001,CDM,320,RC,73140,CPT,TC,,,,,,,282,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,142.692,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,276.36
Xray Toe(S) Tc,PX7366001,CDM,320,RC,73660,CPT,TC,,,,,,,282,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,142.692,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,276.36
Aerobic Isolate - Ref,PX8707790,CDM,300,RC,87077,CPT,90,,,,,,,168,,First Health,Commercial,both,85,,999999999,percent of total billed charges,142.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,164.64
Complete Cbc W/Auto Diff Wbc,PX85025,CDM,300,RC,85025,CPT,,,,,,,,168,,First Health,Commercial,both,85,,999999999,percent of total billed charges,142.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.12,164.64
Insert Straight Catheter,PX51701F,CDM,510,RC,51701,CPT,,,,,,,,168,,First Health,Commercial,both,85,,999999999,percent of total billed charges,142.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.7872,164.64
Org ID Aerobic-Each,PX87077,CDM,300,RC,87077,CPT,,,,,,,,168,,First Health,Commercial,both,85,,999999999,percent of total billed charges,142.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,164.64
DOBUTamine 1000 mcg/mL in dextrose 5% 250 mL premix 1000 mcg/ml Solution 250 mL Flex Cont,J1250.01,CDM,636,RC,J1250,HCPCS,,,,338107302,NDC,250,ML,146.73,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,142.812309,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.951642,143.7954
"Fna Biopsy, W/US Guidance; First Lesion",PX10005F,CDM,510,RC,10005,CPT,,,,,,,,333,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,142.857,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.3282,614.65
Ultrasound Breast Complete,PX7664101,CDM,402,RC,76641,CPT,TC,,,,,,,333,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,142.857,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,326.34
MRI Low Ext Jnt WO/Cont Tc,PX7372101,CDM,610,RC,73721,CPT,TC,,,,,,,3541,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,142.8792,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.63,285.31
Emergency Level II Visit,PX99282P,CDM,981,RC,99282,CPT,,,,,,,,337,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,142.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.9898,328.0021
Facility Emergency Level II Visit,PX99282F,CDM,450,RC,99282,CPT,,,,,,,,387,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,142.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,142.88,379.26
Acetone Assay,PX82010,CDM,300,RC,82010,CPT,,,,,,,,162,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,142.884,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.49,158.76
"Flow Interp,2-8 Markers - Ref",PX8818790,CDM,310,RC,88187,CPT,90,,,,,,,162,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,142.884,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.1,158.76
KIT THORACENTESIS PLEURA SEAL AK-01000-T,120.24,CDM,272,RC,,,,1147-MAIN,LOCAL,,,,,162,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,142.884,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.2948,158.76
Anal Sphincterotomy,PX46080F,CDM,510,RC,46080,CPT,,,,,,,,607,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,142.8895,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.63,598.41
Anal Sphincterotomy,PX46080P,CDM,983,RC,46080,CPT,,,,,,,,525,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,142.8895,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.63,598.41
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604F,CDM,510,RC,20604,CPT,,,,,,,,344,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,142.8976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,142.8976,337.12
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,409662902,NDC,10,ML,146.84,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,14.281,percent of total billed charges,142.919372,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.236966,143.9032
Assay of Psa Total,PX84153,CDM,300,RC,84153,CPT,,,,,,,,157,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,143.027,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.86,153.86
"Chlamydia Trachomatis Dna, Amp Probe",PX87491,CDM,300,RC,87491,CPT,,,,,,,,157,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,143.027,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,153.86
"Cognitive Skill Dev, Ea 15 Min",PX97532,CDM,420,RC,97532,CPT,,,,,,,,157,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,143.027,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.2178,153.86
"Fungal Culture, Other Source - Ref",PX8710290,CDM,300,RC,87102,CPT,90,,,,,,,157,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,143.027,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.71,153.86
Lactate (Ld) (Ldh) Enzyme,PX83615,CDM,300,RC,83615,CPT,,,,,,,,157,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,143.027,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.54,153.86
"Neisseria Gonorrhoeae Dna, Amp Probe",PX87591,CDM,300,RC,87591,CPT,,,,,,,,157,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,143.027,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,153.86
Psa Screening,PXG0103,CDM,300,RC,G0103,HCPCS,,,,,,,,157,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,143.027,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.71,153.86
Remv Ext Canal Foreign Body,PX69200P,CDM,983,RC,69200,CPT,,,,,,,,157,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,143.027,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.2178,152.8081
"Ecg 12 Lead, Tracing Only",PX93005,CDM,730,RC,93005,CPT,,,,,,,,298,,Health Partners,Health Partners Care Plans,both,48,,183.6918182,percent of total billed charges,143.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.44,292.04
"Ecg 12 Lead, Tracing Only",PX93005,CDM,730,RC,93005,CPT,,,,,,,,298,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,143.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.44,292.04
BONE SCREW T8 FULL THREAD 2.4MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12652-MAIN,LOCAL,,,,,289,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,143.055,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
BONE SCREW T8 FULL THREAD 2.4MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12653-MAIN,LOCAL,,,,,289,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,143.055,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
BONE SCREW T8 FULL THREAD 2.7MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12654-MAIN,LOCAL,,,,,289,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,143.055,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Occupational Therapy Eval High Complex,PX97167,CDM,434,RC,97167,CPT,,,,,,,,289,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,143.055,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,283.22
"Troponin, Quantitative",PX84484,CDM,300,RC,84484,CPT,,,,,,,,289,,Humana Choice Care,All Medicare plans,outpatient,49.5,,53.10375,percent of total billed charges,143.055,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.43,283.22
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012365,NDC,0.7,ML,291.98,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,143.0702,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012365,NDC,0.7,ML,291.98,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,143.0702,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012365,NDC,0.7,ML,291.98,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,143.0702,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012388,NDC,0.7,ML,291.98,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,143.0702,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012388,NDC,0.7,ML,291.98,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,143.0702,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012388,NDC,0.7,ML,291.98,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,143.0702,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072310,NDC,0.5,ML,291.98,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,143.0702,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072310,NDC,0.5,ML,291.98,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,143.0702,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072310,NDC,0.5,ML,291.98,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,143.0702,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072388,NDC,0.5,ML,291.98,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,143.0702,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072388,NDC,0.5,ML,291.98,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,143.0702,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072388,NDC,0.5,ML,291.98,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,143.0702,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
Amphetamines; 1 or 2 - Ref,PX8032490,CDM,300,RC,80324,CPT,90,,,,,,,147,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,143.0751,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.0638,144.06
Assay Ph Body Fluids Nos,PX83986,CDM,300,RC,83986,CPT,,,,,,,,147,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,143.0751,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.28,144.06
"Cmv Detect, Amplifi Probe - Ref",PX8749690,CDM,300,RC,87496,CPT,90,,,,,,,147,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,143.0751,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,144.06
"Methlenedioxyamphetamines (Mda, Mdea, Mdma) - Ref",PX8035990,CDM,300,RC,80359,CPT,90,,,,,,,147,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,143.0751,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.0638,144.06
Ph Venous Blood,PX82800,CDM,300,RC,82800,CPT,,,,,,,,147,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,143.0751,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.09,144.06
Islet Cell Antibody - Ref,PX8634190,CDM,300,RC,86341,CPT,90,,,,,,,146,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,143.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.61,143.08
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989001,NDC,50,ML,160.78,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,143.0942,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989002,NDC,50,ML,160.78,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,143.0942,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062430,NDC,0.3,ML,147.12,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,25.0327027,percent of total billed charges,143.191896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801301,NDC,0.3,ML,147.12,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,25.0327027,percent of total billed charges,143.191896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801310,NDC,0.3,ML,147.12,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,25.0327027,percent of total billed charges,143.191896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
STAPLER RELOAD-CURVED CUTTER,27200000,CDM,272,RC,,,,12063-MAIN,LOCAL,,,,,283,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,143.198,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Destruct Benign Lesion, 1-14",PX17110F,CDM,510,RC,17110,CPT,,,,,,,,302,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,143.2,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.97,237.29
"Destruct Benign Lesion, 1-14",PX17110P,CDM,983,RC,17110,CPT,,,,,,,,521,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,143.2,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.97,510.58
MRI Up Extremity Joint W/O Tc,PX7322101,CDM,610,RC,73221,CPT,TC,,,,,,,3319,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,143.201,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.85,285.97
cadexomer iodine 0.9 % Gel 40 g Tube,63700001,CDM,250,RC,,,,,,40565012249,NDC,40,GR,333.86,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,143.22594,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047621,NDC,1,ML,157.28,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,143.28208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.354486,332.1514
Clotting Function Activity - Ref,PX8539790,CDM,300,RC,85397,CPT,90,,,,,,,334,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,143.286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.3,327.32
"Remv F.B.,Eye,Cornea,No Slit",PX65220F,CDM,510,RC,65220,CPT,,,,,,,,334,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,143.286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.7436,348.08
Repeat Control of Nosebleed,PX30906F,CDM,510,RC,30906,CPT,,,,,,,,334,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,143.286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.7436,327.32
X-Ray Abdomen 2+ Views W/ Single Vw Chest (Tc),PX7402201,CDM,320,RC,74022,CPT,TC,,,,,,,334,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,143.286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,327.32
Catheterize for Urine Spec,PXP9612,CDM,300,RC,P9612,HCPCS,,,,,,,,161,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,143.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.1,157.78
Drain/Inject Small Joint/Bursa,PX20600F,CDM,510,RC,20600,CPT,,,,,,,,161,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,143.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.8794,258.75
Drain/Inject Small Joint/Bursa,PX20600P,CDM,983,RC,20600,CPT,,,,,,,,161,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,143.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.8794,258.75
Each Add'l Hour IV Infusion <8 Hour,PX96366,CDM,260,RC,96366,CPT,,,,,,,,161,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,143.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,157.78
hydrocortisone sodium succinate (preservative free) 500 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001612,NDC,1,EA,298.53,,Health Partners,Health Partners Care Plans,both,48,,50.24,percent of total billed charges,143.2944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
hydrocortisone sodium succinate (preservative free) 500 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001612,NDC,1,EA,298.53,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,143.2944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
Exc Skn Bnig0.6-1cm Remain Bdy,PX11421P,CDM,983,RC,11421,CPT,,,,,,,,345,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,143.313,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,143.313,614.65
fat emulsion 20 % Emulsion 250 mL Flex Cont,25000000,CDM,250,RC,,,,,,338051909,NDC,250,ML,292.75,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,143.4475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fat emulsion 20 % Emulsion 250 mL Flex Cont,25000000,CDM,250,RC,,,,,,338051909,NDC,250,ML,292.75,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,143.4475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fat emulsion 20 % Emulsion 250 mL Flex Cont,25000000,CDM,250,RC,,,,,,338051909,NDC,250,ML,292.75,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,143.4475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040304,NDC,10,ML,168.77,,First Health,Commercial,both,85,,999999999,percent of total billed charges,143.4545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040310,NDC,10,ML,168.77,,First Health,Commercial,both,85,,999999999,percent of total billed charges,143.4545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
HERCULES 3 STAGE BALLOON ESOPHAGEAL 12-13.5-15::36-40.5-45MM,27200000,CDM,272,RC,C1726,HCPCS,,11329-MAIN,LOCAL,,,,,289.85,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,143.47575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HERCULES 3 STAGE BALLOON ESOPHAGEAL 15-16.5-18:45-49.5-54MM,27200000,CDM,272,RC,C1726,HCPCS,,11328-MAIN,LOCAL,,,,,289.85,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,143.47575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HERCULES 3 STAGE BALLOON ESOPHAGEAL 18-19-20::54-57-60MM,27200000,CDM,272,RC,C1726,HCPCS,,11330-MAIN,LOCAL,,,,,289.85,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,143.47575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Apply Long Arm Splint,PX29105F,CDM,510,RC,29105,CPT,,,,,,,,290,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,143.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.466,284.2
Assay of Digoxin,PX80162,CDM,300,RC,80162,CPT,,,,,,,,290,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,143.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.18,284.2
Assay of Natriuretic Peptide,PX83880,CDM,300,RC,83880,CPT,,,,,,,,290,,Humana Choice Care,All Medicare plans,outpatient,49.5,,69.168,percent of total billed charges,143.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36,284.2
NEEDLE INTRAOSSEOUS SET 15GA 25MM STABILIZER EZ-IO 9001P,120.216,CDM,272,RC,A4215,HCPCS,,10648-MAIN,LOCAL,,,,,290,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,143.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.466,284.2
NEEDLE INTRAOSSEOUS SET 15GA 45MM STABILIZER EZ-IO 9079P,120.216,CDM,272,RC,A4215,HCPCS,,10297-MAIN,LOCAL,,,,,290,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,143.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.466,284.2
"Digital Mamm, Diag, Unilat, Tc W/Cad Perf",PX7706501,CDM,401,RC,77065,CPT,TC,,,,,,,293,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,99.62,percent of total billed charges,143.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.46,287.14
"Digital Mamm, Diag, Unilat, Tc W/Cad Perf",PX7706501,CDM,401,RC,77065,CPT,TC,,,,,,,293,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,143.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.46,287.14
"Digital Mamm, Diag, Unilat, Tc W/Cad Perf",PX7706501,CDM,401,RC,77065,CPT,TC,,,,,,,293,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,143.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.46,287.14
Drain Skin Abscess Simple,PX10060P,CDM,983,RC,10060,CPT,,,,,,,,293,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,143.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.7122,285.1769
Drain Skin Abscess Simple,PX10060P,CDM,983,RC,10060,CPT,,,,,,,,293,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,143.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.7122,285.1769
Drain Skin Abscess Simple,PX10060P,CDM,983,RC,10060,CPT,,,,,,,,293,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,143.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.7122,285.1769
Kit Gene Analysis D816 Variant(S) - Ref,PX8127390,CDM,300,RC,81273,CPT,90,,,,,,,293,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,143.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,114.49,287.14
Kit Gene Analysis D816 Variant(S) - Ref,PX8127390,CDM,300,RC,81273,CPT,90,,,,,,,293,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,143.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,114.49,287.14
Kit Gene Analysis D816 Variant(S) - Ref,PX8127390,CDM,300,RC,81273,CPT,90,,,,,,,293,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,143.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,114.49,287.14
Repr Superf Wnd Body <2.5cm,PX12001P,CDM,983,RC,12001,CPT,,,,,,,,293,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,235.25,percent of total billed charges,143.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.7122,285.1769
Repr Superf Wnd Body <2.5cm,PX12001P,CDM,983,RC,12001,CPT,,,,,,,,293,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,143.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.7122,285.1769
Repr Superf Wnd Body <2.5cm,PX12001P,CDM,983,RC,12001,CPT,,,,,,,,293,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,143.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.7122,285.1769
prednisoLONE acetate 1 % Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063705,NDC,5,ML,283.79,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,143.59774,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,517096010,NDC,10,ML,157.64,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,143.61004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Blood Clot Factor VIII Test,PX85247,CDM,300,RC,85247,CPT,,,,,,,,169,,First Health,Commercial,both,85,,999999999,percent of total billed charges,143.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.03,165.62
Tap Block Unilateral by Injection(S),PX64486P,CDM,983,RC,64486,CPT,,,,,,,,169,,First Health,Commercial,both,85,,999999999,percent of total billed charges,143.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.2026,164.4877
"Close Rx Dist Fingr Fx,Manipulatn",PX26755F,CDM,510,RC,26755,CPT,,,,,,,,335,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,143.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
"Closed Rx I-P Jt,Toe Dislocation",PX28660F,CDM,510,RC,28660,CPT,,,,,,,,335,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,143.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Insitu Hybridization (Fish),PX8836401,CDM,310,RC,88364,CPT,TC,,,,,,,335,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,143.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Reduce Temporomandibl Disloc,PX21480F,CDM,510,RC,21480,CPT,,,,,,,,335,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,143.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Repr Superf Wnd Face <2.5cm,PX12011F,CDM,510,RC,12011,CPT,,,,,,,,335,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,143.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
"Tiss Cult, Neopl, Bm, Wb - Ref",PX8823790,CDM,310,RC,88237,CPT,90,,,,,,,3141,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,143.75,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.44,143.75
atropine 1 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,60219174903,NDC,5,ML,299.49,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,143.7552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
atropine 1 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,60219174903,NDC,5,ML,299.49,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,143.7552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Ehrlichia (Anaplasma) Ab - Ref,PX8666690,CDM,300,RC,86666,CPT,90,,,,,,,163,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,143.766,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.33,159.74
Xray Ankle 2 Vws,PX7360001,CDM,320,RC,73600,CPT,TC,,,,,,,163,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,143.766,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.7102,159.74
DOBUTamine 1000 mcg/mL in dextrose 5% 250 mL premix 1000 mcg/ml Solution 250 mL Flex Cont,J1250.01,CDM,636,RC,J1250,HCPCS,,,,338107302,NDC,250,ML,146.73,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,143.7954,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.951642,143.7954
nystatin 100000 UNIT/GM Cream 30 g Tube,25000000,CDM,250,RC,,,,,,168005430,NDC,30,GR,147.79,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,143.844007,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Bone Marrow Biopsy(Ies),PX38221F,CDM,510,RC,38221,CPT,,,,,,,,1221,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,143.89,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,43.84,337.6
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,409662902,NDC,10,ML,146.84,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,143.9032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.236966,143.9032
nystatin 100000 UNIT/GM Powder 60 g Bottle,63700001,CDM,250,RC,,,,,,68308015260,NDC,60,GR,335.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,143.9295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Antithrombin III Activity - Ref,PX8530090,CDM,300,RC,85300,CPT,90,,,,,,,158,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,143.938,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.87,154.84
Fac/Trm Hyperkeratotic Skn Lesn2-4,PX11056F,CDM,510,RC,11056,CPT,,,,,,,,158,,Medica,Commercial,both,91.1,,82.69,percent of total billed charges,143.938,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.6332,174.9
"Glucose, Body Fluid Other Than Blood",PX82945,CDM,300,RC,82945,CPT,,,,,,,,158,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,143.938,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.6,154.84
Protein C Activity - Ref,PX8530390,CDM,300,RC,85303,CPT,90,,,,,,,158,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,143.938,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.69,154.84
"Triiodothyronine T3, Tot - Ref",PX8448090,CDM,300,RC,84480,CPT,90,,,,,,,158,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,143.938,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13,154.84
iohexol 300 MG/ML Solution 150 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141365,NDC,150,ML,300,,Health Partners,Health Partners Care Plans,both,48,,1.954953846,percent of total billed charges,144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,294
iohexol 300 MG/ML Solution 150 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141365,NDC,150,ML,300,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,294
US Follicles-Limited Tc,PX7685701,CDM,402,RC,76857,CPT,TC,,,,,,,300,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,294
US Follicles-Limited Tc,PX7685701,CDM,402,RC,76857,CPT,TC,,,,,,,300,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,294
Drain/Inject Large Joint/Bursa,PX20610P,CDM,983,RC,20610,CPT,,,,,,,,291,,Humana Choice Care,All Medicare plans,outpatient,49.5,,69.44333333,percent of total billed charges,144.045,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.8814,283.2303
BLUE EYE SUBMUCOSAL LIFTING AGENT 5ML,27200000,CDM,272,RC,,,,12684-MAIN,LOCAL,,,,,148,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,144.0484,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Mumps,PX86735,CDM,300,RC,86735,CPT,,,,,,,,148,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,144.0484,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.97,145.04
US Guide Needle Bx S&I,PX7694226,CDM,982,RC,76942,CPT,26,,,,,,,148,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,144.0484,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.4792,144.0484
Amphetamines; 1 or 2 - Ref,PX8032490,CDM,300,RC,80324,CPT,90,,,,,,,147,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,144.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.0638,144.06
Assay Ph Body Fluids Nos,PX83986,CDM,300,RC,83986,CPT,,,,,,,,147,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,144.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.28,144.06
Assay Thyroid Stim Hormone,PX84443,CDM,300,RC,84443,CPT,,,,,,,,294,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,22.60294118,percent of total billed charges,144.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.4,288.12
Assay Thyroid Stim Hormone,PX84443,CDM,300,RC,84443,CPT,,,,,,,,294,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,144.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.4,288.12
Assay Thyroid Stim Hormone,PX84443,CDM,300,RC,84443,CPT,,,,,,,,294,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,144.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.4,288.12
"Cmv Detect, Amplifi Probe - Ref",PX8749690,CDM,300,RC,87496,CPT,90,,,,,,,147,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,144.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,144.06
Francisella Tularensis Ab,PX8666890,CDM,300,RC,86668,CPT,90,,,,,,,294,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,144.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.98,288.12
Francisella Tularensis Ab,PX8666890,CDM,300,RC,86668,CPT,90,,,,,,,294,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,144.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.98,288.12
Francisella Tularensis Ab,PX8666890,CDM,300,RC,86668,CPT,90,,,,,,,294,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,144.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.98,288.12
"Methlenedioxyamphetamines (Mda, Mdea, Mdma) - Ref",PX8035990,CDM,300,RC,80359,CPT,90,,,,,,,147,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,144.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.0638,144.06
Ph Venous Blood,PX82800,CDM,300,RC,82800,CPT,,,,,,,,147,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,144.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.09,144.06
Physical Therapy Evaluation High Complex,PX97163,CDM,424,RC,97163,CPT,,,,,,,,294,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,144.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,288.12
Physical Therapy Evaluation High Complex,PX97163,CDM,424,RC,97163,CPT,,,,,,,,294,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,144.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,288.12
Physical Therapy Evaluation High Complex,PX97163,CDM,424,RC,97163,CPT,,,,,,,,294,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,144.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,288.12
cloNIDine 0.1 MG/24HR PATCH WEEKLY 4 Each Box,63700001,CDM,250,RC,,,,,,51862045304,NDC,1,EA,158.16,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,144.08376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Inpt or Obs Disch Day Mngmt <=30 Minutes,PX99238,CDM,982,RC,99238,CPT,,,,,,,,199,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,144.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.85,195.02
Inpt or Obs Disch Day Mngmt <=30 Minutes,PX99238,CDM,982,RC,99238,CPT,,,,,,,,199,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,144.12,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.85,195.02
Xray Mandible Partial Less Than 4 Vws,PX7010001,CDM,320,RC,70100,CPT,TC,,,,,,,347,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,144.1438,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,340.06
Assay of Phenytoin Total,PX80185,CDM,300,RC,80185,CPT,,,,,,,,336,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,144.144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,329.28
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062430,NDC,0.3,ML,147.12,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,144.1776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801301,NDC,0.3,ML,147.12,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,144.1776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801310,NDC,0.3,ML,147.12,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,144.1776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
Acetone Assay,PX82010,CDM,300,RC,82010,CPT,,,,,,,,162,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,144.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.49,158.76
"Flow Interp,2-8 Markers - Ref",PX8818790,CDM,310,RC,88187,CPT,90,,,,,,,162,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,144.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.1,158.76
KIT THORACENTESIS PLEURA SEAL AK-01000-T,120.24,CDM,272,RC,,,,1147-MAIN,LOCAL,,,,,162,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,144.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.2948,158.76
Xray Sacroiliac Jnts 3 or More Vws,PX7220201,CDM,320,RC,72202,CPT,TC,,,,,,,285,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,144.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,279.3
nystatin 100000 UNIT/GM Cream 30 g Tube,25000000,CDM,250,RC,,,,,,51672128902,NDC,30,GR,148.29,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,144.330657,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sulfacetamide 10 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,61314070101,NDC,15,ML,285.48,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,144.45288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
PACLitaxel 150 MG/25ML Concentrate 25 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321701,NDC,25,ML,300.96,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,144.4608,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
PACLitaxel 150 MG/25ML Concentrate 25 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321701,NDC,25,ML,300.96,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,144.4608,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
Xray Facial Bones Less Than 3 Vws,PX7014001,CDM,320,RC,70140,CPT,TC,,,,,,,301,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,144.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,294.98
Xray Facial Bones Less Than 3 Vws,PX7014001,CDM,320,RC,70140,CPT,TC,,,,,,,301,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,144.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,294.98
Asay of Interleukin-6 (Il-6),PX8352990,CDM,300,RC,83529,CPT,90,,,,,,,170,,First Health,Commercial,both,85,,999999999,percent of total billed charges,144.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,166.6
Chem Cautery Granulatn Tissue,PX17250F,CDM,510,RC,17250,CPT,,,,,,,,170,,First Health,Commercial,both,85,,999999999,percent of total billed charges,144.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,174.9
"Chemotherapy Administration, Subq/Im Non-Hormonal Anti-Neoplastic",PX96401,CDM,335,RC,96401,CPT,,,,,,,,170,,First Health,Commercial,both,85,,999999999,percent of total billed charges,144.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,166.6
Collagen Cross Links - Ref,PX8252390,CDM,300,RC,82523,CPT,90,,,,,,,170,,First Health,Commercial,both,85,,999999999,percent of total billed charges,144.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.13,166.6
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800P,CDM,983,RC,40800,CPT,,,,,,,,170,,First Health,Commercial,both,85,,999999999,percent of total billed charges,144.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,614.65
gadoteridol 279.3 MG/ML Solution 17 mL Syringe,A9576,CDM,636,RC,A9576,HCPCS,,,,270111145,NDC,17,ML,170,,First Health,Commercial,both,85,,999999999,percent of total billed charges,144.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.54,166.6
"Inject Nerv Blck,Trigeminal",PX64400P,CDM,983,RC,64400,CPT,,,,,,,,170,,First Health,Commercial,both,85,,999999999,percent of total billed charges,144.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,258.75
"Protein, Total; Serum, Plasma or Whole Blood",PX84155,CDM,300,RC,84155,CPT,,,,,,,,170,,First Health,Commercial,both,85,,999999999,percent of total billed charges,144.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.37,166.6
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012365,NDC,0.7,ML,291.98,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,144.5301,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012388,NDC,0.7,ML,291.98,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,144.5301,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072310,NDC,0.5,ML,291.98,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,144.5301,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072388,NDC,0.5,ML,291.98,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,144.5301,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
folic acid 5 MG/ML Solution 10 mL Vial,J3490.94,CDM,636,RC,J3490,HCPCS,,,,63323018410,NDC,10,ML,336.94,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,144.54726,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,330.2012
Closed Rx Metacarpal Fx,PX26600P,CDM,983,RC,26600,CPT,,,,,,,,295,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,144.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.543,287.1235
Closed Rx Metacarpal Fx,PX26600P,CDM,983,RC,26600,CPT,,,,,,,,295,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,144.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.543,287.1235
Closed Rx Metacarpal Fx,PX26600P,CDM,983,RC,26600,CPT,,,,,,,,295,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,144.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.543,287.1235
Sulfur Colloid per Dose,PXA9541,CDM,343,RC,A9541,HCPCS,,,,,,,,295,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,144.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.543,289.1
Sulfur Colloid per Dose,PXA9541,CDM,343,RC,A9541,HCPCS,,,,,,,,295,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,144.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.543,289.1
Sulfur Colloid per Dose,PXA9541,CDM,343,RC,A9541,HCPCS,,,,,,,,295,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,144.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.543,289.1
Fac/Removal of Skin Tags,PX11200F,CDM,510,RC,11200,CPT,,,,,,,,348,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,144.5592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,144.5592,341.04
Emergency Level II Visit,PX99282P,CDM,981,RC,99282,CPT,,,,,,,,337,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,144.573,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.9898,328.0021
"Chrom Anal, 20-25 Cells - Ref",PX8826490,CDM,310,RC,88264,CPT,90,,,,,,,3141,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,144.61,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.27,144.61
US Pelvic Tc Complete,PX7685601,CDM,402,RC,76856,CPT,TC,,,,,,,472,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,144.63,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.65,144.63
US Pelvic Tc Complete,PX7685601,CDM,402,RC,76856,CPT,TC,,,,,,,472,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,144.63,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.65,144.63
Tx/Pro/Dx Inj Same Drug Adon,PX96376,CDM,260,RC,96376,CPT,,,,,,,,164,,United Healthcare,All Payer,outpatient,88.2,,90.90285714,percent of total billed charges,144.648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.1256,160.72
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,59148000713,NDC,1,EA,170.19,,First Health,Commercial,both,85,,999999999,percent of total billed charges,144.6615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CARBOplatin 600 MG/60ML Solution 60 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703423981,NDC,60,ML,301.42,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,144.6816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.778704,295.3916
CARBOplatin 600 MG/60ML Solution 60 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703423981,NDC,60,ML,301.42,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,144.6816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.778704,295.3916
Blood Culture for Bacteria,PX87040,CDM,300,RC,87040,CPT,,,,,,,,286,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,144.716,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.46,280.28
I&D Bartholin Gland Abscess,PX56420P,CDM,983,RC,56420,CPT,,,,,,,,286,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,144.716,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,118.8044,278.3638
Joint Survey,PX7707726,CDM,982,RC,77077,CPT,26,,,,,,,286,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,144.716,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,278.3638
Lab Culture Bacteria,PX87070,CDM,300,RC,87070,CPT,,,,,,,,286,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,144.716,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.9,280.28
Urine Culture/Colony Count,PX87086,CDM,300,RC,87086,CPT,,,,,,,,286,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,144.716,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4,280.28
EPIX UNIVERSAL CLIP APPLIER,27200000,CDM,272,RC,,,,11708-MAIN,LOCAL,,,,,158.95,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,144.80345,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
nystatin 100000 UNIT/GM Cream 30 g Tube,25000000,CDM,250,RC,,,,,,168005430,NDC,30,GR,147.79,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,144.8342,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Bcr/Abl1 Minor - Ref,PX8120790,CDM,310,RC,81207,CPT,90,,,,,,,1113,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,144.84,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.49,144.84
Iaad Ia Severe Aqt Respir Synd Coronavirus,PX87426,CDM,300,RC,87426,CPT,,,,,,,,159,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,144.849,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.39,155.82
fat emulsion 20 % Emulsion 250 mL Flex Cont,25000000,CDM,250,RC,,,,,,338051909,NDC,250,ML,292.75,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,144.91125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082143,NDC,1,ML,348.85,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,144.91229,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.48,367.9214
"Destruct Benign Lesion, 1-14",PX17110F,CDM,510,RC,17110,CPT,,,,,,,,302,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,144.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.4508,295.96
"Destruct Benign Lesion, 1-14",PX17110F,CDM,510,RC,17110,CPT,,,,,,,,302,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,144.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.4508,295.96
"Echo Heart Xthoracic,Limited",PX9330801,CDM,480,RC,93308,CPT,TC,,,,,,,349,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,144.9746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,144.9746,342.02
"Morphometric Analysis, Tumor - Ref",PX8836090,CDM,310,RC,88360,CPT,90,,,,,,,349,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,144.9746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,144.9746,342.02
Cardiac Rehab II W/ Monitor,PX93798.02,CDM,943,RC,93798,CPT,,,,,,,,338,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,145.002,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.44,495.55
Initial Rx Burn(S) 1st Degree,PX16000F,CDM,510,RC,16000,CPT,,,,,,,,338,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,145.002,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.4052,331.24
"Urinalysis, Auto W/O Scope",PX81003,CDM,300,RC,81003,CPT,,,,,,,,149,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,79.19,percent of total billed charges,145.0217,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.06,146.02
"Digital Mamm, Diag, Unilat, Tc W/Cad Perf",PX7706501,CDM,401,RC,77065,CPT,TC,,,,,,,293,,Humana Choice Care,All Medicare plans,outpatient,49.5,,168.4,percent of total billed charges,145.035,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.46,287.14
Drain Skin Abscess Simple,PX10060P,CDM,983,RC,10060,CPT,,,,,,,,293,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,145.035,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.7122,285.1769
Kit Gene Analysis D816 Variant(S) - Ref,PX8127390,CDM,300,RC,81273,CPT,90,,,,,,,293,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,145.035,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,114.49,287.14
Repr Superf Wnd Body <2.5cm,PX12001P,CDM,983,RC,12001,CPT,,,,,,,,293,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,145.035,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.7122,285.1769
"Apply Forearm Splint,Static",PX29125P,CDM,983,RC,29125,CPT,,,,,,,,296,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,136.885,percent of total billed charges,145.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,288.0968
"Apply Forearm Splint,Static",PX29125P,CDM,983,RC,29125,CPT,,,,,,,,296,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,145.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,288.0968
"Apply Forearm Splint,Static",PX29125P,CDM,983,RC,29125,CPT,,,,,,,,296,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,145.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,288.0968
Apply Lower Leg Splint,PX29515F,CDM,510,RC,29515,CPT,,,,,,,,296,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,145.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.9584,290.08
Apply Lower Leg Splint,PX29515F,CDM,510,RC,29515,CPT,,,,,,,,296,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,145.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.9584,290.08
Apply Lower Leg Splint,PX29515F,CDM,510,RC,29515,CPT,,,,,,,,296,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,145.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.9584,290.08
BLUE EYE SUBMUCOSAL LIFTING AGENT 5ML,27200000,CDM,272,RC,,,,12684-MAIN,LOCAL,,,,,148,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,145.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Drain Skin Abscess Simple,PX10060F,CDM,510,RC,10060,CPT,,,,,,,,296,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,145.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.9584,290.08
Drain Skin Abscess Simple,PX10060F,CDM,510,RC,10060,CPT,,,,,,,,296,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,145.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.9584,290.08
Drain Skin Abscess Simple,PX10060F,CDM,510,RC,10060,CPT,,,,,,,,296,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,145.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.9584,290.08
Mumps,PX86735,CDM,300,RC,86735,CPT,,,,,,,,148,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,145.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.97,145.04
US Guide Needle Bx S&I,PX7694226,CDM,982,RC,76942,CPT,26,,,,,,,148,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,145.04,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.97,145.04
albuterol HFA 108 (90 Base) MCG/ACT Aerosol Solution 8 g Inhaler,25000000,CDM,250,RC,,,,,,173068224,NDC,8,GR,149.04,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,145.060632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Ehrlichia (Anaplasma) Ab - Ref,PX8666690,CDM,300,RC,86666,CPT,90,,,,,,,163,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,145.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.33,159.74
Xray Ankle 2 Vws,PX7360001,CDM,320,RC,73600,CPT,TC,,,,,,,163,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,145.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.7102,159.74
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010365,NDC,100,ML,164.54,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,145.12428,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.174958,180.2416
"Immunofluo Direct, Ea Ab - Ref",PX8834690,CDM,310,RC,88346,CPT,90,,,,,,,55,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,145.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,145.22,243.84
"Immunofluo Direct, Ea Ab - Ref",PX8834690,CDM,310,RC,88346,CPT,90,,,,,,,55,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,145.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,145.22,243.84
"Immunofluo Direct, Ea Ab - Ref",PX8834690,CDM,310,RC,88346,CPT,90,,,,,,,55,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,145.22,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,145.22,243.84
US Retroperitoneal Tc,PX7677001,CDM,402,RC,76770,CPT,TC,,,,,,,566,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,145.29,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.08,145.29
US Retroperitoneal Tc,PX7677001,CDM,402,RC,76770,CPT,TC,,,,,,,566,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,145.29,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.08,145.29
nystatin 100000 UNIT/GM Cream 30 g Tube,25000000,CDM,250,RC,,,,,,51672128902,NDC,30,GR,148.29,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,145.3242,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vancomycin 125 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68180016611,NDC,1,EA,149.33,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,145.342889,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 125 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,47781072902,NDC,1,EA,149.33,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,145.342889,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 125 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,62559039020,NDC,1,EA,149.33,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,145.342889,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"CCP, Antibody - Ref",PX8620090,CDM,300,RC,86200,CPT,90,,,,,,,171,,First Health,Commercial,both,85,,999999999,percent of total billed charges,145.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,167.58
Hepatic Function Panel,PX80076,CDM,300,RC,80076,CPT,,,,,,,,171,,First Health,Commercial,both,85,,999999999,percent of total billed charges,145.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.49,167.58
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105F,CDM,510,RC,11105,CPT,,,,,,,,171,,First Health,Commercial,both,85,,999999999,percent of total billed charges,145.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.0334,167.58
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105P,CDM,983,RC,11105,CPT,,,,,,,,171,,First Health,Commercial,both,85,,999999999,percent of total billed charges,145.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.0334,166.4343
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102F,CDM,510,RC,11102,CPT,,,,,,,,171,,First Health,Commercial,both,85,,999999999,percent of total billed charges,145.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.0334,174.9
Flu Dna Amp Probe 1st 2 Types,PX87502,CDM,300,RC,87502,CPT,,,,,,,,350,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,145.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.84,343
PHENobarbital 130 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047721,NDC,1,ML,338.93,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,145.40097,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.354486,332.1514
"Destruct Benign Lesion, 15+",PX17111F,CDM,510,RC,17111,CPT,,,,,,,,303,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,145.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.8662,296.94
"Destruct Benign Lesion, 15+",PX17111F,CDM,510,RC,17111,CPT,,,,,,,,303,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,145.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.8662,296.94
Strapping of Knee,PX29530F,CDM,420,RC,29530,CPT,,,,,,,,303,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,145.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,296.94
Strapping of Knee,PX29530F,CDM,420,RC,29530,CPT,,,,,,,,303,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,145.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,296.94
Xray Knee 1 or 2 Vws,PX7356001,CDM,320,RC,73560,CPT,TC,,,,,,,303,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,145.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,296.94
Xray Knee 1 or 2 Vws,PX7356001,CDM,320,RC,73560,CPT,TC,,,,,,,303,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,145.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,296.94
"Exc Skn Mal 0.6-1cm Fce,Facial",PX11641P,CDM,983,RC,11641,CPT,,,,,,,,453,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,145.4583,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97.51,493.95
"Fac/Exc Skn Mal 0.6-1cm Fce,Facial",PX11641F,CDM,510,RC,11641,CPT,,,,,,,,680,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,145.4583,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97.51,493.95
Assay Thyroid Stim Hormone,PX84443,CDM,300,RC,84443,CPT,,,,,,,,294,,Humana Choice Care,All Medicare plans,outpatient,49.5,,72.03,percent of total billed charges,145.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.4,288.12
Dihydroxyvitamin D - Ref,PX8265290,CDM,300,RC,82652,CPT,90,,,,,,,165,,United Healthcare,All Payer,outpatient,88.2,,75.46,percent of total billed charges,145.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.3,161.7
Flow Cyto Ea Addtl Marker - Ref,PX8818590,CDM,310,RC,88185,CPT,90,,,,,,,165,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,145.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.541,161.7
Francisella Tularensis Ab,PX8666890,CDM,300,RC,86668,CPT,90,,,,,,,294,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,145.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.98,288.12
Physical Therapy Evaluation High Complex,PX97163,CDM,424,RC,97163,CPT,,,,,,,,294,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,145.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,288.12
Strapping of Shoulder,PX29240F,CDM,420,RC,29240,CPT,,,,,,,,165,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,145.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.541,161.7
fluticasone 110 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173071920,NDC,12,GR,149.67,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,145.673811,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CHOLANGIOGRAM CATHETER REDDICK,27200000,CDM,272,RC,,,,10232-MAIN,LOCAL,,,,,287.98,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,145.71788,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Spirometry Incl Graph Rec Tc,PX9401002,CDM,460,RC,94010,CPT,TC,,,,,,,288,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,145.728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.6352,282.24
Cardiac Rehab II Eval,PX93798.05,CDM,943,RC,93798,CPT,,,,,,,,364,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,145.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.44,495.55
Cardiac Rehab II W/ Monitor,PX93798.02,CDM,943,RC,93798,CPT,,,,,,,,338,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,145.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.44,495.55
Ex for Speech Device Rx Addl,PX92608,CDM,444,RC,92608,CPT,,,,,,,,160,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,145.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.95,156.8
Debride Bone Ea Add 20 Sqcm,PX11047P,CDM,983,RC,11047,CPT,,,,,,,,351,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,145.8054,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,145.8054,341.6283
Debride Tissue/Muscle,PX11043P,CDM,983,RC,11043,CPT,,,,,,,,351,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,145.8054,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,145.8054,548.67
Sars-Cov-2 Covid-19 Antibody,PX86769,CDM,300,RC,86769,CPT,,,,,,,,340,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,145.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.63,333.2
X-Ray Exam Chest 3 Views,PX7104701,CDM,320,RC,71047,CPT,TC,,,,,,,340,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,145.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,333.2
"Off/Outpt Visit,New,Levl III",PX99203P,CDM,983,RC,99203,CPT,,,,,,,,252,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,145.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.07,246.96
"Office/Outpt Visit,New,Levl III",PX99203F,CDM,510,RC,99203,CPT,,,,,,,,252,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,145.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.07,200.33
Joint Survey Tc,PX7707701,CDM,320,RC,77077,CPT,TC,,,,,,,304,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,145.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,297.92
Joint Survey Tc,PX7707701,CDM,320,RC,77077,CPT,TC,,,,,,,304,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,145.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,297.92
Tx/Pro/Dx Inj Same Drug Adon,PX96376,CDM,260,RC,96376,CPT,,,,,,,,164,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,145.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.1256,160.72
Assay of CK (Cpk),PX82550,CDM,300,RC,82550,CPT,,,,,,,,150,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,29.06,percent of total billed charges,145.995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.97,147
Assay of Lactic Acid,PX83605,CDM,300,RC,83605,CPT,,,,,,,,150,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,57.43789474,percent of total billed charges,145.995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.61,147
Assay of Phosphorus,PX84100,CDM,300,RC,84100,CPT,,,,,,,,150,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,147.65,percent of total billed charges,145.995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.35,147
Bilirubin Direct,PX82248,CDM,300,RC,82248,CPT,,,,,,,,150,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,147.65,percent of total billed charges,145.995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.6,147
Bilirubin Total,PX82247,CDM,300,RC,82247,CPT,,,,,,,,150,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,145.995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.6,147
"Drug(S) or Substance(S), Definitive, Qualitative or Quantitative, Not Otherwise Specified; 1-3 - Ref",PX8037590,CDM,300,RC,80375,CPT,90,,,,,,,150,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,145.995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.31,147
"Hsv Detect, Amplif Probe - Ref",PX8752990,CDM,300,RC,87529,CPT,90,,,,,,,150,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,145.995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,147
Magnesium,PX83735,CDM,300,RC,83735,CPT,,,,,,,,150,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,60.63745098,percent of total billed charges,145.995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.14,147
Magnesium - Ref,PX8373590,CDM,300,RC,83735,CPT,90,,,,,,,150,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,60.63745098,percent of total billed charges,145.995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.14,147
Po4 Inorganic (Phosphate) - Ref,PX8410090,CDM,300,RC,84100,CPT,90,,,,,,,150,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,147.65,percent of total billed charges,145.995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.35,147
TB Antigen Response Gamma Interferon T-Cell Susp,PX86481,CDM,300,RC,86481,CPT,,,,,,,,150,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,145.995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.31,147
"Ecg 12 Lead, Tracing Only",PX93005,CDM,730,RC,93005,CPT,,,,,,,,298,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,72.35231707,percent of total billed charges,146.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.44,292.04
"Ecg 12 Lead, Tracing Only",PX93005,CDM,730,RC,93005,CPT,,,,,,,,298,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,146.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.44,292.04
"Ecg 12 Lead, Tracing Only",PX93005,CDM,730,RC,93005,CPT,,,,,,,,298,,United Healthcare,All Medicare advantage plans,outpatient,49,,154.76,percent of total billed charges,146.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.44,292.04
"Urinalysis, Auto W/O Scope",PX81003,CDM,300,RC,81003,CPT,,,,,,,,149,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,146.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.06,146.02
Closed Rx Metacarpal Fx,PX26600P,CDM,983,RC,26600,CPT,,,,,,,,295,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,146.025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.543,287.1235
Sulfur Colloid per Dose,PXA9541,CDM,343,RC,A9541,HCPCS,,,,,,,,295,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,146.025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.543,289.1
albuterol HFA 108 (90 Base) MCG/ACT Aerosol Solution 8 g Inhaler,25000000,CDM,250,RC,,,,,,173068224,NDC,8,GR,149.04,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,146.0592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dexmedeTOMIDine in sodium chloride 200 MCG/50ML Solution 50 mL Flex Cont,25000000,CDM,250,RC,,,,,,338955524,NDC,50,ML,304.32,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,146.0736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dexmedeTOMIDine in sodium chloride 200 MCG/50ML Solution 50 mL Flex Cont,25000000,CDM,250,RC,,,,,,338955524,NDC,50,ML,304.32,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,146.0736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Raltegravir 400 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,6022761,NDC,1,EA,150.2,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,146.18966,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
AIRSEAL 12MM ACCESS PORT AND PALM GRIP OBTURATOR BLADELESS OPTICAL TIP 120MM,27200000,CDM,272,RC,,,,12207-MAIN,LOCAL,,,,,172,,First Health,Commercial,both,85,,999999999,percent of total billed charges,146.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
AIRSEAL TUBE SET TRI LUMEN FILTERED WITH ACTIVATED CHARCOAL,27200000,CDM,272,RC,,,,12206-MAIN,LOCAL,,,,,172,,First Health,Commercial,both,85,,999999999,percent of total billed charges,146.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
BONE SCREW T8 FULL THREAD 2.4MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12652-MAIN,LOCAL,,,,,289,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,146.234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
BONE SCREW T8 FULL THREAD 2.4MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12653-MAIN,LOCAL,,,,,289,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,146.234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
BONE SCREW T8 FULL THREAD 2.7MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12654-MAIN,LOCAL,,,,,289,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,146.234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Occupational Therapy Eval High Complex,PX97167,CDM,434,RC,97167,CPT,,,,,,,,289,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,146.234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,283.22
"Troponin, Quantitative",PX84484,CDM,300,RC,84484,CPT,,,,,,,,289,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,146.234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.43,283.22
hydrocortisone sodium succinate (preservative free) 500 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001612,NDC,1,EA,298.53,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,146.2797,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
hydrocortisone sodium succinate (preservative free) 500 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001612,NDC,1,EA,298.53,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,146.2797,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
hydrocortisone sodium succinate (preservative free) 500 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001612,NDC,1,EA,298.53,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,146.2797,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
Drainage of Hematoma/Fluid (T),PX10140F,CDM,510,RC,10140,CPT,,,,,,,,341,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,146.289,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,141.6514,1416.38
Drainage Scrotal Wall Abscess,PX55100P,CDM,983,RC,55100,CPT,,,,,,,,341,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,146.289,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,141.6514,1416.38
procainamide 500 MG/ML Solution 2 mL Vial,J2690.01,CDM,636,RC,J2690,HCPCS,,,,14789090002,NDC,2,ML,377.75,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,146.32,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.75,187.2
vancomycin 125 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68180016611,NDC,1,EA,149.33,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,146.3434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 125 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,47781072902,NDC,1,EA,149.33,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,146.3434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vancomycin 125 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,62559039020,NDC,1,EA,149.33,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,146.3434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,409337504,NDC,4,ML,150.36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,146.345388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"measles, mumps & rubella vaccine Recon Soln 1 Each Vial",90707,CDM,636,RC,90707,CPT,,,,6468100,NDC,1,EA,381.47,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,146.384,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.09,146.384
"measles, mumps & rubella vaccine Recon Soln 1 Each Vial",90707,CDM,636,RC,90707,CPT,,,,6468100,NDC,1,EA,381.47,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,146.384,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.09,146.384
"Bone Marrow Aspiration(S),Diag",PX38220F,CDM,510,RC,38220,CPT,,,,,,,,305,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,146.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,126.697,1416.38
"Bone Marrow Aspiration(S),Diag",PX38220F,CDM,510,RC,38220,CPT,,,,,,,,305,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,146.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,126.697,1416.38
"Breast Tomosynthesis,Dx Tc Bilat",PX7706201,CDM,401,RC,77062,CPT,TC,,,,,,,166,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,146.412,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.9564,162.68
"Breast Tomosynthesis,Dx Tc Unilat",PX7706101,CDM,401,RC,77061,CPT,TC,,,,,,,166,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,146.412,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.9564,162.68
"Breast Tomosynthesis,Screen Tc",PX7706301,CDM,403,RC,77063,CPT,TC,,,,,,,166,,United Healthcare,All Payer,outpatient,88.2,,75.2590625,percent of total billed charges,146.412,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.59,280.5
Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq,PX87635,CDM,300,RC,87635,CPT,,,,,,,,166,,United Healthcare,All Payer,outpatient,88.2,,127.9755556,percent of total billed charges,146.412,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,224.4
"Closed Rx Big Toe Fx,Manip",PX28495F,CDM,510,RC,28495,CPT,,,,,,,,857,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,146.4216,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.42,384.64
"Closed Rx Big Toe Fx,Manip",PX28495P,CDM,983,RC,28495,CPT,,,,,,,,412,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,146.4216,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.42,403.76
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,990771502,NDC,250,ML,166.02,,United Healthcare,All Payer,outpatient,88.2,,7.6225,percent of total billed charges,146.42964,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.4701,303.0944
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010365,NDC,100,ML,164.54,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,146.4406,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.174958,180.2416
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989001,NDC,50,ML,160.78,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,146.47058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989002,NDC,50,ML,160.78,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,146.47058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
Exc Skin Benig <5mm Remaindr Body,PX11420P,CDM,983,RC,11420,CPT,,,,,,,,299,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,146.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,124.2046,1416.38
Exc Skin Benig <5mm Remaindr Body,PX11420P,CDM,983,RC,11420,CPT,,,,,,,,299,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,146.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,124.2046,1416.38
Exc Skin Benig <5mm Remaindr Body,PX11420P,CDM,983,RC,11420,CPT,,,,,,,,299,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,146.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,124.2046,1416.38
"Apply Forearm Splint,Static",PX29125P,CDM,983,RC,29125,CPT,,,,,,,,296,,Humana Choice Care,All Medicare plans,outpatient,49.5,,55.37,percent of total billed charges,146.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,288.0968
Apply Lower Leg Splint,PX29515F,CDM,510,RC,29515,CPT,,,,,,,,296,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,146.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.9584,290.08
Drain Skin Abscess Simple,PX10060F,CDM,510,RC,10060,CPT,,,,,,,,296,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,146.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.9584,290.08
Creatine Mb Fraction,PX82553,CDM,300,RC,82553,CPT,,,,,,,,353,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,146.6362,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.59,345.94
Fentanyl - Ref,PX8035490,CDM,300,RC,80354,CPT,90,,,,,,,353,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,146.6362,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,345.94
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155F,CDM,370,RC,99155,CPT,,,,,,,,353,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,146.6362,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,345.94
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155P,CDM,983,RC,99155,CPT,,,,,,,,353,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,146.6362,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,343.5749
Pvb Thoracic Single Injection Site W/Img Gid,PX64461F,CDM,510,RC,64461,CPT,,,,,,,,353,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,146.6362,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,604.15
"Immunofluo Direct, Ea Ab - Ref",PX8834690,CDM,310,RC,88346,CPT,90,,,,,,,55,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,146.6513,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,145.22,243.84
HERCULES 3 STAGE BALLOON ESOPHAGEAL 12-13.5-15::36-40.5-45MM,27200000,CDM,272,RC,C1726,HCPCS,,11329-MAIN,LOCAL,,,,,289.85,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,146.6641,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HERCULES 3 STAGE BALLOON ESOPHAGEAL 15-16.5-18:45-49.5-54MM,27200000,CDM,272,RC,C1726,HCPCS,,11328-MAIN,LOCAL,,,,,289.85,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,146.6641,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HERCULES 3 STAGE BALLOON ESOPHAGEAL 18-19-20::54-57-60MM,27200000,CDM,272,RC,C1726,HCPCS,,11330-MAIN,LOCAL,,,,,289.85,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,146.6641,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Catheterize for Urine Spec,PXP9612,CDM,300,RC,P9612,HCPCS,,,,,,,,161,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,146.671,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.1,157.78
Drain/Inject Small Joint/Bursa,PX20600F,CDM,510,RC,20600,CPT,,,,,,,,161,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,146.671,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.8794,258.75
Drain/Inject Small Joint/Bursa,PX20600P,CDM,983,RC,20600,CPT,,,,,,,,161,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,146.671,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.8794,258.75
Each Add'l Hour IV Infusion <8 Hour,PX96366,CDM,260,RC,96366,CPT,,,,,,,,161,,Medica,Commercial,both,91.1,,17.185,percent of total billed charges,146.671,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,157.78
sodium zirconium cyclosilicate 10 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,310111001,NDC,1,EA,172.56,,First Health,Commercial,both,85,,999999999,percent of total billed charges,146.676,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone 110 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173071920,NDC,12,GR,149.67,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,146.6766,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Ctrl Nosebleed,Anter,Simple",PX30901F,CDM,510,RC,30901,CPT,,,,,,,,342,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,146.718,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,335.16
Ultrasound Breast Limited,PX7664201,CDM,402,RC,76642,CPT,TC,,,,,,,342,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,146.718,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,335.16
Apply Long Arm Splint,PX29105F,CDM,510,RC,29105,CPT,,,,,,,,290,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,146.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.466,284.2
Assay of Digoxin,PX80162,CDM,300,RC,80162,CPT,,,,,,,,290,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,146.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.18,284.2
Assay of Natriuretic Peptide,PX83880,CDM,300,RC,83880,CPT,,,,,,,,290,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,146.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36,284.2
NEEDLE INTRAOSSEOUS SET 15GA 25MM STABILIZER EZ-IO 9001P,120.216,CDM,272,RC,A4215,HCPCS,,10648-MAIN,LOCAL,,,,,290,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,146.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.466,284.2
NEEDLE INTRAOSSEOUS SET 15GA 45MM STABILIZER EZ-IO 9079P,120.216,CDM,272,RC,A4215,HCPCS,,10297-MAIN,LOCAL,,,,,290,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,146.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.466,284.2
atropine 1 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,60219174903,NDC,5,ML,299.49,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,146.7501,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
atropine 1 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,60219174903,NDC,5,ML,299.49,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,146.7501,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
atropine 1 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,60219174903,NDC,5,ML,299.49,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,146.7501,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fosfomycin 3 g Packet 1 Each Box,25000000,CDM,250,RC,,,,,,70700026894,NDC,1,EA,353.41,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,146.806514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Dihydroxyvitamin D - Ref,PX8265290,CDM,300,RC,82652,CPT,90,,,,,,,165,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,146.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.3,161.7
Flow Cyto Ea Addtl Marker - Ref,PX8818590,CDM,310,RC,88185,CPT,90,,,,,,,165,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,146.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.541,161.7
Strapping of Shoulder,PX29240F,CDM,420,RC,29240,CPT,,,,,,,,165,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,146.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.541,161.7
Xray Thoracolumbar 2 Vws,PX7208001,CDM,320,RC,72080,CPT,TC,,,,,,,306,,Health Partners,Health Partners Care Plans,both,48,,4.67,percent of total billed charges,146.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,299.88
Xray Thoracolumbar 2 Vws,PX7208001,CDM,320,RC,72080,CPT,TC,,,,,,,306,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,146.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,299.88
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234010,NDC,5,ML,306.2,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,146.976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234010,NDC,5,ML,306.2,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,146.976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234025,NDC,5,ML,306.2,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,146.976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234025,NDC,5,ML,306.2,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,146.976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234099,NDC,5,ML,306.2,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,146.976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234099,NDC,5,ML,306.2,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,146.976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
Assay of CK (Cpk),PX82550,CDM,300,RC,82550,CPT,,,,,,,,150,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,147,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.97,147
Assay of Lactic Acid,PX83605,CDM,300,RC,83605,CPT,,,,,,,,150,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,147,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.61,147
Assay of Phosphorus,PX84100,CDM,300,RC,84100,CPT,,,,,,,,150,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,147,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.35,147
Bilirubin Direct,PX82248,CDM,300,RC,82248,CPT,,,,,,,,150,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,147,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.6,147
Bilirubin Total,PX82247,CDM,300,RC,82247,CPT,,,,,,,,150,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,147,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.6,147
"Drug(S) or Substance(S), Definitive, Qualitative or Quantitative, Not Otherwise Specified; 1-3 - Ref",PX8037590,CDM,300,RC,80375,CPT,90,,,,,,,150,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,147,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.31,147
"Hsv Detect, Amplif Probe - Ref",PX8752990,CDM,300,RC,87529,CPT,90,,,,,,,150,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,147,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,147
iohexol 300 MG/ML Solution 150 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141365,NDC,150,ML,300,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1.980701493,percent of total billed charges,147,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,294
iohexol 300 MG/ML Solution 150 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141365,NDC,150,ML,300,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,147,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,294
iohexol 300 MG/ML Solution 150 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141365,NDC,150,ML,300,,United Healthcare,All Medicare advantage plans,outpatient,49,,1.11035,percent of total billed charges,147,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,294
Magnesium,PX83735,CDM,300,RC,83735,CPT,,,,,,,,150,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,147,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.14,147
Magnesium - Ref,PX8373590,CDM,300,RC,83735,CPT,90,,,,,,,150,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,147,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.14,147
Po4 Inorganic (Phosphate) - Ref,PX8410090,CDM,300,RC,84100,CPT,90,,,,,,,150,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,147,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.35,147
"Spinal Punc,Drain,Theraputic",PX62272P,CDM,983,RC,62272,CPT,,,,,,,,300,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,147,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,124.62,604.15
"Spinal Punc,Drain,Theraputic",PX62272P,CDM,983,RC,62272,CPT,,,,,,,,300,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,147,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,124.62,604.15
"Spinal Punc,Drain,Theraputic",PX62272P,CDM,983,RC,62272,CPT,,,,,,,,300,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,147,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,124.62,604.15
TB Antigen Response Gamma Interferon T-Cell Susp,PX86481,CDM,300,RC,86481,CPT,,,,,,,,150,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,147,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.31,147
US Follicles-Limited Tc,PX7685701,CDM,402,RC,76857,CPT,TC,,,,,,,300,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,147,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,294
US Follicles-Limited Tc,PX7685701,CDM,402,RC,76857,CPT,TC,,,,,,,300,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,147,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,294
US Follicles-Limited Tc,PX7685701,CDM,402,RC,76857,CPT,TC,,,,,,,300,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,147,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,294
clotrimazole-betamethasone 1-0.05 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,51672404801,NDC,15,GR,172.95,,First Health,Commercial,both,85,,999999999,percent of total billed charges,147.0075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
RBC Antibody Screen,PX86850,CDM,300,RC,86850,CPT,,,,,,,,173,,First Health,Commercial,both,85,,999999999,percent of total billed charges,147.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,169.54
"Thyroxin, Free (Free T4)",PX84439,CDM,300,RC,84439,CPT,,,,,,,,173,,First Health,Commercial,both,85,,999999999,percent of total billed charges,147.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.27,169.54
Xray Sinuses Minimum 3 Vws,PX7022001,CDM,320,RC,70220,CPT,TC,,,,,,,354,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,147.0516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,346.92
Lvl 1 Init Hosp Low Mdm or 40 Minutes,PX99221,CDM,982,RC,99221,CPT,,,,,,,,400,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,147.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.29,392
Lvl 1 Init Hosp Low Mdm or 40 Minutes,PX99221,CDM,982,RC,99221,CPT,,,,,,,,400,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,147.11,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.29,392
Infliximab - Ref,PX8023090,CDM,300,RC,80230,CPT,90,,,,,,,343,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,147.147,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.36,336.14
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002F,CDM,510,RC,12002,CPT,,,,,,,,343,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,147.147,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,142.4822,336.14
Raltegravir 400 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,6022761,NDC,1,EA,150.2,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,147.196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Drain/Inject Large Joint/Bursa,PX20610P,CDM,983,RC,20610,CPT,,,,,,,,291,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,147.246,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.8814,283.2303
MRI Brain W & WO Contrast,PX7055301,CDM,610,RC,70553,CPT,TC,,,,,,,3541,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,147.25,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,147.25,434.54
MRI Brain W & WO Contrast,PX7055301,CDM,610,RC,70553,CPT,TC,,,,,,,3541,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,147.25,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,147.25,434.54
etoposide 500 MG/25ML Solution 25 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,703565601,NDC,25,ML,173.28,,First Health,Commercial,both,85,,999999999,percent of total billed charges,147.288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.949434,169.8144
Fungus Isolation Culture,PX87102,CDM,300,RC,87102,CPT,,,,,,,,167,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,147.294,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.71,163.66
Microalbumin Quantitative,PX82043,CDM,300,RC,82043,CPT,,,,,,,,167,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,147.294,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.3,163.66
Wound Cult/Afb,PX87116,CDM,300,RC,87116,CPT,,,,,,,,167,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,147.294,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9,163.66
ARIPiprazole 2 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714014101,NDC,1,EA,151.35,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,147.308955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Injection for Nerve Block,PX64448F,CDM,510,RC,64448,CPT,,,,,,,,873,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,147.35,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.28,147.35
Injection for Nerve Block,PX64448F,CDM,510,RC,64448,CPT,,,,,,,,873,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,147.35,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.28,147.35
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,409337504,NDC,4,ML,150.36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,147.3528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
COOK EMERGENCY PNEUMOTHORAX SET,120.559,CDM,272,RC,,,,12597-MAIN,LOCAL,,,,,307,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,147.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,127.5278,300.86
COOK EMERGENCY PNEUMOTHORAX SET,120.559,CDM,272,RC,,,,12597-MAIN,LOCAL,,,,,307,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,147.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,127.5278,300.86
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,55150012150,NDC,1,EA,151.41,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,13.11107143,percent of total billed charges,147.367353,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
Drainage of Gum Lesion,PX41800F,CDM,510,RC,41800,CPT,,,,,,,,395,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,147.3849,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.82,606.02
Drainage of Gum Lesion,PX41800P,CDM,983,RC,41800,CPT,,,,,,,,839,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,147.3849,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.82,822.22
PACLitaxel 150 MG/25ML Concentrate 25 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321701,NDC,25,ML,300.96,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,147.4704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
PACLitaxel 150 MG/25ML Concentrate 25 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321701,NDC,25,ML,300.96,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,147.4704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
PACLitaxel 150 MG/25ML Concentrate 25 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321701,NDC,25,ML,300.96,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,147.4704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122P,CDM,983,RC,13122,CPT,,,,,,,,301,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,147.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.0354,292.9633
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122P,CDM,983,RC,13122,CPT,,,,,,,,301,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,147.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.0354,292.9633
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122P,CDM,983,RC,13122,CPT,,,,,,,,301,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,147.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.0354,292.9633
Xray Facial Bones Less Than 3 Vws,PX7014001,CDM,320,RC,70140,CPT,TC,,,,,,,301,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,147.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,294.98
Xray Facial Bones Less Than 3 Vws,PX7014001,CDM,320,RC,70140,CPT,TC,,,,,,,301,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,147.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,294.98
Xray Facial Bones Less Than 3 Vws,PX7014001,CDM,320,RC,70140,CPT,TC,,,,,,,301,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,147.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,294.98
"Ecg 12 Lead, Tracing Only",PX93005,CDM,730,RC,93005,CPT,,,,,,,,298,,Humana Choice Care,All Medicare plans,outpatient,49.5,,1.782162162,percent of total billed charges,147.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.44,292.04
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604F,CDM,510,RC,20604,CPT,,,,,,,,344,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,147.576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,142.8976,337.12
insulin regular 100 UNIT/ML Solution 10 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821501,NDC,10,ML,307.46,,Health Partners,Health Partners Care Plans,both,48,,4.547805556,percent of total billed charges,147.5808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
insulin regular 100 UNIT/ML Solution 10 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821501,NDC,10,ML,307.46,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,147.5808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
Acetone Assay,PX82010,CDM,300,RC,82010,CPT,,,,,,,,162,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,147.582,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.49,158.76
"Flow Interp,2-8 Markers - Ref",PX8818790,CDM,310,RC,88187,CPT,90,,,,,,,162,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,147.582,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.1,158.76
KIT THORACENTESIS PLEURA SEAL AK-01000-T,120.24,CDM,272,RC,,,,1147-MAIN,LOCAL,,,,,162,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,147.582,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.2948,158.76
"Hospital Inpt or Obs Care, Admin/Disch Same Date, Moderate Level Mdm >= 70 Minutes",PX99235,CDM,982,RC,99235,CPT,,,,,,,,582,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,147.6144,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,99.73,570.36
MRI L Spine W&WO Contrast,PX7215801,CDM,610,RC,72158,CPT,TC,,,,,,,4178,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,147.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,147.68,435.86
MRI L Spine W&WO Contrast,PX7215801,CDM,610,RC,72158,CPT,TC,,,,,,,4178,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,147.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,147.68,435.86
CARBOplatin 600 MG/60ML Solution 60 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703423981,NDC,60,ML,301.42,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,147.6958,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.778704,295.3916
CARBOplatin 600 MG/60ML Solution 60 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703423981,NDC,60,ML,301.42,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,147.6958,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.778704,295.3916
CARBOplatin 600 MG/60ML Solution 60 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703423981,NDC,60,ML,301.42,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,147.6958,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.778704,295.3916
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,517096001,NDC,10,ML,355.63,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,147.728702,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Breast Tomosynthesis,Dx Tc Bilat",PX7706201,CDM,401,RC,77062,CPT,TC,,,,,,,166,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,147.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.9564,162.68
"Breast Tomosynthesis,Dx Tc Unilat",PX7706101,CDM,401,RC,77061,CPT,TC,,,,,,,166,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,147.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.9564,162.68
"Breast Tomosynthesis,Screen Tc",PX7706301,CDM,403,RC,77063,CPT,TC,,,,,,,166,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,147.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.59,280.5
Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq,PX87635,CDM,300,RC,87635,CPT,,,,,,,,166,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,147.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,224.4
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012365,NDC,0.7,ML,291.98,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,147.74188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012388,NDC,0.7,ML,291.98,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,147.74188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072310,NDC,0.5,ML,291.98,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,147.74188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072388,NDC,0.5,ML,291.98,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,147.74188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,990771502,NDC,250,ML,166.02,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,147.7578,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.4701,303.0944
hydrocortisone sodium succinate (preservative free) 500 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001612,NDC,1,EA,298.53,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,147.77235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
ketoconazole 2 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,168009915,NDC,15,GR,173.97,,First Health,Commercial,both,85,,999999999,percent of total billed charges,147.8745,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium zirconium cyclosilicate 5 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,310110501,NDC,1,EA,151.95,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,147.892935,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Antipsychotics, Not Otherwise Specified; 1-3 - Ref",PX8034290,CDM,300,RC,80342,CPT,90,,,,,,,152,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,147.9416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.1408,148.96
Body Fluid Cell Count,PX89050,CDM,300,RC,89050,CPT,,,,,,,,152,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,103.13,percent of total billed charges,147.9416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.33,148.96
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,39328006712,NDC,473,ML,167.77,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,147.97314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Destruct Benign Lesion, 1-14",PX17110F,CDM,510,RC,17110,CPT,,,,,,,,302,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,147.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.4508,295.96
"Destruct Benign Lesion, 1-14",PX17110F,CDM,510,RC,17110,CPT,,,,,,,,302,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,147.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.4508,295.96
"Destruct Benign Lesion, 1-14",PX17110F,CDM,510,RC,17110,CPT,,,,,,,,302,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,147.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.4508,295.96
Exc Skin Benig <5mm Remaindr Body,PX11420P,CDM,983,RC,11420,CPT,,,,,,,,299,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,148.005,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,124.2046,1416.38
Exc Skn Bnig0.6-1cm Remain Bdy,PX11421P,CDM,983,RC,11421,CPT,,,,,,,,345,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,148.005,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,143.313,614.65
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423F,CDM,510,RC,11423,CPT,,,,,,,,711,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,148.0271,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.6,428.92
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423P,CDM,983,RC,11423,CPT,,,,,,,,569,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,148.0271,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.6,557.62
Injection for Nerve Block,PX64445F,CDM,510,RC,64445,CPT,,,,,,,,385,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,148.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.71,329.3
Injection for Nerve Block,PX64445P,CDM,983,RC,64445,CPT,,,,,,,,385,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,148.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.71,377.3
"Pare/Cut Hyperkeratotic Skin Lesion, Single",PX11055F,CDM,510,RC,11055,CPT,,,,,,,,145,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,148.05,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.59,148.05
MINIBUNION LOCKING SCREW 3.0X24MM,C1713,CDM,278,RC,C1713,HCPCS,,11671-MAIN,LOCAL,,,,,308.55,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,148.104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
MINIBUNION LOCKING SCREW 3.0X24MM,C1713,CDM,278,RC,C1713,HCPCS,,11671-MAIN,LOCAL,,,,,308.55,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,148.104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
fat emulsion 20 % Emulsion 250 mL Flex Cont,25000000,CDM,250,RC,,,,,,338051909,NDC,250,ML,292.75,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,148.1315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Aerobic Isolate - Ref,PX8707790,CDM,300,RC,87077,CPT,90,,,,,,,168,,United Healthcare,All Payer,outpatient,88.2,,84.24,percent of total billed charges,148.176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,164.64
Complete Cbc W/Auto Diff Wbc,PX85025,CDM,300,RC,85025,CPT,,,,,,,,168,,United Healthcare,All Payer,outpatient,88.2,,94.27068182,percent of total billed charges,148.176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.12,164.64
Insert Straight Catheter,PX51701F,CDM,510,RC,51701,CPT,,,,,,,,168,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,148.176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.7872,164.64
Org ID Aerobic-Each,PX87077,CDM,300,RC,87077,CPT,,,,,,,,168,,United Healthcare,All Payer,outpatient,88.2,,84.24,percent of total billed charges,148.176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,164.64
levonorgestrel 1.5 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,68180085211,NDC,1,EA,174.39,,First Health,Commercial,both,85,,999999999,percent of total billed charges,148.2315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atropine 1 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,60219174903,NDC,5,ML,299.49,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,148.24755,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Digital Mamm, Diag, Unilat, Tc W/Cad Perf",PX7706501,CDM,401,RC,77065,CPT,TC,,,,,,,293,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,148.258,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.46,287.14
Drain Skin Abscess Simple,PX10060P,CDM,983,RC,10060,CPT,,,,,,,,293,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,148.258,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.7122,285.1769
Kit Gene Analysis D816 Variant(S) - Ref,PX8127390,CDM,300,RC,81273,CPT,90,,,,,,,293,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,148.258,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,114.49,287.14
Repr Superf Wnd Body <2.5cm,PX12001P,CDM,983,RC,12001,CPT,,,,,,,,293,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,148.258,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.7122,285.1769
Remove Intrauterine Device,PX58301,CDM,983,RC,58301,CPT,,,,,,,,357,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,148.2978,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.2978,347.4681
X-Ray Exam Chest 1 View,PX7104501,CDM,320,RC,71045,CPT,TC,,,,,,,357,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,148.2978,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,349.86
"Xray Chest 1 View, Tc",PX7101001,CDM,320,RC,71010,CPT,TC,,,,,,,357,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,148.2978,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.2978,349.86
Xray Scapula Complete,PX7301001,CDM,320,RC,73010,CPT,TC,,,,,,,357,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,148.2978,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,349.86
LINNEAR CUTTER STAPLE RELOAD GST BLUE 60MM,27200000,CDM,272,RC,,,,12068-MAIN,LOCAL,,,,,309,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,148.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LINNEAR CUTTER STAPLE RELOAD GST BLUE 60MM,27200000,CDM,272,RC,,,,12068-MAIN,LOCAL,,,,,309,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,148.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LINNEAR CUTTER STAPLE RELOAD GST GREEN 60MM,27200000,CDM,272,RC,,,,12069-MAIN,LOCAL,,,,,309,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,148.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LINNEAR CUTTER STAPLE RELOAD GST GREEN 60MM,27200000,CDM,272,RC,,,,12069-MAIN,LOCAL,,,,,309,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,148.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LINNEAR CUTTER STAPLE RELOAD GST WHITE 60MM,27200000,CDM,272,RC,,,,12067-MAIN,LOCAL,,,,,309,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,148.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LINNEAR CUTTER STAPLE RELOAD GST WHITE 60MM,27200000,CDM,272,RC,,,,12067-MAIN,LOCAL,,,,,309,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,148.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ARIPiprazole 2 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714014101,NDC,1,EA,151.35,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,148.323,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035F,CDM,510,RC,12035,CPT,,,,,,,,655,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,148.34,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.34,810.1
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035P,CDM,983,RC,12035,CPT,,,,,,,,1244,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,148.34,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.34,1219.12
MRI Brain W & WO Contrast,PX7055301,CDM,610,RC,70553,CPT,TC,,,,,,,3541,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,148.34,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,147.25,434.54
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,55150012150,NDC,1,EA,151.41,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,148.3818,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.549536,148.3818
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,338035702,NDC,250,ML,309.28,,Health Partners,Health Partners Care Plans,both,48,,31.91277778,percent of total billed charges,148.4544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.4701,303.0944
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,338035702,NDC,250,ML,309.28,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,148.4544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.4701,303.0944
"Destruct Benign Lesion, 15+",PX17111F,CDM,510,RC,17111,CPT,,,,,,,,303,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,148.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.8662,296.94
"Destruct Benign Lesion, 15+",PX17111F,CDM,510,RC,17111,CPT,,,,,,,,303,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,148.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.8662,296.94
"Destruct Benign Lesion, 15+",PX17111F,CDM,510,RC,17111,CPT,,,,,,,,303,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,148.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.8662,296.94
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607P,CDM,983,RC,97607,CPT,,,,,,,,303,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,148.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.8662,348.35
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607P,CDM,983,RC,97607,CPT,,,,,,,,303,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,148.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.8662,348.35
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607P,CDM,983,RC,97607,CPT,,,,,,,,303,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,148.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.8662,348.35
Strapping of Knee,PX29530F,CDM,420,RC,29530,CPT,,,,,,,,303,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,148.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,296.94
Strapping of Knee,PX29530F,CDM,420,RC,29530,CPT,,,,,,,,303,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,148.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,296.94
Strapping of Knee,PX29530F,CDM,420,RC,29530,CPT,,,,,,,,303,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,148.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,296.94
Xray Knee 1 or 2 Vws,PX7356001,CDM,320,RC,73560,CPT,TC,,,,,,,303,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,114.6033333,percent of total billed charges,148.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,296.94
Xray Knee 1 or 2 Vws,PX7356001,CDM,320,RC,73560,CPT,TC,,,,,,,303,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,148.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,296.94
Xray Knee 1 or 2 Vws,PX7356001,CDM,320,RC,73560,CPT,TC,,,,,,,303,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,148.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,296.94
Ehrlichia (Anaplasma) Ab - Ref,PX8666690,CDM,300,RC,86666,CPT,90,,,,,,,163,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,148.493,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.33,159.74
Xray Ankle 2 Vws,PX7360001,CDM,320,RC,73600,CPT,TC,,,,,,,163,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,148.493,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.7102,159.74
iohexol 300 MG/ML Solution 150 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141365,NDC,150,ML,300,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,148.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,294
"Spinal Punc,Drain,Theraputic",PX62272P,CDM,983,RC,62272,CPT,,,,,,,,300,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,148.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,124.62,604.15
US Follicles-Limited Tc,PX7685701,CDM,402,RC,76857,CPT,TC,,,,,,,300,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,148.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,294
MRI T Spine W&WO Contrast,PX7215701,CDM,610,RC,72157,CPT,TC,,,,,,,4178,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,148.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.55,438.49
MRI T Spine W&WO Contrast,PX7215701,CDM,610,RC,72157,CPT,TC,,,,,,,4178,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,148.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.55,438.49
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127303,NDC,2,ML,152.7,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,148.62291,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.43158,173.019
Fungus Isolation Culture,PX87102,CDM,300,RC,87102,CPT,,,,,,,,167,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,148.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.71,163.66
Microalbumin Quantitative,PX82043,CDM,300,RC,82043,CPT,,,,,,,,167,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,148.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.3,163.66
Wound Cult/Afb,PX87116,CDM,300,RC,87116,CPT,,,,,,,,167,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,148.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9,163.66
Declot Vascular Access Device,PX36593F,CDM,510,RC,36593,CPT,,,,,,,,358,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,148.7132,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.7132,350.84
Fac/Irrigation of Bladder,PX51700F,CDM,510,RC,51700,CPT,,,,,,,,358,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,148.7132,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.7132,350.84
X-Ray Exam Abdomen 1 View,PX7401801,CDM,320,RC,74018,CPT,TC,,,,,,,358,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,148.7132,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,350.84
Xray Abdomen Single Ap Vw,PX7400001,CDM,320,RC,74000,CPT,TC,,,,,,,358,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,148.7132,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.7132,350.84
"Sigmoidoscopy,Biopsy",PX45331F,CDM,750,RC,45331,CPT,,,,,,,,1776,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,148.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.5,593.56
"Sigmoidoscopy,Biopsy",PX45331P,CDM,983,RC,45331,CPT,,,,,,,,1316,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,148.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.5,1289.68
Electrolyte Panel,PX80051,CDM,300,RC,80051,CPT,,,,,,,,175,,First Health,Commercial,both,85,,999999999,percent of total billed charges,148.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.43,171.5
"Fac/Trm Hyperkeratotic Skn Lesn,>4",PX11057F,CDM,510,RC,11057,CPT,,,,,,,,175,,First Health,Commercial,both,85,,999999999,percent of total billed charges,148.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.695,174.9
"Gonadotropin, Chorionic (Hcg), Qualitative",PX84703,CDM,300,RC,84703,CPT,,,,,,,,175,,First Health,Commercial,both,85,,999999999,percent of total billed charges,148.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.9,171.5
Protein E-Phoresis Serum,PX84165,CDM,300,RC,84165,CPT,,,,,,,,175,,First Health,Commercial,both,85,,999999999,percent of total billed charges,148.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,171.5
Protein Elp Interp,PX8416526,CDM,300,RC,84165,CPT,26,,,,,,,175,,First Health,Commercial,both,85,,999999999,percent of total billed charges,148.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,171.5
Assay Thyroid Stim Hormone,PX84443,CDM,300,RC,84443,CPT,,,,,,,,294,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,148.764,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.4,288.12
Francisella Tularensis Ab,PX8666890,CDM,300,RC,86668,CPT,90,,,,,,,294,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,148.764,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.98,288.12
Physical Therapy Evaluation High Complex,PX97163,CDM,424,RC,97163,CPT,,,,,,,,294,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,148.764,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,288.12
"Drain Finger Abscess,Simple",PX26010F,CDM,510,RC,26010,CPT,,,,,,,,310,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,148.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.774,303.8
"Drain Finger Abscess,Simple",PX26010F,CDM,510,RC,26010,CPT,,,,,,,,310,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,148.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.774,303.8
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,55150043801,NDC,20,ML,152.9,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,11.07921788,percent of total billed charges,148.81757,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457018120,NDC,20,ML,152.9,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,11.07921788,percent of total billed charges,148.81757,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040304,NDC,10,ML,168.77,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,148.85514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040310,NDC,10,ML,168.77,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,148.85514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
Xray Mandible Partial Less Than 4 Vws,PX7010001,CDM,320,RC,70100,CPT,TC,,,,,,,347,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,148.863,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,340.06
sodium zirconium cyclosilicate 5 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,310110501,NDC,1,EA,151.95,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,148.911,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ELECTRODE ADULT PACING ONESTEP,120.214,CDM,272,RC,A4556,HCPCS,,10242-MAIN,LOCAL,,,,,153,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,148.9149,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.5562,149.94
"Protein, Total; Other Source",PX84157,CDM,300,RC,84157,CPT,,,,,,,,153,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,103.8,percent of total billed charges,148.9149,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.67,149.94
Pulmonary Stress Test,PX94618,CDM,976,RC,94618,CPT,,,,,,,,153,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,148.9149,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.5562,148.9149
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457018100,NDC,20,ML,153.01,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,11.07921788,percent of total billed charges,148.924633,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
"Antipsychotics, Not Otherwise Specified; 1-3 - Ref",PX8034290,CDM,300,RC,80342,CPT,90,,,,,,,152,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,148.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.1408,148.96
Body Fluid Cell Count,PX89050,CDM,300,RC,89050,CPT,,,,,,,,152,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,148.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.33,148.96
"Ctrl Nosebleed,Anter,Complex",PX30903P,CDM,983,RC,30903,CPT,,,,,,,,304,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,148.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,295.8832
"Ctrl Nosebleed,Anter,Complex",PX30903P,CDM,983,RC,30903,CPT,,,,,,,,304,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,148.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,295.8832
"Ctrl Nosebleed,Anter,Complex",PX30903P,CDM,983,RC,30903,CPT,,,,,,,,304,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,148.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,295.8832
Joint Survey Tc,PX7707701,CDM,320,RC,77077,CPT,TC,,,,,,,304,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,148.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,297.92
Joint Survey Tc,PX7707701,CDM,320,RC,77077,CPT,TC,,,,,,,304,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,148.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,297.92
Joint Survey Tc,PX7707701,CDM,320,RC,77077,CPT,TC,,,,,,,304,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,148.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,297.92
PACLitaxel 150 MG/25ML Concentrate 25 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321701,NDC,25,ML,300.96,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,148.9752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122P,CDM,983,RC,13122,CPT,,,,,,,,301,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,148.995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.0354,292.9633
Xray Facial Bones Less Than 3 Vws,PX7014001,CDM,320,RC,70140,CPT,TC,,,,,,,301,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,148.995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,294.98
Blood Clot Factor VIII Test,PX85247,CDM,300,RC,85247,CPT,,,,,,,,169,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,149.058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.03,165.62
Tap Block Unilateral by Injection(S),PX64486P,CDM,983,RC,64486,CPT,,,,,,,,169,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,149.058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.2026,164.4877
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862066230,NDC,1,EA,153.17,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,149.080361,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954201,NDC,10,ML,153.18,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,149.090094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.630972,150.1164
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954210,NDC,10,ML,153.18,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,149.090094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.630972,150.1164
dexmedeTOMIDine in sodium chloride 200 MCG/50ML Solution 50 mL Flex Cont,25000000,CDM,250,RC,,,,,,338955524,NDC,50,ML,304.32,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,149.1168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dexmedeTOMIDine in sodium chloride 200 MCG/50ML Solution 50 mL Flex Cont,25000000,CDM,250,RC,,,,,,338955524,NDC,50,ML,304.32,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,149.1168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dexmedeTOMIDine in sodium chloride 200 MCG/50ML Solution 50 mL Flex Cont,25000000,CDM,250,RC,,,,,,338955524,NDC,50,ML,304.32,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,149.1168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Office/Outpt Visit,New,Levl IV",PX99204F,CDM,510,RC,99204,CPT,,,,,,,,359,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,149.1286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.1286,351.82
"Office/Outpt Visit,New,Levl IV",PX99204P,CDM,983,RC,99204,CPT,,,,,,,,359,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,149.1286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.1286,349.4147
CARBOplatin 600 MG/60ML Solution 60 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703423981,NDC,60,ML,301.42,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,149.2029,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.778704,295.3916
"Compatibility Test,Antiglob Tech",PX86922,CDM,300,RC,86922,CPT,,,,,,,,120,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,149.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.848,149.22
Immunocytochemistry,PX3993,CDM,310,RC,88342,CPT,TC,,,,,,,182,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,149.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.6028,178.36
"Immunofluo Direct, Ea Ab - Ref",PX8834690,CDM,310,RC,88346,CPT,90,,,,,,,55,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,149.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.847,149.22
"In Situ Hybridization (Eg, Fish), Each Probe, Tech",PX8836501,CDM,310,RC,88365,CPT,TC,,,,,,,117,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,149.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.6018,149.22
Lab Imm Spin X-Match,PX8837,CDM,300,RC,86920,CPT,,,,,,,,402,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,149.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.22,393.96
"Morphometric Analysis, Tumor - Ref",PX8836090,CDM,310,RC,88360,CPT,90,,,,,,,349,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,149.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,144.9746,342.02
"Morphometric Analysis,Tumor Immunohistochemistry, Ea Antibody Manual , Tech",PX8836001,CDM,310,RC,88360,CPT,TC,,,,,,,119,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,149.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,149.22
RBC Antibody Elution,PX86860,CDM,300,RC,86860,CPT,,,,,,,,360,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,149.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.22,352.8
Closed Rx Metacarpal Fx,PX26600P,CDM,983,RC,26600,CPT,,,,,,,,295,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,149.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.543,287.1235
Sulfur Colloid per Dose,PXA9541,CDM,343,RC,A9541,HCPCS,,,,,,,,295,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,149.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.543,289.1
Repr Superf Wnd Body <2.5cm,PX12001F,CDM,510,RC,12001,CPT,,,,,,,,311,,Health Partners,Health Partners Care Plans,both,48,,4.615,percent of total billed charges,149.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,129.1894,304.78
Repr Superf Wnd Body <2.5cm,PX12001F,CDM,510,RC,12001,CPT,,,,,,,,311,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,149.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,129.1894,304.78
Xray Skull Less Than 4 Vws,PX7025001,CDM,320,RC,70250,CPT,TC,,,,,,,311,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,149.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,304.78
Xray Skull Less Than 4 Vws,PX7025001,CDM,320,RC,70250,CPT,TC,,,,,,,311,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,149.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,304.78
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801801,NDC,0.8,ML,359.37,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,149.282298,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801810,NDC,0.8,ML,359.37,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,149.282298,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
Fac/Removal of Skin Tags,PX11200F,CDM,510,RC,11200,CPT,,,,,,,,348,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,149.292,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,144.5592,341.04
CT Upper Extremity W/Dye,PX7320101,CDM,350,RC,73201,CPT,TC,,,,,,,2757,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,149.3152,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.22,299.12
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,39328006712,NDC,473,ML,167.77,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,149.3153,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Tx/Pro/Dx Inj Same Drug Adon,PX96376,CDM,260,RC,96376,CPT,,,,,,,,164,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,149.404,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.1256,160.72
"Fna Biopsy, W/US Guidance; First Lesion",PX10005F,CDM,510,RC,10005,CPT,,,,,,,,333,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,149.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.93,278.8
"Fna Biopsy, W/US Guidance; First Lesion",PX10005P,CDM,983,RC,10005,CPT,,,,,,,,621,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,149.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.93,608.58
MRI L Spine W&WO Contrast,PX7215801,CDM,610,RC,72158,CPT,TC,,,,,,,4178,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,149.43,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,147.68,435.86
"Bone Marrow Aspiration(S),Diag",PX38220F,CDM,510,RC,38220,CPT,,,,,,,,305,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,149.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,126.697,1416.38
"Bone Marrow Aspiration(S),Diag",PX38220F,CDM,510,RC,38220,CPT,,,,,,,,305,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,149.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,126.697,1416.38
"Bone Marrow Aspiration(S),Diag",PX38220F,CDM,510,RC,38220,CPT,,,,,,,,305,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,149.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,126.697,1416.38
"Destruct Benign Lesion, 1-14",PX17110F,CDM,510,RC,17110,CPT,,,,,,,,302,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,149.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.4508,295.96
Aerobic Isolate - Ref,PX8707790,CDM,300,RC,87077,CPT,90,,,,,,,168,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,149.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,164.64
Complete Cbc W/Auto Diff Wbc,PX85025,CDM,300,RC,85025,CPT,,,,,,,,168,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,149.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.12,164.64
Insert Straight Catheter,PX51701F,CDM,510,RC,51701,CPT,,,,,,,,168,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,149.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.7872,164.64
Org ID Aerobic-Each,PX87077,CDM,300,RC,87077,CPT,,,,,,,,168,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,149.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,164.64
Closed Rx Mt-Phal Toe Dislocation,PX28630F,CDM,510,RC,28630,CPT,,,,,,,,360,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,149.544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.544,352.8
RBC Antibody Elution,PX86860,CDM,300,RC,86860,CPT,,,,,,,,360,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,149.544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.22,352.8
CCP Antibody,PX86200,CDM,300,RC,86200,CPT,,,,,,,,176,,First Health,Commercial,both,85,,999999999,percent of total billed charges,149.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,172.48
Detect Agent Nos Dna Amp,PX87798,CDM,300,RC,87798,CPT,,,,,,,,176,,First Health,Commercial,both,85,,999999999,percent of total billed charges,149.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,172.48
Eval of Bronchospasm,PX94060,CDM,983,RC,94060,CPT,,,,,,,,176,,First Health,Commercial,both,85,,999999999,percent of total billed charges,149.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.1104,274.21
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151F,CDM,370,RC,99151,CPT,,,,,,,,176,,First Health,Commercial,both,85,,999999999,percent of total billed charges,149.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.1104,172.48
Repr Superf Wnd Face >30cm,PX12018F,CDM,510,RC,12018,CPT,,,,,,,,713,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,149.6326,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.66,358.35
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127303,NDC,2,ML,152.7,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,149.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.43158,173.019
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082143,NDC,1,ML,348.85,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,149.65665,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.48,367.9214
"Echo Heart Xthoracic,Limited",PX9330801,CDM,480,RC,93308,CPT,TC,,,,,,,349,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,149.721,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,144.9746,342.02
"Morphometric Analysis, Tumor - Ref",PX8836090,CDM,310,RC,88360,CPT,90,,,,,,,349,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,149.721,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,144.9746,342.02
"Apply Forearm Splint,Static",PX29125P,CDM,983,RC,29125,CPT,,,,,,,,296,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,149.776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,288.0968
Apply Lower Leg Splint,PX29515F,CDM,510,RC,29515,CPT,,,,,,,,296,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,149.776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.9584,290.08
Drain Skin Abscess Simple,PX10060F,CDM,510,RC,10060,CPT,,,,,,,,296,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,149.776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.9584,290.08
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,55150043801,NDC,20,ML,152.9,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,149.842,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457018120,NDC,20,ML,152.9,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,149.842,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035F,CDM,510,RC,12035,CPT,,,,,,,,655,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,149.86,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.34,810.1
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035F,CDM,510,RC,12035,CPT,,,,,,,,655,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,149.86,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.34,810.1
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035P,CDM,983,RC,12035,CPT,,,,,,,,1244,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,149.86,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.34,1219.12
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035P,CDM,983,RC,12035,CPT,,,,,,,,1244,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,149.86,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.34,1219.12
aztreonam 1 g Recon Soln 1 Each Vial,J0457.01,CDM,636,RC,J0457,HCPCS,,,,63323040124,NDC,1,EA,176.32,,First Health,Commercial,both,85,,999999999,percent of total billed charges,149.872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.32,172.7936
PROSTEP 0.9MM ANTI SKIVE PIN,27200000,CDM,272,RC,,,,12950-MAIN,LOCAL,,,,,154,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,149.8882,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PROSTEP 1.4MM ANTI SKIVE PIN,27200000,CDM,272,RC,,,,12949-MAIN,LOCAL,,,,,154,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,149.8882,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Vit D 1 25-Dihydroxy,PX82652,CDM,300,RC,82652,CPT,,,,,,,,154,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,48.94,percent of total billed charges,149.8882,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.3,150.92
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010365,NDC,100,ML,164.54,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,149.89594,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.174958,180.2416
Asay of Interleukin-6 (Il-6),PX8352990,CDM,300,RC,83529,CPT,90,,,,,,,170,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,149.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,166.6
Chem Cautery Granulatn Tissue,PX17250F,CDM,510,RC,17250,CPT,,,,,,,,170,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,149.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,174.9
"Chemotherapy Administration, Subq/Im Non-Hormonal Anti-Neoplastic",PX96401,CDM,335,RC,96401,CPT,,,,,,,,170,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,149.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,166.6
Collagen Cross Links - Ref,PX8252390,CDM,300,RC,82523,CPT,90,,,,,,,170,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,149.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.13,166.6
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800P,CDM,983,RC,40800,CPT,,,,,,,,170,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,149.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,614.65
ELECTRODE ADULT PACING ONESTEP,120.214,CDM,272,RC,A4556,HCPCS,,10242-MAIN,LOCAL,,,,,153,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,149.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.5562,149.94
gadoteridol 279.3 MG/ML Solution 17 mL Syringe,A9576,CDM,636,RC,A9576,HCPCS,,,,270111145,NDC,17,ML,170,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,149.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.54,166.6
"Inject Nerv Blck,Trigeminal",PX64400P,CDM,983,RC,64400,CPT,,,,,,,,170,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,149.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,258.75
"Protein, Total; Other Source",PX84157,CDM,300,RC,84157,CPT,,,,,,,,153,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,149.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.67,149.94
"Protein, Total; Serum, Plasma or Whole Blood",PX84155,CDM,300,RC,84155,CPT,,,,,,,,170,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,149.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.37,166.6
Pulmonary Stress Test,PX94618,CDM,976,RC,94618,CPT,,,,,,,,153,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,149.94,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.38,149.94
Xray Thoracolumbar 2 Vws,PX7208001,CDM,320,RC,72080,CPT,TC,,,,,,,306,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,149.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,299.88
Xray Thoracolumbar 2 Vws,PX7208001,CDM,320,RC,72080,CPT,TC,,,,,,,306,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,149.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,299.88
Xray Thoracolumbar 2 Vws,PX7208001,CDM,320,RC,72080,CPT,TC,,,,,,,306,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,149.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,299.88
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457018100,NDC,20,ML,153.01,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,149.9498,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.284284,149.9498
"Destruct Benign Lesion, 15+",PX17111F,CDM,510,RC,17111,CPT,,,,,,,,303,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,149.985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.8662,296.94
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607P,CDM,983,RC,97607,CPT,,,,,,,,303,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,149.985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.8662,348.35
Strapping of Knee,PX29530F,CDM,420,RC,29530,CPT,,,,,,,,303,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,149.985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,296.94
Xray Knee 1 or 2 Vws,PX7356001,CDM,320,RC,73560,CPT,TC,,,,,,,303,,Humana Choice Care,All Medicare plans,outpatient,49.5,,296.94,percent of total billed charges,149.985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,296.94
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234010,NDC,5,ML,306.2,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,150.038,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234010,NDC,5,ML,306.2,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,150.038,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234010,NDC,5,ML,306.2,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,150.038,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234025,NDC,5,ML,306.2,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,150.038,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234025,NDC,5,ML,306.2,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,150.038,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234025,NDC,5,ML,306.2,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,150.038,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234099,NDC,5,ML,306.2,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,150.038,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234099,NDC,5,ML,306.2,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,150.038,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234099,NDC,5,ML,306.2,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,150.038,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127332,NDC,2,ML,176.55,,First Health,Commercial,both,85,,999999999,percent of total billed charges,150.0675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.43158,173.019
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862066230,NDC,1,EA,153.17,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,150.1066,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,59148000713,NDC,1,EA,170.19,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,150.10758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954201,NDC,10,ML,153.18,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,150.1164,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.630972,150.1164
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954210,NDC,10,ML,153.18,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,150.1164,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.630972,150.1164
Cv Carotid Imaging-Bilat,PX9388001,CDM,921,RC,93880,CPT,TC,,,,,,,1088,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,150.1405,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.44,266.42
Flu Dna Amp Probe 1st 2 Types,PX87502,CDM,300,RC,87502,CPT,,,,,,,,350,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,150.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.84,343
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040304,NDC,10,ML,168.77,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,150.2053,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040310,NDC,10,ML,168.77,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,150.2053,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032225,NDC,1,EA,176.72,,First Health,Commercial,both,85,,999999999,percent of total billed charges,150.212,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,173.1856
sulfacetamide 10 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,24208067004,NDC,15,ML,312.96,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,150.2208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sulfacetamide 10 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,24208067004,NDC,15,ML,312.96,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,150.2208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Dress/Debrid Small Burn No Anes,PX16020F,CDM,510,RC,16020,CPT,,,,,,,,313,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,150.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.0202,306.74
Dress/Debrid Small Burn No Anes,PX16020F,CDM,510,RC,16020,CPT,,,,,,,,313,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,150.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.0202,306.74
MRI T Spine W&WO Contrast,PX7215701,CDM,610,RC,72157,CPT,TC,,,,,,,4178,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,150.3,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.55,438.49
Dihydroxyvitamin D - Ref,PX8265290,CDM,300,RC,82652,CPT,90,,,,,,,165,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,150.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.3,161.7
Flow Cyto Ea Addtl Marker - Ref,PX8818590,CDM,310,RC,88185,CPT,90,,,,,,,165,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,150.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.541,161.7
Strapping of Shoulder,PX29240F,CDM,420,RC,29240,CPT,,,,,,,,165,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,150.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.541,161.7
Bcr/Abl1 P210 - Ref,PX8120690,CDM,310,RC,81206,CPT,90,,,,,,,1144,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,150.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.33,1121.12
US Pregnancy Tc Follow-Up,PX7681601,CDM,402,RC,76816,CPT,TC,,,,,,,362,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,150.3748,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,354.76
Blood Clot Factor VIII Test,PX85247,CDM,300,RC,85247,CPT,,,,,,,,169,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,150.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.03,165.62
Tap Block Unilateral by Injection(S),PX64486P,CDM,983,RC,64486,CPT,,,,,,,,169,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,150.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.2026,164.4877
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242003706,NDC,0.6,EA,8461.09,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,150.42692,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,134.74,153.11
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012001,NDC,0.6,EA,7764.12,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,150.42692,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,134.74,153.11
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012047,NDC,0.6,EA,10644.69,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,150.42692,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,134.74,153.11
COOK EMERGENCY PNEUMOTHORAX SET,120.559,CDM,272,RC,,,,12597-MAIN,LOCAL,,,,,307,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,150.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,127.5278,300.86
COOK EMERGENCY PNEUMOTHORAX SET,120.559,CDM,272,RC,,,,12597-MAIN,LOCAL,,,,,307,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,150.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,127.5278,300.86
COOK EMERGENCY PNEUMOTHORAX SET,120.559,CDM,272,RC,,,,12597-MAIN,LOCAL,,,,,307,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,150.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,127.5278,300.86
Assay of Ferritin,PX82728,CDM,300,RC,82728,CPT,,,,,,,,177,,First Health,Commercial,both,85,,999999999,percent of total billed charges,150.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.5,173.46
"D-Dimer, Quantitative - Ref",PX8537990,CDM,300,RC,85379,CPT,90,,,,,,,177,,First Health,Commercial,both,85,,999999999,percent of total billed charges,150.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.33,173.46
Fibrin Degradation Quant,PX85379,CDM,300,RC,85379,CPT,,,,,,,,177,,First Health,Commercial,both,85,,999999999,percent of total billed charges,150.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.33,173.46
Inj Tendon/Ligament/Cyst,PX20550F,CDM,510,RC,20550,CPT,,,,,,,,177,,First Health,Commercial,both,85,,999999999,percent of total billed charges,150.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.5258,258.75
"Ctrl Nosebleed,Anter,Complex",PX30903P,CDM,983,RC,30903,CPT,,,,,,,,304,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,150.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,295.8832
Joint Survey Tc,PX7707701,CDM,320,RC,77077,CPT,TC,,,,,,,304,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,150.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,297.92
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,574200815,NDC,15,GR,154.63,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,150.501379,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Debride Bone Ea Add 20 Sqcm,PX11047P,CDM,983,RC,11047,CPT,,,,,,,,351,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,150.579,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,145.8054,341.6283
Debride Tissue/Muscle,PX11043P,CDM,983,RC,11043,CPT,,,,,,,,351,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,150.579,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,145.8054,548.67
dexmedeTOMIDine in sodium chloride 200 MCG/50ML Solution 50 mL Flex Cont,25000000,CDM,250,RC,,,,,,338955524,NDC,50,ML,304.32,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,150.6384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
insulin regular 100 UNIT/ML Solution 10 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821501,NDC,10,ML,307.46,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,3.1136,percent of total billed charges,150.6554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
insulin regular 100 UNIT/ML Solution 10 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821501,NDC,10,ML,307.46,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,150.6554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
insulin regular 100 UNIT/ML Solution 10 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821501,NDC,10,ML,307.46,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,150.6554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
Assay for Vancomycin,PX80202,CDM,300,RC,80202,CPT,,,,,,,,314,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,150.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.41,307.72
Assay for Vancomycin,PX80202,CDM,300,RC,80202,CPT,,,,,,,,314,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,150.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.41,307.72
"Ecg 12 Lead, Tracing Only",PX93005,CDM,730,RC,93005,CPT,,,,,,,,298,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,150.788,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.44,292.04
SET CRICOTHYROTOMY CATHETER 3.5MM ID,120.251,CDM,272,RC,,,,4306-MAIN,LOCAL,,,,,363,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,150.7902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.7902,355.74
SET CRICOTHYROTOMY CATHETER 4MM ID,120.251,CDM,272,RC,,,,3452-MAIN,LOCAL,,,,,363,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,150.7902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.7902,355.74
SET CRICOTHYROTOMY CATHETER 6MM ID,120.251,CDM,272,RC,,,,2887-MAIN,LOCAL,,,,,363,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,150.7902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.7902,355.74
Abd Paracentesis,PX49082F,CDM,510,RC,49082,CPT,,,,,,,,884,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,150.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.5,439.29
"CCP, Antibody - Ref",PX8620090,CDM,300,RC,86200,CPT,90,,,,,,,171,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,150.822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,167.58
Hepatic Function Panel,PX80076,CDM,300,RC,80076,CPT,,,,,,,,171,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,150.822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.49,167.58
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105F,CDM,510,RC,11105,CPT,,,,,,,,171,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,150.822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.0334,167.58
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105P,CDM,983,RC,11105,CPT,,,,,,,,171,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,150.822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.0334,166.4343
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102F,CDM,510,RC,11102,CPT,,,,,,,,171,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,150.822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.0334,174.9
neomycin-polymyxin-gramicidin 1.75-10000-.025 Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,24208079062,NDC,10,ML,314.26,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,150.8448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
neomycin-polymyxin-gramicidin 1.75-10000-.025 Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,24208079062,NDC,10,ML,314.26,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,150.8448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
CYSTOSCOPY PACK I STERILE,120.505,CDM,272,RC,,,,4527-MAIN,LOCAL,,,,,155,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,150.8615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,151.9
"Lab Antibody ID,RBC",PX7605,CDM,300,RC,86870,CPT,,,,,,,,155,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,150.8615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,314.02
"Office/Outpt Visit,Est,Levl II",PX99212F,CDM,510,RC,99212,CPT,,,,,,,,155,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,75.26111111,percent of total billed charges,150.8615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,151.9
"Office/Outpt Visit,Est,Levl II",PX99212P,CDM,983,RC,99212,CPT,,,,,,,,155,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,75.26111111,percent of total billed charges,150.8615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,150.8615
Smear Fluorescent/Acid Stai,PX87206,CDM,300,RC,87206,CPT,,,,,,,,155,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,150.8615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.94,151.9
TB Test Enumeration of T-Cells - Ref,PX8648190,CDM,300,RC,86481,CPT,90,,,,,,,155,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,150.8615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,151.9
"Up GI Endoscopy,Dilatn W Guide",PX43248F,CDM,750,RC,43248,CPT,,,,,,,,1995,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,150.917,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.66,856.45
PROSTEP 0.9MM ANTI SKIVE PIN,27200000,CDM,272,RC,,,,12950-MAIN,LOCAL,,,,,154,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,150.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PROSTEP 1.4MM ANTI SKIVE PIN,27200000,CDM,272,RC,,,,12949-MAIN,LOCAL,,,,,154,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,150.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Vit D 1 25-Dihydroxy,PX82652,CDM,300,RC,82652,CPT,,,,,,,,154,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,150.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.3,150.92
"Bone Marrow Aspiration(S),Diag",PX38220F,CDM,510,RC,38220,CPT,,,,,,,,305,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,150.975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,126.697,1416.38
hydrocortisone sodium succinate (preservative free) 500 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001612,NDC,1,EA,298.53,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,151.05618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
MINIBUNION LOCKING SCREW 3.0X24MM,C1713,CDM,278,RC,C1713,HCPCS,,11671-MAIN,LOCAL,,,,,308.55,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,151.1895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
MINIBUNION LOCKING SCREW 3.0X24MM,C1713,CDM,278,RC,C1713,HCPCS,,11671-MAIN,LOCAL,,,,,308.55,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,151.1895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
MINIBUNION LOCKING SCREW 3.0X24MM,C1713,CDM,278,RC,C1713,HCPCS,,11671-MAIN,LOCAL,,,,,308.55,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,151.1895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Assay Iga/Igd/Igg/Igm Each,PX82784,CDM,300,RC,82784,CPT,,,,,,,,315,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,151.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.53,308.7
Assay Iga/Igd/Igg/Igm Each,PX82784,CDM,300,RC,82784,CPT,,,,,,,,315,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,151.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.53,308.7
Drain/Inject Large Joint/Bursa,PX20610F,CDM,510,RC,20610,CPT,,,,,,,,364,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,151.2056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,151.2056,356.72
Xray Forearm 2 Vws,PX7309001,CDM,320,RC,73090,CPT,TC,,,,,,,364,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,151.2056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,356.72
"Breast Tomosynthesis,Dx Tc Bilat",PX7706201,CDM,401,RC,77062,CPT,TC,,,,,,,166,,Medica,Commercial,both,91.1,,79.38125,percent of total billed charges,151.226,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.9564,162.68
"Breast Tomosynthesis,Dx Tc Unilat",PX7706101,CDM,401,RC,77061,CPT,TC,,,,,,,166,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,151.226,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.9564,162.68
"Breast Tomosynthesis,Screen Tc",PX7706301,CDM,403,RC,77063,CPT,TC,,,,,,,166,,Medica,Commercial,both,91.1,,151.3766667,percent of total billed charges,151.226,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.59,280.5
Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq,PX87635,CDM,300,RC,87635,CPT,,,,,,,,166,,Medica,Commercial,both,91.1,,60.49,percent of total billed charges,151.226,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,224.4
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,990771502,NDC,250,ML,166.02,,Medica,Commercial,both,91.1,,7.37,percent of total billed charges,151.24422,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.4701,303.0944
Exc Skin Benig <5mm Remaindr Body,PX11420P,CDM,983,RC,11420,CPT,,,,,,,,299,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,151.294,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,124.2046,1416.38
Asay of Interleukin-6 (Il-6),PX8352990,CDM,300,RC,83529,CPT,90,,,,,,,170,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,151.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,166.6
Chem Cautery Granulatn Tissue,PX17250F,CDM,510,RC,17250,CPT,,,,,,,,170,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,151.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,174.9
"Chemotherapy Administration, Subq/Im Non-Hormonal Anti-Neoplastic",PX96401,CDM,335,RC,96401,CPT,,,,,,,,170,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,151.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,166.6
Collagen Cross Links - Ref,PX8252390,CDM,300,RC,82523,CPT,90,,,,,,,170,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,151.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.13,166.6
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800P,CDM,983,RC,40800,CPT,,,,,,,,170,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,151.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,614.65
gadoteridol 279.3 MG/ML Solution 17 mL Syringe,A9576,CDM,636,RC,A9576,HCPCS,,,,270111145,NDC,17,ML,170,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,151.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.54,166.6
"Inject Nerv Blck,Trigeminal",PX64400P,CDM,983,RC,64400,CPT,,,,,,,,170,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,151.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,258.75
"Protein, Total; Serum, Plasma or Whole Blood",PX84155,CDM,300,RC,84155,CPT,,,,,,,,170,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,151.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.37,166.6
tranexamic acid 1000 mg in 100 mL 0.7% sodium chloride (premix) 1000-0.7 MG/100ML-% Solution 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,80830232901,NDC,100,ML,155.55,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,151.396815,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
CT Abdomen&Pelvis W/Contrast,PX7417701,CDM,350,RC,74177,CPT,TC,,,,,,,4288,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,151.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,151.4,446.37
CT Abdomen&Pelvis W/Contrast,PX7417701,CDM,350,RC,74177,CPT,TC,,,,,,,4288,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,151.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,151.4,446.37
Drain/Inject Med Joint/Brusa W/US Guide,PX20606P,CDM,983,RC,20606,CPT,,,,,,,,309,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,151.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.3586,604.15
Drain/Inject Med Joint/Brusa W/US Guide,PX20606P,CDM,983,RC,20606,CPT,,,,,,,,309,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,151.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.3586,604.15
Drain/Inject Med Joint/Brusa W/US Guide,PX20606P,CDM,983,RC,20606,CPT,,,,,,,,309,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,151.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.3586,604.15
LINNEAR CUTTER STAPLE RELOAD GST BLUE 60MM,27200000,CDM,272,RC,,,,12068-MAIN,LOCAL,,,,,309,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,151.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LINNEAR CUTTER STAPLE RELOAD GST BLUE 60MM,27200000,CDM,272,RC,,,,12068-MAIN,LOCAL,,,,,309,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,151.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LINNEAR CUTTER STAPLE RELOAD GST BLUE 60MM,27200000,CDM,272,RC,,,,12068-MAIN,LOCAL,,,,,309,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,151.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LINNEAR CUTTER STAPLE RELOAD GST GREEN 60MM,27200000,CDM,272,RC,,,,12069-MAIN,LOCAL,,,,,309,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,151.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LINNEAR CUTTER STAPLE RELOAD GST GREEN 60MM,27200000,CDM,272,RC,,,,12069-MAIN,LOCAL,,,,,309,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,151.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LINNEAR CUTTER STAPLE RELOAD GST GREEN 60MM,27200000,CDM,272,RC,,,,12069-MAIN,LOCAL,,,,,309,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,151.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LINNEAR CUTTER STAPLE RELOAD GST WHITE 60MM,27200000,CDM,272,RC,,,,12067-MAIN,LOCAL,,,,,309,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,151.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LINNEAR CUTTER STAPLE RELOAD GST WHITE 60MM,27200000,CDM,272,RC,,,,12067-MAIN,LOCAL,,,,,309,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,151.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LINNEAR CUTTER STAPLE RELOAD GST WHITE 60MM,27200000,CDM,272,RC,,,,12067-MAIN,LOCAL,,,,,309,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,151.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Naso/Orogastric Tube,PX43752P,CDM,983,RC,43752,CPT,,,,,,,,309,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,151.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.3586,348.08
Naso/Orogastric Tube,PX43752P,CDM,983,RC,43752,CPT,,,,,,,,309,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,151.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.3586,348.08
Naso/Orogastric Tube,PX43752P,CDM,983,RC,43752,CPT,,,,,,,,309,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,151.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.3586,348.08
Creatine Mb Fraction,PX82553,CDM,300,RC,82553,CPT,,,,,,,,353,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,151.437,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.59,345.94
Fentanyl - Ref,PX8035490,CDM,300,RC,80354,CPT,90,,,,,,,353,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,151.437,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,345.94
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155F,CDM,370,RC,99155,CPT,,,,,,,,353,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,151.437,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,345.94
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155P,CDM,983,RC,99155,CPT,,,,,,,,353,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,151.437,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,343.5749
Pvb Thoracic Single Injection Site W/Img Gid,PX64461F,CDM,510,RC,64461,CPT,,,,,,,,353,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,151.437,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,604.15
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,59148000713,NDC,1,EA,170.19,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,151.4691,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Xray Thoracolumbar 2 Vws,PX7208001,CDM,320,RC,72080,CPT,TC,,,,,,,306,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,151.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,299.88
Debride Muscle Ea Add 20 Sqcm,PX11046F,CDM,510,RC,11046,CPT,,,,,,,,248,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,151.5,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.5,151.5
Debride Muscle Ea Add 20 Sqcm,PX11046P,CDM,983,RC,11046,CPT,,,,,,,,198,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,151.5,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.5,194.04
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,574200815,NDC,15,GR,154.63,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,151.5374,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
atropine 1 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,60219174903,NDC,5,ML,299.49,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,151.54194,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,338035702,NDC,250,ML,309.28,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,12.9192,percent of total billed charges,151.5472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.4701,303.0944
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,338035702,NDC,250,ML,309.28,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,151.5472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.4701,303.0944
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,338035702,NDC,250,ML,309.28,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,151.5472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.4701,303.0944
"Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602P,CDM,983,RC,11602,CPT,,,,,,,,1120,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,151.5592,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.66,1097.6
"Fac/Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602F,CDM,510,RC,11602,CPT,,,,,,,,731,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,151.5592,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.66,509.86
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234010,NDC,5,ML,306.2,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,151.569,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234025,NDC,5,ML,306.2,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,151.569,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234099,NDC,5,ML,306.2,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,151.569,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
fosfomycin 3 g Packet 1 Each Box,25000000,CDM,250,RC,,,,,,70700026894,NDC,1,EA,353.41,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,151.61289,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"2019-Ncov Coronavirus, Sars-Cov-2/2019-Ncov (Covid-19)",PXU000290,CDM,300,RC,U0002,HCPCS,90,,,,,,,365,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,151.621,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,357.7
"Closed Rx Spont Hip Disloc,Anesth",PX27257P,CDM,983,RC,27257,CPT,,,,,,,,365,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,151.621,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,151.621,1404.08
X-Ray Exam Femur Min 2 Vws,PX7355201,CDM,320,RC,73552,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,151.621,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Ankle Minimum 3 Vws,PX7361001,CDM,320,RC,73610,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,151.621,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Calcaneus Minimum 2 Vws,PX7365001,CDM,320,RC,73650,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,151.621,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Clavicle Complete,PX7300001,CDM,320,RC,73000,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,151.621,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Elbow 2 Vws,PX7307001,CDM,320,RC,73070,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,151.621,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Hand 2vws Tc,PX7312001,CDM,320,RC,73120,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,151.621,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,357.7
Xray Humerus Minimum 2 Vws,PX7306001,CDM,320,RC,73060,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,151.621,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Shoulder Minimum 2 Vws,PX7303001,CDM,320,RC,73030,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,151.621,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Sternum 2vws Tc,PX7112001,CDM,320,RC,71120,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,151.621,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Tibia & Fibula 2 Vws,PX7359001,CDM,320,RC,73590,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,151.621,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Wrist 2 Vws,PX7310001,CDM,320,RC,73100,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,151.621,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Cast/Strap Procedure Unlisted,PX29799F,CDM,510,RC,29799,CPT,,,,,,,,316,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,151.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,131.2664,309.68
Cast/Strap Procedure Unlisted,PX29799F,CDM,510,RC,29799,CPT,,,,,,,,316,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,151.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,131.2664,309.68
AIRSEAL 12MM ACCESS PORT AND PALM GRIP OBTURATOR BLADELESS OPTICAL TIP 120MM,27200000,CDM,272,RC,,,,12207-MAIN,LOCAL,,,,,172,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,151.704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
AIRSEAL TUBE SET TRI LUMEN FILTERED WITH ACTIVATED CHARCOAL,27200000,CDM,272,RC,,,,12206-MAIN,LOCAL,,,,,172,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,151.704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
iohexol 300 MG/ML Solution 150 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141365,NDC,150,ML,300,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,151.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,294
"Spinal Punc,Drain,Theraputic",PX62272P,CDM,983,RC,62272,CPT,,,,,,,,300,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,151.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,124.62,604.15
US Follicles-Limited Tc,PX7685701,CDM,402,RC,76857,CPT,TC,,,,,,,300,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,151.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,294
Assay Blood Carbon Monoxide,PX82375,CDM,300,RC,82375,CPT,,,,,,,,156,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,151.8348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.3,152.88
"Cortisol, Am",PX7152,CDM,300,RC,82533,CPT,,,,,,,,156,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,151.8348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.95,152.88
DERMABOND PRINEO SKIN CLOSURE SYSTEM 22CM,27200000,CDM,272,RC,,,,12324-MAIN,LOCAL,,,,,156,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,151.8348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Xray Sinuses Minimum 3 Vws,PX7022001,CDM,320,RC,70220,CPT,TC,,,,,,,354,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,151.866,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,346.92
"Cystourethroscopy, With Injection(S) for Chemodenervation of the Bladder",PX52287F,CDM,360,RC,52287,CPT,,,,,,,,2745,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,151.8803,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.53,803.87
CYSTOSCOPY PACK I STERILE,120.505,CDM,272,RC,,,,4527-MAIN,LOCAL,,,,,155,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,151.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,151.9
"Drain Finger Abscess,Simple",PX26010F,CDM,510,RC,26010,CPT,,,,,,,,310,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,151.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.774,303.8
"Drain Finger Abscess,Simple",PX26010F,CDM,510,RC,26010,CPT,,,,,,,,310,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,151.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.774,303.8
"Drain Finger Abscess,Simple",PX26010F,CDM,510,RC,26010,CPT,,,,,,,,310,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,151.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.774,303.8
"Lab Antibody ID,RBC",PX7605,CDM,300,RC,86870,CPT,,,,,,,,155,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,151.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,314.02
"Office/Outpt Visit,Est,Levl II",PX99212F,CDM,510,RC,99212,CPT,,,,,,,,155,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,151.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,151.9
"Office/Outpt Visit,Est,Levl II",PX99212P,CDM,983,RC,99212,CPT,,,,,,,,155,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,151.9,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.04,151.9
Smear Fluorescent/Acid Stai,PX87206,CDM,300,RC,87206,CPT,,,,,,,,155,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,151.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.94,151.9
TB Test Enumeration of T-Cells - Ref,PX8648190,CDM,300,RC,86481,CPT,90,,,,,,,155,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,151.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,151.9
COOK EMERGENCY PNEUMOTHORAX SET,120.559,CDM,272,RC,,,,12597-MAIN,LOCAL,,,,,307,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,151.965,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,127.5278,300.86
Dress/Debrid Med Burn No Anesth,PX16025F,CDM,510,RC,16025,CPT,,,,,,,,366,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,152.0364,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,152.0364,358.68
Ven Duplex Bilateral,PX9397001,CDM,921,RC,93970,CPT,TC,,,,,,,1189,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,152.0695,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.18,269.91
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082143,NDC,1,ML,348.85,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,152.12,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,133.87,158.15
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082152,NDC,1,ML,375.43,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,152.12,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,133.87,158.15
Fungus Isolation Culture,PX87102,CDM,300,RC,87102,CPT,,,,,,,,167,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,152.137,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.71,163.66
Microalbumin Quantitative,PX82043,CDM,300,RC,82043,CPT,,,,,,,,167,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,152.137,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.3,163.66
Wound Cult/Afb,PX87116,CDM,300,RC,87116,CPT,,,,,,,,167,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,152.137,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9,163.66
"Apply Short Leg Cast,Walker",PX29425F,CDM,510,RC,29425,CPT,,,,,,,,179,,First Health,Commercial,both,85,,999999999,percent of total billed charges,152.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.3566,234.62
C Diff Amplified Probe,PX87493,CDM,300,RC,87493,CPT,,,,,,,,179,,First Health,Commercial,both,85,,999999999,percent of total billed charges,152.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.17,175.42
Fibrinogen Test - Ref,PX8536690,CDM,300,RC,85366,CPT,90,,,,,,,179,,First Health,Commercial,both,85,,999999999,percent of total billed charges,152.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.77,175.42
TUBE GASTROSTOMY 18FR REPLACEMENT DYND70318,120.256,CDM,271,RC,B4087,HCPCS,,407-MAIN,LOCAL,,,,,179,,First Health,Commercial,both,85,,999999999,percent of total billed charges,152.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.53,175.42
"CCP, Antibody - Ref",PX8620090,CDM,300,RC,86200,CPT,90,,,,,,,171,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,152.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,167.58
Hepatic Function Panel,PX80076,CDM,300,RC,80076,CPT,,,,,,,,171,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,152.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.49,167.58
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105F,CDM,510,RC,11105,CPT,,,,,,,,171,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,152.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.0334,167.58
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105P,CDM,983,RC,11105,CPT,,,,,,,,171,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,152.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.0334,166.4343
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102F,CDM,510,RC,11102,CPT,,,,,,,,171,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,152.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.0334,174.9
insulin regular 100 UNIT/ML Solution 10 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821501,NDC,10,ML,307.46,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,152.1927,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
sodium zirconium cyclosilicate 10 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,310111001,NDC,1,EA,172.56,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,152.19792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Repr Superf Wnd Body 7.6-12.5,PX12004F,CDM,510,RC,12004,CPT,,,,,,,,453,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,152.2,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,43.41,277.41
Repr Superf Wnd Body 7.6-12.5,PX12004P,CDM,983,RC,12004,CPT,,,,,,,,614,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,152.2,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,43.41,601.72
Abd Duplex Abd-Full,PX9397501,CDM,921,RC,93975,CPT,TC,,,,,,,788,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,152.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.26,367.05
Abd Duplex Abd-Full,PX9397501,CDM,921,RC,93975,CPT,TC,,,,,,,788,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,152.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.26,367.05
PACLitaxel 150 MG/25ML Concentrate 25 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321701,NDC,25,ML,300.96,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,152.28576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122P,CDM,983,RC,13122,CPT,,,,,,,,301,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,152.306,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.0354,292.9633
Xray Facial Bones Less Than 3 Vws,PX7014001,CDM,320,RC,70140,CPT,TC,,,,,,,301,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,152.306,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,294.98
Apply Lower Leg Splint,PX29515P,CDM,983,RC,29515,CPT,,,,,,,,311,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,152.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,129.1894,302.6963
Apply Lower Leg Splint,PX29515P,CDM,983,RC,29515,CPT,,,,,,,,311,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,152.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,129.1894,302.6963
Apply Lower Leg Splint,PX29515P,CDM,983,RC,29515,CPT,,,,,,,,311,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,152.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,129.1894,302.6963
Repr Superf Wnd Body <2.5cm,PX12001F,CDM,510,RC,12001,CPT,,,,,,,,311,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,235.25,percent of total billed charges,152.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,129.1894,304.78
Repr Superf Wnd Body <2.5cm,PX12001F,CDM,510,RC,12001,CPT,,,,,,,,311,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,152.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,129.1894,304.78
Repr Superf Wnd Body <2.5cm,PX12001F,CDM,510,RC,12001,CPT,,,,,,,,311,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,152.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,129.1894,304.78
Xray Skull Less Than 4 Vws,PX7025001,CDM,320,RC,70250,CPT,TC,,,,,,,311,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,152.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,304.78
Xray Skull Less Than 4 Vws,PX7025001,CDM,320,RC,70250,CPT,TC,,,,,,,311,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,152.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,304.78
Xray Skull Less Than 4 Vws,PX7025001,CDM,320,RC,70250,CPT,TC,,,,,,,311,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,152.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,304.78
tranexamic acid 1000 mg in 100 mL 0.7% sodium chloride (premix) 1000-0.7 MG/100ML-% Solution 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,80830232901,NDC,100,ML,155.55,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,152.439,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Xray Foot 2 Vws,PX7362001,CDM,320,RC,73620,CPT,TC,,,,,,,367,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,152.4518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,359.66
CARBOplatin 600 MG/60ML Solution 60 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703423981,NDC,60,ML,301.42,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,152.51852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.778704,295.3916
clotrimazole-betamethasone 1-0.05 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,51672404801,NDC,15,GR,172.95,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,152.5419,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,517096001,NDC,10,ML,355.63,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,152.56527,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
RBC Antibody Screen,PX86850,CDM,300,RC,86850,CPT,,,,,,,,173,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,152.586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,169.54
"Thyroxin, Free (Free T4)",PX84439,CDM,300,RC,84439,CPT,,,,,,,,173,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,152.586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.27,169.54
8MM ENDOWRIST INSTRUMENTS LARGE NEEDLE DRIVER,27200000,CDM,272,RC,,,,11912-MAIN,LOCAL,,,,,318,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,152.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM ENDOWRIST INSTRUMENTS LARGE NEEDLE DRIVER,27200000,CDM,272,RC,,,,11912-MAIN,LOCAL,,,,,318,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,152.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Office/Outpt Visit,Est,Levl V",PX99215F,CDM,510,RC,99215,CPT,,,,,,,,318,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,152.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,311.64
"Office/Outpt Visit,Est,Levl V",PX99215F,CDM,510,RC,99215,CPT,,,,,,,,318,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,152.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,311.64
MINIBUNION LOCKING SCREW 3.0X24MM,C1713,CDM,278,RC,C1713,HCPCS,,11671-MAIN,LOCAL,,,,,308.55,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,152.73225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
COLLAR CERVICAL LARGE WITH TRACH 2 PIECE PHP-T4L,120.184,CDM,274,RC,L0172,HCPCS,,10142-MAIN,LOCAL,,,,,37,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,152.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.3698,152.79
COLLAR CERVICAL MEDIUM WITH TRACH 2 PIECE PHP-T4M,120.183,CDM,274,RC,L0172,HCPCS,,10141-MAIN,LOCAL,,,,,37,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,152.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.3698,152.79
COLLAR CERVICAL SMALL WITH TRACH 2 PIECE PHP-T4S,120.182,CDM,274,RC,L0172,HCPCS,,10140-MAIN,LOCAL,,,,,37,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,152.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.3698,152.79
COLLAR CERVICAL X-LARGE WITH TRACH 2 PIECE OSG2404,120.185,CDM,274,RC,L0172,HCPCS,,10143-MAIN,LOCAL,,,,,49,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,152.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.3546,152.79
Assay of Psa Total,PX84153,CDM,300,RC,84153,CPT,,,,,,,,157,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,152.8081,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.86,153.86
"Chlamydia Trachomatis Dna, Amp Probe",PX87491,CDM,300,RC,87491,CPT,,,,,,,,157,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,76.27,percent of total billed charges,152.8081,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,153.86
"Cognitive Skill Dev, Ea 15 Min",PX97532,CDM,420,RC,97532,CPT,,,,,,,,157,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,152.8081,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.2178,153.86
"Fungal Culture, Other Source - Ref",PX8710290,CDM,300,RC,87102,CPT,90,,,,,,,157,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,152.8081,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.71,153.86
Lactate (Ld) (Ldh) Enzyme,PX83615,CDM,300,RC,83615,CPT,,,,,,,,157,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,152.8081,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.54,153.86
"Neisseria Gonorrhoeae Dna, Amp Probe",PX87591,CDM,300,RC,87591,CPT,,,,,,,,157,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,50.70642857,percent of total billed charges,152.8081,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,153.86
Psa Screening,PXG0103,CDM,300,RC,G0103,HCPCS,,,,,,,,157,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,152.8081,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.71,153.86
Remv Ext Canal Foreign Body,PX69200P,CDM,983,RC,69200,CPT,,,,,,,,157,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,152.8081,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.2178,152.8081
"Destruct Benign Lesion, 1-14",PX17110F,CDM,510,RC,17110,CPT,,,,,,,,302,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,152.812,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.4508,295.96
etoposide 500 MG/25ML Solution 25 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,703565601,NDC,25,ML,173.28,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,152.83296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.949434,169.8144
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,39328006712,NDC,473,ML,167.77,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,152.83847,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
SCOPE ASCOPE4 CYSTO STERILE 601001000,120.497,CDM,272,RC,A4649,HCPCS,,11662-MAIN,LOCAL,,,,,368,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,152.8672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,152.8672,360.64
Assay Blood Carbon Monoxide,PX82375,CDM,300,RC,82375,CPT,,,,,,,,156,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,152.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.3,152.88
Closed Rx Kneecap Dislocatn,PX27560P,CDM,983,RC,27560,CPT,,,,,,,,312,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,152.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,129.6048,303.6696
Closed Rx Kneecap Dislocatn,PX27560P,CDM,983,RC,27560,CPT,,,,,,,,312,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,152.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,129.6048,303.6696
Closed Rx Kneecap Dislocatn,PX27560P,CDM,983,RC,27560,CPT,,,,,,,,312,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,152.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,129.6048,303.6696
"Cortisol, Am",PX7152,CDM,300,RC,82533,CPT,,,,,,,,156,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,152.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.95,152.88
DERMABOND PRINEO SKIN CLOSURE SYSTEM 22CM,27200000,CDM,272,RC,,,,12324-MAIN,LOCAL,,,,,156,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,152.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Apply Lower Leg Splint,PX29515F,CDM,510,RC,29515,CPT,,,,,,,,296,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,152.89,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.54,152.89
Apply Lower Leg Splint,PX29515P,CDM,983,RC,29515,CPT,,,,,,,,311,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,152.89,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.54,304.78
Drain/Inject Med Joint/Brusa W/US Guide,PX20606P,CDM,983,RC,20606,CPT,,,,,,,,309,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,152.955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.3586,604.15
LINNEAR CUTTER STAPLE RELOAD GST BLUE 60MM,27200000,CDM,272,RC,,,,12068-MAIN,LOCAL,,,,,309,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,152.955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LINNEAR CUTTER STAPLE RELOAD GST GREEN 60MM,27200000,CDM,272,RC,,,,12069-MAIN,LOCAL,,,,,309,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,152.955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LINNEAR CUTTER STAPLE RELOAD GST WHITE 60MM,27200000,CDM,272,RC,,,,12067-MAIN,LOCAL,,,,,309,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,152.955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Naso/Orogastric Tube,PX43752P,CDM,983,RC,43752,CPT,,,,,,,,309,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,152.955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.3586,348.08
C-Peptide - Ref,PX8468190,CDM,300,RC,84681,CPT,90,,,,,,,180,,First Health,Commercial,both,85,,999999999,percent of total billed charges,153,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,176.4
"Closed Rx Radial Head Disloc,Child",PX24640P,CDM,983,RC,24640,CPT,,,,,,,,180,,First Health,Commercial,both,85,,999999999,percent of total billed charges,153,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.772,206.02
"Infect Ea Organ, Amp Prob - Ref",PX8779890,CDM,300,RC,87798,CPT,90,,,,,,,180,,First Health,Commercial,both,85,,999999999,percent of total billed charges,153,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,176.4
Mrsa by Amplification Na,PX87641,CDM,300,RC,87641,CPT,,,,,,,,180,,First Health,Commercial,both,85,,999999999,percent of total billed charges,153,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,176.4
Protein Elp,PX84166,CDM,300,RC,84166,CPT,,,,,,,,180,,First Health,Commercial,both,85,,999999999,percent of total billed charges,153,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.35,176.4
Aerobic Isolate - Ref,PX8707790,CDM,300,RC,87077,CPT,90,,,,,,,168,,Medica,Commercial,both,91.1,,8.249444444,percent of total billed charges,153.048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,164.64
Complete Cbc W/Auto Diff Wbc,PX85025,CDM,300,RC,85025,CPT,,,,,,,,168,,Medica,Commercial,both,91.1,,30.20333333,percent of total billed charges,153.048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.12,164.64
Insert Straight Catheter,PX51701F,CDM,510,RC,51701,CPT,,,,,,,,168,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,153.048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.7872,164.64
Org ID Aerobic-Each,PX87077,CDM,300,RC,87077,CPT,,,,,,,,168,,Medica,Commercial,both,91.1,,8.249444444,percent of total billed charges,153.048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,164.64
AIRSEAL 12MM ACCESS PORT AND PALM GRIP OBTURATOR BLADELESS OPTICAL TIP 120MM,27200000,CDM,272,RC,,,,12207-MAIN,LOCAL,,,,,172,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,153.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
AIRSEAL TUBE SET TRI LUMEN FILTERED WITH ACTIVATED CHARCOAL,27200000,CDM,272,RC,,,,12206-MAIN,LOCAL,,,,,172,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,153.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047621,NDC,1,ML,157.28,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,153.080624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.354486,332.1514
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,338035702,NDC,250,ML,309.28,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,153.0936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.4701,303.0944
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242003706,NDC,0.6,EA,8461.09,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,153.11,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,134.74,153.11
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012001,NDC,0.6,EA,7764.12,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,153.11,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,134.74,153.11
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012047,NDC,0.6,EA,10644.69,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,153.11,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,134.74,153.11
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242003706,NDC,0.6,EA,8461.09,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,153.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,134.74,153.11
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242003706,NDC,0.6,EA,8461.09,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,153.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,134.74,153.11
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012001,NDC,0.6,EA,7764.12,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,153.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,134.74,153.11
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012001,NDC,0.6,EA,7764.12,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,153.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,134.74,153.11
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012047,NDC,0.6,EA,10644.69,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,153.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,134.74,153.11
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012047,NDC,0.6,EA,10644.69,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,153.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,134.74,153.11
Fresh Frozen Plasma,PXP9017,CDM,390,RC,P9017,HCPCS,,,,,,,,319,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,153.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.32,312.62
Fresh Frozen Plasma,PXP9017,CDM,390,RC,P9017,HCPCS,,,,,,,,319,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,153.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.32,312.62
"Exc Skn Bnig >4cmtrnk,Arm,Leg",PX11406P,CDM,983,RC,11406,CPT,,,,,,,,1456,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,153.14,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,153.14,1426.88
"Fac/Exc Skn Benig >4cm Trnk,Arm,Lg",PX11406F,CDM,510,RC,11406,CPT,,,,,,,,1127,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,153.14,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,153.14,666.2
Remove Intrauterine Device,PX58301,CDM,983,RC,58301,CPT,,,,,,,,357,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,153.153,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.2978,347.4681
X-Ray Exam Chest 1 View,PX7104501,CDM,320,RC,71045,CPT,TC,,,,,,,357,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,153.153,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,349.86
"Xray Chest 1 View, Tc",PX7101001,CDM,320,RC,71010,CPT,TC,,,,,,,357,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,153.153,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.2978,349.86
Xray Scapula Complete,PX7301001,CDM,320,RC,73010,CPT,TC,,,,,,,357,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,153.153,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,349.86
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,55150017301,NDC,0.5,ML,319.2,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,153.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,55150017301,NDC,0.5,ML,319.2,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,153.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
"Destruct Benign Lesion, 15+",PX17111F,CDM,510,RC,17111,CPT,,,,,,,,303,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,153.318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.8662,296.94
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607P,CDM,983,RC,97607,CPT,,,,,,,,303,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,153.318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.8662,348.35
Strapping of Knee,PX29530F,CDM,420,RC,29530,CPT,,,,,,,,303,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,153.318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,296.94
Xray Knee 1 or 2 Vws,PX7356001,CDM,320,RC,73560,CPT,TC,,,,,,,303,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,153.318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,296.94
sulfacetamide 10 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,24208067004,NDC,15,ML,312.96,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,153.3504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sulfacetamide 10 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,24208067004,NDC,15,ML,312.96,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,153.3504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sulfacetamide 10 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,24208067004,NDC,15,ML,312.96,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,153.3504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Dress/Debrid Small Burn No Anes,PX16020F,CDM,510,RC,16020,CPT,,,,,,,,313,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,153.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.0202,306.74
Dress/Debrid Small Burn No Anes,PX16020F,CDM,510,RC,16020,CPT,,,,,,,,313,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,153.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.0202,306.74
Dress/Debrid Small Burn No Anes,PX16020F,CDM,510,RC,16020,CPT,,,,,,,,313,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,153.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.0202,306.74
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,517096010,NDC,10,ML,157.64,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,153.431012,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ketoconazole 2 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,168009915,NDC,15,GR,173.97,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,153.44154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Drain Finger Abscess,Simple",PX26010F,CDM,510,RC,26010,CPT,,,,,,,,310,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,153.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.774,303.8
sodium zirconium cyclosilicate 10 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,310111001,NDC,1,EA,172.56,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,153.5784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Bone Scan, Whole Body",PX7830601,CDM,341,RC,78306,CPT,TC,,,,,,,1896,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,153.58,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,153.58,453.61
"Bone Scan, Whole Body",PX7830601,CDM,341,RC,78306,CPT,TC,,,,,,,1896,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,153.58,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,153.58,453.61
"Diagnostic Bone Marrow, Biopsy and Aspiration",PX38222F,CDM,761,RC,38222,CPT,,,,,,,,1748,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,153.58,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9,363.89
Declot Vascular Access Device,PX36593F,CDM,510,RC,36593,CPT,,,,,,,,358,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,153.582,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.7132,350.84
Fac/Irrigation of Bladder,PX51700F,CDM,510,RC,51700,CPT,,,,,,,,358,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,153.582,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.7132,350.84
X-Ray Exam Abdomen 1 View,PX7401801,CDM,320,RC,74018,CPT,TC,,,,,,,358,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,153.582,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,350.84
Xray Abdomen Single Ap Vw,PX7400001,CDM,320,RC,74000,CPT,TC,,,,,,,358,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,153.582,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.7132,350.84
Apply Long Leg Splint,PX29505F,CDM,510,RC,29505,CPT,,,,,,,,320,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,153.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.928,313.6
Apply Long Leg Splint,PX29505F,CDM,510,RC,29505,CPT,,,,,,,,320,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,153.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.928,313.6
"IV Infusion, Bamlanivimab, Infusion and Post Admin Monig",PXM0239,CDM,260,RC,M0239,HCPCS,,,,,,,,320,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,153.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.928,313.6
"IV Infusion, Bamlanivimab, Infusion and Post Admin Monig",PXM0239,CDM,260,RC,M0239,HCPCS,,,,,,,,320,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,153.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.928,313.6
Acetaminophen,PX80307E,CDM,300,RC,80307,CPT,,,,,,,,370,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,153.698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Alcohol,PX80307A,CDM,300,RC,80307,CPT,,,,,,,,370,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,153.698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Salicylate,PX80307D,CDM,300,RC,80307,CPT,,,,,,,,370,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,153.698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Urine Drug Screen,PX80307B,CDM,300,RC,80307,CPT,,,,,,,,370,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,153.698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Xray Elbow 3+Vws Tc,PX7308001,CDM,320,RC,73080,CPT,TC,,,,,,,370,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,153.698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,362.6
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040304,NDC,10,ML,168.77,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,153.74947,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040310,NDC,10,ML,168.77,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,153.74947,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
Antithrombin III Activity - Ref,PX8530090,CDM,300,RC,85300,CPT,90,,,,,,,158,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,153.7814,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.87,154.84
Fac/Trm Hyperkeratotic Skn Lesn2-4,PX11056F,CDM,510,RC,11056,CPT,,,,,,,,158,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,68.19,percent of total billed charges,153.7814,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.6332,174.9
"Glucose, Body Fluid Other Than Blood",PX82945,CDM,300,RC,82945,CPT,,,,,,,,158,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,107.19,percent of total billed charges,153.7814,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.6,154.84
Protein C Activity - Ref,PX8530390,CDM,300,RC,85303,CPT,90,,,,,,,158,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,153.7814,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.69,154.84
"Triiodothyronine T3, Tot - Ref",PX8448090,CDM,300,RC,84480,CPT,90,,,,,,,158,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,153.7814,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13,154.84
CT Abdomen&Pelvis W/Contrast,PX7417701,CDM,350,RC,74177,CPT,TC,,,,,,,4288,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,153.79,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,151.4,446.37
"Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404P,CDM,983,RC,11404,CPT,,,,,,,,600,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,153.8069,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.96,588
"Fac/Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404F,CDM,510,RC,11404,CPT,,,,,,,,749,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,153.8069,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.96,468.35
levonorgestrel 1.5 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,68180085211,NDC,1,EA,174.39,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,153.81198,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Ctrl Nosebleed,Anter,Complex",PX30903P,CDM,983,RC,30903,CPT,,,,,,,,304,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,153.824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,295.8832
Joint Survey Tc,PX7707701,CDM,320,RC,77077,CPT,TC,,,,,,,304,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,153.824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,297.92
Alcohol Biomarkers; 1 or 2 - Ref,PX8032190,CDM,300,RC,80321,CPT,90,,,,,,,181,,First Health,Commercial,both,85,,999999999,percent of total billed charges,153.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.1874,177.38
"Lyme Disease, Antibody - Ref",PX8661890,CDM,300,RC,86618,CPT,90,,,,,,,181,,First Health,Commercial,both,85,,999999999,percent of total billed charges,153.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.61,177.38
PHALINX STERILE TRIAL SIZER 45A00000,27200000,CDM,272,RC,,,,12959-MAIN,LOCAL,,,,,181,,First Health,Commercial,both,85,,999999999,percent of total billed charges,153.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Assay for Vancomycin,PX80202,CDM,300,RC,80202,CPT,,,,,,,,314,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,153.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.41,307.72
Assay for Vancomycin,PX80202,CDM,300,RC,80202,CPT,,,,,,,,314,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,153.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.41,307.72
Assay for Vancomycin,PX80202,CDM,300,RC,80202,CPT,,,,,,,,314,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,153.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.41,307.72
Assay of Psa Total,PX84153,CDM,300,RC,84153,CPT,,,,,,,,157,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,153.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.86,153.86
"Chlamydia Trachomatis Dna, Amp Probe",PX87491,CDM,300,RC,87491,CPT,,,,,,,,157,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,153.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,153.86
"Cognitive Skill Dev, Ea 15 Min",PX97532,CDM,420,RC,97532,CPT,,,,,,,,157,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,153.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.2178,153.86
"Fungal Culture, Other Source - Ref",PX8710290,CDM,300,RC,87102,CPT,90,,,,,,,157,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,153.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.71,153.86
Lactate (Ld) (Ldh) Enzyme,PX83615,CDM,300,RC,83615,CPT,,,,,,,,157,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,153.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.54,153.86
"Neisseria Gonorrhoeae Dna, Amp Probe",PX87591,CDM,300,RC,87591,CPT,,,,,,,,157,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,153.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,153.86
Psa Screening,PXG0103,CDM,300,RC,G0103,HCPCS,,,,,,,,157,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,153.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.71,153.86
Remv Ext Canal Foreign Body,PX69200P,CDM,983,RC,69200,CPT,,,,,,,,157,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,153.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.22,167.42
clotrimazole-betamethasone 1-0.05 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,51672404801,NDC,15,GR,172.95,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,153.9255,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
cloNIDine 0.1 MG/24HR PATCH WEEKLY 4 Each Box,63700001,CDM,250,RC,,,,,,51862045304,NDC,1,EA,158.16,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,153.937128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Apply Lower Leg Splint,PX29515P,CDM,983,RC,29515,CPT,,,,,,,,311,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,153.945,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,129.1894,302.6963
Repr Superf Wnd Body <2.5cm,PX12001F,CDM,510,RC,12001,CPT,,,,,,,,311,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,153.945,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,129.1894,304.78
Xray Skull Less Than 4 Vws,PX7025001,CDM,320,RC,70250,CPT,TC,,,,,,,311,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,153.945,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,304.78
Blood Clot Factor VIII Test,PX85247,CDM,300,RC,85247,CPT,,,,,,,,169,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,153.959,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.03,165.62
Tap Block Unilateral by Injection(S),PX64486P,CDM,983,RC,64486,CPT,,,,,,,,169,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,153.959,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.2026,164.4877
RBC Antibody Screen,PX86850,CDM,300,RC,86850,CPT,,,,,,,,173,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,153.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,169.54
"Thyroxin, Free (Free T4)",PX84439,CDM,300,RC,84439,CPT,,,,,,,,173,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,153.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.27,169.54
dexmedeTOMIDine in sodium chloride 200 MCG/50ML Solution 50 mL Flex Cont,25000000,CDM,250,RC,,,,,,338955524,NDC,50,ML,304.32,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,153.98592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
neomycin-polymyxin-gramicidin 1.75-10000-.025 Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,24208079062,NDC,10,ML,314.26,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,153.9874,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
neomycin-polymyxin-gramicidin 1.75-10000-.025 Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,24208079062,NDC,10,ML,314.26,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,153.9874,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
neomycin-polymyxin-gramicidin 1.75-10000-.025 Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,24208079062,NDC,10,ML,314.26,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,153.9874,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Office/Outpt Visit,New,Levl IV",PX99204F,CDM,510,RC,99204,CPT,,,,,,,,359,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,154.011,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.1286,351.82
"Office/Outpt Visit,New,Levl IV",PX99204P,CDM,983,RC,99204,CPT,,,,,,,,359,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,154.011,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.1286,349.4147
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047621,NDC,1,ML,157.28,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,154.1344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.354486,332.1514
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801801,NDC,0.8,ML,359.37,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,154.16973,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801810,NDC,0.8,ML,359.37,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,154.16973,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
etoposide 500 MG/25ML Solution 25 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,703565601,NDC,25,ML,173.28,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,154.2192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.949434,169.8144
"Bone Marrow Aspiration(S),Diag",PX38220F,CDM,510,RC,38220,CPT,,,,,,,,305,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,154.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,126.697,1416.38
Assay Iga/Igd/Igg/Igm Each,PX82784,CDM,300,RC,82784,CPT,,,,,,,,315,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,154.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.53,308.7
Assay Iga/Igd/Igg/Igm Each,PX82784,CDM,300,RC,82784,CPT,,,,,,,,315,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,154.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.53,308.7
Assay Iga/Igd/Igg/Igm Each,PX82784,CDM,300,RC,82784,CPT,,,,,,,,315,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,154.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.53,308.7
Electrolyte Panel,PX80051,CDM,300,RC,80051,CPT,,,,,,,,175,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,154.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.43,171.5
"Fac/Trm Hyperkeratotic Skn Lesn,>4",PX11057F,CDM,510,RC,11057,CPT,,,,,,,,175,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,154.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.695,174.9
"Gonadotropin, Chorionic (Hcg), Qualitative",PX84703,CDM,300,RC,84703,CPT,,,,,,,,175,,United Healthcare,All Payer,outpatient,88.2,,79.43,percent of total billed charges,154.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.9,171.5
Protein E-Phoresis Serum,PX84165,CDM,300,RC,84165,CPT,,,,,,,,175,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,154.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,171.5
Protein Elp Interp,PX8416526,CDM,300,RC,84165,CPT,26,,,,,,,175,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,154.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,171.5
Closed Rx Kneecap Dislocatn,PX27560P,CDM,983,RC,27560,CPT,,,,,,,,312,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,154.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,129.6048,303.6696
Closed Rx Mt-Phal Toe Dislocation,PX28630F,CDM,510,RC,28630,CPT,,,,,,,,360,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,154.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.544,352.8
RBC Antibody Elution,PX86860,CDM,300,RC,86860,CPT,,,,,,,,360,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,154.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.22,352.8
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,517096010,NDC,10,ML,157.64,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,154.4872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Cyto Non Gyn,PX8811201,CDM,310,RC,88112,CPT,TC,,,,,,,372,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,154.5288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,364.56
Phlebotomy,PX99195,CDM,940,RC,99195,CPT,,,,,,,,238,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,154.576,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.49,166.95
Phlebotomy,PX99195,CDM,940,RC,99195,CPT,,,,,,,,238,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,154.576,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.49,166.95
Debride Skin/Subq Ea Ad 20sqcm,PX11045P,CDM,983,RC,11045,CPT,,,,,,,,182,,First Health,Commercial,both,85,,999999999,percent of total billed charges,154.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.6028,177.1406
Immunocytochemistry,PX3993,CDM,310,RC,88342,CPT,TC,,,,,,,182,,First Health,Commercial,both,85,,999999999,percent of total billed charges,154.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.6028,178.36
Infec Agent Direct Probe - Ref,PX8779990,CDM,300,RC,87799,CPT,90,,,,,,,182,,First Health,Commercial,both,85,,999999999,percent of total billed charges,154.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.28,178.36
EPIX UNIVERSAL CLIP APPLIER,27200000,CDM,272,RC,,,,11708-MAIN,LOCAL,,,,,158.95,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,154.706035,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Iaad Ia Severe Aqt Respir Synd Coronavirus,PX87426,CDM,300,RC,87426,CPT,,,,,,,,159,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,154.7547,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.39,155.82
ketoconazole 2 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,16714095501,NDC,15,GR,322.42,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,154.7616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ketoconazole 2 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,16714095501,NDC,15,GR,322.42,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,154.7616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ketoconazole 2 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,168009915,NDC,15,GR,173.97,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,154.8333,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Xray Thoracolumbar 2 Vws,PX7208001,CDM,320,RC,72080,CPT,TC,,,,,,,306,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,154.836,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,299.88
Antithrombin III Activity - Ref,PX8530090,CDM,300,RC,85300,CPT,90,,,,,,,158,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,154.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.87,154.84
Cast/Strap Procedure Unlisted,PX29799F,CDM,510,RC,29799,CPT,,,,,,,,316,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,154.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,131.2664,309.68
Cast/Strap Procedure Unlisted,PX29799F,CDM,510,RC,29799,CPT,,,,,,,,316,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,154.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,131.2664,309.68
Cast/Strap Procedure Unlisted,PX29799F,CDM,510,RC,29799,CPT,,,,,,,,316,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,154.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,131.2664,309.68
Fac/Trm Hyperkeratotic Skn Lesn2-4,PX11056F,CDM,510,RC,11056,CPT,,,,,,,,158,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,154.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.6332,174.9
"Glucose, Body Fluid Other Than Blood",PX82945,CDM,300,RC,82945,CPT,,,,,,,,158,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,154.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.6,154.84
Protein C Activity - Ref,PX8530390,CDM,300,RC,85303,CPT,90,,,,,,,158,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,154.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.69,154.84
"Triiodothyronine T3, Tot - Ref",PX8448090,CDM,300,RC,84480,CPT,90,,,,,,,158,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,154.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13,154.84
Asay of Interleukin-6 (Il-6),PX8352990,CDM,300,RC,83529,CPT,90,,,,,,,170,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,154.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,166.6
Chem Cautery Granulatn Tissue,PX17250F,CDM,510,RC,17250,CPT,,,,,,,,170,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,154.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,174.9
"Chemotherapy Administration, Subq/Im Non-Hormonal Anti-Neoplastic",PX96401,CDM,335,RC,96401,CPT,,,,,,,,170,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,154.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,166.6
Collagen Cross Links - Ref,PX8252390,CDM,300,RC,82523,CPT,90,,,,,,,170,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,154.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.13,166.6
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800P,CDM,983,RC,40800,CPT,,,,,,,,170,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,154.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,614.65
gadoteridol 279.3 MG/ML Solution 17 mL Syringe,A9576,CDM,636,RC,A9576,HCPCS,,,,270111145,NDC,17,ML,170,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,154.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.54,166.6
"Inject Nerv Blck,Trigeminal",PX64400P,CDM,983,RC,64400,CPT,,,,,,,,170,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,154.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,258.75
"Protein, Total; Serum, Plasma or Whole Blood",PX84155,CDM,300,RC,84155,CPT,,,,,,,,170,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,154.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.37,166.6
sulfacetamide 10 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,24208067004,NDC,15,ML,312.96,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,154.9152,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Dress/Debrid Small Burn No Anes,PX16020F,CDM,510,RC,16020,CPT,,,,,,,,313,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,154.935,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.0202,306.74
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234010,NDC,5,ML,306.2,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,154.9372,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234025,NDC,5,ML,306.2,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,154.9372,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234099,NDC,5,ML,306.2,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,154.9372,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
Repr Superf Wnd Face 5.1-7.5,PX12014F,CDM,510,RC,12014,CPT,,,,,,,,453,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,154.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.06,297.47
Repr Superf Wnd Face 5.1-7.5,PX12014P,CDM,983,RC,12014,CPT,,,,,,,,819,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,154.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.06,802.62
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082143,NDC,1,ML,348.85,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,154.9947,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,133.87,158.15
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082152,NDC,1,ML,375.43,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,154.9947,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,133.87,158.15
cloNIDine 0.1 MG/24HR PATCH WEEKLY 4 Each Box,63700001,CDM,250,RC,,,,,,51862045304,NDC,1,EA,158.16,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,154.9968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Xray Ls Spine Bend Tc,PX7212001,CDM,320,RC,72120,CPT,TC,,,,,,,323,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,155.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,316.54
Xray Ls Spine Bend Tc,PX7212001,CDM,320,RC,72120,CPT,TC,,,,,,,323,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,155.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,316.54
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,59148000713,NDC,1,EA,170.19,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,155.04309,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Exc Skn Bnig >4cmtrnk,Arm,Leg",PX11406P,CDM,983,RC,11406,CPT,,,,,,,,1456,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,155.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,153.14,1426.88
"Exc Skn Bnig >4cmtrnk,Arm,Leg",PX11406P,CDM,983,RC,11406,CPT,,,,,,,,1456,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,155.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,153.14,1426.88
"Fac/Exc Skn Benig >4cm Trnk,Arm,Lg",PX11406F,CDM,510,RC,11406,CPT,,,,,,,,1127,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,155.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,153.14,666.2
"Fac/Exc Skn Benig >4cm Trnk,Arm,Lg",PX11406F,CDM,510,RC,11406,CPT,,,,,,,,1127,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,155.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,153.14,666.2
CT Orbit/Ear/Fossa W/O & W/Dye,PX7048201,CDM,350,RC,70482,CPT,TC,,,,,,,1400,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,155.1076,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.92,309.64
US Abdomen Tc,PX7670001,CDM,402,RC,76700,CPT,TC,,,,,,,586,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,155.15,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.35,155.15
US Abdomen Tc,PX7670001,CDM,402,RC,76700,CPT,TC,,,,,,,586,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,155.15,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.35,155.15
levonorgestrel 1.5 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,68180085211,NDC,1,EA,174.39,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,155.2071,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CCP Antibody,PX86200,CDM,300,RC,86200,CPT,,,,,,,,176,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,155.232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,172.48
Detect Agent Nos Dna Amp,PX87798,CDM,300,RC,87798,CPT,,,,,,,,176,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,155.232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,172.48
Eval of Bronchospasm,PX94060,CDM,983,RC,94060,CPT,,,,,,,,176,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,155.232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.1104,274.21
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151F,CDM,370,RC,99151,CPT,,,,,,,,176,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,155.232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.1104,172.48
US Pregnancy Tc Follow-Up,PX7681601,CDM,402,RC,76816,CPT,TC,,,,,,,362,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,155.298,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,354.76
"Colonoscopy,Remv Lesn,Snare",PX45385F,CDM,750,RC,45385,CPT,,,,,,,,1939,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,155.32,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.32,940.85
"Colonoscopy,Remv Lesn,Snare",PX45385P,CDM,983,RC,45385,CPT,,,,,,,,2424,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,155.32,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.32,2375.52
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101F,CDM,510,RC,13101,CPT,,,,,,,,495,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,155.32,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.32,823.93
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101P,CDM,983,RC,13101,CPT,,,,,,,,330,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,155.32,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.32,823.93
COOK EMERGENCY PNEUMOTHORAX SET,120.559,CDM,272,RC,,,,12597-MAIN,LOCAL,,,,,307,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,155.342,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,127.5278,300.86
SUTURE CTD VICRYL 4-0 VIL BR SUTUPK J103T,27200000,CDM,272,RC,,,,4491-MAIN,LOCAL,,,,,373.97,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,155.347138,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Fac/Exc Skin Benig<5mm Remaind Bod,PX11420F,CDM,510,RC,11420,CPT,,,,,,,,374,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,155.3596,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,1416.38
"Fac/Office Consultation,Level III",PX99243F,CDM,510,RC,99213,CPT,,,,,,,,374,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,155.3596,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,366.52
"Inpatient Consult, Level III",PX99253,CDM,983,RC,99253,CPT,,,,,,,,374,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,155.3596,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,364.0142
"Office Consultation,Level III",PX99243P,CDM,983,RC,99243,CPT,,,,,,,,374,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,155.3596,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,364.0142
Removal of Hemorrhoid Clot,PX46320P,CDM,983,RC,46320,CPT,,,,,,,,374,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,155.3596,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,1030.93
Xray Hand 3vws Tc,PX7313001,CDM,320,RC,73130,CPT,TC,,,,,,,374,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,155.3596,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,366.52
Assay for Vancomycin,PX80202,CDM,300,RC,80202,CPT,,,,,,,,314,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,155.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.41,307.72
aztreonam 1 g Recon Soln 1 Each Vial,J0457.01,CDM,636,RC,J0457,HCPCS,,,,63323040124,NDC,1,EA,176.32,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,155.51424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.32,172.7936
Voriconazole - Ref,PX8028590,CDM,300,RC,80285,CPT,90,,,,,,,183,,First Health,Commercial,both,85,,999999999,percent of total billed charges,155.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.86,179.34
neomycin-polymyxin-gramicidin 1.75-10000-.025 Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,24208079062,NDC,10,ML,314.26,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,155.5587,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
insulin regular 100 UNIT/ML Solution 10 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821501,NDC,10,ML,307.46,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,155.57476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127332,NDC,2,ML,176.55,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,155.7171,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.43158,173.019
SET CRICOTHYROTOMY CATHETER 3.5MM ID,120.251,CDM,272,RC,,,,4306-MAIN,LOCAL,,,,,363,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,155.727,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.7902,355.74
SET CRICOTHYROTOMY CATHETER 4MM ID,120.251,CDM,272,RC,,,,3452-MAIN,LOCAL,,,,,363,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,155.727,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.7902,355.74
SET CRICOTHYROTOMY CATHETER 6MM ID,120.251,CDM,272,RC,,,,2887-MAIN,LOCAL,,,,,363,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,155.727,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.7902,355.74
Ex for Speech Device Rx Addl,PX92608,CDM,444,RC,92608,CPT,,,,,,,,160,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,155.728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.95,156.8
Electrolyte Panel,PX80051,CDM,300,RC,80051,CPT,,,,,,,,175,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,155.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.43,171.5
"Fac/Trm Hyperkeratotic Skn Lesn,>4",PX11057F,CDM,510,RC,11057,CPT,,,,,,,,175,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,155.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.695,174.9
"Gonadotropin, Chorionic (Hcg), Qualitative",PX84703,CDM,300,RC,84703,CPT,,,,,,,,175,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,155.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.9,171.5
Protein E-Phoresis Serum,PX84165,CDM,300,RC,84165,CPT,,,,,,,,175,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,155.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,171.5
Protein Elp Interp,PX8416526,CDM,300,RC,84165,CPT,26,,,,,,,175,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,155.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,171.5
EPIX UNIVERSAL CLIP APPLIER,27200000,CDM,272,RC,,,,11708-MAIN,LOCAL,,,,,158.95,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,155.771,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Digital Mamm, Diag, Bilat, Tc W/Cad Perf",PX7706601,CDM,401,RC,77066,CPT,TC,,,,,,,375,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,155.775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.05,367.5
Repr Superf Wnd Face 2.6-5,PX12013F,CDM,510,RC,12013,CPT,,,,,,,,375,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,155.775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.775,367.5
Xray Wrist Minimum 3 Vws,PX7311001,CDM,320,RC,73110,CPT,TC,,,,,,,375,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,155.775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,367.5
"CCP, Antibody - Ref",PX8620090,CDM,300,RC,86200,CPT,90,,,,,,,171,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,155.781,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,167.58
Hepatic Function Panel,PX80076,CDM,300,RC,80076,CPT,,,,,,,,171,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,155.781,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.49,167.58
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105F,CDM,510,RC,11105,CPT,,,,,,,,171,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,155.781,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.0334,167.58
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105P,CDM,983,RC,11105,CPT,,,,,,,,171,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,155.781,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.0334,166.4343
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102F,CDM,510,RC,11102,CPT,,,,,,,,171,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,155.781,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.0334,174.9
8MM ENDOWRIST INSTRUMENTS LARGE NEEDLE DRIVER,27200000,CDM,272,RC,,,,11912-MAIN,LOCAL,,,,,318,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,155.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM ENDOWRIST INSTRUMENTS LARGE NEEDLE DRIVER,27200000,CDM,272,RC,,,,11912-MAIN,LOCAL,,,,,318,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,155.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM ENDOWRIST INSTRUMENTS LARGE NEEDLE DRIVER,27200000,CDM,272,RC,,,,11912-MAIN,LOCAL,,,,,318,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,155.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Drain/Inject Medium Joint/Bursa,PX20605P,CDM,983,RC,20605,CPT,,,,,,,,318,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,155.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,309.5094
Drain/Inject Medium Joint/Bursa,PX20605P,CDM,983,RC,20605,CPT,,,,,,,,318,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,155.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,309.5094
Drain/Inject Medium Joint/Bursa,PX20605P,CDM,983,RC,20605,CPT,,,,,,,,318,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,155.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,309.5094
Iaad Ia Severe Aqt Respir Synd Coronavirus,PX87426,CDM,300,RC,87426,CPT,,,,,,,,159,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,155.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.39,155.82
"Office/Outpt Visit,Est,Levl V",PX99215F,CDM,510,RC,99215,CPT,,,,,,,,318,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,155.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,311.64
"Office/Outpt Visit,Est,Levl V",PX99215F,CDM,510,RC,99215,CPT,,,,,,,,318,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,155.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,311.64
"Office/Outpt Visit,Est,Levl V",PX99215F,CDM,510,RC,99215,CPT,,,,,,,,318,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,155.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,311.64
"Office/Outpt Visit,Est,Levl V",PX99215P,CDM,983,RC,99215,CPT,,,,,,,,318,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,155.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,309.5094
"Office/Outpt Visit,Est,Levl V",PX99215P,CDM,983,RC,99215,CPT,,,,,,,,318,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,155.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,309.5094
"Office/Outpt Visit,Est,Levl V",PX99215P,CDM,983,RC,99215,CPT,,,,,,,,318,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,155.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,309.5094
"Remv F.B.,Eye,Cornea,No Slit",PX65220P,CDM,983,RC,65220,CPT,,,,,,,,318,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,155.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,348.08
"Remv F.B.,Eye,Cornea,No Slit",PX65220P,CDM,983,RC,65220,CPT,,,,,,,,318,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,155.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,348.08
"Remv F.B.,Eye,Cornea,No Slit",PX65220P,CDM,983,RC,65220,CPT,,,,,,,,318,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,155.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,348.08
hydrocortisone sodium succinate (preservative free) 250 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001305,NDC,1,EA,183.32,,First Health,Commercial,both,85,,999999999,percent of total billed charges,155.822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032225,NDC,1,EA,176.72,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,155.86704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,173.1856
Assay Iga/Igd/Igg/Igm Each,PX82784,CDM,300,RC,82784,CPT,,,,,,,,315,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,155.925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.53,308.7
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082152,NDC,1,ML,375.43,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,155.953622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.48,367.9214
"Colonoscopy,Remv Lesn,Snare",PX45385F,CDM,750,RC,45385,CPT,,,,,,,,1939,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,155.97,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.32,940.85
"Colonoscopy,Remv Lesn,Snare",PX45385F,CDM,750,RC,45385,CPT,,,,,,,,1939,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,155.97,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.32,940.85
"Colonoscopy,Remv Lesn,Snare",PX45385P,CDM,983,RC,45385,CPT,,,,,,,,2424,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,155.97,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.32,2375.52
"Colonoscopy,Remv Lesn,Snare",PX45385P,CDM,983,RC,45385,CPT,,,,,,,,2424,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,155.97,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.32,2375.52
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101F,CDM,510,RC,13101,CPT,,,,,,,,495,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,155.97,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.32,823.93
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101F,CDM,510,RC,13101,CPT,,,,,,,,495,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,155.97,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.32,823.93
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101P,CDM,983,RC,13101,CPT,,,,,,,,330,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,155.97,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.32,823.93
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101P,CDM,983,RC,13101,CPT,,,,,,,,330,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,155.97,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.32,823.93
butamben-tetracaine-benzocaine 2-2-14 % Aerosol 5 g Bottle,25000000,CDM,250,RC,,,,,,10223020104,NDC,5,GR,375.52,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,155.991008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156F,CDM,370,RC,99156,CPT,,,,,,,,325,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,318.5
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156F,CDM,370,RC,99156,CPT,,,,,,,,325,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,318.5
Refill/Maint Portable Pump,PX96521,CDM,260,RC,96521,CPT,,,,,,,,325,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,318.5
Refill/Maint Portable Pump,PX96521,CDM,260,RC,96521,CPT,,,,,,,,325,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,318.5
"Remv F.B.,Eye,Embed Conjunc",PX65210F,CDM,510,RC,65210,CPT,,,,,,,,325,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,348.08
"Remv F.B.,Eye,Embed Conjunc",PX65210F,CDM,510,RC,65210,CPT,,,,,,,,325,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,348.08
Somatostatin - Ref,PX8430790,CDM,300,RC,84307,CPT,90,,,,,,,325,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.76,318.5
Somatostatin - Ref,PX8430790,CDM,300,RC,84307,CPT,90,,,,,,,325,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.76,318.5
hepatitis A vaccine 1440 EL U/ML Suspension 1 mL Syringe,90632,CDM,636,RC,90632,CPT,,,,58160082652,NDC,1,ML,375.78,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,156.099012,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,156.099012,368.2644
Assay of Ferritin,PX82728,CDM,300,RC,82728,CPT,,,,,,,,177,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,156.114,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.5,173.46
"D-Dimer, Quantitative - Ref",PX8537990,CDM,300,RC,85379,CPT,90,,,,,,,177,,United Healthcare,All Payer,outpatient,88.2,,343.875,percent of total billed charges,156.114,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.33,173.46
Fibrin Degradation Quant,PX85379,CDM,300,RC,85379,CPT,,,,,,,,177,,United Healthcare,All Payer,outpatient,88.2,,343.875,percent of total billed charges,156.114,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.33,173.46
Inj Tendon/Ligament/Cyst,PX20550F,CDM,510,RC,20550,CPT,,,,,,,,177,,United Healthcare,All Payer,outpatient,88.2,,124.89,percent of total billed charges,156.114,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.5258,258.75
amiodarone 360-4.14 MG/200ML-% Solution 200 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066036020,NDC,200,ML,325.25,,Health Partners,Health Partners Care Plans,both,48,,12.56916667,percent of total billed charges,156.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.35,318.745
amiodarone 360-4.14 MG/200ML-% Solution 200 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066036020,NDC,200,ML,325.25,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,156.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.35,318.745
MINIBUNION LOCKING SCREW 3.0X24MM,C1713,CDM,278,RC,C1713,HCPCS,,11671-MAIN,LOCAL,,,,,308.55,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,156.1263,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Cardiac Rehab II Eval,PX93798.05,CDM,943,RC,93798,CPT,,,,,,,,364,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,156.156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.44,495.55
Drain/Inject Large Joint/Bursa,PX20610F,CDM,510,RC,20610,CPT,,,,,,,,364,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,156.156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,151.2056,356.72
Xray Forearm 2 Vws,PX7309001,CDM,320,RC,73090,CPT,TC,,,,,,,364,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,156.156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,356.72
fat emulsion 20 % Emulsion 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,338051958,NDC,200,ML,375.95,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,156.16963,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Bone Scan, Whole Body",PX7830601,CDM,341,RC,78306,CPT,TC,,,,,,,1896,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,156.19,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,153.58,453.61
Fresh Frozen Plasma,PXP9017,CDM,390,RC,P9017,HCPCS,,,,,,,,319,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,156.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.32,312.62
Fresh Frozen Plasma,PXP9017,CDM,390,RC,P9017,HCPCS,,,,,,,,319,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,156.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.32,312.62
Fresh Frozen Plasma,PXP9017,CDM,390,RC,P9017,HCPCS,,,,,,,,319,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,156.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.32,312.62
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,703574811,NDC,100,ML,183.92,,First Health,Commercial,both,85,,999999999,percent of total billed charges,156.332,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.174958,180.2416
"Inject Nerv Blck,Othr Periph Nerv",PX64450F,CDM,510,RC,64450,CPT,,,,,,,,757,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,156.35,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.96,156.35
"Inject Nerv Blck,Othr Periph Nerv",PX64450P,CDM,983,RC,64450,CPT,,,,,,,,904,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,156.35,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.96,885.92
Drain/Inject Med Joint/Brusa W/US Guide,PX20606P,CDM,983,RC,20606,CPT,,,,,,,,309,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,156.354,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.3586,604.15
LINNEAR CUTTER STAPLE RELOAD GST BLUE 60MM,27200000,CDM,272,RC,,,,12068-MAIN,LOCAL,,,,,309,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,156.354,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LINNEAR CUTTER STAPLE RELOAD GST GREEN 60MM,27200000,CDM,272,RC,,,,12069-MAIN,LOCAL,,,,,309,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,156.354,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LINNEAR CUTTER STAPLE RELOAD GST WHITE 60MM,27200000,CDM,272,RC,,,,12067-MAIN,LOCAL,,,,,309,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,156.354,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Naso/Orogastric Tube,PX43752P,CDM,983,RC,43752,CPT,,,,,,,,309,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,156.354,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.3586,348.08
TUBE TRACH SIZE 3.0MM ID 4.5MM OD SHILEY PEDIATRIC 3.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1185-MAIN,LOCAL,,,,,184,,First Health,Commercial,both,85,,999999999,percent of total billed charges,156.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 3.5MM ID 5.2MM OD SHILEY PEDIATRIC,120.287,CDM,272,RC,A7520,HCPCS,,8813-MAIN,LOCAL,,,,,184,,First Health,Commercial,both,85,,999999999,percent of total billed charges,156.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 4.0MM ID 5.9MM OD SHILEY PEDIATRIC 4.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1187-MAIN,LOCAL,,,,,184,,First Health,Commercial,both,85,,999999999,percent of total billed charges,156.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 5 7.0MM ID 10.1MM OD SHILEY CUFFED 5CN70H,120.287,CDM,272,RC,A7521,HCPCS,,10350-MAIN,LOCAL,,,,,184,,First Health,Commercial,both,85,,999999999,percent of total billed charges,156.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 5.0MM ID 7.1MM OD SHILEY PEDIATRIC 5.0PED,120.287,CDM,272,RC,A7520,HCPCS,,8814-MAIN,LOCAL,,,,,184,,First Health,Commercial,both,85,,999999999,percent of total billed charges,156.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 6 6.0MM ID 8.3MM OD SHILEY CUFFED 6SCT,120.287,CDM,272,RC,A7521,HCPCS,,8812-MAIN,LOCAL,,,,,184,,First Health,Commercial,both,85,,999999999,percent of total billed charges,156.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 6 6.4MM ID 10.8MM OD SHILEY CUFFED 6DCT,120.287,CDM,272,RC,A7521,HCPCS,,1190-MAIN,LOCAL,,,,,184,,First Health,Commercial,both,85,,999999999,percent of total billed charges,156.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 7.5MM ID 10.8MM OD SHILEY CUFFED 6CN75H,120.287,CDM,272,RC,A7521,HCPCS,,8488-MAIN,LOCAL,,,,,184,,First Health,Commercial,both,85,,999999999,percent of total billed charges,156.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 8 7.6MM ID 12.2MM OD SHILEY 8DCT,120.287,CDM,272,RC,A7521,HCPCS,,1192-MAIN,LOCAL,,,,,184,,First Health,Commercial,both,85,,999999999,percent of total billed charges,156.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 8 7.6MM ID 12.22MM OD SHILEY CUFFED 8LPC,120.287,CDM,272,RC,A7521,HCPCS,,8815-MAIN,LOCAL,,,,,184,,First Health,Commercial,both,85,,999999999,percent of total billed charges,156.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 8.0MM ID 10.9MM OD SHILEY CUFFED 8SCT,120.287,CDM,272,RC,A7521,HCPCS,,8811-MAIN,LOCAL,,,,,184,,First Health,Commercial,both,85,,999999999,percent of total billed charges,156.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 10 SHILEY 10LPC,120.287,CDM,272,RC,A7521,HCPCS,,1181-MAIN,LOCAL,,,,,184,,First Health,Commercial,both,85,,999999999,percent of total billed charges,156.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,55150017301,NDC,0.5,ML,319.2,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,156.408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,55150017301,NDC,0.5,ML,319.2,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,156.408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,55150017301,NDC,0.5,ML,319.2,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,156.408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
"MRI,Up Ext,No Jnt,No Cont",PX7321801,CDM,610,RC,73218,CPT,TC,,,,,,,3253,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,156.41,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,156.41,490.42
Cast/Strap Procedure Unlisted,PX29799F,CDM,510,RC,29799,CPT,,,,,,,,316,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,156.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,131.2664,309.68
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989001,NDC,50,ML,160.78,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1.636666667,percent of total billed charges,156.487174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989002,NDC,50,ML,160.78,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1.636666667,percent of total billed charges,156.487174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,338035702,NDC,250,ML,309.28,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,156.49568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.4701,303.0944
"2019-Ncov Coronavirus, Sars-Cov-2/2019-Ncov (Covid-19)",PXU000290,CDM,300,RC,U0002,HCPCS,90,,,,,,,365,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,156.585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,357.7
"Closed Rx Spont Hip Disloc,Anesth",PX27257P,CDM,983,RC,27257,CPT,,,,,,,,365,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,156.585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,151.621,1404.08
Sars-Cov-2 Covid-19 Amp Prb,PX8763590,CDM,300,RC,87635,CPT,90,,,,,,,365,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,156.585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,357.7
X-Ray Exam Femur Min 2 Vws,PX7355201,CDM,320,RC,73552,CPT,TC,,,,,,,365,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,156.585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Ankle Minimum 3 Vws,PX7361001,CDM,320,RC,73610,CPT,TC,,,,,,,365,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,156.585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Calcaneus Minimum 2 Vws,PX7365001,CDM,320,RC,73650,CPT,TC,,,,,,,365,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,156.585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Clavicle Complete,PX7300001,CDM,320,RC,73000,CPT,TC,,,,,,,365,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,156.585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Elbow 2 Vws,PX7307001,CDM,320,RC,73070,CPT,TC,,,,,,,365,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,156.585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Hand 2vws Tc,PX7312001,CDM,320,RC,73120,CPT,TC,,,,,,,365,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,156.585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,357.7
Xray Humerus Minimum 2 Vws,PX7306001,CDM,320,RC,73060,CPT,TC,,,,,,,365,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,156.585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Shoulder Minimum 2 Vws,PX7303001,CDM,320,RC,73030,CPT,TC,,,,,,,365,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,156.585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Sternum 2vws Tc,PX7112001,CDM,320,RC,71120,CPT,TC,,,,,,,365,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,156.585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Tibia & Fibula 2 Vws,PX7359001,CDM,320,RC,73590,CPT,TC,,,,,,,365,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,156.585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Wrist 2 Vws,PX7310001,CDM,320,RC,73100,CPT,TC,,,,,,,365,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,156.585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Repr Superf Wnd Body 12.6-20,PX12005P,CDM,983,RC,12005,CPT,,,,,,,,377,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,156.6058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,156.6058,366.9341
CCP Antibody,PX86200,CDM,300,RC,86200,CPT,,,,,,,,176,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,156.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,172.48
Detect Agent Nos Dna Amp,PX87798,CDM,300,RC,87798,CPT,,,,,,,,176,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,156.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,172.48
Eval of Bronchospasm,PX94060,CDM,983,RC,94060,CPT,,,,,,,,176,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,156.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.1104,274.21
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151F,CDM,370,RC,99151,CPT,,,,,,,,176,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,156.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.1104,172.48
"Office Consultation,Level III",PX99243P,CDM,983,RC,99243,CPT,,,,,,,,374,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,156.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.65,366.52
AIRSEAL 12MM ACCESS PORT AND PALM GRIP OBTURATOR BLADELESS OPTICAL TIP 120MM,27200000,CDM,272,RC,,,,12207-MAIN,LOCAL,,,,,172,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,156.692,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
AIRSEAL TUBE SET TRI LUMEN FILTERED WITH ACTIVATED CHARCOAL,27200000,CDM,272,RC,,,,12206-MAIN,LOCAL,,,,,172,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,156.692,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Drainage Scrotal Wall Abscess,PX55100F,CDM,510,RC,55100,CPT,,,,,,,,634,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,156.6968,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.27,482.88
Drainage Scrotal Wall Abscess,PX55100P,CDM,983,RC,55100,CPT,,,,,,,,341,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,156.6968,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.27,482.88
Catheterize for Urine Spec,PXP9612,CDM,300,RC,P9612,HCPCS,,,,,,,,161,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,156.7013,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.1,157.78
Drain/Inject Small Joint/Bursa,PX20600F,CDM,510,RC,20600,CPT,,,,,,,,161,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,322,percent of total billed charges,156.7013,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.8794,258.75
Drain/Inject Small Joint/Bursa,PX20600P,CDM,983,RC,20600,CPT,,,,,,,,161,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,322,percent of total billed charges,156.7013,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.8794,258.75
Each Add'l Hour IV Infusion <8 Hour,PX96366,CDM,260,RC,96366,CPT,,,,,,,,161,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,121.4354651,percent of total billed charges,156.7013,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,157.78
Apply Long Leg Splint,PX29505F,CDM,510,RC,29505,CPT,,,,,,,,320,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,156.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.928,313.6
Apply Long Leg Splint,PX29505F,CDM,510,RC,29505,CPT,,,,,,,,320,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,156.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.928,313.6
Apply Long Leg Splint,PX29505F,CDM,510,RC,29505,CPT,,,,,,,,320,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,156.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.928,313.6
Ex for Speech Device Rx Addl,PX92608,CDM,444,RC,92608,CPT,,,,,,,,160,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,156.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.95,156.8
"IV Infusion, Bamlanivimab, Infusion and Post Admin Monig",PXM0239,CDM,260,RC,M0239,HCPCS,,,,,,,,320,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,156.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.928,313.6
"IV Infusion, Bamlanivimab, Infusion and Post Admin Monig",PXM0239,CDM,260,RC,M0239,HCPCS,,,,,,,,320,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,156.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.928,313.6
"IV Infusion, Bamlanivimab, Infusion and Post Admin Monig",PXM0239,CDM,260,RC,M0239,HCPCS,,,,,,,,320,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,156.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.928,313.6
"Drain Finger Abscess,Simple",PX26010F,CDM,510,RC,26010,CPT,,,,,,,,310,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,156.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.774,303.8
procainamide 500 MG/ML Solution 2 mL Vial,J2690.01,CDM,636,RC,J2690,HCPCS,,,,14789090002,NDC,2,ML,377.75,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,156.91735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,134.15,370.195
aztreonam 1 g Recon Soln 1 Each Vial,J0457.01,CDM,636,RC,J0457,HCPCS,,,,63323040124,NDC,1,EA,176.32,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,156.9248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.32,172.7936
8MM ENDOWRIST INSTRUMENTS MEGA SUTURE CUT NEEDLE DRIVER,27200000,CDM,272,RC,,,,11914-MAIN,LOCAL,,,,,327,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,156.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM ENDOWRIST INSTRUMENTS MEGA SUTURE CUT NEEDLE DRIVER,27200000,CDM,272,RC,,,,11914-MAIN,LOCAL,,,,,327,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,156.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"IV Infusion Therapy, 1 Hour",PX96365,CDM,260,RC,96365,CPT,,,,,,,,327,,Health Partners,Health Partners Care Plans,both,48,,137.3802941,percent of total billed charges,156.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.8358,320.46
"IV Infusion Therapy, 1 Hour",PX96365,CDM,260,RC,96365,CPT,,,,,,,,327,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,156.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.8358,320.46
Dress/Debrid Med Burn No Anesth,PX16025F,CDM,510,RC,16025,CPT,,,,,,,,366,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,157.014,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,152.0364,358.68
"Inpatient Consult, Level III",PX99253,CDM,983,RC,99253,CPT,,,,,,,,374,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,157.072,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.07,366.52
"Inpatient Consult, Level III",PX99253,CDM,983,RC,99253,CPT,,,,,,,,374,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,157.072,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.07,366.52
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127332,NDC,2,ML,176.55,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,157.1295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.43158,173.019
sodium zirconium cyclosilicate 10 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,310111001,NDC,1,EA,172.56,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,157.20216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Amylase - Ref,PX8215090,CDM,300,RC,82150,CPT,90,,,,,,,185,,First Health,Commercial,both,85,,999999999,percent of total billed charges,157.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.94,181.3
Hepatitis C Rna Quant,PX87522,CDM,300,RC,87522,CPT,,,,,,,,185,,First Health,Commercial,both,85,,999999999,percent of total billed charges,157.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.28,181.3
"Level IV - Surgical Pathology, Gross and Microscopic Examination , Tech",PX3934,CDM,310,RC,88305,CPT,TC,,,,,,,185,,First Health,Commercial,both,85,,999999999,percent of total billed charges,157.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,271.15
"Office/Outpt Visit,Est,Levl III",PX99213F,CDM,510,RC,99213,CPT,,,,,,,,185,,First Health,Commercial,both,85,,999999999,percent of total billed charges,157.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.849,181.3
"Office/Outpt Visit,Est,Levl III",PX99213P,CDM,983,RC,99213,CPT,,,,,,,,185,,First Health,Commercial,both,85,,999999999,percent of total billed charges,157.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.849,180.0605
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032225,NDC,1,EA,176.72,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,157.2808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,173.1856
Apply Lower Leg Splint,PX29515P,CDM,983,RC,29515,CPT,,,,,,,,311,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,157.366,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,129.1894,302.6963
Repr Superf Wnd Body <2.5cm,PX12001F,CDM,510,RC,12001,CPT,,,,,,,,311,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,157.366,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,129.1894,304.78
Xray Skull Less Than 4 Vws,PX7025001,CDM,320,RC,70250,CPT,TC,,,,,,,311,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,157.366,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,304.78
8MM ENDOWRIST INSTRUMENTS LARGE NEEDLE DRIVER,27200000,CDM,272,RC,,,,11912-MAIN,LOCAL,,,,,318,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,157.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Drain/Inject Medium Joint/Bursa,PX20605P,CDM,983,RC,20605,CPT,,,,,,,,318,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,157.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,309.5094
"Office/Outpt Visit,Est,Levl V",PX99215F,CDM,510,RC,99215,CPT,,,,,,,,318,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,157.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,311.64
"Office/Outpt Visit,Est,Levl V",PX99215P,CDM,983,RC,99215,CPT,,,,,,,,318,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,157.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,309.5094
"Remv F.B.,Eye,Cornea,No Slit",PX65220P,CDM,983,RC,65220,CPT,,,,,,,,318,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,157.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,348.08
"Tech-Cytopath Eval, Fna, Rep",PX8817301,CDM,310,RC,88173,CPT,TC,,,,,,,379,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,157.4366,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,371.42
"Chemotherapy, IV Infusion, Each Add'l Sequential Infusion",PX96417,CDM,335,RC,96417,CPT,,,,,,,,328,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,157.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,321.44
"Chemotherapy, IV Infusion, Each Add'l Sequential Infusion",PX96417,CDM,335,RC,96417,CPT,,,,,,,,328,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,157.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,321.44
Xray Foot 2 Vws,PX7362001,CDM,320,RC,73620,CPT,TC,,,,,,,367,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,157.443,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,359.66
Assay of Ferritin,PX82728,CDM,300,RC,82728,CPT,,,,,,,,177,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,157.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.5,173.46
"D-Dimer, Quantitative - Ref",PX8537990,CDM,300,RC,85379,CPT,90,,,,,,,177,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,157.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.33,173.46
Fibrin Degradation Quant,PX85379,CDM,300,RC,85379,CPT,,,,,,,,177,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,157.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.33,173.46
Inj Tendon/Ligament/Cyst,PX20550F,CDM,510,RC,20550,CPT,,,,,,,,177,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,157.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.5258,258.75
clotrimazole-betamethasone 1-0.05 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,51672404801,NDC,15,GR,172.95,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,157.55745,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989001,NDC,50,ML,160.78,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,157.5644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989002,NDC,50,ML,160.78,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,157.5644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.74,157.5644
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031801,NDC,1,ML,185.37,,First Health,Commercial,both,85,,999999999,percent of total billed charges,157.5645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.002698,181.6626
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031825,NDC,1,ML,185.37,,First Health,Commercial,both,85,,999999999,percent of total billed charges,157.5645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.002698,181.6626
nafcillin 2 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,S0032,HCPCS,,,,63323032820,NDC,1,EA,185.37,,First Health,Commercial,both,85,,999999999,percent of total billed charges,157.5645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
RBC Antibody Screen,PX86850,CDM,300,RC,86850,CPT,,,,,,,,173,,Medica,Commercial,both,91.1,,31.306,percent of total billed charges,157.603,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,169.54
"Thyroxin, Free (Free T4)",PX84439,CDM,300,RC,84439,CPT,,,,,,,,173,,Medica,Commercial,both,91.1,,37.11,percent of total billed charges,157.603,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.27,169.54
fentaNYL 50 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,47781042611,NDC,1,EA,185.47,,First Health,Commercial,both,85,,999999999,percent of total billed charges,157.6495,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 50 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,47781042647,NDC,1,EA,185.47,,First Health,Commercial,both,85,,999999999,percent of total billed charges,157.6495,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Acetone Assay,PX82010,CDM,300,RC,82010,CPT,,,,,,,,162,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,157.6746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.49,158.76
"Flow Interp,2-8 Markers - Ref",PX8818790,CDM,310,RC,88187,CPT,90,,,,,,,162,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,157.6746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.1,158.76
KIT THORACENTESIS PLEURA SEAL AK-01000-T,120.24,CDM,272,RC,,,,1147-MAIN,LOCAL,,,,,162,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,157.6746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.2948,158.76
Catheterize for Urine Spec,PXP9612,CDM,300,RC,P9612,HCPCS,,,,,,,,161,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,157.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.1,157.78
Drain/Inject Small Joint/Bursa,PX20600F,CDM,510,RC,20600,CPT,,,,,,,,161,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,157.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.8794,258.75
Drain/Inject Small Joint/Bursa,PX20600P,CDM,983,RC,20600,CPT,,,,,,,,161,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,157.78,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.82,157.78
Each Add'l Hour IV Infusion <8 Hour,PX96366,CDM,260,RC,96366,CPT,,,,,,,,161,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,157.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,157.78
verapamil 2.5 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,409114405,NDC,2,ML,185.65,,First Health,Commercial,both,85,,999999999,percent of total billed charges,157.8025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Closed Rx Elbow Dislocation,PX24600P,CDM,983,RC,24600,CPT,,,,,,,,380,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,157.852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,157.852,369.854
etoposide 500 MG/25ML Solution 25 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,703565601,NDC,25,ML,173.28,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,157.85808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.949434,169.8144
"Tech-Cytopath Eval, Fna, Rep",PX8817301,CDM,310,RC,88173,CPT,TC,,,,,,,379,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,157.86,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.98,162.848
"Tech-Cytopath Eval, Fna, Rep",PX8817301,CDM,310,RC,88173,CPT,TC,,,,,,,379,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,157.86,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.98,162.848
SCOPE ASCOPE4 CYSTO STERILE 601001000,120.497,CDM,272,RC,A4649,HCPCS,,11662-MAIN,LOCAL,,,,,368,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,157.872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,152.8672,360.64
Closed Rx Kneecap Dislocatn,PX27560P,CDM,983,RC,27560,CPT,,,,,,,,312,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,157.872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,129.6048,303.6696
"Apply Short Leg Cast,Walker",PX29425F,CDM,510,RC,29425,CPT,,,,,,,,179,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,157.878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.3566,234.62
C Diff Amplified Probe,PX87493,CDM,300,RC,87493,CPT,,,,,,,,179,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,157.878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.17,175.42
Fibrinogen Test - Ref,PX8536690,CDM,300,RC,85366,CPT,90,,,,,,,179,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,157.878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.77,175.42
TUBE GASTROSTOMY 18FR REPLACEMENT DYND70318,120.256,CDM,271,RC,B4087,HCPCS,,407-MAIN,LOCAL,,,,,179,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,157.878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.53,175.42
Fresh Frozen Plasma,PXP9017,CDM,390,RC,P9017,HCPCS,,,,,,,,319,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,157.905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.32,312.62
Facility Emergency Level 1 Visit,PX99281F,CDM,450,RC,99281,CPT,,,,,,,,329,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,157.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.56,322.42
Facility Emergency Level 1 Visit,PX99281F,CDM,450,RC,99281,CPT,,,,,,,,329,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,157.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.56,322.42
"Amputation Toe,I-P Jt",PX28825F,CDM,510,RC,28825,CPT,,,,,,,,1327,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,157.9812,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.23,605.33
"Amputation Toe,I-P Jt",PX28825P,CDM,983,RC,28825,CPT,,,,,,,,780,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,157.9812,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.23,764.4
"Layr Clos Wnd Face,Facial <2.5cm",PX12051F,CDM,510,RC,12051,CPT,,,,,,,,769,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,157.9812,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.45,590.11
"Layr Clos Wnd Face,Facial <2.5cm",PX12051P,CDM,983,RC,12051,CPT,,,,,,,,615,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,157.9812,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.45,602.7
ketoconazole 2 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,16714095501,NDC,15,GR,322.42,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,157.9858,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ketoconazole 2 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,16714095501,NDC,15,GR,322.42,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,157.9858,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ketoconazole 2 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,16714095501,NDC,15,GR,322.42,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,157.9858,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,55150017301,NDC,0.5,ML,319.2,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,158.004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
nitroPRUSSide 25 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,72485010501,NDC,2,ML,186,,First Health,Commercial,both,85,,999999999,percent of total billed charges,158.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Puncture Drainage of Lesion,PX10160P,CDM,983,RC,10160,CPT,,,,,,,,186,,First Health,Commercial,both,85,,999999999,percent of total billed charges,158.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.2644,348.35
"TB Test, Cell Immunity Measure",PX86480,CDM,300,RC,86480,CPT,,,,,,,,186,,First Health,Commercial,both,85,,999999999,percent of total billed charges,158.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.83,182.28
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082143,NDC,1,ML,348.85,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,158.15,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,133.87,158.15
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082143,NDC,1,ML,348.85,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,158.15,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,133.87,158.15
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082152,NDC,1,ML,375.43,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,158.15,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,133.87,158.15
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082152,NDC,1,ML,375.43,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,158.15,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,133.87,158.15
"Incis/Drain Shldr Absc/Hema,Deep",PX23030P,CDM,983,RC,23030,CPT,,,,,,,,1564,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,158.15,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,158.15,1532.72
Duplex Up Extrem Art Bilat,PX9393001,CDM,921,RC,93930,CPT,TC,,,,,,,835,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,158.178,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.92,280.38
"Xray Mandible Compl, Min 4 Vws",PX7011001,CDM,320,RC,70110,CPT,TC,,,,,,,381,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,158.2674,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,373.38
Xray Ls Spine Bend Tc,PX7212001,CDM,320,RC,72120,CPT,TC,,,,,,,323,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,158.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,316.54
Xray Ls Spine Bend Tc,PX7212001,CDM,320,RC,72120,CPT,TC,,,,,,,323,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,158.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,316.54
Xray Ls Spine Bend Tc,PX7212001,CDM,320,RC,72120,CPT,TC,,,,,,,323,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,158.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,316.54
COLLAR CERVICAL LARGE WITH TRACH 2 PIECE PHP-T4L,120.184,CDM,274,RC,L0172,HCPCS,,10142-MAIN,LOCAL,,,,,37,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,158.31,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,158.31,166.64
COLLAR CERVICAL MEDIUM WITH TRACH 2 PIECE PHP-T4M,120.183,CDM,274,RC,L0172,HCPCS,,10141-MAIN,LOCAL,,,,,37,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,158.31,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,158.31,166.64
COLLAR CERVICAL SMALL WITH TRACH 2 PIECE PHP-T4S,120.182,CDM,274,RC,L0172,HCPCS,,10140-MAIN,LOCAL,,,,,37,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,158.31,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,158.31,166.64
COLLAR CERVICAL X-LARGE WITH TRACH 2 PIECE OSG2404,120.185,CDM,274,RC,L0172,HCPCS,,10143-MAIN,LOCAL,,,,,49,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,158.31,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,158.31,166.64
sulfacetamide 10 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,24208067004,NDC,15,ML,312.96,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,158.35776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Colonoscopy,Control Bleeding",PX45382F,CDM,750,RC,45382,CPT,,,,,,,,1215,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,158.37,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,158.37,1373.91
Dress/Debrid Small Burn No Anes,PX16020F,CDM,510,RC,16020,CPT,,,,,,,,313,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,158.378,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.0202,306.74
Apply Long Leg Splint,PX29505F,CDM,510,RC,29505,CPT,,,,,,,,320,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,158.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.928,313.6
"IV Infusion, Bamlanivimab, Infusion and Post Admin Monig",PXM0239,CDM,260,RC,M0239,HCPCS,,,,,,,,320,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,158.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.928,313.6
"measles, mumps & rubella vaccine Recon Soln 1 Each Vial",90707,CDM,636,RC,90707,CPT,,,,6468100,NDC,1,EA,381.47,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,158.462638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,158.462638,373.8406
ketoconazole 2 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,168009915,NDC,15,GR,173.97,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,158.48667,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
predniSONE 5 mg/5 mL 5 MG/5ML Solution 120 mL Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54372250,NDC,120,ML,186.47,,First Health,Commercial,both,85,,999999999,percent of total billed charges,158.4995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
Emergency Level V Visit,PX99285P,CDM,981,RC,99285,CPT,,,,,,,,1436,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,158.5488,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.81,1407.28
Facility Emergency Level V Visit,PX99285F,CDM,450,RC,99285,CPT,,,,,,,,1464,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,158.5488,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.81,310.96
Ehrlichia (Anaplasma) Ab - Ref,PX8666690,CDM,300,RC,86666,CPT,90,,,,,,,163,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,158.6479,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.33,159.74
Xray Ankle 2 Vws,PX7360001,CDM,320,RC,73600,CPT,TC,,,,,,,163,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,188.33,percent of total billed charges,158.6479,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.7102,159.74
buprenorphine 5 MCG/HR PATCH WEEKLY 4 Each Box,63700001,CDM,250,RC,,,,,,42858075040,NDC,1,EA,330.52,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,158.6496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buprenorphine 5 MCG/HR PATCH WEEKLY 4 Each Box,63700001,CDM,250,RC,,,,,,42858075040,NDC,1,EA,330.52,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,158.6496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"X-Ray Exam Hip,Bilat W/Pelvis 3-4 Vws",PX7352201,CDM,320,RC,73522,CPT,TC,,,,,,,382,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,158.6828,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,374.36
Acetaminophen,PX80307E,CDM,300,RC,80307,CPT,,,,,,,,370,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,158.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Alcohol,PX80307A,CDM,300,RC,80307,CPT,,,,,,,,370,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,158.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Salicylate,PX80307D,CDM,300,RC,80307,CPT,,,,,,,,370,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,158.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Urine Drug Screen,PX80307B,CDM,300,RC,80307,CPT,,,,,,,,370,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,158.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Xray Elbow 3+Vws Tc,PX7308001,CDM,320,RC,73080,CPT,TC,,,,,,,370,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,158.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,362.6
Acetone Assay,PX82010,CDM,300,RC,82010,CPT,,,,,,,,162,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,158.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.49,158.76
C-Peptide - Ref,PX8468190,CDM,300,RC,84681,CPT,90,,,,,,,180,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,158.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,176.4
"Closed Rx Radial Head Disloc,Child",PX24640P,CDM,983,RC,24640,CPT,,,,,,,,180,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,158.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.772,206.02
"Flow Interp,2-8 Markers - Ref",PX8818790,CDM,310,RC,88187,CPT,90,,,,,,,162,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,158.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.1,158.76
"Infect Ea Organ, Amp Prob - Ref",PX8779890,CDM,300,RC,87798,CPT,90,,,,,,,180,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,158.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,176.4
KIT THORACENTESIS PLEURA SEAL AK-01000-T,120.24,CDM,272,RC,,,,1147-MAIN,LOCAL,,,,,162,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,158.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.2948,158.76
Mrsa by Amplification Na,PX87641,CDM,300,RC,87641,CPT,,,,,,,,180,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,158.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,176.4
Protein Elp,PX84166,CDM,300,RC,84166,CPT,,,,,,,,180,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,158.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.35,176.4
"MRI,Up Ext,No Jnt,No Cont",PX7321801,CDM,610,RC,73218,CPT,TC,,,,,,,3253,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,158.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,156.41,490.42
"MRI,Up Ext,No Jnt,No Cont",PX7321801,CDM,610,RC,73218,CPT,TC,,,,,,,3253,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,158.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,156.41,490.42
levonorgestrel 1.5 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,68180085211,NDC,1,EA,174.39,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,158.86929,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay for Vancomycin,PX80202,CDM,300,RC,80202,CPT,,,,,,,,314,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,158.884,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.41,307.72
Insitu Hybridization (Fish),PX8836401,CDM,310,RC,88364,CPT,TC,,,,,,,335,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,158.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.09,164.704
Insitu Hybridization (Fish),PX8836401,CDM,310,RC,88364,CPT,TC,,,,,,,335,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,158.91,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.09,164.704
Fac/Initial Hospital Care Levl II,PX99222F,CDM,510,RC,99222,CPT,,,,,,,,187,,First Health,Commercial,both,85,,999999999,percent of total billed charges,158.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.6798,183.26
"Infect Ag,Eia, Nos, Ea - Ref",PX8744990,CDM,300,RC,87449,CPT,90,,,,,,,187,,First Health,Commercial,both,85,,999999999,percent of total billed charges,158.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,183.26
Initial Hospital Care Levl II,PX99222P,CDM,982,RC,99222,CPT,,,,,,,,187,,First Health,Commercial,both,85,,999999999,percent of total billed charges,158.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.6798,182.0071
Lipid Profile,PX80061,CDM,300,RC,80061,CPT,,,,,,,,245,,Blue Cross Blue Shield of MN,All commercial plans,both,,,184.295,fee schedule,158.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.28,240.1
RETRIEVAL BAG 12/15MM,27200000,CDM,272,RC,,,,12660-MAIN,LOCAL,,,,,187,,First Health,Commercial,both,85,,999999999,percent of total billed charges,158.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
neomycin-polymyxin-gramicidin 1.75-10000-.025 Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,24208079062,NDC,10,ML,314.26,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,159.01556,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Colonoscopy,Control Bleeding",PX45382F,CDM,750,RC,45382,CPT,,,,,,,,1215,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,159.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,158.37,1373.91
"Colonoscopy,Control Bleeding",PX45382F,CDM,750,RC,45382,CPT,,,,,,,,1215,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,159.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,158.37,1373.91
Bcr/Abl1 P210 - Ref,PX8120690,CDM,310,RC,81206,CPT,90,,,,,,,1144,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,159.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,133,160.7709
Bcr/Abl1 P210 - Ref,PX8120690,CDM,310,RC,81206,CPT,90,,,,,,,1144,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,159.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,133,160.7709
Bcr/Abl1 P210 - Ref,PX8120690,CDM,310,RC,81206,CPT,90,,,,,,,1144,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,159.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,133,160.7709
El-1 Fecal Quantitative,PX8265390,CDM,300,RC,82653,CPT,90,,,,,,,383,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,159.0982,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.0982,375.34
"Apply Short Leg Cast,Walker",PX29425F,CDM,510,RC,29425,CPT,,,,,,,,179,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,159.11,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.81,159.11
"Apply Short Leg Cast,Walker",PX29425P,CDM,983,RC,29425,CPT,,,,,,,,119,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,159.11,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.81,159.11
"Ctrl Nosebleed,Anter,Complex",PX30903F,CDM,510,RC,30903,CPT,,,,,,,,456,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,159.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.46,506.4
"Ctrl Nosebleed,Anter,Complex",PX30903P,CDM,983,RC,30903,CPT,,,,,,,,304,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,159.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.46,506.4
Fac/Irrigation of Bladder,PX51700F,CDM,510,RC,51700,CPT,,,,,,,,358,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,159.11,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.1,159.11
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021515,NDC,0.5,ML,187.24,,First Health,Commercial,both,85,,999999999,percent of total billed charges,159.154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.779496,199.7926
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156F,CDM,370,RC,99156,CPT,,,,,,,,325,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,159.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,318.5
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156F,CDM,370,RC,99156,CPT,,,,,,,,325,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,159.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,318.5
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156F,CDM,370,RC,99156,CPT,,,,,,,,325,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,159.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,318.5
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156P,CDM,983,RC,99156,CPT,,,,,,,,325,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,159.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,316.3225
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156P,CDM,983,RC,99156,CPT,,,,,,,,325,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,159.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,316.3225
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156P,CDM,983,RC,99156,CPT,,,,,,,,325,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,159.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,316.3225
Refill/Maint Portable Pump,PX96521,CDM,260,RC,96521,CPT,,,,,,,,325,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,159.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,318.5
Refill/Maint Portable Pump,PX96521,CDM,260,RC,96521,CPT,,,,,,,,325,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,159.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,318.5
Refill/Maint Portable Pump,PX96521,CDM,260,RC,96521,CPT,,,,,,,,325,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,159.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,318.5
"Remv F.B.,Eye,Embed Conjunc",PX65210F,CDM,510,RC,65210,CPT,,,,,,,,325,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,159.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,348.08
"Remv F.B.,Eye,Embed Conjunc",PX65210F,CDM,510,RC,65210,CPT,,,,,,,,325,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,159.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,348.08
"Remv F.B.,Eye,Embed Conjunc",PX65210F,CDM,510,RC,65210,CPT,,,,,,,,325,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,159.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,348.08
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598P,CDM,982,RC,97598,CPT,,,,,,,,325,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,159.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,316.3225
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598P,CDM,982,RC,97598,CPT,,,,,,,,325,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,159.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,316.3225
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598P,CDM,982,RC,97598,CPT,,,,,,,,325,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,159.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,316.3225
Somatostatin - Ref,PX8430790,CDM,300,RC,84307,CPT,90,,,,,,,325,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,159.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.76,318.5
Somatostatin - Ref,PX8430790,CDM,300,RC,84307,CPT,90,,,,,,,325,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,159.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.76,318.5
Somatostatin - Ref,PX8430790,CDM,300,RC,84307,CPT,90,,,,,,,325,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,159.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.76,318.5
Removal of Anal Tabs,PX46230F,CDM,510,RC,46230,CPT,,,,,,,,790,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,159.2656,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.32,652.37
Removal of Anal Tabs,PX46230P,CDM,983,RC,46230,CPT,,,,,,,,1435,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,159.2656,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.32,1406.3
dexAMETHasone 0.1 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,24208072002,NDC,5,ML,331.81,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,159.2688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dexAMETHasone 0.1 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,24208072002,NDC,5,ML,331.81,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,159.2688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pentafluoroprop - tetrafluoroeth Aerosol 116 mL Can,63700001,CDM,250,RC,,,,,,386000802,NDC,207,ML,383.42,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,159.272668,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Apply Short Leg Cast,Walker",PX29425F,CDM,510,RC,29425,CPT,,,,,,,,179,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,159.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.3566,234.62
C Diff Amplified Probe,PX87493,CDM,300,RC,87493,CPT,,,,,,,,179,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,159.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.17,175.42
Fibrinogen Test - Ref,PX8536690,CDM,300,RC,85366,CPT,90,,,,,,,179,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,159.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.77,175.42
TUBE GASTROSTOMY 18FR REPLACEMENT DYND70318,120.256,CDM,271,RC,B4087,HCPCS,,407-MAIN,LOCAL,,,,,179,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,159.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.53,175.42
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070102,NDC,1,ML,383.6,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,159.34744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.92,450.751
amiodarone 360-4.14 MG/200ML-% Solution 200 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066036020,NDC,200,ML,325.25,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,159.3725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.35,318.745
amiodarone 360-4.14 MG/200ML-% Solution 200 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066036020,NDC,200,ML,325.25,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,159.3725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.35,318.745
amiodarone 360-4.14 MG/200ML-% Solution 200 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066036020,NDC,200,ML,325.25,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,159.3725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.35,318.745
Assay Iga/Igd/Igg/Igm Each,PX82784,CDM,300,RC,82784,CPT,,,,,,,,315,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,159.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.53,308.7
Electrolyte Panel,PX80051,CDM,300,RC,80051,CPT,,,,,,,,175,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,159.425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.43,171.5
"Fac/Trm Hyperkeratotic Skn Lesn,>4",PX11057F,CDM,510,RC,11057,CPT,,,,,,,,175,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,159.425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.695,174.9
"Gonadotropin, Chorionic (Hcg), Qualitative",PX84703,CDM,300,RC,84703,CPT,,,,,,,,175,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,159.425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.9,171.5
Protein E-Phoresis Serum,PX84165,CDM,300,RC,84165,CPT,,,,,,,,175,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,159.425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,171.5
Protein Elp Interp,PX8416526,CDM,300,RC,84165,CPT,26,,,,,,,175,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,159.425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,171.5
Lvl 3 Sub Hosp High Mdm or 50 Minutes,PX99233,CDM,982,RC,99233,CPT,,,,,,,,384,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,159.5136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.5136,373.7472
leuprolide 7.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74364203,NDC,1,EA,3782.28,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,159.54,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.54,190.37
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74334603,NDC,1,EA,12509.82,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,159.54,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.54,190.37
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,62935022305,NDC,1,EA,2764.34,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,159.54,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.54,190.37
leuprolide 45 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74347303,NDC,1,EA,21633.89,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,159.54,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.54,190.37
linezolid 600 MG/300ML Solution 300 mL Flex Cont,J2020.01,CDM,636,RC,J2020,HCPCS,,,,9514001,NDC,300,ML,332.42,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,159.5616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.087268,325.7716
linezolid 600 MG/300ML Solution 300 mL Flex Cont,J2020.01,CDM,636,RC,J2020,HCPCS,,,,9514001,NDC,300,ML,332.42,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,159.5616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.087268,325.7716
Cyto Non Gyn,PX8811201,CDM,310,RC,88112,CPT,TC,,,,,,,372,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,159.588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,364.56
ketoconazole 2 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,16714095501,NDC,15,GR,322.42,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,159.5979,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Tx/Pro/Dx Inj Same Drug Adon,PX96376,CDM,260,RC,96376,CPT,,,,,,,,164,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,79.46518519,percent of total billed charges,159.6212,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.1256,160.72
Baloxavir Marboxil(40 MG Dose) 2 x 20 MG tablet therapy pack 2 Each Box,800000,CDM,,,,,,,,50242082802,NDC,1,EA,384.3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,159.63822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Alcohol Biomarkers; 1 or 2 - Ref,PX8032190,CDM,300,RC,80321,CPT,90,,,,,,,181,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,159.642,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.1874,177.38
"Lyme Disease, Antibody - Ref",PX8661890,CDM,300,RC,86618,CPT,90,,,,,,,181,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,159.642,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.61,177.38
PHALINX STERILE TRIAL SIZER 45A00000,27200000,CDM,272,RC,,,,12959-MAIN,LOCAL,,,,,181,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,159.642,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Incis/Drain Shldr Absc/Hema,Deep",PX23030P,CDM,983,RC,23030,CPT,,,,,,,,1564,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,159.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,158.15,1532.72
"Incis/Drain Shldr Absc/Hema,Deep",PX23030P,CDM,983,RC,23030,CPT,,,,,,,,1564,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,159.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,158.15,1532.72
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004F,CDM,510,RC,15004,CPT,,,,,,,,855,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,159.68,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.68,813.56
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004P,CDM,983,RC,15004,CPT,,,,,,,,570,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,159.68,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.68,813.56
Ehrlichia (Anaplasma) Ab - Ref,PX8666690,CDM,300,RC,86666,CPT,90,,,,,,,163,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,159.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.33,159.74
Xray Ankle 2 Vws,PX7360001,CDM,320,RC,73600,CPT,TC,,,,,,,163,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,159.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.7102,159.74
Aaa US Screen Tc,PX7670601,CDM,402,RC,76706,CPT,TC,,,,,,,554,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,159.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.66,159.75
Aaa US Screen Tc,PX7670601,CDM,402,RC,76706,CPT,TC,,,,,,,554,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,159.75,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.66,159.75
Fac/Removal of Skin Tags,PX11200F,CDM,510,RC,11200,CPT,,,,,,,,348,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,159.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.65,193.01
Pvb Thoracic Single Injection Site W/Img Gid,PX64461F,CDM,510,RC,64461,CPT,,,,,,,,353,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,159.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.99,278.1
Pvb Thoracic Single Injection Site W/Img Gid,PX64461P,CDM,983,RC,64461,CPT,,,,,,,,616,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,159.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.99,603.68
Removal of Skin Tags,PX11200P,CDM,983,RC,11200,CPT,,,,,,,,418,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,159.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.65,409.64
"Fna Biopsy, W/US Guidance; First Lesion",PX10005F,CDM,510,RC,10005,CPT,,,,,,,,333,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,159.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.3282,614.65
"Fna Biopsy, W/US Guidance; First Lesion",PX10005F,CDM,510,RC,10005,CPT,,,,,,,,333,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,159.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.3282,614.65
Ultrasound Breast Complete,PX7664101,CDM,402,RC,76641,CPT,TC,,,,,,,333,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,159.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,326.34
Ultrasound Breast Complete,PX7664101,CDM,402,RC,76641,CPT,TC,,,,,,,333,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,159.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,326.34
Xray Ls Spine Bend Tc,PX7212001,CDM,320,RC,72120,CPT,TC,,,,,,,323,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,159.885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,316.54
Cast/Strap Procedure Unlisted,PX29799F,CDM,510,RC,29799,CPT,,,,,,,,316,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,159.896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,131.2664,309.68
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004F,CDM,510,RC,15004,CPT,,,,,,,,855,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,159.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.68,813.56
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004F,CDM,510,RC,15004,CPT,,,,,,,,855,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,159.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.68,813.56
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004P,CDM,983,RC,15004,CPT,,,,,,,,570,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,159.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.68,813.56
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004P,CDM,983,RC,15004,CPT,,,,,,,,570,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,159.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.68,813.56
Apply Long Arm Splint,PX29105P,CDM,983,RC,29105,CPT,,,,,,,,385,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,159.929,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.65,374.7205
Apply Long Leg Splint,PX29505P,CDM,983,RC,29505,CPT,,,,,,,,385,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,159.929,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.65,374.7205
Injection for Nerve Block,PX64445F,CDM,510,RC,64445,CPT,,,,,,,,385,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,159.929,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,604.15
Injection for Nerve Block,PX64445P,CDM,983,RC,64445,CPT,,,,,,,,385,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,159.929,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,604.15
MICA DEPTH GAUGE 150MM STERILE MICA,27200000,CDM,272,RC,,,,12439-MAIN,LOCAL,,,,,385,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,159.929,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"N Block Inj, Plantar Digit",PX64455F,CDM,510,RC,64455,CPT,,,,,,,,385,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,159.929,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,377.3
"N Block Inj, Plantar Digit",PX64455P,CDM,983,RC,64455,CPT,,,,,,,,385,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,159.929,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,374.7205
Xray Temporomandib Jnt Unilat,PX7032801,CDM,320,RC,70328,CPT,TC,,,,,,,385,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,159.929,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,377.3
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010365,NDC,100,ML,164.54,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,160.146782,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.174958,180.2416
C-Peptide - Ref,PX8468190,CDM,300,RC,84681,CPT,90,,,,,,,180,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,160.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,176.4
"Closed Rx Radial Head Disloc,Child",PX24640P,CDM,983,RC,24640,CPT,,,,,,,,180,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,160.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.772,206.02
"Infect Ea Organ, Amp Prob - Ref",PX8779890,CDM,300,RC,87798,CPT,90,,,,,,,180,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,160.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,176.4
Mrsa by Amplification Na,PX87641,CDM,300,RC,87641,CPT,,,,,,,,180,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,160.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,176.4
Protein Elp,PX84166,CDM,300,RC,84166,CPT,,,,,,,,180,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,160.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.35,176.4
8MM ENDOWRIST INSTRUMENTS MEGA SUTURE CUT NEEDLE DRIVER,27200000,CDM,272,RC,,,,11914-MAIN,LOCAL,,,,,327,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,160.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM ENDOWRIST INSTRUMENTS MEGA SUTURE CUT NEEDLE DRIVER,27200000,CDM,272,RC,,,,11914-MAIN,LOCAL,,,,,327,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,160.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM ENDOWRIST INSTRUMENTS MEGA SUTURE CUT NEEDLE DRIVER,27200000,CDM,272,RC,,,,11914-MAIN,LOCAL,,,,,327,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,160.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"IV Infusion Therapy, 1 Hour",PX96365,CDM,260,RC,96365,CPT,,,,,,,,327,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,82.30042553,percent of total billed charges,160.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.8358,320.46
"IV Infusion Therapy, 1 Hour",PX96365,CDM,260,RC,96365,CPT,,,,,,,,327,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,160.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.8358,320.46
"IV Infusion Therapy, 1 Hour",PX96365,CDM,260,RC,96365,CPT,,,,,,,,327,,United Healthcare,All Medicare advantage plans,outpatient,49,,170.66,percent of total billed charges,160.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.8358,320.46
cadexomer iodine 0.9 % Gel 40 g Tube,63700001,CDM,250,RC,,,,,,40565012249,NDC,40,GR,333.86,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,160.2528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cadexomer iodine 0.9 % Gel 40 g Tube,63700001,CDM,250,RC,,,,,,40565012249,NDC,40,GR,333.86,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,160.2528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Clotting Function Activity - Ref,PX8539790,CDM,300,RC,85397,CPT,90,,,,,,,334,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,160.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.3,327.32
Clotting Function Activity - Ref,PX8539790,CDM,300,RC,85397,CPT,90,,,,,,,334,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,160.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.3,327.32
"Remv F.B.,Eye,Cornea,No Slit",PX65220F,CDM,510,RC,65220,CPT,,,,,,,,334,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,160.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.7436,348.08
"Remv F.B.,Eye,Cornea,No Slit",PX65220F,CDM,510,RC,65220,CPT,,,,,,,,334,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,160.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.7436,348.08
Repeat Control of Nosebleed,PX30906F,CDM,510,RC,30906,CPT,,,,,,,,334,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,160.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.7436,327.32
Repeat Control of Nosebleed,PX30906F,CDM,510,RC,30906,CPT,,,,,,,,334,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,160.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.7436,327.32
X-Ray Abdomen 2+ Views W/ Single Vw Chest (Tc),PX7402201,CDM,320,RC,74022,CPT,TC,,,,,,,334,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,160.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,327.32
X-Ray Abdomen 2+ Views W/ Single Vw Chest (Tc),PX7402201,CDM,320,RC,74022,CPT,TC,,,,,,,334,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,160.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,327.32
CCP Antibody,PX86200,CDM,300,RC,86200,CPT,,,,,,,,176,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,160.336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,172.48
Detect Agent Nos Dna Amp,PX87798,CDM,300,RC,87798,CPT,,,,,,,,176,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,160.336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,172.48
Eval of Bronchospasm,PX94060,CDM,983,RC,94060,CPT,,,,,,,,176,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,160.336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.1104,274.21
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151F,CDM,370,RC,99151,CPT,,,,,,,,176,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,160.336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.1104,172.48
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032F,CDM,510,RC,12032,CPT,,,,,,,,386,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,160.3444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.3444,378.28
RELOAD SUREFORM 45 2.5MM WHITE,27200000,CDM,272,RC,,,,12791-MAIN,LOCAL,,,,,386,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,160.3444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 45 3.5MM BLUE,27200000,CDM,272,RC,,,,12792-MAIN,LOCAL,,,,,386,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,160.3444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 45 4.3MM GREEN,27200000,CDM,272,RC,,,,12793-MAIN,LOCAL,,,,,386,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,160.3444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE CTD VICRYL 4-0 VIL BR SUTUPK J103T,27200000,CDM,272,RC,,,,4491-MAIN,LOCAL,,,,,373.97,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,160.43313,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Fac/Exc Skin Benig<5mm Remaind Bod,PX11420F,CDM,510,RC,11420,CPT,,,,,,,,374,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,160.446,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,1416.38
"Fac/Office Consultation,Level III",PX99243F,CDM,510,RC,99213,CPT,,,,,,,,374,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,160.446,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,366.52
"Inpatient Consult, Level III",PX99253,CDM,983,RC,99253,CPT,,,,,,,,374,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,160.446,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,364.0142
"Office Consultation,Level III",PX99243P,CDM,983,RC,99243,CPT,,,,,,,,374,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,160.446,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,364.0142
Removal of Hemorrhoid Clot,PX46320P,CDM,983,RC,46320,CPT,,,,,,,,374,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,160.446,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,1030.93
Xray Hand 3vws Tc,PX7313001,CDM,320,RC,73130,CPT,TC,,,,,,,374,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,160.446,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,366.52
Lvl 3 Init Hosp High Mdm or 75 Minutes,PX99223,CDM,982,RC,99223,CPT,,,,,,,,536,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,160.4784,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.68,525.28
CT Abdomen W/Dye,PX7416001,CDM,350,RC,74160,CPT,TC,,,,,,,3413,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,160.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3344.74
CT Abdomen W/O & W/Dye,PX7417001,CDM,350,RC,74170,CPT,TC,,,,,,,3689,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,160.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3615.22
CT Angio Abdom W/O & W/Dye,PX7417501,CDM,350,RC,74175,CPT,TC,,,,,,,4183,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,160.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,4099.34
CT Angio Abdominal Arteries,PX7563501,CDM,350,RC,75635,CPT,TC,,,,,,,2936,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,160.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,2877.28
CT Angio Lwr Extr W/O&W/Dye,PX7370601,CDM,350,RC,73706,CPT,TC,,,,,,,1554,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,160.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1522.92
CT Angio Upr Extrm W/O&W/Dye,PX7320601,CDM,350,RC,73206,CPT,TC,,,,,,,757,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,160.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
CT Angiograph Pelv W/O&W/Dye,PX7219101,CDM,350,RC,72191,CPT,TC,,,,,,,1458,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,160.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
"CT Angiography, Chest",PX7127501,CDM,350,RC,71275,CPT,TC,,,,,,,3689,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,160.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3615.22
"CT Angiography, Head",PX7049601,CDM,350,RC,70496,CPT,TC,,,,,,,3690,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,160.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3616.2
"CT Angiography, Neck",PX7049801,CDM,350,RC,70498,CPT,TC,,,,,,,3690,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,160.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3616.2
CT Chest Spine W/Dye,PX7212901,CDM,350,RC,72129,CPT,TC,,,,,,,2096,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,160.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,2054.08
CT Head/Brain W/Dye,PX7046001,CDM,350,RC,70460,CPT,TC,,,,,,,3398,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,160.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3330.04
CT Head/Brain W/O & W/Dye,PX7047001,CDM,350,RC,70470,CPT,TC,,,,,,,3671,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,160.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3597.58
CT Lower Extremity W/Dye,PX7370101,CDM,350,RC,73701,CPT,TC,,,,,,,2690,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,160.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,2636.2
CT Lumbar Spine W/O & W/Dye,PX7213301,CDM,350,RC,72133,CPT,TC,,,,,,,4283,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,160.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,4197.34
CT Lwr Extremity W/O&W/Dye,PX7370201,CDM,350,RC,73702,CPT,TC,,,,,,,1235,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,160.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
CT Maxillofacial W/Dye,PX7048701,CDM,350,RC,70487,CPT,TC,,,,,,,3332,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,160.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3265.36
CT Orbit/Ear/Fossa W/O & W/Dye,PX7048201,CDM,350,RC,70482,CPT,TC,,,,,,,1400,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,160.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
CT Pelvis W/Dye,PX7219301,CDM,350,RC,72193,CPT,TC,,,,,,,3330,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,160.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3263.4
CT Soft Tissue Neck W/Dye,PX7049101,CDM,350,RC,70491,CPT,TC,,,,,,,3415,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,160.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3346.7
Diagnostic CT Thorax W/ Contrast,PX7126001,CDM,350,RC,71260,CPT,TC,,,,,,,3415,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,160.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3346.7
Debride Skin/Subq Ea Ad 20sqcm,PX11045P,CDM,983,RC,11045,CPT,,,,,,,,182,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,160.524,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.6028,177.1406
Immunocytochemistry,PX3993,CDM,310,RC,88342,CPT,TC,,,,,,,182,,United Healthcare,All Payer,outpatient,88.2,,86.24,percent of total billed charges,160.524,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.6028,178.36
Infec Agent Direct Probe - Ref,PX8779990,CDM,300,RC,87799,CPT,90,,,,,,,182,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,160.524,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.28,178.36
Dihydroxyvitamin D - Ref,PX8265290,CDM,300,RC,82652,CPT,90,,,,,,,165,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,48.94,percent of total billed charges,160.5945,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.3,161.7
Flow Cyto Ea Addtl Marker - Ref,PX8818590,CDM,310,RC,88185,CPT,90,,,,,,,165,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,160.5945,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.541,161.7
Strapping of Shoulder,PX29240F,CDM,420,RC,29240,CPT,,,,,,,,165,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,160.5945,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.541,161.7
HERNIA BELT MENS TRUSS LARGE,120.526,CDM,274,RC,L8310,HCPCS,,12221-MAIN,LOCAL,,,,,60,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,160.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,160.6
HERNIA BELT MENS TRUSS MEDIUM,120.526,CDM,274,RC,L8310,HCPCS,,12220-MAIN,LOCAL,,,,,60,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,160.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,160.6
HERNIA BELT MENS TRUSS XLARGE,120.526,CDM,274,RC,L8310,HCPCS,,12222-MAIN,LOCAL,,,,,60,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,160.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.924,160.6
aztreonam 1 g Recon Soln 1 Each Vial,J0457.01,CDM,636,RC,J0457,HCPCS,,,,63323040124,NDC,1,EA,176.32,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,160.62752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.32,172.7936
Alcohols - Ref,PX8032090,CDM,300,RC,80320,CPT,90,,,,,,,189,,First Health,Commercial,both,85,,999999999,percent of total billed charges,160.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.5106,185.22
"Chemotherapy, IV Infusion, Each Add'l Sequential Infusion",PX96417,CDM,335,RC,96417,CPT,,,,,,,,328,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,65.6,percent of total billed charges,160.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,321.44
"Chemotherapy, IV Infusion, Each Add'l Sequential Infusion",PX96417,CDM,335,RC,96417,CPT,,,,,,,,328,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,160.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,321.44
"Chemotherapy, IV Infusion, Each Add'l Sequential Infusion",PX96417,CDM,335,RC,96417,CPT,,,,,,,,328,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,160.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,321.44
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762P,CDM,983,RC,43762,CPT,,,,,,,,328,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,160.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.2512,319.2424
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762P,CDM,983,RC,43762,CPT,,,,,,,,328,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,160.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.2512,319.2424
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762P,CDM,983,RC,43762,CPT,,,,,,,,328,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,160.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.2512,319.2424
Tx/Pro/Dx Inj Same Drug Adon,PX96376,CDM,260,RC,96376,CPT,,,,,,,,164,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,160.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.1256,160.72
Drain/Inject Med Joint/Brusa W/US Guide,PX20606F,CDM,510,RC,20606,CPT,,,,,,,,387,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,160.7598,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.7598,604.15
"Ex Sknbngn0.6-1cmtrnk,Arm,Lg",PX11401P,CDM,983,RC,11401,CPT,,,,,,,,387,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,160.7598,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.7598,376.6671
"Exc Skn Benig<5mm Face,Facial",PX11440P,CDM,983,RC,11440,CPT,,,,,,,,387,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,160.7598,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.7598,614.65
Facility Emergency Level II Visit,PX99282F,CDM,450,RC,99282,CPT,,,,,,,,387,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,160.7598,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,142.88,379.26
Bcr/Abl1 P210 - Ref,PX8120690,CDM,310,RC,81206,CPT,90,,,,,,,1144,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,160.7709,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,133,160.7709
"Close Rx Dist Fingr Fx,Manipulatn",PX26755F,CDM,510,RC,26755,CPT,,,,,,,,335,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,160.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
"Close Rx Dist Fingr Fx,Manipulatn",PX26755F,CDM,510,RC,26755,CPT,,,,,,,,335,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,160.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
"Closed Rx I-P Jt,Toe Dislocation",PX28660F,CDM,510,RC,28660,CPT,,,,,,,,335,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,160.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
"Closed Rx I-P Jt,Toe Dislocation",PX28660F,CDM,510,RC,28660,CPT,,,,,,,,335,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,160.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Insitu Hybridization (Fish),PX8836401,CDM,310,RC,88364,CPT,TC,,,,,,,335,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,160.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Insitu Hybridization (Fish),PX8836401,CDM,310,RC,88364,CPT,TC,,,,,,,335,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,160.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Reduce Temporomandibl Disloc,PX21480F,CDM,510,RC,21480,CPT,,,,,,,,335,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,160.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Reduce Temporomandibl Disloc,PX21480F,CDM,510,RC,21480,CPT,,,,,,,,335,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,160.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Repr Superf Wnd Face <2.5cm,PX12011F,CDM,510,RC,12011,CPT,,,,,,,,335,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,160.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Repr Superf Wnd Face <2.5cm,PX12011F,CDM,510,RC,12011,CPT,,,,,,,,335,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,160.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127332,NDC,2,ML,176.55,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,160.83705,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.43158,173.019
"Digital Mamm, Diag, Bilat, Tc W/Cad Perf",PX7706601,CDM,401,RC,77066,CPT,TC,,,,,,,375,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,160.875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.05,367.5
"Digital Mammogram, Screen Bil, Tc W/Cad Perf",PX7706701,CDM,403,RC,77067,CPT,TC,,,,,,,375,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,160.875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.86,561
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156F,CDM,370,RC,99156,CPT,,,,,,,,325,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,160.875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,318.5
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156P,CDM,983,RC,99156,CPT,,,,,,,,325,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,160.875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,316.3225
Refill/Maint Portable Pump,PX96521,CDM,260,RC,96521,CPT,,,,,,,,325,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,160.875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,318.5
"Remv F.B.,Eye,Embed Conjunc",PX65210F,CDM,510,RC,65210,CPT,,,,,,,,325,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,160.875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,348.08
Repr Superf Wnd Face 2.6-5,PX12013F,CDM,510,RC,12013,CPT,,,,,,,,375,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,160.875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.775,367.5
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598P,CDM,982,RC,97598,CPT,,,,,,,,325,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,160.875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,316.3225
Somatostatin - Ref,PX8430790,CDM,300,RC,84307,CPT,90,,,,,,,325,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,160.875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.76,318.5
Xray Wrist Minimum 3 Vws,PX7311001,CDM,320,RC,73110,CPT,TC,,,,,,,375,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,160.875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,367.5
8MM ENDOWRIST INSTRUMENTS LARGE NEEDLE DRIVER,27200000,CDM,272,RC,,,,11912-MAIN,LOCAL,,,,,318,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,160.908,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Drain/Inject Medium Joint/Bursa,PX20605P,CDM,983,RC,20605,CPT,,,,,,,,318,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,160.908,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,309.5094
"Office/Outpt Visit,Est,Levl V",PX99215F,CDM,510,RC,99215,CPT,,,,,,,,318,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,160.908,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,311.64
"Office/Outpt Visit,Est,Levl V",PX99215P,CDM,983,RC,99215,CPT,,,,,,,,318,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,160.908,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,309.5094
"Remv F.B.,Eye,Cornea,No Slit",PX65220P,CDM,983,RC,65220,CPT,,,,,,,,318,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,160.908,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,348.08
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032225,NDC,1,EA,176.72,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,160.99192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,173.1856
amiodarone 360-4.14 MG/200ML-% Solution 200 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066036020,NDC,200,ML,325.25,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,160.99875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.35,318.745
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121F,CDM,510,RC,13121,CPT,,,,,,,,948,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,161,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,161,882.74
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121P,CDM,983,RC,13121,CPT,,,,,,,,632,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,161,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,161,882.74
nystatin 100000 UNIT/GM Powder 60 g Bottle,63700001,CDM,250,RC,,,,,,68308015260,NDC,60,GR,335.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,161.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/GM Powder 60 g Bottle,63700001,CDM,250,RC,,,,,,68308015260,NDC,60,GR,335.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,161.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062001,NDC,0.4,ML,189.48,,First Health,Commercial,both,85,,999999999,percent of total billed charges,161.058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062040,NDC,0.4,ML,189.48,,First Health,Commercial,both,85,,999999999,percent of total billed charges,161.058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801401,NDC,0.4,ML,189.48,,First Health,Commercial,both,85,,999999999,percent of total billed charges,161.058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801410,NDC,0.4,ML,189.48,,First Health,Commercial,both,85,,999999999,percent of total billed charges,161.058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082152,NDC,1,ML,375.43,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,161.05947,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.48,367.9214
Alcohol Biomarkers; 1 or 2 - Ref,PX8032190,CDM,300,RC,80321,CPT,90,,,,,,,181,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,161.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.1874,177.38
"Lyme Disease, Antibody - Ref",PX8661890,CDM,300,RC,86618,CPT,90,,,,,,,181,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,161.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.61,177.38
PHALINX STERILE TRIAL SIZER 45A00000,27200000,CDM,272,RC,,,,12959-MAIN,LOCAL,,,,,181,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,161.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
butamben-tetracaine-benzocaine 2-2-14 % Aerosol 5 g Bottle,25000000,CDM,250,RC,,,,,,10223020104,NDC,5,GR,375.52,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,161.09808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Cytoflo, Cell or Dna Anal - Ref",PX8818290,CDM,310,RC,88182,CPT,90,,,,,,,225,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,161.11,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,161.11,270.528
"Cytoflo, Cell or Dna Anal - Ref",PX8818290,CDM,310,RC,88182,CPT,90,,,,,,,225,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,161.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,161.11,270.528
"Cytoflo, Cell or Dna Anal - Ref",PX8818290,CDM,310,RC,88182,CPT,90,,,,,,,225,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,161.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,161.11,270.528
pegfilgrastim-jmdb 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5108.01,CDM,636,RC,Q5108,HCPCS,,,,67457083306,NDC,0.6,ML,10040,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,161.1717,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.54,164.03
hepatitis A vaccine 1440 EL U/ML Suspension 1 mL Syringe,90632,CDM,636,RC,90632,CPT,,,,58160082652,NDC,1,ML,375.78,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,161.20962,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,156.099012,368.2644
Facility Emergency Level 1 Visit,PX99281F,CDM,450,RC,99281,CPT,,,,,,,,329,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,70.255,percent of total billed charges,161.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.56,322.42
Facility Emergency Level 1 Visit,PX99281F,CDM,450,RC,99281,CPT,,,,,,,,329,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,161.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.56,322.42
Facility Emergency Level 1 Visit,PX99281F,CDM,450,RC,99281,CPT,,,,,,,,329,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,161.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.56,322.42
Assay of Ferritin,PX82728,CDM,300,RC,82728,CPT,,,,,,,,177,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,161.247,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.5,173.46
"D-Dimer, Quantitative - Ref",PX8537990,CDM,300,RC,85379,CPT,90,,,,,,,177,,Medica,Commercial,both,91.1,,48.91,percent of total billed charges,161.247,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.33,173.46
Fibrin Degradation Quant,PX85379,CDM,300,RC,85379,CPT,,,,,,,,177,,Medica,Commercial,both,91.1,,48.91,percent of total billed charges,161.247,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.33,173.46
Inj Tendon/Ligament/Cyst,PX20550F,CDM,510,RC,20550,CPT,,,,,,,,177,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,161.247,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.5258,258.75
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010365,NDC,100,ML,164.54,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,161.2492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.174958,180.2416
Assay of Phenytoin Total,PX80185,CDM,300,RC,80185,CPT,,,,,,,,336,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,161.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,329.28
Assay of Phenytoin Total,PX80185,CDM,300,RC,80185,CPT,,,,,,,,336,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,161.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,329.28
fat emulsion 20 % Emulsion 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,338051958,NDC,200,ML,375.95,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,161.28255,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Voriconazole - Ref,PX8028590,CDM,300,RC,80285,CPT,90,,,,,,,183,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,161.406,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.86,179.34
Fresh Frozen Plasma,PXP9017,CDM,390,RC,P9017,HCPCS,,,,,,,,319,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,161.414,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.32,312.62
Assay of ammonia,PX82140,CDM,300,RC,82140,CPT,,,,,,,,190,,First Health,Commercial,both,85,,999999999,percent of total billed charges,161.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.36,186.2
Assay of protein urine,PX84156,CDM,300,RC,84156,CPT,,,,,,,,190,,First Health,Commercial,both,85,,999999999,percent of total billed charges,161.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.37,186.2
Each Add'l Sequential IV Infusion <1 Hour,PX96367,CDM,260,RC,96367,CPT,,,,,,,,190,,First Health,Commercial,both,85,,999999999,percent of total billed charges,161.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,186.2
"N Block Inj, Common Digit",PX64632F,CDM,510,RC,64632,CPT,,,,,,,,190,,First Health,Commercial,both,85,,999999999,percent of total billed charges,161.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.926,258.75
"Tumor Antigen, Ca-125",PX86304,CDM,300,RC,86304,CPT,,,,,,,,190,,First Health,Commercial,both,85,,999999999,percent of total billed charges,161.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,186.2
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,55150017301,NDC,0.5,ML,319.2,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,161.5152,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
"Breast Tomosynthesis,Dx Tc Bilat",PX7706201,CDM,401,RC,77062,CPT,TC,,,,,,,166,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,161.5678,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.9564,162.68
"Breast Tomosynthesis,Dx Tc Unilat",PX7706101,CDM,401,RC,77061,CPT,TC,,,,,,,166,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,161.5678,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.9564,162.68
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,990771502,NDC,250,ML,166.02,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,11.07921788,percent of total billed charges,161.587266,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.4701,303.0944
ANCHORAGE FIXATION PIN,27200000,CDM,272,RC,,,,12642-MAIN,LOCAL,,,,,389,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,161.5906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Ext Ecg > 48hr to 21 Day Rcrd W/Conect Intl Rcrd,PX0296T,CDM,731,RC,0296T,HCPCS,,,,,,,,389,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,161.5906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,161.5906,381.22
hydrocortisone sodium succinate (preservative free) 250 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001305,NDC,1,EA,183.32,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,161.68824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725P,CDM,983,RC,26725,CPT,,,,,,,,330,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,161.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.082,321.189
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725P,CDM,983,RC,26725,CPT,,,,,,,,330,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,161.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.082,321.189
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725P,CDM,983,RC,26725,CPT,,,,,,,,330,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,161.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.082,321.189
Dihydroxyvitamin D - Ref,PX8265290,CDM,300,RC,82652,CPT,90,,,,,,,165,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,161.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.3,161.7
Flow Cyto Ea Addtl Marker - Ref,PX8818590,CDM,310,RC,88185,CPT,90,,,,,,,165,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,161.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.541,161.7
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101P,CDM,983,RC,13101,CPT,,,,,,,,330,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,161.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.082,548.67
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101P,CDM,983,RC,13101,CPT,,,,,,,,330,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,161.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.082,548.67
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101P,CDM,983,RC,13101,CPT,,,,,,,,330,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,161.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.082,548.67
Strapping of Shoulder,PX29240F,CDM,420,RC,29240,CPT,,,,,,,,165,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,161.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.541,161.7
folic acid 5 MG/ML Solution 10 mL Vial,J3490.94,CDM,636,RC,J3490,HCPCS,,,,63323018410,NDC,10,ML,336.94,,Health Partners,Health Partners Care Plans,both,48,,31.91277778,percent of total billed charges,161.7312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,330.2012
folic acid 5 MG/ML Solution 10 mL Vial,J3490.94,CDM,636,RC,J3490,HCPCS,,,,63323018410,NDC,10,ML,336.94,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,161.7312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,330.2012
Repr Superf Wnd Body 12.6-20,PX12005P,CDM,983,RC,12005,CPT,,,,,,,,377,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,161.733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,156.6058,366.9341
"Initial Observation Care,Levl III",PX99220,CDM,982,RC,99220,CPT,,,,,,,,461,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,161.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,161.76,451.78
"Initial Observation Care,Levl III",PX99220,CDM,982,RC,99220,CPT,,,,,,,,461,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,161.7648,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,161.76,451.78
"Amputation Toe,Mt-P Jt",PX28820F,CDM,510,RC,28820,CPT,,,,,,,,1950,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,161.8344,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.51,615.01
"Amputation Toe,Mt-P Jt",PX28820P,CDM,983,RC,28820,CPT,,,,,,,,1300,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,161.8344,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.51,1274
8MM ENDOWRIST INSTRUMENTS MEGA SUTURE CUT NEEDLE DRIVER,27200000,CDM,272,RC,,,,11914-MAIN,LOCAL,,,,,327,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,161.865,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"IV Infusion Therapy, 1 Hour",PX96365,CDM,260,RC,96365,CPT,,,,,,,,327,,Humana Choice Care,All Medicare plans,outpatient,49.5,,167.1839535,percent of total billed charges,161.865,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.8358,320.46
Apply Long Leg Splint,PX29505F,CDM,510,RC,29505,CPT,,,,,,,,320,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,161.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.928,313.6
"IV Infusion, Bamlanivimab, Infusion and Post Admin Monig",PXM0239,CDM,260,RC,M0239,HCPCS,,,,,,,,320,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,161.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.928,313.6
buprenorphine 5 MCG/HR PATCH WEEKLY 4 Each Box,63700001,CDM,250,RC,,,,,,42858075040,NDC,1,EA,330.52,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,161.9548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buprenorphine 5 MCG/HR PATCH WEEKLY 4 Each Box,63700001,CDM,250,RC,,,,,,42858075040,NDC,1,EA,330.52,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,161.9548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buprenorphine 5 MCG/HR PATCH WEEKLY 4 Each Box,63700001,CDM,250,RC,,,,,,42858075040,NDC,1,EA,330.52,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,161.9548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Debride Skin/Subq Ea Ad 20sqcm,PX11045P,CDM,983,RC,11045,CPT,,,,,,,,182,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,161.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.6028,177.1406
Immunocytochemistry,PX3993,CDM,310,RC,88342,CPT,TC,,,,,,,182,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,161.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.6028,178.36
Infec Agent Direct Probe - Ref,PX8779990,CDM,300,RC,87799,CPT,90,,,,,,,182,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,161.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.28,178.36
Apc Resistance Assay - Ref,PX8530790,CDM,300,RC,85307,CPT,90,,,,,,,390,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,162.006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.05,382.2
"Closed Rx Toe Fx,Manipulatn",PX28515F,CDM,510,RC,28515,CPT,,,,,,,,390,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,162.006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,162.006,382.2
procainamide 500 MG/ML Solution 2 mL Vial,J2690.01,CDM,636,RC,J2690,HCPCS,,,,14789090002,NDC,2,ML,377.75,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,162.05475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,134.15,370.195
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121F,CDM,510,RC,13121,CPT,,,,,,,,948,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,162.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,161,882.74
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121F,CDM,510,RC,13121,CPT,,,,,,,,948,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,162.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,161,882.74
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121P,CDM,983,RC,13121,CPT,,,,,,,,632,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,162.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,161,882.74
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121P,CDM,983,RC,13121,CPT,,,,,,,,632,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,162.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,161,882.74
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,703574811,NDC,100,ML,183.92,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,162.21744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.174958,180.2416
Cardiac Rehab II W/ Monitor,PX93798.02,CDM,943,RC,93798,CPT,,,,,,,,338,,Health Partners,Health Partners Care Plans,both,48,,319.5072222,percent of total billed charges,162.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.44,495.55
Cardiac Rehab II W/ Monitor,PX93798.02,CDM,943,RC,93798,CPT,,,,,,,,338,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,162.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.44,495.55
Initial Rx Burn(S) 1st Degree,PX16000F,CDM,510,RC,16000,CPT,,,,,,,,338,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,162.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.4052,331.24
Initial Rx Burn(S) 1st Degree,PX16000F,CDM,510,RC,16000,CPT,,,,,,,,338,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,162.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.4052,331.24
TUBE TRACH SIZE 3.0MM ID 4.5MM OD SHILEY PEDIATRIC 3.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1185-MAIN,LOCAL,,,,,184,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,162.288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 3.5MM ID 5.2MM OD SHILEY PEDIATRIC,120.287,CDM,272,RC,A7520,HCPCS,,8813-MAIN,LOCAL,,,,,184,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,162.288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 4.0MM ID 5.9MM OD SHILEY PEDIATRIC 4.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1187-MAIN,LOCAL,,,,,184,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,162.288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 5 7.0MM ID 10.1MM OD SHILEY CUFFED 5CN70H,120.287,CDM,272,RC,A7521,HCPCS,,10350-MAIN,LOCAL,,,,,184,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,162.288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 5.0MM ID 7.1MM OD SHILEY PEDIATRIC 5.0PED,120.287,CDM,272,RC,A7520,HCPCS,,8814-MAIN,LOCAL,,,,,184,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,162.288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 6 6.0MM ID 8.3MM OD SHILEY CUFFED 6SCT,120.287,CDM,272,RC,A7521,HCPCS,,8812-MAIN,LOCAL,,,,,184,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,162.288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 6 6.4MM ID 10.8MM OD SHILEY CUFFED 6DCT,120.287,CDM,272,RC,A7521,HCPCS,,1190-MAIN,LOCAL,,,,,184,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,162.288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 7.5MM ID 10.8MM OD SHILEY CUFFED 6CN75H,120.287,CDM,272,RC,A7521,HCPCS,,8488-MAIN,LOCAL,,,,,184,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,162.288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 8 7.6MM ID 12.2MM OD SHILEY 8DCT,120.287,CDM,272,RC,A7521,HCPCS,,1192-MAIN,LOCAL,,,,,184,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,162.288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 8 7.6MM ID 12.22MM OD SHILEY CUFFED 8LPC,120.287,CDM,272,RC,A7521,HCPCS,,8815-MAIN,LOCAL,,,,,184,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,162.288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 8.0MM ID 10.9MM OD SHILEY CUFFED 8SCT,120.287,CDM,272,RC,A7521,HCPCS,,8811-MAIN,LOCAL,,,,,184,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,162.288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 10 SHILEY 10LPC,120.287,CDM,272,RC,A7521,HCPCS,,1181-MAIN,LOCAL,,,,,184,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,162.288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323012594,NDC,1,EA,190.99,,First Health,Commercial,both,85,,999999999,percent of total billed charges,162.3415,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
Assay of Amylase,PX82150,CDM,300,RC,82150,CPT,,,,,,,,191,,First Health,Commercial,both,85,,999999999,percent of total billed charges,162.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.94,187.18
C-Reactive Protein,PX86140,CDM,300,RC,86140,CPT,,,,,,,,191,,First Health,Commercial,both,85,,999999999,percent of total billed charges,162.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,187.18
"Chemotherapy, IV Infusion, Add'l Hour",PX96415,CDM,335,RC,96415,CPT,,,,,,,,191,,First Health,Commercial,both,85,,999999999,percent of total billed charges,162.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,187.18
Fac/Ther Injection Carpal Tunnel,PX20526F,CDM,510,RC,20526,CPT,,,,,,,,191,,First Health,Commercial,both,85,,999999999,percent of total billed charges,162.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.3414,258.75
Urine Pregnancy Test,PX81025,CDM,300,RC,81025,CPT,,,,,,,,191,,First Health,Commercial,both,85,,999999999,percent of total billed charges,162.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.89,187.18
"Chemotherapy, IV Infusion, Each Add'l Sequential Infusion",PX96417,CDM,335,RC,96417,CPT,,,,,,,,328,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,162.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,321.44
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762P,CDM,983,RC,43762,CPT,,,,,,,,328,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,162.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.2512,319.2424
"Initial Observation Care,Levl II",PX99219,CDM,982,RC,99219,CPT,,,,,,,,391,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,162.4214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,162.4214,380.5603
Fungus Isolation Culture,PX87102,CDM,300,RC,87102,CPT,,,,,,,,167,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,162.5411,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.71,163.66
Microalbumin Quantitative,PX82043,CDM,300,RC,82043,CPT,,,,,,,,167,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,162.5411,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.3,163.66
Wound Cult/Afb,PX87116,CDM,300,RC,87116,CPT,,,,,,,,167,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,162.5411,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9,163.66
dexAMETHasone 0.1 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,24208072002,NDC,5,ML,331.81,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,162.5869,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dexAMETHasone 0.1 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,24208072002,NDC,5,ML,331.81,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,162.5869,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dexAMETHasone 0.1 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,24208072002,NDC,5,ML,331.81,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,162.5869,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Tech-Cytopath Eval, Fna, Rep",PX8817301,CDM,310,RC,88173,CPT,TC,,,,,,,379,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,162.591,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,371.42
"Breast Tomosynthesis,Dx Tc Bilat",PX7706201,CDM,401,RC,77062,CPT,TC,,,,,,,166,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,162.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.9564,162.68
"Breast Tomosynthesis,Dx Tc Unilat",PX7706101,CDM,401,RC,77061,CPT,TC,,,,,,,166,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,162.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.9564,162.68
"Breast Tomosynthesis,Screen Tc",PX7706301,CDM,403,RC,77063,CPT,TC,,,,,,,166,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,162.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.59,280.5
Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq,PX87635,CDM,300,RC,87635,CPT,,,,,,,,166,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,162.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,224.4
PHENobarbital 130 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047721,NDC,1,ML,338.93,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,162.6864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.354486,332.1514
PHENobarbital 130 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047721,NDC,1,ML,338.93,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,162.6864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.354486,332.1514
"Cytoflo, Cell or Dna Anal - Ref",PX8818290,CDM,310,RC,88182,CPT,90,,,,,,,225,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,162.6963,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,161.11,270.528
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,990771502,NDC,250,ML,166.02,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,162.6996,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.4701,303.0944
tobramycin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314064305,NDC,5,ML,191.42,,First Health,Commercial,both,85,,999999999,percent of total billed charges,162.707,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Tech-Cytopath Eval, Fna, Rep",PX8817301,CDM,310,RC,88173,CPT,TC,,,,,,,379,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,162.848,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.98,162.848
"Tech-Cytopath Eval, Fna, Rep",PX8817301,CDM,310,RC,88173,CPT,TC,,,,,,,379,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,162.848,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.98,162.848
Facility Emergency Level 1 Visit,PX99281F,CDM,450,RC,99281,CPT,,,,,,,,329,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,162.855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.56,322.42
Voriconazole - Ref,PX8028590,CDM,300,RC,80285,CPT,90,,,,,,,183,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,162.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.86,179.34
linezolid 600 MG/300ML Solution 300 mL Flex Cont,J2020.01,CDM,636,RC,J2020,HCPCS,,,,9514001,NDC,300,ML,332.42,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,162.8858,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.087268,325.7716
linezolid 600 MG/300ML Solution 300 mL Flex Cont,J2020.01,CDM,636,RC,J2020,HCPCS,,,,9514001,NDC,300,ML,332.42,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,162.8858,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.087268,325.7716
linezolid 600 MG/300ML Solution 300 mL Flex Cont,J2020.01,CDM,636,RC,J2020,HCPCS,,,,9514001,NDC,300,ML,332.42,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,162.8858,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.087268,325.7716
"MRI, Pelvis, W/O Then W/",PX7219701,CDM,610,RC,72197,CPT,TC,,,,,,,1612,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,162.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,162.96,480.56
"MRI, Pelvis, W/O Then W/",PX7219701,CDM,610,RC,72197,CPT,TC,,,,,,,1612,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,162.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,162.96,480.56
Closed Rx Elbow Dislocation,PX24600P,CDM,983,RC,24600,CPT,,,,,,,,380,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,163.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,157.852,369.854
"Apply Short Leg Cast,Walker",PX29425F,CDM,510,RC,29425,CPT,,,,,,,,179,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,163.069,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.3566,234.62
C Diff Amplified Probe,PX87493,CDM,300,RC,87493,CPT,,,,,,,,179,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,163.069,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.17,175.42
Fibrinogen Test - Ref,PX8536690,CDM,300,RC,85366,CPT,90,,,,,,,179,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,163.069,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.77,175.42
TUBE GASTROSTOMY 18FR REPLACEMENT DYND70318,120.256,CDM,271,RC,B4087,HCPCS,,407-MAIN,LOCAL,,,,,179,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,163.069,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.53,175.42
ketoconazole 2 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,16714095501,NDC,15,GR,322.42,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,163.14452,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Mra, Head W/Out Contrast",PX7054401,CDM,610,RC,70544,CPT,TC,,,,,,,3541,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,163.1526,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.6,326.73
hydrocortisone sodium succinate (preservative free) 250 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001305,NDC,1,EA,183.32,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,163.1548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
Amylase - Ref,PX8215090,CDM,300,RC,82150,CPT,90,,,,,,,185,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,163.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.94,181.3
"Fna Biopsy, W/US Guidance; First Lesion",PX10005F,CDM,510,RC,10005,CPT,,,,,,,,333,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,163.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.3282,614.65
"Fna Biopsy, W/US Guidance; First Lesion",PX10005F,CDM,510,RC,10005,CPT,,,,,,,,333,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,163.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.3282,614.65
"Fna Biopsy, W/US Guidance; First Lesion",PX10005F,CDM,510,RC,10005,CPT,,,,,,,,333,,United Healthcare,All Medicare advantage plans,outpatient,49,,51.49,percent of total billed charges,163.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.3282,614.65
Hepatitis C Rna Quant,PX87522,CDM,300,RC,87522,CPT,,,,,,,,185,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,163.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.28,181.3
"Level IV - Surgical Pathology, Gross and Microscopic Examination , Tech",PX3934,CDM,310,RC,88305,CPT,TC,,,,,,,185,,United Healthcare,All Payer,outpatient,88.2,,97.26435897,percent of total billed charges,163.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,271.15
"Office/Outpt Visit,Est,Levl III",PX99213F,CDM,510,RC,99213,CPT,,,,,,,,185,,United Healthcare,All Payer,outpatient,88.2,,107.598,percent of total billed charges,163.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.849,181.3
"Office/Outpt Visit,Est,Levl III",PX99213P,CDM,983,RC,99213,CPT,,,,,,,,185,,United Healthcare,All Payer,outpatient,88.2,,107.598,percent of total billed charges,163.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.849,180.0605
Ultrasound Breast Complete,PX7664101,CDM,402,RC,76641,CPT,TC,,,,,,,333,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,163.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,326.34
Ultrasound Breast Complete,PX7664101,CDM,402,RC,76641,CPT,TC,,,,,,,333,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,163.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,326.34
Ultrasound Breast Complete,PX7664101,CDM,402,RC,76641,CPT,TC,,,,,,,333,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,163.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,326.34
"Chest Wall Manipulation,Subsequent",PX94668F,CDM,410,RC,94668,CPT,,,,,,,,192,,First Health,Commercial,both,85,,999999999,percent of total billed charges,163.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.7568,188.16
Hepatitis Be Antibody - Ref,PX8670790,CDM,300,RC,86707,CPT,90,,,,,,,192,,First Health,Commercial,both,85,,999999999,percent of total billed charges,163.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.61,188.16
Infectious Agent Antigen Detection by Immunoassay With Direct Visual Observation.,PX87811,CDM,300,RC,87811,CPT,,,,,,,,192,,First Health,Commercial,both,85,,999999999,percent of total billed charges,163.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.94,188.16
Sars-Cov-2 Covid-19 Antibody,PX86769,CDM,300,RC,86769,CPT,,,,,,,,340,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,163.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.63,333.2
Sars-Cov-2 Covid-19 Antibody,PX86769,CDM,300,RC,86769,CPT,,,,,,,,340,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,163.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.63,333.2
X-Ray Exam Chest 3 Views,PX7104701,CDM,320,RC,71047,CPT,TC,,,,,,,340,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,163.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,333.2
X-Ray Exam Chest 3 Views,PX7104701,CDM,320,RC,71047,CPT,TC,,,,,,,340,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,163.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,333.2
"Fac/Office Consultation,Level III",PX99243F,CDM,510,RC,99213,CPT,,,,,,,,374,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,163.25,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.25,163.25
"Office/Outpt Visit,Est,Levl III",PX99213F,CDM,510,RC,99213,CPT,,,,,,,,185,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,163.25,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.25,163.25
"Office/Outpt Visit,Est,Levl III",PX99213P,CDM,983,RC,99213,CPT,,,,,,,,185,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,163.25,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.25,181.3
6 SHOOTER SAEED MULTIBAND LIGATOR,27200000,CDM,272,RC,,,,12379-MAIN,LOCAL,,,,,393,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,163.2522,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA FIRST MET TRANSLATOR STERILE MICA,27200000,CDM,272,RC,,,,12445-MAIN,LOCAL,,,,,393,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,163.2522,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Tap Block Bilateral by Injection(S),PX64488F,CDM,510,RC,64488,CPT,,,,,,,,393,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,163.2522,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,163.2522,385.14
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,39328006712,NDC,473,ML,167.77,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,163.290541,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725P,CDM,983,RC,26725,CPT,,,,,,,,330,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,163.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.082,321.189
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101P,CDM,983,RC,13101,CPT,,,,,,,,330,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,163.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.082,548.67
Xray Ls Spine Bend Tc,PX7212001,CDM,320,RC,72120,CPT,TC,,,,,,,323,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,163.438,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,316.54
"Complex Drainage, Wound",PX10180F,CDM,510,RC,10180,CPT,,,,,,,,1050,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,163.4399,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.95,547.91
"Complex Drainage, Wound",PX10180P,CDM,983,RC,10180,CPT,,,,,,,,767,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,163.4399,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.95,751.66
"Xray Mandible Compl, Min 4 Vws",PX7011001,CDM,320,RC,70110,CPT,TC,,,,,,,381,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,163.449,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,373.38
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031801,NDC,1,ML,185.37,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,163.49634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.002698,181.6626
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031825,NDC,1,ML,185.37,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,163.49634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.002698,181.6626
nafcillin 2 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,S0032,HCPCS,,,,63323032820,NDC,1,EA,185.37,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,163.49634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Aerobic Isolate - Ref,PX8707790,CDM,300,RC,87077,CPT,90,,,,,,,168,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,47.03190476,percent of total billed charges,163.5144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,164.64
Insert Straight Catheter,PX51701F,CDM,510,RC,51701,CPT,,,,,,,,168,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,163.5144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.7872,164.64
Org ID Aerobic-Each,PX87077,CDM,300,RC,87077,CPT,,,,,,,,168,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,47.03190476,percent of total billed charges,163.5144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,164.64
fentaNYL 50 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,47781042611,NDC,1,EA,185.47,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,163.58454,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 50 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,47781042647,NDC,1,EA,185.47,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,163.58454,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cadexomer iodine 0.9 % Gel 40 g Tube,63700001,CDM,250,RC,,,,,,40565012249,NDC,40,GR,333.86,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,163.5914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cadexomer iodine 0.9 % Gel 40 g Tube,63700001,CDM,250,RC,,,,,,40565012249,NDC,40,GR,333.86,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,163.5914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cadexomer iodine 0.9 % Gel 40 g Tube,63700001,CDM,250,RC,,,,,,40565012249,NDC,40,GR,333.86,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,163.5914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buprenorphine 5 MCG/HR PATCH WEEKLY 4 Each Box,63700001,CDM,250,RC,,,,,,42858075040,NDC,1,EA,330.52,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,163.6074,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"measles, mumps & rubella vaccine Recon Soln 1 Each Vial",90707,CDM,636,RC,90707,CPT,,,,6468100,NDC,1,EA,381.47,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,163.65063,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,158.462638,373.8406
Clotting Function Activity - Ref,PX8539790,CDM,300,RC,85397,CPT,90,,,,,,,334,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,163.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.3,327.32
Clotting Function Activity - Ref,PX8539790,CDM,300,RC,85397,CPT,90,,,,,,,334,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,163.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.3,327.32
Clotting Function Activity - Ref,PX8539790,CDM,300,RC,85397,CPT,90,,,,,,,334,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,163.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.3,327.32
Fungus Isolation Culture,PX87102,CDM,300,RC,87102,CPT,,,,,,,,167,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,163.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.71,163.66
Microalbumin Quantitative,PX82043,CDM,300,RC,82043,CPT,,,,,,,,167,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,163.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.3,163.66
"Remv F.B.,Eye,Cornea,No Slit",PX65220F,CDM,510,RC,65220,CPT,,,,,,,,334,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,163.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.7436,348.08
"Remv F.B.,Eye,Cornea,No Slit",PX65220F,CDM,510,RC,65220,CPT,,,,,,,,334,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,163.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.7436,348.08
"Remv F.B.,Eye,Cornea,No Slit",PX65220F,CDM,510,RC,65220,CPT,,,,,,,,334,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,163.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.7436,348.08
Repeat Control of Nosebleed,PX30906F,CDM,510,RC,30906,CPT,,,,,,,,334,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,163.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.7436,327.32
Repeat Control of Nosebleed,PX30906F,CDM,510,RC,30906,CPT,,,,,,,,334,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,163.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.7436,327.32
Repeat Control of Nosebleed,PX30906F,CDM,510,RC,30906,CPT,,,,,,,,334,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,163.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.7436,327.32
Wound Cult/Afb,PX87116,CDM,300,RC,87116,CPT,,,,,,,,167,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,163.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.9,163.66
X-Ray Abdomen 2+ Views W/ Single Vw Chest (Tc),PX7402201,CDM,320,RC,74022,CPT,TC,,,,,,,334,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,163.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,327.32
X-Ray Abdomen 2+ Views W/ Single Vw Chest (Tc),PX7402201,CDM,320,RC,74022,CPT,TC,,,,,,,334,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,163.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,327.32
X-Ray Abdomen 2+ Views W/ Single Vw Chest (Tc),PX7402201,CDM,320,RC,74022,CPT,TC,,,,,,,334,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,163.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,327.32
clotrimazole-betamethasone 1-0.05 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,66993089815,NDC,15,GR,192.55,,First Health,Commercial,both,85,,999999999,percent of total billed charges,163.6675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Drainage of Hematoma/Fluid (T),PX10140F,CDM,510,RC,10140,CPT,,,,,,,,341,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,163.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,141.6514,1416.38
Drainage of Hematoma/Fluid (T),PX10140F,CDM,510,RC,10140,CPT,,,,,,,,341,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,163.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,141.6514,1416.38
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,703574811,NDC,100,ML,183.92,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,163.6888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.174958,180.2416
verapamil 2.5 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,409114405,NDC,2,ML,185.65,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,163.7433,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
COLLAR CERVICAL LARGE WITH TRACH 2 PIECE PHP-T4L,120.184,CDM,274,RC,L0172,HCPCS,,10142-MAIN,LOCAL,,,,,37,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,163.7453,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,158.31,166.64
COLLAR CERVICAL MEDIUM WITH TRACH 2 PIECE PHP-T4M,120.183,CDM,274,RC,L0172,HCPCS,,10141-MAIN,LOCAL,,,,,37,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,163.7453,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,158.31,166.64
COLLAR CERVICAL SMALL WITH TRACH 2 PIECE PHP-T4S,120.182,CDM,274,RC,L0172,HCPCS,,10140-MAIN,LOCAL,,,,,37,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,163.7453,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,158.31,166.64
COLLAR CERVICAL X-LARGE WITH TRACH 2 PIECE OSG2404,120.185,CDM,274,RC,L0172,HCPCS,,10143-MAIN,LOCAL,,,,,49,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,163.7453,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,158.31,166.64
TUBE TRACH SIZE 3.0MM ID 4.5MM OD SHILEY PEDIATRIC 3.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1185-MAIN,LOCAL,,,,,184,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,163.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 3.5MM ID 5.2MM OD SHILEY PEDIATRIC,120.287,CDM,272,RC,A7520,HCPCS,,8813-MAIN,LOCAL,,,,,184,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,163.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 4.0MM ID 5.9MM OD SHILEY PEDIATRIC 4.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1187-MAIN,LOCAL,,,,,184,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,163.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 5 7.0MM ID 10.1MM OD SHILEY CUFFED 5CN70H,120.287,CDM,272,RC,A7521,HCPCS,,10350-MAIN,LOCAL,,,,,184,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,163.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 5.0MM ID 7.1MM OD SHILEY PEDIATRIC 5.0PED,120.287,CDM,272,RC,A7520,HCPCS,,8814-MAIN,LOCAL,,,,,184,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,163.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 6 6.0MM ID 8.3MM OD SHILEY CUFFED 6SCT,120.287,CDM,272,RC,A7521,HCPCS,,8812-MAIN,LOCAL,,,,,184,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,163.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 6 6.4MM ID 10.8MM OD SHILEY CUFFED 6DCT,120.287,CDM,272,RC,A7521,HCPCS,,1190-MAIN,LOCAL,,,,,184,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,163.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 7.5MM ID 10.8MM OD SHILEY CUFFED 6CN75H,120.287,CDM,272,RC,A7521,HCPCS,,8488-MAIN,LOCAL,,,,,184,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,163.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 8 7.6MM ID 12.2MM OD SHILEY 8DCT,120.287,CDM,272,RC,A7521,HCPCS,,1192-MAIN,LOCAL,,,,,184,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,163.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 8 7.6MM ID 12.22MM OD SHILEY CUFFED 8LPC,120.287,CDM,272,RC,A7521,HCPCS,,8815-MAIN,LOCAL,,,,,184,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,163.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 8.0MM ID 10.9MM OD SHILEY CUFFED 8SCT,120.287,CDM,272,RC,A7521,HCPCS,,8811-MAIN,LOCAL,,,,,184,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,163.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 10 SHILEY 10LPC,120.287,CDM,272,RC,A7521,HCPCS,,1181-MAIN,LOCAL,,,,,184,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,163.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
"MRI, Abdomen W/O+ W/Contr",PX7418301,CDM,610,RC,74183,CPT,TC,,,,,,,4116,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,163.83,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,163.83,483.19
"MRI, Abdomen W/O+ W/Contr",PX7418301,CDM,610,RC,74183,CPT,TC,,,,,,,4116,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,163.83,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,163.83,483.19
dantrolene 20 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,42023012306,NDC,1,EA,394.42,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,163.842068,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"X-Ray Exam Hip,Bilat W/Pelvis 3-4 Vws",PX7352201,CDM,320,RC,73522,CPT,TC,,,,,,,382,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,163.878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,374.36
C-Peptide - Ref,PX8468190,CDM,300,RC,84681,CPT,90,,,,,,,180,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,163.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,176.4
"Closed Rx Radial Head Disloc,Child",PX24640P,CDM,983,RC,24640,CPT,,,,,,,,180,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,163.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.772,206.02
"Infect Ea Organ, Amp Prob - Ref",PX8779890,CDM,300,RC,87798,CPT,90,,,,,,,180,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,163.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,176.4
Mrsa by Amplification Na,PX87641,CDM,300,RC,87641,CPT,,,,,,,,180,,Medica,Commercial,both,91.1,,81.99,percent of total billed charges,163.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,176.4
Protein Elp,PX84166,CDM,300,RC,84166,CPT,,,,,,,,180,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,163.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.35,176.4
pegfilgrastim-jmdb 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5108.01,CDM,636,RC,Q5108,HCPCS,,,,67457083306,NDC,0.6,ML,10040,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,164.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.54,164.03
pegfilgrastim-jmdb 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5108.01,CDM,636,RC,Q5108,HCPCS,,,,67457083306,NDC,0.6,ML,10040,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,164.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.54,164.03
Echo Tt 2d Complete,PX9330701,CDM,480,RC,93307,CPT,TC,,,,,,,2303,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,164.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.95,164.04
Echo Tt 2d Complete,PX9330701,CDM,480,RC,93307,CPT,TC,,,,,,,2303,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,164.04,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.95,164.04
Ag Detect Nos Eia Mult,PX87449,CDM,300,RC,87449,CPT,,,,,,,,193,,First Health,Commercial,both,85,,999999999,percent of total billed charges,164.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,189.14
nitroPRUSSide 25 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,72485010501,NDC,2,ML,186,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,164.052,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Puncture Drainage of Lesion,PX10160P,CDM,983,RC,10160,CPT,,,,,,,,186,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,164.052,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.2644,348.35
"TB Test, Cell Immunity Measure",PX86480,CDM,300,RC,86480,CPT,,,,,,,,186,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,164.052,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.83,182.28
Drainage of Gum Lesion,PX41800F,CDM,510,RC,41800,CPT,,,,,,,,395,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,164.083,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,387.1
"Close Rx Dist Fingr Fx,Manipulatn",PX26755F,CDM,510,RC,26755,CPT,,,,,,,,335,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,164.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
"Close Rx Dist Fingr Fx,Manipulatn",PX26755F,CDM,510,RC,26755,CPT,,,,,,,,335,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,164.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
"Close Rx Dist Fingr Fx,Manipulatn",PX26755F,CDM,510,RC,26755,CPT,,,,,,,,335,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,164.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
"Closed Rx I-P Jt,Toe Dislocation",PX28660F,CDM,510,RC,28660,CPT,,,,,,,,335,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,164.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
"Closed Rx I-P Jt,Toe Dislocation",PX28660F,CDM,510,RC,28660,CPT,,,,,,,,335,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,164.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
"Closed Rx I-P Jt,Toe Dislocation",PX28660F,CDM,510,RC,28660,CPT,,,,,,,,335,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,164.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Insitu Hybridization (Fish),PX8836401,CDM,310,RC,88364,CPT,TC,,,,,,,335,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,35.87,percent of total billed charges,164.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Insitu Hybridization (Fish),PX8836401,CDM,310,RC,88364,CPT,TC,,,,,,,335,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,164.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Insitu Hybridization (Fish),PX8836401,CDM,310,RC,88364,CPT,TC,,,,,,,335,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,164.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Reduce Temporomandibl Disloc,PX21480F,CDM,510,RC,21480,CPT,,,,,,,,335,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,164.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Reduce Temporomandibl Disloc,PX21480F,CDM,510,RC,21480,CPT,,,,,,,,335,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,164.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Reduce Temporomandibl Disloc,PX21480F,CDM,510,RC,21480,CPT,,,,,,,,335,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,164.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Repr Superf Wnd Face <2.5cm,PX12011F,CDM,510,RC,12011,CPT,,,,,,,,335,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,164.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Repr Superf Wnd Face <2.5cm,PX12011F,CDM,510,RC,12011,CPT,,,,,,,,335,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,164.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Repr Superf Wnd Face <2.5cm,PX12011F,CDM,510,RC,12011,CPT,,,,,,,,335,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,164.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
"Ctrl Nosebleed,Anter,Simple",PX30901F,CDM,510,RC,30901,CPT,,,,,,,,342,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,164.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,335.16
"Ctrl Nosebleed,Anter,Simple",PX30901F,CDM,510,RC,30901,CPT,,,,,,,,342,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,164.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,335.16
Ultrasound Breast Limited,PX7664201,CDM,402,RC,76642,CPT,TC,,,,,,,342,,Health Partners,Health Partners Care Plans,both,48,,298.56,percent of total billed charges,164.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,335.16
Ultrasound Breast Limited,PX7664201,CDM,402,RC,76642,CPT,TC,,,,,,,342,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,164.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,335.16
dexAMETHasone 0.1 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,24208072002,NDC,5,ML,331.81,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,164.24595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040304,NDC,10,ML,168.77,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,164.263841,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040310,NDC,10,ML,168.77,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,164.263841,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
NON-LOCKING SCREW 3.5X18MM,C1713,CDM,278,RC,C1713,HCPCS,,12466-MAIN,LOCAL,,,,,395.51,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,164.294854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
El-1 Fecal Quantitative,PX8265390,CDM,300,RC,82653,CPT,90,,,,,,,383,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,164.307,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.0982,375.34
nystatin 100000 UNIT/GM Powder 60 g Bottle,63700001,CDM,250,RC,,,,,,68308015260,NDC,60,GR,335.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,164.395,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/GM Powder 60 g Bottle,63700001,CDM,250,RC,,,,,,68308015260,NDC,60,GR,335.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,164.395,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/GM Powder 60 g Bottle,63700001,CDM,250,RC,,,,,,68308015260,NDC,60,GR,335.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,164.395,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,39328006712,NDC,473,ML,167.77,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,164.4146,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156F,CDM,370,RC,99156,CPT,,,,,,,,325,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,164.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,318.5
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156P,CDM,983,RC,99156,CPT,,,,,,,,325,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,164.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,316.3225
Refill/Maint Portable Pump,PX96521,CDM,260,RC,96521,CPT,,,,,,,,325,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,164.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,318.5
"Remv F.B.,Eye,Embed Conjunc",PX65210F,CDM,510,RC,65210,CPT,,,,,,,,325,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,164.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,348.08
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598P,CDM,982,RC,97598,CPT,,,,,,,,325,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,164.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,316.3225
Somatostatin - Ref,PX8430790,CDM,300,RC,84307,CPT,90,,,,,,,325,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,164.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.76,318.5
predniSONE 5 mg/5 mL 5 MG/5ML Solution 120 mL Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54372250,NDC,120,ML,186.47,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,164.46654,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
"MRI,Upr Ext, Joint,W/Cont",PX7322201,CDM,610,RC,73222,CPT,TC,,,,,,,3541,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,164.48,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,164.48,485.16
"MRI,Upr Ext, Joint,W/Cont",PX7322201,CDM,610,RC,73222,CPT,TC,,,,,,,3541,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,164.48,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,164.48,485.16
Exc Face Les Sc < 2 Cm,PX21011F,CDM,510,RC,21011,CPT,,,,,,,,943,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,164.48,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,164.48,781.73
Exc Face Les Sc < 2 Cm,PX21011P,CDM,983,RC,21011,CPT,,,,,,,,628,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,164.48,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,164.48,781.73
pentafluoroprop - tetrafluoroeth Aerosol 116 mL Can,63700001,CDM,250,RC,,,,,,386000802,NDC,207,ML,383.42,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,164.48718,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Blood Clot Factor VIII Test,PX85247,CDM,300,RC,85247,CPT,,,,,,,,169,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,164.4877,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.03,165.62
Tap Block Unilateral by Injection(S),PX64486P,CDM,983,RC,64486,CPT,,,,,,,,169,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,164.4877,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.2026,164.4877
Neg Pressure Wound Therapy Dme </=50 Sq Cm,PX97605F,CDM,510,RC,97605,CPT,,,,,,,,396,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,164.4984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,164.4984,388.08
NON-LOCKING SCREW 3.5X12MM,27200000,CDM,278,RC,C1713,HCPCS,,11857-MAIN,LOCAL,,,,,396,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,164.4984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NON-LOCKING SCREW 3.5X16MM,27200000,CDM,278,RC,C1713,HCPCS,,11856-MAIN,LOCAL,,,,,396,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,164.4984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NON-LOCKING SCREW 3.5X24MM,27200000,CDM,278,RC,C1713,HCPCS,,11855-MAIN,LOCAL,,,,,396,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,164.4984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
linezolid 600 MG/300ML Solution 300 mL Flex Cont,J2020.01,CDM,636,RC,J2020,HCPCS,,,,9514001,NDC,300,ML,332.42,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,164.5479,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.087268,325.7716
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070102,NDC,1,ML,383.6,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,164.5644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.92,450.751
amiodarone 360-4.14 MG/200ML-% Solution 200 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066036020,NDC,200,ML,325.25,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,164.5765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.35,318.745
Aerobic Isolate - Ref,PX8707790,CDM,300,RC,87077,CPT,90,,,,,,,168,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,164.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,164.64
Assay of Phenytoin Total,PX80185,CDM,300,RC,80185,CPT,,,,,,,,336,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,164.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,329.28
Assay of Phenytoin Total,PX80185,CDM,300,RC,80185,CPT,,,,,,,,336,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,164.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,329.28
Assay of Phenytoin Total,PX80185,CDM,300,RC,80185,CPT,,,,,,,,336,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,164.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,329.28
Complete Cbc W/Auto Diff Wbc,PX85025,CDM,300,RC,85025,CPT,,,,,,,,168,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,164.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.12,164.64
Infliximab - Ref,PX8023090,CDM,300,RC,80230,CPT,90,,,,,,,343,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,164.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.36,336.14
Infliximab - Ref,PX8023090,CDM,300,RC,80230,CPT,90,,,,,,,343,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,164.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.36,336.14
Insert Straight Catheter,PX51701F,CDM,510,RC,51701,CPT,,,,,,,,168,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,164.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.7872,164.64
Org ID Aerobic-Each,PX87077,CDM,300,RC,87077,CPT,,,,,,,,168,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,164.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.41,164.64
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002F,CDM,510,RC,12002,CPT,,,,,,,,343,,Health Partners,Health Partners Care Plans,both,48,,6.33,percent of total billed charges,164.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,142.4822,336.14
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002F,CDM,510,RC,12002,CPT,,,,,,,,343,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,164.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,142.4822,336.14
Amylase - Ref,PX8215090,CDM,300,RC,82150,CPT,90,,,,,,,185,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,164.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.94,181.3
Fac/Cystourethroscopy,PX52000F,CDM,761,RC,52000,CPT,,,,,,,,1601,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,164.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.86,497.4
Hepatitis C Rna Quant,PX87522,CDM,300,RC,87522,CPT,,,,,,,,185,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,164.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.28,181.3
"Level IV - Surgical Pathology, Gross and Microscopic Examination , Tech",PX3934,CDM,310,RC,88305,CPT,TC,,,,,,,185,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,164.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,271.15
"Office/Outpt Visit,Est,Levl III",PX99213F,CDM,510,RC,99213,CPT,,,,,,,,185,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,164.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.849,181.3
"Office/Outpt Visit,Est,Levl III",PX99213P,CDM,983,RC,99213,CPT,,,,,,,,185,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,164.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.849,180.0605
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,781309894,NDC,1,EA,193.75,,First Health,Commercial,both,85,,999999999,percent of total billed charges,164.6875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.461584,189.875
MRI Lower W/O+W Tc,PX7372001,CDM,610,RC,73720,CPT,TC,,,,,,,3174,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,164.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,164.7,485.82
MRI Lower W/O+W Tc,PX7372001,CDM,610,RC,73720,CPT,TC,,,,,,,3174,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,164.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,164.7,485.82
Insitu Hybridization (Fish),PX8836401,CDM,310,RC,88364,CPT,TC,,,,,,,335,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,164.704,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.09,164.704
Insitu Hybridization (Fish),PX8836401,CDM,310,RC,88364,CPT,TC,,,,,,,335,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,164.704,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.09,164.704
Lvl 3 Sub Hosp High Mdm or 50 Minutes,PX99233,CDM,982,RC,99233,CPT,,,,,,,,384,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,164.736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.5136,373.7472
"MRI,Lwrext,No Jnt,No Cont",PX7371801,CDM,610,RC,73718,CPT,TC,,,,,,,3253,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,164.7616,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.47,328.7
"Fna Biopsy, W/US Guidance; First Lesion",PX10005F,CDM,510,RC,10005,CPT,,,,,,,,333,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,164.835,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.3282,614.65
Ultrasound Breast Complete,PX7664101,CDM,402,RC,76641,CPT,TC,,,,,,,333,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,164.835,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,326.34
Baloxavir Marboxil(40 MG Dose) 2 x 20 MG tablet therapy pack 2 Each Box,800000,CDM,,,,,,,,50242082802,NDC,1,EA,384.3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,164.8647,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Alcohol Biomarkers; 1 or 2 - Ref,PX8032190,CDM,300,RC,80321,CPT,90,,,,,,,181,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,164.891,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.1874,177.38
"Lyme Disease, Antibody - Ref",PX8661890,CDM,300,RC,86618,CPT,90,,,,,,,181,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,164.891,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.61,177.38
PHALINX STERILE TRIAL SIZER 45A00000,27200000,CDM,272,RC,,,,12959-MAIN,LOCAL,,,,,181,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,164.891,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Cmv, Quant - Ref",PX8749790,CDM,300,RC,87497,CPT,90,,,,,,,194,,First Health,Commercial,both,85,,999999999,percent of total billed charges,164.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.28,190.12
Hiv-1 Antigens W/Hiv 1/2 Antib,PX87389,CDM,300,RC,87389,CPT,,,,,,,,194,,First Health,Commercial,both,85,,999999999,percent of total billed charges,164.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.08,190.12
Lyme Disease Antibody,PX86618,CDM,300,RC,86618,CPT,,,,,,,,194,,First Health,Commercial,both,85,,999999999,percent of total billed charges,164.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.61,190.12
Fac/Initial Hospital Care Levl II,PX99222F,CDM,510,RC,99222,CPT,,,,,,,,187,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,164.934,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.6798,183.26
"Infect Ag,Eia, Nos, Ea - Ref",PX8744990,CDM,300,RC,87449,CPT,90,,,,,,,187,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,164.934,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,183.26
Initial Hospital Care Levl II,PX99222P,CDM,982,RC,99222,CPT,,,,,,,,187,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,164.934,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.6798,182.0071
RETRIEVAL BAG 12/15MM,27200000,CDM,272,RC,,,,12660-MAIN,LOCAL,,,,,187,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,164.934,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031801,NDC,1,ML,185.37,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,164.9793,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.002698,181.6626
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031825,NDC,1,ML,185.37,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,164.9793,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.002698,181.6626
nafcillin 2 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,S0032,HCPCS,,,,63323032820,NDC,1,EA,185.37,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,164.9793,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Digital Mammogram, Screen Bil, Tc W/Cad Perf",PX7706701,CDM,403,RC,77067,CPT,TC,,,,,,,375,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.86,561
Red Blood Cells Unit,PXP9021,CDM,390,RC,P9021,HCPCS,,,,,,,,1050,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,165.008,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.27,165.008
Red Blood Cells Unit,PXP9021,CDM,390,RC,P9021,HCPCS,,,,,,,,1050,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,165.008,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.27,165.008
fentaNYL 50 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,47781042611,NDC,1,EA,185.47,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,165.0683,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 50 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,47781042647,NDC,1,EA,185.47,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,165.0683,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"MRI,Pelvis W/Out Contrast",PX7219501,CDM,610,RC,72195,CPT,TC,,,,,,,3253,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,165.0834,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.69,329.36
folic acid 5 MG/ML Solution 10 mL Vial,J3490.94,CDM,636,RC,J3490,HCPCS,,,,63323018410,NDC,10,ML,336.94,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,12.9192,percent of total billed charges,165.1006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,330.2012
folic acid 5 MG/ML Solution 10 mL Vial,J3490.94,CDM,636,RC,J3490,HCPCS,,,,63323018410,NDC,10,ML,336.94,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,165.1006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,330.2012
folic acid 5 MG/ML Solution 10 mL Vial,J3490.94,CDM,636,RC,J3490,HCPCS,,,,63323018410,NDC,10,ML,336.94,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,165.1006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,330.2012
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604F,CDM,510,RC,20604,CPT,,,,,,,,344,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,165.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,142.8976,337.12
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604F,CDM,510,RC,20604,CPT,,,,,,,,344,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,165.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,142.8976,337.12
ON Q PAIN BUSTER,27100000,CDM,271,RC,A4305,HCPCS,,6751-MAIN,LOCAL,,,,,194.26,,First Health,Commercial,both,85,,999999999,percent of total billed charges,165.121,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
Emergency Level II Visit,PX99282P,CDM,981,RC,99282,CPT,,,,,,,,337,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,78.56653846,percent of total billed charges,165.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.9898,328.0021
Emergency Level II Visit,PX99282P,CDM,981,RC,99282,CPT,,,,,,,,337,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,165.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.9898,328.0021
Emergency Level II Visit,PX99282P,CDM,981,RC,99282,CPT,,,,,,,,337,,United Healthcare,All Medicare advantage plans,outpatient,49,,55.965,percent of total billed charges,165.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.9898,328.0021
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021515,NDC,0.5,ML,187.24,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,165.14568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.779496,199.7926
Apply Long Arm Splint,PX29105P,CDM,983,RC,29105,CPT,,,,,,,,385,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,165.165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.65,374.7205
Apply Long Leg Splint,PX29505P,CDM,983,RC,29505,CPT,,,,,,,,385,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,165.165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.65,374.7205
Injection for Nerve Block,PX64445F,CDM,510,RC,64445,CPT,,,,,,,,385,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,165.165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,604.15
Injection for Nerve Block,PX64445P,CDM,983,RC,64445,CPT,,,,,,,,385,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,165.165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,604.15
MICA DEPTH GAUGE 150MM STERILE MICA,27200000,CDM,272,RC,,,,12439-MAIN,LOCAL,,,,,385,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,165.165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"N Block Inj, Plantar Digit",PX64455F,CDM,510,RC,64455,CPT,,,,,,,,385,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,165.165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,377.3
"N Block Inj, Plantar Digit",PX64455P,CDM,983,RC,64455,CPT,,,,,,,,385,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,165.165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,374.7205
Xray Temporomandib Jnt Unilat,PX7032801,CDM,320,RC,70328,CPT,TC,,,,,,,385,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,165.165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,377.3
verapamil 2.5 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,409114405,NDC,2,ML,185.65,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,165.2285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
cadexomer iodine 0.9 % Gel 40 g Tube,63700001,CDM,250,RC,,,,,,40565012249,NDC,40,GR,333.86,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,165.2607,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Chrom Anal 15-20 Cells - Ref,PX8826290,CDM,310,RC,88262,CPT,90,,,,,,,398,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,165.3292,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.06,390.04
Clotting Function Activity - Ref,PX8539790,CDM,300,RC,85397,CPT,90,,,,,,,334,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,165.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.3,327.32
"Remv F.B.,Eye,Cornea,No Slit",PX65220F,CDM,510,RC,65220,CPT,,,,,,,,334,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,165.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.7436,348.08
Repeat Control of Nosebleed,PX30906F,CDM,510,RC,30906,CPT,,,,,,,,334,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,165.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.7436,327.32
X-Ray Abdomen 2+ Views W/ Single Vw Chest (Tc),PX7402201,CDM,320,RC,74022,CPT,TC,,,,,,,334,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,165.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,327.32
"MRI, Pelvis, W/O Then W/",PX7219701,CDM,610,RC,72197,CPT,TC,,,,,,,1612,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,165.35,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,162.96,480.56
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040304,NDC,10,ML,168.77,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,165.3946,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040310,NDC,10,ML,168.77,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,165.3946,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
Asay of Interleukin-6 (Il-6),PX8352990,CDM,300,RC,83529,CPT,90,,,,,,,170,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,165.461,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,166.6
Chem Cautery Granulatn Tissue,PX17250F,CDM,510,RC,17250,CPT,,,,,,,,170,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,165.461,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,174.9
"Chemotherapy Administration, Subq/Im Non-Hormonal Anti-Neoplastic",PX96401,CDM,335,RC,96401,CPT,,,,,,,,170,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,165.461,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,166.6
Collagen Cross Links - Ref,PX8252390,CDM,300,RC,82523,CPT,90,,,,,,,170,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,165.461,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.13,166.6
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800P,CDM,983,RC,40800,CPT,,,,,,,,170,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,165.461,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,614.65
gadoteridol 279.3 MG/ML Solution 17 mL Syringe,A9576,CDM,636,RC,A9576,HCPCS,,,,270111145,NDC,17,ML,170,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,165.461,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.54,166.6
"Inject Nerv Blck,Trigeminal",PX64400P,CDM,983,RC,64400,CPT,,,,,,,,170,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,165.461,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,258.75
"Protein, Total; Serum, Plasma or Whole Blood",PX84155,CDM,300,RC,84155,CPT,,,,,,,,170,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,165.461,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.37,166.6
8MM ENDOWRIST INSTRUMENTS MEGA SUTURE CUT NEEDLE DRIVER,27200000,CDM,272,RC,,,,11914-MAIN,LOCAL,,,,,327,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,165.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"IV Infusion Therapy, 1 Hour",PX96365,CDM,260,RC,96365,CPT,,,,,,,,327,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,165.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.8358,320.46
nitroPRUSSide 25 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,72485010501,NDC,2,ML,186,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,165.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Puncture Drainage of Lesion,PX10160P,CDM,983,RC,10160,CPT,,,,,,,,186,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,165.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.2644,348.35
"TB Test, Cell Immunity Measure",PX86480,CDM,300,RC,86480,CPT,,,,,,,,186,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,165.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.83,182.28
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032F,CDM,510,RC,12032,CPT,,,,,,,,386,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,165.594,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.3444,378.28
RELOAD SUREFORM 45 2.5MM WHITE,27200000,CDM,272,RC,,,,12791-MAIN,LOCAL,,,,,386,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,165.594,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 45 3.5MM BLUE,27200000,CDM,272,RC,,,,12792-MAIN,LOCAL,,,,,386,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,165.594,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 45 4.3MM GREEN,27200000,CDM,272,RC,,,,12793-MAIN,LOCAL,,,,,386,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,165.594,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Blood Clot Factor VIII Test,PX85247,CDM,300,RC,85247,CPT,,,,,,,,169,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,165.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.03,165.62
Cardiac Rehab II W/ Monitor,PX93798.02,CDM,943,RC,93798,CPT,,,,,,,,338,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,56.99152941,percent of total billed charges,165.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.44,495.55
Cardiac Rehab II W/ Monitor,PX93798.02,CDM,943,RC,93798,CPT,,,,,,,,338,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,165.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.44,495.55
Cardiac Rehab II W/ Monitor,PX93798.02,CDM,943,RC,93798,CPT,,,,,,,,338,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,165.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.44,495.55
Initial Rx Burn(S) 1st Degree,PX16000F,CDM,510,RC,16000,CPT,,,,,,,,338,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,165.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.4052,331.24
Initial Rx Burn(S) 1st Degree,PX16000F,CDM,510,RC,16000,CPT,,,,,,,,338,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,165.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.4052,331.24
Initial Rx Burn(S) 1st Degree,PX16000F,CDM,510,RC,16000,CPT,,,,,,,,338,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,165.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.4052,331.24
Tap Block Unilateral by Injection(S),PX64486P,CDM,983,RC,64486,CPT,,,,,,,,169,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,165.62,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.81,231.06
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,59148000713,NDC,1,EA,170.19,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,165.645927,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
US Head/Neck Tc,PX7653601,CDM,402,RC,76536,CPT,TC,,,,,,,416,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,165.66,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.06,165.66
US Head/Neck Tc,PX7653601,CDM,402,RC,76536,CPT,TC,,,,,,,416,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,165.66,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.06,165.66
Dress/Debrid Large Burn No Anesth,PX16030F,CDM,510,RC,16030,CPT,,,,,,,,399,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,165.7446,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,165.7446,391.02
"X-Ray Exam Hip,Bilat W/Pelvis 2 Vws",PX7352101,CDM,320,RC,73521,CPT,TC,,,,,,,399,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,165.7446,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,391.02
Xray Lumbosacral 2 or 3 Vws,PX7210001,CDM,320,RC,72100,CPT,TC,,,,,,,399,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,165.7446,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,391.02
Topiramate - Ref,PX8020190,CDM,300,RC,80201,CPT,90,,,,,,,195,,First Health,Commercial,both,85,,999999999,percent of total billed charges,165.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.93,191.1
glucagon rdna (diagnostic) 1 MG Recon Soln 1 Each Vial,J1610.01,CDM,636,RC,J1610,HCPCS,,,,597026010,NDC,1,EA,744.84,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,165.76,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,165.76,191.52
Leukoreduced Rbc's,PXP9016,CDM,390,RC,P9016,HCPCS,,,,,,,,580,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,165.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,165.79,568.4
MRI Orb-Fac-Nec W/O+W/Con,PX7054301,CDM,610,RC,70543,CPT,TC,,,,,,,3541,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,165.79,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,165.79,489.11
MRI Orb-Fac-Nec W/O+W/Con,PX7054301,CDM,610,RC,70543,CPT,TC,,,,,,,3541,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,165.79,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,165.79,489.11
Debride Skin/Subq Ea Ad 20sqcm,PX11045P,CDM,983,RC,11045,CPT,,,,,,,,182,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,165.802,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.6028,177.1406
Immunocytochemistry,PX3993,CDM,310,RC,88342,CPT,TC,,,,,,,182,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,165.802,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.6028,178.36
Infec Agent Direct Probe - Ref,PX8779990,CDM,300,RC,87799,CPT,90,,,,,,,182,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,165.802,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.28,178.36
"Close Rx Dist Fingr Fx,Manipulatn",PX26755F,CDM,510,RC,26755,CPT,,,,,,,,335,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,165.825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
"Closed Rx I-P Jt,Toe Dislocation",PX28660F,CDM,510,RC,28660,CPT,,,,,,,,335,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,165.825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Insitu Hybridization (Fish),PX8836401,CDM,310,RC,88364,CPT,TC,,,,,,,335,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,165.825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Reduce Temporomandibl Disloc,PX21480F,CDM,510,RC,21480,CPT,,,,,,,,335,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,165.825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Repr Superf Wnd Face <2.5cm,PX12011F,CDM,510,RC,12011,CPT,,,,,,,,335,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,165.825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Heart/Lung Resuscitation (Cpr),PX92950F,CDM,480,RC,92950,CPT,,,,,,,,1366,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,165.894,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.13,564.83
Heart/Lung Resuscitation (Cpr),PX92950P,CDM,983,RC,92950,CPT,,,,,,,,1023,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,165.894,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.13,1002.54
predniSONE 5 mg/5 mL 5 MG/5ML Solution 120 mL Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54372250,NDC,120,ML,186.47,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,165.9583,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
"Chemotherapy, IV Infusion, Each Add'l Sequential Infusion",PX96417,CDM,335,RC,96417,CPT,,,,,,,,328,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,165.968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,321.44
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762P,CDM,983,RC,43762,CPT,,,,,,,,328,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,165.968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.2512,319.2424
Drain/Inject Med Joint/Brusa W/US Guide,PX20606F,CDM,510,RC,20606,CPT,,,,,,,,387,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,166.023,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.7598,604.15
"Ex Sknbngn0.6-1cmtrnk,Arm,Lg",PX11401P,CDM,983,RC,11401,CPT,,,,,,,,387,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,166.023,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.7598,376.6671
"Exc Skn Benig<5mm Face,Facial",PX11440P,CDM,983,RC,11440,CPT,,,,,,,,387,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,166.023,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.7598,614.65
Initial Rx Burn(S) 1st Degree,PX16000F,CDM,510,RC,16000,CPT,,,,,,,,338,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,166.03,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.7,166.03
nystatin 100000 UNIT/GM Powder 60 g Bottle,63700001,CDM,250,RC,,,,,,68308015260,NDC,60,GR,335.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,166.0725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PHENobarbital 130 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047721,NDC,1,ML,338.93,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,166.0757,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.354486,332.1514
PHENobarbital 130 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047721,NDC,1,ML,338.93,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,166.0757,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.354486,332.1514
PHENobarbital 130 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047721,NDC,1,ML,338.93,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,166.0757,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.354486,332.1514
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12173-MAIN,LOCAL,,,,,400,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,166.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Lvl 1 Init Hosp Low Mdm or 40 Minutes,PX99221,CDM,982,RC,99221,CPT,,,,,,,,400,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,166.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.16,389.32
"MRI, Abdomen W/O+ W/Contr",PX7418301,CDM,610,RC,74183,CPT,TC,,,,,,,4116,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,166.22,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,163.83,483.19
leuprolide 7.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74364203,NDC,1,EA,3782.28,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,166.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74334603,NDC,1,EA,12509.82,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,166.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,62935022305,NDC,1,EA,2764.34,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,166.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
leuprolide 45 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74347303,NDC,1,EA,21633.89,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,166.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
Assay of Phenytoin Total,PX80185,CDM,300,RC,80185,CPT,,,,,,,,336,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,166.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,329.28
CT Abdomen W/O Dye,PX7415001,CDM,350,RC,74150,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,166.32,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.28,166.32
CT Abdomen W/O Dye,PX7415001,CDM,350,RC,74150,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,166.32,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.28,166.32
HERNIA BELT MENS TRUSS LARGE,120.526,CDM,274,RC,L8310,HCPCS,,12221-MAIN,LOCAL,,,,,60,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,166.4,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.4,175.16
HERNIA BELT MENS TRUSS MEDIUM,120.526,CDM,274,RC,L8310,HCPCS,,12220-MAIN,LOCAL,,,,,60,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,166.4,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.4,175.16
HERNIA BELT MENS TRUSS XLARGE,120.526,CDM,274,RC,L8310,HCPCS,,12222-MAIN,LOCAL,,,,,60,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,166.4,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.4,175.16
Fac/Initial Hospital Care Levl II,PX99222F,CDM,510,RC,99222,CPT,,,,,,,,187,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,166.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.6798,183.26
"Infect Ag,Eia, Nos, Ea - Ref",PX8744990,CDM,300,RC,87449,CPT,90,,,,,,,187,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,166.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,183.26
Initial Hospital Care Levl II,PX99222P,CDM,982,RC,99222,CPT,,,,,,,,187,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,166.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.6798,182.0071
RETRIEVAL BAG 12/15MM,27200000,CDM,272,RC,,,,12660-MAIN,LOCAL,,,,,187,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,166.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"CCP, Antibody - Ref",PX8620090,CDM,300,RC,86200,CPT,90,,,,,,,171,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,166.4343,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,167.58
Hepatic Function Panel,PX80076,CDM,300,RC,80076,CPT,,,,,,,,171,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,52.915,percent of total billed charges,166.4343,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.49,167.58
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105F,CDM,510,RC,11105,CPT,,,,,,,,171,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,166.4343,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.0334,167.58
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105P,CDM,983,RC,11105,CPT,,,,,,,,171,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,166.4343,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.0334,166.4343
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102F,CDM,510,RC,11102,CPT,,,,,,,,171,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,143.07,percent of total billed charges,166.4343,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.0334,174.9
Facility Emergency Level 1 Visit,PX99281F,CDM,450,RC,99281,CPT,,,,,,,,329,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,166.474,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.56,322.42
Xray Mandible Partial Less Than 4 Vws,PX7010001,CDM,320,RC,70100,CPT,TC,,,,,,,347,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,166.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,340.06
Xray Mandible Partial Less Than 4 Vws,PX7010001,CDM,320,RC,70100,CPT,TC,,,,,,,347,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,166.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,340.06
"Calprotectin, Fecal - Ref",PX8399390,CDM,300,RC,83993,CPT,90,,,,,,,401,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,166.5754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18,392.98
"Apply Finger Splint,Static",PX29130F,CDM,420,RC,29130,CPT,,,,,,,,196,,First Health,Commercial,both,85,,999999999,percent of total billed charges,166.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.4184,192.08
Asay of Interleukin-6 (Il-6),PX8352990,CDM,300,RC,83529,CPT,90,,,,,,,170,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,166.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,166.6
Chem Cautery Granulatn Tissue,PX17250F,CDM,510,RC,17250,CPT,,,,,,,,170,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,166.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,174.9
"Chemotherapy Administration, Subq/Im Non-Hormonal Anti-Neoplastic",PX96401,CDM,335,RC,96401,CPT,,,,,,,,170,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,166.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,166.6
Collagen Cross Links - Ref,PX8252390,CDM,300,RC,82523,CPT,90,,,,,,,170,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,166.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.13,166.6
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800P,CDM,983,RC,40800,CPT,,,,,,,,170,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,166.6,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.35,420.61
gadoteridol 279.3 MG/ML Solution 17 mL Syringe,A9576,CDM,636,RC,A9576,HCPCS,,,,270111145,NDC,17,ML,170,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,166.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.54,166.6
Heterophile Antibodies,PX86308,CDM,300,RC,86308,CPT,,,,,,,,196,,First Health,Commercial,both,85,,999999999,percent of total billed charges,166.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,192.08
"Inject Nerv Blck,Trigeminal",PX64400P,CDM,983,RC,64400,CPT,,,,,,,,170,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,166.6,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.1,236.6
"Protein, Total; Serum, Plasma or Whole Blood",PX84155,CDM,300,RC,84155,CPT,,,,,,,,170,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,166.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.37,166.6
Sars-Cov-2 Covid-19 Antibody,PX86769,CDM,300,RC,86769,CPT,,,,,,,,340,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,166.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.63,333.2
Sars-Cov-2 Covid-19 Antibody,PX86769,CDM,300,RC,86769,CPT,,,,,,,,340,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,166.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.63,333.2
Sars-Cov-2 Covid-19 Antibody,PX86769,CDM,300,RC,86769,CPT,,,,,,,,340,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,166.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.63,333.2
X-Ray Exam Chest 3 Views,PX7104701,CDM,320,RC,71047,CPT,TC,,,,,,,340,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,166.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,333.2
X-Ray Exam Chest 3 Views,PX7104701,CDM,320,RC,71047,CPT,TC,,,,,,,340,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,166.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,333.2
X-Ray Exam Chest 3 Views,PX7104701,CDM,320,RC,71047,CPT,TC,,,,,,,340,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,166.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,333.2
COLLAR CERVICAL LARGE WITH TRACH 2 PIECE PHP-T4L,120.184,CDM,274,RC,L0172,HCPCS,,10142-MAIN,LOCAL,,,,,37,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,166.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,158.31,166.64
COLLAR CERVICAL LARGE WITH TRACH 2 PIECE PHP-T4L,120.184,CDM,274,RC,L0172,HCPCS,,10142-MAIN,LOCAL,,,,,37,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,166.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,158.31,166.64
COLLAR CERVICAL LARGE WITH TRACH 2 PIECE PHP-T4L,120.184,CDM,274,RC,L0172,HCPCS,,10142-MAIN,LOCAL,,,,,37,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,166.64,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,158.31,166.64
COLLAR CERVICAL MEDIUM WITH TRACH 2 PIECE PHP-T4M,120.183,CDM,274,RC,L0172,HCPCS,,10141-MAIN,LOCAL,,,,,37,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,166.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,158.31,166.64
COLLAR CERVICAL MEDIUM WITH TRACH 2 PIECE PHP-T4M,120.183,CDM,274,RC,L0172,HCPCS,,10141-MAIN,LOCAL,,,,,37,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,166.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,158.31,166.64
COLLAR CERVICAL MEDIUM WITH TRACH 2 PIECE PHP-T4M,120.183,CDM,274,RC,L0172,HCPCS,,10141-MAIN,LOCAL,,,,,37,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,166.64,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,158.31,166.64
COLLAR CERVICAL SMALL WITH TRACH 2 PIECE PHP-T4S,120.182,CDM,274,RC,L0172,HCPCS,,10140-MAIN,LOCAL,,,,,37,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,166.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,158.31,166.64
COLLAR CERVICAL SMALL WITH TRACH 2 PIECE PHP-T4S,120.182,CDM,274,RC,L0172,HCPCS,,10140-MAIN,LOCAL,,,,,37,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,166.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,158.31,166.64
COLLAR CERVICAL SMALL WITH TRACH 2 PIECE PHP-T4S,120.182,CDM,274,RC,L0172,HCPCS,,10140-MAIN,LOCAL,,,,,37,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,166.64,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,158.31,166.64
COLLAR CERVICAL X-LARGE WITH TRACH 2 PIECE OSG2404,120.185,CDM,274,RC,L0172,HCPCS,,10143-MAIN,LOCAL,,,,,49,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,166.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,158.31,166.64
COLLAR CERVICAL X-LARGE WITH TRACH 2 PIECE OSG2404,120.185,CDM,274,RC,L0172,HCPCS,,10143-MAIN,LOCAL,,,,,49,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,166.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,158.31,166.64
COLLAR CERVICAL X-LARGE WITH TRACH 2 PIECE OSG2404,120.185,CDM,274,RC,L0172,HCPCS,,10143-MAIN,LOCAL,,,,,49,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,166.64,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,158.31,166.64
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021515,NDC,0.5,ML,187.24,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,166.6436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.779496,199.7926
Alcohols - Ref,PX8032090,CDM,300,RC,80320,CPT,90,,,,,,,189,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,166.698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.5106,185.22
Voriconazole - Ref,PX8028590,CDM,300,RC,80285,CPT,90,,,,,,,183,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,166.713,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.86,179.34
folic acid 5 MG/ML Solution 10 mL Vial,J3490.94,CDM,636,RC,J3490,HCPCS,,,,63323018410,NDC,10,ML,336.94,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,166.7853,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,330.2012
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,59148000713,NDC,1,EA,170.19,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,166.7862,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Emergency Level II Visit,PX99282P,CDM,981,RC,99282,CPT,,,,,,,,337,,Humana Choice Care,All Medicare plans,outpatient,49.5,,67.1225,percent of total billed charges,166.815,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.9898,328.0021
MRI Lower W/O+W Tc,PX7372001,CDM,610,RC,73720,CPT,TC,,,,,,,3174,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,166.88,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,164.7,485.82
"MRI,Upr Ext, Joint,W/Cont",PX7322201,CDM,610,RC,73222,CPT,TC,,,,,,,3541,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,166.88,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,164.48,485.16
ANCHORAGE FIXATION PIN,27200000,CDM,272,RC,,,,12642-MAIN,LOCAL,,,,,389,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,166.881,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Ext Ecg > 48hr to 21 Day Rcrd W/Conect Intl Rcrd,PX0296T,CDM,731,RC,0296T,HCPCS,,,,,,,,389,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,166.881,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,161.5906,381.22
azithromycin 200 MG/5ML Recon Susp 15 mL Bottle,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,59762312001,NDC,15,ML,196.35,,First Health,Commercial,both,85,,999999999,percent of total billed charges,166.8975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
ROTH NET PLATINUM RETRIEVER,27200000,CDM,272,RC,,,,7518-MAIN,LOCAL,,,,,196.35,,First Health,Commercial,both,85,,999999999,percent of total billed charges,166.8975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Phlebotomy,PX99195,CDM,940,RC,99195,CPT,,,,,,,,238,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,166.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.49,166.95
Phlebotomy,PX99195,CDM,940,RC,99195,CPT,,,,,,,,238,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,166.95,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.49,166.95
"Colonoscopy,Flex,Diagnostic",PX45378F,CDM,750,RC,45378,CPT,,,,,,,,1286,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,166.972,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.56,704.94
"Colonoscopy,Flex,Diagnostic",PX45378P,CDM,983,RC,45378,CPT,,,,,,,,1200,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,166.972,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.56,1176
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725P,CDM,983,RC,26725,CPT,,,,,,,,330,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,166.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.082,321.189
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101P,CDM,983,RC,13101,CPT,,,,,,,,330,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,166.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.082,548.67
"Cardioversion, Elective;Extern",PX92960F,CDM,480,RC,92960,CPT,,,,,,,,402,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,166.9908,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.9908,568.57
Chem Cautery Granulatn Tissue,PX17250P,CDM,983,RC,17250,CPT,,,,,,,,402,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,166.9908,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.9908,391.2666
Lab Imm Spin X-Match,PX8837,CDM,300,RC,86920,CPT,,,,,,,,402,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,166.9908,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.22,393.96
"Morphometric Analysis, in Situ Hybridization, Each Probe; Manual, Tech",PX8836801,CDM,310,RC,88368,CPT,TC,,,,,,,402,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,166.9908,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.9908,393.96
hydrocortisone sodium succinate (preservative free) 250 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001305,NDC,1,EA,183.32,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,167.00452,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
Fac/Removal of Skin Tags,PX11200F,CDM,510,RC,11200,CPT,,,,,,,,348,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,167.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,144.5592,341.04
Fac/Removal of Skin Tags,PX11200F,CDM,510,RC,11200,CPT,,,,,,,,348,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,167.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,144.5592,341.04
Drainage of Hematoma/Fluid (T),PX10140F,CDM,510,RC,10140,CPT,,,,,,,,341,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,167.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,141.6514,1416.38
Drainage of Hematoma/Fluid (T),PX10140F,CDM,510,RC,10140,CPT,,,,,,,,341,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,167.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,141.6514,1416.38
Drainage of Hematoma/Fluid (T),PX10140F,CDM,510,RC,10140,CPT,,,,,,,,341,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,167.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,141.6514,1416.38
Drainage Scrotal Wall Abscess,PX55100P,CDM,983,RC,55100,CPT,,,,,,,,341,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,167.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,141.6514,1416.38
Drainage Scrotal Wall Abscess,PX55100P,CDM,983,RC,55100,CPT,,,,,,,,341,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,167.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,141.6514,1416.38
Drainage Scrotal Wall Abscess,PX55100P,CDM,983,RC,55100,CPT,,,,,,,,341,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,167.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,141.6514,1416.38
Exc Face Les Sc < 2 Cm,PX21011F,CDM,510,RC,21011,CPT,,,,,,,,943,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,167.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,164.48,781.73
Exc Face Les Sc < 2 Cm,PX21011F,CDM,510,RC,21011,CPT,,,,,,,,943,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,167.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,164.48,781.73
Exc Face Les Sc < 2 Cm,PX21011P,CDM,983,RC,21011,CPT,,,,,,,,628,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,167.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,164.48,781.73
Exc Face Les Sc < 2 Cm,PX21011P,CDM,983,RC,21011,CPT,,,,,,,,628,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,167.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,164.48,781.73
Exc Skin Benig >4cm Remaindr Body,PX11426F,CDM,510,RC,11426,CPT,,,,,,,,1227,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,167.1,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.1,684.19
Exc Skin Benig >4cm Remaindr Body,PX11426P,CDM,983,RC,11426,CPT,,,,,,,,981,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,167.1,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.1,961.38
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062001,NDC,0.4,ML,189.48,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,167.12136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062040,NDC,0.4,ML,189.48,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,167.12136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801401,NDC,0.4,ML,189.48,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,167.12136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801410,NDC,0.4,ML,189.48,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,167.12136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
buprenorphine 5 MCG/HR PATCH WEEKLY 4 Each Box,63700001,CDM,250,RC,,,,,,42858075040,NDC,1,EA,330.52,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,167.24312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
albumin human 25% 25 % Solution 50 mL Flex Cont,P9047,CDM,636,RC,P9047,HCPCS,,,,944049301,NDC,50,ML,402.67,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,167.269118,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.66,394.6166
"Colonoscopy,Flex,Screen",PX2002F,CDM,750,RC,G0105,HCPCS,,,,,,,,2539,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,167.284,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.56,592.75
"Colonoscopy,Screen Prev",PX2004F,CDM,750,RC,G0121,HCPCS,,,,,,,,2502,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,167.284,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.78,593.33
Apc Resistance Assay - Ref,PX8530790,CDM,300,RC,85307,CPT,90,,,,,,,390,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,167.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.05,382.2
Cardiac Rehab II W/ Monitor,PX93798.02,CDM,943,RC,93798,CPT,,,,,,,,338,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,167.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.44,495.55
"Closed Rx Toe Fx,Manipulatn",PX28515F,CDM,510,RC,28515,CPT,,,,,,,,390,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,167.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,162.006,382.2
Initial Rx Burn(S) 1st Degree,PX16000F,CDM,510,RC,16000,CPT,,,,,,,,338,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,167.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.4052,331.24
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041100,NDC,0.5,ML,196.94,,First Health,Commercial,both,85,,999999999,percent of total billed charges,167.399,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.808876,411.2766
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041110,NDC,0.5,ML,196.94,,First Health,Commercial,both,85,,999999999,percent of total billed charges,167.399,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.808876,411.2766
AIRSEAL 12MM ACCESS PORT AND PALM GRIP OBTURATOR BLADELESS OPTICAL TIP 120MM,27200000,CDM,272,RC,,,,12207-MAIN,LOCAL,,,,,172,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,167.4076,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
AIRSEAL TUBE SET TRI LUMEN FILTERED WITH ACTIVATED CHARCOAL,27200000,CDM,272,RC,,,,12206-MAIN,LOCAL,,,,,172,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,167.4076,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Closed Rx Radial Head Disloc,Child",PX24640F,CDM,510,RC,24640,CPT,,,,,,,,270,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,167.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.04,218.61
"Closed Rx Radial Head Disloc,Child",PX24640P,CDM,983,RC,24640,CPT,,,,,,,,180,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,167.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.04,218.61
"Percut Biopsy, Abdominal Mass",PX49180F,CDM,510,RC,49180,CPT,,,,,,,,2084,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,167.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.39,359.04
Remv Ext Canal Foreign Body,PX69200F,CDM,510,RC,69200,CPT,,,,,,,,235,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,167.42,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.22,167.42
Remv Ext Canal Foreign Body,PX69200P,CDM,983,RC,69200,CPT,,,,,,,,157,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,167.42,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.22,167.42
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082143,NDC,1,ML,348.85,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,167.448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.48,367.9214
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082143,NDC,1,ML,348.85,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,167.448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.48,367.9214
Assay Other Fluid Chlorides - Ref,PX8243890,CDM,300,RC,82438,CPT,90,,,,,,,197,,First Health,Commercial,both,85,,999999999,percent of total billed charges,167.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.58,193.06
Tramadol - Ref,PX8037390,CDM,300,RC,80373,CPT,90,,,,,,,197,,First Health,Commercial,both,85,,999999999,percent of total billed charges,167.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.8338,193.06
"Echo Heart Xthoracic,Limited",PX9330801,CDM,480,RC,93308,CPT,TC,,,,,,,349,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,167.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,144.9746,342.02
"Echo Heart Xthoracic,Limited",PX9330801,CDM,480,RC,93308,CPT,TC,,,,,,,349,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,167.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,144.9746,342.02
"Morphometric Analysis, Tumor - Ref",PX8836090,CDM,310,RC,88360,CPT,90,,,,,,,349,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,167.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,144.9746,342.02
"Morphometric Analysis, Tumor - Ref",PX8836090,CDM,310,RC,88360,CPT,90,,,,,,,349,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,167.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,144.9746,342.02
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,703574811,NDC,100,ML,183.92,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,167.55112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.174958,180.2416
"Office/Outpt Visit,New,Levl V",PX99205F,CDM,510,RC,99205,CPT,,,,,,,,456,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,167.5536,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.82,395.88
"Office/Outpt Visit,New,Levl V",PX99205P,CDM,983,RC,99205,CPT,,,,,,,,456,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,167.5536,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.82,446.88
"CCP, Antibody - Ref",PX8620090,CDM,300,RC,86200,CPT,90,,,,,,,171,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,167.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,167.58
"Ctrl Nosebleed,Anter,Simple",PX30901F,CDM,510,RC,30901,CPT,,,,,,,,342,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,83.63333333,percent of total billed charges,167.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,335.16
"Ctrl Nosebleed,Anter,Simple",PX30901F,CDM,510,RC,30901,CPT,,,,,,,,342,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,167.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,335.16
"Ctrl Nosebleed,Anter,Simple",PX30901F,CDM,510,RC,30901,CPT,,,,,,,,342,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,167.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,335.16
Hepatic Function Panel,PX80076,CDM,300,RC,80076,CPT,,,,,,,,171,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,167.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.49,167.58
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105F,CDM,510,RC,11105,CPT,,,,,,,,171,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,167.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.0334,167.58
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105P,CDM,983,RC,11105,CPT,,,,,,,,171,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,167.58,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,167.58
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102F,CDM,510,RC,11102,CPT,,,,,,,,171,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,167.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.0334,174.9
Ultrasound Breast Limited,PX7664201,CDM,402,RC,76642,CPT,TC,,,,,,,342,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,116.28,percent of total billed charges,167.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,335.16
Ultrasound Breast Limited,PX7664201,CDM,402,RC,76642,CPT,TC,,,,,,,342,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,167.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,335.16
Ultrasound Breast Limited,PX7664201,CDM,402,RC,76642,CPT,TC,,,,,,,342,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,167.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,335.16
Assay of ammonia,PX82140,CDM,300,RC,82140,CPT,,,,,,,,190,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,167.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.36,186.2
Assay of protein urine,PX84156,CDM,300,RC,84156,CPT,,,,,,,,190,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,167.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.37,186.2
Each Add'l Sequential IV Infusion <1 Hour,PX96367,CDM,260,RC,96367,CPT,,,,,,,,190,,United Healthcare,All Payer,outpatient,88.2,,123.236,percent of total billed charges,167.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,186.2
"N Block Inj, Common Digit",PX64632F,CDM,510,RC,64632,CPT,,,,,,,,190,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,167.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.926,258.75
"Tumor Antigen, Ca-125",PX86304,CDM,300,RC,86304,CPT,,,,,,,,190,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,167.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,186.2
TUBE TRACH SIZE 3.0MM ID 4.5MM OD SHILEY PEDIATRIC 3.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1185-MAIN,LOCAL,,,,,184,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,167.624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 3.5MM ID 5.2MM OD SHILEY PEDIATRIC,120.287,CDM,272,RC,A7520,HCPCS,,8813-MAIN,LOCAL,,,,,184,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,167.624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 4.0MM ID 5.9MM OD SHILEY PEDIATRIC 4.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1187-MAIN,LOCAL,,,,,184,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,167.624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 5 7.0MM ID 10.1MM OD SHILEY CUFFED 5CN70H,120.287,CDM,272,RC,A7521,HCPCS,,10350-MAIN,LOCAL,,,,,184,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,167.624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 5.0MM ID 7.1MM OD SHILEY PEDIATRIC 5.0PED,120.287,CDM,272,RC,A7520,HCPCS,,8814-MAIN,LOCAL,,,,,184,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,167.624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 6 6.0MM ID 8.3MM OD SHILEY CUFFED 6SCT,120.287,CDM,272,RC,A7521,HCPCS,,8812-MAIN,LOCAL,,,,,184,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,167.624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 6 6.4MM ID 10.8MM OD SHILEY CUFFED 6DCT,120.287,CDM,272,RC,A7521,HCPCS,,1190-MAIN,LOCAL,,,,,184,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,167.624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 7.5MM ID 10.8MM OD SHILEY CUFFED 6CN75H,120.287,CDM,272,RC,A7521,HCPCS,,8488-MAIN,LOCAL,,,,,184,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,167.624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 8 7.6MM ID 12.2MM OD SHILEY 8DCT,120.287,CDM,272,RC,A7521,HCPCS,,1192-MAIN,LOCAL,,,,,184,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,167.624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 8 7.6MM ID 12.22MM OD SHILEY CUFFED 8LPC,120.287,CDM,272,RC,A7521,HCPCS,,8815-MAIN,LOCAL,,,,,184,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,167.624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 8.0MM ID 10.9MM OD SHILEY CUFFED 8SCT,120.287,CDM,272,RC,A7521,HCPCS,,8811-MAIN,LOCAL,,,,,184,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,167.624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 10 SHILEY 10LPC,120.287,CDM,272,RC,A7521,HCPCS,,1181-MAIN,LOCAL,,,,,184,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,167.624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
hydrocortisone sodium succinate (preservative free) 1000 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9000501,NDC,1,EA,403.54,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,167.630516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
MRI Orbit/Face/Neck Tc,PX7054001,CDM,610,RC,70540,CPT,TC,,,,,,,3335,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,167.6578,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,113.43,334.62
"Initial Observation Care,Levl II",PX99219,CDM,982,RC,99219,CPT,,,,,,,,391,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,167.739,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,162.4214,380.5603
MRI Orb-Fac-Nec W/O+W/Con,PX7054301,CDM,610,RC,70543,CPT,TC,,,,,,,3541,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,167.75,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,165.79,489.11
PHENobarbital 130 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047721,NDC,1,ML,338.93,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,167.77035,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.354486,332.1514
Layr Clos Wnd Rest Body 2.6-7.5,PX12042F,CDM,510,RC,12042,CPT,,,,,,,,404,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,167.8216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,395.92
Neg Pressure Wound Therapy Dme >50 Sq Cm,PX97606F,CDM,761,RC,97606,CPT,,,,,,,,404,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,167.8216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,395.92
Remove Foreign Body Simple,PX10120F,CDM,510,RC,10120,CPT,,,,,,,,404,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,167.8216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,395.92
Remove Foreign Body Simple,PX10120P,CDM,983,RC,10120,CPT,,,,,,,,404,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,167.8216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,393.2132
Xray Foot Minimum 3 Vws,PX7363001,CDM,320,RC,73630,CPT,TC,,,,,,,404,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,167.8216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,395.92
Xray Knee 3 Vws,PX7356201,CDM,320,RC,73562,CPT,TC,,,,,,,404,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,167.8216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,395.92
dexAMETHasone 0.1 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,24208072002,NDC,5,ML,331.81,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,167.89586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium zirconium cyclosilicate 10 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,310111001,NDC,1,EA,172.56,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,167.952648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Exc Skin Benig >4cm Remaindr Body,PX11426F,CDM,510,RC,11426,CPT,,,,,,,,1227,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,167.97,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.1,684.19
Exc Skin Benig >4cm Remaindr Body,PX11426F,CDM,510,RC,11426,CPT,,,,,,,,1227,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,167.97,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.1,684.19
Exc Skin Benig >4cm Remaindr Body,PX11426P,CDM,983,RC,11426,CPT,,,,,,,,981,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,167.97,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.1,961.38
Exc Skin Benig >4cm Remaindr Body,PX11426P,CDM,983,RC,11426,CPT,,,,,,,,981,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,167.97,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.1,961.38
Flu Dna Amp Probe 1st 2 Types,PX87502,CDM,300,RC,87502,CPT,,,,,,,,350,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.84,343
Flu Dna Amp Probe 1st 2 Types,PX87502,CDM,300,RC,87502,CPT,,,,,,,,350,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.84,343
Infliximab - Ref,PX8023090,CDM,300,RC,80230,CPT,90,,,,,,,343,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,168.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.36,336.14
Infliximab - Ref,PX8023090,CDM,300,RC,80230,CPT,90,,,,,,,343,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,168.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.36,336.14
Infliximab - Ref,PX8023090,CDM,300,RC,80230,CPT,90,,,,,,,343,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,168.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.36,336.14
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002F,CDM,510,RC,12002,CPT,,,,,,,,343,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,232.72,percent of total billed charges,168.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,142.4822,336.14
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002F,CDM,510,RC,12002,CPT,,,,,,,,343,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,168.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,142.4822,336.14
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002F,CDM,510,RC,12002,CPT,,,,,,,,343,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,168.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,142.4822,336.14
"Injection Hip Arthrogram,Anesth",PX27095F,CDM,510,RC,27095,CPT,,,,,,,,425,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,168.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.95,633.69
"Injection Hip Arthrogram,Anesth",PX27095P,CDM,983,RC,27095,CPT,,,,,,,,425,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,168.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.95,633.69
linezolid 600 MG/300ML Solution 300 mL Flex Cont,J2020.01,CDM,636,RC,J2020,HCPCS,,,,9514001,NDC,300,ML,332.42,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,168.20452,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.087268,325.7716
Alcohols - Ref,PX8032090,CDM,300,RC,80320,CPT,90,,,,,,,189,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,168.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.5106,185.22
Diagnostic Anoscopy,PX46600P,CDM,983,RC,46600,CPT,,,,,,,,405,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,168.237,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,394.1865
CT Pelvis W/O Dye,PX7219201,CDM,350,RC,72192,CPT,TC,,,,,,,2744,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,168.29,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.94,168.29
CT Pelvis W/O Dye,PX7219201,CDM,350,RC,72192,CPT,TC,,,,,,,2744,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,168.29,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.94,168.29
Collect Blood From Picc,PX36592,CDM,949,RC,36592,CPT,,,,,,,,198,,First Health,Commercial,both,85,,999999999,percent of total billed charges,168.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.2492,194.04
Debride Muscle Ea Add 20 Sqcm,PX11046P,CDM,983,RC,11046,CPT,,,,,,,,198,,First Health,Commercial,both,85,,999999999,percent of total billed charges,168.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.2492,192.7134
Insert Simple Cath Foley,PX51702F,CDM,510,RC,51702,CPT,,,,,,,,198,,First Health,Commercial,both,85,,999999999,percent of total billed charges,168.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.2492,194.04
KIT PLEUREVAC CHEST DRAIN S-1100-08LF,120.2,CDM,272,RC,,,,4190-MAIN,LOCAL,,,,,198,,First Health,Commercial,both,85,,999999999,percent of total billed charges,168.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.0466,194.04
Lyme Screen,PX7585,CDM,300,RC,86618,CPT,,,,,,,,198,,First Health,Commercial,both,85,,999999999,percent of total billed charges,168.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.61,194.04
Assay Thyroid Stim Hormone,PX84443,CDM,300,RC,84443,CPT,,,,,,,,294,,Blue Cross Blue Shield of MN,All commercial plans,both,,,150.2786111,fee schedule,168.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.4,288.12
Sars-Cov-2 Covid-19 Antibody,PX86769,CDM,300,RC,86769,CPT,,,,,,,,340,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,168.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.63,333.2
X-Ray Exam Chest 3 Views,PX7104701,CDM,320,RC,71047,CPT,TC,,,,,,,340,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,168.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,333.2
clotrimazole-betamethasone 1-0.05 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,51672404801,NDC,15,GR,172.95,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,168.332235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
RBC Antibody Screen,PX86850,CDM,300,RC,86850,CPT,,,,,,,,173,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,65.86888889,percent of total billed charges,168.3809,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,169.54
"Thyroxin, Free (Free T4)",PX84439,CDM,300,RC,84439,CPT,,,,,,,,173,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,56.65,percent of total billed charges,168.3809,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.27,169.54
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323012594,NDC,1,EA,190.99,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,168.45318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
Assay of Amylase,PX82150,CDM,300,RC,82150,CPT,,,,,,,,191,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,168.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.94,187.18
C-Reactive Protein,PX86140,CDM,300,RC,86140,CPT,,,,,,,,191,,United Healthcare,All Payer,outpatient,88.2,,107.1605263,percent of total billed charges,168.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,187.18
"Chemotherapy, IV Infusion, Add'l Hour",PX96415,CDM,335,RC,96415,CPT,,,,,,,,191,,United Healthcare,All Payer,outpatient,88.2,,101.23,percent of total billed charges,168.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,187.18
Fac/Ther Injection Carpal Tunnel,PX20526F,CDM,510,RC,20526,CPT,,,,,,,,191,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,168.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.3414,258.75
Urine Pregnancy Test,PX81025,CDM,300,RC,81025,CPT,,,,,,,,191,,United Healthcare,All Payer,outpatient,88.2,,151.61,percent of total billed charges,168.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.89,187.18
"Fna Biopsy, W/US Guidance; First Lesion",PX10005F,CDM,510,RC,10005,CPT,,,,,,,,333,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,168.498,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.3282,614.65
Ultrasound Breast Complete,PX7664101,CDM,402,RC,76641,CPT,TC,,,,,,,333,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,168.498,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,326.34
Amylase - Ref,PX8215090,CDM,300,RC,82150,CPT,90,,,,,,,185,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,168.535,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.94,181.3
Hepatitis C Rna Quant,PX87522,CDM,300,RC,87522,CPT,,,,,,,,185,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,168.535,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.28,181.3
"Level IV - Surgical Pathology, Gross and Microscopic Examination , Tech",PX3934,CDM,310,RC,88305,CPT,TC,,,,,,,185,,Medica,Commercial,both,91.1,,86.168,percent of total billed charges,168.535,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,271.15
"Office/Outpt Visit,Est,Levl III",PX99213F,CDM,510,RC,99213,CPT,,,,,,,,185,,Medica,Commercial,both,91.1,,29.80769231,percent of total billed charges,168.535,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.849,181.3
"Office/Outpt Visit,Est,Levl III",PX99213P,CDM,983,RC,99213,CPT,,,,,,,,185,,Medica,Commercial,both,91.1,,29.80769231,percent of total billed charges,168.535,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.849,180.0605
AIRSEAL 12MM ACCESS PORT AND PALM GRIP OBTURATOR BLADELESS OPTICAL TIP 120MM,27200000,CDM,272,RC,,,,12207-MAIN,LOCAL,,,,,172,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,168.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
AIRSEAL TUBE SET TRI LUMEN FILTERED WITH ACTIVATED CHARCOAL,27200000,CDM,272,RC,,,,12206-MAIN,LOCAL,,,,,172,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,168.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604F,CDM,510,RC,20604,CPT,,,,,,,,344,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,168.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,142.8976,337.12
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604F,CDM,510,RC,20604,CPT,,,,,,,,344,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,168.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,142.8976,337.12
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604F,CDM,510,RC,20604,CPT,,,,,,,,344,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,168.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,142.8976,337.12
"Exc Skn Bngn2.1-3cm Fce,Facial",PX11443P,CDM,983,RC,11443,CPT,,,,,,,,650,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,168.5775,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.78,637
"Fac/Exc Skn Bngn 2.1-3cmfce,Facial",PX11443F,CDM,510,RC,11443,CPT,,,,,,,,813,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,168.5775,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.78,475.96
6 SHOOTER SAEED MULTIBAND LIGATOR,27200000,CDM,272,RC,,,,12379-MAIN,LOCAL,,,,,393,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,168.597,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA FIRST MET TRANSLATOR STERILE MICA,27200000,CDM,272,RC,,,,12445-MAIN,LOCAL,,,,,393,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,168.597,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Tap Block Bilateral by Injection(S),PX64488F,CDM,510,RC,64488,CPT,,,,,,,,393,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,168.597,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,163.2522,385.14
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062001,NDC,0.4,ML,189.48,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,168.6372,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062040,NDC,0.4,ML,189.48,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,168.6372,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801401,NDC,0.4,ML,189.48,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,168.6372,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801410,NDC,0.4,ML,189.48,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,168.6372,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598F,CDM,510,RC,97598,CPT,,,,,,,,406,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,168.6524,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,168.6524,397.88
etoposide 500 MG/25ML Solution 25 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,703565601,NDC,25,ML,173.28,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,168.653424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.949434,169.8144
Drainage of Hematoma/Fluid (T),PX10140F,CDM,510,RC,10140,CPT,,,,,,,,341,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,168.795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,141.6514,1416.38
Drainage Scrotal Wall Abscess,PX55100P,CDM,983,RC,55100,CPT,,,,,,,,341,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,168.795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,141.6514,1416.38
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573F,CDM,761,RC,36573,CPT,,,,,,,,1529,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,168.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.83,778.97
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573P,CDM,983,RC,36573,CPT,,,,,,,,1721,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,168.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.83,1686.58
tobramycin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314064305,NDC,5,ML,191.42,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,168.83244,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Closed Rx IP Jt Dislocation,PX26770F,CDM,510,RC,26770,CPT,,,,,,,,1231,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,168.85,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,168.85,628.15
Closed Rx IP Jt Dislocation,PX26770P,CDM,983,RC,26770,CPT,,,,,,,,1353,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,168.85,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,168.85,1325.94
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031801,NDC,1,ML,185.37,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,168.87207,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.002698,181.6626
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031825,NDC,1,ML,185.37,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,168.87207,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.002698,181.6626
nafcillin 2 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,S0032,HCPCS,,,,63323032820,NDC,1,EA,185.37,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,168.87207,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
cadexomer iodine 0.9 % Gel 40 g Tube,63700001,CDM,250,RC,,,,,,40565012249,NDC,40,GR,333.86,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,168.93316,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CT Lumbar Spine W/O Dye,PX7213101,CDM,350,RC,72131,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,168.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.15,168.95
CT Lumbar Spine W/O Dye,PX7213101,CDM,350,RC,72131,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,168.95,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.15,168.95
Diagnostic CT Thorax W/O Contrast,PX7125001,CDM,350,RC,71250,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,168.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.15,168.95
Diagnostic CT Thorax W/O Contrast,PX7125001,CDM,350,RC,71250,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,168.95,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.15,168.95
fentaNYL 50 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,47781042611,NDC,1,EA,185.47,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,168.96317,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 50 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,47781042647,NDC,1,EA,185.47,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,168.96317,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Clotting Function Activity - Ref,PX8539790,CDM,300,RC,85397,CPT,90,,,,,,,334,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,169.004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.3,327.32
"Remv F.B.,Eye,Cornea,No Slit",PX65220F,CDM,510,RC,65220,CPT,,,,,,,,334,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,169.004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.7436,348.08
Repeat Control of Nosebleed,PX30906F,CDM,510,RC,30906,CPT,,,,,,,,334,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,169.004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.7436,327.32
X-Ray Abdomen 2+ Views W/ Single Vw Chest (Tc),PX7402201,CDM,320,RC,74022,CPT,TC,,,,,,,334,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,169.004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,327.32
Exc Skn Bnig0.6-1cm Remain Bdy,PX11421P,CDM,983,RC,11421,CPT,,,,,,,,345,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,169.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,143.313,614.65
Exc Skn Bnig0.6-1cm Remain Bdy,PX11421P,CDM,983,RC,11421,CPT,,,,,,,,345,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,169.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,143.313,614.65
Exc Skn Bnig0.6-1cm Remain Bdy,PX11421P,CDM,983,RC,11421,CPT,,,,,,,,345,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,169.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,143.313,614.65
Assay of ammonia,PX82140,CDM,300,RC,82140,CPT,,,,,,,,190,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,169.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.36,186.2
Assay of protein urine,PX84156,CDM,300,RC,84156,CPT,,,,,,,,190,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,169.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.37,186.2
Each Add'l Sequential IV Infusion <1 Hour,PX96367,CDM,260,RC,96367,CPT,,,,,,,,190,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,169.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,186.2
"N Block Inj, Common Digit",PX64632F,CDM,510,RC,64632,CPT,,,,,,,,190,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,169.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.926,258.75
"Tumor Antigen, Ca-125",PX86304,CDM,300,RC,86304,CPT,,,,,,,,190,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,169.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,186.2
sodium zirconium cyclosilicate 10 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,310111001,NDC,1,EA,172.56,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,169.1088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
verapamil 2.5 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,409114405,NDC,2,ML,185.65,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,169.12715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Inpt or Obs Disch Day Mngmt <=30 Minutes,PX99238,CDM,982,RC,99238,CPT,,,,,,,,199,,First Health,Commercial,both,85,,999999999,percent of total billed charges,169.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.6646,193.6867
dantrolene 20 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,42023012306,NDC,1,EA,394.42,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,169.20618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Exc Skn Bngn3.1-4cm Remain Bdy,PX11424P,CDM,983,RC,11424,CPT,,,,,,,,562,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,169.2197,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.13,550.76
"Exc Skn Malig1.1-2cm Fce,Facal",PX11642P,CDM,983,RC,11642,CPT,,,,,,,,466,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,169.2197,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,113.87,558.97
Fac/Exc Skn Bngn3.1-4cm Remain Bdy,PX11424F,CDM,510,RC,11424,CPT,,,,,,,,931,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,169.2197,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.13,496.71
"Fac/Exc Skn Malig .1-2cm Fce,Facal",PX11642F,CDM,510,RC,11642,CPT,,,,,,,,698,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,169.2197,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,113.87,558.97
"Ctrl Nosebleed,Anter,Simple",PX30901F,CDM,510,RC,30901,CPT,,,,,,,,342,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,169.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,335.16
Ultrasound Breast Limited,PX7664201,CDM,402,RC,76642,CPT,TC,,,,,,,342,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,169.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,335.16
ketoconazole 2 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,168009915,NDC,15,GR,173.97,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,169.325001,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Chest Wall Manipulation,Subsequent",PX94668F,CDM,410,RC,94668,CPT,,,,,,,,192,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,169.344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.7568,188.16
Hepatitis Be Antibody - Ref,PX8670790,CDM,300,RC,86707,CPT,90,,,,,,,192,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,169.344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.61,188.16
Infectious Agent Antigen Detection by Immunoassay With Direct Visual Observation.,PX87811,CDM,300,RC,87811,CPT,,,,,,,,192,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,169.344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.94,188.16
Creatine Mb Fraction,PX82553,CDM,300,RC,82553,CPT,,,,,,,,353,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,169.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.59,345.94
Creatine Mb Fraction,PX82553,CDM,300,RC,82553,CPT,,,,,,,,353,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,169.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.59,345.94
Fentanyl - Ref,PX8035490,CDM,300,RC,80354,CPT,90,,,,,,,353,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,169.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,345.94
Fentanyl - Ref,PX8035490,CDM,300,RC,80354,CPT,90,,,,,,,353,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,169.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,345.94
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155F,CDM,370,RC,99155,CPT,,,,,,,,353,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,169.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,345.94
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155F,CDM,370,RC,99155,CPT,,,,,,,,353,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,169.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,345.94
"Morphometric Analysis, in Situ Hybridization, Each Probe; Manual, Tech",PX8836801,CDM,310,RC,88368,CPT,TC,,,,,,,402,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,169.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.37,175.264
"Morphometric Analysis, in Situ Hybridization, Each Probe; Manual, Tech",PX8836801,CDM,310,RC,88368,CPT,TC,,,,,,,402,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,169.44,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.37,175.264
Pvb Thoracic Single Injection Site W/Img Gid,PX64461F,CDM,510,RC,64461,CPT,,,,,,,,353,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,169.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,604.15
Pvb Thoracic Single Injection Site W/Img Gid,PX64461F,CDM,510,RC,64461,CPT,,,,,,,,353,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,169.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,604.15
nitroPRUSSide 25 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,72485010501,NDC,2,ML,186,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,169.446,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Puncture Drainage of Lesion,PX10160P,CDM,983,RC,10160,CPT,,,,,,,,186,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,169.446,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.2644,348.35
"TB Test, Cell Immunity Measure",PX86480,CDM,300,RC,86480,CPT,,,,,,,,186,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,169.446,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.83,182.28
Drainage of Gum Lesion,PX41800F,CDM,510,RC,41800,CPT,,,,,,,,395,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,169.455,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,387.1
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122F,CDM,510,RC,13122,CPT,,,,,,,,788,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,169.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.39,262.88
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122P,CDM,983,RC,13122,CPT,,,,,,,,301,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,169.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.39,294.98
clotrimazole-betamethasone 1-0.05 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,51672404801,NDC,15,GR,172.95,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,169.491,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Close Rx Dist Fingr Fx,Manipulatn",PX26755F,CDM,510,RC,26755,CPT,,,,,,,,335,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,169.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
"Closed Rx I-P Jt,Toe Dislocation",PX28660F,CDM,510,RC,28660,CPT,,,,,,,,335,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,169.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Insitu Hybridization (Fish),PX8836401,CDM,310,RC,88364,CPT,TC,,,,,,,335,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,169.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Reduce Temporomandibl Disloc,PX21480F,CDM,510,RC,21480,CPT,,,,,,,,335,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,169.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Repr Superf Wnd Face <2.5cm,PX12011F,CDM,510,RC,12011,CPT,,,,,,,,335,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,169.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
RBC Antibody Screen,PX86850,CDM,300,RC,86850,CPT,,,,,,,,173,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,169.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,169.54
"Thyroxin, Free (Free T4)",PX84439,CDM,300,RC,84439,CPT,,,,,,,,173,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,169.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.27,169.54
CT Lower Extremity W/O Dye,PX7370001,CDM,350,RC,73700,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,169.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.37,169.61
CT Lower Extremity W/O Dye,PX7370001,CDM,350,RC,73700,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,169.61,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.37,169.61
fosfomycin 3 g Packet 1 Each Box,25000000,CDM,250,RC,,,,,,70700026894,NDC,1,EA,353.41,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,169.6368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fosfomycin 3 g Packet 1 Each Box,25000000,CDM,250,RC,,,,,,70700026894,NDC,1,EA,353.41,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,169.6368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
NON-LOCKING SCREW 3.5X18MM,C1713,CDM,278,RC,C1713,HCPCS,,12466-MAIN,LOCAL,,,,,395.51,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,169.67379,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
levonorgestrel 1.5 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,68180085211,NDC,1,EA,174.39,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,169.733787,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/GM Powder 60 g Bottle,63700001,CDM,250,RC,,,,,,68308015260,NDC,60,GR,335.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,169.763,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Infliximab - Ref,PX8023090,CDM,300,RC,80230,CPT,90,,,,,,,343,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,169.785,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.36,336.14
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002F,CDM,510,RC,12002,CPT,,,,,,,,343,,Humana Choice Care,All Medicare plans,outpatient,49.5,,114.17,percent of total billed charges,169.785,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,142.4822,336.14
etoposide 500 MG/25ML Solution 25 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,703565601,NDC,25,ML,173.28,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,169.8144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.949434,169.8144
clotrimazole-betamethasone 1-0.05 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,66993089815,NDC,15,GR,192.55,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,169.8291,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Removal of Tunnel Cv Access Device, With Port/Pump",PX36590P,CDM,983,RC,36590,CPT,,,,,,,,1147,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,169.8619,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.39,1124.06
predniSONE 5 mg/5 mL 5 MG/5ML Solution 120 mL Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54372250,NDC,120,ML,186.47,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,169.87417,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
Comprehensive Metabolic Panel,PX80053,CDM,300,RC,80053,CPT,,,,,,,,396,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,169.884,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.68,388.08
Neg Pressure Wound Therapy Dme </=50 Sq Cm,PX97605F,CDM,510,RC,97605,CPT,,,,,,,,396,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,169.884,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,164.4984,388.08
NON-LOCKING SCREW 3.5X12MM,27200000,CDM,278,RC,C1713,HCPCS,,11857-MAIN,LOCAL,,,,,396,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,169.884,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NON-LOCKING SCREW 3.5X16MM,27200000,CDM,278,RC,C1713,HCPCS,,11856-MAIN,LOCAL,,,,,396,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,169.884,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NON-LOCKING SCREW 3.5X24MM,27200000,CDM,278,RC,C1713,HCPCS,,11855-MAIN,LOCAL,,,,,396,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,169.884,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Surgical Diagnostic Exam, Anorectal",PX45990P,CDM,983,RC,45990,CPT,,,,,,,,409,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,169.8986,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,169.8986,2452.93
Xray Sinuses Minimum 3 Vws,PX7022001,CDM,320,RC,70220,CPT,TC,,,,,,,354,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,169.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,346.92
Xray Sinuses Minimum 3 Vws,PX7022001,CDM,320,RC,70220,CPT,TC,,,,,,,354,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,169.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,346.92
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323012594,NDC,1,EA,190.99,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,169.9811,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
Assay of Amylase,PX82150,CDM,300,RC,82150,CPT,,,,,,,,191,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,169.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.94,187.18
C-Reactive Protein,PX86140,CDM,300,RC,86140,CPT,,,,,,,,191,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,169.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,187.18
"Chemotherapy, IV Infusion, Add'l Hour",PX96415,CDM,335,RC,96415,CPT,,,,,,,,191,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,169.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,187.18
Fac/Ther Injection Carpal Tunnel,PX20526F,CDM,510,RC,20526,CPT,,,,,,,,191,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,169.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.3414,258.75
Urine Pregnancy Test,PX81025,CDM,300,RC,81025,CPT,,,,,,,,191,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,169.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.89,187.18
DERMABOND PRINEO SKIN CLOSURE SYSTEM 42CM,27200000,CDM,272,RC,,,,12323-MAIN,LOCAL,,,,,200,,First Health,Commercial,both,85,,999999999,percent of total billed charges,170,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
gadoxetate disodium 0.25 MOL/L Solution 10 mL Vial,A9581,CDM,636,RC,A9581,HCPCS,,,,50419032005,NDC,10,ML,200,,First Health,Commercial,both,85,,999999999,percent of total billed charges,170,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,196
iohexol 300 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141363,NDC,100,ML,200,,First Health,Commercial,both,85,,999999999,percent of total billed charges,170,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,294
iohexol 350 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141491,NDC,100,ML,200,,First Health,Commercial,both,85,,999999999,percent of total billed charges,170,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,294
Lacosamide - Ref,PX8023590,CDM,300,RC,80235,CPT,90,,,,,,,200,,First Health,Commercial,both,85,,999999999,percent of total billed charges,170,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.86,196
Assay of Phenytoin Total,PX80185,CDM,300,RC,80185,CPT,,,,,,,,336,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,170.016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,329.28
Xray Mandible Partial Less Than 4 Vws,PX7010001,CDM,320,RC,70100,CPT,TC,,,,,,,347,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,170.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,340.06
Xray Mandible Partial Less Than 4 Vws,PX7010001,CDM,320,RC,70100,CPT,TC,,,,,,,347,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,170.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,340.06
Xray Mandible Partial Less Than 4 Vws,PX7010001,CDM,320,RC,70100,CPT,TC,,,,,,,347,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,170.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,340.06
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059611,NDC,0.25,EA,200.05,,First Health,Commercial,both,85,,999999999,percent of total billed charges,170.0425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.10077,725.3862
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059613,NDC,0.25,EA,200.05,,First Health,Commercial,both,85,,999999999,percent of total billed charges,170.0425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.10077,725.3862
Remove Foreign Body Complic,PX10121F,CDM,510,RC,10121,CPT,,,,,,,,3575,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,170.183,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,114.52,551.36
Remove Foreign Body Complic,PX10121P,CDM,983,RC,10121,CPT,,,,,,,,651,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,170.183,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,114.52,637.98
Ag Detect Nos Eia Mult,PX87449,CDM,300,RC,87449,CPT,,,,,,,,193,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,170.226,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,189.14
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614900,NDC,1,EA,409.89,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,170.268306,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
CT Chest Spine W/O Dye,PX7212801,CDM,350,RC,72128,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,170.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.9552,170.27
CT Chest Spine W/O Dye,PX7212801,CDM,350,RC,72128,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,170.27,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.9552,170.27
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604F,CDM,510,RC,20604,CPT,,,,,,,,344,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,170.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,142.8976,337.12
"Lab Antibody ID,RBC",PX86870,CDM,300,RC,,,,,,,,,,410,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,170.314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,170.314,401.8
"Supply Technicium Sestamibi,per Dose",PXA9500,CDM,343,RC,A9500,HCPCS,,,,,,,,410,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,170.314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,170.314,401.8
Electrolyte Panel,PX80051,CDM,300,RC,80051,CPT,,,,,,,,175,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,170.3275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.43,171.5
"Fac/Trm Hyperkeratotic Skn Lesn,>4",PX11057F,CDM,510,RC,11057,CPT,,,,,,,,175,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,170.3275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.695,174.9
"Gonadotropin, Chorionic (Hcg), Qualitative",PX84703,CDM,300,RC,84703,CPT,,,,,,,,175,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,133.575,percent of total billed charges,170.3275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.9,171.5
Protein E-Phoresis Serum,PX84165,CDM,300,RC,84165,CPT,,,,,,,,175,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,170.3275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,171.5
Protein Elp Interp,PX8416526,CDM,300,RC,84165,CPT,26,,,,,,,175,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,170.3275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,171.5
Fac/Initial Hospital Care Levl II,PX99222F,CDM,510,RC,99222,CPT,,,,,,,,187,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,170.357,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.6798,183.26
"Infect Ag,Eia, Nos, Ea - Ref",PX8744990,CDM,300,RC,87449,CPT,90,,,,,,,187,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,170.357,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,183.26
Initial Hospital Care Levl II,PX99222P,CDM,982,RC,99222,CPT,,,,,,,,187,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,170.357,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.6798,182.0071
RETRIEVAL BAG 12/15MM,27200000,CDM,272,RC,,,,12660-MAIN,LOCAL,,,,,187,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,170.357,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
tobramycin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314064305,NDC,5,ML,191.42,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,170.3638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320990,NDC,1,EA,410.32,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,170.446928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320995,NDC,1,EA,410.32,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,170.446928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
ketoconazole 2 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,168009915,NDC,15,GR,173.97,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,170.4906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
folic acid 5 MG/ML Solution 10 mL Vial,J3490.94,CDM,636,RC,J3490,HCPCS,,,,63323018410,NDC,10,ML,336.94,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,170.49164,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,330.2012
Fac/Removal of Skin Tags,PX11200F,CDM,510,RC,11200,CPT,,,,,,,,348,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,170.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,144.5592,341.04
Fac/Removal of Skin Tags,PX11200F,CDM,510,RC,11200,CPT,,,,,,,,348,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,170.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,144.5592,341.04
Fac/Removal of Skin Tags,PX11200F,CDM,510,RC,11200,CPT,,,,,,,,348,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,170.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,144.5592,341.04
Emergency Level II Visit,PX99282P,CDM,981,RC,99282,CPT,,,,,,,,337,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,170.522,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.9898,328.0021
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021515,NDC,0.5,ML,187.24,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,170.57564,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.779496,199.7926
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,517096001,NDC,10,ML,355.63,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,170.7024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,517096001,NDC,10,ML,355.63,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,170.7024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
8MM ENDOWRIST INSTRUMENTS TIP-UP FENESTRATED GRASPER,27200000,CDM,272,RC,,,,11911-MAIN,LOCAL,,,,,411,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,170.7294,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Bone Marrow Aspiration and Biopsy,PXG0364F,CDM,510,RC,G0364,HCPCS,,,,,,,,411,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,170.7294,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,170.7294,402.78
Chrom Anal 15-20 Cells - Ref,PX8826290,CDM,310,RC,88262,CPT,90,,,,,,,398,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,170.742,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.06,390.04
Exc Skn Bnig0.6-1cm Remain Bdy,PX11421P,CDM,983,RC,11421,CPT,,,,,,,,345,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,170.775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,143.313,614.65
Low Dose CT Lung Ca Screening,PXG029701,CDM,350,RC,G0297,HCPCS,TC,,,,,,,2812,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,170.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,170.82,170.8227
Low Dose CT Lung Ca Screening,PXG029701,CDM,350,RC,G0297,HCPCS,TC,,,,,,,2812,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,170.8227,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,170.82,170.8227
"Hepatitis a Antibody, Tot - Ref",PX8670890,CDM,300,RC,86708,CPT,90,,,,,,,201,,First Health,Commercial,both,85,,999999999,percent of total billed charges,170.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.36,196.98
Hepatitis B Surface Antibody,PX86706,CDM,300,RC,86706,CPT,,,,,,,,201,,First Health,Commercial,both,85,,999999999,percent of total billed charges,170.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,196.98
KIT 3-LUMEN 7FR X 16CM CENTRALVENOUS CDC-42703-P1A,120.37,CDM,272,RC,C1751,HCPCS,,10707-MAIN,LOCAL,,,,,201,,First Health,Commercial,both,85,,999999999,percent of total billed charges,170.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.4954,196.98
"Injection,Sacroiliac Joint(T)",PX27096F,CDM,510,RC,27096,CPT,,,,,,,,881,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,170.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.7,341.06
"Chest Wall Manipulation,Subsequent",PX94668F,CDM,410,RC,94668,CPT,,,,,,,,192,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,170.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.7568,188.16
Hepatitis Be Antibody - Ref,PX8670790,CDM,300,RC,86707,CPT,90,,,,,,,192,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,170.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.61,188.16
Infectious Agent Antigen Detection by Immunoassay With Direct Visual Observation.,PX87811,CDM,300,RC,87811,CPT,,,,,,,,192,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,170.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.94,188.16
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,781309894,NDC,1,EA,193.75,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,170.8875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.461584,189.875
levonorgestrel 1.5 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,68180085211,NDC,1,EA,174.39,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,170.9022,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CT Neck Spine W/O Dye,PX7212501,CDM,350,RC,72125,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,170.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.81,170.92
CT Neck Spine W/O Dye,PX7212501,CDM,350,RC,72125,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,170.92,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.81,170.92
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082143,NDC,1,ML,348.85,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,170.9365,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.48,367.9214
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082143,NDC,1,ML,348.85,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,170.9365,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.48,367.9214
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082143,NDC,1,ML,348.85,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,170.9365,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.48,367.9214
"Echo Heart Xthoracic,Limited",PX9330801,CDM,480,RC,93308,CPT,TC,,,,,,,349,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,171.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,144.9746,342.02
"Echo Heart Xthoracic,Limited",PX9330801,CDM,480,RC,93308,CPT,TC,,,,,,,349,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,171.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,144.9746,342.02
"Echo Heart Xthoracic,Limited",PX9330801,CDM,480,RC,93308,CPT,TC,,,,,,,349,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,171.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,144.9746,342.02
"Morphometric Analysis, Tumor - Ref",PX8836090,CDM,310,RC,88360,CPT,90,,,,,,,349,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,171.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,144.9746,342.02
"Morphometric Analysis, Tumor - Ref",PX8836090,CDM,310,RC,88360,CPT,90,,,,,,,349,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,171.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,144.9746,342.02
"Morphometric Analysis, Tumor - Ref",PX8836090,CDM,310,RC,88360,CPT,90,,,,,,,349,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,171.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,144.9746,342.02
Cardiac Rehab II W/ Monitor,PX93798.02,CDM,943,RC,93798,CPT,,,,,,,,338,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,171.028,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.44,495.55
Initial Rx Burn(S) 1st Degree,PX16000F,CDM,510,RC,16000,CPT,,,,,,,,338,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,171.028,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.4052,331.24
CT Abd&Pelv 1+ Section/Regns,PX7417801,CDM,350,RC,74178,CPT,TC,,,,,,,4226,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,171.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,171.03,504.23
CT Abd&Pelv 1+ Section/Regns,PX7417801,CDM,350,RC,74178,CPT,TC,,,,,,,4226,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,171.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,171.03,504.23
"Cmv, Quant - Ref",PX8749790,CDM,300,RC,87497,CPT,90,,,,,,,194,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,171.108,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.28,190.12
Hiv-1 Antigens W/Hiv 1/2 Antib,PX87389,CDM,300,RC,87389,CPT,,,,,,,,194,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,171.108,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.08,190.12
Lyme Disease Antibody,PX86618,CDM,300,RC,86618,CPT,,,,,,,,194,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,171.108,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.61,190.12
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545P,CDM,983,RC,23545,CPT,,,,,,,,412,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,171.1448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,171.1448,400.9996
"Closed Rx Big Toe Fx,Manip",PX28495P,CDM,983,RC,28495,CPT,,,,,,,,412,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,171.1448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,171.1448,400.9996
Dress/Debrid Large Burn No Anesth,PX16030F,CDM,510,RC,16030,CPT,,,,,,,,399,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,171.171,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,165.7446,391.02
"X-Ray Exam Hip,Bilat W/Pelvis 2 Vws",PX7352101,CDM,320,RC,73521,CPT,TC,,,,,,,399,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,171.171,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,391.02
Xray Lumbosacral 2 or 3 Vws,PX7210001,CDM,320,RC,72100,CPT,TC,,,,,,,399,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,171.171,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,391.02
CCP Antibody,PX86200,CDM,300,RC,86200,CPT,,,,,,,,176,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,171.3008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,172.48
Detect Agent Nos Dna Amp,PX87798,CDM,300,RC,87798,CPT,,,,,,,,176,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,125.1457143,percent of total billed charges,171.3008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,172.48
Eval of Bronchospasm,PX94060,CDM,983,RC,94060,CPT,,,,,,,,176,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,171.3008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.1104,274.21
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151F,CDM,370,RC,99151,CPT,,,,,,,,176,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,171.3008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.1104,172.48
ON Q PAIN BUSTER,27100000,CDM,271,RC,A4305,HCPCS,,6751-MAIN,LOCAL,,,,,194.26,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,171.33732,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
X-Ray Exam Chest 1 View,PX7104501,CDM,320,RC,71045,CPT,TC,,,,,,,357,,Health Partners,Health Partners Care Plans,both,48,,156.23,percent of total billed charges,171.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,349.86
X-Ray Exam Chest 1 View,PX7104501,CDM,320,RC,71045,CPT,TC,,,,,,,357,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,171.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,349.86
"Xray Chest 1 View, Tc",PX7101001,CDM,320,RC,71010,CPT,TC,,,,,,,357,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,171.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.2978,349.86
"Xray Chest 1 View, Tc",PX7101001,CDM,320,RC,71010,CPT,TC,,,,,,,357,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,171.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.2978,349.86
Xray Scapula Complete,PX7301001,CDM,320,RC,73010,CPT,TC,,,,,,,357,,Health Partners,Health Partners Care Plans,both,48,,160.43,percent of total billed charges,171.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,349.86
Xray Scapula Complete,PX7301001,CDM,320,RC,73010,CPT,TC,,,,,,,357,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,171.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,349.86
clotrimazole-betamethasone 1-0.05 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,66993089815,NDC,15,GR,192.55,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,171.3695,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
PHENobarbital 130 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047721,NDC,1,ML,338.93,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,171.49858,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.354486,332.1514
Electrolyte Panel,PX80051,CDM,300,RC,80051,CPT,,,,,,,,175,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,171.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.43,171.5
"Fac/Trm Hyperkeratotic Skn Lesn,>4",PX11057F,CDM,510,RC,11057,CPT,,,,,,,,175,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,171.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.695,174.9
Flu Dna Amp Probe 1st 2 Types,PX87502,CDM,300,RC,87502,CPT,,,,,,,,350,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,171.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.84,343
Flu Dna Amp Probe 1st 2 Types,PX87502,CDM,300,RC,87502,CPT,,,,,,,,350,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,171.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.84,343
Flu Dna Amp Probe 1st 2 Types,PX87502,CDM,300,RC,87502,CPT,,,,,,,,350,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,171.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.84,343
"Gonadotropin, Chorionic (Hcg), Qualitative",PX84703,CDM,300,RC,84703,CPT,,,,,,,,175,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,171.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.9,171.5
Protein E-Phoresis Serum,PX84165,CDM,300,RC,84165,CPT,,,,,,,,175,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,171.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,171.5
Protein Elp Interp,PX8416526,CDM,300,RC,84165,CPT,26,,,,,,,175,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,171.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,171.5
Exc Skin Benig <5mm Remaindr Body,PX11420P,CDM,983,RC,11420,CPT,,,,,,,,299,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,171.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.35,293.02
Fac/Exc Skin Benig<5mm Remaind Bod,PX11420F,CDM,510,RC,11420,CPT,,,,,,,,374,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,171.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.35,264.27
Fac/Ther Injection Carpal Tunnel,PX20526F,CDM,510,RC,20526,CPT,,,,,,,,191,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,171.57,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.46,171.57
Fac/Trm Hyperkeratotic Skn Lesn2-4,PX11056F,CDM,510,RC,11056,CPT,,,,,,,,158,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,171.57,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.52,171.57
Ther Injection Carpal Tunnel,PX20526P,CDM,983,RC,20526,CPT,,,,,,,,248,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,171.57,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.46,243.04
US Transvaginal Tc,PX7683001,CDM,402,RC,76830,CPT,TC,,,,,,,472,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,171.58,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.03,171.58
US Transvaginal Tc,PX7683001,CDM,402,RC,76830,CPT,TC,,,,,,,472,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,171.58,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.03,171.58
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12173-MAIN,LOCAL,,,,,400,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,171.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Lvl 1 Init Hosp Low Mdm or 40 Minutes,PX99221,CDM,982,RC,99221,CPT,,,,,,,,400,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,171.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.16,389.32
Venous Duplex Scan Uni,PX9397101,CDM,921,RC,93971,CPT,TC,,,,,,,809,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,171.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.23,171.6
Venous Duplex Scan Uni,PX9397101,CDM,921,RC,93971,CPT,TC,,,,,,,809,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,171.6,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.23,171.6
aztreonam 1 g Recon Soln 1 Each Vial,J0457.01,CDM,636,RC,J0457,HCPCS,,,,63323040124,NDC,1,EA,176.32,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,171.612256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.32,172.7936
Xray Mandible Partial Less Than 4 Vws,PX7010001,CDM,320,RC,70100,CPT,TC,,,,,,,347,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,171.765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,340.06
Ag Detect Nos Eia Mult,PX87449,CDM,300,RC,87449,CPT,,,,,,,,193,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,171.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,189.14
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127332,NDC,2,ML,176.55,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,171.836115,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.43158,173.019
Declot Vascular Access Device,PX36593F,CDM,510,RC,36593,CPT,,,,,,,,358,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,171.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.7132,350.84
Declot Vascular Access Device,PX36593F,CDM,510,RC,36593,CPT,,,,,,,,358,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,171.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.7132,350.84
Fac/Irrigation of Bladder,PX51700F,CDM,510,RC,51700,CPT,,,,,,,,358,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,171.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.7132,350.84
Fac/Irrigation of Bladder,PX51700F,CDM,510,RC,51700,CPT,,,,,,,,358,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,171.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.7132,350.84
X-Ray Exam Abdomen 1 View,PX7401801,CDM,320,RC,74018,CPT,TC,,,,,,,358,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,171.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,350.84
X-Ray Exam Abdomen 1 View,PX7401801,CDM,320,RC,74018,CPT,TC,,,,,,,358,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,171.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,350.84
Xray Abdomen Single Ap Vw,PX7400001,CDM,320,RC,74000,CPT,TC,,,,,,,358,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,171.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.7132,350.84
Xray Abdomen Single Ap Vw,PX7400001,CDM,320,RC,74000,CPT,TC,,,,,,,358,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,171.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.7132,350.84
X-Ray Exam Entire Spine 1vw,PX7208101,CDM,320,RC,72081,CPT,TC,,,,,,,414,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,171.9756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,405.72
Debride Bone Ea Add 20 Sqcm,PX11047P,CDM,983,RC,11047,CPT,,,,,,,,351,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,171.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,145.8054,341.6283
Debride Bone Ea Add 20 Sqcm,PX11047P,CDM,983,RC,11047,CPT,,,,,,,,351,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,171.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,145.8054,341.6283
Debride Bone Ea Add 20 Sqcm,PX11047P,CDM,983,RC,11047,CPT,,,,,,,,351,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,171.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,145.8054,341.6283
Debride Tissue/Muscle,PX11043P,CDM,983,RC,11043,CPT,,,,,,,,351,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,171.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,145.8054,548.67
Debride Tissue/Muscle,PX11043P,CDM,983,RC,11043,CPT,,,,,,,,351,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,171.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,145.8054,548.67
Debride Tissue/Muscle,PX11043P,CDM,983,RC,11043,CPT,,,,,,,,351,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,171.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,145.8054,548.67
Topiramate - Ref,PX8020190,CDM,300,RC,80201,CPT,90,,,,,,,195,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,171.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.93,191.1
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032225,NDC,1,EA,176.72,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,172.001576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,173.1856
"Calprotectin, Fecal - Ref",PX8399390,CDM,300,RC,83993,CPT,90,,,,,,,401,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,172.029,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18,392.98
Sars-Cov-2 Covid-19 Antibody,PX86769,CDM,300,RC,86769,CPT,,,,,,,,340,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,172.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.63,333.2
X-Ray Exam Chest 3 Views,PX7104701,CDM,320,RC,71047,CPT,TC,,,,,,,340,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,172.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,333.2
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084243,NDC,0.5,ML,202.42,,First Health,Commercial,both,85,,999999999,percent of total billed charges,172.057,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.085268,203.497
HERNIA BELT MENS TRUSS LARGE,120.526,CDM,274,RC,L8310,HCPCS,,12221-MAIN,LOCAL,,,,,60,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,172.1095,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.4,175.16
HERNIA BELT MENS TRUSS MEDIUM,120.526,CDM,274,RC,L8310,HCPCS,,12220-MAIN,LOCAL,,,,,60,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,172.1095,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.4,175.16
HERNIA BELT MENS TRUSS XLARGE,120.526,CDM,274,RC,L8310,HCPCS,,12222-MAIN,LOCAL,,,,,60,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,172.1095,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.4,175.16
Alcohols - Ref,PX8032090,CDM,300,RC,80320,CPT,90,,,,,,,189,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,172.179,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.5106,185.22
"Digital Mamm, Diag, Unilat, Tc W/Cad Perf",PX7706501,CDM,401,RC,77065,CPT,TC,,,,,,,293,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,172.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.03,172.24
"Digital Mamm, Diag, Unilat, Tc W/Cad Perf",PX7706501,CDM,401,RC,77065,CPT,TC,,,,,,,293,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,172.24,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.03,172.24
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604F,CDM,510,RC,20604,CPT,,,,,,,,344,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,172.26,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.13,172.26
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604P,CDM,983,RC,20604,CPT,,,,,,,,229,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,172.26,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.13,224.42
Fac/Removal of Skin Tags,PX11200F,CDM,510,RC,11200,CPT,,,,,,,,348,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,172.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,144.5592,341.04
Insert Non-Tunnel Cv Catheter >5 Years,PX36556F,CDM,510,RC,36556,CPT,,,,,,,,1025,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,172.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.04,439.29
Insert Non-Tunnel Cv Catheter >5 Years,PX36556P,CDM,983,RC,36556,CPT,,,,,,,,1274,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,172.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.04,1248.52
Assay of Ferritin,PX82728,CDM,300,RC,82728,CPT,,,,,,,,177,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,38.2925,percent of total billed charges,172.2741,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.5,173.46
"D-Dimer, Quantitative - Ref",PX8537990,CDM,300,RC,85379,CPT,90,,,,,,,177,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,69.1877551,percent of total billed charges,172.2741,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.33,173.46
Fibrin Degradation Quant,PX85379,CDM,300,RC,85379,CPT,,,,,,,,177,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,69.1877551,percent of total billed charges,172.2741,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.33,173.46
Inj Tendon/Ligament/Cyst,PX20550F,CDM,510,RC,20550,CPT,,,,,,,,177,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,172.2741,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.5258,258.75
"Office/Outpt Visit,New,Levl IV",PX99204F,CDM,510,RC,99204,CPT,,,,,,,,359,,Health Partners,Health Partners Care Plans,both,48,,337.56,percent of total billed charges,172.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.1286,351.82
"Office/Outpt Visit,New,Levl IV",PX99204F,CDM,510,RC,99204,CPT,,,,,,,,359,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,172.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.1286,351.82
"US Complete Joint, Realtime W/ Img Tc",PX7688101,CDM,402,RC,76881,CPT,TC,,,,,,,415,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,172.391,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,406.7
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,781309894,NDC,1,EA,193.75,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,172.4375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.461584,189.875
"Cardioversion, Elective;Extern",PX92960F,CDM,480,RC,92960,CPT,,,,,,,,402,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,172.458,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.9908,568.57
Chem Cautery Granulatn Tissue,PX17250P,CDM,983,RC,17250,CPT,,,,,,,,402,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,172.458,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.9908,391.2666
Lab Imm Spin X-Match,PX8837,CDM,300,RC,86920,CPT,,,,,,,,402,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,172.458,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.22,393.96
"Morphometric Analysis, in Situ Hybridization, Each Probe; Manual, Tech",PX8836801,CDM,310,RC,88368,CPT,TC,,,,,,,402,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,172.458,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.9908,393.96
CCP Antibody,PX86200,CDM,300,RC,86200,CPT,,,,,,,,176,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,172.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.87,172.48
Detect Agent Nos Dna Amp,PX87798,CDM,300,RC,87798,CPT,,,,,,,,176,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,172.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,172.48
Eval of Bronchospasm,PX94060,CDM,983,RC,94060,CPT,,,,,,,,176,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,172.48,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.08,172.48
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151F,CDM,370,RC,99151,CPT,,,,,,,,176,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,172.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.1104,172.48
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801801,NDC,0.8,ML,359.37,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,172.4976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801801,NDC,0.8,ML,359.37,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,172.4976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801810,NDC,0.8,ML,359.37,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,172.4976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801810,NDC,0.8,ML,359.37,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,172.4976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
Drainage of Hematoma/Fluid (T),PX10140F,CDM,510,RC,10140,CPT,,,,,,,,341,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,172.546,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,141.6514,1416.38
Drainage Scrotal Wall Abscess,PX55100P,CDM,983,RC,55100,CPT,,,,,,,,341,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,172.546,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,141.6514,1416.38
"Excis Tendn/Capsule Lesn,Toes",PX28092F,CDM,510,RC,28092,CPT,,,,,,,,1234,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,172.55,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,172.55,878.59
"Excis Tendn/Capsule Lesn,Toes",PX28092P,CDM,983,RC,28092,CPT,,,,,,,,1913,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,172.55,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,172.55,1874.74
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062001,NDC,0.4,ML,189.48,,Medica,Commercial,both,91.1,,7.8,percent of total billed charges,172.61628,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062040,NDC,0.4,ML,189.48,,Medica,Commercial,both,91.1,,7.8,percent of total billed charges,172.61628,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801401,NDC,0.4,ML,189.48,,Medica,Commercial,both,91.1,,7.8,percent of total billed charges,172.61628,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801410,NDC,0.4,ML,189.48,,Medica,Commercial,both,91.1,,7.8,percent of total billed charges,172.61628,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
baricitinib 2 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,2418230,NDC,0.5,EA,203.12,,First Health,Commercial,both,85,,999999999,percent of total billed charges,172.652,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Cmv, Quant - Ref",PX8749790,CDM,300,RC,87497,CPT,90,,,,,,,194,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,172.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.28,190.12
Hiv-1 Antigens W/Hiv 1/2 Antib,PX87389,CDM,300,RC,87389,CPT,,,,,,,,194,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,172.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.08,190.12
Lyme Disease Antibody,PX86618,CDM,300,RC,86618,CPT,,,,,,,,194,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,172.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.61,190.12
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082143,NDC,1,ML,348.85,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,172.68075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.48,367.9214
pyRIDostigmine bromide 10 MG/2ML Solution 2 mL Ampule,25000000,CDM,250,RC,,,,,,781304095,NDC,2,ML,203.16,,First Health,Commercial,both,85,,999999999,percent of total billed charges,172.686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
glucagon rdna (diagnostic) 1 MG Recon Soln 1 Each Vial,J1610.01,CDM,636,RC,J1610,HCPCS,,,,597026010,NDC,1,EA,744.84,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,172.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,172.71,729.9432
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Suspension 10 mL Bottle,63700001,CDM,250,RC,,,,,,24208063562,NDC,10,ML,415.81,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,172.727474,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
albumin human 25% 25 % Solution 50 mL Flex Cont,P9047,CDM,636,RC,P9047,HCPCS,,,,944049301,NDC,50,ML,402.67,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,172.74543,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.66,394.6166
"Echo Heart Xthoracic,Limited",PX9330801,CDM,480,RC,93308,CPT,TC,,,,,,,349,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,172.755,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,144.9746,342.02
"Morphometric Analysis, Tumor - Ref",PX8836090,CDM,310,RC,88360,CPT,90,,,,,,,349,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,172.755,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,144.9746,342.02
Closed Rx IP Jt Dislocation,PX26770F,CDM,510,RC,26770,CPT,,,,,,,,1231,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,172.77,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,168.85,628.15
Closed Rx IP Jt Dislocation,PX26770F,CDM,510,RC,26770,CPT,,,,,,,,1231,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,172.77,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,168.85,628.15
Closed Rx IP Jt Dislocation,PX26770P,CDM,983,RC,26770,CPT,,,,,,,,1353,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,172.77,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,168.85,1325.94
Closed Rx IP Jt Dislocation,PX26770P,CDM,983,RC,26770,CPT,,,,,,,,1353,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,172.77,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,168.85,1325.94
aztreonam 1 g Recon Soln 1 Each Vial,J0457.01,CDM,636,RC,J0457,HCPCS,,,,63323040124,NDC,1,EA,176.32,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,172.7936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.32,172.7936
Closed Rx Mt-Phal Toe Dislocation,PX28630F,CDM,510,RC,28630,CPT,,,,,,,,360,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,172.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.544,352.8
Closed Rx Mt-Phal Toe Dislocation,PX28630F,CDM,510,RC,28630,CPT,,,,,,,,360,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,172.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.544,352.8
RBC Antibody Elution,PX86860,CDM,300,RC,86860,CPT,,,,,,,,360,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,172.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.22,352.8
RBC Antibody Elution,PX86860,CDM,300,RC,86860,CPT,,,,,,,,360,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,172.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.22,352.8
US Head/Neck Tc,PX7653601,CDM,402,RC,76536,CPT,TC,,,,,,,416,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,172.8064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,407.68
"Office/Outpt Visit,Est,Levl IV",PX99214F,CDM,510,RC,99214,CPT,,,,,,,,256,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,172.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.11,230.23
"Office/Outpt Visit,Est,Levl IV",PX99214P,CDM,983,RC,99214,CPT,,,,,,,,256,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,172.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.11,250.88
"Apply Finger Splint,Static",PX29130F,CDM,420,RC,29130,CPT,,,,,,,,196,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,172.872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.4184,192.08
Heterophile Antibodies,PX86308,CDM,300,RC,86308,CPT,,,,,,,,196,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,172.872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,192.08
ON Q PAIN BUSTER,27100000,CDM,271,RC,A4305,HCPCS,,6751-MAIN,LOCAL,,,,,194.26,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,172.8914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
Skin Sub Graft Trnk/Arm/Leg,PX15271F,CDM,510,RC,15271,CPT,,,,,,,,862,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,172.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.83,320.3
Skin Sub Graft Trnk/Arm/Leg,PX15271P,CDM,983,RC,15271,CPT,,,,,,,,705,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,172.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.83,690.9
Creatine Mb Fraction,PX82553,CDM,300,RC,82553,CPT,,,,,,,,353,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,172.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.59,345.94
Creatine Mb Fraction,PX82553,CDM,300,RC,82553,CPT,,,,,,,,353,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,172.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.59,345.94
Creatine Mb Fraction,PX82553,CDM,300,RC,82553,CPT,,,,,,,,353,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,172.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.59,345.94
Fentanyl - Ref,PX8035490,CDM,300,RC,80354,CPT,90,,,,,,,353,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,172.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,345.94
Fentanyl - Ref,PX8035490,CDM,300,RC,80354,CPT,90,,,,,,,353,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,172.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,345.94
Fentanyl - Ref,PX8035490,CDM,300,RC,80354,CPT,90,,,,,,,353,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,172.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,345.94
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155F,CDM,370,RC,99155,CPT,,,,,,,,353,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,172.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,345.94
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155F,CDM,370,RC,99155,CPT,,,,,,,,353,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,172.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,345.94
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155F,CDM,370,RC,99155,CPT,,,,,,,,353,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,172.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,345.94
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155P,CDM,983,RC,99155,CPT,,,,,,,,353,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,172.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,343.5749
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155P,CDM,983,RC,99155,CPT,,,,,,,,353,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,172.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,343.5749
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155P,CDM,983,RC,99155,CPT,,,,,,,,353,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,172.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,343.5749
Pvb Thoracic Single Injection Site W/Img Gid,PX64461F,CDM,510,RC,64461,CPT,,,,,,,,353,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,172.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,604.15
Pvb Thoracic Single Injection Site W/Img Gid,PX64461F,CDM,510,RC,64461,CPT,,,,,,,,353,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,172.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,604.15
Pvb Thoracic Single Injection Site W/Img Gid,PX64461F,CDM,510,RC,64461,CPT,,,,,,,,353,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,172.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,604.15
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127332,NDC,2,ML,176.55,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,173.019,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.43158,173.019
gemcitabine 1 GM/26.3ML Solution 26.3 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018101,NDC,26.3,ML,203.58,,First Health,Commercial,both,85,,999999999,percent of total billed charges,173.043,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
"Ctrl Nosebleed,Anter,Simple",PX30901F,CDM,510,RC,30901,CPT,,,,,,,,342,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,173.052,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,335.16
Ultrasound Breast Limited,PX7664201,CDM,402,RC,76642,CPT,TC,,,,,,,342,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,173.052,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,335.16
Assay of ammonia,PX82140,CDM,300,RC,82140,CPT,,,,,,,,190,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,173.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.36,186.2
Assay of protein urine,PX84156,CDM,300,RC,84156,CPT,,,,,,,,190,,Medica,Commercial,both,91.1,,81.51,percent of total billed charges,173.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.37,186.2
Each Add'l Sequential IV Infusion <1 Hour,PX96367,CDM,260,RC,96367,CPT,,,,,,,,190,,Medica,Commercial,both,91.1,,11.37909091,percent of total billed charges,173.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,186.2
"N Block Inj, Common Digit",PX64632F,CDM,510,RC,64632,CPT,,,,,,,,190,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,173.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.926,258.75
"Tumor Antigen, Ca-125",PX86304,CDM,300,RC,86304,CPT,,,,,,,,190,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,173.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,186.2
hydrocortisone sodium succinate (preservative free) 1000 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9000501,NDC,1,EA,403.54,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,173.11866,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
fosfomycin 3 g Packet 1 Each Box,25000000,CDM,250,RC,,,,,,70700026894,NDC,1,EA,353.41,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,173.1709,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fosfomycin 3 g Packet 1 Each Box,25000000,CDM,250,RC,,,,,,70700026894,NDC,1,EA,353.41,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,173.1709,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fosfomycin 3 g Packet 1 Each Box,25000000,CDM,250,RC,,,,,,70700026894,NDC,1,EA,353.41,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,173.1709,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
azithromycin 200 MG/5ML Recon Susp 15 mL Bottle,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,59762312001,NDC,15,ML,196.35,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,173.1807,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
ROTH NET PLATINUM RETRIEVER,27200000,CDM,272,RC,,,,7518-MAIN,LOCAL,,,,,196.35,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,173.1807,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032225,NDC,1,EA,176.72,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,173.1856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,173.1856
Xray Ribs Bilat 3 Vws With Pa Chest,PX7111101,CDM,320,RC,71111,CPT,TC,,,,,,,417,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,173.2218,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,408.66
Flu Dna Amp Probe 1st 2 Types,PX87502,CDM,300,RC,87502,CPT,,,,,,,,350,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,173.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.84,343
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021588,NDC,0.5,ML,203.87,,First Health,Commercial,both,85,,999999999,percent of total billed charges,173.2895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.779496,199.7926
Layr Clos Wnd Rest Body 2.6-7.5,PX12042F,CDM,510,RC,12042,CPT,,,,,,,,404,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,173.316,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,395.92
Neg Pressure Wound Therapy Dme >50 Sq Cm,PX97606F,CDM,761,RC,97606,CPT,,,,,,,,404,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,173.316,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,395.92
Remove Foreign Body Simple,PX10120F,CDM,510,RC,10120,CPT,,,,,,,,404,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,173.316,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,395.92
Remove Foreign Body Simple,PX10120P,CDM,983,RC,10120,CPT,,,,,,,,404,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,173.316,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,393.2132
Xray Foot Minimum 3 Vws,PX7363001,CDM,320,RC,73630,CPT,TC,,,,,,,404,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,173.316,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,395.92
Xray Knee 3 Vws,PX7356201,CDM,320,RC,73562,CPT,TC,,,,,,,404,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,173.316,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,395.92
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106P,CDM,983,RC,11106,CPT,,,,,,,,204,,First Health,Commercial,both,85,,999999999,percent of total billed charges,173.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.7416,548.67
"Hospital Inpt or Obs Care, Admin/Disch Same Date Straightforward or Low Level Mdm >= 45 Minutes",PX99234,CDM,982,RC,99234,CPT,,,,,,,,464,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,173.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.32,454.72
"Hospital Inpt or Obs Care, Admin/Disch Same Date Straightforward or Low Level Mdm >= 45 Minutes",PX99234,CDM,982,RC,99234,CPT,,,,,,,,464,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,173.42,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.32,454.72
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151F,CDM,510,RC,13151,CPT,,,,,,,,1143,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,173.43,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,173.43,877.89
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151P,CDM,983,RC,13151,CPT,,,,,,,,1177,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,173.43,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,173.43,1153.46
Assay of Ferritin,PX82728,CDM,300,RC,82728,CPT,,,,,,,,177,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,173.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.5,173.46
"D-Dimer, Quantitative - Ref",PX8537990,CDM,300,RC,85379,CPT,90,,,,,,,177,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,173.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.33,173.46
Fibrin Degradation Quant,PX85379,CDM,300,RC,85379,CPT,,,,,,,,177,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,173.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.33,173.46
Inj Tendon/Ligament/Cyst,PX20550F,CDM,510,RC,20550,CPT,,,,,,,,177,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,173.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.5258,258.75
Xray Sinuses Minimum 3 Vws,PX7022001,CDM,320,RC,70220,CPT,TC,,,,,,,354,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,173.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,346.92
Xray Sinuses Minimum 3 Vws,PX7022001,CDM,320,RC,70220,CPT,TC,,,,,,,354,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,173.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,346.92
Xray Sinuses Minimum 3 Vws,PX7022001,CDM,320,RC,70220,CPT,TC,,,,,,,354,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,173.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,346.92
Topiramate - Ref,PX8020190,CDM,300,RC,80201,CPT,90,,,,,,,195,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,173.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.93,191.1
Infliximab - Ref,PX8023090,CDM,300,RC,80230,CPT,90,,,,,,,343,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,173.558,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.36,336.14
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002F,CDM,510,RC,12002,CPT,,,,,,,,343,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,173.558,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,142.4822,336.14
Removal of Skin Tags,PX11200P,CDM,983,RC,11200,CPT,,,,,,,,418,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,173.6372,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,173.6372,406.8394
CT Abd&Pelv 1+ Section/Regns,PX7417801,CDM,350,RC,74178,CPT,TC,,,,,,,4226,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,173.64,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,171.03,504.23
"Destruct Benign Lesion, 15+",PX17111F,CDM,510,RC,17111,CPT,,,,,,,,303,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,173.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.35,277.41
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041100,NDC,0.5,ML,196.94,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,173.70108,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.808876,411.2766
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041110,NDC,0.5,ML,196.94,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,173.70108,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.808876,411.2766
Drain Skin Abscess Complic,PX10061F,CDM,510,RC,10061,CPT,,,,,,,,889,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,173.7151,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.83,447.59
Drain Skin Abscess Complic,PX10061P,CDM,983,RC,10061,CPT,,,,,,,,561,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,173.7151,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.83,549.78
Debride Bone Ea Add 20 Sqcm,PX11047P,CDM,983,RC,11047,CPT,,,,,,,,351,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,173.745,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,145.8054,341.6283
Debride Tissue/Muscle,PX11043P,CDM,983,RC,11043,CPT,,,,,,,,351,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,173.745,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,145.8054,548.67
Diagnostic Anoscopy,PX46600P,CDM,983,RC,46600,CPT,,,,,,,,405,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,173.745,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,394.1865
Assay Other Fluid Chlorides - Ref,PX8243890,CDM,300,RC,82438,CPT,90,,,,,,,197,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,173.754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.58,193.06
Tramadol - Ref,PX8037390,CDM,300,RC,80373,CPT,90,,,,,,,197,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,173.754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.8338,193.06
US Pregnancy Tc Follow-Up,PX7681601,CDM,402,RC,76816,CPT,TC,,,,,,,362,,Health Partners,Health Partners Care Plans,both,48,,351.14,percent of total billed charges,173.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,354.76
US Pregnancy Tc Follow-Up,PX7681601,CDM,402,RC,76816,CPT,TC,,,,,,,362,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,173.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,354.76
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323012594,NDC,1,EA,190.99,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,173.99189,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
Assay of Amylase,PX82150,CDM,300,RC,82150,CPT,,,,,,,,191,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,174.001,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.94,187.18
C-Reactive Protein,PX86140,CDM,300,RC,86140,CPT,,,,,,,,191,,Medica,Commercial,both,91.1,,41.29217391,percent of total billed charges,174.001,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,187.18
"Chemotherapy, IV Infusion, Add'l Hour",PX96415,CDM,335,RC,96415,CPT,,,,,,,,191,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,174.001,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,187.18
Fac/Ther Injection Carpal Tunnel,PX20526F,CDM,510,RC,20526,CPT,,,,,,,,191,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,174.001,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.3414,258.75
Urine Pregnancy Test,PX81025,CDM,300,RC,81025,CPT,,,,,,,,191,,Medica,Commercial,both,91.1,,87,percent of total billed charges,174.001,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.89,187.18
TRAY PNEUMOTHORAX 14FR 29CM 19 CATHETER SIDEPORTS G56537,120.496,CDM,272,RC,,,,11677-MAIN,LOCAL,,,,,419,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,174.0526,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.0526,410.62
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604F,CDM,510,RC,20604,CPT,,,,,,,,344,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,174.064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,142.8976,337.12
I&D Bartholin Gland Abscess,PX56420F,CDM,510,RC,56420,CPT,,,,,,,,429,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,174.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.08,420.42
I&D Bartholin Gland Abscess,PX56420P,CDM,983,RC,56420,CPT,,,,,,,,286,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,174.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,118.8044,278.3638
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151F,CDM,510,RC,13151,CPT,,,,,,,,1143,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,174.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,173.43,877.89
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151F,CDM,510,RC,13151,CPT,,,,,,,,1143,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,174.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,173.43,877.89
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151P,CDM,983,RC,13151,CPT,,,,,,,,1177,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,174.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,173.43,1153.46
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151P,CDM,983,RC,13151,CPT,,,,,,,,1177,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,174.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,173.43,1153.46
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494301,NDC,0.5,ML,419.2,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,174.13568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.38,410.8454
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494300,NDC,0.5,ML,419.23,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,174.148142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.38,410.8454
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598F,CDM,510,RC,97598,CPT,,,,,,,,406,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,174.174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,168.6524,397.88
"Apply Short Leg Cast,Walker",PX29425F,CDM,510,RC,29425,CPT,,,,,,,,179,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,174.2207,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.3566,234.62
C Diff Amplified Probe,PX87493,CDM,300,RC,87493,CPT,,,,,,,,179,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,174.2207,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.17,175.42
Fibrinogen Test - Ref,PX8536690,CDM,300,RC,85366,CPT,90,,,,,,,179,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,174.2207,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.77,175.42
TUBE GASTROSTOMY 18FR REPLACEMENT DYND70318,120.256,CDM,271,RC,B4087,HCPCS,,407-MAIN,LOCAL,,,,,179,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,174.2207,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.53,175.42
SET CRICOTHYROTOMY CATHETER 3.5MM ID,120.251,CDM,272,RC,,,,4306-MAIN,LOCAL,,,,,363,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,174.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.7902,355.74
SET CRICOTHYROTOMY CATHETER 3.5MM ID,120.251,CDM,272,RC,,,,4306-MAIN,LOCAL,,,,,363,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,174.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.7902,355.74
SET CRICOTHYROTOMY CATHETER 4MM ID,120.251,CDM,272,RC,,,,3452-MAIN,LOCAL,,,,,363,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,174.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.7902,355.74
SET CRICOTHYROTOMY CATHETER 4MM ID,120.251,CDM,272,RC,,,,3452-MAIN,LOCAL,,,,,363,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,174.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.7902,355.74
SET CRICOTHYROTOMY CATHETER 6MM ID,120.251,CDM,272,RC,,,,2887-MAIN,LOCAL,,,,,363,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,174.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.7902,355.74
SET CRICOTHYROTOMY CATHETER 6MM ID,120.251,CDM,272,RC,,,,2887-MAIN,LOCAL,,,,,363,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,174.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.7902,355.74
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,517096001,NDC,10,ML,355.63,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,174.2587,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,517096001,NDC,10,ML,355.63,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,174.2587,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,517096001,NDC,10,ML,355.63,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,174.2587,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041105,NDC,1,ML,419.67,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,174.330918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.808876,411.2766
Closure Superf Wnd Dehis Simple,PX12020F,CDM,510,RC,12020,CPT,,,,,,,,632,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,174.3573,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,117.15,624.7
Closure Superf Wnd Dehis Simple,PX12020P,CDM,983,RC,12020,CPT,,,,,,,,422,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,174.3573,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,117.15,624.7
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,43598054910,NDC,100,ML,205.14,,First Health,Commercial,both,85,,999999999,percent of total billed charges,174.369,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
tobramycin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314064305,NDC,5,ML,191.42,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,174.38362,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Apply Finger Splint,Static",PX29130F,CDM,420,RC,29130,CPT,,,,,,,,196,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,174.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.4184,192.08
Heterophile Antibodies,PX86308,CDM,300,RC,86308,CPT,,,,,,,,196,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,174.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,192.08
"Chemotherapy, IV Push, Single Drug",PX96409,CDM,335,RC,96409,CPT,,,,,,,,502,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,174.51,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.88,174.51
"Chemotherapy, IV Push, Single Drug",PX96409,CDM,335,RC,96409,CPT,,,,,,,,502,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,174.51,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.88,174.51
Exc Skn Bnig0.6-1cm Remain Bdy,PX11421P,CDM,983,RC,11421,CPT,,,,,,,,345,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,174.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,143.313,614.65
Collect Blood From Picc,PX36592,CDM,949,RC,36592,CPT,,,,,,,,198,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,174.636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.2492,194.04
Debride Muscle Ea Add 20 Sqcm,PX11046P,CDM,983,RC,11046,CPT,,,,,,,,198,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,174.636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.2492,192.7134
Insert Simple Cath Foley,PX51702F,CDM,510,RC,51702,CPT,,,,,,,,198,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,174.636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.2492,194.04
KIT PLEUREVAC CHEST DRAIN S-1100-08LF,120.2,CDM,272,RC,,,,4190-MAIN,LOCAL,,,,,198,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,174.636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.0466,194.04
Lyme Screen,PX7585,CDM,300,RC,86618,CPT,,,,,,,,198,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,174.636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.61,194.04
Reconstruc of Nail Bed W Graft,PX11762F,CDM,510,RC,11762,CPT,,,,,,,,1901,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,174.6784,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,117.58,599.1
Cardiac Rehab II Eval,PX93798.05,CDM,943,RC,93798,CPT,,,,,,,,364,,Health Partners,Health Partners Care Plans,both,48,,319.5072222,percent of total billed charges,174.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.44,495.55
Cardiac Rehab II Eval,PX93798.05,CDM,943,RC,93798,CPT,,,,,,,,364,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,174.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.44,495.55
Drain/Inject Large Joint/Bursa,PX20610F,CDM,510,RC,20610,CPT,,,,,,,,364,,Health Partners,Health Partners Care Plans,both,48,,312.25,percent of total billed charges,174.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,151.2056,356.72
Drain/Inject Large Joint/Bursa,PX20610F,CDM,510,RC,20610,CPT,,,,,,,,364,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,174.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,151.2056,356.72
Xray Forearm 2 Vws,PX7309001,CDM,320,RC,73090,CPT,TC,,,,,,,364,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,174.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,356.72
Xray Forearm 2 Vws,PX7309001,CDM,320,RC,73090,CPT,TC,,,,,,,364,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,174.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,356.72
Creatine Mb Fraction,PX82553,CDM,300,RC,82553,CPT,,,,,,,,353,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,174.735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.59,345.94
Fentanyl - Ref,PX8035490,CDM,300,RC,80354,CPT,90,,,,,,,353,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,174.735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,345.94
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155F,CDM,370,RC,99155,CPT,,,,,,,,353,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,174.735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,345.94
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155P,CDM,983,RC,99155,CPT,,,,,,,,353,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,174.735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,343.5749
Pvb Thoracic Single Injection Site W/Img Gid,PX64461F,CDM,510,RC,64461,CPT,,,,,,,,353,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,174.735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,604.15
azithromycin 200 MG/5ML Recon Susp 15 mL Bottle,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,59762312001,NDC,15,ML,196.35,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,174.7515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
ROTH NET PLATINUM RETRIEVER,27200000,CDM,272,RC,,,,7518-MAIN,LOCAL,,,,,196.35,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,174.7515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PREP KIT STAPLE 18MM,27200000,CDM,278,RC,C1713,HCPCS,,11658-MAIN,LOCAL,,,,,420.75,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,174.77955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PREP KIT STAPLE 20MM,27200000,CDM,278,RC,C1713,HCPCS,,11659-MAIN,LOCAL,,,,,420.75,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,174.77955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Chem Cautery Granulatn Tissue,PX17250F,CDM,510,RC,17250,CPT,,,,,,,,170,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,174.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,174.9
Chem Cautery Granulatn Tissue,PX17250P,CDM,983,RC,17250,CPT,,,,,,,,402,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,174.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.9908,391.2666
"Destruct Benign Lesion, 1-14",PX17110F,CDM,510,RC,17110,CPT,,,,,,,,302,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,174.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.4508,295.96
"Destruct Benign Lesion, 1-14",PX17110P,CDM,983,RC,17110,CPT,,,,,,,,521,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,174.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,507.0893
"Destruct Benign Lesion, 15+",PX17111F,CDM,510,RC,17111,CPT,,,,,,,,303,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,174.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.8662,296.94
"Drain Finger Abscess,Simple",PX26010F,CDM,510,RC,26010,CPT,,,,,,,,310,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,174.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.774,303.8
"Drain Finger Abscess,Simple",PX26010P,CDM,983,RC,26010,CPT,,,,,,,,207,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,174.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.9878,201.4731
Drain Skin Abscess Simple,PX10060F,CDM,510,RC,10060,CPT,,,,,,,,296,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,174.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.9584,290.08
Drain Skin Abscess Simple,PX10060P,CDM,983,RC,10060,CPT,,,,,,,,293,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,174.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.7122,285.1769
Dress/Debrid Med Burn No Anesth,PX16025F,CDM,510,RC,16025,CPT,,,,,,,,366,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,174.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,152.0364,358.68
Dress/Debrid Med Burn No Anesth,PX16025P,CDM,983,RC,16025,CPT,,,,,,,,244,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,174.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.3576,237.4852
Dress/Debrid Small Burn No Anes,PX16020F,CDM,510,RC,16020,CPT,,,,,,,,313,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,174.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.0202,306.74
Fac/Removal of Skin Tags,PX11200F,CDM,510,RC,11200,CPT,,,,,,,,348,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,174.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,144.5592,341.04
"Fac/Trm Hyperkeratotic Skn Lesn,>4",PX11057F,CDM,510,RC,11057,CPT,,,,,,,,175,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,174.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.695,174.9
Fac/Trm Hyperkeratotic Skn Lesn2-4,PX11056F,CDM,510,RC,11056,CPT,,,,,,,,158,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,174.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.6332,174.9
Initial Rx Burn(S) 1st Degree,PX16000F,CDM,510,RC,16000,CPT,,,,,,,,338,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,174.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.4052,331.24
Neg Pressure Wound Therapy Dme </=50 Sq Cm,PX97605F,CDM,510,RC,97605,CPT,,,,,,,,396,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,174.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,164.4984,388.08
"Non-Select. Wound Debride., W/O Anesth.; Top. Appl./Wound Assess./Instruct., per Sess.",PX97602,CDM,761,RC,97602,CPT,,,,,,,,212,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,174.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.0648,207.76
"Pare/Cut Hyperkeratotic Skin Lesion, Single",PX11055F,CDM,510,RC,11055,CPT,,,,,,,,145,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,174.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.233,174.9
Removal of Nail Plate,PX11730F,CDM,510,RC,11730,CPT,,,,,,,,229,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,174.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.1266,224.42
Removal of Skin Tags,PX11200P,CDM,983,RC,11200,CPT,,,,,,,,418,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,174.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,173.6372,406.8394
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002F,CDM,510,RC,12002,CPT,,,,,,,,343,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,174.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,142.4822,336.14
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002P,CDM,983,RC,12002,CPT,,,,,,,,486,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,174.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,473.0238
Repr Superf Wnd Body <2.5cm,PX12001F,CDM,510,RC,12001,CPT,,,,,,,,311,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,174.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,129.1894,304.78
Repr Superf Wnd Body <2.5cm,PX12001P,CDM,983,RC,12001,CPT,,,,,,,,293,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,174.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.7122,285.1769
Repr Superf Wnd Body 7.6-12.5,PX12004F,CDM,510,RC,12004,CPT,,,,,,,,453,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,174.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,443.94
Repr Superf Wnd Body 7.6-12.5,PX12004P,CDM,983,RC,12004,CPT,,,,,,,,614,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,174.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,597.6062
Repr Superf Wnd Face <2.5cm,PX12011F,CDM,510,RC,12011,CPT,,,,,,,,335,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,174.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Repr Superf Wnd Face <2.5cm,PX12011P,CDM,983,RC,12011,CPT,,,,,,,,461,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,174.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,448.6913
Repr Superf Wnd Face >30cm,PX12018F,CDM,510,RC,12018,CPT,,,,,,,,713,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,174.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,698.74
Repr Superf Wnd Face 2.6-5,PX12013F,CDM,510,RC,12013,CPT,,,,,,,,375,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,174.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.775,367.5
Repr Superf Wnd Face 2.6-5,PX12013P,CDM,983,RC,12013,CPT,,,,,,,,681,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,174.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,662.8173
Repr Superf Wnd Face 5.1-7.5,PX12014F,CDM,510,RC,12014,CPT,,,,,,,,453,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,174.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,443.94
Repr Superf Wnd Face 5.1-7.5,PX12014P,CDM,983,RC,12014,CPT,,,,,,,,819,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,174.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,797.1327
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597F,CDM,510,RC,97597,CPT,,,,,,,,266,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,174.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.4964,260.68
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597P,CDM,983,RC,97597,CPT,,,,,,,,274,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,174.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,113.8196,266.6842
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102F,CDM,510,RC,11102,CPT,,,,,,,,171,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,174.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.0334,174.9
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102P,CDM,983,RC,11102,CPT,,,,,,,,465,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,174.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,452.5845
"Chest Wall Manipulation,Subsequent",PX94668F,CDM,410,RC,94668,CPT,,,,,,,,192,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,174.912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.7568,188.16
Hepatitis Be Antibody - Ref,PX8670790,CDM,300,RC,86707,CPT,90,,,,,,,192,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,174.912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.61,188.16
Infectious Agent Antigen Detection by Immunoassay With Direct Visual Observation.,PX87811,CDM,300,RC,87811,CPT,,,,,,,,192,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,174.912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.94,188.16
Remove Intrauterine Device,PX58301,CDM,983,RC,58301,CPT,,,,,,,,357,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,174.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.2978,347.4681
Remove Intrauterine Device,PX58301,CDM,983,RC,58301,CPT,,,,,,,,357,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,174.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.2978,347.4681
Remove Intrauterine Device,PX58301,CDM,983,RC,58301,CPT,,,,,,,,357,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,174.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.2978,347.4681
X-Ray Exam Chest 1 View,PX7104501,CDM,320,RC,71045,CPT,TC,,,,,,,357,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,79.9,percent of total billed charges,174.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,349.86
X-Ray Exam Chest 1 View,PX7104501,CDM,320,RC,71045,CPT,TC,,,,,,,357,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,174.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,349.86
X-Ray Exam Chest 1 View,PX7104501,CDM,320,RC,71045,CPT,TC,,,,,,,357,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,174.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,349.86
"Xray Chest 1 View, Tc",PX7101001,CDM,320,RC,71010,CPT,TC,,,,,,,357,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,174.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.2978,349.86
"Xray Chest 1 View, Tc",PX7101001,CDM,320,RC,71010,CPT,TC,,,,,,,357,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,174.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.2978,349.86
"Xray Chest 1 View, Tc",PX7101001,CDM,320,RC,71010,CPT,TC,,,,,,,357,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,174.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.2978,349.86
Xray Scapula Complete,PX7301001,CDM,320,RC,73010,CPT,TC,,,,,,,357,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,174.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,349.86
Xray Scapula Complete,PX7301001,CDM,320,RC,73010,CPT,TC,,,,,,,357,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,174.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,349.86
Xray Scapula Complete,PX7301001,CDM,320,RC,73010,CPT,TC,,,,,,,357,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,174.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,349.86
fosfomycin 3 g Packet 1 Each Box,25000000,CDM,250,RC,,,,,,70700026894,NDC,1,EA,353.41,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,174.93795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Needle Biopsy, Lymph Node(S)",PX38505F,CDM,510,RC,38505,CPT,,,,,,,,667,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,175.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53,360.43
HERNIA BELT MENS TRUSS LARGE,120.526,CDM,274,RC,L8310,HCPCS,,12221-MAIN,LOCAL,,,,,60,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,175.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.4,175.16
HERNIA BELT MENS TRUSS LARGE,120.526,CDM,274,RC,L8310,HCPCS,,12221-MAIN,LOCAL,,,,,60,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,175.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.4,175.16
HERNIA BELT MENS TRUSS LARGE,120.526,CDM,274,RC,L8310,HCPCS,,12221-MAIN,LOCAL,,,,,60,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,175.16,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.4,175.16
HERNIA BELT MENS TRUSS MEDIUM,120.526,CDM,274,RC,L8310,HCPCS,,12220-MAIN,LOCAL,,,,,60,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,175.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.4,175.16
HERNIA BELT MENS TRUSS MEDIUM,120.526,CDM,274,RC,L8310,HCPCS,,12220-MAIN,LOCAL,,,,,60,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,175.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.4,175.16
HERNIA BELT MENS TRUSS MEDIUM,120.526,CDM,274,RC,L8310,HCPCS,,12220-MAIN,LOCAL,,,,,60,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,175.16,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.4,175.16
HERNIA BELT MENS TRUSS XLARGE,120.526,CDM,274,RC,L8310,HCPCS,,12222-MAIN,LOCAL,,,,,60,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,175.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.4,175.16
HERNIA BELT MENS TRUSS XLARGE,120.526,CDM,274,RC,L8310,HCPCS,,12222-MAIN,LOCAL,,,,,60,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,175.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.4,175.16
HERNIA BELT MENS TRUSS XLARGE,120.526,CDM,274,RC,L8310,HCPCS,,12222-MAIN,LOCAL,,,,,60,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,175.16,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.4,175.16
Hepatobiliary System Imaging,PX7822601,CDM,341,RC,78226,CPT,TC,,,,,,,2776,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,175.17,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,175.17,517.37
Hepatobiliary System Imaging,PX7822601,CDM,341,RC,78226,CPT,TC,,,,,,,2776,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,175.17,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,175.17,517.37
C-Peptide - Ref,PX8468190,CDM,300,RC,84681,CPT,90,,,,,,,180,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,175.194,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,176.4
"Closed Rx Radial Head Disloc,Child",PX24640P,CDM,983,RC,24640,CPT,,,,,,,,180,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,175.194,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.772,206.02
"Infect Ea Organ, Amp Prob - Ref",PX8779890,CDM,300,RC,87798,CPT,90,,,,,,,180,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,125.1457143,percent of total billed charges,175.194,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,176.4
Mrsa by Amplification Na,PX87641,CDM,300,RC,87641,CPT,,,,,,,,180,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,175.194,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,176.4
Protein Elp,PX84166,CDM,300,RC,84166,CPT,,,,,,,,180,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,175.194,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.35,176.4
"2019-Ncov Coronavirus, Sars-Cov-2/2019-Ncov (Covid-19)",PXU000290,CDM,300,RC,U0002,HCPCS,90,,,,,,,365,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,175.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,357.7
"2019-Ncov Coronavirus, Sars-Cov-2/2019-Ncov (Covid-19)",PXU000290,CDM,300,RC,U0002,HCPCS,90,,,,,,,365,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,175.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,357.7
Sars-Cov-2 Covid-19 Amp Prb,PX8763590,CDM,300,RC,87635,CPT,90,,,,,,,365,,Health Partners,Health Partners Care Plans,both,48,,52.13,percent of total billed charges,175.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,357.7
Sars-Cov-2 Covid-19 Amp Prb,PX8763590,CDM,300,RC,87635,CPT,90,,,,,,,365,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,175.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,357.7
X-Ray Exam Femur Min 2 Vws,PX7355201,CDM,320,RC,73552,CPT,TC,,,,,,,365,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,175.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
X-Ray Exam Femur Min 2 Vws,PX7355201,CDM,320,RC,73552,CPT,TC,,,,,,,365,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,175.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Ankle Minimum 3 Vws,PX7361001,CDM,320,RC,73610,CPT,TC,,,,,,,365,,Health Partners,Health Partners Care Plans,both,48,,228.09,percent of total billed charges,175.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Ankle Minimum 3 Vws,PX7361001,CDM,320,RC,73610,CPT,TC,,,,,,,365,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,175.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Calcaneus Minimum 2 Vws,PX7365001,CDM,320,RC,73650,CPT,TC,,,,,,,365,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,175.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Calcaneus Minimum 2 Vws,PX7365001,CDM,320,RC,73650,CPT,TC,,,,,,,365,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,175.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Clavicle Complete,PX7300001,CDM,320,RC,73000,CPT,TC,,,,,,,365,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,175.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Clavicle Complete,PX7300001,CDM,320,RC,73000,CPT,TC,,,,,,,365,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,175.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Elbow 2 Vws,PX7307001,CDM,320,RC,73070,CPT,TC,,,,,,,365,,Health Partners,Health Partners Care Plans,both,48,,164.13,percent of total billed charges,175.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Elbow 2 Vws,PX7307001,CDM,320,RC,73070,CPT,TC,,,,,,,365,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,175.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Hand 2vws Tc,PX7312001,CDM,320,RC,73120,CPT,TC,,,,,,,365,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,175.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,357.7
Xray Hand 2vws Tc,PX7312001,CDM,320,RC,73120,CPT,TC,,,,,,,365,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,175.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,357.7
Xray Humerus Minimum 2 Vws,PX7306001,CDM,320,RC,73060,CPT,TC,,,,,,,365,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,175.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Humerus Minimum 2 Vws,PX7306001,CDM,320,RC,73060,CPT,TC,,,,,,,365,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,175.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Shoulder Minimum 2 Vws,PX7303001,CDM,320,RC,73030,CPT,TC,,,,,,,365,,Health Partners,Health Partners Care Plans,both,48,,220.2883333,percent of total billed charges,175.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Shoulder Minimum 2 Vws,PX7303001,CDM,320,RC,73030,CPT,TC,,,,,,,365,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,175.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Sternum 2vws Tc,PX7112001,CDM,320,RC,71120,CPT,TC,,,,,,,365,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,175.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Sternum 2vws Tc,PX7112001,CDM,320,RC,71120,CPT,TC,,,,,,,365,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,175.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Tibia & Fibula 2 Vws,PX7359001,CDM,320,RC,73590,CPT,TC,,,,,,,365,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,175.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Tibia & Fibula 2 Vws,PX7359001,CDM,320,RC,73590,CPT,TC,,,,,,,365,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,175.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Wrist 2 Vws,PX7310001,CDM,320,RC,73100,CPT,TC,,,,,,,365,,Health Partners,Health Partners Care Plans,both,48,,318.64,percent of total billed charges,175.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Wrist 2 Vws,PX7310001,CDM,320,RC,73100,CPT,TC,,,,,,,365,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,175.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Sinuses Minimum 3 Vws,PX7022001,CDM,320,RC,70220,CPT,TC,,,,,,,354,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,175.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,346.92
"Morphometric Analysis, in Situ Hybridization, Each Probe; Manual, Tech",PX8836801,CDM,310,RC,88368,CPT,TC,,,,,,,402,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,175.264,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.37,175.264
"Morphometric Analysis, in Situ Hybridization, Each Probe; Manual, Tech",PX8836801,CDM,310,RC,88368,CPT,TC,,,,,,,402,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,175.264,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.37,175.264
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041100,NDC,0.5,ML,196.94,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,175.2766,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.808876,411.2766
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041110,NDC,0.5,ML,196.94,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,175.2766,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.808876,411.2766
Closure Superf Wnd Dehis Simple,PX12020P,CDM,983,RC,12020,CPT,,,,,,,,422,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,175.2988,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,175.2988,548.67
Assay Other Fluid Chlorides - Ref,PX8243890,CDM,300,RC,82438,CPT,90,,,,,,,197,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,175.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.58,193.06
Tramadol - Ref,PX8037390,CDM,300,RC,80373,CPT,90,,,,,,,197,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,175.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.8338,193.06
Partial Bone Scan,PX7830001,CDM,341,RC,78300,CPT,TC,,,,,,,1391,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,175.381,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,118.89,351.05
clotrimazole-betamethasone 1-0.05 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,66993089815,NDC,15,GR,192.55,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,175.41305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Apply Short Leg Cast,Walker",PX29425F,CDM,510,RC,29425,CPT,,,,,,,,179,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,175.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.3566,234.62
C Diff Amplified Probe,PX87493,CDM,300,RC,87493,CPT,,,,,,,,179,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,175.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.17,175.42
Declot Vascular Access Device,PX36593F,CDM,510,RC,36593,CPT,,,,,,,,358,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,175.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.7132,350.84
Declot Vascular Access Device,PX36593F,CDM,510,RC,36593,CPT,,,,,,,,358,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,175.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.7132,350.84
Declot Vascular Access Device,PX36593F,CDM,510,RC,36593,CPT,,,,,,,,358,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,175.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.7132,350.84
Fac/Irrigation of Bladder,PX51700F,CDM,510,RC,51700,CPT,,,,,,,,358,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,175.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.7132,350.84
Fac/Irrigation of Bladder,PX51700F,CDM,510,RC,51700,CPT,,,,,,,,358,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,175.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.7132,350.84
Fac/Irrigation of Bladder,PX51700F,CDM,510,RC,51700,CPT,,,,,,,,358,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,175.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.7132,350.84
Fibrinogen Test - Ref,PX8536690,CDM,300,RC,85366,CPT,90,,,,,,,179,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,175.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.77,175.42
TUBE GASTROSTOMY 18FR REPLACEMENT DYND70318,120.256,CDM,271,RC,B4087,HCPCS,,407-MAIN,LOCAL,,,,,179,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,175.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.53,175.42
X-Ray Exam Abdomen 1 View,PX7401801,CDM,320,RC,74018,CPT,TC,,,,,,,358,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,225.65,percent of total billed charges,175.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,350.84
X-Ray Exam Abdomen 1 View,PX7401801,CDM,320,RC,74018,CPT,TC,,,,,,,358,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,175.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,350.84
X-Ray Exam Abdomen 1 View,PX7401801,CDM,320,RC,74018,CPT,TC,,,,,,,358,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,175.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,350.84
Xray Abdomen Single Ap Vw,PX7400001,CDM,320,RC,74000,CPT,TC,,,,,,,358,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,175.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.7132,350.84
Xray Abdomen Single Ap Vw,PX7400001,CDM,320,RC,74000,CPT,TC,,,,,,,358,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,175.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.7132,350.84
Xray Abdomen Single Ap Vw,PX7400001,CDM,320,RC,74000,CPT,TC,,,,,,,358,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,175.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.7132,350.84
"Surgical Diagnostic Exam, Anorectal",PX45990P,CDM,983,RC,45990,CPT,,,,,,,,409,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,175.461,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,169.8986,2452.93
Inpt or Obs Disch Day Mngmt <=30 Minutes,PX99238,CDM,982,RC,99238,CPT,,,,,,,,199,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,175.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.6646,193.6867
"US,Preg. Uterus,Fetal/Mat.Eval.,>1st Trim.(>/= 14 Wks 0 Dys),Transabd;Single/First Gest., Tech",PX7680501,CDM,402,RC,76805,CPT,TC,,,,,,,562,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,175.53,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.92,175.53
"US,Preg. Uterus,Fetal/Mat.Eval.,>1st Trim.(>/= 14 Wks 0 Dys),Transabd;Single/First Gest., Tech",PX7680501,CDM,402,RC,76805,CPT,TC,,,,,,,562,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,175.53,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.92,175.53
Xray Mandible Partial Less Than 4 Vws,PX7010001,CDM,320,RC,70100,CPT,TC,,,,,,,347,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,175.582,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,340.06
Art Upper Extremity-Ltd,PX9393101,CDM,921,RC,93931,CPT,TC,,,,,,,718,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,175.67,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.75,175.67
Art Upper Extremity-Ltd,PX9393101,CDM,921,RC,93931,CPT,TC,,,,,,,718,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,175.67,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.75,175.67
Dress/Debrid Med Burn No Anesth,PX16025F,CDM,510,RC,16025,CPT,,,,,,,,366,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,175.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,152.0364,358.68
Dress/Debrid Med Burn No Anesth,PX16025F,CDM,510,RC,16025,CPT,,,,,,,,366,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,175.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,152.0364,358.68
Apply Long Arm Splint,PX29105F,CDM,510,RC,29105,CPT,,,,,,,,290,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,175.72,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.87,175.72
Apply Long Arm Splint,PX29105P,CDM,983,RC,29105,CPT,,,,,,,,385,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,175.72,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.87,377.3
Ag Detect Nos Eia Mult,PX87449,CDM,300,RC,87449,CPT,,,,,,,,193,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,175.823,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,189.14
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614900,NDC,1,EA,409.89,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,175.84281,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
"Lab Antibody ID,RBC",PX86870,CDM,300,RC,,,,,,,,,,410,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,175.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,170.314,401.8
"Supply Technicium Sestamibi,per Dose",PXA9500,CDM,343,RC,A9500,HCPCS,,,,,,,,410,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,175.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,170.314,401.8
"Office/Outpt Visit,New,Levl IV",PX99204F,CDM,510,RC,99204,CPT,,,,,,,,359,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,380.7925,percent of total billed charges,175.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.1286,351.82
"Office/Outpt Visit,New,Levl IV",PX99204F,CDM,510,RC,99204,CPT,,,,,,,,359,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,175.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.1286,351.82
"Office/Outpt Visit,New,Levl IV",PX99204F,CDM,510,RC,99204,CPT,,,,,,,,359,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,175.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.1286,351.82
"Office/Outpt Visit,New,Levl IV",PX99204P,CDM,983,RC,99204,CPT,,,,,,,,359,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,380.7925,percent of total billed charges,175.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.1286,349.4147
"Office/Outpt Visit,New,Levl IV",PX99204P,CDM,983,RC,99204,CPT,,,,,,,,359,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,175.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.1286,349.4147
"Office/Outpt Visit,New,Levl IV",PX99204P,CDM,983,RC,99204,CPT,,,,,,,,359,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,175.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.1286,349.4147
"Drain Finger Abscess,Simple",PX26010P,CDM,983,RC,26010,CPT,,,,,,,,207,,First Health,Commercial,both,85,,999999999,percent of total billed charges,175.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.9878,201.4731
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320990,NDC,1,EA,410.32,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,176.02728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320995,NDC,1,EA,410.32,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,176.02728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,517096001,NDC,10,ML,355.63,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,176.03685,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Fac/Removal of Skin Tags,PX11200F,CDM,510,RC,11200,CPT,,,,,,,,348,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,176.088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,144.5592,341.04
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801801,NDC,0.8,ML,359.37,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,9.81,percent of total billed charges,176.0913,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801801,NDC,0.8,ML,359.37,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,176.0913,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801801,NDC,0.8,ML,359.37,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,176.0913,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801810,NDC,0.8,ML,359.37,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,9.81,percent of total billed charges,176.0913,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801810,NDC,0.8,ML,359.37,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,176.0913,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801810,NDC,0.8,ML,359.37,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,176.0913,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402F,CDM,510,RC,11402,CPT,,,,,,,,424,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,176.1296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.1296,614.65
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402P,CDM,983,RC,11402,CPT,,,,,,,,424,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,176.1296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.1296,614.65
Lab H Pylori Stool Ag,PX87338,CDM,300,RC,87338,CPT,,,,,,,,424,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,176.1296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,415.52
Xray Foot 2 Vws,PX7362001,CDM,320,RC,73620,CPT,TC,,,,,,,367,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,176.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,359.66
Xray Foot 2 Vws,PX7362001,CDM,320,RC,73620,CPT,TC,,,,,,,367,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,176.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,359.66
Alcohol Biomarkers; 1 or 2 - Ref,PX8032190,CDM,300,RC,80321,CPT,90,,,,,,,181,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,176.1673,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.1874,177.38
"Lyme Disease, Antibody - Ref",PX8661890,CDM,300,RC,86618,CPT,90,,,,,,,181,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,176.1673,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.61,177.38
PHALINX STERILE TRIAL SIZER 45A00000,27200000,CDM,272,RC,,,,12959-MAIN,LOCAL,,,,,181,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,176.1673,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Collect Blood From Picc,PX36592,CDM,949,RC,36592,CPT,,,,,,,,198,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,176.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.2492,194.04
Debride Muscle Ea Add 20 Sqcm,PX11046P,CDM,983,RC,11046,CPT,,,,,,,,198,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,176.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.2492,192.7134
Insert Simple Cath Foley,PX51702F,CDM,510,RC,51702,CPT,,,,,,,,198,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,176.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.2492,194.04
KIT PLEUREVAC CHEST DRAIN S-1100-08LF,120.2,CDM,272,RC,,,,4190-MAIN,LOCAL,,,,,198,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,176.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.0466,194.04
Lyme Screen,PX7585,CDM,300,RC,86618,CPT,,,,,,,,198,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,176.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.61,194.04
8MM ENDOWRIST INSTRUMENTS TIP-UP FENESTRATED GRASPER,27200000,CDM,272,RC,,,,11911-MAIN,LOCAL,,,,,411,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,176.319,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Bone Marrow Aspiration and Biopsy,PXG0364F,CDM,510,RC,G0364,HCPCS,,,,,,,,411,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,176.319,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,170.7294,402.78
C-Peptide - Ref,PX8468190,CDM,300,RC,84681,CPT,90,,,,,,,180,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,176.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,176.4
Closed Rx Mt-Phal Toe Dislocation,PX28630F,CDM,510,RC,28630,CPT,,,,,,,,360,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,176.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.544,352.8
Closed Rx Mt-Phal Toe Dislocation,PX28630F,CDM,510,RC,28630,CPT,,,,,,,,360,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,176.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.544,352.8
Closed Rx Mt-Phal Toe Dislocation,PX28630F,CDM,510,RC,28630,CPT,,,,,,,,360,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,176.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.544,352.8
"Closed Rx Radial Head Disloc,Child",PX24640P,CDM,983,RC,24640,CPT,,,,,,,,180,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,176.4,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.04,218.61
DERMABOND PRINEO SKIN CLOSURE SYSTEM 42CM,27200000,CDM,272,RC,,,,12323-MAIN,LOCAL,,,,,200,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,176.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
gadoxetate disodium 0.25 MOL/L Solution 10 mL Vial,A9581,CDM,636,RC,A9581,HCPCS,,,,50419032005,NDC,10,ML,200,,United Healthcare,All Payer,outpatient,88.2,,10.2,percent of total billed charges,176.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,196
"Infect Ea Organ, Amp Prob - Ref",PX8779890,CDM,300,RC,87798,CPT,90,,,,,,,180,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,176.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,176.4
iohexol 300 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141363,NDC,100,ML,200,,United Healthcare,All Payer,outpatient,88.2,,1.614024501,percent of total billed charges,176.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,294
iohexol 350 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141491,NDC,100,ML,200,,United Healthcare,All Payer,outpatient,88.2,,1.614024501,percent of total billed charges,176.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,294
Lacosamide - Ref,PX8023590,CDM,300,RC,80235,CPT,90,,,,,,,200,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,176.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.86,196
Mrsa by Amplification Na,PX87641,CDM,300,RC,87641,CPT,,,,,,,,180,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,176.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.17,176.4
Protein Elp,PX84166,CDM,300,RC,84166,CPT,,,,,,,,180,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,176.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.35,176.4
RBC Antibody Elution,PX86860,CDM,300,RC,86860,CPT,,,,,,,,360,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,176.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.22,352.8
RBC Antibody Elution,PX86860,CDM,300,RC,86860,CPT,,,,,,,,360,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,176.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.22,352.8
RBC Antibody Elution,PX86860,CDM,300,RC,86860,CPT,,,,,,,,360,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,176.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.22,352.8
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059611,NDC,0.25,EA,200.05,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,176.4441,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.10077,725.3862
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059613,NDC,0.25,EA,200.05,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,176.4441,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.10077,725.3862
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084252,NDC,0.5,ML,207.65,,First Health,Commercial,both,85,,999999999,percent of total billed charges,176.5025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.085268,203.497
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,781309894,NDC,1,EA,193.75,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,176.50625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.461584,189.875
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082143,NDC,1,ML,348.85,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,176.5181,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.48,367.9214
"Injection Hip Arthrogram,Anesth",PX27095F,CDM,510,RC,27095,CPT,,,,,,,,425,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,176.545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.545,416.5
"Injection Hip Arthrogram,Anesth",PX27095P,CDM,983,RC,27095,CPT,,,,,,,,425,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,176.545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.545,413.6525
US Abdomen Limited Tc,PX7670501,CDM,402,RC,76705,CPT,TC,,,,,,,425,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,176.545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,416.5
US Ext Non-Vasc Img Lmtd,PX7688201,CDM,402,RC,76882,CPT,TC,,,,,,,425,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,176.545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,416.5
"Echo Heart Xthoracic,Limited",PX9330801,CDM,480,RC,93308,CPT,TC,,,,,,,349,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,176.594,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,144.9746,342.02
"Morphometric Analysis, Tumor - Ref",PX8836090,CDM,310,RC,88360,CPT,90,,,,,,,349,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,176.594,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,144.9746,342.02
SCOPE ASCOPE4 CYSTO STERILE 601001000,120.497,CDM,272,RC,A4649,HCPCS,,11662-MAIN,LOCAL,,,,,368,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,176.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,152.8672,360.64
SCOPE ASCOPE4 CYSTO STERILE 601001000,120.497,CDM,272,RC,A4649,HCPCS,,11662-MAIN,LOCAL,,,,,368,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,176.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,152.8672,360.64
acetaZOLAMIDE 500 MG Recon Soln 1 Each Vial,J1120.01,CDM,636,RC,J1120,HCPCS,,,,39822019001,NDC,1,EA,207.84,,First Health,Commercial,both,85,,999999999,percent of total billed charges,176.664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.336736,203.6832
"Excis Tendn/Capsule Lesn,Toes",PX28092F,CDM,510,RC,28092,CPT,,,,,,,,1234,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,176.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,172.55,878.59
"Excis Tendn/Capsule Lesn,Toes",PX28092F,CDM,510,RC,28092,CPT,,,,,,,,1234,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,176.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,172.55,878.59
"Excis Tendn/Capsule Lesn,Toes",PX28092P,CDM,983,RC,28092,CPT,,,,,,,,1913,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,176.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,172.55,1874.74
"Excis Tendn/Capsule Lesn,Toes",PX28092P,CDM,983,RC,28092,CPT,,,,,,,,1913,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,176.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,172.55,1874.74
Remove Intrauterine Device,PX58301,CDM,983,RC,58301,CPT,,,,,,,,357,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,176.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.2978,347.4681
X-Ray Exam Chest 1 View,PX7104501,CDM,320,RC,71045,CPT,TC,,,,,,,357,,Humana Choice Care,All Medicare plans,outpatient,49.5,,109.33125,percent of total billed charges,176.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,349.86
"Xray Chest 1 View, Tc",PX7101001,CDM,320,RC,71010,CPT,TC,,,,,,,357,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,176.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.2978,349.86
Xray Scapula Complete,PX7301001,CDM,320,RC,73010,CPT,TC,,,,,,,357,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,176.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,349.86
"Cmv, Quant - Ref",PX8749790,CDM,300,RC,87497,CPT,90,,,,,,,194,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,176.734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.28,190.12
Hiv-1 Antigens W/Hiv 1/2 Antib,PX87389,CDM,300,RC,87389,CPT,,,,,,,,194,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,176.734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.08,190.12
Lyme Disease Antibody,PX86618,CDM,300,RC,86618,CPT,,,,,,,,194,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,176.734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.61,190.12
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545P,CDM,983,RC,23545,CPT,,,,,,,,412,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,176.748,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,171.1448,400.9996
"Closed Rx Big Toe Fx,Manip",PX28495P,CDM,983,RC,28495,CPT,,,,,,,,412,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,176.748,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,171.1448,400.9996
Fluoroscopy Guid Needle Plcmt Tc,PX7700201,CDM,320,RC,77002,CPT,TC,,,,,,,662,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,176.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,59.77,176.84
Fluoroscopy Guid Needle Plcmt Tc,PX7700201,CDM,320,RC,77002,CPT,TC,,,,,,,662,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,176.84,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,59.77,176.84
ON Q PAIN BUSTER,27100000,CDM,271,RC,A4305,HCPCS,,6751-MAIN,LOCAL,,,,,194.26,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,176.97086,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
"Inpatient Consult, Level III",PX99253,CDM,983,RC,99253,CPT,,,,,,,,374,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,177.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.07,366.52
"Inpatient Consult, Level III",PX99253,CDM,983,RC,99253,CPT,,,,,,,,374,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,177.01,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.07,366.52
Flu Dna Amp Probe 1st 2 Types,PX87502,CDM,300,RC,87502,CPT,,,,,,,,350,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,177.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.84,343
Inpt or Obs Disch Day Mngmt <=30 Minutes,PX99238,CDM,982,RC,99238,CPT,,,,,,,,199,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,177.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.6646,193.6867
"Close Rx Dist Fingr Fx,Manipulatn",PX26755F,CDM,510,RC,26755,CPT,,,,,,,,335,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,177.14,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,177.14,692.49
"Close Rx Dist Fingr Fx,Manipulatn",PX26755P,CDM,983,RC,26755,CPT,,,,,,,,1260,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,177.14,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,177.14,1234.8
Debride Skin/Subq Ea Ad 20sqcm,PX11045P,CDM,983,RC,11045,CPT,,,,,,,,182,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,177.1406,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.6028,177.1406
Immunocytochemistry,PX3993,CDM,310,RC,88342,CPT,TC,,,,,,,182,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,158.855,percent of total billed charges,177.1406,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.6028,178.36
Infec Agent Direct Probe - Ref,PX8779990,CDM,300,RC,87799,CPT,90,,,,,,,182,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,177.1406,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.28,178.36
Declot Vascular Access Device,PX36593F,CDM,510,RC,36593,CPT,,,,,,,,358,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,177.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.7132,350.84
Fac/Irrigation of Bladder,PX51700F,CDM,510,RC,51700,CPT,,,,,,,,358,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,177.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.7132,350.84
X-Ray Exam Abdomen 1 View,PX7401801,CDM,320,RC,74018,CPT,TC,,,,,,,358,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,177.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,350.84
Xray Abdomen Single Ap Vw,PX7400001,CDM,320,RC,74000,CPT,TC,,,,,,,358,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,177.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.7132,350.84
"Hepatitis a Antibody, Tot - Ref",PX8670890,CDM,300,RC,86708,CPT,90,,,,,,,201,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,177.282,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.36,196.98
Hepatitis B Surface Antibody,PX86706,CDM,300,RC,86706,CPT,,,,,,,,201,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,177.282,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,196.98
KIT 3-LUMEN 7FR X 16CM CENTRALVENOUS CDC-42703-P1A,120.37,CDM,272,RC,C1751,HCPCS,,10707-MAIN,LOCAL,,,,,201,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,177.282,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.4954,196.98
Alcohol Biomarkers; 1 or 2 - Ref,PX8032190,CDM,300,RC,80321,CPT,90,,,,,,,181,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,177.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.1874,177.38
"Lyme Disease, Antibody - Ref",PX8661890,CDM,300,RC,86618,CPT,90,,,,,,,181,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,177.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.61,177.38
PHALINX STERILE TRIAL SIZER 45A00000,27200000,CDM,272,RC,,,,12959-MAIN,LOCAL,,,,,181,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,177.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
US Pregnancy Tc Follow-Up,PX7681601,CDM,402,RC,76816,CPT,TC,,,,,,,362,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,351,percent of total billed charges,177.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,354.76
US Pregnancy Tc Follow-Up,PX7681601,CDM,402,RC,76816,CPT,TC,,,,,,,362,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,177.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,354.76
US Pregnancy Tc Follow-Up,PX7681601,CDM,402,RC,76816,CPT,TC,,,,,,,362,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,177.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,354.76
Acetaminophen,PX80307E,CDM,300,RC,80307,CPT,,,,,,,,370,,Health Partners,Health Partners Care Plans,both,48,,328.4733333,percent of total billed charges,177.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Acetaminophen,PX80307E,CDM,300,RC,80307,CPT,,,,,,,,370,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,177.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Alcohol,PX80307A,CDM,300,RC,80307,CPT,,,,,,,,370,,Health Partners,Health Partners Care Plans,both,48,,328.4733333,percent of total billed charges,177.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Alcohol,PX80307A,CDM,300,RC,80307,CPT,,,,,,,,370,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,177.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Salicylate,PX80307D,CDM,300,RC,80307,CPT,,,,,,,,370,,Health Partners,Health Partners Care Plans,both,48,,328.4733333,percent of total billed charges,177.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Salicylate,PX80307D,CDM,300,RC,80307,CPT,,,,,,,,370,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,177.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Urine Drug Screen,PX80307B,CDM,300,RC,80307,CPT,,,,,,,,370,,Health Partners,Health Partners Care Plans,both,48,,328.4733333,percent of total billed charges,177.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Urine Drug Screen,PX80307B,CDM,300,RC,80307,CPT,,,,,,,,370,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,177.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Xray Elbow 3+Vws Tc,PX7308001,CDM,320,RC,73080,CPT,TC,,,,,,,370,,Health Partners,Health Partners Care Plans,both,48,,233.89,percent of total billed charges,177.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,362.6
Xray Elbow 3+Vws Tc,PX7308001,CDM,320,RC,73080,CPT,TC,,,,,,,370,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,177.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,362.6
Debride Bone Ea Add 20 Sqcm,PX11047P,CDM,983,RC,11047,CPT,,,,,,,,351,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,177.606,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,145.8054,341.6283
Debride Tissue/Muscle,PX11043P,CDM,983,RC,11043,CPT,,,,,,,,351,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,177.606,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,145.8054,548.67
X-Ray Exam Entire Spine 1vw,PX7208101,CDM,320,RC,72081,CPT,TC,,,,,,,414,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,177.606,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,405.72
CT Abdomen W/Dye,PX7416001,CDM,350,RC,74160,CPT,TC,,,,,,,3413,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,177.6336,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.11,354.34
Topiramate - Ref,PX8020190,CDM,300,RC,80201,CPT,90,,,,,,,195,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,177.645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.93,191.1
ACCESSORY KIT FOR GROSHONG 16GA,120.46,CDM,272,RC,C1751,HCPCS,,2967-MAIN,LOCAL,,,,,209,,First Health,Commercial,both,85,,999999999,percent of total billed charges,177.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.8186,204.82
Infection Agent Detect Dna/Rna Probe Tq 12-25,PX87507,CDM,300,RC,87507,CPT,,,,,,,,209,,First Health,Commercial,both,85,,999999999,percent of total billed charges,177.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.8186,382.15
"Organic Acid, Single, Qnt - Ref",PX8392190,CDM,300,RC,83921,CPT,90,,,,,,,209,,First Health,Commercial,both,85,,999999999,percent of total billed charges,177.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.45,204.82
"Office/Outpt Visit,New,Levl IV",PX99204F,CDM,510,RC,99204,CPT,,,,,,,,359,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,177.705,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.1286,351.82
"Office/Outpt Visit,New,Levl IV",PX99204P,CDM,983,RC,99204,CPT,,,,,,,,359,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,177.705,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.1286,349.4147
Hepatobiliary System Imaging,PX7822601,CDM,341,RC,78226,CPT,TC,,,,,,,2776,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,177.79,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,175.17,517.37
Resp Virus 6-11 Targets,PX87632,CDM,300,RC,87632,CPT,,,,,,,,428,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,177.7912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,177.7912,419.44
Xray Thoracic Spine 2 Vws,PX7207001,CDM,320,RC,72070,CPT,TC,,,,,,,428,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,177.7912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,419.44
SET CRICOTHYROTOMY CATHETER 3.5MM ID,120.251,CDM,272,RC,,,,4306-MAIN,LOCAL,,,,,363,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,177.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.7902,355.74
SET CRICOTHYROTOMY CATHETER 3.5MM ID,120.251,CDM,272,RC,,,,4306-MAIN,LOCAL,,,,,363,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,177.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.7902,355.74
SET CRICOTHYROTOMY CATHETER 3.5MM ID,120.251,CDM,272,RC,,,,4306-MAIN,LOCAL,,,,,363,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,177.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.7902,355.74
SET CRICOTHYROTOMY CATHETER 4MM ID,120.251,CDM,272,RC,,,,3452-MAIN,LOCAL,,,,,363,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,177.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.7902,355.74
SET CRICOTHYROTOMY CATHETER 4MM ID,120.251,CDM,272,RC,,,,3452-MAIN,LOCAL,,,,,363,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,177.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.7902,355.74
SET CRICOTHYROTOMY CATHETER 4MM ID,120.251,CDM,272,RC,,,,3452-MAIN,LOCAL,,,,,363,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,177.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.7902,355.74
SET CRICOTHYROTOMY CATHETER 6MM ID,120.251,CDM,272,RC,,,,2887-MAIN,LOCAL,,,,,363,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,177.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.7902,355.74
SET CRICOTHYROTOMY CATHETER 6MM ID,120.251,CDM,272,RC,,,,2887-MAIN,LOCAL,,,,,363,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,177.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.7902,355.74
SET CRICOTHYROTOMY CATHETER 6MM ID,120.251,CDM,272,RC,,,,2887-MAIN,LOCAL,,,,,363,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,177.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.7902,355.74
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801801,NDC,0.8,ML,359.37,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,177.88815,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801810,NDC,0.8,ML,359.37,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,177.88815,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
DERMABOND PRINEO SKIN CLOSURE SYSTEM 42CM,27200000,CDM,272,RC,,,,12323-MAIN,LOCAL,,,,,200,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
gadoxetate disodium 0.25 MOL/L Solution 10 mL Vial,A9581,CDM,636,RC,A9581,HCPCS,,,,50419032005,NDC,10,ML,200,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,196
iohexol 300 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141363,NDC,100,ML,200,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,294
iohexol 350 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141491,NDC,100,ML,200,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,294
Lacosamide - Ref,PX8023590,CDM,300,RC,80235,CPT,90,,,,,,,200,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.86,196
"US Complete Joint, Realtime W/ Img Tc",PX7688101,CDM,402,RC,76881,CPT,TC,,,,,,,415,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,178.035,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,406.7
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059611,NDC,0.25,EA,200.05,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,178.0445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.10077,725.3862
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059613,NDC,0.25,EA,200.05,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,178.0445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.10077,725.3862
Voriconazole - Ref,PX8028590,CDM,300,RC,80285,CPT,90,,,,,,,183,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,178.1139,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.86,179.34
Low Dose CT Lung Ca Screen WO Contrast,PX7127101,CDM,350,RC,71271,CPT,TC,,,,,,,1286,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,178.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.21,178.16
Low Dose CT Lung Ca Screen WO Contrast,PX7127101,CDM,350,RC,71271,CPT,TC,,,,,,,1286,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,178.16,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.21,178.16
Closed Rx Mt-Phal Toe Dislocation,PX28630F,CDM,510,RC,28630,CPT,,,,,,,,360,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,178.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.544,352.8
RBC Antibody Elution,PX86860,CDM,300,RC,86860,CPT,,,,,,,,360,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,178.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.22,352.8
I&D Bartholin Gland Abscess,PX56420F,CDM,510,RC,56420,CPT,,,,,,,,429,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,178.2066,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.08,420.42
CT Pelvis W/Dye,PX7219301,CDM,350,RC,72193,CPT,TC,,,,,,,3330,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,178.2772,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.11,356.31
Cardiac Rehab II Eval,PX93798.05,CDM,943,RC,93798,CPT,,,,,,,,364,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,56.99152941,percent of total billed charges,178.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.44,495.55
Cardiac Rehab II Eval,PX93798.05,CDM,943,RC,93798,CPT,,,,,,,,364,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,178.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.44,495.55
Cardiac Rehab II Eval,PX93798.05,CDM,943,RC,93798,CPT,,,,,,,,364,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,178.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.44,495.55
Debride Skin/Subq Ea Ad 20sqcm,PX11045P,CDM,983,RC,11045,CPT,,,,,,,,182,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,178.36,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.05,178.36
Drain/Inject Large Joint/Bursa,PX20610F,CDM,510,RC,20610,CPT,,,,,,,,364,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,54.45428571,percent of total billed charges,178.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,151.2056,356.72
Drain/Inject Large Joint/Bursa,PX20610F,CDM,510,RC,20610,CPT,,,,,,,,364,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,178.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,151.2056,356.72
Drain/Inject Large Joint/Bursa,PX20610F,CDM,510,RC,20610,CPT,,,,,,,,364,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,178.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,151.2056,356.72
Immunocytochemistry,PX3993,CDM,310,RC,88342,CPT,TC,,,,,,,182,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,178.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.6028,178.36
Infec Agent Direct Probe - Ref,PX8779990,CDM,300,RC,87799,CPT,90,,,,,,,182,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,178.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.28,178.36
Xray Forearm 2 Vws,PX7309001,CDM,320,RC,73090,CPT,TC,,,,,,,364,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,308.7,percent of total billed charges,178.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,356.72
Xray Forearm 2 Vws,PX7309001,CDM,320,RC,73090,CPT,TC,,,,,,,364,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,178.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,356.72
Xray Forearm 2 Vws,PX7309001,CDM,320,RC,73090,CPT,TC,,,,,,,364,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,178.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,356.72
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Suspension 10 mL Bottle,63700001,CDM,250,RC,,,,,,24208063562,NDC,10,ML,415.81,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,178.38249,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone sodium succinate (preservative free) 250 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001305,NDC,1,EA,183.32,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,178.425356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
US Head/Neck Tc,PX7653601,CDM,402,RC,76536,CPT,TC,,,,,,,416,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,178.464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,407.68
AIRSEAL ROBOTIC Xi CAP AND OBTURATOR WITH BLADELESS OPTICAL TIP,27200000,CDM,272,RC,,,,12208-MAIN,LOCAL,,,,,210,,First Health,Commercial,both,85,,999999999,percent of total billed charges,178.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
AIRSEAL ROBOTIC Xi TRI LUMEN FILTERED TUBE SET WITH ACTIVATED CHARCOAL,27200000,CDM,272,RC,,,,12209-MAIN,LOCAL,,,,,210,,First Health,Commercial,both,85,,999999999,percent of total billed charges,178.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Apply Forearm Cast,PX29075F,CDM,510,RC,29075,CPT,,,,,,,,210,,First Health,Commercial,both,85,,999999999,percent of total billed charges,178.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,234.62
Chorionic gonadotropin test,PX84702,CDM,300,RC,84702,CPT,,,,,,,,210,,First Health,Commercial,both,85,,999999999,percent of total billed charges,178.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.8,205.8
"Excision of Nail Fold, Toe",PX11765F,CDM,510,RC,11765,CPT,,,,,,,,210,,First Health,Commercial,both,85,,999999999,percent of total billed charges,178.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,348.35
Fac/Hospital Discharge Day>30 Min,PX99239F,CDM,510,RC,99239,CPT,,,,,,,,210,,First Health,Commercial,both,85,,999999999,percent of total billed charges,178.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,205.8
"Inject Trigger Point, 1 or 2",PX20552P,CDM,983,RC,20552,CPT,,,,,,,,210,,First Health,Commercial,both,85,,999999999,percent of total billed charges,178.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,258.75
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084243,NDC,0.5,ML,202.42,,United Healthcare,All Payer,outpatient,88.2,,154.8066667,percent of total billed charges,178.53444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.085268,203.497
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279210,NDC,10,ML,429.84,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,178.555536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,178.555536,421.2432
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279410,NDC,10,ML,429.84,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,178.555536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,178.555536,421.2432
"Apply Finger Splint,Static",PX29130F,CDM,420,RC,29130,CPT,,,,,,,,196,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,178.556,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.4184,192.08
Heterophile Antibodies,PX86308,CDM,300,RC,86308,CPT,,,,,,,,196,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,178.556,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,192.08
Cyto Non Gyn,PX8811201,CDM,310,RC,88112,CPT,TC,,,,,,,372,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,178.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,364.56
Cyto Non Gyn,PX8811201,CDM,310,RC,88112,CPT,TC,,,,,,,372,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,178.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,364.56
Creatine Mb Fraction,PX82553,CDM,300,RC,82553,CPT,,,,,,,,353,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,178.618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.59,345.94
Fentanyl - Ref,PX8035490,CDM,300,RC,80354,CPT,90,,,,,,,353,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,178.618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,345.94
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155F,CDM,370,RC,99155,CPT,,,,,,,,353,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,178.618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,345.94
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155P,CDM,983,RC,99155,CPT,,,,,,,,353,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,178.618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,343.5749
Pvb Thoracic Single Injection Site W/Img Gid,PX64461F,CDM,510,RC,64461,CPT,,,,,,,,353,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,178.618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,604.15
RELOAD SUREFORM 60 2.5 WHITE 6 ROW BOX/12,27200000,CDM,272,RC,,,,12261-MAIN,LOCAL,,,,,430,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,178.622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 60 3.5 BLUE,27200000,CDM,272,RC,,,,12084-MAIN,LOCAL,,,,,430,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,178.622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 60 4.3 GREEN,27200000,CDM,272,RC,,,,12085-MAIN,LOCAL,,,,,430,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,178.622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
fosfomycin 3 g Packet 1 Each Box,25000000,CDM,250,RC,,,,,,70700026894,NDC,1,EA,353.41,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,178.82546,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"2019-Ncov Coronavirus, Sars-Cov-2/2019-Ncov (Covid-19)",PXU000290,CDM,300,RC,U0002,HCPCS,90,,,,,,,365,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,178.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,357.7
"2019-Ncov Coronavirus, Sars-Cov-2/2019-Ncov (Covid-19)",PXU000290,CDM,300,RC,U0002,HCPCS,90,,,,,,,365,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,178.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,357.7
"2019-Ncov Coronavirus, Sars-Cov-2/2019-Ncov (Covid-19)",PXU000290,CDM,300,RC,U0002,HCPCS,90,,,,,,,365,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,178.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,357.7
"Closed Rx Spont Hip Disloc,Anesth",PX27257P,CDM,983,RC,27257,CPT,,,,,,,,365,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,178.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,151.621,1404.08
"Closed Rx Spont Hip Disloc,Anesth",PX27257P,CDM,983,RC,27257,CPT,,,,,,,,365,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,178.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,151.621,1404.08
"Closed Rx Spont Hip Disloc,Anesth",PX27257P,CDM,983,RC,27257,CPT,,,,,,,,365,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,178.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,151.621,1404.08
Sars-Cov-2 Covid-19 Amp Prb,PX8763590,CDM,300,RC,87635,CPT,90,,,,,,,365,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,5.488461538,percent of total billed charges,178.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,357.7
Sars-Cov-2 Covid-19 Amp Prb,PX8763590,CDM,300,RC,87635,CPT,90,,,,,,,365,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,178.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,357.7
Sars-Cov-2 Covid-19 Amp Prb,PX8763590,CDM,300,RC,87635,CPT,90,,,,,,,365,,United Healthcare,All Medicare advantage plans,outpatient,49,,85.33,percent of total billed charges,178.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,357.7
X-Ray Exam Femur Min 2 Vws,PX7355201,CDM,320,RC,73552,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,178.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
X-Ray Exam Femur Min 2 Vws,PX7355201,CDM,320,RC,73552,CPT,TC,,,,,,,365,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,178.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
X-Ray Exam Femur Min 2 Vws,PX7355201,CDM,320,RC,73552,CPT,TC,,,,,,,365,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,178.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Ankle Minimum 3 Vws,PX7361001,CDM,320,RC,73610,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,176.0642857,percent of total billed charges,178.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Ankle Minimum 3 Vws,PX7361001,CDM,320,RC,73610,CPT,TC,,,,,,,365,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,178.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Ankle Minimum 3 Vws,PX7361001,CDM,320,RC,73610,CPT,TC,,,,,,,365,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,178.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Calcaneus Minimum 2 Vws,PX7365001,CDM,320,RC,73650,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,110.34,percent of total billed charges,178.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Calcaneus Minimum 2 Vws,PX7365001,CDM,320,RC,73650,CPT,TC,,,,,,,365,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,178.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Calcaneus Minimum 2 Vws,PX7365001,CDM,320,RC,73650,CPT,TC,,,,,,,365,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,178.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Clavicle Complete,PX7300001,CDM,320,RC,73000,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,73,percent of total billed charges,178.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Clavicle Complete,PX7300001,CDM,320,RC,73000,CPT,TC,,,,,,,365,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,178.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Clavicle Complete,PX7300001,CDM,320,RC,73000,CPT,TC,,,,,,,365,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,178.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Elbow 2 Vws,PX7307001,CDM,320,RC,73070,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,219,percent of total billed charges,178.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Elbow 2 Vws,PX7307001,CDM,320,RC,73070,CPT,TC,,,,,,,365,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,178.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Elbow 2 Vws,PX7307001,CDM,320,RC,73070,CPT,TC,,,,,,,365,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,178.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Hand 2vws Tc,PX7312001,CDM,320,RC,73120,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,135.63,percent of total billed charges,178.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,357.7
Xray Hand 2vws Tc,PX7312001,CDM,320,RC,73120,CPT,TC,,,,,,,365,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,178.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,357.7
Xray Hand 2vws Tc,PX7312001,CDM,320,RC,73120,CPT,TC,,,,,,,365,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,178.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,357.7
Xray Humerus Minimum 2 Vws,PX7306001,CDM,320,RC,73060,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,72.26666667,percent of total billed charges,178.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Humerus Minimum 2 Vws,PX7306001,CDM,320,RC,73060,CPT,TC,,,,,,,365,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,178.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Humerus Minimum 2 Vws,PX7306001,CDM,320,RC,73060,CPT,TC,,,,,,,365,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,178.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Shoulder Minimum 2 Vws,PX7303001,CDM,320,RC,73030,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,152.2708333,percent of total billed charges,178.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Shoulder Minimum 2 Vws,PX7303001,CDM,320,RC,73030,CPT,TC,,,,,,,365,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,178.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Shoulder Minimum 2 Vws,PX7303001,CDM,320,RC,73030,CPT,TC,,,,,,,365,,United Healthcare,All Medicare advantage plans,outpatient,49,,193.45,percent of total billed charges,178.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Sternum 2vws Tc,PX7112001,CDM,320,RC,71120,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,178.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Sternum 2vws Tc,PX7112001,CDM,320,RC,71120,CPT,TC,,,,,,,365,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,178.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Sternum 2vws Tc,PX7112001,CDM,320,RC,71120,CPT,TC,,,,,,,365,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,178.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Tibia & Fibula 2 Vws,PX7359001,CDM,320,RC,73590,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,226.215,percent of total billed charges,178.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Tibia & Fibula 2 Vws,PX7359001,CDM,320,RC,73590,CPT,TC,,,,,,,365,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,178.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Tibia & Fibula 2 Vws,PX7359001,CDM,320,RC,73590,CPT,TC,,,,,,,365,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,178.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Wrist 2 Vws,PX7310001,CDM,320,RC,73100,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,178.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Wrist 2 Vws,PX7310001,CDM,320,RC,73100,CPT,TC,,,,,,,365,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,178.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Wrist 2 Vws,PX7310001,CDM,320,RC,73100,CPT,TC,,,,,,,365,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,178.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032F,CDM,510,RC,12032,CPT,,,,,,,,386,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,178.8527,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.76,632.31
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032P,CDM,983,RC,12032,CPT,,,,,,,,647,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,178.8527,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.76,634.06
azithromycin 200 MG/5ML Recon Susp 15 mL Bottle,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,59762312001,NDC,15,ML,196.35,,Medica,Commercial,both,91.1,,28.105,percent of total billed charges,178.87485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
ROTH NET PLATINUM RETRIEVER,27200000,CDM,272,RC,,,,7518-MAIN,LOCAL,,,,,196.35,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,178.87485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Hepatitis a Antibody, Tot - Ref",PX8670890,CDM,300,RC,86708,CPT,90,,,,,,,201,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,178.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.36,196.98
Hepatitis B Surface Antibody,PX86706,CDM,300,RC,86706,CPT,,,,,,,,201,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,178.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,196.98
KIT 3-LUMEN 7FR X 16CM CENTRALVENOUS CDC-42703-P1A,120.37,CDM,272,RC,C1751,HCPCS,,10707-MAIN,LOCAL,,,,,201,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,178.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.4954,196.98
Xray Ribs Bilat 3 Vws With Pa Chest,PX7111101,CDM,320,RC,71111,CPT,TC,,,,,,,417,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,178.893,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,408.66
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,703574811,NDC,100,ML,183.92,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,179.009336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.174958,180.2416
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,781344071,NDC,1,EA,430.94,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,179.012476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,179.012476,460.7862
TUBE TRACH SIZE 3.0MM ID 4.5MM OD SHILEY PEDIATRIC 3.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1185-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,179.0872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 3.5MM ID 5.2MM OD SHILEY PEDIATRIC,120.287,CDM,272,RC,A7520,HCPCS,,8813-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,179.0872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 4.0MM ID 5.9MM OD SHILEY PEDIATRIC 4.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1187-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,179.0872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 5 7.0MM ID 10.1MM OD SHILEY CUFFED 5CN70H,120.287,CDM,272,RC,A7521,HCPCS,,10350-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,179.0872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 5.0MM ID 7.1MM OD SHILEY PEDIATRIC 5.0PED,120.287,CDM,272,RC,A7520,HCPCS,,8814-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,179.0872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 6 6.0MM ID 8.3MM OD SHILEY CUFFED 6SCT,120.287,CDM,272,RC,A7521,HCPCS,,8812-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,179.0872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 6 6.4MM ID 10.8MM OD SHILEY CUFFED 6DCT,120.287,CDM,272,RC,A7521,HCPCS,,1190-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,179.0872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 7.5MM ID 10.8MM OD SHILEY CUFFED 6CN75H,120.287,CDM,272,RC,A7521,HCPCS,,8488-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,179.0872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 8 7.6MM ID 12.2MM OD SHILEY 8DCT,120.287,CDM,272,RC,A7521,HCPCS,,1192-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,179.0872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 8 7.6MM ID 12.22MM OD SHILEY CUFFED 8LPC,120.287,CDM,272,RC,A7521,HCPCS,,8815-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,179.0872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 8.0MM ID 10.9MM OD SHILEY CUFFED 8SCT,120.287,CDM,272,RC,A7521,HCPCS,,8811-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,179.0872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 10 SHILEY 10LPC,120.287,CDM,272,RC,A7521,HCPCS,,1181-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,179.0872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
Xray Sinuses Minimum 3 Vws,PX7022001,CDM,320,RC,70220,CPT,TC,,,,,,,354,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,179.124,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,346.92
baricitinib 2 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,2418230,NDC,0.5,EA,203.12,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,179.15184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Dress/Debrid Small Burn No Anes,PX16020F,CDM,510,RC,16020,CPT,,,,,,,,313,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,179.18,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.46,179.18
pyRIDostigmine bromide 10 MG/2ML Solution 2 mL Ampule,25000000,CDM,250,RC,,,,,,781304095,NDC,2,ML,203.16,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,179.18712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
US Pregnancy Tc Follow-Up,PX7681601,CDM,402,RC,76816,CPT,TC,,,,,,,362,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,179.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,354.76
Removal of Skin Tags,PX11200P,CDM,983,RC,11200,CPT,,,,,,,,418,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,179.322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,173.6372,406.8394
Dress/Debrid Med Burn No Anesth,PX16025F,CDM,510,RC,16025,CPT,,,,,,,,366,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,179.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,152.0364,358.68
Dress/Debrid Med Burn No Anesth,PX16025F,CDM,510,RC,16025,CPT,,,,,,,,366,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,179.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,152.0364,358.68
Dress/Debrid Med Burn No Anesth,PX16025F,CDM,510,RC,16025,CPT,,,,,,,,366,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,179.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,152.0364,358.68
Voriconazole - Ref,PX8028590,CDM,300,RC,80285,CPT,90,,,,,,,183,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,179.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.86,179.34
Bone Age Studies Tc,PX7707201,CDM,320,RC,77072,CPT,TC,,,,,,,211,,First Health,Commercial,both,85,,999999999,percent of total billed charges,179.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.6494,206.78
Collect Blood From Picc,PX36592F,CDM,510,RC,36592,CPT,,,,,,,,211,,First Health,Commercial,both,85,,999999999,percent of total billed charges,179.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.6494,206.78
Draw Blood Off Venous Device,PX36591F,CDM,510,RC,36591,CPT,,,,,,,,211,,First Health,Commercial,both,85,,999999999,percent of total billed charges,179.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.6494,206.78
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041100,NDC,0.5,ML,196.94,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,179.41234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.808876,411.2766
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041110,NDC,0.5,ML,196.94,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,179.41234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.808876,411.2766
Xray Eye Foreign Body,PX7003001,CDM,320,RC,70030,CPT,TC,,,,,,,432,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,179.4528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,423.36
Assay Other Fluid Chlorides - Ref,PX8243890,CDM,300,RC,82438,CPT,90,,,,,,,197,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,179.467,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.58,193.06
Tramadol - Ref,PX8037390,CDM,300,RC,80373,CPT,90,,,,,,,197,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,179.467,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.8338,193.06
SUTURE CTD VICRYL 4-0 VIL BR SUTUPK J103T,27200000,CDM,272,RC,,,,4491-MAIN,LOCAL,,,,,373.97,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,179.5056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE CTD VICRYL 4-0 VIL BR SUTUPK J103T,27200000,CDM,272,RC,,,,4491-MAIN,LOCAL,,,,,373.97,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,179.5056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Fac/Exc Skin Benig<5mm Remaind Bod,PX11420F,CDM,510,RC,11420,CPT,,,,,,,,374,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,179.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,1416.38
Fac/Exc Skin Benig<5mm Remaind Bod,PX11420F,CDM,510,RC,11420,CPT,,,,,,,,374,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,179.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,1416.38
"Fac/Office Consultation,Level III",PX99243F,CDM,510,RC,99213,CPT,,,,,,,,374,,Health Partners,Health Partners Care Plans,both,48,,173.62,percent of total billed charges,179.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,366.52
"Fac/Office Consultation,Level III",PX99243F,CDM,510,RC,99213,CPT,,,,,,,,374,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,179.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,366.52
Xray Hand 3vws Tc,PX7313001,CDM,320,RC,73130,CPT,TC,,,,,,,374,,Health Partners,Health Partners Care Plans,both,48,,185.22,percent of total billed charges,179.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,366.52
Xray Hand 3vws Tc,PX7313001,CDM,320,RC,73130,CPT,TC,,,,,,,374,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,179.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,366.52
"Close Rx Dist Fingr Fx,Manipulatn",PX26755F,CDM,510,RC,26755,CPT,,,,,,,,335,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,179.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,177.14,692.49
"Close Rx Dist Fingr Fx,Manipulatn",PX26755F,CDM,510,RC,26755,CPT,,,,,,,,335,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,179.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,177.14,692.49
"Close Rx Dist Fingr Fx,Manipulatn",PX26755P,CDM,983,RC,26755,CPT,,,,,,,,1260,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,179.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,177.14,1234.8
"Close Rx Dist Fingr Fx,Manipulatn",PX26755P,CDM,983,RC,26755,CPT,,,,,,,,1260,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,179.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,177.14,1234.8
gemcitabine 1 GM/26.3ML Solution 26.3 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018101,NDC,26.3,ML,203.58,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,179.55756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
hydrocortisone sodium succinate (preservative free) 250 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001305,NDC,1,EA,183.32,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,179.6536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
SET CRICOTHYROTOMY CATHETER 3.5MM ID,120.251,CDM,272,RC,,,,4306-MAIN,LOCAL,,,,,363,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,179.685,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.7902,355.74
SET CRICOTHYROTOMY CATHETER 4MM ID,120.251,CDM,272,RC,,,,3452-MAIN,LOCAL,,,,,363,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,179.685,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.7902,355.74
SET CRICOTHYROTOMY CATHETER 6MM ID,120.251,CDM,272,RC,,,,2887-MAIN,LOCAL,,,,,363,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,179.685,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.7902,355.74
fluticasone propionate 50 MCG/ACT Suspension 16 g Bottle,63700001,CDM,250,RC,,,,,,50383070016,NDC,16,GR,432.56,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,179.685424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601901,NDC,10,ML,211.47,,First Health,Commercial,both,85,,999999999,percent of total billed charges,179.7495,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.844638,207.2406
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601910,NDC,10,ML,211.47,,First Health,Commercial,both,85,,999999999,percent of total billed charges,179.7495,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.844638,207.2406
TRAY PNEUMOTHORAX 14FR 29CM 19 CATHETER SIDEPORTS G56537,120.496,CDM,272,RC,,,,11677-MAIN,LOCAL,,,,,419,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,179.751,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.0526,410.62
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021588,NDC,0.5,ML,203.87,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,179.81334,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.779496,199.7926
"Exc Skn Mal 2.1-3cmtrnk,Arm,Lg",PX11603P,CDM,983,RC,11603,CPT,,,,,,,,1276,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,179.816,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.07,1250.48
"Fac/Exc Skn Mali2.1-3cmtrnk,Arm,Lg",PX11603F,CDM,510,RC,11603,CPT,,,,,,,,875,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,179.816,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.07,580.42
Xray Foot 2 Vws,PX7362001,CDM,320,RC,73620,CPT,TC,,,,,,,367,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,179.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,359.66
Xray Foot 2 Vws,PX7362001,CDM,320,RC,73620,CPT,TC,,,,,,,367,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,179.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,359.66
Xray Foot 2 Vws,PX7362001,CDM,320,RC,73620,CPT,TC,,,,,,,367,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,179.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,359.66
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494301,NDC,0.5,ML,419.2,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,179.8368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.38,410.8454
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494300,NDC,0.5,ML,419.23,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,179.84967,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.38,410.8454
Closed Rx Bimalleolar Fx,PX27808P,CDM,983,RC,27808,CPT,,,,,,,,433,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,179.8682,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,179.8682,421.4389
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106P,CDM,983,RC,11106,CPT,,,,,,,,204,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,179.928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.7416,548.67
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Solution 10 mL Bottle,63700001,CDM,250,RC,,,,,,61314064610,NDC,10,ML,433.15,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,179.93051,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,517096001,NDC,10,ML,355.63,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,179.94878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Immunofluorescence per Spec Add Singl Antb Stain - Ref,PX8835090,CDM,310,RC,88350,CPT,90,,,,,,,112,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,179.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.42,185.408
Immunofluorescence per Spec Add Singl Antb Stain - Ref,PX8835090,CDM,310,RC,88350,CPT,90,,,,,,,112,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,179.96,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.42,185.408
"Digital Mamm, Diag, Bilat, Tc W/Cad Perf",PX7706601,CDM,401,RC,77066,CPT,TC,,,,,,,375,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,180,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.05,367.5
"Digital Mamm, Diag, Bilat, Tc W/Cad Perf",PX7706601,CDM,401,RC,77066,CPT,TC,,,,,,,375,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,180,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.05,367.5
"Digital Mammogram, Screen Bil, Tc W/Cad Perf",PX7706701,CDM,403,RC,77067,CPT,TC,,,,,,,375,,Health Partners,Health Partners Care Plans,both,48,,337.175625,percent of total billed charges,180,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.86,561
"Digital Mammogram, Screen Bil, Tc W/Cad Perf",PX7706701,CDM,403,RC,77067,CPT,TC,,,,,,,375,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,180,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.86,561
Repr Superf Wnd Face 2.6-5,PX12013F,CDM,510,RC,12013,CPT,,,,,,,,375,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,180,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.775,367.5
Repr Superf Wnd Face 2.6-5,PX12013F,CDM,510,RC,12013,CPT,,,,,,,,375,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,180,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.775,367.5
Xray Wrist Minimum 3 Vws,PX7311001,CDM,320,RC,73110,CPT,TC,,,,,,,375,,Health Partners,Health Partners Care Plans,both,48,,214.6975,percent of total billed charges,180,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,367.5
Xray Wrist Minimum 3 Vws,PX7311001,CDM,320,RC,73110,CPT,TC,,,,,,,375,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,180,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,367.5
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041105,NDC,1,ML,419.67,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,180.03843,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.808876,411.2766
Amylase - Ref,PX8215090,CDM,300,RC,82150,CPT,90,,,,,,,185,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,185.01,percent of total billed charges,180.0605,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.94,181.3
Hepatitis C Rna Quant,PX87522,CDM,300,RC,87522,CPT,,,,,,,,185,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,180.0605,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.28,181.3
"Office/Outpt Visit,Est,Levl III",PX99213F,CDM,510,RC,99213,CPT,,,,,,,,185,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,134.9887097,percent of total billed charges,180.0605,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.849,181.3
"Office/Outpt Visit,Est,Levl III",PX99213P,CDM,983,RC,99213,CPT,,,,,,,,185,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,134.9887097,percent of total billed charges,180.0605,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.849,180.0605
CT Maxillofacialw/O Dye,PX7048601,CDM,350,RC,70486,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,180.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.08,180.13
CT Maxillofacialw/O Dye,PX7048601,CDM,350,RC,70486,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,180.13,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.08,180.13
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084243,NDC,0.5,ML,202.42,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,180.1538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.085268,203.497
Cardiac Rehab II Eval,PX93798.05,CDM,943,RC,93798,CPT,,,,,,,,364,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,180.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.44,495.55
Drain/Inject Large Joint/Bursa,PX20610F,CDM,510,RC,20610,CPT,,,,,,,,364,,Humana Choice Care,All Medicare plans,outpatient,49.5,,69.44333333,percent of total billed charges,180.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,151.2056,356.72
Xray Forearm 2 Vws,PX7309001,CDM,320,RC,73090,CPT,TC,,,,,,,364,,Humana Choice Care,All Medicare plans,outpatient,49.5,,56.26,percent of total billed charges,180.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,356.72
"Non-Select. Wound Debride., W/O Anesth.; Top. Appl./Wound Assess./Instruct., per Sess.",PX97602,CDM,761,RC,97602,CPT,,,,,,,,212,,First Health,Commercial,both,85,,999999999,percent of total billed charges,180.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.0648,207.76
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082152,NDC,1,ML,375.43,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,180.2064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.48,367.9214
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082152,NDC,1,ML,375.43,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,180.2064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.48,367.9214
"Mra, Neck With Contrast",PX7054801,CDM,610,RC,70548,CPT,TC,,,,,,,3541,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,180.208,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.94,360.26
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,703574811,NDC,100,ML,183.92,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,180.2416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.174958,180.2416
butamben-tetracaine-benzocaine 2-2-14 % Aerosol 5 g Bottle,25000000,CDM,250,RC,,,,,,10223020104,NDC,5,GR,375.52,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,180.2496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
butamben-tetracaine-benzocaine 2-2-14 % Aerosol 5 g Bottle,25000000,CDM,250,RC,,,,,,10223020104,NDC,5,GR,375.52,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,180.2496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
SCOPE ASCOPE4 CYSTO STERILE 601001000,120.497,CDM,272,RC,A4649,HCPCS,,11662-MAIN,LOCAL,,,,,368,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,180.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,152.8672,360.64
SCOPE ASCOPE4 CYSTO STERILE 601001000,120.497,CDM,272,RC,A4649,HCPCS,,11662-MAIN,LOCAL,,,,,368,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,180.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,152.8672,360.64
SCOPE ASCOPE4 CYSTO STERILE 601001000,120.497,CDM,272,RC,A4649,HCPCS,,11662-MAIN,LOCAL,,,,,368,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,180.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,152.8672,360.64
TUBE TRACH SIZE 3.0MM ID 4.5MM OD SHILEY PEDIATRIC 3.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1185-MAIN,LOCAL,,,,,184,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,180.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 3.5MM ID 5.2MM OD SHILEY PEDIATRIC,120.287,CDM,272,RC,A7520,HCPCS,,8813-MAIN,LOCAL,,,,,184,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,180.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 4.0MM ID 5.9MM OD SHILEY PEDIATRIC 4.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1187-MAIN,LOCAL,,,,,184,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,180.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 5 7.0MM ID 10.1MM OD SHILEY CUFFED 5CN70H,120.287,CDM,272,RC,A7521,HCPCS,,10350-MAIN,LOCAL,,,,,184,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,180.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 5.0MM ID 7.1MM OD SHILEY PEDIATRIC 5.0PED,120.287,CDM,272,RC,A7520,HCPCS,,8814-MAIN,LOCAL,,,,,184,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,180.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 6 6.0MM ID 8.3MM OD SHILEY CUFFED 6SCT,120.287,CDM,272,RC,A7521,HCPCS,,8812-MAIN,LOCAL,,,,,184,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,180.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 6 6.4MM ID 10.8MM OD SHILEY CUFFED 6DCT,120.287,CDM,272,RC,A7521,HCPCS,,1190-MAIN,LOCAL,,,,,184,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,180.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 7.5MM ID 10.8MM OD SHILEY CUFFED 6CN75H,120.287,CDM,272,RC,A7521,HCPCS,,8488-MAIN,LOCAL,,,,,184,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,180.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 8 7.6MM ID 12.2MM OD SHILEY 8DCT,120.287,CDM,272,RC,A7521,HCPCS,,1192-MAIN,LOCAL,,,,,184,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,180.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 8 7.6MM ID 12.22MM OD SHILEY CUFFED 8LPC,120.287,CDM,272,RC,A7521,HCPCS,,8815-MAIN,LOCAL,,,,,184,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,180.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 8.0MM ID 10.9MM OD SHILEY CUFFED 8SCT,120.287,CDM,272,RC,A7521,HCPCS,,8811-MAIN,LOCAL,,,,,184,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,180.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
TUBE TRACH SIZE 10 SHILEY 10LPC,120.287,CDM,272,RC,A7521,HCPCS,,1181-MAIN,LOCAL,,,,,184,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,180.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.4336,180.32
hepatitis A vaccine 1440 EL U/ML Suspension 1 mL Syringe,90632,CDM,636,RC,90632,CPT,,,,58160082652,NDC,1,ML,375.78,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,180.3744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,156.099012,368.2644
hepatitis A vaccine 1440 EL U/ML Suspension 1 mL Syringe,90632,CDM,636,RC,90632,CPT,,,,58160082652,NDC,1,ML,375.78,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,180.3744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,156.099012,368.2644
Collect Blood From Picc,PX36592,CDM,949,RC,36592,CPT,,,,,,,,198,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,180.378,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.2492,194.04
Debride Muscle Ea Add 20 Sqcm,PX11046P,CDM,983,RC,11046,CPT,,,,,,,,198,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,180.378,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.2492,192.7134
Insert Simple Cath Foley,PX51702F,CDM,510,RC,51702,CPT,,,,,,,,198,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,180.378,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.2492,194.04
KIT PLEUREVAC CHEST DRAIN S-1100-08LF,120.2,CDM,272,RC,,,,4190-MAIN,LOCAL,,,,,198,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,180.378,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.0466,194.04
Lyme Screen,PX7585,CDM,300,RC,86618,CPT,,,,,,,,198,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,180.378,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.61,194.04
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031801,NDC,1,ML,185.37,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,180.420621,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.002698,181.6626
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031825,NDC,1,ML,185.37,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,180.420621,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.002698,181.6626
nafcillin 2 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,S0032,HCPCS,,,,63323032820,NDC,1,EA,185.37,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,180.420621,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ibutilide 1 MG/10ML Solution 10 mL Vial,J1742.01,CDM,636,RC,J1742,HCPCS,,,,9379401,NDC,10,ML,2349.03,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,180.45,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,180.45,559.83
fat emulsion 20 % Emulsion 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,338051958,NDC,200,ML,375.95,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,180.456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fat emulsion 20 % Emulsion 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,338051958,NDC,200,ML,375.95,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,180.456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
PREP KIT STAPLE 18MM,27200000,CDM,278,RC,C1713,HCPCS,,11658-MAIN,LOCAL,,,,,420.75,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,180.50175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PREP KIT STAPLE 20MM,27200000,CDM,278,RC,C1713,HCPCS,,11659-MAIN,LOCAL,,,,,420.75,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,180.50175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Office Consultation,Level III",PX99243P,CDM,983,RC,99243,CPT,,,,,,,,374,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,180.512,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.65,366.52
fentaNYL 50 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,47781042611,NDC,1,EA,185.47,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,180.517951,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 50 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,47781042647,NDC,1,EA,185.47,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,180.517951,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Aspirate Pleura W/O Imaging,PX32554F,CDM,510,RC,32554,CPT,,,,,,,,795,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,180.56,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.88,484.95
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505614700,NDC,1,EA,212.52,,First Health,Commercial,both,85,,999999999,percent of total billed charges,180.642,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
Remove Intrauterine Device,PX58301,CDM,983,RC,58301,CPT,,,,,,,,357,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,180.642,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.2978,347.4681
X-Ray Exam Chest 1 View,PX7104501,CDM,320,RC,71045,CPT,TC,,,,,,,357,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,180.642,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,349.86
"Xray Chest 1 View, Tc",PX7101001,CDM,320,RC,71010,CPT,TC,,,,,,,357,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,180.642,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.2978,349.86
Xray Scapula Complete,PX7301001,CDM,320,RC,73010,CPT,TC,,,,,,,357,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,180.642,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,349.86
"2019-Ncov Coronavirus, Sars-Cov-2/2019-Ncov (Covid-19)",PXU000290,CDM,300,RC,U0002,HCPCS,90,,,,,,,365,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,180.675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,357.7
"Closed Rx Spont Hip Disloc,Anesth",PX27257P,CDM,983,RC,27257,CPT,,,,,,,,365,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,180.675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,151.621,1404.08
Sars-Cov-2 Covid-19 Amp Prb,PX8763590,CDM,300,RC,87635,CPT,90,,,,,,,365,,Humana Choice Care,All Medicare plans,outpatient,49.5,,18.07555556,percent of total billed charges,180.675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,357.7
X-Ray Exam Femur Min 2 Vws,PX7355201,CDM,320,RC,73552,CPT,TC,,,,,,,365,,Humana Choice Care,All Medicare plans,outpatient,49.5,,357.7,percent of total billed charges,180.675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Ankle Minimum 3 Vws,PX7361001,CDM,320,RC,73610,CPT,TC,,,,,,,365,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,180.675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Calcaneus Minimum 2 Vws,PX7365001,CDM,320,RC,73650,CPT,TC,,,,,,,365,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,180.675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Clavicle Complete,PX7300001,CDM,320,RC,73000,CPT,TC,,,,,,,365,,Humana Choice Care,All Medicare plans,outpatient,49.5,,274.4,percent of total billed charges,180.675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Elbow 2 Vws,PX7307001,CDM,320,RC,73070,CPT,TC,,,,,,,365,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,180.675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Hand 2vws Tc,PX7312001,CDM,320,RC,73120,CPT,TC,,,,,,,365,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,180.675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,357.7
Xray Humerus Minimum 2 Vws,PX7306001,CDM,320,RC,73060,CPT,TC,,,,,,,365,,Humana Choice Care,All Medicare plans,outpatient,49.5,,119.2333333,percent of total billed charges,180.675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Shoulder Minimum 2 Vws,PX7303001,CDM,320,RC,73030,CPT,TC,,,,,,,365,,Humana Choice Care,All Medicare plans,outpatient,49.5,,230.715,percent of total billed charges,180.675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Sternum 2vws Tc,PX7112001,CDM,320,RC,71120,CPT,TC,,,,,,,365,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,180.675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Tibia & Fibula 2 Vws,PX7359001,CDM,320,RC,73590,CPT,TC,,,,,,,365,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,180.675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Wrist 2 Vws,PX7310001,CDM,320,RC,73100,CPT,TC,,,,,,,365,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,180.675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
verapamil 2.5 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,409114405,NDC,2,ML,185.65,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,180.693145,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
baricitinib 2 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,2418230,NDC,0.5,EA,203.12,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,180.7768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pyRIDostigmine bromide 10 MG/2ML Solution 2 mL Ampule,25000000,CDM,250,RC,,,,,,781304095,NDC,2,ML,203.16,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,180.8124,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,43598054910,NDC,100,ML,205.14,,United Healthcare,All Payer,outpatient,88.2,,1.151420557,percent of total billed charges,180.93348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
nitroPRUSSide 25 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,72485010501,NDC,2,ML,186,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,181.0338,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Puncture Drainage of Lesion,PX10160P,CDM,983,RC,10160,CPT,,,,,,,,186,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,70.27,percent of total billed charges,181.0338,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.2644,348.35
"TB Test, Cell Immunity Measure",PX86480,CDM,300,RC,86480,CPT,,,,,,,,186,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,181.0338,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.83,182.28
Closure Superf Wnd Dehis Simple,PX12020P,CDM,983,RC,12020,CPT,,,,,,,,422,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,181.038,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,175.2988,548.67
Apply Multlay Comprs Lwr Leg,PX29581F,CDM,510,RC,29581,CPT,,,,,,,,213,,First Health,Commercial,both,85,,999999999,percent of total billed charges,181.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.4802,208.74
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006F,CDM,510,RC,10006,CPT,,,,,,,,213,,First Health,Commercial,both,85,,999999999,percent of total billed charges,181.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.4802,208.74
"GI Pathogen Panel, Pcr - Ref",PX8750790,CDM,300,RC,87507,CPT,90,,,,,,,213,,First Health,Commercial,both,85,,999999999,percent of total billed charges,181.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.4802,382.15
Remove Impacted Ear Wax,PX69210F,CDM,510,RC,69210,CPT,,,,,,,,213,,First Health,Commercial,both,85,,999999999,percent of total billed charges,181.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.44,208.74
Fac/Ligation of Hemorrhoid(S),PX46221F,CDM,510,RC,46221,CPT,,,,,,,,1046,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,181.1004,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.94,590.11
Ligation of Hemorrhoid(S),PX46221P,CDM,983,RC,46221,CPT,,,,,,,,697,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,181.1004,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.94,683.06
X-Ray Exam Abdomen 2 Views,PX7401901,CDM,320,RC,74019,CPT,TC,,,,,,,436,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,181.1144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,427.28
"X-Ray Exam Hip,Unilat W/Pelvis 2-3 Vws",PX7350201,CDM,320,RC,73502,CPT,TC,,,,,,,436,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,181.1144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,427.28
Xray Abdomen Comp Incl Decub and/or Erect,PX7402001,CDM,320,RC,74020,CPT,TC,,,,,,,436,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,181.1144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.1144,427.28
Xray Cervical Spine 2 or 3 Vws,PX7204001,CDM,320,RC,72040,CPT,TC,,,,,,,436,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,181.1144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,427.28
Declot Vascular Access Device,PX36593F,CDM,510,RC,36593,CPT,,,,,,,,358,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,181.148,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.7132,350.84
Fac/Irrigation of Bladder,PX51700F,CDM,510,RC,51700,CPT,,,,,,,,358,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,181.148,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.7132,350.84
X-Ray Exam Abdomen 1 View,PX7401801,CDM,320,RC,74018,CPT,TC,,,,,,,358,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,181.148,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,350.84
Xray Abdomen Single Ap Vw,PX7400001,CDM,320,RC,74000,CPT,TC,,,,,,,358,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,181.148,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.7132,350.84
Dress/Debrid Med Burn No Anesth,PX16025F,CDM,510,RC,16025,CPT,,,,,,,,366,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,181.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,152.0364,358.68
gemcitabine 1 GM/26.3ML Solution 26.3 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018101,NDC,26.3,ML,203.58,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,181.1862,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
Chem Cautery Granulatn Tissue,PX17250F,CDM,510,RC,17250,CPT,,,,,,,,170,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,181.25,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.12,181.25
Chem Cautery Granulatn Tissue,PX17250P,CDM,983,RC,17250,CPT,,,,,,,,402,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,181.25,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.12,393.96
"Mra, Neck W/O+W/ Contrast",PX7054901,CDM,610,RC,70549,CPT,TC,,,,,,,3472,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,181.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.28,535.12
"Mra, Neck W/O+W/ Contrast",PX7054901,CDM,610,RC,70549,CPT,TC,,,,,,,3472,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,181.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.28,535.12
Inpt or Obs Disch Day Mngmt <=30 Minutes,PX99238,CDM,982,RC,99238,CPT,,,,,,,,199,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,181.289,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.6646,193.6867
Acetaminophen,PX80307E,CDM,300,RC,80307,CPT,,,,,,,,370,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,82.08631579,percent of total billed charges,181.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Acetaminophen,PX80307E,CDM,300,RC,80307,CPT,,,,,,,,370,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,181.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Acetaminophen,PX80307E,CDM,300,RC,80307,CPT,,,,,,,,370,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,181.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Alcohol,PX80307A,CDM,300,RC,80307,CPT,,,,,,,,370,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,82.08631579,percent of total billed charges,181.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Alcohol,PX80307A,CDM,300,RC,80307,CPT,,,,,,,,370,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,181.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Alcohol,PX80307A,CDM,300,RC,80307,CPT,,,,,,,,370,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,181.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Amylase - Ref,PX8215090,CDM,300,RC,82150,CPT,90,,,,,,,185,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,181.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.94,181.3
Hepatitis C Rna Quant,PX87522,CDM,300,RC,87522,CPT,,,,,,,,185,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,181.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.28,181.3
"Level IV - Surgical Pathology, Gross and Microscopic Examination , Tech",PX3934,CDM,310,RC,88305,CPT,TC,,,,,,,185,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,181.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,271.15
"Office/Outpt Visit,Est,Levl III",PX99213F,CDM,510,RC,99213,CPT,,,,,,,,185,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,181.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.849,181.3
"Office/Outpt Visit,Est,Levl III",PX99213P,CDM,983,RC,99213,CPT,,,,,,,,185,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,181.3,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.25,181.3
Salicylate,PX80307D,CDM,300,RC,80307,CPT,,,,,,,,370,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,82.08631579,percent of total billed charges,181.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Salicylate,PX80307D,CDM,300,RC,80307,CPT,,,,,,,,370,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,181.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Salicylate,PX80307D,CDM,300,RC,80307,CPT,,,,,,,,370,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,181.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Urine Drug Screen,PX80307B,CDM,300,RC,80307,CPT,,,,,,,,370,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,82.08631579,percent of total billed charges,181.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Urine Drug Screen,PX80307B,CDM,300,RC,80307,CPT,,,,,,,,370,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,181.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Urine Drug Screen,PX80307B,CDM,300,RC,80307,CPT,,,,,,,,370,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,181.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Xray Elbow 3+Vws Tc,PX7308001,CDM,320,RC,73080,CPT,TC,,,,,,,370,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,234.846,percent of total billed charges,181.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,362.6
Xray Elbow 3+Vws Tc,PX7308001,CDM,320,RC,73080,CPT,TC,,,,,,,370,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,181.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,362.6
Xray Elbow 3+Vws Tc,PX7308001,CDM,320,RC,73080,CPT,TC,,,,,,,370,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,181.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,362.6
procainamide 500 MG/ML Solution 2 mL Vial,J2690.01,CDM,636,RC,J2690,HCPCS,,,,14789090002,NDC,2,ML,377.75,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,181.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,134.15,370.195
procainamide 500 MG/ML Solution 2 mL Vial,J2690.01,CDM,636,RC,J2690,HCPCS,,,,14789090002,NDC,2,ML,377.75,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,181.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,134.15,370.195
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060851,NDC,100,ML,213.4,,First Health,Commercial,both,85,,999999999,percent of total billed charges,181.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
"Colonoscope, Submucous Inj",PX45381F,CDM,750,RC,45381,CPT,,,,,,,,1179,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,181.4215,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.59,917.33
"Colonoscope, Submucous Inj",PX45381P,CDM,983,RC,45381,CPT,,,,,,,,1215,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,181.4215,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.59,1190.7
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021588,NDC,0.5,ML,203.87,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,181.4443,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.779496,199.7926
"MESH PROLENE 3X6""",C1781,CDM,278,RC,C1781,HCPCS,,688-MAIN,LOCAL,,,,,213.49,,First Health,Commercial,both,85,,999999999,percent of total billed charges,181.4665,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
predniSONE 5 mg/5 mL 5 MG/5ML Solution 120 mL Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54372250,NDC,120,ML,186.47,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.034877358,percent of total billed charges,181.491251,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
Xray Ribs Unilat 2 Vws,PX7110001,CDM,320,RC,71100,CPT,TC,,,,,,,437,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,181.5298,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,428.26
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106P,CDM,983,RC,11106,CPT,,,,,,,,204,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,181.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.7416,548.67
erythromycin lactobionate 500 MG Recon Soln 1 Each Vial,J1364.01,CDM,636,RC,J1364,HCPCS,,,,409648211,NDC,1,EA,437.09,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,181.567186,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.06,428.3482
"Office/Outpt Visit,New,Levl IV",PX99204F,CDM,510,RC,99204,CPT,,,,,,,,359,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,181.654,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.1286,351.82
"Office/Outpt Visit,New,Levl IV",PX99204P,CDM,983,RC,99204,CPT,,,,,,,,359,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,181.654,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.1286,349.4147
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031801,NDC,1,ML,185.37,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,181.6626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.002698,181.6626
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031825,NDC,1,ML,185.37,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,181.6626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.002698,181.6626
nafcillin 2 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,S0032,HCPCS,,,,63323032820,NDC,1,EA,185.37,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,181.6626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Xray Foot 2 Vws,PX7362001,CDM,320,RC,73620,CPT,TC,,,,,,,367,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,181.665,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,359.66
medroxyPROGESTERone 150 MG/ML Suspension 1 mL Vial,J1050.01,CDM,636,RC,J1050,HCPCS,,,,67457088799,NDC,1,ML,437.38,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,181.687652,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.687652,428.6324
fluticasone propionate 50 MCG/ACT Suspension 16 g Bottle,63700001,CDM,250,RC,,,,,,60505082901,NDC,16,GR,437.4,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,181.69596,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Colonoscopy,Biopsy",PX45380F,CDM,750,RC,45380,CPT,,,,,,,,2465,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,181.7426,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.59,898.65
"Colonoscopy,Biopsy",PX45380P,CDM,983,RC,45380,CPT,,,,,,,,2539,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,181.7426,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.59,2488.22
"Upper GI Endoscopy,Ctrl Bleed",PX43255F,CDM,750,RC,43255,CPT,,,,,,,,1723,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,181.7426,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.59,1292.28
"Upper GI Endoscopy,Ctrl Bleed",PX43255P,CDM,983,RC,43255,CPT,,,,,,,,1148,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,181.7426,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.59,1292.28
fentaNYL 50 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,47781042611,NDC,1,EA,185.47,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,181.7606,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fentaNYL 50 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,47781042647,NDC,1,EA,185.47,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,181.7606,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801801,NDC,0.8,ML,359.37,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,181.84122,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801810,NDC,0.8,ML,359.37,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,181.84122,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402F,CDM,510,RC,11402,CPT,,,,,,,,424,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,181.896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.1296,614.65
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402P,CDM,983,RC,11402,CPT,,,,,,,,424,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,181.896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.1296,614.65
Lab H Pylori Stool Ag,PX87338,CDM,300,RC,87338,CPT,,,,,,,,424,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,181.896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,415.52
Immunofix Elp,PX86335,CDM,300,RC,86335,CPT,,,,,,,,214,,First Health,Commercial,both,85,,999999999,percent of total billed charges,181.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.91,209.72
"Tech-Cytopath Eval, Fna, Rep",PX8817301,CDM,310,RC,88173,CPT,TC,,,,,,,379,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,181.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,371.42
"Tech-Cytopath Eval, Fna, Rep",PX8817301,CDM,310,RC,88173,CPT,TC,,,,,,,379,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,181.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,371.42
verapamil 2.5 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,409114405,NDC,2,ML,185.65,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,181.937,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Debride Bone Ea Add 20 Sqcm,PX11047F,CDM,510,RC,11047,CPT,,,,,,,,438,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,181.9452,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.9452,429.24
US Pregnancy Tc Limited,PX7681501,CDM,402,RC,76815,CPT,TC,,,,,,,438,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,181.9452,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,429.24
Fac/Initial Hospital Care Levl II,PX99222F,CDM,510,RC,99222,CPT,,,,,,,,187,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,182.0071,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.6798,183.26
"Infect Ag,Eia, Nos, Ea - Ref",PX8744990,CDM,300,RC,87449,CPT,90,,,,,,,187,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,182.0071,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,183.26
Initial Hospital Care Levl II,PX99222P,CDM,982,RC,99222,CPT,,,,,,,,187,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,182.0071,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.6798,182.0071
RETRIEVAL BAG 12/15MM,27200000,CDM,272,RC,,,,12660-MAIN,LOCAL,,,,,187,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,182.0071,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Digital Mammogram, Screen Bil, Tc W/Cad Perf",PX7706701,CDM,403,RC,77067,CPT,TC,,,,,,,375,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,182.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.29,182.1
"Digital Mammogram, Screen Bil, Tc W/Cad Perf",PX7706701,CDM,403,RC,77067,CPT,TC,,,,,,,375,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,182.1,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.29,182.1
Closed Rx Mt-Phal Toe Dislocation,PX28630F,CDM,510,RC,28630,CPT,,,,,,,,360,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,182.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.544,352.8
RBC Antibody Elution,PX86860,CDM,300,RC,86860,CPT,,,,,,,,360,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,182.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.22,352.8
SCOPE ASCOPE4 CYSTO STERILE 601001000,120.497,CDM,272,RC,A4649,HCPCS,,11662-MAIN,LOCAL,,,,,368,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,182.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,152.8672,360.64
Fresh Frozen Plasma,PXP9017,CDM,390,RC,P9017,HCPCS,,,,,,,,319,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,182.176,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.49,182.176
Fresh Frozen Plasma,PXP9017,CDM,390,RC,P9017,HCPCS,,,,,,,,319,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,182.176,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.49,182.176
DERMABOND PRINEO SKIN CLOSURE SYSTEM 42CM,27200000,CDM,272,RC,,,,12323-MAIN,LOCAL,,,,,200,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,182.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
gadoxetate disodium 0.25 MOL/L Solution 10 mL Vial,A9581,CDM,636,RC,A9581,HCPCS,,,,50419032005,NDC,10,ML,200,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,182.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,196
iohexol 300 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141363,NDC,100,ML,200,,Medica,Commercial,both,91.1,,0.950916667,percent of total billed charges,182.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,294
iohexol 350 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141491,NDC,100,ML,200,,Medica,Commercial,both,91.1,,0.950916667,percent of total billed charges,182.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,294
Lacosamide - Ref,PX8023590,CDM,300,RC,80235,CPT,90,,,,,,,200,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,182.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.86,196
nystatin-triamcinolone 100000-0.1 UNIT/GM-% Ointment 30 g Tube,25000000,CDM,250,RC,,,,,,52565004230,NDC,30,GR,438.62,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,182.202748,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021515,NDC,0.5,ML,187.24,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,182.240692,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.779496,199.7926
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059611,NDC,0.25,EA,200.05,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,182.24555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.10077,725.3862
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059613,NDC,0.25,EA,200.05,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,182.24555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.10077,725.3862
Cyto Non Gyn,PX8811201,CDM,310,RC,88112,CPT,TC,,,,,,,372,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,182.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,364.56
Cyto Non Gyn,PX8811201,CDM,310,RC,88112,CPT,TC,,,,,,,372,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,182.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,364.56
Cyto Non Gyn,PX8811201,CDM,310,RC,88112,CPT,TC,,,,,,,372,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,182.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,364.56
nitroPRUSSide 25 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,72485010501,NDC,2,ML,186,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,182.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Puncture Drainage of Lesion,PX10160P,CDM,983,RC,10160,CPT,,,,,,,,186,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,182.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.86,270.49
"TB Test, Cell Immunity Measure",PX86480,CDM,300,RC,86480,CPT,,,,,,,,186,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,182.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.83,182.28
"Injection Hip Arthrogram,Anesth",PX27095F,CDM,510,RC,27095,CPT,,,,,,,,425,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,182.325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.545,416.5
"Injection Hip Arthrogram,Anesth",PX27095P,CDM,983,RC,27095,CPT,,,,,,,,425,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,182.325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.545,413.6525
US Abdomen Limited Tc,PX7670501,CDM,402,RC,76705,CPT,TC,,,,,,,425,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,182.325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,416.5
US Ext Non-Vasc Img Lmtd,PX7688201,CDM,402,RC,76882,CPT,TC,,,,,,,425,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,182.325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,416.5
8MM ENDOWRIST INSTRUMENTS 8MM FORCE BIPOLAR IS4000,27200000,CDM,272,RC,,,,11915-MAIN,LOCAL,,,,,439,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,182.3606,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
VISIGI3D 40FR STD WITH BULB,27100000,CDM,271,RC,,,,12812-MAIN,LOCAL,,,,,439,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,182.3606,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
"Mra, Neck W/O+W/ Contrast",PX7054901,CDM,610,RC,70549,CPT,TC,,,,,,,3472,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,182.37,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.28,535.12
leuprolide 7.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74364203,NDC,1,EA,3782.28,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,182.4039,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.54,190.37
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74334603,NDC,1,EA,12509.82,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,182.4039,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.54,190.37
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,62935022305,NDC,1,EA,2764.34,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,182.4039,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.54,190.37
leuprolide 45 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74347303,NDC,1,EA,21633.89,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,182.4039,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.54,190.37
"Drain Finger Abscess,Simple",PX26010P,CDM,983,RC,26010,CPT,,,,,,,,207,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,182.574,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.9878,201.4731
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,43598054910,NDC,100,ML,205.14,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,182.5746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
Apply Multlay Comprs Lwr Leg,PX29581F,CDM,510,RC,29581,CPT,,,,,,,,213,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,182.64,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.01,182.64
Apply Multlay Comprs Lwr Leg,PX29581P,CDM,983,RC,29581,CPT,,,,,,,,142,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,182.64,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.01,182.64
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802201,NDC,0.8,ML,439.77,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,182.680458,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802210,NDC,0.8,ML,439.77,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,182.680458,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
predniSONE 5 mg/5 mL 5 MG/5ML Solution 120 mL Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54372250,NDC,120,ML,186.47,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,182.7406,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,182.7406
Immunoglobulin Subclasses - Ref,PX8278790,CDM,300,RC,82787,CPT,90,,,,,,,215,,First Health,Commercial,both,85,,999999999,percent of total billed charges,182.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.35,210.7
"Incis/Drain Scrotum/Testis,Epididym",PX54700P,CDM,983,RC,54700,CPT,,,,,,,,440,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,182.776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,182.776,1779.39
"Sb Scope,to Ileum,Biopsy",PX44377F,CDM,750,RC,44377,CPT,,,,,,,,1770,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,182.81,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,182.81,609.48
"Sb Scope,to Ileum,Biopsy",PX44377P,CDM,983,RC,44377,CPT,,,,,,,,1180,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,182.81,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,182.81,1156.4
"Xray Mandible Compl, Min 4 Vws",PX7011001,CDM,320,RC,70110,CPT,TC,,,,,,,381,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,182.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,373.38
"Xray Mandible Compl, Min 4 Vws",PX7011001,CDM,320,RC,70110,CPT,TC,,,,,,,381,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,182.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,373.38
Layr Clos Wnd Rest Body 2.6-7.5,PX12042F,CDM,510,RC,12042,CPT,,,,,,,,404,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,183.027,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,123.03,645.45
Layr Clos Wnd Rest Body 2.6-7.5,PX12042P,CDM,983,RC,12042,CPT,,,,,,,,777,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,183.027,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,123.03,761.46
"measles, mumps & rubella vaccine Recon Soln 1 Each Vial",90707,CDM,636,RC,90707,CPT,,,,6468100,NDC,1,EA,381.47,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,183.1056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,158.462638,373.8406
"measles, mumps & rubella vaccine Recon Soln 1 Each Vial",90707,CDM,636,RC,90707,CPT,,,,6468100,NDC,1,EA,381.47,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,183.1056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,158.462638,373.8406
"Hepatitis a Antibody, Tot - Ref",PX8670890,CDM,300,RC,86708,CPT,90,,,,,,,201,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,183.111,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.36,196.98
Hepatitis B Surface Antibody,PX86706,CDM,300,RC,86706,CPT,,,,,,,,201,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,183.111,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,196.98
KIT 3-LUMEN 7FR X 16CM CENTRALVENOUS CDC-42703-P1A,120.37,CDM,272,RC,C1751,HCPCS,,10707-MAIN,LOCAL,,,,,201,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,183.111,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.4954,196.98
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084252,NDC,0.5,ML,207.65,,United Healthcare,All Payer,outpatient,88.2,,154.8066667,percent of total billed charges,183.1473,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.085268,203.497
Acetaminophen,PX80307E,CDM,300,RC,80307,CPT,,,,,,,,370,,Humana Choice Care,All Medicare plans,outpatient,49.5,,535.850625,percent of total billed charges,183.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Alcohol,PX80307A,CDM,300,RC,80307,CPT,,,,,,,,370,,Humana Choice Care,All Medicare plans,outpatient,49.5,,535.850625,percent of total billed charges,183.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Salicylate,PX80307D,CDM,300,RC,80307,CPT,,,,,,,,370,,Humana Choice Care,All Medicare plans,outpatient,49.5,,535.850625,percent of total billed charges,183.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Urine Drug Screen,PX80307B,CDM,300,RC,80307,CPT,,,,,,,,370,,Humana Choice Care,All Medicare plans,outpatient,49.5,,535.850625,percent of total billed charges,183.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Xray Elbow 3+Vws Tc,PX7308001,CDM,320,RC,73080,CPT,TC,,,,,,,370,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,183.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,362.6
US Pregnancy Tc Follow-Up,PX7681601,CDM,402,RC,76816,CPT,TC,,,,,,,362,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,183.172,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,354.76
"Fac/Office Consultation,Level IV",PX99244F,CDM,510,RC,99244,CPT,,,,,,,,441,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,183.1914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,183.1914,432.18
Gastric Intubation Treatment,PX43753F,CDM,510,RC,43753,CPT,,,,,,,,441,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,183.1914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,183.1914,432.18
"Office Consultation,Level IV",PX99244P,CDM,983,RC,99244,CPT,,,,,,,,441,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,183.1914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,183.1914,429.2253
SUTURE CTD VICRYL 4-0 VIL BR SUTUPK J103T,27200000,CDM,272,RC,,,,4491-MAIN,LOCAL,,,,,373.97,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,183.2453,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE CTD VICRYL 4-0 VIL BR SUTUPK J103T,27200000,CDM,272,RC,,,,4491-MAIN,LOCAL,,,,,373.97,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,183.2453,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUTURE CTD VICRYL 4-0 VIL BR SUTUPK J103T,27200000,CDM,272,RC,,,,4491-MAIN,LOCAL,,,,,373.97,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,183.2453,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Fac/Exc Skin Benig<5mm Remaind Bod,PX11420F,CDM,510,RC,11420,CPT,,,,,,,,374,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,183.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,1416.38
Fac/Exc Skin Benig<5mm Remaind Bod,PX11420F,CDM,510,RC,11420,CPT,,,,,,,,374,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,183.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,1416.38
Fac/Exc Skin Benig<5mm Remaind Bod,PX11420F,CDM,510,RC,11420,CPT,,,,,,,,374,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,183.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,1416.38
Fac/Initial Hospital Care Levl II,PX99222F,CDM,510,RC,99222,CPT,,,,,,,,187,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,183.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.6798,183.26
"Fac/Office Consultation,Level III",PX99243F,CDM,510,RC,99213,CPT,,,,,,,,374,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,27.725,percent of total billed charges,183.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,366.52
"Fac/Office Consultation,Level III",PX99243F,CDM,510,RC,99213,CPT,,,,,,,,374,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,183.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,366.52
"Fac/Office Consultation,Level III",PX99243F,CDM,510,RC,99213,CPT,,,,,,,,374,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,183.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,366.52
"Infect Ag,Eia, Nos, Ea - Ref",PX8744990,CDM,300,RC,87449,CPT,90,,,,,,,187,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,183.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,183.26
Initial Hospital Care Levl II,PX99222P,CDM,982,RC,99222,CPT,,,,,,,,187,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,183.26,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.18,232.02
"Inpatient Consult, Level III",PX99253,CDM,983,RC,99253,CPT,,,,,,,,374,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,183.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,364.0142
"Inpatient Consult, Level III",PX99253,CDM,983,RC,99253,CPT,,,,,,,,374,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,183.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,364.0142
"Inpatient Consult, Level III",PX99253,CDM,983,RC,99253,CPT,,,,,,,,374,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,183.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,364.0142
"Office Consultation,Level III",PX99243P,CDM,983,RC,99243,CPT,,,,,,,,374,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,183.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,364.0142
"Office Consultation,Level III",PX99243P,CDM,983,RC,99243,CPT,,,,,,,,374,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,183.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,364.0142
"Office Consultation,Level III",PX99243P,CDM,983,RC,99243,CPT,,,,,,,,374,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,183.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,364.0142
Removal of Hemorrhoid Clot,PX46320P,CDM,983,RC,46320,CPT,,,,,,,,374,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,183.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,1030.93
Removal of Hemorrhoid Clot,PX46320P,CDM,983,RC,46320,CPT,,,,,,,,374,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,183.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,1030.93
Removal of Hemorrhoid Clot,PX46320P,CDM,983,RC,46320,CPT,,,,,,,,374,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,183.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,1030.93
RETRIEVAL BAG 12/15MM,27200000,CDM,272,RC,,,,12660-MAIN,LOCAL,,,,,187,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,183.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Xray Hand 3vws Tc,PX7313001,CDM,320,RC,73130,CPT,TC,,,,,,,374,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,99.06285714,percent of total billed charges,183.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,366.52
Xray Hand 3vws Tc,PX7313001,CDM,320,RC,73130,CPT,TC,,,,,,,374,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,183.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,366.52
Xray Hand 3vws Tc,PX7313001,CDM,320,RC,73130,CPT,TC,,,,,,,374,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,183.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,366.52
acetaZOLAMIDE 500 MG Recon Soln 1 Each Vial,J1120.01,CDM,636,RC,J1120,HCPCS,,,,39822019001,NDC,1,EA,207.84,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,183.31488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.336736,203.6832
"X-Ray Exam Hip,Bilat W/Pelvis 3-4 Vws",PX7352201,CDM,320,RC,73522,CPT,TC,,,,,,,382,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,183.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,374.36
"X-Ray Exam Hip,Bilat W/Pelvis 3-4 Vws",PX7352201,CDM,320,RC,73522,CPT,TC,,,,,,,382,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,183.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,374.36
"Sb Scope,to Ileum,Biopsy",PX44377F,CDM,750,RC,44377,CPT,,,,,,,,1770,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,183.46,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,182.81,609.48
"Sb Scope,to Ileum,Biopsy",PX44377F,CDM,750,RC,44377,CPT,,,,,,,,1770,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,183.46,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,182.81,609.48
"Sb Scope,to Ileum,Biopsy",PX44377P,CDM,983,RC,44377,CPT,,,,,,,,1180,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,183.46,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,182.81,1156.4
"Sb Scope,to Ileum,Biopsy",PX44377P,CDM,983,RC,44377,CPT,,,,,,,,1180,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,183.46,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,182.81,1156.4
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021515,NDC,0.5,ML,187.24,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,183.4952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.779496,199.7926
C-COLLAR ASPEN REGULAR 79-83365,120.25,CDM,274,RC,L0140,HCPCS,,167-MAIN,LOCAL,,,,,216,,First Health,Commercial,both,85,,999999999,percent of total billed charges,183.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.58,211.68
C-COLLAR ASPEN TALL 79-83367,120.25,CDM,274,RC,L0140,HCPCS,,164-MAIN,LOCAL,,,,,216,,First Health,Commercial,both,85,,999999999,percent of total billed charges,183.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.58,211.68
C-COLLAR ASPEN X-TALL 79-83368,120.25,CDM,274,RC,L0140,HCPCS,,168-MAIN,LOCAL,,,,,216,,First Health,Commercial,both,85,,999999999,percent of total billed charges,183.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.58,211.68
"Remv F.B.,Eye,Embed Conjunc",PX65210P,CDM,983,RC,65210,CPT,,,,,,,,216,,First Health,Commercial,both,85,,999999999,percent of total billed charges,183.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,89.7264,348.08
Resp Virus 6-11 Targets,PX87632,CDM,300,RC,87632,CPT,,,,,,,,428,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,183.612,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,177.7912,419.44
Xray Thoracic Spine 2 Vws,PX7207001,CDM,320,RC,72070,CPT,TC,,,,,,,428,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,183.612,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,419.44
Temporal Artery Ligatn or Bx,PX37609F,CDM,510,RC,37609,CPT,,,,,,,,705,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,183.6692,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,124.34,645.45
Temporal Artery Ligatn or Bx,PX37609P,CDM,983,RC,37609,CPT,,,,,,,,965,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,183.6692,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,124.34,945.7
SET CRICOTHYROTOMY CATHETER 3.5MM ID,120.251,CDM,272,RC,,,,4306-MAIN,LOCAL,,,,,363,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,183.678,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.7902,355.74
SET CRICOTHYROTOMY CATHETER 4MM ID,120.251,CDM,272,RC,,,,3452-MAIN,LOCAL,,,,,363,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,183.678,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.7902,355.74
SET CRICOTHYROTOMY CATHETER 6MM ID,120.251,CDM,272,RC,,,,2887-MAIN,LOCAL,,,,,363,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,183.678,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.7902,355.74
"Digital Mamm, Diag, Bilat, Tc W/Cad Perf",PX7706601,CDM,401,RC,77066,CPT,TC,,,,,,,375,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,183.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.05,367.5
"Digital Mamm, Diag, Bilat, Tc W/Cad Perf",PX7706601,CDM,401,RC,77066,CPT,TC,,,,,,,375,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,183.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.05,367.5
"Digital Mamm, Diag, Bilat, Tc W/Cad Perf",PX7706601,CDM,401,RC,77066,CPT,TC,,,,,,,375,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,183.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.05,367.5
"Digital Mammogram, Screen Bil, Tc W/Cad Perf",PX7706701,CDM,403,RC,77067,CPT,TC,,,,,,,375,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,204.2482353,percent of total billed charges,183.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.86,561
"Digital Mammogram, Screen Bil, Tc W/Cad Perf",PX7706701,CDM,403,RC,77067,CPT,TC,,,,,,,375,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,183.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.86,561
"Digital Mammogram, Screen Bil, Tc W/Cad Perf",PX7706701,CDM,403,RC,77067,CPT,TC,,,,,,,375,,United Healthcare,All Medicare advantage plans,outpatient,49,,90.07,percent of total billed charges,183.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.86,561
Repr Superf Wnd Face 2.6-5,PX12013F,CDM,510,RC,12013,CPT,,,,,,,,375,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,242.62,percent of total billed charges,183.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.775,367.5
Repr Superf Wnd Face 2.6-5,PX12013F,CDM,510,RC,12013,CPT,,,,,,,,375,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,183.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.775,367.5
Repr Superf Wnd Face 2.6-5,PX12013F,CDM,510,RC,12013,CPT,,,,,,,,375,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,183.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.775,367.5
Xray Wrist Minimum 3 Vws,PX7311001,CDM,320,RC,73110,CPT,TC,,,,,,,375,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,111.71,percent of total billed charges,183.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,367.5
Xray Wrist Minimum 3 Vws,PX7311001,CDM,320,RC,73110,CPT,TC,,,,,,,375,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,183.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,367.5
Xray Wrist Minimum 3 Vws,PX7311001,CDM,320,RC,73110,CPT,TC,,,,,,,375,,United Healthcare,All Medicare advantage plans,outpatient,49,,183.75,percent of total billed charges,183.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,367.5
El-1 Fecal Quantitative,PX8265390,CDM,300,RC,82653,CPT,90,,,,,,,383,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,183.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.0982,375.34
El-1 Fecal Quantitative,PX8265390,CDM,300,RC,82653,CPT,90,,,,,,,383,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,183.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.0982,375.34
procainamide 500 MG/ML Solution 2 mL Vial,J2690.01,CDM,636,RC,J2690,HCPCS,,,,14789090002,NDC,2,ML,377.75,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,183.91589,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.75,187.2
Alcohols - Ref,PX8032090,CDM,300,RC,80320,CPT,90,,,,,,,189,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,183.9537,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.5106,185.22
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082152,NDC,1,ML,375.43,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,183.9607,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.48,367.9214
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082152,NDC,1,ML,375.43,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,183.9607,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.48,367.9214
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082152,NDC,1,ML,375.43,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,183.9607,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.48,367.9214
butamben-tetracaine-benzocaine 2-2-14 % Aerosol 5 g Bottle,25000000,CDM,250,RC,,,,,,10223020104,NDC,5,GR,375.52,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,184.0048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
butamben-tetracaine-benzocaine 2-2-14 % Aerosol 5 g Bottle,25000000,CDM,250,RC,,,,,,10223020104,NDC,5,GR,375.52,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,184.0048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
butamben-tetracaine-benzocaine 2-2-14 % Aerosol 5 g Bottle,25000000,CDM,250,RC,,,,,,10223020104,NDC,5,GR,375.52,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,184.0048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Closed Rx Metacarpal Fx,PX26600F,CDM,510,RC,26600,CPT,,,,,,,,443,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,184.0222,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,184.0222,434.14
I&D Bartholin Gland Abscess,PX56420F,CDM,510,RC,56420,CPT,,,,,,,,429,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,184.041,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.08,420.42
pentafluoroprop - tetrafluoroeth Aerosol 116 mL Can,63700001,CDM,250,RC,,,,,,386000802,NDC,207,ML,383.42,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,184.0416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pentafluoroprop - tetrafluoroeth Aerosol 116 mL Can,63700001,CDM,250,RC,,,,,,386000802,NDC,207,ML,383.42,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,184.0416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070102,NDC,1,ML,383.6,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,184.128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.92,450.751
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070102,NDC,1,ML,383.6,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,184.128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.92,450.751
hepatitis A vaccine 1440 EL U/ML Suspension 1 mL Syringe,90632,CDM,636,RC,90632,CPT,,,,58160082652,NDC,1,ML,375.78,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,184.1322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,156.099012,368.2644
hepatitis A vaccine 1440 EL U/ML Suspension 1 mL Syringe,90632,CDM,636,RC,90632,CPT,,,,58160082652,NDC,1,ML,375.78,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,184.1322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,156.099012,368.2644
hepatitis A vaccine 1440 EL U/ML Suspension 1 mL Syringe,90632,CDM,636,RC,90632,CPT,,,,58160082652,NDC,1,ML,375.78,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,184.1322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,156.099012,368.2644
Cyto Non Gyn,PX8811201,CDM,310,RC,88112,CPT,TC,,,,,,,372,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,184.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,364.56
Cardiac Rehab II Eval,PX93798.05,CDM,943,RC,93798,CPT,,,,,,,,364,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,184.184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.44,495.55
Drain/Inject Large Joint/Bursa,PX20610F,CDM,510,RC,20610,CPT,,,,,,,,364,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,184.184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,151.2056,356.72
Xray Forearm 2 Vws,PX7309001,CDM,320,RC,73090,CPT,TC,,,,,,,364,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,184.184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,356.72
fat emulsion 20 % Emulsion 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,338051958,NDC,200,ML,375.95,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,184.2155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fat emulsion 20 % Emulsion 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,338051958,NDC,200,ML,375.95,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,184.2155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fat emulsion 20 % Emulsion 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,338051958,NDC,200,ML,375.95,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,184.2155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Drain Finger Abscess,Simple",PX26010P,CDM,983,RC,26010,CPT,,,,,,,,207,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,184.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.9878,201.4731
ACCESSORY KIT FOR GROSHONG 16GA,120.46,CDM,272,RC,C1751,HCPCS,,2967-MAIN,LOCAL,,,,,209,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,184.338,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.8186,204.82
Infection Agent Detect Dna/Rna Probe Tq 12-25,PX87507,CDM,300,RC,87507,CPT,,,,,,,,209,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,184.338,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.8186,382.15
"Organic Acid, Single, Qnt - Ref",PX8392190,CDM,300,RC,83921,CPT,90,,,,,,,209,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,184.338,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.45,204.82
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279210,NDC,10,ML,429.84,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,184.40136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,178.555536,421.2432
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279410,NDC,10,ML,429.84,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,184.40136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,178.555536,421.2432
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084243,NDC,0.5,ML,202.42,,Medica,Commercial,both,91.1,,56.23,percent of total billed charges,184.40462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.085268,203.497
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062001,NDC,0.4,ML,189.48,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,25.0327027,percent of total billed charges,184.420884,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062040,NDC,0.4,ML,189.48,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,25.0327027,percent of total billed charges,184.420884,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801401,NDC,0.4,ML,189.48,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,25.0327027,percent of total billed charges,184.420884,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801410,NDC,0.4,ML,189.48,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,25.0327027,percent of total billed charges,184.420884,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
Procalcitonin,PX84145,CDM,300,RC,84145,CPT,,,,,,,,217,,First Health,Commercial,both,85,,999999999,percent of total billed charges,184.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.96,212.66
TRAY 8 FR 5IN CENTESIS WITH TURKEL  30-CE1CO,120.303,CDM,272,RC,,,,11503-MAIN,LOCAL,,,,,217,,First Health,Commercial,both,85,,999999999,percent of total billed charges,184.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,90.1418,212.66
Baloxavir Marboxil(40 MG Dose) 2 x 20 MG tablet therapy pack 2 Each Box,800000,CDM,,,,,,,,50242082802,NDC,1,EA,384.3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,184.464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Baloxavir Marboxil(40 MG Dose) 2 x 20 MG tablet therapy pack 2 Each Box,800000,CDM,,,,,,,,50242082802,NDC,1,EA,384.3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,184.464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
RELOAD SUREFORM 60 2.5 WHITE 6 ROW BOX/12,27200000,CDM,272,RC,,,,12261-MAIN,LOCAL,,,,,430,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,184.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 60 3.5 BLUE,27200000,CDM,272,RC,,,,12084-MAIN,LOCAL,,,,,430,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,184.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 60 4.3 GREEN,27200000,CDM,272,RC,,,,12085-MAIN,LOCAL,,,,,430,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,184.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802001,NDC,1,ML,444.2,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,184.52068,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802010,NDC,1,ML,444.2,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,184.52068,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
"2019-Ncov Coronavirus, Sars-Cov-2/2019-Ncov (Covid-19)",PXU000290,CDM,300,RC,U0002,HCPCS,90,,,,,,,365,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,184.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,357.7
"Closed Rx Spont Hip Disloc,Anesth",PX27257P,CDM,983,RC,27257,CPT,,,,,,,,365,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,184.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,151.621,1404.08
Sars-Cov-2 Covid-19 Amp Prb,PX8763590,CDM,300,RC,87635,CPT,90,,,,,,,365,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,184.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,357.7
X-Ray Exam Femur Min 2 Vws,PX7355201,CDM,320,RC,73552,CPT,TC,,,,,,,365,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,184.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Ankle Minimum 3 Vws,PX7361001,CDM,320,RC,73610,CPT,TC,,,,,,,365,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,184.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Calcaneus Minimum 2 Vws,PX7365001,CDM,320,RC,73650,CPT,TC,,,,,,,365,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,184.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Clavicle Complete,PX7300001,CDM,320,RC,73000,CPT,TC,,,,,,,365,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,184.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Elbow 2 Vws,PX7307001,CDM,320,RC,73070,CPT,TC,,,,,,,365,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,184.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Hand 2vws Tc,PX7312001,CDM,320,RC,73120,CPT,TC,,,,,,,365,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,184.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,357.7
Xray Humerus Minimum 2 Vws,PX7306001,CDM,320,RC,73060,CPT,TC,,,,,,,365,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,184.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Shoulder Minimum 2 Vws,PX7303001,CDM,320,RC,73030,CPT,TC,,,,,,,365,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,184.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Sternum 2vws Tc,PX7112001,CDM,320,RC,71120,CPT,TC,,,,,,,365,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,184.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Tibia & Fibula 2 Vws,PX7359001,CDM,320,RC,73590,CPT,TC,,,,,,,365,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,184.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Wrist 2 Vws,PX7310001,CDM,320,RC,73100,CPT,TC,,,,,,,365,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,184.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
CT Soft Tissue Neck W/O Dye,PX7049001,CDM,350,RC,70490,CPT,TC,,,,,,,711,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,184.73,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.6,184.73
CT Soft Tissue Neck W/O Dye,PX7049001,CDM,350,RC,70490,CPT,TC,,,,,,,711,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,184.73,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.6,184.73
Repr Superf Wnd Body 12.6-20,PX12005P,CDM,983,RC,12005,CPT,,,,,,,,377,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,184.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,156.6058,366.9341
Repr Superf Wnd Body 12.6-20,PX12005P,CDM,983,RC,12005,CPT,,,,,,,,377,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,184.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,156.6058,366.9341
Repr Superf Wnd Body 12.6-20,PX12005P,CDM,983,RC,12005,CPT,,,,,,,,377,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,184.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,156.6058,366.9341
Trg Gene Rearrangement Anal - Ref,PX8134290,CDM,300,RC,81342,CPT,90,,,,,,,516,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,184.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,184.76,505.68
Injection for Nerve Block,PX64445F,CDM,510,RC,64445,CPT,,,,,,,,385,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,184.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,604.15
Injection for Nerve Block,PX64445F,CDM,510,RC,64445,CPT,,,,,,,,385,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,184.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,604.15
MICA DEPTH GAUGE 150MM STERILE MICA,27200000,CDM,272,RC,,,,12439-MAIN,LOCAL,,,,,385,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,184.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA DEPTH GAUGE 150MM STERILE MICA,27200000,CDM,272,RC,,,,12439-MAIN,LOCAL,,,,,385,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,184.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"N Block Inj, Plantar Digit",PX64455F,CDM,510,RC,64455,CPT,,,,,,,,385,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,184.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,377.3
"N Block Inj, Plantar Digit",PX64455F,CDM,510,RC,64455,CPT,,,,,,,,385,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,184.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,377.3
Xray Temporomandib Jnt Unilat,PX7032801,CDM,320,RC,70328,CPT,TC,,,,,,,385,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,184.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,377.3
Xray Temporomandib Jnt Unilat,PX7032801,CDM,320,RC,70328,CPT,TC,,,,,,,385,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,184.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,377.3
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084252,NDC,0.5,ML,207.65,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,184.8085,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.085268,203.497
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,781344071,NDC,1,EA,430.94,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,184.87326,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,179.012476,460.7862
Assay of ammonia,PX82140,CDM,300,RC,82140,CPT,,,,,,,,190,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,53.71333333,percent of total billed charges,184.927,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.36,186.2
Assay of protein urine,PX84156,CDM,300,RC,84156,CPT,,,,,,,,190,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,184.927,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.37,186.2
Each Add'l Sequential IV Infusion <1 Hour,PX96367,CDM,260,RC,96367,CPT,,,,,,,,190,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,116.87,percent of total billed charges,184.927,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,186.2
"N Block Inj, Common Digit",PX64632F,CDM,510,RC,64632,CPT,,,,,,,,190,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,184.927,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.926,258.75
"Tumor Antigen, Ca-125",PX86304,CDM,300,RC,86304,CPT,,,,,,,,190,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,184.927,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,186.2
acetaZOLAMIDE 500 MG Recon Soln 1 Each Vial,J1120.01,CDM,636,RC,J1120,HCPCS,,,,39822019001,NDC,1,EA,207.84,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,184.9776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.336736,203.6832
"Cardioversion, Elective;Extern",PX92960F,CDM,480,RC,92960,CPT,,,,,,,,402,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,184.98,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.41,267
"Cardioversion, Elective;Extern",PX92960P,CDM,983,RC,92960,CPT,,,,,,,,688,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,184.98,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.41,674.24
baricitinib 2 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,2418230,NDC,0.5,EA,203.12,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,185.04232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pyRIDostigmine bromide 10 MG/2ML Solution 2 mL Ampule,25000000,CDM,250,RC,,,,,,781304095,NDC,2,ML,203.16,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,185.07876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
procainamide 500 MG/ML Solution 2 mL Vial,J2690.01,CDM,636,RC,J2690,HCPCS,,,,14789090002,NDC,2,ML,377.75,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,185.0975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,134.15,370.195
procainamide 500 MG/ML Solution 2 mL Vial,J2690.01,CDM,636,RC,J2690,HCPCS,,,,14789090002,NDC,2,ML,377.75,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,185.0975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,134.15,370.195
procainamide 500 MG/ML Solution 2 mL Vial,J2690.01,CDM,636,RC,J2690,HCPCS,,,,14789090002,NDC,2,ML,377.75,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,185.0975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,134.15,370.195
SUTURE CTD VICRYL 4-0 VIL BR SUTUPK J103T,27200000,CDM,272,RC,,,,4491-MAIN,LOCAL,,,,,373.97,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,185.11515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Fac/Exc Skin Benig<5mm Remaind Bod,PX11420F,CDM,510,RC,11420,CPT,,,,,,,,374,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,185.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,1416.38
"Fac/Office Consultation,Level III",PX99243F,CDM,510,RC,99213,CPT,,,,,,,,374,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,185.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,366.52
"Inpatient Consult, Level III",PX99253,CDM,983,RC,99253,CPT,,,,,,,,374,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,185.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,364.0142
"Office Consultation,Level III",PX99243P,CDM,983,RC,99243,CPT,,,,,,,,374,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,185.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,364.0142
Removal of Hemorrhoid Clot,PX46320P,CDM,983,RC,46320,CPT,,,,,,,,374,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,185.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,1030.93
Xray Hand 3vws Tc,PX7313001,CDM,320,RC,73130,CPT,TC,,,,,,,374,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,185.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,366.52
Dress/Debrid Med Burn No Anesth,PX16025F,CDM,510,RC,16025,CPT,,,,,,,,366,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,185.196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,152.0364,358.68
cabazitaxel 60 MG/1.5ML Solution 6 mL Vial,J9043.01,CDM,636,RC,J9043,HCPCS,,,,24582411,NDC,6,ML,28293.07,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,185.2,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,185.2,220.98
AIRSEAL ROBOTIC Xi CAP AND OBTURATOR WITH BLADELESS OPTICAL TIP,27200000,CDM,272,RC,,,,12208-MAIN,LOCAL,,,,,210,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,185.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
AIRSEAL ROBOTIC Xi TRI LUMEN FILTERED TUBE SET WITH ACTIVATED CHARCOAL,27200000,CDM,272,RC,,,,12209-MAIN,LOCAL,,,,,210,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,185.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Alcohols - Ref,PX8032090,CDM,300,RC,80320,CPT,90,,,,,,,189,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,185.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.5106,185.22
Apply Forearm Cast,PX29075F,CDM,510,RC,29075,CPT,,,,,,,,210,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,185.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,234.62
Chorionic gonadotropin test,PX84702,CDM,300,RC,84702,CPT,,,,,,,,210,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,185.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.8,205.8
"Excision of Nail Fold, Toe",PX11765F,CDM,510,RC,11765,CPT,,,,,,,,210,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,185.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,348.35
Fac/Hospital Discharge Day>30 Min,PX99239F,CDM,510,RC,99239,CPT,,,,,,,,210,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,185.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,205.8
"Inject Trigger Point, 1 or 2",PX20552P,CDM,983,RC,20552,CPT,,,,,,,,210,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,185.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,258.75
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781315972,NDC,1,EA,217.96,,First Health,Commercial,both,85,,999999999,percent of total billed charges,185.266,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86,213.6008
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032F,CDM,510,RC,12032,CPT,,,,,,,,386,,Health Partners,Health Partners Care Plans,both,48,,199.66,percent of total billed charges,185.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.3444,378.28
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032F,CDM,510,RC,12032,CPT,,,,,,,,386,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,185.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.3444,378.28
RELOAD SUREFORM 45 2.5MM WHITE,27200000,CDM,272,RC,,,,12791-MAIN,LOCAL,,,,,386,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,185.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 45 2.5MM WHITE,27200000,CDM,272,RC,,,,12791-MAIN,LOCAL,,,,,386,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,185.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 45 3.5MM BLUE,27200000,CDM,272,RC,,,,12792-MAIN,LOCAL,,,,,386,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,185.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 45 3.5MM BLUE,27200000,CDM,272,RC,,,,12792-MAIN,LOCAL,,,,,386,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,185.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 45 4.3MM GREEN,27200000,CDM,272,RC,,,,12793-MAIN,LOCAL,,,,,386,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,185.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 45 4.3MM GREEN,27200000,CDM,272,RC,,,,12793-MAIN,LOCAL,,,,,386,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,185.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
indocyanine green 25 MG Recon Soln 1 Each Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,70100042402,NDC,1,EA,446.07,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,185.297478,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.29,1354.4776
Xray Eye Foreign Body,PX7003001,CDM,320,RC,70030,CPT,TC,,,,,,,432,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,185.328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,423.36
Immunofluorescence per Spec Add Singl Antb Stain - Ref,PX8835090,CDM,310,RC,88350,CPT,90,,,,,,,112,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,185.408,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.42,185.408
Immunofluorescence per Spec Add Singl Antb Stain - Ref,PX8835090,CDM,310,RC,88350,CPT,90,,,,,,,112,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,185.408,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.42,185.408
gemcitabine 1 GM/26.3ML Solution 26.3 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018101,NDC,26.3,ML,203.58,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,185.46138,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
rifAXIMin 550 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,65649030302,NDC,1,EA,218.25,,First Health,Commercial,both,85,,999999999,percent of total billed charges,185.5125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rifAXIMin 550 MG Tablet 60 Each Box,63700001,CDM,250,RC,,,,,,65649030303,NDC,1,EA,218.25,,First Health,Commercial,both,85,,999999999,percent of total billed charges,185.5125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone propionate 50 MCG/ACT Suspension 16 g Bottle,63700001,CDM,250,RC,,,,,,50383070016,NDC,16,GR,432.56,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,185.56824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Digital Mamm, Diag, Bilat, Tc W/Cad Perf",PX7706601,CDM,401,RC,77066,CPT,TC,,,,,,,375,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,185.625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.05,367.5
"Digital Mammogram, Screen Bil, Tc W/Cad Perf",PX7706701,CDM,403,RC,77067,CPT,TC,,,,,,,375,,Humana Choice Care,All Medicare plans,outpatient,49.5,,79.57928571,percent of total billed charges,185.625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.86,561
Repr Superf Wnd Face 2.6-5,PX12013F,CDM,510,RC,12013,CPT,,,,,,,,375,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,185.625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.775,367.5
Xray Wrist Minimum 3 Vws,PX7311001,CDM,320,RC,73110,CPT,TC,,,,,,,375,,Humana Choice Care,All Medicare plans,outpatient,49.5,,132.9,percent of total billed charges,185.625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,367.5
leuprolide 7.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74364203,NDC,1,EA,3782.28,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,185.66,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.54,190.37
leuprolide 7.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74364203,NDC,1,EA,3782.28,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,185.66,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.54,190.37
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74334603,NDC,1,EA,12509.82,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,185.66,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.54,190.37
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74334603,NDC,1,EA,12509.82,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,185.66,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.54,190.37
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,62935022305,NDC,1,EA,2764.34,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,185.66,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.54,190.37
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,62935022305,NDC,1,EA,2764.34,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,185.66,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.54,190.37
leuprolide 45 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74347303,NDC,1,EA,21633.89,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,185.66,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.54,190.37
leuprolide 45 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74347303,NDC,1,EA,21633.89,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,185.66,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.54,190.37
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062001,NDC,0.4,ML,189.48,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,185.6904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062040,NDC,0.4,ML,189.48,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,185.6904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801401,NDC,0.4,ML,189.48,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,185.6904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801410,NDC,0.4,ML,189.48,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,185.6904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
Xray Foot 2 Vws,PX7362001,CDM,320,RC,73620,CPT,TC,,,,,,,367,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,185.702,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,359.66
"Tech-Cytopath Eval, Fna, Rep",PX8817301,CDM,310,RC,88173,CPT,TC,,,,,,,379,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,185.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,371.42
"Tech-Cytopath Eval, Fna, Rep",PX8817301,CDM,310,RC,88173,CPT,TC,,,,,,,379,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,185.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,371.42
"Tech-Cytopath Eval, Fna, Rep",PX8817301,CDM,310,RC,88173,CPT,TC,,,,,,,379,,United Healthcare,All Medicare advantage plans,outpatient,49,,194.51,percent of total billed charges,185.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,371.42
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021588,NDC,0.5,ML,203.87,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,185.72557,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.779496,199.7926
Closed Rx Bimalleolar Fx,PX27808P,CDM,983,RC,27808,CPT,,,,,,,,433,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,185.757,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,179.8682,421.4389
Drain/Inject Med Joint/Brusa W/US Guide,PX20606F,CDM,510,RC,20606,CPT,,,,,,,,387,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,185.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.7598,604.15
Drain/Inject Med Joint/Brusa W/US Guide,PX20606F,CDM,510,RC,20606,CPT,,,,,,,,387,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,185.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.7598,604.15
Facility Emergency Level II Visit,PX99282F,CDM,450,RC,99282,CPT,,,,,,,,387,,Health Partners,Health Partners Care Plans,both,48,,96.08,percent of total billed charges,185.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,142.88,379.26
Facility Emergency Level II Visit,PX99282F,CDM,450,RC,99282,CPT,,,,,,,,387,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,185.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,142.88,379.26
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Solution 10 mL Bottle,63700001,CDM,250,RC,,,,,,61314064610,NDC,10,ML,433.15,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,185.82135,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082152,NDC,1,ML,375.43,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,185.83785,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.48,367.9214
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106P,CDM,983,RC,11106,CPT,,,,,,,,204,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,185.844,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.7416,548.67
butamben-tetracaine-benzocaine 2-2-14 % Aerosol 5 g Bottle,25000000,CDM,250,RC,,,,,,10223020104,NDC,5,GR,375.52,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,185.8824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323012594,NDC,1,EA,190.99,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,185.890567,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
Assay of Amylase,PX82150,CDM,300,RC,82150,CPT,,,,,,,,191,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,185.01,percent of total billed charges,185.9003,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.94,187.18
C-Reactive Protein,PX86140,CDM,300,RC,86140,CPT,,,,,,,,191,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,81.04477612,percent of total billed charges,185.9003,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,187.18
"Chemotherapy, IV Infusion, Add'l Hour",PX96415,CDM,335,RC,96415,CPT,,,,,,,,191,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,82.16384615,percent of total billed charges,185.9003,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,187.18
Fac/Ther Injection Carpal Tunnel,PX20526F,CDM,510,RC,20526,CPT,,,,,,,,191,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,185.9003,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.3414,258.75
Urine Pregnancy Test,PX81025,CDM,300,RC,81025,CPT,,,,,,,,191,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,94.58,percent of total billed charges,185.9003,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.89,187.18
ACCESSORY KIT FOR GROSHONG 16GA,120.46,CDM,272,RC,C1751,HCPCS,,2967-MAIN,LOCAL,,,,,209,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,186.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.8186,204.82
Infection Agent Detect Dna/Rna Probe Tq 12-25,PX87507,CDM,300,RC,87507,CPT,,,,,,,,209,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,186.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.8186,382.15
"Organic Acid, Single, Qnt - Ref",PX8392190,CDM,300,RC,83921,CPT,90,,,,,,,209,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,186.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.45,204.82
hepatitis A vaccine 1440 EL U/ML Suspension 1 mL Syringe,90632,CDM,636,RC,90632,CPT,,,,58160082652,NDC,1,ML,375.78,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,186.0111,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,156.099012,368.2644
hydrocortisone (perianal) 2.5 % Cream 28.35 g Tube,63700001,CDM,250,RC,,,,,,10631040701,NDC,28.35,GR,447.94,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,186.074276,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Apply Forearm Cast,PX29075F,CDM,510,RC,29075,CPT,,,,,,,,210,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,186.09,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.83,186.09
Apply Forearm Cast,PX29075P,CDM,983,RC,29075,CPT,,,,,,,,140,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,186.09,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.83,186.09
fat emulsion 20 % Emulsion 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,338051958,NDC,200,ML,375.95,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,186.09525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Bone Age Studies Tc,PX7707201,CDM,320,RC,77072,CPT,TC,,,,,,,211,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,186.102,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.6494,206.78
Collect Blood From Picc,PX36592F,CDM,510,RC,36592,CPT,,,,,,,,211,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,186.102,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.6494,206.78
Draw Blood Off Venous Device,PX36591F,CDM,510,RC,36591,CPT,,,,,,,,211,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,186.102,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.6494,206.78
CANNULATED AO HANDLE STERILE MICA SCREW SYSTEM 57S1HNDL,27200000,CDM,272,RC,,,,12446-MAIN,LOCAL,,,,,219,,First Health,Commercial,both,85,,999999999,percent of total billed charges,186.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TUBE SURGICAL IRRIGATION 1PK PD-IT,27200000,CDM,272,RC,,,,12433-MAIN,LOCAL,,,,,219,,First Health,Commercial,both,85,,999999999,percent of total billed charges,186.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Assay of ammonia,PX82140,CDM,300,RC,82140,CPT,,,,,,,,190,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,186.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.36,186.2
Assay of protein urine,PX84156,CDM,300,RC,84156,CPT,,,,,,,,190,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,186.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.37,186.2
Closed Rx Elbow Dislocation,PX24600P,CDM,983,RC,24600,CPT,,,,,,,,380,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,186.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,157.852,369.854
Closed Rx Elbow Dislocation,PX24600P,CDM,983,RC,24600,CPT,,,,,,,,380,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,186.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,157.852,369.854
Closed Rx Elbow Dislocation,PX24600P,CDM,983,RC,24600,CPT,,,,,,,,380,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,186.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,157.852,369.854
Each Add'l Sequential IV Infusion <1 Hour,PX96367,CDM,260,RC,96367,CPT,,,,,,,,190,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,186.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,186.2
"N Block Inj, Common Digit",PX64632F,CDM,510,RC,64632,CPT,,,,,,,,190,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,186.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.926,258.75
"Tumor Antigen, Ca-125",PX86304,CDM,300,RC,86304,CPT,,,,,,,,190,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,186.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.08,186.2
SCOPE ASCOPE4 CYSTO STERILE 601001000,120.497,CDM,272,RC,A4649,HCPCS,,11662-MAIN,LOCAL,,,,,368,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,186.208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,152.8672,360.64
"Layr Clos Wnd Face,Facial 2.5-5",PX12052F,CDM,510,RC,12052,CPT,,,,,,,,585,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,186.238,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.22,656.52
"Layr Clos Wnd Face,Facial 2.5-5",PX12052P,CDM,983,RC,12052,CPT,,,,,,,,776,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,186.238,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.22,760.48
tobramycin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314064305,NDC,5,ML,191.42,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,186.309086,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Airway Inhalation Treatment,PX94640F,CDM,410,RC,94640,CPT,,,,,,,,242,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,186.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,100.5268,237.16
Cpap/Bipap Mgmnt-Pt Own Equipment,PX94660.02F,CDM,410,RC,94660,CPT,,,,,,,,497,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,186.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.33,487.06
"POS Airway Pressure, Bipap",PX94660.01F,CDM,410,RC,94660,CPT,,,,,,,,468,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,186.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.33,458.64
"POS Airway Pressure, Cpap",PX94660F,CDM,410,RC,94660,CPT,,,,,,,,498,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,186.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.33,488.04
gentamicin 0.3 % Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,17478028435,NDC,3.5,GR,219.3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,186.405,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601901,NDC,10,ML,211.47,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,186.51654,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.844638,207.2406
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601910,NDC,10,ML,211.47,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,186.51654,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.844638,207.2406
Repr Superf Wnd Body 12.6-20,PX12005P,CDM,983,RC,12005,CPT,,,,,,,,377,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,186.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,156.6058,366.9341
"Xray Mandible Compl, Min 4 Vws",PX7011001,CDM,320,RC,70110,CPT,TC,,,,,,,381,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,186.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,373.38
"Xray Mandible Compl, Min 4 Vws",PX7011001,CDM,320,RC,70110,CPT,TC,,,,,,,381,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,186.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,373.38
"Xray Mandible Compl, Min 4 Vws",PX7011001,CDM,320,RC,70110,CPT,TC,,,,,,,381,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,186.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,373.38
ANCHORAGE FIXATION PIN,27200000,CDM,272,RC,,,,12642-MAIN,LOCAL,,,,,389,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,186.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ANCHORAGE FIXATION PIN,27200000,CDM,272,RC,,,,12642-MAIN,LOCAL,,,,,389,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,186.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Ext Ecg > 48hr to 21 Day Rcrd W/Conect Intl Rcrd,PX0296T,CDM,731,RC,0296T,HCPCS,,,,,,,,389,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,186.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,161.5906,381.22
Ext Ecg > 48hr to 21 Day Rcrd W/Conect Intl Rcrd,PX0296T,CDM,731,RC,0296T,HCPCS,,,,,,,,389,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,186.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,161.5906,381.22
Incise Finger Tendon Sheath,PX26055F,CDM,510,RC,26055,CPT,,,,,,,,1398,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,186.74,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.74,1232.1
Incise Finger Tendon Sheath,PX26055P,CDM,983,RC,26055,CPT,,,,,,,,932,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,186.74,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.74,1232.1
"Chest Wall Manipulation,Subsequent",PX94668F,CDM,410,RC,94668,CPT,,,,,,,,192,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,186.8736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.7568,188.16
Hepatitis Be Antibody - Ref,PX8670790,CDM,300,RC,86707,CPT,90,,,,,,,192,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,186.8736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.61,188.16
Infectious Agent Antigen Detection by Immunoassay With Direct Visual Observation.,PX87811,CDM,300,RC,87811,CPT,,,,,,,,192,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,186.8736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.94,188.16
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,43598054910,NDC,100,ML,205.14,,Medica,Commercial,both,91.1,,0.687108295,percent of total billed charges,186.88254,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
AIRSEAL ROBOTIC Xi CAP AND OBTURATOR WITH BLADELESS OPTICAL TIP,27200000,CDM,272,RC,,,,12208-MAIN,LOCAL,,,,,210,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,186.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
AIRSEAL ROBOTIC Xi TRI LUMEN FILTERED TUBE SET WITH ACTIVATED CHARCOAL,27200000,CDM,272,RC,,,,12209-MAIN,LOCAL,,,,,210,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,186.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Apply Forearm Cast,PX29075F,CDM,510,RC,29075,CPT,,,,,,,,210,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,186.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,234.62
Chorionic gonadotropin test,PX84702,CDM,300,RC,84702,CPT,,,,,,,,210,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,186.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.8,205.8
"Excision of Nail Fold, Toe",PX11765F,CDM,510,RC,11765,CPT,,,,,,,,210,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,186.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,348.35
Fac/Hospital Discharge Day>30 Min,PX99239F,CDM,510,RC,99239,CPT,,,,,,,,210,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,186.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,205.8
"Inject Trigger Point, 1 or 2",PX20552P,CDM,983,RC,20552,CPT,,,,,,,,210,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,186.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,258.75
"measles, mumps & rubella vaccine Recon Soln 1 Each Vial",90707,CDM,636,RC,90707,CPT,,,,6468100,NDC,1,EA,381.47,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,186.9203,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,158.462638,373.8406
"measles, mumps & rubella vaccine Recon Soln 1 Each Vial",90707,CDM,636,RC,90707,CPT,,,,6468100,NDC,1,EA,381.47,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,186.9203,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,158.462638,373.8406
"measles, mumps & rubella vaccine Recon Soln 1 Each Vial",90707,CDM,636,RC,90707,CPT,,,,6468100,NDC,1,EA,381.47,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,186.9203,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,158.462638,373.8406
"Spinal Punc,Drain,Theraputic",PX62272F,CDM,510,RC,62272,CPT,,,,,,,,450,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,186.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.93,604.15
"Non-Select. Wound Debride., W/O Anesth.; Top. Appl./Wound Assess./Instruct., per Sess.",PX97602,CDM,761,RC,97602,CPT,,,,,,,,212,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,186.984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.0648,207.76
procainamide 500 MG/ML Solution 2 mL Vial,J2690.01,CDM,636,RC,J2690,HCPCS,,,,14789090002,NDC,2,ML,377.75,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,186.98625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,134.15,370.195
Hepatitis a Igm Antibody,PX86709,CDM,300,RC,86709,CPT,,,,,,,,220,,First Health,Commercial,both,85,,999999999,percent of total billed charges,187,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.32,215.6
"Hiv-1, Quantification - Ref",PX8753690,CDM,300,RC,87536,CPT,90,,,,,,,220,,First Health,Commercial,both,85,,999999999,percent of total billed charges,187,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.03,215.6
Immunoassay Nos - Ref,PX8352090,CDM,300,RC,83520,CPT,90,,,,,,,220,,First Health,Commercial,both,85,,999999999,percent of total billed charges,187,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.83,215.6
Leptospira Antibody - Ref,PX8672090,CDM,300,RC,86720,CPT,90,,,,,,,220,,First Health,Commercial,both,85,,999999999,percent of total billed charges,187,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.85,215.6
X-Ray Exam Abdomen 2 Views,PX7401901,CDM,320,RC,74019,CPT,TC,,,,,,,436,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,187.044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,427.28
"X-Ray Exam Hip,Unilat W/Pelvis 2-3 Vws",PX7350201,CDM,320,RC,73502,CPT,TC,,,,,,,436,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,187.044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,427.28
Xray Abdomen Comp Incl Decub and/or Erect,PX7402001,CDM,320,RC,74020,CPT,TC,,,,,,,436,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,187.044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.1144,427.28
Xray Cervical Spine 2 or 3 Vws,PX7204001,CDM,320,RC,72040,CPT,TC,,,,,,,436,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,187.044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,427.28
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323012594,NDC,1,EA,190.99,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,187.1702,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
Assay of Amylase,PX82150,CDM,300,RC,82150,CPT,,,,,,,,191,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,187.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.94,187.18
C-Reactive Protein,PX86140,CDM,300,RC,86140,CPT,,,,,,,,191,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,187.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,187.18
"Chemotherapy, IV Infusion, Add'l Hour",PX96415,CDM,335,RC,96415,CPT,,,,,,,,191,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,187.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,187.18
Fac/Ther Injection Carpal Tunnel,PX20526F,CDM,510,RC,20526,CPT,,,,,,,,191,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,187.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.3414,258.75
Urine Pregnancy Test,PX81025,CDM,300,RC,81025,CPT,,,,,,,,191,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,187.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.89,187.18
"X-Ray Exam Hip,Bilat W/Pelvis 3-4 Vws",PX7352201,CDM,320,RC,73522,CPT,TC,,,,,,,382,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,187.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,374.36
"X-Ray Exam Hip,Bilat W/Pelvis 3-4 Vws",PX7352201,CDM,320,RC,73522,CPT,TC,,,,,,,382,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,187.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,374.36
"X-Ray Exam Hip,Bilat W/Pelvis 3-4 Vws",PX7352201,CDM,320,RC,73522,CPT,TC,,,,,,,382,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,187.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,374.36
Apc Resistance Assay - Ref,PX8530790,CDM,300,RC,85307,CPT,90,,,,,,,390,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,187.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.05,382.2
Apc Resistance Assay - Ref,PX8530790,CDM,300,RC,85307,CPT,90,,,,,,,390,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,187.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.05,382.2
"Closed Rx Toe Fx,Manipulatn",PX28515F,CDM,510,RC,28515,CPT,,,,,,,,390,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,187.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,162.006,382.2
"Closed Rx Toe Fx,Manipulatn",PX28515F,CDM,510,RC,28515,CPT,,,,,,,,390,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,187.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,162.006,382.2
procainamide 500 MG/ML Solution 2 mL Vial,J2690.01,CDM,636,RC,J2690,HCPCS,,,,14789090002,NDC,2,ML,377.75,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,187.2,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.75,187.2
procainamide 500 MG/ML Solution 2 mL Vial,J2690.01,CDM,636,RC,J2690,HCPCS,,,,14789090002,NDC,2,ML,377.75,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,187.2,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.75,187.2
Acetaminophen,PX80307E,CDM,300,RC,80307,CPT,,,,,,,,370,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,187.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Alcohol,PX80307A,CDM,300,RC,80307,CPT,,,,,,,,370,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,187.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Salicylate,PX80307D,CDM,300,RC,80307,CPT,,,,,,,,370,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,187.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Urine Drug Screen,PX80307B,CDM,300,RC,80307,CPT,,,,,,,,370,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,187.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Xray Elbow 3+Vws Tc,PX7308001,CDM,320,RC,73080,CPT,TC,,,,,,,370,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,187.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,362.6
First Hour IV Hydration <1 Hour,PX96360,CDM,260,RC,96360,CPT,,,,,,,,260,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,187.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.004,254.8
"IV Infusion Therapy, 1 Hour",PX96365,CDM,260,RC,96365,CPT,,,,,,,,327,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,187.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.8358,320.46
"IV Push, Single/1st Drug",PX96374,CDM,260,RC,96374,CPT,,,,,,,,259,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,187.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.5886,253.82
Refill/Maint Portable Pump,PX96521,CDM,260,RC,96521,CPT,,,,,,,,325,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,187.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,318.5
clotrimazole-betamethasone 1-0.05 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,66993089815,NDC,15,GR,192.55,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,187.408915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505614700,NDC,1,EA,212.52,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,187.44264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
Xray Ribs Unilat 2 Vws,PX7110001,CDM,320,RC,71100,CPT,TC,,,,,,,437,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,187.473,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,428.26
Drain/Inject Med Joint/Brusa W/US Guide,PX20606F,CDM,510,RC,20606,CPT,,,,,,,,387,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,187.48,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.85,187.48
Drain/Inject Med Joint/Brusa W/US Guide,PX20606P,CDM,983,RC,20606,CPT,,,,,,,,309,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,187.48,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.85,302.82
"Fac/Trm Hyperkeratotic Skn Lesn,>4",PX11057F,CDM,510,RC,11057,CPT,,,,,,,,175,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,187.48,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.66,187.48
erythromycin lactobionate 500 MG Recon Soln 1 Each Vial,J1364.01,CDM,636,RC,J1364,HCPCS,,,,409648211,NDC,1,EA,437.09,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,187.51161,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.06,428.3482
tobramycin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314064305,NDC,5,ML,191.42,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,187.5916,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Tech-Cytopath Eval, Fna, Rep",PX8817301,CDM,310,RC,88173,CPT,TC,,,,,,,379,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,187.605,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,371.42
medroxyPROGESTERone 150 MG/ML Suspension 1 mL Vial,J1050.01,CDM,636,RC,J1050,HCPCS,,,,67457088799,NDC,1,ML,437.38,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,187.63602,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.687652,428.6324
fluticasone propionate 50 MCG/ACT Suspension 16 g Bottle,63700001,CDM,250,RC,,,,,,60505082901,NDC,16,GR,437.4,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,187.6446,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270004,NDC,100,ML,2827.78,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,187.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270010,NDC,100,ML,3458.14,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,187.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 10 GM/100ML Solution 100 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270005,NDC,100,ML,2827.78,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,187.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270006,NDC,100,ML,2912.78,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,187.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270012,NDC,100,ML,3293.58,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,187.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270007,NDC,100,ML,2827.78,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,187.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270013,NDC,100,ML,2827.78,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,187.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
El-1 Fecal Quantitative,PX8265390,CDM,300,RC,82653,CPT,90,,,,,,,383,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,187.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.0982,375.34
El-1 Fecal Quantitative,PX8265390,CDM,300,RC,82653,CPT,90,,,,,,,383,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,187.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.0982,375.34
El-1 Fecal Quantitative,PX8265390,CDM,300,RC,82653,CPT,90,,,,,,,383,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,187.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.0982,375.34
DRILL BIT AO DIA 2.0MMX135MM SCALED,27200000,CDM,272,RC,,,,12640-MAIN,LOCAL,,,,,452,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,187.7608,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Bone Age Studies Tc,PX7707201,CDM,320,RC,77072,CPT,TC,,,,,,,211,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,187.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.6494,206.78
Collect Blood From Picc,PX36592F,CDM,510,RC,36592,CPT,,,,,,,,211,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,187.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.6494,206.78
Draw Blood Off Venous Device,PX36591F,CDM,510,RC,36591,CPT,,,,,,,,211,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,187.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.6494,206.78
Closed Rx Metacarpal Fx,PX26600F,CDM,510,RC,26600,CPT,,,,,,,,443,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,187.83,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,187.83,655.13
Closed Rx Metacarpal Fx,PX26600P,CDM,983,RC,26600,CPT,,,,,,,,295,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,187.83,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,187.83,655.13
Ag Detect Nos Eia Mult,PX87449,CDM,300,RC,87449,CPT,,,,,,,,193,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,187.8469,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,189.14
Remove Impacted Ear Wax,PX69210P,CDM,983,RC,69210,CPT,,,,,,,,221,,First Health,Commercial,both,85,,999999999,percent of total billed charges,187.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.44,215.0993
Apply Multlay Comprs Lwr Leg,PX29581F,CDM,510,RC,29581,CPT,,,,,,,,213,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,187.866,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.4802,208.74
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006F,CDM,510,RC,10006,CPT,,,,,,,,213,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,187.866,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.4802,208.74
"GI Pathogen Panel, Pcr - Ref",PX8750790,CDM,300,RC,87507,CPT,90,,,,,,,213,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,187.866,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.4802,382.15
Remove Impacted Ear Wax,PX69210F,CDM,510,RC,69210,CPT,,,,,,,,213,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,187.866,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.44,208.74
pentafluoroprop - tetrafluoroeth Aerosol 116 mL Can,63700001,CDM,250,RC,,,,,,386000802,NDC,207,ML,383.42,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,187.8758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pentafluoroprop - tetrafluoroeth Aerosol 116 mL Can,63700001,CDM,250,RC,,,,,,386000802,NDC,207,ML,383.42,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,187.8758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pentafluoroprop - tetrafluoroeth Aerosol 116 mL Can,63700001,CDM,250,RC,,,,,,386000802,NDC,207,ML,383.42,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,187.8758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Debride Bone Ea Add 20 Sqcm,PX11047F,CDM,510,RC,11047,CPT,,,,,,,,438,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,187.902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.9452,429.24
US Pregnancy Tc Limited,PX7681501,CDM,402,RC,76815,CPT,TC,,,,,,,438,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,187.902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,429.24
Direct Admit Hospital Observ,PXG0379,CDM,761,RC,G0379,HCPCS,,,,,,,,676,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,187.95,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,187.95,187.95
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070102,NDC,1,ML,383.6,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,187.964,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.92,450.751
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070102,NDC,1,ML,383.6,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,187.964,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.92,450.751
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070102,NDC,1,ML,383.6,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,187.964,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.92,450.751
ibutilide 1 MG/10ML Solution 10 mL Vial,J1742.01,CDM,636,RC,J1742,HCPCS,,,,9379401,NDC,10,ML,2349.03,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,188.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.02,2302.0494
Closed Rx Elbow Dislocation,PX24600P,CDM,983,RC,24600,CPT,,,,,,,,380,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,188.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,157.852,369.854
"Chest Wall Manipulation,Subsequent",PX94668F,CDM,410,RC,94668,CPT,,,,,,,,192,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,188.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.7568,188.16
Hepatitis Be Antibody - Ref,PX8670790,CDM,300,RC,86707,CPT,90,,,,,,,192,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,188.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.61,188.16
Infectious Agent Antigen Detection by Immunoassay With Direct Visual Observation.,PX87811,CDM,300,RC,87811,CPT,,,,,,,,192,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,188.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.94,188.16
Lvl 3 Sub Hosp High Mdm or 50 Minutes,PX99233,CDM,982,RC,99233,CPT,,,,,,,,384,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,188.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.5136,373.7472
Lvl 3 Sub Hosp High Mdm or 50 Minutes,PX99233,CDM,982,RC,99233,CPT,,,,,,,,384,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,188.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.5136,373.7472
Lvl 3 Sub Hosp High Mdm or 50 Minutes,PX99233,CDM,982,RC,99233,CPT,,,,,,,,384,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,188.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.5136,373.7472
glucagon rdna (diagnostic) 1 MG Recon Soln 1 Each Vial,J1610.01,CDM,636,RC,J1610,HCPCS,,,,597026010,NDC,1,EA,744.84,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,188.16233,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,165.76,191.52
nystatin-triamcinolone 100000-0.1 UNIT/GM-% Ointment 30 g Tube,25000000,CDM,250,RC,,,,,,52565004230,NDC,30,GR,438.62,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,188.16798,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Exc Skn Mal 0.6-1cm Fce,Facial",PX11641P,CDM,983,RC,11641,CPT,,,,,,,,453,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,188.1762,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.1762,614.65
Repr Superf Wnd Body 7.6-12.5,PX12004F,CDM,510,RC,12004,CPT,,,,,,,,453,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,188.1762,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,443.94
Repr Superf Wnd Face 5.1-7.5,PX12014F,CDM,510,RC,12014,CPT,,,,,,,,453,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,188.1762,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,443.94
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601901,NDC,10,ML,211.47,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,188.2083,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.844638,207.2406
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601910,NDC,10,ML,211.47,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,188.2083,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.844638,207.2406
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060851,NDC,100,ML,213.4,,United Healthcare,All Payer,outpatient,88.2,,1.151420557,percent of total billed charges,188.2188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
Cyto Non Gyn,PX8811201,CDM,310,RC,88112,CPT,TC,,,,,,,372,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,188.232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,364.56
"MESH PROLENE 3X6""",C1781,CDM,278,RC,C1781,HCPCS,,688-MAIN,LOCAL,,,,,213.49,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,188.29818,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Baloxavir Marboxil(40 MG Dose) 2 x 20 MG tablet therapy pack 2 Each Box,800000,CDM,,,,,,,,50242082802,NDC,1,EA,384.3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,188.307,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Baloxavir Marboxil(40 MG Dose) 2 x 20 MG tablet therapy pack 2 Each Box,800000,CDM,,,,,,,,50242082802,NDC,1,EA,384.3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,188.307,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Baloxavir Marboxil(40 MG Dose) 2 x 20 MG tablet therapy pack 2 Each Box,800000,CDM,,,,,,,,50242082802,NDC,1,EA,384.3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,188.307,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
8MM ENDOWRIST INSTRUMENTS 8MM FORCE BIPOLAR IS4000,27200000,CDM,272,RC,,,,11915-MAIN,LOCAL,,,,,439,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,188.331,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
VISIGI3D 40FR STD WITH BULB,27100000,CDM,271,RC,,,,12812-MAIN,LOCAL,,,,,439,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,188.331,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
glucagon rdna (diagnostic) 1 MG Recon Soln 1 Each Vial,J1610.01,CDM,636,RC,J1610,HCPCS,,,,597026010,NDC,1,EA,744.84,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,188.37,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,165.76,191.52
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,781309894,NDC,1,EA,193.75,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,188.576875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.461584,189.875
"Drain Finger Abscess,Simple",PX26010P,CDM,983,RC,26010,CPT,,,,,,,,207,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,188.577,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.9878,201.4731
X-Ray Exam Entire Spine 2-3 Vws,PX7208201,CDM,320,RC,72082,CPT,TC,,,,,,,454,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,188.5916,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,444.92
"Xray Mandible Compl, Min 4 Vws",PX7011001,CDM,320,RC,70110,CPT,TC,,,,,,,381,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,188.595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,373.38
6 SHOOTER SAEED MULTIBAND LIGATOR,27200000,CDM,272,RC,,,,12379-MAIN,LOCAL,,,,,393,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,188.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
6 SHOOTER SAEED MULTIBAND LIGATOR,27200000,CDM,272,RC,,,,12379-MAIN,LOCAL,,,,,393,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,188.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA FIRST MET TRANSLATOR STERILE MICA,27200000,CDM,272,RC,,,,12445-MAIN,LOCAL,,,,,393,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,188.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA FIRST MET TRANSLATOR STERILE MICA,27200000,CDM,272,RC,,,,12445-MAIN,LOCAL,,,,,393,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,188.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Tap Block Bilateral by Injection(S),PX64488F,CDM,510,RC,64488,CPT,,,,,,,,393,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,188.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,163.2522,385.14
Tap Block Bilateral by Injection(S),PX64488F,CDM,510,RC,64488,CPT,,,,,,,,393,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,188.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,163.2522,385.14
Apply Long Arm Splint,PX29105P,CDM,983,RC,29105,CPT,,,,,,,,385,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,188.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.65,374.7205
Apply Long Arm Splint,PX29105P,CDM,983,RC,29105,CPT,,,,,,,,385,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,188.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.65,374.7205
Apply Long Arm Splint,PX29105P,CDM,983,RC,29105,CPT,,,,,,,,385,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,188.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.65,374.7205
Apply Long Leg Splint,PX29505P,CDM,983,RC,29505,CPT,,,,,,,,385,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,188.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.65,374.7205
Apply Long Leg Splint,PX29505P,CDM,983,RC,29505,CPT,,,,,,,,385,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,188.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.65,374.7205
Apply Long Leg Splint,PX29505P,CDM,983,RC,29505,CPT,,,,,,,,385,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,188.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.65,374.7205
Injection for Nerve Block,PX64445F,CDM,510,RC,64445,CPT,,,,,,,,385,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,326.51,percent of total billed charges,188.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,604.15
Injection for Nerve Block,PX64445F,CDM,510,RC,64445,CPT,,,,,,,,385,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,188.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,604.15
Injection for Nerve Block,PX64445F,CDM,510,RC,64445,CPT,,,,,,,,385,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,188.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,604.15
Injection for Nerve Block,PX64445P,CDM,983,RC,64445,CPT,,,,,,,,385,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,326.51,percent of total billed charges,188.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,604.15
Injection for Nerve Block,PX64445P,CDM,983,RC,64445,CPT,,,,,,,,385,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,188.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,604.15
Injection for Nerve Block,PX64445P,CDM,983,RC,64445,CPT,,,,,,,,385,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,188.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,604.15
MICA DEPTH GAUGE 150MM STERILE MICA,27200000,CDM,272,RC,,,,12439-MAIN,LOCAL,,,,,385,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,188.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA DEPTH GAUGE 150MM STERILE MICA,27200000,CDM,272,RC,,,,12439-MAIN,LOCAL,,,,,385,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,188.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA DEPTH GAUGE 150MM STERILE MICA,27200000,CDM,272,RC,,,,12439-MAIN,LOCAL,,,,,385,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,188.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"N Block Inj, Plantar Digit",PX64455F,CDM,510,RC,64455,CPT,,,,,,,,385,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,188.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,377.3
"N Block Inj, Plantar Digit",PX64455F,CDM,510,RC,64455,CPT,,,,,,,,385,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,188.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,377.3
"N Block Inj, Plantar Digit",PX64455F,CDM,510,RC,64455,CPT,,,,,,,,385,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,188.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,377.3
"N Block Inj, Plantar Digit",PX64455P,CDM,983,RC,64455,CPT,,,,,,,,385,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,188.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,374.7205
"N Block Inj, Plantar Digit",PX64455P,CDM,983,RC,64455,CPT,,,,,,,,385,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,188.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,374.7205
"N Block Inj, Plantar Digit",PX64455P,CDM,983,RC,64455,CPT,,,,,,,,385,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,188.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,374.7205
Xray Temporomandib Jnt Unilat,PX7032801,CDM,320,RC,70328,CPT,TC,,,,,,,385,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,188.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,377.3
Xray Temporomandib Jnt Unilat,PX7032801,CDM,320,RC,70328,CPT,TC,,,,,,,385,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,188.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,377.3
Xray Temporomandib Jnt Unilat,PX7032801,CDM,320,RC,70328,CPT,TC,,,,,,,385,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,188.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,377.3
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802201,NDC,0.8,ML,439.77,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,188.66133,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802210,NDC,0.8,ML,439.77,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,188.66133,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
"Non-Select. Wound Debride., W/O Anesth.; Top. Appl./Wound Assess./Instruct., per Sess.",PX97602,CDM,761,RC,97602,CPT,,,,,,,,212,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,188.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.0648,207.76
clotrimazole-betamethasone 1-0.05 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,66993089815,NDC,15,GR,192.55,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,188.699,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU000390,CDM,300,RC,U0003,HCPCS,90,,,,,,,222,,First Health,Commercial,both,85,,999999999,percent of total billed charges,188.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.2188,217.56
Nfct Ds Bct/Vir Respir Dna/Rna 22 Trgt Sarscov2,PX0202U,CDM,300,RC,0202U,HCPCS,,,,,,,,222,,First Health,Commercial,both,85,,999999999,percent of total billed charges,188.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.2188,382.15
Observation Care Discharge,PX99217,CDM,982,RC,99217,CPT,,,,,,,,222,,First Health,Commercial,both,85,,999999999,percent of total billed charges,188.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.2188,216.0726
Immunofix Elp,PX86335,CDM,300,RC,86335,CPT,,,,,,,,214,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,188.748,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.91,209.72
"Incis/Drain Scrotum/Testis,Epididym",PX54700P,CDM,983,RC,54700,CPT,,,,,,,,440,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,188.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,182.776,1779.39
"Cmv, Quant - Ref",PX8749790,CDM,300,RC,87497,CPT,90,,,,,,,194,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,188.8202,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.28,190.12
Hiv-1 Antigens W/Hiv 1/2 Antib,PX87389,CDM,300,RC,87389,CPT,,,,,,,,194,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,188.8202,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.08,190.12
Lyme Disease Antibody,PX86618,CDM,300,RC,86618,CPT,,,,,,,,194,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,188.8202,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.61,190.12
"measles, mumps & rubella vaccine Recon Soln 1 Each Vial",90707,CDM,636,RC,90707,CPT,,,,6468100,NDC,1,EA,381.47,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,188.82765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,158.462638,373.8406
"N Block Inj, Common Digit",PX64632F,CDM,510,RC,64632,CPT,,,,,,,,190,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,188.86,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.88,188.86
"N Block Inj, Common Digit",PX64632P,CDM,983,RC,64632,CPT,,,,,,,,128,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,188.86,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.88,188.86
Biopsy of Rectum,PX45100F,CDM,510,RC,45100,CPT,,,,,,,,763,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,188.92,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.92,635.07
Biopsy of Rectum,PX45100P,CDM,983,RC,45100,CPT,,,,,,,,509,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,188.92,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.92,635.07
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132F,CDM,510,RC,13132,CPT,,,,,,,,1159,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,188.92,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.92,976.82
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132P,CDM,983,RC,13132,CPT,,,,,,,,774,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,188.92,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.92,976.82
"Ileoscopy Thru Stoma,Diagnostic",PX44380P,CDM,983,RC,44380,CPT,,,,,,,,455,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,189.007,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.007,791.92
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607F,CDM,761,RC,97607,CPT,,,,,,,,455,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,189.007,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.007,445.9
ibutilide 1 MG/10ML Solution 10 mL Vial,J1742.01,CDM,636,RC,J1742,HCPCS,,,,9379401,NDC,10,ML,2349.03,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,189.06309,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,180.45,559.83
ON Q PAIN BUSTER,27100000,CDM,271,RC,A4305,HCPCS,,6751-MAIN,LOCAL,,,,,194.26,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,189.073258,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
"X-Ray Exam Hip,Bilat W/Pelvis 3-4 Vws",PX7352201,CDM,320,RC,73522,CPT,TC,,,,,,,382,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,189.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,374.36
Ag Detect Nos Eia Mult,PX87449,CDM,300,RC,87449,CPT,,,,,,,,193,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,189.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.98,189.14
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032F,CDM,510,RC,12032,CPT,,,,,,,,386,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,57.99666667,percent of total billed charges,189.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.3444,378.28
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032F,CDM,510,RC,12032,CPT,,,,,,,,386,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,189.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.3444,378.28
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032F,CDM,510,RC,12032,CPT,,,,,,,,386,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,189.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.3444,378.28
RELOAD SUREFORM 45 2.5MM WHITE,27200000,CDM,272,RC,,,,12791-MAIN,LOCAL,,,,,386,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,189.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 45 2.5MM WHITE,27200000,CDM,272,RC,,,,12791-MAIN,LOCAL,,,,,386,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,189.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 45 2.5MM WHITE,27200000,CDM,272,RC,,,,12791-MAIN,LOCAL,,,,,386,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,189.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 45 3.5MM BLUE,27200000,CDM,272,RC,,,,12792-MAIN,LOCAL,,,,,386,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,189.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 45 3.5MM BLUE,27200000,CDM,272,RC,,,,12792-MAIN,LOCAL,,,,,386,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,189.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 45 3.5MM BLUE,27200000,CDM,272,RC,,,,12792-MAIN,LOCAL,,,,,386,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,189.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 45 4.3MM GREEN,27200000,CDM,272,RC,,,,12793-MAIN,LOCAL,,,,,386,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,189.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 45 4.3MM GREEN,27200000,CDM,272,RC,,,,12793-MAIN,LOCAL,,,,,386,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,189.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 45 4.3MM GREEN,27200000,CDM,272,RC,,,,12793-MAIN,LOCAL,,,,,386,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,189.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505614700,NDC,1,EA,212.52,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,189.1428,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084252,NDC,0.5,ML,207.65,,Medica,Commercial,both,91.1,,56.23,percent of total billed charges,189.16915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.085268,203.497
"Fac/Office Consultation,Level IV",PX99244F,CDM,510,RC,99244,CPT,,,,,,,,441,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,189.189,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,183.1914,432.18
Gastric Intubation Treatment,PX43753F,CDM,510,RC,43753,CPT,,,,,,,,441,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,189.189,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,183.1914,432.18
"Office Consultation,Level IV",PX99244P,CDM,983,RC,99244,CPT,,,,,,,,441,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,189.189,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,183.1914,429.2253
SUTURE CTD VICRYL 4-0 VIL BR SUTUPK J103T,27200000,CDM,272,RC,,,,4491-MAIN,LOCAL,,,,,373.97,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,189.22882,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Fac/Exc Skin Benig<5mm Remaind Bod,PX11420F,CDM,510,RC,11420,CPT,,,,,,,,374,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,189.244,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,1416.38
"Fac/Office Consultation,Level III",PX99243F,CDM,510,RC,99213,CPT,,,,,,,,374,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,189.244,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,366.52
"Inpatient Consult, Level III",PX99253,CDM,983,RC,99253,CPT,,,,,,,,374,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,189.244,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,364.0142
"Office Consultation,Level III",PX99243P,CDM,983,RC,99243,CPT,,,,,,,,374,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,189.244,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,364.0142
Removal of Hemorrhoid Clot,PX46320P,CDM,983,RC,46320,CPT,,,,,,,,374,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,189.244,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,1030.93
Xray Hand 3vws Tc,PX7313001,CDM,320,RC,73130,CPT,TC,,,,,,,374,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,189.244,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,366.52
dantrolene 20 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,42023012306,NDC,1,EA,394.42,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,189.3216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dantrolene 20 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,42023012306,NDC,1,EA,394.42,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,189.3216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
LEGGING COMPRESSION JUXTALITE LONG LG 33CM,120.369,CDM,271,RC,A6545,HCPCS,,10840-MAIN,LOCAL,,,,,145,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,189.328,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.43,189.328
LEGGING COMPRESSION JUXTALITE LONG LG 33CM,120.369,CDM,271,RC,A6545,HCPCS,,10840-MAIN,LOCAL,,,,,145,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,189.328,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.43,189.328
acetaZOLAMIDE 500 MG Recon Soln 1 Each Vial,J1120.01,CDM,636,RC,J1120,HCPCS,,,,39822019001,NDC,1,EA,207.84,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,189.34224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.336736,203.6832
"Ctrl Nosebleed,Anter,Complex",PX30903F,CDM,510,RC,30903,CPT,,,,,,,,456,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,189.4224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,446.88
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611F,CDM,510,RC,20611,CPT,,,,,,,,456,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,189.4224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.4224,446.88
"Office/Outpt Visit,New,Levl V",PX99205F,CDM,510,RC,99205,CPT,,,,,,,,456,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,189.4224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.4224,446.88
"Office/Outpt Visit,New,Levl V",PX99205P,CDM,983,RC,99205,CPT,,,,,,,,456,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,189.4224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.4224,443.8248
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321801,NDC,50,ML,456,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,189.4224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
Xray Nasal Bones Minimum 3 Vws,PX7016001,CDM,320,RC,70160,CPT,TC,,,,,,,456,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,189.4224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,446.88
"Apply Finger Splint,Static",PX29130P,CDM,983,RC,29130,CPT,,,,,,,,223,,First Health,Commercial,both,85,,999999999,percent of total billed charges,189.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,217.0459
"Apply Forearm Splint,Static",PX29125F,CDM,510,RC,29125,CPT,,,,,,,,223,,First Health,Commercial,both,85,,999999999,percent of total billed charges,189.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,218.54
"Flow Cyto, Tech, 1st Mrkr - Ref",PX8818490,CDM,310,RC,88184,CPT,90,,,,,,,223,,First Health,Commercial,both,85,,999999999,percent of total billed charges,189.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,314.02
"Nephelometry, Each, Nos - Ref",PX8388390,CDM,300,RC,83883,CPT,90,,,,,,,223,,First Health,Commercial,both,85,,999999999,percent of total billed charges,189.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.47,218.54
Reduce Temporomandibl Disloc,PX21480P,CDM,983,RC,21480,CPT,,,,,,,,223,,First Health,Commercial,both,85,,999999999,percent of total billed charges,189.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,217.0459
Apply Multlay Comprs Lwr Leg,PX29581F,CDM,510,RC,29581,CPT,,,,,,,,213,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,189.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.4802,208.74
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006F,CDM,510,RC,10006,CPT,,,,,,,,213,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,189.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.4802,208.74
"GI Pathogen Panel, Pcr - Ref",PX8750790,CDM,300,RC,87507,CPT,90,,,,,,,213,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,189.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.4802,382.15
Incise Finger Tendon Sheath,PX26055F,CDM,510,RC,26055,CPT,,,,,,,,1398,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,189.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.74,1232.1
Incise Finger Tendon Sheath,PX26055F,CDM,510,RC,26055,CPT,,,,,,,,1398,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,189.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.74,1232.1
Incise Finger Tendon Sheath,PX26055P,CDM,983,RC,26055,CPT,,,,,,,,932,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,189.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.74,1232.1
Incise Finger Tendon Sheath,PX26055P,CDM,983,RC,26055,CPT,,,,,,,,932,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,189.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.74,1232.1
Remove Impacted Ear Wax,PX69210F,CDM,510,RC,69210,CPT,,,,,,,,213,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,189.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.44,208.74
El-1 Fecal Quantitative,PX8265390,CDM,300,RC,82653,CPT,90,,,,,,,383,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,189.585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.0982,375.34
Drainage of Gum Lesion,PX41800F,CDM,510,RC,41800,CPT,,,,,,,,395,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,189.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,387.1
Drainage of Gum Lesion,PX41800F,CDM,510,RC,41800,CPT,,,,,,,,395,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,189.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,387.1
Drain/Inject Med Joint/Brusa W/US Guide,PX20606F,CDM,510,RC,20606,CPT,,,,,,,,387,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,189.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.7598,604.15
Drain/Inject Med Joint/Brusa W/US Guide,PX20606F,CDM,510,RC,20606,CPT,,,,,,,,387,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,189.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.7598,604.15
Drain/Inject Med Joint/Brusa W/US Guide,PX20606F,CDM,510,RC,20606,CPT,,,,,,,,387,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,189.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.7598,604.15
"Ex Sknbngn0.6-1cmtrnk,Arm,Lg",PX11401P,CDM,983,RC,11401,CPT,,,,,,,,387,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,189.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.7598,376.6671
"Ex Sknbngn0.6-1cmtrnk,Arm,Lg",PX11401P,CDM,983,RC,11401,CPT,,,,,,,,387,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,189.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.7598,376.6671
"Ex Sknbngn0.6-1cmtrnk,Arm,Lg",PX11401P,CDM,983,RC,11401,CPT,,,,,,,,387,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,189.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.7598,376.6671
"Exc Skn Benig<5mm Face,Facial",PX11440P,CDM,983,RC,11440,CPT,,,,,,,,387,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,189.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.7598,614.65
"Exc Skn Benig<5mm Face,Facial",PX11440P,CDM,983,RC,11440,CPT,,,,,,,,387,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,189.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.7598,614.65
"Exc Skn Benig<5mm Face,Facial",PX11440P,CDM,983,RC,11440,CPT,,,,,,,,387,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,189.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.7598,614.65
Facility Emergency Level II Visit,PX99282F,CDM,450,RC,99282,CPT,,,,,,,,387,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,78.56653846,percent of total billed charges,189.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,142.88,379.26
Facility Emergency Level II Visit,PX99282F,CDM,450,RC,99282,CPT,,,,,,,,387,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,189.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,142.88,379.26
Facility Emergency Level II Visit,PX99282F,CDM,450,RC,99282,CPT,,,,,,,,387,,United Healthcare,All Medicare advantage plans,outpatient,49,,55.965,percent of total billed charges,189.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,142.88,379.26
Immunoglobulin Subclasses - Ref,PX8278790,CDM,300,RC,82787,CPT,90,,,,,,,215,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,189.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.35,210.7
"Digital Mamm, Diag, Bilat, Tc W/Cad Perf",PX7706601,CDM,401,RC,77066,CPT,TC,,,,,,,375,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,189.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.05,367.5
"Digital Mammogram, Screen Bil, Tc W/Cad Perf",PX7706701,CDM,403,RC,77067,CPT,TC,,,,,,,375,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,189.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.86,561
Repr Superf Wnd Face 2.6-5,PX12013F,CDM,510,RC,12013,CPT,,,,,,,,375,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,189.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.775,367.5
Xray Wrist Minimum 3 Vws,PX7311001,CDM,320,RC,73110,CPT,TC,,,,,,,375,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,189.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,367.5
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132F,CDM,510,RC,13132,CPT,,,,,,,,1159,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,189.79,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.92,976.82
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132F,CDM,510,RC,13132,CPT,,,,,,,,1159,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,189.79,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.92,976.82
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132P,CDM,983,RC,13132,CPT,,,,,,,,774,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,189.79,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.92,976.82
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132P,CDM,983,RC,13132,CPT,,,,,,,,774,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,189.79,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.92,976.82
pentafluoroprop - tetrafluoroeth Aerosol 116 mL Can,63700001,CDM,250,RC,,,,,,386000802,NDC,207,ML,383.42,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,189.7929,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Topiramate - Ref,PX8020190,CDM,300,RC,80201,CPT,90,,,,,,,195,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,189.7935,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.93,191.1
"Infectious Disease (Viral Respiratory Tract Infection),",PX0241U,CDM,300,RC,0241U,HCPCS,,,,,,,,457,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,189.8378,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.78,447.86
US Scrotum & Contents Tc,PX7687001,CDM,402,RC,76870,CPT,TC,,,,,,,457,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,189.8378,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,447.86
NON-LOCKING SCREW 3.5X18MM,C1713,CDM,278,RC,C1713,HCPCS,,12466-MAIN,LOCAL,,,,,395.51,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,189.8448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
NON-LOCKING SCREW 3.5X18MM,C1713,CDM,278,RC,C1713,HCPCS,,12466-MAIN,LOCAL,,,,,395.51,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,189.8448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,781309894,NDC,1,EA,193.75,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,189.875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.461584,189.875
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070102,NDC,1,ML,383.6,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,189.882,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.92,450.751
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060851,NDC,100,ML,213.4,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,189.926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
"Morphometric Analysis, Tumor - Ref",PX8836090,CDM,310,RC,88360,CPT,90,,,,,,,349,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,189.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,116.39,195.44
"Morphometric Analysis, Tumor - Ref",PX8836090,CDM,310,RC,88360,CPT,90,,,,,,,349,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,189.96,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,116.39,195.44
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082152,NDC,1,ML,375.43,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,189.96758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.48,367.9214
"MESH PROLENE 3X6""",C1781,CDM,278,RC,C1781,HCPCS,,688-MAIN,LOCAL,,,,,213.49,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,190.0061,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
butamben-tetracaine-benzocaine 2-2-14 % Aerosol 5 g Bottle,25000000,CDM,250,RC,,,,,,10223020104,NDC,5,GR,375.52,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,190.01312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Closed Rx Metacarpal Fx,PX26600F,CDM,510,RC,26600,CPT,,,,,,,,443,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,190.047,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,184.0222,434.14
Comprehensive Metabolic Panel,PX80053,CDM,300,RC,80053,CPT,,,,,,,,396,,Health Partners,Health Partners Care Plans,both,48,,192.1774286,percent of total billed charges,190.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.68,388.08
Comprehensive Metabolic Panel,PX80053,CDM,300,RC,80053,CPT,,,,,,,,396,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,190.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.68,388.08
Lvl 3 Sub Hosp High Mdm or 50 Minutes,PX99233,CDM,982,RC,99233,CPT,,,,,,,,384,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,190.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.5136,373.7472
Neg Pressure Wound Therapy Dme </=50 Sq Cm,PX97605F,CDM,510,RC,97605,CPT,,,,,,,,396,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,190.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,164.4984,388.08
Neg Pressure Wound Therapy Dme </=50 Sq Cm,PX97605F,CDM,510,RC,97605,CPT,,,,,,,,396,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,190.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,164.4984,388.08
NON-LOCKING SCREW 3.5X12MM,27200000,CDM,278,RC,C1713,HCPCS,,11857-MAIN,LOCAL,,,,,396,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,190.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NON-LOCKING SCREW 3.5X12MM,27200000,CDM,278,RC,C1713,HCPCS,,11857-MAIN,LOCAL,,,,,396,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,190.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NON-LOCKING SCREW 3.5X16MM,27200000,CDM,278,RC,C1713,HCPCS,,11856-MAIN,LOCAL,,,,,396,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,190.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NON-LOCKING SCREW 3.5X16MM,27200000,CDM,278,RC,C1713,HCPCS,,11856-MAIN,LOCAL,,,,,396,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,190.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NON-LOCKING SCREW 3.5X24MM,27200000,CDM,278,RC,C1713,HCPCS,,11855-MAIN,LOCAL,,,,,396,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,190.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NON-LOCKING SCREW 3.5X24MM,27200000,CDM,278,RC,C1713,HCPCS,,11855-MAIN,LOCAL,,,,,396,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,190.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Acellular Derm Matrix Implt,PX15777F,CDM,510,RC,15777,CPT,,,,,,,,650,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,190.0912,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,129.14,440.68
"Cmv, Quant - Ref",PX8749790,CDM,300,RC,87497,CPT,90,,,,,,,194,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,190.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.28,190.12
Hiv-1 Antigens W/Hiv 1/2 Antib,PX87389,CDM,300,RC,87389,CPT,,,,,,,,194,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,190.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.08,190.12
Lyme Disease Antibody,PX86618,CDM,300,RC,86618,CPT,,,,,,,,194,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,190.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.61,190.12
hepatitis A vaccine 1440 EL U/ML Suspension 1 mL Syringe,90632,CDM,636,RC,90632,CPT,,,,58160082652,NDC,1,ML,375.78,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,190.14468,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,156.099012,368.2644
"Critical Care, Addl 30 Min",PX99292P,CDM,983,RC,99292,CPT,,,,,,,,542,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,190.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.12,531.16
"Facility Critical Care, Addl 30 Min",PX99292F,CDM,510,RC,99292,CPT,,,,,,,,484,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,190.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.12,214.08
Art Lower Extremity+Upper,PX9392301,CDM,921,RC,93923,CPT,TC,,,,,,,784,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,190.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.67,190.22
Art Lower Extremity+Upper,PX9392301,CDM,921,RC,93923,CPT,TC,,,,,,,784,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,190.22,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.67,190.22
Baloxavir Marboxil(40 MG Dose) 2 x 20 MG tablet therapy pack 2 Each Box,800000,CDM,,,,,,,,50242082802,NDC,1,EA,384.3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,190.2285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
fat emulsion 20 % Emulsion 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,338051958,NDC,200,ML,375.95,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,190.2307,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Apply Long Leg Splint,PX29505F,CDM,510,RC,29505,CPT,,,,,,,,320,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,190.25,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.28,190.25
Apply Long Leg Splint,PX29505P,CDM,983,RC,29505,CPT,,,,,,,,385,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,190.25,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.28,377.3
"Spinal Punc,Drain,Theraputic",PX62272F,CDM,510,RC,62272,CPT,,,,,,,,450,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,190.25,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.79,384.64
"Spinal Punc,Drain,Theraputic",PX62272P,CDM,983,RC,62272,CPT,,,,,,,,300,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,190.25,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.79,384.64
leuprolide 7.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74364203,NDC,1,EA,3782.28,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,190.37,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.54,190.37
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74334603,NDC,1,EA,12509.82,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,190.37,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.54,190.37
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,62935022305,NDC,1,EA,2764.34,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,190.37,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.54,190.37
leuprolide 45 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74347303,NDC,1,EA,21633.89,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,190.37,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.54,190.37
ON Q PAIN BUSTER,27100000,CDM,271,RC,A4305,HCPCS,,6751-MAIN,LOCAL,,,,,194.26,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,190.3748,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
ACCESSORY KIT FOR GROSHONG 16GA,120.46,CDM,272,RC,C1751,HCPCS,,2967-MAIN,LOCAL,,,,,209,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,190.399,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.8186,204.82
Infection Agent Detect Dna/Rna Probe Tq 12-25,PX87507,CDM,300,RC,87507,CPT,,,,,,,,209,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,190.399,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.8186,382.15
"Organic Acid, Single, Qnt - Ref",PX8392190,CDM,300,RC,83921,CPT,90,,,,,,,209,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,190.399,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.45,204.82
Body Fluid Cell Count W Diff,PX89051,CDM,300,RC,89051,CPT,,,,,,,,224,,First Health,Commercial,both,85,,999999999,percent of total billed charges,190.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.13,219.52
Emergency Level I Visit,PX99281P,CDM,981,RC,99281,CPT,,,,,,,,224,,First Health,Commercial,both,85,,999999999,percent of total billed charges,190.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.56,218.0192
ENDOWRIST INSTRUMENTS PERMANENT CAUTERY HOOK 8MM,27200000,CDM,272,RC,,,,12050-MAIN,LOCAL,,,,,224,,First Health,Commercial,both,85,,999999999,percent of total billed charges,190.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Helicobacter Pylori Ab,PX86677,CDM,300,RC,86677,CPT,,,,,,,,224,,First Health,Commercial,both,85,,999999999,percent of total billed charges,190.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.45,219.52
Closed Rx Trimalleolar Fx,PX27816F,CDM,510,RC,27816,CPT,,,,,,,,522,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,190.44,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,190.44,718.09
Closed Rx Trimalleolar Fx,PX27816P,CDM,983,RC,27816,CPT,,,,,,,,826,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,190.44,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,190.44,809.48
Immunofix Elp,PX86335,CDM,300,RC,86335,CPT,,,,,,,,214,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,190.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.91,209.72
C-COLLAR ASPEN REGULAR 79-83365,120.25,CDM,274,RC,L0140,HCPCS,,167-MAIN,LOCAL,,,,,216,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,190.512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.58,211.68
C-COLLAR ASPEN TALL 79-83367,120.25,CDM,274,RC,L0140,HCPCS,,164-MAIN,LOCAL,,,,,216,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,190.512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.58,211.68
C-COLLAR ASPEN X-TALL 79-83368,120.25,CDM,274,RC,L0140,HCPCS,,168-MAIN,LOCAL,,,,,216,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,190.512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.58,211.68
"Remv F.B.,Eye,Embed Conjunc",PX65210P,CDM,983,RC,65210,CPT,,,,,,,,216,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,190.512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,89.7264,348.08
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802001,NDC,1,ML,444.2,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,190.5618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802010,NDC,1,ML,444.2,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,190.5618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
Apply Long Arm Splint,PX29105P,CDM,983,RC,29105,CPT,,,,,,,,385,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,190.575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.65,374.7205
Apply Long Leg Splint,PX29505P,CDM,983,RC,29505,CPT,,,,,,,,385,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,190.575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.65,374.7205
Injection for Nerve Block,PX64445F,CDM,510,RC,64445,CPT,,,,,,,,385,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,190.575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,604.15
Injection for Nerve Block,PX64445P,CDM,983,RC,64445,CPT,,,,,,,,385,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,190.575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,604.15
MICA DEPTH GAUGE 150MM STERILE MICA,27200000,CDM,272,RC,,,,12439-MAIN,LOCAL,,,,,385,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,190.575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"N Block Inj, Plantar Digit",PX64455F,CDM,510,RC,64455,CPT,,,,,,,,385,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,190.575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,377.3
"N Block Inj, Plantar Digit",PX64455P,CDM,983,RC,64455,CPT,,,,,,,,385,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,190.575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,374.7205
Xray Temporomandib Jnt Unilat,PX7032801,CDM,320,RC,70328,CPT,TC,,,,,,,385,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,190.575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,377.3
ANCHORAGE FIXATION PIN,27200000,CDM,272,RC,,,,12642-MAIN,LOCAL,,,,,389,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,190.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ANCHORAGE FIXATION PIN,27200000,CDM,272,RC,,,,12642-MAIN,LOCAL,,,,,389,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,190.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ANCHORAGE FIXATION PIN,27200000,CDM,272,RC,,,,12642-MAIN,LOCAL,,,,,389,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,190.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Ext Ecg > 48hr to 21 Day Rcrd W/Conect Intl Rcrd,PX0296T,CDM,731,RC,0296T,HCPCS,,,,,,,,389,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,190.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,161.5906,381.22
Ext Ecg > 48hr to 21 Day Rcrd W/Conect Intl Rcrd,PX0296T,CDM,731,RC,0296T,HCPCS,,,,,,,,389,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,190.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,161.5906,381.22
Ext Ecg > 48hr to 21 Day Rcrd W/Conect Intl Rcrd,PX0296T,CDM,731,RC,0296T,HCPCS,,,,,,,,389,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,190.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,161.5906,381.22
Resp Virus 3-5 Targets,PX87631,CDM,300,RC,87631,CPT,,,,,,,,459,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,190.6686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.78,449.82
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034F,CDM,510,RC,12034,CPT,,,,,,,,931,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,190.7334,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.27,696.64
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034P,CDM,983,RC,12034,CPT,,,,,,,,1533,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,190.7334,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.27,1502.34
Repr Superf Wnd Body 12.6-20,PX12005P,CDM,983,RC,12005,CPT,,,,,,,,377,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,190.762,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,156.6058,366.9341
"Apply Finger Splint,Static",PX29130F,CDM,420,RC,29130,CPT,,,,,,,,196,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,190.7668,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.4184,192.08
Heterophile Antibodies,PX86308,CDM,300,RC,86308,CPT,,,,,,,,196,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,141.48,percent of total billed charges,190.7668,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,192.08
Chrom Anal 15-20 Cells - Ref,PX8826290,CDM,310,RC,88262,CPT,90,,,,,,,398,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,191.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.06,390.04
Chrom Anal 15-20 Cells - Ref,PX8826290,CDM,310,RC,88262,CPT,90,,,,,,,398,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,191.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.06,390.04
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070110,NDC,1,ML,459.95,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,191.06323,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.92,450.751
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032F,CDM,510,RC,12032,CPT,,,,,,,,386,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,191.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.3444,378.28
RELOAD SUREFORM 45 2.5MM WHITE,27200000,CDM,272,RC,,,,12791-MAIN,LOCAL,,,,,386,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,191.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 45 3.5MM BLUE,27200000,CDM,272,RC,,,,12792-MAIN,LOCAL,,,,,386,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,191.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 45 4.3MM GREEN,27200000,CDM,272,RC,,,,12793-MAIN,LOCAL,,,,,386,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,191.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"DXA, Bone Density Study, Radius/Wrist/Heel",PX7708101,CDM,320,RC,77081,CPT,TC,,,,,,,460,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,191.084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,450.8
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623P,CDM,983,RC,11623,CPT,,,,,,,,460,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,191.084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,191.084,1416.38
"Transvaginal US, Obstetric",PX7681701,CDM,402,RC,76817,CPT,TC,,,,,,,460,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,191.084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,450.8
Apc Resistance Assay - Ref,PX8530790,CDM,300,RC,85307,CPT,90,,,,,,,390,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,191.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.05,382.2
Apc Resistance Assay - Ref,PX8530790,CDM,300,RC,85307,CPT,90,,,,,,,390,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,191.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.05,382.2
Apc Resistance Assay - Ref,PX8530790,CDM,300,RC,85307,CPT,90,,,,,,,390,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,191.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.05,382.2
Biopsy of Rectum,PX45100F,CDM,510,RC,45100,CPT,,,,,,,,763,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,191.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.92,635.07
Biopsy of Rectum,PX45100F,CDM,510,RC,45100,CPT,,,,,,,,763,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,191.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.92,635.07
Biopsy of Rectum,PX45100P,CDM,983,RC,45100,CPT,,,,,,,,509,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,191.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.92,635.07
Biopsy of Rectum,PX45100P,CDM,983,RC,45100,CPT,,,,,,,,509,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,191.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.92,635.07
"Closed Rx Toe Fx,Manipulatn",PX28515F,CDM,510,RC,28515,CPT,,,,,,,,390,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,191.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,162.006,382.2
"Closed Rx Toe Fx,Manipulatn",PX28515F,CDM,510,RC,28515,CPT,,,,,,,,390,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,191.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,162.006,382.2
"Closed Rx Toe Fx,Manipulatn",PX28515F,CDM,510,RC,28515,CPT,,,,,,,,390,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,191.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,162.006,382.2
Topiramate - Ref,PX8020190,CDM,300,RC,80201,CPT,90,,,,,,,195,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,191.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.93,191.1
azithromycin 200 MG/5ML Recon Susp 15 mL Bottle,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,59762312001,NDC,15,ML,196.35,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,16.7575,percent of total billed charges,191.107455,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
ROTH NET PLATINUM RETRIEVER,27200000,CDM,272,RC,,,,7518-MAIN,LOCAL,,,,,196.35,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,191.107455,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
procainamide 500 MG/ML Solution 2 mL Vial,J2690.01,CDM,636,RC,J2690,HCPCS,,,,14789090002,NDC,2,ML,377.75,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,191.1415,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,134.15,370.195
"Cytoflo, Cell or Dna Anal - Ref",PX8818290,CDM,310,RC,88182,CPT,90,,,,,,,225,,First Health,Commercial,both,85,,999999999,percent of total billed charges,191.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,220.5
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153F,CDM,370,RC,99153,CPT,,,,,,,,225,,First Health,Commercial,both,85,,999999999,percent of total billed charges,191.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.465,220.5
AIRSEAL ROBOTIC Xi CAP AND OBTURATOR WITH BLADELESS OPTICAL TIP,27200000,CDM,272,RC,,,,12208-MAIN,LOCAL,,,,,210,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,191.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
AIRSEAL ROBOTIC Xi TRI LUMEN FILTERED TUBE SET WITH ACTIVATED CHARCOAL,27200000,CDM,272,RC,,,,12209-MAIN,LOCAL,,,,,210,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,191.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Apply Forearm Cast,PX29075F,CDM,510,RC,29075,CPT,,,,,,,,210,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,191.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,234.62
Chorionic gonadotropin test,PX84702,CDM,300,RC,84702,CPT,,,,,,,,210,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,191.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.8,205.8
"Excision of Nail Fold, Toe",PX11765F,CDM,510,RC,11765,CPT,,,,,,,,210,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,191.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,348.35
Fac/Hospital Discharge Day>30 Min,PX99239F,CDM,510,RC,99239,CPT,,,,,,,,210,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,191.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,205.8
"Inject Trigger Point, 1 or 2",PX20552P,CDM,983,RC,20552,CPT,,,,,,,,210,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,191.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,258.75
Immunoglobulin Subclasses - Ref,PX8278790,CDM,300,RC,82787,CPT,90,,,,,,,215,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,191.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.35,210.7
indocyanine green 25 MG Recon Soln 1 Each Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,70100042402,NDC,1,EA,446.07,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,191.36403,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.29,1354.4776
Procalcitonin,PX84145,CDM,300,RC,84145,CPT,,,,,,,,217,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,191.394,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.96,212.66
TRAY 8 FR 5IN CENTESIS WITH TURKEL  30-CE1CO,120.303,CDM,272,RC,,,,11503-MAIN,LOCAL,,,,,217,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,191.394,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,90.1418,212.66
albuterol (5 MG/ML) 0.5% Nebulization Solution 20 mL Bottle,J7611.01,CDM,250,RC,,,,,,50383074120,NDC,20,ML,225.2,,First Health,Commercial,both,85,,999999999,percent of total billed charges,191.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.54808,220.696
"Initial Observation Care,Levl III",PX99220,CDM,982,RC,99220,CPT,,,,,,,,461,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,191.4994,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,191.4994,448.6913
Repr Superf Wnd Face <2.5cm,PX12011P,CDM,983,RC,12011,CPT,,,,,,,,461,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,191.4994,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,448.6913
Dress/Debrid Large Burn No Anesth,PX16030F,CDM,510,RC,16030,CPT,,,,,,,,399,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,191.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,165.7446,391.02
Dress/Debrid Large Burn No Anesth,PX16030F,CDM,510,RC,16030,CPT,,,,,,,,399,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,191.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,165.7446,391.02
"X-Ray Exam Hip,Bilat W/Pelvis 2 Vws",PX7352101,CDM,320,RC,73521,CPT,TC,,,,,,,399,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,191.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,391.02
"X-Ray Exam Hip,Bilat W/Pelvis 2 Vws",PX7352101,CDM,320,RC,73521,CPT,TC,,,,,,,399,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,191.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,391.02
Xray Lumbosacral 2 or 3 Vws,PX7210001,CDM,320,RC,72100,CPT,TC,,,,,,,399,,Health Partners,Health Partners Care Plans,both,48,,153.0275,percent of total billed charges,191.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,391.02
Xray Lumbosacral 2 or 3 Vws,PX7210001,CDM,320,RC,72100,CPT,TC,,,,,,,399,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,191.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,391.02
glucagon rdna (diagnostic) 1 MG Recon Soln 1 Each Vial,J1610.01,CDM,636,RC,J1610,HCPCS,,,,597026010,NDC,1,EA,744.84,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,191.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,165.76,191.52
glucagon rdna (diagnostic) 1 MG Recon Soln 1 Each Vial,J1610.01,CDM,636,RC,J1610,HCPCS,,,,597026010,NDC,1,EA,744.84,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,191.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,165.76,191.52
Trb@ Gene Rearrange Amplify - Ref,PX8134090,CDM,300,RC,81340,CPT,90,,,,,,,503,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,191.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,191.56,492.94
Drain/Inject Med Joint/Brusa W/US Guide,PX20606F,CDM,510,RC,20606,CPT,,,,,,,,387,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,191.565,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.7598,604.15
"Ex Sknbngn0.6-1cmtrnk,Arm,Lg",PX11401P,CDM,983,RC,11401,CPT,,,,,,,,387,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,191.565,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.7598,376.6671
"Exc Skn Benig<5mm Face,Facial",PX11440P,CDM,983,RC,11440,CPT,,,,,,,,387,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,191.565,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.7598,614.65
Facility Emergency Level II Visit,PX99282F,CDM,450,RC,99282,CPT,,,,,,,,387,,Humana Choice Care,All Medicare plans,outpatient,49.5,,67.1225,percent of total billed charges,191.565,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,142.88,379.26
"Initial Observation Care,Levl II",PX99219,CDM,982,RC,99219,CPT,,,,,,,,391,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,191.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,162.4214,380.5603
"Initial Observation Care,Levl II",PX99219,CDM,982,RC,99219,CPT,,,,,,,,391,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,191.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,162.4214,380.5603
"Initial Observation Care,Levl II",PX99219,CDM,982,RC,99219,CPT,,,,,,,,391,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,191.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,162.4214,380.5603
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041100,NDC,0.5,ML,196.94,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,191.681702,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.808876,411.2766
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041110,NDC,0.5,ML,196.94,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,191.681702,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.808876,411.2766
Assay Other Fluid Chlorides - Ref,PX8243890,CDM,300,RC,82438,CPT,90,,,,,,,197,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,191.7401,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.58,193.06
Tramadol - Ref,PX8037390,CDM,300,RC,80373,CPT,90,,,,,,,197,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,191.7401,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.8338,193.06
"Tech-Cytopath Eval, Fna, Rep",PX8817301,CDM,310,RC,88173,CPT,TC,,,,,,,379,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,191.774,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,371.42
tiotropium bromide monohydrate 2.5 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597010051,NDC,4,GR,461.7,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,191.79018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tiotropium bromide-olodaterol 2.5-2.5 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597015570,NDC,4,GR,461.7,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,191.79018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
MRI Brain W Contrast Tc,PX7055201,CDM,610,RC,70552,CPT,TC,,,,,,,2637,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,191.7928,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.01,383.92
MRI L Spine W Contrast Tc,PX7214901,CDM,610,RC,72149,CPT,TC,,,,,,,5136,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,191.7928,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.01,383.92
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12173-MAIN,LOCAL,,,,,400,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12173-MAIN,LOCAL,,,,,400,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Apply Finger Splint,Static",PX29130F,CDM,420,RC,29130,CPT,,,,,,,,196,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,192.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.4184,192.08
Heterophile Antibodies,PX86308,CDM,300,RC,86308,CPT,,,,,,,,196,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,192.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.75,192.08
agalsidase beta 5 MG Recon Soln 1 Each Vial,J0180.01,CDM,636,RC,J0180,HCPCS,,,,58468004101,NDC,1,EA,1717.68,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,192.14,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.14,218.34
hydrocortisone (perianal) 2.5 % Cream 28.35 g Tube,63700001,CDM,250,RC,,,,,,10631040701,NDC,28.35,GR,447.94,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,192.16626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Closed Rx Metacarpal Fx,PX26600F,CDM,510,RC,26600,CPT,,,,,,,,443,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,192.18,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,187.83,655.13
Closed Rx Metacarpal Fx,PX26600F,CDM,510,RC,26600,CPT,,,,,,,,443,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,192.18,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,187.83,655.13
Closed Rx Metacarpal Fx,PX26600P,CDM,983,RC,26600,CPT,,,,,,,,295,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,192.18,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,187.83,655.13
Closed Rx Metacarpal Fx,PX26600P,CDM,983,RC,26600,CPT,,,,,,,,295,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,192.18,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,187.83,655.13
Closed Rx Shldr Dislocation,PX23650F,CDM,510,RC,23650,CPT,,,,,,,,689,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,192.18,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.18,720.86
Closed Rx Shldr Dislocation,PX23650P,CDM,983,RC,23650,CPT,,,,,,,,516,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,192.18,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.18,720.86
Bone Age Studies Tc,PX7707201,CDM,320,RC,77072,CPT,TC,,,,,,,211,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,192.221,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.6494,206.78
Collect Blood From Picc,PX36592F,CDM,510,RC,36592,CPT,,,,,,,,211,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,192.221,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.6494,206.78
Draw Blood Off Venous Device,PX36591F,CDM,510,RC,36591,CPT,,,,,,,,211,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,192.221,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.6494,206.78
C-COLLAR ASPEN REGULAR 79-83365,120.25,CDM,274,RC,L0140,HCPCS,,167-MAIN,LOCAL,,,,,216,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,192.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.58,211.68
C-COLLAR ASPEN TALL 79-83367,120.25,CDM,274,RC,L0140,HCPCS,,164-MAIN,LOCAL,,,,,216,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,192.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.58,211.68
C-COLLAR ASPEN X-TALL 79-83368,120.25,CDM,274,RC,L0140,HCPCS,,168-MAIN,LOCAL,,,,,216,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,192.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.58,211.68
"Remv F.B.,Eye,Embed Conjunc",PX65210P,CDM,983,RC,65210,CPT,,,,,,,,216,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,192.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,89.7264,348.08
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781315972,NDC,1,EA,217.96,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,192.24072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86,213.6008
Closed Rx Elbow Dislocation,PX24600P,CDM,983,RC,24600,CPT,,,,,,,,380,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,192.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,157.852,369.854
CT Angio Abd&Pelv W/O&W/Dye,PX7417401,CDM,350,RC,74174,CPT,TC,,,,,,,2757,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,192.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.4,567.99
CT Angio Abd&Pelv W/O&W/Dye,PX7417401,CDM,350,RC,74174,CPT,TC,,,,,,,2757,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,192.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.4,567.99
azithromycin 200 MG/5ML Recon Susp 15 mL Bottle,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,59762312001,NDC,15,ML,196.35,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,192.423,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.75,192.423
ROTH NET PLATINUM RETRIEVER,27200000,CDM,272,RC,,,,7518-MAIN,LOCAL,,,,,196.35,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,192.423,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MRI Pelvis W/Contrast Tc,PX7219601,CDM,610,RC,72196,CPT,TC,,,,,,,3143,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,192.4364,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.45,385.24
"MRI,Lwrext,No Jnt, W/Cont",PX7371901,CDM,610,RC,73719,CPT,TC,,,,,,,3627,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,192.4364,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.23,384.58
"Calprotectin, Fecal - Ref",PX8399390,CDM,300,RC,83993,CPT,90,,,,,,,401,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,192.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18,392.98
"Calprotectin, Fecal - Ref",PX8399390,CDM,300,RC,83993,CPT,90,,,,,,,401,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,192.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18,392.98
rifAXIMin 550 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,65649030302,NDC,1,EA,218.25,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,192.4965,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rifAXIMin 550 MG Tablet 60 Each Box,63700001,CDM,250,RC,,,,,,65649030303,NDC,1,EA,218.25,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,192.4965,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ANCHORAGE FIXATION PIN,27200000,CDM,272,RC,,,,12642-MAIN,LOCAL,,,,,389,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,192.555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Ext Ecg > 48hr to 21 Day Rcrd W/Conect Intl Rcrd,PX0296T,CDM,731,RC,0296T,HCPCS,,,,,,,,389,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,192.555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,161.5906,381.22
6 SHOOTER SAEED MULTIBAND LIGATOR,27200000,CDM,272,RC,,,,12379-MAIN,LOCAL,,,,,393,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,192.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
6 SHOOTER SAEED MULTIBAND LIGATOR,27200000,CDM,272,RC,,,,12379-MAIN,LOCAL,,,,,393,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,192.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
6 SHOOTER SAEED MULTIBAND LIGATOR,27200000,CDM,272,RC,,,,12379-MAIN,LOCAL,,,,,393,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,192.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA FIRST MET TRANSLATOR STERILE MICA,27200000,CDM,272,RC,,,,12445-MAIN,LOCAL,,,,,393,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,192.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA FIRST MET TRANSLATOR STERILE MICA,27200000,CDM,272,RC,,,,12445-MAIN,LOCAL,,,,,393,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,192.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA FIRST MET TRANSLATOR STERILE MICA,27200000,CDM,272,RC,,,,12445-MAIN,LOCAL,,,,,393,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,192.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Tap Block Bilateral by Injection(S),PX64488F,CDM,510,RC,64488,CPT,,,,,,,,393,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,192.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,163.2522,385.14
Tap Block Bilateral by Injection(S),PX64488F,CDM,510,RC,64488,CPT,,,,,,,,393,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,192.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,163.2522,385.14
Tap Block Bilateral by Injection(S),PX64488F,CDM,510,RC,64488,CPT,,,,,,,,393,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,192.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,163.2522,385.14
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601901,NDC,10,ML,211.47,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,192.64917,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.844638,207.2406
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601910,NDC,10,ML,211.47,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,192.64917,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.844638,207.2406
Collect Blood From Picc,PX36592,CDM,949,RC,36592,CPT,,,,,,,,198,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,192.7134,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.2492,194.04
Debride Muscle Ea Add 20 Sqcm,PX11046P,CDM,983,RC,11046,CPT,,,,,,,,198,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,192.7134,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.2492,192.7134
Insert Simple Cath Foley,PX51702F,CDM,510,RC,51702,CPT,,,,,,,,198,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,192.7134,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.2492,194.04
KIT PLEUREVAC CHEST DRAIN S-1100-08LF,120.2,CDM,272,RC,,,,4190-MAIN,LOCAL,,,,,198,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,192.7134,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.0466,194.04
Lyme Screen,PX7585,CDM,300,RC,86618,CPT,,,,,,,,198,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,192.7134,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.61,194.04
"Hospital Inpt or Obs Care, Admin/Disch Same Date Straightforward or Low Level Mdm >= 45 Minutes",PX99234,CDM,982,RC,99234,CPT,,,,,,,,464,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,192.7456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.7456,451.6112
Naso/Orogastric Tube,PX43752F,CDM,510,RC,43752,CPT,,,,,,,,464,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,192.7456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.7456,454.72
rho d immune globulin human 1500 units solution prefilled syringe 1 Each Syringe,J2790.01,CDM,636,RC,J2790,HCPCS,,,,562780500,NDC,1,EA,464.01,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,192.749754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.749754,454.7298
"Xray Mandible Compl, Min 4 Vws",PX7011001,CDM,320,RC,70110,CPT,TC,,,,,,,381,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,192.786,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,373.38
SET SP TUBE INTRODUCER  14CM 8-14FR G15469,120.377,CDM,272,RC,,,,7147-MAIN,LOCAL,,,,,227,,First Health,Commercial,both,85,,999999999,percent of total billed charges,192.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.2958,222.46
Sp Stn for Inclusn Bodies - Ref,PX8720790,CDM,300,RC,87207,CPT,90,,,,,,,227,,First Health,Commercial,both,85,,999999999,percent of total billed charges,192.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.49,222.46
"Cardioversion, Elective;Extern",PX92960F,CDM,480,RC,92960,CPT,,,,,,,,402,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,192.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.9908,568.57
"Cardioversion, Elective;Extern",PX92960F,CDM,480,RC,92960,CPT,,,,,,,,402,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,192.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.9908,568.57
Lab Imm Spin X-Match,PX8837,CDM,300,RC,86920,CPT,,,,,,,,402,,Health Partners,Health Partners Care Plans,both,48,,193.6133333,percent of total billed charges,192.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.22,393.96
Lab Imm Spin X-Match,PX8837,CDM,300,RC,86920,CPT,,,,,,,,402,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,192.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.22,393.96
"Morphometric Analysis, in Situ Hybridization, Each Probe; Manual, Tech",PX8836801,CDM,310,RC,88368,CPT,TC,,,,,,,402,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,192.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.9908,393.96
"Morphometric Analysis, in Situ Hybridization, Each Probe; Manual, Tech",PX8836801,CDM,310,RC,88368,CPT,TC,,,,,,,402,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,192.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.9908,393.96
cabazitaxel 60 MG/1.5ML Solution 6 mL Vial,J9043.01,CDM,636,RC,J9043,HCPCS,,,,24582411,NDC,6,ML,28293.07,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,192.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.96,27727.2086
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041100,NDC,0.5,ML,196.94,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,193.0012,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.808876,411.2766
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041110,NDC,0.5,ML,196.94,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,193.0012,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.808876,411.2766
Fac/Removal of Skin Tags,PX11200F,CDM,510,RC,11200,CPT,,,,,,,,348,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,193.01,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.65,193.01
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569F,CDM,510,RC,36569,CPT,,,,,,,,1217,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,193.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.28,193.01
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569F,CDM,510,RC,36569,CPT,,,,,,,,1217,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,193.01,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.28,193.01
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569P,CDM,983,RC,36569,CPT,,,,,,,,1825,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,193.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.28,1788.5
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569P,CDM,983,RC,36569,CPT,,,,,,,,1825,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,193.01,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.28,1788.5
Removal of Skin Tags,PX11200P,CDM,983,RC,11200,CPT,,,,,,,,418,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,193.01,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.65,409.64
"measles, mumps & rubella vaccine Recon Soln 1 Each Vial",90707,CDM,636,RC,90707,CPT,,,,6468100,NDC,1,EA,381.47,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,193.02382,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,158.462638,373.8406
"Spinal Punc,Drain,Theraputic",PX62272F,CDM,510,RC,62272,CPT,,,,,,,,450,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,193.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.93,604.15
Apc Resistance Assay - Ref,PX8530790,CDM,300,RC,85307,CPT,90,,,,,,,390,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,193.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.05,382.2
"Closed Rx Toe Fx,Manipulatn",PX28515F,CDM,510,RC,28515,CPT,,,,,,,,390,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,193.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,162.006,382.2
Assay Other Fluid Chlorides - Ref,PX8243890,CDM,300,RC,82438,CPT,90,,,,,,,197,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,193.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.58,193.06
Tramadol - Ref,PX8037390,CDM,300,RC,80373,CPT,90,,,,,,,197,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,193.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.8338,193.06
Procalcitonin,PX84145,CDM,300,RC,84145,CPT,,,,,,,,217,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,193.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.96,212.66
TRAY 8 FR 5IN CENTESIS WITH TURKEL  30-CE1CO,120.303,CDM,272,RC,,,,11503-MAIN,LOCAL,,,,,217,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,193.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,90.1418,212.66
"Non-Select. Wound Debride., W/O Anesth.; Top. Appl./Wound Assess./Instruct., per Sess.",PX97602,CDM,761,RC,97602,CPT,,,,,,,,212,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,193.132,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.0648,207.76
CANNULATED AO HANDLE STERILE MICA SCREW SYSTEM 57S1HNDL,27200000,CDM,272,RC,,,,12446-MAIN,LOCAL,,,,,219,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,193.158,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TUBE SURGICAL IRRIGATION 1PK PD-IT,27200000,CDM,272,RC,,,,12433-MAIN,LOCAL,,,,,219,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,193.158,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Drainage of Hematoma/Fluid (P),PX10140P,CDM,983,RC,10140,CPT,,,,,,,,465,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,193.161,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,193.161,1416.38
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102P,CDM,983,RC,11102,CPT,,,,,,,,465,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,193.161,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,452.5845
dantrolene 20 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,42023012306,NDC,1,EA,394.42,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,193.2658,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dantrolene 20 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,42023012306,NDC,1,EA,394.42,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,193.2658,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dantrolene 20 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,42023012306,NDC,1,EA,394.42,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,193.2658,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
albumin human 25% 25 % Solution 50 mL Flex Cont,P9047,CDM,636,RC,P9047,HCPCS,,,,944049301,NDC,50,ML,402.67,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,193.2816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.66,394.6166
albumin human 25% 25 % Solution 50 mL Flex Cont,P9047,CDM,636,RC,P9047,HCPCS,,,,944049301,NDC,50,ML,402.67,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,193.2816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.66,394.6166
"X-Ray Exam Hip,Bilat W/Pelvis 3-4 Vws",PX7352201,CDM,320,RC,73522,CPT,TC,,,,,,,382,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,193.292,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,374.36
gentamicin 0.3 % Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,17478028435,NDC,3.5,GR,219.3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,193.4226,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Initial Observation Care,Levl II",PX99219,CDM,982,RC,99219,CPT,,,,,,,,391,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,193.545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,162.4214,380.5603
Drainage of Gum Lesion,PX41800F,CDM,510,RC,41800,CPT,,,,,,,,395,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,193.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,387.1
Drainage of Gum Lesion,PX41800F,CDM,510,RC,41800,CPT,,,,,,,,395,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,193.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,387.1
Drainage of Gum Lesion,PX41800F,CDM,510,RC,41800,CPT,,,,,,,,395,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,193.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,387.1
"Exc Skn Malig1.1-2cm Fce,Facal",PX11642P,CDM,983,RC,11642,CPT,,,,,,,,466,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,193.5764,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,193.5764,614.65
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505614700,NDC,1,EA,212.52,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,193.60572,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
Inpt or Obs Disch Day Mngmt <=30 Minutes,PX99238,CDM,982,RC,99238,CPT,,,,,,,,199,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,193.6867,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.6646,193.6867
hydrocortisone sodium succinate (preservative free) 1000 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9000501,NDC,1,EA,403.54,,Health Partners,Health Partners Care Plans,both,48,,50.24,percent of total billed charges,193.6992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
hydrocortisone sodium succinate (preservative free) 1000 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9000501,NDC,1,EA,403.54,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,193.6992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
"Excision of Nail Fold, Toe",PX11765F,CDM,510,RC,11765,CPT,,,,,,,,210,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,193.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.68,345.9
El-1 Fecal Quantitative,PX8265390,CDM,300,RC,82653,CPT,90,,,,,,,383,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,193.798,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.0982,375.34
NON-LOCKING SCREW 3.5X18MM,C1713,CDM,278,RC,C1713,HCPCS,,12466-MAIN,LOCAL,,,,,395.51,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,193.7999,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
NON-LOCKING SCREW 3.5X18MM,C1713,CDM,278,RC,C1713,HCPCS,,12466-MAIN,LOCAL,,,,,395.51,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,193.7999,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
NON-LOCKING SCREW 3.5X18MM,C1713,CDM,278,RC,C1713,HCPCS,,12466-MAIN,LOCAL,,,,,395.51,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,193.7999,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
OXALiplatin 50 MG/10ML Solution 10 mL Vial,J9263.01,CDM,636,RC,J9263,HCPCS,,,,955173110,NDC,10,ML,228,,First Health,Commercial,both,85,,999999999,percent of total billed charges,193.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.7112,223.44
DRILL BIT AO DIA 2.0MMX135MM SCALED,27200000,CDM,272,RC,,,,12640-MAIN,LOCAL,,,,,452,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,193.908,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Layr Clos Wnd Rest Body 2.6-7.5,PX12042F,CDM,510,RC,12042,CPT,,,,,,,,404,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,193.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,395.92
Layr Clos Wnd Rest Body 2.6-7.5,PX12042F,CDM,510,RC,12042,CPT,,,,,,,,404,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,193.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,395.92
Neg Pressure Wound Therapy Dme >50 Sq Cm,PX97606F,CDM,761,RC,97606,CPT,,,,,,,,404,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,193.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,395.92
Neg Pressure Wound Therapy Dme >50 Sq Cm,PX97606F,CDM,761,RC,97606,CPT,,,,,,,,404,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,193.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,395.92
Remove Foreign Body Simple,PX10120F,CDM,510,RC,10120,CPT,,,,,,,,404,,Health Partners,Health Partners Care Plans,both,48,,5.99,percent of total billed charges,193.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,395.92
Remove Foreign Body Simple,PX10120F,CDM,510,RC,10120,CPT,,,,,,,,404,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,193.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,395.92
Xray Foot Minimum 3 Vws,PX7363001,CDM,320,RC,73630,CPT,TC,,,,,,,404,,Health Partners,Health Partners Care Plans,both,48,,258.236,percent of total billed charges,193.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,395.92
Xray Foot Minimum 3 Vws,PX7363001,CDM,320,RC,73630,CPT,TC,,,,,,,404,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,193.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,395.92
Xray Knee 3 Vws,PX7356201,CDM,320,RC,73562,CPT,TC,,,,,,,404,,Health Partners,Health Partners Care Plans,both,48,,171.2586667,percent of total billed charges,193.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,395.92
Xray Knee 3 Vws,PX7356201,CDM,320,RC,73562,CPT,TC,,,,,,,404,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,193.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,395.92
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606F,CDM,510,RC,11606,CPT,,,,,,,,1432,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,193.93,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,193.93,933.24
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606P,CDM,983,RC,11606,CPT,,,,,,,,2044,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,193.93,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,193.93,2003.12
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623F,CDM,510,RC,11623,CPT,,,,,,,,690,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,193.9444,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.89,616.39
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623P,CDM,983,RC,11623,CPT,,,,,,,,460,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,193.9444,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.89,616.39
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781315972,NDC,1,EA,217.96,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,193.9844,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86,213.6008
pentafluoroprop - tetrafluoroeth Aerosol 116 mL Can,63700001,CDM,250,RC,,,,,,386000802,NDC,207,ML,383.42,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,194.01052,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,409277602,NDC,200,ML,228.28,,First Health,Commercial,both,85,,999999999,percent of total billed charges,194.038,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.827512,225.8704
Collect Blood From Picc,PX36592,CDM,949,RC,36592,CPT,,,,,,,,198,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,194.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.2492,194.04
Comprehensive Metabolic Panel,PX80053,CDM,300,RC,80053,CPT,,,,,,,,396,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,29.81377778,percent of total billed charges,194.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.68,388.08
Comprehensive Metabolic Panel,PX80053,CDM,300,RC,80053,CPT,,,,,,,,396,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,194.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.68,388.08
Comprehensive Metabolic Panel,PX80053,CDM,300,RC,80053,CPT,,,,,,,,396,,United Healthcare,All Medicare advantage plans,outpatient,49,,209.88,percent of total billed charges,194.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.68,388.08
Debride Muscle Ea Add 20 Sqcm,PX11046P,CDM,983,RC,11046,CPT,,,,,,,,198,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,194.04,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.5,194.04
Hepatitis a Igm Antibody,PX86709,CDM,300,RC,86709,CPT,,,,,,,,220,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,194.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.32,215.6
"Hiv-1, Quantification - Ref",PX8753690,CDM,300,RC,87536,CPT,90,,,,,,,220,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,194.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.03,215.6
Immunoassay Nos - Ref,PX8352090,CDM,300,RC,83520,CPT,90,,,,,,,220,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,194.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.83,215.6
Insert Simple Cath Foley,PX51702F,CDM,510,RC,51702,CPT,,,,,,,,198,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,194.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.2492,194.04
KIT PLEUREVAC CHEST DRAIN S-1100-08LF,120.2,CDM,272,RC,,,,4190-MAIN,LOCAL,,,,,198,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,194.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.0466,194.04
Leptospira Antibody - Ref,PX8672090,CDM,300,RC,86720,CPT,90,,,,,,,220,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,194.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.85,215.6
Lyme Screen,PX7585,CDM,300,RC,86618,CPT,,,,,,,,198,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,194.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.61,194.04
Neg Pressure Wound Therapy Dme </=50 Sq Cm,PX97605F,CDM,510,RC,97605,CPT,,,,,,,,396,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,194.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,164.4984,388.08
Neg Pressure Wound Therapy Dme </=50 Sq Cm,PX97605F,CDM,510,RC,97605,CPT,,,,,,,,396,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,194.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,164.4984,388.08
Neg Pressure Wound Therapy Dme </=50 Sq Cm,PX97605F,CDM,510,RC,97605,CPT,,,,,,,,396,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,194.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,164.4984,388.08
NON-LOCKING SCREW 3.5X12MM,27200000,CDM,278,RC,C1713,HCPCS,,11857-MAIN,LOCAL,,,,,396,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,194.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NON-LOCKING SCREW 3.5X12MM,27200000,CDM,278,RC,C1713,HCPCS,,11857-MAIN,LOCAL,,,,,396,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,194.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NON-LOCKING SCREW 3.5X12MM,27200000,CDM,278,RC,C1713,HCPCS,,11857-MAIN,LOCAL,,,,,396,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,194.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NON-LOCKING SCREW 3.5X16MM,27200000,CDM,278,RC,C1713,HCPCS,,11856-MAIN,LOCAL,,,,,396,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,194.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NON-LOCKING SCREW 3.5X16MM,27200000,CDM,278,RC,C1713,HCPCS,,11856-MAIN,LOCAL,,,,,396,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,194.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NON-LOCKING SCREW 3.5X16MM,27200000,CDM,278,RC,C1713,HCPCS,,11856-MAIN,LOCAL,,,,,396,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,194.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NON-LOCKING SCREW 3.5X24MM,27200000,CDM,278,RC,C1713,HCPCS,,11855-MAIN,LOCAL,,,,,396,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,194.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NON-LOCKING SCREW 3.5X24MM,27200000,CDM,278,RC,C1713,HCPCS,,11855-MAIN,LOCAL,,,,,396,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,194.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NON-LOCKING SCREW 3.5X24MM,27200000,CDM,278,RC,C1713,HCPCS,,11855-MAIN,LOCAL,,,,,396,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,194.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Apply Multlay Comprs Lwr Leg,PX29581F,CDM,510,RC,29581,CPT,,,,,,,,213,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,194.043,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.4802,208.74
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006F,CDM,510,RC,10006,CPT,,,,,,,,213,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,194.043,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.4802,208.74
"GI Pathogen Panel, Pcr - Ref",PX8750790,CDM,300,RC,87507,CPT,90,,,,,,,213,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,194.043,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.4802,382.15
Remove Impacted Ear Wax,PX69210F,CDM,510,RC,69210,CPT,,,,,,,,213,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,194.043,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.44,208.74
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070102,NDC,1,ML,383.6,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,194.1016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.92,450.751
CT Angio Abd&Pelv W/O&W/Dye,PX7417401,CDM,350,RC,74174,CPT,TC,,,,,,,2757,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,194.15,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.4,567.99
rifAXIMin 550 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,65649030302,NDC,1,EA,218.25,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,194.2425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rifAXIMin 550 MG Tablet 60 Each Box,63700001,CDM,250,RC,,,,,,65649030303,NDC,1,EA,218.25,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,194.2425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Lvl 3 Sub Hosp High Mdm or 50 Minutes,PX99233,CDM,982,RC,99233,CPT,,,,,,,,384,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,194.304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.5136,373.7472
"Exc Skn Mal 0.6-1cm Fce,Facial",PX11641P,CDM,983,RC,11641,CPT,,,,,,,,453,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,194.337,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.1762,614.65
Repr Superf Wnd Body 7.6-12.5,PX12004F,CDM,510,RC,12004,CPT,,,,,,,,453,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,194.337,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,443.94
Repr Superf Wnd Face 5.1-7.5,PX12014F,CDM,510,RC,12014,CPT,,,,,,,,453,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,194.337,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,443.94
Closed Rx Kneecap Dislocatn,PX27560F,CDM,510,RC,27560,CPT,,,,,,,,468,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,194.4072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,194.4072,458.64
"POS Airway Pressure, Bipap",PX94660.01F,CDM,410,RC,94660,CPT,,,,,,,,468,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,194.4072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.33,458.64
Vedolizumab - Ref,PX8028090,CDM,300,RC,80280,CPT,90,,,,,,,468,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,194.4072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.36,458.64
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060851,NDC,100,ML,213.4,,Medica,Commercial,both,91.1,,0.687108295,percent of total billed charges,194.4074,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
Baloxavir Marboxil(40 MG Dose) 2 x 20 MG tablet therapy pack 2 Each Box,800000,CDM,,,,,,,,50242082802,NDC,1,EA,384.3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,194.4558,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
"MESH PROLENE 3X6""",C1781,CDM,278,RC,C1781,HCPCS,,688-MAIN,LOCAL,,,,,213.49,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,194.48939,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
6 SHOOTER SAEED MULTIBAND LIGATOR,27200000,CDM,272,RC,,,,12379-MAIN,LOCAL,,,,,393,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,194.535,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA FIRST MET TRANSLATOR STERILE MICA,27200000,CDM,272,RC,,,,12445-MAIN,LOCAL,,,,,393,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,194.535,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Tap Block Bilateral by Injection(S),PX64488F,CDM,510,RC,64488,CPT,,,,,,,,393,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,194.535,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,163.2522,385.14
"Critical Care, E/M 30-74 Minutes",PX99291P,CDM,983,RC,99291,CPT,,,,,,,,1061,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,194.568,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.04,1039.78
"Facility Critical Care, E/M 30-74 Minutes",PX99291F,CDM,510,RC,99291,CPT,,,,,,,,1264,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,194.568,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.04,489.16
patiromer sorbitex calcium 8.4 g Packet 4 Each Box,63700001,CDM,250,RC,,,,,,53436008404,NDC,1,EA,228.96,,First Health,Commercial,both,85,,999999999,percent of total billed charges,194.616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Ctrl Nosebleed,Anter,Simple",PX30901P,CDM,983,RC,30901,CPT,,,,,,,,229,,First Health,Commercial,both,85,,999999999,percent of total billed charges,194.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.1266,222.8857
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604P,CDM,983,RC,20604,CPT,,,,,,,,229,,First Health,Commercial,both,85,,999999999,percent of total billed charges,194.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.1266,258.75
Removal of Nail Plate,PX11730F,CDM,510,RC,11730,CPT,,,,,,,,229,,First Health,Commercial,both,85,,999999999,percent of total billed charges,194.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.1266,224.42
DERMABOND PRINEO SKIN CLOSURE SYSTEM 42CM,27200000,CDM,272,RC,,,,12323-MAIN,LOCAL,,,,,200,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,194.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
gadoxetate disodium 0.25 MOL/L Solution 10 mL Vial,A9581,CDM,636,RC,A9581,HCPCS,,,,50419032005,NDC,10,ML,200,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,194.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,196
iohexol 300 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141363,NDC,100,ML,200,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1.285682353,percent of total billed charges,194.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,294
iohexol 350 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141491,NDC,100,ML,200,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1.285682353,percent of total billed charges,194.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,294
Lacosamide - Ref,PX8023590,CDM,300,RC,80235,CPT,90,,,,,,,200,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,194.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.86,196
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059611,NDC,0.25,EA,200.05,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,717.03,percent of total billed charges,194.708665,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.10077,725.3862
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059613,NDC,0.25,EA,200.05,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,717.03,percent of total billed charges,194.708665,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.10077,725.3862
X-Ray Exam Entire Spine 2-3 Vws,PX7208201,CDM,320,RC,72082,CPT,TC,,,,,,,454,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,194.766,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,444.92
Apply Long Arm Splint,PX29105P,CDM,983,RC,29105,CPT,,,,,,,,385,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,194.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.65,374.7205
Apply Long Leg Splint,PX29505P,CDM,983,RC,29505,CPT,,,,,,,,385,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,194.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.65,374.7205
Closed Rx Trimalleolar Fx,PX27816F,CDM,510,RC,27816,CPT,,,,,,,,522,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,194.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,190.44,718.09
Closed Rx Trimalleolar Fx,PX27816F,CDM,510,RC,27816,CPT,,,,,,,,522,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,194.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,190.44,718.09
Closed Rx Trimalleolar Fx,PX27816P,CDM,983,RC,27816,CPT,,,,,,,,826,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,194.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,190.44,809.48
Closed Rx Trimalleolar Fx,PX27816P,CDM,983,RC,27816,CPT,,,,,,,,826,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,194.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,190.44,809.48
Injection for Nerve Block,PX64445F,CDM,510,RC,64445,CPT,,,,,,,,385,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,194.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,604.15
Injection for Nerve Block,PX64445P,CDM,983,RC,64445,CPT,,,,,,,,385,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,194.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,604.15
MICA DEPTH GAUGE 150MM STERILE MICA,27200000,CDM,272,RC,,,,12439-MAIN,LOCAL,,,,,385,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,194.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"N Block Inj, Plantar Digit",PX64455F,CDM,510,RC,64455,CPT,,,,,,,,385,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,194.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,377.3
"N Block Inj, Plantar Digit",PX64455P,CDM,983,RC,64455,CPT,,,,,,,,385,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,194.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,374.7205
Xray Temporomandib Jnt Unilat,PX7032801,CDM,320,RC,70328,CPT,TC,,,,,,,385,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,194.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,377.3
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598F,CDM,510,RC,97598,CPT,,,,,,,,406,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,194.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,168.6524,397.88
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598F,CDM,510,RC,97598,CPT,,,,,,,,406,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,194.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,168.6524,397.88
CANNULATED AO HANDLE STERILE MICA SCREW SYSTEM 57S1HNDL,27200000,CDM,272,RC,,,,12446-MAIN,LOCAL,,,,,219,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,194.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TUBE SURGICAL IRRIGATION 1PK PD-IT,27200000,CDM,272,RC,,,,12433-MAIN,LOCAL,,,,,219,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,194.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Remove Impacted Ear Wax,PX69210P,CDM,983,RC,69210,CPT,,,,,,,,221,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,194.922,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.44,215.0993
Immunofix Elp,PX86335,CDM,300,RC,86335,CPT,,,,,,,,214,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,194.954,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.91,209.72
Chrom Anal 15-20 Cells - Ref,PX8826290,CDM,310,RC,88262,CPT,90,,,,,,,398,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,195.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.06,390.04
Chrom Anal 15-20 Cells - Ref,PX8826290,CDM,310,RC,88262,CPT,90,,,,,,,398,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,195.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.06,390.04
Chrom Anal 15-20 Cells - Ref,PX8826290,CDM,310,RC,88262,CPT,90,,,,,,,398,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,195.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.06,390.04
Inpt or Obs Disch Day Mngmt <=30 Minutes,PX99238,CDM,982,RC,99238,CPT,,,,,,,,199,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,195.02,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.85,195.02
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606F,CDM,510,RC,11606,CPT,,,,,,,,1432,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,195.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,193.93,933.24
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606F,CDM,510,RC,11606,CPT,,,,,,,,1432,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,195.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,193.93,933.24
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606P,CDM,983,RC,11606,CPT,,,,,,,,2044,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,195.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,193.93,2003.12
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606P,CDM,983,RC,11606,CPT,,,,,,,,2044,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,195.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,193.93,2003.12
gentamicin 0.3 % Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,17478028435,NDC,3.5,GR,219.3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,195.177,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Ileoscopy Thru Stoma,Diagnostic",PX44380P,CDM,983,RC,44380,CPT,,,,,,,,455,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,195.195,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.007,791.92
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607F,CDM,761,RC,97607,CPT,,,,,,,,455,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,195.195,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.007,445.9
dantrolene 20 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,42023012306,NDC,1,EA,394.42,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,195.2379,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
CT Head/Brain W/Dye,PX7046001,CDM,350,RC,70460,CPT,TC,,,,,,,3398,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,195.25,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.1,195.25
CT Head/Brain W/Dye,PX7046001,CDM,350,RC,70460,CPT,TC,,,,,,,3398,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,195.25,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.1,195.25
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032F,CDM,510,RC,12032,CPT,,,,,,,,386,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,195.316,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.3444,378.28
RELOAD SUREFORM 45 2.5MM WHITE,27200000,CDM,272,RC,,,,12791-MAIN,LOCAL,,,,,386,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,195.316,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 45 3.5MM BLUE,27200000,CDM,272,RC,,,,12792-MAIN,LOCAL,,,,,386,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,195.316,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 45 4.3MM GREEN,27200000,CDM,272,RC,,,,12793-MAIN,LOCAL,,,,,386,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,195.316,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,548590000,NDC,1,EA,470.19,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,195.316926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,179.012476,460.7862
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037905,NDC,0.5,ML,229.88,,First Health,Commercial,both,85,,999999999,percent of total billed charges,195.398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
"Morphometric Analysis, Tumor - Ref",PX8836090,CDM,310,RC,88360,CPT,90,,,,,,,349,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,195.44,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,116.39,195.44
"Morphometric Analysis, Tumor - Ref",PX8836090,CDM,310,RC,88360,CPT,90,,,,,,,349,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,195.44,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,116.39,195.44
Trg Gene Rearrangement Anal - Ref,PX8134290,CDM,300,RC,81342,CPT,90,,,,,,,516,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,195.46,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,195.46,201.5
Trg Gene Rearrangement Anal - Ref,PX8134290,CDM,300,RC,81342,CPT,90,,,,,,,516,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,195.46,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,195.46,201.5
Trg Gene Rearrangement Anal - Ref,PX8134290,CDM,300,RC,81342,CPT,90,,,,,,,516,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,195.46,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,195.46,201.5
Dress/Debrid Large Burn No Anesth,PX16030F,CDM,510,RC,16030,CPT,,,,,,,,399,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,195.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,165.7446,391.02
Dress/Debrid Large Burn No Anesth,PX16030F,CDM,510,RC,16030,CPT,,,,,,,,399,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,195.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,165.7446,391.02
Dress/Debrid Large Burn No Anesth,PX16030F,CDM,510,RC,16030,CPT,,,,,,,,399,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,195.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,165.7446,391.02
"X-Ray Exam Hip,Bilat W/Pelvis 2 Vws",PX7352101,CDM,320,RC,73521,CPT,TC,,,,,,,399,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,195.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,391.02
"X-Ray Exam Hip,Bilat W/Pelvis 2 Vws",PX7352101,CDM,320,RC,73521,CPT,TC,,,,,,,399,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,195.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,391.02
"X-Ray Exam Hip,Bilat W/Pelvis 2 Vws",PX7352101,CDM,320,RC,73521,CPT,TC,,,,,,,399,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,195.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,391.02
Xray Lumbosacral 2 or 3 Vws,PX7210001,CDM,320,RC,72100,CPT,TC,,,,,,,399,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,113.2716667,percent of total billed charges,195.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,391.02
Xray Lumbosacral 2 or 3 Vws,PX7210001,CDM,320,RC,72100,CPT,TC,,,,,,,399,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,195.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,391.02
Xray Lumbosacral 2 or 3 Vws,PX7210001,CDM,320,RC,72100,CPT,TC,,,,,,,399,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,195.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,391.02
Drainage of Gum Lesion,PX41800F,CDM,510,RC,41800,CPT,,,,,,,,395,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,195.525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,387.1
"Ctrl Nosebleed,Anter,Complex",PX30903F,CDM,510,RC,30903,CPT,,,,,,,,456,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,195.624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,446.88
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611F,CDM,510,RC,20611,CPT,,,,,,,,456,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,195.624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.4224,446.88
"Office/Outpt Visit,New,Levl V",PX99205F,CDM,510,RC,99205,CPT,,,,,,,,456,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,195.624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.4224,446.88
"Office/Outpt Visit,New,Levl V",PX99205P,CDM,983,RC,99205,CPT,,,,,,,,456,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,195.624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.4224,443.8248
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321801,NDC,50,ML,456,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,195.624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
Xray Nasal Bones Minimum 3 Vws,PX7016001,CDM,320,RC,70160,CPT,TC,,,,,,,456,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,195.624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,446.88
"Hepatitis a Antibody, Tot - Ref",PX8670890,CDM,300,RC,86708,CPT,90,,,,,,,201,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,195.6333,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.36,196.98
Hepatitis B Surface Antibody,PX86706,CDM,300,RC,86706,CPT,,,,,,,,201,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,195.6333,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,196.98
KIT 3-LUMEN 7FR X 16CM CENTRALVENOUS CDC-42703-P1A,120.37,CDM,272,RC,C1751,HCPCS,,10707-MAIN,LOCAL,,,,,201,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,195.6333,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.4954,196.98
NON-LOCKING SCREW 3.5X18MM,C1713,CDM,278,RC,C1713,HCPCS,,12466-MAIN,LOCAL,,,,,395.51,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,195.77745,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Repr Superf Wnd Body 12.6-20,PX12005F,CDM,510,RC,12005,CPT,,,,,,,,565,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,195.78,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.84,369.42
Repr Superf Wnd Body 12.6-20,PX12005P,CDM,983,RC,12005,CPT,,,,,,,,377,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,195.78,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.84,369.46
Hepatitis a Igm Antibody,PX86709,CDM,300,RC,86709,CPT,,,,,,,,220,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,195.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.32,215.6
"Hiv-1, Quantification - Ref",PX8753690,CDM,300,RC,87536,CPT,90,,,,,,,220,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,195.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.03,215.6
Immunoassay Nos - Ref,PX8352090,CDM,300,RC,83520,CPT,90,,,,,,,220,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,195.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.83,215.6
Leptospira Antibody - Ref,PX8672090,CDM,300,RC,86720,CPT,90,,,,,,,220,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,195.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.85,215.6
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU000390,CDM,300,RC,U0003,HCPCS,90,,,,,,,222,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,195.804,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.2188,217.56
Nfct Ds Bct/Vir Respir Dna/Rna 22 Trgt Sarscov2,PX0202U,CDM,300,RC,0202U,HCPCS,,,,,,,,222,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,195.804,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.2188,382.15
Observation Care Discharge,PX99217,CDM,982,RC,99217,CPT,,,,,,,,222,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,195.804,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.2188,216.0726
Drain/Inject Med Joint/Brusa W/US Guide,PX20606F,CDM,510,RC,20606,CPT,,,,,,,,387,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,195.822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.7598,604.15
"Ex Sknbngn0.6-1cmtrnk,Arm,Lg",PX11401P,CDM,983,RC,11401,CPT,,,,,,,,387,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,195.822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.7598,376.6671
"Exc Skn Benig<5mm Face,Facial",PX11440P,CDM,983,RC,11440,CPT,,,,,,,,387,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,195.822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.7598,614.65
Facility Emergency Level II Visit,PX99282F,CDM,450,RC,99282,CPT,,,,,,,,387,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,195.822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,142.88,379.26
Immunoglobulin Subclasses - Ref,PX8278790,CDM,300,RC,82787,CPT,90,,,,,,,215,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,195.865,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.35,210.7
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,143971801,NDC,200,ML,230.48,,First Health,Commercial,both,85,,999999999,percent of total billed charges,195.908,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.827512,225.8704
DERMABOND PRINEO SKIN CLOSURE SYSTEM 42CM,27200000,CDM,272,RC,,,,12323-MAIN,LOCAL,,,,,200,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
gadoxetate disodium 0.25 MOL/L Solution 10 mL Vial,A9581,CDM,636,RC,A9581,HCPCS,,,,50419032005,NDC,10,ML,200,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,196
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12173-MAIN,LOCAL,,,,,400,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12173-MAIN,LOCAL,,,,,400,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12173-MAIN,LOCAL,,,,,400,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
iohexol 300 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141363,NDC,100,ML,200,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,294
iohexol 350 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141491,NDC,100,ML,200,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,294
Lacosamide - Ref,PX8023590,CDM,300,RC,80235,CPT,90,,,,,,,200,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.86,196
Lvl 1 Init Hosp Low Mdm or 40 Minutes,PX99221,CDM,982,RC,99221,CPT,,,,,,,,400,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.16,389.32
Lvl 1 Init Hosp Low Mdm or 40 Minutes,PX99221,CDM,982,RC,99221,CPT,,,,,,,,400,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.16,389.32
Lvl 1 Init Hosp Low Mdm or 40 Minutes,PX99221,CDM,982,RC,99221,CPT,,,,,,,,400,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.16,389.32
Comprehensive Metabolic Panel,PX80053,CDM,300,RC,80053,CPT,,,,,,,,396,,Humana Choice Care,All Medicare plans,outpatient,49.5,,324.0568571,percent of total billed charges,196.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.68,388.08
Neg Pressure Wound Therapy Dme </=50 Sq Cm,PX97605F,CDM,510,RC,97605,CPT,,,,,,,,396,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,196.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,164.4984,388.08
NON-LOCKING SCREW 3.5X12MM,27200000,CDM,278,RC,C1713,HCPCS,,11857-MAIN,LOCAL,,,,,396,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,196.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NON-LOCKING SCREW 3.5X16MM,27200000,CDM,278,RC,C1713,HCPCS,,11856-MAIN,LOCAL,,,,,396,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,196.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NON-LOCKING SCREW 3.5X24MM,27200000,CDM,278,RC,C1713,HCPCS,,11855-MAIN,LOCAL,,,,,396,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,196.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059611,NDC,0.25,EA,200.05,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,196.049,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.10077,725.3862
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059613,NDC,0.25,EA,200.05,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,196.049,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.10077,725.3862
"Infectious Disease (Viral Respiratory Tract Infection),",PX0241U,CDM,300,RC,0241U,HCPCS,,,,,,,,457,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,196.053,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.78,447.86
US Scrotum & Contents Tc,PX7687001,CDM,402,RC,76870,CPT,TC,,,,,,,457,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,196.053,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,447.86
"OB US < 14 Wks, Single Fetus - Radiology, Tech",PX7680101,CDM,402,RC,76801,CPT,TC,,,,,,,472,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,196.0688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,462.56
US Pelvic Tc Complete,PX7685601,CDM,402,RC,76856,CPT,TC,,,,,,,472,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,196.0688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,462.56
US Transvaginal Tc,PX7683001,CDM,402,RC,76830,CPT,TC,,,,,,,472,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,196.0688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,462.56
Lab Basic Metabolic Panel,PX80048,CDM,300,RC,80048,CPT,,,,,,,,236,,Blue Cross Blue Shield of MN,All commercial plans,both,,,75.87054795,fee schedule,196.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.76,231.28
Repr Superf Wnd Body <2.5cm,PX12001F,CDM,510,RC,12001,CPT,,,,,,,,311,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,196.47,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.83,196.47
Repr Superf Wnd Body <2.5cm,PX12001P,CDM,983,RC,12001,CPT,,,,,,,,293,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,196.47,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.83,287.14
"Calprotectin, Fecal - Ref",PX8399390,CDM,300,RC,83993,CPT,90,,,,,,,401,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,172.43,percent of total billed charges,196.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18,392.98
"Calprotectin, Fecal - Ref",PX8399390,CDM,300,RC,83993,CPT,90,,,,,,,401,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,196.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18,392.98
"Calprotectin, Fecal - Ref",PX8399390,CDM,300,RC,83993,CPT,90,,,,,,,401,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,196.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18,392.98
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725F,CDM,510,RC,26725,CPT,,,,,,,,495,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,196.55,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,196.55,740.92
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725P,CDM,983,RC,26725,CPT,,,,,,,,330,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,196.55,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,196.55,740.92
Closed Rx Shldr Dislocation,PX23650F,CDM,510,RC,23650,CPT,,,,,,,,689,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,196.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.18,720.86
Closed Rx Shldr Dislocation,PX23650F,CDM,510,RC,23650,CPT,,,,,,,,689,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,196.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.18,720.86
Closed Rx Shldr Dislocation,PX23650P,CDM,983,RC,23650,CPT,,,,,,,,516,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,196.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.18,720.86
Closed Rx Shldr Dislocation,PX23650P,CDM,983,RC,23650,CPT,,,,,,,,516,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,196.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.18,720.86
"Apply Finger Splint,Static",PX29130P,CDM,983,RC,29130,CPT,,,,,,,,223,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,196.686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,217.0459
"Apply Forearm Splint,Static",PX29125F,CDM,510,RC,29125,CPT,,,,,,,,223,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,196.686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,218.54
"Flow Cyto, Tech, 1st Mrkr - Ref",PX8818490,CDM,310,RC,88184,CPT,90,,,,,,,223,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,196.686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,314.02
"Nephelometry, Each, Nos - Ref",PX8388390,CDM,300,RC,83883,CPT,90,,,,,,,223,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,196.686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.47,218.54
Reduce Temporomandibl Disloc,PX21480P,CDM,983,RC,21480,CPT,,,,,,,,223,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,196.686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,217.0459
Remove Impacted Ear Wax,PX69210P,CDM,983,RC,69210,CPT,,,,,,,,221,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,196.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.44,215.0993
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614900,NDC,1,EA,409.89,,Health Partners,Health Partners Care Plans,both,48,,26.64321429,percent of total billed charges,196.7472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614900,NDC,1,EA,409.89,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,196.7472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
C-COLLAR ASPEN REGULAR 79-83365,120.25,CDM,274,RC,L0140,HCPCS,,167-MAIN,LOCAL,,,,,216,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,196.776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.58,211.68
C-COLLAR ASPEN TALL 79-83367,120.25,CDM,274,RC,L0140,HCPCS,,164-MAIN,LOCAL,,,,,216,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,196.776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.58,211.68
C-COLLAR ASPEN X-TALL 79-83368,120.25,CDM,274,RC,L0140,HCPCS,,168-MAIN,LOCAL,,,,,216,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,196.776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.58,211.68
"Remv F.B.,Eye,Embed Conjunc",PX65210P,CDM,983,RC,65210,CPT,,,,,,,,216,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,196.776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,89.7264,348.08
Bcr/Abl1 Other - Ref,PX8120890,CDM,310,RC,81208,CPT,90,,,,,,,1125,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,196.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,196.79,1102.5
"Lab Antibody ID,RBC",PX86870,CDM,300,RC,,,,,,,,,,410,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,196.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,170.314,401.8
"Lab Antibody ID,RBC",PX86870,CDM,300,RC,,,,,,,,,,410,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,196.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,170.314,401.8
"Supply Technicium Sestamibi,per Dose",PXA9500,CDM,343,RC,A9500,HCPCS,,,,,,,,410,,Health Partners,Health Partners Care Plans,both,48,,772.12,percent of total billed charges,196.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,170.314,401.8
"Supply Technicium Sestamibi,per Dose",PXA9500,CDM,343,RC,A9500,HCPCS,,,,,,,,410,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,196.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,170.314,401.8
ANCHORAGE FIXATION PIN,27200000,CDM,272,RC,,,,12642-MAIN,LOCAL,,,,,389,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,196.834,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Ext Ecg > 48hr to 21 Day Rcrd W/Conect Intl Rcrd,PX0296T,CDM,731,RC,0296T,HCPCS,,,,,,,,389,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,196.834,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,161.5906,381.22
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604F,CDM,510,RC,11604,CPT,,,,,,,,964,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,196.8343,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.63,646.83
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604P,CDM,983,RC,11604,CPT,,,,,,,,1422,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,196.8343,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.63,1393.56
Resp Virus 3-5 Targets,PX87631,CDM,300,RC,87631,CPT,,,,,,,,459,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,196.911,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.78,449.82
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320990,NDC,1,EA,410.32,,Health Partners,Health Partners Care Plans,both,48,,26.64321429,percent of total billed charges,196.9536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320990,NDC,1,EA,410.32,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,196.9536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320995,NDC,1,EA,410.32,,Health Partners,Health Partners Care Plans,both,48,,26.64321429,percent of total billed charges,196.9536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320995,NDC,1,EA,410.32,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,196.9536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
"Cardioversion, Elective;Extern",PX92960F,CDM,480,RC,92960,CPT,,,,,,,,402,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,106.9,percent of total billed charges,196.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.9908,568.57
"Cardioversion, Elective;Extern",PX92960F,CDM,480,RC,92960,CPT,,,,,,,,402,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,196.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.9908,568.57
"Cardioversion, Elective;Extern",PX92960F,CDM,480,RC,92960,CPT,,,,,,,,402,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,196.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.9908,568.57
Chem Cautery Granulatn Tissue,PX17250P,CDM,983,RC,17250,CPT,,,,,,,,402,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,196.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.9908,391.2666
Chem Cautery Granulatn Tissue,PX17250P,CDM,983,RC,17250,CPT,,,,,,,,402,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,196.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.9908,391.2666
Chem Cautery Granulatn Tissue,PX17250P,CDM,983,RC,17250,CPT,,,,,,,,402,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,196.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.9908,391.2666
"Hepatitis a Antibody, Tot - Ref",PX8670890,CDM,300,RC,86708,CPT,90,,,,,,,201,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,196.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.36,196.98
Hepatitis B Surface Antibody,PX86706,CDM,300,RC,86706,CPT,,,,,,,,201,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,196.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.85,196.98
KIT 3-LUMEN 7FR X 16CM CENTRALVENOUS CDC-42703-P1A,120.37,CDM,272,RC,C1751,HCPCS,,10707-MAIN,LOCAL,,,,,201,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,196.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.4954,196.98
Lab Imm Spin X-Match,PX8837,CDM,300,RC,86920,CPT,,,,,,,,402,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,79.44,percent of total billed charges,196.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.22,393.96
Lab Imm Spin X-Match,PX8837,CDM,300,RC,86920,CPT,,,,,,,,402,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,196.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.22,393.96
Lab Imm Spin X-Match,PX8837,CDM,300,RC,86920,CPT,,,,,,,,402,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,196.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.22,393.96
"Morphometric Analysis, in Situ Hybridization, Each Probe; Manual, Tech",PX8836801,CDM,310,RC,88368,CPT,TC,,,,,,,402,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,196.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.9908,393.96
"Morphometric Analysis, in Situ Hybridization, Each Probe; Manual, Tech",PX8836801,CDM,310,RC,88368,CPT,TC,,,,,,,402,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,196.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.9908,393.96
"Morphometric Analysis, in Situ Hybridization, Each Probe; Manual, Tech",PX8836801,CDM,310,RC,88368,CPT,TC,,,,,,,402,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,196.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.9908,393.96
Chrom Anal 15-20 Cells - Ref,PX8826290,CDM,310,RC,88262,CPT,90,,,,,,,398,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,197.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.06,390.04
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084243,NDC,0.5,ML,202.42,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,110.8875,percent of total billed charges,197.015386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.085268,203.497
"Incis/Drain Scrotum/Testis,Epididym",PX54700F,CDM,510,RC,54700,CPT,,,,,,,,660,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,197.1554,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,131.76,443.44
"Incis/Drain Scrotum/Testis,Epididym",PX54700P,CDM,983,RC,54700,CPT,,,,,,,,440,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,197.1554,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,131.76,443.44
Bile Acids Total,PX8223990,CDM,300,RC,82239,CPT,90,,,,,,,232,,First Health,Commercial,both,85,,999999999,percent of total billed charges,197.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,227.36
8MM ENDOWRIST INSTRUMENTS TIP-UP FENESTRATED GRASPER,27200000,CDM,272,RC,,,,11911-MAIN,LOCAL,,,,,411,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,197.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM ENDOWRIST INSTRUMENTS TIP-UP FENESTRATED GRASPER,27200000,CDM,272,RC,,,,11911-MAIN,LOCAL,,,,,411,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,197.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Bone Marrow Aspiration and Biopsy,PXG0364F,CDM,510,RC,G0364,HCPCS,,,,,,,,411,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,197.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,170.7294,402.78
Bone Marrow Aspiration and Biopsy,PXG0364F,CDM,510,RC,G0364,HCPCS,,,,,,,,411,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,197.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,170.7294,402.78
albumin human 25% 25 % Solution 50 mL Flex Cont,P9047,CDM,636,RC,P9047,HCPCS,,,,944049301,NDC,50,ML,402.67,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,197.3083,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.66,394.6166
albumin human 25% 25 % Solution 50 mL Flex Cont,P9047,CDM,636,RC,P9047,HCPCS,,,,944049301,NDC,50,ML,402.67,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,197.3083,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.66,394.6166
albumin human 25% 25 % Solution 50 mL Flex Cont,P9047,CDM,636,RC,P9047,HCPCS,,,,944049301,NDC,50,ML,402.67,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,197.3083,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.66,394.6166
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070110,NDC,1,ML,459.95,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,197.31855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.92,450.751
Apc Resistance Assay - Ref,PX8530790,CDM,300,RC,85307,CPT,90,,,,,,,390,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,197.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.05,382.2
"Closed Rx Toe Fx,Manipulatn",PX28515F,CDM,510,RC,28515,CPT,,,,,,,,390,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,197.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,162.006,382.2
"DXA, Bone Density Study, Radius/Wrist/Heel",PX7708101,CDM,320,RC,77081,CPT,TC,,,,,,,460,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,197.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,450.8
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623P,CDM,983,RC,11623,CPT,,,,,,,,460,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,197.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,191.084,1416.38
"Transvaginal US, Obstetric",PX7681701,CDM,402,RC,76817,CPT,TC,,,,,,,460,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,197.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,450.8
Trg Gene Rearrangement Anal - Ref,PX8134290,CDM,300,RC,81342,CPT,90,,,,,,,516,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,197.3535,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,195.46,201.5
Dress/Debrid Large Burn No Anesth,PX16030F,CDM,510,RC,16030,CPT,,,,,,,,399,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,197.505,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,165.7446,391.02
"X-Ray Exam Hip,Bilat W/Pelvis 2 Vws",PX7352101,CDM,320,RC,73521,CPT,TC,,,,,,,399,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,197.505,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,391.02
Xray Lumbosacral 2 or 3 Vws,PX7210001,CDM,320,RC,72100,CPT,TC,,,,,,,399,,Humana Choice Care,All Medicare plans,outpatient,49.5,,104.2233333,percent of total billed charges,197.505,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,391.02
Body Fluid Cell Count W Diff,PX89051,CDM,300,RC,89051,CPT,,,,,,,,224,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,197.568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.13,219.52
Emergency Level I Visit,PX99281P,CDM,981,RC,99281,CPT,,,,,,,,224,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,197.568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.56,218.0192
ENDOWRIST INSTRUMENTS PERMANENT CAUTERY HOOK 8MM,27200000,CDM,272,RC,,,,12050-MAIN,LOCAL,,,,,224,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,197.568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Helicobacter Pylori Ab,PX86677,CDM,300,RC,86677,CPT,,,,,,,,224,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,197.568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.45,219.52
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU000390,CDM,300,RC,U0003,HCPCS,90,,,,,,,222,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,197.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.2188,217.56
Nfct Ds Bct/Vir Respir Dna/Rna 22 Trgt Sarscov2,PX0202U,CDM,300,RC,0202U,HCPCS,,,,,,,,222,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,197.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.2188,382.15
Observation Care Discharge,PX99217,CDM,982,RC,99217,CPT,,,,,,,,222,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,197.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.2188,216.0726
Procalcitonin,PX84145,CDM,300,RC,84145,CPT,,,,,,,,217,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,197.687,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.96,212.66
TRAY 8 FR 5IN CENTESIS WITH TURKEL  30-CE1CO,120.303,CDM,272,RC,,,,11503-MAIN,LOCAL,,,,,217,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,197.687,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,90.1418,212.66
baricitinib 2 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,2418230,NDC,0.5,EA,203.12,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,197.696696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone sodium succinate (preservative free) 1000 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9000501,NDC,1,EA,403.54,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,197.7346,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
hydrocortisone sodium succinate (preservative free) 1000 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9000501,NDC,1,EA,403.54,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,197.7346,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
hydrocortisone sodium succinate (preservative free) 1000 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9000501,NDC,1,EA,403.54,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,197.7346,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
pyRIDostigmine bromide 10 MG/2ML Solution 2 mL Ampule,25000000,CDM,250,RC,,,,,,781304095,NDC,2,ML,203.16,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,197.735628,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081543,NDC,1,ML,479.89,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,197.744,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.83,197.744
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081543,NDC,1,ML,479.89,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,197.744,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.83,197.744
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081552,NDC,1,ML,479.89,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,197.744,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.83,197.744
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081552,NDC,1,ML,479.89,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,197.744,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.83,197.744
"Initial Observation Care,Levl III",PX99220,CDM,982,RC,99220,CPT,,,,,,,,461,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,197.769,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,191.4994,448.6913
Repr Superf Wnd Face <2.5cm,PX12011P,CDM,983,RC,12011,CPT,,,,,,,,461,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,197.769,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,448.6913
"Initial Observation Care,Levl II",PX99219,CDM,982,RC,99219,CPT,,,,,,,,391,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,197.846,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,162.4214,380.5603
Layr Clos Wnd Rest Body 2.6-7.5,PX12042F,CDM,510,RC,12042,CPT,,,,,,,,404,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,197.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,395.92
Layr Clos Wnd Rest Body 2.6-7.5,PX12042F,CDM,510,RC,12042,CPT,,,,,,,,404,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,197.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,395.92
Layr Clos Wnd Rest Body 2.6-7.5,PX12042F,CDM,510,RC,12042,CPT,,,,,,,,404,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,197.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,395.92
Neg Pressure Wound Therapy Dme >50 Sq Cm,PX97606F,CDM,761,RC,97606,CPT,,,,,,,,404,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,197.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,395.92
Neg Pressure Wound Therapy Dme >50 Sq Cm,PX97606F,CDM,761,RC,97606,CPT,,,,,,,,404,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,197.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,395.92
Neg Pressure Wound Therapy Dme >50 Sq Cm,PX97606F,CDM,761,RC,97606,CPT,,,,,,,,404,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,197.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,395.92
Remove Foreign Body Simple,PX10120F,CDM,510,RC,10120,CPT,,,,,,,,404,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,197.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,395.92
Remove Foreign Body Simple,PX10120F,CDM,510,RC,10120,CPT,,,,,,,,404,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,197.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,395.92
Remove Foreign Body Simple,PX10120F,CDM,510,RC,10120,CPT,,,,,,,,404,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,197.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,395.92
Remove Foreign Body Simple,PX10120P,CDM,983,RC,10120,CPT,,,,,,,,404,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,197.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,393.2132
Remove Foreign Body Simple,PX10120P,CDM,983,RC,10120,CPT,,,,,,,,404,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,197.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,393.2132
Remove Foreign Body Simple,PX10120P,CDM,983,RC,10120,CPT,,,,,,,,404,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,197.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,393.2132
Xray Foot Minimum 3 Vws,PX7363001,CDM,320,RC,73630,CPT,TC,,,,,,,404,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,127.5492308,percent of total billed charges,197.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,395.92
Xray Foot Minimum 3 Vws,PX7363001,CDM,320,RC,73630,CPT,TC,,,,,,,404,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,197.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,395.92
Xray Foot Minimum 3 Vws,PX7363001,CDM,320,RC,73630,CPT,TC,,,,,,,404,,United Healthcare,All Medicare advantage plans,outpatient,49,,207.76,percent of total billed charges,197.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,395.92
Xray Knee 3 Vws,PX7356201,CDM,320,RC,73562,CPT,TC,,,,,,,404,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,129.6476923,percent of total billed charges,197.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,395.92
Xray Knee 3 Vws,PX7356201,CDM,320,RC,73562,CPT,TC,,,,,,,404,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,197.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,395.92
Xray Knee 3 Vws,PX7356201,CDM,320,RC,73562,CPT,TC,,,,,,,404,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,197.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,395.92
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12173-MAIN,LOCAL,,,,,400,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,198,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Lvl 1 Init Hosp Low Mdm or 40 Minutes,PX99221,CDM,982,RC,99221,CPT,,,,,,,,400,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,198,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.16,389.32
TRAY GROSHONG 4FR SAFETY PICC 7617407,120.26,CDM,272,RC,,,,500-MAIN,LOCAL,,,,,233,,First Health,Commercial,both,85,,999999999,percent of total billed charges,198.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.7882,228.34
tiotropium bromide monohydrate 2.5 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597010051,NDC,4,GR,461.7,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,198.0693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tiotropium bromide-olodaterol 2.5-2.5 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597015570,NDC,4,GR,461.7,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,198.0693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"MRI,Lwrext,Jnt W/O+W/Cont",PX7372301,CDM,610,RC,73723,CPT,TC,,,,,,,1850,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,198.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,198.08,583.77
"MRI,Lwrext,Jnt W/O+W/Cont",PX7372301,CDM,610,RC,73723,CPT,TC,,,,,,,1850,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,198.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,198.08,583.77
gemcitabine 1 GM/26.3ML Solution 26.3 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018101,NDC,26.3,ML,203.58,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,198.144414,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
"CT Angiography, Neck",PX7049801,CDM,350,RC,70498,CPT,TC,,,,,,,3690,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,198.2288,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.11,396.41
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084243,NDC,0.5,ML,202.42,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,198.3716,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.085268,203.497
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021588,NDC,0.5,ML,203.87,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,198.426671,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.779496,199.7926
Layr Clos Wnd Rest Body 7.6-12.5,PX12044F,CDM,510,RC,12044,CPT,,,,,,,,785,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,198.4398,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,133.06,796.26
Layr Clos Wnd Rest Body 7.6-12.5,PX12044P,CDM,983,RC,12044,CPT,,,,,,,,523,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,198.4398,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,133.06,796.26
"Cytoflo, Cell or Dna Anal - Ref",PX8818290,CDM,310,RC,88182,CPT,90,,,,,,,225,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,198.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,220.5
Diagnostic Anoscopy,PX46600P,CDM,983,RC,46600,CPT,,,,,,,,405,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,198.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,394.1865
Diagnostic Anoscopy,PX46600P,CDM,983,RC,46600,CPT,,,,,,,,405,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,198.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,394.1865
Diagnostic Anoscopy,PX46600P,CDM,983,RC,46600,CPT,,,,,,,,405,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,198.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,394.1865
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153F,CDM,370,RC,99153,CPT,,,,,,,,225,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,198.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.465,220.5
"Apply Finger Splint,Static",PX29130P,CDM,983,RC,29130,CPT,,,,,,,,223,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,198.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,217.0459
"Apply Forearm Splint,Static",PX29125F,CDM,510,RC,29125,CPT,,,,,,,,223,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,198.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,218.54
"Flow Cyto, Tech, 1st Mrkr - Ref",PX8818490,CDM,310,RC,88184,CPT,90,,,,,,,223,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,198.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,314.02
"Nephelometry, Each, Nos - Ref",PX8388390,CDM,300,RC,83883,CPT,90,,,,,,,223,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,198.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.47,218.54
Reduce Temporomandibl Disloc,PX21480P,CDM,983,RC,21480,CPT,,,,,,,,223,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,198.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,217.0459
"Calprotectin, Fecal - Ref",PX8399390,CDM,300,RC,83993,CPT,90,,,,,,,401,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,198.495,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18,392.98
Excis Forearm/Wrist Tumor Subcutan,PX25075F,CDM,510,RC,25075,CPT,,,,,,,,1421,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,198.51,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,198.51,1082.67
Excis Forearm/Wrist Tumor Subcutan,PX25075P,CDM,983,RC,25075,CPT,,,,,,,,607,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,198.51,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,198.51,1082.67
"CT Angiography, Head",PX7049601,CDM,350,RC,70496,CPT,TC,,,,,,,3690,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,198.5506,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.11,397.07
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106P,CDM,983,RC,11106,CPT,,,,,,,,204,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,198.5532,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.7416,548.67
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781315972,NDC,1,EA,217.96,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,198.56156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86,213.6008
albuterol (5 MG/ML) 0.5% Nebulization Solution 20 mL Bottle,J7611.01,CDM,250,RC,,,,,,50383074120,NDC,20,ML,225.2,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,198.6264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.54808,220.696
X-Ray Exam Entire Spine 1vw,PX7208101,CDM,320,RC,72081,CPT,TC,,,,,,,414,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,198.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,405.72
X-Ray Exam Entire Spine 1vw,PX7208101,CDM,320,RC,72081,CPT,TC,,,,,,,414,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,198.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,405.72
rifAXIMin 550 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,65649030302,NDC,1,EA,218.25,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,198.82575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rifAXIMin 550 MG Tablet 60 Each Box,63700001,CDM,250,RC,,,,,,65649030303,NDC,1,EA,218.25,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,198.82575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
6 SHOOTER SAEED MULTIBAND LIGATOR,27200000,CDM,272,RC,,,,12379-MAIN,LOCAL,,,,,393,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,198.858,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA FIRST MET TRANSLATOR STERILE MICA,27200000,CDM,272,RC,,,,12445-MAIN,LOCAL,,,,,393,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,198.858,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Tap Block Bilateral by Injection(S),PX64488F,CDM,510,RC,64488,CPT,,,,,,,,393,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,198.858,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,163.2522,385.14
CANNULA FOR INJECTION 1.8MM WITH 3MM LUER CONNECTION 8383.65,27200000,CDM,272,RC,,,,12004-MAIN,LOCAL,,,,,234,,First Health,Commercial,both,85,,999999999,percent of total billed charges,198.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Fibrinogen,PX7426,CDM,300,RC,85384,CPT,,,,,,,,234,,First Health,Commercial,both,85,,999999999,percent of total billed charges,198.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.91,229.32
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598F,CDM,510,RC,97598,CPT,,,,,,,,406,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,198.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,168.6524,397.88
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598F,CDM,510,RC,97598,CPT,,,,,,,,406,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,198.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,168.6524,397.88
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598F,CDM,510,RC,97598,CPT,,,,,,,,406,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,198.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,168.6524,397.88
"MRI,Uprext Jnt W/O+W/Cont",PX7322301,CDM,610,RC,73223,CPT,TC,,,,,,,2681,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,198.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,198.95,586.4
"MRI,Uprext Jnt W/O+W/Cont",PX7322301,CDM,610,RC,73223,CPT,TC,,,,,,,2681,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,198.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,198.95,586.4
pembrolizumab 100 MG/4ML Solution 4 mL Vial,J9271.01,CDM,636,RC,J9271,HCPCS,,,,6302602,NDC,4,ML,9627.58,,Blue Cross Blue Shield of MN,All commercial plans,both,,,96.14235,fee schedule,198.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.57,9435.0284
"Cardioversion, Elective;Extern",PX92960F,CDM,480,RC,92960,CPT,,,,,,,,402,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,198.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.9908,568.57
Chem Cautery Granulatn Tissue,PX17250P,CDM,983,RC,17250,CPT,,,,,,,,402,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,198.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.9908,391.2666
Lab Imm Spin X-Match,PX8837,CDM,300,RC,86920,CPT,,,,,,,,402,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,198.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.22,393.96
"Morphometric Analysis, in Situ Hybridization, Each Probe; Manual, Tech",PX8836801,CDM,310,RC,88368,CPT,TC,,,,,,,402,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,198.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.9908,393.96
"Hospital Inpt or Obs Care, Admin/Disch Same Date Straightforward or Low Level Mdm >= 45 Minutes",PX99234,CDM,982,RC,99234,CPT,,,,,,,,464,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,199.056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.7456,451.6112
Naso/Orogastric Tube,PX43752F,CDM,510,RC,43752,CPT,,,,,,,,464,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,199.056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.7456,454.72
baricitinib 2 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,2418230,NDC,0.5,EA,203.12,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,199.0576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rho d immune globulin human 1500 units solution prefilled syringe 1 Each Syringe,J2790.01,CDM,636,RC,J2790,HCPCS,,,,562780500,NDC,1,EA,464.01,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,199.06029,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.749754,454.7298
pyRIDostigmine bromide 10 MG/2ML Solution 2 mL Ampule,25000000,CDM,250,RC,,,,,,781304095,NDC,2,ML,203.16,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,199.0968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Closed Rx Bimalleolar Fx,PX27808F,CDM,510,RC,27808,CPT,,,,,,,,650,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,199.17,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.17,727.77
Closed Rx Bimalleolar Fx,PX27808P,CDM,983,RC,27808,CPT,,,,,,,,433,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,199.17,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.17,727.77
"US Complete Joint, Realtime W/ Img Tc",PX7688101,CDM,402,RC,76881,CPT,TC,,,,,,,415,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,199.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,406.7
"US Complete Joint, Realtime W/ Img Tc",PX7688101,CDM,402,RC,76881,CPT,TC,,,,,,,415,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,199.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,406.7
"Closed Rx I-P Jt,Toe Dislocation",PX28660F,CDM,510,RC,28660,CPT,,,,,,,,335,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,199.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.24,267.03
"Closed Rx I-P Jt,Toe Dislocation",PX28660P,CDM,983,RC,28660,CPT,,,,,,,,628,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,199.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.24,615.44
Debride Bone Ea Add 20 Sqcm,PX11047F,CDM,510,RC,11047,CPT,,,,,,,,438,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,199.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.59,250.43
Debride Bone Ea Add 20 Sqcm,PX11047P,CDM,983,RC,11047,CPT,,,,,,,,351,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,199.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.59,343.98
albumin human 25% 25 % Solution 50 mL Flex Cont,P9047,CDM,636,RC,P9047,HCPCS,,,,944049301,NDC,50,ML,402.67,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,199.32165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.66,394.6166
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081543,NDC,1,ML,479.89,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,199.346306,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.346306,470.2922
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081552,NDC,1,ML,479.89,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,199.346306,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.346306,470.2922
Body Fluid Cell Count W Diff,PX89051,CDM,300,RC,89051,CPT,,,,,,,,224,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,199.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.13,219.52
Emergency Level I Visit,PX99281P,CDM,981,RC,99281,CPT,,,,,,,,224,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,199.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.56,218.0192
ENDOWRIST INSTRUMENTS PERMANENT CAUTERY HOOK 8MM,27200000,CDM,272,RC,,,,12050-MAIN,LOCAL,,,,,224,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,199.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Helicobacter Pylori Ab,PX86677,CDM,300,RC,86677,CPT,,,,,,,,224,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,199.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.45,219.52
Egd Balloon Dil Esoph30 Mm/>,PX43233P,CDM,983,RC,43233,CPT,,,,,,,,480,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,199.392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.392,1662.33
"Sigmoidoscopy,Diagnostic",PX45330P,CDM,983,RC,45330,CPT,,,,,,,,480,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,199.392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.392,798.45
Drainage of Hematoma/Fluid (P),PX10140P,CDM,983,RC,10140,CPT,,,,,,,,465,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,199.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,193.161,1416.38
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102P,CDM,983,RC,11102,CPT,,,,,,,,465,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,199.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,452.5845
gemcitabine 1 GM/26.3ML Solution 26.3 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018101,NDC,26.3,ML,203.58,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,199.5084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
CANNULATED AO HANDLE STERILE MICA SCREW SYSTEM 57S1HNDL,27200000,CDM,272,RC,,,,12446-MAIN,LOCAL,,,,,219,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,199.509,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TUBE SURGICAL IRRIGATION 1PK PD-IT,27200000,CDM,272,RC,,,,12433-MAIN,LOCAL,,,,,219,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,199.509,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
dantrolene 20 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,42023012306,NDC,1,EA,394.42,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,199.57652,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
rabies immune globulin 300 UNIT/2ML Solution 2 mL Vial,90377,CDM,636,RC,90376,CPT,,,,49281019020,NDC,2,ML,3384.84,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,199.58,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.58,479.72
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Suspension 10 mL Bottle,63700001,CDM,250,RC,,,,,,24208063562,NDC,10,ML,415.81,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,199.5888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Suspension 10 mL Bottle,63700001,CDM,250,RC,,,,,,24208063562,NDC,10,ML,415.81,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,199.5888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,43598054910,NDC,100,ML,205.14,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1.094496241,percent of total billed charges,199.662762,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
US Head/Neck Tc,PX7653601,CDM,402,RC,76536,CPT,TC,,,,,,,416,,Health Partners,Health Partners Care Plans,both,48,,377.04,percent of total billed charges,199.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,407.68
US Head/Neck Tc,PX7653601,CDM,402,RC,76536,CPT,TC,,,,,,,416,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,199.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,407.68
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152F,CDM,370,RC,99152,CPT,,,,,,,,235,,First Health,Commercial,both,85,,999999999,percent of total billed charges,199.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97.619,230.3
Occupational Therapy Eval Low Complex,PX97165,CDM,434,RC,97165,CPT,,,,,,,,235,,First Health,Commercial,both,85,,999999999,percent of total billed charges,199.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,230.3
Physical Therapy Evaluation Low Complex,PX97161,CDM,424,RC,97161,CPT,,,,,,,,235,,First Health,Commercial,both,85,,999999999,percent of total billed charges,199.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,392.7
Remv Ext Canal Foreign Body,PX69200F,CDM,510,RC,69200,CPT,,,,,,,,235,,First Health,Commercial,both,85,,999999999,percent of total billed charges,199.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97.619,230.3
"Vitamin D, 25 Hydroxy",PX82306,CDM,300,RC,82306,CPT,,,,,,,,235,,First Health,Commercial,both,85,,999999999,percent of total billed charges,199.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.14,230.3
hydrocortisone sodium succinate (preservative free) 1000 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9000501,NDC,1,EA,403.54,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,199.7523,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
gentamicin 0.3 % Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,17478028435,NDC,3.5,GR,219.3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,199.7823,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021588,NDC,0.5,ML,203.87,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,199.7926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.779496,199.7926
Drainage of Gum Lesion,PX41800F,CDM,510,RC,41800,CPT,,,,,,,,395,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,199.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,387.1
"Exc Skn Malig1.1-2cm Fce,Facal",PX11642P,CDM,983,RC,11642,CPT,,,,,,,,466,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,199.914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,193.5764,614.65
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106P,CDM,983,RC,11106,CPT,,,,,,,,204,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,199.92,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.68,323.07
Resp Virus 6-11 Targets,PX87632,CDM,300,RC,87632,CPT,,,,,,,,428,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,199.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,177.7912,419.44
Art Lower Extremity-Bilat,PX9392501,CDM,921,RC,93925,CPT,TC,,,,,,,1188,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,199.973,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,134.82,354.84
Layr Clos Wnd Rest Body 2.6-7.5,PX12042F,CDM,510,RC,12042,CPT,,,,,,,,404,,Humana Choice Care,All Medicare plans,outpatient,49.5,,0.005,percent of total billed charges,199.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,395.92
Neg Pressure Wound Therapy Dme >50 Sq Cm,PX97606F,CDM,761,RC,97606,CPT,,,,,,,,404,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,199.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,395.92
Remove Foreign Body Simple,PX10120F,CDM,510,RC,10120,CPT,,,,,,,,404,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,199.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,395.92
Remove Foreign Body Simple,PX10120P,CDM,983,RC,10120,CPT,,,,,,,,404,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,199.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,393.2132
Xray Foot Minimum 3 Vws,PX7363001,CDM,320,RC,73630,CPT,TC,,,,,,,404,,Humana Choice Care,All Medicare plans,outpatient,49.5,,109.0788889,percent of total billed charges,199.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,395.92
Xray Knee 3 Vws,PX7356201,CDM,320,RC,73562,CPT,TC,,,,,,,404,,Humana Choice Care,All Medicare plans,outpatient,49.5,,14.56111111,percent of total billed charges,199.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,395.92
"Level V - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3939,CDM,310,RC,88307,CPT,TC,,,,,,,252,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,200.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,200.06,341.216
"Level V - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3939,CDM,310,RC,88307,CPT,TC,,,,,,,252,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,200.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,200.06,341.216
NON-LOCKING SCREW 3.5X18MM,C1713,CDM,278,RC,C1713,HCPCS,,12466-MAIN,LOCAL,,,,,395.51,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,200.12806,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Xray Ribs Bilat 3 Vws With Pa Chest,PX7111101,CDM,320,RC,71111,CPT,TC,,,,,,,417,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,200.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,408.66
Xray Ribs Bilat 3 Vws With Pa Chest,PX7111101,CDM,320,RC,71111,CPT,TC,,,,,,,417,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,200.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,408.66
agalsidase beta 5 MG Recon Soln 1 Each Vial,J0180.01,CDM,636,RC,J0180,HCPCS,,,,58468004101,NDC,1,EA,1717.68,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,200.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,200.2,1683.3264
SET SP TUBE INTRODUCER  14CM 8-14FR G15469,120.377,CDM,272,RC,,,,7147-MAIN,LOCAL,,,,,227,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,200.214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.2958,222.46
Sp Stn for Inclusn Bodies - Ref,PX8720790,CDM,300,RC,87207,CPT,90,,,,,,,227,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,200.214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.49,222.46
"Cytoflo, Cell or Dna Anal - Ref",PX8818290,CDM,310,RC,88182,CPT,90,,,,,,,225,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,200.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,220.5
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153F,CDM,370,RC,99153,CPT,,,,,,,,225,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,200.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.465,220.5
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725F,CDM,510,RC,26725,CPT,,,,,,,,495,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,200.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,196.55,740.92
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725F,CDM,510,RC,26725,CPT,,,,,,,,495,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,200.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,196.55,740.92
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725P,CDM,983,RC,26725,CPT,,,,,,,,330,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,200.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,196.55,740.92
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725P,CDM,983,RC,26725,CPT,,,,,,,,330,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,200.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,196.55,740.92
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,63323027301,NDC,0.5,ML,235.6,,First Health,Commercial,both,85,,999999999,percent of total billed charges,200.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
"Off/Outpt Visit,New,Levl III",PX99203P,CDM,983,RC,99203,CPT,,,,,,,,252,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,200.33,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.07,246.96
"Office/Outpt Visit,New,Levl III",PX99203F,CDM,510,RC,99203,CPT,,,,,,,,252,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,200.33,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.07,200.33
Comprehensive Metabolic Panel,PX80053,CDM,300,RC,80053,CPT,,,,,,,,396,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,200.376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.68,388.08
Neg Pressure Wound Therapy Dme </=50 Sq Cm,PX97605F,CDM,510,RC,97605,CPT,,,,,,,,396,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,200.376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,164.4984,388.08
NON-LOCKING SCREW 3.5X12MM,27200000,CDM,278,RC,C1713,HCPCS,,11857-MAIN,LOCAL,,,,,396,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,200.376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NON-LOCKING SCREW 3.5X16MM,27200000,CDM,278,RC,C1713,HCPCS,,11856-MAIN,LOCAL,,,,,396,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,200.376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NON-LOCKING SCREW 3.5X24MM,27200000,CDM,278,RC,C1713,HCPCS,,11855-MAIN,LOCAL,,,,,396,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,200.376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Surgical Diagnostic Exam, Anorectal",PX45990P,CDM,983,RC,45990,CPT,,,,,,,,409,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,200.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,169.8986,2452.93
"Surgical Diagnostic Exam, Anorectal",PX45990P,CDM,983,RC,45990,CPT,,,,,,,,409,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,200.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,169.8986,2452.93
"Surgical Diagnostic Exam, Anorectal",PX45990P,CDM,983,RC,45990,CPT,,,,,,,,409,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,200.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,169.8986,2452.93
Hepatitis a Igm Antibody,PX86709,CDM,300,RC,86709,CPT,,,,,,,,220,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,200.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.32,215.6
"Hiv-1, Quantification - Ref",PX8753690,CDM,300,RC,87536,CPT,90,,,,,,,220,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,200.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.03,215.6
Immunoassay Nos - Ref,PX8352090,CDM,300,RC,83520,CPT,90,,,,,,,220,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,200.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.83,215.6
Leptospira Antibody - Ref,PX8672090,CDM,300,RC,86720,CPT,90,,,,,,,220,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,200.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.85,215.6
albuterol (5 MG/ML) 0.5% Nebulization Solution 20 mL Bottle,J7611.01,CDM,250,RC,,,,,,50383074120,NDC,20,ML,225.2,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,200.428,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.54808,220.696
Diagnostic Anoscopy,PX46600P,CDM,983,RC,46600,CPT,,,,,,,,405,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,200.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,394.1865
"Biopsy Vulva/Perineum,One Lesn",PX56605F,CDM,510,RC,56605,CPT,,,,,,,,236,,First Health,Commercial,both,85,,999999999,percent of total billed charges,200.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.0344,702.31
Lab Basic Metabolic Panel,PX80048,CDM,300,RC,80048,CPT,,,,,,,,236,,First Health,Commercial,both,85,,999999999,percent of total billed charges,200.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.76,231.28
Closed Rx Kneecap Dislocatn,PX27560F,CDM,510,RC,27560,CPT,,,,,,,,468,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,200.772,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,194.4072,458.64
"POS Airway Pressure, Bipap",PX94660.01F,CDM,410,RC,94660,CPT,,,,,,,,468,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,200.772,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.33,458.64
Vedolizumab - Ref,PX8028090,CDM,300,RC,80280,CPT,90,,,,,,,468,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,200.772,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.36,458.64
"CT Angiography, Chest",PX7127501,CDM,350,RC,71275,CPT,TC,,,,,,,3689,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,200.8032,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.11,401.67
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614900,NDC,1,EA,409.89,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,9.983703704,percent of total billed charges,200.8461,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614900,NDC,1,EA,409.89,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,200.8461,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614900,NDC,1,EA,409.89,,United Healthcare,All Medicare advantage plans,outpatient,49,,3.9675,percent of total billed charges,200.8461,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
"Lab Antibody ID,RBC",PX86870,CDM,300,RC,,,,,,,,,,410,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,200.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,170.314,401.8
"Lab Antibody ID,RBC",PX86870,CDM,300,RC,,,,,,,,,,410,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,200.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,170.314,401.8
"Lab Antibody ID,RBC",PX86870,CDM,300,RC,,,,,,,,,,410,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,200.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,170.314,401.8
"Supply Technicium Sestamibi,per Dose",PXA9500,CDM,343,RC,A9500,HCPCS,,,,,,,,410,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,191.5175,percent of total billed charges,200.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,170.314,401.8
"Supply Technicium Sestamibi,per Dose",PXA9500,CDM,343,RC,A9500,HCPCS,,,,,,,,410,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,200.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,170.314,401.8
"Supply Technicium Sestamibi,per Dose",PXA9500,CDM,343,RC,A9500,HCPCS,,,,,,,,410,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,200.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,170.314,401.8
Excis Forearm/Wrist Tumor Subcutan,PX25075F,CDM,510,RC,25075,CPT,,,,,,,,1421,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,200.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,198.51,1082.67
Excis Forearm/Wrist Tumor Subcutan,PX25075F,CDM,510,RC,25075,CPT,,,,,,,,1421,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,200.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,198.51,1082.67
Excis Forearm/Wrist Tumor Subcutan,PX25075P,CDM,983,RC,25075,CPT,,,,,,,,607,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,200.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,198.51,1082.67
Excis Forearm/Wrist Tumor Subcutan,PX25075P,CDM,983,RC,25075,CPT,,,,,,,,607,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,200.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,198.51,1082.67
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561F,CDM,510,RC,36561,CPT,,,,,,,,2604,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,200.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,200.91,1988.23
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561F,CDM,510,RC,36561,CPT,,,,,,,,2604,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,200.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,200.91,1988.23
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561P,CDM,983,RC,36561,CPT,,,,,,,,1736,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,200.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,200.91,1988.23
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561P,CDM,983,RC,36561,CPT,,,,,,,,1736,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,200.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,200.91,1988.23
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598F,CDM,510,RC,97598,CPT,,,,,,,,406,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,200.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,168.6524,397.88
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,43598054910,NDC,100,ML,205.14,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,201.0372,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
"Fac/Ex Skinbngn0.6-1cmtrnk,Arm,Lg",PX11401F,CDM,510,RC,11401,CPT,,,,,,,,484,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,201.0536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.0536,474.32
"Fac/Exc Skn Benig<5mm Face,Facial",PX11440F,CDM,510,RC,11440,CPT,,,,,,,,484,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,201.0536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.0536,614.65
"Facility Critical Care, Addl 30 Min",PX99292F,CDM,510,RC,99292,CPT,,,,,,,,484,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,201.0536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.0536,474.32
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320990,NDC,1,EA,410.32,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,9.983703704,percent of total billed charges,201.0568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320990,NDC,1,EA,410.32,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,201.0568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320990,NDC,1,EA,410.32,,United Healthcare,All Medicare advantage plans,outpatient,49,,3.9675,percent of total billed charges,201.0568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320995,NDC,1,EA,410.32,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,9.983703704,percent of total billed charges,201.0568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320995,NDC,1,EA,410.32,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,201.0568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320995,NDC,1,EA,410.32,,United Healthcare,All Medicare advantage plans,outpatient,49,,3.9675,percent of total billed charges,201.0568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
OXALiplatin 50 MG/10ML Solution 10 mL Vial,J9263.01,CDM,636,RC,J9263,HCPCS,,,,955173110,NDC,10,ML,228,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,201.096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.7112,223.44
TRAY PNEUMOTHORAX 14FR 29CM 19 CATHETER SIDEPORTS G56537,120.496,CDM,272,RC,,,,11677-MAIN,LOCAL,,,,,419,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,201.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.0526,410.62
TRAY PNEUMOTHORAX 14FR 29CM 19 CATHETER SIDEPORTS G56537,120.496,CDM,272,RC,,,,11677-MAIN,LOCAL,,,,,419,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,201.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.0526,410.62
CT Abdomen W/O & W/Dye,PX7417001,CDM,350,RC,74170,CPT,TC,,,,,,,3689,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,201.125,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.11,401.67
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494301,NDC,0.5,ML,419.2,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,201.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.38,410.8454
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494301,NDC,0.5,ML,419.2,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,201.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.38,410.8454
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494300,NDC,0.5,ML,419.23,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,201.2304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.38,410.8454
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494300,NDC,0.5,ML,419.23,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,201.2304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.38,410.8454
"Biopsy Vulva/Perineum,One Lesn",PX56605F,CDM,510,RC,56605,CPT,,,,,,,,236,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,201.31,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.99,201.31
"Biopsy Vulva/Perineum,One Lesn",PX56605P,CDM,983,RC,56605,CPT,,,,,,,,142,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,201.31,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.99,201.31
Puncture Drainage of Lesion,PX10160F,CDM,510,RC,10160,CPT,,,,,,,,279,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,201.31,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.86,270.49
Puncture Drainage of Lesion,PX10160P,CDM,983,RC,10160,CPT,,,,,,,,186,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,201.31,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.86,270.49
Remove Impacted Ear Wax,PX69210P,CDM,983,RC,69210,CPT,,,,,,,,221,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,201.331,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.44,215.0993
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,409277602,NDC,200,ML,228.28,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,201.34296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.827512,225.8704
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561F,CDM,510,RC,36561,CPT,,,,,,,,2604,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,201.35,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,200.91,1988.23
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561P,CDM,983,RC,36561,CPT,,,,,,,,1736,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,201.35,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,200.91,1988.23
"MRI,Lwrext,Jnt W/O+W/Cont",PX7372301,CDM,610,RC,73723,CPT,TC,,,,,,,1850,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,201.35,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,198.08,583.77
Chrom Anal 15-20 Cells - Ref,PX8826290,CDM,310,RC,88262,CPT,90,,,,,,,398,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,201.388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.06,390.04
8MM ENDOWRIST INSTRUMENTS TIP-UP FENESTRATED GRASPER,27200000,CDM,272,RC,,,,11911-MAIN,LOCAL,,,,,411,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,201.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM ENDOWRIST INSTRUMENTS TIP-UP FENESTRATED GRASPER,27200000,CDM,272,RC,,,,11911-MAIN,LOCAL,,,,,411,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,201.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM ENDOWRIST INSTRUMENTS TIP-UP FENESTRATED GRASPER,27200000,CDM,272,RC,,,,11911-MAIN,LOCAL,,,,,411,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,201.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Bone Marrow Aspiration and Biopsy,PXG0364F,CDM,510,RC,G0364,HCPCS,,,,,,,,411,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,201.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,170.7294,402.78
Bone Marrow Aspiration and Biopsy,PXG0364F,CDM,510,RC,G0364,HCPCS,,,,,,,,411,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,201.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,170.7294,402.78
Bone Marrow Aspiration and Biopsy,PXG0364F,CDM,510,RC,G0364,HCPCS,,,,,,,,411,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,201.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,170.7294,402.78
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041105,NDC,1,ML,419.67,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,201.4416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.808876,411.2766
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041105,NDC,1,ML,419.67,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,201.4416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.808876,411.2766
Exc Skn Beni 0.6-1cm Fcefacial,PX11441P,CDM,983,RC,11441,CPT,,,,,,,,485,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,201.469,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.469,614.65
"Drain Finger Abscess,Simple",PX26010P,CDM,983,RC,26010,CPT,,,,,,,,207,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,201.4731,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.9878,201.4731
Trg Gene Rearrangement Anal - Ref,PX8134290,CDM,300,RC,81342,CPT,90,,,,,,,516,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,201.5,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,195.46,201.5
"Office Consultation,Level III",PX99243P,CDM,983,RC,99243,CPT,,,,,,,,374,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,201.53,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.65,366.52
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,548590000,NDC,1,EA,470.19,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,201.71151,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,179.012476,460.7862
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545P,CDM,983,RC,23545,CPT,,,,,,,,412,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,201.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,171.1448,400.9996
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545P,CDM,983,RC,23545,CPT,,,,,,,,412,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,201.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,171.1448,400.9996
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545P,CDM,983,RC,23545,CPT,,,,,,,,412,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,201.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,171.1448,400.9996
"Closed Rx Big Toe Fx,Manip",PX28495P,CDM,983,RC,28495,CPT,,,,,,,,412,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,201.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,171.1448,400.9996
"Closed Rx Big Toe Fx,Manip",PX28495P,CDM,983,RC,28495,CPT,,,,,,,,412,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,201.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,171.1448,400.9996
"Closed Rx Big Toe Fx,Manip",PX28495P,CDM,983,RC,28495,CPT,,,,,,,,412,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,201.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,171.1448,400.9996
ARTISTA AH 3GRAM ABSORBABLE HEMOSTATIC PARTICLES,27200000,CDM,272,RC,A6199,HCPCS,,10227-MAIN,LOCAL,,,,,486,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,201.8844,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002P,CDM,983,RC,12002,CPT,,,,,,,,486,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,201.8844,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,473.0238
Xray Sinuses Less Than 3 Vws,PX7021001,CDM,320,RC,70210,CPT,TC,,,,,,,486,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,201.8844,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,476.28
Dress/Debrid Large Burn No Anesth,PX16030F,CDM,510,RC,16030,CPT,,,,,,,,399,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,201.894,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,165.7446,391.02
"X-Ray Exam Hip,Bilat W/Pelvis 2 Vws",PX7352101,CDM,320,RC,73521,CPT,TC,,,,,,,399,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,201.894,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,391.02
Xray Lumbosacral 2 or 3 Vws,PX7210001,CDM,320,RC,72100,CPT,TC,,,,,,,399,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,201.894,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,391.02
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,23155052431,NDC,10,ML,486.06,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,201.909324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,23155052441,NDC,10,ML,486.06,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,201.909324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
patiromer sorbitex calcium 8.4 g Packet 4 Each Box,63700001,CDM,250,RC,,,,,,53436008404,NDC,1,EA,228.96,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,201.94272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PREP KIT STAPLE 18MM,27200000,CDM,278,RC,C1713,HCPCS,,11658-MAIN,LOCAL,,,,,420.75,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,201.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PREP KIT STAPLE 18MM,27200000,CDM,278,RC,C1713,HCPCS,,11658-MAIN,LOCAL,,,,,420.75,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,201.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PREP KIT STAPLE 20MM,27200000,CDM,278,RC,C1713,HCPCS,,11659-MAIN,LOCAL,,,,,420.75,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,201.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PREP KIT STAPLE 20MM,27200000,CDM,278,RC,C1713,HCPCS,,11659-MAIN,LOCAL,,,,,420.75,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,201.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Ctrl Nosebleed,Anter,Simple",PX30901P,CDM,983,RC,30901,CPT,,,,,,,,229,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,201.978,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.1266,222.8857
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604P,CDM,983,RC,20604,CPT,,,,,,,,229,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,201.978,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.1266,258.75
Removal of Nail Plate,PX11730F,CDM,510,RC,11730,CPT,,,,,,,,229,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,201.978,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.1266,224.42
"MRI,Uprext Jnt W/O+W/Cont",PX7322301,CDM,610,RC,73223,CPT,TC,,,,,,,2681,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,202,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,198.95,586.4
SET SP TUBE INTRODUCER  14CM 8-14FR G15469,120.377,CDM,272,RC,,,,7147-MAIN,LOCAL,,,,,227,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,202.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.2958,222.46
Sp Stn for Inclusn Bodies - Ref,PX8720790,CDM,300,RC,87207,CPT,90,,,,,,,227,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,202.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.49,222.46
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084252,NDC,0.5,ML,207.65,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,110.8875,percent of total billed charges,202.105745,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.085268,203.497
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591F,CDM,360,RC,49591,CPT,,,,,,,,1556,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,202.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,202.22,709.1
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591F,CDM,360,RC,49591,CPT,,,,,,,,1556,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,202.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,202.22,709.1
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591F,CDM,360,RC,49591,CPT,,,,,,,,1556,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,202.22,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,202.22,709.1
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591P,CDM,982,RC,49591,CPT,,,,,,,,1245,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,202.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,202.22,1220.1
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591P,CDM,982,RC,49591,CPT,,,,,,,,1245,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,202.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,202.22,1220.1
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591P,CDM,982,RC,49591,CPT,,,,,,,,1245,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,202.22,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,202.22,1220.1
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU000390,CDM,300,RC,U0003,HCPCS,90,,,,,,,222,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,202.242,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.2188,217.56
Nfct Ds Bct/Vir Respir Dna/Rna 22 Trgt Sarscov2,PX0202U,CDM,300,RC,0202U,HCPCS,,,,,,,,222,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,202.242,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.2188,382.15
Observation Care Discharge,PX99217,CDM,982,RC,99217,CPT,,,,,,,,222,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,202.242,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.2188,216.0726
acetaZOLAMIDE 500 MG Recon Soln 1 Each Vial,J1120.01,CDM,636,RC,J1120,HCPCS,,,,39822019001,NDC,1,EA,207.84,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,202.290672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.336736,203.6832
Phlebotomy,PX99195,CDM,940,RC,99195,CPT,,,,,,,,238,,First Health,Commercial,both,85,,999999999,percent of total billed charges,202.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.8652,233.24
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12173-MAIN,LOCAL,,,,,400,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,202.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Lvl 1 Init Hosp Low Mdm or 40 Minutes,PX99221,CDM,982,RC,99221,CPT,,,,,,,,400,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,202.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.16,389.32
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,61314054701,NDC,2.5,ML,487.35,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,202.44519,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Surgical Diagnostic Exam, Anorectal",PX45990P,CDM,983,RC,45990,CPT,,,,,,,,409,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,202.455,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,169.8986,2452.93
CT Orbit/Ear/Fosa W/O Dye,PX7048001,CDM,350,RC,70480,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,202.48,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.5,202.48
CT Orbit/Ear/Fosa W/O Dye,PX7048001,CDM,350,RC,70480,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,202.48,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.5,202.48
"OB US < 14 Wks, Single Fetus - Radiology, Tech",PX7680101,CDM,402,RC,76801,CPT,TC,,,,,,,472,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,202.488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,462.56
US Pelvic Tc Complete,PX7685601,CDM,402,RC,76856,CPT,TC,,,,,,,472,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,202.488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,462.56
US Transvaginal Tc,PX7683001,CDM,402,RC,76830,CPT,TC,,,,,,,472,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,202.488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,462.56
Debride Tissue/Muscle/Bone,PX11044F,CDM,510,RC,11044,CPT,,,,,,,,1082,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,202.6141,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.56,646.83
Debride Tissue/Muscle/Bone,PX11044P,CDM,983,RC,11044,CPT,,,,,,,,866,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,202.6141,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.56,848.68
Trb@ Gene Rearrange Amplify - Ref,PX8134090,CDM,300,RC,81340,CPT,90,,,,,,,503,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,202.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,202.65,208.92
Trb@ Gene Rearrange Amplify - Ref,PX8134090,CDM,300,RC,81340,CPT,90,,,,,,,503,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,202.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,202.65,208.92
Trb@ Gene Rearrange Amplify - Ref,PX8134090,CDM,300,RC,81340,CPT,90,,,,,,,503,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,202.65,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,202.65,208.92
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037905,NDC,0.5,ML,229.88,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,202.75416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Suspension 10 mL Bottle,63700001,CDM,250,RC,,,,,,64980044801,NDC,10,ML,488.25,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,202.81905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Drain Finger Abscess,Simple",PX26010P,CDM,983,RC,26010,CPT,,,,,,,,207,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,202.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,89.65,716.7
X-Ray Exam Entire Spine 1vw,PX7208101,CDM,320,RC,72081,CPT,TC,,,,,,,414,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,202.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,405.72
X-Ray Exam Entire Spine 1vw,PX7208101,CDM,320,RC,72081,CPT,TC,,,,,,,414,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,202.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,405.72
X-Ray Exam Entire Spine 1vw,PX7208101,CDM,320,RC,72081,CPT,TC,,,,,,,414,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,202.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,405.72
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614900,NDC,1,EA,409.89,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,202.89555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
"Calprotectin, Fecal - Ref",PX8399390,CDM,300,RC,83993,CPT,90,,,,,,,401,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,202.906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18,392.98
OXALiplatin 50 MG/10ML Solution 10 mL Vial,J9263.01,CDM,636,RC,J9263,HCPCS,,,,955173110,NDC,10,ML,228,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,202.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.7112,223.44
"Lab Antibody ID,RBC",PX86870,CDM,300,RC,,,,,,,,,,410,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,202.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,170.314,401.8
"Supply Technicium Sestamibi,per Dose",PXA9500,CDM,343,RC,A9500,HCPCS,,,,,,,,410,,Humana Choice Care,All Medicare plans,outpatient,49.5,,624.065,percent of total billed charges,202.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,170.314,401.8
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390F,CDM,750,RC,45390,CPT,,,,,,,,1419,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,203.1,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,203.1,677.27
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390P,CDM,982,RC,45390,CPT,,,,,,,,1135,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,203.1,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,203.1,1112.3
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320990,NDC,1,EA,410.32,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,203.1084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320995,NDC,1,EA,410.32,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,203.1084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
Physical Therapy Re-Eval Est Plan Care 20 Mins,PX97164,CDM,424,RC,97164,CPT,,,,,,,,239,,First Health,Commercial,both,85,,999999999,percent of total billed charges,203.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,234.22
"Apply Finger Splint,Static",PX29130P,CDM,983,RC,29130,CPT,,,,,,,,223,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,203.153,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,217.0459
"Apply Forearm Splint,Static",PX29125F,CDM,510,RC,29125,CPT,,,,,,,,223,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,203.153,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,218.54
"Flow Cyto, Tech, 1st Mrkr - Ref",PX8818490,CDM,310,RC,88184,CPT,90,,,,,,,223,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,203.153,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,314.02
"Nephelometry, Each, Nos - Ref",PX8388390,CDM,300,RC,83883,CPT,90,,,,,,,223,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,203.153,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.47,218.54
Reduce Temporomandibl Disloc,PX21480P,CDM,983,RC,21480,CPT,,,,,,,,223,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,203.153,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,217.0459
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,409277602,NDC,200,ML,228.28,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,203.1692,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.827512,225.8704
"Level V - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3939,CDM,310,RC,88307,CPT,TC,,,,,,,252,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,203.21,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,200.06,341.216
DRAIN FLAT JACKSON PRATT 10MM,27100000,CDM,271,RC,,,,334-MAIN,LOCAL,,,,,239.09,,First Health,Commercial,both,85,,999999999,percent of total billed charges,203.2265,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,143971801,NDC,200,ML,230.48,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,203.28336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.827512,225.8704
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614800,NDC,1,EA,239.18,,First Health,Commercial,both,85,,999999999,percent of total billed charges,203.303,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
Closed Rx Bimalleolar Fx,PX27808F,CDM,510,RC,27808,CPT,,,,,,,,650,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,203.32,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.17,727.77
Closed Rx Bimalleolar Fx,PX27808F,CDM,510,RC,27808,CPT,,,,,,,,650,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,203.32,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.17,727.77
Closed Rx Bimalleolar Fx,PX27808P,CDM,983,RC,27808,CPT,,,,,,,,433,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,203.32,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.17,727.77
Closed Rx Bimalleolar Fx,PX27808P,CDM,983,RC,27808,CPT,,,,,,,,433,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,203.32,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.17,727.77
Fac/Hospital Discharge Day>30 Min,PX99239F,CDM,510,RC,99239,CPT,,,,,,,,210,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,203.32,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.8,203.32
Fac/Hospital Discharge Day>30 Min,PX99239F,CDM,510,RC,99239,CPT,,,,,,,,210,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,203.32,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.8,203.32
Hospital Discharge Day>30 Min,PX99239P,CDM,982,RC,99239,CPT,,,,,,,,140,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,203.32,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.8,203.32
Hospital Discharge Day>30 Min,PX99239P,CDM,982,RC,99239,CPT,,,,,,,,140,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,203.32,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.8,203.32
"US Complete Joint, Realtime W/ Img Tc",PX7688101,CDM,402,RC,76881,CPT,TC,,,,,,,415,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,203.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,406.7
"US Complete Joint, Realtime W/ Img Tc",PX7688101,CDM,402,RC,76881,CPT,TC,,,,,,,415,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,203.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,406.7
"US Complete Joint, Realtime W/ Img Tc",PX7688101,CDM,402,RC,76881,CPT,TC,,,,,,,415,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,203.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,406.7
calcitonin (salmon) 200 UNIT/ACT Solution 3.7 mL Bottle,63700001,CDM,250,RC,,,,,,60505082306,NDC,3.7,ML,489.57,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,203.367378,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Cardioversion, Elective;Extern",PX92960F,CDM,480,RC,92960,CPT,,,,,,,,402,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,203.412,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.9908,568.57
Chem Cautery Granulatn Tissue,PX17250P,CDM,983,RC,17250,CPT,,,,,,,,402,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,203.412,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.9908,391.2666
Lab Imm Spin X-Match,PX8837,CDM,300,RC,86920,CPT,,,,,,,,402,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,203.412,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.22,393.96
"Morphometric Analysis, in Situ Hybridization, Each Probe; Manual, Tech",PX8836801,CDM,310,RC,88368,CPT,TC,,,,,,,402,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,203.412,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.9908,393.96
ACCESSORY KIT FOR GROSHONG 16GA,120.46,CDM,272,RC,C1751,HCPCS,,2967-MAIN,LOCAL,,,,,209,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,203.4197,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.8186,204.82
Infection Agent Detect Dna/Rna Probe Tq 12-25,PX87507,CDM,300,RC,87507,CPT,,,,,,,,209,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,101.225,percent of total billed charges,203.4197,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.8186,382.15
"Organic Acid, Single, Qnt - Ref",PX8392190,CDM,300,RC,83921,CPT,90,,,,,,,209,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,203.4197,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.45,204.82
8MM ENDOWRIST INSTRUMENTS TIP-UP FENESTRATED GRASPER,27200000,CDM,272,RC,,,,11911-MAIN,LOCAL,,,,,411,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,203.445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Bone Marrow Aspiration and Biopsy,PXG0364F,CDM,510,RC,G0364,HCPCS,,,,,,,,411,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,203.445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,170.7294,402.78
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084252,NDC,0.5,ML,207.65,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,203.497,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.085268,203.497
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402F,CDM,510,RC,11402,CPT,,,,,,,,424,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,203.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.1296,614.65
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402F,CDM,510,RC,11402,CPT,,,,,,,,424,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,203.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.1296,614.65
Lab H Pylori Stool Ag,PX87338,CDM,300,RC,87338,CPT,,,,,,,,424,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,203.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,415.52
Lab H Pylori Stool Ag,PX87338,CDM,300,RC,87338,CPT,,,,,,,,424,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,203.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,415.52
Xray Knee 4 or More Vws,PX7356401,CDM,320,RC,73564,CPT,TC,,,,,,,490,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,203.546,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,480.2
acetaZOLAMIDE 500 MG Recon Soln 1 Each Vial,J1120.01,CDM,636,RC,J1120,HCPCS,,,,39822019001,NDC,1,EA,207.84,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,203.6832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.336736,203.6832
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Suspension 10 mL Bottle,63700001,CDM,250,RC,,,,,,24208063562,NDC,10,ML,415.81,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,203.7469,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Suspension 10 mL Bottle,63700001,CDM,250,RC,,,,,,24208063562,NDC,10,ML,415.81,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,203.7469,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Suspension 10 mL Bottle,63700001,CDM,250,RC,,,,,,24208063562,NDC,10,ML,415.81,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,203.7469,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
albumin human 25% 25 % Solution 50 mL Flex Cont,P9047,CDM,636,RC,P9047,HCPCS,,,,944049301,NDC,50,ML,402.67,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,203.75102,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.66,394.6166
patiromer sorbitex calcium 8.4 g Packet 4 Each Box,63700001,CDM,250,RC,,,,,,53436008404,NDC,1,EA,228.96,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,203.7744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CT Maxillofacial W/Dye,PX7048701,CDM,350,RC,70487,CPT,TC,,,,,,,3332,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,203.79,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.93,203.79
CT Maxillofacial W/Dye,PX7048701,CDM,350,RC,70487,CPT,TC,,,,,,,3332,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,203.79,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.93,203.79
"Ctrl Nosebleed,Anter,Simple",PX30901P,CDM,983,RC,30901,CPT,,,,,,,,229,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,203.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.1266,222.8857
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604P,CDM,983,RC,20604,CPT,,,,,,,,229,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,203.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.1266,258.75
Removal of Nail Plate,PX11730F,CDM,510,RC,11730,CPT,,,,,,,,229,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,203.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.1266,224.42
US Head/Neck Tc,PX7653601,CDM,402,RC,76536,CPT,TC,,,,,,,416,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,81.9,percent of total billed charges,203.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,407.68
US Head/Neck Tc,PX7653601,CDM,402,RC,76536,CPT,TC,,,,,,,416,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,203.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,407.68
US Head/Neck Tc,PX7653601,CDM,402,RC,76536,CPT,TC,,,,,,,416,,United Healthcare,All Medicare advantage plans,outpatient,49,,73.59,percent of total billed charges,203.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,407.68
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545P,CDM,983,RC,23545,CPT,,,,,,,,412,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,203.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,171.1448,400.9996
"Closed Rx Big Toe Fx,Manip",PX28495P,CDM,983,RC,28495,CPT,,,,,,,,412,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,203.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,171.1448,400.9996
ipratropium 0.06 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,54004641,NDC,15,ML,491.02,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,203.969708,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Injection Hip Arthrogram,Anesth",PX27095F,CDM,510,RC,27095,CPT,,,,,,,,425,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.545,416.5
"Injection Hip Arthrogram,Anesth",PX27095F,CDM,510,RC,27095,CPT,,,,,,,,425,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.545,416.5
US Abdomen Limited Tc,PX7670501,CDM,402,RC,76705,CPT,TC,,,,,,,425,,Health Partners,Health Partners Care Plans,both,48,,412.25,percent of total billed charges,204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,416.5
US Abdomen Limited Tc,PX7670501,CDM,402,RC,76705,CPT,TC,,,,,,,425,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,416.5
US Ext Non-Vasc Img Lmtd,PX7688201,CDM,402,RC,76882,CPT,TC,,,,,,,425,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,416.5
US Ext Non-Vasc Img Lmtd,PX7688201,CDM,402,RC,76882,CPT,TC,,,,,,,425,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,416.5
Body Fluid Cell Count W Diff,PX89051,CDM,300,RC,89051,CPT,,,,,,,,224,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,204.064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.13,219.52
Emergency Level I Visit,PX99281P,CDM,981,RC,99281,CPT,,,,,,,,224,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,204.064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.56,218.0192
ENDOWRIST INSTRUMENTS PERMANENT CAUTERY HOOK 8MM,27200000,CDM,272,RC,,,,12050-MAIN,LOCAL,,,,,224,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,204.064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Helicobacter Pylori Ab,PX86677,CDM,300,RC,86677,CPT,,,,,,,,224,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,204.064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.45,219.52
cefoTEtan 2 g Recon Soln 1 Each Vial,800000,CDM,,,S0074,HCPCS,,,,63323038620,NDC,1,EA,240.2,,First Health,Commercial,both,85,,999999999,percent of total billed charges,204.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390F,CDM,750,RC,45390,CPT,,,,,,,,1419,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,204.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,203.1,677.27
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390F,CDM,750,RC,45390,CPT,,,,,,,,1419,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,204.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,203.1,677.27
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390P,CDM,982,RC,45390,CPT,,,,,,,,1135,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,204.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,203.1,1112.3
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390P,CDM,982,RC,45390,CPT,,,,,,,,1135,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,204.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,203.1,1112.3
hydrocortisone sodium succinate (preservative free) 1000 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9000501,NDC,1,EA,403.54,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,204.19124,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384F,CDM,750,RC,45384,CPT,,,,,,,,2350,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,204.2196,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.09,1011.41
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384P,CDM,983,RC,45384,CPT,,,,,,,,1436,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,204.2196,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.09,1407.28
nystatin 100000 UNIT/GM Powder 60 g Bottle,63700001,CDM,250,RC,,,,,,574200802,NDC,60,GR,491.86,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,204.318644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Xray Ribs Bilat 3 Vws With Pa Chest,PX7111101,CDM,320,RC,71111,CPT,TC,,,,,,,417,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,204.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,408.66
Xray Ribs Bilat 3 Vws With Pa Chest,PX7111101,CDM,320,RC,71111,CPT,TC,,,,,,,417,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,204.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,408.66
Xray Ribs Bilat 3 Vws With Pa Chest,PX7111101,CDM,320,RC,71111,CPT,TC,,,,,,,417,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,204.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,408.66
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762F,CDM,510,RC,43762,CPT,,,,,,,,492,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,204.3768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,204.3768,482.16
AIRSEAL ROBOTIC Xi CAP AND OBTURATOR WITH BLADELESS OPTICAL TIP,27200000,CDM,272,RC,,,,12208-MAIN,LOCAL,,,,,210,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,204.393,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
AIRSEAL ROBOTIC Xi TRI LUMEN FILTERED TUBE SET WITH ACTIVATED CHARCOAL,27200000,CDM,272,RC,,,,12209-MAIN,LOCAL,,,,,210,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,204.393,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Apply Forearm Cast,PX29075F,CDM,510,RC,29075,CPT,,,,,,,,210,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,204.393,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,234.62
Chorionic gonadotropin test,PX84702,CDM,300,RC,84702,CPT,,,,,,,,210,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,84.7225,percent of total billed charges,204.393,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.8,205.8
"Excision of Nail Fold, Toe",PX11765F,CDM,510,RC,11765,CPT,,,,,,,,210,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,204.393,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,348.35
Fac/Hospital Discharge Day>30 Min,PX99239F,CDM,510,RC,99239,CPT,,,,,,,,210,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,204.393,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,205.8
"Inject Trigger Point, 1 or 2",PX20552P,CDM,983,RC,20552,CPT,,,,,,,,210,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,204.393,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,258.75
Layr Clos Wnd Rest Body 2.6-7.5,PX12042F,CDM,510,RC,12042,CPT,,,,,,,,404,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,204.424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,395.92
Neg Pressure Wound Therapy Dme >50 Sq Cm,PX97606F,CDM,761,RC,97606,CPT,,,,,,,,404,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,204.424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,395.92
Remove Foreign Body Simple,PX10120F,CDM,510,RC,10120,CPT,,,,,,,,404,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,204.424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,395.92
Remove Foreign Body Simple,PX10120P,CDM,983,RC,10120,CPT,,,,,,,,404,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,204.424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,393.2132
Xray Foot Minimum 3 Vws,PX7363001,CDM,320,RC,73630,CPT,TC,,,,,,,404,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,204.424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,395.92
Xray Knee 3 Vws,PX7356201,CDM,320,RC,73562,CPT,TC,,,,,,,404,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,204.424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,395.92
umeclidinium 62.5 MCG/ACT Aerosol Powder Breath Activated 7 Each Disp Pack,63700001,CDM,250,RC,,,,,,173087306,NDC,7,EA,492.23,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,204.472342,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,68462018022,NDC,22,GR,240.66,,First Health,Commercial,both,85,,999999999,percent of total billed charges,204.561,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037905,NDC,0.5,ML,229.88,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,204.5932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
Bile Acids Total,PX8223990,CDM,300,RC,82239,CPT,90,,,,,,,232,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,204.624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,227.36
Trb@ Gene Rearrange Amplify - Ref,PX8134090,CDM,300,RC,81340,CPT,90,,,,,,,503,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,204.7342,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,202.65,208.92
ACCESSORY KIT FOR GROSHONG 16GA,120.46,CDM,272,RC,C1751,HCPCS,,2967-MAIN,LOCAL,,,,,209,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,204.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.8186,204.82
Infection Agent Detect Dna/Rna Probe Tq 12-25,PX87507,CDM,300,RC,87507,CPT,,,,,,,,209,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,204.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.8186,382.15
"Organic Acid, Single, Qnt - Ref",PX8392190,CDM,300,RC,83921,CPT,90,,,,,,,209,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,204.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.45,204.82
Removal of Skin Tags,PX11200P,CDM,983,RC,11200,CPT,,,,,,,,418,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,204.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,173.6372,406.8394
Removal of Skin Tags,PX11200P,CDM,983,RC,11200,CPT,,,,,,,,418,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,204.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,173.6372,406.8394
Removal of Skin Tags,PX11200P,CDM,983,RC,11200,CPT,,,,,,,,418,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,204.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,173.6372,406.8394
Egd Balloon Dil Esoph30 Mm/>,PX43233F,CDM,750,RC,43233,CPT,,,,,,,,1120,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,204.8618,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.52,468.35
Egd Balloon Dil Esoph30 Mm/>,PX43233P,CDM,983,RC,43233,CPT,,,,,,,,480,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,204.8618,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.52,470.4
Diagnostic Anoscopy,PX46600P,CDM,983,RC,46600,CPT,,,,,,,,405,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,204.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,394.1865
X-Ray Exam Entire Spine 1vw,PX7208101,CDM,320,RC,72081,CPT,TC,,,,,,,414,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,204.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,405.72
"Cytoflo, Cell or Dna Anal - Ref",PX8818290,CDM,310,RC,88182,CPT,90,,,,,,,225,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,204.975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,220.5
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153F,CDM,370,RC,99153,CPT,,,,,,,,225,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,204.975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.465,220.5
"Level V - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3939,CDM,310,RC,88307,CPT,TC,,,,,,,252,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,205.0551,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,200.06,341.216
ibutilide 1 MG/10ML Solution 10 mL Vial,J1742.01,CDM,636,RC,J1742,HCPCS,,,,9379401,NDC,10,ML,2349.03,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,205.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,180.45,559.83
ibutilide 1 MG/10ML Solution 10 mL Vial,J1742.01,CDM,636,RC,J1742,HCPCS,,,,9379401,NDC,10,ML,2349.03,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,205.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,180.45,559.83
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,143971801,NDC,200,ML,230.48,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,205.1272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.827512,225.8704
albuterol (5 MG/ML) 0.5% Nebulization Solution 20 mL Bottle,J7611.01,CDM,250,RC,,,,,,50383074120,NDC,20,ML,225.2,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,205.1572,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.54808,220.696
CRICOTHROTOMY QUICKTRACH 4MM,120.228,CDM,272,RC,A7520,HCPCS,,8868-MAIN,LOCAL,,,,,494,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,205.2076,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.2076,484.12
SET CRICOTHYROTOMY CATHETER 6MM ID,120.378,CDM,272,RC,,,,11119-MAIN,LOCAL,,,,,494,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,205.2076,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.2076,484.12
TRAY PNEUMOTHORAX 14FR 29CM 19 CATHETER SIDEPORTS G56537,120.496,CDM,272,RC,,,,11677-MAIN,LOCAL,,,,,419,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,205.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.0526,410.62
TRAY PNEUMOTHORAX 14FR 29CM 19 CATHETER SIDEPORTS G56537,120.496,CDM,272,RC,,,,11677-MAIN,LOCAL,,,,,419,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,205.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.0526,410.62
TRAY PNEUMOTHORAX 14FR 29CM 19 CATHETER SIDEPORTS G56537,120.496,CDM,272,RC,,,,11677-MAIN,LOCAL,,,,,419,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,205.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.0526,410.62
Bone Age Studies Tc,PX7707201,CDM,320,RC,77072,CPT,TC,,,,,,,211,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,205.3663,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.6494,206.78
Collect Blood From Picc,PX36592F,CDM,510,RC,36592,CPT,,,,,,,,211,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,205.3663,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.6494,206.78
Draw Blood Off Venous Device,PX36591F,CDM,510,RC,36591,CPT,,,,,,,,211,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,109.875,percent of total billed charges,205.3663,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.6494,206.78
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494301,NDC,0.5,ML,419.2,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,205.408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.38,410.8454
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494301,NDC,0.5,ML,419.2,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,205.408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.38,410.8454
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494301,NDC,0.5,ML,419.2,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,205.408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.38,410.8454
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494300,NDC,0.5,ML,419.23,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,205.4227,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.38,410.8454
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494300,NDC,0.5,ML,419.23,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,205.4227,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.38,410.8454
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494300,NDC,0.5,ML,419.23,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,205.4227,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.38,410.8454
"US Complete Joint, Realtime W/ Img Tc",PX7688101,CDM,402,RC,76881,CPT,TC,,,,,,,415,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,205.425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,406.7
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598F,CDM,510,RC,97598,CPT,,,,,,,,406,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,205.436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,168.6524,397.88
Resp Virus 6-11 Targets,PX87632,CDM,300,RC,87632,CPT,,,,,,,,428,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,205.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,177.7912,419.44
Resp Virus 6-11 Targets,PX87632,CDM,300,RC,87632,CPT,,,,,,,,428,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,205.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,177.7912,419.44
Xray Thoracic Spine 2 Vws,PX7207001,CDM,320,RC,72070,CPT,TC,,,,,,,428,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,205.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,419.44
Xray Thoracic Spine 2 Vws,PX7207001,CDM,320,RC,72070,CPT,TC,,,,,,,428,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,205.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,419.44
ondansetron 4 MG/5ML Solution 25 mL Bottle,S0119.01,CDM,636,RC,S0119,HCPCS,,,,99998-8001-,NDC,25,ML,494.57,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,205.444378,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
Exc Abd Les Sc < 3 Cm,PX22902F,CDM,761,RC,22902,CPT,,,,,,,,3128,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,205.5,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.5,987.89
Exc Abd Les Sc < 3 Cm,PX22902P,CDM,983,RC,22902,CPT,,,,,,,,2086,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,205.5,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.5,2044.28
TRAY GROSHONG 4FR SAFETY PICC 7617407,120.26,CDM,272,RC,,,,500-MAIN,LOCAL,,,,,233,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,205.506,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.7882,228.34
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725F,CDM,510,RC,26725,CPT,,,,,,,,495,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,205.623,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.623,485.1
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101F,CDM,510,RC,13101,CPT,,,,,,,,495,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,205.623,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.623,548.67
Tc99 Mebrofenin to 15 Mci,PXA9537,CDM,343,RC,A9537,HCPCS,,,,,,,,495,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,205.623,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.623,485.1
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041105,NDC,1,ML,419.67,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,205.6383,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.808876,411.2766
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041105,NDC,1,ML,419.67,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,205.6383,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.808876,411.2766
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041105,NDC,1,ML,419.67,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,205.6383,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.808876,411.2766
Airway Inhalation Treatment,PX94640F,CDM,410,RC,94640,CPT,,,,,,,,242,,First Health,Commercial,both,85,,999999999,percent of total billed charges,205.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,100.5268,237.16
"Noninvasv Oxygen Satut,Continuous",PX94762,CDM,460,RC,94762,CPT,,,,,,,,242,,First Health,Commercial,both,85,,999999999,percent of total billed charges,205.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,100.5268,237.16
Therapeutic Activities,PX97530,CDM,420,RC,97530,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All commercial plans,both,,,88.72527778,fee schedule,205.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.22,205.7
AIRSEAL ROBOTIC Xi CAP AND OBTURATOR WITH BLADELESS OPTICAL TIP,27200000,CDM,272,RC,,,,12208-MAIN,LOCAL,,,,,210,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,205.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
AIRSEAL ROBOTIC Xi TRI LUMEN FILTERED TUBE SET WITH ACTIVATED CHARCOAL,27200000,CDM,272,RC,,,,12209-MAIN,LOCAL,,,,,210,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,205.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Apply Forearm Cast,PX29075F,CDM,510,RC,29075,CPT,,,,,,,,210,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,205.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,234.62
Chorionic gonadotropin test,PX84702,CDM,300,RC,84702,CPT,,,,,,,,210,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,205.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.8,205.8
"Excision of Nail Fold, Toe",PX11765F,CDM,510,RC,11765,CPT,,,,,,,,210,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,205.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,348.35
Fac/Hospital Discharge Day>30 Min,PX99239F,CDM,510,RC,99239,CPT,,,,,,,,210,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,205.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,205.8
"Inject Trigger Point, 1 or 2",PX20552P,CDM,983,RC,20552,CPT,,,,,,,,210,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,205.8,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.9,205.8
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601901,NDC,10,ML,211.47,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,205.823751,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.844638,207.2406
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601910,NDC,10,ML,211.47,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,205.823751,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.844638,207.2406
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Suspension 10 mL Bottle,63700001,CDM,250,RC,,,,,,24208063562,NDC,10,ML,415.81,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,205.82595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081543,NDC,1,ML,479.89,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,205.87281,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.346306,470.2922
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081552,NDC,1,ML,479.89,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,205.87281,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.346306,470.2922
Egd Balloon Dil Esoph30 Mm/>,PX43233P,CDM,983,RC,43233,CPT,,,,,,,,480,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,205.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.392,1662.33
I&D Bartholin Gland Abscess,PX56420F,CDM,510,RC,56420,CPT,,,,,,,,429,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,205.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.08,420.42
I&D Bartholin Gland Abscess,PX56420F,CDM,510,RC,56420,CPT,,,,,,,,429,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,205.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.08,420.42
"Sigmoidoscopy,Diagnostic",PX45330P,CDM,983,RC,45330,CPT,,,,,,,,480,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,205.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.392,798.45
US Head/Neck Tc,PX7653601,CDM,402,RC,76536,CPT,TC,,,,,,,416,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,205.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,407.68
"Close Rx Dist Fingr Fx,Manipulatn",PX26755F,CDM,510,RC,26755,CPT,,,,,,,,335,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,206.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
"Close Rx Dist Fingr Fx,Manipulatn",PX26755P,CDM,983,RC,26755,CPT,,,,,,,,1260,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,206.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1226.358
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725F,CDM,510,RC,26725,CPT,,,,,,,,495,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,206.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.623,485.1
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725P,CDM,983,RC,26725,CPT,,,,,,,,330,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,206.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.082,321.189
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545F,CDM,510,RC,23545,CPT,,,,,,,,961,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,206.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,941.78
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545P,CDM,983,RC,23545,CPT,,,,,,,,412,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,206.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,171.1448,400.9996
"Closed Rx Big Toe Fx,Manip",PX28495F,CDM,510,RC,28495,CPT,,,,,,,,857,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,206.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,839.86
"Closed Rx Big Toe Fx,Manip",PX28495P,CDM,983,RC,28495,CPT,,,,,,,,412,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,206.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,171.1448,400.9996
Closed Rx Bimalleolar Fx,PX27808F,CDM,510,RC,27808,CPT,,,,,,,,650,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,206.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,637
Closed Rx Bimalleolar Fx,PX27808P,CDM,983,RC,27808,CPT,,,,,,,,433,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,206.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,179.8682,421.4389
"Closed Rx Dist Fibula Fx,Manip",PX27788F,CDM,510,RC,27788,CPT,,,,,,,,1597,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,206.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1565.06
"Closed Rx Dist Fibula Fx,Manip",PX27788P,CDM,983,RC,27788,CPT,,,,,,,,1277,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,206.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1242.9041
Closed Rx Elbow Dislocation,PX24600F,CDM,510,RC,24600,CPT,,,,,,,,706,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,206.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,691.88
Closed Rx Elbow Dislocation,PX24600P,CDM,983,RC,24600,CPT,,,,,,,,380,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,206.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,157.852,369.854
"Closed Rx I-P Jt,Toe Dislocation",PX28660F,CDM,510,RC,28660,CPT,,,,,,,,335,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,206.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
"Closed Rx I-P Jt,Toe Dislocation",PX28660P,CDM,983,RC,28660,CPT,,,,,,,,628,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,206.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,611.2324
Closed Rx IP Jt Dislocation,PX26770F,CDM,510,RC,26770,CPT,,,,,,,,1231,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,206.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1206.38
Closed Rx IP Jt Dislocation,PX26770P,CDM,983,RC,26770,CPT,,,,,,,,1353,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,206.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1316.8749
Closed Rx Kneecap Disloc+Anesth,PX27562F,CDM,510,RC,27562,CPT,,,,,,,,604,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,206.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,591.92
Closed Rx Kneecap Disloc+Anesth,PX27562P,CDM,983,RC,27562,CPT,,,,,,,,1404,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,206.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1366.5132
Closed Rx Kneecap Dislocatn,PX27560F,CDM,510,RC,27560,CPT,,,,,,,,468,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,206.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,194.4072,458.64
Closed Rx Kneecap Dislocatn,PX27560P,CDM,983,RC,27560,CPT,,,,,,,,312,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,206.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,129.6048,303.6696
Closed Rx Metacarpal Fx,PX26600F,CDM,510,RC,26600,CPT,,,,,,,,443,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,206.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,184.0222,434.14
Closed Rx Metacarpal Fx,PX26600P,CDM,983,RC,26600,CPT,,,,,,,,295,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,206.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.543,287.1235
Closed Rx Mt-Phal Toe Dislocation,PX28630F,CDM,510,RC,28630,CPT,,,,,,,,360,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,206.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.544,352.8
Closed Rx Mt-Phal Toe Dislocation,PX28630P,CDM,983,RC,28630,CPT,,,,,,,,248,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,206.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.0192,241.3784
"Closed Rx Radial Head Disloc,Child",PX24640F,CDM,510,RC,24640,CPT,,,,,,,,270,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,206.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.158,264.6
"Closed Rx Radial Head Disloc,Child",PX24640P,CDM,983,RC,24640,CPT,,,,,,,,180,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,206.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.772,206.02
Closed Rx Shldr Dislocation,PX23650F,CDM,510,RC,23650,CPT,,,,,,,,689,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,206.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,675.22
Closed Rx Shldr Dislocation,PX23650P,CDM,983,RC,23650,CPT,,,,,,,,516,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,206.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,502.2228
"Closed Rx Toe Fx,Manipulatn",PX28515F,CDM,510,RC,28515,CPT,,,,,,,,390,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,206.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,162.006,382.2
"Closed Rx Toe Fx,Manipulatn",PX28515P,CDM,983,RC,28515,CPT,,,,,,,,260,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,206.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.004,253.058
Closed Rx Trimalleolar Fx,PX27816F,CDM,510,RC,27816,CPT,,,,,,,,522,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,206.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,511.56
Closed Rx Trimalleolar Fx,PX27816P,CDM,983,RC,27816,CPT,,,,,,,,826,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,206.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,803.9458
Closed Treat Wrist Dislocation,PX25660P,CDM,983,RC,25660,CPT,,,,,,,,1507,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,206.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1466.7631
Reduce Temporomandibl Disloc,PX21480F,CDM,510,RC,21480,CPT,,,,,,,,335,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,206.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Reduce Temporomandibl Disloc,PX21480P,CDM,983,RC,21480,CPT,,,,,,,,223,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,206.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,217.0459
"Treat Thumb Disloc,Manipulatn",PX26641F,CDM,510,RC,26641,CPT,,,,,,,,1721,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,206.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1686.58
"Treat Thumb Disloc,Manipulatn",PX26641P,CDM,983,RC,26641,CPT,,,,,,,,1902,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,206.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1851.2166
ADVANCED INSTRUMENTS ENDOWRIST SUCTION IRRIGATOR,27200000,CDM,272,RC,,,,11922-MAIN,LOCAL,,,,,496,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,206.0384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LOCKING SCREW T8 FULL THREAD 2.4MM L10MM,C1713,CDM,278,RC,C1713,HCPCS,,12637-MAIN,LOCAL,,,,,496,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,206.0384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LOCKING SCREW T8 FULL THREAD 2.4MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12651-MAIN,LOCAL,,,,,496,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,206.0384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LOCKING SCREW T8 FULL THREAD 2.7MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12638-MAIN,LOCAL,,,,,496,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,206.0384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LOCKING SCREW T8 FULL THREAD 2.7MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12639-MAIN,LOCAL,,,,,496,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,206.0384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"Excis Arm/Elbow Tumor,Subcutan",PX24075F,CDM,510,RC,24075,CPT,,,,,,,,1519,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,206.15,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.15,1108.26
"Excis Arm/Elbow Tumor,Subcutan",PX24075P,CDM,983,RC,24075,CPT,,,,,,,,2458,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,206.15,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.15,2408.84
Apply Long Leg Cast,PX29345F,CDM,510,RC,29345,CPT,,,,,,,,912,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,206.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.29,285.71
PREP KIT STAPLE 18MM,27200000,CDM,278,RC,C1713,HCPCS,,11658-MAIN,LOCAL,,,,,420.75,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,206.1675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PREP KIT STAPLE 18MM,27200000,CDM,278,RC,C1713,HCPCS,,11658-MAIN,LOCAL,,,,,420.75,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,206.1675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PREP KIT STAPLE 18MM,27200000,CDM,278,RC,C1713,HCPCS,,11658-MAIN,LOCAL,,,,,420.75,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,206.1675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PREP KIT STAPLE 20MM,27200000,CDM,278,RC,C1713,HCPCS,,11659-MAIN,LOCAL,,,,,420.75,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,206.1675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PREP KIT STAPLE 20MM,27200000,CDM,278,RC,C1713,HCPCS,,11659-MAIN,LOCAL,,,,,420.75,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,206.1675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PREP KIT STAPLE 20MM,27200000,CDM,278,RC,C1713,HCPCS,,11659-MAIN,LOCAL,,,,,420.75,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,206.1675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279210,NDC,10,ML,429.84,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,206.3232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,178.555536,421.2432
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279210,NDC,10,ML,429.84,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,206.3232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,178.555536,421.2432
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279410,NDC,10,ML,429.84,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,206.3232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,178.555536,421.2432
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279410,NDC,10,ML,429.84,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,206.3232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,178.555536,421.2432
"Non-Select. Wound Debride., W/O Anesth.; Top. Appl./Wound Assess./Instruct., per Sess.",PX97602,CDM,761,RC,97602,CPT,,,,,,,,212,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,206.3396,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.0648,207.76
CANNULA FOR INJECTION 1.8MM WITH 3MM LUER CONNECTION 8383.65,27200000,CDM,272,RC,,,,12004-MAIN,LOCAL,,,,,234,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,206.388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Fibrinogen,PX7426,CDM,300,RC,85384,CPT,,,,,,,,234,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,206.388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.91,229.32
RELOAD SUREFORM 60 2.5 WHITE 6 ROW BOX/12,27200000,CDM,272,RC,,,,12261-MAIN,LOCAL,,,,,430,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,206.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 60 2.5 WHITE 6 ROW BOX/12,27200000,CDM,272,RC,,,,12261-MAIN,LOCAL,,,,,430,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,206.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 60 3.5 BLUE,27200000,CDM,272,RC,,,,12084-MAIN,LOCAL,,,,,430,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,206.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 60 3.5 BLUE,27200000,CDM,272,RC,,,,12084-MAIN,LOCAL,,,,,430,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,206.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 60 4.3 GREEN,27200000,CDM,272,RC,,,,12085-MAIN,LOCAL,,,,,430,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,206.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 60 4.3 GREEN,27200000,CDM,272,RC,,,,12085-MAIN,LOCAL,,,,,430,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,206.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Xray Ribs Bilat 3 Vws With Pa Chest,PX7111101,CDM,320,RC,71111,CPT,TC,,,,,,,417,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,206.415,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,408.66
Cpap/Bipap Mgmnt-Pt Own Equipment,PX94660.02F,CDM,410,RC,94660,CPT,,,,,,,,497,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,206.4538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.33,487.06
Bile Acids Total,PX8223990,CDM,300,RC,82239,CPT,90,,,,,,,232,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,206.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,227.36
Bone Age Studies Tc,PX7707201,CDM,320,RC,77072,CPT,TC,,,,,,,211,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,206.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.6494,206.78
Closure Superf Wnd Dehis Simple,PX12020P,CDM,983,RC,12020,CPT,,,,,,,,422,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,206.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,175.2988,548.67
Closure Superf Wnd Dehis Simple,PX12020P,CDM,983,RC,12020,CPT,,,,,,,,422,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,206.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,175.2988,548.67
Closure Superf Wnd Dehis Simple,PX12020P,CDM,983,RC,12020,CPT,,,,,,,,422,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,206.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,175.2988,548.67
Collect Blood From Picc,PX36592F,CDM,510,RC,36592,CPT,,,,,,,,211,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,206.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.6494,206.78
Draw Blood Off Venous Device,PX36591F,CDM,510,RC,36591,CPT,,,,,,,,211,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,206.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.6494,206.78
SET SP TUBE INTRODUCER  14CM 8-14FR G15469,120.377,CDM,272,RC,,,,7147-MAIN,LOCAL,,,,,227,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,206.797,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.2958,222.46
Sp Stn for Inclusn Bodies - Ref,PX8720790,CDM,300,RC,87207,CPT,90,,,,,,,227,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,206.797,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.49,222.46
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505614700,NDC,1,EA,212.52,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,18.705,percent of total billed charges,206.845716,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611F,CDM,510,RC,20611,CPT,,,,,,,,456,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,206.85,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.21,206.85
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611P,CDM,983,RC,20611,CPT,,,,,,,,272,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,206.85,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.21,266.56
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,781344071,NDC,1,EA,430.94,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,206.8512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,179.012476,460.7862
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,781344071,NDC,1,EA,430.94,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,206.8512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,179.012476,460.7862
Gastric Intubation Treatment,PX43753P,CDM,983,RC,43753,CPT,,,,,,,,498,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,206.8692,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.8692,484.7034
"POS Airway Pressure, Cpap",PX94660F,CDM,410,RC,94660,CPT,,,,,,,,498,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,206.8692,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.33,488.04
Removal of Skin Tags,PX11200P,CDM,983,RC,11200,CPT,,,,,,,,418,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,206.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,173.6372,406.8394
"Surgical Diagnostic Exam, Anorectal",PX45990P,CDM,983,RC,45990,CPT,,,,,,,,409,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,206.954,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,169.8986,2452.93
Explor Metatarso-Phalang Jt,PX28022F,CDM,510,RC,28022,CPT,,,,,,,,1161,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,207.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,207.02,1012.1
Explor Metatarso-Phalang Jt,PX28022P,CDM,983,RC,28022,CPT,,,,,,,,774,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,207.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,207.02,1012.1
"Repair Flex Foot Tendon,Ea",PX28200F,CDM,510,RC,28200,CPT,,,,,,,,1475,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,207.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,207.02,1026.63
Abd Duplex Abd-Full,PX9397501,CDM,921,RC,93975,CPT,TC,,,,,,,788,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,207.046,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.26,367.05
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601901,NDC,10,ML,211.47,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,207.2406,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.844638,207.2406
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601910,NDC,10,ML,211.47,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,207.2406,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.844638,207.2406
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152F,CDM,370,RC,99152,CPT,,,,,,,,235,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,207.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97.619,230.3
Occupational Therapy Eval Low Complex,PX97165,CDM,434,RC,97165,CPT,,,,,,,,235,,United Healthcare,All Payer,outpatient,88.2,,115.9966667,percent of total billed charges,207.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,230.3
Physical Therapy Evaluation Low Complex,PX97161,CDM,424,RC,97161,CPT,,,,,,,,235,,United Healthcare,All Payer,outpatient,88.2,,98.14,percent of total billed charges,207.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,392.7
Remv Ext Canal Foreign Body,PX69200F,CDM,510,RC,69200,CPT,,,,,,,,235,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,207.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97.619,230.3
"Vitamin D, 25 Hydroxy",PX82306,CDM,300,RC,82306,CPT,,,,,,,,235,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,207.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.14,230.3
Apply Multlay Comprs Lwr Leg,PX29581F,CDM,510,RC,29581,CPT,,,,,,,,213,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,207.3129,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.4802,208.74
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006F,CDM,510,RC,10006,CPT,,,,,,,,213,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,207.3129,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.4802,208.74
"GI Pathogen Panel, Pcr - Ref",PX8750790,CDM,300,RC,87507,CPT,90,,,,,,,213,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,101.225,percent of total billed charges,207.3129,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.4802,382.15
Remove Impacted Ear Wax,PX69210F,CDM,510,RC,69210,CPT,,,,,,,,213,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,207.3129,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.44,208.74
Xray Eye Foreign Body,PX7003001,CDM,320,RC,70030,CPT,TC,,,,,,,432,,Health Partners,Health Partners Care Plans,both,48,,172.8,percent of total billed charges,207.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,423.36
Xray Eye Foreign Body,PX7003001,CDM,320,RC,70030,CPT,TC,,,,,,,432,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,207.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,423.36
TRAY GROSHONG 4FR SAFETY PICC 7617407,120.26,CDM,272,RC,,,,500-MAIN,LOCAL,,,,,233,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,207.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.7882,228.34
BINDER PELVIC ADULT STABILIZATION T-PODR,120.357,CDM,271,RC,A4467,HCPCS,,10734-MAIN,LOCAL,,,,,244,,First Health,Commercial,both,85,,999999999,percent of total billed charges,207.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.3576,239.12
"Bone Marrow Aspiration(S),Diag",PX38220P,CDM,983,RC,38220,CPT,,,,,,,,244,,First Health,Commercial,both,85,,999999999,percent of total billed charges,207.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.3576,1416.38
Dress/Debrid Med Burn No Anesth,PX16025P,CDM,983,RC,16025,CPT,,,,,,,,244,,First Health,Commercial,both,85,,999999999,percent of total billed charges,207.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.3576,237.4852
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614900,NDC,1,EA,409.89,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,207.40434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
TRAY PNEUMOTHORAX 14FR 29CM 19 CATHETER SIDEPORTS G56537,120.496,CDM,272,RC,,,,11677-MAIN,LOCAL,,,,,419,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,207.405,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.0526,410.62
"Lab Antibody ID,RBC",PX86870,CDM,300,RC,,,,,,,,,,410,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,207.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,170.314,401.8
"Supply Technicium Sestamibi,per Dose",PXA9500,CDM,343,RC,A9500,HCPCS,,,,,,,,410,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,207.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,170.314,401.8
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494301,NDC,0.5,ML,419.2,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,207.504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.38,410.8454
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494300,NDC,0.5,ML,419.23,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,207.51885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.38,410.8454
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320990,NDC,1,EA,410.32,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,207.62192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320995,NDC,1,EA,410.32,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,207.62192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
fluticasone propionate 50 MCG/ACT Suspension 16 g Bottle,63700001,CDM,250,RC,,,,,,50383070016,NDC,16,GR,432.56,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,207.6288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone propionate 50 MCG/ACT Suspension 16 g Bottle,63700001,CDM,250,RC,,,,,,50383070016,NDC,16,GR,432.56,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,207.6288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Fac/Ex Skinbngn0.6-1cmtrnk,Arm,Lg",PX11401F,CDM,510,RC,11401,CPT,,,,,,,,484,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,207.636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.0536,474.32
"Fac/Exc Skn Benig<5mm Face,Facial",PX11440F,CDM,510,RC,11440,CPT,,,,,,,,484,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,207.636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.0536,614.65
"Facility Critical Care, Addl 30 Min",PX99292F,CDM,510,RC,99292,CPT,,,,,,,,484,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,207.636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.0536,474.32
Sigmoidoscope W/Submuc Inj,PX45335P,CDM,983,RC,45335,CPT,,,,,,,,500,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,207.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,207.7,798.45
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060851,NDC,100,ML,213.4,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1.094496241,percent of total billed charges,207.70222,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
OXALiplatin 50 MG/10ML Solution 10 mL Vial,J9263.01,CDM,636,RC,J9263,HCPCS,,,,955173110,NDC,10,ML,228,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,207.708,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.7112,223.44
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041105,NDC,1,ML,419.67,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,207.73665,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.808876,411.2766
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402F,CDM,510,RC,11402,CPT,,,,,,,,424,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,207.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.1296,614.65
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402F,CDM,510,RC,11402,CPT,,,,,,,,424,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,207.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.1296,614.65
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402F,CDM,510,RC,11402,CPT,,,,,,,,424,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,207.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.1296,614.65
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402P,CDM,983,RC,11402,CPT,,,,,,,,424,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,207.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.1296,614.65
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402P,CDM,983,RC,11402,CPT,,,,,,,,424,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,207.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.1296,614.65
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402P,CDM,983,RC,11402,CPT,,,,,,,,424,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,207.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.1296,614.65
Lab H Pylori Stool Ag,PX87338,CDM,300,RC,87338,CPT,,,,,,,,424,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,207.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,415.52
Lab H Pylori Stool Ag,PX87338,CDM,300,RC,87338,CPT,,,,,,,,424,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,207.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,415.52
Lab H Pylori Stool Ag,PX87338,CDM,300,RC,87338,CPT,,,,,,,,424,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,207.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,415.52
"Non-Select. Wound Debride., W/O Anesth.; Top. Appl./Wound Assess./Instruct., per Sess.",PX97602,CDM,761,RC,97602,CPT,,,,,,,,212,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,207.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.0648,207.76
"MESH PROLENE 3X6""",C1781,CDM,278,RC,C1781,HCPCS,,688-MAIN,LOCAL,,,,,213.49,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1256.29,percent of total billed charges,207.789817,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,63323027301,NDC,0.5,ML,235.6,,United Healthcare,All Payer,outpatient,88.2,,225.03,percent of total billed charges,207.7992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
Exc Abd Les Sc < 3 Cm,PX22902F,CDM,761,RC,22902,CPT,,,,,,,,3128,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,207.89,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.5,987.89
Exc Abd Les Sc < 3 Cm,PX22902F,CDM,761,RC,22902,CPT,,,,,,,,3128,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,207.89,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.5,987.89
Exc Abd Les Sc < 3 Cm,PX22902P,CDM,983,RC,22902,CPT,,,,,,,,2086,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,207.89,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.5,2044.28
Exc Abd Les Sc < 3 Cm,PX22902P,CDM,983,RC,22902,CPT,,,,,,,,2086,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,207.89,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.5,2044.28
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Solution 10 mL Bottle,63700001,CDM,250,RC,,,,,,61314064610,NDC,10,ML,433.15,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,207.912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Solution 10 mL Bottle,63700001,CDM,250,RC,,,,,,61314064610,NDC,10,ML,433.15,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,207.912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rabies immune globulin 300 UNIT/2ML Solution 2 mL Vial,90377,CDM,636,RC,90376,CPT,,,,49281019020,NDC,2,ML,3384.84,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,207.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,207.94,3317.1432
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,409277602,NDC,200,ML,228.28,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,207.96308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.827512,225.8704
8MM ENDOWRIST INSTRUMENTS TIP-UP FENESTRATED GRASPER,27200000,CDM,272,RC,,,,11911-MAIN,LOCAL,,,,,411,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,207.966,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Bone Marrow Aspiration and Biopsy,PXG0364F,CDM,510,RC,G0364,HCPCS,,,,,,,,411,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,207.966,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,170.7294,402.78
cabazitaxel 60 MG/1.5ML Solution 6 mL Vial,J9043.01,CDM,636,RC,J9043,HCPCS,,,,24582411,NDC,6,ML,28293.07,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,208.04339,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,185.2,220.98
Exc Skn Beni 0.6-1cm Fcefacial,PX11441P,CDM,983,RC,11441,CPT,,,,,,,,485,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,208.065,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.469,614.65
"Excis Arm/Elbow Tumor,Subcutan",PX24075F,CDM,510,RC,24075,CPT,,,,,,,,1519,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,208.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.15,1108.26
"Excis Arm/Elbow Tumor,Subcutan",PX24075F,CDM,510,RC,24075,CPT,,,,,,,,1519,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,208.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.15,1108.26
"Excis Arm/Elbow Tumor,Subcutan",PX24075P,CDM,983,RC,24075,CPT,,,,,,,,2458,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,208.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.15,2408.84
"Excis Arm/Elbow Tumor,Subcutan",PX24075P,CDM,983,RC,24075,CPT,,,,,,,,2458,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,208.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.15,2408.84
"Biopsy Vulva/Perineum,One Lesn",PX56605F,CDM,510,RC,56605,CPT,,,,,,,,236,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,208.152,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.0344,702.31
Lab Basic Metabolic Panel,PX80048,CDM,300,RC,80048,CPT,,,,,,,,236,,United Healthcare,All Payer,outpatient,88.2,,145.360625,percent of total billed charges,208.152,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.76,231.28
Bcr/Abl1 Other - Ref,PX8120890,CDM,310,RC,81208,CPT,90,,,,,,,1125,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,208.18,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.18,214.62
Bcr/Abl1 Other - Ref,PX8120890,CDM,310,RC,81208,CPT,90,,,,,,,1125,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,208.18,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.18,214.62
Bcr/Abl1 Other - Ref,PX8120890,CDM,310,RC,81208,CPT,90,,,,,,,1125,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,208.18,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.18,214.62
Fibrinogen Activity - Ref,PX8538490,CDM,300,RC,85384,CPT,90,,,,,,,245,,First Health,Commercial,both,85,,999999999,percent of total billed charges,208.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.91,240.1
"Ileoscopy Thru Stoma,Diagnostic",PX44380F,CDM,750,RC,44380,CPT,,,,,,,,245,,First Health,Commercial,both,85,,999999999,percent of total billed charges,208.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.773,791.92
"Injection Hip Arthrogram,Anesth",PX27095F,CDM,510,RC,27095,CPT,,,,,,,,425,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,208.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.545,416.5
"Injection Hip Arthrogram,Anesth",PX27095F,CDM,510,RC,27095,CPT,,,,,,,,425,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,208.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.545,416.5
"Injection Hip Arthrogram,Anesth",PX27095F,CDM,510,RC,27095,CPT,,,,,,,,425,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,208.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.545,416.5
"Injection Hip Arthrogram,Anesth",PX27095P,CDM,983,RC,27095,CPT,,,,,,,,425,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,208.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.545,413.6525
"Injection Hip Arthrogram,Anesth",PX27095P,CDM,983,RC,27095,CPT,,,,,,,,425,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,208.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.545,413.6525
"Injection Hip Arthrogram,Anesth",PX27095P,CDM,983,RC,27095,CPT,,,,,,,,425,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,208.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.545,413.6525
Lipid Profile,PX80061,CDM,300,RC,80061,CPT,,,,,,,,245,,First Health,Commercial,both,85,,999999999,percent of total billed charges,208.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.28,240.1
Platelet Antibodies - Ref,PX8602290,CDM,300,RC,86022,CPT,90,,,,,,,245,,First Health,Commercial,both,85,,999999999,percent of total billed charges,208.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.84,240.1
US Abdomen Limited Tc,PX7670501,CDM,402,RC,76705,CPT,TC,,,,,,,425,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,76.436,percent of total billed charges,208.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,416.5
US Abdomen Limited Tc,PX7670501,CDM,402,RC,76705,CPT,TC,,,,,,,425,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,208.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,416.5
US Abdomen Limited Tc,PX7670501,CDM,402,RC,76705,CPT,TC,,,,,,,425,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,208.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,416.5
US Ext Non-Vasc Img Lmtd,PX7688201,CDM,402,RC,76882,CPT,TC,,,,,,,425,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,208.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,416.5
US Ext Non-Vasc Img Lmtd,PX7688201,CDM,402,RC,76882,CPT,TC,,,,,,,425,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,208.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,416.5
US Ext Non-Vasc Img Lmtd,PX7688201,CDM,402,RC,76882,CPT,TC,,,,,,,425,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,208.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,416.5
CANNULA FOR INJECTION 1.8MM WITH 3MM LUER CONNECTION 8383.65,27200000,CDM,272,RC,,,,12004-MAIN,LOCAL,,,,,234,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,208.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Fibrinogen,PX7426,CDM,300,RC,85384,CPT,,,,,,,,234,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,208.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.91,229.32
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505614700,NDC,1,EA,212.52,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,208.2696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.565642,208.2696
PREP KIT STAPLE 18MM,27200000,CDM,278,RC,C1713,HCPCS,,11658-MAIN,LOCAL,,,,,420.75,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,208.27125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PREP KIT STAPLE 20MM,27200000,CDM,278,RC,C1713,HCPCS,,11659-MAIN,LOCAL,,,,,420.75,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,208.27125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Immunofix Elp,PX86335,CDM,300,RC,86335,CPT,,,,,,,,214,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,208.2862,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.91,209.72
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545F,CDM,510,RC,23545,CPT,,,,,,,,961,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,208.33,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.33,781.73
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545P,CDM,983,RC,23545,CPT,,,,,,,,412,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,208.33,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.33,781.73
Excis Primary Ganglion Wrist,PX25111F,CDM,510,RC,25111,CPT,,,,,,,,791,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,208.33,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.33,694.57
Excis Primary Ganglion Wrist,PX25111P,CDM,983,RC,25111,CPT,,,,,,,,529,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,208.33,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.33,694.57
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545P,CDM,983,RC,23545,CPT,,,,,,,,412,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,208.472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,171.1448,400.9996
"Closed Rx Big Toe Fx,Manip",PX28495P,CDM,983,RC,28495,CPT,,,,,,,,412,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,208.472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,171.1448,400.9996
ARTISTA AH 3GRAM ABSORBABLE HEMOSTATIC PARTICLES,27200000,CDM,272,RC,A6199,HCPCS,,10227-MAIN,LOCAL,,,,,486,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,208.494,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002P,CDM,983,RC,12002,CPT,,,,,,,,486,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,208.494,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,473.0238
Xray Sinuses Less Than 3 Vws,PX7021001,CDM,320,RC,70210,CPT,TC,,,,,,,486,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,208.494,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,476.28
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,23155052431,NDC,10,ML,486.06,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,208.51974,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,23155052441,NDC,10,ML,486.06,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,208.51974,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Chemotherapy, IV Push, Single Drug",PX96409,CDM,335,RC,96409,CPT,,,,,,,,502,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,208.5308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.5308,491.96
Incise External Hemorrhoid,PX46083F,CDM,510,RC,46083,CPT,,,,,,,,502,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,208.5308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.5308,491.96
patiromer sorbitex calcium 8.4 g Packet 4 Each Box,63700001,CDM,250,RC,,,,,,53436008404,NDC,1,EA,228.96,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,208.58256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Ctrl Nosebleed,Anter,Simple",PX30901P,CDM,983,RC,30901,CPT,,,,,,,,229,,Medica,Commercial,both,91.1,,28,percent of total billed charges,208.619,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.1266,222.8857
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604P,CDM,983,RC,20604,CPT,,,,,,,,229,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,208.619,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.1266,258.75
Removal of Nail Plate,PX11730F,CDM,510,RC,11730,CPT,,,,,,,,229,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,208.619,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.1266,224.42
Apply Multlay Comprs Lwr Leg,PX29581F,CDM,510,RC,29581,CPT,,,,,,,,213,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,208.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.4802,208.74
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006F,CDM,510,RC,10006,CPT,,,,,,,,213,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,208.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.4802,208.74
"GI Pathogen Panel, Pcr - Ref",PX8750790,CDM,300,RC,87507,CPT,90,,,,,,,213,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,208.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.4802,382.15
Remove Impacted Ear Wax,PX69210F,CDM,510,RC,69210,CPT,,,,,,,,213,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,208.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.44,208.74
Biopsy Synovium I-P Jt,PX26110,CDM,983,RC,26110,CPT,,,,,,,,933,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,208.77,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.77,914.34
"Lap,Dx Surgical Abd W/Biopsy",PX49321F,CDM,510,RC,49321,CPT,,,,,,,,874,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,208.77,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.77,718.78
"Lap,Dx Surgical Abd W/Biopsy",PX49321P,CDM,983,RC,49321,CPT,,,,,,,,583,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,208.77,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.77,718.78
Closure Superf Wnd Dehis Simple,PX12020P,CDM,983,RC,12020,CPT,,,,,,,,422,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,208.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,175.2988,548.67
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102F,CDM,510,RC,11102,CPT,,,,,,,,171,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,208.92,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.56,208.92
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102P,CDM,983,RC,11102,CPT,,,,,,,,465,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,208.92,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.56,455.7
Trb@ Gene Rearrange Amplify - Ref,PX8134090,CDM,300,RC,81340,CPT,90,,,,,,,503,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,208.92,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,202.65,208.92
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004004,NDC,120,ML,502.95,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,208.92543,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
Trb@ Gene Rearrange Amplify - Ref,PX8134090,CDM,300,RC,81340,CPT,90,,,,,,,503,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,208.9462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,191.56,492.94
Repair of Vagina,PX57200P,CDM,983,RC,57200,CPT,,,,,,,,1043,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,208.98,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.98,1022.14
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,61314054701,NDC,2.5,ML,487.35,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,209.07315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
KATZ EXTRACTOR OTO-RHINO FOREIGN BODY REMOVER,120.568,CDM,272,RC,,,,12808-MAIN,LOCAL,,,,,246,,First Health,Commercial,both,85,,999999999,percent of total billed charges,209.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.1884,241.08
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060851,NDC,100,ML,213.4,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,209.132,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.900398,209.132
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152F,CDM,370,RC,99152,CPT,,,,,,,,235,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,209.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97.619,230.3
Occupational Therapy Eval Low Complex,PX97165,CDM,434,RC,97165,CPT,,,,,,,,235,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,209.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,230.3
Physical Therapy Evaluation Low Complex,PX97161,CDM,424,RC,97161,CPT,,,,,,,,235,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,209.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,392.7
Remv Ext Canal Foreign Body,PX69200F,CDM,510,RC,69200,CPT,,,,,,,,235,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,209.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97.619,230.3
"Vitamin D, 25 Hydroxy",PX82306,CDM,300,RC,82306,CPT,,,,,,,,235,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,209.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.14,230.3
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,121090204,NDC,120,ML,503.56,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,209.178824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
"MESH PROLENE 3X6""",C1781,CDM,278,RC,C1781,HCPCS,,688-MAIN,LOCAL,,,,,213.49,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,209.2202,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Immunoglobulin Subclasses - Ref,PX8278790,CDM,300,RC,82787,CPT,90,,,,,,,215,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,209.2595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.35,210.7
X-Ray Exam Abdomen 2 Views,PX7401901,CDM,320,RC,74019,CPT,TC,,,,,,,436,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,209.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,427.28
X-Ray Exam Abdomen 2 Views,PX7401901,CDM,320,RC,74019,CPT,TC,,,,,,,436,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,209.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,427.28
"X-Ray Exam Hip,Unilat W/Pelvis 2-3 Vws",PX7350201,CDM,320,RC,73502,CPT,TC,,,,,,,436,,Health Partners,Health Partners Care Plans,both,48,,134.98,percent of total billed charges,209.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,427.28
"X-Ray Exam Hip,Unilat W/Pelvis 2-3 Vws",PX7350201,CDM,320,RC,73502,CPT,TC,,,,,,,436,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,209.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,427.28
Xray Abdomen Comp Incl Decub and/or Erect,PX7402001,CDM,320,RC,74020,CPT,TC,,,,,,,436,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,209.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.1144,427.28
Xray Abdomen Comp Incl Decub and/or Erect,PX7402001,CDM,320,RC,74020,CPT,TC,,,,,,,436,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,209.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.1144,427.28
Xray Cervical Spine 2 or 3 Vws,PX7204001,CDM,320,RC,72040,CPT,TC,,,,,,,436,,Health Partners,Health Partners Care Plans,both,48,,422.92,percent of total billed charges,209.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,427.28
Xray Cervical Spine 2 or 3 Vws,PX7204001,CDM,320,RC,72040,CPT,TC,,,,,,,436,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,209.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,427.28
Irradiated Leukoreduced Rbc's,PXP9040,CDM,390,RC,P9040,HCPCS,,,,,,,,771,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,209.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,209.36,351.536
Irradiated Leukoreduced Rbc's,PXP9040,CDM,390,RC,P9040,HCPCS,,,,,,,,771,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,209.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,209.36,351.536
Irradiated Leukoreduced Rbc's,PXP9040,CDM,390,RC,P9040,HCPCS,,,,,,,,771,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,209.36,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,209.36,351.536
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037905,NDC,0.5,ML,229.88,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,209.42068,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Suspension 10 mL Bottle,63700001,CDM,250,RC,,,,,,64980044801,NDC,10,ML,488.25,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,209.45925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
X-Ray Exam Entire Spine 1vw,PX7208101,CDM,320,RC,72081,CPT,TC,,,,,,,414,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,209.484,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,405.72
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,63323027301,NDC,0.5,ML,235.6,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,209.684,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
CT Abd & Pelvis W/O Contrast,PX7417601,CDM,350,RC,74176,CPT,TC,,,,,,,4288,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,209.71,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.89,209.71
CT Abd & Pelvis W/O Contrast,PX7417601,CDM,350,RC,74176,CPT,TC,,,,,,,4288,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,209.71,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.89,209.71
Immunofix Elp,PX86335,CDM,300,RC,86335,CPT,,,,,,,,214,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,209.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.91,209.72
Resp Virus 6-11 Targets,PX87632,CDM,300,RC,87632,CPT,,,,,,,,428,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,209.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,177.7912,419.44
Resp Virus 6-11 Targets,PX87632,CDM,300,RC,87632,CPT,,,,,,,,428,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,209.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,177.7912,419.44
Resp Virus 6-11 Targets,PX87632,CDM,300,RC,87632,CPT,,,,,,,,428,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,209.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,177.7912,419.44
Xray Thoracic Spine 2 Vws,PX7207001,CDM,320,RC,72070,CPT,TC,,,,,,,428,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,209.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,419.44
Xray Thoracic Spine 2 Vws,PX7207001,CDM,320,RC,72070,CPT,TC,,,,,,,428,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,209.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,419.44
Xray Thoracic Spine 2 Vws,PX7207001,CDM,320,RC,72070,CPT,TC,,,,,,,428,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,209.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,419.44
Xray Ribs Unilat 2 Vws,PX7110001,CDM,320,RC,71100,CPT,TC,,,,,,,437,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,209.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,428.26
Xray Ribs Unilat 2 Vws,PX7110001,CDM,320,RC,71100,CPT,TC,,,,,,,437,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,209.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,428.26
Diagnostic Anoscopy,PX46600F,CDM,510,RC,46600,CPT,,,,,,,,505,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,209.777,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,494.9
erythromycin lactobionate 500 MG Recon Soln 1 Each Vial,J1364.01,CDM,636,RC,J1364,HCPCS,,,,409648211,NDC,1,EA,437.09,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,209.8032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.06,428.3482
erythromycin lactobionate 500 MG Recon Soln 1 Each Vial,J1364.01,CDM,636,RC,J1364,HCPCS,,,,409648211,NDC,1,EA,437.09,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,209.8032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.06,428.3482
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402F,CDM,510,RC,11402,CPT,,,,,,,,424,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,209.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.1296,614.65
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402P,CDM,983,RC,11402,CPT,,,,,,,,424,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,209.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.1296,614.65
Lab H Pylori Stool Ag,PX87338,CDM,300,RC,87338,CPT,,,,,,,,424,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,209.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,415.52
Phlebotomy,PX99195,CDM,940,RC,99195,CPT,,,,,,,,238,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,209.916,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.8652,233.24
medroxyPROGESTERone 150 MG/ML Suspension 1 mL Vial,J1050.01,CDM,636,RC,J1050,HCPCS,,,,67457088799,NDC,1,ML,437.38,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,209.9424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.687652,428.6324
medroxyPROGESTERone 150 MG/ML Suspension 1 mL Vial,J1050.01,CDM,636,RC,J1050,HCPCS,,,,67457088799,NDC,1,ML,437.38,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,209.9424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.687652,428.6324
Drain/Inject Medium Joint/Bursa,PX20605F,CDM,510,RC,20605,CPT,,,,,,,,247,,First Health,Commercial,both,85,,999999999,percent of total billed charges,209.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.6038,258.75
fluticasone propionate 50 MCG/ACT Suspension 16 g Bottle,63700001,CDM,250,RC,,,,,,60505082901,NDC,16,GR,437.4,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,209.952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone propionate 50 MCG/ACT Suspension 16 g Bottle,63700001,CDM,250,RC,,,,,,60505082901,NDC,16,GR,437.4,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,209.952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,143971801,NDC,200,ML,230.48,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,209.96728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.827512,225.8704
Sleep Staging 4 + Pap,PX9581126,CDM,982,RC,95811,CPT,26,,,,,,,1850,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,209.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.22,1813
Sleep Staging 4 + Pap,PX9581126,CDM,982,RC,95811,CPT,26,,,,,,,1850,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,209.99,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.22,1813
"US Complete Joint, Realtime W/ Img Tc",PX7688101,CDM,402,RC,76881,CPT,TC,,,,,,,415,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,209.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,406.7
calcitonin (salmon) 200 UNIT/ACT Solution 3.7 mL Bottle,63700001,CDM,250,RC,,,,,,60505082306,NDC,3.7,ML,489.57,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,210.02553,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Biopsy Vulva/Perineum,One Lesn",PX56605F,CDM,510,RC,56605,CPT,,,,,,,,236,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,210.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.0344,702.31
Lab Basic Metabolic Panel,PX80048,CDM,300,RC,80048,CPT,,,,,,,,236,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,210.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.76,231.28
Bcr/Abl1 Other - Ref,PX8120890,CDM,310,RC,81208,CPT,90,,,,,,,1125,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,210.1895,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.18,214.62
I&D Bartholin Gland Abscess,PX56420F,CDM,510,RC,56420,CPT,,,,,,,,429,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,210.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.08,420.42
I&D Bartholin Gland Abscess,PX56420F,CDM,510,RC,56420,CPT,,,,,,,,429,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,210.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.08,420.42
I&D Bartholin Gland Abscess,PX56420F,CDM,510,RC,56420,CPT,,,,,,,,429,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,210.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.08,420.42
Xray Knee 4 or More Vws,PX7356401,CDM,320,RC,73564,CPT,TC,,,,,,,490,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,210.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,480.2
C-COLLAR ASPEN REGULAR 79-83365,120.25,CDM,274,RC,L0140,HCPCS,,167-MAIN,LOCAL,,,,,216,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,210.2328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.58,211.68
C-COLLAR ASPEN TALL 79-83367,120.25,CDM,274,RC,L0140,HCPCS,,164-MAIN,LOCAL,,,,,216,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,210.2328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.58,211.68
C-COLLAR ASPEN X-TALL 79-83368,120.25,CDM,274,RC,L0140,HCPCS,,168-MAIN,LOCAL,,,,,216,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,210.2328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.58,211.68
"Remv F.B.,Eye,Embed Conjunc",PX65210P,CDM,983,RC,65210,CPT,,,,,,,,216,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,210.2328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,89.7264,348.08
Debride Bone Ea Add 20 Sqcm,PX11047F,CDM,510,RC,11047,CPT,,,,,,,,438,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,210.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.9452,429.24
Debride Bone Ea Add 20 Sqcm,PX11047F,CDM,510,RC,11047,CPT,,,,,,,,438,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,210.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.9452,429.24
US Pregnancy Tc Limited,PX7681501,CDM,402,RC,76815,CPT,TC,,,,,,,438,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,210.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,429.24
US Pregnancy Tc Limited,PX7681501,CDM,402,RC,76815,CPT,TC,,,,,,,438,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,210.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,429.24
"Repair Flex Foot Tendon,Ea",PX28200F,CDM,510,RC,28200,CPT,,,,,,,,1475,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,210.29,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,207.02,1026.63
"Repair Flex Foot Tendon,Ea",PX28200F,CDM,510,RC,28200,CPT,,,,,,,,1475,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,210.29,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,207.02,1026.63
dorzolamide-timolol 2-0.5 % Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,50383023310,NDC,10,ML,506.34,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,210.333636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Injection Hip Arthrogram,Anesth",PX27095F,CDM,510,RC,27095,CPT,,,,,,,,425,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,210.375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.545,416.5
"Injection Hip Arthrogram,Anesth",PX27095P,CDM,983,RC,27095,CPT,,,,,,,,425,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,210.375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.545,413.6525
US Abdomen Limited Tc,PX7670501,CDM,402,RC,76705,CPT,TC,,,,,,,425,,Humana Choice Care,All Medicare plans,outpatient,49.5,,85.99,percent of total billed charges,210.375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,416.5
US Ext Non-Vasc Img Lmtd,PX7688201,CDM,402,RC,76882,CPT,TC,,,,,,,425,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,210.375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,416.5
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Suspension 10 mL Bottle,63700001,CDM,250,RC,,,,,,24208063562,NDC,10,ML,415.81,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,210.39986,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gentamicin 0.1 % Ointment 30 g Tube,25000000,CDM,250,RC,,,,,,713068231,NDC,30,GR,506.64,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,210.458256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
US Head/Neck Tc,PX7653601,CDM,402,RC,76536,CPT,TC,,,,,,,416,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,210.496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,407.68
Lvl 3 Sub Hosp High Mdm or 50 Minutes,PX99233,CDM,982,RC,99233,CPT,,,,,,,,384,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,210.5,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.41,376.32
Lvl 3 Sub Hosp High Mdm or 50 Minutes,PX99233,CDM,982,RC,99233,CPT,,,,,,,,384,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,210.5,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.41,376.32
"Closed Rx Talus Fx,Manipulatn",PX28435F,CDM,510,RC,28435,CPT,,,,,,,,1705,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,210.51,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,210.51,796.26
"Closed Rx Talus Fx,Manipulatn",PX28435P,CDM,983,RC,28435,CPT,,,,,,,,1137,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,210.51,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,210.51,1114.26
I&D Deep Absc/Hematoma Neck/Chest,PX21501F,CDM,510,RC,21501,CPT,,,,,,,,773,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,210.51,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,210.51,1021.1
I&D Deep Absc/Hematoma Neck/Chest,PX21501P,CDM,983,RC,21501,CPT,,,,,,,,515,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,210.51,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,210.51,1021.1
"Removal of Hydrocele,Tunica,Unilat",PX55040P,CDM,983,RC,55040,CPT,,,,,,,,1420,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,210.51,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,210.51,1391.6
nystatin-triamcinolone 100000-0.1 UNIT/GM-% Ointment 30 g Tube,25000000,CDM,250,RC,,,,,,52565004230,NDC,30,GR,438.62,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,210.5376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
nystatin-triamcinolone 100000-0.1 UNIT/GM-% Ointment 30 g Tube,25000000,CDM,250,RC,,,,,,52565004230,NDC,30,GR,438.62,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,210.5376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
neomycin-polymyxin-dexamethasone 3.5-10000-0.1 Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,61314063136,NDC,3.5,GR,247.71,,First Health,Commercial,both,85,,999999999,percent of total billed charges,210.5535,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
neomycin-polymyxin-dexameth 3.5-10000-0.1 Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063006,NDC,5,ML,247.72,,First Health,Commercial,both,85,,999999999,percent of total billed charges,210.562,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221901,NDC,3,ML,506.9,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,210.56626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221905,NDC,3,ML,506.9,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,210.56626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279210,NDC,10,ML,429.84,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,210.6216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,178.555536,421.2432
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279210,NDC,10,ML,429.84,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,210.6216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,178.555536,421.2432
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279210,NDC,10,ML,429.84,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,210.6216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,178.555536,421.2432
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279410,NDC,10,ML,429.84,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,210.6216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,178.555536,421.2432
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279410,NDC,10,ML,429.84,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,210.6216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,178.555536,421.2432
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279410,NDC,10,ML,429.84,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,210.6216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,178.555536,421.2432
ipratropium 0.06 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,54004641,NDC,15,ML,491.02,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,210.64758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Immunoglobulin Subclasses - Ref,PX8278790,CDM,300,RC,82787,CPT,90,,,,,,,215,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,210.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.35,210.7
RELOAD SUREFORM 60 2.5 WHITE 6 ROW BOX/12,27200000,CDM,272,RC,,,,12261-MAIN,LOCAL,,,,,430,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,210.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 60 2.5 WHITE 6 ROW BOX/12,27200000,CDM,272,RC,,,,12261-MAIN,LOCAL,,,,,430,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,210.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 60 2.5 WHITE 6 ROW BOX/12,27200000,CDM,272,RC,,,,12261-MAIN,LOCAL,,,,,430,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,210.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 60 3.5 BLUE,27200000,CDM,272,RC,,,,12084-MAIN,LOCAL,,,,,430,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,210.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 60 3.5 BLUE,27200000,CDM,272,RC,,,,12084-MAIN,LOCAL,,,,,430,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,210.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 60 3.5 BLUE,27200000,CDM,272,RC,,,,12084-MAIN,LOCAL,,,,,430,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,210.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 60 4.3 GREEN,27200000,CDM,272,RC,,,,12085-MAIN,LOCAL,,,,,430,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,210.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 60 4.3 GREEN,27200000,CDM,272,RC,,,,12085-MAIN,LOCAL,,,,,430,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,210.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 60 4.3 GREEN,27200000,CDM,272,RC,,,,12085-MAIN,LOCAL,,,,,430,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,210.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM ENDOWRIST INSTRUMENTS 8MM FORCE BIPOLAR IS4000,27200000,CDM,272,RC,,,,11915-MAIN,LOCAL,,,,,439,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,210.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM ENDOWRIST INSTRUMENTS 8MM FORCE BIPOLAR IS4000,27200000,CDM,272,RC,,,,11915-MAIN,LOCAL,,,,,439,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,210.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
VISIGI3D 40FR STD WITH BULB,27100000,CDM,271,RC,,,,12812-MAIN,LOCAL,,,,,439,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,210.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
VISIGI3D 40FR STD WITH BULB,27100000,CDM,271,RC,,,,12812-MAIN,LOCAL,,,,,439,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,210.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
Explor Metatarso-Phalang Jt,PX28022F,CDM,510,RC,28022,CPT,,,,,,,,1161,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,210.73,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,207.02,1012.1
Explor Metatarso-Phalang Jt,PX28022F,CDM,510,RC,28022,CPT,,,,,,,,1161,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,210.73,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,207.02,1012.1
Explor Metatarso-Phalang Jt,PX28022P,CDM,983,RC,28022,CPT,,,,,,,,774,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,210.73,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,207.02,1012.1
Explor Metatarso-Phalang Jt,PX28022P,CDM,983,RC,28022,CPT,,,,,,,,774,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,210.73,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,207.02,1012.1
Physical Therapy Re-Eval Est Plan Care 20 Mins,PX97164,CDM,424,RC,97164,CPT,,,,,,,,239,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,210.798,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,234.22
Closed Rx Mt-Phal Toe Dislocation,PX28630P,CDM,983,RC,28630,CPT,,,,,,,,248,,First Health,Commercial,both,85,,999999999,percent of total billed charges,210.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.0192,241.3784
Debride Muscle Ea Add 20 Sqcm,PX11046F,CDM,510,RC,11046,CPT,,,,,,,,248,,First Health,Commercial,both,85,,999999999,percent of total billed charges,210.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.0192,243.04
Fetal Profile W/O Stress,PX7681901,CDM,402,RC,76819,CPT,TC,,,,,,,248,,First Health,Commercial,both,85,,999999999,percent of total billed charges,210.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,243.04
Ther Injection Carpal Tunnel,PX20526P,CDM,983,RC,20526,CPT,,,,,,,,248,,First Health,Commercial,both,85,,999999999,percent of total billed charges,210.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.0192,258.75
US Chest Tc,PX7660401,CDM,402,RC,76604,CPT,TC,,,,,,,248,,First Health,Commercial,both,85,,999999999,percent of total billed charges,210.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,243.04
"West Nile Ab, Igg - Ref",PX8678990,CDM,300,RC,86789,CPT,90,,,,,,,248,,First Health,Commercial,both,85,,999999999,percent of total billed charges,210.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,243.04
DRAIN FLAT JACKSON PRATT 10MM,27100000,CDM,271,RC,,,,334-MAIN,LOCAL,,,,,239.09,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,210.87738,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614800,NDC,1,EA,239.18,,United Healthcare,All Payer,outpatient,88.2,,201.07,percent of total billed charges,210.95676,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
Xray Ribs Bilat 3 Vws With Pa Chest,PX7111101,CDM,320,RC,71111,CPT,TC,,,,,,,417,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,211.002,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,408.66
nystatin 100000 UNIT/GM Powder 60 g Bottle,63700001,CDM,250,RC,,,,,,574200802,NDC,60,GR,491.86,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,211.00794,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Inpatient Consult, Level IV",PX99254,CDM,983,RC,99254,CPT,,,,,,,,508,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,211.0232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.0232,494.4364
Lvl 2 Init Hosp Mod Mdm or 55 Minutes,PX99222,CDM,982,RC,99222,CPT,,,,,,,,508,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,211.0232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.0232,494.4364
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762F,CDM,510,RC,43762,CPT,,,,,,,,492,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,211.068,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,204.3768,482.16
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802201,NDC,0.8,ML,439.77,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,211.0896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802201,NDC,0.8,ML,439.77,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,211.0896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802210,NDC,0.8,ML,439.77,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,211.0896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802210,NDC,0.8,ML,439.77,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,211.0896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,781344071,NDC,1,EA,430.94,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,211.1606,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,179.012476,460.7862
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,781344071,NDC,1,EA,430.94,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,211.1606,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,179.012476,460.7862
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,781344071,NDC,1,EA,430.94,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,211.1606,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,179.012476,460.7862
umeclidinium 62.5 MCG/ACT Aerosol Powder Breath Activated 7 Each Disp Pack,63700001,CDM,250,RC,,,,,,173087306,NDC,7,EA,492.23,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,211.16667,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Procalcitonin,PX84145,CDM,300,RC,84145,CPT,,,,,,,,217,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,150.1428571,percent of total billed charges,211.2061,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.96,212.66
TRAY 8 FR 5IN CENTESIS WITH TURKEL  30-CE1CO,120.303,CDM,272,RC,,,,11503-MAIN,LOCAL,,,,,217,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,211.2061,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,90.1418,212.66
Bile Acids Total,PX8223990,CDM,300,RC,82239,CPT,90,,,,,,,232,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,211.352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,227.36
Biopsy Synovium I-P Jt,PX26110,CDM,983,RC,26110,CPT,,,,,,,,933,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,211.38,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.77,914.34
Biopsy Synovium I-P Jt,PX26110,CDM,983,RC,26110,CPT,,,,,,,,933,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,211.38,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.77,914.34
Repair of Vagina,PX57200P,CDM,983,RC,57200,CPT,,,,,,,,1043,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,211.38,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.98,1022.14
Repair of Vagina,PX57200P,CDM,983,RC,57200,CPT,,,,,,,,1043,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,211.38,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.98,1022.14
Acute Hepatitis Panel,PX80074,CDM,300,RC,80074,CPT,,,,,,,,509,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,211.4386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,43.67,498.82
Biopsy of Rectum,PX45100P,CDM,983,RC,45100,CPT,,,,,,,,509,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,211.4386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.4386,2452.93
Removal of Skin Tags,PX11200P,CDM,983,RC,11200,CPT,,,,,,,,418,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,211.508,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,173.6372,406.8394
Resp Virus 6-11 Targets,PX87632,CDM,300,RC,87632,CPT,,,,,,,,428,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,211.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.52,218.06
Resp Virus 6-11 Targets,PX87632,CDM,300,RC,87632,CPT,,,,,,,,428,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,211.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.52,218.06
Resp Virus 6-11 Targets,PX87632,CDM,300,RC,87632,CPT,,,,,,,,428,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,211.52,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.52,218.06
Excis Primary Ganglion Wrist,PX25111F,CDM,510,RC,25111,CPT,,,,,,,,791,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,211.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.33,694.57
Excis Primary Ganglion Wrist,PX25111F,CDM,510,RC,25111,CPT,,,,,,,,791,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,211.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.33,694.57
Excis Primary Ganglion Wrist,PX25111P,CDM,983,RC,25111,CPT,,,,,,,,529,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,211.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.33,694.57
Excis Primary Ganglion Wrist,PX25111P,CDM,983,RC,25111,CPT,,,,,,,,529,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,211.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.33,694.57
"Fac/Office Consultation,Level IV",PX99244F,CDM,510,RC,99244,CPT,,,,,,,,441,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,211.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,183.1914,432.18
"Fac/Office Consultation,Level IV",PX99244F,CDM,510,RC,99244,CPT,,,,,,,,441,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,211.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,183.1914,432.18
Gastric Intubation Treatment,PX43753F,CDM,510,RC,43753,CPT,,,,,,,,441,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,211.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,183.1914,432.18
Gastric Intubation Treatment,PX43753F,CDM,510,RC,43753,CPT,,,,,,,,441,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,211.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,183.1914,432.18
C-COLLAR ASPEN REGULAR 79-83365,120.25,CDM,274,RC,L0140,HCPCS,,167-MAIN,LOCAL,,,,,216,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,211.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.58,211.68
C-COLLAR ASPEN TALL 79-83367,120.25,CDM,274,RC,L0140,HCPCS,,164-MAIN,LOCAL,,,,,216,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,211.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.58,211.68
C-COLLAR ASPEN X-TALL 79-83368,120.25,CDM,274,RC,L0140,HCPCS,,168-MAIN,LOCAL,,,,,216,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,211.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.58,211.68
"Remv F.B.,Eye,Embed Conjunc",PX65210P,CDM,983,RC,65210,CPT,,,,,,,,216,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,211.68,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.69,211.68
Xray Eye Foreign Body,PX7003001,CDM,320,RC,70030,CPT,TC,,,,,,,432,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,211.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,423.36
Xray Eye Foreign Body,PX7003001,CDM,320,RC,70030,CPT,TC,,,,,,,432,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,211.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,423.36
Xray Eye Foreign Body,PX7003001,CDM,320,RC,70030,CPT,TC,,,,,,,432,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,211.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,423.36
Removal of Nail Bed,PX11750F,CDM,510,RC,11750,CPT,,,,,,,,629,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,211.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.91,334.83
Abd Duplex Abd -Follow Up,PX9397602,CDM,921,RC,93976,CPT,TC,,,,,,,784,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,211.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.55,211.74
Abd Duplex Abd -Follow Up,PX9397602,CDM,921,RC,93976,CPT,TC,,,,,,,784,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,211.74,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.55,211.74
Abd Duplex Abd-Follow Up(T),PX9397601,CDM,921,RC,93976,CPT,TC,,,,,,,809,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,211.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.55,211.74
Abd Duplex Abd-Follow Up(T),PX9397601,CDM,921,RC,93976,CPT,TC,,,,,,,809,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,211.74,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.55,211.74
US Doppler Lw Ext Art Tc,PX9392601,CDM,921,RC,93926,CPT,TC,,,,,,,740,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,211.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.89,211.74
US Doppler Lw Ext Art Tc,PX9392601,CDM,921,RC,93926,CPT,TC,,,,,,,740,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,211.74,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.89,211.74
cabazitaxel 60 MG/1.5ML Solution 6 mL Vial,J9043.01,CDM,636,RC,J9043,HCPCS,,,,24582411,NDC,6,ML,28293.07,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,211.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,185.2,220.98
cabazitaxel 60 MG/1.5ML Solution 6 mL Vial,J9043.01,CDM,636,RC,J9043,HCPCS,,,,24582411,NDC,6,ML,28293.07,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,211.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,185.2,220.98
"Fac/Office Consultation,Level IV",PX99244F,CDM,510,RC,99244,CPT,,,,,,,,441,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,211.808,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.11,287.64
"Office Consultation,Level IV",PX99244P,CDM,983,RC,99244,CPT,,,,,,,,441,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,211.808,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.11,432.18
Phlebotomy,PX99195,CDM,940,RC,99195,CPT,,,,,,,,238,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,211.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.8652,233.24
Part Remv Phalanx of Toe,PX28124F,CDM,510,RC,28124,CPT,,,,,,,,2155,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,211.82,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.82,992.04
Part Remv Phalanx of Toe,PX28124P,CDM,983,RC,28124,CPT,,,,,,,,1515,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,211.82,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.82,1484.7
amiodarone 150-4.21 MG/100ML-% Solution 100 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066015010,NDC,100,ML,249.22,,First Health,Commercial,both,85,,999999999,percent of total billed charges,211.837,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.35,318.745
cefoTEtan 2 g Recon Soln 1 Each Vial,800000,CDM,,,S0074,HCPCS,,,,63323038620,NDC,1,EA,240.2,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,211.8564,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Resp Virus 6-11 Targets,PX87632,CDM,300,RC,87632,CPT,,,,,,,,428,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,211.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,177.7912,419.44
Xray Thoracic Spine 2 Vws,PX7207001,CDM,320,RC,72070,CPT,TC,,,,,,,428,,Humana Choice Care,All Medicare plans,outpatient,49.5,,255.4,percent of total billed charges,211.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,419.44
CRICOTHROTOMY QUICKTRACH 4MM,120.228,CDM,272,RC,A7520,HCPCS,,8868-MAIN,LOCAL,,,,,494,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,211.926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.2076,484.12
SET CRICOTHYROTOMY CATHETER 6MM ID,120.378,CDM,272,RC,,,,11119-MAIN,LOCAL,,,,,494,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,211.926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.2076,484.12
fluticasone propionate 50 MCG/ACT Suspension 16 g Bottle,63700001,CDM,250,RC,,,,,,50383070016,NDC,16,GR,432.56,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,211.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone propionate 50 MCG/ACT Suspension 16 g Bottle,63700001,CDM,250,RC,,,,,,50383070016,NDC,16,GR,432.56,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,211.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone propionate 50 MCG/ACT Suspension 16 g Bottle,63700001,CDM,250,RC,,,,,,50383070016,NDC,16,GR,432.56,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,211.9544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cefdinir 250 MG/5ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,16714039301,NDC,60,ML,510.33,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,211.991082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
TRAY PNEUMOTHORAX 14FR 29CM 19 CATHETER SIDEPORTS G56537,120.496,CDM,272,RC,,,,11677-MAIN,LOCAL,,,,,419,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,212.014,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.0526,410.62
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494301,NDC,0.5,ML,419.2,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,212.1152,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.38,410.8454
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494300,NDC,0.5,ML,419.23,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,212.13038,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.38,410.8454
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781315972,NDC,1,EA,217.96,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,212.140468,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86,213.6008
Closed Rx Bimalleolar Fx,PX27808P,CDM,983,RC,27808,CPT,,,,,,,,433,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,212.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,179.8682,421.4389
Closed Rx Bimalleolar Fx,PX27808P,CDM,983,RC,27808,CPT,,,,,,,,433,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,212.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,179.8682,421.4389
Closed Rx Bimalleolar Fx,PX27808P,CDM,983,RC,27808,CPT,,,,,,,,433,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,212.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,179.8682,421.4389
ondansetron 4 MG/5ML Solution 25 mL Bottle,S0119.01,CDM,636,RC,S0119,HCPCS,,,,99998-8001-,NDC,25,ML,494.57,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,212.17053,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Solution 10 mL Bottle,63700001,CDM,250,RC,,,,,,61314064610,NDC,10,ML,433.15,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,212.2435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Solution 10 mL Bottle,63700001,CDM,250,RC,,,,,,61314064610,NDC,10,ML,433.15,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,212.2435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Solution 10 mL Bottle,63700001,CDM,250,RC,,,,,,61314064610,NDC,10,ML,433.15,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,212.2435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,68462018022,NDC,22,GR,240.66,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,212.26212,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
TRAY GROSHONG 4FR SAFETY PICC 7617407,120.26,CDM,272,RC,,,,500-MAIN,LOCAL,,,,,233,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,212.263,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.7882,228.34
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041105,NDC,1,ML,419.67,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,212.35302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.808876,411.2766
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725F,CDM,510,RC,26725,CPT,,,,,,,,495,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,212.355,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.623,485.1
I&D Bartholin Gland Abscess,PX56420F,CDM,510,RC,56420,CPT,,,,,,,,429,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,212.355,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.08,420.42
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101F,CDM,510,RC,13101,CPT,,,,,,,,495,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,212.355,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.623,548.67
Tc99 Mebrofenin to 15 Mci,PXA9537,CDM,343,RC,A9537,HCPCS,,,,,,,,495,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,212.355,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.623,485.1
"I&D Perianal Abscess,Superficial",PX46050,CDM,983,RC,46050,CPT,,,,,,,,1096,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,212.38,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.26,1074.08
"I&D Perianal Abscess,Superficial",PX46050F,CDM,510,RC,46050,CPT,,,,,,,,1463,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,212.38,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.26,492.56
"I&D Perianal Abscess,Superficial",PX46050P,CDM,983,RC,46050,CPT,,,,,,,,993,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,212.38,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.26,973.14
levOCARNitine 200 MG/ML Solution 5 mL Vial,J1955.01,CDM,636,RC,J1955,HCPCS,,,,517104501,NDC,5,ML,249.86,,First Health,Commercial,both,85,,999999999,percent of total billed charges,212.381,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.791844,244.8628
rifAXIMin 550 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,65649030302,NDC,1,EA,218.25,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,212.422725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rifAXIMin 550 MG Tablet 60 Each Box,63700001,CDM,250,RC,,,,,,65649030303,NDC,1,EA,218.25,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,212.422725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153P,CDM,983,RC,99153,CPT,,,,,,,,250,,First Health,Commercial,both,85,,999999999,percent of total billed charges,212.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.85,243.325
sincalide 5 MCG Recon Soln 1 Each Vial,J2805.01,CDM,636,RC,J2805,HCPCS,,,,270055615,NDC,1,EA,250,,First Health,Commercial,both,85,,999999999,percent of total billed charges,212.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.85,245
Withdrawal of Arterial Blood,PX36600F,CDM,510,RC,36600,CPT,,,,,,,,250,,First Health,Commercial,both,85,,999999999,percent of total billed charges,212.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.85,245
Closed Rx Metacarpal Fx,PX26600F,CDM,510,RC,26600,CPT,,,,,,,,443,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,212.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,184.0222,434.14
Closed Rx Metacarpal Fx,PX26600F,CDM,510,RC,26600,CPT,,,,,,,,443,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,212.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,184.0222,434.14
Procalcitonin,PX84145,CDM,300,RC,84145,CPT,,,,,,,,217,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,212.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.96,212.66
TRAY 8 FR 5IN CENTESIS WITH TURKEL  30-CE1CO,120.303,CDM,272,RC,,,,11503-MAIN,LOCAL,,,,,217,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,212.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,90.1418,212.66
DRIVER HEX 2.00MM STERILE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12440-MAIN,LOCAL,,,,,512,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,212.6848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRIVER HEX 2.5MM STERILE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12441-MAIN,LOCAL,,,,,512,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,212.6848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Physical Therapy Re-Eval Est Plan Care 20 Mins,PX97164,CDM,424,RC,97164,CPT,,,,,,,,239,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,212.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,234.22
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279210,NDC,10,ML,429.84,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,212.7708,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,178.555536,421.2432
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279410,NDC,10,ML,429.84,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,212.7708,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,178.555536,421.2432
ADVANCED INSTRUMENTS ENDOWRIST SUCTION IRRIGATOR,27200000,CDM,272,RC,,,,11922-MAIN,LOCAL,,,,,496,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,212.784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LOCKING SCREW T8 FULL THREAD 2.4MM L10MM,C1713,CDM,278,RC,C1713,HCPCS,,12637-MAIN,LOCAL,,,,,496,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,212.784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LOCKING SCREW T8 FULL THREAD 2.4MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12651-MAIN,LOCAL,,,,,496,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,212.784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LOCKING SCREW T8 FULL THREAD 2.7MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12638-MAIN,LOCAL,,,,,496,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,212.784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LOCKING SCREW T8 FULL THREAD 2.7MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12639-MAIN,LOCAL,,,,,496,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,212.784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
DRAIN FLAT JACKSON PRATT 10MM,27100000,CDM,271,RC,,,,334-MAIN,LOCAL,,,,,239.09,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,212.7901,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
RELOAD SUREFORM 60 2.5 WHITE 6 ROW BOX/12,27200000,CDM,272,RC,,,,12261-MAIN,LOCAL,,,,,430,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,212.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 60 3.5 BLUE,27200000,CDM,272,RC,,,,12084-MAIN,LOCAL,,,,,430,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,212.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 60 4.3 GREEN,27200000,CDM,272,RC,,,,12085-MAIN,LOCAL,,,,,430,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,212.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614800,NDC,1,EA,239.18,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,212.8702,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
PREP KIT STAPLE 18MM,27200000,CDM,278,RC,C1713,HCPCS,,11658-MAIN,LOCAL,,,,,420.75,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,212.8995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PREP KIT STAPLE 20MM,27200000,CDM,278,RC,C1713,HCPCS,,11659-MAIN,LOCAL,,,,,420.75,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,212.8995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545F,CDM,510,RC,23545,CPT,,,,,,,,961,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,212.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.33,781.73
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545F,CDM,510,RC,23545,CPT,,,,,,,,961,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,212.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.33,781.73
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545P,CDM,983,RC,23545,CPT,,,,,,,,412,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,212.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.33,781.73
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545P,CDM,983,RC,23545,CPT,,,,,,,,412,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,212.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.33,781.73
CANNULATED AO HANDLE STERILE MICA SCREW SYSTEM 57S1HNDL,27200000,CDM,272,RC,,,,12446-MAIN,LOCAL,,,,,219,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,213.1527,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TUBE SURGICAL IRRIGATION 1PK PD-IT,27200000,CDM,272,RC,,,,12433-MAIN,LOCAL,,,,,219,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,213.1527,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CANNULA FOR INJECTION 1.8MM WITH 3MM LUER CONNECTION 8383.65,27200000,CDM,272,RC,,,,12004-MAIN,LOCAL,,,,,234,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,213.174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Fibrinogen,PX7426,CDM,300,RC,85384,CPT,,,,,,,,234,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,213.174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.91,229.32
Cpap/Bipap Mgmnt-Pt Own Equipment,PX94660.02F,CDM,410,RC,94660,CPT,,,,,,,,497,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,213.213,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.33,487.06
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802001,NDC,1,ML,444.2,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,213.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802001,NDC,1,ML,444.2,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,213.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802010,NDC,1,ML,444.2,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,213.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802010,NDC,1,ML,444.2,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,213.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,781344071,NDC,1,EA,430.94,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,213.3153,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,179.012476,460.7862
Inc/Drain Peritonsil Abscess,PX42700F,CDM,510,RC,42700,CPT,,,,,,,,624,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,213.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,611.52
Inc/Drain Peritonsil Abscess,PX42700P,CDM,983,RC,42700,CPT,,,,,,,,889,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,213.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,865.2637
Insert Emergency Endotrach Airway,PX31500F,CDM,510,RC,31500,CPT,,,,,,,,637,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,213.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,624.26
Insert Emergency Endotrach Airway,PX31500P,CDM,983,RC,31500,CPT,,,,,,,,657,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,213.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,639.4581
Repeat Control of Nosebleed,PX30906F,CDM,510,RC,30906,CPT,,,,,,,,334,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,213.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.7436,327.32
Airway Inhalation Treatment,PX94640F,CDM,410,RC,94640,CPT,,,,,,,,242,,United Healthcare,All Payer,outpatient,88.2,,174.93,percent of total billed charges,213.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,100.5268,237.16
"Noninvasv Oxygen Satut,Continuous",PX94762,CDM,460,RC,94762,CPT,,,,,,,,242,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,213.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,100.5268,237.16
gentamicin 0.3 % Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,17478028435,NDC,3.5,GR,219.3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,213.44469,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Closure Superf Wnd Dehis Simple,PX12020P,CDM,983,RC,12020,CPT,,,,,,,,422,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,213.532,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,175.2988,548.67
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781315972,NDC,1,EA,217.96,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,213.6008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.86,213.6008
X-Ray Exam Abdomen 2 Views,PX7401901,CDM,320,RC,74019,CPT,TC,,,,,,,436,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,141.19,percent of total billed charges,213.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,427.28
X-Ray Exam Abdomen 2 Views,PX7401901,CDM,320,RC,74019,CPT,TC,,,,,,,436,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,213.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,427.28
X-Ray Exam Abdomen 2 Views,PX7401901,CDM,320,RC,74019,CPT,TC,,,,,,,436,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,213.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,427.28
"X-Ray Exam Hip,Unilat W/Pelvis 2-3 Vws",PX7350201,CDM,320,RC,73502,CPT,TC,,,,,,,436,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,104.0034783,percent of total billed charges,213.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,427.28
"X-Ray Exam Hip,Unilat W/Pelvis 2-3 Vws",PX7350201,CDM,320,RC,73502,CPT,TC,,,,,,,436,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,213.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,427.28
"X-Ray Exam Hip,Unilat W/Pelvis 2-3 Vws",PX7350201,CDM,320,RC,73502,CPT,TC,,,,,,,436,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,213.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,427.28
Xray Abdomen Comp Incl Decub and/or Erect,PX7402001,CDM,320,RC,74020,CPT,TC,,,,,,,436,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,213.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.1144,427.28
Xray Abdomen Comp Incl Decub and/or Erect,PX7402001,CDM,320,RC,74020,CPT,TC,,,,,,,436,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,213.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.1144,427.28
Xray Abdomen Comp Incl Decub and/or Erect,PX7402001,CDM,320,RC,74020,CPT,TC,,,,,,,436,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,213.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.1144,427.28
Xray Cervical Spine 2 or 3 Vws,PX7204001,CDM,320,RC,72040,CPT,TC,,,,,,,436,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,96.37666667,percent of total billed charges,213.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,427.28
Xray Cervical Spine 2 or 3 Vws,PX7204001,CDM,320,RC,72040,CPT,TC,,,,,,,436,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,213.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,427.28
Xray Cervical Spine 2 or 3 Vws,PX7204001,CDM,320,RC,72040,CPT,TC,,,,,,,436,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,213.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,427.28
Gastric Intubation Treatment,PX43753P,CDM,983,RC,43753,CPT,,,,,,,,498,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,213.642,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.8692,484.7034
"POS Airway Pressure, Cpap",PX94660F,CDM,410,RC,94660,CPT,,,,,,,,498,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,213.642,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.33,488.04
Resp Virus 6-11 Targets,PX87632,CDM,300,RC,87632,CPT,,,,,,,,428,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,213.7194,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.52,218.06
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022101,NDC,1,EA,514.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,213.7233,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022185,NDC,1,EA,514.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,213.7233,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022189,NDC,1,EA,514.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,213.7233,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
cefoTEtan 2 g Recon Soln 1 Each Vial,800000,CDM,,,S0074,HCPCS,,,,63323038620,NDC,1,EA,240.2,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,213.778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Xray Eye Foreign Body,PX7003001,CDM,320,RC,70030,CPT,TC,,,,,,,432,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,213.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,423.36
rifAXIMin 550 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,65649030302,NDC,1,EA,218.25,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,213.885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
rifAXIMin 550 MG Tablet 60 Each Box,63700001,CDM,250,RC,,,,,,65649030303,NDC,1,EA,218.25,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,213.885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
I&D Deep Absc/Hematoma Neck/Chest,PX21501P,CDM,983,RC,21501,CPT,,,,,,,,515,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,213.931,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.931,2482.37
I&D Deep Absc/Hematoma Neck/Chest,PX21501F,CDM,510,RC,21501,CPT,,,,,,,,773,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,214,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,210.51,1021.1
I&D Deep Absc/Hematoma Neck/Chest,PX21501F,CDM,510,RC,21501,CPT,,,,,,,,773,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,214,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,210.51,1021.1
I&D Deep Absc/Hematoma Neck/Chest,PX21501P,CDM,983,RC,21501,CPT,,,,,,,,515,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,214,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,210.51,1021.1
I&D Deep Absc/Hematoma Neck/Chest,PX21501P,CDM,983,RC,21501,CPT,,,,,,,,515,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,214,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,210.51,1021.1
Abd Duplex Abd-Full,PX9397501,CDM,921,RC,93975,CPT,TC,,,,,,,788,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,214.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,772.24
Art Lower Extremity-Bilat,PX9392501,CDM,921,RC,93925,CPT,TC,,,,,,,1188,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,214.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,1164.24
CT Abd & Pelvis W/O Contrast,PX7417601,CDM,350,RC,74176,CPT,TC,,,,,,,4288,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,214.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,4202.24
Cv Carotid Imaging-Bilat,PX9388001,CDM,921,RC,93880,CPT,TC,,,,,,,1088,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,214.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,1066.24
Duplex Up Extrem Art Bilat,PX9393001,CDM,921,RC,93930,CPT,TC,,,,,,,835,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,214.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,818.3
"Echo Heart Xthoracic,Limited",PX9330801,CDM,480,RC,93308,CPT,TC,,,,,,,349,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,214.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,144.9746,342.02
Echo Tt 2d Complete,PX9330701,CDM,480,RC,93307,CPT,TC,,,,,,,2303,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,214.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,2256.94
Fluoroscope Examination Tc,PX7600001,CDM,320,RC,76000,CPT,TC,,,,,,,597,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,214.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,585.06
"Mra, Head W/Out Contrast",PX7054401,CDM,610,RC,70544,CPT,TC,,,,,,,3541,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,214.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI Abdomen W/O Tc,PX7418101,CDM,610,RC,74181,CPT,TC,,,,,,,2655,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,214.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,2601.9
MRI Brain WO Contrast Tc,PX7055101,CDM,610,RC,70551,CPT,TC,,,,,,,3335,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,214.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3268.3
MRI C-Spine WO Contrast,PX7214101,CDM,610,RC,72141,CPT,TC,,,,,,,3541,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,214.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI L Spine WO Contrast,PX7214801,CDM,610,RC,72148,CPT,TC,,,,,,,3541,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,214.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI Low Ext Jnt WO/Cont Tc,PX7372101,CDM,610,RC,73721,CPT,TC,,,,,,,3541,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,214.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI Orbit/Face/Neck Tc,PX7054001,CDM,610,RC,70540,CPT,TC,,,,,,,3335,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,214.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3268.3
MRI T Spine WO Contrast,PX7214601,CDM,610,RC,72146,CPT,TC,,,,,,,3267,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,214.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3201.66
MRI Up Extremity Joint W/O Tc,PX7322101,CDM,610,RC,73221,CPT,TC,,,,,,,3319,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,214.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3252.62
"MRI,Lwrext,No Jnt,No Cont",PX7371801,CDM,610,RC,73718,CPT,TC,,,,,,,3253,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,214.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3187.94
"MRI,Pelvis W/Out Contrast",PX7219501,CDM,610,RC,72195,CPT,TC,,,,,,,3253,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,214.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3187.94
"MRI,Up Ext,No Jnt,No Cont",PX7321801,CDM,610,RC,73218,CPT,TC,,,,,,,3253,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,214.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3187.94
Ven Duplex Bilateral,PX9397001,CDM,921,RC,93970,CPT,TC,,,,,,,1189,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,214.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,1165.22
"Critical Care, Addl 30 Min",PX99292P,CDM,983,RC,99292,CPT,,,,,,,,542,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,214.08,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.12,531.16
"Facility Critical Care, Addl 30 Min",PX99292F,CDM,510,RC,99292,CPT,,,,,,,,484,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,214.08,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.12,214.08
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152F,CDM,370,RC,99152,CPT,,,,,,,,235,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,214.085,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97.619,230.3
Occupational Therapy Eval Low Complex,PX97165,CDM,434,RC,97165,CPT,,,,,,,,235,,Medica,Commercial,both,91.1,,87.22615385,percent of total billed charges,214.085,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,230.3
Physical Therapy Evaluation Low Complex,PX97161,CDM,424,RC,97161,CPT,,,,,,,,235,,Medica,Commercial,both,91.1,,214.09,percent of total billed charges,214.085,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,392.7
Remv Ext Canal Foreign Body,PX69200F,CDM,510,RC,69200,CPT,,,,,,,,235,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,214.085,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97.619,230.3
"Vitamin D, 25 Hydroxy",PX82306,CDM,300,RC,82306,CPT,,,,,,,,235,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,214.085,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.14,230.3
indocyanine green 25 MG Recon Soln 1 Each Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,70100042402,NDC,1,EA,446.07,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,214.1136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.29,1354.4776
indocyanine green 25 MG Recon Soln 1 Each Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,70100042402,NDC,1,EA,446.07,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,214.1136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.29,1354.4776
fluticasone propionate 50 MCG/ACT Suspension 16 g Bottle,63700001,CDM,250,RC,,,,,,50383070016,NDC,16,GR,432.56,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,214.1172,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Hepatitis a Igm Antibody,PX86709,CDM,300,RC,86709,CPT,,,,,,,,220,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,214.126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.32,215.6
"Hiv-1, Quantification - Ref",PX8753690,CDM,300,RC,87536,CPT,90,,,,,,,220,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,214.126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.03,215.6
Immunoassay Nos - Ref,PX8352090,CDM,300,RC,83520,CPT,90,,,,,,,220,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,214.126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.83,215.6
Leptospira Antibody - Ref,PX8672090,CDM,300,RC,86720,CPT,90,,,,,,,220,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,214.126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.85,215.6
Xray Ribs Unilat 2 Vws,PX7110001,CDM,320,RC,71100,CPT,TC,,,,,,,437,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,214.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,428.26
Xray Ribs Unilat 2 Vws,PX7110001,CDM,320,RC,71100,CPT,TC,,,,,,,437,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,214.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,428.26
Xray Ribs Unilat 2 Vws,PX7110001,CDM,320,RC,71100,CPT,TC,,,,,,,437,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,214.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,428.26
erythromycin lactobionate 500 MG Recon Soln 1 Each Vial,J1364.01,CDM,636,RC,J1364,HCPCS,,,,409648211,NDC,1,EA,437.09,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,214.1741,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.06,428.3482
erythromycin lactobionate 500 MG Recon Soln 1 Each Vial,J1364.01,CDM,636,RC,J1364,HCPCS,,,,409648211,NDC,1,EA,437.09,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,214.1741,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.06,428.3482
erythromycin lactobionate 500 MG Recon Soln 1 Each Vial,J1364.01,CDM,636,RC,J1364,HCPCS,,,,409648211,NDC,1,EA,437.09,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,214.1741,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.06,428.3482
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,68462018022,NDC,22,GR,240.66,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,214.1874,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Inject Trigger Point, 1 or 2",PX20552F,CDM,510,RC,20552,CPT,,,,,,,,252,,First Health,Commercial,both,85,,999999999,percent of total billed charges,214.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,258.75
"Level V - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3939,CDM,310,RC,88307,CPT,TC,,,,,,,252,,First Health,Commercial,both,85,,999999999,percent of total billed charges,214.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,314.02
"Off/Outpt Visit,New,Levl III",PX99203P,CDM,983,RC,99203,CPT,,,,,,,,252,,First Health,Commercial,both,85,,999999999,percent of total billed charges,214.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,245.2716
"Office/Outpt Visit,New,Levl III",PX99203F,CDM,510,RC,99203,CPT,,,,,,,,252,,First Health,Commercial,both,85,,999999999,percent of total billed charges,214.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,246.96
"Removal of Hydrocele,Tunica,Unilat",PX55040P,CDM,983,RC,55040,CPT,,,,,,,,1420,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,214.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,210.51,1391.6
"Removal of Hydrocele,Tunica,Unilat",PX55040P,CDM,983,RC,55040,CPT,,,,,,,,1420,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,214.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,210.51,1391.6
diclofenac 0.1 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,17478089225,NDC,2.5,ML,252.06,,First Health,Commercial,both,85,,999999999,percent of total billed charges,214.251,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
medroxyPROGESTERone 150 MG/ML Suspension 1 mL Vial,J1050.01,CDM,636,RC,J1050,HCPCS,,,,67457088799,NDC,1,ML,437.38,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,214.3162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.687652,428.6324
medroxyPROGESTERone 150 MG/ML Suspension 1 mL Vial,J1050.01,CDM,636,RC,J1050,HCPCS,,,,67457088799,NDC,1,ML,437.38,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,214.3162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.687652,428.6324
medroxyPROGESTERone 150 MG/ML Suspension 1 mL Vial,J1050.01,CDM,636,RC,J1050,HCPCS,,,,67457088799,NDC,1,ML,437.38,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,214.3162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.687652,428.6324
fluticasone propionate 50 MCG/ACT Suspension 16 g Bottle,63700001,CDM,250,RC,,,,,,60505082901,NDC,16,GR,437.4,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,214.326,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone propionate 50 MCG/ACT Suspension 16 g Bottle,63700001,CDM,250,RC,,,,,,60505082901,NDC,16,GR,437.4,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,214.326,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone propionate 50 MCG/ACT Suspension 16 g Bottle,63700001,CDM,250,RC,,,,,,60505082901,NDC,16,GR,437.4,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,214.326,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Closed Rx Bimalleolar Fx,PX27808P,CDM,983,RC,27808,CPT,,,,,,,,433,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,214.335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,179.8682,421.4389
Closed Rx Shldr Dislocation,PX23650P,CDM,983,RC,23650,CPT,,,,,,,,516,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,214.3464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,502.2228
Trg Gene Rearrangement Anal - Ref,PX8134290,CDM,300,RC,81342,CPT,90,,,,,,,516,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,214.3464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,184.76,505.68
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Solution 10 mL Bottle,63700001,CDM,250,RC,,,,,,61314064610,NDC,10,ML,433.15,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,214.40925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Closed Rx Talus Fx,Manipulatn",PX28435F,CDM,510,RC,28435,CPT,,,,,,,,1705,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,214.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,210.51,796.26
"Closed Rx Talus Fx,Manipulatn",PX28435F,CDM,510,RC,28435,CPT,,,,,,,,1705,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,214.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,210.51,796.26
"Closed Rx Talus Fx,Manipulatn",PX28435P,CDM,983,RC,28435,CPT,,,,,,,,1137,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,214.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,210.51,1114.26
"Closed Rx Talus Fx,Manipulatn",PX28435P,CDM,983,RC,28435,CPT,,,,,,,,1137,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,214.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,210.51,1114.26
agalsidase beta 5 MG Recon Soln 1 Each Vial,J0180.01,CDM,636,RC,J0180,HCPCS,,,,58468004101,NDC,1,EA,1717.68,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,214.44522,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.14,218.34
Sigmoidoscope W/Submuc Inj,PX45335P,CDM,983,RC,45335,CPT,,,,,,,,500,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,214.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,207.7,798.45
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402F,CDM,510,RC,11402,CPT,,,,,,,,424,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,214.544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.1296,614.65
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402P,CDM,983,RC,11402,CPT,,,,,,,,424,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,214.544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.1296,614.65
Lab H Pylori Stool Ag,PX87338,CDM,300,RC,87338,CPT,,,,,,,,424,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,214.544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,415.52
Bcr/Abl1 Other - Ref,PX8120890,CDM,310,RC,81208,CPT,90,,,,,,,1125,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,214.62,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.18,214.62
CANNULATED AO HANDLE STERILE MICA SCREW SYSTEM 57S1HNDL,27200000,CDM,272,RC,,,,12446-MAIN,LOCAL,,,,,219,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,214.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Debride Bone Ea Add 20 Sqcm,PX11047F,CDM,510,RC,11047,CPT,,,,,,,,438,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,214.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.9452,429.24
Debride Bone Ea Add 20 Sqcm,PX11047F,CDM,510,RC,11047,CPT,,,,,,,,438,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,214.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.9452,429.24
Debride Bone Ea Add 20 Sqcm,PX11047F,CDM,510,RC,11047,CPT,,,,,,,,438,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,214.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.9452,429.24
TUBE SURGICAL IRRIGATION 1PK PD-IT,27200000,CDM,272,RC,,,,12433-MAIN,LOCAL,,,,,219,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,214.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
US Pregnancy Tc Limited,PX7681501,CDM,402,RC,76815,CPT,TC,,,,,,,438,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,214.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,429.24
US Pregnancy Tc Limited,PX7681501,CDM,402,RC,76815,CPT,TC,,,,,,,438,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,214.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,429.24
US Pregnancy Tc Limited,PX7681501,CDM,402,RC,76815,CPT,TC,,,,,,,438,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,214.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,429.24
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,63323027301,NDC,0.5,ML,235.6,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,214.6316,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
MRI Upper W/O+W Tc,PX7322001,CDM,610,RC,73220,CPT,TC,,,,,,,3253,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,214.66,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.66,633.08
MRI Upper W/O+W Tc,PX7322001,CDM,610,RC,73220,CPT,TC,,,,,,,3253,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,214.66,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.66,633.08
Emergency Level IV Visit,PX99284P,CDM,981,RC,99284,CPT,,,,,,,,914,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,214.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.2,895.72
Emergency Level IV Visit,PX99284P,CDM,981,RC,99284,CPT,,,,,,,,914,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,214.68,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.2,895.72
Facility Emergency Level IV Visit,PX99284F,CDM,450,RC,99284,CPT,,,,,,,,1054,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,214.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.2,214.68
Facility Emergency Level IV Visit,PX99284F,CDM,450,RC,99284,CPT,,,,,,,,1054,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,214.68,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.2,214.68
Immunohisto Antibody Slide Ea Multiplex,PX8834401,CDM,310,RC,88344,CPT,TC,,,,,,,51,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,214.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.6,222.656
Immunohisto Antibody Slide Ea Multiplex,PX8834401,CDM,310,RC,88344,CPT,TC,,,,,,,51,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,214.69,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.6,222.656
"In Situ Hybridization (Eg, Fish), Each Probe, Tech",PX8836501,CDM,310,RC,88365,CPT,TC,,,,,,,117,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,214.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.37,222.272
"In Situ Hybridization (Eg, Fish), Each Probe, Tech",PX8836501,CDM,310,RC,88365,CPT,TC,,,,,,,117,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,214.69,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.37,222.272
gentamicin 0.3 % Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,17478028435,NDC,3.5,GR,219.3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,214.914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
nystatin-triamcinolone 100000-0.1 UNIT/GM-% Ointment 30 g Tube,25000000,CDM,250,RC,,,,,,52565004230,NDC,30,GR,438.62,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,214.9238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
nystatin-triamcinolone 100000-0.1 UNIT/GM-% Ointment 30 g Tube,25000000,CDM,250,RC,,,,,,52565004230,NDC,30,GR,438.62,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,214.9238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
nystatin-triamcinolone 100000-0.1 UNIT/GM-% Ointment 30 g Tube,25000000,CDM,250,RC,,,,,,52565004230,NDC,30,GR,438.62,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,214.9238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Biopsy Vulva/Perineum,One Lesn",PX56605F,CDM,510,RC,56605,CPT,,,,,,,,236,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,214.996,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.0344,702.31
Lab Basic Metabolic Panel,PX80048,CDM,300,RC,80048,CPT,,,,,,,,236,,Medica,Commercial,both,91.1,,34.39740741,percent of total billed charges,214.996,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.76,231.28
hydrocortisone (perianal) 2.5 % Cream 28.35 g Tube,63700001,CDM,250,RC,,,,,,10631040701,NDC,28.35,GR,447.94,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,215.0112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone (perianal) 2.5 % Cream 28.35 g Tube,63700001,CDM,250,RC,,,,,,10631040701,NDC,28.35,GR,447.94,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,215.0112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Lvl 2 Sub Hosp Mod Mdm or 35 Minute,PX99232,CDM,982,RC,99232,CPT,,,,,,,,253,,First Health,Commercial,both,85,,999999999,percent of total billed charges,215.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.0962,246.2449
MESH FLAT SHEET SOFT 3X6 INCH,C1781,CDM,278,RC,C1781,HCPCS,,11773-MAIN,LOCAL,,,,,253,,First Health,Commercial,both,85,,999999999,percent of total billed charges,215.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Subsequent Observation Care,PX99225,CDM,982,RC,99225,CPT,,,,,,,,253,,First Health,Commercial,both,85,,999999999,percent of total billed charges,215.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.0962,246.2449
Tap Block Unilateral by Injection(S),PX64486F,CDM,510,RC,64486,CPT,,,,,,,,253,,First Health,Commercial,both,85,,999999999,percent of total billed charges,215.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.0962,247.94
"Injection Hip Arthrogram,Anesth",PX27095F,CDM,510,RC,27095,CPT,,,,,,,,425,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,215.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.545,416.5
"Injection Hip Arthrogram,Anesth",PX27095P,CDM,983,RC,27095,CPT,,,,,,,,425,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,215.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.545,413.6525
"Manual Ther Tech,1+Regions,Ea 15 Min",PX97140,CDM,420,RC,97140,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All commercial plans,both,,,82.58829431,fee schedule,215.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.4,215.05
Neuromuscular Re-Education,PX97112,CDM,420,RC,97112,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,215.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.95,215.05
Therapeutic Exercises,PX97110,CDM,420,RC,97110,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All commercial plans,both,,,85.89737745,fee schedule,215.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20,215.05
US Abdomen Limited Tc,PX7670501,CDM,402,RC,76705,CPT,TC,,,,,,,425,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,215.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,416.5
US Ext Non-Vasc Img Lmtd,PX7688201,CDM,402,RC,76882,CPT,TC,,,,,,,425,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,215.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,416.5
Remove Impacted Ear Wax,PX69210P,CDM,983,RC,69210,CPT,,,,,,,,221,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,215.0993,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.44,215.0993
8MM ENDOWRIST INSTRUMENTS 8MM FORCE BIPOLAR IS4000,27200000,CDM,272,RC,,,,11915-MAIN,LOCAL,,,,,439,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,215.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM ENDOWRIST INSTRUMENTS 8MM FORCE BIPOLAR IS4000,27200000,CDM,272,RC,,,,11915-MAIN,LOCAL,,,,,439,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,215.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM ENDOWRIST INSTRUMENTS 8MM FORCE BIPOLAR IS4000,27200000,CDM,272,RC,,,,11915-MAIN,LOCAL,,,,,439,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,215.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
VISIGI3D 40FR STD WITH BULB,27100000,CDM,271,RC,,,,12812-MAIN,LOCAL,,,,,439,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,215.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
VISIGI3D 40FR STD WITH BULB,27100000,CDM,271,RC,,,,12812-MAIN,LOCAL,,,,,439,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,215.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
VISIGI3D 40FR STD WITH BULB,27100000,CDM,271,RC,,,,12812-MAIN,LOCAL,,,,,439,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,215.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
"Blood Gases: Ph, Po2 & Pco2",PX82803,CDM,300,RC,82803,CPT,,,,,,,,518,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,215.1772,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.9,507.64
BINDER PELVIC ADULT STABILIZATION T-PODR,120.357,CDM,271,RC,A4467,HCPCS,,10734-MAIN,LOCAL,,,,,244,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,215.208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.3576,239.12
"Bone Marrow Aspiration(S),Diag",PX38220P,CDM,983,RC,38220,CPT,,,,,,,,244,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,215.208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.3576,1416.38
Dress/Debrid Med Burn No Anesth,PX16025P,CDM,983,RC,16025,CPT,,,,,,,,244,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,215.208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.3576,237.4852
"Chemotherapy, IV Push, Single Drug",PX96409,CDM,335,RC,96409,CPT,,,,,,,,502,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,215.358,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.5308,491.96
Incise External Hemorrhoid,PX46083F,CDM,510,RC,46083,CPT,,,,,,,,502,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,215.358,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.5308,491.96
Airway Inhalation Treatment,PX94640F,CDM,410,RC,94640,CPT,,,,,,,,242,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,215.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,100.5268,237.16
"Noninvasv Oxygen Satut,Continuous",PX94762,CDM,460,RC,94762,CPT,,,,,,,,242,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,215.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,100.5268,237.16
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802201,NDC,0.8,ML,439.77,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,9.81,percent of total billed charges,215.4873,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802201,NDC,0.8,ML,439.77,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,215.4873,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802201,NDC,0.8,ML,439.77,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,215.4873,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802210,NDC,0.8,ML,439.77,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,9.81,percent of total billed charges,215.4873,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802210,NDC,0.8,ML,439.77,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,215.4873,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802210,NDC,0.8,ML,439.77,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,215.4873,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
Xray Ac Joints(Bilateral),PX7305001,CDM,320,RC,73050,CPT,TC,,,,,,,519,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,215.5926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,508.62
Hepatitis a Igm Antibody,PX86709,CDM,300,RC,86709,CPT,,,,,,,,220,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,215.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.32,215.6
"Hiv-1, Quantification - Ref",PX8753690,CDM,300,RC,87536,CPT,90,,,,,,,220,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,215.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.03,215.6
Immunoassay Nos - Ref,PX8352090,CDM,300,RC,83520,CPT,90,,,,,,,220,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,215.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.83,215.6
"Incis/Drain Scrotum/Testis,Epididym",PX54700P,CDM,983,RC,54700,CPT,,,,,,,,440,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,215.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,182.776,1779.39
"Incis/Drain Scrotum/Testis,Epididym",PX54700P,CDM,983,RC,54700,CPT,,,,,,,,440,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,215.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,182.776,1779.39
"Incis/Drain Scrotum/Testis,Epididym",PX54700P,CDM,983,RC,54700,CPT,,,,,,,,440,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,215.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,182.776,1779.39
Leptospira Antibody - Ref,PX8672090,CDM,300,RC,86720,CPT,90,,,,,,,220,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,215.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.85,215.6
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004004,NDC,120,ML,502.95,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,215.76555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
Trb@ Gene Rearrange Amplify - Ref,PX8134090,CDM,300,RC,81340,CPT,90,,,,,,,503,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,215.787,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,191.56,492.94
X-Ray Exam Abdomen 2 Views,PX7401901,CDM,320,RC,74019,CPT,TC,,,,,,,436,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,215.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,427.28
"X-Ray Exam Hip,Unilat W/Pelvis 2-3 Vws",PX7350201,CDM,320,RC,73502,CPT,TC,,,,,,,436,,Humana Choice Care,All Medicare plans,outpatient,49.5,,125.628,percent of total billed charges,215.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,427.28
Xray Abdomen Comp Incl Decub and/or Erect,PX7402001,CDM,320,RC,74020,CPT,TC,,,,,,,436,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,215.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.1144,427.28
Xray Cervical Spine 2 or 3 Vws,PX7204001,CDM,320,RC,72040,CPT,TC,,,,,,,436,,Humana Choice Care,All Medicare plans,outpatient,49.5,,167.09,percent of total billed charges,215.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,427.28
Irradiated Leukoreduced Rbc's,PXP9040,CDM,390,RC,P9040,HCPCS,,,,,,,,771,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,215.83,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,209.36,351.536
Abd Paracentesis W/Imaging(P),PX49083P,CDM,983,RC,49083,CPT,,,,,,,,696,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,215.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.45,682.08
Abd Paracentesis W/Imaging(T),PX49083F,CDM,510,RC,49083,CPT,,,,,,,,1006,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,215.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.45,602.56
Thyrstim Immun Glob (Tsi) - Ref,PX8444590,CDM,300,RC,84445,CPT,90,,,,,,,254,,First Health,Commercial,both,85,,999999999,percent of total billed charges,215.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.63,248.92
Fac/Irrigation of Bladder,PX51700F,CDM,510,RC,51700,CPT,,,,,,,,358,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,215.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.7132,350.84
"Genital Surg Proc,Male Unlisted",PX55899F,CDM,510,RC,55899,CPT,,,,,,,,1430,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,215.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,215.91,1401.4
"Genital Surg Proc,Male Unlisted",PX55899P,CDM,983,RC,55899,CPT,,,,,,,,953,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,215.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,215.91,927.5549
Incise External Hemorrhoid,PX46083F,CDM,510,RC,46083,CPT,,,,,,,,502,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,215.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.5308,491.96
Incise External Hemorrhoid,PX46083P,CDM,983,RC,46083,CPT,,,,,,,,956,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,215.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,215.91,930.4748
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762F,CDM,510,RC,43762,CPT,,,,,,,,492,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,215.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,204.3768,482.16
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762P,CDM,983,RC,43762,CPT,,,,,,,,328,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,215.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.2512,319.2424
"Spinal Punc,Drain,Theraputic",PX62272F,CDM,510,RC,62272,CPT,,,,,,,,450,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.93,604.15
"Spinal Punc,Drain,Theraputic",PX62272F,CDM,510,RC,62272,CPT,,,,,,,,450,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.93,604.15
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,121090204,NDC,120,ML,503.56,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,216.02724,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU000390,CDM,300,RC,U0003,HCPCS,90,,,,,,,222,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,216.0726,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.2188,217.56
Nfct Ds Bct/Vir Respir Dna/Rna 22 Trgt Sarscov2,PX0202U,CDM,300,RC,0202U,HCPCS,,,,,,,,222,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,48.74,percent of total billed charges,216.0726,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.2188,382.15
Observation Care Discharge,PX99217,CDM,982,RC,99217,CPT,,,,,,,,222,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,216.0726,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.2188,216.0726
"Fac/Office Consultation,Level IV",PX99244F,CDM,510,RC,99244,CPT,,,,,,,,441,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,216.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,183.1914,432.18
"Fac/Office Consultation,Level IV",PX99244F,CDM,510,RC,99244,CPT,,,,,,,,441,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,216.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,183.1914,432.18
"Fac/Office Consultation,Level IV",PX99244F,CDM,510,RC,99244,CPT,,,,,,,,441,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,216.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,183.1914,432.18
Fibrinogen Activity - Ref,PX8538490,CDM,300,RC,85384,CPT,90,,,,,,,245,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,216.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.91,240.1
Gastric Intubation Treatment,PX43753F,CDM,510,RC,43753,CPT,,,,,,,,441,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,216.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,183.1914,432.18
Gastric Intubation Treatment,PX43753F,CDM,510,RC,43753,CPT,,,,,,,,441,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,216.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,183.1914,432.18
Gastric Intubation Treatment,PX43753F,CDM,510,RC,43753,CPT,,,,,,,,441,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,216.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,183.1914,432.18
"Ileoscopy Thru Stoma,Diagnostic",PX44380F,CDM,750,RC,44380,CPT,,,,,,,,245,,United Healthcare,All Payer,outpatient,88.2,,999999999,case rate,216.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,216.09,6141.46
Lipid Profile,PX80061,CDM,300,RC,80061,CPT,,,,,,,,245,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,216.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.28,240.1
"Office Consultation,Level IV",PX99244P,CDM,983,RC,99244,CPT,,,,,,,,441,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,216.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,183.1914,429.2253
"Office Consultation,Level IV",PX99244P,CDM,983,RC,99244,CPT,,,,,,,,441,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,216.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,183.1914,429.2253
"Office Consultation,Level IV",PX99244P,CDM,983,RC,99244,CPT,,,,,,,,441,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,216.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,183.1914,429.2253
Platelet Antibodies - Ref,PX8602290,CDM,300,RC,86022,CPT,90,,,,,,,245,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,216.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.84,240.1
"Close Rx Fingr Articular Fx,Manip",PX26742F,CDM,510,RC,26742,CPT,,,,,,,,1039,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,216.18,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,216.18,805.95
"Close Rx Fingr Articular Fx,Manip",PX26742P,CDM,983,RC,26742,CPT,,,,,,,,560,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,216.18,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,216.18,805.95
Xray Ribs Unilat 2 Vws,PX7110001,CDM,320,RC,71100,CPT,TC,,,,,,,437,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,216.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,428.26
erythromycin lactobionate 500 MG Recon Soln 1 Each Vial,J1364.01,CDM,636,RC,J1364,HCPCS,,,,409648211,NDC,1,EA,437.09,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,216.35955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.06,428.3482
Refill/Maint Portable Pump,PX96521,CDM,260,RC,96521,CPT,,,,,,,,325,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,216.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.8,216.39
Refill/Maint Portable Pump,PX96521,CDM,260,RC,96521,CPT,,,,,,,,325,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,216.39,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.8,216.39
"Destruct Benign Lesion, 1-14",PX17110P,CDM,983,RC,17110,CPT,,,,,,,,521,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,216.4234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,507.0893
medroxyPROGESTERone 150 MG/ML Suspension 1 mL Vial,J1050.01,CDM,636,RC,J1050,HCPCS,,,,67457088799,NDC,1,ML,437.38,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,216.5031,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.687652,428.6324
fluticasone propionate 50 MCG/ACT Suspension 16 g Bottle,63700001,CDM,250,RC,,,,,,60505082901,NDC,16,GR,437.4,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,216.513,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Resp Virus 6-11 Targets,PX87632,CDM,300,RC,87632,CPT,,,,,,,,428,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,216.568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,177.7912,419.44
Xray Thoracic Spine 2 Vws,PX7207001,CDM,320,RC,72070,CPT,TC,,,,,,,428,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,216.568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,419.44
Remove Impacted Ear Wax,PX69210P,CDM,983,RC,69210,CPT,,,,,,,,221,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,216.58,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.06,216.58
Diagnostic Anoscopy,PX46600F,CDM,510,RC,46600,CPT,,,,,,,,505,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,216.645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,494.9
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800F,CDM,510,RC,40800,CPT,,,,,,,,255,,First Health,Commercial,both,85,,999999999,percent of total billed charges,216.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.927,614.65
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106F,CDM,510,RC,11106,CPT,,,,,,,,255,,First Health,Commercial,both,85,,999999999,percent of total billed charges,216.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.927,548.67
"Inject Nerv Blck,Trigeminal",PX64400F,CDM,510,RC,64400,CPT,,,,,,,,255,,First Health,Commercial,both,85,,999999999,percent of total billed charges,216.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.927,258.75
"Urinalysis, Auto, W/Scope",PX81001,CDM,300,RC,81001,CPT,,,,,,,,255,,First Health,Commercial,both,85,,999999999,percent of total billed charges,216.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.91,249.9
Debride Bone Ea Add 20 Sqcm,PX11047F,CDM,510,RC,11047,CPT,,,,,,,,438,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,216.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.9452,429.24
US Pregnancy Tc Limited,PX7681501,CDM,402,RC,76815,CPT,TC,,,,,,,438,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,216.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,429.24
Phlebotomy,PX99195,CDM,940,RC,99195,CPT,,,,,,,,238,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,216.818,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.8652,233.24
Closed Rx Trimalleolar Fx,PX27816F,CDM,510,RC,27816,CPT,,,,,,,,522,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,216.8388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,511.56
Xray Thoracic Spine 3 Vws,PX7207201,CDM,320,RC,72072,CPT,TC,,,,,,,522,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,216.8388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,511.56
Part Remv Phalanx of Toe,PX28124F,CDM,510,RC,28124,CPT,,,,,,,,2155,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,216.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.82,992.04
Part Remv Phalanx of Toe,PX28124F,CDM,510,RC,28124,CPT,,,,,,,,2155,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,216.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.82,992.04
Part Remv Phalanx of Toe,PX28124P,CDM,983,RC,28124,CPT,,,,,,,,1515,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,216.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.82,1484.7
Part Remv Phalanx of Toe,PX28124P,CDM,983,RC,28124,CPT,,,,,,,,1515,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,216.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.82,1484.7
DRILL BIT AO DIA 2.0MMX135MM SCALED,27200000,CDM,272,RC,,,,12640-MAIN,LOCAL,,,,,452,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,216.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRILL BIT AO DIA 2.0MMX135MM SCALED,27200000,CDM,272,RC,,,,12640-MAIN,LOCAL,,,,,452,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,216.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
KATZ EXTRACTOR OTO-RHINO FOREIGN BODY REMOVER,120.568,CDM,272,RC,,,,12808-MAIN,LOCAL,,,,,246,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,216.972,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.1884,241.08
"Apply Finger Splint,Static",PX29130P,CDM,983,RC,29130,CPT,,,,,,,,223,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,217.0459,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,217.0459
"Apply Forearm Splint,Static",PX29125F,CDM,510,RC,29125,CPT,,,,,,,,223,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,82.99,percent of total billed charges,217.0459,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,218.54
"Flow Cyto, Tech, 1st Mrkr - Ref",PX8818490,CDM,310,RC,88184,CPT,90,,,,,,,223,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,217.0459,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,314.02
"Nephelometry, Each, Nos - Ref",PX8388390,CDM,300,RC,83883,CPT,90,,,,,,,223,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,217.0459,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.47,218.54
Reduce Temporomandibl Disloc,PX21480P,CDM,983,RC,21480,CPT,,,,,,,,223,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,217.0459,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,217.0459
Closed Rx Metacarpal Fx,PX26600F,CDM,510,RC,26600,CPT,,,,,,,,443,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,217.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,184.0222,434.14
Closed Rx Metacarpal Fx,PX26600F,CDM,510,RC,26600,CPT,,,,,,,,443,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,217.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,184.0222,434.14
Closed Rx Metacarpal Fx,PX26600F,CDM,510,RC,26600,CPT,,,,,,,,443,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,217.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,184.0222,434.14
I&D Bartholin Gland Abscess,PX56420F,CDM,510,RC,56420,CPT,,,,,,,,429,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,217.074,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.08,420.42
nystatin-triamcinolone 100000-0.1 UNIT/GM-% Ointment 30 g Tube,25000000,CDM,250,RC,,,,,,52565004230,NDC,30,GR,438.62,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,217.1169,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BINDER PELVIC ADULT STABILIZATION T-PODR,120.357,CDM,271,RC,A4467,HCPCS,,10734-MAIN,LOCAL,,,,,244,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,217.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.3576,239.12
"Bone Marrow Aspiration(S),Diag",PX38220P,CDM,983,RC,38220,CPT,,,,,,,,244,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,217.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.3576,1416.38
Dress/Debrid Med Burn No Anesth,PX16025P,CDM,983,RC,16025,CPT,,,,,,,,244,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,217.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.3576,237.4852
MRI Brain W & WO Contrast,PX7055301,CDM,610,RC,70553,CPT,TC,,,,,,,3541,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,217.215,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,147.25,434.54
dorzolamide-timolol 2-0.5 % Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,50383023310,NDC,10,ML,506.34,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,217.21986,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Layr Clos Wnd Rest Body 7.6-12.5,PX12044P,CDM,983,RC,12044,CPT,,,,,,,,523,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,217.2542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,217.2542,548.67
8MM ENDOWRIST INSTRUMENTS 8MM FORCE BIPOLAR IS4000,27200000,CDM,272,RC,,,,11915-MAIN,LOCAL,,,,,439,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,217.305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
VISIGI3D 40FR STD WITH BULB,27100000,CDM,271,RC,,,,12812-MAIN,LOCAL,,,,,439,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,217.305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
gentamicin 0.1 % Ointment 30 g Tube,25000000,CDM,250,RC,,,,,,713068231,NDC,30,GR,506.64,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,217.34856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Repr Superf Wnd Body 7.6-12.5,PX12004F,CDM,510,RC,12004,CPT,,,,,,,,453,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,217.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,443.94
Repr Superf Wnd Body 7.6-12.5,PX12004F,CDM,510,RC,12004,CPT,,,,,,,,453,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,217.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,443.94
Repr Superf Wnd Face 5.1-7.5,PX12014F,CDM,510,RC,12014,CPT,,,,,,,,453,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,217.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,443.94
Repr Superf Wnd Face 5.1-7.5,PX12014F,CDM,510,RC,12014,CPT,,,,,,,,453,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,217.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,443.94
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221901,NDC,3,ML,506.9,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,217.4601,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221905,NDC,3,ML,506.9,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,217.4601,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279210,NDC,10,ML,429.84,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,217.49904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,178.555536,421.2432
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279410,NDC,10,ML,429.84,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,217.49904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,178.555536,421.2432
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU000390,CDM,300,RC,U0003,HCPCS,90,,,,,,,222,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,217.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.2188,217.56
Nfct Ds Bct/Vir Respir Dna/Rna 22 Trgt Sarscov2,PX0202U,CDM,300,RC,0202U,HCPCS,,,,,,,,222,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,217.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.2188,382.15
Observation Care Discharge,PX99217,CDM,982,RC,99217,CPT,,,,,,,,222,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,217.56,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.96,217.56
RELOAD SUREFORM 60 2.5 WHITE 6 ROW BOX/12,27200000,CDM,272,RC,,,,12261-MAIN,LOCAL,,,,,430,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,217.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 60 3.5 BLUE,27200000,CDM,272,RC,,,,12084-MAIN,LOCAL,,,,,430,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,217.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 60 4.3 GREEN,27200000,CDM,272,RC,,,,12085-MAIN,LOCAL,,,,,430,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,217.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Office/Outpt Visit,Est,Levl IV",PX99214F,CDM,510,RC,99214,CPT,,,,,,,,256,,First Health,Commercial,both,85,,999999999,percent of total billed charges,217.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.3424,250.88
"Office/Outpt Visit,Est,Levl IV",PX99214P,CDM,983,RC,99214,CPT,,,,,,,,256,,First Health,Commercial,both,85,,999999999,percent of total billed charges,217.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.3424,249.1648
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133P,CDM,983,RC,13133,CPT,,,,,,,,256,,First Health,Commercial,both,85,,999999999,percent of total billed charges,217.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.3424,249.1648
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802001,NDC,1,ML,444.2,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,9.81,percent of total billed charges,217.658,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802001,NDC,1,ML,444.2,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,217.658,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802001,NDC,1,ML,444.2,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,217.658,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802010,NDC,1,ML,444.2,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,9.81,percent of total billed charges,217.658,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802010,NDC,1,ML,444.2,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,217.658,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802010,NDC,1,ML,444.2,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,217.658,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802201,NDC,0.8,ML,439.77,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,217.68615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802210,NDC,0.8,ML,439.77,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,217.68615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
Physical Therapy Re-Eval Est Plan Care 20 Mins,PX97164,CDM,424,RC,97164,CPT,,,,,,,,239,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,217.729,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,234.22
"Incis/Drain Scrotum/Testis,Epididym",PX54700P,CDM,983,RC,54700,CPT,,,,,,,,440,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,217.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,182.776,1779.39
DRAIN FLAT JACKSON PRATT 10MM,27100000,CDM,271,RC,,,,334-MAIN,LOCAL,,,,,239.09,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,217.81099,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
Drain/Inject Medium Joint/Bursa,PX20605F,CDM,510,RC,20605,CPT,,,,,,,,247,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,217.854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.6038,258.75
CT Angio Upr Extrm W/O&W/Dye,PX7320601,CDM,350,RC,73206,CPT,TC,,,,,,,757,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,217.8586,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,118.89,435.86
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614800,NDC,1,EA,239.18,,Medica,Commercial,both,91.1,,6.892980769,percent of total billed charges,217.89298,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
X-Ray Exam Entire Spine 2-3 Vws,PX7208201,CDM,320,RC,72082,CPT,TC,,,,,,,454,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,217.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,444.92
X-Ray Exam Entire Spine 2-3 Vws,PX7208201,CDM,320,RC,72082,CPT,TC,,,,,,,454,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,217.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,444.92
"Inpatient Consult, Level IV",PX99254,CDM,983,RC,99254,CPT,,,,,,,,508,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,217.932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.0232,494.4364
Lvl 2 Init Hosp Mod Mdm or 55 Minutes,PX99222,CDM,982,RC,99222,CPT,,,,,,,,508,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,217.932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.0232,494.4364
Body Fluid Cell Count W Diff,PX89051,CDM,300,RC,89051,CPT,,,,,,,,224,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,218.0192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.13,219.52
Emergency Level I Visit,PX99281P,CDM,981,RC,99281,CPT,,,,,,,,224,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,168.53,percent of total billed charges,218.0192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.56,218.0192
ENDOWRIST INSTRUMENTS PERMANENT CAUTERY HOOK 8MM,27200000,CDM,272,RC,,,,12050-MAIN,LOCAL,,,,,224,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,218.0192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Helicobacter Pylori Ab,PX86677,CDM,300,RC,86677,CPT,,,,,,,,224,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,218.0192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.45,219.52
Fibrinogen Activity - Ref,PX8538490,CDM,300,RC,85384,CPT,90,,,,,,,245,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,218.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.91,240.1
"Ileoscopy Thru Stoma,Diagnostic",PX44380F,CDM,750,RC,44380,CPT,,,,,,,,245,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,218.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.773,791.92
Lipid Profile,PX80061,CDM,300,RC,80061,CPT,,,,,,,,245,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,218.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.28,240.1
Platelet Antibodies - Ref,PX8602290,CDM,300,RC,86022,CPT,90,,,,,,,245,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,218.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.84,240.1
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,781344071,NDC,1,EA,430.94,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,218.05564,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,179.012476,460.7862
Resp Virus 6-11 Targets,PX87632,CDM,300,RC,87632,CPT,,,,,,,,428,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,218.06,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.52,218.06
Anal Sphincterotomy,PX46080P,CDM,983,RC,46080,CPT,,,,,,,,525,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,218.085,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,218.085,2452.93
Closed Rx Elbow Dislocation,PX24600F,CDM,510,RC,24600,CPT,,,,,,,,706,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,218.15,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,218.15,814.94
Closed Rx Elbow Dislocation,PX24600P,CDM,983,RC,24600,CPT,,,,,,,,380,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,218.15,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,218.15,814.94
MRI Upper W/O+W Tc,PX7322001,CDM,610,RC,73220,CPT,TC,,,,,,,3253,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,218.15,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.66,633.08
MRI L Spine W&WO Contrast,PX7215801,CDM,610,RC,72158,CPT,TC,,,,,,,4178,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,218.1804,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,147.68,435.86
ammonium lactate 12 % Cream 385 g Tube,63700001,CDM,250,RC,,,,,,45802049326,NDC,385,GR,256.76,,First Health,Commercial,both,85,,999999999,percent of total billed charges,218.246,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
agalsidase beta 5 MG Recon Soln 1 Each Vial,J0180.01,CDM,636,RC,J0180,HCPCS,,,,58468004101,NDC,1,EA,1717.68,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,218.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.14,218.34
agalsidase beta 5 MG Recon Soln 1 Each Vial,J0180.01,CDM,636,RC,J0180,HCPCS,,,,58468004101,NDC,1,EA,1717.68,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,218.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.14,218.34
"Fac/Office Consultation,Level IV",PX99244F,CDM,510,RC,99244,CPT,,,,,,,,441,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,218.295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,183.1914,432.18
Gastric Intubation Treatment,PX43753F,CDM,510,RC,43753,CPT,,,,,,,,441,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,218.295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,183.1914,432.18
"Office Consultation,Level IV",PX99244P,CDM,983,RC,99244,CPT,,,,,,,,441,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,218.295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,183.1914,429.2253
agalsidase beta 5 MG Recon Soln 1 Each Vial,J0180.01,CDM,636,RC,J0180,HCPCS,,,,58468004101,NDC,1,EA,1717.68,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,218.34,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.14,218.34
Acute Hepatitis Panel,PX80074,CDM,300,RC,80074,CPT,,,,,,,,509,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,218.361,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,43.67,498.82
Biopsy of Rectum,PX45100P,CDM,983,RC,45100,CPT,,,,,,,,509,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,218.361,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.4386,2452.93
ipratropium 0.03 % Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,24208039830,NDC,30,ML,256.9,,First Health,Commercial,both,85,,999999999,percent of total billed charges,218.365,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607F,CDM,761,RC,97607,CPT,,,,,,,,455,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,218.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.007,445.9
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607F,CDM,761,RC,97607,CPT,,,,,,,,455,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,218.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.007,445.9
"Inpatient Consult, Level IV",PX99254,CDM,983,RC,99254,CPT,,,,,,,,508,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,218.432,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.73,497.84
"Inpatient Consult, Level IV",PX99254,CDM,983,RC,99254,CPT,,,,,,,,508,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,218.432,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.73,497.84
neomycin-polymyxin-dexamethasone 3.5-10000-0.1 Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,61314063136,NDC,3.5,GR,247.71,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,218.48022,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
neomycin-polymyxin-dexameth 3.5-10000-0.1 Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063006,NDC,5,ML,247.72,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,218.48904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Debride Tissue/Muscle,PX11043F,CDM,510,RC,11043,CPT,,,,,,,,526,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,218.5004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,218.5004,548.67
Hfe Gene - Ref,PX8125690,CDM,300,RC,81256,CPT,90,,,,,,,526,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,218.5004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,59.93,515.48
"Apply Finger Splint,Static",PX29130P,CDM,983,RC,29130,CPT,,,,,,,,223,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,218.54,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.66,218.54
"Apply Forearm Splint,Static",PX29125F,CDM,510,RC,29125,CPT,,,,,,,,223,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,218.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,218.54
"Flow Cyto, Tech, 1st Mrkr - Ref",PX8818490,CDM,310,RC,88184,CPT,90,,,,,,,223,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,218.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,314.02
"Nephelometry, Each, Nos - Ref",PX8388390,CDM,300,RC,83883,CPT,90,,,,,,,223,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,218.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.47,218.54
Reduce Temporomandibl Disloc,PX21480P,CDM,983,RC,21480,CPT,,,,,,,,223,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,218.54,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.54,294.02
indocyanine green 25 MG Recon Soln 1 Each Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,70100042402,NDC,1,EA,446.07,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,4.176666667,percent of total billed charges,218.5743,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.29,1354.4776
indocyanine green 25 MG Recon Soln 1 Each Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,70100042402,NDC,1,EA,446.07,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,218.5743,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.29,1354.4776
indocyanine green 25 MG Recon Soln 1 Each Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,70100042402,NDC,1,EA,446.07,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,218.5743,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.29,1354.4776
Xray Eye Foreign Body,PX7003001,CDM,320,RC,70030,CPT,TC,,,,,,,432,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,218.592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,423.36
"Closed Rx Radial Head Disloc,Child",PX24640F,CDM,510,RC,24640,CPT,,,,,,,,270,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,218.61,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.04,218.61
"Closed Rx Radial Head Disloc,Child",PX24640P,CDM,983,RC,24640,CPT,,,,,,,,180,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,218.61,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.04,218.61
"Surgical Diagnostic Exam, Anorectal",PX45990P,CDM,983,RC,45990,CPT,,,,,,,,409,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,218.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.69,400.82
"Surgical Diagnostic Exam, Anorectal",PX45990P,CDM,983,RC,45990,CPT,,,,,,,,409,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,218.61,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.69,400.82
Closed Rx Mt-Phal Toe Dislocation,PX28630P,CDM,983,RC,28630,CPT,,,,,,,,248,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,218.736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.0192,241.3784
Debride Muscle Ea Add 20 Sqcm,PX11046F,CDM,510,RC,11046,CPT,,,,,,,,248,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,218.736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.0192,243.04
Fetal Profile W/O Stress,PX7681901,CDM,402,RC,76819,CPT,TC,,,,,,,248,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,218.736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,243.04
Ther Injection Carpal Tunnel,PX20526P,CDM,983,RC,20526,CPT,,,,,,,,248,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,218.736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.0192,258.75
US Chest Tc,PX7660401,CDM,402,RC,76604,CPT,TC,,,,,,,248,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,218.736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,243.04
"West Nile Ab, Igg - Ref",PX8678990,CDM,300,RC,86789,CPT,90,,,,,,,248,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,218.736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,243.04
"Close Rx Fingr Articular Fx,Manip",PX26742F,CDM,510,RC,26742,CPT,,,,,,,,1039,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,218.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,216.18,805.95
"Close Rx Fingr Articular Fx,Manip",PX26742F,CDM,510,RC,26742,CPT,,,,,,,,1039,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,218.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,216.18,805.95
"Close Rx Fingr Articular Fx,Manip",PX26742P,CDM,983,RC,26742,CPT,,,,,,,,560,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,218.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,216.18,805.95
"Close Rx Fingr Articular Fx,Manip",PX26742P,CDM,983,RC,26742,CPT,,,,,,,,560,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,218.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,216.18,805.95
MRI C Spine W&WO Contrast,PX7215601,CDM,610,RC,72156,CPT,TC,,,,,,,3541,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,218.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,218.82,437.17
cefoTEtan 2 g Recon Soln 1 Each Vial,800000,CDM,,,S0074,HCPCS,,,,63323038620,NDC,1,EA,240.2,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,218.8222,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
MRI C Spine W&WO Contrast,PX7215601,CDM,610,RC,72156,CPT,TC,,,,,,,3541,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,218.824,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,218.82,437.17
fluticasone propionate 50 MCG/ACT Suspension 16 g Bottle,63700001,CDM,250,RC,,,,,,50383070016,NDC,16,GR,432.56,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,218.87536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Ctrl Nosebleed,Anter,Complex",PX30903F,CDM,510,RC,30903,CPT,,,,,,,,456,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,218.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,446.88
"Ctrl Nosebleed,Anter,Complex",PX30903F,CDM,510,RC,30903,CPT,,,,,,,,456,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,218.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,446.88
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611F,CDM,510,RC,20611,CPT,,,,,,,,456,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,218.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.4224,446.88
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611F,CDM,510,RC,20611,CPT,,,,,,,,456,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,218.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.4224,446.88
"Office/Outpt Visit,New,Levl V",PX99205F,CDM,510,RC,99205,CPT,,,,,,,,456,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,218.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.4224,446.88
"Office/Outpt Visit,New,Levl V",PX99205F,CDM,510,RC,99205,CPT,,,,,,,,456,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,218.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.4224,446.88
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321801,NDC,50,ML,456,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,218.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321801,NDC,50,ML,456,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,218.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
Xray Nasal Bones Minimum 3 Vws,PX7016001,CDM,320,RC,70160,CPT,TC,,,,,,,456,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,218.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,446.88
Xray Nasal Bones Minimum 3 Vws,PX7016001,CDM,320,RC,70160,CPT,TC,,,,,,,456,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,218.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,446.88
cefdinir 250 MG/5ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,16714039301,NDC,60,ML,510.33,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,218.93157,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
KATZ EXTRACTOR OTO-RHINO FOREIGN BODY REMOVER,120.568,CDM,272,RC,,,,12808-MAIN,LOCAL,,,,,246,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,218.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.1884,241.08
"Cytoflo, Cell or Dna Anal - Ref",PX8818290,CDM,310,RC,88182,CPT,90,,,,,,,225,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,218.9925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,220.5
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153F,CDM,370,RC,99153,CPT,,,,,,,,225,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,218.9925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.465,220.5
Closed Rx Bimalleolar Fx,PX27808P,CDM,983,RC,27808,CPT,,,,,,,,433,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,219.098,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,179.8682,421.4389
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Solution 10 mL Bottle,63700001,CDM,250,RC,,,,,,61314064610,NDC,10,ML,433.15,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,219.1739,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
albuterol (5 MG/ML) 0.5% Nebulization Solution 20 mL Bottle,J7611.01,CDM,250,RC,,,,,,50383074120,NDC,20,ML,225.2,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,219.18716,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.54808,220.696
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,68462018022,NDC,22,GR,240.66,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,219.24126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Closed Rx Metacarpal Fx,PX26600F,CDM,510,RC,26600,CPT,,,,,,,,443,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,219.285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,184.0222,434.14
"Needle Biopsy,Muscle",PX20206F,CDM,510,RC,20206,CPT,,,,,,,,258,,First Health,Commercial,both,85,,999999999,percent of total billed charges,219.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.1732,1416.38
"Infectious Disease (Viral Respiratory Tract Infection),",PX0241U,CDM,300,RC,0241U,HCPCS,,,,,,,,457,,Health Partners,Health Partners Care Plans,both,48,,129.84,percent of total billed charges,219.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.78,447.86
"Infectious Disease (Viral Respiratory Tract Infection),",PX0241U,CDM,300,RC,0241U,HCPCS,,,,,,,,457,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,219.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.78,447.86
US Scrotum & Contents Tc,PX7687001,CDM,402,RC,76870,CPT,TC,,,,,,,457,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,219.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,447.86
US Scrotum & Contents Tc,PX7687001,CDM,402,RC,76870,CPT,TC,,,,,,,457,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,219.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,447.86
MRI T Spine W&WO Contrast,PX7215701,CDM,610,RC,72157,CPT,TC,,,,,,,4178,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,219.4676,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.55,438.49
hydrocortisone (perianal) 2.5 % Cream 28.35 g Tube,63700001,CDM,250,RC,,,,,,10631040701,NDC,28.35,GR,447.94,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,219.4906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone (perianal) 2.5 % Cream 28.35 g Tube,63700001,CDM,250,RC,,,,,,10631040701,NDC,28.35,GR,447.94,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,219.4906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone (perianal) 2.5 % Cream 28.35 g Tube,63700001,CDM,250,RC,,,,,,10631040701,NDC,28.35,GR,447.94,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,219.4906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Body Fluid Cell Count W Diff,PX89051,CDM,300,RC,89051,CPT,,,,,,,,224,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,219.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.13,219.52
Emergency Level I Visit,PX99281P,CDM,981,RC,99281,CPT,,,,,,,,224,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,219.52,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.98,219.52
ENDOWRIST INSTRUMENTS PERMANENT CAUTERY HOOK 8MM,27200000,CDM,272,RC,,,,12050-MAIN,LOCAL,,,,,224,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,219.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Helicobacter Pylori Ab,PX86677,CDM,300,RC,86677,CPT,,,,,,,,224,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,219.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.45,219.52
dexmedeTOMIDine in  dextrose 200MCG/50ML -5% Solution 50 mL Flex Cont,25000000,CDM,250,RC,,,,,,44567060224,NDC,50,ML,258.31,,First Health,Commercial,both,85,,999999999,percent of total billed charges,219.5635,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
DRIVER HEX 2.00MM STERILE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12440-MAIN,LOCAL,,,,,512,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,219.648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRIVER HEX 2.5MM STERILE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12441-MAIN,LOCAL,,,,,512,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,219.648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Excis Primary Ganglion Wrist,PX25111P,CDM,983,RC,25111,CPT,,,,,,,,529,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,219.7466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,219.7466,1404.08
amiodarone 150-4.21 MG/100ML-% Solution 100 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066015010,NDC,100,ML,249.22,,United Healthcare,All Payer,outpatient,88.2,,396.835,percent of total billed charges,219.81204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.35,318.745
Drain/Inject Medium Joint/Bursa,PX20605F,CDM,510,RC,20605,CPT,,,,,,,,247,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,219.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.6038,258.75
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802001,NDC,1,ML,444.2,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,219.879,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802010,NDC,1,ML,444.2,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,219.879,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
Closed Rx Kneecap Dislocatn,PX27560F,CDM,510,RC,27560,CPT,,,,,,,,468,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,219.89,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,219.89,807.33
Closed Rx Kneecap Dislocatn,PX27560P,CDM,983,RC,27560,CPT,,,,,,,,312,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,219.89,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,219.89,807.33
Drain Pilonidal Cyst Simpl,PX10080F,CDM,510,RC,10080,CPT,,,,,,,,742,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,219.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.88,521.62
Acth - Ref,PX8202490,CDM,300,RC,82024,CPT,90,,,,,,,259,,First Health,Commercial,both,85,,999999999,percent of total billed charges,220.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.41,253.82
"IV Push, Single/1st Drug",PX96374,CDM,260,RC,96374,CPT,,,,,,,,259,,First Health,Commercial,both,85,,999999999,percent of total billed charges,220.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.5886,253.82
Resp Virus 3-5 Targets,PX87631,CDM,300,RC,87631,CPT,,,,,,,,459,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,220.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.78,449.82
Resp Virus 3-5 Targets,PX87631,CDM,300,RC,87631,CPT,,,,,,,,459,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,220.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.78,449.82
levOCARNitine 200 MG/ML Solution 5 mL Vial,J1955.01,CDM,636,RC,J1955,HCPCS,,,,517104501,NDC,5,ML,249.86,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,220.37652,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.791844,244.8628
neomycin-polymyxin-dexamethasone 3.5-10000-0.1 Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,61314063136,NDC,3.5,GR,247.71,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,220.4619,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Airway Inhalation Treatment,PX94640F,CDM,410,RC,94640,CPT,,,,,,,,242,,Medica,Commercial,both,91.1,,7.173333333,percent of total billed charges,220.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,100.5268,237.16
"Noninvasv Oxygen Satut,Continuous",PX94762,CDM,460,RC,94762,CPT,,,,,,,,242,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,220.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,100.5268,237.16
neomycin-polymyxin-dexameth 3.5-10000-0.1 Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063006,NDC,5,ML,247.72,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,220.4708,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Cytoflo, Cell or Dna Anal - Ref",PX8818290,CDM,310,RC,88182,CPT,90,,,,,,,225,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,220.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,220.5
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153F,CDM,370,RC,99153,CPT,,,,,,,,225,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,220.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.465,220.5
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153P,CDM,983,RC,99153,CPT,,,,,,,,250,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,220.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.85,243.325
sincalide 5 MCG Recon Soln 1 Each Vial,J2805.01,CDM,636,RC,J2805,HCPCS,,,,270055615,NDC,1,EA,250,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,220.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.85,245
"Spinal Punc,Drain,Theraputic",PX62272F,CDM,510,RC,62272,CPT,,,,,,,,450,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,220.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.93,604.15
"Spinal Punc,Drain,Theraputic",PX62272F,CDM,510,RC,62272,CPT,,,,,,,,450,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,220.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.93,604.15
"Spinal Punc,Drain,Theraputic",PX62272F,CDM,510,RC,62272,CPT,,,,,,,,450,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,220.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.93,604.15
Withdrawal of Arterial Blood,PX36600F,CDM,510,RC,36600,CPT,,,,,,,,250,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,220.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.85,245
"Supply Technetium Medronate,to 30 MC",PXA9503,CDM,343,RC,A9503,HCPCS,,,,,,,,531,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,220.5774,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,220.5774,520.38
X-Ray Exam Abdomen 2 Views,PX7401901,CDM,320,RC,74019,CPT,TC,,,,,,,436,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,220.616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,427.28
"X-Ray Exam Hip,Unilat W/Pelvis 2-3 Vws",PX7350201,CDM,320,RC,73502,CPT,TC,,,,,,,436,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,220.616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,427.28
Xray Abdomen Comp Incl Decub and/or Erect,PX7402001,CDM,320,RC,74020,CPT,TC,,,,,,,436,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,220.616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.1144,427.28
Xray Cervical Spine 2 or 3 Vws,PX7204001,CDM,320,RC,72040,CPT,TC,,,,,,,436,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,220.616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,427.28
"Ex Sknbngn0.6-1cmtrnk,Arm,Lg",PX11401P,CDM,983,RC,11401,CPT,,,,,,,,387,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,220.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.19,379.26
"Fac/Ex Skinbngn0.6-1cmtrnk,Arm,Lg",PX11401F,CDM,510,RC,11401,CPT,,,,,,,,484,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,220.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.19,325.84
Remove Foreign Body Simple,PX10120F,CDM,510,RC,10120,CPT,,,,,,,,404,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,220.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.53,317.54
Remove Foreign Body Simple,PX10120P,CDM,983,RC,10120,CPT,,,,,,,,404,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,220.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.53,395.92
albuterol (5 MG/ML) 0.5% Nebulization Solution 20 mL Bottle,J7611.01,CDM,250,RC,,,,,,50383074120,NDC,20,ML,225.2,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,220.696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.54808,220.696
Closed Rx Mt-Phal Toe Dislocation,PX28630P,CDM,983,RC,28630,CPT,,,,,,,,248,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,220.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.0192,241.3784
Debride Muscle Ea Add 20 Sqcm,PX11046F,CDM,510,RC,11046,CPT,,,,,,,,248,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,220.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.0192,243.04
Fetal Profile W/O Stress,PX7681901,CDM,402,RC,76819,CPT,TC,,,,,,,248,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,220.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,243.04
Ther Injection Carpal Tunnel,PX20526P,CDM,983,RC,20526,CPT,,,,,,,,248,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,220.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.0192,258.75
US Chest Tc,PX7660401,CDM,402,RC,76604,CPT,TC,,,,,,,248,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,220.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,243.04
"West Nile Ab, Igg - Ref",PX8678990,CDM,300,RC,86789,CPT,90,,,,,,,248,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,220.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,243.04
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022101,NDC,1,EA,514.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,220.7205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022185,NDC,1,EA,514.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,220.7205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022189,NDC,1,EA,514.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,220.7205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070110,NDC,1,ML,459.95,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,220.776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.92,450.751
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070110,NDC,1,ML,459.95,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,220.776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.92,450.751
"DXA, Bone Density Study, Radius/Wrist/Heel",PX7708101,CDM,320,RC,77081,CPT,TC,,,,,,,460,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,220.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,450.8
"DXA, Bone Density Study, Radius/Wrist/Heel",PX7708101,CDM,320,RC,77081,CPT,TC,,,,,,,460,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,220.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,450.8
"Transvaginal US, Obstetric",PX7681701,CDM,402,RC,76817,CPT,TC,,,,,,,460,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,220.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,450.8
"Transvaginal US, Obstetric",PX7681701,CDM,402,RC,76817,CPT,TC,,,,,,,460,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,220.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,450.8
indocyanine green 25 MG Recon Soln 1 Each Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,70100042402,NDC,1,EA,446.07,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,220.80465,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.29,1354.4776
"Digital Mamm, Diag, Bilat, Tc W/Cad Perf",PX7706601,CDM,401,RC,77066,CPT,TC,,,,,,,375,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,220.89,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.95,220.89
"Digital Mamm, Diag, Bilat, Tc W/Cad Perf",PX7706601,CDM,401,RC,77066,CPT,TC,,,,,,,375,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,220.89,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.95,220.89
US Kidney Transplt Untrsd,PX7677601,CDM,402,RC,76776,CPT,TC,,,,,,,554,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,220.89,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.61,220.89
US Kidney Transplt Untrsd,PX7677601,CDM,402,RC,76776,CPT,TC,,,,,,,554,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,220.89,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.61,220.89
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035F,CDM,510,RC,12035,CPT,,,,,,,,655,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,220.9168,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.34,810.1
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035P,CDM,983,RC,12035,CPT,,,,,,,,1244,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,220.9168,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.34,1219.12
I&D Deep Absc/Hematoma Neck/Chest,PX21501P,CDM,983,RC,21501,CPT,,,,,,,,515,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,220.935,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.931,2482.37
SET SP TUBE INTRODUCER  14CM 8-14FR G15469,120.377,CDM,272,RC,,,,7147-MAIN,LOCAL,,,,,227,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,220.9391,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.2958,222.46
Sp Stn for Inclusn Bodies - Ref,PX8720790,CDM,300,RC,87207,CPT,90,,,,,,,227,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,220.9391,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.49,222.46
cabazitaxel 60 MG/1.5ML Solution 6 mL Vial,J9043.01,CDM,636,RC,J9043,HCPCS,,,,24582411,NDC,6,ML,28293.07,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,220.98,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,185.2,220.98
Blood Clot Factor V Test,PX85220,CDM,300,RC,85220,CPT,,,,,,,,260,,First Health,Commercial,both,85,,999999999,percent of total billed charges,221,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.18,254.8
"Closed Rx Toe Fx,Manipulatn",PX28515P,CDM,983,RC,28515,CPT,,,,,,,,260,,First Health,Commercial,both,85,,999999999,percent of total billed charges,221,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.004,253.058
First Hour IV Hydration <1 Hour,PX96360,CDM,260,RC,96360,CPT,,,,,,,,260,,First Health,Commercial,both,85,,999999999,percent of total billed charges,221,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.004,254.8
Xray Ribs Unilat 2 Vws,PX7110001,CDM,320,RC,71100,CPT,TC,,,,,,,437,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,221.122,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,428.26
erythromycin lactobionate 500 MG Recon Soln 1 Each Vial,J1364.01,CDM,636,RC,J1364,HCPCS,,,,409648211,NDC,1,EA,437.09,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,221.16754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.06,428.3482
"Hemorrhoidectomy,Int/Ext,Simple",PX46255F,CDM,510,RC,46255,CPT,,,,,,,,1627,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,221.21,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,221.21,1082.67
"Hemorrhoidectomy,Int/Ext,Simple",PX46255P,CDM,983,RC,46255,CPT,,,,,,,,2393,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,221.21,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,221.21,2345.14
medroxyPROGESTERone 150 MG/ML Suspension 1 mL Vial,J1050.01,CDM,636,RC,J1050,HCPCS,,,,67457088799,NDC,1,ML,437.38,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,221.31428,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.687652,428.6324
fluticasone propionate 50 MCG/ACT Suspension 16 g Bottle,63700001,CDM,250,RC,,,,,,60505082901,NDC,16,GR,437.4,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,221.3244,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Closed Rx Shldr Dislocation,PX23650P,CDM,983,RC,23650,CPT,,,,,,,,516,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,221.364,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,502.2228
Trg Gene Rearrangement Anal - Ref,PX8134290,CDM,300,RC,81342,CPT,90,,,,,,,516,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,221.364,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,184.76,505.68
Aspirate Pleura W/ Imaging,PX32555F,CDM,761,RC,32555,CPT,,,,,,,,795,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,221.38,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.75,646.83
Aspirate Pleura W/ Imaging,PX32555P,CDM,983,RC,32555,CPT,,,,,,,,536,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,221.38,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.75,646.83
Xray Ribs Bil 3vws Tc,PX7111001,CDM,320,RC,71110,CPT,TC,,,,,,,533,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,221.4082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,522.34
Closed Rx Elbow Dislocation,PX24600F,CDM,510,RC,24600,CPT,,,,,,,,706,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,221.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,218.15,814.94
Closed Rx Elbow Dislocation,PX24600F,CDM,510,RC,24600,CPT,,,,,,,,706,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,221.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,218.15,814.94
Closed Rx Elbow Dislocation,PX24600P,CDM,983,RC,24600,CPT,,,,,,,,380,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,221.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,218.15,814.94
Closed Rx Elbow Dislocation,PX24600P,CDM,983,RC,24600,CPT,,,,,,,,380,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,221.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,218.15,814.94
DRILL BIT AO DIA 2.0MMX135MM SCALED,27200000,CDM,272,RC,,,,12640-MAIN,LOCAL,,,,,452,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,221.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRILL BIT AO DIA 2.0MMX135MM SCALED,27200000,CDM,272,RC,,,,12640-MAIN,LOCAL,,,,,452,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,221.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRILL BIT AO DIA 2.0MMX135MM SCALED,27200000,CDM,272,RC,,,,12640-MAIN,LOCAL,,,,,452,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,221.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
tiotropium bromide monohydrate 2.5 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597010051,NDC,4,GR,461.7,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,221.616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tiotropium bromide monohydrate 2.5 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597010051,NDC,4,GR,461.7,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,221.616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tiotropium bromide-olodaterol 2.5-2.5 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597015570,NDC,4,GR,461.7,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,221.616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tiotropium bromide-olodaterol 2.5-2.5 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597015570,NDC,4,GR,461.7,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,221.616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Debride Bone Ea Add 20 Sqcm,PX11047F,CDM,510,RC,11047,CPT,,,,,,,,438,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,221.628,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.9452,429.24
US Pregnancy Tc Limited,PX7681501,CDM,402,RC,76815,CPT,TC,,,,,,,438,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,221.628,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,429.24
hydrocortisone (perianal) 2.5 % Cream 28.35 g Tube,63700001,CDM,250,RC,,,,,,10631040701,NDC,28.35,GR,447.94,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,221.7303,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
amiodarone 150-4.21 MG/100ML-% Solution 100 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066015010,NDC,100,ML,249.22,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,221.8058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.35,318.745
Calr Gene Analysis Common Variants in Exon 9 - Ref,PX8121990,CDM,300,RC,81219,CPT,90,,,,,,,534,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,221.8236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.52,523.32
"Closed Rx Spont Hip Disloc,Anesth",PX27257F,CDM,510,RC,27257,CPT,,,,,,,,548,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,221.86,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,221.86,755.45
"Closed Rx Spont Hip Disloc,Anesth",PX27257P,CDM,983,RC,27257,CPT,,,,,,,,365,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,221.86,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,221.86,755.45
OXALiplatin 50 MG/10ML Solution 10 mL Vial,J9263.01,CDM,636,RC,J9263,HCPCS,,,,955173110,NDC,10,ML,228,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,221.9124,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.7112,223.44
nystatin-triamcinolone 100000-0.1 UNIT/GM-% Ointment 30 g Tube,25000000,CDM,250,RC,,,,,,52565004230,NDC,30,GR,438.62,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,221.94172,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Exc Skn Mal 0.6-1cm Fce,Facial",PX11641P,CDM,983,RC,11641,CPT,,,,,,,,453,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,221.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.1762,614.65
"Exc Skn Mal 0.6-1cm Fce,Facial",PX11641P,CDM,983,RC,11641,CPT,,,,,,,,453,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,221.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.1762,614.65
"Exc Skn Mal 0.6-1cm Fce,Facial",PX11641P,CDM,983,RC,11641,CPT,,,,,,,,453,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,221.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.1762,614.65
Repr Superf Wnd Body 7.6-12.5,PX12004F,CDM,510,RC,12004,CPT,,,,,,,,453,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,221.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,443.94
Repr Superf Wnd Body 7.6-12.5,PX12004F,CDM,510,RC,12004,CPT,,,,,,,,453,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,221.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,443.94
Repr Superf Wnd Body 7.6-12.5,PX12004F,CDM,510,RC,12004,CPT,,,,,,,,453,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,221.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,443.94
Repr Superf Wnd Face 5.1-7.5,PX12014F,CDM,510,RC,12014,CPT,,,,,,,,453,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,221.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,443.94
Repr Superf Wnd Face 5.1-7.5,PX12014F,CDM,510,RC,12014,CPT,,,,,,,,453,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,221.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,443.94
Repr Superf Wnd Face 5.1-7.5,PX12014F,CDM,510,RC,12014,CPT,,,,,,,,453,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,221.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,443.94
"Hemorrhoidectomy,Int/Ext,Simple",PX46255F,CDM,510,RC,46255,CPT,,,,,,,,1627,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,222.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,221.21,1082.67
"Hemorrhoidectomy,Int/Ext,Simple",PX46255F,CDM,510,RC,46255,CPT,,,,,,,,1627,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,222.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,221.21,1082.67
"Hemorrhoidectomy,Int/Ext,Simple",PX46255P,CDM,983,RC,46255,CPT,,,,,,,,2393,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,222.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,221.21,2345.14
"Hemorrhoidectomy,Int/Ext,Simple",PX46255P,CDM,983,RC,46255,CPT,,,,,,,,2393,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,222.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,221.21,2345.14
8MM ENDOWRIST INSTRUMENTS 8MM FORCE BIPOLAR IS4000,27200000,CDM,272,RC,,,,11915-MAIN,LOCAL,,,,,439,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,222.134,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
VISIGI3D 40FR STD WITH BULB,27100000,CDM,271,RC,,,,12812-MAIN,LOCAL,,,,,439,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,222.134,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,409277602,NDC,200,ML,228.28,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,222.184924,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.827512,225.8704
"Blood Gases: Ph, Po2 & Pco2",PX82803,CDM,300,RC,82803,CPT,,,,,,,,518,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,222.222,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.9,507.64
fluorouracil 5 GM/100ML Solution 100 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,16729027638,NDC,100,ML,261.44,,First Health,Commercial,both,85,,999999999,percent of total billed charges,222.224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,256.2112
CARTER THOMASON CLOSURE SUTURE PASSER XL 10/12MM 15MM CTXL,27200000,CDM,272,RC,,,,12946-MAIN,LOCAL,,,,,535,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,222.239,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Inject Trigger Point, 1 or 2",PX20552F,CDM,510,RC,20552,CPT,,,,,,,,252,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,222.264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,258.75
"Level V - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3939,CDM,310,RC,88307,CPT,TC,,,,,,,252,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,222.264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,314.02
"Off/Outpt Visit,New,Levl III",PX99203P,CDM,983,RC,99203,CPT,,,,,,,,252,,United Healthcare,All Payer,outpatient,88.2,,117.02875,percent of total billed charges,222.264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,245.2716
"Office/Outpt Visit,New,Levl III",PX99203F,CDM,510,RC,99203,CPT,,,,,,,,252,,United Healthcare,All Payer,outpatient,88.2,,117.02875,percent of total billed charges,222.264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,246.96
"In Situ Hybridization (Eg, Fish), Each Probe, Tech",PX8836501,CDM,310,RC,88365,CPT,TC,,,,,,,117,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,222.272,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.37,222.272
"In Situ Hybridization (Eg, Fish), Each Probe, Tech",PX8836501,CDM,310,RC,88365,CPT,TC,,,,,,,117,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,222.272,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.37,222.272
BINDER PELVIC ADULT STABILIZATION T-PODR,120.357,CDM,271,RC,A4467,HCPCS,,10734-MAIN,LOCAL,,,,,244,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,222.284,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.3576,239.12
"Bone Marrow Aspiration(S),Diag",PX38220P,CDM,983,RC,38220,CPT,,,,,,,,244,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,222.284,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.3576,1416.38
Dress/Debrid Med Burn No Anesth,PX16025P,CDM,983,RC,16025,CPT,,,,,,,,244,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,222.284,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.3576,237.4852
diclofenac 0.1 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,17478089225,NDC,2.5,ML,252.06,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,222.31692,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
levOCARNitine 200 MG/ML Solution 5 mL Vial,J1955.01,CDM,636,RC,J1955,HCPCS,,,,517104501,NDC,5,ML,249.86,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,222.3754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.791844,244.8628
SET SP TUBE INTRODUCER  14CM 8-14FR G15469,120.377,CDM,272,RC,,,,7147-MAIN,LOCAL,,,,,227,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,222.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.2958,222.46
Sp Stn for Inclusn Bodies - Ref,PX8720790,CDM,300,RC,87207,CPT,90,,,,,,,227,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,222.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.49,222.46
X-Ray Exam Entire Spine 2-3 Vws,PX7208201,CDM,320,RC,72082,CPT,TC,,,,,,,454,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,222.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,444.92
X-Ray Exam Entire Spine 2-3 Vws,PX7208201,CDM,320,RC,72082,CPT,TC,,,,,,,454,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,222.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,444.92
X-Ray Exam Entire Spine 2-3 Vws,PX7208201,CDM,320,RC,72082,CPT,TC,,,,,,,454,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,222.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,444.92
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153P,CDM,983,RC,99153,CPT,,,,,,,,250,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,222.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.85,243.325
sincalide 5 MCG Recon Soln 1 Each Vial,J2805.01,CDM,636,RC,J2805,HCPCS,,,,270055615,NDC,1,EA,250,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,222.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.85,245
Withdrawal of Arterial Blood,PX36600F,CDM,510,RC,36600,CPT,,,,,,,,250,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,222.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.85,245
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802201,NDC,0.8,ML,439.77,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,222.52362,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802210,NDC,0.8,ML,439.77,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,222.52362,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
"Incis/Drain Scrotum/Testis,Epididym",PX54700P,CDM,983,RC,54700,CPT,,,,,,,,440,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,222.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,182.776,1779.39
Xray Ac Joints(Bilateral),PX7305001,CDM,320,RC,73050,CPT,TC,,,,,,,519,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,222.651,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,508.62
Aspirate Pleura W/ Imaging,PX32555P,CDM,983,RC,32555,CPT,,,,,,,,536,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,222.6544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,222.6544,548.81
Lvl 3 Init Hosp High Mdm or 75 Minutes,PX99223,CDM,982,RC,99223,CPT,,,,,,,,536,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,222.6544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,222.6544,521.6888
Immunohisto Antibody Slide Ea Multiplex,PX8834401,CDM,310,RC,88344,CPT,TC,,,,,,,51,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,222.656,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.6,222.656
Immunohisto Antibody Slide Ea Multiplex,PX8834401,CDM,310,RC,88344,CPT,TC,,,,,,,51,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,222.656,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.6,222.656
Tap Block Bilateral by Injection(S),PX64488P,CDM,983,RC,64488,CPT,,,,,,,,262,,First Health,Commercial,both,85,,999999999,percent of total billed charges,222.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.8348,255.0046
Naso/Orogastric Tube,PX43752F,CDM,510,RC,43752,CPT,,,,,,,,464,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,222.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.7456,454.72
Naso/Orogastric Tube,PX43752F,CDM,510,RC,43752,CPT,,,,,,,,464,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,222.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.7456,454.72
rho d immune globulin human 1500 units solution prefilled syringe 1 Each Syringe,J2790.01,CDM,636,RC,J2790,HCPCS,,,,562780500,NDC,1,EA,464.01,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,222.7248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.749754,454.7298
rho d immune globulin human 1500 units solution prefilled syringe 1 Each Syringe,J2790.01,CDM,636,RC,J2790,HCPCS,,,,562780500,NDC,1,EA,464.01,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,222.7248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.749754,454.7298
Closed Rx Kneecap Dislocatn,PX27560F,CDM,510,RC,27560,CPT,,,,,,,,468,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,222.73,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,219.89,807.33
Closed Rx Kneecap Dislocatn,PX27560F,CDM,510,RC,27560,CPT,,,,,,,,468,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,222.73,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,219.89,807.33
Closed Rx Kneecap Dislocatn,PX27560P,CDM,983,RC,27560,CPT,,,,,,,,312,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,222.73,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,219.89,807.33
Closed Rx Kneecap Dislocatn,PX27560P,CDM,983,RC,27560,CPT,,,,,,,,312,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,222.73,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,219.89,807.33
"Spinal Punc,Drain,Theraputic",PX62272F,CDM,510,RC,62272,CPT,,,,,,,,450,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,222.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.93,604.15
Drain Skin Abscess Simple,PX10060F,CDM,510,RC,10060,CPT,,,,,,,,296,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,222.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.41,264.96
Drain Skin Abscess Simple,PX10060P,CDM,983,RC,10060,CPT,,,,,,,,293,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,222.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.41,287.14
patiromer sorbitex calcium 8.4 g Packet 4 Each Box,63700001,CDM,250,RC,,,,,,53436008404,NDC,1,EA,228.96,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,222.846768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Ctrl Nosebleed,Anter,Simple",PX30901P,CDM,983,RC,30901,CPT,,,,,,,,229,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,222.8857,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.1266,222.8857
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604P,CDM,983,RC,20604,CPT,,,,,,,,229,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,222.8857,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.1266,258.75
Removal of Nail Plate,PX11730F,CDM,510,RC,11730,CPT,,,,,,,,229,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,222.8857,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.1266,224.42
"Ileoscopy Thru Stoma,Diagnostic",PX44380P,CDM,983,RC,44380,CPT,,,,,,,,455,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,222.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.007,791.92
"Ileoscopy Thru Stoma,Diagnostic",PX44380P,CDM,983,RC,44380,CPT,,,,,,,,455,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,222.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.007,791.92
"Ileoscopy Thru Stoma,Diagnostic",PX44380P,CDM,983,RC,44380,CPT,,,,,,,,455,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,222.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.007,791.92
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607F,CDM,761,RC,97607,CPT,,,,,,,,455,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,222.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.007,445.9
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607F,CDM,761,RC,97607,CPT,,,,,,,,455,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,222.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.007,445.9
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607F,CDM,761,RC,97607,CPT,,,,,,,,455,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,222.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.007,445.9
ePHEDrine sulfate 50 MG/ML Solution 1 mL Ampule,25000000,CDM,250,RC,,,,,,17478041510,NDC,1,ML,262.31,,First Health,Commercial,both,85,,999999999,percent of total billed charges,222.9635,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Fac/Office Consultation,Level IV",PX99244F,CDM,510,RC,99244,CPT,,,,,,,,441,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,223.146,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,183.1914,432.18
Gastric Intubation Treatment,PX43753F,CDM,510,RC,43753,CPT,,,,,,,,441,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,223.146,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,183.1914,432.18
Lvl 2 Sub Hosp Mod Mdm or 35 Minute,PX99232,CDM,982,RC,99232,CPT,,,,,,,,253,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,223.146,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.0962,246.2449
MESH FLAT SHEET SOFT 3X6 INCH,C1781,CDM,278,RC,C1781,HCPCS,,11773-MAIN,LOCAL,,,,,253,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,223.146,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Office Consultation,Level IV",PX99244P,CDM,983,RC,99244,CPT,,,,,,,,441,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,223.146,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,183.1914,429.2253
Subsequent Observation Care,PX99225,CDM,982,RC,99225,CPT,,,,,,,,253,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,223.146,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.0962,246.2449
Tap Block Unilateral by Injection(S),PX64486F,CDM,510,RC,64486,CPT,,,,,,,,253,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,223.146,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.0962,247.94
"Closed Rx Spont Hip Disloc,Anesth",PX27257F,CDM,510,RC,27257,CPT,,,,,,,,548,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,223.17,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,221.86,755.45
"Closed Rx Spont Hip Disloc,Anesth",PX27257F,CDM,510,RC,27257,CPT,,,,,,,,548,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,223.17,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,221.86,755.45
"Closed Rx Spont Hip Disloc,Anesth",PX27257P,CDM,983,RC,27257,CPT,,,,,,,,365,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,223.17,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,221.86,755.45
"Closed Rx Spont Hip Disloc,Anesth",PX27257P,CDM,983,RC,27257,CPT,,,,,,,,365,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,223.17,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,221.86,755.45
Fibrinogen Activity - Ref,PX8538490,CDM,300,RC,85384,CPT,90,,,,,,,245,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,223.195,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.91,240.1
"Ileoscopy Thru Stoma,Diagnostic",PX44380F,CDM,750,RC,44380,CPT,,,,,,,,245,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,223.195,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.773,791.92
Lipid Profile,PX80061,CDM,300,RC,80061,CPT,,,,,,,,245,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,223.195,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.28,240.1
Platelet Antibodies - Ref,PX8602290,CDM,300,RC,86022,CPT,90,,,,,,,245,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,223.195,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.84,240.1
CT Abdomen&Pelvis W/Contrast,PX7417701,CDM,350,RC,74177,CPT,TC,,,,,,,4288,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,223.3292,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,151.4,446.37
"Ctrl Nosebleed,Anter,Complex",PX30903F,CDM,510,RC,30903,CPT,,,,,,,,456,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,223.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,446.88
"Ctrl Nosebleed,Anter,Complex",PX30903F,CDM,510,RC,30903,CPT,,,,,,,,456,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,223.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,446.88
"Ctrl Nosebleed,Anter,Complex",PX30903F,CDM,510,RC,30903,CPT,,,,,,,,456,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,223.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,446.88
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611F,CDM,510,RC,20611,CPT,,,,,,,,456,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,223.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.4224,446.88
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611F,CDM,510,RC,20611,CPT,,,,,,,,456,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,223.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.4224,446.88
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611F,CDM,510,RC,20611,CPT,,,,,,,,456,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,223.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.4224,446.88
"Office/Outpt Visit,New,Levl V",PX99205F,CDM,510,RC,99205,CPT,,,,,,,,456,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,223.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.4224,446.88
"Office/Outpt Visit,New,Levl V",PX99205F,CDM,510,RC,99205,CPT,,,,,,,,456,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,223.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.4224,446.88
"Office/Outpt Visit,New,Levl V",PX99205F,CDM,510,RC,99205,CPT,,,,,,,,456,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,223.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.4224,446.88
"Office/Outpt Visit,New,Levl V",PX99205P,CDM,983,RC,99205,CPT,,,,,,,,456,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,223.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.4224,443.8248
"Office/Outpt Visit,New,Levl V",PX99205P,CDM,983,RC,99205,CPT,,,,,,,,456,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,223.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.4224,443.8248
"Office/Outpt Visit,New,Levl V",PX99205P,CDM,983,RC,99205,CPT,,,,,,,,456,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,223.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.4224,443.8248
OXALiplatin 50 MG/10ML Solution 10 mL Vial,J9263.01,CDM,636,RC,J9263,HCPCS,,,,955173110,NDC,10,ML,228,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,223.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.7112,223.44
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321801,NDC,50,ML,456,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,223.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321801,NDC,50,ML,456,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,223.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321801,NDC,50,ML,456,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,223.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
Xray Nasal Bones Minimum 3 Vws,PX7016001,CDM,320,RC,70160,CPT,TC,,,,,,,456,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,223.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,446.88
Xray Nasal Bones Minimum 3 Vws,PX7016001,CDM,320,RC,70160,CPT,TC,,,,,,,456,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,223.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,446.88
Xray Nasal Bones Minimum 3 Vws,PX7016001,CDM,320,RC,70160,CPT,TC,,,,,,,456,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,223.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,446.88
"Destruct Benign Lesion, 1-14",PX17110P,CDM,983,RC,17110,CPT,,,,,,,,521,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,223.509,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,507.0893
"X-Ray Exam Hip,Unilat W/Pelvis 1vw",PX7350101,CDM,320,RC,73501,CPT,TC,,,,,,,263,,First Health,Commercial,both,85,,999999999,percent of total billed charges,223.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,257.74
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,409277602,NDC,200,ML,228.28,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,223.7144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.827512,225.8704
DRILL BIT AO DIA 2.0MMX135MM SCALED,27200000,CDM,272,RC,,,,12640-MAIN,LOCAL,,,,,452,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,223.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037905,NDC,0.5,ML,229.88,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,223.742204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
CP LAG SCREW 3.6MM L22MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12757-MAIN,LOCAL,,,,,539,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,223.9006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
CP LAG SCREW 3.6MM L24MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12650-MAIN,LOCAL,,,,,539,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,223.9006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
CP LAG SCREW 3.6MM L26MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12636-MAIN,LOCAL,,,,,539,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,223.9006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"Infectious Disease (Viral Respiratory Tract Infection),",PX0241U,CDM,300,RC,0241U,HCPCS,,,,,,,,457,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,57.27264706,percent of total billed charges,223.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.78,447.86
"Infectious Disease (Viral Respiratory Tract Infection),",PX0241U,CDM,300,RC,0241U,HCPCS,,,,,,,,457,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,223.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.78,447.86
"Infectious Disease (Viral Respiratory Tract Infection),",PX0241U,CDM,300,RC,0241U,HCPCS,,,,,,,,457,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,223.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.78,447.86
US Scrotum & Contents Tc,PX7687001,CDM,402,RC,76870,CPT,TC,,,,,,,457,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,220.105,percent of total billed charges,223.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,447.86
US Scrotum & Contents Tc,PX7687001,CDM,402,RC,76870,CPT,TC,,,,,,,457,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,223.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,447.86
US Scrotum & Contents Tc,PX7687001,CDM,402,RC,76870,CPT,TC,,,,,,,457,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,223.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,447.86
Closed Rx Trimalleolar Fx,PX27816F,CDM,510,RC,27816,CPT,,,,,,,,522,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,223.938,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,511.56
Xray Thoracic Spine 3 Vws,PX7207201,CDM,320,RC,72072,CPT,TC,,,,,,,522,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,223.938,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,511.56
Thyrstim Immun Glob (Tsi) - Ref,PX8444590,CDM,300,RC,84445,CPT,90,,,,,,,254,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,224.028,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.63,248.92
KATZ EXTRACTOR OTO-RHINO FOREIGN BODY REMOVER,120.568,CDM,272,RC,,,,12808-MAIN,LOCAL,,,,,246,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,224.106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.1884,241.08
"Exc Skn Benig<5mm Face,Facial",PX11440P,CDM,983,RC,11440,CPT,,,,,,,,387,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,224.14,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.28,379.26
"Fac/Exc Skn Benig<5mm Face,Facial",PX11440F,CDM,510,RC,11440,CPT,,,,,,,,484,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,224.14,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.28,299.55
Closed Rx Metacarpal Fx,PX26600F,CDM,510,RC,26600,CPT,,,,,,,,443,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,224.158,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,184.0222,434.14
"Exc Skn Mal 0.6-1cm Fce,Facial",PX11641P,CDM,983,RC,11641,CPT,,,,,,,,453,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,224.235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.1762,614.65
Repr Superf Wnd Body 7.6-12.5,PX12004F,CDM,510,RC,12004,CPT,,,,,,,,453,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,224.235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,443.94
Repr Superf Wnd Face 5.1-7.5,PX12014F,CDM,510,RC,12014,CPT,,,,,,,,453,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,224.235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,443.94
"Inject Trigger Point, 1 or 2",PX20552F,CDM,510,RC,20552,CPT,,,,,,,,252,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,224.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,258.75
"Level V - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3939,CDM,310,RC,88307,CPT,TC,,,,,,,252,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,224.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,314.02
"Off/Outpt Visit,New,Levl III",PX99203P,CDM,983,RC,99203,CPT,,,,,,,,252,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,224.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,245.2716
"Office/Outpt Visit,New,Levl III",PX99203F,CDM,510,RC,99203,CPT,,,,,,,,252,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,224.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,246.96
Xray Sacrum/ Coccyx Minimum 2 Vws,PX7222001,CDM,320,RC,72220,CPT,TC,,,,,,,540,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,224.316,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,529.2
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,143971801,NDC,200,ML,230.48,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,224.326184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.827512,225.8704
diclofenac 0.1 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,17478089225,NDC,2.5,ML,252.06,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,224.3334,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Layr Clos Wnd Rest Body 7.6-12.5,PX12044P,CDM,983,RC,12044,CPT,,,,,,,,523,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,224.367,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,217.2542,548.67
patiromer sorbitex calcium 8.4 g Packet 4 Each Box,63700001,CDM,250,RC,,,,,,53436008404,NDC,1,EA,228.96,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,224.3808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq,PX87635,CDM,300,RC,87635,CPT,,,,,,,,166,,Blue Cross Blue Shield of MN,All commercial plans,both,,,87.26029412,fee schedule,224.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,224.4
Inj Tendon/Ligament/Cyst,PX20550P,CDM,983,RC,20550,CPT,,,,,,,,264,,First Health,Commercial,both,85,,999999999,percent of total billed charges,224.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.6656,258.75
Occupational Therapy Eval Mod Complex,PX97166,CDM,434,RC,97166,CPT,,,,,,,,264,,First Health,Commercial,both,85,,999999999,percent of total billed charges,224.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,258.72
Physical Therapy Evaluation Mod Complex,PX97162,CDM,424,RC,97162,CPT,,,,,,,,264,,First Health,Commercial,both,85,,999999999,percent of total billed charges,224.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,258.72
Renal Function Panel,PX80069,CDM,300,RC,80069,CPT,,,,,,,,264,,First Health,Commercial,both,85,,999999999,percent of total billed charges,224.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.96,258.72
Sars-Cov-2 Covid-19 Amp Prb,PX8763590,CDM,300,RC,87635,CPT,90,,,,,,,365,,Blue Cross Blue Shield of MN,All commercial plans,both,,,87.26029412,fee schedule,224.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,357.7
"Ctrl Nosebleed,Anter,Simple",PX30901P,CDM,983,RC,30901,CPT,,,,,,,,229,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,224.42,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.03,325.15
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604P,CDM,983,RC,20604,CPT,,,,,,,,229,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,224.42,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.13,224.42
Removal of Nail Plate,PX11730F,CDM,510,RC,11730,CPT,,,,,,,,229,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,224.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.1266,224.42
Closed Rx Kneecap Dislocatn,PX27560F,CDM,510,RC,27560,CPT,,,,,,,,468,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,224.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,194.4072,458.64
Closed Rx Kneecap Dislocatn,PX27560F,CDM,510,RC,27560,CPT,,,,,,,,468,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,224.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,194.4072,458.64
"POS Airway Pressure, Bipap",PX94660.01F,CDM,410,RC,94660,CPT,,,,,,,,468,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,224.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.33,458.64
"POS Airway Pressure, Bipap",PX94660.01F,CDM,410,RC,94660,CPT,,,,,,,,468,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,224.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.33,458.64
Vedolizumab - Ref,PX8028090,CDM,300,RC,80280,CPT,90,,,,,,,468,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,224.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.36,458.64
Vedolizumab - Ref,PX8028090,CDM,300,RC,80280,CPT,90,,,,,,,468,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,224.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.36,458.64
X-Ray Exam Entire Spine 2-3 Vws,PX7208201,CDM,320,RC,72082,CPT,TC,,,,,,,454,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,224.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,444.92
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802001,NDC,1,ML,444.2,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,224.7652,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802010,NDC,1,ML,444.2,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,224.7652,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800F,CDM,510,RC,40800,CPT,,,,,,,,255,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,224.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.927,614.65
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106F,CDM,510,RC,11106,CPT,,,,,,,,255,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,224.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.927,548.67
"Inject Nerv Blck,Trigeminal",PX64400F,CDM,510,RC,64400,CPT,,,,,,,,255,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,224.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.927,258.75
Resp Virus 3-5 Targets,PX87631,CDM,300,RC,87631,CPT,,,,,,,,459,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,224.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.78,449.82
Resp Virus 3-5 Targets,PX87631,CDM,300,RC,87631,CPT,,,,,,,,459,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,224.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.78,449.82
Resp Virus 3-5 Targets,PX87631,CDM,300,RC,87631,CPT,,,,,,,,459,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,224.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.78,449.82
"Urinalysis, Auto, W/Scope",PX81001,CDM,300,RC,81001,CPT,,,,,,,,255,,United Healthcare,All Payer,outpatient,88.2,,167.5283333,percent of total billed charges,224.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.91,249.9
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315606,NDC,100,ML,264.64,,First Health,Commercial,both,85,,999999999,percent of total billed charges,224.944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.931456,259.3472
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315695,NDC,100,ML,264.64,,First Health,Commercial,both,85,,999999999,percent of total billed charges,224.944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.931456,259.3472
Drain/Inject Medium Joint/Bursa,PX20605F,CDM,510,RC,20605,CPT,,,,,,,,247,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,225.017,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.6038,258.75
"Tte W/Doppler, Complete",PX9330601,CDM,483,RC,93306,CPT,TC,,,,,,,2191,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,225.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.08,225.12
"Tte W/Doppler, Complete",PX9330601,CDM,483,RC,93306,CPT,TC,,,,,,,2191,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,225.12,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.08,225.12
"Critical Care, Addl 30 Min",PX99292P,CDM,983,RC,99292,CPT,,,,,,,,542,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,225.1468,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,225.1468,527.5286
Lvl 2 Sub Hosp Mod Mdm or 35 Minute,PX99232,CDM,982,RC,99232,CPT,,,,,,,,253,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,225.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.0962,246.2449
MESH FLAT SHEET SOFT 3X6 INCH,C1781,CDM,278,RC,C1781,HCPCS,,11773-MAIN,LOCAL,,,,,253,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,225.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Subsequent Observation Care,PX99225,CDM,982,RC,99225,CPT,,,,,,,,253,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,225.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.0962,246.2449
Tap Block Unilateral by Injection(S),PX64486F,CDM,510,RC,64486,CPT,,,,,,,,253,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,225.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.0962,247.94
Anal Sphincterotomy,PX46080P,CDM,983,RC,46080,CPT,,,,,,,,525,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,225.225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,218.085,2452.93
"Ileoscopy Thru Stoma,Diagnostic",PX44380P,CDM,983,RC,44380,CPT,,,,,,,,455,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,225.225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.007,791.92
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607F,CDM,761,RC,97607,CPT,,,,,,,,455,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,225.225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.007,445.9
Haptoglobin; Quantitative,PX83010,CDM,300,RC,83010,CPT,,,,,,,,265,,First Health,Commercial,both,85,,999999999,percent of total billed charges,225.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.53,259.7
ID Nucleic Acid Sequencing - Ref,PX8715390,CDM,300,RC,87153,CPT,90,,,,,,,265,,First Health,Commercial,both,85,,999999999,percent of total billed charges,225.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.77,259.7
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037905,NDC,0.5,ML,229.88,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,225.2824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.311644,225.2824
"Excise Lesion,Back or Flank",PX21930F,CDM,510,RC,21930,CPT,,,,,,,,1326,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,225.35,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,225.35,1053.61
"Excise Lesion,Back or Flank",PX21930P,CDM,983,RC,21930,CPT,,,,,,,,884,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,225.35,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,225.35,1053.61
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070110,NDC,1,ML,459.95,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,225.3755,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.92,450.751
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070110,NDC,1,ML,459.95,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,225.3755,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.92,450.751
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070110,NDC,1,ML,459.95,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,225.3755,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.92,450.751
"DXA, Bone Density Study, Radius/Wrist/Heel",PX7708101,CDM,320,RC,77081,CPT,TC,,,,,,,460,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,225.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,450.8
"DXA, Bone Density Study, Radius/Wrist/Heel",PX7708101,CDM,320,RC,77081,CPT,TC,,,,,,,460,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,225.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,450.8
"DXA, Bone Density Study, Radius/Wrist/Heel",PX7708101,CDM,320,RC,77081,CPT,TC,,,,,,,460,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,225.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,450.8
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623P,CDM,983,RC,11623,CPT,,,,,,,,460,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,225.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,191.084,1416.38
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623P,CDM,983,RC,11623,CPT,,,,,,,,460,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,225.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,191.084,1416.38
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623P,CDM,983,RC,11623,CPT,,,,,,,,460,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,225.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,191.084,1416.38
"Transvaginal US, Obstetric",PX7681701,CDM,402,RC,76817,CPT,TC,,,,,,,460,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,225.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,450.8
"Transvaginal US, Obstetric",PX7681701,CDM,402,RC,76817,CPT,TC,,,,,,,460,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,225.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,450.8
"Transvaginal US, Obstetric",PX7681701,CDM,402,RC,76817,CPT,TC,,,,,,,460,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,225.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,450.8
"Exc Skn Bngn2.1-3cmtrnk,Arm,Lg",PX11403P,CDM,983,RC,11403,CPT,,,,,,,,543,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,225.5622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,225.5622,614.65
Xray Knee (Both) Ap Stand,PX7356501,CDM,320,RC,73565,CPT,TC,,,,,,,543,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,225.5622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,532.14
CT Angiograph Pelv W/O&W/Dye,PX7219101,CDM,350,RC,72191,CPT,TC,,,,,,,1458,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,225.5818,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,118.89,450.98
Debride Tissue/Muscle,PX11043F,CDM,510,RC,11043,CPT,,,,,,,,526,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,225.654,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,218.5004,548.67
Hfe Gene - Ref,PX8125690,CDM,300,RC,81256,CPT,90,,,,,,,526,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,225.654,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,59.93,515.48
neomycin-polymyxin-dexamethasone 3.5-10000-0.1 Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,61314063136,NDC,3.5,GR,247.71,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,225.66381,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
neomycin-polymyxin-dexameth 3.5-10000-0.1 Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063006,NDC,5,ML,247.72,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,225.67292,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,548590000,NDC,1,EA,470.19,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,225.6912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,179.012476,460.7862
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,548590000,NDC,1,EA,470.19,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,225.6912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,179.012476,460.7862
"Chemotherapy, IV Infusion, 1 Hour",PX96413,CDM,335,RC,96413,CPT,,,,,,,,614,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,225.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.29,225.7
"Chemotherapy, IV Infusion, 1 Hour",PX96413,CDM,335,RC,96413,CPT,,,,,,,,614,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,225.7,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.29,225.7
indocyanine green 25 MG Recon Soln 1 Each Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,70100042402,NDC,1,EA,446.07,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,225.71142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.29,1354.4776
"Ctrl Nosebleed,Anter,Complex",PX30903F,CDM,510,RC,30903,CPT,,,,,,,,456,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,225.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,446.88
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611F,CDM,510,RC,20611,CPT,,,,,,,,456,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,225.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.4224,446.88
"Office/Outpt Visit,New,Levl V",PX99205F,CDM,510,RC,99205,CPT,,,,,,,,456,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,225.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.4224,446.88
"Office/Outpt Visit,New,Levl V",PX99205P,CDM,983,RC,99205,CPT,,,,,,,,456,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,225.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.4224,443.8248
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321801,NDC,50,ML,456,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,225.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
Xray Nasal Bones Minimum 3 Vws,PX7016001,CDM,320,RC,70160,CPT,TC,,,,,,,456,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,225.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,446.88
"Office/Outpt Visit,Est,Levl IV",PX99214F,CDM,510,RC,99214,CPT,,,,,,,,256,,United Healthcare,All Payer,outpatient,88.2,,204.1566667,percent of total billed charges,225.792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.3424,250.88
"Office/Outpt Visit,Est,Levl IV",PX99214P,CDM,983,RC,99214,CPT,,,,,,,,256,,United Healthcare,All Payer,outpatient,88.2,,204.1566667,percent of total billed charges,225.792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.3424,249.1648
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133P,CDM,983,RC,13133,CPT,,,,,,,,256,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,225.792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.3424,249.1648
Bile Acids Total,PX8223990,CDM,300,RC,82239,CPT,90,,,,,,,232,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,225.8056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,227.36
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,143971801,NDC,200,ML,230.48,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,225.8704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.827512,225.8704
"Initial Observation Care,Levl III",PX99220,CDM,982,RC,99220,CPT,,,,,,,,461,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,225.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,191.4994,448.6913
"Initial Observation Care,Levl III",PX99220,CDM,982,RC,99220,CPT,,,,,,,,461,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,225.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,191.4994,448.6913
"Initial Observation Care,Levl III",PX99220,CDM,982,RC,99220,CPT,,,,,,,,461,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,225.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,191.4994,448.6913
Repr Superf Wnd Face <2.5cm,PX12011P,CDM,983,RC,12011,CPT,,,,,,,,461,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,225.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,448.6913
Repr Superf Wnd Face <2.5cm,PX12011P,CDM,983,RC,12011,CPT,,,,,,,,461,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,225.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,448.6913
Repr Superf Wnd Face <2.5cm,PX12011P,CDM,983,RC,12011,CPT,,,,,,,,461,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,225.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,448.6913
CT Angio Abdom W/O & W/Dye,PX7417501,CDM,350,RC,74175,CPT,TC,,,,,,,4183,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,225.9036,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,118.89,451.63
Closed Rx Mt-Phal Toe Dislocation,PX28630P,CDM,983,RC,28630,CPT,,,,,,,,248,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,225.928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.0192,241.3784
Debride Muscle Ea Add 20 Sqcm,PX11046F,CDM,510,RC,11046,CPT,,,,,,,,248,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,225.928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.0192,243.04
Fetal Profile W/O Stress,PX7681901,CDM,402,RC,76819,CPT,TC,,,,,,,248,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,225.928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,243.04
Ther Injection Carpal Tunnel,PX20526P,CDM,983,RC,20526,CPT,,,,,,,,248,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,225.928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.0192,258.75
US Chest Tc,PX7660401,CDM,402,RC,76604,CPT,TC,,,,,,,248,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,225.928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,243.04
"West Nile Ab, Igg - Ref",PX8678990,CDM,300,RC,86789,CPT,90,,,,,,,248,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,225.928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,243.04
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,63323072902,NDC,1,EA,265.95,,First Health,Commercial,both,85,,999999999,percent of total billed charges,226.0575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.47563,793.6922
Thyrstim Immun Glob (Tsi) - Ref,PX8444590,CDM,300,RC,84445,CPT,90,,,,,,,254,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,226.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.63,248.92
"Initial Observation Care,Levl I",PX99218,CDM,982,RC,99218,CPT,,,,,,,,266,,First Health,Commercial,both,85,,999999999,percent of total billed charges,226.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.4964,258.8978
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597F,CDM,510,RC,97597,CPT,,,,,,,,266,,First Health,Commercial,both,85,,999999999,percent of total billed charges,226.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.4964,260.68
"Infectious Disease (Viral Respiratory Tract Infection),",PX0241U,CDM,300,RC,0241U,HCPCS,,,,,,,,457,,Humana Choice Care,All Medicare plans,outpatient,49.5,,395.1705882,percent of total billed charges,226.215,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.78,447.86
US Scrotum & Contents Tc,PX7687001,CDM,402,RC,76870,CPT,TC,,,,,,,457,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,226.215,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,447.86
tiotropium bromide monohydrate 2.5 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597010051,NDC,4,GR,461.7,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,226.233,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tiotropium bromide monohydrate 2.5 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597010051,NDC,4,GR,461.7,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,226.233,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tiotropium bromide monohydrate 2.5 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597010051,NDC,4,GR,461.7,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,226.233,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tiotropium bromide-olodaterol 2.5-2.5 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597015570,NDC,4,GR,461.7,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,226.233,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tiotropium bromide-olodaterol 2.5-2.5 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597015570,NDC,4,GR,461.7,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,226.233,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tiotropium bromide-olodaterol 2.5-2.5 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597015570,NDC,4,GR,461.7,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,226.233,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,49884093547,NDC,100,GR,266.25,,First Health,Commercial,both,85,,999999999,percent of total billed charges,226.3125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ammonium lactate 12 % Cream 385 g Tube,63700001,CDM,250,RC,,,,,,45802049326,NDC,385,GR,256.76,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,226.46232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Bone Scan, Whole Body",PX7830601,CDM,341,RC,78306,CPT,TC,,,,,,,1896,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,226.5472,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,153.58,453.61
"OB US < 14 Wks, Single Fetus - Radiology, Tech",PX7680101,CDM,402,RC,76801,CPT,TC,,,,,,,472,,Health Partners,Health Partners Care Plans,both,48,,457.84,percent of total billed charges,226.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,462.56
"OB US < 14 Wks, Single Fetus - Radiology, Tech",PX7680101,CDM,402,RC,76801,CPT,TC,,,,,,,472,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,226.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,462.56
US Pelvic Tc Complete,PX7685601,CDM,402,RC,76856,CPT,TC,,,,,,,472,,Health Partners,Health Partners Care Plans,both,48,,434.95,percent of total billed charges,226.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,462.56
US Pelvic Tc Complete,PX7685601,CDM,402,RC,76856,CPT,TC,,,,,,,472,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,226.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,462.56
US Transvaginal Tc,PX7683001,CDM,402,RC,76830,CPT,TC,,,,,,,472,,Health Partners,Health Partners Care Plans,both,48,,434.95,percent of total billed charges,226.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,462.56
US Transvaginal Tc,PX7683001,CDM,402,RC,76830,CPT,TC,,,,,,,472,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,226.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,462.56
ipratropium 0.03 % Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,24208039830,NDC,30,ML,256.9,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,226.5858,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydrocortisone (perianal) 2.5 % Cream 28.35 g Tube,63700001,CDM,250,RC,,,,,,10631040701,NDC,28.35,GR,447.94,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,226.65764,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
TRAY GROSHONG 4FR SAFETY PICC 7617407,120.26,CDM,272,RC,,,,500-MAIN,LOCAL,,,,,233,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,226.7789,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.7882,228.34
rabies immune globulin 300 UNIT/2ML Solution 2 mL Vial,90377,CDM,636,RC,90376,CPT,,,,49281019020,NDC,2,ML,3384.84,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,226.79,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.58,479.72
rabies immune globulin 300 UNIT/2ML Solution 2 mL Vial,90377,CDM,636,RC,90376,CPT,,,,49281019020,NDC,2,ML,3384.84,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,226.79,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.58,479.72
Excis Primary Ganglion Wrist,PX25111P,CDM,983,RC,25111,CPT,,,,,,,,529,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,226.941,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,219.7466,1404.08
Xray Shoulder 1 Vw,PX7302001,CDM,320,RC,73020,CPT,TC,,,,,,,267,,First Health,Commercial,both,85,,999999999,percent of total billed charges,226.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,261.66
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800F,CDM,510,RC,40800,CPT,,,,,,,,255,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,226.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.927,614.65
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106F,CDM,510,RC,11106,CPT,,,,,,,,255,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,226.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.927,548.67
"Inject Nerv Blck,Trigeminal",PX64400F,CDM,510,RC,64400,CPT,,,,,,,,255,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,226.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.927,258.75
"Urinalysis, Auto, W/Scope",PX81001,CDM,300,RC,81001,CPT,,,,,,,,255,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,226.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.91,249.9
amiodarone 150-4.21 MG/100ML-% Solution 100 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066015010,NDC,100,ML,249.22,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,227.03942,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.35,318.745
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915801,NDC,1,ML,267.19,,First Health,Commercial,both,85,,999999999,percent of total billed charges,227.1115,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
Resp Virus 3-5 Targets,PX87631,CDM,300,RC,87631,CPT,,,,,,,,459,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,227.205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.78,449.82
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,63323077139,NDC,1,EA,547.2,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,227.30688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
Bile Acids Total,PX8223990,CDM,300,RC,82239,CPT,90,,,,,,,232,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,227.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.7,227.36
"Hospital Inpt or Obs Care, Admin/Disch Same Date Straightforward or Low Level Mdm >= 45 Minutes",PX99234,CDM,982,RC,99234,CPT,,,,,,,,464,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,227.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.7456,451.6112
"Hospital Inpt or Obs Care, Admin/Disch Same Date Straightforward or Low Level Mdm >= 45 Minutes",PX99234,CDM,982,RC,99234,CPT,,,,,,,,464,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,227.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.7456,451.6112
"Hospital Inpt or Obs Care, Admin/Disch Same Date Straightforward or Low Level Mdm >= 45 Minutes",PX99234,CDM,982,RC,99234,CPT,,,,,,,,464,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,227.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.7456,451.6112
Naso/Orogastric Tube,PX43752F,CDM,510,RC,43752,CPT,,,,,,,,464,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,227.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.7456,454.72
Naso/Orogastric Tube,PX43752F,CDM,510,RC,43752,CPT,,,,,,,,464,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,227.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.7456,454.72
Naso/Orogastric Tube,PX43752F,CDM,510,RC,43752,CPT,,,,,,,,464,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,227.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.7456,454.72
rho d immune globulin human 1500 units solution prefilled syringe 1 Each Syringe,J2790.01,CDM,636,RC,J2790,HCPCS,,,,562780500,NDC,1,EA,464.01,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,227.3649,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.749754,454.7298
rho d immune globulin human 1500 units solution prefilled syringe 1 Each Syringe,J2790.01,CDM,636,RC,J2790,HCPCS,,,,562780500,NDC,1,EA,464.01,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,227.3649,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.749754,454.7298
rho d immune globulin human 1500 units solution prefilled syringe 1 Each Syringe,J2790.01,CDM,636,RC,J2790,HCPCS,,,,562780500,NDC,1,EA,464.01,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,227.3649,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.749754,454.7298
"Needle Biopsy,Muscle",PX20206F,CDM,510,RC,20206,CPT,,,,,,,,258,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,227.556,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.1732,1416.38
Exc Skn Bnig0.6-1cm Remain Bdy,PX11421P,CDM,983,RC,11421,CPT,,,,,,,,345,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,227.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.15,338.1
Fac/Exc Skn Beni 0.6-1cm Remain Bdy,PX11421F,CDM,510,RC,11421,CPT,,,,,,,,931,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,227.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.15,333.45
Reconstruc of Nail Bed,PX11760F,CDM,510,RC,11760,CPT,,,,,,,,1162,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,227.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.37,384.64
Reconstruc of Nail Bed,PX11760P,CDM,983,RC,11760,CPT,,,,,,,,903,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,227.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.37,884.94
levOCARNitine 200 MG/ML Solution 5 mL Vial,J1955.01,CDM,636,RC,J1955,HCPCS,,,,517104501,NDC,5,ML,249.86,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,227.62246,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.791844,244.8628
"Closed Rx Spont Hip Disloc,Anesth",PX27257F,CDM,510,RC,27257,CPT,,,,,,,,548,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,227.6392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.6392,1404.08
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070110,NDC,1,ML,459.95,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,227.67525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.92,450.751
"DXA, Bone Density Study, Radius/Wrist/Heel",PX7708101,CDM,320,RC,77081,CPT,TC,,,,,,,460,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,227.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,450.8
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623P,CDM,983,RC,11623,CPT,,,,,,,,460,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,227.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,191.084,1416.38
"Spinal Punc,Drain,Theraputic",PX62272F,CDM,510,RC,62272,CPT,,,,,,,,450,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,227.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.93,604.15
"Transvaginal US, Obstetric",PX7681701,CDM,402,RC,76817,CPT,TC,,,,,,,460,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,227.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,450.8
"Lap,Dx Surgical Abd W/Biopsy",PX49321F,CDM,510,RC,49321,CPT,,,,,,,,874,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,227.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.77,718.78
"Lap,Dx Surgical Abd W/Biopsy",PX49321F,CDM,510,RC,49321,CPT,,,,,,,,874,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,227.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.77,718.78
"Lap,Dx Surgical Abd W/Biopsy",PX49321P,CDM,983,RC,49321,CPT,,,,,,,,583,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,227.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.77,718.78
"Lap,Dx Surgical Abd W/Biopsy",PX49321P,CDM,983,RC,49321,CPT,,,,,,,,583,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,227.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.77,718.78
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153P,CDM,983,RC,99153,CPT,,,,,,,,250,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,227.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.85,243.325
sincalide 5 MCG Recon Soln 1 Each Vial,J2805.01,CDM,636,RC,J2805,HCPCS,,,,270055615,NDC,1,EA,250,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,227.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.85,245
Withdrawal of Arterial Blood,PX36600F,CDM,510,RC,36600,CPT,,,,,,,,250,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,227.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.85,245
CANNULA FOR INJECTION 1.8MM WITH 3MM LUER CONNECTION 8383.65,27200000,CDM,272,RC,,,,12004-MAIN,LOCAL,,,,,234,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,227.7522,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Fibrinogen,PX7426,CDM,300,RC,85384,CPT,,,,,,,,234,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,227.7522,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.91,229.32
tropicamide 1 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,61314035502,NDC,15,ML,267.96,,First Health,Commercial,both,85,,999999999,percent of total billed charges,227.766,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Supply Technetium Medronate,to 30 MC",PXA9503,CDM,343,RC,A9503,HCPCS,,,,,,,,531,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,227.799,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,220.5774,520.38
dexmedeTOMIDine in  dextrose 200MCG/50ML -5% Solution 50 mL Flex Cont,25000000,CDM,250,RC,,,,,,44567060224,NDC,50,ML,258.31,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,227.82942,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Office/Outpt Visit,Est,Levl IV",PX99214F,CDM,510,RC,99214,CPT,,,,,,,,256,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,227.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.3424,250.88
"Office/Outpt Visit,Est,Levl IV",PX99214P,CDM,983,RC,99214,CPT,,,,,,,,256,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,227.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.3424,249.1648
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133P,CDM,983,RC,13133,CPT,,,,,,,,256,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,227.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.3424,249.1648
Drainage of Hematoma/Fluid (P),PX10140P,CDM,983,RC,10140,CPT,,,,,,,,465,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,227.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,193.161,1416.38
Drainage of Hematoma/Fluid (P),PX10140P,CDM,983,RC,10140,CPT,,,,,,,,465,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,227.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,193.161,1416.38
Drainage of Hematoma/Fluid (P),PX10140P,CDM,983,RC,10140,CPT,,,,,,,,465,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,227.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,193.161,1416.38
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102P,CDM,983,RC,11102,CPT,,,,,,,,465,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,227.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,452.5845
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102P,CDM,983,RC,11102,CPT,,,,,,,,465,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,227.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,452.5845
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102P,CDM,983,RC,11102,CPT,,,,,,,,465,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,227.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,452.5845
"Initial Observation Care,Levl III",PX99220,CDM,982,RC,99220,CPT,,,,,,,,461,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,228.195,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,191.4994,448.6913
Repr Superf Wnd Face <2.5cm,PX12011P,CDM,983,RC,12011,CPT,,,,,,,,461,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,228.195,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,448.6913
"Exc Skn Bnig >4cmtrnk,Arm,Leg",PX11406P,CDM,983,RC,11406,CPT,,,,,,,,1456,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,228.3021,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,153.14,1426.88
"Fac/Exc Skn Benig >4cm Trnk,Arm,Lg",PX11406F,CDM,510,RC,11406,CPT,,,,,,,,1127,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,228.3021,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,153.14,666.2
"Exc Skn Malig1.1-2cm Fce,Facal",PX11642P,CDM,983,RC,11642,CPT,,,,,,,,466,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,228.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,193.5764,614.65
"Exc Skn Malig1.1-2cm Fce,Facal",PX11642P,CDM,983,RC,11642,CPT,,,,,,,,466,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,228.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,193.5764,614.65
"Exc Skn Malig1.1-2cm Fce,Facal",PX11642P,CDM,983,RC,11642,CPT,,,,,,,,466,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,228.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,193.5764,614.65
TRAY GROSHONG 4FR SAFETY PICC 7617407,120.26,CDM,272,RC,,,,500-MAIN,LOCAL,,,,,233,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,228.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.7882,228.34
"Excise Lesion,Back or Flank",PX21930F,CDM,510,RC,21930,CPT,,,,,,,,1326,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,228.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,225.35,1053.61
"Excise Lesion,Back or Flank",PX21930F,CDM,510,RC,21930,CPT,,,,,,,,1326,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,228.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,225.35,1053.61
"Excise Lesion,Back or Flank",PX21930P,CDM,983,RC,21930,CPT,,,,,,,,884,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,228.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,225.35,1053.61
"Excise Lesion,Back or Flank",PX21930P,CDM,983,RC,21930,CPT,,,,,,,,884,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,228.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,225.35,1053.61
Acth - Ref,PX8202490,CDM,300,RC,82024,CPT,90,,,,,,,259,,United Healthcare,All Payer,outpatient,88.2,,126.91,percent of total billed charges,228.438,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.41,253.82
"IV Push, Single/1st Drug",PX96374,CDM,260,RC,96374,CPT,,,,,,,,259,,United Healthcare,All Payer,outpatient,88.2,,174.6781818,percent of total billed charges,228.438,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.5886,253.82
ammonium lactate 12 % Cream 385 g Tube,63700001,CDM,250,RC,,,,,,45802049326,NDC,385,GR,256.76,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,228.5164,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tiotropium bromide monohydrate 2.5 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597010051,NDC,4,GR,461.7,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,228.5415,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tiotropium bromide-olodaterol 2.5-2.5 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597015570,NDC,4,GR,461.7,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,228.5415,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Leukoreduced Rbc's,PXP9016,CDM,390,RC,P9016,HCPCS,,,,,,,,580,,UCare,Individual and Family Plans,both,,,292.42,fee schedule,228.608,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.14,228.608
Leukoreduced Rbc's,PXP9016,CDM,390,RC,P9016,HCPCS,,,,,,,,580,,UCare,Individual and Family Plans,both,,,292.42,fee schedule,228.608,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.14,228.608
ipratropium 0.03 % Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,24208039830,NDC,30,ML,256.9,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,228.641,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
NEEDLE INTRAOSSEOUS 15GA 15MM EZ-IO PEDS 9018,120.89,CDM,272,RC,A4215,HCPCS,,4964-MAIN,LOCAL,,,,,269,,First Health,Commercial,both,85,,999999999,percent of total billed charges,228.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.7426,263.62
Xray Ribs Bil 3vws Tc,PX7111001,CDM,320,RC,71110,CPT,TC,,,,,,,533,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,228.657,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,522.34
DRILL BIT AO DIA 2.0MMX135MM SCALED,27200000,CDM,272,RC,,,,12640-MAIN,LOCAL,,,,,452,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,228.712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152F,CDM,370,RC,99152,CPT,,,,,,,,235,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,228.7255,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97.619,230.3
Occupational Therapy Eval Low Complex,PX97165,CDM,434,RC,97165,CPT,,,,,,,,235,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,144.7853125,percent of total billed charges,228.7255,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,230.3
Remv Ext Canal Foreign Body,PX69200F,CDM,510,RC,69200,CPT,,,,,,,,235,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,228.7255,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97.619,230.3
"Vitamin D, 25 Hydroxy",PX82306,CDM,300,RC,82306,CPT,,,,,,,,235,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,228.7255,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.14,230.3
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031P,CDM,983,RC,12031,CPT,,,,,,,,551,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,228.8854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,228.8854,536.2883
Xray Facial Bones Minimum 3 Vws,PX7015001,CDM,320,RC,70150,CPT,TC,,,,,,,551,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,228.8854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,539.98
atropine 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,17478021502,NDC,2,ML,269.45,,First Health,Commercial,both,85,,999999999,percent of total billed charges,229.0325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
atropine 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,60219174802,NDC,2,ML,269.45,,First Health,Commercial,both,85,,999999999,percent of total billed charges,229.0325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Calr Gene Analysis Common Variants in Exon 9 - Ref,PX8121990,CDM,300,RC,81219,CPT,90,,,,,,,534,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,229.086,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.52,523.32
"Exc Skn Mal 0.6-1cm Fce,Facial",PX11641P,CDM,983,RC,11641,CPT,,,,,,,,453,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,229.218,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.1762,614.65
Repr Superf Wnd Body 7.6-12.5,PX12004F,CDM,510,RC,12004,CPT,,,,,,,,453,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,229.218,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,443.94
Repr Superf Wnd Face 5.1-7.5,PX12014F,CDM,510,RC,12014,CPT,,,,,,,,453,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,229.218,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,443.94
"Inj,Lumb Epidur,Blood/Clot Patch",PX62273P,CDM,983,RC,62273,CPT,,,,,,,,552,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,229.3008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,229.3008,604.15
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,63323027301,NDC,0.5,ML,235.6,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,229.30948,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
Blood Clot Factor V Test,PX85220,CDM,300,RC,85220,CPT,,,,,,,,260,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,229.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.18,254.8
CANNULA FOR INJECTION 1.8MM WITH 3MM LUER CONNECTION 8383.65,27200000,CDM,272,RC,,,,12004-MAIN,LOCAL,,,,,234,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,229.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Closed Rx Kneecap Dislocatn,PX27560F,CDM,510,RC,27560,CPT,,,,,,,,468,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,229.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,194.4072,458.64
Closed Rx Kneecap Dislocatn,PX27560F,CDM,510,RC,27560,CPT,,,,,,,,468,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,229.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,194.4072,458.64
Closed Rx Kneecap Dislocatn,PX27560F,CDM,510,RC,27560,CPT,,,,,,,,468,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,229.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,194.4072,458.64
"Closed Rx Toe Fx,Manipulatn",PX28515P,CDM,983,RC,28515,CPT,,,,,,,,260,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,229.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.004,253.058
Fibrinogen,PX7426,CDM,300,RC,85384,CPT,,,,,,,,234,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,229.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.91,229.32
First Hour IV Hydration <1 Hour,PX96360,CDM,260,RC,96360,CPT,,,,,,,,260,,United Healthcare,All Payer,outpatient,88.2,,128.52,percent of total billed charges,229.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.004,254.8
"POS Airway Pressure, Bipap",PX94660.01F,CDM,410,RC,94660,CPT,,,,,,,,468,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,229.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.33,458.64
"POS Airway Pressure, Bipap",PX94660.01F,CDM,410,RC,94660,CPT,,,,,,,,468,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,229.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.33,458.64
"POS Airway Pressure, Bipap",PX94660.01F,CDM,410,RC,94660,CPT,,,,,,,,468,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,229.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.33,458.64
Vedolizumab - Ref,PX8028090,CDM,300,RC,80280,CPT,90,,,,,,,468,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,229.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.36,458.64
Vedolizumab - Ref,PX8028090,CDM,300,RC,80280,CPT,90,,,,,,,468,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,229.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.36,458.64
Vedolizumab - Ref,PX8028090,CDM,300,RC,80280,CPT,90,,,,,,,468,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,229.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.36,458.64
CT Lumbar Spine W/Dye,PX7213201,CDM,350,RC,72132,CPT,TC,,,,,,,3330,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,229.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,114.56,229.43
CT Lumbar Spine W/Dye,PX7213201,CDM,350,RC,72132,CPT,TC,,,,,,,3330,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,229.43,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,114.56,229.43
"Closed Rx Radial Head Disloc,Child",PX24640F,CDM,510,RC,24640,CPT,,,,,,,,270,,First Health,Commercial,both,85,,999999999,percent of total billed charges,229.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.158,264.6
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157F,CDM,370,RC,99157,CPT,,,,,,,,270,,First Health,Commercial,both,85,,999999999,percent of total billed charges,229.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.158,264.6
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157P,CDM,983,RC,99157,CPT,,,,,,,,270,,First Health,Commercial,both,85,,999999999,percent of total billed charges,229.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.158,262.791
Wound Culture Anaerobic,PX87075,CDM,300,RC,87075,CPT,,,,,,,,270,,First Health,Commercial,both,85,,999999999,percent of total billed charges,229.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.68,264.6
CARTER THOMASON CLOSURE SUTURE PASSER XL 10/12MM 15MM CTXL,27200000,CDM,272,RC,,,,12946-MAIN,LOCAL,,,,,535,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,229.515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Inject Trigger Point, 1 or 2",PX20552F,CDM,510,RC,20552,CPT,,,,,,,,252,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,229.572,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,258.75
"Level V - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3939,CDM,310,RC,88307,CPT,TC,,,,,,,252,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,229.572,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,314.02
"Off/Outpt Visit,New,Levl III",PX99203P,CDM,983,RC,99203,CPT,,,,,,,,252,,Medica,Commercial,both,91.1,,5.306666667,percent of total billed charges,229.572,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,245.2716
"Office/Outpt Visit,New,Levl III",PX99203F,CDM,510,RC,99203,CPT,,,,,,,,252,,Medica,Commercial,both,91.1,,5.306666667,percent of total billed charges,229.572,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,246.96
Repair Incis Hernia W Mesh,PX49568F,CDM,510,RC,49568,CPT,,,,,,,,1540,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,229.5865,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,229.5865,229.59
Repair Incis Hernia W Mesh,PX49568P,CDM,983,RC,49568,CPT,,,,,,,,660,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,229.5865,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,229.5865,646.8
Repair Incis Hernia W Mesh,PX49568F,CDM,510,RC,49568,CPT,,,,,,,,1540,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,229.59,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,229.5865,229.59
Repair Incis Hernia W Mesh,PX49568P,CDM,983,RC,49568,CPT,,,,,,,,660,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,229.59,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,229.5865,646.8
"Needle Biopsy,Muscle",PX20206F,CDM,510,RC,20206,CPT,,,,,,,,258,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,229.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.1732,1416.38
diclofenac 0.1 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,17478089225,NDC,2.5,ML,252.06,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,229.62666,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Hospital Inpt or Obs Care, Admin/Disch Same Date Straightforward or Low Level Mdm >= 45 Minutes",PX99234,CDM,982,RC,99234,CPT,,,,,,,,464,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,229.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.7456,451.6112
Naso/Orogastric Tube,PX43752F,CDM,510,RC,43752,CPT,,,,,,,,464,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,229.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.7456,454.72
rho d immune globulin human 1500 units solution prefilled syringe 1 Each Syringe,J2790.01,CDM,636,RC,J2790,HCPCS,,,,562780500,NDC,1,EA,464.01,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,229.68495,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.749754,454.7298
"Biopsy Vulva/Perineum,One Lesn",PX56605F,CDM,510,RC,56605,CPT,,,,,,,,236,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,229.6988,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.0344,702.31
PERFIX PLUG STERILE MEDIUM,C1781,CDM,278,RC,C1781,HCPCS,,11770-MAIN,LOCAL,,,,,553,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,229.7162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
X-Ray Exam Entire Spine 2-3 Vws,PX7208201,CDM,320,RC,72082,CPT,TC,,,,,,,454,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,229.724,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,444.92
dexmedeTOMIDine in  dextrose 200MCG/50ML -5% Solution 50 mL Flex Cont,25000000,CDM,250,RC,,,,,,44567060224,NDC,50,ML,258.31,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,229.8959,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Colonoscopy,Remv Lesn,Snare",PX45385F,CDM,750,RC,45385,CPT,,,,,,,,1939,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,229.9076,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.32,940.85
"Colonoscopy,Remv Lesn,Snare",PX45385P,CDM,983,RC,45385,CPT,,,,,,,,2424,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,229.9076,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.32,2375.52
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101F,CDM,510,RC,13101,CPT,,,,,,,,495,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,229.9076,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.32,823.93
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101P,CDM,983,RC,13101,CPT,,,,,,,,330,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,229.9076,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.32,823.93
Aspirate Pleura W/ Imaging,PX32555P,CDM,983,RC,32555,CPT,,,,,,,,536,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,229.944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,222.6544,548.81
Lvl 3 Init Hosp High Mdm or 75 Minutes,PX99223,CDM,982,RC,99223,CPT,,,,,,,,536,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,229.944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,222.6544,521.6888
lidocaine - transparent dressing 4 % Kit 1 Each Box,63700001,CDM,250,RC,,,,,,496088207,NDC,1,EA,270.63,,First Health,Commercial,both,85,,999999999,percent of total billed charges,230.0355,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CT Lower Extremity W/Dye,PX7370101,CDM,350,RC,73701,CPT,TC,,,,,,,2690,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,230.09,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.88,230.09
CT Lower Extremity W/Dye,PX7370101,CDM,350,RC,73701,CPT,TC,,,,,,,2690,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,230.09,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.88,230.09
Diagnostic CT Thorax W/ Contrast,PX7126001,CDM,350,RC,71260,CPT,TC,,,,,,,3415,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,230.09,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.88,230.09
Diagnostic CT Thorax W/ Contrast,PX7126001,CDM,350,RC,71260,CPT,TC,,,,,,,3415,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,230.09,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.88,230.09
Aaa US Screen Tc,PX7670601,CDM,402,RC,76706,CPT,TC,,,,,,,554,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,230.1316,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,542.92
US Kidney Transplt Untrsd,PX7677601,CDM,402,RC,76776,CPT,TC,,,,,,,554,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,230.1316,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,542.92
Drainage of Hematoma/Fluid (P),PX10140P,CDM,983,RC,10140,CPT,,,,,,,,465,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,230.175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,193.161,1416.38
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102P,CDM,983,RC,11102,CPT,,,,,,,,465,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,230.175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,452.5845
"Ileoscopy Thru Stoma,Diagnostic",PX44380P,CDM,983,RC,44380,CPT,,,,,,,,455,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,230.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.007,791.92
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607F,CDM,761,RC,97607,CPT,,,,,,,,455,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,230.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.007,445.9
"Office/Outpt Visit,Est,Levl IV",PX99214F,CDM,510,RC,99214,CPT,,,,,,,,256,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,230.23,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.11,230.23
"Office/Outpt Visit,Est,Levl IV",PX99214P,CDM,983,RC,99214,CPT,,,,,,,,256,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,230.23,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.11,250.88
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152F,CDM,370,RC,99152,CPT,,,,,,,,235,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,230.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97.619,230.3
Occupational Therapy Eval Low Complex,PX97165,CDM,434,RC,97165,CPT,,,,,,,,235,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,230.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,230.3
Physical Therapy Evaluation Low Complex,PX97161,CDM,424,RC,97161,CPT,,,,,,,,235,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,230.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,392.7
Remv Ext Canal Foreign Body,PX69200F,CDM,510,RC,69200,CPT,,,,,,,,235,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,230.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97.619,230.3
"Vitamin D, 25 Hydroxy",PX82306,CDM,300,RC,82306,CPT,,,,,,,,235,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,230.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.14,230.3
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081543,NDC,1,ML,479.89,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,230.3472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.346306,470.2922
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081543,NDC,1,ML,479.89,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,230.3472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.346306,470.2922
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081552,NDC,1,ML,479.89,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,230.3472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.346306,470.2922
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081552,NDC,1,ML,479.89,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,230.3472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.346306,470.2922
Strapping of Ankle,PX29540F,CDM,420,RC,29540,CPT,,,,,,,,271,,First Health,Commercial,both,85,,999999999,percent of total billed charges,230.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.5734,265.58
Incise External Hemorrhoid,PX46083F,CDM,510,RC,46083,CPT,,,,,,,,502,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,230.37,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.28,433.76
Incise External Hemorrhoid,PX46083P,CDM,983,RC,46083,CPT,,,,,,,,956,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,230.37,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.28,936.88
Remove Intrauterine Device,PX58301,CDM,983,RC,58301,CPT,,,,,,,,357,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,230.37,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.14,349.86
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,548590000,NDC,1,EA,470.19,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,230.3931,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,179.012476,460.7862
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,548590000,NDC,1,EA,470.19,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,230.3931,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,179.012476,460.7862
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,548590000,NDC,1,EA,470.19,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,230.3931,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,179.012476,460.7862
Lvl 2 Sub Hosp Mod Mdm or 35 Minute,PX99232,CDM,982,RC,99232,CPT,,,,,,,,253,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,230.483,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.0962,246.2449
MESH FLAT SHEET SOFT 3X6 INCH,C1781,CDM,278,RC,C1781,HCPCS,,11773-MAIN,LOCAL,,,,,253,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,230.483,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Subsequent Observation Care,PX99225,CDM,982,RC,99225,CPT,,,,,,,,253,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,230.483,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.0962,246.2449
Tap Block Unilateral by Injection(S),PX64486F,CDM,510,RC,64486,CPT,,,,,,,,253,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,230.483,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.0962,247.94
Acth - Ref,PX8202490,CDM,300,RC,82024,CPT,90,,,,,,,259,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,230.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.41,253.82
"IV Push, Single/1st Drug",PX96374,CDM,260,RC,96374,CPT,,,,,,,,259,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,230.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.5886,253.82
Xray Sacroiliac Jnts Less Than 3 Vws,PX7220001,CDM,320,RC,72200,CPT,TC,,,,,,,555,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,230.547,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,543.9
fluorouracil 5 GM/100ML Solution 100 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,16729027638,NDC,100,ML,261.44,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,230.59008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,256.2112
"Exc Skn Malig1.1-2cm Fce,Facal",PX11642P,CDM,983,RC,11642,CPT,,,,,,,,466,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,230.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,193.5764,614.65
"Ctrl Nosebleed,Anter,Complex",PX30903F,CDM,510,RC,30903,CPT,,,,,,,,456,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,230.736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,446.88
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611F,CDM,510,RC,20611,CPT,,,,,,,,456,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,230.736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.4224,446.88
"Office/Outpt Visit,New,Levl V",PX99205F,CDM,510,RC,99205,CPT,,,,,,,,456,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,230.736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.4224,446.88
"Office/Outpt Visit,New,Levl V",PX99205P,CDM,983,RC,99205,CPT,,,,,,,,456,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,230.736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.4224,443.8248
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321801,NDC,50,ML,456,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,230.736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
Xray Nasal Bones Minimum 3 Vws,PX7016001,CDM,320,RC,70160,CPT,TC,,,,,,,456,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,230.736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,446.88
CT Chest Spine W/Dye,PX7212901,CDM,350,RC,72129,CPT,TC,,,,,,,2096,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,230.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.09,230.75
CT Chest Spine W/Dye,PX7212901,CDM,350,RC,72129,CPT,TC,,,,,,,2096,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,230.75,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.09,230.75
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,63323027301,NDC,0.5,ML,235.6,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,230.888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
Xray Chest 2 Views,PX7102001,CDM,320,RC,71020,CPT,TC,,,,,,,556,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,230.9624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,230.9624,544.88
Dress/Debrid Med Burn No Anesth,PX16025F,CDM,510,RC,16025,CPT,,,,,,,,366,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,231.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.06,327.91
Dress/Debrid Med Burn No Anesth,PX16025P,CDM,983,RC,16025,CPT,,,,,,,,244,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,231.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.06,327.91
Tap Block Unilateral by Injection(S),PX64486F,CDM,510,RC,64486,CPT,,,,,,,,253,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,231.06,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.81,231.06
Tap Block Unilateral by Injection(S),PX64486P,CDM,983,RC,64486,CPT,,,,,,,,169,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,231.06,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.81,231.06
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409421505,NDC,5,ML,271.86,,First Health,Commercial,both,85,,999999999,percent of total billed charges,231.081,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
Tap Block Bilateral by Injection(S),PX64488P,CDM,983,RC,64488,CPT,,,,,,,,262,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,231.084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.8348,255.0046
methylPREDNISolone sod succ 1000 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9001820,NDC,1,EA,271.97,,First Health,Commercial,both,85,,999999999,percent of total billed charges,231.1745,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611P,CDM,983,RC,20611,CPT,,,,,,,,272,,First Health,Commercial,both,85,,999999999,percent of total billed charges,231.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.9888,264.7376
CP LAG SCREW 3.6MM L22MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12757-MAIN,LOCAL,,,,,539,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,231.231,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
CP LAG SCREW 3.6MM L24MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12650-MAIN,LOCAL,,,,,539,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,231.231,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
CP LAG SCREW 3.6MM L26MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12636-MAIN,LOCAL,,,,,539,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,231.231,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"Infectious Disease (Viral Respiratory Tract Infection),",PX0241U,CDM,300,RC,0241U,HCPCS,,,,,,,,457,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,231.242,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.78,447.86
US Scrotum & Contents Tc,PX7687001,CDM,402,RC,76870,CPT,TC,,,,,,,457,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,231.242,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,447.86
"Biopsy Vulva/Perineum,One Lesn",PX56605F,CDM,510,RC,56605,CPT,,,,,,,,236,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,231.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.0344,702.31
Lab Basic Metabolic Panel,PX80048,CDM,300,RC,80048,CPT,,,,,,,,236,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,231.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.76,231.28
"OB US < 14 Wks, Single Fetus - Radiology, Tech",PX7680101,CDM,402,RC,76801,CPT,TC,,,,,,,472,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,458,percent of total billed charges,231.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,462.56
"OB US < 14 Wks, Single Fetus - Radiology, Tech",PX7680101,CDM,402,RC,76801,CPT,TC,,,,,,,472,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,231.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,462.56
"OB US < 14 Wks, Single Fetus - Radiology, Tech",PX7680101,CDM,402,RC,76801,CPT,TC,,,,,,,472,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,231.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,462.56
US Pelvic Tc Complete,PX7685601,CDM,402,RC,76856,CPT,TC,,,,,,,472,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,93,percent of total billed charges,231.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,462.56
US Pelvic Tc Complete,PX7685601,CDM,402,RC,76856,CPT,TC,,,,,,,472,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,231.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,462.56
US Pelvic Tc Complete,PX7685601,CDM,402,RC,76856,CPT,TC,,,,,,,472,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,231.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,462.56
US Transvaginal Tc,PX7683001,CDM,402,RC,76830,CPT,TC,,,,,,,472,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,93,percent of total billed charges,231.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,462.56
US Transvaginal Tc,PX7683001,CDM,402,RC,76830,CPT,TC,,,,,,,472,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,231.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,462.56
US Transvaginal Tc,PX7683001,CDM,402,RC,76830,CPT,TC,,,,,,,472,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,231.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,462.56
ePHEDrine sulfate 50 MG/ML Solution 1 mL Ampule,25000000,CDM,250,RC,,,,,,17478041510,NDC,1,ML,262.31,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,231.35742,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Column Chrom Ms, Quant - Ref",PX8254290,CDM,300,RC,82542,CPT,90,,,,,,,557,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,231.3778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.09,545.86
Thyrstim Immun Glob (Tsi) - Ref,PX8444590,CDM,300,RC,84445,CPT,90,,,,,,,254,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,231.394,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.63,248.92
Blood Clot Factor V Test,PX85220,CDM,300,RC,85220,CPT,,,,,,,,260,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,231.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.18,254.8
"Closed Rx Toe Fx,Manipulatn",PX28515P,CDM,983,RC,28515,CPT,,,,,,,,260,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,231.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.004,253.058
First Hour IV Hydration <1 Hour,PX96360,CDM,260,RC,96360,CPT,,,,,,,,260,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,231.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.004,254.8
Irradiated Leukoreduced Rbc's,PXP9040,CDM,390,RC,P9040,HCPCS,,,,,,,,771,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,231.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,231.5,755.58
Phlebotomy,PX99195,CDM,940,RC,99195,CPT,,,,,,,,238,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,340.2,percent of total billed charges,231.6454,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.8652,233.24
Closed Rx Kneecap Dislocatn,PX27560F,CDM,510,RC,27560,CPT,,,,,,,,468,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,231.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,194.4072,458.64
"POS Airway Pressure, Bipap",PX94660.01F,CDM,410,RC,94660,CPT,,,,,,,,468,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,231.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.33,458.64
Vedolizumab - Ref,PX8028090,CDM,300,RC,80280,CPT,90,,,,,,,468,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,231.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.36,458.64
Xray Sacrum/ Coccyx Minimum 2 Vws,PX7222001,CDM,320,RC,72220,CPT,TC,,,,,,,540,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,231.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,529.2
I&D Bartholin Gland Abscess,PX56420F,CDM,510,RC,56420,CPT,,,,,,,,429,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,231.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.02,389.48
I&D Bartholin Gland Abscess,PX56420P,CDM,983,RC,56420,CPT,,,,,,,,286,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,231.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.02,389.48
BRONCHOSCOPE BFLEX 5.0 SINGLE-USE 0570-0449,120.578,CDM,272,RC,,,,13020-MAIN,LOCAL,,,,,558,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,231.7932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,231.7932,546.84
PERFIX PLUG STERILE LARGE,C1781,CDM,278,RC,C1781,HCPCS,,11771-MAIN,LOCAL,,,,,558,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,231.7932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"X-Ray Exam Hip,Unilat W/Pelvis 1vw",PX7350101,CDM,320,RC,73501,CPT,TC,,,,,,,263,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,231.966,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,257.74
Fac/Initial Hospital Care Levl II,PX99222F,CDM,510,RC,99222,CPT,,,,,,,,187,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,232.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.18,232.02
Fac/Initial Hospital Care Levl II,PX99222F,CDM,510,RC,99222,CPT,,,,,,,,187,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,232.02,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.18,232.02
Initial Hospital Care Levl II,PX99222P,CDM,982,RC,99222,CPT,,,,,,,,187,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,232.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.18,232.02
Initial Hospital Care Levl II,PX99222P,CDM,982,RC,99222,CPT,,,,,,,,187,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,232.02,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.18,232.02
Lvl 2 Init Hosp Mod Mdm or 55 Minutes,PX99222,CDM,982,RC,99222,CPT,,,,,,,,508,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,232.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.18,497.84
Lvl 2 Init Hosp Mod Mdm or 55 Minutes,PX99222,CDM,982,RC,99222,CPT,,,,,,,,508,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,232.02,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.18,497.84
Resp Virus 3-5 Targets,PX87631,CDM,300,RC,87631,CPT,,,,,,,,459,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,232.254,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.78,449.82
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800F,CDM,510,RC,40800,CPT,,,,,,,,255,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,232.305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.927,614.65
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106F,CDM,510,RC,11106,CPT,,,,,,,,255,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,232.305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.927,548.67
"Inject Nerv Blck,Trigeminal",PX64400F,CDM,510,RC,64400,CPT,,,,,,,,255,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,232.305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.927,258.75
"Urinalysis, Auto, W/Scope",PX81001,CDM,300,RC,81001,CPT,,,,,,,,255,,Medica,Commercial,both,91.1,,19.9148,percent of total billed charges,232.305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.91,249.9
"Fac/Ex Skinbngn0.6-1cmtrnk,Arm,Lg",PX11401F,CDM,510,RC,11401,CPT,,,,,,,,484,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,232.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.0536,474.32
"Fac/Ex Skinbngn0.6-1cmtrnk,Arm,Lg",PX11401F,CDM,510,RC,11401,CPT,,,,,,,,484,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,232.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.0536,474.32
"Fac/Exc Skn Benig<5mm Face,Facial",PX11440F,CDM,510,RC,11440,CPT,,,,,,,,484,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,232.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.0536,614.65
"Fac/Exc Skn Benig<5mm Face,Facial",PX11440F,CDM,510,RC,11440,CPT,,,,,,,,484,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,232.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.0536,614.65
"Facility Critical Care, Addl 30 Min",PX99292F,CDM,510,RC,99292,CPT,,,,,,,,484,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,232.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.0536,474.32
"Facility Critical Care, Addl 30 Min",PX99292F,CDM,510,RC,99292,CPT,,,,,,,,484,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,232.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.0536,474.32
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032601,NDC,0.5,ML,559.7,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,232.49938,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,1630.2692
"Critical Care, Addl 30 Min",PX99292P,CDM,983,RC,99292,CPT,,,,,,,,542,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,232.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,225.1468,527.5286
Physical Therapy Re-Eval Est Plan Care 20 Mins,PX97164,CDM,424,RC,97164,CPT,,,,,,,,239,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,232.6187,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,234.22
"Close Rx Fingr Articular Fx,Manip",PX26742P,CDM,983,RC,26742,CPT,,,,,,,,560,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,232.624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,232.624,1404.08
"Enzyme Act, Nonradioact - Ref",PX8265790,CDM,300,RC,82657,CPT,90,,,,,,,560,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,232.624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.33,548.8
fluorouracil 5 GM/100ML Solution 100 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,16729027638,NDC,100,ML,261.44,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,232.6816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,256.2112
DRAIN FLAT JACKSON PRATT 10MM,27100000,CDM,271,RC,,,,334-MAIN,LOCAL,,,,,239.09,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,232.706297,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070110,NDC,1,ML,459.95,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,232.7347,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.92,450.751
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,548590000,NDC,1,EA,470.19,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,232.74405,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,179.012476,460.7862
"DXA, Bone Density Study, Radius/Wrist/Heel",PX7708101,CDM,320,RC,77081,CPT,TC,,,,,,,460,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,232.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,450.8
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623P,CDM,983,RC,11623,CPT,,,,,,,,460,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,232.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,191.084,1416.38
"Transvaginal US, Obstetric",PX7681701,CDM,402,RC,76817,CPT,TC,,,,,,,460,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,232.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,450.8
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614800,NDC,1,EA,239.18,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,18.43861111,percent of total billed charges,232.793894,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
Inj Tendon/Ligament/Cyst,PX20550P,CDM,983,RC,20550,CPT,,,,,,,,264,,United Healthcare,All Payer,outpatient,88.2,,124.89,percent of total billed charges,232.848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.6656,258.75
Occupational Therapy Eval Mod Complex,PX97166,CDM,434,RC,97166,CPT,,,,,,,,264,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,232.848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,258.72
Physical Therapy Evaluation Mod Complex,PX97162,CDM,424,RC,97162,CPT,,,,,,,,264,,United Healthcare,All Payer,outpatient,88.2,,135.7185294,percent of total billed charges,232.848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,258.72
Renal Function Panel,PX80069,CDM,300,RC,80069,CPT,,,,,,,,264,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,232.848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.96,258.72
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597P,CDM,983,RC,97597,CPT,,,,,,,,274,,First Health,Commercial,both,85,,999999999,percent of total billed charges,232.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,113.8196,266.6842
"Exc Skn Bngn2.1-3cmtrnk,Arm,Lg",PX11403P,CDM,983,RC,11403,CPT,,,,,,,,543,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,232.947,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,225.5622,614.65
Xray Knee (Both) Ap Stand,PX7356501,CDM,320,RC,73565,CPT,TC,,,,,,,543,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,232.947,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,532.14
Drain Skin Abscess Complic,PX10061P,CDM,983,RC,10061,CPT,,,,,,,,561,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,233.0394,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,233.0394,546.0213
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12130-MAIN,LOCAL,,,,,561,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,233.0394,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Closed Rx Mt-Phal Toe Dislocation,PX28630F,CDM,510,RC,28630,CPT,,,,,,,,360,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,233.14,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.93,327.22
Closed Rx Mt-Phal Toe Dislocation,PX28630P,CDM,983,RC,28630,CPT,,,,,,,,248,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,233.14,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.93,327.22
"Inj,Lumb Epidur,Blood/Clot Patch",PX62273P,CDM,983,RC,62273,CPT,,,,,,,,552,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,233.14,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.02,540.96
Tap Block Bilateral by Injection(S),PX64488P,CDM,983,RC,64488,CPT,,,,,,,,262,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,233.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.8348,255.0046
"Office/Outpt Visit,Est,Levl IV",PX99214F,CDM,510,RC,99214,CPT,,,,,,,,256,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,233.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.3424,250.88
"Office/Outpt Visit,Est,Levl IV",PX99214P,CDM,983,RC,99214,CPT,,,,,,,,256,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,233.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.3424,249.1648
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133P,CDM,983,RC,13133,CPT,,,,,,,,256,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,233.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.3424,249.1648
Phlebotomy,PX99195,CDM,940,RC,99195,CPT,,,,,,,,238,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,233.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.8652,233.24
"Initial Observation Care,Levl III",PX99220,CDM,982,RC,99220,CPT,,,,,,,,461,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,233.266,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,191.4994,448.6913
Repr Superf Wnd Face <2.5cm,PX12011P,CDM,983,RC,12011,CPT,,,,,,,,461,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,233.266,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,448.6913
ARTISTA AH 3GRAM ABSORBABLE HEMOSTATIC PARTICLES,27200000,CDM,272,RC,A6199,HCPCS,,10227-MAIN,LOCAL,,,,,486,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,233.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ARTISTA AH 3GRAM ABSORBABLE HEMOSTATIC PARTICLES,27200000,CDM,272,RC,A6199,HCPCS,,10227-MAIN,LOCAL,,,,,486,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,233.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Xray Sinuses Less Than 3 Vws,PX7021001,CDM,320,RC,70210,CPT,TC,,,,,,,486,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,233.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,476.28
Xray Sinuses Less Than 3 Vws,PX7021001,CDM,320,RC,70210,CPT,TC,,,,,,,486,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,233.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,476.28
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,23155052431,NDC,10,ML,486.06,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,233.3088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,23155052431,NDC,10,ML,486.06,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,233.3088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,23155052441,NDC,10,ML,486.06,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,233.3088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,23155052441,NDC,10,ML,486.06,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,233.3088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062160,NDC,0.6,ML,274.53,,First Health,Commercial,both,85,,999999999,percent of total billed charges,233.3505,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801601,NDC,0.6,ML,274.53,,First Health,Commercial,both,85,,999999999,percent of total billed charges,233.3505,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801610,NDC,0.6,ML,274.53,,First Health,Commercial,both,85,,999999999,percent of total billed charges,233.3505,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
CT Head/Brain W/O & W/Dye,PX7047001,CDM,350,RC,70470,CPT,TC,,,,,,,3671,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,233.38,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.96,233.38
CT Head/Brain W/O & W/Dye,PX7047001,CDM,350,RC,70470,CPT,TC,,,,,,,3671,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,233.38,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.96,233.38
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315606,NDC,100,ML,264.64,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,233.41248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.931456,259.3472
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315695,NDC,100,ML,264.64,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,233.41248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.931456,259.3472
Exc Skn Bngn3.1-4cm Remain Bdy,PX11424P,CDM,983,RC,11424,CPT,,,,,,,,562,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,233.4548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,233.4548,1416.38
"US,Preg. Uterus,Fetal/Mat.Eval.,>1st Trim.(>/= 14 Wks 0 Dys),Transabd;Single/First Gest., Tech",PX7680501,CDM,402,RC,76805,CPT,TC,,,,,,,562,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,233.4548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,550.76
ePHEDrine sulfate 50 MG/ML Solution 1 mL Ampule,25000000,CDM,250,RC,,,,,,17478041510,NDC,1,ML,262.31,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,233.4559,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dexmedeTOMIDine in sodium chloride 400 MCG/100ML Solution 100 mL Bottle,25000000,CDM,250,RC,,,,,,67457092500,NDC,100,ML,562.18,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,233.529572,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tiotropium bromide monohydrate 2.5 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597010051,NDC,4,GR,461.7,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,233.6202,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tiotropium bromide-olodaterol 2.5-2.5 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597015570,NDC,4,GR,461.7,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,233.6202,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"OB US < 14 Wks, Single Fetus - Radiology, Tech",PX7680101,CDM,402,RC,76801,CPT,TC,,,,,,,472,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,233.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,462.56
US Pelvic Tc Complete,PX7685601,CDM,402,RC,76856,CPT,TC,,,,,,,472,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,233.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,462.56
US Transvaginal Tc,PX7683001,CDM,402,RC,76830,CPT,TC,,,,,,,472,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,233.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,462.56
Haptoglobin; Quantitative,PX83010,CDM,300,RC,83010,CPT,,,,,,,,265,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,233.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.53,259.7
ID Nucleic Acid Sequencing - Ref,PX8715390,CDM,300,RC,87153,CPT,90,,,,,,,265,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,233.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.77,259.7
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151P,CDM,983,RC,99151,CPT,,,,,,,,275,,First Health,Commercial,both,85,,999999999,percent of total billed charges,233.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,114.235,267.6575
cefoTEtan 2 g Recon Soln 1 Each Vial,800000,CDM,,,S0074,HCPCS,,,,63323038620,NDC,1,EA,240.2,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,233.78666,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Repr Superf Wnd Face <2.5cm,PX12011F,CDM,510,RC,12011,CPT,,,,,,,,335,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,233.83,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.94,233.83
Repr Superf Wnd Face <2.5cm,PX12011P,CDM,983,RC,12011,CPT,,,,,,,,461,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,233.83,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.94,451.78
ROPivacaine 2 MG/ML Solution 100 mL Bottle,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028568,NDC,100,ML,275.11,,First Health,Commercial,both,85,,999999999,percent of total billed charges,233.8435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.604954,269.6078
Xray Pelvis Compl 3+ Tc,PX7219001,CDM,320,RC,72190,CPT,TC,,,,,,,563,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,233.8702,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,551.74
ammonium lactate 12 % Cream 385 g Tube,63700001,CDM,250,RC,,,,,,45802049326,NDC,385,GR,256.76,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,233.90836,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,61314054701,NDC,2.5,ML,487.35,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,233.928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,61314054701,NDC,2.5,ML,487.35,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,233.928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
CT Upper Extremity W/O Dye,PX7320001,CDM,350,RC,73200,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,234.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.33,234.03
CT Upper Extremity W/O Dye,PX7320001,CDM,350,RC,73200,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,234.03,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,71.33,234.03
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821517,NDC,3,ML,275.33,,First Health,Commercial,both,85,,999999999,percent of total billed charges,234.0305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
ipratropium 0.03 % Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,24208039830,NDC,30,ML,256.9,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,234.0359,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,6384371,NDC,1,EA,563.46,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,234.061284,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
"X-Ray Exam Hip,Unilat W/Pelvis 1vw",PX7350101,CDM,320,RC,73501,CPT,TC,,,,,,,263,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,234.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,257.74
Physical Therapy Re-Eval Est Plan Care 20 Mins,PX97164,CDM,424,RC,97164,CPT,,,,,,,,239,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,234.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,234.22
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,68462018022,NDC,22,GR,240.66,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,234.234378,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
DRAIN FLAT JACKSON PRATT 10MM,27100000,CDM,271,RC,,,,334-MAIN,LOCAL,,,,,239.09,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,234.3082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Suspension 10 mL Bottle,63700001,CDM,250,RC,,,,,,64980044801,NDC,10,ML,488.25,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,234.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Suspension 10 mL Bottle,63700001,CDM,250,RC,,,,,,64980044801,NDC,10,ML,488.25,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,234.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614800,NDC,1,EA,239.18,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,234.3964,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
"Colonoscopy,Control Bleeding",PX45382F,CDM,750,RC,45382,CPT,,,,,,,,1215,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,234.403,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,158.37,1373.91
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,63323072902,NDC,1,EA,265.95,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,234.5679,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.47563,793.6922
Culture Screen Only,PX87081,CDM,300,RC,87081,CPT,,,,,,,,276,,First Health,Commercial,both,85,,999999999,percent of total billed charges,234.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.08,270.48
"Initial Observation Care,Levl I",PX99218,CDM,982,RC,99218,CPT,,,,,,,,266,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,234.612,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.4964,258.8978
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597F,CDM,510,RC,97597,CPT,,,,,,,,266,,United Healthcare,All Payer,outpatient,88.2,,140.98,percent of total billed charges,234.612,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.4964,260.68
Apply Forearm Cast,PX29075F,CDM,510,RC,29075,CPT,,,,,,,,210,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,234.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,234.62
Apply Forearm Cast,PX29075P,CDM,983,RC,29075,CPT,,,,,,,,140,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,234.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.156,234.62
Apply Long Leg Cast,PX29345F,CDM,510,RC,29345,CPT,,,,,,,,912,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,234.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,234.62,893.76
"Apply Short Leg Cast,Walker",PX29425F,CDM,510,RC,29425,CPT,,,,,,,,179,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,234.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.3566,234.62
"Apply Short Leg Cast,Walker",PX29425P,CDM,983,RC,29425,CPT,,,,,,,,119,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,234.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,234.62
Repr Superf Wnd Body 12.6-20,PX12005F,CDM,510,RC,12005,CPT,,,,,,,,565,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,234.701,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,234.701,553.7
Xray Lumbosacral Minimum 4 Vws,PX7211001,CDM,320,RC,72110,CPT,TC,,,,,,,565,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,234.701,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,553.7
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,63323077139,NDC,1,EA,547.2,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,234.7488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
"Hospital Inpt or Obs Care, Admin/Disch Same Date Straightforward or Low Level Mdm >= 45 Minutes",PX99234,CDM,982,RC,99234,CPT,,,,,,,,464,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,234.784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.7456,451.6112
Naso/Orogastric Tube,PX43752F,CDM,510,RC,43752,CPT,,,,,,,,464,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,234.784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.7456,454.72
rho d immune globulin human 1500 units solution prefilled syringe 1 Each Syringe,J2790.01,CDM,636,RC,J2790,HCPCS,,,,562780500,NDC,1,EA,464.01,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,234.78906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.749754,454.7298
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,49884093547,NDC,100,GR,266.25,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,234.8325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Inj Tendon/Ligament/Cyst,PX20550P,CDM,983,RC,20550,CPT,,,,,,,,264,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,234.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.6656,258.75
Occupational Therapy Eval Mod Complex,PX97166,CDM,434,RC,97166,CPT,,,,,,,,264,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,234.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,258.72
Physical Therapy Evaluation Mod Complex,PX97162,CDM,424,RC,97162,CPT,,,,,,,,264,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,234.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,258.72
Renal Function Panel,PX80069,CDM,300,RC,80069,CPT,,,,,,,,264,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,234.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.96,258.72
calcitonin (salmon) 200 UNIT/ACT Solution 3.7 mL Bottle,63700001,CDM,250,RC,,,,,,60505082306,NDC,3.7,ML,489.57,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,234.9936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcitonin (salmon) 200 UNIT/ACT Solution 3.7 mL Bottle,63700001,CDM,250,RC,,,,,,60505082306,NDC,3.7,ML,489.57,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,234.9936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Needle Biopsy,Muscle",PX20206F,CDM,510,RC,20206,CPT,,,,,,,,258,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,235.038,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.1732,1416.38
"Closed Rx Spont Hip Disloc,Anesth",PX27257F,CDM,510,RC,27257,CPT,,,,,,,,548,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,235.092,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.6392,1404.08
US Renal Retroperit Ltd,PX7677501,CDM,402,RC,76775,CPT,TC,,,,,,,566,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,235.1164,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,554.68
US Retroperitoneal Tc,PX7677001,CDM,402,RC,76770,CPT,TC,,,,,,,566,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,235.1164,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,554.68
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081543,NDC,1,ML,479.89,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,235.1461,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.346306,470.2922
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081543,NDC,1,ML,479.89,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,235.1461,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.346306,470.2922
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081543,NDC,1,ML,479.89,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,235.1461,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.346306,470.2922
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081552,NDC,1,ML,479.89,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,235.1461,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.346306,470.2922
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081552,NDC,1,ML,479.89,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,235.1461,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.346306,470.2922
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081552,NDC,1,ML,479.89,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,235.1461,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.346306,470.2922
Egd Balloon Dil Esoph30 Mm/>,PX43233P,CDM,983,RC,43233,CPT,,,,,,,,480,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,235.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.392,1662.33
Egd Balloon Dil Esoph30 Mm/>,PX43233P,CDM,983,RC,43233,CPT,,,,,,,,480,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,235.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.392,1662.33
Egd Balloon Dil Esoph30 Mm/>,PX43233P,CDM,983,RC,43233,CPT,,,,,,,,480,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,235.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.392,1662.33
"Sigmoidoscopy,Diagnostic",PX45330P,CDM,983,RC,45330,CPT,,,,,,,,480,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,235.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.392,798.45
"Sigmoidoscopy,Diagnostic",PX45330P,CDM,983,RC,45330,CPT,,,,,,,,480,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,235.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.392,798.45
"Sigmoidoscopy,Diagnostic",PX45330P,CDM,983,RC,45330,CPT,,,,,,,,480,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,235.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.392,798.45
Xray Knee 4 or More Vws,PX7356401,CDM,320,RC,73564,CPT,TC,,,,,,,490,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,235.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,480.2
Xray Knee 4 or More Vws,PX7356401,CDM,320,RC,73564,CPT,TC,,,,,,,490,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,235.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,480.2
Drainage of Hematoma/Fluid (P),PX10140P,CDM,983,RC,10140,CPT,,,,,,,,465,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,235.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,193.161,1416.38
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102P,CDM,983,RC,11102,CPT,,,,,,,,465,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,235.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,452.5845
dexmedeTOMIDine in  dextrose 200MCG/50ML -5% Solution 50 mL Flex Cont,25000000,CDM,250,RC,,,,,,44567060224,NDC,50,ML,258.31,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,235.32041,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Incis/Drain Shldr Absc/Hema,Deep",PX23030P,CDM,983,RC,23030,CPT,,,,,,,,1564,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,235.3663,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,158.15,1532.72
cefoTEtan 2 g Recon Soln 1 Each Vial,800000,CDM,,,S0074,HCPCS,,,,63323038620,NDC,1,EA,240.2,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,235.396,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
"Molecular Cytog, Ea Probe - Ref",PX8827190,CDM,310,RC,88271,CPT,90,,,,,,,277,,First Health,Commercial,both,85,,999999999,percent of total billed charges,235.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.64,271.46
"Xray Neck, Soft Tissue",PX7036001,CDM,320,RC,70360,CPT,TC,,,,,,,277,,First Health,Commercial,both,85,,999999999,percent of total billed charges,235.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,271.46
Xray Shoulder 1 Vw,PX7302001,CDM,320,RC,73020,CPT,TC,,,,,,,267,,United Healthcare,All Payer,outpatient,88.2,,109.4,percent of total billed charges,235.494,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,261.66
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315606,NDC,100,ML,264.64,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,235.5296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.931456,259.3472
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315695,NDC,100,ML,264.64,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,235.5296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.931456,259.3472
Airway Inhalation Treatment,PX94640F,CDM,410,RC,94640,CPT,,,,,,,,242,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,331.5693333,percent of total billed charges,235.5386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,100.5268,237.16
"Noninvasv Oxygen Satut,Continuous",PX94762,CDM,460,RC,94762,CPT,,,,,,,,242,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,235.5386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,100.5268,237.16
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915801,NDC,1,ML,267.19,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,235.66158,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004F,CDM,510,RC,15004,CPT,,,,,,,,855,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,235.6874,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.68,813.56
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004P,CDM,983,RC,15004,CPT,,,,,,,,570,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,235.6874,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.68,813.56
ipratropium 0.06 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,54004641,NDC,15,ML,491.02,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,235.6896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ipratropium 0.06 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,54004641,NDC,15,ML,491.02,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,235.6896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Exc Skn Malig1.1-2cm Fce,Facal",PX11642P,CDM,983,RC,11642,CPT,,,,,,,,466,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,235.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,193.5764,614.65
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,68462018022,NDC,22,GR,240.66,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,235.8468,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Haptoglobin; Quantitative,PX83010,CDM,300,RC,83010,CPT,,,,,,,,265,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,235.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.53,259.7
ID Nucleic Acid Sequencing - Ref,PX8715390,CDM,300,RC,87153,CPT,90,,,,,,,265,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,235.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.77,259.7
Emergency Level III Visit,PX99283P,CDM,981,RC,99283,CPT,,,,,,,,568,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,235.9472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,235.9472,552.8344
Acth - Ref,PX8202490,CDM,300,RC,82024,CPT,90,,,,,,,259,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,235.949,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.41,253.82
"IV Push, Single/1st Drug",PX96374,CDM,260,RC,96374,CPT,,,,,,,,259,,Medica,Commercial,both,91.1,,61.00125,percent of total billed charges,235.949,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.5886,253.82
nystatin 100000 UNIT/GM Powder 60 g Bottle,63700001,CDM,250,RC,,,,,,574200802,NDC,60,GR,491.86,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,236.0928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/GM Powder 60 g Bottle,63700001,CDM,250,RC,,,,,,574200802,NDC,60,GR,491.86,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,236.0928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762F,CDM,510,RC,43762,CPT,,,,,,,,492,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,236.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,204.3768,482.16
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762F,CDM,510,RC,43762,CPT,,,,,,,,492,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,236.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,204.3768,482.16
umeclidinium 62.5 MCG/ACT Aerosol Powder Breath Activated 7 Each Disp Pack,63700001,CDM,250,RC,,,,,,173087306,NDC,7,EA,492.23,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,236.2704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
umeclidinium 62.5 MCG/ACT Aerosol Powder Breath Activated 7 Each Disp Pack,63700001,CDM,250,RC,,,,,,173087306,NDC,7,EA,492.23,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,236.2704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tropicamide 1 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,61314035502,NDC,15,ML,267.96,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,236.34072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423P,CDM,983,RC,11423,CPT,,,,,,,,569,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,236.3626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,236.3626,1416.38
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031P,CDM,983,RC,12031,CPT,,,,,,,,551,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,236.379,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,228.8854,536.2883
Xray Facial Bones Minimum 3 Vws,PX7015001,CDM,320,RC,70150,CPT,TC,,,,,,,551,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,236.379,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,539.98
"Inject Nerv Blck,Trigeminal",PX64400F,CDM,510,RC,64400,CPT,,,,,,,,255,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,236.6,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.1,236.6
"Inject Nerv Blck,Trigeminal",PX64400P,CDM,983,RC,64400,CPT,,,,,,,,170,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,236.6,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.1,236.6
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,63323072902,NDC,1,EA,265.95,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,236.6955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.47563,793.6922
"Initial Observation Care,Levl I",PX99218,CDM,982,RC,99218,CPT,,,,,,,,266,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,236.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.4964,258.8978
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597F,CDM,510,RC,97597,CPT,,,,,,,,266,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,236.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.4964,260.68
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004P,CDM,983,RC,15004,CPT,,,,,,,,570,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,236.778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,236.778,554.781
"Immunofluo Direct, Ea Ab - Ref",PX8834690,CDM,310,RC,88346,CPT,90,,,,,,,55,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,236.79,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,145.22,243.84
"Immunofluo Direct, Ea Ab - Ref",PX8834690,CDM,310,RC,88346,CPT,90,,,,,,,55,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,236.79,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,145.22,243.84
Closed Rx Kneecap Dislocatn,PX27560F,CDM,510,RC,27560,CPT,,,,,,,,468,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,236.808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,194.4072,458.64
"Inj,Lumb Epidur,Blood/Clot Patch",PX62273P,CDM,983,RC,62273,CPT,,,,,,,,552,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,236.808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,229.3008,604.15
"POS Airway Pressure, Bipap",PX94660.01F,CDM,410,RC,94660,CPT,,,,,,,,468,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,236.808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.33,458.64
Vedolizumab - Ref,PX8028090,CDM,300,RC,80280,CPT,90,,,,,,,468,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,236.808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.36,458.64
Blood Clot Factor V Test,PX85220,CDM,300,RC,85220,CPT,,,,,,,,260,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,236.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.18,254.8
"Closed Rx Toe Fx,Manipulatn",PX28515P,CDM,983,RC,28515,CPT,,,,,,,,260,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,236.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.004,253.058
First Hour IV Hydration <1 Hour,PX96360,CDM,260,RC,96360,CPT,,,,,,,,260,,Medica,Commercial,both,91.1,,14.49666667,percent of total billed charges,236.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.004,254.8
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,49884093547,NDC,100,GR,266.25,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,236.9625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
CRICOTHROTOMY QUICKTRACH 4MM,120.228,CDM,272,RC,A7520,HCPCS,,8868-MAIN,LOCAL,,,,,494,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,237.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.2076,484.12
CRICOTHROTOMY QUICKTRACH 4MM,120.228,CDM,272,RC,A7520,HCPCS,,8868-MAIN,LOCAL,,,,,494,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,237.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.2076,484.12
SET CRICOTHYROTOMY CATHETER 6MM ID,120.378,CDM,272,RC,,,,11119-MAIN,LOCAL,,,,,494,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,237.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.2076,484.12
SET CRICOTHYROTOMY CATHETER 6MM ID,120.378,CDM,272,RC,,,,11119-MAIN,LOCAL,,,,,494,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,237.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.2076,484.12
"Hla Class II Low Res, 1 Locus - Ref",PX8137690,CDM,310,RC,81376,CPT,90,,,,,,,279,,First Health,Commercial,both,85,,999999999,percent of total billed charges,237.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.06,273.42
INSUFLOWPORT & PNEUVIEW  XE SMOKE ELIMINATOR 5MM,27200000,CDM,272,RC,,,,11876-MAIN,LOCAL,,,,,279,,First Health,Commercial,both,85,,999999999,percent of total billed charges,237.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 8MM,27200000,CDM,272,RC,,,,11877-MAIN,LOCAL,,,,,279,,First Health,Commercial,both,85,,999999999,percent of total billed charges,237.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 10MM,27200000,CDM,272,RC,,,,11878-MAIN,LOCAL,,,,,279,,First Health,Commercial,both,85,,999999999,percent of total billed charges,237.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 12MM,27200000,CDM,272,RC,,,,11879-MAIN,LOCAL,,,,,279,,First Health,Commercial,both,85,,999999999,percent of total billed charges,237.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 5MM,27200000,CDM,272,RC,,,,11880-MAIN,LOCAL,,,,,279,,First Health,Commercial,both,85,,999999999,percent of total billed charges,237.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 8MM,27200000,CDM,272,RC,,,,11881-MAIN,LOCAL,,,,,279,,First Health,Commercial,both,85,,999999999,percent of total billed charges,237.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 10MM,27200000,CDM,272,RC,,,,11882-MAIN,LOCAL,,,,,279,,First Health,Commercial,both,85,,999999999,percent of total billed charges,237.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 12MM,27200000,CDM,272,RC,,,,11883-MAIN,LOCAL,,,,,279,,First Health,Commercial,both,85,,999999999,percent of total billed charges,237.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Puncture Drainage of Lesion,PX10160F,CDM,510,RC,10160,CPT,,,,,,,,279,,First Health,Commercial,both,85,,999999999,percent of total billed charges,237.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.8966,348.35
Xray Pelvis 1 or 2 Vws,PX7217001,CDM,320,RC,72170,CPT,TC,,,,,,,279,,First Health,Commercial,both,85,,999999999,percent of total billed charges,237.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,273.42
Airway Inhalation Treatment,PX94640F,CDM,410,RC,94640,CPT,,,,,,,,242,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,237.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,100.5268,237.16
"Fac/Ex Skinbngn0.6-1cmtrnk,Arm,Lg",PX11401F,CDM,510,RC,11401,CPT,,,,,,,,484,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,237.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.0536,474.32
"Fac/Ex Skinbngn0.6-1cmtrnk,Arm,Lg",PX11401F,CDM,510,RC,11401,CPT,,,,,,,,484,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,237.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.0536,474.32
"Fac/Ex Skinbngn0.6-1cmtrnk,Arm,Lg",PX11401F,CDM,510,RC,11401,CPT,,,,,,,,484,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,237.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.0536,474.32
"Fac/Exc Skn Benig<5mm Face,Facial",PX11440F,CDM,510,RC,11440,CPT,,,,,,,,484,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,237.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.0536,614.65
"Fac/Exc Skn Benig<5mm Face,Facial",PX11440F,CDM,510,RC,11440,CPT,,,,,,,,484,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,237.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.0536,614.65
"Fac/Exc Skn Benig<5mm Face,Facial",PX11440F,CDM,510,RC,11440,CPT,,,,,,,,484,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,237.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.0536,614.65
"Facility Critical Care, Addl 30 Min",PX99292F,CDM,510,RC,99292,CPT,,,,,,,,484,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,950.635,percent of total billed charges,237.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.0536,474.32
"Facility Critical Care, Addl 30 Min",PX99292F,CDM,510,RC,99292,CPT,,,,,,,,484,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,237.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.0536,474.32
"Facility Critical Care, Addl 30 Min",PX99292F,CDM,510,RC,99292,CPT,,,,,,,,484,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,237.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.0536,474.32
"Noninvasv Oxygen Satut,Continuous",PX94762,CDM,460,RC,94762,CPT,,,,,,,,242,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,237.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,100.5268,237.16
PERFIX PLUG STERILE MEDIUM,C1781,CDM,278,RC,C1781,HCPCS,,11770-MAIN,LOCAL,,,,,553,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,237.237,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
NEEDLE INTRAOSSEOUS 15GA 15MM EZ-IO PEDS 9018,120.89,CDM,272,RC,A4215,HCPCS,,4964-MAIN,LOCAL,,,,,269,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,237.258,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.7426,263.62
"Destruct Benign Lesion, 1-14",PX17110F,CDM,510,RC,17110,CPT,,,,,,,,302,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,237.29,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.97,237.29
"Destruct Benign Lesion, 1-14",PX17110P,CDM,983,RC,17110,CPT,,,,,,,,521,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,237.29,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.97,510.58
Removal of Hemorrhoid Clot,PX46320F,CDM,510,RC,46320,CPT,,,,,,,,2027,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,237.29,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.24,445.52
Removal of Hemorrhoid Clot,PX46320P,CDM,983,RC,46320,CPT,,,,,,,,374,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,237.29,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.24,445.52
ondansetron 4 MG/5ML Solution 25 mL Bottle,S0119.01,CDM,636,RC,S0119,HCPCS,,,,99998-8001-,NDC,25,ML,494.57,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,237.3936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG/5ML Solution 25 mL Bottle,S0119.01,CDM,636,RC,S0119,HCPCS,,,,99998-8001-,NDC,25,ML,494.57,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,237.3936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
"Office/Outpt Visit,New,Levl IV",PX99204F,CDM,510,RC,99204,CPT,,,,,,,,359,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,237.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.93,300.2
"Office/Outpt Visit,New,Levl IV",PX99204P,CDM,983,RC,99204,CPT,,,,,,,,359,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,237.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.93,351.82
BINDER PELVIC ADULT STABILIZATION T-PODR,120.357,CDM,271,RC,A4467,HCPCS,,10734-MAIN,LOCAL,,,,,244,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,237.4852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.3576,239.12
"Bone Marrow Aspiration(S),Diag",PX38220P,CDM,983,RC,38220,CPT,,,,,,,,244,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,237.4852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.3576,1416.38
Dress/Debrid Med Burn No Anesth,PX16025P,CDM,983,RC,16025,CPT,,,,,,,,244,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,237.4852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.3576,237.4852
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081543,NDC,1,ML,479.89,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,237.54555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.346306,470.2922
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081552,NDC,1,ML,479.89,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,237.54555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.346306,470.2922
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725F,CDM,510,RC,26725,CPT,,,,,,,,495,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,237.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.623,485.1
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725F,CDM,510,RC,26725,CPT,,,,,,,,495,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,237.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.623,485.1
Egd Balloon Dil Esoph30 Mm/>,PX43233P,CDM,983,RC,43233,CPT,,,,,,,,480,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,237.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.392,1662.33
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101F,CDM,510,RC,13101,CPT,,,,,,,,495,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,237.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.623,548.67
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101F,CDM,510,RC,13101,CPT,,,,,,,,495,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,237.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.623,548.67
"Sigmoidoscopy,Diagnostic",PX45330P,CDM,983,RC,45330,CPT,,,,,,,,480,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,237.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.392,798.45
Tc99 Mebrofenin to 15 Mci,PXA9537,CDM,343,RC,A9537,HCPCS,,,,,,,,495,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,237.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.623,485.1
Tc99 Mebrofenin to 15 Mci,PXA9537,CDM,343,RC,A9537,HCPCS,,,,,,,,495,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,237.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.623,485.1
MESH LARGE LEFT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 4X6,120.521,CDM,278,RC,C1781,HCPCS,,12215-MAIN,LOCAL,,,,,572,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,237.6088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,237.6088,560.56
MESH LARGE RIGHT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 4X6,C1781,CDM,278,RC,C1781,HCPCS,,12195-MAIN,LOCAL,,,,,572,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,237.6088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Remove Nasal Foreign Body,PX30300P,CDM,983,RC,30300,CPT,,,,,,,,572,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,237.6088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,556.7276
Xray Shoulder 1 Vw,PX7302001,CDM,320,RC,73020,CPT,TC,,,,,,,267,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,237.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,261.66
Exc Skn Beni 0.6-1cm Fcefacial,PX11441P,CDM,983,RC,11441,CPT,,,,,,,,485,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,237.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.469,614.65
Exc Skn Beni 0.6-1cm Fcefacial,PX11441P,CDM,983,RC,11441,CPT,,,,,,,,485,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,237.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.469,614.65
Exc Skn Beni 0.6-1cm Fcefacial,PX11441P,CDM,983,RC,11441,CPT,,,,,,,,485,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,237.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.469,614.65
atropine 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,17478021502,NDC,2,ML,269.45,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,237.6549,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
atropine 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,60219174802,NDC,2,ML,269.45,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,237.6549,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Aaa US Screen Tc,PX7670601,CDM,402,RC,76706,CPT,TC,,,,,,,554,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,237.666,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,542.92
US Kidney Transplt Untrsd,PX7677601,CDM,402,RC,76776,CPT,TC,,,,,,,554,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,237.666,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,542.92
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915801,NDC,1,ML,267.19,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,237.7991,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,548590000,NDC,1,EA,470.19,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,237.91614,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,179.012476,460.7862
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002F,CDM,510,RC,12002,CPT,,,,,,,,343,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,237.98,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.9,237.98
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002P,CDM,983,RC,12002,CPT,,,,,,,,486,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,237.98,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.9,476.28
Hepatobil Syst Image W/Drug,PX7822701,CDM,341,RC,78227,CPT,TC,,,,,,,1674,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,238,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,238,703.42
Hepatobil Syst Image W/Drug,PX7822701,CDM,341,RC,78227,CPT,TC,,,,,,,1674,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,238,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,238,703.42
"Pertechnetate, Dia, per Mci",PXA9512,CDM,343,RC,A9512,HCPCS,,,,,,,,280,,First Health,Commercial,both,85,,999999999,percent of total billed charges,238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,116.312,274.4
ADVANCED INSTRUMENTS ENDOWRIST SUCTION IRRIGATOR,27200000,CDM,272,RC,,,,11922-MAIN,LOCAL,,,,,496,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,238.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ADVANCED INSTRUMENTS ENDOWRIST SUCTION IRRIGATOR,27200000,CDM,272,RC,,,,11922-MAIN,LOCAL,,,,,496,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,238.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LOCKING SCREW T8 FULL THREAD 2.4MM L10MM,C1713,CDM,278,RC,C1713,HCPCS,,12637-MAIN,LOCAL,,,,,496,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,238.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LOCKING SCREW T8 FULL THREAD 2.4MM L10MM,C1713,CDM,278,RC,C1713,HCPCS,,12637-MAIN,LOCAL,,,,,496,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,238.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LOCKING SCREW T8 FULL THREAD 2.4MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12651-MAIN,LOCAL,,,,,496,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,238.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LOCKING SCREW T8 FULL THREAD 2.4MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12651-MAIN,LOCAL,,,,,496,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,238.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LOCKING SCREW T8 FULL THREAD 2.7MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12638-MAIN,LOCAL,,,,,496,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,238.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LOCKING SCREW T8 FULL THREAD 2.7MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12638-MAIN,LOCAL,,,,,496,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,238.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LOCKING SCREW T8 FULL THREAD 2.7MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12639-MAIN,LOCAL,,,,,496,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,238.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LOCKING SCREW T8 FULL THREAD 2.7MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12639-MAIN,LOCAL,,,,,496,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,238.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Xray Sacroiliac Jnts Less Than 3 Vws,PX7220001,CDM,320,RC,72200,CPT,TC,,,,,,,555,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,238.095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,543.9
ARTISTA AH 3GRAM ABSORBABLE HEMOSTATIC PARTICLES,27200000,CDM,272,RC,A6199,HCPCS,,10227-MAIN,LOCAL,,,,,486,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,238.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ARTISTA AH 3GRAM ABSORBABLE HEMOSTATIC PARTICLES,27200000,CDM,272,RC,A6199,HCPCS,,10227-MAIN,LOCAL,,,,,486,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,238.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ARTISTA AH 3GRAM ABSORBABLE HEMOSTATIC PARTICLES,27200000,CDM,272,RC,A6199,HCPCS,,10227-MAIN,LOCAL,,,,,486,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,238.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002P,CDM,983,RC,12002,CPT,,,,,,,,486,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,232.72,percent of total billed charges,238.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,473.0238
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002P,CDM,983,RC,12002,CPT,,,,,,,,486,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,238.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,473.0238
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002P,CDM,983,RC,12002,CPT,,,,,,,,486,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,238.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,473.0238
Xray Sinuses Less Than 3 Vws,PX7021001,CDM,320,RC,70210,CPT,TC,,,,,,,486,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,99.83,percent of total billed charges,238.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,476.28
Xray Sinuses Less Than 3 Vws,PX7021001,CDM,320,RC,70210,CPT,TC,,,,,,,486,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,238.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,476.28
Xray Sinuses Less Than 3 Vws,PX7021001,CDM,320,RC,70210,CPT,TC,,,,,,,486,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,238.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,476.28
"Closed Rx Radial Head Disloc,Child",PX24640F,CDM,510,RC,24640,CPT,,,,,,,,270,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,238.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.158,264.6
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157F,CDM,370,RC,99157,CPT,,,,,,,,270,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,238.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.158,264.6
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157P,CDM,983,RC,99157,CPT,,,,,,,,270,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,238.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.158,262.791
Wound Culture Anaerobic,PX87075,CDM,300,RC,87075,CPT,,,,,,,,270,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,238.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.68,264.6
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,23155052431,NDC,10,ML,486.06,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,238.1694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,23155052431,NDC,10,ML,486.06,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,238.1694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,23155052431,NDC,10,ML,486.06,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,238.1694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,23155052441,NDC,10,ML,486.06,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,238.1694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,23155052441,NDC,10,ML,486.06,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,238.1694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,23155052441,NDC,10,ML,486.06,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,238.1694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fluorouracil 5 GM/100ML Solution 100 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,16729027638,NDC,100,ML,261.44,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,238.17184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,256.2112
MINIBUNION NON-LOCKING SCREW  2.7X18MM,C1713,CDM,278,RC,C1713,HCPCS,,11670-MAIN,LOCAL,,,,,280.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,238.425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Fibrinogen Activity - Ref,PX8538490,CDM,300,RC,85384,CPT,90,,,,,,,245,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,238.4585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.91,240.1
"Ileoscopy Thru Stoma,Diagnostic",PX44380F,CDM,750,RC,44380,CPT,,,,,,,,245,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,238.4585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.773,791.92
Platelet Antibodies - Ref,PX8602290,CDM,300,RC,86022,CPT,90,,,,,,,245,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,238.4585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.84,240.1
tropicamide 1 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,61314035502,NDC,15,ML,267.96,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,238.4844,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Noninvasv Lo Extrem Art Stress/Rest,PX9392401,CDM,921,RC,93924,CPT,TC,,,,,,,810,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,238.5,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.34,238.5
Noninvasv Lo Extrem Art Stress/Rest,PX9392401,CDM,921,RC,93924,CPT,TC,,,,,,,810,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,238.5,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.34,238.5
X-Ray Exam Chest 2 Views,PX7104601,CDM,320,RC,71046,CPT,TC,,,,,,,556,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,238.524,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,544.88
Xray Chest 2 Views,PX7102001,CDM,320,RC,71020,CPT,TC,,,,,,,556,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,238.524,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,230.9624,544.88
Cpap/Bipap Mgmnt-Pt Own Equipment,PX94660.02F,CDM,410,RC,94660,CPT,,,,,,,,497,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,238.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.33,487.06
Cpap/Bipap Mgmnt-Pt Own Equipment,PX94660.02F,CDM,410,RC,94660,CPT,,,,,,,,497,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,238.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.33,487.06
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121F,CDM,510,RC,13121,CPT,,,,,,,,948,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,238.5773,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,161,882.74
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121P,CDM,983,RC,13121,CPT,,,,,,,,632,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,238.5773,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,161,882.74
"Fac/Office Consultation,Level IV",PX99244F,CDM,510,RC,99244,CPT,,,,,,,,441,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,238.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.11,287.64
"Office Consultation,Level IV",PX99244P,CDM,983,RC,99244,CPT,,,,,,,,441,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,238.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.11,432.18
Multiple Sleep Latency Test,PX9580501,CDM,740,RC,95805,CPT,TC,,,,,,,4313,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,238.66,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,238.66,656.16
Tap Block Bilateral by Injection(S),PX64488P,CDM,983,RC,64488,CPT,,,,,,,,262,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,238.682,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.8348,255.0046
lidocaine - transparent dressing 4 % Kit 1 Each Box,63700001,CDM,250,RC,,,,,,496088207,NDC,1,EA,270.63,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,238.69566,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,61314054701,NDC,2.5,ML,487.35,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,238.8015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,61314054701,NDC,2.5,ML,487.35,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,238.8015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,61314054701,NDC,2.5,ML,487.35,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,238.8015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"OB US < 14 Wks, Single Fetus - Radiology, Tech",PX7680101,CDM,402,RC,76801,CPT,TC,,,,,,,472,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,238.832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,462.56
US Pelvic Tc Complete,PX7685601,CDM,402,RC,76856,CPT,TC,,,,,,,472,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,238.832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,462.56
US Transvaginal Tc,PX7683001,CDM,402,RC,76830,CPT,TC,,,,,,,472,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,238.832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,462.56
8MM ENDOWRIST INSTRUMENTS CADIERE FORCEPS,27200000,CDM,272,RC,,,,11913-MAIN,LOCAL,,,,,281,,First Health,Commercial,both,85,,999999999,percent of total billed charges,238.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
FORCEPS PROGRASP 8MM ENDOWRIST INSTRUMENTS,27200000,CDM,272,RC,,,,12062-MAIN,LOCAL,,,,,281,,First Health,Commercial,both,85,,999999999,percent of total billed charges,238.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Spirometry,PX9401001,CDM,460,RC,94010,CPT,TC,,,,,,,281,,First Health,Commercial,both,85,,999999999,percent of total billed charges,238.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,116.7274,275.38
"DXA, Bone Density Study, Hips/Pelv/Spine",PX7708001,CDM,320,RC,77080,CPT,TC,,,,,,,575,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,238.855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,563.5
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,65162083366,NDC,100,GR,281.12,,First Health,Commercial,both,85,,999999999,percent of total billed charges,238.952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Column Chrom Ms, Quant - Ref",PX8254290,CDM,300,RC,82542,CPT,90,,,,,,,557,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,238.953,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.09,545.86
ePHEDrine sulfate 50 MG/ML Solution 1 mL Ampule,25000000,CDM,250,RC,,,,,,17478041510,NDC,1,ML,262.31,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,238.96441,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Strapping of Ankle,PX29540F,CDM,420,RC,29540,CPT,,,,,,,,271,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,239.022,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.5734,265.58
"POS Airway Pressure, Cpap",PX94660F,CDM,410,RC,94660,CPT,,,,,,,,498,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,239.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.33,488.04
"POS Airway Pressure, Cpap",PX94660F,CDM,410,RC,94660,CPT,,,,,,,,498,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,239.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.33,488.04
BINDER PELVIC ADULT STABILIZATION T-PODR,120.357,CDM,271,RC,A4467,HCPCS,,10734-MAIN,LOCAL,,,,,244,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,239.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.3576,239.12
"Bone Marrow Aspiration(S),Diag",PX38220P,CDM,983,RC,38220,CPT,,,,,,,,244,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,239.12,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.1,326.53
Dress/Debrid Med Burn No Anesth,PX16025P,CDM,983,RC,16025,CPT,,,,,,,,244,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,239.12,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.06,327.91
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Suspension 10 mL Bottle,63700001,CDM,250,RC,,,,,,64980044801,NDC,10,ML,488.25,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,239.2425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Suspension 10 mL Bottle,63700001,CDM,250,RC,,,,,,64980044801,NDC,10,ML,488.25,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,239.2425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Suspension 10 mL Bottle,63700001,CDM,250,RC,,,,,,64980044801,NDC,10,ML,488.25,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,239.2425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Ht Muscle Image Spect, Mult",PX7845201,CDM,340,RC,78452,CPT,TC,,,,,,,2000,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,239.31,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,239.31,707.36
"Ht Muscle Image Spect, Mult",PX7845201,CDM,340,RC,78452,CPT,TC,,,,,,,2000,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,239.31,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,239.31,707.36
Removal of Nail Plate,PX11730F,CDM,510,RC,11730,CPT,,,,,,,,229,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,239.36,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.37,239.36
BRONCHOSCOPE BFLEX 5.0 SINGLE-USE 0570-0449,120.578,CDM,272,RC,,,,13020-MAIN,LOCAL,,,,,558,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,239.382,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,231.7932,546.84
PERFIX PLUG STERILE LARGE,C1781,CDM,278,RC,C1781,HCPCS,,11771-MAIN,LOCAL,,,,,558,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,239.382,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
NEEDLE INTRAOSSEOUS 15GA 15MM EZ-IO PEDS 9018,120.89,CDM,272,RC,A4215,HCPCS,,4964-MAIN,LOCAL,,,,,269,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,239.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.7426,263.62
KATZ EXTRACTOR OTO-RHINO FOREIGN BODY REMOVER,120.568,CDM,272,RC,,,,12808-MAIN,LOCAL,,,,,246,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,239.4318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.1884,241.08
"Fac/Ex Skinbngn0.6-1cmtrnk,Arm,Lg",PX11401F,CDM,510,RC,11401,CPT,,,,,,,,484,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,239.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.0536,474.32
"Fac/Exc Skn Benig<5mm Face,Facial",PX11440F,CDM,510,RC,11440,CPT,,,,,,,,484,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,239.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.0536,614.65
"Facility Critical Care, Addl 30 Min",PX99292F,CDM,510,RC,99292,CPT,,,,,,,,484,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,239.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.0536,474.32
"X-Ray Exam Hip,Unilat W/Pelvis 1vw",PX7350101,CDM,320,RC,73501,CPT,TC,,,,,,,263,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,239.593,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,257.74
Xray Finger(S) Tc,PX7314001,CDM,320,RC,73140,CPT,TC,,,,,,,282,,First Health,Commercial,both,85,,999999999,percent of total billed charges,239.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,276.36
Xray Toe(S) Tc,PX7366001,CDM,320,RC,73660,CPT,TC,,,,,,,282,,First Health,Commercial,both,85,,999999999,percent of total billed charges,239.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,276.36
CT Angio Lwr Extr W/O&W/Dye,PX7370601,CDM,350,RC,73706,CPT,TC,,,,,,,1554,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,239.741,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.11,479.9
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409421505,NDC,5,ML,271.86,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,239.78052,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
atropine 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,17478021502,NDC,2,ML,269.45,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,239.8105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
atropine 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,60219174802,NDC,2,ML,269.45,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,239.8105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
methylPREDNISolone sod succ 1000 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9001820,NDC,1,EA,271.97,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,239.87754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
calcitonin (salmon) 200 UNIT/ACT Solution 3.7 mL Bottle,63700001,CDM,250,RC,,,,,,60505082306,NDC,3.7,ML,489.57,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,239.8893,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcitonin (salmon) 200 UNIT/ACT Solution 3.7 mL Bottle,63700001,CDM,250,RC,,,,,,60505082306,NDC,3.7,ML,489.57,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,239.8893,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
calcitonin (salmon) 200 UNIT/ACT Solution 3.7 mL Bottle,63700001,CDM,250,RC,,,,,,60505082306,NDC,3.7,ML,489.57,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,239.8893,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611P,CDM,983,RC,20611,CPT,,,,,,,,272,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,239.904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.9888,264.7376
Exc Skn Beni 0.6-1cm Fcefacial,PX11441P,CDM,983,RC,11441,CPT,,,,,,,,485,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,240.075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.469,614.65
Fibrinogen Activity - Ref,PX8538490,CDM,300,RC,85384,CPT,90,,,,,,,245,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,240.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.91,240.1
"Ileoscopy Thru Stoma,Diagnostic",PX44380F,CDM,750,RC,44380,CPT,,,,,,,,245,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,240.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.773,791.92
Lipid Profile,PX80061,CDM,300,RC,80061,CPT,,,,,,,,245,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,240.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.28,240.1
Platelet Antibodies - Ref,PX8602290,CDM,300,RC,86022,CPT,90,,,,,,,245,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,240.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.84,240.1
Xray Knee 4 or More Vws,PX7356401,CDM,320,RC,73564,CPT,TC,,,,,,,490,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,240.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,480.2
Xray Knee 4 or More Vws,PX7356401,CDM,320,RC,73564,CPT,TC,,,,,,,490,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,240.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,480.2
Xray Knee 4 or More Vws,PX7356401,CDM,320,RC,73564,CPT,TC,,,,,,,490,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,240.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,480.2
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032601,NDC,0.5,ML,559.7,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,240.1113,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,1630.2692
"Close Rx Fingr Articular Fx,Manip",PX26742P,CDM,983,RC,26742,CPT,,,,,,,,560,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,240.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,232.624,1404.08
"Enzyme Act, Nonradioact - Ref",PX8265790,CDM,300,RC,82657,CPT,90,,,,,,,560,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,240.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.33,548.8
"Closed Rx Radial Head Disloc,Child",PX24640F,CDM,510,RC,24640,CPT,,,,,,,,270,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,240.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.158,264.6
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157F,CDM,370,RC,99157,CPT,,,,,,,,270,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,240.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.158,264.6
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157P,CDM,983,RC,99157,CPT,,,,,,,,270,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,240.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.158,262.791
Wound Culture Anaerobic,PX87075,CDM,300,RC,87075,CPT,,,,,,,,270,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,240.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.68,264.6
"MRI, Pelvis, W/O Then W/",PX7219701,CDM,610,RC,72197,CPT,TC,,,,,,,1612,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,240.3846,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,162.96,480.56
"Ht Muscle Image Spect, Mult",PX7845201,CDM,340,RC,78452,CPT,TC,,,,,,,2000,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,240.4,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,239.31,707.36
Drain/Inject Medium Joint/Bursa,PX20605F,CDM,510,RC,20605,CPT,,,,,,,,247,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,308,percent of total billed charges,240.4051,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.6038,258.75
Inj Tendon/Ligament/Cyst,PX20550P,CDM,983,RC,20550,CPT,,,,,,,,264,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,240.504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.6656,258.75
Occupational Therapy Eval Mod Complex,PX97166,CDM,434,RC,97166,CPT,,,,,,,,264,,Medica,Commercial,both,91.1,,110.09,percent of total billed charges,240.504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,258.72
Physical Therapy Evaluation Mod Complex,PX97162,CDM,424,RC,97162,CPT,,,,,,,,264,,Medica,Commercial,both,91.1,,129.0285714,percent of total billed charges,240.504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,258.72
Renal Function Panel,PX80069,CDM,300,RC,80069,CPT,,,,,,,,264,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,240.504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.96,258.72
STAPLER RELOAD-CURVED CUTTER,27200000,CDM,272,RC,,,,12063-MAIN,LOCAL,,,,,283,,First Health,Commercial,both,85,,999999999,percent of total billed charges,240.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476881,NDC,50,ML,579.12,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,240.566448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
ARTISTA AH 3GRAM ABSORBABLE HEMOSTATIC PARTICLES,27200000,CDM,272,RC,A6199,HCPCS,,10227-MAIN,LOCAL,,,,,486,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,240.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002P,CDM,983,RC,12002,CPT,,,,,,,,486,,Humana Choice Care,All Medicare plans,outpatient,49.5,,114.17,percent of total billed charges,240.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,473.0238
Xray Sinuses Less Than 3 Vws,PX7021001,CDM,320,RC,70210,CPT,TC,,,,,,,486,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,240.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,476.28
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,23155052431,NDC,10,ML,486.06,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,240.5997,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,23155052441,NDC,10,ML,486.06,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,240.5997,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ipratropium 0.06 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,54004641,NDC,15,ML,491.02,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,240.5998,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ipratropium 0.06 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,54004641,NDC,15,ML,491.02,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,240.5998,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ipratropium 0.06 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,54004641,NDC,15,ML,491.02,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,240.5998,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Drain Skin Abscess Complic,PX10061P,CDM,983,RC,10061,CPT,,,,,,,,561,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,240.669,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,233.0394,546.0213
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12130-MAIN,LOCAL,,,,,561,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,240.669,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Injection for Nerve Block,PX64447F,CDM,510,RC,64447,CPT,,,,,,,,3023,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,240.75,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.05,240.75
Injection for Nerve Block,PX64447P,CDM,983,RC,64447,CPT,,,,,,,,3892,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,240.75,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.05,3814.16
lidocaine - transparent dressing 4 % Kit 1 Each Box,63700001,CDM,250,RC,,,,,,496088207,NDC,1,EA,270.63,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,240.8607,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Leukoreduced Rbc's,PXP9016,CDM,390,RC,P9016,HCPCS,,,,,,,,580,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,240.932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,165.79,568.4
"Chemotherapy, IV Push, Single Drug",PX96409,CDM,335,RC,96409,CPT,,,,,,,,502,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,240.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.5308,491.96
"Chemotherapy, IV Push, Single Drug",PX96409,CDM,335,RC,96409,CPT,,,,,,,,502,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,240.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.5308,491.96
Incise External Hemorrhoid,PX46083F,CDM,510,RC,46083,CPT,,,,,,,,502,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,240.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.5308,491.96
Incise External Hemorrhoid,PX46083F,CDM,510,RC,46083,CPT,,,,,,,,502,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,240.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.5308,491.96
nystatin 100000 UNIT/GM Powder 60 g Bottle,63700001,CDM,250,RC,,,,,,574200802,NDC,60,GR,491.86,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,241.0114,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/GM Powder 60 g Bottle,63700001,CDM,250,RC,,,,,,574200802,NDC,60,GR,491.86,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,241.0114,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/GM Powder 60 g Bottle,63700001,CDM,250,RC,,,,,,574200802,NDC,60,GR,491.86,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,241.0114,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
KATZ EXTRACTOR OTO-RHINO FOREIGN BODY REMOVER,120.568,CDM,272,RC,,,,12808-MAIN,LOCAL,,,,,246,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,241.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.1884,241.08
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762F,CDM,510,RC,43762,CPT,,,,,,,,492,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,241.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,204.3768,482.16
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762F,CDM,510,RC,43762,CPT,,,,,,,,492,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,241.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,204.3768,482.16
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762F,CDM,510,RC,43762,CPT,,,,,,,,492,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,241.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,204.3768,482.16
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315606,NDC,100,ML,264.64,,Medica,Commercial,both,91.1,,0.5293,percent of total billed charges,241.08704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.931456,259.3472
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315695,NDC,100,ML,264.64,,Medica,Commercial,both,91.1,,0.5293,percent of total billed charges,241.08704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.931456,259.3472
neomycin-polymyxin-dexamethasone 3.5-10000-0.1 Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,61314063136,NDC,3.5,GR,247.71,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,241.096143,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Exc Skn Bngn3.1-4cm Remain Bdy,PX11424P,CDM,983,RC,11424,CPT,,,,,,,,562,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,241.098,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,233.4548,1416.38
"US,Preg. Uterus,Fetal/Mat.Eval.,>1st Trim.(>/= 14 Wks 0 Dys),Transabd;Single/First Gest., Tech",PX7680501,CDM,402,RC,76805,CPT,TC,,,,,,,562,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,241.098,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,550.76
neomycin-polymyxin-dexameth 3.5-10000-0.1 Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063006,NDC,5,ML,247.72,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,241.105876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Infection Agent Detect Dna/Rna Probe Tq 6-11,PX87506,CDM,300,RC,87506,CPT,,,,,,,,1710,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,241.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,241.14,1675.8
dexmedeTOMIDine in sodium chloride 400 MCG/100ML Solution 100 mL Bottle,25000000,CDM,250,RC,,,,,,67457092500,NDC,100,ML,562.18,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,241.17522,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Strapping of Ankle,PX29540F,CDM,420,RC,29540,CPT,,,,,,,,271,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,241.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.5734,265.58
umeclidinium 62.5 MCG/ACT Aerosol Powder Breath Activated 7 Each Disp Pack,63700001,CDM,250,RC,,,,,,173087306,NDC,7,EA,492.23,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,241.1927,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
umeclidinium 62.5 MCG/ACT Aerosol Powder Breath Activated 7 Each Disp Pack,63700001,CDM,250,RC,,,,,,173087306,NDC,7,EA,492.23,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,241.1927,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
umeclidinium 62.5 MCG/ACT Aerosol Powder Breath Activated 7 Each Disp Pack,63700001,CDM,250,RC,,,,,,173087306,NDC,7,EA,492.23,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,241.1927,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prednisoLONE acetate 1 % Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063705,NDC,5,ML,283.79,,First Health,Commercial,both,85,,999999999,percent of total billed charges,241.2215,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,61314054701,NDC,2.5,ML,487.35,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,241.23825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Closed Rx Mt-Phal Toe Dislocation,PX28630P,CDM,983,RC,28630,CPT,,,,,,,,248,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,241.3784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.0192,241.3784
Debride Muscle Ea Add 20 Sqcm,PX11046F,CDM,510,RC,11046,CPT,,,,,,,,248,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,241.3784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.0192,243.04
Fetal Profile W/O Stress,PX7681901,CDM,402,RC,76819,CPT,TC,,,,,,,248,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,241.3784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,243.04
Ther Injection Carpal Tunnel,PX20526P,CDM,983,RC,20526,CPT,,,,,,,,248,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,241.3784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.0192,258.75
US Chest Tc,PX7660401,CDM,402,RC,76604,CPT,TC,,,,,,,248,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,241.3784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,243.04
"West Nile Ab, Igg - Ref",PX8678990,CDM,300,RC,86789,CPT,90,,,,,,,248,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,241.3784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,243.04
Haptoglobin; Quantitative,PX83010,CDM,300,RC,83010,CPT,,,,,,,,265,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,241.415,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.53,259.7
ID Nucleic Acid Sequencing - Ref,PX8715390,CDM,300,RC,87153,CPT,90,,,,,,,265,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,241.415,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.77,259.7
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004004,NDC,120,ML,502.95,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,241.416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004004,NDC,120,ML,502.95,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,241.416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402F,CDM,510,RC,11402,CPT,,,,,,,,424,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,241.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.08,359.04
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402P,CDM,983,RC,11402,CPT,,,,,,,,424,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,241.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.08,415.52
Trb@ Gene Rearrange Amplify - Ref,PX8134090,CDM,300,RC,81340,CPT,90,,,,,,,503,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,241.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,191.56,492.94
Trb@ Gene Rearrange Amplify - Ref,PX8134090,CDM,300,RC,81340,CPT,90,,,,,,,503,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,241.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,191.56,492.94
Xray Pelvis Compl 3+ Tc,PX7219001,CDM,320,RC,72190,CPT,TC,,,,,,,563,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,241.527,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,551.74
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597P,CDM,983,RC,97597,CPT,,,,,,,,274,,United Healthcare,All Payer,outpatient,88.2,,140.98,percent of total billed charges,241.668,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,113.8196,266.6842
"MRI, Abdomen W/O+ W/Contr",PX7418301,CDM,610,RC,74183,CPT,TC,,,,,,,4116,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,241.6718,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,163.83,483.19
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Suspension 10 mL Bottle,63700001,CDM,250,RC,,,,,,64980044801,NDC,10,ML,488.25,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,241.68375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,121090204,NDC,120,ML,503.56,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,241.7088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,121090204,NDC,120,ML,503.56,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,241.7088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,6384371,NDC,1,EA,563.46,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,241.72434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
"Hospital Inpt or Obs Care, Admin/Disch Same Date, Moderate Level Mdm >= 70 Minutes",PX99235,CDM,982,RC,99235,CPT,,,,,,,,582,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,241.7628,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,241.7628,566.4606
Hepatobil Syst Image W/Drug,PX7822701,CDM,341,RC,78227,CPT,TC,,,,,,,1674,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,241.93,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,238,703.42
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409421505,NDC,5,ML,271.86,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,241.9554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
methylPREDNISolone sod succ 1000 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9001820,NDC,1,EA,271.97,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,242.0533,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
CRICOTHROTOMY QUICKTRACH 4MM,120.228,CDM,272,RC,A7520,HCPCS,,8868-MAIN,LOCAL,,,,,494,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,242.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.2076,484.12
CRICOTHROTOMY QUICKTRACH 4MM,120.228,CDM,272,RC,A7520,HCPCS,,8868-MAIN,LOCAL,,,,,494,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,242.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.2076,484.12
CRICOTHROTOMY QUICKTRACH 4MM,120.228,CDM,272,RC,A7520,HCPCS,,8868-MAIN,LOCAL,,,,,494,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,242.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.2076,484.12
Drain/Inject Medium Joint/Bursa,PX20605F,CDM,510,RC,20605,CPT,,,,,,,,247,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,242.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.6038,258.75
SET CRICOTHYROTOMY CATHETER 6MM ID,120.378,CDM,272,RC,,,,11119-MAIN,LOCAL,,,,,494,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,242.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.2076,484.12
SET CRICOTHYROTOMY CATHETER 6MM ID,120.378,CDM,272,RC,,,,11119-MAIN,LOCAL,,,,,494,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,242.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.2076,484.12
SET CRICOTHYROTOMY CATHETER 6MM ID,120.378,CDM,272,RC,,,,11119-MAIN,LOCAL,,,,,494,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,242.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.2076,484.12
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611P,CDM,983,RC,20611,CPT,,,,,,,,272,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,242.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.9888,264.7376
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062160,NDC,0.6,ML,274.53,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,242.13546,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801601,NDC,0.6,ML,274.53,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,242.13546,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801610,NDC,0.6,ML,274.53,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,242.13546,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
"Lap,Dx Surgical Abd W/Biopsy",PX49321P,CDM,983,RC,49321,CPT,,,,,,,,583,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,242.1782,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,242.1782,5040.74
Xray Sacroiliac Jnts 3 or More Vws,PX7220201,CDM,320,RC,72202,CPT,TC,,,,,,,285,,First Health,Commercial,both,85,,999999999,percent of total billed charges,242.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,279.3
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,63323072902,NDC,1,EA,265.95,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,242.28045,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.47563,793.6922
sugammadex sodium 200 MG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,6542312,NDC,2,ML,583.33,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,242.315282,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Initial Observation Care,Levl I",PX99218,CDM,982,RC,99218,CPT,,,,,,,,266,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,242.326,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.4964,258.8978
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597F,CDM,510,RC,97597,CPT,,,,,,,,266,,Medica,Commercial,both,91.1,,53.2,percent of total billed charges,242.326,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.4964,260.68
calcitonin (salmon) 200 UNIT/ACT Solution 3.7 mL Bottle,63700001,CDM,250,RC,,,,,,60505082306,NDC,3.7,ML,489.57,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,242.33715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ondansetron 4 MG/5ML Solution 25 mL Bottle,S0119.01,CDM,636,RC,S0119,HCPCS,,,,99998-8001-,NDC,25,ML,494.57,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,242.3393,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG/5ML Solution 25 mL Bottle,S0119.01,CDM,636,RC,S0119,HCPCS,,,,99998-8001-,NDC,25,ML,494.57,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,242.3393,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ondansetron 4 MG/5ML Solution 25 mL Bottle,S0119.01,CDM,636,RC,S0119,HCPCS,,,,99998-8001-,NDC,25,ML,494.57,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,242.3393,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
Repr Superf Wnd Body 12.6-20,PX12005F,CDM,510,RC,12005,CPT,,,,,,,,565,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,242.385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,234.701,553.7
Xray Lumbosacral Minimum 4 Vws,PX7211001,CDM,320,RC,72110,CPT,TC,,,,,,,565,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,242.385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,553.7
Diagnostic Anoscopy,PX46600F,CDM,510,RC,46600,CPT,,,,,,,,505,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,242.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,494.9
Diagnostic Anoscopy,PX46600F,CDM,510,RC,46600,CPT,,,,,,,,505,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,242.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,494.9
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725F,CDM,510,RC,26725,CPT,,,,,,,,495,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,242.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.623,485.1
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725F,CDM,510,RC,26725,CPT,,,,,,,,495,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,242.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.623,485.1
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725F,CDM,510,RC,26725,CPT,,,,,,,,495,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,242.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.623,485.1
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101F,CDM,510,RC,13101,CPT,,,,,,,,495,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,242.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.623,548.67
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101F,CDM,510,RC,13101,CPT,,,,,,,,495,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,242.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.623,548.67
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101F,CDM,510,RC,13101,CPT,,,,,,,,495,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,242.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.623,548.67
Tc99 Mebrofenin to 15 Mci,PXA9537,CDM,343,RC,A9537,HCPCS,,,,,,,,495,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,106.2,percent of total billed charges,242.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.623,485.1
Tc99 Mebrofenin to 15 Mci,PXA9537,CDM,343,RC,A9537,HCPCS,,,,,,,,495,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,242.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.623,485.1
Tc99 Mebrofenin to 15 Mci,PXA9537,CDM,343,RC,A9537,HCPCS,,,,,,,,495,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,242.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.623,485.1
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151P,CDM,983,RC,99151,CPT,,,,,,,,275,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,242.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,114.235,267.6575
Xray Knee 4 or More Vws,PX7356401,CDM,320,RC,73564,CPT,TC,,,,,,,490,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,242.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,480.2
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,49884093547,NDC,100,GR,266.25,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,242.55375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
amiodarone 150-4.21 MG/100ML-% Solution 100 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066015010,NDC,100,ML,249.22,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,242.565826,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.35,318.745
ROPivacaine 2 MG/ML Solution 100 mL Bottle,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028568,NDC,100,ML,275.11,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,242.64702,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.604954,269.6078
sulfacetamide 10 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,61314070101,NDC,15,ML,285.48,,First Health,Commercial,both,85,,999999999,percent of total billed charges,242.658,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
neomycin-polymyxin-dexamethasone 3.5-10000-0.1 Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,61314063136,NDC,3.5,GR,247.71,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,242.7558,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
neomycin-polymyxin-dexameth 3.5-10000-0.1 Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063006,NDC,5,ML,247.72,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,242.7656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
US Renal Retroperit Ltd,PX7677501,CDM,402,RC,76775,CPT,TC,,,,,,,566,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,242.814,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,554.68
US Retroperitoneal Tc,PX7677001,CDM,402,RC,76770,CPT,TC,,,,,,,566,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,242.814,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,554.68
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081543,NDC,1,ML,479.89,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,242.82434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.346306,470.2922
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081552,NDC,1,ML,479.89,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,242.82434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.346306,470.2922
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821517,NDC,3,ML,275.33,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,242.84106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
Egd Balloon Dil Esoph30 Mm/>,PX43233P,CDM,983,RC,43233,CPT,,,,,,,,480,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,242.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.392,1662.33
"Sigmoidoscopy,Diagnostic",PX45330P,CDM,983,RC,45330,CPT,,,,,,,,480,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,242.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.392,798.45
MRI Lower W/O+W Tc,PX7372001,CDM,610,RC,73720,CPT,TC,,,,,,,3174,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,242.959,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,164.7,485.82
"MRI,Upr Ext, Joint,W/Cont",PX7322201,CDM,610,RC,73222,CPT,TC,,,,,,,3541,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,242.959,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,164.48,485.16
"Layr Clos Wnd Face,Facial 2.5-5",PX12052F,CDM,510,RC,12052,CPT,,,,,,,,585,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,243.009,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,243.009,573.3
ADVANCED INSTRUMENTS ENDOWRIST SUCTION IRRIGATOR,27200000,CDM,272,RC,,,,11922-MAIN,LOCAL,,,,,496,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,243.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ADVANCED INSTRUMENTS ENDOWRIST SUCTION IRRIGATOR,27200000,CDM,272,RC,,,,11922-MAIN,LOCAL,,,,,496,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,243.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ADVANCED INSTRUMENTS ENDOWRIST SUCTION IRRIGATOR,27200000,CDM,272,RC,,,,11922-MAIN,LOCAL,,,,,496,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,243.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Closed Rx Mt-Phal Toe Dislocation,PX28630P,CDM,983,RC,28630,CPT,,,,,,,,248,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,243.04,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.93,327.22
Debride Muscle Ea Add 20 Sqcm,PX11046F,CDM,510,RC,11046,CPT,,,,,,,,248,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,243.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.0192,243.04
Fetal Profile W/O Stress,PX7681901,CDM,402,RC,76819,CPT,TC,,,,,,,248,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,243.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,243.04
LOCKING SCREW T8 FULL THREAD 2.4MM L10MM,C1713,CDM,278,RC,C1713,HCPCS,,12637-MAIN,LOCAL,,,,,496,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,243.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LOCKING SCREW T8 FULL THREAD 2.4MM L10MM,C1713,CDM,278,RC,C1713,HCPCS,,12637-MAIN,LOCAL,,,,,496,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,243.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LOCKING SCREW T8 FULL THREAD 2.4MM L10MM,C1713,CDM,278,RC,C1713,HCPCS,,12637-MAIN,LOCAL,,,,,496,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,243.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LOCKING SCREW T8 FULL THREAD 2.4MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12651-MAIN,LOCAL,,,,,496,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,243.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LOCKING SCREW T8 FULL THREAD 2.4MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12651-MAIN,LOCAL,,,,,496,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,243.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LOCKING SCREW T8 FULL THREAD 2.4MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12651-MAIN,LOCAL,,,,,496,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,243.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LOCKING SCREW T8 FULL THREAD 2.7MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12638-MAIN,LOCAL,,,,,496,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,243.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LOCKING SCREW T8 FULL THREAD 2.7MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12638-MAIN,LOCAL,,,,,496,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,243.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LOCKING SCREW T8 FULL THREAD 2.7MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12638-MAIN,LOCAL,,,,,496,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,243.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LOCKING SCREW T8 FULL THREAD 2.7MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12639-MAIN,LOCAL,,,,,496,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,243.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LOCKING SCREW T8 FULL THREAD 2.7MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12639-MAIN,LOCAL,,,,,496,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,243.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LOCKING SCREW T8 FULL THREAD 2.7MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12639-MAIN,LOCAL,,,,,496,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,243.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Ther Injection Carpal Tunnel,PX20526P,CDM,983,RC,20526,CPT,,,,,,,,248,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,243.04,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.46,243.04
US Chest Tc,PX7660401,CDM,402,RC,76604,CPT,TC,,,,,,,248,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,243.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,243.04
"West Nile Ab, Igg - Ref",PX8678990,CDM,300,RC,86789,CPT,90,,,,,,,248,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,243.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,243.04
dorzolamide-timolol 2-0.5 % Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,50383023310,NDC,10,ML,506.34,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,243.0432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dorzolamide-timolol 2-0.5 % Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,50383023310,NDC,10,ML,506.34,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,243.0432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ipratropium 0.06 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,54004641,NDC,15,ML,491.02,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,243.0549,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Blood Culture for Bacteria,PX87040,CDM,300,RC,87040,CPT,,,,,,,,286,,First Health,Commercial,both,85,,999999999,percent of total billed charges,243.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.46,280.28
I&D Bartholin Gland Abscess,PX56420P,CDM,983,RC,56420,CPT,,,,,,,,286,,First Health,Commercial,both,85,,999999999,percent of total billed charges,243.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,118.8044,278.3638
Joint Survey,PX7707726,CDM,982,RC,77077,CPT,26,,,,,,,286,,First Health,Commercial,both,85,,999999999,percent of total billed charges,243.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,278.3638
Lab Culture Bacteria,PX87070,CDM,300,RC,87070,CPT,,,,,,,,286,,First Health,Commercial,both,85,,999999999,percent of total billed charges,243.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.9,280.28
Urine Culture/Colony Count,PX87086,CDM,300,RC,87086,CPT,,,,,,,,286,,First Health,Commercial,both,85,,999999999,percent of total billed charges,243.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4,280.28
gentamicin 0.1 % Ointment 30 g Tube,25000000,CDM,250,RC,,,,,,713068231,NDC,30,GR,506.64,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,243.1872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
gentamicin 0.1 % Ointment 30 g Tube,25000000,CDM,250,RC,,,,,,713068231,NDC,30,GR,506.64,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,243.1872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
levOCARNitine 200 MG/ML Solution 5 mL Vial,J1955.01,CDM,636,RC,J1955,HCPCS,,,,517104501,NDC,5,ML,249.86,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,243.188738,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.791844,244.8628
Xray Shoulder 1 Vw,PX7302001,CDM,320,RC,73020,CPT,TC,,,,,,,267,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,243.237,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,261.66
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221901,NDC,3,ML,506.9,,Health Partners,Health Partners Care Plans,both,48,,4.547805556,percent of total billed charges,243.312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221901,NDC,3,ML,506.9,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,243.312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221905,NDC,3,ML,506.9,,Health Partners,Health Partners Care Plans,both,48,,4.547805556,percent of total billed charges,243.312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221905,NDC,3,ML,506.9,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,243.312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153P,CDM,983,RC,99153,CPT,,,,,,,,250,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,243.325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.85,243.325
sincalide 5 MCG Recon Soln 1 Each Vial,J2805.01,CDM,636,RC,J2805,HCPCS,,,,270055615,NDC,1,EA,250,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,243.325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.85,245
Withdrawal of Arterial Blood,PX36600F,CDM,510,RC,36600,CPT,,,,,,,,250,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,48.4,percent of total billed charges,243.325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.85,245
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915801,NDC,1,ML,267.19,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,243.41009,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
US Abdomen Tc,PX7670001,CDM,402,RC,76700,CPT,TC,,,,,,,586,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,243.4244,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,574.28
Culture Screen Only,PX87081,CDM,300,RC,87081,CPT,,,,,,,,276,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,243.432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.08,270.48
nystatin 100000 UNIT/GM Powder 60 g Bottle,63700001,CDM,250,RC,,,,,,574200802,NDC,60,GR,491.86,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,243.4707,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Repr Superf Wnd Face 2.6-5,PX12013F,CDM,510,RC,12013,CPT,,,,,,,,375,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,243.51,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.03,243.51
Repr Superf Wnd Face 2.6-5,PX12013P,CDM,983,RC,12013,CPT,,,,,,,,681,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,243.51,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.03,667.38
Cpap/Bipap Mgmnt-Pt Own Equipment,PX94660.02F,CDM,410,RC,94660,CPT,,,,,,,,497,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,243.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.33,487.06
Cpap/Bipap Mgmnt-Pt Own Equipment,PX94660.02F,CDM,410,RC,94660,CPT,,,,,,,,497,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,243.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.33,487.06
Cpap/Bipap Mgmnt-Pt Own Equipment,PX94660.02F,CDM,410,RC,94660,CPT,,,,,,,,497,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,243.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.33,487.06
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762F,CDM,510,RC,43762,CPT,,,,,,,,492,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,243.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,204.3768,482.16
umeclidinium 62.5 MCG/ACT Aerosol Powder Breath Activated 7 Each Disp Pack,63700001,CDM,250,RC,,,,,,173087306,NDC,7,EA,492.23,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,243.65385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Emergency Level III Visit,PX99283P,CDM,981,RC,99283,CPT,,,,,,,,568,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,243.672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,235.9472,552.8344
Facility Emergency Level III Visit,PX99283F,CDM,450,RC,99283,CPT,,,,,,,,587,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,243.8398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,243.8398,575.26
"Immunofluo Direct, Ea Ab - Ref",PX8834690,CDM,310,RC,88346,CPT,90,,,,,,,55,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,243.84,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,145.22,243.84
"Immunofluo Direct, Ea Ab - Ref",PX8834690,CDM,310,RC,88346,CPT,90,,,,,,,55,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,243.84,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,145.22,243.84
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597P,CDM,983,RC,97597,CPT,,,,,,,,274,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,243.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,113.8196,266.6842
Gastric Intubation Treatment,PX43753P,CDM,983,RC,43753,CPT,,,,,,,,498,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,244.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.8692,484.7034
Gastric Intubation Treatment,PX43753P,CDM,983,RC,43753,CPT,,,,,,,,498,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,244.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.8692,484.7034
Gastric Intubation Treatment,PX43753P,CDM,983,RC,43753,CPT,,,,,,,,498,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,244.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.8692,484.7034
"POS Airway Pressure, Cpap",PX94660F,CDM,410,RC,94660,CPT,,,,,,,,498,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,244.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.33,488.04
"POS Airway Pressure, Cpap",PX94660F,CDM,410,RC,94660,CPT,,,,,,,,498,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,244.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.33,488.04
"POS Airway Pressure, Cpap",PX94660F,CDM,410,RC,94660,CPT,,,,,,,,498,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,244.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.33,488.04
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423P,CDM,983,RC,11423,CPT,,,,,,,,569,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,244.101,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,236.3626,1416.38
tropicamide 1 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,61314035502,NDC,15,ML,267.96,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,244.11156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
amiodarone 150-4.21 MG/100ML-% Solution 100 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066015010,NDC,100,ML,249.22,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,244.2356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.35,318.745
"Molecular Cytog, Ea Probe - Ref",PX8827190,CDM,310,RC,88271,CPT,90,,,,,,,277,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,244.314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.64,271.46
"Xray Neck, Soft Tissue",PX7036001,CDM,320,RC,70360,CPT,TC,,,,,,,277,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,244.314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,271.46
Acute Hepatitis Panel,PX80074,CDM,300,RC,80074,CPT,,,,,,,,509,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,244.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,43.67,498.82
Acute Hepatitis Panel,PX80074,CDM,300,RC,80074,CPT,,,,,,,,509,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,244.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,43.67,498.82
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062160,NDC,0.6,ML,274.53,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,244.3317,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801601,NDC,0.6,ML,274.53,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,244.3317,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801610,NDC,0.6,ML,274.53,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,244.3317,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
CRICOTHROTOMY QUICKTRACH 4MM,120.228,CDM,272,RC,A7520,HCPCS,,8868-MAIN,LOCAL,,,,,494,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,244.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.2076,484.12
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004P,CDM,983,RC,15004,CPT,,,,,,,,570,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,244.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,236.778,554.781
SET CRICOTHYROTOMY CATHETER 6MM ID,120.378,CDM,272,RC,,,,11119-MAIN,LOCAL,,,,,494,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,244.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.2076,484.12
MRI Orb-Fac-Nec W/O+W/Con,PX7054301,CDM,610,RC,70543,CPT,TC,,,,,,,3541,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,244.568,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,165.79,489.11
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151P,CDM,983,RC,99151,CPT,,,,,,,,275,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,244.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,114.235,267.6575
CHOLANGIOGRAM CATHETER REDDICK,27200000,CDM,272,RC,,,,10232-MAIN,LOCAL,,,,,287.98,,First Health,Commercial,both,85,,999999999,percent of total billed charges,244.783,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Spirometry Incl Graph Rec Tc,PX9401002,CDM,460,RC,94010,CPT,TC,,,,,,,288,,First Health,Commercial,both,85,,999999999,percent of total billed charges,244.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.6352,282.24
ondansetron 4 MG/5ML Solution 25 mL Bottle,S0119.01,CDM,636,RC,S0119,HCPCS,,,,99998-8001-,NDC,25,ML,494.57,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,244.81215,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
ROPivacaine 2 MG/ML Solution 100 mL Bottle,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028568,NDC,100,ML,275.11,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,244.8479,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.604954,269.6078
levOCARNitine 200 MG/ML Solution 5 mL Vial,J1955.01,CDM,636,RC,J1955,HCPCS,,,,517104501,NDC,5,ML,249.86,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,244.8628,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.791844,244.8628
Diagnostic Anoscopy,PX46600F,CDM,510,RC,46600,CPT,,,,,,,,505,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,244.9,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.52,244.9
Diagnostic Anoscopy,PX46600P,CDM,983,RC,46600,CPT,,,,,,,,405,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,244.9,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.52,396.9
sevoflurane Solution 250 mL Bottle,25000000,CDM,250,RC,,,,,,66794001525,NDC,250,ML,589.56,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,244.903224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Fac/Ex Skinbngn0.6-1cmtrnk,Arm,Lg",PX11401F,CDM,510,RC,11401,CPT,,,,,,,,484,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,244.904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.0536,474.32
"Fac/Exc Skn Benig<5mm Face,Facial",PX11440F,CDM,510,RC,11440,CPT,,,,,,,,484,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,244.904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.0536,614.65
"Facility Critical Care, Addl 30 Min",PX99292F,CDM,510,RC,99292,CPT,,,,,,,,484,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,244.904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.0536,474.32
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,63323076350,NDC,50,ML,589.57,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,244.907378,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600110,NDC,10,ML,589.63,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,244.932302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
cefdinir 250 MG/5ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,16714039301,NDC,60,ML,510.33,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,244.9584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cefdinir 250 MG/5ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,16714039301,NDC,60,ML,510.33,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,244.9584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
butamben-tetracaine-benzocaine 2-2-14 % Aerosol 20 g Bottle,25000000,CDM,250,RC,,,,,,10223020103,NDC,20,GR,589.76,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,244.986304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153P,CDM,983,RC,99153,CPT,,,,,,,,250,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,245,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.98,245
Sigmoidoscope W/Submuc Inj,PX45335P,CDM,983,RC,45335,CPT,,,,,,,,500,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,207.7,798.45
Sigmoidoscope W/Submuc Inj,PX45335P,CDM,983,RC,45335,CPT,,,,,,,,500,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,207.7,798.45
Sigmoidoscope W/Submuc Inj,PX45335P,CDM,983,RC,45335,CPT,,,,,,,,500,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,207.7,798.45
sincalide 5 MCG Recon Soln 1 Each Vial,J2805.01,CDM,636,RC,J2805,HCPCS,,,,270055615,NDC,1,EA,250,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.85,245
Withdrawal of Arterial Blood,PX36600F,CDM,510,RC,36600,CPT,,,,,,,,250,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.85,245
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725F,CDM,510,RC,26725,CPT,,,,,,,,495,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,245.025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.623,485.1
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101F,CDM,510,RC,13101,CPT,,,,,,,,495,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,245.025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.623,548.67
Tc99 Mebrofenin to 15 Mci,PXA9537,CDM,343,RC,A9537,HCPCS,,,,,,,,495,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,245.025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.623,485.1
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821517,NDC,3,ML,275.33,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,245.0437,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
NEEDLE INTRAOSSEOUS 15GA 15MM EZ-IO PEDS 9018,120.89,CDM,272,RC,A4215,HCPCS,,4964-MAIN,LOCAL,,,,,269,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,245.059,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.7426,263.62
CT Soft Tissue Neck W/Dye,PX7049101,CDM,350,RC,70491,CPT,TC,,,,,,,3415,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,245.21,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.9,245.21
CT Soft Tissue Neck W/Dye,PX7049101,CDM,350,RC,70491,CPT,TC,,,,,,,3415,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,245.21,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.9,245.21
"Inject Trigger Point, 1 or 2",PX20552F,CDM,510,RC,20552,CPT,,,,,,,,252,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,245.2716,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,258.75
"Level V - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3939,CDM,310,RC,88307,CPT,TC,,,,,,,252,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,245.2716,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,314.02
"Off/Outpt Visit,New,Levl III",PX99203P,CDM,983,RC,99203,CPT,,,,,,,,252,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,164.1716667,percent of total billed charges,245.2716,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,245.2716
"Office/Outpt Visit,New,Levl III",PX99203F,CDM,510,RC,99203,CPT,,,,,,,,252,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,164.1716667,percent of total billed charges,245.2716,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,246.96
diclofenac 0.1 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,17478089225,NDC,2.5,ML,252.06,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,245.329998,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
MESH LARGE LEFT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 4X6,120.521,CDM,278,RC,C1781,HCPCS,,12215-MAIN,LOCAL,,,,,572,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,245.388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,237.6088,560.56
MESH LARGE RIGHT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 4X6,C1781,CDM,278,RC,C1781,HCPCS,,12195-MAIN,LOCAL,,,,,572,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,245.388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Remove Nasal Foreign Body,PX30300P,CDM,983,RC,30300,CPT,,,,,,,,572,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,245.388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,556.7276
Exc Skn Beni 0.6-1cm Fcefacial,PX11441P,CDM,983,RC,11441,CPT,,,,,,,,485,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,245.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.469,614.65
atropine 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,17478021502,NDC,2,ML,269.45,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,245.46895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
atropine 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,60219174802,NDC,2,ML,269.45,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,245.46895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BRACE WRIST 8-IN SM LEFT 10432,120.564,CDM,273,RC,L3809,HCPCS,,12720-MAIN,LOCAL,,,,,23,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,245.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 8-IN SM RIGHT 10442,120.564,CDM,273,RC,L3809,HCPCS,,12716-MAIN,LOCAL,,,,,23,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,245.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN LG RIGHT 10464,120.564,CDM,273,RC,L3809,HCPCS,,12719-MAIN,LOCAL,,,,,23,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,245.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN SM LEFT 617083,120.564,CDM,273,RC,L3809,HCPCS,,12722-MAIN,LOCAL,,,,,23,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,245.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN SM RIGHT 10462,120.564,CDM,273,RC,L3809,HCPCS,,12717-MAIN,LOCAL,,,,,23,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,245.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN XL LEFT 10455,120.564,CDM,273,RC,L3809,HCPCS,,12721-MAIN,LOCAL,,,,,23,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,245.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST 10-IN XL RIGHT 10465,120.564,CDM,273,RC,L3809,HCPCS,,12715-MAIN,LOCAL,,,,,23,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,245.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST HAND THUMB LEFT 455-LT,120.315,CDM,274,RC,L3809,HCPCS,,8283-MAIN,LOCAL,,,,,77,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,245.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.9858,245.51
BRACE WRIST HAND THUMB RIGHT 455-RT,120.315,CDM,274,RC,L3809,HCPCS,,8284-MAIN,LOCAL,,,,,77,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,245.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.9858,245.51
BRACE WRIST WRISTPRO LEFT 10-IN LG,120.564,CDM,273,RC,L3809,HCPCS,,12724-MAIN,LOCAL,,,,,23,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,245.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
BRACE WRIST WRISTPRO LEFT 10-IN MED,120.564,CDM,273,RC,L3809,HCPCS,,12723-MAIN,LOCAL,,,,,23,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,245.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.5542,245.51
SPLINT WRIST LARGE ALUMINUM FOREARM LEFT 9101-06,120.87,CDM,274,RC,L3809,HCPCS,,1265-MAIN,LOCAL,,,,,130,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,245.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST LARGE ALUMINUM FOREARM RIGHT 9101-03,120.87,CDM,274,RC,L3809,HCPCS,,1263-MAIN,LOCAL,,,,,130,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,245.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST MEDIUM ALUMINUM FOREARM LEFT 9101-05,120.87,CDM,274,RC,L3809,HCPCS,,1264-MAIN,LOCAL,,,,,130,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,245.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
SPLINT WRIST MEDIUM ALUMINUM FOREARM RIGHT 9101-02,120.87,CDM,274,RC,L3809,HCPCS,,1262-MAIN,LOCAL,,,,,130,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,245.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,54.002,245.51
ADVANCED INSTRUMENTS ENDOWRIST SUCTION IRRIGATOR,27200000,CDM,272,RC,,,,11922-MAIN,LOCAL,,,,,496,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,245.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LOCKING SCREW T8 FULL THREAD 2.4MM L10MM,C1713,CDM,278,RC,C1713,HCPCS,,12637-MAIN,LOCAL,,,,,496,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,245.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LOCKING SCREW T8 FULL THREAD 2.4MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12651-MAIN,LOCAL,,,,,496,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,245.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LOCKING SCREW T8 FULL THREAD 2.7MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12638-MAIN,LOCAL,,,,,496,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,245.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LOCKING SCREW T8 FULL THREAD 2.7MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12639-MAIN,LOCAL,,,,,496,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,245.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"MRI,Up Ext,No Jnt,No Cont",PX7321801,CDM,610,RC,73218,CPT,TC,,,,,,,3253,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,245.5334,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,156.41,490.42
Culture Screen Only,PX87081,CDM,300,RC,87081,CPT,,,,,,,,276,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,245.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.08,270.48
BONE SCREW T8 FULL THREAD 2.4MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12652-MAIN,LOCAL,,,,,289,,First Health,Commercial,both,85,,999999999,percent of total billed charges,245.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
BONE SCREW T8 FULL THREAD 2.4MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12653-MAIN,LOCAL,,,,,289,,First Health,Commercial,both,85,,999999999,percent of total billed charges,245.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
BONE SCREW T8 FULL THREAD 2.7MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12654-MAIN,LOCAL,,,,,289,,First Health,Commercial,both,85,,999999999,percent of total billed charges,245.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Occupational Therapy Eval High Complex,PX97167,CDM,434,RC,97167,CPT,,,,,,,,289,,First Health,Commercial,both,85,,999999999,percent of total billed charges,245.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,283.22
"Troponin, Quantitative",PX84484,CDM,300,RC,84484,CPT,,,,,,,,289,,First Health,Commercial,both,85,,999999999,percent of total billed charges,245.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.43,283.22
DRIVER HEX 2.00MM STERILE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12440-MAIN,LOCAL,,,,,512,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,245.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRIVER HEX 2.00MM STERILE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12440-MAIN,LOCAL,,,,,512,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,245.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRIVER HEX 2.5MM STERILE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12441-MAIN,LOCAL,,,,,512,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,245.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRIVER HEX 2.5MM STERILE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12441-MAIN,LOCAL,,,,,512,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,245.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Inpatient Consult, Level IV",PX99254,CDM,983,RC,99254,CPT,,,,,,,,508,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,245.78,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.73,497.84
"Inpatient Consult, Level IV",PX99254,CDM,983,RC,99254,CPT,,,,,,,,508,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,245.78,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.73,497.84
ARTISTA AH 3GRAM ABSORBABLE HEMOSTATIC PARTICLES,27200000,CDM,272,RC,A6199,HCPCS,,10227-MAIN,LOCAL,,,,,486,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,245.916,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002P,CDM,983,RC,12002,CPT,,,,,,,,486,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,245.916,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,473.0238
Xray Sinuses Less Than 3 Vws,PX7021001,CDM,320,RC,70210,CPT,TC,,,,,,,486,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,245.916,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,476.28
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,23155052431,NDC,10,ML,486.06,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,245.94636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,23155052441,NDC,10,ML,486.06,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,245.94636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Exc Face Les Sc < 2 Cm,PX21011F,CDM,510,RC,21011,CPT,,,,,,,,943,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,245.9626,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,164.48,781.73
Exc Face Les Sc < 2 Cm,PX21011P,CDM,983,RC,21011,CPT,,,,,,,,628,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,245.9626,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,164.48,781.73
"Closed Rx Radial Head Disloc,Child",PX24640F,CDM,510,RC,24640,CPT,,,,,,,,270,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,245.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.158,264.6
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157F,CDM,370,RC,99157,CPT,,,,,,,,270,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,245.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.158,264.6
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157P,CDM,983,RC,99157,CPT,,,,,,,,270,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,245.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.158,262.791
Wound Culture Anaerobic,PX87075,CDM,300,RC,87075,CPT,,,,,,,,270,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,245.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.68,264.6
"Chemotherapy, IV Push, Single Drug",PX96409,CDM,335,RC,96409,CPT,,,,,,,,502,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,245.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.5308,491.96
"Chemotherapy, IV Push, Single Drug",PX96409,CDM,335,RC,96409,CPT,,,,,,,,502,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,245.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.5308,491.96
"Chemotherapy, IV Push, Single Drug",PX96409,CDM,335,RC,96409,CPT,,,,,,,,502,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,245.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.5308,491.96
Incise External Hemorrhoid,PX46083F,CDM,510,RC,46083,CPT,,,,,,,,502,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,245.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.5308,491.96
Incise External Hemorrhoid,PX46083F,CDM,510,RC,46083,CPT,,,,,,,,502,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,245.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.5308,491.96
Incise External Hemorrhoid,PX46083F,CDM,510,RC,46083,CPT,,,,,,,,502,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,245.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.5308,491.96
Cpap/Bipap Mgmnt-Pt Own Equipment,PX94660.02F,CDM,410,RC,94660,CPT,,,,,,,,497,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,246.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.33,487.06
"Treat Thumb Disloc,Manipulatn",PX26641F,CDM,510,RC,26641,CPT,,,,,,,,1721,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,246.07,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.07,905.57
"Treat Thumb Disloc,Manipulatn",PX26641P,CDM,983,RC,26641,CPT,,,,,,,,1902,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,246.07,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.07,1863.96
"Hla Class II Low Res, 1 Locus - Ref",PX8137690,CDM,310,RC,81376,CPT,90,,,,,,,279,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,246.078,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.06,273.42
INSUFLOWPORT & PNEUVIEW  XE SMOKE ELIMINATOR 5MM,27200000,CDM,272,RC,,,,11876-MAIN,LOCAL,,,,,279,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,246.078,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 8MM,27200000,CDM,272,RC,,,,11877-MAIN,LOCAL,,,,,279,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,246.078,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 10MM,27200000,CDM,272,RC,,,,11878-MAIN,LOCAL,,,,,279,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,246.078,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 12MM,27200000,CDM,272,RC,,,,11879-MAIN,LOCAL,,,,,279,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,246.078,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 5MM,27200000,CDM,272,RC,,,,11880-MAIN,LOCAL,,,,,279,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,246.078,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 8MM,27200000,CDM,272,RC,,,,11881-MAIN,LOCAL,,,,,279,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,246.078,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 10MM,27200000,CDM,272,RC,,,,11882-MAIN,LOCAL,,,,,279,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,246.078,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 12MM,27200000,CDM,272,RC,,,,11883-MAIN,LOCAL,,,,,279,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,246.078,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Puncture Drainage of Lesion,PX10160F,CDM,510,RC,10160,CPT,,,,,,,,279,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,246.078,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.8966,348.35
Xray Pelvis 1 or 2 Vws,PX7217001,CDM,320,RC,72170,CPT,TC,,,,,,,279,,United Healthcare,All Payer,outpatient,88.2,,196.86,percent of total billed charges,246.078,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,273.42
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,55111069407,NDC,5,ML,592.4,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,246.08296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.08296,1009.1158
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600121,NDC,10,ML,592.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,246.1245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
Lvl 2 Sub Hosp Mod Mdm or 35 Minute,PX99232,CDM,982,RC,99232,CPT,,,,,,,,253,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,246.2449,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.0962,246.2449
MESH FLAT SHEET SOFT 3X6 INCH,C1781,CDM,278,RC,C1781,HCPCS,,11773-MAIN,LOCAL,,,,,253,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1256.29,percent of total billed charges,246.2449,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Subsequent Observation Care,PX99225,CDM,982,RC,99225,CPT,,,,,,,,253,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,246.2449,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.0962,246.2449
Tap Block Unilateral by Injection(S),PX64486F,CDM,510,RC,64486,CPT,,,,,,,,253,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,246.2449,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.0962,247.94
"Sigmoidoscopy,Remv Lesn,Snare",PX45338F,CDM,510,RC,45338,CPT,,,,,,,,2137,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,246.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.52,620.54
"Sigmoidoscopy,Remv Lesn,Snare",PX45338P,CDM,983,RC,45338,CPT,,,,,,,,1710,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,246.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.52,1675.8
HERCULES 3 STAGE BALLOON ESOPHAGEAL 12-13.5-15::36-40.5-45MM,27200000,CDM,272,RC,C1726,HCPCS,,11329-MAIN,LOCAL,,,,,289.85,,First Health,Commercial,both,85,,999999999,percent of total billed charges,246.3725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HERCULES 3 STAGE BALLOON ESOPHAGEAL 15-16.5-18:45-49.5-54MM,27200000,CDM,272,RC,C1726,HCPCS,,11328-MAIN,LOCAL,,,,,289.85,,First Health,Commercial,both,85,,999999999,percent of total billed charges,246.3725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HERCULES 3 STAGE BALLOON ESOPHAGEAL 18-19-20::54-57-60MM,27200000,CDM,272,RC,C1726,HCPCS,,11330-MAIN,LOCAL,,,,,289.85,,First Health,Commercial,both,85,,999999999,percent of total billed charges,246.3725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004004,NDC,120,ML,502.95,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,246.4455,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004004,NDC,120,ML,502.95,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,246.4455,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004004,NDC,120,ML,502.95,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,246.4455,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
Trb@ Gene Rearrange Amplify - Ref,PX8134090,CDM,300,RC,81340,CPT,90,,,,,,,503,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,246.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,191.56,492.94
Trb@ Gene Rearrange Amplify - Ref,PX8134090,CDM,300,RC,81340,CPT,90,,,,,,,503,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,246.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,191.56,492.94
Trb@ Gene Rearrange Amplify - Ref,PX8134090,CDM,300,RC,81340,CPT,90,,,,,,,503,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,246.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,191.56,492.94
Apply Long Arm Splint,PX29105F,CDM,510,RC,29105,CPT,,,,,,,,290,,First Health,Commercial,both,85,,999999999,percent of total billed charges,246.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.466,284.2
Assay of Digoxin,PX80162,CDM,300,RC,80162,CPT,,,,,,,,290,,First Health,Commercial,both,85,,999999999,percent of total billed charges,246.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.18,284.2
Assay of Natriuretic Peptide,PX83880,CDM,300,RC,83880,CPT,,,,,,,,290,,First Health,Commercial,both,85,,999999999,percent of total billed charges,246.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36,284.2
NEEDLE INTRAOSSEOUS SET 15GA 25MM STABILIZER EZ-IO 9001P,120.216,CDM,272,RC,A4215,HCPCS,,10648-MAIN,LOCAL,,,,,290,,First Health,Commercial,both,85,,999999999,percent of total billed charges,246.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.466,284.2
NEEDLE INTRAOSSEOUS SET 15GA 45MM STABILIZER EZ-IO 9079P,120.216,CDM,272,RC,A4215,HCPCS,,10297-MAIN,LOCAL,,,,,290,,First Health,Commercial,both,85,,999999999,percent of total billed charges,246.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.466,284.2
"Closed Rx Dist Fibula Fx,Manip",PX27788F,CDM,510,RC,27788,CPT,,,,,,,,1597,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,246.51,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.51,915.25
"Closed Rx Dist Fibula Fx,Manip",PX27788P,CDM,983,RC,27788,CPT,,,,,,,,1277,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,246.51,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.51,1251.46
Gastric Intubation Treatment,PX43753P,CDM,983,RC,43753,CPT,,,,,,,,498,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,246.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.8692,484.7034
"POS Airway Pressure, Cpap",PX94660F,CDM,410,RC,94660,CPT,,,,,,,,498,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,246.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.33,488.04
"Molecular Cytog, Ea Probe - Ref",PX8827190,CDM,310,RC,88271,CPT,90,,,,,,,277,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,246.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.64,271.46
"Xray Neck, Soft Tissue",PX7036001,CDM,320,RC,70360,CPT,TC,,,,,,,277,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,246.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,271.46
lidocaine - transparent dressing 4 % Kit 1 Each Box,63700001,CDM,250,RC,,,,,,496088207,NDC,1,EA,270.63,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,246.54393,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,61314054701,NDC,2.5,ML,487.35,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,246.5991,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"DXA, Bone Density Study, Hips/Pelv/Spine",PX7708001,CDM,320,RC,77080,CPT,TC,,,,,,,575,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,246.675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,563.5
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,121090204,NDC,120,ML,503.56,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,246.7444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,121090204,NDC,120,ML,503.56,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,246.7444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,121090204,NDC,120,ML,503.56,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,246.7444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
Strapping of Ankle,PX29540F,CDM,420,RC,29540,CPT,,,,,,,,271,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,246.881,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.5734,265.58
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022101,NDC,1,EA,514.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,246.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022101,NDC,1,EA,514.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,246.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022185,NDC,1,EA,514.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,246.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022185,NDC,1,EA,514.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,246.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022189,NDC,1,EA,514.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,246.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022189,NDC,1,EA,514.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,246.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
"Inject Trigger Point, 1 or 2",PX20552F,CDM,510,RC,20552,CPT,,,,,,,,252,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,246.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,258.75
"Level V - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3939,CDM,310,RC,88307,CPT,TC,,,,,,,252,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,246.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,314.02
"Off/Outpt Visit,New,Levl III",PX99203P,CDM,983,RC,99203,CPT,,,,,,,,252,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,246.96,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.07,246.96
"Office/Outpt Visit,New,Levl III",PX99203F,CDM,510,RC,99203,CPT,,,,,,,,252,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,246.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,246.96
"Pertechnetate, Dia, per Mci",PXA9512,CDM,343,RC,A9512,HCPCS,,,,,,,,280,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,246.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,116.312,274.4
Drainage of Hematoma/Fluid (P),PX10140P,CDM,983,RC,10140,CPT,,,,,,,,465,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,246.97,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.17,455.7
Drainage of Hematoma/Fluid (T),PX10140F,CDM,510,RC,10140,CPT,,,,,,,,341,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,246.97,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.17,354.2
Facility Emergency Level 1 Visit,PX99281F,CDM,450,RC,99281,CPT,,,,,,,,329,,Medica,Minnesota Health care Program (MHCP),outpatient,,,999999999,case rate,247,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247,6141.46
diclofenac 0.1 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,17478089225,NDC,2.5,ML,252.06,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,247.0188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
megestrol 40 MG/ML Suspension 240 mL Bottle,25000000,CDM,250,RC,,,,,,49884090738,NDC,240,ML,594.72,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,247.046688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Suspension 10 mL Bottle,63700001,CDM,250,RC,,,,,,64980044801,NDC,10,ML,488.25,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,247.0545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133F,CDM,510,RC,13133,CPT,,,,,,,,595,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,247.163,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247.163,583.1
"Thrombolysis,Coronary,IV Infusn",PX92977F,CDM,480,RC,92977,CPT,,,,,,,,595,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,247.163,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247.163,583.1
"Thrombolytic Therapy, Stroke",PX37195F,CDM,761,RC,37195,CPT,,,,,,,,595,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,247.163,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247.163,583.1
Thyrstim Immun Glob (Tsi) - Ref,PX8444590,CDM,300,RC,84445,CPT,90,,,,,,,254,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,247.2182,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.63,248.92
Exc Skin Benig >4cm Remaindr Body,PX11426F,CDM,510,RC,11426,CPT,,,,,,,,1227,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,247.247,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.1,684.19
Exc Skin Benig >4cm Remaindr Body,PX11426P,CDM,983,RC,11426,CPT,,,,,,,,981,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,247.247,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.1,961.38
Drain/Inject Large Joint/Bursa,PX20610P,CDM,983,RC,20610,CPT,,,,,,,,291,,First Health,Commercial,both,85,,999999999,percent of total billed charges,247.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.8814,283.2303
MINIBUNION NON-LOCKING SCREW  2.7X18MM,C1713,CDM,278,RC,C1713,HCPCS,,11670-MAIN,LOCAL,,,,,280.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,247.401,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Diagnostic Anoscopy,PX46600F,CDM,510,RC,46600,CPT,,,,,,,,505,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,247.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,494.9
Diagnostic Anoscopy,PX46600F,CDM,510,RC,46600,CPT,,,,,,,,505,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,247.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,494.9
Diagnostic Anoscopy,PX46600F,CDM,510,RC,46600,CPT,,,,,,,,505,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,247.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,494.9
Sigmoidoscope W/Submuc Inj,PX45335P,CDM,983,RC,45335,CPT,,,,,,,,500,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,247.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,207.7,798.45
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800F,CDM,510,RC,40800,CPT,,,,,,,,255,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,247.66,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.35,420.61
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800P,CDM,983,RC,40800,CPT,,,,,,,,170,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,247.66,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.35,420.61
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409421505,NDC,5,ML,271.86,,Medica,Commercial,both,91.1,,51.072,percent of total billed charges,247.66446,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
Trg Gene Rearrangement Anal - Ref,PX8134290,CDM,300,RC,81342,CPT,90,,,,,,,516,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,247.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,184.76,505.68
Trg Gene Rearrangement Anal - Ref,PX8134290,CDM,300,RC,81342,CPT,90,,,,,,,516,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,247.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,184.76,505.68
calcitonin (salmon) 200 UNIT/ACT Solution 3.7 mL Bottle,63700001,CDM,250,RC,,,,,,60505082306,NDC,3.7,ML,489.57,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,247.72242,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
methylPREDNISolone sod succ 1000 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9001820,NDC,1,EA,271.97,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,247.76467,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611P,CDM,983,RC,20611,CPT,,,,,,,,272,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,247.792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.9888,264.7376
8MM ENDOWRIST INSTRUMENTS CADIERE FORCEPS,27200000,CDM,272,RC,,,,11913-MAIN,LOCAL,,,,,281,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,247.842,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
FORCEPS PROGRASP 8MM ENDOWRIST INSTRUMENTS,27200000,CDM,272,RC,,,,12062-MAIN,LOCAL,,,,,281,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,247.842,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Spirometry,PX9401001,CDM,460,RC,94010,CPT,TC,,,,,,,281,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,247.842,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,116.7274,275.38
Lvl 2 Sub Hosp Mod Mdm or 35 Minute,PX99232,CDM,982,RC,99232,CPT,,,,,,,,253,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,247.94,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.54,247.94
MESH FLAT SHEET SOFT 3X6 INCH,C1781,CDM,278,RC,C1781,HCPCS,,11773-MAIN,LOCAL,,,,,253,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,247.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Subsequent Observation Care,PX99225,CDM,982,RC,99225,CPT,,,,,,,,253,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,247.94,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.32,247.94
Tap Block Unilateral by Injection(S),PX64486F,CDM,510,RC,64486,CPT,,,,,,,,253,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,247.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.0962,247.94
Xray Knee 4 or More Vws,PX7356401,CDM,320,RC,73564,CPT,TC,,,,,,,490,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,247.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,480.2
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,65162083366,NDC,100,GR,281.12,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,247.94784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Fluoroscope Examination Tc,PX7600001,CDM,320,RC,76000,CPT,TC,,,,,,,597,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,247.9938,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,585.06
dorzolamide-timolol 2-0.5 % Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,50383023310,NDC,10,ML,506.34,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,248.1066,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dorzolamide-timolol 2-0.5 % Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,50383023310,NDC,10,ML,506.34,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,248.1066,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dorzolamide-timolol 2-0.5 % Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,50383023310,NDC,10,ML,506.34,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,248.1066,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012365,NDC,0.7,ML,291.98,,First Health,Commercial,both,85,,999999999,percent of total billed charges,248.183,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012388,NDC,0.7,ML,291.98,,First Health,Commercial,both,85,,999999999,percent of total billed charges,248.183,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072310,NDC,0.5,ML,291.98,,First Health,Commercial,both,85,,999999999,percent of total billed charges,248.183,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072388,NDC,0.5,ML,291.98,,First Health,Commercial,both,85,,999999999,percent of total billed charges,248.183,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800F,CDM,510,RC,40800,CPT,,,,,,,,255,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,248.1915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.927,614.65
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106F,CDM,510,RC,11106,CPT,,,,,,,,255,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,248.1915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.927,548.67
"Inject Nerv Blck,Trigeminal",PX64400F,CDM,510,RC,64400,CPT,,,,,,,,255,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,248.1915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.927,258.75
"Urinalysis, Auto, W/Scope",PX81001,CDM,300,RC,81001,CPT,,,,,,,,255,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,94.95463768,percent of total billed charges,248.1915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.91,249.9
gentamicin 0.1 % Ointment 30 g Tube,25000000,CDM,250,RC,,,,,,713068231,NDC,30,GR,506.64,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,248.2536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
gentamicin 0.1 % Ointment 30 g Tube,25000000,CDM,250,RC,,,,,,713068231,NDC,30,GR,506.64,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,248.2536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
gentamicin 0.1 % Ointment 30 g Tube,25000000,CDM,250,RC,,,,,,713068231,NDC,30,GR,506.64,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,248.2536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Hla Class II Low Res, 1 Locus - Ref",PX8137690,CDM,310,RC,81376,CPT,90,,,,,,,279,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,248.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.06,273.42
INSUFLOWPORT & PNEUVIEW  XE SMOKE ELIMINATOR 5MM,27200000,CDM,272,RC,,,,11876-MAIN,LOCAL,,,,,279,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,248.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 8MM,27200000,CDM,272,RC,,,,11877-MAIN,LOCAL,,,,,279,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,248.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 10MM,27200000,CDM,272,RC,,,,11878-MAIN,LOCAL,,,,,279,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,248.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 12MM,27200000,CDM,272,RC,,,,11879-MAIN,LOCAL,,,,,279,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,248.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 5MM,27200000,CDM,272,RC,,,,11880-MAIN,LOCAL,,,,,279,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,248.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 8MM,27200000,CDM,272,RC,,,,11881-MAIN,LOCAL,,,,,279,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,248.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 10MM,27200000,CDM,272,RC,,,,11882-MAIN,LOCAL,,,,,279,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,248.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 12MM,27200000,CDM,272,RC,,,,11883-MAIN,LOCAL,,,,,279,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,248.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Puncture Drainage of Lesion,PX10160F,CDM,510,RC,10160,CPT,,,,,,,,279,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,248.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.8966,348.35
Xray Pelvis 1 or 2 Vws,PX7217001,CDM,320,RC,72170,CPT,TC,,,,,,,279,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,248.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,273.42
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221901,NDC,3,ML,506.9,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,3.1136,percent of total billed charges,248.381,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221901,NDC,3,ML,506.9,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,248.381,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221901,NDC,3,ML,506.9,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,248.381,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221905,NDC,3,ML,506.9,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,3.1136,percent of total billed charges,248.381,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221905,NDC,3,ML,506.9,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,248.381,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221905,NDC,3,ML,506.9,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,248.381,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476881,NDC,50,ML,579.12,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,248.44248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
ipratropium 0.06 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,54004641,NDC,15,ML,491.02,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,248.45612,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Chemotherapy, IV Push, Single Drug",PX96409,CDM,335,RC,96409,CPT,,,,,,,,502,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,248.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.5308,491.96
Incise External Hemorrhoid,PX46083F,CDM,510,RC,46083,CPT,,,,,,,,502,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,248.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.5308,491.96
"Blood Gases: Ph, Po2 & Pco2",PX82803,CDM,300,RC,82803,CPT,,,,,,,,518,,Health Partners,Health Partners Care Plans,both,48,,240.17,percent of total billed charges,248.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.9,507.64
"Blood Gases: Ph, Po2 & Pco2",PX82803,CDM,300,RC,82803,CPT,,,,,,,,518,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,248.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.9,507.64
Xray Finger(S) Tc,PX7314001,CDM,320,RC,73140,CPT,TC,,,,,,,282,,United Healthcare,All Payer,outpatient,88.2,,171.835,percent of total billed charges,248.724,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,276.36
Xray Toe(S) Tc,PX7366001,CDM,320,RC,73660,CPT,TC,,,,,,,282,,United Healthcare,All Payer,outpatient,88.2,,138.18,percent of total billed charges,248.724,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,276.36
Leukoreduced Rbc's,PXP9016,CDM,390,RC,P9016,HCPCS,,,,,,,,580,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,248.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,165.79,568.4
fat emulsion 20 % Emulsion 250 mL Flex Cont,25000000,CDM,250,RC,,,,,,338051909,NDC,250,ML,292.75,,First Health,Commercial,both,85,,999999999,percent of total billed charges,248.8375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
nystatin 100000 UNIT/GM Powder 60 g Bottle,63700001,CDM,250,RC,,,,,,574200802,NDC,60,GR,491.86,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,248.88116,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Inpatient Consult, Level IV",PX99254,CDM,983,RC,99254,CPT,,,,,,,,508,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,248.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.0232,494.4364
"Inpatient Consult, Level IV",PX99254,CDM,983,RC,99254,CPT,,,,,,,,508,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,248.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.0232,494.4364
"Inpatient Consult, Level IV",PX99254,CDM,983,RC,99254,CPT,,,,,,,,508,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,248.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.0232,494.4364
Lvl 2 Init Hosp Mod Mdm or 55 Minutes,PX99222,CDM,982,RC,99222,CPT,,,,,,,,508,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,248.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.0232,494.4364
Lvl 2 Init Hosp Mod Mdm or 55 Minutes,PX99222,CDM,982,RC,99222,CPT,,,,,,,,508,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,248.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.0232,494.4364
Lvl 2 Init Hosp Mod Mdm or 55 Minutes,PX99222,CDM,982,RC,99222,CPT,,,,,,,,508,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,248.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.0232,494.4364
Thyrstim Immun Glob (Tsi) - Ref,PX8444590,CDM,300,RC,84445,CPT,90,,,,,,,254,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,248.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.63,248.92
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762F,CDM,510,RC,43762,CPT,,,,,,,,492,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,248.952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,204.3768,482.16
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004004,NDC,120,ML,502.95,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,248.96025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
Trb@ Gene Rearrange Amplify - Ref,PX8134090,CDM,300,RC,81340,CPT,90,,,,,,,503,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,248.985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,191.56,492.94
"Digital Mamm, Diag, Unilat, Tc W/Cad Perf",PX7706501,CDM,401,RC,77065,CPT,TC,,,,,,,293,,First Health,Commercial,both,85,,999999999,percent of total billed charges,249.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.46,287.14
Drain Skin Abscess Simple,PX10060P,CDM,983,RC,10060,CPT,,,,,,,,293,,First Health,Commercial,both,85,,999999999,percent of total billed charges,249.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.7122,285.1769
Kit Gene Analysis D816 Variant(S) - Ref,PX8127390,CDM,300,RC,81273,CPT,90,,,,,,,293,,First Health,Commercial,both,85,,999999999,percent of total billed charges,249.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,114.49,287.14
Repr Superf Wnd Body <2.5cm,PX12001P,CDM,983,RC,12001,CPT,,,,,,,,293,,First Health,Commercial,both,85,,999999999,percent of total billed charges,249.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.7122,285.1769
umeclidinium 62.5 MCG/ACT Aerosol Powder Breath Activated 7 Each Disp Pack,63700001,CDM,250,RC,,,,,,173087306,NDC,7,EA,492.23,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,249.06838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Xray Ac Joints(Bilateral),PX7305001,CDM,320,RC,73050,CPT,TC,,,,,,,519,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,249.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,508.62
Xray Ac Joints(Bilateral),PX7305001,CDM,320,RC,73050,CPT,TC,,,,,,,519,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,249.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,508.62
MRI T Spine WO Contrast,PX7214601,CDM,610,RC,72146,CPT,TC,,,,,,,3267,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,249.15,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.42,249.15
MRI T Spine WO Contrast,PX7214601,CDM,610,RC,72146,CPT,TC,,,,,,,3267,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,249.15,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.42,249.15
"Office/Outpt Visit,Est,Levl IV",PX99214F,CDM,510,RC,99214,CPT,,,,,,,,256,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,125.6914286,percent of total billed charges,249.1648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.3424,250.88
"Office/Outpt Visit,Est,Levl IV",PX99214P,CDM,983,RC,99214,CPT,,,,,,,,256,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,125.6914286,percent of total billed charges,249.1648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.3424,249.1648
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133P,CDM,983,RC,13133,CPT,,,,,,,,256,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,249.1648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.3424,249.1648
"Pertechnetate, Dia, per Mci",PXA9512,CDM,343,RC,A9512,HCPCS,,,,,,,,280,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,249.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,116.312,274.4
DRILL BIT 2.2MM LONG SOLID STERILE MICA,27200000,CDM,272,RC,,,,12985-MAIN,LOCAL,,,,,600,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,249.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404P,CDM,983,RC,11404,CPT,,,,,,,,600,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,249.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,249.24,1416.38
Extremity Study - Vascular Diagnostics,PX9392201,CDM,921,RC,93922,CPT,TC,,,,,,,600,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,249.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,588
Emergency Level III Visit,PX99283P,CDM,981,RC,99283,CPT,,,,,,,,568,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,249.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,235.9472,552.8344
Facility Emergency Level III Visit,PX99283F,CDM,450,RC,99283,CPT,,,,,,,,587,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,249.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,243.8398,575.26
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,121090204,NDC,120,ML,503.56,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,249.2622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
Exs Tumor Arm/Elbow Sc 3cm>,PX24071F,CDM,510,RC,24071,CPT,,,,,,,,1860,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,249.34,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,249.34,852.3
Acute Hepatitis Panel,PX80074,CDM,300,RC,80074,CPT,,,,,,,,509,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,249.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,43.67,498.82
Acute Hepatitis Panel,PX80074,CDM,300,RC,80074,CPT,,,,,,,,509,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,249.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,43.67,498.82
Acute Hepatitis Panel,PX80074,CDM,300,RC,80074,CPT,,,,,,,,509,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,249.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,43.67,498.82
Biopsy of Rectum,PX45100P,CDM,983,RC,45100,CPT,,,,,,,,509,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,249.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.4386,2452.93
Biopsy of Rectum,PX45100P,CDM,983,RC,45100,CPT,,,,,,,,509,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,249.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.4386,2452.93
Biopsy of Rectum,PX45100P,CDM,983,RC,45100,CPT,,,,,,,,509,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,249.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.4386,2452.93
STAPLER RELOAD-CURVED CUTTER,27200000,CDM,272,RC,,,,12063-MAIN,LOCAL,,,,,283,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,249.606,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597P,CDM,983,RC,97597,CPT,,,,,,,,274,,Medica,Commercial,both,91.1,,53.2,percent of total billed charges,249.614,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,113.8196,266.6842
MINIBUNION NON-LOCKING SCREW  2.7X18MM,C1713,CDM,278,RC,C1713,HCPCS,,11670-MAIN,LOCAL,,,,,280.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,249.645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"Hospital Inpt or Obs Care, Admin/Disch Same Date, Moderate Level Mdm >= 70 Minutes",PX99235,CDM,982,RC,99235,CPT,,,,,,,,582,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,249.678,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,241.7628,566.4606
MRI C-Spine WO Contrast,PX7214101,CDM,610,RC,72141,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,249.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.64,249.81
MRI C-Spine WO Contrast,PX7214101,CDM,610,RC,72141,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,249.81,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.64,249.81
Assay Thyroid Stim Hormone,PX84443,CDM,300,RC,84443,CPT,,,,,,,,294,,First Health,Commercial,both,85,,999999999,percent of total billed charges,249.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.4,288.12
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800F,CDM,510,RC,40800,CPT,,,,,,,,255,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,249.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.927,614.65
Francisella Tularensis Ab,PX8666890,CDM,300,RC,86668,CPT,90,,,,,,,294,,First Health,Commercial,both,85,,999999999,percent of total billed charges,249.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.98,288.12
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106F,CDM,510,RC,11106,CPT,,,,,,,,255,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,249.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.927,548.67
"Inject Nerv Blck,Trigeminal",PX64400F,CDM,510,RC,64400,CPT,,,,,,,,255,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,249.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.927,258.75
Physical Therapy Evaluation High Complex,PX97163,CDM,424,RC,97163,CPT,,,,,,,,294,,First Health,Commercial,both,85,,999999999,percent of total billed charges,249.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,288.12
"Urinalysis, Auto, W/Scope",PX81001,CDM,300,RC,81001,CPT,,,,,,,,255,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,249.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.91,249.9
ammonium lactate 12 % Cream 385 g Tube,63700001,CDM,250,RC,,,,,,45802049326,NDC,385,GR,256.76,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,249.904508,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CRICOTHROTOMY QUICKTRACH 4MM,120.228,CDM,272,RC,A7520,HCPCS,,8868-MAIN,LOCAL,,,,,494,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,249.964,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.2076,484.12
SET CRICOTHYROTOMY CATHETER 6MM ID,120.378,CDM,272,RC,,,,11119-MAIN,LOCAL,,,,,494,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,249.964,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.2076,484.12
Diagnostic Anoscopy,PX46600F,CDM,510,RC,46600,CPT,,,,,,,,505,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,249.975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,494.9
ipratropium 0.03 % Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,24208039830,NDC,30,ML,256.9,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,250.04077,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cefdinir 250 MG/5ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,16714039301,NDC,60,ML,510.33,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,250.0617,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cefdinir 250 MG/5ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,16714039301,NDC,60,ML,510.33,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,250.0617,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cefdinir 250 MG/5ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,16714039301,NDC,60,ML,510.33,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,250.0617,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
8MM ENDOWRIST INSTRUMENTS CADIERE FORCEPS,27200000,CDM,272,RC,,,,11913-MAIN,LOCAL,,,,,281,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,250.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
FORCEPS PROGRASP 8MM ENDOWRIST INSTRUMENTS,27200000,CDM,272,RC,,,,12062-MAIN,LOCAL,,,,,281,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,250.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Spirometry,PX9401001,CDM,460,RC,94010,CPT,TC,,,,,,,281,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,250.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,116.7274,275.38
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062160,NDC,0.6,ML,274.53,,Medica,Commercial,both,91.1,,7.8,percent of total billed charges,250.09683,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801601,NDC,0.6,ML,274.53,,Medica,Commercial,both,91.1,,7.8,percent of total billed charges,250.09683,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801610,NDC,0.6,ML,274.53,,Medica,Commercial,both,91.1,,7.8,percent of total billed charges,250.09683,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
"Lap,Dx Surgical Abd W/Biopsy",PX49321P,CDM,983,RC,49321,CPT,,,,,,,,583,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,250.107,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,242.1782,5040.74
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,65162083366,NDC,100,GR,281.12,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,250.1968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Closed Rx Dist Fibula Fx,Manip",PX27788F,CDM,510,RC,27788,CPT,,,,,,,,1597,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,250.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.51,915.25
"Closed Rx Dist Fibula Fx,Manip",PX27788F,CDM,510,RC,27788,CPT,,,,,,,,1597,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,250.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.51,915.25
"Closed Rx Dist Fibula Fx,Manip",PX27788P,CDM,983,RC,27788,CPT,,,,,,,,1277,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,250.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.51,1251.46
"Closed Rx Dist Fibula Fx,Manip",PX27788P,CDM,983,RC,27788,CPT,,,,,,,,1277,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,250.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.51,1251.46
Multiple Sleep Latency Test,PX9580501,CDM,740,RC,95805,CPT,TC,,,,,,,4313,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,250.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,238.66,656.16
Multiple Sleep Latency Test,PX9580501,CDM,740,RC,95805,CPT,TC,,,,,,,4313,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,250.22,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,238.66,656.16
sugammadex sodium 200 MG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,6542312,NDC,2,ML,583.33,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,250.24857,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ondansetron 4 MG/5ML Solution 25 mL Bottle,S0119.01,CDM,636,RC,S0119,HCPCS,,,,99998-8001-,NDC,25,ML,494.57,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,250.25242,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
prednisoLONE acetate 1 % Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063705,NDC,5,ML,283.79,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,250.30278,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Debride Bone Ea Add 20 Sqcm,PX11047F,CDM,510,RC,11047,CPT,,,,,,,,438,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,250.43,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.59,250.43
Debride Bone Ea Add 20 Sqcm,PX11047P,CDM,983,RC,11047,CPT,,,,,,,,351,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,250.43,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.59,343.98
"Remv Foreign Body,Knee/Thigh,Deep",PX27372F,CDM,510,RC,27372,CPT,,,,,,,,1429,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,250.43,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,250.43,1226.56
"Remv Foreign Body,Knee/Thigh,Deep",PX27372P,CDM,983,RC,27372,CPT,,,,,,,,954,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,250.43,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,250.43,1226.56
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725F,CDM,510,RC,26725,CPT,,,,,,,,495,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,250.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.623,485.1
MRI L Spine WO Contrast,PX7214801,CDM,610,RC,72148,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,250.47,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.86,250.47
MRI L Spine WO Contrast,PX7214801,CDM,610,RC,72148,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,250.47,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.86,250.47
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101F,CDM,510,RC,13101,CPT,,,,,,,,495,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,250.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.623,548.67
Tc99 Mebrofenin to 15 Mci,PXA9537,CDM,343,RC,A9537,HCPCS,,,,,,,,495,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,250.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.623,485.1
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151P,CDM,983,RC,99151,CPT,,,,,,,,275,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,250.525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,114.235,267.6575
Closed Rx Trimalleolar Fx,PX27816F,CDM,510,RC,27816,CPT,,,,,,,,522,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,250.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,511.56
Closed Rx Trimalleolar Fx,PX27816F,CDM,510,RC,27816,CPT,,,,,,,,522,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,250.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,511.56
Xray Thoracic Spine 3 Vws,PX7207201,CDM,320,RC,72072,CPT,TC,,,,,,,522,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,250.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,511.56
Xray Thoracic Spine 3 Vws,PX7207201,CDM,320,RC,72072,CPT,TC,,,,,,,522,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,250.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,511.56
ROPivacaine 2 MG/ML Solution 100 mL Bottle,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028568,NDC,100,ML,275.11,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,250.62521,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.604954,269.6078
dorzolamide-timolol 2-0.5 % Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,50383023310,NDC,10,ML,506.34,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,250.6383,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Treat Thumb Disloc,Manipulatn",PX26641F,CDM,510,RC,26641,CPT,,,,,,,,1721,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,250.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.07,905.57
"Treat Thumb Disloc,Manipulatn",PX26641F,CDM,510,RC,26641,CPT,,,,,,,,1721,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,250.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.07,905.57
"Treat Thumb Disloc,Manipulatn",PX26641P,CDM,983,RC,26641,CPT,,,,,,,,1902,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,250.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.07,1863.96
"Treat Thumb Disloc,Manipulatn",PX26641P,CDM,983,RC,26641,CPT,,,,,,,,1902,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,250.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.07,1863.96
Closed Rx Metacarpal Fx,PX26600P,CDM,983,RC,26600,CPT,,,,,,,,295,,First Health,Commercial,both,85,,999999999,percent of total billed charges,250.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.543,287.1235
Sulfur Colloid per Dose,PXA9541,CDM,343,RC,A9541,HCPCS,,,,,,,,295,,First Health,Commercial,both,85,,999999999,percent of total billed charges,250.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.543,289.1
gentamicin 0.1 % Ointment 30 g Tube,25000000,CDM,250,RC,,,,,,713068231,NDC,30,GR,506.64,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,250.7868,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821517,NDC,3,ML,275.33,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,250.82563,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
DRIVER HEX 2.00MM STERILE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12440-MAIN,LOCAL,,,,,512,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,250.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRIVER HEX 2.00MM STERILE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12440-MAIN,LOCAL,,,,,512,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,250.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRIVER HEX 2.00MM STERILE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12440-MAIN,LOCAL,,,,,512,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,250.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRIVER HEX 2.5MM STERILE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12441-MAIN,LOCAL,,,,,512,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,250.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRIVER HEX 2.5MM STERILE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12441-MAIN,LOCAL,,,,,512,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,250.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRIVER HEX 2.5MM STERILE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12441-MAIN,LOCAL,,,,,512,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,250.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Office/Outpt Visit,Est,Levl IV",PX99214F,CDM,510,RC,99214,CPT,,,,,,,,256,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,250.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.3424,250.88
"Office/Outpt Visit,Est,Levl IV",PX99214P,CDM,983,RC,99214,CPT,,,,,,,,256,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,250.88,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.11,250.88
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133P,CDM,983,RC,13133,CPT,,,,,,,,256,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,250.88,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77,348.67
Closed Rx Kneecap Disloc+Anesth,PX27562F,CDM,510,RC,27562,CPT,,,,,,,,604,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,250.9016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,591.92
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221901,NDC,3,ML,506.9,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,250.9155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221905,NDC,3,ML,506.9,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,250.9155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
"Layr Clos Wnd Face,Facial 2.5-5",PX12052F,CDM,510,RC,12052,CPT,,,,,,,,585,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,250.965,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,243.009,573.3
ADVANCED INSTRUMENTS ENDOWRIST SUCTION IRRIGATOR,27200000,CDM,272,RC,,,,11922-MAIN,LOCAL,,,,,496,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,250.976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LOCKING SCREW T8 FULL THREAD 2.4MM L10MM,C1713,CDM,278,RC,C1713,HCPCS,,12637-MAIN,LOCAL,,,,,496,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,250.976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LOCKING SCREW T8 FULL THREAD 2.4MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12651-MAIN,LOCAL,,,,,496,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,250.976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LOCKING SCREW T8 FULL THREAD 2.7MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12638-MAIN,LOCAL,,,,,496,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,250.976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LOCKING SCREW T8 FULL THREAD 2.7MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12639-MAIN,LOCAL,,,,,496,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,250.976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Xray Finger(S) Tc,PX7314001,CDM,320,RC,73140,CPT,TC,,,,,,,282,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,250.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,276.36
Xray Toe(S) Tc,PX7366001,CDM,320,RC,73660,CPT,TC,,,,,,,282,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,250.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,276.36
"Needle Biopsy,Muscle",PX20206F,CDM,510,RC,20206,CPT,,,,,,,,258,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,251.1114,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.1732,1416.38
"Upper GI Endoscopy,Diagnosis",PX43235F,CDM,750,RC,43235,CPT,,,,,,,,2539,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,251.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.04,597.02
"Upper GI Endoscopy,Diagnosis",PX43235P,CDM,983,RC,43235,CPT,,,,,,,,1406,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,251.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.04,1377.88
"Removal Anal Fistula,Subcutaneous",PX46270F,CDM,510,RC,46270,CPT,,,,,,,,1470,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,251.31,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,251.31,1113.8
"Removal Anal Fistula,Subcutaneous",PX46270P,CDM,983,RC,46270,CPT,,,,,,,,980,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,251.31,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,251.31,1113.8
Xray Sacroiliac Jnts 3 or More Vws,PX7220201,CDM,320,RC,72202,CPT,TC,,,,,,,285,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,251.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,279.3
US Abdomen Tc,PX7670001,CDM,402,RC,76700,CPT,TC,,,,,,,586,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,251.394,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,574.28
dexmedeTOMIDine in  dextrose 200MCG/50ML -5% Solution 50 mL Flex Cont,25000000,CDM,250,RC,,,,,,44567060224,NDC,50,ML,258.31,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,251.413123,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Culture Screen Only,PX87081,CDM,300,RC,87081,CPT,,,,,,,,276,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,251.436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.08,270.48
"Inpatient Consult, Level IV",PX99254,CDM,983,RC,99254,CPT,,,,,,,,508,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,251.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.0232,494.4364
Lvl 2 Init Hosp Mod Mdm or 55 Minutes,PX99222,CDM,982,RC,99222,CPT,,,,,,,,508,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,251.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.0232,494.4364
Cpap/Bipap Mgmnt-Pt Own Equipment,PX94660.02F,CDM,410,RC,94660,CPT,,,,,,,,497,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,251.482,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.33,487.06
"Apply Forearm Splint,Static",PX29125P,CDM,983,RC,29125,CPT,,,,,,,,296,,First Health,Commercial,both,85,,999999999,percent of total billed charges,251.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,288.0968
Apply Lower Leg Splint,PX29515F,CDM,510,RC,29515,CPT,,,,,,,,296,,First Health,Commercial,both,85,,999999999,percent of total billed charges,251.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.9584,290.08
Drain Skin Abscess Simple,PX10060F,CDM,510,RC,10060,CPT,,,,,,,,296,,First Health,Commercial,both,85,,999999999,percent of total billed charges,251.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.9584,290.08
ammonium lactate 12 % Cream 385 g Tube,63700001,CDM,250,RC,,,,,,45802049326,NDC,385,GR,256.76,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,251.6248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Fac/Exc Skn Bnig0.6-1cm Fae,Facial",PX11441F,CDM,510,RC,11441,CPT,,,,,,,,606,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,251.7324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,251.7324,614.65
ipratropium 0.03 % Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,24208039830,NDC,30,ML,256.9,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,251.762,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sulfacetamide 10 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,61314070101,NDC,15,ML,285.48,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,251.79336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
STAPLER RELOAD-CURVED CUTTER,27200000,CDM,272,RC,,,,12063-MAIN,LOCAL,,,,,283,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,251.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Acute Hepatitis Panel,PX80074,CDM,300,RC,80074,CPT,,,,,,,,509,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,251.955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,43.67,498.82
Biopsy of Rectum,PX45100P,CDM,983,RC,45100,CPT,,,,,,,,509,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,251.955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.4386,2452.93
Exs Tumor Arm/Elbow Sc 3cm>,PX24071F,CDM,510,RC,24071,CPT,,,,,,,,1860,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,251.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,249.34,852.3
Exs Tumor Arm/Elbow Sc 3cm>,PX24071F,CDM,510,RC,24071,CPT,,,,,,,,1860,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,251.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,249.34,852.3
"Remv Foreign Body,Knee/Thigh,Deep",PX27372F,CDM,510,RC,27372,CPT,,,,,,,,1429,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,251.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,250.43,1226.56
"Remv Foreign Body,Knee/Thigh,Deep",PX27372F,CDM,510,RC,27372,CPT,,,,,,,,1429,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,251.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,250.43,1226.56
"Remv Foreign Body,Knee/Thigh,Deep",PX27372P,CDM,983,RC,27372,CPT,,,,,,,,954,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,251.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,250.43,1226.56
"Remv Foreign Body,Knee/Thigh,Deep",PX27372P,CDM,983,RC,27372,CPT,,,,,,,,954,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,251.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,250.43,1226.56
Gastric Intubation Treatment,PX43753P,CDM,983,RC,43753,CPT,,,,,,,,498,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,251.988,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.8692,484.7034
"POS Airway Pressure, Cpap",PX94660F,CDM,410,RC,94660,CPT,,,,,,,,498,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,251.988,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.33,488.04
Acth - Ref,PX8202490,CDM,300,RC,82024,CPT,90,,,,,,,259,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,252.0847,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.41,253.82
"IV Push, Single/1st Drug",PX96374,CDM,260,RC,96374,CPT,,,,,,,,259,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,129.0406,percent of total billed charges,252.0847,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.5886,253.82
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022101,NDC,1,EA,514.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,252.105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022101,NDC,1,EA,514.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,252.105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022101,NDC,1,EA,514.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,252.105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022185,NDC,1,EA,514.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,252.105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022185,NDC,1,EA,514.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,252.105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022185,NDC,1,EA,514.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,252.105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022189,NDC,1,EA,514.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,252.105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022189,NDC,1,EA,514.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,252.105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022189,NDC,1,EA,514.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,252.105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
Anal Sphincterotomy,PX46080F,CDM,510,RC,46080,CPT,,,,,,,,607,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,252.1478,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,252.1478,2452.93
Excis Forearm/Wrist Tumor Subcutan,PX25075P,CDM,983,RC,25075,CPT,,,,,,,,607,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,252.1478,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,252.1478,1416.38
Open Bx/Excision Inguinofemoral Nodes,PX38531P,CDM,983,RC,38531,CPT,,,,,,,,607,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,252.1478,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,252.1478,3329.99
Blood Culture for Bacteria,PX87040,CDM,300,RC,87040,CPT,,,,,,,,286,,United Healthcare,All Payer,outpatient,88.2,,137.8071429,percent of total billed charges,252.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.46,280.28
I&D Bartholin Gland Abscess,PX56420P,CDM,983,RC,56420,CPT,,,,,,,,286,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,252.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,118.8044,278.3638
Joint Survey,PX7707726,CDM,982,RC,77077,CPT,26,,,,,,,286,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,252.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,278.3638
Lab Culture Bacteria,PX87070,CDM,300,RC,87070,CPT,,,,,,,,286,,United Healthcare,All Payer,outpatient,88.2,,135.73,percent of total billed charges,252.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.9,280.28
Urine Culture/Colony Count,PX87086,CDM,300,RC,87086,CPT,,,,,,,,286,,United Healthcare,All Payer,outpatient,88.2,,185.995,percent of total billed charges,252.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4,280.28
CT Abd&Pelv 1+ Section/Regns,PX7417801,CDM,350,RC,74178,CPT,TC,,,,,,,4226,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,252.2912,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,171.03,504.23
"Molecular Cytog, Ea Probe - Ref",PX8827190,CDM,310,RC,88271,CPT,90,,,,,,,277,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,252.347,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.64,271.46
"Xray Neck, Soft Tissue",PX7036001,CDM,320,RC,70360,CPT,TC,,,,,,,277,,Medica,Commercial,both,91.1,,73.83,percent of total billed charges,252.347,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,271.46
I&D Deep Absc/Hematoma Neck/Chest,PX21501P,CDM,983,RC,21501,CPT,,,,,,,,515,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,252.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.931,2482.37
I&D Deep Absc/Hematoma Neck/Chest,PX21501P,CDM,983,RC,21501,CPT,,,,,,,,515,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,252.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.931,2482.37
I&D Deep Absc/Hematoma Neck/Chest,PX21501P,CDM,983,RC,21501,CPT,,,,,,,,515,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,252.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.931,2482.37
Comprehensive Metabolic Panel,PX80053,CDM,300,RC,80053,CPT,,,,,,,,396,,Blue Cross Blue Shield of MN,All commercial plans,both,,,122.6452,fee schedule,252.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.68,388.08
Debride Tissue/Muscle,PX11043F,CDM,510,RC,11043,CPT,,,,,,,,526,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,252.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,218.5004,548.67
Debride Tissue/Muscle,PX11043F,CDM,510,RC,11043,CPT,,,,,,,,526,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,252.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,218.5004,548.67
Hfe Gene - Ref,PX8125690,CDM,300,RC,81256,CPT,90,,,,,,,526,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,252.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,59.93,515.48
Hfe Gene - Ref,PX8125690,CDM,300,RC,81256,CPT,90,,,,,,,526,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,252.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,59.93,515.48
3.0MM HEADED SCREW LENGTH 16MM,C1713,CDM,278,RC,C1713,HCPCS,,12656-MAIN,LOCAL,,,,,608,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,252.5632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
prednisoLONE acetate 1 % Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063705,NDC,5,ML,283.79,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,252.5731,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
cefdinir 250 MG/5ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,16714039301,NDC,60,ML,510.33,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,252.61335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Closed Rx Shldr Dislocation,PX23650P,CDM,983,RC,23650,CPT,,,,,,,,516,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,252.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,502.2228
Closed Rx Shldr Dislocation,PX23650P,CDM,983,RC,23650,CPT,,,,,,,,516,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,252.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,502.2228
Closed Rx Shldr Dislocation,PX23650P,CDM,983,RC,23650,CPT,,,,,,,,516,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,252.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,502.2228
"Needle Biopsy,Muscle",PX20206F,CDM,510,RC,20206,CPT,,,,,,,,258,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,252.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.1732,1416.38
Trg Gene Rearrangement Anal - Ref,PX8134290,CDM,300,RC,81342,CPT,90,,,,,,,516,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,252.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,184.76,505.68
Trg Gene Rearrangement Anal - Ref,PX8134290,CDM,300,RC,81342,CPT,90,,,,,,,516,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,252.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,184.76,505.68
Trg Gene Rearrangement Anal - Ref,PX8134290,CDM,300,RC,81342,CPT,90,,,,,,,516,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,252.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,184.76,505.68
sevoflurane Solution 250 mL Bottle,25000000,CDM,250,RC,,,,,,66794001525,NDC,250,ML,589.56,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,252.92124,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,63323076350,NDC,50,ML,589.57,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,252.92553,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600110,NDC,10,ML,589.63,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,252.95127,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
"Infectious Disease,Chronic Hep C Virus,Six Assays, Utilizing Serum",PX8159690,CDM,300,RC,81596,CPT,90,,,,,,,609,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,252.9786,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.19,596.82
Sigmoidoscope W/Submuc Inj,PX45335P,CDM,983,RC,45335,CPT,,,,,,,,500,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,253,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,207.7,798.45
butamben-tetracaine-benzocaine 2-2-14 % Aerosol 20 g Bottle,25000000,CDM,250,RC,,,,,,10223020103,NDC,20,GR,589.76,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,253.00704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Blood Clot Factor V Test,PX85220,CDM,300,RC,85220,CPT,,,,,,,,260,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,253.058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.18,254.8
"Closed Rx Toe Fx,Manipulatn",PX28515P,CDM,983,RC,28515,CPT,,,,,,,,260,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,253.058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.004,253.058
First Hour IV Hydration <1 Hour,PX96360,CDM,260,RC,96360,CPT,,,,,,,,260,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,122.7684615,percent of total billed charges,253.058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.004,254.8
dexmedeTOMIDine in  dextrose 200MCG/50ML -5% Solution 50 mL Flex Cont,25000000,CDM,250,RC,,,,,,44567060224,NDC,50,ML,258.31,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,253.1438,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sodium thiosulfate 250 MG/ML Solution 50 mL Vial,J0209.01,CDM,636,RC,J0209,HCPCS,,,,60267070550,NDC,50,ML,609.57,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,253.215378,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,253.215378,597.3786
"Ecg 12 Lead, Tracing Only",PX93005,CDM,730,RC,93005,CPT,,,,,,,,298,,First Health,Commercial,both,85,,999999999,percent of total billed charges,253.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.44,292.04
DRIVER HEX 2.00MM STERILE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12440-MAIN,LOCAL,,,,,512,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,253.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRIVER HEX 2.5MM STERILE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12441-MAIN,LOCAL,,,,,512,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,253.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Removal Anal Fistula,Subcutaneous",PX46270F,CDM,510,RC,46270,CPT,,,,,,,,1470,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,253.48,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,251.31,1113.8
"Removal Anal Fistula,Subcutaneous",PX46270F,CDM,510,RC,46270,CPT,,,,,,,,1470,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,253.48,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,251.31,1113.8
"Removal Anal Fistula,Subcutaneous",PX46270P,CDM,983,RC,46270,CPT,,,,,,,,980,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,253.48,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,251.31,1113.8
"Removal Anal Fistula,Subcutaneous",PX46270P,CDM,983,RC,46270,CPT,,,,,,,,980,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,253.48,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,251.31,1113.8
Xray Sacroiliac Jnts 3 or More Vws,PX7220201,CDM,320,RC,72202,CPT,TC,,,,,,,285,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,253.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,279.3
hydrocortisone sodium succinate (preservative free) 500 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001612,NDC,1,EA,298.53,,First Health,Commercial,both,85,,999999999,percent of total billed charges,253.7505,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
HERNIA MESH LAP PROGRIP SELF FIXATING FLAT SHEET 10X15,C1781,CDM,278,RC,C1781,HCPCS,,12727-MAIN,LOCAL,,,,,611,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,253.8094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Acth - Ref,PX8202490,CDM,300,RC,82024,CPT,90,,,,,,,259,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,253.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.41,253.82
"Blood Gases: Ph, Po2 & Pco2",PX82803,CDM,300,RC,82803,CPT,,,,,,,,518,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,78.64,percent of total billed charges,253.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.9,507.64
"Blood Gases: Ph, Po2 & Pco2",PX82803,CDM,300,RC,82803,CPT,,,,,,,,518,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,253.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.9,507.64
"Blood Gases: Ph, Po2 & Pco2",PX82803,CDM,300,RC,82803,CPT,,,,,,,,518,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,253.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.9,507.64
"IV Push, Single/1st Drug",PX96374,CDM,260,RC,96374,CPT,,,,,,,,259,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,253.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.5886,253.82
"Biopsy, Nail Unit",PX11755F,CDM,510,RC,11755,CPT,,,,,,,,1490,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,253.89,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.73,253.89
ocrelizumab 300 MG/10ML Solution 10 mL Vial,J2350.01,CDM,636,RC,J2350,HCPCS,,,,50242015001,NDC,10,ML,33150,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,253.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.47,32487
CHOLANGIOGRAM CATHETER REDDICK,27200000,CDM,272,RC,,,,10232-MAIN,LOCAL,,,,,287.98,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,253.99836,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Chemotherapy, IV Push, Single Drug",PX96409,CDM,335,RC,96409,CPT,,,,,,,,502,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,254.012,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.5308,491.96
Incise External Hemorrhoid,PX46083F,CDM,510,RC,46083,CPT,,,,,,,,502,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,254.012,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.5308,491.96
Spirometry Incl Graph Rec Tc,PX9401002,CDM,460,RC,94010,CPT,TC,,,,,,,288,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,254.016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.6352,282.24
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200001,NDC,0.5,ML,980.99,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,254.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.02,298.03
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200002,NDC,0.5,ML,980.99,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,254.02,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.02,298.03
sulfacetamide 10 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,61314070101,NDC,15,ML,285.48,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,254.0772,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,55111069407,NDC,5,ML,592.4,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,254.1396,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.08296,1009.1158
Exc Skin Benig <5mm Remaindr Body,PX11420P,CDM,983,RC,11420,CPT,,,,,,,,299,,First Health,Commercial,both,85,,999999999,percent of total billed charges,254.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,124.2046,1416.38
"Hla Class II Low Res, 1 Locus - Ref",PX8137690,CDM,310,RC,81376,CPT,90,,,,,,,279,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,254.169,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.06,273.42
INSUFLOWPORT & PNEUVIEW  XE SMOKE ELIMINATOR 5MM,27200000,CDM,272,RC,,,,11876-MAIN,LOCAL,,,,,279,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,254.169,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 8MM,27200000,CDM,272,RC,,,,11877-MAIN,LOCAL,,,,,279,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,254.169,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 10MM,27200000,CDM,272,RC,,,,11878-MAIN,LOCAL,,,,,279,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,254.169,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 12MM,27200000,CDM,272,RC,,,,11879-MAIN,LOCAL,,,,,279,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,254.169,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 5MM,27200000,CDM,272,RC,,,,11880-MAIN,LOCAL,,,,,279,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,254.169,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 8MM,27200000,CDM,272,RC,,,,11881-MAIN,LOCAL,,,,,279,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,254.169,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 10MM,27200000,CDM,272,RC,,,,11882-MAIN,LOCAL,,,,,279,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,254.169,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 12MM,27200000,CDM,272,RC,,,,11883-MAIN,LOCAL,,,,,279,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,254.169,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Puncture Drainage of Lesion,PX10160F,CDM,510,RC,10160,CPT,,,,,,,,279,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,254.169,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.8966,348.35
Xray Pelvis 1 or 2 Vws,PX7217001,CDM,320,RC,72170,CPT,TC,,,,,,,279,,Medica,Commercial,both,91.1,,143.7933333,percent of total billed charges,254.169,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,273.42
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600121,NDC,10,ML,592.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,254.1825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
Xray Ac Joints(Bilateral),PX7305001,CDM,320,RC,73050,CPT,TC,,,,,,,519,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,254.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,508.62
Xray Ac Joints(Bilateral),PX7305001,CDM,320,RC,73050,CPT,TC,,,,,,,519,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,254.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,508.62
Xray Ac Joints(Bilateral),PX7305001,CDM,320,RC,73050,CPT,TC,,,,,,,519,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,254.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,508.62
BRACE WRIST 8-IN SM LEFT 10432,120.564,CDM,273,RC,L3809,HCPCS,,12720-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,254.37,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST 8-IN SM RIGHT 10442,120.564,CDM,273,RC,L3809,HCPCS,,12716-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,254.37,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST 10-IN LG RIGHT 10464,120.564,CDM,273,RC,L3809,HCPCS,,12719-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,254.37,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST 10-IN SM LEFT 617083,120.564,CDM,273,RC,L3809,HCPCS,,12722-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,254.37,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST 10-IN SM RIGHT 10462,120.564,CDM,273,RC,L3809,HCPCS,,12717-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,254.37,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST 10-IN XL LEFT 10455,120.564,CDM,273,RC,L3809,HCPCS,,12721-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,254.37,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST 10-IN XL RIGHT 10465,120.564,CDM,273,RC,L3809,HCPCS,,12715-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,254.37,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST HAND THUMB LEFT 455-LT,120.315,CDM,274,RC,L3809,HCPCS,,8283-MAIN,LOCAL,,,,,77,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,254.37,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST HAND THUMB RIGHT 455-RT,120.315,CDM,274,RC,L3809,HCPCS,,8284-MAIN,LOCAL,,,,,77,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,254.37,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST WRISTPRO LEFT 10-IN LG,120.564,CDM,273,RC,L3809,HCPCS,,12724-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,254.37,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST WRISTPRO LEFT 10-IN MED,120.564,CDM,273,RC,L3809,HCPCS,,12723-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,254.37,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
SPLINT WRIST LARGE ALUMINUM FOREARM LEFT 9101-06,120.87,CDM,274,RC,L3809,HCPCS,,1265-MAIN,LOCAL,,,,,130,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,254.37,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
SPLINT WRIST LARGE ALUMINUM FOREARM RIGHT 9101-03,120.87,CDM,274,RC,L3809,HCPCS,,1263-MAIN,LOCAL,,,,,130,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,254.37,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
SPLINT WRIST MEDIUM ALUMINUM FOREARM LEFT 9101-05,120.87,CDM,274,RC,L3809,HCPCS,,1264-MAIN,LOCAL,,,,,130,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,254.37,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
SPLINT WRIST MEDIUM ALUMINUM FOREARM RIGHT 9101-02,120.87,CDM,274,RC,L3809,HCPCS,,1262-MAIN,LOCAL,,,,,130,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,254.37,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
fluorouracil 5 GM/100ML Solution 100 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,16729027638,NDC,100,ML,261.44,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,254.459552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,256.2112
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004004,NDC,120,ML,502.95,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,254.4927,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
Trb@ Gene Rearrange Amplify - Ref,PX8134090,CDM,300,RC,81340,CPT,90,,,,,,,503,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,254.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,191.56,492.94
Blood Culture for Bacteria,PX87040,CDM,300,RC,87040,CPT,,,,,,,,286,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,254.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.46,280.28
I&D Bartholin Gland Abscess,PX56420P,CDM,983,RC,56420,CPT,,,,,,,,286,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,254.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,118.8044,278.3638
Joint Survey,PX7707726,CDM,982,RC,77077,CPT,26,,,,,,,286,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,254.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,278.3638
Lab Culture Bacteria,PX87070,CDM,300,RC,87070,CPT,,,,,,,,286,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,254.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.9,280.28
Urine Culture/Colony Count,PX87086,CDM,300,RC,87086,CPT,,,,,,,,286,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,254.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4,280.28
atropine 1 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,60219174903,NDC,5,ML,299.49,,First Health,Commercial,both,85,,999999999,percent of total billed charges,254.5665,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Closed Rx IP Jt Dislocation,PX26770F,CDM,510,RC,26770,CPT,,,,,,,,1231,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,254.6323,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,168.85,628.15
Closed Rx IP Jt Dislocation,PX26770P,CDM,983,RC,26770,CPT,,,,,,,,1353,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,254.6323,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,168.85,1325.94
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022101,NDC,1,EA,514.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,254.6775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022185,NDC,1,EA,514.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,254.6775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022189,NDC,1,EA,514.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,254.6775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
Blood Clot Factor V Test,PX85220,CDM,300,RC,85220,CPT,,,,,,,,260,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,254.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.18,254.8
"Closed Rx Toe Fx,Manipulatn",PX28515P,CDM,983,RC,28515,CPT,,,,,,,,260,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,254.8,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.93,352.82
First Hour IV Hydration <1 Hour,PX96360,CDM,260,RC,96360,CPT,,,,,,,,260,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,254.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.004,254.8
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,121090204,NDC,120,ML,503.56,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,254.80136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
"Supply Technetium Medronate,to 30 MC",PXA9503,CDM,343,RC,A9503,HCPCS,,,,,,,,531,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,254.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,220.5774,520.38
"Supply Technetium Medronate,to 30 MC",PXA9503,CDM,343,RC,A9503,HCPCS,,,,,,,,531,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,254.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,220.5774,520.38
BONE SCREW T8 FULL THREAD 2.4MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12652-MAIN,LOCAL,,,,,289,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,254.898,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
BONE SCREW T8 FULL THREAD 2.4MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12653-MAIN,LOCAL,,,,,289,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,254.898,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
BONE SCREW T8 FULL THREAD 2.7MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12654-MAIN,LOCAL,,,,,289,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,254.898,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Occupational Therapy Eval High Complex,PX97167,CDM,434,RC,97167,CPT,,,,,,,,289,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,254.898,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,283.22
"Troponin, Quantitative",PX84484,CDM,300,RC,84484,CPT,,,,,,,,289,,United Healthcare,All Payer,outpatient,88.2,,187.6382143,percent of total billed charges,254.898,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.43,283.22
I&D Deep Absc/Hematoma Neck/Chest,PX21501P,CDM,983,RC,21501,CPT,,,,,,,,515,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,254.925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.931,2482.37
iohexol 300 MG/ML Solution 150 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141365,NDC,150,ML,300,,First Health,Commercial,both,85,,999999999,percent of total billed charges,255,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,294
"Spinal Punc,Drain,Theraputic",PX62272P,CDM,983,RC,62272,CPT,,,,,,,,300,,First Health,Commercial,both,85,,999999999,percent of total billed charges,255,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,124.62,604.15
US Follicles-Limited Tc,PX7685701,CDM,402,RC,76857,CPT,TC,,,,,,,300,,First Health,Commercial,both,85,,999999999,percent of total billed charges,255,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,294
Tap Block Bilateral by Injection(S),PX64488P,CDM,983,RC,64488,CPT,,,,,,,,262,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,109.76,percent of total billed charges,255.0046,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.8348,255.0046
"Chemotherapy, IV Infusion, 1 Hour",PX96413,CDM,335,RC,96413,CPT,,,,,,,,614,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,255.0556,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.0556,601.72
Repr Superf Wnd Body 7.6-12.5,PX12004P,CDM,983,RC,12004,CPT,,,,,,,,614,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,255.0556,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,597.6062
"Pertechnetate, Dia, per Mci",PXA9512,CDM,343,RC,A9512,HCPCS,,,,,,,,280,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,255.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,116.312,274.4
Infection Agent Detect Dna/Rna Probe Tq 6-11,PX87506,CDM,300,RC,87506,CPT,,,,,,,,1710,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,255.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.1,262.99
Infection Agent Detect Dna/Rna Probe Tq 6-11,PX87506,CDM,300,RC,87506,CPT,,,,,,,,1710,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,255.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.1,262.99
Infection Agent Detect Dna/Rna Probe Tq 6-11,PX87506,CDM,300,RC,87506,CPT,,,,,,,,1710,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,255.1,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.1,262.99
megestrol 40 MG/ML Suspension 240 mL Bottle,25000000,CDM,250,RC,,,,,,49884090738,NDC,240,ML,594.72,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,255.13488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133F,CDM,510,RC,13133,CPT,,,,,,,,595,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,255.255,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247.163,583.1
"Thrombolysis,Coronary,IV Infusn",PX92977F,CDM,480,RC,92977,CPT,,,,,,,,595,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,255.255,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247.163,583.1
"Thrombolytic Therapy, Stroke",PX37195F,CDM,761,RC,37195,CPT,,,,,,,,595,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,255.255,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247.163,583.1
"Destruct Benign Lesion, 1-14",PX17110P,CDM,983,RC,17110,CPT,,,,,,,,521,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,255.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,507.0893
"Destruct Benign Lesion, 1-14",PX17110P,CDM,983,RC,17110,CPT,,,,,,,,521,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,255.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,507.0893
"Destruct Benign Lesion, 1-14",PX17110P,CDM,983,RC,17110,CPT,,,,,,,,521,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,255.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,507.0893
ePHEDrine sulfate 50 MG/ML Solution 1 mL Ampule,25000000,CDM,250,RC,,,,,,17478041510,NDC,1,ML,262.31,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,255.306323,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Closed Rx Shldr Dislocation,PX23650P,CDM,983,RC,23650,CPT,,,,,,,,516,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,255.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,502.2228
Trg Gene Rearrangement Anal - Ref,PX8134290,CDM,300,RC,81342,CPT,90,,,,,,,516,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,255.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,184.76,505.68
"Layr Clos Wnd Face,Facial <2.5cm",PX12051P,CDM,983,RC,12051,CPT,,,,,,,,615,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,255.471,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.471,598.5795
Remove Hemorrhoids & Fissure,PX46257P,CDM,983,RC,46257,CPT,,,,,,,,615,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,255.471,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.471,2452.93
Diagnostic Anoscopy,PX46600F,CDM,510,RC,46600,CPT,,,,,,,,505,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,255.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,494.9
MINIBUNION NON-LOCKING SCREW  2.7X18MM,C1713,CDM,278,RC,C1713,HCPCS,,11670-MAIN,LOCAL,,,,,280.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,255.5355,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
HERCULES 3 STAGE BALLOON ESOPHAGEAL 12-13.5-15::36-40.5-45MM,27200000,CDM,272,RC,C1726,HCPCS,,11329-MAIN,LOCAL,,,,,289.85,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,255.6477,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HERCULES 3 STAGE BALLOON ESOPHAGEAL 15-16.5-18:45-49.5-54MM,27200000,CDM,272,RC,C1726,HCPCS,,11328-MAIN,LOCAL,,,,,289.85,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,255.6477,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HERCULES 3 STAGE BALLOON ESOPHAGEAL 18-19-20::54-57-60MM,27200000,CDM,272,RC,C1726,HCPCS,,11330-MAIN,LOCAL,,,,,289.85,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,255.6477,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Apply Long Arm Splint,PX29105F,CDM,510,RC,29105,CPT,,,,,,,,290,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,255.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.466,284.2
Assay of Digoxin,PX80162,CDM,300,RC,80162,CPT,,,,,,,,290,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,255.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.18,284.2
Assay of Natriuretic Peptide,PX83880,CDM,300,RC,83880,CPT,,,,,,,,290,,United Healthcare,All Payer,outpatient,88.2,,185.1933333,percent of total billed charges,255.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36,284.2
Closed Rx Trimalleolar Fx,PX27816F,CDM,510,RC,27816,CPT,,,,,,,,522,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,255.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,511.56
Closed Rx Trimalleolar Fx,PX27816F,CDM,510,RC,27816,CPT,,,,,,,,522,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,255.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,511.56
Closed Rx Trimalleolar Fx,PX27816F,CDM,510,RC,27816,CPT,,,,,,,,522,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,255.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,511.56
NEEDLE INTRAOSSEOUS SET 15GA 25MM STABILIZER EZ-IO 9001P,120.216,CDM,272,RC,A4215,HCPCS,,10648-MAIN,LOCAL,,,,,290,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,255.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.466,284.2
NEEDLE INTRAOSSEOUS SET 15GA 45MM STABILIZER EZ-IO 9079P,120.216,CDM,272,RC,A4215,HCPCS,,10297-MAIN,LOCAL,,,,,290,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,255.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.466,284.2
Xray Thoracic Spine 3 Vws,PX7207201,CDM,320,RC,72072,CPT,TC,,,,,,,522,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,255.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,511.56
Xray Thoracic Spine 3 Vws,PX7207201,CDM,320,RC,72072,CPT,TC,,,,,,,522,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,255.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,511.56
Xray Thoracic Spine 3 Vws,PX7207201,CDM,320,RC,72072,CPT,TC,,,,,,,522,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,255.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,511.56
PACLitaxel 150 MG/25ML Concentrate 25 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321701,NDC,25,ML,300.96,,First Health,Commercial,both,85,,999999999,percent of total billed charges,255.816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
Xray Ribs Bil 3vws Tc,PX7111001,CDM,320,RC,71110,CPT,TC,,,,,,,533,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,255.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,522.34
Xray Ribs Bil 3vws Tc,PX7111001,CDM,320,RC,71110,CPT,TC,,,,,,,533,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,255.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,522.34
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122P,CDM,983,RC,13122,CPT,,,,,,,,301,,First Health,Commercial,both,85,,999999999,percent of total billed charges,255.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.0354,292.9633
Xray Facial Bones Less Than 3 Vws,PX7014001,CDM,320,RC,70140,CPT,TC,,,,,,,301,,First Health,Commercial,both,85,,999999999,percent of total billed charges,255.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,294.98
Pvb Thoracic Single Injection Site W/Img Gid,PX64461P,CDM,983,RC,64461,CPT,,,,,,,,616,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,255.8864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.8864,604.15
"X-Ray Exam Hip,Unilat W/Pelvis 1vw",PX7350101,CDM,320,RC,73501,CPT,TC,,,,,,,263,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,255.9779,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,257.74
8MM ENDOWRIST INSTRUMENTS CADIERE FORCEPS,27200000,CDM,272,RC,,,,11913-MAIN,LOCAL,,,,,281,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,255.991,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
FORCEPS PROGRASP 8MM ENDOWRIST INSTRUMENTS,27200000,CDM,272,RC,,,,12062-MAIN,LOCAL,,,,,281,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,255.991,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Spirometry,PX9401001,CDM,460,RC,94010,CPT,TC,,,,,,,281,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,255.991,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,116.7274,275.38
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,65162083366,NDC,100,GR,281.12,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,256.10032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Fluoroscope Examination Tc,PX7600001,CDM,320,RC,76000,CPT,TC,,,,,,,597,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,256.113,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,585.06
CARBOplatin 600 MG/60ML Solution 60 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703423981,NDC,60,ML,301.42,,First Health,Commercial,both,85,,999999999,percent of total billed charges,256.207,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.778704,295.3916
dorzolamide-timolol 2-0.5 % Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,50383023310,NDC,10,ML,506.34,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,256.20804,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fluorouracil 5 GM/100ML Solution 100 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,16729027638,NDC,100,ML,261.44,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,256.2112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,256.2112
Layr Clos Wnd Rest Body 7.6-12.5,PX12044P,CDM,983,RC,12044,CPT,,,,,,,,523,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,256.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,217.2542,548.67
Layr Clos Wnd Rest Body 7.6-12.5,PX12044P,CDM,983,RC,12044,CPT,,,,,,,,523,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,256.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,217.2542,548.67
Layr Clos Wnd Rest Body 7.6-12.5,PX12044P,CDM,983,RC,12044,CPT,,,,,,,,523,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,256.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,217.2542,548.67
CHOLANGIOGRAM CATHETER REDDICK,27200000,CDM,272,RC,,,,10232-MAIN,LOCAL,,,,,287.98,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,256.3022,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Calr Gene Analysis Common Variants in Exon 9 - Ref,PX8121990,CDM,300,RC,81219,CPT,90,,,,,,,534,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,256.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.52,523.32
Calr Gene Analysis Common Variants in Exon 9 - Ref,PX8121990,CDM,300,RC,81219,CPT,90,,,,,,,534,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,256.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.52,523.32
Spirometry Incl Graph Rec Tc,PX9401002,CDM,460,RC,94010,CPT,TC,,,,,,,288,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,256.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.6352,282.24
gentamicin 0.1 % Ointment 30 g Tube,25000000,CDM,250,RC,,,,,,713068231,NDC,30,GR,506.64,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,256.35984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Blood Gases: Ph, Po2 & Pco2",PX82803,CDM,300,RC,82803,CPT,,,,,,,,518,,Humana Choice Care,All Medicare plans,outpatient,49.5,,253.82,percent of total billed charges,256.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.9,507.64
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221901,NDC,3,ML,506.9,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,256.4914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221905,NDC,3,ML,506.9,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,256.4914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
"Office/Outpt Visit,Est,Levl V",PX99215F,CDM,510,RC,99215,CPT,,,,,,,,318,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,256.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,89.69,324.12
"Office/Outpt Visit,Est,Levl V",PX99215P,CDM,983,RC,99215,CPT,,,,,,,,318,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,256.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,89.69,324.12
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151F,CDM,510,RC,13151,CPT,,,,,,,,1143,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,256.5589,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,173.43,877.89
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151P,CDM,983,RC,13151,CPT,,,,,,,,1177,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,256.5589,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,173.43,1153.46
Drain/Inject Large Joint/Bursa,PX20610P,CDM,983,RC,20610,CPT,,,,,,,,291,,United Healthcare,All Payer,outpatient,88.2,,123.860625,percent of total billed charges,256.662,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.8814,283.2303
Nafcillin Sodium 10 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323033060,NDC,1,EA,617.91,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,256.679814,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Destruct Benign Lesion, 1-14",PX17110F,CDM,510,RC,17110,CPT,,,,,,,,302,,First Health,Commercial,both,85,,999999999,percent of total billed charges,256.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.4508,295.96
Fac/Exc Skn Bngn1.1-2cm Remain Bdy,PX11422F,CDM,510,RC,11422,CPT,,,,,,,,618,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,256.7172,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,256.7172,1416.38
Tap Block Bilateral by Injection(S),PX64488P,CDM,983,RC,64488,CPT,,,,,,,,262,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,256.76,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.32,285.02
CARTER THOMASON CLOSURE SUTURE PASSER XL 10/12MM 15MM CTXL,27200000,CDM,272,RC,,,,12946-MAIN,LOCAL,,,,,535,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,256.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CARTER THOMASON CLOSURE SUTURE PASSER XL 10/12MM 15MM CTXL,27200000,CDM,272,RC,,,,12946-MAIN,LOCAL,,,,,535,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,256.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Xray Finger(S) Tc,PX7314001,CDM,320,RC,73140,CPT,TC,,,,,,,282,,Medica,Commercial,both,91.1,,124.35,percent of total billed charges,256.902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,276.36
Xray Toe(S) Tc,PX7366001,CDM,320,RC,73660,CPT,TC,,,,,,,282,,Medica,Commercial,both,91.1,,82.715,percent of total billed charges,256.902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,276.36
Xray Ac Joints(Bilateral),PX7305001,CDM,320,RC,73050,CPT,TC,,,,,,,519,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,256.905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,508.62
Inj Tendon/Ligament/Cyst,PX20550P,CDM,983,RC,20550,CPT,,,,,,,,264,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,256.9512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.6656,258.75
Occupational Therapy Eval Mod Complex,PX97166,CDM,434,RC,97166,CPT,,,,,,,,264,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,256.9512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,258.72
Physical Therapy Evaluation Mod Complex,PX97162,CDM,424,RC,97162,CPT,,,,,,,,264,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,164.6592958,percent of total billed charges,256.9512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,258.72
Renal Function Panel,PX80069,CDM,300,RC,80069,CPT,,,,,,,,264,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,217.12,percent of total billed charges,256.9512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.96,258.72
"Inpatient Consult, Level IV",PX99254,CDM,983,RC,99254,CPT,,,,,,,,508,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,257.048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.0232,494.4364
Lvl 2 Init Hosp Mod Mdm or 55 Minutes,PX99222,CDM,982,RC,99222,CPT,,,,,,,,508,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,257.048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.0232,494.4364
ePHEDrine sulfate 50 MG/ML Solution 1 mL Ampule,25000000,CDM,250,RC,,,,,,17478041510,NDC,1,ML,262.31,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,257.0638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BONE SCREW T8 FULL THREAD 2.4MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12652-MAIN,LOCAL,,,,,289,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,257.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
BONE SCREW T8 FULL THREAD 2.4MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12653-MAIN,LOCAL,,,,,289,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,257.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
BONE SCREW T8 FULL THREAD 2.7MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12654-MAIN,LOCAL,,,,,289,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,257.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Occupational Therapy Eval High Complex,PX97167,CDM,434,RC,97167,CPT,,,,,,,,289,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,257.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,283.22
"Troponin, Quantitative",PX84484,CDM,300,RC,84484,CPT,,,,,,,,289,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,257.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.43,283.22
Anal Sphincterotomy,PX46080P,CDM,983,RC,46080,CPT,,,,,,,,525,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,257.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,218.085,2452.93
Anal Sphincterotomy,PX46080P,CDM,983,RC,46080,CPT,,,,,,,,525,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,257.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,218.085,2452.93
Anal Sphincterotomy,PX46080P,CDM,983,RC,46080,CPT,,,,,,,,525,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,257.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,218.085,2452.93
Remove Nasal Foreign Body,PX30300F,CDM,510,RC,30300,CPT,,,,,,,,972,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,257.35,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.84,438.6
Remove Nasal Foreign Body,PX30300P,CDM,983,RC,30300,CPT,,,,,,,,572,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,257.35,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.84,560.56
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133F,CDM,510,RC,13133,CPT,,,,,,,,595,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,257.35,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77,348.67
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133P,CDM,983,RC,13133,CPT,,,,,,,,256,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,257.35,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77,348.67
"Fac/Office Consultation,Level IV",PX99244F,CDM,510,RC,99244,CPT,,,,,,,,441,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,257.376,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.11,287.64
"Office Consultation,Level IV",PX99244P,CDM,983,RC,99244,CPT,,,,,,,,441,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,257.376,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.11,432.18
DRILL BIT 2.2MM LONG SOLID STERILE MICA,27200000,CDM,272,RC,,,,12985-MAIN,LOCAL,,,,,600,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,257.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404P,CDM,983,RC,11404,CPT,,,,,,,,600,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,257.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,249.24,1416.38
Extremity Study - Vascular Diagnostics,PX9392201,CDM,921,RC,93922,CPT,TC,,,,,,,600,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,257.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,588
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012365,NDC,0.7,ML,291.98,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,257.52636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012388,NDC,0.7,ML,291.98,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,257.52636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072310,NDC,0.5,ML,291.98,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,257.52636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072388,NDC,0.5,ML,291.98,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,257.52636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
"Amputation Metatarsal+Toe,Single",PX28810P,CDM,983,RC,28810,CPT,,,,,,,,620,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,257.548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,257.548,2827.75
Colonoscopy,PX44388P,CDM,983,RC,44388,CPT,,,,,,,,620,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,257.548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,257.548,798.45
"Destruct Benign Lesion, 15+",PX17111F,CDM,510,RC,17111,CPT,,,,,,,,303,,First Health,Commercial,both,85,,999999999,percent of total billed charges,257.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.8662,296.94
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607P,CDM,983,RC,97607,CPT,,,,,,,,303,,First Health,Commercial,both,85,,999999999,percent of total billed charges,257.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.8662,348.35
Strapping of Knee,PX29530F,CDM,420,RC,29530,CPT,,,,,,,,303,,First Health,Commercial,both,85,,999999999,percent of total billed charges,257.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,296.94
Xray Knee 1 or 2 Vws,PX7356001,CDM,320,RC,73560,CPT,TC,,,,,,,303,,First Health,Commercial,both,85,,999999999,percent of total billed charges,257.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,296.94
Acute Hepatitis Panel,PX80074,CDM,300,RC,80074,CPT,,,,,,,,509,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,257.554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,43.67,498.82
Biopsy of Rectum,PX45100P,CDM,983,RC,45100,CPT,,,,,,,,509,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,257.554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.4386,2452.93
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315606,NDC,100,ML,264.64,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.949390909,percent of total billed charges,257.574112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.931456,259.3472
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315695,NDC,100,ML,264.64,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.949390909,percent of total billed charges,257.574112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.931456,259.3472
Infection Agent Detect Dna/Rna Probe Tq 6-11,PX87506,CDM,300,RC,87506,CPT,,,,,,,,1710,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,257.6827,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.1,262.99
Debride Tissue/Muscle,PX11043F,CDM,510,RC,11043,CPT,,,,,,,,526,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,257.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,218.5004,548.67
Debride Tissue/Muscle,PX11043F,CDM,510,RC,11043,CPT,,,,,,,,526,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,257.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,218.5004,548.67
Debride Tissue/Muscle,PX11043F,CDM,510,RC,11043,CPT,,,,,,,,526,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,257.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,218.5004,548.67
Hfe Gene - Ref,PX8125690,CDM,300,RC,81256,CPT,90,,,,,,,526,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,257.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,59.93,515.48
Hfe Gene - Ref,PX8125690,CDM,300,RC,81256,CPT,90,,,,,,,526,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,257.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,59.93,515.48
Hfe Gene - Ref,PX8125690,CDM,300,RC,81256,CPT,90,,,,,,,526,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,257.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,59.93,515.48
"X-Ray Exam Hip,Unilat W/Pelvis 1vw",PX7350101,CDM,320,RC,73501,CPT,TC,,,,,,,263,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,257.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,257.74
STAPLER RELOAD-CURVED CUTTER,27200000,CDM,272,RC,,,,12063-MAIN,LOCAL,,,,,283,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,257.813,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Destruct Benign Lesion, 1-14",PX17110P,CDM,983,RC,17110,CPT,,,,,,,,521,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,257.895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,507.0893
Haptoglobin; Quantitative,PX83010,CDM,300,RC,83010,CPT,,,,,,,,265,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,257.9245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.53,259.7
ID Nucleic Acid Sequencing - Ref,PX8715390,CDM,300,RC,87153,CPT,90,,,,,,,265,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,257.9245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.77,259.7
"Fna Biopsy, W/US Guidance; First Lesion",PX10005P,CDM,983,RC,10005,CPT,,,,,,,,621,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,257.9634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,257.9634,614.65
HERCULES 3 STAGE BALLOON ESOPHAGEAL 12-13.5-15::36-40.5-45MM,27200000,CDM,272,RC,C1726,HCPCS,,11329-MAIN,LOCAL,,,,,289.85,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,257.9665,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HERCULES 3 STAGE BALLOON ESOPHAGEAL 15-16.5-18:45-49.5-54MM,27200000,CDM,272,RC,C1726,HCPCS,,11328-MAIN,LOCAL,,,,,289.85,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,257.9665,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HERCULES 3 STAGE BALLOON ESOPHAGEAL 18-19-20::54-57-60MM,27200000,CDM,272,RC,C1726,HCPCS,,11330-MAIN,LOCAL,,,,,289.85,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,257.9665,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Apply Long Arm Splint,PX29105F,CDM,510,RC,29105,CPT,,,,,,,,290,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,258.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.466,284.2
Assay of Digoxin,PX80162,CDM,300,RC,80162,CPT,,,,,,,,290,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,258.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.18,284.2
Assay of Natriuretic Peptide,PX83880,CDM,300,RC,83880,CPT,,,,,,,,290,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,258.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36,284.2
NEEDLE INTRAOSSEOUS SET 15GA 25MM STABILIZER EZ-IO 9001P,120.216,CDM,272,RC,A4215,HCPCS,,10648-MAIN,LOCAL,,,,,290,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,258.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.466,284.2
NEEDLE INTRAOSSEOUS SET 15GA 45MM STABILIZER EZ-IO 9079P,120.216,CDM,272,RC,A4215,HCPCS,,10297-MAIN,LOCAL,,,,,290,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,258.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.466,284.2
fat emulsion 20 % Emulsion 250 mL Flex Cont,25000000,CDM,250,RC,,,,,,338051909,NDC,250,ML,292.75,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,258.2055,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
cefdinir 250 MG/5ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,16714039301,NDC,60,ML,510.33,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,258.22698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Closed Rx Trimalleolar Fx,PX27816F,CDM,510,RC,27816,CPT,,,,,,,,522,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,258.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,511.56
Xray Thoracic Spine 3 Vws,PX7207201,CDM,320,RC,72072,CPT,TC,,,,,,,522,,Humana Choice Care,All Medicare plans,outpatient,49.5,,144.76,percent of total billed charges,258.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,511.56
"Ctrl Nosebleed,Anter,Complex",PX30903P,CDM,983,RC,30903,CPT,,,,,,,,304,,First Health,Commercial,both,85,,999999999,percent of total billed charges,258.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,295.8832
Joint Survey Tc,PX7707701,CDM,320,RC,77077,CPT,TC,,,,,,,304,,First Health,Commercial,both,85,,999999999,percent of total billed charges,258.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,297.92
Hepatobiliary System Imaging,PX7822601,CDM,341,RC,78226,CPT,TC,,,,,,,2776,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,258.4054,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,175.17,517.37
"Digital Mamm, Diag, Unilat, Tc W/Cad Perf",PX7706501,CDM,401,RC,77065,CPT,TC,,,,,,,293,,United Healthcare,All Payer,outpatient,88.2,,145.29,percent of total billed charges,258.426,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.46,287.14
Drain Skin Abscess Simple,PX10060P,CDM,983,RC,10060,CPT,,,,,,,,293,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,258.426,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.7122,285.1769
Kit Gene Analysis D816 Variant(S) - Ref,PX8127390,CDM,300,RC,81273,CPT,90,,,,,,,293,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,258.426,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,114.49,287.14
Repr Superf Wnd Body <2.5cm,PX12001P,CDM,983,RC,12001,CPT,,,,,,,,293,,United Healthcare,All Payer,outpatient,88.2,,104.045,percent of total billed charges,258.426,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.7122,285.1769
prednisoLONE acetate 1 % Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063705,NDC,5,ML,283.79,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,258.53269,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dexmedeTOMIDine in sodium chloride 200 MCG/50ML Solution 50 mL Flex Cont,25000000,CDM,250,RC,,,,,,338955524,NDC,50,ML,304.32,,First Health,Commercial,both,85,,999999999,percent of total billed charges,258.672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
CP LAG SCREW 3.6MM L22MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12757-MAIN,LOCAL,,,,,539,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,258.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
CP LAG SCREW 3.6MM L22MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12757-MAIN,LOCAL,,,,,539,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,258.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
CP LAG SCREW 3.6MM L24MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12650-MAIN,LOCAL,,,,,539,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,258.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
CP LAG SCREW 3.6MM L24MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12650-MAIN,LOCAL,,,,,539,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,258.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
CP LAG SCREW 3.6MM L26MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12636-MAIN,LOCAL,,,,,539,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,258.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
CP LAG SCREW 3.6MM L26MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12636-MAIN,LOCAL,,,,,539,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,258.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Inj Tendon/Ligament/Cyst,PX20550P,CDM,983,RC,20550,CPT,,,,,,,,264,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,258.72,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.78,258.72
Occupational Therapy Eval Mod Complex,PX97166,CDM,434,RC,97166,CPT,,,,,,,,264,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,258.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,258.72
Physical Therapy Evaluation Mod Complex,PX97162,CDM,424,RC,97162,CPT,,,,,,,,264,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,258.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,258.72
Renal Function Panel,PX80069,CDM,300,RC,80069,CPT,,,,,,,,264,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,258.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.96,258.72
Drain/Inject Large Joint/Bursa,PX20610F,CDM,510,RC,20610,CPT,,,,,,,,364,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,258.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,151.2056,356.72
Drain/Inject Large Joint/Bursa,PX20610P,CDM,983,RC,20610,CPT,,,,,,,,291,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,258.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.8814,283.2303
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611F,CDM,510,RC,20611,CPT,,,,,,,,456,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,258.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.4224,446.88
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611P,CDM,983,RC,20611,CPT,,,,,,,,272,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,258.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.9888,264.7376
Drain/Inject Medium Joint/Bursa,PX20605F,CDM,510,RC,20605,CPT,,,,,,,,247,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,258.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.6038,258.75
Drain/Inject Medium Joint/Bursa,PX20605P,CDM,983,RC,20605,CPT,,,,,,,,318,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,258.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,309.5094
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604F,CDM,510,RC,20604,CPT,,,,,,,,344,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,258.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,142.8976,337.12
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604P,CDM,983,RC,20604,CPT,,,,,,,,229,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,258.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.1266,258.75
Drain/Inject Small Joint/Bursa,PX20600F,CDM,510,RC,20600,CPT,,,,,,,,161,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,258.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.8794,258.75
Drain/Inject Small Joint/Bursa,PX20600P,CDM,983,RC,20600,CPT,,,,,,,,161,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,258.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.8794,258.75
Fac/Ther Injection Carpal Tunnel,PX20526F,CDM,510,RC,20526,CPT,,,,,,,,191,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,258.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.3414,258.75
Inj Tendon/Ligament/Cyst,PX20550F,CDM,510,RC,20550,CPT,,,,,,,,177,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,258.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.5258,258.75
Inj Tendon/Ligament/Cyst,PX20550P,CDM,983,RC,20550,CPT,,,,,,,,264,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,258.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.6656,258.75
"Inject Nerv Blck,Trigeminal",PX64400F,CDM,510,RC,64400,CPT,,,,,,,,255,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,258.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.927,258.75
"Inject Nerv Blck,Trigeminal",PX64400P,CDM,983,RC,64400,CPT,,,,,,,,170,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,258.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,258.75
"Inject Trigger Point, 1 or 2",PX20552F,CDM,510,RC,20552,CPT,,,,,,,,252,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,258.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,258.75
"Inject Trigger Point, 1 or 2",PX20552P,CDM,983,RC,20552,CPT,,,,,,,,210,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,258.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,258.75
"N Block Inj, Common Digit",PX64632F,CDM,510,RC,64632,CPT,,,,,,,,190,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,258.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.926,258.75
"N Block Inj, Common Digit",PX64632P,CDM,983,RC,64632,CPT,,,,,,,,128,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,258.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.1712,258.75
"N Block Inj, Plantar Digit",PX64455F,CDM,510,RC,64455,CPT,,,,,,,,385,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,258.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,377.3
"N Block Inj, Plantar Digit",PX64455P,CDM,983,RC,64455,CPT,,,,,,,,385,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,258.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,374.7205
Ther Injection Carpal Tunnel,PX20526P,CDM,983,RC,20526,CPT,,,,,,,,248,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,258.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.0192,258.75
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,63323072902,NDC,1,EA,265.95,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,258.849135,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.47563,793.6922
Layr Clos Wnd Rest Body 7.6-12.5,PX12044P,CDM,983,RC,12044,CPT,,,,,,,,523,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,258.885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,217.2542,548.67
"Initial Observation Care,Levl I",PX99218,CDM,982,RC,99218,CPT,,,,,,,,266,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,258.8978,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.4964,258.8978
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597F,CDM,510,RC,97597,CPT,,,,,,,,266,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,222.54,percent of total billed charges,258.8978,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.4964,260.68
Drain/Inject Large Joint/Bursa,PX20610P,CDM,983,RC,20610,CPT,,,,,,,,291,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,258.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.8814,283.2303
DRIVER HEX 2.00MM STERILE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12440-MAIN,LOCAL,,,,,512,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,259.072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRIVER HEX 2.5MM STERILE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12441-MAIN,LOCAL,,,,,512,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,259.072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Closed Rx Kneecap Disloc+Anesth,PX27562F,CDM,510,RC,27562,CPT,,,,,,,,604,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,259.116,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,591.92
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,49884093547,NDC,100,GR,266.25,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,259.141125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Xray Sacrum/ Coccyx Minimum 2 Vws,PX7222001,CDM,320,RC,72220,CPT,TC,,,,,,,540,,Health Partners,Health Partners Care Plans,both,48,,250.38,percent of total billed charges,259.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,529.2
Xray Sacrum/ Coccyx Minimum 2 Vws,PX7222001,CDM,320,RC,72220,CPT,TC,,,,,,,540,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,259.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,529.2
Inc/Drain Peritonsil Abscess,PX42700F,CDM,510,RC,42700,CPT,,,,,,,,624,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,259.2096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,611.52
Excis Primary Ganglion Wrist,PX25111P,CDM,983,RC,25111,CPT,,,,,,,,529,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,259.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,219.7466,1404.08
Excis Primary Ganglion Wrist,PX25111P,CDM,983,RC,25111,CPT,,,,,,,,529,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,259.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,219.7466,1404.08
Excis Primary Ganglion Wrist,PX25111P,CDM,983,RC,25111,CPT,,,,,,,,529,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,259.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,219.7466,1404.08
"Bone Marrow Aspiration(S),Diag",PX38220F,CDM,510,RC,38220,CPT,,,,,,,,305,,First Health,Commercial,both,85,,999999999,percent of total billed charges,259.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,126.697,1416.38
Assay Thyroid Stim Hormone,PX84443,CDM,300,RC,84443,CPT,,,,,,,,294,,United Healthcare,All Payer,outpatient,88.2,,287.74,percent of total billed charges,259.308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.4,288.12
Francisella Tularensis Ab,PX8666890,CDM,300,RC,86668,CPT,90,,,,,,,294,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,259.308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.98,288.12
Physical Therapy Evaluation High Complex,PX97163,CDM,424,RC,97163,CPT,,,,,,,,294,,United Healthcare,All Payer,outpatient,88.2,,155.82,percent of total billed charges,259.308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,288.12
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315606,NDC,100,ML,264.64,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,259.3472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.931456,259.3472
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315695,NDC,100,ML,264.64,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,259.3472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.931456,259.3472
"Closed Rx Radial Head/Neck Fx,Manip",PX24655F,CDM,510,RC,24655,CPT,,,,,,,,1750,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,259.6,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,259.6,972.67
"Closed Rx Radial Head/Neck Fx,Manip",PX24655P,CDM,983,RC,24655,CPT,,,,,,,,1824,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,259.6,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,259.6,1787.52
Xray Sacroiliac Jnts 3 or More Vws,PX7220201,CDM,320,RC,72202,CPT,TC,,,,,,,285,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,259.635,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,279.3
Haptoglobin; Quantitative,PX83010,CDM,300,RC,83010,CPT,,,,,,,,265,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,259.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.53,259.7
ID Nucleic Acid Sequencing - Ref,PX8715390,CDM,300,RC,87153,CPT,90,,,,,,,265,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,259.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.77,259.7
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012365,NDC,0.7,ML,291.98,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,259.8622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012388,NDC,0.7,ML,291.98,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,259.8622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072310,NDC,0.5,ML,291.98,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,259.8622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072388,NDC,0.5,ML,291.98,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,259.8622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
Xray Shoulder 1 Vw,PX7302001,CDM,320,RC,73020,CPT,TC,,,,,,,267,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,259.8711,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,261.66
Anal Sphincterotomy,PX46080P,CDM,983,RC,46080,CPT,,,,,,,,525,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,259.875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,218.085,2452.93
"Fac/Exc Skn Bnig0.6-1cm Fae,Facial",PX11441F,CDM,510,RC,11441,CPT,,,,,,,,606,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,259.974,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,251.7324,614.65
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915801,NDC,1,ML,267.19,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,260.056027,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
sulfacetamide 10 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,61314070101,NDC,15,ML,285.48,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,260.07228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Xray Thoracolumbar 2 Vws,PX7208001,CDM,320,RC,72080,CPT,TC,,,,,,,306,,First Health,Commercial,both,85,,999999999,percent of total billed charges,260.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,299.88
Closed Rx Metacarpal Fx,PX26600P,CDM,983,RC,26600,CPT,,,,,,,,295,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,260.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.543,287.1235
Sulfur Colloid per Dose,PXA9541,CDM,343,RC,A9541,HCPCS,,,,,,,,295,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,260.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.543,289.1
"Supply Technetium Medronate,to 30 MC",PXA9503,CDM,343,RC,A9503,HCPCS,,,,,,,,531,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,260.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,220.5774,520.38
"Supply Technetium Medronate,to 30 MC",PXA9503,CDM,343,RC,A9503,HCPCS,,,,,,,,531,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,260.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,220.5774,520.38
"Supply Technetium Medronate,to 30 MC",PXA9503,CDM,343,RC,A9503,HCPCS,,,,,,,,531,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,260.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,220.5774,520.38
"Closed Rx Shldr Disloc,Anesthesia",PX23655F,CDM,510,RC,23655,CPT,,,,,,,,1776,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,260.25,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,260.25,871.67
"Closed Rx Shldr Disloc,Anesthesia",PX23655P,CDM,983,RC,23655,CPT,,,,,,,,1421,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,260.25,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,260.25,1392.58
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234010,NDC,5,ML,306.2,,First Health,Commercial,both,85,,999999999,percent of total billed charges,260.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234025,NDC,5,ML,306.2,,First Health,Commercial,both,85,,999999999,percent of total billed charges,260.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234099,NDC,5,ML,306.2,,First Health,Commercial,both,85,,999999999,percent of total billed charges,260.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022101,NDC,1,EA,514.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,260.337,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022185,NDC,1,EA,514.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,260.337,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022189,NDC,1,EA,514.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,260.337,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
Debride Tissue/Muscle,PX11043F,CDM,510,RC,11043,CPT,,,,,,,,526,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,260.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,218.5004,548.67
Hfe Gene - Ref,PX8125690,CDM,300,RC,81256,CPT,90,,,,,,,526,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,260.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,59.93,515.48
Anal Sphincterotomy,PX46080F,CDM,510,RC,46080,CPT,,,,,,,,607,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,260.403,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,252.1478,2452.93
Excis Forearm/Wrist Tumor Subcutan,PX25075P,CDM,983,RC,25075,CPT,,,,,,,,607,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,260.403,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,252.1478,1416.38
Open Bx/Excision Inguinofemoral Nodes,PX38531P,CDM,983,RC,38531,CPT,,,,,,,,607,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,260.403,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,252.1478,3329.99
"Excis Tendn/Capsule Lesn,Toes",PX28092F,CDM,510,RC,28092,CPT,,,,,,,,1234,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,260.4121,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,172.55,878.59
"Excis Tendn/Capsule Lesn,Toes",PX28092P,CDM,983,RC,28092,CPT,,,,,,,,1913,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,260.4121,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,172.55,1874.74
Blood Culture for Bacteria,PX87040,CDM,300,RC,87040,CPT,,,,,,,,286,,Medica,Commercial,both,91.1,,8.121818182,percent of total billed charges,260.546,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.46,280.28
I&D Bartholin Gland Abscess,PX56420P,CDM,983,RC,56420,CPT,,,,,,,,286,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,260.546,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,118.8044,278.3638
Joint Survey,PX7707726,CDM,982,RC,77077,CPT,26,,,,,,,286,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,260.546,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,278.3638
Lab Culture Bacteria,PX87070,CDM,300,RC,87070,CPT,,,,,,,,286,,Medica,Commercial,both,91.1,,126.175,percent of total billed charges,260.546,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.9,280.28
Urine Culture/Colony Count,PX87086,CDM,300,RC,87086,CPT,,,,,,,,286,,Medica,Commercial,both,91.1,,5.310588235,percent of total billed charges,260.546,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4,280.28
fat emulsion 20 % Emulsion 250 mL Flex Cont,25000000,CDM,250,RC,,,,,,338051909,NDC,250,ML,292.75,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,260.5475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
I&D Deep Absc/Hematoma Neck/Chest,PX21501P,CDM,983,RC,21501,CPT,,,,,,,,515,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,260.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.931,2482.37
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,63323072902,NDC,1,EA,265.95,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,260.631,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.47563,793.6922
Xray Knee (Both) Ap Stand,PX7356501,CDM,320,RC,73565,CPT,TC,,,,,,,543,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,260.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,532.14
Xray Knee (Both) Ap Stand,PX7356501,CDM,320,RC,73565,CPT,TC,,,,,,,543,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,260.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,532.14
"Initial Observation Care,Levl I",PX99218,CDM,982,RC,99218,CPT,,,,,,,,266,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,260.68,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.4752,260.68
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597F,CDM,510,RC,97597,CPT,,,,,,,,266,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,260.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.4964,260.68
"Digital Mamm, Diag, Unilat, Tc W/Cad Perf",PX7706501,CDM,401,RC,77065,CPT,TC,,,,,,,293,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,260.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.46,287.14
Drain Skin Abscess Simple,PX10060P,CDM,983,RC,10060,CPT,,,,,,,,293,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,260.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.7122,285.1769
Kit Gene Analysis D816 Variant(S) - Ref,PX8127390,CDM,300,RC,81273,CPT,90,,,,,,,293,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,260.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,114.49,287.14
Repr Superf Wnd Body <2.5cm,PX12001P,CDM,983,RC,12001,CPT,,,,,,,,293,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,260.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.7122,285.1769
tropicamide 1 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,61314035502,NDC,15,ML,267.96,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,260.805468,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
3.0MM HEADED SCREW LENGTH 16MM,C1713,CDM,278,RC,C1713,HCPCS,,12656-MAIN,LOCAL,,,,,608,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,260.832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"Closed Rx I-P Jt,Toe Dislocation",PX28660P,CDM,983,RC,28660,CPT,,,,,,,,628,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,260.8712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,611.2324
Exc Face Les Sc < 2 Cm,PX21011P,CDM,983,RC,21011,CPT,,,,,,,,628,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,260.8712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,260.8712,1416.38
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,49884093547,NDC,100,GR,266.25,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,260.925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
COOK EMERGENCY PNEUMOTHORAX SET,120.559,CDM,272,RC,,,,12597-MAIN,LOCAL,,,,,307,,First Health,Commercial,both,85,,999999999,percent of total billed charges,260.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,127.5278,300.86
MRI Brain WO Contrast Tc,PX7055101,CDM,610,RC,70551,CPT,TC,,,,,,,3335,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,260.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.34,260.99
MRI Brain WO Contrast Tc,PX7055101,CDM,610,RC,70551,CPT,TC,,,,,,,3335,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,260.99,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.34,260.99
"Apply Forearm Splint,Static",PX29125P,CDM,983,RC,29125,CPT,,,,,,,,296,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,261.072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,288.0968
Apply Lower Leg Splint,PX29515F,CDM,510,RC,29515,CPT,,,,,,,,296,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,261.072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.9584,290.08
Drain Skin Abscess Simple,PX10060F,CDM,510,RC,10060,CPT,,,,,,,,296,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,261.072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.9584,290.08
Closed Rx Shldr Dislocation,PX23650P,CDM,983,RC,23650,CPT,,,,,,,,516,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,261.096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,502.2228
Trg Gene Rearrangement Anal - Ref,PX8134290,CDM,300,RC,81342,CPT,90,,,,,,,516,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,261.096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,184.76,505.68
Xray Ribs Bil 3vws Tc,PX7111001,CDM,320,RC,71110,CPT,TC,,,,,,,533,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,261.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,522.34
Xray Ribs Bil 3vws Tc,PX7111001,CDM,320,RC,71110,CPT,TC,,,,,,,533,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,261.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,522.34
Xray Ribs Bil 3vws Tc,PX7111001,CDM,320,RC,71110,CPT,TC,,,,,,,533,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,261.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,522.34
"Infectious Disease,Chronic Hep C Virus,Six Assays, Utilizing Serum",PX8159690,CDM,300,RC,81596,CPT,90,,,,,,,609,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,261.261,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.19,596.82
Removal of Nail Bed,PX11750F,CDM,510,RC,11750,CPT,,,,,,,,629,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,261.2866,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,261.2866,616.42
insulin regular 100 UNIT/ML Solution 10 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821501,NDC,10,ML,307.46,,First Health,Commercial,both,85,,999999999,percent of total billed charges,261.341,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
insulin aspart prot & aspart 70-30 (70-30) 100 UNIT/ML Suspension Pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169369619,NDC,3,ML,629.28,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,261.402912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
sodium thiosulfate 250 MG/ML Solution 50 mL Vial,J0209.01,CDM,636,RC,J0209,HCPCS,,,,60267070550,NDC,50,ML,609.57,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,261.50553,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,253.215378,597.3786
Calr Gene Analysis Common Variants in Exon 9 - Ref,PX8121990,CDM,300,RC,81219,CPT,90,,,,,,,534,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,261.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.52,523.32
Calr Gene Analysis Common Variants in Exon 9 - Ref,PX8121990,CDM,300,RC,81219,CPT,90,,,,,,,534,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,261.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.52,523.32
Calr Gene Analysis Common Variants in Exon 9 - Ref,PX8121990,CDM,300,RC,81219,CPT,90,,,,,,,534,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,261.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.52,523.32
Xray Shoulder 1 Vw,PX7302001,CDM,320,RC,73020,CPT,TC,,,,,,,267,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,261.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,261.66
Assay Thyroid Stim Hormone,PX84443,CDM,300,RC,84443,CPT,,,,,,,,294,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,261.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.4,288.12
Francisella Tularensis Ab,PX8666890,CDM,300,RC,86668,CPT,90,,,,,,,294,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,261.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.98,288.12
Physical Therapy Evaluation High Complex,PX97163,CDM,424,RC,97163,CPT,,,,,,,,294,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,261.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,288.12
"Infect, Organ, Amp Probe - Ref",PX8780190,CDM,300,RC,87801,CPT,90,,,,,,,630,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,261.702,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.37,617.4
MESH XLARGE LEFT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 5X7,120.524,CDM,278,RC,C1781,HCPCS,,12216-MAIN,LOCAL,,,,,630,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,261.702,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,261.702,617.4
MESH XLARGE RIGHT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 5X7,120.524,CDM,278,RC,C1781,HCPCS,,12217-MAIN,LOCAL,,,,,630,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,261.702,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,261.702,617.4
NEEDLE INTRAOSSEOUS 15GA 15MM EZ-IO PEDS 9018,120.89,CDM,272,RC,A4215,HCPCS,,4964-MAIN,LOCAL,,,,,269,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,261.8177,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.7426,263.62
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915801,NDC,1,ML,267.19,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,261.8462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.414682,261.8462
Excis Primary Ganglion Wrist,PX25111P,CDM,983,RC,25111,CPT,,,,,,,,529,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,261.855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,219.7466,1404.08
"Blood Gases: Ph, Po2 & Pco2",PX82803,CDM,300,RC,82803,CPT,,,,,,,,518,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,262.108,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.9,507.64
HERNIA MESH LAP PROGRIP SELF FIXATING FLAT SHEET 10X15,C1781,CDM,278,RC,C1781,HCPCS,,12727-MAIN,LOCAL,,,,,611,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,262.119,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
CARTER THOMASON CLOSURE SUTURE PASSER XL 10/12MM 15MM CTXL,27200000,CDM,272,RC,,,,12946-MAIN,LOCAL,,,,,535,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,262.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CARTER THOMASON CLOSURE SUTURE PASSER XL 10/12MM 15MM CTXL,27200000,CDM,272,RC,,,,12946-MAIN,LOCAL,,,,,535,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,262.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CARTER THOMASON CLOSURE SUTURE PASSER XL 10/12MM 15MM CTXL,27200000,CDM,272,RC,,,,12946-MAIN,LOCAL,,,,,535,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,262.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Amputation Metatarsal+Toe,Single",PX28810F,CDM,510,RC,28810,CPT,,,,,,,,930,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,262.21,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.21,881.35
"Amputation Metatarsal+Toe,Single",PX28810P,CDM,983,RC,28810,CPT,,,,,,,,620,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,262.21,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.21,881.35
atropine 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,17478021502,NDC,2,ML,269.45,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,262.255685,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
atropine 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,60219174802,NDC,2,ML,269.45,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,262.255685,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
MINIBUNION LOCKING SCREW 3.0X24MM,C1713,CDM,278,RC,C1713,HCPCS,,11671-MAIN,LOCAL,,,,,308.55,,First Health,Commercial,both,85,,999999999,percent of total billed charges,262.2675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
MRI Abdomen W/O Tc,PX7418101,CDM,610,RC,74181,CPT,TC,,,,,,,2655,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,262.3,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.78,262.3
MRI Abdomen W/O Tc,PX7418101,CDM,610,RC,74181,CPT,TC,,,,,,,2655,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,262.3,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.78,262.3
CHOLANGIOGRAM CATHETER REDDICK,27200000,CDM,272,RC,,,,10232-MAIN,LOCAL,,,,,287.98,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,262.34978,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Spirometry Incl Graph Rec Tc,PX9401002,CDM,460,RC,94010,CPT,TC,,,,,,,288,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,262.368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.6352,282.24
Closure Superf Wnd Dehis Simple,PX12020F,CDM,510,RC,12020,CPT,,,,,,,,632,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,262.5328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.5328,619.36
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121P,CDM,983,RC,13121,CPT,,,,,,,,632,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,262.5328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.5328,615.1256
Closed Rx Metacarpal Fx,PX26600P,CDM,983,RC,26600,CPT,,,,,,,,295,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,262.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.543,287.1235
Sulfur Colloid per Dose,PXA9541,CDM,343,RC,A9541,HCPCS,,,,,,,,295,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,262.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.543,289.1
tropicamide 1 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,61314035502,NDC,15,ML,267.96,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,262.6008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Xray Ac Joints(Bilateral),PX7305001,CDM,320,RC,73050,CPT,TC,,,,,,,519,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,262.614,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,508.62
Aspirate Pleura W/ Imaging,PX32555P,CDM,983,RC,32555,CPT,,,,,,,,536,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,262.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,222.6544,548.81
Aspirate Pleura W/ Imaging,PX32555P,CDM,983,RC,32555,CPT,,,,,,,,536,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,262.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,222.6544,548.81
Aspirate Pleura W/ Imaging,PX32555P,CDM,983,RC,32555,CPT,,,,,,,,536,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,262.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,222.6544,548.81
Lvl 3 Init Hosp High Mdm or 75 Minutes,PX99223,CDM,982,RC,99223,CPT,,,,,,,,536,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,262.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,222.6544,521.6888
Lvl 3 Init Hosp High Mdm or 75 Minutes,PX99223,CDM,982,RC,99223,CPT,,,,,,,,536,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,262.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,222.6544,521.6888
Lvl 3 Init Hosp High Mdm or 75 Minutes,PX99223,CDM,982,RC,99223,CPT,,,,,,,,536,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,262.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,222.6544,521.6888
Drain/Inject Med Joint/Brusa W/US Guide,PX20606P,CDM,983,RC,20606,CPT,,,,,,,,309,,First Health,Commercial,both,85,,999999999,percent of total billed charges,262.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.3586,604.15
"Lap,Inguinal Hernia Repr,Initial",PX49650F,CDM,510,RC,49650,CPT,,,,,,,,1076,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,262.65,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.65,907.64
"Lap,Inguinal Hernia Repr,Initial",PX49650P,CDM,983,RC,49650,CPT,,,,,,,,717,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,262.65,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.65,907.64
LINNEAR CUTTER STAPLE RELOAD GST BLUE 60MM,27200000,CDM,272,RC,,,,12068-MAIN,LOCAL,,,,,309,,First Health,Commercial,both,85,,999999999,percent of total billed charges,262.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LINNEAR CUTTER STAPLE RELOAD GST GREEN 60MM,27200000,CDM,272,RC,,,,12069-MAIN,LOCAL,,,,,309,,First Health,Commercial,both,85,,999999999,percent of total billed charges,262.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LINNEAR CUTTER STAPLE RELOAD GST WHITE 60MM,27200000,CDM,272,RC,,,,12067-MAIN,LOCAL,,,,,309,,First Health,Commercial,both,85,,999999999,percent of total billed charges,262.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Naso/Orogastric Tube,PX43752P,CDM,983,RC,43752,CPT,,,,,,,,309,,First Health,Commercial,both,85,,999999999,percent of total billed charges,262.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.3586,348.08
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,63323077139,NDC,1,EA,547.2,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,262.656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,63323077139,NDC,1,EA,547.2,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,262.656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
"Closed Rx Radial Head Disloc,Child",PX24640F,CDM,510,RC,24640,CPT,,,,,,,,270,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,262.791,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.158,264.6
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157F,CDM,370,RC,99157,CPT,,,,,,,,270,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,262.791,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.158,264.6
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157P,CDM,983,RC,99157,CPT,,,,,,,,270,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,262.791,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.158,262.791
Wound Culture Anaerobic,PX87075,CDM,300,RC,87075,CPT,,,,,,,,270,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,262.791,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.68,264.6
"Ecg 12 Lead, Tracing Only",PX93005,CDM,730,RC,93005,CPT,,,,,,,,298,,United Healthcare,All Payer,outpatient,88.2,,245.9075,percent of total billed charges,262.836,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.44,292.04
"Supply Technetium Medronate,to 30 MC",PXA9503,CDM,343,RC,A9503,HCPCS,,,,,,,,531,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,262.845,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,220.5774,520.38
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122F,CDM,510,RC,13122,CPT,,,,,,,,788,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,262.88,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.39,262.88
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122P,CDM,983,RC,13122,CPT,,,,,,,,301,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,262.88,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.39,294.98
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,338035702,NDC,250,ML,309.28,,First Health,Commercial,both,85,,999999999,percent of total billed charges,262.888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.4701,303.0944
Infection Agent Detect Dna/Rna Probe Tq 6-11,PX87506,CDM,300,RC,87506,CPT,,,,,,,,1710,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,262.99,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.1,262.99
"Closed Rx Spont Hip Disloc,Anesth",PX27257F,CDM,510,RC,27257,CPT,,,,,,,,548,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,263.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.6392,1404.08
"Closed Rx Spont Hip Disloc,Anesth",PX27257F,CDM,510,RC,27257,CPT,,,,,,,,548,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,263.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.6392,1404.08
BRACE WRIST 8-IN SM LEFT 10432,120.564,CDM,273,RC,L3809,HCPCS,,12720-MAIN,LOCAL,,,,,23,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,263.1506,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST 8-IN SM RIGHT 10442,120.564,CDM,273,RC,L3809,HCPCS,,12716-MAIN,LOCAL,,,,,23,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,263.1506,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST 10-IN LG RIGHT 10464,120.564,CDM,273,RC,L3809,HCPCS,,12719-MAIN,LOCAL,,,,,23,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,263.1506,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST 10-IN SM LEFT 617083,120.564,CDM,273,RC,L3809,HCPCS,,12722-MAIN,LOCAL,,,,,23,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,263.1506,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST 10-IN SM RIGHT 10462,120.564,CDM,273,RC,L3809,HCPCS,,12717-MAIN,LOCAL,,,,,23,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,263.1506,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST 10-IN XL LEFT 10455,120.564,CDM,273,RC,L3809,HCPCS,,12721-MAIN,LOCAL,,,,,23,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,263.1506,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST 10-IN XL RIGHT 10465,120.564,CDM,273,RC,L3809,HCPCS,,12715-MAIN,LOCAL,,,,,23,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,263.1506,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST HAND THUMB LEFT 455-LT,120.315,CDM,274,RC,L3809,HCPCS,,8283-MAIN,LOCAL,,,,,77,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,263.1506,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST HAND THUMB RIGHT 455-RT,120.315,CDM,274,RC,L3809,HCPCS,,8284-MAIN,LOCAL,,,,,77,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,263.1506,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST WRISTPRO LEFT 10-IN LG,120.564,CDM,273,RC,L3809,HCPCS,,12724-MAIN,LOCAL,,,,,23,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,263.1506,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST WRISTPRO LEFT 10-IN MED,120.564,CDM,273,RC,L3809,HCPCS,,12723-MAIN,LOCAL,,,,,23,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,263.1506,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
SPLINT WRIST LARGE ALUMINUM FOREARM LEFT 9101-06,120.87,CDM,274,RC,L3809,HCPCS,,1265-MAIN,LOCAL,,,,,130,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,263.1506,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
SPLINT WRIST LARGE ALUMINUM FOREARM RIGHT 9101-03,120.87,CDM,274,RC,L3809,HCPCS,,1263-MAIN,LOCAL,,,,,130,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,263.1506,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
SPLINT WRIST MEDIUM ALUMINUM FOREARM LEFT 9101-05,120.87,CDM,274,RC,L3809,HCPCS,,1264-MAIN,LOCAL,,,,,130,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,263.1506,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
SPLINT WRIST MEDIUM ALUMINUM FOREARM RIGHT 9101-02,120.87,CDM,274,RC,L3809,HCPCS,,1262-MAIN,LOCAL,,,,,130,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,263.1506,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BONE SCREW T8 FULL THREAD 2.4MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12652-MAIN,LOCAL,,,,,289,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,263.279,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
BONE SCREW T8 FULL THREAD 2.4MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12653-MAIN,LOCAL,,,,,289,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,263.279,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
BONE SCREW T8 FULL THREAD 2.7MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12654-MAIN,LOCAL,,,,,289,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,263.279,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Occupational Therapy Eval High Complex,PX97167,CDM,434,RC,97167,CPT,,,,,,,,289,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,263.279,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,283.22
"Troponin, Quantitative",PX84484,CDM,300,RC,84484,CPT,,,,,,,,289,,Medica,Commercial,both,91.1,,18.554,percent of total billed charges,263.279,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.43,283.22
hydrocortisone sodium succinate (preservative free) 500 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001612,NDC,1,EA,298.53,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,263.30346,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
Drainage Scrotal Wall Abscess,PX55100F,CDM,510,RC,55100,CPT,,,,,,,,634,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,263.3636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,263.3636,1416.38
lidocaine - transparent dressing 4 % Kit 1 Each Box,63700001,CDM,250,RC,,,,,,496088207,NDC,1,EA,270.63,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,263.404179,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Chemotherapy, IV Infusion, 1 Hour",PX96413,CDM,335,RC,96413,CPT,,,,,,,,614,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,263.406,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.0556,601.72
Repr Superf Wnd Body 7.6-12.5,PX12004P,CDM,983,RC,12004,CPT,,,,,,,,614,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,263.406,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,597.6062
"Apply Forearm Splint,Static",PX29125P,CDM,983,RC,29125,CPT,,,,,,,,296,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,263.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,288.0968
Apply Lower Leg Splint,PX29515F,CDM,510,RC,29515,CPT,,,,,,,,296,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,263.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.9584,290.08
Drain Skin Abscess Simple,PX10060F,CDM,510,RC,10060,CPT,,,,,,,,296,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,263.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.9584,290.08
"Drain Finger Abscess,Simple",PX26010F,CDM,510,RC,26010,CPT,,,,,,,,310,,First Health,Commercial,both,85,,999999999,percent of total billed charges,263.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.774,303.8
NEEDLE INTRAOSSEOUS 15GA 15MM EZ-IO PEDS 9018,120.89,CDM,272,RC,A4215,HCPCS,,4964-MAIN,LOCAL,,,,,269,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,263.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.7426,263.62
"Destruct Benign Lesion, 1-14",PX17110P,CDM,983,RC,17110,CPT,,,,,,,,521,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,263.626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,507.0893
"Cytoflo, Cell or Dna Anal - Ref",PX8818290,CDM,310,RC,88182,CPT,90,,,,,,,225,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,263.63,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,161.11,270.528
"Cytoflo, Cell or Dna Anal - Ref",PX8818290,CDM,310,RC,88182,CPT,90,,,,,,,225,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,263.63,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,161.11,270.528
Exc Skin Benig <5mm Remaindr Body,PX11420P,CDM,983,RC,11420,CPT,,,,,,,,299,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,263.718,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,124.2046,1416.38
"Closed Rx Shldr Disloc,Anesthesia",PX23655F,CDM,510,RC,23655,CPT,,,,,,,,1776,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,263.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,260.25,871.67
"Closed Rx Shldr Disloc,Anesthesia",PX23655F,CDM,510,RC,23655,CPT,,,,,,,,1776,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,263.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,260.25,871.67
"Closed Rx Shldr Disloc,Anesthesia",PX23655P,CDM,983,RC,23655,CPT,,,,,,,,1421,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,263.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,260.25,1392.58
"Closed Rx Shldr Disloc,Anesthesia",PX23655P,CDM,983,RC,23655,CPT,,,,,,,,1421,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,263.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,260.25,1392.58
Remove Hemorrhoids & Fissure,PX46257F,CDM,510,RC,46257,CPT,,,,,,,,1141,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,263.74,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,263.74,870.28
Remove Hemorrhoids & Fissure,PX46257P,CDM,983,RC,46257,CPT,,,,,,,,615,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,263.74,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,263.74,870.28
Strapping of Ankle,PX29540F,CDM,420,RC,29540,CPT,,,,,,,,271,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,263.7643,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.5734,265.58
"Layr Clos Wnd Face,Facial <2.5cm",PX12051P,CDM,983,RC,12051,CPT,,,,,,,,615,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,263.835,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.471,598.5795
Remove Hemorrhoids & Fissure,PX46257P,CDM,983,RC,46257,CPT,,,,,,,,615,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,263.835,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.471,2452.93
Xray Ribs Bil 3vws Tc,PX7111001,CDM,320,RC,71110,CPT,TC,,,,,,,533,,Humana Choice Care,All Medicare plans,outpatient,49.5,,165.46,percent of total billed charges,263.835,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,522.34
HERCULES 3 STAGE BALLOON ESOPHAGEAL 12-13.5-15::36-40.5-45MM,27200000,CDM,272,RC,C1726,HCPCS,,11329-MAIN,LOCAL,,,,,289.85,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,264.05335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HERCULES 3 STAGE BALLOON ESOPHAGEAL 15-16.5-18:45-49.5-54MM,27200000,CDM,272,RC,C1726,HCPCS,,11328-MAIN,LOCAL,,,,,289.85,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,264.05335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HERCULES 3 STAGE BALLOON ESOPHAGEAL 18-19-20::54-57-60MM,27200000,CDM,272,RC,C1726,HCPCS,,11330-MAIN,LOCAL,,,,,289.85,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,264.05335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
atropine 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,17478021502,NDC,2,ML,269.45,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,264.061,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
atropine 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,60219174802,NDC,2,ML,269.45,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,264.061,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
CP LAG SCREW 3.6MM L22MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12757-MAIN,LOCAL,,,,,539,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,264.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
CP LAG SCREW 3.6MM L22MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12757-MAIN,LOCAL,,,,,539,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,264.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
CP LAG SCREW 3.6MM L22MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12757-MAIN,LOCAL,,,,,539,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,264.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
CP LAG SCREW 3.6MM L24MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12650-MAIN,LOCAL,,,,,539,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,264.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
CP LAG SCREW 3.6MM L24MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12650-MAIN,LOCAL,,,,,539,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,264.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
CP LAG SCREW 3.6MM L24MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12650-MAIN,LOCAL,,,,,539,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,264.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
CP LAG SCREW 3.6MM L26MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12636-MAIN,LOCAL,,,,,539,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,264.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
CP LAG SCREW 3.6MM L26MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12636-MAIN,LOCAL,,,,,539,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,264.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
CP LAG SCREW 3.6MM L26MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12636-MAIN,LOCAL,,,,,539,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,264.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Closed Rx Trimalleolar Fx,PX27816F,CDM,510,RC,27816,CPT,,,,,,,,522,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,264.132,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,511.56
Xray Thoracic Spine 3 Vws,PX7207201,CDM,320,RC,72072,CPT,TC,,,,,,,522,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,264.132,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,511.56
atropine 1 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,60219174903,NDC,5,ML,299.49,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,264.15018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Apply Long Arm Splint,PX29105F,CDM,510,RC,29105,CPT,,,,,,,,290,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,264.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.466,284.2
Assay of Digoxin,PX80162,CDM,300,RC,80162,CPT,,,,,,,,290,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,264.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.18,284.2
Assay of Natriuretic Peptide,PX83880,CDM,300,RC,83880,CPT,,,,,,,,290,,Medica,Commercial,both,91.1,,23.96833333,percent of total billed charges,264.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36,284.2
NEEDLE INTRAOSSEOUS SET 15GA 25MM STABILIZER EZ-IO 9001P,120.216,CDM,272,RC,A4215,HCPCS,,10648-MAIN,LOCAL,,,,,290,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,264.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.466,284.2
NEEDLE INTRAOSSEOUS SET 15GA 45MM STABILIZER EZ-IO 9079P,120.216,CDM,272,RC,A4215,HCPCS,,10297-MAIN,LOCAL,,,,,290,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,264.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.466,284.2
INSTRUMENT PACKAGE TOEMATE,27200000,CDM,272,RC,,,,11858-MAIN,LOCAL,,,,,636,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,264.1944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSTRUMENT TOEMATE X-SMALL PACKAGE 9H00-T060,27200000,CDM,272,RC,C1713,HCPCS,,11575-MAIN,LOCAL,,,,,636,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,264.1944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Pvb Thoracic Single Injection Site W/Img Gid,PX64461P,CDM,983,RC,64461,CPT,,,,,,,,616,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,264.264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.8864,604.15
Exc Skin Benig <5mm Remaindr Body,PX11420P,CDM,983,RC,11420,CPT,,,,,,,,299,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,264.27,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.35,293.02
Fac/Exc Skin Benig<5mm Remaind Bod,PX11420F,CDM,510,RC,11420,CPT,,,,,,,,374,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,264.27,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.35,264.27
Calr Gene Analysis Common Variants in Exon 9 - Ref,PX8121990,CDM,300,RC,81219,CPT,90,,,,,,,534,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,264.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.52,523.32
Apply Lower Leg Splint,PX29515P,CDM,983,RC,29515,CPT,,,,,,,,311,,First Health,Commercial,both,85,,999999999,percent of total billed charges,264.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,129.1894,302.6963
Repr Superf Wnd Body <2.5cm,PX12001F,CDM,510,RC,12001,CPT,,,,,,,,311,,First Health,Commercial,both,85,,999999999,percent of total billed charges,264.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,129.1894,304.78
Xray Skull Less Than 4 Vws,PX7025001,CDM,320,RC,70250,CPT,TC,,,,,,,311,,First Health,Commercial,both,85,,999999999,percent of total billed charges,264.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,304.78
"Lap,Inguinal Hernia Repr,Initial",PX49650F,CDM,510,RC,49650,CPT,,,,,,,,1076,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,264.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.65,907.64
"Lap,Inguinal Hernia Repr,Initial",PX49650F,CDM,510,RC,49650,CPT,,,,,,,,1076,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,264.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.65,907.64
"Lap,Inguinal Hernia Repr,Initial",PX49650P,CDM,983,RC,49650,CPT,,,,,,,,717,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,264.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.65,907.64
"Lap,Inguinal Hernia Repr,Initial",PX49650P,CDM,983,RC,49650,CPT,,,,,,,,717,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,264.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.65,907.64
Xray Facial Bones Minimum 3 Vws,PX7015001,CDM,320,RC,70150,CPT,TC,,,,,,,551,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,264.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,539.98
Xray Facial Bones Minimum 3 Vws,PX7015001,CDM,320,RC,70150,CPT,TC,,,,,,,551,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,264.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,539.98
"Close Rx Dist Fingr Fx,Manipulatn",PX26755F,CDM,510,RC,26755,CPT,,,,,,,,335,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,264.5864,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,177.14,692.49
"Close Rx Dist Fingr Fx,Manipulatn",PX26755P,CDM,983,RC,26755,CPT,,,,,,,,1260,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,264.5864,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,177.14,1234.8
"Closed Rx Radial Head Disloc,Child",PX24640F,CDM,510,RC,24640,CPT,,,,,,,,270,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,264.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.158,264.6
iohexol 300 MG/ML Solution 150 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141365,NDC,150,ML,300,,United Healthcare,All Payer,outpatient,88.2,,1.614024501,percent of total billed charges,264.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,294
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157F,CDM,370,RC,99157,CPT,,,,,,,,270,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,264.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.158,264.6
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157P,CDM,983,RC,99157,CPT,,,,,,,,270,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,264.6,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.86,264.6
"Spinal Punc,Drain,Theraputic",PX62272P,CDM,983,RC,62272,CPT,,,,,,,,300,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,264.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,124.62,604.15
US Follicles-Limited Tc,PX7685701,CDM,402,RC,76857,CPT,TC,,,,,,,300,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,264.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,294
Wound Culture Anaerobic,PX87075,CDM,300,RC,87075,CPT,,,,,,,,270,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,264.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.68,264.6
Xray Sacrum/ Coccyx Minimum 2 Vws,PX7222001,CDM,320,RC,72220,CPT,TC,,,,,,,540,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,347.7533333,percent of total billed charges,264.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,529.2
Xray Sacrum/ Coccyx Minimum 2 Vws,PX7222001,CDM,320,RC,72220,CPT,TC,,,,,,,540,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,264.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,529.2
Xray Sacrum/ Coccyx Minimum 2 Vws,PX7222001,CDM,320,RC,72220,CPT,TC,,,,,,,540,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,264.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,529.2
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409421505,NDC,5,ML,271.86,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,66.804,percent of total billed charges,264.601338,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
Insert Emergency Endotrach Airway,PX31500F,CDM,510,RC,31500,CPT,,,,,,,,637,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,264.6098,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,624.26
I&D Perirectal Abscess,PX46040F,CDM,510,RC,46040,CPT,,,,,,,,1430,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,264.62,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,264.62,1158.77
I&D Perirectal Abscess,PX46040P,CDM,983,RC,46040,CPT,,,,,,,,953,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,264.62,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,264.62,1158.77
Layr Clos Wnd Rest Body 7.6-12.5,PX12044P,CDM,983,RC,12044,CPT,,,,,,,,523,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,264.638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,217.2542,548.67
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200001,NDC,0.5,ML,980.99,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,264.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,264.67,961.3702
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200002,NDC,0.5,ML,980.99,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,264.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,264.67,961.3702
methylPREDNISolone sod succ 1000 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9001820,NDC,1,EA,271.97,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,264.708401,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611P,CDM,983,RC,20611,CPT,,,,,,,,272,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,264.7376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.9888,264.7376
CARTER THOMASON CLOSURE SUTURE PASSER XL 10/12MM 15MM CTXL,27200000,CDM,272,RC,,,,12946-MAIN,LOCAL,,,,,535,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,264.825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Drain Skin Abscess Simple,PX10060F,CDM,510,RC,10060,CPT,,,,,,,,296,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,264.96,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.41,264.96
Drain Skin Abscess Simple,PX10060P,CDM,983,RC,10060,CPT,,,,,,,,293,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,264.96,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.41,287.14
Nafcillin Sodium 10 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323033060,NDC,1,EA,617.91,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,265.08339,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Drain/Inject Large Joint/Bursa,PX20610P,CDM,983,RC,20610,CPT,,,,,,,,291,,Medica,Commercial,both,91.1,,40.695,percent of total billed charges,265.101,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.8814,283.2303
Fac/Exc Skn Bngn1.1-2cm Remain Bdy,PX11422F,CDM,510,RC,11422,CPT,,,,,,,,618,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,265.122,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,256.7172,1416.38
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,45963061959,NDC,1,EA,638.4,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,265.19136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
Closed Rx Kneecap Dislocatn,PX27560P,CDM,983,RC,27560,CPT,,,,,,,,312,,First Health,Commercial,both,85,,999999999,percent of total billed charges,265.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,129.6048,303.6696
lidocaine - transparent dressing 4 % Kit 1 Each Box,63700001,CDM,250,RC,,,,,,496088207,NDC,1,EA,270.63,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,265.2174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Ecg 12 Lead, Tracing Only",PX93005,CDM,730,RC,93005,CPT,,,,,,,,298,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,265.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.44,292.04
Aspirate Pleura W/ Imaging,PX32555P,CDM,983,RC,32555,CPT,,,,,,,,536,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,265.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,222.6544,548.81
Lvl 3 Init Hosp High Mdm or 75 Minutes,PX99223,CDM,982,RC,99223,CPT,,,,,,,,536,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,265.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,222.6544,521.6888
PERFIX PLUG STERILE MEDIUM,C1781,CDM,278,RC,C1781,HCPCS,,11770-MAIN,LOCAL,,,,,553,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,265.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
PERFIX PLUG STERILE MEDIUM,C1781,CDM,278,RC,C1781,HCPCS,,11770-MAIN,LOCAL,,,,,553,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,265.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
PACLitaxel 150 MG/25ML Concentrate 25 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321701,NDC,25,ML,300.96,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,265.44672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122P,CDM,983,RC,13122,CPT,,,,,,,,301,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,265.482,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.0354,292.9633
Xray Facial Bones Less Than 3 Vws,PX7014001,CDM,320,RC,70140,CPT,TC,,,,,,,301,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,265.482,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,294.98
"Amputation Metatarsal+Toe,Single",PX28810F,CDM,510,RC,28810,CPT,,,,,,,,930,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,265.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.21,881.35
"Amputation Metatarsal+Toe,Single",PX28810F,CDM,510,RC,28810,CPT,,,,,,,,930,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,265.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.21,881.35
"Amputation Metatarsal+Toe,Single",PX28810P,CDM,983,RC,28810,CPT,,,,,,,,620,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,265.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.21,881.35
"Amputation Metatarsal+Toe,Single",PX28810P,CDM,983,RC,28810,CPT,,,,,,,,620,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,265.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.21,881.35
"Closed Rx Radial Head/Neck Fx,Manip",PX24655F,CDM,510,RC,24655,CPT,,,,,,,,1750,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,265.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,259.6,972.67
"Closed Rx Radial Head/Neck Fx,Manip",PX24655F,CDM,510,RC,24655,CPT,,,,,,,,1750,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,265.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,259.6,972.67
"Closed Rx Radial Head/Neck Fx,Manip",PX24655P,CDM,983,RC,24655,CPT,,,,,,,,1824,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,265.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,259.6,1787.52
"Closed Rx Radial Head/Neck Fx,Manip",PX24655P,CDM,983,RC,24655,CPT,,,,,,,,1824,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,265.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,259.6,1787.52
"Critical Care, Addl 30 Min",PX99292P,CDM,983,RC,99292,CPT,,,,,,,,542,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,950.635,percent of total billed charges,265.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,225.1468,527.5286
"Critical Care, Addl 30 Min",PX99292P,CDM,983,RC,99292,CPT,,,,,,,,542,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,265.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,225.1468,527.5286
"Critical Care, Addl 30 Min",PX99292P,CDM,983,RC,99292,CPT,,,,,,,,542,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,265.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,225.1468,527.5286
Strapping of Ankle,PX29540F,CDM,420,RC,29540,CPT,,,,,,,,271,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,265.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.5734,265.58
Anal Sphincterotomy,PX46080P,CDM,983,RC,46080,CPT,,,,,,,,525,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,265.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,218.085,2452.93
hydrocortisone sodium succinate (preservative free) 500 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001612,NDC,1,EA,298.53,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,265.6917,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
Remove Hemorrhoids & Fissure,PX46257F,CDM,510,RC,46257,CPT,,,,,,,,1141,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,265.71,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,263.74,870.28
Remove Hemorrhoids & Fissure,PX46257F,CDM,510,RC,46257,CPT,,,,,,,,1141,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,265.71,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,263.74,870.28
Remove Hemorrhoids & Fissure,PX46257P,CDM,983,RC,46257,CPT,,,,,,,,615,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,265.71,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,263.74,870.28
Remove Hemorrhoids & Fissure,PX46257P,CDM,983,RC,46257,CPT,,,,,,,,615,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,265.71,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,263.74,870.28
CARBOplatin 600 MG/60ML Solution 60 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703423981,NDC,60,ML,301.42,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,265.85244,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.778704,295.3916
REVITA PLACENTAL MEMBRANE 2X3CM 6SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12559-MAIN,LOCAL,,,,,2474,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,265.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,265.9,614.65
REVITA PLACENTAL MEMBRANE 2X3CM 6SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12559-MAIN,LOCAL,,,,,2474,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,265.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,265.9,614.65
REVITA PLACENTAL MEMBRANE 4X4CM 16SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12560-MAIN,LOCAL,,,,,6597,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,265.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,265.9,614.65
REVITA PLACENTAL MEMBRANE 4X4CM 16SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12560-MAIN,LOCAL,,,,,6597,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,265.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,265.9,614.65
REVITA PLACENTAL MEMBRANE 4X6CM 24SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12561-MAIN,LOCAL,,,,,9896,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,265.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,265.9,614.65
REVITA PLACENTAL MEMBRANE 4X6CM 24SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12561-MAIN,LOCAL,,,,,9896,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,265.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,265.9,614.65
REVITA PLACENTAL MEMBRANE 6X6CM 36SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12562-MAIN,LOCAL,,,,,14844,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,265.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,265.9,614.65
REVITA PLACENTAL MEMBRANE 6X6CM 36SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12562-MAIN,LOCAL,,,,,14844,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,265.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,265.9,614.65
REVITA PLACENTAL MEMBRANE 6X8CM 48SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12563-MAIN,LOCAL,,,,,19792,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,265.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,265.9,614.65
REVITA PLACENTAL MEMBRANE 6X8CM 48SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12563-MAIN,LOCAL,,,,,19792,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,265.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,265.9,614.65
Aaa US Screen Tc,PX7670601,CDM,402,RC,76706,CPT,TC,,,,,,,554,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,265.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,542.92
Aaa US Screen Tc,PX7670601,CDM,402,RC,76706,CPT,TC,,,,,,,554,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,265.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,542.92
US Kidney Transplt Untrsd,PX7677601,CDM,402,RC,76776,CPT,TC,,,,,,,554,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,265.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,542.92
US Kidney Transplt Untrsd,PX7677601,CDM,402,RC,76776,CPT,TC,,,,,,,554,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,265.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,542.92
"Amputation Metatarsal+Toe,Single",PX28810P,CDM,983,RC,28810,CPT,,,,,,,,620,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,265.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,257.548,2827.75
Colonoscopy,PX44388P,CDM,983,RC,44388,CPT,,,,,,,,620,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,265.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,257.548,798.45
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012365,NDC,0.7,ML,291.98,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,265.99378,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012388,NDC,0.7,ML,291.98,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,265.99378,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072310,NDC,0.5,ML,291.98,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,265.99378,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072388,NDC,0.5,ML,291.98,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,265.99378,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
sulfacetamide 10 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,24208067004,NDC,15,ML,312.96,,First Health,Commercial,both,85,,999999999,percent of total billed charges,266.016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Dress/Debrid Small Burn No Anes,PX16020F,CDM,510,RC,16020,CPT,,,,,,,,313,,First Health,Commercial,both,85,,999999999,percent of total billed charges,266.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.0202,306.74
"Exc Skn Bngn2.1-3cmtrnk,Arm,Lg",PX11403P,CDM,983,RC,11403,CPT,,,,,,,,543,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,266.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,225.5622,614.65
"Exc Skn Bngn2.1-3cmtrnk,Arm,Lg",PX11403P,CDM,983,RC,11403,CPT,,,,,,,,543,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,266.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,225.5622,614.65
"Exc Skn Bngn2.1-3cmtrnk,Arm,Lg",PX11403P,CDM,983,RC,11403,CPT,,,,,,,,543,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,266.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,225.5622,614.65
Xray Knee (Both) Ap Stand,PX7356501,CDM,320,RC,73565,CPT,TC,,,,,,,543,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,105.4,percent of total billed charges,266.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,532.14
Xray Knee (Both) Ap Stand,PX7356501,CDM,320,RC,73565,CPT,TC,,,,,,,543,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,266.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,532.14
Xray Knee (Both) Ap Stand,PX7356501,CDM,320,RC,73565,CPT,TC,,,,,,,543,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,266.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,532.14
Exc Skin Benig <5mm Remaindr Body,PX11420P,CDM,983,RC,11420,CPT,,,,,,,,299,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,266.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,124.2046,1416.38
Debride Tissue/Muscle,PX11043F,CDM,510,RC,11043,CPT,,,,,,,,526,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,266.156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,218.5004,548.67
Hfe Gene - Ref,PX8125690,CDM,300,RC,81256,CPT,90,,,,,,,526,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,266.156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,59.93,515.48
"Destruct Benign Lesion, 1-14",PX17110F,CDM,510,RC,17110,CPT,,,,,,,,302,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,266.364,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.4508,295.96
Xray Sacroiliac Jnts Less Than 3 Vws,PX7220001,CDM,320,RC,72200,CPT,TC,,,,,,,555,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,266.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,543.9
Xray Sacroiliac Jnts Less Than 3 Vws,PX7220001,CDM,320,RC,72200,CPT,TC,,,,,,,555,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,266.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,543.9
"Fna Biopsy, W/US Guidance; First Lesion",PX10005P,CDM,983,RC,10005,CPT,,,,,,,,621,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,266.409,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,257.9634,614.65
Cv Carotid Imaging-Bilat,PX9388001,CDM,921,RC,93880,CPT,TC,,,,,,,1088,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,266.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.44,266.42
Cv Carotid Imaging-Bilat,PX9388001,CDM,921,RC,93880,CPT,TC,,,,,,,1088,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,266.42,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.44,266.42
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409421505,NDC,5,ML,271.86,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,266.4228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
methylPREDNISolone sod succ 1000 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9001820,NDC,1,EA,271.97,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,266.5306,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,266.5306
atropine 1 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,60219174903,NDC,5,ML,299.49,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,266.5461,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611P,CDM,983,RC,20611,CPT,,,,,,,,272,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,266.56,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.21,266.56
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597P,CDM,983,RC,97597,CPT,,,,,,,,274,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,222.54,percent of total billed charges,266.6842,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,113.8196,266.6842
fat emulsion 20 % Emulsion 250 mL Flex Cont,25000000,CDM,250,RC,,,,,,338051909,NDC,250,ML,292.75,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,266.69525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
CP LAG SCREW 3.6MM L22MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12757-MAIN,LOCAL,,,,,539,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,266.805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
CP LAG SCREW 3.6MM L24MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12650-MAIN,LOCAL,,,,,539,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,266.805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
CP LAG SCREW 3.6MM L26MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12636-MAIN,LOCAL,,,,,539,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,266.805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
X-Ray Exam Chest 2 Views,PX7104601,CDM,320,RC,71046,CPT,TC,,,,,,,556,,Health Partners,Health Partners Care Plans,both,48,,345.4733333,percent of total billed charges,266.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,544.88
X-Ray Exam Chest 2 Views,PX7104601,CDM,320,RC,71046,CPT,TC,,,,,,,556,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,266.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,544.88
Xray Chest 2 Views,PX7102001,CDM,320,RC,71020,CPT,TC,,,,,,,556,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,266.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,230.9624,544.88
Xray Chest 2 Views,PX7102001,CDM,320,RC,71020,CPT,TC,,,,,,,556,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,266.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,230.9624,544.88
Assay for Vancomycin,PX80202,CDM,300,RC,80202,CPT,,,,,,,,314,,First Health,Commercial,both,85,,999999999,percent of total billed charges,266.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.41,307.72
"Digital Mamm, Diag, Unilat, Tc W/Cad Perf",PX7706501,CDM,401,RC,77065,CPT,TC,,,,,,,293,,Medica,Commercial,both,91.1,,58.6,percent of total billed charges,266.923,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.46,287.14
Drain Skin Abscess Simple,PX10060P,CDM,983,RC,10060,CPT,,,,,,,,293,,Medica,Commercial,both,91.1,,229.31,percent of total billed charges,266.923,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.7122,285.1769
Kit Gene Analysis D816 Variant(S) - Ref,PX8127390,CDM,300,RC,81273,CPT,90,,,,,,,293,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,266.923,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,114.49,287.14
Repr Superf Wnd Body <2.5cm,PX12001P,CDM,983,RC,12001,CPT,,,,,,,,293,,Medica,Commercial,both,91.1,,114.92,percent of total billed charges,266.923,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.7122,285.1769
"Cardioversion, Elective;Extern",PX92960F,CDM,480,RC,92960,CPT,,,,,,,,402,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,267,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.41,267
"Cardioversion, Elective;Extern",PX92960P,CDM,983,RC,92960,CPT,,,,,,,,688,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,267,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.41,674.24
iohexol 300 MG/ML Solution 150 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141365,NDC,150,ML,300,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,267,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,294
"Spinal Punc,Drain,Theraputic",PX62272P,CDM,983,RC,62272,CPT,,,,,,,,300,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,267,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,124.62,604.15
US Follicles-Limited Tc,PX7685701,CDM,402,RC,76857,CPT,TC,,,,,,,300,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,267,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,294
I&D Perirectal Abscess,PX46040F,CDM,510,RC,46040,CPT,,,,,,,,1430,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,267.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,264.62,1158.77
I&D Perirectal Abscess,PX46040F,CDM,510,RC,46040,CPT,,,,,,,,1430,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,267.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,264.62,1158.77
I&D Perirectal Abscess,PX46040P,CDM,983,RC,46040,CPT,,,,,,,,953,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,267.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,264.62,1158.77
I&D Perirectal Abscess,PX46040P,CDM,983,RC,46040,CPT,,,,,,,,953,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,267.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,264.62,1158.77
"Biopsy of Prostate,Needle/Punch",PX55700F,CDM,510,RC,55700,CPT,,,,,,,,2039,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,267.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.96,500.17
"Closed Rx I-P Jt,Toe Dislocation",PX28660F,CDM,510,RC,28660,CPT,,,,,,,,335,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,267.03,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.24,267.03
"Closed Rx I-P Jt,Toe Dislocation",PX28660P,CDM,983,RC,28660,CPT,,,,,,,,628,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,267.03,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.24,615.44
PERFIX PLUG STERILE X-LARGE,C1781,CDM,278,RC,C1781,HCPCS,,11772-MAIN,LOCAL,,,,,643,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,267.1022,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
neomycin-polymyxin-gramicidin 1.75-10000-.025 Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,24208079062,NDC,10,ML,314.26,,First Health,Commercial,both,85,,999999999,percent of total billed charges,267.121,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062160,NDC,0.6,ML,274.53,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,25.0327027,percent of total billed charges,267.200049,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801601,NDC,0.6,ML,274.53,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,25.0327027,percent of total billed charges,267.200049,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801610,NDC,0.6,ML,274.53,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,25.0327027,percent of total billed charges,267.200049,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
"Destruct Benign Lesion, 15+",PX17111F,CDM,510,RC,17111,CPT,,,,,,,,303,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,267.246,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.8662,296.94
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607P,CDM,983,RC,97607,CPT,,,,,,,,303,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,267.246,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.8662,348.35
Strapping of Knee,PX29530F,CDM,420,RC,29530,CPT,,,,,,,,303,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,267.246,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,296.94
Xray Knee 1 or 2 Vws,PX7356001,CDM,320,RC,73560,CPT,TC,,,,,,,303,,United Healthcare,All Payer,outpatient,88.2,,216.645,percent of total billed charges,267.246,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,296.94
Xray Sacrum/ Coccyx Minimum 2 Vws,PX7222001,CDM,320,RC,72220,CPT,TC,,,,,,,540,,Humana Choice Care,All Medicare plans,outpatient,49.5,,127.71,percent of total billed charges,267.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,529.2
"Column Chrom Ms, Quant - Ref",PX8254290,CDM,300,RC,82542,CPT,90,,,,,,,557,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,267.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.09,545.86
"Column Chrom Ms, Quant - Ref",PX8254290,CDM,300,RC,82542,CPT,90,,,,,,,557,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,267.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.09,545.86
"Mra, Neck W/O+W/ Contrast",PX7054901,CDM,610,RC,70549,CPT,TC,,,,,,,3472,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,267.4158,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.28,535.12
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151P,CDM,983,RC,99151,CPT,,,,,,,,275,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,267.6575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,114.235,267.6575
Excis Primary Ganglion Wrist,PX25111P,CDM,983,RC,25111,CPT,,,,,,,,529,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,267.674,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,219.7466,1404.08
Inc/Drain Peritonsil Abscess,PX42700F,CDM,510,RC,42700,CPT,,,,,,,,624,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,267.696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,611.52
Assay Iga/Igd/Igg/Igm Each,PX82784,CDM,300,RC,82784,CPT,,,,,,,,315,,First Health,Commercial,both,85,,999999999,percent of total billed charges,267.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.53,308.7
BRACE WRIST 8-IN SM LEFT 10432,120.564,CDM,273,RC,L3809,HCPCS,,12720-MAIN,LOCAL,,,,,23,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,267.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST 8-IN SM LEFT 10432,120.564,CDM,273,RC,L3809,HCPCS,,12720-MAIN,LOCAL,,,,,23,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,267.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST 8-IN SM LEFT 10432,120.564,CDM,273,RC,L3809,HCPCS,,12720-MAIN,LOCAL,,,,,23,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,267.76,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST 8-IN SM RIGHT 10442,120.564,CDM,273,RC,L3809,HCPCS,,12716-MAIN,LOCAL,,,,,23,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,267.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST 8-IN SM RIGHT 10442,120.564,CDM,273,RC,L3809,HCPCS,,12716-MAIN,LOCAL,,,,,23,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,267.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST 8-IN SM RIGHT 10442,120.564,CDM,273,RC,L3809,HCPCS,,12716-MAIN,LOCAL,,,,,23,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,267.76,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST 10-IN LG RIGHT 10464,120.564,CDM,273,RC,L3809,HCPCS,,12719-MAIN,LOCAL,,,,,23,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,267.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST 10-IN LG RIGHT 10464,120.564,CDM,273,RC,L3809,HCPCS,,12719-MAIN,LOCAL,,,,,23,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,267.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST 10-IN LG RIGHT 10464,120.564,CDM,273,RC,L3809,HCPCS,,12719-MAIN,LOCAL,,,,,23,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,267.76,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST 10-IN SM LEFT 617083,120.564,CDM,273,RC,L3809,HCPCS,,12722-MAIN,LOCAL,,,,,23,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,267.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST 10-IN SM LEFT 617083,120.564,CDM,273,RC,L3809,HCPCS,,12722-MAIN,LOCAL,,,,,23,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,267.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST 10-IN SM LEFT 617083,120.564,CDM,273,RC,L3809,HCPCS,,12722-MAIN,LOCAL,,,,,23,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,267.76,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST 10-IN SM RIGHT 10462,120.564,CDM,273,RC,L3809,HCPCS,,12717-MAIN,LOCAL,,,,,23,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,267.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST 10-IN SM RIGHT 10462,120.564,CDM,273,RC,L3809,HCPCS,,12717-MAIN,LOCAL,,,,,23,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,267.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST 10-IN SM RIGHT 10462,120.564,CDM,273,RC,L3809,HCPCS,,12717-MAIN,LOCAL,,,,,23,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,267.76,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST 10-IN XL LEFT 10455,120.564,CDM,273,RC,L3809,HCPCS,,12721-MAIN,LOCAL,,,,,23,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,267.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST 10-IN XL LEFT 10455,120.564,CDM,273,RC,L3809,HCPCS,,12721-MAIN,LOCAL,,,,,23,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,267.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST 10-IN XL LEFT 10455,120.564,CDM,273,RC,L3809,HCPCS,,12721-MAIN,LOCAL,,,,,23,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,267.76,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST 10-IN XL RIGHT 10465,120.564,CDM,273,RC,L3809,HCPCS,,12715-MAIN,LOCAL,,,,,23,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,267.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST 10-IN XL RIGHT 10465,120.564,CDM,273,RC,L3809,HCPCS,,12715-MAIN,LOCAL,,,,,23,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,267.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST 10-IN XL RIGHT 10465,120.564,CDM,273,RC,L3809,HCPCS,,12715-MAIN,LOCAL,,,,,23,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,267.76,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST HAND THUMB LEFT 455-LT,120.315,CDM,274,RC,L3809,HCPCS,,8283-MAIN,LOCAL,,,,,77,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,267.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST HAND THUMB LEFT 455-LT,120.315,CDM,274,RC,L3809,HCPCS,,8283-MAIN,LOCAL,,,,,77,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,267.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST HAND THUMB LEFT 455-LT,120.315,CDM,274,RC,L3809,HCPCS,,8283-MAIN,LOCAL,,,,,77,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,267.76,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST HAND THUMB RIGHT 455-RT,120.315,CDM,274,RC,L3809,HCPCS,,8284-MAIN,LOCAL,,,,,77,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,267.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST HAND THUMB RIGHT 455-RT,120.315,CDM,274,RC,L3809,HCPCS,,8284-MAIN,LOCAL,,,,,77,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,267.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST HAND THUMB RIGHT 455-RT,120.315,CDM,274,RC,L3809,HCPCS,,8284-MAIN,LOCAL,,,,,77,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,267.76,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST WRISTPRO LEFT 10-IN LG,120.564,CDM,273,RC,L3809,HCPCS,,12724-MAIN,LOCAL,,,,,23,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,267.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST WRISTPRO LEFT 10-IN LG,120.564,CDM,273,RC,L3809,HCPCS,,12724-MAIN,LOCAL,,,,,23,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,267.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST WRISTPRO LEFT 10-IN LG,120.564,CDM,273,RC,L3809,HCPCS,,12724-MAIN,LOCAL,,,,,23,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,267.76,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST WRISTPRO LEFT 10-IN MED,120.564,CDM,273,RC,L3809,HCPCS,,12723-MAIN,LOCAL,,,,,23,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,267.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST WRISTPRO LEFT 10-IN MED,120.564,CDM,273,RC,L3809,HCPCS,,12723-MAIN,LOCAL,,,,,23,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,267.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
BRACE WRIST WRISTPRO LEFT 10-IN MED,120.564,CDM,273,RC,L3809,HCPCS,,12723-MAIN,LOCAL,,,,,23,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,267.76,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
SPLINT WRIST LARGE ALUMINUM FOREARM LEFT 9101-06,120.87,CDM,274,RC,L3809,HCPCS,,1265-MAIN,LOCAL,,,,,130,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,267.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
SPLINT WRIST LARGE ALUMINUM FOREARM LEFT 9101-06,120.87,CDM,274,RC,L3809,HCPCS,,1265-MAIN,LOCAL,,,,,130,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,267.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
SPLINT WRIST LARGE ALUMINUM FOREARM LEFT 9101-06,120.87,CDM,274,RC,L3809,HCPCS,,1265-MAIN,LOCAL,,,,,130,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,267.76,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
SPLINT WRIST LARGE ALUMINUM FOREARM RIGHT 9101-03,120.87,CDM,274,RC,L3809,HCPCS,,1263-MAIN,LOCAL,,,,,130,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,267.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
SPLINT WRIST LARGE ALUMINUM FOREARM RIGHT 9101-03,120.87,CDM,274,RC,L3809,HCPCS,,1263-MAIN,LOCAL,,,,,130,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,267.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
SPLINT WRIST LARGE ALUMINUM FOREARM RIGHT 9101-03,120.87,CDM,274,RC,L3809,HCPCS,,1263-MAIN,LOCAL,,,,,130,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,267.76,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
SPLINT WRIST MEDIUM ALUMINUM FOREARM LEFT 9101-05,120.87,CDM,274,RC,L3809,HCPCS,,1264-MAIN,LOCAL,,,,,130,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,267.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
SPLINT WRIST MEDIUM ALUMINUM FOREARM LEFT 9101-05,120.87,CDM,274,RC,L3809,HCPCS,,1264-MAIN,LOCAL,,,,,130,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,267.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
SPLINT WRIST MEDIUM ALUMINUM FOREARM LEFT 9101-05,120.87,CDM,274,RC,L3809,HCPCS,,1264-MAIN,LOCAL,,,,,130,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,267.76,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
SPLINT WRIST MEDIUM ALUMINUM FOREARM RIGHT 9101-02,120.87,CDM,274,RC,L3809,HCPCS,,1262-MAIN,LOCAL,,,,,130,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,267.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
SPLINT WRIST MEDIUM ALUMINUM FOREARM RIGHT 9101-02,120.87,CDM,274,RC,L3809,HCPCS,,1262-MAIN,LOCAL,,,,,130,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,267.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
SPLINT WRIST MEDIUM ALUMINUM FOREARM RIGHT 9101-02,120.87,CDM,274,RC,L3809,HCPCS,,1262-MAIN,LOCAL,,,,,130,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,267.76,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.37,267.76
ROPivacaine 2 MG/ML Solution 100 mL Bottle,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028568,NDC,100,ML,275.11,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,267.764563,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.604954,269.6078
Assay Thyroid Stim Hormone,PX84443,CDM,300,RC,84443,CPT,,,,,,,,294,,Medica,Commercial,both,91.1,,27.6,percent of total billed charges,267.834,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.4,288.12
Francisella Tularensis Ab,PX8666890,CDM,300,RC,86668,CPT,90,,,,,,,294,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,267.834,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.98,288.12
Physical Therapy Evaluation High Complex,PX97163,CDM,424,RC,97163,CPT,,,,,,,,294,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,267.834,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,288.12
BRONCHOSCOPE BFLEX 5.0 SINGLE-USE 0570-0449,120.578,CDM,272,RC,,,,13020-MAIN,LOCAL,,,,,558,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,267.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,231.7932,546.84
BRONCHOSCOPE BFLEX 5.0 SINGLE-USE 0570-0449,120.578,CDM,272,RC,,,,13020-MAIN,LOCAL,,,,,558,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,267.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,231.7932,546.84
PERFIX PLUG STERILE LARGE,C1781,CDM,278,RC,C1781,HCPCS,,11771-MAIN,LOCAL,,,,,558,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,267.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
PERFIX PLUG STERILE LARGE,C1781,CDM,278,RC,C1781,HCPCS,,11771-MAIN,LOCAL,,,,,558,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,267.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
PACLitaxel 150 MG/25ML Concentrate 25 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321701,NDC,25,ML,300.96,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,267.8544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122P,CDM,983,RC,13122,CPT,,,,,,,,301,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,267.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.0354,292.9633
Xray Facial Bones Less Than 3 Vws,PX7014001,CDM,320,RC,70140,CPT,TC,,,,,,,301,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,267.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,294.98
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821517,NDC,3,ML,275.33,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,4.0055,percent of total billed charges,267.978689,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
"Ctrl Nosebleed,Anter,Complex",PX30903P,CDM,983,RC,30903,CPT,,,,,,,,304,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,268.128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,295.8832
Joint Survey Tc,PX7707701,CDM,320,RC,77077,CPT,TC,,,,,,,304,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,268.128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,297.92
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,63323077139,NDC,1,EA,547.2,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,268.128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,63323077139,NDC,1,EA,547.2,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,268.128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,63323077139,NDC,1,EA,547.2,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,268.128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
CARBOplatin 600 MG/60ML Solution 60 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703423981,NDC,60,ML,301.42,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,268.2638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.778704,295.3916
"Critical Care, Addl 30 Min",PX99292P,CDM,983,RC,99292,CPT,,,,,,,,542,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,268.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,225.1468,527.5286
dexmedeTOMIDine in sodium chloride 200 MCG/50ML Solution 50 mL Flex Cont,25000000,CDM,250,RC,,,,,,338955524,NDC,50,ML,304.32,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,268.41024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Closed Rx Spont Hip Disloc,Anesth",PX27257F,CDM,510,RC,27257,CPT,,,,,,,,548,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,268.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.6392,1404.08
"Closed Rx Spont Hip Disloc,Anesth",PX27257F,CDM,510,RC,27257,CPT,,,,,,,,548,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,268.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.6392,1404.08
"Closed Rx Spont Hip Disloc,Anesth",PX27257F,CDM,510,RC,27257,CPT,,,,,,,,548,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,268.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.6392,1404.08
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597P,CDM,983,RC,97597,CPT,,,,,,,,274,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,268.52,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.28,268.52
Cast/Strap Procedure Unlisted,PX29799F,CDM,510,RC,29799,CPT,,,,,,,,316,,First Health,Commercial,both,85,,999999999,percent of total billed charges,268.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,131.2664,309.68
Culture Screen Only,PX87081,CDM,300,RC,87081,CPT,,,,,,,,276,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,268.6308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.08,270.48
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032601,NDC,0.5,ML,559.7,,Health Partners,Health Partners Care Plans,both,48,,1.606958333,percent of total billed charges,268.656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,1630.2692
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032601,NDC,0.5,ML,559.7,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,268.656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,1630.2692
"Supply Technetium Medronate,to 30 MC",PXA9503,CDM,343,RC,A9503,HCPCS,,,,,,,,531,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,268.686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,220.5774,520.38
Closed Rx Metacarpal Fx,PX26600P,CDM,983,RC,26600,CPT,,,,,,,,295,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,268.745,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.543,287.1235
Sulfur Colloid per Dose,PXA9541,CDM,343,RC,A9541,HCPCS,,,,,,,,295,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,268.745,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.543,289.1
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032P,CDM,983,RC,12032,CPT,,,,,,,,647,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,268.7638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,268.7638,629.7251
"Repair Umbilical Hern,5+Y/O,Reduc",PX49585P,CDM,983,RC,49585,CPT,,,,,,,,647,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,268.7638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,268.7638,629.7251
"Destruct Benign Lesion, 1-14",PX17110F,CDM,510,RC,17110,CPT,,,,,,,,302,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,268.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.4508,295.96
"Exc Skn Bngn2.1-3cmtrnk,Arm,Lg",PX11403P,CDM,983,RC,11403,CPT,,,,,,,,543,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,268.785,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,225.5622,614.65
Xray Knee (Both) Ap Stand,PX7356501,CDM,320,RC,73565,CPT,TC,,,,,,,543,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,268.785,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,532.14
"Enzyme Act, Nonradioact - Ref",PX8265790,CDM,300,RC,82657,CPT,90,,,,,,,560,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,268.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.33,548.8
"Enzyme Act, Nonradioact - Ref",PX8265790,CDM,300,RC,82657,CPT,90,,,,,,,560,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,268.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.33,548.8
"Bone Marrow Aspiration(S),Diag",PX38220F,CDM,510,RC,38220,CPT,,,,,,,,305,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,269.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,126.697,1416.38
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062160,NDC,0.6,ML,274.53,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,269.0394,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801601,NDC,0.6,ML,274.53,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,269.0394,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801610,NDC,0.6,ML,274.53,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,269.0394,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
8MM ENDOWRIST INSTRUMENTS MONOPOLAR CURVED SCISSORS,27200000,CDM,272,RC,,,,11909-MAIN,LOCAL,,,,,648,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,269.1792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STAPLER INTERNAL ECHELON FLEX POWERED PLUS LONG LENGTH 440MM,27200000,CDM,272,RC,,,,12065-MAIN,LOCAL,,,,,648,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,269.1792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12130-MAIN,LOCAL,,,,,561,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,269.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12130-MAIN,LOCAL,,,,,561,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,269.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Repair Lip,>1/2 Vert Height",PX40654F,CDM,510,RC,40654,CPT,,,,,,,,2467,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,269.41,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,269.41,1227.25
"Repair Lip,>1/2 Vert Height",PX40654P,CDM,983,RC,40654,CPT,,,,,,,,1329,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,269.41,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,269.41,1302.42
"Closed Rx I-P Jt,Toe Dislocation",PX28660P,CDM,983,RC,28660,CPT,,,,,,,,628,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,269.412,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,611.2324
Exc Face Les Sc < 2 Cm,PX21011P,CDM,983,RC,21011,CPT,,,,,,,,628,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,269.412,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,260.8712,1416.38
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151P,CDM,983,RC,99151,CPT,,,,,,,,275,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,269.5,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.05,269.5
"Molecular Cytog, Ea Probe - Ref",PX8827190,CDM,310,RC,88271,CPT,90,,,,,,,277,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,269.6041,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.64,271.46
"Xray Neck, Soft Tissue",PX7036001,CDM,320,RC,70360,CPT,TC,,,,,,,277,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,269.6041,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,271.46
ROPivacaine 2 MG/ML Solution 100 mL Bottle,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028568,NDC,100,ML,275.11,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,269.6078,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.604954,269.6078
"Apply Forearm Splint,Static",PX29125P,CDM,983,RC,29125,CPT,,,,,,,,296,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,269.656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,288.0968
Apply Lower Leg Splint,PX29515F,CDM,510,RC,29515,CPT,,,,,,,,296,,Medica,Commercial,both,91.1,,8.5,percent of total billed charges,269.656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.9584,290.08
Drain Skin Abscess Simple,PX10060F,CDM,510,RC,10060,CPT,,,,,,,,296,,Medica,Commercial,both,91.1,,229.31,percent of total billed charges,269.656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.9584,290.08
"Destruct Benign Lesion, 15+",PX17111F,CDM,510,RC,17111,CPT,,,,,,,,303,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,269.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.8662,296.94
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607P,CDM,983,RC,97607,CPT,,,,,,,,303,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,269.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.8662,348.35
Strapping of Knee,PX29530F,CDM,420,RC,29530,CPT,,,,,,,,303,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,269.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,296.94
Xray Knee 1 or 2 Vws,PX7356001,CDM,320,RC,73560,CPT,TC,,,,,,,303,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,269.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,296.94
Xray Ribs Bil 3vws Tc,PX7111001,CDM,320,RC,71110,CPT,TC,,,,,,,533,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,269.698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,522.34
"US,Preg. Uterus,Fetal/Mat.Eval.,>1st Trim.(>/= 14 Wks 0 Dys),Transabd;Single/First Gest., Tech",PX7680501,CDM,402,RC,76805,CPT,TC,,,,,,,562,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,269.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,550.76
"US,Preg. Uterus,Fetal/Mat.Eval.,>1st Trim.(>/= 14 Wks 0 Dys),Transabd;Single/First Gest., Tech",PX7680501,CDM,402,RC,76805,CPT,TC,,,,,,,562,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,269.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,550.76
Debride Skin/Tissue,PX11042F,CDM,510,RC,11042,CPT,,,,,,,,1067,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,269.8,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.08,269.8
Debride Skin/Tissue,PX11042P,CDM,983,RC,11042,CPT,,,,,,,,995,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,269.8,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.08,975.1
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821517,NDC,3,ML,275.33,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,269.8234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
Removal of Nail Bed,PX11750F,CDM,510,RC,11750,CPT,,,,,,,,629,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,269.841,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,261.2866,616.42
dexmedeTOMIDine in sodium chloride 400 MCG/100ML Solution 100 mL Bottle,25000000,CDM,250,RC,,,,,,67457092500,NDC,100,ML,562.18,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,269.8464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dexmedeTOMIDine in sodium chloride 400 MCG/100ML Solution 100 mL Bottle,25000000,CDM,250,RC,,,,,,67457092500,NDC,100,ML,562.18,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,269.8464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231001,NDC,10,ML,649.64,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,269.860456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231005,NDC,10,ML,649.64,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,269.860456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
Xray Thoracolumbar 2 Vws,PX7208001,CDM,320,RC,72080,CPT,TC,,,,,,,306,,United Healthcare,All Payer,outpatient,88.2,,156.06,percent of total billed charges,269.892,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,299.88
Ven Duplex Bilateral,PX9397001,CDM,921,RC,93970,CPT,TC,,,,,,,1189,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,269.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.18,269.91
Ven Duplex Bilateral,PX9397001,CDM,921,RC,93970,CPT,TC,,,,,,,1189,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,269.91,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,103.18,269.91
insulin aspart prot & aspart 70-30 (70-30) 100 UNIT/ML Suspension Pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169369619,NDC,3,ML,629.28,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,269.96112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031P,CDM,983,RC,12031,CPT,,,,,,,,551,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,269.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,228.8854,536.2883
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031P,CDM,983,RC,12031,CPT,,,,,,,,551,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,269.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,228.8854,536.2883
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031P,CDM,983,RC,12031,CPT,,,,,,,,551,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,269.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,228.8854,536.2883
Xray Facial Bones Minimum 3 Vws,PX7015001,CDM,320,RC,70150,CPT,TC,,,,,,,551,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,269.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,539.98
Xray Facial Bones Minimum 3 Vws,PX7015001,CDM,320,RC,70150,CPT,TC,,,,,,,551,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,269.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,539.98
Xray Facial Bones Minimum 3 Vws,PX7015001,CDM,320,RC,70150,CPT,TC,,,,,,,551,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,269.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,539.98
Acellular Derm Matrix Implt,PX15777F,CDM,510,RC,15777,CPT,,,,,,,,650,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,270.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.01,637
Closed Rx Bimalleolar Fx,PX27808F,CDM,510,RC,27808,CPT,,,,,,,,650,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,270.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,637
"Exc Skn Bngn2.1-3cm Fce,Facial",PX11443P,CDM,983,RC,11443,CPT,,,,,,,,650,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,270.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.01,1416.38
"Igh, Variable Region Somatic Mutation Analysis",PX8126390,CDM,310,RC,81263,CPT,90,,,,,,,1215,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,270.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.05,1190.7
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234010,NDC,5,ML,306.2,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,270.0684,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234025,NDC,5,ML,306.2,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,270.0684,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234099,NDC,5,ML,306.2,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,270.0684,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
rabies immune globulin 300 UNIT/ML Solution 1 mL Vial,90376,CDM,636,RC,90375,CPT,,,,13533031801,NDC,1,ML,1629.06,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,270.18,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.18,307.02
rabies immune globulin 1500 UNIT/5ML Solution 5 mL Vial,90375,CDM,636,RC,90375,CPT,,,,13533031805,NDC,5,ML,8065.26,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,270.18,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.18,307.02
Calr Gene Analysis Common Variants in Exon 9 - Ref,PX8121990,CDM,300,RC,81219,CPT,90,,,,,,,534,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,270.204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.52,523.32
Xray Pelvis Compl 3+ Tc,PX7219001,CDM,320,RC,72190,CPT,TC,,,,,,,563,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,270.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,551.74
Xray Pelvis Compl 3+ Tc,PX7219001,CDM,320,RC,72190,CPT,TC,,,,,,,563,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,270.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,551.74
"Infect, Organ, Amp Probe - Ref",PX8780190,CDM,300,RC,87801,CPT,90,,,,,,,630,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,270.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.37,617.4
MESH XLARGE LEFT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 5X7,120.524,CDM,278,RC,C1781,HCPCS,,12216-MAIN,LOCAL,,,,,630,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,270.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,261.702,617.4
MESH XLARGE RIGHT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 5X7,120.524,CDM,278,RC,C1781,HCPCS,,12217-MAIN,LOCAL,,,,,630,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,270.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,261.702,617.4
8MM ENDOWRIST INSTRUMENTS LARGE NEEDLE DRIVER,27200000,CDM,272,RC,,,,11912-MAIN,LOCAL,,,,,318,,First Health,Commercial,both,85,,999999999,percent of total billed charges,270.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Drain/Inject Medium Joint/Bursa,PX20605P,CDM,983,RC,20605,CPT,,,,,,,,318,,First Health,Commercial,both,85,,999999999,percent of total billed charges,270.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,309.5094
"Office/Outpt Visit,Est,Levl V",PX99215F,CDM,510,RC,99215,CPT,,,,,,,,318,,First Health,Commercial,both,85,,999999999,percent of total billed charges,270.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,311.64
"Office/Outpt Visit,Est,Levl V",PX99215P,CDM,983,RC,99215,CPT,,,,,,,,318,,First Health,Commercial,both,85,,999999999,percent of total billed charges,270.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,309.5094
"Remv F.B.,Eye,Cornea,No Slit",PX65220P,CDM,983,RC,65220,CPT,,,,,,,,318,,First Health,Commercial,both,85,,999999999,percent of total billed charges,270.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,348.08
"Sb Scope,to Ileum,Biopsy",PX44377F,CDM,750,RC,44377,CPT,,,,,,,,1770,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,270.3662,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,182.81,609.48
"Sb Scope,to Ileum,Biopsy",PX44377P,CDM,983,RC,44377,CPT,,,,,,,,1180,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,270.3662,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,182.81,1156.4
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505F,CDM,510,RC,25505,CPT,,,,,,,,651,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,270.4254,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.4254,1404.08
Remove Foreign Body Complic,PX10121P,CDM,983,RC,10121,CPT,,,,,,,,651,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,270.4254,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.4254,1416.38
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,6384371,NDC,1,EA,563.46,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,270.4608,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,6384371,NDC,1,EA,563.46,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,270.4608,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
Culture Screen Only,PX87081,CDM,300,RC,87081,CPT,,,,,,,,276,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,270.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.08,270.48
"Inj,Lumb Epidur,Blood/Clot Patch",PX62273P,CDM,983,RC,62273,CPT,,,,,,,,552,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,270.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,229.3008,604.15
"Inj,Lumb Epidur,Blood/Clot Patch",PX62273P,CDM,983,RC,62273,CPT,,,,,,,,552,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,270.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,229.3008,604.15
"Inj,Lumb Epidur,Blood/Clot Patch",PX62273P,CDM,983,RC,62273,CPT,,,,,,,,552,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,270.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,229.3008,604.15
Puncture Drainage of Lesion,PX10160F,CDM,510,RC,10160,CPT,,,,,,,,279,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,270.49,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.86,270.49
Puncture Drainage of Lesion,PX10160P,CDM,983,RC,10160,CPT,,,,,,,,186,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,270.49,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.86,270.49
"Cytoflo, Cell or Dna Anal - Ref",PX8818290,CDM,310,RC,88182,CPT,90,,,,,,,225,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,270.528,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,161.11,270.528
"Cytoflo, Cell or Dna Anal - Ref",PX8818290,CDM,310,RC,88182,CPT,90,,,,,,,225,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,270.528,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,161.11,270.528
"Ctrl Nosebleed,Anter,Complex",PX30903P,CDM,983,RC,30903,CPT,,,,,,,,304,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,270.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,295.8832
Joint Survey Tc,PX7707701,CDM,320,RC,77077,CPT,TC,,,,,,,304,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,270.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,297.92
CARTER THOMASON CLOSURE SUTURE PASSER XL 10/12MM 15MM CTXL,27200000,CDM,272,RC,,,,12946-MAIN,LOCAL,,,,,535,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,270.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
COOK EMERGENCY PNEUMOTHORAX SET,120.559,CDM,272,RC,,,,12597-MAIN,LOCAL,,,,,307,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,270.774,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,127.5278,300.86
dexmedeTOMIDine in sodium chloride 200 MCG/50ML Solution 50 mL Flex Cont,25000000,CDM,250,RC,,,,,,338955524,NDC,50,ML,304.32,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,270.8448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,63323077139,NDC,1,EA,547.2,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,270.864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
PERFIX PLUG STERILE MEDIUM,C1781,CDM,278,RC,C1781,HCPCS,,11770-MAIN,LOCAL,,,,,553,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,196.035,percent of total billed charges,270.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
PERFIX PLUG STERILE MEDIUM,C1781,CDM,278,RC,C1781,HCPCS,,11770-MAIN,LOCAL,,,,,553,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,270.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
PERFIX PLUG STERILE MEDIUM,C1781,CDM,278,RC,C1781,HCPCS,,11770-MAIN,LOCAL,,,,,553,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,270.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Closure Superf Wnd Dehis Simple,PX12020F,CDM,510,RC,12020,CPT,,,,,,,,632,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,271.128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.5328,619.36
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121P,CDM,983,RC,13121,CPT,,,,,,,,632,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,271.128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.5328,615.1256
"Ecg 12 Lead, Tracing Only",PX93005,CDM,730,RC,93005,CPT,,,,,,,,298,,Blue Cross Blue Shield of MN,All commercial plans,both,,,130.7503297,fee schedule,271.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.44,292.04
Fresh Frozen Plasma,PXP9017,CDM,390,RC,P9017,HCPCS,,,,,,,,319,,First Health,Commercial,both,85,,999999999,percent of total billed charges,271.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.32,312.62
"Level IV - Surgical Pathology, Gross and Microscopic Examination , Tech",PX3934,CDM,310,RC,88305,CPT,TC,,,,,,,185,,Blue Cross Blue Shield of MN,All commercial plans,both,,,118.731978,fee schedule,271.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,271.15
sugammadex sodium 200 MG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,6542302,NDC,2,ML,652.81,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,271.177274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
insulin regular 100 UNIT/ML Solution 10 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821501,NDC,10,ML,307.46,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,271.17972,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
Repr Superf Wnd Body 12.6-20,PX12005F,CDM,510,RC,12005,CPT,,,,,,,,565,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,271.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,234.701,553.7
Repr Superf Wnd Body 12.6-20,PX12005F,CDM,510,RC,12005,CPT,,,,,,,,565,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,271.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,234.701,553.7
Xray Lumbosacral Minimum 4 Vws,PX7211001,CDM,320,RC,72110,CPT,TC,,,,,,,565,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,271.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,553.7
Xray Lumbosacral Minimum 4 Vws,PX7211001,CDM,320,RC,72110,CPT,TC,,,,,,,565,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,271.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,553.7
Aspirate Pleura W/ Imaging,PX32555P,CDM,983,RC,32555,CPT,,,,,,,,536,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,271.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,222.6544,548.81
Lvl 3 Init Hosp High Mdm or 75 Minutes,PX99223,CDM,982,RC,99223,CPT,,,,,,,,536,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,271.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,222.6544,521.6888
"Closed Rx Spont Hip Disloc,Anesth",PX27257F,CDM,510,RC,27257,CPT,,,,,,,,548,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,271.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.6392,1404.08
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,55150017301,NDC,0.5,ML,319.2,,First Health,Commercial,both,85,,999999999,percent of total billed charges,271.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
Open Bx/Excision Inguinofemoral Nodes,PX38531F,CDM,510,RC,38531,CPT,,,,,,,,912,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,271.37,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,271.37,935.31
Open Bx/Excision Inguinofemoral Nodes,PX38531P,CDM,983,RC,38531,CPT,,,,,,,,607,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,271.37,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,271.37,935.31
"Bone Marrow Aspiration(S),Diag",PX38220F,CDM,510,RC,38220,CPT,,,,,,,,305,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,271.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,126.697,1416.38
Aaa US Screen Tc,PX7670601,CDM,402,RC,76706,CPT,TC,,,,,,,554,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,439.15,percent of total billed charges,271.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,542.92
Aaa US Screen Tc,PX7670601,CDM,402,RC,76706,CPT,TC,,,,,,,554,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,271.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,542.92
Aaa US Screen Tc,PX7670601,CDM,402,RC,76706,CPT,TC,,,,,,,554,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,271.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,542.92
"Molecular Cytog, Ea Probe - Ref",PX8827190,CDM,310,RC,88271,CPT,90,,,,,,,277,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,271.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.64,271.46
US Kidney Transplt Untrsd,PX7677601,CDM,402,RC,76776,CPT,TC,,,,,,,554,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,271.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,542.92
US Kidney Transplt Untrsd,PX7677601,CDM,402,RC,76776,CPT,TC,,,,,,,554,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,271.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,542.92
US Kidney Transplt Untrsd,PX7677601,CDM,402,RC,76776,CPT,TC,,,,,,,554,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,271.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,542.92
"Xray Neck, Soft Tissue",PX7036001,CDM,320,RC,70360,CPT,TC,,,,,,,277,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,271.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,271.46
"Ecg 12 Lead, Tracing Only",PX93005,CDM,730,RC,93005,CPT,,,,,,,,298,,Medica,Commercial,both,91.1,,78.578125,percent of total billed charges,271.478,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.44,292.04
"Hla Class II Low Res, 1 Locus - Ref",PX8137690,CDM,310,RC,81376,CPT,90,,,,,,,279,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,271.5507,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.06,273.42
INSUFLOWPORT & PNEUVIEW  XE SMOKE ELIMINATOR 5MM,27200000,CDM,272,RC,,,,11876-MAIN,LOCAL,,,,,279,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,271.5507,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 8MM,27200000,CDM,272,RC,,,,11877-MAIN,LOCAL,,,,,279,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,271.5507,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 10MM,27200000,CDM,272,RC,,,,11878-MAIN,LOCAL,,,,,279,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,271.5507,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 12MM,27200000,CDM,272,RC,,,,11879-MAIN,LOCAL,,,,,279,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,271.5507,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 5MM,27200000,CDM,272,RC,,,,11880-MAIN,LOCAL,,,,,279,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,271.5507,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 8MM,27200000,CDM,272,RC,,,,11881-MAIN,LOCAL,,,,,279,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,271.5507,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 10MM,27200000,CDM,272,RC,,,,11882-MAIN,LOCAL,,,,,279,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,271.5507,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 12MM,27200000,CDM,272,RC,,,,11883-MAIN,LOCAL,,,,,279,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,271.5507,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Puncture Drainage of Lesion,PX10160F,CDM,510,RC,10160,CPT,,,,,,,,279,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,70.27,percent of total billed charges,271.5507,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.8966,348.35
Xray Pelvis 1 or 2 Vws,PX7217001,CDM,320,RC,72170,CPT,TC,,,,,,,279,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,55.8,percent of total billed charges,271.5507,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,273.42
Injection Hip Arthrogram,PX27093F,CDM,510,RC,27093,CPT,,,,,,,,654,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,271.6716,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,271.6716,640.92
US Renal Retroperit Ltd,PX7677501,CDM,402,RC,76775,CPT,TC,,,,,,,566,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,271.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,554.68
US Renal Retroperit Ltd,PX7677501,CDM,402,RC,76775,CPT,TC,,,,,,,566,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,271.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,554.68
US Retroperitoneal Tc,PX7677001,CDM,402,RC,76770,CPT,TC,,,,,,,566,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,271.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,554.68
US Retroperitoneal Tc,PX7677001,CDM,402,RC,76770,CPT,TC,,,,,,,566,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,271.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,554.68
Xray Sacroiliac Jnts Less Than 3 Vws,PX7220001,CDM,320,RC,72200,CPT,TC,,,,,,,555,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,271.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,543.9
Xray Sacroiliac Jnts Less Than 3 Vws,PX7220001,CDM,320,RC,72200,CPT,TC,,,,,,,555,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,271.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,543.9
Xray Sacroiliac Jnts Less Than 3 Vws,PX7220001,CDM,320,RC,72200,CPT,TC,,,,,,,555,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,271.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,543.9
hydrocortisone sodium succinate (preservative free) 500 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001612,NDC,1,EA,298.53,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,271.96083,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
Drainage Scrotal Wall Abscess,PX55100F,CDM,510,RC,55100,CPT,,,,,,,,634,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,271.986,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,263.3636,1416.38
Apply Long Leg Splint,PX29505F,CDM,510,RC,29505,CPT,,,,,,,,320,,First Health,Commercial,both,85,,999999999,percent of total billed charges,272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.928,313.6
"IV Infusion, Bamlanivimab, Infusion and Post Admin Monig",PXM0239,CDM,260,RC,M0239,HCPCS,,,,,,,,320,,First Health,Commercial,both,85,,999999999,percent of total billed charges,272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.928,313.6
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035F,CDM,510,RC,12035,CPT,,,,,,,,655,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,272.087,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,272.087,641.9
MINIBUNION LOCKING SCREW 3.0X24MM,C1713,CDM,278,RC,C1713,HCPCS,,11671-MAIN,LOCAL,,,,,308.55,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,272.1411,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"Closed Rx Bimalleolar Fx,Manip",PX27810F,CDM,510,RC,27810,CPT,,,,,,,,1026,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,272.25,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,272.25,1021.1
"Closed Rx Bimalleolar Fx,Manip",PX27810P,CDM,983,RC,27810,CPT,,,,,,,,1057,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,272.25,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,272.25,1035.86
"Repair Lip,>1/2 Vert Height",PX40654F,CDM,510,RC,40654,CPT,,,,,,,,2467,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,272.25,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,269.41,1227.25
"Repair Lip,>1/2 Vert Height",PX40654F,CDM,510,RC,40654,CPT,,,,,,,,2467,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,272.25,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,269.41,1227.25
"Repair Lip,>1/2 Vert Height",PX40654P,CDM,983,RC,40654,CPT,,,,,,,,1329,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,272.25,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,269.41,1302.42
"Repair Lip,>1/2 Vert Height",PX40654P,CDM,983,RC,40654,CPT,,,,,,,,1329,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,272.25,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,269.41,1302.42
Xray Thoracolumbar 2 Vws,PX7208001,CDM,320,RC,72080,CPT,TC,,,,,,,306,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,272.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,299.88
Exc Skin Benig <5mm Remaindr Body,PX11420P,CDM,983,RC,11420,CPT,,,,,,,,299,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,272.389,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,124.2046,1416.38
X-Ray Exam Chest 2 Views,PX7104601,CDM,320,RC,71046,CPT,TC,,,,,,,556,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,174.6851282,percent of total billed charges,272.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,544.88
X-Ray Exam Chest 2 Views,PX7104601,CDM,320,RC,71046,CPT,TC,,,,,,,556,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,272.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,544.88
X-Ray Exam Chest 2 Views,PX7104601,CDM,320,RC,71046,CPT,TC,,,,,,,556,,United Healthcare,All Medicare advantage plans,outpatient,49,,285.67,percent of total billed charges,272.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,544.88
Xray Chest 2 Views,PX7102001,CDM,320,RC,71020,CPT,TC,,,,,,,556,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,272.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,230.9624,544.88
Xray Chest 2 Views,PX7102001,CDM,320,RC,71020,CPT,TC,,,,,,,556,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,272.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,230.9624,544.88
Xray Chest 2 Views,PX7102001,CDM,320,RC,71020,CPT,TC,,,,,,,556,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,272.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,230.9624,544.88
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234010,NDC,5,ML,306.2,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,272.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234025,NDC,5,ML,306.2,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,272.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234099,NDC,5,ML,306.2,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,272.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
"Pertechnetate, Dia, per Mci",PXA9512,CDM,343,RC,A9512,HCPCS,,,,,,,,280,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,272.524,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,116.312,274.4
Drain/Inject Med Joint/Brusa W/US Guide,PX20606P,CDM,983,RC,20606,CPT,,,,,,,,309,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,272.538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.3586,604.15
LINNEAR CUTTER STAPLE RELOAD GST BLUE 60MM,27200000,CDM,272,RC,,,,12068-MAIN,LOCAL,,,,,309,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,272.538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LINNEAR CUTTER STAPLE RELOAD GST GREEN 60MM,27200000,CDM,272,RC,,,,12069-MAIN,LOCAL,,,,,309,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,272.538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LINNEAR CUTTER STAPLE RELOAD GST WHITE 60MM,27200000,CDM,272,RC,,,,12067-MAIN,LOCAL,,,,,309,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,272.538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Naso/Orogastric Tube,PX43752P,CDM,983,RC,43752,CPT,,,,,,,,309,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,272.538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.3586,348.08
CP LAG SCREW 3.6MM L22MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12757-MAIN,LOCAL,,,,,539,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,272.734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
CP LAG SCREW 3.6MM L24MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12650-MAIN,LOCAL,,,,,539,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,272.734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
CP LAG SCREW 3.6MM L26MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12636-MAIN,LOCAL,,,,,539,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,272.734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031P,CDM,983,RC,12031,CPT,,,,,,,,551,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,272.745,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,228.8854,536.2883
Xray Facial Bones Minimum 3 Vws,PX7015001,CDM,320,RC,70150,CPT,TC,,,,,,,551,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,272.745,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,539.98
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,338035702,NDC,250,ML,309.28,,United Healthcare,All Payer,outpatient,88.2,,7.6225,percent of total billed charges,272.78496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.4701,303.0944
atropine 1 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,60219174903,NDC,5,ML,299.49,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,272.83539,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
INSTRUMENT PACKAGE TOEMATE,27200000,CDM,272,RC,,,,11858-MAIN,LOCAL,,,,,636,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,272.844,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSTRUMENT TOEMATE X-SMALL PACKAGE 9H00-T060,27200000,CDM,272,RC,C1713,HCPCS,,11575-MAIN,LOCAL,,,,,636,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,272.844,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Open Bx/Excision Inguinofemoral Nodes,PX38531F,CDM,510,RC,38531,CPT,,,,,,,,912,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,272.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,271.37,935.31
Open Bx/Excision Inguinofemoral Nodes,PX38531F,CDM,510,RC,38531,CPT,,,,,,,,912,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,272.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,271.37,935.31
Open Bx/Excision Inguinofemoral Nodes,PX38531P,CDM,983,RC,38531,CPT,,,,,,,,607,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,272.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,271.37,935.31
Open Bx/Excision Inguinofemoral Nodes,PX38531P,CDM,983,RC,38531,CPT,,,,,,,,607,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,272.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,271.37,935.31
Insert Emergency Endotrach Airway,PX31500P,CDM,983,RC,31500,CPT,,,,,,,,657,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,272.9178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,639.4581
"Column Chrom Ms, Quant - Ref",PX8254290,CDM,300,RC,82542,CPT,90,,,,,,,557,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,272.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.09,545.86
"Column Chrom Ms, Quant - Ref",PX8254290,CDM,300,RC,82542,CPT,90,,,,,,,557,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,272.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.09,545.86
"Column Chrom Ms, Quant - Ref",PX8254290,CDM,300,RC,82542,CPT,90,,,,,,,557,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,272.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.09,545.86
MINIBUNION NON-LOCKING SCREW  2.7X18MM,C1713,CDM,278,RC,C1713,HCPCS,,11670-MAIN,LOCAL,,,,,280.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,273.01065,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
COOK EMERGENCY PNEUMOTHORAX SET,120.559,CDM,272,RC,,,,12597-MAIN,LOCAL,,,,,307,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,273.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,127.5278,300.86
"Inj,Lumb Epidur,Blood/Clot Patch",PX62273P,CDM,983,RC,62273,CPT,,,,,,,,552,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,273.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,229.3008,604.15
Xray Sacrum/ Coccyx Minimum 2 Vws,PX7222001,CDM,320,RC,72220,CPT,TC,,,,,,,540,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,273.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,529.2
Dress/Debrid Large Burn No Anesth,PX16030F,CDM,510,RC,16030,CPT,,,,,,,,399,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,273.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.84,410.93
Insert Emergency Endotrach Airway,PX31500F,CDM,510,RC,31500,CPT,,,,,,,,637,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,273.273,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,624.26
iohexol 300 MG/ML Solution 150 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141365,NDC,150,ML,300,,Medica,Commercial,both,91.1,,0.950916667,percent of total billed charges,273.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,294
"Spinal Punc,Drain,Theraputic",PX62272P,CDM,983,RC,62272,CPT,,,,,,,,300,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,273.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,124.62,604.15
US Follicles-Limited Tc,PX7685701,CDM,402,RC,76857,CPT,TC,,,,,,,300,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,273.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,294
BRONCHOSCOPE BFLEX 5.0 SINGLE-USE 0570-0449,120.578,CDM,272,RC,,,,13020-MAIN,LOCAL,,,,,558,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,273.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,231.7932,546.84
BRONCHOSCOPE BFLEX 5.0 SINGLE-USE 0570-0449,120.578,CDM,272,RC,,,,13020-MAIN,LOCAL,,,,,558,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,273.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,231.7932,546.84
BRONCHOSCOPE BFLEX 5.0 SINGLE-USE 0570-0449,120.578,CDM,272,RC,,,,13020-MAIN,LOCAL,,,,,558,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,273.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,231.7932,546.84
"Drain Finger Abscess,Simple",PX26010F,CDM,510,RC,26010,CPT,,,,,,,,310,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,273.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.774,303.8
"Hla Class II Low Res, 1 Locus - Ref",PX8137690,CDM,310,RC,81376,CPT,90,,,,,,,279,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,273.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.06,273.42
INSUFLOWPORT & PNEUVIEW  XE SMOKE ELIMINATOR 5MM,27200000,CDM,272,RC,,,,11876-MAIN,LOCAL,,,,,279,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,273.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 8MM,27200000,CDM,272,RC,,,,11877-MAIN,LOCAL,,,,,279,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,273.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 10MM,27200000,CDM,272,RC,,,,11878-MAIN,LOCAL,,,,,279,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,273.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 12MM,27200000,CDM,272,RC,,,,11879-MAIN,LOCAL,,,,,279,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,273.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 5MM,27200000,CDM,272,RC,,,,11880-MAIN,LOCAL,,,,,279,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,273.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 8MM,27200000,CDM,272,RC,,,,11881-MAIN,LOCAL,,,,,279,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,273.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 10MM,27200000,CDM,272,RC,,,,11882-MAIN,LOCAL,,,,,279,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,273.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 12MM,27200000,CDM,272,RC,,,,11883-MAIN,LOCAL,,,,,279,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,273.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PERFIX PLUG STERILE LARGE,C1781,CDM,278,RC,C1781,HCPCS,,11771-MAIN,LOCAL,,,,,558,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,196.035,percent of total billed charges,273.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
PERFIX PLUG STERILE LARGE,C1781,CDM,278,RC,C1781,HCPCS,,11771-MAIN,LOCAL,,,,,558,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,273.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
PERFIX PLUG STERILE LARGE,C1781,CDM,278,RC,C1781,HCPCS,,11771-MAIN,LOCAL,,,,,558,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,273.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Puncture Drainage of Lesion,PX10160F,CDM,510,RC,10160,CPT,,,,,,,,279,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,273.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.8966,348.35
Xray Pelvis 1 or 2 Vws,PX7217001,CDM,320,RC,72170,CPT,TC,,,,,,,279,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,273.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,273.42
8MM ENDOWRIST INSTRUMENTS CADIERE FORCEPS,27200000,CDM,272,RC,,,,11913-MAIN,LOCAL,,,,,281,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,273.4973,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
FORCEPS PROGRASP 8MM ENDOWRIST INSTRUMENTS,27200000,CDM,272,RC,,,,12062-MAIN,LOCAL,,,,,281,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,273.4973,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Spirometry,PX9401001,CDM,460,RC,94010,CPT,TC,,,,,,,281,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,273.4973,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,116.7274,275.38
Exc Neck Les Sc = 3cm >,PX21552F,CDM,510,RC,21552,CPT,,,,,,,,753,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,273.56,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,273.56,938.08
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,65162083366,NDC,100,GR,281.12,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,273.614096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
insulin regular 100 UNIT/ML Solution 10 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821501,NDC,10,ML,307.46,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,273.6394,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
PERFIX PLUG STERILE MEDIUM,C1781,CDM,278,RC,C1781,HCPCS,,11770-MAIN,LOCAL,,,,,553,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,273.735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Insert Needle,Intraosseous Infusn",PX36680F,CDM,510,RC,36680,CPT,,,,,,,,659,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,273.7486,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,273.7486,645.82
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,45963061959,NDC,1,EA,638.4,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,273.8736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
Repeat Control of Nosebleed,PX30906F,CDM,510,RC,30906,CPT,,,,,,,,334,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,273.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,80.71,780.35
ketoconazole 2 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,16714095501,NDC,15,GR,322.42,,First Health,Commercial,both,85,,999999999,percent of total billed charges,274.057,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
insulin aspart 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169633910,NDC,3,ML,659.76,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,274.064304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
"Incis/Drain Scrotum/Testis,Epididym",PX54700F,CDM,510,RC,54700,CPT,,,,,,,,660,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,274.164,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.164,1779.39
Repair Incis Hernia W Mesh,PX49568P,CDM,983,RC,49568,CPT,,,,,,,,660,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,274.164,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.164,642.378
PACLitaxel 150 MG/25ML Concentrate 25 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321701,NDC,25,ML,300.96,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,274.17456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
"Cardiac Stress Tst,Tracing Only",PX93017,CDM,482,RC,93017,CPT,,,,,,,,1959,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,274.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.21,1919.82
Eval of Bronchospasm,PX94060,CDM,983,RC,94060,CPT,,,,,,,,176,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,274.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.1104,274.21
Gastric Intubation Treatment,PX43753F,CDM,510,RC,43753,CPT,,,,,,,,441,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,274.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,183.1914,432.18
Gastric Intubation Treatment,PX43753P,CDM,983,RC,43753,CPT,,,,,,,,498,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,274.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.8692,484.7034
Heart/Lung Resuscitation (Cpr),PX92950F,CDM,480,RC,92950,CPT,,,,,,,,1366,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,274.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.21,1338.68
Heart/Lung Resuscitation (Cpr),PX92950P,CDM,983,RC,92950,CPT,,,,,,,,1023,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,274.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.21,995.6859
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122P,CDM,983,RC,13122,CPT,,,,,,,,301,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,274.211,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.0354,292.9633
Xray Facial Bones Less Than 3 Vws,PX7014001,CDM,320,RC,70140,CPT,TC,,,,,,,301,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,274.211,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,294.98
Aaa US Screen Tc,PX7670601,CDM,402,RC,76706,CPT,TC,,,,,,,554,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,274.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,542.92
US Kidney Transplt Untrsd,PX7677601,CDM,402,RC,76776,CPT,TC,,,,,,,554,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,274.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,542.92
"Critical Care, Addl 30 Min",PX99292P,CDM,983,RC,99292,CPT,,,,,,,,542,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,274.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,225.1468,527.5286
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032601,NDC,0.5,ML,559.7,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.52069,percent of total billed charges,274.253,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,1630.2692
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032601,NDC,0.5,ML,559.7,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,274.253,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,1630.2692
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032601,NDC,0.5,ML,559.7,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,274.253,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,1630.2692
Apply Lower Leg Splint,PX29515P,CDM,983,RC,29515,CPT,,,,,,,,311,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,274.302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,129.1894,302.6963
Repr Superf Wnd Body <2.5cm,PX12001F,CDM,510,RC,12001,CPT,,,,,,,,311,,United Healthcare,All Payer,outpatient,88.2,,104.045,percent of total billed charges,274.302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,129.1894,304.78
Xray Skull Less Than 4 Vws,PX7025001,CDM,320,RC,70250,CPT,TC,,,,,,,311,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,274.302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,304.78
"Close Rx Fingr Articular Fx,Manip",PX26742P,CDM,983,RC,26742,CPT,,,,,,,,560,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,274.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,232.624,1404.08
"Close Rx Fingr Articular Fx,Manip",PX26742P,CDM,983,RC,26742,CPT,,,,,,,,560,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,274.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,232.624,1404.08
"Close Rx Fingr Articular Fx,Manip",PX26742P,CDM,983,RC,26742,CPT,,,,,,,,560,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,274.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,232.624,1404.08
"Enzyme Act, Nonradioact - Ref",PX8265790,CDM,300,RC,82657,CPT,90,,,,,,,560,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,274.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.33,548.8
"Enzyme Act, Nonradioact - Ref",PX8265790,CDM,300,RC,82657,CPT,90,,,,,,,560,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,274.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.33,548.8
"Enzyme Act, Nonradioact - Ref",PX8265790,CDM,300,RC,82657,CPT,90,,,,,,,560,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,274.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.33,548.8
"Pertechnetate, Dia, per Mci",PXA9512,CDM,343,RC,A9512,HCPCS,,,,,,,,280,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,274.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,116.312,274.4
Xray Finger(S) Tc,PX7314001,CDM,320,RC,73140,CPT,TC,,,,,,,282,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,167.218,percent of total billed charges,274.4706,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,276.36
Xray Toe(S) Tc,PX7366001,CDM,320,RC,73660,CPT,TC,,,,,,,282,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,274.4706,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,276.36
Xray Ls Spine Bend Tc,PX7212001,CDM,320,RC,72120,CPT,TC,,,,,,,323,,First Health,Commercial,both,85,,999999999,percent of total billed charges,274.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,316.54
MESH LARGE LEFT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 4X6,120.521,CDM,278,RC,C1781,HCPCS,,12215-MAIN,LOCAL,,,,,572,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,274.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,237.6088,560.56
MESH LARGE LEFT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 4X6,120.521,CDM,278,RC,C1781,HCPCS,,12215-MAIN,LOCAL,,,,,572,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,274.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,237.6088,560.56
MESH LARGE RIGHT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 4X6,C1781,CDM,278,RC,C1781,HCPCS,,12195-MAIN,LOCAL,,,,,572,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,274.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
MESH LARGE RIGHT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 4X6,C1781,CDM,278,RC,C1781,HCPCS,,12195-MAIN,LOCAL,,,,,572,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,274.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
CARBOplatin 600 MG/60ML Solution 60 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703423981,NDC,60,ML,301.42,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,274.59362,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.778704,295.3916
MINIBUNION LOCKING SCREW 3.0X24MM,C1713,CDM,278,RC,C1713,HCPCS,,11671-MAIN,LOCAL,,,,,308.55,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,274.6095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Xray Sacroiliac Jnts Less Than 3 Vws,PX7220001,CDM,320,RC,72200,CPT,TC,,,,,,,555,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,274.725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,543.9
"Exc Skn Bngn2.1-3cmtrnk,Arm,Lg",PX11403P,CDM,983,RC,11403,CPT,,,,,,,,543,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,274.758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,225.5622,614.65
Xray Knee (Both) Ap Stand,PX7356501,CDM,320,RC,73565,CPT,TC,,,,,,,543,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,274.758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,532.14
Drain Skin Abscess Complic,PX10061P,CDM,983,RC,10061,CPT,,,,,,,,561,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,274.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,233.0394,546.0213
Drain Skin Abscess Complic,PX10061P,CDM,983,RC,10061,CPT,,,,,,,,561,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,274.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,233.0394,546.0213
Drain Skin Abscess Complic,PX10061P,CDM,983,RC,10061,CPT,,,,,,,,561,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,274.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,233.0394,546.0213
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12130-MAIN,LOCAL,,,,,561,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,274.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12130-MAIN,LOCAL,,,,,561,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,274.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12130-MAIN,LOCAL,,,,,561,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,274.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MINIBUNION NON-LOCKING SCREW  2.7X18MM,C1713,CDM,278,RC,C1713,HCPCS,,11670-MAIN,LOCAL,,,,,280.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,274.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Fluoroscopy Guid Needle Plcmt Tc,PX7700201,CDM,320,RC,77002,CPT,TC,,,,,,,662,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,274.9948,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.9948,648.76
Drain/Inject Med Joint/Brusa W/US Guide,PX20606P,CDM,983,RC,20606,CPT,,,,,,,,309,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,275.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.3586,604.15
LINNEAR CUTTER STAPLE RELOAD GST BLUE 60MM,27200000,CDM,272,RC,,,,12068-MAIN,LOCAL,,,,,309,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,275.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LINNEAR CUTTER STAPLE RELOAD GST GREEN 60MM,27200000,CDM,272,RC,,,,12069-MAIN,LOCAL,,,,,309,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,275.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LINNEAR CUTTER STAPLE RELOAD GST WHITE 60MM,27200000,CDM,272,RC,,,,12067-MAIN,LOCAL,,,,,309,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,275.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Naso/Orogastric Tube,PX43752P,CDM,983,RC,43752,CPT,,,,,,,,309,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,275.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.3586,348.08
"Destruct Benign Lesion, 1-14",PX17110F,CDM,510,RC,17110,CPT,,,,,,,,302,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,275.122,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.4508,295.96
Closed Rx Kneecap Dislocatn,PX27560P,CDM,983,RC,27560,CPT,,,,,,,,312,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,275.184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,129.6048,303.6696
X-Ray Exam Chest 2 Views,PX7104601,CDM,320,RC,71046,CPT,TC,,,,,,,556,,Humana Choice Care,All Medicare plans,outpatient,49.5,,128.6415385,percent of total billed charges,275.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,544.88
Xray Chest 2 Views,PX7102001,CDM,320,RC,71020,CPT,TC,,,,,,,556,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,275.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,230.9624,544.88
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,338035702,NDC,250,ML,309.28,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,275.2592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.4701,303.0944
8MM ENDOWRIST INSTRUMENTS CADIERE FORCEPS,27200000,CDM,272,RC,,,,11913-MAIN,LOCAL,,,,,281,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,275.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Exc Skn Bngn3.1-4cm Remain Bdy,PX11424P,CDM,983,RC,11424,CPT,,,,,,,,562,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,275.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,233.4548,1416.38
Exc Skn Bngn3.1-4cm Remain Bdy,PX11424P,CDM,983,RC,11424,CPT,,,,,,,,562,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,275.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,233.4548,1416.38
Exc Skn Bngn3.1-4cm Remain Bdy,PX11424P,CDM,983,RC,11424,CPT,,,,,,,,562,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,275.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,233.4548,1416.38
FORCEPS PROGRASP 8MM ENDOWRIST INSTRUMENTS,27200000,CDM,272,RC,,,,12062-MAIN,LOCAL,,,,,281,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,275.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Spirometry,PX9401001,CDM,460,RC,94010,CPT,TC,,,,,,,281,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,275.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,116.7274,275.38
"US,Preg. Uterus,Fetal/Mat.Eval.,>1st Trim.(>/= 14 Wks 0 Dys),Transabd;Single/First Gest., Tech",PX7680501,CDM,402,RC,76805,CPT,TC,,,,,,,562,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,275.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,550.76
"US,Preg. Uterus,Fetal/Mat.Eval.,>1st Trim.(>/= 14 Wks 0 Dys),Transabd;Single/First Gest., Tech",PX7680501,CDM,402,RC,76805,CPT,TC,,,,,,,562,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,275.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,550.76
"US,Preg. Uterus,Fetal/Mat.Eval.,>1st Trim.(>/= 14 Wks 0 Dys),Transabd;Single/First Gest., Tech",PX7680501,CDM,402,RC,76805,CPT,TC,,,,,,,562,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,275.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,550.76
STAPLER RELOAD-CURVED CUTTER,27200000,CDM,272,RC,,,,12063-MAIN,LOCAL,,,,,283,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,275.4439,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
dexmedeTOMIDine in sodium chloride 400 MCG/100ML Solution 100 mL Bottle,25000000,CDM,250,RC,,,,,,67457092500,NDC,100,ML,562.18,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,275.4682,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dexmedeTOMIDine in sodium chloride 400 MCG/100ML Solution 100 mL Bottle,25000000,CDM,250,RC,,,,,,67457092500,NDC,100,ML,562.18,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,275.4682,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dexmedeTOMIDine in sodium chloride 400 MCG/100ML Solution 100 mL Bottle,25000000,CDM,250,RC,,,,,,67457092500,NDC,100,ML,562.18,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,275.4682,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,65162083366,NDC,100,GR,281.12,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,275.4976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Column Chrom Ms, Quant - Ref",PX8254290,CDM,300,RC,82542,CPT,90,,,,,,,557,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,275.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.09,545.86
Exc Neck Les Sc = 3cm >,PX21552F,CDM,510,RC,21552,CPT,,,,,,,,753,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,275.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,273.56,938.08
Exc Neck Les Sc = 3cm >,PX21552F,CDM,510,RC,21552,CPT,,,,,,,,753,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,275.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,273.56,938.08
Xray Cervical Spine 4 or 5 Vws,PX7205001,CDM,320,RC,72050,CPT,TC,,,,,,,664,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,275.8256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,650.72
Xray Cervical Spine 6 or More Vws,PX7205201,CDM,320,RC,72052,CPT,TC,,,,,,,664,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,275.8256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,650.72
PERFIX PLUG STERILE X-LARGE,C1781,CDM,278,RC,C1781,HCPCS,,11772-MAIN,LOCAL,,,,,643,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,275.847,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Xray Pelvis Compl 3+ Tc,PX7219001,CDM,320,RC,72190,CPT,TC,,,,,,,563,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,275.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,551.74
Xray Pelvis Compl 3+ Tc,PX7219001,CDM,320,RC,72190,CPT,TC,,,,,,,563,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,275.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,551.74
Xray Pelvis Compl 3+ Tc,PX7219001,CDM,320,RC,72190,CPT,TC,,,,,,,563,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,275.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,551.74
"Drain Finger Abscess,Simple",PX26010F,CDM,510,RC,26010,CPT,,,,,,,,310,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,275.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.774,303.8
"DXA, Bone Density Study, Hips/Pelv/Spine",PX7708001,CDM,320,RC,77080,CPT,TC,,,,,,,575,,Health Partners,Health Partners Care Plans,both,48,,364.5125,percent of total billed charges,276,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,563.5
"DXA, Bone Density Study, Hips/Pelv/Spine",PX7708001,CDM,320,RC,77080,CPT,TC,,,,,,,575,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,276,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,563.5
sulfacetamide 10 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,24208067004,NDC,15,ML,312.96,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,276.03072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Destruct Benign Lesion, 15+",PX17111F,CDM,510,RC,17111,CPT,,,,,,,,303,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,276.033,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.8662,296.94
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607P,CDM,983,RC,97607,CPT,,,,,,,,303,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,276.033,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.8662,348.35
Strapping of Knee,PX29530F,CDM,420,RC,29530,CPT,,,,,,,,303,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,276.033,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,296.94
Xray Knee 1 or 2 Vws,PX7356001,CDM,320,RC,73560,CPT,TC,,,,,,,303,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,276.033,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,296.94
Dress/Debrid Small Burn No Anes,PX16020F,CDM,510,RC,16020,CPT,,,,,,,,313,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,276.066,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.0202,306.74
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,6384371,NDC,1,EA,563.46,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,276.0954,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,6384371,NDC,1,EA,563.46,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,276.0954,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,6384371,NDC,1,EA,563.46,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,276.0954,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
BRONCHOSCOPE BFLEX 5.0 SINGLE-USE 0570-0449,120.578,CDM,272,RC,,,,13020-MAIN,LOCAL,,,,,558,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,276.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,231.7932,546.84
PERFIX PLUG STERILE LARGE,C1781,CDM,278,RC,C1781,HCPCS,,11771-MAIN,LOCAL,,,,,558,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,276.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
prednisoLONE acetate 1 % Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063705,NDC,5,ML,283.79,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,276.212807,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156F,CDM,370,RC,99156,CPT,,,,,,,,325,,First Health,Commercial,both,85,,999999999,percent of total billed charges,276.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,318.5
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156P,CDM,983,RC,99156,CPT,,,,,,,,325,,First Health,Commercial,both,85,,999999999,percent of total billed charges,276.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,316.3225
Refill/Maint Portable Pump,PX96521,CDM,260,RC,96521,CPT,,,,,,,,325,,First Health,Commercial,both,85,,999999999,percent of total billed charges,276.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,318.5
"Remv F.B.,Eye,Embed Conjunc",PX65210F,CDM,510,RC,65210,CPT,,,,,,,,325,,First Health,Commercial,both,85,,999999999,percent of total billed charges,276.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,348.08
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598P,CDM,982,RC,97598,CPT,,,,,,,,325,,First Health,Commercial,both,85,,999999999,percent of total billed charges,276.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,316.3225
Somatostatin - Ref,PX8430790,CDM,300,RC,84307,CPT,90,,,,,,,325,,First Health,Commercial,both,85,,999999999,percent of total billed charges,276.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.76,318.5
tiotropium 18 MCG capsule 5 Each Box,63700001,CDM,250,RC,,,,,,597007575,NDC,5,EA,665.18,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,276.315772,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Xray Finger(S) Tc,PX7314001,CDM,320,RC,73140,CPT,TC,,,,,,,282,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,276.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,276.36
Xray Toe(S) Tc,PX7366001,CDM,320,RC,73660,CPT,TC,,,,,,,282,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,276.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,276.36
"Closed Rx Bimalleolar Fx,Manip",PX27810F,CDM,510,RC,27810,CPT,,,,,,,,1026,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,276.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,272.25,1021.1
"Closed Rx Bimalleolar Fx,Manip",PX27810F,CDM,510,RC,27810,CPT,,,,,,,,1026,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,276.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,272.25,1021.1
"Closed Rx Bimalleolar Fx,Manip",PX27810P,CDM,983,RC,27810,CPT,,,,,,,,1057,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,276.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,272.25,1035.86
"Closed Rx Bimalleolar Fx,Manip",PX27810P,CDM,983,RC,27810,CPT,,,,,,,,1057,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,276.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,272.25,1035.86
amiodarone 360-4.14 MG/200ML-% Solution 200 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066036020,NDC,200,ML,325.25,,First Health,Commercial,both,85,,999999999,percent of total billed charges,276.4625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.35,318.745
Revise Median N/Carpal Tunnel Surg,PX64721F,CDM,510,RC,64721,CPT,,,,,,,,2408,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,276.61,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,276.61,940.85
Revise Median N/Carpal Tunnel Surg,PX64721P,CDM,983,RC,64721,CPT,,,,,,,,1927,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,276.61,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,276.61,1888.46
"Remv Foot Foreign Body,Subcutaneous",PX28190F,CDM,510,RC,28190,CPT,,,,,,,,1025,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,276.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.55,499.48
"Remv Foot Foreign Body,Subcutaneous",PX28190P,CDM,983,RC,28190,CPT,,,,,,,,683,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,276.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.55,669.34
Apply Lower Leg Splint,PX29515P,CDM,983,RC,29515,CPT,,,,,,,,311,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,276.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,129.1894,302.6963
Repr Superf Wnd Body <2.5cm,PX12001F,CDM,510,RC,12001,CPT,,,,,,,,311,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,276.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,129.1894,304.78
Xray Skull Less Than 4 Vws,PX7025001,CDM,320,RC,70250,CPT,TC,,,,,,,311,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,276.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,304.78
Repr Superf Wnd Body 12.6-20,PX12005F,CDM,510,RC,12005,CPT,,,,,,,,565,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,276.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,234.701,553.7
Repr Superf Wnd Body 12.6-20,PX12005F,CDM,510,RC,12005,CPT,,,,,,,,565,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,276.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,234.701,553.7
Repr Superf Wnd Body 12.6-20,PX12005F,CDM,510,RC,12005,CPT,,,,,,,,565,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,276.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,234.701,553.7
Xray Lumbosacral Minimum 4 Vws,PX7211001,CDM,320,RC,72110,CPT,TC,,,,,,,565,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,276.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,553.7
Xray Lumbosacral Minimum 4 Vws,PX7211001,CDM,320,RC,72110,CPT,TC,,,,,,,565,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,276.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,553.7
Xray Lumbosacral Minimum 4 Vws,PX7211001,CDM,320,RC,72110,CPT,TC,,,,,,,565,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,276.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,553.7
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004164,NDC,1,EA,666.52,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,276.872408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004110,NDC,1,EA,666.53,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,276.876562,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,63323077139,NDC,1,EA,547.2,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,276.8832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
"Ctrl Nosebleed,Anter,Complex",PX30903P,CDM,983,RC,30903,CPT,,,,,,,,304,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,276.944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,295.8832
Joint Survey Tc,PX7707701,CDM,320,RC,77077,CPT,TC,,,,,,,304,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,276.944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,297.92
Assay for Vancomycin,PX80202,CDM,300,RC,80202,CPT,,,,,,,,314,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,276.948,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.41,307.72
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032601,NDC,0.5,ML,559.7,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,277.0515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,1630.2692
"Needle Biopsy, Lymph Node(S)",PX38505F,CDM,510,RC,38505,CPT,,,,,,,,667,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,277.0718,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,277.0718,1416.38
neomycin-polymyxin-gramicidin 1.75-10000-.025 Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,24208079062,NDC,10,ML,314.26,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,277.17732,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Close Rx Fingr Articular Fx,Manip",PX26742P,CDM,983,RC,26742,CPT,,,,,,,,560,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,277.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,232.624,1404.08
"Enzyme Act, Nonradioact - Ref",PX8265790,CDM,300,RC,82657,CPT,90,,,,,,,560,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,277.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.33,548.8
dexmedeTOMIDine in sodium chloride 200 MCG/50ML Solution 50 mL Flex Cont,25000000,CDM,250,RC,,,,,,338955524,NDC,50,ML,304.32,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,277.23552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Closed Rx Spont Hip Disloc,Anesth",PX27257F,CDM,510,RC,27257,CPT,,,,,,,,548,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,277.288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.6392,1404.08
STAPLER RELOAD-CURVED CUTTER,27200000,CDM,272,RC,,,,12063-MAIN,LOCAL,,,,,283,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,277.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
US Renal Retroperit Ltd,PX7677501,CDM,402,RC,76775,CPT,TC,,,,,,,566,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,277.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,554.68
US Renal Retroperit Ltd,PX7677501,CDM,402,RC,76775,CPT,TC,,,,,,,566,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,277.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,554.68
US Renal Retroperit Ltd,PX7677501,CDM,402,RC,76775,CPT,TC,,,,,,,566,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,277.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,554.68
US Retroperitoneal Tc,PX7677001,CDM,402,RC,76770,CPT,TC,,,,,,,566,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,236.11,percent of total billed charges,277.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,554.68
US Retroperitoneal Tc,PX7677001,CDM,402,RC,76770,CPT,TC,,,,,,,566,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,277.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,554.68
US Retroperitoneal Tc,PX7677001,CDM,402,RC,76770,CPT,TC,,,,,,,566,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,277.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,554.68
Xray Sacroiliac Jnts 3 or More Vws,PX7220201,CDM,320,RC,72202,CPT,TC,,,,,,,285,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,277.3905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,279.3
"Destruct Benign Lesion, 15+",PX17111F,CDM,510,RC,17111,CPT,,,,,,,,303,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,277.41,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.35,277.41
Repr Superf Wnd Body 7.6-12.5,PX12004F,CDM,510,RC,12004,CPT,,,,,,,,453,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,277.41,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,43.41,277.41
Repr Superf Wnd Body 7.6-12.5,PX12004P,CDM,983,RC,12004,CPT,,,,,,,,614,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,277.41,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,43.41,601.72
"Fac/Exc Skn Beni1.1-2cm Fce,Facial",PX11442F,CDM,510,RC,11442,CPT,,,,,,,,668,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,277.4872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,277.4872,654.64
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032P,CDM,983,RC,12032,CPT,,,,,,,,647,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,277.563,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,268.7638,629.7251
"Repair Umbilical Hern,5+Y/O,Reduc",PX49585P,CDM,983,RC,49585,CPT,,,,,,,,647,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,277.563,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,268.7638,629.7251
gadoterate meglumine 10 mmol/20 mL Solution 20 mL Vial,A9575,CDM,636,RC,A9575,HCPCS,,,,67684200003,NDC,20,ML,668.27,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,277.599358,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,277.599358,654.9046
Closed Rx Kneecap Dislocatn,PX27560P,CDM,983,RC,27560,CPT,,,,,,,,312,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,277.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,129.6048,303.6696
Drain Skin Abscess Complic,PX10061P,CDM,983,RC,10061,CPT,,,,,,,,561,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,277.695,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,233.0394,546.0213
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12130-MAIN,LOCAL,,,,,561,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,277.695,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Assay Iga/Igd/Igg/Igm Each,PX82784,CDM,300,RC,82784,CPT,,,,,,,,315,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,277.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.53,308.7
"Bone Marrow Aspiration(S),Diag",PX38220F,CDM,510,RC,38220,CPT,,,,,,,,305,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,277.855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,126.697,1416.38
sulfacetamide 10 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,61314070101,NDC,15,ML,285.48,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,277.857684,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
8MM ENDOWRIST INSTRUMENTS MEGA SUTURE CUT NEEDLE DRIVER,27200000,CDM,272,RC,,,,11914-MAIN,LOCAL,,,,,327,,First Health,Commercial,both,85,,999999999,percent of total billed charges,277.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"IV Infusion Therapy, 1 Hour",PX96365,CDM,260,RC,96365,CPT,,,,,,,,327,,First Health,Commercial,both,85,,999999999,percent of total billed charges,277.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.8358,320.46
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476881,NDC,50,ML,579.12,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,277.9776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476881,NDC,50,ML,579.12,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,277.9776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
8MM ENDOWRIST INSTRUMENTS MONOPOLAR CURVED SCISSORS,27200000,CDM,272,RC,,,,11909-MAIN,LOCAL,,,,,648,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,277.992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STAPLER INTERNAL ECHELON FLEX POWERED PLUS LONG LENGTH 440MM,27200000,CDM,272,RC,,,,12065-MAIN,LOCAL,,,,,648,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,277.992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Pvb Thoracic Single Injection Site W/Img Gid,PX64461F,CDM,510,RC,64461,CPT,,,,,,,,353,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,278.1,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.99,278.1
Pvb Thoracic Single Injection Site W/Img Gid,PX64461P,CDM,983,RC,64461,CPT,,,,,,,,616,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,278.1,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.99,603.68
prednisoLONE acetate 1 % Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063705,NDC,5,ML,283.79,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,278.1142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Exc Skn Bngn3.1-4cm Remain Bdy,PX11424P,CDM,983,RC,11424,CPT,,,,,,,,562,,Humana Choice Care,All Medicare plans,outpatient,49.5,,1207.36,percent of total billed charges,278.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,233.4548,1416.38
"US,Preg. Uterus,Fetal/Mat.Eval.,>1st Trim.(>/= 14 Wks 0 Dys),Transabd;Single/First Gest., Tech",PX7680501,CDM,402,RC,76805,CPT,TC,,,,,,,562,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,278.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,550.76
dexmedeTOMIDine in sodium chloride 400 MCG/100ML Solution 100 mL Bottle,25000000,CDM,250,RC,,,,,,67457092500,NDC,100,ML,562.18,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,278.2791,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Emergency Level III Visit,PX99283P,CDM,981,RC,99283,CPT,,,,,,,,568,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,137.8311224,percent of total billed charges,278.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,235.9472,552.8344
Emergency Level III Visit,PX99283P,CDM,981,RC,99283,CPT,,,,,,,,568,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,278.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,235.9472,552.8344
Emergency Level III Visit,PX99283P,CDM,981,RC,99283,CPT,,,,,,,,568,,United Healthcare,All Medicare advantage plans,outpatient,49,,105.785,percent of total billed charges,278.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,235.9472,552.8344
Blood Culture for Bacteria,PX87040,CDM,300,RC,87040,CPT,,,,,,,,286,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,129.0014583,percent of total billed charges,278.3638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.46,280.28
I&D Bartholin Gland Abscess,PX56420P,CDM,983,RC,56420,CPT,,,,,,,,286,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,278.3638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,118.8044,278.3638
Joint Survey,PX7707726,CDM,982,RC,77077,CPT,26,,,,,,,286,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,278.3638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,278.3638
Lab Culture Bacteria,PX87070,CDM,300,RC,87070,CPT,,,,,,,,286,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,235.545,percent of total billed charges,278.3638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.9,280.28
Urine Culture/Colony Count,PX87086,CDM,300,RC,87086,CPT,,,,,,,,286,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,77.35470588,percent of total billed charges,278.3638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4,280.28
Leukoreduced Rbc's,PXP9016,CDM,390,RC,P9016,HCPCS,,,,,,,,580,,Health Partners,Health Partners Care Plans,both,48,,280.2809091,percent of total billed charges,278.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,165.79,568.4
Leukoreduced Rbc's,PXP9016,CDM,390,RC,P9016,HCPCS,,,,,,,,580,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,278.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,165.79,568.4
sulfacetamide 10 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,24208067004,NDC,15,ML,312.96,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,278.5344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Dress/Debrid Small Burn No Anes,PX16020F,CDM,510,RC,16020,CPT,,,,,,,,313,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,278.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.0202,306.74
Xray Pelvis Compl 3+ Tc,PX7219001,CDM,320,RC,72190,CPT,TC,,,,,,,563,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,278.685,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,551.74
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231001,NDC,10,ML,649.64,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,278.69556,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231005,NDC,10,ML,649.64,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,278.69556,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
Cast/Strap Procedure Unlisted,PX29799F,CDM,510,RC,29799,CPT,,,,,,,,316,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,278.712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,131.2664,309.68
Xray Thoracolumbar 2 Vws,PX7208001,CDM,320,RC,72080,CPT,TC,,,,,,,306,,Medica,Commercial,both,91.1,,51.2,percent of total billed charges,278.766,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,299.88
"Chemotherapy, IV Infusion, Each Add'l Sequential Infusion",PX96417,CDM,335,RC,96417,CPT,,,,,,,,328,,First Health,Commercial,both,85,,999999999,percent of total billed charges,278.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,321.44
Exc Skn Beni 0.6-1cm Fcefacial,PX11441P,CDM,983,RC,11441,CPT,,,,,,,,485,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,278.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.64,475.3
"Fac/Exc Skn Bnig0.6-1cm Fae,Facial",PX11441F,CDM,510,RC,11441,CPT,,,,,,,,606,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,278.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.64,363.89
"Fna Biopsy, W/US Guidance; First Lesion",PX10005F,CDM,510,RC,10005,CPT,,,,,,,,333,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,278.8,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.93,278.8
"Fna Biopsy, W/US Guidance; First Lesion",PX10005P,CDM,983,RC,10005,CPT,,,,,,,,621,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,278.8,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.93,608.58
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762P,CDM,983,RC,43762,CPT,,,,,,,,328,,First Health,Commercial,both,85,,999999999,percent of total billed charges,278.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.2512,319.2424
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031P,CDM,983,RC,12031,CPT,,,,,,,,551,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,278.806,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,228.8854,536.2883
Xray Facial Bones Minimum 3 Vws,PX7015001,CDM,320,RC,70150,CPT,TC,,,,,,,551,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,278.806,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,539.98
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423P,CDM,983,RC,11423,CPT,,,,,,,,569,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,278.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,236.3626,1416.38
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423P,CDM,983,RC,11423,CPT,,,,,,,,569,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,278.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,236.3626,1416.38
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423P,CDM,983,RC,11423,CPT,,,,,,,,569,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,278.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,236.3626,1416.38
Acellular Derm Matrix Implt,PX15777F,CDM,510,RC,15777,CPT,,,,,,,,650,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,278.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.01,637
Closed Rx Bimalleolar Fx,PX27808F,CDM,510,RC,27808,CPT,,,,,,,,650,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,278.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,637
"Exc Skn Bngn2.1-3cm Fce,Facial",PX11443P,CDM,983,RC,11443,CPT,,,,,,,,650,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,278.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.01,1416.38
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,6384371,NDC,1,EA,563.46,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,278.9127,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234010,NDC,5,ML,306.2,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,278.9482,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234025,NDC,5,ML,306.2,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,278.9482,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234099,NDC,5,ML,306.2,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,278.9482,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
"Closed Rx Trimalleolar Fx,Manip",PX27818F,CDM,510,RC,27818,CPT,,,,,,,,813,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,279.01,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,279.01,1059.15
"Closed Rx Trimalleolar Fx,Manip",PX27818P,CDM,983,RC,27818,CPT,,,,,,,,1352,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,279.01,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,279.01,1324.96
"Molecular Path Proc, Level 2 - Ref",PX8140190,CDM,310,RC,81401,CPT,90,,,,,,,672,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,279.1488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.62,658.56
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505F,CDM,510,RC,25505,CPT,,,,,,,,651,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,279.279,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.4254,1404.08
Remove Foreign Body Complic,PX10121P,CDM,983,RC,10121,CPT,,,,,,,,651,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,279.279,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.4254,1416.38
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004P,CDM,983,RC,15004,CPT,,,,,,,,570,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,279.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,236.778,554.781
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004P,CDM,983,RC,15004,CPT,,,,,,,,570,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,279.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,236.778,554.781
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004P,CDM,983,RC,15004,CPT,,,,,,,,570,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,279.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,236.778,554.781
Xray Sacroiliac Jnts 3 or More Vws,PX7220201,CDM,320,RC,72202,CPT,TC,,,,,,,285,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,279.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,279.3
"Inj,Lumb Epidur,Blood/Clot Patch",PX62273P,CDM,983,RC,62273,CPT,,,,,,,,552,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,279.312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,229.3008,604.15
BOOT AIRSELECT SHORT LARGE 01ES-L,120.45,CDM,274,RC,L4360,HCPCS,,11890-MAIN,LOCAL,,,,,93,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,279.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT MEDIUM 01ES-M,120.45,CDM,274,RC,L4360,HCPCS,,11889-MAIN,LOCAL,,,,,93,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,279.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT SMALL 01ES-S,120.45,CDM,274,RC,L4360,HCPCS,,11888-MAIN,LOCAL,,,,,93,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,279.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT X-LARGE 01ES-XL,120.45,CDM,274,RC,L4360,HCPCS,,11891-MAIN,LOCAL,,,,,93,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,279.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT SHORT X-SMALL 01ES-XS,120.45,CDM,274,RC,L4360,HCPCS,,11887-MAIN,LOCAL,,,,,93,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,279.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD LARGE 01EF-L,120.45,CDM,274,RC,L4360,HCPCS,,11697-MAIN,LOCAL,,,,,93,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,279.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD MEDIUM 01EF-M,120.45,CDM,274,RC,L4360,HCPCS,,11696-MAIN,LOCAL,,,,,93,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,279.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD SMALL 01EF-S,120.45,CDM,274,RC,L4360,HCPCS,,11695-MAIN,LOCAL,,,,,93,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,279.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD X-LARGE 01EF-XL,120.45,CDM,274,RC,L4360,HCPCS,,11698-MAIN,LOCAL,,,,,93,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,279.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
BOOT AIRSELECT STANDARD X-SMALL 01EF-XS,120.45,CDM,274,RC,L4360,HCPCS,,11694-MAIN,LOCAL,,,,,93,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,279.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
SPLINT FOOT SMALL STRUT WALK 11-1383-2-00000,120.45,CDM,274,RC,L4360,HCPCS,,1205-MAIN,LOCAL,,,,,93,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,279.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.6322,279.32
Incise Finger Tendon Sheath,PX26055F,CDM,510,RC,26055,CPT,,,,,,,,1398,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,279.357,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.74,1232.1
Incise Finger Tendon Sheath,PX26055P,CDM,983,RC,26055,CPT,,,,,,,,932,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,279.357,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.74,1232.1
Assay for Vancomycin,PX80202,CDM,300,RC,80202,CPT,,,,,,,,314,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,279.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.41,307.72
"Fac/Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601F,CDM,510,RC,11601,CPT,,,,,,,,673,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,279.5642,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,279.5642,659.54
Facility Emergency Level 1 Visit,PX99281F,CDM,450,RC,99281,CPT,,,,,,,,329,,First Health,Commercial,both,85,,999999999,percent of total billed charges,279.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.56,322.42
Repr Superf Wnd Body 12.6-20,PX12005F,CDM,510,RC,12005,CPT,,,,,,,,565,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,279.675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,234.701,553.7
Xray Lumbosacral Minimum 4 Vws,PX7211001,CDM,320,RC,72110,CPT,TC,,,,,,,565,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,279.675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,553.7
COOK EMERGENCY PNEUMOTHORAX SET,120.559,CDM,272,RC,,,,12597-MAIN,LOCAL,,,,,307,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,279.677,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,127.5278,300.86
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132F,CDM,510,RC,13132,CPT,,,,,,,,1159,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,279.6781,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.92,976.82
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132P,CDM,983,RC,13132,CPT,,,,,,,,774,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,279.6781,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.92,976.82
neomycin-polymyxin-gramicidin 1.75-10000-.025 Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,24208079062,NDC,10,ML,314.26,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,279.6914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sulfacetamide 10 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,61314070101,NDC,15,ML,285.48,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,279.7704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
PERFIX PLUG STERILE MEDIUM,C1781,CDM,278,RC,C1781,HCPCS,,11770-MAIN,LOCAL,,,,,553,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,279.818,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
rabies immune globulin 300 UNIT/ML Solution 1 mL Vial,90376,CDM,636,RC,90375,CPT,,,,13533031801,NDC,1,ML,1629.06,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,279.95316,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.18,307.02
rabies immune globulin 1500 UNIT/5ML Solution 5 mL Vial,90375,CDM,636,RC,90375,CPT,,,,13533031805,NDC,5,ML,8065.26,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,279.95316,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.18,307.02
sugammadex sodium 200 MG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,6542312,NDC,2,ML,583.33,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,279.9984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sugammadex sodium 200 MG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,6542312,NDC,2,ML,583.33,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,279.9984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sugammadex sodium 200 MG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,6542302,NDC,2,ML,652.81,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,280.05549,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
insulin regular 100 UNIT/ML Solution 10 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821501,NDC,10,ML,307.46,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,280.09606,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
"Initial Repair of Entrapped Hernia of Abdomen, Less Than 3 Cm in Length",PX49592,CDM,982,RC,49592,CPT,,,,,,,,2164,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,280.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,280.1,2120.72
"Initial Repair of Entrapped Hernia of Abdomen, Less Than 3 Cm in Length",PX49592,CDM,982,RC,49592,CPT,,,,,,,,2164,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,280.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,280.1,2120.72
Revise Median N/Carpal Tunnel Surg,PX64721F,CDM,510,RC,64721,CPT,,,,,,,,2408,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,280.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,276.61,940.85
Revise Median N/Carpal Tunnel Surg,PX64721F,CDM,510,RC,64721,CPT,,,,,,,,2408,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,280.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,276.61,940.85
Revise Median N/Carpal Tunnel Surg,PX64721P,CDM,983,RC,64721,CPT,,,,,,,,1927,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,280.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,276.61,1888.46
Revise Median N/Carpal Tunnel Surg,PX64721P,CDM,983,RC,64721,CPT,,,,,,,,1927,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,280.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,276.61,1888.46
US Renal Retroperit Ltd,PX7677501,CDM,402,RC,76775,CPT,TC,,,,,,,566,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,280.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,554.68
US Retroperitoneal Tc,PX7677001,CDM,402,RC,76770,CPT,TC,,,,,,,566,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,280.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,554.68
Remove Intrauterine Device,PX58301,CDM,983,RC,58301,CPT,,,,,,,,357,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,280.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.2978,347.4681
Blood Culture for Bacteria,PX87040,CDM,300,RC,87040,CPT,,,,,,,,286,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,280.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.46,280.28
I&D Bartholin Gland Abscess,PX56420P,CDM,983,RC,56420,CPT,,,,,,,,286,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,280.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.02,389.48
Joint Survey,PX7707726,CDM,982,RC,77077,CPT,26,,,,,,,286,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,280.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.25,280.28
Lab Culture Bacteria,PX87070,CDM,300,RC,87070,CPT,,,,,,,,286,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,280.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.9,280.28
MESH LARGE LEFT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 4X6,120.521,CDM,278,RC,C1781,HCPCS,,12215-MAIN,LOCAL,,,,,572,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,196.035,percent of total billed charges,280.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,237.6088,560.56
MESH LARGE LEFT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 4X6,120.521,CDM,278,RC,C1781,HCPCS,,12215-MAIN,LOCAL,,,,,572,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,280.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,237.6088,560.56
MESH LARGE LEFT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 4X6,120.521,CDM,278,RC,C1781,HCPCS,,12215-MAIN,LOCAL,,,,,572,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,280.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,237.6088,560.56
MESH LARGE RIGHT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 4X6,C1781,CDM,278,RC,C1781,HCPCS,,12195-MAIN,LOCAL,,,,,572,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,196.035,percent of total billed charges,280.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
MESH LARGE RIGHT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 4X6,C1781,CDM,278,RC,C1781,HCPCS,,12195-MAIN,LOCAL,,,,,572,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,280.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
MESH LARGE RIGHT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 4X6,C1781,CDM,278,RC,C1781,HCPCS,,12195-MAIN,LOCAL,,,,,572,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,280.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Remove Nasal Foreign Body,PX30300P,CDM,983,RC,30300,CPT,,,,,,,,572,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,280.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,556.7276
Remove Nasal Foreign Body,PX30300P,CDM,983,RC,30300,CPT,,,,,,,,572,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,280.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,556.7276
Remove Nasal Foreign Body,PX30300P,CDM,983,RC,30300,CPT,,,,,,,,572,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,280.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,556.7276
Urine Culture/Colony Count,PX87086,CDM,300,RC,87086,CPT,,,,,,,,286,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,280.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.4,280.28
CHOLANGIOGRAM CATHETER REDDICK,27200000,CDM,272,RC,,,,10232-MAIN,LOCAL,,,,,287.98,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,280.290934,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Spirometry Incl Graph Rec Tc,PX9401002,CDM,460,RC,94010,CPT,TC,,,,,,,288,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,280.3104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.6352,282.24
"Initial Repair of Entrapped Hernia of Abdomen, Less Than 3 Cm in Length",PX49592,CDM,982,RC,49592,CPT,,,,,,,,2164,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,280.32,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,280.1,2120.72
Aaa US Screen Tc,PX7670601,CDM,402,RC,76706,CPT,TC,,,,,,,554,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,280.324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,542.92
US Kidney Transplt Untrsd,PX7677601,CDM,402,RC,76776,CPT,TC,,,,,,,554,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,280.324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,542.92
Assay Iga/Igd/Igg/Igm Each,PX82784,CDM,300,RC,82784,CPT,,,,,,,,315,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,280.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.53,308.7
Duplex Up Extrem Art Bilat,PX9393001,CDM,921,RC,93930,CPT,TC,,,,,,,835,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,280.38,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.92,280.38
Duplex Up Extrem Art Bilat,PX9393001,CDM,921,RC,93930,CPT,TC,,,,,,,835,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,280.38,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.92,280.38
Injection for Shoulder Arthrogram,PX23350F,CDM,510,RC,23350,CPT,,,,,,,,675,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,280.395,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,280.395,661.5
8MM ENDOWRIST INSTRUMENTS LARGE NEEDLE DRIVER,27200000,CDM,272,RC,,,,11912-MAIN,LOCAL,,,,,318,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,280.476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Drain/Inject Medium Joint/Bursa,PX20605P,CDM,983,RC,20605,CPT,,,,,,,,318,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,280.476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,309.5094
"Office/Outpt Visit,Est,Levl V",PX99215F,CDM,510,RC,99215,CPT,,,,,,,,318,,United Healthcare,All Payer,outpatient,88.2,,101.92,percent of total billed charges,280.476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,311.64
"Office/Outpt Visit,Est,Levl V",PX99215P,CDM,983,RC,99215,CPT,,,,,,,,318,,United Healthcare,All Payer,outpatient,88.2,,101.92,percent of total billed charges,280.476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,309.5094
"Remv F.B.,Eye,Cornea,No Slit",PX65220P,CDM,983,RC,65220,CPT,,,,,,,,318,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,280.476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,348.08
"Breast Tomosynthesis,Screen Tc",PX7706301,CDM,403,RC,77063,CPT,TC,,,,,,,166,,Blue Cross Blue Shield of MN,All commercial plans,both,,,286.1771212,fee schedule,280.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.59,280.5
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725P,CDM,983,RC,26725,CPT,,,,,,,,330,,First Health,Commercial,both,85,,999999999,percent of total billed charges,280.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.082,321.189
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101P,CDM,983,RC,13101,CPT,,,,,,,,330,,First Health,Commercial,both,85,,999999999,percent of total billed charges,280.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.082,548.67
Injection Hip Arthrogram,PX27093F,CDM,510,RC,27093,CPT,,,,,,,,654,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,280.566,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,271.6716,640.92
"Layr Clos Wnd Face,Facial 2.5-5",PX12052F,CDM,510,RC,12052,CPT,,,,,,,,585,,Health Partners,Health Partners Care Plans,both,48,,11.67,percent of total billed charges,280.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,243.009,573.3
"Layr Clos Wnd Face,Facial 2.5-5",PX12052F,CDM,510,RC,12052,CPT,,,,,,,,585,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,280.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,243.009,573.3
Direct Admit Hospital Observ,PXG0379,CDM,761,RC,G0379,HCPCS,,,,,,,,676,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,280.8104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,280.8104,662.48
Xray Sacroiliac Jnts Less Than 3 Vws,PX7220001,CDM,320,RC,72200,CPT,TC,,,,,,,555,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,280.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,543.9
oseltamivir 6 MG/ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,68180067801,NDC,60,ML,676.25,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,280.91425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
buprenorphine 5 MCG/HR PATCH WEEKLY 4 Each Box,63700001,CDM,250,RC,,,,,,42858075040,NDC,1,EA,330.52,,First Health,Commercial,both,85,,999999999,percent of total billed charges,280.942,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035F,CDM,510,RC,12035,CPT,,,,,,,,655,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,280.995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,272.087,641.9
MINIBUNION LOCKING SCREW 3.0X24MM,C1713,CDM,278,RC,C1713,HCPCS,,11671-MAIN,LOCAL,,,,,308.55,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,281.08905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Emergency Level III Visit,PX99283P,CDM,981,RC,99283,CPT,,,,,,,,568,,Humana Choice Care,All Medicare plans,outpatient,49.5,,242.278,percent of total billed charges,281.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,235.9472,552.8344
Cast/Strap Procedure Unlisted,PX29799F,CDM,510,RC,29799,CPT,,,,,,,,316,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,281.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,131.2664,309.68
US Abdomen Tc,PX7670001,CDM,402,RC,76700,CPT,TC,,,,,,,586,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,281.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,574.28
US Abdomen Tc,PX7670001,CDM,402,RC,76700,CPT,TC,,,,,,,586,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,281.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,574.28
BONE SCREW T8 FULL THREAD 2.4MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12652-MAIN,LOCAL,,,,,289,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,281.2837,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
BONE SCREW T8 FULL THREAD 2.4MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12653-MAIN,LOCAL,,,,,289,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,281.2837,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
BONE SCREW T8 FULL THREAD 2.7MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12654-MAIN,LOCAL,,,,,289,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,281.2837,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Occupational Therapy Eval High Complex,PX97167,CDM,434,RC,97167,CPT,,,,,,,,289,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,281.2837,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,283.22
"Troponin, Quantitative",PX84484,CDM,300,RC,84484,CPT,,,,,,,,289,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,104.2775824,percent of total billed charges,281.2837,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.43,283.22
X-Ray Exam Chest 2 Views,PX7104601,CDM,320,RC,71046,CPT,TC,,,,,,,556,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,281.336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,544.88
Xray Chest 2 Views,PX7102001,CDM,320,RC,71020,CPT,TC,,,,,,,556,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,281.336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,230.9624,544.88
Fresh Frozen Plasma,PXP9017,CDM,390,RC,P9017,HCPCS,,,,,,,,319,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,281.358,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.32,312.62
Drain/Inject Med Joint/Brusa W/US Guide,PX20606P,CDM,983,RC,20606,CPT,,,,,,,,309,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,281.499,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.3586,604.15
LINNEAR CUTTER STAPLE RELOAD GST BLUE 60MM,27200000,CDM,272,RC,,,,12068-MAIN,LOCAL,,,,,309,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,281.499,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LINNEAR CUTTER STAPLE RELOAD GST GREEN 60MM,27200000,CDM,272,RC,,,,12069-MAIN,LOCAL,,,,,309,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,281.499,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LINNEAR CUTTER STAPLE RELOAD GST WHITE 60MM,27200000,CDM,272,RC,,,,12067-MAIN,LOCAL,,,,,309,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,281.499,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Naso/Orogastric Tube,PX43752P,CDM,983,RC,43752,CPT,,,,,,,,309,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,281.499,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.3586,348.08
rabies immune globulin 300 UNIT/ML Solution 1 mL Vial,90376,CDM,636,RC,90375,CPT,,,,13533031801,NDC,1,ML,1629.06,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,281.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,281.51,1596.4788
rabies immune globulin 1500 UNIT/5ML Solution 5 mL Vial,90375,CDM,636,RC,90375,CPT,,,,13533031805,NDC,5,ML,8065.26,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,281.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,281.51,7903.9548
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,55150017301,NDC,0.5,ML,319.2,,United Healthcare,All Payer,outpatient,88.2,,225.03,percent of total billed charges,281.5344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
Biopsy of Rectum,PX45100F,CDM,510,RC,45100,CPT,,,,,,,,763,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,281.6047,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.92,635.07
Biopsy of Rectum,PX45100P,CDM,983,RC,45100,CPT,,,,,,,,509,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,281.6047,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.92,635.07
Temporary External Pacing,PX92953F,CDM,480,RC,92953,CPT,,,,,,,,678,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,281.6412,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,281.6412,664.44
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423P,CDM,983,RC,11423,CPT,,,,,,,,569,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,281.655,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,236.3626,1416.38
"DXA, Bone Density Study, Hips/Pelv/Spine",PX7708001,CDM,320,RC,77080,CPT,TC,,,,,,,575,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,122.8016667,percent of total billed charges,281.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,563.5
"DXA, Bone Density Study, Hips/Pelv/Spine",PX7708001,CDM,320,RC,77080,CPT,TC,,,,,,,575,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,281.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,563.5
"DXA, Bone Density Study, Hips/Pelv/Spine",PX7708001,CDM,320,RC,77080,CPT,TC,,,,,,,575,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,281.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,563.5
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,338035702,NDC,250,ML,309.28,,Medica,Commercial,both,91.1,,7.37,percent of total billed charges,281.75408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.4701,303.0944
Facility Emergency Level III Visit,PX99283F,CDM,450,RC,99283,CPT,,,,,,,,587,,Health Partners,Health Partners Care Plans,both,48,,314.8597674,percent of total billed charges,281.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,243.8398,575.26
Facility Emergency Level III Visit,PX99283F,CDM,450,RC,99283,CPT,,,,,,,,587,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,281.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,243.8398,575.26
"Column Chrom Ms, Quant - Ref",PX8254290,CDM,300,RC,82542,CPT,90,,,,,,,557,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,281.842,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.09,545.86
Insert Emergency Endotrach Airway,PX31500P,CDM,983,RC,31500,CPT,,,,,,,,657,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,281.853,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,639.4581
dexAMETHasone 0.1 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,24208072002,NDC,5,ML,331.81,,First Health,Commercial,both,85,,999999999,percent of total billed charges,282.0385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Fac/Ex Skn Bngn2.1-3cm Trnk,Arm,Lg",PX11403F,CDM,510,RC,11403,CPT,,,,,,,,679,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,282.0566,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,282.0566,665.42
HERCULES 3 STAGE BALLOON ESOPHAGEAL 12-13.5-15::36-40.5-45MM,27200000,CDM,272,RC,C1726,HCPCS,,11329-MAIN,LOCAL,,,,,289.85,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,282.111005,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HERCULES 3 STAGE BALLOON ESOPHAGEAL 15-16.5-18:45-49.5-54MM,27200000,CDM,272,RC,C1726,HCPCS,,11328-MAIN,LOCAL,,,,,289.85,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,282.111005,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HERCULES 3 STAGE BALLOON ESOPHAGEAL 18-19-20::54-57-60MM,27200000,CDM,272,RC,C1726,HCPCS,,11330-MAIN,LOCAL,,,,,289.85,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,282.111005,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004P,CDM,983,RC,15004,CPT,,,,,,,,570,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,282.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,236.778,554.781
CHOLANGIOGRAM CATHETER REDDICK,27200000,CDM,272,RC,,,,10232-MAIN,LOCAL,,,,,287.98,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,282.2204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Apply Long Leg Splint,PX29505F,CDM,510,RC,29505,CPT,,,,,,,,320,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,282.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.928,313.6
"IV Infusion, Bamlanivimab, Infusion and Post Admin Monig",PXM0239,CDM,260,RC,M0239,HCPCS,,,,,,,,320,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,282.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.928,313.6
Spirometry Incl Graph Rec Tc,PX9401002,CDM,460,RC,94010,CPT,TC,,,,,,,288,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,282.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.6352,282.24
Apply Long Arm Splint,PX29105F,CDM,510,RC,29105,CPT,,,,,,,,290,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,282.257,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.466,284.2
Assay of Digoxin,PX80162,CDM,300,RC,80162,CPT,,,,,,,,290,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,282.257,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.18,284.2
Assay of Natriuretic Peptide,PX83880,CDM,300,RC,83880,CPT,,,,,,,,290,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,75.09,percent of total billed charges,282.257,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36,284.2
NEEDLE INTRAOSSEOUS SET 15GA 25MM STABILIZER EZ-IO 9001P,120.216,CDM,272,RC,A4215,HCPCS,,10648-MAIN,LOCAL,,,,,290,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,282.257,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.466,284.2
NEEDLE INTRAOSSEOUS SET 15GA 45MM STABILIZER EZ-IO 9079P,120.216,CDM,272,RC,A4215,HCPCS,,10297-MAIN,LOCAL,,,,,290,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,282.257,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.466,284.2
BRONCHOSCOPE BFLEX 5.0 SINGLE-USE 0570-0449,120.578,CDM,272,RC,,,,13020-MAIN,LOCAL,,,,,558,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,282.348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,231.7932,546.84
PERFIX PLUG STERILE LARGE,C1781,CDM,278,RC,C1781,HCPCS,,11771-MAIN,LOCAL,,,,,558,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,282.348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Drain Finger Abscess,Simple",PX26010F,CDM,510,RC,26010,CPT,,,,,,,,310,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,282.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.774,303.8
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010202,NDC,1,EA,680,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,282.472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 1 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010101,NDC,1,EA,680,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,282.472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010102,NDC,1,EA,680,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,282.472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
"Fac/Exc Skn Mal 0.6-1cm Fce,Facial",PX11641F,CDM,510,RC,11641,CPT,,,,,,,,680,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,282.472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,282.472,666.4
Observation Initial,PXG0378.03,CDM,762,RC,G0378,HCPCS,,,,,,,,680,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,282.472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,282.472,666.4
linezolid 600 MG/300ML Solution 300 mL Flex Cont,J2020.01,CDM,636,RC,J2020,HCPCS,,,,9514001,NDC,300,ML,332.42,,First Health,Commercial,both,85,,999999999,percent of total billed charges,282.557,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.087268,325.7716
"Insert Needle,Intraosseous Infusn",PX36680F,CDM,510,RC,36680,CPT,,,,,,,,659,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,282.711,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,273.7486,645.82
"Hospital Inpt or Obs Care, Admin/Disch Same Date, Moderate Level Mdm >= 70 Minutes",PX99235,CDM,982,RC,99235,CPT,,,,,,,,582,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,282.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,99.73,570.36
"Hospital Inpt or Obs Care, Admin/Disch Same Date, Moderate Level Mdm >= 70 Minutes",PX99235,CDM,982,RC,99235,CPT,,,,,,,,582,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,282.85,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,99.73,570.36
Repr Superf Wnd Face 2.6-5,PX12013P,CDM,983,RC,12013,CPT,,,,,,,,681,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,282.8874,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,662.8173
sevoflurane Solution 250 mL Bottle,25000000,CDM,250,RC,,,,,,66794001525,NDC,250,ML,589.56,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,282.9888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sevoflurane Solution 250 mL Bottle,25000000,CDM,250,RC,,,,,,66794001525,NDC,250,ML,589.56,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,282.9888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,63323076350,NDC,50,ML,589.57,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,282.9936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,63323076350,NDC,50,ML,589.57,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,282.9936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
8MM ENDOWRIST INSTRUMENTS LARGE NEEDLE DRIVER,27200000,CDM,272,RC,,,,11912-MAIN,LOCAL,,,,,318,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,283.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Drain/Inject Medium Joint/Bursa,PX20605P,CDM,983,RC,20605,CPT,,,,,,,,318,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,283.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,309.5094
"Office/Outpt Visit,Est,Levl V",PX99215F,CDM,510,RC,99215,CPT,,,,,,,,318,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,283.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,311.64
"Office/Outpt Visit,Est,Levl V",PX99215P,CDM,983,RC,99215,CPT,,,,,,,,318,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,283.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,309.5094
"Remv F.B.,Eye,Cornea,No Slit",PX65220P,CDM,983,RC,65220,CPT,,,,,,,,318,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,283.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,348.08
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600110,NDC,10,ML,589.63,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,283.0224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600110,NDC,10,ML,589.63,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,283.0224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
insulin aspart 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169633910,NDC,3,ML,659.76,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,283.03704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
"Fna Biopsy, W/US Guidance; First Lesion",PX10005F,CDM,510,RC,10005,CPT,,,,,,,,333,,First Health,Commercial,both,85,,999999999,percent of total billed charges,283.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.3282,614.65
Ultrasound Breast Complete,PX7664101,CDM,402,RC,76641,CPT,TC,,,,,,,333,,First Health,Commercial,both,85,,999999999,percent of total billed charges,283.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,326.34
butamben-tetracaine-benzocaine 2-2-14 % Aerosol 20 g Bottle,25000000,CDM,250,RC,,,,,,10223020103,NDC,20,GR,589.76,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,283.0848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
butamben-tetracaine-benzocaine 2-2-14 % Aerosol 20 g Bottle,25000000,CDM,250,RC,,,,,,10223020103,NDC,20,GR,589.76,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,283.0848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Incis/Drain Scrotum/Testis,Epididym",PX54700F,CDM,510,RC,54700,CPT,,,,,,,,660,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,283.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.164,1779.39
MESH LARGE LEFT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 4X6,120.521,CDM,278,RC,C1781,HCPCS,,12215-MAIN,LOCAL,,,,,572,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,283.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,237.6088,560.56
MESH LARGE RIGHT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 4X6,C1781,CDM,278,RC,C1781,HCPCS,,12195-MAIN,LOCAL,,,,,572,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,283.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Remove Nasal Foreign Body,PX30300P,CDM,983,RC,30300,CPT,,,,,,,,572,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,283.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,556.7276
Repair Incis Hernia W Mesh,PX49568P,CDM,983,RC,49568,CPT,,,,,,,,660,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,283.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.164,642.378
"Closed Rx Trimalleolar Fx,Manip",PX27818F,CDM,510,RC,27818,CPT,,,,,,,,813,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,283.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,279.01,1059.15
"Closed Rx Trimalleolar Fx,Manip",PX27818F,CDM,510,RC,27818,CPT,,,,,,,,813,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,283.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,279.01,1059.15
"Closed Rx Trimalleolar Fx,Manip",PX27818P,CDM,983,RC,27818,CPT,,,,,,,,1352,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,283.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,279.01,1324.96
"Closed Rx Trimalleolar Fx,Manip",PX27818P,CDM,983,RC,27818,CPT,,,,,,,,1352,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,283.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,279.01,1324.96
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032601,NDC,0.5,ML,559.7,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,283.2082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,1630.2692
Closed Rx Metacarpal Fx,PX26600F,CDM,510,RC,26600,CPT,,,,,,,,443,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,283.2102,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,187.83,655.13
Closed Rx Metacarpal Fx,PX26600P,CDM,983,RC,26600,CPT,,,,,,,,295,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,283.2102,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,187.83,655.13
BONE SCREW T8 FULL THREAD 2.4MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12652-MAIN,LOCAL,,,,,289,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,283.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
BONE SCREW T8 FULL THREAD 2.4MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12653-MAIN,LOCAL,,,,,289,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,283.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
BONE SCREW T8 FULL THREAD 2.7MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12654-MAIN,LOCAL,,,,,289,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,283.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Occupational Therapy Eval High Complex,PX97167,CDM,434,RC,97167,CPT,,,,,,,,289,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,283.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,283.22
"Troponin, Quantitative",PX84484,CDM,300,RC,84484,CPT,,,,,,,,289,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,283.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.43,283.22
Drain/Inject Large Joint/Bursa,PX20610P,CDM,983,RC,20610,CPT,,,,,,,,291,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,141.5171429,percent of total billed charges,283.2303,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.8814,283.2303
Apply Lower Leg Splint,PX29515P,CDM,983,RC,29515,CPT,,,,,,,,311,,Medica,Commercial,both,91.1,,8.5,percent of total billed charges,283.321,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,129.1894,302.6963
Repr Superf Wnd Body <2.5cm,PX12001F,CDM,510,RC,12001,CPT,,,,,,,,311,,Medica,Commercial,both,91.1,,114.92,percent of total billed charges,283.321,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,129.1894,304.78
Xray Skull Less Than 4 Vws,PX7025001,CDM,320,RC,70250,CPT,TC,,,,,,,311,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,283.321,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,304.78
CT Lumbar Spine W/O & W/Dye,PX7213301,CDM,350,RC,72133,CPT,TC,,,,,,,4283,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,283.34,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.98,283.34
CT Lumbar Spine W/O & W/Dye,PX7213301,CDM,350,RC,72133,CPT,TC,,,,,,,4283,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,283.34,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.98,283.34
CT Lwr Extremity W/O&W/Dye,PX7370201,CDM,350,RC,73702,CPT,TC,,,,,,,1235,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,283.34,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.98,283.34
CT Lwr Extremity W/O&W/Dye,PX7370201,CDM,350,RC,73702,CPT,TC,,,,,,,1235,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,283.34,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.98,283.34
"Close Rx Fingr Articular Fx,Manip",PX26742P,CDM,983,RC,26742,CPT,,,,,,,,560,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,283.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,232.624,1404.08
"Enzyme Act, Nonradioact - Ref",PX8265790,CDM,300,RC,82657,CPT,90,,,,,,,560,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,283.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.33,548.8
Exc Skn Bngn1.1-2cm Remain Bdy,PX11422P,CDM,983,RC,11422,CPT,,,,,,,,822,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,283.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.95,805.56
Fac/Exc Skn Bngn1.1-2cm Remain Bdy,PX11422F,CDM,510,RC,11422,CPT,,,,,,,,618,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,283.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.95,374.26
"Upper GI Endoscopy,Biopsy",PX43239F,CDM,750,RC,43239,CPT,,,,,,,,2364,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,283.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.86,780.35
"Upper GI Endoscopy,Biopsy",PX43239P,CDM,983,RC,43239,CPT,,,,,,,,2458,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,283.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.86,2408.84
"Remv Foot Foreign Body,Subcutaneous",PX28190P,CDM,983,RC,28190,CPT,,,,,,,,683,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,283.7182,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,283.7182,664.7639
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476881,NDC,50,ML,579.12,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,283.7688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476881,NDC,50,ML,579.12,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,283.7688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476881,NDC,50,ML,579.12,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,283.7688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
cadexomer iodine 0.9 % Gel 40 g Tube,63700001,CDM,250,RC,,,,,,40565012249,NDC,40,GR,333.86,,First Health,Commercial,both,85,,999999999,percent of total billed charges,283.781,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CT Angio Abd&Pelv W/O&W/Dye,PX7417401,CDM,350,RC,74174,CPT,TC,,,,,,,2757,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,283.8276,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.4,567.99
Drain Skin Abscess Complic,PX10061P,CDM,983,RC,10061,CPT,,,,,,,,561,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,283.866,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,233.0394,546.0213
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12130-MAIN,LOCAL,,,,,561,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,283.866,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Clotting Function Activity - Ref,PX8539790,CDM,300,RC,85397,CPT,90,,,,,,,334,,First Health,Commercial,both,85,,999999999,percent of total billed charges,283.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.3,327.32
"Remv F.B.,Eye,Cornea,No Slit",PX65220F,CDM,510,RC,65220,CPT,,,,,,,,334,,First Health,Commercial,both,85,,999999999,percent of total billed charges,283.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.7436,348.08
Repeat Control of Nosebleed,PX30906F,CDM,510,RC,30906,CPT,,,,,,,,334,,First Health,Commercial,both,85,,999999999,percent of total billed charges,283.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.7436,327.32
X-Ray Abdomen 2+ Views W/ Single Vw Chest (Tc),PX7402201,CDM,320,RC,74022,CPT,TC,,,,,,,334,,First Health,Commercial,both,85,,999999999,percent of total billed charges,283.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,327.32
Fresh Frozen Plasma,PXP9017,CDM,390,RC,P9017,HCPCS,,,,,,,,319,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,283.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.32,312.62
Fluoroscopy Guid Needle Plcmt Tc,PX7700201,CDM,320,RC,77002,CPT,TC,,,,,,,662,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,283.998,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.9948,648.76
HERCULES 3 STAGE BALLOON ESOPHAGEAL 12-13.5-15::36-40.5-45MM,27200000,CDM,272,RC,C1726,HCPCS,,11329-MAIN,LOCAL,,,,,289.85,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,284.053,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HERCULES 3 STAGE BALLOON ESOPHAGEAL 15-16.5-18:45-49.5-54MM,27200000,CDM,272,RC,C1726,HCPCS,,11328-MAIN,LOCAL,,,,,289.85,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,284.053,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HERCULES 3 STAGE BALLOON ESOPHAGEAL 18-19-20::54-57-60MM,27200000,CDM,272,RC,C1726,HCPCS,,11330-MAIN,LOCAL,,,,,289.85,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,284.053,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,55150017301,NDC,0.5,ML,319.2,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,284.088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
"Spinal Puncture,Lumbar,Diagnostic",PX62270F,CDM,510,RC,62270,CPT,,,,,,,,684,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,284.1336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,284.1336,670.32
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012365,NDC,0.7,ML,291.98,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,284.184134,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012388,NDC,0.7,ML,291.98,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,284.184134,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072310,NDC,0.5,ML,291.98,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,284.184134,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072388,NDC,0.5,ML,291.98,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,284.184134,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
Apply Long Arm Splint,PX29105F,CDM,510,RC,29105,CPT,,,,,,,,290,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,284.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.466,284.2
Assay of Digoxin,PX80162,CDM,300,RC,80162,CPT,,,,,,,,290,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,284.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.18,284.2
Assay of Natriuretic Peptide,PX83880,CDM,300,RC,83880,CPT,,,,,,,,290,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,284.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36,284.2
Leukoreduced Rbc's,PXP9016,CDM,390,RC,P9016,HCPCS,,,,,,,,580,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,114.64,percent of total billed charges,284.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,165.79,568.4
Leukoreduced Rbc's,PXP9016,CDM,390,RC,P9016,HCPCS,,,,,,,,580,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,284.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,165.79,568.4
Leukoreduced Rbc's,PXP9016,CDM,390,RC,P9016,HCPCS,,,,,,,,580,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,284.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,165.79,568.4
NEEDLE INTRAOSSEOUS SET 15GA 25MM STABILIZER EZ-IO 9001P,120.216,CDM,272,RC,A4215,HCPCS,,10648-MAIN,LOCAL,,,,,290,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,284.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.466,284.2
NEEDLE INTRAOSSEOUS SET 15GA 45MM STABILIZER EZ-IO 9079P,120.216,CDM,272,RC,A4215,HCPCS,,10297-MAIN,LOCAL,,,,,290,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,284.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,120.466,284.2
Closed Rx Kneecap Dislocatn,PX27560P,CDM,983,RC,27560,CPT,,,,,,,,312,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,284.232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,129.6048,303.6696
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,55111069407,NDC,5,ML,592.4,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,284.352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.08296,1009.1158
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,55111069407,NDC,5,ML,592.4,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,284.352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.08296,1009.1158
Exc Skn Bngn3.1-4cm Remain Bdy,PX11424P,CDM,983,RC,11424,CPT,,,,,,,,562,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,284.372,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,233.4548,1416.38
"US,Preg. Uterus,Fetal/Mat.Eval.,>1st Trim.(>/= 14 Wks 0 Dys),Transabd;Single/First Gest., Tech",PX7680501,CDM,402,RC,76805,CPT,TC,,,,,,,562,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,284.372,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,550.76
ketoconazole 2 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,16714095501,NDC,15,GR,322.42,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,284.37444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600121,NDC,10,ML,592.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,284.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600121,NDC,10,ML,592.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,284.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
dexmedeTOMIDine in sodium chloride 400 MCG/100ML Solution 100 mL Bottle,25000000,CDM,250,RC,,,,,,67457092500,NDC,100,ML,562.18,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,284.46308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"DXA, Bone Density Study, Hips/Pelv/Spine",PX7708001,CDM,320,RC,77080,CPT,TC,,,,,,,575,,Humana Choice Care,All Medicare plans,outpatient,49.5,,356.29,percent of total billed charges,284.625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,563.5
"Close Rx Dist Fingr Fx,Manipulatn",PX26755F,CDM,510,RC,26755,CPT,,,,,,,,335,,First Health,Commercial,both,85,,999999999,percent of total billed charges,284.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
"Closed Rx I-P Jt,Toe Dislocation",PX28660F,CDM,510,RC,28660,CPT,,,,,,,,335,,First Health,Commercial,both,85,,999999999,percent of total billed charges,284.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Insitu Hybridization (Fish),PX8836401,CDM,310,RC,88364,CPT,TC,,,,,,,335,,First Health,Commercial,both,85,,999999999,percent of total billed charges,284.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Reduce Temporomandibl Disloc,PX21480F,CDM,510,RC,21480,CPT,,,,,,,,335,,First Health,Commercial,both,85,,999999999,percent of total billed charges,284.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Repr Superf Wnd Face <2.5cm,PX12011F,CDM,510,RC,12011,CPT,,,,,,,,335,,First Health,Commercial,both,85,,999999999,percent of total billed charges,284.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Apply Long Leg Splint,PX29505F,CDM,510,RC,29505,CPT,,,,,,,,320,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,284.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.928,313.6
"IV Infusion, Bamlanivimab, Infusion and Post Admin Monig",PXM0239,CDM,260,RC,M0239,HCPCS,,,,,,,,320,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,284.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.928,313.6
Xray Cervical Spine 4 or 5 Vws,PX7205001,CDM,320,RC,72050,CPT,TC,,,,,,,664,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,284.856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,650.72
Xray Cervical Spine 6 or More Vws,PX7205201,CDM,320,RC,72052,CPT,TC,,,,,,,664,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,284.856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,650.72
Xray Pelvis Compl 3+ Tc,PX7219001,CDM,320,RC,72190,CPT,TC,,,,,,,563,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,284.878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,551.74
Xray Ls Spine Bend Tc,PX7212001,CDM,320,RC,72120,CPT,TC,,,,,,,323,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,284.886,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,316.54
fat emulsion 20 % Emulsion 250 mL Flex Cont,25000000,CDM,250,RC,,,,,,338051909,NDC,250,ML,292.75,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,284.933575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Inc/Drain Peritonsil Abscess,PX42700F,CDM,510,RC,42700,CPT,,,,,,,,624,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,285.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.38,402.63
Inc/Drain Peritonsil Abscess,PX42700P,CDM,983,RC,42700,CPT,,,,,,,,889,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,285.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.38,871.22
Tap Block Bilateral by Injection(S),PX64488F,CDM,510,RC,64488,CPT,,,,,,,,393,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,285.02,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.32,285.02
Tap Block Bilateral by Injection(S),PX64488P,CDM,983,RC,64488,CPT,,,,,,,,262,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,285.02,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.32,285.02
sulfacetamide 10 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,24208067004,NDC,15,ML,312.96,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,285.10656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,6384371,NDC,1,EA,563.46,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,285.11076,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
Dress/Debrid Small Burn No Anes,PX16020F,CDM,510,RC,16020,CPT,,,,,,,,313,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,285.143,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.0202,306.74
nystatin 100000 UNIT/GM Powder 60 g Bottle,63700001,CDM,250,RC,,,,,,68308015260,NDC,60,GR,335.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,285.175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Digital Mamm, Diag, Unilat, Tc W/Cad Perf",PX7706501,CDM,401,RC,77065,CPT,TC,,,,,,,293,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,175.8,percent of total billed charges,285.1769,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.46,287.14
Drain Skin Abscess Simple,PX10060P,CDM,983,RC,10060,CPT,,,,,,,,293,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,285.1769,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.7122,285.1769
Kit Gene Analysis D816 Variant(S) - Ref,PX8127390,CDM,300,RC,81273,CPT,90,,,,,,,293,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,285.1769,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,114.49,287.14
Repr Superf Wnd Body <2.5cm,PX12001P,CDM,983,RC,12001,CPT,,,,,,,,293,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,151.8521429,percent of total billed charges,285.1769,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.7122,285.1769
Drain/Inject Large Joint/Bursa,PX20610P,CDM,983,RC,20610,CPT,,,,,,,,291,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,285.18,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,27.48,285.18
"Hospital Inpt or Obs Care, Admin/Disch Same Date, Moderate Level Mdm >= 70 Minutes",PX99235,CDM,982,RC,99235,CPT,,,,,,,,582,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,285.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,241.7628,566.4606
"Hospital Inpt or Obs Care, Admin/Disch Same Date, Moderate Level Mdm >= 70 Minutes",PX99235,CDM,982,RC,99235,CPT,,,,,,,,582,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,285.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,241.7628,566.4606
"Hospital Inpt or Obs Care, Admin/Disch Same Date, Moderate Level Mdm >= 70 Minutes",PX99235,CDM,982,RC,99235,CPT,,,,,,,,582,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,285.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,241.7628,566.4606
MRI Low Ext Jnt WO/Cont Tc,PX7372101,CDM,610,RC,73721,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,285.31,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.63,285.31
MRI Low Ext Jnt WO/Cont Tc,PX7372101,CDM,610,RC,73721,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,285.31,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.63,285.31
tiotropium 18 MCG capsule 5 Each Box,63700001,CDM,250,RC,,,,,,597007575,NDC,5,EA,665.18,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,285.36222,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
megestrol 40 MG/ML Suspension 240 mL Bottle,25000000,CDM,250,RC,,,,,,49884090738,NDC,240,ML,594.72,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,285.4656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
megestrol 40 MG/ML Suspension 240 mL Bottle,25000000,CDM,250,RC,,,,,,49884090738,NDC,240,ML,594.72,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,285.4656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Assay of Phenytoin Total,PX80185,CDM,300,RC,80185,CPT,,,,,,,,336,,First Health,Commercial,both,85,,999999999,percent of total billed charges,285.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,329.28
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133F,CDM,510,RC,13133,CPT,,,,,,,,595,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,285.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247.163,583.1
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133F,CDM,510,RC,13133,CPT,,,,,,,,595,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,285.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247.163,583.1
"Thrombolysis,Coronary,IV Infusn",PX92977F,CDM,480,RC,92977,CPT,,,,,,,,595,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,285.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247.163,583.1
"Thrombolysis,Coronary,IV Infusn",PX92977F,CDM,480,RC,92977,CPT,,,,,,,,595,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,285.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247.163,583.1
"Thrombolytic Therapy, Stroke",PX37195F,CDM,761,RC,37195,CPT,,,,,,,,595,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,285.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247.163,583.1
"Thrombolytic Therapy, Stroke",PX37195F,CDM,761,RC,37195,CPT,,,,,,,,595,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,285.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247.163,583.1
"Lap,Dx Surgical Abd W/Biopsy",PX49321P,CDM,983,RC,49321,CPT,,,,,,,,583,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,285.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,242.1782,5040.74
"Lap,Dx Surgical Abd W/Biopsy",PX49321P,CDM,983,RC,49321,CPT,,,,,,,,583,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,285.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,242.1782,5040.74
"Lap,Dx Surgical Abd W/Biopsy",PX49321P,CDM,983,RC,49321,CPT,,,,,,,,583,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,285.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,242.1782,5040.74
"Igh, Variable Region Somatic Mutation Analysis",PX8126390,CDM,310,RC,81263,CPT,90,,,,,,,1215,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,285.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,285.68,294.52
"Igh, Variable Region Somatic Mutation Analysis",PX8126390,CDM,310,RC,81263,CPT,90,,,,,,,1215,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,285.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,285.68,294.52
"Igh, Variable Region Somatic Mutation Analysis",PX8126390,CDM,310,RC,81263,CPT,90,,,,,,,1215,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,285.68,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,285.68,294.52
Apply Long Leg Cast,PX29345F,CDM,510,RC,29345,CPT,,,,,,,,912,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,285.71,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.29,285.71
"rabies vaccine, pcec Recon Susp 1 Each Vial",90675,CDM,636,RC,90675,CPT,,,,58160096412,NDC,1,EA,1544.83,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,285.77,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,285.77,324.74
"Cardioversion, Elective;Extern",PX92960P,CDM,983,RC,92960,CPT,,,,,,,,688,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,285.7952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,285.7952,669.6304
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031F,CDM,510,RC,12031,CPT,,,,,,,,688,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,285.7952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,285.7952,674.24
sugammadex sodium 200 MG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,6542312,NDC,2,ML,583.33,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,285.8317,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sugammadex sodium 200 MG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,6542312,NDC,2,ML,583.33,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,285.8317,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sugammadex sodium 200 MG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,6542312,NDC,2,ML,583.33,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,285.8317,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Repr Superf Wnd Body 12.6-20,PX12005F,CDM,510,RC,12005,CPT,,,,,,,,565,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,285.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,234.701,553.7
Xray Lumbosacral Minimum 4 Vws,PX7211001,CDM,320,RC,72110,CPT,TC,,,,,,,565,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,285.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,553.7
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004164,NDC,1,EA,666.52,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,285.93708,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004110,NDC,1,EA,666.53,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,285.94137,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
MRI Up Extremity Joint W/O Tc,PX7322101,CDM,610,RC,73221,CPT,TC,,,,,,,3319,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,285.97,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.85,285.97
MRI Up Extremity Joint W/O Tc,PX7322101,CDM,610,RC,73221,CPT,TC,,,,,,,3319,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,285.97,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.85,285.97
Assay for Vancomycin,PX80202,CDM,300,RC,80202,CPT,,,,,,,,314,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,286.054,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.41,307.72
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012365,NDC,0.7,ML,291.98,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,286.1404,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012388,NDC,0.7,ML,291.98,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,286.1404,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072310,NDC,0.5,ML,291.98,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,286.1404,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072388,NDC,0.5,ML,291.98,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,286.1404,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.3,286.1404
"Needle Biopsy, Lymph Node(S)",PX38505F,CDM,510,RC,38505,CPT,,,,,,,,667,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,286.143,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,277.0718,1416.38
Francisella Tularensis Ab,PX8666890,CDM,300,RC,86668,CPT,90,,,,,,,294,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,286.1502,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.98,288.12
Physical Therapy Evaluation High Complex,PX97163,CDM,424,RC,97163,CPT,,,,,,,,294,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,286.1502,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,288.12
Closed Rx Shldr Dislocation,PX23650F,CDM,510,RC,23650,CPT,,,,,,,,689,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,286.2106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,675.22
neomycin-polymyxin-gramicidin 1.75-10000-.025 Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,24208079062,NDC,10,ML,314.26,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,286.29086,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
US Renal Retroperit Ltd,PX7677501,CDM,402,RC,76775,CPT,TC,,,,,,,566,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,286.396,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,554.68
US Retroperitoneal Tc,PX7677001,CDM,402,RC,76770,CPT,TC,,,,,,,566,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,286.396,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,554.68
folic acid 5 MG/ML Solution 10 mL Vial,J3490.94,CDM,636,RC,J3490,HCPCS,,,,63323018410,NDC,10,ML,336.94,,First Health,Commercial,both,85,,999999999,percent of total billed charges,286.399,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,330.2012
Exc Back Les Sc = 3 Cm,PX21931P,CDM,983,RC,21931,CPT,,,,,,,,2135,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,286.43,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,286.43,2092.3
Emergency Level II Visit,PX99282P,CDM,981,RC,99282,CPT,,,,,,,,337,,First Health,Commercial,both,85,,999999999,percent of total billed charges,286.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.9898,328.0021
Fluoroscope Examination Tc,PX7600001,CDM,320,RC,76000,CPT,TC,,,,,,,597,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,286.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,585.06
Fluoroscope Examination Tc,PX7600001,CDM,320,RC,76000,CPT,TC,,,,,,,597,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,286.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,585.06
"Fac/Exc Skn Beni1.1-2cm Fce,Facial",PX11442F,CDM,510,RC,11442,CPT,,,,,,,,668,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,286.572,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,277.4872,654.64
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623F,CDM,510,RC,11623,CPT,,,,,,,,690,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,286.626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,286.626,1416.38
"Layr Clos Wnd Face,Facial 2.5-5",PX12052F,CDM,510,RC,12052,CPT,,,,,,,,585,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,286.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,243.009,573.3
"Layr Clos Wnd Face,Facial 2.5-5",PX12052F,CDM,510,RC,12052,CPT,,,,,,,,585,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,286.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,243.009,573.3
"Layr Clos Wnd Face,Facial 2.5-5",PX12052F,CDM,510,RC,12052,CPT,,,,,,,,585,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,286.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,243.009,573.3
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156F,CDM,370,RC,99156,CPT,,,,,,,,325,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,286.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,318.5
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156P,CDM,983,RC,99156,CPT,,,,,,,,325,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,286.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,316.3225
Refill/Maint Portable Pump,PX96521,CDM,260,RC,96521,CPT,,,,,,,,325,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,286.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,318.5
"Remv F.B.,Eye,Embed Conjunc",PX65210F,CDM,510,RC,65210,CPT,,,,,,,,325,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,286.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,348.08
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598P,CDM,982,RC,97598,CPT,,,,,,,,325,,United Healthcare,All Payer,outpatient,88.2,,215.18,percent of total billed charges,286.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,316.3225
Somatostatin - Ref,PX8430790,CDM,300,RC,84307,CPT,90,,,,,,,325,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,286.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.76,318.5
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476881,NDC,50,ML,579.12,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,286.6644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
gadoterate meglumine 10 mmol/20 mL Solution 20 mL Vial,A9575,CDM,636,RC,A9575,HCPCS,,,,67684200003,NDC,20,ML,668.27,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,286.68783,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,277.599358,654.9046
amiodarone 360-4.14 MG/200ML-% Solution 200 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066036020,NDC,200,ML,325.25,,United Healthcare,All Payer,outpatient,88.2,,396.835,percent of total billed charges,286.8705,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.35,318.745
fat emulsion 20 % Emulsion 250 mL Flex Cont,25000000,CDM,250,RC,,,,,,338051909,NDC,250,ML,292.75,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,286.895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ketoconazole 2 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,16714095501,NDC,15,GR,322.42,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,286.9538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Assay Iga/Igd/Igg/Igm Each,PX82784,CDM,300,RC,82784,CPT,,,,,,,,315,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,286.965,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.53,308.7
Closed Rx Trimalleolar Fx,PX27816F,CDM,510,RC,27816,CPT,,,,,,,,522,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,287.0634,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,190.44,718.09
Closed Rx Trimalleolar Fx,PX27816P,CDM,983,RC,27816,CPT,,,,,,,,826,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,287.0634,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,190.44,809.48
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606F,CDM,510,RC,11606,CPT,,,,,,,,1432,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,287.0634,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,193.93,933.24
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606P,CDM,983,RC,11606,CPT,,,,,,,,2044,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,287.0634,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,193.93,2003.12
Leukoreduced Rbc's,PXP9016,CDM,390,RC,P9016,HCPCS,,,,,,,,580,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,287.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,165.79,568.4
moxifloxacin 0.5 % Solution 3 mL Bottle,25000000,CDM,250,RC,,,,,,60505058204,NDC,3,ML,691.15,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,287.10371,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Closed Rx Metacarpal Fx,PX26600P,CDM,983,RC,26600,CPT,,,,,,,,295,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,287.1235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.543,287.1235
Sulfur Colloid per Dose,PXA9541,CDM,343,RC,A9541,HCPCS,,,,,,,,295,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,287.1235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.543,289.1
"Digital Mamm, Diag, Unilat, Tc W/Cad Perf",PX7706501,CDM,401,RC,77065,CPT,TC,,,,,,,293,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,287.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.46,287.14
Drain Skin Abscess Simple,PX10060P,CDM,983,RC,10060,CPT,,,,,,,,293,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,287.14,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.41,287.14
Kit Gene Analysis D816 Variant(S) - Ref,PX8127390,CDM,300,RC,81273,CPT,90,,,,,,,293,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,287.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,114.49,287.14
Repr Superf Wnd Body <2.5cm,PX12001P,CDM,983,RC,12001,CPT,,,,,,,,293,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,287.14,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.83,287.14
US Abdomen Tc,PX7670001,CDM,402,RC,76700,CPT,TC,,,,,,,586,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,287.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,574.28
US Abdomen Tc,PX7670001,CDM,402,RC,76700,CPT,TC,,,,,,,586,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,287.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,574.28
US Abdomen Tc,PX7670001,CDM,402,RC,76700,CPT,TC,,,,,,,586,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,287.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,574.28
trastuzumab 150 MG Recon Soln 1 Each Vial,J9355.01,CDM,636,RC,J9355,HCPCS,,,,50242013201,NDC,1,EA,3179.17,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,287.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.77,3115.5866
filgrastim-ayow 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,800000,CDM,,,,,,,,70121157001,NDC,0.5,ML,691.62,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,287.298948,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Cardiac Rehab II W/ Monitor,PX93798.02,CDM,943,RC,93798,CPT,,,,,,,,338,,First Health,Commercial,both,85,,999999999,percent of total billed charges,287.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.44,495.55
Initial Rx Burn(S) 1st Degree,PX16000F,CDM,510,RC,16000,CPT,,,,,,,,338,,First Health,Commercial,both,85,,999999999,percent of total billed charges,287.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.4052,331.24
Emergency Level III Visit,PX99283P,CDM,981,RC,99283,CPT,,,,,,,,568,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,287.408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,235.9472,552.8344
Xray Ls Spine Bend Tc,PX7212001,CDM,320,RC,72120,CPT,TC,,,,,,,323,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,287.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,316.54
Facility Emergency Level III Visit,PX99283F,CDM,450,RC,99283,CPT,,,,,,,,587,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,137.8311224,percent of total billed charges,287.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,243.8398,575.26
Facility Emergency Level III Visit,PX99283F,CDM,450,RC,99283,CPT,,,,,,,,587,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,287.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,243.8398,575.26
Facility Emergency Level III Visit,PX99283F,CDM,450,RC,99283,CPT,,,,,,,,587,,United Healthcare,All Medicare advantage plans,outpatient,49,,105.785,percent of total billed charges,287.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,243.8398,575.26
"Fac/Office Consultation,Level IV",PX99244F,CDM,510,RC,99244,CPT,,,,,,,,441,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,287.64,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.11,287.64
"Office Consultation,Level IV",PX99244P,CDM,983,RC,99244,CPT,,,,,,,,441,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,287.64,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.11,432.18
Closed Treat Wrist Dislocation,PX25660P,CDM,983,RC,25660,CPT,,,,,,,,1507,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,287.74,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,287.74,1476.86
Cast/Strap Procedure Unlisted,PX29799F,CDM,510,RC,29799,CPT,,,,,,,,316,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,287.876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,131.2664,309.68
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423P,CDM,983,RC,11423,CPT,,,,,,,,569,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,287.914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,236.3626,1416.38
DRILL BIT 2.2MM LONG SOLID STERILE MICA,27200000,CDM,272,RC,,,,12985-MAIN,LOCAL,,,,,600,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRILL BIT 2.2MM LONG SOLID STERILE MICA,27200000,CDM,272,RC,,,,12985-MAIN,LOCAL,,,,,600,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Extremity Study - Vascular Diagnostics,PX9392201,CDM,921,RC,93922,CPT,TC,,,,,,,600,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,588
Extremity Study - Vascular Diagnostics,PX9392201,CDM,921,RC,93922,CPT,TC,,,,,,,600,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,588
"Hospital Inpt or Obs Care, Admin/Disch Same Date, Moderate Level Mdm >= 70 Minutes",PX99235,CDM,982,RC,99235,CPT,,,,,,,,582,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,288.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,241.7628,566.4606
PHENobarbital 130 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047721,NDC,1,ML,338.93,,First Health,Commercial,both,85,,999999999,percent of total billed charges,288.0905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.354486,332.1514
"Apply Forearm Splint,Static",PX29125P,CDM,983,RC,29125,CPT,,,,,,,,296,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,82.99,percent of total billed charges,288.0968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,288.0968
Apply Lower Leg Splint,PX29515F,CDM,510,RC,29515,CPT,,,,,,,,296,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,108.5633333,percent of total billed charges,288.0968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.9584,290.08
Drain Skin Abscess Simple,PX10060F,CDM,510,RC,10060,CPT,,,,,,,,296,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,288.0968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.9584,290.08
Assay Thyroid Stim Hormone,PX84443,CDM,300,RC,84443,CPT,,,,,,,,294,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,288.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,15.4,288.12
Francisella Tularensis Ab,PX8666890,CDM,300,RC,86668,CPT,90,,,,,,,294,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,288.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.98,288.12
Physical Therapy Evaluation High Complex,PX97163,CDM,424,RC,97163,CPT,,,,,,,,294,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,288.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,288.12
"Molecular Path Proc, Level 2 - Ref",PX8140190,CDM,310,RC,81401,CPT,90,,,,,,,672,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,288.288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.62,658.56
8MM ENDOWRIST INSTRUMENTS MEGA SUTURE CUT NEEDLE DRIVER,27200000,CDM,272,RC,,,,11914-MAIN,LOCAL,,,,,327,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,288.414,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"IV Infusion Therapy, 1 Hour",PX96365,CDM,260,RC,96365,CPT,,,,,,,,327,,United Healthcare,All Payer,outpatient,88.2,,119.485,percent of total billed charges,288.414,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.8358,320.46
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004P,CDM,983,RC,15004,CPT,,,,,,,,570,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,288.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,236.778,554.781
Insert Emergency Endotrach Airway,PX31500F,CDM,510,RC,31500,CPT,,,,,,,,637,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,288.48,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.64,288.48
Insert Emergency Endotrach Airway,PX31500F,CDM,510,RC,31500,CPT,,,,,,,,637,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,288.48,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.64,288.48
Insert Emergency Endotrach Airway,PX31500P,CDM,983,RC,31500,CPT,,,,,,,,657,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,288.48,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.64,643.86
Insert Emergency Endotrach Airway,PX31500P,CDM,983,RC,31500,CPT,,,,,,,,657,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,288.48,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.64,643.86
"Igh, Variable Region Somatic Mutation Analysis",PX8126390,CDM,310,RC,81263,CPT,90,,,,,,,1215,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,288.4891,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,285.68,294.52
"Lap,Dx Surgical Abd W/Biopsy",PX49321P,CDM,983,RC,49321,CPT,,,,,,,,583,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,288.585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,242.1782,5040.74
Exc Back Les Sc = 3 Cm,PX21931P,CDM,983,RC,21931,CPT,,,,,,,,2135,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,288.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,286.43,2092.3
Exc Back Les Sc = 3 Cm,PX21931P,CDM,983,RC,21931,CPT,,,,,,,,2135,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,288.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,286.43,2092.3
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200001,NDC,0.5,ML,980.99,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,288.66,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.02,298.03
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200002,NDC,0.5,ML,980.99,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,288.66,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.02,298.03
"Fac/Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601F,CDM,510,RC,11601,CPT,,,,,,,,673,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,288.717,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,279.5642,659.54
sugammadex sodium 200 MG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,6542312,NDC,2,ML,583.33,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,288.74835,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sevoflurane Solution 250 mL Bottle,25000000,CDM,250,RC,,,,,,66794001525,NDC,250,ML,589.56,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,288.8844,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sevoflurane Solution 250 mL Bottle,25000000,CDM,250,RC,,,,,,66794001525,NDC,250,ML,589.56,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,288.8844,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sevoflurane Solution 250 mL Bottle,25000000,CDM,250,RC,,,,,,66794001525,NDC,250,ML,589.56,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,288.8844,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,63323076350,NDC,50,ML,589.57,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,288.8893,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,63323076350,NDC,50,ML,589.57,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,288.8893,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,63323076350,NDC,50,ML,589.57,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,288.8893,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600110,NDC,10,ML,589.63,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,288.9187,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600110,NDC,10,ML,589.63,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,288.9187,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600110,NDC,10,ML,589.63,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,288.9187,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
butamben-tetracaine-benzocaine 2-2-14 % Aerosol 20 g Bottle,25000000,CDM,250,RC,,,,,,10223020103,NDC,20,GR,589.76,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,288.9824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
butamben-tetracaine-benzocaine 2-2-14 % Aerosol 20 g Bottle,25000000,CDM,250,RC,,,,,,10223020103,NDC,20,GR,589.76,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,288.9824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
butamben-tetracaine-benzocaine 2-2-14 % Aerosol 20 g Bottle,25000000,CDM,250,RC,,,,,,10223020103,NDC,20,GR,589.76,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,288.9824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Sars-Cov-2 Covid-19 Antibody,PX86769,CDM,300,RC,86769,CPT,,,,,,,,340,,First Health,Commercial,both,85,,999999999,percent of total billed charges,289,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.63,333.2
X-Ray Exam Chest 3 Views,PX7104701,CDM,320,RC,71047,CPT,TC,,,,,,,340,,First Health,Commercial,both,85,,999999999,percent of total billed charges,289,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,333.2
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505F,CDM,510,RC,24505,CPT,,,,,,,,2109,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,289.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.04,1086.13
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505P,CDM,983,RC,24505,CPT,,,,,,,,2353,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,289.04,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.04,2305.94
Closed Rx Metacarpal Fx,PX26600P,CDM,983,RC,26600,CPT,,,,,,,,295,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,289.1,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,187.83,655.13
Sulfur Colloid per Dose,PXA9541,CDM,343,RC,A9541,HCPCS,,,,,,,,295,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,289.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.543,289.1
Abd Paracentesis W/Imaging(P),PX49083P,CDM,983,RC,49083,CPT,,,,,,,,696,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,289.1184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.1184,791.92
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156F,CDM,370,RC,99156,CPT,,,,,,,,325,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,289.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,318.5
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156P,CDM,983,RC,99156,CPT,,,,,,,,325,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,289.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,316.3225
Refill/Maint Portable Pump,PX96521,CDM,260,RC,96521,CPT,,,,,,,,325,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,289.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,318.5
"Remv F.B.,Eye,Embed Conjunc",PX65210F,CDM,510,RC,65210,CPT,,,,,,,,325,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,289.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,348.08
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598P,CDM,982,RC,97598,CPT,,,,,,,,325,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,289.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,316.3225
Somatostatin - Ref,PX8430790,CDM,300,RC,84307,CPT,90,,,,,,,325,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,289.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.76,318.5
"Chemotherapy, IV Infusion, Each Add'l Sequential Infusion",PX96417,CDM,335,RC,96417,CPT,,,,,,,,328,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,289.296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,321.44
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762P,CDM,983,RC,43762,CPT,,,,,,,,328,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,289.296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.2512,319.2424
BOOT AIRSELECT SHORT LARGE 01ES-L,120.45,CDM,274,RC,L4360,HCPCS,,11890-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,289.4,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
BOOT AIRSELECT SHORT MEDIUM 01ES-M,120.45,CDM,274,RC,L4360,HCPCS,,11889-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,289.4,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
BOOT AIRSELECT SHORT SMALL 01ES-S,120.45,CDM,274,RC,L4360,HCPCS,,11888-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,289.4,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
BOOT AIRSELECT SHORT X-LARGE 01ES-XL,120.45,CDM,274,RC,L4360,HCPCS,,11891-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,289.4,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
BOOT AIRSELECT SHORT X-SMALL 01ES-XS,120.45,CDM,274,RC,L4360,HCPCS,,11887-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,289.4,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
BOOT AIRSELECT STANDARD LARGE 01EF-L,120.45,CDM,274,RC,L4360,HCPCS,,11697-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,289.4,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
BOOT AIRSELECT STANDARD MEDIUM 01EF-M,120.45,CDM,274,RC,L4360,HCPCS,,11696-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,289.4,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
BOOT AIRSELECT STANDARD SMALL 01EF-S,120.45,CDM,274,RC,L4360,HCPCS,,11695-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,289.4,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
BOOT AIRSELECT STANDARD X-LARGE 01EF-XL,120.45,CDM,274,RC,L4360,HCPCS,,11698-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,289.4,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
BOOT AIRSELECT STANDARD X-SMALL 01EF-XS,120.45,CDM,274,RC,L4360,HCPCS,,11694-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,289.4,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
SPLINT FOOT SMALL STRUT WALK 11-1383-2-00000,120.45,CDM,274,RC,L4360,HCPCS,,1205-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,289.4,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
MESH LARGE LEFT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 4X6,120.521,CDM,278,RC,C1781,HCPCS,,12215-MAIN,LOCAL,,,,,572,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,289.432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,237.6088,560.56
MESH LARGE RIGHT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 4X6,C1781,CDM,278,RC,C1781,HCPCS,,12195-MAIN,LOCAL,,,,,572,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,289.432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Remove Nasal Foreign Body,PX30300P,CDM,983,RC,30300,CPT,,,,,,,,572,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,289.432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,556.7276
amiodarone 360-4.14 MG/200ML-% Solution 200 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066036020,NDC,200,ML,325.25,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,289.4725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.35,318.745
Ligation of Hemorrhoid(S),PX46221P,CDM,983,RC,46221,CPT,,,,,,,,697,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,289.5338,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.5338,798.45
STAPLER INTERNAL POWERED 29MM CURVED CIRCULAR,27200000,CDM,272,RC,,,,12024-MAIN,LOCAL,,,,,697,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,289.5338,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STAPLER INTERNAL POWERED 31MM CURVED CIRCULAR,27200000,CDM,272,RC,,,,12025-MAIN,LOCAL,,,,,697,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,289.5338,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Injection for Shoulder Arthrogram,PX23350F,CDM,510,RC,23350,CPT,,,,,,,,675,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,289.575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,280.395,661.5
"Layr Clos Wnd Face,Facial 2.5-5",PX12052F,CDM,510,RC,12052,CPT,,,,,,,,585,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,289.575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,243.009,573.3
Closed Rx Shldr Dislocation,PX23650F,CDM,510,RC,23650,CPT,,,,,,,,689,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,289.6322,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.18,720.86
Closed Rx Shldr Dislocation,PX23650P,CDM,983,RC,23650,CPT,,,,,,,,516,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,289.6322,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.18,720.86
8MM ENDOWRIST INSTRUMENTS LARGE NEEDLE DRIVER,27200000,CDM,272,RC,,,,11912-MAIN,LOCAL,,,,,318,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,289.698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Drain/Inject Medium Joint/Bursa,PX20605P,CDM,983,RC,20605,CPT,,,,,,,,318,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,289.698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,309.5094
"Office/Outpt Visit,Est,Levl V",PX99215F,CDM,510,RC,99215,CPT,,,,,,,,318,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,289.698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,311.64
"Office/Outpt Visit,Est,Levl V",PX99215P,CDM,983,RC,99215,CPT,,,,,,,,318,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,289.698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,309.5094
"Remv F.B.,Eye,Cornea,No Slit",PX65220P,CDM,983,RC,65220,CPT,,,,,,,,318,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,289.698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,348.08
Drainage of Hematoma/Fluid (T),PX10140F,CDM,510,RC,10140,CPT,,,,,,,,341,,First Health,Commercial,both,85,,999999999,percent of total billed charges,289.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,141.6514,1416.38
Drainage Scrotal Wall Abscess,PX55100P,CDM,983,RC,55100,CPT,,,,,,,,341,,First Health,Commercial,both,85,,999999999,percent of total billed charges,289.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,141.6514,1416.38
Closed Rx Kneecap Disloc+Anesth,PX27562F,CDM,510,RC,27562,CPT,,,,,,,,604,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,289.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,591.92
Closed Rx Kneecap Disloc+Anesth,PX27562F,CDM,510,RC,27562,CPT,,,,,,,,604,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,289.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,591.92
"Fac/Exc Skn Malig .1-2cm Fce,Facal",PX11642F,CDM,510,RC,11642,CPT,,,,,,,,698,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,289.9492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.9492,684.04
rabies immune globulin 300 UNIT/ML Solution 1 mL Vial,90376,CDM,636,RC,90375,CPT,,,,13533031801,NDC,1,ML,1629.06,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,289.98,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.18,307.02
rabies immune globulin 1500 UNIT/5ML Solution 5 mL Vial,90375,CDM,636,RC,90375,CPT,,,,13533031805,NDC,5,ML,8065.26,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,289.98,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.18,307.02
Direct Admit Hospital Observ,PXG0379,CDM,761,RC,G0379,HCPCS,,,,,,,,676,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,290.004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,280.8104,662.48
US Abdomen Tc,PX7670001,CDM,402,RC,76700,CPT,TC,,,,,,,586,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,290.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,574.28
"Apply Forearm Splint,Static",PX29125P,CDM,983,RC,29125,CPT,,,,,,,,296,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,290.08,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.08,290.08
Apply Lower Leg Splint,PX29515F,CDM,510,RC,29515,CPT,,,,,,,,296,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,290.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.9584,290.08
Drain Skin Abscess Simple,PX10060F,CDM,510,RC,10060,CPT,,,,,,,,296,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,290.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.9584,290.08
oseltamivir 6 MG/ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,68180067801,NDC,60,ML,676.25,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,290.11125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Facility Emergency Level 1 Visit,PX99281F,CDM,450,RC,99281,CPT,,,,,,,,329,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,290.178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.56,322.42
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,55111069407,NDC,5,ML,592.4,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,12.50188889,percent of total billed charges,290.276,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.08296,1009.1158
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,55111069407,NDC,5,ML,592.4,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,290.276,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.08296,1009.1158
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,55111069407,NDC,5,ML,592.4,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,290.276,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.08296,1009.1158
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600121,NDC,10,ML,592.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,290.325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600121,NDC,10,ML,592.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,290.325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600121,NDC,10,ML,592.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,290.325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
hydrocortisone sodium succinate (preservative free) 500 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001612,NDC,1,EA,298.53,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,290.559249,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
Facility Emergency Level III Visit,PX99283F,CDM,450,RC,99283,CPT,,,,,,,,587,,Humana Choice Care,All Medicare plans,outpatient,49.5,,242.278,percent of total billed charges,290.565,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,243.8398,575.26
Fresh Frozen Plasma,PXP9017,CDM,390,RC,P9017,HCPCS,,,,,,,,319,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,290.609,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.32,312.62
"Ctrl Nosebleed,Anter,Simple",PX30901F,CDM,510,RC,30901,CPT,,,,,,,,342,,First Health,Commercial,both,85,,999999999,percent of total billed charges,290.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,335.16
Ultrasound Breast Limited,PX7664201,CDM,402,RC,76642,CPT,TC,,,,,,,342,,First Health,Commercial,both,85,,999999999,percent of total billed charges,290.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,335.16
CATHETER BIPOLAR ELECTROHEMOSTASIS 7FR 300CM M00560070,27200000,CDM,272,RC,,,,12909-MAIN,LOCAL,,,,,700,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,290.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,55150017301,NDC,0.5,ML,319.2,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,290.7912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
Temporary External Pacing,PX92953F,CDM,480,RC,92953,CPT,,,,,,,,678,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,290.862,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,281.6412,664.44
"Fac/Exc Skn Bnig0.6-1cm Fae,Facial",PX11441F,CDM,510,RC,11441,CPT,,,,,,,,606,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,290.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,251.7324,614.65
"Fac/Exc Skn Bnig0.6-1cm Fae,Facial",PX11441F,CDM,510,RC,11441,CPT,,,,,,,,606,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,290.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,251.7324,614.65
"DXA, Bone Density Study, Hips/Pelv/Spine",PX7708001,CDM,320,RC,77080,CPT,TC,,,,,,,575,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,290.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,563.5
Exc Skin Benig <5mm Remaindr Body,PX11420P,CDM,983,RC,11420,CPT,,,,,,,,299,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,291.0167,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,124.2046,1416.38
8MM ENDOWRIST INSTRUMENTS MEGA SUTURE CUT NEEDLE DRIVER,27200000,CDM,272,RC,,,,11914-MAIN,LOCAL,,,,,327,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,291.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"IV Infusion Therapy, 1 Hour",PX96365,CDM,260,RC,96365,CPT,,,,,,,,327,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,291.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.8358,320.46
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725P,CDM,983,RC,26725,CPT,,,,,,,,330,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,291.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.082,321.189
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101P,CDM,983,RC,13101,CPT,,,,,,,,330,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,291.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.082,548.67
DRILL BIT 2.2MMX60MM STERILE MICA CANNULATED,27200000,CDM,272,RC,,,,12437-MAIN,LOCAL,,,,,701,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,291.1954,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRILL BIT 3.0MMX60MM STERILE MICA CANNULATED,27200000,CDM,272,RC,,,,12438-MAIN,LOCAL,,,,,701,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,291.1954,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Fac/Ex Skn Bngn2.1-3cm Trnk,Arm,Lg",PX11403F,CDM,510,RC,11403,CPT,,,,,,,,679,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,291.291,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,282.0566,665.42
Anal Sphincterotomy,PX46080F,CDM,510,RC,46080,CPT,,,,,,,,607,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,291.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,252.1478,2452.93
Anal Sphincterotomy,PX46080F,CDM,510,RC,46080,CPT,,,,,,,,607,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,291.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,252.1478,2452.93
megestrol 40 MG/ML Suspension 240 mL Bottle,25000000,CDM,250,RC,,,,,,49884090738,NDC,240,ML,594.72,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,291.4128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
megestrol 40 MG/ML Suspension 240 mL Bottle,25000000,CDM,250,RC,,,,,,49884090738,NDC,240,ML,594.72,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,291.4128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
megestrol 40 MG/ML Suspension 240 mL Bottle,25000000,CDM,250,RC,,,,,,49884090738,NDC,240,ML,594.72,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,291.4128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
atropine 1 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,60219174903,NDC,5,ML,299.49,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,291.493617,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
buprenorphine 5 MCG/HR PATCH WEEKLY 4 Each Box,63700001,CDM,250,RC,,,,,,42858075040,NDC,1,EA,330.52,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,291.51864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Apply Long Leg Splint,PX29505F,CDM,510,RC,29505,CPT,,,,,,,,320,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,291.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.928,313.6
"IV Infusion, Bamlanivimab, Infusion and Post Admin Monig",PXM0239,CDM,260,RC,M0239,HCPCS,,,,,,,,320,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,291.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.928,313.6
Infliximab - Ref,PX8023090,CDM,300,RC,80230,CPT,90,,,,,,,343,,First Health,Commercial,both,85,,999999999,percent of total billed charges,291.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.36,336.14
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133F,CDM,510,RC,13133,CPT,,,,,,,,595,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,291.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247.163,583.1
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133F,CDM,510,RC,13133,CPT,,,,,,,,595,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,291.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247.163,583.1
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133F,CDM,510,RC,13133,CPT,,,,,,,,595,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,291.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247.163,583.1
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002F,CDM,510,RC,12002,CPT,,,,,,,,343,,First Health,Commercial,both,85,,999999999,percent of total billed charges,291.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,142.4822,336.14
"Thrombolysis,Coronary,IV Infusn",PX92977F,CDM,480,RC,92977,CPT,,,,,,,,595,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,291.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247.163,583.1
"Thrombolysis,Coronary,IV Infusn",PX92977F,CDM,480,RC,92977,CPT,,,,,,,,595,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,291.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247.163,583.1
"Thrombolysis,Coronary,IV Infusn",PX92977F,CDM,480,RC,92977,CPT,,,,,,,,595,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,291.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247.163,583.1
"Thrombolytic Therapy, Stroke",PX37195F,CDM,761,RC,37195,CPT,,,,,,,,595,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,291.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247.163,583.1
"Thrombolytic Therapy, Stroke",PX37195F,CDM,761,RC,37195,CPT,,,,,,,,595,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,291.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247.163,583.1
"Thrombolytic Therapy, Stroke",PX37195F,CDM,761,RC,37195,CPT,,,,,,,,595,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,291.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247.163,583.1
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010202,NDC,1,EA,680,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,291.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 1 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010101,NDC,1,EA,680,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,291.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010102,NDC,1,EA,680,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,291.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
"Fac/Exc Skn Mal 0.6-1cm Fce,Facial",PX11641F,CDM,510,RC,11641,CPT,,,,,,,,680,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,291.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,282.472,666.4
Observation Initial,PXG0378.03,CDM,762,RC,G0378,HCPCS,,,,,,,,680,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,291.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,282.472,666.4
sevoflurane Solution 250 mL Bottle,25000000,CDM,250,RC,,,,,,66794001525,NDC,250,ML,589.56,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,291.8322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,63323076350,NDC,50,ML,589.57,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,291.83715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
3.0MM HEADED SCREW LENGTH 16MM,C1713,CDM,278,RC,C1713,HCPCS,,12656-MAIN,LOCAL,,,,,608,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,291.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
3.0MM HEADED SCREW LENGTH 16MM,C1713,CDM,278,RC,C1713,HCPCS,,12656-MAIN,LOCAL,,,,,608,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,291.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600110,NDC,10,ML,589.63,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,291.86685,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
"Chemotherapy, IV Infusion, Each Add'l Sequential Infusion",PX96417,CDM,335,RC,96417,CPT,,,,,,,,328,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,291.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,321.44
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762P,CDM,983,RC,43762,CPT,,,,,,,,328,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,291.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.2512,319.2424
butamben-tetracaine-benzocaine 2-2-14 % Aerosol 20 g Bottle,25000000,CDM,250,RC,,,,,,10223020103,NDC,20,GR,589.76,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,291.9312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
iohexol 300 MG/ML Solution 150 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141365,NDC,150,ML,300,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1.285682353,percent of total billed charges,291.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,294
"Spinal Punc,Drain,Theraputic",PX62272P,CDM,983,RC,62272,CPT,,,,,,,,300,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,291.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,124.62,604.15
US Follicles-Limited Tc,PX7685701,CDM,402,RC,76857,CPT,TC,,,,,,,300,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,291.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,294
"Ecg 12 Lead, Tracing Only",PX93005,CDM,730,RC,93005,CPT,,,,,,,,298,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,292.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.44,292.04
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200001,NDC,0.5,ML,980.99,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,292.08318,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.02,298.03
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200002,NDC,0.5,ML,980.99,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,292.08318,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.02,298.03
Closed Treat Wrist Dislocation,PX25660P,CDM,983,RC,25660,CPT,,,,,,,,1507,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,292.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,287.74,1476.86
Closed Treat Wrist Dislocation,PX25660P,CDM,983,RC,25660,CPT,,,,,,,,1507,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,292.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,287.74,1476.86
Repr Superf Wnd Face 2.6-5,PX12013P,CDM,983,RC,12013,CPT,,,,,,,,681,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,292.149,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,662.8173
"MRI,Lwrext,Jnt W/O+W/Cont",PX7372301,CDM,610,RC,73723,CPT,TC,,,,,,,1850,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,292.1944,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,198.08,583.77
"Infectious Disease,Chronic Hep C Virus,Six Assays, Utilizing Serum",PX8159690,CDM,300,RC,81596,CPT,90,,,,,,,609,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,292.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.19,596.82
"Infectious Disease,Chronic Hep C Virus,Six Assays, Utilizing Serum",PX8159690,CDM,300,RC,81596,CPT,90,,,,,,,609,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,292.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.19,596.82
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604F,CDM,510,RC,20604,CPT,,,,,,,,344,,First Health,Commercial,both,85,,999999999,percent of total billed charges,292.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,142.8976,337.12
Fluoroscope Examination Tc,PX7600001,CDM,320,RC,76000,CPT,TC,,,,,,,597,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,506.31,percent of total billed charges,292.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,585.06
Fluoroscope Examination Tc,PX7600001,CDM,320,RC,76000,CPT,TC,,,,,,,597,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,292.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,585.06
Fluoroscope Examination Tc,PX7600001,CDM,320,RC,76000,CPT,TC,,,,,,,597,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,292.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,585.06
hydrocortisone sodium succinate (preservative free) 500 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001612,NDC,1,EA,298.53,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,292.5594,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
sodium thiosulfate 250 MG/ML Solution 50 mL Vial,J0209.01,CDM,636,RC,J0209,HCPCS,,,,60267070550,NDC,50,ML,609.57,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,292.5936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,253.215378,597.3786
sodium thiosulfate 250 MG/ML Solution 50 mL Vial,J0209.01,CDM,636,RC,J0209,HCPCS,,,,60267070550,NDC,50,ML,609.57,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,292.5936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,253.215378,597.3786
dexAMETHasone 0.1 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,24208072002,NDC,5,ML,331.81,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,292.65642,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505F,CDM,510,RC,24505,CPT,,,,,,,,2109,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,292.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.04,1086.13
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505F,CDM,510,RC,24505,CPT,,,,,,,,2109,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,292.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.04,1086.13
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505P,CDM,983,RC,24505,CPT,,,,,,,,2353,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,292.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.04,2305.94
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505P,CDM,983,RC,24505,CPT,,,,,,,,2353,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,292.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.04,2305.94
Facility Emergency Level 1 Visit,PX99281F,CDM,450,RC,99281,CPT,,,,,,,,329,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,292.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.56,322.42
Skin Sub Graft Trnk/Arm/Leg,PX15271P,CDM,983,RC,15271,CPT,,,,,,,,705,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,292.857,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,292.857,1593.14
"Spinal Puncture,Lumbar,Diagnostic",PX62270P,CDM,983,RC,62270,CPT,,,,,,,,705,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,292.857,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,292.857,686.1765
Temporal Artery Ligatn or Bx,PX37609F,CDM,510,RC,37609,CPT,,,,,,,,705,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,292.857,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,292.857,1416.38
PACLitaxel 150 MG/25ML Concentrate 25 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321701,NDC,25,ML,300.96,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,292.924368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122P,CDM,983,RC,13122,CPT,,,,,,,,301,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,292.9633,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.0354,292.9633
Xray Facial Bones Less Than 3 Vws,PX7014001,CDM,320,RC,70140,CPT,TC,,,,,,,301,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,292.9633,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,294.98
"Remv Foot Foreign Body,Subcutaneous",PX28190P,CDM,983,RC,28190,CPT,,,,,,,,683,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,293.007,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,283.7182,664.7639
Exc Skin Benig <5mm Remaindr Body,PX11420P,CDM,983,RC,11420,CPT,,,,,,,,299,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,293.02,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.35,293.02
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476881,NDC,50,ML,579.12,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,293.03472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
linezolid 600 MG/300ML Solution 300 mL Flex Cont,J2020.01,CDM,636,RC,J2020,HCPCS,,,,9514001,NDC,300,ML,332.42,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,293.19444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.087268,325.7716
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,55111069407,NDC,5,ML,592.4,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,293.238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.08296,1009.1158
Exc Skn Bnig0.6-1cm Remain Bdy,PX11421P,CDM,983,RC,11421,CPT,,,,,,,,345,,First Health,Commercial,both,85,,999999999,percent of total billed charges,293.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,143.313,614.65
Closed Rx Elbow Dislocation,PX24600F,CDM,510,RC,24600,CPT,,,,,,,,706,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,293.2724,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,691.88
HERNIA MESH LAP PROGRIP SELF FIXATING FLAT SHEET 10X15,C1781,CDM,278,RC,C1781,HCPCS,,12727-MAIN,LOCAL,,,,,611,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,293.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
HERNIA MESH LAP PROGRIP SELF FIXATING FLAT SHEET 10X15,C1781,CDM,278,RC,C1781,HCPCS,,12727-MAIN,LOCAL,,,,,611,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,293.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600121,NDC,10,ML,592.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,293.2875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
CARBOplatin 600 MG/60ML Solution 60 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703423981,NDC,60,ML,301.42,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,293.372086,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.778704,295.3916
"Spinal Puncture,Lumbar,Diagnostic",PX62270F,CDM,510,RC,62270,CPT,,,,,,,,684,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,293.436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,284.1336,670.32
Leukoreduced Rbc's,PXP9016,CDM,390,RC,P9016,HCPCS,,,,,,,,580,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,293.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,165.79,568.4
"MRI,Uprext Jnt W/O+W/Cont",PX7322301,CDM,610,RC,73223,CPT,TC,,,,,,,2681,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,293.4816,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,198.95,586.4
atropine 1 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,60219174903,NDC,5,ML,299.49,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,293.5002,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725P,CDM,983,RC,26725,CPT,,,,,,,,330,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,293.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.082,321.189
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101P,CDM,983,RC,13101,CPT,,,,,,,,330,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,293.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.082,548.67
"Fna Biopsy, W/US Guidance; First Lesion",PX10005F,CDM,510,RC,10005,CPT,,,,,,,,333,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,293.706,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.3282,614.65
Ultrasound Breast Complete,PX7664101,CDM,402,RC,76641,CPT,TC,,,,,,,333,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,293.706,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,326.34
ketoconazole 2 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,16714095501,NDC,15,GR,322.42,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,293.72462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Destruct Benign Lesion, 1-14",PX17110F,CDM,510,RC,17110,CPT,,,,,,,,302,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,293.9366,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.4508,295.96
DRILL BIT 2.2MM LONG SOLID STERILE MICA,27200000,CDM,272,RC,,,,12985-MAIN,LOCAL,,,,,600,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,294,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRILL BIT 2.2MM LONG SOLID STERILE MICA,27200000,CDM,272,RC,,,,12985-MAIN,LOCAL,,,,,600,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,294,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRILL BIT 2.2MM LONG SOLID STERILE MICA,27200000,CDM,272,RC,,,,12985-MAIN,LOCAL,,,,,600,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,294,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404P,CDM,983,RC,11404,CPT,,,,,,,,600,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,322.2,percent of total billed charges,294,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,249.24,1416.38
"Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404P,CDM,983,RC,11404,CPT,,,,,,,,600,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,294,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,249.24,1416.38
"Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404P,CDM,983,RC,11404,CPT,,,,,,,,600,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,294,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,249.24,1416.38
Extremity Study - Vascular Diagnostics,PX9392201,CDM,921,RC,93922,CPT,TC,,,,,,,600,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,294,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,588
Extremity Study - Vascular Diagnostics,PX9392201,CDM,921,RC,93922,CPT,TC,,,,,,,600,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,294,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,588
Extremity Study - Vascular Diagnostics,PX9392201,CDM,921,RC,93922,CPT,TC,,,,,,,600,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,294,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,588
iohexol 300 MG/ML Solution 150 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141365,NDC,150,ML,300,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,294,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.08,294
"Spinal Punc,Drain,Theraputic",PX62272P,CDM,983,RC,62272,CPT,,,,,,,,300,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,294,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.79,384.64
US Follicles-Limited Tc,PX7685701,CDM,402,RC,76857,CPT,TC,,,,,,,300,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,294,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,294
Reduce Temporomandibl Disloc,PX21480F,CDM,510,RC,21480,CPT,,,,,,,,335,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,294.02,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.54,294.02
Reduce Temporomandibl Disloc,PX21480P,CDM,983,RC,21480,CPT,,,,,,,,223,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,294.02,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.54,294.02
buprenorphine 5 MCG/HR PATCH WEEKLY 4 Each Box,63700001,CDM,250,RC,,,,,,42858075040,NDC,1,EA,330.52,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,294.1628,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Xray Ls Spine Bend Tc,PX7212001,CDM,320,RC,72120,CPT,TC,,,,,,,323,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,294.253,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,316.54
megestrol 40 MG/ML Suspension 240 mL Bottle,25000000,CDM,250,RC,,,,,,49884090738,NDC,240,ML,594.72,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,294.3864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
cadexomer iodine 0.9 % Gel 40 g Tube,63700001,CDM,250,RC,,,,,,40565012249,NDC,40,GR,333.86,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,294.46452,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Hospital Inpt or Obs Care, Admin/Disch Same Date, Moderate Level Mdm >= 70 Minutes",PX99235,CDM,982,RC,99235,CPT,,,,,,,,582,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,294.492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,241.7628,566.4606
"Igh, Variable Region Somatic Mutation Analysis",PX8126390,CDM,310,RC,81263,CPT,90,,,,,,,1215,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,294.52,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,285.68,294.52
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133F,CDM,510,RC,13133,CPT,,,,,,,,595,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,294.525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247.163,583.1
"Thrombolysis,Coronary,IV Infusn",PX92977F,CDM,480,RC,92977,CPT,,,,,,,,595,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,294.525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247.163,583.1
"Thrombolytic Therapy, Stroke",PX37195F,CDM,761,RC,37195,CPT,,,,,,,,595,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,294.525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247.163,583.1
Clotting Function Activity - Ref,PX8539790,CDM,300,RC,85397,CPT,90,,,,,,,334,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,294.588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.3,327.32
"Remv F.B.,Eye,Cornea,No Slit",PX65220F,CDM,510,RC,65220,CPT,,,,,,,,334,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,294.588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.7436,348.08
Repeat Control of Nosebleed,PX30906F,CDM,510,RC,30906,CPT,,,,,,,,334,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,294.588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.7436,327.32
X-Ray Abdomen 2+ Views W/ Single Vw Chest (Tc),PX7402201,CDM,320,RC,74022,CPT,TC,,,,,,,334,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,294.588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,327.32
"Chemotherapy, IV Infusion, 1 Hour",PX96413,CDM,335,RC,96413,CPT,,,,,,,,614,,Health Partners,Health Partners Care Plans,both,48,,284.68,percent of total billed charges,294.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.0556,601.72
"Chemotherapy, IV Infusion, 1 Hour",PX96413,CDM,335,RC,96413,CPT,,,,,,,,614,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,294.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.0556,601.72
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725F,CDM,510,RC,26725,CPT,,,,,,,,495,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,294.7698,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,196.55,740.92
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725P,CDM,983,RC,26725,CPT,,,,,,,,330,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,294.7698,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,196.55,740.92
"Destruct Benign Lesion, 15+",PX17111F,CDM,510,RC,17111,CPT,,,,,,,,303,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,294.9099,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.8662,296.94
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607P,CDM,983,RC,97607,CPT,,,,,,,,303,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,294.9099,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.8662,348.35
Strapping of Knee,PX29530F,CDM,420,RC,29530,CPT,,,,,,,,303,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,294.9099,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,296.94
Xray Knee 1 or 2 Vws,PX7356001,CDM,320,RC,73560,CPT,TC,,,,,,,303,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,181.8,percent of total billed charges,294.9099,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,296.94
PACLitaxel 150 MG/25ML Concentrate 25 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321701,NDC,25,ML,300.96,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,294.9408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
Xray Mandible Partial Less Than 4 Vws,PX7010001,CDM,320,RC,70100,CPT,TC,,,,,,,347,,First Health,Commercial,both,85,,999999999,percent of total billed charges,294.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,340.06
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122P,CDM,983,RC,13122,CPT,,,,,,,,301,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,294.98,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.39,294.98
Xray Facial Bones Less Than 3 Vws,PX7014001,CDM,320,RC,70140,CPT,TC,,,,,,,301,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,294.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,294.98
"Lap,Dx Surgical Abd W/Biopsy",PX49321P,CDM,983,RC,49321,CPT,,,,,,,,583,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,294.998,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,242.1782,5040.74
"Casiri and Imdevimab,Admin,Repeat Dose",PXM0240,CDM,771,RC,M0240,HCPCS,,,,,,,,1555,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,295.15,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,295.15,450
"IV Infusion, Bamlanivimab and Etesevimab, Infusion and Monitoring",PXM0245,CDM,260,RC,M0245,HCPCS,,,,,,,,1555,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,295.15,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,295.15,450
"IV Infusion, Casirivimab and Imdevimab, IV and Post Admr",PXM0243,CDM,771,RC,M0243,HCPCS,,,,,,,,1555,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,295.15,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,295.15,450
"Cardioversion, Elective;Extern",PX92960P,CDM,983,RC,92960,CPT,,,,,,,,688,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,295.152,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,285.7952,669.6304
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031F,CDM,510,RC,12031,CPT,,,,,,,,688,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,295.152,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,285.7952,674.24
sugammadex sodium 200 MG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,6542312,NDC,2,ML,583.33,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,295.16498,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dexAMETHasone 0.1 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,24208072002,NDC,5,ML,331.81,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,295.3109,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423F,CDM,510,RC,11423,CPT,,,,,,,,711,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,295.3494,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,295.3494,1416.38
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505F,CDM,510,RC,25505,CPT,,,,,,,,651,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,295.37,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,295.37,1095.81
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505P,CDM,983,RC,25505,CPT,,,,,,,,977,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,295.37,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,295.37,1095.81
CARBOplatin 600 MG/60ML Solution 60 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703423981,NDC,60,ML,301.42,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,295.3916,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.778704,295.3916
"Close Rx Dist Fingr Fx,Manipulatn",PX26755F,CDM,510,RC,26755,CPT,,,,,,,,335,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,295.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
"Closed Rx I-P Jt,Toe Dislocation",PX28660F,CDM,510,RC,28660,CPT,,,,,,,,335,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,295.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Insitu Hybridization (Fish),PX8836401,CDM,310,RC,88364,CPT,TC,,,,,,,335,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,295.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Reduce Temporomandibl Disloc,PX21480F,CDM,510,RC,21480,CPT,,,,,,,,335,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,295.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Repr Superf Wnd Face <2.5cm,PX12011F,CDM,510,RC,12011,CPT,,,,,,,,335,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,295.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Fluoroscope Examination Tc,PX7600001,CDM,320,RC,76000,CPT,TC,,,,,,,597,,Humana Choice Care,All Medicare plans,outpatient,49.5,,188.55,percent of total billed charges,295.515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,585.06
Closed Rx Shldr Dislocation,PX23650F,CDM,510,RC,23650,CPT,,,,,,,,689,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,295.581,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,675.22
Fac/Removal of Skin Tags,PX11200F,CDM,510,RC,11200,CPT,,,,,,,,348,,First Health,Commercial,both,85,,999999999,percent of total billed charges,295.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,144.5592,341.04
linezolid 600 MG/300ML Solution 300 mL Flex Cont,J2020.01,CDM,636,RC,J2020,HCPCS,,,,9514001,NDC,300,ML,332.42,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,295.8538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.087268,325.7716
"Chemotherapy, IV Infusion, 1 Hour",PX96413,CDM,335,RC,96413,CPT,,,,,,,,614,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,295.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.0556,601.72
"Chemotherapy, IV Push, Single Drug",PX96409,CDM,335,RC,96409,CPT,,,,,,,,502,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,295.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.5308,491.96
Declot Vascular Access Device,PX36593F,CDM,510,RC,36593,CPT,,,,,,,,358,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,295.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.7132,350.84
"Thrombolysis,Coronary,IV Infusn",PX92977F,CDM,480,RC,92977,CPT,,,,,,,,595,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,295.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247.163,583.1
"Thrombolytic Therapy, Stroke",PX37195F,CDM,761,RC,37195,CPT,,,,,,,,595,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,295.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247.163,583.1
"Ctrl Nosebleed,Anter,Complex",PX30903P,CDM,983,RC,30903,CPT,,,,,,,,304,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,295.8832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,295.8832
Joint Survey Tc,PX7707701,CDM,320,RC,77077,CPT,TC,,,,,,,304,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,295.8832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,297.92
nystatin 100000 UNIT/GM Powder 60 g Bottle,63700001,CDM,250,RC,,,,,,68308015260,NDC,60,GR,335.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,295.911,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Closed Rx Kneecap Disloc+Anesth,PX27562F,CDM,510,RC,27562,CPT,,,,,,,,604,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,295.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,591.92
Closed Rx Kneecap Disloc+Anesth,PX27562F,CDM,510,RC,27562,CPT,,,,,,,,604,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,295.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,591.92
Closed Rx Kneecap Disloc+Anesth,PX27562F,CDM,510,RC,27562,CPT,,,,,,,,604,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,295.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,591.92
"Destruct Benign Lesion, 1-14",PX17110F,CDM,510,RC,17110,CPT,,,,,,,,302,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,295.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.4508,295.96
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623F,CDM,510,RC,11623,CPT,,,,,,,,690,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,296.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,286.626,1416.38
"Layr Clos Wnd Face,Facial 2.5-5",PX12052F,CDM,510,RC,12052,CPT,,,,,,,,585,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,296.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,243.009,573.3
Excis Forearm/Wrist Tumor Subcutan,PX25075F,CDM,510,RC,25075,CPT,,,,,,,,1421,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,296.0542,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,198.51,1082.67
Excis Forearm/Wrist Tumor Subcutan,PX25075P,CDM,983,RC,25075,CPT,,,,,,,,607,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,296.0542,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,198.51,1082.67
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561F,CDM,510,RC,36561,CPT,,,,,,,,2604,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,296.0542,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,200.91,1988.23
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561P,CDM,983,RC,36561,CPT,,,,,,,,1736,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,296.0542,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,200.91,1988.23
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156F,CDM,370,RC,99156,CPT,,,,,,,,325,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,296.075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,318.5
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156P,CDM,983,RC,99156,CPT,,,,,,,,325,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,296.075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,316.3225
Refill/Maint Portable Pump,PX96521,CDM,260,RC,96521,CPT,,,,,,,,325,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,296.075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,318.5
"Remv F.B.,Eye,Embed Conjunc",PX65210F,CDM,510,RC,65210,CPT,,,,,,,,325,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,296.075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,348.08
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598P,CDM,982,RC,97598,CPT,,,,,,,,325,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,296.075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,316.3225
Somatostatin - Ref,PX8430790,CDM,300,RC,84307,CPT,90,,,,,,,325,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,296.075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.76,318.5
Repr Superf Wnd Face >30cm,PX12018F,CDM,510,RC,12018,CPT,,,,,,,,713,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,296.1802,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,698.74
dexmedeTOMIDine in sodium chloride 200 MCG/50ML Solution 50 mL Flex Cont,25000000,CDM,250,RC,,,,,,338955524,NDC,50,ML,304.32,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,296.194656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
amiodarone 360-4.14 MG/200ML-% Solution 200 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066036020,NDC,200,ML,325.25,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,296.30275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.35,318.745
Assay of Phenytoin Total,PX80185,CDM,300,RC,80185,CPT,,,,,,,,336,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,296.352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,329.28
"Fna Biopsy, W/US Guidance; First Lesion",PX10005F,CDM,510,RC,10005,CPT,,,,,,,,333,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,296.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.3282,614.65
Ultrasound Breast Complete,PX7664101,CDM,402,RC,76641,CPT,TC,,,,,,,333,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,296.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,326.34
moxifloxacin 0.5 % Solution 3 mL Bottle,25000000,CDM,250,RC,,,,,,60505058204,NDC,3,ML,691.15,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,296.50335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
US Abdomen Tc,PX7670001,CDM,402,RC,76700,CPT,TC,,,,,,,586,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,296.516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,574.28
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082143,NDC,1,ML,348.85,,First Health,Commercial,both,85,,999999999,percent of total billed charges,296.5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.48,367.9214
Nafcillin Sodium 10 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323033060,NDC,1,EA,617.91,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,296.5968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Nafcillin Sodium 10 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323033060,NDC,1,EA,617.91,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,296.5968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Fac/Exc Skn Bngn1.1-2cm Remain Bdy,PX11422F,CDM,510,RC,11422,CPT,,,,,,,,618,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,296.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,256.7172,1416.38
Fac/Exc Skn Bngn1.1-2cm Remain Bdy,PX11422F,CDM,510,RC,11422,CPT,,,,,,,,618,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,296.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,256.7172,1416.38
"Echo Heart Xthoracic,Limited",PX9330801,CDM,480,RC,93308,CPT,TC,,,,,,,349,,First Health,Commercial,both,85,,999999999,percent of total billed charges,296.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,144.9746,342.02
"Morphometric Analysis, Tumor - Ref",PX8836090,CDM,310,RC,88360,CPT,90,,,,,,,349,,First Health,Commercial,both,85,,999999999,percent of total billed charges,296.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,144.9746,342.02
filgrastim-ayow 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,800000,CDM,,,,,,,,70121157001,NDC,0.5,ML,691.62,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,296.70498,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
"Bone Marrow Aspiration(S),Diag",PX38220F,CDM,510,RC,38220,CPT,,,,,,,,305,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,296.8565,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,126.697,1416.38
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565F,CDM,510,RC,25565,CPT,,,,,,,,1250,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,296.9,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,296.9,1116.57
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565P,CDM,983,RC,25565,CPT,,,,,,,,830,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,296.9,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,296.9,1116.57
"Destruct Benign Lesion, 15+",PX17111F,CDM,510,RC,17111,CPT,,,,,,,,303,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,296.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.8662,296.94
"Fac/Exc Skn Bnig0.6-1cm Fae,Facial",PX11441F,CDM,510,RC,11441,CPT,,,,,,,,606,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,296.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,251.7324,614.65
"Fac/Exc Skn Bnig0.6-1cm Fae,Facial",PX11441F,CDM,510,RC,11441,CPT,,,,,,,,606,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,296.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,251.7324,614.65
"Fac/Exc Skn Bnig0.6-1cm Fae,Facial",PX11441F,CDM,510,RC,11441,CPT,,,,,,,,606,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,296.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,251.7324,614.65
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607P,CDM,983,RC,97607,CPT,,,,,,,,303,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,296.94,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.42,459.07
Strapping of Knee,PX29530F,CDM,420,RC,29530,CPT,,,,,,,,303,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,296.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,296.94
Xray Knee 1 or 2 Vws,PX7356001,CDM,320,RC,73560,CPT,TC,,,,,,,303,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,296.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,296.94
DRILL BIT 2.2MM LONG SOLID STERILE MICA,27200000,CDM,272,RC,,,,12985-MAIN,LOCAL,,,,,600,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,297,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404P,CDM,983,RC,11404,CPT,,,,,,,,600,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,297,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,249.24,1416.38
Extremity Study - Vascular Diagnostics,PX9392201,CDM,921,RC,93922,CPT,TC,,,,,,,600,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,297,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,588
Facility Emergency Level III Visit,PX99283F,CDM,450,RC,99283,CPT,,,,,,,,587,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,297.022,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,243.8398,575.26
cadexomer iodine 0.9 % Gel 40 g Tube,63700001,CDM,250,RC,,,,,,40565012249,NDC,40,GR,333.86,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,297.1354,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
folic acid 5 MG/ML Solution 10 mL Vial,J3490.94,CDM,636,RC,J3490,HCPCS,,,,63323018410,NDC,10,ML,336.94,,United Healthcare,All Payer,outpatient,88.2,,7.6225,percent of total billed charges,297.18108,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,330.2012
Emergency Level II Visit,PX99282P,CDM,981,RC,99282,CPT,,,,,,,,337,,United Healthcare,All Payer,outpatient,88.2,,133.9271429,percent of total billed charges,297.234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.9898,328.0021
Clotting Function Activity - Ref,PX8539790,CDM,300,RC,85397,CPT,90,,,,,,,334,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,297.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.3,327.32
"Remv F.B.,Eye,Cornea,No Slit",PX65220F,CDM,510,RC,65220,CPT,,,,,,,,334,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,297.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.7436,348.08
Repeat Control of Nosebleed,PX30906F,CDM,510,RC,30906,CPT,,,,,,,,334,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,297.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.7436,327.32
X-Ray Abdomen 2+ Views W/ Single Vw Chest (Tc),PX7402201,CDM,320,RC,74022,CPT,TC,,,,,,,334,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,297.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,327.32
Anal Sphincterotomy,PX46080F,CDM,510,RC,46080,CPT,,,,,,,,607,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,297.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,252.1478,2452.93
Anal Sphincterotomy,PX46080F,CDM,510,RC,46080,CPT,,,,,,,,607,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,297.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,252.1478,2452.93
Anal Sphincterotomy,PX46080F,CDM,510,RC,46080,CPT,,,,,,,,607,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,297.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,252.1478,2452.93
Excis Forearm/Wrist Tumor Subcutan,PX25075P,CDM,983,RC,25075,CPT,,,,,,,,607,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,297.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,252.1478,1416.38
Excis Forearm/Wrist Tumor Subcutan,PX25075P,CDM,983,RC,25075,CPT,,,,,,,,607,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,297.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,252.1478,1416.38
Excis Forearm/Wrist Tumor Subcutan,PX25075P,CDM,983,RC,25075,CPT,,,,,,,,607,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,297.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,252.1478,1416.38
Open Bx/Excision Inguinofemoral Nodes,PX38531P,CDM,983,RC,38531,CPT,,,,,,,,607,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,297.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,252.1478,3329.99
Open Bx/Excision Inguinofemoral Nodes,PX38531P,CDM,983,RC,38531,CPT,,,,,,,,607,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,297.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,252.1478,3329.99
Open Bx/Excision Inguinofemoral Nodes,PX38531P,CDM,983,RC,38531,CPT,,,,,,,,607,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,297.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,252.1478,3329.99
"Drain Finger Abscess,Simple",PX26010F,CDM,510,RC,26010,CPT,,,,,,,,310,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,297.47,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,89.65,716.7
"Drain Finger Abscess,Simple",PX26010P,CDM,983,RC,26010,CPT,,,,,,,,207,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,297.47,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,89.65,716.7
Repr Superf Wnd Face 5.1-7.5,PX12014F,CDM,510,RC,12014,CPT,,,,,,,,453,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,297.47,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.06,297.47
Repr Superf Wnd Face 5.1-7.5,PX12014P,CDM,983,RC,12014,CPT,,,,,,,,819,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,297.47,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.06,802.62
Flu Dna Amp Probe 1st 2 Types,PX87502,CDM,300,RC,87502,CPT,,,,,,,,350,,First Health,Commercial,both,85,,999999999,percent of total billed charges,297.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.84,343
"rabies vaccine, pcec Recon Susp 1 Each Vial",90675,CDM,636,RC,90675,CPT,,,,58160096412,NDC,1,EA,1544.83,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,297.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,297.75,1513.9334
Xray Thoracolumbar 2 Vws,PX7208001,CDM,320,RC,72080,CPT,TC,,,,,,,306,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,61.2,percent of total billed charges,297.8298,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,299.88
"Lap,Inguinal Hernia Repr,Initial",PX49650P,CDM,983,RC,49650,CPT,,,,,,,,717,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,297.8418,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,297.8418,5040.74
8MM ENDOWRIST INSTRUMENTS MEGA SUTURE CUT NEEDLE DRIVER,27200000,CDM,272,RC,,,,11914-MAIN,LOCAL,,,,,327,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,297.897,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"IV Infusion Therapy, 1 Hour",PX96365,CDM,260,RC,96365,CPT,,,,,,,,327,,Medica,Commercial,both,91.1,,120.8164088,percent of total billed charges,297.897,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.8358,320.46
3.0MM HEADED SCREW LENGTH 16MM,C1713,CDM,278,RC,C1713,HCPCS,,12656-MAIN,LOCAL,,,,,608,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,297.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
3.0MM HEADED SCREW LENGTH 16MM,C1713,CDM,278,RC,C1713,HCPCS,,12656-MAIN,LOCAL,,,,,608,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,297.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
3.0MM HEADED SCREW LENGTH 16MM,C1713,CDM,278,RC,C1713,HCPCS,,12656-MAIN,LOCAL,,,,,608,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,297.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"Ctrl Nosebleed,Anter,Complex",PX30903P,CDM,983,RC,30903,CPT,,,,,,,,304,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,297.92,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.46,506.4
Joint Survey Tc,PX7707701,CDM,320,RC,77077,CPT,TC,,,,,,,304,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,297.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,297.92
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591F,CDM,360,RC,49591,CPT,,,,,,,,1556,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,297.9808,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,202.22,709.1
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591P,CDM,982,RC,49591,CPT,,,,,,,,1245,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,297.9808,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,202.22,1220.1
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234010,NDC,5,ML,306.2,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.5924,percent of total billed charges,298.02446,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234025,NDC,5,ML,306.2,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.5924,percent of total billed charges,298.02446,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234099,NDC,5,ML,306.2,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.5924,percent of total billed charges,298.02446,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200001,NDC,0.5,ML,980.99,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,298.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.02,298.03
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200001,NDC,0.5,ML,980.99,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,298.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.02,298.03
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200002,NDC,0.5,ML,980.99,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,298.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.02,298.03
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200002,NDC,0.5,ML,980.99,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,298.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,254.02,298.03
Cardiac Rehab II W/ Monitor,PX93798.02,CDM,943,RC,93798,CPT,,,,,,,,338,,United Healthcare,All Payer,outpatient,88.2,,186.3051282,percent of total billed charges,298.116,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.44,495.55
Initial Rx Burn(S) 1st Degree,PX16000F,CDM,510,RC,16000,CPT,,,,,,,,338,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,298.116,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.4052,331.24
"Close Rx Dist Fingr Fx,Manipulatn",PX26755F,CDM,510,RC,26755,CPT,,,,,,,,335,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,298.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
"Closed Rx I-P Jt,Toe Dislocation",PX28660F,CDM,510,RC,28660,CPT,,,,,,,,335,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,298.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Insitu Hybridization (Fish),PX8836401,CDM,310,RC,88364,CPT,TC,,,,,,,335,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,298.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Reduce Temporomandibl Disloc,PX21480F,CDM,510,RC,21480,CPT,,,,,,,,335,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,298.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Repr Superf Wnd Face <2.5cm,PX12011F,CDM,510,RC,12011,CPT,,,,,,,,335,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,298.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
dexmedeTOMIDine in sodium chloride 200 MCG/50ML Solution 50 mL Flex Cont,25000000,CDM,250,RC,,,,,,338955524,NDC,50,ML,304.32,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,298.2336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Art Upper Extremity-Ltd,PX9393101,CDM,921,RC,93931,CPT,TC,,,,,,,718,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,298.2572,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,703.64
sevoflurane Solution 250 mL Bottle,25000000,CDM,250,RC,,,,,,66794001525,NDC,250,ML,589.56,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,298.31736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,63323076350,NDC,50,ML,589.57,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,298.32242,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
Debride Bone Ea Add 20 Sqcm,PX11047P,CDM,983,RC,11047,CPT,,,,,,,,351,,First Health,Commercial,both,85,,999999999,percent of total billed charges,298.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,145.8054,341.6283
Debride Tissue/Muscle,PX11043P,CDM,983,RC,11043,CPT,,,,,,,,351,,First Health,Commercial,both,85,,999999999,percent of total billed charges,298.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,145.8054,548.67
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600110,NDC,10,ML,589.63,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,298.35278,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
"Infectious Disease,Chronic Hep C Virus,Six Assays, Utilizing Serum",PX8159690,CDM,300,RC,81596,CPT,90,,,,,,,609,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,298.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.19,596.82
"Infectious Disease,Chronic Hep C Virus,Six Assays, Utilizing Serum",PX8159690,CDM,300,RC,81596,CPT,90,,,,,,,609,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,298.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.19,596.82
"Infectious Disease,Chronic Hep C Virus,Six Assays, Utilizing Serum",PX8159690,CDM,300,RC,81596,CPT,90,,,,,,,609,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,298.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.19,596.82
butamben-tetracaine-benzocaine 2-2-14 % Aerosol 20 g Bottle,25000000,CDM,250,RC,,,,,,10223020103,NDC,20,GR,589.76,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,298.41856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Abd Paracentesis W/Imaging(P),PX49083P,CDM,983,RC,49083,CPT,,,,,,,,696,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,298.584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.1184,791.92
nystatin 100000 UNIT/GM Powder 60 g Bottle,63700001,CDM,250,RC,,,,,,68308015260,NDC,60,GR,335.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,298.595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium thiosulfate 250 MG/ML Solution 50 mL Vial,J0209.01,CDM,636,RC,J0209,HCPCS,,,,60267070550,NDC,50,ML,609.57,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,298.6893,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,253.215378,597.3786
sodium thiosulfate 250 MG/ML Solution 50 mL Vial,J0209.01,CDM,636,RC,J0209,HCPCS,,,,60267070550,NDC,50,ML,609.57,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,298.6893,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,253.215378,597.3786
sodium thiosulfate 250 MG/ML Solution 50 mL Vial,J0209.01,CDM,636,RC,J0209,HCPCS,,,,60267070550,NDC,50,ML,609.57,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,298.6893,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,253.215378,597.3786
COOK EMERGENCY PNEUMOTHORAX SET,120.559,CDM,272,RC,,,,12597-MAIN,LOCAL,,,,,307,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,298.8031,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,127.5278,300.86
"Chemotherapy, IV Infusion, Each Add'l Sequential Infusion",PX96417,CDM,335,RC,96417,CPT,,,,,,,,328,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,298.808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,321.44
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762P,CDM,983,RC,43762,CPT,,,,,,,,328,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,298.808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.2512,319.2424
"Bone Marrow Aspiration(S),Diag",PX38220F,CDM,510,RC,38220,CPT,,,,,,,,305,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,298.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,126.697,1416.38
PHENobarbital 130 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047721,NDC,1,ML,338.93,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,298.93626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.354486,332.1514
Closed Rx Kneecap Disloc+Anesth,PX27562F,CDM,510,RC,27562,CPT,,,,,,,,604,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,298.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,591.92
Ligation of Hemorrhoid(S),PX46221P,CDM,983,RC,46221,CPT,,,,,,,,697,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,299.013,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.5338,798.45
STAPLER INTERNAL POWERED 29MM CURVED CIRCULAR,27200000,CDM,272,RC,,,,12024-MAIN,LOCAL,,,,,697,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,299.013,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STAPLER INTERNAL POWERED 31MM CURVED CIRCULAR,27200000,CDM,272,RC,,,,12025-MAIN,LOCAL,,,,,697,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,299.013,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Assay of Phenytoin Total,PX80185,CDM,300,RC,80185,CPT,,,,,,,,336,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,299.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,329.28
"Sigmoidoscopy,Diagnostic",PX45330F,CDM,510,RC,45330,CPT,,,,,,,,720,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,299.088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,299.088,798.45
CT Upper Extremity W/Dye,PX7320101,CDM,350,RC,73201,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,299.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.22,299.12
CT Upper Extremity W/Dye,PX7320101,CDM,350,RC,73201,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,299.12,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.22,299.12
BOOT AIRSELECT SHORT LARGE 01ES-L,120.45,CDM,274,RC,L4360,HCPCS,,11890-MAIN,LOCAL,,,,,93,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,299.181,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
BOOT AIRSELECT SHORT MEDIUM 01ES-M,120.45,CDM,274,RC,L4360,HCPCS,,11889-MAIN,LOCAL,,,,,93,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,299.181,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
BOOT AIRSELECT SHORT SMALL 01ES-S,120.45,CDM,274,RC,L4360,HCPCS,,11888-MAIN,LOCAL,,,,,93,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,299.181,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
BOOT AIRSELECT SHORT X-LARGE 01ES-XL,120.45,CDM,274,RC,L4360,HCPCS,,11891-MAIN,LOCAL,,,,,93,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,299.181,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
BOOT AIRSELECT SHORT X-SMALL 01ES-XS,120.45,CDM,274,RC,L4360,HCPCS,,11887-MAIN,LOCAL,,,,,93,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,299.181,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
BOOT AIRSELECT STANDARD LARGE 01EF-L,120.45,CDM,274,RC,L4360,HCPCS,,11697-MAIN,LOCAL,,,,,93,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,299.181,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
BOOT AIRSELECT STANDARD MEDIUM 01EF-M,120.45,CDM,274,RC,L4360,HCPCS,,11696-MAIN,LOCAL,,,,,93,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,299.181,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
BOOT AIRSELECT STANDARD SMALL 01EF-S,120.45,CDM,274,RC,L4360,HCPCS,,11695-MAIN,LOCAL,,,,,93,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,299.181,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
BOOT AIRSELECT STANDARD X-LARGE 01EF-XL,120.45,CDM,274,RC,L4360,HCPCS,,11698-MAIN,LOCAL,,,,,93,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,299.181,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
BOOT AIRSELECT STANDARD X-SMALL 01EF-XS,120.45,CDM,274,RC,L4360,HCPCS,,11694-MAIN,LOCAL,,,,,93,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,299.181,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
SPLINT FOOT SMALL STRUT WALK 11-1383-2-00000,120.45,CDM,274,RC,L4360,HCPCS,,1205-MAIN,LOCAL,,,,,93,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,299.181,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
insulin regular 100 UNIT/ML Solution 10 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821501,NDC,10,ML,307.46,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,4.0055,percent of total billed charges,299.250818,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
Closed Rx Bimalleolar Fx,PX27808F,CDM,510,RC,27808,CPT,,,,,,,,650,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,299.2652,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.17,727.77
Closed Rx Bimalleolar Fx,PX27808P,CDM,983,RC,27808,CPT,,,,,,,,433,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,299.2652,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.17,727.77
"Hemorrhoidectomy,Int/Ext,Complx",PX46260F,CDM,750,RC,46260,CPT,,,,,,,,1350,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,299.3,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,299.3,1007.26
HERNIA MESH LAP PROGRIP SELF FIXATING FLAT SHEET 10X15,C1781,CDM,278,RC,C1781,HCPCS,,12727-MAIN,LOCAL,,,,,611,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,196.035,percent of total billed charges,299.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
HERNIA MESH LAP PROGRIP SELF FIXATING FLAT SHEET 10X15,C1781,CDM,278,RC,C1781,HCPCS,,12727-MAIN,LOCAL,,,,,611,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,299.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
HERNIA MESH LAP PROGRIP SELF FIXATING FLAT SHEET 10X15,C1781,CDM,278,RC,C1781,HCPCS,,12727-MAIN,LOCAL,,,,,611,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,299.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Fac/Exc Skn Malig .1-2cm Fce,Facal",PX11642F,CDM,510,RC,11642,CPT,,,,,,,,698,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,299.442,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.9492,684.04
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505F,CDM,510,RC,25505,CPT,,,,,,,,651,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,299.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,295.37,1095.81
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505F,CDM,510,RC,25505,CPT,,,,,,,,651,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,299.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,295.37,1095.81
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505P,CDM,983,RC,25505,CPT,,,,,,,,977,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,299.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,295.37,1095.81
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505P,CDM,983,RC,25505,CPT,,,,,,,,977,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,299.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,295.37,1095.81
Inc/Drain Peritonsil Abscess,PX42700F,CDM,510,RC,42700,CPT,,,,,,,,624,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,299.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,611.52
Inc/Drain Peritonsil Abscess,PX42700F,CDM,510,RC,42700,CPT,,,,,,,,624,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,299.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,611.52
"Exc Skn Benig<5mm Face,Facial",PX11440P,CDM,983,RC,11440,CPT,,,,,,,,387,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,299.55,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.28,379.26
"Fac/Exc Skn Benig<5mm Face,Facial",PX11440F,CDM,510,RC,11440,CPT,,,,,,,,484,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,299.55,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.28,299.55
"Colonoscopy,Transendoscopic Stent",PX45387F,CDM,750,RC,45387,CPT,,,,,,,,3228,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,299.5863,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,299.5863,299.59
"Colonoscopy,Transendoscopic Stent",PX45387P,CDM,983,RC,45387,CPT,,,,,,,,3587,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,299.5863,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,299.5863,3515.26
"Colonoscopy,Transendoscopic Stent",PX45387F,CDM,750,RC,45387,CPT,,,,,,,,3228,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,299.59,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,299.5863,299.59
"Colonoscopy,Transendoscopic Stent",PX45387P,CDM,983,RC,45387,CPT,,,,,,,,3587,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,299.59,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,299.5863,3515.26
Facility Emergency Level 1 Visit,PX99281F,CDM,450,RC,99281,CPT,,,,,,,,329,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,299.719,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.56,322.42
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565F,CDM,510,RC,25565,CPT,,,,,,,,1250,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,299.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,296.9,1116.57
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565F,CDM,510,RC,25565,CPT,,,,,,,,1250,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,299.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,296.9,1116.57
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565P,CDM,983,RC,25565,CPT,,,,,,,,830,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,299.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,296.9,1116.57
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565P,CDM,983,RC,25565,CPT,,,,,,,,830,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,299.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,296.9,1116.57
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,55111069407,NDC,5,ML,592.4,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,299.7544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.08296,1009.1158
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600121,NDC,10,ML,592.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,299.805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
folic acid 5 MG/ML Solution 10 mL Vial,J3490.94,CDM,636,RC,J3490,HCPCS,,,,63323018410,NDC,10,ML,336.94,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,299.8766,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,330.2012
Sars-Cov-2 Covid-19 Antibody,PX86769,CDM,300,RC,86769,CPT,,,,,,,,340,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,299.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.63,333.2
X-Ray Exam Chest 3 Views,PX7104701,CDM,320,RC,71047,CPT,TC,,,,,,,340,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,299.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,333.2
Xray Thoracolumbar 2 Vws,PX7208001,CDM,320,RC,72080,CPT,TC,,,,,,,306,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,299.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,299.88
Emergency Level II Visit,PX99282P,CDM,981,RC,99282,CPT,,,,,,,,337,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,299.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.9898,328.0021
"Fac/Exc Skn Bnig0.6-1cm Fae,Facial",PX11441F,CDM,510,RC,11441,CPT,,,,,,,,606,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,299.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,251.7324,614.65
Creatine Mb Fraction,PX82553,CDM,300,RC,82553,CPT,,,,,,,,353,,First Health,Commercial,both,85,,999999999,percent of total billed charges,300.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.59,345.94
Fentanyl - Ref,PX8035490,CDM,300,RC,80354,CPT,90,,,,,,,353,,First Health,Commercial,both,85,,999999999,percent of total billed charges,300.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,345.94
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155F,CDM,370,RC,99155,CPT,,,,,,,,353,,First Health,Commercial,both,85,,999999999,percent of total billed charges,300.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,345.94
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155P,CDM,983,RC,99155,CPT,,,,,,,,353,,First Health,Commercial,both,85,,999999999,percent of total billed charges,300.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,343.5749
Pvb Thoracic Single Injection Site W/Img Gid,PX64461F,CDM,510,RC,64461,CPT,,,,,,,,353,,First Health,Commercial,both,85,,999999999,percent of total billed charges,300.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,604.15
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234010,NDC,5,ML,306.2,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,300.076,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234025,NDC,5,ML,306.2,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,300.076,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234099,NDC,5,ML,306.2,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,300.076,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
"Office/Outpt Visit,New,Levl IV",PX99204F,CDM,510,RC,99204,CPT,,,,,,,,359,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,300.2,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.93,300.2
"Office/Outpt Visit,New,Levl IV",PX99204P,CDM,983,RC,99204,CPT,,,,,,,,359,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,300.2,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.93,351.82
CATHETER BIPOLAR ELECTROHEMOSTASIS 7FR 300CM M00560070,27200000,CDM,272,RC,,,,12909-MAIN,LOCAL,,,,,700,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,300.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MINIBUNION LOCKING SCREW 3.0X24MM,C1713,CDM,278,RC,C1713,HCPCS,,11671-MAIN,LOCAL,,,,,308.55,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,300.311715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
fosfomycin 3 g Packet 1 Each Box,25000000,CDM,250,RC,,,,,,70700026894,NDC,1,EA,353.41,,First Health,Commercial,both,85,,999999999,percent of total billed charges,300.3985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Anal Sphincterotomy,PX46080F,CDM,510,RC,46080,CPT,,,,,,,,607,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,300.465,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,252.1478,2452.93
Excis Forearm/Wrist Tumor Subcutan,PX25075P,CDM,983,RC,25075,CPT,,,,,,,,607,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,300.465,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,252.1478,1416.38
Open Bx/Excision Inguinofemoral Nodes,PX38531P,CDM,983,RC,38531,CPT,,,,,,,,607,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,300.465,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,252.1478,3329.99
brimonidine 0.15 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314014405,NDC,5,ML,723.62,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,300.591748,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725P,CDM,983,RC,26725,CPT,,,,,,,,330,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,300.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.082,321.189
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101P,CDM,983,RC,13101,CPT,,,,,,,,330,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,300.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.082,548.67
DRILL BIT 2.2MMX60MM STERILE MICA CANNULATED,27200000,CDM,272,RC,,,,12437-MAIN,LOCAL,,,,,701,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,300.729,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRILL BIT 3.0MMX60MM STERILE MICA CANNULATED,27200000,CDM,272,RC,,,,12438-MAIN,LOCAL,,,,,701,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,300.729,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Drain/Inject Med Joint/Brusa W/US Guide,PX20606P,CDM,983,RC,20606,CPT,,,,,,,,309,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,300.7497,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.3586,604.15
LINNEAR CUTTER STAPLE RELOAD GST BLUE 60MM,27200000,CDM,272,RC,,,,12068-MAIN,LOCAL,,,,,309,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,300.7497,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LINNEAR CUTTER STAPLE RELOAD GST GREEN 60MM,27200000,CDM,272,RC,,,,12069-MAIN,LOCAL,,,,,309,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,300.7497,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LINNEAR CUTTER STAPLE RELOAD GST WHITE 60MM,27200000,CDM,272,RC,,,,12067-MAIN,LOCAL,,,,,309,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,300.7497,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Naso/Orogastric Tube,PX43752P,CDM,983,RC,43752,CPT,,,,,,,,309,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,300.7497,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.3586,348.08
Drainage of Hematoma/Fluid (T),PX10140F,CDM,510,RC,10140,CPT,,,,,,,,341,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,300.762,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,141.6514,1416.38
Drainage Scrotal Wall Abscess,PX55100P,CDM,983,RC,55100,CPT,,,,,,,,341,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,300.762,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,141.6514,1416.38
Cardiac Rehab II W/ Monitor,PX93798.02,CDM,943,RC,93798,CPT,,,,,,,,338,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,300.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.44,495.55
Initial Rx Burn(S) 1st Degree,PX16000F,CDM,510,RC,16000,CPT,,,,,,,,338,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,300.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.4052,331.24
"Hemorrhoidectomy,Int/Ext,Complx",PX46260F,CDM,750,RC,46260,CPT,,,,,,,,1350,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,300.83,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,299.3,1007.26
"Hemorrhoidectomy,Int/Ext,Complx",PX46260F,CDM,750,RC,46260,CPT,,,,,,,,1350,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,300.83,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,299.3,1007.26
"Chemotherapy, IV Infusion, 1 Hour",PX96413,CDM,335,RC,96413,CPT,,,,,,,,614,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,211.2288889,percent of total billed charges,300.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.0556,601.72
"Chemotherapy, IV Infusion, 1 Hour",PX96413,CDM,335,RC,96413,CPT,,,,,,,,614,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,300.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.0556,601.72
"Chemotherapy, IV Infusion, 1 Hour",PX96413,CDM,335,RC,96413,CPT,,,,,,,,614,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,300.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.0556,601.72
COOK EMERGENCY PNEUMOTHORAX SET,120.559,CDM,272,RC,,,,12597-MAIN,LOCAL,,,,,307,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,300.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,127.5278,300.86
Repr Superf Wnd Body 7.6-12.5,PX12004P,CDM,983,RC,12004,CPT,,,,,,,,614,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,300.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,597.6062
Repr Superf Wnd Body 7.6-12.5,PX12004P,CDM,983,RC,12004,CPT,,,,,,,,614,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,300.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,597.6062
Repr Superf Wnd Body 7.6-12.5,PX12004P,CDM,983,RC,12004,CPT,,,,,,,,614,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,300.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,597.6062
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390F,CDM,750,RC,45390,CPT,,,,,,,,1419,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,300.8707,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,203.1,677.27
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390P,CDM,982,RC,45390,CPT,,,,,,,,1135,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,300.8707,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,203.1,1112.3
Xray Sinuses Minimum 3 Vws,PX7022001,CDM,320,RC,70220,CPT,TC,,,,,,,354,,First Health,Commercial,both,85,,999999999,percent of total billed charges,300.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,346.92
megestrol 40 MG/ML Suspension 240 mL Bottle,25000000,CDM,250,RC,,,,,,49884090738,NDC,240,ML,594.72,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,300.92832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
3.0MM HEADED SCREW LENGTH 16MM,C1713,CDM,278,RC,C1713,HCPCS,,12656-MAIN,LOCAL,,,,,608,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,300.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,338035702,NDC,250,ML,309.28,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,11.07921788,percent of total billed charges,301.022224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.4701,303.0944
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133F,CDM,510,RC,13133,CPT,,,,,,,,595,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,301.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247.163,583.1
"Thrombolysis,Coronary,IV Infusn",PX92977F,CDM,480,RC,92977,CPT,,,,,,,,595,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,301.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247.163,583.1
"Thrombolytic Therapy, Stroke",PX37195F,CDM,761,RC,37195,CPT,,,,,,,,595,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,301.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247.163,583.1
buprenorphine 5 MCG/HR PATCH WEEKLY 4 Each Box,63700001,CDM,250,RC,,,,,,42858075040,NDC,1,EA,330.52,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,301.10372,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
insulin regular 100 UNIT/ML Solution 10 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821501,NDC,10,ML,307.46,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,301.3108,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
"Layr Clos Wnd Face,Facial <2.5cm",PX12051P,CDM,983,RC,12051,CPT,,,,,,,,615,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,301.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.471,598.5795
"Layr Clos Wnd Face,Facial <2.5cm",PX12051P,CDM,983,RC,12051,CPT,,,,,,,,615,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,301.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.471,598.5795
"Layr Clos Wnd Face,Facial <2.5cm",PX12051P,CDM,983,RC,12051,CPT,,,,,,,,615,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,301.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.471,598.5795
Remove Hemorrhoids & Fissure,PX46257P,CDM,983,RC,46257,CPT,,,,,,,,615,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,301.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.471,2452.93
Remove Hemorrhoids & Fissure,PX46257P,CDM,983,RC,46257,CPT,,,,,,,,615,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,301.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.471,2452.93
Remove Hemorrhoids & Fissure,PX46257P,CDM,983,RC,46257,CPT,,,,,,,,615,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,301.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.471,2452.93
"Infectious Disease,Chronic Hep C Virus,Six Assays, Utilizing Serum",PX8159690,CDM,300,RC,81596,CPT,90,,,,,,,609,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,301.455,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.19,596.82
"Ctrl Nosebleed,Anter,Simple",PX30901F,CDM,510,RC,30901,CPT,,,,,,,,342,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,301.644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,335.16
Ultrasound Breast Limited,PX7664201,CDM,402,RC,76642,CPT,TC,,,,,,,342,,United Healthcare,All Payer,outpatient,88.2,,171.26,percent of total billed charges,301.644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,335.16
PHENobarbital 130 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047721,NDC,1,ML,338.93,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,301.6477,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.354486,332.1514
"Drain Finger Abscess,Simple",PX26010F,CDM,510,RC,26010,CPT,,,,,,,,310,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,301.723,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.774,303.8
sodium thiosulfate 250 MG/ML Solution 50 mL Vial,J0209.01,CDM,636,RC,J0209,HCPCS,,,,60267070550,NDC,50,ML,609.57,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,301.73715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,253.215378,597.3786
Pvb Thoracic Single Injection Site W/Img Gid,PX64461P,CDM,983,RC,64461,CPT,,,,,,,,616,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,301.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.8864,604.15
Pvb Thoracic Single Injection Site W/Img Gid,PX64461P,CDM,983,RC,64461,CPT,,,,,,,,616,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,301.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.8864,604.15
Pvb Thoracic Single Injection Site W/Img Gid,PX64461P,CDM,983,RC,64461,CPT,,,,,,,,616,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,301.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.8864,604.15
Removal of Nail Bed,PX11750F,CDM,510,RC,11750,CPT,,,,,,,,629,,Health Partners,Health Partners Care Plans,both,48,,490.13,percent of total billed charges,301.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,261.2866,616.42
Removal of Nail Bed,PX11750F,CDM,510,RC,11750,CPT,,,,,,,,629,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,301.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,261.2866,616.42
insulin aspart prot & aspart 70-30 (70-30) 100 UNIT/ML Suspension Pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169369619,NDC,3,ML,629.28,,Health Partners,Health Partners Care Plans,both,48,,4.547805556,percent of total billed charges,302.0544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
insulin aspart prot & aspart 70-30 (70-30) 100 UNIT/ML Suspension Pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169369619,NDC,3,ML,629.28,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,302.0544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
Fluoroscope Examination Tc,PX7600001,CDM,320,RC,76000,CPT,TC,,,,,,,597,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,302.082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,585.06
dexAMETHasone 0.1 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,24208072002,NDC,5,ML,331.81,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,302.27891,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,517096001,NDC,10,ML,355.63,,First Health,Commercial,both,85,,999999999,percent of total billed charges,302.2855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
MINIBUNION LOCKING SCREW 3.0X24MM,C1713,CDM,278,RC,C1713,HCPCS,,11671-MAIN,LOCAL,,,,,308.55,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,302.379,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"Infect, Organ, Amp Probe - Ref",PX8780190,CDM,300,RC,87801,CPT,90,,,,,,,630,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,302.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.37,617.4
"Infect, Organ, Amp Probe - Ref",PX8780190,CDM,300,RC,87801,CPT,90,,,,,,,630,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,302.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.37,617.4
MESH XLARGE LEFT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 5X7,120.524,CDM,278,RC,C1781,HCPCS,,12216-MAIN,LOCAL,,,,,630,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,302.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,261.702,617.4
MESH XLARGE LEFT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 5X7,120.524,CDM,278,RC,C1781,HCPCS,,12216-MAIN,LOCAL,,,,,630,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,302.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,261.702,617.4
MESH XLARGE RIGHT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 5X7,120.524,CDM,278,RC,C1781,HCPCS,,12217-MAIN,LOCAL,,,,,630,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,302.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,261.702,617.4
MESH XLARGE RIGHT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 5X7,120.524,CDM,278,RC,C1781,HCPCS,,12217-MAIN,LOCAL,,,,,630,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,302.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,261.702,617.4
HERNIA MESH LAP PROGRIP SELF FIXATING FLAT SHEET 10X15,C1781,CDM,278,RC,C1781,HCPCS,,12727-MAIN,LOCAL,,,,,611,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,302.445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Skin Sub Graft Trnk/Arm/Leg,PX15271P,CDM,983,RC,15271,CPT,,,,,,,,705,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,302.445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,292.857,1593.14
"Spinal Puncture,Lumbar,Diagnostic",PX62270P,CDM,983,RC,62270,CPT,,,,,,,,705,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,302.445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,292.857,686.1765
Temporal Artery Ligatn or Bx,PX37609F,CDM,510,RC,37609,CPT,,,,,,,,705,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,302.445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,292.857,1416.38
Infliximab - Ref,PX8023090,CDM,300,RC,80230,CPT,90,,,,,,,343,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,302.526,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.36,336.14
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002F,CDM,510,RC,12002,CPT,,,,,,,,343,,United Healthcare,All Payer,outpatient,88.2,,145.0711111,percent of total billed charges,302.526,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,142.4822,336.14
Sars-Cov-2 Covid-19 Antibody,PX86769,CDM,300,RC,86769,CPT,,,,,,,,340,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,302.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.63,333.2
X-Ray Exam Chest 3 Views,PX7104701,CDM,320,RC,71047,CPT,TC,,,,,,,340,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,302.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,333.2
Apply Lower Leg Splint,PX29515P,CDM,983,RC,29515,CPT,,,,,,,,311,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,108.5633333,percent of total billed charges,302.6963,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,129.1894,302.6963
Repr Superf Wnd Body <2.5cm,PX12001F,CDM,510,RC,12001,CPT,,,,,,,,311,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,151.8521429,percent of total billed charges,302.6963,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,129.1894,304.78
Xray Skull Less Than 4 Vws,PX7025001,CDM,320,RC,70250,CPT,TC,,,,,,,311,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,302.6963,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,304.78
Nafcillin Sodium 10 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323033060,NDC,1,EA,617.91,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,302.7759,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Nafcillin Sodium 10 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323033060,NDC,1,EA,617.91,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,302.7759,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Nafcillin Sodium 10 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323033060,NDC,1,EA,617.91,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,302.7759,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Drain/Inject Med Joint/Brusa W/US Guide,PX20606P,CDM,983,RC,20606,CPT,,,,,,,,309,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,302.82,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,31.85,302.82
Fac/Exc Skn Bngn1.1-2cm Remain Bdy,PX11422F,CDM,510,RC,11422,CPT,,,,,,,,618,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,302.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,256.7172,1416.38
Fac/Exc Skn Bngn1.1-2cm Remain Bdy,PX11422F,CDM,510,RC,11422,CPT,,,,,,,,618,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,302.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,256.7172,1416.38
Fac/Exc Skn Bngn1.1-2cm Remain Bdy,PX11422F,CDM,510,RC,11422,CPT,,,,,,,,618,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,302.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,256.7172,1416.38
LINNEAR CUTTER STAPLE RELOAD GST BLUE 60MM,27200000,CDM,272,RC,,,,12068-MAIN,LOCAL,,,,,309,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,302.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LINNEAR CUTTER STAPLE RELOAD GST GREEN 60MM,27200000,CDM,272,RC,,,,12069-MAIN,LOCAL,,,,,309,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,302.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LINNEAR CUTTER STAPLE RELOAD GST WHITE 60MM,27200000,CDM,272,RC,,,,12067-MAIN,LOCAL,,,,,309,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,302.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Naso/Orogastric Tube,PX43752P,CDM,983,RC,43752,CPT,,,,,,,,309,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,302.82,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.21,302.82
linezolid 600 MG/300ML Solution 300 mL Flex Cont,J2020.01,CDM,636,RC,J2020,HCPCS,,,,9514001,NDC,300,ML,332.42,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,302.83462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.087268,325.7716
Closed Rx Elbow Dislocation,PX24600F,CDM,510,RC,24600,CPT,,,,,,,,706,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,302.874,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,691.88
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,338035702,NDC,250,ML,309.28,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,303.0944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.4701,303.0944
Closure Superf Wnd Dehis Simple,PX12020F,CDM,510,RC,12020,CPT,,,,,,,,632,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,303.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.5328,619.36
Closure Superf Wnd Dehis Simple,PX12020F,CDM,510,RC,12020,CPT,,,,,,,,632,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,303.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.5328,619.36
"Fna Biopsy, W/US Guidance; First Lesion",PX10005F,CDM,510,RC,10005,CPT,,,,,,,,333,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,303.363,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.3282,614.65
Ultrasound Breast Complete,PX7664101,CDM,402,RC,76641,CPT,TC,,,,,,,333,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,303.363,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,326.34
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604F,CDM,510,RC,20604,CPT,,,,,,,,344,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,303.408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,142.8976,337.12
Remove Intrauterine Device,PX58301,CDM,983,RC,58301,CPT,,,,,,,,357,,First Health,Commercial,both,85,,999999999,percent of total billed charges,303.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.2978,347.4681
X-Ray Exam Chest 1 View,PX7104501,CDM,320,RC,71045,CPT,TC,,,,,,,357,,First Health,Commercial,both,85,,999999999,percent of total billed charges,303.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,349.86
"Xray Chest 1 View, Tc",PX7101001,CDM,320,RC,71010,CPT,TC,,,,,,,357,,First Health,Commercial,both,85,,999999999,percent of total billed charges,303.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.2978,349.86
Xray Scapula Complete,PX7301001,CDM,320,RC,73010,CPT,TC,,,,,,,357,,First Health,Commercial,both,85,,999999999,percent of total billed charges,303.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,349.86
Drainage of Hematoma/Fluid (T),PX10140F,CDM,510,RC,10140,CPT,,,,,,,,341,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,303.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,141.6514,1416.38
Drainage Scrotal Wall Abscess,PX55100P,CDM,983,RC,55100,CPT,,,,,,,,341,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,303.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,141.6514,1416.38
DRILL BIT 2.2MM LONG SOLID STERILE MICA,27200000,CDM,272,RC,,,,12985-MAIN,LOCAL,,,,,600,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,303.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404P,CDM,983,RC,11404,CPT,,,,,,,,600,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,303.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,249.24,1416.38
Extremity Study - Vascular Diagnostics,PX9392201,CDM,921,RC,93922,CPT,TC,,,,,,,600,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,303.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,588
"Fac/Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602F,CDM,510,RC,11602,CPT,,,,,,,,731,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,303.6574,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,303.6574,716.38
Closed Rx Kneecap Dislocatn,PX27560P,CDM,983,RC,27560,CPT,,,,,,,,312,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,303.6696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,129.6048,303.6696
"Spinal Puncture,Lumbar,Diagnostic",PX62270F,CDM,510,RC,62270,CPT,,,,,,,,684,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,303.7,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.3,303.7
"Spinal Puncture,Lumbar,Diagnostic",PX62270P,CDM,983,RC,62270,CPT,,,,,,,,705,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,303.7,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.3,690.9
"Amputation Metatarsal+Toe,Single",PX28810P,CDM,983,RC,28810,CPT,,,,,,,,620,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,303.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,257.548,2827.75
"Amputation Metatarsal+Toe,Single",PX28810P,CDM,983,RC,28810,CPT,,,,,,,,620,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,303.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,257.548,2827.75
"Amputation Metatarsal+Toe,Single",PX28810P,CDM,983,RC,28810,CPT,,,,,,,,620,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,303.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,257.548,2827.75
Colonoscopy,PX44388P,CDM,983,RC,44388,CPT,,,,,,,,620,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,303.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,257.548,798.45
Colonoscopy,PX44388P,CDM,983,RC,44388,CPT,,,,,,,,620,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,303.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,257.548,798.45
Colonoscopy,PX44388P,CDM,983,RC,44388,CPT,,,,,,,,620,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,303.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,257.548,798.45
"Drain Finger Abscess,Simple",PX26010F,CDM,510,RC,26010,CPT,,,,,,,,310,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,303.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.774,303.8
"Chemotherapy, IV Infusion, 1 Hour",PX96413,CDM,335,RC,96413,CPT,,,,,,,,614,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,303.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.0556,601.72
Repr Superf Wnd Body 7.6-12.5,PX12004P,CDM,983,RC,12004,CPT,,,,,,,,614,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,303.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,597.6062
cadexomer iodine 0.9 % Gel 40 g Tube,63700001,CDM,250,RC,,,,,,40565012249,NDC,40,GR,333.86,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,304.14646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Clotting Function Activity - Ref,PX8539790,CDM,300,RC,85397,CPT,90,,,,,,,334,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,304.274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.3,327.32
"Remv F.B.,Eye,Cornea,No Slit",PX65220F,CDM,510,RC,65220,CPT,,,,,,,,334,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,304.274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.7436,348.08
Repeat Control of Nosebleed,PX30906F,CDM,510,RC,30906,CPT,,,,,,,,334,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,304.274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.7436,327.32
X-Ray Abdomen 2+ Views W/ Single Vw Chest (Tc),PX7402201,CDM,320,RC,74022,CPT,TC,,,,,,,334,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,304.274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,327.32
Exc Skn Bnig0.6-1cm Remain Bdy,PX11421P,CDM,983,RC,11421,CPT,,,,,,,,345,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,304.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,143.313,614.65
"Fna Biopsy, W/US Guidance; First Lesion",PX10005P,CDM,983,RC,10005,CPT,,,,,,,,621,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,304.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,257.9634,614.65
"Fna Biopsy, W/US Guidance; First Lesion",PX10005P,CDM,983,RC,10005,CPT,,,,,,,,621,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,304.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,257.9634,614.65
"Fna Biopsy, W/US Guidance; First Lesion",PX10005P,CDM,983,RC,10005,CPT,,,,,,,,621,,United Healthcare,All Medicare advantage plans,outpatient,49,,51.49,percent of total billed charges,304.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,257.9634,614.65
Declot Vascular Access Device,PX36593F,CDM,510,RC,36593,CPT,,,,,,,,358,,First Health,Commercial,both,85,,999999999,percent of total billed charges,304.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.7132,350.84
Fac/Irrigation of Bladder,PX51700F,CDM,510,RC,51700,CPT,,,,,,,,358,,First Health,Commercial,both,85,,999999999,percent of total billed charges,304.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.7132,350.84
X-Ray Exam Abdomen 1 View,PX7401801,CDM,320,RC,74018,CPT,TC,,,,,,,358,,First Health,Commercial,both,85,,999999999,percent of total billed charges,304.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,350.84
Xray Abdomen Single Ap Vw,PX7400001,CDM,320,RC,74000,CPT,TC,,,,,,,358,,First Health,Commercial,both,85,,999999999,percent of total billed charges,304.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.7132,350.84
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605F,CDM,510,RC,24605,CPT,,,,,,,,1124,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,304.32,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,304.32,1019.71
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605P,CDM,983,RC,24605,CPT,,,,,,,,750,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,304.32,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,304.32,1019.71
Drainage Scrotal Wall Abscess,PX55100F,CDM,510,RC,55100,CPT,,,,,,,,634,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,304.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,263.3636,1416.38
Drainage Scrotal Wall Abscess,PX55100F,CDM,510,RC,55100,CPT,,,,,,,,634,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,304.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,263.3636,1416.38
"Ctrl Nosebleed,Anter,Simple",PX30901F,CDM,510,RC,30901,CPT,,,,,,,,342,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,304.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,335.16
Ultrasound Breast Limited,PX7664201,CDM,402,RC,76642,CPT,TC,,,,,,,342,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,304.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,335.16
"Layr Clos Wnd Face,Facial <2.5cm",PX12051P,CDM,983,RC,12051,CPT,,,,,,,,615,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,304.425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.471,598.5795
Remove Hemorrhoids & Fissure,PX46257P,CDM,983,RC,46257,CPT,,,,,,,,615,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,304.425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.471,2452.93
sulfacetamide 10 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,24208067004,NDC,15,ML,312.96,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,304.603968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BOOT AIRSELECT SHORT LARGE 01ES-L,120.45,CDM,274,RC,L4360,HCPCS,,11890-MAIN,LOCAL,,,,,93,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,304.63,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
BOOT AIRSELECT SHORT LARGE 01ES-L,120.45,CDM,274,RC,L4360,HCPCS,,11890-MAIN,LOCAL,,,,,93,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,304.63,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
BOOT AIRSELECT SHORT LARGE 01ES-L,120.45,CDM,274,RC,L4360,HCPCS,,11890-MAIN,LOCAL,,,,,93,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,304.63,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
BOOT AIRSELECT SHORT MEDIUM 01ES-M,120.45,CDM,274,RC,L4360,HCPCS,,11889-MAIN,LOCAL,,,,,93,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,304.63,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
BOOT AIRSELECT SHORT MEDIUM 01ES-M,120.45,CDM,274,RC,L4360,HCPCS,,11889-MAIN,LOCAL,,,,,93,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,304.63,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
BOOT AIRSELECT SHORT MEDIUM 01ES-M,120.45,CDM,274,RC,L4360,HCPCS,,11889-MAIN,LOCAL,,,,,93,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,304.63,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
BOOT AIRSELECT SHORT SMALL 01ES-S,120.45,CDM,274,RC,L4360,HCPCS,,11888-MAIN,LOCAL,,,,,93,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,304.63,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
BOOT AIRSELECT SHORT SMALL 01ES-S,120.45,CDM,274,RC,L4360,HCPCS,,11888-MAIN,LOCAL,,,,,93,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,304.63,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
BOOT AIRSELECT SHORT SMALL 01ES-S,120.45,CDM,274,RC,L4360,HCPCS,,11888-MAIN,LOCAL,,,,,93,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,304.63,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
BOOT AIRSELECT SHORT X-LARGE 01ES-XL,120.45,CDM,274,RC,L4360,HCPCS,,11891-MAIN,LOCAL,,,,,93,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,304.63,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
BOOT AIRSELECT SHORT X-LARGE 01ES-XL,120.45,CDM,274,RC,L4360,HCPCS,,11891-MAIN,LOCAL,,,,,93,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,304.63,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
BOOT AIRSELECT SHORT X-LARGE 01ES-XL,120.45,CDM,274,RC,L4360,HCPCS,,11891-MAIN,LOCAL,,,,,93,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,304.63,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
BOOT AIRSELECT SHORT X-SMALL 01ES-XS,120.45,CDM,274,RC,L4360,HCPCS,,11887-MAIN,LOCAL,,,,,93,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,304.63,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
BOOT AIRSELECT SHORT X-SMALL 01ES-XS,120.45,CDM,274,RC,L4360,HCPCS,,11887-MAIN,LOCAL,,,,,93,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,304.63,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
BOOT AIRSELECT SHORT X-SMALL 01ES-XS,120.45,CDM,274,RC,L4360,HCPCS,,11887-MAIN,LOCAL,,,,,93,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,304.63,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
BOOT AIRSELECT STANDARD LARGE 01EF-L,120.45,CDM,274,RC,L4360,HCPCS,,11697-MAIN,LOCAL,,,,,93,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,304.63,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
BOOT AIRSELECT STANDARD LARGE 01EF-L,120.45,CDM,274,RC,L4360,HCPCS,,11697-MAIN,LOCAL,,,,,93,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,304.63,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
BOOT AIRSELECT STANDARD LARGE 01EF-L,120.45,CDM,274,RC,L4360,HCPCS,,11697-MAIN,LOCAL,,,,,93,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,304.63,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
BOOT AIRSELECT STANDARD MEDIUM 01EF-M,120.45,CDM,274,RC,L4360,HCPCS,,11696-MAIN,LOCAL,,,,,93,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,304.63,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
BOOT AIRSELECT STANDARD MEDIUM 01EF-M,120.45,CDM,274,RC,L4360,HCPCS,,11696-MAIN,LOCAL,,,,,93,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,304.63,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
BOOT AIRSELECT STANDARD MEDIUM 01EF-M,120.45,CDM,274,RC,L4360,HCPCS,,11696-MAIN,LOCAL,,,,,93,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,304.63,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
BOOT AIRSELECT STANDARD SMALL 01EF-S,120.45,CDM,274,RC,L4360,HCPCS,,11695-MAIN,LOCAL,,,,,93,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,304.63,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
BOOT AIRSELECT STANDARD SMALL 01EF-S,120.45,CDM,274,RC,L4360,HCPCS,,11695-MAIN,LOCAL,,,,,93,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,304.63,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
BOOT AIRSELECT STANDARD SMALL 01EF-S,120.45,CDM,274,RC,L4360,HCPCS,,11695-MAIN,LOCAL,,,,,93,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,304.63,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
BOOT AIRSELECT STANDARD X-LARGE 01EF-XL,120.45,CDM,274,RC,L4360,HCPCS,,11698-MAIN,LOCAL,,,,,93,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,304.63,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
BOOT AIRSELECT STANDARD X-LARGE 01EF-XL,120.45,CDM,274,RC,L4360,HCPCS,,11698-MAIN,LOCAL,,,,,93,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,304.63,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
BOOT AIRSELECT STANDARD X-LARGE 01EF-XL,120.45,CDM,274,RC,L4360,HCPCS,,11698-MAIN,LOCAL,,,,,93,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,304.63,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
BOOT AIRSELECT STANDARD X-SMALL 01EF-XS,120.45,CDM,274,RC,L4360,HCPCS,,11694-MAIN,LOCAL,,,,,93,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,304.63,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
BOOT AIRSELECT STANDARD X-SMALL 01EF-XS,120.45,CDM,274,RC,L4360,HCPCS,,11694-MAIN,LOCAL,,,,,93,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,304.63,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
BOOT AIRSELECT STANDARD X-SMALL 01EF-XS,120.45,CDM,274,RC,L4360,HCPCS,,11694-MAIN,LOCAL,,,,,93,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,304.63,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
SPLINT FOOT SMALL STRUT WALK 11-1383-2-00000,120.45,CDM,274,RC,L4360,HCPCS,,1205-MAIN,LOCAL,,,,,93,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,304.63,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
SPLINT FOOT SMALL STRUT WALK 11-1383-2-00000,120.45,CDM,274,RC,L4360,HCPCS,,1205-MAIN,LOCAL,,,,,93,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,304.63,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
SPLINT FOOT SMALL STRUT WALK 11-1383-2-00000,120.45,CDM,274,RC,L4360,HCPCS,,1205-MAIN,LOCAL,,,,,93,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,304.63,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.4,304.63
Dress/Debrid Small Burn No Anes,PX16020F,CDM,510,RC,16020,CPT,,,,,,,,313,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,304.6429,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.0202,306.74
Apply Lower Leg Splint,PX29515P,CDM,983,RC,29515,CPT,,,,,,,,311,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,304.78,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.54,304.78
Repr Superf Wnd Body <2.5cm,PX12001F,CDM,510,RC,12001,CPT,,,,,,,,311,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,304.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,129.1894,304.78
Xray Skull Less Than 4 Vws,PX7025001,CDM,320,RC,70250,CPT,TC,,,,,,,311,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,304.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,304.78
Jak2 Gene - Ref,PX8127090,CDM,300,RC,81270,CPT,90,,,,,,,734,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,304.9036,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.04,719.32
Pvb Thoracic Single Injection Site W/Img Gid,PX64461P,CDM,983,RC,64461,CPT,,,,,,,,616,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,304.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.8864,604.15
CT Soft Tissue Neck W/O Dye,PX7049001,CDM,350,RC,70490,CPT,TC,,,,,,,711,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,305.019,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,1198.67
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423F,CDM,510,RC,11423,CPT,,,,,,,,711,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,305.019,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,295.3494,1416.38
"Office/Outpt Visit,New,Levl IV",PX99204F,CDM,510,RC,99204,CPT,,,,,,,,359,,First Health,Commercial,both,85,,999999999,percent of total billed charges,305.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.1286,351.82
"Office/Outpt Visit,New,Levl IV",PX99204P,CDM,983,RC,99204,CPT,,,,,,,,359,,First Health,Commercial,both,85,,999999999,percent of total billed charges,305.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.1286,349.4147
"Close Rx Dist Fingr Fx,Manipulatn",PX26755F,CDM,510,RC,26755,CPT,,,,,,,,335,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,305.185,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
"Closed Rx I-P Jt,Toe Dislocation",PX28660F,CDM,510,RC,28660,CPT,,,,,,,,335,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,305.185,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Insitu Hybridization (Fish),PX8836401,CDM,310,RC,88364,CPT,TC,,,,,,,335,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,305.185,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Reduce Temporomandibl Disloc,PX21480F,CDM,510,RC,21480,CPT,,,,,,,,335,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,305.185,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Repr Superf Wnd Face <2.5cm,PX12011F,CDM,510,RC,12011,CPT,,,,,,,,335,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,305.185,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Infliximab - Ref,PX8023090,CDM,300,RC,80230,CPT,90,,,,,,,343,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,305.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.36,336.14
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002F,CDM,510,RC,12002,CPT,,,,,,,,343,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,305.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,142.4822,336.14
INSTRUMENT PACKAGE TOEMATE,27200000,CDM,272,RC,,,,11858-MAIN,LOCAL,,,,,636,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,305.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSTRUMENT PACKAGE TOEMATE,27200000,CDM,272,RC,,,,11858-MAIN,LOCAL,,,,,636,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,305.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSTRUMENT TOEMATE X-SMALL PACKAGE 9H00-T060,27200000,CDM,272,RC,C1713,HCPCS,,11575-MAIN,LOCAL,,,,,636,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,305.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSTRUMENT TOEMATE X-SMALL PACKAGE 9H00-T060,27200000,CDM,272,RC,C1713,HCPCS,,11575-MAIN,LOCAL,,,,,636,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,305.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801801,NDC,0.8,ML,359.37,,First Health,Commercial,both,85,,999999999,percent of total billed charges,305.4645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801810,NDC,0.8,ML,359.37,,First Health,Commercial,both,85,,999999999,percent of total billed charges,305.4645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
Assay for Vancomycin,PX80202,CDM,300,RC,80202,CPT,,,,,,,,314,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,305.6162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.41,307.72
Closed Rx Kneecap Disloc+Anesth,PX27562F,CDM,510,RC,27562,CPT,,,,,,,,604,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,305.624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,591.92
nystatin 100000 UNIT/GM Powder 60 g Bottle,63700001,CDM,250,RC,,,,,,68308015260,NDC,60,GR,335.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,305.6405,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Closed Rx Kneecap Dislocatn,PX27560P,CDM,983,RC,27560,CPT,,,,,,,,312,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,305.76,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,219.89,807.33
Inc/Drain Peritonsil Abscess,PX42700F,CDM,510,RC,42700,CPT,,,,,,,,624,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,305.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,611.52
Inc/Drain Peritonsil Abscess,PX42700F,CDM,510,RC,42700,CPT,,,,,,,,624,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,305.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,611.52
Inc/Drain Peritonsil Abscess,PX42700F,CDM,510,RC,42700,CPT,,,,,,,,624,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,305.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,611.52
Insert Emergency Endotrach Airway,PX31500F,CDM,510,RC,31500,CPT,,,,,,,,637,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,305.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,624.26
Insert Emergency Endotrach Airway,PX31500F,CDM,510,RC,31500,CPT,,,,,,,,637,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,305.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,624.26
Nafcillin Sodium 10 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323033060,NDC,1,EA,617.91,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,305.86545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
neomycin-polymyxin-gramicidin 1.75-10000-.025 Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,24208079062,NDC,10,ML,314.26,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,305.869258,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Repr Superf Wnd Face >30cm,PX12018F,CDM,510,RC,12018,CPT,,,,,,,,713,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,305.877,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,698.74
Fac/Exc Skn Bngn1.1-2cm Remain Bdy,PX11422F,CDM,510,RC,11422,CPT,,,,,,,,618,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,305.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,256.7172,1416.38
Closed Rx Mt-Phal Toe Dislocation,PX28630F,CDM,510,RC,28630,CPT,,,,,,,,360,,First Health,Commercial,both,85,,999999999,percent of total billed charges,306,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.544,352.8
RBC Antibody Elution,PX86860,CDM,300,RC,86860,CPT,,,,,,,,360,,First Health,Commercial,both,85,,999999999,percent of total billed charges,306,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.22,352.8
CT Angio Abdominal Arteries,PX7563501,CDM,350,RC,75635,CPT,TC,,,,,,,2936,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,306.0318,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.11,612.7
Xray Mandible Partial Less Than 4 Vws,PX7010001,CDM,320,RC,70100,CPT,TC,,,,,,,347,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,306.054,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,340.06
Assay of Phenytoin Total,PX80185,CDM,300,RC,80185,CPT,,,,,,,,336,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,306.096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,329.28
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604F,CDM,510,RC,20604,CPT,,,,,,,,344,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,306.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,142.8976,337.12
Exc Abd Les Sc < 3 Cm,PX22902F,CDM,761,RC,22902,CPT,,,,,,,,3128,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,306.3294,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.5,987.89
Exc Abd Les Sc < 3 Cm,PX22902P,CDM,983,RC,22902,CPT,,,,,,,,2086,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,306.3294,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.5,2044.28
"Excis Arm/Elbow Tumor,Subcutan",PX24075F,CDM,510,RC,24075,CPT,,,,,,,,1519,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,306.3294,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.15,1108.26
"Excis Arm/Elbow Tumor,Subcutan",PX24075P,CDM,983,RC,24075,CPT,,,,,,,,2458,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,306.3294,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.15,2408.84
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,45963061959,NDC,1,EA,638.4,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,306.432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,45963061959,NDC,1,EA,638.4,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,306.432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
Assay Iga/Igd/Igg/Igm Each,PX82784,CDM,300,RC,82784,CPT,,,,,,,,315,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,306.5895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.53,308.7
"Fac/Exc Skn Bnig0.6-1cm Fae,Facial",PX11441F,CDM,510,RC,11441,CPT,,,,,,,,606,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,306.636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,251.7324,614.65
sulfacetamide 10 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,24208067004,NDC,15,ML,312.96,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,306.7008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Dress/Debrid Small Burn No Anes,PX16020F,CDM,510,RC,16020,CPT,,,,,,,,313,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,306.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.0202,306.74
"Amputation Metatarsal+Toe,Single",PX28810P,CDM,983,RC,28810,CPT,,,,,,,,620,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,306.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,257.548,2827.75
Colonoscopy,PX44388P,CDM,983,RC,44388,CPT,,,,,,,,620,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,306.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,257.548,798.45
Fac/Removal of Skin Tags,PX11200F,CDM,510,RC,11200,CPT,,,,,,,,348,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,306.936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,144.5592,341.04
folic acid 5 MG/ML Solution 10 mL Vial,J3490.94,CDM,636,RC,J3490,HCPCS,,,,63323018410,NDC,10,ML,336.94,,Medica,Commercial,both,91.1,,7.37,percent of total billed charges,306.95234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,330.2012
Emergency Level II Visit,PX99282P,CDM,981,RC,99282,CPT,,,,,,,,337,,Medica,Commercial,both,91.1,,126.83375,percent of total billed charges,307.007,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.9898,328.0021
rabies immune globulin 300 UNIT/ML Solution 1 mL Vial,90376,CDM,636,RC,90375,CPT,,,,13533031801,NDC,1,ML,1629.06,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,307.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.18,307.02
rabies immune globulin 300 UNIT/ML Solution 1 mL Vial,90376,CDM,636,RC,90375,CPT,,,,13533031801,NDC,1,ML,1629.06,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,307.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.18,307.02
rabies immune globulin 1500 UNIT/5ML Solution 5 mL Vial,90375,CDM,636,RC,90375,CPT,,,,13533031805,NDC,5,ML,8065.26,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,307.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.18,307.02
rabies immune globulin 1500 UNIT/5ML Solution 5 mL Vial,90375,CDM,636,RC,90375,CPT,,,,13533031805,NDC,5,ML,8065.26,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,307.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.18,307.02
Exc Skn Bnig0.6-1cm Remain Bdy,PX11421P,CDM,983,RC,11421,CPT,,,,,,,,345,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,307.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,143.313,614.65
Anal Sphincterotomy,PX46080F,CDM,510,RC,46080,CPT,,,,,,,,607,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,307.142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,252.1478,2452.93
Excis Forearm/Wrist Tumor Subcutan,PX25075P,CDM,983,RC,25075,CPT,,,,,,,,607,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,307.142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,252.1478,1416.38
Open Bx/Excision Inguinofemoral Nodes,PX38531P,CDM,983,RC,38531,CPT,,,,,,,,607,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,307.142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,252.1478,3329.99
perflutren protein A microsphere Suspension 3 mL Vial,Q9956,CDM,636,RC,Q9956,HCPCS,,,,407270703,NDC,3,ML,739.41,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,307.150914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,307.150914,724.6218
"Exc Skn Beig1.1-2cm Face,Facil",PX11442P,CDM,983,RC,11442,CPT,,,,,,,,886,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,307.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.15,868.28
"Fac/Exc Skn Beni1.1-2cm Fce,Facial",PX11442F,CDM,510,RC,11442,CPT,,,,,,,,668,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,307.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.15,404.01
Lvl 3 Init Hosp High Mdm or 75 Minutes,PX99223,CDM,982,RC,99223,CPT,,,,,,,,536,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,307.37,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.68,525.28
Lvl 3 Init Hosp High Mdm or 75 Minutes,PX99223,CDM,982,RC,99223,CPT,,,,,,,,536,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,307.37,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.68,525.28
"Fna Biopsy, W/US Guidance; First Lesion",PX10005P,CDM,983,RC,10005,CPT,,,,,,,,621,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,307.395,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,257.9634,614.65
US Doppler Lw Ext Art Tc,PX9392601,CDM,921,RC,93926,CPT,TC,,,,,,,740,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,307.396,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,725.2
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059303,NDC,1,EA,740.19,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,307.474926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.10077,725.3862
Cast/Strap Procedure Unlisted,PX29799F,CDM,510,RC,29799,CPT,,,,,,,,316,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,307.5628,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,131.2664,309.68
"Lap,Inguinal Hernia Repr,Initial",PX49650P,CDM,983,RC,49650,CPT,,,,,,,,717,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,307.593,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,297.8418,5040.74
3.0MM HEADED SCREW LENGTH 16MM,C1713,CDM,278,RC,C1713,HCPCS,,12656-MAIN,LOCAL,,,,,608,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,307.648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082143,NDC,1,ML,348.85,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,307.6857,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.48,367.9214
US Pregnancy Tc Follow-Up,PX7681601,CDM,402,RC,76816,CPT,TC,,,,,,,362,,First Health,Commercial,both,85,,999999999,percent of total billed charges,307.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,354.76
Assay for Vancomycin,PX80202,CDM,300,RC,80202,CPT,,,,,,,,314,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,307.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.41,307.72
"Closed Rx I-P Jt,Toe Dislocation",PX28660P,CDM,983,RC,28660,CPT,,,,,,,,628,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,307.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,611.2324
"Closed Rx I-P Jt,Toe Dislocation",PX28660P,CDM,983,RC,28660,CPT,,,,,,,,628,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,307.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,611.2324
"Closed Rx I-P Jt,Toe Dislocation",PX28660P,CDM,983,RC,28660,CPT,,,,,,,,628,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,307.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,611.2324
Exc Face Les Sc < 2 Cm,PX21011P,CDM,983,RC,21011,CPT,,,,,,,,628,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,307.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,260.8712,1416.38
Exc Face Les Sc < 2 Cm,PX21011P,CDM,983,RC,21011,CPT,,,,,,,,628,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,307.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,260.8712,1416.38
Exc Face Les Sc < 2 Cm,PX21011P,CDM,983,RC,21011,CPT,,,,,,,,628,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,307.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,260.8712,1416.38
"Echo Heart Xthoracic,Limited",PX9330801,CDM,480,RC,93308,CPT,TC,,,,,,,349,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,307.818,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,144.9746,342.02
"Morphometric Analysis, Tumor - Ref",PX8836090,CDM,310,RC,88360,CPT,90,,,,,,,349,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,307.818,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,144.9746,342.02
"Closed Rx Toe Fx,Manipulatn",PX28515F,CDM,510,RC,28515,CPT,,,,,,,,390,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,307.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.93,352.82
"Closed Rx Toe Fx,Manipulatn",PX28515P,CDM,983,RC,28515,CPT,,,,,,,,260,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,307.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.93,352.82
"Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601P,CDM,983,RC,11601,CPT,,,,,,,,1046,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,307.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.37,1025.08
"Fac/Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601F,CDM,510,RC,11601,CPT,,,,,,,,673,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,307.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.37,476.65
Cardiac Rehab II W/ Monitor,PX93798.02,CDM,943,RC,93798,CPT,,,,,,,,338,,Medica,Commercial,both,91.1,,130.934,percent of total billed charges,307.918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.44,495.55
Initial Rx Burn(S) 1st Degree,PX16000F,CDM,510,RC,16000,CPT,,,,,,,,338,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,307.918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.4052,331.24
neomycin-polymyxin-gramicidin 1.75-10000-.025 Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,24208079062,NDC,10,ML,314.26,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,307.9748,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Art Upper Extremity-Ltd,PX9393101,CDM,921,RC,93931,CPT,TC,,,,,,,718,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,308.022,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,703.64
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605F,CDM,510,RC,24605,CPT,,,,,,,,1124,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,308.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,304.32,1019.71
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605F,CDM,510,RC,24605,CPT,,,,,,,,1124,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,308.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,304.32,1019.71
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605P,CDM,983,RC,24605,CPT,,,,,,,,750,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,308.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,304.32,1019.71
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605P,CDM,983,RC,24605,CPT,,,,,,,,750,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,308.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,304.32,1019.71
"Infectious Disease,Chronic Hep C Virus,Six Assays, Utilizing Serum",PX8159690,CDM,300,RC,81596,CPT,90,,,,,,,609,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,308.154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.19,596.82
Removal of Nail Bed,PX11750F,CDM,510,RC,11750,CPT,,,,,,,,629,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,551,percent of total billed charges,308.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,261.2866,616.42
Removal of Nail Bed,PX11750F,CDM,510,RC,11750,CPT,,,,,,,,629,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,308.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,261.2866,616.42
Removal of Nail Bed,PX11750F,CDM,510,RC,11750,CPT,,,,,,,,629,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,308.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,261.2866,616.42
Drain Pilonidal Cyst Simpl,PX10080F,CDM,510,RC,10080,CPT,,,,,,,,742,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,308.2268,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,308.2268,727.16
Fna W/Image,PX10022F,CDM,510,RC,10022,CPT,,,,,,,,742,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,308.2268,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,308.2268,727.16
insulin aspart prot & aspart 70-30 (70-30) 100 UNIT/ML Suspension Pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169369619,NDC,3,ML,629.28,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,3.1136,percent of total billed charges,308.3472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
insulin aspart prot & aspart 70-30 (70-30) 100 UNIT/ML Suspension Pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169369619,NDC,3,ML,629.28,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,308.3472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
insulin aspart prot & aspart 70-30 (70-30) 100 UNIT/ML Suspension Pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169369619,NDC,3,ML,629.28,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,308.3472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
sodium thiosulfate 250 MG/ML Solution 50 mL Vial,J0209.01,CDM,636,RC,J0209,HCPCS,,,,60267070550,NDC,50,ML,609.57,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,308.44242,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,253.215378,597.3786
SET CRICOTHYROTOMY CATHETER 3.5MM ID,120.251,CDM,272,RC,,,,4306-MAIN,LOCAL,,,,,363,,First Health,Commercial,both,85,,999999999,percent of total billed charges,308.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.7902,355.74
SET CRICOTHYROTOMY CATHETER 4MM ID,120.251,CDM,272,RC,,,,3452-MAIN,LOCAL,,,,,363,,First Health,Commercial,both,85,,999999999,percent of total billed charges,308.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.7902,355.74
SET CRICOTHYROTOMY CATHETER 6MM ID,120.251,CDM,272,RC,,,,2887-MAIN,LOCAL,,,,,363,,First Health,Commercial,both,85,,999999999,percent of total billed charges,308.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.7902,355.74
PERFIX PLUG STERILE X-LARGE,C1781,CDM,278,RC,C1781,HCPCS,,11772-MAIN,LOCAL,,,,,643,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,308.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
PERFIX PLUG STERILE X-LARGE,C1781,CDM,278,RC,C1781,HCPCS,,11772-MAIN,LOCAL,,,,,643,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,308.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Assay Iga/Igd/Igg/Igm Each,PX82784,CDM,300,RC,82784,CPT,,,,,,,,315,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,308.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.53,308.7
Flu Dna Amp Probe 1st 2 Types,PX87502,CDM,300,RC,87502,CPT,,,,,,,,350,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,308.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.84,343
"Infect, Organ, Amp Probe - Ref",PX8780190,CDM,300,RC,87801,CPT,90,,,,,,,630,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,308.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.37,617.4
"Infect, Organ, Amp Probe - Ref",PX8780190,CDM,300,RC,87801,CPT,90,,,,,,,630,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,308.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.37,617.4
"Infect, Organ, Amp Probe - Ref",PX8780190,CDM,300,RC,87801,CPT,90,,,,,,,630,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,308.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.37,617.4
MESH XLARGE LEFT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 5X7,120.524,CDM,278,RC,C1781,HCPCS,,12216-MAIN,LOCAL,,,,,630,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,196.035,percent of total billed charges,308.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,261.702,617.4
MESH XLARGE LEFT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 5X7,120.524,CDM,278,RC,C1781,HCPCS,,12216-MAIN,LOCAL,,,,,630,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,308.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,261.702,617.4
MESH XLARGE LEFT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 5X7,120.524,CDM,278,RC,C1781,HCPCS,,12216-MAIN,LOCAL,,,,,630,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,308.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,261.702,617.4
MESH XLARGE RIGHT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 5X7,120.524,CDM,278,RC,C1781,HCPCS,,12217-MAIN,LOCAL,,,,,630,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,196.035,percent of total billed charges,308.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,261.702,617.4
MESH XLARGE RIGHT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 5X7,120.524,CDM,278,RC,C1781,HCPCS,,12217-MAIN,LOCAL,,,,,630,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,308.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,261.702,617.4
MESH XLARGE RIGHT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 5X7,120.524,CDM,278,RC,C1781,HCPCS,,12217-MAIN,LOCAL,,,,,630,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,308.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,261.702,617.4
PHENobarbital 130 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047721,NDC,1,ML,338.93,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,308.76523,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.354486,332.1514
Xray Mandible Partial Less Than 4 Vws,PX7010001,CDM,320,RC,70100,CPT,TC,,,,,,,347,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,308.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,340.06
Inc/Drain Peritonsil Abscess,PX42700F,CDM,510,RC,42700,CPT,,,,,,,,624,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,308.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,611.52
"Sigmoidoscopy,Diagnostic",PX45330F,CDM,510,RC,45330,CPT,,,,,,,,720,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,308.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,299.088,798.45
HERNIA MESH LAP PROGRIP SELF FIXATING FLAT SHEET 10X15,C1781,CDM,278,RC,C1781,HCPCS,,12727-MAIN,LOCAL,,,,,611,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,309.166,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Lap,Dx Surgical Abd W/Biopsy",PX49321F,CDM,510,RC,49321,CPT,,,,,,,,874,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,309.2193,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.77,718.78
"Lap,Dx Surgical Abd W/Biopsy",PX49321P,CDM,983,RC,49321,CPT,,,,,,,,583,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,309.2193,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.77,718.78
Cardiac Rehab II Eval,PX93798.05,CDM,943,RC,93798,CPT,,,,,,,,364,,First Health,Commercial,both,85,,999999999,percent of total billed charges,309.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.44,495.55
Drain/Inject Large Joint/Bursa,PX20610F,CDM,510,RC,20610,CPT,,,,,,,,364,,First Health,Commercial,both,85,,999999999,percent of total billed charges,309.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,151.2056,356.72
Xray Forearm 2 Vws,PX7309001,CDM,320,RC,73090,CPT,TC,,,,,,,364,,First Health,Commercial,both,85,,999999999,percent of total billed charges,309.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,356.72
glucagon rdna (diagnostic) 1 MG Recon Soln 1 Each Vial,J1610.01,CDM,636,RC,J1610,HCPCS,,,,597026010,NDC,1,EA,744.84,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,309.406536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,172.71,729.9432
8MM ENDOWRIST INSTRUMENTS LARGE NEEDLE DRIVER,27200000,CDM,272,RC,,,,11912-MAIN,LOCAL,,,,,318,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,309.5094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Drain/Inject Medium Joint/Bursa,PX20605P,CDM,983,RC,20605,CPT,,,,,,,,318,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,308,percent of total billed charges,309.5094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,309.5094
"Office/Outpt Visit,Est,Levl V",PX99215F,CDM,510,RC,99215,CPT,,,,,,,,318,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,309.5094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,311.64
"Office/Outpt Visit,Est,Levl V",PX99215P,CDM,983,RC,99215,CPT,,,,,,,,318,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,309.5094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,309.5094
"Remv F.B.,Eye,Cornea,No Slit",PX65220P,CDM,983,RC,65220,CPT,,,,,,,,318,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,309.5094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,348.08
Debride Bone Ea Add 20 Sqcm,PX11047P,CDM,983,RC,11047,CPT,,,,,,,,351,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,309.582,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,145.8054,341.6283
Debride Tissue/Muscle,PX11043P,CDM,983,RC,11043,CPT,,,,,,,,351,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,309.582,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,145.8054,548.67
CT Orbit/Ear/Fossa W/O & W/Dye,PX7048201,CDM,350,RC,70482,CPT,TC,,,,,,,1400,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,309.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.92,309.64
CT Orbit/Ear/Fossa W/O & W/Dye,PX7048201,CDM,350,RC,70482,CPT,TC,,,,,,,1400,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,309.64,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.92,309.64
Cast/Strap Procedure Unlisted,PX29799F,CDM,510,RC,29799,CPT,,,,,,,,316,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,309.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,131.2664,309.68
Closure Superf Wnd Dehis Simple,PX12020F,CDM,510,RC,12020,CPT,,,,,,,,632,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,309.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.5328,619.36
Closure Superf Wnd Dehis Simple,PX12020F,CDM,510,RC,12020,CPT,,,,,,,,632,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,309.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.5328,619.36
Closure Superf Wnd Dehis Simple,PX12020F,CDM,510,RC,12020,CPT,,,,,,,,632,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,309.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.5328,619.36
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121P,CDM,983,RC,13121,CPT,,,,,,,,632,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,309.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.5328,615.1256
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121P,CDM,983,RC,13121,CPT,,,,,,,,632,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,309.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.5328,615.1256
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121P,CDM,983,RC,13121,CPT,,,,,,,,632,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,309.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.5328,615.1256
Fac/Removal of Skin Tags,PX11200F,CDM,510,RC,11200,CPT,,,,,,,,348,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,309.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,144.5592,341.04
Sars-Cov-2 Covid-19 Antibody,PX86769,CDM,300,RC,86769,CPT,,,,,,,,340,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,309.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.63,333.2
X-Ray Exam Chest 3 Views,PX7104701,CDM,320,RC,71047,CPT,TC,,,,,,,340,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,309.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,333.2
umeclidinium-vilanterol 62.5-25 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173086906,NDC,14,EA,745.86,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,309.830244,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Repair Flex Foot Tendon,Ea",PX28200F,CDM,510,RC,28200,CPT,,,,,,,,1475,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,309.8615,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,207.02,1026.63
Explor Metatarso-Phalang Jt,PX28022F,CDM,510,RC,28022,CPT,,,,,,,,1161,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,310.1826,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,207.02,1012.1
Explor Metatarso-Phalang Jt,PX28022P,CDM,983,RC,28022,CPT,,,,,,,,774,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,310.1826,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,207.02,1012.1
"Closed Rx Weight Bear Dist Tib,Manip",PX27825F,CDM,510,RC,27825,CPT,,,,,,,,2695,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,310.21,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.21,1163.61
"Closed Rx Weight Bear Dist Tib,Manip",PX27825P,CDM,983,RC,27825,CPT,,,,,,,,1796,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,310.21,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.21,1760.08
"2019-Ncov Coronavirus, Sars-Cov-2/2019-Ncov (Covid-19)",PXU000290,CDM,300,RC,U0002,HCPCS,90,,,,,,,365,,First Health,Commercial,both,85,,999999999,percent of total billed charges,310.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,357.7
"Closed Rx Spont Hip Disloc,Anesth",PX27257P,CDM,983,RC,27257,CPT,,,,,,,,365,,First Health,Commercial,both,85,,999999999,percent of total billed charges,310.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,151.621,1404.08
Sars-Cov-2 Covid-19 Amp Prb,PX8763590,CDM,300,RC,87635,CPT,90,,,,,,,365,,First Health,Commercial,both,85,,999999999,percent of total billed charges,310.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,357.7
X-Ray Exam Femur Min 2 Vws,PX7355201,CDM,320,RC,73552,CPT,TC,,,,,,,365,,First Health,Commercial,both,85,,999999999,percent of total billed charges,310.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Ankle Minimum 3 Vws,PX7361001,CDM,320,RC,73610,CPT,TC,,,,,,,365,,First Health,Commercial,both,85,,999999999,percent of total billed charges,310.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Calcaneus Minimum 2 Vws,PX7365001,CDM,320,RC,73650,CPT,TC,,,,,,,365,,First Health,Commercial,both,85,,999999999,percent of total billed charges,310.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Clavicle Complete,PX7300001,CDM,320,RC,73000,CPT,TC,,,,,,,365,,First Health,Commercial,both,85,,999999999,percent of total billed charges,310.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Elbow 2 Vws,PX7307001,CDM,320,RC,73070,CPT,TC,,,,,,,365,,First Health,Commercial,both,85,,999999999,percent of total billed charges,310.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Hand 2vws Tc,PX7312001,CDM,320,RC,73120,CPT,TC,,,,,,,365,,First Health,Commercial,both,85,,999999999,percent of total billed charges,310.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,357.7
Xray Humerus Minimum 2 Vws,PX7306001,CDM,320,RC,73060,CPT,TC,,,,,,,365,,First Health,Commercial,both,85,,999999999,percent of total billed charges,310.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Shoulder Minimum 2 Vws,PX7303001,CDM,320,RC,73030,CPT,TC,,,,,,,365,,First Health,Commercial,both,85,,999999999,percent of total billed charges,310.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Sternum 2vws Tc,PX7112001,CDM,320,RC,71120,CPT,TC,,,,,,,365,,First Health,Commercial,both,85,,999999999,percent of total billed charges,310.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Tibia & Fibula 2 Vws,PX7359001,CDM,320,RC,73590,CPT,TC,,,,,,,365,,First Health,Commercial,both,85,,999999999,percent of total billed charges,310.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Wrist 2 Vws,PX7310001,CDM,320,RC,73100,CPT,TC,,,,,,,365,,First Health,Commercial,both,85,,999999999,percent of total billed charges,310.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
"IV Infusion, Bamlanivimab, Infusion and Post Admin Monig",PXM0239,CDM,260,RC,M0239,HCPCS,,,,,,,,320,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,310.3,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.3,310.3
"IV Infusion, Bamlanivimab, Infusion and Post Admin Monig",PXM0239,CDM,260,RC,M0239,HCPCS,,,,,,,,320,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,310.3,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.3,310.3
2.1MM CANNULATED DRILL BIT,27200000,CDM,272,RC,,,,12657-MAIN,LOCAL,,,,,747,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,310.3038,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
US Guide Needle Bx S&I,PX7694201,CDM,402,RC,76942,CPT,TC,,,,,,,747,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,310.3038,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.3038,732.06
brimonidine 0.15 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314014405,NDC,5,ML,723.62,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,310.43298,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082143,NDC,1,ML,348.85,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,310.4765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.48,367.9214
Fresh Frozen Plasma,PXP9017,CDM,390,RC,P9017,HCPCS,,,,,,,,319,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,310.4827,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.32,312.62
"Echo Heart Xthoracic,Limited",PX9330801,CDM,480,RC,93308,CPT,TC,,,,,,,349,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,310.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,144.9746,342.02
"Morphometric Analysis, Tumor - Ref",PX8836090,CDM,310,RC,88360,CPT,90,,,,,,,349,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,310.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,144.9746,342.02
Closed Rx Kneecap Disloc+Anesth,PX27562F,CDM,510,RC,27562,CPT,,,,,,,,604,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,310.64,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.64,1044.62
Closed Rx Kneecap Disloc+Anesth,PX27562P,CDM,983,RC,27562,CPT,,,,,,,,1404,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,310.64,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.64,1375.92
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752F,CDM,510,RC,27752,CPT,,,,,,,,2280,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,310.64,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.64,1144.93
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752P,CDM,983,RC,27752,CPT,,,,,,,,2495,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,310.64,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.64,2445.1
Drainage of Hematoma/Fluid (T),PX10140F,CDM,510,RC,10140,CPT,,,,,,,,341,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,310.651,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,141.6514,1416.38
Drainage Scrotal Wall Abscess,PX55100P,CDM,983,RC,55100,CPT,,,,,,,,341,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,310.651,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,141.6514,1416.38
Drainage Scrotal Wall Abscess,PX55100F,CDM,510,RC,55100,CPT,,,,,,,,634,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,310.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,263.3636,1416.38
Drainage Scrotal Wall Abscess,PX55100F,CDM,510,RC,55100,CPT,,,,,,,,634,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,310.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,263.3636,1416.38
Drainage Scrotal Wall Abscess,PX55100F,CDM,510,RC,55100,CPT,,,,,,,,634,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,310.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,263.3636,1416.38
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,55150017301,NDC,0.5,ML,319.2,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,310.67736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
"Chemotherapy, IV Infusion, 1 Hour",PX96413,CDM,335,RC,96413,CPT,,,,,,,,614,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,310.684,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.0556,601.72
Repr Superf Wnd Body 7.6-12.5,PX12004P,CDM,983,RC,12004,CPT,,,,,,,,614,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,310.684,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,597.6062
"Closed Rx I-P Jt,Toe Dislocation",PX28660P,CDM,983,RC,28660,CPT,,,,,,,,628,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,310.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,611.2324
Exc Face Les Sc < 2 Cm,PX21011P,CDM,983,RC,21011,CPT,,,,,,,,628,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,310.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,260.8712,1416.38
Emergency Level V Visit,PX99285P,CDM,981,RC,99285,CPT,,,,,,,,1436,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,310.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.81,1407.28
Emergency Level V Visit,PX99285P,CDM,981,RC,99285,CPT,,,,,,,,1436,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,310.96,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.81,1407.28
Facility Emergency Level V Visit,PX99285F,CDM,450,RC,99285,CPT,,,,,,,,1464,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,310.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.81,310.96
Facility Emergency Level V Visit,PX99285F,CDM,450,RC,99285,CPT,,,,,,,,1464,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,310.96,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.81,310.96
8MM ENDOWRIST INSTRUMENTS MONOPOLAR CURVED SCISSORS,27200000,CDM,272,RC,,,,11909-MAIN,LOCAL,,,,,648,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,311.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM ENDOWRIST INSTRUMENTS MONOPOLAR CURVED SCISSORS,27200000,CDM,272,RC,,,,11909-MAIN,LOCAL,,,,,648,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,311.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STAPLER INTERNAL ECHELON FLEX POWERED PLUS LONG LENGTH 440MM,27200000,CDM,272,RC,,,,12065-MAIN,LOCAL,,,,,648,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,311.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STAPLER INTERNAL ECHELON FLEX POWERED PLUS LONG LENGTH 440MM,27200000,CDM,272,RC,,,,12065-MAIN,LOCAL,,,,,648,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,311.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Dress/Debrid Med Burn No Anesth,PX16025F,CDM,510,RC,16025,CPT,,,,,,,,366,,First Health,Commercial,both,85,,999999999,percent of total billed charges,311.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,152.0364,358.68
"Fac/Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404F,CDM,510,RC,11404,CPT,,,,,,,,749,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,311.1346,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,311.1346,1416.38
Biopsy Synovium I-P Jt,PX26110,CDM,983,RC,26110,CPT,,,,,,,,933,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,311.1459,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.77,914.34
Repair of Vagina,PX57200P,CDM,983,RC,57200,CPT,,,,,,,,1043,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,311.1459,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.98,1022.14
"Layr Clos Wnd Face,Facial <2.5cm",PX12051P,CDM,983,RC,12051,CPT,,,,,,,,615,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,311.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.471,598.5795
Remove Hemorrhoids & Fissure,PX46257P,CDM,983,RC,46257,CPT,,,,,,,,615,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,311.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.471,2452.93
Creatine Mb Fraction,PX82553,CDM,300,RC,82553,CPT,,,,,,,,353,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,311.346,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.59,345.94
Fentanyl - Ref,PX8035490,CDM,300,RC,80354,CPT,90,,,,,,,353,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,311.346,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,345.94
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155F,CDM,370,RC,99155,CPT,,,,,,,,353,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,311.346,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,345.94
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155P,CDM,983,RC,99155,CPT,,,,,,,,353,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,311.346,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,343.5749
Pvb Thoracic Single Injection Site W/Img Gid,PX64461F,CDM,510,RC,64461,CPT,,,,,,,,353,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,311.346,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,604.15
Removal of Nail Bed,PX11750F,CDM,510,RC,11750,CPT,,,,,,,,629,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,311.355,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,261.2866,616.42
Apply Long Leg Splint,PX29505F,CDM,510,RC,29505,CPT,,,,,,,,320,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,311.456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.928,313.6
"IV Infusion, Bamlanivimab, Infusion and Post Admin Monig",PXM0239,CDM,260,RC,M0239,HCPCS,,,,,,,,320,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,311.456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.928,313.6
insulin aspart prot & aspart 70-30 (70-30) 100 UNIT/ML Suspension Pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169369619,NDC,3,ML,629.28,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,311.4936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
Flu Dna Amp Probe 1st 2 Types,PX87502,CDM,300,RC,87502,CPT,,,,,,,,350,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,311.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.84,343
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605P,CDM,983,RC,24605,CPT,,,,,,,,750,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,311.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,311.55,1404.08
Sigmoidoscope W/Submuc Inj,PX45335F,CDM,750,RC,45335,CPT,,,,,,,,750,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,311.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,311.55,798.45
"Ctrl Nosebleed,Anter,Simple",PX30901F,CDM,510,RC,30901,CPT,,,,,,,,342,,Medica,Commercial,both,91.1,,28,percent of total billed charges,311.562,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,335.16
Ultrasound Breast Limited,PX7664201,CDM,402,RC,76642,CPT,TC,,,,,,,342,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,311.562,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,335.16
8MM ENDOWRIST INSTRUMENTS LARGE NEEDLE DRIVER,27200000,CDM,272,RC,,,,11912-MAIN,LOCAL,,,,,318,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,311.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Drain/Inject Medium Joint/Bursa,PX20605P,CDM,983,RC,20605,CPT,,,,,,,,318,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,311.64,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.47,311.64
INSTRUMENT PACKAGE TOEMATE,27200000,CDM,272,RC,,,,11858-MAIN,LOCAL,,,,,636,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,311.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSTRUMENT PACKAGE TOEMATE,27200000,CDM,272,RC,,,,11858-MAIN,LOCAL,,,,,636,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,311.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSTRUMENT PACKAGE TOEMATE,27200000,CDM,272,RC,,,,11858-MAIN,LOCAL,,,,,636,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,311.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSTRUMENT TOEMATE X-SMALL PACKAGE 9H00-T060,27200000,CDM,272,RC,C1713,HCPCS,,11575-MAIN,LOCAL,,,,,636,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,311.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSTRUMENT TOEMATE X-SMALL PACKAGE 9H00-T060,27200000,CDM,272,RC,C1713,HCPCS,,11575-MAIN,LOCAL,,,,,636,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,311.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSTRUMENT TOEMATE X-SMALL PACKAGE 9H00-T060,27200000,CDM,272,RC,C1713,HCPCS,,11575-MAIN,LOCAL,,,,,636,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,311.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Office/Outpt Visit,Est,Levl V",PX99215F,CDM,510,RC,99215,CPT,,,,,,,,318,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,311.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,311.64
"Office/Outpt Visit,Est,Levl V",PX99215P,CDM,983,RC,99215,CPT,,,,,,,,318,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,311.64,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,89.69,324.12
"Remv F.B.,Eye,Cornea,No Slit",PX65220P,CDM,983,RC,65220,CPT,,,,,,,,318,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,311.64,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.52,311.64
Pvb Thoracic Single Injection Site W/Img Gid,PX64461P,CDM,983,RC,64461,CPT,,,,,,,,616,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,311.696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.8864,604.15
fosfomycin 3 g Packet 1 Each Box,25000000,CDM,250,RC,,,,,,70700026894,NDC,1,EA,353.41,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,311.70762,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Excis Primary Ganglion Wrist,PX25111F,CDM,510,RC,25111,CPT,,,,,,,,791,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,311.7881,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.33,694.57
Excis Primary Ganglion Wrist,PX25111P,CDM,983,RC,25111,CPT,,,,,,,,529,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,311.7881,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.33,694.57
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231001,NDC,10,ML,649.64,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,311.8272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231001,NDC,10,ML,649.64,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,311.8272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231005,NDC,10,ML,649.64,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,311.8272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231005,NDC,10,ML,649.64,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,311.8272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
"Infect, Organ, Amp Probe - Ref",PX8780190,CDM,300,RC,87801,CPT,90,,,,,,,630,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,311.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.37,617.4
MESH XLARGE LEFT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 5X7,120.524,CDM,278,RC,C1781,HCPCS,,12216-MAIN,LOCAL,,,,,630,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,311.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,261.702,617.4
MESH XLARGE RIGHT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 5X7,120.524,CDM,278,RC,C1781,HCPCS,,12217-MAIN,LOCAL,,,,,630,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,311.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,261.702,617.4
Xray Foot 2 Vws,PX7362001,CDM,320,RC,73620,CPT,TC,,,,,,,367,,First Health,Commercial,both,85,,999999999,percent of total billed charges,311.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,359.66
Acellular Derm Matrix Implt,PX15777F,CDM,510,RC,15777,CPT,,,,,,,,650,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.01,637
Acellular Derm Matrix Implt,PX15777F,CDM,510,RC,15777,CPT,,,,,,,,650,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.01,637
Closed Rx Bimalleolar Fx,PX27808F,CDM,510,RC,27808,CPT,,,,,,,,650,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,637
Closed Rx Bimalleolar Fx,PX27808F,CDM,510,RC,27808,CPT,,,,,,,,650,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,637
Insert Emergency Endotrach Airway,PX31500F,CDM,510,RC,31500,CPT,,,,,,,,637,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1101.39625,percent of total billed charges,312.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,624.26
Insert Emergency Endotrach Airway,PX31500F,CDM,510,RC,31500,CPT,,,,,,,,637,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,312.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,624.26
Insert Emergency Endotrach Airway,PX31500F,CDM,510,RC,31500,CPT,,,,,,,,637,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,312.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,624.26
Xray Sinuses Minimum 3 Vws,PX7022001,CDM,320,RC,70220,CPT,TC,,,,,,,354,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,312.228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,346.92
perflutren lipid microsphere 6.52 MG/ML Suspension 2 mL Vial,Q9957,CDM,636,RC,Q9957,HCPCS,,,,11994001101,NDC,2,ML,751.71,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,312.260334,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,312.260334,736.6758
Debride Bone Ea Add 20 Sqcm,PX11047P,CDM,983,RC,11047,CPT,,,,,,,,351,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,312.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,145.8054,341.6283
Debride Tissue/Muscle,PX11043P,CDM,983,RC,11043,CPT,,,,,,,,351,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,312.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,145.8054,548.67
Infliximab - Ref,PX8023090,CDM,300,RC,80230,CPT,90,,,,,,,343,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,312.473,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.36,336.14
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002F,CDM,510,RC,12002,CPT,,,,,,,,343,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,312.473,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,142.4822,336.14
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505F,CDM,510,RC,25505,CPT,,,,,,,,651,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,312.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.4254,1404.08
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505F,CDM,510,RC,25505,CPT,,,,,,,,651,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,312.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.4254,1404.08
Fresh Frozen Plasma,PXP9017,CDM,390,RC,P9017,HCPCS,,,,,,,,319,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,312.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.32,312.62
Nafcillin Sodium 10 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323033060,NDC,1,EA,617.91,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,312.66246,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Exc Skn Bngn2.1-3cmtrnk,Arm,Lg",PX11403P,CDM,983,RC,11403,CPT,,,,,,,,543,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,312.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.02,532.14
"Fac/Ex Skn Bngn2.1-3cm Trnk,Arm,Lg",PX11403F,CDM,510,RC,11403,CPT,,,,,,,,679,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,312.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.02,413.7
Fac/Exc Skn Bngn1.1-2cm Remain Bdy,PX11422F,CDM,510,RC,11422,CPT,,,,,,,,618,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,312.708,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,256.7172,1416.38
oseltamivir 6 MG/ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,4082205,NDC,60,ML,752.82,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,312.721428,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Exc Neck Les Sc = 3cm >,PX21552F,CDM,510,RC,21552,CPT,,,,,,,,753,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,312.7962,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,312.7962,2482.37
SCOPE ASCOPE4 CYSTO STERILE 601001000,120.497,CDM,272,RC,A4649,HCPCS,,11662-MAIN,LOCAL,,,,,368,,First Health,Commercial,both,85,,999999999,percent of total billed charges,312.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,152.8672,360.64
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,45963061959,NDC,1,EA,638.4,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,312.816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,45963061959,NDC,1,EA,638.4,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,312.816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,45963061959,NDC,1,EA,638.4,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,312.816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,55150017301,NDC,0.5,ML,319.2,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,312.816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,36.841826,312.816
Closure Superf Wnd Dehis Simple,PX12020F,CDM,510,RC,12020,CPT,,,,,,,,632,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,312.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.5328,619.36
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121P,CDM,983,RC,13121,CPT,,,,,,,,632,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,312.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.5328,615.1256
sugammadex sodium 200 MG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,6542302,NDC,2,ML,652.81,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,313.3488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sugammadex sodium 200 MG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,6542302,NDC,2,ML,652.81,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,313.3488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604F,CDM,510,RC,20604,CPT,,,,,,,,344,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,313.384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,142.8976,337.12
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545F,CDM,510,RC,23545,CPT,,,,,,,,961,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,313.3936,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.33,781.73
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545P,CDM,983,RC,23545,CPT,,,,,,,,412,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,313.3936,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.33,781.73
"Fac/Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602F,CDM,510,RC,11602,CPT,,,,,,,,731,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,313.599,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,303.6574,716.38
Apply Long Leg Splint,PX29505F,CDM,510,RC,29505,CPT,,,,,,,,320,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,313.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.928,313.6
"IV Infusion, Bamlanivimab, Infusion and Post Admin Monig",PXM0239,CDM,260,RC,M0239,HCPCS,,,,,,,,320,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,313.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.928,313.6
"HERNIA MESH 3D MAX MID ANATOMICAL MESH LEFT SIZE L 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,11976-MAIN,LOCAL,,,,,755,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,313.627,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"HERNIA MESH 3D MAX MID ANATOMICAL MESH RIGHT SIZE L 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,11977-MAIN,LOCAL,,,,,755,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,313.627,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,517096001,NDC,10,ML,355.63,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,313.66566,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752F,CDM,510,RC,27752,CPT,,,,,,,,2280,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,313.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.64,1144.93
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752F,CDM,510,RC,27752,CPT,,,,,,,,2280,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,313.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.64,1144.93
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752P,CDM,983,RC,27752,CPT,,,,,,,,2495,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,313.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.64,2445.1
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752P,CDM,983,RC,27752,CPT,,,,,,,,2495,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,313.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.64,2445.1
"Closed Rx Weight Bear Dist Tib,Manip",PX27825F,CDM,510,RC,27825,CPT,,,,,,,,2695,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,313.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.21,1163.61
"Closed Rx Weight Bear Dist Tib,Manip",PX27825F,CDM,510,RC,27825,CPT,,,,,,,,2695,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,313.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.21,1163.61
"Closed Rx Weight Bear Dist Tib,Manip",PX27825P,CDM,983,RC,27825,CPT,,,,,,,,1796,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,313.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.21,1760.08
"Closed Rx Weight Bear Dist Tib,Manip",PX27825P,CDM,983,RC,27825,CPT,,,,,,,,1796,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,313.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.21,1760.08
"Amputation Metatarsal+Toe,Single",PX28810P,CDM,983,RC,28810,CPT,,,,,,,,620,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,313.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,257.548,2827.75
Colonoscopy,PX44388P,CDM,983,RC,44388,CPT,,,,,,,,620,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,313.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,257.548,798.45
ketoconazole 2 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,16714095501,NDC,15,GR,322.42,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,313.811386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Drainage Scrotal Wall Abscess,PX55100F,CDM,510,RC,55100,CPT,,,,,,,,634,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,313.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,263.3636,1416.38
Injection Hip Arthrogram,PX27093F,CDM,510,RC,27093,CPT,,,,,,,,654,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,313.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,271.6716,640.92
Injection Hip Arthrogram,PX27093F,CDM,510,RC,27093,CPT,,,,,,,,654,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,313.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,271.6716,640.92
Blood Type Antigen Donor Ea,PX86902,CDM,300,RC,86902,CPT,,,,,,,,43,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,314.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,17.8622,314.02
"Flow Cyto, Tech, 1st Mrkr - Ref",PX8818490,CDM,310,RC,88184,CPT,90,,,,,,,223,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,314.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.6342,314.02
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; 1st",PX88184,CDM,310,RC,88184,CPT,,,,,,,,96,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,314.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.8784,314.02
Immunohisto Antibody Slide Ea Multiplex,PX8834401,CDM,310,RC,88344,CPT,TC,,,,,,,51,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,314.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.1854,314.02
"Lab Antibody ID,RBC",PX7605,CDM,300,RC,86870,CPT,,,,,,,,155,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,314.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.387,314.02
"Level V - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3939,CDM,310,RC,88307,CPT,TC,,,,,,,252,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,314.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.6808,314.02
"Morphometric Analysis, in Situ Hybridization, Each Probe; Manual, Tech",PX8836801,CDM,310,RC,88368,CPT,TC,,,,,,,402,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,314.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.9908,393.96
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031F,CDM,510,RC,12031,CPT,,,,,,,,688,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,314.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.55,547.21
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031P,CDM,983,RC,12031,CPT,,,,,,,,551,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,314.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.55,547.21
"Up GI Endoscopy,Ball Dil,30mm",PX43249F,CDM,750,RC,43249,CPT,,,,,,,,2596,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,314.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.8,2216.53
"Up GI Endoscopy,Ball Dil,30mm",PX43249P,CDM,983,RC,43249,CPT,,,,,,,,1731,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,314.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.8,2216.53
Creatine Mb Fraction,PX82553,CDM,300,RC,82553,CPT,,,,,,,,353,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,314.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.59,345.94
Fentanyl - Ref,PX8035490,CDM,300,RC,80354,CPT,90,,,,,,,353,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,314.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,345.94
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155F,CDM,370,RC,99155,CPT,,,,,,,,353,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,314.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,345.94
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155P,CDM,983,RC,99155,CPT,,,,,,,,353,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,314.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,343.5749
Pvb Thoracic Single Injection Site W/Img Gid,PX64461F,CDM,510,RC,64461,CPT,,,,,,,,353,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,314.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,604.15
"Fna Biopsy, W/US Guidance; First Lesion",PX10005P,CDM,983,RC,10005,CPT,,,,,,,,621,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,314.226,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,257.9634,614.65
Exc Skn Bnig0.6-1cm Remain Bdy,PX11421P,CDM,983,RC,11421,CPT,,,,,,,,345,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,314.295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,143.313,614.65
Xray Ls Spine Bend Tc,PX7212001,CDM,320,RC,72120,CPT,TC,,,,,,,323,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,273.92,percent of total billed charges,314.3759,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,316.54
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035F,CDM,510,RC,12035,CPT,,,,,,,,655,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,314.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,272.087,641.9
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035F,CDM,510,RC,12035,CPT,,,,,,,,655,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,314.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,272.087,641.9
"Inject Nerv Blck,Othr Periph Nerv",PX64450F,CDM,510,RC,64450,CPT,,,,,,,,757,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,314.4578,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,314.4578,741.86
prednisoLONE acetate 0.12 % Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,11980017405,NDC,5,ML,757.07,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,314.486878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Acetaminophen,PX80307E,CDM,300,RC,80307,CPT,,,,,,,,370,,First Health,Commercial,both,85,,999999999,percent of total billed charges,314.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Alcohol,PX80307A,CDM,300,RC,80307,CPT,,,,,,,,370,,First Health,Commercial,both,85,,999999999,percent of total billed charges,314.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Salicylate,PX80307D,CDM,300,RC,80307,CPT,,,,,,,,370,,First Health,Commercial,both,85,,999999999,percent of total billed charges,314.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Urine Drug Screen,PX80307B,CDM,300,RC,80307,CPT,,,,,,,,370,,First Health,Commercial,both,85,,999999999,percent of total billed charges,314.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Xray Elbow 3+Vws Tc,PX7308001,CDM,320,RC,73080,CPT,TC,,,,,,,370,,First Health,Commercial,both,85,,999999999,percent of total billed charges,314.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,362.6
fosfomycin 3 g Packet 1 Each Box,25000000,CDM,250,RC,,,,,,70700026894,NDC,1,EA,353.41,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,314.5349,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Heart/Lung Resuscitation (Cpr),PX92950F,CDM,480,RC,92950,CPT,,,,,,,,1366,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,314.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.13,564.83
Heart/Lung Resuscitation (Cpr),PX92950P,CDM,983,RC,92950,CPT,,,,,,,,1023,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,314.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.13,1002.54
Closed Rx Kneecap Disloc+Anesth,PX27562F,CDM,510,RC,27562,CPT,,,,,,,,604,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,314.78,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.64,1044.62
Closed Rx Kneecap Disloc+Anesth,PX27562F,CDM,510,RC,27562,CPT,,,,,,,,604,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,314.78,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.64,1044.62
Closed Rx Kneecap Disloc+Anesth,PX27562P,CDM,983,RC,27562,CPT,,,,,,,,1404,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,314.78,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.64,1375.92
Closed Rx Kneecap Disloc+Anesth,PX27562P,CDM,983,RC,27562,CPT,,,,,,,,1404,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,314.78,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.64,1375.92
INSTRUMENT PACKAGE TOEMATE,27200000,CDM,272,RC,,,,11858-MAIN,LOCAL,,,,,636,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,314.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSTRUMENT TOEMATE X-SMALL PACKAGE 9H00-T060,27200000,CDM,272,RC,C1713,HCPCS,,11575-MAIN,LOCAL,,,,,636,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,314.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Remove Intrauterine Device,PX58301,CDM,983,RC,58301,CPT,,,,,,,,357,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,314.874,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.2978,347.4681
X-Ray Exam Chest 1 View,PX7104501,CDM,320,RC,71045,CPT,TC,,,,,,,357,,United Healthcare,All Payer,outpatient,88.2,,236.3995455,percent of total billed charges,314.874,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,349.86
"Xray Chest 1 View, Tc",PX7101001,CDM,320,RC,71010,CPT,TC,,,,,,,357,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,314.874,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.2978,349.86
Xray Scapula Complete,PX7301001,CDM,320,RC,73010,CPT,TC,,,,,,,357,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,314.874,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,349.86
Jak2 Gene - Ref,PX8127090,CDM,300,RC,81270,CPT,90,,,,,,,734,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,314.886,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.04,719.32
Xray Sinuses Minimum 3 Vws,PX7022001,CDM,320,RC,70220,CPT,TC,,,,,,,354,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,315.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,346.92
PERFIX PLUG STERILE X-LARGE,C1781,CDM,278,RC,C1781,HCPCS,,11772-MAIN,LOCAL,,,,,643,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,196.035,percent of total billed charges,315.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
PERFIX PLUG STERILE X-LARGE,C1781,CDM,278,RC,C1781,HCPCS,,11772-MAIN,LOCAL,,,,,643,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,315.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
PERFIX PLUG STERILE X-LARGE,C1781,CDM,278,RC,C1781,HCPCS,,11772-MAIN,LOCAL,,,,,643,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,315.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Insert Emergency Endotrach Airway,PX31500F,CDM,510,RC,31500,CPT,,,,,,,,637,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,315.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,624.26
I&D Deep Absc/Hematoma Neck/Chest,PX21501F,CDM,510,RC,21501,CPT,,,,,,,,773,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,315.3202,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,210.51,1021.1
I&D Deep Absc/Hematoma Neck/Chest,PX21501P,CDM,983,RC,21501,CPT,,,,,,,,515,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,315.3202,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,210.51,1021.1
"Removal of Hydrocele,Tunica,Unilat",PX55040P,CDM,983,RC,55040,CPT,,,,,,,,1420,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,315.3202,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,210.51,1391.6
"US Guide, Vascular Access",PX7693701,CDM,402,RC,76937,CPT,TC,,,,,,,760,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,315.704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,315.704,744.8
Inc/Drain Peritonsil Abscess,PX42700F,CDM,510,RC,42700,CPT,,,,,,,,624,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,315.744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,611.52
Declot Vascular Access Device,PX36593F,CDM,510,RC,36593,CPT,,,,,,,,358,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,315.756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.7132,350.84
Fac/Irrigation of Bladder,PX51700F,CDM,510,RC,51700,CPT,,,,,,,,358,,United Healthcare,All Payer,outpatient,88.2,,175.42,percent of total billed charges,315.756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.7132,350.84
X-Ray Exam Abdomen 1 View,PX7401801,CDM,320,RC,74018,CPT,TC,,,,,,,358,,United Healthcare,All Payer,outpatient,88.2,,211.32,percent of total billed charges,315.756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,350.84
Xray Abdomen Single Ap Vw,PX7400001,CDM,320,RC,74000,CPT,TC,,,,,,,358,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,315.756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.7132,350.84
"Repair Ing Hernia,5+Y/O,Reducibl",PX49505P,CDM,983,RC,49505,CPT,,,,,,,,2048,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,315.88,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,315.88,2007.04
"Closed Rx Talus Fx,Manipulatn",PX28435F,CDM,510,RC,28435,CPT,,,,,,,,1705,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,315.9624,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,210.51,796.26
"Closed Rx Talus Fx,Manipulatn",PX28435P,CDM,983,RC,28435,CPT,,,,,,,,1137,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,315.9624,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,210.51,1114.26
ketoconazole 2 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,16714095501,NDC,15,GR,322.42,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,315.9716,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,45963061959,NDC,1,EA,638.4,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,316.008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
Xray Mandible Partial Less Than 4 Vws,PX7010001,CDM,320,RC,70100,CPT,TC,,,,,,,347,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,316.117,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,340.06
Cyto Non Gyn,PX8811201,CDM,310,RC,88112,CPT,TC,,,,,,,372,,First Health,Commercial,both,85,,999999999,percent of total billed charges,316.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,364.56
"rabies vaccine, pcec Recon Susp 1 Each Vial",90675,CDM,636,RC,90675,CPT,,,,58160096412,NDC,1,EA,1544.83,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,316.31113,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,285.77,324.74
"Insert Needle,Intraosseous Infusn",PX36680F,CDM,510,RC,36680,CPT,,,,,,,,659,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,316.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,273.7486,645.82
"Insert Needle,Intraosseous Infusn",PX36680F,CDM,510,RC,36680,CPT,,,,,,,,659,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,316.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,273.7486,645.82
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156F,CDM,370,RC,99156,CPT,,,,,,,,325,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,316.3225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,318.5
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156P,CDM,983,RC,99156,CPT,,,,,,,,325,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,316.3225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,316.3225
Refill/Maint Portable Pump,PX96521,CDM,260,RC,96521,CPT,,,,,,,,325,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,316.3225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,318.5
"Remv F.B.,Eye,Embed Conjunc",PX65210F,CDM,510,RC,65210,CPT,,,,,,,,325,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,316.3225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,348.08
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598P,CDM,982,RC,97598,CPT,,,,,,,,325,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,316.3225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,316.3225
Somatostatin - Ref,PX8430790,CDM,300,RC,84307,CPT,90,,,,,,,325,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,316.3225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.76,318.5
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,517096001,NDC,10,ML,355.63,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,316.5107,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Xray Ls Spine Bend Tc,PX7212001,CDM,320,RC,72120,CPT,TC,,,,,,,323,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,316.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,316.54
amiodarone 360-4.14 MG/200ML-% Solution 200 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066036020,NDC,200,ML,325.25,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,316.565825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.35,318.745
"Office/Outpt Visit,New,Levl IV",PX99204F,CDM,510,RC,99204,CPT,,,,,,,,359,,United Healthcare,All Payer,outpatient,88.2,,306.94,percent of total billed charges,316.638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.1286,351.82
"Office/Outpt Visit,New,Levl IV",PX99204P,CDM,983,RC,99204,CPT,,,,,,,,359,,United Healthcare,All Payer,outpatient,88.2,,306.94,percent of total billed charges,316.638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.1286,349.4147
insulin aspart 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169633910,NDC,3,ML,659.76,,Health Partners,Health Partners Care Plans,both,48,,4.547805556,percent of total billed charges,316.6848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
insulin aspart 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169633910,NDC,3,ML,659.76,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,316.6848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
"Incis/Drain Scrotum/Testis,Epididym",PX54700F,CDM,510,RC,54700,CPT,,,,,,,,660,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,316.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.164,1779.39
"Incis/Drain Scrotum/Testis,Epididym",PX54700F,CDM,510,RC,54700,CPT,,,,,,,,660,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,316.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.164,1779.39
Debride Tissue/Muscle,PX11043F,CDM,510,RC,11043,CPT,,,,,,,,526,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,316.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.8,483.57
Debride Tissue/Muscle,PX11043P,CDM,983,RC,11043,CPT,,,,,,,,351,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,316.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.8,483.57
Biopsy of Rectum,PX45100F,CDM,510,RC,45100,CPT,,,,,,,,763,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,316.9502,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,316.9502,2452.93
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801801,NDC,0.8,ML,359.37,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,316.96434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801810,NDC,0.8,ML,359.37,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,316.96434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
MRI Upper W/O+W Tc,PX7322001,CDM,610,RC,73220,CPT,TC,,,,,,,3253,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,316.973,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.66,633.08
Fac/Removal of Skin Tags,PX11200F,CDM,510,RC,11200,CPT,,,,,,,,348,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,317.028,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,144.5592,341.04
"Colonoscopy,Flex,Screen",PX2002F,CDM,750,RC,G0105,HCPCS,,,,,,,,2539,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,317.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.56,592.75
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032P,CDM,983,RC,12032,CPT,,,,,,,,647,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,57.99666667,percent of total billed charges,317.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,268.7638,629.7251
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032P,CDM,983,RC,12032,CPT,,,,,,,,647,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,317.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,268.7638,629.7251
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032P,CDM,983,RC,12032,CPT,,,,,,,,647,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,317.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,268.7638,629.7251
"Repair Umbilical Hern,5+Y/O,Reduc",PX49585P,CDM,983,RC,49585,CPT,,,,,,,,647,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,317.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,268.7638,629.7251
"Repair Umbilical Hern,5+Y/O,Reduc",PX49585P,CDM,983,RC,49585,CPT,,,,,,,,647,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,317.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,268.7638,629.7251
"Repair Umbilical Hern,5+Y/O,Reduc",PX49585P,CDM,983,RC,49585,CPT,,,,,,,,647,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,317.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,268.7638,629.7251
perflutren protein A microsphere Suspension 3 mL Vial,Q9956,CDM,636,RC,Q9956,HCPCS,,,,407270703,NDC,3,ML,739.41,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,317.20689,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,307.150914,724.6218
"Repair Ing Hernia,5+Y/O,Reducibl",PX49505P,CDM,983,RC,49505,CPT,,,,,,,,2048,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,317.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,315.88,2007.04
"Repair Ing Hernia,5+Y/O,Reducibl",PX49505P,CDM,983,RC,49505,CPT,,,,,,,,2048,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,317.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,315.88,2007.04
US Doppler Lw Ext Art Tc,PX9392601,CDM,921,RC,93926,CPT,TC,,,,,,,740,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,317.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,725.2
8MM ENDOWRIST INSTRUMENTS MONOPOLAR CURVED SCISSORS,27200000,CDM,272,RC,,,,11909-MAIN,LOCAL,,,,,648,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,317.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM ENDOWRIST INSTRUMENTS MONOPOLAR CURVED SCISSORS,27200000,CDM,272,RC,,,,11909-MAIN,LOCAL,,,,,648,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,317.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM ENDOWRIST INSTRUMENTS MONOPOLAR CURVED SCISSORS,27200000,CDM,272,RC,,,,11909-MAIN,LOCAL,,,,,648,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,317.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Closed Rx Mt-Phal Toe Dislocation,PX28630F,CDM,510,RC,28630,CPT,,,,,,,,360,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,317.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.544,352.8
RBC Antibody Elution,PX86860,CDM,300,RC,86860,CPT,,,,,,,,360,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,317.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.22,352.8
STAPLER INTERNAL ECHELON FLEX POWERED PLUS LONG LENGTH 440MM,27200000,CDM,272,RC,,,,12065-MAIN,LOCAL,,,,,648,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,317.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STAPLER INTERNAL ECHELON FLEX POWERED PLUS LONG LENGTH 440MM,27200000,CDM,272,RC,,,,12065-MAIN,LOCAL,,,,,648,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,317.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STAPLER INTERNAL ECHELON FLEX POWERED PLUS LONG LENGTH 440MM,27200000,CDM,272,RC,,,,12065-MAIN,LOCAL,,,,,648,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,317.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Remove Foreign Body Simple,PX10120F,CDM,510,RC,10120,CPT,,,,,,,,404,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,317.54,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.53,317.54
Remove Foreign Body Simple,PX10120P,CDM,983,RC,10120,CPT,,,,,,,,404,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,317.54,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.53,395.92
Tube Thoracostomy Inc Wtr Seal,PX32551F,CDM,510,RC,32551,CPT,,,,,,,,989,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,317.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.49,317.54
Tube Thoracostomy Inc Wtr Seal,PX32551F,CDM,510,RC,32551,CPT,,,,,,,,989,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,317.54,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.49,317.54
Tube Thoracostomy Inc Wtr Seal,PX32551P,CDM,983,RC,32551,CPT,,,,,,,,1236,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,317.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.49,1211.28
Tube Thoracostomy Inc Wtr Seal,PX32551P,CDM,983,RC,32551,CPT,,,,,,,,1236,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,317.54,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.49,1211.28
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059303,NDC,1,EA,740.19,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,317.54151,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.10077,725.3862
"Colonoscopy,Screen Prev",PX2004F,CDM,750,RC,G0121,HCPCS,,,,,,,,2502,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,317.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.78,593.33
Remove Intrauterine Device,PX58301,CDM,983,RC,58301,CPT,,,,,,,,357,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,317.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.2978,347.4681
X-Ray Exam Chest 1 View,PX7104501,CDM,320,RC,71045,CPT,TC,,,,,,,357,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,317.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,349.86
"Xray Chest 1 View, Tc",PX7101001,CDM,320,RC,71010,CPT,TC,,,,,,,357,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,317.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.2978,349.86
Xray Scapula Complete,PX7301001,CDM,320,RC,73010,CPT,TC,,,,,,,357,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,317.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,349.86
Fluoroscopy Guid Needle Plcmt Tc,PX7700201,CDM,320,RC,77002,CPT,TC,,,,,,,662,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,317.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.9948,648.76
Fluoroscopy Guid Needle Plcmt Tc,PX7700201,CDM,320,RC,77002,CPT,TC,,,,,,,662,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,317.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.9948,648.76
"Closed Rx I-P Jt,Toe Dislocation",PX28660P,CDM,983,RC,28660,CPT,,,,,,,,628,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,317.768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,611.2324
Exc Face Les Sc < 2 Cm,PX21011P,CDM,983,RC,21011,CPT,,,,,,,,628,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,317.768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,260.8712,1416.38
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082143,NDC,1,ML,348.85,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,317.80235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.48,367.9214
SUTURE CTD VICRYL 4-0 VIL BR SUTUPK J103T,27200000,CDM,272,RC,,,,4491-MAIN,LOCAL,,,,,373.97,,First Health,Commercial,both,85,,999999999,percent of total billed charges,317.8745,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Fac/Exc Skin Benig<5mm Remaind Bod,PX11420F,CDM,510,RC,11420,CPT,,,,,,,,374,,First Health,Commercial,both,85,,999999999,percent of total billed charges,317.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,1416.38
"Fac/Office Consultation,Level III",PX99243F,CDM,510,RC,99213,CPT,,,,,,,,374,,First Health,Commercial,both,85,,999999999,percent of total billed charges,317.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,366.52
"Inpatient Consult, Level III",PX99253,CDM,983,RC,99253,CPT,,,,,,,,374,,First Health,Commercial,both,85,,999999999,percent of total billed charges,317.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,364.0142
"Office Consultation,Level III",PX99243P,CDM,983,RC,99243,CPT,,,,,,,,374,,First Health,Commercial,both,85,,999999999,percent of total billed charges,317.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,364.0142
Removal of Hemorrhoid Clot,PX46320P,CDM,983,RC,46320,CPT,,,,,,,,374,,First Health,Commercial,both,85,,999999999,percent of total billed charges,317.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,1030.93
Xray Hand 3vws Tc,PX7313001,CDM,320,RC,73130,CPT,TC,,,,,,,374,,First Health,Commercial,both,85,,999999999,percent of total billed charges,317.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,366.52
"Echo Heart Xthoracic,Limited",PX9330801,CDM,480,RC,93308,CPT,TC,,,,,,,349,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,317.939,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,144.9746,342.02
"Morphometric Analysis, Tumor - Ref",PX8836090,CDM,310,RC,88360,CPT,90,,,,,,,349,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,317.939,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,144.9746,342.02
8MM ENDOWRIST INSTRUMENTS MEGA SUTURE CUT NEEDLE DRIVER,27200000,CDM,272,RC,,,,11914-MAIN,LOCAL,,,,,327,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,318.2691,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"IV Infusion Therapy, 1 Hour",PX96365,CDM,260,RC,96365,CPT,,,,,,,,327,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,168.3126733,percent of total billed charges,318.2691,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.8358,320.46
Removal of Nail Bed,PX11750F,CDM,510,RC,11750,CPT,,,,,,,,629,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,318.274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,261.2866,616.42
PERFIX PLUG STERILE X-LARGE,C1781,CDM,278,RC,C1781,HCPCS,,11772-MAIN,LOCAL,,,,,643,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,318.285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Drain Pilonidal Cyst Simpl,PX10080F,CDM,510,RC,10080,CPT,,,,,,,,742,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,318.318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,308.2268,727.16
Fna W/Image,PX10022F,CDM,510,RC,10022,CPT,,,,,,,,742,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,318.318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,308.2268,727.16
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231001,NDC,10,ML,649.64,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,318.3236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231001,NDC,10,ML,649.64,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,318.3236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231001,NDC,10,ML,649.64,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,318.3236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231005,NDC,10,ML,649.64,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,318.3236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231005,NDC,10,ML,649.64,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,318.3236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231005,NDC,10,ML,649.64,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,318.3236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
insulin aspart prot & aspart 70-30 (70-30) 100 UNIT/ML Suspension Pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169369619,NDC,3,ML,629.28,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,318.41568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
Acellular Derm Matrix Implt,PX15777F,CDM,510,RC,15777,CPT,,,,,,,,650,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,318.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.01,637
Acellular Derm Matrix Implt,PX15777F,CDM,510,RC,15777,CPT,,,,,,,,650,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,318.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.01,637
Acellular Derm Matrix Implt,PX15777F,CDM,510,RC,15777,CPT,,,,,,,,650,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,318.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.01,637
Closed Rx Bimalleolar Fx,PX27808F,CDM,510,RC,27808,CPT,,,,,,,,650,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,318.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,637
Closed Rx Bimalleolar Fx,PX27808F,CDM,510,RC,27808,CPT,,,,,,,,650,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,318.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,637
Closed Rx Bimalleolar Fx,PX27808F,CDM,510,RC,27808,CPT,,,,,,,,650,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,318.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,637
"Exc Skn Bngn2.1-3cm Fce,Facial",PX11443P,CDM,983,RC,11443,CPT,,,,,,,,650,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,318.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.01,1416.38
"Exc Skn Bngn2.1-3cm Fce,Facial",PX11443P,CDM,983,RC,11443,CPT,,,,,,,,650,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,318.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.01,1416.38
"Exc Skn Bngn2.1-3cm Fce,Facial",PX11443P,CDM,983,RC,11443,CPT,,,,,,,,650,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,318.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.01,1416.38
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156F,CDM,370,RC,99156,CPT,,,,,,,,325,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,318.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,318.5
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156P,CDM,983,RC,99156,CPT,,,,,,,,325,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,318.5,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.02,318.5
Refill/Maint Portable Pump,PX96521,CDM,260,RC,96521,CPT,,,,,,,,325,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,318.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,318.5
"Remv F.B.,Eye,Embed Conjunc",PX65210F,CDM,510,RC,65210,CPT,,,,,,,,325,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,318.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,348.08
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598P,CDM,982,RC,97598,CPT,,,,,,,,325,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,318.5,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.59,318.5
Somatostatin - Ref,PX8430790,CDM,300,RC,84307,CPT,90,,,,,,,325,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,318.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.76,318.5
"Complex Drainage, Wound",PX10180P,CDM,983,RC,10180,CPT,,,,,,,,767,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,318.6118,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,318.6118,2482.37
Declot Vascular Access Device,PX36593F,CDM,510,RC,36593,CPT,,,,,,,,358,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,318.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.7132,350.84
Fac/Irrigation of Bladder,PX51700F,CDM,510,RC,51700,CPT,,,,,,,,358,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,318.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.7132,350.84
X-Ray Exam Abdomen 1 View,PX7401801,CDM,320,RC,74018,CPT,TC,,,,,,,358,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,318.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,350.84
Xray Abdomen Single Ap Vw,PX7400001,CDM,320,RC,74000,CPT,TC,,,,,,,358,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,318.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.7132,350.84
Xray Cervical Spine 4 or 5 Vws,PX7205001,CDM,320,RC,72050,CPT,TC,,,,,,,664,,Health Partners,Health Partners Care Plans,both,48,,132.8,percent of total billed charges,318.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,650.72
Xray Cervical Spine 4 or 5 Vws,PX7205001,CDM,320,RC,72050,CPT,TC,,,,,,,664,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,318.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,650.72
Xray Cervical Spine 6 or More Vws,PX7205201,CDM,320,RC,72052,CPT,TC,,,,,,,664,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,318.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,650.72
Xray Cervical Spine 6 or More Vws,PX7205201,CDM,320,RC,72052,CPT,TC,,,,,,,664,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,318.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,650.72
amiodarone 360-4.14 MG/200ML-% Solution 200 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066036020,NDC,200,ML,325.25,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,318.745,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.35,318.745
"Digital Mamm, Diag, Bilat, Tc W/Cad Perf",PX7706601,CDM,401,RC,77066,CPT,TC,,,,,,,375,,First Health,Commercial,both,85,,999999999,percent of total billed charges,318.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.05,367.5
"Digital Mammogram, Screen Bil, Tc W/Cad Perf",PX7706701,CDM,403,RC,77067,CPT,TC,,,,,,,375,,First Health,Commercial,both,85,,999999999,percent of total billed charges,318.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.86,561
Repr Superf Wnd Face 2.6-5,PX12013F,CDM,510,RC,12013,CPT,,,,,,,,375,,First Health,Commercial,both,85,,999999999,percent of total billed charges,318.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.775,367.5
Xray Wrist Minimum 3 Vws,PX7311001,CDM,320,RC,73110,CPT,TC,,,,,,,375,,First Health,Commercial,both,85,,999999999,percent of total billed charges,318.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,367.5
"Infect, Organ, Amp Probe - Ref",PX8780190,CDM,300,RC,87801,CPT,90,,,,,,,630,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,318.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.37,617.4
MESH XLARGE LEFT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 5X7,120.524,CDM,278,RC,C1781,HCPCS,,12216-MAIN,LOCAL,,,,,630,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,318.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,261.702,617.4
MESH XLARGE RIGHT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 5X7,120.524,CDM,278,RC,C1781,HCPCS,,12217-MAIN,LOCAL,,,,,630,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,318.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,261.702,617.4
Flu Dna Amp Probe 1st 2 Types,PX87502,CDM,300,RC,87502,CPT,,,,,,,,350,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,318.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.84,343
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505F,CDM,510,RC,25505,CPT,,,,,,,,651,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,318.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.4254,1404.08
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505F,CDM,510,RC,25505,CPT,,,,,,,,651,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,318.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.4254,1404.08
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505F,CDM,510,RC,25505,CPT,,,,,,,,651,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,318.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.4254,1404.08
Remove Foreign Body Complic,PX10121P,CDM,983,RC,10121,CPT,,,,,,,,651,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,318.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.4254,1416.38
Remove Foreign Body Complic,PX10121P,CDM,983,RC,10121,CPT,,,,,,,,651,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,318.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.4254,1416.38
Remove Foreign Body Complic,PX10121P,CDM,983,RC,10121,CPT,,,,,,,,651,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,318.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.4254,1416.38
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082152,NDC,1,ML,375.43,,First Health,Commercial,both,85,,999999999,percent of total billed charges,319.1155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.48,367.9214
butamben-tetracaine-benzocaine 2-2-14 % Aerosol 5 g Bottle,25000000,CDM,250,RC,,,,,,10223020104,NDC,5,GR,375.52,,First Health,Commercial,both,85,,999999999,percent of total billed charges,319.192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Chemotherapy, IV Infusion, Each Add'l Sequential Infusion",PX96417,CDM,335,RC,96417,CPT,,,,,,,,328,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,319.2424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,321.44
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762P,CDM,983,RC,43762,CPT,,,,,,,,328,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,319.2424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.2512,319.2424
US Pregnancy Tc Follow-Up,PX7681601,CDM,402,RC,76816,CPT,TC,,,,,,,362,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,319.284,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,354.76
tiotropium 18 MCG capsule 5 Each Box,63700001,CDM,250,RC,,,,,,597007575,NDC,5,EA,665.18,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,319.2864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tiotropium 18 MCG capsule 5 Each Box,63700001,CDM,250,RC,,,,,,597007575,NDC,5,EA,665.18,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,319.2864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hepatitis A vaccine 1440 EL U/ML Suspension 1 mL Syringe,90632,CDM,636,RC,90632,CPT,,,,58160082652,NDC,1,ML,375.78,,First Health,Commercial,both,85,,999999999,percent of total billed charges,319.413,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,156.099012,368.2644
"Layr Clos Wnd Face,Facial <2.5cm",PX12051F,CDM,510,RC,12051,CPT,,,,,,,,769,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,319.4426,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,319.4426,753.62
Part Remv Phalanx of Toe,PX28124F,CDM,510,RC,28124,CPT,,,,,,,,2155,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,319.4945,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.82,992.04
Part Remv Phalanx of Toe,PX28124P,CDM,983,RC,28124,CPT,,,,,,,,1515,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,319.4945,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.82,1484.7
"Office/Outpt Visit,New,Levl IV",PX99204F,CDM,510,RC,99204,CPT,,,,,,,,359,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,319.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.1286,351.82
"Office/Outpt Visit,New,Levl IV",PX99204P,CDM,983,RC,99204,CPT,,,,,,,,359,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,319.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.1286,349.4147
glucagon rdna (diagnostic) 1 MG Recon Soln 1 Each Vial,J1610.01,CDM,636,RC,J1610,HCPCS,,,,597026010,NDC,1,EA,744.84,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,319.53636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,172.71,729.9432
fat emulsion 20 % Emulsion 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,338051958,NDC,200,ML,375.95,,First Health,Commercial,both,85,,999999999,percent of total billed charges,319.5575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Closed Rx Big Toe Fx,Manip",PX28495F,CDM,510,RC,28495,CPT,,,,,,,,857,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,319.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.42,384.64
"Closed Rx Big Toe Fx,Manip",PX28495P,CDM,983,RC,28495,CPT,,,,,,,,412,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,319.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.42,403.76
Colonoscopy,PX44388F,CDM,750,RC,44388,CPT,,,,,,,,930,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,319.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.89,655.83
Colonoscopy,PX44388P,CDM,983,RC,44388,CPT,,,,,,,,620,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,319.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.89,655.83
Debride Bone Ea Add 20 Sqcm,PX11047P,CDM,983,RC,11047,CPT,,,,,,,,351,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,319.761,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,145.8054,341.6283
Debride Tissue/Muscle,PX11043P,CDM,983,RC,11043,CPT,,,,,,,,351,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,319.761,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,145.8054,548.67
Closure Superf Wnd Dehis Simple,PX12020F,CDM,510,RC,12020,CPT,,,,,,,,632,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,319.792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.5328,619.36
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121P,CDM,983,RC,13121,CPT,,,,,,,,632,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,319.792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.5328,615.1256
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801801,NDC,0.8,ML,359.37,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,319.8393,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801810,NDC,0.8,ML,359.37,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,319.8393,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
sugammadex sodium 200 MG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,6542302,NDC,2,ML,652.81,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,319.8769,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sugammadex sodium 200 MG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,6542302,NDC,2,ML,652.81,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,319.8769,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
sugammadex sodium 200 MG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,6542302,NDC,2,ML,652.81,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,319.8769,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004164,NDC,1,EA,666.52,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,319.9296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004164,NDC,1,EA,666.52,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,319.9296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004110,NDC,1,EA,666.53,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,319.9344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004110,NDC,1,EA,666.53,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,319.9344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
umeclidinium-vilanterol 62.5-25 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173086906,NDC,14,EA,745.86,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,319.97394,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Needle Biopsy, Lymph Node(S)",PX38505F,CDM,510,RC,38505,CPT,,,,,,,,667,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,320.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,277.0718,1416.38
"Needle Biopsy, Lymph Node(S)",PX38505F,CDM,510,RC,38505,CPT,,,,,,,,667,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,320.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,277.0718,1416.38
SET CRICOTHYROTOMY CATHETER 3.5MM ID,120.251,CDM,272,RC,,,,4306-MAIN,LOCAL,,,,,363,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,320.166,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.7902,355.74
SET CRICOTHYROTOMY CATHETER 4MM ID,120.251,CDM,272,RC,,,,3452-MAIN,LOCAL,,,,,363,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,320.166,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.7902,355.74
SET CRICOTHYROTOMY CATHETER 6MM ID,120.251,CDM,272,RC,,,,2887-MAIN,LOCAL,,,,,363,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,320.166,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.7902,355.74
Facility Emergency Level 1 Visit,PX99281F,CDM,450,RC,99281,CPT,,,,,,,,329,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,168.53,percent of total billed charges,320.2157,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.56,322.42
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032P,CDM,983,RC,12032,CPT,,,,,,,,647,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,320.265,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,268.7638,629.7251
"Repair Umbilical Hern,5+Y/O,Reduc",PX49585P,CDM,983,RC,49585,CPT,,,,,,,,647,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,320.265,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,268.7638,629.7251
Irradiated Leukoreduced Rbc's,PXP9040,CDM,390,RC,P9040,HCPCS,,,,,,,,771,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,320.2734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,231.5,755.58
Skin Sub Graft Trnk/Arm/Leg,PX15271F,CDM,510,RC,15271,CPT,,,,,,,,862,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,320.3,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.83,320.3
Skin Sub Graft Trnk/Arm/Leg,PX15271P,CDM,983,RC,15271,CPT,,,,,,,,705,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,320.3,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.83,690.9
Closed Rx Mt-Phal Toe Dislocation,PX28630F,CDM,510,RC,28630,CPT,,,,,,,,360,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,320.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.544,352.8
RBC Antibody Elution,PX86860,CDM,300,RC,86860,CPT,,,,,,,,360,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,320.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.22,352.8
Repr Superf Wnd Body 12.6-20,PX12005P,CDM,983,RC,12005,CPT,,,,,,,,377,,First Health,Commercial,both,85,,999999999,percent of total billed charges,320.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,156.6058,366.9341
8MM ENDOWRIST INSTRUMENTS MEGA SUTURE CUT NEEDLE DRIVER,27200000,CDM,272,RC,,,,11914-MAIN,LOCAL,,,,,327,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,320.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Injection Hip Arthrogram,PX27093F,CDM,510,RC,27093,CPT,,,,,,,,654,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,320.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,271.6716,640.92
Injection Hip Arthrogram,PX27093F,CDM,510,RC,27093,CPT,,,,,,,,654,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,320.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,271.6716,640.92
Injection Hip Arthrogram,PX27093F,CDM,510,RC,27093,CPT,,,,,,,,654,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,320.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,271.6716,640.92
"IV Infusion Therapy, 1 Hour",PX96365,CDM,260,RC,96365,CPT,,,,,,,,327,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,320.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.8358,320.46
2.1MM CANNULATED DRILL BIT,27200000,CDM,272,RC,,,,12657-MAIN,LOCAL,,,,,747,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,320.463,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
US Guide Needle Bx S&I,PX7694201,CDM,402,RC,76942,CPT,TC,,,,,,,747,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,320.463,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.3038,732.06
"Fac/Exc Skn Beni1.1-2cm Fce,Facial",PX11442F,CDM,510,RC,11442,CPT,,,,,,,,668,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,320.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,277.4872,654.64
"Fac/Exc Skn Beni1.1-2cm Fce,Facial",PX11442F,CDM,510,RC,11442,CPT,,,,,,,,668,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,320.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,277.4872,654.64
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12173-SURG,LOCAL,,,,,772,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,320.6888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM ENDOWRIST INSTRUMENTS MONOPOLAR CURVED SCISSORS,27200000,CDM,272,RC,,,,11909-MAIN,LOCAL,,,,,648,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,320.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STAPLER INTERNAL ECHELON FLEX POWERED PLUS LONG LENGTH 440MM,27200000,CDM,272,RC,,,,12065-MAIN,LOCAL,,,,,648,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,320.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
gadoterate meglumine 10 mmol/20 mL Solution 20 mL Vial,A9575,CDM,636,RC,A9575,HCPCS,,,,67684200003,NDC,20,ML,668.27,,Health Partners,Health Partners Care Plans,both,48,,2.190876106,percent of total billed charges,320.7696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,277.599358,654.9046
gadoterate meglumine 10 mmol/20 mL Solution 20 mL Vial,A9575,CDM,636,RC,A9575,HCPCS,,,,67684200003,NDC,20,ML,668.27,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,320.7696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,277.599358,654.9046
Drainage Scrotal Wall Abscess,PX55100F,CDM,510,RC,55100,CPT,,,,,,,,634,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,320.804,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,263.3636,1416.38
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035F,CDM,510,RC,12035,CPT,,,,,,,,655,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,320.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,272.087,641.9
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035F,CDM,510,RC,12035,CPT,,,,,,,,655,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,320.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,272.087,641.9
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035F,CDM,510,RC,12035,CPT,,,,,,,,655,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,320.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,272.087,641.9
Cardiac Rehab II Eval,PX93798.05,CDM,943,RC,93798,CPT,,,,,,,,364,,United Healthcare,All Payer,outpatient,88.2,,186.3051282,percent of total billed charges,321.048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.44,495.55
Drain/Inject Large Joint/Bursa,PX20610F,CDM,510,RC,20610,CPT,,,,,,,,364,,United Healthcare,All Payer,outpatient,88.2,,123.860625,percent of total billed charges,321.048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,151.2056,356.72
Xray Forearm 2 Vws,PX7309001,CDM,320,RC,73090,CPT,TC,,,,,,,364,,United Healthcare,All Payer,outpatient,88.2,,207.7,percent of total billed charges,321.048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,356.72
procainamide 500 MG/ML Solution 2 mL Vial,J2690.01,CDM,636,RC,J2690,HCPCS,,,,14789090002,NDC,2,ML,377.75,,First Health,Commercial,both,85,,999999999,percent of total billed charges,321.0875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,134.15,370.195
I&D Deep Absc/Hematoma Neck/Chest,PX21501F,CDM,510,RC,21501,CPT,,,,,,,,773,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,321.1042,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.1042,2482.37
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725P,CDM,983,RC,26725,CPT,,,,,,,,330,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,321.189,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.082,321.189
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101P,CDM,983,RC,13101,CPT,,,,,,,,330,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,321.189,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.082,548.67
"Fac/Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404F,CDM,510,RC,11404,CPT,,,,,,,,749,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,321.321,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,311.1346,1416.38
"Chemotherapy, IV Infusion, Each Add'l Sequential Infusion",PX96417,CDM,335,RC,96417,CPT,,,,,,,,328,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,321.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.54,321.44
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762P,CDM,983,RC,43762,CPT,,,,,,,,328,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,321.44,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.03,467.66
Explor Metatarso-Phalang Jt,PX28022P,CDM,983,RC,28022,CPT,,,,,,,,774,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,321.5196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.5196,2827.75
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132P,CDM,983,RC,13132,CPT,,,,,,,,774,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,321.5196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.5196,753.3342
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231001,NDC,10,ML,649.64,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,321.5718,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231005,NDC,10,ML,649.64,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,321.5718,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
Creatine Mb Fraction,PX82553,CDM,300,RC,82553,CPT,,,,,,,,353,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,321.583,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.59,345.94
Fentanyl - Ref,PX8035490,CDM,300,RC,80354,CPT,90,,,,,,,353,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,321.583,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,345.94
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155F,CDM,370,RC,99155,CPT,,,,,,,,353,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,321.583,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,345.94
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155P,CDM,983,RC,99155,CPT,,,,,,,,353,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,321.583,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,343.5749
Pvb Thoracic Single Injection Site W/Img Gid,PX64461F,CDM,510,RC,64461,CPT,,,,,,,,353,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,321.583,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,604.15
buprenorphine 5 MCG/HR PATCH WEEKLY 4 Each Box,63700001,CDM,250,RC,,,,,,42858075040,NDC,1,EA,330.52,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,321.695116,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Acellular Derm Matrix Implt,PX15777F,CDM,510,RC,15777,CPT,,,,,,,,650,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,321.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.01,637
Closed Rx Bimalleolar Fx,PX27808F,CDM,510,RC,27808,CPT,,,,,,,,650,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,321.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,637
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605P,CDM,983,RC,24605,CPT,,,,,,,,750,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,321.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,311.55,1404.08
"Exc Skn Bngn2.1-3cm Fce,Facial",PX11443P,CDM,983,RC,11443,CPT,,,,,,,,650,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,321.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.01,1416.38
Sigmoidoscope W/Submuc Inj,PX45335F,CDM,750,RC,45335,CPT,,,,,,,,750,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,321.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,311.55,798.45
INSTRUMENT PACKAGE TOEMATE,27200000,CDM,272,RC,,,,11858-MAIN,LOCAL,,,,,636,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,321.816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSTRUMENT TOEMATE X-SMALL PACKAGE 9H00-T060,27200000,CDM,272,RC,C1713,HCPCS,,11575-MAIN,LOCAL,,,,,636,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,321.816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"2019-Ncov Coronavirus, Sars-Cov-2/2019-Ncov (Covid-19)",PXU000290,CDM,300,RC,U0002,HCPCS,90,,,,,,,365,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,321.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,357.7
"Closed Rx Spont Hip Disloc,Anesth",PX27257P,CDM,983,RC,27257,CPT,,,,,,,,365,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,321.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,151.621,1404.08
Insert Emergency Endotrach Airway,PX31500P,CDM,983,RC,31500,CPT,,,,,,,,657,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1101.39625,percent of total billed charges,321.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,639.4581
Insert Emergency Endotrach Airway,PX31500P,CDM,983,RC,31500,CPT,,,,,,,,657,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,321.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,639.4581
Insert Emergency Endotrach Airway,PX31500P,CDM,983,RC,31500,CPT,,,,,,,,657,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,321.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,639.4581
Sars-Cov-2 Covid-19 Amp Prb,PX8763590,CDM,300,RC,87635,CPT,90,,,,,,,365,,United Healthcare,All Payer,outpatient,88.2,,127.9755556,percent of total billed charges,321.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,357.7
X-Ray Exam Femur Min 2 Vws,PX7355201,CDM,320,RC,73552,CPT,TC,,,,,,,365,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,321.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Ankle Minimum 3 Vws,PX7361001,CDM,320,RC,73610,CPT,TC,,,,,,,365,,United Healthcare,All Payer,outpatient,88.2,,204.1066667,percent of total billed charges,321.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Calcaneus Minimum 2 Vws,PX7365001,CDM,320,RC,73650,CPT,TC,,,,,,,365,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,321.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Clavicle Complete,PX7300001,CDM,320,RC,73000,CPT,TC,,,,,,,365,,United Healthcare,All Payer,outpatient,88.2,,640,percent of total billed charges,321.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Elbow 2 Vws,PX7307001,CDM,320,RC,73070,CPT,TC,,,,,,,365,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,321.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Hand 2vws Tc,PX7312001,CDM,320,RC,73120,CPT,TC,,,,,,,365,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,321.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,357.7
Xray Humerus Minimum 2 Vws,PX7306001,CDM,320,RC,73060,CPT,TC,,,,,,,365,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,321.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Shoulder Minimum 2 Vws,PX7303001,CDM,320,RC,73030,CPT,TC,,,,,,,365,,United Healthcare,All Payer,outpatient,88.2,,184.8911111,percent of total billed charges,321.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Sternum 2vws Tc,PX7112001,CDM,320,RC,71120,CPT,TC,,,,,,,365,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,321.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Tibia & Fibula 2 Vws,PX7359001,CDM,320,RC,73590,CPT,TC,,,,,,,365,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,321.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Wrist 2 Vws,PX7310001,CDM,320,RC,73100,CPT,TC,,,,,,,365,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,321.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Room Rate Transitional Care Private,PX11900000,CDM,119,RC,,,,,,,,,,775,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,321.935,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.935,759.5
fosfomycin 3 g Packet 1 Each Box,25000000,CDM,250,RC,,,,,,70700026894,NDC,1,EA,353.41,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,321.95651,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Close Rx Fingr Articular Fx,Manip",PX26742F,CDM,510,RC,26742,CPT,,,,,,,,1039,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,322.0633,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,216.18,805.95
"Close Rx Fingr Articular Fx,Manip",PX26742P,CDM,983,RC,26742,CPT,,,,,,,,560,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,322.0633,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,216.18,805.95
"Tech-Cytopath Eval, Fna, Rep",PX8817301,CDM,310,RC,88173,CPT,TC,,,,,,,379,,First Health,Commercial,both,85,,999999999,percent of total billed charges,322.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,371.42
US Pregnancy Tc Follow-Up,PX7681601,CDM,402,RC,76816,CPT,TC,,,,,,,362,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,322.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,354.76
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505F,CDM,510,RC,25505,CPT,,,,,,,,651,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,322.245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.4254,1404.08
Remove Foreign Body Complic,PX10121P,CDM,983,RC,10121,CPT,,,,,,,,651,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,322.245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.4254,1416.38
Insert Emergency Endotrach Airway,PX31500F,CDM,510,RC,31500,CPT,,,,,,,,637,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,322.322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,624.26
"Layr Clos Wnd Face,Facial 2.5-5",PX12052P,CDM,983,RC,12052,CPT,,,,,,,,776,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,322.3504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,322.3504,755.2808
Drainage of Gum Lesion,PX41800F,CDM,510,RC,41800,CPT,,,,,,,,395,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,322.38,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.82,606.02
Drainage of Gum Lesion,PX41800P,CDM,983,RC,41800,CPT,,,,,,,,839,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,322.38,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.82,822.22
"Exc Skn Mal 0.6-1cm Fce,Facial",PX11641P,CDM,983,RC,11641,CPT,,,,,,,,453,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,322.38,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97.51,493.95
"Fac/Exc Skn Mal 0.6-1cm Fce,Facial",PX11641F,CDM,510,RC,11641,CPT,,,,,,,,680,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,322.38,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97.51,493.95
Facility Emergency Level 1 Visit,PX99281F,CDM,450,RC,99281,CPT,,,,,,,,329,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,322.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.56,322.42
perflutren lipid microsphere 6.52 MG/ML Suspension 2 mL Vial,Q9957,CDM,636,RC,Q9957,HCPCS,,,,11994001101,NDC,2,ML,751.71,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,322.48359,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,312.260334,736.6758
Xray Sinuses Minimum 3 Vws,PX7022001,CDM,320,RC,70220,CPT,TC,,,,,,,354,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,322.494,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,346.92
"Molecular Path Proc, Level 2 - Ref",PX8140190,CDM,310,RC,81401,CPT,90,,,,,,,672,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,322.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.62,658.56
"Molecular Path Proc, Level 2 - Ref",PX8140190,CDM,310,RC,81401,CPT,90,,,,,,,672,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,322.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.62,658.56
"rabies vaccine, pcec Recon Susp 1 Each Vial",90675,CDM,636,RC,90675,CPT,,,,58160096412,NDC,1,EA,1544.83,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,322.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,285.77,324.74
"rabies vaccine, pcec Recon Susp 1 Each Vial",90675,CDM,636,RC,90675,CPT,,,,58160096412,NDC,1,EA,1544.83,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,322.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,285.77,324.74
Layr Clos Wnd Rest Body 2.6-7.5,PX12042P,CDM,983,RC,12042,CPT,,,,,,,,777,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,322.7658,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,322.7658,756.2541
Dress/Debrid Med Burn No Anesth,PX16025F,CDM,510,RC,16025,CPT,,,,,,,,366,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,322.812,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,152.0364,358.68
"Insert Needle,Intraosseous Infusn",PX36680F,CDM,510,RC,36680,CPT,,,,,,,,659,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,541.93,percent of total billed charges,322.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,273.7486,645.82
"Insert Needle,Intraosseous Infusn",PX36680F,CDM,510,RC,36680,CPT,,,,,,,,659,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,322.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,273.7486,645.82
"Insert Needle,Intraosseous Infusn",PX36680F,CDM,510,RC,36680,CPT,,,,,,,,659,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,322.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,273.7486,645.82
"Office/Outpt Visit,New,Levl V",PX99205F,CDM,510,RC,99205,CPT,,,,,,,,456,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,322.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.82,395.88
"Office/Outpt Visit,New,Levl V",PX99205P,CDM,983,RC,99205,CPT,,,,,,,,456,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,322.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.82,446.88
dexAMETHasone 0.1 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,24208072002,NDC,5,ML,331.81,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,322.950673,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
oseltamivir 6 MG/ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,4082205,NDC,60,ML,752.82,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,322.95978,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Closed Rx Elbow Dislocation,PX24600P,CDM,983,RC,24600,CPT,,,,,,,,380,,First Health,Commercial,both,85,,999999999,percent of total billed charges,323,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,157.852,369.854
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,45963061959,NDC,1,EA,638.4,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,323.0304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
Exc Neck Les Sc = 3cm >,PX21552F,CDM,510,RC,21552,CPT,,,,,,,,753,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,323.037,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,312.7962,2482.37
"Fac/Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601F,CDM,510,RC,11601,CPT,,,,,,,,673,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,323.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,279.5642,659.54
"Fac/Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601F,CDM,510,RC,11601,CPT,,,,,,,,673,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,323.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,279.5642,659.54
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106F,CDM,510,RC,11106,CPT,,,,,,,,255,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,323.07,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.68,323.07
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106P,CDM,983,RC,11106,CPT,,,,,,,,204,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,323.07,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.68,323.07
SET CRICOTHYROTOMY CATHETER 3.5MM ID,120.251,CDM,272,RC,,,,4306-MAIN,LOCAL,,,,,363,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,323.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.7902,355.74
SET CRICOTHYROTOMY CATHETER 4MM ID,120.251,CDM,272,RC,,,,3452-MAIN,LOCAL,,,,,363,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,323.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.7902,355.74
SET CRICOTHYROTOMY CATHETER 6MM ID,120.251,CDM,272,RC,,,,2887-MAIN,LOCAL,,,,,363,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,323.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.7902,355.74
sugammadex sodium 200 MG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,6542302,NDC,2,ML,652.81,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,323.14095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
insulin aspart 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169633910,NDC,3,ML,659.76,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,3.1136,percent of total billed charges,323.2824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
insulin aspart 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169633910,NDC,3,ML,659.76,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,323.2824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
insulin aspart 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169633910,NDC,3,ML,659.76,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,323.2824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725P,CDM,983,RC,26725,CPT,,,,,,,,330,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,323.4,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,196.55,740.92
"Incis/Drain Scrotum/Testis,Epididym",PX54700F,CDM,510,RC,54700,CPT,,,,,,,,660,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,323.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.164,1779.39
"Incis/Drain Scrotum/Testis,Epididym",PX54700F,CDM,510,RC,54700,CPT,,,,,,,,660,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,323.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.164,1779.39
"Incis/Drain Scrotum/Testis,Epididym",PX54700F,CDM,510,RC,54700,CPT,,,,,,,,660,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,323.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.164,1779.39
Repair Incis Hernia W Mesh,PX49568P,CDM,983,RC,49568,CPT,,,,,,,,660,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,323.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.164,642.378
Repair Incis Hernia W Mesh,PX49568P,CDM,983,RC,49568,CPT,,,,,,,,660,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,323.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.164,642.378
Repair Incis Hernia W Mesh,PX49568P,CDM,983,RC,49568,CPT,,,,,,,,660,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,323.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.164,642.378
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101P,CDM,983,RC,13101,CPT,,,,,,,,330,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,323.4,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.32,823.93
linezolid 600 MG/300ML Solution 300 mL Flex Cont,J2020.01,CDM,636,RC,J2020,HCPCS,,,,9514001,NDC,300,ML,332.42,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,323.544386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.087268,325.7716
Xray Foot 2 Vws,PX7362001,CDM,320,RC,73620,CPT,TC,,,,,,,367,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,323.694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,359.66
Injection Hip Arthrogram,PX27093F,CDM,510,RC,27093,CPT,,,,,,,,654,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,323.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,271.6716,640.92
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016425,NDC,1,ML,779.43,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,323.775222,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.66,898.7384
"Xray Mandible Compl, Min 4 Vws",PX7011001,CDM,320,RC,70110,CPT,TC,,,,,,,381,,First Health,Commercial,both,85,,999999999,percent of total billed charges,323.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,373.38
"HERNIA MESH 3D MAX MID ANATOMICAL MESH LEFT SIZE L 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,11976-MAIN,LOCAL,,,,,755,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,323.895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"HERNIA MESH 3D MAX MID ANATOMICAL MESH RIGHT SIZE L 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,11977-MAIN,LOCAL,,,,,755,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,323.895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
buprenorphine 5 MCG/HR PATCH WEEKLY 4 Each Box,63700001,CDM,250,RC,,,,,,42858075040,NDC,1,EA,330.52,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,323.9096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Cardiac Rehab II Eval,PX93798.05,CDM,943,RC,93798,CPT,,,,,,,,364,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,323.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.44,495.55
Drain/Inject Large Joint/Bursa,PX20610F,CDM,510,RC,20610,CPT,,,,,,,,364,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,323.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,151.2056,356.72
Xray Forearm 2 Vws,PX7309001,CDM,320,RC,73090,CPT,TC,,,,,,,364,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,323.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,356.72
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,517096001,NDC,10,ML,355.63,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,323.97893,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Injection for Shoulder Arthrogram,PX23350F,CDM,510,RC,23350,CPT,,,,,,,,675,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,280.395,661.5
Injection for Shoulder Arthrogram,PX23350F,CDM,510,RC,23350,CPT,,,,,,,,675,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,280.395,661.5
"Amputation Toe,I-P Jt",PX28825P,CDM,983,RC,28825,CPT,,,,,,,,780,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,324.012,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,324.012,2827.75
"Fna Biopsy, W/US Guidance; First Lesion",PX10005F,CDM,510,RC,10005,CPT,,,,,,,,333,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,266.4,percent of total billed charges,324.1089,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.3282,614.65
Ultrasound Breast Complete,PX7664101,CDM,402,RC,76641,CPT,TC,,,,,,,333,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,324.1089,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,326.34
"Office/Outpt Visit,Est,Levl V",PX99215F,CDM,510,RC,99215,CPT,,,,,,,,318,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,324.12,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,89.69,324.12
"Office/Outpt Visit,Est,Levl V",PX99215P,CDM,983,RC,99215,CPT,,,,,,,,318,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,324.12,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,89.69,324.12
"Correct Bunion,Metatarsal Osteotomy",PX28296F,CDM,510,RC,28296,CPT,,,,,,,,8100,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,324.17,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,324.17,1834.65
"Correct Bunion,Metatarsal Osteotomy",PX28296P,CDM,983,RC,28296,CPT,,,,,,,,2150,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,324.17,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,324.17,2107
"Polysomnography, 4 or More",PX9581001,CDM,740,RC,95810,CPT,TC,,,,,,,4313,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,324.17,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,324.17,887.09
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035F,CDM,510,RC,12035,CPT,,,,,,,,655,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,324.225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,272.087,641.9
"measles, mumps & rubella vaccine Recon Soln 1 Each Vial",90707,CDM,636,RC,90707,CPT,,,,6468100,NDC,1,EA,381.47,,First Health,Commercial,both,85,,999999999,percent of total billed charges,324.2495,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,158.462638,373.8406
Fluoroscopy Guid Needle Plcmt Tc,PX7700201,CDM,320,RC,77002,CPT,TC,,,,,,,662,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,131.6,percent of total billed charges,324.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.9948,648.76
Fluoroscopy Guid Needle Plcmt Tc,PX7700201,CDM,320,RC,77002,CPT,TC,,,,,,,662,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,324.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.9948,648.76
Fluoroscopy Guid Needle Plcmt Tc,PX7700201,CDM,320,RC,77002,CPT,TC,,,,,,,662,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,324.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.9948,648.76
Direct Admit Hospital Observ,PXG0379,CDM,761,RC,G0379,HCPCS,,,,,,,,676,,Health Partners,Health Partners Care Plans,both,48,,622.93,percent of total billed charges,324.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,280.8104,662.48
Direct Admit Hospital Observ,PXG0379,CDM,761,RC,G0379,HCPCS,,,,,,,,676,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,324.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,280.8104,662.48
SCOPE ASCOPE4 CYSTO STERILE 601001000,120.497,CDM,272,RC,A4649,HCPCS,,11662-MAIN,LOCAL,,,,,368,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,324.576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,152.8672,360.64
oseltamivir 6 MG/ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,68180067801,NDC,60,ML,676.25,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,324.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 6 MG/ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,68180067801,NDC,60,ML,676.25,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,324.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"X-Ray Exam Hip,Bilat W/Pelvis 3-4 Vws",PX7352201,CDM,320,RC,73522,CPT,TC,,,,,,,382,,First Health,Commercial,both,85,,999999999,percent of total billed charges,324.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,374.36
"rabies vaccine, pcec Recon Susp 1 Each Vial",90675,CDM,636,RC,90675,CPT,,,,58160096412,NDC,1,EA,1544.83,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,324.74,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,285.77,324.74
CT Angio Upr Extrm W/O&W/Dye,PX7320601,CDM,350,RC,73206,CPT,TC,,,,,,,757,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,324.753,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
"Inject Nerv Blck,Othr Periph Nerv",PX64450F,CDM,510,RC,64450,CPT,,,,,,,,757,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,324.753,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,314.4578,741.86
prednisoLONE acetate 0.12 % Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,11980017405,NDC,5,ML,757.07,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,324.78303,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"2019-Ncov Coronavirus, Sars-Cov-2/2019-Ncov (Covid-19)",PXU000290,CDM,300,RC,U0002,HCPCS,90,,,,,,,365,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,324.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,357.7
"Closed Rx Spont Hip Disloc,Anesth",PX27257P,CDM,983,RC,27257,CPT,,,,,,,,365,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,324.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,151.621,1404.08
Sars-Cov-2 Covid-19 Amp Prb,PX8763590,CDM,300,RC,87635,CPT,90,,,,,,,365,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,324.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,357.7
X-Ray Exam Femur Min 2 Vws,PX7355201,CDM,320,RC,73552,CPT,TC,,,,,,,365,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,324.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Ankle Minimum 3 Vws,PX7361001,CDM,320,RC,73610,CPT,TC,,,,,,,365,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,324.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Calcaneus Minimum 2 Vws,PX7365001,CDM,320,RC,73650,CPT,TC,,,,,,,365,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,324.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Clavicle Complete,PX7300001,CDM,320,RC,73000,CPT,TC,,,,,,,365,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,324.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Elbow 2 Vws,PX7307001,CDM,320,RC,73070,CPT,TC,,,,,,,365,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,324.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Hand 2vws Tc,PX7312001,CDM,320,RC,73120,CPT,TC,,,,,,,365,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,324.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,357.7
Xray Humerus Minimum 2 Vws,PX7306001,CDM,320,RC,73060,CPT,TC,,,,,,,365,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,324.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Shoulder Minimum 2 Vws,PX7303001,CDM,320,RC,73030,CPT,TC,,,,,,,365,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,324.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Sternum 2vws Tc,PX7112001,CDM,320,RC,71120,CPT,TC,,,,,,,365,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,324.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Tibia & Fibula 2 Vws,PX7359001,CDM,320,RC,73590,CPT,TC,,,,,,,365,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,324.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Wrist 2 Vws,PX7310001,CDM,320,RC,73100,CPT,TC,,,,,,,365,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,324.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
cadexomer iodine 0.9 % Gel 40 g Tube,63700001,CDM,250,RC,,,,,,40565012249,NDC,40,GR,333.86,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,324.945938,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Clotting Function Activity - Ref,PX8539790,CDM,300,RC,85397,CPT,90,,,,,,,334,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,325.0822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.3,327.32
"Remv F.B.,Eye,Cornea,No Slit",PX65220F,CDM,510,RC,65220,CPT,,,,,,,,334,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,325.0822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.7436,348.08
Repeat Control of Nosebleed,PX30906F,CDM,510,RC,30906,CPT,,,,,,,,334,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,325.0822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.7436,327.32
X-Ray Abdomen 2+ Views W/ Single Vw Chest (Tc),PX7402201,CDM,320,RC,74022,CPT,TC,,,,,,,334,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,325.0822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,327.32
"Ctrl Nosebleed,Anter,Simple",PX30901F,CDM,510,RC,30901,CPT,,,,,,,,342,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,325.15,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.03,325.15
"Ctrl Nosebleed,Anter,Simple",PX30901P,CDM,983,RC,30901,CPT,,,,,,,,229,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,325.15,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.03,325.15
dexAMETHasone 0.1 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,24208072002,NDC,5,ML,331.81,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,325.1738,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Insert Emergency Endotrach Airway,PX31500P,CDM,983,RC,31500,CPT,,,,,,,,657,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,325.215,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,639.4581
Remove Intrauterine Device,PX58301,CDM,983,RC,58301,CPT,,,,,,,,357,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,325.227,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.2978,347.4681
X-Ray Exam Chest 1 View,PX7104501,CDM,320,RC,71045,CPT,TC,,,,,,,357,,Medica,Commercial,both,91.1,,63.17458333,percent of total billed charges,325.227,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,349.86
"Xray Chest 1 View, Tc",PX7101001,CDM,320,RC,71010,CPT,TC,,,,,,,357,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,325.227,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.2978,349.86
Xray Scapula Complete,PX7301001,CDM,320,RC,73010,CPT,TC,,,,,,,357,,Medica,Commercial,both,91.1,,238.09,percent of total billed charges,325.227,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,349.86
PERFIX PLUG STERILE X-LARGE,C1781,CDM,278,RC,C1781,HCPCS,,11772-MAIN,LOCAL,,,,,643,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,325.358,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Xray Cervical Spine 4 or 5 Vws,PX7205001,CDM,320,RC,72050,CPT,TC,,,,,,,664,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,325.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,650.72
Xray Cervical Spine 4 or 5 Vws,PX7205001,CDM,320,RC,72050,CPT,TC,,,,,,,664,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,325.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,650.72
Xray Cervical Spine 4 or 5 Vws,PX7205001,CDM,320,RC,72050,CPT,TC,,,,,,,664,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,325.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,650.72
Xray Cervical Spine 6 or More Vws,PX7205201,CDM,320,RC,72052,CPT,TC,,,,,,,664,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,325.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,650.72
Xray Cervical Spine 6 or More Vws,PX7205201,CDM,320,RC,72052,CPT,TC,,,,,,,664,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,325.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,650.72
Xray Cervical Spine 6 or More Vws,PX7205201,CDM,320,RC,72052,CPT,TC,,,,,,,664,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,325.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,650.72
Temporary External Pacing,PX92953F,CDM,480,RC,92953,CPT,,,,,,,,678,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,325.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,281.6412,664.44
Temporary External Pacing,PX92953F,CDM,480,RC,92953,CPT,,,,,,,,678,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,325.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,281.6412,664.44
El-1 Fecal Quantitative,PX8265390,CDM,300,RC,82653,CPT,90,,,,,,,383,,First Health,Commercial,both,85,,999999999,percent of total billed charges,325.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.0982,375.34
Abd Duplex Abd -Follow Up,PX9397602,CDM,921,RC,93976,CPT,TC,,,,,,,784,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,325.6736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,768.32
Art Lower Extremity+Upper,PX9392301,CDM,921,RC,93923,CPT,TC,,,,,,,784,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,325.6736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.46,768.32
Dress/Debrid Med Burn No Anesth,PX16025F,CDM,510,RC,16025,CPT,,,,,,,,366,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,325.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,152.0364,358.68
linezolid 600 MG/300ML Solution 300 mL Flex Cont,J2020.01,CDM,636,RC,J2020,HCPCS,,,,9514001,NDC,300,ML,332.42,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,325.7716,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.087268,325.7716
"Ex Sknbngn0.6-1cmtrnk,Arm,Lg",PX11401P,CDM,983,RC,11401,CPT,,,,,,,,387,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,325.84,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.19,379.26
"Fac/Ex Skinbngn0.6-1cmtrnk,Arm,Lg",PX11401F,CDM,510,RC,11401,CPT,,,,,,,,484,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,325.84,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.19,325.84
pentafluoroprop - tetrafluoroeth Aerosol 116 mL Can,63700001,CDM,250,RC,,,,,,386000802,NDC,207,ML,383.42,,First Health,Commercial,both,85,,999999999,percent of total billed charges,325.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Closed Rx Elbow Dislocation,PX24600F,CDM,510,RC,24600,CPT,,,,,,,,706,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,325.9165,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,218.15,814.94
Closed Rx Elbow Dislocation,PX24600P,CDM,983,RC,24600,CPT,,,,,,,,380,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,325.9165,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,218.15,814.94
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605F,CDM,510,RC,25605,CPT,,,,,,,,1178,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,325.92,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,325.92,1160.15
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605P,CDM,983,RC,25605,CPT,,,,,,,,785,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,325.92,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,325.92,1160.15
"Fac/Ex Skn Bngn2.1-3cm Trnk,Arm,Lg",PX11403F,CDM,510,RC,11403,CPT,,,,,,,,679,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,325.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,282.0566,665.42
"Fac/Ex Skn Bngn2.1-3cm Trnk,Arm,Lg",PX11403F,CDM,510,RC,11403,CPT,,,,,,,,679,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,325.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,282.0566,665.42
tiotropium 18 MCG capsule 5 Each Box,63700001,CDM,250,RC,,,,,,597007575,NDC,5,EA,665.18,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,325.9382,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tiotropium 18 MCG capsule 5 Each Box,63700001,CDM,250,RC,,,,,,597007575,NDC,5,EA,665.18,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,325.9382,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tiotropium 18 MCG capsule 5 Each Box,63700001,CDM,250,RC,,,,,,597007575,NDC,5,EA,665.18,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,325.9382,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"US Guide, Vascular Access",PX7693701,CDM,402,RC,76937,CPT,TC,,,,,,,760,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,326.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,315.704,744.8
"Close Rx Dist Fingr Fx,Manipulatn",PX26755F,CDM,510,RC,26755,CPT,,,,,,,,335,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,326.0555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
"Closed Rx I-P Jt,Toe Dislocation",PX28660F,CDM,510,RC,28660,CPT,,,,,,,,335,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,326.0555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Insitu Hybridization (Fish),PX8836401,CDM,310,RC,88364,CPT,TC,,,,,,,335,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,326.0555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Reduce Temporomandibl Disloc,PX21480F,CDM,510,RC,21480,CPT,,,,,,,,335,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,326.0555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Repr Superf Wnd Face <2.5cm,PX12011F,CDM,510,RC,12011,CPT,,,,,,,,335,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,263.4025,percent of total billed charges,326.0555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070102,NDC,1,ML,383.6,,First Health,Commercial,both,85,,999999999,percent of total billed charges,326.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.92,450.751
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605P,CDM,983,RC,25605,CPT,,,,,,,,785,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,326.089,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,326.089,1404.08
Layr Clos Wnd Rest Body 7.6-12.5,PX12044F,CDM,510,RC,12044,CPT,,,,,,,,785,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,326.089,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,326.089,769.3
Declot Vascular Access Device,PX36593F,CDM,510,RC,36593,CPT,,,,,,,,358,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,326.138,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.7132,350.84
Fac/Irrigation of Bladder,PX51700F,CDM,510,RC,51700,CPT,,,,,,,,358,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,326.138,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.7132,350.84
X-Ray Exam Abdomen 1 View,PX7401801,CDM,320,RC,74018,CPT,TC,,,,,,,358,,Medica,Commercial,both,91.1,,56.55,percent of total billed charges,326.138,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,350.84
Xray Abdomen Single Ap Vw,PX7400001,CDM,320,RC,74000,CPT,TC,,,,,,,358,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,326.138,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.7132,350.84
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310001,NDC,0.528,ML,785.14,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,326.147156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.22,877.002
"Insert Needle,Intraosseous Infusn",PX36680F,CDM,510,RC,36680,CPT,,,,,,,,659,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,326.205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,273.7486,645.82
Acetaminophen,PX80307E,CDM,300,RC,80307,CPT,,,,,,,,370,,United Healthcare,All Payer,outpatient,88.2,,362.16,percent of total billed charges,326.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Alcohol,PX80307A,CDM,300,RC,80307,CPT,,,,,,,,370,,United Healthcare,All Payer,outpatient,88.2,,362.16,percent of total billed charges,326.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
"Fna Biopsy, W/US Guidance; First Lesion",PX10005F,CDM,510,RC,10005,CPT,,,,,,,,333,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,326.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.3282,614.65
Salicylate,PX80307D,CDM,300,RC,80307,CPT,,,,,,,,370,,United Healthcare,All Payer,outpatient,88.2,,362.16,percent of total billed charges,326.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Ultrasound Breast Complete,PX7664101,CDM,402,RC,76641,CPT,TC,,,,,,,333,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,326.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,326.34
Urine Drug Screen,PX80307B,CDM,300,RC,80307,CPT,,,,,,,,370,,United Healthcare,All Payer,outpatient,88.2,,362.16,percent of total billed charges,326.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Xray Elbow 3+Vws Tc,PX7308001,CDM,320,RC,73080,CPT,TC,,,,,,,370,,United Healthcare,All Payer,outpatient,88.2,,181.3,percent of total billed charges,326.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,362.6
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010202,NDC,1,EA,680,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,326.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010202,NDC,1,EA,680,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,326.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 1 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010101,NDC,1,EA,680,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,326.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 1 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010101,NDC,1,EA,680,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,326.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010102,NDC,1,EA,680,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,326.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010102,NDC,1,EA,680,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,326.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
"Fac/Exc Skn Mal 0.6-1cm Fce,Facial",PX11641F,CDM,510,RC,11641,CPT,,,,,,,,680,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,326.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,282.472,666.4
"Fac/Exc Skn Mal 0.6-1cm Fce,Facial",PX11641F,CDM,510,RC,11641,CPT,,,,,,,,680,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,326.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,282.472,666.4
Lvl 3 Sub Hosp High Mdm or 50 Minutes,PX99233,CDM,982,RC,99233,CPT,,,,,,,,384,,First Health,Commercial,both,85,,999999999,percent of total billed charges,326.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.5136,373.7472
Observation Initial,PXG0378.03,CDM,762,RC,G0378,HCPCS,,,,,,,,680,,Health Partners,Health Partners Care Plans,both,48,,31.46803468,percent of total billed charges,326.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,282.472,666.4
Observation Initial,PXG0378.03,CDM,762,RC,G0378,HCPCS,,,,,,,,680,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,326.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,282.472,666.4
"Bone Marrow Aspiration(S),Diag",PX38220F,CDM,510,RC,38220,CPT,,,,,,,,305,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,326.53,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.1,326.53
"Bone Marrow Aspiration(S),Diag",PX38220P,CDM,983,RC,38220,CPT,,,,,,,,244,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,326.53,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.1,326.53
nystatin 100000 UNIT/GM Powder 60 g Bottle,63700001,CDM,250,RC,,,,,,68308015260,NDC,60,GR,335.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,326.54215,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
insulin aspart 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169633910,NDC,3,ML,659.76,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,326.5812,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004164,NDC,1,EA,666.52,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,66.655,percent of total billed charges,326.5948,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004164,NDC,1,EA,666.52,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,326.5948,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004164,NDC,1,EA,666.52,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,326.5948,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004110,NDC,1,EA,666.53,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,66.655,percent of total billed charges,326.5997,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004110,NDC,1,EA,666.53,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,326.5997,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004110,NDC,1,EA,666.53,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,326.5997,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
Xray Foot 2 Vws,PX7362001,CDM,320,RC,73620,CPT,TC,,,,,,,367,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,326.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,359.66
Baloxavir Marboxil(40 MG Dose) 2 x 20 MG tablet therapy pack 2 Each Box,800000,CDM,,,,,,,,50242082802,NDC,1,EA,384.3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,326.655,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
"Incis/Drain Scrotum/Testis,Epididym",PX54700F,CDM,510,RC,54700,CPT,,,,,,,,660,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,326.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.164,1779.39
Repair Incis Hernia W Mesh,PX49568P,CDM,983,RC,49568,CPT,,,,,,,,660,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,326.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.164,642.378
"Mra, Head W/Out Contrast",PX7054401,CDM,610,RC,70544,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,326.73,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.6,326.73
"Mra, Head W/Out Contrast",PX7054401,CDM,610,RC,70544,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,326.73,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.6,326.73
"Needle Biopsy, Lymph Node(S)",PX38505F,CDM,510,RC,38505,CPT,,,,,,,,667,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,133.4,percent of total billed charges,326.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,277.0718,1416.38
"Needle Biopsy, Lymph Node(S)",PX38505F,CDM,510,RC,38505,CPT,,,,,,,,667,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,326.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,277.0718,1416.38
"Needle Biopsy, Lymph Node(S)",PX38505F,CDM,510,RC,38505,CPT,,,,,,,,667,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,326.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,277.0718,1416.38
Assay of Phenytoin Total,PX80185,CDM,300,RC,80185,CPT,,,,,,,,336,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,327.0288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,329.28
"Office/Outpt Visit,New,Levl IV",PX99204F,CDM,510,RC,99204,CPT,,,,,,,,359,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,327.049,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.1286,351.82
"Office/Outpt Visit,New,Levl IV",PX99204P,CDM,983,RC,99204,CPT,,,,,,,,359,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,327.049,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.1286,349.4147
cadexomer iodine 0.9 % Gel 40 g Tube,63700001,CDM,250,RC,,,,,,40565012249,NDC,40,GR,333.86,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,327.1828,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Hemorrhoidectomy,Int/Ext,Simple",PX46255F,CDM,510,RC,46255,CPT,,,,,,,,1627,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,327.2009,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,221.21,1082.67
"Hemorrhoidectomy,Int/Ext,Simple",PX46255P,CDM,983,RC,46255,CPT,,,,,,,,2393,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,327.2009,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,221.21,2345.14
Closed Rx Mt-Phal Toe Dislocation,PX28630F,CDM,510,RC,28630,CPT,,,,,,,,360,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,327.22,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.93,327.22
Closed Rx Mt-Phal Toe Dislocation,PX28630P,CDM,983,RC,28630,CPT,,,,,,,,248,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,327.22,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.93,327.22
Apply Long Arm Splint,PX29105P,CDM,983,RC,29105,CPT,,,,,,,,385,,First Health,Commercial,both,85,,999999999,percent of total billed charges,327.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.65,374.7205
Apply Long Leg Splint,PX29505P,CDM,983,RC,29505,CPT,,,,,,,,385,,First Health,Commercial,both,85,,999999999,percent of total billed charges,327.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.65,374.7205
Injection for Nerve Block,PX64445F,CDM,510,RC,64445,CPT,,,,,,,,385,,First Health,Commercial,both,85,,999999999,percent of total billed charges,327.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,604.15
Injection for Nerve Block,PX64445P,CDM,983,RC,64445,CPT,,,,,,,,385,,First Health,Commercial,both,85,,999999999,percent of total billed charges,327.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,604.15
MICA DEPTH GAUGE 150MM STERILE MICA,27200000,CDM,272,RC,,,,12439-MAIN,LOCAL,,,,,385,,First Health,Commercial,both,85,,999999999,percent of total billed charges,327.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"N Block Inj, Plantar Digit",PX64455F,CDM,510,RC,64455,CPT,,,,,,,,385,,First Health,Commercial,both,85,,999999999,percent of total billed charges,327.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,377.3
"N Block Inj, Plantar Digit",PX64455P,CDM,983,RC,64455,CPT,,,,,,,,385,,First Health,Commercial,both,85,,999999999,percent of total billed charges,327.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,374.7205
Xray Temporomandib Jnt Unilat,PX7032801,CDM,320,RC,70328,CPT,TC,,,,,,,385,,First Health,Commercial,both,85,,999999999,percent of total billed charges,327.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,377.3
Clotting Function Activity - Ref,PX8539790,CDM,300,RC,85397,CPT,90,,,,,,,334,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,327.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.3,327.32
"Fac/Exc Skn Beni1.1-2cm Fce,Facial",PX11442F,CDM,510,RC,11442,CPT,,,,,,,,668,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,327.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,277.4872,654.64
"Fac/Exc Skn Beni1.1-2cm Fce,Facial",PX11442F,CDM,510,RC,11442,CPT,,,,,,,,668,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,327.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,277.4872,654.64
"Fac/Exc Skn Beni1.1-2cm Fce,Facial",PX11442F,CDM,510,RC,11442,CPT,,,,,,,,668,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,327.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,277.4872,654.64
"Remv F.B.,Eye,Cornea,No Slit",PX65220F,CDM,510,RC,65220,CPT,,,,,,,,334,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,327.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.7436,348.08
Repeat Control of Nosebleed,PX30906F,CDM,510,RC,30906,CPT,,,,,,,,334,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,327.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.7436,327.32
X-Ray Abdomen 2+ Views W/ Single Vw Chest (Tc),PX7402201,CDM,320,RC,74022,CPT,TC,,,,,,,334,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,327.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,327.32
Biopsy of Rectum,PX45100F,CDM,510,RC,45100,CPT,,,,,,,,763,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,327.327,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,316.9502,2452.93
Abd Duplex Abd-Full,PX9397501,CDM,921,RC,93975,CPT,TC,,,,,,,788,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,327.3352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,772.24
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122F,CDM,510,RC,13122,CPT,,,,,,,,788,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,327.3352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,327.3352,772.24
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032P,CDM,983,RC,12032,CPT,,,,,,,,647,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,327.382,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,268.7638,629.7251
"Repair Umbilical Hern,5+Y/O,Reduc",PX49585P,CDM,983,RC,49585,CPT,,,,,,,,647,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,327.382,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,268.7638,629.7251
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801801,NDC,0.8,ML,359.37,,Medica,Commercial,both,91.1,,7.8,percent of total billed charges,327.38607,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801810,NDC,0.8,ML,359.37,,Medica,Commercial,both,91.1,,7.8,percent of total billed charges,327.38607,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
gadoterate meglumine 10 mmol/20 mL Solution 20 mL Vial,A9575,CDM,636,RC,A9575,HCPCS,,,,67684200003,NDC,20,ML,668.27,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.892636029,percent of total billed charges,327.4523,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,277.599358,654.9046
gadoterate meglumine 10 mmol/20 mL Solution 20 mL Vial,A9575,CDM,636,RC,A9575,HCPCS,,,,67684200003,NDC,20,ML,668.27,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,327.4523,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,277.599358,654.9046
gadoterate meglumine 10 mmol/20 mL Solution 20 mL Vial,A9575,CDM,636,RC,A9575,HCPCS,,,,67684200003,NDC,20,ML,668.27,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,327.4523,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,277.599358,654.9046
SCOPE ASCOPE4 CYSTO STERILE 601001000,120.497,CDM,272,RC,A4649,HCPCS,,11662-MAIN,LOCAL,,,,,368,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,327.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,152.8672,360.64
Fluoroscopy Guid Needle Plcmt Tc,PX7700201,CDM,320,RC,77002,CPT,TC,,,,,,,662,,Humana Choice Care,All Medicare plans,outpatient,49.5,,508.58,percent of total billed charges,327.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.9948,648.76
8MM ENDOWRIST INSTRUMENTS MONOPOLAR CURVED SCISSORS,27200000,CDM,272,RC,,,,11909-MAIN,LOCAL,,,,,648,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,327.888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STAPLER INTERNAL ECHELON FLEX POWERED PLUS LONG LENGTH 440MM,27200000,CDM,272,RC,,,,12065-MAIN,LOCAL,,,,,648,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,327.888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Dress/Debrid Med Burn No Anesth,PX16025F,CDM,510,RC,16025,CPT,,,,,,,,366,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,327.91,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.06,327.91
Dress/Debrid Med Burn No Anesth,PX16025P,CDM,983,RC,16025,CPT,,,,,,,,244,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,327.91,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.06,327.91
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423F,CDM,510,RC,11423,CPT,,,,,,,,711,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,327.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.6,428.92
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423P,CDM,983,RC,11423,CPT,,,,,,,,569,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,327.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.6,557.62
folic acid 5 MG/ML Solution 10 mL Vial,J3490.94,CDM,636,RC,J3490,HCPCS,,,,63323018410,NDC,10,ML,336.94,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,11.07921788,percent of total billed charges,327.943702,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,330.2012
Closed Rx Mt-Phal Toe Dislocation,PX28630F,CDM,510,RC,28630,CPT,,,,,,,,360,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,327.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.544,352.8
RBC Antibody Elution,PX86860,CDM,300,RC,86860,CPT,,,,,,,,360,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,327.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.22,352.8
Emergency Level II Visit,PX99282P,CDM,981,RC,99282,CPT,,,,,,,,337,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,167.3126923,percent of total billed charges,328.0021,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.9898,328.0021
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032F,CDM,510,RC,12032,CPT,,,,,,,,386,,First Health,Commercial,both,85,,999999999,percent of total billed charges,328.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.3444,378.28
RELOAD SUREFORM 45 2.5MM WHITE,27200000,CDM,272,RC,,,,12791-MAIN,LOCAL,,,,,386,,First Health,Commercial,both,85,,999999999,percent of total billed charges,328.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 45 3.5MM BLUE,27200000,CDM,272,RC,,,,12792-MAIN,LOCAL,,,,,386,,First Health,Commercial,both,85,,999999999,percent of total billed charges,328.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 45 4.3MM GREEN,27200000,CDM,272,RC,,,,12793-MAIN,LOCAL,,,,,386,,First Health,Commercial,both,85,,999999999,percent of total billed charges,328.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Cyto Non Gyn,PX8811201,CDM,310,RC,88112,CPT,TC,,,,,,,372,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,328.104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,364.56
Closed Rx Kneecap Dislocatn,PX27560F,CDM,510,RC,27560,CPT,,,,,,,,468,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,328.1642,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,219.89,807.33
Closed Rx Kneecap Dislocatn,PX27560P,CDM,983,RC,27560,CPT,,,,,,,,312,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,328.1642,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,219.89,807.33
Removal of Anal Tabs,PX46230F,CDM,510,RC,46230,CPT,,,,,,,,790,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,328.166,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,328.166,2452.93
"Close Rx Dist Fingr Fx,Manipulatn",PX26755F,CDM,510,RC,26755,CPT,,,,,,,,335,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,328.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
"Closed Rx I-P Jt,Toe Dislocation",PX28660F,CDM,510,RC,28660,CPT,,,,,,,,335,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,328.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Insitu Hybridization (Fish),PX8836401,CDM,310,RC,88364,CPT,TC,,,,,,,335,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,328.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Reduce Temporomandibl Disloc,PX21480F,CDM,510,RC,21480,CPT,,,,,,,,335,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,328.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
Repr Superf Wnd Face <2.5cm,PX12011F,CDM,510,RC,12011,CPT,,,,,,,,335,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,328.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.159,328.3
"Spinal Puncture,Lumbar,Diagnostic",PX62270F,CDM,510,RC,62270,CPT,,,,,,,,684,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,328.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,284.1336,670.32
"Spinal Puncture,Lumbar,Diagnostic",PX62270F,CDM,510,RC,62270,CPT,,,,,,,,684,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,328.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,284.1336,670.32
Excis Primary Ganglion Wrist,PX25111F,CDM,510,RC,25111,CPT,,,,,,,,791,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,328.5814,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,328.5814,1404.08
Anal Sphincterotomy,PX46080F,CDM,510,RC,46080,CPT,,,,,,,,607,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,328.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.63,598.41
Anal Sphincterotomy,PX46080P,CDM,983,RC,46080,CPT,,,,,,,,525,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,328.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.63,598.41
Xray Cervical Spine 4 or 5 Vws,PX7205001,CDM,320,RC,72050,CPT,TC,,,,,,,664,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,328.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,650.72
Xray Cervical Spine 6 or More Vws,PX7205201,CDM,320,RC,72052,CPT,TC,,,,,,,664,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,328.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,650.72
"MRI,Lwrext,No Jnt,No Cont",PX7371801,CDM,610,RC,73718,CPT,TC,,,,,,,3253,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,328.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.47,328.7
"MRI,Lwrext,No Jnt,No Cont",PX7371801,CDM,610,RC,73718,CPT,TC,,,,,,,3253,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,328.7,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.47,328.7
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231001,NDC,10,ML,649.64,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,328.71784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231005,NDC,10,ML,649.64,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,328.71784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
nystatin 100000 UNIT/GM Powder 60 g Bottle,63700001,CDM,250,RC,,,,,,68308015260,NDC,60,GR,335.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,328.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Closed Rx Spont Hip Disloc,Anesth",PX27257F,CDM,510,RC,27257,CPT,,,,,,,,548,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,328.8064,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,221.86,755.45
"Closed Rx Spont Hip Disloc,Anesth",PX27257P,CDM,983,RC,27257,CPT,,,,,,,,365,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,328.8064,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,221.86,755.45
Acellular Derm Matrix Implt,PX15777F,CDM,510,RC,15777,CPT,,,,,,,,650,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,328.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.01,637
Closed Rx Bimalleolar Fx,PX27808F,CDM,510,RC,27808,CPT,,,,,,,,650,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,328.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,637
"Exc Skn Bngn2.1-3cm Fce,Facial",PX11443P,CDM,983,RC,11443,CPT,,,,,,,,650,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,328.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.01,1416.38
Drain/Inject Med Joint/Brusa W/US Guide,PX20606F,CDM,510,RC,20606,CPT,,,,,,,,387,,First Health,Commercial,both,85,,999999999,percent of total billed charges,328.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.7598,604.15
"Ex Sknbngn0.6-1cmtrnk,Arm,Lg",PX11401P,CDM,983,RC,11401,CPT,,,,,,,,387,,First Health,Commercial,both,85,,999999999,percent of total billed charges,328.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.7598,376.6671
"Exc Skn Benig<5mm Face,Facial",PX11440P,CDM,983,RC,11440,CPT,,,,,,,,387,,First Health,Commercial,both,85,,999999999,percent of total billed charges,328.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.7598,614.65
Facility Emergency Level II Visit,PX99282F,CDM,450,RC,99282,CPT,,,,,,,,387,,First Health,Commercial,both,85,,999999999,percent of total billed charges,328.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,142.88,379.26
Initial Rx Burn(S) 1st Degree,PX16000F,CDM,510,RC,16000,CPT,,,,,,,,338,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,328.9754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.4052,331.24
Xray Ribs Unilat 2 Vws With Pa Chest,PX7110101,CDM,320,RC,71101,CPT,TC,,,,,,,792,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,328.9968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,776.16
"Complex Drainage, Wound",PX10180P,CDM,983,RC,10180,CPT,,,,,,,,767,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,329.043,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,318.6118,2482.37
tiotropium 18 MCG capsule 5 Each Box,63700001,CDM,250,RC,,,,,,597007575,NDC,5,EA,665.18,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,329.2641,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Assay of Phenytoin Total,PX80185,CDM,300,RC,80185,CPT,,,,,,,,336,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,329.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.15,329.28
"Molecular Path Proc, Level 2 - Ref",PX8140190,CDM,310,RC,81401,CPT,90,,,,,,,672,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,329.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.62,658.56
"Molecular Path Proc, Level 2 - Ref",PX8140190,CDM,310,RC,81401,CPT,90,,,,,,,672,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,329.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.62,658.56
"Molecular Path Proc, Level 2 - Ref",PX8140190,CDM,310,RC,81401,CPT,90,,,,,,,672,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,329.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.62,658.56
Acetaminophen,PX80307E,CDM,300,RC,80307,CPT,,,,,,,,370,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,329.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Alcohol,PX80307A,CDM,300,RC,80307,CPT,,,,,,,,370,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,329.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Injection for Nerve Block,PX64445F,CDM,510,RC,64445,CPT,,,,,,,,385,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,329.3,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.71,329.3
Injection for Nerve Block,PX64445P,CDM,983,RC,64445,CPT,,,,,,,,385,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,329.3,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.71,377.3
Salicylate,PX80307D,CDM,300,RC,80307,CPT,,,,,,,,370,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,329.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Urine Drug Screen,PX80307B,CDM,300,RC,80307,CPT,,,,,,,,370,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,329.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Xray Elbow 3+Vws Tc,PX7308001,CDM,320,RC,73080,CPT,TC,,,,,,,370,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,329.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,362.6
"MRI,Pelvis W/Out Contrast",PX7219501,CDM,610,RC,72195,CPT,TC,,,,,,,3253,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,329.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.69,329.36
"MRI,Pelvis W/Out Contrast",PX7219501,CDM,610,RC,72195,CPT,TC,,,,,,,3253,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,329.36,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.69,329.36
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505F,CDM,510,RC,25505,CPT,,,,,,,,651,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,329.406,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.4254,1404.08
Remove Foreign Body Complic,PX10121P,CDM,983,RC,10121,CPT,,,,,,,,651,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,329.406,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.4254,1416.38
"Fac/Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601F,CDM,510,RC,11601,CPT,,,,,,,,673,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,64.48,percent of total billed charges,329.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,279.5642,659.54
"Fac/Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601F,CDM,510,RC,11601,CPT,,,,,,,,673,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,329.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,279.5642,659.54
"Fac/Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601F,CDM,510,RC,11601,CPT,,,,,,,,673,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,329.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,279.5642,659.54
US Pregnancy Tc Follow-Up,PX7681601,CDM,402,RC,76816,CPT,TC,,,,,,,362,,Medica,Commercial,both,91.1,,296.8,percent of total billed charges,329.782,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,354.76
desflurane Solution 240 mL Bottle,25000000,CDM,250,RC,,,,,,10019064134,NDC,240,ML,793.95,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,329.80683,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
SUTURE CTD VICRYL 4-0 VIL BR SUTUPK J103T,27200000,CDM,272,RC,,,,4491-MAIN,LOCAL,,,,,373.97,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,329.84154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Fac/Exc Skin Benig<5mm Remaind Bod,PX11420F,CDM,510,RC,11420,CPT,,,,,,,,374,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,329.868,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,1416.38
"Fac/Office Consultation,Level III",PX99243F,CDM,510,RC,99213,CPT,,,,,,,,374,,United Healthcare,All Payer,outpatient,88.2,,107.598,percent of total billed charges,329.868,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,366.52
"Inpatient Consult, Level III",PX99253,CDM,983,RC,99253,CPT,,,,,,,,374,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,329.868,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,364.0142
"Office Consultation,Level III",PX99243P,CDM,983,RC,99243,CPT,,,,,,,,374,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,329.868,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,364.0142
Removal of Hemorrhoid Clot,PX46320P,CDM,983,RC,46320,CPT,,,,,,,,374,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,329.868,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,1030.93
Xray Hand 3vws Tc,PX7313001,CDM,320,RC,73130,CPT,TC,,,,,,,374,,United Healthcare,All Payer,outpatient,88.2,,351.56,percent of total billed charges,329.868,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,366.52
PHENobarbital 130 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047721,NDC,1,ML,338.93,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,329.880569,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.354486,332.1514
"Layr Clos Wnd Face,Facial <2.5cm",PX12051F,CDM,510,RC,12051,CPT,,,,,,,,769,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,329.901,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,319.4426,753.62
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004164,NDC,1,EA,666.52,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,329.9274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
"Level V - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3939,CDM,310,RC,88307,CPT,TC,,,,,,,252,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,329.93,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,200.06,341.216
"Level V - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3939,CDM,310,RC,88307,CPT,TC,,,,,,,252,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,329.93,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,200.06,341.216
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004110,NDC,1,EA,666.53,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,329.93235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605F,CDM,510,RC,25605,CPT,,,,,,,,1178,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,330.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,325.92,1160.15
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605F,CDM,510,RC,25605,CPT,,,,,,,,1178,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,330.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,325.92,1160.15
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605P,CDM,983,RC,25605,CPT,,,,,,,,785,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,330.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,325.92,1160.15
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605P,CDM,983,RC,25605,CPT,,,,,,,,785,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,330.06,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,325.92,1160.15
"Needle Biopsy, Lymph Node(S)",PX38505F,CDM,510,RC,38505,CPT,,,,,,,,667,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,330.165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,277.0718,1416.38
folic acid 5 MG/ML Solution 10 mL Vial,J3490.94,CDM,636,RC,J3490,HCPCS,,,,63323018410,NDC,10,ML,336.94,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,330.2012,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,330.2012
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031F,CDM,510,RC,12031,CPT,,,,,,,,688,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,330.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,285.7952,674.24
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031F,CDM,510,RC,12031,CPT,,,,,,,,688,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,330.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,285.7952,674.24
Aspirate Pleura W/ Imaging,PX32555F,CDM,761,RC,32555,CPT,,,,,,,,795,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,330.243,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,330.243,779.1
Aspirate Pleura W/O Imaging,PX32554F,CDM,510,RC,32554,CPT,,,,,,,,795,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,330.243,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,330.243,779.1
Emergency Level II Visit,PX99282P,CDM,981,RC,99282,CPT,,,,,,,,337,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,330.26,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.53,330.26
sugammadex sodium 200 MG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,6542302,NDC,2,ML,652.81,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,330.32186,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Correct Bunion,Metatarsal Osteotomy",PX28296F,CDM,510,RC,28296,CPT,,,,,,,,8100,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,330.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,324.17,1834.65
"Correct Bunion,Metatarsal Osteotomy",PX28296F,CDM,510,RC,28296,CPT,,,,,,,,8100,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,330.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,324.17,1834.65
"Correct Bunion,Metatarsal Osteotomy",PX28296P,CDM,983,RC,28296,CPT,,,,,,,,2150,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,330.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,324.17,2107
"Correct Bunion,Metatarsal Osteotomy",PX28296P,CDM,983,RC,28296,CPT,,,,,,,,2150,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,330.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,324.17,2107
ANCHORAGE FIXATION PIN,27200000,CDM,272,RC,,,,12642-MAIN,LOCAL,,,,,389,,First Health,Commercial,both,85,,999999999,percent of total billed charges,330.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Ext Ecg > 48hr to 21 Day Rcrd W/Conect Intl Rcrd,PX0296T,CDM,731,RC,0296T,HCPCS,,,,,,,,389,,First Health,Commercial,both,85,,999999999,percent of total billed charges,330.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,161.5906,381.22
"Fac/Exc Skn Beni1.1-2cm Fce,Facial",PX11442F,CDM,510,RC,11442,CPT,,,,,,,,668,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,330.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,277.4872,654.64
SET CRICOTHYROTOMY CATHETER 3.5MM ID,120.251,CDM,272,RC,,,,4306-MAIN,LOCAL,,,,,363,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,330.693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.7902,355.74
SET CRICOTHYROTOMY CATHETER 4MM ID,120.251,CDM,272,RC,,,,3452-MAIN,LOCAL,,,,,363,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,330.693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.7902,355.74
SET CRICOTHYROTOMY CATHETER 6MM ID,120.251,CDM,272,RC,,,,2887-MAIN,LOCAL,,,,,363,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,330.693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.7902,355.74
Closed Rx Shldr Dislocation,PX23650F,CDM,510,RC,23650,CPT,,,,,,,,689,,Health Partners,Health Partners Care Plans,both,48,,262.985,percent of total billed charges,330.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,675.22
Closed Rx Shldr Dislocation,PX23650F,CDM,510,RC,23650,CPT,,,,,,,,689,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,330.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,675.22
"Digital Mamm, Diag, Bilat, Tc W/Cad Perf",PX7706601,CDM,401,RC,77066,CPT,TC,,,,,,,375,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,330.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.05,367.5
"Digital Mammogram, Screen Bil, Tc W/Cad Perf",PX7706701,CDM,403,RC,77067,CPT,TC,,,,,,,375,,United Healthcare,All Payer,outpatient,88.2,,206.851875,percent of total billed charges,330.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.86,561
Injection for Shoulder Arthrogram,PX23350F,CDM,510,RC,23350,CPT,,,,,,,,675,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,330.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,280.395,661.5
Injection for Shoulder Arthrogram,PX23350F,CDM,510,RC,23350,CPT,,,,,,,,675,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,330.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,280.395,661.5
Injection for Shoulder Arthrogram,PX23350F,CDM,510,RC,23350,CPT,,,,,,,,675,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,330.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,280.395,661.5
Repr Superf Wnd Face 2.6-5,PX12013F,CDM,510,RC,12013,CPT,,,,,,,,375,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,330.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.775,367.5
Xray Wrist Minimum 3 Vws,PX7311001,CDM,320,RC,73110,CPT,TC,,,,,,,375,,United Healthcare,All Payer,outpatient,88.2,,200.3845455,percent of total billed charges,330.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,367.5
Irradiated Leukoreduced Rbc's,PXP9040,CDM,390,RC,P9040,HCPCS,,,,,,,,771,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,330.759,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,231.5,755.58
gadoterate meglumine 10 mmol/20 mL Solution 20 mL Vial,A9575,CDM,636,RC,A9575,HCPCS,,,,67684200003,NDC,20,ML,668.27,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,330.79365,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,277.599358,654.9046
Sars-Cov-2 Covid-19 Antibody,PX86769,CDM,300,RC,86769,CPT,,,,,,,,340,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,330.922,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.63,333.2
X-Ray Exam Chest 3 Views,PX7104701,CDM,320,RC,71047,CPT,TC,,,,,,,340,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,330.922,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,333.2
Injection Hip Arthrogram,PX27093F,CDM,510,RC,27093,CPT,,,,,,,,654,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,330.924,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,271.6716,640.92
Cyto Non Gyn,PX8811201,CDM,310,RC,88112,CPT,TC,,,,,,,372,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,331.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,364.56
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082152,NDC,1,ML,375.43,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,331.12926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.48,367.9214
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12173-SURG,LOCAL,,,,,772,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,331.188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623F,CDM,510,RC,11623,CPT,,,,,,,,690,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,331.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,286.626,1416.38
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623F,CDM,510,RC,11623,CPT,,,,,,,,690,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,331.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,286.626,1416.38
butamben-tetracaine-benzocaine 2-2-14 % Aerosol 5 g Bottle,25000000,CDM,250,RC,,,,,,10223020104,NDC,5,GR,375.52,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,331.20864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Cardiac Rehab II W/ Monitor,PX93798.02,CDM,943,RC,93798,CPT,,,,,,,,338,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,331.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.44,495.55
Direct Admit Hospital Observ,PXG0379,CDM,761,RC,G0379,HCPCS,,,,,,,,676,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,331.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,280.8104,662.48
Direct Admit Hospital Observ,PXG0379,CDM,761,RC,G0379,HCPCS,,,,,,,,676,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,331.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,280.8104,662.48
Direct Admit Hospital Observ,PXG0379,CDM,761,RC,G0379,HCPCS,,,,,,,,676,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,331.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,280.8104,662.48
Initial Rx Burn(S) 1st Degree,PX16000F,CDM,510,RC,16000,CPT,,,,,,,,338,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,331.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.4052,331.24
oseltamivir 6 MG/ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,68180067801,NDC,60,ML,676.25,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,331.3625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 6 MG/ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,68180067801,NDC,60,ML,676.25,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,331.3625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 6 MG/ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,68180067801,NDC,60,ML,676.25,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,331.3625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035F,CDM,510,RC,12035,CPT,,,,,,,,655,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,331.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,272.087,641.9
hepatitis A vaccine 1440 EL U/ML Suspension 1 mL Syringe,90632,CDM,636,RC,90632,CPT,,,,58160082652,NDC,1,ML,375.78,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,331.43796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,156.099012,368.2644
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598046562,NDC,1,EA,798,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,331.4892,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
Apc Resistance Assay - Ref,PX8530790,CDM,300,RC,85307,CPT,90,,,,,,,390,,First Health,Commercial,both,85,,999999999,percent of total billed charges,331.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.05,382.2
"Closed Rx Toe Fx,Manipulatn",PX28515F,CDM,510,RC,28515,CPT,,,,,,,,390,,First Health,Commercial,both,85,,999999999,percent of total billed charges,331.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,162.006,382.2
fat emulsion 20 % Emulsion 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,338051958,NDC,200,ML,375.95,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,331.5879,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Cardiac Rehab II Eval,PX93798.05,CDM,943,RC,93798,CPT,,,,,,,,364,,Medica,Commercial,both,91.1,,130.934,percent of total billed charges,331.604,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.44,495.55
Drain/Inject Large Joint/Bursa,PX20610F,CDM,510,RC,20610,CPT,,,,,,,,364,,Medica,Commercial,both,91.1,,40.695,percent of total billed charges,331.604,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,151.2056,356.72
Xray Forearm 2 Vws,PX7309001,CDM,320,RC,73090,CPT,TC,,,,,,,364,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,331.604,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,356.72
I&D Deep Absc/Hematoma Neck/Chest,PX21501F,CDM,510,RC,21501,CPT,,,,,,,,773,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,331.617,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.1042,2482.37
moxifloxacin 0.5 % Solution 3 mL Bottle,25000000,CDM,250,RC,,,,,,60505058204,NDC,3,ML,691.15,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,331.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
moxifloxacin 0.5 % Solution 3 mL Bottle,25000000,CDM,250,RC,,,,,,60505058204,NDC,3,ML,691.15,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,331.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Drainage of Hematoma/Fluid (T),PX10140F,CDM,510,RC,10140,CPT,,,,,,,,341,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,331.8953,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,141.6514,1416.38
Drainage Scrotal Wall Abscess,PX55100P,CDM,983,RC,55100,CPT,,,,,,,,341,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,331.8953,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,141.6514,1416.38
filgrastim-ayow 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,800000,CDM,,,,,,,,70121157001,NDC,0.5,ML,691.62,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,331.9776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
filgrastim-ayow 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,800000,CDM,,,,,,,,70121157001,NDC,0.5,ML,691.62,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,331.9776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Explor Metatarso-Phalang Jt,PX28022P,CDM,983,RC,28022,CPT,,,,,,,,774,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,332.046,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.5196,2827.75
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132P,CDM,983,RC,13132,CPT,,,,,,,,774,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,332.046,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.5196,753.3342
PHENobarbital 130 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047721,NDC,1,ML,338.93,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,332.1514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.354486,332.1514
Temporary External Pacing,PX92953F,CDM,480,RC,92953,CPT,,,,,,,,678,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,332.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,281.6412,664.44
Temporary External Pacing,PX92953F,CDM,480,RC,92953,CPT,,,,,,,,678,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,332.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,281.6412,664.44
Temporary External Pacing,PX92953F,CDM,480,RC,92953,CPT,,,,,,,,678,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,332.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,281.6412,664.44
"Initial Observation Care,Levl II",PX99219,CDM,982,RC,99219,CPT,,,,,,,,391,,First Health,Commercial,both,85,,999999999,percent of total billed charges,332.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,162.4214,380.5603
Insert Emergency Endotrach Airway,PX31500P,CDM,983,RC,31500,CPT,,,,,,,,657,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,332.442,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,639.4581
Room Rate Transitional Care Private,PX11900000,CDM,119,RC,,,,,,,,,,775,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,332.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.935,759.5
Repr Superf Wnd Body 12.6-20,PX12005P,CDM,983,RC,12005,CPT,,,,,,,,377,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,332.514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,156.6058,366.9341
"2019-Ncov Coronavirus, Sars-Cov-2/2019-Ncov (Covid-19)",PXU000290,CDM,300,RC,U0002,HCPCS,90,,,,,,,365,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,332.515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,357.7
"Closed Rx Spont Hip Disloc,Anesth",PX27257P,CDM,983,RC,27257,CPT,,,,,,,,365,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,332.515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,151.621,1404.08
Sars-Cov-2 Covid-19 Amp Prb,PX8763590,CDM,300,RC,87635,CPT,90,,,,,,,365,,Medica,Commercial,both,91.1,,60.49,percent of total billed charges,332.515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,357.7
X-Ray Exam Femur Min 2 Vws,PX7355201,CDM,320,RC,73552,CPT,TC,,,,,,,365,,Medica,Commercial,both,91.1,,131.6,percent of total billed charges,332.515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Ankle Minimum 3 Vws,PX7361001,CDM,320,RC,73610,CPT,TC,,,,,,,365,,Medica,Commercial,both,91.1,,155.7946154,percent of total billed charges,332.515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Calcaneus Minimum 2 Vws,PX7365001,CDM,320,RC,73650,CPT,TC,,,,,,,365,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,332.515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Clavicle Complete,PX7300001,CDM,320,RC,73000,CPT,TC,,,,,,,365,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,332.515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Elbow 2 Vws,PX7307001,CDM,320,RC,73070,CPT,TC,,,,,,,365,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,332.515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Hand 2vws Tc,PX7312001,CDM,320,RC,73120,CPT,TC,,,,,,,365,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,332.515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,357.7
Xray Humerus Minimum 2 Vws,PX7306001,CDM,320,RC,73060,CPT,TC,,,,,,,365,,Medica,Commercial,both,91.1,,49.6,percent of total billed charges,332.515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Shoulder Minimum 2 Vws,PX7303001,CDM,320,RC,73030,CPT,TC,,,,,,,365,,Medica,Commercial,both,91.1,,107.43,percent of total billed charges,332.515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Sternum 2vws Tc,PX7112001,CDM,320,RC,71120,CPT,TC,,,,,,,365,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,332.515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Tibia & Fibula 2 Vws,PX7359001,CDM,320,RC,73590,CPT,TC,,,,,,,365,,Medica,Commercial,both,91.1,,57.99,percent of total billed charges,332.515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Wrist 2 Vws,PX7310001,CDM,320,RC,73100,CPT,TC,,,,,,,365,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,332.515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
"Molecular Path Proc, Level 2 - Ref",PX8140190,CDM,310,RC,81401,CPT,90,,,,,,,672,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,332.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.62,658.56
"Fac/Ex Skn Bngn2.1-3cm Trnk,Arm,Lg",PX11403F,CDM,510,RC,11403,CPT,,,,,,,,679,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,332.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,282.0566,665.42
"Fac/Ex Skn Bngn2.1-3cm Trnk,Arm,Lg",PX11403F,CDM,510,RC,11403,CPT,,,,,,,,679,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,332.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,282.0566,665.42
"Fac/Ex Skn Bngn2.1-3cm Trnk,Arm,Lg",PX11403F,CDM,510,RC,11403,CPT,,,,,,,,679,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,332.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,282.0566,665.42
SUTURE CTD VICRYL 4-0 VIL BR SUTUPK J103T,27200000,CDM,272,RC,,,,4491-MAIN,LOCAL,,,,,373.97,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,332.8333,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Fac/Exc Skin Benig<5mm Remaind Bod,PX11420F,CDM,510,RC,11420,CPT,,,,,,,,374,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,332.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,1416.38
"Fac/Office Consultation,Level III",PX99243F,CDM,510,RC,99213,CPT,,,,,,,,374,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,332.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,366.52
"Inpatient Consult, Level III",PX99253,CDM,983,RC,99253,CPT,,,,,,,,374,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,332.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,364.0142
"Office Consultation,Level III",PX99243P,CDM,983,RC,99243,CPT,,,,,,,,374,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,332.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,364.0142
Removal of Hemorrhoid Clot,PX46320P,CDM,983,RC,46320,CPT,,,,,,,,374,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,332.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,1030.93
Xray Hand 3vws Tc,PX7313001,CDM,320,RC,73130,CPT,TC,,,,,,,374,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,332.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,366.52
"Ctrl Nosebleed,Anter,Simple",PX30901F,CDM,510,RC,30901,CPT,,,,,,,,342,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,332.8686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,335.16
Ultrasound Breast Limited,PX7664201,CDM,402,RC,76642,CPT,TC,,,,,,,342,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,267.708,percent of total billed charges,332.8686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,335.16
"Layr Clos Wnd Face,Facial 2.5-5",PX12052P,CDM,983,RC,12052,CPT,,,,,,,,776,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,332.904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,322.3504,755.2808
"Fac/Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601F,CDM,510,RC,11601,CPT,,,,,,,,673,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,333.135,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,279.5642,659.54
procainamide 500 MG/ML Solution 2 mL Vial,J2690.01,CDM,636,RC,J2690,HCPCS,,,,14789090002,NDC,2,ML,377.75,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,333.1755,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,134.15,370.195
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010202,NDC,1,EA,680,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,150.5666667,percent of total billed charges,333.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010202,NDC,1,EA,680,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,333.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010202,NDC,1,EA,680,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,333.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 1 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010101,NDC,1,EA,680,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,150.5666667,percent of total billed charges,333.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 1 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010101,NDC,1,EA,680,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,333.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 1 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010101,NDC,1,EA,680,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,333.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010102,NDC,1,EA,680,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,150.5666667,percent of total billed charges,333.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010102,NDC,1,EA,680,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,333.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010102,NDC,1,EA,680,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,333.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
"Fac/Exc Skn Mal 0.6-1cm Fce,Facial",PX11641F,CDM,510,RC,11641,CPT,,,,,,,,680,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,333.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,282.472,666.4
"Fac/Exc Skn Mal 0.6-1cm Fce,Facial",PX11641F,CDM,510,RC,11641,CPT,,,,,,,,680,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,333.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,282.472,666.4
"Fac/Exc Skn Mal 0.6-1cm Fce,Facial",PX11641F,CDM,510,RC,11641,CPT,,,,,,,,680,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,333.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,282.472,666.4
Observation Initial,PXG0378.03,CDM,762,RC,G0378,HCPCS,,,,,,,,680,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,16.0672657,percent of total billed charges,333.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,282.472,666.4
Observation Initial,PXG0378.03,CDM,762,RC,G0378,HCPCS,,,,,,,,680,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,333.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,282.472,666.4
Observation Initial,PXG0378.03,CDM,762,RC,G0378,HCPCS,,,,,,,,680,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,333.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,282.472,666.4
Sars-Cov-2 Covid-19 Antibody,PX86769,CDM,300,RC,86769,CPT,,,,,,,,340,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,333.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.63,333.2
X-Ray Exam Chest 3 Views,PX7104701,CDM,320,RC,71047,CPT,TC,,,,,,,340,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,333.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,333.2
Layr Clos Wnd Rest Body 2.6-7.5,PX12042P,CDM,983,RC,12042,CPT,,,,,,,,777,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,333.333,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,322.7658,756.2541
Dress/Debrid Med Burn No Anesth,PX16025F,CDM,510,RC,16025,CPT,,,,,,,,366,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,333.426,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,152.0364,358.68
Exc Skn Bnig0.6-1cm Remain Bdy,PX11421P,CDM,983,RC,11421,CPT,,,,,,,,345,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,333.45,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.15,338.1
Fac/Exc Skn Beni 0.6-1cm Remain Bdy,PX11421F,CDM,510,RC,11421,CPT,,,,,,,,931,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,333.45,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.15,333.45
"Insert Needle,Intraosseous Infusn",PX36680F,CDM,510,RC,36680,CPT,,,,,,,,659,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,333.454,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,273.7486,645.82
Repr Superf Wnd Face 2.6-5,PX12013P,CDM,983,RC,12013,CPT,,,,,,,,681,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,242.62,percent of total billed charges,333.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,662.8173
Repr Superf Wnd Face 2.6-5,PX12013P,CDM,983,RC,12013,CPT,,,,,,,,681,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,333.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,662.8173
Repr Superf Wnd Face 2.6-5,PX12013P,CDM,983,RC,12013,CPT,,,,,,,,681,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,333.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,662.8173
"Digital Mamm, Diag, Bilat, Tc W/Cad Perf",PX7706601,CDM,401,RC,77066,CPT,TC,,,,,,,375,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,333.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.05,367.5
"Digital Mammogram, Screen Bil, Tc W/Cad Perf",PX7706701,CDM,403,RC,77067,CPT,TC,,,,,,,375,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,333.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.86,561
Repr Superf Wnd Face 2.6-5,PX12013F,CDM,510,RC,12013,CPT,,,,,,,,375,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,333.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.775,367.5
Xray Wrist Minimum 3 Vws,PX7311001,CDM,320,RC,73110,CPT,TC,,,,,,,375,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,333.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,367.5
insulin aspart 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169633910,NDC,3,ML,659.76,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,333.83856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
Infliximab - Ref,PX8023090,CDM,300,RC,80230,CPT,90,,,,,,,343,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,166.135,percent of total billed charges,333.8419,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.36,336.14
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002F,CDM,510,RC,12002,CPT,,,,,,,,343,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,172.96,percent of total billed charges,333.8419,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,142.4822,336.14
"Incis/Drain Scrotum/Testis,Epididym",PX54700F,CDM,510,RC,54700,CPT,,,,,,,,660,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,333.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.164,1779.39
Repair Incis Hernia W Mesh,PX49568P,CDM,983,RC,49568,CPT,,,,,,,,660,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,333.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.164,642.378
ibutilide 1 MG/10ML Solution 10 mL Vial,J1742.01,CDM,636,RC,J1742,HCPCS,,,,9379401,NDC,10,ML,2349.03,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,334,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,180.45,559.83
ibutilide 1 MG/10ML Solution 10 mL Vial,J1742.01,CDM,636,RC,J1742,HCPCS,,,,9379401,NDC,10,ML,2349.03,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,334,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,180.45,559.83
6 SHOOTER SAEED MULTIBAND LIGATOR,27200000,CDM,272,RC,,,,12379-MAIN,LOCAL,,,,,393,,First Health,Commercial,both,85,,999999999,percent of total billed charges,334.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA FIRST MET TRANSLATOR STERILE MICA,27200000,CDM,272,RC,,,,12445-MAIN,LOCAL,,,,,393,,First Health,Commercial,both,85,,999999999,percent of total billed charges,334.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Tap Block Bilateral by Injection(S),PX64488F,CDM,510,RC,64488,CPT,,,,,,,,393,,First Health,Commercial,both,85,,999999999,percent of total billed charges,334.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,163.2522,385.14
Injection for Shoulder Arthrogram,PX23350F,CDM,510,RC,23350,CPT,,,,,,,,675,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,334.125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,280.395,661.5
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082152,NDC,1,ML,375.43,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,334.1327,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.48,367.9214
"Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602P,CDM,983,RC,11602,CPT,,,,,,,,1120,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,334.14,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.66,1097.6
"Fac/Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602F,CDM,510,RC,11602,CPT,,,,,,,,731,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,334.14,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.66,509.86
Drainage of Hematoma/Fluid (T),PX10140F,CDM,510,RC,10140,CPT,,,,,,,,341,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,334.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,141.6514,1416.38
Drainage Scrotal Wall Abscess,PX55100P,CDM,983,RC,55100,CPT,,,,,,,,341,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,334.18,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.27,482.88
butamben-tetracaine-benzocaine 2-2-14 % Aerosol 5 g Bottle,25000000,CDM,250,RC,,,,,,10223020104,NDC,5,GR,375.52,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,334.2128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Tech-Cytopath Eval, Fna, Rep",PX8817301,CDM,310,RC,88173,CPT,TC,,,,,,,379,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,334.278,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,371.42
Xray Foot 2 Vws,PX7362001,CDM,320,RC,73620,CPT,TC,,,,,,,367,,Medica,Commercial,both,91.1,,238.68,percent of total billed charges,334.337,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,359.66
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016425,NDC,1,ML,779.43,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,334.37547,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.66,898.7384
hepatitis A vaccine 1440 EL U/ML Suspension 1 mL Syringe,90632,CDM,636,RC,90632,CPT,,,,58160082652,NDC,1,ML,375.78,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,334.4442,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,156.099012,368.2644
STAPLER INTERNAL POWERED 29MM CURVED CIRCULAR,27200000,CDM,272,RC,,,,12024-MAIN,LOCAL,,,,,697,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,334.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STAPLER INTERNAL POWERED 29MM CURVED CIRCULAR,27200000,CDM,272,RC,,,,12024-MAIN,LOCAL,,,,,697,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,334.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STAPLER INTERNAL POWERED 31MM CURVED CIRCULAR,27200000,CDM,272,RC,,,,12025-MAIN,LOCAL,,,,,697,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,334.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STAPLER INTERNAL POWERED 31MM CURVED CIRCULAR,27200000,CDM,272,RC,,,,12025-MAIN,LOCAL,,,,,697,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,334.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
fat emulsion 20 % Emulsion 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,338051958,NDC,200,ML,375.95,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,334.5955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Amputation Toe,I-P Jt",PX28825P,CDM,983,RC,28825,CPT,,,,,,,,780,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,334.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,324.012,2827.75
Direct Admit Hospital Observ,PXG0379,CDM,761,RC,G0379,HCPCS,,,,,,,,676,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,334.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,280.8104,662.48
MRI Orbit/Face/Neck Tc,PX7054001,CDM,610,RC,70540,CPT,TC,,,,,,,3335,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,334.62,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,113.43,334.62
MRI Orbit/Face/Neck Tc,PX7054001,CDM,610,RC,70540,CPT,TC,,,,,,,3335,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,334.62,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,113.43,334.62
"Remv Foot Foreign Body,Subcutaneous",PX28190P,CDM,983,RC,28190,CPT,,,,,,,,683,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,334.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,283.7182,664.7639
"Remv Foot Foreign Body,Subcutaneous",PX28190P,CDM,983,RC,28190,CPT,,,,,,,,683,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,334.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,283.7182,664.7639
"Remv Foot Foreign Body,Subcutaneous",PX28190P,CDM,983,RC,28190,CPT,,,,,,,,683,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,334.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,283.7182,664.7639
oseltamivir 6 MG/ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,68180067801,NDC,60,ML,676.25,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,334.74375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604F,CDM,510,RC,20604,CPT,,,,,,,,344,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,334.8152,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,142.8976,337.12
Removal of Nail Bed,PX11750F,CDM,510,RC,11750,CPT,,,,,,,,629,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,334.83,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.91,334.83
Fluoroscopy Guid Needle Plcmt Tc,PX7700201,CDM,320,RC,77002,CPT,TC,,,,,,,662,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,334.972,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.9948,648.76
"Fac/Exc Skn Malig .1-2cm Fce,Facal",PX11642F,CDM,510,RC,11642,CPT,,,,,,,,698,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,335.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.9492,684.04
"Fac/Exc Skn Malig .1-2cm Fce,Facal",PX11642F,CDM,510,RC,11642,CPT,,,,,,,,698,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,335.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.9492,684.04
"Ctrl Nosebleed,Anter,Simple",PX30901F,CDM,510,RC,30901,CPT,,,,,,,,342,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,335.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,335.16
"Spinal Puncture,Lumbar,Diagnostic",PX62270F,CDM,510,RC,62270,CPT,,,,,,,,684,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,335.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,284.1336,670.32
"Spinal Puncture,Lumbar,Diagnostic",PX62270F,CDM,510,RC,62270,CPT,,,,,,,,684,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,335.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,284.1336,670.32
"Spinal Puncture,Lumbar,Diagnostic",PX62270F,CDM,510,RC,62270,CPT,,,,,,,,684,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,335.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,284.1336,670.32
Ultrasound Breast Limited,PX7664201,CDM,402,RC,76642,CPT,TC,,,,,,,342,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,335.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,335.16
Closed Rx Elbow Dislocation,PX24600P,CDM,983,RC,24600,CPT,,,,,,,,380,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,335.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,157.852,369.854
SCOPE ASCOPE4 CYSTO STERILE 601001000,120.497,CDM,272,RC,A4649,HCPCS,,11662-MAIN,LOCAL,,,,,368,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,335.248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,152.8672,360.64
dantrolene 20 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,42023012306,NDC,1,EA,394.42,,First Health,Commercial,both,85,,999999999,percent of total billed charges,335.257,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Injection for Shoulder Arthrogram,PX23350F,CDM,510,RC,23350,CPT,,,,,,,,675,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,335.52,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.54,335.52
Repr Superf Wnd Body 12.6-20,PX12005P,CDM,983,RC,12005,CPT,,,,,,,,377,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,335.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,156.6058,366.9341
Temporary External Pacing,PX92953F,CDM,480,RC,92953,CPT,,,,,,,,678,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,335.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,281.6412,664.44
Drainage of Gum Lesion,PX41800F,CDM,510,RC,41800,CPT,,,,,,,,395,,First Health,Commercial,both,85,,999999999,percent of total billed charges,335.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,387.1
Exc Skn Bnig0.6-1cm Remain Bdy,PX11421P,CDM,983,RC,11421,CPT,,,,,,,,345,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,335.7885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,143.313,614.65
CT Abd&Pelv 1+ Section/Regns,PX7417801,CDM,350,RC,74178,CPT,TC,,,,,,,4226,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,335.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4141.48
CT Abdomen&Pelvis W/Contrast,PX7417701,CDM,350,RC,74177,CPT,TC,,,,,,,4288,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,335.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4202.24
CT Angio Abd&Pelv W/O&W/Dye,PX7417401,CDM,350,RC,74174,CPT,TC,,,,,,,2757,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,335.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2701.86
CT Lumbar Spine W/Dye,PX7213201,CDM,350,RC,72132,CPT,TC,,,,,,,3330,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,335.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3263.4
CT Upper Extremity W/Dye,PX7320101,CDM,350,RC,73201,CPT,TC,,,,,,,2757,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,335.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2701.86
"Mra, Neck W/O+W/ Contrast",PX7054901,CDM,610,RC,70549,CPT,TC,,,,,,,3472,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,335.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3402.56
"Mra, Neck With Contrast",PX7054801,CDM,610,RC,70548,CPT,TC,,,,,,,3541,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,335.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI Brain W & WO Contrast,PX7055301,CDM,610,RC,70553,CPT,TC,,,,,,,3541,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,335.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI Brain W Contrast Tc,PX7055201,CDM,610,RC,70552,CPT,TC,,,,,,,2637,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,335.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2584.26
MRI C Spine W&WO Contrast,PX7215601,CDM,610,RC,72156,CPT,TC,,,,,,,3541,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,335.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI L Spine W Contrast Tc,PX7214901,CDM,610,RC,72149,CPT,TC,,,,,,,5136,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,335.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,5033.28
MRI L Spine W&WO Contrast,PX7215801,CDM,610,RC,72158,CPT,TC,,,,,,,4178,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,335.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4094.44
MRI Lower W/O+W Tc,PX7372001,CDM,610,RC,73720,CPT,TC,,,,,,,3174,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,335.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3110.52
MRI Orb-Fac-Nec W/O+W/Con,PX7054301,CDM,610,RC,70543,CPT,TC,,,,,,,3541,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,335.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI Pelvis W/Contrast Tc,PX7219601,CDM,610,RC,72196,CPT,TC,,,,,,,3143,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,335.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3080.14
MRI T Spine W&WO Contrast,PX7215701,CDM,610,RC,72157,CPT,TC,,,,,,,4178,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,335.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4094.44
MRI Upper W/O+W Tc,PX7322001,CDM,610,RC,73220,CPT,TC,,,,,,,3253,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,335.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3187.94
"MRI, Abdomen W/O+ W/Contr",PX7418301,CDM,610,RC,74183,CPT,TC,,,,,,,4116,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,335.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4033.68
"MRI, Pelvis, W/O Then W/",PX7219701,CDM,610,RC,72197,CPT,TC,,,,,,,1612,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,335.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2066.35
"MRI,Lwrext,Jnt W/O+W/Cont",PX7372301,CDM,610,RC,73723,CPT,TC,,,,,,,1850,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,335.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2066.35
"MRI,Lwrext,No Jnt, W/Cont",PX7371901,CDM,610,RC,73719,CPT,TC,,,,,,,3627,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,335.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3554.46
"MRI,Uprext Jnt W/O+W/Cont",PX7322301,CDM,610,RC,73223,CPT,TC,,,,,,,2681,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,335.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2627.38
Xray Cervical Spine 4 or 5 Vws,PX7205001,CDM,320,RC,72050,CPT,TC,,,,,,,664,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,335.984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,650.72
Xray Cervical Spine 6 or More Vws,PX7205201,CDM,320,RC,72052,CPT,TC,,,,,,,664,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,335.984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,650.72
CATHETER BIPOLAR ELECTROHEMOSTASIS 7FR 300CM M00560070,27200000,CDM,272,RC,,,,12909-MAIN,LOCAL,,,,,700,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CATHETER BIPOLAR ELECTROHEMOSTASIS 7FR 300CM M00560070,27200000,CDM,272,RC,,,,12909-MAIN,LOCAL,,,,,700,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Xray Mandible Compl, Min 4 Vws",PX7011001,CDM,320,RC,70110,CPT,TC,,,,,,,381,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,336.042,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,373.38
Abd Duplex Abd-Follow Up(T),PX9397601,CDM,921,RC,93976,CPT,TC,,,,,,,809,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,336.0586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,792.82
Venous Duplex Scan Uni,PX9397101,CDM,921,RC,93971,CPT,TC,,,,,,,809,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,336.0586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,792.82
"Fac/Ex Skn Bngn2.1-3cm Trnk,Arm,Lg",PX11403F,CDM,510,RC,11403,CPT,,,,,,,,679,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,336.105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,282.0566,665.42
Infliximab - Ref,PX8023090,CDM,300,RC,80230,CPT,90,,,,,,,343,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,336.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.36,336.14
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002F,CDM,510,RC,12002,CPT,,,,,,,,343,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,336.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,142.4822,336.14
NON-LOCKING SCREW 3.5X18MM,C1713,CDM,278,RC,C1713,HCPCS,,12466-MAIN,LOCAL,,,,,395.51,,First Health,Commercial,both,85,,999999999,percent of total billed charges,336.1835,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"Excise Lesion,Back or Flank",PX21930F,CDM,510,RC,21930,CPT,,,,,,,,1326,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,336.1917,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,225.35,1053.61
"Excise Lesion,Back or Flank",PX21930P,CDM,983,RC,21930,CPT,,,,,,,,884,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,336.1917,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,225.35,1053.61
procainamide 500 MG/ML Solution 2 mL Vial,J2690.01,CDM,636,RC,J2690,HCPCS,,,,14789090002,NDC,2,ML,377.75,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,336.1975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,134.15,370.195
Abd Duplex Abd -Follow Up,PX9397602,CDM,921,RC,93976,CPT,TC,,,,,,,784,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,336.336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,768.32
Art Lower Extremity+Upper,PX9392301,CDM,921,RC,93923,CPT,TC,,,,,,,784,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,336.336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.46,768.32
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,25021019110,NDC,1,EA,809.89,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,336.428306,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.47563,793.6922
"measles, mumps & rubella vaccine Recon Soln 1 Each Vial",90707,CDM,636,RC,90707,CPT,,,,6468100,NDC,1,EA,381.47,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,336.45654,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,158.462638,373.8406
Noninvasv Lo Extrem Art Stress/Rest,PX9392401,CDM,921,RC,93924,CPT,TC,,,,,,,810,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,336.474,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.46,793.8
DRILL BIT 2.2MMX60MM STERILE MICA CANNULATED,27200000,CDM,272,RC,,,,12437-MAIN,LOCAL,,,,,701,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,336.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRILL BIT 2.2MMX60MM STERILE MICA CANNULATED,27200000,CDM,272,RC,,,,12437-MAIN,LOCAL,,,,,701,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,336.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRILL BIT 3.0MMX60MM STERILE MICA CANNULATED,27200000,CDM,272,RC,,,,12438-MAIN,LOCAL,,,,,701,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,336.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRILL BIT 3.0MMX60MM STERILE MICA CANNULATED,27200000,CDM,272,RC,,,,12438-MAIN,LOCAL,,,,,701,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,336.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
tiotropium 18 MCG capsule 5 Each Box,63700001,CDM,250,RC,,,,,,597007575,NDC,5,EA,665.18,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,336.58108,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Comprehensive Metabolic Panel,PX80053,CDM,300,RC,80053,CPT,,,,,,,,396,,First Health,Commercial,both,85,,999999999,percent of total billed charges,336.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.68,388.08
Neg Pressure Wound Therapy Dme </=50 Sq Cm,PX97605F,CDM,510,RC,97605,CPT,,,,,,,,396,,First Health,Commercial,both,85,,999999999,percent of total billed charges,336.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,164.4984,388.08
NON-LOCKING SCREW 3.5X12MM,27200000,CDM,278,RC,C1713,HCPCS,,11857-MAIN,LOCAL,,,,,396,,First Health,Commercial,both,85,,999999999,percent of total billed charges,336.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NON-LOCKING SCREW 3.5X16MM,27200000,CDM,278,RC,C1713,HCPCS,,11856-MAIN,LOCAL,,,,,396,,First Health,Commercial,both,85,,999999999,percent of total billed charges,336.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NON-LOCKING SCREW 3.5X24MM,27200000,CDM,278,RC,C1713,HCPCS,,11855-MAIN,LOCAL,,,,,396,,First Health,Commercial,both,85,,999999999,percent of total billed charges,336.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010202,NDC,1,EA,680,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,336.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 1 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010101,NDC,1,EA,680,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,336.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010102,NDC,1,EA,680,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,336.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
"Fac/Exc Skn Mal 0.6-1cm Fce,Facial",PX11641F,CDM,510,RC,11641,CPT,,,,,,,,680,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,336.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,282.472,666.4
Observation Initial,PXG0378.03,CDM,762,RC,G0378,HCPCS,,,,,,,,680,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,336.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,282.472,666.4
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605P,CDM,983,RC,25605,CPT,,,,,,,,785,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,336.765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,326.089,1404.08
Layr Clos Wnd Rest Body 7.6-12.5,PX12044F,CDM,510,RC,12044,CPT,,,,,,,,785,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,336.765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,326.089,769.3
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310001,NDC,0.528,ML,785.14,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,336.82506,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.22,877.002
"X-Ray Exam Hip,Bilat W/Pelvis 3-4 Vws",PX7352201,CDM,320,RC,73522,CPT,TC,,,,,,,382,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,336.924,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,374.36
travoprost (BAK Free) 0.004 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,65026025,NDC,2.5,ML,811.3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,337.01402,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Acetaminophen,PX80307E,CDM,300,RC,80307,CPT,,,,,,,,370,,Medica,Commercial,both,91.1,,151.53875,percent of total billed charges,337.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Alcohol,PX80307A,CDM,300,RC,80307,CPT,,,,,,,,370,,Medica,Commercial,both,91.1,,151.53875,percent of total billed charges,337.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Salicylate,PX80307D,CDM,300,RC,80307,CPT,,,,,,,,370,,Medica,Commercial,both,91.1,,151.53875,percent of total billed charges,337.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Urine Drug Screen,PX80307B,CDM,300,RC,80307,CPT,,,,,,,,370,,Medica,Commercial,both,91.1,,151.53875,percent of total billed charges,337.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Xray Elbow 3+Vws Tc,PX7308001,CDM,320,RC,73080,CPT,TC,,,,,,,370,,Medica,Commercial,both,91.1,,76.53666667,percent of total billed charges,337.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,362.6
Repr Superf Wnd Face 2.6-5,PX12013P,CDM,983,RC,12013,CPT,,,,,,,,681,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,337.095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,662.8173
"Cardioversion, Elective;Extern",PX92960P,CDM,983,RC,92960,CPT,,,,,,,,688,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,106.9,percent of total billed charges,337.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,285.7952,669.6304
"Cardioversion, Elective;Extern",PX92960P,CDM,983,RC,92960,CPT,,,,,,,,688,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,337.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,285.7952,669.6304
"Cardioversion, Elective;Extern",PX92960P,CDM,983,RC,92960,CPT,,,,,,,,688,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,337.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,285.7952,669.6304
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604F,CDM,510,RC,20604,CPT,,,,,,,,344,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,337.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,142.8976,337.12
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031F,CDM,510,RC,12031,CPT,,,,,,,,688,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,337.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,285.7952,674.24
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031F,CDM,510,RC,12031,CPT,,,,,,,,688,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,337.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,285.7952,674.24
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031F,CDM,510,RC,12031,CPT,,,,,,,,688,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,337.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,285.7952,674.24
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004164,NDC,1,EA,666.52,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,337.25912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
"Initial Repair of Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49593P,CDM,982,RC,49593,CPT,,,,,,,,2606,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,337.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,337.26,2553.88
"Initial Repair of Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49593P,CDM,982,RC,49593,CPT,,,,,,,,2606,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,337.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,337.26,2553.88
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004110,NDC,1,EA,666.53,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,337.26418,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
"Tech-Cytopath Eval, Fna, Rep",PX8817301,CDM,310,RC,88173,CPT,TC,,,,,,,379,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,337.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,371.42
"Needle Biopsy, Lymph Node(S)",PX38505F,CDM,510,RC,38505,CPT,,,,,,,,667,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,337.502,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,277.0718,1416.38
Bone Marrow Biopsy(Ies),PX38221F,CDM,510,RC,38221,CPT,,,,,,,,1221,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,337.6,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,43.84,337.6
Closed Rx Shldr Dislocation,PX23650F,CDM,510,RC,23650,CPT,,,,,,,,689,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,337.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,675.22
Closed Rx Shldr Dislocation,PX23650F,CDM,510,RC,23650,CPT,,,,,,,,689,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,337.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,675.22
Closed Rx Shldr Dislocation,PX23650F,CDM,510,RC,23650,CPT,,,,,,,,689,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,337.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,675.22
"Closed Rx Trimalleolar Fx,Manip",PX27818F,CDM,510,RC,27818,CPT,,,,,,,,813,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,337.7202,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,337.7202,1404.08
"Fac/Exc Skn Bngn 2.1-3cmfce,Facial",PX11443F,CDM,510,RC,11443,CPT,,,,,,,,813,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,337.7202,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,337.7202,1416.38
Xray Mandible Partial Less Than 4 Vws,PX7010001,CDM,320,RC,70100,CPT,TC,,,,,,,347,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,337.7351,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,340.06
El-1 Fecal Quantitative,PX8265390,CDM,300,RC,82653,CPT,90,,,,,,,383,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,337.806,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.0982,375.34
"Initial Repair of Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49593P,CDM,982,RC,49593,CPT,,,,,,,,2606,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,337.91,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,337.26,2553.88
"Fac/Exc Skn Beni1.1-2cm Fce,Facial",PX11442F,CDM,510,RC,11442,CPT,,,,,,,,668,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,338.008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,277.4872,654.64
Abd Duplex Abd-Full,PX9397501,CDM,921,RC,93975,CPT,TC,,,,,,,788,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,338.052,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,772.24
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122F,CDM,510,RC,13122,CPT,,,,,,,,788,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,338.052,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,327.3352,772.24
"Remv Foot Foreign Body,Subcutaneous",PX28190P,CDM,983,RC,28190,CPT,,,,,,,,683,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,338.085,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,283.7182,664.7639
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623F,CDM,510,RC,11623,CPT,,,,,,,,690,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,338.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,286.626,1416.38
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623F,CDM,510,RC,11623,CPT,,,,,,,,690,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,338.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,286.626,1416.38
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623F,CDM,510,RC,11623,CPT,,,,,,,,690,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,338.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,286.626,1416.38
Exc Skn Bnig0.6-1cm Remain Bdy,PX11421P,CDM,983,RC,11421,CPT,,,,,,,,345,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,338.1,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.15,338.1
gadoterate meglumine 10 mmol/20 mL Solution 20 mL Vial,A9575,CDM,636,RC,A9575,HCPCS,,,,67684200003,NDC,20,ML,668.27,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,338.14462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,277.599358,654.9046
pentafluoroprop - tetrafluoroeth Aerosol 116 mL Can,63700001,CDM,250,RC,,,,,,386000802,NDC,207,ML,383.42,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,338.17644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Closed Rx Elbow Dislocation,PX24600P,CDM,983,RC,24600,CPT,,,,,,,,380,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,338.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,157.852,369.854
Chrom Anal 15-20 Cells - Ref,PX8826290,CDM,310,RC,88262,CPT,90,,,,,,,398,,First Health,Commercial,both,85,,999999999,percent of total billed charges,338.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.06,390.04
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070102,NDC,1,ML,383.6,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,338.3352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.92,450.751
Temporal Artery Ligatn or Bx,PX37609F,CDM,510,RC,37609,CPT,,,,,,,,705,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,338.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,292.857,1416.38
Temporal Artery Ligatn or Bx,PX37609F,CDM,510,RC,37609,CPT,,,,,,,,705,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,338.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,292.857,1416.38
"Polysomnography, 4 or More",PX9581001,CDM,740,RC,95810,CPT,TC,,,,,,,4313,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,338.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,324.17,887.09
"Polysomnography, 4 or More",PX9581001,CDM,740,RC,95810,CPT,TC,,,,,,,4313,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,338.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,324.17,887.09
"Spinal Puncture,Lumbar,Diagnostic",PX62270F,CDM,510,RC,62270,CPT,,,,,,,,684,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,338.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,284.1336,670.32
moxifloxacin 0.5 % Solution 3 mL Bottle,25000000,CDM,250,RC,,,,,,60505058204,NDC,3,ML,691.15,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,338.6635,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
moxifloxacin 0.5 % Solution 3 mL Bottle,25000000,CDM,250,RC,,,,,,60505058204,NDC,3,ML,691.15,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,338.6635,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
moxifloxacin 0.5 % Solution 3 mL Bottle,25000000,CDM,250,RC,,,,,,60505058204,NDC,3,ML,691.15,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,338.6635,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Lvl 3 Sub Hosp High Mdm or 50 Minutes,PX99233,CDM,982,RC,99233,CPT,,,,,,,,384,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,338.688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.5136,373.7472
Fac/Removal of Skin Tags,PX11200F,CDM,510,RC,11200,CPT,,,,,,,,348,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,338.7084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,144.5592,341.04
Closed Rx Elbow Dislocation,PX24600F,CDM,510,RC,24600,CPT,,,,,,,,706,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,338.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,691.88
Closed Rx Elbow Dislocation,PX24600F,CDM,510,RC,24600,CPT,,,,,,,,706,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,338.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,691.88
Cyto Non Gyn,PX8811201,CDM,310,RC,88112,CPT,TC,,,,,,,372,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,338.892,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,364.56
filgrastim-ayow 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,800000,CDM,,,,,,,,70121157001,NDC,0.5,ML,691.62,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,338.8938,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
filgrastim-ayow 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,800000,CDM,,,,,,,,70121157001,NDC,0.5,ML,691.62,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,338.8938,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
filgrastim-ayow 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,800000,CDM,,,,,,,,70121157001,NDC,0.5,ML,691.62,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,338.8938,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Removal of Anal Tabs,PX46230F,CDM,510,RC,46230,CPT,,,,,,,,790,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,338.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,328.166,2452.93
Baloxavir Marboxil(40 MG Dose) 2 x 20 MG tablet therapy pack 2 Each Box,800000,CDM,,,,,,,,50242082802,NDC,1,EA,384.3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,338.9526,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
"Xray Mandible Compl, Min 4 Vws",PX7011001,CDM,320,RC,70110,CPT,TC,,,,,,,381,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,339.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,373.38
Dress/Debrid Large Burn No Anesth,PX16030F,CDM,510,RC,16030,CPT,,,,,,,,399,,First Health,Commercial,both,85,,999999999,percent of total billed charges,339.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,165.7446,391.02
"X-Ray Exam Hip,Bilat W/Pelvis 2 Vws",PX7352101,CDM,320,RC,73521,CPT,TC,,,,,,,399,,First Health,Commercial,both,85,,999999999,percent of total billed charges,339.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,391.02
Xray Lumbosacral 2 or 3 Vws,PX7210001,CDM,320,RC,72100,CPT,TC,,,,,,,399,,First Health,Commercial,both,85,,999999999,percent of total billed charges,339.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,391.02
Excis Primary Ganglion Wrist,PX25111F,CDM,510,RC,25111,CPT,,,,,,,,791,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,339.339,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,328.5814,1404.08
Polysomnography W/Cpap,PX9581101,CDM,740,RC,95811,CPT,TC,,,,,,,4575,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,339.44,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,339.44,928.39
"measles, mumps & rubella vaccine Recon Soln 1 Each Vial",90707,CDM,636,RC,90707,CPT,,,,6468100,NDC,1,EA,381.47,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,339.5083,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,158.462638,373.8406
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082143,NDC,1,ML,348.85,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,339.535705,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.48,367.9214
Apply Long Arm Splint,PX29105P,CDM,983,RC,29105,CPT,,,,,,,,385,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,339.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.65,374.7205
Apply Long Leg Splint,PX29505P,CDM,983,RC,29505,CPT,,,,,,,,385,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,339.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.65,374.7205
Injection for Nerve Block,PX64445F,CDM,510,RC,64445,CPT,,,,,,,,385,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,339.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,604.15
Injection for Nerve Block,PX64445P,CDM,983,RC,64445,CPT,,,,,,,,385,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,339.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,604.15
MICA DEPTH GAUGE 150MM STERILE MICA,27200000,CDM,272,RC,,,,12439-MAIN,LOCAL,,,,,385,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,339.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"N Block Inj, Plantar Digit",PX64455F,CDM,510,RC,64455,CPT,,,,,,,,385,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,339.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,377.3
"N Block Inj, Plantar Digit",PX64455P,CDM,983,RC,64455,CPT,,,,,,,,385,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,339.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,374.7205
Xray Temporomandib Jnt Unilat,PX7032801,CDM,320,RC,70328,CPT,TC,,,,,,,385,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,339.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,377.3
"Up GI Endoscopy,Dilatn W Guide",PX43248F,CDM,750,RC,43248,CPT,,,,,,,,1995,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,339.67,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.66,856.45
"Echo Heart Xthoracic,Limited",PX9330801,CDM,480,RC,93308,CPT,TC,,,,,,,349,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,339.6817,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,144.9746,342.02
"Morphometric Analysis, Tumor - Ref",PX8836090,CDM,310,RC,88360,CPT,90,,,,,,,349,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,339.6817,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,144.9746,342.02
Xray Ribs Unilat 2 Vws With Pa Chest,PX7110101,CDM,320,RC,71101,CPT,TC,,,,,,,792,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,339.768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,776.16
"X-Ray Exam Hip,Bilat W/Pelvis 3-4 Vws",PX7352201,CDM,320,RC,73522,CPT,TC,,,,,,,382,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,339.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,374.36
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12173-MAIN,LOCAL,,,,,400,,First Health,Commercial,both,85,,999999999,percent of total billed charges,340,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Lvl 1 Init Hosp Low Mdm or 40 Minutes,PX99221,CDM,982,RC,99221,CPT,,,,,,,,400,,First Health,Commercial,both,85,,999999999,percent of total billed charges,340,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.16,389.32
"Molecular Path Proc, Level 2 - Ref",PX8140190,CDM,310,RC,81401,CPT,90,,,,,,,672,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,340.032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.62,658.56
Xray Mandible Partial Less Than 4 Vws,PX7010001,CDM,320,RC,70100,CPT,TC,,,,,,,347,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,340.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,340.06
Repr Superf Wnd Face 5.1-7.5,PX12014P,CDM,983,RC,12014,CPT,,,,,,,,819,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,340.2126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,797.1327
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032F,CDM,510,RC,12032,CPT,,,,,,,,386,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,340.452,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.3444,378.28
RELOAD SUREFORM 45 2.5MM WHITE,27200000,CDM,272,RC,,,,12791-MAIN,LOCAL,,,,,386,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,340.452,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 45 3.5MM BLUE,27200000,CDM,272,RC,,,,12792-MAIN,LOCAL,,,,,386,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,340.452,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 45 4.3MM GREEN,27200000,CDM,272,RC,,,,12793-MAIN,LOCAL,,,,,386,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,340.452,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Fac/Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601F,CDM,510,RC,11601,CPT,,,,,,,,673,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,340.538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,279.5642,659.54
"Cardioversion, Elective;Extern",PX92960P,CDM,983,RC,92960,CPT,,,,,,,,688,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,340.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,285.7952,669.6304
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031F,CDM,510,RC,12031,CPT,,,,,,,,688,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,340.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,285.7952,674.24
desflurane Solution 240 mL Bottle,25000000,CDM,250,RC,,,,,,10019064134,NDC,240,ML,793.95,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,340.60455,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Flu Dna Amp Probe 1st 2 Types,PX87502,CDM,300,RC,87502,CPT,,,,,,,,350,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,340.655,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.84,343
SUTURE CTD VICRYL 4-0 VIL BR SUTUPK J103T,27200000,CDM,272,RC,,,,4491-MAIN,LOCAL,,,,,373.97,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,340.68667,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Fac/Exc Skin Benig<5mm Remaind Bod,PX11420F,CDM,510,RC,11420,CPT,,,,,,,,374,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,340.714,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,1416.38
"Fac/Office Consultation,Level III",PX99243F,CDM,510,RC,99213,CPT,,,,,,,,374,,Medica,Commercial,both,91.1,,29.80769231,percent of total billed charges,340.714,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,366.52
"Inpatient Consult, Level III",PX99253,CDM,983,RC,99253,CPT,,,,,,,,374,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,340.714,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,364.0142
"Office Consultation,Level III",PX99243P,CDM,983,RC,99243,CPT,,,,,,,,374,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,340.714,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,364.0142
Removal of Hemorrhoid Clot,PX46320P,CDM,983,RC,46320,CPT,,,,,,,,374,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,340.714,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,1030.93
Xray Hand 3vws Tc,PX7313001,CDM,320,RC,73130,CPT,TC,,,,,,,374,,Medica,Commercial,both,91.1,,36.3,percent of total billed charges,340.714,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,366.52
"Calprotectin, Fecal - Ref",PX8399390,CDM,300,RC,83993,CPT,90,,,,,,,401,,First Health,Commercial,both,85,,999999999,percent of total billed charges,340.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18,392.98
El-1 Fecal Quantitative,PX8265390,CDM,300,RC,82653,CPT,90,,,,,,,383,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,340.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.0982,375.34
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021080166,NDC,5,ML,820.8,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,340.96032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092401,NDC,0.5,ML,820.88,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,340.993552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092491,NDC,0.5,ML,820.88,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,340.993552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092410,NDC,0.5,ML,820.89,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,340.997706,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
Abd Paracentesis W/Imaging(P),PX49083P,CDM,983,RC,49083,CPT,,,,,,,,696,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,341.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.1184,791.92
Abd Paracentesis W/Imaging(P),PX49083P,CDM,983,RC,49083,CPT,,,,,,,,696,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,341.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.1184,791.92
Abd Paracentesis W/Imaging(P),PX49083P,CDM,983,RC,49083,CPT,,,,,,,,696,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,341.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.1184,791.92
Fac/Removal of Skin Tags,PX11200F,CDM,510,RC,11200,CPT,,,,,,,,348,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,341.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,144.5592,341.04
TAPER POST TOE JOINT HEMICAP 9.5MM ARTICULATING METATARSAL STERILE,C1713,CDM,278,RC,C1713,HCPCS,,12531-MAIN,LOCAL,,,,,821,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,341.0434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Aspirate Pleura W/ Imaging,PX32555F,CDM,761,RC,32555,CPT,,,,,,,,795,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,341.055,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,330.243,779.1
Aspirate Pleura W/O Imaging,PX32554F,CDM,510,RC,32554,CPT,,,,,,,,795,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,341.055,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,330.243,779.1
Closed Rx Shldr Dislocation,PX23650F,CDM,510,RC,23650,CPT,,,,,,,,689,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,341.055,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,675.22
"Injection,Sacroiliac Joint(T)",PX27096F,CDM,510,RC,27096,CPT,,,,,,,,881,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,341.06,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.7,341.06
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,60505619301,NDC,5,ML,821.36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,341.192944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.08296,1009.1158
"Level V - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3939,CDM,310,RC,88307,CPT,TC,,,,,,,252,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,341.216,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,200.06,341.216
"Level V - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3939,CDM,310,RC,88307,CPT,TC,,,,,,,252,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,341.216,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,200.06,341.216
pentafluoroprop - tetrafluoroeth Aerosol 116 mL Can,63700001,CDM,250,RC,,,,,,386000802,NDC,207,ML,383.42,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,341.2438,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CT Soft Tissue Neck W/O Dye,PX7049001,CDM,350,RC,70490,CPT,TC,,,,,,,711,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,341.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,1198.67
CT Soft Tissue Neck W/O Dye,PX7049001,CDM,350,RC,70490,CPT,TC,,,,,,,711,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,341.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,1198.67
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423F,CDM,510,RC,11423,CPT,,,,,,,,711,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,341.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,295.3494,1416.38
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423F,CDM,510,RC,11423,CPT,,,,,,,,711,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,341.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,295.3494,1416.38
Drain/Inject Med Joint/Brusa W/US Guide,PX20606F,CDM,510,RC,20606,CPT,,,,,,,,387,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,341.334,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.7598,604.15
"Ex Sknbngn0.6-1cmtrnk,Arm,Lg",PX11401P,CDM,983,RC,11401,CPT,,,,,,,,387,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,341.334,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.7598,376.6671
"Exc Skn Benig<5mm Face,Facial",PX11440P,CDM,983,RC,11440,CPT,,,,,,,,387,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,341.334,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.7598,614.65
Facility Emergency Level II Visit,PX99282F,CDM,450,RC,99282,CPT,,,,,,,,387,,United Healthcare,All Payer,outpatient,88.2,,133.9271429,percent of total billed charges,341.334,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,142.88,379.26
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070102,NDC,1,ML,383.6,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,341.404,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.92,450.751
Exc Skn Bngn1.1-2cm Remain Bdy,PX11422P,CDM,983,RC,11422,CPT,,,,,,,,822,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,341.4588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,341.4588,1416.38
Ligation of Hemorrhoid(S),PX46221P,CDM,983,RC,46221,CPT,,,,,,,,697,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,341.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.5338,798.45
Ligation of Hemorrhoid(S),PX46221P,CDM,983,RC,46221,CPT,,,,,,,,697,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,341.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.5338,798.45
Ligation of Hemorrhoid(S),PX46221P,CDM,983,RC,46221,CPT,,,,,,,,697,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,341.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.5338,798.45
STAPLER INTERNAL POWERED 29MM CURVED CIRCULAR,27200000,CDM,272,RC,,,,12024-MAIN,LOCAL,,,,,697,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,341.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STAPLER INTERNAL POWERED 29MM CURVED CIRCULAR,27200000,CDM,272,RC,,,,12024-MAIN,LOCAL,,,,,697,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,341.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STAPLER INTERNAL POWERED 29MM CURVED CIRCULAR,27200000,CDM,272,RC,,,,12024-MAIN,LOCAL,,,,,697,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,341.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STAPLER INTERNAL POWERED 31MM CURVED CIRCULAR,27200000,CDM,272,RC,,,,12025-MAIN,LOCAL,,,,,697,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,341.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STAPLER INTERNAL POWERED 31MM CURVED CIRCULAR,27200000,CDM,272,RC,,,,12025-MAIN,LOCAL,,,,,697,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,341.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STAPLER INTERNAL POWERED 31MM CURVED CIRCULAR,27200000,CDM,272,RC,,,,12025-MAIN,LOCAL,,,,,697,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,341.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623F,CDM,510,RC,11623,CPT,,,,,,,,690,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,341.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,286.626,1416.38
Injection for Shoulder Arthrogram,PX23350F,CDM,510,RC,23350,CPT,,,,,,,,675,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,341.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,280.395,661.5
"Digital Mamm, Diag, Bilat, Tc W/Cad Perf",PX7706601,CDM,401,RC,77066,CPT,TC,,,,,,,375,,Medica,Commercial,both,91.1,,179.4375,percent of total billed charges,341.625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.05,367.5
"Digital Mammogram, Screen Bil, Tc W/Cad Perf",PX7706701,CDM,403,RC,77067,CPT,TC,,,,,,,375,,Medica,Commercial,both,91.1,,313.5990909,percent of total billed charges,341.625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.86,561
Repr Superf Wnd Face 2.6-5,PX12013F,CDM,510,RC,12013,CPT,,,,,,,,375,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,341.625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.775,367.5
Xray Wrist Minimum 3 Vws,PX7311001,CDM,320,RC,73110,CPT,TC,,,,,,,375,,Medica,Commercial,both,91.1,,134.28,percent of total billed charges,341.625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,367.5
Debride Bone Ea Add 20 Sqcm,PX11047P,CDM,983,RC,11047,CPT,,,,,,,,351,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,341.6283,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,145.8054,341.6283
Debride Tissue/Muscle,PX11043P,CDM,983,RC,11043,CPT,,,,,,,,351,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,341.6283,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,145.8054,548.67
"Cardioversion, Elective;Extern",PX92960F,CDM,480,RC,92960,CPT,,,,,,,,402,,First Health,Commercial,both,85,,999999999,percent of total billed charges,341.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.9908,568.57
Chem Cautery Granulatn Tissue,PX17250P,CDM,983,RC,17250,CPT,,,,,,,,402,,First Health,Commercial,both,85,,999999999,percent of total billed charges,341.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.9908,391.2666
Lab Imm Spin X-Match,PX8837,CDM,300,RC,86920,CPT,,,,,,,,402,,First Health,Commercial,both,85,,999999999,percent of total billed charges,341.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.22,393.96
"Morphometric Analysis, in Situ Hybridization, Each Probe; Manual, Tech",PX8836801,CDM,310,RC,88368,CPT,TC,,,,,,,402,,First Health,Commercial,both,85,,999999999,percent of total billed charges,341.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.9908,393.96
Lvl 3 Sub Hosp High Mdm or 50 Minutes,PX99233,CDM,982,RC,99233,CPT,,,,,,,,384,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,341.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.5136,373.7472
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082143,NDC,1,ML,348.85,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,341.873,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.48,367.9214
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082152,NDC,1,ML,375.43,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,342.01673,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.48,367.9214
"Echo Heart Xthoracic,Limited",PX9330801,CDM,480,RC,93308,CPT,TC,,,,,,,349,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,342.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,144.9746,342.02
"Fac/Exc Skn Malig .1-2cm Fce,Facal",PX11642F,CDM,510,RC,11642,CPT,,,,,,,,698,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,342.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.9492,684.04
"Fac/Exc Skn Malig .1-2cm Fce,Facal",PX11642F,CDM,510,RC,11642,CPT,,,,,,,,698,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,342.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.9492,684.04
"Fac/Exc Skn Malig .1-2cm Fce,Facal",PX11642F,CDM,510,RC,11642,CPT,,,,,,,,698,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,342.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.9492,684.04
"Morphometric Analysis, Tumor - Ref",PX8836090,CDM,310,RC,88360,CPT,90,,,,,,,349,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,342.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,144.9746,342.02
Baloxavir Marboxil(40 MG Dose) 2 x 20 MG tablet therapy pack 2 Each Box,800000,CDM,,,,,,,,50242082802,NDC,1,EA,384.3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,342.027,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Direct Admit Hospital Observ,PXG0379,CDM,761,RC,G0379,HCPCS,,,,,,,,676,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,342.056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,280.8104,662.48
butamben-tetracaine-benzocaine 2-2-14 % Aerosol 5 g Bottle,25000000,CDM,250,RC,,,,,,10223020104,NDC,5,GR,375.52,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,342.09872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
moxifloxacin 0.5 % Solution 3 mL Bottle,25000000,CDM,250,RC,,,,,,60505058204,NDC,3,ML,691.15,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,342.11925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
oseltamivir 6 MG/ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,68180067801,NDC,60,ML,676.25,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,342.1825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Repr Superf Wnd Face >30cm,PX12018F,CDM,510,RC,12018,CPT,,,,,,,,713,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,342.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,698.74
Repr Superf Wnd Face >30cm,PX12018F,CDM,510,RC,12018,CPT,,,,,,,,713,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,342.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,698.74
albumin human 25% 25 % Solution 50 mL Flex Cont,P9047,CDM,636,RC,P9047,HCPCS,,,,944049301,NDC,50,ML,402.67,,First Health,Commercial,both,85,,999999999,percent of total billed charges,342.2695,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.66,394.6166
hepatitis A vaccine 1440 EL U/ML Suspension 1 mL Syringe,90632,CDM,636,RC,90632,CPT,,,,58160082652,NDC,1,ML,375.78,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,342.33558,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,156.099012,368.2644
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598046562,NDC,1,EA,798,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,342.342,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
filgrastim-ayow 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,800000,CDM,,,,,,,,70121157001,NDC,0.5,ML,691.62,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,342.3519,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
fat emulsion 20 % Emulsion 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,338051958,NDC,200,ML,375.95,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,342.49045,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Lap,Inguinal Hernia Repr,Recur",PX49651F,CDM,510,RC,49651,CPT,,,,,,,,1568,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,342.5,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,342.5,1184.36
"Lap,Inguinal Hernia Repr,Recur",PX49651P,CDM,983,RC,49651,CPT,,,,,,,,2035,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,342.5,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,342.5,1994.3
Apply Long Arm Splint,PX29105P,CDM,983,RC,29105,CPT,,,,,,,,385,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,342.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.65,374.7205
Apply Long Leg Splint,PX29505P,CDM,983,RC,29505,CPT,,,,,,,,385,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,342.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.65,374.7205
Injection for Nerve Block,PX64445F,CDM,510,RC,64445,CPT,,,,,,,,385,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,342.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,604.15
Injection for Nerve Block,PX64445P,CDM,983,RC,64445,CPT,,,,,,,,385,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,342.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,604.15
MICA DEPTH GAUGE 150MM STERILE MICA,27200000,CDM,272,RC,,,,12439-MAIN,LOCAL,,,,,385,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,342.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"N Block Inj, Plantar Digit",PX64455F,CDM,510,RC,64455,CPT,,,,,,,,385,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,342.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,377.3
"N Block Inj, Plantar Digit",PX64455P,CDM,983,RC,64455,CPT,,,,,,,,385,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,342.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,374.7205
Xray Temporomandib Jnt Unilat,PX7032801,CDM,320,RC,70328,CPT,TC,,,,,,,385,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,342.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,377.3
CATHETER BIPOLAR ELECTROHEMOSTASIS 7FR 300CM M00560070,27200000,CDM,272,RC,,,,12909-MAIN,LOCAL,,,,,700,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,343,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CATHETER BIPOLAR ELECTROHEMOSTASIS 7FR 300CM M00560070,27200000,CDM,272,RC,,,,12909-MAIN,LOCAL,,,,,700,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,343,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CATHETER BIPOLAR ELECTROHEMOSTASIS 7FR 300CM M00560070,27200000,CDM,272,RC,,,,12909-MAIN,LOCAL,,,,,700,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,343,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Flu Dna Amp Probe 1st 2 Types,PX87502,CDM,300,RC,87502,CPT,,,,,,,,350,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,343,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.84,343
hydrocortisone sodium succinate (preservative free) 1000 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9000501,NDC,1,EA,403.54,,First Health,Commercial,both,85,,999999999,percent of total billed charges,343.009,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
Temporary External Pacing,PX92953F,CDM,480,RC,92953,CPT,,,,,,,,678,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,343.068,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,281.6412,664.44
ANCHORAGE FIXATION PIN,27200000,CDM,272,RC,,,,12642-MAIN,LOCAL,,,,,389,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,343.098,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Ext Ecg > 48hr to 21 Day Rcrd W/Conect Intl Rcrd,PX0296T,CDM,731,RC,0296T,HCPCS,,,,,,,,389,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,343.098,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,161.5906,381.22
Closed Rx Trimalleolar Fx,PX27816P,CDM,983,RC,27816,CPT,,,,,,,,826,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,343.1204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,803.9458
Layr Clos Wnd Rest Body 2.6-7.5,PX12042F,CDM,510,RC,12042,CPT,,,,,,,,404,,First Health,Commercial,both,85,,999999999,percent of total billed charges,343.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,395.92
Neg Pressure Wound Therapy Dme >50 Sq Cm,PX97606F,CDM,761,RC,97606,CPT,,,,,,,,404,,First Health,Commercial,both,85,,999999999,percent of total billed charges,343.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,395.92
Remove Foreign Body Simple,PX10120F,CDM,510,RC,10120,CPT,,,,,,,,404,,First Health,Commercial,both,85,,999999999,percent of total billed charges,343.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,395.92
Remove Foreign Body Simple,PX10120P,CDM,983,RC,10120,CPT,,,,,,,,404,,First Health,Commercial,both,85,,999999999,percent of total billed charges,343.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,393.2132
Xray Foot Minimum 3 Vws,PX7363001,CDM,320,RC,73630,CPT,TC,,,,,,,404,,First Health,Commercial,both,85,,999999999,percent of total billed charges,343.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,395.92
Xray Knee 3 Vws,PX7356201,CDM,320,RC,73562,CPT,TC,,,,,,,404,,First Health,Commercial,both,85,,999999999,percent of total billed charges,343.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,395.92
Repr Superf Wnd Body 12.6-20,PX12005P,CDM,983,RC,12005,CPT,,,,,,,,377,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,343.447,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,156.6058,366.9341
DRILL BIT 2.2MMX60MM STERILE MICA CANNULATED,27200000,CDM,272,RC,,,,12437-MAIN,LOCAL,,,,,701,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,343.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRILL BIT 2.2MMX60MM STERILE MICA CANNULATED,27200000,CDM,272,RC,,,,12437-MAIN,LOCAL,,,,,701,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,343.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRILL BIT 2.2MMX60MM STERILE MICA CANNULATED,27200000,CDM,272,RC,,,,12437-MAIN,LOCAL,,,,,701,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,343.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRILL BIT 3.0MMX60MM STERILE MICA CANNULATED,27200000,CDM,272,RC,,,,12438-MAIN,LOCAL,,,,,701,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,343.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRILL BIT 3.0MMX60MM STERILE MICA CANNULATED,27200000,CDM,272,RC,,,,12438-MAIN,LOCAL,,,,,701,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,343.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRILL BIT 3.0MMX60MM STERILE MICA CANNULATED,27200000,CDM,272,RC,,,,12438-MAIN,LOCAL,,,,,701,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,343.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032F,CDM,510,RC,12032,CPT,,,,,,,,386,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,343.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.3444,378.28
RELOAD SUREFORM 45 2.5MM WHITE,27200000,CDM,272,RC,,,,12791-MAIN,LOCAL,,,,,386,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,343.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 45 3.5MM BLUE,27200000,CDM,272,RC,,,,12792-MAIN,LOCAL,,,,,386,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,343.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 45 4.3MM GREEN,27200000,CDM,272,RC,,,,12793-MAIN,LOCAL,,,,,386,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,343.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Fac/Ex Skn Bngn2.1-3cm Trnk,Arm,Lg",PX11403F,CDM,510,RC,11403,CPT,,,,,,,,679,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,343.574,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,282.0566,665.42
Creatine Mb Fraction,PX82553,CDM,300,RC,82553,CPT,,,,,,,,353,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,343.5749,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.59,345.94
Fentanyl - Ref,PX8035490,CDM,300,RC,80354,CPT,90,,,,,,,353,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,343.5749,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,345.94
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155F,CDM,370,RC,99155,CPT,,,,,,,,353,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,343.5749,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,345.94
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155P,CDM,983,RC,99155,CPT,,,,,,,,353,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,343.5749,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,343.5749
Pvb Thoracic Single Injection Site W/Img Gid,PX64461F,CDM,510,RC,64461,CPT,,,,,,,,353,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,343.5749,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,604.15
"Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404P,CDM,983,RC,11404,CPT,,,,,,,,600,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,343.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.96,588
"Fac/Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404F,CDM,510,RC,11404,CPT,,,,,,,,749,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,343.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.96,468.35
fosfomycin 3 g Packet 1 Each Box,25000000,CDM,250,RC,,,,,,70700026894,NDC,1,EA,353.41,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,343.973953,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Apc Resistance Assay - Ref,PX8530790,CDM,300,RC,85307,CPT,90,,,,,,,390,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,343.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.05,382.2
"Closed Rx Toe Fx,Manipulatn",PX28515F,CDM,510,RC,28515,CPT,,,,,,,,390,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,343.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,162.006,382.2
Debride Bone Ea Add 20 Sqcm,PX11047P,CDM,983,RC,11047,CPT,,,,,,,,351,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,343.98,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,57.59,343.98
Debride Tissue/Muscle,PX11043P,CDM,983,RC,11043,CPT,,,,,,,,351,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,343.98,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.8,483.57
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010202,NDC,1,EA,680,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,344.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 1 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010101,NDC,1,EA,680,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,344.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010102,NDC,1,EA,680,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,344.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
"Fac/Exc Skn Mal 0.6-1cm Fce,Facial",PX11641F,CDM,510,RC,11641,CPT,,,,,,,,680,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,344.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,282.472,666.4
Observation Initial,PXG0378.03,CDM,762,RC,G0378,HCPCS,,,,,,,,680,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,344.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,282.472,666.4
procainamide 500 MG/ML Solution 2 mL Vial,J2690.01,CDM,636,RC,J2690,HCPCS,,,,14789090002,NDC,2,ML,377.75,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,344.13025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,134.15,370.195
Diagnostic Anoscopy,PX46600P,CDM,983,RC,46600,CPT,,,,,,,,405,,First Health,Commercial,both,85,,999999999,percent of total billed charges,344.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,394.1865
Drain/Inject Med Joint/Brusa W/US Guide,PX20606F,CDM,510,RC,20606,CPT,,,,,,,,387,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,344.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.7598,604.15
"Ex Sknbngn0.6-1cmtrnk,Arm,Lg",PX11401P,CDM,983,RC,11401,CPT,,,,,,,,387,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,344.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.7598,376.6671
"Exc Skn Benig<5mm Face,Facial",PX11440P,CDM,983,RC,11440,CPT,,,,,,,,387,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,344.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.7598,614.65
Facility Emergency Level II Visit,PX99282F,CDM,450,RC,99282,CPT,,,,,,,,387,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,344.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,142.88,379.26
"Lap,Inguinal Hernia Repr,Recur",PX49651F,CDM,510,RC,49651,CPT,,,,,,,,1568,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,344.46,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,342.5,1184.36
"Lap,Inguinal Hernia Repr,Recur",PX49651F,CDM,510,RC,49651,CPT,,,,,,,,1568,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,344.46,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,342.5,1184.36
"Lap,Inguinal Hernia Repr,Recur",PX49651P,CDM,983,RC,49651,CPT,,,,,,,,2035,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,344.46,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,342.5,1994.3
"Lap,Inguinal Hernia Repr,Recur",PX49651P,CDM,983,RC,49651,CPT,,,,,,,,2035,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,344.46,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,342.5,1994.3
Abd Paracentesis W/Imaging(P),PX49083P,CDM,983,RC,49083,CPT,,,,,,,,696,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,344.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.1184,791.92
Xray Sinuses Minimum 3 Vws,PX7022001,CDM,320,RC,70220,CPT,TC,,,,,,,354,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,344.5482,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,346.92
Repr Superf Wnd Face 2.6-5,PX12013P,CDM,983,RC,12013,CPT,,,,,,,,681,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,344.586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,662.8173
Art Upper Extremity-Ltd,PX9393101,CDM,921,RC,93931,CPT,TC,,,,,,,718,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,344.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,703.64
Art Upper Extremity-Ltd,PX9393101,CDM,921,RC,93931,CPT,TC,,,,,,,718,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,344.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,703.64
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565P,CDM,983,RC,25565,CPT,,,,,,,,830,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,344.782,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,344.782,1404.08
"Initial Observation Care,Levl II",PX99219,CDM,982,RC,99219,CPT,,,,,,,,391,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,344.862,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,162.4214,380.5603
Ligation of Hemorrhoid(S),PX46221P,CDM,983,RC,46221,CPT,,,,,,,,697,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,345.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.5338,798.45
STAPLER INTERNAL POWERED 29MM CURVED CIRCULAR,27200000,CDM,272,RC,,,,12024-MAIN,LOCAL,,,,,697,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,345.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STAPLER INTERNAL POWERED 31MM CURVED CIRCULAR,27200000,CDM,272,RC,,,,12025-MAIN,LOCAL,,,,,697,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,345.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598F,CDM,510,RC,97598,CPT,,,,,,,,406,,First Health,Commercial,both,85,,999999999,percent of total billed charges,345.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,168.6524,397.88
"Cystourethroscopy, With Injection(S) for Chemodenervation of the Bladder",PX52287F,CDM,360,RC,52287,CPT,,,,,,,,2745,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,345.21,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.53,803.87
"Tech-Cytopath Eval, Fna, Rep",PX8817301,CDM,310,RC,88173,CPT,TC,,,,,,,379,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,345.269,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,371.42
Skin Sub Graft Trnk/Arm/Leg,PX15271P,CDM,983,RC,15271,CPT,,,,,,,,705,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,345.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,292.857,1593.14
Skin Sub Graft Trnk/Arm/Leg,PX15271P,CDM,983,RC,15271,CPT,,,,,,,,705,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,345.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,292.857,1593.14
Skin Sub Graft Trnk/Arm/Leg,PX15271P,CDM,983,RC,15271,CPT,,,,,,,,705,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,345.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,292.857,1593.14
"Spinal Puncture,Lumbar,Diagnostic",PX62270P,CDM,983,RC,62270,CPT,,,,,,,,705,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,345.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,292.857,686.1765
"Spinal Puncture,Lumbar,Diagnostic",PX62270P,CDM,983,RC,62270,CPT,,,,,,,,705,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,345.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,292.857,686.1765
"Spinal Puncture,Lumbar,Diagnostic",PX62270P,CDM,983,RC,62270,CPT,,,,,,,,705,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,345.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,292.857,686.1765
Temporal Artery Ligatn or Bx,PX37609F,CDM,510,RC,37609,CPT,,,,,,,,705,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,345.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,292.857,1416.38
Temporal Artery Ligatn or Bx,PX37609F,CDM,510,RC,37609,CPT,,,,,,,,705,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,345.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,292.857,1416.38
Temporal Artery Ligatn or Bx,PX37609F,CDM,510,RC,37609,CPT,,,,,,,,705,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,345.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,292.857,1416.38
"Fac/Exc Skn Malig .1-2cm Fce,Facal",PX11642F,CDM,510,RC,11642,CPT,,,,,,,,698,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,345.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.9492,684.04
"Remv Foot Foreign Body,Subcutaneous",PX28190P,CDM,983,RC,28190,CPT,,,,,,,,683,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,345.598,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,283.7182,664.7639
"Sigmoidoscopy,Diagnostic",PX45330F,CDM,510,RC,45330,CPT,,,,,,,,720,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,345.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,299.088,798.45
"Sigmoidoscopy,Diagnostic",PX45330F,CDM,510,RC,45330,CPT,,,,,,,,720,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,345.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,299.088,798.45
"HERNIA MESH 3D MAX MID ANATOMICAL MESH RIGHT SIZE XL 5"" X 7""",C1781,CDM,278,RC,C1781,HCPCS,,11979-MAIN,LOCAL,,,,,832,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,345.6128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"HERNIA MESH 3DMAX MID MESH EXTRA-LARGE LEFT 5"" X 7""",C1781,CDM,278,RC,C1781,HCPCS,,11978-MAIN,LOCAL,,,,,832,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,345.6128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Excision of Nail Fold, Toe",PX11765F,CDM,510,RC,11765,CPT,,,,,,,,210,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,345.9,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.68,345.9
Closed Rx Elbow Dislocation,PX24600F,CDM,510,RC,24600,CPT,,,,,,,,706,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,345.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,691.88
Closed Rx Elbow Dislocation,PX24600F,CDM,510,RC,24600,CPT,,,,,,,,706,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,345.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,691.88
Closed Rx Elbow Dislocation,PX24600F,CDM,510,RC,24600,CPT,,,,,,,,706,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,345.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,691.88
Creatine Mb Fraction,PX82553,CDM,300,RC,82553,CPT,,,,,,,,353,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,345.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,10.59,345.94
Fentanyl - Ref,PX8035490,CDM,300,RC,80354,CPT,90,,,,,,,353,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,345.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,345.94
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155F,CDM,370,RC,99155,CPT,,,,,,,,353,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,345.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,345.94
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155P,CDM,983,RC,99155,CPT,,,,,,,,353,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,345.94,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.39,345.94
Pvb Thoracic Single Injection Site W/Img Gid,PX64461F,CDM,510,RC,64461,CPT,,,,,,,,353,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,345.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,604.15
"Spinal Puncture,Lumbar,Diagnostic",PX62270F,CDM,510,RC,62270,CPT,,,,,,,,684,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,346.104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,284.1336,670.32
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,517096001,NDC,10,ML,355.63,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,346.134679,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Closed Rx Elbow Dislocation,PX24600P,CDM,983,RC,24600,CPT,,,,,,,,380,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,346.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,157.852,369.854
ANCHORAGE FIXATION PIN,27200000,CDM,272,RC,,,,12642-MAIN,LOCAL,,,,,389,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,346.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Ext Ecg > 48hr to 21 Day Rcrd W/Conect Intl Rcrd,PX0296T,CDM,731,RC,0296T,HCPCS,,,,,,,,389,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,346.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,161.5906,381.22
fosfomycin 3 g Packet 1 Each Box,25000000,CDM,250,RC,,,,,,70700026894,NDC,1,EA,353.41,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,346.3418,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
CATHETER BIPOLAR ELECTROHEMOSTASIS 7FR 300CM M00560070,27200000,CDM,272,RC,,,,12909-MAIN,LOCAL,,,,,700,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,346.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
6 SHOOTER SAEED MULTIBAND LIGATOR,27200000,CDM,272,RC,,,,12379-MAIN,LOCAL,,,,,393,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,346.626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA FIRST MET TRANSLATOR STERILE MICA,27200000,CDM,272,RC,,,,12445-MAIN,LOCAL,,,,,393,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,346.626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Tap Block Bilateral by Injection(S),PX64488F,CDM,510,RC,64488,CPT,,,,,,,,393,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,346.626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,163.2522,385.14
Duplex Up Extrem Art Bilat,PX9393001,CDM,921,RC,93930,CPT,TC,,,,,,,835,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,346.859,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,818.3
Xray Sinuses Minimum 3 Vws,PX7022001,CDM,320,RC,70220,CPT,TC,,,,,,,354,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,346.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,346.92
DRILL BIT 2.2MMX60MM STERILE MICA CANNULATED,27200000,CDM,272,RC,,,,12437-MAIN,LOCAL,,,,,701,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,346.995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRILL BIT 3.0MMX60MM STERILE MICA CANNULATED,27200000,CDM,272,RC,,,,12438-MAIN,LOCAL,,,,,701,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,346.995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Abd Duplex Abd-Follow Up(T),PX9397601,CDM,921,RC,93976,CPT,TC,,,,,,,809,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,347.061,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,792.82
Venous Duplex Scan Uni,PX9397101,CDM,921,RC,93971,CPT,TC,,,,,,,809,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,347.061,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,792.82
"Xray Mandible Compl, Min 4 Vws",PX7011001,CDM,320,RC,70110,CPT,TC,,,,,,,381,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,347.091,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,373.38
Apc Resistance Assay - Ref,PX8530790,CDM,300,RC,85307,CPT,90,,,,,,,390,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,347.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.05,382.2
"Closed Rx Toe Fx,Manipulatn",PX28515F,CDM,510,RC,28515,CPT,,,,,,,,390,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,347.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,162.006,382.2
brimonidine 0.15 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314014405,NDC,5,ML,723.62,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,347.3376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
brimonidine 0.15 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314014405,NDC,5,ML,723.62,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,347.3376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,25021019110,NDC,1,EA,809.89,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,347.44281,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.47563,793.6922
Remove Intrauterine Device,PX58301,CDM,983,RC,58301,CPT,,,,,,,,357,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,347.4681,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.2978,347.4681
X-Ray Exam Chest 1 View,PX7104501,CDM,320,RC,71045,CPT,TC,,,,,,,357,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,140.3962121,percent of total billed charges,347.4681,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,349.86
"Xray Chest 1 View, Tc",PX7101001,CDM,320,RC,71010,CPT,TC,,,,,,,357,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,347.4681,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.2978,349.86
Xray Scapula Complete,PX7301001,CDM,320,RC,73010,CPT,TC,,,,,,,357,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,282.5933333,percent of total billed charges,347.4681,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,349.86
Noninvasv Lo Extrem Art Stress/Rest,PX9392401,CDM,921,RC,93924,CPT,TC,,,,,,,810,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,347.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.46,793.8
"measles, mumps & rubella vaccine Recon Soln 1 Each Vial",90707,CDM,636,RC,90707,CPT,,,,6468100,NDC,1,EA,381.47,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,347.51917,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,158.462638,373.8406
"Surgical Diagnostic Exam, Anorectal",PX45990P,CDM,983,RC,45990,CPT,,,,,,,,409,,First Health,Commercial,both,85,,999999999,percent of total billed charges,347.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,169.8986,2452.93
dantrolene 20 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,42023012306,NDC,1,EA,394.42,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,347.87844,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Initial Observation Care,Levl II",PX99219,CDM,982,RC,99219,CPT,,,,,,,,391,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,347.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,162.4214,380.5603
"X-Ray Exam Hip,Bilat W/Pelvis 3-4 Vws",PX7352201,CDM,320,RC,73522,CPT,TC,,,,,,,382,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,348.002,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,374.36
travoprost (BAK Free) 0.004 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,65026025,NDC,2.5,ML,811.3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,348.0477,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Insert Needle,Intraosseous Infusn",PX36680F,CDM,510,RC,36680,CPT,,,,,,,,659,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,348.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,273.7486,645.82
Naso/Orogastric Tube,PX43752F,CDM,510,RC,43752,CPT,,,,,,,,464,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,348.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.7456,454.72
Naso/Orogastric Tube,PX43752P,CDM,983,RC,43752,CPT,,,,,,,,309,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,348.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.3586,348.08
"Remv F.B.,Eye,Cornea,No Slit",PX65220F,CDM,510,RC,65220,CPT,,,,,,,,334,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,348.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.7436,348.08
"Remv F.B.,Eye,Cornea,No Slit",PX65220P,CDM,983,RC,65220,CPT,,,,,,,,318,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,348.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.0972,348.08
"Remv F.B.,Eye,Embed Conjunc",PX65210F,CDM,510,RC,65210,CPT,,,,,,,,325,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,348.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,135.005,348.08
"Remv F.B.,Eye,Embed Conjunc",PX65210P,CDM,983,RC,65210,CPT,,,,,,,,216,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,348.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,89.7264,348.08
"Cardioversion, Elective;Extern",PX92960P,CDM,983,RC,92960,CPT,,,,,,,,688,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,348.128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,285.7952,669.6304
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031F,CDM,510,RC,12031,CPT,,,,,,,,688,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,348.128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,285.7952,674.24
Debride Skin/Tissue,PX11042F,CDM,510,RC,11042,CPT,,,,,,,,1067,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,348.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1045.66
Debride Skin/Tissue,PX11042P,CDM,983,RC,11042,CPT,,,,,,,,995,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,348.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,968.4335
Drain Skin Abscess Complic,PX10061F,CDM,510,RC,10061,CPT,,,,,,,,889,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,348.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,871.22
Drain Skin Abscess Complic,PX10061P,CDM,983,RC,10061,CPT,,,,,,,,561,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,348.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,233.0394,546.0213
Dress/Debrid Large Burn No Anesth,PX16030F,CDM,510,RC,16030,CPT,,,,,,,,399,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,348.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,165.7446,391.02
"Ex Sknbngn0.6-1cmtrnk,Arm,Lg",PX11401P,CDM,983,RC,11401,CPT,,,,,,,,387,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,348.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.7598,376.6671
"Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602P,CDM,983,RC,11602,CPT,,,,,,,,1120,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,348.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1090.096
"Excision of Nail Fold, Toe",PX11765F,CDM,510,RC,11765,CPT,,,,,,,,210,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,348.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.234,348.35
"Fac/Ex Skinbngn0.6-1cmtrnk,Arm,Lg",PX11401F,CDM,510,RC,11401,CPT,,,,,,,,484,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,348.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.0536,474.32
"Fac/Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602F,CDM,510,RC,11602,CPT,,,,,,,,731,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,348.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,303.6574,716.38
"Layr Clos Wnd Face,Facial <2.5cm",PX12051F,CDM,510,RC,12051,CPT,,,,,,,,769,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,348.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,319.4426,753.62
"Layr Clos Wnd Face,Facial <2.5cm",PX12051P,CDM,983,RC,12051,CPT,,,,,,,,615,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,348.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.471,598.5795
"Layr Clos Wnd Face,Facial 2.5-5",PX12052F,CDM,510,RC,12052,CPT,,,,,,,,585,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,348.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,243.009,573.3
"Layr Clos Wnd Face,Facial 2.5-5",PX12052P,CDM,983,RC,12052,CPT,,,,,,,,776,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,348.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,322.3504,755.2808
Layr Clos Wnd Rest Body 2.6-7.5,PX12042F,CDM,510,RC,12042,CPT,,,,,,,,404,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,348.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,395.92
Layr Clos Wnd Rest Body 2.6-7.5,PX12042P,CDM,983,RC,12042,CPT,,,,,,,,777,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,348.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,322.7658,756.2541
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031F,CDM,510,RC,12031,CPT,,,,,,,,688,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,348.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,285.7952,674.24
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031P,CDM,983,RC,12031,CPT,,,,,,,,551,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,348.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,228.8854,536.2883
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032F,CDM,510,RC,12032,CPT,,,,,,,,386,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,348.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.3444,378.28
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032P,CDM,983,RC,12032,CPT,,,,,,,,647,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,348.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,268.7638,629.7251
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034F,CDM,510,RC,12034,CPT,,,,,,,,931,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,348.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,912.38
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034P,CDM,983,RC,12034,CPT,,,,,,,,1533,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,348.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1492.0689
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035F,CDM,510,RC,12035,CPT,,,,,,,,655,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,348.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,272.087,641.9
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035P,CDM,983,RC,12035,CPT,,,,,,,,1244,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,348.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1210.7852
Neg Pressure Wound Therapy Dme >50 Sq Cm,PX97606F,CDM,761,RC,97606,CPT,,,,,,,,404,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,348.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,395.92
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607F,CDM,761,RC,97607,CPT,,,,,,,,455,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,348.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.007,445.9
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607P,CDM,983,RC,97607,CPT,,,,,,,,303,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,348.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.8662,348.35
Puncture Drainage of Lesion,PX10160F,CDM,510,RC,10160,CPT,,,,,,,,279,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,348.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.8966,348.35
Puncture Drainage of Lesion,PX10160P,CDM,983,RC,10160,CPT,,,,,,,,186,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,348.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.2644,348.35
Removal of Nail Bed,PX11750F,CDM,510,RC,11750,CPT,,,,,,,,629,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,348.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,261.2866,616.42
Remove Foreign Body Simple,PX10120F,CDM,510,RC,10120,CPT,,,,,,,,404,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,348.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,395.92
Remove Foreign Body Simple,PX10120P,CDM,983,RC,10120,CPT,,,,,,,,404,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,348.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,393.2132
Repr Superf Wnd Body 12.6-20,PX12005F,CDM,510,RC,12005,CPT,,,,,,,,565,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,348.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,234.701,553.7
Repr Superf Wnd Body 12.6-20,PX12005P,CDM,983,RC,12005,CPT,,,,,,,,377,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,348.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,156.6058,366.9341
CT Soft Tissue Neck W/O Dye,PX7049001,CDM,350,RC,70490,CPT,TC,,,,,,,711,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,348.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,1198.67
CT Soft Tissue Neck W/O Dye,PX7049001,CDM,350,RC,70490,CPT,TC,,,,,,,711,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,348.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,1198.67
CT Soft Tissue Neck W/O Dye,PX7049001,CDM,350,RC,70490,CPT,TC,,,,,,,711,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,348.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,1198.67
Drainage of Gum Lesion,PX41800F,CDM,510,RC,41800,CPT,,,,,,,,395,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,348.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,387.1
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423F,CDM,510,RC,11423,CPT,,,,,,,,711,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,348.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,295.3494,1416.38
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423F,CDM,510,RC,11423,CPT,,,,,,,,711,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,348.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,295.3494,1416.38
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423F,CDM,510,RC,11423,CPT,,,,,,,,711,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,348.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,295.3494,1416.38
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614900,NDC,1,EA,409.89,,First Health,Commercial,both,85,,999999999,percent of total billed charges,348.4065,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
Declot Vascular Access Device,PX36593F,CDM,510,RC,36593,CPT,,,,,,,,358,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,348.4414,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.7132,350.84
Fac/Irrigation of Bladder,PX51700F,CDM,510,RC,51700,CPT,,,,,,,,358,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,348.4414,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.7132,350.84
X-Ray Exam Abdomen 1 View,PX7401801,CDM,320,RC,74018,CPT,TC,,,,,,,358,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,348.4414,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,350.84
Xray Abdomen Single Ap Vw,PX7400001,CDM,320,RC,74000,CPT,TC,,,,,,,358,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,348.4414,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.7132,350.84
"Lab Antibody ID,RBC",PX86870,CDM,300,RC,,,,,,,,,,410,,First Health,Commercial,both,85,,999999999,percent of total billed charges,348.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,170.314,401.8
"Supply Technicium Sestamibi,per Dose",PXA9500,CDM,343,RC,A9500,HCPCS,,,,,,,,410,,First Health,Commercial,both,85,,999999999,percent of total billed charges,348.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,170.314,401.8
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,517096001,NDC,10,ML,355.63,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,348.5174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Blood Transfusion Service,PX36430,CDM,391,RC,36430,CPT,,,,,,,,839,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,348.5206,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.5206,822.22
Drainage of Gum Lesion,PX41800P,CDM,983,RC,41800,CPT,,,,,,,,839,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,348.5206,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,816.5987
Closed Rx Shldr Dislocation,PX23650F,CDM,510,RC,23650,CPT,,,,,,,,689,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,348.634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,675.22
"Inj,Lumb Epidur,Blood/Clot Patch",PX62273P,CDM,983,RC,62273,CPT,,,,,,,,552,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,348.67,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.02,540.96
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133F,CDM,510,RC,13133,CPT,,,,,,,,595,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,348.67,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77,348.67
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133P,CDM,983,RC,13133,CPT,,,,,,,,256,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,348.67,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77,348.67
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320990,NDC,1,EA,410.32,,First Health,Commercial,both,85,,999999999,percent of total billed charges,348.772,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320995,NDC,1,EA,410.32,,First Health,Commercial,both,85,,999999999,percent of total billed charges,348.772,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
"Closed Rx Trimalleolar Fx,Manip",PX27818F,CDM,510,RC,27818,CPT,,,,,,,,813,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,348.777,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,337.7202,1404.08
"Fac/Exc Skn Bngn 2.1-3cmfce,Facial",PX11443F,CDM,510,RC,11443,CPT,,,,,,,,813,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,348.777,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,337.7202,1416.38
NON-LOCKING SCREW 3.5X18MM,C1713,CDM,278,RC,C1713,HCPCS,,12466-MAIN,LOCAL,,,,,395.51,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,348.83982,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
El-1 Fecal Quantitative,PX8265390,CDM,300,RC,82653,CPT,90,,,,,,,383,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,348.913,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.0982,375.34
Skin Sub Graft Trnk/Arm/Leg,PX15271P,CDM,983,RC,15271,CPT,,,,,,,,705,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,348.975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,292.857,1593.14
"Spinal Puncture,Lumbar,Diagnostic",PX62270P,CDM,983,RC,62270,CPT,,,,,,,,705,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,348.975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,292.857,686.1765
Temporal Artery Ligatn or Bx,PX37609F,CDM,510,RC,37609,CPT,,,,,,,,705,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,348.975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,292.857,1416.38
"Casiri and Imdevimab,Admin,Repeat Dose",PXM0240,CDM,771,RC,M0240,HCPCS,,,,,,,,1555,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,349.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,295.15,450
"Casiri and Imdevimab,Admin,Repeat Dose",PXM0240,CDM,771,RC,M0240,HCPCS,,,,,,,,1555,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,349.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,295.15,450
"IV Infusion, Bamlanivimab and Etesevimab, Infusion and Monitoring",PXM0245,CDM,260,RC,M0245,HCPCS,,,,,,,,1555,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,349.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,295.15,450
"IV Infusion, Bamlanivimab and Etesevimab, Infusion and Monitoring",PXM0245,CDM,260,RC,M0245,HCPCS,,,,,,,,1555,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,349.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,295.15,450
"IV Infusion, Casirivimab and Imdevimab, IV and Post Admr",PXM0243,CDM,771,RC,M0243,HCPCS,,,,,,,,1555,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,349.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,295.15,450
"IV Infusion, Casirivimab and Imdevimab, IV and Post Admr",PXM0243,CDM,771,RC,M0243,HCPCS,,,,,,,,1555,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,349.04,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,295.15,450
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623F,CDM,510,RC,11623,CPT,,,,,,,,690,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,349.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,286.626,1416.38
Comprehensive Metabolic Panel,PX80053,CDM,300,RC,80053,CPT,,,,,,,,396,,United Healthcare,All Payer,outpatient,88.2,,208.05,percent of total billed charges,349.272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.68,388.08
Neg Pressure Wound Therapy Dme </=50 Sq Cm,PX97605F,CDM,510,RC,97605,CPT,,,,,,,,396,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,349.272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,164.4984,388.08
NON-LOCKING SCREW 3.5X12MM,27200000,CDM,278,RC,C1713,HCPCS,,11857-MAIN,LOCAL,,,,,396,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,349.272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NON-LOCKING SCREW 3.5X16MM,27200000,CDM,278,RC,C1713,HCPCS,,11856-MAIN,LOCAL,,,,,396,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,349.272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NON-LOCKING SCREW 3.5X24MM,27200000,CDM,278,RC,C1713,HCPCS,,11855-MAIN,LOCAL,,,,,396,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,349.272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
pentafluoroprop - tetrafluoroeth Aerosol 116 mL Can,63700001,CDM,250,RC,,,,,,386000802,NDC,207,ML,383.42,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,349.29562,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
8MM ENDOWRIST INSTRUMENTS TIP-UP FENESTRATED GRASPER,27200000,CDM,272,RC,,,,11911-MAIN,LOCAL,,,,,411,,First Health,Commercial,both,85,,999999999,percent of total billed charges,349.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Bone Marrow Aspiration and Biopsy,PXG0364F,CDM,510,RC,G0364,HCPCS,,,,,,,,411,,First Health,Commercial,both,85,,999999999,percent of total billed charges,349.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,170.7294,402.78
Repr Superf Wnd Face >30cm,PX12018F,CDM,510,RC,12018,CPT,,,,,,,,713,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,349.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,698.74
Repr Superf Wnd Face >30cm,PX12018F,CDM,510,RC,12018,CPT,,,,,,,,713,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,349.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,698.74
Repr Superf Wnd Face >30cm,PX12018F,CDM,510,RC,12018,CPT,,,,,,,,713,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,349.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,698.74
"Office/Outpt Visit,New,Levl IV",PX99204F,CDM,510,RC,99204,CPT,,,,,,,,359,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,421.8466667,percent of total billed charges,349.4147,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.1286,351.82
"Office/Outpt Visit,New,Levl IV",PX99204P,CDM,983,RC,99204,CPT,,,,,,,,359,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,421.8466667,percent of total billed charges,349.4147,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.1286,349.4147
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070102,NDC,1,ML,383.6,,Medica,Commercial,both,91.1,,0.343333333,percent of total billed charges,349.4596,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.92,450.751
Closed Rx Elbow Dislocation,PX24600F,CDM,510,RC,24600,CPT,,,,,,,,706,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,349.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,691.88
MINIBUNION DRILL KIT,27200000,CDM,278,RC,C1713,HCPCS,,11669-MAIN,LOCAL,,,,,841.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,349.5591,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
moxifloxacin 0.5 % Solution 3 mL Bottle,25000000,CDM,250,RC,,,,,,60505058204,NDC,3,ML,691.15,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,349.7219,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
6 SHOOTER SAEED MULTIBAND LIGATOR,27200000,CDM,272,RC,,,,12379-MAIN,LOCAL,,,,,393,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,349.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA FIRST MET TRANSLATOR STERILE MICA,27200000,CDM,272,RC,,,,12445-MAIN,LOCAL,,,,,393,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,349.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Tap Block Bilateral by Injection(S),PX64488F,CDM,510,RC,64488,CPT,,,,,,,,393,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,349.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,163.2522,385.14
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801801,NDC,0.8,ML,359.37,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,25.0327027,percent of total billed charges,349.774821,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801810,NDC,0.8,ML,359.37,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,25.0327027,percent of total billed charges,349.774821,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
Lvl 3 Sub Hosp High Mdm or 50 Minutes,PX99233,CDM,982,RC,99233,CPT,,,,,,,,384,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,349.824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.5136,373.7472
Remove Intrauterine Device,PX58301,CDM,983,RC,58301,CPT,,,,,,,,357,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,349.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.14,349.86
X-Ray Exam Chest 1 View,PX7104501,CDM,320,RC,71045,CPT,TC,,,,,,,357,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,349.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,349.86
"Xray Chest 1 View, Tc",PX7101001,CDM,320,RC,71010,CPT,TC,,,,,,,357,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,349.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.2978,349.86
Xray Scapula Complete,PX7301001,CDM,320,RC,73010,CPT,TC,,,,,,,357,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,349.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,349.86
filgrastim-ayow 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,800000,CDM,,,,,,,,70121157001,NDC,0.5,ML,691.62,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,349.95972,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Baloxavir Marboxil(40 MG Dose) 2 x 20 MG tablet therapy pack 2 Each Box,800000,CDM,,,,,,,,50242082802,NDC,1,EA,384.3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,350.0973,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
"Sigmoidoscopy,Screen Prev",PX2001F,CDM,750,RC,45330,CPT,,,,,,,,843,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,350.1822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,350.1822,826.14
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545P,CDM,983,RC,23545,CPT,,,,,,,,412,,First Health,Commercial,both,85,,999999999,percent of total billed charges,350.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,171.1448,400.9996
"Closed Rx Big Toe Fx,Manip",PX28495P,CDM,983,RC,28495,CPT,,,,,,,,412,,First Health,Commercial,both,85,,999999999,percent of total billed charges,350.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,171.1448,400.9996
Closed Rx Mt-Phal Toe Dislocation,PX28630F,CDM,510,RC,28630,CPT,,,,,,,,360,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,350.388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.544,352.8
RBC Antibody Elution,PX86860,CDM,300,RC,86860,CPT,,,,,,,,360,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,350.388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.22,352.8
Apply Long Arm Splint,PX29105P,CDM,983,RC,29105,CPT,,,,,,,,385,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,350.735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.65,374.7205
Apply Long Leg Splint,PX29505P,CDM,983,RC,29505,CPT,,,,,,,,385,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,350.735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.65,374.7205
Injection for Nerve Block,PX64445F,CDM,510,RC,64445,CPT,,,,,,,,385,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,350.735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,604.15
Injection for Nerve Block,PX64445P,CDM,983,RC,64445,CPT,,,,,,,,385,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,350.735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,604.15
MICA DEPTH GAUGE 150MM STERILE MICA,27200000,CDM,272,RC,,,,12439-MAIN,LOCAL,,,,,385,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,350.735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"N Block Inj, Plantar Digit",PX64455F,CDM,510,RC,64455,CPT,,,,,,,,385,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,350.735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,377.3
"N Block Inj, Plantar Digit",PX64455P,CDM,983,RC,64455,CPT,,,,,,,,385,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,350.735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,374.7205
Xray Temporomandib Jnt Unilat,PX7032801,CDM,320,RC,70328,CPT,TC,,,,,,,385,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,350.735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,377.3
Drainage Scrotal Wall Abscess,PX55100F,CDM,510,RC,55100,CPT,,,,,,,,634,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,350.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.27,482.88
Drainage Scrotal Wall Abscess,PX55100P,CDM,983,RC,55100,CPT,,,,,,,,341,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,350.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.27,482.88
Declot Vascular Access Device,PX36593F,CDM,510,RC,36593,CPT,,,,,,,,358,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,350.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.7132,350.84
Fac/Irrigation of Bladder,PX51700F,CDM,510,RC,51700,CPT,,,,,,,,358,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,350.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.7132,350.84
X-Ray Exam Abdomen 1 View,PX7401801,CDM,320,RC,74018,CPT,TC,,,,,,,358,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,350.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,350.84
Xray Abdomen Single Ap Vw,PX7400001,CDM,320,RC,74000,CPT,TC,,,,,,,358,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,350.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.7132,350.84
"Fac/Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602F,CDM,510,RC,11602,CPT,,,,,,,,731,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,350.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,303.6574,716.38
"Fac/Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602F,CDM,510,RC,11602,CPT,,,,,,,,731,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,350.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,303.6574,716.38
dantrolene 20 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,42023012306,NDC,1,EA,394.42,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,351.0338,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Chrom Anal 15-20 Cells - Ref,PX8826290,CDM,310,RC,88262,CPT,90,,,,,,,398,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,351.036,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.06,390.04
Partial Bone Scan,PX7830001,CDM,341,RC,78300,CPT,TC,,,,,,,1391,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,351.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,118.89,351.05
Partial Bone Scan,PX7830001,CDM,341,RC,78300,CPT,TC,,,,,,,1391,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,351.05,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,118.89,351.05
Hepatobil Syst Image W/Drug,PX7822701,CDM,341,RC,78227,CPT,TC,,,,,,,1674,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,351.0838,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,238,703.42
"Lap,Inguinal Hernia Repr,Initial",PX49650P,CDM,983,RC,49650,CPT,,,,,,,,717,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1460.52625,percent of total billed charges,351.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,297.8418,5040.74
"Lap,Inguinal Hernia Repr,Initial",PX49650P,CDM,983,RC,49650,CPT,,,,,,,,717,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,351.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,297.8418,5040.74
"Lap,Inguinal Hernia Repr,Initial",PX49650P,CDM,983,RC,49650,CPT,,,,,,,,717,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,351.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,297.8418,5040.74
Repr Superf Wnd Face 5.1-7.5,PX12014P,CDM,983,RC,12014,CPT,,,,,,,,819,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,351.351,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,797.1327
"Layr Clos Wnd Face,Facial <2.5cm",PX12051F,CDM,510,RC,12051,CPT,,,,,,,,769,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,351.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.45,590.11
"Layr Clos Wnd Face,Facial <2.5cm",PX12051P,CDM,983,RC,12051,CPT,,,,,,,,615,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,351.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.45,602.7
Irradiated Leukoreduced Rbc's,PXP9040,CDM,390,RC,P9040,HCPCS,,,,,,,,771,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,351.536,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,209.36,351.536
Irradiated Leukoreduced Rbc's,PXP9040,CDM,390,RC,P9040,HCPCS,,,,,,,,771,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,351.536,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,209.36,351.536
Drainage of Gum Lesion,PX41800F,CDM,510,RC,41800,CPT,,,,,,,,395,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,351.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,387.1
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032F,CDM,510,RC,12032,CPT,,,,,,,,386,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,351.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.3444,378.28
RELOAD SUREFORM 45 2.5MM WHITE,27200000,CDM,272,RC,,,,12791-MAIN,LOCAL,,,,,386,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,351.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 45 3.5MM BLUE,27200000,CDM,272,RC,,,,12792-MAIN,LOCAL,,,,,386,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,351.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 45 4.3MM GREEN,27200000,CDM,272,RC,,,,12793-MAIN,LOCAL,,,,,386,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,351.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Art Upper Extremity-Ltd,PX9393101,CDM,921,RC,93931,CPT,TC,,,,,,,718,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,351.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,703.64
Art Upper Extremity-Ltd,PX9393101,CDM,921,RC,93931,CPT,TC,,,,,,,718,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,351.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,703.64
Art Upper Extremity-Ltd,PX9393101,CDM,921,RC,93931,CPT,TC,,,,,,,718,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,351.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,703.64
"Office/Outpt Visit,New,Levl IV",PX99204F,CDM,510,RC,99204,CPT,,,,,,,,359,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,351.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.1286,351.82
"Office/Outpt Visit,New,Levl IV",PX99204P,CDM,983,RC,99204,CPT,,,,,,,,359,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,351.82,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,82.93,351.82
X-Ray Exam Entire Spine 1vw,PX7208101,CDM,320,RC,72081,CPT,TC,,,,,,,414,,First Health,Commercial,both,85,,999999999,percent of total billed charges,351.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,405.72
Dress/Debrid Large Burn No Anesth,PX16030F,CDM,510,RC,16030,CPT,,,,,,,,399,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,351.918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,165.7446,391.02
"X-Ray Exam Hip,Bilat W/Pelvis 2 Vws",PX7352101,CDM,320,RC,73521,CPT,TC,,,,,,,399,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,351.918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,391.02
Xray Lumbosacral 2 or 3 Vws,PX7210001,CDM,320,RC,72100,CPT,TC,,,,,,,399,,United Healthcare,All Payer,outpatient,88.2,,253.84,percent of total billed charges,351.918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,391.02
CT Soft Tissue Neck W/O Dye,PX7049001,CDM,350,RC,70490,CPT,TC,,,,,,,711,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,351.945,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,1198.67
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423F,CDM,510,RC,11423,CPT,,,,,,,,711,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,351.945,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,295.3494,1416.38
NON-LOCKING SCREW 3.5X18MM,C1713,CDM,278,RC,C1713,HCPCS,,12466-MAIN,LOCAL,,,,,395.51,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,352.0039,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021080166,NDC,5,ML,820.8,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,352.1232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092401,NDC,0.5,ML,820.88,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,352.15752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092491,NDC,0.5,ML,820.88,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,352.15752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092410,NDC,0.5,ML,820.89,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,352.16181,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
Abd Paracentesis W/Imaging(P),PX49083P,CDM,983,RC,49083,CPT,,,,,,,,696,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,352.176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.1184,791.92
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801801,NDC,0.8,ML,359.37,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,352.1826,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801810,NDC,0.8,ML,359.37,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,352.1826,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
TAPER POST TOE JOINT HEMICAP 9.5MM ARTICULATING METATARSAL STERILE,C1713,CDM,278,RC,C1713,HCPCS,,12531-MAIN,LOCAL,,,,,821,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,352.209,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Jak2 Gene - Ref,PX8127090,CDM,300,RC,81270,CPT,90,,,,,,,734,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,352.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.04,719.32
Jak2 Gene - Ref,PX8127090,CDM,300,RC,81270,CPT,90,,,,,,,734,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,352.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.04,719.32
US Pregnancy Tc Follow-Up,PX7681601,CDM,402,RC,76816,CPT,TC,,,,,,,362,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,351,percent of total billed charges,352.3346,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,354.76
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,60505619301,NDC,5,ML,821.36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,352.36344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.08296,1009.1158
Comprehensive Metabolic Panel,PX80053,CDM,300,RC,80053,CPT,,,,,,,,396,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,352.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.68,388.08
Neg Pressure Wound Therapy Dme </=50 Sq Cm,PX97605F,CDM,510,RC,97605,CPT,,,,,,,,396,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,352.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,164.4984,388.08
NON-LOCKING SCREW 3.5X12MM,27200000,CDM,278,RC,C1713,HCPCS,,11857-MAIN,LOCAL,,,,,396,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,352.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NON-LOCKING SCREW 3.5X16MM,27200000,CDM,278,RC,C1713,HCPCS,,11856-MAIN,LOCAL,,,,,396,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,352.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NON-LOCKING SCREW 3.5X24MM,27200000,CDM,278,RC,C1713,HCPCS,,11855-MAIN,LOCAL,,,,,396,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,352.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CT Abdomen W/O Dye,PX7415001,CDM,350,RC,74150,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,352.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Chest Spine W/O Dye,PX7212801,CDM,350,RC,72128,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,352.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Lower Extremity W/O Dye,PX7370001,CDM,350,RC,73700,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,352.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Lumbar Spine W/O Dye,PX7213101,CDM,350,RC,72131,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,352.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Maxillofacialw/O Dye,PX7048601,CDM,350,RC,70486,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,352.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Neck Spine W/O Dye,PX7212501,CDM,350,RC,72125,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,352.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Orbit/Ear/Fosa W/O Dye,PX7048001,CDM,350,RC,70480,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,352.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Pelvis W/O Dye,PX7219201,CDM,350,RC,72192,CPT,TC,,,,,,,2744,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,352.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2689.12
CT Soft Tissue Neck W/O Dye,PX7049001,CDM,350,RC,70490,CPT,TC,,,,,,,711,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,352.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,1198.67
CT Upper Extremity W/O Dye,PX7320001,CDM,350,RC,73200,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,352.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
Diagnostic CT Thorax W/O Contrast,PX7125001,CDM,350,RC,71250,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,352.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
Drain/Inject Med Joint/Brusa W/US Guide,PX20606F,CDM,510,RC,20606,CPT,,,,,,,,387,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,352.557,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.7598,604.15
"Ex Sknbngn0.6-1cmtrnk,Arm,Lg",PX11401P,CDM,983,RC,11401,CPT,,,,,,,,387,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,352.557,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.7598,376.6671
"Exc Skn Benig<5mm Face,Facial",PX11440P,CDM,983,RC,11440,CPT,,,,,,,,387,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,352.557,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.7598,614.65
Facility Emergency Level II Visit,PX99282F,CDM,450,RC,99282,CPT,,,,,,,,387,,Medica,Commercial,both,91.1,,126.83375,percent of total billed charges,352.557,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,142.88,379.26
Exc Skn Bngn1.1-2cm Remain Bdy,PX11422P,CDM,983,RC,11422,CPT,,,,,,,,822,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,352.638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,341.4588,1416.38
Ligation of Hemorrhoid(S),PX46221P,CDM,983,RC,46221,CPT,,,,,,,,697,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,352.682,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.5338,798.45
STAPLER INTERNAL POWERED 29MM CURVED CIRCULAR,27200000,CDM,272,RC,,,,12024-MAIN,LOCAL,,,,,697,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,352.682,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STAPLER INTERNAL POWERED 31MM CURVED CIRCULAR,27200000,CDM,272,RC,,,,12025-MAIN,LOCAL,,,,,697,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,352.682,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"US Complete Joint, Realtime W/ Img Tc",PX7688101,CDM,402,RC,76881,CPT,TC,,,,,,,415,,First Health,Commercial,both,85,,999999999,percent of total billed charges,352.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,406.7
Closed Rx Mt-Phal Toe Dislocation,PX28630F,CDM,510,RC,28630,CPT,,,,,,,,360,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,352.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.544,352.8
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12173-MAIN,LOCAL,,,,,400,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,352.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Lvl 1 Init Hosp Low Mdm or 40 Minutes,PX99221,CDM,982,RC,99221,CPT,,,,,,,,400,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,352.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.16,389.32
RBC Antibody Elution,PX86860,CDM,300,RC,86860,CPT,,,,,,,,360,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,352.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.22,352.8
"Sigmoidoscopy,Diagnostic",PX45330F,CDM,510,RC,45330,CPT,,,,,,,,720,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,352.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,299.088,798.45
"Sigmoidoscopy,Diagnostic",PX45330F,CDM,510,RC,45330,CPT,,,,,,,,720,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,352.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,299.088,798.45
"Sigmoidoscopy,Diagnostic",PX45330F,CDM,510,RC,45330,CPT,,,,,,,,720,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,352.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,299.088,798.45
"Closed Rx Toe Fx,Manipulatn",PX28515F,CDM,510,RC,28515,CPT,,,,,,,,390,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,352.82,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.93,352.82
"Closed Rx Toe Fx,Manipulatn",PX28515P,CDM,983,RC,28515,CPT,,,,,,,,260,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,352.82,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.93,352.82
Repr Superf Wnd Face >30cm,PX12018F,CDM,510,RC,12018,CPT,,,,,,,,713,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,352.935,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,698.74
"Ht Muscle Image Spect, Mult",PX7845201,CDM,340,RC,78452,CPT,TC,,,,,,,2000,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,353.0146,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,239.31,707.36
"Fac/Exc Skn Malig .1-2cm Fce,Facal",PX11642F,CDM,510,RC,11642,CPT,,,,,,,,698,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,353.188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.9492,684.04
SET CRICOTHYROTOMY CATHETER 3.5MM ID,120.251,CDM,272,RC,,,,4306-MAIN,LOCAL,,,,,363,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,353.3079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.7902,355.74
SET CRICOTHYROTOMY CATHETER 4MM ID,120.251,CDM,272,RC,,,,3452-MAIN,LOCAL,,,,,363,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,353.3079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.7902,355.74
SET CRICOTHYROTOMY CATHETER 6MM ID,120.251,CDM,272,RC,,,,2887-MAIN,LOCAL,,,,,363,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,353.3079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.7902,355.74
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Suspension 10 mL Bottle,63700001,CDM,250,RC,,,,,,24208063562,NDC,10,ML,415.81,,First Health,Commercial,both,85,,999999999,percent of total billed charges,353.4385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
brinzolamide-brimonidine 1-0.2 % Suspension 8 mL Bottle,63700001,CDM,250,RC,,,,,,65414727,NDC,8,ML,850.88,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,353.455552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
US Head/Neck Tc,PX7653601,CDM,402,RC,76536,CPT,TC,,,,,,,416,,First Health,Commercial,both,85,,999999999,percent of total billed charges,353.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,407.68
"Calprotectin, Fecal - Ref",PX8399390,CDM,300,RC,83993,CPT,90,,,,,,,401,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,353.682,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18,392.98
CATHETER BIPOLAR ELECTROHEMOSTASIS 7FR 300CM M00560070,27200000,CDM,272,RC,,,,12909-MAIN,LOCAL,,,,,700,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,354.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Drainage of Hematoma/Fluid (P),PX10140P,CDM,983,RC,10140,CPT,,,,,,,,465,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,354.2,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.17,455.7
Drainage of Hematoma/Fluid (T),PX10140F,CDM,510,RC,10140,CPT,,,,,,,,341,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,354.2,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.17,354.2
Chrom Anal 15-20 Cells - Ref,PX8826290,CDM,310,RC,88262,CPT,90,,,,,,,398,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,354.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.06,390.04
Polysomnography W/Cpap,PX9581101,CDM,740,RC,95811,CPT,TC,,,,,,,4575,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,354.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,339.44,928.39
Polysomnography W/Cpap,PX9581101,CDM,740,RC,95811,CPT,TC,,,,,,,4575,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,354.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,339.44,928.39
Drain/Inject Large Joint/Bursa,PX20610F,CDM,510,RC,20610,CPT,,,,,,,,364,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,141.5171429,percent of total billed charges,354.2812,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,151.2056,356.72
Xray Forearm 2 Vws,PX7309001,CDM,320,RC,73090,CPT,TC,,,,,,,364,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,186.09,percent of total billed charges,354.2812,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,356.72
CT Abdomen W/Dye,PX7416001,CDM,350,RC,74160,CPT,TC,,,,,,,3413,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,354.34,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.11,354.34
CT Abdomen W/Dye,PX7416001,CDM,350,RC,74160,CPT,TC,,,,,,,3413,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,354.34,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.11,354.34
Closed Rx Trimalleolar Fx,PX27816P,CDM,983,RC,27816,CPT,,,,,,,,826,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,354.354,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,803.9458
ANCHORAGE FIXATION PIN,27200000,CDM,272,RC,,,,12642-MAIN,LOCAL,,,,,389,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,354.379,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Ext Ecg > 48hr to 21 Day Rcrd W/Conect Intl Rcrd,PX0296T,CDM,731,RC,0296T,HCPCS,,,,,,,,389,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,354.379,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,161.5906,381.22
Xray Ribs Bilat 3 Vws With Pa Chest,PX7111101,CDM,320,RC,71111,CPT,TC,,,,,,,417,,First Health,Commercial,both,85,,999999999,percent of total billed charges,354.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,408.66
"Cardioversion, Elective;Extern",PX92960F,CDM,480,RC,92960,CPT,,,,,,,,402,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,354.564,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.9908,568.57
Chem Cautery Granulatn Tissue,PX17250P,CDM,983,RC,17250,CPT,,,,,,,,402,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,354.564,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.9908,391.2666
Lab Imm Spin X-Match,PX8837,CDM,300,RC,86920,CPT,,,,,,,,402,,United Healthcare,All Payer,outpatient,88.2,,40.2,percent of total billed charges,354.564,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.22,393.96
"Morphometric Analysis, in Situ Hybridization, Each Probe; Manual, Tech",PX8836801,CDM,310,RC,88368,CPT,TC,,,,,,,402,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,354.564,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.9908,393.96
brimonidine 0.15 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314014405,NDC,5,ML,723.62,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,354.5738,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
brimonidine 0.15 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314014405,NDC,5,ML,723.62,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,354.5738,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
brimonidine 0.15 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314014405,NDC,5,ML,723.62,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,354.5738,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
DRILL BIT 2.2MMX60MM STERILE MICA CANNULATED,27200000,CDM,272,RC,,,,12437-MAIN,LOCAL,,,,,701,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,354.706,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRILL BIT 3.0MMX60MM STERILE MICA CANNULATED,27200000,CDM,272,RC,,,,12438-MAIN,LOCAL,,,,,701,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,354.706,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
US Pregnancy Tc Follow-Up,PX7681601,CDM,402,RC,76816,CPT,TC,,,,,,,362,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,354.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,354.76
Art Lower Extremity-Bilat,PX9392501,CDM,921,RC,93925,CPT,TC,,,,,,,1188,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,354.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,134.82,354.84
Art Lower Extremity-Bilat,PX9392501,CDM,921,RC,93925,CPT,TC,,,,,,,1188,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,354.84,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,134.82,354.84
"Lap,Inguinal Hernia Repr,Initial",PX49650P,CDM,983,RC,49650,CPT,,,,,,,,717,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,354.915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,297.8418,5040.74
perflutren protein A microsphere Suspension 3 mL Vial,Q9956,CDM,636,RC,Q9956,HCPCS,,,,407270703,NDC,3,ML,739.41,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,354.9168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,307.150914,724.6218
perflutren protein A microsphere Suspension 3 mL Vial,Q9956,CDM,636,RC,Q9956,HCPCS,,,,407270703,NDC,3,ML,739.41,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,354.9168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,307.150914,724.6218
"Repair Ing Hernia,5+Y/O,Strang",PX49507F,CDM,510,RC,49507,CPT,,,,,,,,1977,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,354.93,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,354.93,1229.33
"Repair Ing Hernia,5+Y/O,Strang",PX49507P,CDM,983,RC,49507,CPT,,,,,,,,2482,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,354.93,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,354.93,2432.36
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016401,NDC,1,ML,854.49,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,354.955146,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.66,898.7384
Dress/Debrid Large Burn No Anesth,PX16030F,CDM,510,RC,16030,CPT,,,,,,,,399,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,355.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,165.7446,391.02
"X-Ray Exam Hip,Bilat W/Pelvis 2 Vws",PX7352101,CDM,320,RC,73521,CPT,TC,,,,,,,399,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,355.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,391.02
Xray Lumbosacral 2 or 3 Vws,PX7210001,CDM,320,RC,72100,CPT,TC,,,,,,,399,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,355.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,391.02
albumin human 25% 25 % Solution 50 mL Flex Cont,P9047,CDM,636,RC,P9047,HCPCS,,,,944049301,NDC,50,ML,402.67,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,355.15494,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.66,394.6166
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004F,CDM,510,RC,15004,CPT,,,,,,,,855,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,355.167,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,355.167,837.9
US Doppler Lw Ext Art Tc,PX9392601,CDM,921,RC,93926,CPT,TC,,,,,,,740,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,355.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,725.2
US Doppler Lw Ext Art Tc,PX9392601,CDM,921,RC,93926,CPT,TC,,,,,,,740,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,355.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,725.2
"2019-Ncov Coronavirus, Sars-Cov-2/2019-Ncov (Covid-19)",PXU000290,CDM,300,RC,U0002,HCPCS,90,,,,,,,365,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,355.2545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,357.7
"Closed Rx Spont Hip Disloc,Anesth",PX27257P,CDM,983,RC,27257,CPT,,,,,,,,365,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,355.2545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,151.621,1404.08
X-Ray Exam Femur Min 2 Vws,PX7355201,CDM,320,RC,73552,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,148.7433333,percent of total billed charges,355.2545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Ankle Minimum 3 Vws,PX7361001,CDM,320,RC,73610,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,275.2779167,percent of total billed charges,355.2545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Calcaneus Minimum 2 Vws,PX7365001,CDM,320,RC,73650,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,355.2545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Clavicle Complete,PX7300001,CDM,320,RC,73000,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,355.2545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Elbow 2 Vws,PX7307001,CDM,320,RC,73070,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,355.2545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Hand 2vws Tc,PX7312001,CDM,320,RC,73120,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,355.2545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,357.7
Xray Humerus Minimum 2 Vws,PX7306001,CDM,320,RC,73060,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,355.2545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Shoulder Minimum 2 Vws,PX7303001,CDM,320,RC,73030,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,161.9570833,percent of total billed charges,355.2545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Sternum 2vws Tc,PX7112001,CDM,320,RC,71120,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,355.2545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Tibia & Fibula 2 Vws,PX7359001,CDM,320,RC,73590,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,140.48,percent of total billed charges,355.2545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Wrist 2 Vws,PX7310001,CDM,320,RC,73100,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,359.25,percent of total billed charges,355.2545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Apc Resistance Assay - Ref,PX8530790,CDM,300,RC,85307,CPT,90,,,,,,,390,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,355.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.05,382.2
"Closed Rx Toe Fx,Manipulatn",PX28515F,CDM,510,RC,28515,CPT,,,,,,,,390,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,355.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,162.006,382.2
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059303,NDC,1,EA,740.19,,Health Partners,Health Partners Care Plans,both,48,,343.21,percent of total billed charges,355.2912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.10077,725.3862
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059303,NDC,1,EA,740.19,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,355.2912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.10077,725.3862
Removal of Skin Tags,PX11200P,CDM,983,RC,11200,CPT,,,,,,,,418,,First Health,Commercial,both,85,,999999999,percent of total billed charges,355.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,173.6372,406.8394
Art Upper Extremity-Ltd,PX9393101,CDM,921,RC,93931,CPT,TC,,,,,,,718,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,355.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,703.64
SET CRICOTHYROTOMY CATHETER 3.5MM ID,120.251,CDM,272,RC,,,,4306-MAIN,LOCAL,,,,,363,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,355.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.7902,355.74
SET CRICOTHYROTOMY CATHETER 4MM ID,120.251,CDM,272,RC,,,,3452-MAIN,LOCAL,,,,,363,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,355.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.7902,355.74
SET CRICOTHYROTOMY CATHETER 6MM ID,120.251,CDM,272,RC,,,,2887-MAIN,LOCAL,,,,,363,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,355.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.7902,355.74
hydrocortisone sodium succinate (preservative free) 1000 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9000501,NDC,1,EA,403.54,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,355.92228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
"Closed Rx Big Toe Fx,Manip",PX28495F,CDM,510,RC,28495,CPT,,,,,,,,857,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,355.9978,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,839.86
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12173-MAIN,LOCAL,,,,,400,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Lvl 1 Init Hosp Low Mdm or 40 Minutes,PX99221,CDM,982,RC,99221,CPT,,,,,,,,400,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.16,389.32
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565P,CDM,983,RC,25565,CPT,,,,,,,,830,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,356.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,344.782,1404.08
TRAY PNEUMOTHORAX 14FR 29CM 19 CATHETER SIDEPORTS G56537,120.496,CDM,272,RC,,,,11677-MAIN,LOCAL,,,,,419,,First Health,Commercial,both,85,,999999999,percent of total billed charges,356.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.0526,410.62
Drain Pilonidal Cyst Simpl,PX10080F,CDM,510,RC,10080,CPT,,,,,,,,742,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,356.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,308.2268,727.16
Drain Pilonidal Cyst Simpl,PX10080F,CDM,510,RC,10080,CPT,,,,,,,,742,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,356.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,308.2268,727.16
Fna W/Image,PX10022F,CDM,510,RC,10022,CPT,,,,,,,,742,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,356.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,308.2268,727.16
Fna W/Image,PX10022F,CDM,510,RC,10022,CPT,,,,,,,,742,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,356.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,308.2268,727.16
"Initial Observation Care,Levl II",PX99219,CDM,982,RC,99219,CPT,,,,,,,,391,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,356.201,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,162.4214,380.5603
Dress/Debrid Med Burn No Anesth,PX16025F,CDM,510,RC,16025,CPT,,,,,,,,366,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,356.2278,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,152.0364,358.68
"Repair Ing Hernia,5+Y/O,Strang",PX49507F,CDM,510,RC,49507,CPT,,,,,,,,1977,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,356.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,354.93,1229.33
"Repair Ing Hernia,5+Y/O,Strang",PX49507F,CDM,510,RC,49507,CPT,,,,,,,,1977,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,356.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,354.93,1229.33
"Repair Ing Hernia,5+Y/O,Strang",PX49507P,CDM,983,RC,49507,CPT,,,,,,,,2482,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,356.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,354.93,2432.36
"Repair Ing Hernia,5+Y/O,Strang",PX49507P,CDM,983,RC,49507,CPT,,,,,,,,2482,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,356.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,354.93,2432.36
CT Pelvis W/Dye,PX7219301,CDM,350,RC,72193,CPT,TC,,,,,,,3330,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,356.31,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.11,356.31
CT Pelvis W/Dye,PX7219301,CDM,350,RC,72193,CPT,TC,,,,,,,3330,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,356.31,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.11,356.31
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494301,NDC,0.5,ML,419.2,,First Health,Commercial,both,85,,999999999,percent of total billed charges,356.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.38,410.8454
Layr Clos Wnd Rest Body 2.6-7.5,PX12042F,CDM,510,RC,12042,CPT,,,,,,,,404,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,356.328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,395.92
Neg Pressure Wound Therapy Dme >50 Sq Cm,PX97606F,CDM,761,RC,97606,CPT,,,,,,,,404,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,356.328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,395.92
Remove Foreign Body Simple,PX10120F,CDM,510,RC,10120,CPT,,,,,,,,404,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,356.328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,395.92
Remove Foreign Body Simple,PX10120P,CDM,983,RC,10120,CPT,,,,,,,,404,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,356.328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,393.2132
Xray Foot Minimum 3 Vws,PX7363001,CDM,320,RC,73630,CPT,TC,,,,,,,404,,United Healthcare,All Payer,outpatient,88.2,,198.016,percent of total billed charges,356.328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,395.92
Xray Knee 3 Vws,PX7356201,CDM,320,RC,73562,CPT,TC,,,,,,,404,,United Healthcare,All Payer,outpatient,88.2,,215.492,percent of total billed charges,356.328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,395.92
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494300,NDC,0.5,ML,419.23,,First Health,Commercial,both,85,,999999999,percent of total billed charges,356.3455,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.38,410.8454
"Sigmoidoscopy,Diagnostic",PX45330F,CDM,510,RC,45330,CPT,,,,,,,,720,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,356.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,299.088,798.45
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041105,NDC,1,ML,419.67,,First Health,Commercial,both,85,,999999999,percent of total billed charges,356.7195,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.808876,411.2766
Cardiac Rehab II Eval,PX93798.05,CDM,943,RC,93798,CPT,,,,,,,,364,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,356.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.44,495.55
Drain/Inject Large Joint/Bursa,PX20610F,CDM,510,RC,20610,CPT,,,,,,,,364,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,356.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,151.2056,356.72
Xray Forearm 2 Vws,PX7309001,CDM,320,RC,73090,CPT,TC,,,,,,,364,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,356.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,356.72
Skin Sub Graft Trnk/Arm/Leg,PX15271P,CDM,983,RC,15271,CPT,,,,,,,,705,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,356.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,292.857,1593.14
"Spinal Puncture,Lumbar,Diagnostic",PX62270P,CDM,983,RC,62270,CPT,,,,,,,,705,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,356.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,292.857,686.1765
Temporal Artery Ligatn or Bx,PX37609F,CDM,510,RC,37609,CPT,,,,,,,,705,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,356.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,292.857,1416.38
"Calprotectin, Fecal - Ref",PX8399390,CDM,300,RC,83993,CPT,90,,,,,,,401,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,356.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18,392.98
"HERNIA MESH 3D MAX MID ANATOMICAL MESH RIGHT SIZE XL 5"" X 7""",C1781,CDM,278,RC,C1781,HCPCS,,11979-MAIN,LOCAL,,,,,832,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,356.928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"HERNIA MESH 3DMAX MID MESH EXTRA-LARGE LEFT 5"" X 7""",C1781,CDM,278,RC,C1781,HCPCS,,11978-MAIN,LOCAL,,,,,832,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,356.928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Xray Foot 2 Vws,PX7362001,CDM,320,RC,73620,CPT,TC,,,,,,,367,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,357.2011,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,359.66
Diagnostic Anoscopy,PX46600P,CDM,983,RC,46600,CPT,,,,,,,,405,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,357.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,394.1865
Closed Rx Elbow Dislocation,PX24600F,CDM,510,RC,24600,CPT,,,,,,,,706,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,357.236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,691.88
GRAFIXPL PRIME PLACENTAL MEMBRANE 16MM DISC 2SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12763-MAIN,LOCAL,,,,,860,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,357.244,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
glucagon rdna (diagnostic) 1 MG Recon Soln 1 Each Vial,J1610.01,CDM,636,RC,J1610,HCPCS,,,,597026010,NDC,1,EA,744.84,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,357.5232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,172.71,729.9432
glucagon rdna (diagnostic) 1 MG Recon Soln 1 Each Vial,J1610.01,CDM,636,RC,J1610,HCPCS,,,,597026010,NDC,1,EA,744.84,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,357.5232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,172.71,729.9432
PREP KIT STAPLE 18MM,27200000,CDM,278,RC,C1713,HCPCS,,11658-MAIN,LOCAL,,,,,420.75,,First Health,Commercial,both,85,,999999999,percent of total billed charges,357.6375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PREP KIT STAPLE 20MM,27200000,CDM,278,RC,C1713,HCPCS,,11659-MAIN,LOCAL,,,,,420.75,,First Health,Commercial,both,85,,999999999,percent of total billed charges,357.6375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Amputation Toe,I-P Jt",PX28825F,CDM,510,RC,28825,CPT,,,,,,,,1327,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,357.66,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.23,605.33
"Amputation Toe,I-P Jt",PX28825P,CDM,983,RC,28825,CPT,,,,,,,,780,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,357.66,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.23,764.4
"2019-Ncov Coronavirus, Sars-Cov-2/2019-Ncov (Covid-19)",PXU000290,CDM,300,RC,U0002,HCPCS,90,,,,,,,365,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,357.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,357.7
"Closed Rx Spont Hip Disloc,Anesth",PX27257P,CDM,983,RC,27257,CPT,,,,,,,,365,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,357.7,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,221.86,755.45
Sars-Cov-2 Covid-19 Amp Prb,PX8763590,CDM,300,RC,87635,CPT,90,,,,,,,365,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,357.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.05,357.7
X-Ray Exam Femur Min 2 Vws,PX7355201,CDM,320,RC,73552,CPT,TC,,,,,,,365,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,357.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Ankle Minimum 3 Vws,PX7361001,CDM,320,RC,73610,CPT,TC,,,,,,,365,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,357.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Calcaneus Minimum 2 Vws,PX7365001,CDM,320,RC,73650,CPT,TC,,,,,,,365,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,357.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Clavicle Complete,PX7300001,CDM,320,RC,73000,CPT,TC,,,,,,,365,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,357.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Elbow 2 Vws,PX7307001,CDM,320,RC,73070,CPT,TC,,,,,,,365,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,357.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Hand 2vws Tc,PX7312001,CDM,320,RC,73120,CPT,TC,,,,,,,365,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,357.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,357.7
Xray Humerus Minimum 2 Vws,PX7306001,CDM,320,RC,73060,CPT,TC,,,,,,,365,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,357.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Shoulder Minimum 2 Vws,PX7303001,CDM,320,RC,73030,CPT,TC,,,,,,,365,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,357.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Sternum 2vws Tc,PX7112001,CDM,320,RC,71120,CPT,TC,,,,,,,365,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,357.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Tibia & Fibula 2 Vws,PX7359001,CDM,320,RC,73590,CPT,TC,,,,,,,365,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,357.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
Xray Wrist 2 Vws,PX7310001,CDM,320,RC,73100,CPT,TC,,,,,,,365,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,357.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,357.7
"Cardioversion, Elective;Extern",PX92960F,CDM,480,RC,92960,CPT,,,,,,,,402,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,357.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.9908,568.57
Chem Cautery Granulatn Tissue,PX17250P,CDM,983,RC,17250,CPT,,,,,,,,402,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,357.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.9908,391.2666
Lab Imm Spin X-Match,PX8837,CDM,300,RC,86920,CPT,,,,,,,,402,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,357.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.22,393.96
"Morphometric Analysis, in Situ Hybridization, Each Probe; Manual, Tech",PX8836801,CDM,310,RC,88368,CPT,TC,,,,,,,402,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,357.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.9908,393.96
umeclidinium-vilanterol 62.5-25 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173086906,NDC,14,EA,745.86,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,358.0128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
umeclidinium-vilanterol 62.5-25 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173086906,NDC,14,EA,745.86,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,358.0128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
6 SHOOTER SAEED MULTIBAND LIGATOR,27200000,CDM,272,RC,,,,12379-MAIN,LOCAL,,,,,393,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,358.023,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA FIRST MET TRANSLATOR STERILE MICA,27200000,CDM,272,RC,,,,12445-MAIN,LOCAL,,,,,393,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,358.023,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Tap Block Bilateral by Injection(S),PX64488F,CDM,510,RC,64488,CPT,,,,,,,,393,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,358.023,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,163.2522,385.14
Skin Sub Graft Trnk/Arm/Leg,PX15271F,CDM,510,RC,15271,CPT,,,,,,,,862,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,358.0748,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,358.0748,1593.14
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598F,CDM,510,RC,97598,CPT,,,,,,,,406,,United Healthcare,All Payer,outpatient,88.2,,215.18,percent of total billed charges,358.092,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,168.6524,397.88
SCOPE ASCOPE4 CYSTO STERILE 601001000,120.497,CDM,272,RC,A4649,HCPCS,,11662-MAIN,LOCAL,,,,,368,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,358.1744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,152.8672,360.64
"Fac/Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602F,CDM,510,RC,11602,CPT,,,,,,,,731,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,358.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,303.6574,716.38
"Fac/Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602F,CDM,510,RC,11602,CPT,,,,,,,,731,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,358.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,303.6574,716.38
"Fac/Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602F,CDM,510,RC,11602,CPT,,,,,,,,731,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,358.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,303.6574,716.38
brimonidine 0.15 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314014405,NDC,5,ML,723.62,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,358.1919,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Duplex Up Extrem Art Bilat,PX9393001,CDM,921,RC,93930,CPT,TC,,,,,,,835,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,358.215,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,818.3
Repr Superf Wnd Face >30cm,PX12018F,CDM,510,RC,12018,CPT,,,,,,,,713,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,358.35,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.66,358.35
Repr Superf Wnd Face >30cm,PX12018F,CDM,510,RC,12018,CPT,,,,,,,,713,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,358.35,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.66,358.35
albumin human 25% 25 % Solution 50 mL Flex Cont,P9047,CDM,636,RC,P9047,HCPCS,,,,944049301,NDC,50,ML,402.67,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,358.3763,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.66,394.6166
2.1MM CANNULATED DRILL BIT,27200000,CDM,272,RC,,,,12657-MAIN,LOCAL,,,,,747,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,358.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
2.1MM CANNULATED DRILL BIT,27200000,CDM,272,RC,,,,12657-MAIN,LOCAL,,,,,747,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,358.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
US Guide Needle Bx S&I,PX7694201,CDM,402,RC,76942,CPT,TC,,,,,,,747,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,358.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.3038,732.06
US Guide Needle Bx S&I,PX7694201,CDM,402,RC,76942,CPT,TC,,,,,,,747,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,358.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.3038,732.06
Dress/Debrid Med Burn No Anesth,PX16025F,CDM,510,RC,16025,CPT,,,,,,,,366,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,358.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,152.0364,358.68
Closure Superf Wnd Dehis Simple,PX12020P,CDM,983,RC,12020,CPT,,,,,,,,422,,First Health,Commercial,both,85,,999999999,percent of total billed charges,358.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,175.2988,548.67
Cns Dna/Rna Amp Probe Multiple Subtypes 12-25,PX87483,CDM,300,RC,87483,CPT,,,,,,,,864,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,358.9056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,358.9056,846.72
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402F,CDM,510,RC,11402,CPT,,,,,,,,424,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,359.04,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.08,359.04
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402P,CDM,983,RC,11402,CPT,,,,,,,,424,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,359.04,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.08,415.52
"Percut Biopsy, Abdominal Mass",PX49180F,CDM,510,RC,49180,CPT,,,,,,,,2084,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,359.04,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.39,359.04
hydrocortisone sodium succinate (preservative free) 1000 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9000501,NDC,1,EA,403.54,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,359.1506,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
dantrolene 20 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,42023012306,NDC,1,EA,394.42,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,359.31662,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Fac/Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404F,CDM,510,RC,11404,CPT,,,,,,,,749,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,359.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,311.1346,1416.38
"Fac/Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404F,CDM,510,RC,11404,CPT,,,,,,,,749,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,359.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,311.1346,1416.38
Layr Clos Wnd Rest Body 2.6-7.5,PX12042F,CDM,510,RC,12042,CPT,,,,,,,,404,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,359.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,395.92
Neg Pressure Wound Therapy Dme >50 Sq Cm,PX97606F,CDM,761,RC,97606,CPT,,,,,,,,404,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,359.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,395.92
Remove Foreign Body Simple,PX10120F,CDM,510,RC,10120,CPT,,,,,,,,404,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,359.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,395.92
Remove Foreign Body Simple,PX10120P,CDM,983,RC,10120,CPT,,,,,,,,404,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,359.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,393.2132
Xray Foot Minimum 3 Vws,PX7363001,CDM,320,RC,73630,CPT,TC,,,,,,,404,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,359.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,395.92
Xray Knee 3 Vws,PX7356201,CDM,320,RC,73562,CPT,TC,,,,,,,404,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,359.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,395.92
Jak2 Gene - Ref,PX8127090,CDM,300,RC,81270,CPT,90,,,,,,,734,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,359.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.04,719.32
Jak2 Gene - Ref,PX8127090,CDM,300,RC,81270,CPT,90,,,,,,,734,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,359.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.04,719.32
Jak2 Gene - Ref,PX8127090,CDM,300,RC,81270,CPT,90,,,,,,,734,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,359.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.04,719.32
Xray Foot 2 Vws,PX7362001,CDM,320,RC,73620,CPT,TC,,,,,,,367,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,359.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,359.66
Debride Tissue/Muscle/Bone,PX11044P,CDM,983,RC,11044,CPT,,,,,,,,866,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,359.7364,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,359.7364,1416.38
CT Soft Tissue Neck W/O Dye,PX7049001,CDM,350,RC,70490,CPT,TC,,,,,,,711,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,359.766,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,1198.67
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423F,CDM,510,RC,11423,CPT,,,,,,,,711,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,359.766,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,295.3494,1416.38
Drainage of Gum Lesion,PX41800F,CDM,510,RC,41800,CPT,,,,,,,,395,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,359.845,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,387.1
Blood Transfusion Service,PX36430,CDM,391,RC,36430,CPT,,,,,,,,839,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,359.931,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.5206,822.22
Drainage of Gum Lesion,PX41800P,CDM,983,RC,41800,CPT,,,,,,,,839,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,359.931,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,816.5987
Sigmoidoscope W/Submuc Inj,PX45335F,CDM,750,RC,45335,CPT,,,,,,,,750,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,360,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,311.55,798.45
Sigmoidoscope W/Submuc Inj,PX45335F,CDM,750,RC,45335,CPT,,,,,,,,750,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,360,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,311.55,798.45
Acetaminophen,PX80307E,CDM,300,RC,80307,CPT,,,,,,,,370,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,323.1134694,percent of total billed charges,360.121,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Alcohol,PX80307A,CDM,300,RC,80307,CPT,,,,,,,,370,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,323.1134694,percent of total billed charges,360.121,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Salicylate,PX80307D,CDM,300,RC,80307,CPT,,,,,,,,370,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,323.1134694,percent of total billed charges,360.121,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Urine Drug Screen,PX80307B,CDM,300,RC,80307,CPT,,,,,,,,370,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,323.1134694,percent of total billed charges,360.121,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Xray Elbow 3+Vws Tc,PX7308001,CDM,320,RC,73080,CPT,TC,,,,,,,370,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,254.6488889,percent of total billed charges,360.121,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,362.6
"Mra, Neck With Contrast",PX7054801,CDM,610,RC,70548,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,360.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.94,360.26
"Mra, Neck With Contrast",PX7054801,CDM,610,RC,70548,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,360.26,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.94,360.26
NON-LOCKING SCREW 3.5X18MM,C1713,CDM,278,RC,C1713,HCPCS,,12466-MAIN,LOCAL,,,,,395.51,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,360.30961,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"Bone Scan, Whole Body",PX7830601,CDM,341,RC,78306,CPT,TC,,,,,,,1896,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,360.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,360.31,1858.08
Hepatobiliary System Imaging,PX7822601,CDM,341,RC,78226,CPT,TC,,,,,,,2776,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,360.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,360.31,2720.48
Partial Bone Scan,PX7830001,CDM,341,RC,78300,CPT,TC,,,,,,,1391,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,360.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,360.31,1363.18
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402F,CDM,510,RC,11402,CPT,,,,,,,,424,,First Health,Commercial,both,85,,999999999,percent of total billed charges,360.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.1296,614.65
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402P,CDM,983,RC,11402,CPT,,,,,,,,424,,First Health,Commercial,both,85,,999999999,percent of total billed charges,360.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.1296,614.65
Lab H Pylori Stool Ag,PX87338,CDM,300,RC,87338,CPT,,,,,,,,424,,First Health,Commercial,both,85,,999999999,percent of total billed charges,360.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,415.52
"Needle Biopsy, Lymph Node(S)",PX38505F,CDM,510,RC,38505,CPT,,,,,,,,667,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,360.43,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53,360.43
Diagnostic Anoscopy,PX46600P,CDM,983,RC,46600,CPT,,,,,,,,405,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,360.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,394.1865
SCOPE ASCOPE4 CYSTO STERILE 601001000,120.497,CDM,272,RC,A4649,HCPCS,,11662-MAIN,LOCAL,,,,,368,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,360.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,152.8672,360.64
"Surgical Diagnostic Exam, Anorectal",PX45990P,CDM,983,RC,45990,CPT,,,,,,,,409,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,360.738,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,169.8986,2452.93
Comprehensive Metabolic Panel,PX80053,CDM,300,RC,80053,CPT,,,,,,,,396,,Medica,Commercial,both,91.1,,48.7574359,percent of total billed charges,360.756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.68,388.08
Neg Pressure Wound Therapy Dme </=50 Sq Cm,PX97605F,CDM,510,RC,97605,CPT,,,,,,,,396,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,360.756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,164.4984,388.08
NON-LOCKING SCREW 3.5X12MM,27200000,CDM,278,RC,C1713,HCPCS,,11857-MAIN,LOCAL,,,,,396,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,360.756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NON-LOCKING SCREW 3.5X16MM,27200000,CDM,278,RC,C1713,HCPCS,,11856-MAIN,LOCAL,,,,,396,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,360.756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NON-LOCKING SCREW 3.5X24MM,27200000,CDM,278,RC,C1713,HCPCS,,11855-MAIN,LOCAL,,,,,396,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,360.756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Repr Superf Wnd Face >30cm,PX12018F,CDM,510,RC,12018,CPT,,,,,,,,713,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,360.778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,698.74
perflutren lipid microsphere 6.52 MG/ML Suspension 2 mL Vial,Q9957,CDM,636,RC,Q9957,HCPCS,,,,11994001101,NDC,2,ML,751.71,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,360.8208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,312.260334,736.6758
perflutren lipid microsphere 6.52 MG/ML Suspension 2 mL Vial,Q9957,CDM,636,RC,Q9957,HCPCS,,,,11994001101,NDC,2,ML,751.71,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,360.8208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,312.260334,736.6758
MINIBUNION DRILL KIT,27200000,CDM,278,RC,C1713,HCPCS,,11669-MAIN,LOCAL,,,,,841.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,361.0035,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Injection Hip Arthrogram,Anesth",PX27095F,CDM,510,RC,27095,CPT,,,,,,,,425,,First Health,Commercial,both,85,,999999999,percent of total billed charges,361.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.545,416.5
"Injection Hip Arthrogram,Anesth",PX27095P,CDM,983,RC,27095,CPT,,,,,,,,425,,First Health,Commercial,both,85,,999999999,percent of total billed charges,361.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.545,413.6525
US Abdomen Limited Tc,PX7670501,CDM,402,RC,76705,CPT,TC,,,,,,,425,,First Health,Commercial,both,85,,999999999,percent of total billed charges,361.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,416.5
US Ext Non-Vasc Img Lmtd,PX7688201,CDM,402,RC,76882,CPT,TC,,,,,,,425,,First Health,Commercial,both,85,,999999999,percent of total billed charges,361.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,416.5
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598F,CDM,510,RC,97598,CPT,,,,,,,,406,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,361.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,168.6524,397.88
oseltamivir 6 MG/ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,4082205,NDC,60,ML,752.82,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,361.3536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 6 MG/ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,4082205,NDC,60,ML,752.82,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,361.3536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Exc Neck Les Sc = 3cm >,PX21552F,CDM,510,RC,21552,CPT,,,,,,,,753,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,361.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,312.7962,2482.37
Exc Neck Les Sc = 3cm >,PX21552F,CDM,510,RC,21552,CPT,,,,,,,,753,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,361.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,312.7962,2482.37
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614900,NDC,1,EA,409.89,,United Healthcare,All Payer,outpatient,88.2,,201.07,percent of total billed charges,361.52298,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
"Lab Antibody ID,RBC",PX86870,CDM,300,RC,,,,,,,,,,410,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,361.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,170.314,401.8
"Supply Technicium Sestamibi,per Dose",PXA9500,CDM,343,RC,A9500,HCPCS,,,,,,,,410,,United Healthcare,All Payer,outpatient,88.2,,17.86580645,percent of total billed charges,361.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,170.314,401.8
"Sigmoidoscopy,Screen Prev",PX2001F,CDM,750,RC,45330,CPT,,,,,,,,843,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,361.647,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,350.1822,826.14
"Fac/Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602F,CDM,510,RC,11602,CPT,,,,,,,,731,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,361.845,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,303.6574,716.38
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320990,NDC,1,EA,410.32,,United Healthcare,All Payer,outpatient,88.2,,201.07,percent of total billed charges,361.90224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320995,NDC,1,EA,410.32,,United Healthcare,All Payer,outpatient,88.2,,201.07,percent of total billed charges,361.90224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
Cyto Non Gyn,PX8811201,CDM,310,RC,88112,CPT,TC,,,,,,,372,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,362.0676,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,364.56
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535F,CDM,510,RC,24535,CPT,,,,,,,,2514,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,362.13,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,362.13,1333.79
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535P,CDM,983,RC,24535,CPT,,,,,,,,2887,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,362.13,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,362.13,2829.26
perflutren protein A microsphere Suspension 3 mL Vial,Q9956,CDM,636,RC,Q9956,HCPCS,,,,407270703,NDC,3,ML,739.41,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,49.29666667,percent of total billed charges,362.3109,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,307.150914,724.6218
perflutren protein A microsphere Suspension 3 mL Vial,Q9956,CDM,636,RC,Q9956,HCPCS,,,,407270703,NDC,3,ML,739.41,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,362.3109,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,307.150914,724.6218
perflutren protein A microsphere Suspension 3 mL Vial,Q9956,CDM,636,RC,Q9956,HCPCS,,,,407270703,NDC,3,ML,739.41,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,362.3109,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,307.150914,724.6218
"HERNIA MESH 3D MAX MID ANATOMICAL MESH LEFT SIZE L 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,11976-MAIN,LOCAL,,,,,755,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,362.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"HERNIA MESH 3D MAX MID ANATOMICAL MESH LEFT SIZE L 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,11976-MAIN,LOCAL,,,,,755,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,362.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"HERNIA MESH 3D MAX MID ANATOMICAL MESH RIGHT SIZE L 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,11977-MAIN,LOCAL,,,,,755,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,362.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"HERNIA MESH 3D MAX MID ANATOMICAL MESH RIGHT SIZE L 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,11977-MAIN,LOCAL,,,,,755,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,362.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Removal of Anal Tabs,PX46230F,CDM,510,RC,46230,CPT,,,,,,,,790,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,362.5,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.32,652.37
Removal of Anal Tabs,PX46230P,CDM,983,RC,46230,CPT,,,,,,,,1435,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,362.5,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.32,1406.3
8MM ENDOWRIST INSTRUMENTS TIP-UP FENESTRATED GRASPER,27200000,CDM,272,RC,,,,11911-MAIN,LOCAL,,,,,411,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,362.502,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Bone Marrow Aspiration and Biopsy,PXG0364F,CDM,510,RC,G0364,HCPCS,,,,,,,,411,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,362.502,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,170.7294,402.78
Chrom Anal 15-20 Cells - Ref,PX8826290,CDM,310,RC,88262,CPT,90,,,,,,,398,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,362.578,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.06,390.04
Acetaminophen,PX80307E,CDM,300,RC,80307,CPT,,,,,,,,370,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,362.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Alcohol,PX80307A,CDM,300,RC,80307,CPT,,,,,,,,370,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,362.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Salicylate,PX80307D,CDM,300,RC,80307,CPT,,,,,,,,370,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,362.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
Urine Drug Screen,PX80307B,CDM,300,RC,80307,CPT,,,,,,,,370,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,362.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.98,362.6
US Doppler Lw Ext Art Tc,PX9392601,CDM,921,RC,93926,CPT,TC,,,,,,,740,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,362.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,725.2
US Doppler Lw Ext Art Tc,PX9392601,CDM,921,RC,93926,CPT,TC,,,,,,,740,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,362.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,725.2
US Doppler Lw Ext Art Tc,PX9392601,CDM,921,RC,93926,CPT,TC,,,,,,,740,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,362.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,725.2
Xray Elbow 3+Vws Tc,PX7308001,CDM,320,RC,73080,CPT,TC,,,,,,,370,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,362.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,362.6
Injection for Nerve Block,PX64448F,CDM,510,RC,64448,CPT,,,,,,,,873,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,362.6442,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,362.6442,855.54
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059303,NDC,1,EA,740.19,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,362.6931,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.10077,725.3862
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059303,NDC,1,EA,740.19,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,362.6931,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.10077,725.3862
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059303,NDC,1,EA,740.19,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,362.6931,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.10077,725.3862
"Lap,Appendectomy",PX44970P,CDM,983,RC,44970,CPT,,,,,,,,1700,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,362.78,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,362.78,1666
"Lap,Inguinal Hernia Repr,Initial",PX49650P,CDM,983,RC,49650,CPT,,,,,,,,717,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,362.802,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,297.8418,5040.74
"Lap,Dx Surgical Abd W/Biopsy",PX49321F,CDM,510,RC,49321,CPT,,,,,,,,874,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,363.0596,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.0596,5040.74
Art Upper Extremity-Ltd,PX9393101,CDM,921,RC,93931,CPT,TC,,,,,,,718,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,363.308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,703.64
Jak2 Gene - Ref,PX8127090,CDM,300,RC,81270,CPT,90,,,,,,,734,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,363.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.04,719.32
CT Angio Upr Extrm W/O&W/Dye,PX7320601,CDM,350,RC,73206,CPT,TC,,,,,,,757,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,363.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
CT Angio Upr Extrm W/O&W/Dye,PX7320601,CDM,350,RC,73206,CPT,TC,,,,,,,757,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,363.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
"Inject Nerv Blck,Othr Periph Nerv",PX64450F,CDM,510,RC,64450,CPT,,,,,,,,757,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,363.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,314.4578,741.86
"Inject Nerv Blck,Othr Periph Nerv",PX64450F,CDM,510,RC,64450,CPT,,,,,,,,757,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,363.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,314.4578,741.86
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545P,CDM,983,RC,23545,CPT,,,,,,,,412,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,363.384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,171.1448,400.9996
"Closed Rx Big Toe Fx,Manip",PX28495P,CDM,983,RC,28495,CPT,,,,,,,,412,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,363.384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,171.1448,400.9996
prednisoLONE acetate 0.12 % Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,11980017405,NDC,5,ML,757.07,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,363.3936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
prednisoLONE acetate 0.12 % Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,11980017405,NDC,5,ML,757.07,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,363.3936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Fac/Exc Skn Mali2.1-3cmtrnk,Arm,Lg",PX11603F,CDM,510,RC,11603,CPT,,,,,,,,875,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,363.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.475,857.5
Dress/Debrid Large Burn No Anesth,PX16030F,CDM,510,RC,16030,CPT,,,,,,,,399,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,363.489,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,165.7446,391.02
"X-Ray Exam Hip,Bilat W/Pelvis 2 Vws",PX7352101,CDM,320,RC,73521,CPT,TC,,,,,,,399,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,363.489,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,391.02
Xray Lumbosacral 2 or 3 Vws,PX7210001,CDM,320,RC,72100,CPT,TC,,,,,,,399,,Medica,Commercial,both,91.1,,53.2,percent of total billed charges,363.489,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,391.02
Drain Pilonidal Cyst Simpl,PX10080F,CDM,510,RC,10080,CPT,,,,,,,,742,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,363.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,308.2268,727.16
Drain Pilonidal Cyst Simpl,PX10080F,CDM,510,RC,10080,CPT,,,,,,,,742,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,363.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,308.2268,727.16
Drain Pilonidal Cyst Simpl,PX10080F,CDM,510,RC,10080,CPT,,,,,,,,742,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,363.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,308.2268,727.16
Fna W/Image,PX10022F,CDM,510,RC,10022,CPT,,,,,,,,742,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,363.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,308.2268,727.16
Fna W/Image,PX10022F,CDM,510,RC,10022,CPT,,,,,,,,742,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,363.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,308.2268,727.16
Fna W/Image,PX10022F,CDM,510,RC,10022,CPT,,,,,,,,742,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,363.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,308.2268,727.16
cocaine 4% 4 % Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527172874,NDC,4,ML,875.53,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,363.695162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
Resp Virus 6-11 Targets,PX87632,CDM,300,RC,87632,CPT,,,,,,,,428,,First Health,Commercial,both,85,,999999999,percent of total billed charges,363.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,177.7912,419.44
Xray Thoracic Spine 2 Vws,PX7207001,CDM,320,RC,72070,CPT,TC,,,,,,,428,,First Health,Commercial,both,85,,999999999,percent of total billed charges,363.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,419.44
"Diagnostic Bone Marrow, Biopsy and Aspiration",PX38222F,CDM,761,RC,38222,CPT,,,,,,,,1748,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,363.89,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.9,363.89
Exc Skn Beni 0.6-1cm Fcefacial,PX11441P,CDM,983,RC,11441,CPT,,,,,,,,485,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,363.89,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.64,475.3
"Fac/Exc Skn Bnig0.6-1cm Fae,Facial",PX11441F,CDM,510,RC,11441,CPT,,,,,,,,606,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,363.89,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.64,363.89
SUTURE CTD VICRYL 4-0 VIL BR SUTUPK J103T,27200000,CDM,272,RC,,,,4491-MAIN,LOCAL,,,,,373.97,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,363.985001,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Surgical Diagnostic Exam, Anorectal",PX45990P,CDM,983,RC,45990,CPT,,,,,,,,409,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,364.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,169.8986,2452.93
Fac/Exc Skin Benig<5mm Remaind Bod,PX11420F,CDM,510,RC,11420,CPT,,,,,,,,374,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,364.0142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,1416.38
"Fac/Office Consultation,Level III",PX99243F,CDM,510,RC,99213,CPT,,,,,,,,374,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,134.9887097,percent of total billed charges,364.0142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,366.52
"Inpatient Consult, Level III",PX99253,CDM,983,RC,99253,CPT,,,,,,,,374,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,364.0142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,364.0142
"Office Consultation,Level III",PX99243P,CDM,983,RC,99243,CPT,,,,,,,,374,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,364.0142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,364.0142
Removal of Hemorrhoid Clot,PX46320P,CDM,983,RC,46320,CPT,,,,,,,,374,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,364.0142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,1030.93
Xray Hand 3vws Tc,PX7313001,CDM,320,RC,73130,CPT,TC,,,,,,,374,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,144.03375,percent of total billed charges,364.0142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,366.52
"Lap,Appendectomy",PX44970P,CDM,983,RC,44970,CPT,,,,,,,,1700,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,364.31,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,362.78,1666
"Lap,Appendectomy",PX44970P,CDM,983,RC,44970,CPT,,,,,,,,1700,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,364.31,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,362.78,1666
"Sigmoidoscopy,Diagnostic",PX45330F,CDM,510,RC,45330,CPT,,,,,,,,720,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,364.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,299.088,798.45
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12173-MAIN,LOCAL,,,,,400,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,364.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Lvl 1 Init Hosp Low Mdm or 40 Minutes,PX99221,CDM,982,RC,99221,CPT,,,,,,,,400,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,364.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.16,389.32
Cyto Non Gyn,PX8811201,CDM,310,RC,88112,CPT,TC,,,,,,,372,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,364.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,364.56
I&D Bartholin Gland Abscess,PX56420F,CDM,510,RC,56420,CPT,,,,,,,,429,,First Health,Commercial,both,85,,999999999,percent of total billed charges,364.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.08,420.42
"US Guide, Vascular Access",PX7693701,CDM,402,RC,76937,CPT,TC,,,,,,,760,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,364.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,315.704,744.8
"US Guide, Vascular Access",PX7693701,CDM,402,RC,76937,CPT,TC,,,,,,,760,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,364.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,315.704,744.8
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614900,NDC,1,EA,409.89,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,364.8021,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
"Lab Antibody ID,RBC",PX86870,CDM,300,RC,,,,,,,,,,410,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,364.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,170.314,401.8
"Supply Technicium Sestamibi,per Dose",PXA9500,CDM,343,RC,A9500,HCPCS,,,,,,,,410,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,364.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,170.314,401.8
glucagon rdna (diagnostic) 1 MG Recon Soln 1 Each Vial,J1610.01,CDM,636,RC,J1610,HCPCS,,,,597026010,NDC,1,EA,744.84,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,148.97,percent of total billed charges,364.9716,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,172.71,729.9432
glucagon rdna (diagnostic) 1 MG Recon Soln 1 Each Vial,J1610.01,CDM,636,RC,J1610,HCPCS,,,,597026010,NDC,1,EA,744.84,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,364.9716,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,172.71,729.9432
glucagon rdna (diagnostic) 1 MG Recon Soln 1 Each Vial,J1610.01,CDM,636,RC,J1610,HCPCS,,,,597026010,NDC,1,EA,744.84,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,364.9716,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,172.71,729.9432
"Digital Mamm, Diag, Bilat, Tc W/Cad Perf",PX7706601,CDM,401,RC,77066,CPT,TC,,,,,,,375,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,279.4033333,percent of total billed charges,364.9875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.05,367.5
Repr Superf Wnd Face 2.6-5,PX12013F,CDM,510,RC,12013,CPT,,,,,,,,375,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,51.02,percent of total billed charges,364.9875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.775,367.5
Xray Wrist Minimum 3 Vws,PX7311001,CDM,320,RC,73110,CPT,TC,,,,,,,375,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,169.6329412,percent of total billed charges,364.9875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,367.5
brinzolamide-brimonidine 1-0.2 % Suspension 8 mL Bottle,63700001,CDM,250,RC,,,,,,65414727,NDC,8,ML,850.88,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,365.02752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
X-Ray Exam Entire Spine 1vw,PX7208101,CDM,320,RC,72081,CPT,TC,,,,,,,414,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,365.148,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,405.72
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320990,NDC,1,EA,410.32,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,365.1848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320995,NDC,1,EA,410.32,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,365.1848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
"Calprotectin, Fecal - Ref",PX8399390,CDM,300,RC,83993,CPT,90,,,,,,,401,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,365.311,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18,392.98
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279210,NDC,10,ML,429.84,,First Health,Commercial,both,85,,999999999,percent of total billed charges,365.364,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,178.555536,421.2432
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279410,NDC,10,ML,429.84,,First Health,Commercial,both,85,,999999999,percent of total billed charges,365.364,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,178.555536,421.2432
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082152,NDC,1,ML,375.43,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,365.406019,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.48,367.9214
umeclidinium-vilanterol 62.5-25 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173086906,NDC,14,EA,745.86,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,365.4714,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
umeclidinium-vilanterol 62.5-25 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173086906,NDC,14,EA,745.86,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,365.4714,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
umeclidinium-vilanterol 62.5-25 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173086906,NDC,14,EA,745.86,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,365.4714,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
butamben-tetracaine-benzocaine 2-2-14 % Aerosol 5 g Bottle,25000000,CDM,250,RC,,,,,,10223020104,NDC,5,GR,375.52,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,365.493616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
RELOAD SUREFORM 60 2.5 WHITE 6 ROW BOX/12,27200000,CDM,272,RC,,,,12261-MAIN,LOCAL,,,,,430,,First Health,Commercial,both,85,,999999999,percent of total billed charges,365.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 60 3.5 BLUE,27200000,CDM,272,RC,,,,12084-MAIN,LOCAL,,,,,430,,First Health,Commercial,both,85,,999999999,percent of total billed charges,365.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 60 4.3 GREEN,27200000,CDM,272,RC,,,,12085-MAIN,LOCAL,,,,,430,,First Health,Commercial,both,85,,999999999,percent of total billed charges,365.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
hepatitis A vaccine 1440 EL U/ML Suspension 1 mL Syringe,90632,CDM,636,RC,90632,CPT,,,,58160082652,NDC,1,ML,375.78,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,365.746674,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,156.099012,368.2644
8MM ENDOWRIST INSTRUMENTS TIP-UP FENESTRATED GRASPER,27200000,CDM,272,RC,,,,11911-MAIN,LOCAL,,,,,411,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,365.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Bone Marrow Aspiration and Biopsy,PXG0364F,CDM,510,RC,G0364,HCPCS,,,,,,,,411,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,365.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,170.7294,402.78
fat emulsion 20 % Emulsion 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,338051958,NDC,200,ML,375.95,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,365.912135,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Injection,Sacroiliac Joint(T)",PX27096F,CDM,510,RC,27096,CPT,,,,,,,,881,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,365.9674,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,365.9674,863.38
perflutren protein A microsphere Suspension 3 mL Vial,Q9956,CDM,636,RC,Q9956,HCPCS,,,,407270703,NDC,3,ML,739.41,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,366.00795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,307.150914,724.6218
2.1MM CANNULATED DRILL BIT,27200000,CDM,272,RC,,,,12657-MAIN,LOCAL,,,,,747,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,366.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
2.1MM CANNULATED DRILL BIT,27200000,CDM,272,RC,,,,12657-MAIN,LOCAL,,,,,747,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,366.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
2.1MM CANNULATED DRILL BIT,27200000,CDM,272,RC,,,,12657-MAIN,LOCAL,,,,,747,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,366.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
US Guide Needle Bx S&I,PX7694201,CDM,402,RC,76942,CPT,TC,,,,,,,747,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,149.4,percent of total billed charges,366.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.3038,732.06
US Guide Needle Bx S&I,PX7694201,CDM,402,RC,76942,CPT,TC,,,,,,,747,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,366.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.3038,732.06
US Guide Needle Bx S&I,PX7694201,CDM,402,RC,76942,CPT,TC,,,,,,,747,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,366.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.3038,732.06
"US Complete Joint, Realtime W/ Img Tc",PX7688101,CDM,402,RC,76881,CPT,TC,,,,,,,415,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,366.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,406.7
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266F,CDM,510,RC,27266,CPT,,,,,,,,1684,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,366.05,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,366.05,1230.71
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266P,CDM,983,RC,27266,CPT,,,,,,,,2275,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,366.05,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,366.05,2229.5
Trauma Activation,PX68200010,CDM,684,RC,G0390,HCPCS,,,,,,,,1243,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,366.12,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,366.12,366.12
REVITA PLACENTAL MEMBRANE 2X3CM 6SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12559-MAIN,LOCAL,,,,,2474,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,366.12677,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,265.9,614.65
REVITA PLACENTAL MEMBRANE 4X4CM 16SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12560-MAIN,LOCAL,,,,,6597,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,366.12677,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,265.9,614.65
REVITA PLACENTAL MEMBRANE 4X6CM 24SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12561-MAIN,LOCAL,,,,,9896,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,366.12677,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,265.9,614.65
REVITA PLACENTAL MEMBRANE 6X6CM 36SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12562-MAIN,LOCAL,,,,,14844,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,366.12677,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,265.9,614.65
REVITA PLACENTAL MEMBRANE 6X8CM 48SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12563-MAIN,LOCAL,,,,,19792,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,366.12677,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,265.9,614.65
brimonidine 0.15 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314014405,NDC,5,ML,723.62,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,366.15172,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Cardioversion, Elective;Extern",PX92960F,CDM,480,RC,92960,CPT,,,,,,,,402,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,366.222,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.9908,568.57
Chem Cautery Granulatn Tissue,PX17250P,CDM,983,RC,17250,CPT,,,,,,,,402,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,366.222,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.9908,391.2666
Lab Imm Spin X-Match,PX8837,CDM,300,RC,86920,CPT,,,,,,,,402,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,366.222,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.22,393.96
"Morphometric Analysis, in Situ Hybridization, Each Probe; Manual, Tech",PX8836801,CDM,310,RC,88368,CPT,TC,,,,,,,402,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,366.222,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.9908,393.96
Biopsy of Rectum,PX45100F,CDM,510,RC,45100,CPT,,,,,,,,763,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,366.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,316.9502,2452.93
Biopsy of Rectum,PX45100F,CDM,510,RC,45100,CPT,,,,,,,,763,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,366.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,316.9502,2452.93
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,781344071,NDC,1,EA,430.94,,First Health,Commercial,both,85,,999999999,percent of total billed charges,366.299,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,179.012476,460.7862
US Doppler Lw Ext Art Tc,PX9392601,CDM,921,RC,93926,CPT,TC,,,,,,,740,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,366.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,725.2
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059303,NDC,1,EA,740.19,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,366.39405,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.10077,725.3862
SUTURE CTD VICRYL 4-0 VIL BR SUTUPK J103T,27200000,CDM,272,RC,,,,4491-MAIN,LOCAL,,,,,373.97,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,366.4906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Fac/Exc Skin Benig<5mm Remaind Bod,PX11420F,CDM,510,RC,11420,CPT,,,,,,,,374,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,366.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,1416.38
"Fac/Office Consultation,Level III",PX99243F,CDM,510,RC,99213,CPT,,,,,,,,374,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,366.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,366.52
"Inpatient Consult, Level III",PX99253,CDM,983,RC,99253,CPT,,,,,,,,374,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,366.52,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.07,366.52
"Office Consultation,Level III",PX99243P,CDM,983,RC,99243,CPT,,,,,,,,374,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,366.52,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.65,366.52
Removal of Hemorrhoid Clot,PX46320P,CDM,983,RC,46320,CPT,,,,,,,,374,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,366.52,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.24,445.52
Xray Hand 3vws Tc,PX7313001,CDM,320,RC,73130,CPT,TC,,,,,,,374,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,366.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,366.52
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016401,NDC,1,ML,854.49,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,366.57621,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.66,898.7384
"Amputation Toe,Mt-P Jt",PX28820F,CDM,510,RC,28820,CPT,,,,,,,,1950,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,366.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.51,615.01
"Amputation Toe,Mt-P Jt",PX28820P,CDM,983,RC,28820,CPT,,,,,,,,1300,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,366.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.51,1274
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545P,CDM,983,RC,23545,CPT,,,,,,,,412,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,366.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,171.1448,400.9996
"Closed Rx Big Toe Fx,Manip",PX28495P,CDM,983,RC,28495,CPT,,,,,,,,412,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,366.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,171.1448,400.9996
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Suspension 10 mL Bottle,63700001,CDM,250,RC,,,,,,24208063562,NDC,10,ML,415.81,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,366.74442,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004F,CDM,510,RC,15004,CPT,,,,,,,,855,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,366.795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,355.167,837.9
albumin human 25% 25 % Solution 50 mL Flex Cont,P9047,CDM,636,RC,P9047,HCPCS,,,,944049301,NDC,50,ML,402.67,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,366.83237,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.66,394.6166
US Head/Neck Tc,PX7653601,CDM,402,RC,76536,CPT,TC,,,,,,,416,,United Healthcare,All Payer,outpatient,88.2,,203.84,percent of total billed charges,366.912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,407.68
Repr Superf Wnd Body 12.6-20,PX12005P,CDM,983,RC,12005,CPT,,,,,,,,377,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,366.9341,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,156.6058,366.9341
"Fac/Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404F,CDM,510,RC,11404,CPT,,,,,,,,749,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,322.2,percent of total billed charges,367.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,311.1346,1416.38
"Fac/Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404F,CDM,510,RC,11404,CPT,,,,,,,,749,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,367.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,311.1346,1416.38
"Fac/Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404F,CDM,510,RC,11404,CPT,,,,,,,,749,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,367.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,311.1346,1416.38
Abd Duplex Abd-Full,PX9397501,CDM,921,RC,93975,CPT,TC,,,,,,,788,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,367.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.26,367.05
Abd Duplex Abd-Full,PX9397501,CDM,921,RC,93975,CPT,TC,,,,,,,788,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,367.05,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.26,367.05
Xray Eye Foreign Body,PX7003001,CDM,320,RC,70030,CPT,TC,,,,,,,432,,First Health,Commercial,both,85,,999999999,percent of total billed charges,367.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,423.36
Abd Paracentesis,PX49082F,CDM,510,RC,49082,CPT,,,,,,,,884,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,367.2136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,367.2136,866.32
"Excise Lesion,Back or Flank",PX21930P,CDM,983,RC,21930,CPT,,,,,,,,884,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,367.2136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,367.2136,1416.38
Drain Pilonidal Cyst Simpl,PX10080F,CDM,510,RC,10080,CPT,,,,,,,,742,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,367.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,308.2268,727.16
Fna W/Image,PX10022F,CDM,510,RC,10022,CPT,,,,,,,,742,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,367.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,308.2268,727.16
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605P,CDM,983,RC,24605,CPT,,,,,,,,750,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,367.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,311.55,1404.08
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605P,CDM,983,RC,24605,CPT,,,,,,,,750,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,367.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,311.55,1404.08
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605P,CDM,983,RC,24605,CPT,,,,,,,,750,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,367.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,311.55,1404.08
"Digital Mamm, Diag, Bilat, Tc W/Cad Perf",PX7706601,CDM,401,RC,77066,CPT,TC,,,,,,,375,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,367.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.05,367.5
"Digital Mammogram, Screen Bil, Tc W/Cad Perf",PX7706701,CDM,403,RC,77067,CPT,TC,,,,,,,375,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,367.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.86,561
Repr Superf Wnd Face 2.6-5,PX12013F,CDM,510,RC,12013,CPT,,,,,,,,375,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,367.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.775,367.5
Sigmoidoscope W/Submuc Inj,PX45335F,CDM,750,RC,45335,CPT,,,,,,,,750,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,367.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,311.55,798.45
Sigmoidoscope W/Submuc Inj,PX45335F,CDM,750,RC,45335,CPT,,,,,,,,750,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,367.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,311.55,798.45
Sigmoidoscope W/Submuc Inj,PX45335F,CDM,750,RC,45335,CPT,,,,,,,,750,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,367.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,311.55,798.45
Xray Wrist Minimum 3 Vws,PX7311001,CDM,320,RC,73110,CPT,TC,,,,,,,375,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,367.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,367.5
hydrocortisone sodium succinate (preservative free) 1000 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9000501,NDC,1,EA,403.54,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,367.62494,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
"Closed Rx Big Toe Fx,Manip",PX28495F,CDM,510,RC,28495,CPT,,,,,,,,857,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,367.653,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,839.86
procainamide 500 MG/ML Solution 2 mL Vial,J2690.01,CDM,636,RC,J2690,HCPCS,,,,14789090002,NDC,2,ML,377.75,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,367.664075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,134.15,370.195
fluticasone propionate 50 MCG/ACT Suspension 16 g Bottle,63700001,CDM,250,RC,,,,,,50383070016,NDC,16,GR,432.56,,First Health,Commercial,both,85,,999999999,percent of total billed charges,367.676,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Xray Ribs Bilat 3 Vws With Pa Chest,PX7111101,CDM,320,RC,71111,CPT,TC,,,,,,,417,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,367.794,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,408.66
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082152,NDC,1,ML,375.43,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,367.9214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,139.48,367.9214
butamben-tetracaine-benzocaine 2-2-14 % Aerosol 5 g Bottle,25000000,CDM,250,RC,,,,,,10223020104,NDC,5,GR,375.52,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,368.0096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Layr Clos Wnd Rest Body 2.6-7.5,PX12042F,CDM,510,RC,12042,CPT,,,,,,,,404,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,368.044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,395.92
Neg Pressure Wound Therapy Dme >50 Sq Cm,PX97606F,CDM,761,RC,97606,CPT,,,,,,,,404,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,368.044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,395.92
Remove Foreign Body Simple,PX10120F,CDM,510,RC,10120,CPT,,,,,,,,404,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,368.044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,395.92
Remove Foreign Body Simple,PX10120P,CDM,983,RC,10120,CPT,,,,,,,,404,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,368.044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,393.2132
Xray Foot Minimum 3 Vws,PX7363001,CDM,320,RC,73630,CPT,TC,,,,,,,404,,Medica,Commercial,both,91.1,,214.165,percent of total billed charges,368.044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,395.92
Xray Knee 3 Vws,PX7356201,CDM,320,RC,73562,CPT,TC,,,,,,,404,,Medica,Commercial,both,91.1,,136.6346154,percent of total billed charges,368.044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,395.92
"Exc Skn Beig1.1-2cm Face,Facil",PX11442P,CDM,983,RC,11442,CPT,,,,,,,,886,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,368.0444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,368.0444,862.3438
Closed Rx Bimalleolar Fx,PX27808P,CDM,983,RC,27808,CPT,,,,,,,,433,,First Health,Commercial,both,85,,999999999,percent of total billed charges,368.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,179.8682,421.4389
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Solution 10 mL Bottle,63700001,CDM,250,RC,,,,,,61314064610,NDC,10,ML,433.15,,First Health,Commercial,both,85,,999999999,percent of total billed charges,368.1775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535F,CDM,510,RC,24535,CPT,,,,,,,,2514,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,368.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,362.13,1333.79
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535F,CDM,510,RC,24535,CPT,,,,,,,,2514,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,368.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,362.13,1333.79
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535P,CDM,983,RC,24535,CPT,,,,,,,,2887,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,368.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,362.13,2829.26
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535P,CDM,983,RC,24535,CPT,,,,,,,,2887,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,368.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,362.13,2829.26
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266F,CDM,510,RC,27266,CPT,,,,,,,,1684,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,368.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,366.05,1230.71
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266F,CDM,510,RC,27266,CPT,,,,,,,,1684,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,368.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,366.05,1230.71
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266P,CDM,983,RC,27266,CPT,,,,,,,,2275,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,368.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,366.05,2229.5
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266P,CDM,983,RC,27266,CPT,,,,,,,,2275,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,368.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,366.05,2229.5
hepatitis A vaccine 1440 EL U/ML Suspension 1 mL Syringe,90632,CDM,636,RC,90632,CPT,,,,58160082652,NDC,1,ML,375.78,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,368.2644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,156.099012,368.2644
"Closed Rx Dist Fibula Fx,Manip",PX27788F,CDM,510,RC,27788,CPT,,,,,,,,1597,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,368.3017,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.51,915.25
"Closed Rx Dist Fibula Fx,Manip",PX27788P,CDM,983,RC,27788,CPT,,,,,,,,1277,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,368.3017,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.51,1251.46
perflutren lipid microsphere 6.52 MG/ML Suspension 2 mL Vial,Q9957,CDM,636,RC,Q9957,HCPCS,,,,11994001101,NDC,2,ML,751.71,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,98.89666667,percent of total billed charges,368.3379,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,312.260334,736.6758
perflutren lipid microsphere 6.52 MG/ML Suspension 2 mL Vial,Q9957,CDM,636,RC,Q9957,HCPCS,,,,11994001101,NDC,2,ML,751.71,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,368.3379,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,312.260334,736.6758
perflutren lipid microsphere 6.52 MG/ML Suspension 2 mL Vial,Q9957,CDM,636,RC,Q9957,HCPCS,,,,11994001101,NDC,2,ML,751.71,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,368.3379,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,312.260334,736.6758
fat emulsion 20 % Emulsion 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,338051958,NDC,200,ML,375.95,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,368.431,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
X-Ray Exam Entire Spine 1vw,PX7208101,CDM,320,RC,72081,CPT,TC,,,,,,,414,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,368.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,405.72
Removal of Skin Tags,PX11200P,CDM,983,RC,11200,CPT,,,,,,,,418,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,368.676,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,173.6372,406.8394
glucagon rdna (diagnostic) 1 MG Recon Soln 1 Each Vial,J1610.01,CDM,636,RC,J1610,HCPCS,,,,597026010,NDC,1,EA,744.84,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,368.6958,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,172.71,729.9432
Multiple Sleep Latency Test,PX9580501,CDM,740,RC,95805,CPT,TC,,,,,,,4313,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,368.8524,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,238.66,656.16
STAPLER SUREFORM 45 SPU IS4000,27200000,CDM,272,RC,,,,12794-MAIN,LOCAL,,,,,888,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,368.8752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Tech-Cytopath Eval, Fna, Rep",PX8817301,CDM,310,RC,88173,CPT,TC,,,,,,,379,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,249.01,percent of total billed charges,368.8807,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,371.42
oseltamivir 6 MG/ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,4082205,NDC,60,ML,752.82,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,368.8818,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 6 MG/ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,4082205,NDC,60,ML,752.82,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,368.8818,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 6 MG/ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,4082205,NDC,60,ML,752.82,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,368.8818,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
GRAFIXPL PRIME PLACENTAL MEMBRANE 16MM DISC 2SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12763-MAIN,LOCAL,,,,,860,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,368.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
"Treat Thumb Disloc,Manipulatn",PX26641F,CDM,510,RC,26641,CPT,,,,,,,,1721,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,368.9439,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.07,905.57
"Treat Thumb Disloc,Manipulatn",PX26641P,CDM,983,RC,26641,CPT,,,,,,,,1902,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,368.9439,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.07,1863.96
Diagnostic Anoscopy,PX46600P,CDM,983,RC,46600,CPT,,,,,,,,405,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,368.955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,394.1865
Exc Neck Les Sc = 3cm >,PX21552F,CDM,510,RC,21552,CPT,,,,,,,,753,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,368.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,312.7962,2482.37
Exc Neck Les Sc = 3cm >,PX21552F,CDM,510,RC,21552,CPT,,,,,,,,753,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,368.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,312.7962,2482.37
Exc Neck Les Sc = 3cm >,PX21552F,CDM,510,RC,21552,CPT,,,,,,,,753,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,368.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,312.7962,2482.37
"Layr Clos Wnd Face,Facial <2.5cm",PX12051F,CDM,510,RC,12051,CPT,,,,,,,,769,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,369.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,319.4426,753.62
"Layr Clos Wnd Face,Facial <2.5cm",PX12051F,CDM,510,RC,12051,CPT,,,,,,,,769,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,369.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,319.4426,753.62
umeclidinium-vilanterol 62.5-25 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173086906,NDC,14,EA,745.86,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,369.2007,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Drain Skin Abscess Complic,PX10061F,CDM,510,RC,10061,CPT,,,,,,,,889,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,369.2906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,871.22
Inc/Drain Peritonsil Abscess,PX42700P,CDM,983,RC,42700,CPT,,,,,,,,889,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,369.2906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,865.2637
"US Complete Joint, Realtime W/ Img Tc",PX7688101,CDM,402,RC,76881,CPT,TC,,,,,,,415,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,369.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,406.7
Repr Superf Wnd Body 12.6-20,PX12005F,CDM,510,RC,12005,CPT,,,,,,,,565,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,369.42,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.84,369.42
Repr Superf Wnd Body 12.6-20,PX12005P,CDM,983,RC,12005,CPT,,,,,,,,377,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,369.42,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.84,369.46
Repr Superf Wnd Body 12.6-20,PX12005P,CDM,983,RC,12005,CPT,,,,,,,,377,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,369.46,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,55.84,369.46
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,115169449,NDC,1,EA,889.46,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,369.481684,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54505010202,NDC,1,EA,889.46,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,369.481684,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
TRAY PNEUMOTHORAX 14FR 29CM 19 CATHETER SIDEPORTS G56537,120.496,CDM,272,RC,,,,11677-MAIN,LOCAL,,,,,419,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,369.558,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.0526,410.62
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494301,NDC,0.5,ML,419.2,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,369.7344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.38,410.8454
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494300,NDC,0.5,ML,419.23,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,369.76086,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.38,410.8454
2.1MM CANNULATED DRILL BIT,27200000,CDM,272,RC,,,,12657-MAIN,LOCAL,,,,,747,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,369.765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
US Guide Needle Bx S&I,PX7694201,CDM,402,RC,76942,CPT,TC,,,,,,,747,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,369.765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.3038,732.06
Skin Sub Graft Trnk/Arm/Leg,PX15271F,CDM,510,RC,15271,CPT,,,,,,,,862,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,369.798,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,358.0748,1593.14
Closed Rx Elbow Dislocation,PX24600P,CDM,983,RC,24600,CPT,,,,,,,,380,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,369.854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,157.852,369.854
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598F,CDM,510,RC,97598,CPT,,,,,,,,406,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,369.866,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,168.6524,397.88
"Fac/Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602F,CDM,510,RC,11602,CPT,,,,,,,,731,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,369.886,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,303.6574,716.38
"HERNIA MESH 3D MAX MID ANATOMICAL MESH LEFT SIZE L 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,11976-MAIN,LOCAL,,,,,755,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,196.035,percent of total billed charges,369.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"HERNIA MESH 3D MAX MID ANATOMICAL MESH LEFT SIZE L 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,11976-MAIN,LOCAL,,,,,755,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,369.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"HERNIA MESH 3D MAX MID ANATOMICAL MESH LEFT SIZE L 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,11976-MAIN,LOCAL,,,,,755,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,369.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"HERNIA MESH 3D MAX MID ANATOMICAL MESH RIGHT SIZE L 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,11977-MAIN,LOCAL,,,,,755,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,196.035,percent of total billed charges,369.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"HERNIA MESH 3D MAX MID ANATOMICAL MESH RIGHT SIZE L 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,11977-MAIN,LOCAL,,,,,755,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,369.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"HERNIA MESH 3D MAX MID ANATOMICAL MESH RIGHT SIZE L 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,11977-MAIN,LOCAL,,,,,755,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,369.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Suspension 10 mL Bottle,63700001,CDM,250,RC,,,,,,24208063562,NDC,10,ML,415.81,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,370.0709,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Irradiated Leukoreduced Rbc's,PXP9040,CDM,390,RC,P9040,HCPCS,,,,,,,,771,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,370.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,231.5,755.58
Irradiated Leukoreduced Rbc's,PXP9040,CDM,390,RC,P9040,HCPCS,,,,,,,,771,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,370.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,231.5,755.58
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041105,NDC,1,ML,419.67,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,370.14894,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.808876,411.2766
procainamide 500 MG/ML Solution 2 mL Vial,J2690.01,CDM,636,RC,J2690,HCPCS,,,,14789090002,NDC,2,ML,377.75,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,370.195,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,134.15,370.195
US Head/Neck Tc,PX7653601,CDM,402,RC,76536,CPT,TC,,,,,,,416,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,370.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,407.68
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12173-SURG,LOCAL,,,,,772,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,370.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12173-SURG,LOCAL,,,,,772,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,370.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
X-Ray Exam Abdomen 2 Views,PX7401901,CDM,320,RC,74019,CPT,TC,,,,,,,436,,First Health,Commercial,both,85,,999999999,percent of total billed charges,370.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,427.28
"X-Ray Exam Hip,Unilat W/Pelvis 2-3 Vws",PX7350201,CDM,320,RC,73502,CPT,TC,,,,,,,436,,First Health,Commercial,both,85,,999999999,percent of total billed charges,370.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,427.28
Xray Abdomen Comp Incl Decub and/or Erect,PX7402001,CDM,320,RC,74020,CPT,TC,,,,,,,436,,First Health,Commercial,both,85,,999999999,percent of total billed charges,370.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.1144,427.28
Xray Cervical Spine 2 or 3 Vws,PX7204001,CDM,320,RC,72040,CPT,TC,,,,,,,436,,First Health,Commercial,both,85,,999999999,percent of total billed charges,370.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,427.28
Cns Dna/Rna Amp Probe Multiple Subtypes 12-25,PX87483,CDM,300,RC,87483,CPT,,,,,,,,864,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,370.656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,358.9056,846.72
"Fac/Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404F,CDM,510,RC,11404,CPT,,,,,,,,749,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,370.755,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,311.1346,1416.38
"Xray Mandible Compl, Min 4 Vws",PX7011001,CDM,320,RC,70110,CPT,TC,,,,,,,381,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,370.8273,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,373.38
Exs Tumor Arm/Elbow Sc 3cm>,PX24071F,CDM,510,RC,24071,CPT,,,,,,,,1860,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,370.8705,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,249.34,852.3
CT Angio Upr Extrm W/O&W/Dye,PX7320601,CDM,350,RC,73206,CPT,TC,,,,,,,757,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,370.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
CT Angio Upr Extrm W/O&W/Dye,PX7320601,CDM,350,RC,73206,CPT,TC,,,,,,,757,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,370.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
CT Angio Upr Extrm W/O&W/Dye,PX7320601,CDM,350,RC,73206,CPT,TC,,,,,,,757,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,370.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
"Inject Nerv Blck,Othr Periph Nerv",PX64450F,CDM,510,RC,64450,CPT,,,,,,,,757,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,370.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,314.4578,741.86
"Inject Nerv Blck,Othr Periph Nerv",PX64450F,CDM,510,RC,64450,CPT,,,,,,,,757,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,370.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,314.4578,741.86
"Inject Nerv Blck,Othr Periph Nerv",PX64450F,CDM,510,RC,64450,CPT,,,,,,,,757,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,370.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,314.4578,741.86
prednisoLONE acetate 0.12 % Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,11980017405,NDC,5,ML,757.07,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,370.9643,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
prednisoLONE acetate 0.12 % Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,11980017405,NDC,5,ML,757.07,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,370.9643,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
prednisoLONE acetate 0.12 % Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,11980017405,NDC,5,ML,757.07,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,370.9643,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
I&D Deep Absc/Hematoma Neck/Chest,PX21501F,CDM,510,RC,21501,CPT,,,,,,,,773,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,371.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.1042,2482.37
I&D Deep Absc/Hematoma Neck/Chest,PX21501F,CDM,510,RC,21501,CPT,,,,,,,,773,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,371.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.1042,2482.37
PREP KIT STAPLE 18MM,27200000,CDM,278,RC,C1713,HCPCS,,11658-MAIN,LOCAL,,,,,420.75,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,371.1015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PREP KIT STAPLE 20MM,27200000,CDM,278,RC,C1713,HCPCS,,11659-MAIN,LOCAL,,,,,420.75,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,371.1015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Xray Ribs Bilat 3 Vws With Pa Chest,PX7111101,CDM,320,RC,71111,CPT,TC,,,,,,,417,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,371.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,408.66
"Remv Foreign Body,Knee/Thigh,Deep",PX27372F,CDM,510,RC,27372,CPT,,,,,,,,1429,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,371.1916,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,250.43,1226.56
"Remv Foreign Body,Knee/Thigh,Deep",PX27372P,CDM,983,RC,27372,CPT,,,,,,,,954,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,371.1916,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,250.43,1226.56
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605P,CDM,983,RC,24605,CPT,,,,,,,,750,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,371.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,311.55,1404.08
Sigmoidoscope W/Submuc Inj,PX45335F,CDM,750,RC,45335,CPT,,,,,,,,750,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,371.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,311.55,798.45
"measles, mumps & rubella vaccine Recon Soln 1 Each Vial",90707,CDM,636,RC,90707,CPT,,,,6468100,NDC,1,EA,381.47,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,371.284751,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,158.462638,373.8406
Jak2 Gene - Ref,PX8127090,CDM,300,RC,81270,CPT,90,,,,,,,734,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,371.404,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.04,719.32
"Tech-Cytopath Eval, Fna, Rep",PX8817301,CDM,310,RC,88173,CPT,TC,,,,,,,379,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,371.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.34,371.42
Xray Ribs Unilat 2 Vws,PX7110001,CDM,320,RC,71100,CPT,TC,,,,,,,437,,First Health,Commercial,both,85,,999999999,percent of total billed charges,371.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,428.26
Debride Tissue/Muscle/Bone,PX11044P,CDM,983,RC,11044,CPT,,,,,,,,866,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,371.514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,359.7364,1416.38
erythromycin lactobionate 500 MG Recon Soln 1 Each Vial,J1364.01,CDM,636,RC,J1364,HCPCS,,,,409648211,NDC,1,EA,437.09,,First Health,Commercial,both,85,,999999999,percent of total billed charges,371.5265,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.06,428.3482
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310002,NDC,0.528,ML,894.9,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,371.74146,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.22,877.002
medroxyPROGESTERone 150 MG/ML Suspension 1 mL Vial,J1050.01,CDM,636,RC,J1050,HCPCS,,,,67457088799,NDC,1,ML,437.38,,First Health,Commercial,both,85,,999999999,percent of total billed charges,371.773,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.687652,428.6324
fluticasone propionate 50 MCG/ACT Suspension 16 g Bottle,63700001,CDM,250,RC,,,,,,60505082901,NDC,16,GR,437.4,,First Health,Commercial,both,85,,999999999,percent of total billed charges,371.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"X-Ray Exam Hip,Bilat W/Pelvis 3-4 Vws",PX7352201,CDM,320,RC,73522,CPT,TC,,,,,,,382,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,370.04,percent of total billed charges,371.8006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,374.36
Room Rate Transitional Care Private,PX11900000,CDM,119,RC,,,,,,,,,,775,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,372,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.935,759.5
Room Rate Transitional Care Private,PX11900000,CDM,119,RC,,,,,,,,,,775,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,372,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.935,759.5
Removal of Skin Tags,PX11200P,CDM,983,RC,11200,CPT,,,,,,,,418,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,372.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,173.6372,406.8394
perflutren lipid microsphere 6.52 MG/ML Suspension 2 mL Vial,Q9957,CDM,636,RC,Q9957,HCPCS,,,,11994001101,NDC,2,ML,751.71,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,372.09645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,312.260334,736.6758
Closure Superf Wnd Dehis Simple,PX12020P,CDM,983,RC,12020,CPT,,,,,,,,422,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,372.204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,175.2988,548.67
Debride Bone Ea Add 20 Sqcm,PX11047F,CDM,510,RC,11047,CPT,,,,,,,,438,,First Health,Commercial,both,85,,999999999,percent of total billed charges,372.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.9452,429.24
US Pregnancy Tc Limited,PX7681501,CDM,402,RC,76815,CPT,TC,,,,,,,438,,First Health,Commercial,both,85,,999999999,percent of total billed charges,372.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,429.24
Closed Rx Elbow Dislocation,PX24600P,CDM,983,RC,24600,CPT,,,,,,,,380,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,372.4,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,218.15,814.94
"US Guide, Vascular Access",PX7693701,CDM,402,RC,76937,CPT,TC,,,,,,,760,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,372.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,315.704,744.8
"US Guide, Vascular Access",PX7693701,CDM,402,RC,76937,CPT,TC,,,,,,,760,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,372.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,315.704,744.8
"US Guide, Vascular Access",PX7693701,CDM,402,RC,76937,CPT,TC,,,,,,,760,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,372.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,315.704,744.8
"Surgical Diagnostic Exam, Anorectal",PX45990P,CDM,983,RC,45990,CPT,,,,,,,,409,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,372.599,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,169.8986,2452.93
oseltamivir 6 MG/ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,4082205,NDC,60,ML,752.82,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,372.6459,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Exc Neck Les Sc = 3cm >,PX21552F,CDM,510,RC,21552,CPT,,,,,,,,753,,Humana Choice Care,All Medicare plans,outpatient,49.5,,3023.3,percent of total billed charges,372.735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,312.7962,2482.37
El-1 Fecal Quantitative,PX8265390,CDM,300,RC,82653,CPT,90,,,,,,,383,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,372.7739,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.0982,375.34
nystatin-triamcinolone 100000-0.1 UNIT/GM-% Ointment 30 g Tube,25000000,CDM,250,RC,,,,,,52565004230,NDC,30,GR,438.62,,First Health,Commercial,both,85,,999999999,percent of total billed charges,372.827,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Complex Drainage, Wound",PX10180F,CDM,510,RC,10180,CPT,,,,,,,,1050,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,372.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.95,547.91
"Complex Drainage, Wound",PX10180P,CDM,983,RC,10180,CPT,,,,,,,,767,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,372.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.95,751.66
TRAY PNEUMOTHORAX 14FR 29CM 19 CATHETER SIDEPORTS G56537,120.496,CDM,272,RC,,,,11677-MAIN,LOCAL,,,,,419,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,372.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.0526,410.62
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494301,NDC,0.5,ML,419.2,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,373.088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.38,410.8454
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494300,NDC,0.5,ML,419.23,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,373.1147,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.38,410.8454
"Removal Anal Fistula,Subcutaneous",PX46270F,CDM,510,RC,46270,CPT,,,,,,,,1470,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,373.1182,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,251.31,1113.8
"Removal Anal Fistula,Subcutaneous",PX46270P,CDM,983,RC,46270,CPT,,,,,,,,980,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,373.1182,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,251.31,1113.8
8MM ENDOWRIST INSTRUMENTS 8MM FORCE BIPOLAR IS4000,27200000,CDM,272,RC,,,,11915-MAIN,LOCAL,,,,,439,,First Health,Commercial,both,85,,999999999,percent of total billed charges,373.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
VISIGI3D 40FR STD WITH BULB,27100000,CDM,271,RC,,,,12812-MAIN,LOCAL,,,,,439,,First Health,Commercial,both,85,,999999999,percent of total billed charges,373.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
pentafluoroprop - tetrafluoroeth Aerosol 116 mL Can,63700001,CDM,250,RC,,,,,,386000802,NDC,207,ML,383.42,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,373.182686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070102,NDC,1,ML,383.6,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,373.35788,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.92,450.751
"Xray Mandible Compl, Min 4 Vws",PX7011001,CDM,320,RC,70110,CPT,TC,,,,,,,381,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,373.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,373.38
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614900,NDC,1,EA,409.89,,Medica,Commercial,both,91.1,,6.892980769,percent of total billed charges,373.40979,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041105,NDC,1,ML,419.67,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,373.5063,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.808876,411.2766
"Lab Antibody ID,RBC",PX86870,CDM,300,RC,,,,,,,,,,410,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,373.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,170.314,401.8
"Supply Technicium Sestamibi,per Dose",PXA9500,CDM,343,RC,A9500,HCPCS,,,,,,,,410,,Medica,Commercial,both,91.1,,368.4625,percent of total billed charges,373.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,170.314,401.8
"Exc Skn Bngn2.1-3cm Fce,Facial",PX11443P,CDM,983,RC,11443,CPT,,,,,,,,650,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,373.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.78,637
"Fac/Exc Skn Bngn 2.1-3cmfce,Facial",PX11443F,CDM,510,RC,11443,CPT,,,,,,,,813,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,373.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.78,475.96
"HERNIA MESH 3D MAX MID ANATOMICAL MESH LEFT SIZE L 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,11976-MAIN,LOCAL,,,,,755,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,373.725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"HERNIA MESH 3D MAX MID ANATOMICAL MESH RIGHT SIZE L 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,11977-MAIN,LOCAL,,,,,755,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,373.725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Lvl 3 Sub Hosp High Mdm or 50 Minutes,PX99233,CDM,982,RC,99233,CPT,,,,,,,,384,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,373.7472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.5136,373.7472
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320990,NDC,1,EA,410.32,,Medica,Commercial,both,91.1,,6.892980769,percent of total billed charges,373.80152,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320995,NDC,1,EA,410.32,,Medica,Commercial,both,91.1,,6.892980769,percent of total billed charges,373.80152,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802201,NDC,0.8,ML,439.77,,First Health,Commercial,both,85,,999999999,percent of total billed charges,373.8045,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802210,NDC,0.8,ML,439.77,,First Health,Commercial,both,85,,999999999,percent of total billed charges,373.8045,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
"measles, mumps & rubella vaccine Recon Soln 1 Each Vial",90707,CDM,636,RC,90707,CPT,,,,6468100,NDC,1,EA,381.47,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,373.8406,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,158.462638,373.8406
MIS STERILE INSTRUMENT PACK WITH BLADE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12432-MAIN,LOCAL,,,,,900,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,373.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Biopsy of Rectum,PX45100F,CDM,510,RC,45100,CPT,,,,,,,,763,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,373.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,316.9502,2452.93
Biopsy of Rectum,PX45100F,CDM,510,RC,45100,CPT,,,,,,,,763,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,373.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,316.9502,2452.93
Biopsy of Rectum,PX45100F,CDM,510,RC,45100,CPT,,,,,,,,763,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,373.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,316.9502,2452.93
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402F,CDM,510,RC,11402,CPT,,,,,,,,424,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,373.968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.1296,614.65
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402P,CDM,983,RC,11402,CPT,,,,,,,,424,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,373.968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.1296,614.65
Lab H Pylori Stool Ag,PX87338,CDM,300,RC,87338,CPT,,,,,,,,424,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,373.968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,415.52
"Incis/Drain Scrotum/Testis,Epididym",PX54700P,CDM,983,RC,54700,CPT,,,,,,,,440,,First Health,Commercial,both,85,,999999999,percent of total billed charges,374,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,182.776,1779.39
Baloxavir Marboxil(40 MG Dose) 2 x 20 MG tablet therapy pack 2 Each Box,800000,CDM,,,,,,,,50242082802,NDC,1,EA,384.3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,374.03919,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016425,NDC,1,ML,779.43,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,374.1264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.66,898.7384
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016425,NDC,1,ML,779.43,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,374.1264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.66,898.7384
perflutren protein A microsphere Suspension 3 mL Vial,Q9956,CDM,636,RC,Q9956,HCPCS,,,,407270703,NDC,3,ML,739.41,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,374.14146,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,307.150914,724.6218
Exc Skn Bngn1.1-2cm Remain Bdy,PX11422P,CDM,983,RC,11422,CPT,,,,,,,,822,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,374.26,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.95,805.56
Fac/Exc Skn Bngn1.1-2cm Remain Bdy,PX11422F,CDM,510,RC,11422,CPT,,,,,,,,618,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,374.26,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.95,374.26
"X-Ray Exam Hip,Bilat W/Pelvis 3-4 Vws",PX7352201,CDM,320,RC,73522,CPT,TC,,,,,,,382,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,374.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,374.36
8MM ENDOWRIST INSTRUMENTS TIP-UP FENESTRATED GRASPER,27200000,CDM,272,RC,,,,11911-MAIN,LOCAL,,,,,411,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,374.421,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Bone Marrow Aspiration and Biopsy,PXG0364F,CDM,510,RC,G0364,HCPCS,,,,,,,,411,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,374.421,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,170.7294,402.78
US Doppler Lw Ext Art Tc,PX9392601,CDM,921,RC,93926,CPT,TC,,,,,,,740,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,374.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,725.2
PREP KIT STAPLE 18MM,27200000,CDM,278,RC,C1713,HCPCS,,11658-MAIN,LOCAL,,,,,420.75,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,374.4675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PREP KIT STAPLE 20MM,27200000,CDM,278,RC,C1713,HCPCS,,11659-MAIN,LOCAL,,,,,420.75,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,374.4675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Injection for Nerve Block,PX64448F,CDM,510,RC,64448,CPT,,,,,,,,873,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,374.517,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,362.6442,855.54
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059303,NDC,1,EA,740.19,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,374.53614,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.10077,725.3862
CT Angio Upr Extrm W/O&W/Dye,PX7320601,CDM,350,RC,73206,CPT,TC,,,,,,,757,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,374.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
"Inject Nerv Blck,Othr Periph Nerv",PX64450F,CDM,510,RC,64450,CPT,,,,,,,,757,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,374.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,314.4578,741.86
Apply Long Arm Splint,PX29105P,CDM,983,RC,29105,CPT,,,,,,,,385,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,374.7205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.65,374.7205
Apply Long Leg Splint,PX29505P,CDM,983,RC,29505,CPT,,,,,,,,385,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,374.7205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.65,374.7205
Injection for Nerve Block,PX64445F,CDM,510,RC,64445,CPT,,,,,,,,385,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,374.7205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,604.15
Injection for Nerve Block,PX64445P,CDM,983,RC,64445,CPT,,,,,,,,385,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,374.7205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,604.15
MICA DEPTH GAUGE 150MM STERILE MICA,27200000,CDM,272,RC,,,,12439-MAIN,LOCAL,,,,,385,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,374.7205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"N Block Inj, Plantar Digit",PX64455F,CDM,510,RC,64455,CPT,,,,,,,,385,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,77,percent of total billed charges,374.7205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,377.3
"N Block Inj, Plantar Digit",PX64455P,CDM,983,RC,64455,CPT,,,,,,,,385,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,77,percent of total billed charges,374.7205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,374.7205
Xray Temporomandib Jnt Unilat,PX7032801,CDM,320,RC,70328,CPT,TC,,,,,,,385,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,374.7205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,377.3
prednisoLONE acetate 0.12 % Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,11980017405,NDC,5,ML,757.07,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,374.74965,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Fac/Office Consultation,Level IV",PX99244F,CDM,510,RC,99244,CPT,,,,,,,,441,,First Health,Commercial,both,85,,999999999,percent of total billed charges,374.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,183.1914,432.18
Gastric Intubation Treatment,PX43753F,CDM,510,RC,43753,CPT,,,,,,,,441,,First Health,Commercial,both,85,,999999999,percent of total billed charges,374.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,183.1914,432.18
"Office Consultation,Level IV",PX99244P,CDM,983,RC,99244,CPT,,,,,,,,441,,First Health,Commercial,both,85,,999999999,percent of total billed charges,374.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,183.1914,429.2253
"Injection Hip Arthrogram,Anesth",PX27095F,CDM,510,RC,27095,CPT,,,,,,,,425,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,374.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.545,416.5
"Injection Hip Arthrogram,Anesth",PX27095P,CDM,983,RC,27095,CPT,,,,,,,,425,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,374.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.545,413.6525
US Abdomen Limited Tc,PX7670501,CDM,402,RC,76705,CPT,TC,,,,,,,425,,United Healthcare,All Payer,outpatient,88.2,,249.9,percent of total billed charges,374.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,416.5
US Ext Non-Vasc Img Lmtd,PX7688201,CDM,402,RC,76882,CPT,TC,,,,,,,425,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,374.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,416.5
"Lap,Dx Surgical Abd W/Biopsy",PX49321F,CDM,510,RC,49321,CPT,,,,,,,,874,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,374.946,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.0596,5040.74
Reconstruc of Nail Bed,PX11760P,CDM,983,RC,11760,CPT,,,,,,,,903,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,375.1062,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,375.1062,878.8899
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545P,CDM,983,RC,23545,CPT,,,,,,,,412,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,375.332,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,171.1448,400.9996
"Closed Rx Big Toe Fx,Manip",PX28495P,CDM,983,RC,28495,CPT,,,,,,,,412,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,375.332,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,171.1448,400.9996
El-1 Fecal Quantitative,PX8265390,CDM,300,RC,82653,CPT,90,,,,,,,383,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,375.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.0982,375.34
"Fac/Exc Skn Mali2.1-3cmtrnk,Arm,Lg",PX11603F,CDM,510,RC,11603,CPT,,,,,,,,875,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,375.375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.475,857.5
Drain Pilonidal Cyst Simpl,PX10080F,CDM,510,RC,10080,CPT,,,,,,,,742,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,375.452,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,308.2268,727.16
Fna W/Image,PX10022F,CDM,510,RC,10022,CPT,,,,,,,,742,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,375.452,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,308.2268,727.16
"Inject Nerv Blck,Othr Periph Nerv",PX64450P,CDM,983,RC,64450,CPT,,,,,,,,904,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,375.5216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,375.5216,879.8632
Closure Superf Wnd Dehis Simple,PX12020P,CDM,983,RC,12020,CPT,,,,,,,,422,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,375.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,175.2988,548.67
cocaine 4% 4 % Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527172874,NDC,4,ML,875.53,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,375.60237,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032F,CDM,510,RC,12032,CPT,,,,,,,,386,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,375.6938,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.3444,378.28
RELOAD SUREFORM 45 2.5MM WHITE,27200000,CDM,272,RC,,,,12791-MAIN,LOCAL,,,,,386,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,375.6938,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 45 3.5MM BLUE,27200000,CDM,272,RC,,,,12792-MAIN,LOCAL,,,,,386,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,375.6938,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 45 4.3MM GREEN,27200000,CDM,272,RC,,,,12793-MAIN,LOCAL,,,,,386,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,375.6938,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
pentafluoroprop - tetrafluoroeth Aerosol 116 mL Can,63700001,CDM,250,RC,,,,,,386000802,NDC,207,ML,383.42,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,375.7516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Complex Drainage, Wound",PX10180P,CDM,983,RC,10180,CPT,,,,,,,,767,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,375.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,318.6118,2482.37
"Complex Drainage, Wound",PX10180P,CDM,983,RC,10180,CPT,,,,,,,,767,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,375.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,318.6118,2482.37
"Complex Drainage, Wound",PX10180P,CDM,983,RC,10180,CPT,,,,,,,,767,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,375.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,318.6118,2482.37
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070102,NDC,1,ML,383.6,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,375.928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.92,450.751
"US Guide, Vascular Access",PX7693701,CDM,402,RC,76937,CPT,TC,,,,,,,760,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,376.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,315.704,744.8
"Repair of Recurrent Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49615F,CDM,360,RC,49615,CPT,,,,,,,,2908,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,376.31,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,376.31,1322.72
"Repair of Recurrent Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49615F,CDM,360,RC,49615,CPT,,,,,,,,2908,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,376.31,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,376.31,1322.72
Abd Duplex Abd -Follow Up,PX9397602,CDM,921,RC,93976,CPT,TC,,,,,,,784,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,376.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,768.32
Abd Duplex Abd -Follow Up,PX9397602,CDM,921,RC,93976,CPT,TC,,,,,,,784,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,376.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,768.32
Art Lower Extremity+Upper,PX9392301,CDM,921,RC,93923,CPT,TC,,,,,,,784,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,376.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.46,768.32
Art Lower Extremity+Upper,PX9392301,CDM,921,RC,93923,CPT,TC,,,,,,,784,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,376.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.46,768.32
Lvl 3 Sub Hosp High Mdm or 50 Minutes,PX99233,CDM,982,RC,99233,CPT,,,,,,,,384,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,376.32,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.41,376.32
Closed Rx Metacarpal Fx,PX26600F,CDM,510,RC,26600,CPT,,,,,,,,443,,First Health,Commercial,both,85,,999999999,percent of total billed charges,376.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,184.0222,434.14
Baloxavir Marboxil(40 MG Dose) 2 x 20 MG tablet therapy pack 2 Each Box,800000,CDM,,,,,,,,50242082802,NDC,1,EA,384.3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,376.614,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Drain/Inject Med Joint/Brusa W/US Guide,PX20606F,CDM,510,RC,20606,CPT,,,,,,,,387,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,376.6671,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.7598,604.15
"Ex Sknbngn0.6-1cmtrnk,Arm,Lg",PX11401P,CDM,983,RC,11401,CPT,,,,,,,,387,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,376.6671,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.7598,376.6671
"Exc Skn Benig<5mm Face,Facial",PX11440P,CDM,983,RC,11440,CPT,,,,,,,,387,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,376.6671,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.7598,614.65
Facility Emergency Level II Visit,PX99282F,CDM,450,RC,99282,CPT,,,,,,,,387,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,167.3126923,percent of total billed charges,376.6671,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,142.88,379.26
Layr Clos Wnd Rest Body 7.6-12.5,PX12044F,CDM,510,RC,12044,CPT,,,,,,,,785,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,376.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,326.089,769.3
Layr Clos Wnd Rest Body 7.6-12.5,PX12044F,CDM,510,RC,12044,CPT,,,,,,,,785,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,376.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,326.089,769.3
"Layr Clos Wnd Face,Facial <2.5cm",PX12051F,CDM,510,RC,12051,CPT,,,,,,,,769,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,376.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,319.4426,753.62
"Layr Clos Wnd Face,Facial <2.5cm",PX12051F,CDM,510,RC,12051,CPT,,,,,,,,769,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,376.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,319.4426,753.62
"Layr Clos Wnd Face,Facial <2.5cm",PX12051F,CDM,510,RC,12051,CPT,,,,,,,,769,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,376.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,319.4426,753.62
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310001,NDC,0.528,ML,785.14,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,376.8672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.22,877.002
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310001,NDC,0.528,ML,785.14,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,376.8672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.22,877.002
glucagon rdna (diagnostic) 1 MG Recon Soln 1 Each Vial,J1610.01,CDM,636,RC,J1610,HCPCS,,,,597026010,NDC,1,EA,744.84,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,376.88904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,172.71,729.9432
"Colonoscopy,Flex,Diagnostic",PX45378F,CDM,750,RC,45378,CPT,,,,,,,,1286,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,377.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.56,704.94
"Colonoscopy,Flex,Diagnostic",PX45378P,CDM,983,RC,45378,CPT,,,,,,,,1200,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,377.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.56,1176
"Exc Skn Malig1.1-2cm Fce,Facal",PX11642P,CDM,983,RC,11642,CPT,,,,,,,,466,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,377.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,113.87,558.97
"Fac/Exc Skn Malig .1-2cm Fce,Facal",PX11642F,CDM,510,RC,11642,CPT,,,,,,,,698,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,377.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,113.87,558.97
X-Ray Exam Entire Spine 1vw,PX7208101,CDM,320,RC,72081,CPT,TC,,,,,,,414,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,377.154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,405.72
"Repair of Recurrent Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49615F,CDM,360,RC,49615,CPT,,,,,,,,2908,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,377.18,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,376.31,1322.72
Apply Long Arm Splint,PX29105P,CDM,983,RC,29105,CPT,,,,,,,,385,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,377.3,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.87,377.3
Apply Long Leg Splint,PX29505P,CDM,983,RC,29505,CPT,,,,,,,,385,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,377.3,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.28,377.3
Injection for Nerve Block,PX64445F,CDM,510,RC,64445,CPT,,,,,,,,385,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,377.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,604.15
Injection for Nerve Block,PX64445P,CDM,983,RC,64445,CPT,,,,,,,,385,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,377.3,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.71,377.3
MICA DEPTH GAUGE 150MM STERILE MICA,27200000,CDM,272,RC,,,,12439-MAIN,LOCAL,,,,,385,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,377.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"N Block Inj, Plantar Digit",PX64455F,CDM,510,RC,64455,CPT,,,,,,,,385,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,377.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,377.3
"N Block Inj, Plantar Digit",PX64455P,CDM,983,RC,64455,CPT,,,,,,,,385,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,377.3,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.72,377.3
Xray Temporomandib Jnt Unilat,PX7032801,CDM,320,RC,70328,CPT,TC,,,,,,,385,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,377.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,377.3
"Critical Care, E/M 30-74 Minutes",PX99291P,CDM,983,RC,99291,CPT,,,,,,,,1061,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,377.34,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.04,1039.78
"Facility Critical Care, E/M 30-74 Minutes",PX99291F,CDM,510,RC,99291,CPT,,,,,,,,1264,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,377.34,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.04,489.16
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402F,CDM,510,RC,11402,CPT,,,,,,,,424,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,377.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.1296,614.65
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402P,CDM,983,RC,11402,CPT,,,,,,,,424,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,377.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.1296,614.65
Lab H Pylori Stool Ag,PX87338,CDM,300,RC,87338,CPT,,,,,,,,424,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,377.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,415.52
umeclidinium-vilanterol 62.5-25 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173086906,NDC,14,EA,745.86,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,377.40516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Resp Virus 6-11 Targets,PX87632,CDM,300,RC,87632,CPT,,,,,,,,428,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,377.496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,177.7912,419.44
Xray Thoracic Spine 2 Vws,PX7207001,CDM,320,RC,72070,CPT,TC,,,,,,,428,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,377.496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,419.44
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802001,NDC,1,ML,444.2,,First Health,Commercial,both,85,,999999999,percent of total billed charges,377.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802010,NDC,1,ML,444.2,,First Health,Commercial,both,85,,999999999,percent of total billed charges,377.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
Biopsy of Rectum,PX45100F,CDM,510,RC,45100,CPT,,,,,,,,763,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,377.685,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,316.9502,2452.93
Exc Skn Bngn3.1-4cm Remain Bdy,PX11424P,CDM,983,RC,11424,CPT,,,,,,,,562,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,377.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.13,550.76
Fac/Exc Skn Bngn3.1-4cm Remain Bdy,PX11424F,CDM,510,RC,11424,CPT,,,,,,,,931,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,377.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.13,496.71
Irradiated Leukoreduced Rbc's,PXP9040,CDM,390,RC,P9040,HCPCS,,,,,,,,771,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,377.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,231.5,755.58
Irradiated Leukoreduced Rbc's,PXP9040,CDM,390,RC,P9040,HCPCS,,,,,,,,771,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,377.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,231.5,755.58
Irradiated Leukoreduced Rbc's,PXP9040,CDM,390,RC,P9040,HCPCS,,,,,,,,771,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,377.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,231.5,755.58
"Injection,Sacroiliac Joint(T)",PX27096F,CDM,510,RC,27096,CPT,,,,,,,,881,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,377.949,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,365.9674,863.38
2.1MM CANNULATED DRILL BIT,27200000,CDM,272,RC,,,,12657-MAIN,LOCAL,,,,,747,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,377.982,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
US Guide Needle Bx S&I,PX7694201,CDM,402,RC,76942,CPT,TC,,,,,,,747,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,377.982,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.3038,732.06
"US Complete Joint, Realtime W/ Img Tc",PX7688101,CDM,402,RC,76881,CPT,TC,,,,,,,415,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,378.065,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,406.7
Abd Duplex Abd-Full,PX9397501,CDM,921,RC,93975,CPT,TC,,,,,,,788,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,378.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,772.24
Abd Duplex Abd-Full,PX9397501,CDM,921,RC,93975,CPT,TC,,,,,,,788,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,378.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,772.24
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122F,CDM,510,RC,13122,CPT,,,,,,,,788,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,378.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,327.3352,772.24
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122F,CDM,510,RC,13122,CPT,,,,,,,,788,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,378.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,327.3352,772.24
"Injection Hip Arthrogram,Anesth",PX27095F,CDM,510,RC,27095,CPT,,,,,,,,425,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,378.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.545,416.5
"Injection Hip Arthrogram,Anesth",PX27095P,CDM,983,RC,27095,CPT,,,,,,,,425,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,378.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.545,413.6525
US Abdomen Limited Tc,PX7670501,CDM,402,RC,76705,CPT,TC,,,,,,,425,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,378.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,416.5
US Ext Non-Vasc Img Lmtd,PX7688201,CDM,402,RC,76882,CPT,TC,,,,,,,425,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,378.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,416.5
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12173-SURG,LOCAL,,,,,772,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,378.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12173-SURG,LOCAL,,,,,772,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,378.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12173-SURG,LOCAL,,,,,772,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,378.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032F,CDM,510,RC,12032,CPT,,,,,,,,386,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,378.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.3444,378.28
RELOAD SUREFORM 45 2.5MM WHITE,27200000,CDM,272,RC,,,,12791-MAIN,LOCAL,,,,,386,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,378.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 45 3.5MM BLUE,27200000,CDM,272,RC,,,,12792-MAIN,LOCAL,,,,,386,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,378.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 45 4.3MM GREEN,27200000,CDM,272,RC,,,,12793-MAIN,LOCAL,,,,,386,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,378.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
I&D Bartholin Gland Abscess,PX56420F,CDM,510,RC,56420,CPT,,,,,,,,429,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,378.378,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.08,420.42
ANCHORAGE FIXATION PIN,27200000,CDM,272,RC,,,,12642-MAIN,LOCAL,,,,,389,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,378.6137,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Ext Ecg > 48hr to 21 Day Rcrd W/Conect Intl Rcrd,PX0296T,CDM,731,RC,0296T,HCPCS,,,,,,,,389,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,378.6137,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,161.5906,381.22
I&D Deep Absc/Hematoma Neck/Chest,PX21501F,CDM,510,RC,21501,CPT,,,,,,,,773,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,378.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.1042,2482.37
I&D Deep Absc/Hematoma Neck/Chest,PX21501F,CDM,510,RC,21501,CPT,,,,,,,,773,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,378.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.1042,2482.37
I&D Deep Absc/Hematoma Neck/Chest,PX21501F,CDM,510,RC,21501,CPT,,,,,,,,773,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,378.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.1042,2482.37
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Suspension 10 mL Bottle,63700001,CDM,250,RC,,,,,,24208063562,NDC,10,ML,415.81,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,378.80291,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Apply Long Leg Cast,PX29345F,CDM,510,RC,29345,CPT,,,,,,,,912,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,378.8448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,234.62,893.76
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598030562,NDC,1,EA,912,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,378.8448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
Open Bx/Excision Inguinofemoral Nodes,PX38531F,CDM,510,RC,38531,CPT,,,,,,,,912,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,378.8448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,378.8448,3329.99
US Head/Neck Tc,PX7653601,CDM,402,RC,76536,CPT,TC,,,,,,,416,,Medica,Commercial,both,91.1,,73.2,percent of total billed charges,378.976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,407.68
"Fac/Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404F,CDM,510,RC,11404,CPT,,,,,,,,749,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,378.994,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,311.1346,1416.38
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279210,NDC,10,ML,429.84,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,379.11888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,178.555536,421.2432
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279410,NDC,10,ML,429.84,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,379.11888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,178.555536,421.2432
indocyanine green 25 MG Recon Soln 1 Each Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,70100042402,NDC,1,EA,446.07,,First Health,Commercial,both,85,,999999999,percent of total billed charges,379.1595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.29,1354.4776
Removal of Anal Tabs,PX46230F,CDM,510,RC,46230,CPT,,,,,,,,790,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,379.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,328.166,2452.93
Removal of Anal Tabs,PX46230F,CDM,510,RC,46230,CPT,,,,,,,,790,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,379.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,328.166,2452.93
Abd Paracentesis,PX49082F,CDM,510,RC,49082,CPT,,,,,,,,884,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,379.236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,367.2136,866.32
"Excise Lesion,Back or Flank",PX21930P,CDM,983,RC,21930,CPT,,,,,,,,884,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,379.236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,367.2136,1416.38
Blood Transfusion Service,PX36430,CDM,391,RC,36430,CPT,,,,,,,,839,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,379.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.5206,822.22
Drain/Inject Med Joint/Brusa W/US Guide,PX20606F,CDM,510,RC,20606,CPT,,,,,,,,387,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,379.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.7598,604.15
"Ex Sknbngn0.6-1cmtrnk,Arm,Lg",PX11401P,CDM,983,RC,11401,CPT,,,,,,,,387,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,379.26,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.19,379.26
"Exc Skn Benig<5mm Face,Facial",PX11440P,CDM,983,RC,11440,CPT,,,,,,,,387,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,379.26,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.28,379.26
Explor Metatarso-Phalang Jt,PX28022P,CDM,983,RC,28022,CPT,,,,,,,,774,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,379.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.5196,2827.75
Explor Metatarso-Phalang Jt,PX28022P,CDM,983,RC,28022,CPT,,,,,,,,774,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,379.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.5196,2827.75
Explor Metatarso-Phalang Jt,PX28022P,CDM,983,RC,28022,CPT,,,,,,,,774,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,379.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.5196,2827.75
Facility Emergency Level II Visit,PX99282F,CDM,450,RC,99282,CPT,,,,,,,,387,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,379.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,142.88,379.26
RELOAD SUREFORM 60 2.5 WHITE 6 ROW BOX/12,27200000,CDM,272,RC,,,,12261-MAIN,LOCAL,,,,,430,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,379.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 60 3.5 BLUE,27200000,CDM,272,RC,,,,12084-MAIN,LOCAL,,,,,430,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,379.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 60 4.3 GREEN,27200000,CDM,272,RC,,,,12085-MAIN,LOCAL,,,,,430,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,379.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132P,CDM,983,RC,13132,CPT,,,,,,,,774,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,379.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.5196,753.3342
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132P,CDM,983,RC,13132,CPT,,,,,,,,774,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,379.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.5196,753.3342
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132P,CDM,983,RC,13132,CPT,,,,,,,,774,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,379.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.5196,753.3342
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605P,CDM,983,RC,24605,CPT,,,,,,,,750,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,379.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,311.55,1404.08
Sigmoidoscope W/Submuc Inj,PX45335F,CDM,750,RC,45335,CPT,,,,,,,,750,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,379.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,311.55,798.45
Revise Ulnar Nerve at Elbow,PX64718P,CDM,983,RC,64718,CPT,,,,,,,,1642,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,379.58,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,379.58,1609.16
Apc Resistance Assay - Ref,PX8530790,CDM,300,RC,85307,CPT,90,,,,,,,390,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,379.587,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.05,382.2
"Closed Rx Toe Fx,Manipulatn",PX28515F,CDM,510,RC,28515,CPT,,,,,,,,390,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,379.587,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,162.006,382.2
"Complex Drainage, Wound",PX10180P,CDM,983,RC,10180,CPT,,,,,,,,767,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,379.665,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,318.6118,2482.37
Emergency Level IV Visit,PX99284P,CDM,981,RC,99284,CPT,,,,,,,,914,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,379.6756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,379.6756,889.5962
Excis Primary Ganglion Wrist,PX25111F,CDM,510,RC,25111,CPT,,,,,,,,791,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,379.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,328.5814,1404.08
Excis Primary Ganglion Wrist,PX25111F,CDM,510,RC,25111,CPT,,,,,,,,791,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,379.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,328.5814,1404.08
Room Rate Transitional Care Private,PX11900000,CDM,119,RC,,,,,,,,,,775,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,379.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.935,759.5
Room Rate Transitional Care Private,PX11900000,CDM,119,RC,,,,,,,,,,775,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,379.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.935,759.5
Room Rate Transitional Care Private,PX11900000,CDM,119,RC,,,,,,,,,,775,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,379.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.935,759.5
"CT Colonography, Screen",PX7426301,CDM,350,RC,74263,CPT,TC,,,,,,,3330,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,379.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,379.8,1118.24
"CT Colonography, Screen",PX7426301,CDM,350,RC,74263,CPT,TC,,,,,,,3330,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,379.8,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,379.8,1118.24
Xray Ribs Bilat 3 Vws With Pa Chest,PX7111101,CDM,320,RC,71111,CPT,TC,,,,,,,417,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,379.887,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,408.66
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,781344071,NDC,1,EA,430.94,,United Healthcare,All Payer,outpatient,88.2,,211.17,percent of total billed charges,380.08908,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,179.012476,460.7862
"Exc Skn Beig1.1-2cm Face,Facil",PX11442P,CDM,983,RC,11442,CPT,,,,,,,,886,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,380.094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,368.0444,862.3438
Xray Ribs Unilat 2 Vws With Pa Chest,PX7110101,CDM,320,RC,71101,CPT,TC,,,,,,,792,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,380.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,776.16
Xray Ribs Unilat 2 Vws With Pa Chest,PX7110101,CDM,320,RC,71101,CPT,TC,,,,,,,792,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,380.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,776.16
"Layr Clos Wnd Face,Facial 2.5-5",PX12052P,CDM,983,RC,12052,CPT,,,,,,,,776,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,380.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,322.3504,755.2808
"Layr Clos Wnd Face,Facial 2.5-5",PX12052P,CDM,983,RC,12052,CPT,,,,,,,,776,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,380.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,322.3504,755.2808
"Layr Clos Wnd Face,Facial 2.5-5",PX12052P,CDM,983,RC,12052,CPT,,,,,,,,776,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,380.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,322.3504,755.2808
perflutren lipid microsphere 6.52 MG/ML Suspension 2 mL Vial,Q9957,CDM,636,RC,Q9957,HCPCS,,,,11994001101,NDC,2,ML,751.71,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,380.36526,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,312.260334,736.6758
"Initial Observation Care,Levl II",PX99219,CDM,982,RC,99219,CPT,,,,,,,,391,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,380.5603,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,162.4214,380.5603
"Layr Clos Wnd Face,Facial <2.5cm",PX12051F,CDM,510,RC,12051,CPT,,,,,,,,769,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,380.655,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,319.4426,753.62
Layr Clos Wnd Rest Body 2.6-7.5,PX12042P,CDM,983,RC,12042,CPT,,,,,,,,777,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,380.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,322.7658,756.2541
Layr Clos Wnd Rest Body 2.6-7.5,PX12042P,CDM,983,RC,12042,CPT,,,,,,,,777,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,380.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,322.7658,756.2541
Layr Clos Wnd Rest Body 2.6-7.5,PX12042P,CDM,983,RC,12042,CPT,,,,,,,,777,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,380.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,322.7658,756.2541
hydrocortisone (perianal) 2.5 % Cream 28.35 g Tube,63700001,CDM,250,RC,,,,,,10631040701,NDC,28.35,GR,447.94,,First Health,Commercial,both,85,,999999999,percent of total billed charges,380.749,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Removal of Skin Tags,PX11200P,CDM,983,RC,11200,CPT,,,,,,,,418,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,380.798,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,173.6372,406.8394
"Repair Recurr Inguin Hern,Reducibl",PX49520F,CDM,510,RC,49520,CPT,,,,,,,,1983,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,380.89,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,380.89,1324.11
"Repair Recurr Inguin Hern,Reducibl",PX49520P,CDM,983,RC,49520,CPT,,,,,,,,1983,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,380.89,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,380.89,1943.34
Resp Virus 6-11 Targets,PX87632,CDM,300,RC,87632,CPT,,,,,,,,428,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,380.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,177.7912,419.44
Xray Thoracic Spine 2 Vws,PX7207001,CDM,320,RC,72070,CPT,TC,,,,,,,428,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,380.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,419.44
oseltamivir 6 MG/ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,4082205,NDC,60,ML,752.82,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,380.92692,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
STAPLER SUREFORM 45 SPU IS4000,27200000,CDM,272,RC,,,,12794-MAIN,LOCAL,,,,,888,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,380.952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016410,NDC,1,ML,917.08,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,380.955032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.66,898.7384
Exc Neck Les Sc = 3cm >,PX21552F,CDM,510,RC,21552,CPT,,,,,,,,753,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,381.018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,312.7962,2482.37
Xray Eye Foreign Body,PX7003001,CDM,320,RC,70030,CPT,TC,,,,,,,432,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,381.024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,423.36
desflurane Solution 240 mL Bottle,25000000,CDM,250,RC,,,,,,10019064134,NDC,240,ML,793.95,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,381.096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
desflurane Solution 240 mL Bottle,25000000,CDM,250,RC,,,,,,10019064134,NDC,240,ML,793.95,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,381.096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ANCHORAGE FIXATION PIN,27200000,CDM,272,RC,,,,12642-MAIN,LOCAL,,,,,389,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,381.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Ext Ecg > 48hr to 21 Day Rcrd W/Conect Intl Rcrd,PX0296T,CDM,731,RC,0296T,HCPCS,,,,,,,,389,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,381.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,161.5906,381.22
mometasone - formoterol 100-5 MCG/ACT Aerosol 8.8 g Inhaler,25000000,CDM,250,RC,,,,,,85720607,NDC,8.8,GR,918.07,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,381.366278,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
mometasone - formoterol 200-5 MCG/ACT Aerosol 8.8 g Inhaler,25000000,CDM,250,RC,,,,,,85461005,NDC,8.8,GR,918.07,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,381.366278,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Drain Skin Abscess Complic,PX10061F,CDM,510,RC,10061,CPT,,,,,,,,889,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,381.381,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,871.22
Inc/Drain Peritonsil Abscess,PX42700P,CDM,983,RC,42700,CPT,,,,,,,,889,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,381.381,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,865.2637
fluticasone propionate 50 MCG/ACT Suspension 16 g Bottle,63700001,CDM,250,RC,,,,,,50383070016,NDC,16,GR,432.56,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,381.51792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,115169449,NDC,1,EA,889.46,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,381.57834,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54505010202,NDC,1,EA,889.46,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,381.57834,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
Aspirate Pleura W/ Imaging,PX32555F,CDM,761,RC,32555,CPT,,,,,,,,795,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,381.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,330.243,779.1
Aspirate Pleura W/ Imaging,PX32555F,CDM,761,RC,32555,CPT,,,,,,,,795,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,381.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,330.243,779.1
Aspirate Pleura W/O Imaging,PX32554F,CDM,510,RC,32554,CPT,,,,,,,,795,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,381.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,330.243,779.1
Aspirate Pleura W/O Imaging,PX32554F,CDM,510,RC,32554,CPT,,,,,,,,795,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,381.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,330.243,779.1
Irradiated Leukoreduced Rbc's,PXP9040,CDM,390,RC,P9040,HCPCS,,,,,,,,771,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,381.645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,231.5,755.58
TRAY PNEUMOTHORAX 14FR 29CM 19 CATHETER SIDEPORTS G56537,120.496,CDM,272,RC,,,,11677-MAIN,LOCAL,,,,,419,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,381.709,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.0526,410.62
I&D Bartholin Gland Abscess,PX56420F,CDM,510,RC,56420,CPT,,,,,,,,429,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,381.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.08,420.42
Remove Foreign Body Complic,PX10121F,CDM,510,RC,10121,CPT,,,,,,,,3575,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,381.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,114.52,551.36
Remove Foreign Body Complic,PX10121P,CDM,983,RC,10121,CPT,,,,,,,,651,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,381.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,114.52,637.98
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494301,NDC,0.5,ML,419.2,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,381.8912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.38,410.8454
Closed Rx Bimalleolar Fx,PX27808P,CDM,983,RC,27808,CPT,,,,,,,,433,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,381.906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,179.8682,421.4389
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494300,NDC,0.5,ML,419.23,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,381.91853,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.38,410.8454
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016425,NDC,1,ML,779.43,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,381.9207,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.66,898.7384
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016425,NDC,1,ML,779.43,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,381.9207,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.66,898.7384
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016425,NDC,1,ML,779.43,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,381.9207,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.66,898.7384
"HERNIA MESH 3D MAX MID ANATOMICAL MESH LEFT SIZE L 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,11976-MAIN,LOCAL,,,,,755,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,382.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"HERNIA MESH 3D MAX MID ANATOMICAL MESH RIGHT SIZE L 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,11977-MAIN,LOCAL,,,,,755,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,382.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Solution 10 mL Bottle,63700001,CDM,250,RC,,,,,,61314064610,NDC,10,ML,433.15,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,382.0383,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12173-SURG,LOCAL,,,,,772,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,382.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Cns Dna/Rna Amp Probe Multiple Subtypes 12-25,PX87483,CDM,300,RC,87483,CPT,,,,,,,,864,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,382.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,358.9056,846.72
"GI Pathogen Panel, Pcr - Ref",PX8750790,CDM,300,RC,87507,CPT,90,,,,,,,213,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,382.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.4802,382.15
Infection Agent Detect Dna/Rna Probe Tq 12-25,PX87507,CDM,300,RC,87507,CPT,,,,,,,,209,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,382.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.8186,382.15
Nfct Ds Bct/Vir Respir Dna/Rna 22 Trgt Sarscov2,PX0202U,CDM,300,RC,0202U,HCPCS,,,,,,,,222,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,382.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.2188,382.15
"Amputation Toe,I-P Jt",PX28825P,CDM,983,RC,28825,CPT,,,,,,,,780,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,382.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,324.012,2827.75
"Amputation Toe,I-P Jt",PX28825P,CDM,983,RC,28825,CPT,,,,,,,,780,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,382.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,324.012,2827.75
"Amputation Toe,I-P Jt",PX28825P,CDM,983,RC,28825,CPT,,,,,,,,780,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,382.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,324.012,2827.75
Apc Resistance Assay - Ref,PX8530790,CDM,300,RC,85307,CPT,90,,,,,,,390,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,382.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.05,382.2
"Closed Rx Toe Fx,Manipulatn",PX28515F,CDM,510,RC,28515,CPT,,,,,,,,390,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,382.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,162.006,382.2
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041105,NDC,1,ML,419.67,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,382.31937,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.808876,411.2766
"Repair Recurr Inguin Hern,Reducibl",PX49520F,CDM,510,RC,49520,CPT,,,,,,,,1983,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,382.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,380.89,1324.11
"Repair Recurr Inguin Hern,Reducibl",PX49520F,CDM,510,RC,49520,CPT,,,,,,,,1983,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,382.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,380.89,1324.11
"Repair Recurr Inguin Hern,Reducibl",PX49520P,CDM,983,RC,49520,CPT,,,,,,,,1983,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,382.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,380.89,1943.34
"Repair Recurr Inguin Hern,Reducibl",PX49520P,CDM,983,RC,49520,CPT,,,,,,,,1983,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,382.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,380.89,1943.34
"Spinal Punc,Drain,Theraputic",PX62272F,CDM,510,RC,62272,CPT,,,,,,,,450,,First Health,Commercial,both,85,,999999999,percent of total billed charges,382.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.93,604.15
6 SHOOTER SAEED MULTIBAND LIGATOR,27200000,CDM,272,RC,,,,12379-MAIN,LOCAL,,,,,393,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,382.5069,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA FIRST MET TRANSLATOR STERILE MICA,27200000,CDM,272,RC,,,,12445-MAIN,LOCAL,,,,,393,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,382.5069,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Tap Block Bilateral by Injection(S),PX64488F,CDM,510,RC,64488,CPT,,,,,,,,393,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,109.76,percent of total billed charges,382.5069,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,163.2522,385.14
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279210,NDC,10,ML,429.84,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,382.5576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,178.555536,421.2432
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279410,NDC,10,ML,429.84,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,382.5576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,178.555536,421.2432
I&D Deep Absc/Hematoma Neck/Chest,PX21501F,CDM,510,RC,21501,CPT,,,,,,,,773,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,382.635,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.1042,2482.37
RELOAD SUREFORM 60 2.5 WHITE 6 ROW BOX/12,27200000,CDM,272,RC,,,,12261-MAIN,LOCAL,,,,,430,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,382.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 60 3.5 BLUE,27200000,CDM,272,RC,,,,12084-MAIN,LOCAL,,,,,430,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,382.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 60 4.3 GREEN,27200000,CDM,272,RC,,,,12085-MAIN,LOCAL,,,,,430,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,382.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598046562,NDC,1,EA,798,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,383.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598046562,NDC,1,EA,798,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,383.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
CT Angio Upr Extrm W/O&W/Dye,PX7320601,CDM,350,RC,73206,CPT,TC,,,,,,,757,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,383.042,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
"Inject Nerv Blck,Othr Periph Nerv",PX64450F,CDM,510,RC,64450,CPT,,,,,,,,757,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,383.042,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,314.4578,741.86
prednisoLONE acetate 0.12 % Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,11980017405,NDC,5,ML,757.07,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,383.07742,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Explor Metatarso-Phalang Jt,PX28022P,CDM,983,RC,28022,CPT,,,,,,,,774,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,383.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.5196,2827.75
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132P,CDM,983,RC,13132,CPT,,,,,,,,774,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,383.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.5196,753.3342
"Initial Observation Care,Levl II",PX99219,CDM,982,RC,99219,CPT,,,,,,,,391,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,383.18,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.31,383.18
PREP KIT STAPLE 18MM,27200000,CDM,278,RC,C1713,HCPCS,,11658-MAIN,LOCAL,,,,,420.75,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,383.30325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PREP KIT STAPLE 20MM,27200000,CDM,278,RC,C1713,HCPCS,,11659-MAIN,LOCAL,,,,,420.75,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,383.30325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,781344071,NDC,1,EA,430.94,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,383.5366,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,179.012476,460.7862
Room Rate Transitional Care Private,PX11900000,CDM,119,RC,,,,,,,,,,775,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,383.625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.935,759.5
dantrolene 20 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,42023012306,NDC,1,EA,394.42,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,383.888986,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310002,NDC,0.528,ML,894.9,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,383.9121,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.22,877.002
MRI Brain W Contrast Tc,PX7055201,CDM,610,RC,70552,CPT,TC,,,,,,,2637,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,383.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.01,383.92
MRI Brain W Contrast Tc,PX7055201,CDM,610,RC,70552,CPT,TC,,,,,,,2637,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,383.92,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.01,383.92
MRI L Spine W Contrast Tc,PX7214901,CDM,610,RC,72149,CPT,TC,,,,,,,5136,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,383.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.01,383.92
MRI L Spine W Contrast Tc,PX7214901,CDM,610,RC,72149,CPT,TC,,,,,,,5136,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,383.92,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.01,383.92
"Layr Clos Wnd Face,Facial 2.5-5",PX12052P,CDM,983,RC,12052,CPT,,,,,,,,776,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,384.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,322.3504,755.2808
Abd Duplex Abd -Follow Up,PX9397602,CDM,921,RC,93976,CPT,TC,,,,,,,784,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,387.145,percent of total billed charges,384.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,768.32
Abd Duplex Abd -Follow Up,PX9397602,CDM,921,RC,93976,CPT,TC,,,,,,,784,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,384.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,768.32
Abd Duplex Abd -Follow Up,PX9397602,CDM,921,RC,93976,CPT,TC,,,,,,,784,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,384.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,768.32
Art Lower Extremity+Upper,PX9392301,CDM,921,RC,93923,CPT,TC,,,,,,,784,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,384.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.46,768.32
Art Lower Extremity+Upper,PX9392301,CDM,921,RC,93923,CPT,TC,,,,,,,784,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,384.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.46,768.32
Art Lower Extremity+Upper,PX9392301,CDM,921,RC,93923,CPT,TC,,,,,,,784,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,384.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.46,768.32
Revise Ulnar Nerve at Elbow,PX64718P,CDM,983,RC,64718,CPT,,,,,,,,1642,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,384.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,379.58,1609.16
Revise Ulnar Nerve at Elbow,PX64718P,CDM,983,RC,64718,CPT,,,,,,,,1642,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,384.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,379.58,1609.16
DRILL BIT AO DIA 2.0MMX135MM SCALED,27200000,CDM,272,RC,,,,12640-MAIN,LOCAL,,,,,452,,First Health,Commercial,both,85,,999999999,percent of total billed charges,384.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Closure Superf Wnd Dehis Simple,PX12020P,CDM,983,RC,12020,CPT,,,,,,,,422,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,384.442,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,175.2988,548.67
Drainage of Gum Lesion,PX41800F,CDM,510,RC,41800,CPT,,,,,,,,395,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,384.4535,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,387.1
Xray Eye Foreign Body,PX7003001,CDM,320,RC,70030,CPT,TC,,,,,,,432,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,384.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,423.36
X-Ray Exam Abdomen 2 Views,PX7401901,CDM,320,RC,74019,CPT,TC,,,,,,,436,,United Healthcare,All Payer,outpatient,88.2,,207.27,percent of total billed charges,384.552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,427.28
"X-Ray Exam Hip,Unilat W/Pelvis 2-3 Vws",PX7350201,CDM,320,RC,73502,CPT,TC,,,,,,,436,,United Healthcare,All Payer,outpatient,88.2,,217.1566667,percent of total billed charges,384.552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,427.28
Xray Abdomen Comp Incl Decub and/or Erect,PX7402001,CDM,320,RC,74020,CPT,TC,,,,,,,436,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,384.552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.1144,427.28
Xray Cervical Spine 2 or 3 Vws,PX7204001,CDM,320,RC,72040,CPT,TC,,,,,,,436,,United Healthcare,All Payer,outpatient,88.2,,218.915,percent of total billed charges,384.552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,427.28
"US Guide, Vascular Access",PX7693701,CDM,402,RC,76937,CPT,TC,,,,,,,760,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,384.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,315.704,744.8
"MRI,Lwrext,No Jnt, W/Cont",PX7371901,CDM,610,RC,73719,CPT,TC,,,,,,,3627,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,384.58,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.23,384.58
"MRI,Lwrext,No Jnt, W/Cont",PX7371901,CDM,610,RC,73719,CPT,TC,,,,,,,3627,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,384.58,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.23,384.58
Layr Clos Wnd Rest Body 2.6-7.5,PX12042P,CDM,983,RC,12042,CPT,,,,,,,,777,,Humana Choice Care,All Medicare plans,outpatient,49.5,,0.005,percent of total billed charges,384.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,322.7658,756.2541
"Closed Rx Big Toe Fx,Manip",PX28495F,CDM,510,RC,28495,CPT,,,,,,,,857,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,384.64,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.42,384.64
"Closed Rx Big Toe Fx,Manip",PX28495P,CDM,983,RC,28495,CPT,,,,,,,,412,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,384.64,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.42,403.76
Drain Skin Abscess Complic,PX10061F,CDM,510,RC,10061,CPT,,,,,,,,889,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,384.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.83,447.59
Drain Skin Abscess Complic,PX10061P,CDM,983,RC,10061,CPT,,,,,,,,561,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,384.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.83,549.78
Reconstruc of Nail Bed,PX11760F,CDM,510,RC,11760,CPT,,,,,,,,1162,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,384.64,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.37,384.64
Reconstruc of Nail Bed,PX11760P,CDM,983,RC,11760,CPT,,,,,,,,903,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,384.64,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.37,884.94
"Spinal Punc,Drain,Theraputic",PX62272F,CDM,510,RC,62272,CPT,,,,,,,,450,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,384.64,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.79,384.64
"Spinal Punc,Drain,Theraputic",PX62272P,CDM,983,RC,62272,CPT,,,,,,,,300,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,384.64,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,52.79,384.64
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605P,CDM,983,RC,25605,CPT,,,,,,,,785,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,384.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,326.089,1404.08
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605P,CDM,983,RC,25605,CPT,,,,,,,,785,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,384.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,326.089,1404.08
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605P,CDM,983,RC,25605,CPT,,,,,,,,785,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,384.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,326.089,1404.08
Layr Clos Wnd Rest Body 7.6-12.5,PX12044F,CDM,510,RC,12044,CPT,,,,,,,,785,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,384.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,326.089,769.3
Layr Clos Wnd Rest Body 7.6-12.5,PX12044F,CDM,510,RC,12044,CPT,,,,,,,,785,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,384.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,326.089,769.3
Layr Clos Wnd Rest Body 7.6-12.5,PX12044F,CDM,510,RC,12044,CPT,,,,,,,,785,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,384.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,326.089,769.3
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310001,NDC,0.528,ML,785.14,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,384.7186,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.22,877.002
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310001,NDC,0.528,ML,785.14,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,384.7186,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.22,877.002
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310001,NDC,0.528,ML,785.14,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,384.7186,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.22,877.002
NON-LOCKING SCREW 3.5X18MM,C1713,CDM,278,RC,C1713,HCPCS,,12466-MAIN,LOCAL,,,,,395.51,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,384.949883,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
fluticasone propionate 50 MCG/ACT Suspension 16 g Bottle,63700001,CDM,250,RC,,,,,,50383070016,NDC,16,GR,432.56,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,384.9784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Exc Skn Mal 0.6-1cm Fce,Facial",PX11641P,CDM,983,RC,11641,CPT,,,,,,,,453,,First Health,Commercial,both,85,,999999999,percent of total billed charges,385.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.1762,614.65
Repr Superf Wnd Body 7.6-12.5,PX12004F,CDM,510,RC,12004,CPT,,,,,,,,453,,First Health,Commercial,both,85,,999999999,percent of total billed charges,385.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,443.94
Repr Superf Wnd Face 5.1-7.5,PX12014F,CDM,510,RC,12014,CPT,,,,,,,,453,,First Health,Commercial,both,85,,999999999,percent of total billed charges,385.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,443.94
6 SHOOTER SAEED MULTIBAND LIGATOR,27200000,CDM,272,RC,,,,12379-MAIN,LOCAL,,,,,393,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,385.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA FIRST MET TRANSLATOR STERILE MICA,27200000,CDM,272,RC,,,,12445-MAIN,LOCAL,,,,,393,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,385.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Tap Block Bilateral by Injection(S),PX64488F,CDM,510,RC,64488,CPT,,,,,,,,393,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,385.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,163.2522,385.14
MRI Pelvis W/Contrast Tc,PX7219601,CDM,610,RC,72196,CPT,TC,,,,,,,3143,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,385.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.45,385.24
MRI Pelvis W/Contrast Tc,PX7219601,CDM,610,RC,72196,CPT,TC,,,,,,,3143,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,385.24,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.45,385.24
"CT Colonography, Screen",PX7426301,CDM,350,RC,74263,CPT,TC,,,,,,,3330,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,385.26,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,379.8,1118.24
Closed Rx Bimalleolar Fx,PX27808P,CDM,983,RC,27808,CPT,,,,,,,,433,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,385.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,179.8682,421.4389
Neg Pressure Wound Therapy Dme </=50 Sq Cm,PX97605F,CDM,510,RC,97605,CPT,,,,,,,,396,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,385.4268,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,164.4984,388.08
NON-LOCKING SCREW 3.5X12MM,27200000,CDM,278,RC,C1713,HCPCS,,11857-MAIN,LOCAL,,,,,396,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,385.4268,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NON-LOCKING SCREW 3.5X16MM,27200000,CDM,278,RC,C1713,HCPCS,,11856-MAIN,LOCAL,,,,,396,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,385.4268,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NON-LOCKING SCREW 3.5X24MM,27200000,CDM,278,RC,C1713,HCPCS,,11855-MAIN,LOCAL,,,,,396,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,385.4268,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Xray Ribs Unilat 2 Vws,PX7110001,CDM,320,RC,71100,CPT,TC,,,,,,,437,,United Healthcare,All Payer,outpatient,88.2,,214.13,percent of total billed charges,385.434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,428.26
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Solution 10 mL Bottle,63700001,CDM,250,RC,,,,,,61314064610,NDC,10,ML,433.15,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,385.5035,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
erythromycin lactobionate 500 MG Recon Soln 1 Each Vial,J1364.01,CDM,636,RC,J1364,HCPCS,,,,409648211,NDC,1,EA,437.09,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,385.51338,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.06,428.3482
medroxyPROGESTERone 150 MG/ML Suspension 1 mL Vial,J1050.01,CDM,636,RC,J1050,HCPCS,,,,67457088799,NDC,1,ML,437.38,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,385.76916,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.687652,428.6324
fluticasone propionate 50 MCG/ACT Suspension 16 g Bottle,63700001,CDM,250,RC,,,,,,60505082901,NDC,16,GR,437.4,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,385.7868,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016425,NDC,1,ML,779.43,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,385.81785,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.66,898.7384
X-Ray Exam Entire Spine 2-3 Vws,PX7208201,CDM,320,RC,72082,CPT,TC,,,,,,,454,,First Health,Commercial,both,85,,999999999,percent of total billed charges,385.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,444.92
Biopsy of Rectum,PX45100F,CDM,510,RC,45100,CPT,,,,,,,,763,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,386.078,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,316.9502,2452.93
MIS STERILE INSTRUMENT PACK WITH BLADE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12432-MAIN,LOCAL,,,,,900,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,386.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Amputation Toe,I-P Jt",PX28825P,CDM,983,RC,28825,CPT,,,,,,,,780,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,386.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,324.012,2827.75
Abd Duplex Abd-Full,PX9397501,CDM,921,RC,93975,CPT,TC,,,,,,,788,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,386.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,772.24
Abd Duplex Abd-Full,PX9397501,CDM,921,RC,93975,CPT,TC,,,,,,,788,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,386.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,772.24
Abd Duplex Abd-Full,PX9397501,CDM,921,RC,93975,CPT,TC,,,,,,,788,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,386.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,772.24
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122F,CDM,510,RC,13122,CPT,,,,,,,,788,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,386.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,327.3352,772.24
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122F,CDM,510,RC,13122,CPT,,,,,,,,788,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,386.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,327.3352,772.24
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122F,CDM,510,RC,13122,CPT,,,,,,,,788,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,386.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,327.3352,772.24
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402F,CDM,510,RC,11402,CPT,,,,,,,,424,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,386.264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.1296,614.65
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402P,CDM,983,RC,11402,CPT,,,,,,,,424,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,386.264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.1296,614.65
Lab H Pylori Stool Ag,PX87338,CDM,300,RC,87338,CPT,,,,,,,,424,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,386.264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,415.52
Debride Bone Ea Add 20 Sqcm,PX11047F,CDM,510,RC,11047,CPT,,,,,,,,438,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,386.316,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.9452,429.24
US Pregnancy Tc Limited,PX7681501,CDM,402,RC,76815,CPT,TC,,,,,,,438,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,386.316,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,429.24
"Amputation Metatarsal+Toe,Single",PX28810F,CDM,510,RC,28810,CPT,,,,,,,,930,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,386.322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.322,2827.75
Colonoscopy,PX44388F,CDM,750,RC,44388,CPT,,,,,,,,930,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,386.322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.322,911.4
dantrolene 20 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,42023012306,NDC,1,EA,394.42,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,386.5316,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Sigmoidoscopy,Diagnostic",PX45330F,CDM,510,RC,45330,CPT,,,,,,,,720,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,386.72,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.68,386.72
"Sigmoidoscopy,Diagnostic",PX45330P,CDM,983,RC,45330,CPT,,,,,,,,480,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,386.72,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.68,470.4
"Sigmoidoscopy,Screen Prev",PX2001F,CDM,750,RC,45330,CPT,,,,,,,,843,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,386.72,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.68,386.72
Fac/Exc Skn Beni 0.6-1cm Remain Bdy,PX11421F,CDM,510,RC,11421,CPT,,,,,,,,931,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,386.7374,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.7374,912.38
Fac/Exc Skn Bngn3.1-4cm Remain Bdy,PX11424F,CDM,510,RC,11424,CPT,,,,,,,,931,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,386.7374,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.7374,1416.38
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034F,CDM,510,RC,12034,CPT,,,,,,,,931,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,386.7374,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,912.38
"Ileoscopy Thru Stoma,Diagnostic",PX44380P,CDM,983,RC,44380,CPT,,,,,,,,455,,First Health,Commercial,both,85,,999999999,percent of total billed charges,386.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.007,791.92
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607F,CDM,761,RC,97607,CPT,,,,,,,,455,,First Health,Commercial,both,85,,999999999,percent of total billed charges,386.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.007,445.9
nystatin-triamcinolone 100000-0.1 UNIT/GM-% Ointment 30 g Tube,25000000,CDM,250,RC,,,,,,52565004230,NDC,30,GR,438.62,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,386.86284,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Emergency Level IV Visit,PX99284P,CDM,981,RC,99284,CPT,,,,,,,,914,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,386.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,379.6756,889.5962
Facility Emergency Level IV Visit,PX99284F,CDM,450,RC,99284,CPT,,,,,,,,1054,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,386.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.93,1032.92
Drainage of Gum Lesion,PX41800F,CDM,510,RC,41800,CPT,,,,,,,,395,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,387.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,387.1
Removal of Anal Tabs,PX46230F,CDM,510,RC,46230,CPT,,,,,,,,790,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,387.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,328.166,2452.93
Removal of Anal Tabs,PX46230F,CDM,510,RC,46230,CPT,,,,,,,,790,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,387.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,328.166,2452.93
Removal of Anal Tabs,PX46230F,CDM,510,RC,46230,CPT,,,,,,,,790,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,387.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,328.166,2452.93
Incise Finger Tendon Sheath,PX26055P,CDM,983,RC,26055,CPT,,,,,,,,932,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,387.1528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,387.1528,1404.08
"Injection Hip Arthrogram,Anesth",PX27095F,CDM,510,RC,27095,CPT,,,,,,,,425,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,387.175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.545,416.5
"Injection Hip Arthrogram,Anesth",PX27095P,CDM,983,RC,27095,CPT,,,,,,,,425,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,387.175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.545,413.6525
US Abdomen Limited Tc,PX7670501,CDM,402,RC,76705,CPT,TC,,,,,,,425,,Medica,Commercial,both,91.1,,46.46,percent of total billed charges,387.175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,416.5
US Ext Non-Vasc Img Lmtd,PX7688201,CDM,402,RC,76882,CPT,TC,,,,,,,425,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,387.175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,416.5
8MM ENDOWRIST INSTRUMENTS 8MM FORCE BIPOLAR IS4000,27200000,CDM,272,RC,,,,11915-MAIN,LOCAL,,,,,439,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,387.198,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
VISIGI3D 40FR STD WITH BULB,27100000,CDM,271,RC,,,,12812-MAIN,LOCAL,,,,,439,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,387.198,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
Chrom Anal 15-20 Cells - Ref,PX8826290,CDM,310,RC,88262,CPT,90,,,,,,,398,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,387.3734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.06,390.04
Reconstruc of Nail Bed,PX11760P,CDM,983,RC,11760,CPT,,,,,,,,903,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,387.387,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,375.1062,878.8899
Biopsy Synovium I-P Jt,PX26110,CDM,983,RC,26110,CPT,,,,,,,,933,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,387.5682,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,387.5682,1404.08
Excis Primary Ganglion Wrist,PX25111F,CDM,510,RC,25111,CPT,,,,,,,,791,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,387.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,328.5814,1404.08
Excis Primary Ganglion Wrist,PX25111F,CDM,510,RC,25111,CPT,,,,,,,,791,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,387.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,328.5814,1404.08
Excis Primary Ganglion Wrist,PX25111F,CDM,510,RC,25111,CPT,,,,,,,,791,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,387.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,328.5814,1404.08
NON-LOCKING SCREW 3.5X18MM,C1713,CDM,278,RC,C1713,HCPCS,,12466-MAIN,LOCAL,,,,,395.51,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,387.5998,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"Ctrl Nosebleed,Anter,Complex",PX30903F,CDM,510,RC,30903,CPT,,,,,,,,456,,First Health,Commercial,both,85,,999999999,percent of total billed charges,387.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,446.88
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611F,CDM,510,RC,20611,CPT,,,,,,,,456,,First Health,Commercial,both,85,,999999999,percent of total billed charges,387.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.4224,446.88
"Office/Outpt Visit,New,Levl V",PX99205F,CDM,510,RC,99205,CPT,,,,,,,,456,,First Health,Commercial,both,85,,999999999,percent of total billed charges,387.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.4224,446.88
"Office/Outpt Visit,New,Levl V",PX99205P,CDM,983,RC,99205,CPT,,,,,,,,456,,First Health,Commercial,both,85,,999999999,percent of total billed charges,387.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.4224,443.8248
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321801,NDC,50,ML,456,,First Health,Commercial,both,85,,999999999,percent of total billed charges,387.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
Xray Nasal Bones Minimum 3 Vws,PX7016001,CDM,320,RC,70160,CPT,TC,,,,,,,456,,First Health,Commercial,both,85,,999999999,percent of total billed charges,387.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,446.88
"Inject Nerv Blck,Othr Periph Nerv",PX64450P,CDM,983,RC,64450,CPT,,,,,,,,904,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,387.816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,375.5216,879.8632
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802201,NDC,0.8,ML,439.77,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,387.87714,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802210,NDC,0.8,ML,439.77,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,387.87714,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
X-Ray Exam Abdomen 2 Views,PX7401901,CDM,320,RC,74019,CPT,TC,,,,,,,436,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,388.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,427.28
"X-Ray Exam Hip,Unilat W/Pelvis 2-3 Vws",PX7350201,CDM,320,RC,73502,CPT,TC,,,,,,,436,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,388.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,427.28
Xray Abdomen Comp Incl Decub and/or Erect,PX7402001,CDM,320,RC,74020,CPT,TC,,,,,,,436,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,388.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.1144,427.28
Xray Cervical Spine 2 or 3 Vws,PX7204001,CDM,320,RC,72040,CPT,TC,,,,,,,436,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,388.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,427.28
Abd Duplex Abd -Follow Up,PX9397602,CDM,921,RC,93976,CPT,TC,,,,,,,784,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,388.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,768.32
Art Lower Extremity+Upper,PX9392301,CDM,921,RC,93923,CPT,TC,,,,,,,784,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,388.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.46,768.32
Comprehensive Metabolic Panel,PX80053,CDM,300,RC,80053,CPT,,,,,,,,396,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,388.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,9.68,388.08
"Incis/Drain Scrotum/Testis,Epididym",PX54700P,CDM,983,RC,54700,CPT,,,,,,,,440,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,388.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,182.776,1779.39
Neg Pressure Wound Therapy Dme </=50 Sq Cm,PX97605F,CDM,510,RC,97605,CPT,,,,,,,,396,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,388.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,164.4984,388.08
NON-LOCKING SCREW 3.5X12MM,27200000,CDM,278,RC,C1713,HCPCS,,11857-MAIN,LOCAL,,,,,396,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,388.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NON-LOCKING SCREW 3.5X16MM,27200000,CDM,278,RC,C1713,HCPCS,,11856-MAIN,LOCAL,,,,,396,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,388.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
NON-LOCKING SCREW 3.5X24MM,27200000,CDM,278,RC,C1713,HCPCS,,11855-MAIN,LOCAL,,,,,396,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,388.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Xray Ribs Unilat 2 Vws With Pa Chest,PX7110101,CDM,320,RC,71101,CPT,TC,,,,,,,792,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,158.4,percent of total billed charges,388.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,776.16
Xray Ribs Unilat 2 Vws With Pa Chest,PX7110101,CDM,320,RC,71101,CPT,TC,,,,,,,792,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,388.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,776.16
Xray Ribs Unilat 2 Vws With Pa Chest,PX7110101,CDM,320,RC,71101,CPT,TC,,,,,,,792,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,388.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,776.16
Reconstruc of Nail Bed W Graft,PX11762F,CDM,510,RC,11762,CPT,,,,,,,,1901,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,388.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,117.58,599.1
"Complex Drainage, Wound",PX10180P,CDM,983,RC,10180,CPT,,,,,,,,767,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,388.102,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,318.6118,2482.37
"Closed Rx Shldr Disloc,Anesthesia",PX23655F,CDM,510,RC,23655,CPT,,,,,,,,1776,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,388.2099,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,260.25,871.67
"Closed Rx Shldr Disloc,Anesthesia",PX23655P,CDM,983,RC,23655,CPT,,,,,,,,1421,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,388.2099,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,260.25,1392.58
Abd Duplex Abd-Follow Up(T),PX9397601,CDM,921,RC,93976,CPT,TC,,,,,,,809,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,388.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,792.82
Abd Duplex Abd-Follow Up(T),PX9397601,CDM,921,RC,93976,CPT,TC,,,,,,,809,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,388.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,792.82
Venous Duplex Scan Uni,PX9397101,CDM,921,RC,93971,CPT,TC,,,,,,,809,,Health Partners,Health Partners Care Plans,both,48,,12.36,percent of total billed charges,388.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,792.82
Venous Duplex Scan Uni,PX9397101,CDM,921,RC,93971,CPT,TC,,,,,,,809,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,388.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,792.82
Dress/Debrid Large Burn No Anesth,PX16030F,CDM,510,RC,16030,CPT,,,,,,,,399,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,388.3467,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,165.7446,391.02
"X-Ray Exam Hip,Bilat W/Pelvis 2 Vws",PX7352101,CDM,320,RC,73521,CPT,TC,,,,,,,399,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,388.3467,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,391.02
Xray Lumbosacral 2 or 3 Vws,PX7210001,CDM,320,RC,72100,CPT,TC,,,,,,,399,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,204.0333333,percent of total billed charges,388.3467,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,391.02
"Infectious Disease (Viral Respiratory Tract Infection),",PX0241U,CDM,300,RC,0241U,HCPCS,,,,,,,,457,,First Health,Commercial,both,85,,999999999,percent of total billed charges,388.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.78,447.86
US Scrotum & Contents Tc,PX7687001,CDM,402,RC,76870,CPT,TC,,,,,,,457,,First Health,Commercial,both,85,,999999999,percent of total billed charges,388.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,447.86
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605P,CDM,983,RC,25605,CPT,,,,,,,,785,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,388.575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,326.089,1404.08
Layr Clos Wnd Rest Body 7.6-12.5,PX12044F,CDM,510,RC,12044,CPT,,,,,,,,785,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,388.575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,326.089,769.3
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310001,NDC,0.528,ML,785.14,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,388.6443,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.22,877.002
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,25021019110,NDC,1,EA,809.89,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,388.7472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.47563,793.6922
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,25021019110,NDC,1,EA,809.89,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,388.7472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.47563,793.6922
"Removal of Tunnel Cv Access Device, With Port/Pump",PX36590P,CDM,983,RC,36590,CPT,,,,,,,,1147,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,388.79,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.39,1124.06
Noninvasv Lo Extrem Art Stress/Rest,PX9392401,CDM,921,RC,93924,CPT,TC,,,,,,,810,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,388.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.46,793.8
Noninvasv Lo Extrem Art Stress/Rest,PX9392401,CDM,921,RC,93924,CPT,TC,,,,,,,810,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,388.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.46,793.8
Xray Ribs Unilat 2 Vws,PX7110001,CDM,320,RC,71100,CPT,TC,,,,,,,437,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,388.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,428.26
"Fac/Office Consultation,Level IV",PX99244F,CDM,510,RC,99244,CPT,,,,,,,,441,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,388.962,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,183.1914,432.18
Gastric Intubation Treatment,PX43753F,CDM,510,RC,43753,CPT,,,,,,,,441,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,388.962,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,183.1914,432.18
"Office Consultation,Level IV",PX99244P,CDM,983,RC,99244,CPT,,,,,,,,441,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,388.962,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,183.1914,429.2253
erythromycin lactobionate 500 MG Recon Soln 1 Each Vial,J1364.01,CDM,636,RC,J1364,HCPCS,,,,409648211,NDC,1,EA,437.09,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,389.0101,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.06,428.3482
desflurane Solution 240 mL Bottle,25000000,CDM,250,RC,,,,,,10019064134,NDC,240,ML,793.95,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,389.0355,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
desflurane Solution 240 mL Bottle,25000000,CDM,250,RC,,,,,,10019064134,NDC,240,ML,793.95,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,389.0355,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
desflurane Solution 240 mL Bottle,25000000,CDM,250,RC,,,,,,10019064134,NDC,240,ML,793.95,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,389.0355,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Layr Clos Wnd Face,Facial <2.5cm",PX12051F,CDM,510,RC,12051,CPT,,,,,,,,769,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,389.114,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,319.4426,753.62
"Lap,Inguinal Hernia Repr,Initial",PX49650F,CDM,510,RC,49650,CPT,,,,,,,,1076,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,389.1732,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.65,907.64
"Lap,Inguinal Hernia Repr,Initial",PX49650P,CDM,983,RC,49650,CPT,,,,,,,,717,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,389.1732,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.65,907.64
medroxyPROGESTERone 150 MG/ML Suspension 1 mL Vial,J1050.01,CDM,636,RC,J1050,HCPCS,,,,67457088799,NDC,1,ML,437.38,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,389.2682,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.687652,428.6324
fluticasone propionate 50 MCG/ACT Suspension 16 g Bottle,63700001,CDM,250,RC,,,,,,60505082901,NDC,16,GR,437.4,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,389.286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12173-MAIN,LOCAL,,,,,400,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,389.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Lvl 1 Init Hosp Low Mdm or 40 Minutes,PX99221,CDM,982,RC,99221,CPT,,,,,,,,400,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,389.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.16,389.32
travoprost (BAK Free) 0.004 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,65026025,NDC,2.5,ML,811.3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,389.424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
travoprost (BAK Free) 0.004 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,65026025,NDC,2.5,ML,811.3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,389.424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
budesonide-formoterol 80-4.5 MCG/ACT Aerosol 6.9 g Inhaler,63700001,CDM,250,RC,,,,,,186037228,NDC,6.9,GR,937.58,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,389.470732,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
I&D Bartholin Gland Abscess,PX56420F,CDM,510,RC,56420,CPT,,,,,,,,429,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,389.48,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.02,389.48
I&D Bartholin Gland Abscess,PX56420P,CDM,983,RC,56420,CPT,,,,,,,,286,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,389.48,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.02,389.48
Aspirate Pleura W/ Imaging,PX32555F,CDM,761,RC,32555,CPT,,,,,,,,795,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,389.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,330.243,779.1
Aspirate Pleura W/ Imaging,PX32555F,CDM,761,RC,32555,CPT,,,,,,,,795,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,389.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,330.243,779.1
Aspirate Pleura W/ Imaging,PX32555F,CDM,761,RC,32555,CPT,,,,,,,,795,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,389.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,330.243,779.1
Aspirate Pleura W/O Imaging,PX32554F,CDM,510,RC,32554,CPT,,,,,,,,795,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,389.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,330.243,779.1
Aspirate Pleura W/O Imaging,PX32554F,CDM,510,RC,32554,CPT,,,,,,,,795,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,389.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,330.243,779.1
Aspirate Pleura W/O Imaging,PX32554F,CDM,510,RC,32554,CPT,,,,,,,,795,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,389.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,330.243,779.1
Exc Abdom Tum Subfac > 5 Cm,PX22901P,CDM,983,RC,22901,CPT,,,,,,,,938,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,389.6452,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,389.6452,2482.37
Debride Bone Ea Add 20 Sqcm,PX11047F,CDM,510,RC,11047,CPT,,,,,,,,438,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,389.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.9452,429.24
US Pregnancy Tc Limited,PX7681501,CDM,402,RC,76815,CPT,TC,,,,,,,438,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,389.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,429.24
Resp Virus 6-11 Targets,PX87632,CDM,300,RC,87632,CPT,,,,,,,,428,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,389.908,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,177.7912,419.44
Xray Thoracic Spine 2 Vws,PX7207001,CDM,320,RC,72070,CPT,TC,,,,,,,428,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,389.908,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,419.44
Chrom Anal 15-20 Cells - Ref,PX8826290,CDM,310,RC,88262,CPT,90,,,,,,,398,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,390.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.06,390.04
Abd Duplex Abd-Full,PX9397501,CDM,921,RC,93975,CPT,TC,,,,,,,788,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,390.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,772.24
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122F,CDM,510,RC,13122,CPT,,,,,,,,788,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,390.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,327.3352,772.24
Irradiated Leukoreduced Rbc's,PXP9040,CDM,390,RC,P9040,HCPCS,,,,,,,,771,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,390.126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,231.5,755.58
Resp Virus 3-5 Targets,PX87631,CDM,300,RC,87631,CPT,,,,,,,,459,,First Health,Commercial,both,85,,999999999,percent of total billed charges,390.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.78,449.82
"Closed Rx Trimalleolar Fx,Manip",PX27818F,CDM,510,RC,27818,CPT,,,,,,,,813,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,390.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,337.7202,1404.08
"Closed Rx Trimalleolar Fx,Manip",PX27818F,CDM,510,RC,27818,CPT,,,,,,,,813,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,390.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,337.7202,1404.08
"Fac/Exc Skn Bngn 2.1-3cmfce,Facial",PX11443F,CDM,510,RC,11443,CPT,,,,,,,,813,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,390.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,337.7202,1416.38
"Fac/Exc Skn Bngn 2.1-3cmfce,Facial",PX11443F,CDM,510,RC,11443,CPT,,,,,,,,813,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,390.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,337.7202,1416.38
"Calprotectin, Fecal - Ref",PX8399390,CDM,300,RC,83993,CPT,90,,,,,,,401,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,390.2933,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18,392.98
nystatin-triamcinolone 100000-0.1 UNIT/GM-% Ointment 30 g Tube,25000000,CDM,250,RC,,,,,,52565004230,NDC,30,GR,438.62,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,390.3718,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12173-SURG,LOCAL,,,,,772,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,390.632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM ENDOWRIST INSTRUMENTS 8MM FORCE BIPOLAR IS4000,27200000,CDM,272,RC,,,,11915-MAIN,LOCAL,,,,,439,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,390.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
VISIGI3D 40FR STD WITH BULB,27100000,CDM,271,RC,,,,12812-MAIN,LOCAL,,,,,439,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,390.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
Closed Rx Metacarpal Fx,PX26600F,CDM,510,RC,26600,CPT,,,,,,,,443,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,390.726,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,184.0222,434.14
I&D Bartholin Gland Abscess,PX56420F,CDM,510,RC,56420,CPT,,,,,,,,429,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,390.819,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.08,420.42
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070110,NDC,1,ML,459.95,,First Health,Commercial,both,85,,999999999,percent of total billed charges,390.9575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.92,450.751
"DXA, Bone Density Study, Radius/Wrist/Heel",PX7708101,CDM,320,RC,77081,CPT,TC,,,,,,,460,,First Health,Commercial,both,85,,999999999,percent of total billed charges,391,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,450.8
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623P,CDM,983,RC,11623,CPT,,,,,,,,460,,First Health,Commercial,both,85,,999999999,percent of total billed charges,391,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,191.084,1416.38
"Transvaginal US, Obstetric",PX7681701,CDM,402,RC,76817,CPT,TC,,,,,,,460,,First Health,Commercial,both,85,,999999999,percent of total billed charges,391,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,450.8
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598046562,NDC,1,EA,798,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,391.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598046562,NDC,1,EA,798,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,391.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598046562,NDC,1,EA,798,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,391.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
Dress/Debrid Large Burn No Anesth,PX16030F,CDM,510,RC,16030,CPT,,,,,,,,399,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,391.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,165.7446,391.02
"X-Ray Exam Hip,Bilat W/Pelvis 2 Vws",PX7352101,CDM,320,RC,73521,CPT,TC,,,,,,,399,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,391.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,391.02
Xray Lumbosacral 2 or 3 Vws,PX7210001,CDM,320,RC,72100,CPT,TC,,,,,,,399,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,391.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,391.02
Removal of Anal Tabs,PX46230F,CDM,510,RC,46230,CPT,,,,,,,,790,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,391.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,328.166,2452.93
"Amputation Metatarsal+Toe,Single",PX28810F,CDM,510,RC,28810,CPT,,,,,,,,930,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,391.0998,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.21,881.35
"Amputation Metatarsal+Toe,Single",PX28810P,CDM,983,RC,28810,CPT,,,,,,,,620,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,391.0998,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.21,881.35
"Closed Rx Radial Head/Neck Fx,Manip",PX24655F,CDM,510,RC,24655,CPT,,,,,,,,1750,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,391.0998,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,259.6,972.67
"Closed Rx Radial Head/Neck Fx,Manip",PX24655P,CDM,983,RC,24655,CPT,,,,,,,,1824,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,391.0998,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,259.6,1787.52
Remove Hemorrhoids & Fissure,PX46257F,CDM,510,RC,46257,CPT,,,,,,,,1141,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,391.0998,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,263.74,870.28
Remove Hemorrhoids & Fissure,PX46257P,CDM,983,RC,46257,CPT,,,,,,,,615,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,391.0998,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,263.74,870.28
I&D Deep Absc/Hematoma Neck/Chest,PX21501F,CDM,510,RC,21501,CPT,,,,,,,,773,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,391.138,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.1042,2482.37
Apply Long Leg Cast,PX29345F,CDM,510,RC,29345,CPT,,,,,,,,912,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,391.248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,234.62,893.76
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598030562,NDC,1,EA,912,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,391.248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
Open Bx/Excision Inguinofemoral Nodes,PX38531F,CDM,510,RC,38531,CPT,,,,,,,,912,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,391.248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,378.8448,3329.99
"Cardioversion, Elective;Extern",PX92960F,CDM,480,RC,92960,CPT,,,,,,,,402,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,391.2666,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.9908,568.57
Chem Cautery Granulatn Tissue,PX17250P,CDM,983,RC,17250,CPT,,,,,,,,402,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,391.2666,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.9908,391.2666
Lab Imm Spin X-Match,PX8837,CDM,300,RC,86920,CPT,,,,,,,,402,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,235.864,percent of total billed charges,391.2666,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.22,393.96
"Morphometric Analysis, in Situ Hybridization, Each Probe; Manual, Tech",PX8836801,CDM,310,RC,88368,CPT,TC,,,,,,,402,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,391.2666,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.9908,393.96
STAPLER CONTOUR CURVED CUTTER,27200000,CDM,272,RC,,,,12064-MAIN,LOCAL,,,,,942,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,391.3068,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802201,NDC,0.8,ML,439.77,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,391.3953,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802210,NDC,0.8,ML,439.77,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,391.3953,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
Excis Primary Ganglion Wrist,PX25111F,CDM,510,RC,25111,CPT,,,,,,,,791,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,391.545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,328.5814,1404.08
Closure Superf Wnd Dehis Simple,PX12020F,CDM,510,RC,12020,CPT,,,,,,,,632,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,391.56,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,117.15,624.7
Closure Superf Wnd Dehis Simple,PX12020P,CDM,983,RC,12020,CPT,,,,,,,,422,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,391.56,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,117.15,624.7
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279210,NDC,10,ML,429.84,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,391.58424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,178.555536,421.2432
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279410,NDC,10,ML,429.84,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,391.58424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,178.555536,421.2432
"Incis/Drain Scrotum/Testis,Epididym",PX54700P,CDM,983,RC,54700,CPT,,,,,,,,440,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,391.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,182.776,1779.39
Explor Metatarso-Phalang Jt,PX28022P,CDM,983,RC,28022,CPT,,,,,,,,774,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,391.644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.5196,2827.75
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132P,CDM,983,RC,13132,CPT,,,,,,,,774,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,391.644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.5196,753.3342
Exc Face Les Sc < 2 Cm,PX21011F,CDM,510,RC,21011,CPT,,,,,,,,943,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,391.7222,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,391.7222,1416.38
RELOAD SUREFORM 60 2.5 WHITE 6 ROW BOX/12,27200000,CDM,272,RC,,,,12261-MAIN,LOCAL,,,,,430,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,391.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 60 3.5 BLUE,27200000,CDM,272,RC,,,,12084-MAIN,LOCAL,,,,,430,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,391.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 60 4.3 GREEN,27200000,CDM,272,RC,,,,12085-MAIN,LOCAL,,,,,430,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,391.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802001,NDC,1,ML,444.2,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,391.7844,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802010,NDC,1,ML,444.2,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,391.7844,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
"Initial Observation Care,Levl III",PX99220,CDM,982,RC,99220,CPT,,,,,,,,461,,First Health,Commercial,both,85,,999999999,percent of total billed charges,391.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,191.4994,448.6913
Repr Superf Wnd Face <2.5cm,PX12011P,CDM,983,RC,12011,CPT,,,,,,,,461,,First Health,Commercial,both,85,,999999999,percent of total billed charges,391.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,448.6913
albumin human 25% 25 % Solution 50 mL Flex Cont,P9047,CDM,636,RC,P9047,HCPCS,,,,944049301,NDC,50,ML,402.67,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,391.918711,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.66,394.6166
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12173-MAIN,LOCAL,,,,,400,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Lvl 1 Init Hosp Low Mdm or 40 Minutes,PX99221,CDM,982,RC,99221,CPT,,,,,,,,400,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,392,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.29,392
Xray Ribs Unilat 2 Vws With Pa Chest,PX7110101,CDM,320,RC,71101,CPT,TC,,,,,,,792,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,392.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,776.16
Emergency Level IV Visit,PX99284P,CDM,981,RC,99284,CPT,,,,,,,,914,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,392.106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,379.6756,889.5962
Room Rate Transitional Care Private,PX11900000,CDM,119,RC,,,,,,,,,,775,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,392.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.935,759.5
tiotropium bromide monohydrate 2.5 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597010051,NDC,4,GR,461.7,,First Health,Commercial,both,85,,999999999,percent of total billed charges,392.445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tiotropium bromide-olodaterol 2.5-2.5 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597015570,NDC,4,GR,461.7,,First Health,Commercial,both,85,,999999999,percent of total billed charges,392.445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Fac/Office Consultation,Level IV",PX99244F,CDM,510,RC,99244,CPT,,,,,,,,441,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,392.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,183.1914,432.18
Gastric Intubation Treatment,PX43753F,CDM,510,RC,43753,CPT,,,,,,,,441,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,392.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,183.1914,432.18
"Office Consultation,Level IV",PX99244P,CDM,983,RC,99244,CPT,,,,,,,,441,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,392.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,183.1914,429.2253
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,781344071,NDC,1,EA,430.94,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,392.58634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,179.012476,460.7862
fidaxomicin 200 MG Tablet 20 Each Bottle,25000000,CDM,250,RC,,,,,,52015008001,NDC,1,EA,945.16,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,392.619464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Layr Clos Wnd Face,Facial 2.5-5",PX12052P,CDM,983,RC,12052,CPT,,,,,,,,776,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,392.656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,322.3504,755.2808
Physical Therapy Evaluation Low Complex,PX97161,CDM,424,RC,97161,CPT,,,,,,,,235,,Blue Cross Blue Shield of MN,All commercial plans,both,,,133.5,fee schedule,392.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.19,392.7
hydrocortisone sodium succinate (preservative free) 1000 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9000501,NDC,1,EA,403.54,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,392.765482,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
"Calprotectin, Fecal - Ref",PX8399390,CDM,300,RC,83993,CPT,90,,,,,,,401,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,392.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18,392.98
desflurane Solution 240 mL Bottle,25000000,CDM,250,RC,,,,,,10019064134,NDC,240,ML,793.95,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,393.00525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
I&D Perirectal Abscess,PX46040F,CDM,510,RC,46040,CPT,,,,,,,,1430,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,393.0264,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,264.62,1158.77
I&D Perirectal Abscess,PX46040P,CDM,983,RC,46040,CPT,,,,,,,,953,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,393.0264,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,264.62,1158.77
Layr Clos Wnd Rest Body 2.6-7.5,PX12042P,CDM,983,RC,12042,CPT,,,,,,,,777,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,393.162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,322.7658,756.2541
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956401,NDC,1,EA,1611.2,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,393.18,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,393.18,446.8
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956410,NDC,1,EA,1689.17,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,393.18,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,393.18,446.8
Layr Clos Wnd Rest Body 2.6-7.5,PX12042F,CDM,510,RC,12042,CPT,,,,,,,,404,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,393.2132,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,395.92
Neg Pressure Wound Therapy Dme >50 Sq Cm,PX97606F,CDM,761,RC,97606,CPT,,,,,,,,404,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,393.2132,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,395.92
Remove Foreign Body Simple,PX10120F,CDM,510,RC,10120,CPT,,,,,,,,404,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,443.6366667,percent of total billed charges,393.2132,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,395.92
Remove Foreign Body Simple,PX10120P,CDM,983,RC,10120,CPT,,,,,,,,404,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,443.6366667,percent of total billed charges,393.2132,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,393.2132
Xray Foot Minimum 3 Vws,PX7363001,CDM,320,RC,73630,CPT,TC,,,,,,,404,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,172.9896429,percent of total billed charges,393.2132,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,395.92
Xray Knee 3 Vws,PX7356201,CDM,320,RC,73562,CPT,TC,,,,,,,404,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,180.4903125,percent of total billed charges,393.2132,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,395.92
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016410,NDC,1,ML,917.08,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,393.42732,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.66,898.7384
indocyanine green 25 MG Recon Soln 1 Each Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,70100042402,NDC,1,EA,446.07,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,393.43374,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.29,1354.4776
Aspirate Pleura W/ Imaging,PX32555F,CDM,761,RC,32555,CPT,,,,,,,,795,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,393.525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,330.243,779.1
Aspirate Pleura W/O Imaging,PX32554F,CDM,510,RC,32554,CPT,,,,,,,,795,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,393.525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,330.243,779.1
Xray Eye Foreign Body,PX7003001,CDM,320,RC,70030,CPT,TC,,,,,,,432,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,393.552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,423.36
CATHETER PUREWICK FEMALE EXTERNAL PWF030K,120.414,CDM,272,RC,A6590,HCPCS,,11836-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,393.59,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.87,406.9505
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121F,CDM,510,RC,13121,CPT,,,,,,,,948,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,393.7992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,393.7992,929.04
mometasone - formoterol 100-5 MCG/ACT Aerosol 8.8 g Inhaler,25000000,CDM,250,RC,,,,,,85720607,NDC,8.8,GR,918.07,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,393.85203,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
mometasone - formoterol 200-5 MCG/ACT Aerosol 8.8 g Inhaler,25000000,CDM,250,RC,,,,,,85461005,NDC,8.8,GR,918.07,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,393.85203,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Cardioversion, Elective;Extern",PX92960F,CDM,480,RC,92960,CPT,,,,,,,,402,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,393.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.9908,568.57
Chem Cautery Granulatn Tissue,PX17250P,CDM,983,RC,17250,CPT,,,,,,,,402,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,393.96,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.12,393.96
Lab Imm Spin X-Match,PX8837,CDM,300,RC,86920,CPT,,,,,,,,402,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,393.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,149.22,393.96
"Morphometric Analysis, in Situ Hybridization, Each Probe; Manual, Tech",PX8836801,CDM,310,RC,88368,CPT,TC,,,,,,,402,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,393.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.9908,393.96
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021080166,NDC,5,ML,820.8,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,393.984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021080166,NDC,5,ML,820.8,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,393.984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092401,NDC,0.5,ML,820.88,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,394.0224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092401,NDC,0.5,ML,820.88,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,394.0224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092491,NDC,0.5,ML,820.88,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,394.0224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092491,NDC,0.5,ML,820.88,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,394.0224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092410,NDC,0.5,ML,820.89,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,394.0272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092410,NDC,0.5,ML,820.89,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,394.0272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
fluticasone propionate 50 MCG/ACT Suspension 16 g Bottle,63700001,CDM,250,RC,,,,,,50383070016,NDC,16,GR,432.56,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,394.06216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
TAPER POST TOE JOINT HEMICAP 9.5MM ARTICULATING METATARSAL STERILE,C1713,CDM,278,RC,C1713,HCPCS,,12531-MAIN,LOCAL,,,,,821,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,394.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
TAPER POST TOE JOINT HEMICAP 9.5MM ARTICULATING METATARSAL STERILE,C1713,CDM,278,RC,C1713,HCPCS,,12531-MAIN,LOCAL,,,,,821,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,394.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Diagnostic Anoscopy,PX46600P,CDM,983,RC,46600,CPT,,,,,,,,405,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,90.16,percent of total billed charges,394.1865,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,394.1865
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,60505619301,NDC,5,ML,821.36,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,394.2528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.08296,1009.1158
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,60505619301,NDC,5,ML,821.36,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,394.2528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.08296,1009.1158
Closed Rx Metacarpal Fx,PX26600F,CDM,510,RC,26600,CPT,,,,,,,,443,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,394.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,184.0222,434.14
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032F,CDM,510,RC,12032,CPT,,,,,,,,386,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,394.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.76,632.31
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032P,CDM,983,RC,12032,CPT,,,,,,,,647,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,394.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.76,634.06
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016425,NDC,1,ML,779.43,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,394.39158,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.66,898.7384
"Hospital Inpt or Obs Care, Admin/Disch Same Date Straightforward or Low Level Mdm >= 45 Minutes",PX99234,CDM,982,RC,99234,CPT,,,,,,,,464,,First Health,Commercial,both,85,,999999999,percent of total billed charges,394.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.7456,451.6112
Naso/Orogastric Tube,PX43752F,CDM,510,RC,43752,CPT,,,,,,,,464,,First Health,Commercial,both,85,,999999999,percent of total billed charges,394.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.7456,454.72
rho d immune globulin human 1500 units solution prefilled syringe 1 Each Syringe,J2790.01,CDM,636,RC,J2790,HCPCS,,,,562780500,NDC,1,EA,464.01,,First Health,Commercial,both,85,,999999999,percent of total billed charges,394.4085,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.749754,454.7298
Closed Rx Bimalleolar Fx,PX27808P,CDM,983,RC,27808,CPT,,,,,,,,433,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,394.463,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,179.8682,421.4389
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Solution 10 mL Bottle,63700001,CDM,250,RC,,,,,,61314064610,NDC,10,ML,433.15,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,394.59965,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
albumin human 25% 25 % Solution 50 mL Flex Cont,P9047,CDM,636,RC,P9047,HCPCS,,,,944049301,NDC,50,ML,402.67,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,394.6166,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.66,394.6166
"Amputation Toe,I-P Jt",PX28825P,CDM,983,RC,28825,CPT,,,,,,,,780,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,394.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,324.012,2827.75
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598046562,NDC,1,EA,798,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,395.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
hydrocortisone (perianal) 2.5 % Cream 28.35 g Tube,63700001,CDM,250,RC,,,,,,10631040701,NDC,28.35,GR,447.94,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,395.08308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598F,CDM,510,RC,97598,CPT,,,,,,,,406,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,395.1598,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,168.6524,397.88
Drainage of Hematoma/Fluid (P),PX10140P,CDM,983,RC,10140,CPT,,,,,,,,465,,First Health,Commercial,both,85,,999999999,percent of total billed charges,395.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,193.161,1416.38
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102P,CDM,983,RC,11102,CPT,,,,,,,,465,,First Health,Commercial,both,85,,999999999,percent of total billed charges,395.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,452.5845
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802001,NDC,1,ML,444.2,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,395.338,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802010,NDC,1,ML,444.2,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,395.338,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
hydrocortisone sodium succinate (preservative free) 1000 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9000501,NDC,1,EA,403.54,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,395.4692,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.983666,395.4692
Anus Surgery Procedure Unlisted,PX46999P,CDM,983,RC,46999,CPT,,,,,,,,953,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,395.8762,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,395.8762,927.5549
"Genital Surg Proc,Male Unlisted",PX55899P,CDM,983,RC,55899,CPT,,,,,,,,953,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,395.8762,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,215.91,927.5549
I&D Perirectal Abscess,PX46040P,CDM,983,RC,46040,CPT,,,,,,,,953,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,395.8762,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,395.8762,1030.93
"Office/Outpt Visit,New,Levl V",PX99205F,CDM,510,RC,99205,CPT,,,,,,,,456,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,395.88,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.82,395.88
"Office/Outpt Visit,New,Levl V",PX99205P,CDM,983,RC,99205,CPT,,,,,,,,456,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,395.88,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.82,446.88
Layr Clos Wnd Rest Body 2.6-7.5,PX12042F,CDM,510,RC,12042,CPT,,,,,,,,404,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,395.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,395.92
Neg Pressure Wound Therapy Dme >50 Sq Cm,PX97606F,CDM,761,RC,97606,CPT,,,,,,,,404,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,395.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,395.92
Remove Foreign Body Simple,PX10120F,CDM,510,RC,10120,CPT,,,,,,,,404,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,395.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.8216,395.92
Remove Foreign Body Simple,PX10120P,CDM,983,RC,10120,CPT,,,,,,,,404,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,395.92,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.53,395.92
Xray Foot Minimum 3 Vws,PX7363001,CDM,320,RC,73630,CPT,TC,,,,,,,404,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,395.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,395.92
Xray Knee 3 Vws,PX7356201,CDM,320,RC,73562,CPT,TC,,,,,,,404,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,395.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,395.92
"Exc Skn Malig1.1-2cm Fce,Facal",PX11642P,CDM,983,RC,11642,CPT,,,,,,,,466,,First Health,Commercial,both,85,,999999999,percent of total billed charges,396.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,193.5764,614.65
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060002,NDC,2,ML,953.57,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,396.112978,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.11,934.4986
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060010,NDC,2,ML,953.57,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,396.112978,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.11,934.4986
"Lap,Cholecystectomy",PX47562F,CDM,510,RC,47562,CPT,,,,,,,,1473,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,396.16,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,396.16,1378.07
"Lap,Cholecystectomy",PX47562P,CDM,983,RC,47562,CPT,,,,,,,,983,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,396.16,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,396.16,1378.07
"Remv Foreign Body,Knee/Thigh,Deep",PX27372P,CDM,983,RC,27372,CPT,,,,,,,,954,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,396.2916,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,396.2916,2482.37
Abd Duplex Abd-Follow Up(T),PX9397601,CDM,921,RC,93976,CPT,TC,,,,,,,809,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,387.145,percent of total billed charges,396.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,792.82
Abd Duplex Abd-Follow Up(T),PX9397601,CDM,921,RC,93976,CPT,TC,,,,,,,809,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,396.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,792.82
Abd Duplex Abd-Follow Up(T),PX9397601,CDM,921,RC,93976,CPT,TC,,,,,,,809,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,396.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,792.82
"CT Angiography, Neck",PX7049801,CDM,350,RC,70498,CPT,TC,,,,,,,3690,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,396.41,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.11,396.41
"CT Angiography, Neck",PX7049801,CDM,350,RC,70498,CPT,TC,,,,,,,3690,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,396.41,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.11,396.41
Venous Duplex Scan Uni,PX9397101,CDM,921,RC,93971,CPT,TC,,,,,,,809,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,205.7616667,percent of total billed charges,396.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,792.82
Venous Duplex Scan Uni,PX9397101,CDM,921,RC,93971,CPT,TC,,,,,,,809,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,396.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,792.82
Venous Duplex Scan Uni,PX9397101,CDM,921,RC,93971,CPT,TC,,,,,,,809,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,396.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,792.82
Abd Duplex Abd -Follow Up,PX9397602,CDM,921,RC,93976,CPT,TC,,,,,,,784,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,396.704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,768.32
Art Lower Extremity+Upper,PX9392301,CDM,921,RC,93923,CPT,TC,,,,,,,784,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,396.704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.46,768.32
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,25021019110,NDC,1,EA,809.89,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,396.8461,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.47563,793.6922
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,25021019110,NDC,1,EA,809.89,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,396.8461,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.47563,793.6922
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,25021019110,NDC,1,EA,809.89,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,396.8461,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.47563,793.6922
Diagnostic Anoscopy,PX46600P,CDM,983,RC,46600,CPT,,,,,,,,405,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,396.9,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.52,396.9
Noninvasv Lo Extrem Art Stress/Rest,PX9392401,CDM,921,RC,93924,CPT,TC,,,,,,,810,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,396.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.46,793.8
Noninvasv Lo Extrem Art Stress/Rest,PX9392401,CDM,921,RC,93924,CPT,TC,,,,,,,810,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,396.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.46,793.8
Noninvasv Lo Extrem Art Stress/Rest,PX9392401,CDM,921,RC,93924,CPT,TC,,,,,,,810,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,396.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.46,793.8
"Spinal Punc,Drain,Theraputic",PX62272F,CDM,510,RC,62272,CPT,,,,,,,,450,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,396.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.93,604.15
indocyanine green 25 MG Recon Soln 1 Each Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,70100042402,NDC,1,EA,446.07,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,397.0023,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.29,1354.4776
"CT Angiography, Head",PX7049601,CDM,350,RC,70496,CPT,TC,,,,,,,3690,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,397.07,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.11,397.07
"CT Angiography, Head",PX7049601,CDM,350,RC,70496,CPT,TC,,,,,,,3690,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,397.07,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.11,397.07
Incise External Hemorrhoid,PX46083P,CDM,983,RC,46083,CPT,,,,,,,,956,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,397.1224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,215.91,930.4748
X-Ray Exam Abdomen 2 Views,PX7401901,CDM,320,RC,74019,CPT,TC,,,,,,,436,,Medica,Commercial,both,91.1,,216.21,percent of total billed charges,397.196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,427.28
"X-Ray Exam Hip,Unilat W/Pelvis 2-3 Vws",PX7350201,CDM,320,RC,73502,CPT,TC,,,,,,,436,,Medica,Commercial,both,91.1,,62.25,percent of total billed charges,397.196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,427.28
Xray Abdomen Comp Incl Decub and/or Erect,PX7402001,CDM,320,RC,74020,CPT,TC,,,,,,,436,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,397.196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.1144,427.28
Xray Cervical Spine 2 or 3 Vws,PX7204001,CDM,320,RC,72040,CPT,TC,,,,,,,436,,Medica,Commercial,both,91.1,,98.805,percent of total billed charges,397.196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,427.28
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605P,CDM,983,RC,25605,CPT,,,,,,,,785,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,397.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,326.089,1404.08
Layr Clos Wnd Rest Body 7.6-12.5,PX12044F,CDM,510,RC,12044,CPT,,,,,,,,785,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,397.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,326.089,769.3
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310001,NDC,0.528,ML,785.14,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,397.28084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.22,877.002
travoprost (BAK Free) 0.004 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,65026025,NDC,2.5,ML,811.3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,397.537,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
travoprost (BAK Free) 0.004 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,65026025,NDC,2.5,ML,811.3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,397.537,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
travoprost (BAK Free) 0.004 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,65026025,NDC,2.5,ML,811.3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,397.537,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Closed Rx Kneecap Dislocatn,PX27560F,CDM,510,RC,27560,CPT,,,,,,,,468,,First Health,Commercial,both,85,,999999999,percent of total billed charges,397.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,194.4072,458.64
"POS Airway Pressure, Bipap",PX94660.01F,CDM,410,RC,94660,CPT,,,,,,,,468,,First Health,Commercial,both,85,,999999999,percent of total billed charges,397.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.33,458.64
Vedolizumab - Ref,PX8028090,CDM,300,RC,80280,CPT,90,,,,,,,468,,First Health,Commercial,both,85,,999999999,percent of total billed charges,397.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.36,458.64
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598F,CDM,510,RC,97598,CPT,,,,,,,,406,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,397.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,168.6524,397.88
"Lap,Cholecystectomy",PX47562F,CDM,510,RC,47562,CPT,,,,,,,,1473,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,397.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,396.16,1378.07
"Lap,Cholecystectomy",PX47562F,CDM,510,RC,47562,CPT,,,,,,,,1473,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,397.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,396.16,1378.07
"Lap,Cholecystectomy",PX47562P,CDM,983,RC,47562,CPT,,,,,,,,983,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,397.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,396.16,1378.07
"Lap,Cholecystectomy",PX47562P,CDM,983,RC,47562,CPT,,,,,,,,983,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,397.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,396.16,1378.07
"Surgical Diagnostic Exam, Anorectal",PX45990P,CDM,983,RC,45990,CPT,,,,,,,,409,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,398.0797,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,169.8986,2452.93
Xray Ribs Unilat 2 Vws,PX7110001,CDM,320,RC,71100,CPT,TC,,,,,,,437,,Medica,Commercial,both,91.1,,84.8,percent of total billed charges,398.107,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,428.26
erythromycin lactobionate 500 MG Recon Soln 1 Each Vial,J1364.01,CDM,636,RC,J1364,HCPCS,,,,409648211,NDC,1,EA,437.09,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,398.18899,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.06,428.3482
"Closed Rx Trimalleolar Fx,Manip",PX27818F,CDM,510,RC,27818,CPT,,,,,,,,813,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,398.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,337.7202,1404.08
"Closed Rx Trimalleolar Fx,Manip",PX27818F,CDM,510,RC,27818,CPT,,,,,,,,813,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,398.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,337.7202,1404.08
"Closed Rx Trimalleolar Fx,Manip",PX27818F,CDM,510,RC,27818,CPT,,,,,,,,813,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,398.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,337.7202,1404.08
"Fac/Exc Skn Bngn 2.1-3cmfce,Facial",PX11443F,CDM,510,RC,11443,CPT,,,,,,,,813,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,398.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,337.7202,1416.38
"Fac/Exc Skn Bngn 2.1-3cmfce,Facial",PX11443F,CDM,510,RC,11443,CPT,,,,,,,,813,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,398.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,337.7202,1416.38
"Fac/Exc Skn Bngn 2.1-3cmfce,Facial",PX11443F,CDM,510,RC,11443,CPT,,,,,,,,813,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,398.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,337.7202,1416.38
medroxyPROGESTERone 150 MG/ML Suspension 1 mL Vial,J1050.01,CDM,636,RC,J1050,HCPCS,,,,67457088799,NDC,1,ML,437.38,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,398.45318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.687652,428.6324
fluticasone propionate 50 MCG/ACT Suspension 16 g Bottle,63700001,CDM,250,RC,,,,,,60505082901,NDC,16,GR,437.4,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,398.4714,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DRILL BIT AO DIA 2.0MMX135MM SCALED,27200000,CDM,272,RC,,,,12640-MAIN,LOCAL,,,,,452,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,398.664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
hydrocortisone (perianal) 2.5 % Cream 28.35 g Tube,63700001,CDM,250,RC,,,,,,10631040701,NDC,28.35,GR,447.94,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,398.6666,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Abd Duplex Abd-Full,PX9397501,CDM,921,RC,93975,CPT,TC,,,,,,,788,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,398.728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,772.24
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122F,CDM,510,RC,13122,CPT,,,,,,,,788,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,398.728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,327.3352,772.24
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614900,NDC,1,EA,409.89,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,18.43861111,percent of total billed charges,398.945937,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
"Amputation Metatarsal+Toe,Single",PX28810F,CDM,510,RC,28810,CPT,,,,,,,,930,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,398.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.322,2827.75
Colonoscopy,PX44388F,CDM,750,RC,44388,CPT,,,,,,,,930,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,398.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.322,911.4
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527197174,NDC,4,ML,960.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,398.9917,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
Debride Bone Ea Add 20 Sqcm,PX11047F,CDM,510,RC,11047,CPT,,,,,,,,438,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,399.018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.9452,429.24
US Pregnancy Tc Limited,PX7681501,CDM,402,RC,76815,CPT,TC,,,,,,,438,,Medica,Commercial,both,91.1,,399.02,percent of total billed charges,399.018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,429.24
"Lab Antibody ID,RBC",PX86870,CDM,300,RC,,,,,,,,,,410,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,399.053,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,170.314,401.8
"Supply Technicium Sestamibi,per Dose",PXA9500,CDM,343,RC,A9500,HCPCS,,,,,,,,410,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,579.1433333,percent of total billed charges,399.053,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,170.314,401.8
"Repair Umbilical Hern,5+Y/O,Reduc",PX49585F,CDM,510,RC,49585,CPT,,,,,,,,969,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,399.1273,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,399.1273,399.13
"Repair Umbilical Hern,5+Y/O,Reduc",PX49585P,CDM,983,RC,49585,CPT,,,,,,,,647,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,399.1273,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,399.1273,634.06
"Thrombolytic Therapy, Stroke",PX37195F,CDM,761,RC,37195,CPT,,,,,,,,595,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,399.1273,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,399.1273,665.83
"Repair Umbilical Hern,5+Y/O,Reduc",PX49585F,CDM,510,RC,49585,CPT,,,,,,,,969,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,399.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,399.1273,399.13
"Repair Umbilical Hern,5+Y/O,Reduc",PX49585P,CDM,983,RC,49585,CPT,,,,,,,,647,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,399.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,399.1273,634.06
"Exc Skn Mal 2.1-3cmtrnk,Arm,Lg",PX11603P,CDM,983,RC,11603,CPT,,,,,,,,1276,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,399.17,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.07,1250.48
"Fac/Exc Skn Mali2.1-3cmtrnk,Arm,Lg",PX11603F,CDM,510,RC,11603,CPT,,,,,,,,875,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,399.17,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.07,580.42
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545F,CDM,510,RC,23545,CPT,,,,,,,,961,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,399.1994,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,941.78
"HERNIA MESH 3D MAX MID ANATOMICAL MESH RIGHT SIZE XL 5"" X 7""",C1781,CDM,278,RC,C1781,HCPCS,,11979-MAIN,LOCAL,,,,,832,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,399.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"HERNIA MESH 3D MAX MID ANATOMICAL MESH RIGHT SIZE XL 5"" X 7""",C1781,CDM,278,RC,C1781,HCPCS,,11979-MAIN,LOCAL,,,,,832,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,399.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"HERNIA MESH 3DMAX MID MESH EXTRA-LARGE LEFT 5"" X 7""",C1781,CDM,278,RC,C1781,HCPCS,,11978-MAIN,LOCAL,,,,,832,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,399.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"HERNIA MESH 3DMAX MID MESH EXTRA-LARGE LEFT 5"" X 7""",C1781,CDM,278,RC,C1781,HCPCS,,11978-MAIN,LOCAL,,,,,832,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,399.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320990,NDC,1,EA,410.32,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,18.43861111,percent of total billed charges,399.364456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320995,NDC,1,EA,410.32,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,18.43861111,percent of total billed charges,399.364456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
Fac/Exc Skn Beni 0.6-1cm Remain Bdy,PX11421F,CDM,510,RC,11421,CPT,,,,,,,,931,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,399.399,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.7374,912.38
Fac/Exc Skn Bngn3.1-4cm Remain Bdy,PX11424F,CDM,510,RC,11424,CPT,,,,,,,,931,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,399.399,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.7374,1416.38
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034F,CDM,510,RC,12034,CPT,,,,,,,,931,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,399.399,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,912.38
"Exc Skn Mal 0.6-1cm Fce,Facial",PX11641P,CDM,983,RC,11641,CPT,,,,,,,,453,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,399.546,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.1762,614.65
Repr Superf Wnd Body 7.6-12.5,PX12004F,CDM,510,RC,12004,CPT,,,,,,,,453,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,399.546,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,443.94
Repr Superf Wnd Face 5.1-7.5,PX12014F,CDM,510,RC,12014,CPT,,,,,,,,453,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,399.546,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,443.94
nystatin-triamcinolone 100000-0.1 UNIT/GM-% Ointment 30 g Tube,25000000,CDM,250,RC,,,,,,52565004230,NDC,30,GR,438.62,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,399.58282,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,548590000,NDC,1,EA,470.19,,First Health,Commercial,both,85,,999999999,percent of total billed charges,399.6615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,179.012476,460.7862
Removal of Anal Tabs,PX46230F,CDM,510,RC,46230,CPT,,,,,,,,790,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,399.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,328.166,2452.93
Incise Finger Tendon Sheath,PX26055P,CDM,983,RC,26055,CPT,,,,,,,,932,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,399.828,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,387.1528,1404.08
8MM ENDOWRIST INSTRUMENTS 8MM FORCE BIPOLAR IS4000,27200000,CDM,272,RC,,,,11915-MAIN,LOCAL,,,,,439,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,399.929,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
VISIGI3D 40FR STD WITH BULB,27100000,CDM,271,RC,,,,12812-MAIN,LOCAL,,,,,439,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,399.929,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
8MM ENDOWRIST INSTRUMENTS TIP-UP FENESTRATED GRASPER,27200000,CDM,272,RC,,,,11911-MAIN,LOCAL,,,,,411,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,400.0263,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Bone Marrow Aspiration and Biopsy,PXG0364F,CDM,510,RC,G0364,HCPCS,,,,,,,,411,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,400.0263,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,170.7294,402.78
Excis Primary Ganglion Wrist,PX25111F,CDM,510,RC,25111,CPT,,,,,,,,791,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,400.246,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,328.5814,1404.08
Biopsy Synovium I-P Jt,PX26110,CDM,983,RC,26110,CPT,,,,,,,,933,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,400.257,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,387.5682,1404.08
X-Ray Exam Entire Spine 2-3 Vws,PX7208201,CDM,320,RC,72082,CPT,TC,,,,,,,454,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,400.428,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,444.92
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604F,CDM,510,RC,11604,CPT,,,,,,,,964,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,400.4456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,400.4456,944.72
Abd Duplex Abd-Follow Up(T),PX9397601,CDM,921,RC,93976,CPT,TC,,,,,,,809,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,400.455,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,792.82
Venous Duplex Scan Uni,PX9397101,CDM,921,RC,93971,CPT,TC,,,,,,,809,,Humana Choice Care,All Medicare plans,outpatient,49.5,,272.73,percent of total billed charges,400.455,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,792.82
"Spinal Punc,Drain,Theraputic",PX62272F,CDM,510,RC,62272,CPT,,,,,,,,450,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,400.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.93,604.15
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802201,NDC,0.8,ML,439.77,,Medica,Commercial,both,91.1,,7.8,percent of total billed charges,400.63047,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802210,NDC,0.8,ML,439.77,,Medica,Commercial,both,91.1,,7.8,percent of total billed charges,400.63047,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
"Repair Lip,>1/2 Vert Height",PX40654F,CDM,510,RC,40654,CPT,,,,,,,,2467,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,400.7328,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,269.41,1227.25
"Repair Lip,>1/2 Vert Height",PX40654P,CDM,983,RC,40654,CPT,,,,,,,,1329,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,400.7328,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,269.41,1302.42
Xray Ribs Unilat 2 Vws With Pa Chest,PX7110101,CDM,320,RC,71101,CPT,TC,,,,,,,792,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,400.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,776.16
Duplex Up Extrem Art Bilat,PX9393001,CDM,921,RC,93930,CPT,TC,,,,,,,835,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,400.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,818.3
Duplex Up Extrem Art Bilat,PX9393001,CDM,921,RC,93930,CPT,TC,,,,,,,835,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,400.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,818.3
"Surgical Diagnostic Exam, Anorectal",PX45990P,CDM,983,RC,45990,CPT,,,,,,,,409,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,400.82,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.69,400.82
"Incis/Drain Scrotum/Testis,Epididym",PX54700P,CDM,983,RC,54700,CPT,,,,,,,,440,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,400.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,182.776,1779.39
Temporal Artery Ligatn or Bx,PX37609P,CDM,983,RC,37609,CPT,,,,,,,,965,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,400.861,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,400.861,1416.38
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,25021019110,NDC,1,EA,809.89,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,400.89555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.47563,793.6922
Noninvasv Lo Extrem Art Stress/Rest,PX9392401,CDM,921,RC,93924,CPT,TC,,,,,,,810,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,400.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.46,793.8
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545P,CDM,983,RC,23545,CPT,,,,,,,,412,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,400.9996,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,171.1448,400.9996
"Closed Rx Big Toe Fx,Manip",PX28495P,CDM,983,RC,28495,CPT,,,,,,,,412,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,400.9996,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,171.1448,400.9996
"OB US < 14 Wks, Single Fetus - Radiology, Tech",PX7680101,CDM,402,RC,76801,CPT,TC,,,,,,,472,,First Health,Commercial,both,85,,999999999,percent of total billed charges,401.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,462.56
US Pelvic Tc Complete,PX7685601,CDM,402,RC,76856,CPT,TC,,,,,,,472,,First Health,Commercial,both,85,,999999999,percent of total billed charges,401.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,462.56
US Transvaginal Tc,PX7683001,CDM,402,RC,76830,CPT,TC,,,,,,,472,,First Health,Commercial,both,85,,999999999,percent of total billed charges,401.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,462.56
Fac/Ligation of Hemorrhoid(S),PX46221F,CDM,510,RC,46221,CPT,,,,,,,,1046,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,401.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.94,590.11
Ligation of Hemorrhoid(S),PX46221P,CDM,983,RC,46221,CPT,,,,,,,,697,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,401.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.94,683.06
"Ileoscopy Thru Stoma,Diagnostic",PX44380P,CDM,983,RC,44380,CPT,,,,,,,,455,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,401.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.007,791.92
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607F,CDM,761,RC,97607,CPT,,,,,,,,455,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,401.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.007,445.9
Repr Superf Wnd Face 5.1-7.5,PX12014P,CDM,983,RC,12014,CPT,,,,,,,,819,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,401.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,797.1327
Repr Superf Wnd Face 5.1-7.5,PX12014P,CDM,983,RC,12014,CPT,,,,,,,,819,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,401.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,797.1327
Repr Superf Wnd Face 5.1-7.5,PX12014P,CDM,983,RC,12014,CPT,,,,,,,,819,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,401.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,797.1327
travoprost (BAK Free) 0.004 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,65026025,NDC,2.5,ML,811.3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,401.5935,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
CT Abdomen W/O & W/Dye,PX7417001,CDM,350,RC,74170,CPT,TC,,,,,,,3689,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,401.67,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.11,401.67
CT Abdomen W/O & W/Dye,PX7417001,CDM,350,RC,74170,CPT,TC,,,,,,,3689,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,401.67,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.11,401.67
"CT Angiography, Chest",PX7127501,CDM,350,RC,71275,CPT,TC,,,,,,,3689,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,401.67,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.11,401.67
"CT Angiography, Chest",PX7127501,CDM,350,RC,71275,CPT,TC,,,,,,,3689,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,401.67,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.11,401.67
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614900,NDC,1,EA,409.89,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,401.6922,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
desflurane Solution 240 mL Bottle,25000000,CDM,250,RC,,,,,,10019064134,NDC,240,ML,793.95,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,401.7387,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Fac/Office Consultation,Level IV",PX99244F,CDM,510,RC,99244,CPT,,,,,,,,441,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,401.751,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,183.1914,432.18
Gastric Intubation Treatment,PX43753F,CDM,510,RC,43753,CPT,,,,,,,,441,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,401.751,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,183.1914,432.18
"Office Consultation,Level IV",PX99244P,CDM,983,RC,99244,CPT,,,,,,,,441,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,401.751,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,183.1914,429.2253
"Lab Antibody ID,RBC",PX86870,CDM,300,RC,,,,,,,,,,410,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,401.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,170.314,401.8
"Supply Technicium Sestamibi,per Dose",PXA9500,CDM,343,RC,A9500,HCPCS,,,,,,,,410,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,401.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,170.314,401.8
Open Bx/Excision Inguinofemoral Nodes,PX38531F,CDM,510,RC,38531,CPT,,,,,,,,912,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,402.0172,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,271.37,935.31
Open Bx/Excision Inguinofemoral Nodes,PX38531P,CDM,983,RC,38531,CPT,,,,,,,,607,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,402.0172,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,271.37,935.31
X-Ray Exam Chest 2 Views,PX7104601,CDM,320,RC,71046,CPT,TC,,,,,,,556,,Blue Cross Blue Shield of MN,All commercial plans,both,,,250.1638,fee schedule,402.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,544.88
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320990,NDC,1,EA,410.32,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,402.1136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320995,NDC,1,EA,410.32,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,402.1136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.462,402.1136
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021080166,NDC,5,ML,820.8,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,57.34422222,percent of total billed charges,402.192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021080166,NDC,5,ML,820.8,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,402.192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021080166,NDC,5,ML,820.8,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,402.192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
"Ctrl Nosebleed,Anter,Complex",PX30903F,CDM,510,RC,30903,CPT,,,,,,,,456,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,402.192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,446.88
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611F,CDM,510,RC,20611,CPT,,,,,,,,456,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,402.192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.4224,446.88
"Office/Outpt Visit,New,Levl V",PX99205F,CDM,510,RC,99205,CPT,,,,,,,,456,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,402.192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.4224,446.88
"Office/Outpt Visit,New,Levl V",PX99205P,CDM,983,RC,99205,CPT,,,,,,,,456,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,402.192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.4224,443.8248
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321801,NDC,50,ML,456,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,402.192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
Xray Nasal Bones Minimum 3 Vws,PX7016001,CDM,320,RC,70160,CPT,TC,,,,,,,456,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,402.192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,446.88
budesonide-formoterol 80-4.5 MCG/ACT Aerosol 6.9 g Inhaler,63700001,CDM,250,RC,,,,,,186037228,NDC,6.9,GR,937.58,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,402.22182,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092401,NDC,0.5,ML,820.88,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,402.2312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092401,NDC,0.5,ML,820.88,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,402.2312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092401,NDC,0.5,ML,820.88,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,402.2312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092491,NDC,0.5,ML,820.88,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,402.2312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092491,NDC,0.5,ML,820.88,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,402.2312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092491,NDC,0.5,ML,820.88,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,402.2312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092410,NDC,0.5,ML,820.89,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,402.2361,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092410,NDC,0.5,ML,820.89,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,402.2361,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092410,NDC,0.5,ML,820.89,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,402.2361,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
Aspirate Pleura W/ Imaging,PX32555F,CDM,761,RC,32555,CPT,,,,,,,,795,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,402.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,330.243,779.1
Aspirate Pleura W/O Imaging,PX32554F,CDM,510,RC,32554,CPT,,,,,,,,795,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,402.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,330.243,779.1
DRILL BIT AO DIA 2.0MMX135MM SCALED,27200000,CDM,272,RC,,,,12640-MAIN,LOCAL,,,,,452,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,402.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TAPER POST TOE JOINT HEMICAP 9.5MM ARTICULATING METATARSAL STERILE,C1713,CDM,278,RC,C1713,HCPCS,,12531-MAIN,LOCAL,,,,,821,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,402.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
TAPER POST TOE JOINT HEMICAP 9.5MM ARTICULATING METATARSAL STERILE,C1713,CDM,278,RC,C1713,HCPCS,,12531-MAIN,LOCAL,,,,,821,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,402.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
TAPER POST TOE JOINT HEMICAP 9.5MM ARTICULATING METATARSAL STERILE,C1713,CDM,278,RC,C1713,HCPCS,,12531-MAIN,LOCAL,,,,,821,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,402.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Exc Abdom Tum Subfac > 5 Cm,PX22901P,CDM,983,RC,22901,CPT,,,,,,,,938,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,402.402,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,389.6452,2482.37
"Closed Rx Trimalleolar Fx,Manip",PX27818F,CDM,510,RC,27818,CPT,,,,,,,,813,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,402.435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,337.7202,1404.08
"Fac/Exc Skn Bngn 2.1-3cmfce,Facial",PX11443F,CDM,510,RC,11443,CPT,,,,,,,,813,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,402.435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,337.7202,1416.38
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,60505619301,NDC,5,ML,821.36,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,12.50188889,percent of total billed charges,402.4664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.08296,1009.1158
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,60505619301,NDC,5,ML,821.36,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,402.4664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.08296,1009.1158
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,60505619301,NDC,5,ML,821.36,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,402.4664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.08296,1009.1158
"Repair Umbilical Hern,5+Y/O,Reduc",PX49585F,CDM,510,RC,49585,CPT,,,,,,,,969,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,402.5226,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,402.5226,949.62
Inc/Drain Peritonsil Abscess,PX42700F,CDM,510,RC,42700,CPT,,,,,,,,624,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,402.63,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.38,402.63
Inc/Drain Peritonsil Abscess,PX42700P,CDM,983,RC,42700,CPT,,,,,,,,889,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,402.63,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.38,871.22
Blood Transfusion Service,PX36430,CDM,391,RC,36430,CPT,,,,,,,,839,,Health Partners,Health Partners Care Plans,both,48,,414.8285714,percent of total billed charges,402.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.5206,822.22
Blood Transfusion Service,PX36430,CDM,391,RC,36430,CPT,,,,,,,,839,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,402.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.5206,822.22
8MM ENDOWRIST INSTRUMENTS TIP-UP FENESTRATED GRASPER,27200000,CDM,272,RC,,,,11911-MAIN,LOCAL,,,,,411,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,402.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Bone Marrow Aspiration and Biopsy,PXG0364F,CDM,510,RC,G0364,HCPCS,,,,,,,,411,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,402.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,170.7294,402.78
Exc Skn Bngn1.1-2cm Remain Bdy,PX11422P,CDM,983,RC,11422,CPT,,,,,,,,822,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,402.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,341.4588,1416.38
Exc Skn Bngn1.1-2cm Remain Bdy,PX11422P,CDM,983,RC,11422,CPT,,,,,,,,822,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,402.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,341.4588,1416.38
Exc Skn Bngn1.1-2cm Remain Bdy,PX11422P,CDM,983,RC,11422,CPT,,,,,,,,822,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,402.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,341.4588,1416.38
X-Ray Exam Entire Spine 1vw,PX7208101,CDM,320,RC,72081,CPT,TC,,,,,,,414,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,402.9462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,405.72
"Infectious Disease (Viral Respiratory Tract Infection),",PX0241U,CDM,300,RC,0241U,HCPCS,,,,,,,,457,,United Healthcare,All Payer,outpatient,88.2,,205.2691667,percent of total billed charges,403.074,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.78,447.86
US Scrotum & Contents Tc,PX7687001,CDM,402,RC,76870,CPT,TC,,,,,,,457,,United Healthcare,All Payer,outpatient,88.2,,322.46,percent of total billed charges,403.074,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,447.86
"Exc Skn Mal 0.6-1cm Fce,Facial",PX11641P,CDM,983,RC,11641,CPT,,,,,,,,453,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,403.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.1762,614.65
Repr Superf Wnd Body 7.6-12.5,PX12004F,CDM,510,RC,12004,CPT,,,,,,,,453,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,403.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,443.94
Repr Superf Wnd Face 5.1-7.5,PX12014F,CDM,510,RC,12014,CPT,,,,,,,,453,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,403.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,443.94
Closed Rx Metacarpal Fx,PX26600F,CDM,510,RC,26600,CPT,,,,,,,,443,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,403.573,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,184.0222,434.14
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545P,CDM,983,RC,23545,CPT,,,,,,,,412,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,403.76,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.33,781.73
"Closed Rx Big Toe Fx,Manip",PX28495P,CDM,983,RC,28495,CPT,,,,,,,,412,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,403.76,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.42,403.76
Remove Nasal Foreign Body,PX30300F,CDM,510,RC,30300,CPT,,,,,,,,972,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,403.7688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,952.56
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598046562,NDC,1,EA,798,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,403.788,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
Exc Abdom Tum Subfac > 5 Cm,PX22901F,CDM,761,RC,22901,CPT,,,,,,,,1408,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,403.8,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,403.8,1393.98
Exc Abdom Tum Subfac > 5 Cm,PX22901P,CDM,983,RC,22901,CPT,,,,,,,,938,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,403.8,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,403.8,1393.98
"US Complete Joint, Realtime W/ Img Tc",PX7688101,CDM,402,RC,76881,CPT,TC,,,,,,,415,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,403.9195,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,406.7
MINIBUNION DRILL KIT,27200000,CDM,278,RC,C1713,HCPCS,,11669-MAIN,LOCAL,,,,,841.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,403.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MINIBUNION DRILL KIT,27200000,CDM,278,RC,C1713,HCPCS,,11669-MAIN,LOCAL,,,,,841.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,403.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Exc Skn Beig1.1-2cm Face,Facil",PX11442P,CDM,983,RC,11442,CPT,,,,,,,,886,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,404.01,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.15,868.28
"Fac/Exc Skn Beni1.1-2cm Fce,Facial",PX11442F,CDM,510,RC,11442,CPT,,,,,,,,668,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,404.01,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.15,404.01
X-Ray Exam Entire Spine 2-3 Vws,PX7208201,CDM,320,RC,72082,CPT,TC,,,,,,,454,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,404.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,444.92
STAPLER CONTOUR CURVED CUTTER,27200000,CDM,272,RC,,,,12064-MAIN,LOCAL,,,,,942,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,404.118,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Cns Dna/Rna Amp Probe Multiple Subtypes 12-25,PX87483,CDM,300,RC,87483,CPT,,,,,,,,864,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,404.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,404.28,416.78
Cns Dna/Rna Amp Probe Multiple Subtypes 12-25,PX87483,CDM,300,RC,87483,CPT,,,,,,,,864,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,404.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,404.28,416.78
Cns Dna/Rna Amp Probe Multiple Subtypes 12-25,PX87483,CDM,300,RC,87483,CPT,,,,,,,,864,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,404.28,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,404.28,416.78
"GI Pathogen Panel, Pcr - Ref",PX8750790,CDM,300,RC,87507,CPT,90,,,,,,,213,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,404.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,404.28,416.78
"GI Pathogen Panel, Pcr - Ref",PX8750790,CDM,300,RC,87507,CPT,90,,,,,,,213,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,404.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,404.28,416.78
"GI Pathogen Panel, Pcr - Ref",PX8750790,CDM,300,RC,87507,CPT,90,,,,,,,213,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,404.28,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,404.28,416.78
Infection Agent Detect Dna/Rna Probe Tq 12-25,PX87507,CDM,300,RC,87507,CPT,,,,,,,,209,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,404.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,404.28,416.78
Infection Agent Detect Dna/Rna Probe Tq 12-25,PX87507,CDM,300,RC,87507,CPT,,,,,,,,209,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,404.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,404.28,416.78
Infection Agent Detect Dna/Rna Probe Tq 12-25,PX87507,CDM,300,RC,87507,CPT,,,,,,,,209,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,404.28,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,404.28,416.78
Nfct Ds Bct/Vir Respir Dna/Rna 22 Trgt Sarscov2,PX0202U,CDM,300,RC,0202U,HCPCS,,,,,,,,222,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,404.28,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,404.28,416.78
Exc Face Les Sc < 2 Cm,PX21011F,CDM,510,RC,21011,CPT,,,,,,,,943,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,404.547,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,391.7222,1416.38
"Sigmoidoscopy,Screen Prev",PX2001F,CDM,750,RC,45330,CPT,,,,,,,,843,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,404.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,350.1822,826.14
"Sigmoidoscopy,Screen Prev",PX2001F,CDM,750,RC,45330,CPT,,,,,,,,843,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,404.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,350.1822,826.14
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802001,NDC,1,ML,444.2,,Medica,Commercial,both,91.1,,7.8,percent of total billed charges,404.6662,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802010,NDC,1,ML,444.2,,Medica,Commercial,both,91.1,,7.8,percent of total billed charges,404.6662,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Suspension 10 mL Bottle,63700001,CDM,250,RC,,,,,,24208063562,NDC,10,ML,415.81,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,404.707873,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Closed Rx Trimalleolar Fx,PX27816P,CDM,983,RC,27816,CPT,,,,,,,,826,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,404.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,803.9458
Closed Rx Trimalleolar Fx,PX27816P,CDM,983,RC,27816,CPT,,,,,,,,826,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,404.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,803.9458
Closed Rx Trimalleolar Fx,PX27816P,CDM,983,RC,27816,CPT,,,,,,,,826,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,404.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,803.9458
Resp Virus 3-5 Targets,PX87631,CDM,300,RC,87631,CPT,,,,,,,,459,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,404.838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.78,449.82
US Head/Neck Tc,PX7653601,CDM,402,RC,76536,CPT,TC,,,,,,,416,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,208,percent of total billed charges,404.8928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,407.68
"Ileoscopy Thru Stoma,Diagnostic",PX44380P,CDM,983,RC,44380,CPT,,,,,,,,455,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,404.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.007,791.92
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607F,CDM,761,RC,97607,CPT,,,,,,,,455,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,404.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.007,445.9
Layr Clos Wnd Rest Body 2.6-7.5,PX12042F,CDM,510,RC,12042,CPT,,,,,,,,404,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,405.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,123.03,645.45
Layr Clos Wnd Rest Body 2.6-7.5,PX12042P,CDM,983,RC,12042,CPT,,,,,,,,777,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,405.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,123.03,761.46
Repr Superf Wnd Face 5.1-7.5,PX12014P,CDM,983,RC,12014,CPT,,,,,,,,819,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,405.405,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,797.1327
fidaxomicin 200 MG Tablet 20 Each Bottle,25000000,CDM,250,RC,,,,,,52015008001,NDC,1,EA,945.16,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,405.47364,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BUPivacaine liposome 1.3 % Suspension 20 mL Vial,C9290.01,CDM,636,RC,C9290,HCPCS,,,,65250026604,NDC,10,ML,976.43,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,405.609022,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,405.609022,956.9014
ciprofloxacin-dexAMETHasone 0.3-0.1 % Suspension 7.5 mL Bottle,25000000,CDM,250,RC,,,,,,43598032675,NDC,7.5,ML,976.53,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,405.650562,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070110,NDC,1,ML,459.95,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,405.6759,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.92,450.751
X-Ray Exam Entire Spine 1vw,PX7208101,CDM,320,RC,72081,CPT,TC,,,,,,,414,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,405.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,405.72
"DXA, Bone Density Study, Radius/Wrist/Heel",PX7708101,CDM,320,RC,77081,CPT,TC,,,,,,,460,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,405.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,450.8
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623P,CDM,983,RC,11623,CPT,,,,,,,,460,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,405.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,191.084,1416.38
"Transvaginal US, Obstetric",PX7681701,CDM,402,RC,76817,CPT,TC,,,,,,,460,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,405.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,450.8
"Ctrl Nosebleed,Anter,Complex",PX30903F,CDM,510,RC,30903,CPT,,,,,,,,456,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,405.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,446.88
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611F,CDM,510,RC,20611,CPT,,,,,,,,456,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,405.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.4224,446.88
"Office/Outpt Visit,New,Levl V",PX99205F,CDM,510,RC,99205,CPT,,,,,,,,456,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,405.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.4224,446.88
"Office/Outpt Visit,New,Levl V",PX99205P,CDM,983,RC,99205,CPT,,,,,,,,456,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,405.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.4224,443.8248
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321801,NDC,50,ML,456,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,405.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
Xray Nasal Bones Minimum 3 Vws,PX7016001,CDM,320,RC,70160,CPT,TC,,,,,,,456,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,405.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,446.88
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505P,CDM,983,RC,25505,CPT,,,,,,,,977,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,405.8458,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,405.8458,1404.08
Xray Ribs Bilat 3 Vws With Pa Chest,PX7111101,CDM,320,RC,71111,CPT,TC,,,,,,,417,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,405.8661,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,408.66
Exc Neck Les Sc = 3cm >,PX21552F,CDM,510,RC,21552,CPT,,,,,,,,753,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,405.8704,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,273.56,938.08
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021080166,NDC,5,ML,820.8,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,406.296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092401,NDC,0.5,ML,820.88,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,406.3356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092491,NDC,0.5,ML,820.88,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,406.3356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092410,NDC,0.5,ML,820.89,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,406.34055,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
indocyanine green 25 MG Recon Soln 1 Each Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,70100042402,NDC,1,EA,446.07,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,406.36977,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.29,1354.4776
TAPER POST TOE JOINT HEMICAP 9.5MM ARTICULATING METATARSAL STERILE,C1713,CDM,278,RC,C1713,HCPCS,,12531-MAIN,LOCAL,,,,,821,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,406.395,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,60505619301,NDC,5,ML,821.36,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,406.5732,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.08296,1009.1158
"Initial Observation Care,Levl III",PX99220,CDM,982,RC,99220,CPT,,,,,,,,461,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,406.602,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,191.4994,448.6913
Repr Superf Wnd Face <2.5cm,PX12011P,CDM,983,RC,12011,CPT,,,,,,,,461,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,406.602,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,448.6913
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121F,CDM,510,RC,13121,CPT,,,,,,,,948,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,406.692,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,393.7992,929.04
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565P,CDM,983,RC,25565,CPT,,,,,,,,830,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,406.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,344.782,1404.08
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565P,CDM,983,RC,25565,CPT,,,,,,,,830,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,406.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,344.782,1404.08
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565P,CDM,983,RC,25565,CPT,,,,,,,,830,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,406.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,344.782,1404.08
"US Complete Joint, Realtime W/ Img Tc",PX7688101,CDM,402,RC,76881,CPT,TC,,,,,,,415,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,406.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,406.7
"Infectious Disease (Viral Respiratory Tract Infection),",PX0241U,CDM,300,RC,0241U,HCPCS,,,,,,,,457,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,406.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.78,447.86
US Scrotum & Contents Tc,PX7687001,CDM,402,RC,76870,CPT,TC,,,,,,,457,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,406.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,447.86
"Closed Rx Bimalleolar Fx,Manip",PX27810F,CDM,510,RC,27810,CPT,,,,,,,,1026,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,406.8337,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,272.25,1021.1
"Closed Rx Bimalleolar Fx,Manip",PX27810P,CDM,983,RC,27810,CPT,,,,,,,,1057,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,406.8337,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,272.25,1035.86
Removal of Skin Tags,PX11200P,CDM,983,RC,11200,CPT,,,,,,,,418,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,406.8394,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,173.6372,406.8394
Exc Abdom Tum Subfac > 5 Cm,PX22901F,CDM,761,RC,22901,CPT,,,,,,,,1408,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,406.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,403.8,1393.98
Exc Abdom Tum Subfac > 5 Cm,PX22901F,CDM,761,RC,22901,CPT,,,,,,,,1408,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,406.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,403.8,1393.98
Exc Abdom Tum Subfac > 5 Cm,PX22901P,CDM,983,RC,22901,CPT,,,,,,,,938,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,406.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,403.8,1393.98
Exc Abdom Tum Subfac > 5 Cm,PX22901P,CDM,983,RC,22901,CPT,,,,,,,,938,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,406.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,403.8,1393.98
Exc Skn Bngn1.1-2cm Remain Bdy,PX11422P,CDM,983,RC,11422,CPT,,,,,,,,822,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,406.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,341.4588,1416.38
CATHETER PUREWICK FEMALE EXTERNAL PWF030K,120.414,CDM,272,RC,A6590,HCPCS,,11836-MAIN,LOCAL,,,,,42,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,406.95,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.87,406.9505
CATHETER PUREWICK FEMALE EXTERNAL PWF030K,120.414,CDM,272,RC,A6590,HCPCS,,11836-MAIN,LOCAL,,,,,42,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,406.9505,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.87,406.9505
"Removal Anal Fistula,Subcutaneous",PX46270P,CDM,983,RC,46270,CPT,,,,,,,,980,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,407.092,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,407.092,2452.93
tiotropium bromide monohydrate 2.5 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597010051,NDC,4,GR,461.7,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,407.2194,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tiotropium bromide-olodaterol 2.5-2.5 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597015570,NDC,4,GR,461.7,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,407.2194,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Suspension 10 mL Bottle,63700001,CDM,250,RC,,,,,,24208063562,NDC,10,ML,415.81,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,407.4938,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200001,NDC,0.5,ML,980.99,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,407.503246,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,264.67,961.3702
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200002,NDC,0.5,ML,980.99,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,407.503246,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,264.67,961.3702
Exc Skin Benig >4cm Remaindr Body,PX11426P,CDM,983,RC,11426,CPT,,,,,,,,981,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,407.5074,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,407.5074,2482.37
"HERNIA MESH 3D MAX MID ANATOMICAL MESH RIGHT SIZE XL 5"" X 7""",C1781,CDM,278,RC,C1781,HCPCS,,11979-MAIN,LOCAL,,,,,832,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,196.035,percent of total billed charges,407.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"HERNIA MESH 3D MAX MID ANATOMICAL MESH RIGHT SIZE XL 5"" X 7""",C1781,CDM,278,RC,C1781,HCPCS,,11979-MAIN,LOCAL,,,,,832,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,407.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"HERNIA MESH 3D MAX MID ANATOMICAL MESH RIGHT SIZE XL 5"" X 7""",C1781,CDM,278,RC,C1781,HCPCS,,11979-MAIN,LOCAL,,,,,832,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,407.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"HERNIA MESH 3DMAX MID MESH EXTRA-LARGE LEFT 5"" X 7""",C1781,CDM,278,RC,C1781,HCPCS,,11978-MAIN,LOCAL,,,,,832,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,196.035,percent of total billed charges,407.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"HERNIA MESH 3DMAX MID MESH EXTRA-LARGE LEFT 5"" X 7""",C1781,CDM,278,RC,C1781,HCPCS,,11978-MAIN,LOCAL,,,,,832,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,407.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"HERNIA MESH 3DMAX MID MESH EXTRA-LARGE LEFT 5"" X 7""",C1781,CDM,278,RC,C1781,HCPCS,,11978-MAIN,LOCAL,,,,,832,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,407.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
US Head/Neck Tc,PX7653601,CDM,402,RC,76536,CPT,TC,,,,,,,416,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,407.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,407.68
TRAY PNEUMOTHORAX 14FR 29CM 19 CATHETER SIDEPORTS G56537,120.496,CDM,272,RC,,,,11677-MAIN,LOCAL,,,,,419,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,407.8127,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.0526,410.62
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081543,NDC,1,ML,479.89,,First Health,Commercial,both,85,,999999999,percent of total billed charges,407.9065,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.346306,470.2922
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081552,NDC,1,ML,479.89,,First Health,Commercial,both,85,,999999999,percent of total billed charges,407.9065,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.346306,470.2922
Egd Balloon Dil Esoph30 Mm/>,PX43233P,CDM,983,RC,43233,CPT,,,,,,,,480,,First Health,Commercial,both,85,,999999999,percent of total billed charges,408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.392,1662.33
"Sigmoidoscopy,Diagnostic",PX45330P,CDM,983,RC,45330,CPT,,,,,,,,480,,First Health,Commercial,both,85,,999999999,percent of total billed charges,408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.392,798.45
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494301,NDC,0.5,ML,419.2,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,408.00736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.38,410.8454
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494300,NDC,0.5,ML,419.23,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,408.036559,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.38,410.8454
hydrocortisone (perianal) 2.5 % Cream 28.35 g Tube,63700001,CDM,250,RC,,,,,,10631040701,NDC,28.35,GR,447.94,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,408.07334,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Upper GI Endoscopy,Ctrl Bleed",PX43255F,CDM,750,RC,43255,CPT,,,,,,,,1723,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,408.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.59,1292.28
"Upper GI Endoscopy,Ctrl Bleed",PX43255P,CDM,983,RC,43255,CPT,,,,,,,,1148,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,408.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.59,1292.28
"Lap,Cholecystectomy",PX47562P,CDM,983,RC,47562,CPT,,,,,,,,983,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,408.3382,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,408.3382,5040.74
brinzolamide-brimonidine 1-0.2 % Suspension 8 mL Bottle,63700001,CDM,250,RC,,,,,,65414727,NDC,8,ML,850.88,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,408.4224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
brinzolamide-brimonidine 1-0.2 % Suspension 8 mL Bottle,63700001,CDM,250,RC,,,,,,65414727,NDC,8,ML,850.88,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,408.4224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Nfct Ds Bct/Vir Respir Dna/Rna 22 Trgt Sarscov2,PX0202U,CDM,300,RC,0202U,HCPCS,,,,,,,,222,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,408.44152,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,404.28,416.78
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041105,NDC,1,ML,419.67,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,408.464811,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.808876,411.2766
Cns Dna/Rna Amp Probe Multiple Subtypes 12-25,PX87483,CDM,300,RC,87483,CPT,,,,,,,,864,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,408.5057,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,404.28,416.78
"GI Pathogen Panel, Pcr - Ref",PX8750790,CDM,300,RC,87507,CPT,90,,,,,,,213,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,408.5057,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,404.28,416.78
Infection Agent Detect Dna/Rna Probe Tq 12-25,PX87507,CDM,300,RC,87507,CPT,,,,,,,,209,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,408.5057,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,404.28,416.78
Resp Virus 3-5 Targets,PX87631,CDM,300,RC,87631,CPT,,,,,,,,459,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,408.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.78,449.82
Xray Ribs Bilat 3 Vws With Pa Chest,PX7111101,CDM,320,RC,71111,CPT,TC,,,,,,,417,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,408.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,408.66
Anus Surgery Procedure Unlisted,PX46999P,CDM,983,RC,46999,CPT,,,,,,,,953,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,408.837,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,395.8762,927.5549
"Genital Surg Proc,Male Unlisted",PX55899P,CDM,983,RC,55899,CPT,,,,,,,,953,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,408.837,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,215.91,927.5549
I&D Perirectal Abscess,PX46040P,CDM,983,RC,46040,CPT,,,,,,,,953,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,408.837,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,395.8762,1030.93
"Colonoscope, Submucous Inj",PX45381F,CDM,750,RC,45381,CPT,,,,,,,,1179,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,408.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.59,917.33
"Colonoscope, Submucous Inj",PX45381P,CDM,983,RC,45381,CPT,,,,,,,,1215,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,408.85,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.59,1190.7
"Ileoscopy Thru Stoma,Diagnostic",PX44380F,CDM,750,RC,44380,CPT,,,,,,,,245,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,408.85,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.12,408.85
"Ileoscopy Thru Stoma,Diagnostic",PX44380P,CDM,983,RC,44380,CPT,,,,,,,,455,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,408.85,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.12,445.9
Closed Rx Trimalleolar Fx,PX27816P,CDM,983,RC,27816,CPT,,,,,,,,826,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,408.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,803.9458
"Fix Exten Tendon,Dorsum Fingr,Ea",PX26418F,CDM,510,RC,26418,CPT,,,,,,,,1750,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,409.03,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,409.03,1317.19
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060002,NDC,2,ML,953.57,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,409.08153,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.11,934.4986
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060010,NDC,2,ML,953.57,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,409.08153,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.11,934.4986
Duplex Up Extrem Art Bilat,PX9393001,CDM,921,RC,93930,CPT,TC,,,,,,,835,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,409.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,818.3
Duplex Up Extrem Art Bilat,PX9393001,CDM,921,RC,93930,CPT,TC,,,,,,,835,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,409.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,818.3
Duplex Up Extrem Art Bilat,PX9393001,CDM,921,RC,93930,CPT,TC,,,,,,,835,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,409.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,818.3
"Hospital Inpt or Obs Care, Admin/Disch Same Date Straightforward or Low Level Mdm >= 45 Minutes",PX99234,CDM,982,RC,99234,CPT,,,,,,,,464,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,409.248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.7456,451.6112
Naso/Orogastric Tube,PX43752F,CDM,510,RC,43752,CPT,,,,,,,,464,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,409.248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.7456,454.72
rho d immune globulin human 1500 units solution prefilled syringe 1 Each Syringe,J2790.01,CDM,636,RC,J2790,HCPCS,,,,562780500,NDC,1,EA,464.01,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,409.25682,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.749754,454.7298
"Remv Foreign Body,Knee/Thigh,Deep",PX27372P,CDM,983,RC,27372,CPT,,,,,,,,954,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,409.266,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,396.2916,2482.37
Abd Duplex Abd-Follow Up(T),PX9397601,CDM,921,RC,93976,CPT,TC,,,,,,,809,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,409.354,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,792.82
Venous Duplex Scan Uni,PX9397101,CDM,921,RC,93971,CPT,TC,,,,,,,809,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,409.354,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,792.82
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070110,NDC,1,ML,459.95,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,409.3555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.92,450.751
"DXA, Bone Density Study, Radius/Wrist/Heel",PX7708101,CDM,320,RC,77081,CPT,TC,,,,,,,460,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,409.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,450.8
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623P,CDM,983,RC,11623,CPT,,,,,,,,460,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,409.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,191.084,1416.38
"Transvaginal US, Obstetric",PX7681701,CDM,402,RC,76817,CPT,TC,,,,,,,460,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,409.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,450.8
PREP KIT STAPLE 18MM,27200000,CDM,278,RC,C1713,HCPCS,,11658-MAIN,LOCAL,,,,,420.75,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,409.515975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PREP KIT STAPLE 20MM,27200000,CDM,278,RC,C1713,HCPCS,,11659-MAIN,LOCAL,,,,,420.75,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,409.515975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Colonoscopy,Biopsy",PX45380F,CDM,750,RC,45380,CPT,,,,,,,,2465,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,409.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.59,898.65
"Colonoscopy,Biopsy",PX45380P,CDM,983,RC,45380,CPT,,,,,,,,2539,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,409.55,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.59,2488.22
Removal of Skin Tags,PX11200P,CDM,983,RC,11200,CPT,,,,,,,,418,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,409.64,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.65,409.64
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956401,NDC,1,EA,1611.2,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,409.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,409.66,1655.3866
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956410,NDC,1,EA,1689.17,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,409.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,409.66,1655.3866
"Fix Exten Tendon,Dorsum Fingr,Ea",PX26418F,CDM,510,RC,26418,CPT,,,,,,,,1750,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,409.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,409.03,1317.19
"Fix Exten Tendon,Dorsum Fingr,Ea",PX26418F,CDM,510,RC,26418,CPT,,,,,,,,1750,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,409.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,409.03,1317.19
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,25021019110,NDC,1,EA,809.89,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,409.80434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.47563,793.6922
Noninvasv Lo Extrem Art Stress/Rest,PX9392401,CDM,921,RC,93924,CPT,TC,,,,,,,810,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,409.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.46,793.8
"Spinal Punc,Drain,Theraputic",PX62272F,CDM,510,RC,62272,CPT,,,,,,,,450,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,409.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.93,604.15
Incise External Hemorrhoid,PX46083P,CDM,983,RC,46083,CPT,,,,,,,,956,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,410.124,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,215.91,930.4748
Drainage of Hematoma/Fluid (P),PX10140P,CDM,983,RC,10140,CPT,,,,,,,,465,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,410.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,193.161,1416.38
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102P,CDM,983,RC,11102,CPT,,,,,,,,465,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,410.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,452.5845
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016401,NDC,1,ML,854.49,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,410.1552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.66,898.7384
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016401,NDC,1,ML,854.49,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,410.1552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.66,898.7384
"Initial Observation Care,Levl III",PX99220,CDM,982,RC,99220,CPT,,,,,,,,461,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,410.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,191.4994,448.6913
Repr Superf Wnd Face <2.5cm,PX12011P,CDM,983,RC,12011,CPT,,,,,,,,461,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,410.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,448.6913
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004F,CDM,510,RC,15004,CPT,,,,,,,,855,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,410.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,355.167,837.9
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004F,CDM,510,RC,15004,CPT,,,,,,,,855,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,410.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,355.167,837.9
travoprost (BAK Free) 0.004 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,65026025,NDC,2.5,ML,811.3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,410.5178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
TRAY PNEUMOTHORAX 14FR 29CM 19 CATHETER SIDEPORTS G56537,120.496,CDM,272,RC,,,,11677-MAIN,LOCAL,,,,,419,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,410.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.0526,410.62
Closure Superf Wnd Dehis Simple,PX12020P,CDM,983,RC,12020,CPT,,,,,,,,422,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,410.7326,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,175.2988,548.67
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494301,NDC,0.5,ML,419.2,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,410.816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.38,410.8454
Tube Thoracostomy Inc Wtr Seal,PX32551F,CDM,510,RC,32551,CPT,,,,,,,,989,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,410.8306,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,410.8306,1399.13
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494300,NDC,0.5,ML,419.23,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,410.8454,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.38,410.8454
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565P,CDM,983,RC,25565,CPT,,,,,,,,830,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,410.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,344.782,1404.08
tiotropium bromide monohydrate 2.5 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597010051,NDC,4,GR,461.7,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,410.913,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tiotropium bromide-olodaterol 2.5-2.5 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597015570,NDC,4,GR,461.7,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,410.913,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Dress/Debrid Large Burn No Anesth,PX16030F,CDM,510,RC,16030,CPT,,,,,,,,399,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,410.93,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.84,410.93
clobetasol 0.05 % Cream 60 g Tube,63700001,CDM,250,RC,,,,,,168030160,NDC,60,GR,989.25,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,410.93445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Exc Skn Malig1.1-2cm Fce,Facal",PX11642P,CDM,983,RC,11642,CPT,,,,,,,,466,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,411.012,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,193.5764,614.65
Blood Transfusion Service,PX36430,CDM,391,RC,36430,CPT,,,,,,,,839,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,165.3,percent of total billed charges,411.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.5206,822.22
Blood Transfusion Service,PX36430,CDM,391,RC,36430,CPT,,,,,,,,839,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,411.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.5206,822.22
Blood Transfusion Service,PX36430,CDM,391,RC,36430,CPT,,,,,,,,839,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,411.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.5206,822.22
Drainage of Gum Lesion,PX41800P,CDM,983,RC,41800,CPT,,,,,,,,839,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,411.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,816.5987
Drainage of Gum Lesion,PX41800P,CDM,983,RC,41800,CPT,,,,,,,,839,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,411.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,816.5987
Drainage of Gum Lesion,PX41800P,CDM,983,RC,41800,CPT,,,,,,,,839,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,411.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,816.5987
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041105,NDC,1,ML,419.67,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,411.2766,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.808876,411.2766
"Closed Rx Big Toe Fx,Manip",PX28495F,CDM,510,RC,28495,CPT,,,,,,,,857,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,411.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,839.86
"Closed Rx Big Toe Fx,Manip",PX28495F,CDM,510,RC,28495,CPT,,,,,,,,857,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,411.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,839.86
"Closed Rx Trimalleolar Fx,Manip",PX27818F,CDM,510,RC,27818,CPT,,,,,,,,813,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,411.378,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,337.7202,1404.08
"Fac/Exc Skn Bngn 2.1-3cmfce,Facial",PX11443F,CDM,510,RC,11443,CPT,,,,,,,,813,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,411.378,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,337.7202,1416.38
"Fac/Ex Skinbngn0.6-1cmtrnk,Arm,Lg",PX11401F,CDM,510,RC,11401,CPT,,,,,,,,484,,First Health,Commercial,both,85,,999999999,percent of total billed charges,411.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.0536,474.32
"Fac/Exc Skn Benig<5mm Face,Facial",PX11440F,CDM,510,RC,11440,CPT,,,,,,,,484,,First Health,Commercial,both,85,,999999999,percent of total billed charges,411.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.0536,614.65
"Facility Critical Care, Addl 30 Min",PX99292F,CDM,510,RC,99292,CPT,,,,,,,,484,,First Health,Commercial,both,85,,999999999,percent of total billed charges,411.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.0536,474.32
STAPLER SUREFORM 60 SPU IS4000,27200000,CDM,272,RC,,,,12086-MAIN,LOCAL,,,,,991,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,411.6614,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRILL BIT AO DIA 2.0MMX135MM SCALED,27200000,CDM,272,RC,,,,12640-MAIN,LOCAL,,,,,452,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,411.772,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"HERNIA MESH 3D MAX MID ANATOMICAL MESH RIGHT SIZE XL 5"" X 7""",C1781,CDM,278,RC,C1781,HCPCS,,11979-MAIN,LOCAL,,,,,832,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,411.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"HERNIA MESH 3DMAX MID MESH EXTRA-LARGE LEFT 5"" X 7""",C1781,CDM,278,RC,C1781,HCPCS,,11978-MAIN,LOCAL,,,,,832,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,411.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527197174,NDC,4,ML,960.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,412.0545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
Exc Skn Beni 0.6-1cm Fcefacial,PX11441P,CDM,983,RC,11441,CPT,,,,,,,,485,,First Health,Commercial,both,85,,999999999,percent of total billed charges,412.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.469,614.65
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545F,CDM,510,RC,23545,CPT,,,,,,,,961,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,412.269,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,941.78
"Initial Repair of Entrapped Hernia of Abdomen, Less Than 3 Cm in Length",PX49592,CDM,982,RC,49592,CPT,,,,,,,,2164,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,412.2924,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,280.1,2120.72
Revise Median N/Carpal Tunnel Surg,PX64721F,CDM,510,RC,64721,CPT,,,,,,,,2408,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,412.2924,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,276.61,940.85
Revise Median N/Carpal Tunnel Surg,PX64721P,CDM,983,RC,64721,CPT,,,,,,,,1927,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,412.2924,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,276.61,1888.46
MINIBUNION DRILL KIT,27200000,CDM,278,RC,C1713,HCPCS,,11669-MAIN,LOCAL,,,,,841.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,412.335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MINIBUNION DRILL KIT,27200000,CDM,278,RC,C1713,HCPCS,,11669-MAIN,LOCAL,,,,,841.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,412.335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MINIBUNION DRILL KIT,27200000,CDM,278,RC,C1713,HCPCS,,11669-MAIN,LOCAL,,,,,841.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,412.335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PREP KIT STAPLE 18MM,27200000,CDM,278,RC,C1713,HCPCS,,11658-MAIN,LOCAL,,,,,420.75,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,412.335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PREP KIT STAPLE 20MM,27200000,CDM,278,RC,C1713,HCPCS,,11659-MAIN,LOCAL,,,,,420.75,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,412.335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"I&D Perianal Abscess,Superficial",PX46050P,CDM,983,RC,46050,CPT,,,,,,,,993,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,412.4922,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,412.4922,966.4869
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402F,CDM,510,RC,11402,CPT,,,,,,,,424,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,412.6792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.1296,614.65
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402P,CDM,983,RC,11402,CPT,,,,,,,,424,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,412.6792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.1296,614.65
Lab H Pylori Stool Ag,PX87338,CDM,300,RC,87338,CPT,,,,,,,,424,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,412.6792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,415.52
"Exc Skn Mal 0.6-1cm Fce,Facial",PX11641P,CDM,983,RC,11641,CPT,,,,,,,,453,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,412.683,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.1762,614.65
Repr Superf Wnd Body 7.6-12.5,PX12004F,CDM,510,RC,12004,CPT,,,,,,,,453,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,412.683,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,443.94
Repr Superf Wnd Face 5.1-7.5,PX12014F,CDM,510,RC,12014,CPT,,,,,,,,453,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,412.683,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,443.94
Closed Rx Kneecap Dislocatn,PX27560F,CDM,510,RC,27560,CPT,,,,,,,,468,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,412.776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,194.4072,458.64
"POS Airway Pressure, Bipap",PX94660.01F,CDM,410,RC,94660,CPT,,,,,,,,468,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,412.776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.33,458.64
Vedolizumab - Ref,PX8028090,CDM,300,RC,80280,CPT,90,,,,,,,468,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,412.776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.36,458.64
GRAFIXPL PRIME PLACENTAL MEMBRANE 16MM DISC 2SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12763-MAIN,LOCAL,,,,,860,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,412.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
GRAFIXPL PRIME PLACENTAL MEMBRANE 16MM DISC 2SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12763-MAIN,LOCAL,,,,,860,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,412.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
"Hospital Inpt or Obs Care, Admin/Disch Same Date Straightforward or Low Level Mdm >= 45 Minutes",PX99234,CDM,982,RC,99234,CPT,,,,,,,,464,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,412.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.7456,451.6112
Naso/Orogastric Tube,PX43752F,CDM,510,RC,43752,CPT,,,,,,,,464,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,412.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.7456,454.72
rho d immune globulin human 1500 units solution prefilled syringe 1 Each Syringe,J2790.01,CDM,636,RC,J2790,HCPCS,,,,562780500,NDC,1,EA,464.01,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,412.9689,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.749754,454.7298
"Layr Clos Wnd Face,Facial 2.5-5",PX12052F,CDM,510,RC,12052,CPT,,,,,,,,585,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,413,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.22,656.52
"Layr Clos Wnd Face,Facial 2.5-5",PX12052P,CDM,983,RC,12052,CPT,,,,,,,,776,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,413,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.22,760.48
"Casiri and Imdevimab,Admin,Repeat Dose",PXM0240,CDM,771,RC,M0240,HCPCS,,,,,,,,1555,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,413.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,413.06,1523.9
"IV Infusion, Bamlanivimab and Etesevimab, Infusion and Monitoring",PXM0245,CDM,260,RC,M0245,HCPCS,,,,,,,,1555,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,413.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,413.06,1523.9
"IV Infusion, Casirivimab and Imdevimab, IV and Post Admr",PXM0243,CDM,771,RC,M0243,HCPCS,,,,,,,,1555,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,413.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,413.06,1684.87
"Sigmoidoscopy,Screen Prev",PX2001F,CDM,750,RC,45330,CPT,,,,,,,,843,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,413.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,350.1822,826.14
"Sigmoidoscopy,Screen Prev",PX2001F,CDM,750,RC,45330,CPT,,,,,,,,843,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,413.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,350.1822,826.14
"Sigmoidoscopy,Screen Prev",PX2001F,CDM,750,RC,45330,CPT,,,,,,,,843,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,413.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,350.1822,826.14
ARTISTA AH 3GRAM ABSORBABLE HEMOSTATIC PARTICLES,27200000,CDM,272,RC,A6199,HCPCS,,10227-MAIN,LOCAL,,,,,486,,First Health,Commercial,both,85,,999999999,percent of total billed charges,413.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002P,CDM,983,RC,12002,CPT,,,,,,,,486,,First Health,Commercial,both,85,,999999999,percent of total billed charges,413.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,473.0238
Xray Sinuses Less Than 3 Vws,PX7021001,CDM,320,RC,70210,CPT,TC,,,,,,,486,,First Health,Commercial,both,85,,999999999,percent of total billed charges,413.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,476.28
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,23155052431,NDC,10,ML,486.06,,First Health,Commercial,both,85,,999999999,percent of total billed charges,413.151,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,23155052441,NDC,10,ML,486.06,,First Health,Commercial,both,85,,999999999,percent of total billed charges,413.151,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Debride Skin/Tissue,PX11042P,CDM,983,RC,11042,CPT,,,,,,,,995,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,413.323,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,968.4335
Duplex Up Extrem Art Bilat,PX9393001,CDM,921,RC,93930,CPT,TC,,,,,,,835,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,413.325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,818.3
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604F,CDM,510,RC,11604,CPT,,,,,,,,964,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,413.556,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,400.4456,944.72
Closure Superf Wnd Dehis Simple,PX12020P,CDM,983,RC,12020,CPT,,,,,,,,422,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,413.56,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,117.15,624.7
X-Ray Exam Entire Spine 2-3 Vws,PX7208201,CDM,320,RC,72082,CPT,TC,,,,,,,454,,Medica,Commercial,both,91.1,,330.87,percent of total billed charges,413.594,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,444.92
"Injection Hip Arthrogram,Anesth",PX27095F,CDM,510,RC,27095,CPT,,,,,,,,425,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,413.6525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.545,416.5
"Injection Hip Arthrogram,Anesth",PX27095P,CDM,983,RC,27095,CPT,,,,,,,,425,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,413.6525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.545,413.6525
US Abdomen Limited Tc,PX7670501,CDM,402,RC,76705,CPT,TC,,,,,,,425,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,253.0054545,percent of total billed charges,413.6525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,416.5
US Ext Non-Vasc Img Lmtd,PX7688201,CDM,402,RC,76882,CPT,TC,,,,,,,425,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,413.6525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,416.5
"Exc Skn Bngn2.1-3cmtrnk,Arm,Lg",PX11403P,CDM,983,RC,11403,CPT,,,,,,,,543,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,413.7,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.02,532.14
"Fac/Ex Skn Bngn2.1-3cm Trnk,Arm,Lg",PX11403F,CDM,510,RC,11403,CPT,,,,,,,,679,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,413.7,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.02,413.7
HERNIA PATCH VENTRALEX SMALL,C1781,CDM,278,RC,C1781,HCPCS,,10203-MAIN,LOCAL,,,,,995.96,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,413.721784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Skin Sub Graft Trnk/Arm/Leg,PX15271F,CDM,510,RC,15271,CPT,,,,,,,,862,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,413.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,358.0748,1593.14
Skin Sub Graft Trnk/Arm/Leg,PX15271F,CDM,510,RC,15271,CPT,,,,,,,,862,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,413.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,358.0748,1593.14
Drainage of Hematoma/Fluid (P),PX10140P,CDM,983,RC,10140,CPT,,,,,,,,465,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,413.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,193.161,1416.38
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102P,CDM,983,RC,11102,CPT,,,,,,,,465,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,413.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,452.5845
Temporal Artery Ligatn or Bx,PX37609P,CDM,983,RC,37609,CPT,,,,,,,,965,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,413.985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,400.861,1416.38
Factor VIII (Ahg) 1-Stage,PX85240,CDM,300,RC,85240,CPT,,,,,,,,997,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,414.1538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.41,977.06
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,61314054701,NDC,2.5,ML,487.35,,First Health,Commercial,both,85,,999999999,percent of total billed charges,414.2475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Repr Superf Wnd Face 5.1-7.5,PX12014P,CDM,983,RC,12014,CPT,,,,,,,,819,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,414.414,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,797.1327
"Ileoscopy Thru Stoma,Diagnostic",PX44380P,CDM,983,RC,44380,CPT,,,,,,,,455,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,414.505,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.007,791.92
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607F,CDM,761,RC,97607,CPT,,,,,,,,455,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,414.505,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.007,445.9
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,548590000,NDC,1,EA,470.19,,United Healthcare,All Payer,outpatient,88.2,,211.17,percent of total billed charges,414.70758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,179.012476,460.7862
Cns Dna/Rna Amp Probe Multiple Subtypes 12-25,PX87483,CDM,300,RC,87483,CPT,,,,,,,,864,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,414.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,358.9056,846.72
Cns Dna/Rna Amp Probe Multiple Subtypes 12-25,PX87483,CDM,300,RC,87483,CPT,,,,,,,,864,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,414.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,358.9056,846.72
"Exc Skn Malig1.1-2cm Fce,Facal",PX11642P,CDM,983,RC,11642,CPT,,,,,,,,466,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,414.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,193.5764,614.65
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,16714081501,NDC,5,ML,998.95,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,414.96383,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Suspension 10 mL Bottle,63700001,CDM,250,RC,,,,,,64980044801,NDC,10,ML,488.25,,First Health,Commercial,both,85,,999999999,percent of total billed charges,415.0125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Blood Transfusion Service,PX36430,CDM,391,RC,36430,CPT,,,,,,,,839,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,415.305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.5206,822.22
Drainage of Gum Lesion,PX41800P,CDM,983,RC,41800,CPT,,,,,,,,839,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,415.305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,816.5987
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021080166,NDC,5,ML,820.8,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,415.3248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092401,NDC,0.5,ML,820.88,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,415.36528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092491,NDC,0.5,ML,820.88,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,415.36528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092410,NDC,0.5,ML,820.89,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,415.37034,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
"Ctrl Nosebleed,Anter,Complex",PX30903F,CDM,510,RC,30903,CPT,,,,,,,,456,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,415.416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,446.88
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611F,CDM,510,RC,20611,CPT,,,,,,,,456,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,415.416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.4224,446.88
"Office/Outpt Visit,New,Levl V",PX99205F,CDM,510,RC,99205,CPT,,,,,,,,456,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,415.416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.4224,446.88
"Office/Outpt Visit,New,Levl V",PX99205P,CDM,983,RC,99205,CPT,,,,,,,,456,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,415.416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.4224,443.8248
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321801,NDC,50,ML,456,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,415.416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
Xray Nasal Bones Minimum 3 Vws,PX7016001,CDM,320,RC,70160,CPT,TC,,,,,,,456,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,415.416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,446.88
TAPER POST TOE JOINT HEMICAP 9.5MM ARTICULATING METATARSAL STERILE,C1713,CDM,278,RC,C1713,HCPCS,,12531-MAIN,LOCAL,,,,,821,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,415.426,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402F,CDM,510,RC,11402,CPT,,,,,,,,424,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,415.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.1296,614.65
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402P,CDM,983,RC,11402,CPT,,,,,,,,424,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,415.52,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.08,415.52
Lab H Pylori Stool Ag,PX87338,CDM,300,RC,87338,CPT,,,,,,,,424,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,415.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.19,415.52
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,60505619301,NDC,5,ML,821.36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,415.60816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.08296,1009.1158
"Repair Umbilical Hern,5+Y/O,Reduc",PX49585F,CDM,510,RC,49585,CPT,,,,,,,,969,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,415.701,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,402.5226,949.62
Exc Skn Bngn1.1-2cm Remain Bdy,PX11422P,CDM,983,RC,11422,CPT,,,,,,,,822,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,415.932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,341.4588,1416.38
calcitonin (salmon) 200 UNIT/ACT Solution 3.7 mL Bottle,63700001,CDM,250,RC,,,,,,60505082306,NDC,3.7,ML,489.57,,First Health,Commercial,both,85,,999999999,percent of total billed charges,416.1345,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"OB US < 14 Wks, Single Fetus - Radiology, Tech",PX7680101,CDM,402,RC,76801,CPT,TC,,,,,,,472,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,416.304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,462.56
US Pelvic Tc Complete,PX7685601,CDM,402,RC,76856,CPT,TC,,,,,,,472,,United Healthcare,All Payer,outpatient,88.2,,183.2,percent of total billed charges,416.304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,462.56
US Transvaginal Tc,PX7683001,CDM,402,RC,76830,CPT,TC,,,,,,,472,,United Healthcare,All Payer,outpatient,88.2,,153.575,percent of total billed charges,416.304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,462.56
"Infectious Disease (Viral Respiratory Tract Infection),",PX0241U,CDM,300,RC,0241U,HCPCS,,,,,,,,457,,Medica,Commercial,both,91.1,,30.2552381,percent of total billed charges,416.327,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.78,447.86
US Scrotum & Contents Tc,PX7687001,CDM,402,RC,76870,CPT,TC,,,,,,,457,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,416.327,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,447.86
"Injection Hip Arthrogram,Anesth",PX27095F,CDM,510,RC,27095,CPT,,,,,,,,425,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,416.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.545,416.5
"Injection Hip Arthrogram,Anesth",PX27095P,CDM,983,RC,27095,CPT,,,,,,,,425,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,416.5,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.95,633.69
US Abdomen Limited Tc,PX7670501,CDM,402,RC,76705,CPT,TC,,,,,,,425,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,416.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,416.5
US Ext Non-Vasc Img Lmtd,PX7688201,CDM,402,RC,76882,CPT,TC,,,,,,,425,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,416.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,416.5
Xray Knee 4 or More Vws,PX7356401,CDM,320,RC,73564,CPT,TC,,,,,,,490,,First Health,Commercial,both,85,,999999999,percent of total billed charges,416.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,480.2
Closed Rx Kneecap Dislocatn,PX27560F,CDM,510,RC,27560,CPT,,,,,,,,468,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,416.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,194.4072,458.64
"POS Airway Pressure, Bipap",PX94660.01F,CDM,410,RC,94660,CPT,,,,,,,,468,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,416.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.33,458.64
Vedolizumab - Ref,PX8028090,CDM,300,RC,80280,CPT,90,,,,,,,468,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,416.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.36,458.64
MINIBUNION DRILL KIT,27200000,CDM,278,RC,C1713,HCPCS,,11669-MAIN,LOCAL,,,,,841.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,416.5425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Resp Virus 6-11 Targets,PX87632,CDM,300,RC,87632,CPT,,,,,,,,428,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,416.5724,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,177.7912,419.44
Xray Thoracic Spine 2 Vws,PX7207001,CDM,320,RC,72070,CPT,TC,,,,,,,428,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,333.2875,percent of total billed charges,416.5724,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,419.44
Cns Dna/Rna Amp Probe Multiple Subtypes 12-25,PX87483,CDM,300,RC,87483,CPT,,,,,,,,864,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,416.78,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,404.28,416.78
"GI Pathogen Panel, Pcr - Ref",PX8750790,CDM,300,RC,87507,CPT,90,,,,,,,213,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,416.78,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,404.28,416.78
Infection Agent Detect Dna/Rna Probe Tq 12-25,PX87507,CDM,300,RC,87507,CPT,,,,,,,,209,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,416.78,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,404.28,416.78
Nfct Ds Bct/Vir Respir Dna/Rna 22 Trgt Sarscov2,PX0202U,CDM,300,RC,0202U,HCPCS,,,,,,,,222,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,416.78,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,404.28,416.78
Nfct Ds Bct/Vir Respir Dna/Rna 22 Trgt Sarscov2,PX0202U,CDM,300,RC,0202U,HCPCS,,,,,,,,222,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,416.78,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,404.28,416.78
Nfct Ds Bct/Vir Respir Dna/Rna 22 Trgt Sarscov2,PX0202U,CDM,300,RC,0202U,HCPCS,,,,,,,,222,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,416.78,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,404.28,416.78
"Closed Rx Trimalleolar Fx,Manip",PX27818F,CDM,510,RC,27818,CPT,,,,,,,,813,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,416.7878,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,279.01,1059.15
"Closed Rx Trimalleolar Fx,Manip",PX27818P,CDM,983,RC,27818,CPT,,,,,,,,1352,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,416.7878,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,279.01,1324.96
brinzolamide-brimonidine 1-0.2 % Suspension 8 mL Bottle,63700001,CDM,250,RC,,,,,,65414727,NDC,8,ML,850.88,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,416.9312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
brinzolamide-brimonidine 1-0.2 % Suspension 8 mL Bottle,63700001,CDM,250,RC,,,,,,65414727,NDC,8,ML,850.88,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,416.9312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
brinzolamide-brimonidine 1-0.2 % Suspension 8 mL Bottle,63700001,CDM,250,RC,,,,,,65414727,NDC,8,ML,850.88,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,416.9312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Remove Nasal Foreign Body,PX30300F,CDM,510,RC,30300,CPT,,,,,,,,972,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,416.988,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,952.56
"Sigmoidoscopy,Screen Prev",PX2001F,CDM,750,RC,45330,CPT,,,,,,,,843,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,417.285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,350.1822,826.14
ipratropium 0.06 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,54004641,NDC,15,ML,491.02,,First Health,Commercial,both,85,,999999999,percent of total billed charges,417.367,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
I&D Bartholin Gland Abscess,PX56420F,CDM,510,RC,56420,CPT,,,,,,,,429,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,417.5457,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.08,420.42
Abd Paracentesis W/Imaging(T),PX49083F,CDM,510,RC,49083,CPT,,,,,,,,1006,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,417.8924,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,417.8924,985.88
Closed Rx Trimalleolar Fx,PX27816P,CDM,983,RC,27816,CPT,,,,,,,,826,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,417.956,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,803.9458
nystatin 100000 UNIT/GM Powder 60 g Bottle,63700001,CDM,250,RC,,,,,,574200802,NDC,60,GR,491.86,,First Health,Commercial,both,85,,999999999,percent of total billed charges,418.081,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Resp Virus 3-5 Targets,PX87631,CDM,300,RC,87631,CPT,,,,,,,,459,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,418.149,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.78,449.82
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762F,CDM,510,RC,43762,CPT,,,,,,,,492,,First Health,Commercial,both,85,,999999999,percent of total billed charges,418.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,204.3768,482.16
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279210,NDC,10,ML,429.84,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,418.363272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,178.555536,421.2432
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279410,NDC,10,ML,429.84,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,418.363272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,178.555536,421.2432
umeclidinium 62.5 MCG/ACT Aerosol Powder Breath Activated 7 Each Disp Pack,63700001,CDM,250,RC,,,,,,173087306,NDC,7,EA,492.23,,First Health,Commercial,both,85,,999999999,percent of total billed charges,418.3955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,548590000,NDC,1,EA,470.19,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,418.4691,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,179.012476,460.7862
RELOAD SUREFORM 60 2.5 WHITE 6 ROW BOX/12,27200000,CDM,272,RC,,,,12261-MAIN,LOCAL,,,,,430,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,418.519,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 60 3.5 BLUE,27200000,CDM,272,RC,,,,12084-MAIN,LOCAL,,,,,430,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,418.519,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 60 4.3 GREEN,27200000,CDM,272,RC,,,,12085-MAIN,LOCAL,,,,,430,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,418.519,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016401,NDC,1,ML,854.49,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,418.7001,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.66,898.7384
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016401,NDC,1,ML,854.49,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,418.7001,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.66,898.7384
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016401,NDC,1,ML,854.49,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,418.7001,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.66,898.7384
BUPivacaine liposome 1.3 % Suspension 20 mL Vial,C9290.01,CDM,636,RC,C9290,HCPCS,,,,65250026604,NDC,10,ML,976.43,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,418.88847,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,405.609022,956.9014
ciprofloxacin-dexAMETHasone 0.3-0.1 % Suspension 7.5 mL Bottle,25000000,CDM,250,RC,,,,,,43598032675,NDC,7.5,ML,976.53,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,418.93137,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004F,CDM,510,RC,15004,CPT,,,,,,,,855,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,418.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,355.167,837.9
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004F,CDM,510,RC,15004,CPT,,,,,,,,855,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,418.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,355.167,837.9
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004F,CDM,510,RC,15004,CPT,,,,,,,,855,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,418.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,355.167,837.9
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070110,NDC,1,ML,459.95,,Medica,Commercial,both,91.1,,0.343333333,percent of total billed charges,419.01445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.92,450.751
Injection for Nerve Block,PX64448F,CDM,510,RC,64448,CPT,,,,,,,,873,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,419.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,362.6442,855.54
Injection for Nerve Block,PX64448F,CDM,510,RC,64448,CPT,,,,,,,,873,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,419.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,362.6442,855.54
"DXA, Bone Density Study, Radius/Wrist/Heel",PX7708101,CDM,320,RC,77081,CPT,TC,,,,,,,460,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,419.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,450.8
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623P,CDM,983,RC,11623,CPT,,,,,,,,460,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,419.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,191.084,1416.38
"Transvaginal US, Obstetric",PX7681701,CDM,402,RC,76817,CPT,TC,,,,,,,460,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,419.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,450.8
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505P,CDM,983,RC,25505,CPT,,,,,,,,977,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,419.133,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,405.8458,1404.08
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,781344071,NDC,1,EA,430.94,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,419.433902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,179.012476,460.7862
Resp Virus 6-11 Targets,PX87632,CDM,300,RC,87632,CPT,,,,,,,,428,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,419.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,177.7912,419.44
Xray Thoracic Spine 2 Vws,PX7207001,CDM,320,RC,72070,CPT,TC,,,,,,,428,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,419.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,419.44
"Lap,Dx Surgical Abd W/Biopsy",PX49321F,CDM,510,RC,49321,CPT,,,,,,,,874,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,419.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.0596,5040.74
"Lap,Dx Surgical Abd W/Biopsy",PX49321F,CDM,510,RC,49321,CPT,,,,,,,,874,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,419.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.0596,5040.74
CRICOTHROTOMY QUICKTRACH 4MM,120.228,CDM,272,RC,A7520,HCPCS,,8868-MAIN,LOCAL,,,,,494,,First Health,Commercial,both,85,,999999999,percent of total billed charges,419.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.2076,484.12
SET CRICOTHYROTOMY CATHETER 6MM ID,120.378,CDM,272,RC,,,,11119-MAIN,LOCAL,,,,,494,,First Health,Commercial,both,85,,999999999,percent of total billed charges,419.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.2076,484.12
"Closed Rx Big Toe Fx,Manip",PX28495F,CDM,510,RC,28495,CPT,,,,,,,,857,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,419.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,839.86
"Closed Rx Big Toe Fx,Manip",PX28495F,CDM,510,RC,28495,CPT,,,,,,,,857,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,419.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,839.86
"Closed Rx Big Toe Fx,Manip",PX28495F,CDM,510,RC,28495,CPT,,,,,,,,857,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,419.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,839.86
"Initial Observation Care,Levl III",PX99220,CDM,982,RC,99220,CPT,,,,,,,,461,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,419.971,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,191.4994,448.6913
Repr Superf Wnd Face <2.5cm,PX12011P,CDM,983,RC,12011,CPT,,,,,,,,461,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,419.971,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,448.6913
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565P,CDM,983,RC,25565,CPT,,,,,,,,830,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,419.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,344.782,1404.08
"Fac/Exc Skn Mali2.1-3cmtrnk,Arm,Lg",PX11603F,CDM,510,RC,11603,CPT,,,,,,,,875,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,420,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.475,857.5
"Fac/Exc Skn Mali2.1-3cmtrnk,Arm,Lg",PX11603F,CDM,510,RC,11603,CPT,,,,,,,,875,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,420,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.475,857.5
"OB US < 14 Wks, Single Fetus - Radiology, Tech",PX7680101,CDM,402,RC,76801,CPT,TC,,,,,,,472,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,420.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,462.56
US Pelvic Tc Complete,PX7685601,CDM,402,RC,76856,CPT,TC,,,,,,,472,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,420.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,462.56
US Transvaginal Tc,PX7683001,CDM,402,RC,76830,CPT,TC,,,,,,,472,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,420.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,462.56
cocaine 4% 4 % Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527172874,NDC,4,ML,875.53,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,420.2544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
cocaine 4% 4 % Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527172874,NDC,4,ML,875.53,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,420.2544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
esmolol 2500 MG/250ML Solution 250 mL Flex Cont,J1805.01,CDM,636,RC,J1805,HCPCS,,,,10019067010,NDC,250,ML,1011.8,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,420.30172,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.24,991.564
ondansetron 4 MG/5ML Solution 25 mL Bottle,S0119.01,CDM,636,RC,S0119,HCPCS,,,,99998-8001-,NDC,25,ML,494.57,,First Health,Commercial,both,85,,999999999,percent of total billed charges,420.3845,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
I&D Bartholin Gland Abscess,PX56420F,CDM,510,RC,56420,CPT,,,,,,,,429,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,420.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.08,420.42
"Removal Anal Fistula,Subcutaneous",PX46270P,CDM,983,RC,46270,CPT,,,,,,,,980,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,420.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,407.092,2452.93
Xray Eye Foreign Body,PX7003001,CDM,320,RC,70030,CPT,TC,,,,,,,432,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,420.4656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,423.36
tiotropium bromide monohydrate 2.5 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597010051,NDC,4,GR,461.7,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,420.6087,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tiotropium bromide-olodaterol 2.5-2.5 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597015570,NDC,4,GR,461.7,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,420.6087,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800F,CDM,510,RC,40800,CPT,,,,,,,,255,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,420.61,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.35,420.61
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800P,CDM,983,RC,40800,CPT,,,,,,,,170,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,420.61,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,76.35,420.61
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725F,CDM,510,RC,26725,CPT,,,,,,,,495,,First Health,Commercial,both,85,,999999999,percent of total billed charges,420.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.623,485.1
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101F,CDM,510,RC,13101,CPT,,,,,,,,495,,First Health,Commercial,both,85,,999999999,percent of total billed charges,420.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.623,548.67
Tc99 Mebrofenin to 15 Mci,PXA9537,CDM,343,RC,A9537,HCPCS,,,,,,,,495,,First Health,Commercial,both,85,,999999999,percent of total billed charges,420.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.623,485.1
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200001,NDC,0.5,ML,980.99,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,420.84471,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,264.67,961.3702
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200002,NDC,0.5,ML,980.99,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,420.84471,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,264.67,961.3702
Exc Skin Benig >4cm Remaindr Body,PX11426P,CDM,983,RC,11426,CPT,,,,,,,,981,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,420.849,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,407.5074,2482.37
"HERNIA MESH 3D MAX MID ANATOMICAL MESH RIGHT SIZE XL 5"" X 7""",C1781,CDM,278,RC,C1781,HCPCS,,11979-MAIN,LOCAL,,,,,832,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,420.992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"HERNIA MESH 3DMAX MID MESH EXTRA-LARGE LEFT 5"" X 7""",C1781,CDM,278,RC,C1781,HCPCS,,11978-MAIN,LOCAL,,,,,832,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,420.992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
fluticasone propionate 50 MCG/ACT Suspension 16 g Bottle,63700001,CDM,250,RC,,,,,,50383070016,NDC,16,GR,432.56,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,421.010648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
brinzolamide-brimonidine 1-0.2 % Suspension 8 mL Bottle,63700001,CDM,250,RC,,,,,,65414727,NDC,8,ML,850.88,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,421.1856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279210,NDC,10,ML,429.84,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,421.2432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,178.555536,421.2432
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279410,NDC,10,ML,429.84,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,421.2432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,178.555536,421.2432
GRAFIXPL PRIME PLACENTAL MEMBRANE 16MM DISC 2SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12763-MAIN,LOCAL,,,,,860,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,421.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
GRAFIXPL PRIME PLACENTAL MEMBRANE 16MM DISC 2SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12763-MAIN,LOCAL,,,,,860,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,421.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
GRAFIXPL PRIME PLACENTAL MEMBRANE 16MM DISC 2SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12763-MAIN,LOCAL,,,,,860,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,421.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
RELOAD SUREFORM 60 2.5 WHITE 6 ROW BOX/12,27200000,CDM,272,RC,,,,12261-MAIN,LOCAL,,,,,430,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,421.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 60 3.5 BLUE,27200000,CDM,272,RC,,,,12084-MAIN,LOCAL,,,,,430,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,421.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RELOAD SUREFORM 60 4.3 GREEN,27200000,CDM,272,RC,,,,12085-MAIN,LOCAL,,,,,430,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,421.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Closed Rx Bimalleolar Fx,PX27808P,CDM,983,RC,27808,CPT,,,,,,,,433,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,421.4389,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,179.8682,421.4389
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Solution 10 mL Bottle,63700001,CDM,250,RC,,,,,,61314064610,NDC,10,ML,433.15,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,421.584895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ADVANCED INSTRUMENTS ENDOWRIST SUCTION IRRIGATOR,27200000,CDM,272,RC,,,,11922-MAIN,LOCAL,,,,,496,,First Health,Commercial,both,85,,999999999,percent of total billed charges,421.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LOCKING SCREW T8 FULL THREAD 2.4MM L10MM,C1713,CDM,278,RC,C1713,HCPCS,,12637-MAIN,LOCAL,,,,,496,,First Health,Commercial,both,85,,999999999,percent of total billed charges,421.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LOCKING SCREW T8 FULL THREAD 2.4MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12651-MAIN,LOCAL,,,,,496,,First Health,Commercial,both,85,,999999999,percent of total billed charges,421.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LOCKING SCREW T8 FULL THREAD 2.7MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12638-MAIN,LOCAL,,,,,496,,First Health,Commercial,both,85,,999999999,percent of total billed charges,421.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LOCKING SCREW T8 FULL THREAD 2.7MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12639-MAIN,LOCAL,,,,,496,,First Health,Commercial,both,85,,999999999,percent of total billed charges,421.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"Lap,Cholecystectomy",PX47562P,CDM,983,RC,47562,CPT,,,,,,,,983,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,421.707,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,408.3382,5040.74
belimumab 120 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010101,NDC,1,EA,1015.95,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,422.02563,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.72,3453.2358
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,781344071,NDC,1,EA,430.94,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,422.3212,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,179.012476,460.7862
Skin Sub Graft Trnk/Arm/Leg,PX15271F,CDM,510,RC,15271,CPT,,,,,,,,862,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,422.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,358.0748,1593.14
Skin Sub Graft Trnk/Arm/Leg,PX15271F,CDM,510,RC,15271,CPT,,,,,,,,862,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,422.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,358.0748,1593.14
Skin Sub Graft Trnk/Arm/Leg,PX15271F,CDM,510,RC,15271,CPT,,,,,,,,862,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,422.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,358.0748,1593.14
Cpap/Bipap Mgmnt-Pt Own Equipment,PX94660.02F,CDM,410,RC,94660,CPT,,,,,,,,497,,First Health,Commercial,both,85,,999999999,percent of total billed charges,422.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.33,487.06
Duplex Up Extrem Art Bilat,PX9393001,CDM,921,RC,93930,CPT,TC,,,,,,,835,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,422.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,818.3
Temporal Artery Ligatn or Bx,PX37609F,CDM,510,RC,37609,CPT,,,,,,,,705,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,422.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,124.34,645.45
Temporal Artery Ligatn or Bx,PX37609P,CDM,983,RC,37609,CPT,,,,,,,,965,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,422.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,124.34,945.7
"Hospital Inpt or Obs Care, Admin/Disch Same Date Straightforward or Low Level Mdm >= 45 Minutes",PX99234,CDM,982,RC,99234,CPT,,,,,,,,464,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,422.704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.7456,451.6112
Naso/Orogastric Tube,PX43752F,CDM,510,RC,43752,CPT,,,,,,,,464,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,422.704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.7456,454.72
rho d immune globulin human 1500 units solution prefilled syringe 1 Each Syringe,J2790.01,CDM,636,RC,J2790,HCPCS,,,,562780500,NDC,1,EA,464.01,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,422.71311,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.749754,454.7298
"Injection,Sacroiliac Joint(T)",PX27096F,CDM,510,RC,27096,CPT,,,,,,,,881,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,422.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,365.9674,863.38
"Injection,Sacroiliac Joint(T)",PX27096F,CDM,510,RC,27096,CPT,,,,,,,,881,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,422.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,365.9674,863.38
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016401,NDC,1,ML,854.49,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,422.97255,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.66,898.7384
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004F,CDM,510,RC,15004,CPT,,,,,,,,855,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,423.225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,355.167,837.9
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081543,NDC,1,ML,479.89,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,423.26298,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.346306,470.2922
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081552,NDC,1,ML,479.89,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,423.26298,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.346306,470.2922
Gastric Intubation Treatment,PX43753P,CDM,983,RC,43753,CPT,,,,,,,,498,,First Health,Commercial,both,85,,999999999,percent of total billed charges,423.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.8692,484.7034
"POS Airway Pressure, Cpap",PX94660F,CDM,410,RC,94660,CPT,,,,,,,,498,,First Health,Commercial,both,85,,999999999,percent of total billed charges,423.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.33,488.04
Cns Dna/Rna Amp Probe Multiple Subtypes 12-25,PX87483,CDM,300,RC,87483,CPT,,,,,,,,864,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,423.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,358.9056,846.72
Cns Dna/Rna Amp Probe Multiple Subtypes 12-25,PX87483,CDM,300,RC,87483,CPT,,,,,,,,864,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,423.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,358.9056,846.72
Cns Dna/Rna Amp Probe Multiple Subtypes 12-25,PX87483,CDM,300,RC,87483,CPT,,,,,,,,864,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,423.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,358.9056,846.72
Egd Balloon Dil Esoph30 Mm/>,PX43233P,CDM,983,RC,43233,CPT,,,,,,,,480,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,423.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.392,1662.33
"Sigmoidoscopy,Diagnostic",PX45330P,CDM,983,RC,45330,CPT,,,,,,,,480,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,423.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.392,798.45
Xray Eye Foreign Body,PX7003001,CDM,320,RC,70030,CPT,TC,,,,,,,432,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,423.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,423.36
Drainage of Hematoma/Fluid (P),PX10140P,CDM,983,RC,10140,CPT,,,,,,,,465,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,423.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,193.161,1416.38
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102P,CDM,983,RC,11102,CPT,,,,,,,,465,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,423.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,452.5845
fluticasone propionate 50 MCG/ACT Suspension 16 g Bottle,63700001,CDM,250,RC,,,,,,50383070016,NDC,16,GR,432.56,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,423.9088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Closed Rx Big Toe Fx,Manip",PX28495F,CDM,510,RC,28495,CPT,,,,,,,,857,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,424.215,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,839.86
Tube Thoracostomy Inc Wtr Seal,PX32551F,CDM,510,RC,32551,CPT,,,,,,,,989,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,424.281,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,410.8306,1399.13
Abd Paracentesis,PX49082F,CDM,510,RC,49082,CPT,,,,,,,,884,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,424.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,367.2136,866.32
Abd Paracentesis,PX49082F,CDM,510,RC,49082,CPT,,,,,,,,884,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,424.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,367.2136,866.32
Closed Rx Bimalleolar Fx,PX27808P,CDM,983,RC,27808,CPT,,,,,,,,433,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,424.34,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.17,727.77
Debride Tissue/Muscle/Bone,PX11044P,CDM,983,RC,11044,CPT,,,,,,,,866,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,424.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,359.7364,1416.38
Debride Tissue/Muscle/Bone,PX11044P,CDM,983,RC,11044,CPT,,,,,,,,866,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,424.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,359.7364,1416.38
Debride Tissue/Muscle/Bone,PX11044P,CDM,983,RC,11044,CPT,,,,,,,,866,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,424.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,359.7364,1416.38
X-Ray Exam Abdomen 2 Views,PX7401901,CDM,320,RC,74019,CPT,TC,,,,,,,436,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,313.4283333,percent of total billed charges,424.3588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,427.28
"X-Ray Exam Hip,Unilat W/Pelvis 2-3 Vws",PX7350201,CDM,320,RC,73502,CPT,TC,,,,,,,436,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,223.5836842,percent of total billed charges,424.3588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,427.28
Xray Abdomen Comp Incl Decub and/or Erect,PX7402001,CDM,320,RC,74020,CPT,TC,,,,,,,436,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,424.3588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.1144,427.28
Xray Cervical Spine 2 or 3 Vws,PX7204001,CDM,320,RC,72040,CPT,TC,,,,,,,436,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,255.355,percent of total billed charges,424.3588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,427.28
clobetasol 0.05 % Cream 60 g Tube,63700001,CDM,250,RC,,,,,,168030160,NDC,60,GR,989.25,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,424.38825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,71288020185,NDC,5,ML,1021.7,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,424.41418,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,424.41418,1239.6216
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Solution 10 mL Bottle,63700001,CDM,250,RC,,,,,,61314064610,NDC,10,ML,433.15,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,424.487,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Exc Skn Malig1.1-2cm Fce,Facal",PX11642P,CDM,983,RC,11642,CPT,,,,,,,,466,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,424.526,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,193.5764,614.65
Blood Transfusion Service,PX36430,CDM,391,RC,36430,CPT,,,,,,,,839,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,424.534,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.5206,822.22
Drainage of Gum Lesion,PX41800P,CDM,983,RC,41800,CPT,,,,,,,,839,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,424.534,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,816.5987
Exc Back Les Sc = 3 Cm,PX21931P,CDM,983,RC,21931,CPT,,,,,,,,2135,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,424.8153,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,286.43,2092.3
Heart/Lung Resuscitation (Cpr),PX92950P,CDM,983,RC,92950,CPT,,,,,,,,1023,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,424.9542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.21,995.6859
Sigmoidoscope W/Submuc Inj,PX45335P,CDM,983,RC,45335,CPT,,,,,,,,500,,First Health,Commercial,both,85,,999999999,percent of total billed charges,425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,207.7,798.45
STAPLER SUREFORM 60 SPU IS4000,27200000,CDM,272,RC,,,,12086-MAIN,LOCAL,,,,,991,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,425.139,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Xray Ribs Unilat 2 Vws,PX7110001,CDM,320,RC,71100,CPT,TC,,,,,,,437,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,425.3321,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,428.26
erythromycin lactobionate 500 MG Recon Soln 1 Each Vial,J1364.01,CDM,636,RC,J1364,HCPCS,,,,409648211,NDC,1,EA,437.09,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,425.419697,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.06,428.3482
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034F,CDM,510,RC,12034,CPT,,,,,,,,931,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,425.46,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.27,696.64
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034P,CDM,983,RC,12034,CPT,,,,,,,,1533,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,425.46,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.27,1502.34
GRAFIXPL PRIME PLACENTAL MEMBRANE 16MM DISC 2SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12763-MAIN,LOCAL,,,,,860,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,425.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
medroxyPROGESTERone 150 MG/ML Suspension 1 mL Vial,J1050.01,CDM,636,RC,J1050,HCPCS,,,,67457088799,NDC,1,ML,437.38,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,425.701954,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.687652,428.6324
fluticasone propionate 50 MCG/ACT Suspension 16 g Bottle,63700001,CDM,250,RC,,,,,,60505082901,NDC,16,GR,437.4,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,425.72142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Insert Non-Tunnel Cv Catheter >5 Years,PX36556F,CDM,510,RC,36556,CPT,,,,,,,,1025,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,425.785,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,425.785,2784.63
"Remv Foot Foreign Body,Subcutaneous",PX28190F,CDM,510,RC,28190,CPT,,,,,,,,1025,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,425.785,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,425.785,1004.5
MINIBUNION DRILL KIT,27200000,CDM,278,RC,C1713,HCPCS,,11669-MAIN,LOCAL,,,,,841.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,425.799,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
fluticasone-salmeterol 250-50 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069604,NDC,14,EA,1025.13,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,425.839002,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone furoate-vilanterol 100-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173085914,NDC,28,EA,1025.38,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,425.942852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"I&D Perianal Abscess,Superficial",PX46050P,CDM,983,RC,46050,CPT,,,,,,,,993,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,425.997,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,412.4922,966.4869
"Repair Umbilical Hern,5+Y/O,Strang",PX49587F,CDM,510,RC,49587,CPT,,,,,,,,1110,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,426.0997,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,426.0997,426.1
"Repair Umbilical Hern,5+Y/O,Strang",PX49587P,CDM,983,RC,49587,CPT,,,,,,,,2182,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,426.0997,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,426.0997,2138.36
"Repair Umbilical Hern,5+Y/O,Strang",PX49587F,CDM,510,RC,49587,CPT,,,,,,,,1110,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,426.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,426.0997,426.1
"Repair Umbilical Hern,5+Y/O,Strang",PX49587P,CDM,983,RC,49587,CPT,,,,,,,,2182,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,426.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,426.0997,2138.36
"Closed Rx Bimalleolar Fx,Manip",PX27810F,CDM,510,RC,27810,CPT,,,,,,,,1026,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,426.2004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,426.2004,1404.08
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409422801,NDC,100,ML,1026,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,426.2004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
STAPLER SUREFORM 45 SPU IS4000,27200000,CDM,272,RC,,,,12794-MAIN,LOCAL,,,,,888,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,426.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STAPLER SUREFORM 45 SPU IS4000,27200000,CDM,272,RC,,,,12794-MAIN,LOCAL,,,,,888,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,426.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Debride Bone Ea Add 20 Sqcm,PX11047F,CDM,510,RC,11047,CPT,,,,,,,,438,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,426.3054,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.9452,429.24
US Pregnancy Tc Limited,PX7681501,CDM,402,RC,76815,CPT,TC,,,,,,,438,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,426.3054,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,429.24
Closed Rx Kneecap Dislocatn,PX27560F,CDM,510,RC,27560,CPT,,,,,,,,468,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,426.348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,194.4072,458.64
"POS Airway Pressure, Bipap",PX94660.01F,CDM,410,RC,94660,CPT,,,,,,,,468,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,426.348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.33,458.64
Vedolizumab - Ref,PX8028090,CDM,300,RC,80280,CPT,90,,,,,,,468,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,426.348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.36,458.64
"Sigmoidoscopy,Screen Prev",PX2001F,CDM,750,RC,45330,CPT,,,,,,,,843,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,426.558,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,350.1822,826.14
Skin Sub Graft Trnk/Arm/Leg,PX15271F,CDM,510,RC,15271,CPT,,,,,,,,862,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,426.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,358.0748,1593.14
"Chemotherapy, IV Push, Single Drug",PX96409,CDM,335,RC,96409,CPT,,,,,,,,502,,First Health,Commercial,both,85,,999999999,percent of total billed charges,426.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.5308,491.96
Incise External Hemorrhoid,PX46083F,CDM,510,RC,46083,CPT,,,,,,,,502,,First Health,Commercial,both,85,,999999999,percent of total billed charges,426.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.5308,491.96
Drain Skin Abscess Complic,PX10061F,CDM,510,RC,10061,CPT,,,,,,,,889,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,426.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,871.22
Drain Skin Abscess Complic,PX10061F,CDM,510,RC,10061,CPT,,,,,,,,889,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,426.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,871.22
Debride Skin/Tissue,PX11042P,CDM,983,RC,11042,CPT,,,,,,,,995,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,426.855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,968.4335
"Fac/Ex Skinbngn0.6-1cmtrnk,Arm,Lg",PX11401F,CDM,510,RC,11401,CPT,,,,,,,,484,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,426.888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.0536,474.32
"Fac/Exc Skn Benig<5mm Face,Facial",PX11440F,CDM,510,RC,11440,CPT,,,,,,,,484,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,426.888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.0536,614.65
"Facility Critical Care, Addl 30 Min",PX99292F,CDM,510,RC,99292,CPT,,,,,,,,484,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,426.888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.0536,474.32
nystatin-triamcinolone 100000-0.1 UNIT/GM-% Ointment 30 g Tube,25000000,CDM,250,RC,,,,,,52565004230,NDC,30,GR,438.62,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,426.908846,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,115169449,NDC,1,EA,889.46,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,426.9408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,115169449,NDC,1,EA,889.46,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,426.9408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54505010202,NDC,1,EA,889.46,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,426.9408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54505010202,NDC,1,EA,889.46,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,426.9408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
"Needle Biopsy,Muscle",PX20206P,CDM,983,RC,20206,CPT,,,,,,,,1028,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,427.0312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,427.0312,1416.38
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081543,NDC,1,ML,479.89,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,427.1021,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.346306,470.2922
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081552,NDC,1,ML,479.89,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,427.1021,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.346306,470.2922
Egd Balloon Dil Esoph30 Mm/>,PX43233P,CDM,983,RC,43233,CPT,,,,,,,,480,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,427.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.392,1662.33
"Sigmoidoscopy,Diagnostic",PX45330P,CDM,983,RC,45330,CPT,,,,,,,,480,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,427.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.392,798.45
HERNIA PATCH VENTRALEX SMALL,C1781,CDM,278,RC,C1781,HCPCS,,10203-MAIN,LOCAL,,,,,995.96,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,427.26684,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
8MM ENDOWRIST INSTRUMENTS 8MM FORCE BIPOLAR IS4000,27200000,CDM,272,RC,,,,11915-MAIN,LOCAL,,,,,439,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,427.2787,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
VISIGI3D 40FR STD WITH BULB,27100000,CDM,271,RC,,,,12812-MAIN,LOCAL,,,,,439,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,427.2787,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
X-Ray Exam Abdomen 2 Views,PX7401901,CDM,320,RC,74019,CPT,TC,,,,,,,436,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,427.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,427.28
"X-Ray Exam Hip,Unilat W/Pelvis 2-3 Vws",PX7350201,CDM,320,RC,73502,CPT,TC,,,,,,,436,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,427.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,427.28
Xray Abdomen Comp Incl Decub and/or Erect,PX7402001,CDM,320,RC,74020,CPT,TC,,,,,,,436,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,427.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.1144,427.28
Xray Cervical Spine 2 or 3 Vws,PX7204001,CDM,320,RC,72040,CPT,TC,,,,,,,436,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,427.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,427.28
"Closure of Gastrostomy,Surgical",PX43870P,CDM,983,RC,43870,CPT,,,,,,,,4012,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,427.35,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,427.35,3931.76
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004004,NDC,120,ML,502.95,,First Health,Commercial,both,85,,999999999,percent of total billed charges,427.5075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
Trb@ Gene Rearrange Amplify - Ref,PX8134090,CDM,300,RC,81340,CPT,90,,,,,,,503,,First Health,Commercial,both,85,,999999999,percent of total billed charges,427.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,191.56,492.94
"Closure of Gastrostomy,Surgical",PX43870P,CDM,983,RC,43870,CPT,,,,,,,,4012,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,427.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,427.35,3931.76
"Closure of Gastrostomy,Surgical",PX43870P,CDM,983,RC,43870,CPT,,,,,,,,4012,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,427.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,427.35,3931.76
Cns Dna/Rna Amp Probe Multiple Subtypes 12-25,PX87483,CDM,300,RC,87483,CPT,,,,,,,,864,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,427.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,358.9056,846.72
Factor VIII (Ahg) 1-Stage,PX85240,CDM,300,RC,85240,CPT,,,,,,,,997,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,427.713,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.41,977.06
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,63323067305,NDC,5,ML,1029.71,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,427.741534,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.08296,1009.1158
Exc Skn Beni 0.6-1cm Fcefacial,PX11441P,CDM,983,RC,11441,CPT,,,,,,,,485,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,427.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.469,614.65
Injection for Nerve Block,PX64448F,CDM,510,RC,64448,CPT,,,,,,,,873,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,427.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,362.6442,855.54
Injection for Nerve Block,PX64448F,CDM,510,RC,64448,CPT,,,,,,,,873,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,427.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,362.6442,855.54
Injection for Nerve Block,PX64448F,CDM,510,RC,64448,CPT,,,,,,,,873,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,427.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,362.6442,855.54
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,121090204,NDC,120,ML,503.56,,First Health,Commercial,both,85,,999999999,percent of total billed charges,428.026,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802201,NDC,0.8,ML,439.77,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,25.0327027,percent of total billed charges,428.028141,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802210,NDC,0.8,ML,439.77,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,25.0327027,percent of total billed charges,428.028141,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
"Incis/Drain Scrotum/Testis,Epididym",PX54700P,CDM,983,RC,54700,CPT,,,,,,,,440,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,428.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,182.776,1779.39
"Lap,Dx Surgical Abd W/Biopsy",PX49321F,CDM,510,RC,49321,CPT,,,,,,,,874,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,428.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.0596,5040.74
"Lap,Dx Surgical Abd W/Biopsy",PX49321F,CDM,510,RC,49321,CPT,,,,,,,,874,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,428.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.0596,5040.74
"Lap,Dx Surgical Abd W/Biopsy",PX49321F,CDM,510,RC,49321,CPT,,,,,,,,874,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,428.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.0596,5040.74
Xray Ribs Unilat 2 Vws,PX7110001,CDM,320,RC,71100,CPT,TC,,,,,,,437,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,428.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,428.26
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,548590000,NDC,1,EA,470.19,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,428.34309,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,179.012476,460.7862
erythromycin lactobionate 500 MG Recon Soln 1 Each Vial,J1364.01,CDM,636,RC,J1364,HCPCS,,,,409648211,NDC,1,EA,437.09,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,428.3482,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.06,428.3482
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,16714081501,NDC,5,ML,998.95,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,428.54955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
medroxyPROGESTERone 150 MG/ML Suspension 1 mL Vial,J1050.01,CDM,636,RC,J1050,HCPCS,,,,67457088799,NDC,1,ML,437.38,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,428.6324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.687652,428.6324
ARTISTA AH 3GRAM ABSORBABLE HEMOSTATIC PARTICLES,27200000,CDM,272,RC,A6199,HCPCS,,10227-MAIN,LOCAL,,,,,486,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,428.652,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
fluticasone propionate 50 MCG/ACT Suspension 16 g Bottle,63700001,CDM,250,RC,,,,,,60505082901,NDC,16,GR,437.4,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,428.652,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002P,CDM,983,RC,12002,CPT,,,,,,,,486,,United Healthcare,All Payer,outpatient,88.2,,145.0711111,percent of total billed charges,428.652,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,473.0238
Xray Sinuses Less Than 3 Vws,PX7021001,CDM,320,RC,70210,CPT,TC,,,,,,,486,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,428.652,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,476.28
Debride Tissue/Muscle/Bone,PX11044P,CDM,983,RC,11044,CPT,,,,,,,,866,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,428.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,359.7364,1416.38
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,23155052431,NDC,10,ML,486.06,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,428.70492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,23155052441,NDC,10,ML,486.06,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,428.70492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Fac/Exc Skn Mali2.1-3cmtrnk,Arm,Lg",PX11603F,CDM,510,RC,11603,CPT,,,,,,,,875,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,428.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.475,857.5
"Fac/Exc Skn Mali2.1-3cmtrnk,Arm,Lg",PX11603F,CDM,510,RC,11603,CPT,,,,,,,,875,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,428.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.475,857.5
"Fac/Exc Skn Mali2.1-3cmtrnk,Arm,Lg",PX11603F,CDM,510,RC,11603,CPT,,,,,,,,875,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,428.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.475,857.5
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423F,CDM,510,RC,11423,CPT,,,,,,,,711,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,428.92,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.6,428.92
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423P,CDM,983,RC,11423,CPT,,,,,,,,569,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,428.92,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.6,557.62
cocaine 4% 4 % Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527172874,NDC,4,ML,875.53,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,429.0097,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
cocaine 4% 4 % Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527172874,NDC,4,ML,875.53,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,429.0097,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
cocaine 4% 4 % Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527172874,NDC,4,ML,875.53,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,429.0097,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
"Fac/Office Consultation,Level IV",PX99244F,CDM,510,RC,99244,CPT,,,,,,,,441,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,429.2253,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,183.1914,432.18
Gastric Intubation Treatment,PX43753F,CDM,510,RC,43753,CPT,,,,,,,,441,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,429.2253,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,183.1914,432.18
"Office Consultation,Level IV",PX99244P,CDM,983,RC,99244,CPT,,,,,,,,441,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,429.2253,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,183.1914,429.2253
Debride Bone Ea Add 20 Sqcm,PX11047F,CDM,510,RC,11047,CPT,,,,,,,,438,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,429.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.9452,429.24
US Pregnancy Tc Limited,PX7681501,CDM,402,RC,76815,CPT,TC,,,,,,,438,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,429.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,429.24
Diagnostic Anoscopy,PX46600F,CDM,510,RC,46600,CPT,,,,,,,,505,,First Health,Commercial,both,85,,999999999,percent of total billed charges,429.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,494.9
Place Needle in Vein,PX36000P,CDM,983,RC,36000,CPT,,,,,,,,1034,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,429.5236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,429.5236,1006.3922
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310002,NDC,0.528,ML,894.9,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,429.552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.22,877.002
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310002,NDC,0.528,ML,894.9,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,429.552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.22,877.002
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,61314054701,NDC,2.5,ML,487.35,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,429.8427,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
nystatin-triamcinolone 100000-0.1 UNIT/GM-% Ointment 30 g Tube,25000000,CDM,250,RC,,,,,,52565004230,NDC,30,GR,438.62,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,429.8476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"OB US < 14 Wks, Single Fetus - Radiology, Tech",PX7680101,CDM,402,RC,76801,CPT,TC,,,,,,,472,,Medica,Commercial,both,91.1,,429.99,percent of total billed charges,429.992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,462.56
US Pelvic Tc Complete,PX7685601,CDM,402,RC,76856,CPT,TC,,,,,,,472,,Medica,Commercial,both,91.1,,429.99,percent of total billed charges,429.992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,462.56
US Transvaginal Tc,PX7683001,CDM,402,RC,76830,CPT,TC,,,,,,,472,,Medica,Commercial,both,91.1,,386.99,percent of total billed charges,429.992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,462.56
8MM ENDOWRIST INSTRUMENTS 8MM FORCE BIPOLAR IS4000,27200000,CDM,272,RC,,,,11915-MAIN,LOCAL,,,,,439,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,430.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
VISIGI3D 40FR STD WITH BULB,27100000,CDM,271,RC,,,,12812-MAIN,LOCAL,,,,,439,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,430.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.71124,430.22
Closed Treat Wrist Dislocation,PX25660P,CDM,983,RC,25660,CPT,,,,,,,,1507,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,430.274,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,287.74,1476.86
dorzolamide-timolol 2-0.5 % Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,50383023310,NDC,10,ML,506.34,,First Health,Commercial,both,85,,999999999,percent of total billed charges,430.389,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
brinzolamide-brimonidine 1-0.2 % Suspension 8 mL Bottle,63700001,CDM,250,RC,,,,,,65414727,NDC,8,ML,850.88,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,430.54528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Suspension 10 mL Bottle,63700001,CDM,250,RC,,,,,,64980044801,NDC,10,ML,488.25,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,430.6365,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gentamicin 0.1 % Ointment 30 g Tube,25000000,CDM,250,RC,,,,,,713068231,NDC,30,GR,506.64,,First Health,Commercial,both,85,,999999999,percent of total billed charges,430.644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Fac/Ex Skinbngn0.6-1cmtrnk,Arm,Lg",PX11401F,CDM,510,RC,11401,CPT,,,,,,,,484,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,430.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.0536,474.32
"Fac/Exc Skn Benig<5mm Face,Facial",PX11440F,CDM,510,RC,11440,CPT,,,,,,,,484,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,430.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.0536,614.65
"Facility Critical Care, Addl 30 Min",PX99292F,CDM,510,RC,99292,CPT,,,,,,,,484,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,430.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.0536,474.32
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221901,NDC,3,ML,506.9,,First Health,Commercial,both,85,,999999999,percent of total billed charges,430.865,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221905,NDC,3,ML,506.9,,First Health,Commercial,both,85,,999999999,percent of total billed charges,430.865,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802201,NDC,0.8,ML,439.77,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,430.9746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802210,NDC,0.8,ML,439.77,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,430.9746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
Closed Rx Metacarpal Fx,PX26600F,CDM,510,RC,26600,CPT,,,,,,,,443,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,431.1719,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,184.0222,434.14
"Incis/Drain Scrotum/Testis,Epididym",PX54700P,CDM,983,RC,54700,CPT,,,,,,,,440,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,431.2,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,131.76,443.44
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505F,CDM,510,RC,24505,CPT,,,,,,,,2109,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,431.2373,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.04,1086.13
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505P,CDM,983,RC,24505,CPT,,,,,,,,2353,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,431.2373,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.04,2305.94
"Lap,Cholecystectomy/Graph",PX47563F,CDM,510,RC,47563,CPT,,,,,,,,1556,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,431.28,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,431.28,1497.75
Abd Paracentesis W/Imaging(T),PX49083F,CDM,510,RC,49083,CPT,,,,,,,,1006,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,431.574,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,417.8924,985.88
"Close Rx Fingr Articular Fx,Manip",PX26742F,CDM,510,RC,26742,CPT,,,,,,,,1039,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,431.6006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,431.6006,1404.08
Exc Skn Beni 0.6-1cm Fcefacial,PX11441P,CDM,983,RC,11441,CPT,,,,,,,,485,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,431.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.469,614.65
"Injection,Sacroiliac Joint(T)",PX27096F,CDM,510,RC,27096,CPT,,,,,,,,881,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,431.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,365.9674,863.38
"Injection,Sacroiliac Joint(T)",PX27096F,CDM,510,RC,27096,CPT,,,,,,,,881,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,431.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,365.9674,863.38
"Injection,Sacroiliac Joint(T)",PX27096F,CDM,510,RC,27096,CPT,,,,,,,,881,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,431.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,365.9674,863.38
"Inpatient Consult, Level IV",PX99254,CDM,983,RC,99254,CPT,,,,,,,,508,,First Health,Commercial,both,85,,999999999,percent of total billed charges,431.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.0232,494.4364
Lvl 2 Init Hosp Mod Mdm or 55 Minutes,PX99222,CDM,982,RC,99222,CPT,,,,,,,,508,,First Health,Commercial,both,85,,999999999,percent of total billed charges,431.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.0232,494.4364
calcitonin (salmon) 200 UNIT/ACT Solution 3.7 mL Bottle,63700001,CDM,250,RC,,,,,,60505082306,NDC,3.7,ML,489.57,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,431.80074,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Lap,Cholecystectomy/Graph",PX47563F,CDM,510,RC,47563,CPT,,,,,,,,1556,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,431.94,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,431.28,1497.75
"Lap,Cholecystectomy/Graph",PX47563F,CDM,510,RC,47563,CPT,,,,,,,,1556,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,431.94,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,431.28,1497.75
MIS STERILE INSTRUMENT PACK WITH BLADE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12432-MAIN,LOCAL,,,,,900,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MIS STERILE INSTRUMENT PACK WITH BLADE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12432-MAIN,LOCAL,,,,,900,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Injection for Nerve Block,PX64448F,CDM,510,RC,64448,CPT,,,,,,,,873,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,432.135,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,362.6442,855.54
"Fac/Office Consultation,Level IV",PX99244F,CDM,510,RC,99244,CPT,,,,,,,,441,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,432.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,183.1914,432.18
Gastric Intubation Treatment,PX43753F,CDM,510,RC,43753,CPT,,,,,,,,441,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,432.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,183.1914,432.18
"Office Consultation,Level IV",PX99244P,CDM,983,RC,99244,CPT,,,,,,,,441,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,432.18,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.11,432.18
Xray Knee 4 or More Vws,PX7356401,CDM,320,RC,73564,CPT,TC,,,,,,,490,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,432.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,480.2
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802001,NDC,1,ML,444.2,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,25.0327027,percent of total billed charges,432.33986,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802010,NDC,1,ML,444.2,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,25.0327027,percent of total billed charges,432.33986,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016401,NDC,1,ML,854.49,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,432.37194,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.66,898.7384
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623F,CDM,510,RC,11623,CPT,,,,,,,,690,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,432.38,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.89,616.39
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623P,CDM,983,RC,11623,CPT,,,,,,,,460,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,432.38,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.89,616.39
ARTISTA AH 3GRAM ABSORBABLE HEMOSTATIC PARTICLES,27200000,CDM,272,RC,A6199,HCPCS,,10227-MAIN,LOCAL,,,,,486,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,432.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002P,CDM,983,RC,12002,CPT,,,,,,,,486,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,432.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,473.0238
Xray Sinuses Less Than 3 Vws,PX7021001,CDM,320,RC,70210,CPT,TC,,,,,,,486,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,432.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,476.28
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,23155052431,NDC,10,ML,486.06,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,432.5934,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,23155052441,NDC,10,ML,486.06,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,432.5934,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Lap,Dx Surgical Abd W/Biopsy",PX49321F,CDM,510,RC,49321,CPT,,,,,,,,874,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,432.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.0596,5040.74
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004F,CDM,510,RC,15004,CPT,,,,,,,,855,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,432.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,355.167,837.9
Acute Hepatitis Panel,PX80074,CDM,300,RC,80074,CPT,,,,,,,,509,,First Health,Commercial,both,85,,999999999,percent of total billed charges,432.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,43.67,498.82
Biopsy of Rectum,PX45100P,CDM,983,RC,45100,CPT,,,,,,,,509,,First Health,Commercial,both,85,,999999999,percent of total billed charges,432.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.4386,2452.93
ipratropium 0.06 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,54004641,NDC,15,ML,491.02,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,433.07964,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Leukoreduced Platelets,PXP9035,CDM,390,RC,P9035,HCPCS,,,,,,,,1350,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,433.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,433.08,1323
"Fac/Exc Skn Mali2.1-3cmtrnk,Arm,Lg",PX11603F,CDM,510,RC,11603,CPT,,,,,,,,875,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,433.125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.475,857.5
Abd Paracentesis,PX49082F,CDM,510,RC,49082,CPT,,,,,,,,884,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,433.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,367.2136,866.32
Abd Paracentesis,PX49082F,CDM,510,RC,49082,CPT,,,,,,,,884,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,433.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,367.2136,866.32
Abd Paracentesis,PX49082F,CDM,510,RC,49082,CPT,,,,,,,,884,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,433.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,367.2136,866.32
"Excise Lesion,Back or Flank",PX21930P,CDM,983,RC,21930,CPT,,,,,,,,884,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,433.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,367.2136,1416.38
"Excise Lesion,Back or Flank",PX21930P,CDM,983,RC,21930,CPT,,,,,,,,884,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,433.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,367.2136,1416.38
"Excise Lesion,Back or Flank",PX21930P,CDM,983,RC,21930,CPT,,,,,,,,884,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,433.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,367.2136,1416.38
Repair of Vagina,PX57200P,CDM,983,RC,57200,CPT,,,,,,,,1043,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,433.2622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,433.2622,2731.23
cocaine 4% 4 % Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527172874,NDC,4,ML,875.53,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,433.38735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
"Closed Rx Big Toe Fx,Manip",PX28495F,CDM,510,RC,28495,CPT,,,,,,,,857,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,433.642,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,839.86
Lap Incis Hernia Reducible,PX49654P,CDM,983,RC,49654,CPT,,,,,,,,1044,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,433.6776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,433.6776,1016.1252
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,61314054701,NDC,2.5,ML,487.35,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,433.7415,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Incise External Hemorrhoid,PX46083F,CDM,510,RC,46083,CPT,,,,,,,,502,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,433.76,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.28,433.76
Incise External Hemorrhoid,PX46083P,CDM,983,RC,46083,CPT,,,,,,,,956,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,433.76,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.28,936.88
cefdinir 250 MG/5ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,16714039301,NDC,60,ML,510.33,,First Health,Commercial,both,85,,999999999,percent of total billed charges,433.7805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
nystatin 100000 UNIT/GM Powder 60 g Bottle,63700001,CDM,250,RC,,,,,,574200802,NDC,60,GR,491.86,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,433.82052,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762F,CDM,510,RC,43762,CPT,,,,,,,,492,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,433.944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,204.3768,482.16
esmolol 2500 MG/250ML Solution 250 mL Flex Cont,J1805.01,CDM,636,RC,J1805,HCPCS,,,,10019067010,NDC,250,ML,1011.8,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,434.0622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.24,991.564
Closed Rx Metacarpal Fx,PX26600F,CDM,510,RC,26600,CPT,,,,,,,,443,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,434.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,184.0222,434.14
"Exc Skn Beig1.1-2cm Face,Facil",PX11442P,CDM,983,RC,11442,CPT,,,,,,,,886,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,434.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,368.0444,862.3438
"Exc Skn Beig1.1-2cm Face,Facil",PX11442P,CDM,983,RC,11442,CPT,,,,,,,,886,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,434.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,368.0444,862.3438
"Exc Skn Beig1.1-2cm Face,Facil",PX11442P,CDM,983,RC,11442,CPT,,,,,,,,886,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,434.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,368.0444,862.3438
umeclidinium 62.5 MCG/ACT Aerosol Powder Breath Activated 7 Each Disp Pack,63700001,CDM,250,RC,,,,,,173087306,NDC,7,EA,492.23,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,434.14686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
indocyanine green 25 MG Recon Soln 1 Each Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,70100042402,NDC,1,EA,446.07,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,15.50733333,percent of total billed charges,434.159931,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.29,1354.4776
"Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601P,CDM,983,RC,11601,CPT,,,,,,,,1046,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,434.5084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,434.5084,1018.0718
Fac/Ligation of Hemorrhoid(S),PX46221F,CDM,510,RC,46221,CPT,,,,,,,,1046,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,434.5084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,434.5084,1025.08
MRI Brain W & WO Contrast,PX7055301,CDM,610,RC,70553,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,434.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,147.25,434.54
MRI Brain W & WO Contrast,PX7055301,CDM,610,RC,70553,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,434.54,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,147.25,434.54
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Suspension 10 mL Bottle,63700001,CDM,250,RC,,,,,,64980044801,NDC,10,ML,488.25,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,434.5425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
filgrastim-sndz 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314031801,NDC,0.5,ML,1047.2,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,435.00688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,1630.2692
STAPLER SUREFORM 45 SPU IS4000,27200000,CDM,272,RC,,,,12794-MAIN,LOCAL,,,,,888,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,435.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STAPLER SUREFORM 45 SPU IS4000,27200000,CDM,272,RC,,,,12794-MAIN,LOCAL,,,,,888,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,435.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STAPLER SUREFORM 45 SPU IS4000,27200000,CDM,272,RC,,,,12794-MAIN,LOCAL,,,,,888,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,435.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
BRACE KNEE LARGE SHORTRUNNER 21754,120.387,CDM,274,RC,L1833,HCPCS,,10044-MAIN,LOCAL,,,,,101,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,435.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE MEDIUM SHORTRUNNER 21753,120.387,CDM,274,RC,L1833,HCPCS,,10126-MAIN,LOCAL,,,,,101,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,435.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE SMALL SHORTRUNNER 21752,120.387,CDM,274,RC,L1833,HCPCS,,10900-MAIN,LOCAL,,,,,101,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,435.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE X-LARGE SHORTRUNNER 21755,120.387,CDM,274,RC,L1833,HCPCS,,3444-MAIN,LOCAL,,,,,101,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,435.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
BRACE KNEE XX-LARGE SHORTRUNNER 21756,120.387,CDM,274,RC,L1833,HCPCS,,10615-MAIN,LOCAL,,,,,101,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,435.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.9554,435.14
GRAFIXPL PRIME PLACENTAL MEMBRANE 16MM DISC 2SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12763-MAIN,LOCAL,,,,,860,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,435.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
DRIVER HEX 2.00MM STERILE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12440-MAIN,LOCAL,,,,,512,,First Health,Commercial,both,85,,999999999,percent of total billed charges,435.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRIVER HEX 2.5MM STERILE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12441-MAIN,LOCAL,,,,,512,,First Health,Commercial,both,85,,999999999,percent of total billed charges,435.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802001,NDC,1,ML,444.2,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,435.316,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802010,NDC,1,ML,444.2,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,435.316,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.178206,435.316
Drain Skin Abscess Complic,PX10061F,CDM,510,RC,10061,CPT,,,,,,,,889,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,435.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,871.22
Drain Skin Abscess Complic,PX10061F,CDM,510,RC,10061,CPT,,,,,,,,889,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,435.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,871.22
Drain Skin Abscess Complic,PX10061F,CDM,510,RC,10061,CPT,,,,,,,,889,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,435.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,871.22
Inc/Drain Peritonsil Abscess,PX42700P,CDM,983,RC,42700,CPT,,,,,,,,889,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,435.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,865.2637
Inc/Drain Peritonsil Abscess,PX42700P,CDM,983,RC,42700,CPT,,,,,,,,889,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,435.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,865.2637
Inc/Drain Peritonsil Abscess,PX42700P,CDM,983,RC,42700,CPT,,,,,,,,889,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,435.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,865.2637
CRICOTHROTOMY QUICKTRACH 4MM,120.228,CDM,272,RC,A7520,HCPCS,,8868-MAIN,LOCAL,,,,,494,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,435.708,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.2076,484.12
SET CRICOTHYROTOMY CATHETER 6MM ID,120.378,CDM,272,RC,,,,11119-MAIN,LOCAL,,,,,494,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,435.708,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.2076,484.12
calcitonin (salmon) 200 UNIT/ACT Solution 3.7 mL Bottle,63700001,CDM,250,RC,,,,,,60505082306,NDC,3.7,ML,489.57,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,435.7173,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,115169449,NDC,1,EA,889.46,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,150.5666667,percent of total billed charges,435.8354,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,115169449,NDC,1,EA,889.46,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,435.8354,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,115169449,NDC,1,EA,889.46,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,435.8354,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54505010202,NDC,1,EA,889.46,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,150.5666667,percent of total billed charges,435.8354,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54505010202,NDC,1,EA,889.46,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,435.8354,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54505010202,NDC,1,EA,889.46,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,435.8354,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
belimumab 120 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010101,NDC,1,EA,1015.95,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,435.84255,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.72,3453.2358
CT Angio Upr Extrm W/O&W/Dye,PX7320601,CDM,350,RC,73206,CPT,TC,,,,,,,757,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,435.86,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,118.89,435.86
CT Angio Upr Extrm W/O&W/Dye,PX7320601,CDM,350,RC,73206,CPT,TC,,,,,,,757,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,435.86,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,118.89,435.86
MRI L Spine W&WO Contrast,PX7215801,CDM,610,RC,72158,CPT,TC,,,,,,,4178,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,435.86,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,147.68,435.86
MRI L Spine W&WO Contrast,PX7215801,CDM,610,RC,72158,CPT,TC,,,,,,,4178,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,435.86,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,147.68,435.86
hydrocortisone (perianal) 2.5 % Cream 28.35 g Tube,63700001,CDM,250,RC,,,,,,10631040701,NDC,28.35,GR,447.94,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,435.980002,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Injection,Sacroiliac Joint(T)",PX27096F,CDM,510,RC,27096,CPT,,,,,,,,881,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,436.095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,365.9674,863.38
Xray Knee 4 or More Vws,PX7356401,CDM,320,RC,73564,CPT,TC,,,,,,,490,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,436.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,480.2
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,781325394,NDC,1,EA,1049.95,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,436.14923,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,72485020101,NDC,1,EA,1049.95,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,436.14923,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
"Complex Drainage, Wound",PX10180F,CDM,510,RC,10180,CPT,,,,,,,,1050,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,436.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,436.17,2482.37
Red Blood Cells Unit,PXP9021,CDM,390,RC,P9021,HCPCS,,,,,,,,1050,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,436.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.17,1029
Skin Sub Graft Trnk/Arm/Leg,PX15271F,CDM,510,RC,15271,CPT,,,,,,,,862,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,436.172,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,358.0748,1593.14
ondansetron 4 MG/5ML Solution 25 mL Bottle,S0119.01,CDM,636,RC,S0119,HCPCS,,,,99998-8001-,NDC,25,ML,494.57,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,436.21074,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956401,NDC,1,EA,1611.2,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,436.51473,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,393.18,446.8
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956410,NDC,1,EA,1689.17,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,436.51473,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,393.18,446.8
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725F,CDM,510,RC,26725,CPT,,,,,,,,495,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,436.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.623,485.1
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101F,CDM,510,RC,13101,CPT,,,,,,,,495,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,436.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.623,548.67
Tc99 Mebrofenin to 15 Mci,PXA9537,CDM,343,RC,A9537,HCPCS,,,,,,,,495,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,436.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.623,485.1
ipratropium 0.06 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,54004641,NDC,15,ML,491.02,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,437.0078,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
indocyanine green 25 MG Recon Soln 1 Each Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,70100042402,NDC,1,EA,446.07,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,437.1486,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.29,1354.4776
MRI C Spine W&WO Contrast,PX7215601,CDM,610,RC,72156,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,437.17,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,218.82,437.17
MRI C Spine W&WO Contrast,PX7215601,CDM,610,RC,72156,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,437.17,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,218.82,437.17
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081543,NDC,1,ML,479.89,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,437.17979,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.346306,470.2922
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081552,NDC,1,ML,479.89,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,437.17979,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.346306,470.2922
Cns Dna/Rna Amp Probe Multiple Subtypes 12-25,PX87483,CDM,300,RC,87483,CPT,,,,,,,,864,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,437.184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,358.9056,846.72
Egd Balloon Dil Esoph30 Mm/>,PX43233P,CDM,983,RC,43233,CPT,,,,,,,,480,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,437.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.392,1662.33
"Sigmoidoscopy,Diagnostic",PX45330P,CDM,983,RC,45330,CPT,,,,,,,,480,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,437.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.392,798.45
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022101,NDC,1,EA,514.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,437.325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022185,NDC,1,EA,514.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,437.325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022189,NDC,1,EA,514.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,437.325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
ADVANCED INSTRUMENTS ENDOWRIST SUCTION IRRIGATOR,27200000,CDM,272,RC,,,,11922-MAIN,LOCAL,,,,,496,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,437.472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LOCKING SCREW T8 FULL THREAD 2.4MM L10MM,C1713,CDM,278,RC,C1713,HCPCS,,12637-MAIN,LOCAL,,,,,496,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,437.472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LOCKING SCREW T8 FULL THREAD 2.4MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12651-MAIN,LOCAL,,,,,496,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,437.472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LOCKING SCREW T8 FULL THREAD 2.7MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12638-MAIN,LOCAL,,,,,496,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,437.472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LOCKING SCREW T8 FULL THREAD 2.7MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12639-MAIN,LOCAL,,,,,496,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,437.472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Abd Paracentesis,PX49082F,CDM,510,RC,49082,CPT,,,,,,,,884,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,437.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,367.2136,866.32
"Excise Lesion,Back or Flank",PX21930P,CDM,983,RC,21930,CPT,,,,,,,,884,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,437.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,367.2136,1416.38
I&D Deep Absc/Hematoma Neck/Chest,PX21501P,CDM,983,RC,21501,CPT,,,,,,,,515,,First Health,Commercial,both,85,,999999999,percent of total billed charges,437.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.931,2482.37
nystatin 100000 UNIT/GM Powder 60 g Bottle,63700001,CDM,250,RC,,,,,,574200802,NDC,60,GR,491.86,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,437.7554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Apply Long Leg Cast,PX29345F,CDM,510,RC,29345,CPT,,,,,,,,912,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,437.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,234.62,893.76
Apply Long Leg Cast,PX29345F,CDM,510,RC,29345,CPT,,,,,,,,912,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,437.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,234.62,893.76
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598030562,NDC,1,EA,912,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,437.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598030562,NDC,1,EA,912,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,437.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
Open Bx/Excision Inguinofemoral Nodes,PX38531F,CDM,510,RC,38531,CPT,,,,,,,,912,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,437.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,378.8448,3329.99
Open Bx/Excision Inguinofemoral Nodes,PX38531F,CDM,510,RC,38531,CPT,,,,,,,,912,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,437.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,378.8448,3329.99
Facility Emergency Level IV Visit,PX99284F,CDM,450,RC,99284,CPT,,,,,,,,1054,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,437.8316,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.93,1032.92
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762F,CDM,510,RC,43762,CPT,,,,,,,,492,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,437.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,204.3768,482.16
"Spinal Punc,Drain,Theraputic",PX62272F,CDM,510,RC,62272,CPT,,,,,,,,450,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,437.985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.93,604.15
umeclidinium 62.5 MCG/ACT Aerosol Powder Breath Activated 7 Each Disp Pack,63700001,CDM,250,RC,,,,,,173087306,NDC,7,EA,492.23,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,438.0847,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Debride Tissue/Muscle/Bone,PX11044P,CDM,983,RC,11044,CPT,,,,,,,,866,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,438.196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,359.7364,1416.38
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,71288020185,NDC,5,ML,1021.7,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,438.3093,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,424.41418,1239.6216
Cpap/Bipap Mgmnt-Pt Own Equipment,PX94660.02F,CDM,410,RC,94660,CPT,,,,,,,,497,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,438.354,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.33,487.06
MRI T Spine W&WO Contrast,PX7215701,CDM,610,RC,72157,CPT,TC,,,,,,,4178,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,438.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.55,438.49
MRI T Spine W&WO Contrast,PX7215701,CDM,610,RC,72157,CPT,TC,,,,,,,4178,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,438.49,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.55,438.49
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310002,NDC,0.528,ML,894.9,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,438.501,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.22,877.002
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310002,NDC,0.528,ML,894.9,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,438.501,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.22,877.002
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310002,NDC,0.528,ML,894.9,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,438.501,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.22,877.002
"Exc Skn Beig1.1-2cm Face,Facil",PX11442P,CDM,983,RC,11442,CPT,,,,,,,,886,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,438.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,368.0444,862.3438
Closed Rx Shldr Dislocation,PX23650P,CDM,983,RC,23650,CPT,,,,,,,,516,,First Health,Commercial,both,85,,999999999,percent of total billed charges,438.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,502.2228
Trg Gene Rearrangement Anal - Ref,PX8134290,CDM,300,RC,81342,CPT,90,,,,,,,516,,First Health,Commercial,both,85,,999999999,percent of total billed charges,438.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,184.76,505.68
Remove Nasal Foreign Body,PX30300F,CDM,510,RC,30300,CPT,,,,,,,,972,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,438.6,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.84,438.6
Remove Nasal Foreign Body,PX30300P,CDM,983,RC,30300,CPT,,,,,,,,572,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,438.6,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.84,560.56
Heart/Lung Resuscitation (Cpr),PX92950P,CDM,983,RC,92950,CPT,,,,,,,,1023,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,438.867,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.21,995.6859
hydrocortisone (perianal) 2.5 % Cream 28.35 g Tube,63700001,CDM,250,RC,,,,,,10631040701,NDC,28.35,GR,447.94,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,438.9812,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Closed Rx Bimalleolar Fx,Manip",PX27810P,CDM,983,RC,27810,CPT,,,,,,,,1057,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,439.0778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,439.0778,1404.08
Gastric Intubation Treatment,PX43753P,CDM,983,RC,43753,CPT,,,,,,,,498,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,439.236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.8692,484.7034
"POS Airway Pressure, Cpap",PX94660F,CDM,410,RC,94660,CPT,,,,,,,,498,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,439.236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.33,488.04
Abd Paracentesis,PX49082F,CDM,510,RC,49082,CPT,,,,,,,,884,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,439.29,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.5,439.29
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604F,CDM,510,RC,11604,CPT,,,,,,,,964,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,439.29,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.63,646.83
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604P,CDM,983,RC,11604,CPT,,,,,,,,1422,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,439.29,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.63,1393.56
Insert Non-Tunnel Cv Catheter >5 Years,PX36556F,CDM,510,RC,36556,CPT,,,,,,,,1025,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,439.29,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.04,439.29
Insert Non-Tunnel Cv Catheter >5 Years,PX36556P,CDM,983,RC,36556,CPT,,,,,,,,1274,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,439.29,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.04,1248.52
STAPLER SUREFORM 45 SPU IS4000,27200000,CDM,272,RC,,,,12794-MAIN,LOCAL,,,,,888,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,439.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CRICOTHROTOMY QUICKTRACH 4MM,120.228,CDM,272,RC,A7520,HCPCS,,8868-MAIN,LOCAL,,,,,494,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,439.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.2076,484.12
SET CRICOTHYROTOMY CATHETER 6MM ID,120.378,CDM,272,RC,,,,11119-MAIN,LOCAL,,,,,494,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,439.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.2076,484.12
Insert Non-Tunnel Cv Catheter >5 Years,PX36556F,CDM,510,RC,36556,CPT,,,,,,,,1025,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,439.725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,425.785,2784.63
"Remv Foot Foreign Body,Subcutaneous",PX28190F,CDM,510,RC,28190,CPT,,,,,,,,1025,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,439.725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,425.785,1004.5
fluticasone-salmeterol 250-50 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069604,NDC,14,EA,1025.13,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,439.78077,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone furoate-vilanterol 100-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173085914,NDC,28,EA,1025.38,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,439.88802,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DRILL BIT AO DIA 2.0MMX135MM SCALED,27200000,CDM,272,RC,,,,12640-MAIN,LOCAL,,,,,452,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,439.9316,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Drain Skin Abscess Complic,PX10061F,CDM,510,RC,10061,CPT,,,,,,,,889,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,440.055,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,871.22
Inc/Drain Peritonsil Abscess,PX42700P,CDM,983,RC,42700,CPT,,,,,,,,889,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,440.055,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,865.2637
"Closed Rx Bimalleolar Fx,Manip",PX27810F,CDM,510,RC,27810,CPT,,,,,,,,1026,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,440.154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,426.2004,1404.08
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409422801,NDC,100,ML,1026,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,440.154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
ondansetron 4 MG/5ML Solution 25 mL Bottle,S0119.01,CDM,636,RC,S0119,HCPCS,,,,99998-8001-,NDC,25,ML,494.57,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,440.1673,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016410,NDC,1,ML,917.08,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,440.1984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.66,898.7384
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016410,NDC,1,ML,917.08,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,440.1984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.66,898.7384
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,115169449,NDC,1,EA,889.46,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,440.2827,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54505010202,NDC,1,EA,889.46,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,440.2827,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
"Blood Gases: Ph, Po2 & Pco2",PX82803,CDM,300,RC,82803,CPT,,,,,,,,518,,First Health,Commercial,both,85,,999999999,percent of total billed charges,440.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.9,507.64
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725F,CDM,510,RC,26725,CPT,,,,,,,,495,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,440.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.623,485.1
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101F,CDM,510,RC,13101,CPT,,,,,,,,495,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,440.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.623,548.67
Tc99 Mebrofenin to 15 Mci,PXA9537,CDM,343,RC,A9537,HCPCS,,,,,,,,495,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,440.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.623,485.1
mometasone - formoterol 100-5 MCG/ACT Aerosol 8.8 g Inhaler,25000000,CDM,250,RC,,,,,,85720607,NDC,8.8,GR,918.07,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,440.6736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
mometasone - formoterol 100-5 MCG/ACT Aerosol 8.8 g Inhaler,25000000,CDM,250,RC,,,,,,85720607,NDC,8.8,GR,918.07,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,440.6736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
mometasone - formoterol 200-5 MCG/ACT Aerosol 8.8 g Inhaler,25000000,CDM,250,RC,,,,,,85461005,NDC,8.8,GR,918.07,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,440.6736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
mometasone - formoterol 200-5 MCG/ACT Aerosol 8.8 g Inhaler,25000000,CDM,250,RC,,,,,,85461005,NDC,8.8,GR,918.07,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,440.6736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Acellular Derm Matrix Implt,PX15777F,CDM,510,RC,15777,CPT,,,,,,,,650,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,440.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,129.14,440.68
Acellular Derm Matrix Implt,PX15777F,CDM,510,RC,15777,CPT,,,,,,,,650,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,440.68,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,129.14,440.68
"Critical Care, E/M 30-74 Minutes",PX99291P,CDM,983,RC,99291,CPT,,,,,,,,1061,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,440.7394,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,440.7394,1032.6713
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505F,CDM,510,RC,25505,CPT,,,,,,,,651,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,440.8703,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,295.37,1095.81
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505P,CDM,983,RC,25505,CPT,,,,,,,,977,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,440.8703,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,295.37,1095.81
"Exc Skn Mal 0.6-1cm Fce,Facial",PX11641P,CDM,983,RC,11641,CPT,,,,,,,,453,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,440.9049,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.1762,614.65
Repr Superf Wnd Body 7.6-12.5,PX12004F,CDM,510,RC,12004,CPT,,,,,,,,453,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,52.065,percent of total billed charges,440.9049,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,443.94
Repr Superf Wnd Face 5.1-7.5,PX12014F,CDM,510,RC,12014,CPT,,,,,,,,453,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,440.9049,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,443.94
"Fac/Ex Skinbngn0.6-1cmtrnk,Arm,Lg",PX11401F,CDM,510,RC,11401,CPT,,,,,,,,484,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,440.924,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.0536,474.32
"Fac/Exc Skn Benig<5mm Face,Facial",PX11440F,CDM,510,RC,11440,CPT,,,,,,,,484,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,440.924,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.0536,614.65
"Facility Critical Care, Addl 30 Min",PX99292F,CDM,510,RC,99292,CPT,,,,,,,,484,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,440.924,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.0536,474.32
MIS STERILE INSTRUMENT PACK WITH BLADE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12432-MAIN,LOCAL,,,,,900,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,441,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MIS STERILE INSTRUMENT PACK WITH BLADE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12432-MAIN,LOCAL,,,,,900,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,441,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MIS STERILE INSTRUMENT PACK WITH BLADE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12432-MAIN,LOCAL,,,,,900,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,441,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Sigmoidoscope W/Submuc Inj,PX45335P,CDM,983,RC,45335,CPT,,,,,,,,500,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,441,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,207.7,798.45
"Spinal Punc,Drain,Theraputic",PX62272F,CDM,510,RC,62272,CPT,,,,,,,,450,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,441,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.93,604.15
"Needle Biopsy,Muscle",PX20206P,CDM,983,RC,20206,CPT,,,,,,,,1028,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,441.012,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,427.0312,1416.38
Xray Ac Joints(Bilateral),PX7305001,CDM,320,RC,73050,CPT,TC,,,,,,,519,,First Health,Commercial,both,85,,999999999,percent of total billed charges,441.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,508.62
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565F,CDM,510,RC,25565,CPT,,,,,,,,1250,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,441.1914,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,296.9,1116.57
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565P,CDM,983,RC,25565,CPT,,,,,,,,830,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,441.1914,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,296.9,1116.57
ADVANCED INSTRUMENTS ENDOWRIST SUCTION IRRIGATOR,27200000,CDM,272,RC,,,,11922-MAIN,LOCAL,,,,,496,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,441.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LOCKING SCREW T8 FULL THREAD 2.4MM L10MM,C1713,CDM,278,RC,C1713,HCPCS,,12637-MAIN,LOCAL,,,,,496,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,441.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LOCKING SCREW T8 FULL THREAD 2.4MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12651-MAIN,LOCAL,,,,,496,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,441.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LOCKING SCREW T8 FULL THREAD 2.7MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12638-MAIN,LOCAL,,,,,496,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,441.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LOCKING SCREW T8 FULL THREAD 2.7MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12639-MAIN,LOCAL,,,,,496,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,441.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Injection for Nerve Block,PX64448F,CDM,510,RC,64448,CPT,,,,,,,,873,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,441.738,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,362.6442,855.54
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,63323067305,NDC,5,ML,1029.71,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,441.74559,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.08296,1009.1158
Exc Skn Beni 0.6-1cm Fcefacial,PX11441P,CDM,983,RC,11441,CPT,,,,,,,,485,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,441.835,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.469,614.65
X-Ray Exam Entire Spine 2-3 Vws,PX7208201,CDM,320,RC,72082,CPT,TC,,,,,,,454,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,441.8782,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,444.92
"Casiri and Imdevimab,Admin,Repeat Dose",PXM0240,CDM,771,RC,M0240,HCPCS,,,,,,,,1555,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,442.11231,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,295.15,450
"IV Infusion, Bamlanivimab and Etesevimab, Infusion and Monitoring",PXM0245,CDM,260,RC,M0245,HCPCS,,,,,,,,1555,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,442.11231,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,295.15,450
"IV Infusion, Casirivimab and Imdevimab, IV and Post Admr",PXM0243,CDM,771,RC,M0243,HCPCS,,,,,,,,1555,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,442.11231,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,295.15,450
"Lap,Dx Surgical Abd W/Biopsy",PX49321F,CDM,510,RC,49321,CPT,,,,,,,,874,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,442.244,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.0596,5040.74
Cpap/Bipap Mgmnt-Pt Own Equipment,PX94660.02F,CDM,410,RC,94660,CPT,,,,,,,,497,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,442.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.33,487.06
Reconstruc of Nail Bed,PX11760P,CDM,983,RC,11760,CPT,,,,,,,,903,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,442.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,375.1062,878.8899
Reconstruc of Nail Bed,PX11760P,CDM,983,RC,11760,CPT,,,,,,,,903,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,442.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,375.1062,878.8899
Reconstruc of Nail Bed,PX11760P,CDM,983,RC,11760,CPT,,,,,,,,903,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,442.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,375.1062,878.8899
ARTISTA AH 3GRAM ABSORBABLE HEMOSTATIC PARTICLES,27200000,CDM,272,RC,A6199,HCPCS,,10227-MAIN,LOCAL,,,,,486,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,442.746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002P,CDM,983,RC,12002,CPT,,,,,,,,486,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,442.746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,473.0238
Xray Sinuses Less Than 3 Vws,PX7021001,CDM,320,RC,70210,CPT,TC,,,,,,,486,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,442.746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,476.28
"Fac/Exc Skn Mali2.1-3cmtrnk,Arm,Lg",PX11603F,CDM,510,RC,11603,CPT,,,,,,,,875,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,442.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.475,857.5
"Chemotherapy, IV Push, Single Drug",PX96409,CDM,335,RC,96409,CPT,,,,,,,,502,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,442.764,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.5308,491.96
Incise External Hemorrhoid,PX46083F,CDM,510,RC,46083,CPT,,,,,,,,502,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,442.764,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.5308,491.96
"Hemorrhoidectomy,Int/Ext,Complx",PX46260F,CDM,750,RC,46260,CPT,,,,,,,,1350,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,442.7969,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,299.3,1007.26
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,23155052431,NDC,10,ML,486.06,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,442.80066,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,23155052441,NDC,10,ML,486.06,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,442.80066,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Destruct Benign Lesion, 1-14",PX17110P,CDM,983,RC,17110,CPT,,,,,,,,521,,First Health,Commercial,both,85,,999999999,percent of total billed charges,442.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,507.0893
"Ileoscopy Thru Stoma,Diagnostic",PX44380P,CDM,983,RC,44380,CPT,,,,,,,,455,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,442.8515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.007,791.92
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607F,CDM,761,RC,97607,CPT,,,,,,,,455,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,442.8515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.007,445.9
DRILL BIT AO DIA 2.0MMX135MM SCALED,27200000,CDM,272,RC,,,,12640-MAIN,LOCAL,,,,,452,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,442.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Inject Nerv Blck,Othr Periph Nerv",PX64450P,CDM,983,RC,64450,CPT,,,,,,,,904,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,442.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,375.5216,879.8632
"Inject Nerv Blck,Othr Periph Nerv",PX64450P,CDM,983,RC,64450,CPT,,,,,,,,904,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,442.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,375.5216,879.8632
"Inject Nerv Blck,Othr Periph Nerv",PX64450P,CDM,983,RC,64450,CPT,,,,,,,,904,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,442.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,375.5216,879.8632
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310002,NDC,0.528,ML,894.9,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,442.9755,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.22,877.002
cocaine 4% 4 % Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527172874,NDC,4,ML,875.53,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,443.01818,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
Gastric Intubation Treatment,PX43753P,CDM,983,RC,43753,CPT,,,,,,,,498,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,443.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.8692,484.7034
"POS Airway Pressure, Cpap",PX94660F,CDM,410,RC,94660,CPT,,,,,,,,498,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,443.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.33,488.04
Debride Skin/Tissue,PX11042F,CDM,510,RC,11042,CPT,,,,,,,,1067,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,443.2318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1045.66
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,64950036204,NDC,4,ML,1067.22,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,443.323188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
"Incis/Drain Scrotum/Testis,Epididym",PX54700F,CDM,510,RC,54700,CPT,,,,,,,,660,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,443.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,131.76,443.44
"Incis/Drain Scrotum/Testis,Epididym",PX54700F,CDM,510,RC,54700,CPT,,,,,,,,660,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,443.44,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,131.76,443.44
"Incis/Drain Scrotum/Testis,Epididym",PX54700P,CDM,983,RC,54700,CPT,,,,,,,,440,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,443.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,131.76,443.44
"Incis/Drain Scrotum/Testis,Epididym",PX54700P,CDM,983,RC,54700,CPT,,,,,,,,440,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,443.44,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,131.76,443.44
Place Needle in Vein,PX36000P,CDM,983,RC,36000,CPT,,,,,,,,1034,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,443.586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,429.5236,1006.3922
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004004,NDC,120,ML,502.95,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,443.6019,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
Trb@ Gene Rearrange Amplify - Ref,PX8134090,CDM,300,RC,81340,CPT,90,,,,,,,503,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,443.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,191.56,492.94
Closed Rx Trimalleolar Fx,PX27816F,CDM,510,RC,27816,CPT,,,,,,,,522,,First Health,Commercial,both,85,,999999999,percent of total billed charges,443.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,511.56
Xray Thoracic Spine 3 Vws,PX7207201,CDM,320,RC,72072,CPT,TC,,,,,,,522,,First Health,Commercial,both,85,,999999999,percent of total billed charges,443.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,511.56
"Ctrl Nosebleed,Anter,Complex",PX30903F,CDM,510,RC,30903,CPT,,,,,,,,456,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,443.8248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,446.88
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611F,CDM,510,RC,20611,CPT,,,,,,,,456,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,443.8248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.4224,446.88
"Office/Outpt Visit,New,Levl V",PX99205F,CDM,510,RC,99205,CPT,,,,,,,,456,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,443.8248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.4224,446.88
"Office/Outpt Visit,New,Levl V",PX99205P,CDM,983,RC,99205,CPT,,,,,,,,456,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,443.8248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.4224,443.8248
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321801,NDC,50,ML,456,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,443.8248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
Xray Nasal Bones Minimum 3 Vws,PX7016001,CDM,320,RC,70160,CPT,TC,,,,,,,456,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,443.8248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,446.88
"Exc Skn Mal 0.6-1cm Fce,Facial",PX11641P,CDM,983,RC,11641,CPT,,,,,,,,453,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,443.94,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97.51,493.95
Repr Superf Wnd Body 7.6-12.5,PX12004F,CDM,510,RC,12004,CPT,,,,,,,,453,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,443.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,443.94
Repr Superf Wnd Face 5.1-7.5,PX12014F,CDM,510,RC,12014,CPT,,,,,,,,453,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,443.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,443.94
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,61314054701,NDC,2.5,ML,487.35,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,443.97585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,121090204,NDC,120,ML,503.56,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,444.13992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
Layr Clos Wnd Rest Body 7.6-12.5,PX12044F,CDM,510,RC,12044,CPT,,,,,,,,785,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,444.14,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,133.06,796.26
Layr Clos Wnd Rest Body 7.6-12.5,PX12044P,CDM,983,RC,12044,CPT,,,,,,,,523,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,444.14,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,133.06,796.26
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956401,NDC,1,EA,1611.2,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,444.31,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,393.18,446.8
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956401,NDC,1,EA,1611.2,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,444.31,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,393.18,446.8
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956410,NDC,1,EA,1689.17,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,444.31,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,393.18,446.8
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956410,NDC,1,EA,1689.17,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,444.31,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,393.18,446.8
Layr Clos Wnd Rest Body 7.6-12.5,PX12044P,CDM,983,RC,12044,CPT,,,,,,,,523,,First Health,Commercial,both,85,,999999999,percent of total billed charges,444.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,217.2542,548.67
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Suspension 10 mL Bottle,63700001,CDM,250,RC,,,,,,64980044801,NDC,10,ML,488.25,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,444.79575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Infectious Disease (Viral Respiratory Tract Infection),",PX0241U,CDM,300,RC,0241U,HCPCS,,,,,,,,457,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,153.4915873,percent of total billed charges,444.7981,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.78,447.86
US Scrotum & Contents Tc,PX7687001,CDM,402,RC,76870,CPT,TC,,,,,,,457,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,372.745,percent of total billed charges,444.7981,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,447.86
X-Ray Exam Entire Spine 2-3 Vws,PX7208201,CDM,320,RC,72082,CPT,TC,,,,,,,454,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,444.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,444.92
Sigmoidoscope W/Submuc Inj,PX45335P,CDM,983,RC,45335,CPT,,,,,,,,500,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,207.7,798.45
Diagnostic Anoscopy,PX46600F,CDM,510,RC,46600,CPT,,,,,,,,505,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,445.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,494.9
MIS STERILE INSTRUMENT PACK WITH BLADE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12432-MAIN,LOCAL,,,,,900,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,445.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Removal of Hemorrhoid Clot,PX46320F,CDM,510,RC,46320,CPT,,,,,,,,2027,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,445.52,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.24,445.52
Removal of Hemorrhoid Clot,PX46320P,CDM,983,RC,46320,CPT,,,,,,,,374,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,445.52,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.24,445.52
"Close Rx Fingr Articular Fx,Manip",PX26742F,CDM,510,RC,26742,CPT,,,,,,,,1039,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,445.731,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,431.6006,1404.08
"Injection,Sacroiliac Joint(T)",PX27096F,CDM,510,RC,27096,CPT,,,,,,,,881,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,445.786,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,365.9674,863.38
"Ileoscopy Thru Stoma,Diagnostic",PX44380P,CDM,983,RC,44380,CPT,,,,,,,,455,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,445.9,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.12,445.9
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607F,CDM,761,RC,97607,CPT,,,,,,,,455,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,445.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.007,445.9
calcitonin (salmon) 200 UNIT/ACT Solution 3.7 mL Bottle,63700001,CDM,250,RC,,,,,,60505082306,NDC,3.7,ML,489.57,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,445.99827,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Anal Sphincterotomy,PX46080P,CDM,983,RC,46080,CPT,,,,,,,,525,,First Health,Commercial,both,85,,999999999,percent of total billed charges,446.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,218.085,2452.93
CT Abdomen&Pelvis W/Contrast,PX7417701,CDM,350,RC,74177,CPT,TC,,,,,,,4288,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,446.37,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,151.4,446.37
CT Abdomen&Pelvis W/Contrast,PX7417701,CDM,350,RC,74177,CPT,TC,,,,,,,4288,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,446.37,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,151.4,446.37
Xray Knee 4 or More Vws,PX7356401,CDM,320,RC,73564,CPT,TC,,,,,,,490,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,446.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,480.2
"Amputation Metatarsal+Toe,Single",PX28810F,CDM,510,RC,28810,CPT,,,,,,,,930,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,446.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.322,2827.75
"Amputation Metatarsal+Toe,Single",PX28810F,CDM,510,RC,28810,CPT,,,,,,,,930,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,446.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.322,2827.75
Colonoscopy,PX44388F,CDM,750,RC,44388,CPT,,,,,,,,930,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,446.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.322,911.4
Colonoscopy,PX44388F,CDM,750,RC,44388,CPT,,,,,,,,930,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,446.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.322,911.4
dorzolamide-timolol 2-0.5 % Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,50383023310,NDC,10,ML,506.34,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,446.59188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
CT Abdomen W/Dye,PX7416001,CDM,350,RC,74160,CPT,TC,,,,,,,3413,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,446.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3344.74
CT Abdomen W/O & W/Dye,PX7417001,CDM,350,RC,74170,CPT,TC,,,,,,,3689,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,446.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3615.22
CT Angio Abdom W/O & W/Dye,PX7417501,CDM,350,RC,74175,CPT,TC,,,,,,,4183,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,446.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,4099.34
CT Angio Lwr Extr W/O&W/Dye,PX7370601,CDM,350,RC,73706,CPT,TC,,,,,,,1554,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,446.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1522.92
CT Angio Upr Extrm W/O&W/Dye,PX7320601,CDM,350,RC,73206,CPT,TC,,,,,,,757,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,446.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
CT Angiograph Pelv W/O&W/Dye,PX7219101,CDM,350,RC,72191,CPT,TC,,,,,,,1458,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,446.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
"CT Angiography, Chest",PX7127501,CDM,350,RC,71275,CPT,TC,,,,,,,3689,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,446.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3615.22
"CT Angiography, Head",PX7049601,CDM,350,RC,70496,CPT,TC,,,,,,,3690,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,446.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3616.2
"CT Angiography, Neck",PX7049801,CDM,350,RC,70498,CPT,TC,,,,,,,3690,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,446.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3616.2
CT Chest Spine W/Dye,PX7212901,CDM,350,RC,72129,CPT,TC,,,,,,,2096,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,446.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,2054.08
CT Head/Brain W/Dye,PX7046001,CDM,350,RC,70460,CPT,TC,,,,,,,3398,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,446.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3330.04
CT Head/Brain W/O & W/Dye,PX7047001,CDM,350,RC,70470,CPT,TC,,,,,,,3671,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,446.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3597.58
CT Lower Extremity W/Dye,PX7370101,CDM,350,RC,73701,CPT,TC,,,,,,,2690,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,446.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,2636.2
CT Lumbar Spine W/O & W/Dye,PX7213301,CDM,350,RC,72133,CPT,TC,,,,,,,4283,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,446.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,4197.34
CT Lwr Extremity W/O&W/Dye,PX7370201,CDM,350,RC,73702,CPT,TC,,,,,,,1235,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,446.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
CT Maxillofacial W/Dye,PX7048701,CDM,350,RC,70487,CPT,TC,,,,,,,3332,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,446.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3265.36
CT Orbit/Ear/Fossa W/O & W/Dye,PX7048201,CDM,350,RC,70482,CPT,TC,,,,,,,1400,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,446.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
CT Pelvis W/Dye,PX7219301,CDM,350,RC,72193,CPT,TC,,,,,,,3330,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,446.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3263.4
CT Soft Tissue Neck W/Dye,PX7049101,CDM,350,RC,70491,CPT,TC,,,,,,,3415,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,446.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3346.7
Diagnostic CT Thorax W/ Contrast,PX7126001,CDM,350,RC,71260,CPT,TC,,,,,,,3415,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,446.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3346.7
Resp Virus 3-5 Targets,PX87631,CDM,300,RC,87631,CPT,,,,,,,,459,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,446.7447,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.78,449.82
"Chemotherapy, IV Push, Single Drug",PX96409,CDM,335,RC,96409,CPT,,,,,,,,502,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,446.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.5308,491.96
Incise External Hemorrhoid,PX46083F,CDM,510,RC,46083,CPT,,,,,,,,502,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,446.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.5308,491.96
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956401,NDC,1,EA,1611.2,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,446.8,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,393.18,446.8
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956410,NDC,1,EA,1689.17,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,446.8,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,393.18,446.8
gentamicin 0.1 % Ointment 30 g Tube,25000000,CDM,250,RC,,,,,,713068231,NDC,30,GR,506.64,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,446.85648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Apply Long Leg Cast,PX29345F,CDM,510,RC,29345,CPT,,,,,,,,912,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,446.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,234.62,893.76
Apply Long Leg Cast,PX29345F,CDM,510,RC,29345,CPT,,,,,,,,912,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,446.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,234.62,893.76
Apply Long Leg Cast,PX29345F,CDM,510,RC,29345,CPT,,,,,,,,912,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,446.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,234.62,893.76
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598030562,NDC,1,EA,912,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,446.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598030562,NDC,1,EA,912,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,446.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598030562,NDC,1,EA,912,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,446.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
"Ctrl Nosebleed,Anter,Complex",PX30903F,CDM,510,RC,30903,CPT,,,,,,,,456,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,446.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,446.88
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611F,CDM,510,RC,20611,CPT,,,,,,,,456,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,446.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.4224,446.88
Fac/Exc Skn Beni 0.6-1cm Remain Bdy,PX11421F,CDM,510,RC,11421,CPT,,,,,,,,931,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,446.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.7374,912.38
Fac/Exc Skn Beni 0.6-1cm Remain Bdy,PX11421F,CDM,510,RC,11421,CPT,,,,,,,,931,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,446.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.7374,912.38
Fac/Exc Skn Bngn3.1-4cm Remain Bdy,PX11424F,CDM,510,RC,11424,CPT,,,,,,,,931,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,446.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.7374,1416.38
Fac/Exc Skn Bngn3.1-4cm Remain Bdy,PX11424F,CDM,510,RC,11424,CPT,,,,,,,,931,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,446.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.7374,1416.38
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034F,CDM,510,RC,12034,CPT,,,,,,,,931,,Health Partners,Health Partners Care Plans,both,48,,6.17,percent of total billed charges,446.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,912.38
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034F,CDM,510,RC,12034,CPT,,,,,,,,931,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,446.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,912.38
"Office/Outpt Visit,New,Levl V",PX99205F,CDM,510,RC,99205,CPT,,,,,,,,456,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,446.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.4224,446.88
"Office/Outpt Visit,New,Levl V",PX99205P,CDM,983,RC,99205,CPT,,,,,,,,456,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,446.88,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.82,446.88
Open Bx/Excision Inguinofemoral Nodes,PX38531F,CDM,510,RC,38531,CPT,,,,,,,,912,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,446.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,378.8448,3329.99
Open Bx/Excision Inguinofemoral Nodes,PX38531F,CDM,510,RC,38531,CPT,,,,,,,,912,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,446.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,378.8448,3329.99
Open Bx/Excision Inguinofemoral Nodes,PX38531F,CDM,510,RC,38531,CPT,,,,,,,,912,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,446.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,378.8448,3329.99
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321801,NDC,50,ML,456,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,446.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
Xray Nasal Bones Minimum 3 Vws,PX7016001,CDM,320,RC,70160,CPT,TC,,,,,,,456,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,446.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,446.88
"Lap,Inguinal Hernia Repr,Initial",PX49650F,CDM,510,RC,49650,CPT,,,,,,,,1076,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,446.9704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,446.9704,5040.74
Reconstruc of Nail Bed,PX11760P,CDM,983,RC,11760,CPT,,,,,,,,903,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,446.985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,375.1062,878.8899
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221901,NDC,3,ML,506.9,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,447.0858,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221905,NDC,3,ML,506.9,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,447.0858,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
Debride Tissue/Muscle,PX11043F,CDM,510,RC,11043,CPT,,,,,,,,526,,First Health,Commercial,both,85,,999999999,percent of total billed charges,447.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,218.5004,548.67
Hfe Gene - Ref,PX8125690,CDM,300,RC,81256,CPT,90,,,,,,,526,,First Health,Commercial,both,85,,999999999,percent of total billed charges,447.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,59.93,515.48
Abd Paracentesis,PX49082F,CDM,510,RC,49082,CPT,,,,,,,,884,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,447.304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,367.2136,866.32
"Excise Lesion,Back or Flank",PX21930P,CDM,983,RC,21930,CPT,,,,,,,,884,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,447.304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,367.2136,1416.38
ipratropium 0.06 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,54004641,NDC,15,ML,491.02,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,447.31922,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Unlisted Molecular Path Proc - Ref,PX8147990,CDM,310,RC,81479,CPT,90,,,,,,,1077,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,447.3858,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,447.3858,1055.46
Repair of Vagina,PX57200P,CDM,983,RC,57200,CPT,,,,,,,,1043,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,447.447,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,433.2622,2731.23
"Inject Nerv Blck,Othr Periph Nerv",PX64450P,CDM,983,RC,64450,CPT,,,,,,,,904,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,447.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,375.5216,879.8632
Drain Skin Abscess Complic,PX10061F,CDM,510,RC,10061,CPT,,,,,,,,889,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,447.59,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.83,447.59
Drain Skin Abscess Complic,PX10061P,CDM,983,RC,10061,CPT,,,,,,,,561,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,447.59,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.83,549.78
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004004,NDC,120,ML,502.95,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,447.6255,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070110,NDC,1,ML,459.95,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,447.669335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.92,450.751
Trb@ Gene Rearrange Amplify - Ref,PX8134090,CDM,300,RC,81340,CPT,90,,,,,,,503,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,447.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,191.56,492.94
"DXA, Bone Density Study, Radius/Wrist/Heel",PX7708101,CDM,320,RC,77081,CPT,TC,,,,,,,460,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,447.718,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,450.8
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623P,CDM,983,RC,11623,CPT,,,,,,,,460,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,447.718,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,191.084,1416.38
"Transvaginal US, Obstetric",PX7681701,CDM,402,RC,76817,CPT,TC,,,,,,,460,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,401.44,percent of total billed charges,447.718,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,450.8
Emergency Level IV Visit,PX99284P,CDM,981,RC,99284,CPT,,,,,,,,914,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,155.5942775,percent of total billed charges,447.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,379.6756,889.5962
Emergency Level IV Visit,PX99284P,CDM,981,RC,99284,CPT,,,,,,,,914,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,447.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,379.6756,889.5962
Emergency Level IV Visit,PX99284P,CDM,981,RC,99284,CPT,,,,,,,,914,,United Healthcare,All Medicare advantage plans,outpatient,49,,306.9366667,percent of total billed charges,447.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,379.6756,889.5962
"Infectious Disease (Viral Respiratory Tract Infection),",PX0241U,CDM,300,RC,0241U,HCPCS,,,,,,,,457,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,447.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.78,447.86
US Scrotum & Contents Tc,PX7687001,CDM,402,RC,76870,CPT,TC,,,,,,,457,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,447.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,447.86
Lap Incis Hernia Reducible,PX49654P,CDM,983,RC,49654,CPT,,,,,,,,1044,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,447.876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,433.6776,1016.1252
budesonide-formoterol 160-4.5 MCG/ACT Aerosol 6 g Inhaler,63700001,CDM,250,RC,,,,,,186037028,NDC,6,GR,1078.55,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,448.02967,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Inpatient Consult, Level IV",PX99254,CDM,983,RC,99254,CPT,,,,,,,,508,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,448.056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.0232,494.4364
Lvl 2 Init Hosp Mod Mdm or 55 Minutes,PX99222,CDM,982,RC,99222,CPT,,,,,,,,508,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,448.056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.0232,494.4364
nystatin 100000 UNIT/GM Powder 60 g Bottle,63700001,CDM,250,RC,,,,,,574200802,NDC,60,GR,491.86,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,448.08446,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,121090204,NDC,120,ML,503.56,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,448.1684,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762F,CDM,510,RC,43762,CPT,,,,,,,,492,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,448.212,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,204.3768,482.16
"Exc Skn Beig1.1-2cm Face,Facil",PX11442P,CDM,983,RC,11442,CPT,,,,,,,,886,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,448.316,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,368.0444,862.3438
umeclidinium 62.5 MCG/ACT Aerosol Powder Breath Activated 7 Each Disp Pack,63700001,CDM,250,RC,,,,,,173087306,NDC,7,EA,492.23,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,448.42153,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Initial Observation Care,Levl III",PX99220,CDM,982,RC,99220,CPT,,,,,,,,461,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,448.6913,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,191.4994,448.6913
Repr Superf Wnd Face <2.5cm,PX12011P,CDM,983,RC,12011,CPT,,,,,,,,461,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,263.4025,percent of total billed charges,448.6913,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,448.6913
"Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601P,CDM,983,RC,11601,CPT,,,,,,,,1046,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,448.734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,434.5084,1018.0718
Fac/Ligation of Hemorrhoid(S),PX46221F,CDM,510,RC,46221,CPT,,,,,,,,1046,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,448.734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,434.5084,1025.08
Acute Hepatitis Panel,PX80074,CDM,300,RC,80074,CPT,,,,,,,,509,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,448.938,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,43.67,498.82
Biopsy of Rectum,PX45100P,CDM,983,RC,45100,CPT,,,,,,,,509,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,448.938,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.4386,2452.93
filgrastim-sndz 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314031801,NDC,0.5,ML,1047.2,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,449.2488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,1630.2692
STAPLER SUREFORM 45 SPU IS4000,27200000,CDM,272,RC,,,,12794-MAIN,LOCAL,,,,,888,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,449.328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016410,NDC,1,ML,917.08,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,449.3692,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.66,898.7384
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016410,NDC,1,ML,917.08,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,449.3692,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.66,898.7384
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016410,NDC,1,ML,917.08,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,449.3692,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.66,898.7384
tiotropium bromide monohydrate 2.5 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597010051,NDC,4,GR,461.7,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,449.37261,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tiotropium bromide-olodaterol 2.5-2.5 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597015570,NDC,4,GR,461.7,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,449.37261,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Diagnostic Anoscopy,PX46600F,CDM,510,RC,46600,CPT,,,,,,,,505,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,449.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,494.9
Debride Tissue/Muscle/Bone,PX11044F,CDM,510,RC,11044,CPT,,,,,,,,1082,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,449.4628,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,449.4628,1416.38
Excis Primary Ganglion Wrist,PX25111P,CDM,983,RC,25111,CPT,,,,,,,,529,,First Health,Commercial,both,85,,999999999,percent of total billed charges,449.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,219.7466,1404.08
Resp Virus 3-5 Targets,PX87631,CDM,300,RC,87631,CPT,,,,,,,,459,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,449.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.78,449.82
Drain Skin Abscess Complic,PX10061F,CDM,510,RC,10061,CPT,,,,,,,,889,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,449.834,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,871.22
Inc/Drain Peritonsil Abscess,PX42700P,CDM,983,RC,42700,CPT,,,,,,,,889,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,449.834,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,865.2637
mometasone - formoterol 100-5 MCG/ACT Aerosol 8.8 g Inhaler,25000000,CDM,250,RC,,,,,,85720607,NDC,8.8,GR,918.07,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,449.8543,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
mometasone - formoterol 100-5 MCG/ACT Aerosol 8.8 g Inhaler,25000000,CDM,250,RC,,,,,,85720607,NDC,8.8,GR,918.07,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,449.8543,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
mometasone - formoterol 100-5 MCG/ACT Aerosol 8.8 g Inhaler,25000000,CDM,250,RC,,,,,,85720607,NDC,8.8,GR,918.07,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,449.8543,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
mometasone - formoterol 200-5 MCG/ACT Aerosol 8.8 g Inhaler,25000000,CDM,250,RC,,,,,,85461005,NDC,8.8,GR,918.07,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,449.8543,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
mometasone - formoterol 200-5 MCG/ACT Aerosol 8.8 g Inhaler,25000000,CDM,250,RC,,,,,,85461005,NDC,8.8,GR,918.07,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,449.8543,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
mometasone - formoterol 200-5 MCG/ACT Aerosol 8.8 g Inhaler,25000000,CDM,250,RC,,,,,,85461005,NDC,8.8,GR,918.07,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,449.8543,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Closed Rx Femur Shaft Fx+Manip,PX27502P,CDM,983,RC,27502,CPT,,,,,,,,1083,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,449.8782,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,449.8782,1404.08
"Casiri and Imdevimab,Admin,Repeat Dose",PXM0240,CDM,771,RC,M0240,HCPCS,,,,,,,,1555,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,450,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,295.15,450
"IV Infusion, Bamlanivimab and Etesevimab, Infusion and Monitoring",PXM0245,CDM,260,RC,M0245,HCPCS,,,,,,,,1555,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,450,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,295.15,450
"IV Infusion, Casirivimab and Imdevimab, IV and Post Admr",PXM0243,CDM,771,RC,M0243,HCPCS,,,,,,,,1555,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,450,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,295.15,450
CRICOTHROTOMY QUICKTRACH 4MM,120.228,CDM,272,RC,A7520,HCPCS,,8868-MAIN,LOCAL,,,,,494,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,450.034,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.2076,484.12
SET CRICOTHYROTOMY CATHETER 6MM ID,120.378,CDM,272,RC,,,,11119-MAIN,LOCAL,,,,,494,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,450.034,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.2076,484.12
budesonide-formoterol 80-4.5 MCG/ACT Aerosol 6.9 g Inhaler,63700001,CDM,250,RC,,,,,,186037228,NDC,6.9,GR,937.58,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,450.0384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
budesonide-formoterol 80-4.5 MCG/ACT Aerosol 6.9 g Inhaler,63700001,CDM,250,RC,,,,,,186037228,NDC,6.9,GR,937.58,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,450.0384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,115169449,NDC,1,EA,889.46,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,450.06676,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54505010202,NDC,1,EA,889.46,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,450.06676,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
cefdinir 250 MG/5ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,16714039301,NDC,60,ML,510.33,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,450.11106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
collagenase 250 UNIT/GM Ointment 30 g Tube,63700001,CDM,250,RC,,,,,,50484001030,NDC,30,GR,1083.77,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,450.198058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,781325394,NDC,1,EA,1049.95,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,450.42855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,72485020101,NDC,1,EA,1049.95,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,450.42855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
"Complex Drainage, Wound",PX10180F,CDM,510,RC,10180,CPT,,,,,,,,1050,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,450.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,436.17,2482.37
Red Blood Cells Unit,PXP9021,CDM,390,RC,P9021,HCPCS,,,,,,,,1050,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,450.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.17,1029
ondansetron 4 MG/5ML Solution 25 mL Bottle,S0119.01,CDM,636,RC,S0119,HCPCS,,,,99998-8001-,NDC,25,ML,494.57,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,450.55327,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
dorzolamide-timolol 2-0.5 % Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,50383023310,NDC,10,ML,506.34,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,450.6426,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070110,NDC,1,ML,459.95,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,450.751,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,19.92,450.751
"DXA, Bone Density Study, Radius/Wrist/Heel",PX7708101,CDM,320,RC,77081,CPT,TC,,,,,,,460,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,450.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,450.8
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623P,CDM,983,RC,11623,CPT,,,,,,,,460,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,450.8,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.89,616.39
"Transvaginal US, Obstetric",PX7681701,CDM,402,RC,76817,CPT,TC,,,,,,,460,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,450.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,450.8
gentamicin 0.1 % Ointment 30 g Tube,25000000,CDM,250,RC,,,,,,713068231,NDC,30,GR,506.64,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,450.9096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725F,CDM,510,RC,26725,CPT,,,,,,,,495,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,450.945,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.623,485.1
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101F,CDM,510,RC,13101,CPT,,,,,,,,495,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,450.945,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.623,548.67
Tc99 Mebrofenin to 15 Mci,PXA9537,CDM,343,RC,A9537,HCPCS,,,,,,,,495,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,450.945,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.623,485.1
CT Angiograph Pelv W/O&W/Dye,PX7219101,CDM,350,RC,72191,CPT,TC,,,,,,,1458,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,450.98,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,118.89,450.98
CT Angiograph Pelv W/O&W/Dye,PX7219101,CDM,350,RC,72191,CPT,TC,,,,,,,1458,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,450.98,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,118.89,450.98
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221901,NDC,3,ML,506.9,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,451.141,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221905,NDC,3,ML,506.9,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,451.141,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
"Supply Technetium Medronate,to 30 MC",PXA9503,CDM,343,RC,A9503,HCPCS,,,,,,,,531,,First Health,Commercial,both,85,,999999999,percent of total billed charges,451.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,220.5774,520.38
Apply Long Leg Cast,PX29345F,CDM,510,RC,29345,CPT,,,,,,,,912,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,451.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,234.62,893.76
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598030562,NDC,1,EA,912,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,451.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
Open Bx/Excision Inguinofemoral Nodes,PX38531F,CDM,510,RC,38531,CPT,,,,,,,,912,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,451.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,378.8448,3329.99
DRIVER HEX 2.00MM STERILE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12440-MAIN,LOCAL,,,,,512,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,451.584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRIVER HEX 2.5MM STERILE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12441-MAIN,LOCAL,,,,,512,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,451.584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Hospital Inpt or Obs Care, Admin/Disch Same Date Straightforward or Low Level Mdm >= 45 Minutes",PX99234,CDM,982,RC,99234,CPT,,,,,,,,464,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,451.6112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.7456,451.6112
Naso/Orogastric Tube,PX43752F,CDM,510,RC,43752,CPT,,,,,,,,464,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,451.6112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.7456,454.72
rho d immune globulin human 1500 units solution prefilled syringe 1 Each Syringe,J2790.01,CDM,636,RC,J2790,HCPCS,,,,562780500,NDC,1,EA,464.01,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,451.620933,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.749754,454.7298
CT Angio Abdom W/O & W/Dye,PX7417501,CDM,350,RC,74175,CPT,TC,,,,,,,4183,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,451.63,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,118.89,451.63
CT Angio Abdom W/O & W/Dye,PX7417501,CDM,350,RC,74175,CPT,TC,,,,,,,4183,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,451.63,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,118.89,451.63
"Initial Observation Care,Levl III",PX99220,CDM,982,RC,99220,CPT,,,,,,,,461,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,451.78,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,161.76,451.78
Repr Superf Wnd Face <2.5cm,PX12011P,CDM,983,RC,12011,CPT,,,,,,,,461,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,451.78,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.94,451.78
fluticasone-vilanterol 200-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173088214,NDC,28,EA,1087.68,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,451.822272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ADVANCED INSTRUMENTS ENDOWRIST SUCTION IRRIGATOR,27200000,CDM,272,RC,,,,11922-MAIN,LOCAL,,,,,496,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,451.856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LOCKING SCREW T8 FULL THREAD 2.4MM L10MM,C1713,CDM,278,RC,C1713,HCPCS,,12637-MAIN,LOCAL,,,,,496,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,451.856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LOCKING SCREW T8 FULL THREAD 2.4MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12651-MAIN,LOCAL,,,,,496,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,451.856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LOCKING SCREW T8 FULL THREAD 2.7MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12638-MAIN,LOCAL,,,,,496,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,451.856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LOCKING SCREW T8 FULL THREAD 2.7MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12639-MAIN,LOCAL,,,,,496,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,451.856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Cv Carotid Imaging-Bilat,PX9388001,CDM,921,RC,93880,CPT,TC,,,,,,,1088,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,451.9552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,1066.24
"Inpatient Consult, Level IV",PX99254,CDM,983,RC,99254,CPT,,,,,,,,508,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,452.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.0232,494.4364
Lvl 2 Init Hosp Mod Mdm or 55 Minutes,PX99222,CDM,982,RC,99222,CPT,,,,,,,,508,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,452.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.0232,494.4364
STAPLER CONTOUR CURVED CUTTER,27200000,CDM,272,RC,,,,12064-MAIN,LOCAL,,,,,942,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,452.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STAPLER CONTOUR CURVED CUTTER,27200000,CDM,272,RC,,,,12064-MAIN,LOCAL,,,,,942,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,452.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Emergency Level IV Visit,PX99284P,CDM,981,RC,99284,CPT,,,,,,,,914,,Humana Choice Care,All Medicare plans,outpatient,49.5,,421.3001282,percent of total billed charges,452.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,379.6756,889.5962
tiotropium bromide monohydrate 2.5 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597010051,NDC,4,GR,461.7,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,452.466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
tiotropium bromide-olodaterol 2.5-2.5 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597015570,NDC,4,GR,461.7,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,452.466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Drainage of Hematoma/Fluid (P),PX10140P,CDM,983,RC,10140,CPT,,,,,,,,465,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,452.5845,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,193.161,1416.38
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102P,CDM,983,RC,11102,CPT,,,,,,,,465,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,143.07,percent of total billed charges,452.5845,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,452.5845
Exc Face Les Sc < 2 Cm,PX21011F,CDM,510,RC,21011,CPT,,,,,,,,943,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,452.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,391.7222,1416.38
Exc Face Les Sc < 2 Cm,PX21011F,CDM,510,RC,21011,CPT,,,,,,,,943,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,452.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,391.7222,1416.38
Cpap/Bipap Mgmnt-Pt Own Equipment,PX94660.02F,CDM,410,RC,94660,CPT,,,,,,,,497,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,452.767,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.33,487.06
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310002,NDC,0.528,ML,894.9,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,452.8194,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.22,877.002
Acute Hepatitis Panel,PX80074,CDM,300,RC,80074,CPT,,,,,,,,509,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,453.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,43.67,498.82
Biopsy of Rectum,PX45100P,CDM,983,RC,45100,CPT,,,,,,,,509,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,453.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.4386,2452.93
Xray Ribs Bil 3vws Tc,PX7111001,CDM,320,RC,71110,CPT,TC,,,,,,,533,,First Health,Commercial,both,85,,999999999,percent of total billed charges,453.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,522.34
"Needle Biopsy,Muscle",PX20206F,CDM,510,RC,20206,CPT,,,,,,,,258,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,453.13,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.55,453.13
"Needle Biopsy,Muscle",PX20206P,CDM,983,RC,20206,CPT,,,,,,,,1028,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,453.13,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.55,1007.44
"Closed Rx Bimalleolar Fx,Manip",PX27810P,CDM,983,RC,27810,CPT,,,,,,,,1057,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,453.453,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,439.0778,1404.08
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595F,CDM,360,RC,49595,CPT,,,,,,,,3503,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,453.53,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,453.53,1595.98
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595F,CDM,360,RC,49595,CPT,,,,,,,,3503,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,453.53,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,453.53,1595.98
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595P,CDM,982,RC,49595,CPT,,,,,,,,3503,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,453.53,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,453.53,3432.94
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595P,CDM,982,RC,49595,CPT,,,,,,,,3503,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,453.53,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,453.53,3432.94
"Exc Skn Malig1.1-2cm Fce,Facal",PX11642P,CDM,983,RC,11642,CPT,,,,,,,,466,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,453.5578,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,193.5764,614.65
"Bone Scan, Whole Body",PX7830601,CDM,341,RC,78306,CPT,TC,,,,,,,1896,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,453.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,153.58,453.61
"Bone Scan, Whole Body",PX7830601,CDM,341,RC,78306,CPT,TC,,,,,,,1896,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,453.61,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,153.58,453.61
fidaxomicin 200 MG Tablet 20 Each Bottle,25000000,CDM,250,RC,,,,,,52015008001,NDC,1,EA,945.16,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,453.6768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fidaxomicin 200 MG Tablet 20 Each Bottle,25000000,CDM,250,RC,,,,,,52015008001,NDC,1,EA,945.16,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,453.6768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Gastric Intubation Treatment,PX43753P,CDM,983,RC,43753,CPT,,,,,,,,498,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,453.678,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.8692,484.7034
"POS Airway Pressure, Cpap",PX94660F,CDM,410,RC,94660,CPT,,,,,,,,498,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,453.678,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.33,488.04
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605F,CDM,510,RC,24605,CPT,,,,,,,,1124,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,453.7143,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,304.32,1019.71
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605P,CDM,983,RC,24605,CPT,,,,,,,,750,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,453.7143,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,304.32,1019.71
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022101,NDC,1,EA,514.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,453.789,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022185,NDC,1,EA,514.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,453.789,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022189,NDC,1,EA,514.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,453.789,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
Calr Gene Analysis Common Variants in Exon 9 - Ref,PX8121990,CDM,300,RC,81219,CPT,90,,,,,,,534,,First Health,Commercial,both,85,,999999999,percent of total billed charges,453.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.52,523.32
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016410,NDC,1,ML,917.08,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,453.9546,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.66,898.7384
cefdinir 250 MG/5ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,16714039301,NDC,60,ML,510.33,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,454.1937,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
I&D Deep Absc/Hematoma Neck/Chest,PX21501P,CDM,983,RC,21501,CPT,,,,,,,,515,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,454.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.931,2482.37
Amputation Finger/Thumb,PX26951F,CDM,510,RC,26951,CPT,,,,,,,,3253,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,454.41,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,454.41,1480.45
Amputation Finger/Thumb,PX26951P,CDM,983,RC,26951,CPT,,,,,,,,2603,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,454.41,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,454.41,2550.94
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595F,CDM,360,RC,49595,CPT,,,,,,,,3503,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,454.41,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,453.53,1595.98
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595P,CDM,982,RC,49595,CPT,,,,,,,,3503,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,454.41,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,453.53,3432.94
mometasone - formoterol 100-5 MCG/ACT Aerosol 8.8 g Inhaler,25000000,CDM,250,RC,,,,,,85720607,NDC,8.8,GR,918.07,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,454.44465,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
mometasone - formoterol 200-5 MCG/ACT Aerosol 8.8 g Inhaler,25000000,CDM,250,RC,,,,,,85461005,NDC,8.8,GR,918.07,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,454.44465,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Hospital Inpt or Obs Care, Admin/Disch Same Date Straightforward or Low Level Mdm >= 45 Minutes",PX99234,CDM,982,RC,99234,CPT,,,,,,,,464,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,454.72,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,61.32,454.72
Naso/Orogastric Tube,PX43752F,CDM,510,RC,43752,CPT,,,,,,,,464,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,454.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.7456,454.72
rho d immune globulin human 1500 units solution prefilled syringe 1 Each Syringe,J2790.01,CDM,636,RC,J2790,HCPCS,,,,562780500,NDC,1,EA,464.01,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,454.7298,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.749754,454.7298
CARTER THOMASON CLOSURE SUTURE PASSER XL 10/12MM 15MM CTXL,27200000,CDM,272,RC,,,,12946-MAIN,LOCAL,,,,,535,,First Health,Commercial,both,85,,999999999,percent of total billed charges,454.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121F,CDM,510,RC,13121,CPT,,,,,,,,948,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,455.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,393.7992,929.04
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121F,CDM,510,RC,13121,CPT,,,,,,,,948,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,455.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,393.7992,929.04
Closed Rx Shldr Dislocation,PX23650P,CDM,983,RC,23650,CPT,,,,,,,,516,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,455.112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,502.2228
Trg Gene Rearrangement Anal - Ref,PX8134290,CDM,300,RC,81342,CPT,90,,,,,,,516,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,455.112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,184.76,505.68
"Critical Care, E/M 30-74 Minutes",PX99291P,CDM,983,RC,99291,CPT,,,,,,,,1061,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,455.169,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,440.7394,1032.6713
"I&D Perianal Abscess,Superficial",PX46050,CDM,983,RC,46050,CPT,,,,,,,,1096,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,455.2784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,455.2784,1066.7368
MIS STERILE INSTRUMENT PACK WITH BLADE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12432-MAIN,LOCAL,,,,,900,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,455.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Sigmoidoscope W/Submuc Inj,PX45335P,CDM,983,RC,45335,CPT,,,,,,,,500,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,455.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,207.7,798.45
Closed Rx Kneecap Dislocatn,PX27560F,CDM,510,RC,27560,CPT,,,,,,,,468,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,455.5044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,194.4072,458.64
"POS Airway Pressure, Bipap",PX94660.01F,CDM,410,RC,94660,CPT,,,,,,,,468,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,455.5044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.33,458.64
Vedolizumab - Ref,PX8028090,CDM,300,RC,80280,CPT,90,,,,,,,468,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,455.5044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.36,458.64
Aspirate Pleura W/ Imaging,PX32555P,CDM,983,RC,32555,CPT,,,,,,,,536,,First Health,Commercial,both,85,,999999999,percent of total billed charges,455.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,222.6544,548.81
Lvl 3 Init Hosp High Mdm or 75 Minutes,PX99223,CDM,982,RC,99223,CPT,,,,,,,,536,,First Health,Commercial,both,85,,999999999,percent of total billed charges,455.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,222.6544,521.6888
DRIVER HEX 2.00MM STERILE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12440-MAIN,LOCAL,,,,,512,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,455.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRIVER HEX 2.5MM STERILE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12441-MAIN,LOCAL,,,,,512,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,455.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Amputation Metatarsal+Toe,Single",PX28810F,CDM,510,RC,28810,CPT,,,,,,,,930,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,455.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.322,2827.75
"Amputation Metatarsal+Toe,Single",PX28810F,CDM,510,RC,28810,CPT,,,,,,,,930,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,455.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.322,2827.75
"Amputation Metatarsal+Toe,Single",PX28810F,CDM,510,RC,28810,CPT,,,,,,,,930,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,455.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.322,2827.75
Colonoscopy,PX44388F,CDM,750,RC,44388,CPT,,,,,,,,930,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,455.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.322,911.4
Colonoscopy,PX44388F,CDM,750,RC,44388,CPT,,,,,,,,930,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,455.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.322,911.4
Colonoscopy,PX44388F,CDM,750,RC,44388,CPT,,,,,,,,930,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,455.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.322,911.4
Drainage of Hematoma/Fluid (P),PX10140P,CDM,983,RC,10140,CPT,,,,,,,,465,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,455.7,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.17,455.7
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102P,CDM,983,RC,11102,CPT,,,,,,,,465,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,455.7,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.56,455.7
Amputation Finger/Thumb,PX26951F,CDM,510,RC,26951,CPT,,,,,,,,3253,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,456.15,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,454.41,1480.45
Amputation Finger/Thumb,PX26951F,CDM,510,RC,26951,CPT,,,,,,,,3253,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,456.15,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,454.41,1480.45
Amputation Finger/Thumb,PX26951P,CDM,983,RC,26951,CPT,,,,,,,,2603,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,456.15,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,454.41,2550.94
Amputation Finger/Thumb,PX26951P,CDM,983,RC,26951,CPT,,,,,,,,2603,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,456.15,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,454.41,2550.94
"Fusion Foot Bones,Midtarsal,Multi",PX28730F,CDM,510,RC,28730,CPT,,,,,,,,2299,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,456.15,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,456.15,1517.12
Fac/Exc Skn Beni 0.6-1cm Remain Bdy,PX11421F,CDM,510,RC,11421,CPT,,,,,,,,931,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,456.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.7374,912.38
Fac/Exc Skn Beni 0.6-1cm Remain Bdy,PX11421F,CDM,510,RC,11421,CPT,,,,,,,,931,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,456.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.7374,912.38
Fac/Exc Skn Beni 0.6-1cm Remain Bdy,PX11421F,CDM,510,RC,11421,CPT,,,,,,,,931,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,456.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.7374,912.38
Fac/Exc Skn Bngn3.1-4cm Remain Bdy,PX11424F,CDM,510,RC,11424,CPT,,,,,,,,931,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,456.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.7374,1416.38
Fac/Exc Skn Bngn3.1-4cm Remain Bdy,PX11424F,CDM,510,RC,11424,CPT,,,,,,,,931,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,456.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.7374,1416.38
Fac/Exc Skn Bngn3.1-4cm Remain Bdy,PX11424F,CDM,510,RC,11424,CPT,,,,,,,,931,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,456.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.7374,1416.38
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034F,CDM,510,RC,12034,CPT,,,,,,,,931,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,456.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,912.38
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034F,CDM,510,RC,12034,CPT,,,,,,,,931,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,456.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,912.38
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034F,CDM,510,RC,12034,CPT,,,,,,,,931,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,456.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,912.38
"Exc Skn Malig1.1-2cm Fce,Facal",PX11642P,CDM,983,RC,11642,CPT,,,,,,,,466,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,456.68,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,113.87,558.97
Incise Finger Tendon Sheath,PX26055P,CDM,983,RC,26055,CPT,,,,,,,,932,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,502.8,percent of total billed charges,456.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,387.1528,1404.08
Incise Finger Tendon Sheath,PX26055P,CDM,983,RC,26055,CPT,,,,,,,,932,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,456.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,387.1528,1404.08
Incise Finger Tendon Sheath,PX26055P,CDM,983,RC,26055,CPT,,,,,,,,932,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,456.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,387.1528,1404.08
"Blood Gases: Ph, Po2 & Pco2",PX82803,CDM,300,RC,82803,CPT,,,,,,,,518,,United Healthcare,All Payer,outpatient,88.2,,332.505,percent of total billed charges,456.876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.9,507.64
Reconstruc of Nail Bed,PX11760P,CDM,983,RC,11760,CPT,,,,,,,,903,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,456.918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,375.1062,878.8899
Biopsy Synovium I-P Jt,PX26110,CDM,983,RC,26110,CPT,,,,,,,,933,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,457.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,387.5682,1404.08
Biopsy Synovium I-P Jt,PX26110,CDM,983,RC,26110,CPT,,,,,,,,933,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,457.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,387.5682,1404.08
Biopsy Synovium I-P Jt,PX26110,CDM,983,RC,26110,CPT,,,,,,,,933,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,457.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,387.5682,1404.08
"Chemotherapy, IV Push, Single Drug",PX96409,CDM,335,RC,96409,CPT,,,,,,,,502,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,457.322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.5308,491.96
Incise External Hemorrhoid,PX46083F,CDM,510,RC,46083,CPT,,,,,,,,502,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,457.322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.5308,491.96
"Inject Nerv Blck,Othr Periph Nerv",PX64450P,CDM,983,RC,64450,CPT,,,,,,,,904,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,457.424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,375.5216,879.8632
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,548590000,NDC,1,EA,470.19,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,457.635927,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,179.012476,460.7862
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060002,NDC,2,ML,953.57,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,457.7136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.11,934.4986
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060002,NDC,2,ML,953.57,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,457.7136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.11,934.4986
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060010,NDC,2,ML,953.57,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,457.7136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.11,934.4986
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060010,NDC,2,ML,953.57,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,457.7136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.11,934.4986
Debride Skin/Tissue,PX11042F,CDM,510,RC,11042,CPT,,,,,,,,1067,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,457.743,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1045.66
Xray Ac Joints(Bilateral),PX7305001,CDM,320,RC,73050,CPT,TC,,,,,,,519,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,457.758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,508.62
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,64950036204,NDC,4,ML,1067.22,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,457.83738,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022101,NDC,1,EA,514.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,457.905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022185,NDC,1,EA,514.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,457.905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022189,NDC,1,EA,514.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,457.905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
CP LAG SCREW 3.6MM L22MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12757-MAIN,LOCAL,,,,,539,,First Health,Commercial,both,85,,999999999,percent of total billed charges,458.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
CP LAG SCREW 3.6MM L24MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12650-MAIN,LOCAL,,,,,539,,First Health,Commercial,both,85,,999999999,percent of total billed charges,458.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
CP LAG SCREW 3.6MM L26MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12636-MAIN,LOCAL,,,,,539,,First Health,Commercial,both,85,,999999999,percent of total billed charges,458.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004004,NDC,120,ML,502.95,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,458.18745,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
Trb@ Gene Rearrange Amplify - Ref,PX8134090,CDM,300,RC,81340,CPT,90,,,,,,,503,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,458.233,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,191.56,492.94
I&D Deep Absc/Hematoma Neck/Chest,PX21501P,CDM,983,RC,21501,CPT,,,,,,,,515,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,458.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.931,2482.37
Closed Rx Kneecap Dislocatn,PX27560F,CDM,510,RC,27560,CPT,,,,,,,,468,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,458.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,194.4072,458.64
"POS Airway Pressure, Bipap",PX94660.01F,CDM,410,RC,94660,CPT,,,,,,,,468,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,458.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.33,458.64
Vedolizumab - Ref,PX8028090,CDM,300,RC,80280,CPT,90,,,,,,,468,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,458.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.36,458.64
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,121090204,NDC,120,ML,503.56,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,458.74316,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
Xray Sacrum/ Coccyx Minimum 2 Vws,PX7222001,CDM,320,RC,72220,CPT,TC,,,,,,,540,,First Health,Commercial,both,85,,999999999,percent of total billed charges,459,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,529.2
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607F,CDM,761,RC,97607,CPT,,,,,,,,455,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,459.07,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.42,459.07
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607P,CDM,983,RC,97607,CPT,,,,,,,,303,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,459.07,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.42,459.07
"Fusion Foot Bones,Midtarsal,Multi",PX28730F,CDM,510,RC,28730,CPT,,,,,,,,2299,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,459.2,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,456.15,1517.12
"Fusion Foot Bones,Midtarsal,Multi",PX28730F,CDM,510,RC,28730,CPT,,,,,,,,2299,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,459.2,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,456.15,1517.12
Closed Rx Shldr Dislocation,PX23650P,CDM,983,RC,23650,CPT,,,,,,,,516,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,459.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,502.2228
Trg Gene Rearrangement Anal - Ref,PX8134290,CDM,300,RC,81342,CPT,90,,,,,,,516,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,459.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,184.76,505.68
"Removal of Tunnel Cv Access Device, With Port/Pump",PX36590P,CDM,983,RC,36590,CPT,,,,,,,,1147,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,459.36,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.39,1124.06
"OB US < 14 Wks, Single Fetus - Radiology, Tech",PX7680101,CDM,402,RC,76801,CPT,TC,,,,,,,472,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,428.755,percent of total billed charges,459.3976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,462.56
US Pelvic Tc Complete,PX7685601,CDM,402,RC,76856,CPT,TC,,,,,,,472,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,379.9134783,percent of total billed charges,459.3976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,462.56
US Transvaginal Tc,PX7683001,CDM,402,RC,76830,CPT,TC,,,,,,,472,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,299.62,percent of total billed charges,459.3976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,462.56
budesonide-formoterol 80-4.5 MCG/ACT Aerosol 6.9 g Inhaler,63700001,CDM,250,RC,,,,,,186037228,NDC,6.9,GR,937.58,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,459.4142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
budesonide-formoterol 80-4.5 MCG/ACT Aerosol 6.9 g Inhaler,63700001,CDM,250,RC,,,,,,186037228,NDC,6.9,GR,937.58,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,459.4142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
budesonide-formoterol 80-4.5 MCG/ACT Aerosol 6.9 g Inhaler,63700001,CDM,250,RC,,,,,,186037228,NDC,6.9,GR,937.58,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,459.4142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Destruct Benign Lesion, 1-14",PX17110P,CDM,983,RC,17110,CPT,,,,,,,,521,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,459.522,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,507.0893
Exc Abdom Tum Subfac > 5 Cm,PX22901P,CDM,983,RC,22901,CPT,,,,,,,,938,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,459.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,389.6452,2482.37
Exc Abdom Tum Subfac > 5 Cm,PX22901P,CDM,983,RC,22901,CPT,,,,,,,,938,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,459.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,389.6452,2482.37
Exc Abdom Tum Subfac > 5 Cm,PX22901P,CDM,983,RC,22901,CPT,,,,,,,,938,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,459.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,389.6452,2482.37
Diagnostic Anoscopy,PX46600F,CDM,510,RC,46600,CPT,,,,,,,,505,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,460.055,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,494.9
"Amputation Metatarsal+Toe,Single",PX28810F,CDM,510,RC,28810,CPT,,,,,,,,930,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,460.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.322,2827.75
Colonoscopy,PX44388F,CDM,750,RC,44388,CPT,,,,,,,,930,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,460.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.322,911.4
Closed Rx Trimalleolar Fx,PX27816F,CDM,510,RC,27816,CPT,,,,,,,,522,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,460.404,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,511.56
Xray Thoracic Spine 3 Vws,PX7207201,CDM,320,RC,72072,CPT,TC,,,,,,,522,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,460.404,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,511.56
"Critical Care, Addl 30 Min",PX99292P,CDM,983,RC,99292,CPT,,,,,,,,542,,First Health,Commercial,both,85,,999999999,percent of total billed charges,460.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,225.1468,527.5286
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,548590000,NDC,1,EA,470.19,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,460.7862,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,179.012476,460.7862
Fac/Exc Skn Beni 0.6-1cm Remain Bdy,PX11421F,CDM,510,RC,11421,CPT,,,,,,,,931,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,460.845,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.7374,912.38
Fac/Exc Skn Bngn3.1-4cm Remain Bdy,PX11424F,CDM,510,RC,11424,CPT,,,,,,,,931,,Humana Choice Care,All Medicare plans,outpatient,49.5,,1207.36,percent of total billed charges,460.845,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.7374,1416.38
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034F,CDM,510,RC,12034,CPT,,,,,,,,931,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,460.845,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,912.38
"Blood Gases: Ph, Po2 & Pco2",PX82803,CDM,300,RC,82803,CPT,,,,,,,,518,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,461.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.9,507.64
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527197174,NDC,4,ML,960.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,461.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527197174,NDC,4,ML,960.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,461.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
"Repair Umbilical Hern,5+Y/O,Strang",PX49587F,CDM,510,RC,49587,CPT,,,,,,,,1110,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,461.094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,461.094,1087.8
dorzolamide-timolol 2-0.5 % Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,50383023310,NDC,10,ML,506.34,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,461.27574,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545F,CDM,510,RC,23545,CPT,,,,,,,,961,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,461.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,941.78
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545F,CDM,510,RC,23545,CPT,,,,,,,,961,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,461.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,941.78
Layr Clos Wnd Rest Body 7.6-12.5,PX12044P,CDM,983,RC,12044,CPT,,,,,,,,523,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,461.286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,217.2542,548.67
Incise Finger Tendon Sheath,PX26055P,CDM,983,RC,26055,CPT,,,,,,,,932,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,461.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,387.1528,1404.08
Apply Long Leg Cast,PX29345F,CDM,510,RC,29345,CPT,,,,,,,,912,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,461.472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,234.62,893.76
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598030562,NDC,1,EA,912,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,461.472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
Open Bx/Excision Inguinofemoral Nodes,PX38531F,CDM,510,RC,38531,CPT,,,,,,,,912,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,461.472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,378.8448,3329.99
gentamicin 0.1 % Ointment 30 g Tube,25000000,CDM,250,RC,,,,,,713068231,NDC,30,GR,506.64,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,461.54904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Exc Skn Bngn2.1-3cmtrnk,Arm,Lg",PX11403P,CDM,983,RC,11403,CPT,,,,,,,,543,,First Health,Commercial,both,85,,999999999,percent of total billed charges,461.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,225.5622,614.65
Xray Knee (Both) Ap Stand,PX7356501,CDM,320,RC,73565,CPT,TC,,,,,,,543,,First Health,Commercial,both,85,,999999999,percent of total billed charges,461.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,532.14
STAPLER CONTOUR CURVED CUTTER,27200000,CDM,272,RC,,,,12064-MAIN,LOCAL,,,,,942,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,461.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STAPLER CONTOUR CURVED CUTTER,27200000,CDM,272,RC,,,,12064-MAIN,LOCAL,,,,,942,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,461.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STAPLER CONTOUR CURVED CUTTER,27200000,CDM,272,RC,,,,12064-MAIN,LOCAL,,,,,942,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,461.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Lap,Inguinal Hernia Repr,Initial",PX49650F,CDM,510,RC,49650,CPT,,,,,,,,1076,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,461.604,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,446.9704,5040.74
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221901,NDC,3,ML,506.9,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,461.7859,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221905,NDC,3,ML,506.9,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,461.7859,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
Biopsy Synovium I-P Jt,PX26110,CDM,983,RC,26110,CPT,,,,,,,,933,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,461.835,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,387.5682,1404.08
Xray Ac Joints(Bilateral),PX7305001,CDM,320,RC,73050,CPT,TC,,,,,,,519,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,461.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,508.62
Unlisted Molecular Path Proc - Ref,PX8147990,CDM,310,RC,81479,CPT,90,,,,,,,1077,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,462.033,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,447.3858,1055.46
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752F,CDM,510,RC,27752,CPT,,,,,,,,2280,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,462.0629,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.64,1144.93
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752P,CDM,983,RC,27752,CPT,,,,,,,,2495,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,462.0629,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.64,2445.1
"Closed Rx Weight Bear Dist Tib,Manip",PX27825F,CDM,510,RC,27825,CPT,,,,,,,,2695,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,462.0629,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.21,1163.61
"Closed Rx Weight Bear Dist Tib,Manip",PX27825P,CDM,983,RC,27825,CPT,,,,,,,,1796,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,462.0629,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.21,1760.08
Exc Face Les Sc < 2 Cm,PX21011F,CDM,510,RC,21011,CPT,,,,,,,,943,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,462.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,391.7222,1416.38
Exc Face Les Sc < 2 Cm,PX21011F,CDM,510,RC,21011,CPT,,,,,,,,943,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,462.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,391.7222,1416.38
Exc Face Les Sc < 2 Cm,PX21011F,CDM,510,RC,21011,CPT,,,,,,,,943,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,462.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,391.7222,1416.38
Bcr/Abl1 Minor - Ref,PX8120790,CDM,310,RC,81207,CPT,90,,,,,,,1113,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,462.3402,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.8,1090.74
MICA BURR 2X12MM STERILE MICA,27200000,CDM,272,RC,,,,12447-MAIN,LOCAL,,,,,1113,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,462.3402,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA BURR 2X20MM STERILE MICA,27200000,CDM,272,RC,,,,12448-MAIN,LOCAL,,,,,1113,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,462.3402,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA CUTTING BURR 3X20MM LONG MICA,27200000,CDM,272,RC,,,,12434-MAIN,LOCAL,,,,,1113,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,462.3402,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA WEDGE BURR 3.1X13MM STERILE,27200000,CDM,272,RC,,,,12435-MAIN,LOCAL,,,,,1113,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,462.3402,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Emergency Level IV Visit,PX99284P,CDM,981,RC,99284,CPT,,,,,,,,914,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,462.484,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,379.6756,889.5962
"OB US < 14 Wks, Single Fetus - Radiology, Tech",PX7680101,CDM,402,RC,76801,CPT,TC,,,,,,,472,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,462.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,462.56
US Pelvic Tc Complete,PX7685601,CDM,402,RC,76856,CPT,TC,,,,,,,472,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,462.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,462.56
US Transvaginal Tc,PX7683001,CDM,402,RC,76830,CPT,TC,,,,,,,472,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,462.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,462.56
budesonide-formoterol 160-4.5 MCG/ACT Aerosol 6 g Inhaler,63700001,CDM,250,RC,,,,,,186037028,NDC,6,GR,1078.55,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,462.69795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604F,CDM,510,RC,11604,CPT,,,,,,,,964,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,462.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,400.4456,944.72
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604F,CDM,510,RC,11604,CPT,,,,,,,,964,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,462.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,400.4456,944.72
diazePAM 2.5 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,68682065020,NDC,1,EA,1114.05,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,462.77637,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Inpatient Consult, Level IV",PX99254,CDM,983,RC,99254,CPT,,,,,,,,508,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,462.788,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.0232,494.4364
Lvl 2 Init Hosp Mod Mdm or 55 Minutes,PX99222,CDM,982,RC,99222,CPT,,,,,,,,508,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,462.788,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.0232,494.4364
Anal Sphincterotomy,PX46080P,CDM,983,RC,46080,CPT,,,,,,,,525,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,463.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,218.085,2452.93
fidaxomicin 200 MG Tablet 20 Each Bottle,25000000,CDM,250,RC,,,,,,52015008001,NDC,1,EA,945.16,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,463.1284,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fidaxomicin 200 MG Tablet 20 Each Bottle,25000000,CDM,250,RC,,,,,,52015008001,NDC,1,EA,945.16,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,463.1284,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fidaxomicin 200 MG Tablet 20 Each Bottle,25000000,CDM,250,RC,,,,,,52015008001,NDC,1,EA,945.16,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,463.1284,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Closed Rx Kneecap Disloc+Anesth,PX27562F,CDM,510,RC,27562,CPT,,,,,,,,604,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,463.6684,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.64,1044.62
Closed Rx Kneecap Disloc+Anesth,PX27562P,CDM,983,RC,27562,CPT,,,,,,,,1404,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,463.6684,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.64,1375.92
"Destruct Benign Lesion, 1-14",PX17110P,CDM,983,RC,17110,CPT,,,,,,,,521,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,463.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,507.0893
Acute Hepatitis Panel,PX80074,CDM,300,RC,80074,CPT,,,,,,,,509,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,463.699,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,43.67,498.82
Biopsy of Rectum,PX45100P,CDM,983,RC,45100,CPT,,,,,,,,509,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,463.699,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.4386,2452.93
Debride Tissue/Muscle,PX11043F,CDM,510,RC,11043,CPT,,,,,,,,526,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,463.932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,218.5004,548.67
Hfe Gene - Ref,PX8125690,CDM,300,RC,81256,CPT,90,,,,,,,526,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,463.932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,59.93,515.48
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016410,NDC,1,ML,917.08,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,464.04248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.66,898.7384
budesonide-formoterol 80-4.5 MCG/ACT Aerosol 6.9 g Inhaler,63700001,CDM,250,RC,,,,,,186037228,NDC,6.9,GR,937.58,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,464.1021,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Debride Tissue/Muscle/Bone,PX11044F,CDM,510,RC,11044,CPT,,,,,,,,1082,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,464.178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,449.4628,1416.38
Exc Abdom Tum Subfac > 5 Cm,PX22901P,CDM,983,RC,22901,CPT,,,,,,,,938,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,464.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,389.6452,2482.37
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121F,CDM,510,RC,13121,CPT,,,,,,,,948,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,464.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,393.7992,929.04
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121F,CDM,510,RC,13121,CPT,,,,,,,,948,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,464.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,393.7992,929.04
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121F,CDM,510,RC,13121,CPT,,,,,,,,948,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,464.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,393.7992,929.04
mometasone - formoterol 100-5 MCG/ACT Aerosol 8.8 g Inhaler,25000000,CDM,250,RC,,,,,,85720607,NDC,8.8,GR,918.07,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,464.54342,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
mometasone - formoterol 200-5 MCG/ACT Aerosol 8.8 g Inhaler,25000000,CDM,250,RC,,,,,,85461005,NDC,8.8,GR,918.07,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,464.54342,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Closed Rx Trimalleolar Fx,PX27816F,CDM,510,RC,27816,CPT,,,,,,,,522,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,464.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,511.56
Xray Thoracic Spine 3 Vws,PX7207201,CDM,320,RC,72072,CPT,TC,,,,,,,522,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,464.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,511.56
Closed Rx Femur Shaft Fx+Manip,PX27502P,CDM,983,RC,27502,CPT,,,,,,,,1083,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,464.607,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,449.8782,1404.08
Debride Tissue/Muscle/Bone,PX11044F,CDM,510,RC,11044,CPT,,,,,,,,1082,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,464.89,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.56,646.83
Debride Tissue/Muscle/Bone,PX11044P,CDM,983,RC,11044,CPT,,,,,,,,866,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,464.89,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.56,848.68
cefdinir 250 MG/5ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,16714039301,NDC,60,ML,510.33,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,464.91063,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
collagenase 250 UNIT/GM Ointment 30 g Tube,63700001,CDM,250,RC,,,,,,50484001030,NDC,30,GR,1083.77,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,464.93733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,63323077139,NDC,1,EA,547.2,,First Health,Commercial,both,85,,999999999,percent of total billed charges,465.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
"Repair Umbilical Hern,5+Y/O,Reduc",PX49585F,CDM,510,RC,49585,CPT,,,,,,,,969,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,465.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,402.5226,949.62
"Repair Umbilical Hern,5+Y/O,Reduc",PX49585F,CDM,510,RC,49585,CPT,,,,,,,,969,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,465.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,402.5226,949.62
Egd Balloon Dil Esoph30 Mm/>,PX43233F,CDM,750,RC,43233,CPT,,,,,,,,1120,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,465.248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,465.248,1662.33
"Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602P,CDM,983,RC,11602,CPT,,,,,,,,1120,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,465.248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1090.096
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830P,CDM,983,RC,15830,CPT,,,,,,,,1120,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,465.248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,465.248,5696.92
"Remv F.B.,Eye,Ant Chmbr/Lens",PX65235F,CDM,510,RC,65235,CPT,,,,,,,,2788,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,465.32,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,465.32,1508.82
Layr Clos Wnd Rest Body 7.6-12.5,PX12044P,CDM,983,RC,12044,CPT,,,,,,,,523,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,465.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,217.2542,548.67
"Closed Rx Spont Hip Disloc,Anesth",PX27257F,CDM,510,RC,27257,CPT,,,,,,,,548,,First Health,Commercial,both,85,,999999999,percent of total billed charges,465.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.6392,1404.08
BRACE KNEE LARGE SHORTRUNNER 21754,120.387,CDM,274,RC,L1833,HCPCS,,10044-MAIN,LOCAL,,,,,101,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,466.1433,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.1433,634.77
BRACE KNEE MEDIUM SHORTRUNNER 21753,120.387,CDM,274,RC,L1833,HCPCS,,10126-MAIN,LOCAL,,,,,101,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,466.1433,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.1433,634.77
BRACE KNEE SMALL SHORTRUNNER 21752,120.387,CDM,274,RC,L1833,HCPCS,,10900-MAIN,LOCAL,,,,,101,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,466.1433,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.1433,634.77
BRACE KNEE X-LARGE SHORTRUNNER 21755,120.387,CDM,274,RC,L1833,HCPCS,,3444-MAIN,LOCAL,,,,,101,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,466.1433,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.1433,634.77
BRACE KNEE XX-LARGE SHORTRUNNER 21756,120.387,CDM,274,RC,L1833,HCPCS,,10615-MAIN,LOCAL,,,,,101,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,466.1433,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.1433,634.77
Closed Rx Femur Shaft Fx+Manip,PX27502F,CDM,510,RC,27502,CPT,,,,,,,,1625,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,466.19,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.19,1580.76
Closed Rx Femur Shaft Fx+Manip,PX27502P,CDM,983,RC,27502,CPT,,,,,,,,1083,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,466.19,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.19,1580.76
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384F,CDM,750,RC,45384,CPT,,,,,,,,2350,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,466.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.09,1011.41
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384P,CDM,983,RC,45384,CPT,,,,,,,,1436,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,466.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.09,1407.28
STAPLER CONTOUR CURVED CUTTER,27200000,CDM,272,RC,,,,12064-MAIN,LOCAL,,,,,942,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,466.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Irrad/Lr Platelets,PXP9037,CDM,390,RC,P9037,HCPCS,,,,,,,,1617,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,466.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.33,783.04
Irrad/Lr Platelets,PXP9037,CDM,390,RC,P9037,HCPCS,,,,,,,,1617,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,466.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.33,783.04
Irrad/Lr Platelets,PXP9037,CDM,390,RC,P9037,HCPCS,,,,,,,,1617,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,466.33,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.33,783.04
Leukoreduced Platelets,PXP9035,CDM,390,RC,P9035,HCPCS,,,,,,,,1350,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,466.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.33,783.04
Leukoreduced Platelets,PXP9035,CDM,390,RC,P9035,HCPCS,,,,,,,,1350,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,466.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.33,783.04
Leukoreduced Platelets,PXP9035,CDM,390,RC,P9035,HCPCS,,,,,,,,1350,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,466.33,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.33,783.04
DRIVER HEX 2.00MM STERILE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12440-MAIN,LOCAL,,,,,512,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,466.432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRIVER HEX 2.5MM STERILE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12441-MAIN,LOCAL,,,,,512,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,466.432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Remove Nasal Foreign Body,PX30300F,CDM,510,RC,30300,CPT,,,,,,,,972,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,466.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,952.56
Remove Nasal Foreign Body,PX30300F,CDM,510,RC,30300,CPT,,,,,,,,972,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,466.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,952.56
Excis Primary Ganglion Wrist,PX25111P,CDM,983,RC,25111,CPT,,,,,,,,529,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,466.578,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,219.7466,1404.08
fluticasone-vilanterol 200-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173088214,NDC,28,EA,1087.68,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,466.61472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Cv Carotid Imaging-Bilat,PX9388001,CDM,921,RC,93880,CPT,TC,,,,,,,1088,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,466.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,1066.24
Exc Face Les Sc < 2 Cm,PX21011F,CDM,510,RC,21011,CPT,,,,,,,,943,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,466.785,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,391.7222,1416.38
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605F,CDM,510,RC,24605,CPT,,,,,,,,1124,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,466.9096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.9096,1404.08
Anus Surgery Procedure Unlisted,PX46999P,CDM,983,RC,46999,CPT,,,,,,,,953,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,466.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,395.8762,927.5549
Anus Surgery Procedure Unlisted,PX46999P,CDM,983,RC,46999,CPT,,,,,,,,953,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,466.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,395.8762,927.5549
Anus Surgery Procedure Unlisted,PX46999P,CDM,983,RC,46999,CPT,,,,,,,,953,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,466.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,395.8762,927.5549
"Genital Surg Proc,Male Unlisted",PX55899P,CDM,983,RC,55899,CPT,,,,,,,,953,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,466.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,215.91,927.5549
"Genital Surg Proc,Male Unlisted",PX55899P,CDM,983,RC,55899,CPT,,,,,,,,953,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,466.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,215.91,927.5549
"Genital Surg Proc,Male Unlisted",PX55899P,CDM,983,RC,55899,CPT,,,,,,,,953,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,466.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,215.91,927.5549
I&D Perirectal Abscess,PX46040P,CDM,983,RC,46040,CPT,,,,,,,,953,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,466.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,395.8762,1030.93
I&D Perirectal Abscess,PX46040P,CDM,983,RC,46040,CPT,,,,,,,,953,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,466.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,395.8762,1030.93
I&D Perirectal Abscess,PX46040P,CDM,983,RC,46040,CPT,,,,,,,,953,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,466.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,395.8762,1030.93
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081543,NDC,1,ML,479.89,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,467.076937,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.346306,470.2922
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081552,NDC,1,ML,479.89,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,467.076937,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.346306,470.2922
Egd Balloon Dil Esoph30 Mm/>,PX43233P,CDM,983,RC,43233,CPT,,,,,,,,480,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,467.184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.392,1662.33
"Sigmoidoscopy,Diagnostic",PX45330P,CDM,983,RC,45330,CPT,,,,,,,,480,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,467.184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.392,798.45
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060002,NDC,2,ML,953.57,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,467.2493,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.11,934.4986
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060002,NDC,2,ML,953.57,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,467.2493,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.11,934.4986
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060002,NDC,2,ML,953.57,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,467.2493,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.11,934.4986
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060010,NDC,2,ML,953.57,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,467.2493,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.11,934.4986
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060010,NDC,2,ML,953.57,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,467.2493,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.11,934.4986
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060010,NDC,2,ML,953.57,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,467.2493,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.11,934.4986
Anal Sphincterotomy,PX46080P,CDM,983,RC,46080,CPT,,,,,,,,525,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,467.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,218.085,2452.93
Bcr/Abl1 Other - Ref,PX8120890,CDM,310,RC,81208,CPT,90,,,,,,,1125,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,467.325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,196.79,1102.5
"Remv Foreign Body,Knee/Thigh,Deep",PX27372P,CDM,983,RC,27372,CPT,,,,,,,,954,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,467.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,396.2916,2482.37
"Remv Foreign Body,Knee/Thigh,Deep",PX27372P,CDM,983,RC,27372,CPT,,,,,,,,954,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,467.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,396.2916,2482.37
"Remv Foreign Body,Knee/Thigh,Deep",PX27372P,CDM,983,RC,27372,CPT,,,,,,,,954,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,467.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,396.2916,2482.37
"Repair Ing Hernia,5+Y/O,Reducibl",PX49505P,CDM,983,RC,49505,CPT,,,,,,,,2048,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,467.5216,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,315.88,2007.04
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762F,CDM,510,RC,43762,CPT,,,,,,,,492,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,467.66,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.03,467.66
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762P,CDM,983,RC,43762,CPT,,,,,,,,328,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,467.66,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.03,467.66
Closed Rx Femur Shaft Fx+Manip,PX27502F,CDM,510,RC,27502,CPT,,,,,,,,1625,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,467.71,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.19,1580.76
Closed Rx Femur Shaft Fx+Manip,PX27502F,CDM,510,RC,27502,CPT,,,,,,,,1625,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,467.71,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.19,1580.76
Closed Rx Femur Shaft Fx+Manip,PX27502P,CDM,983,RC,27502,CPT,,,,,,,,1083,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,467.71,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.19,1580.76
Closed Rx Femur Shaft Fx+Manip,PX27502P,CDM,983,RC,27502,CPT,,,,,,,,1083,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,467.71,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.19,1580.76
fidaxomicin 200 MG Tablet 20 Each Bottle,25000000,CDM,250,RC,,,,,,52015008001,NDC,1,EA,945.16,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,467.8542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Debride Tissue/Muscle,PX11043F,CDM,510,RC,11043,CPT,,,,,,,,526,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,468.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,218.5004,548.67
Hfe Gene - Ref,PX8125690,CDM,300,RC,81256,CPT,90,,,,,,,526,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,468.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,59.93,515.48
"Fac/Exc Skn Benig >4cm Trnk,Arm,Lg",PX11406F,CDM,510,RC,11406,CPT,,,,,,,,1127,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,468.1558,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,468.1558,1416.38
Multiple Sleep Latency Test,PX9580501,CDM,740,RC,95805,CPT,TC,,,,,,,4313,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,468.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,468.24,4226.74
"Supply Technetium Medronate,to 30 MC",PXA9503,CDM,343,RC,A9503,HCPCS,,,,,,,,531,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,468.342,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,220.5774,520.38
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031P,CDM,983,RC,12031,CPT,,,,,,,,551,,First Health,Commercial,both,85,,999999999,percent of total billed charges,468.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,228.8854,536.2883
Xray Facial Bones Minimum 3 Vws,PX7015001,CDM,320,RC,70150,CPT,TC,,,,,,,551,,First Health,Commercial,both,85,,999999999,percent of total billed charges,468.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,539.98
Egd Balloon Dil Esoph30 Mm/>,PX43233F,CDM,750,RC,43233,CPT,,,,,,,,1120,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,468.35,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.52,468.35
Egd Balloon Dil Esoph30 Mm/>,PX43233F,CDM,750,RC,43233,CPT,,,,,,,,1120,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,468.35,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.52,468.35
Egd Balloon Dil Esoph30 Mm/>,PX43233P,CDM,983,RC,43233,CPT,,,,,,,,480,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,468.35,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.52,470.4
Egd Balloon Dil Esoph30 Mm/>,PX43233P,CDM,983,RC,43233,CPT,,,,,,,,480,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,468.35,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.52,470.4
"Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404P,CDM,983,RC,11404,CPT,,,,,,,,600,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,468.35,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.96,588
"Fac/Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404F,CDM,510,RC,11404,CPT,,,,,,,,749,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,468.35,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.96,468.35
Incise External Hemorrhoid,PX46083P,CDM,983,RC,46083,CPT,,,,,,,,956,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,468.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,215.91,930.4748
Incise External Hemorrhoid,PX46083P,CDM,983,RC,46083,CPT,,,,,,,,956,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,468.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,215.91,930.4748
Incise External Hemorrhoid,PX46083P,CDM,983,RC,46083,CPT,,,,,,,,956,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,468.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,215.91,930.4748
BUPivacaine liposome 1.3 % Suspension 20 mL Vial,C9290.01,CDM,636,RC,C9290,HCPCS,,,,65250026604,NDC,10,ML,976.43,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,468.6864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,405.609022,956.9014
BUPivacaine liposome 1.3 % Suspension 20 mL Vial,C9290.01,CDM,636,RC,C9290,HCPCS,,,,65250026604,NDC,10,ML,976.43,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,468.6864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,405.609022,956.9014
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022101,NDC,1,EA,514.5,,Medica,Commercial,both,91.1,,42.235,percent of total billed charges,468.7095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022185,NDC,1,EA,514.5,,Medica,Commercial,both,91.1,,42.235,percent of total billed charges,468.7095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022189,NDC,1,EA,514.5,,Medica,Commercial,both,91.1,,42.235,percent of total billed charges,468.7095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
ciprofloxacin-dexAMETHasone 0.3-0.1 % Suspension 7.5 mL Bottle,25000000,CDM,250,RC,,,,,,43598032675,NDC,7.5,ML,976.53,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,468.7344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ciprofloxacin-dexAMETHasone 0.3-0.1 % Suspension 7.5 mL Bottle,25000000,CDM,250,RC,,,,,,43598032675,NDC,7.5,ML,976.53,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,468.7344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
I&D Deep Absc/Hematoma Neck/Chest,PX21501P,CDM,983,RC,21501,CPT,,,,,,,,515,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,469.165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.931,2482.37
"Inj,Lumb Epidur,Blood/Clot Patch",PX62273P,CDM,983,RC,62273,CPT,,,,,,,,552,,First Health,Commercial,both,85,,999999999,percent of total billed charges,469.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,229.3008,604.15
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121F,CDM,510,RC,13121,CPT,,,,,,,,948,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,469.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,393.7992,929.04
PERFIX PLUG STERILE MEDIUM,C1781,CDM,278,RC,C1781,HCPCS,,11770-MAIN,LOCAL,,,,,553,,First Health,Commercial,both,85,,999999999,percent of total billed charges,470.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Closed Rx Shldr Dislocation,PX23650P,CDM,983,RC,23650,CPT,,,,,,,,516,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,470.076,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,502.2228
Trg Gene Rearrangement Anal - Ref,PX8134290,CDM,300,RC,81342,CPT,90,,,,,,,516,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,470.076,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,184.76,505.68
Xray Ribs Bil 3vws Tc,PX7111001,CDM,320,RC,71110,CPT,TC,,,,,,,533,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,470.106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,522.34
rabies immune globulin 300 UNIT/2ML Solution 2 mL Vial,90377,CDM,636,RC,90376,CPT,,,,49281019020,NDC,2,ML,3384.84,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,470.15059,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.58,479.72
"I&D Perianal Abscess,Superficial",PX46050,CDM,983,RC,46050,CPT,,,,,,,,1096,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,470.184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,455.2784,1066.7368
CT Head/Brain W/O Dye,PX7045001,CDM,350,RC,70450,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,470.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081543,NDC,1,ML,479.89,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,470.2922,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.346306,470.2922
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081552,NDC,1,ML,479.89,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,470.2922,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.346306,470.2922
Egd Balloon Dil Esoph30 Mm/>,PX43233P,CDM,983,RC,43233,CPT,,,,,,,,480,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,470.4,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.52,470.4
"Sigmoidoscopy,Diagnostic",PX45330P,CDM,983,RC,45330,CPT,,,,,,,,480,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,470.4,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.68,470.4
"Amputation Metatarsal+Toe,Single",PX28810F,CDM,510,RC,28810,CPT,,,,,,,,930,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,470.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.322,2827.75
Colonoscopy,PX44388F,CDM,750,RC,44388,CPT,,,,,,,,930,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,470.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.322,911.4
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527197174,NDC,4,ML,960.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,470.645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527197174,NDC,4,ML,960.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,470.645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527197174,NDC,4,ML,960.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,470.645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
Excis Primary Ganglion Wrist,PX25111P,CDM,983,RC,25111,CPT,,,,,,,,529,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,470.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,219.7466,1404.08
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200001,NDC,0.5,ML,980.99,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,470.8752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,264.67,961.3702
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200001,NDC,0.5,ML,980.99,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,470.8752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,264.67,961.3702
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200002,NDC,0.5,ML,980.99,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,470.8752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,264.67,961.3702
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200002,NDC,0.5,ML,980.99,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,470.8752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,264.67,961.3702
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545F,CDM,510,RC,23545,CPT,,,,,,,,961,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,470.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,941.78
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545F,CDM,510,RC,23545,CPT,,,,,,,,961,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,470.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,941.78
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545F,CDM,510,RC,23545,CPT,,,,,,,,961,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,470.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,941.78
Aaa US Screen Tc,PX7670601,CDM,402,RC,76706,CPT,TC,,,,,,,554,,First Health,Commercial,both,85,,999999999,percent of total billed charges,470.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,542.92
US Kidney Transplt Untrsd,PX7677601,CDM,402,RC,76776,CPT,TC,,,,,,,554,,First Health,Commercial,both,85,,999999999,percent of total billed charges,470.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,542.92
Calr Gene Analysis Common Variants in Exon 9 - Ref,PX8121990,CDM,300,RC,81219,CPT,90,,,,,,,534,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,470.988,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.52,523.32
"Fac/Ex Skinbngn0.6-1cmtrnk,Arm,Lg",PX11401F,CDM,510,RC,11401,CPT,,,,,,,,484,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,471.0772,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.0536,474.32
"Fac/Exc Skn Benig<5mm Face,Facial",PX11440F,CDM,510,RC,11440,CPT,,,,,,,,484,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,471.0772,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.0536,614.65
"Facility Critical Care, Addl 30 Min",PX99292F,CDM,510,RC,99292,CPT,,,,,,,,484,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,410.47,percent of total billed charges,471.0772,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.0536,474.32
Fac/Exc Skn Beni 0.6-1cm Remain Bdy,PX11421F,CDM,510,RC,11421,CPT,,,,,,,,931,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,471.086,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.7374,912.38
Fac/Exc Skn Bngn3.1-4cm Remain Bdy,PX11424F,CDM,510,RC,11424,CPT,,,,,,,,931,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,471.086,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.7374,1416.38
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034F,CDM,510,RC,12034,CPT,,,,,,,,931,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,471.086,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,912.38
"Remv F.B.,Eye,Ant Chmbr/Lens",PX65235F,CDM,510,RC,65235,CPT,,,,,,,,2788,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,471.2,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,465.32,1508.82
"Remv F.B.,Eye,Ant Chmbr/Lens",PX65235F,CDM,510,RC,65235,CPT,,,,,,,,2788,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,471.2,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,465.32,1508.82
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390P,CDM,982,RC,45390,CPT,,,,,,,,1135,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,471.479,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,471.479,2452.93
Incise Finger Tendon Sheath,PX26055P,CDM,983,RC,26055,CPT,,,,,,,,932,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,471.592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,387.1528,1404.08
Anus Surgery Procedure Unlisted,PX46999P,CDM,983,RC,46999,CPT,,,,,,,,953,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,471.735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,395.8762,927.5549
"Genital Surg Proc,Male Unlisted",PX55899P,CDM,983,RC,55899,CPT,,,,,,,,953,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,471.735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,215.91,927.5549
I&D Perirectal Abscess,PX46040P,CDM,983,RC,46040,CPT,,,,,,,,953,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,471.735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,395.8762,1030.93
Xray Sacroiliac Jnts Less Than 3 Vws,PX7220001,CDM,320,RC,72200,CPT,TC,,,,,,,555,,First Health,Commercial,both,85,,999999999,percent of total billed charges,471.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,543.9
CARTER THOMASON CLOSURE SUTURE PASSER XL 10/12MM 15MM CTXL,27200000,CDM,272,RC,,,,12946-MAIN,LOCAL,,,,,535,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,471.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Blood Gases: Ph, Po2 & Pco2",PX82803,CDM,300,RC,82803,CPT,,,,,,,,518,,Medica,Commercial,both,91.1,,156.8433333,percent of total billed charges,471.898,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.9,507.64
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060002,NDC,2,ML,953.57,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,472.01715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.11,934.4986
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060010,NDC,2,ML,953.57,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,472.01715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.11,934.4986
Exc Skn Beni 0.6-1cm Fcefacial,PX11441P,CDM,983,RC,11441,CPT,,,,,,,,485,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,472.0505,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.469,614.65
Biopsy Synovium I-P Jt,PX26110,CDM,983,RC,26110,CPT,,,,,,,,933,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,472.098,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,387.5682,1404.08
Hepatobil Syst Image W/Drug,PX7822701,CDM,341,RC,78227,CPT,TC,,,,,,,1674,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,472.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,472.19,1640.52
"Remv Foreign Body,Knee/Thigh,Deep",PX27372P,CDM,983,RC,27372,CPT,,,,,,,,954,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,472.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,396.2916,2482.37
"Closed Rx Talus Fx,Manipulatn",PX28435P,CDM,983,RC,28435,CPT,,,,,,,,1137,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,472.3098,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,472.3098,1404.08
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604F,CDM,510,RC,11604,CPT,,,,,,,,964,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,472.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,400.4456,944.72
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604F,CDM,510,RC,11604,CPT,,,,,,,,964,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,472.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,400.4456,944.72
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604F,CDM,510,RC,11604,CPT,,,,,,,,964,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,472.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,400.4456,944.72
"Supply Technetium Medronate,to 30 MC",PXA9503,CDM,343,RC,A9503,HCPCS,,,,,,,,531,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,472.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,220.5774,520.38
X-Ray Exam Chest 2 Views,PX7104601,CDM,320,RC,71046,CPT,TC,,,,,,,556,,First Health,Commercial,both,85,,999999999,percent of total billed charges,472.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,544.88
Xray Chest 2 Views,PX7102001,CDM,320,RC,71020,CPT,TC,,,,,,,556,,First Health,Commercial,both,85,,999999999,percent of total billed charges,472.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,230.9624,544.88
Aspirate Pleura W/ Imaging,PX32555P,CDM,983,RC,32555,CPT,,,,,,,,536,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,472.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,222.6544,548.81
Lvl 3 Init Hosp High Mdm or 75 Minutes,PX99223,CDM,982,RC,99223,CPT,,,,,,,,536,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,472.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,222.6544,521.6888
Xray Ac Joints(Bilateral),PX7305001,CDM,320,RC,73050,CPT,TC,,,,,,,519,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,472.809,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,508.62
Temporal Artery Ligatn or Bx,PX37609P,CDM,983,RC,37609,CPT,,,,,,,,965,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,472.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,400.861,1416.38
Temporal Artery Ligatn or Bx,PX37609P,CDM,983,RC,37609,CPT,,,,,,,,965,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,472.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,400.861,1416.38
Temporal Artery Ligatn or Bx,PX37609P,CDM,983,RC,37609,CPT,,,,,,,,965,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,472.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,400.861,1416.38
ARTISTA AH 3GRAM ABSORBABLE HEMOSTATIC PARTICLES,27200000,CDM,272,RC,A6199,HCPCS,,10227-MAIN,LOCAL,,,,,486,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,473.0238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002P,CDM,983,RC,12002,CPT,,,,,,,,486,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,172.96,percent of total billed charges,473.0238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,473.0238
Xray Sinuses Less Than 3 Vws,PX7021001,CDM,320,RC,70210,CPT,TC,,,,,,,486,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,265.01,percent of total billed charges,473.0238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,476.28
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,23155052431,NDC,10,ML,486.06,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,473.082198,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,23155052441,NDC,10,ML,486.06,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,473.082198,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Incise External Hemorrhoid,PX46083P,CDM,983,RC,46083,CPT,,,,,,,,956,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,473.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,215.91,930.4748
"Column Chrom Ms, Quant - Ref",PX8254290,CDM,300,RC,82542,CPT,90,,,,,,,557,,First Health,Commercial,both,85,,999999999,percent of total billed charges,473.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.09,545.86
Remove Hemorrhoids & Fissure,PX46257F,CDM,510,RC,46257,CPT,,,,,,,,1141,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,473.9714,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,473.9714,2452.93
BRONCHOSCOPE BFLEX 5.0 SINGLE-USE 0570-0449,120.578,CDM,272,RC,,,,13020-MAIN,LOCAL,,,,,558,,First Health,Commercial,both,85,,999999999,percent of total billed charges,474.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,231.7932,546.84
PERFIX PLUG STERILE LARGE,C1781,CDM,278,RC,C1781,HCPCS,,11771-MAIN,LOCAL,,,,,558,,First Health,Commercial,both,85,,999999999,percent of total billed charges,474.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Fac/Ex Skinbngn0.6-1cmtrnk,Arm,Lg",PX11401F,CDM,510,RC,11401,CPT,,,,,,,,484,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,474.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.0536,474.32
"Fac/Exc Skn Benig<5mm Face,Facial",PX11440F,CDM,510,RC,11440,CPT,,,,,,,,484,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,474.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.0536,614.65
"Facility Critical Care, Addl 30 Min",PX99292F,CDM,510,RC,99292,CPT,,,,,,,,484,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,474.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.0536,474.32
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,61314054701,NDC,2.5,ML,487.35,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,474.337755,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Xray Ribs Bil 3vws Tc,PX7111001,CDM,320,RC,71110,CPT,TC,,,,,,,533,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,474.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,522.34
budesonide-formoterol 80-4.5 MCG/ACT Aerosol 6.9 g Inhaler,63700001,CDM,250,RC,,,,,,186037228,NDC,6.9,GR,937.58,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,474.41548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
paliperidone palmitate ER 234 MG/1.5ML suspension prefilled syringe 1.5 mL Syringe,J2426.01,CDM,636,RC,J2426,HCPCS,,,,50458056401,NDC,0.25,ML,1142.14,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,474.444956,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.12,1119.2972
BRACE KNEE LARGE SHORTRUNNER 21754,120.387,CDM,274,RC,L1833,HCPCS,,10044-MAIN,LOCAL,,,,,101,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,474.58,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.1433,634.77
BRACE KNEE LARGE SHORTRUNNER 21754,120.387,CDM,274,RC,L1833,HCPCS,,10044-MAIN,LOCAL,,,,,101,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,474.58,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.1433,634.77
BRACE KNEE LARGE SHORTRUNNER 21754,120.387,CDM,274,RC,L1833,HCPCS,,10044-MAIN,LOCAL,,,,,101,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,474.58,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.1433,634.77
BRACE KNEE MEDIUM SHORTRUNNER 21753,120.387,CDM,274,RC,L1833,HCPCS,,10126-MAIN,LOCAL,,,,,101,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,474.58,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.1433,634.77
BRACE KNEE MEDIUM SHORTRUNNER 21753,120.387,CDM,274,RC,L1833,HCPCS,,10126-MAIN,LOCAL,,,,,101,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,474.58,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.1433,634.77
BRACE KNEE MEDIUM SHORTRUNNER 21753,120.387,CDM,274,RC,L1833,HCPCS,,10126-MAIN,LOCAL,,,,,101,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,474.58,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.1433,634.77
BRACE KNEE SMALL SHORTRUNNER 21752,120.387,CDM,274,RC,L1833,HCPCS,,10900-MAIN,LOCAL,,,,,101,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,474.58,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.1433,634.77
BRACE KNEE SMALL SHORTRUNNER 21752,120.387,CDM,274,RC,L1833,HCPCS,,10900-MAIN,LOCAL,,,,,101,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,474.58,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.1433,634.77
BRACE KNEE SMALL SHORTRUNNER 21752,120.387,CDM,274,RC,L1833,HCPCS,,10900-MAIN,LOCAL,,,,,101,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,474.58,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.1433,634.77
BRACE KNEE X-LARGE SHORTRUNNER 21755,120.387,CDM,274,RC,L1833,HCPCS,,3444-MAIN,LOCAL,,,,,101,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,474.58,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.1433,634.77
BRACE KNEE X-LARGE SHORTRUNNER 21755,120.387,CDM,274,RC,L1833,HCPCS,,3444-MAIN,LOCAL,,,,,101,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,474.58,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.1433,634.77
BRACE KNEE X-LARGE SHORTRUNNER 21755,120.387,CDM,274,RC,L1833,HCPCS,,3444-MAIN,LOCAL,,,,,101,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,474.58,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.1433,634.77
BRACE KNEE XX-LARGE SHORTRUNNER 21756,120.387,CDM,274,RC,L1833,HCPCS,,10615-MAIN,LOCAL,,,,,101,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,474.58,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.1433,634.77
BRACE KNEE XX-LARGE SHORTRUNNER 21756,120.387,CDM,274,RC,L1833,HCPCS,,10615-MAIN,LOCAL,,,,,101,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,474.58,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.1433,634.77
BRACE KNEE XX-LARGE SHORTRUNNER 21756,120.387,CDM,274,RC,L1833,HCPCS,,10615-MAIN,LOCAL,,,,,101,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,474.58,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.1433,634.77
Exc Abdom Tum Subfac > 5 Cm,PX22901P,CDM,983,RC,22901,CPT,,,,,,,,938,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,474.628,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,389.6452,2482.37
"Destruct Benign Lesion, 1-14",PX17110P,CDM,983,RC,17110,CPT,,,,,,,,521,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,474.631,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,507.0893
Tube Thoracostomy Inc Wtr Seal,PX32551F,CDM,510,RC,32551,CPT,,,,,,,,989,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,474.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,410.8306,1399.13
Tube Thoracostomy Inc Wtr Seal,PX32551F,CDM,510,RC,32551,CPT,,,,,,,,989,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,474.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,410.8306,1399.13
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151F,CDM,510,RC,13151,CPT,,,,,,,,1143,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,474.8022,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,474.8022,1120.14
"Repair Umbilical Hern,5+Y/O,Reduc",PX49585F,CDM,510,RC,49585,CPT,,,,,,,,969,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,474.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,402.5226,949.62
"Repair Umbilical Hern,5+Y/O,Reduc",PX49585F,CDM,510,RC,49585,CPT,,,,,,,,969,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,474.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,402.5226,949.62
"Repair Umbilical Hern,5+Y/O,Reduc",PX49585F,CDM,510,RC,49585,CPT,,,,,,,,969,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,474.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,402.5226,949.62
clobetasol 0.05 % Cream 60 g Tube,63700001,CDM,250,RC,,,,,,168030160,NDC,60,GR,989.25,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,474.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clobetasol 0.05 % Cream 60 g Tube,63700001,CDM,250,RC,,,,,,168030160,NDC,60,GR,989.25,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,474.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Suspension 10 mL Bottle,63700001,CDM,250,RC,,,,,,64980044801,NDC,10,ML,488.25,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,475.213725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Bcr/Abl1 P210 - Ref,PX8120690,CDM,310,RC,81206,CPT,90,,,,,,,1144,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,475.2176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.33,1121.12
Calr Gene Analysis Common Variants in Exon 9 - Ref,PX8121990,CDM,300,RC,81219,CPT,90,,,,,,,534,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,475.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.52,523.32
Exc Skn Beni 0.6-1cm Fcefacial,PX11441P,CDM,983,RC,11441,CPT,,,,,,,,485,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,475.3,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.64,475.3
CP LAG SCREW 3.6MM L22MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12757-MAIN,LOCAL,,,,,539,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,475.398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
CP LAG SCREW 3.6MM L24MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12650-MAIN,LOCAL,,,,,539,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,475.398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
CP LAG SCREW 3.6MM L26MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12636-MAIN,LOCAL,,,,,539,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,475.398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527197174,NDC,4,ML,960.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,475.4475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
Closed Rx Trimalleolar Fx,PX27816F,CDM,510,RC,27816,CPT,,,,,,,,522,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,475.542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,511.56
Xray Thoracic Spine 3 Vws,PX7207201,CDM,320,RC,72072,CPT,TC,,,,,,,522,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,475.542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,511.56
STAPLER SUREFORM 60 SPU IS4000,27200000,CDM,272,RC,,,,12086-MAIN,LOCAL,,,,,991,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,475.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STAPLER SUREFORM 60 SPU IS4000,27200000,CDM,272,RC,,,,12086-MAIN,LOCAL,,,,,991,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,475.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545F,CDM,510,RC,23545,CPT,,,,,,,,961,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,475.695,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,941.78
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032601,NDC,0.5,ML,559.7,,First Health,Commercial,both,85,,999999999,percent of total billed charges,475.745,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,1630.2692
"Exc Skn Bngn2.1-3cm Fce,Facial",PX11443P,CDM,983,RC,11443,CPT,,,,,,,,650,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,475.96,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.78,637
"Fac/Exc Skn Bngn 2.1-3cmfce,Facial",PX11443F,CDM,510,RC,11443,CPT,,,,,,,,813,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,475.96,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.78,475.96
"Close Rx Fingr Articular Fx,Manip",PX26742P,CDM,983,RC,26742,CPT,,,,,,,,560,,First Health,Commercial,both,85,,999999999,percent of total billed charges,476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,232.624,1404.08
"Enzyme Act, Nonradioact - Ref",PX8265790,CDM,300,RC,82657,CPT,90,,,,,,,560,,First Health,Commercial,both,85,,999999999,percent of total billed charges,476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.33,548.8
CARTER THOMASON CLOSURE SUTURE PASSER XL 10/12MM 15MM CTXL,27200000,CDM,272,RC,,,,12946-MAIN,LOCAL,,,,,535,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,476.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Repair Umbilical Hern,5+Y/O,Strang",PX49587F,CDM,510,RC,49587,CPT,,,,,,,,1110,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,476.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,461.094,1087.8
ARTISTA AH 3GRAM ABSORBABLE HEMOSTATIC PARTICLES,27200000,CDM,272,RC,A6199,HCPCS,,10227-MAIN,LOCAL,,,,,486,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,476.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Remove Nasal Foreign Body,PX30300F,CDM,510,RC,30300,CPT,,,,,,,,972,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,476.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,952.56
Remove Nasal Foreign Body,PX30300F,CDM,510,RC,30300,CPT,,,,,,,,972,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,476.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,952.56
Remove Nasal Foreign Body,PX30300F,CDM,510,RC,30300,CPT,,,,,,,,972,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,476.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,952.56
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002P,CDM,983,RC,12002,CPT,,,,,,,,486,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,476.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.9,476.28
Xray Sinuses Less Than 3 Vws,PX7021001,CDM,320,RC,70210,CPT,TC,,,,,,,486,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,476.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,476.28
Xray Sacrum/ Coccyx Minimum 2 Vws,PX7222001,CDM,320,RC,72220,CPT,TC,,,,,,,540,,United Healthcare,All Payer,outpatient,88.2,,452.47,percent of total billed charges,476.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,529.2
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,23155052431,NDC,10,ML,486.06,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,476.3388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,23155052441,NDC,10,ML,486.06,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,476.3388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Layr Clos Wnd Rest Body 7.6-12.5,PX12044P,CDM,983,RC,12044,CPT,,,,,,,,523,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,476.453,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,217.2542,548.67
"Removal of Tunnel Cv Access Device, With Port/Pump",PX36590P,CDM,983,RC,36590,CPT,,,,,,,,1147,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,476.4638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,476.4638,1399.13
calcitonin (salmon) 200 UNIT/ACT Solution 3.7 mL Bottle,63700001,CDM,250,RC,,,,,,60505082306,NDC,3.7,ML,489.57,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,476.498481,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601P,CDM,983,RC,11601,CPT,,,,,,,,1046,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,476.65,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.37,1025.08
"Fac/Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601F,CDM,510,RC,11601,CPT,,,,,,,,673,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,476.65,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.37,476.65
STAPLER CONTOUR CURVED CUTTER,27200000,CDM,272,RC,,,,12064-MAIN,LOCAL,,,,,942,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,476.652,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Drain Skin Abscess Complic,PX10061P,CDM,983,RC,10061,CPT,,,,,,,,561,,First Health,Commercial,both,85,,999999999,percent of total billed charges,476.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,233.0394,546.0213
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12130-MAIN,LOCAL,,,,,561,,First Health,Commercial,both,85,,999999999,percent of total billed charges,476.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Upper GI Endoscopy,Ctrl Bleed",PX43255P,CDM,983,RC,43255,CPT,,,,,,,,1148,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,476.8792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,476.8792,1662.33
Xray Knee 4 or More Vws,PX7356401,CDM,320,RC,73564,CPT,TC,,,,,,,490,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,476.917,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,480.2
Aspirate Pleura W/ Imaging,PX32555P,CDM,983,RC,32555,CPT,,,,,,,,536,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,477.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,222.6544,548.81
Lvl 3 Init Hosp High Mdm or 75 Minutes,PX99223,CDM,982,RC,99223,CPT,,,,,,,,536,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,477.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,222.6544,521.6888
Exc Face Les Sc < 2 Cm,PX21011F,CDM,510,RC,21011,CPT,,,,,,,,943,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,477.158,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,391.7222,1416.38
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604F,CDM,510,RC,11604,CPT,,,,,,,,964,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,477.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,400.4456,944.72
Injection Hip Arthrogram,PX27093F,CDM,510,RC,27093,CPT,,,,,,,,654,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,477.34,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.66,477.34
Bcr/Abl1 Minor - Ref,PX8120790,CDM,310,RC,81207,CPT,90,,,,,,,1113,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,477.477,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.8,1090.74
MICA BURR 2X12MM STERILE MICA,27200000,CDM,272,RC,,,,12447-MAIN,LOCAL,,,,,1113,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,477.477,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA BURR 2X20MM STERILE MICA,27200000,CDM,272,RC,,,,12448-MAIN,LOCAL,,,,,1113,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,477.477,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA CUTTING BURR 3X20MM LONG MICA,27200000,CDM,272,RC,,,,12434-MAIN,LOCAL,,,,,1113,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,477.477,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA WEDGE BURR 3.1X13MM STERILE,27200000,CDM,272,RC,,,,12435-MAIN,LOCAL,,,,,1113,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,477.477,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,61314054701,NDC,2.5,ML,487.35,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,477.603,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Temporal Artery Ligatn or Bx,PX37609P,CDM,983,RC,37609,CPT,,,,,,,,965,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,477.675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,400.861,1416.38
Exc Skn Bngn3.1-4cm Remain Bdy,PX11424P,CDM,983,RC,11424,CPT,,,,,,,,562,,First Health,Commercial,both,85,,999999999,percent of total billed charges,477.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,233.4548,1416.38
"US,Preg. Uterus,Fetal/Mat.Eval.,>1st Trim.(>/= 14 Wks 0 Dys),Transabd;Single/First Gest., Tech",PX7680501,CDM,402,RC,76805,CPT,TC,,,,,,,562,,First Health,Commercial,both,85,,999999999,percent of total billed charges,477.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,550.76
dexmedeTOMIDine in sodium chloride 400 MCG/100ML Solution 100 mL Bottle,25000000,CDM,250,RC,,,,,,67457092500,NDC,100,ML,562.18,,First Health,Commercial,both,85,,999999999,percent of total billed charges,477.853,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ipratropium 0.06 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,54004641,NDC,15,ML,491.02,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,477.909766,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2.5 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,68682065020,NDC,1,EA,1114.05,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,477.92745,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Critical Care, Addl 30 Min",PX99292P,CDM,983,RC,99292,CPT,,,,,,,,542,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,478.044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,225.1468,527.5286
HERNIA PATCH VENTRALEX SMALL,C1781,CDM,278,RC,C1781,HCPCS,,10203-MAIN,LOCAL,,,,,995.96,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,478.0608,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
HERNIA PATCH VENTRALEX SMALL,C1781,CDM,278,RC,C1781,HCPCS,,10203-MAIN,LOCAL,,,,,995.96,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,478.0608,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
fidaxomicin 200 MG Tablet 20 Each Bottle,25000000,CDM,250,RC,,,,,,52015008001,NDC,1,EA,945.16,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,478.25096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Anal Sphincterotomy,PX46080P,CDM,983,RC,46080,CPT,,,,,,,,525,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,478.275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,218.085,2452.93
BUPivacaine liposome 1.3 % Suspension 20 mL Vial,C9290.01,CDM,636,RC,C9290,HCPCS,,,,65250026604,NDC,10,ML,976.43,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,2.39315685,percent of total billed charges,478.4507,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,405.609022,956.9014
BUPivacaine liposome 1.3 % Suspension 20 mL Vial,C9290.01,CDM,636,RC,C9290,HCPCS,,,,65250026604,NDC,10,ML,976.43,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,478.4507,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,405.609022,956.9014
BUPivacaine liposome 1.3 % Suspension 20 mL Vial,C9290.01,CDM,636,RC,C9290,HCPCS,,,,65250026604,NDC,10,ML,976.43,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,478.4507,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,405.609022,956.9014
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Suspension 10 mL Bottle,63700001,CDM,250,RC,,,,,,64980044801,NDC,10,ML,488.25,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,478.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ciprofloxacin-dexAMETHasone 0.3-0.1 % Suspension 7.5 mL Bottle,25000000,CDM,250,RC,,,,,,43598032675,NDC,7.5,ML,976.53,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,478.4997,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ciprofloxacin-dexAMETHasone 0.3-0.1 % Suspension 7.5 mL Bottle,25000000,CDM,250,RC,,,,,,43598032675,NDC,7.5,ML,976.53,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,478.4997,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ciprofloxacin-dexAMETHasone 0.3-0.1 % Suspension 7.5 mL Bottle,25000000,CDM,250,RC,,,,,,43598032675,NDC,7.5,ML,976.53,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,478.4997,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Xray Pelvis Compl 3+ Tc,PX7219001,CDM,320,RC,72190,CPT,TC,,,,,,,563,,First Health,Commercial,both,85,,999999999,percent of total billed charges,478.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,551.74
Factor VIII (Ahg) 1-Stage,PX85240,CDM,300,RC,85240,CPT,,,,,,,,997,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,478.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.41,977.06
Factor VIII (Ahg) 1-Stage,PX85240,CDM,300,RC,85240,CPT,,,,,,,,997,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,478.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.41,977.06
nystatin 100000 UNIT/GM Powder 60 g Bottle,63700001,CDM,250,RC,,,,,,574200802,NDC,60,GR,491.86,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,478.727338,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505P,CDM,983,RC,25505,CPT,,,,,,,,977,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,478.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,405.8458,1404.08
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505P,CDM,983,RC,25505,CPT,,,,,,,,977,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,478.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,405.8458,1404.08
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505P,CDM,983,RC,25505,CPT,,,,,,,,977,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,478.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,405.8458,1404.08
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762F,CDM,510,RC,43762,CPT,,,,,,,,492,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,478.8636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,204.3768,482.16
"Exc Skn Bngn2.1-3cmtrnk,Arm,Lg",PX11403P,CDM,983,RC,11403,CPT,,,,,,,,543,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,478.926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,225.5622,614.65
Xray Knee (Both) Ap Stand,PX7356501,CDM,320,RC,73565,CPT,TC,,,,,,,543,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,478.926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,532.14
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,6384371,NDC,1,EA,563.46,,First Health,Commercial,both,85,,999999999,percent of total billed charges,478.941,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
umeclidinium 62.5 MCG/ACT Aerosol Powder Breath Activated 7 Each Disp Pack,63700001,CDM,250,RC,,,,,,173087306,NDC,7,EA,492.23,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,479.087459,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Debride Tissue/Muscle,PX11043F,CDM,510,RC,11043,CPT,,,,,,,,526,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,479.186,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,218.5004,548.67
Hfe Gene - Ref,PX8125690,CDM,300,RC,81256,CPT,90,,,,,,,526,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,479.186,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,59.93,515.48
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,16714081501,NDC,5,ML,998.95,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,479.496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,16714081501,NDC,5,ML,998.95,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,479.496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
"Repair Umbilical Hern,5+Y/O,Reduc",PX49585F,CDM,510,RC,49585,CPT,,,,,,,,969,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,479.655,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,402.5226,949.62
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121F,CDM,510,RC,13121,CPT,,,,,,,,948,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,479.688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,393.7992,929.04
CP LAG SCREW 3.6MM L22MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12757-MAIN,LOCAL,,,,,539,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,479.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
CP LAG SCREW 3.6MM L24MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12650-MAIN,LOCAL,,,,,539,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,479.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
CP LAG SCREW 3.6MM L26MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12636-MAIN,LOCAL,,,,,539,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,479.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
rabies immune globulin 300 UNIT/2ML Solution 2 mL Vial,90377,CDM,636,RC,90376,CPT,,,,49281019020,NDC,2,ML,3384.84,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,479.72,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.58,479.72
calcitonin (salmon) 200 UNIT/ACT Solution 3.7 mL Bottle,63700001,CDM,250,RC,,,,,,60505082306,NDC,3.7,ML,489.57,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,479.7786,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CT Angio Lwr Extr W/O&W/Dye,PX7370601,CDM,350,RC,73706,CPT,TC,,,,,,,1554,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,479.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.11,479.9
CT Angio Lwr Extr W/O&W/Dye,PX7370601,CDM,350,RC,73706,CPT,TC,,,,,,,1554,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,479.9,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.11,479.9
"Removal Anal Fistula,Subcutaneous",PX46270P,CDM,983,RC,46270,CPT,,,,,,,,980,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,480.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,407.092,2452.93
"Removal Anal Fistula,Subcutaneous",PX46270P,CDM,983,RC,46270,CPT,,,,,,,,980,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,480.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,407.092,2452.93
"Removal Anal Fistula,Subcutaneous",PX46270P,CDM,983,RC,46270,CPT,,,,,,,,980,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,480.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,407.092,2452.93
Xray Knee 4 or More Vws,PX7356401,CDM,320,RC,73564,CPT,TC,,,,,,,490,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,480.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,480.2
Repr Superf Wnd Body 12.6-20,PX12005F,CDM,510,RC,12005,CPT,,,,,,,,565,,First Health,Commercial,both,85,,999999999,percent of total billed charges,480.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,234.701,553.7
Xray Lumbosacral Minimum 4 Vws,PX7211001,CDM,320,RC,72110,CPT,TC,,,,,,,565,,First Health,Commercial,both,85,,999999999,percent of total billed charges,480.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,553.7
Egd Balloon Dil Esoph30 Mm/>,PX43233F,CDM,750,RC,43233,CPT,,,,,,,,1120,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,480.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,465.248,1662.33
"Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602P,CDM,983,RC,11602,CPT,,,,,,,,1120,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,480.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1090.096
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830P,CDM,983,RC,15830,CPT,,,,,,,,1120,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,480.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,465.248,5696.92
"MRI, Pelvis, W/O Then W/",PX7219701,CDM,610,RC,72197,CPT,TC,,,,,,,1612,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,480.56,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,162.96,480.56
"MRI, Pelvis, W/O Then W/",PX7219701,CDM,610,RC,72197,CPT,TC,,,,,,,1612,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,480.56,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,162.96,480.56
Xray Sacrum/ Coccyx Minimum 2 Vws,PX7222001,CDM,320,RC,72220,CPT,TC,,,,,,,540,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,480.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,529.2
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200001,NDC,0.5,ML,980.99,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,480.6851,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,264.67,961.3702
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200001,NDC,0.5,ML,980.99,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,480.6851,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,264.67,961.3702
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200001,NDC,0.5,ML,980.99,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,480.6851,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,264.67,961.3702
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200002,NDC,0.5,ML,980.99,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,480.6851,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,264.67,961.3702
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200002,NDC,0.5,ML,980.99,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,480.6851,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,264.67,961.3702
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200002,NDC,0.5,ML,980.99,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,480.6851,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,264.67,961.3702
Exc Skin Benig >4cm Remaindr Body,PX11426P,CDM,983,RC,11426,CPT,,,,,,,,981,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,480.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,407.5074,2482.37
Exc Skin Benig >4cm Remaindr Body,PX11426P,CDM,983,RC,11426,CPT,,,,,,,,981,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,480.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,407.5074,2482.37
Exc Skin Benig >4cm Remaindr Body,PX11426P,CDM,983,RC,11426,CPT,,,,,,,,981,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,480.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,407.5074,2482.37
Irrad/Lr Platelets,PXP9037,CDM,390,RC,P9037,HCPCS,,,,,,,,1617,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,480.75,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.33,783.04
Leukoreduced Platelets,PXP9035,CDM,390,RC,P9035,HCPCS,,,,,,,,1350,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,480.75,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.33,783.04
CRICOTHROTOMY QUICKTRACH 4MM,120.228,CDM,272,RC,A7520,HCPCS,,8868-MAIN,LOCAL,,,,,494,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,480.8102,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.2076,484.12
SET CRICOTHYROTOMY CATHETER 6MM ID,120.378,CDM,272,RC,,,,11119-MAIN,LOCAL,,,,,494,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,480.8102,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.2076,484.12
US Renal Retroperit Ltd,PX7677501,CDM,402,RC,76775,CPT,TC,,,,,,,566,,First Health,Commercial,both,85,,999999999,percent of total billed charges,481.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,554.68
US Retroperitoneal Tc,PX7677001,CDM,402,RC,76770,CPT,TC,,,,,,,566,,First Health,Commercial,both,85,,999999999,percent of total billed charges,481.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,554.68
Remove Nasal Foreign Body,PX30300F,CDM,510,RC,30300,CPT,,,,,,,,972,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,481.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,952.56
ipratropium 0.06 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,54004641,NDC,15,ML,491.02,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,481.1996,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ondansetron 4 MG/5ML Solution 25 mL Bottle,S0119.01,CDM,636,RC,S0119,HCPCS,,,,99998-8001-,NDC,25,ML,494.57,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,481.364981,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132F,CDM,510,RC,13132,CPT,,,,,,,,1159,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,481.4486,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,481.4486,1135.82
"Lap,Cholecystectomy",PX47562P,CDM,983,RC,47562,CPT,,,,,,,,983,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,2083.4,percent of total billed charges,481.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,408.3382,5040.74
"Lap,Cholecystectomy",PX47562P,CDM,983,RC,47562,CPT,,,,,,,,983,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,481.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,408.3382,5040.74
"Lap,Cholecystectomy",PX47562P,CDM,983,RC,47562,CPT,,,,,,,,983,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,481.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,408.3382,5040.74
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725F,CDM,510,RC,26725,CPT,,,,,,,,495,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,481.7835,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.623,485.1
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101F,CDM,510,RC,13101,CPT,,,,,,,,495,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,481.7835,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.623,548.67
Tc99 Mebrofenin to 15 Mci,PXA9537,CDM,343,RC,A9537,HCPCS,,,,,,,,495,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,481.7835,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.623,485.1
Excis Primary Ganglion Wrist,PX25111P,CDM,983,RC,25111,CPT,,,,,,,,529,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,481.919,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,219.7466,1404.08
"Tte W/Doppler, Complete",PX9330601,CDM,483,RC,93306,CPT,TC,,,,,,,2191,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,481.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,481.95,2889.15
nystatin 100000 UNIT/GM Powder 60 g Bottle,63700001,CDM,250,RC,,,,,,574200802,NDC,60,GR,491.86,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,482.0228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762F,CDM,510,RC,43762,CPT,,,,,,,,492,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,482.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,204.3768,482.16
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605F,CDM,510,RC,24605,CPT,,,,,,,,1124,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,482.196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.9096,1404.08
Anus Surgery Procedure Unlisted,PX46999P,CDM,983,RC,46999,CPT,,,,,,,,953,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,482.218,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,395.8762,927.5549
"Genital Surg Proc,Male Unlisted",PX55899P,CDM,983,RC,55899,CPT,,,,,,,,953,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,482.218,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,215.91,927.5549
I&D Perirectal Abscess,PX46040P,CDM,983,RC,46040,CPT,,,,,,,,953,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,482.218,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,395.8762,1030.93
Explor Metatarso-Phalang Jt,PX28022F,CDM,510,RC,28022,CPT,,,,,,,,1161,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,482.2794,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,482.2794,2827.75
"Critical Care, Addl 30 Min",PX99292P,CDM,983,RC,99292,CPT,,,,,,,,542,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,482.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,225.1468,527.5286
umeclidinium 62.5 MCG/ACT Aerosol Powder Breath Activated 7 Each Disp Pack,63700001,CDM,250,RC,,,,,,173087306,NDC,7,EA,492.23,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,482.3854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060002,NDC,2,ML,953.57,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,482.50642,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.11,934.4986
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060010,NDC,2,ML,953.57,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,482.50642,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.11,934.4986
Bcr/Abl1 Other - Ref,PX8120890,CDM,310,RC,81208,CPT,90,,,,,,,1125,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,482.625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,196.79,1102.5
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,63323077139,NDC,1,EA,547.2,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,482.6304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
Reconstruc of Nail Bed,PX11760F,CDM,510,RC,11760,CPT,,,,,,,,1162,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,482.6948,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,482.6948,1138.76
"Remv Foreign Body,Knee/Thigh,Deep",PX27372P,CDM,983,RC,27372,CPT,,,,,,,,954,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,482.724,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,396.2916,2482.37
ADVANCED INSTRUMENTS ENDOWRIST SUCTION IRRIGATOR,27200000,CDM,272,RC,,,,11922-MAIN,LOCAL,,,,,496,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,482.7568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LOCKING SCREW T8 FULL THREAD 2.4MM L10MM,C1713,CDM,278,RC,C1713,HCPCS,,12637-MAIN,LOCAL,,,,,496,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,482.7568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LOCKING SCREW T8 FULL THREAD 2.4MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12651-MAIN,LOCAL,,,,,496,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,482.7568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LOCKING SCREW T8 FULL THREAD 2.7MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12638-MAIN,LOCAL,,,,,496,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,482.7568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LOCKING SCREW T8 FULL THREAD 2.7MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12639-MAIN,LOCAL,,,,,496,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,482.7568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Emergency Level III Visit,PX99283P,CDM,981,RC,99283,CPT,,,,,,,,568,,First Health,Commercial,both,85,,999999999,percent of total billed charges,482.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,235.9472,552.8344
Abd Paracentesis W/Imaging(T),PX49083F,CDM,510,RC,49083,CPT,,,,,,,,1006,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,482.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,417.8924,985.88
Abd Paracentesis W/Imaging(T),PX49083F,CDM,510,RC,49083,CPT,,,,,,,,1006,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,482.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,417.8924,985.88
Drainage Scrotal Wall Abscess,PX55100F,CDM,510,RC,55100,CPT,,,,,,,,634,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,482.88,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.27,482.88
Drainage Scrotal Wall Abscess,PX55100P,CDM,983,RC,55100,CPT,,,,,,,,341,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,482.88,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,104.27,482.88
"MRI, Abdomen W/O+ W/Contr",PX7418301,CDM,610,RC,74183,CPT,TC,,,,,,,4116,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,483.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,163.83,483.19
"MRI, Abdomen W/O+ W/Contr",PX7418301,CDM,610,RC,74183,CPT,TC,,,,,,,4116,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,483.19,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,163.83,483.19
"Exc Skn Bngn2.1-3cmtrnk,Arm,Lg",PX11403P,CDM,983,RC,11403,CPT,,,,,,,,543,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,483.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,225.5622,614.65
Xray Knee (Both) Ap Stand,PX7356501,CDM,320,RC,73565,CPT,TC,,,,,,,543,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,483.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,532.14
BUPivacaine liposome 1.3 % Suspension 20 mL Vial,C9290.01,CDM,636,RC,C9290,HCPCS,,,,65250026604,NDC,10,ML,976.43,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,483.33285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,405.609022,956.9014
"Closed Rx Spont Hip Disloc,Anesth",PX27257F,CDM,510,RC,27257,CPT,,,,,,,,548,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,483.336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.6392,1404.08
ciprofloxacin-dexAMETHasone 0.3-0.1 % Suspension 7.5 mL Bottle,25000000,CDM,250,RC,,,,,,43598032675,NDC,7.5,ML,976.53,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,483.38235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Fac/Exc Skn Benig >4cm Trnk,Arm,Lg",PX11406F,CDM,510,RC,11406,CPT,,,,,,,,1127,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,483.483,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,468.1558,1416.38
Debride Tissue/Muscle,PX11043F,CDM,510,RC,11043,CPT,,,,,,,,526,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,483.57,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.8,483.57
Debride Tissue/Muscle,PX11043P,CDM,983,RC,11043,CPT,,,,,,,,351,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,483.57,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.8,483.57
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505P,CDM,983,RC,25505,CPT,,,,,,,,977,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,483.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,405.8458,1404.08
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423P,CDM,983,RC,11423,CPT,,,,,,,,569,,First Health,Commercial,both,85,,999999999,percent of total billed charges,483.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,236.3626,1416.38
Cpap/Bipap Mgmnt-Pt Own Equipment,PX94660.02F,CDM,410,RC,94660,CPT,,,,,,,,497,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,483.7301,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.33,487.06
Incise External Hemorrhoid,PX46083P,CDM,983,RC,46083,CPT,,,,,,,,956,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,483.736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,215.91,930.4748
"Supply Technetium Medronate,to 30 MC",PXA9503,CDM,343,RC,A9503,HCPCS,,,,,,,,531,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,483.741,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,220.5774,520.38
beclomethasone  HFA 80 MCG/ACT Aerosol Breath Activated 10.6 g Inhaler,63700001,CDM,250,RC,,,,,,59310030480,NDC,10.6,GR,1164.84,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,483.874536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CRICOTHROTOMY QUICKTRACH 4MM,120.228,CDM,272,RC,A7520,HCPCS,,8868-MAIN,LOCAL,,,,,494,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,484.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.2076,484.12
SET CRICOTHYROTOMY CATHETER 6MM ID,120.378,CDM,272,RC,,,,11119-MAIN,LOCAL,,,,,494,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,484.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.2076,484.12
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004P,CDM,983,RC,15004,CPT,,,,,,,,570,,First Health,Commercial,both,85,,999999999,percent of total billed charges,484.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,236.778,554.781
Tube Thoracostomy Inc Wtr Seal,PX32551F,CDM,510,RC,32551,CPT,,,,,,,,989,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,484.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,410.8306,1399.13
Tube Thoracostomy Inc Wtr Seal,PX32551F,CDM,510,RC,32551,CPT,,,,,,,,989,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,484.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,410.8306,1399.13
Tube Thoracostomy Inc Wtr Seal,PX32551F,CDM,510,RC,32551,CPT,,,,,,,,989,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,484.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,410.8306,1399.13
ondansetron 4 MG/5ML Solution 25 mL Bottle,S0119.01,CDM,636,RC,S0119,HCPCS,,,,99998-8001-,NDC,25,ML,494.57,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,484.6786,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.087214,484.6786
Gastric Intubation Treatment,PX43753P,CDM,983,RC,43753,CPT,,,,,,,,498,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,484.7034,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.8692,484.7034
"POS Airway Pressure, Cpap",PX94660F,CDM,410,RC,94660,CPT,,,,,,,,498,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,484.7034,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.33,488.04
clobetasol 0.05 % Cream 60 g Tube,63700001,CDM,250,RC,,,,,,168030160,NDC,60,GR,989.25,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,484.7325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clobetasol 0.05 % Cream 60 g Tube,63700001,CDM,250,RC,,,,,,168030160,NDC,60,GR,989.25,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,484.7325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clobetasol 0.05 % Cream 60 g Tube,63700001,CDM,250,RC,,,,,,168030160,NDC,60,GR,989.25,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,484.7325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Aspirate Pleura W/O Imaging,PX32554F,CDM,510,RC,32554,CPT,,,,,,,,795,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,484.95,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,53.88,484.95
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725F,CDM,510,RC,26725,CPT,,,,,,,,495,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,485.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.623,485.1
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101F,CDM,510,RC,13101,CPT,,,,,,,,495,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,485.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.623,548.67
Tc99 Mebrofenin to 15 Mci,PXA9537,CDM,343,RC,A9537,HCPCS,,,,,,,,495,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,485.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.623,485.1
"Removal Anal Fistula,Subcutaneous",PX46270P,CDM,983,RC,46270,CPT,,,,,,,,980,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,485.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,407.092,2452.93
"MRI,Upr Ext, Joint,W/Cont",PX7322201,CDM,610,RC,73222,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,485.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,164.48,485.16
"MRI,Upr Ext, Joint,W/Cont",PX7322201,CDM,610,RC,73222,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,485.16,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,164.48,485.16
Xray Ribs Bil 3vws Tc,PX7111001,CDM,320,RC,71110,CPT,TC,,,,,,,533,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,485.563,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,522.34
STAPLER SUREFORM 60 SPU IS4000,27200000,CDM,272,RC,,,,12086-MAIN,LOCAL,,,,,991,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,485.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STAPLER SUREFORM 60 SPU IS4000,27200000,CDM,272,RC,,,,12086-MAIN,LOCAL,,,,,991,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,485.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STAPLER SUREFORM 60 SPU IS4000,27200000,CDM,272,RC,,,,12086-MAIN,LOCAL,,,,,991,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,485.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200001,NDC,0.5,ML,980.99,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,485.59005,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,264.67,961.3702
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200002,NDC,0.5,ML,980.99,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,485.59005,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,264.67,961.3702
Exc Skin Benig >4cm Remaindr Body,PX11426P,CDM,983,RC,11426,CPT,,,,,,,,981,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,485.595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,407.5074,2482.37
ADVANCED INSTRUMENTS VESSEL SEALER EXTEND,27200000,CDM,272,RC,,,,11923-MAIN,LOCAL,,,,,1169,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,485.6026,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
esmolol 2500 MG/250ML Solution 250 mL Flex Cont,J1805.01,CDM,636,RC,J1805,HCPCS,,,,10019067010,NDC,250,ML,1011.8,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,485.664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.24,991.564
esmolol 2500 MG/250ML Solution 250 mL Flex Cont,J1805.01,CDM,636,RC,J1805,HCPCS,,,,10019067010,NDC,250,ML,1011.8,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,485.664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.24,991.564
MRI Lower W/O+W Tc,PX7372001,CDM,610,RC,73720,CPT,TC,,,,,,,3174,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,485.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,164.7,485.82
MRI Lower W/O+W Tc,PX7372001,CDM,610,RC,73720,CPT,TC,,,,,,,3174,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,485.82,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,164.7,485.82
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605F,CDM,510,RC,25605,CPT,,,,,,,,1178,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,485.8243,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,325.92,1160.15
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605P,CDM,983,RC,25605,CPT,,,,,,,,785,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,485.8243,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,325.92,1160.15
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031P,CDM,983,RC,12031,CPT,,,,,,,,551,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,485.982,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,228.8854,536.2883
Xray Facial Bones Minimum 3 Vws,PX7015001,CDM,320,RC,70150,CPT,TC,,,,,,,551,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,485.982,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,539.98
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527197174,NDC,4,ML,960.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,486.013,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
ADVANCED INSTRUMENTS ENDOWRIST SUCTION IRRIGATOR,27200000,CDM,272,RC,,,,11922-MAIN,LOCAL,,,,,496,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,486.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
LOCKING SCREW T8 FULL THREAD 2.4MM L10MM,C1713,CDM,278,RC,C1713,HCPCS,,12637-MAIN,LOCAL,,,,,496,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,486.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LOCKING SCREW T8 FULL THREAD 2.4MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12651-MAIN,LOCAL,,,,,496,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,486.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LOCKING SCREW T8 FULL THREAD 2.7MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12638-MAIN,LOCAL,,,,,496,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,486.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LOCKING SCREW T8 FULL THREAD 2.7MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12639-MAIN,LOCAL,,,,,496,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,486.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
MESH LARGE LEFT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 4X6,120.521,CDM,278,RC,C1781,HCPCS,,12215-MAIN,LOCAL,,,,,572,,First Health,Commercial,both,85,,999999999,percent of total billed charges,486.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,237.6088,560.56
MESH LARGE RIGHT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 4X6,C1781,CDM,278,RC,C1781,HCPCS,,12195-MAIN,LOCAL,,,,,572,,First Health,Commercial,both,85,,999999999,percent of total billed charges,486.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Remove Nasal Foreign Body,PX30300P,CDM,983,RC,30300,CPT,,,,,,,,572,,First Health,Commercial,both,85,,999999999,percent of total billed charges,486.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,556.7276
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545F,CDM,510,RC,23545,CPT,,,,,,,,961,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,486.266,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,941.78
"Correct Bunion,Metatarsal Osteotomy",PX28296F,CDM,510,RC,28296,CPT,,,,,,,,8100,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,486.4665,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,324.17,1834.65
"Correct Bunion,Metatarsal Osteotomy",PX28296P,CDM,983,RC,28296,CPT,,,,,,,,2150,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,486.4665,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,324.17,2107
Calr Gene Analysis Common Variants in Exon 9 - Ref,PX8121990,CDM,300,RC,81219,CPT,90,,,,,,,534,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,486.474,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.52,523.32
"I&D Perianal Abscess,Superficial",PX46050P,CDM,983,RC,46050,CPT,,,,,,,,993,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,486.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,412.4922,966.4869
"I&D Perianal Abscess,Superficial",PX46050P,CDM,983,RC,46050,CPT,,,,,,,,993,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,486.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,412.4922,966.4869
"I&D Perianal Abscess,Superficial",PX46050P,CDM,983,RC,46050,CPT,,,,,,,,993,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,486.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,412.4922,966.4869
"Lap,Cholecystectomy",PX47562P,CDM,983,RC,47562,CPT,,,,,,,,983,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,486.585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,408.3382,5040.74
Sigmoidoscope W/Submuc Inj,PX45335P,CDM,983,RC,45335,CPT,,,,,,,,500,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,486.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,207.7,798.45
STIFNECK ADULT,120.77,CDM,274,RC,L0180,HCPCS,,991-MAIN,LOCAL,,,,,119,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,486.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,486.73
STIFNECK PEDIATRIC,120.77,CDM,274,RC,L0180,HCPCS,,998-MAIN,LOCAL,,,,,119,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,486.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.4326,486.73
"Inj,Lumb Epidur,Blood/Clot Patch",PX62273P,CDM,983,RC,62273,CPT,,,,,,,,552,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,486.864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,229.3008,604.15
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390P,CDM,982,RC,45390,CPT,,,,,,,,1135,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,486.915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,471.479,2452.93
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,63323077139,NDC,1,EA,547.2,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,487.008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
Cpap/Bipap Mgmnt-Pt Own Equipment,PX94660.02F,CDM,410,RC,94660,CPT,,,,,,,,497,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,487.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.33,487.06
CARTER THOMASON CLOSURE SUTURE PASSER XL 10/12MM 15MM CTXL,27200000,CDM,272,RC,,,,12946-MAIN,LOCAL,,,,,535,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,487.385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Debride Skin/Tissue,PX11042P,CDM,983,RC,11042,CPT,,,,,,,,995,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,440.455,percent of total billed charges,487.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,968.4335
Debride Skin/Tissue,PX11042P,CDM,983,RC,11042,CPT,,,,,,,,995,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,487.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,968.4335
Debride Skin/Tissue,PX11042P,CDM,983,RC,11042,CPT,,,,,,,,995,,United Healthcare,All Medicare advantage plans,outpatient,49,,565.51,percent of total billed charges,487.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,968.4335
belimumab 120 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010101,NDC,1,EA,1015.95,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,487.656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.72,3453.2358
belimumab 120 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010101,NDC,1,EA,1015.95,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,487.656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.72,3453.2358
"Closed Rx Spont Hip Disloc,Anesth",PX27257F,CDM,510,RC,27257,CPT,,,,,,,,548,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,487.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.6392,1404.08
PERFIX PLUG STERILE MEDIUM,C1781,CDM,278,RC,C1781,HCPCS,,11770-MAIN,LOCAL,,,,,553,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,487.746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Closed Rx Talus Fx,Manipulatn",PX28435P,CDM,983,RC,28435,CPT,,,,,,,,1137,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,487.773,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,472.3098,1404.08
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604F,CDM,510,RC,11604,CPT,,,,,,,,964,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,487.784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,400.4456,944.72
HERNIA PATCH VENTRALEX SMALL,C1781,CDM,278,RC,C1781,HCPCS,,10203-MAIN,LOCAL,,,,,995.96,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,196.035,percent of total billed charges,488.0204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
HERNIA PATCH VENTRALEX SMALL,C1781,CDM,278,RC,C1781,HCPCS,,10203-MAIN,LOCAL,,,,,995.96,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,488.0204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
HERNIA PATCH VENTRALEX SMALL,C1781,CDM,278,RC,C1781,HCPCS,,10203-MAIN,LOCAL,,,,,995.96,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,488.0204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Gastric Intubation Treatment,PX43753P,CDM,983,RC,43753,CPT,,,,,,,,498,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,488.04,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.65,488.04
"POS Airway Pressure, Cpap",PX94660F,CDM,410,RC,94660,CPT,,,,,,,,498,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,488.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.33,488.04
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180P,CDM,983,RC,44180,CPT,,,,,,,,1175,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,488.095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,488.095,5040.74
Temporal Artery Ligatn or Bx,PX37609P,CDM,983,RC,37609,CPT,,,,,,,,965,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,488.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,400.861,1416.38
Aspirate Pleura W/ Imaging,PX32555P,CDM,983,RC,32555,CPT,,,,,,,,536,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,488.296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,222.6544,548.81
Lvl 3 Init Hosp High Mdm or 75 Minutes,PX99223,CDM,982,RC,99223,CPT,,,,,,,,536,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,488.296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,222.6544,521.6888
"VENTRALIGHT MESH ST WITH ECHO 2 - 10 CM X 15 CM - 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,12007-MAIN,LOCAL,,,,,1176,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,488.5104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Factor VIII (Ahg) 1-Stage,PX85240,CDM,300,RC,85240,CPT,,,,,,,,997,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,488.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.41,977.06
Factor VIII (Ahg) 1-Stage,PX85240,CDM,300,RC,85240,CPT,,,,,,,,997,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,488.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.41,977.06
Factor VIII (Ahg) 1-Stage,PX85240,CDM,300,RC,85240,CPT,,,,,,,,997,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,488.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.41,977.06
"Chemotherapy, IV Push, Single Drug",PX96409,CDM,335,RC,96409,CPT,,,,,,,,502,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,488.5966,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.5308,491.96
Incise External Hemorrhoid,PX46083F,CDM,510,RC,46083,CPT,,,,,,,,502,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,488.5966,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.5308,491.96
Aaa US Screen Tc,PX7670601,CDM,402,RC,76706,CPT,TC,,,,,,,554,,United Healthcare,All Payer,outpatient,88.2,,266.56,percent of total billed charges,488.628,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,542.92
US Kidney Transplt Untrsd,PX7677601,CDM,402,RC,76776,CPT,TC,,,,,,,554,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,488.628,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,542.92
"DXA, Bone Density Study, Hips/Pelv/Spine",PX7708001,CDM,320,RC,77080,CPT,TC,,,,,,,575,,First Health,Commercial,both,85,,999999999,percent of total billed charges,488.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,563.5
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151P,CDM,983,RC,13151,CPT,,,,,,,,1177,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,488.9258,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,488.9258,1145.5741
MRI Orb-Fac-Nec W/O+W/Con,PX7054301,CDM,610,RC,70543,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,489.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,165.79,489.11
MRI Orb-Fac-Nec W/O+W/Con,PX7054301,CDM,610,RC,70543,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,489.11,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,165.79,489.11
"Critical Care, E/M 30-74 Minutes",PX99291P,CDM,983,RC,99291,CPT,,,,,,,,1061,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,489.16,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.04,1039.78
"Facility Critical Care, E/M 30-74 Minutes",PX99291F,CDM,510,RC,99291,CPT,,,,,,,,1264,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,489.16,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.04,489.16
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605F,CDM,510,RC,25605,CPT,,,,,,,,1178,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,489.3412,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,489.3412,1404.08
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,16714081501,NDC,5,ML,998.95,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,57.34422222,percent of total billed charges,489.4855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,16714081501,NDC,5,ML,998.95,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,489.4855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,16714081501,NDC,5,ML,998.95,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,489.4855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
Remove Hemorrhoids & Fissure,PX46257F,CDM,510,RC,46257,CPT,,,,,,,,1141,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,489.489,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,473.9714,2452.93
Xray Sacroiliac Jnts Less Than 3 Vws,PX7220001,CDM,320,RC,72200,CPT,TC,,,,,,,555,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,489.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,543.9
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004004,NDC,120,ML,502.95,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,489.521235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
Tube Thoracostomy Inc Wtr Seal,PX32551F,CDM,510,RC,32551,CPT,,,,,,,,989,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,489.555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,410.8306,1399.13
Trb@ Gene Rearrange Amplify - Ref,PX8134090,CDM,300,RC,81340,CPT,90,,,,,,,503,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,489.5699,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,191.56,492.94
clobetasol 0.05 % Cream 60 g Tube,63700001,CDM,250,RC,,,,,,168030160,NDC,60,GR,989.25,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,489.67875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Colonoscope, Submucous Inj",PX45381F,CDM,750,RC,45381,CPT,,,,,,,,1179,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,489.7566,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,489.7566,1155.42
paliperidone palmitate ER 234 MG/1.5ML suspension prefilled syringe 1.5 mL Syringe,J2426.01,CDM,636,RC,J2426,HCPCS,,,,50458056401,NDC,0.25,ML,1142.14,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,489.97806,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.12,1119.2972
Sigmoidoscope W/Submuc Inj,PX45335P,CDM,983,RC,45335,CPT,,,,,,,,500,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,490,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.23,602.56
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,121090204,NDC,120,ML,503.56,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,490.114948,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
"Sb Scope,to Ileum,Biopsy",PX44377P,CDM,983,RC,44377,CPT,,,,,,,,1180,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,490.172,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,490.172,1662.33
"Repair Umbilical Hern,5+Y/O,Reduc",PX49585F,CDM,510,RC,49585,CPT,,,,,,,,969,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,490.314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,402.5226,949.62
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151F,CDM,510,RC,13151,CPT,,,,,,,,1143,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,490.347,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,474.8022,1120.14
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031P,CDM,983,RC,12031,CPT,,,,,,,,551,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,490.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,228.8854,536.2883
Xray Facial Bones Minimum 3 Vws,PX7015001,CDM,320,RC,70150,CPT,TC,,,,,,,551,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,490.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,539.98
X-Ray Exam Chest 2 Views,PX7104601,CDM,320,RC,71046,CPT,TC,,,,,,,556,,United Healthcare,All Payer,outpatient,88.2,,289.351875,percent of total billed charges,490.392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,544.88
Xray Chest 2 Views,PX7102001,CDM,320,RC,71020,CPT,TC,,,,,,,556,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,490.392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,230.9624,544.88
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,71288020185,NDC,5,ML,1021.7,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,490.416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,424.41418,1239.6216
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,71288020185,NDC,5,ML,1021.7,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,490.416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,424.41418,1239.6216
"MRI,Up Ext,No Jnt,No Cont",PX7321801,CDM,610,RC,73218,CPT,TC,,,,,,,3253,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,490.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,156.41,490.42
"MRI,Up Ext,No Jnt,No Cont",PX7321801,CDM,610,RC,73218,CPT,TC,,,,,,,3253,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,490.42,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,156.41,490.42
STAPLER SUREFORM 60 SPU IS4000,27200000,CDM,272,RC,,,,12086-MAIN,LOCAL,,,,,991,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,490.545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Bcr/Abl1 P210 - Ref,PX8120690,CDM,310,RC,81206,CPT,90,,,,,,,1144,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,490.776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.33,1121.12
GROSHONG PICC NXT 4FR,120.218,CDM,272,RC,,,,498-MAIN,LOCAL,,,,,1182,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,491.0028,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,491.0028,1158.36
CP LAG SCREW 3.6MM L22MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12757-MAIN,LOCAL,,,,,539,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,491.029,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
CP LAG SCREW 3.6MM L24MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12650-MAIN,LOCAL,,,,,539,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,491.029,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
CP LAG SCREW 3.6MM L26MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12636-MAIN,LOCAL,,,,,539,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,491.029,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"Column Chrom Ms, Quant - Ref",PX8254290,CDM,300,RC,82542,CPT,90,,,,,,,557,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,491.274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.09,545.86
"Inj,Lumb Epidur,Blood/Clot Patch",PX62273P,CDM,983,RC,62273,CPT,,,,,,,,552,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,491.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,229.3008,604.15
Diagnostic Anoscopy,PX46600F,CDM,510,RC,46600,CPT,,,,,,,,505,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,90.16,percent of total billed charges,491.5165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,494.9
"I&D Perianal Abscess,Superficial",PX46050P,CDM,983,RC,46050,CPT,,,,,,,,993,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,491.535,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,412.4922,966.4869
Remove Nasal Foreign Body,PX30300F,CDM,510,RC,30300,CPT,,,,,,,,972,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,491.832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,952.56
Xray Sacrum/ Coccyx Minimum 2 Vws,PX7222001,CDM,320,RC,72220,CPT,TC,,,,,,,540,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,491.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,529.2
"Chemotherapy, IV Push, Single Drug",PX96409,CDM,335,RC,96409,CPT,,,,,,,,502,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,491.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.5308,491.96
Incise External Hemorrhoid,PX46083F,CDM,510,RC,46083,CPT,,,,,,,,502,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,491.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.5308,491.96
Insert Non-Tunnel Cv Catheter >5 Years,PX36556F,CDM,510,RC,36556,CPT,,,,,,,,1025,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,425.785,2784.63
Insert Non-Tunnel Cv Catheter >5 Years,PX36556F,CDM,510,RC,36556,CPT,,,,,,,,1025,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,425.785,2784.63
"Remv Foot Foreign Body,Subcutaneous",PX28190F,CDM,510,RC,28190,CPT,,,,,,,,1025,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,425.785,1004.5
"Remv Foot Foreign Body,Subcutaneous",PX28190F,CDM,510,RC,28190,CPT,,,,,,,,1025,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,425.785,1004.5
fluticasone-salmeterol 250-50 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069604,NDC,14,EA,1025.13,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,492.0624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone-salmeterol 250-50 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069604,NDC,14,EA,1025.13,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,492.0624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Removal of Tunnel Cv Access Device, With Port/Pump",PX36590P,CDM,983,RC,36590,CPT,,,,,,,,1147,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,492.063,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,476.4638,1399.13
BRONCHOSCOPE BFLEX 5.0 SINGLE-USE 0570-0449,120.578,CDM,272,RC,,,,13020-MAIN,LOCAL,,,,,558,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,492.156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,231.7932,546.84
PERFIX PLUG STERILE LARGE,C1781,CDM,278,RC,C1781,HCPCS,,11771-MAIN,LOCAL,,,,,558,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,492.156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
PERFIX PLUG STERILE MEDIUM,C1781,CDM,278,RC,C1781,HCPCS,,11770-MAIN,LOCAL,,,,,553,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,492.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
fluticasone furoate-vilanterol 100-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173085914,NDC,28,EA,1025.38,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,492.1824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone furoate-vilanterol 100-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173085914,NDC,28,EA,1025.38,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,492.1824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476881,NDC,50,ML,579.12,,First Health,Commercial,both,85,,999999999,percent of total billed charges,492.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
"Closed Rx Bimalleolar Fx,Manip",PX27810F,CDM,510,RC,27810,CPT,,,,,,,,1026,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,492.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,426.2004,1404.08
"Closed Rx Bimalleolar Fx,Manip",PX27810F,CDM,510,RC,27810,CPT,,,,,,,,1026,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,492.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,426.2004,1404.08
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409422801,NDC,100,ML,1026,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,492.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409422801,NDC,100,ML,1026,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,492.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
"Upper GI Endoscopy,Ctrl Bleed",PX43255P,CDM,983,RC,43255,CPT,,,,,,,,1148,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,492.492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,476.8792,1662.33
Debride Skin/Tissue,PX11042P,CDM,983,RC,11042,CPT,,,,,,,,995,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,492.525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,968.4335
"I&D Perianal Abscess,Superficial",PX46050,CDM,983,RC,46050,CPT,,,,,,,,1096,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,492.56,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.26,1074.08
"I&D Perianal Abscess,Superficial",PX46050F,CDM,510,RC,46050,CPT,,,,,,,,1463,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,492.56,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.26,492.56
"I&D Perianal Abscess,Superficial",PX46050P,CDM,983,RC,46050,CPT,,,,,,,,993,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,492.56,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.26,973.14
dorzolamide-timolol 2-0.5 % Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,50383023310,NDC,10,ML,506.34,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,492.820722,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004004,NDC,120,ML,502.95,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,492.891,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
Abd Paracentesis W/Imaging(T),PX49083F,CDM,510,RC,49083,CPT,,,,,,,,1006,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,492.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,417.8924,985.88
Abd Paracentesis W/Imaging(T),PX49083F,CDM,510,RC,49083,CPT,,,,,,,,1006,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,492.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,417.8924,985.88
Abd Paracentesis W/Imaging(T),PX49083F,CDM,510,RC,49083,CPT,,,,,,,,1006,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,492.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,417.8924,985.88
Trb@ Gene Rearrange Amplify - Ref,PX8134090,CDM,300,RC,81340,CPT,90,,,,,,,503,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,492.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,191.56,492.94
Facility Emergency Level II Visit,PX99282F,CDM,450,RC,99282,CPT,,,,,,,,387,,Medica,Minnesota Health care Program (MHCP),outpatient,,,999999999,case rate,493,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,493,6141.46
Leukoreduced Rbc's,PXP9016,CDM,390,RC,P9016,HCPCS,,,,,,,,580,,First Health,Commercial,both,85,,999999999,percent of total billed charges,493,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,165.79,568.4
HERNIA PATCH VENTRALEX SMALL,C1781,CDM,278,RC,C1781,HCPCS,,10203-MAIN,LOCAL,,,,,995.96,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,493.0002,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Aaa US Screen Tc,PX7670601,CDM,402,RC,76706,CPT,TC,,,,,,,554,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,493.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,542.92
US Kidney Transplt Untrsd,PX7677601,CDM,402,RC,76776,CPT,TC,,,,,,,554,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,493.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,542.92
gentamicin 0.1 % Ointment 30 g Tube,25000000,CDM,250,RC,,,,,,713068231,NDC,30,GR,506.64,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,493.112712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221901,NDC,3,ML,506.9,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,4.0055,percent of total billed charges,493.36577,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221905,NDC,3,ML,506.9,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,4.0055,percent of total billed charges,493.36577,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,121090204,NDC,120,ML,503.56,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,493.4888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.6079,493.4888
Art Lower Extremity-Bilat,PX9392501,CDM,921,RC,93925,CPT,TC,,,,,,,1188,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,493.4952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,1164.24
Factor VIII (Ahg) 1-Stage,PX85240,CDM,300,RC,85240,CPT,,,,,,,,997,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,493.515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.41,977.06
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032601,NDC,0.5,ML,559.7,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,493.6554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,1630.2692
"Critical Care, Addl 30 Min",PX99292P,CDM,983,RC,99292,CPT,,,,,,,,542,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,493.762,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,225.1468,527.5286
Ven Duplex Bilateral,PX9397001,CDM,921,RC,93970,CPT,TC,,,,,,,1189,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,493.9106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,1165.22
"Close Rx Fingr Articular Fx,Manip",PX26742P,CDM,983,RC,26742,CPT,,,,,,,,560,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,493.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,232.624,1404.08
"Enzyme Act, Nonradioact - Ref",PX8265790,CDM,300,RC,82657,CPT,90,,,,,,,560,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,493.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.33,548.8
"Exc Skn Mal 0.6-1cm Fce,Facial",PX11641P,CDM,983,RC,11641,CPT,,,,,,,,453,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,493.95,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97.51,493.95
"Fac/Exc Skn Mal 0.6-1cm Fce,Facial",PX11641F,CDM,510,RC,11641,CPT,,,,,,,,680,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,493.95,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,97.51,493.95
Xray Sacroiliac Jnts Less Than 3 Vws,PX7220001,CDM,320,RC,72200,CPT,TC,,,,,,,555,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,493.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,543.9
BUPivacaine liposome 1.3 % Suspension 20 mL Vial,C9290.01,CDM,636,RC,C9290,HCPCS,,,,65250026604,NDC,10,ML,976.43,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,494.07358,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,405.609022,956.9014
ciprofloxacin-dexAMETHasone 0.3-0.1 % Suspension 7.5 mL Bottle,25000000,CDM,250,RC,,,,,,43598032675,NDC,7.5,ML,976.53,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,494.12418,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,63323067305,NDC,5,ML,1029.71,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,494.2608,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.08296,1009.1158
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,63323067305,NDC,5,ML,1029.71,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,494.2608,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.08296,1009.1158
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505P,CDM,983,RC,25505,CPT,,,,,,,,977,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,494.362,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,405.8458,1404.08
"Inpatient Consult, Level IV",PX99254,CDM,983,RC,99254,CPT,,,,,,,,508,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,494.4364,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.0232,494.4364
Lvl 2 Init Hosp Mod Mdm or 55 Minutes,PX99222,CDM,982,RC,99222,CPT,,,,,,,,508,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,494.4364,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.0232,494.4364
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,16714081501,NDC,5,ML,998.95,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,494.48025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
"Exc Skn Bngn2.1-3cmtrnk,Arm,Lg",PX11403P,CDM,983,RC,11403,CPT,,,,,,,,543,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,494.673,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,225.5622,614.65
Xray Knee (Both) Ap Stand,PX7356501,CDM,320,RC,73565,CPT,TC,,,,,,,543,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,494.673,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,532.14
"Hospital Inpt or Obs Care, Admin/Disch Same Date, Moderate Level Mdm >= 70 Minutes",PX99235,CDM,982,RC,99235,CPT,,,,,,,,582,,First Health,Commercial,both,85,,999999999,percent of total billed charges,494.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,241.7628,566.4606
Drain Skin Abscess Complic,PX10061P,CDM,983,RC,10061,CPT,,,,,,,,561,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,494.802,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,233.0394,546.0213
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12130-MAIN,LOCAL,,,,,561,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,494.802,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
X-Ray Exam Chest 2 Views,PX7104601,CDM,320,RC,71046,CPT,TC,,,,,,,556,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,494.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,544.88
Xray Chest 2 Views,PX7102001,CDM,320,RC,71020,CPT,TC,,,,,,,556,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,494.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,230.9624,544.88
Diagnostic Anoscopy,PX46600F,CDM,510,RC,46600,CPT,,,,,,,,505,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,494.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,494.9
Acute Hepatitis Panel,PX80074,CDM,300,RC,80074,CPT,,,,,,,,509,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,495.4097,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,43.67,498.82
Biopsy of Rectum,PX45100P,CDM,983,RC,45100,CPT,,,,,,,,509,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,495.4097,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.4386,2452.93
Cardiac Rehab II Eval,PX93798.05,CDM,943,RC,93798,CPT,,,,,,,,364,,Blue Cross Blue Shield of MN,All commercial plans,both,,,316.7718868,fee schedule,495.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.44,495.55
Cardiac Rehab II W/ Monitor,PX93798.02,CDM,943,RC,93798,CPT,,,,,,,,338,,Blue Cross Blue Shield of MN,All commercial plans,both,,,316.7718868,fee schedule,495.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.44,495.55
"IV Infusion, Casirivimab and Imdevimab, IV and Post Admr",PXM0243,CDM,771,RC,M0243,HCPCS,,,,,,,,1555,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,495.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,413.06,1684.87
"Lap,Dx Surgical Abd W/Biopsy",PX49321P,CDM,983,RC,49321,CPT,,,,,,,,583,,First Health,Commercial,both,85,,999999999,percent of total billed charges,495.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,242.1782,5040.74
Exc Skn Bngn3.1-4cm Remain Bdy,PX11424P,CDM,983,RC,11424,CPT,,,,,,,,562,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,495.684,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,233.4548,1416.38
"US,Preg. Uterus,Fetal/Mat.Eval.,>1st Trim.(>/= 14 Wks 0 Dys),Transabd;Single/First Gest., Tech",PX7680501,CDM,402,RC,76805,CPT,TC,,,,,,,562,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,495.684,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,550.76
"Column Chrom Ms, Quant - Ref",PX8254290,CDM,300,RC,82542,CPT,90,,,,,,,557,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,495.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.09,545.86
esmolol 2500 MG/250ML Solution 250 mL Flex Cont,J1805.01,CDM,636,RC,J1805,HCPCS,,,,10019067010,NDC,250,ML,1011.8,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,495.782,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.24,991.564
esmolol 2500 MG/250ML Solution 250 mL Flex Cont,J1805.01,CDM,636,RC,J1805,HCPCS,,,,10019067010,NDC,250,ML,1011.8,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,495.782,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.24,991.564
esmolol 2500 MG/250ML Solution 250 mL Flex Cont,J1805.01,CDM,636,RC,J1805,HCPCS,,,,10019067010,NDC,250,ML,1011.8,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,495.782,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.24,991.564
sugammadex sodium 200 MG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,6542312,NDC,2,ML,583.33,,First Health,Commercial,both,85,,999999999,percent of total billed charges,495.8305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
dexmedeTOMIDine in sodium chloride 400 MCG/100ML Solution 100 mL Bottle,25000000,CDM,250,RC,,,,,,67457092500,NDC,100,ML,562.18,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,495.84276,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Removal Anal Fistula,Subcutaneous",PX46270P,CDM,983,RC,46270,CPT,,,,,,,,980,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,495.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,407.092,2452.93
dorzolamide-timolol 2-0.5 % Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,50383023310,NDC,10,ML,506.34,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,496.2132,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200001,NDC,0.5,ML,980.99,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,496.38094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,264.67,961.3702
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200002,NDC,0.5,ML,980.99,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,496.38094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,264.67,961.3702
Exc Skin Benig >4cm Remaindr Body,PX11426P,CDM,983,RC,11426,CPT,,,,,,,,981,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,496.386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,407.5074,2482.37
gentamicin 0.1 % Ointment 30 g Tube,25000000,CDM,250,RC,,,,,,713068231,NDC,30,GR,506.64,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,496.5072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Xray Pelvis Compl 3+ Tc,PX7219001,CDM,320,RC,72190,CPT,TC,,,,,,,563,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,496.566,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,551.74
BRONCHOSCOPE BFLEX 5.0 SINGLE-USE 0570-0449,120.578,CDM,272,RC,,,,13020-MAIN,LOCAL,,,,,558,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,496.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,231.7932,546.84
PERFIX PLUG STERILE LARGE,C1781,CDM,278,RC,C1781,HCPCS,,11771-MAIN,LOCAL,,,,,558,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,496.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
cefdinir 250 MG/5ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,16714039301,NDC,60,ML,510.33,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,496.704189,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Exc Skn Bngn3.1-4cm Remain Bdy,PX11424P,CDM,983,RC,11424,CPT,,,,,,,,562,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,496.71,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.13,550.76
Fac/Exc Skn Bngn3.1-4cm Remain Bdy,PX11424F,CDM,510,RC,11424,CPT,,,,,,,,931,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,496.71,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.13,496.71
"Initial Repair of Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49593P,CDM,982,RC,49593,CPT,,,,,,,,2606,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,496.7417,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,337.26,2553.88
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221901,NDC,3,ML,506.9,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,496.762,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221905,NDC,3,ML,506.9,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,496.762,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,6384371,NDC,1,EA,563.46,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,496.97172,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132F,CDM,510,RC,13132,CPT,,,,,,,,1159,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,497.211,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,481.4486,1135.82
"Layr Clos Wnd Face,Facial 2.5-5",PX12052F,CDM,510,RC,12052,CPT,,,,,,,,585,,First Health,Commercial,both,85,,999999999,percent of total billed charges,497.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,243.009,573.3
"Lap,Cholecystectomy",PX47562P,CDM,983,RC,47562,CPT,,,,,,,,983,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,497.398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,408.3382,5040.74
Fac/Cystourethroscopy,PX52000F,CDM,761,RC,52000,CPT,,,,,,,,1601,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,497.4,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,48.86,497.4
belimumab 120 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010101,NDC,1,EA,1015.95,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,497.8155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.72,3453.2358
belimumab 120 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010101,NDC,1,EA,1015.95,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,497.8155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.72,3453.2358
belimumab 120 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010101,NDC,1,EA,1015.95,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,497.8155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.72,3453.2358
"Inpatient Consult, Level IV",PX99254,CDM,983,RC,99254,CPT,,,,,,,,508,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,497.84,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,87.73,497.84
Lvl 2 Init Hosp Mod Mdm or 55 Minutes,PX99222,CDM,982,RC,99222,CPT,,,,,,,,508,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,497.84,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,81.18,497.84
Abd Paracentesis W/Imaging(T),PX49083F,CDM,510,RC,49083,CPT,,,,,,,,1006,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,497.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,417.8924,985.88
Explor Metatarso-Phalang Jt,PX28022F,CDM,510,RC,28022,CPT,,,,,,,,1161,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,498.069,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,482.2794,2827.75
US Abdomen Tc,PX7670001,CDM,402,RC,76700,CPT,TC,,,,,,,586,,First Health,Commercial,both,85,,999999999,percent of total billed charges,498.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,574.28
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032601,NDC,0.5,ML,559.7,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,498.133,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,1630.2692
DRIVER HEX 2.00MM STERILE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12440-MAIN,LOCAL,,,,,512,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,498.3296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRIVER HEX 2.5MM STERILE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12441-MAIN,LOCAL,,,,,512,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,498.3296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Repr Superf Wnd Body 12.6-20,PX12005F,CDM,510,RC,12005,CPT,,,,,,,,565,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,498.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,234.701,553.7
Xray Lumbosacral Minimum 4 Vws,PX7211001,CDM,320,RC,72110,CPT,TC,,,,,,,565,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,498.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,553.7
"Close Rx Fingr Articular Fx,Manip",PX26742P,CDM,983,RC,26742,CPT,,,,,,,,560,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,498.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,232.624,1404.08
"Enzyme Act, Nonradioact - Ref",PX8265790,CDM,300,RC,82657,CPT,90,,,,,,,560,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,498.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.33,548.8
Level 1 Additional Procedure,PX36000080,CDM,360,RC,,,,,,,,,,1200,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,498.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,498.48,1176
Reconstruc of Nail Bed,PX11760F,CDM,510,RC,11760,CPT,,,,,,,,1162,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,498.498,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,482.6948,1138.76
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,63323077139,NDC,1,EA,547.2,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,498.4992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
"Polysomnography, 4 or More",PX9581001,CDM,740,RC,95810,CPT,TC,,,,,,,4313,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,498.6576,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,324.17,887.09
"Close Rx Fingr Articular Fx,Manip",PX26742F,CDM,510,RC,26742,CPT,,,,,,,,1039,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,498.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,431.6006,1404.08
"Close Rx Fingr Articular Fx,Manip",PX26742F,CDM,510,RC,26742,CPT,,,,,,,,1039,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,498.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,431.6006,1404.08
Acute Hepatitis Panel,PX80074,CDM,300,RC,80074,CPT,,,,,,,,509,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,498.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,43.67,498.82
Biopsy of Rectum,PX45100P,CDM,983,RC,45100,CPT,,,,,,,,509,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,498.82,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.92,635.07
Facility Emergency Level III Visit,PX99283F,CDM,450,RC,99283,CPT,,,,,,,,587,,First Health,Commercial,both,85,,999999999,percent of total billed charges,498.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,243.8398,575.26
US Renal Retroperit Ltd,PX7677501,CDM,402,RC,76775,CPT,TC,,,,,,,566,,United Healthcare,All Payer,outpatient,88.2,,277.34,percent of total billed charges,499.212,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,554.68
US Retroperitoneal Tc,PX7677001,CDM,402,RC,76770,CPT,TC,,,,,,,566,,United Healthcare,All Payer,outpatient,88.2,,290.97,percent of total billed charges,499.212,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,554.68
"Closed Rx Spont Hip Disloc,Anesth",PX27257F,CDM,510,RC,27257,CPT,,,,,,,,548,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,499.228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.6392,1404.08
Drain Skin Abscess Complic,PX10061P,CDM,983,RC,10061,CPT,,,,,,,,561,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,499.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,233.0394,546.0213
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12130-MAIN,LOCAL,,,,,561,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,499.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Remv Foot Foreign Body,Subcutaneous",PX28190F,CDM,510,RC,28190,CPT,,,,,,,,1025,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,499.48,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.55,499.48
"Remv Foot Foreign Body,Subcutaneous",PX28190P,CDM,983,RC,28190,CPT,,,,,,,,683,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,499.48,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.55,669.34
beclomethasone  HFA 80 MCG/ACT Aerosol Breath Activated 10.6 g Inhaler,63700001,CDM,250,RC,,,,,,59310030480,NDC,10.6,GR,1164.84,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,499.71636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cefdinir 250 MG/5ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,16714039301,NDC,60,ML,510.33,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,500.1234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Biopsy of Prostate,Needle/Punch",PX55700F,CDM,510,RC,55700,CPT,,,,,,,,2039,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,500.17,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,78.96,500.17
Exc Skn Bngn3.1-4cm Remain Bdy,PX11424P,CDM,983,RC,11424,CPT,,,,,,,,562,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,500.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,233.4548,1416.38
"US,Preg. Uterus,Fetal/Mat.Eval.,>1st Trim.(>/= 14 Wks 0 Dys),Transabd;Single/First Gest., Tech",PX7680501,CDM,402,RC,76805,CPT,TC,,,,,,,562,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,500.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,550.76
dexmedeTOMIDine in sodium chloride 400 MCG/100ML Solution 100 mL Bottle,25000000,CDM,250,RC,,,,,,67457092500,NDC,100,ML,562.18,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,500.3402,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Tube Thoracostomy Inc Wtr Seal,PX32551F,CDM,510,RC,32551,CPT,,,,,,,,989,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,500.434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,410.8306,1399.13
clobetasol 0.05 % Cream 60 g Tube,63700001,CDM,250,RC,,,,,,168030160,NDC,60,GR,989.25,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,500.5605,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,71288020185,NDC,5,ML,1021.7,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,63.2475,percent of total billed charges,500.633,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,424.41418,1239.6216
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,71288020185,NDC,5,ML,1021.7,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,500.633,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,424.41418,1239.6216
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,71288020185,NDC,5,ML,1021.7,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,500.633,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,424.41418,1239.6216
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022101,NDC,1,EA,514.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,214.76,percent of total billed charges,500.76285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022185,NDC,1,EA,514.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,214.76,percent of total billed charges,500.76285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022189,NDC,1,EA,514.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,214.76,percent of total billed charges,500.76285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
esmolol 2500 MG/250ML Solution 250 mL Flex Cont,J1805.01,CDM,636,RC,J1805,HCPCS,,,,10019067010,NDC,250,ML,1011.8,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,500.841,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.24,991.564
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035F,CDM,510,RC,12035,CPT,,,,,,,,655,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,500.86,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.34,810.1
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035P,CDM,983,RC,12035,CPT,,,,,,,,1244,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,500.86,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.34,1219.12
Emergency Level III Visit,PX99283P,CDM,981,RC,99283,CPT,,,,,,,,568,,United Healthcare,All Payer,outpatient,88.2,,188.4141558,percent of total billed charges,500.976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,235.9472,552.8344
Xray Pelvis Compl 3+ Tc,PX7219001,CDM,320,RC,72190,CPT,TC,,,,,,,563,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,501.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,551.74
sevoflurane Solution 250 mL Bottle,25000000,CDM,250,RC,,,,,,66794001525,NDC,250,ML,589.56,,First Health,Commercial,both,85,,999999999,percent of total billed charges,501.126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,63323076350,NDC,50,ML,589.57,,First Health,Commercial,both,85,,999999999,percent of total billed charges,501.1345,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600110,NDC,10,ML,589.63,,First Health,Commercial,both,85,,999999999,percent of total billed charges,501.1855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
I&D Deep Absc/Hematoma Neck/Chest,PX21501P,CDM,983,RC,21501,CPT,,,,,,,,515,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,501.2495,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.931,2482.37
Heart/Lung Resuscitation (Cpr),PX92950P,CDM,983,RC,92950,CPT,,,,,,,,1023,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,501.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.21,995.6859
Heart/Lung Resuscitation (Cpr),PX92950P,CDM,983,RC,92950,CPT,,,,,,,,1023,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,501.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.21,995.6859
Heart/Lung Resuscitation (Cpr),PX92950P,CDM,983,RC,92950,CPT,,,,,,,,1023,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,501.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.21,995.6859
butamben-tetracaine-benzocaine 2-2-14 % Aerosol 20 g Bottle,25000000,CDM,250,RC,,,,,,10223020103,NDC,20,GR,589.76,,First Health,Commercial,both,85,,999999999,percent of total billed charges,501.296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
STAPLER SUREFORM 60 SPU IS4000,27200000,CDM,272,RC,,,,12086-MAIN,LOCAL,,,,,991,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,501.446,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,6384371,NDC,1,EA,563.46,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,501.4794,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
ADVANCED INSTRUMENTS VESSEL SEALER EXTEND,27200000,CDM,272,RC,,,,11923-MAIN,LOCAL,,,,,1169,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,501.501,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRIVER HEX 2.00MM STERILE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12440-MAIN,LOCAL,,,,,512,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,501.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRIVER HEX 2.5MM STERILE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12441-MAIN,LOCAL,,,,,512,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,501.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423P,CDM,983,RC,11423,CPT,,,,,,,,569,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,501.858,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,236.3626,1416.38
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031P,CDM,983,RC,12031,CPT,,,,,,,,551,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,501.961,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,228.8854,536.2883
Xray Facial Bones Minimum 3 Vws,PX7015001,CDM,320,RC,70150,CPT,TC,,,,,,,551,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,501.961,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,539.98
Fac/Ligation of Hemorrhoid(S),PX46221F,CDM,510,RC,46221,CPT,,,,,,,,1046,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,502.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,434.5084,1025.08
Fac/Ligation of Hemorrhoid(S),PX46221F,CDM,510,RC,46221,CPT,,,,,,,,1046,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,502.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,434.5084,1025.08
Closed Rx Shldr Dislocation,PX23650P,CDM,983,RC,23650,CPT,,,,,,,,516,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,464.39,percent of total billed charges,502.2228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,502.2228
Trg Gene Rearrangement Anal - Ref,PX8134290,CDM,300,RC,81342,CPT,90,,,,,,,516,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,502.2228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,184.76,505.68
Insert Non-Tunnel Cv Catheter >5 Years,PX36556F,CDM,510,RC,36556,CPT,,,,,,,,1025,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,610.875,percent of total billed charges,502.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,425.785,2784.63
Insert Non-Tunnel Cv Catheter >5 Years,PX36556F,CDM,510,RC,36556,CPT,,,,,,,,1025,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,502.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,425.785,2784.63
Insert Non-Tunnel Cv Catheter >5 Years,PX36556F,CDM,510,RC,36556,CPT,,,,,,,,1025,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,502.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,425.785,2784.63
"Remv Foot Foreign Body,Subcutaneous",PX28190F,CDM,510,RC,28190,CPT,,,,,,,,1025,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,502.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,425.785,1004.5
"Remv Foot Foreign Body,Subcutaneous",PX28190F,CDM,510,RC,28190,CPT,,,,,,,,1025,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,502.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,425.785,1004.5
"Remv Foot Foreign Body,Subcutaneous",PX28190F,CDM,510,RC,28190,CPT,,,,,,,,1025,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,502.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,425.785,1004.5
fluticasone-salmeterol 250-50 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069604,NDC,14,EA,1025.13,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,502.3137,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone-salmeterol 250-50 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069604,NDC,14,EA,1025.13,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,502.3137,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone-salmeterol 250-50 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069604,NDC,14,EA,1025.13,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,502.3137,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone furoate-vilanterol 100-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173085914,NDC,28,EA,1025.38,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,502.4362,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone furoate-vilanterol 100-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173085914,NDC,28,EA,1025.38,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,502.4362,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone furoate-vilanterol 100-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173085914,NDC,28,EA,1025.38,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,502.4362,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"I&D Perianal Abscess,Superficial",PX46050P,CDM,983,RC,46050,CPT,,,,,,,,993,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,502.458,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,412.4922,966.4869
filgrastim-sndz 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314031801,NDC,0.5,ML,1047.2,,Health Partners,Health Partners Care Plans,both,48,,1.606958333,percent of total billed charges,502.656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,1630.2692
filgrastim-sndz 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314031801,NDC,0.5,ML,1047.2,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,502.656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,1630.2692
"Closed Rx Bimalleolar Fx,Manip",PX27810F,CDM,510,RC,27810,CPT,,,,,,,,1026,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,502.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,426.2004,1404.08
"Closed Rx Bimalleolar Fx,Manip",PX27810F,CDM,510,RC,27810,CPT,,,,,,,,1026,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,502.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,426.2004,1404.08
"Closed Rx Bimalleolar Fx,Manip",PX27810F,CDM,510,RC,27810,CPT,,,,,,,,1026,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,502.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,426.2004,1404.08
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004P,CDM,983,RC,15004,CPT,,,,,,,,570,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,502.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,236.778,554.781
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409422801,NDC,100,ML,1026,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,57.34422222,percent of total billed charges,502.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409422801,NDC,100,ML,1026,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,502.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409422801,NDC,100,ML,1026,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,502.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
Repr Superf Wnd Body 12.6-20,PX12005F,CDM,510,RC,12005,CPT,,,,,,,,565,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,502.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,234.701,553.7
Xray Lumbosacral Minimum 4 Vws,PX7211001,CDM,320,RC,72110,CPT,TC,,,,,,,565,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,502.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,553.7
"Inj,Lumb Epidur,Blood/Clot Patch",PX62273P,CDM,983,RC,62273,CPT,,,,,,,,552,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,502.872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,229.3008,604.15
belimumab 120 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010101,NDC,1,EA,1015.95,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,502.89525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.72,3453.2358
Debride Skin/Tissue,PX11042P,CDM,983,RC,11042,CPT,,,,,,,,995,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,503.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,968.4335
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,55111069407,NDC,5,ML,592.4,,First Health,Commercial,both,85,,999999999,percent of total billed charges,503.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.08296,1009.1158
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600121,NDC,10,ML,592.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,503.625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
diazePAM 10 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,93613832,NDC,1,EA,1212.57,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,503.701578,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Needle Biopsy,Muscle",PX20206P,CDM,983,RC,20206,CPT,,,,,,,,1028,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,503.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,427.0312,1416.38
"Needle Biopsy,Muscle",PX20206P,CDM,983,RC,20206,CPT,,,,,,,,1028,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,503.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,427.0312,1416.38
"Needle Biopsy,Muscle",PX20206P,CDM,983,RC,20206,CPT,,,,,,,,1028,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,503.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,427.0312,1416.38
US Renal Retroperit Ltd,PX7677501,CDM,402,RC,76775,CPT,TC,,,,,,,566,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,503.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,554.68
US Retroperitoneal Tc,PX7677001,CDM,402,RC,76770,CPT,TC,,,,,,,566,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,503.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,554.68
PERFIX PLUG STERILE MEDIUM,C1781,CDM,278,RC,C1781,HCPCS,,11770-MAIN,LOCAL,,,,,553,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,503.783,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
HERNIA PATCH VENTRALEX SMALL,C1781,CDM,278,RC,C1781,HCPCS,,10203-MAIN,LOCAL,,,,,995.96,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,503.95576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,781325394,NDC,1,EA,1049.95,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,503.976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,781325394,NDC,1,EA,1049.95,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,503.976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,72485020101,NDC,1,EA,1049.95,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,503.976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,72485020101,NDC,1,EA,1049.95,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,503.976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
"Complex Drainage, Wound",PX10180F,CDM,510,RC,10180,CPT,,,,,,,,1050,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,436.17,2482.37
"Complex Drainage, Wound",PX10180F,CDM,510,RC,10180,CPT,,,,,,,,1050,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,436.17,2482.37
Red Blood Cells Unit,PXP9021,CDM,390,RC,P9021,HCPCS,,,,,,,,1050,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.17,1029
Red Blood Cells Unit,PXP9021,CDM,390,RC,P9021,HCPCS,,,,,,,,1050,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.17,1029
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180P,CDM,983,RC,44180,CPT,,,,,,,,1175,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,504.075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,488.095,5040.74
"Blood Gases: Ph, Po2 & Pco2",PX82803,CDM,300,RC,82803,CPT,,,,,,,,518,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,219.525,percent of total billed charges,504.1694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.9,507.64
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022101,NDC,1,EA,514.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,504.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022185,NDC,1,EA,514.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,504.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022189,NDC,1,EA,514.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,504.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
CT Abd&Pelv 1+ Section/Regns,PX7417801,CDM,350,RC,74178,CPT,TC,,,,,,,4226,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,504.23,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,171.03,504.23
CT Abd&Pelv 1+ Section/Regns,PX7417801,CDM,350,RC,74178,CPT,TC,,,,,,,4226,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,504.23,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,171.03,504.23
STIFNECK ADULT,120.77,CDM,274,RC,L0180,HCPCS,,991-MAIN,LOCAL,,,,,119,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,504.3,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,504.3,530.84
STIFNECK PEDIATRIC,120.77,CDM,274,RC,L0180,HCPCS,,998-MAIN,LOCAL,,,,,119,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,504.3,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,504.3,530.84
Factor VIII (Ahg) 1-Stage,PX85240,CDM,300,RC,85240,CPT,,,,,,,,997,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,504.482,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.41,977.06
MESH LARGE LEFT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 4X6,120.521,CDM,278,RC,C1781,HCPCS,,12215-MAIN,LOCAL,,,,,572,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,504.504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,237.6088,560.56
MESH LARGE RIGHT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 4X6,C1781,CDM,278,RC,C1781,HCPCS,,12195-MAIN,LOCAL,,,,,572,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,504.504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Remove Nasal Foreign Body,PX30300P,CDM,983,RC,30300,CPT,,,,,,,,572,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,504.504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,556.7276
"VENTRALIGHT MESH ST WITH ECHO 2 - 10 CM X 15 CM - 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,12007-MAIN,LOCAL,,,,,1176,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,504.504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,63323067305,NDC,5,ML,1029.71,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,12.50188889,percent of total billed charges,504.5579,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.08296,1009.1158
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,63323067305,NDC,5,ML,1029.71,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,504.5579,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.08296,1009.1158
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,63323067305,NDC,5,ML,1029.71,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,504.5579,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.08296,1009.1158
Aaa US Screen Tc,PX7670601,CDM,402,RC,76706,CPT,TC,,,,,,,554,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,504.694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,542.92
US Kidney Transplt Untrsd,PX7677601,CDM,402,RC,76776,CPT,TC,,,,,,,554,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,504.694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,542.92
I&D Deep Absc/Hematoma Neck/Chest,PX21501P,CDM,983,RC,21501,CPT,,,,,,,,515,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,504.7,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,210.51,1021.1
"Colonoscope, Submucous Inj",PX45381P,CDM,983,RC,45381,CPT,,,,,,,,1215,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,504.711,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,504.711,1182.5595
"Colonoscopy,Control Bleeding",PX45382F,CDM,750,RC,45382,CPT,,,,,,,,1215,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,504.711,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,504.711,1190.7
"Igh, Variable Region Somatic Mutation Analysis",PX8126390,CDM,310,RC,81263,CPT,90,,,,,,,1215,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,504.711,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.05,1190.7
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151P,CDM,983,RC,13151,CPT,,,,,,,,1177,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,504.933,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,488.9258,1145.5741
Xray Ac Joints(Bilateral),PX7305001,CDM,320,RC,73050,CPT,TC,,,,,,,519,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,505.1427,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,508.62
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605F,CDM,510,RC,25605,CPT,,,,,,,,1178,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,505.362,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,489.3412,1404.08
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,16714081501,NDC,5,ML,998.95,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,505.4687,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
megestrol 40 MG/ML Suspension 240 mL Bottle,25000000,CDM,250,RC,,,,,,49884090738,NDC,240,ML,594.72,,First Health,Commercial,both,85,,999999999,percent of total billed charges,505.512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Emergency Level III Visit,PX99283P,CDM,981,RC,99283,CPT,,,,,,,,568,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,505.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,235.9472,552.8344
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569F,CDM,510,RC,36569,CPT,,,,,,,,1217,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,505.5418,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,505.5418,1399.13
Xray Sacroiliac Jnts Less Than 3 Vws,PX7220001,CDM,320,RC,72200,CPT,TC,,,,,,,555,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,505.605,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,543.9
Closed Rx Shldr Dislocation,PX23650P,CDM,983,RC,23650,CPT,,,,,,,,516,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,505.68,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.18,720.86
Trg Gene Rearrangement Anal - Ref,PX8134290,CDM,300,RC,81342,CPT,90,,,,,,,516,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,505.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,184.76,505.68
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,71288020185,NDC,5,ML,1021.7,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,505.7415,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,424.41418,1239.6216
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133F,CDM,510,RC,13133,CPT,,,,,,,,595,,First Health,Commercial,both,85,,999999999,percent of total billed charges,505.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247.163,583.1
"Thrombolysis,Coronary,IV Infusn",PX92977F,CDM,480,RC,92977,CPT,,,,,,,,595,,First Health,Commercial,both,85,,999999999,percent of total billed charges,505.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247.163,583.1
"Thrombolytic Therapy, Stroke",PX37195F,CDM,761,RC,37195,CPT,,,,,,,,595,,First Health,Commercial,both,85,,999999999,percent of total billed charges,505.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247.163,583.1
"Colonoscope, Submucous Inj",PX45381F,CDM,750,RC,45381,CPT,,,,,,,,1179,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,505.791,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,489.7566,1155.42
Facility Emergency Level IV Visit,PX99284F,CDM,450,RC,99284,CPT,,,,,,,,1054,,Health Partners,Health Partners Care Plans,both,48,,489.6642105,percent of total billed charges,505.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.93,1032.92
Facility Emergency Level IV Visit,PX99284F,CDM,450,RC,99284,CPT,,,,,,,,1054,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,505.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.93,1032.92
"Sb Scope,to Ileum,Biopsy",PX44377P,CDM,983,RC,44377,CPT,,,,,,,,1180,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,506.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,490.172,1662.33
Heart/Lung Resuscitation (Cpr),PX92950P,CDM,983,RC,92950,CPT,,,,,,,,1023,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,506.385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.21,995.6859
"Ctrl Nosebleed,Anter,Complex",PX30903F,CDM,510,RC,30903,CPT,,,,,,,,456,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,506.4,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.46,506.4
"Ctrl Nosebleed,Anter,Complex",PX30903P,CDM,983,RC,30903,CPT,,,,,,,,304,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,506.4,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.46,506.4
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423P,CDM,983,RC,11423,CPT,,,,,,,,569,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,506.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,236.3626,1416.38
X-Ray Exam Chest 2 Views,PX7104601,CDM,320,RC,71046,CPT,TC,,,,,,,556,,Medica,Commercial,both,91.1,,116.0885,percent of total billed charges,506.516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,544.88
Xray Chest 2 Views,PX7102001,CDM,320,RC,71020,CPT,TC,,,,,,,556,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,506.516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,230.9624,544.88
Place Needle in Vein,PX36000P,CDM,983,RC,36000,CPT,,,,,,,,1034,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,506.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,429.5236,1006.3922
Place Needle in Vein,PX36000P,CDM,983,RC,36000,CPT,,,,,,,,1034,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,506.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,429.5236,1006.3922
Place Needle in Vein,PX36000P,CDM,983,RC,36000,CPT,,,,,,,,1034,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,506.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,429.5236,1006.3922
GROSHONG PICC NXT 4FR,120.218,CDM,272,RC,,,,498-MAIN,LOCAL,,,,,1182,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,507.078,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,491.0028,1158.36
"Destruct Benign Lesion, 1-14",PX17110P,CDM,983,RC,17110,CPT,,,,,,,,521,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,507.0893,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,507.0893
"DXA, Bone Density Study, Hips/Pelv/Spine",PX7708001,CDM,320,RC,77080,CPT,TC,,,,,,,575,,United Healthcare,All Payer,outpatient,88.2,,289.085,percent of total billed charges,507.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,563.5
Bone Marrow Biopsy(Ies),PX38221F,CDM,510,RC,38221,CPT,,,,,,,,1221,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,507.2034,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,507.2034,1416.38
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004P,CDM,983,RC,15004,CPT,,,,,,,,570,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,507.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,236.778,554.781
"Lap,Inguinal Hernia Repr,Recur",PX49651F,CDM,510,RC,49651,CPT,,,,,,,,1568,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,507.338,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,342.5,1184.36
"Lap,Inguinal Hernia Repr,Recur",PX49651P,CDM,983,RC,49651,CPT,,,,,,,,2035,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,507.338,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,342.5,1994.3
Insert Non-Tunnel Cv Catheter >5 Years,PX36556F,CDM,510,RC,36556,CPT,,,,,,,,1025,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,507.375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,425.785,2784.63
"Remv Foot Foreign Body,Subcutaneous",PX28190F,CDM,510,RC,28190,CPT,,,,,,,,1025,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,507.375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,425.785,1004.5
"Column Chrom Ms, Quant - Ref",PX8254290,CDM,300,RC,82542,CPT,90,,,,,,,557,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,507.427,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.09,545.86
fluticasone-salmeterol 250-50 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069604,NDC,14,EA,1025.13,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,507.43935,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Fluoroscope Examination Tc,PX7600001,CDM,320,RC,76000,CPT,TC,,,,,,,597,,First Health,Commercial,both,85,,999999999,percent of total billed charges,507.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,585.06
fluticasone furoate-vilanterol 100-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173085914,NDC,28,EA,1025.38,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,507.5631,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Blood Gases: Ph, Po2 & Pco2",PX82803,CDM,300,RC,82803,CPT,,,,,,,,518,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,507.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.9,507.64
"Closed Rx Bimalleolar Fx,Manip",PX27810F,CDM,510,RC,27810,CPT,,,,,,,,1026,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,507.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,426.2004,1404.08
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409422801,NDC,100,ML,1026,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,507.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
Closed Rx Trimalleolar Fx,PX27816F,CDM,510,RC,27816,CPT,,,,,,,,522,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,508.0626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,511.56
Xray Thoracic Spine 3 Vws,PX7207201,CDM,320,RC,72072,CPT,TC,,,,,,,522,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,104.4,percent of total billed charges,508.0626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,511.56
BRONCHOSCOPE BFLEX 5.0 SINGLE-USE 0570-0449,120.578,CDM,272,RC,,,,13020-MAIN,LOCAL,,,,,558,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,508.338,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,231.7932,546.84
PERFIX PLUG STERILE LARGE,C1781,CDM,278,RC,C1781,HCPCS,,11771-MAIN,LOCAL,,,,,558,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,508.338,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Xray Ac Joints(Bilateral),PX7305001,CDM,320,RC,73050,CPT,TC,,,,,,,519,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,508.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,508.62
"Needle Biopsy,Muscle",PX20206P,CDM,983,RC,20206,CPT,,,,,,,,1028,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,508.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,427.0312,1416.38
Layr Clos Wnd Rest Body 7.6-12.5,PX12044P,CDM,983,RC,12044,CPT,,,,,,,,523,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,509.0359,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,217.2542,548.67
Abd Paracentesis W/Imaging(T),PX49083F,CDM,510,RC,49083,CPT,,,,,,,,1006,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,509.036,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,417.8924,985.88
MESH LARGE LEFT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 4X6,120.521,CDM,278,RC,C1781,HCPCS,,12215-MAIN,LOCAL,,,,,572,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,509.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,237.6088,560.56
MESH LARGE RIGHT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 4X6,C1781,CDM,278,RC,C1781,HCPCS,,12195-MAIN,LOCAL,,,,,572,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,509.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Remove Nasal Foreign Body,PX30300P,CDM,983,RC,30300,CPT,,,,,,,,572,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,509.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,556.7276
"Close Rx Fingr Articular Fx,Manip",PX26742F,CDM,510,RC,26742,CPT,,,,,,,,1039,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,509.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,431.6006,1404.08
"Close Rx Fingr Articular Fx,Manip",PX26742F,CDM,510,RC,26742,CPT,,,,,,,,1039,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,509.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,431.6006,1404.08
"Close Rx Fingr Articular Fx,Manip",PX26742F,CDM,510,RC,26742,CPT,,,,,,,,1039,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,509.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,431.6006,1404.08
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101F,CDM,510,RC,13101,CPT,,,,,,,,495,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,509.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.32,823.93
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101P,CDM,983,RC,13101,CPT,,,,,,,,330,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,509.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.32,823.93
Art Lower Extremity-Bilat,PX9392501,CDM,921,RC,93925,CPT,TC,,,,,,,1188,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,509.652,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,1164.24
Exc Skin Benig >4cm Remaindr Body,PX11426F,CDM,510,RC,11426,CPT,,,,,,,,1227,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,509.6958,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,509.6958,2482.37
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,63323067305,NDC,5,ML,1029.71,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,509.70645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.08296,1009.1158
"Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602P,CDM,983,RC,11602,CPT,,,,,,,,1120,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,509.86,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.66,1097.6
"Fac/Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602F,CDM,510,RC,11602,CPT,,,,,,,,731,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,509.86,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.66,509.86
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032601,NDC,0.5,ML,559.7,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,509.8867,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,1630.2692
DRILL BIT 2.2MM LONG SOLID STERILE MICA,27200000,CDM,272,RC,,,,12985-MAIN,LOCAL,,,,,600,,First Health,Commercial,both,85,,999999999,percent of total billed charges,510,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404P,CDM,983,RC,11404,CPT,,,,,,,,600,,First Health,Commercial,both,85,,999999999,percent of total billed charges,510,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,249.24,1416.38
Extremity Study - Vascular Diagnostics,PX9392201,CDM,921,RC,93922,CPT,TC,,,,,,,600,,First Health,Commercial,both,85,,999999999,percent of total billed charges,510,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,588
Ven Duplex Bilateral,PX9397001,CDM,921,RC,93970,CPT,TC,,,,,,,1189,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,510.081,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,1165.22
"Close Rx Fingr Articular Fx,Manip",PX26742P,CDM,983,RC,26742,CPT,,,,,,,,560,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,510.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,232.624,1404.08
"Enzyme Act, Nonradioact - Ref",PX8265790,CDM,300,RC,82657,CPT,90,,,,,,,560,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,510.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.33,548.8
filgrastim 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513020991,NDC,0.5,ML,1228.49,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,510.314746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
"Destruct Benign Lesion, 1-14",PX17110P,CDM,983,RC,17110,CPT,,,,,,,,521,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,510.58,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,42.97,510.58
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476881,NDC,50,ML,579.12,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,510.78384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
Remv Periton FB From Perit Cav,PX49402F,CDM,510,RC,49402,CPT,,,,,,,,3573,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,510.91,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,510.91,1776.54
Remv Periton FB From Perit Cav,PX49402P,CDM,983,RC,49402,CPT,,,,,,,,3897,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,510.91,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,510.91,3819.06
Anal Sphincterotomy,PX46080P,CDM,983,RC,46080,CPT,,,,,,,,525,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,510.9825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,218.085,2452.93
Repair of Vagina,PX57200P,CDM,983,RC,57200,CPT,,,,,,,,1043,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,511.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,433.2622,2731.23
Repair of Vagina,PX57200P,CDM,983,RC,57200,CPT,,,,,,,,1043,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,511.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,433.2622,2731.23
Repair of Vagina,PX57200P,CDM,983,RC,57200,CPT,,,,,,,,1043,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,511.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,433.2622,2731.23
Drain Skin Abscess Complic,PX10061P,CDM,983,RC,10061,CPT,,,,,,,,561,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,511.071,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,233.0394,546.0213
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12130-MAIN,LOCAL,,,,,561,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,511.071,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Closed Rx IP Jt Dislocation,PX26770F,CDM,510,RC,26770,CPT,,,,,,,,1231,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,511.3574,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1206.38
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096321,NDC,30,ML,1231.47,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,511.552638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,511.552638,1206.8406
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096330,NDC,30,ML,1231.47,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,511.552638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,511.552638,1206.8406
Closed Rx Trimalleolar Fx,PX27816F,CDM,510,RC,27816,CPT,,,,,,,,522,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,511.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,511.56
Lap Incis Hernia Reducible,PX49654P,CDM,983,RC,49654,CPT,,,,,,,,1044,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,511.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,433.6776,1016.1252
Lap Incis Hernia Reducible,PX49654P,CDM,983,RC,49654,CPT,,,,,,,,1044,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,511.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,433.6776,1016.1252
Lap Incis Hernia Reducible,PX49654P,CDM,983,RC,49654,CPT,,,,,,,,1044,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,511.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,433.6776,1016.1252
Leukoreduced Rbc's,PXP9016,CDM,390,RC,P9016,HCPCS,,,,,,,,580,,United Healthcare,All Payer,outpatient,88.2,,58,percent of total billed charges,511.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,165.79,568.4
Xray Thoracic Spine 3 Vws,PX7207201,CDM,320,RC,72072,CPT,TC,,,,,,,522,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,511.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,511.56
"DXA, Bone Density Study, Hips/Pelv/Spine",PX7708001,CDM,320,RC,77080,CPT,TC,,,,,,,575,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,511.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,563.5
Place Needle in Vein,PX36000P,CDM,983,RC,36000,CPT,,,,,,,,1034,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,511.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,429.5236,1006.3922
Debride Tissue/Muscle,PX11043F,CDM,510,RC,11043,CPT,,,,,,,,526,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,511.9558,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,218.5004,548.67
Hfe Gene - Ref,PX8125690,CDM,300,RC,81256,CPT,90,,,,,,,526,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,511.9558,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,59.93,515.48
esmolol 2500 MG/250ML Solution 250 mL Flex Cont,J1805.01,CDM,636,RC,J1805,HCPCS,,,,10019067010,NDC,250,ML,1011.8,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,511.9708,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.24,991.564
Exc Skn Bngn3.1-4cm Remain Bdy,PX11424P,CDM,983,RC,11424,CPT,,,,,,,,562,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,511.982,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,233.4548,1416.38
"US,Preg. Uterus,Fetal/Mat.Eval.,>1st Trim.(>/= 14 Wks 0 Dys),Transabd;Single/First Gest., Tech",PX7680501,CDM,402,RC,76805,CPT,TC,,,,,,,562,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,511.982,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,550.76
dexmedeTOMIDine in sodium chloride 400 MCG/100ML Solution 100 mL Bottle,25000000,CDM,250,RC,,,,,,67457092500,NDC,100,ML,562.18,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,512.14598,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Debride Skin/Tissue,PX11042F,CDM,510,RC,11042,CPT,,,,,,,,1067,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,512.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1045.66
Debride Skin/Tissue,PX11042F,CDM,510,RC,11042,CPT,,,,,,,,1067,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,512.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1045.66
Remv Periton FB From Perit Cav,PX49402F,CDM,510,RC,49402,CPT,,,,,,,,3573,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,512.21,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,510.91,1776.54
Remv Periton FB From Perit Cav,PX49402F,CDM,510,RC,49402,CPT,,,,,,,,3573,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,512.21,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,510.91,1776.54
Remv Periton FB From Perit Cav,PX49402P,CDM,983,RC,49402,CPT,,,,,,,,3897,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,512.21,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,510.91,3819.06
Remv Periton FB From Perit Cav,PX49402P,CDM,983,RC,49402,CPT,,,,,,,,3897,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,512.21,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,510.91,3819.06
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,64950036204,NDC,4,ML,1067.22,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,512.2656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,64950036204,NDC,4,ML,1067.22,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,512.2656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
"Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601P,CDM,983,RC,11601,CPT,,,,,,,,1046,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,64.48,percent of total billed charges,512.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,434.5084,1018.0718
"Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601P,CDM,983,RC,11601,CPT,,,,,,,,1046,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,512.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,434.5084,1018.0718
"Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601P,CDM,983,RC,11601,CPT,,,,,,,,1046,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,512.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,434.5084,1018.0718
Fac/Ligation of Hemorrhoid(S),PX46221F,CDM,510,RC,46221,CPT,,,,,,,,1046,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,512.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,434.5084,1025.08
Fac/Ligation of Hemorrhoid(S),PX46221F,CDM,510,RC,46221,CPT,,,,,,,,1046,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,512.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,434.5084,1025.08
Fac/Ligation of Hemorrhoid(S),PX46221F,CDM,510,RC,46221,CPT,,,,,,,,1046,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,512.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,434.5084,1025.08
Layr Clos Wnd Rest Body 7.6-12.5,PX12044P,CDM,983,RC,12044,CPT,,,,,,,,523,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,512.54,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,133.06,796.26
"Excis Tendn/Capsule Lesn,Toes",PX28092F,CDM,510,RC,28092,CPT,,,,,,,,1234,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,512.6036,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,512.6036,1404.08
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,310095036,NDC,1,EA,1234.2,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,512.68668,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,512.68668,1209.516
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,70720095036,NDC,1,EA,1234.2,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,512.68668,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,512.68668,1209.516
Xray Pelvis Compl 3+ Tc,PX7219001,CDM,320,RC,72190,CPT,TC,,,,,,,563,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,512.893,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,551.74
filgrastim-sndz 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314031801,NDC,0.5,ML,1047.2,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.52069,percent of total billed charges,513.128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,1630.2692
filgrastim-sndz 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314031801,NDC,0.5,ML,1047.2,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,513.128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,1630.2692
filgrastim-sndz 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314031801,NDC,0.5,ML,1047.2,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,513.128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,1630.2692
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,6384371,NDC,1,EA,563.46,,Medica,Commercial,both,91.1,,42.235,percent of total billed charges,513.31206,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
"Hospital Inpt or Obs Care, Admin/Disch Same Date, Moderate Level Mdm >= 70 Minutes",PX99235,CDM,982,RC,99235,CPT,,,,,,,,582,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,513.324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,241.7628,566.4606
Closed Rx Kneecap Disloc+Anesth,PX27562F,CDM,510,RC,27562,CPT,,,,,,,,604,,First Health,Commercial,both,85,,999999999,percent of total billed charges,513.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,591.92
Tube Thoracostomy Inc Wtr Seal,PX32551P,CDM,983,RC,32551,CPT,,,,,,,,1236,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,513.4344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,513.4344,1399.13
"Thrombolytic Therapy, Stroke",PX37195F,CDM,761,RC,37195,CPT,,,,,,,,595,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,513.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,399.1273,665.83
"Thrombolytic Therapy, Stroke",PX37195F,CDM,761,RC,37195,CPT,,,,,,,,595,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,513.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,399.1273,665.83
"Thrombolytic Therapy, Stroke",PX37195F,CDM,761,RC,37195,CPT,,,,,,,,595,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,513.74,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,399.1273,665.83
belimumab 120 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010101,NDC,1,EA,1015.95,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,514.0707,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.72,3453.2358
"Lap,Dx Surgical Abd W/Biopsy",PX49321P,CDM,983,RC,49321,CPT,,,,,,,,583,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,514.206,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,242.1782,5040.74
"Close Rx Fingr Articular Fx,Manip",PX26742F,CDM,510,RC,26742,CPT,,,,,,,,1039,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,514.305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,431.6006,1404.08
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,781325394,NDC,1,EA,1049.95,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,514.4755,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,781325394,NDC,1,EA,1049.95,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,514.4755,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,781325394,NDC,1,EA,1049.95,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,514.4755,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,72485020101,NDC,1,EA,1049.95,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,514.4755,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,72485020101,NDC,1,EA,1049.95,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,514.4755,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,72485020101,NDC,1,EA,1049.95,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,514.4755,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
sugammadex sodium 200 MG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,6542312,NDC,2,ML,583.33,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,514.49706,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Anal Sphincterotomy,PX46080P,CDM,983,RC,46080,CPT,,,,,,,,525,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,514.5,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.63,598.41
"Complex Drainage, Wound",PX10180F,CDM,510,RC,10180,CPT,,,,,,,,1050,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,514.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,436.17,2482.37
"Complex Drainage, Wound",PX10180F,CDM,510,RC,10180,CPT,,,,,,,,1050,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,514.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,436.17,2482.37
"Complex Drainage, Wound",PX10180F,CDM,510,RC,10180,CPT,,,,,,,,1050,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,514.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,436.17,2482.37
Red Blood Cells Unit,PXP9021,CDM,390,RC,P9021,HCPCS,,,,,,,,1050,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,514.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.17,1029
Red Blood Cells Unit,PXP9021,CDM,390,RC,P9021,HCPCS,,,,,,,,1050,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,514.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.17,1029
Red Blood Cells Unit,PXP9021,CDM,390,RC,P9021,HCPCS,,,,,,,,1050,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,514.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.17,1029
Repr Superf Wnd Body 12.6-20,PX12005F,CDM,510,RC,12005,CPT,,,,,,,,565,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,514.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,234.701,553.7
Xray Lumbosacral Minimum 4 Vws,PX7211001,CDM,320,RC,72110,CPT,TC,,,,,,,565,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,514.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,553.7
"Colonoscopy,Flex,Diagnostic",PX45378P,CDM,983,RC,45378,CPT,,,,,,,,1200,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,514.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,514.8,4661.91
Level 1 Additional Procedure,PX36000080,CDM,360,RC,,,,,,,,,,1200,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,514.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,498.48,1176
Excis Primary Ganglion Wrist,PX25111P,CDM,983,RC,25111,CPT,,,,,,,,529,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,514.8757,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,219.7466,1404.08
"Fac/Exc Skn Bnig0.6-1cm Fae,Facial",PX11441F,CDM,510,RC,11441,CPT,,,,,,,,606,,First Health,Commercial,both,85,,999999999,percent of total billed charges,515.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,251.7324,614.65
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476881,NDC,50,ML,579.12,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,515.4168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
Debride Tissue/Muscle,PX11043F,CDM,510,RC,11043,CPT,,,,,,,,526,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,515.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,218.5004,548.67
Hfe Gene - Ref,PX8125690,CDM,300,RC,81256,CPT,90,,,,,,,526,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,515.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,59.93,515.48
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,93598627,NDC,1,EA,1241.11,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,515.557094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
US Renal Retroperit Ltd,PX7677501,CDM,402,RC,76775,CPT,TC,,,,,,,566,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,515.626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,554.68
US Retroperitoneal Tc,PX7677001,CDM,402,RC,76770,CPT,TC,,,,,,,566,,Medica,Commercial,both,91.1,,272.9,percent of total billed charges,515.626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,554.68
Anal Sphincterotomy,PX46080F,CDM,510,RC,46080,CPT,,,,,,,,607,,First Health,Commercial,both,85,,999999999,percent of total billed charges,515.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,252.1478,2452.93
Excis Forearm/Wrist Tumor Subcutan,PX25075P,CDM,983,RC,25075,CPT,,,,,,,,607,,First Health,Commercial,both,85,,999999999,percent of total billed charges,515.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,252.1478,1416.38
Open Bx/Excision Inguinofemoral Nodes,PX38531P,CDM,983,RC,38531,CPT,,,,,,,,607,,First Health,Commercial,both,85,,999999999,percent of total billed charges,515.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,252.1478,3329.99
"Layr Clos Wnd Face,Facial 2.5-5",PX12052F,CDM,510,RC,12052,CPT,,,,,,,,585,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,515.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,243.009,573.3
Leukoreduced Rbc's,PXP9016,CDM,390,RC,P9016,HCPCS,,,,,,,,580,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,516.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,165.79,568.4
Repair of Vagina,PX57200P,CDM,983,RC,57200,CPT,,,,,,,,1043,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,516.285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,433.2622,2731.23
Trauma Activation,PX68200010,CDM,684,RC,G0390,HCPCS,,,,,,,,1243,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,516.3422,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,516.3422,1218.14
Facility Emergency Level IV Visit,PX99284F,CDM,450,RC,99284,CPT,,,,,,,,1054,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,155.5942775,percent of total billed charges,516.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.93,1032.92
Facility Emergency Level IV Visit,PX99284F,CDM,450,RC,99284,CPT,,,,,,,,1054,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,516.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.93,1032.92
Facility Emergency Level IV Visit,PX99284F,CDM,450,RC,99284,CPT,,,,,,,,1054,,United Healthcare,All Medicare advantage plans,outpatient,49,,306.9366667,percent of total billed charges,516.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.93,1032.92
"Lap,Inguinal Hernia Repr,Initial",PX49650F,CDM,510,RC,49650,CPT,,,,,,,,1076,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,516.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,446.9704,5040.74
"Lap,Inguinal Hernia Repr,Initial",PX49650F,CDM,510,RC,49650,CPT,,,,,,,,1076,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,516.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,446.9704,5040.74
HARMONIC 1100 SHEARS 20CM SHAFT HAR1120,27200000,CDM,272,RC,,,,12924-MAIN,LOCAL,,,,,1244,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,516.7576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035P,CDM,983,RC,12035,CPT,,,,,,,,1244,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,516.7576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1210.7852
Lap Incis Hernia Reducible,PX49654P,CDM,983,RC,49654,CPT,,,,,,,,1044,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,516.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,433.6776,1016.1252
3.0MM HEADED SCREW LENGTH 16MM,C1713,CDM,278,RC,C1713,HCPCS,,12656-MAIN,LOCAL,,,,,608,,First Health,Commercial,both,85,,999999999,percent of total billed charges,516.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"Supply Technetium Medronate,to 30 MC",PXA9503,CDM,343,RC,A9503,HCPCS,,,,,,,,531,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,516.8223,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,220.5774,520.38
US Abdomen Tc,PX7670001,CDM,402,RC,76700,CPT,TC,,,,,,,586,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,516.852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,574.28
Unlisted Molecular Path Proc - Ref,PX8147990,CDM,310,RC,81479,CPT,90,,,,,,,1077,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,516.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,447.3858,1055.46
Unlisted Molecular Path Proc - Ref,PX8147990,CDM,310,RC,81479,CPT,90,,,,,,,1077,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,516.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,447.3858,1055.46
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,71288020185,NDC,5,ML,1021.7,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,516.9802,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,424.41418,1239.6216
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591P,CDM,982,RC,49591,CPT,,,,,,,,1245,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,517.173,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,517.173,3022.41
Hepatobiliary System Imaging,PX7822601,CDM,341,RC,78226,CPT,TC,,,,,,,2776,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,517.37,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,175.17,517.37
Hepatobiliary System Imaging,PX7822601,CDM,341,RC,78226,CPT,TC,,,,,,,2776,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,517.37,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,175.17,517.37
Emergency Level III Visit,PX99283P,CDM,981,RC,99283,CPT,,,,,,,,568,,Medica,Commercial,both,91.1,,153.5669444,percent of total billed charges,517.448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,235.9472,552.8344
Heart/Lung Resuscitation (Cpr),PX92950P,CDM,983,RC,92950,CPT,,,,,,,,1023,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,517.638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.21,995.6859
"Infectious Disease,Chronic Hep C Virus,Six Assays, Utilizing Serum",PX8159690,CDM,300,RC,81596,CPT,90,,,,,,,609,,First Health,Commercial,both,85,,999999999,percent of total billed charges,517.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.19,596.82
budesonide-formoterol 160-4.5 MCG/ACT Aerosol 6 g Inhaler,63700001,CDM,250,RC,,,,,,186037028,NDC,6,GR,1078.55,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,517.704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
budesonide-formoterol 160-4.5 MCG/ACT Aerosol 6 g Inhaler,63700001,CDM,250,RC,,,,,,186037028,NDC,6,GR,1078.55,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,517.704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Facility Emergency Level III Visit,PX99283F,CDM,450,RC,99283,CPT,,,,,,,,587,,United Healthcare,All Payer,outpatient,88.2,,188.4141558,percent of total billed charges,517.734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,243.8398,575.26
"Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601P,CDM,983,RC,11601,CPT,,,,,,,,1046,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,517.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,434.5084,1018.0718
Fac/Ligation of Hemorrhoid(S),PX46221F,CDM,510,RC,46221,CPT,,,,,,,,1046,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,517.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,434.5084,1025.08
"Closed Rx Bimalleolar Fx,Manip",PX27810P,CDM,983,RC,27810,CPT,,,,,,,,1057,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,517.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,439.0778,1404.08
"Closed Rx Bimalleolar Fx,Manip",PX27810P,CDM,983,RC,27810,CPT,,,,,,,,1057,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,517.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,439.0778,1404.08
"Closed Rx Bimalleolar Fx,Manip",PX27810P,CDM,983,RC,27810,CPT,,,,,,,,1057,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,517.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,439.0778,1404.08
"Hospital Inpt or Obs Care, Admin/Disch Same Date, Moderate Level Mdm >= 70 Minutes",PX99235,CDM,982,RC,99235,CPT,,,,,,,,582,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,517.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,241.7628,566.4606
sodium thiosulfate 250 MG/ML Solution 50 mL Vial,J0209.01,CDM,636,RC,J0209,HCPCS,,,,60267070550,NDC,50,ML,609.57,,First Health,Commercial,both,85,,999999999,percent of total billed charges,518.1345,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,253.215378,597.3786
"Colonoscopy,Remv Lesn,Snare",PX45385F,CDM,750,RC,45385,CPT,,,,,,,,1939,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,518.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.32,940.85
"Colonoscopy,Remv Lesn,Snare",PX45385P,CDM,983,RC,45385,CPT,,,,,,,,2424,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,518.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.32,2375.52
"Exc Skn Bnig >4cmtrnk,Arm,Leg",PX11406P,CDM,983,RC,11406,CPT,,,,,,,,1456,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,518.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,153.14,1426.88
"Fac/Exc Skn Benig >4cm Trnk,Arm,Lg",PX11406F,CDM,510,RC,11406,CPT,,,,,,,,1127,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,518.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,153.14,666.2
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423P,CDM,983,RC,11423,CPT,,,,,,,,569,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,518.359,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,236.3626,1416.38
filgrastim-sndz 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314031801,NDC,0.5,ML,1047.2,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,518.364,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,1630.2692
Excis Primary Ganglion Wrist,PX25111P,CDM,983,RC,25111,CPT,,,,,,,,529,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,518.42,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.33,694.57
Insert Non-Tunnel Cv Catheter >5 Years,PX36556F,CDM,510,RC,36556,CPT,,,,,,,,1025,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,518.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,425.785,2784.63
"Remv Foot Foreign Body,Subcutaneous",PX28190F,CDM,510,RC,28190,CPT,,,,,,,,1025,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,518.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,425.785,1004.5
fluticasone-salmeterol 250-50 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069604,NDC,14,EA,1025.13,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,518.71578,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Xray Ribs Bil 3vws Tc,PX7111001,CDM,320,RC,71110,CPT,TC,,,,,,,533,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,518.7689,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,522.34
fluticasone furoate-vilanterol 100-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173085914,NDC,28,EA,1025.38,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,518.84228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Lap,Dx Surgical Abd W/Biopsy",PX49321P,CDM,983,RC,49321,CPT,,,,,,,,583,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,518.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,242.1782,5040.74
"Closed Rx Bimalleolar Fx,Manip",PX27810F,CDM,510,RC,27810,CPT,,,,,,,,1026,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,519.156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,426.2004,1404.08
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409422801,NDC,100,ML,1026,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,519.156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
sugammadex sodium 200 MG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,6542312,NDC,2,ML,583.33,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,519.1637,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565F,CDM,510,RC,25565,CPT,,,,,,,,1250,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,519.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,519.25,1404.08
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004P,CDM,983,RC,15004,CPT,,,,,,,,570,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,519.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,236.778,554.781
HERNIA MESH LAP PROGRIP SELF FIXATING FLAT SHEET 10X15,C1781,CDM,278,RC,C1781,HCPCS,,12727-MAIN,LOCAL,,,,,611,,First Health,Commercial,both,85,,999999999,percent of total billed charges,519.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Debride Tissue/Muscle/Bone,PX11044F,CDM,510,RC,11044,CPT,,,,,,,,1082,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,519.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,449.4628,1416.38
Debride Tissue/Muscle/Bone,PX11044F,CDM,510,RC,11044,CPT,,,,,,,,1082,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,519.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,449.4628,1416.38
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,781325394,NDC,1,EA,1049.95,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,519.72525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,72485020101,NDC,1,EA,1049.95,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,519.72525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
Calr Gene Analysis Common Variants in Exon 9 - Ref,PX8121990,CDM,300,RC,81219,CPT,90,,,,,,,534,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,519.7422,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.52,523.32
"Complex Drainage, Wound",PX10180F,CDM,510,RC,10180,CPT,,,,,,,,1050,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,519.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,436.17,2482.37
Red Blood Cells Unit,PXP9021,CDM,390,RC,P9021,HCPCS,,,,,,,,1050,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,519.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.17,1029
"Critical Care, E/M 30-74 Minutes",PX99291P,CDM,983,RC,99291,CPT,,,,,,,,1061,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,293.09125,percent of total billed charges,519.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,440.7394,1032.6713
"Critical Care, E/M 30-74 Minutes",PX99291P,CDM,983,RC,99291,CPT,,,,,,,,1061,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,519.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,440.7394,1032.6713
"Critical Care, E/M 30-74 Minutes",PX99291P,CDM,983,RC,99291,CPT,,,,,,,,1061,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,519.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,440.7394,1032.6713
sevoflurane Solution 250 mL Bottle,25000000,CDM,250,RC,,,,,,66794001525,NDC,250,ML,589.56,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,519.99192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,63323076350,NDC,50,ML,589.57,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,520.00074,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600110,NDC,10,ML,589.63,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,520.05366,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
"Needle Biopsy,Muscle",PX20206P,CDM,983,RC,20206,CPT,,,,,,,,1028,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,520.168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,427.0312,1416.38
butamben-tetracaine-benzocaine 2-2-14 % Aerosol 20 g Bottle,25000000,CDM,250,RC,,,,,,10223020103,NDC,20,GR,589.76,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,520.16832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
diazePAM 10 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,93613832,NDC,1,EA,1212.57,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,520.19253,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
collagenase 250 UNIT/GM Ointment 30 g Tube,63700001,CDM,250,RC,,,,,,50484001030,NDC,30,GR,1083.77,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,520.2096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
collagenase 250 UNIT/GM Ointment 30 g Tube,63700001,CDM,250,RC,,,,,,50484001030,NDC,30,GR,1083.77,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,520.2096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Supply Technetium Medronate,to 30 MC",PXA9503,CDM,343,RC,A9503,HCPCS,,,,,,,,531,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,520.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,220.5774,520.38
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 15DEGREE 14MM,27200000,CDM,272,RC,,,,12600-MAIN,LOCAL,,,,,1253,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,520.4962,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 45DEGREE 8MM,27200000,CDM,272,RC,,,,12599-MAIN,LOCAL,,,,,1253,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,520.4962,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 45DEGREE 14MM,27200000,CDM,272,RC,,,,12598-MAIN,LOCAL,,,,,1253,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,520.4962,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 15DEGREE 14MM,27200000,CDM,272,RC,,,,12603-MAIN,LOCAL,,,,,1253,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,520.4962,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 45DEGREE 8MM,27200000,CDM,272,RC,,,,12602-MAIN,LOCAL,,,,,1253,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,520.4962,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 45DEGREE 14MM,27200000,CDM,272,RC,,,,12601-MAIN,LOCAL,,,,,1253,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,520.4962,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Layr Clos Wnd Face,Facial 2.5-5",PX12052F,CDM,510,RC,12052,CPT,,,,,,,,585,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,520.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,243.009,573.3
CARTER THOMASON CLOSURE SUTURE PASSER XL 10/12MM 15MM CTXL,27200000,CDM,272,RC,,,,12946-MAIN,LOCAL,,,,,535,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,520.7155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,63323067305,NDC,5,ML,1029.71,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,521.03326,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.08296,1009.1158
MESH LARGE LEFT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 4X6,120.521,CDM,278,RC,C1781,HCPCS,,12215-MAIN,LOCAL,,,,,572,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,521.092,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,237.6088,560.56
MESH LARGE RIGHT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 4X6,C1781,CDM,278,RC,C1781,HCPCS,,12195-MAIN,LOCAL,,,,,572,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,521.092,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Remove Nasal Foreign Body,PX30300P,CDM,983,RC,30300,CPT,,,,,,,,572,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,521.092,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,556.7276
"Colonoscope, Submucous Inj",PX45381P,CDM,983,RC,45381,CPT,,,,,,,,1215,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,521.235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,504.711,1182.5595
"Colonoscopy,Control Bleeding",PX45382F,CDM,750,RC,45382,CPT,,,,,,,,1215,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,521.235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,504.711,1190.7
"Igh, Variable Region Somatic Mutation Analysis",PX8126390,CDM,310,RC,81263,CPT,90,,,,,,,1215,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,521.235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.05,1190.7
STIFNECK ADULT,120.77,CDM,274,RC,L0180,HCPCS,,991-MAIN,LOCAL,,,,,119,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,521.4757,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,504.3,530.84
STIFNECK PEDIATRIC,120.77,CDM,274,RC,L0180,HCPCS,,998-MAIN,LOCAL,,,,,119,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,521.4757,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,504.3,530.84
US Abdomen Tc,PX7670001,CDM,402,RC,76700,CPT,TC,,,,,,,586,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,521.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,574.28
Drain Pilonidal Cyst Simpl,PX10080F,CDM,510,RC,10080,CPT,,,,,,,,742,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,521.62,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.88,521.62
Aspirate Pleura W/ Imaging,PX32555P,CDM,983,RC,32555,CPT,,,,,,,,536,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1115.8,percent of total billed charges,521.6888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,222.6544,548.81
Lvl 3 Init Hosp High Mdm or 75 Minutes,PX99223,CDM,982,RC,99223,CPT,,,,,,,,536,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,521.6888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,222.6544,521.6888
Facility Emergency Level IV Visit,PX99284F,CDM,450,RC,99284,CPT,,,,,,,,1054,,Humana Choice Care,All Medicare plans,outpatient,49.5,,421.3001282,percent of total billed charges,521.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.93,1032.92
"Chemotherapy, IV Infusion, 1 Hour",PX96413,CDM,335,RC,96413,CPT,,,,,,,,614,,First Health,Commercial,both,85,,999999999,percent of total billed charges,521.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.0556,601.72
Repr Superf Wnd Body 7.6-12.5,PX12004P,CDM,983,RC,12004,CPT,,,,,,,,614,,First Health,Commercial,both,85,,999999999,percent of total billed charges,521.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,597.6062
fluticasone-vilanterol 200-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173088214,NDC,28,EA,1087.68,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,522.0864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone-vilanterol 200-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173088214,NDC,28,EA,1087.68,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,522.0864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569F,CDM,510,RC,36569,CPT,,,,,,,,1217,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,522.093,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,505.5418,1399.13
Polysomnography W/Cpap,PX9581101,CDM,740,RC,95811,CPT,TC,,,,,,,4575,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,522.1125,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,339.44,928.39
Cv Carotid Imaging-Bilat,PX9388001,CDM,921,RC,93880,CPT,TC,,,,,,,1088,,Health Partners,Health Partners Care Plans,both,48,,791.55,percent of total billed charges,522.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,1066.24
Cv Carotid Imaging-Bilat,PX9388001,CDM,921,RC,93880,CPT,TC,,,,,,,1088,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,522.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,1066.24
Xray Ribs Bil 3vws Tc,PX7111001,CDM,320,RC,71110,CPT,TC,,,,,,,533,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,522.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,522.34
Facility Emergency Level III Visit,PX99283F,CDM,450,RC,99283,CPT,,,,,,,,587,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,522.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,243.8398,575.26
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,55111069407,NDC,5,ML,592.4,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,522.4968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.08296,1009.1158
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600121,NDC,10,ML,592.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,522.585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
"Layr Clos Wnd Face,Facial <2.5cm",PX12051P,CDM,983,RC,12051,CPT,,,,,,,,615,,First Health,Commercial,both,85,,999999999,percent of total billed charges,522.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.471,598.5795
Remove Hemorrhoids & Fissure,PX46257P,CDM,983,RC,46257,CPT,,,,,,,,615,,First Health,Commercial,both,85,,999999999,percent of total billed charges,522.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.471,2452.93
Debride Skin/Tissue,PX11042F,CDM,510,RC,11042,CPT,,,,,,,,1067,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,440.455,percent of total billed charges,522.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1045.66
Debride Skin/Tissue,PX11042F,CDM,510,RC,11042,CPT,,,,,,,,1067,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,522.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1045.66
Debride Skin/Tissue,PX11042F,CDM,510,RC,11042,CPT,,,,,,,,1067,,United Healthcare,All Medicare advantage plans,outpatient,49,,565.51,percent of total billed charges,522.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1045.66
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,64950036204,NDC,4,ML,1067.22,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,522.9378,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,64950036204,NDC,4,ML,1067.22,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,522.9378,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,64950036204,NDC,4,ML,1067.22,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,522.9378,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
Place Needle in Vein,PX36000P,CDM,983,RC,36000,CPT,,,,,,,,1034,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,523.204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,429.5236,1006.3922
"Closed Rx Bimalleolar Fx,Manip",PX27810P,CDM,983,RC,27810,CPT,,,,,,,,1057,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,523.215,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,439.0778,1404.08
Calr Gene Analysis Common Variants in Exon 9 - Ref,PX8121990,CDM,300,RC,81219,CPT,90,,,,,,,534,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,523.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.52,523.32
"Close Rx Dist Fingr Fx,Manipulatn",PX26755P,CDM,983,RC,26755,CPT,,,,,,,,1260,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,523.404,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1226.358
Lap Rpr Vent Umbilical Hernia,PX49652P,CDM,983,RC,49652,CPT,,,,,,,,1260,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,523.404,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,523.404,1226.358
Pvb Thoracic Single Injection Site W/Img Gid,PX64461P,CDM,983,RC,64461,CPT,,,,,,,,616,,First Health,Commercial,both,85,,999999999,percent of total billed charges,523.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.8864,604.15
Bone Marrow Biopsy(Ies),PX38221F,CDM,510,RC,38221,CPT,,,,,,,,1221,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,523.809,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,507.2034,1416.38
"DXA, Bone Density Study, Hips/Pelv/Spine",PX7708001,CDM,320,RC,77080,CPT,TC,,,,,,,575,,Medica,Commercial,both,91.1,,378.29,percent of total billed charges,523.825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,563.5
DYNAFORCE MPJ REAMERS CUP/CONE 20MM,27200000,CDM,272,RC,,,,11853-MAIN,LOCAL,,,,,1262,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,524.2348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CARTER THOMASON CLOSURE SUTURE PASSER XL 10/12MM 15MM CTXL,27200000,CDM,272,RC,,,,12946-MAIN,LOCAL,,,,,535,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,524.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Repair Ing Hernia,5+Y/O,Strang",PX49507F,CDM,510,RC,49507,CPT,,,,,,,,1977,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,524.3563,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,354.93,1229.33
"Repair Ing Hernia,5+Y/O,Strang",PX49507P,CDM,983,RC,49507,CPT,,,,,,,,2482,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,524.3563,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,354.93,2432.36
megestrol 40 MG/ML Suspension 240 mL Bottle,25000000,CDM,250,RC,,,,,,49884090738,NDC,240,ML,594.72,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,524.54304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
CP LAG SCREW 3.6MM L22MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12757-MAIN,LOCAL,,,,,539,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,524.6087,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
CP LAG SCREW 3.6MM L24MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12650-MAIN,LOCAL,,,,,539,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,524.6087,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
CP LAG SCREW 3.6MM L26MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12636-MAIN,LOCAL,,,,,539,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,524.6087,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
sevoflurane Solution 250 mL Bottle,25000000,CDM,250,RC,,,,,,66794001525,NDC,250,ML,589.56,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,524.7084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,63323076350,NDC,50,ML,589.57,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,524.7173,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600110,NDC,10,ML,589.63,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,524.7707,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133F,CDM,510,RC,13133,CPT,,,,,,,,595,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,524.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247.163,583.1
"Thrombolysis,Coronary,IV Infusn",PX92977F,CDM,480,RC,92977,CPT,,,,,,,,595,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,524.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247.163,583.1
"Thrombolytic Therapy, Stroke",PX37195F,CDM,761,RC,37195,CPT,,,,,,,,595,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,524.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247.163,583.1
butamben-tetracaine-benzocaine 2-2-14 % Aerosol 20 g Bottle,25000000,CDM,250,RC,,,,,,10223020103,NDC,20,GR,589.76,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,524.8864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Facility Critical Care, E/M 30-74 Minutes",PX99291F,CDM,510,RC,99291,CPT,,,,,,,,1264,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,525.0656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,525.0656,1238.72
"Critical Care, E/M 30-74 Minutes",PX99291P,CDM,983,RC,99291,CPT,,,,,,,,1061,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,525.195,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,440.7394,1032.6713
Nafcillin Sodium 10 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323033060,NDC,1,EA,617.91,,First Health,Commercial,both,85,,999999999,percent of total billed charges,525.2235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Aspirate Pleura W/ Imaging,PX32555P,CDM,983,RC,32555,CPT,,,,,,,,536,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,525.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.75,646.83
Lvl 3 Init Hosp High Mdm or 75 Minutes,PX99223,CDM,982,RC,99223,CPT,,,,,,,,536,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,525.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,108.68,525.28
Fac/Exc Skn Bngn1.1-2cm Remain Bdy,PX11422F,CDM,510,RC,11422,CPT,,,,,,,,618,,First Health,Commercial,both,85,,999999999,percent of total billed charges,525.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,256.7172,1416.38
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,469650189,NDC,5,ML,1264.92,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,525.447768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,424.41418,1239.6216
Xray Sacrum/ Coccyx Minimum 2 Vws,PX7222001,CDM,320,RC,72220,CPT,TC,,,,,,,540,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,525.582,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,529.2
"Close Rx Fingr Articular Fx,Manip",PX26742F,CDM,510,RC,26742,CPT,,,,,,,,1039,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,525.734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,431.6006,1404.08
Exc Skin Benig >4cm Remaindr Body,PX11426F,CDM,510,RC,11426,CPT,,,,,,,,1227,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,526.383,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,509.6958,2482.37
Fluoroscope Examination Tc,PX7600001,CDM,320,RC,76000,CPT,TC,,,,,,,597,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,526.554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,585.06
"Amputation Metatarsal+Toe,Single",PX28810P,CDM,983,RC,28810,CPT,,,,,,,,620,,First Health,Commercial,both,85,,999999999,percent of total billed charges,527,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,257.548,2827.75
Colonoscopy,PX44388P,CDM,983,RC,44388,CPT,,,,,,,,620,,First Health,Commercial,both,85,,999999999,percent of total billed charges,527,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,257.548,798.45
filgrastim 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513020991,NDC,0.5,ML,1228.49,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,527.02221,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
"Colonoscopy,Control Bleeding",PX45382F,CDM,750,RC,45382,CPT,,,,,,,,1215,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,527.15,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,158.37,1373.91
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,55111069407,NDC,5,ML,592.4,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,527.236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.08296,1009.1158
"Lap,Inguinal Hernia Repr,Initial",PX49650F,CDM,510,RC,49650,CPT,,,,,,,,1076,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1460.52625,percent of total billed charges,527.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,446.9704,5040.74
"Lap,Inguinal Hernia Repr,Initial",PX49650F,CDM,510,RC,49650,CPT,,,,,,,,1076,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,527.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,446.9704,5040.74
"Lap,Inguinal Hernia Repr,Initial",PX49650F,CDM,510,RC,49650,CPT,,,,,,,,1076,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,527.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,446.9704,5040.74
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600121,NDC,10,ML,592.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,527.325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
"Critical Care, Addl 30 Min",PX99292P,CDM,983,RC,99292,CPT,,,,,,,,542,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,410.47,percent of total billed charges,527.5286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,225.1468,527.5286
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476881,NDC,50,ML,579.12,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,527.57832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
Unlisted Molecular Path Proc - Ref,PX8147990,CDM,310,RC,81479,CPT,90,,,,,,,1077,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,527.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,447.3858,1055.46
Unlisted Molecular Path Proc - Ref,PX8147990,CDM,310,RC,81479,CPT,90,,,,,,,1077,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,527.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,447.3858,1055.46
Unlisted Molecular Path Proc - Ref,PX8147990,CDM,310,RC,81479,CPT,90,,,,,,,1077,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,527.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,447.3858,1055.46
Repair of Vagina,PX57200P,CDM,983,RC,57200,CPT,,,,,,,,1043,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,527.758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,433.2622,2731.23
"Fna Biopsy, W/US Guidance; First Lesion",PX10005P,CDM,983,RC,10005,CPT,,,,,,,,621,,First Health,Commercial,both,85,,999999999,percent of total billed charges,527.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,257.9634,614.65
Closed Rx IP Jt Dislocation,PX26770F,CDM,510,RC,26770,CPT,,,,,,,,1231,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,528.099,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1206.38
Debride Skin/Tissue,PX11042F,CDM,510,RC,11042,CPT,,,,,,,,1067,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,528.165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1045.66
CP LAG SCREW 3.6MM L22MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12757-MAIN,LOCAL,,,,,539,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,528.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
CP LAG SCREW 3.6MM L24MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12650-MAIN,LOCAL,,,,,539,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,528.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
CP LAG SCREW 3.6MM L26MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12636-MAIN,LOCAL,,,,,539,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,528.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Lap Incis Hernia Reducible,PX49654P,CDM,983,RC,49654,CPT,,,,,,,,1044,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,528.264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,433.6776,1016.1252
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,64950036204,NDC,4,ML,1067.22,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,528.2739,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096321,NDC,30,ML,1231.47,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,528.30063,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,511.552638,1206.8406
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096330,NDC,30,ML,1231.47,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,528.30063,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,511.552638,1206.8406
Leukoreduced Rbc's,PXP9016,CDM,390,RC,P9016,HCPCS,,,,,,,,580,,Medica,Commercial,both,91.1,,112.6,percent of total billed charges,528.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,165.79,568.4
budesonide-formoterol 160-4.5 MCG/ACT Aerosol 6 g Inhaler,63700001,CDM,250,RC,,,,,,186037028,NDC,6,GR,1078.55,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,528.4895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
budesonide-formoterol 160-4.5 MCG/ACT Aerosol 6 g Inhaler,63700001,CDM,250,RC,,,,,,186037028,NDC,6,GR,1078.55,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,528.4895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
budesonide-formoterol 160-4.5 MCG/ACT Aerosol 6 g Inhaler,63700001,CDM,250,RC,,,,,,186037028,NDC,6,GR,1078.55,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,528.4895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Exc Skn Bngn2.1-3cmtrnk,Arm,Lg",PX11403P,CDM,983,RC,11403,CPT,,,,,,,,543,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,528.5019,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,225.5622,614.65
Xray Knee (Both) Ap Stand,PX7356501,CDM,320,RC,73565,CPT,TC,,,,,,,543,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,528.5019,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,532.14
DRILL BIT 2.2MM LONG SOLID STERILE MICA,27200000,CDM,272,RC,,,,12985-MAIN,LOCAL,,,,,600,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,529.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404P,CDM,983,RC,11404,CPT,,,,,,,,600,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,529.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,249.24,1416.38
Extremity Study - Vascular Diagnostics,PX9392201,CDM,921,RC,93922,CPT,TC,,,,,,,600,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,529.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,588
Xray Sacrum/ Coccyx Minimum 2 Vws,PX7222001,CDM,320,RC,72220,CPT,TC,,,,,,,540,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,529.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,529.2
Insert Non-Tunnel Cv Catheter >5 Years,PX36556P,CDM,983,RC,36556,CPT,,,,,,,,1274,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,529.2196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,529.2196,2784.63
"Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601P,CDM,983,RC,11601,CPT,,,,,,,,1046,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,529.276,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,434.5084,1018.0718
Fac/Ligation of Hemorrhoid(S),PX46221F,CDM,510,RC,46221,CPT,,,,,,,,1046,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,529.276,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,434.5084,1025.08
megestrol 40 MG/ML Suspension 240 mL Bottle,25000000,CDM,250,RC,,,,,,49884090738,NDC,240,ML,594.72,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,529.3008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Excis Tendn/Capsule Lesn,Toes",PX28092F,CDM,510,RC,28092,CPT,,,,,,,,1234,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,529.386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,512.6036,1404.08
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,310095036,NDC,1,EA,1234.2,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,529.4718,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,512.68668,1209.516
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,70720095036,NDC,1,EA,1234.2,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,529.4718,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,512.68668,1209.516
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133F,CDM,510,RC,13133,CPT,,,,,,,,595,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,529.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247.163,583.1
"Thrombolysis,Coronary,IV Infusn",PX92977F,CDM,480,RC,92977,CPT,,,,,,,,595,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,529.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247.163,583.1
"Thrombolytic Therapy, Stroke",PX37195F,CDM,761,RC,37195,CPT,,,,,,,,595,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,529.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247.163,583.1
CT Lwr Extremity W/O&W/Dye,PX7370201,CDM,350,RC,73702,CPT,TC,,,,,,,1235,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,529.815,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
filgrastim-sndz 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314031801,NDC,0.5,ML,1047.2,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,529.8832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,1630.2692
"Exc Skn Mal 2.1-3cmtrnk,Arm,Lg",PX11603P,CDM,983,RC,11603,CPT,,,,,,,,1276,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,530.0504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,530.0504,1241.9308
Debride Tissue/Muscle/Bone,PX11044F,CDM,510,RC,11044,CPT,,,,,,,,1082,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,530.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,449.4628,1416.38
Debride Tissue/Muscle/Bone,PX11044F,CDM,510,RC,11044,CPT,,,,,,,,1082,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,530.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,449.4628,1416.38
Debride Tissue/Muscle/Bone,PX11044F,CDM,510,RC,11044,CPT,,,,,,,,1082,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,530.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,449.4628,1416.38
"Hospital Inpt or Obs Care, Admin/Disch Same Date, Moderate Level Mdm >= 70 Minutes",PX99235,CDM,982,RC,99235,CPT,,,,,,,,582,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,530.202,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,241.7628,566.4606
Tube Thoracostomy Inc Wtr Seal,PX32551P,CDM,983,RC,32551,CPT,,,,,,,,1236,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,530.244,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,513.4344,1399.13
Inc/Drain Peritonsil Abscess,PX42700F,CDM,510,RC,42700,CPT,,,,,,,,624,,First Health,Commercial,both,85,,999999999,percent of total billed charges,530.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,611.52
"Closed Rx Dist Fibula Fx,Manip",PX27788P,CDM,983,RC,27788,CPT,,,,,,,,1277,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,530.4658,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1242.9041
Closed Rx Femur Shaft Fx+Manip,PX27502P,CDM,983,RC,27502,CPT,,,,,,,,1083,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,530.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,449.8782,1404.08
Closed Rx Femur Shaft Fx+Manip,PX27502P,CDM,983,RC,27502,CPT,,,,,,,,1083,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,530.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,449.8782,1404.08
Closed Rx Femur Shaft Fx+Manip,PX27502P,CDM,983,RC,27502,CPT,,,,,,,,1083,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,530.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,449.8782,1404.08
STIFNECK ADULT,120.77,CDM,274,RC,L0180,HCPCS,,991-MAIN,LOCAL,,,,,119,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,530.84,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,504.3,530.84
STIFNECK PEDIATRIC,120.77,CDM,274,RC,L0180,HCPCS,,998-MAIN,LOCAL,,,,,119,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,530.84,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,504.3,530.84
STIFNECK ADULT,120.77,CDM,274,RC,L0180,HCPCS,,991-MAIN,LOCAL,,,,,119,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,530.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,504.3,530.84
STIFNECK ADULT,120.77,CDM,274,RC,L0180,HCPCS,,991-MAIN,LOCAL,,,,,119,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,530.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,504.3,530.84
STIFNECK PEDIATRIC,120.77,CDM,274,RC,L0180,HCPCS,,998-MAIN,LOCAL,,,,,119,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,530.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,504.3,530.84
STIFNECK PEDIATRIC,120.77,CDM,274,RC,L0180,HCPCS,,998-MAIN,LOCAL,,,,,119,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,530.84,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,504.3,530.84
collagenase 250 UNIT/GM Ointment 30 g Tube,63700001,CDM,250,RC,,,,,,50484001030,NDC,30,GR,1083.77,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,531.0473,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
collagenase 250 UNIT/GM Ointment 30 g Tube,63700001,CDM,250,RC,,,,,,50484001030,NDC,30,GR,1083.77,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,531.0473,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
collagenase 250 UNIT/GM Ointment 30 g Tube,63700001,CDM,250,RC,,,,,,50484001030,NDC,30,GR,1083.77,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,531.0473,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Lap,Dx Surgical Abd W/Biopsy",PX49321P,CDM,983,RC,49321,CPT,,,,,,,,583,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,531.113,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,242.1782,5040.74
"Critical Care, Addl 30 Min",PX99292P,CDM,983,RC,99292,CPT,,,,,,,,542,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,531.16,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.12,531.16
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,781325394,NDC,1,EA,1049.95,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,531.2747,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,72485020101,NDC,1,EA,1049.95,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,531.2747,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
"Complex Drainage, Wound",PX10180F,CDM,510,RC,10180,CPT,,,,,,,,1050,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,531.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,436.17,2482.37
Red Blood Cells Unit,PXP9021,CDM,390,RC,P9021,HCPCS,,,,,,,,1050,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,531.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.17,1029
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121F,CDM,510,RC,13121,CPT,,,,,,,,948,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,531.3,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,161,882.74
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121P,CDM,983,RC,13121,CPT,,,,,,,,632,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,531.3,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,161,882.74
Fluoroscope Examination Tc,PX7600001,CDM,320,RC,76000,CPT,TC,,,,,,,597,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,531.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,585.06
sugammadex sodium 200 MG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,6542312,NDC,2,ML,583.33,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,531.41363,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,70839036204,NDC,4,ML,1280.66,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,531.986164,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
"Exc Skn Bngn2.1-3cmtrnk,Arm,Lg",PX11403P,CDM,983,RC,11403,CPT,,,,,,,,543,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,532.14,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.02,532.14
Xray Knee (Both) Ap Stand,PX7356501,CDM,320,RC,73565,CPT,TC,,,,,,,543,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,532.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,532.14
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,93598627,NDC,1,EA,1241.11,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,532.43619,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,63323077139,NDC,1,EA,547.2,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,532.58976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
"Lap,Inguinal Hernia Repr,Initial",PX49650F,CDM,510,RC,49650,CPT,,,,,,,,1076,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,532.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,446.9704,5040.74
Closed Rx Kneecap Disloc+Anesth,PX27562F,CDM,510,RC,27562,CPT,,,,,,,,604,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,532.728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,591.92
"Repair Umbilical Hern,5+Y/O,Strang",PX49587F,CDM,510,RC,49587,CPT,,,,,,,,1110,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,532.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,461.094,1087.8
"Repair Umbilical Hern,5+Y/O,Strang",PX49587F,CDM,510,RC,49587,CPT,,,,,,,,1110,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,532.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,461.094,1087.8
"Layr Clos Wnd Face,Facial 2.5-5",PX12052F,CDM,510,RC,12052,CPT,,,,,,,,585,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,532.935,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,243.009,573.3
fluticasone-vilanterol 200-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173088214,NDC,28,EA,1087.68,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,532.9632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone-vilanterol 200-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173088214,NDC,28,EA,1087.68,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,532.9632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone-vilanterol 200-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173088214,NDC,28,EA,1087.68,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,532.9632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Unlisted Molecular Path Proc - Ref,PX8147990,CDM,310,RC,81479,CPT,90,,,,,,,1077,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,533.115,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,447.3858,1055.46
Cv Carotid Imaging-Bilat,PX9388001,CDM,921,RC,93880,CPT,TC,,,,,,,1088,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,217.6,percent of total billed charges,533.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,1066.24
Cv Carotid Imaging-Bilat,PX9388001,CDM,921,RC,93880,CPT,TC,,,,,,,1088,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,533.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,1066.24
Cv Carotid Imaging-Bilat,PX9388001,CDM,921,RC,93880,CPT,TC,,,,,,,1088,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,533.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,1066.24
Trauma Activation,PX68200010,CDM,684,RC,G0390,HCPCS,,,,,,,,1243,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,533.247,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,516.3422,1218.14
Facility Emergency Level IV Visit,PX99284F,CDM,450,RC,99284,CPT,,,,,,,,1054,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,533.324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.93,1032.92
"Closed Rx Spont Hip Disloc,Anesth",PX27257F,CDM,510,RC,27257,CPT,,,,,,,,548,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,533.3684,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.6392,1404.08
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004F,CDM,510,RC,15004,CPT,,,,,,,,855,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,533.38,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.68,813.56
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004P,CDM,983,RC,15004,CPT,,,,,,,,570,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,533.38,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.68,813.56
HARMONIC 1100 SHEARS 20CM SHAFT HAR1120,27200000,CDM,272,RC,,,,12924-MAIN,LOCAL,,,,,1244,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,533.676,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035P,CDM,983,RC,12035,CPT,,,,,,,,1244,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,533.676,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1210.7852
"Closed Rx I-P Jt,Toe Dislocation",PX28660P,CDM,983,RC,28660,CPT,,,,,,,,628,,First Health,Commercial,both,85,,999999999,percent of total billed charges,533.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,611.2324
Exc Face Les Sc < 2 Cm,PX21011P,CDM,983,RC,21011,CPT,,,,,,,,628,,First Health,Commercial,both,85,,999999999,percent of total billed charges,533.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,260.8712,1416.38
US Abdomen Tc,PX7670001,CDM,402,RC,76700,CPT,TC,,,,,,,586,,Medica,Commercial,both,91.1,,206.39,percent of total billed charges,533.846,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,574.28
budesonide-formoterol 160-4.5 MCG/ACT Aerosol 6 g Inhaler,63700001,CDM,250,RC,,,,,,186037028,NDC,6,GR,1078.55,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,533.88225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DRILL BIT 2.2MM LONG SOLID STERILE MICA,27200000,CDM,272,RC,,,,12985-MAIN,LOCAL,,,,,600,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,534,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404P,CDM,983,RC,11404,CPT,,,,,,,,600,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,534,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,249.24,1416.38
Extremity Study - Vascular Diagnostics,PX9392201,CDM,921,RC,93922,CPT,TC,,,,,,,600,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,534,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,588
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591P,CDM,982,RC,49591,CPT,,,,,,,,1245,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,534.105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,517.173,3022.41
Low Dose CT Lung Ca Screen WO Contrast,PX7127101,CDM,350,RC,71271,CPT,TC,,,,,,,1286,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,534.2044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,1260.28
Bcr/Abl1 Minor - Ref,PX8120790,CDM,310,RC,81207,CPT,90,,,,,,,1113,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,534.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.8,1090.74
Bcr/Abl1 Minor - Ref,PX8120790,CDM,310,RC,81207,CPT,90,,,,,,,1113,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,534.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.8,1090.74
MICA BURR 2X12MM STERILE MICA,27200000,CDM,272,RC,,,,12447-MAIN,LOCAL,,,,,1113,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,534.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA BURR 2X12MM STERILE MICA,27200000,CDM,272,RC,,,,12447-MAIN,LOCAL,,,,,1113,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,534.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA BURR 2X20MM STERILE MICA,27200000,CDM,272,RC,,,,12448-MAIN,LOCAL,,,,,1113,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,534.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA BURR 2X20MM STERILE MICA,27200000,CDM,272,RC,,,,12448-MAIN,LOCAL,,,,,1113,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,534.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA CUTTING BURR 3X20MM LONG MICA,27200000,CDM,272,RC,,,,12434-MAIN,LOCAL,,,,,1113,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,534.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA CUTTING BURR 3X20MM LONG MICA,27200000,CDM,272,RC,,,,12434-MAIN,LOCAL,,,,,1113,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,534.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA WEDGE BURR 3.1X13MM STERILE,27200000,CDM,272,RC,,,,12435-MAIN,LOCAL,,,,,1113,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,534.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA WEDGE BURR 3.1X13MM STERILE,27200000,CDM,272,RC,,,,12435-MAIN,LOCAL,,,,,1113,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,534.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Fac/Exc Skn Bnig0.6-1cm Fae,Facial",PX11441F,CDM,510,RC,11441,CPT,,,,,,,,606,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,534.492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,251.7324,614.65
Removal of Nail Bed,PX11750F,CDM,510,RC,11750,CPT,,,,,,,,629,,First Health,Commercial,both,85,,999999999,percent of total billed charges,534.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,261.2866,616.42
diazePAM 2.5 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,68682065020,NDC,1,EA,1114.05,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,534.744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2.5 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,68682065020,NDC,1,EA,1114.05,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,534.744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Facility Emergency Level III Visit,PX99283F,CDM,450,RC,99283,CPT,,,,,,,,587,,Medica,Commercial,both,91.1,,153.5669444,percent of total billed charges,534.757,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,243.8398,575.26
"Incis/Drain Shldr Absc/Hema,Deep",PX23030P,CDM,983,RC,23030,CPT,,,,,,,,1564,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,534.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,158.15,1532.72
"Closed Rx Bimalleolar Fx,Manip",PX27810P,CDM,983,RC,27810,CPT,,,,,,,,1057,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,534.842,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,439.0778,1404.08
insulin aspart prot & aspart 70-30 (70-30) 100 UNIT/ML Suspension Pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169369619,NDC,3,ML,629.28,,First Health,Commercial,both,85,,999999999,percent of total billed charges,534.888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
diazePAM 2.5 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,66490065020,NDC,1,EA,1288,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,535.0352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Mra, Neck W/O+W/ Contrast",PX7054901,CDM,610,RC,70549,CPT,TC,,,,,,,3472,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,535.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.28,535.12
"Mra, Neck W/O+W/ Contrast",PX7054901,CDM,610,RC,70549,CPT,TC,,,,,,,3472,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,535.12,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,181.28,535.12
Anal Sphincterotomy,PX46080F,CDM,510,RC,46080,CPT,,,,,,,,607,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,535.374,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,252.1478,2452.93
Excis Forearm/Wrist Tumor Subcutan,PX25075P,CDM,983,RC,25075,CPT,,,,,,,,607,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,535.374,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,252.1478,1416.38
Open Bx/Excision Inguinofemoral Nodes,PX38531P,CDM,983,RC,38531,CPT,,,,,,,,607,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,535.374,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,252.1478,3329.99
"Infect, Organ, Amp Probe - Ref",PX8780190,CDM,300,RC,87801,CPT,90,,,,,,,630,,First Health,Commercial,both,85,,999999999,percent of total billed charges,535.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.37,617.4
MESH XLARGE LEFT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 5X7,120.524,CDM,278,RC,C1781,HCPCS,,12216-MAIN,LOCAL,,,,,630,,First Health,Commercial,both,85,,999999999,percent of total billed charges,535.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,261.702,617.4
MESH XLARGE RIGHT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 5X7,120.524,CDM,278,RC,C1781,HCPCS,,12217-MAIN,LOCAL,,,,,630,,First Health,Commercial,both,85,,999999999,percent of total billed charges,535.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,261.702,617.4
Debride Tissue/Muscle/Bone,PX11044F,CDM,510,RC,11044,CPT,,,,,,,,1082,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,535.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,449.4628,1416.38
ADVANCED INSTRUMENTS 8MM SYNCHROSEAL IS4000,27200000,CDM,272,RC,,,,11924-MAIN,LOCAL,,,,,1290,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,535.866,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,310095036,NDC,1,EA,1234.2,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,535.92,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,535.92,639.46
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,70720095036,NDC,1,EA,1234.2,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,535.92,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,535.92,639.46
Closed Rx Femur Shaft Fx+Manip,PX27502P,CDM,983,RC,27502,CPT,,,,,,,,1083,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,536.085,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,449.8782,1404.08
"Lap,Appendectomy",PX44970P,CDM,983,RC,44970,CPT,,,,,,,,1700,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,536.237,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,362.78,1666
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565F,CDM,510,RC,25565,CPT,,,,,,,,1250,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,536.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,519.25,1404.08
3.0MM HEADED SCREW LENGTH 16MM,C1713,CDM,278,RC,C1713,HCPCS,,12656-MAIN,LOCAL,,,,,608,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,536.256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,63323077139,NDC,1,EA,547.2,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,536.256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031P,CDM,983,RC,12031,CPT,,,,,,,,551,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,536.2883,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,228.8854,536.2883
Xray Facial Bones Minimum 3 Vws,PX7015001,CDM,320,RC,70150,CPT,TC,,,,,,,551,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,536.2883,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,539.98
collagenase 250 UNIT/GM Ointment 30 g Tube,63700001,CDM,250,RC,,,,,,50484001030,NDC,30,GR,1083.77,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,536.46615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Critical Care, E/M 30-74 Minutes",PX99291P,CDM,983,RC,99291,CPT,,,,,,,,1061,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,536.866,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,440.7394,1032.6713
"Closed Rx Spont Hip Disloc,Anesth",PX27257F,CDM,510,RC,27257,CPT,,,,,,,,548,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,537.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.6392,1404.08
"I&D Perianal Abscess,Superficial",PX46050,CDM,983,RC,46050,CPT,,,,,,,,1096,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,537.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,455.2784,1066.7368
"I&D Perianal Abscess,Superficial",PX46050,CDM,983,RC,46050,CPT,,,,,,,,1096,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,537.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,455.2784,1066.7368
"I&D Perianal Abscess,Superficial",PX46050,CDM,983,RC,46050,CPT,,,,,,,,1096,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,537.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,455.2784,1066.7368
sevoflurane Solution 250 mL Bottle,25000000,CDM,250,RC,,,,,,66794001525,NDC,250,ML,589.56,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,537.08916,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,63323076350,NDC,50,ML,589.57,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,537.09827,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
"Infectious Disease,Chronic Hep C Virus,Six Assays, Utilizing Serum",PX8159690,CDM,300,RC,81596,CPT,90,,,,,,,609,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,537.138,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.19,596.82
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600110,NDC,10,ML,589.63,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,537.15293,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
Closure Superf Wnd Dehis Simple,PX12020F,CDM,510,RC,12020,CPT,,,,,,,,632,,First Health,Commercial,both,85,,999999999,percent of total billed charges,537.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.5328,619.36
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121P,CDM,983,RC,13121,CPT,,,,,,,,632,,First Health,Commercial,both,85,,999999999,percent of total billed charges,537.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.5328,615.1256
"Inj,Lumb Epidur,Blood/Clot Patch",PX62273P,CDM,983,RC,62273,CPT,,,,,,,,552,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,537.2616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,229.3008,604.15
butamben-tetracaine-benzocaine 2-2-14 % Aerosol 20 g Bottle,25000000,CDM,250,RC,,,,,,10223020103,NDC,20,GR,589.76,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,537.27136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 15DEGREE 14MM,27200000,CDM,272,RC,,,,12600-MAIN,LOCAL,,,,,1253,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,537.537,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 45DEGREE 8MM,27200000,CDM,272,RC,,,,12599-MAIN,LOCAL,,,,,1253,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,537.537,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 45DEGREE 14MM,27200000,CDM,272,RC,,,,12598-MAIN,LOCAL,,,,,1253,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,537.537,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 15DEGREE 14MM,27200000,CDM,272,RC,,,,12603-MAIN,LOCAL,,,,,1253,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,537.537,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 45DEGREE 8MM,27200000,CDM,272,RC,,,,12602-MAIN,LOCAL,,,,,1253,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,537.537,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 45DEGREE 14MM,27200000,CDM,272,RC,,,,12601-MAIN,LOCAL,,,,,1253,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,537.537,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Closed Rx Kneecap Disloc+Anesth,PX27562F,CDM,510,RC,27562,CPT,,,,,,,,604,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,537.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,591.92
Egd Balloon Dil Esoph30 Mm/>,PX43233F,CDM,750,RC,43233,CPT,,,,,,,,1120,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,537.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,465.248,1662.33
Egd Balloon Dil Esoph30 Mm/>,PX43233F,CDM,750,RC,43233,CPT,,,,,,,,1120,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,537.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,465.248,1662.33
sodium thiosulfate 250 MG/ML Solution 50 mL Vial,J0209.01,CDM,636,RC,J0209,HCPCS,,,,60267070550,NDC,50,ML,609.57,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,537.64074,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,253.215378,597.3786
PERFIX PLUG STERILE MEDIUM,C1781,CDM,278,RC,C1781,HCPCS,,11770-MAIN,LOCAL,,,,,553,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1256.29,percent of total billed charges,538.2349,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
fluticasone-vilanterol 200-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173088214,NDC,28,EA,1087.68,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,538.4016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Cv Carotid Imaging-Bilat,PX9388001,CDM,921,RC,93880,CPT,TC,,,,,,,1088,,Humana Choice Care,All Medicare plans,outpatient,49.5,,400.9,percent of total billed charges,538.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,1066.24
Drainage Scrotal Wall Abscess,PX55100F,CDM,510,RC,55100,CPT,,,,,,,,634,,First Health,Commercial,both,85,,999999999,percent of total billed charges,538.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,263.3636,1416.38
HERNIA MESH LAP PROGRIP SELF FIXATING FLAT SHEET 10X15,C1781,CDM,278,RC,C1781,HCPCS,,12727-MAIN,LOCAL,,,,,611,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,538.902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Aaa US Screen Tc,PX7670601,CDM,402,RC,76706,CPT,TC,,,,,,,554,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,480.26,percent of total billed charges,539.2082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,542.92
US Kidney Transplt Untrsd,PX7677601,CDM,402,RC,76776,CPT,TC,,,,,,,554,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,539.2082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,542.92
"Fac/Exc Skn Bnig0.6-1cm Fae,Facial",PX11441F,CDM,510,RC,11441,CPT,,,,,,,,606,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,539.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,251.7324,614.65
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605F,CDM,510,RC,24605,CPT,,,,,,,,1124,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,539.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.9096,1404.08
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605F,CDM,510,RC,24605,CPT,,,,,,,,1124,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,539.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.9096,1404.08
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,55111069407,NDC,5,ML,592.4,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,539.6764,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.08296,1009.1158
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600121,NDC,10,ML,592.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,539.7675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
Debride Skin/Tissue,PX11042F,CDM,510,RC,11042,CPT,,,,,,,,1067,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,539.902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1045.66
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031P,CDM,983,RC,12031,CPT,,,,,,,,551,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,539.98,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.55,547.21
Xray Facial Bones Minimum 3 Vws,PX7015001,CDM,320,RC,70150,CPT,TC,,,,,,,551,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,539.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,539.98
Bcr/Abl1 Other - Ref,PX8120890,CDM,310,RC,81208,CPT,90,,,,,,,1125,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,540,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,196.79,1102.5
Bcr/Abl1 Other - Ref,PX8120890,CDM,310,RC,81208,CPT,90,,,,,,,1125,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,540,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,196.79,1102.5
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,64950036204,NDC,4,ML,1067.22,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,540.01332,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
"Amputation Toe,Mt-P Jt",PX28820P,CDM,983,RC,28820,CPT,,,,,,,,1300,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,540.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,540.02,2827.75
Xray Sacroiliac Jnts Less Than 3 Vws,PX7220001,CDM,320,RC,72200,CPT,TC,,,,,,,555,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,540.1815,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,543.9
Anal Sphincterotomy,PX46080F,CDM,510,RC,46080,CPT,,,,,,,,607,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,540.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,252.1478,2452.93
Excis Forearm/Wrist Tumor Subcutan,PX25075P,CDM,983,RC,25075,CPT,,,,,,,,607,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,540.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,252.1478,1416.38
Open Bx/Excision Inguinofemoral Nodes,PX38531P,CDM,983,RC,38531,CPT,,,,,,,,607,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,540.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,252.1478,3329.99
"Close Rx Dist Fingr Fx,Manipulatn",PX26755P,CDM,983,RC,26755,CPT,,,,,,,,1260,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,540.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1226.358
Lap Rpr Vent Umbilical Hernia,PX49652P,CDM,983,RC,49652,CPT,,,,,,,,1260,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,540.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,523.404,1226.358
INSTRUMENT PACKAGE TOEMATE,27200000,CDM,272,RC,,,,11858-MAIN,LOCAL,,,,,636,,First Health,Commercial,both,85,,999999999,percent of total billed charges,540.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSTRUMENT TOEMATE X-SMALL PACKAGE 9H00-T060,27200000,CDM,272,RC,C1713,HCPCS,,11575-MAIN,LOCAL,,,,,636,,First Health,Commercial,both,85,,999999999,percent of total billed charges,540.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Fac/Exc Skn Benig >4cm Trnk,Arm,Lg",PX11406F,CDM,510,RC,11406,CPT,,,,,,,,1127,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,540.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,468.1558,1416.38
"Fac/Exc Skn Benig >4cm Trnk,Arm,Lg",PX11406F,CDM,510,RC,11406,CPT,,,,,,,,1127,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,540.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,468.1558,1416.38
"Inj,Lumb Epidur,Blood/Clot Patch",PX62273P,CDM,983,RC,62273,CPT,,,,,,,,552,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,540.96,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.02,540.96
3.0MM HEADED SCREW LENGTH 16MM,C1713,CDM,278,RC,C1713,HCPCS,,12656-MAIN,LOCAL,,,,,608,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,541.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Xray Chest 2 Views,PX7102001,CDM,320,RC,71020,CPT,TC,,,,,,,556,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,541.1548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,230.9624,544.88
DYNAFORCE MPJ REAMERS CUP/CONE 20MM,27200000,CDM,272,RC,,,,11853-MAIN,LOCAL,,,,,1262,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,541.398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Insert Emergency Endotrach Airway,PX31500F,CDM,510,RC,31500,CPT,,,,,,,,637,,First Health,Commercial,both,85,,999999999,percent of total billed charges,541.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,624.26
"Chemotherapy, IV Infusion, 1 Hour",PX96413,CDM,335,RC,96413,CPT,,,,,,,,614,,United Healthcare,All Payer,outpatient,88.2,,304.795,percent of total billed charges,541.548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.0556,601.72
Repr Superf Wnd Body 7.6-12.5,PX12004P,CDM,983,RC,12004,CPT,,,,,,,,614,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,541.548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,597.6062
megestrol 40 MG/ML Suspension 240 mL Bottle,25000000,CDM,250,RC,,,,,,49884090738,NDC,240,ML,594.72,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,541.78992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
PERFIX PLUG STERILE MEDIUM,C1781,CDM,278,RC,C1781,HCPCS,,11770-MAIN,LOCAL,,,,,553,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,541.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Infectious Disease,Chronic Hep C Virus,Six Assays, Utilizing Serum",PX8159690,CDM,300,RC,81596,CPT,90,,,,,,,609,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,542.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.19,596.82
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133F,CDM,510,RC,13133,CPT,,,,,,,,595,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,542.045,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247.163,583.1
"Thrombolysis,Coronary,IV Infusn",PX92977F,CDM,480,RC,92977,CPT,,,,,,,,595,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,542.045,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247.163,583.1
"Thrombolytic Therapy, Stroke",PX37195F,CDM,761,RC,37195,CPT,,,,,,,,595,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,542.045,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247.163,583.1
"Column Chrom Ms, Quant - Ref",PX8254290,CDM,300,RC,82542,CPT,90,,,,,,,557,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,542.1281,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.09,545.86
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502050102,NDC,1,EA,1305.38,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,542.254852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
"Facility Critical Care, E/M 30-74 Minutes",PX99291F,CDM,510,RC,99291,CPT,,,,,,,,1264,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,542.256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,525.0656,1238.72
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535F,CDM,510,RC,24535,CPT,,,,,,,,2514,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,542.3379,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,362.13,1333.79
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535P,CDM,983,RC,24535,CPT,,,,,,,,2887,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,542.3379,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,362.13,2829.26
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266F,CDM,510,RC,27266,CPT,,,,,,,,1684,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,542.3379,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,366.05,1230.71
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266P,CDM,983,RC,27266,CPT,,,,,,,,2275,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,542.3379,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,366.05,2229.5
"Layr Clos Wnd Face,Facial <2.5cm",PX12051P,CDM,983,RC,12051,CPT,,,,,,,,615,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,542.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.471,598.5795
Remove Hemorrhoids & Fissure,PX46257P,CDM,983,RC,46257,CPT,,,,,,,,615,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,542.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.471,2452.93
sodium thiosulfate 250 MG/ML Solution 50 mL Vial,J0209.01,CDM,636,RC,J0209,HCPCS,,,,60267070550,NDC,50,ML,609.57,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,542.5173,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,253.215378,597.3786
"I&D Perianal Abscess,Superficial",PX46050,CDM,983,RC,46050,CPT,,,,,,,,1096,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,542.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,455.2784,1066.7368
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,45963061959,NDC,1,EA,638.4,,First Health,Commercial,both,85,,999999999,percent of total billed charges,542.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,469650189,NDC,5,ML,1264.92,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,542.65068,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,424.41418,1239.6216
Aaa US Screen Tc,PX7670601,CDM,402,RC,76706,CPT,TC,,,,,,,554,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,542.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,542.92
US Kidney Transplt Untrsd,PX7677601,CDM,402,RC,76776,CPT,TC,,,,,,,554,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,542.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,542.92
BRONCHOSCOPE BFLEX 5.0 SINGLE-USE 0570-0449,120.578,CDM,272,RC,,,,13020-MAIN,LOCAL,,,,,558,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,543.1014,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,231.7932,546.84
PERFIX PLUG STERILE LARGE,C1781,CDM,278,RC,C1781,HCPCS,,11771-MAIN,LOCAL,,,,,558,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1256.29,percent of total billed charges,543.1014,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Pvb Thoracic Single Injection Site W/Img Gid,PX64461P,CDM,983,RC,64461,CPT,,,,,,,,616,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,543.312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.8864,604.15
HERNIA MESH LAP PROGRIP SELF FIXATING FLAT SHEET 10X15,C1781,CDM,278,RC,C1781,HCPCS,,12727-MAIN,LOCAL,,,,,611,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,543.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Fluoroscope Examination Tc,PX7600001,CDM,320,RC,76000,CPT,TC,,,,,,,597,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,543.867,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,585.06
"Repair Umbilical Hern,5+Y/O,Strang",PX49587F,CDM,510,RC,49587,CPT,,,,,,,,1110,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,543.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,461.094,1087.8
"Repair Umbilical Hern,5+Y/O,Strang",PX49587F,CDM,510,RC,49587,CPT,,,,,,,,1110,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,543.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,461.094,1087.8
"Repair Umbilical Hern,5+Y/O,Strang",PX49587F,CDM,510,RC,49587,CPT,,,,,,,,1110,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,543.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,461.094,1087.8
Xray Sacroiliac Jnts Less Than 3 Vws,PX7220001,CDM,320,RC,72200,CPT,TC,,,,,,,555,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,543.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,543.9
HERNIA PATCH VENTRALEX MEDIUM,C1781,CDM,278,RC,C1781,HCPCS,,10202-MAIN,LOCAL,,,,,1309.75,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,544.07015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
MESH VENTRALIGHT ECHO 2.0 POSITIONING 11CM ROUND,120.525,CDM,278,RC,C1781,HCPCS,,12219-MAIN,LOCAL,,,,,1310,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,544.174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,544.174,1283.8
"Lap,Inguinal Hernia Repr,Initial",PX49650F,CDM,510,RC,49650,CPT,,,,,,,,1076,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,544.456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,446.9704,5040.74
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032601,NDC,0.5,ML,559.7,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1.757613333,percent of total billed charges,544.75601,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,1630.2692
X-Ray Exam Chest 2 Views,PX7104601,CDM,320,RC,71046,CPT,TC,,,,,,,556,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,544.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.39,544.88
Xray Chest 2 Views,PX7102001,CDM,320,RC,71020,CPT,TC,,,,,,,556,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,544.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,230.9624,544.88
Unlisted Molecular Path Proc - Ref,PX8147990,CDM,310,RC,81479,CPT,90,,,,,,,1077,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,544.962,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,447.3858,1055.46
Nafcillin Sodium 10 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323033060,NDC,1,EA,617.91,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,544.99662,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Close Rx Fingr Articular Fx,Manip",PX26742P,CDM,983,RC,26742,CPT,,,,,,,,560,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,545.048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,232.624,1404.08
"Enzyme Act, Nonradioact - Ref",PX8265790,CDM,300,RC,82657,CPT,90,,,,,,,560,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,545.048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.33,548.8
Fac/Exc Skn Bngn1.1-2cm Remain Bdy,PX11422F,CDM,510,RC,11422,CPT,,,,,,,,618,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,545.076,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,256.7172,1416.38
Bcr/Abl1 Minor - Ref,PX8120790,CDM,310,RC,81207,CPT,90,,,,,,,1113,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,545.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.8,1090.74
Bcr/Abl1 Minor - Ref,PX8120790,CDM,310,RC,81207,CPT,90,,,,,,,1113,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,545.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.8,1090.74
Bcr/Abl1 Minor - Ref,PX8120790,CDM,310,RC,81207,CPT,90,,,,,,,1113,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,545.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.8,1090.74
MICA BURR 2X12MM STERILE MICA,27200000,CDM,272,RC,,,,12447-MAIN,LOCAL,,,,,1113,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,545.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA BURR 2X12MM STERILE MICA,27200000,CDM,272,RC,,,,12447-MAIN,LOCAL,,,,,1113,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,545.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA BURR 2X12MM STERILE MICA,27200000,CDM,272,RC,,,,12447-MAIN,LOCAL,,,,,1113,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,545.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA BURR 2X20MM STERILE MICA,27200000,CDM,272,RC,,,,12448-MAIN,LOCAL,,,,,1113,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,545.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA BURR 2X20MM STERILE MICA,27200000,CDM,272,RC,,,,12448-MAIN,LOCAL,,,,,1113,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,545.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA BURR 2X20MM STERILE MICA,27200000,CDM,272,RC,,,,12448-MAIN,LOCAL,,,,,1113,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,545.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA CUTTING BURR 3X20MM LONG MICA,27200000,CDM,272,RC,,,,12434-MAIN,LOCAL,,,,,1113,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,545.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA CUTTING BURR 3X20MM LONG MICA,27200000,CDM,272,RC,,,,12434-MAIN,LOCAL,,,,,1113,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,545.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA CUTTING BURR 3X20MM LONG MICA,27200000,CDM,272,RC,,,,12434-MAIN,LOCAL,,,,,1113,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,545.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA WEDGE BURR 3.1X13MM STERILE,27200000,CDM,272,RC,,,,12435-MAIN,LOCAL,,,,,1113,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,545.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA WEDGE BURR 3.1X13MM STERILE,27200000,CDM,272,RC,,,,12435-MAIN,LOCAL,,,,,1113,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,545.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA WEDGE BURR 3.1X13MM STERILE,27200000,CDM,272,RC,,,,12435-MAIN,LOCAL,,,,,1113,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,545.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
budesonide-formoterol 160-4.5 MCG/ACT Aerosol 6 g Inhaler,63700001,CDM,250,RC,,,,,,186037028,NDC,6,GR,1078.55,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,545.7463,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Column Chrom Ms, Quant - Ref",PX8254290,CDM,300,RC,82542,CPT,90,,,,,,,557,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,545.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.09,545.86
diazePAM 2.5 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,68682065020,NDC,1,EA,1114.05,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,545.8845,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2.5 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,68682065020,NDC,1,EA,1114.05,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,545.8845,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2.5 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,68682065020,NDC,1,EA,1114.05,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,545.8845,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Drain Skin Abscess Complic,PX10061P,CDM,983,RC,10061,CPT,,,,,,,,561,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,546.0213,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,233.0394,546.0213
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12130-MAIN,LOCAL,,,,,561,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,546.0213,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Chemotherapy, IV Infusion, 1 Hour",PX96413,CDM,335,RC,96413,CPT,,,,,,,,614,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,546.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.0556,601.72
Repr Superf Wnd Body 7.6-12.5,PX12004P,CDM,983,RC,12004,CPT,,,,,,,,614,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,546.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,597.6062
Insert Non-Tunnel Cv Catheter >5 Years,PX36556P,CDM,983,RC,36556,CPT,,,,,,,,1274,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,546.546,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,529.2196,2784.63
PERFIX PLUG STERILE X-LARGE,C1781,CDM,278,RC,C1781,HCPCS,,11772-MAIN,LOCAL,,,,,643,,First Health,Commercial,both,85,,999999999,percent of total billed charges,546.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
DRILL BIT 2.2MM LONG SOLID STERILE MICA,27200000,CDM,272,RC,,,,12985-MAIN,LOCAL,,,,,600,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,546.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404P,CDM,983,RC,11404,CPT,,,,,,,,600,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,546.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,249.24,1416.38
Extremity Study - Vascular Diagnostics,PX9392201,CDM,921,RC,93922,CPT,TC,,,,,,,600,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,546.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,588
"Sigmoidoscopy,Biopsy",PX45331P,CDM,983,RC,45331,CPT,,,,,,,,1316,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,546.6664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,546.6664,1280.8628
"Amputation Metatarsal+Toe,Single",PX28810P,CDM,983,RC,28810,CPT,,,,,,,,620,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,546.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,257.548,2827.75
BRONCHOSCOPE BFLEX 5.0 SINGLE-USE 0570-0449,120.578,CDM,272,RC,,,,13020-MAIN,LOCAL,,,,,558,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,546.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,231.7932,546.84
Colonoscopy,PX44388P,CDM,983,RC,44388,CPT,,,,,,,,620,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,546.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,257.548,798.45
PERFIX PLUG STERILE LARGE,C1781,CDM,278,RC,C1781,HCPCS,,11771-MAIN,LOCAL,,,,,558,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,546.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Exc Skn Bngn3.1-4cm Remain Bdy,PX11424P,CDM,983,RC,11424,CPT,,,,,,,,562,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,546.9946,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,233.4548,1416.38
"US,Preg. Uterus,Fetal/Mat.Eval.,>1st Trim.(>/= 14 Wks 0 Dys),Transabd;Single/First Gest., Tech",PX7680501,CDM,402,RC,76805,CPT,TC,,,,,,,562,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,534.78,percent of total billed charges,546.9946,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,550.76
dexmedeTOMIDine in sodium chloride 400 MCG/100ML Solution 100 mL Bottle,25000000,CDM,250,RC,,,,,,67457092500,NDC,100,ML,562.18,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,547.169794,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Exc Face Les Sc < 2 Cm,PX21011F,CDM,510,RC,21011,CPT,,,,,,,,943,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,547.21,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,164.48,781.73
Exc Face Les Sc < 2 Cm,PX21011P,CDM,983,RC,21011,CPT,,,,,,,,628,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,547.21,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,164.48,781.73
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031F,CDM,510,RC,12031,CPT,,,,,,,,688,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,547.21,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.55,547.21
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031P,CDM,983,RC,12031,CPT,,,,,,,,551,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,547.21,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,95.55,547.21
"Layr Clos Wnd Face,Facial <2.5cm",PX12051P,CDM,983,RC,12051,CPT,,,,,,,,615,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,547.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.471,598.5795
Remove Hemorrhoids & Fissure,PX46257P,CDM,983,RC,46257,CPT,,,,,,,,615,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,547.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.471,2452.93
"Exc Skn Mal 2.1-3cmtrnk,Arm,Lg",PX11603P,CDM,983,RC,11603,CPT,,,,,,,,1276,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,547.404,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,530.0504,1241.9308
Ventilator Mgmt.Subsequent Days,PX94003F,CDM,410,RC,94003,CPT,,,,,,,,1686,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,547.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,547.46,1652.28
Debride Tissue/Muscle/Bone,PX11044F,CDM,510,RC,11044,CPT,,,,,,,,1082,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,547.492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,449.4628,1416.38
Remove Hemorrhoids & Fissure,PX46257F,CDM,510,RC,46257,CPT,,,,,,,,1141,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,547.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,473.9714,2452.93
Remove Hemorrhoids & Fissure,PX46257F,CDM,510,RC,46257,CPT,,,,,,,,1141,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,547.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,473.9714,2452.93
"Fna Biopsy, W/US Guidance; First Lesion",PX10005P,CDM,983,RC,10005,CPT,,,,,,,,621,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,547.722,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,257.9634,614.65
"Closed Rx Dist Fibula Fx,Manip",PX27788P,CDM,983,RC,27788,CPT,,,,,,,,1277,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,547.833,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1242.9041
"Complex Drainage, Wound",PX10180F,CDM,510,RC,10180,CPT,,,,,,,,1050,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,547.91,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.95,547.91
"Complex Drainage, Wound",PX10180P,CDM,983,RC,10180,CPT,,,,,,,,767,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,547.91,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.95,751.66
Xray Pelvis Compl 3+ Tc,PX7219001,CDM,320,RC,72190,CPT,TC,,,,,,,563,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,547.9679,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,551.74
Closed Rx Femur Shaft Fx+Manip,PX27502P,CDM,983,RC,27502,CPT,,,,,,,,1083,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,547.998,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,449.8782,1404.08
paliperidone palmitate ER 234 MG/1.5ML suspension prefilled syringe 1.5 mL Syringe,J2426.01,CDM,636,RC,J2426,HCPCS,,,,50458056401,NDC,0.25,ML,1142.14,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,548.2272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.12,1119.2972
paliperidone palmitate ER 234 MG/1.5ML suspension prefilled syringe 1.5 mL Syringe,J2426.01,CDM,636,RC,J2426,HCPCS,,,,50458056401,NDC,0.25,ML,1142.14,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,548.2272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.12,1119.2972
Pvb Thoracic Single Injection Site W/Img Gid,PX64461P,CDM,983,RC,64461,CPT,,,,,,,,616,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,548.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.8864,604.15
collagenase 250 UNIT/GM Ointment 30 g Tube,63700001,CDM,250,RC,,,,,,50484001030,NDC,30,GR,1083.77,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,548.38762,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,6384371,NDC,1,EA,563.46,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,214.76,percent of total billed charges,548.415618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032601,NDC,0.5,ML,559.7,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,548.506,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,1630.2692
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151F,CDM,510,RC,13151,CPT,,,,,,,,1143,,Health Partners,Health Partners Care Plans,both,48,,563.345,percent of total billed charges,548.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,474.8022,1120.14
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151F,CDM,510,RC,13151,CPT,,,,,,,,1143,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,548.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,474.8022,1120.14
Closure Superf Wnd Dehis Simple,PX12020F,CDM,510,RC,12020,CPT,,,,,,,,632,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,548.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.5328,619.36
Closure Superf Wnd Dehis Simple,PX12020P,CDM,983,RC,12020,CPT,,,,,,,,422,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,548.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,175.2988,548.67
Debride Tissue/Muscle,PX11043F,CDM,510,RC,11043,CPT,,,,,,,,526,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,548.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,218.5004,548.67
Debride Tissue/Muscle,PX11043P,CDM,983,RC,11043,CPT,,,,,,,,351,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,548.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,145.8054,548.67
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106F,CDM,510,RC,11106,CPT,,,,,,,,255,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,548.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.927,548.67
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106P,CDM,983,RC,11106,CPT,,,,,,,,204,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,548.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.7416,548.67
Layr Clos Wnd Rest Body 7.6-12.5,PX12044F,CDM,510,RC,12044,CPT,,,,,,,,785,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,548.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,326.089,769.3
Layr Clos Wnd Rest Body 7.6-12.5,PX12044P,CDM,983,RC,12044,CPT,,,,,,,,523,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,548.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,217.2542,548.67
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004F,CDM,510,RC,15004,CPT,,,,,,,,855,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,548.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,355.167,837.9
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004P,CDM,983,RC,15004,CPT,,,,,,,,570,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,548.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,236.778,554.781
Reconstruc of Nail Bed,PX11760F,CDM,510,RC,11760,CPT,,,,,,,,1162,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,548.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,482.6948,1138.76
Reconstruc of Nail Bed,PX11760P,CDM,983,RC,11760,CPT,,,,,,,,903,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,548.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,375.1062,878.8899
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132F,CDM,510,RC,13132,CPT,,,,,,,,1159,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,548.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,481.4486,1135.82
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132P,CDM,983,RC,13132,CPT,,,,,,,,774,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,548.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.5196,753.3342
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151F,CDM,510,RC,13151,CPT,,,,,,,,1143,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,548.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,474.8022,1120.14
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151P,CDM,983,RC,13151,CPT,,,,,,,,1177,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,548.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,488.9258,1145.5741
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121F,CDM,510,RC,13121,CPT,,,,,,,,948,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,548.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,393.7992,929.04
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121P,CDM,983,RC,13121,CPT,,,,,,,,632,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,548.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.5328,615.1256
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101F,CDM,510,RC,13101,CPT,,,,,,,,495,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,548.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.623,548.67
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101P,CDM,983,RC,13101,CPT,,,,,,,,330,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,548.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,137.082,548.67
Surgical Cleansing of Skin,PX11000P,CDM,983,RC,11000,CPT,,,,,,,,145,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,548.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,60.233,548.67
"Close Rx Fingr Articular Fx,Manip",PX26742P,CDM,983,RC,26742,CPT,,,,,,,,560,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,548.8,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,216.18,805.95
Egd Balloon Dil Esoph30 Mm/>,PX43233F,CDM,750,RC,43233,CPT,,,,,,,,1120,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,548.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,465.248,1662.33
Egd Balloon Dil Esoph30 Mm/>,PX43233F,CDM,750,RC,43233,CPT,,,,,,,,1120,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,548.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,465.248,1662.33
Egd Balloon Dil Esoph30 Mm/>,PX43233F,CDM,750,RC,43233,CPT,,,,,,,,1120,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,548.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,465.248,1662.33
"Enzyme Act, Nonradioact - Ref",PX8265790,CDM,300,RC,82657,CPT,90,,,,,,,560,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,548.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,20.33,548.8
"Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602P,CDM,983,RC,11602,CPT,,,,,,,,1120,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,548.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1090.096
"Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602P,CDM,983,RC,11602,CPT,,,,,,,,1120,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,548.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1090.096
"Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602P,CDM,983,RC,11602,CPT,,,,,,,,1120,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,548.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1090.096
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830P,CDM,983,RC,15830,CPT,,,,,,,,1120,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,548.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,465.248,5696.92
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830P,CDM,983,RC,15830,CPT,,,,,,,,1120,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,548.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,465.248,5696.92
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830P,CDM,983,RC,15830,CPT,,,,,,,,1120,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,548.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,465.248,5696.92
Aspirate Pleura W/ Imaging,PX32555F,CDM,761,RC,32555,CPT,,,,,,,,795,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,548.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,330.243,779.1
Aspirate Pleura W/ Imaging,PX32555P,CDM,983,RC,32555,CPT,,,,,,,,536,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,548.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,222.6544,548.81
Aspirate Pleura W/O Imaging,PX32554F,CDM,510,RC,32554,CPT,,,,,,,,795,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,548.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,330.243,779.1
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180F,CDM,510,RC,44180,CPT,,,,,,,,1763,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,548.86,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,548.86,1910.75
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180P,CDM,983,RC,44180,CPT,,,,,,,,1175,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,548.86,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,548.86,1910.75
Bcr/Abl1 P210 - Ref,PX8120690,CDM,310,RC,81206,CPT,90,,,,,,,1144,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,549.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.33,1121.12
Bcr/Abl1 P210 - Ref,PX8120690,CDM,310,RC,81206,CPT,90,,,,,,,1144,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,549.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.33,1121.12
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,70839036204,NDC,4,ML,1280.66,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,549.40314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
"Repair Umbilical Hern,5+Y/O,Strang",PX49587F,CDM,510,RC,49587,CPT,,,,,,,,1110,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,549.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,461.094,1087.8
Drain Skin Abscess Complic,PX10061P,CDM,983,RC,10061,CPT,,,,,,,,561,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,549.78,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.83,549.78
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12130-MAIN,LOCAL,,,,,561,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,549.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Repr Superf Wnd Body 12.6-20,PX12005F,CDM,510,RC,12005,CPT,,,,,,,,565,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,549.9145,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,234.701,553.7
Xray Lumbosacral Minimum 4 Vws,PX7211001,CDM,320,RC,72110,CPT,TC,,,,,,,565,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,549.9145,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,553.7
Nafcillin Sodium 10 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323033060,NDC,1,EA,617.91,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,549.9399,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032P,CDM,983,RC,12032,CPT,,,,,,,,647,,First Health,Commercial,both,85,,999999999,percent of total billed charges,549.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,268.7638,629.7251
"Repair Umbilical Hern,5+Y/O,Reduc",PX49585P,CDM,983,RC,49585,CPT,,,,,,,,647,,First Health,Commercial,both,85,,999999999,percent of total billed charges,549.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,268.7638,629.7251
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180F,CDM,510,RC,44180,CPT,,,,,,,,1763,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,549.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,548.86,1910.75
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180F,CDM,510,RC,44180,CPT,,,,,,,,1763,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,549.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,548.86,1910.75
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180P,CDM,983,RC,44180,CPT,,,,,,,,1175,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,549.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,548.86,1910.75
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180P,CDM,983,RC,44180,CPT,,,,,,,,1175,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,549.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,548.86,1910.75
Fac/Exc Skn Bngn1.1-2cm Remain Bdy,PX11422F,CDM,510,RC,11422,CPT,,,,,,,,618,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,550.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,256.7172,1416.38
Closed Rx Kneecap Disloc+Anesth,PX27562F,CDM,510,RC,27562,CPT,,,,,,,,604,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,550.244,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,591.92
fluticasone-vilanterol 200-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173088214,NDC,28,EA,1087.68,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,550.36608,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Inc/Drain Peritonsil Abscess,PX42700F,CDM,510,RC,42700,CPT,,,,,,,,624,,United Healthcare,All Payer,outpatient,88.2,,43.67274074,percent of total billed charges,550.368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,611.52
HERNIA PATCH VENTRALEX LARGE,C1781,CDM,278,RC,C1781,HCPCS,,10201-MAIN,LOCAL,,,,,1325.08,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,550.438232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Cv Carotid Imaging-Bilat,PX9388001,CDM,921,RC,93880,CPT,TC,,,,,,,1088,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,550.528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,1066.24
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605F,CDM,510,RC,24605,CPT,,,,,,,,1124,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,550.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.9096,1404.08
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605F,CDM,510,RC,24605,CPT,,,,,,,,1124,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,550.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.9096,1404.08
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605F,CDM,510,RC,24605,CPT,,,,,,,,1124,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,550.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.9096,1404.08
Exc Skn Bngn3.1-4cm Remain Bdy,PX11424P,CDM,983,RC,11424,CPT,,,,,,,,562,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,550.76,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.13,550.76
"US,Preg. Uterus,Fetal/Mat.Eval.,>1st Trim.(>/= 14 Wks 0 Dys),Transabd;Single/First Gest., Tech",PX7680501,CDM,402,RC,76805,CPT,TC,,,,,,,562,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,550.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,550.76
8MM ENDOWRIST INSTRUMENTS MONOPOLAR CURVED SCISSORS,27200000,CDM,272,RC,,,,11909-MAIN,LOCAL,,,,,648,,First Health,Commercial,both,85,,999999999,percent of total billed charges,550.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STAPLER INTERNAL ECHELON FLEX POWERED PLUS LONG LENGTH 440MM,27200000,CDM,272,RC,,,,12065-MAIN,LOCAL,,,,,648,,First Health,Commercial,both,85,,999999999,percent of total billed charges,550.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Excise Lesion,Back or Flank",PX21930F,CDM,510,RC,21930,CPT,,,,,,,,1326,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,550.8204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,550.8204,1416.38
US Renal Retroperit Ltd,PX7677501,CDM,402,RC,76775,CPT,TC,,,,,,,566,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,236.98,percent of total billed charges,550.8878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,554.68
US Retroperitoneal Tc,PX7677001,CDM,402,RC,76770,CPT,TC,,,,,,,566,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,231.0433333,percent of total billed charges,550.8878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,554.68
Bcr/Abl1 Minor - Ref,PX8120790,CDM,310,RC,81207,CPT,90,,,,,,,1113,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,550.935,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.8,1090.74
MICA BURR 2X12MM STERILE MICA,27200000,CDM,272,RC,,,,12447-MAIN,LOCAL,,,,,1113,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,550.935,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA BURR 2X20MM STERILE MICA,27200000,CDM,272,RC,,,,12448-MAIN,LOCAL,,,,,1113,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,550.935,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA CUTTING BURR 3X20MM LONG MICA,27200000,CDM,272,RC,,,,12434-MAIN,LOCAL,,,,,1113,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,550.935,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA WEDGE BURR 3.1X13MM STERILE,27200000,CDM,272,RC,,,,12435-MAIN,LOCAL,,,,,1113,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,550.935,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
dexmedeTOMIDine in sodium chloride 400 MCG/100ML Solution 100 mL Bottle,25000000,CDM,250,RC,,,,,,67457092500,NDC,100,ML,562.18,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,550.9364,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Amputation Toe,I-P Jt",PX28825F,CDM,510,RC,28825,CPT,,,,,,,,1327,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,551.2358,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,551.2358,2827.75
Lap Rpr Vent Umbilical Hernia Incarcerated or Strangulated,PX49653P,CDM,983,RC,49653,CPT,,,,,,,,1327,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,551.2358,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,551.2358,1291.5691
Bcr/Abl1 Other - Ref,PX8120890,CDM,310,RC,81208,CPT,90,,,,,,,1125,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,551.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,196.79,1102.5
Bcr/Abl1 Other - Ref,PX8120890,CDM,310,RC,81208,CPT,90,,,,,,,1125,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,551.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,196.79,1102.5
Bcr/Abl1 Other - Ref,PX8120890,CDM,310,RC,81208,CPT,90,,,,,,,1125,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,551.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,196.79,1102.5
Remove Foreign Body Complic,PX10121F,CDM,510,RC,10121,CPT,,,,,,,,3575,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,551.36,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,114.52,551.36
Remove Foreign Body Complic,PX10121P,CDM,983,RC,10121,CPT,,,,,,,,651,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,551.36,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,114.52,637.98
diazePAM 2.5 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,68682065020,NDC,1,EA,1114.05,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,551.45475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Colonoscopy,Flex,Diagnostic",PX45378F,CDM,750,RC,45378,CPT,,,,,,,,1286,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,551.694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,551.694,4661.91
Low Dose CT Lung Ca Screen WO Contrast,PX7127101,CDM,350,RC,71271,CPT,TC,,,,,,,1286,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,551.694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,1260.28
Xray Pelvis Compl 3+ Tc,PX7219001,CDM,320,RC,72190,CPT,TC,,,,,,,563,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,551.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,551.74
"Amputation Metatarsal+Toe,Single",PX28810P,CDM,983,RC,28810,CPT,,,,,,,,620,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,551.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,257.548,2827.75
Colonoscopy,PX44388P,CDM,983,RC,44388,CPT,,,,,,,,620,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,551.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,257.548,798.45
"Fac/Exc Skn Bnig0.6-1cm Fae,Facial",PX11441F,CDM,510,RC,11441,CPT,,,,,,,,606,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,552.066,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,251.7324,614.65
"Repair Lip,>1/2 Vert Height",PX40654P,CDM,983,RC,40654,CPT,,,,,,,,1329,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,552.0666,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,552.0666,1332.3
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,6384371,NDC,1,EA,563.46,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,552.1908,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.7233,552.1908
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231001,NDC,10,ML,649.64,,First Health,Commercial,both,85,,999999999,percent of total billed charges,552.194,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231005,NDC,10,ML,649.64,,First Health,Commercial,both,85,,999999999,percent of total billed charges,552.194,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
"Fac/Exc Skn Benig >4cm Trnk,Arm,Lg",PX11406F,CDM,510,RC,11406,CPT,,,,,,,,1127,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,298.165,percent of total billed charges,552.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,468.1558,1416.38
"Fac/Exc Skn Benig >4cm Trnk,Arm,Lg",PX11406F,CDM,510,RC,11406,CPT,,,,,,,,1127,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,552.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,468.1558,1416.38
"Fac/Exc Skn Benig >4cm Trnk,Arm,Lg",PX11406F,CDM,510,RC,11406,CPT,,,,,,,,1127,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,552.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,468.1558,1416.38
Acellular Derm Matrix Implt,PX15777F,CDM,510,RC,15777,CPT,,,,,,,,650,,First Health,Commercial,both,85,,999999999,percent of total billed charges,552.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.01,637
Closed Rx Bimalleolar Fx,PX27808F,CDM,510,RC,27808,CPT,,,,,,,,650,,First Health,Commercial,both,85,,999999999,percent of total billed charges,552.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,637
"Exc Skn Bngn2.1-3cm Fce,Facial",PX11443P,CDM,983,RC,11443,CPT,,,,,,,,650,,First Health,Commercial,both,85,,999999999,percent of total billed charges,552.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.01,1416.38
diazePAM 2.5 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,66490065020,NDC,1,EA,1288,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,552.552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Fna Biopsy, W/US Guidance; First Lesion",PX10005P,CDM,983,RC,10005,CPT,,,,,,,,621,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,552.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,257.9634,614.65
Emergency Level III Visit,PX99283P,CDM,981,RC,99283,CPT,,,,,,,,568,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,216.8694253,percent of total billed charges,552.8344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,235.9472,552.8344
Anal Sphincterotomy,PX46080F,CDM,510,RC,46080,CPT,,,,,,,,607,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,552.977,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,252.1478,2452.93
Excis Forearm/Wrist Tumor Subcutan,PX25075P,CDM,983,RC,25075,CPT,,,,,,,,607,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,552.977,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,252.1478,1416.38
Open Bx/Excision Inguinofemoral Nodes,PX38531P,CDM,983,RC,38531,CPT,,,,,,,,607,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,552.977,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,252.1478,3329.99
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505F,CDM,510,RC,25505,CPT,,,,,,,,651,,First Health,Commercial,both,85,,999999999,percent of total billed charges,553.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.4254,1404.08
Remove Foreign Body Complic,PX10121P,CDM,983,RC,10121,CPT,,,,,,,,651,,First Health,Commercial,both,85,,999999999,percent of total billed charges,553.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.4254,1416.38
ADVANCED INSTRUMENTS 8MM SYNCHROSEAL IS4000,27200000,CDM,272,RC,,,,11924-MAIN,LOCAL,,,,,1290,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,553.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Repr Superf Wnd Body 12.6-20,PX12005F,CDM,510,RC,12005,CPT,,,,,,,,565,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,553.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,234.701,553.7
Xray Lumbosacral Minimum 4 Vws,PX7211001,CDM,320,RC,72110,CPT,TC,,,,,,,565,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,553.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,553.7
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423P,CDM,983,RC,11423,CPT,,,,,,,,569,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,553.8077,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,236.3626,1416.38
3.0MM HEADED SCREW LENGTH 16MM,C1713,CDM,278,RC,C1713,HCPCS,,12656-MAIN,LOCAL,,,,,608,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,553.888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"Closed Rx I-P Jt,Toe Dislocation",PX28660P,CDM,983,RC,28660,CPT,,,,,,,,628,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,553.896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,611.2324
Exc Face Les Sc < 2 Cm,PX21011P,CDM,983,RC,21011,CPT,,,,,,,,628,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,553.896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,260.8712,1416.38
"Repair of Recurrent Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49615F,CDM,360,RC,49615,CPT,,,,,,,,2908,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,554.2186,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,376.31,1322.72
Egd Balloon Dil Esoph30 Mm/>,PX43233F,CDM,750,RC,43233,CPT,,,,,,,,1120,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,554.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,465.248,1662.33
"Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602P,CDM,983,RC,11602,CPT,,,,,,,,1120,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,554.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1090.096
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830P,CDM,983,RC,15830,CPT,,,,,,,,1120,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,554.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,465.248,5696.92
"I&D Perianal Abscess,Superficial",PX46050,CDM,983,RC,46050,CPT,,,,,,,,1096,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,554.576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,455.2784,1066.7368
US Renal Retroperit Ltd,PX7677501,CDM,402,RC,76775,CPT,TC,,,,,,,566,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,554.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,554.68
US Retroperitoneal Tc,PX7677001,CDM,402,RC,76770,CPT,TC,,,,,,,566,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,554.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,554.68
Removal of Nail Bed,PX11750F,CDM,510,RC,11750,CPT,,,,,,,,629,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,554.778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,261.2866,616.42
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004P,CDM,983,RC,15004,CPT,,,,,,,,570,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,554.781,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,236.778,554.781
"Infectious Disease,Chronic Hep C Virus,Six Assays, Utilizing Serum",PX8159690,CDM,300,RC,81596,CPT,90,,,,,,,609,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,554.799,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.19,596.82
sugammadex sodium 200 MG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,6542302,NDC,2,ML,652.81,,First Health,Commercial,both,85,,999999999,percent of total billed charges,554.8885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
insulin aspart prot & aspart 70-30 (70-30) 100 UNIT/ML Suspension Pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169369619,NDC,3,ML,629.28,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,555.02496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
sodium thiosulfate 250 MG/ML Solution 50 mL Vial,J0209.01,CDM,636,RC,J0209,HCPCS,,,,60267070550,NDC,50,ML,609.57,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,555.31827,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,253.215378,597.3786
Inc/Drain Peritonsil Abscess,PX42700F,CDM,510,RC,42700,CPT,,,,,,,,624,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,555.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,611.52
"Infect, Organ, Amp Probe - Ref",PX8780190,CDM,300,RC,87801,CPT,90,,,,,,,630,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,555.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.37,617.4
MESH XLARGE LEFT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 5X7,120.524,CDM,278,RC,C1781,HCPCS,,12216-MAIN,LOCAL,,,,,630,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,555.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,261.702,617.4
MESH XLARGE RIGHT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 5X7,120.524,CDM,278,RC,C1781,HCPCS,,12217-MAIN,LOCAL,,,,,630,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,555.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,261.702,617.4
Injection Hip Arthrogram,PX27093F,CDM,510,RC,27093,CPT,,,,,,,,654,,First Health,Commercial,both,85,,999999999,percent of total billed charges,555.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,271.6716,640.92
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390P,CDM,982,RC,45390,CPT,,,,,,,,1135,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,556.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,471.479,2452.93
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390P,CDM,982,RC,45390,CPT,,,,,,,,1135,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,556.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,471.479,2452.93
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390P,CDM,982,RC,45390,CPT,,,,,,,,1135,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,556.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,471.479,2452.93
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132F,CDM,510,RC,13132,CPT,,,,,,,,1159,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,556.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,481.4486,1135.82
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132F,CDM,510,RC,13132,CPT,,,,,,,,1159,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,556.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,481.4486,1135.82
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605F,CDM,510,RC,24605,CPT,,,,,,,,1124,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,556.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.9096,1404.08
HERNIA MESH LAP PROGRIP SELF FIXATING FLAT SHEET 10X15,C1781,CDM,278,RC,C1781,HCPCS,,12727-MAIN,LOCAL,,,,,611,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,556.621,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Emergency Level III Visit,PX99283P,CDM,981,RC,99283,CPT,,,,,,,,568,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,556.64,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,43.86,556.64
MESH LARGE LEFT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 4X6,120.521,CDM,278,RC,C1781,HCPCS,,12215-MAIN,LOCAL,,,,,572,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1256.29,percent of total billed charges,556.7276,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,237.6088,560.56
MESH LARGE RIGHT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 4X6,C1781,CDM,278,RC,C1781,HCPCS,,12195-MAIN,LOCAL,,,,,572,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1256.29,percent of total billed charges,556.7276,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Remove Nasal Foreign Body,PX30300P,CDM,983,RC,30300,CPT,,,,,,,,572,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,556.7276,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,556.7276
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035F,CDM,510,RC,12035,CPT,,,,,,,,655,,First Health,Commercial,both,85,,999999999,percent of total billed charges,556.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,272.087,641.9
Bcr/Abl1 Other - Ref,PX8120890,CDM,310,RC,81208,CPT,90,,,,,,,1125,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,556.875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,196.79,1102.5
"Closed Rx Talus Fx,Manipulatn",PX28435P,CDM,983,RC,28435,CPT,,,,,,,,1137,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,557.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,472.3098,1404.08
"Closed Rx Talus Fx,Manipulatn",PX28435P,CDM,983,RC,28435,CPT,,,,,,,,1137,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,557.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,472.3098,1404.08
"Closed Rx Talus Fx,Manipulatn",PX28435P,CDM,983,RC,28435,CPT,,,,,,,,1137,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,557.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,472.3098,1404.08
Explor Metatarso-Phalang Jt,PX28022F,CDM,510,RC,28022,CPT,,,,,,,,1161,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,557.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,482.2794,2827.75
Explor Metatarso-Phalang Jt,PX28022F,CDM,510,RC,28022,CPT,,,,,,,,1161,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,557.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,482.2794,2827.75
Closure Superf Wnd Dehis Simple,PX12020F,CDM,510,RC,12020,CPT,,,,,,,,632,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,557.424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.5328,619.36
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121P,CDM,983,RC,13121,CPT,,,,,,,,632,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,557.424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.5328,615.1256
Exc Skin Benig >4cm Remaindr Body,PX11426F,CDM,510,RC,11426,CPT,,,,,,,,1227,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,557.59,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.1,684.19
Exc Skin Benig >4cm Remaindr Body,PX11426P,CDM,983,RC,11426,CPT,,,,,,,,981,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,557.59,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.1,961.38
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423P,CDM,983,RC,11423,CPT,,,,,,,,569,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,557.62,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.6,557.62
"Amputation Toe,Mt-P Jt",PX28820P,CDM,983,RC,28820,CPT,,,,,,,,1300,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,557.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,540.02,2827.75
Reconstruc of Nail Bed,PX11760F,CDM,510,RC,11760,CPT,,,,,,,,1162,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,557.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,482.6948,1138.76
Reconstruc of Nail Bed,PX11760F,CDM,510,RC,11760,CPT,,,,,,,,1162,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,557.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,482.6948,1138.76
"Fac/Exc Skn Benig >4cm Trnk,Arm,Lg",PX11406F,CDM,510,RC,11406,CPT,,,,,,,,1127,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,557.865,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,468.1558,1416.38
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,310095036,NDC,1,EA,1234.2,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,558.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,512.68668,1209.516
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,70720095036,NDC,1,EA,1234.2,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,558.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,512.68668,1209.516
Insert Emergency Endotrach Airway,PX31500P,CDM,983,RC,31500,CPT,,,,,,,,657,,First Health,Commercial,both,85,,999999999,percent of total billed charges,558.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,639.4581
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004P,CDM,983,RC,15004,CPT,,,,,,,,570,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,558.6,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.68,813.56
"Closed Rx I-P Jt,Toe Dislocation",PX28660P,CDM,983,RC,28660,CPT,,,,,,,,628,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,558.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,611.2324
Exc Face Les Sc < 2 Cm,PX21011P,CDM,983,RC,21011,CPT,,,,,,,,628,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,558.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,260.8712,1416.38
"Exc Skn Malig1.1-2cm Fce,Facal",PX11642P,CDM,983,RC,11642,CPT,,,,,,,,466,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,558.97,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,113.87,558.97
"Fac/Exc Skn Malig .1-2cm Fce,Facal",PX11642F,CDM,510,RC,11642,CPT,,,,,,,,698,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,558.97,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,113.87,558.97
Remove Hemorrhoids & Fissure,PX46257F,CDM,510,RC,46257,CPT,,,,,,,,1141,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,559.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,473.9714,2452.93
Remove Hemorrhoids & Fissure,PX46257F,CDM,510,RC,46257,CPT,,,,,,,,1141,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,559.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,473.9714,2452.93
Remove Hemorrhoids & Fissure,PX46257F,CDM,510,RC,46257,CPT,,,,,,,,1141,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,559.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,473.9714,2452.93
beclomethasone  HFA 80 MCG/ACT Aerosol Breath Activated 10.6 g Inhaler,63700001,CDM,250,RC,,,,,,59310030480,NDC,10.6,GR,1164.84,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,559.1232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
beclomethasone  HFA 80 MCG/ACT Aerosol Breath Activated 10.6 g Inhaler,63700001,CDM,250,RC,,,,,,59310030480,NDC,10.6,GR,1164.84,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,559.1232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Drainage Scrotal Wall Abscess,PX55100F,CDM,510,RC,55100,CPT,,,,,,,,634,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,559.188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,263.3636,1416.38
"Chemotherapy, IV Infusion, 1 Hour",PX96413,CDM,335,RC,96413,CPT,,,,,,,,614,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,559.354,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.0556,601.72
Repr Superf Wnd Body 7.6-12.5,PX12004P,CDM,983,RC,12004,CPT,,,,,,,,614,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,559.354,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,597.6062
"DXA, Bone Density Study, Hips/Pelv/Spine",PX7708001,CDM,320,RC,77080,CPT,TC,,,,,,,575,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,303.7688889,percent of total billed charges,559.6475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,563.5
paliperidone palmitate ER 234 MG/1.5ML suspension prefilled syringe 1.5 mL Syringe,J2426.01,CDM,636,RC,J2426,HCPCS,,,,50458056401,NDC,0.25,ML,1142.14,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,559.6486,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.12,1119.2972
paliperidone palmitate ER 234 MG/1.5ML suspension prefilled syringe 1.5 mL Syringe,J2426.01,CDM,636,RC,J2426,HCPCS,,,,50458056401,NDC,0.25,ML,1142.14,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,559.6486,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.12,1119.2972
paliperidone palmitate ER 234 MG/1.5ML suspension prefilled syringe 1.5 mL Syringe,J2426.01,CDM,636,RC,J2426,HCPCS,,,,50458056401,NDC,0.25,ML,1142.14,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,559.6486,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.12,1119.2972
Removal of Nail Bed,PX11750F,CDM,510,RC,11750,CPT,,,,,,,,629,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,559.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,261.2866,616.42
ibutilide 1 MG/10ML Solution 10 mL Vial,J1742.01,CDM,636,RC,J1742,HCPCS,,,,9379401,NDC,10,ML,2349.03,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,559.83,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,180.45,559.83
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502050102,NDC,1,EA,1305.38,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,560.00802,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
insulin aspart prot & aspart 70-30 (70-30) 100 UNIT/ML Suspension Pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169369619,NDC,3,ML,629.28,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,560.0592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151F,CDM,510,RC,13151,CPT,,,,,,,,1143,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,560.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,474.8022,1120.14
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151F,CDM,510,RC,13151,CPT,,,,,,,,1143,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,560.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,474.8022,1120.14
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151F,CDM,510,RC,13151,CPT,,,,,,,,1143,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,560.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,474.8022,1120.14
"Insert Needle,Intraosseous Infusn",PX36680F,CDM,510,RC,36680,CPT,,,,,,,,659,,First Health,Commercial,both,85,,999999999,percent of total billed charges,560.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,273.7486,645.82
"CT Colonography, Screen",PX7426301,CDM,350,RC,74263,CPT,TC,,,,,,,3330,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,560.2538,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,379.8,1118.24
"Layr Clos Wnd Face,Facial <2.5cm",PX12051P,CDM,983,RC,12051,CPT,,,,,,,,615,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,560.265,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.471,598.5795
Remove Hemorrhoids & Fissure,PX46257P,CDM,983,RC,46257,CPT,,,,,,,,615,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,560.265,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.471,2452.93
Bcr/Abl1 P210 - Ref,PX8120690,CDM,310,RC,81206,CPT,90,,,,,,,1144,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,560.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.33,1121.12
Bcr/Abl1 P210 - Ref,PX8120690,CDM,310,RC,81206,CPT,90,,,,,,,1144,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,560.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.33,1121.12
Bcr/Abl1 P210 - Ref,PX8120690,CDM,310,RC,81206,CPT,90,,,,,,,1144,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,560.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.33,1121.12
MESH LARGE LEFT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 4X6,120.521,CDM,278,RC,C1781,HCPCS,,12215-MAIN,LOCAL,,,,,572,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,560.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,237.6088,560.56
MESH LARGE RIGHT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 4X6,C1781,CDM,278,RC,C1781,HCPCS,,12195-MAIN,LOCAL,,,,,572,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,560.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Remove Nasal Foreign Body,PX30300P,CDM,983,RC,30300,CPT,,,,,,,,572,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,560.56,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,79.84,560.56
"Infect, Organ, Amp Probe - Ref",PX8780190,CDM,300,RC,87801,CPT,90,,,,,,,630,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,560.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.37,617.4
MESH XLARGE LEFT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 5X7,120.524,CDM,278,RC,C1781,HCPCS,,12216-MAIN,LOCAL,,,,,630,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,560.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,261.702,617.4
MESH XLARGE RIGHT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 5X7,120.524,CDM,278,RC,C1781,HCPCS,,12217-MAIN,LOCAL,,,,,630,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,560.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,261.702,617.4
"Hemorrhoidectomy,Int/Ext,Complx",PX46260F,CDM,750,RC,46260,CPT,,,,,,,,1350,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,560.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,560.79,2452.93
Leukoreduced Platelets,PXP9035,CDM,390,RC,P9035,HCPCS,,,,,,,,1350,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,560.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,433.08,1323
insulin aspart 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169633910,NDC,3,ML,659.76,,First Health,Commercial,both,85,,999999999,percent of total billed charges,560.796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
INSTRUMENT PACKAGE TOEMATE,27200000,CDM,272,RC,,,,11858-MAIN,LOCAL,,,,,636,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,560.952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSTRUMENT TOEMATE X-SMALL PACKAGE 9H00-T060,27200000,CDM,272,RC,C1713,HCPCS,,11575-MAIN,LOCAL,,,,,636,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,560.952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Digital Mammogram, Screen Bil, Tc W/Cad Perf",PX7706701,CDM,403,RC,77067,CPT,TC,,,,,,,375,,Blue Cross Blue Shield of MN,All commercial plans,both,,,224.5045783,fee schedule,561,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.86,561
"Incis/Drain Scrotum/Testis,Epididym",PX54700F,CDM,510,RC,54700,CPT,,,,,,,,660,,First Health,Commercial,both,85,,999999999,percent of total billed charges,561,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.164,1779.39
Repair Incis Hernia W Mesh,PX49568P,CDM,983,RC,49568,CPT,,,,,,,,660,,First Health,Commercial,both,85,,999999999,percent of total billed charges,561,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.164,642.378
ADVANCED INSTRUMENTS VESSEL SEALER EXTEND,27200000,CDM,272,RC,,,,11923-MAIN,LOCAL,,,,,1169,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,561.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ADVANCED INSTRUMENTS VESSEL SEALER EXTEND,27200000,CDM,272,RC,,,,11923-MAIN,LOCAL,,,,,1169,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,561.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Direct Admit Hospital Observ,PXG0379,CDM,761,RC,G0379,HCPCS,,,,,,,,676,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,561.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,280.8104,662.48
Emergency Level V Visit,PX99285P,CDM,981,RC,99285,CPT,,,,,,,,1436,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,561.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,561.13,1397.6588
Facility Emergency Level V Visit,PX99285F,CDM,450,RC,99285,CPT,,,,,,,,1464,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,561.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,561.13,1434.72
Pvb Thoracic Single Injection Site W/Img Gid,PX64461P,CDM,983,RC,64461,CPT,,,,,,,,616,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,561.176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.8864,604.15
"Closed Rx Trimalleolar Fx,Manip",PX27818P,CDM,983,RC,27818,CPT,,,,,,,,1352,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,561.6208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,561.6208,1404.08
"Repair Umbilical Hern,5+Y/O,Strang",PX49587F,CDM,510,RC,49587,CPT,,,,,,,,1110,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,561.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,461.094,1087.8
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390P,CDM,982,RC,45390,CPT,,,,,,,,1135,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,561.825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,471.479,2452.93
Insert Emergency Endotrach Airway,PX31500F,CDM,510,RC,31500,CPT,,,,,,,,637,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,561.834,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,624.26
HERNIA PATCH VENTRALEX MEDIUM,C1781,CDM,278,RC,C1781,HCPCS,,10202-MAIN,LOCAL,,,,,1309.75,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,561.88275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
MESH VENTRALIGHT ECHO 2.0 POSITIONING 11CM ROUND,120.525,CDM,278,RC,C1781,HCPCS,,12219-MAIN,LOCAL,,,,,1310,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,561.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,544.174,1283.8
"Removal of Tunnel Cv Access Device, With Port/Pump",PX36590P,CDM,983,RC,36590,CPT,,,,,,,,1147,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,562.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,476.4638,1399.13
"Removal of Tunnel Cv Access Device, With Port/Pump",PX36590P,CDM,983,RC,36590,CPT,,,,,,,,1147,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,562.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,476.4638,1399.13
"Removal of Tunnel Cv Access Device, With Port/Pump",PX36590P,CDM,983,RC,36590,CPT,,,,,,,,1147,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,562.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,476.4638,1399.13
Closed Rx IP Jt Dislocation,PX26770P,CDM,983,RC,26770,CPT,,,,,,,,1353,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,562.0362,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1316.8749
Closure Superf Wnd Dehis Simple,PX12020F,CDM,510,RC,12020,CPT,,,,,,,,632,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,562.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.5328,619.36
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121P,CDM,983,RC,13121,CPT,,,,,,,,632,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,562.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.5328,615.1256
"Upper GI Endoscopy,Ctrl Bleed",PX43255P,CDM,983,RC,43255,CPT,,,,,,,,1148,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,562.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,476.8792,1662.33
"Upper GI Endoscopy,Ctrl Bleed",PX43255P,CDM,983,RC,43255,CPT,,,,,,,,1148,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,562.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,476.8792,1662.33
"Upper GI Endoscopy,Ctrl Bleed",PX43255P,CDM,983,RC,43255,CPT,,,,,,,,1148,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,562.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,476.8792,1662.33
Fluoroscopy Guid Needle Plcmt Tc,PX7700201,CDM,320,RC,77002,CPT,TC,,,,,,,662,,First Health,Commercial,both,85,,999999999,percent of total billed charges,562.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.9948,648.76
"Closed Rx Talus Fx,Manipulatn",PX28435P,CDM,983,RC,28435,CPT,,,,,,,,1137,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,562.815,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,472.3098,1404.08
Nafcillin Sodium 10 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323033060,NDC,1,EA,617.91,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,562.91601,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Fac/Exc Skn Bngn1.1-2cm Remain Bdy,PX11422F,CDM,510,RC,11422,CPT,,,,,,,,618,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,562.998,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,256.7172,1416.38
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,45963061959,NDC,1,EA,638.4,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,563.0688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
Bcr/Abl1 Minor - Ref,PX8120790,CDM,310,RC,81207,CPT,90,,,,,,,1113,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,563.178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.8,1090.74
MICA BURR 2X12MM STERILE MICA,27200000,CDM,272,RC,,,,12447-MAIN,LOCAL,,,,,1113,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,563.178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA BURR 2X20MM STERILE MICA,27200000,CDM,272,RC,,,,12448-MAIN,LOCAL,,,,,1113,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,563.178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA CUTTING BURR 3X20MM LONG MICA,27200000,CDM,272,RC,,,,12434-MAIN,LOCAL,,,,,1113,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,563.178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA WEDGE BURR 3.1X13MM STERILE,27200000,CDM,272,RC,,,,12435-MAIN,LOCAL,,,,,1113,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,563.178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Repair Recurr Inguin Hern,Reducibl",PX49520F,CDM,510,RC,49520,CPT,,,,,,,,1983,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,563.2094,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,380.89,1324.11
"Repair Recurr Inguin Hern,Reducibl",PX49520P,CDM,983,RC,49520,CPT,,,,,,,,1983,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,563.2094,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,380.89,1943.34
"DXA, Bone Density Study, Hips/Pelv/Spine",PX7708001,CDM,320,RC,77080,CPT,TC,,,,,,,575,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,563.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,563.5
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476881,NDC,50,ML,579.12,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,563.657496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
diazePAM 2.5 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,68682065020,NDC,1,EA,1114.05,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,563.7093,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Drainage Scrotal Wall Abscess,PX55100F,CDM,510,RC,55100,CPT,,,,,,,,634,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,564.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,263.3636,1416.38
Xray Cervical Spine 4 or 5 Vws,PX7205001,CDM,320,RC,72050,CPT,TC,,,,,,,664,,First Health,Commercial,both,85,,999999999,percent of total billed charges,564.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,650.72
Xray Cervical Spine 6 or More Vws,PX7205201,CDM,320,RC,72052,CPT,TC,,,,,,,664,,First Health,Commercial,both,85,,999999999,percent of total billed charges,564.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,650.72
"VENTRALIGHT MESH ST WITH ECHO 2 - 10 CM X 15 CM - 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,12007-MAIN,LOCAL,,,,,1176,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,564.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"VENTRALIGHT MESH ST WITH ECHO 2 - 10 CM X 15 CM - 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,12007-MAIN,LOCAL,,,,,1176,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,564.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Leukoreduced Rbc's,PXP9016,CDM,390,RC,P9016,HCPCS,,,,,,,,580,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,182.988,percent of total billed charges,564.514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,165.79,568.4
"Sigmoidoscopy,Biopsy",PX45331P,CDM,983,RC,45331,CPT,,,,,,,,1316,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,564.564,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,546.6664,1280.8628
Remove Hemorrhoids & Fissure,PX46257F,CDM,510,RC,46257,CPT,,,,,,,,1141,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,564.795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,473.9714,2452.93
"Amputation Metatarsal+Toe,Single",PX28810P,CDM,983,RC,28810,CPT,,,,,,,,620,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,564.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,257.548,2827.75
Colonoscopy,PX44388P,CDM,983,RC,44388,CPT,,,,,,,,620,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,564.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,257.548,798.45
Heart/Lung Resuscitation (Cpr),PX92950F,CDM,480,RC,92950,CPT,,,,,,,,1366,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,564.83,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.13,564.83
Heart/Lung Resuscitation (Cpr),PX92950P,CDM,983,RC,92950,CPT,,,,,,,,1023,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,564.83,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.13,1002.54
paliperidone palmitate ER 234 MG/1.5ML suspension prefilled syringe 1.5 mL Syringe,J2426.01,CDM,636,RC,J2426,HCPCS,,,,50458056401,NDC,0.25,ML,1142.14,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,565.3593,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.12,1119.2972
tiotropium 18 MCG capsule 5 Each Box,63700001,CDM,250,RC,,,,,,597007575,NDC,5,EA,665.18,,First Health,Commercial,both,85,,999999999,percent of total billed charges,565.403,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605F,CDM,510,RC,25605,CPT,,,,,,,,1178,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,565.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,489.3412,1404.08
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605F,CDM,510,RC,25605,CPT,,,,,,,,1178,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,565.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,489.3412,1404.08
Revise Ulnar Nerve at Elbow,PX64718P,CDM,983,RC,64718,CPT,,,,,,,,1642,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,565.4571,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,379.58,1609.16
"Fna Biopsy, W/US Guidance; First Lesion",PX10005P,CDM,983,RC,10005,CPT,,,,,,,,621,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,565.731,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,257.9634,614.65
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151F,CDM,510,RC,13151,CPT,,,,,,,,1143,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,565.785,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,474.8022,1120.14
"Colonoscope, Submucous Inj",PX45381F,CDM,750,RC,45381,CPT,,,,,,,,1179,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,565.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,489.7566,1155.42
"Colonoscope, Submucous Inj",PX45381F,CDM,750,RC,45381,CPT,,,,,,,,1179,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,565.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,489.7566,1155.42
INSTRUMENT PACKAGE TOEMATE,27200000,CDM,272,RC,,,,11858-MAIN,LOCAL,,,,,636,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,566.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSTRUMENT TOEMATE X-SMALL PACKAGE 9H00-T060,27200000,CDM,272,RC,C1713,HCPCS,,11575-MAIN,LOCAL,,,,,636,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,566.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Bcr/Abl1 P210 - Ref,PX8120690,CDM,310,RC,81206,CPT,90,,,,,,,1144,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,566.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.33,1121.12
"Hospital Inpt or Obs Care, Admin/Disch Same Date, Moderate Level Mdm >= 70 Minutes",PX99235,CDM,982,RC,99235,CPT,,,,,,,,582,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,566.4606,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,241.7628,566.4606
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004164,NDC,1,EA,666.52,,First Health,Commercial,both,85,,999999999,percent of total billed charges,566.542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004110,NDC,1,EA,666.53,,First Health,Commercial,both,85,,999999999,percent of total billed charges,566.5505,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
Egd Balloon Dil Esoph30 Mm/>,PX43233F,CDM,750,RC,43233,CPT,,,,,,,,1120,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,566.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,465.248,1662.33
"Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602P,CDM,983,RC,11602,CPT,,,,,,,,1120,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,566.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1090.096
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830P,CDM,983,RC,15830,CPT,,,,,,,,1120,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,566.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,465.248,5696.92
Insert Emergency Endotrach Airway,PX31500F,CDM,510,RC,31500,CPT,,,,,,,,637,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,566.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,624.26
"Needle Biopsy, Lymph Node(S)",PX38505F,CDM,510,RC,38505,CPT,,,,,,,,667,,First Health,Commercial,both,85,,999999999,percent of total billed charges,566.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,277.0718,1416.38
PERFIX PLUG STERILE X-LARGE,C1781,CDM,278,RC,C1781,HCPCS,,11772-MAIN,LOCAL,,,,,643,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,567.126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
GROSHONG PICC NXT 4FR,120.218,CDM,272,RC,,,,498-MAIN,LOCAL,,,,,1182,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,567.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,491.0028,1158.36
GROSHONG PICC NXT 4FR,120.218,CDM,272,RC,,,,498-MAIN,LOCAL,,,,,1182,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,567.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,491.0028,1158.36
"Lap,Dx Surgical Abd W/Biopsy",PX49321P,CDM,983,RC,49321,CPT,,,,,,,,583,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,567.4339,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,242.1782,5040.74
Heart/Lung Resuscitation (Cpr),PX92950F,CDM,480,RC,92950,CPT,,,,,,,,1366,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,567.4364,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.21,1338.68
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476881,NDC,50,ML,579.12,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,567.5376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
sugammadex sodium 200 MG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,6542312,NDC,2,ML,583.33,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,567.755089,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Removal of Tunnel Cv Access Device, With Port/Pump",PX36590P,CDM,983,RC,36590,CPT,,,,,,,,1147,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,567.765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,476.4638,1399.13
"Fac/Exc Skn Beni1.1-2cm Fce,Facial",PX11442F,CDM,510,RC,11442,CPT,,,,,,,,668,,First Health,Commercial,both,85,,999999999,percent of total billed charges,567.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,277.4872,654.64
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132F,CDM,510,RC,13132,CPT,,,,,,,,1159,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,567.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,481.4486,1135.82
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132F,CDM,510,RC,13132,CPT,,,,,,,,1159,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,567.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,481.4486,1135.82
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132F,CDM,510,RC,13132,CPT,,,,,,,,1159,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,567.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,481.4486,1135.82
CT Angio Abd&Pelv W/O&W/Dye,PX7417401,CDM,350,RC,74174,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,567.99,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.4,567.99
CT Angio Abd&Pelv W/O&W/Dye,PX7417401,CDM,350,RC,74174,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,567.99,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.4,567.99
gadoterate meglumine 10 mmol/20 mL Solution 20 mL Vial,A9575,CDM,636,RC,A9575,HCPCS,,,,67684200003,NDC,20,ML,668.27,,First Health,Commercial,both,85,,999999999,percent of total billed charges,568.0295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,277.599358,654.9046
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,45963061959,NDC,1,EA,638.4,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,568.176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
"Upper GI Endoscopy,Ctrl Bleed",PX43255P,CDM,983,RC,43255,CPT,,,,,,,,1148,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,568.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,476.8792,1662.33
zoledronic acid 5 MG/100ML Solution 100 mL Bottle,J3489.01,CDM,636,RC,J3489,HCPCS,,,,55111068852,NDC,100,ML,1368,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,568.2672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,63323096600,NDC,100,ML,1368,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,568.2672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
Leukoreduced Rbc's,PXP9016,CDM,390,RC,P9016,HCPCS,,,,,,,,580,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,568.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,165.79,568.4
HERNIA PATCH VENTRALEX LARGE,C1781,CDM,278,RC,C1781,HCPCS,,10201-MAIN,LOCAL,,,,,1325.08,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,568.45932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Inc/Drain Peritonsil Abscess,PX42700F,CDM,510,RC,42700,CPT,,,,,,,,624,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,568.464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,611.52
"Cardioversion, Elective;Extern",PX92960F,CDM,480,RC,92960,CPT,,,,,,,,402,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,568.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.9908,568.57
"Cardioversion, Elective;Extern",PX92960P,CDM,983,RC,92960,CPT,,,,,,,,688,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,568.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,285.7952,669.6304
Temporary External Pacing,PX92953F,CDM,480,RC,92953,CPT,,,,,,,,678,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,568.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,281.6412,664.44
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605F,CDM,510,RC,24605,CPT,,,,,,,,1124,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,568.744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.9096,1404.08
"Excise Lesion,Back or Flank",PX21930F,CDM,510,RC,21930,CPT,,,,,,,,1326,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,568.854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,550.8204,1416.38
Explor Metatarso-Phalang Jt,PX28022F,CDM,510,RC,28022,CPT,,,,,,,,1161,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,568.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,482.2794,2827.75
Explor Metatarso-Phalang Jt,PX28022F,CDM,510,RC,28022,CPT,,,,,,,,1161,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,568.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,482.2794,2827.75
Explor Metatarso-Phalang Jt,PX28022F,CDM,510,RC,28022,CPT,,,,,,,,1161,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,568.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,482.2794,2827.75
Bcr/Abl1 Other - Ref,PX8120890,CDM,310,RC,81208,CPT,90,,,,,,,1125,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,569.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,196.79,1102.5
"Amputation Toe,I-P Jt",PX28825F,CDM,510,RC,28825,CPT,,,,,,,,1327,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,569.283,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,551.2358,2827.75
Lap Rpr Vent Umbilical Hernia Incarcerated or Strangulated,PX49653P,CDM,983,RC,49653,CPT,,,,,,,,1327,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,569.283,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,551.2358,1291.5691
Reconstruc of Nail Bed,PX11760F,CDM,510,RC,11760,CPT,,,,,,,,1162,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,569.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,482.6948,1138.76
Reconstruc of Nail Bed,PX11760F,CDM,510,RC,11760,CPT,,,,,,,,1162,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,569.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,482.6948,1138.76
Reconstruc of Nail Bed,PX11760F,CDM,510,RC,11760,CPT,,,,,,,,1162,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,569.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,482.6948,1138.76
"Layr Clos Wnd Face,Facial 2.5-5",PX12052F,CDM,510,RC,12052,CPT,,,,,,,,585,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,569.3805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,243.009,573.3
"Repair Lip,>1/2 Vert Height",PX40654P,CDM,983,RC,40654,CPT,,,,,,,,1329,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,570.141,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,552.0666,1332.3
Art Lower Extremity-Bilat,PX9392501,CDM,921,RC,93925,CPT,TC,,,,,,,1188,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,570.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,1164.24
Art Lower Extremity-Bilat,PX9392501,CDM,921,RC,93925,CPT,TC,,,,,,,1188,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,570.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,1164.24
"Fac/Exc Skn Benig >4cm Trnk,Arm,Lg",PX11406F,CDM,510,RC,11406,CPT,,,,,,,,1127,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,570.262,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,468.1558,1416.38
US Abdomen Tc,PX7670001,CDM,402,RC,76700,CPT,TC,,,,,,,586,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,442.176,percent of total billed charges,570.3538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,574.28
"Hospital Inpt or Obs Care, Admin/Disch Same Date, Moderate Level Mdm >= 70 Minutes",PX99235,CDM,982,RC,99235,CPT,,,,,,,,582,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,570.36,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,99.73,570.36
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032P,CDM,983,RC,12032,CPT,,,,,,,,647,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,570.654,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,268.7638,629.7251
"Repair Umbilical Hern,5+Y/O,Reduc",PX49585P,CDM,983,RC,49585,CPT,,,,,,,,647,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,570.654,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,268.7638,629.7251
Ven Duplex Bilateral,PX9397001,CDM,921,RC,93970,CPT,TC,,,,,,,1189,,Health Partners,Health Partners Care Plans,both,48,,237.8,percent of total billed charges,570.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,1165.22
Ven Duplex Bilateral,PX9397001,CDM,921,RC,93970,CPT,TC,,,,,,,1189,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,570.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,1165.22
Closed Rx IP Jt Dislocation,PX26770F,CDM,510,RC,26770,CPT,,,,,,,,1231,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,570.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,168.85,628.15
Closed Rx IP Jt Dislocation,PX26770P,CDM,983,RC,26770,CPT,,,,,,,,1353,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,570.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,168.85,1325.94
beclomethasone  HFA 80 MCG/ACT Aerosol Breath Activated 10.6 g Inhaler,63700001,CDM,250,RC,,,,,,59310030480,NDC,10.6,GR,1164.84,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,570.7716,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
beclomethasone  HFA 80 MCG/ACT Aerosol Breath Activated 10.6 g Inhaler,63700001,CDM,250,RC,,,,,,59310030480,NDC,10.6,GR,1164.84,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,570.7716,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
beclomethasone  HFA 80 MCG/ACT Aerosol Breath Activated 10.6 g Inhaler,63700001,CDM,250,RC,,,,,,59310030480,NDC,10.6,GR,1164.84,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,570.7716,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Molecular Path Proc, Level 2 - Ref",PX8140190,CDM,310,RC,81401,CPT,90,,,,,,,672,,First Health,Commercial,both,85,,999999999,percent of total billed charges,571.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.62,658.56
Facility Emergency Level III Visit,PX99283F,CDM,450,RC,99283,CPT,,,,,,,,587,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,216.8694253,percent of total billed charges,571.3271,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,243.8398,575.26
"Lap,Dx Surgical Abd W/Biopsy",PX49321P,CDM,983,RC,49321,CPT,,,,,,,,583,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,571.34,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.77,718.78
8MM ENDOWRIST INSTRUMENTS MONOPOLAR CURVED SCISSORS,27200000,CDM,272,RC,,,,11909-MAIN,LOCAL,,,,,648,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,571.536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STAPLER INTERNAL ECHELON FLEX POWERED PLUS LONG LENGTH 440MM,27200000,CDM,272,RC,,,,12065-MAIN,LOCAL,,,,,648,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,571.536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
sugammadex sodium 200 MG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,6542312,NDC,2,ML,583.33,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,571.6634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Fac/Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601F,CDM,510,RC,11601,CPT,,,,,,,,673,,First Health,Commercial,both,85,,999999999,percent of total billed charges,572.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,279.5642,659.54
"Closed Rx I-P Jt,Toe Dislocation",PX28660P,CDM,983,RC,28660,CPT,,,,,,,,628,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,572.108,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,611.2324
Exc Face Les Sc < 2 Cm,PX21011P,CDM,983,RC,21011,CPT,,,,,,,,628,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,572.108,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,260.8712,1416.38
PERFIX PLUG STERILE X-LARGE,C1781,CDM,278,RC,C1781,HCPCS,,11772-MAIN,LOCAL,,,,,643,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,572.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Excis Tendn/Capsule Lesn,Toes",PX28092F,CDM,510,RC,28092,CPT,,,,,,,,1234,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,572.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,172.55,878.59
"Excis Tendn/Capsule Lesn,Toes",PX28092P,CDM,983,RC,28092,CPT,,,,,,,,1913,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,572.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,172.55,1874.74
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151F,CDM,510,RC,13151,CPT,,,,,,,,1143,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,572.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,173.43,877.89
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151P,CDM,983,RC,13151,CPT,,,,,,,,1177,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,572.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,173.43,1153.46
ADVANCED INSTRUMENTS VESSEL SEALER EXTEND,27200000,CDM,272,RC,,,,11923-MAIN,LOCAL,,,,,1169,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,572.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ADVANCED INSTRUMENTS VESSEL SEALER EXTEND,27200000,CDM,272,RC,,,,11923-MAIN,LOCAL,,,,,1169,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,572.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ADVANCED INSTRUMENTS VESSEL SEALER EXTEND,27200000,CDM,272,RC,,,,11923-MAIN,LOCAL,,,,,1169,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,572.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231001,NDC,10,ML,649.64,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,572.98248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231005,NDC,10,ML,649.64,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,572.98248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
Removal of Nail Bed,PX11750F,CDM,510,RC,11750,CPT,,,,,,,,629,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,573.019,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,261.2866,616.42
insulin aspart prot & aspart 70-30 (70-30) 100 UNIT/ML Suspension Pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169369619,NDC,3,ML,629.28,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,573.27408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
Acellular Derm Matrix Implt,PX15777F,CDM,510,RC,15777,CPT,,,,,,,,650,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,573.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.01,637
Closed Rx Bimalleolar Fx,PX27808F,CDM,510,RC,27808,CPT,,,,,,,,650,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,573.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,637
"Exc Skn Bngn2.1-3cm Fce,Facial",PX11443P,CDM,983,RC,11443,CPT,,,,,,,,650,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,573.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.01,1416.38
"Layr Clos Wnd Face,Facial 2.5-5",PX12052F,CDM,510,RC,12052,CPT,,,,,,,,585,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,573.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,243.009,573.3
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132F,CDM,510,RC,13132,CPT,,,,,,,,1159,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,573.705,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,481.4486,1135.82
Injection for Shoulder Arthrogram,PX23350F,CDM,510,RC,23350,CPT,,,,,,,,675,,First Health,Commercial,both,85,,999999999,percent of total billed charges,573.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,280.395,661.5
sevoflurane Solution 250 mL Bottle,25000000,CDM,250,RC,,,,,,66794001525,NDC,250,ML,589.56,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,573.818748,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,63323076350,NDC,50,ML,589.57,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,573.828481,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600110,NDC,10,ML,589.63,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,573.886879,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
"Infect, Organ, Amp Probe - Ref",PX8780190,CDM,300,RC,87801,CPT,90,,,,,,,630,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,573.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.37,617.4
MESH XLARGE LEFT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 5X7,120.524,CDM,278,RC,C1781,HCPCS,,12216-MAIN,LOCAL,,,,,630,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,573.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,261.702,617.4
MESH XLARGE RIGHT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 5X7,120.524,CDM,278,RC,C1781,HCPCS,,12217-MAIN,LOCAL,,,,,630,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,573.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,261.702,617.4
butamben-tetracaine-benzocaine 2-2-14 % Aerosol 20 g Bottle,25000000,CDM,250,RC,,,,,,10223020103,NDC,20,GR,589.76,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,574.013408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
methylene blue 50 MG/10ML Solution 10 mL Ampule,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,517037405,NDC,10,ML,1382.12,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,574.132648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.29,1354.4776
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505F,CDM,510,RC,25505,CPT,,,,,,,,651,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,574.182,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.4254,1404.08
Remove Foreign Body Complic,PX10121P,CDM,983,RC,10121,CPT,,,,,,,,651,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,574.182,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.4254,1416.38
US Abdomen Tc,PX7670001,CDM,402,RC,76700,CPT,TC,,,,,,,586,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,574.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,574.28
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390P,CDM,982,RC,45390,CPT,,,,,,,,1135,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,574.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,471.479,2452.93
liraglutide 18 MG/3ML solution pen-injector 3 mL Pen,63700001,CDM,250,RC,,,,,,169406013,NDC,3,ML,1382.75,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,574.39435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Direct Admit Hospital Observ,PXG0379,CDM,761,RC,G0379,HCPCS,,,,,,,,676,,First Health,Commercial,both,85,,999999999,percent of total billed charges,574.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,280.8104,662.48
Explor Metatarso-Phalang Jt,PX28022F,CDM,510,RC,28022,CPT,,,,,,,,1161,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,574.695,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,482.2794,2827.75
oseltamivir 6 MG/ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,68180067801,NDC,60,ML,676.25,,First Health,Commercial,both,85,,999999999,percent of total billed charges,574.8125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Reconstruc of Nail Bed,PX11760F,CDM,510,RC,11760,CPT,,,,,,,,1162,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,575.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,482.6948,1138.76
Facility Emergency Level III Visit,PX99283F,CDM,450,RC,99283,CPT,,,,,,,,587,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,575.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,243.8398,575.26
"Closed Rx Talus Fx,Manipulatn",PX28435P,CDM,983,RC,28435,CPT,,,,,,,,1137,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,575.322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,472.3098,1404.08
POWERPORT ISP MRI IMPLANTABLE PORT 8FR,C1788,CDM,278,RC,C1788,HCPCS,,11998-MAIN,LOCAL,,,,,1385,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,575.329,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,575.329,1357.3
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180P,CDM,983,RC,44180,CPT,,,,,,,,1175,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,575.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,488.095,5040.74
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180P,CDM,983,RC,44180,CPT,,,,,,,,1175,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,575.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,488.095,5040.74
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180P,CDM,983,RC,44180,CPT,,,,,,,,1175,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,575.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,488.095,5040.74
Closure Superf Wnd Dehis Simple,PX12020F,CDM,510,RC,12020,CPT,,,,,,,,632,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,575.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.5328,619.36
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121P,CDM,983,RC,13121,CPT,,,,,,,,632,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,575.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.5328,615.1256
sugammadex sodium 200 MG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,6542302,NDC,2,ML,652.81,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,575.77842,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032P,CDM,983,RC,12032,CPT,,,,,,,,647,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,575.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,268.7638,629.7251
"Repair Umbilical Hern,5+Y/O,Reduc",PX49585P,CDM,983,RC,49585,CPT,,,,,,,,647,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,575.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,268.7638,629.7251
Level 1 Additional Procedure,PX36000080,CDM,360,RC,,,,,,,,,,1200,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,498.48,1176
Level 1 Additional Procedure,PX36000080,CDM,360,RC,,,,,,,,,,1200,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,498.48,1176
"VENTRALIGHT MESH ST WITH ECHO 2 - 10 CM X 15 CM - 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,12007-MAIN,LOCAL,,,,,1176,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,196.035,percent of total billed charges,576.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"VENTRALIGHT MESH ST WITH ECHO 2 - 10 CM X 15 CM - 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,12007-MAIN,LOCAL,,,,,1176,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,576.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"VENTRALIGHT MESH ST WITH ECHO 2 - 10 CM X 15 CM - 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,12007-MAIN,LOCAL,,,,,1176,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,576.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Temporary External Pacing,PX92953F,CDM,480,RC,92953,CPT,,,,,,,,678,,First Health,Commercial,both,85,,999999999,percent of total billed charges,576.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,281.6412,664.44
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,55111069407,NDC,5,ML,592.4,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,576.58292,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.08296,1009.1158
beclomethasone  HFA 80 MCG/ACT Aerosol Breath Activated 10.6 g Inhaler,63700001,CDM,250,RC,,,,,,59310030480,NDC,10.6,GR,1164.84,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,576.5958,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600121,NDC,10,ML,592.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,576.68025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
8MM ENDOWRIST INSTRUMENTS MONOPOLAR CURVED SCISSORS,27200000,CDM,272,RC,,,,11909-MAIN,LOCAL,,,,,648,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,576.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STAPLER INTERNAL ECHELON FLEX POWERED PLUS LONG LENGTH 440MM,27200000,CDM,272,RC,,,,12065-MAIN,LOCAL,,,,,648,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,576.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151P,CDM,983,RC,13151,CPT,,,,,,,,1177,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,576.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,488.9258,1145.5741
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151P,CDM,983,RC,13151,CPT,,,,,,,,1177,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,576.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,488.9258,1145.5741
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151P,CDM,983,RC,13151,CPT,,,,,,,,1177,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,576.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,488.9258,1145.5741
Injection Hip Arthrogram,PX27093F,CDM,510,RC,27093,CPT,,,,,,,,654,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,576.828,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,271.6716,640.92
"Fac/Ex Skn Bngn2.1-3cm Trnk,Arm,Lg",PX11403F,CDM,510,RC,11403,CPT,,,,,,,,679,,First Health,Commercial,both,85,,999999999,percent of total billed charges,577.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,282.0566,665.42
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605F,CDM,510,RC,25605,CPT,,,,,,,,1178,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,577.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,489.3412,1404.08
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605F,CDM,510,RC,25605,CPT,,,,,,,,1178,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,577.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,489.3412,1404.08
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605F,CDM,510,RC,25605,CPT,,,,,,,,1178,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,577.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,489.3412,1404.08
Remove Hemorrhoids & Fissure,PX46257F,CDM,510,RC,46257,CPT,,,,,,,,1141,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,577.346,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,473.9714,2452.93
Drainage Scrotal Wall Abscess,PX55100F,CDM,510,RC,55100,CPT,,,,,,,,634,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,577.574,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,263.3636,1416.38
"Colonoscope, Submucous Inj",PX45381F,CDM,750,RC,45381,CPT,,,,,,,,1179,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,577.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,489.7566,1155.42
"Colonoscope, Submucous Inj",PX45381F,CDM,750,RC,45381,CPT,,,,,,,,1179,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,577.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,489.7566,1155.42
"Colonoscope, Submucous Inj",PX45381F,CDM,750,RC,45381,CPT,,,,,,,,1179,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,577.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,489.7566,1155.42
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035F,CDM,510,RC,12035,CPT,,,,,,,,655,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,577.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,272.087,641.9
sevoflurane Solution 250 mL Bottle,25000000,CDM,250,RC,,,,,,66794001525,NDC,250,ML,589.56,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,577.7688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,63323076350,NDC,50,ML,589.57,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,577.7786,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,24.246898,577.7786
Partial Bone Scan,PX7830001,CDM,341,RC,78300,CPT,TC,,,,,,,1391,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,577.8214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,360.31,1363.18
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600110,NDC,10,ML,589.63,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,577.8374,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
paliperidone palmitate ER 234 MG/1.5ML suspension prefilled syringe 1.5 mL Syringe,J2426.01,CDM,636,RC,J2426,HCPCS,,,,50458056401,NDC,0.25,ML,1142.14,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,577.92284,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.12,1119.2972
butamben-tetracaine-benzocaine 2-2-14 % Aerosol 20 g Bottle,25000000,CDM,250,RC,,,,,,10223020103,NDC,20,GR,589.76,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,577.9648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010202,NDC,1,EA,680,,First Health,Commercial,both,85,,999999999,percent of total billed charges,578,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 1 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010101,NDC,1,EA,680,,First Health,Commercial,both,85,,999999999,percent of total billed charges,578,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010102,NDC,1,EA,680,,First Health,Commercial,both,85,,999999999,percent of total billed charges,578,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
"Fac/Exc Skn Mal 0.6-1cm Fce,Facial",PX11641F,CDM,510,RC,11641,CPT,,,,,,,,680,,First Health,Commercial,both,85,,999999999,percent of total billed charges,578,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,282.472,666.4
Observation Initial,PXG0378.03,CDM,762,RC,G0378,HCPCS,,,,,,,,680,,First Health,Commercial,both,85,,999999999,percent of total billed charges,578,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,282.472,666.4
CT Abd & Pelvis W/O Contrast,PX7417601,CDM,350,RC,74176,CPT,TC,,,,,,,4288,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,578.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,4202.24
"Mra, Head W/Out Contrast",PX7054401,CDM,610,RC,70544,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,578.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI Abdomen W/O Tc,PX7418101,CDM,610,RC,74181,CPT,TC,,,,,,,2655,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,578.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,2601.9
MRI Brain WO Contrast Tc,PX7055101,CDM,610,RC,70551,CPT,TC,,,,,,,3335,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,578.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3268.3
MRI C-Spine WO Contrast,PX7214101,CDM,610,RC,72141,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,578.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI L Spine WO Contrast,PX7214801,CDM,610,RC,72148,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,578.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI Low Ext Jnt WO/Cont Tc,PX7372101,CDM,610,RC,73721,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,578.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI Orbit/Face/Neck Tc,PX7054001,CDM,610,RC,70540,CPT,TC,,,,,,,3335,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,578.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3268.3
MRI T Spine WO Contrast,PX7214601,CDM,610,RC,72146,CPT,TC,,,,,,,3267,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,578.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3201.66
MRI Up Extremity Joint W/O Tc,PX7322101,CDM,610,RC,73221,CPT,TC,,,,,,,3319,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,578.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3252.62
"MRI,Lwrext,No Jnt,No Cont",PX7371801,CDM,610,RC,73718,CPT,TC,,,,,,,3253,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,578.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3187.94
"MRI,Pelvis W/Out Contrast",PX7219501,CDM,610,RC,72195,CPT,TC,,,,,,,3253,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,578.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3187.94
"MRI,Up Ext,No Jnt,No Cont",PX7321801,CDM,610,RC,73218,CPT,TC,,,,,,,3253,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,578.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3187.94
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231001,NDC,10,ML,649.64,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,578.1796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231005,NDC,10,ML,649.64,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,578.1796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
"Sb Scope,to Ileum,Biopsy",PX44377P,CDM,983,RC,44377,CPT,,,,,,,,1180,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,578.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,490.172,1662.33
"Sb Scope,to Ileum,Biopsy",PX44377P,CDM,983,RC,44377,CPT,,,,,,,,1180,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,578.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,490.172,1662.33
"Sb Scope,to Ileum,Biopsy",PX44377P,CDM,983,RC,44377,CPT,,,,,,,,1180,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,578.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,490.172,1662.33
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151F,CDM,510,RC,13151,CPT,,,,,,,,1143,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,578.358,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,474.8022,1120.14
Acellular Derm Matrix Implt,PX15777F,CDM,510,RC,15777,CPT,,,,,,,,650,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,578.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.01,637
Closed Rx Bimalleolar Fx,PX27808F,CDM,510,RC,27808,CPT,,,,,,,,650,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,578.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,637
"Exc Skn Bngn2.1-3cm Fce,Facial",PX11443P,CDM,983,RC,11443,CPT,,,,,,,,650,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,578.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.01,1416.38
ADVANCED INSTRUMENTS VESSEL SEALER EXTEND,27200000,CDM,272,RC,,,,11923-MAIN,LOCAL,,,,,1169,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,578.655,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
megestrol 40 MG/ML Suspension 240 mL Bottle,25000000,CDM,250,RC,,,,,,49884090738,NDC,240,ML,594.72,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,578.840976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Repr Superf Wnd Face 2.6-5,PX12013P,CDM,983,RC,12013,CPT,,,,,,,,681,,First Health,Commercial,both,85,,999999999,percent of total billed charges,578.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,662.8173
Bcr/Abl1 P210 - Ref,PX8120690,CDM,310,RC,81206,CPT,90,,,,,,,1144,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,578.864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.33,1121.12
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133F,CDM,510,RC,13133,CPT,,,,,,,,595,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,579.1135,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247.163,583.1
"Thrombolysis,Coronary,IV Infusn",PX92977F,CDM,480,RC,92977,CPT,,,,,,,,595,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,579.1135,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247.163,583.1
"Thrombolytic Therapy, Stroke",PX37195F,CDM,761,RC,37195,CPT,,,,,,,,595,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,579.1135,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247.163,583.1
"Hemorrhoidectomy,Int/Ext,Complx",PX46260F,CDM,750,RC,46260,CPT,,,,,,,,1350,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,579.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,560.79,2452.93
Leukoreduced Platelets,PXP9035,CDM,390,RC,P9035,HCPCS,,,,,,,,1350,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,579.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,433.08,1323
GROSHONG PICC NXT 4FR,120.218,CDM,272,RC,,,,498-MAIN,LOCAL,,,,,1182,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,579.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,491.0028,1158.36
GROSHONG PICC NXT 4FR,120.218,CDM,272,RC,,,,498-MAIN,LOCAL,,,,,1182,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,579.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,491.0028,1158.36
GROSHONG PICC NXT 4FR,120.218,CDM,272,RC,,,,498-MAIN,LOCAL,,,,,1182,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,579.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,491.0028,1158.36
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505F,CDM,510,RC,25505,CPT,,,,,,,,651,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,579.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.4254,1404.08
Remove Foreign Body Complic,PX10121P,CDM,983,RC,10121,CPT,,,,,,,,651,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,579.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.4254,1416.38
INSTRUMENT PACKAGE TOEMATE,27200000,CDM,272,RC,,,,11858-MAIN,LOCAL,,,,,636,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,579.396,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSTRUMENT TOEMATE X-SMALL PACKAGE 9H00-T060,27200000,CDM,272,RC,C1713,HCPCS,,11575-MAIN,LOCAL,,,,,636,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,579.396,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Insert Emergency Endotrach Airway,PX31500P,CDM,983,RC,31500,CPT,,,,,,,,657,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,579.474,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,639.4581
"Closed Rx Trimalleolar Fx,Manip",PX27818P,CDM,983,RC,27818,CPT,,,,,,,,1352,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,580.008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,561.6208,1404.08
Insert Emergency Endotrach Airway,PX31500F,CDM,510,RC,31500,CPT,,,,,,,,637,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,580.307,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,624.26
OBINutuzumab 1000 MG/40ML Solution 40 mL Vial,J9301.01,CDM,636,RC,J9301,HCPCS,,,,50242007001,NDC,4,ML,1397.15,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,580.37611,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.12,1369.207
"Removal of Tunnel Cv Access Device, With Port/Pump",PX36590P,CDM,983,RC,36590,CPT,,,,,,,,1147,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,580.382,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,476.4638,1399.13
"Exc Skn Mal 2.1-3cmtrnk,Arm,Lg",PX11603P,CDM,983,RC,11603,CPT,,,,,,,,1276,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,580.42,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.07,1250.48
"Fac/Exc Skn Mali2.1-3cmtrnk,Arm,Lg",PX11603F,CDM,510,RC,11603,CPT,,,,,,,,875,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,580.42,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.07,580.42
Closed Rx IP Jt Dislocation,PX26770P,CDM,983,RC,26770,CPT,,,,,,,,1353,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,580.437,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1316.8749
"Remv Foot Foreign Body,Subcutaneous",PX28190P,CDM,983,RC,28190,CPT,,,,,,,,683,,First Health,Commercial,both,85,,999999999,percent of total billed charges,580.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,283.7182,664.7639
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,55111069407,NDC,5,ML,592.4,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,580.552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.08296,1009.1158
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600121,NDC,10,ML,592.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,580.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.29,580.65
Incise Finger Tendon Sheath,PX26055F,CDM,510,RC,26055,CPT,,,,,,,,1398,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,580.7292,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,580.7292,1404.08
"Upper GI Endoscopy,Ctrl Bleed",PX43255P,CDM,983,RC,43255,CPT,,,,,,,,1148,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,580.888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,476.8792,1662.33
sugammadex sodium 200 MG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,6542302,NDC,2,ML,652.81,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,581.0009,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Fluoroscope Examination Tc,PX7600001,CDM,320,RC,76000,CPT,TC,,,,,,,597,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,581.0601,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,585.06
"Insert Needle,Intraosseous Infusn",PX36680F,CDM,510,RC,36680,CPT,,,,,,,,659,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,581.238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,273.7486,645.82
"Spinal Puncture,Lumbar,Diagnostic",PX62270F,CDM,510,RC,62270,CPT,,,,,,,,684,,First Health,Commercial,both,85,,999999999,percent of total billed charges,581.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,284.1336,670.32
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,45963061959,NDC,1,EA,638.4,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,581.5824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180P,CDM,983,RC,44180,CPT,,,,,,,,1175,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,581.625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,488.095,5040.74
insulin aspart 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169633910,NDC,3,ML,659.76,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,581.90832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781324494,NDC,1,EA,1400.9,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,581.93386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
diazePAM 10 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,93613832,NDC,1,EA,1212.57,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,582.0336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 10 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,93613832,NDC,1,EA,1212.57,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,582.0336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Injection Hip Arthrogram,PX27093F,CDM,510,RC,27093,CPT,,,,,,,,654,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,582.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,271.6716,640.92
Art Lower Extremity-Bilat,PX9392501,CDM,921,RC,93925,CPT,TC,,,,,,,1188,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,582.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,1164.24
Art Lower Extremity-Bilat,PX9392501,CDM,921,RC,93925,CPT,TC,,,,,,,1188,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,582.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,1164.24
Art Lower Extremity-Bilat,PX9392501,CDM,921,RC,93925,CPT,TC,,,,,,,1188,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,582.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,1164.24
"Incis/Drain Scrotum/Testis,Epididym",PX54700F,CDM,510,RC,54700,CPT,,,,,,,,660,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,582.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.164,1779.39
Repair Incis Hernia W Mesh,PX49568P,CDM,983,RC,49568,CPT,,,,,,,,660,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,582.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.164,642.378
"VENTRALIGHT MESH ST WITH ECHO 2 - 10 CM X 15 CM - 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,12007-MAIN,LOCAL,,,,,1176,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,582.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Ven Duplex Bilateral,PX9397001,CDM,921,RC,93970,CPT,TC,,,,,,,1189,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,230.8,percent of total billed charges,582.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,1165.22
Ven Duplex Bilateral,PX9397001,CDM,921,RC,93970,CPT,TC,,,,,,,1189,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,582.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,1165.22
Ven Duplex Bilateral,PX9397001,CDM,921,RC,93970,CPT,TC,,,,,,,1189,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,582.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,1165.22
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151P,CDM,983,RC,13151,CPT,,,,,,,,1177,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,582.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,488.9258,1145.5741
megestrol 40 MG/ML Suspension 240 mL Bottle,25000000,CDM,250,RC,,,,,,49884090738,NDC,240,ML,594.72,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,582.8256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035F,CDM,510,RC,12035,CPT,,,,,,,,655,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,582.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,272.087,641.9
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,16714085701,NDC,1,EA,1403.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,583.0139,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133F,CDM,510,RC,13133,CPT,,,,,,,,595,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,583.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247.163,583.1
"Thrombolysis,Coronary,IV Infusn",PX92977F,CDM,480,RC,92977,CPT,,,,,,,,595,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,583.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247.163,583.1
"Thrombolytic Therapy, Stroke",PX37195F,CDM,761,RC,37195,CPT,,,,,,,,595,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,583.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247.163,583.1
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605F,CDM,510,RC,25605,CPT,,,,,,,,1178,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,583.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,489.3412,1404.08
"Colonoscopy,Control Bleeding",PX45382F,CDM,750,RC,45382,CPT,,,,,,,,1215,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,583.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,504.711,1190.7
"Colonoscopy,Control Bleeding",PX45382F,CDM,750,RC,45382,CPT,,,,,,,,1215,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,583.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,504.711,1190.7
"Igh, Variable Region Somatic Mutation Analysis",PX8126390,CDM,310,RC,81263,CPT,90,,,,,,,1215,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,583.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.05,1190.7
"Igh, Variable Region Somatic Mutation Analysis",PX8126390,CDM,310,RC,81263,CPT,90,,,,,,,1215,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,583.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.05,1190.7
Closed Rx Kneecap Disloc+Anesth,PX27562P,CDM,983,RC,27562,CPT,,,,,,,,1404,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,583.2216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1366.5132
"Colonoscope, Submucous Inj",PX45381F,CDM,750,RC,45381,CPT,,,,,,,,1179,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,583.605,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,489.7566,1155.42
"MRI,Lwrext,Jnt W/O+W/Cont",PX7372301,CDM,610,RC,73723,CPT,TC,,,,,,,1850,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,583.77,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,198.08,583.77
"MRI,Lwrext,Jnt W/O+W/Cont",PX7372301,CDM,610,RC,73723,CPT,TC,,,,,,,1850,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,583.77,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,198.08,583.77
liraglutide 18 MG/3ML solution pen-injector 3 mL Pen,63700001,CDM,250,RC,,,,,,169406012,NDC,3,ML,1405.33,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,583.774082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Fluoroscopy Guid Needle Plcmt Tc,PX7700201,CDM,320,RC,77002,CPT,TC,,,,,,,662,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,583.884,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.9948,648.76
DRILL BIT 2.2MM LONG SOLID STERILE MICA,27200000,CDM,272,RC,,,,12985-MAIN,LOCAL,,,,,600,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,583.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404P,CDM,983,RC,11404,CPT,,,,,,,,600,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,583.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,249.24,1416.38
Extremity Study - Vascular Diagnostics,PX9392201,CDM,921,RC,93922,CPT,TC,,,,,,,600,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,583.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,588
"Sb Scope,to Ileum,Biopsy",PX44377P,CDM,983,RC,44377,CPT,,,,,,,,1180,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,584.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,490.172,1662.33
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569F,CDM,510,RC,36569,CPT,,,,,,,,1217,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,584.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,505.5418,1399.13
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569F,CDM,510,RC,36569,CPT,,,,,,,,1217,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,584.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,505.5418,1399.13
Insert Emergency Endotrach Airway,PX31500P,CDM,983,RC,31500,CPT,,,,,,,,657,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,584.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,639.4581
"Cardioversion, Elective;Extern",PX92960P,CDM,983,RC,92960,CPT,,,,,,,,688,,First Health,Commercial,both,85,,999999999,percent of total billed charges,584.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,285.7952,669.6304
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031F,CDM,510,RC,12031,CPT,,,,,,,,688,,First Health,Commercial,both,85,,999999999,percent of total billed charges,584.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,285.7952,674.24
Exc Abdom Tum Subfac > 5 Cm,PX22901F,CDM,761,RC,22901,CPT,,,,,,,,1408,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,584.8832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,584.8832,2482.37
Fluoroscope Examination Tc,PX7600001,CDM,320,RC,76000,CPT,TC,,,,,,,597,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,585.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,585.06
GROSHONG PICC NXT 4FR,120.218,CDM,272,RC,,,,498-MAIN,LOCAL,,,,,1182,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,585.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,491.0028,1158.36
Xray Cervical Spine 4 or 5 Vws,PX7205001,CDM,320,RC,72050,CPT,TC,,,,,,,664,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,585.648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,650.72
Xray Cervical Spine 6 or More Vws,PX7205201,CDM,320,RC,72052,CPT,TC,,,,,,,664,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,585.648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,650.72
Closed Rx Shldr Dislocation,PX23650F,CDM,510,RC,23650,CPT,,,,,,,,689,,First Health,Commercial,both,85,,999999999,percent of total billed charges,585.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,675.22
"Lap,Cholecystectomy",PX47562F,CDM,510,RC,47562,CPT,,,,,,,,1473,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,585.6864,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,396.16,1378.07
"Lap,Cholecystectomy",PX47562P,CDM,983,RC,47562,CPT,,,,,,,,983,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,585.6864,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,396.16,1378.07
PERFIX PLUG STERILE X-LARGE,C1781,CDM,278,RC,C1781,HCPCS,,11772-MAIN,LOCAL,,,,,643,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,585.773,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Heart/Lung Resuscitation (Cpr),PX92950F,CDM,480,RC,92950,CPT,,,,,,,,1366,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,586.014,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.21,1338.68
Bone Marrow Biopsy(Ies),PX38221F,CDM,510,RC,38221,CPT,,,,,,,,1221,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,586.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,507.2034,1416.38
Bone Marrow Biopsy(Ies),PX38221F,CDM,510,RC,38221,CPT,,,,,,,,1221,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,586.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,507.2034,1416.38
"MRI,Uprext Jnt W/O+W/Cont",PX7322301,CDM,610,RC,73223,CPT,TC,,,,,,,2681,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,586.4,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,198.95,586.4
"MRI,Uprext Jnt W/O+W/Cont",PX7322301,CDM,610,RC,73223,CPT,TC,,,,,,,2681,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,586.4,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,198.95,586.4
darbepoetin alfa 40 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002104,NDC,0.4,ML,1411.78,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,586.453412,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132F,CDM,510,RC,13132,CPT,,,,,,,,1159,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,586.454,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,481.4486,1135.82
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623F,CDM,510,RC,11623,CPT,,,,,,,,690,,First Health,Commercial,both,85,,999999999,percent of total billed charges,586.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,286.626,1416.38
"Insert Needle,Intraosseous Infusn",PX36680F,CDM,510,RC,36680,CPT,,,,,,,,659,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,586.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,273.7486,645.82
tiotropium 18 MCG capsule 5 Each Box,63700001,CDM,250,RC,,,,,,597007575,NDC,5,EA,665.18,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,586.68876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zoledronic acid 5 MG/100ML Solution 100 mL Bottle,J3489.01,CDM,636,RC,J3489,HCPCS,,,,55111068852,NDC,100,ML,1368,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,586.872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,63323096600,NDC,100,ML,1368,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,586.872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
insulin aspart 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169633910,NDC,3,ML,659.76,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,587.1864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
"Incis/Drain Scrotum/Testis,Epididym",PX54700F,CDM,510,RC,54700,CPT,,,,,,,,660,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,587.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.164,1779.39
Repair Incis Hernia W Mesh,PX49568P,CDM,983,RC,49568,CPT,,,,,,,,660,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,587.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.164,642.378
Explor Metatarso-Phalang Jt,PX28022F,CDM,510,RC,28022,CPT,,,,,,,,1161,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,587.466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,482.2794,2827.75
moxifloxacin 0.5 % Solution 3 mL Bottle,25000000,CDM,250,RC,,,,,,60505058204,NDC,3,ML,691.15,,First Health,Commercial,both,85,,999999999,percent of total billed charges,587.4775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004164,NDC,1,EA,666.52,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,587.87064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
Closed Rx Kneecap Disloc+Anesth,PX27562F,CDM,510,RC,27562,CPT,,,,,,,,604,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,587.8732,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,591.92
filgrastim-ayow 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,800000,CDM,,,,,,,,70121157001,NDC,0.5,ML,691.62,,First Health,Commercial,both,85,,999999999,percent of total billed charges,587.877,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004110,NDC,1,EA,666.53,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,587.87946,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
Reconstruc of Nail Bed,PX11760F,CDM,510,RC,11760,CPT,,,,,,,,1162,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,587.972,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,482.6948,1138.76
"Colonoscopy,Flex,Diagnostic",PX45378P,CDM,983,RC,45378,CPT,,,,,,,,1200,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1803.195,percent of total billed charges,588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,514.8,4661.91
"Colonoscopy,Flex,Diagnostic",PX45378P,CDM,983,RC,45378,CPT,,,,,,,,1200,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,514.8,4661.91
"Colonoscopy,Flex,Diagnostic",PX45378P,CDM,983,RC,45378,CPT,,,,,,,,1200,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,514.8,4661.91
DRILL BIT 2.2MM LONG SOLID STERILE MICA,27200000,CDM,272,RC,,,,12985-MAIN,LOCAL,,,,,600,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404P,CDM,983,RC,11404,CPT,,,,,,,,600,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,588,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.96,588
Extremity Study - Vascular Diagnostics,PX9392201,CDM,921,RC,93922,CPT,TC,,,,,,,600,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,588
Level 1 Additional Procedure,PX36000080,CDM,360,RC,,,,,,,,,,1200,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,498.48,1176
Level 1 Additional Procedure,PX36000080,CDM,360,RC,,,,,,,,,,1200,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,498.48,1176
Level 1 Additional Procedure,PX36000080,CDM,360,RC,,,,,,,,,,1200,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,498.48,1176
Art Lower Extremity-Bilat,PX9392501,CDM,921,RC,93925,CPT,TC,,,,,,,1188,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,588.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,1164.24
"Needle Biopsy, Lymph Node(S)",PX38505F,CDM,510,RC,38505,CPT,,,,,,,,667,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,588.294,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,277.0718,1416.38
Ven Duplex Bilateral,PX9397001,CDM,921,RC,93970,CPT,TC,,,,,,,1189,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,588.555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,1165.22
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,310095036,NDC,1,EA,1234.2,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,588.83968,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,535.92,639.46
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,70720095036,NDC,1,EA,1234.2,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,588.83968,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,535.92,639.46
Exc Skin Benig >4cm Remaindr Body,PX11426F,CDM,510,RC,11426,CPT,,,,,,,,1227,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,588.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,509.6958,2482.37
Exc Skin Benig >4cm Remaindr Body,PX11426F,CDM,510,RC,11426,CPT,,,,,,,,1227,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,588.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,509.6958,2482.37
onabotulinumtoxinA 50 units Recon Soln 1 Each Vial,J0585.03,CDM,636,RC,J0585,HCPCS,,,,23391950,NDC,1,EA,1418.14,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,589.095356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.51,1389.7772
"Fac/Exc Skn Beni1.1-2cm Fce,Facial",PX11442F,CDM,510,RC,11442,CPT,,,,,,,,668,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,589.176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,277.4872,654.64
Fluoroscopy Guid Needle Plcmt Tc,PX7700201,CDM,320,RC,77002,CPT,TC,,,,,,,662,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,589.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.9948,648.76
beclomethasone  HFA 80 MCG/ACT Aerosol Breath Activated 10.6 g Inhaler,63700001,CDM,250,RC,,,,,,59310030480,NDC,10.6,GR,1164.84,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,589.40904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
gadoterate meglumine 10 mmol/20 mL Solution 20 mL Vial,A9575,CDM,636,RC,A9575,HCPCS,,,,67684200003,NDC,20,ML,668.27,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,589.41414,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,277.599358,654.9046
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032P,CDM,983,RC,12032,CPT,,,,,,,,647,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,589.417,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,268.7638,629.7251
"Repair Umbilical Hern,5+Y/O,Reduc",PX49585P,CDM,983,RC,49585,CPT,,,,,,,,647,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,589.417,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,268.7638,629.7251
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390F,CDM,750,RC,45390,CPT,,,,,,,,1419,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,589.4526,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,589.4526,2452.93
filgrastim 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513020991,NDC,0.5,ML,1228.49,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,589.6752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
filgrastim 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513020991,NDC,0.5,ML,1228.49,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,589.6752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
"Fac/Exc Skn Bnig0.6-1cm Fae,Facial",PX11441F,CDM,510,RC,11441,CPT,,,,,,,,606,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,589.8198,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,251.7324,614.65
"Removal of Hydrocele,Tunica,Unilat",PX55040P,CDM,983,RC,55040,CPT,,,,,,,,1420,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,589.868,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,589.868,3022.41
Fac/Ligation of Hemorrhoid(S),PX46221F,CDM,510,RC,46221,CPT,,,,,,,,1046,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,590.11,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.94,590.11
"Layr Clos Wnd Face,Facial <2.5cm",PX12051F,CDM,510,RC,12051,CPT,,,,,,,,769,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,590.11,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.45,590.11
"Layr Clos Wnd Face,Facial <2.5cm",PX12051P,CDM,983,RC,12051,CPT,,,,,,,,615,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,590.11,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.45,602.7
Ligation of Hemorrhoid(S),PX46221P,CDM,983,RC,46221,CPT,,,,,,,,697,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,590.11,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.94,683.06
"Closed Rx Shldr Disloc,Anesthesia",PX23655P,CDM,983,RC,23655,CPT,,,,,,,,1421,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,590.2834,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,590.2834,1404.08
Excis Forearm/Wrist Tumor Subcutan,PX25075F,CDM,510,RC,25075,CPT,,,,,,,,1421,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,590.2834,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,590.2834,1416.38
8MM ENDOWRIST INSTRUMENTS MONOPOLAR CURVED SCISSORS,27200000,CDM,272,RC,,,,11909-MAIN,LOCAL,,,,,648,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,590.328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STAPLER INTERNAL ECHELON FLEX POWERED PLUS LONG LENGTH 440MM,27200000,CDM,272,RC,,,,12065-MAIN,LOCAL,,,,,648,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,590.328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604P,CDM,983,RC,11604,CPT,,,,,,,,1422,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,590.6988,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,590.6988,1384.0326
Anal Sphincterotomy,PX46080F,CDM,510,RC,46080,CPT,,,,,,,,607,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,590.7931,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,252.1478,2452.93
Excis Forearm/Wrist Tumor Subcutan,PX25075P,CDM,983,RC,25075,CPT,,,,,,,,607,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,590.7931,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,252.1478,1416.38
Open Bx/Excision Inguinofemoral Nodes,PX38531P,CDM,983,RC,38531,CPT,,,,,,,,607,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,590.7931,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,252.1478,3329.99
Closed Rx IP Jt Dislocation,PX26770F,CDM,510,RC,26770,CPT,,,,,,,,1231,,Health Partners,Health Partners Care Plans,both,48,,684.745,percent of total billed charges,590.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1206.38
Closed Rx IP Jt Dislocation,PX26770F,CDM,510,RC,26770,CPT,,,,,,,,1231,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,590.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1206.38
Xray Cervical Spine 4 or 5 Vws,PX7205001,CDM,320,RC,72050,CPT,TC,,,,,,,664,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,590.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,650.72
Xray Cervical Spine 6 or More Vws,PX7205201,CDM,320,RC,72052,CPT,TC,,,,,,,664,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,590.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,650.72
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096321,NDC,30,ML,1231.47,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,591.1056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,511.552638,1206.8406
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096321,NDC,30,ML,1231.47,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,591.1056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,511.552638,1206.8406
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096330,NDC,30,ML,1231.47,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,591.1056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,511.552638,1206.8406
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096330,NDC,30,ML,1231.47,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,591.1056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,511.552638,1206.8406
ADVANCED INSTRUMENTS VESSEL SEALER EXTEND,27200000,CDM,272,RC,,,,11923-MAIN,LOCAL,,,,,1169,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,591.514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Abd Paracentesis W/Imaging(P),PX49083P,CDM,983,RC,49083,CPT,,,,,,,,696,,First Health,Commercial,both,85,,999999999,percent of total billed charges,591.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.1184,791.92
3.0MM HEADED SCREW LENGTH 16MM,C1713,CDM,278,RC,C1713,HCPCS,,12656-MAIN,LOCAL,,,,,608,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,591.7664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231001,NDC,10,ML,649.64,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,591.82204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231005,NDC,10,ML,649.64,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,591.82204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
Closed Rx Kneecap Disloc+Anesth,PX27562F,CDM,510,RC,27562,CPT,,,,,,,,604,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,591.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,591.92
tiotropium 18 MCG capsule 5 Each Box,63700001,CDM,250,RC,,,,,,597007575,NDC,5,EA,665.18,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,592.0102,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Acellular Derm Matrix Implt,PX15777F,CDM,510,RC,15777,CPT,,,,,,,,650,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,592.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.01,637
Closed Rx Bimalleolar Fx,PX27808F,CDM,510,RC,27808,CPT,,,,,,,,650,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,592.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,637
"Exc Skn Bngn2.1-3cm Fce,Facial",PX11443P,CDM,983,RC,11443,CPT,,,,,,,,650,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,592.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.01,1416.38
"Excis Tendn/Capsule Lesn,Toes",PX28092F,CDM,510,RC,28092,CPT,,,,,,,,1234,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,592.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,512.6036,1404.08
"Excis Tendn/Capsule Lesn,Toes",PX28092F,CDM,510,RC,28092,CPT,,,,,,,,1234,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,592.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,512.6036,1404.08
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,310095036,NDC,1,EA,1234.2,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,592.416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,512.68668,1209.516
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,310095036,NDC,1,EA,1234.2,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,592.416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,512.68668,1209.516
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,70720095036,NDC,1,EA,1234.2,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,592.416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,512.68668,1209.516
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,70720095036,NDC,1,EA,1234.2,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,592.416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,512.68668,1209.516
Ligation of Hemorrhoid(S),PX46221P,CDM,983,RC,46221,CPT,,,,,,,,697,,First Health,Commercial,both,85,,999999999,percent of total billed charges,592.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.5338,798.45
STAPLER INTERNAL POWERED 29MM CURVED CIRCULAR,27200000,CDM,272,RC,,,,12024-MAIN,LOCAL,,,,,697,,First Health,Commercial,both,85,,999999999,percent of total billed charges,592.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STAPLER INTERNAL POWERED 31MM CURVED CIRCULAR,27200000,CDM,272,RC,,,,12025-MAIN,LOCAL,,,,,697,,First Health,Commercial,both,85,,999999999,percent of total billed charges,592.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Molecular Path Proc, Level 2 - Ref",PX8140190,CDM,310,RC,81401,CPT,90,,,,,,,672,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,592.704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.62,658.56
"Infectious Disease,Chronic Hep C Virus,Six Assays, Utilizing Serum",PX8159690,CDM,300,RC,81596,CPT,90,,,,,,,609,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,592.7397,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.19,596.82
"Colonoscopy,Flex,Screen",PX2002F,CDM,750,RC,G0105,HCPCS,,,,,,,,2539,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,592.75,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.56,592.75
CT Lwr Extremity W/O&W/Dye,PX7370201,CDM,350,RC,73702,CPT,TC,,,,,,,1235,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,592.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
CT Lwr Extremity W/O&W/Dye,PX7370201,CDM,350,RC,73702,CPT,TC,,,,,,,1235,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,592.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
"Close Rx Dist Fingr Fx,Manipulatn",PX26755F,CDM,510,RC,26755,CPT,,,,,,,,335,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,592.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,177.14,692.49
"Close Rx Dist Fingr Fx,Manipulatn",PX26755P,CDM,983,RC,26755,CPT,,,,,,,,1260,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,592.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,177.14,1234.8
methylene blue 50 MG/10ML Solution 10 mL Ampule,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,517037405,NDC,10,ML,1382.12,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,592.92948,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.29,1354.4776
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505F,CDM,510,RC,25505,CPT,,,,,,,,651,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,593.061,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.4254,1404.08
Remove Foreign Body Complic,PX10121P,CDM,983,RC,10121,CPT,,,,,,,,651,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,593.061,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.4254,1416.38
liraglutide 18 MG/3ML solution pen-injector 3 mL Pen,63700001,CDM,250,RC,,,,,,169406013,NDC,3,ML,1382.75,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,593.19975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004164,NDC,1,EA,666.52,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,593.2028,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004110,NDC,1,EA,666.53,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,593.2117,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
sodium thiosulfate 250 MG/ML Solution 50 mL Vial,J0209.01,CDM,636,RC,J0209,HCPCS,,,,60267070550,NDC,50,ML,609.57,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,593.294481,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,253.215378,597.3786
"Fac/Exc Skn Malig .1-2cm Fce,Facal",PX11642F,CDM,510,RC,11642,CPT,,,,,,,,698,,First Health,Commercial,both,85,,999999999,percent of total billed charges,593.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.9492,684.04
"Colonoscopy,Screen Prev",PX2004F,CDM,750,RC,G0121,HCPCS,,,,,,,,2502,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,593.33,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.78,593.33
"Sigmoidoscopy,Biopsy",PX45331F,CDM,750,RC,45331,CPT,,,,,,,,1776,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,593.56,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.5,593.56
"Sigmoidoscopy,Biopsy",PX45331P,CDM,983,RC,45331,CPT,,,,,,,,1316,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,593.56,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.5,1289.68
"Fac/Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601F,CDM,510,RC,11601,CPT,,,,,,,,673,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,593.586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,279.5642,659.54
"Remv Foreign Body,Knee/Thigh,Deep",PX27372F,CDM,510,RC,27372,CPT,,,,,,,,1429,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,593.6066,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,593.6066,2482.37
"Needle Biopsy, Lymph Node(S)",PX38505F,CDM,510,RC,38505,CPT,,,,,,,,667,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,593.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,277.0718,1416.38
"Fac/Exc Skn Bnig0.6-1cm Fae,Facial",PX11441F,CDM,510,RC,11441,CPT,,,,,,,,606,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,593.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,251.7324,614.65
"Colonoscopy,Flex,Diagnostic",PX45378P,CDM,983,RC,45378,CPT,,,,,,,,1200,,Humana Choice Care,All Medicare plans,outpatient,49.5,,840.1866667,percent of total billed charges,594,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,514.8,4661.91
Level 1 Additional Procedure,PX36000080,CDM,360,RC,,,,,,,,,,1200,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,594,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,498.48,1176
"Genital Surg Proc,Male Unlisted",PX55899F,CDM,510,RC,55899,CPT,,,,,,,,1430,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,594.022,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,215.91,1401.4
I&D Perirectal Abscess,PX46040F,CDM,510,RC,46040,CPT,,,,,,,,1430,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,594.022,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,594.022,1401.4
diazePAM 10 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,93613832,NDC,1,EA,1212.57,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,594.1593,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 10 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,93613832,NDC,1,EA,1212.57,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,594.1593,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 10 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,93613832,NDC,1,EA,1212.57,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,594.1593,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
POWERPORT ISP MRI IMPLANTABLE PORT 8FR,C1788,CDM,278,RC,C1788,HCPCS,,11998-MAIN,LOCAL,,,,,1385,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,594.165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,575.329,1357.3
Anus Surgery Procedure Unlisted,PX46999F,CDM,510,RC,46999,CPT,,,,,,,,1431,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,594.4374,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,594.4374,1402.38
"Fac/Exc Skn Beni1.1-2cm Fce,Facial",PX11442F,CDM,510,RC,11442,CPT,,,,,,,,668,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,594.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,277.4872,654.64
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180P,CDM,983,RC,44180,CPT,,,,,,,,1175,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,594.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,488.095,5040.74
HERNIA MESH LAP PROGRIP SELF FIXATING FLAT SHEET 10X15,C1781,CDM,278,RC,C1781,HCPCS,,12727-MAIN,LOCAL,,,,,611,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1256.29,percent of total billed charges,594.6863,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
sugammadex sodium 200 MG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,6542302,NDC,2,ML,652.81,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,594.70991,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
gadoterate meglumine 10 mmol/20 mL Solution 20 mL Vial,A9575,CDM,636,RC,A9575,HCPCS,,,,67684200003,NDC,20,ML,668.27,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,594.7603,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,277.599358,654.9046
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606F,CDM,510,RC,11606,CPT,,,,,,,,1432,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,594.8528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,594.8528,1416.38
Anal Sphincterotomy,PX46080F,CDM,510,RC,46080,CPT,,,,,,,,607,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,594.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,252.1478,2452.93
Excis Forearm/Wrist Tumor Subcutan,PX25075P,CDM,983,RC,25075,CPT,,,,,,,,607,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,594.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,198.51,1082.67
Open Bx/Excision Inguinofemoral Nodes,PX38531P,CDM,983,RC,38531,CPT,,,,,,,,607,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,594.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,271.37,935.31
CATHETER BIPOLAR ELECTROHEMOSTASIS 7FR 300CM M00560070,27200000,CDM,272,RC,,,,12909-MAIN,LOCAL,,,,,700,,First Health,Commercial,both,85,,999999999,percent of total billed charges,595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"VENTRALIGHT MESH ST WITH ECHO 2 - 10 CM X 15 CM - 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,12007-MAIN,LOCAL,,,,,1176,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,595.056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Colonoscope, Submucous Inj",PX45381P,CDM,983,RC,45381,CPT,,,,,,,,1215,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,595.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,504.711,1182.5595
"Colonoscope, Submucous Inj",PX45381P,CDM,983,RC,45381,CPT,,,,,,,,1215,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,595.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,504.711,1182.5595
"Colonoscope, Submucous Inj",PX45381P,CDM,983,RC,45381,CPT,,,,,,,,1215,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,595.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,504.711,1182.5595
"Colonoscopy,Control Bleeding",PX45382F,CDM,750,RC,45382,CPT,,,,,,,,1215,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,595.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,504.711,1190.7
"Colonoscopy,Control Bleeding",PX45382F,CDM,750,RC,45382,CPT,,,,,,,,1215,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,595.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,504.711,1190.7
"Colonoscopy,Control Bleeding",PX45382F,CDM,750,RC,45382,CPT,,,,,,,,1215,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,595.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,504.711,1190.7
"Igh, Variable Region Somatic Mutation Analysis",PX8126390,CDM,310,RC,81263,CPT,90,,,,,,,1215,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,595.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.05,1190.7
"Igh, Variable Region Somatic Mutation Analysis",PX8126390,CDM,310,RC,81263,CPT,90,,,,,,,1215,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,595.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.05,1190.7
"Igh, Variable Region Somatic Mutation Analysis",PX8126390,CDM,310,RC,81263,CPT,90,,,,,,,1215,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,595.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.05,1190.7
Injection for Shoulder Arthrogram,PX23350F,CDM,510,RC,23350,CPT,,,,,,,,675,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,595.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,280.395,661.5
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151P,CDM,983,RC,13151,CPT,,,,,,,,1177,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,595.562,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,488.9258,1145.5741
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,93598627,NDC,1,EA,1241.11,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,595.7328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,93598627,NDC,1,EA,1241.11,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,595.7328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
Injection Hip Arthrogram,PX27093F,CDM,510,RC,27093,CPT,,,,,,,,654,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,595.794,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,271.6716,640.92
3.0MM HEADED SCREW LENGTH 16MM,C1713,CDM,278,RC,C1713,HCPCS,,12656-MAIN,LOCAL,,,,,608,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,595.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
DRILL BIT 2.2MMX60MM STERILE MICA CANNULATED,27200000,CDM,272,RC,,,,12437-MAIN,LOCAL,,,,,701,,First Health,Commercial,both,85,,999999999,percent of total billed charges,595.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRILL BIT 3.0MMX60MM STERILE MICA CANNULATED,27200000,CDM,272,RC,,,,12438-MAIN,LOCAL,,,,,701,,First Health,Commercial,both,85,,999999999,percent of total billed charges,595.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605F,CDM,510,RC,25605,CPT,,,,,,,,1178,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,596.068,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,489.3412,1404.08
Removal of Anal Tabs,PX46230P,CDM,983,RC,46230,CPT,,,,,,,,1435,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,596.099,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,596.099,2452.93
Direct Admit Hospital Observ,PXG0379,CDM,761,RC,G0379,HCPCS,,,,,,,,676,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,596.232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,280.8104,662.48
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569F,CDM,510,RC,36569,CPT,,,,,,,,1217,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,596.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,505.5418,1399.13
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569F,CDM,510,RC,36569,CPT,,,,,,,,1217,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,596.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,505.5418,1399.13
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569F,CDM,510,RC,36569,CPT,,,,,,,,1217,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,596.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,505.5418,1399.13
oseltamivir 6 MG/ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,68180067801,NDC,60,ML,676.25,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,596.4525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Emergency Level V Visit,PX99285P,CDM,981,RC,99285,CPT,,,,,,,,1436,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,596.5144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,561.13,1397.6588
"Colonoscope, Submucous Inj",PX45381F,CDM,750,RC,45381,CPT,,,,,,,,1179,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,596.574,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,489.7566,1155.42
Trauma Activation,PX68200010,CDM,684,RC,G0390,HCPCS,,,,,,,,1243,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,596.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,516.3422,1218.14
Trauma Activation,PX68200010,CDM,684,RC,G0390,HCPCS,,,,,,,,1243,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,596.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,516.3422,1218.14
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035F,CDM,510,RC,12035,CPT,,,,,,,,655,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,596.705,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,272.087,641.9
Partial Bone Scan,PX7830001,CDM,341,RC,78300,CPT,TC,,,,,,,1391,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,596.739,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,360.31,1363.18
Fac/Cystourethroscopy,PX52000F,CDM,761,RC,52000,CPT,,,,,,,,1601,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,596.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,596.77,1568.98
"Infectious Disease,Chronic Hep C Virus,Six Assays, Utilizing Serum",PX8159690,CDM,300,RC,81596,CPT,90,,,,,,,609,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,596.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.19,596.82
"Upper GI Endoscopy,Diagnosis",PX43235F,CDM,750,RC,43235,CPT,,,,,,,,2539,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,597.02,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.04,597.02
"Upper GI Endoscopy,Diagnosis",PX43235P,CDM,983,RC,43235,CPT,,,,,,,,1406,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,597.02,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.04,1377.88
"Sb Scope,to Ileum,Biopsy",PX44377P,CDM,983,RC,44377,CPT,,,,,,,,1180,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,597.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,490.172,1662.33
HARMONIC 1100 SHEARS 20CM SHAFT HAR1120,27200000,CDM,272,RC,,,,12924-MAIN,LOCAL,,,,,1244,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,597.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HARMONIC 1100 SHEARS 20CM SHAFT HAR1120,27200000,CDM,272,RC,,,,12924-MAIN,LOCAL,,,,,1244,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,597.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
sodium thiosulfate 250 MG/ML Solution 50 mL Vial,J0209.01,CDM,636,RC,J0209,HCPCS,,,,60267070550,NDC,50,ML,609.57,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,597.3786,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,253.215378,597.3786
"Chemotherapy, IV Infusion, 1 Hour",PX96413,CDM,335,RC,96413,CPT,,,,,,,,614,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,343.4821739,percent of total billed charges,597.6062,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.0556,601.72
Repr Superf Wnd Body 7.6-12.5,PX12004P,CDM,983,RC,12004,CPT,,,,,,,,614,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,52.065,percent of total billed charges,597.6062,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,597.6062
Temporary External Pacing,PX92953F,CDM,480,RC,92953,CPT,,,,,,,,678,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,597.996,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,281.6412,664.44
"Molecular Path Proc, Level 2 - Ref",PX8140190,CDM,310,RC,81401,CPT,90,,,,,,,672,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,598.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.62,658.56
GROSHONG PICC NXT 4FR,120.218,CDM,272,RC,,,,498-MAIN,LOCAL,,,,,1182,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,598.092,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,491.0028,1158.36
Bone Marrow Biopsy(Ies),PX38221F,CDM,510,RC,38221,CPT,,,,,,,,1221,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,598.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,507.2034,1416.38
Bone Marrow Biopsy(Ies),PX38221F,CDM,510,RC,38221,CPT,,,,,,,,1221,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,598.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,507.2034,1416.38
Bone Marrow Biopsy(Ies),PX38221F,CDM,510,RC,38221,CPT,,,,,,,,1221,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,598.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,507.2034,1416.38
Anal Sphincterotomy,PX46080F,CDM,510,RC,46080,CPT,,,,,,,,607,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,598.41,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.63,598.41
Anal Sphincterotomy,PX46080P,CDM,983,RC,46080,CPT,,,,,,,,525,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,598.41,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.63,598.41
Insert Emergency Endotrach Airway,PX31500P,CDM,983,RC,31500,CPT,,,,,,,,657,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,598.527,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,639.4581
"Layr Clos Wnd Face,Facial <2.5cm",PX12051P,CDM,983,RC,12051,CPT,,,,,,,,615,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,598.5795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.471,598.5795
Remove Hemorrhoids & Fissure,PX46257P,CDM,983,RC,46257,CPT,,,,,,,,615,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,598.5795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.471,2452.93
HERNIA MESH LAP PROGRIP SELF FIXATING FLAT SHEET 10X15,C1781,CDM,278,RC,C1781,HCPCS,,12727-MAIN,LOCAL,,,,,611,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,598.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Exc Abdom Tum Subfac > 5 Cm,PX22901F,CDM,761,RC,22901,CPT,,,,,,,,1408,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,598.8515,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,403.8,1393.98
Exc Abdom Tum Subfac > 5 Cm,PX22901P,CDM,983,RC,22901,CPT,,,,,,,,938,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,598.8515,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,403.8,1393.98
"Fac/Ex Skn Bngn2.1-3cm Trnk,Arm,Lg",PX11403F,CDM,510,RC,11403,CPT,,,,,,,,679,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,598.878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,282.0566,665.42
"Fac/Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601F,CDM,510,RC,11601,CPT,,,,,,,,673,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,598.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,279.5642,659.54
Reconstruc of Nail Bed W Graft,PX11762F,CDM,510,RC,11762,CPT,,,,,,,,1901,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,599.1,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,117.58,599.1
Skin Sub Graft Trnk/Arm/Leg,PX15271P,CDM,983,RC,15271,CPT,,,,,,,,705,,First Health,Commercial,both,85,,999999999,percent of total billed charges,599.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,292.857,1593.14
"Spinal Puncture,Lumbar,Diagnostic",PX62270P,CDM,983,RC,62270,CPT,,,,,,,,705,,First Health,Commercial,both,85,,999999999,percent of total billed charges,599.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,292.857,686.1765
Temporal Artery Ligatn or Bx,PX37609F,CDM,510,RC,37609,CPT,,,,,,,,705,,First Health,Commercial,both,85,,999999999,percent of total billed charges,599.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,292.857,1416.38
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,310095036,NDC,1,EA,1234.2,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,599.34,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,535.92,639.46
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,310095036,NDC,1,EA,1234.2,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,599.34,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,535.92,639.46
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,70720095036,NDC,1,EA,1234.2,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,599.34,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,535.92,639.46
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,70720095036,NDC,1,EA,1234.2,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,599.34,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,535.92,639.46
OBINutuzumab 1000 MG/40ML Solution 40 mL Vial,J9301.01,CDM,636,RC,J9301,HCPCS,,,,50242007001,NDC,4,ML,1397.15,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,599.37735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.12,1369.207
Pvb Thoracic Single Injection Site W/Img Gid,PX64461P,CDM,983,RC,64461,CPT,,,,,,,,616,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,599.5528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.8864,604.15
Incise Finger Tendon Sheath,PX26055F,CDM,510,RC,26055,CPT,,,,,,,,1398,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,599.742,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,580.7292,1404.08
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010202,NDC,1,EA,680,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,599.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 1 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010101,NDC,1,EA,680,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,599.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010102,NDC,1,EA,680,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,599.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
"Fac/Exc Skn Mal 0.6-1cm Fce,Facial",PX11641F,CDM,510,RC,11641,CPT,,,,,,,,680,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,599.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,282.472,666.4
Observation Initial,PXG0378.03,CDM,762,RC,G0378,HCPCS,,,,,,,,680,,United Healthcare,All Payer,outpatient,88.2,,71.48527778,percent of total billed charges,599.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,282.472,666.4
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565F,CDM,510,RC,25565,CPT,,,,,,,,1250,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,600,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,519.25,1404.08
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565F,CDM,510,RC,25565,CPT,,,,,,,,1250,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,600,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,519.25,1404.08
Closed Rx Elbow Dislocation,PX24600F,CDM,510,RC,24600,CPT,,,,,,,,706,,First Health,Commercial,both,85,,999999999,percent of total billed charges,600.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,691.88
diazePAM 10 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,93613832,NDC,1,EA,1212.57,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,600.22215,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Insert Needle,Intraosseous Infusn",PX36680F,CDM,510,RC,36680,CPT,,,,,,,,659,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,600.349,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,273.7486,645.82
CT Orbit/Ear/Fossa W/O & W/Dye,PX7048201,CDM,350,RC,70482,CPT,TC,,,,,,,1400,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,600.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
Repr Superf Wnd Face 2.6-5,PX12013P,CDM,983,RC,12013,CPT,,,,,,,,681,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,600.642,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,662.8173
Injection for Shoulder Arthrogram,PX23350F,CDM,510,RC,23350,CPT,,,,,,,,675,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,600.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,280.395,661.5
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781324494,NDC,1,EA,1400.9,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,600.9861,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
insulin aspart 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169633910,NDC,3,ML,659.76,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,601.04136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
Art Lower Extremity-Bilat,PX9392501,CDM,921,RC,93925,CPT,TC,,,,,,,1188,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,601.128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,1164.24
Exc Skin Benig >4cm Remaindr Body,PX11426F,CDM,510,RC,11426,CPT,,,,,,,,1227,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,601.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,509.6958,2482.37
Exc Skin Benig >4cm Remaindr Body,PX11426F,CDM,510,RC,11426,CPT,,,,,,,,1227,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,601.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,509.6958,2482.37
Exc Skin Benig >4cm Remaindr Body,PX11426F,CDM,510,RC,11426,CPT,,,,,,,,1227,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,601.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,509.6958,2482.37
"Incis/Drain Scrotum/Testis,Epididym",PX54700F,CDM,510,RC,54700,CPT,,,,,,,,660,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,601.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.164,1779.39
Repair Incis Hernia W Mesh,PX49568P,CDM,983,RC,49568,CPT,,,,,,,,660,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,601.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.164,642.378
Nafcillin Sodium 10 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323033060,NDC,1,EA,617.91,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,601.411803,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Colonoscope, Submucous Inj",PX45381P,CDM,983,RC,45381,CPT,,,,,,,,1215,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,601.425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,504.711,1182.5595
"Colonoscopy,Control Bleeding",PX45382F,CDM,750,RC,45382,CPT,,,,,,,,1215,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,601.425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,504.711,1190.7
"Igh, Variable Region Somatic Mutation Analysis",PX8126390,CDM,310,RC,81263,CPT,90,,,,,,,1215,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,601.425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.05,1190.7
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 15DEGREE 14MM,27200000,CDM,272,RC,,,,12600-MAIN,LOCAL,,,,,1253,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,601.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 15DEGREE 14MM,27200000,CDM,272,RC,,,,12600-MAIN,LOCAL,,,,,1253,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,601.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 45DEGREE 8MM,27200000,CDM,272,RC,,,,12599-MAIN,LOCAL,,,,,1253,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,601.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 45DEGREE 8MM,27200000,CDM,272,RC,,,,12599-MAIN,LOCAL,,,,,1253,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,601.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 45DEGREE 14MM,27200000,CDM,272,RC,,,,12598-MAIN,LOCAL,,,,,1253,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,601.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 45DEGREE 14MM,27200000,CDM,272,RC,,,,12598-MAIN,LOCAL,,,,,1253,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,601.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 15DEGREE 14MM,27200000,CDM,272,RC,,,,12603-MAIN,LOCAL,,,,,1253,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,601.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 15DEGREE 14MM,27200000,CDM,272,RC,,,,12603-MAIN,LOCAL,,,,,1253,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,601.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 45DEGREE 8MM,27200000,CDM,272,RC,,,,12602-MAIN,LOCAL,,,,,1253,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,601.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 45DEGREE 8MM,27200000,CDM,272,RC,,,,12602-MAIN,LOCAL,,,,,1253,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,601.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 45DEGREE 14MM,27200000,CDM,272,RC,,,,12601-MAIN,LOCAL,,,,,1253,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,601.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 45DEGREE 14MM,27200000,CDM,272,RC,,,,12601-MAIN,LOCAL,,,,,1253,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,601.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Fac/Exc Skn Bngn1.1-2cm Remain Bdy,PX11422F,CDM,510,RC,11422,CPT,,,,,,,,618,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,601.4994,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,256.7172,1416.38
Ven Duplex Bilateral,PX9397001,CDM,921,RC,93970,CPT,TC,,,,,,,1189,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,601.634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,1165.22
Direct Admit Hospital Observ,PXG0379,CDM,761,RC,G0379,HCPCS,,,,,,,,676,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,601.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,280.8104,662.48
"Chemotherapy, IV Infusion, 1 Hour",PX96413,CDM,335,RC,96413,CPT,,,,,,,,614,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,601.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.0556,601.72
Repr Superf Wnd Body 7.6-12.5,PX12004P,CDM,983,RC,12004,CPT,,,,,,,,614,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,601.72,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,43.41,601.72
oseltamivir 6 MG/ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,68180067801,NDC,60,ML,676.25,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,601.8625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
filgrastim 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513020991,NDC,0.5,ML,1228.49,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,601.9601,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
filgrastim 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513020991,NDC,0.5,ML,1228.49,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,601.9601,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
filgrastim 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513020991,NDC,0.5,ML,1228.49,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,601.9601,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,16714085701,NDC,1,EA,1403.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,602.1015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
Closed Rx Kneecap Disloc+Anesth,PX27562P,CDM,983,RC,27562,CPT,,,,,,,,1404,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,602.316,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1366.5132
"Remv Foot Foreign Body,Subcutaneous",PX28190P,CDM,983,RC,28190,CPT,,,,,,,,683,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,602.406,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,283.7182,664.7639
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569F,CDM,510,RC,36569,CPT,,,,,,,,1217,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,602.415,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,505.5418,1399.13
Abd Paracentesis W/Imaging(P),PX49083P,CDM,983,RC,49083,CPT,,,,,,,,696,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,602.56,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.45,682.08
Abd Paracentesis W/Imaging(T),PX49083F,CDM,510,RC,49083,CPT,,,,,,,,1006,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,602.56,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.45,602.56
Sigmoidoscope W/Submuc Inj,PX45335F,CDM,750,RC,45335,CPT,,,,,,,,750,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,602.56,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.23,602.56
Sigmoidoscope W/Submuc Inj,PX45335P,CDM,983,RC,45335,CPT,,,,,,,,500,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,602.56,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.23,602.56
"Layr Clos Wnd Face,Facial <2.5cm",PX12051P,CDM,983,RC,12051,CPT,,,,,,,,615,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,602.7,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.45,602.7
Remove Hemorrhoids & Fissure,PX46257P,CDM,983,RC,46257,CPT,,,,,,,,615,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,602.7,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,263.74,870.28
liraglutide 18 MG/3ML solution pen-injector 3 mL Pen,63700001,CDM,250,RC,,,,,,169406012,NDC,3,ML,1405.33,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,602.88657,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Fix Exten Tendon,Dorsum Fingr,Ea",PX26418F,CDM,510,RC,26418,CPT,,,,,,,,1750,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,603.0258,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,409.03,1317.19
Fluoroscopy Guid Needle Plcmt Tc,PX7700201,CDM,320,RC,77002,CPT,TC,,,,,,,662,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,603.082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.9948,648.76
"Upper GI Endoscopy,Diagnosis",PX43235P,CDM,983,RC,43235,CPT,,,,,,,,1406,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,603.174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,603.174,3859.68
Closed Rx IP Jt Dislocation,PX26770F,CDM,510,RC,26770,CPT,,,,,,,,1231,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,603.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1206.38
Closed Rx IP Jt Dislocation,PX26770F,CDM,510,RC,26770,CPT,,,,,,,,1231,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,603.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1206.38
Closed Rx IP Jt Dislocation,PX26770F,CDM,510,RC,26770,CPT,,,,,,,,1231,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,603.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1206.38
"Spinal Puncture,Lumbar,Diagnostic",PX62270F,CDM,510,RC,62270,CPT,,,,,,,,684,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,603.288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,284.1336,670.32
Temporary External Pacing,PX92953F,CDM,480,RC,92953,CPT,,,,,,,,678,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,603.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,281.6412,664.44
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096321,NDC,30,ML,1231.47,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,603.4203,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,511.552638,1206.8406
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096321,NDC,30,ML,1231.47,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,603.4203,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,511.552638,1206.8406
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096321,NDC,30,ML,1231.47,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,603.4203,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,511.552638,1206.8406
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096330,NDC,30,ML,1231.47,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,603.4203,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,511.552638,1206.8406
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096330,NDC,30,ML,1231.47,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,603.4203,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,511.552638,1206.8406
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096330,NDC,30,ML,1231.47,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,603.4203,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,511.552638,1206.8406
"Amputation Metatarsal+Toe,Single",PX28810P,CDM,983,RC,28810,CPT,,,,,,,,620,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,603.446,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,257.548,2827.75
Colonoscopy,PX44388P,CDM,983,RC,44388,CPT,,,,,,,,620,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,603.446,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,257.548,798.45
Pvb Thoracic Single Injection Site W/Img Gid,PX64461P,CDM,983,RC,64461,CPT,,,,,,,,616,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,603.68,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.99,603.68
Exc Abdom Tum Subfac > 5 Cm,PX22901F,CDM,761,RC,22901,CPT,,,,,,,,1408,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,604.032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,584.8832,2482.37
Drain/Inject Med Joint/Brusa W/US Guide,PX20606F,CDM,510,RC,20606,CPT,,,,,,,,387,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,604.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.7598,604.15
Drain/Inject Med Joint/Brusa W/US Guide,PX20606P,CDM,983,RC,20606,CPT,,,,,,,,309,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,604.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.3586,604.15
"Inj,Lumb Epidur,Blood/Clot Patch",PX62273P,CDM,983,RC,62273,CPT,,,,,,,,552,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,604.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,229.3008,604.15
"Inject Nerv Blck,Othr Periph Nerv",PX64450F,CDM,510,RC,64450,CPT,,,,,,,,757,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,604.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,314.4578,741.86
"Inject Nerv Blck,Othr Periph Nerv",PX64450P,CDM,983,RC,64450,CPT,,,,,,,,904,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,604.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,375.5216,879.8632
Injection for Nerve Block,PX64445F,CDM,510,RC,64445,CPT,,,,,,,,385,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,604.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,604.15
Injection for Nerve Block,PX64445P,CDM,983,RC,64445,CPT,,,,,,,,385,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,604.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.929,604.15
Injection for Nerve Block,PX64447F,CDM,510,RC,64447,CPT,,,,,,,,3023,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,604.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,604.15,2962.54
Injection for Nerve Block,PX64447P,CDM,983,RC,64447,CPT,,,,,,,,3892,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,604.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,604.15,3788.0836
Pvb Thoracic Single Injection Site W/Img Gid,PX64461F,CDM,510,RC,64461,CPT,,,,,,,,353,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,604.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,146.6362,604.15
Pvb Thoracic Single Injection Site W/Img Gid,PX64461P,CDM,983,RC,64461,CPT,,,,,,,,616,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,604.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.8864,604.15
"Spinal Punc,Drain,Theraputic",PX62272F,CDM,510,RC,62272,CPT,,,,,,,,450,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,604.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.93,604.15
"Spinal Punc,Drain,Theraputic",PX62272P,CDM,983,RC,62272,CPT,,,,,,,,300,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,604.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,124.62,604.15
"Spinal Puncture,Lumbar,Diagnostic",PX62270F,CDM,510,RC,62270,CPT,,,,,,,,684,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,604.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,284.1336,670.32
"Spinal Puncture,Lumbar,Diagnostic",PX62270P,CDM,983,RC,62270,CPT,,,,,,,,705,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,604.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,292.857,686.1765
"Fac/Ex Skn Bngn2.1-3cm Trnk,Arm,Lg",PX11403F,CDM,510,RC,11403,CPT,,,,,,,,679,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,604.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,282.0566,665.42
CT Soft Tissue Neck W/O Dye,PX7049001,CDM,350,RC,70490,CPT,TC,,,,,,,711,,First Health,Commercial,both,85,,999999999,percent of total billed charges,604.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,1198.67
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423F,CDM,510,RC,11423,CPT,,,,,,,,711,,First Health,Commercial,both,85,,999999999,percent of total billed charges,604.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,295.3494,1416.38
Bone Marrow Biopsy(Ies),PX38221F,CDM,510,RC,38221,CPT,,,,,,,,1221,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,604.395,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,507.2034,1416.38
"Fna Biopsy, W/US Guidance; First Lesion",PX10005P,CDM,983,RC,10005,CPT,,,,,,,,621,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,266.4,percent of total billed charges,604.4193,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,257.9634,614.65
"Excis Tendn/Capsule Lesn,Toes",PX28092F,CDM,510,RC,28092,CPT,,,,,,,,1234,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,604.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,512.6036,1404.08
"Excis Tendn/Capsule Lesn,Toes",PX28092F,CDM,510,RC,28092,CPT,,,,,,,,1234,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,604.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,512.6036,1404.08
"Excis Tendn/Capsule Lesn,Toes",PX28092F,CDM,510,RC,28092,CPT,,,,,,,,1234,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,604.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,512.6036,1404.08
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,310095036,NDC,1,EA,1234.2,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,604.758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,512.68668,1209.516
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,310095036,NDC,1,EA,1234.2,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,604.758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,512.68668,1209.516
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,310095036,NDC,1,EA,1234.2,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,604.758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,512.68668,1209.516
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,70720095036,NDC,1,EA,1234.2,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,604.758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,512.68668,1209.516
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,70720095036,NDC,1,EA,1234.2,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,604.758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,512.68668,1209.516
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,70720095036,NDC,1,EA,1234.2,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,604.758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,512.68668,1209.516
"Exc Skn Bnig >4cmtrnk,Arm,Leg",PX11406P,CDM,983,RC,11406,CPT,,,,,,,,1456,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,604.8224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,604.8224,1417.1248
Xray Cervical Spine 4 or 5 Vws,PX7205001,CDM,320,RC,72050,CPT,TC,,,,,,,664,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,604.904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,650.72
Xray Cervical Spine 6 or More Vws,PX7205201,CDM,320,RC,72052,CPT,TC,,,,,,,664,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,604.904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,650.72
CT Lwr Extremity W/O&W/Dye,PX7370201,CDM,350,RC,73702,CPT,TC,,,,,,,1235,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,605.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
CT Lwr Extremity W/O&W/Dye,PX7370201,CDM,350,RC,73702,CPT,TC,,,,,,,1235,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,605.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
CT Lwr Extremity W/O&W/Dye,PX7370201,CDM,350,RC,73702,CPT,TC,,,,,,,1235,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,605.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010202,NDC,1,EA,680,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,605.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 1 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010101,NDC,1,EA,680,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,605.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010102,NDC,1,EA,680,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,605.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
"Fac/Exc Skn Mal 0.6-1cm Fce,Facial",PX11641F,CDM,510,RC,11641,CPT,,,,,,,,680,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,605.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,282.472,666.4
Observation Initial,PXG0378.03,CDM,762,RC,G0378,HCPCS,,,,,,,,680,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,605.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,282.472,666.4
"Amputation Toe,I-P Jt",PX28825F,CDM,510,RC,28825,CPT,,,,,,,,1327,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,605.33,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.23,605.33
"Amputation Toe,I-P Jt",PX28825P,CDM,983,RC,28825,CPT,,,,,,,,780,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,605.33,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.23,764.4
Nafcillin Sodium 10 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323033060,NDC,1,EA,617.91,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,605.5518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Fac/Exc Skn Bngn1.1-2cm Remain Bdy,PX11422F,CDM,510,RC,11422,CPT,,,,,,,,618,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,605.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,256.7172,1416.38
Tube Thoracostomy Inc Wtr Seal,PX32551P,CDM,983,RC,32551,CPT,,,,,,,,1236,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,605.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,513.4344,1399.13
Tube Thoracostomy Inc Wtr Seal,PX32551P,CDM,983,RC,32551,CPT,,,,,,,,1236,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,605.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,513.4344,1399.13
Tube Thoracostomy Inc Wtr Seal,PX32551P,CDM,983,RC,32551,CPT,,,,,,,,1236,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,605.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,513.4344,1399.13
darbepoetin alfa 40 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002104,NDC,0.4,ML,1411.78,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,605.65362,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
DYNAFORCE MPJ REAMERS CUP/CONE 20MM,27200000,CDM,272,RC,,,,11853-MAIN,LOCAL,,,,,1262,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,605.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNAFORCE MPJ REAMERS CUP/CONE 20MM,27200000,CDM,272,RC,,,,11853-MAIN,LOCAL,,,,,1262,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,605.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
tiotropium 18 MCG capsule 5 Each Box,63700001,CDM,250,RC,,,,,,597007575,NDC,5,EA,665.18,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,605.97898,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Drainage of Gum Lesion,PX41800F,CDM,510,RC,41800,CPT,,,,,,,,395,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,606.02,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.82,606.02
Drainage of Gum Lesion,PX41800P,CDM,983,RC,41800,CPT,,,,,,,,839,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,606.02,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.82,822.22
Repr Superf Wnd Face >30cm,PX12018F,CDM,510,RC,12018,CPT,,,,,,,,713,,First Health,Commercial,both,85,,999999999,percent of total billed charges,606.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,698.74
Repr Superf Wnd Face 2.6-5,PX12013P,CDM,983,RC,12013,CPT,,,,,,,,681,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,606.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,662.8173
"Facility Critical Care, E/M 30-74 Minutes",PX99291F,CDM,510,RC,99291,CPT,,,,,,,,1264,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,606.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,525.0656,1238.72
"Facility Critical Care, E/M 30-74 Minutes",PX99291F,CDM,510,RC,99291,CPT,,,,,,,,1264,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,606.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,525.0656,1238.72
"Cardioversion, Elective;Extern",PX92960P,CDM,983,RC,92960,CPT,,,,,,,,688,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,606.816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,285.7952,669.6304
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031F,CDM,510,RC,12031,CPT,,,,,,,,688,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,606.816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,285.7952,674.24
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,469650189,NDC,5,ML,1264.92,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,607.1616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,424.41418,1239.6216
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,469650189,NDC,5,ML,1264.92,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,607.1616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,424.41418,1239.6216
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004164,NDC,1,EA,666.52,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,607.19972,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
"Colonoscopy,Flex,Diagnostic",PX45378P,CDM,983,RC,45378,CPT,,,,,,,,1200,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,607.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,514.8,4661.91
Level 1 Additional Procedure,PX36000080,CDM,360,RC,,,,,,,,,,1200,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,607.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,498.48,1176
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004110,NDC,1,EA,666.53,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,607.20883,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
Inc/Drain Peritonsil Abscess,PX42700F,CDM,510,RC,42700,CPT,,,,,,,,624,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,607.3392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,611.52
Exc Skin Benig >4cm Remaindr Body,PX11426F,CDM,510,RC,11426,CPT,,,,,,,,1227,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,607.365,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,509.6958,2482.37
"Amputation Metatarsal+Toe,Single",PX28810P,CDM,983,RC,28810,CPT,,,,,,,,620,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,607.6,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.21,881.35
Colonoscopy,PX44388P,CDM,983,RC,44388,CPT,,,,,,,,620,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,607.6,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.89,655.83
"Needle Biopsy, Lymph Node(S)",PX38505F,CDM,510,RC,38505,CPT,,,,,,,,667,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,607.637,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,277.0718,1416.38
Closed Rx Shldr Dislocation,PX23650F,CDM,510,RC,23650,CPT,,,,,,,,689,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,607.698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,675.22
"I&D Perianal Abscess,Superficial",PX46050F,CDM,510,RC,46050,CPT,,,,,,,,1463,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,607.7302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,607.7302,1433.74
CT Abd&Pelv 1+ Section/Regns,PX7417801,CDM,350,RC,74178,CPT,TC,,,,,,,4226,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,607.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4141.48
CT Abdomen&Pelvis W/Contrast,PX7417701,CDM,350,RC,74177,CPT,TC,,,,,,,4288,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,607.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4202.24
CT Angio Abd&Pelv W/O&W/Dye,PX7417401,CDM,350,RC,74174,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,607.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2701.86
CT Lumbar Spine W/Dye,PX7213201,CDM,350,RC,72132,CPT,TC,,,,,,,3330,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,607.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3263.4
CT Upper Extremity W/Dye,PX7320101,CDM,350,RC,73201,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,607.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2701.86
"Mra, Neck W/O+W/ Contrast",PX7054901,CDM,610,RC,70549,CPT,TC,,,,,,,3472,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,607.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3402.56
"Mra, Neck With Contrast",PX7054801,CDM,610,RC,70548,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,607.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI Brain W & WO Contrast,PX7055301,CDM,610,RC,70553,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,607.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI Brain W Contrast Tc,PX7055201,CDM,610,RC,70552,CPT,TC,,,,,,,2637,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,607.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2584.26
MRI C Spine W&WO Contrast,PX7215601,CDM,610,RC,72156,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,607.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI L Spine W Contrast Tc,PX7214901,CDM,610,RC,72149,CPT,TC,,,,,,,5136,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,607.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,5033.28
MRI L Spine W&WO Contrast,PX7215801,CDM,610,RC,72158,CPT,TC,,,,,,,4178,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,607.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4094.44
MRI Lower W/O+W Tc,PX7372001,CDM,610,RC,73720,CPT,TC,,,,,,,3174,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,607.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3110.52
MRI Orb-Fac-Nec W/O+W/Con,PX7054301,CDM,610,RC,70543,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,607.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI Pelvis W/Contrast Tc,PX7219601,CDM,610,RC,72196,CPT,TC,,,,,,,3143,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,607.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3080.14
MRI T Spine W&WO Contrast,PX7215701,CDM,610,RC,72157,CPT,TC,,,,,,,4178,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,607.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4094.44
MRI Upper W/O+W Tc,PX7322001,CDM,610,RC,73220,CPT,TC,,,,,,,3253,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,607.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3187.94
"MRI, Abdomen W/O+ W/Contr",PX7418301,CDM,610,RC,74183,CPT,TC,,,,,,,4116,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,607.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4033.68
"MRI, Pelvis, W/O Then W/",PX7219701,CDM,610,RC,72197,CPT,TC,,,,,,,1612,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,607.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2066.35
"MRI,Lwrext,Jnt W/O+W/Cont",PX7372301,CDM,610,RC,73723,CPT,TC,,,,,,,1850,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,607.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2066.35
"MRI,Lwrext,No Jnt, W/Cont",PX7371901,CDM,610,RC,73719,CPT,TC,,,,,,,3627,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,607.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3554.46
"MRI,Uprext Jnt W/O+W/Cont",PX7322301,CDM,610,RC,73223,CPT,TC,,,,,,,2681,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,607.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2627.38
"Remv Foot Foreign Body,Subcutaneous",PX28190P,CDM,983,RC,28190,CPT,,,,,,,,683,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,607.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,283.7182,664.7639
filgrastim 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513020991,NDC,0.5,ML,1228.49,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,608.10255,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,93598627,NDC,1,EA,1241.11,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,150.5666667,percent of total billed charges,608.1439,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,93598627,NDC,1,EA,1241.11,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,608.1439,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,93598627,NDC,1,EA,1241.11,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,608.1439,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
Facility Emergency Level V Visit,PX99285F,CDM,450,RC,99285,CPT,,,,,,,,1464,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,608.1456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,561.13,1434.72
onabotulinumtoxinA 50 units Recon Soln 1 Each Vial,J0585.03,CDM,636,RC,J0585,HCPCS,,,,23391950,NDC,1,EA,1418.14,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,608.38206,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.51,1389.7772
"Fac/Exc Skn Beni1.1-2cm Fce,Facial",PX11442F,CDM,510,RC,11442,CPT,,,,,,,,668,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,608.548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,277.4872,654.64
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623F,CDM,510,RC,11623,CPT,,,,,,,,690,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,608.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,286.626,1416.38
"Fna Biopsy, W/US Guidance; First Lesion",PX10005P,CDM,983,RC,10005,CPT,,,,,,,,621,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,608.58,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.93,608.58
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390F,CDM,750,RC,45390,CPT,,,,,,,,1419,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,608.751,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,589.4526,2452.93
"Spinal Puncture,Lumbar,Diagnostic",PX62270F,CDM,510,RC,62270,CPT,,,,,,,,684,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,608.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,284.1336,670.32
gadoterate meglumine 10 mmol/20 mL Solution 20 mL Vial,A9575,CDM,636,RC,A9575,HCPCS,,,,67684200003,NDC,20,ML,668.27,,Medica,Commercial,both,91.1,,2.234201835,percent of total billed charges,608.79397,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,277.599358,654.9046
Trauma Activation,PX68200010,CDM,684,RC,G0390,HCPCS,,,,,,,,1243,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,609.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,516.3422,1218.14
Trauma Activation,PX68200010,CDM,684,RC,G0390,HCPCS,,,,,,,,1243,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,609.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,516.3422,1218.14
Trauma Activation,PX68200010,CDM,684,RC,G0390,HCPCS,,,,,,,,1243,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,609.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,516.3422,1218.14
"Removal of Hydrocele,Tunica,Unilat",PX55040P,CDM,983,RC,55040,CPT,,,,,,,,1420,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,609.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,589.868,3022.41
Closed Rx IP Jt Dislocation,PX26770F,CDM,510,RC,26770,CPT,,,,,,,,1231,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,609.345,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1206.38
"Lap,Inguinal Hernia Repr,Initial",PX49650P,CDM,983,RC,49650,CPT,,,,,,,,717,,First Health,Commercial,both,85,,999999999,percent of total billed charges,609.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,297.8418,5040.74
"Sb Scope,to Ileum,Biopsy",PX44377F,CDM,750,RC,44377,CPT,,,,,,,,1770,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,609.48,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,182.81,609.48
"Sb Scope,to Ileum,Biopsy",PX44377F,CDM,750,RC,44377,CPT,,,,,,,,1770,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,609.48,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,182.81,609.48
"Sb Scope,to Ileum,Biopsy",PX44377P,CDM,983,RC,44377,CPT,,,,,,,,1180,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,609.48,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,182.81,1156.4
"Sb Scope,to Ileum,Biopsy",PX44377P,CDM,983,RC,44377,CPT,,,,,,,,1180,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,609.48,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,182.81,1156.4
HARMONIC 1100 SHEARS 20CM SHAFT HAR1120,27200000,CDM,272,RC,,,,12924-MAIN,LOCAL,,,,,1244,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,609.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HARMONIC 1100 SHEARS 20CM SHAFT HAR1120,27200000,CDM,272,RC,,,,12924-MAIN,LOCAL,,,,,1244,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,609.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HARMONIC 1100 SHEARS 20CM SHAFT HAR1120,27200000,CDM,272,RC,,,,12924-MAIN,LOCAL,,,,,1244,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,609.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035P,CDM,983,RC,12035,CPT,,,,,,,,1244,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,609.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1210.7852
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035P,CDM,983,RC,12035,CPT,,,,,,,,1244,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,609.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1210.7852
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035P,CDM,983,RC,12035,CPT,,,,,,,,1244,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,609.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1210.7852
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096321,NDC,30,ML,1231.47,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,609.57765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,511.552638,1206.8406
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096330,NDC,30,ML,1231.47,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,609.57765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,511.552638,1206.8406
moxifloxacin 0.5 % Solution 3 mL Bottle,25000000,CDM,250,RC,,,,,,60505058204,NDC,3,ML,691.15,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,609.5943,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Closed Rx Shldr Disloc,Anesthesia",PX23655P,CDM,983,RC,23655,CPT,,,,,,,,1421,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,609.609,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,590.2834,1404.08
Excis Forearm/Wrist Tumor Subcutan,PX25075F,CDM,510,RC,25075,CPT,,,,,,,,1421,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,609.609,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,590.2834,1416.38
filgrastim-ayow 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,800000,CDM,,,,,,,,70121157001,NDC,0.5,ML,691.62,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,610.00884,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604P,CDM,983,RC,11604,CPT,,,,,,,,1422,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,610.038,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,590.6988,1384.0326
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591P,CDM,982,RC,49591,CPT,,,,,,,,1245,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,610.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,517.173,3022.41
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591P,CDM,982,RC,49591,CPT,,,,,,,,1245,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,610.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,517.173,3022.41
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591P,CDM,982,RC,49591,CPT,,,,,,,,1245,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,610.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,517.173,3022.41
Art Upper Extremity-Ltd,PX9393101,CDM,921,RC,93931,CPT,TC,,,,,,,718,,First Health,Commercial,both,85,,999999999,percent of total billed charges,610.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,703.64
"Removal Anal Fistula,Subcutaneous",PX46270F,CDM,510,RC,46270,CPT,,,,,,,,1470,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,610.638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,610.638,2452.93
"Excis Tendn/Capsule Lesn,Toes",PX28092F,CDM,510,RC,28092,CPT,,,,,,,,1234,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,610.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,512.6036,1404.08
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,310095036,NDC,1,EA,1234.2,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,610.929,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,512.68668,1209.516
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,70720095036,NDC,1,EA,1234.2,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,610.929,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,512.68668,1209.516
"MRI,Upr Ext, Joint,W/Cont",PX7322201,CDM,610,RC,73222,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,611.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,611.05,3470.18
"Closed Rx I-P Jt,Toe Dislocation",PX28660P,CDM,983,RC,28660,CPT,,,,,,,,628,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,611.2324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,611.2324
Exc Face Les Sc < 2 Cm,PX21011P,CDM,983,RC,21011,CPT,,,,,,,,628,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,611.2324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,260.8712,1416.38
CT Lwr Extremity W/O&W/Dye,PX7370201,CDM,350,RC,73702,CPT,TC,,,,,,,1235,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,611.325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
Inc/Drain Peritonsil Abscess,PX42700F,CDM,510,RC,42700,CPT,,,,,,,,624,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,611.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,611.52
Tube Thoracostomy Inc Wtr Seal,PX32551P,CDM,983,RC,32551,CPT,,,,,,,,1236,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,611.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,513.4344,1399.13
"Lap,Cholecystectomy",PX47562F,CDM,510,RC,47562,CPT,,,,,,,,1473,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,611.8842,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,611.8842,5040.74
"Sigmoidoscopy,Diagnostic",PX45330F,CDM,510,RC,45330,CPT,,,,,,,,720,,First Health,Commercial,both,85,,999999999,percent of total billed charges,612,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,299.088,798.45
"Molecular Path Proc, Level 2 - Ref",PX8140190,CDM,310,RC,81401,CPT,90,,,,,,,672,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,612.192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.62,658.56
Removal of Nail Bed,PX11750F,CDM,510,RC,11750,CPT,,,,,,,,629,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,612.2057,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,261.2866,616.42
"Cardioversion, Elective;Extern",PX92960P,CDM,983,RC,92960,CPT,,,,,,,,688,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,612.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,285.7952,669.6304
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031F,CDM,510,RC,12031,CPT,,,,,,,,688,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,612.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,285.7952,674.24
insulin aspart prot & aspart 70-30 (70-30) 100 UNIT/ML Suspension Pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169369619,NDC,3,ML,629.28,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,4.0055,percent of total billed charges,612.478224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565F,CDM,510,RC,25565,CPT,,,,,,,,1250,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,612.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,519.25,1404.08
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565F,CDM,510,RC,25565,CPT,,,,,,,,1250,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,612.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,519.25,1404.08
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565F,CDM,510,RC,25565,CPT,,,,,,,,1250,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,612.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,519.25,1404.08
CT Angio Abdominal Arteries,PX7563501,CDM,350,RC,75635,CPT,TC,,,,,,,2936,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,612.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.11,612.7
CT Angio Abdominal Arteries,PX7563501,CDM,350,RC,75635,CPT,TC,,,,,,,2936,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,612.7,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.11,612.7
"Repair Flex Foot Tendon,Ea",PX28200F,CDM,510,RC,28200,CPT,,,,,,,,1475,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,612.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,612.715,2827.75
"Remv Foreign Body,Knee/Thigh,Deep",PX27372F,CDM,510,RC,27372,CPT,,,,,,,,1429,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,613.041,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,593.6066,2482.37
"Fac/Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601F,CDM,510,RC,11601,CPT,,,,,,,,673,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,613.103,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,279.5642,659.54
"Infect, Organ, Amp Probe - Ref",PX8780190,CDM,300,RC,87801,CPT,90,,,,,,,630,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,613.179,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.37,617.4
MESH XLARGE LEFT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 5X7,120.524,CDM,278,RC,C1781,HCPCS,,12216-MAIN,LOCAL,,,,,630,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1256.29,percent of total billed charges,613.179,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,261.702,617.4
MESH XLARGE RIGHT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 5X7,120.524,CDM,278,RC,C1781,HCPCS,,12217-MAIN,LOCAL,,,,,630,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1256.29,percent of total billed charges,613.179,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,261.702,617.4
Closed Rx Shldr Dislocation,PX23650F,CDM,510,RC,23650,CPT,,,,,,,,689,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,613.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,675.22
"Genital Surg Proc,Male Unlisted",PX55899F,CDM,510,RC,55899,CPT,,,,,,,,1430,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,613.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,215.91,1401.4
I&D Perirectal Abscess,PX46040F,CDM,510,RC,46040,CPT,,,,,,,,1430,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,613.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,594.022,1401.4
diazePAM 10 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,93613832,NDC,1,EA,1212.57,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,613.56042,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Abd Paracentesis W/Imaging(P),PX49083P,CDM,983,RC,49083,CPT,,,,,,,,696,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,613.872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.1184,791.92
Anus Surgery Procedure Unlisted,PX46999F,CDM,510,RC,46999,CPT,,,,,,,,1431,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,613.899,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,594.4374,1402.38
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 15DEGREE 14MM,27200000,CDM,272,RC,,,,12600-MAIN,LOCAL,,,,,1253,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,613.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 15DEGREE 14MM,27200000,CDM,272,RC,,,,12600-MAIN,LOCAL,,,,,1253,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,613.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 15DEGREE 14MM,27200000,CDM,272,RC,,,,12600-MAIN,LOCAL,,,,,1253,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,613.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 45DEGREE 8MM,27200000,CDM,272,RC,,,,12599-MAIN,LOCAL,,,,,1253,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,613.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 45DEGREE 8MM,27200000,CDM,272,RC,,,,12599-MAIN,LOCAL,,,,,1253,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,613.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 45DEGREE 8MM,27200000,CDM,272,RC,,,,12599-MAIN,LOCAL,,,,,1253,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,613.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 45DEGREE 14MM,27200000,CDM,272,RC,,,,12598-MAIN,LOCAL,,,,,1253,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,613.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 45DEGREE 14MM,27200000,CDM,272,RC,,,,12598-MAIN,LOCAL,,,,,1253,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,613.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 45DEGREE 14MM,27200000,CDM,272,RC,,,,12598-MAIN,LOCAL,,,,,1253,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,613.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 15DEGREE 14MM,27200000,CDM,272,RC,,,,12603-MAIN,LOCAL,,,,,1253,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,613.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 15DEGREE 14MM,27200000,CDM,272,RC,,,,12603-MAIN,LOCAL,,,,,1253,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,613.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 15DEGREE 14MM,27200000,CDM,272,RC,,,,12603-MAIN,LOCAL,,,,,1253,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,613.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 45DEGREE 8MM,27200000,CDM,272,RC,,,,12602-MAIN,LOCAL,,,,,1253,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,613.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 45DEGREE 8MM,27200000,CDM,272,RC,,,,12602-MAIN,LOCAL,,,,,1253,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,613.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 45DEGREE 8MM,27200000,CDM,272,RC,,,,12602-MAIN,LOCAL,,,,,1253,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,613.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 45DEGREE 14MM,27200000,CDM,272,RC,,,,12601-MAIN,LOCAL,,,,,1253,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,613.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 45DEGREE 14MM,27200000,CDM,272,RC,,,,12601-MAIN,LOCAL,,,,,1253,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,613.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 45DEGREE 14MM,27200000,CDM,272,RC,,,,12601-MAIN,LOCAL,,,,,1253,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,613.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623F,CDM,510,RC,11623,CPT,,,,,,,,690,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,614.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,286.626,1416.38
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606F,CDM,510,RC,11606,CPT,,,,,,,,1432,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,614.328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,594.8528,1416.38
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,93598627,NDC,1,EA,1241.11,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,614.34945,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
"Biopsy, Nail Unit",PX11755F,CDM,510,RC,11755,CPT,,,,,,,,1490,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,614.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,614.65,1460.2
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800F,CDM,510,RC,40800,CPT,,,,,,,,255,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,614.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,105.927,614.65
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800P,CDM,983,RC,40800,CPT,,,,,,,,170,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,614.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.618,614.65
Drain Pilonidal Cyst Simpl,PX10080F,CDM,510,RC,10080,CPT,,,,,,,,742,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,614.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,308.2268,727.16
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402F,CDM,510,RC,11402,CPT,,,,,,,,424,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,614.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.1296,614.65
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402P,CDM,983,RC,11402,CPT,,,,,,,,424,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,614.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,176.1296,614.65
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604F,CDM,510,RC,11604,CPT,,,,,,,,964,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,614.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,400.4456,944.72
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604P,CDM,983,RC,11604,CPT,,,,,,,,1422,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,614.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,590.6988,1384.0326
"Exc Skn Beig1.1-2cm Face,Facil",PX11442P,CDM,983,RC,11442,CPT,,,,,,,,886,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,614.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,368.0444,862.3438
Exc Skn Beni 0.6-1cm Fcefacial,PX11441P,CDM,983,RC,11441,CPT,,,,,,,,485,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,614.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.469,614.65
"Exc Skn Benig<5mm Face,Facial",PX11440P,CDM,983,RC,11440,CPT,,,,,,,,387,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,614.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.7598,614.65
"Exc Skn Bngn2.1-3cmtrnk,Arm,Lg",PX11403P,CDM,983,RC,11403,CPT,,,,,,,,543,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,614.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,225.5622,614.65
Exc Skn Bnig0.6-1cm Remain Bdy,PX11421P,CDM,983,RC,11421,CPT,,,,,,,,345,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,614.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,143.313,614.65
"Exc Skn Mal 0.6-1cm Fce,Facial",PX11641P,CDM,983,RC,11641,CPT,,,,,,,,453,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,614.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.1762,614.65
"Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601P,CDM,983,RC,11601,CPT,,,,,,,,1046,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,614.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,434.5084,1018.0718
"Exc Skn Mal 2.1-3cmtrnk,Arm,Lg",PX11603P,CDM,983,RC,11603,CPT,,,,,,,,1276,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,614.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,530.0504,1241.9308
"Exc Skn Malig1.1-2cm Fce,Facal",PX11642P,CDM,983,RC,11642,CPT,,,,,,,,466,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,614.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,193.5764,614.65
"Fac/Ex Skn Bngn2.1-3cm Trnk,Arm,Lg",PX11403F,CDM,510,RC,11403,CPT,,,,,,,,679,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,614.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,282.0566,665.42
Fac/Exc Skn Beni 0.6-1cm Remain Bdy,PX11421F,CDM,510,RC,11421,CPT,,,,,,,,931,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,614.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.7374,912.38
"Fac/Exc Skn Beni1.1-2cm Fce,Facial",PX11442F,CDM,510,RC,11442,CPT,,,,,,,,668,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,614.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,277.4872,654.64
"Fac/Exc Skn Benig<5mm Face,Facial",PX11440F,CDM,510,RC,11440,CPT,,,,,,,,484,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,614.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,201.0536,614.65
"Fac/Exc Skn Bnig0.6-1cm Fae,Facial",PX11441F,CDM,510,RC,11441,CPT,,,,,,,,606,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,614.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,251.7324,614.65
"Fac/Exc Skn Mal 0.6-1cm Fce,Facial",PX11641F,CDM,510,RC,11641,CPT,,,,,,,,680,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,614.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,282.472,666.4
"Fac/Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601F,CDM,510,RC,11601,CPT,,,,,,,,673,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,614.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,279.5642,659.54
"Fac/Exc Skn Mali2.1-3cmtrnk,Arm,Lg",PX11603F,CDM,510,RC,11603,CPT,,,,,,,,875,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,614.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.475,857.5
"Fac/Exc Skn Malig .1-2cm Fce,Facal",PX11642F,CDM,510,RC,11642,CPT,,,,,,,,698,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,614.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.9492,684.04
"Fna Biopsy, W/US Guidance; First Lesion",PX10005F,CDM,510,RC,10005,CPT,,,,,,,,333,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,614.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.3282,614.65
"Fna Biopsy, W/US Guidance; First Lesion",PX10005P,CDM,983,RC,10005,CPT,,,,,,,,621,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,614.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,257.9634,614.65
"Remv Foot Foreign Body,Subcutaneous",PX28190F,CDM,510,RC,28190,CPT,,,,,,,,1025,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,614.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,425.785,1004.5
"Remv Foot Foreign Body,Subcutaneous",PX28190P,CDM,983,RC,28190,CPT,,,,,,,,683,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,614.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,283.7182,664.7639
REVITA PLACENTAL MEMBRANE 2X3CM 6SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12559-MAIN,LOCAL,,,,,2474,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,614.65,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,265.9,614.65
REVITA PLACENTAL MEMBRANE 4X4CM 16SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12560-MAIN,LOCAL,,,,,6597,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,614.65,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,265.9,614.65
REVITA PLACENTAL MEMBRANE 4X6CM 24SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12561-MAIN,LOCAL,,,,,9896,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,614.65,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,265.9,614.65
REVITA PLACENTAL MEMBRANE 6X6CM 36SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12562-MAIN,LOCAL,,,,,14844,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,614.65,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,265.9,614.65
REVITA PLACENTAL MEMBRANE 6X8CM 48SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12563-MAIN,LOCAL,,,,,19792,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,614.65,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,265.9,614.65
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,70839036204,NDC,4,ML,1280.66,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,614.7168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,70839036204,NDC,4,ML,1280.66,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,614.7168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
Ligation of Hemorrhoid(S),PX46221P,CDM,983,RC,46221,CPT,,,,,,,,697,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,614.754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.5338,798.45
STAPLER INTERNAL POWERED 29MM CURVED CIRCULAR,27200000,CDM,272,RC,,,,12024-MAIN,LOCAL,,,,,697,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,614.754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STAPLER INTERNAL POWERED 31MM CURVED CIRCULAR,27200000,CDM,272,RC,,,,12025-MAIN,LOCAL,,,,,697,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,614.754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Colonoscope, Submucous Inj",PX45381P,CDM,983,RC,45381,CPT,,,,,,,,1215,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,614.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,504.711,1182.5595
"Colonoscopy,Control Bleeding",PX45382F,CDM,750,RC,45382,CPT,,,,,,,,1215,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,614.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,504.711,1190.7
"Igh, Variable Region Somatic Mutation Analysis",PX8126390,CDM,310,RC,81263,CPT,90,,,,,,,1215,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,614.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.05,1190.7
Injection for Shoulder Arthrogram,PX23350F,CDM,510,RC,23350,CPT,,,,,,,,675,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,614.925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,280.395,661.5
"Amputation Toe,Mt-P Jt",PX28820F,CDM,510,RC,28820,CPT,,,,,,,,1950,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,615.01,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.51,615.01
"Amputation Toe,Mt-P Jt",PX28820P,CDM,983,RC,28820,CPT,,,,,,,,1300,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,615.01,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.51,1274
brimonidine 0.15 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314014405,NDC,5,ML,723.62,,First Health,Commercial,both,85,,999999999,percent of total billed charges,615.077,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
moxifloxacin 0.5 % Solution 3 mL Bottle,25000000,CDM,250,RC,,,,,,60505058204,NDC,3,ML,691.15,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,615.1235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Closure Superf Wnd Dehis Simple,PX12020F,CDM,510,RC,12020,CPT,,,,,,,,632,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,615.1256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.5328,619.36
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121P,CDM,983,RC,13121,CPT,,,,,,,,632,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,615.1256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.5328,615.1256
Trauma Activation,PX68200010,CDM,684,RC,G0390,HCPCS,,,,,,,,1243,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,615.285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,516.3422,1218.14
"Closed Rx I-P Jt,Toe Dislocation",PX28660P,CDM,983,RC,28660,CPT,,,,,,,,628,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,615.44,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.24,615.44
Exc Face Les Sc < 2 Cm,PX21011P,CDM,983,RC,21011,CPT,,,,,,,,628,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,615.44,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,164.48,781.73
filgrastim-ayow 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,800000,CDM,,,,,,,,70121157001,NDC,0.5,ML,691.62,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,615.5418,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Removal of Anal Tabs,PX46230P,CDM,983,RC,46230,CPT,,,,,,,,1435,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,615.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,596.099,2452.93
"Fac/Exc Skn Malig .1-2cm Fce,Facal",PX11642F,CDM,510,RC,11642,CPT,,,,,,,,698,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,615.636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.9492,684.04
HARMONIC 1100 SHEARS 20CM SHAFT HAR1120,27200000,CDM,272,RC,,,,12924-MAIN,LOCAL,,,,,1244,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,615.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035P,CDM,983,RC,12035,CPT,,,,,,,,1244,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,615.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1210.7852
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569F,CDM,510,RC,36569,CPT,,,,,,,,1217,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,615.802,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,505.5418,1399.13
Direct Admit Hospital Observ,PXG0379,CDM,761,RC,G0379,HCPCS,,,,,,,,676,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,615.836,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,280.8104,662.48
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384P,CDM,983,RC,45384,CPT,,,,,,,,1436,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,616.044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,616.044,4050.42
Emergency Level V Visit,PX99285P,CDM,981,RC,99285,CPT,,,,,,,,1436,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,616.044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,561.13,1397.6588
oseltamivir 6 MG/ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,68180067801,NDC,60,ML,676.25,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,616.06375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591P,CDM,982,RC,49591,CPT,,,,,,,,1245,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,616.275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,517.173,3022.41
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623F,CDM,510,RC,11623,CPT,,,,,,,,690,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,616.39,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.89,616.39
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623P,CDM,983,RC,11623,CPT,,,,,,,,460,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,616.39,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,130.89,616.39
Removal of Nail Bed,PX11750F,CDM,510,RC,11750,CPT,,,,,,,,629,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,616.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,261.2866,616.42
Irrad/Lr Platelets,PXP9037,CDM,390,RC,P9037,HCPCS,,,,,,,,1617,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,616.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,616.6,1584.66
insulin aspart prot & aspart 70-30 (70-30) 100 UNIT/ML Suspension Pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169369619,NDC,3,ML,629.28,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,616.6944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
Drainage Scrotal Wall Abscess,PX55100F,CDM,510,RC,55100,CPT,,,,,,,,634,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,617.0722,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,263.3636,1416.38
"Colonoscopy,Flex,Diagnostic",PX45378F,CDM,750,RC,45378,CPT,,,,,,,,1286,,Health Partners,Health Partners Care Plans,both,48,,862.22,percent of total billed charges,617.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,551.694,4661.91
"Colonoscopy,Flex,Diagnostic",PX45378F,CDM,750,RC,45378,CPT,,,,,,,,1286,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,617.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,551.694,4661.91
Low Dose CT Lung Ca Screen WO Contrast,PX7127101,CDM,350,RC,71271,CPT,TC,,,,,,,1286,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,617.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,1260.28
Low Dose CT Lung Ca Screen WO Contrast,PX7127101,CDM,350,RC,71271,CPT,TC,,,,,,,1286,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,617.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,1260.28
CATHETER BIPOLAR ELECTROHEMOSTASIS 7FR 300CM M00560070,27200000,CDM,272,RC,,,,12909-MAIN,LOCAL,,,,,700,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,617.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Close Rx Dist Fingr Fx,Manipulatn",PX26755P,CDM,983,RC,26755,CPT,,,,,,,,1260,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,617.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1226.358
"Close Rx Dist Fingr Fx,Manipulatn",PX26755P,CDM,983,RC,26755,CPT,,,,,,,,1260,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,617.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1226.358
"Close Rx Dist Fingr Fx,Manipulatn",PX26755P,CDM,983,RC,26755,CPT,,,,,,,,1260,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,617.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1226.358
"Infect, Organ, Amp Probe - Ref",PX8780190,CDM,300,RC,87801,CPT,90,,,,,,,630,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,617.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,64.37,617.4
Lap Rpr Vent Umbilical Hernia,PX49652P,CDM,983,RC,49652,CPT,,,,,,,,1260,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,617.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,523.404,1226.358
Lap Rpr Vent Umbilical Hernia,PX49652P,CDM,983,RC,49652,CPT,,,,,,,,1260,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,617.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,523.404,1226.358
Lap Rpr Vent Umbilical Hernia,PX49652P,CDM,983,RC,49652,CPT,,,,,,,,1260,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,617.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,523.404,1226.358
MESH XLARGE LEFT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 5X7,120.524,CDM,278,RC,C1781,HCPCS,,12216-MAIN,LOCAL,,,,,630,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,617.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,261.702,617.4
MESH XLARGE RIGHT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 5X7,120.524,CDM,278,RC,C1781,HCPCS,,12217-MAIN,LOCAL,,,,,630,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,617.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,261.702,617.4
Temporary External Pacing,PX92953F,CDM,480,RC,92953,CPT,,,,,,,,678,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,617.658,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,281.6412,664.44
Bone Marrow Biopsy(Ies),PX38221F,CDM,510,RC,38221,CPT,,,,,,,,1221,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,617.826,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,507.2034,1416.38
diazePAM 2.5 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,66490065020,NDC,1,EA,1288,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,618.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2.5 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,66490065020,NDC,1,EA,1288,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,618.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DRILL BIT 2.2MMX60MM STERILE MICA CANNULATED,27200000,CDM,272,RC,,,,12437-MAIN,LOCAL,,,,,701,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,618.282,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRILL BIT 3.0MMX60MM STERILE MICA CANNULATED,27200000,CDM,272,RC,,,,12438-MAIN,LOCAL,,,,,701,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,618.282,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNAFORCE MPJ REAMERS CUP/CONE 20MM,27200000,CDM,272,RC,,,,11853-MAIN,LOCAL,,,,,1262,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,618.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNAFORCE MPJ REAMERS CUP/CONE 20MM,27200000,CDM,272,RC,,,,11853-MAIN,LOCAL,,,,,1262,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,618.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNAFORCE MPJ REAMERS CUP/CONE 20MM,27200000,CDM,272,RC,,,,11853-MAIN,LOCAL,,,,,1262,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,618.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Fac/Ex Skn Bngn2.1-3cm Trnk,Arm,Lg",PX11403F,CDM,510,RC,11403,CPT,,,,,,,,679,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,618.569,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,282.0566,665.42
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565F,CDM,510,RC,25565,CPT,,,,,,,,1250,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,618.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,519.25,1404.08
"Biopsy, Nail Unit",PX11755F,CDM,510,RC,11755,CPT,,,,,,,,1490,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,618.946,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,614.65,1460.2
INSTRUMENT PACKAGE TOEMATE,27200000,CDM,272,RC,,,,11858-MAIN,LOCAL,,,,,636,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,619.0188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSTRUMENT TOEMATE X-SMALL PACKAGE 9H00-T060,27200000,CDM,272,RC,C1713,HCPCS,,11575-MAIN,LOCAL,,,,,636,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,619.0188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ADVANCED INSTRUMENTS 8MM SYNCHROSEAL IS4000,27200000,CDM,272,RC,,,,11924-MAIN,LOCAL,,,,,1290,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,619.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ADVANCED INSTRUMENTS 8MM SYNCHROSEAL IS4000,27200000,CDM,272,RC,,,,11924-MAIN,LOCAL,,,,,1290,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,619.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Closure Superf Wnd Dehis Simple,PX12020F,CDM,510,RC,12020,CPT,,,,,,,,632,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,619.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.5328,619.36
"Facility Critical Care, E/M 30-74 Minutes",PX99291F,CDM,510,RC,99291,CPT,,,,,,,,1264,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,293.09125,percent of total billed charges,619.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,525.0656,1238.72
"Facility Critical Care, E/M 30-74 Minutes",PX99291F,CDM,510,RC,99291,CPT,,,,,,,,1264,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,619.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,525.0656,1238.72
"Facility Critical Care, E/M 30-74 Minutes",PX99291F,CDM,510,RC,99291,CPT,,,,,,,,1264,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,619.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,525.0656,1238.72
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121P,CDM,983,RC,13121,CPT,,,,,,,,632,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,619.36,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,161,882.74
Abd Paracentesis W/Imaging(P),PX49083P,CDM,983,RC,49083,CPT,,,,,,,,696,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,619.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.1184,791.92
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010202,NDC,1,EA,680,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,619.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 1 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010101,NDC,1,EA,680,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,619.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010102,NDC,1,EA,680,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,619.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
"Fac/Exc Skn Mal 0.6-1cm Fce,Facial",PX11641F,CDM,510,RC,11641,CPT,,,,,,,,680,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,619.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,282.472,666.4
Observation Initial,PXG0378.03,CDM,762,RC,G0378,HCPCS,,,,,,,,680,,Medica,Commercial,both,91.1,,11.65186441,percent of total billed charges,619.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,282.472,666.4
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,469650189,NDC,5,ML,1264.92,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,63.2475,percent of total billed charges,619.8108,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,424.41418,1239.6216
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,469650189,NDC,5,ML,1264.92,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,619.8108,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,424.41418,1239.6216
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,469650189,NDC,5,ML,1264.92,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,619.8108,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,424.41418,1239.6216
Insert Emergency Endotrach Airway,PX31500F,CDM,510,RC,31500,CPT,,,,,,,,637,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,283.315,percent of total billed charges,619.9921,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,624.26
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 15DEGREE 14MM,27200000,CDM,272,RC,,,,12600-MAIN,LOCAL,,,,,1253,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,620.235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 45DEGREE 8MM,27200000,CDM,272,RC,,,,12599-MAIN,LOCAL,,,,,1253,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,620.235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 45DEGREE 14MM,27200000,CDM,272,RC,,,,12598-MAIN,LOCAL,,,,,1253,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,620.235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 15DEGREE 14MM,27200000,CDM,272,RC,,,,12603-MAIN,LOCAL,,,,,1253,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,620.235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 45DEGREE 8MM,27200000,CDM,272,RC,,,,12602-MAIN,LOCAL,,,,,1253,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,620.235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 45DEGREE 14MM,27200000,CDM,272,RC,,,,12601-MAIN,LOCAL,,,,,1253,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,620.235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Ligation of Hemorrhoid(S),PX46221P,CDM,983,RC,46221,CPT,,,,,,,,697,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,620.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.5338,798.45
STAPLER INTERNAL POWERED 29MM CURVED CIRCULAR,27200000,CDM,272,RC,,,,12024-MAIN,LOCAL,,,,,697,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,620.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STAPLER INTERNAL POWERED 31MM CURVED CIRCULAR,27200000,CDM,272,RC,,,,12025-MAIN,LOCAL,,,,,697,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,620.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Repr Superf Wnd Face 2.6-5,PX12013P,CDM,983,RC,12013,CPT,,,,,,,,681,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,620.391,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,662.8173
"Sigmoidoscopy,Remv Lesn,Snare",PX45338F,CDM,510,RC,45338,CPT,,,,,,,,2137,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,620.54,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.52,620.54
"Sigmoidoscopy,Remv Lesn,Snare",PX45338P,CDM,983,RC,45338,CPT,,,,,,,,1710,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,620.54,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.52,1675.8
Exc Skin Benig >4cm Remaindr Body,PX11426F,CDM,510,RC,11426,CPT,,,,,,,,1227,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,620.862,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,509.6958,2482.37
"Fac/Exc Skn Malig .1-2cm Fce,Facal",PX11642F,CDM,510,RC,11642,CPT,,,,,,,,698,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,621.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.9492,684.04
Incise Finger Tendon Sheath,PX26055F,CDM,510,RC,26055,CPT,,,,,,,,1398,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,621.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.74,1232.1
Incise Finger Tendon Sheath,PX26055P,CDM,983,RC,26055,CPT,,,,,,,,932,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,621.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.74,1232.1
Drainage Scrotal Wall Abscess,PX55100F,CDM,510,RC,55100,CPT,,,,,,,,634,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,621.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,263.3636,1416.38
"Fac/Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602F,CDM,510,RC,11602,CPT,,,,,,,,731,,First Health,Commercial,both,85,,999999999,percent of total billed charges,621.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,303.6574,716.38
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,45963061959,NDC,1,EA,638.4,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,621.35472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
filgrastim 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513020991,NDC,0.5,ML,1228.49,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,621.61594,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
Skin Sub Graft Trnk/Arm/Leg,PX15271P,CDM,983,RC,15271,CPT,,,,,,,,705,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,621.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,292.857,1593.14
"Spinal Puncture,Lumbar,Diagnostic",PX62270P,CDM,983,RC,62270,CPT,,,,,,,,705,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,621.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,292.857,686.1765
Temporal Artery Ligatn or Bx,PX37609F,CDM,510,RC,37609,CPT,,,,,,,,705,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,621.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,292.857,1416.38
"Remv Foot Foreign Body,Subcutaneous",PX28190P,CDM,983,RC,28190,CPT,,,,,,,,683,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,622.213,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,283.7182,664.7639
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132F,CDM,510,RC,13132,CPT,,,,,,,,1159,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,622.62,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.92,976.82
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132P,CDM,983,RC,13132,CPT,,,,,,,,774,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,622.62,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.92,976.82
Closed Rx Elbow Dislocation,PX24600F,CDM,510,RC,24600,CPT,,,,,,,,706,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,622.692,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,691.88
Closed Rx IP Jt Dislocation,PX26770F,CDM,510,RC,26770,CPT,,,,,,,,1231,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,622.886,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1206.38
CATHETER BIPOLAR ELECTROHEMOSTASIS 7FR 300CM M00560070,27200000,CDM,272,RC,,,,12909-MAIN,LOCAL,,,,,700,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,623,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Level 2 Additional Procedure,PX36000081,CDM,360,RC,,,,,,,,,,1500,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,623.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,623.1,1470
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096321,NDC,30,ML,1231.47,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,623.12382,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,511.552638,1206.8406
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096330,NDC,30,ML,1231.47,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,623.12382,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,511.552638,1206.8406
"Spinal Puncture,Lumbar,Diagnostic",PX62270F,CDM,510,RC,62270,CPT,,,,,,,,684,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,623.124,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,284.1336,670.32
INSTRUMENT PACKAGE TOEMATE,27200000,CDM,272,RC,,,,11858-MAIN,LOCAL,,,,,636,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,623.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
INSTRUMENT TOEMATE X-SMALL PACKAGE 9H00-T060,27200000,CDM,272,RC,C1713,HCPCS,,11575-MAIN,LOCAL,,,,,636,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,623.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Close Rx Dist Fingr Fx,Manipulatn",PX26755P,CDM,983,RC,26755,CPT,,,,,,,,1260,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,623.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1226.358
Lap Rpr Vent Umbilical Hernia,PX49652P,CDM,983,RC,49652,CPT,,,,,,,,1260,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,623.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,523.404,1226.358
DRILL BIT 2.2MMX60MM STERILE MICA CANNULATED,27200000,CDM,272,RC,,,,12437-MAIN,LOCAL,,,,,701,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,623.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRILL BIT 3.0MMX60MM STERILE MICA CANNULATED,27200000,CDM,272,RC,,,,12438-MAIN,LOCAL,,,,,701,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,623.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Jak2 Gene - Ref,PX8127090,CDM,300,RC,81270,CPT,90,,,,,,,734,,First Health,Commercial,both,85,,999999999,percent of total billed charges,623.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.04,719.32
Closed Rx Metacarpal Fx,PX26600F,CDM,510,RC,26600,CPT,,,,,,,,443,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,624,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,187.83,655.13
Closed Rx Metacarpal Fx,PX26600P,CDM,983,RC,26600,CPT,,,,,,,,295,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,624,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,187.83,655.13
Insert Emergency Endotrach Airway,PX31500F,CDM,510,RC,31500,CPT,,,,,,,,637,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,624.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,624.26
Insert Non-Tunnel Cv Catheter >5 Years,PX36556P,CDM,983,RC,36556,CPT,,,,,,,,1274,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,610.875,percent of total billed charges,624.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,529.2196,2784.63
Insert Non-Tunnel Cv Catheter >5 Years,PX36556P,CDM,983,RC,36556,CPT,,,,,,,,1274,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,624.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,529.2196,2784.63
Insert Non-Tunnel Cv Catheter >5 Years,PX36556P,CDM,983,RC,36556,CPT,,,,,,,,1274,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,624.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,529.2196,2784.63
"Excis Tendn/Capsule Lesn,Toes",PX28092F,CDM,510,RC,28092,CPT,,,,,,,,1234,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,624.404,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,512.6036,1404.08
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,310095036,NDC,1,EA,1234.2,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,624.5052,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,512.68668,1209.516
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,70720095036,NDC,1,EA,1234.2,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,624.5052,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,512.68668,1209.516
"Exc Skn Bnig >4cmtrnk,Arm,Leg",PX11406P,CDM,983,RC,11406,CPT,,,,,,,,1456,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,624.624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,604.8224,1417.1248
DYNAFORCE MPJ REAMERS CUP/CONE 20MM,27200000,CDM,272,RC,,,,11853-MAIN,LOCAL,,,,,1262,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,624.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Closure Superf Wnd Dehis Simple,PX12020F,CDM,510,RC,12020,CPT,,,,,,,,632,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,624.7,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,117.15,624.7
Closure Superf Wnd Dehis Simple,PX12020P,CDM,983,RC,12020,CPT,,,,,,,,422,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,624.7,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,117.15,624.7
CT Lwr Extremity W/O&W/Dye,PX7370201,CDM,350,RC,73702,CPT,TC,,,,,,,1235,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,624.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
MESH SURGICAL NON-ABSORBABLE PLUG 6INW X 6INL,C1781,CDM,272,RC,C1781,HCPCS,,12005-MAIN,LOCAL,,,,,1505,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,625.177,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
MESH SURGICAL NON-ABSORBABLE PLUG 12INW X 12INL,C1781,CDM,278,RC,C1781,HCPCS,,12006-MAIN,LOCAL,,,,,1505,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,625.177,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Exc Skn Mal 2.1-3cmtrnk,Arm,Lg",PX11603P,CDM,983,RC,11603,CPT,,,,,,,,1276,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,625.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,530.0504,1241.9308
"Exc Skn Mal 2.1-3cmtrnk,Arm,Lg",PX11603P,CDM,983,RC,11603,CPT,,,,,,,,1276,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,625.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,530.0504,1241.9308
"Exc Skn Mal 2.1-3cmtrnk,Arm,Lg",PX11603P,CDM,983,RC,11603,CPT,,,,,,,,1276,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,625.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,530.0504,1241.9308
Tube Thoracostomy Inc Wtr Seal,PX32551P,CDM,983,RC,32551,CPT,,,,,,,,1236,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,625.416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,513.4344,1399.13
CT Angiograph Pelv W/O&W/Dye,PX7219101,CDM,350,RC,72191,CPT,TC,,,,,,,1458,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,625.482,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,45963061959,NDC,1,EA,638.4,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,625.632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.2006,625.632
"Facility Critical Care, E/M 30-74 Minutes",PX99291F,CDM,510,RC,99291,CPT,,,,,,,,1264,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,625.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,525.0656,1238.72
"Closed Rx Dist Fibula Fx,Manip",PX27788P,CDM,983,RC,27788,CPT,,,,,,,,1277,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,625.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1242.9041
"Closed Rx Dist Fibula Fx,Manip",PX27788P,CDM,983,RC,27788,CPT,,,,,,,,1277,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,625.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1242.9041
"Closed Rx Dist Fibula Fx,Manip",PX27788P,CDM,983,RC,27788,CPT,,,,,,,,1277,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,625.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1242.9041
PERFIX PLUG STERILE X-LARGE,C1781,CDM,278,RC,C1781,HCPCS,,11772-MAIN,LOCAL,,,,,643,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1256.29,percent of total billed charges,625.8319,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Closed Treat Wrist Dislocation,PX25660P,CDM,983,RC,25660,CPT,,,,,,,,1507,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,626.0078,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1466.7631
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,469650189,NDC,5,ML,1264.92,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,626.1354,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,424.41418,1239.6216
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502050102,NDC,1,EA,1305.38,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,626.5824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502050102,NDC,1,EA,1305.38,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,626.5824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
"Cardioversion, Elective;Extern",PX92960P,CDM,983,RC,92960,CPT,,,,,,,,688,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,626.768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,285.7952,669.6304
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031F,CDM,510,RC,12031,CPT,,,,,,,,688,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,626.768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,285.7952,674.24
CT Soft Tissue Neck W/O Dye,PX7049001,CDM,350,RC,70490,CPT,TC,,,,,,,711,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,627.102,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,1198.67
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423F,CDM,510,RC,11423,CPT,,,,,,,,711,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,627.102,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,295.3494,1416.38
Skin Sub Graft Trnk/Arm/Leg,PX15271P,CDM,983,RC,15271,CPT,,,,,,,,705,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,627.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,292.857,1593.14
"Spinal Puncture,Lumbar,Diagnostic",PX62270P,CDM,983,RC,62270,CPT,,,,,,,,705,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,627.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,292.857,686.1765
Temporal Artery Ligatn or Bx,PX37609F,CDM,510,RC,37609,CPT,,,,,,,,705,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,627.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,292.857,1416.38
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,70839036204,NDC,4,ML,1280.66,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,627.5234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,70839036204,NDC,4,ML,1280.66,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,627.5234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,70839036204,NDC,4,ML,1280.66,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,627.5234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
"I&D Perianal Abscess,Superficial",PX46050F,CDM,510,RC,46050,CPT,,,,,,,,1463,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,627.627,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,607.7302,1433.74
Closed Rx Shldr Dislocation,PX23650F,CDM,510,RC,23650,CPT,,,,,,,,689,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,627.679,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,675.22
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,93598627,NDC,1,EA,1241.11,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,628.00166,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
Closed Rx IP Jt Dislocation,PX26770F,CDM,510,RC,26770,CPT,,,,,,,,1231,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,628.15,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,168.85,628.15
Closed Rx IP Jt Dislocation,PX26770P,CDM,983,RC,26770,CPT,,,,,,,,1353,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,628.15,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,168.85,1325.94
Closed Rx Elbow Dislocation,PX24600F,CDM,510,RC,24600,CPT,,,,,,,,706,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,628.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,691.88
perflutren protein A microsphere Suspension 3 mL Vial,Q9956,CDM,636,RC,Q9956,HCPCS,,,,407270703,NDC,3,ML,739.41,,First Health,Commercial,both,85,,999999999,percent of total billed charges,628.4985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,307.150914,724.6218
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623F,CDM,510,RC,11623,CPT,,,,,,,,690,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,628.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,286.626,1416.38
HERNIA PATCH VENTRALEX MEDIUM,C1781,CDM,278,RC,C1781,HCPCS,,10202-MAIN,LOCAL,,,,,1309.75,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,628.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
HERNIA PATCH VENTRALEX MEDIUM,C1781,CDM,278,RC,C1781,HCPCS,,10202-MAIN,LOCAL,,,,,1309.75,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,628.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
MESH VENTRALIGHT ECHO 2.0 POSITIONING 11CM ROUND,120.525,CDM,278,RC,C1781,HCPCS,,12219-MAIN,LOCAL,,,,,1310,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,628.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,544.174,1283.8
MESH VENTRALIGHT ECHO 2.0 POSITIONING 11CM ROUND,120.525,CDM,278,RC,C1781,HCPCS,,12219-MAIN,LOCAL,,,,,1310,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,628.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,544.174,1283.8
Repr Superf Wnd Face >30cm,PX12018F,CDM,510,RC,12018,CPT,,,,,,,,713,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,628.866,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,698.74
Trauma Activation,PX68200010,CDM,684,RC,G0390,HCPCS,,,,,,,,1243,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,628.958,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,516.3422,1218.14
US Doppler Lw Ext Art Tc,PX9392601,CDM,921,RC,93926,CPT,TC,,,,,,,740,,First Health,Commercial,both,85,,999999999,percent of total billed charges,629,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,725.2
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059303,NDC,1,EA,740.19,,First Health,Commercial,both,85,,999999999,percent of total billed charges,629.1615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.10077,725.3862
Part Remv Phalanx of Toe,PX28124P,CDM,983,RC,28124,CPT,,,,,,,,1515,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,629.331,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,629.331,2827.75
HARMONIC 1100 SHEARS 20CM SHAFT HAR1120,27200000,CDM,272,RC,,,,12924-MAIN,LOCAL,,,,,1244,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,629.464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035P,CDM,983,RC,12035,CPT,,,,,,,,1244,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,629.464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1210.7852
moxifloxacin 0.5 % Solution 3 mL Bottle,25000000,CDM,250,RC,,,,,,60505058204,NDC,3,ML,691.15,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,629.63765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Closure of Gastrostomy,Surgical",PX43870P,CDM,983,RC,43870,CPT,,,,,,,,4012,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,629.6771,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,427.35,3931.76
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032P,CDM,983,RC,12032,CPT,,,,,,,,647,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,629.7251,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,268.7638,629.7251
"Repair Umbilical Hern,5+Y/O,Reduc",PX49585P,CDM,983,RC,49585,CPT,,,,,,,,647,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,629.7251,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,268.7638,629.7251
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591P,CDM,982,RC,49591,CPT,,,,,,,,1245,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,629.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,517.173,3022.41
filgrastim-ayow 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,800000,CDM,,,,,,,,70121157001,NDC,0.5,ML,691.62,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,630.06582,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
"Colonoscopy,Flex,Diagnostic",PX45378F,CDM,750,RC,45378,CPT,,,,,,,,1286,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1803.195,percent of total billed charges,630.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,551.694,4661.91
"Colonoscopy,Flex,Diagnostic",PX45378F,CDM,750,RC,45378,CPT,,,,,,,,1286,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,630.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,551.694,4661.91
"Colonoscopy,Flex,Diagnostic",PX45378F,CDM,750,RC,45378,CPT,,,,,,,,1286,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,630.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,551.694,4661.91
Low Dose CT Lung Ca Screen WO Contrast,PX7127101,CDM,350,RC,71271,CPT,TC,,,,,,,1286,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,630.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,1260.28
Low Dose CT Lung Ca Screen WO Contrast,PX7127101,CDM,350,RC,71271,CPT,TC,,,,,,,1286,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,630.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,1260.28
Low Dose CT Lung Ca Screen WO Contrast,PX7127101,CDM,350,RC,71271,CPT,TC,,,,,,,1286,,United Healthcare,All Medicare advantage plans,outpatient,49,,681.58,percent of total billed charges,630.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,1260.28
PERFIX PLUG STERILE X-LARGE,C1781,CDM,278,RC,C1781,HCPCS,,11772-MAIN,LOCAL,,,,,643,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,630.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
carboprost 250 MCG/ML Solution 1 mL Ampule,25000000,CDM,250,RC,,,,,,9085608,NDC,1,ML,1517.13,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,630.215802,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Insert Non-Tunnel Cv Catheter >5 Years,PX36556P,CDM,983,RC,36556,CPT,,,,,,,,1274,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,630.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,529.2196,2784.63
"Removal Anal Fistula,Subcutaneous",PX46270F,CDM,510,RC,46270,CPT,,,,,,,,1470,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,630.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,610.638,2452.93
8MM ENDOWRIST INSTRUMENTS MONOPOLAR CURVED SCISSORS,27200000,CDM,272,RC,,,,11909-MAIN,LOCAL,,,,,648,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,630.6984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STAPLER INTERNAL ECHELON FLEX POWERED PLUS LONG LENGTH 440MM,27200000,CDM,272,RC,,,,12065-MAIN,LOCAL,,,,,648,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,630.6984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Drain Pilonidal Cyst Simpl,PX10080F,CDM,510,RC,10080,CPT,,,,,,,,742,,First Health,Commercial,both,85,,999999999,percent of total billed charges,630.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,308.2268,727.16
Fna W/Image,PX10022F,CDM,510,RC,10022,CPT,,,,,,,,742,,First Health,Commercial,both,85,,999999999,percent of total billed charges,630.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,308.2268,727.16
"Excis Arm/Elbow Tumor,Subcutan",PX24075F,CDM,510,RC,24075,CPT,,,,,,,,1519,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,630.9926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,630.9926,1488.62
diazePAM 2.5 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,66490065020,NDC,1,EA,1288,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,631.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2.5 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,66490065020,NDC,1,EA,1288,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,631.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2.5 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,66490065020,NDC,1,EA,1288,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,631.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Exc Skn Mal 2.1-3cmtrnk,Arm,Lg",PX11603P,CDM,983,RC,11603,CPT,,,,,,,,1276,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,631.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,530.0504,1241.9308
"Lap,Cholecystectomy",PX47562F,CDM,510,RC,47562,CPT,,,,,,,,1473,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,631.917,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,611.8842,5040.74
ADVANCED INSTRUMENTS 8MM SYNCHROSEAL IS4000,27200000,CDM,272,RC,,,,11924-MAIN,LOCAL,,,,,1290,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,632.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ADVANCED INSTRUMENTS 8MM SYNCHROSEAL IS4000,27200000,CDM,272,RC,,,,11924-MAIN,LOCAL,,,,,1290,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,632.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ADVANCED INSTRUMENTS 8MM SYNCHROSEAL IS4000,27200000,CDM,272,RC,,,,11924-MAIN,LOCAL,,,,,1290,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,632.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Closed Rx Dist Fibula Fx,Manip",PX27788P,CDM,983,RC,27788,CPT,,,,,,,,1277,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,632.115,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1242.9041
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231001,NDC,10,ML,649.64,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.5924,percent of total billed charges,632.294612,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231005,NDC,10,ML,649.64,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.5924,percent of total billed charges,632.294612,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032F,CDM,510,RC,12032,CPT,,,,,,,,386,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,632.31,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.76,632.31
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032P,CDM,983,RC,12032,CPT,,,,,,,,647,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,632.31,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.76,634.06
"Lap,Inguinal Hernia Repr,Initial",PX49650P,CDM,983,RC,49650,CPT,,,,,,,,717,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,632.394,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,297.8418,5040.74
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565F,CDM,510,RC,25565,CPT,,,,,,,,1250,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,632.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,519.25,1404.08
Acellular Derm Matrix Implt,PX15777F,CDM,510,RC,15777,CPT,,,,,,,,650,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,632.645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.01,637
Closed Rx Bimalleolar Fx,PX27808F,CDM,510,RC,27808,CPT,,,,,,,,650,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,632.645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,637
"Exc Skn Bngn2.1-3cm Fce,Facial",PX11443P,CDM,983,RC,11443,CPT,,,,,,,,650,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,632.645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.01,1416.38
"Repair Flex Foot Tendon,Ea",PX28200F,CDM,510,RC,28200,CPT,,,,,,,,1475,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,632.775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,612.715,2827.75
CT Soft Tissue Neck W/O Dye,PX7049001,CDM,350,RC,70490,CPT,TC,,,,,,,711,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,632.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,1198.67
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423F,CDM,510,RC,11423,CPT,,,,,,,,711,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,632.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,295.3494,1416.38
MRI Upper W/O+W Tc,PX7322001,CDM,610,RC,73220,CPT,TC,,,,,,,3253,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,633.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.66,633.08
MRI Upper W/O+W Tc,PX7322001,CDM,610,RC,73220,CPT,TC,,,,,,,3253,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,633.08,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.66,633.08
glucagon rdna (diagnostic) 1 MG Recon Soln 1 Each Vial,J1610.01,CDM,636,RC,J1610,HCPCS,,,,597026010,NDC,1,EA,744.84,,First Health,Commercial,both,85,,999999999,percent of total billed charges,633.114,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,172.71,729.9432
Art Upper Extremity-Ltd,PX9393101,CDM,921,RC,93931,CPT,TC,,,,,,,718,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,633.276,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,703.64
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505F,CDM,510,RC,25505,CPT,,,,,,,,651,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,633.6183,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.4254,1404.08
Remove Foreign Body Complic,PX10121P,CDM,983,RC,10121,CPT,,,,,,,,651,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,633.6183,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.4254,1416.38
"Injection Hip Arthrogram,Anesth",PX27095F,CDM,510,RC,27095,CPT,,,,,,,,425,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,633.69,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.95,633.69
"Injection Hip Arthrogram,Anesth",PX27095P,CDM,983,RC,27095,CPT,,,,,,,,425,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,633.69,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.95,633.69
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,70839036204,NDC,4,ML,1280.66,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,633.9267,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
umeclidinium-vilanterol 62.5-25 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173086906,NDC,14,EA,745.86,,First Health,Commercial,both,85,,999999999,percent of total billed charges,633.981,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 15DEGREE 14MM,27200000,CDM,272,RC,,,,12600-MAIN,LOCAL,,,,,1253,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,634.018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 45DEGREE 8MM,27200000,CDM,272,RC,,,,12599-MAIN,LOCAL,,,,,1253,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,634.018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 45DEGREE 14MM,27200000,CDM,272,RC,,,,12598-MAIN,LOCAL,,,,,1253,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,634.018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 15DEGREE 14MM,27200000,CDM,272,RC,,,,12603-MAIN,LOCAL,,,,,1253,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,634.018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 45DEGREE 8MM,27200000,CDM,272,RC,,,,12602-MAIN,LOCAL,,,,,1253,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,634.018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 45DEGREE 14MM,27200000,CDM,272,RC,,,,12601-MAIN,LOCAL,,,,,1253,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,634.018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Abd Paracentesis W/Imaging(P),PX49083P,CDM,983,RC,49083,CPT,,,,,,,,696,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,634.056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.1184,791.92
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032P,CDM,983,RC,12032,CPT,,,,,,,,647,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,634.06,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,119.76,634.06
"Repair Umbilical Hern,5+Y/O,Reduc",PX49585P,CDM,983,RC,49585,CPT,,,,,,,,647,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,634.06,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,399.1273,634.06
Repr Superf Wnd Face >30cm,PX12018F,CDM,510,RC,12018,CPT,,,,,,,,713,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,634.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,698.74
diazePAM 10 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,187065820,NDC,1,EA,1527.87,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,634.677198,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BRACE KNEE LARGE SHORTRUNNER 21754,120.387,CDM,274,RC,L1833,HCPCS,,10044-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,634.77,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.1433,634.77
BRACE KNEE MEDIUM SHORTRUNNER 21753,120.387,CDM,274,RC,L1833,HCPCS,,10126-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,634.77,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.1433,634.77
BRACE KNEE SMALL SHORTRUNNER 21752,120.387,CDM,274,RC,L1833,HCPCS,,10900-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,634.77,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.1433,634.77
BRACE KNEE X-LARGE SHORTRUNNER 21755,120.387,CDM,274,RC,L1833,HCPCS,,3444-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,634.77,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.1433,634.77
BRACE KNEE XX-LARGE SHORTRUNNER 21756,120.387,CDM,274,RC,L1833,HCPCS,,10615-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,634.77,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.1433,634.77
2.1MM CANNULATED DRILL BIT,27200000,CDM,272,RC,,,,12657-MAIN,LOCAL,,,,,747,,First Health,Commercial,both,85,,999999999,percent of total billed charges,634.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
US Guide Needle Bx S&I,PX7694201,CDM,402,RC,76942,CPT,TC,,,,,,,747,,First Health,Commercial,both,85,,999999999,percent of total billed charges,634.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.3038,732.06
Ligation of Hemorrhoid(S),PX46221P,CDM,983,RC,46221,CPT,,,,,,,,697,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,634.967,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.5338,798.45
STAPLER INTERNAL POWERED 29MM CURVED CIRCULAR,27200000,CDM,272,RC,,,,12024-MAIN,LOCAL,,,,,697,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,634.967,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STAPLER INTERNAL POWERED 31MM CURVED CIRCULAR,27200000,CDM,272,RC,,,,12025-MAIN,LOCAL,,,,,697,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,634.967,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
8MM ENDOWRIST INSTRUMENTS MONOPOLAR CURVED SCISSORS,27200000,CDM,272,RC,,,,11909-MAIN,LOCAL,,,,,648,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,635.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Sigmoidoscopy,Diagnostic",PX45330F,CDM,510,RC,45330,CPT,,,,,,,,720,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,635.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,299.088,798.45
STAPLER INTERNAL ECHELON FLEX POWERED PLUS LONG LENGTH 440MM,27200000,CDM,272,RC,,,,12065-MAIN,LOCAL,,,,,648,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,635.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Biopsy of Rectum,PX45100F,CDM,510,RC,45100,CPT,,,,,,,,763,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,635.07,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.92,635.07
Biopsy of Rectum,PX45100F,CDM,510,RC,45100,CPT,,,,,,,,763,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,635.07,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.92,635.07
Biopsy of Rectum,PX45100P,CDM,983,RC,45100,CPT,,,,,,,,509,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,635.07,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.92,635.07
Biopsy of Rectum,PX45100P,CDM,983,RC,45100,CPT,,,,,,,,509,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,635.07,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.92,635.07
GRAFIXPL PRIME PLACENTAL MEMBRANE 1.5 x2CM 3SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12764-MAIN,LOCAL,,,,,1529,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,635.1466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573F,CDM,761,RC,36573,CPT,,,,,,,,1529,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,635.1466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,635.1466,1498.42
sugammadex sodium 200 MG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,6542302,NDC,2,ML,652.81,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,635.379973,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Fac/Exc Skn Malig .1-2cm Fce,Facal",PX11642F,CDM,510,RC,11642,CPT,,,,,,,,698,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,635.878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.9492,684.04
HERNIA PATCH VENTRALEX LARGE,C1781,CDM,278,RC,C1781,HCPCS,,10201-MAIN,LOCAL,,,,,1325.08,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,636.0384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
HERNIA PATCH VENTRALEX LARGE,C1781,CDM,278,RC,C1781,HCPCS,,10201-MAIN,LOCAL,,,,,1325.08,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,636.0384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Lap,Cholecystectomy/Graph",PX47563F,CDM,510,RC,47563,CPT,,,,,,,,1556,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,636.0991,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,431.28,1497.75
"Excise Lesion,Back or Flank",PX21930F,CDM,510,RC,21930,CPT,,,,,,,,1326,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,636.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,550.8204,1416.38
"Excise Lesion,Back or Flank",PX21930F,CDM,510,RC,21930,CPT,,,,,,,,1326,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,636.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,550.8204,1416.38
Injection Hip Arthrogram,PX27093F,CDM,510,RC,27093,CPT,,,,,,,,654,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,636.5382,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,271.6716,640.92
"Colonoscopy,Flex,Diagnostic",PX45378F,CDM,750,RC,45378,CPT,,,,,,,,1286,,Humana Choice Care,All Medicare plans,outpatient,49.5,,840.1866667,percent of total billed charges,636.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,551.694,4661.91
Low Dose CT Lung Ca Screen WO Contrast,PX7127101,CDM,350,RC,71271,CPT,TC,,,,,,,1286,,Humana Choice Care,All Medicare plans,outpatient,49.5,,901.1,percent of total billed charges,636.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,1260.28
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231001,NDC,10,ML,649.64,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,636.6472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231005,NDC,10,ML,649.64,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,636.6472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,38.02987,636.6472
"Fac/Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404F,CDM,510,RC,11404,CPT,,,,,,,,749,,First Health,Commercial,both,85,,999999999,percent of total billed charges,636.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,311.1346,1416.38
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034P,CDM,983,RC,12034,CPT,,,,,,,,1533,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,636.8082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1492.0689
"Amputation Toe,I-P Jt",PX28825F,CDM,510,RC,28825,CPT,,,,,,,,1327,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,636.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,551.2358,2827.75
"Amputation Toe,I-P Jt",PX28825F,CDM,510,RC,28825,CPT,,,,,,,,1327,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,636.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,551.2358,2827.75
Acellular Derm Matrix Implt,PX15777F,CDM,510,RC,15777,CPT,,,,,,,,650,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,637,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.01,637
"Amputation Toe,Mt-P Jt",PX28820P,CDM,983,RC,28820,CPT,,,,,,,,1300,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,637,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,540.02,2827.75
"Amputation Toe,Mt-P Jt",PX28820P,CDM,983,RC,28820,CPT,,,,,,,,1300,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,637,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,540.02,2827.75
"Amputation Toe,Mt-P Jt",PX28820P,CDM,983,RC,28820,CPT,,,,,,,,1300,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,637,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,540.02,2827.75
Closed Rx Bimalleolar Fx,PX27808F,CDM,510,RC,27808,CPT,,,,,,,,650,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,637,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,637
"Exc Skn Bngn2.1-3cm Fce,Facial",PX11443P,CDM,983,RC,11443,CPT,,,,,,,,650,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,637,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.78,637
Closed Rx Trimalleolar Fx,PX27816F,CDM,510,RC,27816,CPT,,,,,,,,522,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,637.15,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,190.44,718.09
Closed Rx Trimalleolar Fx,PX27816P,CDM,983,RC,27816,CPT,,,,,,,,826,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,637.15,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,190.44,809.48
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605P,CDM,983,RC,24605,CPT,,,,,,,,750,,First Health,Commercial,both,85,,999999999,percent of total billed charges,637.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,311.55,1404.08
Sigmoidoscope W/Submuc Inj,PX45335F,CDM,750,RC,45335,CPT,,,,,,,,750,,First Health,Commercial,both,85,,999999999,percent of total billed charges,637.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,311.55,798.45
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035F,CDM,510,RC,12035,CPT,,,,,,,,655,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,637.5115,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,272.087,641.9
diazePAM 2.5 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,66490065020,NDC,1,EA,1288,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,637.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Close Rx Dist Fingr Fx,Manipulatn",PX26755P,CDM,983,RC,26755,CPT,,,,,,,,1260,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,637.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1226.358
Lap Rpr Vent Umbilical Hernia,PX49652P,CDM,983,RC,49652,CPT,,,,,,,,1260,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,637.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,523.404,1226.358
CATHETER BIPOLAR ELECTROHEMOSTASIS 7FR 300CM M00560070,27200000,CDM,272,RC,,,,12909-MAIN,LOCAL,,,,,700,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,637.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505F,CDM,510,RC,25505,CPT,,,,,,,,651,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,637.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.4254,1404.08
Remove Foreign Body Complic,PX10121P,CDM,983,RC,10121,CPT,,,,,,,,651,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,637.98,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,114.52,637.98
"Lap,Inguinal Hernia Repr,Initial",PX49650P,CDM,983,RC,49650,CPT,,,,,,,,717,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,638.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,297.8418,5040.74
brimonidine 0.15 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314014405,NDC,5,ML,723.62,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,638.23284,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
ADVANCED INSTRUMENTS 8MM SYNCHROSEAL IS4000,27200000,CDM,272,RC,,,,11924-MAIN,LOCAL,,,,,1290,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,638.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNAFORCE MPJ REAMERS CUP/CONE 20MM,27200000,CDM,272,RC,,,,11853-MAIN,LOCAL,,,,,1262,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,638.572,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRILL BIT 2.2MMX60MM STERILE MICA CANNULATED,27200000,CDM,272,RC,,,,12437-MAIN,LOCAL,,,,,701,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,638.611,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRILL BIT 3.0MMX60MM STERILE MICA CANNULATED,27200000,CDM,272,RC,,,,12438-MAIN,LOCAL,,,,,701,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,638.611,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
perflutren lipid microsphere 6.52 MG/ML Suspension 2 mL Vial,Q9957,CDM,636,RC,Q9957,HCPCS,,,,11994001101,NDC,2,ML,751.71,,First Health,Commercial,both,85,,999999999,percent of total billed charges,638.9535,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,312.260334,736.6758
Art Upper Extremity-Ltd,PX9393101,CDM,921,RC,93931,CPT,TC,,,,,,,718,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,639.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,703.64
"Biopsy, Nail Unit",PX11755F,CDM,510,RC,11755,CPT,,,,,,,,1490,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,639.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,614.65,1460.2
PEMEtrexed Disodium 100 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2764001,NDC,1,EA,1539.32,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,639.433528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.01,7924.2996
Insert Emergency Endotrach Airway,PX31500P,CDM,983,RC,31500,CPT,,,,,,,,657,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,283.315,percent of total billed charges,639.4581,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,639.4581
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,310095036,NDC,1,EA,1234.2,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,639.46,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,535.92,639.46
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,70720095036,NDC,1,EA,1234.2,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,639.46,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,535.92,639.46
"Facility Critical Care, E/M 30-74 Minutes",PX99291F,CDM,510,RC,99291,CPT,,,,,,,,1264,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,639.584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,525.0656,1238.72
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502050102,NDC,1,EA,1305.38,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,150.5666667,percent of total billed charges,639.6362,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502050102,NDC,1,EA,1305.38,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,639.6362,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502050102,NDC,1,EA,1305.38,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,639.6362,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
Repair Incis Hernia W Mesh,PX49568F,CDM,510,RC,49568,CPT,,,,,,,,1540,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,639.716,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,639.716,1509.2
sugammadex sodium 200 MG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,6542302,NDC,2,ML,652.81,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,639.7538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
oseltamivir 6 MG/ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,4082205,NDC,60,ML,752.82,,First Health,Commercial,both,85,,999999999,percent of total billed charges,639.897,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,469650189,NDC,5,ML,1264.92,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,640.04952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,424.41418,1239.6216
Exc Neck Les Sc = 3cm >,PX21552F,CDM,510,RC,21552,CPT,,,,,,,,753,,First Health,Commercial,both,85,,999999999,percent of total billed charges,640.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,312.7962,2482.37
"Lap,Esophagogast Fundoplasty",PX43280F,CDM,510,RC,43280,CPT,,,,,,,,6713,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,640.49,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,640.49,2235.9
"Lap,Esophagogast Fundoplasty",PX43280P,CDM,983,RC,43280,CPT,,,,,,,,4449,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,640.49,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,640.49,4360.02
"Lap,Esophagogast Fundoplasty",PX43280F,CDM,510,RC,43280,CPT,,,,,,,,6713,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,640.71,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,640.49,2235.9
"Lap,Esophagogast Fundoplasty",PX43280F,CDM,510,RC,43280,CPT,,,,,,,,6713,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,640.71,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,640.49,2235.9
"Lap,Esophagogast Fundoplasty",PX43280P,CDM,983,RC,43280,CPT,,,,,,,,4449,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,640.71,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,640.49,4360.02
"Lap,Esophagogast Fundoplasty",PX43280P,CDM,983,RC,43280,CPT,,,,,,,,4449,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,640.71,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,640.49,4360.02
"Sigmoidoscopy,Diagnostic",PX45330F,CDM,510,RC,45330,CPT,,,,,,,,720,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,640.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,299.088,798.45
Injection Hip Arthrogram,PX27093F,CDM,510,RC,27093,CPT,,,,,,,,654,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,640.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,271.6716,640.92
"Insert Needle,Intraosseous Infusn",PX36680F,CDM,510,RC,36680,CPT,,,,,,,,659,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,641.4047,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,273.7486,645.82
"rabies vaccine, pcec Recon Susp 1 Each Vial",90675,CDM,636,RC,90675,CPT,,,,58160096412,NDC,1,EA,1544.83,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,641.722382,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,297.75,1513.9334
"HERNIA MESH 3D MAX MID ANATOMICAL MESH LEFT SIZE L 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,11976-MAIN,LOCAL,,,,,755,,First Health,Commercial,both,85,,999999999,percent of total billed charges,641.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"HERNIA MESH 3D MAX MID ANATOMICAL MESH RIGHT SIZE L 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,11977-MAIN,LOCAL,,,,,755,,First Health,Commercial,both,85,,999999999,percent of total billed charges,641.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
HERNIA PATCH VENTRALEX MEDIUM,C1781,CDM,278,RC,C1781,HCPCS,,10202-MAIN,LOCAL,,,,,1309.75,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,196.035,percent of total billed charges,641.7775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
HERNIA PATCH VENTRALEX MEDIUM,C1781,CDM,278,RC,C1781,HCPCS,,10202-MAIN,LOCAL,,,,,1309.75,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,641.7775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
HERNIA PATCH VENTRALEX MEDIUM,C1781,CDM,278,RC,C1781,HCPCS,,10202-MAIN,LOCAL,,,,,1309.75,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,641.7775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035F,CDM,510,RC,12035,CPT,,,,,,,,655,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,641.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,272.087,641.9
MESH VENTRALIGHT ECHO 2.0 POSITIONING 11CM ROUND,120.525,CDM,278,RC,C1781,HCPCS,,12219-MAIN,LOCAL,,,,,1310,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,196.035,percent of total billed charges,641.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,544.174,1283.8
MESH VENTRALIGHT ECHO 2.0 POSITIONING 11CM ROUND,120.525,CDM,278,RC,C1781,HCPCS,,12219-MAIN,LOCAL,,,,,1310,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,641.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,544.174,1283.8
MESH VENTRALIGHT ECHO 2.0 POSITIONING 11CM ROUND,120.525,CDM,278,RC,C1781,HCPCS,,12219-MAIN,LOCAL,,,,,1310,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,641.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,544.174,1283.8
insulin aspart 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169633910,NDC,3,ML,659.76,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,4.0055,percent of total billed charges,642.144408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
Skin Sub Graft Trnk/Arm/Leg,PX15271P,CDM,983,RC,15271,CPT,,,,,,,,705,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,642.255,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,292.857,1593.14
"Spinal Puncture,Lumbar,Diagnostic",PX62270P,CDM,983,RC,62270,CPT,,,,,,,,705,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,642.255,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,292.857,686.1765
Temporal Artery Ligatn or Bx,PX37609F,CDM,510,RC,37609,CPT,,,,,,,,705,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,642.255,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,292.857,1416.38
"Incis/Drain Scrotum/Testis,Epididym",PX54700F,CDM,510,RC,54700,CPT,,,,,,,,660,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,642.378,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.164,1779.39
Repair Incis Hernia W Mesh,PX49568P,CDM,983,RC,49568,CPT,,,,,,,,660,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,642.378,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.164,642.378
Closed Rx Elbow Dislocation,PX24600F,CDM,510,RC,24600,CPT,,,,,,,,706,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,643.166,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,691.88
CT Angio Upr Extrm W/O&W/Dye,PX7320601,CDM,350,RC,73206,CPT,TC,,,,,,,757,,First Health,Commercial,both,85,,999999999,percent of total billed charges,643.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
"Inject Nerv Blck,Othr Periph Nerv",PX64450F,CDM,510,RC,64450,CPT,,,,,,,,757,,First Health,Commercial,both,85,,999999999,percent of total billed charges,643.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,314.4578,741.86
"Amputation Toe,Mt-P Jt",PX28820P,CDM,983,RC,28820,CPT,,,,,,,,1300,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,643.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,540.02,2827.75
Level 2 Additional Procedure,PX36000081,CDM,360,RC,,,,,,,,,,1500,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,643.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,623.1,1470
prednisoLONE acetate 0.12 % Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,11980017405,NDC,5,ML,757.07,,First Health,Commercial,both,85,,999999999,percent of total billed charges,643.5095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Insert Emergency Endotrach Airway,PX31500P,CDM,983,RC,31500,CPT,,,,,,,,657,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,643.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.64,643.86
brimonidine 0.15 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314014405,NDC,5,ML,723.62,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,644.0218,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Fluoroscopy Guid Needle Plcmt Tc,PX7700201,CDM,320,RC,77002,CPT,TC,,,,,,,662,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,128.4,percent of total billed charges,644.3246,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.9948,648.76
Insert Non-Tunnel Cv Catheter >5 Years,PX36556P,CDM,983,RC,36556,CPT,,,,,,,,1274,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,644.644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,529.2196,2784.63
"Fac/Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602F,CDM,510,RC,11602,CPT,,,,,,,,731,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,644.742,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,303.6574,716.38
"Sigmoidoscopy,Biopsy",PX45331P,CDM,983,RC,45331,CPT,,,,,,,,1316,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,644.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,546.6664,1280.8628
"Sigmoidoscopy,Biopsy",PX45331P,CDM,983,RC,45331,CPT,,,,,,,,1316,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,644.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,546.6664,1280.8628
"Sigmoidoscopy,Biopsy",PX45331P,CDM,983,RC,45331,CPT,,,,,,,,1316,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,644.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,546.6664,1280.8628
Lap Sleeve Gastrectomy,PX43775,CDM,982,RC,43775,CPT,,,,,,,,5030,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,645.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,645.08,4929.4
Lap Sleeve Gastrectomy,PX43775,CDM,982,RC,43775,CPT,,,,,,,,5030,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,645.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,645.08,4929.4
Layr Clos Wnd Rest Body 2.6-7.5,PX12042F,CDM,510,RC,12042,CPT,,,,,,,,404,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,645.45,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,123.03,645.45
Layr Clos Wnd Rest Body 2.6-7.5,PX12042P,CDM,983,RC,12042,CPT,,,,,,,,777,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,645.45,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,123.03,761.46
Temporal Artery Ligatn or Bx,PX37609F,CDM,510,RC,37609,CPT,,,,,,,,705,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,645.45,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,124.34,645.45
Temporal Artery Ligatn or Bx,PX37609P,CDM,983,RC,37609,CPT,,,,,,,,965,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,645.45,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,124.34,945.7
MESH SURGICAL NON-ABSORBABLE PLUG 6INW X 6INL,C1781,CDM,272,RC,C1781,HCPCS,,12005-MAIN,LOCAL,,,,,1505,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,645.645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
MESH SURGICAL NON-ABSORBABLE PLUG 12INW X 12INL,C1781,CDM,278,RC,C1781,HCPCS,,12006-MAIN,LOCAL,,,,,1505,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,645.645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Exc Skn Mal 2.1-3cmtrnk,Arm,Lg",PX11603P,CDM,983,RC,11603,CPT,,,,,,,,1276,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,645.656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,530.0504,1241.9308
"Insert Needle,Intraosseous Infusn",PX36680F,CDM,510,RC,36680,CPT,,,,,,,,659,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,645.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,273.7486,645.82
"Casiri and Imdevimab,Admin,Repeat Dose",PXM0240,CDM,771,RC,M0240,HCPCS,,,,,,,,1555,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,645.947,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,413.06,1523.9
"IV Infusion, Bamlanivimab and Etesevimab, Infusion and Monitoring",PXM0245,CDM,260,RC,M0245,HCPCS,,,,,,,,1555,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,645.947,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,413.06,1523.9
"US Guide, Vascular Access",PX7693701,CDM,402,RC,76937,CPT,TC,,,,,,,760,,First Health,Commercial,both,85,,999999999,percent of total billed charges,646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,315.704,744.8
"Closed Rx Dist Fibula Fx,Manip",PX27788P,CDM,983,RC,27788,CPT,,,,,,,,1277,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,646.162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1242.9041
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502050102,NDC,1,EA,1305.38,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,646.1631,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
Xray Cervical Spine 4 or 5 Vws,PX7205001,CDM,320,RC,72050,CPT,TC,,,,,,,664,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,646.2712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,650.72
Xray Cervical Spine 6 or More Vws,PX7205201,CDM,320,RC,72052,CPT,TC,,,,,,,664,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,646.2712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,650.72
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591F,CDM,360,RC,49591,CPT,,,,,,,,1556,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,646.3624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,646.3624,3022.41
"Lap,Cholecystectomy/Graph",PX47563F,CDM,510,RC,47563,CPT,,,,,,,,1556,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,646.3624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,646.3624,5040.74
Closed Treat Wrist Dislocation,PX25660P,CDM,983,RC,25660,CPT,,,,,,,,1507,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,646.503,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1466.7631
insulin aspart 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169633910,NDC,3,ML,659.76,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,646.5648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,18.468684,646.5648
"Incis/Drain Scrotum/Testis,Epididym",PX54700F,CDM,510,RC,54700,CPT,,,,,,,,660,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,646.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.164,1779.39
Repair Incis Hernia W Mesh,PX49568P,CDM,983,RC,49568,CPT,,,,,,,,660,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,646.8,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,229.5865,646.8
Aspirate Pleura W/ Imaging,PX32555F,CDM,761,RC,32555,CPT,,,,,,,,795,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,646.83,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.75,646.83
Aspirate Pleura W/ Imaging,PX32555P,CDM,983,RC,32555,CPT,,,,,,,,536,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,646.83,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,66.75,646.83
Debride Tissue/Muscle/Bone,PX11044F,CDM,510,RC,11044,CPT,,,,,,,,1082,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,646.83,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.56,646.83
Debride Tissue/Muscle/Bone,PX11044P,CDM,983,RC,11044,CPT,,,,,,,,866,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,646.83,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.56,848.68
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604F,CDM,510,RC,11604,CPT,,,,,,,,964,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,646.83,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.63,646.83
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604P,CDM,983,RC,11604,CPT,,,,,,,,1422,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,646.83,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.63,1393.56
Jak2 Gene - Ref,PX8127090,CDM,300,RC,81270,CPT,90,,,,,,,734,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,647.388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.04,719.32
tiotropium 18 MCG capsule 5 Each Box,63700001,CDM,250,RC,,,,,,597007575,NDC,5,EA,665.18,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,647.419694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Lap Sleeve Gastrectomy,PX43775,CDM,982,RC,43775,CPT,,,,,,,,5030,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,647.69,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,645.08,4929.4
CT Soft Tissue Neck W/O Dye,PX7049001,CDM,350,RC,70490,CPT,TC,,,,,,,711,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,647.721,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,1198.67
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423F,CDM,510,RC,11423,CPT,,,,,,,,711,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,647.721,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,295.3494,1416.38
"Hemorrhoidectomy,Int/Ext,Complx",PX46260F,CDM,750,RC,46260,CPT,,,,,,,,1350,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,560.79,2452.93
"Hemorrhoidectomy,Int/Ext,Complx",PX46260F,CDM,750,RC,46260,CPT,,,,,,,,1350,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,560.79,2452.93
Leukoreduced Platelets,PXP9035,CDM,390,RC,P9035,HCPCS,,,,,,,,1350,,Health Partners,Health Partners Care Plans,both,48,,625.95,percent of total billed charges,648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,433.08,1323
Leukoreduced Platelets,PXP9035,CDM,390,RC,P9035,HCPCS,,,,,,,,1350,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,433.08,1323
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,70839036204,NDC,4,ML,1280.66,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,648.01396,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
HERNIA PATCH VENTRALEX MEDIUM,C1781,CDM,278,RC,C1781,HCPCS,,10202-MAIN,LOCAL,,,,,1309.75,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,648.32625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
MESH VENTRALIGHT ECHO 2.0 POSITIONING 11CM ROUND,120.525,CDM,278,RC,C1781,HCPCS,,12219-MAIN,LOCAL,,,,,1310,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,648.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,544.174,1283.8
Biopsy of Rectum,PX45100F,CDM,510,RC,45100,CPT,,,,,,,,763,,First Health,Commercial,both,85,,999999999,percent of total billed charges,648.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,316.9502,2452.93
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004164,NDC,1,EA,666.52,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,648.723916,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004110,NDC,1,EA,666.53,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,648.733649,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
Fluoroscopy Guid Needle Plcmt Tc,PX7700201,CDM,320,RC,77002,CPT,TC,,,,,,,662,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,648.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.9948,648.76
"Needle Biopsy, Lymph Node(S)",PX38505F,CDM,510,RC,38505,CPT,,,,,,,,667,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,649.1911,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,277.0718,1416.38
HERNIA PATCH VENTRALEX LARGE,C1781,CDM,278,RC,C1781,HCPCS,,10201-MAIN,LOCAL,,,,,1325.08,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,196.035,percent of total billed charges,649.2892,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
HERNIA PATCH VENTRALEX LARGE,C1781,CDM,278,RC,C1781,HCPCS,,10201-MAIN,LOCAL,,,,,1325.08,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,649.2892,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
HERNIA PATCH VENTRALEX LARGE,C1781,CDM,278,RC,C1781,HCPCS,,10201-MAIN,LOCAL,,,,,1325.08,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,649.2892,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Repr Superf Wnd Face >30cm,PX12018F,CDM,510,RC,12018,CPT,,,,,,,,713,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,649.543,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,698.74
"Incis/Drain Shldr Absc/Hema,Deep",PX23030P,CDM,983,RC,23030,CPT,,,,,,,,1564,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,649.6856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,649.6856,2482.37
"Excise Lesion,Back or Flank",PX21930F,CDM,510,RC,21930,CPT,,,,,,,,1326,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,649.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,550.8204,1416.38
"Excise Lesion,Back or Flank",PX21930F,CDM,510,RC,21930,CPT,,,,,,,,1326,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,649.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,550.8204,1416.38
"Excise Lesion,Back or Flank",PX21930F,CDM,510,RC,21930,CPT,,,,,,,,1326,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,649.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,550.8204,1416.38
"Freeing Bowel Adhesion,Enterolysis",PX44005F,CDM,360,RC,44005,CPT,,,,,,,,2744,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,649.87,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,649.87,2262.88
Part Remv Phalanx of Toe,PX28124P,CDM,983,RC,28124,CPT,,,,,,,,1515,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,649.935,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,629.331,2827.75
"Fac/Exc Skn Beni1.1-2cm Fce,Facial",PX11442F,CDM,510,RC,11442,CPT,,,,,,,,668,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,650.1644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,277.4872,654.64
"Amputation Toe,I-P Jt",PX28825F,CDM,510,RC,28825,CPT,,,,,,,,1327,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,650.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,551.2358,2827.75
"Amputation Toe,I-P Jt",PX28825F,CDM,510,RC,28825,CPT,,,,,,,,1327,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,650.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,551.2358,2827.75
"Amputation Toe,I-P Jt",PX28825F,CDM,510,RC,28825,CPT,,,,,,,,1327,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,650.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,551.2358,2827.75
Lap Rpr Vent Umbilical Hernia Incarcerated or Strangulated,PX49653P,CDM,983,RC,49653,CPT,,,,,,,,1327,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,650.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,551.2358,1291.5691
Lap Rpr Vent Umbilical Hernia Incarcerated or Strangulated,PX49653P,CDM,983,RC,49653,CPT,,,,,,,,1327,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,650.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,551.2358,1291.5691
Lap Rpr Vent Umbilical Hernia Incarcerated or Strangulated,PX49653P,CDM,983,RC,49653,CPT,,,,,,,,1327,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,650.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,551.2358,1291.5691
Closed Rx Shldr Dislocation,PX23650F,CDM,510,RC,23650,CPT,,,,,,,,689,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,650.29,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.18,720.86
Closed Rx Shldr Dislocation,PX23650P,CDM,983,RC,23650,CPT,,,,,,,,516,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,650.29,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.18,720.86
"Freeing Bowel Adhesion,Enterolysis",PX44005F,CDM,360,RC,44005,CPT,,,,,,,,2744,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,650.3,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,649.87,2262.88
"Freeing Bowel Adhesion,Enterolysis",PX44005F,CDM,360,RC,44005,CPT,,,,,,,,2744,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,650.3,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,649.87,2262.88
cycloPHOSphamide 500 MG Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781323394,NDC,1,EA,1565.71,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,650.395934,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
gadoterate meglumine 10 mmol/20 mL Solution 20 mL Vial,A9575,CDM,636,RC,A9575,HCPCS,,,,67684200003,NDC,20,ML,668.27,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,2.09908,percent of total billed charges,650.427191,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,277.599358,654.9046
"Fac/Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602F,CDM,510,RC,11602,CPT,,,,,,,,731,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,650.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,303.6574,716.38
"Colonoscopy,Flex,Diagnostic",PX45378F,CDM,750,RC,45378,CPT,,,,,,,,1286,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,650.716,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,551.694,4661.91
Low Dose CT Lung Ca Screen WO Contrast,PX7127101,CDM,350,RC,71271,CPT,TC,,,,,,,1286,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,650.716,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,1260.28
Xray Cervical Spine 4 or 5 Vws,PX7205001,CDM,320,RC,72050,CPT,TC,,,,,,,664,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,650.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,650.72
Xray Cervical Spine 6 or More Vws,PX7205201,CDM,320,RC,72052,CPT,TC,,,,,,,664,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,650.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,650.72
carboprost 250 MCG/ML Solution 1 mL Ampule,25000000,CDM,250,RC,,,,,,9085608,NDC,1,ML,1517.13,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,650.84877,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Repair Lip,>1/2 Vert Height",PX40654P,CDM,983,RC,40654,CPT,,,,,,,,1329,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,651.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,552.0666,1332.3
"Repair Lip,>1/2 Vert Height",PX40654P,CDM,983,RC,40654,CPT,,,,,,,,1329,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,651.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,552.0666,1332.3
"Repair Lip,>1/2 Vert Height",PX40654P,CDM,983,RC,40654,CPT,,,,,,,,1329,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,651.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,552.0666,1332.3
"Lap,Inguinal Hernia Repr,Recur",PX49651F,CDM,510,RC,49651,CPT,,,,,,,,1568,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,651.3472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,651.3472,5040.74
"Sigmoidoscopy,Biopsy",PX45331P,CDM,983,RC,45331,CPT,,,,,,,,1316,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,651.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,546.6664,1280.8628
"Excis Arm/Elbow Tumor,Subcutan",PX24075F,CDM,510,RC,24075,CPT,,,,,,,,1519,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,651.651,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,630.9926,1488.62
diazePAM 2.5 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,66490065020,NDC,1,EA,1288,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,651.728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PROSTEP HV SCREW 3.0X16MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12986-MAIN,LOCAL,,,,,1569,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,651.7626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
tiotropium 18 MCG capsule 5 Each Box,63700001,CDM,250,RC,,,,,,597007575,NDC,5,EA,665.18,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,651.8764,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Complex Drainage, Wound",PX10180P,CDM,983,RC,10180,CPT,,,,,,,,767,,First Health,Commercial,both,85,,999999999,percent of total billed charges,651.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,318.6118,2482.37
perflutren protein A microsphere Suspension 3 mL Vial,Q9956,CDM,636,RC,Q9956,HCPCS,,,,407270703,NDC,3,ML,739.41,,United Healthcare,All Payer,outpatient,88.2,,176.877,percent of total billed charges,652.15962,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,307.150914,724.6218
Removal of Anal Tabs,PX46230F,CDM,510,RC,46230,CPT,,,,,,,,790,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,652.37,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.32,652.37
Removal of Anal Tabs,PX46230P,CDM,983,RC,46230,CPT,,,,,,,,1435,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,652.37,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.32,1406.3
US Doppler Lw Ext Art Tc,PX9392601,CDM,921,RC,93926,CPT,TC,,,,,,,740,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,652.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,725.2
ADVANCED INSTRUMENTS 8MM SYNCHROSEAL IS4000,27200000,CDM,272,RC,,,,11924-MAIN,LOCAL,,,,,1290,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,652.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059303,NDC,1,EA,740.19,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,652.84758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.10077,725.3862
"Lap,Inguinal Hernia Repr,Initial",PX49650P,CDM,983,RC,49650,CPT,,,,,,,,717,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,653.187,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,297.8418,5040.74
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004164,NDC,1,EA,666.52,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,653.1896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004110,NDC,1,EA,666.53,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,653.1994,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
Jak2 Gene - Ref,PX8127090,CDM,300,RC,81270,CPT,90,,,,,,,734,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,653.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.04,719.32
"Layr Clos Wnd Face,Facial <2.5cm",PX12051F,CDM,510,RC,12051,CPT,,,,,,,,769,,First Health,Commercial,both,85,,999999999,percent of total billed charges,653.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,319.4426,753.62
"Needle Biopsy, Lymph Node(S)",PX38505F,CDM,510,RC,38505,CPT,,,,,,,,667,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,653.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,277.0718,1416.38
"Molecular Path Proc, Level 2 - Ref",PX8140190,CDM,310,RC,81401,CPT,90,,,,,,,672,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,654.0576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.62,658.56
Art Upper Extremity-Ltd,PX9393101,CDM,921,RC,93931,CPT,TC,,,,,,,718,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,654.098,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,703.64
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606F,CDM,510,RC,11606,CPT,,,,,,,,1432,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,654.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,193.93,933.24
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606P,CDM,983,RC,11606,CPT,,,,,,,,2044,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,654.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,193.93,2003.12
Drain Pilonidal Cyst Simpl,PX10080F,CDM,510,RC,10080,CPT,,,,,,,,742,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,654.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,308.2268,727.16
Fna W/Image,PX10022F,CDM,510,RC,10022,CPT,,,,,,,,742,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,654.444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,308.2268,727.16
"Fac/Exc Skn Beni1.1-2cm Fce,Facial",PX11442F,CDM,510,RC,11442,CPT,,,,,,,,668,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,654.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,277.4872,654.64
gadoterate meglumine 10 mmol/20 mL Solution 20 mL Vial,A9575,CDM,636,RC,A9575,HCPCS,,,,67684200003,NDC,20,ML,668.27,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,654.9046,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,277.599358,654.9046
"Fac/Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601F,CDM,510,RC,11601,CPT,,,,,,,,673,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,655.0309,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,279.5642,659.54
Closed Rx Metacarpal Fx,PX26600F,CDM,510,RC,26600,CPT,,,,,,,,443,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,655.13,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,187.83,655.13
Closed Rx Metacarpal Fx,PX26600P,CDM,983,RC,26600,CPT,,,,,,,,295,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,655.13,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,187.83,655.13
Irradiated Leukoreduced Rbc's,PXP9040,CDM,390,RC,P9040,HCPCS,,,,,,,,771,,First Health,Commercial,both,85,,999999999,percent of total billed charges,655.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,231.5,755.58
diazePAM 10 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,187065820,NDC,1,EA,1527.87,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,655.45623,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Heart/Lung Resuscitation (Cpr),PX92950F,CDM,480,RC,92950,CPT,,,,,,,,1366,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,655.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.21,1338.68
Heart/Lung Resuscitation (Cpr),PX92950F,CDM,480,RC,92950,CPT,,,,,,,,1366,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,655.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.21,1338.68
Colonoscopy,PX44388F,CDM,750,RC,44388,CPT,,,,,,,,930,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,655.83,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.89,655.83
Colonoscopy,PX44388P,CDM,983,RC,44388,CPT,,,,,,,,620,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,655.83,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,94.89,655.83
HERNIA PATCH VENTRALEX LARGE,C1781,CDM,278,RC,C1781,HCPCS,,10201-MAIN,LOCAL,,,,,1325.08,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,655.9146,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Sigmoidoscopy,Diagnostic",PX45330F,CDM,510,RC,45330,CPT,,,,,,,,720,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,655.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,299.088,798.45
GRAFIXPL PRIME PLACENTAL MEMBRANE 1.5 x2CM 3SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12764-MAIN,LOCAL,,,,,1529,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,655.941,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573F,CDM,761,RC,36573,CPT,,,,,,,,1529,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,655.941,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,635.1466,1498.42
Lap Rpr Vent Umbilical Hernia,PX49652F,CDM,510,RC,49652,CPT,,,,,,,,1890,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,656.0073,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,656.0073,656.01
Lap Rpr Vent Umbilical Hernia,PX49652P,CDM,983,RC,49652,CPT,,,,,,,,1260,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,656.0073,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,656.0073,1234.8
Lap Rpr Vent Umbilical Hernia,PX49652F,CDM,510,RC,49652,CPT,,,,,,,,1890,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,656.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,656.0073,656.01
Lap Rpr Vent Umbilical Hernia,PX49652P,CDM,983,RC,49652,CPT,,,,,,,,1260,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,656.01,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,656.0073,1234.8
Multiple Sleep Latency Test,PX9580501,CDM,740,RC,95805,CPT,TC,,,,,,,4313,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,656.16,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,238.66,656.16
Multiple Sleep Latency Test,PX9580501,CDM,740,RC,95805,CPT,TC,,,,,,,4313,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,656.16,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,238.66,656.16
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12173-SURG,LOCAL,,,,,772,,First Health,Commercial,both,85,,999999999,percent of total billed charges,656.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Excise Lesion,Back or Flank",PX21930F,CDM,510,RC,21930,CPT,,,,,,,,1326,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,656.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,550.8204,1416.38
"Layr Clos Wnd Face,Facial 2.5-5",PX12052F,CDM,510,RC,12052,CPT,,,,,,,,585,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,656.52,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.22,656.52
"Layr Clos Wnd Face,Facial 2.5-5",PX12052P,CDM,983,RC,12052,CPT,,,,,,,,776,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,656.52,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.22,760.48
zoledronic acid 5 MG/100ML Solution 100 mL Bottle,J3489.01,CDM,636,RC,J3489,HCPCS,,,,55111068852,NDC,100,ML,1368,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,656.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
zoledronic acid 5 MG/100ML Solution 100 mL Bottle,J3489.01,CDM,636,RC,J3489,HCPCS,,,,55111068852,NDC,100,ML,1368,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,656.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,63323096600,NDC,100,ML,1368,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,656.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,63323096600,NDC,100,ML,1368,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,656.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
"Amputation Toe,I-P Jt",PX28825F,CDM,510,RC,28825,CPT,,,,,,,,1327,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,656.865,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,551.2358,2827.75
Lap Rpr Vent Umbilical Hernia Incarcerated or Strangulated,PX49653P,CDM,983,RC,49653,CPT,,,,,,,,1327,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,656.865,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,551.2358,1291.5691
glucagon rdna (diagnostic) 1 MG Recon Soln 1 Each Vial,J1610.01,CDM,636,RC,J1610,HCPCS,,,,597026010,NDC,1,EA,744.84,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,656.94888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,172.71,729.9432
Injection for Shoulder Arthrogram,PX23350F,CDM,510,RC,23350,CPT,,,,,,,,675,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,656.9775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,280.395,661.5
I&D Deep Absc/Hematoma Neck/Chest,PX21501F,CDM,510,RC,21501,CPT,,,,,,,,773,,First Health,Commercial,both,85,,999999999,percent of total billed charges,657.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.1042,2482.37
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034P,CDM,983,RC,12034,CPT,,,,,,,,1533,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,657.657,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1492.0689
"Amputation Toe,Mt-P Jt",PX28820P,CDM,983,RC,28820,CPT,,,,,,,,1300,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,657.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,540.02,2827.75
umeclidinium-vilanterol 62.5-25 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173086906,NDC,14,EA,745.86,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,657.84852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Repair Lip,>1/2 Vert Height",PX40654P,CDM,983,RC,40654,CPT,,,,,,,,1329,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,657.855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,552.0666,1332.3
Explor Metatarso-Phalang Jt,PX28022P,CDM,983,RC,28022,CPT,,,,,,,,774,,First Health,Commercial,both,85,,999999999,percent of total billed charges,657.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.5196,2827.75
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132P,CDM,983,RC,13132,CPT,,,,,,,,774,,First Health,Commercial,both,85,,999999999,percent of total billed charges,657.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.5196,753.3342
Direct Admit Hospital Observ,PXG0379,CDM,761,RC,G0379,HCPCS,,,,,,,,676,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,391.35,percent of total billed charges,657.9508,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,280.8104,662.48
perflutren protein A microsphere Suspension 3 mL Vial,Q9956,CDM,636,RC,Q9956,HCPCS,,,,407270703,NDC,3,ML,739.41,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,658.0749,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,307.150914,724.6218
oseltamivir 6 MG/ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,68180067801,NDC,60,ML,676.25,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,658.194125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Molecular Path Proc, Level 2 - Ref",PX8140190,CDM,310,RC,81401,CPT,90,,,,,,,672,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,658.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.62,658.56
US Doppler Lw Ext Art Tc,PX9392601,CDM,921,RC,93926,CPT,TC,,,,,,,740,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,658.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,725.2
Room Rate Transitional Care Private,PX11900000,CDM,119,RC,,,,,,,,,,775,,First Health,Commercial,both,85,,999999999,percent of total billed charges,658.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.935,759.5
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059303,NDC,1,EA,740.19,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,658.7691,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.10077,725.3862
2.1MM CANNULATED DRILL BIT,27200000,CDM,272,RC,,,,12657-MAIN,LOCAL,,,,,747,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,658.854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
US Guide Needle Bx S&I,PX7694201,CDM,402,RC,76942,CPT,TC,,,,,,,747,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,658.854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.3038,732.06
brimonidine 0.15 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314014405,NDC,5,ML,723.62,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,659.21782,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725F,CDM,510,RC,26725,CPT,,,,,,,,495,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,659.29,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,196.55,740.92
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725P,CDM,983,RC,26725,CPT,,,,,,,,330,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,659.29,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,196.55,740.92
"Fac/Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601F,CDM,510,RC,11601,CPT,,,,,,,,673,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,659.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,279.5642,659.54
"Layr Clos Wnd Face,Facial 2.5-5",PX12052P,CDM,983,RC,12052,CPT,,,,,,,,776,,First Health,Commercial,both,85,,999999999,percent of total billed charges,659.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,322.3504,755.2808
Temporary External Pacing,PX92953F,CDM,480,RC,92953,CPT,,,,,,,,678,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,659.8974,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,281.6412,664.44
PEMEtrexed Disodium 100 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2764001,NDC,1,EA,1539.32,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,660.36828,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.01,7924.2996
Drain Pilonidal Cyst Simpl,PX10080F,CDM,510,RC,10080,CPT,,,,,,,,742,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,660.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,308.2268,727.16
Fna W/Image,PX10022F,CDM,510,RC,10022,CPT,,,,,,,,742,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,660.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,308.2268,727.16
Layr Clos Wnd Rest Body 2.6-7.5,PX12042P,CDM,983,RC,12042,CPT,,,,,,,,777,,First Health,Commercial,both,85,,999999999,percent of total billed charges,660.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,322.7658,756.2541
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502050102,NDC,1,EA,1305.38,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,660.52228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
"Fac/Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404F,CDM,510,RC,11404,CPT,,,,,,,,749,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,660.618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,311.1346,1416.38
Repair Incis Hernia W Mesh,PX49568F,CDM,510,RC,49568,CPT,,,,,,,,1540,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,660.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,639.716,1509.2
"Fac/Ex Skn Bngn2.1-3cm Trnk,Arm,Lg",PX11403F,CDM,510,RC,11403,CPT,,,,,,,,679,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,660.8707,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,282.0566,665.42
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605P,CDM,983,RC,24605,CPT,,,,,,,,750,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,661.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,311.55,1404.08
"Hemorrhoidectomy,Int/Ext,Complx",PX46260F,CDM,750,RC,46260,CPT,,,,,,,,1350,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,461.815,percent of total billed charges,661.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,560.79,2452.93
"Hemorrhoidectomy,Int/Ext,Complx",PX46260F,CDM,750,RC,46260,CPT,,,,,,,,1350,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,661.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,560.79,2452.93
"Hemorrhoidectomy,Int/Ext,Complx",PX46260F,CDM,750,RC,46260,CPT,,,,,,,,1350,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,661.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,560.79,2452.93
Injection for Shoulder Arthrogram,PX23350F,CDM,510,RC,23350,CPT,,,,,,,,675,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,661.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,280.395,661.5
Leukoreduced Platelets,PXP9035,CDM,390,RC,P9035,HCPCS,,,,,,,,1350,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,661.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,433.08,1323
Leukoreduced Platelets,PXP9035,CDM,390,RC,P9035,HCPCS,,,,,,,,1350,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,661.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,433.08,1323
Leukoreduced Platelets,PXP9035,CDM,390,RC,P9035,HCPCS,,,,,,,,1350,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,661.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,433.08,1323
Sigmoidoscope W/Submuc Inj,PX45335F,CDM,750,RC,45335,CPT,,,,,,,,750,,United Healthcare,All Payer,outpatient,88.2,,999999999,case rate,661.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,661.5,6141.46
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010202,NDC,1,EA,680,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,229.0777778,percent of total billed charges,661.844,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 1 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010101,NDC,1,EA,680,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,229.0777778,percent of total billed charges,661.844,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010102,NDC,1,EA,680,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,229.0777778,percent of total billed charges,661.844,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
"Fac/Exc Skn Mal 0.6-1cm Fce,Facial",PX11641F,CDM,510,RC,11641,CPT,,,,,,,,680,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,661.844,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,282.472,666.4
Observation Initial,PXG0378.03,CDM,762,RC,G0378,HCPCS,,,,,,,,680,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,52.74723866,percent of total billed charges,661.844,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,282.472,666.4
Closed Rx Bimalleolar Fx,PX27808F,CDM,510,RC,27808,CPT,,,,,,,,650,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,662.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.17,727.77
Closed Rx Bimalleolar Fx,PX27808P,CDM,983,RC,27808,CPT,,,,,,,,433,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,662.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.17,727.77
"Closed Rx Trimalleolar Fx,Manip",PX27818P,CDM,983,RC,27818,CPT,,,,,,,,1352,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,662.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,561.6208,1404.08
"Closed Rx Trimalleolar Fx,Manip",PX27818P,CDM,983,RC,27818,CPT,,,,,,,,1352,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,662.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,561.6208,1404.08
"Closed Rx Trimalleolar Fx,Manip",PX27818P,CDM,983,RC,27818,CPT,,,,,,,,1352,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,662.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,561.6208,1404.08
Direct Admit Hospital Observ,PXG0379,CDM,761,RC,G0379,HCPCS,,,,,,,,676,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,662.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,280.8104,662.48
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016425,NDC,1,ML,779.43,,First Health,Commercial,both,85,,999999999,percent of total billed charges,662.5155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.66,898.7384
oseltamivir 6 MG/ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,68180067801,NDC,60,ML,676.25,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,662.725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"rabies vaccine, pcec Recon Susp 1 Each Vial",90675,CDM,636,RC,90675,CPT,,,,58160096412,NDC,1,EA,1544.83,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,662.73207,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,297.75,1513.9334
HERNIA PATCH VENTRALEX MEDIUM,C1781,CDM,278,RC,C1781,HCPCS,,10202-MAIN,LOCAL,,,,,1309.75,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,662.7335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Repr Superf Wnd Face 2.6-5,PX12013P,CDM,983,RC,12013,CPT,,,,,,,,681,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,51.02,percent of total billed charges,662.8173,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,662.8173
MESH VENTRALIGHT ECHO 2.0 POSITIONING 11CM ROUND,120.525,CDM,278,RC,C1781,HCPCS,,12219-MAIN,LOCAL,,,,,1310,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,662.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,544.174,1283.8
glucagon rdna (diagnostic) 1 MG Recon Soln 1 Each Vial,J1610.01,CDM,636,RC,J1610,HCPCS,,,,597026010,NDC,1,EA,744.84,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,662.9076,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,172.71,729.9432
Closed Rx IP Jt Dislocation,PX26770P,CDM,983,RC,26770,CPT,,,,,,,,1353,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,662.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1316.8749
Closed Rx IP Jt Dislocation,PX26770P,CDM,983,RC,26770,CPT,,,,,,,,1353,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,662.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1316.8749
Closed Rx IP Jt Dislocation,PX26770P,CDM,983,RC,26770,CPT,,,,,,,,1353,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,662.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1316.8749
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021083082,NDC,100,ML,1596,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,662.9784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
"Amputation Toe,I-P Jt",PX28825P,CDM,983,RC,28825,CPT,,,,,,,,780,,First Health,Commercial,both,85,,999999999,percent of total billed charges,663,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,324.012,2827.75
perflutren lipid microsphere 6.52 MG/ML Suspension 2 mL Vial,Q9957,CDM,636,RC,Q9957,HCPCS,,,,11994001101,NDC,2,ML,751.71,,United Healthcare,All Payer,outpatient,88.2,,242.2966667,percent of total billed charges,663.00822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,312.260334,736.6758
"Closed Rx Dist Fibula Fx,Manip",PX27788F,CDM,510,RC,27788,CPT,,,,,,,,1597,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,663.3938,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1565.06
methylene blue 50 MG/10ML Solution 10 mL Ampule,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,517037405,NDC,10,ML,1382.12,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,663.4176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.29,1354.4776
methylene blue 50 MG/10ML Solution 10 mL Ampule,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,517037405,NDC,10,ML,1382.12,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,663.4176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.29,1354.4776
liraglutide 18 MG/3ML solution pen-injector 3 mL Pen,63700001,CDM,250,RC,,,,,,169406013,NDC,3,ML,1382.75,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,663.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
liraglutide 18 MG/3ML solution pen-injector 3 mL Pen,63700001,CDM,250,RC,,,,,,169406013,NDC,3,ML,1382.75,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,663.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
umeclidinium-vilanterol 62.5-25 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173086906,NDC,14,EA,745.86,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,663.8154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oseltamivir 6 MG/ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,4082205,NDC,60,ML,752.82,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,663.98724,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Exc Neck Les Sc = 3cm >,PX21552F,CDM,510,RC,21552,CPT,,,,,,,,753,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,664.146,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,312.7962,2482.37
Temporary External Pacing,PX92953F,CDM,480,RC,92953,CPT,,,,,,,,678,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,664.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,281.6412,664.44
Or Level 1,PX36000001,CDM,360,RC,,,,,,,,,,1600,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,664.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,664.64,1568
"Remv Foot Foreign Body,Subcutaneous",PX28190P,CDM,983,RC,28190,CPT,,,,,,,,683,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,664.7639,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,283.7182,664.7639
POWERPORT ISP MRI IMPLANTABLE PORT 8FR,C1788,CDM,278,RC,C1788,HCPCS,,11998-MAIN,LOCAL,,,,,1385,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,664.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,575.329,1357.3
POWERPORT ISP MRI IMPLANTABLE PORT 8FR,C1788,CDM,278,RC,C1788,HCPCS,,11998-MAIN,LOCAL,,,,,1385,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,664.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,575.329,1357.3
2.1MM CANNULATED DRILL BIT,27200000,CDM,272,RC,,,,12657-MAIN,LOCAL,,,,,747,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,664.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
US Guide Needle Bx S&I,PX7694201,CDM,402,RC,76942,CPT,TC,,,,,,,747,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,664.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.3038,732.06
Fac/Cystourethroscopy,PX52000F,CDM,761,RC,52000,CPT,,,,,,,,1601,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,665.0554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,596.77,1568.98
albuterol-ipratropium 20-100 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597002402,NDC,4,GR,1601.75,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,665.36695,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Fac/Ex Skn Bngn2.1-3cm Trnk,Arm,Lg",PX11403F,CDM,510,RC,11403,CPT,,,,,,,,679,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,665.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,282.0566,665.42
"Spinal Puncture,Lumbar,Diagnostic",PX62270F,CDM,510,RC,62270,CPT,,,,,,,,684,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,464.08,percent of total billed charges,665.7372,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,284.1336,670.32
"Thrombolytic Therapy, Stroke",PX37195F,CDM,761,RC,37195,CPT,,,,,,,,595,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,665.83,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,399.1273,665.83
"Sigmoidoscopy,Biopsy",PX45331P,CDM,983,RC,45331,CPT,,,,,,,,1316,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,665.896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,546.6664,1280.8628
"HERNIA MESH 3D MAX MID ANATOMICAL MESH LEFT SIZE L 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,11976-MAIN,LOCAL,,,,,755,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,665.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"HERNIA MESH 3D MAX MID ANATOMICAL MESH RIGHT SIZE L 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,11977-MAIN,LOCAL,,,,,755,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,665.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Fac/Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602F,CDM,510,RC,11602,CPT,,,,,,,,731,,Medica,Commercial,both,91.1,,113.795,percent of total billed charges,665.941,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,303.6574,716.38
"Exc Skn Bnig >4cmtrnk,Arm,Leg",PX11406P,CDM,983,RC,11406,CPT,,,,,,,,1456,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,666.2,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,153.14,1426.88
"Fac/Exc Skn Benig >4cm Trnk,Arm,Lg",PX11406F,CDM,510,RC,11406,CPT,,,,,,,,1127,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,666.2,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,153.14,666.2
Abd Duplex Abd -Follow Up,PX9397602,CDM,921,RC,93976,CPT,TC,,,,,,,784,,First Health,Commercial,both,85,,999999999,percent of total billed charges,666.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,768.32
Art Lower Extremity+Upper,PX9392301,CDM,921,RC,93923,CPT,TC,,,,,,,784,,First Health,Commercial,both,85,,999999999,percent of total billed charges,666.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.46,768.32
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010202,NDC,1,EA,680,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,666.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 1 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010101,NDC,1,EA,680,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,666.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010102,NDC,1,EA,680,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,666.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
"Fac/Exc Skn Mal 0.6-1cm Fce,Facial",PX11641F,CDM,510,RC,11641,CPT,,,,,,,,680,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,666.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,282.472,666.4
Observation Initial,PXG0378.03,CDM,762,RC,G0378,HCPCS,,,,,,,,680,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,666.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,282.472,666.4
"Fac/Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404F,CDM,510,RC,11404,CPT,,,,,,,,749,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,666.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,311.1346,1416.38
CT Angio Lwr Extr W/O&W/Dye,PX7370601,CDM,350,RC,73706,CPT,TC,,,,,,,1554,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,666.666,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1522.92
"Casiri and Imdevimab,Admin,Repeat Dose",PXM0240,CDM,771,RC,M0240,HCPCS,,,,,,,,1555,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,667.095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,413.06,1523.9
"IV Infusion, Bamlanivimab and Etesevimab, Infusion and Monitoring",PXM0245,CDM,260,RC,M0245,HCPCS,,,,,,,,1555,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,667.095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,413.06,1523.9
"IV Infusion, Casirivimab and Imdevimab, IV and Post Admr",PXM0243,CDM,771,RC,M0243,HCPCS,,,,,,,,1555,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,667.095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,413.06,1684.87
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605P,CDM,983,RC,25605,CPT,,,,,,,,785,,First Health,Commercial,both,85,,999999999,percent of total billed charges,667.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,326.089,1404.08
Layr Clos Wnd Rest Body 7.6-12.5,PX12044F,CDM,510,RC,12044,CPT,,,,,,,,785,,First Health,Commercial,both,85,,999999999,percent of total billed charges,667.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,326.089,769.3
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310001,NDC,0.528,ML,785.14,,First Health,Commercial,both,85,,999999999,percent of total billed charges,667.369,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.22,877.002
Repr Superf Wnd Face 2.6-5,PX12013P,CDM,983,RC,12013,CPT,,,,,,,,681,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,667.38,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.03,667.38
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605P,CDM,983,RC,24605,CPT,,,,,,,,750,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,667.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,311.55,1404.08
Sigmoidoscope W/Submuc Inj,PX45335F,CDM,750,RC,45335,CPT,,,,,,,,750,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,667.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,311.55,798.45
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591F,CDM,360,RC,49591,CPT,,,,,,,,1556,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,667.524,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,646.3624,3022.41
"Lap,Cholecystectomy/Graph",PX47563F,CDM,510,RC,47563,CPT,,,,,,,,1556,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,667.524,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,646.3624,5040.74
Excis Forearm/Wrist Tumor Subcutan,PX25075F,CDM,510,RC,25075,CPT,,,,,,,,1421,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,667.59,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,198.51,1082.67
Excis Forearm/Wrist Tumor Subcutan,PX25075P,CDM,983,RC,25075,CPT,,,,,,,,607,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,667.59,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,198.51,1082.67
CT Angio Upr Extrm W/O&W/Dye,PX7320601,CDM,350,RC,73206,CPT,TC,,,,,,,757,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,667.674,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
"Inject Nerv Blck,Othr Periph Nerv",PX64450F,CDM,510,RC,64450,CPT,,,,,,,,757,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,667.674,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,314.4578,741.86
Partial Bone Scan,PX7830001,CDM,341,RC,78300,CPT,TC,,,,,,,1391,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,667.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,360.31,1363.18
Partial Bone Scan,PX7830001,CDM,341,RC,78300,CPT,TC,,,,,,,1391,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,667.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,360.31,1363.18
prednisoLONE acetate 0.12 % Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,11980017405,NDC,5,ML,757.07,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,667.73574,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595F,CDM,360,RC,49595,CPT,,,,,,,,3503,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,667.888,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,453.53,1595.98
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595P,CDM,982,RC,49595,CPT,,,,,,,,3503,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,667.888,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,453.53,3432.94
"Hemorrhoidectomy,Int/Ext,Complx",PX46260F,CDM,750,RC,46260,CPT,,,,,,,,1350,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,668.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,560.79,2452.93
Leukoreduced Platelets,PXP9035,CDM,390,RC,P9035,HCPCS,,,,,,,,1350,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,668.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,433.08,1323
"Lap,Cholecystectomy/Explore",PX47564F,CDM,510,RC,47564,CPT,,,,,,,,2419,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,668.41,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,668.41,2327.91
"Lap,Cholecystectomy/Explore",PX47564P,CDM,983,RC,47564,CPT,,,,,,,,1613,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,668.41,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,668.41,2327.91
Jak2 Gene - Ref,PX8127090,CDM,300,RC,81270,CPT,90,,,,,,,734,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,668.674,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.04,719.32
perflutren lipid microsphere 6.52 MG/ML Suspension 2 mL Vial,Q9957,CDM,636,RC,Q9957,HCPCS,,,,11994001101,NDC,2,ML,751.71,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,669.0219,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,312.260334,736.6758
"Closed Rx Trimalleolar Fx,Manip",PX27818P,CDM,983,RC,27818,CPT,,,,,,,,1352,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,669.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,561.6208,1404.08
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956401,NDC,1,EA,1611.2,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,669.29248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,409.66,1655.3866
Heart/Lung Resuscitation (Cpr),PX92950F,CDM,480,RC,92950,CPT,,,,,,,,1366,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,669.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.21,1338.68
Heart/Lung Resuscitation (Cpr),PX92950F,CDM,480,RC,92950,CPT,,,,,,,,1366,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,669.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.21,1338.68
Heart/Lung Resuscitation (Cpr),PX92950F,CDM,480,RC,92950,CPT,,,,,,,,1366,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,669.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.21,1338.68
"Remv Foot Foreign Body,Subcutaneous",PX28190P,CDM,983,RC,28190,CPT,,,,,,,,683,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,669.34,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.55,669.34
"Cardioversion, Elective;Extern",PX92960P,CDM,983,RC,92960,CPT,,,,,,,,688,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,669.6304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,285.7952,669.6304
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031F,CDM,510,RC,12031,CPT,,,,,,,,688,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,669.6304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,285.7952,674.24
Closed Rx IP Jt Dislocation,PX26770P,CDM,983,RC,26770,CPT,,,,,,,,1353,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,669.735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1316.8749
Abd Duplex Abd-Full,PX9397501,CDM,921,RC,93975,CPT,TC,,,,,,,788,,First Health,Commercial,both,85,,999999999,percent of total billed charges,669.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,772.24
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122F,CDM,510,RC,13122,CPT,,,,,,,,788,,First Health,Commercial,both,85,,999999999,percent of total billed charges,669.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,327.3352,772.24
oseltamivir 6 MG/ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,4082205,NDC,60,ML,752.82,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,670.0098,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Lap,Cholecystectomy/Explore",PX47564P,CDM,983,RC,47564,CPT,,,,,,,,1613,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,670.0402,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,670.0402,8992.74
Exc Neck Les Sc = 3cm >,PX21552F,CDM,510,RC,21552,CPT,,,,,,,,753,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,670.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,312.7962,2482.37
"Spinal Puncture,Lumbar,Diagnostic",PX62270F,CDM,510,RC,62270,CPT,,,,,,,,684,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,670.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,284.1336,670.32
zoledronic acid 5 MG/100ML Solution 100 mL Bottle,J3489.01,CDM,636,RC,J3489,HCPCS,,,,55111068852,NDC,100,ML,1368,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,57.34422222,percent of total billed charges,670.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
zoledronic acid 5 MG/100ML Solution 100 mL Bottle,J3489.01,CDM,636,RC,J3489,HCPCS,,,,55111068852,NDC,100,ML,1368,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,670.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
zoledronic acid 5 MG/100ML Solution 100 mL Bottle,J3489.01,CDM,636,RC,J3489,HCPCS,,,,55111068852,NDC,100,ML,1368,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,670.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,63323096600,NDC,100,ML,1368,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,57.34422222,percent of total billed charges,670.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,63323096600,NDC,100,ML,1368,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,670.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,63323096600,NDC,100,ML,1368,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,670.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
"US Guide, Vascular Access",PX7693701,CDM,402,RC,76937,CPT,TC,,,,,,,760,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,670.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,315.704,744.8
"Lap,Cholecystectomy/Explore",PX47564F,CDM,510,RC,47564,CPT,,,,,,,,2419,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,670.38,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,668.41,2327.91
"Lap,Cholecystectomy/Explore",PX47564F,CDM,510,RC,47564,CPT,,,,,,,,2419,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,670.38,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,668.41,2327.91
"Lap,Cholecystectomy/Explore",PX47564P,CDM,983,RC,47564,CPT,,,,,,,,1613,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,670.38,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,668.41,2327.91
"Lap,Cholecystectomy/Explore",PX47564P,CDM,983,RC,47564,CPT,,,,,,,,1613,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,670.38,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,668.41,2327.91
HERNIA PATCH VENTRALEX LARGE,C1781,CDM,278,RC,C1781,HCPCS,,10201-MAIN,LOCAL,,,,,1325.08,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,670.49048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Closed Rx Shldr Dislocation,PX23650F,CDM,510,RC,23650,CPT,,,,,,,,689,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,464.39,percent of total billed charges,670.6037,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,675.22
OBINutuzumab 1000 MG/40ML Solution 40 mL Vial,J9301.01,CDM,636,RC,J9301,HCPCS,,,,50242007001,NDC,4,ML,1397.15,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,670.632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.12,1369.207
OBINutuzumab 1000 MG/40ML Solution 40 mL Vial,J9301.01,CDM,636,RC,J9301,HCPCS,,,,50242007001,NDC,4,ML,1397.15,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,670.632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.12,1369.207
"Excise Lesion,Back or Flank",PX21930F,CDM,510,RC,21930,CPT,,,,,,,,1326,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,670.956,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,550.8204,1416.38
"Incis/Drain Shldr Absc/Hema,Deep",PX23030P,CDM,983,RC,23030,CPT,,,,,,,,1564,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,670.956,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,649.6856,2482.37
Incise Finger Tendon Sheath,PX26055F,CDM,510,RC,26055,CPT,,,,,,,,1398,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,671.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,580.7292,1404.08
Incise Finger Tendon Sheath,PX26055F,CDM,510,RC,26055,CPT,,,,,,,,1398,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,671.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,580.7292,1404.08
Amputation Finger/Thumb,PX26951F,CDM,510,RC,26951,CPT,,,,,,,,3253,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,671.4201,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,454.41,1480.45
Amputation Finger/Thumb,PX26951P,CDM,983,RC,26951,CPT,,,,,,,,2603,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,671.4201,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,454.41,2550.94
"Amputation Toe,I-P Jt",PX28825F,CDM,510,RC,28825,CPT,,,,,,,,1327,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,671.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,551.2358,2827.75
Lap Rpr Vent Umbilical Hernia Incarcerated or Strangulated,PX49653P,CDM,983,RC,49653,CPT,,,,,,,,1327,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,671.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,551.2358,1291.5691
Removal of Anal Tabs,PX46230F,CDM,510,RC,46230,CPT,,,,,,,,790,,First Health,Commercial,both,85,,999999999,percent of total billed charges,671.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,328.166,2452.93
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623F,CDM,510,RC,11623,CPT,,,,,,,,690,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,671.577,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,286.626,1416.38
cycloPHOSphamide 500 MG Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781323394,NDC,1,EA,1565.71,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,671.68959,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
Irrad/Lr Platelets,PXP9037,CDM,390,RC,P9037,HCPCS,,,,,,,,1617,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,671.7018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,616.6,1584.66
"HERNIA MESH 3D MAX MID ANATOMICAL MESH LEFT SIZE L 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,11976-MAIN,LOCAL,,,,,755,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,671.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"HERNIA MESH 3D MAX MID ANATOMICAL MESH RIGHT SIZE L 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,11977-MAIN,LOCAL,,,,,755,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,671.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
CT Orbit/Ear/Fossa W/O & W/Dye,PX7048201,CDM,350,RC,70482,CPT,TC,,,,,,,1400,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
CT Orbit/Ear/Fossa W/O & W/Dye,PX7048201,CDM,350,RC,70482,CPT,TC,,,,,,,1400,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
Excis Primary Ganglion Wrist,PX25111F,CDM,510,RC,25111,CPT,,,,,,,,791,,First Health,Commercial,both,85,,999999999,percent of total billed charges,672.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,328.5814,1404.08
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781324494,NDC,1,EA,1400.9,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,672.432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781324494,NDC,1,EA,1400.9,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,672.432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
"Repair Lip,>1/2 Vert Height",PX40654P,CDM,983,RC,40654,CPT,,,,,,,,1329,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,672.474,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,552.0666,1332.3
"Lap,Inguinal Hernia Repr,Recur",PX49651F,CDM,510,RC,49651,CPT,,,,,,,,1568,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,672.672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,651.3472,5040.74
moxifloxacin 0.5 % Solution 3 mL Bottle,25000000,CDM,250,RC,,,,,,60505058204,NDC,3,ML,691.15,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,672.696295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Biopsy of Rectum,PX45100F,CDM,510,RC,45100,CPT,,,,,,,,763,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,672.966,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,316.9502,2452.93
PROSTEP HV SCREW 3.0X16MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12986-MAIN,LOCAL,,,,,1569,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,673.101,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
filgrastim-ayow 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,800000,CDM,,,,,,,,70121157001,NDC,0.5,ML,691.62,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,673.153746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Xray Ribs Unilat 2 Vws With Pa Chest,PX7110101,CDM,320,RC,71101,CPT,TC,,,,,,,792,,First Health,Commercial,both,85,,999999999,percent of total billed charges,673.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,776.16
perflutren protein A microsphere Suspension 3 mL Vial,Q9956,CDM,636,RC,Q9956,HCPCS,,,,407270703,NDC,3,ML,739.41,,Medica,Commercial,both,91.1,,134.8922222,percent of total billed charges,673.60251,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,307.150914,724.6218
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,16714085701,NDC,1,EA,1403.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,673.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,16714085701,NDC,1,EA,1403.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,673.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
CT Angio Upr Extrm W/O&W/Dye,PX7320601,CDM,350,RC,73206,CPT,TC,,,,,,,757,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,673.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
"Inject Nerv Blck,Othr Periph Nerv",PX64450F,CDM,510,RC,64450,CPT,,,,,,,,757,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,673.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,314.4578,741.86
prednisoLONE acetate 0.12 % Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,11980017405,NDC,5,ML,757.07,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,673.7923,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
US Doppler Lw Ext Art Tc,PX9392601,CDM,921,RC,93926,CPT,TC,,,,,,,740,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,674.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,725.2
"Cardioversion, Elective;Extern",PX92960P,CDM,983,RC,92960,CPT,,,,,,,,688,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,674.24,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,67.41,674.24
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031F,CDM,510,RC,12031,CPT,,,,,,,,688,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,674.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,285.7952,674.24
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059303,NDC,1,EA,740.19,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,674.31309,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.10077,725.3862
liraglutide 18 MG/3ML solution pen-injector 3 mL Pen,63700001,CDM,250,RC,,,,,,169406012,NDC,3,ML,1405.33,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,674.5584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
liraglutide 18 MG/3ML solution pen-injector 3 mL Pen,63700001,CDM,250,RC,,,,,,169406012,NDC,3,ML,1405.33,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,674.5584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Lap Sleeve Gastrectomy,PX43775,CDM,982,RC,43775,CPT,,,,,,,,5030,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,674.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,674.85,4895.699
desflurane Solution 240 mL Bottle,25000000,CDM,250,RC,,,,,,10019064134,NDC,240,ML,793.95,,First Health,Commercial,both,85,,999999999,percent of total billed charges,674.8575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Closed Rx Femur Shaft Fx+Manip,PX27502F,CDM,510,RC,27502,CPT,,,,,,,,1625,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,675.025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,675.025,1592.5
Closed Rx Shldr Dislocation,PX23650F,CDM,510,RC,23650,CPT,,,,,,,,689,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,675.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,675.22
clobetasol 0.05 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,42291007760,NDC,60,GR,1625.97,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,675.427938,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Aspirate Pleura W/ Imaging,PX32555F,CDM,761,RC,32555,CPT,,,,,,,,795,,First Health,Commercial,both,85,,999999999,percent of total billed charges,675.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,330.243,779.1
Aspirate Pleura W/O Imaging,PX32554F,CDM,510,RC,32554,CPT,,,,,,,,795,,First Health,Commercial,both,85,,999999999,percent of total billed charges,675.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,330.243,779.1
Exc Abdom Tum Subfac > 5 Cm,PX22901F,CDM,761,RC,22901,CPT,,,,,,,,1408,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,675.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,584.8832,2482.37
Exc Abdom Tum Subfac > 5 Cm,PX22901F,CDM,761,RC,22901,CPT,,,,,,,,1408,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,675.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,584.8832,2482.37
"Hemorrhoidectomy,Int/Ext,Simple",PX46255F,CDM,510,RC,46255,CPT,,,,,,,,1627,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,675.8558,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,675.8558,2452.93
"Fusion Foot Bones,Midtarsal,Multi",PX28730F,CDM,510,RC,28730,CPT,,,,,,,,2299,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,675.9155,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,456.15,1517.12
Drain Pilonidal Cyst Simpl,PX10080F,CDM,510,RC,10080,CPT,,,,,,,,742,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,675.962,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,308.2268,727.16
Fna W/Image,PX10022F,CDM,510,RC,10022,CPT,,,,,,,,742,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,675.962,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,308.2268,727.16
Heart/Lung Resuscitation (Cpr),PX92950F,CDM,480,RC,92950,CPT,,,,,,,,1366,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,676.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.21,1338.68
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623F,CDM,510,RC,11623,CPT,,,,,,,,690,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,676.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,286.626,1416.38
"US Guide, Vascular Access",PX7693701,CDM,402,RC,76937,CPT,TC,,,,,,,760,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,676.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,315.704,744.8
"Complex Drainage, Wound",PX10180P,CDM,983,RC,10180,CPT,,,,,,,,767,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,676.494,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,318.6118,2482.37
rabies immune globulin 300 UNIT/ML Solution 1 mL Vial,90376,CDM,636,RC,90375,CPT,,,,13533031801,NDC,1,ML,1629.06,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,676.711524,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,281.51,1596.4788
"Freeing Bowel Adhesion,Enterolysis",PX44005F,CDM,360,RC,44005,CPT,,,,,,,,2744,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,677.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,677.12,2689.12
zoledronic acid 5 MG/100ML Solution 100 mL Bottle,J3489.01,CDM,636,RC,J3489,HCPCS,,,,55111068852,NDC,100,ML,1368,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,677.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,63323096600,NDC,100,ML,1368,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,677.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
methylene blue 50 MG/10ML Solution 10 mL Ampule,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,517037405,NDC,10,ML,1382.12,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,4.176666667,percent of total billed charges,677.2388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.29,1354.4776
methylene blue 50 MG/10ML Solution 10 mL Ampule,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,517037405,NDC,10,ML,1382.12,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,677.2388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.29,1354.4776
methylene blue 50 MG/10ML Solution 10 mL Ampule,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,517037405,NDC,10,ML,1382.12,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,677.2388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.29,1354.4776
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390F,CDM,750,RC,45390,CPT,,,,,,,,1419,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,677.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,203.1,677.27
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390F,CDM,750,RC,45390,CPT,,,,,,,,1419,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,677.27,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,203.1,677.27
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390P,CDM,982,RC,45390,CPT,,,,,,,,1135,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,677.27,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,203.1,1112.3
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390P,CDM,982,RC,45390,CPT,,,,,,,,1135,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,677.27,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,203.1,1112.3
moxifloxacin 0.5 % Solution 3 mL Bottle,25000000,CDM,250,RC,,,,,,60505058204,NDC,3,ML,691.15,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,677.327,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Abd Paracentesis W/Imaging(P),PX49083P,CDM,983,RC,49083,CPT,,,,,,,,696,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,677.4168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.1184,791.92
liraglutide 18 MG/3ML solution pen-injector 3 mL Pen,63700001,CDM,250,RC,,,,,,169406013,NDC,3,ML,1382.75,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,677.5475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
liraglutide 18 MG/3ML solution pen-injector 3 mL Pen,63700001,CDM,250,RC,,,,,,169406013,NDC,3,ML,1382.75,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,677.5475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
liraglutide 18 MG/3ML solution pen-injector 3 mL Pen,63700001,CDM,250,RC,,,,,,169406013,NDC,3,ML,1382.75,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,677.5475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
darbepoetin alfa 40 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002104,NDC,0.4,ML,1411.78,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,677.6544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
darbepoetin alfa 40 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002104,NDC,0.4,ML,1411.78,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,677.6544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
filgrastim-ayow 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,800000,CDM,,,,,,,,70121157001,NDC,0.5,ML,691.62,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,677.7876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
"Layr Clos Wnd Face,Facial <2.5cm",PX12051F,CDM,510,RC,12051,CPT,,,,,,,,769,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,678.258,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,319.4426,753.62
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598046562,NDC,1,EA,798,,First Health,Commercial,both,85,,999999999,percent of total billed charges,678.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
Ligation of Hemorrhoid(S),PX46221P,CDM,983,RC,46221,CPT,,,,,,,,697,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,838.87,percent of total billed charges,678.3901,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.5338,798.45
STAPLER INTERNAL POWERED 29MM CURVED CIRCULAR,27200000,CDM,272,RC,,,,12024-MAIN,LOCAL,,,,,697,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,678.3901,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STAPLER INTERNAL POWERED 31MM CURVED CIRCULAR,27200000,CDM,272,RC,,,,12025-MAIN,LOCAL,,,,,697,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,678.3901,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
glucagon rdna (diagnostic) 1 MG Recon Soln 1 Each Vial,J1610.01,CDM,636,RC,J1610,HCPCS,,,,597026010,NDC,1,EA,744.84,,Medica,Commercial,both,91.1,,119.18,percent of total billed charges,678.54924,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,172.71,729.9432
POWERPORT ISP MRI IMPLANTABLE PORT 8FR,C1788,CDM,278,RC,C1788,HCPCS,,11998-MAIN,LOCAL,,,,,1385,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,678.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,575.329,1357.3
POWERPORT ISP MRI IMPLANTABLE PORT 8FR,C1788,CDM,278,RC,C1788,HCPCS,,11998-MAIN,LOCAL,,,,,1385,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,678.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,575.329,1357.3
POWERPORT ISP MRI IMPLANTABLE PORT 8FR,C1788,CDM,278,RC,C1788,HCPCS,,11998-MAIN,LOCAL,,,,,1385,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,678.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,575.329,1357.3
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561F,CDM,510,RC,36561,CPT,,,,,,,,2604,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,678.66,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,200.91,1988.23
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561P,CDM,983,RC,36561,CPT,,,,,,,,1736,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,678.66,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,200.91,1988.23
Biopsy of Rectum,PX45100F,CDM,510,RC,45100,CPT,,,,,,,,763,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,679.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,316.9502,2452.93
"Fac/Exc Skn Malig .1-2cm Fce,Facal",PX11642F,CDM,510,RC,11642,CPT,,,,,,,,698,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,679.3634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.9492,684.04
umeclidinium-vilanterol 62.5-25 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173086906,NDC,14,EA,745.86,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,679.47846,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Irradiated Leukoreduced Rbc's,PXP9040,CDM,390,RC,P9040,HCPCS,,,,,,,,771,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,680.022,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,231.5,755.58
2.1MM CANNULATED DRILL BIT,27200000,CDM,272,RC,,,,12657-MAIN,LOCAL,,,,,747,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,680.517,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
US Guide Needle Bx S&I,PX7694201,CDM,402,RC,76942,CPT,TC,,,,,,,747,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,680.517,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.3038,732.06
onabotulinumtoxinA 50 units Recon Soln 1 Each Vial,J0585.03,CDM,636,RC,J0585,HCPCS,,,,23391950,NDC,1,EA,1418.14,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,680.7072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.51,1389.7772
onabotulinumtoxinA 50 units Recon Soln 1 Each Vial,J0585.03,CDM,636,RC,J0585,HCPCS,,,,23391950,NDC,1,EA,1418.14,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,680.7072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.51,1389.7772
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12173-SURG,LOCAL,,,,,772,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,680.904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390F,CDM,750,RC,45390,CPT,,,,,,,,1419,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,681.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,589.4526,2452.93
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390F,CDM,750,RC,45390,CPT,,,,,,,,1419,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,681.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,589.4526,2452.93
CATHETER BIPOLAR ELECTROHEMOSTASIS 7FR 300CM M00560070,27200000,CDM,272,RC,,,,12909-MAIN,LOCAL,,,,,700,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,681.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Partial Bone Scan,PX7830001,CDM,341,RC,78300,CPT,TC,,,,,,,1391,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,681.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,360.31,1363.18
Partial Bone Scan,PX7830001,CDM,341,RC,78300,CPT,TC,,,,,,,1391,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,681.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,360.31,1363.18
Partial Bone Scan,PX7830001,CDM,341,RC,78300,CPT,TC,,,,,,,1391,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,681.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,360.31,1363.18
I&D Deep Absc/Hematoma Neck/Chest,PX21501F,CDM,510,RC,21501,CPT,,,,,,,,773,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,681.786,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.1042,2482.37
Excis Forearm/Wrist Tumor Subcutan,PX25075F,CDM,510,RC,25075,CPT,,,,,,,,1421,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,682.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,590.2834,1416.38
Excis Forearm/Wrist Tumor Subcutan,PX25075F,CDM,510,RC,25075,CPT,,,,,,,,1421,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,682.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,590.2834,1416.38
Abd Paracentesis W/Imaging(P),PX49083P,CDM,983,RC,49083,CPT,,,,,,,,696,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,682.08,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,65.45,682.08
Revise Ulnar Nerve at Elbow,PX64718P,CDM,983,RC,64718,CPT,,,,,,,,1642,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,682.0868,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,682.0868,1686.76
DRILL BIT 2.2MMX60MM STERILE MICA CANNULATED,27200000,CDM,272,RC,,,,12437-MAIN,LOCAL,,,,,701,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,682.2833,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRILL BIT 3.0MMX60MM STERILE MICA CANNULATED,27200000,CDM,272,RC,,,,12438-MAIN,LOCAL,,,,,701,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,682.2833,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Fac/Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404F,CDM,510,RC,11404,CPT,,,,,,,,749,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,682.339,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,311.1346,1416.38
"Complex Drainage, Wound",PX10180P,CDM,983,RC,10180,CPT,,,,,,,,767,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,682.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,318.6118,2482.37
Explor Metatarso-Phalang Jt,PX28022P,CDM,983,RC,28022,CPT,,,,,,,,774,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,682.668,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.5196,2827.75
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132P,CDM,983,RC,13132,CPT,,,,,,,,774,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,682.668,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.5196,753.3342
FIXATION COMPONENT TOE JOINT PROXIMAL PHALANGEAL DF-P,C1713,CDM,278,RC,C1713,HCPCS,,12529-MAIN,LOCAL,,,,,1644,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,682.9176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,60505611000,NDC,5,ML,1644.33,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,683.054682,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
Ligation of Hemorrhoid(S),PX46221P,CDM,983,RC,46221,CPT,,,,,,,,697,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,683.06,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.94,683.06
STAPLER INTERNAL POWERED 29MM CURVED CIRCULAR,27200000,CDM,272,RC,,,,12024-MAIN,LOCAL,,,,,697,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,683.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
STAPLER INTERNAL POWERED 31MM CURVED CIRCULAR,27200000,CDM,272,RC,,,,12025-MAIN,LOCAL,,,,,697,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,683.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Hemorrhoidectomy,Int/Ext,Complx",PX46260F,CDM,750,RC,46260,CPT,,,,,,,,1350,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,683.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,560.79,2452.93
Leukoreduced Platelets,PXP9035,CDM,390,RC,P9035,HCPCS,,,,,,,,1350,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,683.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,433.08,1323
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605P,CDM,983,RC,24605,CPT,,,,,,,,750,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,683.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,311.55,1404.08
Sigmoidoscope W/Submuc Inj,PX45335F,CDM,750,RC,45335,CPT,,,,,,,,750,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,683.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,311.55,798.45
Room Rate Transitional Care Private,PX11900000,CDM,119,RC,,,,,,,,,,775,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,683.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.935,759.5
"Fac/Exc Skn Malig .1-2cm Fce,Facal",PX11642F,CDM,510,RC,11642,CPT,,,,,,,,698,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,684.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.9492,684.04
"Closed Rx Trimalleolar Fx,Manip",PX27818P,CDM,983,RC,27818,CPT,,,,,,,,1352,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,684.112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,561.6208,1404.08
methylene blue 50 MG/10ML Solution 10 mL Ampule,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,517037405,NDC,10,ML,1382.12,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,684.1494,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.29,1354.4776
Exc Skin Benig >4cm Remaindr Body,PX11426F,CDM,510,RC,11426,CPT,,,,,,,,1227,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,684.19,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.1,684.19
Exc Skin Benig >4cm Remaindr Body,PX11426P,CDM,983,RC,11426,CPT,,,,,,,,981,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,684.19,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.1,961.38
"Layr Clos Wnd Face,Facial <2.5cm",PX12051F,CDM,510,RC,12051,CPT,,,,,,,,769,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,684.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,319.4426,753.62
"Layr Clos Wnd Face,Facial 2.5-5",PX12052P,CDM,983,RC,12052,CPT,,,,,,,,776,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,684.432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,322.3504,755.2808
liraglutide 18 MG/3ML solution pen-injector 3 mL Pen,63700001,CDM,250,RC,,,,,,169406013,NDC,3,ML,1382.75,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,684.46125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
OBINutuzumab 1000 MG/40ML Solution 40 mL Vial,J9301.01,CDM,636,RC,J9301,HCPCS,,,,50242007001,NDC,4,ML,1397.15,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,684.6035,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.12,1369.207
OBINutuzumab 1000 MG/40ML Solution 40 mL Vial,J9301.01,CDM,636,RC,J9301,HCPCS,,,,50242007001,NDC,4,ML,1397.15,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,684.6035,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.12,1369.207
OBINutuzumab 1000 MG/40ML Solution 40 mL Vial,J9301.01,CDM,636,RC,J9301,HCPCS,,,,50242007001,NDC,4,ML,1397.15,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,684.6035,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.12,1369.207
Closed Rx IP Jt Dislocation,PX26770P,CDM,983,RC,26770,CPT,,,,,,,,1353,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,684.618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1316.8749
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021083082,NDC,100,ML,1596,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,684.684,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
perflutren lipid microsphere 6.52 MG/ML Suspension 2 mL Vial,Q9957,CDM,636,RC,Q9957,HCPCS,,,,11994001101,NDC,2,ML,751.71,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,684.80781,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,312.260334,736.6758
Incise Finger Tendon Sheath,PX26055F,CDM,510,RC,26055,CPT,,,,,,,,1398,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,502.8,percent of total billed charges,685.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,580.7292,1404.08
Incise Finger Tendon Sheath,PX26055F,CDM,510,RC,26055,CPT,,,,,,,,1398,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,685.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,580.7292,1404.08
Incise Finger Tendon Sheath,PX26055F,CDM,510,RC,26055,CPT,,,,,,,,1398,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,685.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,580.7292,1404.08
"Closed Rx Dist Fibula Fx,Manip",PX27788F,CDM,510,RC,27788,CPT,,,,,,,,1597,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,685.113,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1565.06
Layr Clos Wnd Rest Body 2.6-7.5,PX12042P,CDM,983,RC,12042,CPT,,,,,,,,777,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,685.314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,322.7658,756.2541
"Repair Flex Foot Tendon,Ea",PX28200F,CDM,510,RC,28200,CPT,,,,,,,,1475,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,685.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,207.02,1026.63
POWERPORT ISP MRI IMPLANTABLE PORT 8FR,C1788,CDM,278,RC,C1788,HCPCS,,11998-MAIN,LOCAL,,,,,1385,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,685.575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,575.329,1357.3
oseltamivir 6 MG/ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,4082205,NDC,60,ML,752.82,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,685.81902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Remv Foreign Body,Knee/Thigh,Deep",PX27372F,CDM,510,RC,27372,CPT,,,,,,,,1429,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,685.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,593.6066,2482.37
"Remv Foreign Body,Knee/Thigh,Deep",PX27372F,CDM,510,RC,27372,CPT,,,,,,,,1429,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,685.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,593.6066,2482.37
Exc Neck Les Sc = 3cm >,PX21552F,CDM,510,RC,21552,CPT,,,,,,,,753,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,685.983,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,312.7962,2482.37
CATHETER BIPOLAR ELECTROHEMOSTASIS 7FR 300CM M00560070,27200000,CDM,272,RC,,,,12909-MAIN,LOCAL,,,,,700,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CT Orbit/Ear/Fossa W/O & W/Dye,PX7048201,CDM,350,RC,70482,CPT,TC,,,,,,,1400,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
CT Orbit/Ear/Fossa W/O & W/Dye,PX7048201,CDM,350,RC,70482,CPT,TC,,,,,,,1400,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
CT Orbit/Ear/Fossa W/O & W/Dye,PX7048201,CDM,350,RC,70482,CPT,TC,,,,,,,1400,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
Skin Sub Graft Trnk/Arm/Leg,PX15271P,CDM,983,RC,15271,CPT,,,,,,,,705,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,686.1765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,292.857,1593.14
"Spinal Puncture,Lumbar,Diagnostic",PX62270P,CDM,983,RC,62270,CPT,,,,,,,,705,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,464.08,percent of total billed charges,686.1765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,292.857,686.1765
Temporal Artery Ligatn or Bx,PX37609F,CDM,510,RC,37609,CPT,,,,,,,,705,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,686.1765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,292.857,1416.38
Irradiated Leukoreduced Rbc's,PXP9040,CDM,390,RC,P9040,HCPCS,,,,,,,,771,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,686.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,231.5,755.58
"Genital Surg Proc,Male Unlisted",PX55899F,CDM,510,RC,55899,CPT,,,,,,,,1430,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,686.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,215.91,1401.4
"Genital Surg Proc,Male Unlisted",PX55899F,CDM,510,RC,55899,CPT,,,,,,,,1430,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,686.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,215.91,1401.4
I&D Perirectal Abscess,PX46040F,CDM,510,RC,46040,CPT,,,,,,,,1430,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,686.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,594.022,1401.4
I&D Perirectal Abscess,PX46040F,CDM,510,RC,46040,CPT,,,,,,,,1430,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,686.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,594.022,1401.4
Or Level 1,PX36000001,CDM,360,RC,,,,,,,,,,1600,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,686.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,664.64,1568
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781324494,NDC,1,EA,1400.9,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,686.441,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781324494,NDC,1,EA,1400.9,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,686.441,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781324494,NDC,1,EA,1400.9,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,686.441,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
Fac/Cystourethroscopy,PX52000F,CDM,761,RC,52000,CPT,,,,,,,,1601,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,686.829,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,596.77,1568.98
Anus Surgery Procedure Unlisted,PX46999F,CDM,510,RC,46999,CPT,,,,,,,,1431,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,686.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,594.4374,1402.38
Anus Surgery Procedure Unlisted,PX46999F,CDM,510,RC,46999,CPT,,,,,,,,1431,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,686.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,594.4374,1402.38
Explor Metatarso-Phalang Jt,PX28022F,CDM,510,RC,28022,CPT,,,,,,,,1161,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,686.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,207.02,1012.1
Explor Metatarso-Phalang Jt,PX28022P,CDM,983,RC,28022,CPT,,,,,,,,774,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,686.96,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,207.02,1012.1
DRILL BIT 2.2MMX60MM STERILE MICA CANNULATED,27200000,CDM,272,RC,,,,12437-MAIN,LOCAL,,,,,701,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,686.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DRILL BIT 3.0MMX60MM STERILE MICA CANNULATED,27200000,CDM,272,RC,,,,12438-MAIN,LOCAL,,,,,701,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,686.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12173-SURG,LOCAL,,,,,772,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,687.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Closed Rx Elbow Dislocation,PX24600F,CDM,510,RC,24600,CPT,,,,,,,,706,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,687.1498,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,691.88
albuterol-ipratropium 20-100 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597002402,NDC,4,GR,1601.75,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,687.15075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606F,CDM,510,RC,11606,CPT,,,,,,,,1432,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,687.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,594.8528,1416.38
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606F,CDM,510,RC,11606,CPT,,,,,,,,1432,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,687.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,594.8528,1416.38
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016425,NDC,1,ML,779.43,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,687.45726,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.66,898.7384
Abd Duplex Abd-Follow Up(T),PX9397601,CDM,921,RC,93976,CPT,TC,,,,,,,809,,First Health,Commercial,both,85,,999999999,percent of total billed charges,687.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,792.82
Venous Duplex Scan Uni,PX9397101,CDM,921,RC,93971,CPT,TC,,,,,,,809,,First Health,Commercial,both,85,,999999999,percent of total billed charges,687.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,792.82
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,16714085701,NDC,1,EA,1403.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,687.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,16714085701,NDC,1,EA,1403.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,687.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,16714085701,NDC,1,EA,1403.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,687.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
"HERNIA MESH 3D MAX MID ANATOMICAL MESH LEFT SIZE L 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,11976-MAIN,LOCAL,,,,,755,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,687.805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"HERNIA MESH 3D MAX MID ANATOMICAL MESH RIGHT SIZE L 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,11977-MAIN,LOCAL,,,,,755,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,687.805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Amputation Toe,I-P Jt",PX28825P,CDM,983,RC,28825,CPT,,,,,,,,780,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,687.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,324.012,2827.75
Closed Rx Kneecap Disloc+Anesth,PX27562P,CDM,983,RC,27562,CPT,,,,,,,,1404,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,687.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1366.5132
Closed Rx Kneecap Disloc+Anesth,PX27562P,CDM,983,RC,27562,CPT,,,,,,,,1404,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,687.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1366.5132
Closed Rx Kneecap Disloc+Anesth,PX27562P,CDM,983,RC,27562,CPT,,,,,,,,1404,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,687.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1366.5132
I&D Deep Absc/Hematoma Neck/Chest,PX21501F,CDM,510,RC,21501,CPT,,,,,,,,773,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,687.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.1042,2482.37
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,25021019110,NDC,1,EA,809.89,,First Health,Commercial,both,85,,999999999,percent of total billed charges,688.4065,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.47563,793.6922
Closed Rx Femur Shaft Fx+Manip,PX27502F,CDM,510,RC,27502,CPT,,,,,,,,1625,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,688.4384,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.19,1580.76
Closed Rx Femur Shaft Fx+Manip,PX27502P,CDM,983,RC,27502,CPT,,,,,,,,1083,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,688.4384,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.19,1580.76
Noninvasv Lo Extrem Art Stress/Rest,PX9392401,CDM,921,RC,93924,CPT,TC,,,,,,,810,,First Health,Commercial,both,85,,999999999,percent of total billed charges,688.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.46,793.8
Partial Bone Scan,PX7830001,CDM,341,RC,78300,CPT,TC,,,,,,,1391,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,688.545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,360.31,1363.18
liraglutide 18 MG/3ML solution pen-injector 3 mL Pen,63700001,CDM,250,RC,,,,,,169406012,NDC,3,ML,1405.33,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,688.6117,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
liraglutide 18 MG/3ML solution pen-injector 3 mL Pen,63700001,CDM,250,RC,,,,,,169406012,NDC,3,ML,1405.33,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,688.6117,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
liraglutide 18 MG/3ML solution pen-injector 3 mL Pen,63700001,CDM,250,RC,,,,,,169406012,NDC,3,ML,1405.33,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,688.6117,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Explor Metatarso-Phalang Jt,PX28022P,CDM,983,RC,28022,CPT,,,,,,,,774,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,688.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.5196,2827.75
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132P,CDM,983,RC,13132,CPT,,,,,,,,774,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,688.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.5196,753.3342
"Upper GI Endoscopy,Diagnosis",PX43235P,CDM,983,RC,43235,CPT,,,,,,,,1406,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,688.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,603.174,3859.68
"Upper GI Endoscopy,Diagnosis",PX43235P,CDM,983,RC,43235,CPT,,,,,,,,1406,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,688.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,603.174,3859.68
"Upper GI Endoscopy,Diagnosis",PX43235P,CDM,983,RC,43235,CPT,,,,,,,,1406,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,688.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,603.174,3859.68
travoprost (BAK Free) 0.004 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,65026025,NDC,2.5,ML,811.3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,689.605,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
CT Angio Upr Extrm W/O&W/Dye,PX7320601,CDM,350,RC,73206,CPT,TC,,,,,,,757,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,689.627,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
"Inject Nerv Blck,Othr Periph Nerv",PX64450F,CDM,510,RC,64450,CPT,,,,,,,,757,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,689.627,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,314.4578,741.86
prednisoLONE acetate 0.12 % Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,11980017405,NDC,5,ML,757.07,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,689.69077,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Room Rate Transitional Care Private,PX11900000,CDM,119,RC,,,,,,,,,,775,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,689.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.935,759.5
Exc Abdom Tum Subfac > 5 Cm,PX22901F,CDM,761,RC,22901,CPT,,,,,,,,1408,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,689.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,584.8832,2482.37
Exc Abdom Tum Subfac > 5 Cm,PX22901F,CDM,761,RC,22901,CPT,,,,,,,,1408,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,689.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,584.8832,2482.37
Exc Abdom Tum Subfac > 5 Cm,PX22901F,CDM,761,RC,22901,CPT,,,,,,,,1408,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,689.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,584.8832,2482.37
"Layr Clos Wnd Face,Facial 2.5-5",PX12052P,CDM,983,RC,12052,CPT,,,,,,,,776,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,690.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,322.3504,755.2808
Skin Sub Graft Trnk/Arm/Leg,PX15271P,CDM,983,RC,15271,CPT,,,,,,,,705,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,690.9,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.83,690.9
"Spinal Puncture,Lumbar,Diagnostic",PX62270P,CDM,983,RC,62270,CPT,,,,,,,,705,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,690.9,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.3,690.9
Temporal Artery Ligatn or Bx,PX37609F,CDM,510,RC,37609,CPT,,,,,,,,705,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,690.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,292.857,1416.38
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032605,NDC,0.8,ML,1663.54,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,691.034516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,1630.2692
"Closed Rx Trimalleolar Fx,Manip",PX27818F,CDM,510,RC,27818,CPT,,,,,,,,813,,First Health,Commercial,both,85,,999999999,percent of total billed charges,691.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,337.7202,1404.08
"Fac/Exc Skn Bngn 2.1-3cmfce,Facial",PX11443F,CDM,510,RC,11443,CPT,,,,,,,,813,,First Health,Commercial,both,85,,999999999,percent of total billed charges,691.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,337.7202,1416.38
Heart/Lung Resuscitation (Cpr),PX92950F,CDM,480,RC,92950,CPT,,,,,,,,1366,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,691.196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.21,1338.68
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956401,NDC,1,EA,1611.2,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,691.2048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,409.66,1655.3866
Abd Duplex Abd -Follow Up,PX9397602,CDM,921,RC,93976,CPT,TC,,,,,,,784,,United Healthcare,All Payer,outpatient,88.2,,553.19,percent of total billed charges,691.488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,768.32
Art Lower Extremity+Upper,PX9392301,CDM,921,RC,93923,CPT,TC,,,,,,,784,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,691.488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.46,768.32
Layr Clos Wnd Rest Body 2.6-7.5,PX12042P,CDM,983,RC,12042,CPT,,,,,,,,777,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,691.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,322.7658,756.2541
"MRI, Pelvis, W/O Then W/",PX7219701,CDM,610,RC,72197,CPT,TC,,,,,,,1612,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,691.548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2066.35
OBINutuzumab 1000 MG/40ML Solution 40 mL Vial,J9301.01,CDM,636,RC,J9301,HCPCS,,,,50242007001,NDC,4,ML,1397.15,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,691.58925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.12,1369.207
darbepoetin alfa 40 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002104,NDC,0.4,ML,1411.78,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,691.7722,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
darbepoetin alfa 40 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002104,NDC,0.4,ML,1411.78,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,691.7722,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
darbepoetin alfa 40 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002104,NDC,0.4,ML,1411.78,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,691.7722,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
Closed Rx Elbow Dislocation,PX24600F,CDM,510,RC,24600,CPT,,,,,,,,706,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,691.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,691.88
"Lap,Cholecystectomy/Explore",PX47564P,CDM,983,RC,47564,CPT,,,,,,,,1613,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,691.977,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,670.0402,8992.74
Incise Finger Tendon Sheath,PX26055F,CDM,510,RC,26055,CPT,,,,,,,,1398,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,692.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,580.7292,1404.08
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423F,CDM,510,RC,11423,CPT,,,,,,,,711,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,692.0163,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,295.3494,1416.38
clobetasol 0.05 % Cream 60 g Tube,63700001,CDM,250,RC,,,,,,69238153206,NDC,60,GR,1665.95,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,692.03563,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zoledronic acid 5 MG/100ML Solution 100 mL Bottle,J3489.01,CDM,636,RC,J3489,HCPCS,,,,55111068852,NDC,100,ML,1368,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,692.208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,63323096600,NDC,100,ML,1368,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,692.208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
"US Guide, Vascular Access",PX7693701,CDM,402,RC,76937,CPT,TC,,,,,,,760,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,692.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,315.704,744.8
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605P,CDM,983,RC,25605,CPT,,,,,,,,785,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,692.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,326.089,1404.08
Layr Clos Wnd Rest Body 7.6-12.5,PX12044F,CDM,510,RC,12044,CPT,,,,,,,,785,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,692.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,326.089,769.3
"Close Rx Dist Fingr Fx,Manipulatn",PX26755F,CDM,510,RC,26755,CPT,,,,,,,,335,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,692.49,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,177.14,692.49
"Close Rx Dist Fingr Fx,Manipulatn",PX26755P,CDM,983,RC,26755,CPT,,,,,,,,1260,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,692.49,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,177.14,1234.8
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310001,NDC,0.528,ML,785.14,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,692.49348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.22,877.002
CT Orbit/Ear/Fossa W/O & W/Dye,PX7048201,CDM,350,RC,70482,CPT,TC,,,,,,,1400,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781324494,NDC,1,EA,1400.9,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,693.4455,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016425,NDC,1,ML,779.43,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,693.6927,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.66,898.7384
Irrad/Lr Platelets,PXP9037,CDM,390,RC,P9037,HCPCS,,,,,,,,1617,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,693.693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,616.6,1584.66
"Remv F.B.,Eye,Ant Chmbr/Lens",PX65235F,CDM,510,RC,65235,CPT,,,,,,,,2788,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,693.8971,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,465.32,1508.82
Repr Superf Wnd Face >30cm,PX12018F,CDM,510,RC,12018,CPT,,,,,,,,713,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1344.4,percent of total billed charges,693.9629,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,698.74
fluticasone-salmeterol 500-50 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069704,NDC,14,EA,1670.75,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,694.02955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Amputation Toe,I-P Jt",PX28825P,CDM,983,RC,28825,CPT,,,,,,,,780,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,694.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,324.012,2827.75
Biopsy Synovium I-P Jt,PX26110,CDM,983,RC,26110,CPT,,,,,,,,933,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,694.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.77,914.34
Biopsy Synovium I-P Jt,PX26110,CDM,983,RC,26110,CPT,,,,,,,,933,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,694.57,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.77,914.34
Excis Primary Ganglion Wrist,PX25111F,CDM,510,RC,25111,CPT,,,,,,,,791,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,694.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.33,694.57
Excis Primary Ganglion Wrist,PX25111F,CDM,510,RC,25111,CPT,,,,,,,,791,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,694.57,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.33,694.57
Excis Primary Ganglion Wrist,PX25111P,CDM,983,RC,25111,CPT,,,,,,,,529,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,694.57,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.33,694.57
Excis Primary Ganglion Wrist,PX25111P,CDM,983,RC,25111,CPT,,,,,,,,529,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,694.57,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.33,694.57
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,16714085701,NDC,1,EA,1403.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,694.7325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
onabotulinumtoxinA 50 units Recon Soln 1 Each Vial,J0585.03,CDM,636,RC,J0585,HCPCS,,,,23391950,NDC,1,EA,1418.14,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,694.8886,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.51,1389.7772
onabotulinumtoxinA 50 units Recon Soln 1 Each Vial,J0585.03,CDM,636,RC,J0585,HCPCS,,,,23391950,NDC,1,EA,1418.14,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,694.8886,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.51,1389.7772
onabotulinumtoxinA 50 units Recon Soln 1 Each Vial,J0585.03,CDM,636,RC,J0585,HCPCS,,,,23391950,NDC,1,EA,1418.14,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,694.8886,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.51,1389.7772
Closed Rx Kneecap Disloc+Anesth,PX27562P,CDM,983,RC,27562,CPT,,,,,,,,1404,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,694.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1366.5132
Abd Duplex Abd-Full,PX9397501,CDM,921,RC,93975,CPT,TC,,,,,,,788,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,695.016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,772.24
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122F,CDM,510,RC,13122,CPT,,,,,,,,788,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,695.016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,327.3352,772.24
Biopsy of Rectum,PX45100F,CDM,510,RC,45100,CPT,,,,,,,,763,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,695.093,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,316.9502,2452.93
"Excis Arm/Elbow Tumor,Subcutan",PX24075F,CDM,510,RC,24075,CPT,,,,,,,,1519,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,695.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.15,1108.26
"Excis Arm/Elbow Tumor,Subcutan",PX24075P,CDM,983,RC,24075,CPT,,,,,,,,2458,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,695.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.15,2408.84
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390F,CDM,750,RC,45390,CPT,,,,,,,,1419,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,695.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,589.4526,2452.93
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390F,CDM,750,RC,45390,CPT,,,,,,,,1419,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,695.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,589.4526,2452.93
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390F,CDM,750,RC,45390,CPT,,,,,,,,1419,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,695.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,589.4526,2452.93
Hepatobil Syst Image W/Drug,PX7822701,CDM,341,RC,78227,CPT,TC,,,,,,,1674,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,695.3796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,472.19,1640.52
liraglutide 18 MG/3ML solution pen-injector 3 mL Pen,63700001,CDM,250,RC,,,,,,169406012,NDC,3,ML,1405.33,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,695.63835,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Removal of Hydrocele,Tunica,Unilat",PX55040P,CDM,983,RC,55040,CPT,,,,,,,,1420,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,695.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,589.868,3022.41
"Removal of Hydrocele,Tunica,Unilat",PX55040P,CDM,983,RC,55040,CPT,,,,,,,,1420,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,695.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,589.868,3022.41
"Removal of Hydrocele,Tunica,Unilat",PX55040P,CDM,983,RC,55040,CPT,,,,,,,,1420,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,695.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,589.868,3022.41
"Upper GI Endoscopy,Diagnosis",PX43235P,CDM,983,RC,43235,CPT,,,,,,,,1406,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,695.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,603.174,3859.68
Repr Superf Wnd Face 5.1-7.5,PX12014P,CDM,983,RC,12014,CPT,,,,,,,,819,,First Health,Commercial,both,85,,999999999,percent of total billed charges,696.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,797.1327
"Closed Rx Shldr Disloc,Anesthesia",PX23655P,CDM,983,RC,23655,CPT,,,,,,,,1421,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,696.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,590.2834,1404.08
"Closed Rx Shldr Disloc,Anesthesia",PX23655P,CDM,983,RC,23655,CPT,,,,,,,,1421,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,696.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,590.2834,1404.08
"Closed Rx Shldr Disloc,Anesthesia",PX23655P,CDM,983,RC,23655,CPT,,,,,,,,1421,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,696.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,590.2834,1404.08
Excis Forearm/Wrist Tumor Subcutan,PX25075F,CDM,510,RC,25075,CPT,,,,,,,,1421,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,696.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,590.2834,1416.38
Excis Forearm/Wrist Tumor Subcutan,PX25075F,CDM,510,RC,25075,CPT,,,,,,,,1421,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,696.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,590.2834,1416.38
Excis Forearm/Wrist Tumor Subcutan,PX25075F,CDM,510,RC,25075,CPT,,,,,,,,1421,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,696.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,590.2834,1416.38
Targeted Genomic Sequence Analysis Panel 5-50 Genes - Ref,PX8145090,CDM,300,RC,81450,CPT,90,,,,,,,2936,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,696.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,696.41,2877.28
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034F,CDM,510,RC,12034,CPT,,,,,,,,931,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,696.64,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.27,696.64
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034P,CDM,983,RC,12034,CPT,,,,,,,,1533,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,696.64,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.27,1502.34
CT Soft Tissue Neck W/O Dye,PX7049001,CDM,350,RC,70490,CPT,TC,,,,,,,711,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,696.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,1198.67
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423F,CDM,510,RC,11423,CPT,,,,,,,,711,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,696.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,295.3494,1416.38
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604P,CDM,983,RC,11604,CPT,,,,,,,,1422,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,696.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,590.6988,1384.0326
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604P,CDM,983,RC,11604,CPT,,,,,,,,1422,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,696.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,590.6988,1384.0326
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604P,CDM,983,RC,11604,CPT,,,,,,,,1422,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,696.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,590.6988,1384.0326
Removal of Anal Tabs,PX46230F,CDM,510,RC,46230,CPT,,,,,,,,790,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,696.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,328.166,2452.93
Exc Abdom Tum Subfac > 5 Cm,PX22901F,CDM,761,RC,22901,CPT,,,,,,,,1408,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,696.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,584.8832,2482.37
Closed Rx Femur Shaft Fx+Manip,PX27502F,CDM,510,RC,27502,CPT,,,,,,,,1625,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,697.125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,675.025,1592.5
clobetasol 0.05 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,42291007760,NDC,60,GR,1625.97,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,697.54113,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Excis Primary Ganglion Wrist,PX25111F,CDM,510,RC,25111,CPT,,,,,,,,791,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,697.662,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,328.5814,1404.08
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021080166,NDC,5,ML,820.8,,First Health,Commercial,both,85,,999999999,percent of total billed charges,697.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092401,NDC,0.5,ML,820.88,,First Health,Commercial,both,85,,999999999,percent of total billed charges,697.748,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092491,NDC,0.5,ML,820.88,,First Health,Commercial,both,85,,999999999,percent of total billed charges,697.748,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092410,NDC,0.5,ML,820.89,,First Health,Commercial,both,85,,999999999,percent of total billed charges,697.7565,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
Abd Duplex Abd -Follow Up,PX9397602,CDM,921,RC,93976,CPT,TC,,,,,,,784,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,697.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,768.32
Art Lower Extremity+Upper,PX9392301,CDM,921,RC,93923,CPT,TC,,,,,,,784,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,697.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.46,768.32
TAPER POST TOE JOINT HEMICAP 9.5MM ARTICULATING METATARSAL STERILE,C1713,CDM,278,RC,C1713,HCPCS,,12531-MAIN,LOCAL,,,,,821,,First Health,Commercial,both,85,,999999999,percent of total billed charges,697.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"Lap,Inguinal Hernia Repr,Initial",PX49650P,CDM,983,RC,49650,CPT,,,,,,,,717,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,697.8561,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,297.8418,5040.74
"Hemorrhoidectomy,Int/Ext,Simple",PX46255F,CDM,510,RC,46255,CPT,,,,,,,,1627,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,697.983,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,675.8558,2452.93
Repair of Vagina,PX57200P,CDM,983,RC,57200,CPT,,,,,,,,1043,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,698.03,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.98,1022.14
Repair of Vagina,PX57200P,CDM,983,RC,57200,CPT,,,,,,,,1043,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,698.03,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.98,1022.14
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,60505619301,NDC,5,ML,821.36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,698.156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.08296,1009.1158
Xray Ribs Unilat 2 Vws With Pa Chest,PX7110101,CDM,320,RC,71101,CPT,TC,,,,,,,792,,United Healthcare,All Payer,outpatient,88.2,,376.32,percent of total billed charges,698.544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,776.16
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605P,CDM,983,RC,25605,CPT,,,,,,,,785,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,698.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,326.089,1404.08
Layr Clos Wnd Rest Body 7.6-12.5,PX12044F,CDM,510,RC,12044,CPT,,,,,,,,785,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,698.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,326.089,769.3
Exc Skn Bngn1.1-2cm Remain Bdy,PX11422P,CDM,983,RC,11422,CPT,,,,,,,,822,,First Health,Commercial,both,85,,999999999,percent of total billed charges,698.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,341.4588,1416.38
"Complex Drainage, Wound",PX10180P,CDM,983,RC,10180,CPT,,,,,,,,767,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,698.737,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,318.6118,2482.37
Repr Superf Wnd Face >30cm,PX12018F,CDM,510,RC,12018,CPT,,,,,,,,713,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,698.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,698.74
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310001,NDC,0.528,ML,785.14,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,698.7746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.22,877.002
Art Upper Extremity-Ltd,PX9393101,CDM,921,RC,93931,CPT,TC,,,,,,,718,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,698.8294,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,703.64
darbepoetin alfa 40 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002104,NDC,0.4,ML,1411.78,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,698.8311,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
rabies immune globulin 300 UNIT/ML Solution 1 mL Vial,90376,CDM,636,RC,90375,CPT,,,,13533031801,NDC,1,ML,1629.06,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,698.86674,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,281.51,1596.4788
methylene blue 50 MG/10ML Solution 10 mL Ampule,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,517037405,NDC,10,ML,1382.12,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,699.35272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.29,1354.4776
"MRI,Upr Ext, Joint,W/Cont",PX7322201,CDM,610,RC,73222,CPT,TC,,,,,,,3541,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,699.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,611.05,3470.18
"Tte W/Doppler, Complete",PXC8929,CDM,480,RC,C8929,HCPCS,TC,,,,,,,1927,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,699.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,699.48,1888.46
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266F,CDM,510,RC,27266,CPT,,,,,,,,1684,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,699.5336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,699.5336,1650.32
PROSTEP MICA SCREW 3.0X34MM STERILE IMPLANT,27200000,CDM,272,RC,,,,13042-MAIN,LOCAL,,,,,1684,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,699.5336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
liraglutide 18 MG/3ML solution pen-injector 3 mL Pen,63700001,CDM,250,RC,,,,,,169406013,NDC,3,ML,1382.75,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,699.6715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CT Angiograph Pelv W/O&W/Dye,PX7219101,CDM,350,RC,72191,CPT,TC,,,,,,,1458,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,699.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
CT Angiograph Pelv W/O&W/Dye,PX7219101,CDM,350,RC,72191,CPT,TC,,,,,,,1458,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,699.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
"Remv Foreign Body,Knee/Thigh,Deep",PX27372F,CDM,510,RC,27372,CPT,,,,,,,,1429,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,700.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,593.6066,2482.37
"Remv Foreign Body,Knee/Thigh,Deep",PX27372F,CDM,510,RC,27372,CPT,,,,,,,,1429,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,700.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,593.6066,2482.37
"Remv Foreign Body,Knee/Thigh,Deep",PX27372F,CDM,510,RC,27372,CPT,,,,,,,,1429,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,700.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,593.6066,2482.37
desflurane Solution 240 mL Bottle,25000000,CDM,250,RC,,,,,,10019064134,NDC,240,ML,793.95,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,700.2639,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Ventilator Mgmt.Subsequent Days,PX94003F,CDM,410,RC,94003,CPT,,,,,,,,1686,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,700.3644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,547.46,1652.28
"Layr Clos Wnd Face,Facial <2.5cm",PX12051F,CDM,510,RC,12051,CPT,,,,,,,,769,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,700.559,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,319.4426,753.62
"Genital Surg Proc,Male Unlisted",PX55899F,CDM,510,RC,55899,CPT,,,,,,,,1430,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,700.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,215.91,1401.4
"Genital Surg Proc,Male Unlisted",PX55899F,CDM,510,RC,55899,CPT,,,,,,,,1430,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,700.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,215.91,1401.4
"Genital Surg Proc,Male Unlisted",PX55899F,CDM,510,RC,55899,CPT,,,,,,,,1430,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,700.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,215.91,1401.4
I&D Perirectal Abscess,PX46040F,CDM,510,RC,46040,CPT,,,,,,,,1430,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,700.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,594.022,1401.4
I&D Perirectal Abscess,PX46040F,CDM,510,RC,46040,CPT,,,,,,,,1430,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,700.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,594.022,1401.4
I&D Perirectal Abscess,PX46040F,CDM,510,RC,46040,CPT,,,,,,,,1430,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,700.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,594.022,1401.4
"Sigmoidoscopy,Diagnostic",PX45330F,CDM,510,RC,45330,CPT,,,,,,,,720,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,700.776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,299.088,798.45
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545F,CDM,510,RC,23545,CPT,,,,,,,,961,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,700.79,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.33,781.73
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545P,CDM,983,RC,23545,CPT,,,,,,,,412,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,700.79,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.33,781.73
POWERPORT ISP MRI IMPLANTABLE PORT 8FR,C1788,CDM,278,RC,C1788,HCPCS,,11998-MAIN,LOCAL,,,,,1385,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,700.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,575.329,1357.3
Anus Surgery Procedure Unlisted,PX46999F,CDM,510,RC,46999,CPT,,,,,,,,1431,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,701.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,594.4374,1402.38
Anus Surgery Procedure Unlisted,PX46999F,CDM,510,RC,46999,CPT,,,,,,,,1431,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,701.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,594.4374,1402.38
Anus Surgery Procedure Unlisted,PX46999F,CDM,510,RC,46999,CPT,,,,,,,,1431,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,701.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,594.4374,1402.38
Aspirate Pleura W/ Imaging,PX32555F,CDM,761,RC,32555,CPT,,,,,,,,795,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,701.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,330.243,779.1
Aspirate Pleura W/O Imaging,PX32554F,CDM,510,RC,32554,CPT,,,,,,,,795,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,701.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,330.243,779.1
Room Rate General,PX12000000,CDM,120,RC,,,,,,,,,,1688,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,701.1952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,701.1952,1654.24
Sulfur Colloid per Dose,PXA9541,CDM,343,RC,A9541,HCPCS,,,,,,,,295,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,701.306,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44,701.306
Abd Duplex Abd-Full,PX9397501,CDM,921,RC,93975,CPT,TC,,,,,,,788,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,701.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,772.24
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122F,CDM,510,RC,13122,CPT,,,,,,,,788,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,701.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,327.3352,772.24
Part Remv Phalanx of Toe,PX28124F,CDM,510,RC,28124,CPT,,,,,,,,2155,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,701.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.82,992.04
Part Remv Phalanx of Toe,PX28124P,CDM,983,RC,28124,CPT,,,,,,,,1515,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,701.49,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.82,1484.7
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606F,CDM,510,RC,11606,CPT,,,,,,,,1432,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,701.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,594.8528,1416.38
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606F,CDM,510,RC,11606,CPT,,,,,,,,1432,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,701.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,594.8528,1416.38
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606F,CDM,510,RC,11606,CPT,,,,,,,,1432,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,701.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,594.8528,1416.38
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956410,NDC,1,EA,1689.17,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,701.681218,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,409.66,1655.3866
onabotulinumtoxinA 50 units Recon Soln 1 Each Vial,J0585.03,CDM,636,RC,J0585,HCPCS,,,,23391950,NDC,1,EA,1418.14,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,701.9793,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.51,1389.7772
DOCEtaxel 20 MG/ML Concentrate 1 mL Vial,63600000,CDM,636,RC,J9171,HCPCS,,,,955102001,NDC,1,ML,1690.09,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,702.063386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
Closed Rx Trimalleolar Fx,PX27816P,CDM,983,RC,27816,CPT,,,,,,,,826,,First Health,Commercial,both,85,,999999999,percent of total billed charges,702.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,803.9458
"I&D Perianal Abscess,Superficial",PX46050F,CDM,510,RC,46050,CPT,,,,,,,,1463,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,702.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,607.7302,1433.74
"I&D Perianal Abscess,Superficial",PX46050F,CDM,510,RC,46050,CPT,,,,,,,,1463,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,702.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,607.7302,1433.74
"Biopsy Vulva/Perineum,One Lesn",PX56605F,CDM,510,RC,56605,CPT,,,,,,,,236,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,702.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.0344,702.31
"Biopsy Vulva/Perineum,One Lesn",PX56605P,CDM,983,RC,56605,CPT,,,,,,,,142,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,702.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,58.9868,702.31
Irradiated Leukoreduced Rbc's,PXP9040,CDM,390,RC,P9040,HCPCS,,,,,,,,771,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,702.381,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,231.5,755.58
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390F,CDM,750,RC,45390,CPT,,,,,,,,1419,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,702.405,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,589.4526,2452.93
"Lap,Inguinal Hernia Repr,Initial",PX49650P,CDM,983,RC,49650,CPT,,,,,,,,717,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,702.66,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.65,907.64
Facility Emergency Level V Visit,PX99285F,CDM,450,RC,99285,CPT,,,,,,,,1464,,Health Partners,Health Partners Care Plans,both,48,,483.1033333,percent of total billed charges,702.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,561.13,1434.72
Facility Emergency Level V Visit,PX99285F,CDM,450,RC,99285,CPT,,,,,,,,1464,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,702.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,561.13,1434.72
Exc Abd Les Sc < 3 Cm,PX22902F,CDM,761,RC,22902,CPT,,,,,,,,3128,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,702.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.5,987.89
Exc Abd Les Sc < 3 Cm,PX22902P,CDM,983,RC,22902,CPT,,,,,,,,2086,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,702.87,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.5,2044.28
"Removal of Hydrocele,Tunica,Unilat",PX55040P,CDM,983,RC,55040,CPT,,,,,,,,1420,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,702.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,589.868,3022.41
Removal of Anal Tabs,PX46230F,CDM,510,RC,46230,CPT,,,,,,,,790,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,703.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,328.166,2452.93
Removal of Anal Tabs,PX46230P,CDM,983,RC,46230,CPT,,,,,,,,1435,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,703.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,596.099,2452.93
Removal of Anal Tabs,PX46230P,CDM,983,RC,46230,CPT,,,,,,,,1435,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,703.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,596.099,2452.93
Removal of Anal Tabs,PX46230P,CDM,983,RC,46230,CPT,,,,,,,,1435,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,703.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,596.099,2452.93
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12173-SURG,LOCAL,,,,,772,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,703.292,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Closed Rx Shldr Disloc,Anesthesia",PX23655P,CDM,983,RC,23655,CPT,,,,,,,,1421,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,703.395,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,590.2834,1404.08
Excis Forearm/Wrist Tumor Subcutan,PX25075F,CDM,510,RC,25075,CPT,,,,,,,,1421,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,703.395,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,590.2834,1416.38
Hepatobil Syst Image W/Drug,PX7822701,CDM,341,RC,78227,CPT,TC,,,,,,,1674,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,703.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,238,703.42
Hepatobil Syst Image W/Drug,PX7822701,CDM,341,RC,78227,CPT,TC,,,,,,,1674,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,703.42,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,238,703.42
Art Upper Extremity-Ltd,PX9393101,CDM,921,RC,93931,CPT,TC,,,,,,,718,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,703.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,703.64
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384P,CDM,983,RC,45384,CPT,,,,,,,,1436,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,703.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,616.044,4050.42
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384P,CDM,983,RC,45384,CPT,,,,,,,,1436,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,703.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,616.044,4050.42
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384P,CDM,983,RC,45384,CPT,,,,,,,,1436,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,703.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,616.044,4050.42
Emergency Level V Visit,PX99285P,CDM,981,RC,99285,CPT,,,,,,,,1436,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,252.2584211,percent of total billed charges,703.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,561.13,1397.6588
Emergency Level V Visit,PX99285P,CDM,981,RC,99285,CPT,,,,,,,,1436,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,703.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,561.13,1397.6588
Emergency Level V Visit,PX99285P,CDM,981,RC,99285,CPT,,,,,,,,1436,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,703.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,561.13,1397.6588
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598046562,NDC,1,EA,798,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,703.836,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
Partial Bone Scan,PX7830001,CDM,341,RC,78300,CPT,TC,,,,,,,1391,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,703.846,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,360.31,1363.18
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604P,CDM,983,RC,11604,CPT,,,,,,,,1422,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,703.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,590.6988,1384.0326
Excis Primary Ganglion Wrist,PX25111F,CDM,510,RC,25111,CPT,,,,,,,,791,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,703.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,328.5814,1404.08
I&D Deep Absc/Hematoma Neck/Chest,PX21501F,CDM,510,RC,21501,CPT,,,,,,,,773,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,704.203,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.1042,2482.37
brimonidine 0.15 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314014405,NDC,5,ML,723.62,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,704.299346,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Revise Ulnar Nerve at Elbow,PX64718P,CDM,983,RC,64718,CPT,,,,,,,,1642,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,704.418,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,682.0868,1686.76
Xray Ribs Unilat 2 Vws With Pa Chest,PX7110101,CDM,320,RC,71101,CPT,TC,,,,,,,792,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,704.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,776.16
"Colonoscopy,Flex,Diagnostic",PX45378F,CDM,750,RC,45378,CPT,,,,,,,,1286,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,704.94,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.56,704.94
"Colonoscopy,Flex,Diagnostic",PX45378P,CDM,983,RC,45378,CPT,,,,,,,,1200,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,704.94,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.56,1176
Explor Metatarso-Phalang Jt,PX28022P,CDM,983,RC,28022,CPT,,,,,,,,774,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,705.114,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.5196,2827.75
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132P,CDM,983,RC,13132,CPT,,,,,,,,774,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,705.114,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.5196,753.3342
FIXATION COMPONENT TOE JOINT PROXIMAL PHALANGEAL DF-P,C1713,CDM,278,RC,C1713,HCPCS,,12529-MAIN,LOCAL,,,,,1644,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,705.276,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,60505611000,NDC,5,ML,1644.33,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,705.41757,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565P,CDM,983,RC,25565,CPT,,,,,,,,830,,First Health,Commercial,both,85,,999999999,percent of total billed charges,705.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,344.782,1404.08
"Removal Anal Fistula,Subcutaneous",PX46270F,CDM,510,RC,46270,CPT,,,,,,,,1470,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,705.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,610.638,2452.93
"Removal Anal Fistula,Subcutaneous",PX46270F,CDM,510,RC,46270,CPT,,,,,,,,1470,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,705.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,610.638,2452.93
"Sigmoidoscopy,Diagnostic",PX45330F,CDM,510,RC,45330,CPT,,,,,,,,720,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,705.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,299.088,798.45
"Closed Rx Talus Fx,Manipulatn",PX28435F,CDM,510,RC,28435,CPT,,,,,,,,1705,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,705.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,210.51,796.26
"Closed Rx Talus Fx,Manipulatn",PX28435P,CDM,983,RC,28435,CPT,,,,,,,,1137,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,705.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,210.51,1114.26
Room Rate Transitional Care Private,PX11900000,CDM,119,RC,,,,,,,,,,775,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,706.025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.935,759.5
"Lap,Appendectomy",PX44970P,CDM,983,RC,44970,CPT,,,,,,,,1700,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,706.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,706.18,5040.74
"Removal of Hydrocele,Tunica,Unilat",PX55040P,CDM,983,RC,55040,CPT,,,,,,,,1420,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,706.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,210.51,1391.6
"Removal of Hydrocele,Tunica,Unilat",PX55040P,CDM,983,RC,55040,CPT,,,,,,,,1420,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,706.33,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,210.51,1391.6
desflurane Solution 240 mL Bottle,25000000,CDM,250,RC,,,,,,10019064134,NDC,240,ML,793.95,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,706.6155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Layr Clos Wnd Face,Facial 2.5-5",PX12052P,CDM,983,RC,12052,CPT,,,,,,,,776,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,706.936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,322.3504,755.2808
OBINutuzumab 1000 MG/40ML Solution 40 mL Vial,J9301.01,CDM,636,RC,J9301,HCPCS,,,,50242007001,NDC,4,ML,1397.15,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,706.9579,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.12,1369.207
"Lap,Cholecystectomy",PX47562F,CDM,510,RC,47562,CPT,,,,,,,,1473,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,707.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,611.8842,5040.74
"Lap,Cholecystectomy",PX47562F,CDM,510,RC,47562,CPT,,,,,,,,1473,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,707.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,611.8842,5040.74
"HERNIA MESH 3D MAX MID ANATOMICAL MESH RIGHT SIZE XL 5"" X 7""",C1781,CDM,278,RC,C1781,HCPCS,,11979-MAIN,LOCAL,,,,,832,,First Health,Commercial,both,85,,999999999,percent of total billed charges,707.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"HERNIA MESH 3DMAX MID MESH EXTRA-LARGE LEFT 5"" X 7""",C1781,CDM,278,RC,C1781,HCPCS,,11978-MAIN,LOCAL,,,,,832,,First Health,Commercial,both,85,,999999999,percent of total billed charges,707.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Remv Foreign Body,Knee/Thigh,Deep",PX27372F,CDM,510,RC,27372,CPT,,,,,,,,1429,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,707.355,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,593.6066,2482.37
"Ht Muscle Image Spect, Mult",PX7845201,CDM,340,RC,78452,CPT,TC,,,,,,,2000,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,707.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,239.31,707.36
"Ht Muscle Image Spect, Mult",PX7845201,CDM,340,RC,78452,CPT,TC,,,,,,,2000,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,707.36,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,239.31,707.36
Incise Finger Tendon Sheath,PX26055F,CDM,510,RC,26055,CPT,,,,,,,,1398,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,707.388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,580.7292,1404.08
Aspirate Pleura W/ Imaging,PX32555F,CDM,761,RC,32555,CPT,,,,,,,,795,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,707.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,330.243,779.1
Aspirate Pleura W/O Imaging,PX32554F,CDM,510,RC,32554,CPT,,,,,,,,795,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,707.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,330.243,779.1
Layr Clos Wnd Rest Body 2.6-7.5,PX12042P,CDM,983,RC,12042,CPT,,,,,,,,777,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,707.847,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,322.7658,756.2541
"Genital Surg Proc,Male Unlisted",PX55899F,CDM,510,RC,55899,CPT,,,,,,,,1430,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,707.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,215.91,1401.4
I&D Perirectal Abscess,PX46040F,CDM,510,RC,46040,CPT,,,,,,,,1430,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,707.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,594.022,1401.4
"Repair Flex Foot Tendon,Ea",PX28200F,CDM,510,RC,28200,CPT,,,,,,,,1475,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,708,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,612.715,2827.75
"Repair Flex Foot Tendon,Ea",PX28200F,CDM,510,RC,28200,CPT,,,,,,,,1475,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,708,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,612.715,2827.75
"Closed Rx Talus Fx,Manipulatn",PX28435F,CDM,510,RC,28435,CPT,,,,,,,,1705,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,708.257,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,708.257,1670.9
Anus Surgery Procedure Unlisted,PX46999F,CDM,510,RC,46999,CPT,,,,,,,,1431,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,708.345,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,594.4374,1402.38
CT Orbit/Ear/Fossa W/O & W/Dye,PX7048201,CDM,350,RC,70482,CPT,TC,,,,,,,1400,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,708.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606F,CDM,510,RC,11606,CPT,,,,,,,,1432,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,708.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,594.8528,1416.38
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781324494,NDC,1,EA,1400.9,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,708.8554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
I&D Deep Absc/Hematoma Neck/Chest,PX21501F,CDM,510,RC,21501,CPT,,,,,,,,773,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,709.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,210.51,1021.1
I&D Deep Absc/Hematoma Neck/Chest,PX21501P,CDM,983,RC,21501,CPT,,,,,,,,515,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,709.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,210.51,1021.1
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591F,CDM,360,RC,49591,CPT,,,,,,,,1556,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,709.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,202.22,709.1
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591F,CDM,360,RC,49591,CPT,,,,,,,,1556,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,709.1,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,202.22,709.1
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591P,CDM,982,RC,49591,CPT,,,,,,,,1245,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,709.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,202.22,1220.1
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591P,CDM,982,RC,49591,CPT,,,,,,,,1245,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,709.1,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,202.22,1220.1
brimonidine 0.15 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314014405,NDC,5,ML,723.62,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,709.1476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,67457061910,NDC,100,ML,1707.48,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,709.287192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
Duplex Up Extrem Art Bilat,PX9393001,CDM,921,RC,93930,CPT,TC,,,,,,,835,,First Health,Commercial,both,85,,999999999,percent of total billed charges,709.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,818.3
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016425,NDC,1,ML,779.43,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,710.06073,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.66,898.7384
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,16714085701,NDC,1,EA,1403.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,710.171,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598046562,NDC,1,EA,798,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,710.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
Removal of Anal Tabs,PX46230P,CDM,983,RC,46230,CPT,,,,,,,,1435,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,710.325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,596.099,2452.93
Infection Agent Detect Dna/Rna Probe Tq 6-11,PX87506,CDM,300,RC,87506,CPT,,,,,,,,1710,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,710.334,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,241.14,1675.8
"Sigmoidoscopy,Remv Lesn,Snare",PX45338P,CDM,983,RC,45338,CPT,,,,,,,,1710,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,710.334,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,710.334,1664.343
Closed Rx Kneecap Disloc+Anesth,PX27562P,CDM,983,RC,27562,CPT,,,,,,,,1404,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,710.424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1366.5132
"Amputation Toe,I-P Jt",PX28825P,CDM,983,RC,28825,CPT,,,,,,,,780,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,710.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,324.012,2827.75
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384P,CDM,983,RC,45384,CPT,,,,,,,,1436,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,710.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,616.044,4050.42
Emergency Level V Visit,PX99285P,CDM,981,RC,99285,CPT,,,,,,,,1436,,Humana Choice Care,All Medicare plans,outpatient,49.5,,443.94,percent of total billed charges,710.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,561.13,1397.6588
liraglutide 18 MG/3ML solution pen-injector 3 mL Pen,63700001,CDM,250,RC,,,,,,169406012,NDC,3,ML,1405.33,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,711.09698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Upper GI Endoscopy,Diagnosis",PX43235P,CDM,983,RC,43235,CPT,,,,,,,,1406,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,711.436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,603.174,3859.68
"Fac/Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602F,CDM,510,RC,11602,CPT,,,,,,,,731,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,711.4823,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,303.6574,716.38
Exc Abdom Tum Subfac > 5 Cm,PX22901F,CDM,761,RC,22901,CPT,,,,,,,,1408,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,712.448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,584.8832,2482.37
Blood Transfusion Service,PX36430,CDM,391,RC,36430,CPT,,,,,,,,839,,First Health,Commercial,both,85,,999999999,percent of total billed charges,713.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.5206,822.22
Drainage of Gum Lesion,PX41800P,CDM,983,RC,41800,CPT,,,,,,,,839,,First Health,Commercial,both,85,,999999999,percent of total billed charges,713.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,816.5987
"Exc Skn Bnig >4cmtrnk,Arm,Leg",PX11406P,CDM,983,RC,11406,CPT,,,,,,,,1456,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,298.165,percent of total billed charges,713.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,604.8224,1417.1248
"Exc Skn Bnig >4cmtrnk,Arm,Leg",PX11406P,CDM,983,RC,11406,CPT,,,,,,,,1456,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,713.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,604.8224,1417.1248
"Exc Skn Bnig >4cmtrnk,Arm,Leg",PX11406P,CDM,983,RC,11406,CPT,,,,,,,,1456,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,713.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,604.8224,1417.1248
agalsidase beta 5 MG Recon Soln 1 Each Vial,J0180.01,CDM,636,RC,J0180,HCPCS,,,,58468004101,NDC,1,EA,1717.68,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,713.524272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,200.2,1683.3264
Abd Duplex Abd-Follow Up(T),PX9397601,CDM,921,RC,93976,CPT,TC,,,,,,,809,,United Healthcare,All Payer,outpatient,88.2,,553.19,percent of total billed charges,713.538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,792.82
Venous Duplex Scan Uni,PX9397101,CDM,921,RC,93971,CPT,TC,,,,,,,809,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,713.538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,792.82
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032605,NDC,0.8,ML,1663.54,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,713.65866,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,1630.2692
Abd Duplex Abd -Follow Up,PX9397602,CDM,921,RC,93976,CPT,TC,,,,,,,784,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,714.224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,768.32
Art Lower Extremity+Upper,PX9392301,CDM,921,RC,93923,CPT,TC,,,,,,,784,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,714.224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.46,768.32
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,25021019110,NDC,1,EA,809.89,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,714.32298,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.47563,793.6922
darbepoetin alfa 40 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002104,NDC,0.4,ML,1411.78,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,714.36068,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
Jak2 Gene - Ref,PX8127090,CDM,300,RC,81270,CPT,90,,,,,,,734,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,714.4022,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.04,719.32
CT Angiograph Pelv W/O&W/Dye,PX7219101,CDM,350,RC,72191,CPT,TC,,,,,,,1458,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,714.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
CT Angiograph Pelv W/O&W/Dye,PX7219101,CDM,350,RC,72191,CPT,TC,,,,,,,1458,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,714.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
CT Angiograph Pelv W/O&W/Dye,PX7219101,CDM,350,RC,72191,CPT,TC,,,,,,,1458,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,714.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
Noninvasv Lo Extrem Art Stress/Rest,PX9392401,CDM,921,RC,93924,CPT,TC,,,,,,,810,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,714.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.46,793.8
clobetasol 0.05 % Cream 60 g Tube,63700001,CDM,250,RC,,,,,,69238153206,NDC,60,GR,1665.95,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,714.69255,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573P,CDM,983,RC,36573,CPT,,,,,,,,1721,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,714.9034,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,714.9034,1675.0493
"Treat Thumb Disloc,Manipulatn",PX26641F,CDM,510,RC,26641,CPT,,,,,,,,1721,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,714.9034,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1686.58
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605P,CDM,983,RC,25605,CPT,,,,,,,,785,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,715.135,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,326.089,1404.08
Layr Clos Wnd Rest Body 7.6-12.5,PX12044F,CDM,510,RC,12044,CPT,,,,,,,,785,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,715.135,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,326.089,769.3
"Biopsy, Nail Unit",PX11755F,CDM,510,RC,11755,CPT,,,,,,,,1490,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,715.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,614.65,1460.2
"Biopsy, Nail Unit",PX11755F,CDM,510,RC,11755,CPT,,,,,,,,1490,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,715.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,614.65,1460.2
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310001,NDC,0.528,ML,785.14,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,715.26254,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.22,877.002
MINIBUNION DRILL KIT,27200000,CDM,278,RC,C1713,HCPCS,,11669-MAIN,LOCAL,,,,,841.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,715.275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
travoprost (BAK Free) 0.004 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,65026025,NDC,2.5,ML,811.3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,715.5666,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Upper GI Endoscopy,Ctrl Bleed",PX43255F,CDM,750,RC,43255,CPT,,,,,,,,1723,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,715.7342,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,715.7342,1688.54
"Fac/Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602F,CDM,510,RC,11602,CPT,,,,,,,,731,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,716.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,303.6574,716.38
"Sigmoidoscopy,Screen Prev",PX2001F,CDM,750,RC,45330,CPT,,,,,,,,843,,First Health,Commercial,both,85,,999999999,percent of total billed charges,716.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,350.1822,826.14
"Drain Finger Abscess,Simple",PX26010F,CDM,510,RC,26010,CPT,,,,,,,,310,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,716.7,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,89.65,716.7
"Drain Finger Abscess,Simple",PX26010P,CDM,983,RC,26010,CPT,,,,,,,,207,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,716.7,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,89.65,716.7
fluticasone-salmeterol 500-50 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069704,NDC,14,EA,1670.75,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,716.75175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"I&D Perianal Abscess,Superficial",PX46050F,CDM,510,RC,46050,CPT,,,,,,,,1463,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,716.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,607.7302,1433.74
"I&D Perianal Abscess,Superficial",PX46050F,CDM,510,RC,46050,CPT,,,,,,,,1463,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,716.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,607.7302,1433.74
"I&D Perianal Abscess,Superficial",PX46050F,CDM,510,RC,46050,CPT,,,,,,,,1463,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,716.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,607.7302,1433.74
"Closed Rx Trimalleolar Fx,Manip",PX27818F,CDM,510,RC,27818,CPT,,,,,,,,813,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,717.066,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,337.7202,1404.08
"Fac/Exc Skn Bngn 2.1-3cmfce,Facial",PX11443F,CDM,510,RC,11443,CPT,,,,,,,,813,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,717.066,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,337.7202,1416.38
Facility Emergency Level V Visit,PX99285F,CDM,450,RC,99285,CPT,,,,,,,,1464,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,252.2584211,percent of total billed charges,717.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,561.13,1434.72
Facility Emergency Level V Visit,PX99285F,CDM,450,RC,99285,CPT,,,,,,,,1464,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,717.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,561.13,1434.72
Facility Emergency Level V Visit,PX99285F,CDM,450,RC,99285,CPT,,,,,,,,1464,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,717.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,561.13,1434.72
onabotulinumtoxinA 50 units Recon Soln 1 Each Vial,J0585.03,CDM,636,RC,J0585,HCPCS,,,,23391950,NDC,1,EA,1418.14,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,717.57884,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.51,1389.7772
Abd Duplex Abd-Full,PX9397501,CDM,921,RC,93975,CPT,TC,,,,,,,788,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,717.868,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,772.24
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122F,CDM,510,RC,13122,CPT,,,,,,,,788,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,717.868,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,327.3352,772.24
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390F,CDM,750,RC,45390,CPT,,,,,,,,1419,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,718.014,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,589.4526,2452.93
Closed Rx Trimalleolar Fx,PX27816F,CDM,510,RC,27816,CPT,,,,,,,,522,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,718.09,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,190.44,718.09
Closed Rx Trimalleolar Fx,PX27816P,CDM,983,RC,27816,CPT,,,,,,,,826,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,718.09,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,190.44,809.48
Hepatobil Syst Image W/Drug,PX7822701,CDM,341,RC,78227,CPT,TC,,,,,,,1674,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,718.146,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,472.19,1640.52
"Removal of Hydrocele,Tunica,Unilat",PX55040P,CDM,983,RC,55040,CPT,,,,,,,,1420,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,718.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,589.868,3022.41
"Lap,Dx Surgical Abd W/Biopsy",PX49321F,CDM,510,RC,49321,CPT,,,,,,,,874,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,718.78,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.77,718.78
"Lap,Dx Surgical Abd W/Biopsy",PX49321F,CDM,510,RC,49321,CPT,,,,,,,,874,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,718.78,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.77,718.78
"Lap,Dx Surgical Abd W/Biopsy",PX49321P,CDM,983,RC,49321,CPT,,,,,,,,583,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,718.78,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.77,718.78
"Lap,Dx Surgical Abd W/Biopsy",PX49321P,CDM,983,RC,49321,CPT,,,,,,,,583,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,718.78,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.77,718.78
"Closed Rx Shldr Disloc,Anesthesia",PX23655P,CDM,983,RC,23655,CPT,,,,,,,,1421,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,719.026,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,590.2834,1404.08
Excis Forearm/Wrist Tumor Subcutan,PX25075F,CDM,510,RC,25075,CPT,,,,,,,,1421,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,719.026,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,590.2834,1416.38
Jak2 Gene - Ref,PX8127090,CDM,300,RC,81270,CPT,90,,,,,,,734,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,719.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.04,719.32
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604P,CDM,983,RC,11604,CPT,,,,,,,,1422,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,719.532,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,590.6988,1384.0326
perflutren protein A microsphere Suspension 3 mL Vial,Q9956,CDM,636,RC,Q9956,HCPCS,,,,407270703,NDC,3,ML,739.41,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,141.8455556,percent of total billed charges,719.667753,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,307.150914,724.6218
Removal of Anal Tabs,PX46230F,CDM,510,RC,46230,CPT,,,,,,,,790,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,719.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,328.166,2452.93
Level 2 Additional Procedure,PX36000081,CDM,360,RC,,,,,,,,,,1500,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,720,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,623.1,1470
Level 2 Additional Procedure,PX36000081,CDM,360,RC,,,,,,,,,,1500,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,720,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,623.1,1470
Abd Duplex Abd-Follow Up(T),PX9397601,CDM,921,RC,93976,CPT,TC,,,,,,,809,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,720.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,792.82
Venous Duplex Scan Uni,PX9397101,CDM,921,RC,93971,CPT,TC,,,,,,,809,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,720.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,792.82
US Doppler Lw Ext Art Tc,PX9392601,CDM,921,RC,93926,CPT,TC,,,,,,,740,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,720.242,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,725.2
"Removal Anal Fistula,Subcutaneous",PX46270F,CDM,510,RC,46270,CPT,,,,,,,,1470,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,720.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,610.638,2452.93
"Removal Anal Fistula,Subcutaneous",PX46270F,CDM,510,RC,46270,CPT,,,,,,,,1470,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,720.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,610.638,2452.93
"Removal Anal Fistula,Subcutaneous",PX46270F,CDM,510,RC,46270,CPT,,,,,,,,1470,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,720.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,610.638,2452.93
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059303,NDC,1,EA,740.19,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,717.03,percent of total billed charges,720.426927,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.10077,725.3862
Excis Primary Ganglion Wrist,PX25111F,CDM,510,RC,25111,CPT,,,,,,,,791,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,720.601,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,328.5814,1404.08
"Exc Skn Bnig >4cmtrnk,Arm,Leg",PX11406P,CDM,983,RC,11406,CPT,,,,,,,,1456,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,720.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,604.8224,1417.1248
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,25021019110,NDC,1,EA,809.89,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,720.8021,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.47563,793.6922
Closed Rx Shldr Dislocation,PX23650F,CDM,510,RC,23650,CPT,,,,,,,,689,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,720.86,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.18,720.86
Closed Rx Shldr Dislocation,PX23650P,CDM,983,RC,23650,CPT,,,,,,,,516,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,720.86,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.18,720.86
Noninvasv Lo Extrem Art Stress/Rest,PX9392401,CDM,921,RC,93924,CPT,TC,,,,,,,810,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,720.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.46,793.8
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561P,CDM,983,RC,36561,CPT,,,,,,,,1736,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,721.1344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,721.1344,2784.63
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830F,CDM,510,RC,15830,CPT,,,,,,,,2080,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,721.42,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,721.42,2434.44
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830P,CDM,983,RC,15830,CPT,,,,,,,,1120,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,721.42,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,721.42,2434.44
Xray Ribs Unilat 2 Vws With Pa Chest,PX7110101,CDM,320,RC,71101,CPT,TC,,,,,,,792,,Medica,Commercial,both,91.1,,121.6,percent of total billed charges,721.512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,776.16
CT Angiograph Pelv W/O&W/Dye,PX7219101,CDM,350,RC,72191,CPT,TC,,,,,,,1458,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,721.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
"Lap,Cholecystectomy",PX47562F,CDM,510,RC,47562,CPT,,,,,,,,1473,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,2083.4,percent of total billed charges,721.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,611.8842,5040.74
"Lap,Cholecystectomy",PX47562F,CDM,510,RC,47562,CPT,,,,,,,,1473,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,721.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,611.8842,5040.74
"Lap,Cholecystectomy",PX47562F,CDM,510,RC,47562,CPT,,,,,,,,1473,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,721.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,611.8842,5040.74
travoprost (BAK Free) 0.004 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,65026025,NDC,2.5,ML,811.3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,722.057,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Drain Pilonidal Cyst Simpl,PX10080F,CDM,510,RC,10080,CPT,,,,,,,,742,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,722.1886,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,308.2268,727.16
Fna W/Image,PX10022F,CDM,510,RC,10022,CPT,,,,,,,,742,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,722.1886,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,308.2268,727.16
"Close Rx Fingr Articular Fx,Manip",PX26742F,CDM,510,RC,26742,CPT,,,,,,,,1039,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,722.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,216.18,805.95
"Close Rx Fingr Articular Fx,Manip",PX26742P,CDM,983,RC,26742,CPT,,,,,,,,560,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,722.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,216.18,805.95
Repr Superf Wnd Face 5.1-7.5,PX12014P,CDM,983,RC,12014,CPT,,,,,,,,819,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,722.358,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,797.1327
MESH SURGICAL NON-ABSORBABLE PLUG 6INW X 6INL,C1781,CDM,272,RC,C1781,HCPCS,,12005-MAIN,LOCAL,,,,,1505,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,722.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
MESH SURGICAL NON-ABSORBABLE PLUG 6INW X 6INL,C1781,CDM,272,RC,C1781,HCPCS,,12005-MAIN,LOCAL,,,,,1505,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,722.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
MESH SURGICAL NON-ABSORBABLE PLUG 12INW X 12INL,C1781,CDM,278,RC,C1781,HCPCS,,12006-MAIN,LOCAL,,,,,1505,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,722.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
MESH SURGICAL NON-ABSORBABLE PLUG 12INW X 12INL,C1781,CDM,278,RC,C1781,HCPCS,,12006-MAIN,LOCAL,,,,,1505,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,722.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266F,CDM,510,RC,27266,CPT,,,,,,,,1684,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,722.436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,699.5336,1650.32
PROSTEP MICA SCREW 3.0X34MM STERILE IMPLANT,27200000,CDM,272,RC,,,,13042-MAIN,LOCAL,,,,,1684,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,722.436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Repair Flex Foot Tendon,Ea",PX28200F,CDM,510,RC,28200,CPT,,,,,,,,1475,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.84,percent of total billed charges,722.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,612.715,2827.75
"Repair Flex Foot Tendon,Ea",PX28200F,CDM,510,RC,28200,CPT,,,,,,,,1475,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,722.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,612.715,2827.75
"Repair Flex Foot Tendon,Ea",PX28200F,CDM,510,RC,28200,CPT,,,,,,,,1475,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,722.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,612.715,2827.75
"Remv Foreign Body,Knee/Thigh,Deep",PX27372F,CDM,510,RC,27372,CPT,,,,,,,,1429,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,723.074,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,593.6066,2482.37
brinzolamide-brimonidine 1-0.2 % Suspension 8 mL Bottle,63700001,CDM,250,RC,,,,,,65414727,NDC,8,ML,850.88,,First Health,Commercial,both,85,,999999999,percent of total billed charges,723.248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
desflurane Solution 240 mL Bottle,25000000,CDM,250,RC,,,,,,10019064134,NDC,240,ML,793.95,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,723.28845,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Ventilator Mgmt.Subsequent Days,PX94003F,CDM,410,RC,94003,CPT,,,,,,,,1686,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,723.294,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,547.46,1652.28
"Closed Rx Trimalleolar Fx,Manip",PX27818F,CDM,510,RC,27818,CPT,,,,,,,,813,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,723.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,337.7202,1404.08
"Fac/Exc Skn Bngn 2.1-3cmfce,Facial",PX11443F,CDM,510,RC,11443,CPT,,,,,,,,813,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,723.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,337.7202,1416.38
"Genital Surg Proc,Male Unlisted",PX55899F,CDM,510,RC,55899,CPT,,,,,,,,1430,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,723.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,215.91,1401.4
I&D Perirectal Abscess,PX46040F,CDM,510,RC,46040,CPT,,,,,,,,1430,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,723.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,594.022,1401.4
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021080166,NDC,5,ML,820.8,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,723.9456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092401,NDC,0.5,ML,820.88,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,724.01616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092491,NDC,0.5,ML,820.88,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,724.01616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092410,NDC,0.5,ML,820.89,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,724.02498,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830F,CDM,510,RC,15830,CPT,,,,,,,,2080,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,724.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,721.42,2434.44
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830F,CDM,510,RC,15830,CPT,,,,,,,,2080,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,724.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,721.42,2434.44
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830P,CDM,983,RC,15830,CPT,,,,,,,,1120,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,724.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,721.42,2434.44
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830P,CDM,983,RC,15830,CPT,,,,,,,,1120,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,724.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,721.42,2434.44
Anus Surgery Procedure Unlisted,PX46999F,CDM,510,RC,46999,CPT,,,,,,,,1431,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,724.086,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,594.4374,1402.38
TAPER POST TOE JOINT HEMICAP 9.5MM ARTICULATING METATARSAL STERILE,C1713,CDM,278,RC,C1713,HCPCS,,12531-MAIN,LOCAL,,,,,821,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,724.122,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Room Rate General,PX12000000,CDM,120,RC,,,,,,,,,,1688,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,724.152,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,701.1952,1654.24
"I&D Perianal Abscess,Superficial",PX46050F,CDM,510,RC,46050,CPT,,,,,,,,1463,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,724.185,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,607.7302,1433.74
Aspirate Pleura W/ Imaging,PX32555F,CDM,761,RC,32555,CPT,,,,,,,,795,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,724.245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,330.243,779.1
Aspirate Pleura W/O Imaging,PX32554F,CDM,510,RC,32554,CPT,,,,,,,,795,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,724.245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,330.243,779.1
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,60505619301,NDC,5,ML,821.36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,724.43952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.08296,1009.1158
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606F,CDM,510,RC,11606,CPT,,,,,,,,1432,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,724.592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,594.8528,1416.38
perflutren protein A microsphere Suspension 3 mL Vial,Q9956,CDM,636,RC,Q9956,HCPCS,,,,407270703,NDC,3,ML,739.41,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,724.6218,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,307.150914,724.6218
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956410,NDC,1,EA,1689.17,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,724.65393,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,409.66,1655.3866
Facility Emergency Level V Visit,PX99285F,CDM,450,RC,99285,CPT,,,,,,,,1464,,Humana Choice Care,All Medicare plans,outpatient,49.5,,443.94,percent of total billed charges,724.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,561.13,1434.72
glucagon rdna (diagnostic) 1 MG Recon Soln 1 Each Vial,J1610.01,CDM,636,RC,J1610,HCPCS,,,,597026010,NDC,1,EA,744.84,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,724.952772,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,172.71,729.9432
Exc Skn Bngn1.1-2cm Remain Bdy,PX11422P,CDM,983,RC,11422,CPT,,,,,,,,822,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,725.004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,341.4588,1416.38
DOCEtaxel 20 MG/ML Concentrate 1 mL Vial,63600000,CDM,636,RC,J9171,HCPCS,,,,955102001,NDC,1,ML,1690.09,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,725.04861,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
US Doppler Lw Ext Art Tc,PX9392601,CDM,921,RC,93926,CPT,TC,,,,,,,740,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,725.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,725.2
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059303,NDC,1,EA,740.19,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,725.3862,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,83.10077,725.3862
fluticasone 220 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173072020,NDC,12,GR,1746.36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,725.437944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
umeclidinium-vilanterol 62.5-25 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173086906,NDC,14,EA,745.86,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,725.945538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Removal of Anal Tabs,PX46230P,CDM,983,RC,46230,CPT,,,,,,,,1435,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,726.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,596.099,2452.93
"Diagnostic Bone Marrow, Biopsy and Aspiration",PX38222F,CDM,761,RC,38222,CPT,,,,,,,,1748,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,726.1192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,726.1192,2482.37
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016401,NDC,1,ML,854.49,,First Health,Commercial,both,85,,999999999,percent of total billed charges,726.3165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.66,898.7384
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384P,CDM,983,RC,45384,CPT,,,,,,,,1436,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,726.616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,616.044,4050.42
Emergency Level V Visit,PX99285P,CDM,981,RC,99285,CPT,,,,,,,,1436,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,726.616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,561.13,1397.6588
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004F,CDM,510,RC,15004,CPT,,,,,,,,855,,First Health,Commercial,both,85,,999999999,percent of total billed charges,726.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,355.167,837.9
"Closed Rx Radial Head/Neck Fx,Manip",PX24655F,CDM,510,RC,24655,CPT,,,,,,,,1750,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,726.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,726.95,1715
"Fix Exten Tendon,Dorsum Fingr,Ea",PX26418F,CDM,510,RC,26418,CPT,,,,,,,,1750,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,726.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,726.95,1715
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598046562,NDC,1,EA,798,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,726.978,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
2.1MM CANNULATED DRILL BIT,27200000,CDM,272,RC,,,,12657-MAIN,LOCAL,,,,,747,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,727.0551,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
US Guide Needle Bx S&I,PX7694201,CDM,402,RC,76942,CPT,TC,,,,,,,747,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,727.0551,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.3038,732.06
Drain Pilonidal Cyst Simpl,PX10080F,CDM,510,RC,10080,CPT,,,,,,,,742,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,727.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,308.2268,727.16
Fna W/Image,PX10022F,CDM,510,RC,10022,CPT,,,,,,,,742,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,727.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,308.2268,727.16
"Removal Anal Fistula,Subcutaneous",PX46270F,CDM,510,RC,46270,CPT,,,,,,,,1470,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,727.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,610.638,2452.93
Closed Rx Bimalleolar Fx,PX27808F,CDM,510,RC,27808,CPT,,,,,,,,650,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,727.77,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.17,727.77
Closed Rx Bimalleolar Fx,PX27808P,CDM,983,RC,27808,CPT,,,,,,,,433,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,727.77,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.17,727.77
carboprost 250 MCG/ML Solution 1 mL Ampule,25000000,CDM,250,RC,,,,,,9085608,NDC,1,ML,1517.13,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,728.2224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
carboprost 250 MCG/ML Solution 1 mL Ampule,25000000,CDM,250,RC,,,,,,9085608,NDC,1,ML,1517.13,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,728.2224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Closed Rx Big Toe Fx,Manip",PX28495F,CDM,510,RC,28495,CPT,,,,,,,,857,,First Health,Commercial,both,85,,999999999,percent of total billed charges,728.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,839.86
Closed Rx Trimalleolar Fx,PX27816P,CDM,983,RC,27816,CPT,,,,,,,,826,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,728.532,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,803.9458
Repr Superf Wnd Face 5.1-7.5,PX12014P,CDM,983,RC,12014,CPT,,,,,,,,819,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,728.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,797.1327
"Fac/Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404F,CDM,510,RC,11404,CPT,,,,,,,,749,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,729.0017,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,311.1346,1416.38
"Excis Arm/Elbow Tumor,Subcutan",PX24075F,CDM,510,RC,24075,CPT,,,,,,,,1519,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,729.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,630.9926,1488.62
"Excis Arm/Elbow Tumor,Subcutan",PX24075F,CDM,510,RC,24075,CPT,,,,,,,,1519,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,729.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,630.9926,1488.62
"Lap,Cholecystectomy",PX47562F,CDM,510,RC,47562,CPT,,,,,,,,1473,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,729.135,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,611.8842,5040.74
"Lap,Appendectomy",PX44970P,CDM,983,RC,44970,CPT,,,,,,,,1700,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,729.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,706.18,5040.74
glucagon rdna (diagnostic) 1 MG Recon Soln 1 Each Vial,J1610.01,CDM,636,RC,J1610,HCPCS,,,,597026010,NDC,1,EA,744.84,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,729.9432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,172.71,729.9432
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605P,CDM,983,RC,24605,CPT,,,,,,,,750,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,729.975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,311.55,1404.08
Sigmoidoscope W/Submuc Inj,PX45335F,CDM,750,RC,45335,CPT,,,,,,,,750,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,729.975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,311.55,798.45
"Biopsy, Nail Unit",PX11755F,CDM,510,RC,11755,CPT,,,,,,,,1490,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,730.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,614.65,1460.2
"Biopsy, Nail Unit",PX11755F,CDM,510,RC,11755,CPT,,,,,,,,1490,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,730.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,614.65,1460.2
"Biopsy, Nail Unit",PX11755F,CDM,510,RC,11755,CPT,,,,,,,,1490,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,730.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,614.65,1460.2
"Repair Flex Foot Tendon,Ea",PX28200F,CDM,510,RC,28200,CPT,,,,,,,,1475,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,730.125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,612.715,2827.75
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021080166,NDC,5,ML,820.8,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,730.512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092401,NDC,0.5,ML,820.88,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,730.5832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092491,NDC,0.5,ML,820.88,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,730.5832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092410,NDC,0.5,ML,820.89,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,730.5921,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
TAPER POST TOE JOINT HEMICAP 9.5MM ARTICULATING METATARSAL STERILE,C1713,CDM,278,RC,C1713,HCPCS,,12531-MAIN,LOCAL,,,,,821,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,730.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
umeclidinium-vilanterol 62.5-25 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173086906,NDC,14,EA,745.86,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,730.9428,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
GRAFIXPL PRIME PLACENTAL MEMBRANE 16MM DISC 2SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12763-MAIN,LOCAL,,,,,860,,First Health,Commercial,both,85,,999999999,percent of total billed charges,731,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,60505619301,NDC,5,ML,821.36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,731.0104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.08296,1009.1158
fluticasone 220 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,66993008096,NDC,12,GR,1760.13,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,731.158002,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Closed Rx Talus Fx,Manipulatn",PX28435F,CDM,510,RC,28435,CPT,,,,,,,,1705,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,731.445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,708.257,1670.9
Exc Skn Bngn1.1-2cm Remain Bdy,PX11422P,CDM,983,RC,11422,CPT,,,,,,,,822,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,731.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,341.4588,1416.38
perflutren lipid microsphere 6.52 MG/ML Suspension 2 mL Vial,Q9957,CDM,636,RC,Q9957,HCPCS,,,,11994001101,NDC,2,ML,751.71,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,100.52,percent of total billed charges,731.639343,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,312.260334,736.6758
2.1MM CANNULATED DRILL BIT,27200000,CDM,272,RC,,,,12657-MAIN,LOCAL,,,,,747,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,732.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
US Guide Needle Bx S&I,PX7694201,CDM,402,RC,76942,CPT,TC,,,,,,,747,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,732.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.3038,732.06
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565P,CDM,983,RC,25565,CPT,,,,,,,,830,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,732.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,344.782,1404.08
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180F,CDM,510,RC,44180,CPT,,,,,,,,1763,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,732.3502,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,732.3502,5040.74
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,67457061910,NDC,100,ML,1707.48,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,732.50892,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
Skin Sub Graft Trnk/Arm/Leg,PX15271F,CDM,510,RC,15271,CPT,,,,,,,,862,,First Health,Commercial,both,85,,999999999,percent of total billed charges,732.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,358.0748,1593.14
oseltamivir 6 MG/ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,4082205,NDC,60,ML,752.82,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,732.719706,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Exc Neck Les Sc = 3cm >,PX21552F,CDM,510,RC,21552,CPT,,,,,,,,753,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1412.37,percent of total billed charges,732.8949,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,312.7962,2482.37
diazePAM 10 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,187065820,NDC,1,EA,1527.87,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,733.3776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 10 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,187065820,NDC,1,EA,1527.87,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,733.3776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Infection Agent Detect Dna/Rna Probe Tq 6-11,PX87506,CDM,300,RC,87506,CPT,,,,,,,,1710,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,733.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,241.14,1675.8
"Sigmoidoscopy,Remv Lesn,Snare",PX45338P,CDM,983,RC,45338,CPT,,,,,,,,1710,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,733.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,710.334,1664.343
"HERNIA MESH 3D MAX MID ANATOMICAL MESH RIGHT SIZE XL 5"" X 7""",C1781,CDM,278,RC,C1781,HCPCS,,11979-MAIN,LOCAL,,,,,832,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,733.824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"HERNIA MESH 3DMAX MID MESH EXTRA-LARGE LEFT 5"" X 7""",C1781,CDM,278,RC,C1781,HCPCS,,11978-MAIN,LOCAL,,,,,832,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,733.824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
GRAFIXPL PRIME PLACENTAL MEMBRANE 1.5 x2CM 3SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12764-MAIN,LOCAL,,,,,1529,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,733.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
GRAFIXPL PRIME PLACENTAL MEMBRANE 1.5 x2CM 3SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12764-MAIN,LOCAL,,,,,1529,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,733.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573F,CDM,761,RC,36573,CPT,,,,,,,,1529,,Health Partners,Health Partners Care Plans,both,48,,95.12,percent of total billed charges,733.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,635.1466,1498.42
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573F,CDM,761,RC,36573,CPT,,,,,,,,1529,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,733.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,635.1466,1498.42
"Fac/Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404F,CDM,510,RC,11404,CPT,,,,,,,,749,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,734.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,311.1346,1416.38
Cns Dna/Rna Amp Probe Multiple Subtypes 12-25,PX87483,CDM,300,RC,87483,CPT,,,,,,,,864,,First Health,Commercial,both,85,,999999999,percent of total billed charges,734.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,358.9056,846.72
"HERNIA MESH 3D MAX MID ANATOMICAL MESH LEFT SIZE L 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,11976-MAIN,LOCAL,,,,,755,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1256.29,percent of total billed charges,734.8415,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"HERNIA MESH 3D MAX MID ANATOMICAL MESH RIGHT SIZE L 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,11977-MAIN,LOCAL,,,,,755,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1256.29,percent of total billed charges,734.8415,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605P,CDM,983,RC,24605,CPT,,,,,,,,750,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,735,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,304.32,1019.71
Level 2 Additional Procedure,PX36000081,CDM,360,RC,,,,,,,,,,1500,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,623.1,1470
Level 2 Additional Procedure,PX36000081,CDM,360,RC,,,,,,,,,,1500,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,623.1,1470
Level 2 Additional Procedure,PX36000081,CDM,360,RC,,,,,,,,,,1500,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,623.1,1470
Sigmoidoscope W/Submuc Inj,PX45335F,CDM,750,RC,45335,CPT,,,,,,,,750,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,311.55,798.45
Closed Rx Trimalleolar Fx,PX27816P,CDM,983,RC,27816,CPT,,,,,,,,826,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,735.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,803.9458
"Sb Scope,to Ileum,Biopsy",PX44377F,CDM,750,RC,44377,CPT,,,,,,,,1770,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,735.258,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,735.258,1734.6
Closed Rx Kneecap Dislocatn,PX27560F,CDM,510,RC,27560,CPT,,,,,,,,468,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,736.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,219.89,807.33
Closed Rx Kneecap Dislocatn,PX27560P,CDM,983,RC,27560,CPT,,,,,,,,312,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,736.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,219.89,807.33
Debride Tissue/Muscle/Bone,PX11044P,CDM,983,RC,11044,CPT,,,,,,,,866,,First Health,Commercial,both,85,,999999999,percent of total billed charges,736.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,359.7364,1416.38
Duplex Up Extrem Art Bilat,PX9393001,CDM,921,RC,93930,CPT,TC,,,,,,,835,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,736.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,818.3
perflutren lipid microsphere 6.52 MG/ML Suspension 2 mL Vial,Q9957,CDM,636,RC,Q9957,HCPCS,,,,11994001101,NDC,2,ML,751.71,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,736.6758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,312.260334,736.6758
"Exc Skn Bnig >4cmtrnk,Arm,Leg",PX11406P,CDM,983,RC,11406,CPT,,,,,,,,1456,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,736.736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,604.8224,1417.1248
Targeted Genomic Sequence Analysis Panel 5-50 Genes - Ref,PX8145090,CDM,300,RC,81450,CPT,90,,,,,,,2936,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,736.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,736.74,759.53
Targeted Genomic Sequence Analysis Panel 5-50 Genes - Ref,PX8145090,CDM,300,RC,81450,CPT,90,,,,,,,2936,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,736.74,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,736.74,759.53
Targeted Genomic Sequence Analysis Panel 5-50 Genes - Ref,PX8145090,CDM,300,RC,81450,CPT,90,,,,,,,2936,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,736.74,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,736.74,759.53
"Inject Nerv Blck,Othr Periph Nerv",PX64450F,CDM,510,RC,64450,CPT,,,,,,,,757,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,736.7881,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,314.4578,741.86
prednisoLONE acetate 0.12 % Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,11980017405,NDC,5,ML,757.07,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,736.856231,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
agalsidase beta 5 MG Recon Soln 1 Each Vial,J0180.01,CDM,636,RC,J0180,HCPCS,,,,58468004101,NDC,1,EA,1717.68,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,736.88472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,200.2,1683.3264
Abd Duplex Abd-Follow Up(T),PX9397601,CDM,921,RC,93976,CPT,TC,,,,,,,809,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,736.999,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,792.82
Venous Duplex Scan Uni,PX9397101,CDM,921,RC,93971,CPT,TC,,,,,,,809,,Medica,Commercial,both,91.1,,654.555,percent of total billed charges,736.999,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,792.82
MESH SURGICAL NON-ABSORBABLE PLUG 6INW X 6INL,C1781,CDM,272,RC,C1781,HCPCS,,12005-MAIN,LOCAL,,,,,1505,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,196.035,percent of total billed charges,737.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
MESH SURGICAL NON-ABSORBABLE PLUG 6INW X 6INL,C1781,CDM,272,RC,C1781,HCPCS,,12005-MAIN,LOCAL,,,,,1505,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,737.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
MESH SURGICAL NON-ABSORBABLE PLUG 6INW X 6INL,C1781,CDM,272,RC,C1781,HCPCS,,12005-MAIN,LOCAL,,,,,1505,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,737.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
MESH SURGICAL NON-ABSORBABLE PLUG 12INW X 12INL,C1781,CDM,278,RC,C1781,HCPCS,,12006-MAIN,LOCAL,,,,,1505,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,196.035,percent of total billed charges,737.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
MESH SURGICAL NON-ABSORBABLE PLUG 12INW X 12INL,C1781,CDM,278,RC,C1781,HCPCS,,12006-MAIN,LOCAL,,,,,1505,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,737.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
MESH SURGICAL NON-ABSORBABLE PLUG 12INW X 12INL,C1781,CDM,278,RC,C1781,HCPCS,,12006-MAIN,LOCAL,,,,,1505,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,737.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Closed Rx Elbow Dislocation,PX24600F,CDM,510,RC,24600,CPT,,,,,,,,706,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,737.46,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,218.15,814.94
Closed Rx Elbow Dislocation,PX24600P,CDM,983,RC,24600,CPT,,,,,,,,380,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,737.46,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,218.15,814.94
"Biopsy, Nail Unit",PX11755F,CDM,510,RC,11755,CPT,,,,,,,,1490,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,737.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,614.65,1460.2
CT Angiograph Pelv W/O&W/Dye,PX7219101,CDM,350,RC,72191,CPT,TC,,,,,,,1458,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,737.748,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
"Closed Rx Shldr Disloc,Anesthesia",PX23655F,CDM,510,RC,23655,CPT,,,,,,,,1776,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,737.7504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,737.7504,1740.48
"Sigmoidoscopy,Biopsy",PX45331F,CDM,750,RC,45331,CPT,,,,,,,,1776,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,737.7504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,737.7504,1740.48
oseltamivir 6 MG/ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,4082205,NDC,60,ML,752.82,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,737.7636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,25021019110,NDC,1,EA,809.89,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,737.80979,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.47563,793.6922
Noninvasv Lo Extrem Art Stress/Rest,PX9392401,CDM,921,RC,93924,CPT,TC,,,,,,,810,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,737.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.46,793.8
Exc Neck Les Sc = 3cm >,PX21552F,CDM,510,RC,21552,CPT,,,,,,,,753,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,737.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,312.7962,2482.37
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573P,CDM,983,RC,36573,CPT,,,,,,,,1721,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,738.309,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,714.9034,1675.0493
"Treat Thumb Disloc,Manipulatn",PX26641F,CDM,510,RC,26641,CPT,,,,,,,,1721,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,738.309,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1686.58
Closed Treat Wrist Dislocation,PX25660P,CDM,983,RC,25660,CPT,,,,,,,,1507,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,738.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1466.7631
Closed Treat Wrist Dislocation,PX25660P,CDM,983,RC,25660,CPT,,,,,,,,1507,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,738.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1466.7631
Closed Treat Wrist Dislocation,PX25660P,CDM,983,RC,25660,CPT,,,,,,,,1507,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,738.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1466.7631
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565P,CDM,983,RC,25565,CPT,,,,,,,,830,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,738.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,344.782,1404.08
PEMEtrexed Disodium 100 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2764001,NDC,1,EA,1539.32,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,738.8736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.01,7924.2996
PEMEtrexed Disodium 100 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2764001,NDC,1,EA,1539.32,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,738.8736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.01,7924.2996
travoprost (BAK Free) 0.004 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,65026025,NDC,2.5,ML,811.3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,739.0943,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Upper GI Endoscopy,Ctrl Bleed",PX43255F,CDM,750,RC,43255,CPT,,,,,,,,1723,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,739.167,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,715.7342,1688.54
Repair Incis Hernia W Mesh,PX49568F,CDM,510,RC,49568,CPT,,,,,,,,1540,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,739.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,639.716,1509.2
Repair Incis Hernia W Mesh,PX49568F,CDM,510,RC,49568,CPT,,,,,,,,1540,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,739.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,639.716,1509.2
"US Guide, Vascular Access",PX7693701,CDM,402,RC,76937,CPT,TC,,,,,,,760,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,739.708,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,315.704,744.8
"HERNIA MESH 3D MAX MID ANATOMICAL MESH LEFT SIZE L 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,11976-MAIN,LOCAL,,,,,755,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,739.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"HERNIA MESH 3D MAX MID ANATOMICAL MESH RIGHT SIZE L 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,11977-MAIN,LOCAL,,,,,755,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,739.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Blood Transfusion Service,PX36430,CDM,391,RC,36430,CPT,,,,,,,,839,,United Healthcare,All Payer,outpatient,88.2,,83.9,percent of total billed charges,739.998,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.5206,822.22
Drainage of Gum Lesion,PX41800P,CDM,983,RC,41800,CPT,,,,,,,,839,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,739.998,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,816.5987
Facility Emergency Level III Visit,PX99283F,CDM,450,RC,99283,CPT,,,,,,,,587,,Medica,Minnesota Health care Program (MHCP),outpatient,,,999999999,case rate,740,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,740,6141.46
"I&D Perianal Abscess,Superficial",PX46050F,CDM,510,RC,46050,CPT,,,,,,,,1463,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,740.278,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,607.7302,1433.74
"HERNIA MESH 3D MAX MID ANATOMICAL MESH RIGHT SIZE XL 5"" X 7""",C1781,CDM,278,RC,C1781,HCPCS,,11979-MAIN,LOCAL,,,,,832,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,740.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"HERNIA MESH 3DMAX MID MESH EXTRA-LARGE LEFT 5"" X 7""",C1781,CDM,278,RC,C1781,HCPCS,,11978-MAIN,LOCAL,,,,,832,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,740.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Closed Rx Trimalleolar Fx,Manip",PX27818F,CDM,510,RC,27818,CPT,,,,,,,,813,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,740.643,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,337.7202,1404.08
"Fac/Exc Skn Bngn 2.1-3cmfce,Facial",PX11443F,CDM,510,RC,11443,CPT,,,,,,,,813,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,740.643,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,337.7202,1416.38
Facility Emergency Level V Visit,PX99285F,CDM,450,RC,99285,CPT,,,,,,,,1464,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,740.784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,561.13,1434.72
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725F,CDM,510,RC,26725,CPT,,,,,,,,495,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,740.92,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,196.55,740.92
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725P,CDM,983,RC,26725,CPT,,,,,,,,330,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,740.92,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,196.55,740.92
"rabies vaccine, pcec Recon Susp 1 Each Vial",90675,CDM,636,RC,90675,CPT,,,,58160096412,NDC,1,EA,1544.83,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,741.5184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,297.75,1513.9334
"rabies vaccine, pcec Recon Susp 1 Each Vial",90675,CDM,636,RC,90675,CPT,,,,58160096412,NDC,1,EA,1544.83,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,741.5184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,297.75,1513.9334
"Hemorrhoidectomy,Int/Ext,Simple",PX46255F,CDM,510,RC,46255,CPT,,,,,,,,1627,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,741.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,221.21,1082.67
"Hemorrhoidectomy,Int/Ext,Simple",PX46255P,CDM,983,RC,46255,CPT,,,,,,,,2393,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,741.61,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,221.21,2345.14
CT Angio Upr Extrm W/O&W/Dye,PX7320601,CDM,350,RC,73206,CPT,TC,,,,,,,757,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,741.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
"Inject Nerv Blck,Othr Periph Nerv",PX64450F,CDM,510,RC,64450,CPT,,,,,,,,757,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,741.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,314.4578,741.86
prednisoLONE acetate 0.12 % Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,11980017405,NDC,5,ML,757.07,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,741.9286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Injection for Nerve Block,PX64448F,CDM,510,RC,64448,CPT,,,,,,,,873,,First Health,Commercial,both,85,,999999999,percent of total billed charges,742.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,362.6442,855.54
MINIBUNION DRILL KIT,27200000,CDM,278,RC,C1713,HCPCS,,11669-MAIN,LOCAL,,,,,841.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,742.203,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Part Remv Phalanx of Toe,PX28124P,CDM,983,RC,28124,CPT,,,,,,,,1515,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,742.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,629.331,2827.75
Part Remv Phalanx of Toe,PX28124P,CDM,983,RC,28124,CPT,,,,,,,,1515,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,742.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,629.331,2827.75
Part Remv Phalanx of Toe,PX28124P,CDM,983,RC,28124,CPT,,,,,,,,1515,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,742.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,629.331,2827.75
Level 2 Additional Procedure,PX36000081,CDM,360,RC,,,,,,,,,,1500,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,742.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,623.1,1470
"Up GI Endoscopy,Ball Dil,30mm",PX43249P,CDM,983,RC,43249,CPT,,,,,,,,1731,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,742.599,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,742.599,3257.54
Biopsy of Rectum,PX45100F,CDM,510,RC,45100,CPT,,,,,,,,763,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,742.6279,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,316.9502,2452.93
"Lap,Dx Surgical Abd W/Biopsy",PX49321F,CDM,510,RC,49321,CPT,,,,,,,,874,,First Health,Commercial,both,85,,999999999,percent of total billed charges,742.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.0596,5040.74
Duplex Up Extrem Art Bilat,PX9393001,CDM,921,RC,93930,CPT,TC,,,,,,,835,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,743.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,818.3
Lap Incis Hernia Reducible,PX49654F,CDM,510,RC,49654,CPT,,,,,,,,1964,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,743.3465,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,743.3465,743.35
Lap Incis Hernia Reducible,PX49654P,CDM,983,RC,49654,CPT,,,,,,,,1044,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,743.3465,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,743.3465,1023.12
Lap Incis Hernia Reducible,PX49654F,CDM,510,RC,49654,CPT,,,,,,,,1964,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,743.35,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,743.3465,743.35
Lap Incis Hernia Reducible,PX49654P,CDM,983,RC,49654,CPT,,,,,,,,1044,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,743.35,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,743.3465,1023.12
carboprost 250 MCG/ML Solution 1 mL Ampule,25000000,CDM,250,RC,,,,,,9085608,NDC,1,ML,1517.13,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,743.3937,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
carboprost 250 MCG/ML Solution 1 mL Ampule,25000000,CDM,250,RC,,,,,,9085608,NDC,1,ML,1517.13,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,743.3937,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
carboprost 250 MCG/ML Solution 1 mL Ampule,25000000,CDM,250,RC,,,,,,9085608,NDC,1,ML,1517.13,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,743.3937,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Sigmoidoscopy,Screen Prev",PX2001F,CDM,750,RC,45330,CPT,,,,,,,,843,,United Healthcare,All Payer,outpatient,88.2,,999999999,case rate,743.526,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,743.526,6141.46
"Fac/Exc Skn Mali2.1-3cmtrnk,Arm,Lg",PX11603F,CDM,510,RC,11603,CPT,,,,,,,,875,,First Health,Commercial,both,85,,999999999,percent of total billed charges,743.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.475,857.5
"Removal Anal Fistula,Subcutaneous",PX46270F,CDM,510,RC,46270,CPT,,,,,,,,1470,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,743.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,610.638,2452.93
cocaine 4% 4 % Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527172874,NDC,4,ML,875.53,,First Health,Commercial,both,85,,999999999,percent of total billed charges,744.2005,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
"Excis Arm/Elbow Tumor,Subcutan",PX24075F,CDM,510,RC,24075,CPT,,,,,,,,1519,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,744.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,630.9926,1488.62
"Excis Arm/Elbow Tumor,Subcutan",PX24075F,CDM,510,RC,24075,CPT,,,,,,,,1519,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,744.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,630.9926,1488.62
"Excis Arm/Elbow Tumor,Subcutan",PX24075F,CDM,510,RC,24075,CPT,,,,,,,,1519,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,744.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,630.9926,1488.62
Targeted Genomic Sequence Analysis Panel 5-50 Genes - Ref,PX8145090,CDM,300,RC,81450,CPT,90,,,,,,,2936,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,744.488,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,736.74,759.53
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561P,CDM,983,RC,36561,CPT,,,,,,,,1736,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,744.744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,721.1344,2784.63
"US Guide, Vascular Access",PX7693701,CDM,402,RC,76937,CPT,TC,,,,,,,760,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,744.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,315.704,744.8
MESH SURGICAL NON-ABSORBABLE PLUG 6INW X 6INL,C1781,CDM,272,RC,C1781,HCPCS,,12005-MAIN,LOCAL,,,,,1505,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,744.975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
MESH SURGICAL NON-ABSORBABLE PLUG 12INW X 12INL,C1781,CDM,278,RC,C1781,HCPCS,,12006-MAIN,LOCAL,,,,,1505,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,744.975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Lap,Cholecystectomy",PX47562F,CDM,510,RC,47562,CPT,,,,,,,,1473,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,745.338,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,611.8842,5040.74
CT Angio Lwr Extr W/O&W/Dye,PX7370601,CDM,350,RC,73706,CPT,TC,,,,,,,1554,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,745.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1522.92
CT Angio Lwr Extr W/O&W/Dye,PX7370601,CDM,350,RC,73706,CPT,TC,,,,,,,1554,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,745.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1522.92
Closed Treat Wrist Dislocation,PX25660P,CDM,983,RC,25660,CPT,,,,,,,,1507,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,745.965,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1466.7631
"Closed Rx Weight Bear Dist Tib,Manip",PX27825P,CDM,983,RC,27825,CPT,,,,,,,,1796,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,746.0584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,746.0584,1748.0468
Repr Superf Wnd Face 5.1-7.5,PX12014P,CDM,983,RC,12014,CPT,,,,,,,,819,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,746.109,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,797.1327
"Repair Flex Foot Tendon,Ea",PX28200F,CDM,510,RC,28200,CPT,,,,,,,,1475,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,746.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,612.715,2827.75
"Casiri and Imdevimab,Admin,Repeat Dose",PXM0240,CDM,771,RC,M0240,HCPCS,,,,,,,,1555,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,746.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,413.06,1523.9
"Casiri and Imdevimab,Admin,Repeat Dose",PXM0240,CDM,771,RC,M0240,HCPCS,,,,,,,,1555,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,746.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,413.06,1523.9
"IV Infusion, Bamlanivimab and Etesevimab, Infusion and Monitoring",PXM0245,CDM,260,RC,M0245,HCPCS,,,,,,,,1555,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,746.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,413.06,1523.9
"IV Infusion, Bamlanivimab and Etesevimab, Infusion and Monitoring",PXM0245,CDM,260,RC,M0245,HCPCS,,,,,,,,1555,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,746.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,413.06,1523.9
"IV Infusion, Casirivimab and Imdevimab, IV and Post Admr",PXM0243,CDM,771,RC,M0243,HCPCS,,,,,,,,1555,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,746.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,413.06,1684.87
"IV Infusion, Casirivimab and Imdevimab, IV and Post Admr",PXM0243,CDM,771,RC,M0243,HCPCS,,,,,,,,1555,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,746.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,413.06,1684.87
"Complex Drainage, Wound",PX10180P,CDM,983,RC,10180,CPT,,,,,,,,767,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,746.5211,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,318.6118,2482.37
Blood Transfusion Service,PX36430,CDM,391,RC,36430,CPT,,,,,,,,839,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,746.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.5206,822.22
Drainage of Gum Lesion,PX41800P,CDM,983,RC,41800,CPT,,,,,,,,839,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,746.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,816.5987
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591F,CDM,360,RC,49591,CPT,,,,,,,,1556,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,746.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,646.3624,3022.41
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591F,CDM,360,RC,49591,CPT,,,,,,,,1556,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,746.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,646.3624,3022.41
"Lap,Cholecystectomy/Graph",PX47563F,CDM,510,RC,47563,CPT,,,,,,,,1556,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,746.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,646.3624,5040.74
"Lap,Cholecystectomy/Graph",PX47563F,CDM,510,RC,47563,CPT,,,,,,,,1556,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,746.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,646.3624,5040.74
Biopsy of Rectum,PX45100F,CDM,510,RC,45100,CPT,,,,,,,,763,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,747.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,316.9502,2452.93
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021080166,NDC,5,ML,820.8,,Medica,Commercial,both,91.1,,51.072,percent of total billed charges,747.7488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092401,NDC,0.5,ML,820.88,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,747.82168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092491,NDC,0.5,ML,820.88,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,747.82168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092410,NDC,0.5,ML,820.89,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,747.83079,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
TAPER POST TOE JOINT HEMICAP 9.5MM ARTICULATING METATARSAL STERILE,C1713,CDM,278,RC,C1713,HCPCS,,12531-MAIN,LOCAL,,,,,821,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,747.931,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,60505619301,NDC,5,ML,821.36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,748.25896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.08296,1009.1158
"Layr Clos Wnd Face,Facial <2.5cm",PX12051F,CDM,510,RC,12051,CPT,,,,,,,,769,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,748.4677,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,319.4426,753.62
diazePAM 10 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,187065820,NDC,1,EA,1527.87,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,748.6563,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 10 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,187065820,NDC,1,EA,1527.87,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,748.6563,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 10 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,187065820,NDC,1,EA,1527.87,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,748.6563,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Exc Skn Bngn1.1-2cm Remain Bdy,PX11422P,CDM,983,RC,11422,CPT,,,,,,,,822,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,748.842,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,341.4588,1416.38
"Injection,Sacroiliac Joint(T)",PX27096F,CDM,510,RC,27096,CPT,,,,,,,,881,,First Health,Commercial,both,85,,999999999,percent of total billed charges,748.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,365.9674,863.38
MINIBUNION DRILL KIT,27200000,CDM,278,RC,C1713,HCPCS,,11669-MAIN,LOCAL,,,,,841.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,748.935,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
fluticasone 220 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173072020,NDC,12,GR,1746.36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,749.18844,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
GRAFIXPL PRIME PLACENTAL MEMBRANE 1.5 x2CM 3SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12764-MAIN,LOCAL,,,,,1529,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,749.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
GRAFIXPL PRIME PLACENTAL MEMBRANE 1.5 x2CM 3SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12764-MAIN,LOCAL,,,,,1529,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,749.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
GRAFIXPL PRIME PLACENTAL MEMBRANE 1.5 x2CM 3SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12764-MAIN,LOCAL,,,,,1529,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,749.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573F,CDM,761,RC,36573,CPT,,,,,,,,1529,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,749.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,635.1466,1498.42
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573F,CDM,761,RC,36573,CPT,,,,,,,,1529,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,749.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,635.1466,1498.42
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573F,CDM,761,RC,36573,CPT,,,,,,,,1529,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,749.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,635.1466,1498.42
"Diagnostic Bone Marrow, Biopsy and Aspiration",PX38222F,CDM,761,RC,38222,CPT,,,,,,,,1748,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,749.892,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,726.1192,2482.37
Part Remv Phalanx of Toe,PX28124P,CDM,983,RC,28124,CPT,,,,,,,,1515,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,749.925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,629.331,2827.75
PROSTEP MICA SCREW 3.0X20MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12442-MAIN,LOCAL,,,,,1806,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,750.2124,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 3.0X40MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12443-MAIN,LOCAL,,,,,1806,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,750.2124,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X52MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12444-MAIN,LOCAL,,,,,1806,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,750.2124,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"Sigmoidoscopy,Screen Prev",PX2001F,CDM,750,RC,45330,CPT,,,,,,,,843,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,750.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,350.1822,826.14
Irradiated Leukoreduced Rbc's,PXP9040,CDM,390,RC,P9040,HCPCS,,,,,,,,771,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,750.4143,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,231.5,755.58
brinzolamide-brimonidine 1-0.2 % Suspension 8 mL Bottle,63700001,CDM,250,RC,,,,,,65414727,NDC,8,ML,850.88,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,750.47616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Closed Rx Radial Head/Neck Fx,Manip",PX24655F,CDM,510,RC,24655,CPT,,,,,,,,1750,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,750.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,726.95,1715
"Fix Exten Tendon,Dorsum Fingr,Ea",PX26418F,CDM,510,RC,26418,CPT,,,,,,,,1750,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,750.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,726.95,1715
carboprost 250 MCG/ML Solution 1 mL Ampule,25000000,CDM,250,RC,,,,,,9085608,NDC,1,ML,1517.13,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,750.97935,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034P,CDM,983,RC,12034,CPT,,,,,,,,1533,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,751.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1492.0689
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034P,CDM,983,RC,12034,CPT,,,,,,,,1533,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,751.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1492.0689
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034P,CDM,983,RC,12034,CPT,,,,,,,,1533,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,751.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1492.0689
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12173-SURG,LOCAL,,,,,772,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,751.3876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Abd Paracentesis,PX49082F,CDM,510,RC,49082,CPT,,,,,,,,884,,First Health,Commercial,both,85,,999999999,percent of total billed charges,751.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,367.2136,866.32
"Excise Lesion,Back or Flank",PX21930P,CDM,983,RC,21930,CPT,,,,,,,,884,,First Health,Commercial,both,85,,999999999,percent of total billed charges,751.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,367.2136,1416.38
cycloPHOSphamide 500 MG Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781323394,NDC,1,EA,1565.71,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,751.5408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
cycloPHOSphamide 500 MG Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781323394,NDC,1,EA,1565.71,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,751.5408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
"Complex Drainage, Wound",PX10180P,CDM,983,RC,10180,CPT,,,,,,,,767,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,751.66,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.95,751.66
"Excis Arm/Elbow Tumor,Subcutan",PX24075F,CDM,510,RC,24075,CPT,,,,,,,,1519,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,751.905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,630.9926,1488.62
clobetasol 0.05 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,21922001707,NDC,60,GR,1810.35,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,752.01939,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
I&D Deep Absc/Hematoma Neck/Chest,PX21501F,CDM,510,RC,21501,CPT,,,,,,,,773,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,752.3609,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.1042,2482.37
Closed Rx Trimalleolar Fx,PX27816P,CDM,983,RC,27816,CPT,,,,,,,,826,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,752.486,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,803.9458
"Lap,Inguinal Hernia Repr,Recur",PX49651F,CDM,510,RC,49651,CPT,,,,,,,,1568,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,752.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,651.3472,5040.74
"Lap,Inguinal Hernia Repr,Recur",PX49651F,CDM,510,RC,49651,CPT,,,,,,,,1568,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,752.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,651.3472,5040.74
"Exc Skn Beig1.1-2cm Face,Facil",PX11442P,CDM,983,RC,11442,CPT,,,,,,,,886,,First Health,Commercial,both,85,,999999999,percent of total billed charges,753.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,368.0444,862.3438
PROSTEP HV SCREW 3.0X16MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12986-MAIN,LOCAL,,,,,1569,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,753.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP HV SCREW 3.0X16MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12986-MAIN,LOCAL,,,,,1569,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,753.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Explor Metatarso-Phalang Jt,PX28022P,CDM,983,RC,28022,CPT,,,,,,,,774,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,753.3342,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.5196,2827.75
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132P,CDM,983,RC,13132,CPT,,,,,,,,774,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,268.45,percent of total billed charges,753.3342,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.5196,753.3342
"Layr Clos Wnd Face,Facial <2.5cm",PX12051F,CDM,510,RC,12051,CPT,,,,,,,,769,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,753.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,319.4426,753.62
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016401,NDC,1,ML,854.49,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,753.66018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.66,898.7384
"Biopsy, Nail Unit",PX11755F,CDM,510,RC,11755,CPT,,,,,,,,1490,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,753.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,614.65,1460.2
Remv Periton FB From Perit Cav,PX49402F,CDM,510,RC,49402,CPT,,,,,,,,3573,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,753.9428,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,510.91,1776.54
Remv Periton FB From Perit Cav,PX49402P,CDM,983,RC,49402,CPT,,,,,,,,3897,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,753.9428,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,510.91,3819.06
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004F,CDM,510,RC,15004,CPT,,,,,,,,855,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,754.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,355.167,837.9
PEMEtrexed Disodium 100 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2764001,NDC,1,EA,1539.32,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,754.2668,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.01,7924.2996
PEMEtrexed Disodium 100 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2764001,NDC,1,EA,1539.32,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,754.2668,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.01,7924.2996
PEMEtrexed Disodium 100 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2764001,NDC,1,EA,1539.32,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,754.2668,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.01,7924.2996
Room Rate Transitional Care Private,PX11900000,CDM,119,RC,,,,,,,,,,775,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,754.3075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.935,759.5
MESH VENTRALIGHT ECHO 2.0 POSITIONING 15CM ROUND,C1781,CDM,278,RC,C1781,HCPCS,,12842-MAIN,LOCAL,,,,,1816,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,754.3664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Repair Incis Hernia W Mesh,PX49568F,CDM,510,RC,49568,CPT,,,,,,,,1540,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,754.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,639.716,1509.2
Repair Incis Hernia W Mesh,PX49568F,CDM,510,RC,49568,CPT,,,,,,,,1540,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,754.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,639.716,1509.2
Repair Incis Hernia W Mesh,PX49568F,CDM,510,RC,49568,CPT,,,,,,,,1540,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,754.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,639.716,1509.2
STAPLER SUREFORM 45 SPU IS4000,27200000,CDM,272,RC,,,,12794-MAIN,LOCAL,,,,,888,,First Health,Commercial,both,85,,999999999,percent of total billed charges,754.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
fluticasone 220 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,66993008096,NDC,12,GR,1760.13,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,755.09577,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Layr Clos Wnd Face,Facial 2.5-5",PX12052P,CDM,983,RC,12052,CPT,,,,,,,,776,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,755.2808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,322.3504,755.2808
"Closed Rx Spont Hip Disloc,Anesth",PX27257F,CDM,510,RC,27257,CPT,,,,,,,,548,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,755.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,221.86,755.45
"Closed Rx Spont Hip Disloc,Anesth",PX27257F,CDM,510,RC,27257,CPT,,,,,,,,548,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,755.45,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,221.86,755.45
"Closed Rx Spont Hip Disloc,Anesth",PX27257P,CDM,983,RC,27257,CPT,,,,,,,,365,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,755.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,221.86,755.45
"Closed Rx Spont Hip Disloc,Anesth",PX27257P,CDM,983,RC,27257,CPT,,,,,,,,365,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,755.45,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,221.86,755.45
Irradiated Leukoreduced Rbc's,PXP9040,CDM,390,RC,P9040,HCPCS,,,,,,,,771,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,755.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,231.5,755.58
Drain Skin Abscess Complic,PX10061F,CDM,510,RC,10061,CPT,,,,,,,,889,,First Health,Commercial,both,85,,999999999,percent of total billed charges,755.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,871.22
Inc/Drain Peritonsil Abscess,PX42700P,CDM,983,RC,42700,CPT,,,,,,,,889,,First Health,Commercial,both,85,,999999999,percent of total billed charges,755.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,865.2637
"Closed Rx Big Toe Fx,Manip",PX28495F,CDM,510,RC,28495,CPT,,,,,,,,857,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,755.874,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,839.86
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,115169449,NDC,1,EA,889.46,,First Health,Commercial,both,85,,999999999,percent of total billed charges,756.041,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54505010202,NDC,1,EA,889.46,,First Health,Commercial,both,85,,999999999,percent of total billed charges,756.041,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565P,CDM,983,RC,25565,CPT,,,,,,,,830,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,756.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,344.782,1404.08
Layr Clos Wnd Rest Body 2.6-7.5,PX12042P,CDM,983,RC,12042,CPT,,,,,,,,777,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,756.2541,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,322.7658,756.2541
diazePAM 10 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,187065820,NDC,1,EA,1527.87,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,756.29565,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180F,CDM,510,RC,44180,CPT,,,,,,,,1763,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,756.327,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,732.3502,5040.74
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12173-SURG,LOCAL,,,,,772,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,756.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
GRAFIXPL PRIME PLACENTAL MEMBRANE 1.5 x2CM 3SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12764-MAIN,LOCAL,,,,,1529,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,756.855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573F,CDM,761,RC,36573,CPT,,,,,,,,1529,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,756.855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,635.1466,1498.42
Room Rate General Iso,PX12000001,CDM,120,RC,,,,,,,,,,1822,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,756.8588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,756.8588,1785.56
"rabies vaccine, pcec Recon Susp 1 Each Vial",90675,CDM,636,RC,90675,CPT,,,,58160096412,NDC,1,EA,1544.83,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,756.9667,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,297.75,1513.9334
"rabies vaccine, pcec Recon Susp 1 Each Vial",90675,CDM,636,RC,90675,CPT,,,,58160096412,NDC,1,EA,1544.83,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,756.9667,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,297.75,1513.9334
"rabies vaccine, pcec Recon Susp 1 Each Vial",90675,CDM,636,RC,90675,CPT,,,,58160096412,NDC,1,EA,1544.83,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,756.9667,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,297.75,1513.9334
brinzolamide-brimonidine 1-0.2 % Suspension 8 mL Bottle,63700001,CDM,250,RC,,,,,,65414727,NDC,8,ML,850.88,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,757.2832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
I&D Deep Absc/Hematoma Neck/Chest,PX21501F,CDM,510,RC,21501,CPT,,,,,,,,773,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,757.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.1042,2482.37
"Closed Rx Radial Head/Neck Fx,Manip",PX24655P,CDM,983,RC,24655,CPT,,,,,,,,1824,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,757.6896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,757.6896,1775.2992
"HERNIA MESH 3D MAX MID ANATOMICAL MESH RIGHT SIZE XL 5"" X 7""",C1781,CDM,278,RC,C1781,HCPCS,,11979-MAIN,LOCAL,,,,,832,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,757.952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"HERNIA MESH 3DMAX MID MESH EXTRA-LARGE LEFT 5"" X 7""",C1781,CDM,278,RC,C1781,HCPCS,,11978-MAIN,LOCAL,,,,,832,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,757.952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569P,CDM,983,RC,36569,CPT,,,,,,,,1825,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,758.105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,758.105,1776.2725
Explor Metatarso-Phalang Jt,PX28022P,CDM,983,RC,28022,CPT,,,,,,,,774,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,758.52,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,207.02,1012.1
GRAFIXPL PRIME PLACENTAL MEMBRANE 16MM DISC 2SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12763-MAIN,LOCAL,,,,,860,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,758.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132P,CDM,983,RC,13132,CPT,,,,,,,,774,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,758.52,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.92,976.82
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016425,NDC,1,ML,779.43,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,758.619219,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.66,898.7384
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034P,CDM,983,RC,12034,CPT,,,,,,,,1533,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,758.835,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1492.0689
Level 2 Additional Procedure,PX36000081,CDM,360,RC,,,,,,,,,,1500,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,759,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,623.1,1470
"Amputation Toe,I-P Jt",PX28825P,CDM,983,RC,28825,CPT,,,,,,,,780,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,759.174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,324.012,2827.75
"Sb Scope,to Ileum,Biopsy",PX44377F,CDM,750,RC,44377,CPT,,,,,,,,1770,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,759.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,735.258,1734.6
Room Rate Transitional Care Private,PX11900000,CDM,119,RC,,,,,,,,,,775,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,759.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.935,759.5
Targeted Genomic Sequence Analysis Panel 5-50 Genes - Ref,PX8145090,CDM,300,RC,81450,CPT,90,,,,,,,2936,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,759.53,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,736.74,759.53
RESTRATA WOUND MATRIX 2.5CM X 2.5CM TOTAL 6.25CM,27200000,CDM,272,RC,A2007,HCPCS,,11733-MAIN,LOCAL,,,,,1829,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,759.7666,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Skin Sub Graft Trnk/Arm/Leg,PX15271F,CDM,510,RC,15271,CPT,,,,,,,,862,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,760.284,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,358.0748,1593.14
"Layr Clos Wnd Face,Facial 2.5-5",PX12052P,CDM,983,RC,12052,CPT,,,,,,,,776,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,760.48,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.22,760.48
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016401,NDC,1,ML,854.49,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,760.4961,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.66,898.7384
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310002,NDC,0.528,ML,894.9,,First Health,Commercial,both,85,,999999999,percent of total billed charges,760.665,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.22,877.002
Duplex Up Extrem Art Bilat,PX9393001,CDM,921,RC,93930,CPT,TC,,,,,,,835,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,760.685,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,818.3
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004F,CDM,510,RC,15004,CPT,,,,,,,,855,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,760.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,355.167,837.9
Peramivir 200 MG/20ML Solution 20 mL Vial,800000,CDM,,,,,,,,61364018101,NDC,20,ML,1832.6,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,761.26204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
CT Angio Lwr Extr W/O&W/Dye,PX7370601,CDM,350,RC,73706,CPT,TC,,,,,,,1554,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,761.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1522.92
CT Angio Lwr Extr W/O&W/Dye,PX7370601,CDM,350,RC,73706,CPT,TC,,,,,,,1554,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,761.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1522.92
CT Angio Lwr Extr W/O&W/Dye,PX7370601,CDM,350,RC,73706,CPT,TC,,,,,,,1554,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,761.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1522.92
Layr Clos Wnd Rest Body 2.6-7.5,PX12042P,CDM,983,RC,12042,CPT,,,,,,,,777,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,761.46,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,123.03,761.46
MESH SURGICAL NON-ABSORBABLE PLUG 6INW X 6INL,C1781,CDM,272,RC,C1781,HCPCS,,12005-MAIN,LOCAL,,,,,1505,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,761.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
MESH SURGICAL NON-ABSORBABLE PLUG 12INW X 12INL,C1781,CDM,278,RC,C1781,HCPCS,,12006-MAIN,LOCAL,,,,,1505,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,761.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Closed Rx Shldr Disloc,Anesthesia",PX23655F,CDM,510,RC,23655,CPT,,,,,,,,1776,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,761.904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,737.7504,1740.48
"Sigmoidoscopy,Biopsy",PX45331F,CDM,750,RC,45331,CPT,,,,,,,,1776,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,761.904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,737.7504,1740.48
"Casiri and Imdevimab,Admin,Repeat Dose",PXM0240,CDM,771,RC,M0240,HCPCS,,,,,,,,1555,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,761.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,413.06,1523.9
"Casiri and Imdevimab,Admin,Repeat Dose",PXM0240,CDM,771,RC,M0240,HCPCS,,,,,,,,1555,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,761.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,413.06,1523.9
"Casiri and Imdevimab,Admin,Repeat Dose",PXM0240,CDM,771,RC,M0240,HCPCS,,,,,,,,1555,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,761.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,413.06,1523.9
"IV Infusion, Bamlanivimab and Etesevimab, Infusion and Monitoring",PXM0245,CDM,260,RC,M0245,HCPCS,,,,,,,,1555,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,761.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,413.06,1523.9
"IV Infusion, Bamlanivimab and Etesevimab, Infusion and Monitoring",PXM0245,CDM,260,RC,M0245,HCPCS,,,,,,,,1555,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,761.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,413.06,1523.9
"IV Infusion, Bamlanivimab and Etesevimab, Infusion and Monitoring",PXM0245,CDM,260,RC,M0245,HCPCS,,,,,,,,1555,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,761.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,413.06,1523.9
"IV Infusion, Casirivimab and Imdevimab, IV and Post Admr",PXM0243,CDM,771,RC,M0243,HCPCS,,,,,,,,1555,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,761.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,413.06,1684.87
"IV Infusion, Casirivimab and Imdevimab, IV and Post Admr",PXM0243,CDM,771,RC,M0243,HCPCS,,,,,,,,1555,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,761.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,413.06,1684.87
"IV Infusion, Casirivimab and Imdevimab, IV and Post Admr",PXM0243,CDM,771,RC,M0243,HCPCS,,,,,,,,1555,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,761.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,413.06,1684.87
PEMEtrexed Disodium 100 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2764001,NDC,1,EA,1539.32,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,761.9634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.01,7924.2996
Cns Dna/Rna Amp Probe Multiple Subtypes 12-25,PX87483,CDM,300,RC,87483,CPT,,,,,,,,864,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,762.048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,358.9056,846.72
Repair Incis Hernia W Mesh,PX49568F,CDM,510,RC,49568,CPT,,,,,,,,1540,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,762.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,639.716,1509.2
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591F,CDM,360,RC,49591,CPT,,,,,,,,1556,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,762.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,646.3624,3022.41
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591F,CDM,360,RC,49591,CPT,,,,,,,,1556,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,762.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,646.3624,3022.41
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591F,CDM,360,RC,49591,CPT,,,,,,,,1556,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,762.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,646.3624,3022.41
"Lap,Cholecystectomy/Graph",PX47563F,CDM,510,RC,47563,CPT,,,,,,,,1556,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,762.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,646.3624,5040.74
"Lap,Cholecystectomy/Graph",PX47563F,CDM,510,RC,47563,CPT,,,,,,,,1556,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,762.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,646.3624,5040.74
"Lap,Cholecystectomy/Graph",PX47563F,CDM,510,RC,47563,CPT,,,,,,,,1556,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,762.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,646.3624,5040.74
Closed Treat Wrist Dislocation,PX25660P,CDM,983,RC,25660,CPT,,,,,,,,1507,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,762.542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1466.7631
"Closed Rx Big Toe Fx,Manip",PX28495F,CDM,510,RC,28495,CPT,,,,,,,,857,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,762.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,839.86
Abd Duplex Abd -Follow Up,PX9397602,CDM,921,RC,93976,CPT,TC,,,,,,,784,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,639.675,percent of total billed charges,763.0672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,768.32
Art Lower Extremity+Upper,PX9392301,CDM,921,RC,93923,CPT,TC,,,,,,,784,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,763.0672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.46,768.32
Debride Tissue/Muscle/Bone,PX11044P,CDM,983,RC,11044,CPT,,,,,,,,866,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,763.812,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,359.7364,1416.38
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016425,NDC,1,ML,779.43,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,763.8414,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.66,898.7384
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605P,CDM,983,RC,25605,CPT,,,,,,,,785,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,764.0405,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,326.089,1404.08
Layr Clos Wnd Rest Body 7.6-12.5,PX12044F,CDM,510,RC,12044,CPT,,,,,,,,785,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,764.0405,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,326.089,769.3
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310001,NDC,0.528,ML,785.14,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,764.176762,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.22,877.002
Blood Transfusion Service,PX36430,CDM,391,RC,36430,CPT,,,,,,,,839,,Medica,Commercial,both,91.1,,162.8,percent of total billed charges,764.329,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.5206,822.22
Drainage of Gum Lesion,PX41800P,CDM,983,RC,41800,CPT,,,,,,,,839,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,764.329,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,816.5987
"Amputation Toe,I-P Jt",PX28825P,CDM,983,RC,28825,CPT,,,,,,,,780,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,764.4,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,106.23,764.4
"rabies vaccine, pcec Recon Susp 1 Each Vial",90675,CDM,636,RC,90675,CPT,,,,58160096412,NDC,1,EA,1544.83,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,764.69085,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,297.75,1513.9334
MIS STERILE INSTRUMENT PACK WITH BLADE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12432-MAIN,LOCAL,,,,,900,,First Health,Commercial,both,85,,999999999,percent of total billed charges,765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
GRAFIXPL PRIME PLACENTAL MEMBRANE 16MM DISC 2SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12763-MAIN,LOCAL,,,,,860,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,765.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
DYNABUNION PLATE STERILE INSTRUMENT KIT,27200000,CDM,272,RC,,,,12465-MAIN,LOCAL,,,,,1843,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,765.5822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021083082,NDC,100,ML,1596,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,766.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021083082,NDC,100,ML,1596,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,766.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
"Incis/Drain Shldr Absc/Hema,Deep",PX23030P,CDM,983,RC,23030,CPT,,,,,,,,1564,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,766.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,649.6856,2482.37
"Incis/Drain Shldr Absc/Hema,Deep",PX23030P,CDM,983,RC,23030,CPT,,,,,,,,1564,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,766.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,649.6856,2482.37
"Incis/Drain Shldr Absc/Hema,Deep",PX23030P,CDM,983,RC,23030,CPT,,,,,,,,1564,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,766.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,649.6856,2482.37
"Closed Rx Dist Fibula Fx,Manip",PX27788F,CDM,510,RC,27788,CPT,,,,,,,,1597,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,766.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1565.06
"Closed Rx Dist Fibula Fx,Manip",PX27788F,CDM,510,RC,27788,CPT,,,,,,,,1597,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,766.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1565.06
Part Remv Phalanx of Toe,PX28124P,CDM,983,RC,28124,CPT,,,,,,,,1515,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,766.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,629.331,2827.75
MINIBUNION DRILL KIT,27200000,CDM,278,RC,C1713,HCPCS,,11669-MAIN,LOCAL,,,,,841.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,766.6065,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Abd Duplex Abd-Full,PX9397501,CDM,921,RC,93975,CPT,TC,,,,,,,788,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,766.9604,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,772.24
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122F,CDM,510,RC,13122,CPT,,,,,,,,788,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,766.9604,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,327.3352,772.24
Skin Sub Graft Trnk/Arm/Leg,PX15271F,CDM,510,RC,15271,CPT,,,,,,,,862,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,767.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,358.0748,1593.14
cycloPHOSphamide 500 MG Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781323394,NDC,1,EA,1565.71,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,767.1979,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
cycloPHOSphamide 500 MG Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781323394,NDC,1,EA,1565.71,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,767.1979,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
cycloPHOSphamide 500 MG Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781323394,NDC,1,EA,1565.71,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,767.1979,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
ferumoxytol 510 MG/17ML Solution 17 mL Vial,Q0138.01,CDM,636,RC,Q0138,HCPCS,,,,781315401,NDC,17,ML,1846.91,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,767.206414,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.32,1809.9718
Reconstruc of Nail Bed,PX11760P,CDM,983,RC,11760,CPT,,,,,,,,903,,First Health,Commercial,both,85,,999999999,percent of total billed charges,767.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,375.1062,878.8899
carboprost 250 MCG/ML Solution 1 mL Ampule,25000000,CDM,250,RC,,,,,,9085608,NDC,1,ML,1517.13,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,767.66778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Excise Lesion,Back or Flank",PX21930F,CDM,510,RC,21930,CPT,,,,,,,,1326,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,767.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,225.35,1053.61
"Excise Lesion,Back or Flank",PX21930P,CDM,983,RC,21930,CPT,,,,,,,,884,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,767.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,225.35,1053.61
"Sigmoidoscopy,Screen Prev",PX2001F,CDM,750,RC,45330,CPT,,,,,,,,843,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,767.973,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,350.1822,826.14
Or Level 1,PX36000001,CDM,360,RC,,,,,,,,,,1600,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,664.64,1568
Or Level 1,PX36000001,CDM,360,RC,,,,,,,,,,1600,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,664.64,1568
Abd Duplex Abd -Follow Up,PX9397602,CDM,921,RC,93976,CPT,TC,,,,,,,784,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,768.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,768.32
Art Lower Extremity+Upper,PX9392301,CDM,921,RC,93923,CPT,TC,,,,,,,784,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,768.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.46,768.32
"Lap,Inguinal Hernia Repr,Recur",PX49651F,CDM,510,RC,49651,CPT,,,,,,,,1568,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,768.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,651.3472,5040.74
"Lap,Inguinal Hernia Repr,Recur",PX49651F,CDM,510,RC,49651,CPT,,,,,,,,1568,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,768.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,651.3472,5040.74
"Lap,Inguinal Hernia Repr,Recur",PX49651F,CDM,510,RC,49651,CPT,,,,,,,,1568,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,768.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,651.3472,5040.74
"Inject Nerv Blck,Othr Periph Nerv",PX64450P,CDM,983,RC,64450,CPT,,,,,,,,904,,First Health,Commercial,both,85,,999999999,percent of total billed charges,768.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,375.5216,879.8632
Fac/Cystourethroscopy,PX52000F,CDM,761,RC,52000,CPT,,,,,,,,1601,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,768.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,596.77,1568.98
Fac/Cystourethroscopy,PX52000F,CDM,761,RC,52000,CPT,,,,,,,,1601,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,768.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,596.77,1568.98
Sleep Staging 4 + Pap,PX9581126,CDM,982,RC,95811,CPT,26,,,,,,,1850,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,768.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,768.49,1800.605
"Excis Arm/Elbow Tumor,Subcutan",PX24075F,CDM,510,RC,24075,CPT,,,,,,,,1519,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,768.614,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,630.9926,1488.62
PROSTEP HV SCREW 3.0X16MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12986-MAIN,LOCAL,,,,,1569,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,768.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP HV SCREW 3.0X16MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12986-MAIN,LOCAL,,,,,1569,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,768.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP HV SCREW 3.0X16MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12986-MAIN,LOCAL,,,,,1569,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,768.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
albuterol-ipratropium 20-100 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597002402,NDC,4,GR,1601.75,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,768.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
albuterol-ipratropium 20-100 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597002402,NDC,4,GR,1601.75,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,768.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Removal of Anal Tabs,PX46230F,CDM,510,RC,46230,CPT,,,,,,,,790,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,768.907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,328.166,2452.93
Cns Dna/Rna Amp Probe Multiple Subtypes 12-25,PX87483,CDM,300,RC,87483,CPT,,,,,,,,864,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,768.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,358.9056,846.72
CT Angio Lwr Extr W/O&W/Dye,PX7370601,CDM,350,RC,73706,CPT,TC,,,,,,,1554,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,769.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1522.92
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605P,CDM,983,RC,25605,CPT,,,,,,,,785,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,769.3,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,325.92,1160.15
Layr Clos Wnd Rest Body 7.6-12.5,PX12044F,CDM,510,RC,12044,CPT,,,,,,,,785,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,769.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,326.089,769.3
REAMER FOR CROSS PLATES,27200000,CDM,272,RC,,,,12641-MAIN,LOCAL,,,,,1852,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,769.3208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310001,NDC,0.528,ML,785.14,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,769.4372,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.22,877.002
"Casiri and Imdevimab,Admin,Repeat Dose",PXM0240,CDM,771,RC,M0240,HCPCS,,,,,,,,1555,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,769.725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,413.06,1523.9
"IV Infusion, Bamlanivimab and Etesevimab, Infusion and Monitoring",PXM0245,CDM,260,RC,M0245,HCPCS,,,,,,,,1555,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,769.725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,413.06,1523.9
"IV Infusion, Casirivimab and Imdevimab, IV and Post Admr",PXM0243,CDM,771,RC,M0243,HCPCS,,,,,,,,1555,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,769.725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,413.06,1684.87
Excis Primary Ganglion Wrist,PX25111F,CDM,510,RC,25111,CPT,,,,,,,,791,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,769.8803,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,328.5814,1404.08
Injection for Nerve Block,PX64448F,CDM,510,RC,64448,CPT,,,,,,,,873,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,769.986,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,362.6442,855.54
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591F,CDM,360,RC,49591,CPT,,,,,,,,1556,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,770.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,646.3624,3022.41
"Lap,Cholecystectomy/Graph",PX47563F,CDM,510,RC,47563,CPT,,,,,,,,1556,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,770.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,646.3624,5040.74
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,781307912,NDC,5,ML,1854.23,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,770.247142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.74,1938.2734
"Closed Rx Weight Bear Dist Tib,Manip",PX27825P,CDM,983,RC,27825,CPT,,,,,,,,1796,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,770.484,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,746.0584,1748.0468
Debride Tissue/Muscle/Bone,PX11044P,CDM,983,RC,11044,CPT,,,,,,,,866,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,770.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,359.7364,1416.38
Xray Ribs Unilat 2 Vws With Pa Chest,PX7110101,CDM,320,RC,71101,CPT,TC,,,,,,,792,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,537.35,percent of total billed charges,770.8536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,776.16
"Lap,Dx Surgical Abd W/Biopsy",PX49321F,CDM,510,RC,49321,CPT,,,,,,,,874,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,770.868,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.0596,5040.74
"Fac/Exc Skn Mali2.1-3cmtrnk,Arm,Lg",PX11603F,CDM,510,RC,11603,CPT,,,,,,,,875,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,771.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.475,857.5
cocaine 4% 4 % Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527172874,NDC,4,ML,875.53,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,772.21746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
Abd Duplex Abd-Full,PX9397501,CDM,921,RC,93975,CPT,TC,,,,,,,788,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,772.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,772.24
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122F,CDM,510,RC,13122,CPT,,,,,,,,788,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,772.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,327.3352,772.24
Exs Tumor Arm/Elbow Sc 3cm>,PX24071F,CDM,510,RC,24071,CPT,,,,,,,,1860,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,772.644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,772.644,2482.37
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING4X6,C1781,CDM,278,RC,C1781,HCPCS,,12505-MAIN,LOCAL,,,,,1860,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,772.644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
desflurane Solution 240 mL Bottle,25000000,CDM,250,RC,,,,,,10019064134,NDC,240,ML,793.95,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,772.751535,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
MINIBUNION INSTRUMENT KIT,27200000,CDM,278,RC,C1713,HCPCS,,11668-MAIN,LOCAL,,,,,1860.65,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,772.91401,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
diazePAM 10 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,187065820,NDC,1,EA,1527.87,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,773.10222,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956401,NDC,1,EA,1611.2,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,773.376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,409.66,1655.3866
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956401,NDC,1,EA,1611.2,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,773.376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,409.66,1655.3866
GRAFIXPL PRIME PLACENTAL MEMBRANE 1.5 x2CM 3SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12764-MAIN,LOCAL,,,,,1529,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,773.674,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573F,CDM,761,RC,36573,CPT,,,,,,,,1529,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,773.674,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,635.1466,1498.42
"MRI, Pelvis, W/O Then W/",PX7219701,CDM,610,RC,72197,CPT,TC,,,,,,,1612,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,773.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2066.35
"MRI, Pelvis, W/O Then W/",PX7219701,CDM,610,RC,72197,CPT,TC,,,,,,,1612,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,773.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2066.35
Aspirate Pleura W/ Imaging,PX32555F,CDM,761,RC,32555,CPT,,,,,,,,795,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1115.8,percent of total billed charges,773.7735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,330.243,779.1
Aspirate Pleura W/O Imaging,PX32554F,CDM,510,RC,32554,CPT,,,,,,,,795,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,773.7735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,330.243,779.1
"Incis/Drain Shldr Absc/Hema,Deep",PX23030P,CDM,983,RC,23030,CPT,,,,,,,,1564,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,774.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,649.6856,2482.37
Removal of Anal Tabs,PX46230F,CDM,510,RC,46230,CPT,,,,,,,,790,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,774.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,328.166,2452.93
PROSTEP MICA SCREW 3.0X20MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12442-MAIN,LOCAL,,,,,1806,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,774.774,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 3.0X40MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12443-MAIN,LOCAL,,,,,1806,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,774.774,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X52MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12444-MAIN,LOCAL,,,,,1806,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,774.774,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
cycloPHOSphamide 500 MG Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781323394,NDC,1,EA,1565.71,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,775.02645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
brinzolamide-brimonidine 1-0.2 % Suspension 8 mL Bottle,63700001,CDM,250,RC,,,,,,65414727,NDC,8,ML,850.88,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,775.15168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Excis Primary Ganglion Wrist,PX25111F,CDM,510,RC,25111,CPT,,,,,,,,791,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,775.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,328.5814,1404.08
Apply Long Leg Cast,PX29345F,CDM,510,RC,29345,CPT,,,,,,,,912,,First Health,Commercial,both,85,,999999999,percent of total billed charges,775.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,234.62,893.76
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598030562,NDC,1,EA,912,,First Health,Commercial,both,85,,999999999,percent of total billed charges,775.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
Open Bx/Excision Inguinofemoral Nodes,PX38531F,CDM,510,RC,38531,CPT,,,,,,,,912,,First Health,Commercial,both,85,,999999999,percent of total billed charges,775.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,378.8448,3329.99
"Critical Care, E/M 30-74 Minutes",PX99291P,CDM,983,RC,99291,CPT,,,,,,,,1061,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,775.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,440.7394,1032.6713
"Facility Critical Care, E/M 30-74 Minutes",PX99291F,CDM,510,RC,99291,CPT,,,,,,,,1264,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,775.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,525.0656,1238.72
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034P,CDM,983,RC,12034,CPT,,,,,,,,1533,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,775.698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1492.0689
Irrad/Lr Platelets,PXP9037,CDM,390,RC,P9037,HCPCS,,,,,,,,1617,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,776.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,616.6,1584.66
Irrad/Lr Platelets,PXP9037,CDM,390,RC,P9037,HCPCS,,,,,,,,1617,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,776.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,616.6,1584.66
"Lap,Inguinal Hernia Repr,Recur",PX49651F,CDM,510,RC,49651,CPT,,,,,,,,1568,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,776.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,651.3472,5040.74
Xray Ribs Unilat 2 Vws With Pa Chest,PX7110101,CDM,320,RC,71101,CPT,TC,,,,,,,792,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,776.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,776.16
clobetasol 0.05 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,21922001707,NDC,60,GR,1810.35,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,776.64015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
PROSTEP HV SCREW 3.0X16MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12986-MAIN,LOCAL,,,,,1569,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,776.655,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598046562,NDC,1,EA,798,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,776.6934,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
Emergency Level IV Visit,PX99284P,CDM,981,RC,99284,CPT,,,,,,,,914,,First Health,Commercial,both,85,,999999999,percent of total billed charges,776.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,379.6756,889.5962
Injection for Nerve Block,PX64448F,CDM,510,RC,64448,CPT,,,,,,,,873,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,776.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,362.6442,855.54
"Injection,Sacroiliac Joint(T)",PX27096F,CDM,510,RC,27096,CPT,,,,,,,,881,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,777.042,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,365.9674,863.38
"Lap,Dx Surgical Abd W/Biopsy",PX49321F,CDM,510,RC,49321,CPT,,,,,,,,874,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,777.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.0596,5040.74
desflurane Solution 240 mL Bottle,25000000,CDM,250,RC,,,,,,10019064134,NDC,240,ML,793.95,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,778.071,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016401,NDC,1,ML,854.49,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,778.44039,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.66,898.7384
"Fac/Exc Skn Mali2.1-3cmtrnk,Arm,Lg",PX11603F,CDM,510,RC,11603,CPT,,,,,,,,875,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,778.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.475,857.5
PEMEtrexed Disodium 100 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2764001,NDC,1,EA,1539.32,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,778.89592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.01,7924.2996
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004F,CDM,510,RC,15004,CPT,,,,,,,,855,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,778.905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,355.167,837.9
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573F,CDM,761,RC,36573,CPT,,,,,,,,1529,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,778.97,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.83,778.97
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573P,CDM,983,RC,36573,CPT,,,,,,,,1721,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,778.97,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.83,1686.58
MESH VENTRALIGHT ECHO 2.0 POSITIONING 15CM ROUND,C1781,CDM,278,RC,C1781,HCPCS,,12842-MAIN,LOCAL,,,,,1816,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,779.064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Aspirate Pleura W/ Imaging,PX32555F,CDM,761,RC,32555,CPT,,,,,,,,795,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,779.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,330.243,779.1
Aspirate Pleura W/O Imaging,PX32554F,CDM,510,RC,32554,CPT,,,,,,,,795,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,779.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,330.243,779.1
cocaine 4% 4 % Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527172874,NDC,4,ML,875.53,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,779.2217,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
Repair Incis Hernia W Mesh,PX49568F,CDM,510,RC,49568,CPT,,,,,,,,1540,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,779.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,639.716,1509.2
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016410,NDC,1,ML,917.08,,First Health,Commercial,both,85,,999999999,percent of total billed charges,779.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.66,898.7384
Abd Paracentesis,PX49082F,CDM,510,RC,49082,CPT,,,,,,,,884,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,779.688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,367.2136,866.32
"Excise Lesion,Back or Flank",PX21930P,CDM,983,RC,21930,CPT,,,,,,,,884,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,779.688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,367.2136,1416.38
Closed Rx Femur Shaft Fx+Manip,PX27502F,CDM,510,RC,27502,CPT,,,,,,,,1625,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,780,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,675.025,1592.5
Closed Rx Femur Shaft Fx+Manip,PX27502F,CDM,510,RC,27502,CPT,,,,,,,,1625,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,780,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,675.025,1592.5
Repeat Control of Nosebleed,PX30906F,CDM,510,RC,30906,CPT,,,,,,,,334,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,780.35,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,80.71,780.35
"Upper GI Endoscopy,Biopsy",PX43239F,CDM,750,RC,43239,CPT,,,,,,,,2364,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,780.35,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.86,780.35
"Upper GI Endoscopy,Biopsy",PX43239P,CDM,983,RC,43239,CPT,,,,,,,,2458,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,780.35,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.86,2408.84
mometasone - formoterol 100-5 MCG/ACT Aerosol 8.8 g Inhaler,25000000,CDM,250,RC,,,,,,85720607,NDC,8.8,GR,918.07,,First Health,Commercial,both,85,,999999999,percent of total billed charges,780.3595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
mometasone - formoterol 200-5 MCG/ACT Aerosol 8.8 g Inhaler,25000000,CDM,250,RC,,,,,,85461005,NDC,8.8,GR,918.07,,First Health,Commercial,both,85,,999999999,percent of total billed charges,780.3595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
clobetasol 0.05 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,42291007760,NDC,60,GR,1625.97,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,780.4656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clobetasol 0.05 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,42291007760,NDC,60,GR,1625.97,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,780.4656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Closed Rx Big Toe Fx,Manip",PX28495F,CDM,510,RC,28495,CPT,,,,,,,,857,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,780.727,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,839.86
"Hemorrhoidectomy,Int/Ext,Simple",PX46255F,CDM,510,RC,46255,CPT,,,,,,,,1627,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,780.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,675.8558,2452.93
"Hemorrhoidectomy,Int/Ext,Simple",PX46255F,CDM,510,RC,46255,CPT,,,,,,,,1627,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,780.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,675.8558,2452.93
"Exc Skn Beig1.1-2cm Face,Facil",PX11442P,CDM,983,RC,11442,CPT,,,,,,,,886,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,781.452,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,368.0444,862.3438
Room Rate General Iso,PX12000001,CDM,120,RC,,,,,,,,,,1822,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,781.638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,756.8588,1785.56
"rabies vaccine, pcec Recon Susp 1 Each Vial",90675,CDM,636,RC,90675,CPT,,,,58160096412,NDC,1,EA,1544.83,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,781.68398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,297.75,1513.9334
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545F,CDM,510,RC,23545,CPT,,,,,,,,961,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,781.73,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.33,781.73
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545P,CDM,983,RC,23545,CPT,,,,,,,,412,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,781.73,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.33,781.73
Exc Face Les Sc < 2 Cm,PX21011F,CDM,510,RC,21011,CPT,,,,,,,,943,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,781.73,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,164.48,781.73
Exc Face Les Sc < 2 Cm,PX21011P,CDM,983,RC,21011,CPT,,,,,,,,628,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,781.73,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,164.48,781.73
rabies immune globulin 300 UNIT/ML Solution 1 mL Vial,90376,CDM,636,RC,90375,CPT,,,,13533031801,NDC,1,ML,1629.06,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,781.9488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,281.51,1596.4788
rabies immune globulin 300 UNIT/ML Solution 1 mL Vial,90376,CDM,636,RC,90375,CPT,,,,13533031801,NDC,1,ML,1629.06,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,781.9488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,281.51,1596.4788
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598046562,NDC,1,EA,798,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,782.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021083082,NDC,100,ML,1596,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,57.34422222,percent of total billed charges,782.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021083082,NDC,100,ML,1596,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,782.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021083082,NDC,100,ML,1596,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,782.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
"Closed Rx Radial Head/Neck Fx,Manip",PX24655P,CDM,983,RC,24655,CPT,,,,,,,,1824,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,782.496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,757.6896,1775.2992
"Closed Rx Dist Fibula Fx,Manip",PX27788F,CDM,510,RC,27788,CPT,,,,,,,,1597,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,782.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1565.06
"Closed Rx Dist Fibula Fx,Manip",PX27788F,CDM,510,RC,27788,CPT,,,,,,,,1597,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,782.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1565.06
"Closed Rx Dist Fibula Fx,Manip",PX27788F,CDM,510,RC,27788,CPT,,,,,,,,1597,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,782.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1565.06
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569P,CDM,983,RC,36569,CPT,,,,,,,,1825,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,782.925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,758.105,1776.2725
Irrad/Lr Platelets,PXP9037,CDM,390,RC,P9037,HCPCS,,,,,,,,1617,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,783.04,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.33,783.04
Irrad/Lr Platelets,PXP9037,CDM,390,RC,P9037,HCPCS,,,,,,,,1617,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,783.04,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.33,783.04
Leukoreduced Platelets,PXP9035,CDM,390,RC,P9035,HCPCS,,,,,,,,1350,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,783.04,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.33,783.04
Leukoreduced Platelets,PXP9035,CDM,390,RC,P9035,HCPCS,,,,,,,,1350,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,783.04,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.33,783.04
STAPLER SUREFORM 45 SPU IS4000,27200000,CDM,272,RC,,,,12794-MAIN,LOCAL,,,,,888,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,783.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
GRAFIXPL PRIME PLACENTAL MEMBRANE 16MM DISC 2SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12763-MAIN,LOCAL,,,,,860,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,783.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
Or Level 1,PX36000001,CDM,360,RC,,,,,,,,,,1600,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,664.64,1568
Or Level 1,PX36000001,CDM,360,RC,,,,,,,,,,1600,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,664.64,1568
Or Level 1,PX36000001,CDM,360,RC,,,,,,,,,,1600,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,664.64,1568
"Injection,Sacroiliac Joint(T)",PX27096F,CDM,510,RC,27096,CPT,,,,,,,,881,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,784.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,365.9674,863.38
Drain Skin Abscess Complic,PX10061F,CDM,510,RC,10061,CPT,,,,,,,,889,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,784.098,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,871.22
Inc/Drain Peritonsil Abscess,PX42700P,CDM,983,RC,42700,CPT,,,,,,,,889,,United Healthcare,All Payer,outpatient,88.2,,43.67274074,percent of total billed charges,784.098,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,865.2637
Fac/Cystourethroscopy,PX52000F,CDM,761,RC,52000,CPT,,,,,,,,1601,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,784.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,596.77,1568.98
Fac/Cystourethroscopy,PX52000F,CDM,761,RC,52000,CPT,,,,,,,,1601,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,784.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,596.77,1568.98
Fac/Cystourethroscopy,PX52000F,CDM,761,RC,52000,CPT,,,,,,,,1601,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,784.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,596.77,1568.98
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,115169449,NDC,1,EA,889.46,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,784.50372,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54505010202,NDC,1,EA,889.46,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,784.50372,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
RESTRATA WOUND MATRIX 2.5CM X 2.5CM TOTAL 6.25CM,27200000,CDM,272,RC,A2007,HCPCS,,11733-MAIN,LOCAL,,,,,1829,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,784.641,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
albuterol-ipratropium 20-100 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597002402,NDC,4,GR,1601.75,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,784.8575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
albuterol-ipratropium 20-100 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597002402,NDC,4,GR,1601.75,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,784.8575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
albuterol-ipratropium 20-100 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597002402,NDC,4,GR,1601.75,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,784.8575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Lap Rpr Vent Umbilical Hernia,PX49652F,CDM,510,RC,49652,CPT,,,,,,,,1890,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,785.106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,785.106,1852.2
Skin Sub Graft Trnk/Arm/Leg,PX15271F,CDM,510,RC,15271,CPT,,,,,,,,862,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,785.282,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,358.0748,1593.14
Peramivir 200 MG/20ML Solution 20 mL Vial,800000,CDM,,,,,,,,61364018101,NDC,20,ML,1832.6,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,786.1854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
CT Angio Lwr Extr W/O&W/Dye,PX7370601,CDM,350,RC,73706,CPT,TC,,,,,,,1554,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,786.324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1522.92
Abd Paracentesis,PX49082F,CDM,510,RC,49082,CPT,,,,,,,,884,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,786.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,367.2136,866.32
"Excise Lesion,Back or Flank",PX21930P,CDM,983,RC,21930,CPT,,,,,,,,884,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,786.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,367.2136,1416.38
"Casiri and Imdevimab,Admin,Repeat Dose",PXM0240,CDM,771,RC,M0240,HCPCS,,,,,,,,1555,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,786.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,413.06,1523.9
"IV Infusion, Bamlanivimab and Etesevimab, Infusion and Monitoring",PXM0245,CDM,260,RC,M0245,HCPCS,,,,,,,,1555,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,786.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,413.06,1523.9
"IV Infusion, Casirivimab and Imdevimab, IV and Post Admr",PXM0243,CDM,771,RC,M0243,HCPCS,,,,,,,,1555,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,786.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,413.06,1684.87
Cns Dna/Rna Amp Probe Multiple Subtypes 12-25,PX87483,CDM,300,RC,87483,CPT,,,,,,,,864,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,787.104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,358.9056,846.72
fluticasone-umeclidin-vilant 100-62.5-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173088714,NDC,28,EA,1894.99,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,787.178846,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591F,CDM,360,RC,49591,CPT,,,,,,,,1556,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,787.336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,646.3624,3022.41
"Lap,Cholecystectomy/Graph",PX47563F,CDM,510,RC,47563,CPT,,,,,,,,1556,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,787.336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,646.3624,5040.74
Abd Duplex Abd-Follow Up(T),PX9397601,CDM,921,RC,93976,CPT,TC,,,,,,,809,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,639.675,percent of total billed charges,787.3997,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,792.82
Venous Duplex Scan Uni,PX9397101,CDM,921,RC,93971,CPT,TC,,,,,,,809,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,318.72,percent of total billed charges,787.3997,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,792.82
"Bone Scan, Whole Body",PX7830601,CDM,341,RC,78306,CPT,TC,,,,,,,1896,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,787.5984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,360.31,1858.08
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,25021019110,NDC,1,EA,809.89,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,788.265937,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.47563,793.6922
Noninvasv Lo Extrem Art Stress/Rest,PX9392401,CDM,921,RC,93924,CPT,TC,,,,,,,810,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,788.373,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.46,793.8
"Exc Skn Beig1.1-2cm Face,Facil",PX11442P,CDM,983,RC,11442,CPT,,,,,,,,886,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,788.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,368.0444,862.3438
Debride Tissue/Muscle/Bone,PX11044P,CDM,983,RC,11044,CPT,,,,,,,,866,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,788.926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,359.7364,1416.38
FIXATION COMPONENT TOE JOINT PROXIMAL PHALANGEAL DF-P,C1713,CDM,278,RC,C1713,HCPCS,,12529-MAIN,LOCAL,,,,,1644,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,789.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
FIXATION COMPONENT TOE JOINT PROXIMAL PHALANGEAL DF-P,C1713,CDM,278,RC,C1713,HCPCS,,12529-MAIN,LOCAL,,,,,1644,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,789.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Or Level 2,PX36000002,CDM,360,RC,,,,,,,,,,1900,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,789.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,789.26,1862
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,60505611000,NDC,5,ML,1644.33,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,789.2784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,60505611000,NDC,5,ML,1644.33,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,789.2784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310002,NDC,0.528,ML,894.9,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,789.3018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.22,877.002
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956401,NDC,1,EA,1611.2,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,789.488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,409.66,1655.3866
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956401,NDC,1,EA,1611.2,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,789.488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,409.66,1655.3866
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956401,NDC,1,EA,1611.2,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,789.488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,409.66,1655.3866
travoprost (BAK Free) 0.004 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,65026025,NDC,2.5,ML,811.3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,789.63829,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Reconstruc of Nail Bed W Graft,PX11762F,CDM,510,RC,11762,CPT,,,,,,,,1901,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,789.6754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,789.6754,1862.98
"MRI, Pelvis, W/O Then W/",PX7219701,CDM,610,RC,72197,CPT,TC,,,,,,,1612,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,789.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2066.35
"MRI, Pelvis, W/O Then W/",PX7219701,CDM,610,RC,72197,CPT,TC,,,,,,,1612,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,789.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2066.35
"MRI, Pelvis, W/O Then W/",PX7219701,CDM,610,RC,72197,CPT,TC,,,,,,,1612,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,789.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2066.35
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021083082,NDC,100,ML,1596,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,790.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
"Treat Thumb Disloc,Manipulatn",PX26641P,CDM,983,RC,26641,CPT,,,,,,,,1902,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,790.0908,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1851.2166
STAPLER SUREFORM 45 SPU IS4000,27200000,CDM,272,RC,,,,12794-MAIN,LOCAL,,,,,888,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,790.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Lap,Cholecystectomy/Explore",PX47564P,CDM,983,RC,47564,CPT,,,,,,,,1613,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,790.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,670.0402,8992.74
"Lap,Cholecystectomy/Explore",PX47564P,CDM,983,RC,47564,CPT,,,,,,,,1613,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,790.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,670.0402,8992.74
"Lap,Cholecystectomy/Explore",PX47564P,CDM,983,RC,47564,CPT,,,,,,,,1613,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,790.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,670.0402,8992.74
"Amputation Metatarsal+Toe,Single",PX28810F,CDM,510,RC,28810,CPT,,,,,,,,930,,First Health,Commercial,both,85,,999999999,percent of total billed charges,790.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.322,2827.75
Colonoscopy,PX44388F,CDM,750,RC,44388,CPT,,,,,,,,930,,First Health,Commercial,both,85,,999999999,percent of total billed charges,790.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.322,911.4
"Closed Rx Dist Fibula Fx,Manip",PX27788F,CDM,510,RC,27788,CPT,,,,,,,,1597,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,790.515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1565.06
DYNABUNION PLATE STERILE INSTRUMENT KIT,27200000,CDM,272,RC,,,,12465-MAIN,LOCAL,,,,,1843,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,790.647,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
fluticasone-salmeterol 230-21 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,66993008896,NDC,12,GR,1904.14,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,790.979756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Drain Skin Abscess Complic,PX10061F,CDM,510,RC,10061,CPT,,,,,,,,889,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,791.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,871.22
Inc/Drain Peritonsil Abscess,PX42700P,CDM,983,RC,42700,CPT,,,,,,,,889,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,791.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,865.2637
"Closed Rx Trimalleolar Fx,Manip",PX27818F,CDM,510,RC,27818,CPT,,,,,,,,813,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,791.2929,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,337.7202,1404.08
"Fac/Exc Skn Bngn 2.1-3cmfce,Facial",PX11443F,CDM,510,RC,11443,CPT,,,,,,,,813,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,791.2929,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,337.7202,1416.38
Fac/Exc Skn Beni 0.6-1cm Remain Bdy,PX11421F,CDM,510,RC,11421,CPT,,,,,,,,931,,First Health,Commercial,both,85,,999999999,percent of total billed charges,791.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.7374,912.38
Fac/Exc Skn Bngn3.1-4cm Remain Bdy,PX11424F,CDM,510,RC,11424,CPT,,,,,,,,931,,First Health,Commercial,both,85,,999999999,percent of total billed charges,791.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.7374,1416.38
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034F,CDM,510,RC,12034,CPT,,,,,,,,931,,First Health,Commercial,both,85,,999999999,percent of total billed charges,791.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,912.38
"Incis/Drain Shldr Absc/Hema,Deep",PX23030P,CDM,983,RC,23030,CPT,,,,,,,,1564,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,791.384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,649.6856,2482.37
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,115169449,NDC,1,EA,889.46,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,791.6194,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54505010202,NDC,1,EA,889.46,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,791.6194,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
Abd Paracentesis,PX49082F,CDM,510,RC,49082,CPT,,,,,,,,884,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,791.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,367.2136,866.32
Abd Paracentesis W/Imaging(P),PX49083P,CDM,983,RC,49083,CPT,,,,,,,,696,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,791.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.1184,791.92
Abd Paracentesis W/Imaging(T),PX49083F,CDM,510,RC,49083,CPT,,,,,,,,1006,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,791.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,417.8924,985.88
"Ileoscopy Thru Stoma,Diagnostic",PX44380F,CDM,750,RC,44380,CPT,,,,,,,,245,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,791.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.773,791.92
"Ileoscopy Thru Stoma,Diagnostic",PX44380P,CDM,983,RC,44380,CPT,,,,,,,,455,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,791.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,189.007,791.92
"Up GI Endoscopy,Dilatn W Guide",PX43248F,CDM,750,RC,43248,CPT,,,,,,,,1995,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,791.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,1955.1
"Upper GI Endoscopy,Biopsy",PX43239F,CDM,750,RC,43239,CPT,,,,,,,,2364,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,791.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,3859.68
"Upper GI Endoscopy,Biopsy",PX43239P,CDM,983,RC,43239,CPT,,,,,,,,2458,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,791.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,3859.68
"Upper GI Endoscopy,Diagnosis",PX43235F,CDM,750,RC,43235,CPT,,,,,,,,2539,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,791.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,3859.68
"Upper GI Endoscopy,Diagnosis",PX43235P,CDM,983,RC,43235,CPT,,,,,,,,1406,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,791.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,603.174,3859.68
Or Level 1,PX36000001,CDM,360,RC,,,,,,,,,,1600,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,664.64,1568
Incise Finger Tendon Sheath,PX26055P,CDM,983,RC,26055,CPT,,,,,,,,932,,First Health,Commercial,both,85,,999999999,percent of total billed charges,792.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,387.1528,1404.08
cycloPHOSphamide 500 MG Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781323394,NDC,1,EA,1565.71,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,792.24926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
ferumoxytol 510 MG/17ML Solution 17 mL Vial,Q0138.01,CDM,636,RC,Q0138,HCPCS,,,,781315401,NDC,17,ML,1846.91,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,792.32439,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.32,1809.9718
Irrad/Lr Platelets,PXP9037,CDM,390,RC,P9037,HCPCS,,,,,,,,1617,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,792.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,616.6,1584.66
Irrad/Lr Platelets,PXP9037,CDM,390,RC,P9037,HCPCS,,,,,,,,1617,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,792.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,616.6,1584.66
Irrad/Lr Platelets,PXP9037,CDM,390,RC,P9037,HCPCS,,,,,,,,1617,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,792.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,616.6,1584.66
Fac/Cystourethroscopy,PX52000F,CDM,761,RC,52000,CPT,,,,,,,,1601,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,792.495,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,596.77,1568.98
Abd Duplex Abd-Follow Up(T),PX9397601,CDM,921,RC,93976,CPT,TC,,,,,,,809,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,792.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,792.82
Venous Duplex Scan Uni,PX9397101,CDM,921,RC,93971,CPT,TC,,,,,,,809,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,792.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,792.82
albuterol-ipratropium 20-100 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597002402,NDC,4,GR,1601.75,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,792.86625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Biopsy Synovium I-P Jt,PX26110,CDM,983,RC,26110,CPT,,,,,,,,933,,First Health,Commercial,both,85,,999999999,percent of total billed charges,793.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,387.5682,1404.08
"Lap,Inguinal Hernia Repr,Recur",PX49651F,CDM,510,RC,49651,CPT,,,,,,,,1568,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,793.408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,651.3472,5040.74
"MRI,Lwrext,Jnt W/O+W/Cont",PX7372301,CDM,610,RC,73723,CPT,TC,,,,,,,1850,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,793.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2066.35
Sleep Staging 4 + Pap,PX9581126,CDM,982,RC,95811,CPT,26,,,,,,,1850,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,793.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,768.49,1800.605
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,25021019110,NDC,1,EA,809.89,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,793.6922,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,110.47563,793.6922
MIS STERILE INSTRUMENT PACK WITH BLADE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12432-MAIN,LOCAL,,,,,900,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,793.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Noninvasv Lo Extrem Art Stress/Rest,PX9392401,CDM,921,RC,93924,CPT,TC,,,,,,,810,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,793.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.46,793.8
GRAFIXPL PRIME PLACENTAL MEMBRANE 2x3CM 6SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12765-MAIN,LOCAL,,,,,1911,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,793.8294,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
PROSTEP HV SCREW 3.0X16MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12986-MAIN,LOCAL,,,,,1569,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,793.914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
REAMER FOR CROSS PLATES,27200000,CDM,272,RC,,,,12641-MAIN,LOCAL,,,,,1852,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,794.508,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Excis Tendn/Capsule Lesn,Toes",PX28092P,CDM,983,RC,28092,CPT,,,,,,,,1913,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,794.6602,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,794.6602,1861.9229
travoprost (BAK Free) 0.004 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,65026025,NDC,2.5,ML,811.3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,795.074,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Injection for Nerve Block,PX64448F,CDM,510,RC,64448,CPT,,,,,,,,873,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,795.303,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,362.6442,855.54
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,781307912,NDC,5,ML,1854.23,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,795.46467,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.74,1938.2734
riTUXimab 100 MG/10ML Solution 10 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005121,NDC,10,ML,1916.61,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,796.159794,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.61,8682.8588
"Lap,Dx Surgical Abd W/Biopsy",PX49321F,CDM,510,RC,49321,CPT,,,,,,,,874,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,796.214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.0596,5040.74
Closed Rx Femur Shaft Fx+Manip,PX27502F,CDM,510,RC,27502,CPT,,,,,,,,1625,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,796.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,675.025,1592.5
Closed Rx Femur Shaft Fx+Manip,PX27502F,CDM,510,RC,27502,CPT,,,,,,,,1625,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,796.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,675.025,1592.5
Closed Rx Femur Shaft Fx+Manip,PX27502F,CDM,510,RC,27502,CPT,,,,,,,,1625,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,796.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,675.025,1592.5
"Closed Rx Talus Fx,Manipulatn",PX28435F,CDM,510,RC,28435,CPT,,,,,,,,1705,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,796.26,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,210.51,796.26
"Closed Rx Talus Fx,Manipulatn",PX28435P,CDM,983,RC,28435,CPT,,,,,,,,1137,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,796.26,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,210.51,1114.26
Layr Clos Wnd Rest Body 7.6-12.5,PX12044F,CDM,510,RC,12044,CPT,,,,,,,,785,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,796.26,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,133.06,796.26
Layr Clos Wnd Rest Body 7.6-12.5,PX12044P,CDM,983,RC,12044,CPT,,,,,,,,523,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,796.26,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,133.06,796.26
Injection for Nerve Block,PX64448F,CDM,510,RC,64448,CPT,,,,,,,,873,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,796.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,362.6442,855.54
Reconstruc of Nail Bed,PX11760P,CDM,983,RC,11760,CPT,,,,,,,,903,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,796.446,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,375.1062,878.8899
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310002,NDC,0.528,ML,894.9,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,796.461,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.22,877.002
clobetasol 0.05 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,42291007760,NDC,60,GR,1625.97,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,796.7253,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clobetasol 0.05 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,42291007760,NDC,60,GR,1625.97,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,796.7253,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clobetasol 0.05 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,42291007760,NDC,60,GR,1625.97,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,796.7253,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Closed Rx Trimalleolar Fx,Manip",PX27818F,CDM,510,RC,27818,CPT,,,,,,,,813,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,796.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,337.7202,1404.08
"Fac/Exc Skn Bngn 2.1-3cmfce,Facial",PX11443F,CDM,510,RC,11443,CPT,,,,,,,,813,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,796.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,337.7202,1416.38
budesonide-formoterol 80-4.5 MCG/ACT Aerosol 6.9 g Inhaler,63700001,CDM,250,RC,,,,,,186037228,NDC,6.9,GR,937.58,,First Health,Commercial,both,85,,999999999,percent of total billed charges,796.943,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Fac/Exc Skn Mali2.1-3cmtrnk,Arm,Lg",PX11603F,CDM,510,RC,11603,CPT,,,,,,,,875,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,797.125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.475,857.5
Repr Superf Wnd Face 5.1-7.5,PX12014P,CDM,983,RC,12014,CPT,,,,,,,,819,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,797.1327,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,174.9,797.1327
"Hemorrhoidectomy,Int/Ext,Simple",PX46255F,CDM,510,RC,46255,CPT,,,,,,,,1627,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,797.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,675.8558,2452.93
"Hemorrhoidectomy,Int/Ext,Simple",PX46255F,CDM,510,RC,46255,CPT,,,,,,,,1627,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,797.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,675.8558,2452.93
"Hemorrhoidectomy,Int/Ext,Simple",PX46255F,CDM,510,RC,46255,CPT,,,,,,,,1627,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,797.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,675.8558,2452.93
Exc Abdom Tum Subfac > 5 Cm,PX22901P,CDM,983,RC,22901,CPT,,,,,,,,938,,First Health,Commercial,both,85,,999999999,percent of total billed charges,797.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,389.6452,2482.37
"Inject Nerv Blck,Othr Periph Nerv",PX64450P,CDM,983,RC,64450,CPT,,,,,,,,904,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,797.328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,375.5216,879.8632
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956401,NDC,1,EA,1611.2,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,797.544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,409.66,1655.3866
cocaine 4% 4 % Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527172874,NDC,4,ML,875.53,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,797.60783,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
alteplase 100 MG Recon Soln 1 Each Syringe,J2997.01,CDM,636,RC,J2997,HCPCS,,,,88888800475,NDC,0.09,EA,1920.88,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,797.933552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
Exs Tumor Arm/Elbow Sc 3cm>,PX24071F,CDM,510,RC,24071,CPT,,,,,,,,1860,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,797.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,772.644,2482.37
"MRI, Pelvis, W/O Then W/",PX7219701,CDM,610,RC,72197,CPT,TC,,,,,,,1612,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,797.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2066.35
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING4X6,C1781,CDM,278,RC,C1781,HCPCS,,12505-MAIN,LOCAL,,,,,1860,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,797.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
MINIBUNION INSTRUMENT KIT,27200000,CDM,278,RC,C1713,HCPCS,,11668-MAIN,LOCAL,,,,,1860.65,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,798.21885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
rabies immune globulin 300 UNIT/ML Solution 1 mL Vial,90376,CDM,636,RC,90375,CPT,,,,13533031801,NDC,1,ML,1629.06,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,798.2394,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,281.51,1596.4788
rabies immune globulin 300 UNIT/ML Solution 1 mL Vial,90376,CDM,636,RC,90375,CPT,,,,13533031801,NDC,1,ML,1629.06,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,798.2394,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,281.51,1596.4788
rabies immune globulin 300 UNIT/ML Solution 1 mL Vial,90376,CDM,636,RC,90375,CPT,,,,13533031801,NDC,1,ML,1629.06,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,798.2394,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,281.51,1596.4788
"Lap,Cholecystectomy/Explore",PX47564P,CDM,983,RC,47564,CPT,,,,,,,,1613,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,798.435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,670.0402,8992.74
Anus Surgery Procedure Unlisted,PX46999F,CDM,510,RC,46999,CPT,,,,,,,,1431,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,798.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,594.4374,1402.38
Anus Surgery Procedure Unlisted,PX46999P,CDM,983,RC,46999,CPT,,,,,,,,953,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,798.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,395.8762,927.5549
Colonoscopy,PX44388F,CDM,750,RC,44388,CPT,,,,,,,,930,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,798.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.322,911.4
Colonoscopy,PX44388P,CDM,983,RC,44388,CPT,,,,,,,,620,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,798.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,257.548,798.45
"Colonoscopy,Flex,Diagnostic",PX45378F,CDM,750,RC,45378,CPT,,,,,,,,1286,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,798.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,551.694,4661.91
"Colonoscopy,Flex,Diagnostic",PX45378P,CDM,983,RC,45378,CPT,,,,,,,,1200,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,798.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,514.8,4661.91
"Colonoscopy,Flex,Screen",PX2002F,CDM,750,RC,G0105,HCPCS,,,,,,,,2539,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,798.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,798.45,3885.86
"Colonoscopy,Screen Prev",PX2004F,CDM,750,RC,G0121,HCPCS,,,,,,,,2502,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,798.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,798.45,3885.86
Fac/Ligation of Hemorrhoid(S),PX46221F,CDM,510,RC,46221,CPT,,,,,,,,1046,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,798.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,434.5084,1025.08
"I&D Perianal Abscess,Superficial",PX46050,CDM,983,RC,46050,CPT,,,,,,,,1096,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,798.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,455.2784,1066.7368
"I&D Perianal Abscess,Superficial",PX46050F,CDM,510,RC,46050,CPT,,,,,,,,1463,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,798.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,607.7302,1433.74
"I&D Perianal Abscess,Superficial",PX46050P,CDM,983,RC,46050,CPT,,,,,,,,993,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,798.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,412.4922,966.4869
Ligation of Hemorrhoid(S),PX46221P,CDM,983,RC,46221,CPT,,,,,,,,697,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,798.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.5338,798.45
Sigmoidoscope W/Submuc Inj,PX45335F,CDM,750,RC,45335,CPT,,,,,,,,750,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,798.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,311.55,798.45
Sigmoidoscope W/Submuc Inj,PX45335P,CDM,983,RC,45335,CPT,,,,,,,,500,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,798.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,207.7,798.45
"Sigmoidoscopy,Biopsy",PX45331F,CDM,750,RC,45331,CPT,,,,,,,,1776,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,798.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,737.7504,1740.48
"Sigmoidoscopy,Biopsy",PX45331P,CDM,983,RC,45331,CPT,,,,,,,,1316,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,798.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,546.6664,1280.8628
"Sigmoidoscopy,Diagnostic",PX45330F,CDM,510,RC,45330,CPT,,,,,,,,720,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,798.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,299.088,798.45
"Sigmoidoscopy,Diagnostic",PX45330P,CDM,983,RC,45330,CPT,,,,,,,,480,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,798.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.392,798.45
"Sigmoidoscopy,Screen Prev",PX2001F,CDM,750,RC,45330,CPT,,,,,,,,843,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,798.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,350.1822,826.14
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032605,NDC,0.8,ML,1663.54,,Health Partners,Health Partners Care Plans,both,48,,1.606958333,percent of total billed charges,798.4992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,1630.2692
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032605,NDC,0.8,ML,1663.54,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,798.4992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,1630.2692
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021080166,NDC,5,ML,820.8,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,66.804,percent of total billed charges,798.88464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092401,NDC,0.5,ML,820.88,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,798.962504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092491,NDC,0.5,ML,820.88,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,798.962504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092410,NDC,0.5,ML,820.89,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,798.972237,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
TAPER POST TOE JOINT HEMICAP 9.5MM ARTICULATING METATARSAL STERILE,C1713,CDM,278,RC,C1713,HCPCS,,12531-MAIN,LOCAL,,,,,821,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,799.0793,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,60505619301,NDC,5,ML,821.36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,799.429688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.08296,1009.1158
clobetasol 0.05 % Cream 60 g Tube,63700001,CDM,250,RC,,,,,,69238153206,NDC,60,GR,1665.95,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,799.656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clobetasol 0.05 % Cream 60 g Tube,63700001,CDM,250,RC,,,,,,69238153206,NDC,60,GR,1665.95,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,799.656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Exc Skn Bngn1.1-2cm Remain Bdy,PX11422P,CDM,983,RC,11422,CPT,,,,,,,,822,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,800.0526,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,341.4588,1416.38
Irrad/Lr Platelets,PXP9037,CDM,390,RC,P9037,HCPCS,,,,,,,,1617,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,800.415,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,616.6,1584.66
Revise Median N/Carpal Tunnel Surg,PX64721P,CDM,983,RC,64721,CPT,,,,,,,,1927,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,800.4758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,800.4758,1875.5491
"Tte W/Doppler, Complete",PXC8929,CDM,480,RC,C8929,HCPCS,TC,,,,,,,1927,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,800.4758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,699.48,1888.46
STAPLER CONTOUR CURVED CUTTER,27200000,CDM,272,RC,,,,12064-MAIN,LOCAL,,,,,942,,First Health,Commercial,both,85,,999999999,percent of total billed charges,800.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MIS STERILE INSTRUMENT PACK WITH BLADE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12432-MAIN,LOCAL,,,,,900,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,801,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Exc Face Les Sc < 2 Cm,PX21011F,CDM,510,RC,21011,CPT,,,,,,,,943,,First Health,Commercial,both,85,,999999999,percent of total billed charges,801.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,391.7222,1416.38
inFLIXimab-dyyb 100 MG Recon Soln 1 Each Vial,Q5103.01,CDM,636,RC,Q5103,HCPCS,,,,69080901,NDC,1,EA,1930.42,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,801.896468,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.85,1891.8116
fluticasone-salmeterol 500-50 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069704,NDC,14,EA,1670.75,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,801.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone-salmeterol 500-50 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069704,NDC,14,EA,1670.75,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,801.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Injection,Sacroiliac Joint(T)",PX27096F,CDM,510,RC,27096,CPT,,,,,,,,881,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,802.591,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,365.9674,863.38
Repr Superf Wnd Face 5.1-7.5,PX12014P,CDM,983,RC,12014,CPT,,,,,,,,819,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,802.62,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.06,802.62
fidaxomicin 200 MG Tablet 20 Each Bottle,25000000,CDM,250,RC,,,,,,52015008001,NDC,1,EA,945.16,,First Health,Commercial,both,85,,999999999,percent of total billed charges,803.386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Hepatobil Syst Image W/Drug,PX7822701,CDM,341,RC,78227,CPT,TC,,,,,,,1674,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,803.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,472.19,1640.52
Hepatobil Syst Image W/Drug,PX7822701,CDM,341,RC,78227,CPT,TC,,,,,,,1674,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,803.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,472.19,1640.52
Reconstruc of Nail Bed,PX11760P,CDM,983,RC,11760,CPT,,,,,,,,903,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,803.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,375.1062,878.8899
"Cystourethroscopy, With Injection(S) for Chemodenervation of the Bladder",PX52287F,CDM,360,RC,52287,CPT,,,,,,,,2745,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,803.87,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,102.53,803.87
Closed Rx Trimalleolar Fx,PX27816P,CDM,983,RC,27816,CPT,,,,,,,,826,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,803.9458,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,803.9458
Closed Rx Femur Shaft Fx+Manip,PX27502F,CDM,510,RC,27502,CPT,,,,,,,,1625,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,804.375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,675.025,1592.5
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021080166,NDC,5,ML,820.8,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,804.384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
Apply Long Leg Cast,PX29345F,CDM,510,RC,29345,CPT,,,,,,,,912,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,804.384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,234.62,893.76
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598030562,NDC,1,EA,912,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,804.384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
Open Bx/Excision Inguinofemoral Nodes,PX38531F,CDM,510,RC,38531,CPT,,,,,,,,912,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,804.384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,378.8448,3329.99
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092401,NDC,0.5,ML,820.88,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,804.4624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092491,NDC,0.5,ML,820.88,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,804.4624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092410,NDC,0.5,ML,820.89,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,804.4722,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
"Inject Nerv Blck,Othr Periph Nerv",PX64450P,CDM,983,RC,64450,CPT,,,,,,,,904,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,804.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,375.5216,879.8632
Revise Ulnar Nerve at Elbow,PX64718P,CDM,983,RC,64718,CPT,,,,,,,,1642,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,804.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,682.0868,1686.76
Revise Ulnar Nerve at Elbow,PX64718P,CDM,983,RC,64718,CPT,,,,,,,,1642,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,804.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,682.0868,1686.76
Revise Ulnar Nerve at Elbow,PX64718P,CDM,983,RC,64718,CPT,,,,,,,,1642,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,804.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,682.0868,1686.76
TAPER POST TOE JOINT HEMICAP 9.5MM ARTICULATING METATARSAL STERILE,C1713,CDM,278,RC,C1713,HCPCS,,12531-MAIN,LOCAL,,,,,821,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,804.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
clobetasol 0.05 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,42291007760,NDC,60,GR,1625.97,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,804.85515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,60505619301,NDC,5,ML,821.36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,804.9328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.08296,1009.1158
Abd Paracentesis,PX49082F,CDM,510,RC,49082,CPT,,,,,,,,884,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,805.324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,367.2136,866.32
"Excise Lesion,Back or Flank",PX21930P,CDM,983,RC,21930,CPT,,,,,,,,884,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,805.324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,367.2136,1416.38
"Hemorrhoidectomy,Int/Ext,Simple",PX46255F,CDM,510,RC,46255,CPT,,,,,,,,1627,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,805.365,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,675.8558,2452.93
Exc Skn Bngn1.1-2cm Remain Bdy,PX11422P,CDM,983,RC,11422,CPT,,,,,,,,822,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,805.56,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,85.95,805.56
FIXATION COMPONENT TOE JOINT PROXIMAL PHALANGEAL DF-P,C1713,CDM,278,RC,C1713,HCPCS,,12529-MAIN,LOCAL,,,,,1644,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,805.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
FIXATION COMPONENT TOE JOINT PROXIMAL PHALANGEAL DF-P,C1713,CDM,278,RC,C1713,HCPCS,,12529-MAIN,LOCAL,,,,,1644,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,805.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
FIXATION COMPONENT TOE JOINT PROXIMAL PHALANGEAL DF-P,C1713,CDM,278,RC,C1713,HCPCS,,12529-MAIN,LOCAL,,,,,1644,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,805.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,60505611000,NDC,5,ML,1644.33,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,57.34422222,percent of total billed charges,805.7217,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,60505611000,NDC,5,ML,1644.33,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,805.7217,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,60505611000,NDC,5,ML,1644.33,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,805.7217,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121F,CDM,510,RC,13121,CPT,,,,,,,,948,,First Health,Commercial,both,85,,999999999,percent of total billed charges,805.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,393.7992,929.04
"Close Rx Fingr Articular Fx,Manip",PX26742F,CDM,510,RC,26742,CPT,,,,,,,,1039,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,805.95,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,216.18,805.95
"Close Rx Fingr Articular Fx,Manip",PX26742P,CDM,983,RC,26742,CPT,,,,,,,,560,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,805.95,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,216.18,805.95
Emergency Level IV Visit,PX99284P,CDM,981,RC,99284,CPT,,,,,,,,914,,United Healthcare,All Payer,outpatient,88.2,,65.75748315,percent of total billed charges,806.148,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,379.6756,889.5962
rabies immune globulin 300 UNIT/ML Solution 1 mL Vial,90376,CDM,636,RC,90375,CPT,,,,13533031801,NDC,1,ML,1629.06,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,806.3847,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,281.51,1596.4788
"Exc Skn Beig1.1-2cm Face,Facil",PX11442P,CDM,983,RC,11442,CPT,,,,,,,,886,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,807.146,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,368.0444,862.3438
Closed Rx Kneecap Dislocatn,PX27560F,CDM,510,RC,27560,CPT,,,,,,,,468,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,807.33,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,219.89,807.33
Closed Rx Kneecap Dislocatn,PX27560P,CDM,983,RC,27560,CPT,,,,,,,,312,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,807.33,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,219.89,807.33
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021083082,NDC,100,ML,1596,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,807.576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565P,CDM,983,RC,25565,CPT,,,,,,,,830,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,807.839,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,344.782,1404.08
"Closed Rx Dist Fibula Fx,Manip",PX27788F,CDM,510,RC,27788,CPT,,,,,,,,1597,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,808.082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1565.06
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266F,CDM,510,RC,27266,CPT,,,,,,,,1684,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,808.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,699.5336,1650.32
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266F,CDM,510,RC,27266,CPT,,,,,,,,1684,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,808.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,699.5336,1650.32
PROSTEP MICA SCREW 3.0X34MM STERILE IMPLANT,27200000,CDM,272,RC,,,,13042-MAIN,LOCAL,,,,,1684,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,808.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PROSTEP MICA SCREW 3.0X34MM STERILE IMPLANT,27200000,CDM,272,RC,,,,13042-MAIN,LOCAL,,,,,1684,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,808.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016410,NDC,1,ML,917.08,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,808.86456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.66,898.7384
STAPLER SUREFORM 45 SPU IS4000,27200000,CDM,272,RC,,,,12794-MAIN,LOCAL,,,,,888,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,808.968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Ventilator Mgmt.Subsequent Days,PX94003F,CDM,410,RC,94003,CPT,,,,,,,,1686,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,809.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,547.46,1652.28
Ventilator Mgmt.Subsequent Days,PX94003F,CDM,410,RC,94003,CPT,,,,,,,,1686,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,809.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,547.46,1652.28
Closed Rx Trimalleolar Fx,PX27816P,CDM,983,RC,27816,CPT,,,,,,,,826,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,809.48,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,190.44,809.48
Or Level 1,PX36000001,CDM,360,RC,,,,,,,,,,1600,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,809.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,664.64,1568
mometasone - formoterol 100-5 MCG/ACT Aerosol 8.8 g Inhaler,25000000,CDM,250,RC,,,,,,85720607,NDC,8.8,GR,918.07,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,809.73774,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
mometasone - formoterol 200-5 MCG/ACT Aerosol 8.8 g Inhaler,25000000,CDM,250,RC,,,,,,85461005,NDC,8.8,GR,918.07,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,809.73774,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"HERNIA MESH 3D MAX MID ANATOMICAL MESH RIGHT SIZE XL 5"" X 7""",C1781,CDM,278,RC,C1781,HCPCS,,11979-MAIN,LOCAL,,,,,832,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1256.29,percent of total billed charges,809.7856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"HERNIA MESH 3DMAX MID MESH EXTRA-LARGE LEFT 5"" X 7""",C1781,CDM,278,RC,C1781,HCPCS,,11978-MAIN,LOCAL,,,,,832,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1256.29,percent of total billed charges,809.7856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180F,CDM,510,RC,44180,CPT,,,,,,,,1763,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,809.8142,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,548.86,1910.75
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180P,CDM,983,RC,44180,CPT,,,,,,,,1175,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,809.8142,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,548.86,1910.75
Drain Skin Abscess Complic,PX10061F,CDM,510,RC,10061,CPT,,,,,,,,889,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,809.879,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,871.22
Inc/Drain Peritonsil Abscess,PX42700P,CDM,983,RC,42700,CPT,,,,,,,,889,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,809.879,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,865.2637
"Amputation Toe,Mt-P Jt",PX28820F,CDM,510,RC,28820,CPT,,,,,,,,1950,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,810.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,810.03,2827.75
Anus Surgery Procedure Unlisted,PX46999P,CDM,983,RC,46999,CPT,,,,,,,,953,,First Health,Commercial,both,85,,999999999,percent of total billed charges,810.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,395.8762,927.5549
"Genital Surg Proc,Male Unlisted",PX55899P,CDM,983,RC,55899,CPT,,,,,,,,953,,First Health,Commercial,both,85,,999999999,percent of total billed charges,810.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,215.91,927.5549
I&D Perirectal Abscess,PX46040P,CDM,983,RC,46040,CPT,,,,,,,,953,,First Health,Commercial,both,85,,999999999,percent of total billed charges,810.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,395.8762,1030.93
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035F,CDM,510,RC,12035,CPT,,,,,,,,655,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,810.1,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.34,810.1
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035P,CDM,983,RC,12035,CPT,,,,,,,,1244,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,810.1,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.34,1219.12
Fac/Cystourethroscopy,PX52000F,CDM,761,RC,52000,CPT,,,,,,,,1601,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,810.106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,596.77,1568.98
Room Rate General,PX12000000,CDM,120,RC,,,,,,,,,,1688,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,810.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,701.1952,1654.24
Room Rate General,PX12000000,CDM,120,RC,,,,,,,,,,1688,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,810.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,701.1952,1654.24
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,115169449,NDC,1,EA,889.46,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,810.29806,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54505010202,NDC,1,EA,889.46,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,810.29806,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
albuterol-ipratropium 20-100 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597002402,NDC,4,GR,1601.75,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,810.4855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060002,NDC,2,ML,953.57,,First Health,Commercial,both,85,,999999999,percent of total billed charges,810.5345,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.11,934.4986
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060010,NDC,2,ML,953.57,,First Health,Commercial,both,85,,999999999,percent of total billed charges,810.5345,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.11,934.4986
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956410,NDC,1,EA,1689.17,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,810.8016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,409.66,1655.3866
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956410,NDC,1,EA,1689.17,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,810.8016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,409.66,1655.3866
Lap Rpr Vent Umbilical Hernia,PX49652F,CDM,510,RC,49652,CPT,,,,,,,,1890,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,810.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,785.106,1852.2
"Remv Foreign Body,Knee/Thigh,Deep",PX27372P,CDM,983,RC,27372,CPT,,,,,,,,954,,First Health,Commercial,both,85,,999999999,percent of total billed charges,810.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,396.2916,2482.37
DOCEtaxel 20 MG/ML Concentrate 1 mL Vial,63600000,CDM,636,RC,J9171,HCPCS,,,,955102001,NDC,1,ML,1690.09,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,811.2432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
DOCEtaxel 20 MG/ML Concentrate 1 mL Vial,63600000,CDM,636,RC,J9171,HCPCS,,,,955102001,NDC,1,ML,1690.09,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,811.2432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
Apply Long Leg Cast,PX29345F,CDM,510,RC,29345,CPT,,,,,,,,912,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,811.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,234.62,893.76
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598030562,NDC,1,EA,912,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,811.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
Open Bx/Excision Inguinofemoral Nodes,PX38531F,CDM,510,RC,38531,CPT,,,,,,,,912,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,811.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,378.8448,3329.99
FORCEPS SPOON JAWSIZE 10MMX36 KIT,27200000,CDM,272,RC,,,,11749-MAIN,LOCAL,,,,,1955,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,812.107,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Incise External Hemorrhoid,PX46083P,CDM,983,RC,46083,CPT,,,,,,,,956,,First Health,Commercial,both,85,,999999999,percent of total billed charges,812.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,215.91,930.4748
Duplex Up Extrem Art Bilat,PX9393001,CDM,921,RC,93930,CPT,TC,,,,,,,835,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,812.7055,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,818.3
Revise Ulnar Nerve at Elbow,PX64718P,CDM,983,RC,64718,CPT,,,,,,,,1642,,Humana Choice Care,All Medicare plans,outpatient,49.5,,4373.73,percent of total billed charges,812.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,682.0868,1686.76
fluticasone-umeclidin-vilant 100-62.5-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173088714,NDC,28,EA,1894.99,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,812.95071,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Bone Scan, Whole Body",PX7830601,CDM,341,RC,78306,CPT,TC,,,,,,,1896,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,813.384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,360.31,1858.08
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565P,CDM,983,RC,25565,CPT,,,,,,,,830,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,813.4,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,296.9,1116.57
Emergency Level IV Visit,PX99284P,CDM,981,RC,99284,CPT,,,,,,,,914,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,813.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,379.6756,889.5962
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004F,CDM,510,RC,15004,CPT,,,,,,,,855,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,813.56,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.68,813.56
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004P,CDM,983,RC,15004,CPT,,,,,,,,570,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,813.56,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,159.68,813.56
"Cardiac Stress Tst,Tracing Only",PX93017,CDM,482,RC,93017,CPT,,,,,,,,1959,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,813.7686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.21,1919.82
FIXATION COMPONENT TOE JOINT PROXIMAL PHALANGEAL DF-P,C1713,CDM,278,RC,C1713,HCPCS,,12529-MAIN,LOCAL,,,,,1644,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,813.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,60505611000,NDC,5,ML,1644.33,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,813.94335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
Closed Rx Elbow Dislocation,PX24600F,CDM,510,RC,24600,CPT,,,,,,,,706,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,814.94,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,218.15,814.94
Closed Rx Elbow Dislocation,PX24600P,CDM,983,RC,24600,CPT,,,,,,,,380,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,814.94,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,218.15,814.94
Or Level 2,PX36000002,CDM,360,RC,,,,,,,,,,1900,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,815.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,789.26,1862
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032605,NDC,0.8,ML,1663.54,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,0.52069,percent of total billed charges,815.1346,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,1630.2692
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032605,NDC,0.8,ML,1663.54,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,815.1346,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,1630.2692
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032605,NDC,0.8,ML,1663.54,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,815.1346,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,1630.2692
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310002,NDC,0.528,ML,894.9,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,815.2539,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.22,877.002
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956401,NDC,1,EA,1611.2,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,815.2672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,409.66,1655.3866
"HERNIA MESH 3D MAX MID ANATOMICAL MESH RIGHT SIZE XL 5"" X 7""",C1781,CDM,278,RC,C1781,HCPCS,,11979-MAIN,LOCAL,,,,,832,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,815.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"HERNIA MESH 3DMAX MID MESH EXTRA-LARGE LEFT 5"" X 7""",C1781,CDM,278,RC,C1781,HCPCS,,11978-MAIN,LOCAL,,,,,832,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,815.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Reconstruc of Nail Bed W Graft,PX11762F,CDM,510,RC,11762,CPT,,,,,,,,1901,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,815.529,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,789.6754,1862.98
"MRI, Pelvis, W/O Then W/",PX7219701,CDM,610,RC,72197,CPT,TC,,,,,,,1612,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,815.672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2066.35
Lap Incis Hernia Reducible,PX49654F,CDM,510,RC,49654,CPT,,,,,,,,1964,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,815.8456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,815.8456,1924.72
"Treat Thumb Disloc,Manipulatn",PX26641P,CDM,983,RC,26641,CPT,,,,,,,,1902,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,815.958,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1851.2166
"Lap,Cholecystectomy/Explore",PX47564P,CDM,983,RC,47564,CPT,,,,,,,,1613,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,816.178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,670.0402,8992.74
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016410,NDC,1,ML,917.08,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,816.2012,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.66,898.7384
clobetasol 0.05 % Cream 60 g Tube,63700001,CDM,250,RC,,,,,,69238153206,NDC,60,GR,1665.95,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,816.3155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clobetasol 0.05 % Cream 60 g Tube,63700001,CDM,250,RC,,,,,,69238153206,NDC,60,GR,1665.95,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,816.3155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clobetasol 0.05 % Cream 60 g Tube,63700001,CDM,250,RC,,,,,,69238153206,NDC,60,GR,1665.95,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,816.3155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527197174,NDC,4,ML,960.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,816.425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
Blood Transfusion Service,PX36430,CDM,391,RC,36430,CPT,,,,,,,,839,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,438.2033333,percent of total billed charges,816.5987,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.5206,822.22
Drainage of Gum Lesion,PX41800P,CDM,983,RC,41800,CPT,,,,,,,,839,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,816.5987,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,816.5987
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545F,CDM,510,RC,23545,CPT,,,,,,,,961,,First Health,Commercial,both,85,,999999999,percent of total billed charges,816.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,941.78
fluticasone-salmeterol 230-21 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,66993008896,NDC,12,GR,1904.14,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,816.87606,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290101,NDC,1,EA,1966.88,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,817.041952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.77,1927.5424
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290102,NDC,1,EA,1966.88,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,817.041952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.77,1927.5424
mometasone - formoterol 100-5 MCG/ACT Aerosol 8.8 g Inhaler,25000000,CDM,250,RC,,,,,,85720607,NDC,8.8,GR,918.07,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,817.0823,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
mometasone - formoterol 200-5 MCG/ACT Aerosol 8.8 g Inhaler,25000000,CDM,250,RC,,,,,,85461005,NDC,8.8,GR,918.07,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,817.0823,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Irrad/Lr Platelets,PXP9037,CDM,390,RC,P9037,HCPCS,,,,,,,,1617,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,818.202,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,616.6,1584.66
Duplex Up Extrem Art Bilat,PX9393001,CDM,921,RC,93930,CPT,TC,,,,,,,835,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,818.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,818.3
"Closed Rx Talus Fx,Manipulatn",PX28435F,CDM,510,RC,28435,CPT,,,,,,,,1705,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,818.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,708.257,1670.9
"Closed Rx Talus Fx,Manipulatn",PX28435F,CDM,510,RC,28435,CPT,,,,,,,,1705,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,818.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,708.257,1670.9
fluticasone-salmeterol 500-50 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069704,NDC,14,EA,1670.75,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,818.6675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone-salmeterol 500-50 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069704,NDC,14,EA,1670.75,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,818.6675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone-salmeterol 500-50 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069704,NDC,14,EA,1670.75,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,818.6675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
MINIBUNION DRILL KIT,27200000,CDM,278,RC,C1713,HCPCS,,11669-MAIN,LOCAL,,,,,841.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,819.03195,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604F,CDM,510,RC,11604,CPT,,,,,,,,964,,First Health,Commercial,both,85,,999999999,percent of total billed charges,819.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,400.4456,944.72
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,67457061910,NDC,100,ML,1707.48,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,819.5904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,67457061910,NDC,100,ML,1707.48,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,819.5904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
GRAFIXPL PRIME PLACENTAL MEMBRANE 2x3CM 6SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12765-MAIN,LOCAL,,,,,1911,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,819.819,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
MIS STERILE INSTRUMENT PACK WITH BLADE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12432-MAIN,LOCAL,,,,,900,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,819.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Temporal Artery Ligatn or Bx,PX37609P,CDM,983,RC,37609,CPT,,,,,,,,965,,First Health,Commercial,both,85,,999999999,percent of total billed charges,820.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,400.861,1416.38
"Amputation Metatarsal+Toe,Single",PX28810F,CDM,510,RC,28810,CPT,,,,,,,,930,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,820.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.322,2827.75
Colonoscopy,PX44388F,CDM,750,RC,44388,CPT,,,,,,,,930,,United Healthcare,All Payer,outpatient,88.2,,999999999,case rate,820.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,820.26,6141.46
Hepatobil Syst Image W/Drug,PX7822701,CDM,341,RC,78227,CPT,TC,,,,,,,1674,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,334.8,percent of total billed charges,820.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,472.19,1640.52
Hepatobil Syst Image W/Drug,PX7822701,CDM,341,RC,78227,CPT,TC,,,,,,,1674,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,820.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,472.19,1640.52
Hepatobil Syst Image W/Drug,PX7822701,CDM,341,RC,78227,CPT,TC,,,,,,,1674,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,820.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,472.19,1640.52
"Sigmoidoscopy,Screen Prev",PX2001F,CDM,750,RC,45330,CPT,,,,,,,,843,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,820.4919,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,350.1822,826.14
"Excis Tendn/Capsule Lesn,Toes",PX28092P,CDM,983,RC,28092,CPT,,,,,,,,1913,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,820.677,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,794.6602,1861.9229
Infection Agent Detect Dna/Rna Probe Tq 6-11,PX87506,CDM,300,RC,87506,CPT,,,,,,,,1710,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,820.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,241.14,1675.8
Infection Agent Detect Dna/Rna Probe Tq 6-11,PX87506,CDM,300,RC,87506,CPT,,,,,,,,1710,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,820.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,241.14,1675.8
Lap Rpr Vent Umbilical Hernia Incarcerated or Strangulated,PX49653F,CDM,510,RC,49653,CPT,,,,,,,,1990,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,821.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,821.05,821.0527
Lap Rpr Vent Umbilical Hernia Incarcerated or Strangulated,PX49653P,CDM,983,RC,49653,CPT,,,,,,,,1327,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,821.05,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,821.05,1300.46
Lap Rpr Vent Umbilical Hernia Incarcerated or Strangulated,PX49653F,CDM,510,RC,49653,CPT,,,,,,,,1990,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,821.0527,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,821.05,821.0527
Lap Rpr Vent Umbilical Hernia Incarcerated or Strangulated,PX49653P,CDM,983,RC,49653,CPT,,,,,,,,1327,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,821.0527,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,821.05,1300.46
Fac/Exc Skn Beni 0.6-1cm Remain Bdy,PX11421F,CDM,510,RC,11421,CPT,,,,,,,,931,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,821.142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.7374,912.38
Fac/Exc Skn Bngn3.1-4cm Remain Bdy,PX11424F,CDM,510,RC,11424,CPT,,,,,,,,931,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,821.142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.7374,1416.38
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034F,CDM,510,RC,12034,CPT,,,,,,,,931,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,821.142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,912.38
"Repair Ing Hernia,5+Y/O,Strang",PX49507F,CDM,510,RC,49507,CPT,,,,,,,,1977,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,821.2458,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,821.2458,3022.41
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,310072010,NDC,5,ML,1977.83,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,821.590582,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.74,1938.2734
Incise Finger Tendon Sheath,PX26055P,CDM,983,RC,26055,CPT,,,,,,,,932,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,822.024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,387.1528,1404.08
Blood Transfusion Service,PX36430,CDM,391,RC,36430,CPT,,,,,,,,839,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,822.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.5206,822.22
Drainage of Gum Lesion,PX41800P,CDM,983,RC,41800,CPT,,,,,,,,839,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,822.22,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,98.82,822.22
riTUXimab 100 MG/10ML Solution 10 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005121,NDC,10,ML,1916.61,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,822.22569,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.61,8682.8588
Closed Rx Femur Shaft Fx+Manip,PX27502F,CDM,510,RC,27502,CPT,,,,,,,,1625,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,822.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,675.025,1592.5
Reconstruc of Nail Bed,PX11760P,CDM,983,RC,11760,CPT,,,,,,,,903,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,822.633,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,375.1062,878.8899
clobetasol 0.05 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,42291007760,NDC,60,GR,1625.97,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,822.74082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Biopsy Synovium I-P Jt,PX26110,CDM,983,RC,26110,CPT,,,,,,,,933,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,822.906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,387.5682,1404.08
"Hemorrhoidectomy,Int/Ext,Simple",PX46255F,CDM,510,RC,46255,CPT,,,,,,,,1627,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,823.262,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,675.8558,2452.93
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032605,NDC,0.8,ML,1663.54,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,823.4523,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,1630.2692
"Inject Nerv Blck,Othr Periph Nerv",PX64450P,CDM,983,RC,64450,CPT,,,,,,,,904,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,823.544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,375.5216,879.8632
"Repair Umbilical Hern,5+Y/O,Reduc",PX49585F,CDM,510,RC,49585,CPT,,,,,,,,969,,First Health,Commercial,both,85,,999999999,percent of total billed charges,823.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,402.5226,949.62
"Repair Recurr Inguin Hern,Reducibl",PX49520F,CDM,510,RC,49520,CPT,,,,,,,,1983,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,823.7382,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,823.7382,3022.41
"Repair Recurr Inguin Hern,Reducibl",PX49520P,CDM,983,RC,49520,CPT,,,,,,,,1983,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,823.7382,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,823.7382,3022.41
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101F,CDM,510,RC,13101,CPT,,,,,,,,495,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,823.93,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.32,823.93
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101P,CDM,983,RC,13101,CPT,,,,,,,,330,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,823.93,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.32,823.93
alteplase 100 MG Recon Soln 1 Each Syringe,J2997.01,CDM,636,RC,J2997,HCPCS,,,,88888800475,NDC,0.09,EA,1920.88,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,824.05752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
rabies immune globulin 300 UNIT/ML Solution 1 mL Vial,90376,CDM,636,RC,90375,CPT,,,,13533031801,NDC,1,ML,1629.06,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,824.30436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,281.51,1596.4788
agalsidase beta 5 MG Recon Soln 1 Each Vial,J0180.01,CDM,636,RC,J0180,HCPCS,,,,58468004101,NDC,1,EA,1717.68,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,824.4864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,200.2,1683.3264
agalsidase beta 5 MG Recon Soln 1 Each Vial,J0180.01,CDM,636,RC,J0180,HCPCS,,,,58468004101,NDC,1,EA,1717.68,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,824.4864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,200.2,1683.3264
"Treat Thumb Disloc,Manipulatn",PX26641F,CDM,510,RC,26641,CPT,,,,,,,,1721,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,824.63,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.07,905.57
"Treat Thumb Disloc,Manipulatn",PX26641P,CDM,983,RC,26641,CPT,,,,,,,,1902,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,824.63,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.07,1863.96
clobetasol 0.05 % Cream 60 g Tube,63700001,CDM,250,RC,,,,,,69238153206,NDC,60,GR,1665.95,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,824.64525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
MINIBUNION DRILL KIT,27200000,CDM,278,RC,C1713,HCPCS,,11669-MAIN,LOCAL,,,,,841.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,824.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266F,CDM,510,RC,27266,CPT,,,,,,,,1684,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,825.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,699.5336,1650.32
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266F,CDM,510,RC,27266,CPT,,,,,,,,1684,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,825.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,699.5336,1650.32
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266F,CDM,510,RC,27266,CPT,,,,,,,,1684,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,825.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,699.5336,1650.32
PROSTEP MICA SCREW 3.0X34MM STERILE IMPLANT,27200000,CDM,272,RC,,,,13042-MAIN,LOCAL,,,,,1684,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,825.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PROSTEP MICA SCREW 3.0X34MM STERILE IMPLANT,27200000,CDM,272,RC,,,,13042-MAIN,LOCAL,,,,,1684,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,825.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PROSTEP MICA SCREW 3.0X34MM STERILE IMPLANT,27200000,CDM,272,RC,,,,13042-MAIN,LOCAL,,,,,1684,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,825.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Treat Thumb Disloc,Manipulatn",PX26641F,CDM,510,RC,26641,CPT,,,,,,,,1721,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,826.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1686.58
"Treat Thumb Disloc,Manipulatn",PX26641F,CDM,510,RC,26641,CPT,,,,,,,,1721,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,826.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1686.58
"Sigmoidoscopy,Screen Prev",PX2001F,CDM,750,RC,45330,CPT,,,,,,,,843,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,826.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,350.1822,826.14
Ventilator Mgmt.Subsequent Days,PX94003F,CDM,410,RC,94003,CPT,,,,,,,,1686,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,826.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,547.46,1652.28
Ventilator Mgmt.Subsequent Days,PX94003F,CDM,410,RC,94003,CPT,,,,,,,,1686,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,826.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,547.46,1652.28
Ventilator Mgmt.Subsequent Days,PX94003F,CDM,410,RC,94003,CPT,,,,,,,,1686,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,826.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,547.46,1652.28
Remove Nasal Foreign Body,PX30300F,CDM,510,RC,30300,CPT,,,,,,,,972,,First Health,Commercial,both,85,,999999999,percent of total billed charges,826.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,952.56
Lap Rpr Vent Umbilical Hernia Incarcerated or Strangulated,PX49653F,CDM,510,RC,49653,CPT,,,,,,,,1990,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,826.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,826.646,1950.2
Revise Median N/Carpal Tunnel Surg,PX64721P,CDM,983,RC,64721,CPT,,,,,,,,1927,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,826.683,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,800.4758,1875.5491
"Tte W/Doppler, Complete",PXC8929,CDM,480,RC,C8929,HCPCS,TC,,,,,,,1927,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,826.683,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,699.48,1888.46
"Closed Rx Dist Fibula Fx,Manip",PX27788F,CDM,510,RC,27788,CPT,,,,,,,,1597,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,826.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.51,915.25
"Closed Rx Dist Fibula Fx,Manip",PX27788P,CDM,983,RC,27788,CPT,,,,,,,,1277,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,826.7,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.51,1251.46
budesonide-formoterol 80-4.5 MCG/ACT Aerosol 6.9 g Inhaler,63700001,CDM,250,RC,,,,,,186037228,NDC,6.9,GR,937.58,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,826.94556,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone-salmeterol 500-50 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069704,NDC,14,EA,1670.75,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,827.02125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Upper GI Endoscopy,Ctrl Bleed",PX43255F,CDM,750,RC,43255,CPT,,,,,,,,1723,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,827.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,715.7342,1688.54
"Upper GI Endoscopy,Ctrl Bleed",PX43255F,CDM,750,RC,43255,CPT,,,,,,,,1723,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,827.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,715.7342,1688.54
Room Rate General,PX12000000,CDM,120,RC,,,,,,,,,,1688,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,827.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,701.1952,1654.24
Room Rate General,PX12000000,CDM,120,RC,,,,,,,,,,1688,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,827.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,701.1952,1654.24
Room Rate General,PX12000000,CDM,120,RC,,,,,,,,,,1688,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,827.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,701.1952,1654.24
hydroxocobalamin 5 g Recon Soln 1 Each Box,J3424.01,CDM,636,RC,J3424,HCPCS,,,,11704037001,NDC,1,EA,1991.16,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,827.127864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,827.127864,1951.3368
Exc Abdom Tum Subfac > 5 Cm,PX22901P,CDM,983,RC,22901,CPT,,,,,,,,938,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,827.316,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,389.6452,2482.37
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956410,NDC,1,EA,1689.17,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,827.6933,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,409.66,1655.3866
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956410,NDC,1,EA,1689.17,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,827.6933,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,409.66,1655.3866
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956410,NDC,1,EA,1689.17,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,827.6933,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,409.66,1655.3866
"Amputation Metatarsal+Toe,Single",PX28810F,CDM,510,RC,28810,CPT,,,,,,,,930,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,827.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.322,2827.75
Colonoscopy,PX44388F,CDM,750,RC,44388,CPT,,,,,,,,930,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,827.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.322,911.4
DOCEtaxel 20 MG/ML Concentrate 1 mL Vial,63600000,CDM,636,RC,J9171,HCPCS,,,,955102001,NDC,1,ML,1690.09,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,828.1441,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
DOCEtaxel 20 MG/ML Concentrate 1 mL Vial,63600000,CDM,636,RC,J9171,HCPCS,,,,955102001,NDC,1,ML,1690.09,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,828.1441,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
DOCEtaxel 20 MG/ML Concentrate 1 mL Vial,63600000,CDM,636,RC,J9171,HCPCS,,,,955102001,NDC,1,ML,1690.09,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,828.1441,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
inFLIXimab-dyyb 100 MG Recon Soln 1 Each Vial,Q5103.01,CDM,636,RC,Q5103,HCPCS,,,,69080901,NDC,1,EA,1930.42,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,828.15018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.85,1891.8116
brinzolamide-brimonidine 1-0.2 % Suspension 8 mL Bottle,63700001,CDM,250,RC,,,,,,65414727,NDC,8,ML,850.88,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,828.161504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Fac/Exc Skn Beni 0.6-1cm Remain Bdy,PX11421F,CDM,510,RC,11421,CPT,,,,,,,,931,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,828.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.7374,912.38
Fac/Exc Skn Bngn3.1-4cm Remain Bdy,PX11424F,CDM,510,RC,11424,CPT,,,,,,,,931,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,828.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.7374,1416.38
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034F,CDM,510,RC,12034,CPT,,,,,,,,931,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,828.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,912.38
Hepatobil Syst Image W/Drug,PX7822701,CDM,341,RC,78227,CPT,TC,,,,,,,1674,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,828.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,472.19,1640.52
"Up GI Endoscopy,Dilatn W Guide",PX43248F,CDM,750,RC,43248,CPT,,,,,,,,1995,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,828.723,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,1955.1
Incise Finger Tendon Sheath,PX26055P,CDM,983,RC,26055,CPT,,,,,,,,932,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,829.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,387.1528,1404.08
BUPivacaine liposome 1.3 % Suspension 20 mL Vial,C9290.01,CDM,636,RC,C9290,HCPCS,,,,65250026604,NDC,10,ML,976.43,,First Health,Commercial,both,85,,999999999,percent of total billed charges,829.9655,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,405.609022,956.9014
ciprofloxacin-dexAMETHasone 0.3-0.1 % Suspension 7.5 mL Bottle,25000000,CDM,250,RC,,,,,,43598032675,NDC,7.5,ML,976.53,,First Health,Commercial,both,85,,999999999,percent of total billed charges,830.0505,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Biopsy Synovium I-P Jt,PX26110,CDM,983,RC,26110,CPT,,,,,,,,933,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,830.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,387.5682,1404.08
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505P,CDM,983,RC,25505,CPT,,,,,,,,977,,First Health,Commercial,both,85,,999999999,percent of total billed charges,830.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,405.8458,1404.08
Apply Long Leg Cast,PX29345F,CDM,510,RC,29345,CPT,,,,,,,,912,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,830.832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,234.62,893.76
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598030562,NDC,1,EA,912,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,830.832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
Open Bx/Excision Inguinofemoral Nodes,PX38531F,CDM,510,RC,38531,CPT,,,,,,,,912,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,830.832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,378.8448,3329.99
STAPLER CONTOUR CURVED CUTTER,27200000,CDM,272,RC,,,,12064-MAIN,LOCAL,,,,,942,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,830.844,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Revise Ulnar Nerve at Elbow,PX64718P,CDM,983,RC,64718,CPT,,,,,,,,1642,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,830.852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,682.0868,1686.76
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016401,NDC,1,ML,854.49,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,831.675117,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.66,898.7384
Exc Face Les Sc < 2 Cm,PX21011F,CDM,510,RC,21011,CPT,,,,,,,,943,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,831.726,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,391.7222,1416.38
"Colonoscopy,Remv Lesn,Snare",PX45385F,CDM,750,RC,45385,CPT,,,,,,,,1939,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,831.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,831.831,4050.42
FIXATION COMPONENT TOE JOINT PROXIMAL PHALANGEAL DF-P,C1713,CDM,278,RC,C1713,HCPCS,,12529-MAIN,LOCAL,,,,,1644,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,831.864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,60505611000,NDC,5,ML,1644.33,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,832.03098,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004F,CDM,510,RC,15004,CPT,,,,,,,,855,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,832.1715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,355.167,837.9
fluticasone-salmeterol 230-21 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173071720,NDC,12,GR,2004.35,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,832.60699,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Emergency Level IV Visit,PX99284P,CDM,981,RC,99284,CPT,,,,,,,,914,,Medica,Commercial,both,91.1,,164.8116379,percent of total billed charges,832.654,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,379.6756,889.5962
"Lap,Appendectomy",PX44970P,CDM,983,RC,44970,CPT,,,,,,,,1700,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,833,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,706.18,5040.74
"Lap,Appendectomy",PX44970P,CDM,983,RC,44970,CPT,,,,,,,,1700,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,833,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,706.18,5040.74
"Lap,Appendectomy",PX44970P,CDM,983,RC,44970,CPT,,,,,,,,1700,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,833,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,706.18,5040.74
"Removal Anal Fistula,Subcutaneous",PX46270P,CDM,983,RC,46270,CPT,,,,,,,,980,,First Health,Commercial,both,85,,999999999,percent of total billed charges,833,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,407.092,2452.93
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266F,CDM,510,RC,27266,CPT,,,,,,,,1684,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,833.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,699.5336,1650.32
PROSTEP MICA SCREW 3.0X34MM STERILE IMPLANT,27200000,CDM,272,RC,,,,13042-MAIN,LOCAL,,,,,1684,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,833.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
fidaxomicin 200 MG Tablet 20 Each Bottle,25000000,CDM,250,RC,,,,,,52015008001,NDC,1,EA,945.16,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,833.63112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200001,NDC,0.5,ML,980.99,,First Health,Commercial,both,85,,999999999,percent of total billed charges,833.8415,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,264.67,961.3702
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200002,NDC,0.5,ML,980.99,,First Health,Commercial,both,85,,999999999,percent of total billed charges,833.8415,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,264.67,961.3702
Exc Skin Benig >4cm Remaindr Body,PX11426P,CDM,983,RC,11426,CPT,,,,,,,,981,,First Health,Commercial,both,85,,999999999,percent of total billed charges,833.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,407.5074,2482.37
brinzolamide-brimonidine 1-0.2 % Suspension 8 mL Bottle,63700001,CDM,250,RC,,,,,,65414727,NDC,8,ML,850.88,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,833.8624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Closed Rx Big Toe Fx,Manip",PX28495F,CDM,510,RC,28495,CPT,,,,,,,,857,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,834.1181,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,839.86
budesonide-formoterol 80-4.5 MCG/ACT Aerosol 6.9 g Inhaler,63700001,CDM,250,RC,,,,,,186037228,NDC,6.9,GR,937.58,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,834.4462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Ventilator Mgmt.Subsequent Days,PX94003F,CDM,410,RC,94003,CPT,,,,,,,,1686,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,834.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,547.46,1652.28
Exc Abdom Tum Subfac > 5 Cm,PX22901P,CDM,983,RC,22901,CPT,,,,,,,,938,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,834.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,389.6452,2482.37
"Closed Rx Talus Fx,Manipulatn",PX28435F,CDM,510,RC,28435,CPT,,,,,,,,1705,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,835.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,708.257,1670.9
"Closed Rx Talus Fx,Manipulatn",PX28435F,CDM,510,RC,28435,CPT,,,,,,,,1705,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,835.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,708.257,1670.9
"Closed Rx Talus Fx,Manipulatn",PX28435F,CDM,510,RC,28435,CPT,,,,,,,,1705,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,835.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,708.257,1670.9
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016410,NDC,1,ML,917.08,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,835.45988,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.66,898.7384
"Lap,Cholecystectomy",PX47562P,CDM,983,RC,47562,CPT,,,,,,,,983,,First Health,Commercial,both,85,,999999999,percent of total billed charges,835.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,408.3382,5040.74
Room Rate General,PX12000000,CDM,120,RC,,,,,,,,,,1688,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,835.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,701.1952,1654.24
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121F,CDM,510,RC,13121,CPT,,,,,,,,948,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,836.136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,393.7992,929.04
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956410,NDC,1,EA,1689.17,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,836.13915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,409.66,1655.3866
mometasone - formoterol 100-5 MCG/ACT Aerosol 8.8 g Inhaler,25000000,CDM,250,RC,,,,,,85720607,NDC,8.8,GR,918.07,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,836.36177,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
mometasone - formoterol 200-5 MCG/ACT Aerosol 8.8 g Inhaler,25000000,CDM,250,RC,,,,,,85461005,NDC,8.8,GR,918.07,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,836.36177,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Amputation Toe,Mt-P Jt",PX28820F,CDM,510,RC,28820,CPT,,,,,,,,1950,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,836.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,810.03,2827.75
DOCEtaxel 20 MG/ML Concentrate 1 mL Vial,63600000,CDM,636,RC,J9171,HCPCS,,,,955102001,NDC,1,ML,1690.09,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,836.59455,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,67457061910,NDC,100,ML,1707.48,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,57.34422222,percent of total billed charges,836.6652,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,67457061910,NDC,100,ML,1707.48,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,836.6652,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,67457061910,NDC,100,ML,1707.48,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,836.6652,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
GRAFIXPL PRIME PLACENTAL MEMBRANE 16MM DISC 2SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12763-MAIN,LOCAL,,,,,860,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,837.038,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016401,NDC,1,ML,854.49,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,837.4002,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.66,898.7384
Infection Agent Detect Dna/Rna Probe Tq 6-11,PX87506,CDM,300,RC,87506,CPT,,,,,,,,1710,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,837.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,241.14,1675.8
Infection Agent Detect Dna/Rna Probe Tq 6-11,PX87506,CDM,300,RC,87506,CPT,,,,,,,,1710,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,837.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,241.14,1675.8
Infection Agent Detect Dna/Rna Probe Tq 6-11,PX87506,CDM,300,RC,87506,CPT,,,,,,,,1710,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,837.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,241.14,1675.8
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004F,CDM,510,RC,15004,CPT,,,,,,,,855,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,837.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,355.167,837.9
"Sigmoidoscopy,Remv Lesn,Snare",PX45338P,CDM,983,RC,45338,CPT,,,,,,,,1710,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,837.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,710.334,1664.343
"Sigmoidoscopy,Remv Lesn,Snare",PX45338P,CDM,983,RC,45338,CPT,,,,,,,,1710,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,837.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,710.334,1664.343
"Sigmoidoscopy,Remv Lesn,Snare",PX45338P,CDM,983,RC,45338,CPT,,,,,,,,1710,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,837.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,710.334,1664.343
fluticasone 220 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173072020,NDC,12,GR,1746.36,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,838.2528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone 220 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173072020,NDC,12,GR,1746.36,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,838.2528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
STAPLER CONTOUR CURVED CUTTER,27200000,CDM,272,RC,,,,12064-MAIN,LOCAL,,,,,942,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,838.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
FORCEPS SPOON JAWSIZE 10MMX36 KIT,27200000,CDM,272,RC,,,,11749-MAIN,LOCAL,,,,,1955,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,838.695,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Skin Sub Graft Trnk/Arm/Leg,PX15271F,CDM,510,RC,15271,CPT,,,,,,,,862,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,838.9846,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,358.0748,1593.14
"Diagnostic Bone Marrow, Biopsy and Aspiration",PX38222F,CDM,761,RC,38222,CPT,,,,,,,,1748,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,839.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,726.1192,2482.37
"Diagnostic Bone Marrow, Biopsy and Aspiration",PX38222F,CDM,761,RC,38222,CPT,,,,,,,,1748,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,839.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,726.1192,2482.37
Exc Face Les Sc < 2 Cm,PX21011F,CDM,510,RC,21011,CPT,,,,,,,,943,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,839.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,391.7222,1416.38
"Closed Rx Big Toe Fx,Manip",PX28495F,CDM,510,RC,28495,CPT,,,,,,,,857,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,839.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,839.86
"Closed Rx Radial Head/Neck Fx,Manip",PX24655F,CDM,510,RC,24655,CPT,,,,,,,,1750,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,840,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,726.95,1715
"Closed Rx Radial Head/Neck Fx,Manip",PX24655F,CDM,510,RC,24655,CPT,,,,,,,,1750,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,840,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,726.95,1715
"Fix Exten Tendon,Dorsum Fingr,Ea",PX26418F,CDM,510,RC,26418,CPT,,,,,,,,1750,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,840,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,726.95,1715
"Fix Exten Tendon,Dorsum Fingr,Ea",PX26418F,CDM,510,RC,26418,CPT,,,,,,,,1750,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,840,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,726.95,1715
"Cardiac Stress Tst,Tracing Only",PX93017,CDM,482,RC,93017,CPT,,,,,,,,1959,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,840.411,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.21,1919.82
"Removal Anal Fistula,Subcutaneous",PX46270F,CDM,510,RC,46270,CPT,,,,,,,,1470,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,840.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,251.31,1113.8
"Removal Anal Fistula,Subcutaneous",PX46270P,CDM,983,RC,46270,CPT,,,,,,,,980,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,840.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,251.31,1113.8
Anus Surgery Procedure Unlisted,PX46999P,CDM,983,RC,46999,CPT,,,,,,,,953,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,840.546,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,395.8762,927.5549
"Genital Surg Proc,Male Unlisted",PX55899P,CDM,983,RC,55899,CPT,,,,,,,,953,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,840.546,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,215.91,927.5549
I&D Perirectal Abscess,PX46040P,CDM,983,RC,46040,CPT,,,,,,,,953,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,840.546,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,395.8762,1030.93
Tube Thoracostomy Inc Wtr Seal,PX32551F,CDM,510,RC,32551,CPT,,,,,,,,989,,First Health,Commercial,both,85,,999999999,percent of total billed charges,840.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,410.8306,1399.13
clobetasol 0.05 % Cream 60 g Tube,63700001,CDM,250,RC,,,,,,168030160,NDC,60,GR,989.25,,First Health,Commercial,both,85,,999999999,percent of total billed charges,840.8625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Cns Dna/Rna Amp Probe Multiple Subtypes 12-25,PX87483,CDM,300,RC,87483,CPT,,,,,,,,864,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,586.2,percent of total billed charges,840.9312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,358.9056,846.72
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060002,NDC,2,ML,953.57,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,841.04874,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.11,934.4986
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060010,NDC,2,ML,953.57,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,841.04874,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.11,934.4986
fidaxomicin 200 MG Tablet 20 Each Bottle,25000000,CDM,250,RC,,,,,,52015008001,NDC,1,EA,945.16,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,841.1924,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Remv Foreign Body,Knee/Thigh,Deep",PX27372P,CDM,983,RC,27372,CPT,,,,,,,,954,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,841.428,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,396.2916,2482.37
"Lap,Appendectomy",PX44970P,CDM,983,RC,44970,CPT,,,,,,,,1700,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,841.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,706.18,5040.74
agalsidase beta 5 MG Recon Soln 1 Each Vial,J0180.01,CDM,636,RC,J0180,HCPCS,,,,58468004101,NDC,1,EA,1717.68,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,841.6632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,200.2,1683.3264
agalsidase beta 5 MG Recon Soln 1 Each Vial,J0180.01,CDM,636,RC,J0180,HCPCS,,,,58468004101,NDC,1,EA,1717.68,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,841.6632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,200.2,1683.3264
agalsidase beta 5 MG Recon Soln 1 Each Vial,J0180.01,CDM,636,RC,J0180,HCPCS,,,,58468004101,NDC,1,EA,1717.68,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,841.6632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,200.2,1683.3264
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032605,NDC,0.8,ML,1663.54,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,841.75124,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,1630.2692
Removal of Hemorrhoid Clot,PX46320F,CDM,510,RC,46320,CPT,,,,,,,,2027,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,842.0158,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,842.0158,1986.46
STAPLER SUREFORM 60 SPU IS4000,27200000,CDM,272,RC,,,,12086-MAIN,LOCAL,,,,,991,,First Health,Commercial,both,85,,999999999,percent of total billed charges,842.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Lap Incis Hernia Reducible,PX49654F,CDM,510,RC,49654,CPT,,,,,,,,1964,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,842.556,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,815.8456,1924.72
GRAFIXPL PRIME PLACENTAL MEMBRANE 16MM DISC 2SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12763-MAIN,LOCAL,,,,,860,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,842.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
Debride Tissue/Muscle/Bone,PX11044P,CDM,983,RC,11044,CPT,,,,,,,,866,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,216.4,percent of total billed charges,842.8778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,359.7364,1416.38
clobetasol 0.05 % Cream 60 g Tube,63700001,CDM,250,RC,,,,,,69238153206,NDC,60,GR,1665.95,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,842.9707,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Incise External Hemorrhoid,PX46083P,CDM,983,RC,46083,CPT,,,,,,,,956,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,843.192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,215.91,930.4748
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573P,CDM,983,RC,36573,CPT,,,,,,,,1721,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,843.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,714.9034,1675.0493
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573P,CDM,983,RC,36573,CPT,,,,,,,,1721,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,843.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,714.9034,1675.0493
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573P,CDM,983,RC,36573,CPT,,,,,,,,1721,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,843.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,714.9034,1675.0493
"Treat Thumb Disloc,Manipulatn",PX26641F,CDM,510,RC,26641,CPT,,,,,,,,1721,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1022.934,percent of total billed charges,843.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1686.58
"Treat Thumb Disloc,Manipulatn",PX26641F,CDM,510,RC,26641,CPT,,,,,,,,1721,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,843.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1686.58
"Treat Thumb Disloc,Manipulatn",PX26641F,CDM,510,RC,26641,CPT,,,,,,,,1721,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,843.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1686.58
"Remv Foreign Body,Knee/Thigh,Deep",PX27372F,CDM,510,RC,27372,CPT,,,,,,,,1429,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,843.3,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,250.43,1226.56
"Remv Foreign Body,Knee/Thigh,Deep",PX27372P,CDM,983,RC,27372,CPT,,,,,,,,954,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,843.3,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,250.43,1226.56
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121F,CDM,510,RC,13121,CPT,,,,,,,,948,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,843.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,393.7992,929.04
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290101,NDC,1,EA,1966.88,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,843.79152,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.77,1927.5424
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290102,NDC,1,EA,1966.88,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,843.79152,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.77,1927.5424
"Closed Rx Talus Fx,Manipulatn",PX28435F,CDM,510,RC,28435,CPT,,,,,,,,1705,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,843.975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,708.257,1670.9
"I&D Perianal Abscess,Superficial",PX46050P,CDM,983,RC,46050,CPT,,,,,,,,993,,First Health,Commercial,both,85,,999999999,percent of total billed charges,844.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,412.4922,966.4869
"Upper GI Endoscopy,Ctrl Bleed",PX43255F,CDM,750,RC,43255,CPT,,,,,,,,1723,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,844.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,715.7342,1688.54
"Upper GI Endoscopy,Ctrl Bleed",PX43255F,CDM,750,RC,43255,CPT,,,,,,,,1723,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,844.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,715.7342,1688.54
"Upper GI Endoscopy,Ctrl Bleed",PX43255F,CDM,750,RC,43255,CPT,,,,,,,,1723,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,844.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,715.7342,1688.54
Skin Sub Graft Trnk/Arm/Leg,PX15271F,CDM,510,RC,15271,CPT,,,,,,,,862,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,844.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,358.0748,1593.14
fluticasone 220 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,66993008096,NDC,12,GR,1760.13,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,844.8624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone 220 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,66993008096,NDC,12,GR,1760.13,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,844.8624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,67457061910,NDC,100,ML,1707.48,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,845.2026,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
"Lap,Inguinal Hernia Repr,Recur",PX49651P,CDM,983,RC,49651,CPT,,,,,,,,2035,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,845.339,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,845.339,5040.74
fluticasone-salmeterol 500-50 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069704,NDC,14,EA,1670.75,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,845.3995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Debride Skin/Tissue,PX11042P,CDM,983,RC,11042,CPT,,,,,,,,995,,First Health,Commercial,both,85,,999999999,percent of total billed charges,845.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,968.4335
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180F,CDM,510,RC,44180,CPT,,,,,,,,1763,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,846.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,732.3502,5040.74
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180F,CDM,510,RC,44180,CPT,,,,,,,,1763,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,846.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,732.3502,5040.74
Infection Agent Detect Dna/Rna Probe Tq 6-11,PX87506,CDM,300,RC,87506,CPT,,,,,,,,1710,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,846.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,241.14,1675.8
"Sigmoidoscopy,Remv Lesn,Snare",PX45338P,CDM,983,RC,45338,CPT,,,,,,,,1710,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,846.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,710.334,1664.343
HERNIA PATCH VENTRALEX SMALL,C1781,CDM,278,RC,C1781,HCPCS,,10203-MAIN,LOCAL,,,,,995.96,,First Health,Commercial,both,85,,999999999,percent of total billed charges,846.566,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Cns Dna/Rna Amp Probe Multiple Subtypes 12-25,PX87483,CDM,300,RC,87483,CPT,,,,,,,,864,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,846.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,358.9056,846.72
"Biopsy of Prostate,Needle/Punch",PX55700F,CDM,510,RC,55700,CPT,,,,,,,,2039,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,847.0006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,847.0006,1998.22
Hepatobil Syst Image W/Drug,PX7822701,CDM,341,RC,78227,CPT,TC,,,,,,,1674,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,847.044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,472.19,1640.52
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527197174,NDC,4,ML,960.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,847.161,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
"Amputation Metatarsal+Toe,Single",PX28810F,CDM,510,RC,28810,CPT,,,,,,,,930,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,847.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.322,2827.75
Colonoscopy,PX44388F,CDM,750,RC,44388,CPT,,,,,,,,930,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,847.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.322,911.4
Factor VIII (Ahg) 1-Stage,PX85240,CDM,300,RC,85240,CPT,,,,,,,,997,,First Health,Commercial,both,85,,999999999,percent of total billed charges,847.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.41,977.06
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545F,CDM,510,RC,23545,CPT,,,,,,,,961,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,847.602,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,941.78
"Repair Ing Hernia,5+Y/O,Strang",PX49507F,CDM,510,RC,49507,CPT,,,,,,,,1977,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,848.133,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,821.2458,3022.41
Fac/Exc Skn Beni 0.6-1cm Remain Bdy,PX11421F,CDM,510,RC,11421,CPT,,,,,,,,931,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,848.141,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.7374,912.38
Fac/Exc Skn Bngn3.1-4cm Remain Bdy,PX11424F,CDM,510,RC,11424,CPT,,,,,,,,931,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,848.141,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.7374,1416.38
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034F,CDM,510,RC,12034,CPT,,,,,,,,931,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,848.141,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,912.38
Anus Surgery Procedure Unlisted,PX46999P,CDM,983,RC,46999,CPT,,,,,,,,953,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,848.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,395.8762,927.5549
"Genital Surg Proc,Male Unlisted",PX55899P,CDM,983,RC,55899,CPT,,,,,,,,953,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,848.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,215.91,927.5549
I&D Perirectal Abscess,PX46040P,CDM,983,RC,46040,CPT,,,,,,,,953,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,848.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,395.8762,1030.93
"Up GI Endoscopy,Ball Dil,30mm",PX43249P,CDM,983,RC,43249,CPT,,,,,,,,1731,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,848.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,742.599,3257.54
"Up GI Endoscopy,Ball Dil,30mm",PX43249P,CDM,983,RC,43249,CPT,,,,,,,,1731,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,848.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,742.599,3257.54
"Up GI Endoscopy,Ball Dil,30mm",PX43249P,CDM,983,RC,43249,CPT,,,,,,,,1731,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,848.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,742.599,3257.54
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,310072010,NDC,5,ML,1977.83,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,848.48907,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.74,1938.2734
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060002,NDC,2,ML,953.57,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,848.6773,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.11,934.4986
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060010,NDC,2,ML,953.57,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,848.6773,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.11,934.4986
Debride Tissue/Muscle/Bone,PX11044P,CDM,983,RC,11044,CPT,,,,,,,,866,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,848.68,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,136.56,848.68
Incise Finger Tendon Sheath,PX26055P,CDM,983,RC,26055,CPT,,,,,,,,932,,Medica,Commercial,both,91.1,,2419.62,percent of total billed charges,849.052,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,387.1528,1404.08
"Remv Foreign Body,Knee/Thigh,Deep",PX27372P,CDM,983,RC,27372,CPT,,,,,,,,954,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,849.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,396.2916,2482.37
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606P,CDM,983,RC,11606,CPT,,,,,,,,2044,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,849.0776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,849.0776,1989.4252
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,16714081501,NDC,5,ML,998.95,,First Health,Commercial,both,85,,999999999,percent of total billed charges,849.1075,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
"Sb Scope,to Ileum,Biopsy",PX44377F,CDM,750,RC,44377,CPT,,,,,,,,1770,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,849.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,735.258,1734.6
"Sb Scope,to Ileum,Biopsy",PX44377F,CDM,750,RC,44377,CPT,,,,,,,,1770,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,849.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,735.258,1734.6
Injection for Nerve Block,PX64448F,CDM,510,RC,64448,CPT,,,,,,,,873,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,849.6909,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,362.6442,855.54
"Tte W/Doppler, Complete",PX9330601,CDM,483,RC,93306,CPT,TC,,,,,,,2191,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,849.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,481.95,2889.15
Biopsy Synovium I-P Jt,PX26110,CDM,983,RC,26110,CPT,,,,,,,,933,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,849.963,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,387.5682,1404.08
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604F,CDM,510,RC,11604,CPT,,,,,,,,964,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,850.248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,400.4456,944.72
agalsidase beta 5 MG Recon Soln 1 Each Vial,J0180.01,CDM,636,RC,J0180,HCPCS,,,,58468004101,NDC,1,EA,1717.68,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,850.2516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,200.2,1683.3264
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561P,CDM,983,RC,36561,CPT,,,,,,,,1736,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,850.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,721.1344,2784.63
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561P,CDM,983,RC,36561,CPT,,,,,,,,1736,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,850.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,721.1344,2784.63
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561P,CDM,983,RC,36561,CPT,,,,,,,,1736,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,850.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,721.1344,2784.63
"Lap,Dx Surgical Abd W/Biopsy",PX49321F,CDM,510,RC,49321,CPT,,,,,,,,874,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,850.6642,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.0596,5040.74
"Repair Recurr Inguin Hern,Reducibl",PX49520F,CDM,510,RC,49520,CPT,,,,,,,,1983,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,850.707,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,823.7382,3022.41
"Repair Recurr Inguin Hern,Reducibl",PX49520P,CDM,983,RC,49520,CPT,,,,,,,,1983,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,850.707,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,823.7382,3022.41
"Repair Ing Hernia,5+Y/O,Reducibl",PX49505P,CDM,983,RC,49505,CPT,,,,,,,,2048,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,850.7392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,850.7392,3022.41
Incise External Hemorrhoid,PX46083P,CDM,983,RC,46083,CPT,,,,,,,,956,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,850.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,215.91,930.4748
Temporal Artery Ligatn or Bx,PX37609P,CDM,983,RC,37609,CPT,,,,,,,,965,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,851.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,400.861,1416.38
"Fac/Exc Skn Mali2.1-3cmtrnk,Arm,Lg",PX11603F,CDM,510,RC,11603,CPT,,,,,,,,875,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,851.6375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.475,857.5
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573P,CDM,983,RC,36573,CPT,,,,,,,,1721,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,851.895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,714.9034,1675.0493
"Treat Thumb Disloc,Manipulatn",PX26641F,CDM,510,RC,26641,CPT,,,,,,,,1721,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,851.895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1686.58
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266F,CDM,510,RC,27266,CPT,,,,,,,,1684,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,852.104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,699.5336,1650.32
PROSTEP MICA SCREW 3.0X34MM STERILE IMPLANT,27200000,CDM,272,RC,,,,13042-MAIN,LOCAL,,,,,1684,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,852.104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
cocaine 4% 4 % Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527172874,NDC,4,ML,875.53,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,852.153349,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
Exs Tumor Arm/Elbow Sc 3cm>,PX24071F,CDM,510,RC,24071,CPT,,,,,,,,1860,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,852.3,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,249.34,852.3
Exs Tumor Arm/Elbow Sc 3cm>,PX24071F,CDM,510,RC,24071,CPT,,,,,,,,1860,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,852.3,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,249.34,852.3
"Closed Rx Shldr Disloc,Anesthesia",PX23655F,CDM,510,RC,23655,CPT,,,,,,,,1776,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,852.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,737.7504,1740.48
"Closed Rx Shldr Disloc,Anesthesia",PX23655F,CDM,510,RC,23655,CPT,,,,,,,,1776,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,852.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,737.7504,1740.48
"Sigmoidoscopy,Biopsy",PX45331F,CDM,750,RC,45331,CPT,,,,,,,,1776,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,852.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,737.7504,1740.48
"Sigmoidoscopy,Biopsy",PX45331F,CDM,750,RC,45331,CPT,,,,,,,,1776,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,852.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,737.7504,1740.48
"Upper GI Endoscopy,Ctrl Bleed",PX43255F,CDM,750,RC,43255,CPT,,,,,,,,1723,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,852.885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,715.7342,1688.54
Ventilator Mgmt.Subsequent Days,PX94003F,CDM,410,RC,94003,CPT,,,,,,,,1686,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,853.116,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,547.46,1652.28
Lap Rpr Vent Umbilical Hernia Incarcerated or Strangulated,PX49653F,CDM,510,RC,49653,CPT,,,,,,,,1990,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,853.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,826.646,1950.2
Room Rate General,PX12000000,CDM,120,RC,,,,,,,,,,1688,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,854.128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,701.1952,1654.24
budesonide-formoterol 80-4.5 MCG/ACT Aerosol 6.9 g Inhaler,63700001,CDM,250,RC,,,,,,186037228,NDC,6.9,GR,937.58,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,854.13538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydroxocobalamin 5 g Recon Soln 1 Each Box,J3424.01,CDM,636,RC,J3424,HCPCS,,,,11704037001,NDC,1,EA,1991.16,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,854.20764,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,827.127864,1951.3368
Exc Abdom Tum Subfac > 5 Cm,PX22901P,CDM,983,RC,22901,CPT,,,,,,,,938,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,854.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,389.6452,2482.37
"Repair Umbilical Hern,5+Y/O,Reduc",PX49585F,CDM,510,RC,49585,CPT,,,,,,,,969,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,854.658,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,402.5226,949.62
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956410,NDC,1,EA,1689.17,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,854.72002,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,409.66,1655.3866
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527197174,NDC,4,ML,960.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,854.845,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
Abd Paracentesis W/Imaging(T),PX49083F,CDM,510,RC,49083,CPT,,,,,,,,1006,,First Health,Commercial,both,85,,999999999,percent of total billed charges,855.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,417.8924,985.88
DOCEtaxel 20 MG/ML Concentrate 1 mL Vial,63600000,CDM,636,RC,J9171,HCPCS,,,,955102001,NDC,1,ML,1690.09,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,855.18554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545F,CDM,510,RC,23545,CPT,,,,,,,,961,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,855.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,941.78
Injection for Nerve Block,PX64448F,CDM,510,RC,64448,CPT,,,,,,,,873,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,855.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,362.6442,855.54
fluticasone 220 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173072020,NDC,12,GR,1746.36,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,855.7164,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone 220 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173072020,NDC,12,GR,1746.36,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,855.7164,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone 220 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173072020,NDC,12,GR,1746.36,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,855.7164,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Up GI Endoscopy,Dilatn W Guide",PX43248F,CDM,750,RC,43248,CPT,,,,,,,,1995,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,855.855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,1955.1
"Up GI Endoscopy,Dilatn W Guide",PX43248F,CDM,750,RC,43248,CPT,,,,,,,,1995,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,856.45,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.66,856.45
"Diagnostic Bone Marrow, Biopsy and Aspiration",PX38222F,CDM,761,RC,38222,CPT,,,,,,,,1748,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,181.71,percent of total billed charges,856.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,726.1192,2482.37
"Diagnostic Bone Marrow, Biopsy and Aspiration",PX38222F,CDM,761,RC,38222,CPT,,,,,,,,1748,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,856.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,726.1192,2482.37
"Diagnostic Bone Marrow, Biopsy and Aspiration",PX38222F,CDM,761,RC,38222,CPT,,,,,,,,1748,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,856.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,726.1192,2482.37
"Lap,Dx Surgical Abd W/Biopsy",PX49321F,CDM,510,RC,49321,CPT,,,,,,,,874,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,856.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.0596,5040.74
"Up GI Endoscopy,Ball Dil,30mm",PX43249P,CDM,983,RC,43249,CPT,,,,,,,,1731,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,856.845,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,742.599,3257.54
Remove Nasal Foreign Body,PX30300F,CDM,510,RC,30300,CPT,,,,,,,,972,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,857.304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,952.56
"Injection,Sacroiliac Joint(T)",PX27096F,CDM,510,RC,27096,CPT,,,,,,,,881,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,857.4773,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,365.9674,863.38
"Closed Rx Radial Head/Neck Fx,Manip",PX24655F,CDM,510,RC,24655,CPT,,,,,,,,1750,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,857.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,726.95,1715
"Closed Rx Radial Head/Neck Fx,Manip",PX24655F,CDM,510,RC,24655,CPT,,,,,,,,1750,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,857.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,726.95,1715
"Closed Rx Radial Head/Neck Fx,Manip",PX24655F,CDM,510,RC,24655,CPT,,,,,,,,1750,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,857.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,726.95,1715
"Fac/Exc Skn Mali2.1-3cmtrnk,Arm,Lg",PX11603F,CDM,510,RC,11603,CPT,,,,,,,,875,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,857.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.475,857.5
"Fix Exten Tendon,Dorsum Fingr,Ea",PX26418F,CDM,510,RC,26418,CPT,,,,,,,,1750,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,857.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,726.95,1715
"Fix Exten Tendon,Dorsum Fingr,Ea",PX26418F,CDM,510,RC,26418,CPT,,,,,,,,1750,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,857.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,726.95,1715
"Fix Exten Tendon,Dorsum Fingr,Ea",PX26418F,CDM,510,RC,26418,CPT,,,,,,,,1750,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,857.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,726.95,1715
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604F,CDM,510,RC,11604,CPT,,,,,,,,964,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,857.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,400.4456,944.72
"Ht Muscle Image Spect, Mult",PX7845201,CDM,340,RC,78452,CPT,TC,,,,,,,2000,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,858,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,858,5292.1
cocaine 4% 4 % Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527172874,NDC,4,ML,875.53,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,858.0194,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
STAPLER CONTOUR CURVED CUTTER,27200000,CDM,272,RC,,,,12064-MAIN,LOCAL,,,,,942,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,858.162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Temporal Artery Ligatn or Bx,PX37609P,CDM,983,RC,37609,CPT,,,,,,,,965,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,858.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,400.861,1416.38
Exc Face Les Sc < 2 Cm,PX21011F,CDM,510,RC,21011,CPT,,,,,,,,943,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,859.073,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,391.7222,1416.38
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561P,CDM,983,RC,36561,CPT,,,,,,,,1736,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,859.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,721.1344,2784.63
fluticasone-salmeterol 230-21 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173071720,NDC,12,GR,2004.35,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,859.86615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
esmolol 2500 MG/250ML Solution 250 mL Flex Cont,J1805.01,CDM,636,RC,J1805,HCPCS,,,,10019067010,NDC,250,ML,1011.8,,First Health,Commercial,both,85,,999999999,percent of total billed charges,860.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.24,991.564
"Lap,Appendectomy",PX44970P,CDM,983,RC,44970,CPT,,,,,,,,1700,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,860.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,706.18,5040.74
Abd Paracentesis,PX49082F,CDM,510,RC,49082,CPT,,,,,,,,884,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,860.3972,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,367.2136,866.32
"Excise Lesion,Back or Flank",PX21930P,CDM,983,RC,21930,CPT,,,,,,,,884,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,4019.13,percent of total billed charges,860.3972,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,367.2136,1416.38
fidaxomicin 200 MG Tablet 20 Each Bottle,25000000,CDM,250,RC,,,,,,52015008001,NDC,1,EA,945.16,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,861.04076,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
BUPivacaine liposome 1.3 % Suspension 20 mL Vial,C9290.01,CDM,636,RC,C9290,HCPCS,,,,65250026604,NDC,10,ML,976.43,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,861.21126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,405.609022,956.9014
ciprofloxacin-dexAMETHasone 0.3-0.1 % Suspension 7.5 mL Bottle,25000000,CDM,250,RC,,,,,,43598032675,NDC,7.5,ML,976.53,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,861.29946,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505P,CDM,983,RC,25505,CPT,,,,,,,,977,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,861.714,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,405.8458,1404.08
"Exc Skn Beig1.1-2cm Face,Facil",PX11442P,CDM,983,RC,11442,CPT,,,,,,,,886,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,862.3438,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,368.0444,862.3438
"Repair Umbilical Hern,5+Y/O,Reduc",PX49585F,CDM,510,RC,49585,CPT,,,,,,,,969,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,862.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,402.5226,949.62
fluticasone 220 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,66993008096,NDC,12,GR,1760.13,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,862.4637,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone 220 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,66993008096,NDC,12,GR,1760.13,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,862.4637,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone 220 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,66993008096,NDC,12,GR,1760.13,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,862.4637,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Closed Rx Talus Fx,Manipulatn",PX28435F,CDM,510,RC,28435,CPT,,,,,,,,1705,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,862.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,708.257,1670.9
"Injection,Sacroiliac Joint(T)",PX27096F,CDM,510,RC,27096,CPT,,,,,,,,881,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,863.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,365.9674,863.38
belimumab 120 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010101,NDC,1,EA,1015.95,,First Health,Commercial,both,85,,999999999,percent of total billed charges,863.5575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.72,3453.2358
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121F,CDM,510,RC,13121,CPT,,,,,,,,948,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,863.628,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,393.7992,929.04
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180F,CDM,510,RC,44180,CPT,,,,,,,,1763,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,863.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,732.3502,5040.74
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180F,CDM,510,RC,44180,CPT,,,,,,,,1763,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,863.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,732.3502,5040.74
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180F,CDM,510,RC,44180,CPT,,,,,,,,1763,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,863.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,732.3502,5040.74
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,67457061910,NDC,100,ML,1707.48,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,863.98488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830F,CDM,510,RC,15830,CPT,,,,,,,,2080,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,864.032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,864.032,5696.92
STAPLER SUREFORM 45 SPU IS4000,27200000,CDM,272,RC,,,,12794-MAIN,LOCAL,,,,,888,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,864.2904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Removal Anal Fistula,Subcutaneous",PX46270P,CDM,983,RC,46270,CPT,,,,,,,,980,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,864.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,407.092,2452.93
fluticasone 220 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173072020,NDC,12,GR,1746.36,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,864.4482,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Remove Nasal Foreign Body,PX30300F,CDM,510,RC,30300,CPT,,,,,,,,972,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,865.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,952.56
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200001,NDC,0.5,ML,980.99,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,865.23318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,264.67,961.3702
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200002,NDC,0.5,ML,980.99,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,865.23318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,264.67,961.3702
Exc Skin Benig >4cm Remaindr Body,PX11426P,CDM,983,RC,11426,CPT,,,,,,,,981,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,865.242,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,407.5074,2482.37
"Diagnostic Bone Marrow, Biopsy and Aspiration",PX38222F,CDM,761,RC,38222,CPT,,,,,,,,1748,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,865.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,726.1192,2482.37
Infection Agent Detect Dna/Rna Probe Tq 6-11,PX87506,CDM,300,RC,87506,CPT,,,,,,,,1710,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,865.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,241.14,1675.8
"Sigmoidoscopy,Remv Lesn,Snare",PX45338P,CDM,983,RC,45338,CPT,,,,,,,,1710,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,865.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,710.334,1664.343
Drain Skin Abscess Complic,PX10061F,CDM,510,RC,10061,CPT,,,,,,,,889,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,865.2637,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,871.22
Inc/Drain Peritonsil Abscess,PX42700P,CDM,983,RC,42700,CPT,,,,,,,,889,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,865.2637,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.39,865.2637
"Percut Biopsy, Abdominal Mass",PX49180F,CDM,510,RC,49180,CPT,,,,,,,,2084,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,865.6936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,865.6936,2042.32
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,115169449,NDC,1,EA,889.46,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,229.0777778,percent of total billed charges,865.711418,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54505010202,NDC,1,EA,889.46,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,229.0777778,percent of total billed charges,865.711418,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
"Closed Rx Radial Head/Neck Fx,Manip",PX24655F,CDM,510,RC,24655,CPT,,,,,,,,1750,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,866.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,726.95,1715
"Fix Exten Tendon,Dorsum Fingr,Ea",PX26418F,CDM,510,RC,26418,CPT,,,,,,,,1750,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,866.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,726.95,1715
Abd Paracentesis,PX49082F,CDM,510,RC,49082,CPT,,,,,,,,884,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,866.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,367.2136,866.32
"Excise Lesion,Back or Flank",PX21930P,CDM,983,RC,21930,CPT,,,,,,,,884,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,866.32,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,225.35,1053.61
Exc Abd Les Sc < 3 Cm,PX22902P,CDM,983,RC,22902,CPT,,,,,,,,2086,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,866.5244,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,866.5244,2030.3038
PROSTEP MICA SCREW 3.0X20MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12442-MAIN,LOCAL,,,,,1806,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,866.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 3.0X20MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12442-MAIN,LOCAL,,,,,1806,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,866.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 3.0X40MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12443-MAIN,LOCAL,,,,,1806,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,866.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 3.0X40MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12443-MAIN,LOCAL,,,,,1806,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,866.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X52MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12444-MAIN,LOCAL,,,,,1806,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,866.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X52MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12444-MAIN,LOCAL,,,,,1806,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,866.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"Lap,Cholecystectomy",PX47562P,CDM,983,RC,47562,CPT,,,,,,,,983,,United Healthcare,All Payer,outpatient,88.2,,5782.04,percent of total billed charges,867.006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,408.3382,5040.74
"Sb Scope,to Ileum,Biopsy",PX44377F,CDM,750,RC,44377,CPT,,,,,,,,1770,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,867.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,735.258,1734.6
"Sb Scope,to Ileum,Biopsy",PX44377F,CDM,750,RC,44377,CPT,,,,,,,,1770,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,867.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,735.258,1734.6
"Sb Scope,to Ileum,Biopsy",PX44377F,CDM,750,RC,44377,CPT,,,,,,,,1770,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,867.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,735.258,1734.6
Anus Surgery Procedure Unlisted,PX46999P,CDM,983,RC,46999,CPT,,,,,,,,953,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,868.183,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,395.8762,927.5549
"Genital Surg Proc,Male Unlisted",PX55899P,CDM,983,RC,55899,CPT,,,,,,,,953,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,868.183,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,215.91,927.5549
I&D Perirectal Abscess,PX46040P,CDM,983,RC,46040,CPT,,,,,,,,953,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,868.183,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,395.8762,1030.93
"Exc Skn Beig1.1-2cm Face,Facil",PX11442P,CDM,983,RC,11442,CPT,,,,,,,,886,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,868.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.15,868.28
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,71288020185,NDC,5,ML,1021.7,,First Health,Commercial,both,85,,999999999,percent of total billed charges,868.445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,424.41418,1239.6216
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060002,NDC,2,ML,953.57,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,868.70227,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.11,934.4986
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060010,NDC,2,ML,953.57,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,868.70227,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.11,934.4986
clobetasol 0.05 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,21922001707,NDC,60,GR,1810.35,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,868.968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clobetasol 0.05 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,21922001707,NDC,60,GR,1810.35,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,868.968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
BUPivacaine liposome 1.3 % Suspension 20 mL Vial,C9290.01,CDM,636,RC,C9290,HCPCS,,,,65250026604,NDC,10,ML,976.43,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,869.0227,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,405.609022,956.9014
"Remv Foreign Body,Knee/Thigh,Deep",PX27372P,CDM,983,RC,27372,CPT,,,,,,,,954,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,869.094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,396.2916,2482.37
ciprofloxacin-dexAMETHasone 0.3-0.1 % Suspension 7.5 mL Bottle,25000000,CDM,250,RC,,,,,,43598032675,NDC,7.5,ML,976.53,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,869.1117,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
agalsidase beta 5 MG Recon Soln 1 Each Vial,J0180.01,CDM,636,RC,J0180,HCPCS,,,,58468004101,NDC,1,EA,1717.68,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,869.14608,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,200.2,1683.3264
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505P,CDM,983,RC,25505,CPT,,,,,,,,977,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,869.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,405.8458,1404.08
Heart/Lung Resuscitation (Cpr),PX92950P,CDM,983,RC,92950,CPT,,,,,,,,1023,,First Health,Commercial,both,85,,999999999,percent of total billed charges,869.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.21,995.6859
Removal of Hemorrhoid Clot,PX46320F,CDM,510,RC,46320,CPT,,,,,,,,2027,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,869.583,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,842.0158,1986.46
"Closed Rx Shldr Disloc,Anesthesia",PX23655F,CDM,510,RC,23655,CPT,,,,,,,,1776,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,870.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,737.7504,1740.48
"Closed Rx Shldr Disloc,Anesthesia",PX23655F,CDM,510,RC,23655,CPT,,,,,,,,1776,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,870.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,737.7504,1740.48
"Closed Rx Shldr Disloc,Anesthesia",PX23655F,CDM,510,RC,23655,CPT,,,,,,,,1776,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,870.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,737.7504,1740.48
"Sigmoidoscopy,Biopsy",PX45331F,CDM,750,RC,45331,CPT,,,,,,,,1776,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,870.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,737.7504,1740.48
"Sigmoidoscopy,Biopsy",PX45331F,CDM,750,RC,45331,CPT,,,,,,,,1776,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,870.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,737.7504,1740.48
"Sigmoidoscopy,Biopsy",PX45331F,CDM,750,RC,45331,CPT,,,,,,,,1776,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,870.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,737.7504,1740.48
STAPLER SUREFORM 45 SPU IS4000,27200000,CDM,272,RC,,,,12794-MAIN,LOCAL,,,,,888,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,870.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Remove Hemorrhoids & Fissure,PX46257F,CDM,510,RC,46257,CPT,,,,,,,,1141,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,870.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,263.74,870.28
Remove Hemorrhoids & Fissure,PX46257F,CDM,510,RC,46257,CPT,,,,,,,,1141,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,870.28,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,263.74,870.28
Remove Hemorrhoids & Fissure,PX46257P,CDM,983,RC,46257,CPT,,,,,,,,615,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,870.28,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,263.74,870.28
Remove Hemorrhoids & Fissure,PX46257P,CDM,983,RC,46257,CPT,,,,,,,,615,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,870.28,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,263.74,870.28
MICA SCREW 4.0X32MM FULLY THREADED STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12894-MAIN,LOCAL,,,,,2096,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,870.6784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 3.0X38MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12984-MAIN,LOCAL,,,,,2096,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,870.6784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X42MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12948-MAIN,LOCAL,,,,,2096,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,870.6784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X44MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12893-MAIN,LOCAL,,,,,2096,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,870.6784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X56MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12947-MAIN,LOCAL,,,,,2096,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,870.6784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573P,CDM,983,RC,36573,CPT,,,,,,,,1721,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,870.826,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,714.9034,1675.0493
"Treat Thumb Disloc,Manipulatn",PX26641F,CDM,510,RC,26641,CPT,,,,,,,,1721,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,870.826,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1686.58
Incise External Hemorrhoid,PX46083P,CDM,983,RC,46083,CPT,,,,,,,,956,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,870.916,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,215.91,930.4748
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310002,NDC,0.528,ML,894.9,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,871.00617,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.22,877.002
Drain Skin Abscess Complic,PX10061F,CDM,510,RC,10061,CPT,,,,,,,,889,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,871.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,871.22
Inc/Drain Peritonsil Abscess,PX42700P,CDM,983,RC,42700,CPT,,,,,,,,889,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,871.22,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,86.38,871.22
Insert Non-Tunnel Cv Catheter >5 Years,PX36556F,CDM,510,RC,36556,CPT,,,,,,,,1025,,First Health,Commercial,both,85,,999999999,percent of total billed charges,871.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,425.785,2784.63
"Remv Foot Foreign Body,Subcutaneous",PX28190F,CDM,510,RC,28190,CPT,,,,,,,,1025,,First Health,Commercial,both,85,,999999999,percent of total billed charges,871.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,425.785,1004.5
fluticasone 220 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,66993008096,NDC,12,GR,1760.13,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,871.26435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone-salmeterol 250-50 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069604,NDC,14,EA,1025.13,,First Health,Commercial,both,85,,999999999,percent of total billed charges,871.3605,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone furoate-vilanterol 100-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173085914,NDC,28,EA,1025.38,,First Health,Commercial,both,85,,999999999,percent of total billed charges,871.573,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Closed Rx Shldr Disloc,Anesthesia",PX23655F,CDM,510,RC,23655,CPT,,,,,,,,1776,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,871.67,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,260.25,871.67
"Closed Rx Shldr Disloc,Anesthesia",PX23655F,CDM,510,RC,23655,CPT,,,,,,,,1776,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,871.67,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,260.25,871.67
"Closed Rx Shldr Disloc,Anesthesia",PX23655P,CDM,983,RC,23655,CPT,,,,,,,,1421,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,871.67,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,260.25,1392.58
"Closed Rx Shldr Disloc,Anesthesia",PX23655P,CDM,983,RC,23655,CPT,,,,,,,,1421,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,871.67,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,260.25,1392.58
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,115169449,NDC,1,EA,889.46,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,871.6708,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54505010202,NDC,1,EA,889.46,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,871.6708,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
MESH VENTRALIGHT ECHO 2.0 POSITIONING 15CM ROUND,C1781,CDM,278,RC,C1781,HCPCS,,12842-MAIN,LOCAL,,,,,1816,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,871.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
MESH VENTRALIGHT ECHO 2.0 POSITIONING 15CM ROUND,C1781,CDM,278,RC,C1781,HCPCS,,12842-MAIN,LOCAL,,,,,1816,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,871.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Upper GI Endoscopy,Ctrl Bleed",PX43255F,CDM,750,RC,43255,CPT,,,,,,,,1723,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,871.838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,715.7342,1688.54
"Closed Rx Bimalleolar Fx,Manip",PX27810F,CDM,510,RC,27810,CPT,,,,,,,,1026,,First Health,Commercial,both,85,,999999999,percent of total billed charges,872.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,426.2004,1404.08
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409422801,NDC,100,ML,1026,,First Health,Commercial,both,85,,999999999,percent of total billed charges,872.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
"Removal Anal Fistula,Subcutaneous",PX46270P,CDM,983,RC,46270,CPT,,,,,,,,980,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,872.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,407.092,2452.93
Tube Thoracostomy Inc Wtr Seal,PX32551F,CDM,510,RC,32551,CPT,,,,,,,,989,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,872.298,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,410.8306,1399.13
Level 3 Additional Procedure,PX36000082,CDM,360,RC,,,,,,,,,,2100,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,872.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,872.34,2058
Or Level 3,PX36000003,CDM,360,RC,,,,,,,,,,2100,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,872.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,872.34,2058
clobetasol 0.05 % Cream 60 g Tube,63700001,CDM,250,RC,,,,,,168030160,NDC,60,GR,989.25,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,872.5185,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180F,CDM,510,RC,44180,CPT,,,,,,,,1763,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,872.685,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,732.3502,5040.74
"Lap,Inguinal Hernia Repr,Recur",PX49651P,CDM,983,RC,49651,CPT,,,,,,,,2035,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,873.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,845.339,5040.74
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200001,NDC,0.5,ML,980.99,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,873.0811,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,264.67,961.3702
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200002,NDC,0.5,ML,980.99,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,873.0811,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,264.67,961.3702
Exc Skin Benig >4cm Remaindr Body,PX11426P,CDM,983,RC,11426,CPT,,,,,,,,981,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,873.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,407.5074,2482.37
"Needle Biopsy,Muscle",PX20206P,CDM,983,RC,20206,CPT,,,,,,,,1028,,First Health,Commercial,both,85,,999999999,percent of total billed charges,873.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,427.0312,1416.38
STAPLER SUREFORM 60 SPU IS4000,27200000,CDM,272,RC,,,,12086-MAIN,LOCAL,,,,,991,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,874.062,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Room Rate General Iso,PX12000001,CDM,120,RC,,,,,,,,,,1822,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,874.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,756.8588,1785.56
Room Rate General Iso,PX12000001,CDM,120,RC,,,,,,,,,,1822,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,874.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,756.8588,1785.56
"Biopsy of Prostate,Needle/Punch",PX55700F,CDM,510,RC,55700,CPT,,,,,,,,2039,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,874.731,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,847.0006,1998.22
"Lap,Cholecystectomy",PX47562P,CDM,983,RC,47562,CPT,,,,,,,,983,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,874.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,408.3382,5040.74
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527197174,NDC,4,ML,960.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,875.0155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,63323067305,NDC,5,ML,1029.71,,First Health,Commercial,both,85,,999999999,percent of total billed charges,875.2535,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.08296,1009.1158
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545F,CDM,510,RC,23545,CPT,,,,,,,,961,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,875.471,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,941.78
"Closed Rx Radial Head/Neck Fx,Manip",PX24655F,CDM,510,RC,24655,CPT,,,,,,,,1750,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,875.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,259.6,972.67
"Closed Rx Radial Head/Neck Fx,Manip",PX24655P,CDM,983,RC,24655,CPT,,,,,,,,1824,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,875.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,259.6,1787.52
"I&D Perianal Abscess,Superficial",PX46050P,CDM,983,RC,46050,CPT,,,,,,,,993,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,875.826,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,412.4922,966.4869
"Up GI Endoscopy,Ball Dil,30mm",PX43249P,CDM,983,RC,43249,CPT,,,,,,,,1731,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,875.886,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,742.599,3257.54
MIS STERILE INSTRUMENT PACK WITH BLADE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12432-MAIN,LOCAL,,,,,900,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,875.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505F,CDM,510,RC,24505,CPT,,,,,,,,2109,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,876.0786,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,876.0786,2066.82
"Sb Scope,to Ileum,Biopsy",PX44377F,CDM,750,RC,44377,CPT,,,,,,,,1770,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,876.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,735.258,1734.6
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606P,CDM,983,RC,11606,CPT,,,,,,,,2044,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,876.876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,849.0776,1989.4252
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310002,NDC,0.528,ML,894.9,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,877.002,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,30.22,877.002
Debride Skin/Tissue,PX11042P,CDM,983,RC,11042,CPT,,,,,,,,995,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,877.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,968.4335
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151F,CDM,510,RC,13151,CPT,,,,,,,,1143,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,877.89,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,173.43,877.89
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151P,CDM,983,RC,13151,CPT,,,,,,,,1177,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,877.89,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,173.43,1153.46
RESTRATA WOUND MATRIX 2.5CM X 2.5CM TOTAL 6.25CM,27200000,CDM,272,RC,A2007,HCPCS,,11733-MAIN,LOCAL,,,,,1829,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,877.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RESTRATA WOUND MATRIX 2.5CM X 2.5CM TOTAL 6.25CM,27200000,CDM,272,RC,A2007,HCPCS,,11733-MAIN,LOCAL,,,,,1829,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,877.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604F,CDM,510,RC,11604,CPT,,,,,,,,964,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,878.204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,400.4456,944.72
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561P,CDM,983,RC,36561,CPT,,,,,,,,1736,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,878.416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,721.1344,2784.63
HERNIA PATCH VENTRALEX SMALL,C1781,CDM,278,RC,C1781,HCPCS,,10203-MAIN,LOCAL,,,,,995.96,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,878.43672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Excis Tendn/Capsule Lesn,Toes",PX28092F,CDM,510,RC,28092,CPT,,,,,,,,1234,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,878.59,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,172.55,878.59
"Excis Tendn/Capsule Lesn,Toes",PX28092P,CDM,983,RC,28092,CPT,,,,,,,,1913,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,878.59,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,172.55,1874.74
"Repair Ing Hernia,5+Y/O,Reducibl",PX49505P,CDM,983,RC,49505,CPT,,,,,,,,2048,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,878.592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,850.7392,3022.41
Reconstruc of Nail Bed,PX11760P,CDM,983,RC,11760,CPT,,,,,,,,903,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,878.8899,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,375.1062,878.8899
Place Needle in Vein,PX36000P,CDM,983,RC,36000,CPT,,,,,,,,1034,,First Health,Commercial,both,85,,999999999,percent of total billed charges,878.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,429.5236,1006.3922
Temporal Artery Ligatn or Bx,PX37609P,CDM,983,RC,37609,CPT,,,,,,,,965,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,879.115,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,400.861,1416.38
"Closed Rx Shldr Disloc,Anesthesia",PX23655F,CDM,510,RC,23655,CPT,,,,,,,,1776,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,879.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,737.7504,1740.48
"Sigmoidoscopy,Biopsy",PX45331F,CDM,750,RC,45331,CPT,,,,,,,,1776,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,879.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,737.7504,1740.48
Factor VIII (Ahg) 1-Stage,PX85240,CDM,300,RC,85240,CPT,,,,,,,,997,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,879.354,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.41,977.06
Peramivir 200 MG/20ML Solution 20 mL Vial,800000,CDM,,,,,,,,61364018101,NDC,20,ML,1832.6,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,879.648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Peramivir 200 MG/20ML Solution 20 mL Vial,800000,CDM,,,,,,,,61364018101,NDC,20,ML,1832.6,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,879.648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
"Inject Nerv Blck,Othr Periph Nerv",PX64450P,CDM,983,RC,64450,CPT,,,,,,,,904,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,879.8632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,375.5216,879.8632
"Closed Rx Weight Bear Dist Tib,Manip",PX27825P,CDM,983,RC,27825,CPT,,,,,,,,1796,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,880.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,746.0584,1748.0468
"Closed Rx Weight Bear Dist Tib,Manip",PX27825P,CDM,983,RC,27825,CPT,,,,,,,,1796,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,880.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,746.0584,1748.0468
"Closed Rx Weight Bear Dist Tib,Manip",PX27825P,CDM,983,RC,27825,CPT,,,,,,,,1796,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,880.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,746.0584,1748.0468
Tube Thoracostomy Inc Wtr Seal,PX32551F,CDM,510,RC,32551,CPT,,,,,,,,989,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,880.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,410.8306,1399.13
clobetasol 0.05 % Cream 60 g Tube,63700001,CDM,250,RC,,,,,,168030160,NDC,60,GR,989.25,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,880.4325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ULTRAGUIDE CTR SX-ONE MICROKNIFE 600112-001,27200000,CDM,272,RC,,,,13106-MAIN,LOCAL,,,,,2121,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,881.0634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,16714081501,NDC,5,ML,998.95,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,881.0739,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
"Amputation Metatarsal+Toe,Single",PX28810F,CDM,510,RC,28810,CPT,,,,,,,,930,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,881.35,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.21,881.35
"Amputation Metatarsal+Toe,Single",PX28810F,CDM,510,RC,28810,CPT,,,,,,,,930,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,881.35,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.21,881.35
"Amputation Metatarsal+Toe,Single",PX28810P,CDM,983,RC,28810,CPT,,,,,,,,620,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,881.35,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.21,881.35
"Amputation Metatarsal+Toe,Single",PX28810P,CDM,983,RC,28810,CPT,,,,,,,,620,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,881.35,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.21,881.35
STAPLER SUREFORM 60 SPU IS4000,27200000,CDM,272,RC,,,,12086-MAIN,LOCAL,,,,,991,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,881.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MIS STERILE INSTRUMENT PACK WITH BLADE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12432-MAIN,LOCAL,,,,,900,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,882,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121F,CDM,510,RC,13121,CPT,,,,,,,,948,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,882.74,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,161,882.74
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121P,CDM,983,RC,13121,CPT,,,,,,,,632,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,882.74,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,161,882.74
"Repair Umbilical Hern,5+Y/O,Reduc",PX49585F,CDM,510,RC,49585,CPT,,,,,,,,969,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,882.759,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,402.5226,949.62
"Close Rx Fingr Articular Fx,Manip",PX26742F,CDM,510,RC,26742,CPT,,,,,,,,1039,,First Health,Commercial,both,85,,999999999,percent of total billed charges,883.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,431.6006,1404.08
fluticasone 220 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173072020,NDC,12,GR,1746.36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,883.65816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"I&D Perianal Abscess,Superficial",PX46050P,CDM,983,RC,46050,CPT,,,,,,,,993,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,883.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,412.4922,966.4869
"Diagnostic Bone Marrow, Biopsy and Aspiration",PX38222F,CDM,761,RC,38222,CPT,,,,,,,,1748,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,884.488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,726.1192,2482.37
DYNABUNION PLATE STERILE INSTRUMENT KIT,27200000,CDM,272,RC,,,,12465-MAIN,LOCAL,,,,,1843,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,884.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNABUNION PLATE STERILE INSTRUMENT KIT,27200000,CDM,272,RC,,,,12465-MAIN,LOCAL,,,,,1843,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,884.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PROSTEP MICA SCREW 3.0X20MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12442-MAIN,LOCAL,,,,,1806,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,884.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 3.0X20MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12442-MAIN,LOCAL,,,,,1806,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,884.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 3.0X20MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12442-MAIN,LOCAL,,,,,1806,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,884.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 3.0X40MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12443-MAIN,LOCAL,,,,,1806,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,884.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 3.0X40MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12443-MAIN,LOCAL,,,,,1806,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,884.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 3.0X40MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12443-MAIN,LOCAL,,,,,1806,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,884.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X52MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12444-MAIN,LOCAL,,,,,1806,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,884.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X52MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12444-MAIN,LOCAL,,,,,1806,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,884.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X52MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12444-MAIN,LOCAL,,,,,1806,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,884.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Reconstruc of Nail Bed,PX11760P,CDM,983,RC,11760,CPT,,,,,,,,903,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,884.94,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,69.37,884.94
Remove Nasal Foreign Body,PX30300F,CDM,510,RC,30300,CPT,,,,,,,,972,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,885.492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,952.56
"Closed Rx Radial Head/Neck Fx,Manip",PX24655F,CDM,510,RC,24655,CPT,,,,,,,,1750,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,885.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,726.95,1715
"Fix Exten Tendon,Dorsum Fingr,Ea",PX26418F,CDM,510,RC,26418,CPT,,,,,,,,1750,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,885.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,726.95,1715
Debride Skin/Tissue,PX11042P,CDM,983,RC,11042,CPT,,,,,,,,995,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,885.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,968.4335
"Inject Nerv Blck,Othr Periph Nerv",PX64450P,CDM,983,RC,64450,CPT,,,,,,,,904,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,885.92,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.96,885.92
HERNIA PATCH VENTRALEX SMALL,C1781,CDM,278,RC,C1781,HCPCS,,10203-MAIN,LOCAL,,,,,995.96,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,886.4044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
ferumoxytol 510 MG/17ML Solution 17 mL Vial,Q0138.01,CDM,636,RC,Q0138,HCPCS,,,,781315401,NDC,17,ML,1846.91,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,886.5168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.32,1809.9718
ferumoxytol 510 MG/17ML Solution 17 mL Vial,Q0138.01,CDM,636,RC,Q0138,HCPCS,,,,781315401,NDC,17,ML,1846.91,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,886.5168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.32,1809.9718
Repair of Vagina,PX57200P,CDM,983,RC,57200,CPT,,,,,,,,1043,,First Health,Commercial,both,85,,999999999,percent of total billed charges,886.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,433.2622,2731.23
Exc Back Les Sc = 3 Cm,PX21931P,CDM,983,RC,21931,CPT,,,,,,,,2135,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,886.879,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,886.879,2077.9955
clobetasol 0.05 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,21922001707,NDC,60,GR,1810.35,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,887.0715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clobetasol 0.05 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,21922001707,NDC,60,GR,1810.35,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,887.0715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
clobetasol 0.05 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,21922001707,NDC,60,GR,1810.35,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,887.0715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Polysomnography, 4 or More",PX9581001,CDM,740,RC,95810,CPT,TC,,,,,,,4313,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,887.09,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,324.17,887.09
"Polysomnography, 4 or More",PX9581001,CDM,740,RC,95810,CPT,TC,,,,,,,4313,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,887.09,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,324.17,887.09
Abd Paracentesis W/Imaging(T),PX49083F,CDM,510,RC,49083,CPT,,,,,,,,1006,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,887.292,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,417.8924,985.88
Factor VIII (Ahg) 1-Stage,PX85240,CDM,300,RC,85240,CPT,,,,,,,,997,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,887.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.41,977.06
Lap Incis Hernia Reducible,PX49654P,CDM,983,RC,49654,CPT,,,,,,,,1044,,First Health,Commercial,both,85,,999999999,percent of total billed charges,887.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,433.6776,1016.1252
Apply Long Leg Cast,PX29345F,CDM,510,RC,29345,CPT,,,,,,,,912,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,887.6496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,234.62,893.76
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598030562,NDC,1,EA,912,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,887.6496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
Open Bx/Excision Inguinofemoral Nodes,PX38531F,CDM,510,RC,38531,CPT,,,,,,,,912,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,887.6496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,378.8448,3329.99
"Sigmoidoscopy,Remv Lesn,Snare",PX45338F,CDM,510,RC,45338,CPT,,,,,,,,2137,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,887.7098,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,887.7098,2094.26
"MRI,Lwrext,Jnt W/O+W/Cont",PX7372301,CDM,610,RC,73723,CPT,TC,,,,,,,1850,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2066.35
"MRI,Lwrext,Jnt W/O+W/Cont",PX7372301,CDM,610,RC,73723,CPT,TC,,,,,,,1850,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2066.35
REAMER FOR CROSS PLATES,27200000,CDM,272,RC,,,,12641-MAIN,LOCAL,,,,,1852,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,888.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
REAMER FOR CROSS PLATES,27200000,CDM,272,RC,,,,12641-MAIN,LOCAL,,,,,1852,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,888.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Closed Rx Weight Bear Dist Tib,Manip",PX27825P,CDM,983,RC,27825,CPT,,,,,,,,1796,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,889.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,746.0584,1748.0468
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,16714081501,NDC,5,ML,998.95,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,889.0655,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
"Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601P,CDM,983,RC,11601,CPT,,,,,,,,1046,,First Health,Commercial,both,85,,999999999,percent of total billed charges,889.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,434.5084,1018.0718
Fac/Ligation of Hemorrhoid(S),PX46221F,CDM,510,RC,46221,CPT,,,,,,,,1046,,First Health,Commercial,both,85,,999999999,percent of total billed charges,889.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,434.5084,1025.08
BUPivacaine liposome 1.3 % Suspension 20 mL Vial,C9290.01,CDM,636,RC,C9290,HCPCS,,,,65250026604,NDC,10,ML,976.43,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,889.52773,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,405.609022,956.9014
Emergency Level IV Visit,PX99284P,CDM,981,RC,99284,CPT,,,,,,,,914,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,290.657994,percent of total billed charges,889.5962,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,379.6756,889.5962
ciprofloxacin-dexAMETHasone 0.3-0.1 % Suspension 7.5 mL Bottle,25000000,CDM,250,RC,,,,,,43598032675,NDC,7.5,ML,976.53,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,889.61883,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
MESH VENTRALIGHT ECHO 2.0 POSITIONING 15CM ROUND,C1781,CDM,278,RC,C1781,HCPCS,,12842-MAIN,LOCAL,,,,,1816,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,196.035,percent of total billed charges,889.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
MESH VENTRALIGHT ECHO 2.0 POSITIONING 15CM ROUND,C1781,CDM,278,RC,C1781,HCPCS,,12842-MAIN,LOCAL,,,,,1816,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,889.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
MESH VENTRALIGHT ECHO 2.0 POSITIONING 15CM ROUND,C1781,CDM,278,RC,C1781,HCPCS,,12842-MAIN,LOCAL,,,,,1816,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,889.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,781307912,NDC,5,ML,1854.23,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,890.0304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.74,1938.2734
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,781307912,NDC,5,ML,1854.23,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,890.0304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.74,1938.2734
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505P,CDM,983,RC,25505,CPT,,,,,,,,977,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,890.047,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,405.8458,1404.08
filgrastim-sndz 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314031801,NDC,0.5,ML,1047.2,,First Health,Commercial,both,85,,999999999,percent of total billed charges,890.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,1630.2692
fluticasone 220 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,66993008096,NDC,12,GR,1760.13,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,890.62578,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180F,CDM,510,RC,44180,CPT,,,,,,,,1763,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,892.078,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,732.3502,5040.74
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830F,CDM,510,RC,15830,CPT,,,,,,,,2080,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,892.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,864.032,5696.92
esmolol 2500 MG/250ML Solution 250 mL Flex Cont,J1805.01,CDM,636,RC,J1805,HCPCS,,,,10019067010,NDC,250,ML,1011.8,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,892.4076,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.24,991.564
I&D Perirectal Abscess,PX46040F,CDM,510,RC,46040,CPT,,,,,,,,1430,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,892.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,264.62,1158.77
I&D Perirectal Abscess,PX46040P,CDM,983,RC,46040,CPT,,,,,,,,953,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,892.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,264.62,1158.77
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,781325394,NDC,1,EA,1049.95,,First Health,Commercial,both,85,,999999999,percent of total billed charges,892.4575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,72485020101,NDC,1,EA,1049.95,,First Health,Commercial,both,85,,999999999,percent of total billed charges,892.4575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
"Complex Drainage, Wound",PX10180F,CDM,510,RC,10180,CPT,,,,,,,,1050,,First Health,Commercial,both,85,,999999999,percent of total billed charges,892.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,436.17,2482.37
Red Blood Cells Unit,PXP9021,CDM,390,RC,P9021,HCPCS,,,,,,,,1050,,First Health,Commercial,both,85,,999999999,percent of total billed charges,892.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.17,1029
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016410,NDC,1,ML,917.08,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,892.593964,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.66,898.7384
"Removal Anal Fistula,Subcutaneous",PX46270P,CDM,983,RC,46270,CPT,,,,,,,,980,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,892.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,407.092,2452.93
Room Rate General Iso,PX12000001,CDM,120,RC,,,,,,,,,,1822,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,892.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,756.8588,1785.56
Room Rate General Iso,PX12000001,CDM,120,RC,,,,,,,,,,1822,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,892.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,756.8588,1785.56
Room Rate General Iso,PX12000001,CDM,120,RC,,,,,,,,,,1822,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,892.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,756.8588,1785.56
Exs Tumor Arm/Elbow Sc 3cm>,PX24071F,CDM,510,RC,24071,CPT,,,,,,,,1860,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,892.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,772.644,2482.37
Exs Tumor Arm/Elbow Sc 3cm>,PX24071F,CDM,510,RC,24071,CPT,,,,,,,,1860,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,892.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,772.644,2482.37
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING4X6,C1781,CDM,278,RC,C1781,HCPCS,,12505-MAIN,LOCAL,,,,,1860,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,892.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING4X6,C1781,CDM,278,RC,C1781,HCPCS,,12505-MAIN,LOCAL,,,,,1860,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,892.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Correct Bunion,Metatarsal Osteotomy",PX28296P,CDM,983,RC,28296,CPT,,,,,,,,2150,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,893.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,893.11,2827.75
MINIBUNION INSTRUMENT KIT,27200000,CDM,278,RC,C1713,HCPCS,,11668-MAIN,LOCAL,,,,,1860.65,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,893.112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MINIBUNION INSTRUMENT KIT,27200000,CDM,278,RC,C1713,HCPCS,,11668-MAIN,LOCAL,,,,,1860.65,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,893.112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
mometasone - formoterol 100-5 MCG/ACT Aerosol 8.8 g Inhaler,25000000,CDM,250,RC,,,,,,85720607,NDC,8.8,GR,918.07,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,893.557531,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
mometasone - formoterol 200-5 MCG/ACT Aerosol 8.8 g Inhaler,25000000,CDM,250,RC,,,,,,85461005,NDC,8.8,GR,918.07,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,893.557531,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200001,NDC,0.5,ML,980.99,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,893.68189,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,264.67,961.3702
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200002,NDC,0.5,ML,980.99,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,893.68189,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,264.67,961.3702
Exc Skin Benig >4cm Remaindr Body,PX11426P,CDM,983,RC,11426,CPT,,,,,,,,981,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,893.691,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,407.5074,2482.37
Apply Long Leg Cast,PX29345F,CDM,510,RC,29345,CPT,,,,,,,,912,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,893.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,234.62,893.76
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598030562,NDC,1,EA,912,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,893.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
"Closed Rx Radial Head/Neck Fx,Manip",PX24655P,CDM,983,RC,24655,CPT,,,,,,,,1824,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,893.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,757.6896,1775.2992
"Closed Rx Radial Head/Neck Fx,Manip",PX24655P,CDM,983,RC,24655,CPT,,,,,,,,1824,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,893.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,757.6896,1775.2992
"Closed Rx Radial Head/Neck Fx,Manip",PX24655P,CDM,983,RC,24655,CPT,,,,,,,,1824,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,893.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,757.6896,1775.2992
Open Bx/Excision Inguinofemoral Nodes,PX38531F,CDM,510,RC,38531,CPT,,,,,,,,912,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,893.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,378.8448,3329.99
"Repair Lip,>1/2 Vert Height",PX40654F,CDM,510,RC,40654,CPT,,,,,,,,2467,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,893.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,269.41,1227.25
"Repair Lip,>1/2 Vert Height",PX40654P,CDM,983,RC,40654,CPT,,,,,,,,1329,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,893.81,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,269.41,1302.42
PROSTEP MICA SCREW 3.0X20MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12442-MAIN,LOCAL,,,,,1806,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,893.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 3.0X40MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12443-MAIN,LOCAL,,,,,1806,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,893.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X52MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12444-MAIN,LOCAL,,,,,1806,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,893.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"Percut Biopsy, Abdominal Mass",PX49180F,CDM,510,RC,49180,CPT,,,,,,,,2084,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,894.036,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,865.6936,2042.32
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569P,CDM,983,RC,36569,CPT,,,,,,,,1825,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,894.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,758.105,1776.2725
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569P,CDM,983,RC,36569,CPT,,,,,,,,1825,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,894.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,758.105,1776.2725
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569P,CDM,983,RC,36569,CPT,,,,,,,,1825,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,894.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,758.105,1776.2725
Exc Abd Les Sc < 3 Cm,PX22902P,CDM,983,RC,22902,CPT,,,,,,,,2086,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,894.894,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,866.5244,2030.3038
Part Remv Phalanx of Toe,PX28124F,CDM,510,RC,28124,CPT,,,,,,,,2155,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,895.187,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,895.187,2827.75
Abd Paracentesis W/Imaging(T),PX49083F,CDM,510,RC,49083,CPT,,,,,,,,1006,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,895.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,417.8924,985.88
"Lap,Cholecystectomy",PX47562P,CDM,983,RC,47562,CPT,,,,,,,,983,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,895.513,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,408.3382,5040.74
"Sb Scope,to Ileum,Biopsy",PX44377F,CDM,750,RC,44377,CPT,,,,,,,,1770,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,895.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,735.258,1734.6
Emergency Level IV Visit,PX99284P,CDM,981,RC,99284,CPT,,,,,,,,914,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,895.72,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,74.2,895.72
Facility Emergency Level IV Visit,PX99284F,CDM,450,RC,99284,CPT,,,,,,,,1054,,First Health,Commercial,both,85,,999999999,percent of total billed charges,895.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.93,1032.92
belimumab 120 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010101,NDC,1,EA,1015.95,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,896.0679,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.72,3453.2358
clobetasol 0.05 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,21922001707,NDC,60,GR,1810.35,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,896.12325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
RESTRATA WOUND MATRIX 2.5CM X 2.5CM TOTAL 6.25CM,27200000,CDM,272,RC,A2007,HCPCS,,11733-MAIN,LOCAL,,,,,1829,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,896.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RESTRATA WOUND MATRIX 2.5CM X 2.5CM TOTAL 6.25CM,27200000,CDM,272,RC,A2007,HCPCS,,11733-MAIN,LOCAL,,,,,1829,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,896.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RESTRATA WOUND MATRIX 2.5CM X 2.5CM TOTAL 6.25CM,27200000,CDM,272,RC,A2007,HCPCS,,11733-MAIN,LOCAL,,,,,1829,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,896.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Peramivir 200 MG/20ML Solution 20 mL Vial,800000,CDM,,,,,,,,61364018101,NDC,20,ML,1832.6,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,897.974,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Peramivir 200 MG/20ML Solution 20 mL Vial,800000,CDM,,,,,,,,61364018101,NDC,20,ML,1832.6,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,897.974,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Peramivir 200 MG/20ML Solution 20 mL Vial,800000,CDM,,,,,,,,61364018101,NDC,20,ML,1832.6,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,897.974,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
"Closed Rx Bimalleolar Fx,Manip",PX27810P,CDM,983,RC,27810,CPT,,,,,,,,1057,,First Health,Commercial,both,85,,999999999,percent of total billed charges,898.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,439.0778,1404.08
"Colonoscopy,Biopsy",PX45380F,CDM,750,RC,45380,CPT,,,,,,,,2465,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,898.65,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.59,898.65
"Colonoscopy,Biopsy",PX45380P,CDM,983,RC,45380,CPT,,,,,,,,2539,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,898.65,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.59,2488.22
"Closed Rx Shldr Disloc,Anesthesia",PX23655F,CDM,510,RC,23655,CPT,,,,,,,,1776,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,898.656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,737.7504,1740.48
"Sigmoidoscopy,Biopsy",PX45331F,CDM,750,RC,45331,CPT,,,,,,,,1776,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,898.656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,737.7504,1740.48
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016410,NDC,1,ML,917.08,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,898.7384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.66,898.7384
MESH VENTRALIGHT ECHO 2.0 POSITIONING 15CM ROUND,C1781,CDM,278,RC,C1781,HCPCS,,12842-MAIN,LOCAL,,,,,1816,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,898.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Initial Repair of Entrapped Hernia of Abdomen, Less Than 3 Cm in Length",PX49592,CDM,982,RC,49592,CPT,,,,,,,,2164,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,898.9256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,898.9256,5040.74
CT Chest Spine W/Dye,PX7212901,CDM,350,RC,72129,CPT,TC,,,,,,,2096,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,899.184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,2054.08
MICA SCREW 4.0X32MM FULLY THREADED STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12894-MAIN,LOCAL,,,,,2096,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,899.184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 3.0X38MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12984-MAIN,LOCAL,,,,,2096,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,899.184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X42MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12948-MAIN,LOCAL,,,,,2096,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,899.184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X44MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12893-MAIN,LOCAL,,,,,2096,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,899.184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X56MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12947-MAIN,LOCAL,,,,,2096,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,899.184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
mometasone - formoterol 100-5 MCG/ACT Aerosol 8.8 g Inhaler,25000000,CDM,250,RC,,,,,,85720607,NDC,8.8,GR,918.07,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,899.7086,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
mometasone - formoterol 200-5 MCG/ACT Aerosol 8.8 g Inhaler,25000000,CDM,250,RC,,,,,,85461005,NDC,8.8,GR,918.07,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,899.7086,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
esmolol 2500 MG/250ML Solution 250 mL Flex Cont,J1805.01,CDM,636,RC,J1805,HCPCS,,,,10019067010,NDC,250,ML,1011.8,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,900.502,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.24,991.564
Level 3 Additional Procedure,PX36000082,CDM,360,RC,,,,,,,,,,2100,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,900.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,872.34,2058
Or Level 3,PX36000003,CDM,360,RC,,,,,,,,,,2100,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,900.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,872.34,2058
Tube Thoracostomy Inc Wtr Seal,PX32551F,CDM,510,RC,32551,CPT,,,,,,,,989,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,900.979,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,410.8306,1399.13
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,71288020185,NDC,5,ML,1021.7,,United Healthcare,All Payer,outpatient,88.2,,123.966,percent of total billed charges,901.1394,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,424.41418,1239.6216
clobetasol 0.05 % Cream 60 g Tube,63700001,CDM,250,RC,,,,,,168030160,NDC,60,GR,989.25,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,901.20675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x3CM 9SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12766-MAIN,LOCAL,,,,,2171,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,901.8334,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
"Critical Care, E/M 30-74 Minutes",PX99291P,CDM,983,RC,99291,CPT,,,,,,,,1061,,First Health,Commercial,both,85,,999999999,percent of total billed charges,901.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,440.7394,1032.6713
Room Rate General Iso,PX12000001,CDM,120,RC,,,,,,,,,,1822,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,901.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,756.8588,1785.56
nivolumab 40 MG/4ML Solution 4 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377211,NDC,4,ML,2171.7,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,902.12418,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.5,12769.6548
Heart/Lung Resuscitation (Cpr),PX92950P,CDM,983,RC,92950,CPT,,,,,,,,1023,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,902.286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.21,995.6859
STAPLER SUREFORM 60 SPU IS4000,27200000,CDM,272,RC,,,,12086-MAIN,LOCAL,,,,,991,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,902.801,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Closed Rx Radial Head/Neck Fx,Manip",PX24655P,CDM,983,RC,24655,CPT,,,,,,,,1824,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,902.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,757.6896,1775.2992
DYNABUNION PLATE STERILE INSTRUMENT KIT,27200000,CDM,272,RC,,,,12465-MAIN,LOCAL,,,,,1843,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,903.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNABUNION PLATE STERILE INSTRUMENT KIT,27200000,CDM,272,RC,,,,12465-MAIN,LOCAL,,,,,1843,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,903.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNABUNION PLATE STERILE INSTRUMENT KIT,27200000,CDM,272,RC,,,,12465-MAIN,LOCAL,,,,,1843,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,903.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569P,CDM,983,RC,36569,CPT,,,,,,,,1825,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,903.375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,758.105,1776.2725
Insert Non-Tunnel Cv Catheter >5 Years,PX36556F,CDM,510,RC,36556,CPT,,,,,,,,1025,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,904.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,425.785,2784.63
"Remv Foot Foreign Body,Subcutaneous",PX28190F,CDM,510,RC,28190,CPT,,,,,,,,1025,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,904.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,425.785,1004.5
fluticasone-salmeterol 250-50 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069604,NDC,14,EA,1025.13,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,904.16466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
belimumab 120 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010101,NDC,1,EA,1015.95,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,904.1955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.72,3453.2358
fluticasone furoate-vilanterol 100-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173085914,NDC,28,EA,1025.38,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,904.38516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"I&D Perianal Abscess,Superficial",PX46050P,CDM,983,RC,46050,CPT,,,,,,,,993,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,904.623,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,412.4922,966.4869
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505F,CDM,510,RC,24505,CPT,,,,,,,,2109,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,904.761,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,876.0786,2066.82
"Closed Rx Bimalleolar Fx,Manip",PX27810F,CDM,510,RC,27810,CPT,,,,,,,,1026,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,904.932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,426.2004,1404.08
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409422801,NDC,100,ML,1026,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,904.932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
ferumoxytol 510 MG/17ML Solution 17 mL Vial,Q0138.01,CDM,636,RC,Q0138,HCPCS,,,,781315401,NDC,17,ML,1846.91,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,904.9859,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.32,1809.9718
ferumoxytol 510 MG/17ML Solution 17 mL Vial,Q0138.01,CDM,636,RC,Q0138,HCPCS,,,,781315401,NDC,17,ML,1846.91,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,904.9859,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.32,1809.9718
ferumoxytol 510 MG/17ML Solution 17 mL Vial,Q0138.01,CDM,636,RC,Q0138,HCPCS,,,,781315401,NDC,17,ML,1846.91,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,904.9859,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.32,1809.9718
"Amputation Metatarsal+Toe,Single",PX28810F,CDM,510,RC,28810,CPT,,,,,,,,930,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,905.169,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.322,2827.75
Colonoscopy,PX44388F,CDM,750,RC,44388,CPT,,,,,,,,930,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,905.169,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.322,911.4
RESTRATA WOUND MATRIX 2.5CM X 2.5CM TOTAL 6.25CM,27200000,CDM,272,RC,A2007,HCPCS,,11733-MAIN,LOCAL,,,,,1829,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,905.355,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Treat Thumb Disloc,Manipulatn",PX26641F,CDM,510,RC,26641,CPT,,,,,,,,1721,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,905.57,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.07,905.57
"Treat Thumb Disloc,Manipulatn",PX26641P,CDM,983,RC,26641,CPT,,,,,,,,1902,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,905.57,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.07,1863.96
Fac/Exc Skn Beni 0.6-1cm Remain Bdy,PX11421F,CDM,510,RC,11421,CPT,,,,,,,,931,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,906.1423,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.7374,912.38
Fac/Exc Skn Bngn3.1-4cm Remain Bdy,PX11424F,CDM,510,RC,11424,CPT,,,,,,,,931,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,906.1423,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.7374,1416.38
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034F,CDM,510,RC,12034,CPT,,,,,,,,931,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,906.1423,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,912.38
"Repair Umbilical Hern,5+Y/O,Strang",PX49587P,CDM,983,RC,49587,CPT,,,,,,,,2182,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,906.4028,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,906.4028,2123.7406
Lap Paraesophag Hern Repair,PX43281,CDM,982,RC,43281,CPT,,,,,,,,5950,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,906.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,906.42,5831
Lap Paraesophag Hern Repair,PX43281,CDM,982,RC,43281,CPT,,,,,,,,5950,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,906.42,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,906.42,5831
Debride Skin/Tissue,PX11042P,CDM,983,RC,11042,CPT,,,,,,,,995,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,906.445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,968.4335
"MRI,Lwrext,Jnt W/O+W/Cont",PX7372301,CDM,610,RC,73723,CPT,TC,,,,,,,1850,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,906.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2066.35
"MRI,Lwrext,Jnt W/O+W/Cont",PX7372301,CDM,610,RC,73723,CPT,TC,,,,,,,1850,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,906.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2066.35
"MRI,Lwrext,Jnt W/O+W/Cont",PX7372301,CDM,610,RC,73723,CPT,TC,,,,,,,1850,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,906.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2066.35
Sleep Staging 4 + Pap,PX9581126,CDM,982,RC,95811,CPT,26,,,,,,,1850,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,906.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,768.49,1800.605
Sleep Staging 4 + Pap,PX9581126,CDM,982,RC,95811,CPT,26,,,,,,,1850,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,906.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,768.49,1800.605
Sleep Staging 4 + Pap,PX9581126,CDM,982,RC,95811,CPT,26,,,,,,,1850,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,906.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,768.49,1800.605
"Needle Biopsy,Muscle",PX20206P,CDM,983,RC,20206,CPT,,,,,,,,1028,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,906.696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,427.0312,1416.38
Debride Skin/Tissue,PX11042F,CDM,510,RC,11042,CPT,,,,,,,,1067,,First Health,Commercial,both,85,,999999999,percent of total billed charges,906.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1045.66
Incise Finger Tendon Sheath,PX26055P,CDM,983,RC,26055,CPT,,,,,,,,932,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,706.1,percent of total billed charges,907.1156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,387.1528,1404.08
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,64950036204,NDC,4,ML,1067.22,,First Health,Commercial,both,85,,999999999,percent of total billed charges,907.137,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
Peramivir 200 MG/20ML Solution 20 mL Vial,800000,CDM,,,,,,,,61364018101,NDC,20,ML,1832.6,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,907.137,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Lap Rpr Vent Umbilical Hernia,PX49652F,CDM,510,RC,49652,CPT,,,,,,,,1890,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,907.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,785.106,1852.2
Lap Rpr Vent Umbilical Hernia,PX49652F,CDM,510,RC,49652,CPT,,,,,,,,1890,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,907.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,785.106,1852.2
HERNIA PATCH VENTRALEX SMALL,C1781,CDM,278,RC,C1781,HCPCS,,10203-MAIN,LOCAL,,,,,995.96,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,907.31956,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
REAMER FOR CROSS PLATES,27200000,CDM,272,RC,,,,12641-MAIN,LOCAL,,,,,1852,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,907.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
REAMER FOR CROSS PLATES,27200000,CDM,272,RC,,,,12641-MAIN,LOCAL,,,,,1852,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,907.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
REAMER FOR CROSS PLATES,27200000,CDM,272,RC,,,,12641-MAIN,LOCAL,,,,,1852,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,907.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Lap Paraesophag Hern Repair,PX43281,CDM,982,RC,43281,CPT,,,,,,,,5950,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,907.51,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,906.42,5831
"Lap,Inguinal Hernia Repr,Initial",PX49650F,CDM,510,RC,49650,CPT,,,,,,,,1076,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,907.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.65,907.64
"Lap,Inguinal Hernia Repr,Initial",PX49650F,CDM,510,RC,49650,CPT,,,,,,,,1076,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,907.64,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.65,907.64
"Lap,Inguinal Hernia Repr,Initial",PX49650P,CDM,983,RC,49650,CPT,,,,,,,,717,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,907.64,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.65,907.64
"Lap,Inguinal Hernia Repr,Initial",PX49650P,CDM,983,RC,49650,CPT,,,,,,,,717,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,907.64,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,262.65,907.64
Biopsy Synovium I-P Jt,PX26110,CDM,983,RC,26110,CPT,,,,,,,,933,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,908.0889,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,387.5682,1404.08
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,63323067305,NDC,5,ML,1029.71,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,908.20422,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.08296,1009.1158
Factor VIII (Ahg) 1-Stage,PX85240,CDM,300,RC,85240,CPT,,,,,,,,997,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,908.267,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.41,977.06
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,781307912,NDC,5,ML,1854.23,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,908.5727,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.74,1938.2734
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,781307912,NDC,5,ML,1854.23,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,908.5727,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.74,1938.2734
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,781307912,NDC,5,ML,1854.23,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,908.5727,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.74,1938.2734
"Closed Rx Weight Bear Dist Tib,Manip",PX27825P,CDM,983,RC,27825,CPT,,,,,,,,1796,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,908.776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,746.0584,1748.0468
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,71288020185,NDC,5,ML,1021.7,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,909.313,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,424.41418,1239.6216
fluticasone-umeclidin-vilant 100-62.5-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173088714,NDC,28,EA,1894.99,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,909.5952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone-umeclidin-vilant 100-62.5-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173088714,NDC,28,EA,1894.99,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,909.5952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ULTRAGUIDE CTR SX-ONE MICROKNIFE 600112-001,27200000,CDM,272,RC,,,,13106-MAIN,LOCAL,,,,,2121,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,909.909,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,16714081501,NDC,5,ML,998.95,,Medica,Commercial,both,91.1,,51.072,percent of total billed charges,910.04345,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
"Bone Scan, Whole Body",PX7830601,CDM,341,RC,78306,CPT,TC,,,,,,,1896,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,910.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,360.31,1858.08
"Bone Scan, Whole Body",PX7830601,CDM,341,RC,78306,CPT,TC,,,,,,,1896,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,910.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,360.31,1858.08
Heart/Lung Resuscitation (Cpr),PX92950P,CDM,983,RC,92950,CPT,,,,,,,,1023,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,910.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.21,995.6859
"Amputation Metatarsal+Toe,Single",PX28810F,CDM,510,RC,28810,CPT,,,,,,,,930,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,911.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.322,2827.75
Colonoscopy,PX44388F,CDM,750,RC,44388,CPT,,,,,,,,930,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,911.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.322,911.4
Exs Tumor Arm/Elbow Sc 3cm>,PX24071F,CDM,510,RC,24071,CPT,,,,,,,,1860,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,911.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,772.644,2482.37
Exs Tumor Arm/Elbow Sc 3cm>,PX24071F,CDM,510,RC,24071,CPT,,,,,,,,1860,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,911.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,772.644,2482.37
Exs Tumor Arm/Elbow Sc 3cm>,PX24071F,CDM,510,RC,24071,CPT,,,,,,,,1860,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,911.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,772.644,2482.37
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING4X6,C1781,CDM,278,RC,C1781,HCPCS,,12505-MAIN,LOCAL,,,,,1860,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,196.035,percent of total billed charges,911.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING4X6,C1781,CDM,278,RC,C1781,HCPCS,,12505-MAIN,LOCAL,,,,,1860,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,911.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING4X6,C1781,CDM,278,RC,C1781,HCPCS,,12505-MAIN,LOCAL,,,,,1860,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,911.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
MINIBUNION INSTRUMENT KIT,27200000,CDM,278,RC,C1713,HCPCS,,11668-MAIN,LOCAL,,,,,1860.65,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,911.7185,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MINIBUNION INSTRUMENT KIT,27200000,CDM,278,RC,C1713,HCPCS,,11668-MAIN,LOCAL,,,,,1860.65,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,911.7185,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MINIBUNION INSTRUMENT KIT,27200000,CDM,278,RC,C1713,HCPCS,,11668-MAIN,LOCAL,,,,,1860.65,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,911.7185,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Place Needle in Vein,PX36000P,CDM,983,RC,36000,CPT,,,,,,,,1034,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,911.988,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,429.5236,1006.3922
Or Level 2,PX36000002,CDM,360,RC,,,,,,,,,,1900,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,789.26,1862
Or Level 2,PX36000002,CDM,360,RC,,,,,,,,,,1900,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,789.26,1862
Insert Non-Tunnel Cv Catheter >5 Years,PX36556F,CDM,510,RC,36556,CPT,,,,,,,,1025,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,912.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,425.785,2784.63
"Remv Foot Foreign Body,Subcutaneous",PX28190F,CDM,510,RC,28190,CPT,,,,,,,,1025,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,912.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,425.785,1004.5
DYNABUNION PLATE STERILE INSTRUMENT KIT,27200000,CDM,272,RC,,,,12465-MAIN,LOCAL,,,,,1843,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,912.285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
fluticasone-salmeterol 250-50 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069604,NDC,14,EA,1025.13,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,912.3657,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Fac/Exc Skn Beni 0.6-1cm Remain Bdy,PX11421F,CDM,510,RC,11421,CPT,,,,,,,,931,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,912.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.7374,912.38
Fac/Exc Skn Bngn3.1-4cm Remain Bdy,PX11424F,CDM,510,RC,11424,CPT,,,,,,,,931,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,912.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.7374,1416.38
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034F,CDM,510,RC,12034,CPT,,,,,,,,931,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,912.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,912.38
Reconstruc of Nail Bed W Graft,PX11762F,CDM,510,RC,11762,CPT,,,,,,,,1901,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,912.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,789.6754,1862.98
Reconstruc of Nail Bed W Graft,PX11762F,CDM,510,RC,11762,CPT,,,,,,,,1901,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,912.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,789.6754,1862.98
budesonide-formoterol 80-4.5 MCG/ACT Aerosol 6.9 g Inhaler,63700001,CDM,250,RC,,,,,,186037228,NDC,6.9,GR,937.58,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,912.546614,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone furoate-vilanterol 100-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173085914,NDC,28,EA,1025.38,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,912.5882,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Exc Abdom Tum Subfac > 5 Cm,PX22901P,CDM,983,RC,22901,CPT,,,,,,,,938,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,912.9554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,389.6452,2482.37
"Closed Rx Bimalleolar Fx,Manip",PX27810F,CDM,510,RC,27810,CPT,,,,,,,,1026,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,913.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,426.2004,1404.08
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409422801,NDC,100,ML,1026,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,913.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
Incise Finger Tendon Sheath,PX26055P,CDM,983,RC,26055,CPT,,,,,,,,932,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,913.36,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.74,1232.1
Polysomnography W/Cpap,PX9581101,CDM,740,RC,95811,CPT,TC,,,,,,,4575,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,913.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,913.4,4483.5
"Polysomnography, 4 or More",PX9581001,CDM,740,RC,95810,CPT,TC,,,,,,,4313,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,913.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,913.4,4226.74
Sleep Staging 4 + Pap,PX9581126,CDM,982,RC,95811,CPT,26,,,,,,,1850,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,913.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,768.49,1800.605
PROSTEP MICA SCREW 3.0X20MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12442-MAIN,LOCAL,,,,,1806,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,913.836,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 3.0X40MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12443-MAIN,LOCAL,,,,,1806,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,913.836,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X52MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12444-MAIN,LOCAL,,,,,1806,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,913.836,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
fluticasone-salmeterol 230-21 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,66993008896,NDC,12,GR,1904.14,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,913.9872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone-salmeterol 230-21 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,66993008896,NDC,12,GR,1904.14,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,913.9872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ferumoxytol 510 MG/17ML Solution 17 mL Vial,Q0138.01,CDM,636,RC,Q0138,HCPCS,,,,781315401,NDC,17,ML,1846.91,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,914.22045,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.32,1809.9718
Biopsy Synovium I-P Jt,PX26110,CDM,983,RC,26110,CPT,,,,,,,,933,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,914.34,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.77,914.34
"Lap,Inguinal Hernia Repr,Initial",PX49650F,CDM,510,RC,49650,CPT,,,,,,,,1076,,First Health,Commercial,both,85,,999999999,percent of total billed charges,914.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,446.9704,5040.74
"Needle Biopsy,Muscle",PX20206P,CDM,983,RC,20206,CPT,,,,,,,,1028,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,914.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,427.0312,1416.38
"Closed Rx Dist Fibula Fx,Manip",PX27788F,CDM,510,RC,27788,CPT,,,,,,,,1597,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,915.25,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.51,915.25
"Closed Rx Dist Fibula Fx,Manip",PX27788P,CDM,983,RC,27788,CPT,,,,,,,,1277,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,915.25,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.51,1251.46
Unlisted Molecular Path Proc - Ref,PX8147990,CDM,310,RC,81479,CPT,90,,,,,,,1077,,First Health,Commercial,both,85,,999999999,percent of total billed charges,915.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,447.3858,1055.46
"MRI,Lwrext,Jnt W/O+W/Cont",PX7372301,CDM,610,RC,73723,CPT,TC,,,,,,,1850,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,915.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2066.35
Sleep Staging 4 + Pap,PX9581126,CDM,982,RC,95811,CPT,26,,,,,,,1850,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,915.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,768.49,1800.605
Exc Back Les Sc = 3 Cm,PX21931P,CDM,983,RC,21931,CPT,,,,,,,,2135,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,915.915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,886.879,2077.9955
clobetasol 0.05 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,21922001707,NDC,60,GR,1810.35,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,916.0371,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Close Rx Fingr Articular Fx,Manip",PX26742F,CDM,510,RC,26742,CPT,,,,,,,,1039,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,916.398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,431.6006,1404.08
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,63323067305,NDC,5,ML,1029.71,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,916.4419,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.08296,1009.1158
Abd Paracentesis W/Imaging(T),PX49083F,CDM,510,RC,49083,CPT,,,,,,,,1006,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,916.466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,417.8924,985.88
REAMER FOR CROSS PLATES,27200000,CDM,272,RC,,,,12641-MAIN,LOCAL,,,,,1852,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,916.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
budesonide-formoterol 160-4.5 MCG/ACT Aerosol 6 g Inhaler,63700001,CDM,250,RC,,,,,,186037028,NDC,6,GR,1078.55,,First Health,Commercial,both,85,,999999999,percent of total billed charges,916.7675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Sigmoidoscopy,Remv Lesn,Snare",PX45338F,CDM,510,RC,45338,CPT,,,,,,,,2137,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,916.773,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,887.7098,2094.26
STAPLER CONTOUR CURVED CUTTER,27200000,CDM,272,RC,,,,12064-MAIN,LOCAL,,,,,942,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,916.8486,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
GRAFIXPL PRIME PLACENTAL MEMBRANE 2x3CM 6SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12765-MAIN,LOCAL,,,,,1911,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,917.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
GRAFIXPL PRIME PLACENTAL MEMBRANE 2x3CM 6SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12765-MAIN,LOCAL,,,,,1911,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,917.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
"Colonoscope, Submucous Inj",PX45381F,CDM,750,RC,45381,CPT,,,,,,,,1179,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,917.33,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.59,917.33
"Colonoscope, Submucous Inj",PX45381P,CDM,983,RC,45381,CPT,,,,,,,,1215,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,917.33,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.59,1190.7
"Incis/Drain Shldr Absc/Hema,Deep",PX23030P,CDM,983,RC,23030,CPT,,,,,,,,1564,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,917.33,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,158.15,1532.72
Exc Face Les Sc < 2 Cm,PX21011F,CDM,510,RC,21011,CPT,,,,,,,,943,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,917.8219,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,391.7222,1416.38
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,781307912,NDC,5,ML,1854.23,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,917.84385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.74,1938.2734
"Closed Rx Bimalleolar Fx,Manip",PX27810F,CDM,510,RC,27810,CPT,,,,,,,,1026,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,918.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,272.25,1021.1
"Closed Rx Bimalleolar Fx,Manip",PX27810P,CDM,983,RC,27810,CPT,,,,,,,,1057,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,918.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,272.25,1035.86
budesonide-formoterol 80-4.5 MCG/ACT Aerosol 6.9 g Inhaler,63700001,CDM,250,RC,,,,,,186037228,NDC,6.9,GR,937.58,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,918.8284,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
MESH VENTRALIGHT ECHO 2.0 POSITIONING 15CM ROUND,C1781,CDM,278,RC,C1781,HCPCS,,12842-MAIN,LOCAL,,,,,1816,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,918.896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
omalizumab 150 MG Recon Soln 1 Each Vial,J2357.01,CDM,636,RC,J2357,HCPCS,,,,50242004062,NDC,1,EA,2212.7,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,919.15558,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.02,2168.446
Exc Abdom Tum Subfac > 5 Cm,PX22901P,CDM,983,RC,22901,CPT,,,,,,,,938,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,919.24,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,403.8,1393.98
Debride Tissue/Muscle/Bone,PX11044F,CDM,510,RC,11044,CPT,,,,,,,,1082,,First Health,Commercial,both,85,,999999999,percent of total billed charges,919.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,449.4628,1416.38
fidaxomicin 200 MG Tablet 20 Each Bottle,25000000,CDM,250,RC,,,,,,52015008001,NDC,1,EA,945.16,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,919.924228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Repair of Vagina,PX57200P,CDM,983,RC,57200,CPT,,,,,,,,1043,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,919.926,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,433.2622,2731.23
riTUXimab 100 MG/10ML Solution 10 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005121,NDC,10,ML,1916.61,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,919.9728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.61,8682.8588
riTUXimab 100 MG/10ML Solution 10 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005121,NDC,10,ML,1916.61,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,919.9728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.61,8682.8588
Place Needle in Vein,PX36000P,CDM,983,RC,36000,CPT,,,,,,,,1034,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,920.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,429.5236,1006.3922
fluticasone-salmeterol 100-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,54032656,NDC,60,EA,2215.63,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,920.372702,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Closed Rx Femur Shaft Fx+Manip,PX27502P,CDM,983,RC,27502,CPT,,,,,,,,1083,,First Health,Commercial,both,85,,999999999,percent of total billed charges,920.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,449.8782,1404.08
Exs Tumor Arm/Elbow Sc 3cm>,PX24071F,CDM,510,RC,24071,CPT,,,,,,,,1860,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,920.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,772.644,2482.37
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING4X6,C1781,CDM,278,RC,C1781,HCPCS,,12505-MAIN,LOCAL,,,,,1860,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,920.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Lap Incis Hernia Reducible,PX49654P,CDM,983,RC,49654,CPT,,,,,,,,1044,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,920.808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,433.6776,1016.1252
MINIBUNION INSTRUMENT KIT,27200000,CDM,278,RC,C1713,HCPCS,,11668-MAIN,LOCAL,,,,,1860.65,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,921.02175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
collagenase 250 UNIT/GM Ointment 30 g Tube,63700001,CDM,250,RC,,,,,,50484001030,NDC,30,GR,1083.77,,First Health,Commercial,both,85,,999999999,percent of total billed charges,921.2045,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
esmolol 2500 MG/250ML Solution 250 mL Flex Cont,J1805.01,CDM,636,RC,J1805,HCPCS,,,,10019067010,NDC,250,ML,1011.8,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,921.7498,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.24,991.564
Room Rate General Iso,PX12000001,CDM,120,RC,,,,,,,,,,1822,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,921.932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,756.8588,1785.56
alteplase 100 MG Recon Soln 1 Each Syringe,J2997.01,CDM,636,RC,J2997,HCPCS,,,,88888800475,NDC,0.09,EA,1920.88,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,922.0224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
alteplase 100 MG Recon Soln 1 Each Syringe,J2997.01,CDM,636,RC,J2997,HCPCS,,,,88888800475,NDC,0.09,EA,1920.88,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,922.0224,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
OSTEOSET RESORBABLE MINI BEAD KIT FAST CURE CALCIUM SULFATE 5CC,C1713,CDM,278,RC,C1713,HCPCS,,12303-MAIN,LOCAL,,,,,2220,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,922.188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"Correct Bunion,Metatarsal Osteotomy",PX28296P,CDM,983,RC,28296,CPT,,,,,,,,2150,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,922.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,893.11,2827.75
"Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601P,CDM,983,RC,11601,CPT,,,,,,,,1046,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,922.572,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,434.5084,1018.0718
Fac/Ligation of Hemorrhoid(S),PX46221F,CDM,510,RC,46221,CPT,,,,,,,,1046,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,922.572,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,434.5084,1025.08
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121F,CDM,510,RC,13121,CPT,,,,,,,,948,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,922.6884,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,393.7992,929.04
"Closed Rx Radial Head/Neck Fx,Manip",PX24655P,CDM,983,RC,24655,CPT,,,,,,,,1824,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,922.944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,757.6896,1775.2992
STAPLER CONTOUR CURVED CUTTER,27200000,CDM,272,RC,,,,12064-MAIN,LOCAL,,,,,942,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,923.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569P,CDM,983,RC,36569,CPT,,,,,,,,1825,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,923.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,758.105,1776.2725
filgrastim-sndz 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314031801,NDC,0.5,ML,1047.2,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,923.6304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,1630.2692
Exc Face Les Sc < 2 Cm,PX21011F,CDM,510,RC,21011,CPT,,,,,,,,943,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,924.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,391.7222,1416.38
Part Remv Phalanx of Toe,PX28124F,CDM,510,RC,28124,CPT,,,,,,,,2155,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,924.495,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,895.187,2827.75
fluticasone-vilanterol 200-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173088214,NDC,28,EA,1087.68,,First Health,Commercial,both,85,,999999999,percent of total billed charges,924.528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Close Rx Fingr Articular Fx,Manip",PX26742F,CDM,510,RC,26742,CPT,,,,,,,,1039,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,924.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,431.6006,1404.08
Cv Carotid Imaging-Bilat,PX9388001,CDM,921,RC,93880,CPT,TC,,,,,,,1088,,First Health,Commercial,both,85,,999999999,percent of total billed charges,924.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,1066.24
Revise Median N/Carpal Tunnel Surg,PX64721F,CDM,510,RC,64721,CPT,,,,,,,,2408,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,924.94,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,276.61,940.85
Revise Median N/Carpal Tunnel Surg,PX64721P,CDM,983,RC,64721,CPT,,,,,,,,1927,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,924.94,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,276.61,1888.46
"Tte W/Doppler, Complete",PXC8929,CDM,480,RC,C8929,HCPCS,TC,,,,,,,1927,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,924.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,699.48,1888.46
"Tte W/Doppler, Complete",PXC8929,CDM,480,RC,C8929,HCPCS,TC,,,,,,,1927,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,924.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,699.48,1888.46
RESTRATA WOUND MATRIX 2.5CM X 2.5CM TOTAL 6.25CM,27200000,CDM,272,RC,A2007,HCPCS,,11733-MAIN,LOCAL,,,,,1829,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,925.474,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
belimumab 120 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010101,NDC,1,EA,1015.95,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,925.53045,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.72,3453.2358
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,781325394,NDC,1,EA,1049.95,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,926.0559,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,72485020101,NDC,1,EA,1049.95,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,926.0559,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
"Complex Drainage, Wound",PX10180F,CDM,510,RC,10180,CPT,,,,,,,,1050,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,926.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,436.17,2482.37
Lap Rpr Vent Umbilical Hernia,PX49652F,CDM,510,RC,49652,CPT,,,,,,,,1890,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,926.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,785.106,1852.2
Lap Rpr Vent Umbilical Hernia,PX49652F,CDM,510,RC,49652,CPT,,,,,,,,1890,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,926.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,785.106,1852.2
Lap Rpr Vent Umbilical Hernia,PX49652F,CDM,510,RC,49652,CPT,,,,,,,,1890,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,926.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,785.106,1852.2
Red Blood Cells Unit,PXP9021,CDM,390,RC,P9021,HCPCS,,,,,,,,1050,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,926.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.17,1029
fidaxomicin 200 MG Tablet 20 Each Bottle,25000000,CDM,250,RC,,,,,,52015008001,NDC,1,EA,945.16,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,926.2568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
inFLIXimab-dyyb 100 MG Recon Soln 1 Each Vial,Q5103.01,CDM,636,RC,Q5103,HCPCS,,,,69080901,NDC,1,EA,1930.42,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,926.6016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.85,1891.8116
inFLIXimab-dyyb 100 MG Recon Soln 1 Each Vial,Q5103.01,CDM,636,RC,Q5103,HCPCS,,,,69080901,NDC,1,EA,1930.42,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,926.6016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.85,1891.8116
Peramivir 200 MG/20ML Solution 20 mL Vial,800000,CDM,,,,,,,,61364018101,NDC,20,ML,1832.6,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,927.2956,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Anus Surgery Procedure Unlisted,PX46999P,CDM,983,RC,46999,CPT,,,,,,,,953,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,927.5549,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,395.8762,927.5549
"Genital Surg Proc,Male Unlisted",PX55899P,CDM,983,RC,55899,CPT,,,,,,,,953,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,927.5549,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,215.91,927.5549
I&D Perirectal Abscess,PX46040P,CDM,983,RC,46040,CPT,,,,,,,,953,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,927.5549,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,395.8762,1030.93
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060002,NDC,2,ML,953.57,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,928.109681,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.11,934.4986
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060010,NDC,2,ML,953.57,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,928.109681,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.11,934.4986
Repair of Vagina,PX57200P,CDM,983,RC,57200,CPT,,,,,,,,1043,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,928.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,433.2622,2731.23
"Initial Repair of Entrapped Hernia of Abdomen, Less Than 3 Cm in Length",PX49592,CDM,982,RC,49592,CPT,,,,,,,,2164,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,928.356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,898.9256,5040.74
Polysomnography W/Cpap,PX9581101,CDM,740,RC,95811,CPT,TC,,,,,,,4575,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,928.39,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,339.44,928.39
Polysomnography W/Cpap,PX9581101,CDM,740,RC,95811,CPT,TC,,,,,,,4575,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,928.39,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,339.44,928.39
"Remv Foreign Body,Knee/Thigh,Deep",PX27372P,CDM,983,RC,27372,CPT,,,,,,,,954,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,928.5282,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,396.2916,2482.37
fluticasone-umeclidin-vilant 100-62.5-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173088714,NDC,28,EA,1894.99,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,928.5451,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone-umeclidin-vilant 100-62.5-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173088714,NDC,28,EA,1894.99,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,928.5451,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone-umeclidin-vilant 100-62.5-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173088714,NDC,28,EA,1894.99,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,928.5451,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Bone Scan, Whole Body",PX7830601,CDM,341,RC,78306,CPT,TC,,,,,,,1896,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,929.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,360.31,1858.08
"Bone Scan, Whole Body",PX7830601,CDM,341,RC,78306,CPT,TC,,,,,,,1896,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,929.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,360.31,1858.08
"Bone Scan, Whole Body",PX7830601,CDM,341,RC,78306,CPT,TC,,,,,,,1896,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,929.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,360.31,1858.08
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121F,CDM,510,RC,13121,CPT,,,,,,,,948,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,929.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,393.7992,929.04
Lap Incis Hernia Reducible,PX49654P,CDM,983,RC,49654,CPT,,,,,,,,1044,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,929.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,433.6776,1016.1252
Facility Emergency Level IV Visit,PX99284F,CDM,450,RC,99284,CPT,,,,,,,,1054,,United Healthcare,All Payer,outpatient,88.2,,65.75748315,percent of total billed charges,929.628,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.93,1032.92
Incise External Hemorrhoid,PX46083P,CDM,983,RC,46083,CPT,,,,,,,,956,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,930.4748,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,215.91,930.4748
"Colonoscopy,Remv Lesn,Snare",PX45385F,CDM,750,RC,45385,CPT,,,,,,,,1939,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,930.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,831.831,4050.42
"Colonoscopy,Remv Lesn,Snare",PX45385F,CDM,750,RC,45385,CPT,,,,,,,,1939,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,930.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,831.831,4050.42
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,71288020185,NDC,5,ML,1021.7,,Medica,Commercial,both,91.1,,288.0925,percent of total billed charges,930.7687,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,424.41418,1239.6216
"Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601P,CDM,983,RC,11601,CPT,,,,,,,,1046,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,930.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,434.5084,1018.0718
Fac/Ligation of Hemorrhoid(S),PX46221F,CDM,510,RC,46221,CPT,,,,,,,,1046,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,930.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,434.5084,1025.08
Or Level 2,PX36000002,CDM,360,RC,,,,,,,,,,1900,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,931,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,789.26,1862
Or Level 2,PX36000002,CDM,360,RC,,,,,,,,,,1900,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,931,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,789.26,1862
Or Level 2,PX36000002,CDM,360,RC,,,,,,,,,,1900,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,931,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,789.26,1862
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x3CM 9SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12766-MAIN,LOCAL,,,,,2171,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,931.359,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
Reconstruc of Nail Bed W Graft,PX11762F,CDM,510,RC,11762,CPT,,,,,,,,1901,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,931.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,789.6754,1862.98
Reconstruc of Nail Bed W Graft,PX11762F,CDM,510,RC,11762,CPT,,,,,,,,1901,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,931.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,789.6754,1862.98
Reconstruc of Nail Bed W Graft,PX11762F,CDM,510,RC,11762,CPT,,,,,,,,1901,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,931.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,789.6754,1862.98
"I&D Perianal Abscess,Superficial",PX46050,CDM,983,RC,46050,CPT,,,,,,,,1096,,First Health,Commercial,both,85,,999999999,percent of total billed charges,931.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,455.2784,1066.7368
nivolumab 40 MG/4ML Solution 4 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377211,NDC,4,ML,2171.7,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,931.6593,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.5,12769.6548
Heart/Lung Resuscitation (Cpr),PX92950P,CDM,983,RC,92950,CPT,,,,,,,,1023,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,931.953,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.21,995.6859
"Treat Thumb Disloc,Manipulatn",PX26641P,CDM,983,RC,26641,CPT,,,,,,,,1902,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1022.934,percent of total billed charges,931.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1851.2166
"Treat Thumb Disloc,Manipulatn",PX26641P,CDM,983,RC,26641,CPT,,,,,,,,1902,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,931.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1851.2166
"Treat Thumb Disloc,Manipulatn",PX26641P,CDM,983,RC,26641,CPT,,,,,,,,1902,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,931.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1851.2166
filgrastim-sndz 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314031801,NDC,0.5,ML,1047.2,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,932.008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,1630.2692
"Closed Rx Bimalleolar Fx,Manip",PX27810P,CDM,983,RC,27810,CPT,,,,,,,,1057,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,932.274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,439.0778,1404.08
DYNABUNION PLATE STERILE INSTRUMENT KIT,27200000,CDM,272,RC,,,,12465-MAIN,LOCAL,,,,,1843,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,932.558,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
fluticasone-salmeterol 230-21 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,66993008896,NDC,12,GR,1904.14,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,933.0286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone-salmeterol 230-21 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,66993008896,NDC,12,GR,1904.14,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,933.0286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone-salmeterol 230-21 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,66993008896,NDC,12,GR,1904.14,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,933.0286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606F,CDM,510,RC,11606,CPT,,,,,,,,1432,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,933.24,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,193.93,933.24
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606P,CDM,983,RC,11606,CPT,,,,,,,,2044,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,933.24,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,193.93,2003.12
Insert Non-Tunnel Cv Catheter >5 Years,PX36556F,CDM,510,RC,36556,CPT,,,,,,,,1025,,Medica,Commercial,both,91.1,,131.535,percent of total billed charges,933.775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,425.785,2784.63
"Remv Foot Foreign Body,Subcutaneous",PX28190F,CDM,510,RC,28190,CPT,,,,,,,,1025,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,933.775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,425.785,1004.5
fluticasone-salmeterol 250-50 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069604,NDC,14,EA,1025.13,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,933.89343,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Anus Surgery Procedure Unlisted,PX46999P,CDM,983,RC,46999,CPT,,,,,,,,953,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,933.94,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,933.94,933.94
"Genital Surg Proc,Male Unlisted",PX55899P,CDM,983,RC,55899,CPT,,,,,,,,953,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,933.94,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,933.94,933.94
I&D Perirectal Abscess,PX46040P,CDM,983,RC,46040,CPT,,,,,,,,953,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,933.94,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,264.62,1158.77
fluticasone furoate-vilanterol 100-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173085914,NDC,28,EA,1025.38,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,934.12118,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,781325394,NDC,1,EA,1049.95,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,934.4555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,72485020101,NDC,1,EA,1049.95,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,934.4555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060002,NDC,2,ML,953.57,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,934.4986,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.11,934.4986
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060010,NDC,2,ML,953.57,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,934.4986,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.11,934.4986
"Complex Drainage, Wound",PX10180F,CDM,510,RC,10180,CPT,,,,,,,,1050,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,934.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,436.17,2482.37
Red Blood Cells Unit,PXP9021,CDM,390,RC,P9021,HCPCS,,,,,,,,1050,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,934.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.17,1029
ferumoxytol 510 MG/17ML Solution 17 mL Vial,Q0138.01,CDM,636,RC,Q0138,HCPCS,,,,781315401,NDC,17,ML,1846.91,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,934.53646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.32,1809.9718
"Closed Rx Bimalleolar Fx,Manip",PX27810F,CDM,510,RC,27810,CPT,,,,,,,,1026,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,934.686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,426.2004,1404.08
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409422801,NDC,100,ML,1026,,Medica,Commercial,both,91.1,,51.072,percent of total billed charges,934.686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527197174,NDC,4,ML,960.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,934.85465,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
"Remv Foreign Body,Knee/Thigh,Deep",PX27372P,CDM,983,RC,27372,CPT,,,,,,,,954,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,934.92,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,250.43,1226.56
Open Bx/Excision Inguinofemoral Nodes,PX38531F,CDM,510,RC,38531,CPT,,,,,,,,912,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,935.31,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,271.37,935.31
Open Bx/Excision Inguinofemoral Nodes,PX38531F,CDM,510,RC,38531,CPT,,,,,,,,912,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,935.31,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,271.37,935.31
Open Bx/Excision Inguinofemoral Nodes,PX38531P,CDM,983,RC,38531,CPT,,,,,,,,607,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,935.31,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,271.37,935.31
Open Bx/Excision Inguinofemoral Nodes,PX38531P,CDM,983,RC,38531,CPT,,,,,,,,607,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,935.31,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,271.37,935.31
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545F,CDM,510,RC,23545,CPT,,,,,,,,961,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,935.3413,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,941.78
Lap Rpr Vent Umbilical Hernia,PX49652F,CDM,510,RC,49652,CPT,,,,,,,,1890,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,935.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,785.106,1852.2
"Critical Care, E/M 30-74 Minutes",PX99291P,CDM,983,RC,99291,CPT,,,,,,,,1061,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,935.802,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,440.7394,1032.6713
"Amputation Toe,Mt-P Jt",PX28820F,CDM,510,RC,28820,CPT,,,,,,,,1950,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,810.03,2827.75
"Amputation Toe,Mt-P Jt",PX28820F,CDM,510,RC,28820,CPT,,,,,,,,1950,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,810.03,2827.75
"Repair Umbilical Hern,5+Y/O,Strang",PX49587P,CDM,983,RC,49587,CPT,,,,,,,,2182,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,936.078,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,906.4028,2123.7406
"MRI,Lwrext,Jnt W/O+W/Cont",PX7372301,CDM,610,RC,73723,CPT,TC,,,,,,,1850,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,936.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2066.35
Sleep Staging 4 + Pap,PX9581126,CDM,982,RC,95811,CPT,26,,,,,,,1850,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,936.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,768.49,1800.605
GRAFIXPL PRIME PLACENTAL MEMBRANE 2x3CM 6SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12765-MAIN,LOCAL,,,,,1911,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,936.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
GRAFIXPL PRIME PLACENTAL MEMBRANE 2x3CM 6SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12765-MAIN,LOCAL,,,,,1911,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,936.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
GRAFIXPL PRIME PLACENTAL MEMBRANE 2x3CM 6SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12765-MAIN,LOCAL,,,,,1911,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,936.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
"Needle Biopsy,Muscle",PX20206P,CDM,983,RC,20206,CPT,,,,,,,,1028,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,936.508,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,427.0312,1416.38
Incise External Hemorrhoid,PX46083P,CDM,983,RC,46083,CPT,,,,,,,,956,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,936.88,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,68.28,936.88
REAMER FOR CROSS PLATES,27200000,CDM,272,RC,,,,12641-MAIN,LOCAL,,,,,1852,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,937.112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Excis Tendn/Capsule Lesn,Toes",PX28092P,CDM,983,RC,28092,CPT,,,,,,,,1913,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,937.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,794.6602,1861.9229
"Excis Tendn/Capsule Lesn,Toes",PX28092P,CDM,983,RC,28092,CPT,,,,,,,,1913,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,937.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,794.6602,1861.9229
"Excis Tendn/Capsule Lesn,Toes",PX28092P,CDM,983,RC,28092,CPT,,,,,,,,1913,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,937.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,794.6602,1861.9229
fluticasone-umeclidin-vilant 100-62.5-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173088714,NDC,28,EA,1894.99,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,938.02005,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Facility Emergency Level IV Visit,PX99284F,CDM,450,RC,99284,CPT,,,,,,,,1054,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,938.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.93,1032.92
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,63323067305,NDC,5,ML,1029.71,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,938.06581,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.08296,1009.1158
Exc Neck Les Sc = 3cm >,PX21552F,CDM,510,RC,21552,CPT,,,,,,,,753,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,938.08,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,273.56,938.08
Exc Neck Les Sc = 3cm >,PX21552F,CDM,510,RC,21552,CPT,,,,,,,,753,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,938.08,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,273.56,938.08
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,781307912,NDC,5,ML,1854.23,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,938.24038,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.74,1938.2734
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604F,CDM,510,RC,11604,CPT,,,,,,,,964,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,938.2612,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,400.4456,944.72
FORCEPS SPOON JAWSIZE 10MMX36 KIT,27200000,CDM,272,RC,,,,11749-MAIN,LOCAL,,,,,1955,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,938.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
FORCEPS SPOON JAWSIZE 10MMX36 KIT,27200000,CDM,272,RC,,,,11749-MAIN,LOCAL,,,,,1955,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,938.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Bone Scan, Whole Body",PX7830601,CDM,341,RC,78306,CPT,TC,,,,,,,1896,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,938.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,360.31,1858.08
riTUXimab 100 MG/10ML Solution 10 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005121,NDC,10,ML,1916.61,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,939.1389,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.61,8682.8588
riTUXimab 100 MG/10ML Solution 10 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005121,NDC,10,ML,1916.61,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,939.1389,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.61,8682.8588
riTUXimab 100 MG/10ML Solution 10 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005121,NDC,10,ML,1916.61,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,939.1389,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.61,8682.8588
Temporal Artery Ligatn or Bx,PX37609P,CDM,983,RC,37609,CPT,,,,,,,,965,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,939.2345,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,400.861,1416.38
"Tte W/Doppler, Complete",PX9330601,CDM,483,RC,93306,CPT,TC,,,,,,,2191,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,939.939,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,481.95,2889.15
"Cardiac Stress Tst,Tracing Only",PX93017,CDM,482,RC,93017,CPT,,,,,,,,1959,,Health Partners,Health Partners Care Plans,both,48,,1900.23,percent of total billed charges,940.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.21,1919.82
"Cardiac Stress Tst,Tracing Only",PX93017,CDM,482,RC,93017,CPT,,,,,,,,1959,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,940.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.21,1919.82
Or Level 2,PX36000002,CDM,360,RC,,,,,,,,,,1900,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,940.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,789.26,1862
"Closed Rx Bimalleolar Fx,Manip",PX27810P,CDM,983,RC,27810,CPT,,,,,,,,1057,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,940.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,439.0778,1404.08
"Colonoscopy,Remv Lesn,Snare",PX45385F,CDM,750,RC,45385,CPT,,,,,,,,1939,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,940.85,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.32,940.85
"Colonoscopy,Remv Lesn,Snare",PX45385P,CDM,983,RC,45385,CPT,,,,,,,,2424,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,940.85,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.32,2375.52
Revise Median N/Carpal Tunnel Surg,PX64721F,CDM,510,RC,64721,CPT,,,,,,,,2408,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,940.85,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,276.61,940.85
Revise Median N/Carpal Tunnel Surg,PX64721P,CDM,983,RC,64721,CPT,,,,,,,,1927,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,940.85,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,276.61,1888.46
Reconstruc of Nail Bed W Graft,PX11762F,CDM,510,RC,11762,CPT,,,,,,,,1901,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,940.995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,789.6754,1862.98
Debride Skin/Tissue,PX11042F,CDM,510,RC,11042,CPT,,,,,,,,1067,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,941.094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1045.66
Exs Tumor Arm/Elbow Sc 3cm>,PX24071F,CDM,510,RC,24071,CPT,,,,,,,,1860,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,941.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,772.644,2482.37
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING4X6,C1781,CDM,278,RC,C1781,HCPCS,,12505-MAIN,LOCAL,,,,,1860,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,941.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
alteplase 100 MG Recon Soln 1 Each Syringe,J2997.01,CDM,636,RC,J2997,HCPCS,,,,88888800475,NDC,0.09,EA,1920.88,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,66.655,percent of total billed charges,941.2312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
alteplase 100 MG Recon Soln 1 Each Syringe,J2997.01,CDM,636,RC,J2997,HCPCS,,,,88888800475,NDC,0.09,EA,1920.88,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,941.2312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
alteplase 100 MG Recon Soln 1 Each Syringe,J2997.01,CDM,636,RC,J2997,HCPCS,,,,88888800475,NDC,0.09,EA,1920.88,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,941.2312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,64950036204,NDC,4,ML,1067.22,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,941.28804,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527197174,NDC,4,ML,960.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,941.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
MINIBUNION INSTRUMENT KIT,27200000,CDM,278,RC,C1713,HCPCS,,11668-MAIN,LOCAL,,,,,1860.65,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,941.4889,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Treat Thumb Disloc,Manipulatn",PX26641P,CDM,983,RC,26641,CPT,,,,,,,,1902,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,941.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1851.2166
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545F,CDM,510,RC,23545,CPT,,,,,,,,961,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,941.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,941.78
Place Needle in Vein,PX36000P,CDM,983,RC,36000,CPT,,,,,,,,1034,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,941.974,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,429.5236,1006.3922
fluticasone-salmeterol 230-21 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,66993008896,NDC,12,GR,1904.14,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,942.5493,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Lap Incis Hernia Reducible,PX49654F,CDM,510,RC,49654,CPT,,,,,,,,1964,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,942.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,815.8456,1924.72
Lap Incis Hernia Reducible,PX49654F,CDM,510,RC,49654,CPT,,,,,,,,1964,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,942.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,815.8456,1924.72
"Closed Rx Trimalleolar Fx,Manip",PX27818F,CDM,510,RC,27818,CPT,,,,,,,,813,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,942.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,279.01,1059.15
"Closed Rx Trimalleolar Fx,Manip",PX27818P,CDM,983,RC,27818,CPT,,,,,,,,1352,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,942.92,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,279.01,1324.96
"Repair Umbilical Hern,5+Y/O,Reduc",PX49585F,CDM,510,RC,49585,CPT,,,,,,,,969,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,943.1277,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,402.5226,949.62
"Lap,Esophagogast Fundoplasty",PX43280F,CDM,510,RC,43280,CPT,,,,,,,,6713,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,943.3918,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,640.49,2235.9
"Lap,Esophagogast Fundoplasty",PX43280P,CDM,983,RC,43280,CPT,,,,,,,,4449,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,943.3918,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,640.49,4360.02
"Repair Umbilical Hern,5+Y/O,Strang",PX49587F,CDM,510,RC,49587,CPT,,,,,,,,1110,,First Health,Commercial,both,85,,999999999,percent of total billed charges,943.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,461.094,1087.8
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290101,NDC,1,EA,1966.88,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,944.1024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.77,1927.5424
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290101,NDC,1,EA,1966.88,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,944.1024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.77,1927.5424
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290102,NDC,1,EA,1966.88,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,944.1024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.77,1927.5424
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290102,NDC,1,EA,1966.88,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,944.1024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.77,1927.5424
"CT Colonography, Screen",PX7426301,CDM,350,RC,74263,CPT,TC,,,,,,,3330,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,944.128,Non facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,379.8,1118.24
"CT Colonography, Screen",PX7426301,CDM,350,RC,74263,CPT,TC,,,,,,,3330,,UCare,Individual and Family Plans,both,,,999999999,fee schedule,944.128,Facility,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,379.8,1118.24
Revise Median N/Carpal Tunnel Surg,PX64721P,CDM,983,RC,64721,CPT,,,,,,,,1927,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,944.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,800.4758,1875.5491
Revise Median N/Carpal Tunnel Surg,PX64721P,CDM,983,RC,64721,CPT,,,,,,,,1927,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,944.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,800.4758,1875.5491
Revise Median N/Carpal Tunnel Surg,PX64721P,CDM,983,RC,64721,CPT,,,,,,,,1927,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,944.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,800.4758,1875.5491
"Tte W/Doppler, Complete",PXC8929,CDM,480,RC,C8929,HCPCS,TC,,,,,,,1927,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,944.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,699.48,1888.46
"Tte W/Doppler, Complete",PXC8929,CDM,480,RC,C8929,HCPCS,TC,,,,,,,1927,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,944.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,699.48,1888.46
"Tte W/Doppler, Complete",PXC8929,CDM,480,RC,C8929,HCPCS,TC,,,,,,,1927,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,944.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,699.48,1888.46
"Critical Care, E/M 30-74 Minutes",PX99291P,CDM,983,RC,99291,CPT,,,,,,,,1061,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,944.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,440.7394,1032.6713
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604F,CDM,510,RC,11604,CPT,,,,,,,,964,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,944.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,400.4456,944.72
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266P,CDM,983,RC,27266,CPT,,,,,,,,2275,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,945.035,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,945.035,2214.2575
Temporal Artery Ligatn or Bx,PX37609P,CDM,983,RC,37609,CPT,,,,,,,,965,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,945.7,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,124.34,945.7
inFLIXimab-dyyb 100 MG Recon Soln 1 Each Vial,Q5103.01,CDM,636,RC,Q5103,HCPCS,,,,69080901,NDC,1,EA,1930.42,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,945.9058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.85,1891.8116
inFLIXimab-dyyb 100 MG Recon Soln 1 Each Vial,Q5103.01,CDM,636,RC,Q5103,HCPCS,,,,69080901,NDC,1,EA,1930.42,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,945.9058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.85,1891.8116
inFLIXimab-dyyb 100 MG Recon Soln 1 Each Vial,Q5103.01,CDM,636,RC,Q5103,HCPCS,,,,69080901,NDC,1,EA,1930.42,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,945.9058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.85,1891.8116
GRAFIXPL PRIME PLACENTAL MEMBRANE 2x3CM 6SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12765-MAIN,LOCAL,,,,,1911,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,945.945,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
Remove Nasal Foreign Body,PX30300F,CDM,510,RC,30300,CPT,,,,,,,,972,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,946.0476,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,952.56
Bcr/Abl1 Minor - Ref,PX8120790,CDM,310,RC,81207,CPT,90,,,,,,,1113,,First Health,Commercial,both,85,,999999999,percent of total billed charges,946.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.8,1090.74
MICA BURR 2X12MM STERILE MICA,27200000,CDM,272,RC,,,,12447-MAIN,LOCAL,,,,,1113,,First Health,Commercial,both,85,,999999999,percent of total billed charges,946.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA BURR 2X20MM STERILE MICA,27200000,CDM,272,RC,,,,12448-MAIN,LOCAL,,,,,1113,,First Health,Commercial,both,85,,999999999,percent of total billed charges,946.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA CUTTING BURR 3X20MM LONG MICA,27200000,CDM,272,RC,,,,12434-MAIN,LOCAL,,,,,1113,,First Health,Commercial,both,85,,999999999,percent of total billed charges,946.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA WEDGE BURR 3.1X13MM STERILE,27200000,CDM,272,RC,,,,12435-MAIN,LOCAL,,,,,1113,,First Health,Commercial,both,85,,999999999,percent of total billed charges,946.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Close Rx Fingr Articular Fx,Manip",PX26742F,CDM,510,RC,26742,CPT,,,,,,,,1039,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,946.529,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,431.6006,1404.08
"Excis Tendn/Capsule Lesn,Toes",PX28092P,CDM,983,RC,28092,CPT,,,,,,,,1913,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,946.935,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,794.6602,1861.9229
diazePAM 2.5 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,68682065020,NDC,1,EA,1114.05,,First Health,Commercial,both,85,,999999999,percent of total billed charges,946.9425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752F,CDM,510,RC,27752,CPT,,,,,,,,2280,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,947.112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,947.112,2234.4
riTUXimab 100 MG/10ML Solution 10 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005121,NDC,10,ML,1916.61,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,948.72195,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.61,8682.8588
"Repair Ing Hernia,5+Y/O,Strang",PX49507F,CDM,510,RC,49507,CPT,,,,,,,,1977,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,948.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,821.2458,3022.41
"Repair Ing Hernia,5+Y/O,Strang",PX49507F,CDM,510,RC,49507,CPT,,,,,,,,1977,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,948.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,821.2458,3022.41
"Lap,Inguinal Hernia Repr,Initial",PX49650F,CDM,510,RC,49650,CPT,,,,,,,,1076,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,949.032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,446.9704,5040.74
omalizumab 150 MG Recon Soln 1 Each Vial,J2357.01,CDM,636,RC,J2357,HCPCS,,,,50242004062,NDC,1,EA,2212.7,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,949.2483,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.02,2168.446
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,310072010,NDC,5,ML,1977.83,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,949.3584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.74,1938.2734
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,310072010,NDC,5,ML,1977.83,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,949.3584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.74,1938.2734
"Repair Umbilical Hern,5+Y/O,Reduc",PX49585F,CDM,510,RC,49585,CPT,,,,,,,,969,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,949.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,402.5226,949.62
Debride Skin/Tissue,PX11042F,CDM,510,RC,11042,CPT,,,,,,,,1067,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,949.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1045.66
Lap Sleeve Gastrectomy,PX43775,CDM,982,RC,43775,CPT,,,,,,,,5030,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,949.8138,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,645.08,4929.4
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,64950036204,NDC,4,ML,1067.22,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,949.8258,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
Unlisted Molecular Path Proc - Ref,PX8147990,CDM,310,RC,81479,CPT,90,,,,,,,1077,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,949.914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,447.3858,1055.46
"Colonoscopy,Remv Lesn,Snare",PX45385F,CDM,750,RC,45385,CPT,,,,,,,,1939,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,710.9625,percent of total billed charges,950.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,831.831,4050.42
"Colonoscopy,Remv Lesn,Snare",PX45385F,CDM,750,RC,45385,CPT,,,,,,,,1939,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,950.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,831.831,4050.42
"Colonoscopy,Remv Lesn,Snare",PX45385F,CDM,750,RC,45385,CPT,,,,,,,,1939,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,950.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,831.831,4050.42
Repair of Vagina,PX57200P,CDM,983,RC,57200,CPT,,,,,,,,1043,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,950.173,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,433.2622,2731.23
BUPivacaine liposome 1.3 % Suspension 20 mL Vial,C9290.01,CDM,636,RC,C9290,HCPCS,,,,65250026604,NDC,10,ML,976.43,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,5.824409871,percent of total billed charges,950.359319,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,405.609022,956.9014
ciprofloxacin-dexAMETHasone 0.3-0.1 % Suspension 7.5 mL Bottle,25000000,CDM,250,RC,,,,,,43598032675,NDC,7.5,ML,976.53,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,950.456649,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fluticasone-salmeterol 100-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,54032656,NDC,60,EA,2215.63,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,950.50527,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
alteplase 100 MG Recon Soln 1 Each Syringe,J2997.01,CDM,636,RC,J2997,HCPCS,,,,88888800475,NDC,0.09,EA,1920.88,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,950.8356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505P,CDM,983,RC,25505,CPT,,,,,,,,977,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,950.9141,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,405.8458,1404.08
Lap Incis Hernia Reducible,PX49654P,CDM,983,RC,49654,CPT,,,,,,,,1044,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,951.084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,433.6776,1016.1252
budesonide-formoterol 160-4.5 MCG/ACT Aerosol 6 g Inhaler,63700001,CDM,250,RC,,,,,,186037028,NDC,6,GR,1078.55,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,951.2811,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Repair Recurr Inguin Hern,Reducibl",PX49520F,CDM,510,RC,49520,CPT,,,,,,,,1983,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,951.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,823.7382,3022.41
"Repair Recurr Inguin Hern,Reducibl",PX49520F,CDM,510,RC,49520,CPT,,,,,,,,1983,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,951.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,823.7382,3022.41
Egd Balloon Dil Esoph30 Mm/>,PX43233F,CDM,750,RC,43233,CPT,,,,,,,,1120,,First Health,Commercial,both,85,,999999999,percent of total billed charges,952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,465.248,1662.33
"Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602P,CDM,983,RC,11602,CPT,,,,,,,,1120,,First Health,Commercial,both,85,,999999999,percent of total billed charges,952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1090.096
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830P,CDM,983,RC,15830,CPT,,,,,,,,1120,,First Health,Commercial,both,85,,999999999,percent of total billed charges,952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,465.248,5696.92
OSTEOSET RESORBABLE MINI BEAD KIT FAST CURE CALCIUM SULFATE 5CC,C1713,CDM,278,RC,C1713,HCPCS,,12303-MAIN,LOCAL,,,,,2220,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,952.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Remove Nasal Foreign Body,PX30300F,CDM,510,RC,30300,CPT,,,,,,,,972,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,952.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.6,952.56
"Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601P,CDM,983,RC,11601,CPT,,,,,,,,1046,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,952.906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,434.5084,1018.0718
Fac/Ligation of Hemorrhoid(S),PX46221F,CDM,510,RC,46221,CPT,,,,,,,,1046,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,952.906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,434.5084,1025.08
"Removal Anal Fistula,Subcutaneous",PX46270P,CDM,983,RC,46270,CPT,,,,,,,,980,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,953.834,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,407.092,2452.93
Revise Median N/Carpal Tunnel Surg,PX64721P,CDM,983,RC,64721,CPT,,,,,,,,1927,,Humana Choice Care,All Medicare plans,outpatient,49.5,,527.025,percent of total billed charges,953.865,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,800.4758,1875.5491
"Tte W/Doppler, Complete",PXC8929,CDM,480,RC,C8929,HCPCS,TC,,,,,,,1927,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,953.865,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,699.48,1888.46
filgrastim-sndz 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314031801,NDC,0.5,ML,1047.2,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,953.9992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,1630.2692
Debride Tissue/Muscle/Bone,PX11044F,CDM,510,RC,11044,CPT,,,,,,,,1082,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,954.324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,449.4628,1416.38
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200001,NDC,0.5,ML,980.99,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,954.797567,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,264.67,961.3702
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200002,NDC,0.5,ML,980.99,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,954.797567,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,264.67,961.3702
Exc Skin Benig >4cm Remaindr Body,PX11426P,CDM,983,RC,11426,CPT,,,,,,,,981,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,954.8073,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,407.5074,2482.37
"Fusion Foot Bones,Midtarsal,Multi",PX28730F,CDM,510,RC,28730,CPT,,,,,,,,2299,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,955.0046,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,955.0046,11497.76
Lap Rpr Vent Umbilical Hernia Incarcerated or Strangulated,PX49653F,CDM,510,RC,49653,CPT,,,,,,,,1990,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,955.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,826.646,1950.2
Lap Rpr Vent Umbilical Hernia Incarcerated or Strangulated,PX49653F,CDM,510,RC,49653,CPT,,,,,,,,1990,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,955.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,826.646,1950.2
Closed Rx Femur Shaft Fx+Manip,PX27502P,CDM,983,RC,27502,CPT,,,,,,,,1083,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,955.206,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,449.8782,1404.08
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605F,CDM,510,RC,24605,CPT,,,,,,,,1124,,First Health,Commercial,both,85,,999999999,percent of total billed charges,955.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.9096,1404.08
"Amputation Toe,Mt-P Jt",PX28820F,CDM,510,RC,28820,CPT,,,,,,,,1950,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,955.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,810.03,2827.75
"Amputation Toe,Mt-P Jt",PX28820F,CDM,510,RC,28820,CPT,,,,,,,,1950,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,955.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,810.03,2827.75
"Amputation Toe,Mt-P Jt",PX28820F,CDM,510,RC,28820,CPT,,,,,,,,1950,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,955.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,810.03,2827.75
inFLIXimab-dyyb 100 MG Recon Soln 1 Each Vial,Q5103.01,CDM,636,RC,Q5103,HCPCS,,,,69080901,NDC,1,EA,1930.42,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,955.5579,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.85,1891.8116
hydroxocobalamin 5 g Recon Soln 1 Each Box,J3424.01,CDM,636,RC,J3424,HCPCS,,,,11704037001,NDC,1,EA,1991.16,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,955.7568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,827.127864,1951.3368
hydroxocobalamin 5 g Recon Soln 1 Each Box,J3424.01,CDM,636,RC,J3424,HCPCS,,,,11704037001,NDC,1,EA,1991.16,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,955.7568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,827.127864,1951.3368
collagenase 250 UNIT/GM Ointment 30 g Tube,63700001,CDM,250,RC,,,,,,50484001030,NDC,30,GR,1083.77,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,955.88514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Bcr/Abl1 Other - Ref,PX8120890,CDM,310,RC,81208,CPT,90,,,,,,,1125,,First Health,Commercial,both,85,,999999999,percent of total billed charges,956.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,196.79,1102.5
Lap Rpr Vent Umbilical Hernia,PX49652F,CDM,510,RC,49652,CPT,,,,,,,,1890,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,956.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,785.106,1852.2
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,781325394,NDC,1,EA,1049.95,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,956.50445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,72485020101,NDC,1,EA,1049.95,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,956.50445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
"Complex Drainage, Wound",PX10180F,CDM,510,RC,10180,CPT,,,,,,,,1050,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,956.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,436.17,2482.37
Red Blood Cells Unit,PXP9021,CDM,390,RC,P9021,HCPCS,,,,,,,,1050,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,956.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.17,1029
Echo Tt 2d Complete,PX9330701,CDM,480,RC,93307,CPT,TC,,,,,,,2303,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,956.6662,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,2256.94
"Lap,Cholecystectomy",PX47562P,CDM,983,RC,47562,CPT,,,,,,,,983,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,4431.597143,percent of total billed charges,956.7539,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,408.3382,5040.74
BUPivacaine liposome 1.3 % Suspension 20 mL Vial,C9290.01,CDM,636,RC,C9290,HCPCS,,,,65250026604,NDC,10,ML,976.43,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,956.9014,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,405.609022,956.9014
ciprofloxacin-dexAMETHasone 0.3-0.1 % Suspension 7.5 mL Bottle,25000000,CDM,250,RC,,,,,,43598032675,NDC,7.5,ML,976.53,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,956.9994,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Freeing Bowel Adhesion,Enterolysis",PX44005F,CDM,360,RC,44005,CPT,,,,,,,,2744,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,957.1991,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,649.87,2262.88
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505P,CDM,983,RC,25505,CPT,,,,,,,,977,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,957.46,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,295.37,1095.81
"Up GI Endoscopy,Dilatn W Guide",PX43248F,CDM,750,RC,43248,CPT,,,,,,,,1995,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,957.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,1955.1
"Up GI Endoscopy,Dilatn W Guide",PX43248F,CDM,750,RC,43248,CPT,,,,,,,,1995,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,957.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,1955.1
"Lap,Inguinal Hernia Repr,Initial",PX49650F,CDM,510,RC,49650,CPT,,,,,,,,1076,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,957.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,446.9704,5040.74
"Fac/Exc Skn Benig >4cm Trnk,Arm,Lg",PX11406F,CDM,510,RC,11406,CPT,,,,,,,,1127,,First Health,Commercial,both,85,,999999999,percent of total billed charges,957.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,468.1558,1416.38
FORCEPS SPOON JAWSIZE 10MMX36 KIT,27200000,CDM,272,RC,,,,11749-MAIN,LOCAL,,,,,1955,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,957.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
FORCEPS SPOON JAWSIZE 10MMX36 KIT,27200000,CDM,272,RC,,,,11749-MAIN,LOCAL,,,,,1955,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,957.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
FORCEPS SPOON JAWSIZE 10MMX36 KIT,27200000,CDM,272,RC,,,,11749-MAIN,LOCAL,,,,,1955,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,957.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Up GI Endoscopy,Ball Dil,30mm",PX43249F,CDM,750,RC,43249,CPT,,,,,,,,2596,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,958.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,958.1,3257.54
"Up GI Endoscopy,Ball Dil,30mm",PX43249P,CDM,983,RC,43249,CPT,,,,,,,,1731,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,958.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,742.599,3257.54
Unlisted Molecular Path Proc - Ref,PX8147990,CDM,310,RC,81479,CPT,90,,,,,,,1077,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,958.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,447.3858,1055.46
fluticasone-umeclidin-vilant 100-62.5-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173088714,NDC,28,EA,1894.99,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,958.86494,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone-vilanterol 200-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173088214,NDC,28,EA,1087.68,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,959.33376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Bone Scan, Whole Body",PX7830601,CDM,341,RC,78306,CPT,TC,,,,,,,1896,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,959.376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,360.31,1858.08
Cv Carotid Imaging-Bilat,PX9388001,CDM,921,RC,93880,CPT,TC,,,,,,,1088,,United Healthcare,All Payer,outpatient,88.2,,533.12,percent of total billed charges,959.616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,1066.24
"Colonoscopy,Remv Lesn,Snare",PX45385F,CDM,750,RC,45385,CPT,,,,,,,,1939,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,959.805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,831.831,4050.42
budesonide-formoterol 160-4.5 MCG/ACT Aerosol 6 g Inhaler,63700001,CDM,250,RC,,,,,,186037028,NDC,6,GR,1078.55,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,959.9095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Cardiac Stress Tst,Tracing Only",PX93017,CDM,482,RC,93017,CPT,,,,,,,,1959,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,473.8215385,percent of total billed charges,959.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.21,1919.82
"Cardiac Stress Tst,Tracing Only",PX93017,CDM,482,RC,93017,CPT,,,,,,,,1959,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,959.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.21,1919.82
"Cardiac Stress Tst,Tracing Only",PX93017,CDM,482,RC,93017,CPT,,,,,,,,1959,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,959.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.21,1919.82
"Ht Muscle Image Spect, Mult",PX7845201,CDM,340,RC,78452,CPT,TC,,,,,,,2000,,Health Partners,Health Partners Care Plans,both,48,,969.18,percent of total billed charges,960,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,858,5292.1
"Ht Muscle Image Spect, Mult",PX7845201,CDM,340,RC,78452,CPT,TC,,,,,,,2000,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,960,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,858,5292.1
Facility Emergency Level IV Visit,PX99284F,CDM,450,RC,99284,CPT,,,,,,,,1054,,Medica,Commercial,both,91.1,,164.8116379,percent of total billed charges,960.194,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.93,1032.92
"Removal Anal Fistula,Subcutaneous",PX46270P,CDM,983,RC,46270,CPT,,,,,,,,980,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,960.4,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,251.31,1113.8
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200001,NDC,0.5,ML,980.99,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,961.3702,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,264.67,961.3702
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200002,NDC,0.5,ML,980.99,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,961.3702,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,264.67,961.3702
Exc Skin Benig >4cm Remaindr Body,PX11426P,CDM,983,RC,11426,CPT,,,,,,,,981,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,961.38,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,167.1,961.38
Or Level 2,PX36000002,CDM,360,RC,,,,,,,,,,1900,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,961.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,789.26,1862
Reconstruc of Nail Bed W Graft,PX11762F,CDM,510,RC,11762,CPT,,,,,,,,1901,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,961.906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,789.6754,1862.98
fluticasone-salmeterol 230-21 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173071720,NDC,12,GR,2004.35,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,962.088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone-salmeterol 230-21 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173071720,NDC,12,GR,2004.35,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,962.088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Lap Incis Hernia Reducible,PX49654F,CDM,510,RC,49654,CPT,,,,,,,,1964,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,962.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,815.8456,1924.72
Lap Incis Hernia Reducible,PX49654F,CDM,510,RC,49654,CPT,,,,,,,,1964,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,962.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,815.8456,1924.72
Lap Incis Hernia Reducible,PX49654F,CDM,510,RC,49654,CPT,,,,,,,,1964,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,962.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,815.8456,1924.72
"Treat Thumb Disloc,Manipulatn",PX26641P,CDM,983,RC,26641,CPT,,,,,,,,1902,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,962.412,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1851.2166
Tube Thoracostomy Inc Wtr Seal,PX32551F,CDM,510,RC,32551,CPT,,,,,,,,989,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,611.29,percent of total billed charges,962.5937,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,410.8306,1399.13
clobetasol 0.05 % Cream 60 g Tube,63700001,CDM,250,RC,,,,,,168030160,NDC,60,GR,989.25,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,962.837025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Closed Rx Bimalleolar Fx,Manip",PX27810P,CDM,983,RC,27810,CPT,,,,,,,,1057,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,962.927,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,439.0778,1404.08
Debride Tissue/Muscle/Bone,PX11044F,CDM,510,RC,11044,CPT,,,,,,,,1082,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,962.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,449.4628,1416.38
"Lap,Cholecystectomy",PX47562P,CDM,983,RC,47562,CPT,,,,,,,,983,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,963.34,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,396.16,1378.07
fluticasone-salmeterol 230-21 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,66993008896,NDC,12,GR,1904.14,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,963.49484,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Closed Treat Wrist Dislocation,PX25660P,CDM,983,RC,25660,CPT,,,,,,,,1507,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,963.68,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,287.74,1476.86
Closed Treat Wrist Dislocation,PX25660P,CDM,983,RC,25660,CPT,,,,,,,,1507,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,963.68,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,287.74,1476.86
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290101,NDC,1,EA,1966.88,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,2.46342,percent of total billed charges,963.7712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.77,1927.5424
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290101,NDC,1,EA,1966.88,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,963.7712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.77,1927.5424
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290101,NDC,1,EA,1966.88,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,963.7712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.77,1927.5424
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290102,NDC,1,EA,1966.88,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,2.46342,percent of total billed charges,963.7712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.77,1927.5424
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290102,NDC,1,EA,1966.88,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,963.7712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.77,1927.5424
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290102,NDC,1,EA,1966.88,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,963.7712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.77,1927.5424
Closed Rx Femur Shaft Fx+Manip,PX27502P,CDM,983,RC,27502,CPT,,,,,,,,1083,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,963.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,449.8782,1404.08
eriBULin 1 MG/2ML Solution 2 mL Vial,J9179.01,CDM,636,RC,J9179,HCPCS,,,,62856038901,NDC,2,ML,2321.52,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,964.359408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.87,2275.0896
STAPLER SUREFORM 60 SPU IS4000,27200000,CDM,272,RC,,,,12086-MAIN,LOCAL,,,,,991,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,964.5403,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
collagenase 250 UNIT/GM Ointment 30 g Tube,63700001,CDM,250,RC,,,,,,50484001030,NDC,30,GR,1083.77,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,964.5553,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390P,CDM,982,RC,45390,CPT,,,,,,,,1135,,First Health,Commercial,both,85,,999999999,percent of total billed charges,964.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,471.479,2452.93
"Amputation Toe,Mt-P Jt",PX28820F,CDM,510,RC,28820,CPT,,,,,,,,1950,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,965.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,810.03,2827.75
"Closed Rx Talus Fx,Manipulatn",PX28435P,CDM,983,RC,28435,CPT,,,,,,,,1137,,First Health,Commercial,both,85,,999999999,percent of total billed charges,966.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,472.3098,1404.08
"I&D Perianal Abscess,Superficial",PX46050P,CDM,983,RC,46050,CPT,,,,,,,,993,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1268.66,percent of total billed charges,966.4869,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,412.4922,966.4869
"Critical Care, E/M 30-74 Minutes",PX99291P,CDM,983,RC,99291,CPT,,,,,,,,1061,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,966.571,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,440.7394,1032.6713
"I&D Perianal Abscess,Superficial",PX46050,CDM,983,RC,46050,CPT,,,,,,,,1096,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,966.672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,455.2784,1066.7368
GRAFIXPL PRIME PLACENTAL MEMBRANE 2x3CM 6SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12765-MAIN,LOCAL,,,,,1911,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,966.966,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
FORCEPS SPOON JAWSIZE 10MMX36 KIT,27200000,CDM,272,RC,,,,11749-MAIN,LOCAL,,,,,1955,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,967.725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Excis Tendn/Capsule Lesn,Toes",PX28092P,CDM,983,RC,28092,CPT,,,,,,,,1913,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,967.978,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,794.6602,1861.9229
fluticasone-vilanterol 200-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173088214,NDC,28,EA,1087.68,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,968.0352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Cv Carotid Imaging-Bilat,PX9388001,CDM,921,RC,93880,CPT,TC,,,,,,,1088,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,968.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,1066.24
Debride Skin/Tissue,PX11042P,CDM,983,RC,11042,CPT,,,,,,,,995,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,388.9685714,percent of total billed charges,968.4335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,968.4335
"Repair Ing Hernia,5+Y/O,Strang",PX49507F,CDM,510,RC,49507,CPT,,,,,,,,1977,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,968.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,821.2458,3022.41
"Repair Ing Hernia,5+Y/O,Strang",PX49507F,CDM,510,RC,49507,CPT,,,,,,,,1977,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,968.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,821.2458,3022.41
"Repair Ing Hernia,5+Y/O,Strang",PX49507F,CDM,510,RC,49507,CPT,,,,,,,,1977,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,968.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,821.2458,3022.41
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,310072010,NDC,5,ML,1977.83,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,969.1367,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.74,1938.2734
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,310072010,NDC,5,ML,1977.83,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,969.1367,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.74,1938.2734
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,310072010,NDC,5,ML,1977.83,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,969.1367,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.74,1938.2734
Tube Thoracostomy Inc Wtr Seal,PX32551F,CDM,510,RC,32551,CPT,,,,,,,,989,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,969.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,410.8306,1399.13
HERNIA PATCH VENTRALEX SMALL,C1781,CDM,278,RC,C1781,HCPCS,,10203-MAIN,LOCAL,,,,,995.96,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1256.29,percent of total billed charges,969.367868,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
clobetasol 0.05 % Cream 60 g Tube,63700001,CDM,250,RC,,,,,,168030160,NDC,60,GR,989.25,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,969.465,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Cardiac Stress Tst,Tracing Only",PX93017,CDM,482,RC,93017,CPT,,,,,,,,1959,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,969.705,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.21,1919.82
riTUXimab 100 MG/10ML Solution 10 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005121,NDC,10,ML,1916.61,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,969.80466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.61,8682.8588
Remove Hemorrhoids & Fissure,PX46257F,CDM,510,RC,46257,CPT,,,,,,,,1141,,First Health,Commercial,both,85,,999999999,percent of total billed charges,969.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,473.9714,2452.93
Factor VIII (Ahg) 1-Stage,PX85240,CDM,300,RC,85240,CPT,,,,,,,,997,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,970.3801,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.41,977.06
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505F,CDM,510,RC,24505,CPT,,,,,,,,2109,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,970.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.04,1086.13
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505P,CDM,983,RC,24505,CPT,,,,,,,,2353,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,970.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.04,2305.94
paliperidone palmitate ER 234 MG/1.5ML suspension prefilled syringe 1.5 mL Syringe,J2426.01,CDM,636,RC,J2426,HCPCS,,,,50458056401,NDC,0.25,ML,1142.14,,First Health,Commercial,both,85,,999999999,percent of total billed charges,970.819,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.12,1119.2972
STAPLER SUREFORM 60 SPU IS4000,27200000,CDM,272,RC,,,,12086-MAIN,LOCAL,,,,,991,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,971.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151F,CDM,510,RC,13151,CPT,,,,,,,,1143,,First Health,Commercial,both,85,,999999999,percent of total billed charges,971.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,474.8022,1120.14
"Repair Recurr Inguin Hern,Reducibl",PX49520F,CDM,510,RC,49520,CPT,,,,,,,,1983,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,971.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,823.7382,3022.41
"Repair Recurr Inguin Hern,Reducibl",PX49520F,CDM,510,RC,49520,CPT,,,,,,,,1983,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,971.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,823.7382,3022.41
"Repair Recurr Inguin Hern,Reducibl",PX49520F,CDM,510,RC,49520,CPT,,,,,,,,1983,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,971.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,823.7382,3022.41
"Repair Recurr Inguin Hern,Reducibl",PX49520P,CDM,983,RC,49520,CPT,,,,,,,,1983,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,971.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,823.7382,3022.41
"Repair Recurr Inguin Hern,Reducibl",PX49520P,CDM,983,RC,49520,CPT,,,,,,,,1983,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,971.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,823.7382,3022.41
"Repair Recurr Inguin Hern,Reducibl",PX49520P,CDM,983,RC,49520,CPT,,,,,,,,1983,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,971.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,823.7382,3022.41
alteplase 100 MG Recon Soln 1 Each Syringe,J2997.01,CDM,636,RC,J2997,HCPCS,,,,88888800475,NDC,0.09,EA,1920.88,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,971.96528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001501,NDC,1,EA,2340,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,972.036,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.3,2361.4178
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001503,NDC,1,EA,2340,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,972.036,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.3,2361.4178
Debride Skin/Tissue,PX11042F,CDM,510,RC,11042,CPT,,,,,,,,1067,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,972.037,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1045.66
Lap Incis Hernia Reducible,PX49654F,CDM,510,RC,49654,CPT,,,,,,,,1964,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,972.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,815.8456,1924.72
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,64950036204,NDC,4,ML,1067.22,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,972.23742,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,16714081501,NDC,5,ML,998.95,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,66.804,percent of total billed charges,972.278035,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
Bcr/Abl1 P210 - Ref,PX8120690,CDM,310,RC,81206,CPT,90,,,,,,,1144,,First Health,Commercial,both,85,,999999999,percent of total billed charges,972.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.33,1121.12
"Closed Rx Radial Head/Neck Fx,Manip",PX24655F,CDM,510,RC,24655,CPT,,,,,,,,1750,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,972.67,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,259.6,972.67
"Closed Rx Radial Head/Neck Fx,Manip",PX24655P,CDM,983,RC,24655,CPT,,,,,,,,1824,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,972.67,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,259.6,1787.52
Removal of Hemorrhoid Clot,PX46320F,CDM,510,RC,46320,CPT,,,,,,,,2027,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,972.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,842.0158,1986.46
Removal of Hemorrhoid Clot,PX46320F,CDM,510,RC,46320,CPT,,,,,,,,2027,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,972.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,842.0158,1986.46
"I&D Perianal Abscess,Superficial",PX46050P,CDM,983,RC,46050,CPT,,,,,,,,993,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,973.14,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.26,973.14
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290101,NDC,1,EA,1966.88,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,973.6056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.77,1927.5424
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290102,NDC,1,EA,1966.88,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,973.6056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.77,1927.5424
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x4CM 12SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12767-MAIN,LOCAL,,,,,2345,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,974.113,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
"Removal of Tunnel Cv Access Device, With Port/Pump",PX36590P,CDM,983,RC,36590,CPT,,,,,,,,1147,,First Health,Commercial,both,85,,999999999,percent of total billed charges,974.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,476.4638,1399.13
Revise Median N/Carpal Tunnel Surg,PX64721P,CDM,983,RC,64721,CPT,,,,,,,,1927,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,975.062,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,800.4758,1875.5491
"Tte W/Doppler, Complete",PXC8929,CDM,480,RC,C8929,HCPCS,TC,,,,,,,1927,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,975.062,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,699.48,1888.46
Debride Skin/Tissue,PX11042P,CDM,983,RC,11042,CPT,,,,,,,,995,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,975.1,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,37.08,975.1
Lap Rpr Vent Umbilical Hernia Incarcerated or Strangulated,PX49653F,CDM,510,RC,49653,CPT,,,,,,,,1990,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,975.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,826.646,1950.2
Lap Rpr Vent Umbilical Hernia Incarcerated or Strangulated,PX49653F,CDM,510,RC,49653,CPT,,,,,,,,1990,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,975.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,826.646,1950.2
Lap Rpr Vent Umbilical Hernia Incarcerated or Strangulated,PX49653F,CDM,510,RC,49653,CPT,,,,,,,,1990,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,975.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,826.646,1950.2
"I&D Perianal Abscess,Superficial",PX46050,CDM,983,RC,46050,CPT,,,,,,,,1096,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,975.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,455.2784,1066.7368
hydroxocobalamin 5 g Recon Soln 1 Each Box,J3424.01,CDM,636,RC,J3424,HCPCS,,,,11704037001,NDC,1,EA,1991.16,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,975.6684,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,827.127864,1951.3368
hydroxocobalamin 5 g Recon Soln 1 Each Box,J3424.01,CDM,636,RC,J3424,HCPCS,,,,11704037001,NDC,1,EA,1991.16,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,975.6684,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,827.127864,1951.3368
hydroxocobalamin 5 g Recon Soln 1 Each Box,J3424.01,CDM,636,RC,J3424,HCPCS,,,,11704037001,NDC,1,EA,1991.16,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,975.6684,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,827.127864,1951.3368
onabotulinumtoxinA 100 units Recon Soln 1 Each Vial,J0585.01,CDM,636,RC,J0585,HCPCS,,,,23114501,NDC,1,EA,2348.77,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,975.679058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.51,2301.7946
ibutilide 1 MG/10ML Solution 10 mL Vial,J1742.01,CDM,636,RC,J1742,HCPCS,,,,9379401,NDC,10,ML,2349.03,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,975.787062,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.02,2302.0494
"Upper GI Endoscopy,Ctrl Bleed",PX43255P,CDM,983,RC,43255,CPT,,,,,,,,1148,,First Health,Commercial,both,85,,999999999,percent of total billed charges,975.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,476.8792,1662.33
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266P,CDM,983,RC,27266,CPT,,,,,,,,2275,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,975.975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,945.035,2214.2575
HERNIA PATCH VENTRALEX SMALL,C1781,CDM,278,RC,C1781,HCPCS,,10203-MAIN,LOCAL,,,,,995.96,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,976.0408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
inFLIXimab-dyyb 100 MG Recon Soln 1 Each Vial,Q5103.01,CDM,636,RC,Q5103,HCPCS,,,,69080901,NDC,1,EA,1930.42,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,976.79252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.85,1891.8116
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132F,CDM,510,RC,13132,CPT,,,,,,,,1159,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,976.82,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.92,976.82
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132P,CDM,983,RC,13132,CPT,,,,,,,,774,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,976.82,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.92,976.82
Factor VIII (Ahg) 1-Stage,PX85240,CDM,300,RC,85240,CPT,,,,,,,,997,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,977.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,16.41,977.06
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505P,CDM,983,RC,24505,CPT,,,,,,,,2353,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,977.4362,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,977.4362,2290.1749
"Up GI Endoscopy,Dilatn W Guide",PX43248F,CDM,750,RC,43248,CPT,,,,,,,,1995,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,977.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,1955.1
"Up GI Endoscopy,Dilatn W Guide",PX43248F,CDM,750,RC,43248,CPT,,,,,,,,1995,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,977.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,1955.1
"Up GI Endoscopy,Dilatn W Guide",PX43248F,CDM,750,RC,43248,CPT,,,,,,,,1995,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,977.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,1955.1
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752F,CDM,510,RC,27752,CPT,,,,,,,,2280,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,978.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,947.112,2234.4
"Repair Ing Hernia,5+Y/O,Strang",PX49507F,CDM,510,RC,49507,CPT,,,,,,,,1977,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,978.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,821.2458,3022.41
"Biopsy of Prostate,Needle/Punch",PX55700F,CDM,510,RC,55700,CPT,,,,,,,,2039,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,978.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,847.0006,1998.22
"Biopsy of Prostate,Needle/Punch",PX55700F,CDM,510,RC,55700,CPT,,,,,,,,2039,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,978.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,847.0006,1998.22
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,16714081501,NDC,5,ML,998.95,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,978.971,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
"Repair Umbilical Hern,5+Y/O,Strang",PX49587F,CDM,510,RC,49587,CPT,,,,,,,,1110,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,979.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,461.094,1087.8
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,310072010,NDC,5,ML,1977.83,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,979.02585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.74,1938.2734
Abd Paracentesis W/Imaging(T),PX49083F,CDM,510,RC,49083,CPT,,,,,,,,1006,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,979.1398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,417.8924,985.88
"Ht Muscle Image Spect, Mult",PX7845201,CDM,340,RC,78452,CPT,TC,,,,,,,2000,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,450.9683333,percent of total billed charges,980,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,858,5292.1
"Ht Muscle Image Spect, Mult",PX7845201,CDM,340,RC,78452,CPT,TC,,,,,,,2000,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,980,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,858,5292.1
"Ht Muscle Image Spect, Mult",PX7845201,CDM,340,RC,78452,CPT,TC,,,,,,,2000,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,980,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,858,5292.1
"Lap,Inguinal Hernia Repr,Initial",PX49650F,CDM,510,RC,49650,CPT,,,,,,,,1076,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,980.236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,446.9704,5040.74
"Colonoscopy,Remv Lesn,Snare",PX45385F,CDM,750,RC,45385,CPT,,,,,,,,1939,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,981.134,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,831.831,4050.42
Unlisted Molecular Path Proc - Ref,PX8147990,CDM,310,RC,81479,CPT,90,,,,,,,1077,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,981.147,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,447.3858,1055.46
"Repair Recurr Inguin Hern,Reducibl",PX49520F,CDM,510,RC,49520,CPT,,,,,,,,1983,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,981.585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,823.7382,3022.41
"Repair Recurr Inguin Hern,Reducibl",PX49520P,CDM,983,RC,49520,CPT,,,,,,,,1983,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,981.585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,823.7382,3022.41
Bcr/Abl1 Minor - Ref,PX8120790,CDM,310,RC,81207,CPT,90,,,,,,,1113,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,981.666,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.8,1090.74
MICA BURR 2X12MM STERILE MICA,27200000,CDM,272,RC,,,,12447-MAIN,LOCAL,,,,,1113,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,981.666,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA BURR 2X20MM STERILE MICA,27200000,CDM,272,RC,,,,12448-MAIN,LOCAL,,,,,1113,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,981.666,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA CUTTING BURR 3X20MM LONG MICA,27200000,CDM,272,RC,,,,12434-MAIN,LOCAL,,,,,1113,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,981.666,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA WEDGE BURR 3.1X13MM STERILE,27200000,CDM,272,RC,,,,12435-MAIN,LOCAL,,,,,1113,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,981.666,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
fluticasone-salmeterol 230-21 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173071720,NDC,12,GR,2004.35,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,982.1315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone-salmeterol 230-21 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173071720,NDC,12,GR,2004.35,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,982.1315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone-salmeterol 230-21 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173071720,NDC,12,GR,2004.35,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,982.1315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
budesonide-formoterol 160-4.5 MCG/ACT Aerosol 6 g Inhaler,63700001,CDM,250,RC,,,,,,186037028,NDC,6,GR,1078.55,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,982.55905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2.5 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,68682065020,NDC,1,EA,1114.05,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,982.5921,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
darbepoetin alfa 500 MCG/ML solution prefilled syringe 1 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513003201,NDC,0.3,ML,2368.44,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,983.849976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
esmolol 2500 MG/250ML Solution 250 mL Flex Cont,J1805.01,CDM,636,RC,J1805,HCPCS,,,,10019067010,NDC,250,ML,1011.8,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,984.78494,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.24,991.564
Lap Rpr Vent Umbilical Hernia Incarcerated or Strangulated,PX49653F,CDM,510,RC,49653,CPT,,,,,,,,1990,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,985.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,826.646,1950.2
Exc Back Les Sc = 3 Cm,PX21931P,CDM,983,RC,21931,CPT,,,,,,,,2135,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,985.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,286.43,2092.3
Exc Back Les Sc = 3 Cm,PX21931P,CDM,983,RC,21931,CPT,,,,,,,,2135,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,985.12,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,286.43,2092.3
"Initial Repair of Entrapped Hernia of Abdomen, Less Than 3 Cm in Length",PX49592,CDM,982,RC,49592,CPT,,,,,,,,2164,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,985.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,280.1,2120.72
"Initial Repair of Entrapped Hernia of Abdomen, Less Than 3 Cm in Length",PX49592,CDM,982,RC,49592,CPT,,,,,,,,2164,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,985.12,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,280.1,2120.72
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132F,CDM,510,RC,13132,CPT,,,,,,,,1159,,First Health,Commercial,both,85,,999999999,percent of total billed charges,985.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,481.4486,1135.82
hydroxocobalamin 5 g Recon Soln 1 Each Box,J3424.01,CDM,636,RC,J3424,HCPCS,,,,11704037001,NDC,1,EA,1991.16,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,985.6242,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,827.127864,1951.3368
Debride Tissue/Muscle/Bone,PX11044F,CDM,510,RC,11044,CPT,,,,,,,,1082,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,985.702,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,449.4628,1416.38
Abd Paracentesis W/Imaging(T),PX49083F,CDM,510,RC,49083,CPT,,,,,,,,1006,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,985.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,417.8924,985.88
"Fusion Foot Bones,Midtarsal,Multi",PX28730F,CDM,510,RC,28730,CPT,,,,,,,,2299,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,986.271,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,955.0046,11497.76
Closed Rx Femur Shaft Fx+Manip,PX27502P,CDM,983,RC,27502,CPT,,,,,,,,1083,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,986.613,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,449.8782,1404.08
"Amputation Toe,Mt-P Jt",PX28820F,CDM,510,RC,28820,CPT,,,,,,,,1950,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,986.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,810.03,2827.75
Explor Metatarso-Phalang Jt,PX28022F,CDM,510,RC,28022,CPT,,,,,,,,1161,,First Health,Commercial,both,85,,999999999,percent of total billed charges,986.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,482.2794,2827.75
"Lap,Cholecystectomy/Explore",PX47564F,CDM,510,RC,47564,CPT,,,,,,,,2419,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,987.0614,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,668.41,2327.91
"Lap,Cholecystectomy/Explore",PX47564P,CDM,983,RC,47564,CPT,,,,,,,,1613,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,987.0614,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,668.41,2327.91
collagenase 250 UNIT/GM Ointment 30 g Tube,63700001,CDM,250,RC,,,,,,50484001030,NDC,30,GR,1083.77,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,987.31447,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Up GI Endoscopy,Dilatn W Guide",PX43248F,CDM,750,RC,43248,CPT,,,,,,,,1995,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,987.525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,1955.1
Reconstruc of Nail Bed,PX11760F,CDM,510,RC,11760,CPT,,,,,,,,1162,,First Health,Commercial,both,85,,999999999,percent of total billed charges,987.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,482.6948,1138.76
Egd Balloon Dil Esoph30 Mm/>,PX43233F,CDM,750,RC,43233,CPT,,,,,,,,1120,,United Healthcare,All Payer,outpatient,88.2,,999999999,case rate,987.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,987.84,6141.46
"Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602P,CDM,983,RC,11602,CPT,,,,,,,,1120,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,987.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1090.096
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830P,CDM,983,RC,15830,CPT,,,,,,,,1120,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,987.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,465.248,5696.92
Exc Abd Les Sc < 3 Cm,PX22902F,CDM,761,RC,22902,CPT,,,,,,,,3128,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,987.89,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.5,987.89
Exc Abd Les Sc < 3 Cm,PX22902P,CDM,983,RC,22902,CPT,,,,,,,,2086,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,987.89,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.5,2044.28
"Repair Umbilical Hern,5+Y/O,Strang",PX49587F,CDM,510,RC,49587,CPT,,,,,,,,1110,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,987.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,461.094,1087.8
Echo Tt 2d Complete,PX9330701,CDM,480,RC,93307,CPT,TC,,,,,,,2303,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,987.987,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,2256.94
belimumab 120 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010101,NDC,1,EA,1015.95,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,60.46849794,percent of total billed charges,988.824135,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.72,3453.2358
FORCEPS SPOON JAWSIZE 10MMX36 KIT,27200000,CDM,272,RC,,,,11749-MAIN,LOCAL,,,,,1955,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,989.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Ht Muscle Image Spect, Mult",PX7845201,CDM,340,RC,78452,CPT,TC,,,,,,,2000,,Humana Choice Care,All Medicare plans,outpatient,49.5,,1568,percent of total billed charges,990,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,858,5292.1
beclomethasone  HFA 80 MCG/ACT Aerosol Breath Activated 10.6 g Inhaler,63700001,CDM,250,RC,,,,,,59310030480,NDC,10.6,GR,1164.84,,First Health,Commercial,both,85,,999999999,percent of total billed charges,990.114,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Bcr/Abl1 Minor - Ref,PX8120790,CDM,310,RC,81207,CPT,90,,,,,,,1113,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,990.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.8,1090.74
MICA BURR 2X12MM STERILE MICA,27200000,CDM,272,RC,,,,12447-MAIN,LOCAL,,,,,1113,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,990.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA BURR 2X20MM STERILE MICA,27200000,CDM,272,RC,,,,12448-MAIN,LOCAL,,,,,1113,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,990.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA CUTTING BURR 3X20MM LONG MICA,27200000,CDM,272,RC,,,,12434-MAIN,LOCAL,,,,,1113,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,990.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA WEDGE BURR 3.1X13MM STERILE,27200000,CDM,272,RC,,,,12435-MAIN,LOCAL,,,,,1113,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,990.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
fluticasone-vilanterol 200-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173088214,NDC,28,EA,1087.68,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,990.87648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Cv Carotid Imaging-Bilat,PX9388001,CDM,921,RC,93880,CPT,TC,,,,,,,1088,,Medica,Commercial,both,91.1,,126.9,percent of total billed charges,991.168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,1066.24
"Cardiac Stress Tst,Tracing Only",PX93017,CDM,482,RC,93017,CPT,,,,,,,,1959,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,991.254,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.21,1919.82
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505F,CDM,510,RC,25505,CPT,,,,,,,,651,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,991.35,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,295.37,1095.81
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505P,CDM,983,RC,25505,CPT,,,,,,,,977,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,991.35,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,295.37,1095.81
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605F,CDM,510,RC,24605,CPT,,,,,,,,1124,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,991.368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.9096,1404.08
diazePAM 2.5 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,68682065020,NDC,1,EA,1114.05,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,991.5045,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
esmolol 2500 MG/250ML Solution 250 mL Flex Cont,J1805.01,CDM,636,RC,J1805,HCPCS,,,,10019067010,NDC,250,ML,1011.8,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,991.564,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.24,991.564
Part Remv Phalanx of Toe,PX28124F,CDM,510,RC,28124,CPT,,,,,,,,2155,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,992.04,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.82,992.04
Part Remv Phalanx of Toe,PX28124P,CDM,983,RC,28124,CPT,,,,,,,,1515,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,992.04,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.82,1484.7
fluticasone-salmeterol 230-21 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173071720,NDC,12,GR,2004.35,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,992.15325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Bcr/Abl1 Other - Ref,PX8120890,CDM,310,RC,81208,CPT,90,,,,,,,1125,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,992.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,196.79,1102.5
Removal of Hemorrhoid Clot,PX46320F,CDM,510,RC,46320,CPT,,,,,,,,2027,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,993.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,842.0158,1986.46
Removal of Hemorrhoid Clot,PX46320F,CDM,510,RC,46320,CPT,,,,,,,,2027,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,993.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,842.0158,1986.46
Removal of Hemorrhoid Clot,PX46320F,CDM,510,RC,46320,CPT,,,,,,,,2027,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,993.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,842.0158,1986.46
HARMONIC 110 SHEARS 36CM SHAFT,27200000,CDM,272,RC,,,,12043-MAIN,LOCAL,,,,,2392,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,993.6368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ADVANCED INSTRUMENTS VESSEL SEALER EXTEND,27200000,CDM,272,RC,,,,11923-MAIN,LOCAL,,,,,1169,,First Health,Commercial,both,85,,999999999,percent of total billed charges,993.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Lap Incis Hernia Reducible,PX49654F,CDM,510,RC,49654,CPT,,,,,,,,1964,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,993.784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,815.8456,1924.72
"Fac/Exc Skn Benig >4cm Trnk,Arm,Lg",PX11406F,CDM,510,RC,11406,CPT,,,,,,,,1127,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,994.014,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,468.1558,1416.38
"Hemorrhoidectomy,Int/Ext,Simple",PX46255P,CDM,983,RC,46255,CPT,,,,,,,,2393,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,994.0522,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,994.0522,2452.93
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,71288020185,NDC,5,ML,1021.7,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,63.2475,percent of total billed charges,994.42061,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,424.41418,1239.6216
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290101,NDC,1,EA,1966.88,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,995.24128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.77,1927.5424
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290102,NDC,1,EA,1966.88,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,995.24128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.77,1927.5424
belimumab 120 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010101,NDC,1,EA,1015.95,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,995.631,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.72,3453.2358
Heart/Lung Resuscitation (Cpr),PX92950P,CDM,983,RC,92950,CPT,,,,,,,,1023,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,995.6859,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.21,995.6859
eriBULin 1 MG/2ML Solution 2 mL Vial,J9179.01,CDM,636,RC,J9179,HCPCS,,,,62856038901,NDC,2,ML,2321.52,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,995.93208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.87,2275.0896
Egd Balloon Dil Esoph30 Mm/>,PX43233F,CDM,750,RC,43233,CPT,,,,,,,,1120,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,996.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,465.248,1662.33
"Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602P,CDM,983,RC,11602,CPT,,,,,,,,1120,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,996.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1090.096
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830P,CDM,983,RC,15830,CPT,,,,,,,,1120,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,996.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,465.248,5696.92
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565F,CDM,510,RC,25565,CPT,,,,,,,,1250,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,996.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,296.9,1116.57
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565P,CDM,983,RC,25565,CPT,,,,,,,,830,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,996.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,296.9,1116.57
"Lap,Inguinal Hernia Repr,Recur",PX49651P,CDM,983,RC,49651,CPT,,,,,,,,2035,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,997.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,845.339,5040.74
"Lap,Inguinal Hernia Repr,Recur",PX49651P,CDM,983,RC,49651,CPT,,,,,,,,2035,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,997.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,845.339,5040.74
"Lap,Inguinal Hernia Repr,Recur",PX49651P,CDM,983,RC,49651,CPT,,,,,,,,2035,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,997.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,845.339,5040.74
Insert Non-Tunnel Cv Catheter >5 Years,PX36556F,CDM,510,RC,36556,CPT,,,,,,,,1025,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,876.98,percent of total billed charges,997.6325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,425.785,2784.63
"Remv Foot Foreign Body,Subcutaneous",PX28190F,CDM,510,RC,28190,CPT,,,,,,,,1025,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,997.6325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,425.785,1004.5
fluticasone-salmeterol 250-50 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069604,NDC,14,EA,1025.13,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,997.759029,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone furoate-vilanterol 100-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173085914,NDC,28,EA,1025.38,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,998.002354,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830F,CDM,510,RC,15830,CPT,,,,,,,,2080,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,998.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,864.032,5696.92
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830F,CDM,510,RC,15830,CPT,,,,,,,,2080,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,998.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,864.032,5696.92
"I&D Perianal Abscess,Superficial",PX46050,CDM,983,RC,46050,CPT,,,,,,,,1096,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,998.456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,455.2784,1066.7368
"Closed Rx Bimalleolar Fx,Manip",PX27810F,CDM,510,RC,27810,CPT,,,,,,,,1026,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,998.6058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,426.2004,1404.08
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409422801,NDC,100,ML,1026,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,66.804,percent of total billed charges,998.6058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180P,CDM,983,RC,44180,CPT,,,,,,,,1175,,First Health,Commercial,both,85,,999999999,percent of total billed charges,998.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,488.095,5040.74
"Biopsy of Prostate,Needle/Punch",PX55700F,CDM,510,RC,55700,CPT,,,,,,,,2039,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,999.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,847.0006,1998.22
"Biopsy of Prostate,Needle/Punch",PX55700F,CDM,510,RC,55700,CPT,,,,,,,,2039,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,999.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,847.0006,1998.22
"Biopsy of Prostate,Needle/Punch",PX55700F,CDM,510,RC,55700,CPT,,,,,,,,2039,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,999.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,847.0006,1998.22
"VENTRALIGHT MESH ST WITH ECHO 2 - 10 CM X 15 CM - 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,12007-MAIN,LOCAL,,,,,1176,,First Health,Commercial,both,85,,999999999,percent of total billed charges,999.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Revise Median N/Carpal Tunnel Surg,PX64721F,CDM,510,RC,64721,CPT,,,,,,,,2408,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1000.2832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1000.2832,2359.84
"Percut Biopsy, Abdominal Mass",PX49180F,CDM,510,RC,49180,CPT,,,,,,,,2084,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1000.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,865.6936,2042.32
"Percut Biopsy, Abdominal Mass",PX49180F,CDM,510,RC,49180,CPT,,,,,,,,2084,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1000.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,865.6936,2042.32
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605F,CDM,510,RC,24605,CPT,,,,,,,,1124,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1000.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.9096,1404.08
"Repair Ing Hernia,5+Y/O,Strang",PX49507F,CDM,510,RC,49507,CPT,,,,,,,,1977,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1000.362,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,821.2458,3022.41
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151P,CDM,983,RC,13151,CPT,,,,,,,,1177,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1000.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,488.9258,1145.5741
"Needle Biopsy,Muscle",PX20206P,CDM,983,RC,20206,CPT,,,,,,,,1028,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1000.5524,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,427.0312,1416.38
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,310072010,NDC,5,ML,1977.83,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1000.78198,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.74,1938.2734
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,70842014003,NDC,1,EA,2409.61,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1000.951994,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.3,2361.4178
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390P,CDM,982,RC,45390,CPT,,,,,,,,1135,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1001.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,471.479,2452.93
Bcr/Abl1 Other - Ref,PX8120890,CDM,310,RC,81208,CPT,90,,,,,,,1125,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1001.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,196.79,1102.5
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,71288020185,NDC,5,ML,1021.7,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1001.266,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,424.41418,1239.6216
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605F,CDM,510,RC,25605,CPT,,,,,,,,1178,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1001.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,489.3412,1404.08
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606P,CDM,983,RC,11606,CPT,,,,,,,,2044,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1001.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,849.0776,1989.4252
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606P,CDM,983,RC,11606,CPT,,,,,,,,2044,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1001.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,849.0776,1989.4252
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606P,CDM,983,RC,11606,CPT,,,,,,,,2044,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1001.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,849.0776,1989.4252
"Colonoscope, Submucous Inj",PX45381F,CDM,750,RC,45381,CPT,,,,,,,,1179,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1002.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,489.7566,1155.42
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,63323067305,NDC,5,ML,1029.71,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1002.216743,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.08296,1009.1158
Heart/Lung Resuscitation (Cpr),PX92950P,CDM,983,RC,92950,CPT,,,,,,,,1023,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1002.54,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.13,1002.54
"Closed Rx Talus Fx,Manipulatn",PX28435P,CDM,983,RC,28435,CPT,,,,,,,,1137,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1002.834,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,472.3098,1404.08
"Sb Scope,to Ileum,Biopsy",PX44377P,CDM,983,RC,44377,CPT,,,,,,,,1180,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1003,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,490.172,1662.33
"Fac/Exc Skn Benig >4cm Trnk,Arm,Lg",PX11406F,CDM,510,RC,11406,CPT,,,,,,,,1127,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1003.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,468.1558,1416.38
Removal of Hemorrhoid Clot,PX46320F,CDM,510,RC,46320,CPT,,,,,,,,2027,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1003.365,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,842.0158,1986.46
"Repair Recurr Inguin Hern,Reducibl",PX49520F,CDM,510,RC,49520,CPT,,,,,,,,1983,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1003.398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,823.7382,3022.41
"Repair Recurr Inguin Hern,Reducibl",PX49520P,CDM,983,RC,49520,CPT,,,,,,,,1983,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1003.398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,823.7382,3022.41
"Repair Ing Hernia,5+Y/O,Reducibl",PX49505P,CDM,983,RC,49505,CPT,,,,,,,,2048,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1003.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,850.7392,3022.41
"Repair Ing Hernia,5+Y/O,Reducibl",PX49505P,CDM,983,RC,49505,CPT,,,,,,,,2048,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1003.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,850.7392,3022.41
"Repair Ing Hernia,5+Y/O,Reducibl",PX49505P,CDM,983,RC,49505,CPT,,,,,,,,2048,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1003.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,850.7392,3022.41
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001501,NDC,1,EA,2340,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1003.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.3,2361.4178
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001503,NDC,1,EA,2340,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1003.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.3,2361.4178
Insert Non-Tunnel Cv Catheter >5 Years,PX36556F,CDM,510,RC,36556,CPT,,,,,,,,1025,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1004.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,425.785,2784.63
"Remv Foot Foreign Body,Subcutaneous",PX28190F,CDM,510,RC,28190,CPT,,,,,,,,1025,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1004.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,425.785,1004.5
fluticasone-salmeterol 250-50 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069604,NDC,14,EA,1025.13,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1004.6274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
GROSHONG PICC NXT 4FR,120.218,CDM,272,RC,,,,498-MAIN,LOCAL,,,,,1182,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1004.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,491.0028,1158.36
"Lap,Cholecystectomy/Explore",PX47564F,CDM,510,RC,47564,CPT,,,,,,,,2419,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1004.8526,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1004.8526,8992.74
fluticasone furoate-vilanterol 100-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173085914,NDC,28,EA,1025.38,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1004.8724,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Closed Rx Bimalleolar Fx,Manip",PX27810F,CDM,510,RC,27810,CPT,,,,,,,,1026,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1005.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,426.2004,1404.08
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409422801,NDC,100,ML,1026,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1005.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x4CM 12SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12767-MAIN,LOCAL,,,,,2345,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1006.005,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
CT Chest Spine W/Dye,PX7212901,CDM,350,RC,72129,CPT,TC,,,,,,,2096,,Health Partners,Health Partners Care Plans,both,48,,971.84,percent of total billed charges,1006.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,2054.08
CT Chest Spine W/Dye,PX7212901,CDM,350,RC,72129,CPT,TC,,,,,,,2096,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1006.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,2054.08
MICA SCREW 4.0X32MM FULLY THREADED STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12894-MAIN,LOCAL,,,,,2096,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1006.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
MICA SCREW 4.0X32MM FULLY THREADED STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12894-MAIN,LOCAL,,,,,2096,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1006.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 3.0X38MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12984-MAIN,LOCAL,,,,,2096,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1006.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 3.0X38MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12984-MAIN,LOCAL,,,,,2096,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1006.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X42MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12948-MAIN,LOCAL,,,,,2096,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1006.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X42MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12948-MAIN,LOCAL,,,,,2096,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1006.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X44MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12893-MAIN,LOCAL,,,,,2096,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1006.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X44MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12893-MAIN,LOCAL,,,,,2096,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1006.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X56MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12947-MAIN,LOCAL,,,,,2096,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1006.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X56MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12947-MAIN,LOCAL,,,,,2096,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1006.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Remove Hemorrhoids & Fissure,PX46257F,CDM,510,RC,46257,CPT,,,,,,,,1141,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1006.362,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,473.9714,2452.93
Place Needle in Vein,PX36000P,CDM,983,RC,36000,CPT,,,,,,,,1034,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1006.3922,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,429.5236,1006.3922
Lap Rpr Vent Umbilical Hernia Incarcerated or Strangulated,PX49653F,CDM,510,RC,49653,CPT,,,,,,,,1990,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1006.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,826.646,1950.2
"Hemorrhoidectomy,Int/Ext,Complx",PX46260F,CDM,750,RC,46260,CPT,,,,,,,,1350,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1007.26,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,299.3,1007.26
"Hemorrhoidectomy,Int/Ext,Complx",PX46260F,CDM,750,RC,46260,CPT,,,,,,,,1350,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1007.26,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,299.3,1007.26
"Lap,Inguinal Hernia Repr,Recur",PX49651P,CDM,983,RC,49651,CPT,,,,,,,,2035,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1007.325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,845.339,5040.74
paliperidone palmitate ER 234 MG/1.5ML suspension prefilled syringe 1.5 mL Syringe,J2426.01,CDM,636,RC,J2426,HCPCS,,,,50458056401,NDC,0.25,ML,1142.14,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1007.36748,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.12,1119.2972
"Needle Biopsy,Muscle",PX20206P,CDM,983,RC,20206,CPT,,,,,,,,1028,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1007.44,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,35.55,1007.44
hydroxocobalamin 5 g Recon Soln 1 Each Box,J3424.01,CDM,636,RC,J3424,HCPCS,,,,11704037001,NDC,1,EA,1991.16,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1007.52696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,827.127864,1951.3368
onabotulinumtoxinA 100 units Recon Soln 1 Each Vial,J0585.01,CDM,636,RC,J0585,HCPCS,,,,23114501,NDC,1,EA,2348.77,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1007.62233,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.51,2301.7946
ibutilide 1 MG/10ML Solution 10 mL Vial,J1742.01,CDM,636,RC,J1742,HCPCS,,,,9379401,NDC,10,ML,2349.03,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1007.73387,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.02,2302.0494
Level 3 Additional Procedure,PX36000082,CDM,360,RC,,,,,,,,,,2100,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,872.34,2058
Level 3 Additional Procedure,PX36000082,CDM,360,RC,,,,,,,,,,2100,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,872.34,2058
Or Level 3,PX36000003,CDM,360,RC,,,,,,,,,,2100,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,872.34,2058
Or Level 3,PX36000003,CDM,360,RC,,,,,,,,,,2100,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,872.34,2058
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151F,CDM,510,RC,13151,CPT,,,,,,,,1143,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1008.126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,474.8022,1120.14
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384F,CDM,750,RC,45384,CPT,,,,,,,,2350,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1008.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1008.15,4050.42
Bcr/Abl1 P210 - Ref,PX8120690,CDM,310,RC,81206,CPT,90,,,,,,,1144,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1009.008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.33,1121.12
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,63323067305,NDC,5,ML,1029.71,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1009.1158,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.08296,1009.1158
"Biopsy of Prostate,Needle/Punch",PX55700F,CDM,510,RC,55700,CPT,,,,,,,,2039,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1009.305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,847.0006,1998.22
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505P,CDM,983,RC,24505,CPT,,,,,,,,2353,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1009.437,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,977.4362,2290.1749
"Up GI Endoscopy,Dilatn W Guide",PX43248F,CDM,750,RC,43248,CPT,,,,,,,,1995,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1009.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,1955.1
Art Lower Extremity-Bilat,PX9392501,CDM,921,RC,93925,CPT,TC,,,,,,,1188,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1009.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,1164.24
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390P,CDM,982,RC,45390,CPT,,,,,,,,1135,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1010.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,471.479,2452.93
Room Rate Icc,PX20601000,CDM,206,RC,,,,,,,,,,2432,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1010.2528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1010.2528,2383.36
Ven Duplex Bilateral,PX9397001,CDM,921,RC,93970,CPT,TC,,,,,,,1189,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1010.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,1165.22
"Repair Umbilical Hern,5+Y/O,Strang",PX49587F,CDM,510,RC,49587,CPT,,,,,,,,1110,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1011.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,461.094,1087.8
"Close Rx Fingr Articular Fx,Manip",PX26742F,CDM,510,RC,26742,CPT,,,,,,,,1039,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1011.2587,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,431.6006,1404.08
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384F,CDM,750,RC,45384,CPT,,,,,,,,2350,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1011.41,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.09,1011.41
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384P,CDM,983,RC,45384,CPT,,,,,,,,1436,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1011.41,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.09,1407.28
"Removal of Tunnel Cv Access Device, With Port/Pump",PX36590P,CDM,983,RC,36590,CPT,,,,,,,,1147,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1011.654,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,476.4638,1399.13
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606P,CDM,983,RC,11606,CPT,,,,,,,,2044,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1011.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,849.0776,1989.4252
"Closed Rx Talus Fx,Manipulatn",PX28435P,CDM,983,RC,28435,CPT,,,,,,,,1137,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1011.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,472.3098,1404.08
"Ht Muscle Image Spect, Mult",PX7845201,CDM,340,RC,78452,CPT,TC,,,,,,,2000,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1012,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,858,5292.1
Explor Metatarso-Phalang Jt,PX28022F,CDM,510,RC,28022,CPT,,,,,,,,1161,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1012.1,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,207.02,1012.1
Explor Metatarso-Phalang Jt,PX28022P,CDM,983,RC,28022,CPT,,,,,,,,774,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1012.1,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,207.02,1012.1
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505F,CDM,510,RC,24505,CPT,,,,,,,,2109,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1012.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,876.0786,2066.82
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505F,CDM,510,RC,24505,CPT,,,,,,,,2109,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1012.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,876.0786,2066.82
"Upper GI Endoscopy,Ctrl Bleed",PX43255P,CDM,983,RC,43255,CPT,,,,,,,,1148,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1012.536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,476.8792,1662.33
Place Needle in Vein,PX36000P,CDM,983,RC,36000,CPT,,,,,,,,1034,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1013.32,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.45,1013.32
"Repair Ing Hernia,5+Y/O,Reducibl",PX49505P,CDM,983,RC,49505,CPT,,,,,,,,2048,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1013.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,850.7392,3022.41
Bcr/Abl1 Minor - Ref,PX8120790,CDM,310,RC,81207,CPT,90,,,,,,,1113,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1013.943,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.8,1090.74
MICA BURR 2X12MM STERILE MICA,27200000,CDM,272,RC,,,,12447-MAIN,LOCAL,,,,,1113,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1013.943,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA BURR 2X20MM STERILE MICA,27200000,CDM,272,RC,,,,12448-MAIN,LOCAL,,,,,1113,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1013.943,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA CUTTING BURR 3X20MM LONG MICA,27200000,CDM,272,RC,,,,12434-MAIN,LOCAL,,,,,1113,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1013.943,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA WEDGE BURR 3.1X13MM STERILE,27200000,CDM,272,RC,,,,12435-MAIN,LOCAL,,,,,1113,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1013.943,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Upper GI Endoscopy,Biopsy",PX43239F,CDM,750,RC,43239,CPT,,,,,,,,2364,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1014.156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,3859.68
fluticasone-salmeterol 230-21 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173071720,NDC,12,GR,2004.35,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1014.2011,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
diazePAM 2.5 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,68682065020,NDC,1,EA,1114.05,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1014.89955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Repair of Vagina,PX57200P,CDM,983,RC,57200,CPT,,,,,,,,1043,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1015.1519,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,433.2622,2731.23
Remove Hemorrhoids & Fissure,PX46257F,CDM,510,RC,46257,CPT,,,,,,,,1141,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1015.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,473.9714,2452.93
darbepoetin alfa 500 MCG/ML solution prefilled syringe 1 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513003201,NDC,0.3,ML,2368.44,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1016.06076,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
Lap Incis Hernia Reducible,PX49654P,CDM,983,RC,49654,CPT,,,,,,,,1044,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1016.1252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,433.6776,1016.1252
paliperidone palmitate ER 234 MG/1.5ML suspension prefilled syringe 1.5 mL Syringe,J2426.01,CDM,636,RC,J2426,HCPCS,,,,50458056401,NDC,0.25,ML,1142.14,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1016.5046,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.12,1119.2972
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151F,CDM,510,RC,13151,CPT,,,,,,,,1143,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1017.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,474.8022,1120.14
"Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601P,CDM,983,RC,11601,CPT,,,,,,,,1046,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1018.0718,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,434.5084,1018.0718
Fac/Ligation of Hemorrhoid(S),PX46221F,CDM,510,RC,46221,CPT,,,,,,,,1046,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,838.87,percent of total billed charges,1018.0718,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,434.5084,1025.08
ULTRAGUIDE CTR SX-ONE MICROKNIFE 600112-001,27200000,CDM,272,RC,,,,13106-MAIN,LOCAL,,,,,2121,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1018.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ULTRAGUIDE CTR SX-ONE MICROKNIFE 600112-001,27200000,CDM,272,RC,,,,13106-MAIN,LOCAL,,,,,2121,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1018.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Bcr/Abl1 P210 - Ref,PX8120690,CDM,310,RC,81206,CPT,90,,,,,,,1144,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1018.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.33,1121.12
"Close Rx Fingr Articular Fx,Manip",PX26742F,CDM,510,RC,26742,CPT,,,,,,,,1039,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1018.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,431.6006,1404.08
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830F,CDM,510,RC,15830,CPT,,,,,,,,2080,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1019.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,864.032,5696.92
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830F,CDM,510,RC,15830,CPT,,,,,,,,2080,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1019.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,864.032,5696.92
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830F,CDM,510,RC,15830,CPT,,,,,,,,2080,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1019.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,864.032,5696.92
filgrastim-sndz 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314031801,NDC,0.5,ML,1047.2,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1.757613333,percent of total billed charges,1019.23976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,1630.2692
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605F,CDM,510,RC,24605,CPT,,,,,,,,1124,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1019.71,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,304.32,1019.71
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605F,CDM,510,RC,24605,CPT,,,,,,,,1124,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1019.71,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,304.32,1019.71
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605P,CDM,983,RC,24605,CPT,,,,,,,,750,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1019.71,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,304.32,1019.71
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605P,CDM,983,RC,24605,CPT,,,,,,,,750,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1019.71,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,304.32,1019.71
"Colonoscopy,Flex,Diagnostic",PX45378P,CDM,983,RC,45378,CPT,,,,,,,,1200,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1020,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,514.8,4661.91
Level 1 Additional Procedure,PX36000080,CDM,360,RC,,,,,,,,,,1200,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1020,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,498.48,1176
Egd Balloon Dil Esoph30 Mm/>,PX43233F,CDM,750,RC,43233,CPT,,,,,,,,1120,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1020.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,465.248,1662.33
"Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602P,CDM,983,RC,11602,CPT,,,,,,,,1120,,Medica,Commercial,both,91.1,,113.795,percent of total billed charges,1020.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1090.096
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830P,CDM,983,RC,15830,CPT,,,,,,,,1120,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1020.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,465.248,5696.92
"Removal of Tunnel Cv Access Device, With Port/Pump",PX36590P,CDM,983,RC,36590,CPT,,,,,,,,1147,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1020.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,476.4638,1399.13
"Excis Arm/Elbow Tumor,Subcutan",PX24075P,CDM,983,RC,24075,CPT,,,,,,,,2458,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1021.0532,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1021.0532,2392.3714
"Closed Rx Bimalleolar Fx,Manip",PX27810F,CDM,510,RC,27810,CPT,,,,,,,,1026,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1021.1,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,272.25,1021.1
"Closed Rx Bimalleolar Fx,Manip",PX27810P,CDM,983,RC,27810,CPT,,,,,,,,1057,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1021.1,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,272.25,1035.86
I&D Deep Absc/Hematoma Neck/Chest,PX21501F,CDM,510,RC,21501,CPT,,,,,,,,773,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1021.1,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,210.51,1021.1
I&D Deep Absc/Hematoma Neck/Chest,PX21501P,CDM,983,RC,21501,CPT,,,,,,,,515,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1021.1,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,210.51,1021.1
"Percut Biopsy, Abdominal Mass",PX49180F,CDM,510,RC,49180,CPT,,,,,,,,2084,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1021.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,865.6936,2042.32
"Percut Biopsy, Abdominal Mass",PX49180F,CDM,510,RC,49180,CPT,,,,,,,,2084,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1021.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,865.6936,2042.32
"Percut Biopsy, Abdominal Mass",PX49180F,CDM,510,RC,49180,CPT,,,,,,,,2084,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1021.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,865.6936,2042.32
"Upper GI Endoscopy,Ctrl Bleed",PX43255P,CDM,983,RC,43255,CPT,,,,,,,,1148,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1021.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,476.8792,1662.33
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,781325394,NDC,1,EA,1049.95,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1021.916335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,72485020101,NDC,1,EA,1049.95,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1021.916335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
"Complex Drainage, Wound",PX10180F,CDM,510,RC,10180,CPT,,,,,,,,1050,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1021.965,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,436.17,2482.37
Red Blood Cells Unit,PXP9021,CDM,390,RC,P9021,HCPCS,,,,,,,,1050,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1021.965,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.17,1029
inFLIXimab 100 MG Recon Soln 1 Each Vial,J1745.01,CDM,636,RC,J1745,HCPCS,,,,57894003001,NDC,1,EA,2382.35,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1022.02815,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.49,2334.703
Exc Abd Les Sc < 3 Cm,PX22902P,CDM,983,RC,22902,CPT,,,,,,,,2086,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1022.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,866.5244,2030.3038
Exc Abd Les Sc < 3 Cm,PX22902P,CDM,983,RC,22902,CPT,,,,,,,,2086,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1022.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,866.5244,2030.3038
Exc Abd Les Sc < 3 Cm,PX22902P,CDM,983,RC,22902,CPT,,,,,,,,2086,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1022.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,866.5244,2030.3038
Repair of Vagina,PX57200P,CDM,983,RC,57200,CPT,,,,,,,,1043,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1022.14,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,208.98,1022.14
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132F,CDM,510,RC,13132,CPT,,,,,,,,1159,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1022.238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,481.4486,1135.82
Lap Incis Hernia Reducible,PX49654P,CDM,983,RC,49654,CPT,,,,,,,,1044,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1023.12,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,743.3465,1023.12
ramuCIRumab 100 MG/10ML Solution 10 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2766901,NDC,10,ML,2463.3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1023.25482,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.57,12070.17
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605F,CDM,510,RC,24605,CPT,,,,,,,,1124,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1023.964,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.9096,1404.08
Explor Metatarso-Phalang Jt,PX28022F,CDM,510,RC,28022,CPT,,,,,,,,1161,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1024.002,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,482.2794,2827.75
"Repair Lip,>1/2 Vert Height",PX40654F,CDM,510,RC,40654,CPT,,,,,,,,2467,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1024.7918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1024.7918,2417.66
Bcr/Abl1 Other - Ref,PX8120890,CDM,310,RC,81208,CPT,90,,,,,,,1125,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1024.875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,196.79,1102.5
Reconstruc of Nail Bed,PX11760F,CDM,510,RC,11760,CPT,,,,,,,,1162,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1024.884,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,482.6948,1138.76
"Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601P,CDM,983,RC,11601,CPT,,,,,,,,1046,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1025.08,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.37,1025.08
Fac/Ligation of Hemorrhoid(S),PX46221F,CDM,510,RC,46221,CPT,,,,,,,,1046,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1025.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,434.5084,1025.08
Removal of Hemorrhoid Clot,PX46320F,CDM,510,RC,46320,CPT,,,,,,,,2027,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1025.662,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,842.0158,1986.46
"Sigmoidoscopy,Remv Lesn,Snare",PX45338F,CDM,510,RC,45338,CPT,,,,,,,,2137,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1025.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,887.7098,2094.26
"Sigmoidoscopy,Remv Lesn,Snare",PX45338F,CDM,510,RC,45338,CPT,,,,,,,,2137,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1025.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,887.7098,2094.26
Facility Emergency Level IV Visit,PX99284F,CDM,450,RC,99284,CPT,,,,,,,,1054,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,290.657994,percent of total billed charges,1025.8582,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.93,1032.92
HARMONIC 110 SHEARS 36CM SHAFT,27200000,CDM,272,RC,,,,12043-MAIN,LOCAL,,,,,2392,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1026.168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
filgrastim-sndz 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314031801,NDC,0.5,ML,1047.2,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1026.256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,1630.2692
"Hemorrhoidectomy,Int/Ext,Simple",PX46255P,CDM,983,RC,46255,CPT,,,,,,,,2393,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1026.597,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,994.0522,2452.93
"Repair Flex Foot Tendon,Ea",PX28200F,CDM,510,RC,28200,CPT,,,,,,,,1475,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1026.63,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,207.02,1026.63
"Fac/Exc Skn Benig >4cm Trnk,Arm,Lg",PX11406F,CDM,510,RC,11406,CPT,,,,,,,,1127,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1026.697,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,468.1558,1416.38
CT Chest Spine W/Dye,PX7212901,CDM,350,RC,72129,CPT,TC,,,,,,,2096,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1027.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,2054.08
CT Chest Spine W/Dye,PX7212901,CDM,350,RC,72129,CPT,TC,,,,,,,2096,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1027.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,2054.08
CT Chest Spine W/Dye,PX7212901,CDM,350,RC,72129,CPT,TC,,,,,,,2096,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1027.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,2054.08
MICA SCREW 4.0X32MM FULLY THREADED STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12894-MAIN,LOCAL,,,,,2096,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,1027.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
MICA SCREW 4.0X32MM FULLY THREADED STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12894-MAIN,LOCAL,,,,,2096,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1027.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
MICA SCREW 4.0X32MM FULLY THREADED STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12894-MAIN,LOCAL,,,,,2096,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1027.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 3.0X38MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12984-MAIN,LOCAL,,,,,2096,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,1027.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 3.0X38MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12984-MAIN,LOCAL,,,,,2096,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1027.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 3.0X38MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12984-MAIN,LOCAL,,,,,2096,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1027.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X42MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12948-MAIN,LOCAL,,,,,2096,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,1027.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X42MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12948-MAIN,LOCAL,,,,,2096,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1027.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X42MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12948-MAIN,LOCAL,,,,,2096,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1027.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X44MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12893-MAIN,LOCAL,,,,,2096,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,1027.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X44MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12893-MAIN,LOCAL,,,,,2096,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1027.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X44MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12893-MAIN,LOCAL,,,,,2096,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1027.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X56MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12947-MAIN,LOCAL,,,,,2096,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,1027.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X56MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12947-MAIN,LOCAL,,,,,2096,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1027.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X56MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12947-MAIN,LOCAL,,,,,2096,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1027.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
beclomethasone  HFA 80 MCG/ACT Aerosol Breath Activated 10.6 g Inhaler,63700001,CDM,250,RC,,,,,,59310030480,NDC,10.6,GR,1164.84,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1027.38888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
REVITA PLACENTAL MEMBRANE 2X3CM 6SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12559-MAIN,LOCAL,,,,,2474,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1027.6996,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
"Closed Rx Bimalleolar Fx,Manip",PX27810P,CDM,983,RC,27810,CPT,,,,,,,,1057,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1028.7781,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,439.0778,1404.08
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,781325394,NDC,1,EA,1049.95,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1028.951,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,72485020101,NDC,1,EA,1049.95,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1028.951,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.30688,1028.951
"Complex Drainage, Wound",PX10180F,CDM,510,RC,10180,CPT,,,,,,,,1050,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1029,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,436.17,2482.37
Level 3 Additional Procedure,PX36000082,CDM,360,RC,,,,,,,,,,2100,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1029,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,872.34,2058
Level 3 Additional Procedure,PX36000082,CDM,360,RC,,,,,,,,,,2100,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1029,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,872.34,2058
Level 3 Additional Procedure,PX36000082,CDM,360,RC,,,,,,,,,,2100,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1029,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,872.34,2058
Or Level 3,PX36000003,CDM,360,RC,,,,,,,,,,2100,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1029,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,872.34,2058
Or Level 3,PX36000003,CDM,360,RC,,,,,,,,,,2100,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1029,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,872.34,2058
Or Level 3,PX36000003,CDM,360,RC,,,,,,,,,,2100,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1029,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,872.34,2058
Red Blood Cells Unit,PXP9021,CDM,390,RC,P9021,HCPCS,,,,,,,,1050,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1029,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,125.17,1029
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830F,CDM,510,RC,15830,CPT,,,,,,,,2080,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1029.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,864.032,5696.92
"Lap,Inguinal Hernia Repr,Recur",PX49651P,CDM,983,RC,49651,CPT,,,,,,,,2035,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1029.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,845.339,5040.74
diazePAM 10 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,93613832,NDC,1,EA,1212.57,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1030.6845,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Colonoscope, Submucous Inj",PX45381F,CDM,750,RC,45381,CPT,,,,,,,,1179,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1030.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,489.7566,1155.42
"Colonoscope, Submucous Inj",PX45381P,CDM,983,RC,45381,CPT,,,,,,,,1215,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1030.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,504.711,1182.5595
"Colonoscopy,Biopsy",PX45380F,CDM,750,RC,45380,CPT,,,,,,,,2465,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1030.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1030.93,4050.42
"Colonoscopy,Biopsy",PX45380P,CDM,983,RC,45380,CPT,,,,,,,,2539,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1030.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1030.93,4050.42
"Colonoscopy,Control Bleeding",PX45382F,CDM,750,RC,45382,CPT,,,,,,,,1215,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1030.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,504.711,1190.7
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384F,CDM,750,RC,45384,CPT,,,,,,,,2350,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1030.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1008.15,4050.42
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384P,CDM,983,RC,45384,CPT,,,,,,,,1436,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1030.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,616.044,4050.42
"Colonoscopy,Remv Lesn,Snare",PX45385F,CDM,750,RC,45385,CPT,,,,,,,,1939,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1030.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,831.831,4050.42
"Colonoscopy,Remv Lesn,Snare",PX45385P,CDM,983,RC,45385,CPT,,,,,,,,2424,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1030.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1030.93,4050.42
I&D Perirectal Abscess,PX46040F,CDM,510,RC,46040,CPT,,,,,,,,1430,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1030.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,594.022,1401.4
I&D Perirectal Abscess,PX46040P,CDM,983,RC,46040,CPT,,,,,,,,953,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1030.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,395.8762,1030.93
Removal of Hemorrhoid Clot,PX46320F,CDM,510,RC,46320,CPT,,,,,,,,2027,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1030.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,842.0158,1986.46
Removal of Hemorrhoid Clot,PX46320P,CDM,983,RC,46320,CPT,,,,,,,,374,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1030.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,1030.93
"Sigmoidoscopy,Remv Lesn,Snare",PX45338F,CDM,510,RC,45338,CPT,,,,,,,,2137,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1030.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,887.7098,2094.26
"Sigmoidoscopy,Remv Lesn,Snare",PX45338P,CDM,983,RC,45338,CPT,,,,,,,,1710,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1030.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,710.334,1664.343
"Repair Ing Hernia,5+Y/O,Strang",PX49507P,CDM,983,RC,49507,CPT,,,,,,,,2482,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1031.0228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1031.0228,3022.41
ADVANCED INSTRUMENTS VESSEL SEALER EXTEND,27200000,CDM,272,RC,,,,11923-MAIN,LOCAL,,,,,1169,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1031.058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132F,CDM,510,RC,13132,CPT,,,,,,,,1159,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1031.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,481.4486,1135.82
"Percut Biopsy, Abdominal Mass",PX49180F,CDM,510,RC,49180,CPT,,,,,,,,2084,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1031.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,865.6936,2042.32
"Biopsy of Prostate,Needle/Punch",PX55700F,CDM,510,RC,55700,CPT,,,,,,,,2039,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1031.734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,847.0006,1998.22
Exc Abd Les Sc < 3 Cm,PX22902P,CDM,983,RC,22902,CPT,,,,,,,,2086,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1032.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,866.5244,2030.3038
"Critical Care, E/M 30-74 Minutes",PX99291P,CDM,983,RC,99291,CPT,,,,,,,,1061,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,971.295,percent of total billed charges,1032.6713,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,440.7394,1032.6713
"Colonoscope, Submucous Inj",PX45381P,CDM,983,RC,45381,CPT,,,,,,,,1215,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1032.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,504.711,1182.5595
"Colonoscopy,Control Bleeding",PX45382F,CDM,750,RC,45382,CPT,,,,,,,,1215,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1032.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,504.711,1190.7
"Igh, Variable Region Somatic Mutation Analysis",PX8126390,CDM,310,RC,81263,CPT,90,,,,,,,1215,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1032.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.05,1190.7
Facility Emergency Level IV Visit,PX99284F,CDM,450,RC,99284,CPT,,,,,,,,1054,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1032.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.93,1032.92
Revise Median N/Carpal Tunnel Surg,PX64721F,CDM,510,RC,64721,CPT,,,,,,,,2408,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1033.032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1000.2832,2359.84
Explor Metatarso-Phalang Jt,PX28022F,CDM,510,RC,28022,CPT,,,,,,,,1161,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1033.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,482.2794,2827.75
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505F,CDM,510,RC,24505,CPT,,,,,,,,2109,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1033.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,876.0786,2066.82
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505F,CDM,510,RC,24505,CPT,,,,,,,,2109,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1033.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,876.0786,2066.82
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505F,CDM,510,RC,24505,CPT,,,,,,,,2109,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1033.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,876.0786,2066.82
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,70842014003,NDC,1,EA,2409.61,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1033.72269,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.3,2361.4178
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390P,CDM,982,RC,45390,CPT,,,,,,,,1135,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1033.985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,471.479,2452.93
Reconstruc of Nail Bed,PX11760F,CDM,510,RC,11760,CPT,,,,,,,,1162,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1034.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,482.6948,1138.76
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606P,CDM,983,RC,11606,CPT,,,,,,,,2044,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1034.264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,849.0776,1989.4252
Part Remv Phalanx of Toe,PX28124F,CDM,510,RC,28124,CPT,,,,,,,,2155,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1034.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,895.187,2827.75
Part Remv Phalanx of Toe,PX28124F,CDM,510,RC,28124,CPT,,,,,,,,2155,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1034.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,895.187,2827.75
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569F,CDM,510,RC,36569,CPT,,,,,,,,1217,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1034.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,505.5418,1399.13
"Closed Rx Talus Fx,Manipulatn",PX28435P,CDM,983,RC,28435,CPT,,,,,,,,1137,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1035.807,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,472.3098,1404.08
"Closed Rx Bimalleolar Fx,Manip",PX27810P,CDM,983,RC,27810,CPT,,,,,,,,1057,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1035.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,272.25,1035.86
"Repair Ing Hernia,5+Y/O,Reducibl",PX49505P,CDM,983,RC,49505,CPT,,,,,,,,2048,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1036.288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,850.7392,3022.41
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180P,CDM,983,RC,44180,CPT,,,,,,,,1175,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1036.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,488.095,5040.74
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752P,CDM,983,RC,27752,CPT,,,,,,,,2495,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1036.423,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1036.423,2428.3835
beclomethasone  HFA 80 MCG/ACT Aerosol Breath Activated 10.6 g Inhaler,63700001,CDM,250,RC,,,,,,59310030480,NDC,10.6,GR,1164.84,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1036.7076,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"VENTRALIGHT MESH ST WITH ECHO 2 - 10 CM X 15 CM - 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,12007-MAIN,LOCAL,,,,,1176,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1037.232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
CT Chest Spine W/Dye,PX7212901,CDM,350,RC,72129,CPT,TC,,,,,,,2096,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1037.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,2054.08
MICA SCREW 4.0X32MM FULLY THREADED STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12894-MAIN,LOCAL,,,,,2096,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1037.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 3.0X38MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12984-MAIN,LOCAL,,,,,2096,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1037.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X42MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12948-MAIN,LOCAL,,,,,2096,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1037.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X44MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12893-MAIN,LOCAL,,,,,2096,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1037.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X56MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12947-MAIN,LOCAL,,,,,2096,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1037.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"Lap,Cholecystectomy/Explore",PX47564F,CDM,510,RC,47564,CPT,,,,,,,,2419,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1037.751,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1004.8526,8992.74
Bone Marrow Biopsy(Ies),PX38221F,CDM,510,RC,38221,CPT,,,,,,,,1221,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1037.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,507.2034,1416.38
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151P,CDM,983,RC,13151,CPT,,,,,,,,1177,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1038.114,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,488.9258,1145.5741
Debride Skin/Tissue,PX11042F,CDM,510,RC,11042,CPT,,,,,,,,1067,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,388.9685714,percent of total billed charges,1038.5111,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1045.66
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,64950036204,NDC,4,ML,1067.22,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1038.725226,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605F,CDM,510,RC,25605,CPT,,,,,,,,1178,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1038.996,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,489.3412,1404.08
ULTRAGUIDE CTR SX-ONE MICROKNIFE 600112-001,27200000,CDM,272,RC,,,,13106-MAIN,LOCAL,,,,,2121,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1039.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ULTRAGUIDE CTR SX-ONE MICROKNIFE 600112-001,27200000,CDM,272,RC,,,,13106-MAIN,LOCAL,,,,,2121,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1039.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ULTRAGUIDE CTR SX-ONE MICROKNIFE 600112-001,27200000,CDM,272,RC,,,,13106-MAIN,LOCAL,,,,,2121,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1039.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Remove Hemorrhoids & Fissure,PX46257F,CDM,510,RC,46257,CPT,,,,,,,,1141,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1039.451,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,473.9714,2452.93
Level 3 Additional Procedure,PX36000082,CDM,360,RC,,,,,,,,,,2100,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1039.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,872.34,2058
Or Level 3,PX36000003,CDM,360,RC,,,,,,,,,,2100,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1039.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,872.34,2058
"Critical Care, E/M 30-74 Minutes",PX99291P,CDM,983,RC,99291,CPT,,,,,,,,1061,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1039.78,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.04,1039.78
"Colonoscope, Submucous Inj",PX45381F,CDM,750,RC,45381,CPT,,,,,,,,1179,,United Healthcare,All Payer,outpatient,88.2,,999999999,case rate,1039.878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1039.878,6141.46
"Colonoscopy,Remv Lesn,Snare",PX45385P,CDM,983,RC,45385,CPT,,,,,,,,2424,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1039.896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1030.93,4050.42
ADVANCED INSTRUMENTS VESSEL SEALER EXTEND,27200000,CDM,272,RC,,,,11923-MAIN,LOCAL,,,,,1169,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1040.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
paliperidone palmitate ER 234 MG/1.5ML suspension prefilled syringe 1.5 mL Syringe,J2426.01,CDM,636,RC,J2426,HCPCS,,,,50458056401,NDC,0.25,ML,1142.14,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1040.48954,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.12,1119.2972
"Sb Scope,to Ileum,Biopsy",PX44377P,CDM,983,RC,44377,CPT,,,,,,,,1180,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1040.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,490.172,1662.33
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151F,CDM,510,RC,13151,CPT,,,,,,,,1143,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1041.273,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,474.8022,1120.14
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x3CM 9SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12766-MAIN,LOCAL,,,,,2171,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1042.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x3CM 9SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12766-MAIN,LOCAL,,,,,2171,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1042.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
Bcr/Abl1 P210 - Ref,PX8120690,CDM,310,RC,81206,CPT,90,,,,,,,1144,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1042.184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.33,1121.12
nivolumab 40 MG/4ML Solution 4 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377211,NDC,4,ML,2171.7,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1042.416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.5,12769.6548
nivolumab 40 MG/4ML Solution 4 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377211,NDC,4,ML,2171.7,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1042.416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.5,12769.6548
GROSHONG PICC NXT 4FR,120.218,CDM,272,RC,,,,498-MAIN,LOCAL,,,,,1182,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1042.524,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,491.0028,1158.36
Exc Skin Benig >4cm Remaindr Body,PX11426F,CDM,510,RC,11426,CPT,,,,,,,,1227,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1042.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,509.6958,2482.37
Room Rate Icc,PX20601000,CDM,206,RC,,,,,,,,,,2432,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1043.328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1010.2528,2383.36
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505F,CDM,510,RC,24505,CPT,,,,,,,,2109,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1043.955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,876.0786,2066.82
filgrastim 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513020991,NDC,0.5,ML,1228.49,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1044.2165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535F,CDM,510,RC,24535,CPT,,,,,,,,2514,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1044.3156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1044.3156,2463.72
Closed Rx Kneecap Disloc+Anesth,PX27562F,CDM,510,RC,27562,CPT,,,,,,,,604,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1044.62,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.64,1044.62
Closed Rx Kneecap Disloc+Anesth,PX27562F,CDM,510,RC,27562,CPT,,,,,,,,604,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1044.62,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.64,1044.62
Closed Rx Kneecap Disloc+Anesth,PX27562P,CDM,983,RC,27562,CPT,,,,,,,,1404,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1044.62,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.64,1375.92
Closed Rx Kneecap Disloc+Anesth,PX27562P,CDM,983,RC,27562,CPT,,,,,,,,1404,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1044.62,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.64,1375.92
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752F,CDM,510,RC,27752,CPT,,,,,,,,2280,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1044.62,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.64,1144.93
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752P,CDM,983,RC,27752,CPT,,,,,,,,2495,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1044.62,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.64,2445.1
DYNABUNION STERILE INSTRUMENT KIT,27200000,CDM,272,RC,,,,11850-MAIN,LOCAL,,,,,2515,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1044.731,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Removal of Tunnel Cv Access Device, With Port/Pump",PX36590P,CDM,983,RC,36590,CPT,,,,,,,,1147,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1044.917,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,476.4638,1399.13
Room Rate Icc Iso,PX20601001,CDM,206,RC,,,,,,,,,,2517,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1045.5618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1045.5618,2466.66
Debride Skin/Tissue,PX11042F,CDM,510,RC,11042,CPT,,,,,,,,1067,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1045.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1045.66
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180P,CDM,983,RC,44180,CPT,,,,,,,,1175,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1045.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,488.095,5040.74
"Upper GI Endoscopy,Ctrl Bleed",PX43255P,CDM,983,RC,43255,CPT,,,,,,,,1148,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1045.828,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,476.8792,1662.33
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,64950036204,NDC,4,ML,1067.22,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1045.8756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
Exc Back Les Sc = 3 Cm,PX21931P,CDM,983,RC,21931,CPT,,,,,,,,2135,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1046.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,886.879,2077.9955
Exc Back Les Sc = 3 Cm,PX21931P,CDM,983,RC,21931,CPT,,,,,,,,2135,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1046.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,886.879,2077.9955
Exc Back Les Sc = 3 Cm,PX21931P,CDM,983,RC,21931,CPT,,,,,,,,2135,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1046.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,886.879,2077.9955
Closed Rx IP Jt Dislocation,PX26770F,CDM,510,RC,26770,CPT,,,,,,,,1231,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1046.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1206.38
"VENTRALIGHT MESH ST WITH ECHO 2 - 10 CM X 15 CM - 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,12007-MAIN,LOCAL,,,,,1176,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1046.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Closed Rx Weight Bear Dist Tib,Manip",PX27825F,CDM,510,RC,27825,CPT,,,,,,,,2695,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1046.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.21,1163.61
"Closed Rx Weight Bear Dist Tib,Manip",PX27825P,CDM,983,RC,27825,CPT,,,,,,,,1796,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1046.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.21,1760.08
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096321,NDC,30,ML,1231.47,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1046.7495,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,511.552638,1206.8406
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096330,NDC,30,ML,1231.47,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1046.7495,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,511.552638,1206.8406
"Sigmoidoscopy,Remv Lesn,Snare",PX45338F,CDM,510,RC,45338,CPT,,,,,,,,2137,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1047.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,887.7098,2094.26
"Sigmoidoscopy,Remv Lesn,Snare",PX45338F,CDM,510,RC,45338,CPT,,,,,,,,2137,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1047.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,887.7098,2094.26
"Sigmoidoscopy,Remv Lesn,Snare",PX45338F,CDM,510,RC,45338,CPT,,,,,,,,2137,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1047.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,887.7098,2094.26
"Lap,Inguinal Hernia Repr,Initial",PX49650F,CDM,510,RC,49650,CPT,,,,,,,,1076,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1047.2708,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,446.9704,5040.74
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151P,CDM,983,RC,13151,CPT,,,,,,,,1177,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1047.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,488.9258,1145.5741
Art Lower Extremity-Bilat,PX9392501,CDM,921,RC,93925,CPT,TC,,,,,,,1188,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1047.816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,1164.24
Unlisted Molecular Path Proc - Ref,PX8147990,CDM,310,RC,81479,CPT,90,,,,,,,1077,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1048.2441,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,447.3858,1055.46
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605F,CDM,510,RC,25605,CPT,,,,,,,,1178,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1048.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,489.3412,1404.08
Ven Duplex Bilateral,PX9397001,CDM,921,RC,93970,CPT,TC,,,,,,,1189,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1048.698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,1165.22
"Excis Tendn/Capsule Lesn,Toes",PX28092F,CDM,510,RC,28092,CPT,,,,,,,,1234,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1048.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,512.6036,1404.08
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,310095036,NDC,1,EA,1234.2,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1049.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,512.68668,1209.516
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,70720095036,NDC,1,EA,1234.2,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1049.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,512.68668,1209.516
"Colonoscope, Submucous Inj",PX45381F,CDM,750,RC,45381,CPT,,,,,,,,1179,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1049.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,489.7566,1155.42
CT Lwr Extremity W/O&W/Dye,PX7370201,CDM,350,RC,73702,CPT,TC,,,,,,,1235,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1049.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
budesonide-formoterol 160-4.5 MCG/ACT Aerosol 6 g Inhaler,63700001,CDM,250,RC,,,,,,186037028,NDC,6,GR,1078.55,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1049.752715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ULTRAGUIDE CTR SX-ONE MICROKNIFE 600112-001,27200000,CDM,272,RC,,,,13106-MAIN,LOCAL,,,,,2121,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1049.895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Sb Scope,to Ileum,Biopsy",PX44377P,CDM,983,RC,44377,CPT,,,,,,,,1180,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1050.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,490.172,1662.33
Tube Thoracostomy Inc Wtr Seal,PX32551P,CDM,983,RC,32551,CPT,,,,,,,,1236,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1050.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,513.4344,1399.13
"Tte W/Doppler, Complete",PX9330601,CDM,483,RC,93306,CPT,TC,,,,,,,2191,,Health Partners,Health Partners Care Plans,both,48,,1755.483333,percent of total billed charges,1051.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,481.95,2889.15
"Tte W/Doppler, Complete",PX9330601,CDM,483,RC,93306,CPT,TC,,,,,,,2191,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1051.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,481.95,2889.15
GROSHONG PICC NXT 4FR,120.218,CDM,272,RC,,,,498-MAIN,LOCAL,,,,,1182,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1051.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,491.0028,1158.36
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830F,CDM,510,RC,15830,CPT,,,,,,,,2080,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1052.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,864.032,5696.92
Debride Tissue/Muscle/Bone,PX11044F,CDM,510,RC,11044,CPT,,,,,,,,1082,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,216.4,percent of total billed charges,1053.1106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,449.4628,1416.38
"Correct Bunion,Metatarsal Osteotomy",PX28296P,CDM,983,RC,28296,CPT,,,,,,,,2150,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1053.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,893.11,2827.75
"Correct Bunion,Metatarsal Osteotomy",PX28296P,CDM,983,RC,28296,CPT,,,,,,,,2150,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1053.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,893.11,2827.75
"Correct Bunion,Metatarsal Osteotomy",PX28296P,CDM,983,RC,28296,CPT,,,,,,,,2150,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1053.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,893.11,2827.75
"Excise Lesion,Back or Flank",PX21930F,CDM,510,RC,21930,CPT,,,,,,,,1326,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1053.61,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,225.35,1053.61
"Excise Lesion,Back or Flank",PX21930P,CDM,983,RC,21930,CPT,,,,,,,,884,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1053.61,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,225.35,1053.61
Closed Rx Femur Shaft Fx+Manip,PX27502P,CDM,983,RC,27502,CPT,,,,,,,,1083,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1054.0839,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,449.8782,1404.08
"Lap,Inguinal Hernia Repr,Initial",PX49650F,CDM,510,RC,49650,CPT,,,,,,,,1076,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1054.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,446.9704,5040.74
"Excis Arm/Elbow Tumor,Subcutan",PX24075P,CDM,983,RC,24075,CPT,,,,,,,,2458,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1054.482,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1021.0532,2392.3714
"Upper GI Endoscopy,Biopsy",PX43239P,CDM,983,RC,43239,CPT,,,,,,,,2458,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1054.482,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,3859.68
"Percut Biopsy, Abdominal Mass",PX49180F,CDM,510,RC,49180,CPT,,,,,,,,2084,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1054.504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,865.6936,2042.32
collagenase 250 UNIT/GM Ointment 30 g Tube,63700001,CDM,250,RC,,,,,,50484001030,NDC,30,GR,1083.77,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1054.833341,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,93598627,NDC,1,EA,1241.11,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1054.9435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
Unlisted Molecular Path Proc - Ref,PX8147990,CDM,310,RC,81479,CPT,90,,,,,,,1077,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1055.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,447.3858,1055.46
Exc Abd Les Sc < 3 Cm,PX22902P,CDM,983,RC,22902,CPT,,,,,,,,2086,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1055.516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,866.5244,2030.3038
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132F,CDM,510,RC,13132,CPT,,,,,,,,1159,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1055.849,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,481.4486,1135.82
Part Remv Phalanx of Toe,PX28124F,CDM,510,RC,28124,CPT,,,,,,,,2155,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1055.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,895.187,2827.75
Part Remv Phalanx of Toe,PX28124F,CDM,510,RC,28124,CPT,,,,,,,,2155,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1055.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,895.187,2827.75
Part Remv Phalanx of Toe,PX28124F,CDM,510,RC,28124,CPT,,,,,,,,2155,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1055.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,895.187,2827.75
Trauma Activation,PX68200010,CDM,684,RC,G0390,HCPCS,,,,,,,,1243,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1056.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,516.3422,1218.14
ramuCIRumab 100 MG/10ML Solution 10 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2766901,NDC,10,ML,2463.3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1056.7557,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.57,12070.17
Exc Back Les Sc = 3 Cm,PX21931P,CDM,983,RC,21931,CPT,,,,,,,,2135,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1056.825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,886.879,2077.9955
budesonide-formoterol 160-4.5 MCG/ACT Aerosol 6 g Inhaler,63700001,CDM,250,RC,,,,,,186037028,NDC,6,GR,1078.55,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1056.979,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Art Lower Extremity-Bilat,PX9392501,CDM,921,RC,93925,CPT,TC,,,,,,,1188,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1057.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,1164.24
HARMONIC 1100 SHEARS 20CM SHAFT HAR1120,27200000,CDM,272,RC,,,,12924-MAIN,LOCAL,,,,,1244,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1057.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035P,CDM,983,RC,12035,CPT,,,,,,,,1244,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1057.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1210.7852
"Colonoscopy,Biopsy",PX45380F,CDM,750,RC,45380,CPT,,,,,,,,2465,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1057.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1030.93,4050.42
Explor Metatarso-Phalang Jt,PX28022F,CDM,510,RC,28022,CPT,,,,,,,,1161,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1057.671,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,482.2794,2827.75
"Sigmoidoscopy,Remv Lesn,Snare",PX45338F,CDM,510,RC,45338,CPT,,,,,,,,2137,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1057.815,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,887.7098,2094.26
Ven Duplex Bilateral,PX9397001,CDM,921,RC,93970,CPT,TC,,,,,,,1189,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1058.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,1165.22
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591P,CDM,982,RC,49591,CPT,,,,,,,,1245,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1058.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,517.173,3022.41
"Repair Lip,>1/2 Vert Height",PX40654F,CDM,510,RC,40654,CPT,,,,,,,,2467,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1058.343,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1024.7918,2417.66
"Colonoscopy,Flex,Diagnostic",PX45378P,CDM,983,RC,45378,CPT,,,,,,,,1200,,United Healthcare,All Payer,outpatient,88.2,,415.81,percent of total billed charges,1058.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,514.8,4661.91
Level 1 Additional Procedure,PX36000080,CDM,360,RC,,,,,,,,,,1200,,United Healthcare,All Payer,outpatient,88.2,,999999999,case rate,1058.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1058.4,6141.46
Reconstruc of Nail Bed,PX11760F,CDM,510,RC,11760,CPT,,,,,,,,1162,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1058.582,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,482.6948,1138.76
fluticasone-vilanterol 200-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173088214,NDC,28,EA,1087.68,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1058.638944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Cv Carotid Imaging-Bilat,PX9388001,CDM,921,RC,93880,CPT,TC,,,,,,,1088,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,865.23,percent of total billed charges,1058.9504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,1066.24
"Closed Rx Trimalleolar Fx,Manip",PX27818F,CDM,510,RC,27818,CPT,,,,,,,,813,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1059.15,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,279.01,1059.15
"Closed Rx Trimalleolar Fx,Manip",PX27818P,CDM,983,RC,27818,CPT,,,,,,,,1352,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1059.15,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,279.01,1324.96
Debride Tissue/Muscle/Bone,PX11044F,CDM,510,RC,11044,CPT,,,,,,,,1082,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1060.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,449.4628,1416.38
"Initial Repair of Entrapped Hernia of Abdomen, Less Than 3 Cm in Length",PX49592,CDM,982,RC,49592,CPT,,,,,,,,2164,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,87.14,percent of total billed charges,1060.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,898.9256,5040.74
"Initial Repair of Entrapped Hernia of Abdomen, Less Than 3 Cm in Length",PX49592,CDM,982,RC,49592,CPT,,,,,,,,2164,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1060.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,898.9256,5040.74
"Initial Repair of Entrapped Hernia of Abdomen, Less Than 3 Cm in Length",PX49592,CDM,982,RC,49592,CPT,,,,,,,,2164,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1060.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,898.9256,5040.74
CT Chest Spine W/Dye,PX7212901,CDM,350,RC,72129,CPT,TC,,,,,,,2096,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1060.576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,2054.08
MICA SCREW 4.0X32MM FULLY THREADED STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12894-MAIN,LOCAL,,,,,2096,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1060.576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 3.0X38MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12984-MAIN,LOCAL,,,,,2096,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1060.576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X42MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12948-MAIN,LOCAL,,,,,2096,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1060.576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X44MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12893-MAIN,LOCAL,,,,,2096,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1060.576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X56MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12947-MAIN,LOCAL,,,,,2096,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1060.576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
beclomethasone  HFA 80 MCG/ACT Aerosol Breath Activated 10.6 g Inhaler,63700001,CDM,250,RC,,,,,,59310030480,NDC,10.6,GR,1164.84,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1061.16924,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Closed Rx Femur Shaft Fx+Manip,PX27502P,CDM,983,RC,27502,CPT,,,,,,,,1083,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1061.34,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.19,1580.76
REVITA PLACENTAL MEMBRANE 2X3CM 6SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12559-MAIN,LOCAL,,,,,2474,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1061.346,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
collagenase 250 UNIT/GM Ointment 30 g Tube,63700001,CDM,250,RC,,,,,,50484001030,NDC,30,GR,1083.77,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1062.0946,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
omalizumab 150 MG Recon Soln 1 Each Vial,J2357.01,CDM,636,RC,J2357,HCPCS,,,,50242004062,NDC,1,EA,2212.7,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1062.096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.02,2168.446
omalizumab 150 MG Recon Soln 1 Each Vial,J2357.01,CDM,636,RC,J2357,HCPCS,,,,50242004062,NDC,1,EA,2212.7,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1062.096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.02,2168.446
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565F,CDM,510,RC,25565,CPT,,,,,,,,1250,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1062.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,519.25,1404.08
Level 3 Additional Procedure,PX36000082,CDM,360,RC,,,,,,,,,,2100,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1062.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,872.34,2058
Or Level 3,PX36000003,CDM,360,RC,,,,,,,,,,2100,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1062.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,872.34,2058
fluticasone-salmeterol 100-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,54032656,NDC,60,EA,2215.63,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1063.5024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone-salmeterol 100-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,54032656,NDC,60,EA,2215.63,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1063.5024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Cytogenomic Neoplasia (Genome-Wide) Microarray Analysis - Ref,PX8127790,CDM,310,RC,81277,CPT,90,,,,,,,3850,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1063.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1063.6,3773
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x3CM 9SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12766-MAIN,LOCAL,,,,,2171,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1063.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x3CM 9SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12766-MAIN,LOCAL,,,,,2171,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1063.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x3CM 9SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12766-MAIN,LOCAL,,,,,2171,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1063.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
nivolumab 40 MG/4ML Solution 4 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377211,NDC,4,ML,2171.7,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1064.133,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.5,12769.6548
nivolumab 40 MG/4ML Solution 4 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377211,NDC,4,ML,2171.7,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1064.133,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.5,12769.6548
nivolumab 40 MG/4ML Solution 4 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377211,NDC,4,ML,2171.7,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1064.133,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.5,12769.6548
"Correct Bunion,Metatarsal Osteotomy",PX28296P,CDM,983,RC,28296,CPT,,,,,,,,2150,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1064.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,893.11,2827.75
"Repair Ing Hernia,5+Y/O,Strang",PX49507P,CDM,983,RC,49507,CPT,,,,,,,,2482,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1064.778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1031.0228,3022.41
ADVANCED INSTRUMENTS VESSEL SEALER EXTEND,27200000,CDM,272,RC,,,,11923-MAIN,LOCAL,,,,,1169,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1064.959,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 15DEGREE 14MM,27200000,CDM,272,RC,,,,12600-MAIN,LOCAL,,,,,1253,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1065.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 45DEGREE 8MM,27200000,CDM,272,RC,,,,12599-MAIN,LOCAL,,,,,1253,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1065.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 45DEGREE 14MM,27200000,CDM,272,RC,,,,12598-MAIN,LOCAL,,,,,1253,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1065.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 15DEGREE 14MM,27200000,CDM,272,RC,,,,12603-MAIN,LOCAL,,,,,1253,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1065.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 45DEGREE 8MM,27200000,CDM,272,RC,,,,12602-MAIN,LOCAL,,,,,1253,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1065.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 45DEGREE 14MM,27200000,CDM,272,RC,,,,12601-MAIN,LOCAL,,,,,1253,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1065.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PACLitaxel protein-bound particle 100 MG Recon Susp 1 Each Vial,J9264.01,CDM,636,RC,J9264,HCPCS,,,,68817013450,NDC,1,EA,2564.76,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1065.401304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.1,2513.4648
OSTEOSET RESORBABLE MINI BEAD KIT FAST CURE CALCIUM SULFATE 5CC,C1713,CDM,278,RC,C1713,HCPCS,,12303-MAIN,LOCAL,,,,,2220,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1065.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
OSTEOSET RESORBABLE MINI BEAD KIT FAST CURE CALCIUM SULFATE 5CC,C1713,CDM,278,RC,C1713,HCPCS,,12303-MAIN,LOCAL,,,,,2220,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1065.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830F,CDM,510,RC,15830,CPT,,,,,,,,2080,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1065.7309,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,721.42,2434.44
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830P,CDM,983,RC,15830,CPT,,,,,,,,1120,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1065.7309,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,721.42,2434.44
fluticasone-vilanterol 200-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173088214,NDC,28,EA,1087.68,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1065.9264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Cv Carotid Imaging-Bilat,PX9388001,CDM,921,RC,93880,CPT,TC,,,,,,,1088,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1066.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,1066.24
Part Remv Phalanx of Toe,PX28124F,CDM,510,RC,28124,CPT,,,,,,,,2155,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1066.725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,895.187,2827.75
"I&D Perianal Abscess,Superficial",PX46050,CDM,983,RC,46050,CPT,,,,,,,,1096,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1268.66,percent of total billed charges,1066.7368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,455.2784,1066.7368
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505F,CDM,510,RC,24505,CPT,,,,,,,,2109,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1067.154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,876.0786,2066.82
APLIGRAF LIVING BI-LAYERED SKIN SUBSTITUTE,120.514,CDM,278,RC,Q4101,HCPCS,,12082-MAIN,LOCAL,,,,,2569,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1067.1626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1067.1626,2517.62
"Colonoscopy,Flex,Diagnostic",PX45378P,CDM,983,RC,45378,CPT,,,,,,,,1200,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1068,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,514.8,4661.91
Level 1 Additional Procedure,PX36000080,CDM,360,RC,,,,,,,,,,1200,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1068,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,498.48,1176
"Repair Umbilical Hern,5+Y/O,Strang",PX49587P,CDM,983,RC,49587,CPT,,,,,,,,2182,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1069.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,906.4028,2123.7406
"Repair Umbilical Hern,5+Y/O,Strang",PX49587P,CDM,983,RC,49587,CPT,,,,,,,,2182,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1069.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,906.4028,2123.7406
"Repair Umbilical Hern,5+Y/O,Strang",PX49587P,CDM,983,RC,49587,CPT,,,,,,,,2182,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1069.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,906.4028,2123.7406
diazePAM 10 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,93613832,NDC,1,EA,1212.57,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1069.48674,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752P,CDM,983,RC,27752,CPT,,,,,,,,2495,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1070.355,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1036.423,2428.3835
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180P,CDM,983,RC,44180,CPT,,,,,,,,1175,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1070.425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,488.095,5040.74
"Close Rx Dist Fingr Fx,Manipulatn",PX26755P,CDM,983,RC,26755,CPT,,,,,,,,1260,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1071,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1226.358
Lap Rpr Vent Umbilical Hernia,PX49652P,CDM,983,RC,49652,CPT,,,,,,,,1260,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1071,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,523.404,1226.358
"Initial Repair of Entrapped Hernia of Abdomen, Less Than 3 Cm in Length",PX49592,CDM,982,RC,49592,CPT,,,,,,,,2164,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1071.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,898.9256,5040.74
"VENTRALIGHT MESH ST WITH ECHO 2 - 10 CM X 15 CM - 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,12007-MAIN,LOCAL,,,,,1176,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1071.336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Colonoscope, Submucous Inj",PX45381P,CDM,983,RC,45381,CPT,,,,,,,,1215,,United Healthcare,All Payer,outpatient,88.2,,398.48,percent of total billed charges,1071.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,504.711,1182.5595
"Colonoscopy,Control Bleeding",PX45382F,CDM,750,RC,45382,CPT,,,,,,,,1215,,United Healthcare,All Payer,outpatient,88.2,,999999999,case rate,1071.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1071.63,6141.46
"Igh, Variable Region Somatic Mutation Analysis",PX8126390,CDM,310,RC,81263,CPT,90,,,,,,,1215,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1071.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.05,1190.7
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151P,CDM,983,RC,13151,CPT,,,,,,,,1177,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1072.247,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,488.9258,1145.5741
DYNAFORCE MPJ REAMERS CUP/CONE 20MM,27200000,CDM,272,RC,,,,11853-MAIN,LOCAL,,,,,1262,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1072.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605F,CDM,510,RC,25605,CPT,,,,,,,,1178,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1073.158,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,489.3412,1404.08
ULTRAGUIDE CTR SX-ONE MICROKNIFE 600112-001,27200000,CDM,272,RC,,,,13106-MAIN,LOCAL,,,,,2121,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1073.226,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Colonoscopy,Screen Prev",PX2004F,CDM,750,RC,G0121,HCPCS,,,,,,,,2502,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1073.358,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,798.45,3885.86
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569F,CDM,510,RC,36569,CPT,,,,,,,,1217,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1073.394,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,505.5418,1399.13
"Tte W/Doppler, Complete",PX9330601,CDM,483,RC,93306,CPT,TC,,,,,,,2191,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,420.3483333,percent of total billed charges,1073.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,481.95,2889.15
"Tte W/Doppler, Complete",PX9330601,CDM,483,RC,93306,CPT,TC,,,,,,,2191,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1073.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,481.95,2889.15
"Tte W/Doppler, Complete",PX9330601,CDM,483,RC,93306,CPT,TC,,,,,,,2191,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1073.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,481.95,2889.15
"Colonoscope, Submucous Inj",PX45381F,CDM,750,RC,45381,CPT,,,,,,,,1179,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1074.069,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,489.7566,1155.42
"I&D Perianal Abscess,Superficial",PX46050,CDM,983,RC,46050,CPT,,,,,,,,1096,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1074.08,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,63.26,1074.08
"Correct Bunion,Metatarsal Osteotomy",PX28296F,CDM,510,RC,28296,CPT,,,,,,,,8100,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1074.37,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,324.17,1834.65
"Correct Bunion,Metatarsal Osteotomy",PX28296P,CDM,983,RC,28296,CPT,,,,,,,,2150,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1074.37,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,324.17,2107
"Facility Critical Care, E/M 30-74 Minutes",PX99291F,CDM,510,RC,99291,CPT,,,,,,,,1264,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1074.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,525.0656,1238.72
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x3CM 9SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12766-MAIN,LOCAL,,,,,2171,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1074.645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
"Sb Scope,to Ileum,Biopsy",PX44377P,CDM,983,RC,44377,CPT,,,,,,,,1180,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1074.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,490.172,1662.33
nivolumab 40 MG/4ML Solution 4 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377211,NDC,4,ML,2171.7,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1074.9915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.5,12769.6548
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,469650189,NDC,5,ML,1264.92,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1075.182,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,424.41418,1239.6216
GROSHONG PICC NXT 4FR,120.218,CDM,272,RC,,,,498-MAIN,LOCAL,,,,,1182,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1076.802,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,491.0028,1158.36
Bone Marrow Biopsy(Ies),PX38221F,CDM,510,RC,38221,CPT,,,,,,,,1221,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1076.922,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,507.2034,1416.38
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535F,CDM,510,RC,24535,CPT,,,,,,,,2514,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1078.506,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1044.3156,2463.72
DYNABUNION STERILE INSTRUMENT KIT,27200000,CDM,272,RC,,,,11850-MAIN,LOCAL,,,,,2515,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1078.935,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
diazePAM 10 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,93613832,NDC,1,EA,1212.57,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1079.1873,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Room Rate Icc Iso,PX20601001,CDM,206,RC,,,,,,,,,,2517,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1079.793,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1045.5618,2466.66
fomepizole 1 GM/ML Solution 1.5 mL Vial,J1451.01,CDM,636,RC,J1451,HCPCS,,,,39822071001,NDC,1.5,ML,2600,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1080.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.14,2548
"Repair Umbilical Hern,5+Y/O,Strang",PX49587P,CDM,983,RC,49587,CPT,,,,,,,,2182,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1080.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,906.4028,2123.7406
Exc Back Les Sc = 3 Cm,PX21931P,CDM,983,RC,21931,CPT,,,,,,,,2135,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1080.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,886.879,2077.9955
"Repair Umbilical Hern,5+Y/O,Strang",PX49587F,CDM,510,RC,49587,CPT,,,,,,,,1110,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1080.363,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,461.094,1087.8
Amputation Finger/Thumb,PX26951P,CDM,983,RC,26951,CPT,,,,,,,,2603,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1081.2862,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1081.2862,2827.75
"Sigmoidoscopy,Remv Lesn,Snare",PX45338F,CDM,510,RC,45338,CPT,,,,,,,,2137,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1081.322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,887.7098,2094.26
"Colonoscope, Submucous Inj",PX45381P,CDM,983,RC,45381,CPT,,,,,,,,1215,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1081.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,504.711,1182.5595
"Colonoscopy,Control Bleeding",PX45382F,CDM,750,RC,45382,CPT,,,,,,,,1215,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1081.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,504.711,1190.7
"Igh, Variable Region Somatic Mutation Analysis",PX8126390,CDM,310,RC,81263,CPT,90,,,,,,,1215,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1081.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.05,1190.7
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561F,CDM,510,RC,36561,CPT,,,,,,,,2604,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1081.7016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1081.7016,2784.63
Exc Skin Benig >4cm Remaindr Body,PX11426F,CDM,510,RC,11426,CPT,,,,,,,,1227,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1082.214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,509.6958,2482.37
Art Lower Extremity-Bilat,PX9392501,CDM,921,RC,93925,CPT,TC,,,,,,,1188,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1082.268,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,1164.24
"Initial Repair of Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49593P,CDM,982,RC,49593,CPT,,,,,,,,2606,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1082.5324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1082.5324,3022.41
Excis Forearm/Wrist Tumor Subcutan,PX25075F,CDM,510,RC,25075,CPT,,,,,,,,1421,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1082.67,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,198.51,1082.67
Excis Forearm/Wrist Tumor Subcutan,PX25075P,CDM,983,RC,25075,CPT,,,,,,,,607,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1082.67,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,198.51,1082.67
"Hemorrhoidectomy,Int/Ext,Simple",PX46255F,CDM,510,RC,46255,CPT,,,,,,,,1627,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1082.67,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,221.21,1082.67
"Hemorrhoidectomy,Int/Ext,Simple",PX46255P,CDM,983,RC,46255,CPT,,,,,,,,2393,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1082.67,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,221.21,2345.14
Insert Non-Tunnel Cv Catheter >5 Years,PX36556P,CDM,983,RC,36556,CPT,,,,,,,,1274,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1082.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,529.2196,2784.63
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569F,CDM,510,RC,36569,CPT,,,,,,,,1217,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1083.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,505.5418,1399.13
Ven Duplex Bilateral,PX9397001,CDM,921,RC,93970,CPT,TC,,,,,,,1189,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1083.179,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,1165.22
Bcr/Abl1 Minor - Ref,PX8120790,CDM,310,RC,81207,CPT,90,,,,,,,1113,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1083.2829,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.8,1090.74
MICA BURR 2X12MM STERILE MICA,27200000,CDM,272,RC,,,,12447-MAIN,LOCAL,,,,,1113,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1083.2829,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA BURR 2X20MM STERILE MICA,27200000,CDM,272,RC,,,,12448-MAIN,LOCAL,,,,,1113,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1083.2829,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA CUTTING BURR 3X20MM LONG MICA,27200000,CDM,272,RC,,,,12434-MAIN,LOCAL,,,,,1113,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1083.2829,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA WEDGE BURR 3.1X13MM STERILE,27200000,CDM,272,RC,,,,12435-MAIN,LOCAL,,,,,1113,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1083.2829,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
filgrastim 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513020991,NDC,0.5,ML,1228.49,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1083.52818,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
Facility Emergency Level IV Visit,PX99284F,CDM,450,RC,99284,CPT,,,,,,,,1054,,Medica,Minnesota Health care Program (MHCP),outpatient,,,999999999,case rate,1084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1084,6141.46
omalizumab 150 MG Recon Soln 1 Each Vial,J2357.01,CDM,636,RC,J2357,HCPCS,,,,50242004062,NDC,1,EA,2212.7,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1084.223,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.02,2168.446
omalizumab 150 MG Recon Soln 1 Each Vial,J2357.01,CDM,636,RC,J2357,HCPCS,,,,50242004062,NDC,1,EA,2212.7,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1084.223,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.02,2168.446
omalizumab 150 MG Recon Soln 1 Each Vial,J2357.01,CDM,636,RC,J2357,HCPCS,,,,50242004062,NDC,1,EA,2212.7,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1084.223,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.02,2168.446
diazePAM 2.5 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,68682065020,NDC,1,EA,1114.05,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1084.304865,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Tte W/Doppler, Complete",PX9330601,CDM,483,RC,93306,CPT,TC,,,,,,,2191,,Humana Choice Care,All Medicare plans,outpatient,49.5,,783.175,percent of total billed charges,1084.545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,481.95,2889.15
"Exc Skn Mal 2.1-3cmtrnk,Arm,Lg",PX11603P,CDM,983,RC,11603,CPT,,,,,,,,1276,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1084.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,530.0504,1241.9308
Lap Partial Colectomy/Coloproctostomy,PX44207F,CDM,750,RC,44207,CPT,,,,,,,,4170,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1085.08,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1085.08,3724.65
"Closed Rx Dist Fibula Fx,Manip",PX27788P,CDM,983,RC,27788,CPT,,,,,,,,1277,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1085.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1242.9041
Lap Partial Colectomy/Coloproctostomy,PX44207F,CDM,750,RC,44207,CPT,,,,,,,,4170,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1085.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1085.08,3724.65
Lap Partial Colectomy/Coloproctostomy,PX44207F,CDM,750,RC,44207,CPT,,,,,,,,4170,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1085.52,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1085.08,3724.65
fluticasone-salmeterol 100-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,54032656,NDC,60,EA,2215.63,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1085.6587,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone-salmeterol 100-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,54032656,NDC,60,EA,2215.63,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1085.6587,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
fluticasone-salmeterol 100-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,54032656,NDC,60,EA,2215.63,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1085.6587,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Closed Rx IP Jt Dislocation,PX26770F,CDM,510,RC,26770,CPT,,,,,,,,1231,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1085.742,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1206.38
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505F,CDM,510,RC,24505,CPT,,,,,,,,2109,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1086.13,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.04,1086.13
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505P,CDM,983,RC,24505,CPT,,,,,,,,2353,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1086.13,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.04,2305.94
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096321,NDC,30,ML,1231.47,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1086.15654,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,511.552638,1206.8406
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096330,NDC,30,ML,1231.47,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1086.15654,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,511.552638,1206.8406
Bone Marrow Biopsy(Ies),PX38221F,CDM,510,RC,38221,CPT,,,,,,,,1221,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1086.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,507.2034,1416.38
OSTEOSET RESORBABLE MINI BEAD KIT FAST CURE CALCIUM SULFATE 5CC,C1713,CDM,278,RC,C1713,HCPCS,,12303-MAIN,LOCAL,,,,,2220,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,1087.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
OSTEOSET RESORBABLE MINI BEAD KIT FAST CURE CALCIUM SULFATE 5CC,C1713,CDM,278,RC,C1713,HCPCS,,12303-MAIN,LOCAL,,,,,2220,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1087.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
OSTEOSET RESORBABLE MINI BEAD KIT FAST CURE CALCIUM SULFATE 5CC,C1713,CDM,278,RC,C1713,HCPCS,,12303-MAIN,LOCAL,,,,,2220,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1087.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"Repair Umbilical Hern,5+Y/O,Strang",PX49587F,CDM,510,RC,49587,CPT,,,,,,,,1110,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1087.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,461.094,1087.8
"Correct Bunion,Metatarsal Osteotomy",PX28296P,CDM,983,RC,28296,CPT,,,,,,,,2150,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1087.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,893.11,2827.75
"Excis Tendn/Capsule Lesn,Toes",PX28092F,CDM,510,RC,28092,CPT,,,,,,,,1234,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1088.388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,512.6036,1404.08
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,70839036204,NDC,4,ML,1280.66,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1088.561,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,310095036,NDC,1,EA,1234.2,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1088.5644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,512.68668,1209.516
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,70720095036,NDC,1,EA,1234.2,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1088.5644,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,512.68668,1209.516
"Colonoscopy,Biopsy",PX45380P,CDM,983,RC,45380,CPT,,,,,,,,2539,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1089.231,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1030.93,4050.42
"Colonoscopy,Flex,Screen",PX2002F,CDM,750,RC,G0105,HCPCS,,,,,,,,2539,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1089.231,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,798.45,3885.86
"Upper GI Endoscopy,Diagnosis",PX43235F,CDM,750,RC,43235,CPT,,,,,,,,2539,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1089.231,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,3859.68
CT Lwr Extremity W/O&W/Dye,PX7370201,CDM,350,RC,73702,CPT,TC,,,,,,,1235,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1089.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
Egd Balloon Dil Esoph30 Mm/>,PX43233F,CDM,750,RC,43233,CPT,,,,,,,,1120,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1090.096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,465.248,1662.33
"Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602P,CDM,983,RC,11602,CPT,,,,,,,,1120,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1090.096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1090.096
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830P,CDM,983,RC,15830,CPT,,,,,,,,1120,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1090.096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,465.248,5696.92
Tube Thoracostomy Inc Wtr Seal,PX32551P,CDM,983,RC,32551,CPT,,,,,,,,1236,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1090.152,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,513.4344,1399.13
Part Remv Phalanx of Toe,PX28124F,CDM,510,RC,28124,CPT,,,,,,,,2155,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1090.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,895.187,2827.75
Bcr/Abl1 Minor - Ref,PX8120790,CDM,310,RC,81207,CPT,90,,,,,,,1113,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1090.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.8,1090.74
MICA BURR 2X12MM STERILE MICA,27200000,CDM,272,RC,,,,12447-MAIN,LOCAL,,,,,1113,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1090.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA BURR 2X20MM STERILE MICA,27200000,CDM,272,RC,,,,12448-MAIN,LOCAL,,,,,1113,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1090.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA CUTTING BURR 3X20MM LONG MICA,27200000,CDM,272,RC,,,,12434-MAIN,LOCAL,,,,,1113,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1090.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MICA WEDGE BURR 3.1X13MM STERILE,27200000,CDM,272,RC,,,,12435-MAIN,LOCAL,,,,,1113,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1090.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
diazePAM 2.5 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,68682065020,NDC,1,EA,1114.05,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1091.769,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Exc Skin Benig >4cm Remaindr Body,PX11426F,CDM,510,RC,11426,CPT,,,,,,,,1227,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1092.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,509.6958,2482.37
"Colonoscopy,Flex,Diagnostic",PX45378F,CDM,750,RC,45378,CPT,,,,,,,,1286,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1093.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,551.694,4661.91
Low Dose CT Lung Ca Screen WO Contrast,PX7127101,CDM,350,RC,71271,CPT,TC,,,,,,,1286,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1093.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,1260.28
"Colonoscopy,Flex,Diagnostic",PX45378P,CDM,983,RC,45378,CPT,,,,,,,,1200,,Medica,Commercial,both,91.1,,341.1125,percent of total billed charges,1093.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,514.8,4661.91
Level 1 Additional Procedure,PX36000080,CDM,360,RC,,,,,,,,,,1200,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1093.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,498.48,1176
filgrastim 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513020991,NDC,0.5,ML,1228.49,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1093.3561,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605F,CDM,510,RC,24605,CPT,,,,,,,,1124,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1093.9892,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.9096,1404.08
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752F,CDM,510,RC,27752,CPT,,,,,,,,2280,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1094.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,947.112,2234.4
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752F,CDM,510,RC,27752,CPT,,,,,,,,2280,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1094.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,947.112,2234.4
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605F,CDM,510,RC,25605,CPT,,,,,,,,1178,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1094.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,325.92,1160.15
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605P,CDM,983,RC,25605,CPT,,,,,,,,785,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1094.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,325.92,1160.15
"Repair Ing Hernia,5+Y/O,Reducibl",PX49505P,CDM,983,RC,49505,CPT,,,,,,,,2048,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1094.43,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,315.88,2007.04
"Repair Ing Hernia,5+Y/O,Reducibl",PX49505P,CDM,983,RC,49505,CPT,,,,,,,,2048,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1094.43,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,315.88,2007.04
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,93598627,NDC,1,EA,1241.11,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1094.65902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
diazePAM 2.5 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,66490065020,NDC,1,EA,1288,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1094.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Bcr/Abl1 Other - Ref,PX8120890,CDM,310,RC,81208,CPT,90,,,,,,,1125,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1094.9625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,196.79,1102.5
"Initial Repair of Entrapped Hernia of Abdomen, Less Than 3 Cm in Length",PX49592,CDM,982,RC,49592,CPT,,,,,,,,2164,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1094.984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,898.9256,5040.74
omalizumab 150 MG Recon Soln 1 Each Vial,J2357.01,CDM,636,RC,J2357,HCPCS,,,,50242004062,NDC,1,EA,2212.7,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1095.2865,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.02,2168.446
Closed Rx IP Jt Dislocation,PX26770F,CDM,510,RC,26770,CPT,,,,,,,,1231,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1095.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1206.38
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505F,CDM,510,RC,25505,CPT,,,,,,,,651,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1095.81,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,295.37,1095.81
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505P,CDM,983,RC,25505,CPT,,,,,,,,977,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1095.81,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,295.37,1095.81
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096321,NDC,30,ML,1231.47,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1096.0083,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,511.552638,1206.8406
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096330,NDC,30,ML,1231.47,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1096.0083,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,511.552638,1206.8406
Trauma Activation,PX68200010,CDM,684,RC,G0390,HCPCS,,,,,,,,1243,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1096.326,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,516.3422,1218.14
ADVANCED INSTRUMENTS 8MM SYNCHROSEAL IS4000,27200000,CDM,272,RC,,,,11924-MAIN,LOCAL,,,,,1290,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1096.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
fluticasone-salmeterol 100-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,54032656,NDC,60,EA,2215.63,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1096.73685,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Fac/Exc Skn Benig >4cm Trnk,Arm,Lg",PX11406F,CDM,510,RC,11406,CPT,,,,,,,,1127,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1096.9091,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,468.1558,1416.38
HARMONIC 1100 SHEARS 20CM SHAFT HAR1120,27200000,CDM,272,RC,,,,12924-MAIN,LOCAL,,,,,1244,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1097.208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035P,CDM,983,RC,12035,CPT,,,,,,,,1244,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1097.208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1210.7852
Egd Balloon Dil Esoph30 Mm/>,PX43233F,CDM,750,RC,43233,CPT,,,,,,,,1120,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1097.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,465.248,1662.33
"Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602P,CDM,983,RC,11602,CPT,,,,,,,,1120,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1097.6,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.66,1097.6
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830P,CDM,983,RC,15830,CPT,,,,,,,,1120,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1097.6,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,721.42,2434.44
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591P,CDM,982,RC,49591,CPT,,,,,,,,1245,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1098.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,517.173,3022.41
"Excis Tendn/Capsule Lesn,Toes",PX28092F,CDM,510,RC,28092,CPT,,,,,,,,1234,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1098.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,512.6036,1404.08
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,310095036,NDC,1,EA,1234.2,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1098.438,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,512.68668,1209.516
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,70720095036,NDC,1,EA,1234.2,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1098.438,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,512.68668,1209.516
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x3CM 9SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12766-MAIN,LOCAL,,,,,2171,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1098.526,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
nivolumab 40 MG/4ML Solution 4 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377211,NDC,4,ML,2171.7,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1098.8802,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.5,12769.6548
OSTEOSET RESORBABLE MINI BEAD KIT FAST CURE CALCIUM SULFATE 5CC,C1713,CDM,278,RC,C1713,HCPCS,,12303-MAIN,LOCAL,,,,,2220,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1098.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
CT Lwr Extremity W/O&W/Dye,PX7370201,CDM,350,RC,73702,CPT,TC,,,,,,,1235,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1099.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
Tube Thoracostomy Inc Wtr Seal,PX32551P,CDM,983,RC,32551,CPT,,,,,,,,1236,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1100.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,513.4344,1399.13
PACLitaxel protein-bound particle 100 MG Recon Susp 1 Each Vial,J9264.01,CDM,636,RC,J9264,HCPCS,,,,68817013450,NDC,1,EA,2564.76,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1100.28204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.1,2513.4648
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605F,CDM,510,RC,24605,CPT,,,,,,,,1124,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1101.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.9096,1404.08
APLIGRAF LIVING BI-LAYERED SKIN SUBSTITUTE,120.514,CDM,278,RC,Q4101,HCPCS,,12082-MAIN,LOCAL,,,,,2569,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1102.101,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1067.1626,2517.62
Bcr/Abl1 Other - Ref,PX8120890,CDM,310,RC,81208,CPT,90,,,,,,,1125,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1102.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,196.79,1102.5
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565F,CDM,510,RC,25565,CPT,,,,,,,,1250,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1102.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,519.25,1404.08
"Fusion Foot Bones,Midtarsal,Multi",PX28730F,CDM,510,RC,28730,CPT,,,,,,,,2299,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1103.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,955.0046,11497.76
"Fusion Foot Bones,Midtarsal,Multi",PX28730F,CDM,510,RC,28730,CPT,,,,,,,,2299,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1103.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,955.0046,11497.76
"Repair Umbilical Hern,5+Y/O,Strang",PX49587P,CDM,983,RC,49587,CPT,,,,,,,,2182,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1104.092,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,906.4028,2123.7406
"Fac/Exc Skn Benig >4cm Trnk,Arm,Lg",PX11406F,CDM,510,RC,11406,CPT,,,,,,,,1127,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1104.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,468.1558,1416.38
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,93598627,NDC,1,EA,1241.11,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1104.5879,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
diazePAM 10 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,93613832,NDC,1,EA,1212.57,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1104.65127,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390P,CDM,982,RC,45390,CPT,,,,,,,,1135,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1104.6955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,471.479,2452.93
"Amputation Toe,Mt-P Jt",PX28820P,CDM,983,RC,28820,CPT,,,,,,,,1300,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,540.02,2827.75
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 15DEGREE 14MM,27200000,CDM,272,RC,,,,12600-MAIN,LOCAL,,,,,1253,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1105.146,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 45DEGREE 8MM,27200000,CDM,272,RC,,,,12599-MAIN,LOCAL,,,,,1253,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1105.146,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 45DEGREE 14MM,27200000,CDM,272,RC,,,,12598-MAIN,LOCAL,,,,,1253,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1105.146,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 15DEGREE 14MM,27200000,CDM,272,RC,,,,12603-MAIN,LOCAL,,,,,1253,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1105.146,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 45DEGREE 8MM,27200000,CDM,272,RC,,,,12602-MAIN,LOCAL,,,,,1253,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1105.146,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 45DEGREE 14MM,27200000,CDM,272,RC,,,,12601-MAIN,LOCAL,,,,,1253,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1105.146,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Echo Tt 2d Complete,PX9330701,CDM,480,RC,93307,CPT,TC,,,,,,,2303,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1105.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,2256.94
Echo Tt 2d Complete,PX9330701,CDM,480,RC,93307,CPT,TC,,,,,,,2303,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1105.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,2256.94
Trauma Activation,PX68200010,CDM,684,RC,G0390,HCPCS,,,,,,,,1243,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1106.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,516.3422,1218.14
"Closed Rx Talus Fx,Manipulatn",PX28435P,CDM,983,RC,28435,CPT,,,,,,,,1137,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1106.6421,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,472.3098,1404.08
"Colonoscope, Submucous Inj",PX45381P,CDM,983,RC,45381,CPT,,,,,,,,1215,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1106.865,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,504.711,1182.5595
"Colonoscopy,Control Bleeding",PX45382F,CDM,750,RC,45382,CPT,,,,,,,,1215,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1106.865,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,504.711,1190.7
"Igh, Variable Region Somatic Mutation Analysis",PX8126390,CDM,310,RC,81263,CPT,90,,,,,,,1215,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1106.865,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.05,1190.7
HARMONIC 1100 SHEARS 20CM SHAFT HAR1120,27200000,CDM,272,RC,,,,12924-MAIN,LOCAL,,,,,1244,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1107.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035P,CDM,983,RC,12035,CPT,,,,,,,,1244,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1107.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1210.7852
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591P,CDM,982,RC,49591,CPT,,,,,,,,1245,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1108.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,517.173,3022.41
"Excis Arm/Elbow Tumor,Subcutan",PX24075F,CDM,510,RC,24075,CPT,,,,,,,,1519,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1108.26,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.15,1108.26
"Excis Arm/Elbow Tumor,Subcutan",PX24075P,CDM,983,RC,24075,CPT,,,,,,,,2458,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1108.26,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.15,2408.84
"Tte W/Doppler, Complete",PX9330601,CDM,483,RC,93306,CPT,TC,,,,,,,2191,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1108.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,481.95,2889.15
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569F,CDM,510,RC,36569,CPT,,,,,,,,1217,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1108.687,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,505.5418,1399.13
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502050102,NDC,1,EA,1305.38,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1109.573,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
Remove Hemorrhoids & Fissure,PX46257F,CDM,510,RC,46257,CPT,,,,,,,,1141,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1110.5353,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,473.9714,2452.93
"Close Rx Dist Fingr Fx,Manipulatn",PX26755P,CDM,983,RC,26755,CPT,,,,,,,,1260,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1111.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1226.358
Lap Rpr Vent Umbilical Hernia,PX49652P,CDM,983,RC,49652,CPT,,,,,,,,1260,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1111.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,523.404,1226.358
paliperidone palmitate ER 234 MG/1.5ML suspension prefilled syringe 1.5 mL Syringe,J2426.01,CDM,636,RC,J2426,HCPCS,,,,50458056401,NDC,0.25,ML,1142.14,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1111.644862,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.12,1119.2972
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390P,CDM,982,RC,45390,CPT,,,,,,,,1135,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1112.3,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,203.1,1112.3
Bone Marrow Biopsy(Ies),PX38221F,CDM,510,RC,38221,CPT,,,,,,,,1221,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1112.331,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,507.2034,1416.38
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151F,CDM,510,RC,13151,CPT,,,,,,,,1143,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,918.945,percent of total billed charges,1112.4819,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,474.8022,1120.14
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565F,CDM,510,RC,25565,CPT,,,,,,,,1250,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1112.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,519.25,1404.08
DYNAFORCE MPJ REAMERS CUP/CONE 20MM,27200000,CDM,272,RC,,,,11853-MAIN,LOCAL,,,,,1262,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1113.084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HERNIA PATCH VENTRALEX MEDIUM,C1781,CDM,278,RC,C1781,HCPCS,,10202-MAIN,LOCAL,,,,,1309.75,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1113.2875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Bcr/Abl1 P210 - Ref,PX8120690,CDM,310,RC,81206,CPT,90,,,,,,,1144,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1113.4552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.33,1121.12
MESH VENTRALIGHT ECHO 2.0 POSITIONING 11CM ROUND,120.525,CDM,278,RC,C1781,HCPCS,,12219-MAIN,LOCAL,,,,,1310,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1113.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,544.174,1283.8
"Up GI Endoscopy,Ball Dil,30mm",PX43249F,CDM,750,RC,43249,CPT,,,,,,,,2596,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1113.684,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,958.1,3257.54
"Removal Anal Fistula,Subcutaneous",PX46270F,CDM,510,RC,46270,CPT,,,,,,,,1470,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1113.8,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,251.31,1113.8
"Removal Anal Fistula,Subcutaneous",PX46270P,CDM,983,RC,46270,CPT,,,,,,,,980,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1113.8,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,251.31,1113.8
"Closed Rx Talus Fx,Manipulatn",PX28435P,CDM,983,RC,28435,CPT,,,,,,,,1137,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1114.26,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,210.51,1114.26
eriBULin 1 MG/2ML Solution 2 mL Vial,J9179.01,CDM,636,RC,J9179,HCPCS,,,,62856038901,NDC,2,ML,2321.52,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1114.3296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.87,2275.0896
eriBULin 1 MG/2ML Solution 2 mL Vial,J9179.01,CDM,636,RC,J9179,HCPCS,,,,62856038901,NDC,2,ML,2321.52,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1114.3296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.87,2275.0896
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266P,CDM,983,RC,27266,CPT,,,,,,,,2275,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1114.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,945.035,2214.2575
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266P,CDM,983,RC,27266,CPT,,,,,,,,2275,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1114.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,945.035,2214.2575
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266P,CDM,983,RC,27266,CPT,,,,,,,,2275,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1114.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,945.035,2214.2575
"Facility Critical Care, E/M 30-74 Minutes",PX99291F,CDM,510,RC,99291,CPT,,,,,,,,1264,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1114.848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,525.0656,1238.72
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 15DEGREE 14MM,27200000,CDM,272,RC,,,,12600-MAIN,LOCAL,,,,,1253,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1115.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 45DEGREE 8MM,27200000,CDM,272,RC,,,,12599-MAIN,LOCAL,,,,,1253,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1115.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 45DEGREE 14MM,27200000,CDM,272,RC,,,,12598-MAIN,LOCAL,,,,,1253,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1115.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 15DEGREE 14MM,27200000,CDM,272,RC,,,,12603-MAIN,LOCAL,,,,,1253,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1115.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 45DEGREE 8MM,27200000,CDM,272,RC,,,,12602-MAIN,LOCAL,,,,,1253,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1115.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 45DEGREE 14MM,27200000,CDM,272,RC,,,,12601-MAIN,LOCAL,,,,,1253,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1115.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
fomepizole 1 GM/ML Solution 1.5 mL Vial,J1451.01,CDM,636,RC,J1451,HCPCS,,,,39822071001,NDC,1.5,ML,2600,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1115.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.14,2548
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,469650189,NDC,5,ML,1264.92,,United Healthcare,All Payer,outpatient,88.2,,123.966,percent of total billed charges,1115.65944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,424.41418,1239.6216
"Removal of Tunnel Cv Access Device, With Port/Pump",PX36590P,CDM,983,RC,36590,CPT,,,,,,,,1147,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1116.3751,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,476.4638,1399.13
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565F,CDM,510,RC,25565,CPT,,,,,,,,1250,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1116.57,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,296.9,1116.57
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565P,CDM,983,RC,25565,CPT,,,,,,,,830,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1116.57,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,296.9,1116.57
Amputation Finger/Thumb,PX26951P,CDM,983,RC,26951,CPT,,,,,,,,2603,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1116.687,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1081.2862,2827.75
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561F,CDM,510,RC,36561,CPT,,,,,,,,2604,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1117.116,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1081.7016,2784.63
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752F,CDM,510,RC,27752,CPT,,,,,,,,2280,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1117.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,947.112,2234.4
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752F,CDM,510,RC,27752,CPT,,,,,,,,2280,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1117.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,947.112,2234.4
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752F,CDM,510,RC,27752,CPT,,,,,,,,2280,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1117.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,947.112,2234.4
"Upper GI Endoscopy,Ctrl Bleed",PX43255P,CDM,983,RC,43255,CPT,,,,,,,,1148,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1117.3484,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,476.8792,1662.33
Exc Skin Benig >4cm Remaindr Body,PX11426F,CDM,510,RC,11426,CPT,,,,,,,,1227,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1117.797,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,509.6958,2482.37
"Initial Repair of Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49593P,CDM,982,RC,49593,CPT,,,,,,,,2606,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1117.974,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1082.5324,3022.41
Remove Hemorrhoids & Fissure,PX46257F,CDM,510,RC,46257,CPT,,,,,,,,1141,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1118.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,473.9714,2452.93
"CT Colonography, Screen",PX7426301,CDM,350,RC,74263,CPT,TC,,,,,,,3330,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1118.24,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,379.8,1118.24
"CT Colonography, Screen",PX7426301,CDM,350,RC,74263,CPT,TC,,,,,,,3330,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1118.24,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,379.8,1118.24
"Sigmoidoscopy,Biopsy",PX45331P,CDM,983,RC,45331,CPT,,,,,,,,1316,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1118.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,546.6664,1280.8628
filgrastim 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513020991,NDC,0.5,ML,1228.49,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1119.15439,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
paliperidone palmitate ER 234 MG/1.5ML suspension prefilled syringe 1.5 mL Syringe,J2426.01,CDM,636,RC,J2426,HCPCS,,,,50458056401,NDC,0.25,ML,1142.14,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1119.2972,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.12,1119.2972
"Closed Rx Weight Bear Dist Tib,Manip",PX27825F,CDM,510,RC,27825,CPT,,,,,,,,2695,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1119.503,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1119.503,2641.1
omalizumab 150 MG Recon Soln 1 Each Vial,J2357.01,CDM,636,RC,J2357,HCPCS,,,,50242004062,NDC,1,EA,2212.7,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1119.6262,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.02,2168.446
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151F,CDM,510,RC,13151,CPT,,,,,,,,1143,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1120.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,474.8022,1120.14
fluticasone-salmeterol 100-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,54032656,NDC,60,EA,2215.63,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1121.10878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Bcr/Abl1 P210 - Ref,PX8120690,CDM,310,RC,81206,CPT,90,,,,,,,1144,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1121.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,150.33,1121.12
"Close Rx Dist Fingr Fx,Manipulatn",PX26755P,CDM,983,RC,26755,CPT,,,,,,,,1260,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1121.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1226.358
Lap Rpr Vent Umbilical Hernia,PX49652P,CDM,983,RC,49652,CPT,,,,,,,,1260,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1121.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,523.404,1226.358
Closed Rx IP Jt Dislocation,PX26770F,CDM,510,RC,26770,CPT,,,,,,,,1231,,Medica,Commercial,both,91.1,,97.47,percent of total billed charges,1121.441,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1206.38
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096321,NDC,30,ML,1231.47,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1121.86917,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,511.552638,1206.8406
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096330,NDC,30,ML,1231.47,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1121.86917,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,511.552638,1206.8406
trastuzumab-dttb 150 MG Recon Soln 1 Each Vial,J9999.55,CDM,636,RC,J9999,HCPCS,,,,78206014701,NDC,1,EA,2702.3,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1122.53542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1122.53542,2648.254
DYNAFORCE MPJ REAMERS CUP/CONE 20MM,27200000,CDM,272,RC,,,,11853-MAIN,LOCAL,,,,,1262,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1123.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001501,NDC,1,EA,2340,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1123.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.3,2361.4178
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001501,NDC,1,EA,2340,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1123.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.3,2361.4178
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001503,NDC,1,EA,2340,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1123.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.3,2361.4178
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001503,NDC,1,EA,2340,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1123.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.3,2361.4178
OSTEOSET RESORBABLE MINI BEAD KIT FAST CURE CALCIUM SULFATE 5CC,C1713,CDM,278,RC,C1713,HCPCS,,12303-MAIN,LOCAL,,,,,2220,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1123.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Insert Non-Tunnel Cv Catheter >5 Years,PX36556P,CDM,983,RC,36556,CPT,,,,,,,,1274,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1123.668,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,529.2196,2784.63
"Removal of Tunnel Cv Access Device, With Port/Pump",PX36590P,CDM,983,RC,36590,CPT,,,,,,,,1147,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1124.06,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,115.39,1124.06
"Excis Tendn/Capsule Lesn,Toes",PX28092F,CDM,510,RC,28092,CPT,,,,,,,,1234,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1124.174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,512.6036,1404.08
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,310095036,NDC,1,EA,1234.2,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1124.3562,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,512.68668,1209.516
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,70720095036,NDC,1,EA,1234.2,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1124.3562,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,512.68668,1209.516
"Facility Critical Care, E/M 30-74 Minutes",PX99291F,CDM,510,RC,99291,CPT,,,,,,,,1264,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1124.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,525.0656,1238.72
"Upper GI Endoscopy,Ctrl Bleed",PX43255P,CDM,983,RC,43255,CPT,,,,,,,,1148,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1125.04,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.59,1292.28
CT Lwr Extremity W/O&W/Dye,PX7370201,CDM,350,RC,73702,CPT,TC,,,,,,,1235,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1125.085,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
Cytogenomic Neoplasia (Genome-Wide) Microarray Analysis - Ref,PX8127790,CDM,310,RC,81277,CPT,90,,,,,,,3850,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1125.2,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1125.2,1160
Cytogenomic Neoplasia (Genome-Wide) Microarray Analysis - Ref,PX8127790,CDM,310,RC,81277,CPT,90,,,,,,,3850,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1125.2,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1125.2,1160
Cytogenomic Neoplasia (Genome-Wide) Microarray Analysis - Ref,PX8127790,CDM,310,RC,81277,CPT,90,,,,,,,3850,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,1125.2,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1125.2,1160
"Exc Skn Mal 2.1-3cmtrnk,Arm,Lg",PX11603P,CDM,983,RC,11603,CPT,,,,,,,,1276,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1125.432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,530.0504,1241.9308
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x4CM 12SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12767-MAIN,LOCAL,,,,,2345,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1125.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x4CM 12SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12767-MAIN,LOCAL,,,,,2345,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1125.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,469650189,NDC,5,ML,1264.92,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1125.7788,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,424.41418,1239.6216
Tube Thoracostomy Inc Wtr Seal,PX32551P,CDM,983,RC,32551,CPT,,,,,,,,1236,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1125.996,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,513.4344,1399.13
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266P,CDM,983,RC,27266,CPT,,,,,,,,2275,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1126.125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,945.035,2214.2575
"Closed Rx Dist Fibula Fx,Manip",PX27788P,CDM,983,RC,27788,CPT,,,,,,,,1277,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1126.314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1242.9041
HERNIA PATCH VENTRALEX LARGE,C1781,CDM,278,RC,C1781,HCPCS,,10201-MAIN,LOCAL,,,,,1325.08,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1126.318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Fusion Foot Bones,Midtarsal,Multi",PX28730F,CDM,510,RC,28730,CPT,,,,,,,,2299,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1126.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,955.0046,11497.76
"Fusion Foot Bones,Midtarsal,Multi",PX28730F,CDM,510,RC,28730,CPT,,,,,,,,2299,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1126.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,955.0046,11497.76
"Fusion Foot Bones,Midtarsal,Multi",PX28730F,CDM,510,RC,28730,CPT,,,,,,,,2299,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1126.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,955.0046,11497.76
"Excise Lesion,Back or Flank",PX21930F,CDM,510,RC,21930,CPT,,,,,,,,1326,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1127.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,550.8204,1416.38
onabotulinumtoxinA 100 units Recon Soln 1 Each Vial,J0585.01,CDM,636,RC,J0585,HCPCS,,,,23114501,NDC,1,EA,2348.77,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1127.4096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.51,2301.7946
onabotulinumtoxinA 100 units Recon Soln 1 Each Vial,J0585.01,CDM,636,RC,J0585,HCPCS,,,,23114501,NDC,1,EA,2348.77,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1127.4096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.51,2301.7946
ibutilide 1 MG/10ML Solution 10 mL Vial,J1742.01,CDM,636,RC,J1742,HCPCS,,,,9379401,NDC,10,ML,2349.03,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1127.5344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.02,2302.0494
ibutilide 1 MG/10ML Solution 10 mL Vial,J1742.01,CDM,636,RC,J1742,HCPCS,,,,9379401,NDC,10,ML,2349.03,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1127.5344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.02,2302.0494
"Amputation Toe,I-P Jt",PX28825F,CDM,510,RC,28825,CPT,,,,,,,,1327,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1127.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,551.2358,2827.75
Lap Rpr Vent Umbilical Hernia Incarcerated or Strangulated,PX49653P,CDM,983,RC,49653,CPT,,,,,,,,1327,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1127.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,551.2358,1291.5691
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384F,CDM,750,RC,45384,CPT,,,,,,,,2350,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1008.15,4050.42
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384F,CDM,750,RC,45384,CPT,,,,,,,,2350,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1008.15,4050.42
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132F,CDM,510,RC,13132,CPT,,,,,,,,1159,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,268.45,percent of total billed charges,1128.0547,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,481.4486,1135.82
Echo Tt 2d Complete,PX9330701,CDM,480,RC,93307,CPT,TC,,,,,,,2303,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1128.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,2256.94
Echo Tt 2d Complete,PX9330701,CDM,480,RC,93307,CPT,TC,,,,,,,2303,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1128.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,2256.94
Echo Tt 2d Complete,PX9330701,CDM,480,RC,93307,CPT,TC,,,,,,,2303,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1128.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,2256.94
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752F,CDM,510,RC,27752,CPT,,,,,,,,2280,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1128.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,947.112,2234.4
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,70839036204,NDC,4,ML,1280.66,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1129.54212,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
"Repair Lip,>1/2 Vert Height",PX40654P,CDM,983,RC,40654,CPT,,,,,,,,1329,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1129.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,552.0666,1332.3
Explor Metatarso-Phalang Jt,PX28022F,CDM,510,RC,28022,CPT,,,,,,,,1161,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1130.0013,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,482.2794,2827.75
Lap Partial Colectomy/Coloproctostomy,PX44207F,CDM,750,RC,44207,CPT,,,,,,,,4170,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1130.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1130.58,4086.6
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,93598627,NDC,1,EA,1241.11,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1130.65121,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
Reconstruc of Nail Bed,PX11760F,CDM,510,RC,11760,CPT,,,,,,,,1162,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1130.9746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,482.6948,1138.76
MRI Brain W Contrast Tc,PX7055201,CDM,610,RC,70552,CPT,TC,,,,,,,2637,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1131.273,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2584.26
Trauma Activation,PX68200010,CDM,684,RC,G0390,HCPCS,,,,,,,,1243,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1132.373,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,516.3422,1218.14
HARMONIC 1100 SHEARS 20CM SHAFT HAR1120,27200000,CDM,272,RC,,,,12924-MAIN,LOCAL,,,,,1244,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1133.284,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035P,CDM,983,RC,12035,CPT,,,,,,,,1244,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1133.284,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1210.7852
beclomethasone  HFA 80 MCG/ACT Aerosol Breath Activated 10.6 g Inhaler,63700001,CDM,250,RC,,,,,,59310030480,NDC,10.6,GR,1164.84,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1133.738772,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Insert Non-Tunnel Cv Catheter >5 Years,PX36556P,CDM,983,RC,36556,CPT,,,,,,,,1274,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1133.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,529.2196,2784.63
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591P,CDM,982,RC,49591,CPT,,,,,,,,1245,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1134.195,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,517.173,3022.41
"Colonoscopy,Flex,Diagnostic",PX45378F,CDM,750,RC,45378,CPT,,,,,,,,1286,,United Healthcare,All Payer,outpatient,88.2,,999999999,case rate,1134.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1134.252,6141.46
Low Dose CT Lung Ca Screen WO Contrast,PX7127101,CDM,350,RC,71271,CPT,TC,,,,,,,1286,,United Healthcare,All Payer,outpatient,88.2,,712.0433333,percent of total billed charges,1134.252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,1260.28
"Upper GI Endoscopy,Biopsy",PX43239F,CDM,750,RC,43239,CPT,,,,,,,,2364,,Health Partners,Health Partners Care Plans,both,48,,627.99,percent of total billed charges,1134.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,3859.68
"Upper GI Endoscopy,Biopsy",PX43239F,CDM,750,RC,43239,CPT,,,,,,,,2364,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1134.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,3859.68
"Upper GI Endoscopy,Biopsy",PX43239F,CDM,750,RC,43239,CPT,,,,,,,,2364,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,1135.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,3859.68
"Upper GI Endoscopy,Biopsy",PX43239P,CDM,983,RC,43239,CPT,,,,,,,,2458,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,1135.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,3859.68
"Upper GI Endoscopy,Diagnosis",PX43235F,CDM,750,RC,43235,CPT,,,,,,,,2539,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,1135.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,3859.68
"Upper GI Endoscopy,Diagnosis",PX43235P,CDM,983,RC,43235,CPT,,,,,,,,1406,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,1135.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,603.174,3859.68
"Exc Skn Mal 2.1-3cmtrnk,Arm,Lg",PX11603P,CDM,983,RC,11603,CPT,,,,,,,,1276,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1135.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,530.0504,1241.9308
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132F,CDM,510,RC,13132,CPT,,,,,,,,1159,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1135.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,481.4486,1135.82
diazePAM 2.5 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,66490065020,NDC,1,EA,1288,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1136.016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Closed Rx Dist Fibula Fx,Manip",PX27788P,CDM,983,RC,27788,CPT,,,,,,,,1277,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1136.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1242.9041
darbepoetin alfa 500 MCG/ML solution prefilled syringe 1 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513003201,NDC,0.3,ML,2368.44,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1136.8512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
darbepoetin alfa 500 MCG/ML solution prefilled syringe 1 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513003201,NDC,0.3,ML,2368.44,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1136.8512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
Cytogenomic Neoplasia (Genome-Wide) Microarray Analysis - Ref,PX8127790,CDM,310,RC,81277,CPT,90,,,,,,,3850,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1136.9487,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1125.2,1160
eriBULin 1 MG/2ML Solution 2 mL Vial,J9179.01,CDM,636,RC,J9179,HCPCS,,,,62856038901,NDC,2,ML,2321.52,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1137.5448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.87,2275.0896
eriBULin 1 MG/2ML Solution 2 mL Vial,J9179.01,CDM,636,RC,J9179,HCPCS,,,,62856038901,NDC,2,ML,2321.52,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1137.5448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.87,2275.0896
eriBULin 1 MG/2ML Solution 2 mL Vial,J9179.01,CDM,636,RC,J9179,HCPCS,,,,62856038901,NDC,2,ML,2321.52,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1137.5448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.87,2275.0896
ADVANCED INSTRUMENTS 8MM SYNCHROSEAL IS4000,27200000,CDM,272,RC,,,,11924-MAIN,LOCAL,,,,,1290,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1137.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Explor Metatarso-Phalang Jt,PX28022F,CDM,510,RC,28022,CPT,,,,,,,,1161,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1137.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,482.2794,2827.75
ADVANCED INSTRUMENTS VESSEL SEALER EXTEND,27200000,CDM,272,RC,,,,11923-MAIN,LOCAL,,,,,1169,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1137.7877,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Fusion Foot Bones,Midtarsal,Multi",PX28730F,CDM,510,RC,28730,CPT,,,,,,,,2299,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1138.005,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,955.0046,11497.76
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565F,CDM,510,RC,25565,CPT,,,,,,,,1250,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1138.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,519.25,1404.08
Reconstruc of Nail Bed,PX11760F,CDM,510,RC,11760,CPT,,,,,,,,1162,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1138.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,482.6948,1138.76
MRI Abdomen W/O Tc,PX7418101,CDM,610,RC,74181,CPT,TC,,,,,,,2655,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1138.995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,2601.9
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,70839036204,NDC,4,ML,1280.66,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1139.7874,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
"Freeing Bowel Adhesion,Enterolysis",PX44005F,CDM,360,RC,44005,CPT,,,,,,,,2744,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1139.8576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,677.12,2689.12
Echo Tt 2d Complete,PX9330701,CDM,480,RC,93307,CPT,TC,,,,,,,2303,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1139.985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,2256.94
"Cystourethroscopy, With Injection(S) for Chemodenervation of the Bladder",PX52287F,CDM,360,RC,52287,CPT,,,,,,,,2745,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1140.273,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1140.273,2690.1
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 15DEGREE 14MM,27200000,CDM,272,RC,,,,12600-MAIN,LOCAL,,,,,1253,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1141.483,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 45DEGREE 8MM,27200000,CDM,272,RC,,,,12599-MAIN,LOCAL,,,,,1253,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1141.483,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 45DEGREE 14MM,27200000,CDM,272,RC,,,,12598-MAIN,LOCAL,,,,,1253,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1141.483,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 15DEGREE 14MM,27200000,CDM,272,RC,,,,12603-MAIN,LOCAL,,,,,1253,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1141.483,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 45DEGREE 8MM,27200000,CDM,272,RC,,,,12602-MAIN,LOCAL,,,,,1253,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1141.483,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 45DEGREE 14MM,27200000,CDM,272,RC,,,,12601-MAIN,LOCAL,,,,,1253,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1141.483,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
beclomethasone  HFA 80 MCG/ACT Aerosol Breath Activated 10.6 g Inhaler,63700001,CDM,250,RC,,,,,,59310030480,NDC,10.6,GR,1164.84,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1141.5432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Colonoscopy,Flex,Screen",PX2002F,CDM,750,RC,G0105,HCPCS,,,,,,,,2539,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,1142.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,798.45,3885.86
"Colonoscopy,Screen Prev",PX2004F,CDM,750,RC,G0121,HCPCS,,,,,,,,2502,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,1142.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,798.45,3885.86
inFLIXimab 100 MG Recon Soln 1 Each Vial,J1745.01,CDM,636,RC,J1745,HCPCS,,,,57894003001,NDC,1,EA,2382.35,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1143.528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.49,2334.703
inFLIXimab 100 MG Recon Soln 1 Each Vial,J1745.01,CDM,636,RC,J1745,HCPCS,,,,57894003001,NDC,1,EA,2382.35,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1143.528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.49,2334.703
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180P,CDM,983,RC,44180,CPT,,,,,,,,1175,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1143.6275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,488.095,5040.74
"Colonoscopy,Flex,Diagnostic",PX45378F,CDM,750,RC,45378,CPT,,,,,,,,1286,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1144.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,551.694,4661.91
Low Dose CT Lung Ca Screen WO Contrast,PX7127101,CDM,350,RC,71271,CPT,TC,,,,,,,1286,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1144.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,1260.28
"VENTRALIGHT MESH ST WITH ECHO 2 - 10 CM X 15 CM - 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,12007-MAIN,LOCAL,,,,,1176,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1256.29,percent of total billed charges,1144.6008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752F,CDM,510,RC,27752,CPT,,,,,,,,2280,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1144.93,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.64,1144.93
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752P,CDM,983,RC,27752,CPT,,,,,,,,2495,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1144.93,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.64,2445.1
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151P,CDM,983,RC,13151,CPT,,,,,,,,1177,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,918.945,percent of total billed charges,1145.5741,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,488.9258,1145.5741
ADVANCED INSTRUMENTS VESSEL SEALER EXTEND,27200000,CDM,272,RC,,,,11923-MAIN,LOCAL,,,,,1169,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1145.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
diazePAM 2.5 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,66490065020,NDC,1,EA,1288,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1146.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605F,CDM,510,RC,25605,CPT,,,,,,,,1178,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1146.5474,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,489.3412,1404.08
"Amputation Toe,Mt-P Jt",PX28820P,CDM,983,RC,28820,CPT,,,,,,,,1300,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1146.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,540.02,2827.75
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001501,NDC,1,EA,2340,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1146.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.3,2361.4178
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001501,NDC,1,EA,2340,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1146.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.3,2361.4178
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001501,NDC,1,EA,2340,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1146.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.3,2361.4178
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001503,NDC,1,EA,2340,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1146.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.3,2361.4178
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001503,NDC,1,EA,2340,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1146.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.3,2361.4178
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001503,NDC,1,EA,2340,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1146.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.3,2361.4178
"Hemorrhoidectomy,Int/Ext,Complx",PX46260F,CDM,750,RC,46260,CPT,,,,,,,,1350,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1147.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,560.79,2452.93
Leukoreduced Platelets,PXP9035,CDM,390,RC,P9035,HCPCS,,,,,,,,1350,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1147.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,433.08,1323
"Colonoscope, Submucous Inj",PX45381F,CDM,750,RC,45381,CPT,,,,,,,,1179,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1179,percent of total billed charges,1147.5207,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,489.7566,1155.42
"Close Rx Dist Fingr Fx,Manipulatn",PX26755P,CDM,983,RC,26755,CPT,,,,,,,,1260,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1147.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1226.358
Lap Rpr Vent Umbilical Hernia,PX49652P,CDM,983,RC,49652,CPT,,,,,,,,1260,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1147.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,523.404,1226.358
ADVANCED INSTRUMENTS 8MM SYNCHROSEAL IS4000,27200000,CDM,272,RC,,,,11924-MAIN,LOCAL,,,,,1290,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1148.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HARMONIC 110 SHEARS 36CM SHAFT,27200000,CDM,272,RC,,,,12043-MAIN,LOCAL,,,,,2392,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1148.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HARMONIC 110 SHEARS 36CM SHAFT,27200000,CDM,272,RC,,,,12043-MAIN,LOCAL,,,,,2392,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1148.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,62935022305,NDC,1,EA,2764.34,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1148.306836,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
"Sb Scope,to Ileum,Biopsy",PX44377P,CDM,983,RC,44377,CPT,,,,,,,,1180,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1148.494,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,490.172,1662.33
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x4CM 12SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12767-MAIN,LOCAL,,,,,2345,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1149.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x4CM 12SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12767-MAIN,LOCAL,,,,,2345,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1149.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x4CM 12SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12767-MAIN,LOCAL,,,,,2345,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1149.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
eriBULin 1 MG/2ML Solution 2 mL Vial,J9179.01,CDM,636,RC,J9179,HCPCS,,,,62856038901,NDC,2,ML,2321.52,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1149.1524,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.87,2275.0896
"Closed Rx Trimalleolar Fx,Manip",PX27818P,CDM,983,RC,27818,CPT,,,,,,,,1352,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1149.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,561.6208,1404.08
DYNAFORCE MPJ REAMERS CUP/CONE 20MM,27200000,CDM,272,RC,,,,11853-MAIN,LOCAL,,,,,1262,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1149.682,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Closed Rx IP Jt Dislocation,PX26770P,CDM,983,RC,26770,CPT,,,,,,,,1353,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1150.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1316.8749
"MRI,Uprext Jnt W/O+W/Cont",PX7322301,CDM,610,RC,73223,CPT,TC,,,,,,,2681,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1150.149,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2627.38
GROSHONG PICC NXT 4FR,120.218,CDM,272,RC,,,,498-MAIN,LOCAL,,,,,1182,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1150.4406,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,491.0028,1158.36
onabotulinumtoxinA 100 units Recon Soln 1 Each Vial,J0585.01,CDM,636,RC,J0585,HCPCS,,,,23114501,NDC,1,EA,2348.77,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1150.8973,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.51,2301.7946
onabotulinumtoxinA 100 units Recon Soln 1 Each Vial,J0585.01,CDM,636,RC,J0585,HCPCS,,,,23114501,NDC,1,EA,2348.77,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1150.8973,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.51,2301.7946
onabotulinumtoxinA 100 units Recon Soln 1 Each Vial,J0585.01,CDM,636,RC,J0585,HCPCS,,,,23114501,NDC,1,EA,2348.77,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1150.8973,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.51,2301.7946
ibutilide 1 MG/10ML Solution 10 mL Vial,J1742.01,CDM,636,RC,J1742,HCPCS,,,,9379401,NDC,10,ML,2349.03,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1151.0247,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.02,2302.0494
ibutilide 1 MG/10ML Solution 10 mL Vial,J1742.01,CDM,636,RC,J1742,HCPCS,,,,9379401,NDC,10,ML,2349.03,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1151.0247,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.02,2302.0494
ibutilide 1 MG/10ML Solution 10 mL Vial,J1742.01,CDM,636,RC,J1742,HCPCS,,,,9379401,NDC,10,ML,2349.03,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1151.0247,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.02,2302.0494
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266P,CDM,983,RC,27266,CPT,,,,,,,,2275,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1151.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,945.035,2214.2575
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502050102,NDC,1,EA,1305.38,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1151.34516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384F,CDM,750,RC,45384,CPT,,,,,,,,2350,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1151.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1008.15,4050.42
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384F,CDM,750,RC,45384,CPT,,,,,,,,2350,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1151.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1008.15,4050.42
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384F,CDM,750,RC,45384,CPT,,,,,,,,2350,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1151.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1008.15,4050.42
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180P,CDM,983,RC,44180,CPT,,,,,,,,1175,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1151.5,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,548.86,1910.75
"Facility Critical Care, E/M 30-74 Minutes",PX99291F,CDM,510,RC,99291,CPT,,,,,,,,1264,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1151.504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,525.0656,1238.72
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,469650189,NDC,5,ML,1264.92,,Medica,Commercial,both,91.1,,288.0925,percent of total billed charges,1152.34212,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,424.41418,1239.6216
"VENTRALIGHT MESH ST WITH ECHO 2 - 10 CM X 15 CM - 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,12007-MAIN,LOCAL,,,,,1176,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1152.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505P,CDM,983,RC,24505,CPT,,,,,,,,2353,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1152.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,977.4362,2290.1749
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505P,CDM,983,RC,24505,CPT,,,,,,,,2353,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1152.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,977.4362,2290.1749
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505P,CDM,983,RC,24505,CPT,,,,,,,,2353,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1152.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,977.4362,2290.1749
Hepatobiliary System Imaging,PX7822601,CDM,341,RC,78226,CPT,TC,,,,,,,2776,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1153.1504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,360.31,2720.48
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151P,CDM,983,RC,13151,CPT,,,,,,,,1177,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1153.46,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,173.43,1153.46
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752F,CDM,510,RC,27752,CPT,,,,,,,,2280,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1153.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,947.112,2234.4
CT Lower Extremity W/Dye,PX7370101,CDM,350,RC,73701,CPT,TC,,,,,,,2690,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1154.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,2636.2
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605F,CDM,510,RC,25605,CPT,,,,,,,,1178,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1154.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,489.3412,1404.08
HERNIA PATCH VENTRALEX MEDIUM,C1781,CDM,278,RC,C1781,HCPCS,,10202-MAIN,LOCAL,,,,,1309.75,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1155.1995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Colonoscope, Submucous Inj",PX45381F,CDM,750,RC,45381,CPT,,,,,,,,1179,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1155.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,489.7566,1155.42
MESH VENTRALIGHT ECHO 2.0 POSITIONING 11CM ROUND,120.525,CDM,278,RC,C1781,HCPCS,,12219-MAIN,LOCAL,,,,,1310,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1155.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,544.174,1283.8
Revise Median N/Carpal Tunnel Surg,PX64721F,CDM,510,RC,64721,CPT,,,,,,,,2408,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1155.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1000.2832,2359.84
Revise Median N/Carpal Tunnel Surg,PX64721F,CDM,510,RC,64721,CPT,,,,,,,,2408,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1155.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1000.2832,2359.84
"Closed Rx Weight Bear Dist Tib,Manip",PX27825F,CDM,510,RC,27825,CPT,,,,,,,,2695,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1156.155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1119.503,2641.1
Art Lower Extremity-Bilat,PX9392501,CDM,921,RC,93925,CPT,TC,,,,,,,1188,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1156.2804,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,1164.24
"Sb Scope,to Ileum,Biopsy",PX44377P,CDM,983,RC,44377,CPT,,,,,,,,1180,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1156.4,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,182.81,1156.4
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,70842014003,NDC,1,EA,2409.61,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1156.6128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.3,2361.4178
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,70842014003,NDC,1,EA,2409.61,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1156.6128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.3,2361.4178
"Amputation Toe,Mt-P Jt",PX28820P,CDM,983,RC,28820,CPT,,,,,,,,1300,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1157,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,540.02,2827.75
Ven Duplex Bilateral,PX9397001,CDM,921,RC,93970,CPT,TC,,,,,,,1189,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1157.2537,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,1165.22
carfilzomib 30 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010201,NDC,1,EA,2785.91,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1157.267014,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.23,5460.3836
"Remv F.B.,Eye,Ant Chmbr/Lens",PX65235F,CDM,510,RC,65235,CPT,,,,,,,,2788,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1158.1352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1158.1352,2732.24
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001501,NDC,1,EA,2340,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1158.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.3,2361.4178
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001503,NDC,1,EA,2340,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1158.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.3,2361.4178
GROSHONG PICC NXT 4FR,120.218,CDM,272,RC,,,,498-MAIN,LOCAL,,,,,1182,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1158.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,491.0028,1158.36
"Upper GI Endoscopy,Biopsy",PX43239F,CDM,750,RC,43239,CPT,,,,,,,,2364,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,2132.28,percent of total billed charges,1158.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,3859.68
"Upper GI Endoscopy,Biopsy",PX43239F,CDM,750,RC,43239,CPT,,,,,,,,2364,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1158.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,3859.68
"Upper GI Endoscopy,Biopsy",PX43239F,CDM,750,RC,43239,CPT,,,,,,,,2364,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1158.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,3859.68
I&D Perirectal Abscess,PX46040F,CDM,510,RC,46040,CPT,,,,,,,,1430,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1158.77,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,264.62,1158.77
I&D Perirectal Abscess,PX46040P,CDM,983,RC,46040,CPT,,,,,,,,953,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1158.77,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,264.62,1158.77
trastuzumab-dttb 150 MG Recon Soln 1 Each Vial,J9999.55,CDM,636,RC,J9999,HCPCS,,,,78206014701,NDC,1,EA,2702.3,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1159.2867,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1122.53542,2648.254
Cytogenomic Neoplasia (Genome-Wide) Microarray Analysis - Ref,PX8127790,CDM,310,RC,81277,CPT,90,,,,,,,3850,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1160,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1125.2,1160
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605F,CDM,510,RC,25605,CPT,,,,,,,,1178,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1160.15,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,325.92,1160.15
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605P,CDM,983,RC,25605,CPT,,,,,,,,785,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1160.15,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,325.92,1160.15
darbepoetin alfa 500 MCG/ML solution prefilled syringe 1 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513003201,NDC,0.3,ML,2368.44,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1160.5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
darbepoetin alfa 500 MCG/ML solution prefilled syringe 1 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513003201,NDC,0.3,ML,2368.44,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1160.5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
darbepoetin alfa 500 MCG/ML solution prefilled syringe 1 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513003201,NDC,0.3,ML,2368.44,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1160.5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
Insert Non-Tunnel Cv Catheter >5 Years,PX36556P,CDM,983,RC,36556,CPT,,,,,,,,1274,,Medica,Commercial,both,91.1,,131.535,percent of total billed charges,1160.614,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,529.2196,2784.63
"Sigmoidoscopy,Biopsy",PX45331P,CDM,983,RC,45331,CPT,,,,,,,,1316,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1160.712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,546.6664,1280.8628
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x4CM 12SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12767-MAIN,LOCAL,,,,,2345,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1160.775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
Heart/Lung Resuscitation (Cpr),PX92950F,CDM,480,RC,92950,CPT,,,,,,,,1366,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1161.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.21,1338.68
"Lap,Cholecystectomy/Explore",PX47564F,CDM,510,RC,47564,CPT,,,,,,,,2419,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1161.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1004.8526,8992.74
"Lap,Cholecystectomy/Explore",PX47564F,CDM,510,RC,47564,CPT,,,,,,,,2419,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1161.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1004.8526,8992.74
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502050102,NDC,1,EA,1305.38,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1161.7882,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
"Exc Skn Mal 2.1-3cmtrnk,Arm,Lg",PX11603P,CDM,983,RC,11603,CPT,,,,,,,,1276,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1162.436,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,530.0504,1241.9308
onabotulinumtoxinA 100 units Recon Soln 1 Each Vial,J0585.01,CDM,636,RC,J0585,HCPCS,,,,23114501,NDC,1,EA,2348.77,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1162.64115,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.51,2301.7946
ibutilide 1 MG/10ML Solution 10 mL Vial,J1742.01,CDM,636,RC,J1742,HCPCS,,,,9379401,NDC,10,ML,2349.03,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1162.76985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.02,2302.0494
zoledronic acid 5 MG/100ML Solution 100 mL Bottle,J3489.01,CDM,636,RC,J3489,HCPCS,,,,55111068852,NDC,100,ML,1368,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1162.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,63323096600,NDC,100,ML,1368,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1162.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384F,CDM,750,RC,45384,CPT,,,,,,,,2350,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1163.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1008.15,4050.42
"Fusion Foot Bones,Midtarsal,Multi",PX28730F,CDM,510,RC,28730,CPT,,,,,,,,2299,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1163.294,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,955.0046,11497.76
"Closed Rx Dist Fibula Fx,Manip",PX27788P,CDM,983,RC,27788,CPT,,,,,,,,1277,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1163.347,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1242.9041
"Closed Rx Weight Bear Dist Tib,Manip",PX27825F,CDM,510,RC,27825,CPT,,,,,,,,2695,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1163.61,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.21,1163.61
"Closed Rx Weight Bear Dist Tib,Manip",PX27825P,CDM,983,RC,27825,CPT,,,,,,,,1796,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1163.61,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.21,1760.08
Art Lower Extremity-Bilat,PX9392501,CDM,921,RC,93925,CPT,TC,,,,,,,1188,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1164.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,1164.24
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505P,CDM,983,RC,24505,CPT,,,,,,,,2353,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1164.735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,977.4362,2290.1749
Ven Duplex Bilateral,PX9397001,CDM,921,RC,93970,CPT,TC,,,,,,,1189,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1165.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,1165.22
Echo Tt 2d Complete,PX9330701,CDM,480,RC,93307,CPT,TC,,,,,,,2303,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1165.318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,2256.94
HERNIA PATCH VENTRALEX MEDIUM,C1781,CDM,278,RC,C1781,HCPCS,,10202-MAIN,LOCAL,,,,,1309.75,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1165.6775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
MESH VENTRALIGHT ECHO 2.0 POSITIONING 11CM ROUND,120.525,CDM,278,RC,C1781,HCPCS,,12219-MAIN,LOCAL,,,,,1310,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1165.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,544.174,1283.8
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,70839036204,NDC,4,ML,1280.66,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1166.68126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
inFLIXimab 100 MG Recon Soln 1 Each Vial,J1745.01,CDM,636,RC,J1745,HCPCS,,,,57894003001,NDC,1,EA,2382.35,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,202.047,percent of total billed charges,1167.3515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.49,2334.703
inFLIXimab 100 MG Recon Soln 1 Each Vial,J1745.01,CDM,636,RC,J1745,HCPCS,,,,57894003001,NDC,1,EA,2382.35,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1167.3515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.49,2334.703
inFLIXimab 100 MG Recon Soln 1 Each Vial,J1745.01,CDM,636,RC,J1745,HCPCS,,,,57894003001,NDC,1,EA,2382.35,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1167.3515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.49,2334.703
Room Rate Icc,PX20601000,CDM,206,RC,,,,,,,,,,2432,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1167.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1010.2528,2383.36
Room Rate Icc,PX20601000,CDM,206,RC,,,,,,,,,,2432,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1167.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1010.2528,2383.36
Level 1 Additional Procedure,PX36000080,CDM,360,RC,,,,,,,,,,1200,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1167.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,498.48,1176
Low Dose CT Lung Ca Screening,PXG029701,CDM,350,RC,G0297,HCPCS,TC,,,,,,,2812,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1168.1048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1168.1048,2755.76
HERNIA PATCH VENTRALEX LARGE,C1781,CDM,278,RC,C1781,HCPCS,,10201-MAIN,LOCAL,,,,,1325.08,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1168.72056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Excise Lesion,Back or Flank",PX21930F,CDM,510,RC,21930,CPT,,,,,,,,1326,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1169.532,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,550.8204,1416.38
"Upper GI Endoscopy,Biopsy",PX43239F,CDM,750,RC,43239,CPT,,,,,,,,2364,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1170.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,3859.68
"Amputation Toe,I-P Jt",PX28825F,CDM,510,RC,28825,CPT,,,,,,,,1327,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1170.414,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,551.2358,2827.75
Lap Rpr Vent Umbilical Hernia Incarcerated or Strangulated,PX49653P,CDM,983,RC,49653,CPT,,,,,,,,1327,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1170.414,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,551.2358,1291.5691
"Sigmoidoscopy,Biopsy",PX45331P,CDM,983,RC,45331,CPT,,,,,,,,1316,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1171.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,546.6664,1280.8628
"Colonoscopy,Flex,Diagnostic",PX45378F,CDM,750,RC,45378,CPT,,,,,,,,1286,,Medica,Commercial,both,91.1,,341.1125,percent of total billed charges,1171.546,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,551.694,4661.91
Low Dose CT Lung Ca Screen WO Contrast,PX7127101,CDM,350,RC,71271,CPT,TC,,,,,,,1286,,Medica,Commercial,both,91.1,,607.33,percent of total billed charges,1171.546,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,1260.28
HARMONIC 110 SHEARS 36CM SHAFT,27200000,CDM,272,RC,,,,12043-MAIN,LOCAL,,,,,2392,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1172.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HARMONIC 110 SHEARS 36CM SHAFT,27200000,CDM,272,RC,,,,12043-MAIN,LOCAL,,,,,2392,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1172.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HARMONIC 110 SHEARS 36CM SHAFT,27200000,CDM,272,RC,,,,12043-MAIN,LOCAL,,,,,2392,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1172.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Repair Lip,>1/2 Vert Height",PX40654P,CDM,983,RC,40654,CPT,,,,,,,,1329,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1172.178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,552.0666,1332.3
darbepoetin alfa 500 MCG/ML solution prefilled syringe 1 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513003201,NDC,0.3,ML,2368.44,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1172.3778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
"Hemorrhoidectomy,Int/Ext,Simple",PX46255P,CDM,983,RC,46255,CPT,,,,,,,,2393,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1172.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,994.0522,2452.93
"Hemorrhoidectomy,Int/Ext,Simple",PX46255P,CDM,983,RC,46255,CPT,,,,,,,,2393,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1172.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,994.0522,2452.93
"Hemorrhoidectomy,Int/Ext,Simple",PX46255P,CDM,983,RC,46255,CPT,,,,,,,,2393,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1172.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,994.0522,2452.93
diazePAM 2.5 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,66490065020,NDC,1,EA,1288,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1173.368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
eriBULin 1 MG/2ML Solution 2 mL Vial,J9179.01,CDM,636,RC,J9179,HCPCS,,,,62856038901,NDC,2,ML,2321.52,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1174.68912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.87,2275.0896
methylene blue 50 MG/10ML Solution 10 mL Ampule,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,517037405,NDC,10,ML,1382.12,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1174.802,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.29,1354.4776
ADVANCED INSTRUMENTS 8MM SYNCHROSEAL IS4000,27200000,CDM,272,RC,,,,11924-MAIN,LOCAL,,,,,1290,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1175.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
liraglutide 18 MG/3ML solution pen-injector 3 mL Pen,63700001,CDM,250,RC,,,,,,169406013,NDC,3,ML,1382.75,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1175.3375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Colonoscopy,Flex,Diagnostic",PX45378P,CDM,983,RC,45378,CPT,,,,,,,,1200,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1176,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.56,1176
Level 1 Additional Procedure,PX36000080,CDM,360,RC,,,,,,,,,,1200,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,498.48,1176
CT Pelvis W/O Dye,PX7219201,CDM,350,RC,72192,CPT,TC,,,,,,,2744,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1177.176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2689.12
"Freeing Bowel Adhesion,Enterolysis",PX44005F,CDM,360,RC,44005,CPT,,,,,,,,2744,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1177.176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,677.12,2689.12
POWERPORT ISP MRI IMPLANTABLE PORT 8FR,C1788,CDM,278,RC,C1788,HCPCS,,11998-MAIN,LOCAL,,,,,1385,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1177.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,575.329,1357.3
"Cystourethroscopy, With Injection(S) for Chemodenervation of the Bladder",PX52287F,CDM,360,RC,52287,CPT,,,,,,,,2745,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1177.605,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1140.273,2690.1
inFLIXimab 100 MG Recon Soln 1 Each Vial,J1745.01,CDM,636,RC,J1745,HCPCS,,,,57894003001,NDC,1,EA,2382.35,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1179.26325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.49,2334.703
HERNIA PATCH VENTRALEX LARGE,C1781,CDM,278,RC,C1781,HCPCS,,10201-MAIN,LOCAL,,,,,1325.08,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1179.3212,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Revise Median N/Carpal Tunnel Surg,PX64721F,CDM,510,RC,64721,CPT,,,,,,,,2408,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1179.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1000.2832,2359.84
Revise Median N/Carpal Tunnel Surg,PX64721F,CDM,510,RC,64721,CPT,,,,,,,,2408,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1179.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1000.2832,2359.84
Revise Median N/Carpal Tunnel Surg,PX64721F,CDM,510,RC,64721,CPT,,,,,,,,2408,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1179.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1000.2832,2359.84
"Excise Lesion,Back or Flank",PX21930F,CDM,510,RC,21930,CPT,,,,,,,,1326,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1180.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,550.8204,1416.38
diazePAM 10 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,93613832,NDC,1,EA,1212.57,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1180.194381,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,70842014003,NDC,1,EA,2409.61,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1180.7089,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.3,2361.4178
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,70842014003,NDC,1,EA,2409.61,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1180.7089,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.3,2361.4178
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,70842014003,NDC,1,EA,2409.61,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1180.7089,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.3,2361.4178
"Amputation Toe,I-P Jt",PX28825F,CDM,510,RC,28825,CPT,,,,,,,,1327,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1181.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,551.2358,2827.75
Lap Rpr Vent Umbilical Hernia Incarcerated or Strangulated,PX49653P,CDM,983,RC,49653,CPT,,,,,,,,1327,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1181.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,551.2358,1291.5691
Partial Bone Scan,PX7830001,CDM,341,RC,78300,CPT,TC,,,,,,,1391,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1182.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,360.31,1363.18
ramuCIRumab 100 MG/10ML Solution 10 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2766901,NDC,10,ML,2463.3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1182.384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.57,12070.17
ramuCIRumab 100 MG/10ML Solution 10 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2766901,NDC,10,ML,2463.3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1182.384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.57,12070.17
"Colonoscope, Submucous Inj",PX45381P,CDM,983,RC,45381,CPT,,,,,,,,1215,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1179,percent of total billed charges,1182.5595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,504.711,1182.5595
"Colonoscopy,Control Bleeding",PX45382F,CDM,750,RC,45382,CPT,,,,,,,,1215,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1182.5595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,504.711,1190.7
"Igh, Variable Region Somatic Mutation Analysis",PX8126390,CDM,310,RC,81263,CPT,90,,,,,,,1215,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1182.5595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.05,1190.7
CT Abdomen W/O Dye,PX7415001,CDM,350,RC,74150,CPT,TC,,,,,,,2757,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1182.753,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Angio Abd&Pelv W/O&W/Dye,PX7417401,CDM,350,RC,74174,CPT,TC,,,,,,,2757,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1182.753,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2701.86
CT Chest Spine W/O Dye,PX7212801,CDM,350,RC,72128,CPT,TC,,,,,,,2757,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1182.753,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Head/Brain W/O Dye,PX7045001,CDM,350,RC,70450,CPT,TC,,,,,,,2757,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1182.753,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Lower Extremity W/O Dye,PX7370001,CDM,350,RC,73700,CPT,TC,,,,,,,2757,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1182.753,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Lumbar Spine W/O Dye,PX7213101,CDM,350,RC,72131,CPT,TC,,,,,,,2757,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1182.753,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Maxillofacialw/O Dye,PX7048601,CDM,350,RC,70486,CPT,TC,,,,,,,2757,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1182.753,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Neck Spine W/O Dye,PX7212501,CDM,350,RC,72125,CPT,TC,,,,,,,2757,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1182.753,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Orbit/Ear/Fosa W/O Dye,PX7048001,CDM,350,RC,70480,CPT,TC,,,,,,,2757,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1182.753,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Upper Extremity W/Dye,PX7320101,CDM,350,RC,73201,CPT,TC,,,,,,,2757,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1182.753,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2701.86
CT Upper Extremity W/O Dye,PX7320001,CDM,350,RC,73200,CPT,TC,,,,,,,2757,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1182.753,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
Diagnostic CT Thorax W/O Contrast,PX7125001,CDM,350,RC,71250,CPT,TC,,,,,,,2757,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1182.753,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
"Repair Lip,>1/2 Vert Height",PX40654P,CDM,983,RC,40654,CPT,,,,,,,,1329,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1182.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,552.0666,1332.3
Facility Emergency Level V Visit,PX99285F,CDM,450,RC,99285,CPT,,,,,,,,1464,,Medica,Minnesota Health care Program (MHCP),outpatient,,,999999999,case rate,1183,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1183,6141.46
"Colonoscopy,Biopsy",PX45380F,CDM,750,RC,45380,CPT,,,,,,,,2465,,Health Partners,Health Partners Care Plans,both,48,,2351.19,percent of total billed charges,1183.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1030.93,4050.42
"Colonoscopy,Biopsy",PX45380F,CDM,750,RC,45380,CPT,,,,,,,,2465,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1183.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1030.93,4050.42
HARMONIC 110 SHEARS 36CM SHAFT,27200000,CDM,272,RC,,,,12043-MAIN,LOCAL,,,,,2392,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1184.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001501,NDC,1,EA,2340,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1184.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.3,2361.4178
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001503,NDC,1,EA,2340,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1184.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.3,2361.4178
"Repair Lip,>1/2 Vert Height",PX40654F,CDM,510,RC,40654,CPT,,,,,,,,2467,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1184.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1024.7918,2417.66
"Repair Lip,>1/2 Vert Height",PX40654F,CDM,510,RC,40654,CPT,,,,,,,,2467,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1184.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1024.7918,2417.66
"Amputation Toe,Mt-P Jt",PX28820P,CDM,983,RC,28820,CPT,,,,,,,,1300,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1184.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,540.02,2827.75
"Lap,Inguinal Hernia Repr,Recur",PX49651F,CDM,510,RC,49651,CPT,,,,,,,,1568,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1184.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,342.5,1184.36
"Lap,Inguinal Hernia Repr,Recur",PX49651F,CDM,510,RC,49651,CPT,,,,,,,,1568,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1184.36,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,342.5,1184.36
"Lap,Inguinal Hernia Repr,Recur",PX49651P,CDM,983,RC,49651,CPT,,,,,,,,2035,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1184.36,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,342.5,1994.3
"Lap,Inguinal Hernia Repr,Recur",PX49651P,CDM,983,RC,49651,CPT,,,,,,,,2035,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1184.36,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,342.5,1994.3
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569F,CDM,510,RC,36569,CPT,,,,,,,,1217,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1184.5061,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,505.5418,1399.13
"Hemorrhoidectomy,Int/Ext,Simple",PX46255P,CDM,983,RC,46255,CPT,,,,,,,,2393,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1184.535,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,994.0522,2452.93
hepatitis B immune globulin 312 UNIT/ML Solution 5 mL Vial,90371,CDM,636,RC,90371,CPT,,,,59730420301,NDC,5,ML,2851.63,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1184.567102,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.6,2794.5974
"Lap,Cholecystectomy/Explore",PX47564F,CDM,510,RC,47564,CPT,,,,,,,,2419,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1185.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1004.8526,8992.74
"Lap,Cholecystectomy/Explore",PX47564F,CDM,510,RC,47564,CPT,,,,,,,,2419,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1185.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1004.8526,8992.74
"Lap,Cholecystectomy/Explore",PX47564F,CDM,510,RC,47564,CPT,,,,,,,,2419,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1185.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1004.8526,8992.74
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,62935022305,NDC,1,EA,2764.34,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1185.90186,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
"Initial Repair of Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49593P,CDM,982,RC,49593,CPT,,,,,,,,2606,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1186.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,337.26,2553.88
"Initial Repair of Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49593P,CDM,982,RC,49593,CPT,,,,,,,,2606,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1186.44,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,337.26,2553.88
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x4CM 12SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12767-MAIN,LOCAL,,,,,2345,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1186.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
REVITA PLACENTAL MEMBRANE 2X3CM 6SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12559-MAIN,LOCAL,,,,,2474,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1187.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
REVITA PLACENTAL MEMBRANE 2X3CM 6SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12559-MAIN,LOCAL,,,,,2474,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1187.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
OBINutuzumab 1000 MG/40ML Solution 40 mL Vial,J9301.01,CDM,636,RC,J9301,HCPCS,,,,50242007001,NDC,4,ML,1397.15,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1187.5775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.12,1369.207
"Colonoscopy,Remv Lesn,Snare",PX45385P,CDM,983,RC,45385,CPT,,,,,,,,2424,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,710.9625,percent of total billed charges,1187.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1030.93,4050.42
"Colonoscopy,Remv Lesn,Snare",PX45385P,CDM,983,RC,45385,CPT,,,,,,,,2424,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1187.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1030.93,4050.42
"Colonoscopy,Remv Lesn,Snare",PX45385P,CDM,983,RC,45385,CPT,,,,,,,,2424,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1187.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1030.93,4050.42
Incise Finger Tendon Sheath,PX26055F,CDM,510,RC,26055,CPT,,,,,,,,1398,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1188.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,580.7292,1404.08
diazePAM 10 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,93613832,NDC,1,EA,1212.57,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1188.3186,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Bone Marrow Biopsy(Ies),PX38221F,CDM,510,RC,38221,CPT,,,,,,,,1221,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1188.3993,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,507.2034,1416.38
onabotulinumtoxinA 100 units Recon Soln 1 Each Vial,J0585.01,CDM,636,RC,J0585,HCPCS,,,,23114501,NDC,1,EA,2348.77,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1188.47762,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.51,2301.7946
ibutilide 1 MG/10ML Solution 10 mL Vial,J1742.01,CDM,636,RC,J1742,HCPCS,,,,9379401,NDC,10,ML,2349.03,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1188.60918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.02,2302.0494
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384F,CDM,750,RC,45384,CPT,,,,,,,,2350,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1189.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1008.15,4050.42
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502050102,NDC,1,EA,1305.38,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1189.20118,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
CT Orbit/Ear/Fossa W/O & W/Dye,PX7048201,CDM,350,RC,70482,CPT,TC,,,,,,,1400,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1190,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
IMPLANT PACKAGE TOEMATE,27200000,CDM,278,RC,C1713,HCPCS,,11859-MAIN,LOCAL,,,,,2865,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1190.121,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
IMPLANT TOEMATE X-SMALL PACKAGE 9H00-T050,C1713,CDM,278,RC,C1713,HCPCS,,11574-MAIN,LOCAL,,,,,2865,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1190.121,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505P,CDM,983,RC,24505,CPT,,,,,,,,2353,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1190.618,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,977.4362,2290.1749
"Colonoscope, Submucous Inj",PX45381P,CDM,983,RC,45381,CPT,,,,,,,,1215,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1190.7,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.59,1190.7
"Colonoscopy,Control Bleeding",PX45382F,CDM,750,RC,45382,CPT,,,,,,,,1215,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1190.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,504.711,1190.7
"Hemorrhoidectomy,Int/Ext,Complx",PX46260F,CDM,750,RC,46260,CPT,,,,,,,,1350,,United Healthcare,All Payer,outpatient,88.2,,999999999,case rate,1190.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1190.7,6141.46
"Igh, Variable Region Somatic Mutation Analysis",PX8126390,CDM,310,RC,81263,CPT,90,,,,,,,1215,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1190.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.05,1190.7
Leukoreduced Platelets,PXP9035,CDM,390,RC,P9035,HCPCS,,,,,,,,1350,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1190.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,433.08,1323
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781324494,NDC,1,EA,1400.9,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1190.765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
Hepatobiliary System Imaging,PX7822601,CDM,341,RC,78226,CPT,TC,,,,,,,2776,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1190.904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,360.31,2720.48
"Colonoscopy,Biopsy",PX45380F,CDM,750,RC,45380,CPT,,,,,,,,2465,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,1191.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1030.93,4050.42
"Colonoscopy,Biopsy",PX45380P,CDM,983,RC,45380,CPT,,,,,,,,2539,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,1191.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1030.93,4050.42
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384F,CDM,750,RC,45384,CPT,,,,,,,,2350,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,1191.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1008.15,4050.42
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384P,CDM,983,RC,45384,CPT,,,,,,,,1436,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,1191.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,616.044,4050.42
"Colonoscopy,Remv Lesn,Snare",PX45385F,CDM,750,RC,45385,CPT,,,,,,,,1939,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,1191.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,831.831,4050.42
"Colonoscopy,Remv Lesn,Snare",PX45385P,CDM,983,RC,45385,CPT,,,,,,,,2424,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,1191.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1030.93,4050.42
Room Rate Icc,PX20601000,CDM,206,RC,,,,,,,,,,2432,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1191.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1010.2528,2383.36
Room Rate Icc,PX20601000,CDM,206,RC,,,,,,,,,,2432,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1191.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1010.2528,2383.36
Room Rate Icc,PX20601000,CDM,206,RC,,,,,,,,,,2432,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1191.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1010.2528,2383.36
Revise Median N/Carpal Tunnel Surg,PX64721F,CDM,510,RC,64721,CPT,,,,,,,,2408,,Humana Choice Care,All Medicare plans,outpatient,49.5,,527.025,percent of total billed charges,1191.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1000.2832,2359.84
"Closed Rx Trimalleolar Fx,Manip",PX27818P,CDM,983,RC,27818,CPT,,,,,,,,1352,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1192.464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,561.6208,1404.08
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569F,CDM,510,RC,36569,CPT,,,,,,,,1217,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1192.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,505.5418,1399.13
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,70842014003,NDC,1,EA,2409.61,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1192.75695,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.3,2361.4178
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,16714085701,NDC,1,EA,1403.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1192.975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
HERNIA PATCH VENTRALEX MEDIUM,C1781,CDM,278,RC,C1781,HCPCS,,10202-MAIN,LOCAL,,,,,1309.75,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1193.18225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Closed Rx IP Jt Dislocation,PX26770P,CDM,983,RC,26770,CPT,,,,,,,,1353,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1193.346,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1316.8749
Closed Rx Kneecap Disloc+Anesth,PX27562P,CDM,983,RC,27562,CPT,,,,,,,,1404,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1193.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1366.5132
MESH VENTRALIGHT ECHO 2.0 POSITIONING 11CM ROUND,120.525,CDM,278,RC,C1781,HCPCS,,12219-MAIN,LOCAL,,,,,1310,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1193.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,544.174,1283.8
"Cytogen, Interp/Report - Ref",PX8829190,CDM,310,RC,88291,CPT,90,,,,,,,2874,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1193.8596,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.95,2816.52
Exc Skin Benig >4cm Remaindr Body,PX11426F,CDM,510,RC,11426,CPT,,,,,,,,1227,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1194.2391,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,509.6958,2482.37
liraglutide 18 MG/3ML solution pen-injector 3 mL Pen,63700001,CDM,250,RC,,,,,,169406012,NDC,3,ML,1405.33,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1194.5305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Upper GI Endoscopy,Diagnosis",PX43235P,CDM,983,RC,43235,CPT,,,,,,,,1406,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1195.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,603.174,3859.68
carfilzomib 30 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010201,NDC,1,EA,2785.91,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1195.15539,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.23,5460.3836
filgrastim 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513020991,NDC,0.5,ML,1228.49,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1195.689317,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
"Remv F.B.,Eye,Ant Chmbr/Lens",PX65235F,CDM,510,RC,65235,CPT,,,,,,,,2788,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1196.052,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1158.1352,2732.24
Trauma Activation,PX68200010,CDM,684,RC,G0390,HCPCS,,,,,,,,1243,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1196.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,516.3422,1218.14
"Upper GI Endoscopy,Biopsy",PX43239F,CDM,750,RC,43239,CPT,,,,,,,,2364,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1196.184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,3859.68
Bone Marrow Biopsy(Ies),PX38221F,CDM,510,RC,38221,CPT,,,,,,,,1221,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1196.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,507.2034,1416.38
Exc Abdom Tum Subfac > 5 Cm,PX22901F,CDM,761,RC,22901,CPT,,,,,,,,1408,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1196.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,584.8832,2482.37
"Lap,Cholecystectomy/Explore",PX47564F,CDM,510,RC,47564,CPT,,,,,,,,2419,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1197.405,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1004.8526,8992.74
Closed Rx IP Jt Dislocation,PX26770F,CDM,510,RC,26770,CPT,,,,,,,,1231,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1198.1323,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1206.38
darbepoetin alfa 500 MCG/ML solution prefilled syringe 1 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513003201,NDC,0.3,ML,2368.44,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1198.43064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096321,NDC,30,ML,1231.47,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1198.589751,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,511.552638,1206.8406
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096330,NDC,30,ML,1231.47,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1198.589751,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,511.552638,1206.8406
CT Abdomen W/O Dye,PX7415001,CDM,350,RC,74150,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,1198.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Chest Spine W/O Dye,PX7212801,CDM,350,RC,72128,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All commercial plans,both,,,551.4,fee schedule,1198.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Lower Extremity W/O Dye,PX7370001,CDM,350,RC,73700,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All commercial plans,both,,,621.31,fee schedule,1198.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Lumbar Spine W/O Dye,PX7213101,CDM,350,RC,72131,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All commercial plans,both,,,674.888,fee schedule,1198.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Maxillofacialw/O Dye,PX7048601,CDM,350,RC,70486,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All commercial plans,both,,,1250.101667,fee schedule,1198.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Neck Spine W/O Dye,PX7212501,CDM,350,RC,72125,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All commercial plans,both,,,978.3880952,fee schedule,1198.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Orbit/Ear/Fosa W/O Dye,PX7048001,CDM,350,RC,70480,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All commercial plans,both,,,1636.74,fee schedule,1198.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Pelvis W/O Dye,PX7219201,CDM,350,RC,72192,CPT,TC,,,,,,,2744,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,1198.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2689.12
CT Soft Tissue Neck W/O Dye,PX7049001,CDM,350,RC,70490,CPT,TC,,,,,,,711,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,1198.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,1198.67
CT Upper Extremity W/O Dye,PX7320001,CDM,350,RC,73200,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All commercial plans,both,,,1436.71,fee schedule,1198.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
Diagnostic CT Thorax W/O Contrast,PX7125001,CDM,350,RC,71250,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All commercial plans,both,,,1487.361,fee schedule,1198.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
"Sigmoidoscopy,Biopsy",PX45331P,CDM,983,RC,45331,CPT,,,,,,,,1316,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1198.876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,546.6664,1280.8628
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535P,CDM,983,RC,24535,CPT,,,,,,,,2887,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1199.2598,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1199.2598,2809.9171
"Colonoscopy,Remv Lesn,Snare",PX45385P,CDM,983,RC,45385,CPT,,,,,,,,2424,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1199.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1030.93,4050.42
darbepoetin alfa 40 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002104,NDC,0.4,ML,1411.78,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1200.013,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
"Colonoscopy,Screen Prev",PX2004F,CDM,750,RC,G0121,HCPCS,,,,,,,,2502,,Health Partners,Health Partners Care Plans,both,48,,1160.09,percent of total billed charges,1200.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,798.45,3885.86
"Colonoscopy,Screen Prev",PX2004F,CDM,750,RC,G0121,HCPCS,,,,,,,,2502,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1200.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,798.45,3885.86
"Excis Tendn/Capsule Lesn,Toes",PX28092F,CDM,510,RC,28092,CPT,,,,,,,,1234,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,246.8,percent of total billed charges,1201.0522,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,512.6036,1404.08
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,310095036,NDC,1,EA,1234.2,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1201.24686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,512.68668,1209.516
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,70720095036,NDC,1,EA,1234.2,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1201.24686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,512.68668,1209.516
"Hemorrhoidectomy,Int/Ext,Complx",PX46260F,CDM,750,RC,46260,CPT,,,,,,,,1350,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1201.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,560.79,2452.93
Leukoreduced Platelets,PXP9035,CDM,390,RC,P9035,HCPCS,,,,,,,,1350,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1201.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,433.08,1323
Exc Skin Benig >4cm Remaindr Body,PX11426F,CDM,510,RC,11426,CPT,,,,,,,,1227,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1202.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,509.6958,2482.37
Tube Thoracostomy Inc Wtr Seal,PX32551P,CDM,983,RC,32551,CPT,,,,,,,,1236,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,611.29,percent of total billed charges,1202.9988,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,513.4344,1399.13
"Closed Rx Trimalleolar Fx,Manip",PX27818P,CDM,983,RC,27818,CPT,,,,,,,,1352,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1203.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,561.6208,1404.08
Room Rate Icc,PX20601000,CDM,206,RC,,,,,,,,,,2432,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1203.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1010.2528,2383.36
filgrastim 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513020991,NDC,0.5,ML,1228.49,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1203.9202,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.78,1203.9202
Closed Rx IP Jt Dislocation,PX26770P,CDM,983,RC,26770,CPT,,,,,,,,1353,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1204.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1316.8749
"Excis Arm/Elbow Tumor,Subcutan",PX24075P,CDM,983,RC,24075,CPT,,,,,,,,2458,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1204.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1021.0532,2392.3714
"Excis Arm/Elbow Tumor,Subcutan",PX24075P,CDM,983,RC,24075,CPT,,,,,,,,2458,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1204.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1021.0532,2392.3714
"Excis Arm/Elbow Tumor,Subcutan",PX24075P,CDM,983,RC,24075,CPT,,,,,,,,2458,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1204.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1021.0532,2392.3714
"Upper GI Endoscopy,Biopsy",PX43239P,CDM,983,RC,43239,CPT,,,,,,,,2458,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,2132.28,percent of total billed charges,1204.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,3859.68
"Upper GI Endoscopy,Biopsy",PX43239P,CDM,983,RC,43239,CPT,,,,,,,,2458,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1204.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,3859.68
"Upper GI Endoscopy,Biopsy",PX43239P,CDM,983,RC,43239,CPT,,,,,,,,2458,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1204.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,3859.68
Heart/Lung Resuscitation (Cpr),PX92950F,CDM,480,RC,92950,CPT,,,,,,,,1366,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1204.812,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.21,1338.68
DOCEtaxel 160 MG/16ML Solution 16 mL Vial,J9171.01,CDM,636,RC,J9171,HCPCS,,,,409173201,NDC,16,ML,2901.69,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1205.362026,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1205.362026,2843.6562
onabotulinumtoxinA 50 units Recon Soln 1 Each Vial,J0585.03,CDM,636,RC,J0585,HCPCS,,,,23391950,NDC,1,EA,1418.14,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1205.419,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.51,1389.7772
inFLIXimab 100 MG Recon Soln 1 Each Vial,J1745.01,CDM,636,RC,J1745,HCPCS,,,,57894003001,NDC,1,EA,2382.35,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1205.4691,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.49,2334.703
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390F,CDM,750,RC,45390,CPT,,,,,,,,1419,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1206.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,589.4526,2452.93
Low Dose CT Lung Ca Screening,PXG029701,CDM,350,RC,G0297,HCPCS,TC,,,,,,,2812,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1206.348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1168.1048,2755.76
Closed Rx IP Jt Dislocation,PX26770F,CDM,510,RC,26770,CPT,,,,,,,,1231,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1206.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1206.38
zoledronic acid 5 MG/100ML Solution 100 mL Bottle,J3489.01,CDM,636,RC,J3489,HCPCS,,,,55111068852,NDC,100,ML,1368,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1206.576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,63323096600,NDC,100,ML,1368,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1206.576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535F,CDM,510,RC,24535,CPT,,,,,,,,2514,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1206.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1044.3156,2463.72
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535F,CDM,510,RC,24535,CPT,,,,,,,,2514,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1206.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1044.3156,2463.72
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096321,NDC,30,ML,1231.47,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1206.8406,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,511.552638,1206.8406
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096330,NDC,30,ML,1231.47,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1206.8406,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,511.552638,1206.8406
"Removal of Hydrocele,Tunica,Unilat",PX55040P,CDM,983,RC,55040,CPT,,,,,,,,1420,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1207,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,589.868,3022.41
ramuCIRumab 100 MG/10ML Solution 10 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2766901,NDC,10,ML,2463.3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1207.017,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.57,12070.17
ramuCIRumab 100 MG/10ML Solution 10 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2766901,NDC,10,ML,2463.3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1207.017,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.57,12070.17
ramuCIRumab 100 MG/10ML Solution 10 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2766901,NDC,10,ML,2463.3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1207.017,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.57,12070.17
HERNIA PATCH VENTRALEX LARGE,C1781,CDM,278,RC,C1781,HCPCS,,10201-MAIN,LOCAL,,,,,1325.08,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1207.14788,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
DYNABUNION STERILE INSTRUMENT KIT,27200000,CDM,272,RC,,,,11850-MAIN,LOCAL,,,,,2515,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1207.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNABUNION STERILE INSTRUMENT KIT,27200000,CDM,272,RC,,,,11850-MAIN,LOCAL,,,,,2515,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1207.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Closed Rx Shldr Disloc,Anesthesia",PX23655P,CDM,983,RC,23655,CPT,,,,,,,,1421,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1207.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,590.2834,1404.08
"Colonoscopy,Biopsy",PX45380F,CDM,750,RC,45380,CPT,,,,,,,,2465,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,783.81125,percent of total billed charges,1207.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1030.93,4050.42
"Colonoscopy,Biopsy",PX45380F,CDM,750,RC,45380,CPT,,,,,,,,2465,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1207.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1030.93,4050.42
"Colonoscopy,Biopsy",PX45380F,CDM,750,RC,45380,CPT,,,,,,,,2465,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1207.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1030.93,4050.42
Excis Forearm/Wrist Tumor Subcutan,PX25075F,CDM,510,RC,25075,CPT,,,,,,,,1421,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1207.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,590.2834,1416.38
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,93598627,NDC,1,EA,1241.11,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,229.0777778,percent of total billed charges,1207.972363,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
"Repair of Recurrent Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49615F,CDM,360,RC,49615,CPT,,,,,,,,2908,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1207.9832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1207.9832,3022.41
"Excise Lesion,Back or Flank",PX21930F,CDM,510,RC,21930,CPT,,,,,,,,1326,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1207.986,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,550.8204,1416.38
Room Rate Icc Iso,PX20601001,CDM,206,RC,,,,,,,,,,2517,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1208.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1045.5618,2466.66
Room Rate Icc Iso,PX20601001,CDM,206,RC,,,,,,,,,,2517,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1208.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1045.5618,2466.66
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604P,CDM,983,RC,11604,CPT,,,,,,,,1422,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1208.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,590.6988,1384.0326
"Repair Lip,>1/2 Vert Height",PX40654F,CDM,510,RC,40654,CPT,,,,,,,,2467,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1208.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1024.7918,2417.66
"Repair Lip,>1/2 Vert Height",PX40654F,CDM,510,RC,40654,CPT,,,,,,,,2467,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1208.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1024.7918,2417.66
"Repair Lip,>1/2 Vert Height",PX40654F,CDM,510,RC,40654,CPT,,,,,,,,2467,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1208.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1024.7918,2417.66
"Amputation Toe,I-P Jt",PX28825F,CDM,510,RC,28825,CPT,,,,,,,,1327,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1208.897,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,551.2358,2827.75
Lap Rpr Vent Umbilical Hernia Incarcerated or Strangulated,PX49653P,CDM,983,RC,49653,CPT,,,,,,,,1327,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1208.897,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,551.2358,1291.5691
"Excis Tendn/Capsule Lesn,Toes",PX28092F,CDM,510,RC,28092,CPT,,,,,,,,1234,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1209.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,512.6036,1404.08
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,310095036,NDC,1,EA,1234.2,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1209.516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,512.68668,1209.516
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,70720095036,NDC,1,EA,1234.2,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1209.516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,512.68668,1209.516
Trauma Activation,PX68200010,CDM,684,RC,G0390,HCPCS,,,,,,,,1243,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1209.8119,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,516.3422,1218.14
CT Lwr Extremity W/O&W/Dye,PX7370201,CDM,350,RC,73702,CPT,TC,,,,,,,1235,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1210.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
HARMONIC 110 SHEARS 36CM SHAFT,27200000,CDM,272,RC,,,,12043-MAIN,LOCAL,,,,,2392,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1210.352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Repair Lip,>1/2 Vert Height",PX40654P,CDM,983,RC,40654,CPT,,,,,,,,1329,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1210.719,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,552.0666,1332.3
HARMONIC 1100 SHEARS 20CM SHAFT HAR1120,27200000,CDM,272,RC,,,,12924-MAIN,LOCAL,,,,,1244,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1210.7852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035P,CDM,983,RC,12035,CPT,,,,,,,,1244,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1210.7852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1210.7852
"Hemorrhoidectomy,Int/Ext,Simple",PX46255P,CDM,983,RC,46255,CPT,,,,,,,,2393,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1210.858,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,994.0522,2452.93
Tube Thoracostomy Inc Wtr Seal,PX32551P,CDM,983,RC,32551,CPT,,,,,,,,1236,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1211.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,92.49,1211.28
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591P,CDM,982,RC,49591,CPT,,,,,,,,1245,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,6542.19,percent of total billed charges,1211.7585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,517.173,3022.41
REVITA PLACENTAL MEMBRANE 2X3CM 6SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12559-MAIN,LOCAL,,,,,2474,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1212.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
REVITA PLACENTAL MEMBRANE 2X3CM 6SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12559-MAIN,LOCAL,,,,,2474,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1212.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
REVITA PLACENTAL MEMBRANE 2X3CM 6SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12559-MAIN,LOCAL,,,,,2474,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1212.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270004,NDC,100,ML,2827.78,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1213.11762,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 10 GM/100ML Solution 100 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270005,NDC,100,ML,2827.78,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1213.11762,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270007,NDC,100,ML,2827.78,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1213.11762,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270013,NDC,100,ML,2827.78,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1213.11762,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
"Remv Foreign Body,Knee/Thigh,Deep",PX27372F,CDM,510,RC,27372,CPT,,,,,,,,1429,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1214.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,593.6066,2482.37
"Genital Surg Proc,Male Unlisted",PX55899F,CDM,510,RC,55899,CPT,,,,,,,,1430,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1215.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,215.91,1401.4
I&D Perirectal Abscess,PX46040F,CDM,510,RC,46040,CPT,,,,,,,,1430,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1215.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,594.022,1401.4
Heart/Lung Resuscitation (Cpr),PX92950F,CDM,480,RC,92950,CPT,,,,,,,,1366,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1215.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.21,1338.68
"Repair Ing Hernia,5+Y/O,Strang",PX49507P,CDM,983,RC,49507,CPT,,,,,,,,2482,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1216.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1031.0228,3022.41
"Repair Ing Hernia,5+Y/O,Strang",PX49507P,CDM,983,RC,49507,CPT,,,,,,,,2482,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1216.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1031.0228,3022.41
"Repair Ing Hernia,5+Y/O,Strang",PX49507P,CDM,983,RC,49507,CPT,,,,,,,,2482,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1216.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1031.0228,3022.41
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,93598627,NDC,1,EA,1241.11,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1216.2878,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
Anus Surgery Procedure Unlisted,PX46999F,CDM,510,RC,46999,CPT,,,,,,,,1431,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1216.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,594.4374,1402.38
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565F,CDM,510,RC,25565,CPT,,,,,,,,1250,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1216.625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,519.25,1404.08
"Excis Arm/Elbow Tumor,Subcutan",PX24075P,CDM,983,RC,24075,CPT,,,,,,,,2458,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1216.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1021.0532,2392.3714
"Upper GI Endoscopy,Biopsy",PX43239P,CDM,983,RC,43239,CPT,,,,,,,,2458,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1216.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,3859.68
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606F,CDM,510,RC,11606,CPT,,,,,,,,1432,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1217.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,594.8528,1416.38
zoledronic acid 5 MG/100ML Solution 100 mL Bottle,J3489.01,CDM,636,RC,J3489,HCPCS,,,,55111068852,NDC,100,ML,1368,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1217.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,63323096600,NDC,100,ML,1368,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1217.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
Trauma Activation,PX68200010,CDM,684,RC,G0390,HCPCS,,,,,,,,1243,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1218.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,516.3422,1218.14
Revise Median N/Carpal Tunnel Surg,PX64721F,CDM,510,RC,64721,CPT,,,,,,,,2408,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1218.448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1000.2832,2359.84
"Colonoscopy,Flex,Screen",PX2002F,CDM,750,RC,G0105,HCPCS,,,,,,,,2539,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1218.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,798.45,3885.86
"Colonoscopy,Flex,Screen",PX2002F,CDM,750,RC,G0105,HCPCS,,,,,,,,2539,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1218.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,798.45,3885.86
"Upper GI Endoscopy,Diagnosis",PX43235F,CDM,750,RC,43235,CPT,,,,,,,,2539,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1218.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,3859.68
"Upper GI Endoscopy,Diagnosis",PX43235F,CDM,750,RC,43235,CPT,,,,,,,,2539,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1218.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,3859.68
methylene blue 50 MG/10ML Solution 10 mL Ampule,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,517037405,NDC,10,ML,1382.12,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1219.02984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.29,1354.4776
HARMONIC 1100 SHEARS 20CM SHAFT HAR1120,27200000,CDM,272,RC,,,,12924-MAIN,LOCAL,,,,,1244,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1219.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035P,CDM,983,RC,12035,CPT,,,,,,,,1244,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1219.12,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,148.34,1219.12
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,70842014003,NDC,1,EA,2409.61,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1219.26266,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.3,2361.4178
ramuCIRumab 100 MG/10ML Solution 10 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2766901,NDC,10,ML,2463.3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1219.3335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.57,12070.17
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 15DEGREE 14MM,27200000,CDM,272,RC,,,,12600-MAIN,LOCAL,,,,,1253,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1219.5449,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 45DEGREE 8MM,27200000,CDM,272,RC,,,,12599-MAIN,LOCAL,,,,,1253,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1219.5449,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 45DEGREE 14MM,27200000,CDM,272,RC,,,,12598-MAIN,LOCAL,,,,,1253,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1219.5449,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 15DEGREE 14MM,27200000,CDM,272,RC,,,,12603-MAIN,LOCAL,,,,,1253,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1219.5449,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 45DEGREE 8MM,27200000,CDM,272,RC,,,,12602-MAIN,LOCAL,,,,,1253,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1219.5449,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 45DEGREE 14MM,27200000,CDM,272,RC,,,,12601-MAIN,LOCAL,,,,,1253,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1219.5449,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
liraglutide 18 MG/3ML solution pen-injector 3 mL Pen,63700001,CDM,250,RC,,,,,,169406013,NDC,3,ML,1382.75,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1219.5855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CT Angio Abdominal Arteries,PX7563501,CDM,350,RC,75635,CPT,TC,,,,,,,2936,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1219.6144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,2877.28
Targeted Genomic Sequence Analysis Panel 5-50 Genes - Ref,PX8145090,CDM,300,RC,81450,CPT,90,,,,,,,2936,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1219.6144,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,696.41,2877.28
Removal of Anal Tabs,PX46230P,CDM,983,RC,46230,CPT,,,,,,,,1435,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1219.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,596.099,2452.93
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591P,CDM,982,RC,49591,CPT,,,,,,,,1245,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1220.1,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,202.22,1220.1
"Colonoscopy,Biopsy",PX45380F,CDM,750,RC,45380,CPT,,,,,,,,2465,,Humana Choice Care,All Medicare plans,outpatient,49.5,,1711.665,percent of total billed charges,1220.175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1030.93,4050.42
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384P,CDM,983,RC,45384,CPT,,,,,,,,1436,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1220.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,616.044,4050.42
Emergency Level V Visit,PX99285P,CDM,981,RC,99285,CPT,,,,,,,,1436,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1220.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,561.13,1397.6588
"Repair Lip,>1/2 Vert Height",PX40654F,CDM,510,RC,40654,CPT,,,,,,,,2467,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1221.165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1024.7918,2417.66
POWERPORT ISP MRI IMPLANTABLE PORT 8FR,C1788,CDM,278,RC,C1788,HCPCS,,11998-MAIN,LOCAL,,,,,1385,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1221.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,575.329,1357.3
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752P,CDM,983,RC,27752,CPT,,,,,,,,2495,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1222.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1036.423,2428.3835
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752P,CDM,983,RC,27752,CPT,,,,,,,,2495,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1222.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1036.423,2428.3835
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752P,CDM,983,RC,27752,CPT,,,,,,,,2495,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1222.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1036.423,2428.3835
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535F,CDM,510,RC,24535,CPT,,,,,,,,2514,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1223.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,362.13,1333.79
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535P,CDM,983,RC,24535,CPT,,,,,,,,2887,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1223.1,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,362.13,2829.26
hepatitis B immune globulin 312 UNIT/ML Solution 5 mL Vial,90371,CDM,636,RC,90371,CPT,,,,59730420301,NDC,5,ML,2851.63,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1223.34927,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.6,2794.5974
"Lap,Cholecystectomy/Explore",PX47564F,CDM,510,RC,47564,CPT,,,,,,,,2419,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1224.014,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1004.8526,8992.74
REVITA PLACENTAL MEMBRANE 2X3CM 6SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12559-MAIN,LOCAL,,,,,2474,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1224.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565F,CDM,510,RC,25565,CPT,,,,,,,,1250,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,519.25,1404.08
"Colonoscopy,Screen Prev",PX2004F,CDM,750,RC,G0121,HCPCS,,,,,,,,2502,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1225.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,798.45,3885.86
"Colonoscopy,Screen Prev",PX2004F,CDM,750,RC,G0121,HCPCS,,,,,,,,2502,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1225.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,798.45,3885.86
"Colonoscopy,Screen Prev",PX2004F,CDM,750,RC,G0121,HCPCS,,,,,,,,2502,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1225.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,798.45,3885.86
"Close Rx Dist Fingr Fx,Manipulatn",PX26755P,CDM,983,RC,26755,CPT,,,,,,,,1260,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1226.358,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1226.358
Lap Rpr Vent Umbilical Hernia,PX49652P,CDM,983,RC,49652,CPT,,,,,,,,1260,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1226.358,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,523.404,1226.358
"Colonoscopy,Remv Lesn,Snare",PX45385P,CDM,983,RC,45385,CPT,,,,,,,,2424,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1226.544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1030.93,4050.42
"Remv Foreign Body,Knee/Thigh,Deep",PX27372F,CDM,510,RC,27372,CPT,,,,,,,,1429,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1226.56,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,250.43,1226.56
"Remv Foreign Body,Knee/Thigh,Deep",PX27372P,CDM,983,RC,27372,CPT,,,,,,,,954,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1226.56,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,250.43,1226.56
Partial Bone Scan,PX7830001,CDM,341,RC,78300,CPT,TC,,,,,,,1391,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1226.862,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,360.31,1363.18
"Repair Lip,>1/2 Vert Height",PX40654F,CDM,510,RC,40654,CPT,,,,,,,,2467,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1227.25,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,269.41,1227.25
"Repair Lip,>1/2 Vert Height",PX40654P,CDM,983,RC,40654,CPT,,,,,,,,1329,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1227.25,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,269.41,1302.42
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 15DEGREE 14MM,27200000,CDM,272,RC,,,,12600-MAIN,LOCAL,,,,,1253,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1227.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 45DEGREE 8MM,27200000,CDM,272,RC,,,,12599-MAIN,LOCAL,,,,,1253,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1227.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 45DEGREE 14MM,27200000,CDM,272,RC,,,,12598-MAIN,LOCAL,,,,,1253,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1227.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 15DEGREE 14MM,27200000,CDM,272,RC,,,,12603-MAIN,LOCAL,,,,,1253,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1227.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 45DEGREE 8MM,27200000,CDM,272,RC,,,,12602-MAIN,LOCAL,,,,,1253,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1227.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 45DEGREE 14MM,27200000,CDM,272,RC,,,,12601-MAIN,LOCAL,,,,,1253,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1227.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNAFORCE MPJ REAMERS CUP/CONE 20MM,27200000,CDM,272,RC,,,,11853-MAIN,LOCAL,,,,,1262,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1228.3046,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Repair Ing Hernia,5+Y/O,Strang",PX49507P,CDM,983,RC,49507,CPT,,,,,,,,2482,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1228.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1031.0228,3022.41
IMPLANT PACKAGE TOEMATE,27200000,CDM,278,RC,C1713,HCPCS,,11859-MAIN,LOCAL,,,,,2865,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1229.085,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
IMPLANT TOEMATE X-SMALL PACKAGE 9H00-T050,C1713,CDM,278,RC,C1713,HCPCS,,11574-MAIN,LOCAL,,,,,2865,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1229.085,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"Repair Ing Hernia,5+Y/O,Strang",PX49507F,CDM,510,RC,49507,CPT,,,,,,,,1977,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1229.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,354.93,1229.33
"Repair Ing Hernia,5+Y/O,Strang",PX49507F,CDM,510,RC,49507,CPT,,,,,,,,1977,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1229.33,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,354.93,1229.33
"Repair Ing Hernia,5+Y/O,Strang",PX49507P,CDM,983,RC,49507,CPT,,,,,,,,2482,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1229.33,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,354.93,2432.36
"Repair Ing Hernia,5+Y/O,Strang",PX49507P,CDM,983,RC,49507,CPT,,,,,,,,2482,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1229.33,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,354.93,2432.36
"Hemorrhoidectomy,Int/Ext,Complx",PX46260F,CDM,750,RC,46260,CPT,,,,,,,,1350,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1229.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,560.79,2452.93
Leukoreduced Platelets,PXP9035,CDM,390,RC,P9035,HCPCS,,,,,,,,1350,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1229.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,433.08,1323
methylene blue 50 MG/10ML Solution 10 mL Ampule,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,517037405,NDC,10,ML,1382.12,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1230.0868,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.29,1354.4776
"Facility Critical Care, E/M 30-74 Minutes",PX99291F,CDM,510,RC,99291,CPT,,,,,,,,1264,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,971.295,percent of total billed charges,1230.2512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,525.0656,1238.72
Room Rate Icc,PX20601000,CDM,206,RC,,,,,,,,,,2432,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1230.592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1010.2528,2383.36
liraglutide 18 MG/3ML solution pen-injector 3 mL Pen,63700001,CDM,250,RC,,,,,,169406013,NDC,3,ML,1382.75,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1230.6475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266F,CDM,510,RC,27266,CPT,,,,,,,,1684,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1230.71,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,366.05,1230.71
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266F,CDM,510,RC,27266,CPT,,,,,,,,1684,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1230.71,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,366.05,1230.71
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266P,CDM,983,RC,27266,CPT,,,,,,,,2275,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1230.71,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,366.05,2229.5
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266P,CDM,983,RC,27266,CPT,,,,,,,,2275,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1230.71,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,366.05,2229.5
PACLitaxel protein-bound particle 100 MG Recon Susp 1 Each Vial,J9264.01,CDM,636,RC,J9264,HCPCS,,,,68817013450,NDC,1,EA,2564.76,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1231.0848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.1,2513.4648
PACLitaxel protein-bound particle 100 MG Recon Susp 1 Each Vial,J9264.01,CDM,636,RC,J9264,HCPCS,,,,68817013450,NDC,1,EA,2564.76,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1231.0848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.1,2513.4648
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,469650189,NDC,5,ML,1264.92,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,63.2475,percent of total billed charges,1231.146636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,424.41418,1239.6216
"Closed Rx Trimalleolar Fx,Manip",PX27818P,CDM,983,RC,27818,CPT,,,,,,,,1352,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1231.672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,561.6208,1404.08
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535F,CDM,510,RC,24535,CPT,,,,,,,,2514,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1231.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1044.3156,2463.72
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535F,CDM,510,RC,24535,CPT,,,,,,,,2514,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1231.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1044.3156,2463.72
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535F,CDM,510,RC,24535,CPT,,,,,,,,2514,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1231.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1044.3156,2463.72
Incise Finger Tendon Sheath,PX26055F,CDM,510,RC,26055,CPT,,,,,,,,1398,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1232.1,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.74,1232.1
Incise Finger Tendon Sheath,PX26055P,CDM,983,RC,26055,CPT,,,,,,,,932,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1232.1,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,186.74,1232.1
OBINutuzumab 1000 MG/40ML Solution 40 mL Vial,J9301.01,CDM,636,RC,J9301,HCPCS,,,,50242007001,NDC,4,ML,1397.15,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1232.2863,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.12,1369.207
DYNABUNION STERILE INSTRUMENT KIT,27200000,CDM,272,RC,,,,11850-MAIN,LOCAL,,,,,2515,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1232.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNABUNION STERILE INSTRUMENT KIT,27200000,CDM,272,RC,,,,11850-MAIN,LOCAL,,,,,2515,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1232.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNABUNION STERILE INSTRUMENT KIT,27200000,CDM,272,RC,,,,11850-MAIN,LOCAL,,,,,2515,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1232.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Closed Rx IP Jt Dislocation,PX26770P,CDM,983,RC,26770,CPT,,,,,,,,1353,,Medica,Commercial,both,91.1,,97.47,percent of total billed charges,1232.583,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1316.8749
POWERPORT ISP MRI IMPLANTABLE PORT 8FR,C1788,CDM,278,RC,C1788,HCPCS,,11998-MAIN,LOCAL,,,,,1385,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1232.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,575.329,1357.3
"Cytogen, Interp/Report - Ref",PX8829190,CDM,310,RC,88291,CPT,90,,,,,,,2874,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1232.946,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.95,2816.52
Incise Finger Tendon Sheath,PX26055F,CDM,510,RC,26055,CPT,,,,,,,,1398,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1233.036,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,580.7292,1404.08
APLIGRAF LIVING BI-LAYERED SKIN SUBSTITUTE,120.514,CDM,278,RC,Q4101,HCPCS,,12082-MAIN,LOCAL,,,,,2569,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1233.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1067.1626,2517.62
APLIGRAF LIVING BI-LAYERED SKIN SUBSTITUTE,120.514,CDM,278,RC,Q4101,HCPCS,,12082-MAIN,LOCAL,,,,,2569,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1233.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1067.1626,2517.62
Room Rate Icc Iso,PX20601001,CDM,206,RC,,,,,,,,,,2517,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1233.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1045.5618,2466.66
Room Rate Icc Iso,PX20601001,CDM,206,RC,,,,,,,,,,2517,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1233.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1045.5618,2466.66
Room Rate Icc Iso,PX20601001,CDM,206,RC,,,,,,,,,,2517,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1233.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1045.5618,2466.66
"Close Rx Dist Fingr Fx,Manipulatn",PX26755P,CDM,983,RC,26755,CPT,,,,,,,,1260,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1234.8,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,177.14,1234.8
CT Orbit/Ear/Fossa W/O & W/Dye,PX7048201,CDM,350,RC,70482,CPT,TC,,,,,,,1400,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1234.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
Lap Rpr Vent Umbilical Hernia,PX49652P,CDM,983,RC,49652,CPT,,,,,,,,1260,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1234.8,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,656.0073,1234.8
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752P,CDM,983,RC,27752,CPT,,,,,,,,2495,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1235.025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1036.423,2428.3835
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781324494,NDC,1,EA,1400.9,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1235.5938,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
DYNAFORCE MPJ REAMERS CUP/CONE 20MM,27200000,CDM,272,RC,,,,11853-MAIN,LOCAL,,,,,1262,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1236.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Exc Skn Bnig >4cmtrnk,Arm,Leg",PX11406P,CDM,983,RC,11406,CPT,,,,,,,,1456,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1237.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,604.8224,1417.1248
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,16714085701,NDC,1,EA,1403.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1237.887,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
Partial Bone Scan,PX7830001,CDM,341,RC,78300,CPT,TC,,,,,,,1391,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1237.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,360.31,1363.18
Closed Rx Kneecap Disloc+Anesth,PX27562P,CDM,983,RC,27562,CPT,,,,,,,,1404,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1238.328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1366.5132
"Colonoscopy,Screen Prev",PX2004F,CDM,750,RC,G0121,HCPCS,,,,,,,,2502,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1238.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,798.45,3885.86
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535P,CDM,983,RC,24535,CPT,,,,,,,,2887,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1238.523,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1199.2598,2809.9171
"Facility Critical Care, E/M 30-74 Minutes",PX99291F,CDM,510,RC,99291,CPT,,,,,,,,1264,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1238.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,525.0656,1238.72
CT Angiograph Pelv W/O&W/Dye,PX7219101,CDM,350,RC,72191,CPT,TC,,,,,,,1458,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1239.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
liraglutide 18 MG/3ML solution pen-injector 3 mL Pen,63700001,CDM,250,RC,,,,,,169406012,NDC,3,ML,1405.33,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1239.50106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,469650189,NDC,5,ML,1264.92,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1239.6216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,424.41418,1239.6216
Insert Non-Tunnel Cv Catheter >5 Years,PX36556P,CDM,983,RC,36556,CPT,,,,,,,,1274,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,876.98,percent of total billed charges,1239.9842,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,529.2196,2784.63
"Upper GI Endoscopy,Diagnosis",PX43235P,CDM,983,RC,43235,CPT,,,,,,,,1406,,United Healthcare,All Payer,outpatient,88.2,,671.12,percent of total billed charges,1240.092,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,603.174,3859.68
"Ht Muscle Image Spect, Mult",PX7845201,CDM,340,RC,78452,CPT,TC,,,,,,,2000,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1240.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,858,5292.1
cycloPHOSphamide 2 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,10019095701,NDC,1,EA,2988.6,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1241.46444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
Exc Abdom Tum Subfac > 5 Cm,PX22901F,CDM,761,RC,22901,CPT,,,,,,,,1408,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1241.856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,584.8832,2482.37
"Exc Skn Mal 2.1-3cmtrnk,Arm,Lg",PX11603P,CDM,983,RC,11603,CPT,,,,,,,,1276,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1241.9308,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,530.0504,1241.9308
"Closed Rx Dist Fibula Fx,Manip",PX27788P,CDM,983,RC,27788,CPT,,,,,,,,1277,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1242.9041,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1242.9041
OBINutuzumab 1000 MG/40ML Solution 40 mL Vial,J9301.01,CDM,636,RC,J9301,HCPCS,,,,50242007001,NDC,4,ML,1397.15,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1243.4635,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.12,1369.207
"I&D Perianal Abscess,Superficial",PX46050F,CDM,510,RC,46050,CPT,,,,,,,,1463,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1243.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,607.7302,1433.74
"Excis Arm/Elbow Tumor,Subcutan",PX24075P,CDM,983,RC,24075,CPT,,,,,,,,2458,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1243.748,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1021.0532,2392.3714
"Upper GI Endoscopy,Biopsy",PX43239P,CDM,983,RC,43239,CPT,,,,,,,,2458,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1243.748,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,3859.68
"Colonoscopy,Biopsy",PX45380P,CDM,983,RC,45380,CPT,,,,,,,,2539,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,783.81125,percent of total billed charges,1244.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1030.93,4050.42
"Colonoscopy,Biopsy",PX45380P,CDM,983,RC,45380,CPT,,,,,,,,2539,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1244.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1030.93,4050.42
"Colonoscopy,Biopsy",PX45380P,CDM,983,RC,45380,CPT,,,,,,,,2539,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1244.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1030.93,4050.42
"Colonoscopy,Flex,Screen",PX2002F,CDM,750,RC,G0105,HCPCS,,,,,,,,2539,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1244.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,798.45,3885.86
"Colonoscopy,Flex,Screen",PX2002F,CDM,750,RC,G0105,HCPCS,,,,,,,,2539,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1244.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,798.45,3885.86
"Colonoscopy,Flex,Screen",PX2002F,CDM,750,RC,G0105,HCPCS,,,,,,,,2539,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1244.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,798.45,3885.86
"Upper GI Endoscopy,Diagnosis",PX43235F,CDM,750,RC,43235,CPT,,,,,,,,2539,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1244.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,3859.68
"Upper GI Endoscopy,Diagnosis",PX43235F,CDM,750,RC,43235,CPT,,,,,,,,2539,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1244.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,3859.68
"Upper GI Endoscopy,Diagnosis",PX43235F,CDM,750,RC,43235,CPT,,,,,,,,2539,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1244.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,3859.68
Incise Finger Tendon Sheath,PX26055F,CDM,510,RC,26055,CPT,,,,,,,,1398,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1244.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,580.7292,1404.08
Facility Emergency Level V Visit,PX99285F,CDM,450,RC,99285,CPT,,,,,,,,1464,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1244.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,561.13,1434.72
Heart/Lung Resuscitation (Cpr),PX92950F,CDM,480,RC,92950,CPT,,,,,,,,1366,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1244.426,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.21,1338.68
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535F,CDM,510,RC,24535,CPT,,,,,,,,2514,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1244.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1044.3156,2463.72
DOCEtaxel 160 MG/16ML Solution 16 mL Vial,J9171.01,CDM,636,RC,J9171,HCPCS,,,,409173201,NDC,16,ML,2901.69,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1244.82501,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1205.362026,2843.6562
DYNABUNION STERILE INSTRUMENT KIT,27200000,CDM,272,RC,,,,11850-MAIN,LOCAL,,,,,2515,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1244.925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
darbepoetin alfa 40 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002104,NDC,0.4,ML,1411.78,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1245.18996,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
Room Rate Icc Iso,PX20601001,CDM,206,RC,,,,,,,,,,2517,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1245.915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1045.5618,2466.66
CT Orbit/Ear/Fossa W/O & W/Dye,PX7048201,CDM,350,RC,70482,CPT,TC,,,,,,,1400,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1246,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
"Up GI Endoscopy,Ball Dil,30mm",PX43249F,CDM,750,RC,43249,CPT,,,,,,,,2596,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1246.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,958.1,3257.54
"Up GI Endoscopy,Ball Dil,30mm",PX43249F,CDM,750,RC,43249,CPT,,,,,,,,2596,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1246.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,958.1,3257.54
zoledronic acid 5 MG/100ML Solution 100 mL Bottle,J3489.01,CDM,636,RC,J3489,HCPCS,,,,55111068852,NDC,100,ML,1368,,Medica,Commercial,both,91.1,,51.072,percent of total billed charges,1246.248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,63323096600,NDC,100,ML,1368,,Medica,Commercial,both,91.1,,51.072,percent of total billed charges,1246.248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
ramuCIRumab 100 MG/10ML Solution 10 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2766901,NDC,10,ML,2463.3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1246.4298,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.57,12070.17
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,70839036204,NDC,4,ML,1280.66,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1246.466378,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781324494,NDC,1,EA,1400.9,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1246.801,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
"Colonoscopy,Biopsy",PX45380F,CDM,750,RC,45380,CPT,,,,,,,,2465,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1247.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1030.93,4050.42
"Repair of Recurrent Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49615F,CDM,360,RC,49615,CPT,,,,,,,,2908,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1247.532,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1207.9832,3022.41
fomepizole 1 GM/ML Solution 1.5 mL Vial,J1451.01,CDM,636,RC,J1451,HCPCS,,,,39822071001,NDC,1.5,ML,2600,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.14,2548
fomepizole 1 GM/ML Solution 1.5 mL Vial,J1451.01,CDM,636,RC,J1451,HCPCS,,,,39822071001,NDC,1.5,ML,2600,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.14,2548
"Repair Lip,>1/2 Vert Height",PX40654F,CDM,510,RC,40654,CPT,,,,,,,,2467,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1248.302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1024.7918,2417.66
Insert Non-Tunnel Cv Catheter >5 Years,PX36556P,CDM,983,RC,36556,CPT,,,,,,,,1274,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1248.52,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,51.04,1248.52
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,16714085701,NDC,1,EA,1403.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1249.115,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
"Removal Anal Fistula,Subcutaneous",PX46270F,CDM,510,RC,46270,CPT,,,,,,,,1470,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1249.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,610.638,2452.93
Closed Rx Kneecap Disloc+Anesth,PX27562P,CDM,983,RC,27562,CPT,,,,,,,,1404,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1249.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1366.5132
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270006,NDC,100,ML,2912.78,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1249.58262,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561F,CDM,510,RC,36561,CPT,,,,,,,,2604,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1249.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1081.7016,2784.63
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561F,CDM,510,RC,36561,CPT,,,,,,,,2604,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1249.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1081.7016,2784.63
"Exc Skn Mal 2.1-3cmtrnk,Arm,Lg",PX11603P,CDM,983,RC,11603,CPT,,,,,,,,1276,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1250.48,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,121.07,1250.48
liraglutide 18 MG/3ML solution pen-injector 3 mL Pen,63700001,CDM,250,RC,,,,,,169406012,NDC,3,ML,1405.33,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1250.7437,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
onabotulinumtoxinA 50 units Recon Soln 1 Each Vial,J0585.03,CDM,636,RC,J0585,HCPCS,,,,23391950,NDC,1,EA,1418.14,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1250.79948,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.51,1389.7772
"Upper GI Endoscopy,Diagnosis",PX43235P,CDM,983,RC,43235,CPT,,,,,,,,1406,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1251.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,603.174,3859.68
"Closed Rx Dist Fibula Fx,Manip",PX27788P,CDM,983,RC,27788,CPT,,,,,,,,1277,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1251.46,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.51,1251.46
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390F,CDM,750,RC,45390,CPT,,,,,,,,1419,,United Healthcare,All Payer,outpatient,88.2,,999999999,case rate,1251.558,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1251.558,6141.46
Low Dose CT Lung Ca Screen WO Contrast,PX7127101,CDM,350,RC,71271,CPT,TC,,,,,,,1286,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,869.1136364,percent of total billed charges,1251.6638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,1260.28
REVITA PLACENTAL MEMBRANE 2X3CM 6SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12559-MAIN,LOCAL,,,,,2474,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1251.844,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
"Lap,Cholecystectomy",PX47562F,CDM,510,RC,47562,CPT,,,,,,,,1473,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1252.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,611.8842,5040.74
"Removal of Hydrocele,Tunica,Unilat",PX55040P,CDM,983,RC,55040,CPT,,,,,,,,1420,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1252.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,589.868,3022.41
Exc Abdom Tum Subfac > 5 Cm,PX22901F,CDM,761,RC,22901,CPT,,,,,,,,1408,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1253.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,584.8832,2482.37
"Closed Rx Shldr Disloc,Anesthesia",PX23655P,CDM,983,RC,23655,CPT,,,,,,,,1421,,United Healthcare,All Payer,outpatient,88.2,,675.23,percent of total billed charges,1253.322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,590.2834,1404.08
Excis Forearm/Wrist Tumor Subcutan,PX25075F,CDM,510,RC,25075,CPT,,,,,,,,1421,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1253.322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,590.2834,1416.38
diazePAM 2.5 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,66490065020,NDC,1,EA,1288,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1253.6104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Repair Flex Foot Tendon,Ea",PX28200F,CDM,510,RC,28200,CPT,,,,,,,,1475,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1253.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,612.715,2827.75
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604P,CDM,983,RC,11604,CPT,,,,,,,,1422,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1254.204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,590.6988,1384.0326
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,70839036204,NDC,4,ML,1280.66,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1255.0468,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.695162,1255.0468
ADVANCED INSTRUMENTS 8MM SYNCHROSEAL IS4000,27200000,CDM,272,RC,,,,11924-MAIN,LOCAL,,,,,1290,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1255.557,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Injection for Nerve Block,PX64447F,CDM,510,RC,64447,CPT,,,,,,,,3023,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1255.7542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,604.15,2962.54
"Repair Ing Hernia,5+Y/O,Strang",PX49507P,CDM,983,RC,49507,CPT,,,,,,,,2482,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1255.892,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1031.0228,3022.41
darbepoetin alfa 40 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002104,NDC,0.4,ML,1411.78,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1256.4842,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
PACLitaxel protein-bound particle 100 MG Recon Susp 1 Each Vial,J9264.01,CDM,636,RC,J9264,HCPCS,,,,68817013450,NDC,1,EA,2564.76,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1256.7324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.1,2513.4648
PACLitaxel protein-bound particle 100 MG Recon Susp 1 Each Vial,J9264.01,CDM,636,RC,J9264,HCPCS,,,,68817013450,NDC,1,EA,2564.76,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1256.7324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.1,2513.4648
PACLitaxel protein-bound particle 100 MG Recon Susp 1 Each Vial,J9264.01,CDM,636,RC,J9264,HCPCS,,,,68817013450,NDC,1,EA,2564.76,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1256.7324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.1,2513.4648
"Colonoscopy,Biopsy",PX45380P,CDM,983,RC,45380,CPT,,,,,,,,2539,,Humana Choice Care,All Medicare plans,outpatient,49.5,,1711.665,percent of total billed charges,1256.805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1030.93,4050.42
"Colonoscopy,Flex,Screen",PX2002F,CDM,750,RC,G0105,HCPCS,,,,,,,,2539,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1256.805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,798.45,3885.86
"Upper GI Endoscopy,Diagnosis",PX43235F,CDM,750,RC,43235,CPT,,,,,,,,2539,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1256.805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,3859.68
"Lap,Appendectomy",PX44970P,CDM,983,RC,44970,CPT,,,,,,,,1700,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1257.69,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,362.78,1666
"Lap,Appendectomy",PX44970P,CDM,983,RC,44970,CPT,,,,,,,,1700,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1257.69,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,362.78,1666
APLIGRAF LIVING BI-LAYERED SKIN SUBSTITUTE,120.514,CDM,278,RC,Q4101,HCPCS,,12082-MAIN,LOCAL,,,,,2569,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1258.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1067.1626,2517.62
APLIGRAF LIVING BI-LAYERED SKIN SUBSTITUTE,120.514,CDM,278,RC,Q4101,HCPCS,,12082-MAIN,LOCAL,,,,,2569,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1258.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1067.1626,2517.62
APLIGRAF LIVING BI-LAYERED SKIN SUBSTITUTE,120.514,CDM,278,RC,Q4101,HCPCS,,12082-MAIN,LOCAL,,,,,2569,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1258.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1067.1626,2517.62
methylene blue 50 MG/10ML Solution 10 mL Ampule,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,517037405,NDC,10,ML,1382.12,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1259.11132,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.29,1354.4776
CT Angio Abdominal Arteries,PX7563501,CDM,350,RC,75635,CPT,TC,,,,,,,2936,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1259.544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,2877.28
Targeted Genomic Sequence Analysis Panel 5-50 Genes - Ref,PX8145090,CDM,300,RC,81450,CPT,90,,,,,,,2936,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1259.544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,696.41,2877.28
liraglutide 18 MG/3ML solution pen-injector 3 mL Pen,63700001,CDM,250,RC,,,,,,169406013,NDC,3,ML,1382.75,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1259.68525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Colonoscopy,Flex,Diagnostic",PX45378F,CDM,750,RC,45378,CPT,,,,,,,,1286,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1260.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,551.694,4661.91
Low Dose CT Lung Ca Screen WO Contrast,PX7127101,CDM,350,RC,71271,CPT,TC,,,,,,,1286,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1260.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,1260.28
"Remv Foreign Body,Knee/Thigh,Deep",PX27372F,CDM,510,RC,27372,CPT,,,,,,,,1429,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1260.378,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,593.6066,2482.37
"Genital Surg Proc,Male Unlisted",PX55899F,CDM,510,RC,55899,CPT,,,,,,,,1430,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1261.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,215.91,1401.4
I&D Perirectal Abscess,PX46040F,CDM,510,RC,46040,CPT,,,,,,,,1430,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1261.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,594.022,1401.4
POWERPORT ISP MRI IMPLANTABLE PORT 8FR,C1788,CDM,278,RC,C1788,HCPCS,,11998-MAIN,LOCAL,,,,,1385,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1261.735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,575.329,1357.3
Anus Surgery Procedure Unlisted,PX46999F,CDM,510,RC,46999,CPT,,,,,,,,1431,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1262.142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,594.4374,1402.38
onabotulinumtoxinA 50 units Recon Soln 1 Each Vial,J0585.03,CDM,636,RC,J0585,HCPCS,,,,23391950,NDC,1,EA,1418.14,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1262.1446,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.51,1389.7772
diazePAM 2.5 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,66490065020,NDC,1,EA,1288,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1262.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
RESTRATA WOUND MATRIX 2.5CM X 5CM TOTAL 12.5CM,27200000,CDM,272,RC,A2007,HCPCS,,11734-MAIN,LOCAL,,,,,3039,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1262.4006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752P,CDM,983,RC,27752,CPT,,,,,,,,2495,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1262.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1036.423,2428.3835
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390F,CDM,750,RC,45390,CPT,,,,,,,,1419,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1262.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,589.4526,2452.93
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606F,CDM,510,RC,11606,CPT,,,,,,,,1432,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1263.024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,594.8528,1416.38
"Removal of Hydrocele,Tunica,Unilat",PX55040P,CDM,983,RC,55040,CPT,,,,,,,,1420,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1263.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,589.868,3022.41
ADVANCED INSTRUMENTS 8MM SYNCHROSEAL IS4000,27200000,CDM,272,RC,,,,11924-MAIN,LOCAL,,,,,1290,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1264.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Closed Rx Shldr Disloc,Anesthesia",PX23655P,CDM,983,RC,23655,CPT,,,,,,,,1421,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1264.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,590.2834,1404.08
Excis Forearm/Wrist Tumor Subcutan,PX25075F,CDM,510,RC,25075,CPT,,,,,,,,1421,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1264.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,590.2834,1416.38
"Amputation Toe,Mt-P Jt",PX28820P,CDM,983,RC,28820,CPT,,,,,,,,1300,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1265.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,540.02,2827.75
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604P,CDM,983,RC,11604,CPT,,,,,,,,1422,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1265.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,590.6988,1384.0326
Removal of Anal Tabs,PX46230P,CDM,983,RC,46230,CPT,,,,,,,,1435,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1265.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,596.099,2452.93
MRI Brain W Contrast Tc,PX7055201,CDM,610,RC,70552,CPT,TC,,,,,,,2637,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1265.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2584.26
MRI Brain W Contrast Tc,PX7055201,CDM,610,RC,70552,CPT,TC,,,,,,,2637,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1265.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2584.26
"Colonoscopy,Screen Prev",PX2004F,CDM,750,RC,G0121,HCPCS,,,,,,,,2502,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1266.012,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,798.45,3885.86
"Biopsy, Nail Unit",PX11755F,CDM,510,RC,11755,CPT,,,,,,,,1490,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1266.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,614.65,1460.2
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384P,CDM,983,RC,45384,CPT,,,,,,,,1436,,United Healthcare,All Payer,outpatient,88.2,,699.11,percent of total billed charges,1266.552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,616.044,4050.42
Emergency Level V Visit,PX99285P,CDM,981,RC,99285,CPT,,,,,,,,1436,,United Healthcare,All Payer,outpatient,88.2,,83.42808511,percent of total billed charges,1266.552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,561.13,1397.6588
Partial Bone Scan,PX7830001,CDM,341,RC,78300,CPT,TC,,,,,,,1391,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1267.201,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,360.31,1363.18
PACLitaxel protein-bound particle 100 MG Recon Susp 1 Each Vial,J9264.01,CDM,636,RC,J9264,HCPCS,,,,68817013450,NDC,1,EA,2564.76,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1269.5562,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.1,2513.4648
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502050102,NDC,1,EA,1305.38,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,229.0777778,percent of total billed charges,1270.526354,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
APLIGRAF LIVING BI-LAYERED SKIN SUBSTITUTE,120.514,CDM,278,RC,Q4101,HCPCS,,12082-MAIN,LOCAL,,,,,2569,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1271.655,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1067.1626,2517.62
"Remv Foreign Body,Knee/Thigh,Deep",PX27372F,CDM,510,RC,27372,CPT,,,,,,,,1429,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1271.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,593.6066,2482.37
"Up GI Endoscopy,Ball Dil,30mm",PX43249F,CDM,750,RC,43249,CPT,,,,,,,,2596,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1272.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,958.1,3257.54
"Up GI Endoscopy,Ball Dil,30mm",PX43249F,CDM,750,RC,43249,CPT,,,,,,,,2596,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1272.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,958.1,3257.54
"Up GI Endoscopy,Ball Dil,30mm",PX43249F,CDM,750,RC,43249,CPT,,,,,,,,2596,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1272.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,958.1,3257.54
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535F,CDM,510,RC,24535,CPT,,,,,,,,2514,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1272.084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1044.3156,2463.72
DYNABUNION STERILE INSTRUMENT KIT,27200000,CDM,272,RC,,,,11850-MAIN,LOCAL,,,,,2515,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1272.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Genital Surg Proc,Male Unlisted",PX55899F,CDM,510,RC,55899,CPT,,,,,,,,1430,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1272.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,215.91,1401.4
I&D Perirectal Abscess,PX46040F,CDM,510,RC,46040,CPT,,,,,,,,1430,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1272.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,594.022,1401.4
OBINutuzumab 1000 MG/40ML Solution 40 mL Vial,J9301.01,CDM,636,RC,J9301,HCPCS,,,,50242007001,NDC,4,ML,1397.15,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1272.80365,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.12,1369.207
Incise Finger Tendon Sheath,PX26055F,CDM,510,RC,26055,CPT,,,,,,,,1398,,Medica,Commercial,both,91.1,,2419.62,percent of total billed charges,1273.578,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,580.7292,1404.08
Anus Surgery Procedure Unlisted,PX46999F,CDM,510,RC,46999,CPT,,,,,,,,1431,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1273.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,594.4374,1402.38
Revise Ulnar Nerve at Elbow,PX64718P,CDM,983,RC,64718,CPT,,,,,,,,1642,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1273.6,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,379.58,1609.16
Revise Ulnar Nerve at Elbow,PX64718P,CDM,983,RC,64718,CPT,,,,,,,,1642,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1273.6,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,379.58,1609.16
Room Rate Icc Iso,PX20601001,CDM,206,RC,,,,,,,,,,2517,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1273.602,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1045.5618,2466.66
"Amputation Toe,Mt-P Jt",PX28820P,CDM,983,RC,28820,CPT,,,,,,,,1300,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1274,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.51,1274
fomepizole 1 GM/ML Solution 1.5 mL Vial,J1451.01,CDM,636,RC,J1451,HCPCS,,,,39822071001,NDC,1.5,ML,2600,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.14,2548
fomepizole 1 GM/ML Solution 1.5 mL Vial,J1451.01,CDM,636,RC,J1451,HCPCS,,,,39822071001,NDC,1.5,ML,2600,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.14,2548
fomepizole 1 GM/ML Solution 1.5 mL Vial,J1451.01,CDM,636,RC,J1451,HCPCS,,,,39822071001,NDC,1.5,ML,2600,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.14,2548
MRI Abdomen W/O Tc,PX7418101,CDM,610,RC,74181,CPT,TC,,,,,,,2655,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1274.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,2601.9
MRI Abdomen W/O Tc,PX7418101,CDM,610,RC,74181,CPT,TC,,,,,,,2655,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1274.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,2601.9
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606F,CDM,510,RC,11606,CPT,,,,,,,,1432,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1274.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,594.8528,1416.38
HERNIA PATCH VENTRALEX MEDIUM,C1781,CDM,278,RC,C1781,HCPCS,,10202-MAIN,LOCAL,,,,,1309.75,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1256.29,percent of total billed charges,1274.779675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Level 2 Additional Procedure,PX36000081,CDM,360,RC,,,,,,,,,,1500,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,623.1,1470
MESH VENTRALIGHT ECHO 2.0 POSITIONING 11CM ROUND,120.525,CDM,278,RC,C1781,HCPCS,,12219-MAIN,LOCAL,,,,,1310,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1256.29,percent of total billed charges,1275.023,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,544.174,1283.8
CT Orbit/Ear/Fossa W/O & W/Dye,PX7048201,CDM,350,RC,70482,CPT,TC,,,,,,,1400,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1275.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
Amputation Finger/Thumb,PX26951P,CDM,983,RC,26951,CPT,,,,,,,,2603,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1275.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1081.2862,2827.75
Amputation Finger/Thumb,PX26951P,CDM,983,RC,26951,CPT,,,,,,,,2603,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1275.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1081.2862,2827.75
Amputation Finger/Thumb,PX26951P,CDM,983,RC,26951,CPT,,,,,,,,2603,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1275.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1081.2862,2827.75
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561F,CDM,510,RC,36561,CPT,,,,,,,,2604,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1275.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1081.7016,2784.63
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561F,CDM,510,RC,36561,CPT,,,,,,,,2604,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1275.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1081.7016,2784.63
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561F,CDM,510,RC,36561,CPT,,,,,,,,2604,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1275.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1081.7016,2784.63
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781324494,NDC,1,EA,1400.9,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1276.2199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
"Initial Repair of Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49593P,CDM,982,RC,49593,CPT,,,,,,,,2606,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1276.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1082.5324,3022.41
"Initial Repair of Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49593P,CDM,982,RC,49593,CPT,,,,,,,,2606,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1276.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1082.5324,3022.41
"Initial Repair of Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49593P,CDM,982,RC,49593,CPT,,,,,,,,2606,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1276.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1082.5324,3022.41
Removal of Anal Tabs,PX46230P,CDM,983,RC,46230,CPT,,,,,,,,1435,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1277.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,596.099,2452.93
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384P,CDM,983,RC,45384,CPT,,,,,,,,1436,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1278.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,616.044,4050.42
Emergency Level V Visit,PX99285P,CDM,981,RC,99285,CPT,,,,,,,,1436,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1278.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,561.13,1397.6588
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,16714085701,NDC,1,EA,1403.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1278.5885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
Closed Rx Kneecap Disloc+Anesth,PX27562P,CDM,983,RC,27562,CPT,,,,,,,,1404,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1279.044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1366.5132
MESH SURGICAL NON-ABSORBABLE PLUG 6INW X 6INL,C1781,CDM,272,RC,C1781,HCPCS,,12005-MAIN,LOCAL,,,,,1505,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1279.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
MESH SURGICAL NON-ABSORBABLE PLUG 12INW X 12INL,C1781,CDM,278,RC,C1781,HCPCS,,12006-MAIN,LOCAL,,,,,1505,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1279.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502050102,NDC,1,EA,1305.38,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1279.2724,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.392496,1279.2724
liraglutide 18 MG/3ML solution pen-injector 3 mL Pen,63700001,CDM,250,RC,,,,,,169406012,NDC,3,ML,1405.33,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1280.25563,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Sigmoidoscopy,Biopsy",PX45331P,CDM,983,RC,45331,CPT,,,,,,,,1316,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,3321.4,percent of total billed charges,1280.8628,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,546.6664,1280.8628
"Upper GI Endoscopy,Diagnosis",PX43235P,CDM,983,RC,43235,CPT,,,,,,,,1406,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1280.866,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,603.174,3859.68
Closed Treat Wrist Dislocation,PX25660P,CDM,983,RC,25660,CPT,,,,,,,,1507,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1280.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1466.7631
HIMAX PLUS 18X18X18,27200000,CDM,278,RC,C1713,HCPCS,,11660-MAIN,LOCAL,,,,,3085.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1281.7167,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HIMAX PLUS 20X20X20,27200000,CDM,278,RC,C1713,HCPCS,,11661-MAIN,LOCAL,,,,,3085.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1281.7167,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
cycloPHOSphamide 2 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,10019095701,NDC,1,EA,2988.6,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1282.1094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
Exc Abdom Tum Subfac > 5 Cm,PX22901F,CDM,761,RC,22901,CPT,,,,,,,,1408,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1282.688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,584.8832,2482.37
HERNIA PATCH VENTRALEX MEDIUM,C1781,CDM,278,RC,C1781,HCPCS,,10202-MAIN,LOCAL,,,,,1309.75,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1283.555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
MESH VENTRALIGHT ECHO 2.0 POSITIONING 11CM ROUND,120.525,CDM,278,RC,C1781,HCPCS,,12219-MAIN,LOCAL,,,,,1310,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1283.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,544.174,1283.8
"Exc Skn Bnig >4cmtrnk,Arm,Leg",PX11406P,CDM,983,RC,11406,CPT,,,,,,,,1456,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1284.192,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,604.8224,1417.1248
"Colonoscopy,Biopsy",PX45380P,CDM,983,RC,45380,CPT,,,,,,,,2539,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1284.734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1030.93,4050.42
"Colonoscopy,Flex,Screen",PX2002F,CDM,750,RC,G0105,HCPCS,,,,,,,,2539,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1284.734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,798.45,3885.86
"Upper GI Endoscopy,Diagnosis",PX43235F,CDM,750,RC,43235,CPT,,,,,,,,2539,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1284.734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,3859.68
"Up GI Endoscopy,Ball Dil,30mm",PX43249F,CDM,750,RC,43249,CPT,,,,,,,,2596,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1285.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,958.1,3257.54
CT Angiograph Pelv W/O&W/Dye,PX7219101,CDM,350,RC,72191,CPT,TC,,,,,,,1458,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1285.956,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
darbepoetin alfa 40 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002104,NDC,0.4,ML,1411.78,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1286.13158,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
"MRI,Uprext Jnt W/O+W/Cont",PX7322301,CDM,610,RC,73223,CPT,TC,,,,,,,2681,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1286.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2627.38
"MRI,Uprext Jnt W/O+W/Cont",PX7322301,CDM,610,RC,73223,CPT,TC,,,,,,,2681,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1286.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2627.38
fomepizole 1 GM/ML Solution 1.5 mL Vial,J1451.01,CDM,636,RC,J1451,HCPCS,,,,39822071001,NDC,1.5,ML,2600,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.14,2548
Part Remv Phalanx of Toe,PX28124P,CDM,983,RC,28124,CPT,,,,,,,,1515,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1287.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,629.331,2827.75
Amputation Finger/Thumb,PX26951P,CDM,983,RC,26951,CPT,,,,,,,,2603,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1288.485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1081.2862,2827.75
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561F,CDM,510,RC,36561,CPT,,,,,,,,2604,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1288.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1081.7016,2784.63
carboprost 250 MCG/ML Solution 1 mL Ampule,25000000,CDM,250,RC,,,,,,9085608,NDC,1,ML,1517.13,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1289.5605,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Sigmoidoscopy,Biopsy",PX45331P,CDM,983,RC,45331,CPT,,,,,,,,1316,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1289.68,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,44.5,1289.68
HERNIA PATCH VENTRALEX LARGE,C1781,CDM,278,RC,C1781,HCPCS,,10201-MAIN,LOCAL,,,,,1325.08,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1256.29,percent of total billed charges,1289.700364,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Initial Repair of Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49593P,CDM,982,RC,49593,CPT,,,,,,,,2606,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1289.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1082.5324,3022.41
"I&D Perianal Abscess,Superficial",PX46050F,CDM,510,RC,46050,CPT,,,,,,,,1463,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1290.366,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,607.7302,1433.74
"Excise Lesion,Back or Flank",PX21930F,CDM,510,RC,21930,CPT,,,,,,,,1326,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,4019.13,percent of total billed charges,1290.5958,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,550.8204,1416.38
"Excis Arm/Elbow Tumor,Subcutan",PX24075F,CDM,510,RC,24075,CPT,,,,,,,,1519,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1291.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,630.9926,1488.62
CT Lower Extremity W/Dye,PX7370101,CDM,350,RC,73701,CPT,TC,,,,,,,2690,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1291.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,2636.2
CT Lower Extremity W/Dye,PX7370101,CDM,350,RC,73701,CPT,TC,,,,,,,2690,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1291.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,2636.2
Facility Emergency Level V Visit,PX99285F,CDM,450,RC,99285,CPT,,,,,,,,1464,,United Healthcare,All Payer,outpatient,88.2,,83.42808511,percent of total billed charges,1291.248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,561.13,1434.72
"Amputation Toe,I-P Jt",PX28825F,CDM,510,RC,28825,CPT,,,,,,,,1327,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1291.5691,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,551.2358,2827.75
Lap Rpr Vent Umbilical Hernia Incarcerated or Strangulated,PX49653P,CDM,983,RC,49653,CPT,,,,,,,,1327,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1291.5691,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,551.2358,1291.5691
degarelix acetate 40 mg/mL Recon Soln 1 Each Vial,J9155.01,CDM,636,RC,J9155,HCPCS,,,,55566840301,NDC,2,EA,3109.33,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1291.615682,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.83,3047.1434
onabotulinumtoxinA 50 units Recon Soln 1 Each Vial,J0585.03,CDM,636,RC,J0585,HCPCS,,,,23391950,NDC,1,EA,1418.14,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1291.92554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.51,1389.7772
MRI Brain W Contrast Tc,PX7055201,CDM,610,RC,70552,CPT,TC,,,,,,,2637,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1292.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2584.26
MRI Brain W Contrast Tc,PX7055201,CDM,610,RC,70552,CPT,TC,,,,,,,2637,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1292.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2584.26
MRI Brain W Contrast Tc,PX7055201,CDM,610,RC,70552,CPT,TC,,,,,,,2637,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1292.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2584.26
"Upper GI Endoscopy,Ctrl Bleed",PX43255F,CDM,750,RC,43255,CPT,,,,,,,,1723,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1292.28,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.59,1292.28
"Upper GI Endoscopy,Ctrl Bleed",PX43255P,CDM,983,RC,43255,CPT,,,,,,,,1148,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1292.28,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.59,1292.28
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390F,CDM,750,RC,45390,CPT,,,,,,,,1419,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1292.709,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,589.4526,2452.93
"Repair Lip,>1/2 Vert Height",PX40654P,CDM,983,RC,40654,CPT,,,,,,,,1329,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1293.5157,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,552.0666,1332.3
"Closed Rx Weight Bear Dist Tib,Manip",PX27825F,CDM,510,RC,27825,CPT,,,,,,,,2695,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1293.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1119.503,2641.1
"Closed Rx Weight Bear Dist Tib,Manip",PX27825F,CDM,510,RC,27825,CPT,,,,,,,,2695,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1293.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1119.503,2641.1
"Removal of Hydrocele,Tunica,Unilat",PX55040P,CDM,983,RC,55040,CPT,,,,,,,,1420,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1293.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,589.868,3022.41
"Closed Rx Shldr Disloc,Anesthesia",PX23655P,CDM,983,RC,23655,CPT,,,,,,,,1421,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1294.531,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,590.2834,1404.08
Excis Forearm/Wrist Tumor Subcutan,PX25075F,CDM,510,RC,25075,CPT,,,,,,,,1421,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1294.531,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,590.2834,1416.38
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604P,CDM,983,RC,11604,CPT,,,,,,,,1422,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1295.442,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,590.6988,1384.0326
"Exc Skn Bnig >4cmtrnk,Arm,Leg",PX11406P,CDM,983,RC,11406,CPT,,,,,,,,1456,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1295.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,604.8224,1417.1248
"Removal Anal Fistula,Subcutaneous",PX46270F,CDM,510,RC,46270,CPT,,,,,,,,1470,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1296.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,610.638,2452.93
Injection for Nerve Block,PX64447F,CDM,510,RC,64447,CPT,,,,,,,,3023,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1296.867,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,604.15,2962.54
trastuzumab-dttb 150 MG Recon Soln 1 Each Vial,J9999.55,CDM,636,RC,J9999,HCPCS,,,,78206014701,NDC,1,EA,2702.3,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1297.104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1122.53542,2648.254
trastuzumab-dttb 150 MG Recon Soln 1 Each Vial,J9999.55,CDM,636,RC,J9999,HCPCS,,,,78206014701,NDC,1,EA,2702.3,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1297.104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1122.53542,2648.254
CT Angiograph Pelv W/O&W/Dye,PX7219101,CDM,350,RC,72191,CPT,TC,,,,,,,1458,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1297.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
PACLitaxel protein-bound particle 100 MG Recon Susp 1 Each Vial,J9264.01,CDM,636,RC,J9264,HCPCS,,,,68817013450,NDC,1,EA,2564.76,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1297.76856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.1,2513.4648
HERNIA PATCH VENTRALEX LARGE,C1781,CDM,278,RC,C1781,HCPCS,,10201-MAIN,LOCAL,,,,,1325.08,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1298.5784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
diazePAM 10 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,187065820,NDC,1,EA,1527.87,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1298.6895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Lap,Cholecystectomy",PX47562F,CDM,510,RC,47562,CPT,,,,,,,,1473,,United Healthcare,All Payer,outpatient,88.2,,5782.04,percent of total billed charges,1299.186,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,611.8842,5040.74
Exc Abd Les Sc < 3 Cm,PX22902F,CDM,761,RC,22902,CPT,,,,,,,,3128,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1299.3712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1299.3712,3065.44
"Excise Lesion,Back or Flank",PX21930F,CDM,510,RC,21930,CPT,,,,,,,,1326,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1299.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,550.8204,1416.38
GRAFIXPL PRIME PLACENTAL MEMBRANE 1.5 x2CM 3SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12764-MAIN,LOCAL,,,,,1529,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1299.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573F,CDM,761,RC,36573,CPT,,,,,,,,1529,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1299.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,635.1466,1498.42
APLIGRAF LIVING BI-LAYERED SKIN SUBSTITUTE,120.514,CDM,278,RC,Q4101,HCPCS,,12082-MAIN,LOCAL,,,,,2569,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1299.914,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1067.1626,2517.62
"Amputation Toe,I-P Jt",PX28825F,CDM,510,RC,28825,CPT,,,,,,,,1327,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1300.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,551.2358,2827.75
Lap Rpr Vent Umbilical Hernia Incarcerated or Strangulated,PX49653P,CDM,983,RC,49653,CPT,,,,,,,,1327,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1300.46,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,821.05,1300.46
MRI Abdomen W/O Tc,PX7418101,CDM,610,RC,74181,CPT,TC,,,,,,,2655,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1300.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,2601.9
MRI Abdomen W/O Tc,PX7418101,CDM,610,RC,74181,CPT,TC,,,,,,,2655,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1300.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,2601.9
MRI Abdomen W/O Tc,PX7418101,CDM,610,RC,74181,CPT,TC,,,,,,,2655,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1300.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,2601.9
"Repair Flex Foot Tendon,Ea",PX28200F,CDM,510,RC,28200,CPT,,,,,,,,1475,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1300.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,612.715,2827.75
"Remv Foreign Body,Knee/Thigh,Deep",PX27372F,CDM,510,RC,27372,CPT,,,,,,,,1429,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1301.819,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,593.6066,2482.37
"I&D Perianal Abscess,Superficial",PX46050F,CDM,510,RC,46050,CPT,,,,,,,,1463,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1302.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,607.7302,1433.74
"Repair Lip,>1/2 Vert Height",PX40654P,CDM,983,RC,40654,CPT,,,,,,,,1329,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1302.42,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,269.41,1302.42
"Genital Surg Proc,Male Unlisted",PX55899F,CDM,510,RC,55899,CPT,,,,,,,,1430,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1302.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,215.91,1401.4
I&D Perirectal Abscess,PX46040F,CDM,510,RC,46040,CPT,,,,,,,,1430,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1302.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,594.022,1401.4
Facility Emergency Level V Visit,PX99285F,CDM,450,RC,99285,CPT,,,,,,,,1464,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1302.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,561.13,1434.72
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034P,CDM,983,RC,12034,CPT,,,,,,,,1533,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1303.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1492.0689
Anus Surgery Procedure Unlisted,PX46999F,CDM,510,RC,46999,CPT,,,,,,,,1431,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1303.641,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,594.4374,1402.38
RESTRATA WOUND MATRIX 2.5CM X 5CM TOTAL 12.5CM,27200000,CDM,272,RC,A2007,HCPCS,,11734-MAIN,LOCAL,,,,,3039,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1303.731,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606F,CDM,510,RC,11606,CPT,,,,,,,,1432,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1304.552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,594.8528,1416.38
"Chrom Anal, 20-25 Cells - Ref",PX8826490,CDM,310,RC,88264,CPT,90,,,,,,,3141,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1304.7714,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.59,3078.18
"Tiss Cult, Neopl, Bm, Wb - Ref",PX8823790,CDM,310,RC,88237,CPT,90,,,,,,,3141,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1304.7714,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,131.8,3078.18
MRI Brain W Contrast Tc,PX7055201,CDM,610,RC,70552,CPT,TC,,,,,,,2637,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1305.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2584.26
Removal of Anal Tabs,PX46230P,CDM,983,RC,46230,CPT,,,,,,,,1435,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1307.285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,596.099,2452.93
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384P,CDM,983,RC,45384,CPT,,,,,,,,1436,,Medica,Commercial,both,91.1,,352.5,percent of total billed charges,1308.196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,616.044,4050.42
Emergency Level V Visit,PX99285P,CDM,981,RC,99285,CPT,,,,,,,,1436,,Medica,Commercial,both,91.1,,361.354,percent of total billed charges,1308.196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,561.13,1397.6588
"Removal Anal Fistula,Subcutaneous",PX46270F,CDM,510,RC,46270,CPT,,,,,,,,1470,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1308.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,610.638,2452.93
PEMEtrexed Disodium 100 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2764001,NDC,1,EA,1539.32,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1308.422,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.01,7924.2996
Repair Incis Hernia W Mesh,PX49568F,CDM,510,RC,49568,CPT,,,,,,,,1540,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1309,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,639.716,1509.2
"Lap,Cholecystectomy",PX47562F,CDM,510,RC,47562,CPT,,,,,,,,1473,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1310.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,611.8842,5040.74
darbepoetin alfa 200 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002801,NDC,0.4,ML,3157.92,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1311.799968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
"Repair Flex Foot Tendon,Ea",PX28200F,CDM,510,RC,28200,CPT,,,,,,,,1475,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1312.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,612.715,2827.75
"rabies vaccine, pcec Recon Susp 1 Each Vial",90675,CDM,636,RC,90675,CPT,,,,58160096412,NDC,1,EA,1544.83,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1313.1055,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,297.75,1513.9334
"Up GI Endoscopy,Ball Dil,30mm",PX43249F,CDM,750,RC,43249,CPT,,,,,,,,2596,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1313.576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,958.1,3257.54
"MRI,Uprext Jnt W/O+W/Cont",PX7322301,CDM,610,RC,73223,CPT,TC,,,,,,,2681,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1313.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2627.38
"MRI,Uprext Jnt W/O+W/Cont",PX7322301,CDM,610,RC,73223,CPT,TC,,,,,,,2681,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1313.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2627.38
"MRI,Uprext Jnt W/O+W/Cont",PX7322301,CDM,610,RC,73223,CPT,TC,,,,,,,2681,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1313.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2627.38
"Hemorrhoidectomy,Int/Ext,Complx",PX46260F,CDM,750,RC,46260,CPT,,,,,,,,1350,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1313.955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,560.79,2452.93
Leukoreduced Platelets,PXP9035,CDM,390,RC,P9035,HCPCS,,,,,,,,1350,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1313.955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,433.08,1323
"Biopsy, Nail Unit",PX11755F,CDM,510,RC,11755,CPT,,,,,,,,1490,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1314.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,614.65,1460.2
MRI Abdomen W/O Tc,PX7418101,CDM,610,RC,74181,CPT,TC,,,,,,,2655,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1314.225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,2601.9
fomepizole 1 GM/ML Solution 1.5 mL Vial,J1451.01,CDM,636,RC,J1451,HCPCS,,,,39822071001,NDC,1.5,ML,2600,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1315.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.14,2548
"Closed Rx Trimalleolar Fx,Manip",PX27818P,CDM,983,RC,27818,CPT,,,,,,,,1352,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1315.9016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,561.6208,1404.08
Closed Rx IP Jt Dislocation,PX26770P,CDM,983,RC,26770,CPT,,,,,,,,1353,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1316.8749,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1316.8749
Amputation Finger/Thumb,PX26951P,CDM,983,RC,26951,CPT,,,,,,,,2603,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1317.118,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1081.2862,2827.75
CT Pelvis W/O Dye,PX7219201,CDM,350,RC,72192,CPT,TC,,,,,,,2744,,Health Partners,Health Partners Care Plans,both,48,,1272.29,percent of total billed charges,1317.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2689.12
CT Pelvis W/O Dye,PX7219201,CDM,350,RC,72192,CPT,TC,,,,,,,2744,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1317.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2689.12
"Freeing Bowel Adhesion,Enterolysis",PX44005F,CDM,360,RC,44005,CPT,,,,,,,,2744,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1317.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,677.12,2689.12
"Freeing Bowel Adhesion,Enterolysis",PX44005F,CDM,360,RC,44005,CPT,,,,,,,,2744,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1317.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,677.12,2689.12
"Fix Exten Tendon,Dorsum Fingr,Ea",PX26418F,CDM,510,RC,26418,CPT,,,,,,,,1750,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1317.19,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,409.03,1317.19
"Fix Exten Tendon,Dorsum Fingr,Ea",PX26418F,CDM,510,RC,26418,CPT,,,,,,,,1750,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1317.19,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,409.03,1317.19
"Cystourethroscopy, With Injection(S) for Chemodenervation of the Bladder",PX52287F,CDM,360,RC,52287,CPT,,,,,,,,2745,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1317.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1140.273,2690.1
"Cystourethroscopy, With Injection(S) for Chemodenervation of the Bladder",PX52287F,CDM,360,RC,52287,CPT,,,,,,,,2745,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1317.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1140.273,2690.1
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561F,CDM,510,RC,36561,CPT,,,,,,,,2604,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1317.624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1081.7016,2784.63
CT Lower Extremity W/Dye,PX7370101,CDM,350,RC,73701,CPT,TC,,,,,,,2690,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1318.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,2636.2
CT Lower Extremity W/Dye,PX7370101,CDM,350,RC,73701,CPT,TC,,,,,,,2690,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1318.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,2636.2
CT Lower Extremity W/Dye,PX7370101,CDM,350,RC,73701,CPT,TC,,,,,,,2690,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1318.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,2636.2
"Initial Repair of Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49593P,CDM,982,RC,49593,CPT,,,,,,,,2606,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1318.636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1082.5324,3022.41
"Closed Rx Weight Bear Dist Tib,Manip",PX27825F,CDM,510,RC,27825,CPT,,,,,,,,2695,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1320.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1119.503,2641.1
"Closed Rx Weight Bear Dist Tib,Manip",PX27825F,CDM,510,RC,27825,CPT,,,,,,,,2695,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1320.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1119.503,2641.1
"Closed Rx Weight Bear Dist Tib,Manip",PX27825F,CDM,510,RC,27825,CPT,,,,,,,,2695,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1320.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1119.503,2641.1
CT Angio Lwr Extr W/O&W/Dye,PX7370601,CDM,350,RC,73706,CPT,TC,,,,,,,1554,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1320.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1522.92
"Casiri and Imdevimab,Admin,Repeat Dose",PXM0240,CDM,771,RC,M0240,HCPCS,,,,,,,,1555,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1321.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,413.06,1523.9
"IV Infusion, Bamlanivimab and Etesevimab, Infusion and Monitoring",PXM0245,CDM,260,RC,M0245,HCPCS,,,,,,,,1555,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1321.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,413.06,1523.9
"IV Infusion, Casirivimab and Imdevimab, IV and Post Admr",PXM0243,CDM,771,RC,M0243,HCPCS,,,,,,,,1555,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1321.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,413.06,1684.87
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591F,CDM,360,RC,49591,CPT,,,,,,,,1556,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1322.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,646.3624,3022.41
"Lap,Cholecystectomy/Graph",PX47563F,CDM,510,RC,47563,CPT,,,,,,,,1556,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1322.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,646.3624,5040.74
"Repair of Recurrent Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49615F,CDM,360,RC,49615,CPT,,,,,,,,2908,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1322.72,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,376.31,1322.72
"Repair of Recurrent Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49615F,CDM,360,RC,49615,CPT,,,,,,,,2908,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1322.72,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,376.31,1322.72
"Hemorrhoidectomy,Int/Ext,Complx",PX46260F,CDM,750,RC,46260,CPT,,,,,,,,1350,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1323,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,560.79,2452.93
Leukoreduced Platelets,PXP9035,CDM,390,RC,P9035,HCPCS,,,,,,,,1350,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1323,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,433.08,1323
Level 2 Additional Procedure,PX36000081,CDM,360,RC,,,,,,,,,,1500,,United Healthcare,All Payer,outpatient,88.2,,999999999,case rate,1323,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1323,6141.46
CT Abdomen W/O Dye,PX7415001,CDM,350,RC,74150,CPT,TC,,,,,,,2757,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1323.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Abdomen W/O Dye,PX7415001,CDM,350,RC,74150,CPT,TC,,,,,,,2757,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1323.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Angio Abd&Pelv W/O&W/Dye,PX7417401,CDM,350,RC,74174,CPT,TC,,,,,,,2757,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1323.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2701.86
CT Angio Abd&Pelv W/O&W/Dye,PX7417401,CDM,350,RC,74174,CPT,TC,,,,,,,2757,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1323.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2701.86
CT Chest Spine W/O Dye,PX7212801,CDM,350,RC,72128,CPT,TC,,,,,,,2757,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1323.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Chest Spine W/O Dye,PX7212801,CDM,350,RC,72128,CPT,TC,,,,,,,2757,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1323.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Head/Brain W/O Dye,PX7045001,CDM,350,RC,70450,CPT,TC,,,,,,,2757,,Health Partners,Health Partners Care Plans,both,48,,1565.645714,percent of total billed charges,1323.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Head/Brain W/O Dye,PX7045001,CDM,350,RC,70450,CPT,TC,,,,,,,2757,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1323.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Lower Extremity W/O Dye,PX7370001,CDM,350,RC,73700,CPT,TC,,,,,,,2757,,Health Partners,Health Partners Care Plans,both,48,,1207.78,percent of total billed charges,1323.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Lower Extremity W/O Dye,PX7370001,CDM,350,RC,73700,CPT,TC,,,,,,,2757,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1323.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Lumbar Spine W/O Dye,PX7213101,CDM,350,RC,72131,CPT,TC,,,,,,,2757,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1323.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Lumbar Spine W/O Dye,PX7213101,CDM,350,RC,72131,CPT,TC,,,,,,,2757,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1323.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Maxillofacialw/O Dye,PX7048601,CDM,350,RC,70486,CPT,TC,,,,,,,2757,,Health Partners,Health Partners Care Plans,both,48,,1744.8725,percent of total billed charges,1323.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Maxillofacialw/O Dye,PX7048601,CDM,350,RC,70486,CPT,TC,,,,,,,2757,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1323.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Neck Spine W/O Dye,PX7212501,CDM,350,RC,72125,CPT,TC,,,,,,,2757,,Health Partners,Health Partners Care Plans,both,48,,914.865,percent of total billed charges,1323.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Neck Spine W/O Dye,PX7212501,CDM,350,RC,72125,CPT,TC,,,,,,,2757,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1323.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Orbit/Ear/Fosa W/O Dye,PX7048001,CDM,350,RC,70480,CPT,TC,,,,,,,2757,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1323.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Orbit/Ear/Fosa W/O Dye,PX7048001,CDM,350,RC,70480,CPT,TC,,,,,,,2757,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1323.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Upper Extremity W/Dye,PX7320101,CDM,350,RC,73201,CPT,TC,,,,,,,2757,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1323.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2701.86
CT Upper Extremity W/Dye,PX7320101,CDM,350,RC,73201,CPT,TC,,,,,,,2757,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1323.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2701.86
CT Upper Extremity W/O Dye,PX7320001,CDM,350,RC,73200,CPT,TC,,,,,,,2757,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1323.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Upper Extremity W/O Dye,PX7320001,CDM,350,RC,73200,CPT,TC,,,,,,,2757,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1323.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
Diagnostic CT Thorax W/O Contrast,PX7125001,CDM,350,RC,71250,CPT,TC,,,,,,,2757,,Health Partners,Health Partners Care Plans,both,48,,2674.28,percent of total billed charges,1323.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
Diagnostic CT Thorax W/O Contrast,PX7125001,CDM,350,RC,71250,CPT,TC,,,,,,,2757,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1323.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
HIMAX PLUS 18X18X18,27200000,CDM,278,RC,C1713,HCPCS,,11660-MAIN,LOCAL,,,,,3085.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1323.6795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HIMAX PLUS 20X20X20,27200000,CDM,278,RC,C1713,HCPCS,,11661-MAIN,LOCAL,,,,,3085.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1323.6795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Repair Recurr Inguin Hern,Reducibl",PX49520F,CDM,510,RC,49520,CPT,,,,,,,,1983,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1324.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,380.89,1324.11
"Repair Recurr Inguin Hern,Reducibl",PX49520F,CDM,510,RC,49520,CPT,,,,,,,,1983,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1324.11,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,380.89,1324.11
"Repair Recurr Inguin Hern,Reducibl",PX49520P,CDM,983,RC,49520,CPT,,,,,,,,1983,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1324.11,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,380.89,1943.34
"Repair Recurr Inguin Hern,Reducibl",PX49520P,CDM,983,RC,49520,CPT,,,,,,,,1983,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1324.11,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,380.89,1943.34
trastuzumab-dttb 150 MG Recon Soln 1 Each Vial,J9999.55,CDM,636,RC,J9999,HCPCS,,,,78206014701,NDC,1,EA,2702.3,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1324.127,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1122.53542,2648.254
trastuzumab-dttb 150 MG Recon Soln 1 Each Vial,J9999.55,CDM,636,RC,J9999,HCPCS,,,,78206014701,NDC,1,EA,2702.3,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1324.127,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1122.53542,2648.254
trastuzumab-dttb 150 MG Recon Soln 1 Each Vial,J9999.55,CDM,636,RC,J9999,HCPCS,,,,78206014701,NDC,1,EA,2702.3,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1324.127,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1122.53542,2648.254
"Closed Rx Trimalleolar Fx,Manip",PX27818P,CDM,983,RC,27818,CPT,,,,,,,,1352,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1324.96,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,279.01,1324.96
Closed Rx IP Jt Dislocation,PX26770P,CDM,983,RC,26770,CPT,,,,,,,,1353,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1325.94,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,168.85,1325.94
"Biopsy, Nail Unit",PX11755F,CDM,510,RC,11755,CPT,,,,,,,,1490,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1326.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,614.65,1460.2
"Exc Skn Bnig >4cmtrnk,Arm,Leg",PX11406P,CDM,983,RC,11406,CPT,,,,,,,,1456,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1326.416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,604.8224,1417.1248
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,62935022305,NDC,1,EA,2764.34,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1326.8832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,62935022305,NDC,1,EA,2764.34,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1326.8832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
"MRI,Uprext Jnt W/O+W/Cont",PX7322301,CDM,610,RC,73223,CPT,TC,,,,,,,2681,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1327.095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2627.38
MESH SURGICAL NON-ABSORBABLE PLUG 6INW X 6INL,C1781,CDM,272,RC,C1781,HCPCS,,12005-MAIN,LOCAL,,,,,1505,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1327.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
MESH SURGICAL NON-ABSORBABLE PLUG 12INW X 12INL,C1781,CDM,278,RC,C1781,HCPCS,,12006-MAIN,LOCAL,,,,,1505,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1327.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
CT Angiograph Pelv W/O&W/Dye,PX7219101,CDM,350,RC,72191,CPT,TC,,,,,,,1458,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1328.238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
Closed Treat Wrist Dislocation,PX25660P,CDM,983,RC,25660,CPT,,,,,,,,1507,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1329.174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1466.7631
Level 4 Additional Procedure,PX36000083,CDM,360,RC,,,,,,,,,,3200,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1329.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1329.28,3136
"Incis/Drain Shldr Absc/Hema,Deep",PX23030P,CDM,983,RC,23030,CPT,,,,,,,,1564,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1329.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,649.6856,2482.37
Heart/Lung Resuscitation (Cpr),PX92950F,CDM,480,RC,92950,CPT,,,,,,,,1366,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1329.5278,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.21,1338.68
cycloPHOSphamide 500 MG Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781323394,NDC,1,EA,1565.71,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1330.8535,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
zoledronic acid 5 MG/100ML Solution 100 mL Bottle,J3489.01,CDM,636,RC,J3489,HCPCS,,,,55111068852,NDC,100,ML,1368,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,66.804,percent of total billed charges,1331.4744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,63323096600,NDC,100,ML,1368,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,66.804,percent of total billed charges,1331.4744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
CT Lower Extremity W/Dye,PX7370101,CDM,350,RC,73701,CPT,TC,,,,,,,2690,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1331.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,2636.2
"Repair Lip,>1/2 Vert Height",PX40654F,CDM,510,RC,40654,CPT,,,,,,,,2467,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1332.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1024.7918,2417.66
"Repair Lip,>1/2 Vert Height",PX40654P,CDM,983,RC,40654,CPT,,,,,,,,1329,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1332.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,552.0666,1332.3
Hepatobiliary System Imaging,PX7822601,CDM,341,RC,78226,CPT,TC,,,,,,,2776,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1332.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,360.31,2720.48
Hepatobiliary System Imaging,PX7822601,CDM,341,RC,78226,CPT,TC,,,,,,,2776,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1332.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,360.31,2720.48
"I&D Perianal Abscess,Superficial",PX46050F,CDM,510,RC,46050,CPT,,,,,,,,1463,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1332.793,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,607.7302,1433.74
"Lap,Inguinal Hernia Repr,Recur",PX49651F,CDM,510,RC,49651,CPT,,,,,,,,1568,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1332.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,651.3472,5040.74
PROSTEP HV SCREW 3.0X16MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12986-MAIN,LOCAL,,,,,1569,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1333.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Facility Emergency Level V Visit,PX99285F,CDM,450,RC,99285,CPT,,,,,,,,1464,,Medica,Commercial,both,91.1,,361.354,percent of total billed charges,1333.704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,561.13,1434.72
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535F,CDM,510,RC,24535,CPT,,,,,,,,2514,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1333.79,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,362.13,1333.79
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535P,CDM,983,RC,24535,CPT,,,,,,,,2887,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1333.79,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,362.13,2829.26
degarelix acetate 40 mg/mL Recon Soln 1 Each Vial,J9155.01,CDM,636,RC,J9155,HCPCS,,,,55566840301,NDC,2,EA,3109.33,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1333.90257,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.83,3047.1434
"Closed Rx Weight Bear Dist Tib,Manip",PX27825F,CDM,510,RC,27825,CPT,,,,,,,,2695,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1334.025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1119.503,2641.1
MRI Brain W Contrast Tc,PX7055201,CDM,610,RC,70552,CPT,TC,,,,,,,2637,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1334.322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2584.26
Lap Paraesophag Hern Repair,PX43281,CDM,982,RC,43281,CPT,,,,,,,,5950,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1334.4916,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,906.42,5831
Level 2 Additional Procedure,PX36000081,CDM,360,RC,,,,,,,,,,1500,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,623.1,1470
Part Remv Phalanx of Toe,PX28124P,CDM,983,RC,28124,CPT,,,,,,,,1515,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1336.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,629.331,2827.75
carfilzomib 30 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010201,NDC,1,EA,2785.91,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1337.2368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.23,5460.3836
carfilzomib 30 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010201,NDC,1,EA,2785.91,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1337.2368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.23,5460.3836
trastuzumab-dttb 150 MG Recon Soln 1 Each Vial,J9999.55,CDM,636,RC,J9999,HCPCS,,,,78206014701,NDC,1,EA,2702.3,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1337.6385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1122.53542,2648.254
carboprost 250 MCG/ML Solution 1 mL Ampule,25000000,CDM,250,RC,,,,,,9085608,NDC,1,ML,1517.13,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1338.10866,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Remv F.B.,Eye,Ant Chmbr/Lens",PX65235F,CDM,510,RC,65235,CPT,,,,,,,,2788,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1338.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1158.1352,2732.24
"Remv F.B.,Eye,Ant Chmbr/Lens",PX65235F,CDM,510,RC,65235,CPT,,,,,,,,2788,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1338.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1158.1352,2732.24
Heart/Lung Resuscitation (Cpr),PX92950F,CDM,480,RC,92950,CPT,,,,,,,,1366,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1338.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.21,1338.68
"Removal Anal Fistula,Subcutaneous",PX46270F,CDM,510,RC,46270,CPT,,,,,,,,1470,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1339.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,610.638,2452.93
MESH SURGICAL NON-ABSORBABLE PLUG 6INW X 6INL,C1781,CDM,272,RC,C1781,HCPCS,,12005-MAIN,LOCAL,,,,,1505,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1339.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
MESH SURGICAL NON-ABSORBABLE PLUG 12INW X 12INL,C1781,CDM,278,RC,C1781,HCPCS,,12006-MAIN,LOCAL,,,,,1505,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1339.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Excis Arm/Elbow Tumor,Subcutan",PX24075F,CDM,510,RC,24075,CPT,,,,,,,,1519,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1339.758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,630.9926,1488.62
zoledronic acid 5 MG/100ML Solution 100 mL Bottle,J3489.01,CDM,636,RC,J3489,HCPCS,,,,55111068852,NDC,100,ML,1368,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1340.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,63323096600,NDC,100,ML,1368,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1340.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
"Colonoscopy,Transendoscopic Stent",PX45387F,CDM,750,RC,45387,CPT,,,,,,,,3228,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1340.9112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1340.9112,3163.44
Closed Treat Wrist Dislocation,PX25660P,CDM,983,RC,25660,CPT,,,,,,,,1507,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1341.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1466.7631
"Lap,Cholecystectomy",PX47562F,CDM,510,RC,47562,CPT,,,,,,,,1473,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1341.903,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,611.8842,5040.74
Exc Abd Les Sc < 3 Cm,PX22902F,CDM,761,RC,22902,CPT,,,,,,,,3128,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1341.912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1299.3712,3065.44
MRI Abdomen W/O Tc,PX7418101,CDM,610,RC,74181,CPT,TC,,,,,,,2655,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1343.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,2601.9
"Repair Flex Foot Tendon,Ea",PX28200F,CDM,510,RC,28200,CPT,,,,,,,,1475,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1343.725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,612.715,2827.75
CT Pelvis W/O Dye,PX7219201,CDM,350,RC,72192,CPT,TC,,,,,,,2744,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,548.8,percent of total billed charges,1344.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2689.12
CT Pelvis W/O Dye,PX7219201,CDM,350,RC,72192,CPT,TC,,,,,,,2744,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1344.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2689.12
CT Pelvis W/O Dye,PX7219201,CDM,350,RC,72192,CPT,TC,,,,,,,2744,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1344.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2689.12
"Freeing Bowel Adhesion,Enterolysis",PX44005F,CDM,360,RC,44005,CPT,,,,,,,,2744,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1344.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,677.12,2689.12
"Freeing Bowel Adhesion,Enterolysis",PX44005F,CDM,360,RC,44005,CPT,,,,,,,,2744,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1344.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,677.12,2689.12
"Freeing Bowel Adhesion,Enterolysis",PX44005F,CDM,360,RC,44005,CPT,,,,,,,,2744,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1344.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,677.12,2689.12
"Cystourethroscopy, With Injection(S) for Chemodenervation of the Bladder",PX52287F,CDM,360,RC,52287,CPT,,,,,,,,2745,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1345.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1140.273,2690.1
"Cystourethroscopy, With Injection(S) for Chemodenervation of the Bladder",PX52287F,CDM,360,RC,52287,CPT,,,,,,,,2745,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1345.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1140.273,2690.1
"Cystourethroscopy, With Injection(S) for Chemodenervation of the Bladder",PX52287F,CDM,360,RC,52287,CPT,,,,,,,,2745,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1345.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1140.273,2690.1
methylene blue 50 MG/10ML Solution 10 mL Ampule,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,517037405,NDC,10,ML,1382.12,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,15.50733333,percent of total billed charges,1345.217396,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.29,1354.4776
liraglutide 18 MG/3ML solution pen-injector 3 mL Pen,63700001,CDM,250,RC,,,,,,169406013,NDC,3,ML,1382.75,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1345.830575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING 8 IN CIRCLE,C1781,CDM,278,RC,C1781,HCPCS,,12506-MAIN,LOCAL,,,,,3240,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1345.896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Chrom Anal, 20-25 Cells - Ref",PX8826490,CDM,310,RC,88264,CPT,90,,,,,,,3141,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1347.489,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.59,3078.18
"Tiss Cult, Neopl, Bm, Wb - Ref",PX8823790,CDM,310,RC,88237,CPT,90,,,,,,,3141,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1347.489,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,131.8,3078.18
diazePAM 10 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,187065820,NDC,1,EA,1527.87,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1347.58134,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
POWERPORT ISP MRI IMPLANTABLE PORT 8FR,C1788,CDM,278,RC,C1788,HCPCS,,11998-MAIN,LOCAL,,,,,1385,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1348.0205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,575.329,1357.3
MRI Pelvis W/Contrast Tc,PX7219601,CDM,610,RC,72196,CPT,TC,,,,,,,3143,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1348.347,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3080.14
Part Remv Phalanx of Toe,PX28124P,CDM,983,RC,28124,CPT,,,,,,,,1515,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1348.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,629.331,2827.75
GRAFIXPL PRIME PLACENTAL MEMBRANE 1.5 x2CM 3SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12764-MAIN,LOCAL,,,,,1529,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1348.578,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573F,CDM,761,RC,36573,CPT,,,,,,,,1529,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1348.578,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,635.1466,1498.42
Low Dose CT Lung Ca Screening,PXG029701,CDM,350,RC,G0297,HCPCS,TC,,,,,,,2812,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1349.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1168.1048,2755.76
Low Dose CT Lung Ca Screening,PXG029701,CDM,350,RC,G0297,HCPCS,TC,,,,,,,2812,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1349.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1168.1048,2755.76
carboprost 250 MCG/ML Solution 1 mL Ampule,25000000,CDM,250,RC,,,,,,9085608,NDC,1,ML,1517.13,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1350.2457,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
CT Abdomen W/O Dye,PX7415001,CDM,350,RC,74150,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1350.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Abdomen W/O Dye,PX7415001,CDM,350,RC,74150,CPT,TC,,,,,,,2757,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1350.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Abdomen W/O Dye,PX7415001,CDM,350,RC,74150,CPT,TC,,,,,,,2757,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1350.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Angio Abd&Pelv W/O&W/Dye,PX7417401,CDM,350,RC,74174,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,506.4,percent of total billed charges,1350.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2701.86
CT Angio Abd&Pelv W/O&W/Dye,PX7417401,CDM,350,RC,74174,CPT,TC,,,,,,,2757,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1350.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2701.86
CT Angio Abd&Pelv W/O&W/Dye,PX7417401,CDM,350,RC,74174,CPT,TC,,,,,,,2757,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1350.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2701.86
CT Chest Spine W/O Dye,PX7212801,CDM,350,RC,72128,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,543.3,percent of total billed charges,1350.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Chest Spine W/O Dye,PX7212801,CDM,350,RC,72128,CPT,TC,,,,,,,2757,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1350.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Chest Spine W/O Dye,PX7212801,CDM,350,RC,72128,CPT,TC,,,,,,,2757,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1350.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Head/Brain W/O Dye,PX7045001,CDM,350,RC,70450,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,620.0495652,percent of total billed charges,1350.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Head/Brain W/O Dye,PX7045001,CDM,350,RC,70450,CPT,TC,,,,,,,2757,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1350.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Head/Brain W/O Dye,PX7045001,CDM,350,RC,70450,CPT,TC,,,,,,,2757,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1350.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Lower Extremity W/O Dye,PX7370001,CDM,350,RC,73700,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,551.4,percent of total billed charges,1350.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Lower Extremity W/O Dye,PX7370001,CDM,350,RC,73700,CPT,TC,,,,,,,2757,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1350.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Lower Extremity W/O Dye,PX7370001,CDM,350,RC,73700,CPT,TC,,,,,,,2757,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1350.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Lumbar Spine W/O Dye,PX7213101,CDM,350,RC,72131,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,547.35,percent of total billed charges,1350.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Lumbar Spine W/O Dye,PX7213101,CDM,350,RC,72131,CPT,TC,,,,,,,2757,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1350.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Lumbar Spine W/O Dye,PX7213101,CDM,350,RC,72131,CPT,TC,,,,,,,2757,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1350.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Maxillofacialw/O Dye,PX7048601,CDM,350,RC,70486,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,582.715,percent of total billed charges,1350.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Maxillofacialw/O Dye,PX7048601,CDM,350,RC,70486,CPT,TC,,,,,,,2757,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1350.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Maxillofacialw/O Dye,PX7048601,CDM,350,RC,70486,CPT,TC,,,,,,,2757,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1350.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Neck Spine W/O Dye,PX7212501,CDM,350,RC,72125,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,708.0311765,percent of total billed charges,1350.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Neck Spine W/O Dye,PX7212501,CDM,350,RC,72125,CPT,TC,,,,,,,2757,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1350.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Neck Spine W/O Dye,PX7212501,CDM,350,RC,72125,CPT,TC,,,,,,,2757,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1350.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Orbit/Ear/Fosa W/O Dye,PX7048001,CDM,350,RC,70480,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,551.4,percent of total billed charges,1350.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Orbit/Ear/Fosa W/O Dye,PX7048001,CDM,350,RC,70480,CPT,TC,,,,,,,2757,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1350.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Orbit/Ear/Fosa W/O Dye,PX7048001,CDM,350,RC,70480,CPT,TC,,,,,,,2757,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1350.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Upper Extremity W/Dye,PX7320101,CDM,350,RC,73201,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1350.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2701.86
CT Upper Extremity W/Dye,PX7320101,CDM,350,RC,73201,CPT,TC,,,,,,,2757,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1350.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2701.86
CT Upper Extremity W/Dye,PX7320101,CDM,350,RC,73201,CPT,TC,,,,,,,2757,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1350.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2701.86
CT Upper Extremity W/O Dye,PX7320001,CDM,350,RC,73200,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,614.03,percent of total billed charges,1350.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Upper Extremity W/O Dye,PX7320001,CDM,350,RC,73200,CPT,TC,,,,,,,2757,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1350.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Upper Extremity W/O Dye,PX7320001,CDM,350,RC,73200,CPT,TC,,,,,,,2757,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1350.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
Diagnostic CT Thorax W/O Contrast,PX7125001,CDM,350,RC,71250,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,551.4,percent of total billed charges,1350.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
Diagnostic CT Thorax W/O Contrast,PX7125001,CDM,350,RC,71250,CPT,TC,,,,,,,2757,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1350.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
Diagnostic CT Thorax W/O Contrast,PX7125001,CDM,350,RC,71250,CPT,TC,,,,,,,2757,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1350.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
Amputation Finger/Thumb,PX26951F,CDM,510,RC,26951,CPT,,,,,,,,3253,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1351.2962,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1351.2962,3187.94
"Excis Arm/Elbow Tumor,Subcutan",PX24075F,CDM,510,RC,24075,CPT,,,,,,,,1519,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1351.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,630.9926,1488.62
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034P,CDM,983,RC,12034,CPT,,,,,,,,1533,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1352.106,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1492.0689
Partial Bone Scan,PX7830001,CDM,341,RC,78300,CPT,TC,,,,,,,1391,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1353.8603,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,360.31,1363.18
methylene blue 50 MG/10ML Solution 10 mL Ampule,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,517037405,NDC,10,ML,1382.12,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1354.4776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.29,1354.4776
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,62935022305,NDC,1,EA,2764.34,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,721.12,percent of total billed charges,1354.5266,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,62935022305,NDC,1,EA,2764.34,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1354.5266,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,62935022305,NDC,1,EA,2764.34,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1354.5266,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
darbepoetin alfa 200 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002801,NDC,0.4,ML,3157.92,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1354.74768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
liraglutide 18 MG/3ML solution pen-injector 3 mL Pen,63700001,CDM,250,RC,,,,,,169406013,NDC,3,ML,1382.75,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1355.095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"MRI,Uprext Jnt W/O+W/Cont",PX7322301,CDM,610,RC,73223,CPT,TC,,,,,,,2681,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1356.586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2627.38
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021083082,NDC,100,ML,1596,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1356.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
POWERPORT ISP MRI IMPLANTABLE PORT 8FR,C1788,CDM,278,RC,C1788,HCPCS,,11998-MAIN,LOCAL,,,,,1385,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1357.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,575.329,1357.3
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270004,NDC,100,ML,2827.78,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1357.3344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270004,NDC,100,ML,2827.78,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1357.3344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 10 GM/100ML Solution 100 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270005,NDC,100,ML,2827.78,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1357.3344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 10 GM/100ML Solution 100 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270005,NDC,100,ML,2827.78,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1357.3344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270007,NDC,100,ML,2827.78,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1357.3344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270007,NDC,100,ML,2827.78,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1357.3344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270013,NDC,100,ML,2827.78,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1357.3344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270013,NDC,100,ML,2827.78,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1357.3344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
"Biopsy, Nail Unit",PX11755F,CDM,510,RC,11755,CPT,,,,,,,,1490,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1357.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,614.65,1460.2
"Closed Rx Dist Fibula Fx,Manip",PX27788F,CDM,510,RC,27788,CPT,,,,,,,,1597,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1357.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1565.06
PEMEtrexed Disodium 100 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2764001,NDC,1,EA,1539.32,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1357.68024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.01,7924.2996
CT Pelvis W/O Dye,PX7219201,CDM,350,RC,72192,CPT,TC,,,,,,,2744,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1358.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2689.12
"Freeing Bowel Adhesion,Enterolysis",PX44005F,CDM,360,RC,44005,CPT,,,,,,,,2744,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1358.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,677.12,2689.12
Repair Incis Hernia W Mesh,PX49568F,CDM,510,RC,49568,CPT,,,,,,,,1540,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1358.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,639.716,1509.2
bortezomib 3.5 MG Recon Soln 1 Each Vial,J9041.01,CDM,636,RC,J9041,HCPCS,,,,63020004901,NDC,1,EA,3270.12,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1358.407848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.79,3204.7176
"Cystourethroscopy, With Injection(S) for Chemodenervation of the Bladder",PX52287F,CDM,360,RC,52287,CPT,,,,,,,,2745,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1358.775,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1140.273,2690.1
diazePAM 10 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,187065820,NDC,1,EA,1527.87,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1359.8043,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
OBINutuzumab 1000 MG/40ML Solution 40 mL Vial,J9301.01,CDM,636,RC,J9301,HCPCS,,,,50242007001,NDC,4,ML,1397.15,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1359.846095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.12,1369.207
Or Level 1,PX36000001,CDM,360,RC,,,,,,,,,,1600,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1360,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,664.64,1568
Hepatobiliary System Imaging,PX7822601,CDM,341,RC,78226,CPT,TC,,,,,,,2776,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1360.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,360.31,2720.48
Hepatobiliary System Imaging,PX7822601,CDM,341,RC,78226,CPT,TC,,,,,,,2776,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1360.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,360.31,2720.48
Hepatobiliary System Imaging,PX7822601,CDM,341,RC,78226,CPT,TC,,,,,,,2776,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1360.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,360.31,2720.48
Incise Finger Tendon Sheath,PX26055F,CDM,510,RC,26055,CPT,,,,,,,,1398,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,706.1,percent of total billed charges,1360.6734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,580.7292,1404.08
GRAFIXPL PRIME PLACENTAL MEMBRANE 1.5 x2CM 3SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12764-MAIN,LOCAL,,,,,1529,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1360.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573F,CDM,761,RC,36573,CPT,,,,,,,,1529,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1360.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,635.1466,1498.42
Fac/Cystourethroscopy,PX52000F,CDM,761,RC,52000,CPT,,,,,,,,1601,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1360.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,596.77,1568.98
CT Lower Extremity W/Dye,PX7370101,CDM,350,RC,73701,CPT,TC,,,,,,,2690,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1361.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,2636.2
albuterol-ipratropium 20-100 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597002402,NDC,4,GR,1601.75,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1361.4875,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
MRI Lower W/O+W Tc,PX7372001,CDM,610,RC,73720,CPT,TC,,,,,,,3174,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1361.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3110.52
"rabies vaccine, pcec Recon Susp 1 Each Vial",90675,CDM,636,RC,90675,CPT,,,,58160096412,NDC,1,EA,1544.83,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1362.54006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,297.75,1513.9334
Partial Bone Scan,PX7830001,CDM,341,RC,78300,CPT,TC,,,,,,,1391,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1363.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,360.31,1363.18
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781324494,NDC,1,EA,1400.9,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1363.49597,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
"Closed Rx Weight Bear Dist Tib,Manip",PX27825F,CDM,510,RC,27825,CPT,,,,,,,,2695,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1363.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1119.503,2641.1
trastuzumab 150 MG Recon Soln 1 Each Vial,J9355.01,CDM,636,RC,J9355,HCPCS,,,,50242013201,NDC,1,EA,3179.17,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1363.86393,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.77,3115.5866
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034P,CDM,983,RC,12034,CPT,,,,,,,,1533,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1364.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1492.0689
CT Abdomen W/O Dye,PX7415001,CDM,350,RC,74150,CPT,TC,,,,,,,2757,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1364.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Angio Abd&Pelv W/O&W/Dye,PX7417401,CDM,350,RC,74174,CPT,TC,,,,,,,2757,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1364.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2701.86
CT Chest Spine W/O Dye,PX7212801,CDM,350,RC,72128,CPT,TC,,,,,,,2757,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1364.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Head/Brain W/O Dye,PX7045001,CDM,350,RC,70450,CPT,TC,,,,,,,2757,,Humana Choice Care,All Medicare plans,outpatient,49.5,,1062.217857,percent of total billed charges,1364.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Lower Extremity W/O Dye,PX7370001,CDM,350,RC,73700,CPT,TC,,,,,,,2757,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1364.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Lumbar Spine W/O Dye,PX7213101,CDM,350,RC,72131,CPT,TC,,,,,,,2757,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1364.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Maxillofacialw/O Dye,PX7048601,CDM,350,RC,70486,CPT,TC,,,,,,,2757,,Humana Choice Care,All Medicare plans,outpatient,49.5,,2701.86,percent of total billed charges,1364.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Neck Spine W/O Dye,PX7212501,CDM,350,RC,72125,CPT,TC,,,,,,,2757,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1364.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Orbit/Ear/Fosa W/O Dye,PX7048001,CDM,350,RC,70480,CPT,TC,,,,,,,2757,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1364.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Upper Extremity W/Dye,PX7320101,CDM,350,RC,73201,CPT,TC,,,,,,,2757,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1364.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2701.86
CT Upper Extremity W/O Dye,PX7320001,CDM,350,RC,73200,CPT,TC,,,,,,,2757,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1364.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
Diagnostic CT Thorax W/O Contrast,PX7125001,CDM,350,RC,71250,CPT,TC,,,,,,,2757,,Humana Choice Care,All Medicare plans,outpatient,49.5,,482.9,percent of total billed charges,1364.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
carfilzomib 30 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010201,NDC,1,EA,2785.91,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,18.57291429,percent of total billed charges,1365.0959,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.23,5460.3836
carfilzomib 30 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010201,NDC,1,EA,2785.91,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1365.0959,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.23,5460.3836
carfilzomib 30 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010201,NDC,1,EA,2785.91,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1365.0959,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.23,5460.3836
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,16714085701,NDC,1,EA,1403.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1366.02655,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
"Remv F.B.,Eye,Ant Chmbr/Lens",PX65235F,CDM,510,RC,65235,CPT,,,,,,,,2788,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1366.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1158.1352,2732.24
"Remv F.B.,Eye,Ant Chmbr/Lens",PX65235F,CDM,510,RC,65235,CPT,,,,,,,,2788,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1366.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1158.1352,2732.24
"Remv F.B.,Eye,Ant Chmbr/Lens",PX65235F,CDM,510,RC,65235,CPT,,,,,,,,2788,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1366.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1158.1352,2732.24
Level 2 Additional Procedure,PX36000081,CDM,360,RC,,,,,,,,,,1500,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1366.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,623.1,1470
Closed Rx Kneecap Disloc+Anesth,PX27562P,CDM,983,RC,27562,CPT,,,,,,,,1404,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1366.5132,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1366.5132
trastuzumab-dttb 150 MG Recon Soln 1 Each Vial,J9999.55,CDM,636,RC,J9999,HCPCS,,,,78206014701,NDC,1,EA,2702.3,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1367.3638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1122.53542,2648.254
liraglutide 18 MG/3ML solution pen-injector 3 mL Pen,63700001,CDM,250,RC,,,,,,169406012,NDC,3,ML,1405.33,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1367.807689,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,62935022305,NDC,1,EA,2764.34,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1368.3483,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
hepatitis B immune globulin 312 UNIT/ML Solution 5 mL Vial,90371,CDM,636,RC,90371,CPT,,,,59730420301,NDC,5,ML,2851.63,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1368.7824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.6,2794.5974
hepatitis B immune globulin 312 UNIT/ML Solution 5 mL Vial,90371,CDM,636,RC,90371,CPT,,,,59730420301,NDC,5,ML,2851.63,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1368.7824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.6,2794.5974
OBINutuzumab 1000 MG/40ML Solution 40 mL Vial,J9301.01,CDM,636,RC,J9301,HCPCS,,,,50242007001,NDC,4,ML,1397.15,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1369.207,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,47.12,1369.207
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956401,NDC,1,EA,1611.2,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1369.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,409.66,1655.3866
PEMEtrexed Disodium 100 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2764001,NDC,1,EA,1539.32,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1369.9948,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.01,7924.2996
Incise Finger Tendon Sheath,PX26055F,CDM,510,RC,26055,CPT,,,,,,,,1398,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1370.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,580.7292,1404.08
"MRI, Pelvis, W/O Then W/",PX7219701,CDM,610,RC,72197,CPT,TC,,,,,,,1612,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1370.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2066.35
Exc Abdom Tum Subfac > 5 Cm,PX22901F,CDM,761,RC,22901,CPT,,,,,,,,1408,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1370.4064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,584.8832,2482.37
Repair Incis Hernia W Mesh,PX49568F,CDM,510,RC,49568,CPT,,,,,,,,1540,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1370.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,639.716,1509.2
CT Angio Lwr Extr W/O&W/Dye,PX7370601,CDM,350,RC,73706,CPT,TC,,,,,,,1554,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1370.628,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1522.92
"Lap,Cholecystectomy/Explore",PX47564P,CDM,983,RC,47564,CPT,,,,,,,,1613,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1371.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,670.0402,8992.74
MESH SURGICAL NON-ABSORBABLE PLUG 6INW X 6INL,C1781,CDM,272,RC,C1781,HCPCS,,12005-MAIN,LOCAL,,,,,1505,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1371.055,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
MESH SURGICAL NON-ABSORBABLE PLUG 12INW X 12INL,C1781,CDM,278,RC,C1781,HCPCS,,12006-MAIN,LOCAL,,,,,1505,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1371.055,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Colonoscopy,Flex,Diagnostic",PX45378F,CDM,750,RC,45378,CPT,,,,,,,,1286,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,1371.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,551.694,4661.91
"Colonoscopy,Flex,Diagnostic",PX45378P,CDM,983,RC,45378,CPT,,,,,,,,1200,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,1371.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,514.8,4661.91
"Casiri and Imdevimab,Admin,Repeat Dose",PXM0240,CDM,771,RC,M0240,HCPCS,,,,,,,,1555,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1371.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,413.06,1523.9
"IV Infusion, Bamlanivimab and Etesevimab, Infusion and Monitoring",PXM0245,CDM,260,RC,M0245,HCPCS,,,,,,,,1555,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1371.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,413.06,1523.9
"IV Infusion, Casirivimab and Imdevimab, IV and Post Admr",PXM0243,CDM,771,RC,M0243,HCPCS,,,,,,,,1555,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1371.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,413.06,1684.87
CT Orbit/Ear/Fossa W/O & W/Dye,PX7048201,CDM,350,RC,70482,CPT,TC,,,,,,,1400,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1372,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591F,CDM,360,RC,49591,CPT,,,,,,,,1556,,United Healthcare,All Payer,outpatient,88.2,,999999999,case rate,1372.392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1372.392,6141.46
"Lap,Cholecystectomy/Graph",PX47563F,CDM,510,RC,47563,CPT,,,,,,,,1556,,United Healthcare,All Payer,outpatient,88.2,,13122.74,percent of total billed charges,1372.392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,646.3624,5040.74
Level 4 Additional Procedure,PX36000083,CDM,360,RC,,,,,,,,,,3200,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1372.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1329.28,3136
Closed Treat Wrist Dislocation,PX25660P,CDM,983,RC,25660,CPT,,,,,,,,1507,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1372.877,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1466.7631
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781324494,NDC,1,EA,1400.9,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1372.882,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
"Colonoscopy,Control Bleeding",PX45382F,CDM,750,RC,45382,CPT,,,,,,,,1215,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1373.91,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,158.37,1373.91
darbepoetin alfa 40 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002104,NDC,0.4,ML,1411.78,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.7895,percent of total billed charges,1374.085474,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
Hepatobiliary System Imaging,PX7822601,CDM,341,RC,78226,CPT,TC,,,,,,,2776,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1374.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,360.31,2720.48
Irrad/Lr Platelets,PXP9037,CDM,390,RC,P9037,HCPCS,,,,,,,,1617,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1374.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,616.6,1584.66
"rabies vaccine, pcec Recon Susp 1 Each Vial",90675,CDM,636,RC,90675,CPT,,,,58160096412,NDC,1,EA,1544.83,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1374.8987,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,297.75,1513.9334
IMPLANT PACKAGE TOEMATE,27200000,CDM,278,RC,C1713,HCPCS,,11859-MAIN,LOCAL,,,,,2865,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1375.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
IMPLANT PACKAGE TOEMATE,27200000,CDM,278,RC,C1713,HCPCS,,11859-MAIN,LOCAL,,,,,2865,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1375.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
IMPLANT TOEMATE X-SMALL PACKAGE 9H00-T050,C1713,CDM,278,RC,C1713,HCPCS,,11574-MAIN,LOCAL,,,,,2865,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1375.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
IMPLANT TOEMATE X-SMALL PACKAGE 9H00-T050,C1713,CDM,278,RC,C1713,HCPCS,,11574-MAIN,LOCAL,,,,,2865,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1375.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,16714085701,NDC,1,EA,1403.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1375.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
Closed Rx Kneecap Disloc+Anesth,PX27562P,CDM,983,RC,27562,CPT,,,,,,,,1404,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1375.92,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.64,1375.92
liraglutide 18 MG/3ML solution pen-injector 3 mL Pen,63700001,CDM,250,RC,,,,,,169406012,NDC,3,ML,1405.33,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1377.2234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Low Dose CT Lung Ca Screening,PXG029701,CDM,350,RC,G0297,HCPCS,TC,,,,,,,2812,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1377.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1168.1048,2755.76
Low Dose CT Lung Ca Screening,PXG029701,CDM,350,RC,G0297,HCPCS,TC,,,,,,,2812,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1377.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1168.1048,2755.76
Low Dose CT Lung Ca Screening,PXG029701,CDM,350,RC,G0297,HCPCS,TC,,,,,,,2812,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1377.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1168.1048,2755.76
"Upper GI Endoscopy,Diagnosis",PX43235P,CDM,983,RC,43235,CPT,,,,,,,,1406,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1377.88,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,75.04,1377.88
"Lap,Cholecystectomy",PX47562F,CDM,510,RC,47562,CPT,,,,,,,,1473,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1378.07,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,396.16,1378.07
"Lap,Cholecystectomy",PX47562F,CDM,510,RC,47562,CPT,,,,,,,,1473,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1378.07,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,396.16,1378.07
"Lap,Cholecystectomy",PX47562P,CDM,983,RC,47562,CPT,,,,,,,,983,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1378.07,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,396.16,1378.07
"Lap,Cholecystectomy",PX47562P,CDM,983,RC,47562,CPT,,,,,,,,983,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1378.07,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,396.16,1378.07
carfilzomib 30 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010201,NDC,1,EA,2785.91,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1379.02545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.23,5460.3836
"Incis/Drain Shldr Absc/Hema,Deep",PX23030P,CDM,983,RC,23030,CPT,,,,,,,,1564,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1379.448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,649.6856,2482.37
"Cytogen, Interp/Report - Ref",PX8829190,CDM,310,RC,88291,CPT,90,,,,,,,2874,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1379.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.95,2816.52
"Cytogen, Interp/Report - Ref",PX8829190,CDM,310,RC,88291,CPT,90,,,,,,,2874,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1379.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.95,2816.52
Exc Abdom Tum Subfac > 5 Cm,PX22901F,CDM,761,RC,22901,CPT,,,,,,,,1408,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1379.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,584.8832,2482.37
"Remv F.B.,Eye,Ant Chmbr/Lens",PX65235F,CDM,510,RC,65235,CPT,,,,,,,,2788,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1380.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1158.1352,2732.24
Part Remv Phalanx of Toe,PX28124P,CDM,983,RC,28124,CPT,,,,,,,,1515,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1380.165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,629.331,2827.75
onabotulinumtoxinA 50 units Recon Soln 1 Each Vial,J0585.03,CDM,636,RC,J0585,HCPCS,,,,23391950,NDC,1,EA,1418.14,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1380.275662,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.51,1389.7772
cycloPHOSphamide 500 MG Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781323394,NDC,1,EA,1565.71,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1380.95622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390F,CDM,750,RC,45390,CPT,,,,,,,,1419,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1381.1127,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,589.4526,2452.93
Closed Rx Femur Shaft Fx+Manip,PX27502F,CDM,510,RC,27502,CPT,,,,,,,,1625,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1381.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,675.025,1592.5
clobetasol 0.05 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,42291007760,NDC,60,GR,1625.97,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1382.0745,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Removal of Hydrocele,Tunica,Unilat",PX55040P,CDM,983,RC,55040,CPT,,,,,,,,1420,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1382.086,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,589.868,3022.41
carboprost 250 MCG/ML Solution 1 mL Ampule,25000000,CDM,250,RC,,,,,,9085608,NDC,1,ML,1517.13,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1382.10543,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
"Hemorrhoidectomy,Int/Ext,Simple",PX46255F,CDM,510,RC,46255,CPT,,,,,,,,1627,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1382.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,675.8558,2452.93
"Lap,Inguinal Hernia Repr,Recur",PX49651F,CDM,510,RC,49651,CPT,,,,,,,,1568,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1382.976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,651.3472,5040.74
"Closed Rx Shldr Disloc,Anesthesia",PX23655P,CDM,983,RC,23655,CPT,,,,,,,,1421,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1383.0593,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,590.2834,1404.08
Excis Forearm/Wrist Tumor Subcutan,PX25075F,CDM,510,RC,25075,CPT,,,,,,,,1421,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1383.0593,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,590.2834,1416.38
CT Angio Lwr Extr W/O&W/Dye,PX7370601,CDM,350,RC,73706,CPT,TC,,,,,,,1554,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1383.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1522.92
"CT Colonography, Screen",PX7426301,CDM,350,RC,74263,CPT,TC,,,,,,,3330,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1383.282,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1383.282,3263.4
darbepoetin alfa 40 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002104,NDC,0.4,ML,1411.78,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1383.5444,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
"Excis Arm/Elbow Tumor,Subcutan",PX24075F,CDM,510,RC,24075,CPT,,,,,,,,1519,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1383.809,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,630.9926,1488.62
PROSTEP HV SCREW 3.0X16MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12986-MAIN,LOCAL,,,,,1569,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1383.858,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"Casiri and Imdevimab,Admin,Repeat Dose",PXM0240,CDM,771,RC,M0240,HCPCS,,,,,,,,1555,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1383.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,413.06,1523.9
"IV Infusion, Bamlanivimab and Etesevimab, Infusion and Monitoring",PXM0245,CDM,260,RC,M0245,HCPCS,,,,,,,,1555,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1383.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,413.06,1523.9
"IV Infusion, Casirivimab and Imdevimab, IV and Post Admr",PXM0243,CDM,771,RC,M0243,HCPCS,,,,,,,,1555,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1383.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,413.06,1684.87
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604P,CDM,983,RC,11604,CPT,,,,,,,,1422,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1384.0326,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,590.6988,1384.0326
rabies immune globulin 300 UNIT/ML Solution 1 mL Vial,90376,CDM,636,RC,90375,CPT,,,,13533031801,NDC,1,ML,1629.06,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1384.701,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,281.51,1596.4788
"Colonoscopy,Transendoscopic Stent",PX45387F,CDM,750,RC,45387,CPT,,,,,,,,3228,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1384.812,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1340.9112,3163.44
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591F,CDM,360,RC,49591,CPT,,,,,,,,1556,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1384.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,646.3624,3022.41
"Lap,Cholecystectomy/Graph",PX47563F,CDM,510,RC,47563,CPT,,,,,,,,1556,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1384.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,646.3624,5040.74
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270004,NDC,100,ML,2827.78,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,62.691,percent of total billed charges,1385.6122,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270004,NDC,100,ML,2827.78,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1385.6122,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270004,NDC,100,ML,2827.78,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1385.6122,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 10 GM/100ML Solution 100 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270005,NDC,100,ML,2827.78,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,62.691,percent of total billed charges,1385.6122,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 10 GM/100ML Solution 100 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270005,NDC,100,ML,2827.78,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1385.6122,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 10 GM/100ML Solution 100 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270005,NDC,100,ML,2827.78,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1385.6122,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270007,NDC,100,ML,2827.78,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,62.691,percent of total billed charges,1385.6122,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270007,NDC,100,ML,2827.78,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1385.6122,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270007,NDC,100,ML,2827.78,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1385.6122,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270013,NDC,100,ML,2827.78,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,62.691,percent of total billed charges,1385.6122,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270013,NDC,100,ML,2827.78,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1385.6122,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270013,NDC,100,ML,2827.78,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1385.6122,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
CT Pelvis W/O Dye,PX7219201,CDM,350,RC,72192,CPT,TC,,,,,,,2744,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1388.464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2689.12
"Freeing Bowel Adhesion,Enterolysis",PX44005F,CDM,360,RC,44005,CPT,,,,,,,,2744,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1388.464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,677.12,2689.12
"Cystourethroscopy, With Injection(S) for Chemodenervation of the Bladder",PX52287F,CDM,360,RC,52287,CPT,,,,,,,,2745,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1388.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1140.273,2690.1
onabotulinumtoxinA 50 units Recon Soln 1 Each Vial,J0585.03,CDM,636,RC,J0585,HCPCS,,,,23391950,NDC,1,EA,1418.14,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1389.7772,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.51,1389.7772
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING 8 IN CIRCLE,C1781,CDM,278,RC,C1781,HCPCS,,12506-MAIN,LOCAL,,,,,3240,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1389.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390F,CDM,750,RC,45390,CPT,,,,,,,,1419,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1390.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,589.4526,2452.93
"Remv Foreign Body,Knee/Thigh,Deep",PX27372F,CDM,510,RC,27372,CPT,,,,,,,,1429,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1390.8457,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,593.6066,2482.37
"Removal of Hydrocele,Tunica,Unilat",PX55040P,CDM,983,RC,55040,CPT,,,,,,,,1420,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1391.6,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,210.51,1391.6
"Genital Surg Proc,Male Unlisted",PX55899F,CDM,510,RC,55899,CPT,,,,,,,,1430,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1391.819,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,215.91,1401.4
I&D Perirectal Abscess,PX46040F,CDM,510,RC,46040,CPT,,,,,,,,1430,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1391.819,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,594.022,1401.4
diazePAM 10 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,187065820,NDC,1,EA,1527.87,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1391.88957,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Low Dose CT Lung Ca Screening,PXG029701,CDM,350,RC,G0297,HCPCS,TC,,,,,,,2812,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1391.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1168.1048,2755.76
"Incis/Drain Shldr Absc/Hema,Deep",PX23030P,CDM,983,RC,23030,CPT,,,,,,,,1564,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1391.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,649.6856,2482.37
"Closed Rx Shldr Disloc,Anesthesia",PX23655P,CDM,983,RC,23655,CPT,,,,,,,,1421,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1392.58,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,260.25,1392.58
Excis Forearm/Wrist Tumor Subcutan,PX25075F,CDM,510,RC,25075,CPT,,,,,,,,1421,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1392.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,590.2834,1416.38
Anus Surgery Procedure Unlisted,PX46999F,CDM,510,RC,46999,CPT,,,,,,,,1431,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1392.7923,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,594.4374,1402.38
DOCEtaxel 160 MG/16ML Solution 16 mL Vial,J9171.01,CDM,636,RC,J9171,HCPCS,,,,409173201,NDC,16,ML,2901.69,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1392.8112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1205.362026,2843.6562
DOCEtaxel 160 MG/16ML Solution 16 mL Vial,J9171.01,CDM,636,RC,J9171,HCPCS,,,,409173201,NDC,16,ML,2901.69,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1392.8112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1205.362026,2843.6562
GRAFIXPL PRIME PLACENTAL MEMBRANE 1.5 x2CM 3SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12764-MAIN,LOCAL,,,,,1529,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1392.919,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573F,CDM,761,RC,36573,CPT,,,,,,,,1529,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1392.919,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,635.1466,1498.42
cycloPHOSphamide 500 MG Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781323394,NDC,1,EA,1565.71,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1393.4819,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604P,CDM,983,RC,11604,CPT,,,,,,,,1422,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1393.56,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.63,1393.56
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606F,CDM,510,RC,11606,CPT,,,,,,,,1432,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1393.7656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,594.8528,1416.38
Exc Abdom Tum Subfac > 5 Cm,PX22901F,CDM,761,RC,22901,CPT,,,,,,,,1408,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1393.98,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,403.8,1393.98
Exc Abdom Tum Subfac > 5 Cm,PX22901F,CDM,761,RC,22901,CPT,,,,,,,,1408,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1393.98,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,403.8,1393.98
Exc Abdom Tum Subfac > 5 Cm,PX22901P,CDM,983,RC,22901,CPT,,,,,,,,938,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1393.98,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,403.8,1393.98
Exc Abdom Tum Subfac > 5 Cm,PX22901P,CDM,983,RC,22901,CPT,,,,,,,,938,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1393.98,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,403.8,1393.98
CT Abdomen W/O Dye,PX7415001,CDM,350,RC,74150,CPT,TC,,,,,,,2757,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1395.042,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Angio Abd&Pelv W/O&W/Dye,PX7417401,CDM,350,RC,74174,CPT,TC,,,,,,,2757,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1395.042,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2701.86
CT Chest Spine W/O Dye,PX7212801,CDM,350,RC,72128,CPT,TC,,,,,,,2757,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1395.042,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Head/Brain W/O Dye,PX7045001,CDM,350,RC,70450,CPT,TC,,,,,,,2757,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1395.042,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Lower Extremity W/O Dye,PX7370001,CDM,350,RC,73700,CPT,TC,,,,,,,2757,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1395.042,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Lumbar Spine W/O Dye,PX7213101,CDM,350,RC,72131,CPT,TC,,,,,,,2757,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1395.042,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Maxillofacialw/O Dye,PX7048601,CDM,350,RC,70486,CPT,TC,,,,,,,2757,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1395.042,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Neck Spine W/O Dye,PX7212501,CDM,350,RC,72125,CPT,TC,,,,,,,2757,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1395.042,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Orbit/Ear/Fosa W/O Dye,PX7048001,CDM,350,RC,70480,CPT,TC,,,,,,,2757,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1395.042,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Upper Extremity W/Dye,PX7320101,CDM,350,RC,73201,CPT,TC,,,,,,,2757,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1395.042,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2701.86
CT Upper Extremity W/O Dye,PX7320001,CDM,350,RC,73200,CPT,TC,,,,,,,2757,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1395.042,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
Diagnostic CT Thorax W/O Contrast,PX7125001,CDM,350,RC,71250,CPT,TC,,,,,,,2757,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1395.042,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
"Lap,Inguinal Hernia Repr,Recur",PX49651F,CDM,510,RC,49651,CPT,,,,,,,,1568,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1395.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,651.3472,5040.74
Amputation Finger/Thumb,PX26951F,CDM,510,RC,26951,CPT,,,,,,,,3253,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1395.537,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1351.2962,3187.94
MRI Upper W/O+W Tc,PX7322001,CDM,610,RC,73220,CPT,TC,,,,,,,3253,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1395.537,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3187.94
"MRI,Lwrext,No Jnt,No Cont",PX7371801,CDM,610,RC,73718,CPT,TC,,,,,,,3253,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1395.537,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3187.94
"MRI,Pelvis W/Out Contrast",PX7219501,CDM,610,RC,72195,CPT,TC,,,,,,,3253,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1395.537,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3187.94
"MRI,Up Ext,No Jnt,No Cont",PX7321801,CDM,610,RC,73218,CPT,TC,,,,,,,3253,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1395.537,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3187.94
Revise Ulnar Nerve at Elbow,PX64718P,CDM,983,RC,64718,CPT,,,,,,,,1642,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1395.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,682.0868,1686.76
"Repair of Recurrent Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49615F,CDM,360,RC,49615,CPT,,,,,,,,2908,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1395.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1207.9832,3022.41
"Repair of Recurrent Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49615F,CDM,360,RC,49615,CPT,,,,,,,,2908,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1395.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1207.9832,3022.41
PROSTEP HV SCREW 3.0X16MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12986-MAIN,LOCAL,,,,,1569,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1396.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034P,CDM,983,RC,12034,CPT,,,,,,,,1533,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1396.563,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1492.0689
Removal of Anal Tabs,PX46230P,CDM,983,RC,46230,CPT,,,,,,,,1435,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1396.6855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,596.099,2452.93
hepatitis B immune globulin 312 UNIT/ML Solution 5 mL Vial,90371,CDM,636,RC,90371,CPT,,,,59730420301,NDC,5,ML,2851.63,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1397.2987,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.6,2794.5974
hepatitis B immune globulin 312 UNIT/ML Solution 5 mL Vial,90371,CDM,636,RC,90371,CPT,,,,59730420301,NDC,5,ML,2851.63,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1397.2987,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.6,2794.5974
hepatitis B immune globulin 312 UNIT/ML Solution 5 mL Vial,90371,CDM,636,RC,90371,CPT,,,,59730420301,NDC,5,ML,2851.63,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1397.2987,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.6,2794.5974
FIXATION COMPONENT TOE JOINT PROXIMAL PHALANGEAL DF-P,C1713,CDM,278,RC,C1713,HCPCS,,12529-MAIN,LOCAL,,,,,1644,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1397.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Emergency Level V Visit,PX99285P,CDM,981,RC,99285,CPT,,,,,,,,1436,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,364.9595,percent of total billed charges,1397.6588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,561.13,1397.6588
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,60505611000,NDC,5,ML,1644.33,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1397.6805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270006,NDC,100,ML,2912.78,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1398.1344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270006,NDC,100,ML,2912.78,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1398.1344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,62935022305,NDC,1,EA,2764.34,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1398.75604,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573F,CDM,761,RC,36573,CPT,,,,,,,,1529,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1399.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,635.1466,1498.42
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573P,CDM,983,RC,36573,CPT,,,,,,,,1721,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1399.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,714.9034,1675.0493
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569F,CDM,510,RC,36569,CPT,,,,,,,,1217,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1399.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,505.5418,1399.13
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569P,CDM,983,RC,36569,CPT,,,,,,,,1825,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1399.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,758.105,1776.2725
"Removal of Tunnel Cv Access Device, With Port/Pump",PX36590P,CDM,983,RC,36590,CPT,,,,,,,,1147,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1399.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,476.4638,1399.13
Tube Thoracostomy Inc Wtr Seal,PX32551F,CDM,510,RC,32551,CPT,,,,,,,,989,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1399.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,410.8306,1399.13
Tube Thoracostomy Inc Wtr Seal,PX32551P,CDM,983,RC,32551,CPT,,,,,,,,1236,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1399.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,513.4344,1399.13
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270004,NDC,100,ML,2827.78,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1399.7511,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 10 GM/100ML Solution 100 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270005,NDC,100,ML,2827.78,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1399.7511,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270007,NDC,100,ML,2827.78,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1399.7511,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270013,NDC,100,ML,2827.78,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1399.7511,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
"Remv Foreign Body,Knee/Thigh,Deep",PX27372F,CDM,510,RC,27372,CPT,,,,,,,,1429,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1400.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,593.6066,2482.37
"Genital Surg Proc,Male Unlisted",PX55899F,CDM,510,RC,55899,CPT,,,,,,,,1430,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1401.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,215.91,1401.4
I&D Perirectal Abscess,PX46040F,CDM,510,RC,46040,CPT,,,,,,,,1430,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1401.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,594.022,1401.4
MRI T Spine WO Contrast,PX7214601,CDM,610,RC,72146,CPT,TC,,,,,,,3267,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1401.543,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3201.66
PEMEtrexed Disodium 100 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2764001,NDC,1,EA,1539.32,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1402.32052,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.01,7924.2996
Anus Surgery Procedure Unlisted,PX46999F,CDM,510,RC,46999,CPT,,,,,,,,1431,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1402.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,594.4374,1402.38
bortezomib 3.5 MG Recon Soln 1 Each Vial,J9041.01,CDM,636,RC,J9041,HCPCS,,,,63020004901,NDC,1,EA,3270.12,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1402.88148,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.79,3204.7176
Repair Incis Hernia W Mesh,PX49568F,CDM,510,RC,49568,CPT,,,,,,,,1540,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1402.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,639.716,1509.2
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606F,CDM,510,RC,11606,CPT,,,,,,,,1432,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1403.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,594.8528,1416.38
IMPLANT PACKAGE TOEMATE,27200000,CDM,278,RC,C1713,HCPCS,,11859-MAIN,LOCAL,,,,,2865,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,1403.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
IMPLANT PACKAGE TOEMATE,27200000,CDM,278,RC,C1713,HCPCS,,11859-MAIN,LOCAL,,,,,2865,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1403.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
IMPLANT PACKAGE TOEMATE,27200000,CDM,278,RC,C1713,HCPCS,,11859-MAIN,LOCAL,,,,,2865,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1403.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
IMPLANT TOEMATE X-SMALL PACKAGE 9H00-T050,C1713,CDM,278,RC,C1713,HCPCS,,11574-MAIN,LOCAL,,,,,2865,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,1403.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
IMPLANT TOEMATE X-SMALL PACKAGE 9H00-T050,C1713,CDM,278,RC,C1713,HCPCS,,11574-MAIN,LOCAL,,,,,2865,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1403.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
IMPLANT TOEMATE X-SMALL PACKAGE 9H00-T050,C1713,CDM,278,RC,C1713,HCPCS,,11574-MAIN,LOCAL,,,,,2865,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1403.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Biopsy Synovium I-P Jt,PX26110,CDM,983,RC,26110,CPT,,,,,,,,933,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1404.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,387.5682,1404.08
"Close Rx Fingr Articular Fx,Manip",PX26742F,CDM,510,RC,26742,CPT,,,,,,,,1039,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1404.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,431.6006,1404.08
"Close Rx Fingr Articular Fx,Manip",PX26742P,CDM,983,RC,26742,CPT,,,,,,,,560,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1404.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,232.624,1404.08
"Closed Rx Bimalleolar Fx,Manip",PX27810F,CDM,510,RC,27810,CPT,,,,,,,,1026,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1404.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,426.2004,1404.08
"Closed Rx Bimalleolar Fx,Manip",PX27810P,CDM,983,RC,27810,CPT,,,,,,,,1057,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1404.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,439.0778,1404.08
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605F,CDM,510,RC,25605,CPT,,,,,,,,1178,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1404.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,489.3412,1404.08
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605P,CDM,983,RC,25605,CPT,,,,,,,,785,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1404.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,326.089,1404.08
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605F,CDM,510,RC,24605,CPT,,,,,,,,1124,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1404.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.9096,1404.08
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605P,CDM,983,RC,24605,CPT,,,,,,,,750,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1404.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,311.55,1404.08
Closed Rx Femur Shaft Fx+Manip,PX27502F,CDM,510,RC,27502,CPT,,,,,,,,1625,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1404.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,675.025,1592.5
Closed Rx Femur Shaft Fx+Manip,PX27502P,CDM,983,RC,27502,CPT,,,,,,,,1083,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1404.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,449.8782,1404.08
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535F,CDM,510,RC,24535,CPT,,,,,,,,2514,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1404.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1044.3156,2463.72
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535P,CDM,983,RC,24535,CPT,,,,,,,,2887,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1404.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1199.2598,2809.9171
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505F,CDM,510,RC,24505,CPT,,,,,,,,2109,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1404.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,876.0786,2066.82
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505P,CDM,983,RC,24505,CPT,,,,,,,,2353,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1404.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,977.4362,2290.1749
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266F,CDM,510,RC,27266,CPT,,,,,,,,1684,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1404.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,699.5336,1650.32
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266P,CDM,983,RC,27266,CPT,,,,,,,,2275,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1404.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,945.035,2214.2575
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565F,CDM,510,RC,25565,CPT,,,,,,,,1250,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1404.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,519.25,1404.08
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565P,CDM,983,RC,25565,CPT,,,,,,,,830,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1404.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,344.782,1404.08
"Closed Rx Radial Head/Neck Fx,Manip",PX24655F,CDM,510,RC,24655,CPT,,,,,,,,1750,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1404.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,726.95,1715
"Closed Rx Radial Head/Neck Fx,Manip",PX24655P,CDM,983,RC,24655,CPT,,,,,,,,1824,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1404.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,757.6896,1775.2992
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505F,CDM,510,RC,25505,CPT,,,,,,,,651,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1404.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.4254,1404.08
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505P,CDM,983,RC,25505,CPT,,,,,,,,977,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1404.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,405.8458,1404.08
"Closed Rx Shldr Disloc,Anesthesia",PX23655F,CDM,510,RC,23655,CPT,,,,,,,,1776,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1404.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,737.7504,1740.48
"Closed Rx Shldr Disloc,Anesthesia",PX23655P,CDM,983,RC,23655,CPT,,,,,,,,1421,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1404.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,590.2834,1404.08
"Closed Rx Spont Hip Disloc,Anesth",PX27257F,CDM,510,RC,27257,CPT,,,,,,,,548,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1404.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,227.6392,1404.08
"Closed Rx Spont Hip Disloc,Anesth",PX27257P,CDM,983,RC,27257,CPT,,,,,,,,365,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1404.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,151.621,1404.08
"Closed Rx Talus Fx,Manipulatn",PX28435F,CDM,510,RC,28435,CPT,,,,,,,,1705,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1404.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,708.257,1670.9
"Closed Rx Talus Fx,Manipulatn",PX28435P,CDM,983,RC,28435,CPT,,,,,,,,1137,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1404.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,472.3098,1404.08
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752F,CDM,510,RC,27752,CPT,,,,,,,,2280,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1404.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,947.112,2234.4
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752P,CDM,983,RC,27752,CPT,,,,,,,,2495,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1404.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1036.423,2428.3835
"Closed Rx Trimalleolar Fx,Manip",PX27818F,CDM,510,RC,27818,CPT,,,,,,,,813,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1404.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,337.7202,1404.08
"Closed Rx Trimalleolar Fx,Manip",PX27818P,CDM,983,RC,27818,CPT,,,,,,,,1352,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1404.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,561.6208,1404.08
"Closed Rx Weight Bear Dist Tib,Manip",PX27825F,CDM,510,RC,27825,CPT,,,,,,,,2695,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1404.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1119.503,2641.1
"Closed Rx Weight Bear Dist Tib,Manip",PX27825P,CDM,983,RC,27825,CPT,,,,,,,,1796,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1404.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,746.0584,1748.0468
Excis Primary Ganglion Wrist,PX25111F,CDM,510,RC,25111,CPT,,,,,,,,791,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1404.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,328.5814,1404.08
Excis Primary Ganglion Wrist,PX25111P,CDM,983,RC,25111,CPT,,,,,,,,529,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1404.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,219.7466,1404.08
"Excis Tendn/Capsule Lesn,Toes",PX28092F,CDM,510,RC,28092,CPT,,,,,,,,1234,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1404.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,512.6036,1404.08
"Excis Tendn/Capsule Lesn,Toes",PX28092P,CDM,983,RC,28092,CPT,,,,,,,,1913,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1404.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,794.6602,1861.9229
"Fix Exten Tendon,Dorsum Fingr,Ea",PX26418F,CDM,510,RC,26418,CPT,,,,,,,,1750,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1404.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,726.95,1715
Incise Finger Tendon Sheath,PX26055F,CDM,510,RC,26055,CPT,,,,,,,,1398,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1404.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,580.7292,1404.08
Incise Finger Tendon Sheath,PX26055P,CDM,983,RC,26055,CPT,,,,,,,,932,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1404.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,387.1528,1404.08
Hepatobiliary System Imaging,PX7822601,CDM,341,RC,78226,CPT,TC,,,,,,,2776,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1404.656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,360.31,2720.48
rabies immune globulin 300 UNIT/2ML Solution 2 mL Vial,90377,CDM,636,RC,90376,CPT,,,,49281019020,NDC,2,ML,3384.84,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1406.062536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,207.94,3317.1432
Removal of Anal Tabs,PX46230P,CDM,983,RC,46230,CPT,,,,,,,,1435,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1406.3,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.32,1406.3
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384P,CDM,983,RC,45384,CPT,,,,,,,,1436,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1407.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,138.09,1407.28
Emergency Level V Visit,PX99285P,CDM,981,RC,99285,CPT,,,,,,,,1436,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1407.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.81,1407.28
"rabies vaccine, pcec Recon Susp 1 Each Vial",90675,CDM,636,RC,90675,CPT,,,,58160096412,NDC,1,EA,1544.83,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1407.34013,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,297.75,1513.9334
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021083082,NDC,100,ML,1596,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1407.672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
"Cytogen, Interp/Report - Ref",PX8829190,CDM,310,RC,88291,CPT,90,,,,,,,2874,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1408.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.95,2816.52
"Cytogen, Interp/Report - Ref",PX8829190,CDM,310,RC,88291,CPT,90,,,,,,,2874,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1408.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.95,2816.52
"Cytogen, Interp/Report - Ref",PX8829190,CDM,310,RC,88291,CPT,90,,,,,,,2874,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1408.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.95,2816.52
"Closed Rx Dist Fibula Fx,Manip",PX27788F,CDM,510,RC,27788,CPT,,,,,,,,1597,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1408.554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1565.06
CT Angio Abdominal Arteries,PX7563501,CDM,350,RC,75635,CPT,TC,,,,,,,2936,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1409.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,2877.28
CT Angio Abdominal Arteries,PX7563501,CDM,350,RC,75635,CPT,TC,,,,,,,2936,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1409.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,2877.28
Targeted Genomic Sequence Analysis Panel 5-50 Genes - Ref,PX8145090,CDM,300,RC,81450,CPT,90,,,,,,,2936,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1409.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,696.41,2877.28
Targeted Genomic Sequence Analysis Panel 5-50 Genes - Ref,PX8145090,CDM,300,RC,81450,CPT,90,,,,,,,2936,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1409.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,696.41,2877.28
carfilzomib 30 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010201,NDC,1,EA,2785.91,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1409.67046,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.23,5460.3836
"Remv F.B.,Eye,Ant Chmbr/Lens",PX65235F,CDM,510,RC,65235,CPT,,,,,,,,2788,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1410.728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1158.1352,2732.24
Or Level 1,PX36000001,CDM,360,RC,,,,,,,,,,1600,,United Healthcare,All Payer,outpatient,88.2,,999999999,case rate,1411.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1411.2,6141.46
hepatitis B immune globulin 312 UNIT/ML Solution 5 mL Vial,90371,CDM,636,RC,90371,CPT,,,,59730420301,NDC,5,ML,2851.63,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1411.55685,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.6,2794.5974
Fac/Cystourethroscopy,PX52000F,CDM,761,RC,52000,CPT,,,,,,,,1601,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1412.082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,596.77,1568.98
albuterol-ipratropium 20-100 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597002402,NDC,4,GR,1601.75,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1412.7435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270012,NDC,100,ML,3293.58,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1412.94582,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
KIT GASTRIC LAVAGE 2075,120.257,CDM,272,RC,C7510,HCPCS,,410-MAIN,LOCAL,,,,,44,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1413.36,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1413.36,1566.45
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032605,NDC,0.8,ML,1663.54,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1414.009,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,1630.2692
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535P,CDM,983,RC,24535,CPT,,,,,,,,2887,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1414.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1199.2598,2809.9171
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535P,CDM,983,RC,24535,CPT,,,,,,,,2887,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1414.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1199.2598,2809.9171
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535P,CDM,983,RC,24535,CPT,,,,,,,,2887,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1414.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1199.2598,2809.9171
CT Angio Lwr Extr W/O&W/Dye,PX7370601,CDM,350,RC,73706,CPT,TC,,,,,,,1554,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1415.694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1522.92
clobetasol 0.05 % Cream 60 g Tube,63700001,CDM,250,RC,,,,,,69238153206,NDC,60,GR,1665.95,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1416.0575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Bone Marrow Aspiration(S),Diag",PX38220F,CDM,510,RC,38220,CPT,,,,,,,,305,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1416.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,126.697,1416.38
"Bone Marrow Aspiration(S),Diag",PX38220P,CDM,983,RC,38220,CPT,,,,,,,,244,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1416.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,101.3576,1416.38
Bone Marrow Biopsy(Ies),PX38221F,CDM,510,RC,38221,CPT,,,,,,,,1221,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1416.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,507.2034,1416.38
Debride Tissue/Muscle/Bone,PX11044F,CDM,510,RC,11044,CPT,,,,,,,,1082,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1416.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,449.4628,1416.38
Debride Tissue/Muscle/Bone,PX11044P,CDM,983,RC,11044,CPT,,,,,,,,866,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1416.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,359.7364,1416.38
Drainage of Hematoma/Fluid (P),PX10140P,CDM,983,RC,10140,CPT,,,,,,,,465,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1416.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,193.161,1416.38
Drainage of Hematoma/Fluid (T),PX10140F,CDM,510,RC,10140,CPT,,,,,,,,341,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1416.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,141.6514,1416.38
Drainage Scrotal Wall Abscess,PX55100F,CDM,510,RC,55100,CPT,,,,,,,,634,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1416.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,263.3636,1416.38
Drainage Scrotal Wall Abscess,PX55100P,CDM,983,RC,55100,CPT,,,,,,,,341,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1416.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,141.6514,1416.38
Exc Abd Les Sc < 3 Cm,PX22902F,CDM,761,RC,22902,CPT,,,,,,,,3128,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1416.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1299.3712,3065.44
Exc Abd Les Sc < 3 Cm,PX22902P,CDM,983,RC,22902,CPT,,,,,,,,2086,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1416.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,866.5244,2030.3038
Exc Back Les Sc = 3 Cm,PX21931P,CDM,983,RC,21931,CPT,,,,,,,,2135,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1416.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,886.879,2077.9955
Exc Face Les Sc < 2 Cm,PX21011F,CDM,510,RC,21011,CPT,,,,,,,,943,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1416.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,391.7222,1416.38
Exc Face Les Sc < 2 Cm,PX21011P,CDM,983,RC,21011,CPT,,,,,,,,628,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1416.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,260.8712,1416.38
Exc Skin Benig <5mm Remaindr Body,PX11420P,CDM,983,RC,11420,CPT,,,,,,,,299,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1416.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,124.2046,1416.38
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423F,CDM,510,RC,11423,CPT,,,,,,,,711,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1416.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,295.3494,1416.38
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423P,CDM,983,RC,11423,CPT,,,,,,,,569,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1416.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,236.3626,1416.38
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606F,CDM,510,RC,11606,CPT,,,,,,,,1432,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1416.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,594.8528,1416.38
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606P,CDM,983,RC,11606,CPT,,,,,,,,2044,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1416.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,849.0776,1989.4252
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623F,CDM,510,RC,11623,CPT,,,,,,,,690,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1416.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,286.626,1416.38
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623P,CDM,983,RC,11623,CPT,,,,,,,,460,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1416.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,191.084,1416.38
Exc Skn Bngn1.1-2cm Remain Bdy,PX11422P,CDM,983,RC,11422,CPT,,,,,,,,822,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1416.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,341.4588,1416.38
"Exc Skn Bngn2.1-3cm Fce,Facial",PX11443P,CDM,983,RC,11443,CPT,,,,,,,,650,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1416.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.01,1416.38
Exc Skn Bngn3.1-4cm Remain Bdy,PX11424P,CDM,983,RC,11424,CPT,,,,,,,,562,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1416.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,233.4548,1416.38
"Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404P,CDM,983,RC,11404,CPT,,,,,,,,600,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1416.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,249.24,1416.38
"Exc Skn Bnig >4cmtrnk,Arm,Leg",PX11406P,CDM,983,RC,11406,CPT,,,,,,,,1456,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1416.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,604.8224,1417.1248
"Excis Arm/Elbow Tumor,Subcutan",PX24075F,CDM,510,RC,24075,CPT,,,,,,,,1519,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1416.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,630.9926,1488.62
"Excis Arm/Elbow Tumor,Subcutan",PX24075P,CDM,983,RC,24075,CPT,,,,,,,,2458,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1416.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1021.0532,2392.3714
Excis Forearm/Wrist Tumor Subcutan,PX25075F,CDM,510,RC,25075,CPT,,,,,,,,1421,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1416.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,590.2834,1416.38
Excis Forearm/Wrist Tumor Subcutan,PX25075P,CDM,983,RC,25075,CPT,,,,,,,,607,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1416.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,252.1478,1416.38
"Excise Lesion,Back or Flank",PX21930F,CDM,510,RC,21930,CPT,,,,,,,,1326,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1416.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,550.8204,1416.38
"Excise Lesion,Back or Flank",PX21930P,CDM,983,RC,21930,CPT,,,,,,,,884,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1416.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,367.2136,1416.38
Fac/Exc Skin Benig<5mm Remaind Bod,PX11420F,CDM,510,RC,11420,CPT,,,,,,,,374,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1416.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.3596,1416.38
"Fac/Exc Skn Benig >4cm Trnk,Arm,Lg",PX11406F,CDM,510,RC,11406,CPT,,,,,,,,1127,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1416.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,468.1558,1416.38
"Fac/Exc Skn Bngn 2.1-3cmfce,Facial",PX11443F,CDM,510,RC,11443,CPT,,,,,,,,813,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1416.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,337.7202,1416.38
Fac/Exc Skn Bngn1.1-2cm Remain Bdy,PX11422F,CDM,510,RC,11422,CPT,,,,,,,,618,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1416.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,256.7172,1416.38
Fac/Exc Skn Bngn3.1-4cm Remain Bdy,PX11424F,CDM,510,RC,11424,CPT,,,,,,,,931,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1416.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.7374,1416.38
"Fac/Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404F,CDM,510,RC,11404,CPT,,,,,,,,749,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1416.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,311.1346,1416.38
"Needle Biopsy, Lymph Node(S)",PX38505F,CDM,510,RC,38505,CPT,,,,,,,,667,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1416.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,277.0718,1416.38
"Needle Biopsy,Muscle",PX20206F,CDM,510,RC,20206,CPT,,,,,,,,258,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1416.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,107.1732,1416.38
"Needle Biopsy,Muscle",PX20206P,CDM,983,RC,20206,CPT,,,,,,,,1028,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1416.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,427.0312,1416.38
"Percut Biopsy, Abdominal Mass",PX49180F,CDM,510,RC,49180,CPT,,,,,,,,2084,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1416.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,865.6936,2042.32
Remove Foreign Body Complic,PX10121F,CDM,510,RC,10121,CPT,,,,,,,,3575,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1416.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1416.38,3503.5
Remove Foreign Body Complic,PX10121P,CDM,983,RC,10121,CPT,,,,,,,,651,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1416.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,270.4254,1416.38
Temporal Artery Ligatn or Bx,PX37609F,CDM,510,RC,37609,CPT,,,,,,,,705,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1416.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,292.857,1416.38
Temporal Artery Ligatn or Bx,PX37609P,CDM,983,RC,37609,CPT,,,,,,,,965,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1416.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,400.861,1416.38
"Casiri and Imdevimab,Admin,Repeat Dose",PXM0240,CDM,771,RC,M0240,HCPCS,,,,,,,,1555,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1416.605,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,413.06,1523.9
"IV Infusion, Bamlanivimab and Etesevimab, Infusion and Monitoring",PXM0245,CDM,260,RC,M0245,HCPCS,,,,,,,,1555,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1416.605,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,413.06,1523.9
"IV Infusion, Casirivimab and Imdevimab, IV and Post Admr",PXM0243,CDM,771,RC,M0243,HCPCS,,,,,,,,1555,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1416.605,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,413.06,1684.87
"Exc Skn Bnig >4cmtrnk,Arm,Leg",PX11406P,CDM,983,RC,11406,CPT,,,,,,,,1456,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1417.1248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,604.8224,1417.1248
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591F,CDM,360,RC,49591,CPT,,,,,,,,1556,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1417.516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,646.3624,3022.41
"Lap,Cholecystectomy/Graph",PX47563F,CDM,510,RC,47563,CPT,,,,,,,,1556,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1417.516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,646.3624,5040.74
IMPLANT PACKAGE TOEMATE,27200000,CDM,278,RC,C1713,HCPCS,,11859-MAIN,LOCAL,,,,,2865,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1418.175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
IMPLANT TOEMATE X-SMALL PACKAGE 9H00-T050,C1713,CDM,278,RC,C1713,HCPCS,,11574-MAIN,LOCAL,,,,,2865,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1418.175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
fluticasone-salmeterol 500-50 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069704,NDC,14,EA,1670.75,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1420.1375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021083082,NDC,100,ML,1596,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1420.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956401,NDC,1,EA,1611.2,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1421.0784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,409.66,1655.3866
"Closed Rx Dist Fibula Fx,Manip",PX27788F,CDM,510,RC,27788,CPT,,,,,,,,1597,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1421.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1565.06
"MRI, Pelvis, W/O Then W/",PX7219701,CDM,610,RC,72197,CPT,TC,,,,,,,1612,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1421.784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2066.35
DOCEtaxel 160 MG/16ML Solution 16 mL Vial,J9171.01,CDM,636,RC,J9171,HCPCS,,,,409173201,NDC,16,ML,2901.69,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1421.8281,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1205.362026,2843.6562
DOCEtaxel 160 MG/16ML Solution 16 mL Vial,J9171.01,CDM,636,RC,J9171,HCPCS,,,,409173201,NDC,16,ML,2901.69,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1421.8281,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1205.362026,2843.6562
DOCEtaxel 160 MG/16ML Solution 16 mL Vial,J9171.01,CDM,636,RC,J9171,HCPCS,,,,409173201,NDC,16,ML,2901.69,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1421.8281,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1205.362026,2843.6562
"Cytogen, Interp/Report - Ref",PX8829190,CDM,310,RC,88291,CPT,90,,,,,,,2874,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1422.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.95,2816.52
"Lap,Cholecystectomy/Explore",PX47564P,CDM,983,RC,47564,CPT,,,,,,,,1613,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1422.666,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,670.0402,8992.74
Low Dose CT Lung Ca Screening,PXG029701,CDM,350,RC,G0297,HCPCS,TC,,,,,,,2812,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1422.872,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1168.1048,2755.76
Hepatobil Syst Image W/Drug,PX7822701,CDM,341,RC,78227,CPT,TC,,,,,,,1674,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1422.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,472.19,1640.52
MRI Up Extremity Joint W/O Tc,PX7322101,CDM,610,RC,73221,CPT,TC,,,,,,,3319,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1423.851,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3252.62
"I&D Perianal Abscess,Superficial",PX46050F,CDM,510,RC,46050,CPT,,,,,,,,1463,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1268.66,percent of total billed charges,1423.9379,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,607.7302,1433.74
Or Level 1,PX36000001,CDM,360,RC,,,,,,,,,,1600,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,664.64,1568
"Incis/Drain Shldr Absc/Hema,Deep",PX23030P,CDM,983,RC,23030,CPT,,,,,,,,1564,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1424.804,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,649.6856,2482.37
Fac/Cystourethroscopy,PX52000F,CDM,761,RC,52000,CPT,,,,,,,,1601,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1424.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,596.77,1568.98
Facility Emergency Level V Visit,PX99285F,CDM,450,RC,99285,CPT,,,,,,,,1464,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,364.9595,percent of total billed charges,1424.9112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,561.13,1434.72
"Repair of Recurrent Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49615F,CDM,360,RC,49615,CPT,,,,,,,,2908,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1424.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1207.9832,3022.41
"Repair of Recurrent Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49615F,CDM,360,RC,49615,CPT,,,,,,,,2908,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1424.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1207.9832,3022.41
"Repair of Recurrent Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49615F,CDM,360,RC,49615,CPT,,,,,,,,2908,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1424.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1207.9832,3022.41
albuterol-ipratropium 20-100 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597002402,NDC,4,GR,1601.75,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1425.5575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Irrad/Lr Platelets,PXP9037,CDM,390,RC,P9037,HCPCS,,,,,,,,1617,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1426.194,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,616.6,1584.66
cycloPHOSphamide 500 MG Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781323394,NDC,1,EA,1565.71,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1426.36181,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
"Exc Skn Bnig >4cmtrnk,Arm,Leg",PX11406P,CDM,983,RC,11406,CPT,,,,,,,,1456,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1426.88,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,153.14,1426.88
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270006,NDC,100,ML,2912.78,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,62.691,percent of total billed charges,1427.2622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270006,NDC,100,ML,2912.78,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1427.2622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270006,NDC,100,ML,2912.78,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1427.2622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
"Lap,Inguinal Hernia Repr,Recur",PX49651F,CDM,510,RC,49651,CPT,,,,,,,,1568,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1428.448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,651.3472,5040.74
"CT Colonography, Screen",PX7426301,CDM,350,RC,74263,CPT,TC,,,,,,,3330,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1428.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1383.282,3263.4
CT Lumbar Spine W/Dye,PX7213201,CDM,350,RC,72132,CPT,TC,,,,,,,3330,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1428.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3263.4
CT Pelvis W/Dye,PX7219301,CDM,350,RC,72193,CPT,TC,,,,,,,3330,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1428.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3263.4
CT Angiograph Pelv W/O&W/Dye,PX7219101,CDM,350,RC,72191,CPT,TC,,,,,,,1458,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1428.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535P,CDM,983,RC,24535,CPT,,,,,,,,2887,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1429.065,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1199.2598,2809.9171
PROSTEP HV SCREW 3.0X16MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12986-MAIN,LOCAL,,,,,1569,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1429.359,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
CT Maxillofacial W/Dye,PX7048701,CDM,350,RC,70487,CPT,TC,,,,,,,3332,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1429.428,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3265.36
MRI Brain WO Contrast Tc,PX7055101,CDM,610,RC,70551,CPT,TC,,,,,,,3335,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1430.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3268.3
MRI Orbit/Face/Neck Tc,PX7054001,CDM,610,RC,70540,CPT,TC,,,,,,,3335,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1430.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3268.3
"Removal Anal Fistula,Subcutaneous",PX46270F,CDM,510,RC,46270,CPT,,,,,,,,1470,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1430.751,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,610.638,2452.93
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270004,NDC,100,ML,2827.78,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1430.85668,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 10 GM/100ML Solution 100 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270005,NDC,100,ML,2827.78,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1430.85668,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270007,NDC,100,ML,2827.78,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1430.85668,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270013,NDC,100,ML,2827.78,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1430.85668,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266F,CDM,510,RC,27266,CPT,,,,,,,,1684,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1431.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,699.5336,1650.32
PROSTEP MICA SCREW 3.0X34MM STERILE IMPLANT,27200000,CDM,272,RC,,,,13042-MAIN,LOCAL,,,,,1684,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1431.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Ventilator Mgmt.Subsequent Days,PX94003F,CDM,410,RC,94003,CPT,,,,,,,,1686,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1433.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,547.46,1652.28
Closed Rx Femur Shaft Fx+Manip,PX27502F,CDM,510,RC,27502,CPT,,,,,,,,1625,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1433.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,675.025,1592.5
"Lap,Cholecystectomy",PX47562F,CDM,510,RC,47562,CPT,,,,,,,,1473,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,4431.597143,percent of total billed charges,1433.6709,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,611.8842,5040.74
"I&D Perianal Abscess,Superficial",PX46050F,CDM,510,RC,46050,CPT,,,,,,,,1463,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1433.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,607.7302,1433.74
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956401,NDC,1,EA,1611.2,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1433.968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,409.66,1655.3866
clobetasol 0.05 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,42291007760,NDC,60,GR,1625.97,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1434.10554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
cycloPHOSphamide 2 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,10019095701,NDC,1,EA,2988.6,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1434.528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
cycloPHOSphamide 2 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,10019095701,NDC,1,EA,2988.6,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1434.528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
"MRI, Pelvis, W/O Then W/",PX7219701,CDM,610,RC,72197,CPT,TC,,,,,,,1612,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1434.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2066.35
Facility Emergency Level V Visit,PX99285F,CDM,450,RC,99285,CPT,,,,,,,,1464,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1434.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,561.13,1434.72
Room Rate General,PX12000000,CDM,120,RC,,,,,,,,,,1688,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1434.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,701.1952,1654.24
"Hemorrhoidectomy,Int/Ext,Simple",PX46255F,CDM,510,RC,46255,CPT,,,,,,,,1627,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1435.014,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,675.8558,2452.93
"Lap,Cholecystectomy/Explore",PX47564P,CDM,983,RC,47564,CPT,,,,,,,,1613,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1435.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,670.0402,8992.74
"Repair Flex Foot Tendon,Ea",PX28200F,CDM,510,RC,28200,CPT,,,,,,,,1475,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1435.6175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,612.715,2827.75
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956410,NDC,1,EA,1689.17,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1435.7945,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,409.66,1655.3866
DOCEtaxel 160 MG/16ML Solution 16 mL Vial,J9171.01,CDM,636,RC,J9171,HCPCS,,,,409173201,NDC,16,ML,2901.69,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1436.33655,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1205.362026,2843.6562
DOCEtaxel 20 MG/ML Concentrate 1 mL Vial,63600000,CDM,636,RC,J9171,HCPCS,,,,955102001,NDC,1,ML,1690.09,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1436.5765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
rabies immune globulin 300 UNIT/ML Solution 1 mL Vial,90376,CDM,636,RC,90375,CPT,,,,13533031801,NDC,1,ML,1629.06,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1436.83092,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,281.51,1596.4788
CT Angio Abdominal Arteries,PX7563501,CDM,350,RC,75635,CPT,TC,,,,,,,2936,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1438.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,2877.28
CT Angio Abdominal Arteries,PX7563501,CDM,350,RC,75635,CPT,TC,,,,,,,2936,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1438.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,2877.28
CT Angio Abdominal Arteries,PX7563501,CDM,350,RC,75635,CPT,TC,,,,,,,2936,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1438.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,2877.28
Targeted Genomic Sequence Analysis Panel 5-50 Genes - Ref,PX8145090,CDM,300,RC,81450,CPT,90,,,,,,,2936,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1438.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,696.41,2877.28
Targeted Genomic Sequence Analysis Panel 5-50 Genes - Ref,PX8145090,CDM,300,RC,81450,CPT,90,,,,,,,2936,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1438.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,696.41,2877.28
Targeted Genomic Sequence Analysis Panel 5-50 Genes - Ref,PX8145090,CDM,300,RC,81450,CPT,90,,,,,,,2936,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1438.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,696.41,2877.28
Irrad/Lr Platelets,PXP9037,CDM,390,RC,P9037,HCPCS,,,,,,,,1617,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1439.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,616.6,1584.66
"Repair of Recurrent Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49615F,CDM,360,RC,49615,CPT,,,,,,,,2908,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1439.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1207.9832,3022.41
"Removal Anal Fistula,Subcutaneous",PX46270F,CDM,510,RC,46270,CPT,,,,,,,,1470,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1440.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,610.638,2452.93
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270006,NDC,100,ML,2912.78,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1441.8261,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
hepatitis B immune globulin 312 UNIT/ML Solution 5 mL Vial,90371,CDM,636,RC,90371,CPT,,,,59730420301,NDC,5,ML,2851.63,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1442.92478,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.6,2794.5974
"Lap,Cholecystectomy",PX47562F,CDM,510,RC,47562,CPT,,,,,,,,1473,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1443.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,611.8842,5040.74
"Lap,Appendectomy",PX44970P,CDM,983,RC,44970,CPT,,,,,,,,1700,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,706.18,5040.74
"Repair Flex Foot Tendon,Ea",PX28200F,CDM,510,RC,28200,CPT,,,,,,,,1475,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1445.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,612.715,2827.75
Closed Rx Femur Shaft Fx+Manip,PX27502F,CDM,510,RC,27502,CPT,,,,,,,,1625,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1446.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,675.025,1592.5
clobetasol 0.05 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,42291007760,NDC,60,GR,1625.97,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1447.1133,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Hemorrhoidectomy,Int/Ext,Simple",PX46255F,CDM,510,RC,46255,CPT,,,,,,,,1627,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1448.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,675.8558,2452.93
Revise Ulnar Nerve at Elbow,PX64718P,CDM,983,RC,64718,CPT,,,,,,,,1642,,United Healthcare,All Payer,outpatient,88.2,,1157.89,percent of total billed charges,1448.244,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,682.0868,1686.76
"Closed Rx Talus Fx,Manipulatn",PX28435F,CDM,510,RC,28435,CPT,,,,,,,,1705,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1449.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,708.257,1670.9
IMPLANT PACKAGE TOEMATE,27200000,CDM,278,RC,C1713,HCPCS,,11859-MAIN,LOCAL,,,,,2865,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1449.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
IMPLANT TOEMATE X-SMALL PACKAGE 9H00-T050,C1713,CDM,278,RC,C1713,HCPCS,,11574-MAIN,LOCAL,,,,,2865,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1449.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
rabies immune globulin 300 UNIT/ML Solution 1 mL Vial,90376,CDM,636,RC,90375,CPT,,,,13533031801,NDC,1,ML,1629.06,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1449.8634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,281.51,1596.4788
FIXATION COMPONENT TOE JOINT PROXIMAL PHALANGEAL DF-P,C1713,CDM,278,RC,C1713,HCPCS,,12529-MAIN,LOCAL,,,,,1644,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1450.008,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"Biopsy, Nail Unit",PX11755F,CDM,510,RC,11755,CPT,,,,,,,,1490,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1450.217,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,614.65,1460.2
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,60505611000,NDC,5,ML,1644.33,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1450.29906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
Injection for Nerve Block,PX64447F,CDM,510,RC,64447,CPT,,,,,,,,3023,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1451.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,604.15,2962.54
Injection for Nerve Block,PX64447F,CDM,510,RC,64447,CPT,,,,,,,,3023,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1451.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,604.15,2962.54
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,67457061910,NDC,100,ML,1707.48,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1451.358,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
rabies immune globulin 300 UNIT/2ML Solution 2 mL Vial,90377,CDM,636,RC,90376,CPT,,,,49281019020,NDC,2,ML,3384.84,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1452.09636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,207.94,3317.1432
CT Angio Abdominal Arteries,PX7563501,CDM,350,RC,75635,CPT,TC,,,,,,,2936,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1453.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,2877.28
Targeted Genomic Sequence Analysis Panel 5-50 Genes - Ref,PX8145090,CDM,300,RC,81450,CPT,90,,,,,,,2936,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1453.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,696.41,2877.28
Infection Agent Detect Dna/Rna Probe Tq 6-11,PX87506,CDM,300,RC,87506,CPT,,,,,,,,1710,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1453.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,241.14,1675.8
"Sigmoidoscopy,Remv Lesn,Snare",PX45338P,CDM,983,RC,45338,CPT,,,,,,,,1710,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1453.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,710.334,1664.343
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021083082,NDC,100,ML,1596,,Medica,Commercial,both,91.1,,51.072,percent of total billed charges,1453.956,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
"Cytogen, Interp/Report - Ref",PX8829190,CDM,310,RC,88291,CPT,90,,,,,,,2874,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1454.244,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.95,2816.52
"Closed Rx Dist Fibula Fx,Manip",PX27788F,CDM,510,RC,27788,CPT,,,,,,,,1597,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1454.867,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1565.06
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595F,CDM,360,RC,49595,CPT,,,,,,,,3503,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1455.1462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1455.1462,3432.94
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595P,CDM,982,RC,49595,CPT,,,,,,,,3503,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1455.1462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1455.1462,3409.4699
Or Level 1,PX36000001,CDM,360,RC,,,,,,,,,,1600,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1457.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,664.64,1568
CT Head/Brain W/Dye,PX7046001,CDM,350,RC,70460,CPT,TC,,,,,,,3398,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1457.742,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3330.04
Fac/Cystourethroscopy,PX52000F,CDM,761,RC,52000,CPT,,,,,,,,1601,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1458.511,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,596.77,1568.98
RESTRATA WOUND MATRIX 2.5CM X 5CM TOTAL 12.5CM,27200000,CDM,272,RC,A2007,HCPCS,,11734-MAIN,LOCAL,,,,,3039,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1458.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RESTRATA WOUND MATRIX 2.5CM X 5CM TOTAL 12.5CM,27200000,CDM,272,RC,A2007,HCPCS,,11734-MAIN,LOCAL,,,,,3039,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1458.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
albuterol-ipratropium 20-100 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597002402,NDC,4,GR,1601.75,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1459.19425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Level 2 Additional Procedure,PX36000081,CDM,360,RC,,,,,,,,,,1500,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1459.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,623.1,1470
agalsidase beta 5 MG Recon Soln 1 Each Vial,J0180.01,CDM,636,RC,J0180,HCPCS,,,,58468004101,NDC,1,EA,1717.68,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1460.028,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,200.2,1683.3264
"Biopsy, Nail Unit",PX11755F,CDM,510,RC,11755,CPT,,,,,,,,1490,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1460.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,614.65,1460.2
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535P,CDM,983,RC,24535,CPT,,,,,,,,2887,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1460.822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1199.2598,2809.9171
"VENTRALIGHT MESH ST WITH ECHO 2 - 15 CM X 20 CM 6"" X 8""",C1781,CDM,278,RC,C1781,HCPCS,,12008-MAIN,LOCAL,,,,,3518,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1461.3772,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Revise Ulnar Nerve at Elbow,PX64718P,CDM,983,RC,64718,CPT,,,,,,,,1642,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1461.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,682.0868,1686.76
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573P,CDM,983,RC,36573,CPT,,,,,,,,1721,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1462.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,714.9034,1675.0493
"Treat Thumb Disloc,Manipulatn",PX26641F,CDM,510,RC,26641,CPT,,,,,,,,1721,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1462.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1686.58
FIXATION COMPONENT TOE JOINT PROXIMAL PHALANGEAL DF-P,C1713,CDM,278,RC,C1713,HCPCS,,12529-MAIN,LOCAL,,,,,1644,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1463.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,60505611000,NDC,5,ML,1644.33,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1463.4537,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
belimumab (400v) 400 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010201,NDC,1,EA,3523.71,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1463.749134,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.72,3453.2358
CT Abdomen W/Dye,PX7416001,CDM,350,RC,74160,CPT,TC,,,,,,,3413,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1464.177,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3344.74
cycloPHOSphamide 2 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,10019095701,NDC,1,EA,2988.6,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1464.414,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
cycloPHOSphamide 2 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,10019095701,NDC,1,EA,2988.6,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1464.414,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
cycloPHOSphamide 2 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,10019095701,NDC,1,EA,2988.6,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1464.414,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
"Upper GI Endoscopy,Ctrl Bleed",PX43255F,CDM,750,RC,43255,CPT,,,,,,,,1723,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1464.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,715.7342,1688.54
MESH SURGICAL NON-ABSORBABLE PLUG 6INW X 6INL,C1781,CDM,272,RC,C1781,HCPCS,,12005-MAIN,LOCAL,,,,,1505,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1256.29,percent of total billed charges,1464.8165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
MESH SURGICAL NON-ABSORBABLE PLUG 12INW X 12INL,C1781,CDM,278,RC,C1781,HCPCS,,12006-MAIN,LOCAL,,,,,1505,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1256.29,percent of total billed charges,1464.8165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
CT Soft Tissue Neck W/Dye,PX7049101,CDM,350,RC,70491,CPT,TC,,,,,,,3415,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1465.035,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3346.7
Diagnostic CT Thorax W/ Contrast,PX7126001,CDM,350,RC,71260,CPT,TC,,,,,,,3415,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1465.035,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3346.7
Closed Treat Wrist Dislocation,PX25660P,CDM,983,RC,25660,CPT,,,,,,,,1507,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1466.7631,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1466.7631
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032605,NDC,0.8,ML,1663.54,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1467.24228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,1630.2692
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956401,NDC,1,EA,1611.2,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1467.8032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,409.66,1655.3866
DOCEtaxel 160 MG/16ML Solution 16 mL Vial,J9171.01,CDM,636,RC,J9171,HCPCS,,,,409173201,NDC,16,ML,2901.69,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1468.25514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1205.362026,2843.6562
"MRI, Pelvis, W/O Then W/",PX7219701,CDM,610,RC,72197,CPT,TC,,,,,,,1612,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1468.532,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2066.35
clobetasol 0.05 % Cream 60 g Tube,63700001,CDM,250,RC,,,,,,69238153206,NDC,60,GR,1665.95,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1469.3679,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Lap,Cholecystectomy/Explore",PX47564P,CDM,983,RC,47564,CPT,,,,,,,,1613,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1469.443,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,670.0402,8992.74
Level 2 Additional Procedure,PX36000081,CDM,360,RC,,,,,,,,,,1500,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1470,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,623.1,1470
"Up GI Endoscopy,Ball Dil,30mm",PX43249P,CDM,983,RC,43249,CPT,,,,,,,,1731,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1471.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,742.599,3257.54
"Repair of Recurrent Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49615F,CDM,360,RC,49615,CPT,,,,,,,,2908,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1471.448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1207.9832,3022.41
DYNANITE PIP - STRAIGHT 12MM - WITH INSTRUMENTATION,27200000,CDM,278,RC,C1713,HCPCS,,11626-MAIN,LOCAL,,,,,3543.65,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1472.03221,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP - STRAIGHT 14MM - WITH INSTRUMENTATION,27200000,CDM,278,RC,C1713,HCPCS,,11627-MAIN,LOCAL,,,,,3543.65,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1472.03221,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT BENT 12MM,27200000,CDM,278,RC,C1713,HCPCS,,11629-MAIN,LOCAL,,,,,3543.65,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1472.03221,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT BENT 14MM,27200000,CDM,278,RC,C1713,HCPCS,,11631-MAIN,LOCAL,,,,,3543.65,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1472.03221,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT BENT 16MM,27200000,CDM,278,RC,C1713,HCPCS,,11633-MAIN,LOCAL,,,,,3543.65,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1472.03221,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT STRAIGHT 12MM,27200000,CDM,278,RC,C1713,HCPCS,,11628-MAIN,LOCAL,,,,,3543.65,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1472.03221,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT STRAIGHT 14MM,27200000,CDM,278,RC,C1713,HCPCS,,11630-MAIN,LOCAL,,,,,3543.65,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1472.03221,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT STRAIGHT 16MM,27200000,CDM,278,RC,C1713,HCPCS,,11632-MAIN,LOCAL,,,,,3543.65,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1472.03221,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Irrad/Lr Platelets,PXP9037,CDM,390,RC,P9037,HCPCS,,,,,,,,1617,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1473.087,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,616.6,1584.66
fluticasone-salmeterol 500-50 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069704,NDC,14,EA,1670.75,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1473.6015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270006,NDC,100,ML,2912.78,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1473.86668,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
Part Remv Phalanx of Toe,PX28124P,CDM,983,RC,28124,CPT,,,,,,,,1515,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1474.5495,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,629.331,2827.75
MESH SURGICAL NON-ABSORBABLE PLUG 6INW X 6INL,C1781,CDM,272,RC,C1781,HCPCS,,12005-MAIN,LOCAL,,,,,1505,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1474.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
MESH SURGICAL NON-ABSORBABLE PLUG 12INW X 12INL,C1781,CDM,278,RC,C1781,HCPCS,,12006-MAIN,LOCAL,,,,,1505,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1474.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561P,CDM,983,RC,36561,CPT,,,,,,,,1736,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1475.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,721.1344,2784.63
"Closure of Gastrostomy,Surgical",PX43870P,CDM,983,RC,43870,CPT,,,,,,,,4012,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1476.3,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,427.35,3931.76
"Closure of Gastrostomy,Surgical",PX43870P,CDM,983,RC,43870,CPT,,,,,,,,4012,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1476.3,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,427.35,3931.76
Hepatobil Syst Image W/Drug,PX7822701,CDM,341,RC,78227,CPT,TC,,,,,,,1674,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1476.468,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,472.19,1640.52
carboprost 250 MCG/ML Solution 1 mL Ampule,25000000,CDM,250,RC,,,,,,9085608,NDC,1,ML,1517.13,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1476.622629,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
Closed Treat Wrist Dislocation,PX25660P,CDM,983,RC,25660,CPT,,,,,,,,1507,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1476.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,287.74,1476.86
"Excis Arm/Elbow Tumor,Subcutan",PX24075F,CDM,510,RC,24075,CPT,,,,,,,,1519,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1478.4427,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,630.9926,1488.62
cycloPHOSphamide 2 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,10019095701,NDC,1,EA,2988.6,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1479.357,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
Closed Rx Femur Shaft Fx+Manip,PX27502F,CDM,510,RC,27502,CPT,,,,,,,,1625,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1480.375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,675.025,1592.5
Amputation Finger/Thumb,PX26951F,CDM,510,RC,26951,CPT,,,,,,,,3253,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1480.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,454.41,1480.45
Amputation Finger/Thumb,PX26951F,CDM,510,RC,26951,CPT,,,,,,,,3253,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1480.45,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,454.41,1480.45
Amputation Finger/Thumb,PX26951P,CDM,983,RC,26951,CPT,,,,,,,,2603,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1480.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,454.41,2550.94
Amputation Finger/Thumb,PX26951P,CDM,983,RC,26951,CPT,,,,,,,,2603,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1480.45,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,454.41,2550.94
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032605,NDC,0.8,ML,1663.54,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1480.5506,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,1630.2692
HIMAX PLUS 18X18X18,27200000,CDM,278,RC,C1713,HCPCS,,11660-MAIN,LOCAL,,,,,3085.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1481.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HIMAX PLUS 18X18X18,27200000,CDM,278,RC,C1713,HCPCS,,11660-MAIN,LOCAL,,,,,3085.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1481.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HIMAX PLUS 20X20X20,27200000,CDM,278,RC,C1713,HCPCS,,11661-MAIN,LOCAL,,,,,3085.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1481.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HIMAX PLUS 20X20X20,27200000,CDM,278,RC,C1713,HCPCS,,11661-MAIN,LOCAL,,,,,3085.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1481.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
clobetasol 0.05 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,42291007760,NDC,60,GR,1625.97,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1481.25867,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Injection for Nerve Block,PX64447F,CDM,510,RC,64447,CPT,,,,,,,,3023,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,2932.295,percent of total billed charges,1481.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,604.15,2962.54
Injection for Nerve Block,PX64447F,CDM,510,RC,64447,CPT,,,,,,,,3023,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1481.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,604.15,2962.54
Injection for Nerve Block,PX64447F,CDM,510,RC,64447,CPT,,,,,,,,3023,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1481.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,604.15,2962.54
"Hemorrhoidectomy,Int/Ext,Simple",PX46255F,CDM,510,RC,46255,CPT,,,,,,,,1627,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1482.197,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,675.8558,2452.93
clobetasol 0.05 % Cream 60 g Tube,63700001,CDM,250,RC,,,,,,69238153206,NDC,60,GR,1665.95,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1482.6955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270010,NDC,100,ML,3458.14,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1483.54206,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
rabies immune globulin 300 UNIT/ML Solution 1 mL Vial,90376,CDM,636,RC,90375,CPT,,,,13533031801,NDC,1,ML,1629.06,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1484.07366,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,281.51,1596.4788
Remv Periton FB From Perit Cav,PX49402F,CDM,510,RC,49402,CPT,,,,,,,,3573,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1484.2242,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1484.2242,3501.54
fluticasone 220 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173072020,NDC,12,GR,1746.36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1484.406,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Part Remv Phalanx of Toe,PX28124P,CDM,983,RC,28124,CPT,,,,,,,,1515,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1484.7,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.82,1484.7
Remove Foreign Body Complic,PX10121F,CDM,510,RC,10121,CPT,,,,,,,,3575,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1485.055,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1416.38,3503.5
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266F,CDM,510,RC,27266,CPT,,,,,,,,1684,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1485.288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,699.5336,1650.32
PROSTEP MICA SCREW 3.0X34MM STERILE IMPLANT,27200000,CDM,272,RC,,,,13042-MAIN,LOCAL,,,,,1684,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1485.288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CT Angio Abdominal Arteries,PX7563501,CDM,350,RC,75635,CPT,TC,,,,,,,2936,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1485.616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,2877.28
Targeted Genomic Sequence Analysis Panel 5-50 Genes - Ref,PX8145090,CDM,300,RC,81450,CPT,90,,,,,,,2936,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1485.616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,696.41,2877.28
"Diagnostic Bone Marrow, Biopsy and Aspiration",PX38222F,CDM,761,RC,38222,CPT,,,,,,,,1748,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1485.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,726.1192,2482.37
carboprost 250 MCG/ML Solution 1 mL Ampule,25000000,CDM,250,RC,,,,,,9085608,NDC,1,ML,1517.13,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1486.7874,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
fluticasone-salmeterol 500-50 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069704,NDC,14,EA,1670.75,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1486.9675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Ventilator Mgmt.Subsequent Days,PX94003F,CDM,410,RC,94003,CPT,,,,,,,,1686,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1487.052,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,547.46,1652.28
diazePAM 10 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,187065820,NDC,1,EA,1527.87,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1487.075871,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Closed Rx Radial Head/Neck Fx,Manip",PX24655F,CDM,510,RC,24655,CPT,,,,,,,,1750,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1487.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,726.95,1715
"Fix Exten Tendon,Dorsum Fingr,Ea",PX26418F,CDM,510,RC,26418,CPT,,,,,,,,1750,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1487.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,726.95,1715
GRAFIXPL PRIME PLACENTAL MEMBRANE 1.5 x2CM 3SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12764-MAIN,LOCAL,,,,,1529,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1488.1757,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573F,CDM,761,RC,36573,CPT,,,,,,,,1529,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1488.1757,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,635.1466,1498.42
"Excis Arm/Elbow Tumor,Subcutan",PX24075F,CDM,510,RC,24075,CPT,,,,,,,,1519,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1488.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,630.9926,1488.62
Room Rate General,PX12000000,CDM,120,RC,,,,,,,,,,1688,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1488.816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,701.1952,1654.24
RESTRATA WOUND MATRIX 2.5CM X 5CM TOTAL 12.5CM,27200000,CDM,272,RC,A2007,HCPCS,,11734-MAIN,LOCAL,,,,,3039,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1489.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RESTRATA WOUND MATRIX 2.5CM X 5CM TOTAL 12.5CM,27200000,CDM,272,RC,A2007,HCPCS,,11734-MAIN,LOCAL,,,,,3039,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1489.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RESTRATA WOUND MATRIX 2.5CM X 5CM TOTAL 12.5CM,27200000,CDM,272,RC,A2007,HCPCS,,11734-MAIN,LOCAL,,,,,3039,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1489.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Mra, Neck W/O+W/ Contrast",PX7054901,CDM,610,RC,70549,CPT,TC,,,,,,,3472,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1489.488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3402.56
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956410,NDC,1,EA,1689.17,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1489.84794,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,409.66,1655.3866
Hepatobil Syst Image W/Drug,PX7822701,CDM,341,RC,78227,CPT,TC,,,,,,,1674,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1489.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,472.19,1640.52
"Colonoscopy,Transendoscopic Stent",PX45387P,CDM,983,RC,45387,CPT,,,,,,,,3587,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1490.0398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1490.0398,3491.2271
DOCEtaxel 20 MG/ML Concentrate 1 mL Vial,63600000,CDM,636,RC,J9171,HCPCS,,,,955102001,NDC,1,ML,1690.09,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1490.65938,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034P,CDM,983,RC,12034,CPT,,,,,,,,1533,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1492.0689,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,348.35,1492.0689
degarelix acetate 40 mg/mL Recon Soln 1 Each Vial,J9155.01,CDM,636,RC,J9155,HCPCS,,,,55566840301,NDC,2,EA,3109.33,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1492.4784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.83,3047.1434
degarelix acetate 40 mg/mL Recon Soln 1 Each Vial,J9155.01,CDM,636,RC,J9155,HCPCS,,,,55566840301,NDC,2,EA,3109.33,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1492.4784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.83,3047.1434
Revise Ulnar Nerve at Elbow,PX64718P,CDM,983,RC,64718,CPT,,,,,,,,1642,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1495.862,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,682.0868,1686.76
fluticasone 220 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,66993008096,NDC,12,GR,1760.13,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1496.1105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Injection for Nerve Block,PX64447F,CDM,510,RC,64447,CPT,,,,,,,,3023,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1496.385,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,604.15,2962.54
diazePAM 10 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,187065820,NDC,1,EA,1527.87,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1497.3126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
FIXATION COMPONENT TOE JOINT PROXIMAL PHALANGEAL DF-P,C1713,CDM,278,RC,C1713,HCPCS,,12529-MAIN,LOCAL,,,,,1644,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1497.684,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"Lap,Cholecystectomy/Graph",PX47563F,CDM,510,RC,47563,CPT,,,,,,,,1556,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1497.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,431.28,1497.75
"Lap,Cholecystectomy/Graph",PX47563F,CDM,510,RC,47563,CPT,,,,,,,,1556,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1497.75,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,431.28,1497.75
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,60505611000,NDC,5,ML,1644.33,,Medica,Commercial,both,91.1,,51.072,percent of total billed charges,1497.98463,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
PEMEtrexed Disodium 100 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2764001,NDC,1,EA,1539.32,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1498.220156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.01,7924.2996
GRAFIXPL PRIME PLACENTAL MEMBRANE 1.5 x2CM 3SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12764-MAIN,LOCAL,,,,,1529,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1498.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573F,CDM,761,RC,36573,CPT,,,,,,,,1529,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1498.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,635.1466,1498.42
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180F,CDM,510,RC,44180,CPT,,,,,,,,1763,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1498.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,732.3502,5040.74
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266F,CDM,510,RC,27266,CPT,,,,,,,,1684,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1498.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,699.5336,1650.32
PROSTEP MICA SCREW 3.0X34MM STERILE IMPLANT,27200000,CDM,272,RC,,,,13042-MAIN,LOCAL,,,,,1684,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1498.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Repair Incis Hernia W Mesh,PX49568F,CDM,510,RC,49568,CPT,,,,,,,,1540,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1498.882,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,639.716,1509.2
"Lap,Appendectomy",PX44970P,CDM,983,RC,44970,CPT,,,,,,,,1700,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1499.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,706.18,5040.74
Ventilator Mgmt.Subsequent Days,PX94003F,CDM,410,RC,94003,CPT,,,,,,,,1686,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1500.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,547.46,1652.28
Exc Abd Les Sc < 3 Cm,PX22902F,CDM,761,RC,22902,CPT,,,,,,,,3128,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1501.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1299.3712,3065.44
Exc Abd Les Sc < 3 Cm,PX22902F,CDM,761,RC,22902,CPT,,,,,,,,3128,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1501.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1299.3712,3065.44
Room Rate General,PX12000000,CDM,120,RC,,,,,,,,,,1688,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1502.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,701.1952,1654.24
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034P,CDM,983,RC,12034,CPT,,,,,,,,1533,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1502.34,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,128.27,1502.34
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595F,CDM,360,RC,49595,CPT,,,,,,,,3503,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1502.787,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1455.1462,3432.94
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595P,CDM,982,RC,49595,CPT,,,,,,,,3503,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1502.787,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1455.1462,3409.4699
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956410,NDC,1,EA,1689.17,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1503.3613,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,409.66,1655.3866
"rabies vaccine, pcec Recon Susp 1 Each Vial",90675,CDM,636,RC,90675,CPT,,,,58160096412,NDC,1,EA,1544.83,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1503.583039,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,297.75,1513.9334
"Closed Rx Talus Fx,Manipulatn",PX28435F,CDM,510,RC,28435,CPT,,,,,,,,1705,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1503.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,708.257,1670.9
DOCEtaxel 20 MG/ML Concentrate 1 mL Vial,63600000,CDM,636,RC,J9171,HCPCS,,,,955102001,NDC,1,ML,1690.09,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1504.1801,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
RESTRATA WOUND MATRIX 2.5CM X 5CM TOTAL 12.5CM,27200000,CDM,272,RC,A2007,HCPCS,,11734-MAIN,LOCAL,,,,,3039,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1504.305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Sb Scope,to Ileum,Biopsy",PX44377F,CDM,750,RC,44377,CPT,,,,,,,,1770,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1504.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,735.258,1734.6
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,67457061910,NDC,100,ML,1707.48,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1505.99736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
"Chrom Anal, 20-25 Cells - Ref",PX8826490,CDM,310,RC,88264,CPT,90,,,,,,,3141,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1507.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.59,3078.18
"Chrom Anal, 20-25 Cells - Ref",PX8826490,CDM,310,RC,88264,CPT,90,,,,,,,3141,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1507.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.59,3078.18
"Tiss Cult, Neopl, Bm, Wb - Ref",PX8823790,CDM,310,RC,88237,CPT,90,,,,,,,3141,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1507.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,131.8,3078.18
"Tiss Cult, Neopl, Bm, Wb - Ref",PX8823790,CDM,310,RC,88237,CPT,90,,,,,,,3141,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1507.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,131.8,3078.18
Infection Agent Detect Dna/Rna Probe Tq 6-11,PX87506,CDM,300,RC,87506,CPT,,,,,,,,1710,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1508.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,241.14,1675.8
"Sigmoidoscopy,Remv Lesn,Snare",PX45338P,CDM,983,RC,45338,CPT,,,,,,,,1710,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1508.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,710.334,1664.343
PEMEtrexed Disodium 100 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2764001,NDC,1,EA,1539.32,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1508.5336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.01,7924.2996
MRI Pelvis W/Contrast Tc,PX7219601,CDM,610,RC,72196,CPT,TC,,,,,,,3143,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1508.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3080.14
MRI Pelvis W/Contrast Tc,PX7219601,CDM,610,RC,72196,CPT,TC,,,,,,,3143,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1508.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3080.14
"Remv F.B.,Eye,Ant Chmbr/Lens",PX65235F,CDM,510,RC,65235,CPT,,,,,,,,2788,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1508.82,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,465.32,1508.82
"Remv F.B.,Eye,Ant Chmbr/Lens",PX65235F,CDM,510,RC,65235,CPT,,,,,,,,2788,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1508.82,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,465.32,1508.82
Repair Incis Hernia W Mesh,PX49568F,CDM,510,RC,49568,CPT,,,,,,,,1540,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1509.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,639.716,1509.2
"VENTRALIGHT MESH ST WITH ECHO 2 - 15 CM X 20 CM 6"" X 8""",C1781,CDM,278,RC,C1781,HCPCS,,12008-MAIN,LOCAL,,,,,3518,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1509.222,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Closed Rx Shldr Disloc,Anesthesia",PX23655F,CDM,510,RC,23655,CPT,,,,,,,,1776,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1509.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,737.7504,1740.48
"Sigmoidoscopy,Biopsy",PX45331F,CDM,750,RC,45331,CPT,,,,,,,,1776,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1509.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,737.7504,1740.48
belimumab (400v) 400 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010201,NDC,1,EA,3523.71,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1511.67159,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.72,3453.2358
HIMAX PLUS 18X18X18,27200000,CDM,278,RC,C1713,HCPCS,,11660-MAIN,LOCAL,,,,,3085.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,1511.895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HIMAX PLUS 18X18X18,27200000,CDM,278,RC,C1713,HCPCS,,11660-MAIN,LOCAL,,,,,3085.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1511.895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HIMAX PLUS 18X18X18,27200000,CDM,278,RC,C1713,HCPCS,,11660-MAIN,LOCAL,,,,,3085.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1511.895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HIMAX PLUS 20X20X20,27200000,CDM,278,RC,C1713,HCPCS,,11661-MAIN,LOCAL,,,,,3085.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,1511.895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HIMAX PLUS 20X20X20,27200000,CDM,278,RC,C1713,HCPCS,,11661-MAIN,LOCAL,,,,,3085.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1511.895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HIMAX PLUS 20X20X20,27200000,CDM,278,RC,C1713,HCPCS,,11661-MAIN,LOCAL,,,,,3085.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1511.895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
cycloPHOSphamide 2 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,10019095701,NDC,1,EA,2988.6,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1512.2316,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
"Lap,Appendectomy",PX44970P,CDM,983,RC,44970,CPT,,,,,,,,1700,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1513,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,706.18,5040.74
"Casiri and Imdevimab,Admin,Repeat Dose",PXM0240,CDM,771,RC,M0240,HCPCS,,,,,,,,1555,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1513.4815,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,413.06,1523.9
"IV Infusion, Bamlanivimab and Etesevimab, Infusion and Monitoring",PXM0245,CDM,260,RC,M0245,HCPCS,,,,,,,,1555,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1513.4815,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,413.06,1523.9
"rabies vaccine, pcec Recon Susp 1 Each Vial",90675,CDM,636,RC,90675,CPT,,,,58160096412,NDC,1,EA,1544.83,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1513.9334,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,297.75,1513.9334
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591F,CDM,360,RC,49591,CPT,,,,,,,,1556,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,6542.19,percent of total billed charges,1514.4548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,646.3624,3022.41
"Lap,Cholecystectomy/Graph",PX47563F,CDM,510,RC,47563,CPT,,,,,,,,1556,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1514.4548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,646.3624,5040.74
agalsidase beta 5 MG Recon Soln 1 Each Vial,J0180.01,CDM,636,RC,J0180,HCPCS,,,,58468004101,NDC,1,EA,1717.68,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1514.99376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,200.2,1683.3264
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032605,NDC,0.8,ML,1663.54,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1515.48494,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,1630.2692
darbepoetin alfa 200 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002801,NDC,0.4,ML,3157.92,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1515.8016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
darbepoetin alfa 200 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002801,NDC,0.4,ML,3157.92,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1515.8016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
"Fusion Foot Bones,Midtarsal,Multi",PX28730F,CDM,510,RC,28730,CPT,,,,,,,,2299,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1517.12,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,456.15,1517.12
"Fusion Foot Bones,Midtarsal,Multi",PX28730F,CDM,510,RC,28730,CPT,,,,,,,,2299,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1517.12,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,456.15,1517.12
"Closed Rx Talus Fx,Manipulatn",PX28435F,CDM,510,RC,28435,CPT,,,,,,,,1705,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1517.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,708.257,1670.9
clobetasol 0.05 % Cream 60 g Tube,63700001,CDM,250,RC,,,,,,69238153206,NDC,60,GR,1665.95,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1517.68045,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573P,CDM,983,RC,36573,CPT,,,,,,,,1721,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1517.922,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,714.9034,1675.0493
"Treat Thumb Disloc,Manipulatn",PX26641F,CDM,510,RC,26641,CPT,,,,,,,,1721,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1517.922,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1686.58
CT Abdomen W/Dye,PX7416001,CDM,350,RC,74160,CPT,TC,,,,,,,3413,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,1518.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3344.74
CT Abdomen W/O & W/Dye,PX7417001,CDM,350,RC,74170,CPT,TC,,,,,,,3689,,Blue Cross Blue Shield of MN,All commercial plans,both,,,2266.95,fee schedule,1518.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3615.22
CT Angio Abdom W/O & W/Dye,PX7417501,CDM,350,RC,74175,CPT,TC,,,,,,,4183,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,1518.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,4099.34
CT Angio Lwr Extr W/O&W/Dye,PX7370601,CDM,350,RC,73706,CPT,TC,,,,,,,1554,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,1518.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1522.92
CT Angio Upr Extrm W/O&W/Dye,PX7320601,CDM,350,RC,73206,CPT,TC,,,,,,,757,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,1518.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
CT Angiograph Pelv W/O&W/Dye,PX7219101,CDM,350,RC,72191,CPT,TC,,,,,,,1458,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,1518.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
"CT Angiography, Chest",PX7127501,CDM,350,RC,71275,CPT,TC,,,,,,,3689,,Blue Cross Blue Shield of MN,All commercial plans,both,,,1248.281429,fee schedule,1518.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3615.22
"CT Angiography, Head",PX7049601,CDM,350,RC,70496,CPT,TC,,,,,,,3690,,Blue Cross Blue Shield of MN,All commercial plans,both,,,1370.441111,fee schedule,1518.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3616.2
"CT Angiography, Neck",PX7049801,CDM,350,RC,70498,CPT,TC,,,,,,,3690,,Blue Cross Blue Shield of MN,All commercial plans,both,,,1628.52625,fee schedule,1518.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3616.2
CT Chest Spine W/Dye,PX7212901,CDM,350,RC,72129,CPT,TC,,,,,,,2096,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,1518.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,2054.08
CT Head/Brain W/Dye,PX7046001,CDM,350,RC,70460,CPT,TC,,,,,,,3398,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,1518.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3330.04
CT Head/Brain W/O & W/Dye,PX7047001,CDM,350,RC,70470,CPT,TC,,,,,,,3671,,Blue Cross Blue Shield of MN,All commercial plans,both,,,581.7133333,fee schedule,1518.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3597.58
CT Lower Extremity W/Dye,PX7370101,CDM,350,RC,73701,CPT,TC,,,,,,,2690,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,1518.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,2636.2
CT Lumbar Spine W/O & W/Dye,PX7213301,CDM,350,RC,72133,CPT,TC,,,,,,,4283,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,1518.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,4197.34
CT Lwr Extremity W/O&W/Dye,PX7370201,CDM,350,RC,73702,CPT,TC,,,,,,,1235,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,1518.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
CT Maxillofacial W/Dye,PX7048701,CDM,350,RC,70487,CPT,TC,,,,,,,3332,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,1518.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3265.36
CT Orbit/Ear/Fossa W/O & W/Dye,PX7048201,CDM,350,RC,70482,CPT,TC,,,,,,,1400,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,1518.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1518.44
CT Pelvis W/Dye,PX7219301,CDM,350,RC,72193,CPT,TC,,,,,,,3330,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,1518.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3263.4
CT Soft Tissue Neck W/Dye,PX7049101,CDM,350,RC,70491,CPT,TC,,,,,,,3415,,Blue Cross Blue Shield of MN,All commercial plans,both,,,1405.038333,fee schedule,1518.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3346.7
Diagnostic CT Thorax W/ Contrast,PX7126001,CDM,350,RC,71260,CPT,TC,,,,,,,3415,,Blue Cross Blue Shield of MN,All commercial plans,both,,,1141.359167,fee schedule,1518.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3346.7
"Mra, Head W/Out Contrast",PX7054401,CDM,610,RC,70544,CPT,TC,,,,,,,3541,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1519.089,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
"Mra, Neck With Contrast",PX7054801,CDM,610,RC,70548,CPT,TC,,,,,,,3541,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1519.089,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI Brain W & WO Contrast,PX7055301,CDM,610,RC,70553,CPT,TC,,,,,,,3541,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1519.089,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI C Spine W&WO Contrast,PX7215601,CDM,610,RC,72156,CPT,TC,,,,,,,3541,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1519.089,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI C-Spine WO Contrast,PX7214101,CDM,610,RC,72141,CPT,TC,,,,,,,3541,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1519.089,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI L Spine WO Contrast,PX7214801,CDM,610,RC,72148,CPT,TC,,,,,,,3541,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1519.089,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI Low Ext Jnt WO/Cont Tc,PX7372101,CDM,610,RC,73721,CPT,TC,,,,,,,3541,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1519.089,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI Orb-Fac-Nec W/O+W/Con,PX7054301,CDM,610,RC,70543,CPT,TC,,,,,,,3541,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1519.089,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
"MRI,Upr Ext, Joint,W/Cont",PX7322201,CDM,610,RC,73222,CPT,TC,,,,,,,3541,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1519.089,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,611.05,3470.18
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,67457061910,NDC,100,ML,1707.48,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1519.6572,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
"Upper GI Endoscopy,Ctrl Bleed",PX43255F,CDM,750,RC,43255,CPT,,,,,,,,1723,,United Healthcare,All Payer,outpatient,88.2,,999999999,case rate,1519.686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1519.686,6141.46
DYNANITE PIP - STRAIGHT 12MM - WITH INSTRUMENTATION,27200000,CDM,278,RC,C1713,HCPCS,,11626-MAIN,LOCAL,,,,,3543.65,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1520.22585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP - STRAIGHT 14MM - WITH INSTRUMENTATION,27200000,CDM,278,RC,C1713,HCPCS,,11627-MAIN,LOCAL,,,,,3543.65,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1520.22585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT BENT 12MM,27200000,CDM,278,RC,C1713,HCPCS,,11629-MAIN,LOCAL,,,,,3543.65,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1520.22585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT BENT 14MM,27200000,CDM,278,RC,C1713,HCPCS,,11631-MAIN,LOCAL,,,,,3543.65,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1520.22585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT BENT 16MM,27200000,CDM,278,RC,C1713,HCPCS,,11633-MAIN,LOCAL,,,,,3543.65,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1520.22585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT STRAIGHT 12MM,27200000,CDM,278,RC,C1713,HCPCS,,11628-MAIN,LOCAL,,,,,3543.65,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1520.22585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT STRAIGHT 14MM,27200000,CDM,278,RC,C1713,HCPCS,,11630-MAIN,LOCAL,,,,,3543.65,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1520.22585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT STRAIGHT 16MM,27200000,CDM,278,RC,C1713,HCPCS,,11632-MAIN,LOCAL,,,,,3543.65,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1520.22585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Infection Agent Detect Dna/Rna Probe Tq 6-11,PX87506,CDM,300,RC,87506,CPT,,,,,,,,1710,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1521.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,241.14,1675.8
"Sigmoidoscopy,Remv Lesn,Snare",PX45338P,CDM,983,RC,45338,CPT,,,,,,,,1710,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1521.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,710.334,1664.343
fluticasone-salmeterol 500-50 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069704,NDC,14,EA,1670.75,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1522.05325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Incis/Drain Shldr Absc/Hema,Deep",PX23030P,CDM,983,RC,23030,CPT,,,,,,,,1564,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1522.2412,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,649.6856,2482.37
CT Angio Lwr Extr W/O&W/Dye,PX7370601,CDM,350,RC,73706,CPT,TC,,,,,,,1554,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1522.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,1522.92
MRI Lower W/O+W Tc,PX7372001,CDM,610,RC,73720,CPT,TC,,,,,,,3174,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1523.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3110.52
MRI Lower W/O+W Tc,PX7372001,CDM,610,RC,73720,CPT,TC,,,,,,,3174,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1523.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3110.52
degarelix acetate 40 mg/mL Recon Soln 1 Each Vial,J9155.01,CDM,636,RC,J9155,HCPCS,,,,55566840301,NDC,2,EA,3109.33,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1523.5717,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.83,3047.1434
degarelix acetate 40 mg/mL Recon Soln 1 Each Vial,J9155.01,CDM,636,RC,J9155,HCPCS,,,,55566840301,NDC,2,EA,3109.33,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1523.5717,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.83,3047.1434
degarelix acetate 40 mg/mL Recon Soln 1 Each Vial,J9155.01,CDM,636,RC,J9155,HCPCS,,,,55566840301,NDC,2,EA,3109.33,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1523.5717,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.83,3047.1434
"Casiri and Imdevimab,Admin,Repeat Dose",PXM0240,CDM,771,RC,M0240,HCPCS,,,,,,,,1555,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1523.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,413.06,1523.9
"IV Infusion, Bamlanivimab and Etesevimab, Infusion and Monitoring",PXM0245,CDM,260,RC,M0245,HCPCS,,,,,,,,1555,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1523.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,413.06,1523.9
"IV Infusion, Casirivimab and Imdevimab, IV and Post Admr",PXM0243,CDM,771,RC,M0243,HCPCS,,,,,,,,1555,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1523.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,413.06,1684.87
cycloPHOSphamide 500 MG Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781323394,NDC,1,EA,1565.71,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1523.905543,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591F,CDM,360,RC,49591,CPT,,,,,,,,1556,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1524.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,646.3624,3022.41
"Lap,Cholecystectomy/Graph",PX47563F,CDM,510,RC,47563,CPT,,,,,,,,1556,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1524.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,646.3624,5040.74
Hepatobil Syst Image W/Drug,PX7822701,CDM,341,RC,78227,CPT,TC,,,,,,,1674,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1525.014,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,472.19,1640.52
trastuzumab 150 MG Recon Soln 1 Each Vial,J9355.01,CDM,636,RC,J9355,HCPCS,,,,50242013201,NDC,1,EA,3179.17,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1526.0016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.77,3115.5866
trastuzumab 150 MG Recon Soln 1 Each Vial,J9355.01,CDM,636,RC,J9355,HCPCS,,,,50242013201,NDC,1,EA,3179.17,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1526.0016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.77,3115.5866
"Lap,Inguinal Hernia Repr,Recur",PX49651F,CDM,510,RC,49651,CPT,,,,,,,,1568,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1526.1344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,651.3472,5040.74
"Closed Rx Weight Bear Dist Tib,Manip",PX27825P,CDM,983,RC,27825,CPT,,,,,,,,1796,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1526.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,746.0584,1748.0468
"Up GI Endoscopy,Ball Dil,30mm",PX43249P,CDM,983,RC,43249,CPT,,,,,,,,1731,,United Healthcare,All Payer,outpatient,88.2,,1272.04,percent of total billed charges,1526.742,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,742.599,3257.54
PROSTEP HV SCREW 3.0X16MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12986-MAIN,LOCAL,,,,,1569,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1527.1077,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
HIMAX PLUS 18X18X18,27200000,CDM,278,RC,C1713,HCPCS,,11660-MAIN,LOCAL,,,,,3085.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1527.3225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HIMAX PLUS 20X20X20,27200000,CDM,278,RC,C1713,HCPCS,,11661-MAIN,LOCAL,,,,,3085.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1527.3225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
agalsidase beta 5 MG Recon Soln 1 Each Vial,J0180.01,CDM,636,RC,J0180,HCPCS,,,,58468004101,NDC,1,EA,1717.68,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1528.7352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,200.2,1683.3264
Injection for Nerve Block,PX64447F,CDM,510,RC,64447,CPT,,,,,,,,3023,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1529.638,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,604.15,2962.54
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561P,CDM,983,RC,36561,CPT,,,,,,,,1736,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1531.152,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,721.1344,2784.63
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573P,CDM,983,RC,36573,CPT,,,,,,,,1721,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1531.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,714.9034,1675.0493
"Treat Thumb Disloc,Manipulatn",PX26641F,CDM,510,RC,26641,CPT,,,,,,,,1721,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1531.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1686.58
Exc Abd Les Sc < 3 Cm,PX22902F,CDM,761,RC,22902,CPT,,,,,,,,3128,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1532.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1299.3712,3065.44
Exc Abd Les Sc < 3 Cm,PX22902F,CDM,761,RC,22902,CPT,,,,,,,,3128,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1532.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1299.3712,3065.44
Exc Abd Les Sc < 3 Cm,PX22902F,CDM,761,RC,22902,CPT,,,,,,,,3128,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1532.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1299.3712,3065.44
"Incis/Drain Shldr Absc/Hema,Deep",PX23030P,CDM,983,RC,23030,CPT,,,,,,,,1564,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1532.72,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,158.15,1532.72
Remv Periton FB From Perit Cav,PX49402F,CDM,510,RC,49402,CPT,,,,,,,,3573,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1532.817,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1484.2242,3501.54
"Upper GI Endoscopy,Ctrl Bleed",PX43255F,CDM,750,RC,43255,CPT,,,,,,,,1723,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1533.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,715.7342,1688.54
Remove Foreign Body Complic,PX10121F,CDM,510,RC,10121,CPT,,,,,,,,3575,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1533.675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1416.38,3503.5
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266F,CDM,510,RC,27266,CPT,,,,,,,,1684,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1534.124,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,699.5336,1650.32
PROSTEP MICA SCREW 3.0X34MM STERILE IMPLANT,27200000,CDM,272,RC,,,,13042-MAIN,LOCAL,,,,,1684,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1534.124,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
cycloPHOSphamide 500 MG Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781323394,NDC,1,EA,1565.71,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1534.3958,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
ALLOGRAFT BONE AUGMENT INJECTABLE KIT 1.5CC,C1734,CDM,278,RC,C1734,HCPCS,,12632-MAIN,LOCAL,,,,,3694,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1534.4876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1534.4876,3620.12
PROSTEP MICA SCREW 3.0X20MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12442-MAIN,LOCAL,,,,,1806,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1535.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 3.0X40MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12443-MAIN,LOCAL,,,,,1806,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1535.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X52MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12444-MAIN,LOCAL,,,,,1806,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1535.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Ventilator Mgmt.Subsequent Days,PX94003F,CDM,410,RC,94003,CPT,,,,,,,,1686,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1535.946,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,547.46,1652.28
Level 4 Additional Procedure,PX36000083,CDM,360,RC,,,,,,,,,,3200,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1329.28,3136
Level 4 Additional Procedure,PX36000083,CDM,360,RC,,,,,,,,,,3200,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1329.28,3136
"Lap,Inguinal Hernia Repr,Recur",PX49651F,CDM,510,RC,49651,CPT,,,,,,,,1568,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1536.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,651.3472,5040.74
PROSTEP HV SCREW 3.0X16MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12986-MAIN,LOCAL,,,,,1569,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1537.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
RESTRATA WOUND MATRIX 2.5CM X 5CM TOTAL 12.5CM,27200000,CDM,272,RC,A2007,HCPCS,,11734-MAIN,LOCAL,,,,,3039,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1537.734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Room Rate General,PX12000000,CDM,120,RC,,,,,,,,,,1688,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1537.768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,701.1952,1654.24
clobetasol 0.05 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,21922001707,NDC,60,GR,1810.35,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1538.7975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Colonoscopy,Transendoscopic Stent",PX45387P,CDM,983,RC,45387,CPT,,,,,,,,3587,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1538.823,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1490.0398,3491.2271
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956410,NDC,1,EA,1689.17,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1538.83387,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,409.66,1655.3866
"Chrom Anal, 20-25 Cells - Ref",PX8826490,CDM,310,RC,88264,CPT,90,,,,,,,3141,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1539.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.59,3078.18
"Chrom Anal, 20-25 Cells - Ref",PX8826490,CDM,310,RC,88264,CPT,90,,,,,,,3141,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1539.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.59,3078.18
"Chrom Anal, 20-25 Cells - Ref",PX8826490,CDM,310,RC,88264,CPT,90,,,,,,,3141,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1539.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.59,3078.18
"Tiss Cult, Neopl, Bm, Wb - Ref",PX8823790,CDM,310,RC,88237,CPT,90,,,,,,,3141,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1539.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,131.8,3078.18
"Tiss Cult, Neopl, Bm, Wb - Ref",PX8823790,CDM,310,RC,88237,CPT,90,,,,,,,3141,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1539.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,131.8,3078.18
"Tiss Cult, Neopl, Bm, Wb - Ref",PX8823790,CDM,310,RC,88237,CPT,90,,,,,,,3141,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1539.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,131.8,3078.18
degarelix acetate 40 mg/mL Recon Soln 1 Each Vial,J9155.01,CDM,636,RC,J9155,HCPCS,,,,55566840301,NDC,2,EA,3109.33,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1539.11835,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.83,3047.1434
DOCEtaxel 20 MG/ML Concentrate 1 mL Vial,63600000,CDM,636,RC,J9171,HCPCS,,,,955102001,NDC,1,ML,1690.09,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1539.67199,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
MRI Pelvis W/Contrast Tc,PX7219601,CDM,610,RC,72196,CPT,TC,,,,,,,3143,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1540.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3080.14
MRI Pelvis W/Contrast Tc,PX7219601,CDM,610,RC,72196,CPT,TC,,,,,,,3143,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1540.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3080.14
MRI Pelvis W/Contrast Tc,PX7219601,CDM,610,RC,72196,CPT,TC,,,,,,,3143,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1540.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3080.14
fluticasone 220 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173072020,NDC,12,GR,1746.36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1540.28952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Up GI Endoscopy,Ball Dil,30mm",PX43249P,CDM,983,RC,43249,CPT,,,,,,,,1731,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1540.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,742.599,3257.54
GOLIMumab 50 MG/4ML Solution 4 mL Vial,J1602.01,CDM,636,RC,J1602,HCPCS,,,,57894035001,NDC,4,ML,3709.76,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1541.034304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.31,3635.5648
"Diagnostic Bone Marrow, Biopsy and Aspiration",PX38222F,CDM,761,RC,38222,CPT,,,,,,,,1748,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1541.736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,726.1192,2482.37
"Closed Rx Radial Head/Neck Fx,Manip",PX24655F,CDM,510,RC,24655,CPT,,,,,,,,1750,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1543.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,726.95,1715
"Fix Exten Tendon,Dorsum Fingr,Ea",PX26418F,CDM,510,RC,26418,CPT,,,,,,,,1750,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1543.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,726.95,1715
MESH VENTRALIGHT ECHO 2.0 POSITIONING 15CM ROUND,C1781,CDM,278,RC,C1781,HCPCS,,12842-MAIN,LOCAL,,,,,1816,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1543.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561P,CDM,983,RC,36561,CPT,,,,,,,,1736,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1545.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,721.1344,2784.63
darbepoetin alfa 200 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002801,NDC,0.4,ML,3157.92,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1547.3808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
darbepoetin alfa 200 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002801,NDC,0.4,ML,3157.92,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1547.3808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
darbepoetin alfa 200 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002801,NDC,0.4,ML,3157.92,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1547.3808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
Exc Abd Les Sc < 3 Cm,PX22902F,CDM,761,RC,22902,CPT,,,,,,,,3128,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1548.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1299.3712,3065.44
"Lap,Appendectomy",PX44970P,CDM,983,RC,44970,CPT,,,,,,,,1700,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1548.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,706.18,5040.74
Room Rate General Iso,PX12000001,CDM,120,RC,,,,,,,,,,1822,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1548.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,756.8588,1785.56
"Colonoscopy,Transendoscopic Stent",PX45387F,CDM,750,RC,45387,CPT,,,,,,,,3228,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1549.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1340.9112,3163.44
"Colonoscopy,Transendoscopic Stent",PX45387F,CDM,750,RC,45387,CPT,,,,,,,,3228,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1549.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1340.9112,3163.44
"Closed Rx Radial Head/Neck Fx,Manip",PX24655P,CDM,983,RC,24655,CPT,,,,,,,,1824,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1550.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,757.6896,1775.2992
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569P,CDM,983,RC,36569,CPT,,,,,,,,1825,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1551.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,758.105,1776.2725
fluticasone 220 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,66993008096,NDC,12,GR,1760.13,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1552.43466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Closed Rx Talus Fx,Manipulatn",PX28435F,CDM,510,RC,28435,CPT,,,,,,,,1705,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1553.255,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,708.257,1670.9
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021083082,NDC,100,ML,1596,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,66.804,percent of total billed charges,1553.3868,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
fluticasone 220 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173072020,NDC,12,GR,1746.36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1554.2604,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Closed Rx Dist Fibula Fx,Manip",PX27788F,CDM,510,RC,27788,CPT,,,,,,,,1597,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1554.3601,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1565.06
RESTRATA WOUND MATRIX 2.5CM X 2.5CM TOTAL 6.25CM,27200000,CDM,272,RC,A2007,HCPCS,,11733-MAIN,LOCAL,,,,,1829,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1554.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Chrom Anal, 20-25 Cells - Ref",PX8826490,CDM,310,RC,88264,CPT,90,,,,,,,3141,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1554.795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.59,3078.18
"Tiss Cult, Neopl, Bm, Wb - Ref",PX8823790,CDM,310,RC,88237,CPT,90,,,,,,,3141,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1554.795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,131.8,3078.18
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180F,CDM,510,RC,44180,CPT,,,,,,,,1763,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1554.966,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,732.3502,5040.74
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING 8 IN CIRCLE,C1781,CDM,278,RC,C1781,HCPCS,,12506-MAIN,LOCAL,,,,,3240,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1555.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING 8 IN CIRCLE,C1781,CDM,278,RC,C1781,HCPCS,,12506-MAIN,LOCAL,,,,,3240,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1555.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
MRI Lower W/O+W Tc,PX7372001,CDM,610,RC,73720,CPT,TC,,,,,,,3174,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1578.74,percent of total billed charges,1555.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3110.52
MRI Lower W/O+W Tc,PX7372001,CDM,610,RC,73720,CPT,TC,,,,,,,3174,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1555.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3110.52
MRI Lower W/O+W Tc,PX7372001,CDM,610,RC,73720,CPT,TC,,,,,,,3174,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1555.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3110.52
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,67457061910,NDC,100,ML,1707.48,,Medica,Commercial,both,91.1,,51.072,percent of total billed charges,1555.51428,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
"Diagnostic Bone Marrow, Biopsy and Aspiration",PX38222F,CDM,761,RC,38222,CPT,,,,,,,,1748,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1555.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,726.1192,2482.37
MRI Pelvis W/Contrast Tc,PX7219601,CDM,610,RC,72196,CPT,TC,,,,,,,3143,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1555.785,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3080.14
"MRI,Lwrext,No Jnt, W/Cont",PX7371901,CDM,610,RC,73719,CPT,TC,,,,,,,3627,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1555.983,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3554.46
"Ht Muscle Image Spect, Mult",PX7845201,CDM,340,RC,78452,CPT,TC,,,,,,,2000,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,,,999999999,fee schedule,1556.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,858,5292.1
Or Level 1,PX36000001,CDM,360,RC,,,,,,,,,,1600,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1557.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,664.64,1568
"Closed Rx Radial Head/Neck Fx,Manip",PX24655F,CDM,510,RC,24655,CPT,,,,,,,,1750,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1557.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,726.95,1715
"Fix Exten Tendon,Dorsum Fingr,Ea",PX26418F,CDM,510,RC,26418,CPT,,,,,,,,1750,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1557.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,726.95,1715
Peramivir 200 MG/20ML Solution 20 mL Vial,800000,CDM,,,,,,,,61364018101,NDC,20,ML,1832.6,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1557.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
trastuzumab 150 MG Recon Soln 1 Each Vial,J9355.01,CDM,636,RC,J9355,HCPCS,,,,50242013201,NDC,1,EA,3179.17,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1557.7933,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.77,3115.5866
trastuzumab 150 MG Recon Soln 1 Each Vial,J9355.01,CDM,636,RC,J9355,HCPCS,,,,50242013201,NDC,1,EA,3179.17,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1557.7933,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.77,3115.5866
trastuzumab 150 MG Recon Soln 1 Each Vial,J9355.01,CDM,636,RC,J9355,HCPCS,,,,50242013201,NDC,1,EA,3179.17,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1557.7933,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.77,3115.5866
Infection Agent Detect Dna/Rna Probe Tq 6-11,PX87506,CDM,300,RC,87506,CPT,,,,,,,,1710,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1557.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,241.14,1675.8
"Sigmoidoscopy,Remv Lesn,Snare",PX45338P,CDM,983,RC,45338,CPT,,,,,,,,1710,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1557.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,710.334,1664.343
Fac/Cystourethroscopy,PX52000F,CDM,761,RC,52000,CPT,,,,,,,,1601,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1558.2533,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,596.77,1568.98
albuterol-ipratropium 20-100 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597002402,NDC,4,GR,1601.75,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1558.983275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Sb Scope,to Ileum,Biopsy",PX44377F,CDM,750,RC,44377,CPT,,,,,,,,1770,,United Healthcare,All Payer,outpatient,88.2,,999999999,case rate,1561.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1561.14,6141.46
HIMAX PLUS 18X18X18,27200000,CDM,278,RC,C1713,HCPCS,,11660-MAIN,LOCAL,,,,,3085.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1561.263,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HIMAX PLUS 20X20X20,27200000,CDM,278,RC,C1713,HCPCS,,11661-MAIN,LOCAL,,,,,3085.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1561.263,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Amputation Finger/Thumb,PX26951F,CDM,510,RC,26951,CPT,,,,,,,,3253,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1561.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1351.2962,3187.94
Amputation Finger/Thumb,PX26951F,CDM,510,RC,26951,CPT,,,,,,,,3253,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1561.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1351.2962,3187.94
MRI Upper W/O+W Tc,PX7322001,CDM,610,RC,73220,CPT,TC,,,,,,,3253,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1561.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3187.94
MRI Upper W/O+W Tc,PX7322001,CDM,610,RC,73220,CPT,TC,,,,,,,3253,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1561.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3187.94
"MRI,Lwrext,No Jnt,No Cont",PX7371801,CDM,610,RC,73718,CPT,TC,,,,,,,3253,,Health Partners,Health Partners Care Plans,both,48,,1338.395,percent of total billed charges,1561.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3187.94
"MRI,Lwrext,No Jnt,No Cont",PX7371801,CDM,610,RC,73718,CPT,TC,,,,,,,3253,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1561.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3187.94
"MRI,Pelvis W/Out Contrast",PX7219501,CDM,610,RC,72195,CPT,TC,,,,,,,3253,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1561.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3187.94
"MRI,Pelvis W/Out Contrast",PX7219501,CDM,610,RC,72195,CPT,TC,,,,,,,3253,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1561.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3187.94
"MRI,Up Ext,No Jnt,No Cont",PX7321801,CDM,610,RC,73218,CPT,TC,,,,,,,3253,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1561.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3187.94
"MRI,Up Ext,No Jnt,No Cont",PX7321801,CDM,610,RC,73218,CPT,TC,,,,,,,3253,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1561.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3187.94
darbepoetin alfa 200 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002801,NDC,0.4,ML,3157.92,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1563.1704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021083082,NDC,100,ML,1596,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1564.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
agalsidase beta 5 MG Recon Soln 1 Each Vial,J0180.01,CDM,636,RC,J0180,HCPCS,,,,58468004101,NDC,1,EA,1717.68,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1564.80648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,200.2,1683.3264
"Closed Rx Dist Fibula Fx,Manip",PX27788F,CDM,510,RC,27788,CPT,,,,,,,,1597,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1565.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1565.06
"Closed Rx Shldr Disloc,Anesthesia",PX23655F,CDM,510,RC,23655,CPT,,,,,,,,1776,,United Healthcare,All Payer,outpatient,88.2,,675.23,percent of total billed charges,1566.432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,737.7504,1740.48
"Sigmoidoscopy,Biopsy",PX45331F,CDM,750,RC,45331,CPT,,,,,,,,1776,,United Healthcare,All Payer,outpatient,88.2,,999999999,case rate,1566.432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1566.432,6141.46
KIT GASTRIC LAVAGE 2075,120.257,CDM,272,RC,C7510,HCPCS,,410-MAIN,LOCAL,,,,,44,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,1566.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1413.36,1566.45
KIT GASTRIC LAVAGE 2075,120.257,CDM,272,RC,C7510,HCPCS,,410-MAIN,LOCAL,,,,,44,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,1566.45,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1413.36,1566.45
fluticasone 220 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,66993008096,NDC,12,GR,1760.13,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1566.5157,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
DYNABUNION PLATE STERILE INSTRUMENT KIT,27200000,CDM,272,RC,,,,12465-MAIN,LOCAL,,,,,1843,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1566.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573P,CDM,983,RC,36573,CPT,,,,,,,,1721,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1567.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,714.9034,1675.0493
"Treat Thumb Disloc,Manipulatn",PX26641F,CDM,510,RC,26641,CPT,,,,,,,,1721,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1567.831,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1686.58
Level 4 Additional Procedure,PX36000083,CDM,360,RC,,,,,,,,,,3200,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1329.28,3136
Level 4 Additional Procedure,PX36000083,CDM,360,RC,,,,,,,,,,3200,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1329.28,3136
Level 4 Additional Procedure,PX36000083,CDM,360,RC,,,,,,,,,,3200,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1329.28,3136
Or Level 1,PX36000001,CDM,360,RC,,,,,,,,,,1600,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1568,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,664.64,1568
MRI T Spine WO Contrast,PX7214601,CDM,610,RC,72146,CPT,TC,,,,,,,3267,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1568.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3201.66
MRI T Spine WO Contrast,PX7214601,CDM,610,RC,72146,CPT,TC,,,,,,,3267,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1568.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3201.66
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956401,NDC,1,EA,1611.2,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1568.18096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,409.66,1655.3866
Fac/Cystourethroscopy,PX52000F,CDM,761,RC,52000,CPT,,,,,,,,1601,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1568.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,596.77,1568.98
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180F,CDM,510,RC,44180,CPT,,,,,,,,1763,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1569.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,732.3502,5040.74
"Upper GI Endoscopy,Ctrl Bleed",PX43255F,CDM,750,RC,43255,CPT,,,,,,,,1723,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1569.653,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,715.7342,1688.54
bortezomib 3.5 MG Recon Soln 1 Each Vial,J9041.01,CDM,636,RC,J9041,HCPCS,,,,63020004901,NDC,1,EA,3270.12,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1569.6576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.79,3204.7176
bortezomib 3.5 MG Recon Soln 1 Each Vial,J9041.01,CDM,636,RC,J9041,HCPCS,,,,63020004901,NDC,1,EA,3270.12,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1569.6576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.79,3204.7176
albuterol-ipratropium 20-100 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597002402,NDC,4,GR,1601.75,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1569.715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ferumoxytol 510 MG/17ML Solution 17 mL Vial,Q0138.01,CDM,636,RC,Q0138,HCPCS,,,,781315401,NDC,17,ML,1846.91,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1569.8735,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.32,1809.9718
"Lap,Cholecystectomy/Explore",PX47564P,CDM,983,RC,47564,CPT,,,,,,,,1613,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1569.9329,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,670.0402,8992.74
MRI Lower W/O+W Tc,PX7372001,CDM,610,RC,73720,CPT,TC,,,,,,,3174,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1571.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3110.52
leuprolide 7.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74364203,NDC,1,EA,3782.28,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1571.159112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
"MRI,Lwrext,Jnt W/O+W/Cont",PX7372301,CDM,610,RC,73723,CPT,TC,,,,,,,1850,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1572.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2066.35
Sleep Staging 4 + Pap,PX9581126,CDM,982,RC,95811,CPT,26,,,,,,,1850,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1572.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,768.49,1800.605
degarelix acetate 40 mg/mL Recon Soln 1 Each Vial,J9155.01,CDM,636,RC,J9155,HCPCS,,,,55566840301,NDC,2,EA,3109.33,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1573.32098,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.83,3047.1434
Room Rate Swing General,PX12000010,CDM,120,RC,,,,,,,,,,3788,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1573.5352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1573.5352,3712.24
Room Rate Swing General Iso,PX12000011,CDM,120,RC,,,,,,,,,,3788,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1573.5352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1573.5352,3712.24
trastuzumab 150 MG Recon Soln 1 Each Vial,J9355.01,CDM,636,RC,J9355,HCPCS,,,,50242013201,NDC,1,EA,3179.17,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1573.68915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.77,3115.5866
Irrad/Lr Platelets,PXP9037,CDM,390,RC,P9037,HCPCS,,,,,,,,1617,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1573.8261,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,616.6,1584.66
REAMER FOR CROSS PLATES,27200000,CDM,272,RC,,,,12641-MAIN,LOCAL,,,,,1852,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1574.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CT Head/Brain W/O & W/Dye,PX7047001,CDM,350,RC,70470,CPT,TC,,,,,,,3671,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1574.859,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3597.58
romiPLOStim 250 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022101,NDC,1,EA,3791.51,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1574.993254,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.04,6877.885
"Sb Scope,to Ileum,Biopsy",PX44377F,CDM,750,RC,44377,CPT,,,,,,,,1770,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1575.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,735.258,1734.6
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,781307912,NDC,5,ML,1854.23,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1576.0955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.74,1938.2734
"Up GI Endoscopy,Ball Dil,30mm",PX43249P,CDM,983,RC,43249,CPT,,,,,,,,1731,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1576.941,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,742.599,3257.54
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956401,NDC,1,EA,1611.2,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1578.976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,409.66,1655.3866
"MRI, Pelvis, W/O Then W/",PX7219701,CDM,610,RC,72197,CPT,TC,,,,,,,1612,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1579.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2066.35
Or Level 4,PX36000004,CDM,360,RC,,,,,,,,,,3805,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1580.597,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1580.597,3728.9
"Closed Rx Shldr Disloc,Anesthesia",PX23655F,CDM,510,RC,23655,CPT,,,,,,,,1776,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1580.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,737.7504,1740.48
"Sigmoidoscopy,Biopsy",PX45331F,CDM,750,RC,45331,CPT,,,,,,,,1776,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1580.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,737.7504,1740.48
"Lap,Cholecystectomy/Explore",PX47564P,CDM,983,RC,47564,CPT,,,,,,,,1613,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1580.74,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,668.41,2327.91
Closed Rx Femur Shaft Fx+Manip,PX27502F,CDM,510,RC,27502,CPT,,,,,,,,1625,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1580.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.19,1580.76
Closed Rx Femur Shaft Fx+Manip,PX27502F,CDM,510,RC,27502,CPT,,,,,,,,1625,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1580.76,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.19,1580.76
Closed Rx Femur Shaft Fx+Manip,PX27502P,CDM,983,RC,27502,CPT,,,,,,,,1083,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1580.76,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.19,1580.76
Closed Rx Femur Shaft Fx+Manip,PX27502P,CDM,983,RC,27502,CPT,,,,,,,,1083,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1580.76,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,466.19,1580.76
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270012,NDC,100,ML,3293.58,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1580.9184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270012,NDC,100,ML,3293.58,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1580.9184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
Exs Tumor Arm/Elbow Sc 3cm>,PX24071F,CDM,510,RC,24071,CPT,,,,,,,,1860,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1581,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,772.644,2482.37
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING4X6,C1781,CDM,278,RC,C1781,HCPCS,,12505-MAIN,LOCAL,,,,,1860,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1581,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561P,CDM,983,RC,36561,CPT,,,,,,,,1736,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1581.496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,721.1344,2784.63
MINIBUNION INSTRUMENT KIT,27200000,CDM,278,RC,C1713,HCPCS,,11668-MAIN,LOCAL,,,,,1860.65,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1581.5525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Closed Rx Femur Shaft Fx+Manip,PX27502F,CDM,510,RC,27502,CPT,,,,,,,,1625,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1581.6125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,675.025,1592.5
"Colonoscopy,Transendoscopic Stent",PX45387F,CDM,750,RC,45387,CPT,,,,,,,,3228,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1581.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1340.9112,3163.44
"Colonoscopy,Transendoscopic Stent",PX45387F,CDM,750,RC,45387,CPT,,,,,,,,3228,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1581.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1340.9112,3163.44
"Colonoscopy,Transendoscopic Stent",PX45387F,CDM,750,RC,45387,CPT,,,,,,,,3228,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1581.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1340.9112,3163.44
clobetasol 0.05 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,42291007760,NDC,60,GR,1625.97,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1582.556601,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CT Abdomen W/O & W/Dye,PX7417001,CDM,350,RC,74170,CPT,TC,,,,,,,3689,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1582.581,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3615.22
"CT Angiography, Chest",PX7127501,CDM,350,RC,71275,CPT,TC,,,,,,,3689,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1582.581,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3615.22
Exc Abd Les Sc < 3 Cm,PX22902F,CDM,761,RC,22902,CPT,,,,,,,,3128,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1582.768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1299.3712,3065.44
"CT Angiography, Head",PX7049601,CDM,350,RC,70496,CPT,TC,,,,,,,3690,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1583.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3616.2
"CT Angiography, Neck",PX7049801,CDM,350,RC,70498,CPT,TC,,,,,,,3690,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1583.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3616.2
"Hemorrhoidectomy,Int/Ext,Simple",PX46255F,CDM,510,RC,46255,CPT,,,,,,,,1627,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1592.5,percent of total billed charges,1583.5591,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,675.8558,2452.93
Level 4 Additional Procedure,PX36000083,CDM,360,RC,,,,,,,,,,3200,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1329.28,3136
"Closed Rx Weight Bear Dist Tib,Manip",PX27825P,CDM,983,RC,27825,CPT,,,,,,,,1796,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1584.072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,746.0584,1748.0468
Irrad/Lr Platelets,PXP9037,CDM,390,RC,P9037,HCPCS,,,,,,,,1617,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1584.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,616.6,1584.66
ALLOGRAFT BONE AUGMENT INJECTABLE KIT 1.5CC,C1734,CDM,278,RC,C1734,HCPCS,,12632-MAIN,LOCAL,,,,,3694,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1584.726,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1534.4876,3620.12
rabies immune globulin 300 UNIT/ML Solution 1 mL Vial,90376,CDM,636,RC,90375,CPT,,,,13533031801,NDC,1,ML,1629.06,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1585.564098,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,281.51,1596.4788
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING 8 IN CIRCLE,C1781,CDM,278,RC,C1781,HCPCS,,12506-MAIN,LOCAL,,,,,3240,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,196.035,percent of total billed charges,1587.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING 8 IN CIRCLE,C1781,CDM,278,RC,C1781,HCPCS,,12506-MAIN,LOCAL,,,,,3240,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1587.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING 8 IN CIRCLE,C1781,CDM,278,RC,C1781,HCPCS,,12506-MAIN,LOCAL,,,,,3240,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1587.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Chrom Anal, 20-25 Cells - Ref",PX8826490,CDM,310,RC,88264,CPT,90,,,,,,,3141,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1589.346,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.59,3078.18
"Tiss Cult, Neopl, Bm, Wb - Ref",PX8823790,CDM,310,RC,88237,CPT,90,,,,,,,3141,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1589.346,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,131.8,3078.18
MRI Pelvis W/Contrast Tc,PX7219601,CDM,610,RC,72196,CPT,TC,,,,,,,3143,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1590.358,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3080.14
fluticasone 220 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173072020,NDC,12,GR,1746.36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1590.93396,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
GOLIMumab 50 MG/4ML Solution 4 mL Vial,J1602.01,CDM,636,RC,J1602,HCPCS,,,,57894035001,NDC,4,ML,3709.76,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1591.48704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.31,3635.5648
"Diagnostic Bone Marrow, Biopsy and Aspiration",PX38222F,CDM,761,RC,38222,CPT,,,,,,,,1748,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1592.428,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,726.1192,2482.37
Closed Rx Femur Shaft Fx+Manip,PX27502F,CDM,510,RC,27502,CPT,,,,,,,,1625,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1592.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,675.025,1592.5
PROSTEP MICA SCREW 3.0X20MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12442-MAIN,LOCAL,,,,,1806,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1592.892,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 3.0X40MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12443-MAIN,LOCAL,,,,,1806,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1592.892,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X52MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12444-MAIN,LOCAL,,,,,1806,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1592.892,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
MRI Up Extremity Joint W/O Tc,PX7322101,CDM,610,RC,73221,CPT,TC,,,,,,,3319,,Health Partners,Health Partners Care Plans,both,48,,2736.51,percent of total billed charges,1593.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3252.62
MRI Up Extremity Joint W/O Tc,PX7322101,CDM,610,RC,73221,CPT,TC,,,,,,,3319,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1593.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3252.62
Reconstruc of Nail Bed W Graft,PX11762F,CDM,510,RC,11762,CPT,,,,,,,,1901,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1593.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,789.6754,1862.98
Skin Sub Graft Trnk/Arm/Leg,PX15271F,CDM,510,RC,15271,CPT,,,,,,,,862,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1593.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,358.0748,1593.14
Skin Sub Graft Trnk/Arm/Leg,PX15271P,CDM,983,RC,15271,CPT,,,,,,,,705,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1593.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,292.857,1593.14
clobetasol 0.05 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,42291007760,NDC,60,GR,1625.97,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1593.4506,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Amputation Finger/Thumb,PX26951F,CDM,510,RC,26951,CPT,,,,,,,,3253,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1593.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1351.2962,3187.94
Amputation Finger/Thumb,PX26951F,CDM,510,RC,26951,CPT,,,,,,,,3253,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1593.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1351.2962,3187.94
Amputation Finger/Thumb,PX26951F,CDM,510,RC,26951,CPT,,,,,,,,3253,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1593.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1351.2962,3187.94
MRI Upper W/O+W Tc,PX7322001,CDM,610,RC,73220,CPT,TC,,,,,,,3253,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1593.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3187.94
MRI Upper W/O+W Tc,PX7322001,CDM,610,RC,73220,CPT,TC,,,,,,,3253,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1593.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3187.94
MRI Upper W/O+W Tc,PX7322001,CDM,610,RC,73220,CPT,TC,,,,,,,3253,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1593.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3187.94
"MRI,Lwrext,No Jnt,No Cont",PX7371801,CDM,610,RC,73718,CPT,TC,,,,,,,3253,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1593.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3187.94
"MRI,Lwrext,No Jnt,No Cont",PX7371801,CDM,610,RC,73718,CPT,TC,,,,,,,3253,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1593.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3187.94
"MRI,Lwrext,No Jnt,No Cont",PX7371801,CDM,610,RC,73718,CPT,TC,,,,,,,3253,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1593.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3187.94
"MRI,Pelvis W/Out Contrast",PX7219501,CDM,610,RC,72195,CPT,TC,,,,,,,3253,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,650.6,percent of total billed charges,1593.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3187.94
"MRI,Pelvis W/Out Contrast",PX7219501,CDM,610,RC,72195,CPT,TC,,,,,,,3253,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1593.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3187.94
"MRI,Pelvis W/Out Contrast",PX7219501,CDM,610,RC,72195,CPT,TC,,,,,,,3253,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1593.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3187.94
"MRI,Up Ext,No Jnt,No Cont",PX7321801,CDM,610,RC,73218,CPT,TC,,,,,,,3253,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1593.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3187.94
"MRI,Up Ext,No Jnt,No Cont",PX7321801,CDM,610,RC,73218,CPT,TC,,,,,,,3253,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1593.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3187.94
"MRI,Up Ext,No Jnt,No Cont",PX7321801,CDM,610,RC,73218,CPT,TC,,,,,,,3253,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1593.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3187.94
"Closed Rx Radial Head/Neck Fx,Manip",PX24655F,CDM,510,RC,24655,CPT,,,,,,,,1750,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1594.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,726.95,1715
"Fix Exten Tendon,Dorsum Fingr,Ea",PX26418F,CDM,510,RC,26418,CPT,,,,,,,,1750,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1594.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,726.95,1715
"Hemorrhoidectomy,Int/Ext,Simple",PX46255F,CDM,510,RC,46255,CPT,,,,,,,,1627,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1594.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,675.8558,2452.93
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595F,CDM,360,RC,49595,CPT,,,,,,,,3503,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1595.98,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,453.53,1595.98
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595F,CDM,360,RC,49595,CPT,,,,,,,,3503,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1595.98,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,453.53,1595.98
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595P,CDM,982,RC,49595,CPT,,,,,,,,3503,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1595.98,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,453.53,3432.94
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595P,CDM,982,RC,49595,CPT,,,,,,,,3503,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1595.98,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,453.53,3432.94
rabies immune globulin 300 UNIT/ML Solution 1 mL Vial,90376,CDM,636,RC,90375,CPT,,,,13533031801,NDC,1,ML,1629.06,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1596.4788,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,281.51,1596.4788
clobetasol 0.05 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,21922001707,NDC,60,GR,1810.35,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1596.7287,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Colonoscopy,Transendoscopic Stent",PX45387F,CDM,750,RC,45387,CPT,,,,,,,,3228,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1597.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1340.9112,3163.44
darbepoetin alfa 200 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002801,NDC,0.4,ML,3157.92,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1597.90752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
Lap Partial Colectomy/Coloproctostomy,PX44207F,CDM,750,RC,44207,CPT,,,,,,,,4170,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,1598.1147,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1085.08,3724.65
Revise Ulnar Nerve at Elbow,PX64718P,CDM,983,RC,64718,CPT,,,,,,,,1642,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1598.1586,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,682.0868,1686.76
"CT Colonography, Screen",PX7426301,CDM,350,RC,74263,CPT,TC,,,,,,,3330,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1598.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1383.282,3263.4
"CT Colonography, Screen",PX7426301,CDM,350,RC,74263,CPT,TC,,,,,,,3330,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1598.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1383.282,3263.4
CT Lumbar Spine W/Dye,PX7213201,CDM,350,RC,72132,CPT,TC,,,,,,,3330,,Health Partners,Health Partners Care Plans,both,48,,1544.01,percent of total billed charges,1598.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3263.4
CT Lumbar Spine W/Dye,PX7213201,CDM,350,RC,72132,CPT,TC,,,,,,,3330,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1598.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3263.4
CT Pelvis W/Dye,PX7219301,CDM,350,RC,72193,CPT,TC,,,,,,,3330,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1598.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3263.4
CT Pelvis W/Dye,PX7219301,CDM,350,RC,72193,CPT,TC,,,,,,,3330,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1598.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3263.4
"Closed Rx Weight Bear Dist Tib,Manip",PX27825P,CDM,983,RC,27825,CPT,,,,,,,,1796,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1598.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,746.0584,1748.0468
CT Head/Brain W/O Dye,PX7045001,CDM,350,RC,70450,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999.3662222,fee schedule,1598.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
Cytogenomic Neoplasia (Genome-Wide) Microarray Analysis - Ref,PX8127790,CDM,310,RC,81277,CPT,90,,,,,,,3850,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1599.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1063.6,3773
CT Maxillofacial W/Dye,PX7048701,CDM,350,RC,70487,CPT,TC,,,,,,,3332,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1599.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3265.36
CT Maxillofacial W/Dye,PX7048701,CDM,350,RC,70487,CPT,TC,,,,,,,3332,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1599.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3265.36
FIXATION COMPONENT TOE JOINT PROXIMAL PHALANGEAL DF-P,C1713,CDM,278,RC,C1713,HCPCS,,12529-MAIN,LOCAL,,,,,1644,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1600.1052,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,60505611000,NDC,5,ML,1644.33,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,66.804,percent of total billed charges,1600.426389,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
MRI Brain WO Contrast Tc,PX7055101,CDM,610,RC,70551,CPT,TC,,,,,,,3335,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1600.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3268.3
MRI Brain WO Contrast Tc,PX7055101,CDM,610,RC,70551,CPT,TC,,,,,,,3335,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1600.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3268.3
MRI Orbit/Face/Neck Tc,PX7054001,CDM,610,RC,70540,CPT,TC,,,,,,,3335,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1600.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3268.3
MRI Orbit/Face/Neck Tc,PX7054001,CDM,610,RC,70540,CPT,TC,,,,,,,3335,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1600.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3268.3
MRI T Spine WO Contrast,PX7214601,CDM,610,RC,72146,CPT,TC,,,,,,,3267,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1600.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3201.66
MRI T Spine WO Contrast,PX7214601,CDM,610,RC,72146,CPT,TC,,,,,,,3267,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1600.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3201.66
MRI T Spine WO Contrast,PX7214601,CDM,610,RC,72146,CPT,TC,,,,,,,3267,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1600.83,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3201.66
MESH VENTRALIGHT ECHO 2.0 POSITIONING 15CM ROUND,C1781,CDM,278,RC,C1781,HCPCS,,12842-MAIN,LOCAL,,,,,1816,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1601.712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
bortezomib 3.5 MG Recon Soln 1 Each Vial,J9041.01,CDM,636,RC,J9041,HCPCS,,,,63020004901,NDC,1,EA,3270.12,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,5.636292835,percent of total billed charges,1602.3588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.79,3204.7176
bortezomib 3.5 MG Recon Soln 1 Each Vial,J9041.01,CDM,636,RC,J9041,HCPCS,,,,63020004901,NDC,1,EA,3270.12,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1602.3588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.79,3204.7176
bortezomib 3.5 MG Recon Soln 1 Each Vial,J9041.01,CDM,636,RC,J9041,HCPCS,,,,63020004901,NDC,1,EA,3270.12,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1602.3588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.79,3204.7176
fluticasone 220 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,66993008096,NDC,12,GR,1760.13,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1603.47843,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING 8 IN CIRCLE,C1781,CDM,278,RC,C1781,HCPCS,,12506-MAIN,LOCAL,,,,,3240,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1603.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
MRI Lower W/O+W Tc,PX7372001,CDM,610,RC,73720,CPT,TC,,,,,,,3174,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1606.044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3110.52
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180F,CDM,510,RC,44180,CPT,,,,,,,,1763,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1606.093,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,732.3502,5040.74
Lap Rpr Vent Umbilical Hernia,PX49652F,CDM,510,RC,49652,CPT,,,,,,,,1890,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1606.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,785.106,1852.2
Room Rate General Iso,PX12000001,CDM,120,RC,,,,,,,,,,1822,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1607.004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,756.8588,1785.56
PROSTEP MICA SCREW 3.0X20MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12442-MAIN,LOCAL,,,,,1806,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1607.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 3.0X40MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12443-MAIN,LOCAL,,,,,1806,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1607.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X52MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12444-MAIN,LOCAL,,,,,1806,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1607.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
trastuzumab 150 MG Recon Soln 1 Each Vial,J9355.01,CDM,636,RC,J9355,HCPCS,,,,50242013201,NDC,1,EA,3179.17,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1608.66002,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.77,3115.5866
"Closed Rx Radial Head/Neck Fx,Manip",PX24655P,CDM,983,RC,24655,CPT,,,,,,,,1824,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1608.768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,757.6896,1775.2992
Revise Ulnar Nerve at Elbow,PX64718P,CDM,983,RC,64718,CPT,,,,,,,,1642,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1609.16,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,379.58,1609.16
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569P,CDM,983,RC,36569,CPT,,,,,,,,1825,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1609.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,758.105,1776.2725
Amputation Finger/Thumb,PX26951F,CDM,510,RC,26951,CPT,,,,,,,,3253,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1610.235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1351.2962,3187.94
MRI Upper W/O+W Tc,PX7322001,CDM,610,RC,73220,CPT,TC,,,,,,,3253,,Humana Choice Care,All Medicare plans,outpatient,49.5,,1330.2,percent of total billed charges,1610.235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3187.94
"MRI,Lwrext,No Jnt,No Cont",PX7371801,CDM,610,RC,73718,CPT,TC,,,,,,,3253,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1610.235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3187.94
"MRI,Pelvis W/Out Contrast",PX7219501,CDM,610,RC,72195,CPT,TC,,,,,,,3253,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1610.235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3187.94
"MRI,Up Ext,No Jnt,No Cont",PX7321801,CDM,610,RC,73218,CPT,TC,,,,,,,3253,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1610.235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3187.94
fluticasone-umeclidin-vilant 100-62.5-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173088714,NDC,28,EA,1894.99,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1610.7415,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
FIXATION COMPONENT TOE JOINT PROXIMAL PHALANGEAL DF-P,C1713,CDM,278,RC,C1713,HCPCS,,12529-MAIN,LOCAL,,,,,1644,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1611.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
clobetasol 0.05 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,21922001707,NDC,60,GR,1810.35,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1611.2115,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,60505611000,NDC,5,ML,1644.33,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1611.4434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
"Bone Scan, Whole Body",PX7830601,CDM,341,RC,78306,CPT,TC,,,,,,,1896,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1611.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,360.31,1858.08
"Sb Scope,to Ileum,Biopsy",PX44377F,CDM,750,RC,44377,CPT,,,,,,,,1770,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1612.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,735.258,1734.6
RESTRATA WOUND MATRIX 2.5CM X 2.5CM TOTAL 6.25CM,27200000,CDM,272,RC,A2007,HCPCS,,11733-MAIN,LOCAL,,,,,1829,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1613.178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270012,NDC,100,ML,3293.58,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,62.691,percent of total billed charges,1613.8542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270012,NDC,100,ML,3293.58,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1613.8542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270012,NDC,100,ML,3293.58,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1613.8542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
Or Level 2,PX36000002,CDM,360,RC,,,,,,,,,,1900,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,789.26,1862
Reconstruc of Nail Bed W Graft,PX11762F,CDM,510,RC,11762,CPT,,,,,,,,1901,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1615.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,789.6754,1862.98
MESH VENTRALIGHT ECHO 2.0 POSITIONING 15CM ROUND,C1781,CDM,278,RC,C1781,HCPCS,,12842-MAIN,LOCAL,,,,,1816,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1616.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Peramivir 200 MG/20ML Solution 20 mL Vial,800000,CDM,,,,,,,,61364018101,NDC,20,ML,1832.6,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1616.3532,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
"Treat Thumb Disloc,Manipulatn",PX26641P,CDM,983,RC,26641,CPT,,,,,,,,1902,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1616.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1851.2166
Injection for Nerve Block,PX64447P,CDM,983,RC,64447,CPT,,,,,,,,3892,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1616.7368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,604.15,3788.0836
MRI T Spine WO Contrast,PX7214601,CDM,610,RC,72146,CPT,TC,,,,,,,3267,,Humana Choice Care,All Medicare plans,outpatient,49.5,,1853.3,percent of total billed charges,1617.165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3201.66
"Closed Rx Shldr Disloc,Anesthesia",PX23655F,CDM,510,RC,23655,CPT,,,,,,,,1776,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1617.936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,737.7504,1740.48
"Sigmoidoscopy,Biopsy",PX45331F,CDM,750,RC,45331,CPT,,,,,,,,1776,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1617.936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,737.7504,1740.48
fluticasone-salmeterol 230-21 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,66993008896,NDC,12,GR,1904.14,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1618.519,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
bortezomib 3.5 MG Recon Soln 1 Each Vial,J9041.01,CDM,636,RC,J9041,HCPCS,,,,63020004901,NDC,1,EA,3270.12,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1618.7094,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.79,3204.7176
Remv Periton FB From Perit Cav,PX49402P,CDM,983,RC,49402,CPT,,,,,,,,3897,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1618.8138,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1618.8138,3792.9501
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032605,NDC,0.8,ML,1663.54,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1.757613333,percent of total billed charges,1619.123482,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,1630.2692
Level 4 Additional Procedure,PX36000083,CDM,360,RC,,,,,,,,,,3200,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1619.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1329.28,3136
clobetasol 0.05 % Cream 60 g Tube,63700001,CDM,250,RC,,,,,,69238153206,NDC,60,GR,1665.95,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1621.469135,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Room Rate General Iso,PX12000001,CDM,120,RC,,,,,,,,,,1822,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1621.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,756.8588,1785.56
LARGE HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12836-MAIN,LOCAL,,,,,3905,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1622.137,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
MEDIUM HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12835-MAIN,LOCAL,,,,,3905,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1622.137,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
SMALL HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12655-MAIN,LOCAL,,,,,3905,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1622.137,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
leuprolide 7.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74364203,NDC,1,EA,3782.28,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1622.59812,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
"Closed Rx Radial Head/Neck Fx,Manip",PX24655P,CDM,983,RC,24655,CPT,,,,,,,,1824,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1623.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,757.6896,1775.2992
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569P,CDM,983,RC,36569,CPT,,,,,,,,1825,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1624.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,758.105,1776.2725
GRAFIXPL PRIME PLACENTAL MEMBRANE 2x3CM 6SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12765-MAIN,LOCAL,,,,,1911,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1624.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
rabies immune globulin 300 UNIT/2ML Solution 2 mL Vial,90377,CDM,636,RC,90376,CPT,,,,49281019020,NDC,2,ML,3384.84,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1624.7232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,207.94,3317.1432
rabies immune globulin 300 UNIT/2ML Solution 2 mL Vial,90377,CDM,636,RC,90376,CPT,,,,49281019020,NDC,2,ML,3384.84,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1624.7232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,207.94,3317.1432
Room Rate Swing General,PX12000010,CDM,120,RC,,,,,,,,,,3788,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1625.052,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1573.5352,3712.24
Room Rate Swing General Iso,PX12000011,CDM,120,RC,,,,,,,,,,3788,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1625.052,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1573.5352,3712.24
DYNABUNION PLATE STERILE INSTRUMENT KIT,27200000,CDM,272,RC,,,,12465-MAIN,LOCAL,,,,,1843,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1625.526,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Excis Tendn/Capsule Lesn,Toes",PX28092P,CDM,983,RC,28092,CPT,,,,,,,,1913,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1626.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,794.6602,1861.9229
fluticasone-salmeterol 500-50 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069704,NDC,14,EA,1670.75,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1626.140975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
MRI Up Extremity Joint W/O Tc,PX7322101,CDM,610,RC,73221,CPT,TC,,,,,,,3319,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1387.465,percent of total billed charges,1626.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3252.62
MRI Up Extremity Joint W/O Tc,PX7322101,CDM,610,RC,73221,CPT,TC,,,,,,,3319,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1626.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3252.62
MRI Up Extremity Joint W/O Tc,PX7322101,CDM,610,RC,73221,CPT,TC,,,,,,,3319,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1626.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3252.62
romiPLOStim 250 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022101,NDC,1,EA,3791.51,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1626.55779,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.04,6877.885
RESTRATA WOUND MATRIX 2.5CM X 2.5CM TOTAL 6.25CM,27200000,CDM,272,RC,A2007,HCPCS,,11733-MAIN,LOCAL,,,,,1829,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1627.81,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PLANTAR PLATE IMPLANT SET GRAVITY REPAIR,C1713,CDM,278,RC,C1713,HCPCS,,12649-MAIN,LOCAL,,,,,3921,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1628.7834,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
ferumoxytol 510 MG/17ML Solution 17 mL Vial,Q0138.01,CDM,636,RC,Q0138,HCPCS,,,,781315401,NDC,17,ML,1846.91,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1628.97462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.32,1809.9718
riTUXimab 100 MG/10ML Solution 10 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005121,NDC,10,ML,1916.61,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1629.1185,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.61,8682.8588
Hepatobil Syst Image W/Drug,PX7822701,CDM,341,RC,78227,CPT,TC,,,,,,,1674,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1629.3042,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,472.19,1640.52
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032605,NDC,0.8,ML,1663.54,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1630.2692,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.28,1630.2692
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270012,NDC,100,ML,3293.58,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1630.3221,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
Peramivir 200 MG/20ML Solution 20 mL Vial,800000,CDM,,,,,,,,61364018101,NDC,20,ML,1832.6,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1631.014,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
CT Head/Brain W/Dye,PX7046001,CDM,350,RC,70460,CPT,TC,,,,,,,3398,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1631.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3330.04
CT Head/Brain W/Dye,PX7046001,CDM,350,RC,70460,CPT,TC,,,,,,,3398,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1631.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3330.04
"CT Colonography, Screen",PX7426301,CDM,350,RC,74263,CPT,TC,,,,,,,3330,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1631.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1383.282,3263.4
"CT Colonography, Screen",PX7426301,CDM,350,RC,74263,CPT,TC,,,,,,,3330,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1631.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1383.282,3263.4
"CT Colonography, Screen",PX7426301,CDM,350,RC,74263,CPT,TC,,,,,,,3330,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1631.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1383.282,3263.4
CT Lumbar Spine W/Dye,PX7213201,CDM,350,RC,72132,CPT,TC,,,,,,,3330,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1631.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3263.4
CT Lumbar Spine W/Dye,PX7213201,CDM,350,RC,72132,CPT,TC,,,,,,,3330,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1631.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3263.4
CT Lumbar Spine W/Dye,PX7213201,CDM,350,RC,72132,CPT,TC,,,,,,,3330,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1631.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3263.4
CT Pelvis W/Dye,PX7219301,CDM,350,RC,72193,CPT,TC,,,,,,,3330,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1631.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3263.4
CT Pelvis W/Dye,PX7219301,CDM,350,RC,72193,CPT,TC,,,,,,,3330,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1631.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3263.4
CT Pelvis W/Dye,PX7219301,CDM,350,RC,72193,CPT,TC,,,,,,,3330,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1631.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3263.4
"MRI,Lwrext,Jnt W/O+W/Cont",PX7372301,CDM,610,RC,73723,CPT,TC,,,,,,,1850,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1631.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2066.35
Sleep Staging 4 + Pap,PX9581126,CDM,982,RC,95811,CPT,26,,,,,,,1850,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1631.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,768.49,1800.605
Or Level 4,PX36000004,CDM,360,RC,,,,,,,,,,3805,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1632.345,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1580.597,3728.9
clobetasol 0.05 % Cream 60 g Tube,63700001,CDM,250,RC,,,,,,69238153206,NDC,60,GR,1665.95,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1632.631,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CT Maxillofacial W/Dye,PX7048701,CDM,350,RC,70487,CPT,TC,,,,,,,3332,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1632.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3265.36
CT Maxillofacial W/Dye,PX7048701,CDM,350,RC,70487,CPT,TC,,,,,,,3332,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1632.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3265.36
CT Maxillofacial W/Dye,PX7048701,CDM,350,RC,70487,CPT,TC,,,,,,,3332,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1632.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3265.36
alteplase 100 MG Recon Soln 1 Each Syringe,J2997.01,CDM,636,RC,J2997,HCPCS,,,,88888800475,NDC,0.09,EA,1920.88,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1632.748,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
"Colonoscopy,Transendoscopic Stent",PX45387F,CDM,750,RC,45387,CPT,,,,,,,,3228,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1633.368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1340.9112,3163.44
REAMER FOR CROSS PLATES,27200000,CDM,272,RC,,,,12641-MAIN,LOCAL,,,,,1852,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1633.464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MRI Brain WO Contrast Tc,PX7055101,CDM,610,RC,70551,CPT,TC,,,,,,,3335,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1074.48,percent of total billed charges,1634.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3268.3
MRI Brain WO Contrast Tc,PX7055101,CDM,610,RC,70551,CPT,TC,,,,,,,3335,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1634.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3268.3
MRI Brain WO Contrast Tc,PX7055101,CDM,610,RC,70551,CPT,TC,,,,,,,3335,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1634.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3268.3
MRI Orbit/Face/Neck Tc,PX7054001,CDM,610,RC,70540,CPT,TC,,,,,,,3335,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1634.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3268.3
MRI Orbit/Face/Neck Tc,PX7054001,CDM,610,RC,70540,CPT,TC,,,,,,,3335,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1634.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3268.3
MRI Orbit/Face/Neck Tc,PX7054001,CDM,610,RC,70540,CPT,TC,,,,,,,3335,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1634.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3268.3
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,781307912,NDC,5,ML,1854.23,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1635.43086,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.74,1938.2734
"Closed Rx Weight Bear Dist Tib,Manip",PX27825P,CDM,983,RC,27825,CPT,,,,,,,,1796,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1636.156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,746.0584,1748.0468
fluticasone-salmeterol 500-50 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069704,NDC,14,EA,1670.75,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1637.335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Revise Median N/Carpal Tunnel Surg,PX64721P,CDM,983,RC,64721,CPT,,,,,,,,1927,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1637.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,800.4758,1875.5491
"Tte W/Doppler, Complete",PXC8929,CDM,480,RC,C8929,HCPCS,TC,,,,,,,1927,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1637.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,699.48,1888.46
CT Abdomen W/Dye,PX7416001,CDM,350,RC,74160,CPT,TC,,,,,,,3413,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1638.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3344.74
CT Abdomen W/Dye,PX7416001,CDM,350,RC,74160,CPT,TC,,,,,,,3413,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1638.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3344.74
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266F,CDM,510,RC,27266,CPT,,,,,,,,1684,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1639.0372,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,699.5336,1650.32
PROSTEP MICA SCREW 3.0X34MM STERILE IMPLANT,27200000,CDM,272,RC,,,,13042-MAIN,LOCAL,,,,,1684,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1639.0372,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CT Soft Tissue Neck W/Dye,PX7049101,CDM,350,RC,70491,CPT,TC,,,,,,,3415,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1639.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3346.7
CT Soft Tissue Neck W/Dye,PX7049101,CDM,350,RC,70491,CPT,TC,,,,,,,3415,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1639.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3346.7
Diagnostic CT Thorax W/ Contrast,PX7126001,CDM,350,RC,71260,CPT,TC,,,,,,,3415,,Health Partners,Health Partners Care Plans,both,48,,1994.17,percent of total billed charges,1639.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3346.7
Diagnostic CT Thorax W/ Contrast,PX7126001,CDM,350,RC,71260,CPT,TC,,,,,,,3415,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1639.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3346.7
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING 8 IN CIRCLE,C1781,CDM,278,RC,C1781,HCPCS,,12506-MAIN,LOCAL,,,,,3240,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1639.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
DYNABUNION PLATE STERILE INSTRUMENT KIT,27200000,CDM,272,RC,,,,12465-MAIN,LOCAL,,,,,1843,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1640.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Exs Tumor Arm/Elbow Sc 3cm>,PX24071F,CDM,510,RC,24071,CPT,,,,,,,,1860,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1640.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,772.644,2482.37
Hepatobil Syst Image W/Drug,PX7822701,CDM,341,RC,78227,CPT,TC,,,,,,,1674,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1640.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,472.19,1640.52
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING4X6,C1781,CDM,278,RC,C1781,HCPCS,,12505-MAIN,LOCAL,,,,,1860,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1640.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
inFLIXimab-dyyb 100 MG Recon Soln 1 Each Vial,Q5103.01,CDM,636,RC,Q5103,HCPCS,,,,69080901,NDC,1,EA,1930.42,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1640.857,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.85,1891.8116
Ventilator Mgmt.Subsequent Days,PX94003F,CDM,410,RC,94003,CPT,,,,,,,,1686,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1640.9838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,547.46,1652.28
MINIBUNION INSTRUMENT KIT,27200000,CDM,278,RC,C1713,HCPCS,,11668-MAIN,LOCAL,,,,,1860.65,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1641.0933,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MRI Up Extremity Joint W/O Tc,PX7322101,CDM,610,RC,73221,CPT,TC,,,,,,,3319,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1642.905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3252.62
Room Rate General,PX12000000,CDM,120,RC,,,,,,,,,,1688,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1642.9304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,701.1952,1654.24
ferumoxytol 510 MG/17ML Solution 17 mL Vial,Q0138.01,CDM,636,RC,Q0138,HCPCS,,,,781315401,NDC,17,ML,1846.91,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1643.7499,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.32,1809.9718
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956410,NDC,1,EA,1689.17,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1644.069161,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,409.66,1655.3866
DOCEtaxel 20 MG/ML Concentrate 1 mL Vial,63600000,CDM,636,RC,J9171,HCPCS,,,,955102001,NDC,1,ML,1690.09,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1644.964597,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
PROSTEP MICA SCREW 3.0X20MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12442-MAIN,LOCAL,,,,,1806,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1645.266,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 3.0X40MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12443-MAIN,LOCAL,,,,,1806,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1645.266,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X52MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12444-MAIN,LOCAL,,,,,1806,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1645.266,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Amputation Finger/Thumb,PX26951F,CDM,510,RC,26951,CPT,,,,,,,,3253,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1646.018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1351.2962,3187.94
MRI Upper W/O+W Tc,PX7322001,CDM,610,RC,73220,CPT,TC,,,,,,,3253,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1646.018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3187.94
"MRI,Lwrext,No Jnt,No Cont",PX7371801,CDM,610,RC,73718,CPT,TC,,,,,,,3253,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1646.018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3187.94
"MRI,Pelvis W/Out Contrast",PX7219501,CDM,610,RC,72195,CPT,TC,,,,,,,3253,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1646.018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3187.94
"MRI,Up Ext,No Jnt,No Cont",PX7321801,CDM,610,RC,73218,CPT,TC,,,,,,,3253,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1646.018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3187.94
"MRI,Lwrext,Jnt W/O+W/Cont",PX7372301,CDM,610,RC,73723,CPT,TC,,,,,,,1850,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1646.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2066.35
Sleep Staging 4 + Pap,PX9581126,CDM,982,RC,95811,CPT,26,,,,,,,1850,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1646.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,768.49,1800.605
"Colonoscopy,Remv Lesn,Snare",PX45385F,CDM,750,RC,45385,CPT,,,,,,,,1939,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1648.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,831.831,4050.42
REAMER FOR CROSS PLATES,27200000,CDM,272,RC,,,,12641-MAIN,LOCAL,,,,,1852,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1648.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MODULAR INSERT TOE JOINT 2.5MM 3.6MMTHK PROXIMAL PHALANGEAL,C1713,CDM,278,RC,C1713,HCPCS,,12530-MAIN,LOCAL,,,,,3968,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1648.3072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"CT Colonography, Screen",PX7426301,CDM,350,RC,74263,CPT,TC,,,,,,,3330,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1648.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1383.282,3263.4
CT Lumbar Spine W/Dye,PX7213201,CDM,350,RC,72132,CPT,TC,,,,,,,3330,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1648.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3263.4
CT Pelvis W/Dye,PX7219301,CDM,350,RC,72193,CPT,TC,,,,,,,3330,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1648.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3263.4
clobetasol 0.05 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,21922001707,NDC,60,GR,1810.35,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1649.22885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CT Maxillofacial W/Dye,PX7048701,CDM,350,RC,70487,CPT,TC,,,,,,,3332,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1649.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3265.36
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,781307912,NDC,5,ML,1854.23,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1650.2647,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.74,1938.2734
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266F,CDM,510,RC,27266,CPT,,,,,,,,1684,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1650.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,699.5336,1650.32
PROSTEP MICA SCREW 3.0X34MM STERILE IMPLANT,27200000,CDM,272,RC,,,,13042-MAIN,LOCAL,,,,,1684,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1650.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MRI Brain WO Contrast Tc,PX7055101,CDM,610,RC,70551,CPT,TC,,,,,,,3335,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1650.825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3268.3
MRI Orbit/Face/Neck Tc,PX7054001,CDM,610,RC,70540,CPT,TC,,,,,,,3335,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1650.825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3268.3
Cytogenomic Neoplasia (Genome-Wide) Microarray Analysis - Ref,PX8127790,CDM,310,RC,81277,CPT,90,,,,,,,3850,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1651.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1063.6,3773
Ventilator Mgmt.Subsequent Days,PX94003F,CDM,410,RC,94003,CPT,,,,,,,,1686,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1652.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,547.46,1652.28
MRI T Spine WO Contrast,PX7214601,CDM,610,RC,72146,CPT,TC,,,,,,,3267,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1653.102,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3201.66
Room Rate General,PX12000000,CDM,120,RC,,,,,,,,,,1688,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1654.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,701.1952,1654.24
MESH VENTRALIGHT ECHO 2.0 POSITIONING 15CM ROUND,C1781,CDM,278,RC,C1781,HCPCS,,12842-MAIN,LOCAL,,,,,1816,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1654.376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Lap,Appendectomy",PX44970P,CDM,983,RC,44970,CPT,,,,,,,,1700,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1483.07,percent of total billed charges,1654.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,706.18,5040.74
bortezomib 3.5 MG Recon Soln 1 Each Vial,J9041.01,CDM,636,RC,J9041,HCPCS,,,,63020004901,NDC,1,EA,3270.12,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1654.68072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.79,3204.7176
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956410,NDC,1,EA,1689.17,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1655.3866,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,409.66,1655.3866
Exs Tumor Arm/Elbow Sc 3cm>,PX24071F,CDM,510,RC,24071,CPT,,,,,,,,1860,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1655.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,772.644,2482.37
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING4X6,C1781,CDM,278,RC,C1781,HCPCS,,12505-MAIN,LOCAL,,,,,1860,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1655.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
MINIBUNION INSTRUMENT KIT,27200000,CDM,278,RC,C1713,HCPCS,,11668-MAIN,LOCAL,,,,,1860.65,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1655.9785,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DOCEtaxel 20 MG/ML Concentrate 1 mL Vial,63600000,CDM,636,RC,J9171,HCPCS,,,,955102001,NDC,1,ML,1690.09,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1656.2882,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.325126,1656.2882
"Amputation Toe,Mt-P Jt",PX28820F,CDM,510,RC,28820,CPT,,,,,,,,1950,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1657.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,810.03,2827.75
rabies immune globulin 300 UNIT/2ML Solution 2 mL Vial,90377,CDM,636,RC,90376,CPT,,,,49281019020,NDC,2,ML,3384.84,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1658.5716,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,207.94,3317.1432
rabies immune globulin 300 UNIT/2ML Solution 2 mL Vial,90377,CDM,636,RC,90376,CPT,,,,49281019020,NDC,2,ML,3384.84,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1658.5716,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,207.94,3317.1432
rabies immune globulin 300 UNIT/2ML Solution 2 mL Vial,90377,CDM,636,RC,90376,CPT,,,,49281019020,NDC,2,ML,3384.84,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1658.5716,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,207.94,3317.1432
"Closed Rx Talus Fx,Manipulatn",PX28435F,CDM,510,RC,28435,CPT,,,,,,,,1705,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1659.4765,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,708.257,1670.9
Room Rate General Iso,PX12000001,CDM,120,RC,,,,,,,,,,1822,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1659.842,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,756.8588,1785.56
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270010,NDC,100,ML,3458.14,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1659.9072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270010,NDC,100,ML,3458.14,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1659.9072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
"Closed Rx Radial Head/Neck Fx,Manip",PX24655P,CDM,983,RC,24655,CPT,,,,,,,,1824,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1661.664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,757.6896,1775.2992
FORCEPS SPOON JAWSIZE 10MMX36 KIT,27200000,CDM,272,RC,,,,11749-MAIN,LOCAL,,,,,1955,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1661.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,67457061910,NDC,100,ML,1707.48,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,66.804,percent of total billed charges,1661.890284,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
Egd Balloon Dil Esoph30 Mm/>,PX43233F,CDM,750,RC,43233,CPT,,,,,,,,1120,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1662.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,465.248,1662.33
Egd Balloon Dil Esoph30 Mm/>,PX43233P,CDM,983,RC,43233,CPT,,,,,,,,480,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1662.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,199.392,1662.33
"Sb Scope,to Ileum,Biopsy",PX44377F,CDM,750,RC,44377,CPT,,,,,,,,1770,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1662.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,735.258,1734.6
"Sb Scope,to Ileum,Biopsy",PX44377P,CDM,983,RC,44377,CPT,,,,,,,,1180,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1662.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,490.172,1662.33
"Up GI Endoscopy,Ball Dil,30mm",PX43249F,CDM,750,RC,43249,CPT,,,,,,,,2596,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1662.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,958.1,3257.54
"Up GI Endoscopy,Ball Dil,30mm",PX43249P,CDM,983,RC,43249,CPT,,,,,,,,1731,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1662.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,742.599,3257.54
"Upper GI Endoscopy,Ctrl Bleed",PX43255F,CDM,750,RC,43255,CPT,,,,,,,,1723,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1662.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,715.7342,1688.54
"Upper GI Endoscopy,Ctrl Bleed",PX43255P,CDM,983,RC,43255,CPT,,,,,,,,1148,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1662.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,476.8792,1662.33
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569P,CDM,983,RC,36569,CPT,,,,,,,,1825,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1662.575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,758.105,1776.2725
Infection Agent Detect Dna/Rna Probe Tq 6-11,PX87506,CDM,300,RC,87506,CPT,,,,,,,,1710,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1664.343,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,241.14,1675.8
"Sigmoidoscopy,Remv Lesn,Snare",PX45338P,CDM,983,RC,45338,CPT,,,,,,,,1710,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1664.343,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,710.334,1664.343
CT Head/Brain W/Dye,PX7046001,CDM,350,RC,70460,CPT,TC,,,,,,,3398,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1665.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3330.04
CT Head/Brain W/Dye,PX7046001,CDM,350,RC,70460,CPT,TC,,,,,,,3398,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1665.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3330.04
CT Head/Brain W/Dye,PX7046001,CDM,350,RC,70460,CPT,TC,,,,,,,3398,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1665.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3330.04
"Cardiac Stress Tst,Tracing Only",PX93017,CDM,482,RC,93017,CPT,,,,,,,,1959,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1665.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.21,1919.82
"Lap,Appendectomy",PX44970P,CDM,983,RC,44970,CPT,,,,,,,,1700,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1666,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,362.78,1666
RESTRATA WOUND MATRIX 2.5CM X 2.5CM TOTAL 6.25CM,27200000,CDM,272,RC,A2007,HCPCS,,11733-MAIN,LOCAL,,,,,1829,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1666.219,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270012,NDC,100,ML,3293.58,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1666.55148,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
"Mra, Neck W/O+W/ Contrast",PX7054901,CDM,610,RC,70549,CPT,TC,,,,,,,3472,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1666.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3402.56
"Mra, Neck W/O+W/ Contrast",PX7054901,CDM,610,RC,70549,CPT,TC,,,,,,,3472,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1666.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3402.56
"Closure of Gastrostomy,Surgical",PX43870P,CDM,983,RC,43870,CPT,,,,,,,,4012,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1666.5848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1666.5848,3904.8796
Lap Rpr Vent Umbilical Hernia,PX49652F,CDM,510,RC,49652,CPT,,,,,,,,1890,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1666.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,785.106,1852.2
Lap Incis Hernia Reducible,PX49654F,CDM,510,RC,49654,CPT,,,,,,,,1964,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1669.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,815.8456,1924.72
Peramivir 200 MG/20ML Solution 20 mL Vial,800000,CDM,,,,,,,,61364018101,NDC,20,ML,1832.6,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1669.4986,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Injection for Nerve Block,PX64447P,CDM,983,RC,64447,CPT,,,,,,,,3892,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1669.668,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,604.15,3788.0836
"Closed Rx Talus Fx,Manipulatn",PX28435F,CDM,510,RC,28435,CPT,,,,,,,,1705,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1670.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,708.257,1670.9
fluticasone-umeclidin-vilant 100-62.5-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173088714,NDC,28,EA,1894.99,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1671.38118,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Remv Periton FB From Perit Cav,PX49402P,CDM,983,RC,49402,CPT,,,,,,,,3897,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1671.813,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1618.8138,3792.9501
agalsidase beta 5 MG Recon Soln 1 Each Vial,J0180.01,CDM,636,RC,J0180,HCPCS,,,,58468004101,NDC,1,EA,1717.68,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1671.817944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,200.2,1683.3264
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290101,NDC,1,EA,1966.88,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1671.848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.77,1927.5424
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290102,NDC,1,EA,1966.88,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1671.848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.77,1927.5424
"Bone Scan, Whole Body",PX7830601,CDM,341,RC,78306,CPT,TC,,,,,,,1896,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1672.272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,360.31,1858.08
CT Abdomen W/Dye,PX7416001,CDM,350,RC,74160,CPT,TC,,,,,,,3413,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,2894.55,percent of total billed charges,1672.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3344.74
CT Abdomen W/Dye,PX7416001,CDM,350,RC,74160,CPT,TC,,,,,,,3413,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1672.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3344.74
CT Abdomen W/Dye,PX7416001,CDM,350,RC,74160,CPT,TC,,,,,,,3413,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1672.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3344.74
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,67457061910,NDC,100,ML,1707.48,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1673.3304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.930644,1673.3304
CT Soft Tissue Neck W/Dye,PX7049101,CDM,350,RC,70491,CPT,TC,,,,,,,3415,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,676.3333333,percent of total billed charges,1673.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3346.7
CT Soft Tissue Neck W/Dye,PX7049101,CDM,350,RC,70491,CPT,TC,,,,,,,3415,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1673.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3346.7
CT Soft Tissue Neck W/Dye,PX7049101,CDM,350,RC,70491,CPT,TC,,,,,,,3415,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1673.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3346.7
Diagnostic CT Thorax W/ Contrast,PX7126001,CDM,350,RC,71260,CPT,TC,,,,,,,3415,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,675.9411765,percent of total billed charges,1673.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3346.7
Diagnostic CT Thorax W/ Contrast,PX7126001,CDM,350,RC,71260,CPT,TC,,,,,,,3415,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1673.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3346.7
Diagnostic CT Thorax W/ Contrast,PX7126001,CDM,350,RC,71260,CPT,TC,,,,,,,3415,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1673.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3346.7
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573P,CDM,983,RC,36573,CPT,,,,,,,,1721,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1675.0493,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,714.9034,1675.0493
"Treat Thumb Disloc,Manipulatn",PX26641F,CDM,510,RC,26641,CPT,,,,,,,,1721,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1675.0493,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1686.58
LARGE HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12836-MAIN,LOCAL,,,,,3905,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1675.245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
MEDIUM HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12835-MAIN,LOCAL,,,,,3905,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1675.245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
SMALL HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12655-MAIN,LOCAL,,,,,3905,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1675.245,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
rabies immune globulin 300 UNIT/2ML Solution 2 mL Vial,90377,CDM,636,RC,90376,CPT,,,,49281019020,NDC,2,ML,3384.84,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1675.4958,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,207.94,3317.1432
Infection Agent Detect Dna/Rna Probe Tq 6-11,PX87506,CDM,300,RC,87506,CPT,,,,,,,,1710,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1675.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,241.14,1675.8
Or Level 2,PX36000002,CDM,360,RC,,,,,,,,,,1900,,United Healthcare,All Payer,outpatient,88.2,,999999999,case rate,1675.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1675.8,6141.46
"Sigmoidoscopy,Remv Lesn,Snare",PX45338P,CDM,983,RC,45338,CPT,,,,,,,,1710,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1675.8,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.52,1675.8
Reconstruc of Nail Bed W Graft,PX11762F,CDM,510,RC,11762,CPT,,,,,,,,1901,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1676.682,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,789.6754,1862.98
"Upper GI Endoscopy,Ctrl Bleed",PX43255F,CDM,750,RC,43255,CPT,,,,,,,,1723,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1676.9959,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,715.7342,1688.54
"Treat Thumb Disloc,Manipulatn",PX26641P,CDM,983,RC,26641,CPT,,,,,,,,1902,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1677.564,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1851.2166
DYNABUNION PLATE STERILE INSTRUMENT KIT,27200000,CDM,272,RC,,,,12465-MAIN,LOCAL,,,,,1843,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1678.973,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MRI Up Extremity Joint W/O Tc,PX7322101,CDM,610,RC,73221,CPT,TC,,,,,,,3319,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1679.414,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3252.62
fluticasone-salmeterol 230-21 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,66993008896,NDC,12,GR,1904.14,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1679.45148,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Repair Ing Hernia,5+Y/O,Strang",PX49507F,CDM,510,RC,49507,CPT,,,,,,,,1977,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1680.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,821.2458,3022.41
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,310072010,NDC,5,ML,1977.83,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1681.1555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.74,1938.2734
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595F,CDM,360,RC,49595,CPT,,,,,,,,3503,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1681.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1455.1462,3432.94
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595F,CDM,360,RC,49595,CPT,,,,,,,,3503,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1681.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1455.1462,3432.94
CT Head/Brain W/Dye,PX7046001,CDM,350,RC,70460,CPT,TC,,,,,,,3398,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1682.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3330.04
Lap Rpr Vent Umbilical Hernia,PX49652F,CDM,510,RC,49652,CPT,,,,,,,,1890,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1682.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,785.106,1852.2
PLANTAR PLATE IMPLANT SET GRAVITY REPAIR,C1713,CDM,278,RC,C1713,HCPCS,,12649-MAIN,LOCAL,,,,,3921,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1682.109,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
ferumoxytol 510 MG/17ML Solution 17 mL Vial,Q0138.01,CDM,636,RC,Q0138,HCPCS,,,,781315401,NDC,17,ML,1846.91,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1682.53501,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.32,1809.9718
agalsidase beta 5 MG Recon Soln 1 Each Vial,J0180.01,CDM,636,RC,J0180,HCPCS,,,,58468004101,NDC,1,EA,1717.68,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1683.3264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,200.2,1683.3264
"IV Infusion, Casirivimab and Imdevimab, IV and Post Admr",PXM0243,CDM,771,RC,M0243,HCPCS,,,,,,,,1555,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,1684.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,413.06,1684.87
"CT Colonography, Screen",PX7426301,CDM,350,RC,74263,CPT,TC,,,,,,,3330,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1684.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1383.282,3263.4
CT Lumbar Spine W/Dye,PX7213201,CDM,350,RC,72132,CPT,TC,,,,,,,3330,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1684.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3263.4
CT Pelvis W/Dye,PX7219301,CDM,350,RC,72193,CPT,TC,,,,,,,3330,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1684.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3263.4
"MRI,Lwrext,Jnt W/O+W/Cont",PX7372301,CDM,610,RC,73723,CPT,TC,,,,,,,1850,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1685.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2066.35
Sleep Staging 4 + Pap,PX9581126,CDM,982,RC,95811,CPT,26,,,,,,,1850,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1685.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,768.49,1800.605
GRAFIXPL PRIME PLACENTAL MEMBRANE 2x3CM 6SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12765-MAIN,LOCAL,,,,,1911,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1685.502,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
"Repair Recurr Inguin Hern,Reducibl",PX49520F,CDM,510,RC,49520,CPT,,,,,,,,1983,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1685.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,823.7382,3022.41
"Repair Recurr Inguin Hern,Reducibl",PX49520P,CDM,983,RC,49520,CPT,,,,,,,,1983,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1685.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,823.7382,3022.41
CT Maxillofacial W/Dye,PX7048701,CDM,350,RC,70487,CPT,TC,,,,,,,3332,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1685.992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3265.36
fluticasone-umeclidin-vilant 100-62.5-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173088714,NDC,28,EA,1894.99,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1686.5411,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573P,CDM,983,RC,36573,CPT,,,,,,,,1721,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1686.58,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,50.83,1686.58
"Treat Thumb Disloc,Manipulatn",PX26641F,CDM,510,RC,26641,CPT,,,,,,,,1721,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1686.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1686.58
Revise Median N/Carpal Tunnel Surg,PX64721F,CDM,510,RC,64721,CPT,,,,,,,,2408,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1686.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1000.2832,2359.84
Revise Median N/Carpal Tunnel Surg,PX64721P,CDM,983,RC,64721,CPT,,,,,,,,1927,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1686.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,800.4758,1875.5491
Revise Ulnar Nerve at Elbow,PX64718P,CDM,983,RC,64718,CPT,,,,,,,,1642,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1686.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,682.0868,1686.76
REAMER FOR CROSS PLATES,27200000,CDM,272,RC,,,,12641-MAIN,LOCAL,,,,,1852,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1687.172,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Excis Tendn/Capsule Lesn,Toes",PX28092P,CDM,983,RC,28092,CPT,,,,,,,,1913,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1687.266,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,794.6602,1861.9229
"Bone Scan, Whole Body",PX7830601,CDM,341,RC,78306,CPT,TC,,,,,,,1896,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1687.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,360.31,1858.08
MRI Brain WO Contrast Tc,PX7055101,CDM,610,RC,70551,CPT,TC,,,,,,,3335,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1687.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3268.3
MRI Orbit/Face/Neck Tc,PX7054001,CDM,610,RC,70540,CPT,TC,,,,,,,3335,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1687.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3268.3
"Upper GI Endoscopy,Ctrl Bleed",PX43255F,CDM,750,RC,43255,CPT,,,,,,,,1723,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1688.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,715.7342,1688.54
"VENTRALIGHT MESH ST WITH ECHO 2 - 15 CM X 20 CM 6"" X 8""",C1781,CDM,278,RC,C1781,HCPCS,,12008-MAIN,LOCAL,,,,,3518,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1688.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"VENTRALIGHT MESH ST WITH ECHO 2 - 15 CM X 20 CM 6"" X 8""",C1781,CDM,278,RC,C1781,HCPCS,,12008-MAIN,LOCAL,,,,,3518,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1688.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,781307912,NDC,5,ML,1854.23,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1689.20353,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.74,1938.2734
CT Abdomen W/Dye,PX7416001,CDM,350,RC,74160,CPT,TC,,,,,,,3413,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1689.435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3344.74
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561P,CDM,983,RC,36561,CPT,,,,,,,,1736,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1689.6488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,721.1344,2784.63
CT Soft Tissue Neck W/Dye,PX7049101,CDM,350,RC,70491,CPT,TC,,,,,,,3415,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1690.425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3346.7
Diagnostic CT Thorax W/ Contrast,PX7126001,CDM,350,RC,71260,CPT,TC,,,,,,,3415,,Humana Choice Care,All Medicare plans,outpatient,49.5,,1378.85,percent of total billed charges,1690.425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3346.7
riTUXimab 100 MG/10ML Solution 10 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005121,NDC,10,ML,1916.61,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1690.45002,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.61,8682.8588
Or Level 2,PX36000002,CDM,360,RC,,,,,,,,,,1900,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1691,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,789.26,1862
belimumab (400v) 400 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010201,NDC,1,EA,3523.71,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1691.3808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.72,3453.2358
belimumab (400v) 400 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010201,NDC,1,EA,3523.71,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1691.3808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.72,3453.2358
Lap Rpr Vent Umbilical Hernia Incarcerated or Strangulated,PX49653F,CDM,510,RC,49653,CPT,,,,,,,,1990,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1691.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,826.646,1950.2
Reconstruc of Nail Bed W Graft,PX11762F,CDM,510,RC,11762,CPT,,,,,,,,1901,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1691.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,789.6754,1862.98
hydroxocobalamin 5 g Recon Soln 1 Each Box,J3424.01,CDM,636,RC,J3424,HCPCS,,,,11704037001,NDC,1,EA,1991.16,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1692.486,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,827.127864,1951.3368
"Treat Thumb Disloc,Manipulatn",PX26641P,CDM,983,RC,26641,CPT,,,,,,,,1902,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1692.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1851.2166
alteplase 100 MG Recon Soln 1 Each Syringe,J2997.01,CDM,636,RC,J2997,HCPCS,,,,88888800475,NDC,0.09,EA,1920.88,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1694.21616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
Exs Tumor Arm/Elbow Sc 3cm>,PX24071F,CDM,510,RC,24071,CPT,,,,,,,,1860,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1694.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,772.644,2482.37
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING4X6,C1781,CDM,278,RC,C1781,HCPCS,,12505-MAIN,LOCAL,,,,,1860,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1694.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270010,NDC,100,ML,3458.14,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,62.691,percent of total billed charges,1694.4886,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270010,NDC,100,ML,3458.14,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1694.4886,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270010,NDC,100,ML,3458.14,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1694.4886,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
fluticasone-salmeterol 230-21 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,66993008896,NDC,12,GR,1904.14,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1694.6846,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
MINIBUNION INSTRUMENT KIT,27200000,CDM,278,RC,C1713,HCPCS,,11668-MAIN,LOCAL,,,,,1860.65,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1695.05215,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Up GI Endoscopy,Dilatn W Guide",PX43248F,CDM,750,RC,43248,CPT,,,,,,,,1995,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1695.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,1955.1
"Up GI Endoscopy,Ball Dil,30mm",PX43249P,CDM,983,RC,43249,CPT,,,,,,,,1731,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1696.38,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.8,2216.53
Revise Median N/Carpal Tunnel Surg,PX64721P,CDM,983,RC,64721,CPT,,,,,,,,1927,,United Healthcare,All Payer,outpatient,88.2,,2244.02,percent of total billed charges,1699.614,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,800.4758,1875.5491
"Tte W/Doppler, Complete",PXC8929,CDM,480,RC,C8929,HCPCS,TC,,,,,,,1927,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1699.614,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,699.48,1888.46
"Mra, Head W/Out Contrast",PX7054401,CDM,610,RC,70544,CPT,TC,,,,,,,3541,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1699.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
"Mra, Head W/Out Contrast",PX7054401,CDM,610,RC,70544,CPT,TC,,,,,,,3541,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1699.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
"Mra, Neck With Contrast",PX7054801,CDM,610,RC,70548,CPT,TC,,,,,,,3541,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1699.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
"Mra, Neck With Contrast",PX7054801,CDM,610,RC,70548,CPT,TC,,,,,,,3541,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1699.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI Brain W & WO Contrast,PX7055301,CDM,610,RC,70553,CPT,TC,,,,,,,3541,,Health Partners,Health Partners Care Plans,both,48,,1149.28,percent of total billed charges,1699.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI Brain W & WO Contrast,PX7055301,CDM,610,RC,70553,CPT,TC,,,,,,,3541,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1699.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI C Spine W&WO Contrast,PX7215601,CDM,610,RC,72156,CPT,TC,,,,,,,3541,,Health Partners,Health Partners Care Plans,both,48,,708.2,percent of total billed charges,1699.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI C Spine W&WO Contrast,PX7215601,CDM,610,RC,72156,CPT,TC,,,,,,,3541,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1699.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI C-Spine WO Contrast,PX7214101,CDM,610,RC,72141,CPT,TC,,,,,,,3541,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1699.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI C-Spine WO Contrast,PX7214101,CDM,610,RC,72141,CPT,TC,,,,,,,3541,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1699.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI L Spine WO Contrast,PX7214801,CDM,610,RC,72148,CPT,TC,,,,,,,3541,,Health Partners,Health Partners Care Plans,both,48,,3434.77,percent of total billed charges,1699.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI L Spine WO Contrast,PX7214801,CDM,610,RC,72148,CPT,TC,,,,,,,3541,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1699.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI Low Ext Jnt WO/Cont Tc,PX7372101,CDM,610,RC,73721,CPT,TC,,,,,,,3541,,Health Partners,Health Partners Care Plans,both,48,,2331.816667,percent of total billed charges,1699.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI Low Ext Jnt WO/Cont Tc,PX7372101,CDM,610,RC,73721,CPT,TC,,,,,,,3541,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1699.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI Orb-Fac-Nec W/O+W/Con,PX7054301,CDM,610,RC,70543,CPT,TC,,,,,,,3541,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1699.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI Orb-Fac-Nec W/O+W/Con,PX7054301,CDM,610,RC,70543,CPT,TC,,,,,,,3541,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1699.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
"MRI,Upr Ext, Joint,W/Cont",PX7322201,CDM,610,RC,73222,CPT,TC,,,,,,,3541,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1699.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,611.05,3470.18
"MRI,Upr Ext, Joint,W/Cont",PX7322201,CDM,610,RC,73222,CPT,TC,,,,,,,3541,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1699.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,611.05,3470.18
fluticasone 220 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173072020,NDC,12,GR,1746.36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1699.732188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Ht Muscle Image Spect, Mult",PX7845201,CDM,340,RC,78452,CPT,TC,,,,,,,2000,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1700,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,858,5292.1
GRAFIXPL PRIME PLACENTAL MEMBRANE 2x3CM 6SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12765-MAIN,LOCAL,,,,,1911,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1700.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
DYNANITE PIP - STRAIGHT 12MM - WITH INSTRUMENTATION,27200000,CDM,278,RC,C1713,HCPCS,,11626-MAIN,LOCAL,,,,,3543.65,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1700.952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP - STRAIGHT 12MM - WITH INSTRUMENTATION,27200000,CDM,278,RC,C1713,HCPCS,,11626-MAIN,LOCAL,,,,,3543.65,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1700.952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP - STRAIGHT 14MM - WITH INSTRUMENTATION,27200000,CDM,278,RC,C1713,HCPCS,,11627-MAIN,LOCAL,,,,,3543.65,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1700.952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP - STRAIGHT 14MM - WITH INSTRUMENTATION,27200000,CDM,278,RC,C1713,HCPCS,,11627-MAIN,LOCAL,,,,,3543.65,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1700.952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT BENT 12MM,27200000,CDM,278,RC,C1713,HCPCS,,11629-MAIN,LOCAL,,,,,3543.65,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1700.952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT BENT 12MM,27200000,CDM,278,RC,C1713,HCPCS,,11629-MAIN,LOCAL,,,,,3543.65,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1700.952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT BENT 14MM,27200000,CDM,278,RC,C1713,HCPCS,,11631-MAIN,LOCAL,,,,,3543.65,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1700.952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT BENT 14MM,27200000,CDM,278,RC,C1713,HCPCS,,11631-MAIN,LOCAL,,,,,3543.65,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1700.952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT BENT 16MM,27200000,CDM,278,RC,C1713,HCPCS,,11633-MAIN,LOCAL,,,,,3543.65,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1700.952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT BENT 16MM,27200000,CDM,278,RC,C1713,HCPCS,,11633-MAIN,LOCAL,,,,,3543.65,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1700.952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT STRAIGHT 12MM,27200000,CDM,278,RC,C1713,HCPCS,,11628-MAIN,LOCAL,,,,,3543.65,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1700.952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT STRAIGHT 12MM,27200000,CDM,278,RC,C1713,HCPCS,,11628-MAIN,LOCAL,,,,,3543.65,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1700.952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT STRAIGHT 14MM,27200000,CDM,278,RC,C1713,HCPCS,,11630-MAIN,LOCAL,,,,,3543.65,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1700.952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT STRAIGHT 14MM,27200000,CDM,278,RC,C1713,HCPCS,,11630-MAIN,LOCAL,,,,,3543.65,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1700.952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT STRAIGHT 16MM,27200000,CDM,278,RC,C1713,HCPCS,,11632-MAIN,LOCAL,,,,,3543.65,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1700.952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT STRAIGHT 16MM,27200000,CDM,278,RC,C1713,HCPCS,,11632-MAIN,LOCAL,,,,,3543.65,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1700.952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561P,CDM,983,RC,36561,CPT,,,,,,,,1736,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1701.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,200.91,1988.23
"Mra, Neck W/O+W/ Contrast",PX7054901,CDM,610,RC,70549,CPT,TC,,,,,,,3472,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1701.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3402.56
"Mra, Neck W/O+W/ Contrast",PX7054901,CDM,610,RC,70549,CPT,TC,,,,,,,3472,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1701.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3402.56
"Mra, Neck W/O+W/ Contrast",PX7054901,CDM,610,RC,70549,CPT,TC,,,,,,,3472,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1701.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3402.56
"Diagnostic Bone Marrow, Biopsy and Aspiration",PX38222F,CDM,761,RC,38222,CPT,,,,,,,,1748,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1701.3284,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,726.1192,2482.37
MODULAR INSERT TOE JOINT 2.5MM 3.6MMTHK PROXIMAL PHALANGEAL,C1713,CDM,278,RC,C1713,HCPCS,,12530-MAIN,LOCAL,,,,,3968,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1702.272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"Excis Tendn/Capsule Lesn,Toes",PX28092P,CDM,983,RC,28092,CPT,,,,,,,,1913,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1702.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,794.6602,1861.9229
inFLIXimab-dyyb 100 MG Recon Soln 1 Each Vial,Q5103.01,CDM,636,RC,Q5103,HCPCS,,,,69080901,NDC,1,EA,1930.42,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1702.63044,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.85,1891.8116
"Closed Rx Radial Head/Neck Fx,Manip",PX24655F,CDM,510,RC,24655,CPT,,,,,,,,1750,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1703.275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,726.95,1715
"Fix Exten Tendon,Dorsum Fingr,Ea",PX26418F,CDM,510,RC,26418,CPT,,,,,,,,1750,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1703.275,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,726.95,1715
fluticasone-salmeterol 230-21 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173071720,NDC,12,GR,2004.35,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1703.6975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
riTUXimab 100 MG/10ML Solution 10 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005121,NDC,10,ML,1916.61,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1705.7829,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.61,8682.8588
alteplase 100 MG Recon Soln 1 Each Syringe,J2997.01,CDM,636,RC,J2997,HCPCS,,,,88888800475,NDC,0.09,EA,1920.88,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1709.5832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
"Colonoscopy,Remv Lesn,Snare",PX45385F,CDM,750,RC,45385,CPT,,,,,,,,1939,,United Healthcare,All Payer,outpatient,88.2,,999999999,case rate,1710.198,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1710.198,6141.46
fluticasone 220 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173072020,NDC,12,GR,1746.36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1711.4328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270010,NDC,100,ML,3458.14,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1711.7793,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
rabies immune globulin 300 UNIT/2ML Solution 2 mL Vial,90377,CDM,636,RC,90376,CPT,,,,49281019020,NDC,2,ML,3384.84,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1712.72904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,207.94,3317.1432
"Diagnostic Bone Marrow, Biopsy and Aspiration",PX38222F,CDM,761,RC,38222,CPT,,,,,,,,1748,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1713.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,726.1192,2482.37
fluticasone 220 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,66993008096,NDC,12,GR,1760.13,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1713.134529,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Closed Rx Radial Head/Neck Fx,Manip",PX24655F,CDM,510,RC,24655,CPT,,,,,,,,1750,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,726.95,1715
"Fix Exten Tendon,Dorsum Fingr,Ea",PX26418F,CDM,510,RC,26418,CPT,,,,,,,,1750,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,726.95,1715
Revise Median N/Carpal Tunnel Surg,PX64721P,CDM,983,RC,64721,CPT,,,,,,,,1927,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1715.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,800.4758,1875.5491
"Tte W/Doppler, Complete",PXC8929,CDM,480,RC,C8929,HCPCS,TC,,,,,,,1927,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1715.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,699.48,1888.46
Remv Periton FB From Perit Cav,PX49402F,CDM,510,RC,49402,CPT,,,,,,,,3573,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1715.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1484.2242,3501.54
Remv Periton FB From Perit Cav,PX49402F,CDM,510,RC,49402,CPT,,,,,,,,3573,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1715.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1484.2242,3501.54
ustekinumab 130 MG/26ML Solution 26 mL Vial,J3358.01,CDM,636,RC,J3358,HCPCS,,,,57894005427,NDC,26,ML,4130,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1715.602,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.56,4047.4
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180F,CDM,510,RC,44180,CPT,,,,,,,,1763,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1715.9279,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,732.3502,5040.74
Remove Foreign Body Complic,PX10121F,CDM,510,RC,10121,CPT,,,,,,,,3575,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1716,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1416.38,3503.5
Remove Foreign Body Complic,PX10121F,CDM,510,RC,10121,CPT,,,,,,,,3575,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1716,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1416.38,3503.5
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595F,CDM,360,RC,49595,CPT,,,,,,,,3503,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1716.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1455.1462,3432.94
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595F,CDM,360,RC,49595,CPT,,,,,,,,3503,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1716.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1455.1462,3432.94
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595F,CDM,360,RC,49595,CPT,,,,,,,,3503,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1716.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1455.1462,3432.94
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595P,CDM,982,RC,49595,CPT,,,,,,,,3503,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1716.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1455.1462,3409.4699
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595P,CDM,982,RC,49595,CPT,,,,,,,,3503,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1716.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1455.1462,3409.4699
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595P,CDM,982,RC,49595,CPT,,,,,,,,3503,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1716.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1455.1462,3409.4699
inFLIXimab-dyyb 100 MG Recon Soln 1 Each Vial,Q5103.01,CDM,636,RC,Q5103,HCPCS,,,,69080901,NDC,1,EA,1930.42,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1718.0738,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.85,1891.8116
"Mra, Neck W/O+W/ Contrast",PX7054901,CDM,610,RC,70549,CPT,TC,,,,,,,3472,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1718.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3402.56
CT Head/Brain W/Dye,PX7046001,CDM,350,RC,70460,CPT,TC,,,,,,,3398,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1719.388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3330.04
"Amputation Toe,Mt-P Jt",PX28820F,CDM,510,RC,28820,CPT,,,,,,,,1950,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1719.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,810.03,2827.75
"Closure of Gastrostomy,Surgical",PX43870P,CDM,983,RC,43870,CPT,,,,,,,,4012,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1721.148,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1666.5848,3904.8796
Lap Rpr Vent Umbilical Hernia,PX49652F,CDM,510,RC,49652,CPT,,,,,,,,1890,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1721.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,785.106,1852.2
"Sb Scope,to Ileum,Biopsy",PX44377F,CDM,750,RC,44377,CPT,,,,,,,,1770,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1722.741,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,735.258,1734.6
Removal of Hemorrhoid Clot,PX46320F,CDM,510,RC,46320,CPT,,,,,,,,2027,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1722.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,842.0158,1986.46
"VENTRALIGHT MESH ST WITH ECHO 2 - 15 CM X 20 CM 6"" X 8""",C1781,CDM,278,RC,C1781,HCPCS,,12008-MAIN,LOCAL,,,,,3518,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,196.035,percent of total billed charges,1723.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"VENTRALIGHT MESH ST WITH ECHO 2 - 15 CM X 20 CM 6"" X 8""",C1781,CDM,278,RC,C1781,HCPCS,,12008-MAIN,LOCAL,,,,,3518,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1723.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"VENTRALIGHT MESH ST WITH ECHO 2 - 15 CM X 20 CM 6"" X 8""",C1781,CDM,278,RC,C1781,HCPCS,,12008-MAIN,LOCAL,,,,,3518,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1723.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
FORCEPS SPOON JAWSIZE 10MMX36 KIT,27200000,CDM,272,RC,,,,11749-MAIN,LOCAL,,,,,1955,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1724.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
fluticasone 220 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,66993008096,NDC,12,GR,1760.13,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1724.9274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Colonoscopy,Remv Lesn,Snare",PX45385F,CDM,750,RC,45385,CPT,,,,,,,,1939,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1725.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,831.831,4050.42
fluticasone-umeclidin-vilant 100-62.5-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173088714,NDC,28,EA,1894.99,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1726.33589,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
belimumab (400v) 400 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010201,NDC,1,EA,3523.71,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1726.6179,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.72,3453.2358
belimumab (400v) 400 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010201,NDC,1,EA,3523.71,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1726.6179,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.72,3453.2358
belimumab (400v) 400 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010201,NDC,1,EA,3523.71,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1726.6179,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.72,3453.2358
CT Abdomen W/Dye,PX7416001,CDM,350,RC,74160,CPT,TC,,,,,,,3413,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1726.978,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3344.74
"Bone Scan, Whole Body",PX7830601,CDM,341,RC,78306,CPT,TC,,,,,,,1896,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1727.256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,360.31,1858.08
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180F,CDM,510,RC,44180,CPT,,,,,,,,1763,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1727.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,732.3502,5040.74
"Cardiac Stress Tst,Tracing Only",PX93017,CDM,482,RC,93017,CPT,,,,,,,,1959,,United Healthcare,All Payer,outpatient,88.2,,948.542,percent of total billed charges,1727.838,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.21,1919.82
CT Soft Tissue Neck W/Dye,PX7049101,CDM,350,RC,70491,CPT,TC,,,,,,,3415,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1727.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3346.7
Diagnostic CT Thorax W/ Contrast,PX7126001,CDM,350,RC,71260,CPT,TC,,,,,,,3415,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1727.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3346.7
"Closed Rx Shldr Disloc,Anesthesia",PX23655F,CDM,510,RC,23655,CPT,,,,,,,,1776,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1728.5808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,737.7504,1740.48
"Sigmoidoscopy,Biopsy",PX45331F,CDM,750,RC,45331,CPT,,,,,,,,1776,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,3321.4,percent of total billed charges,1728.5808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,737.7504,1740.48
"Lap,Inguinal Hernia Repr,Recur",PX49651P,CDM,983,RC,49651,CPT,,,,,,,,2035,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1729.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,845.339,5040.74
Or Level 2,PX36000002,CDM,360,RC,,,,,,,,,,1900,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1730.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,789.26,1862
Reconstruc of Nail Bed W Graft,PX11762F,CDM,510,RC,11762,CPT,,,,,,,,1901,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1731.811,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,789.6754,1862.98
Lap Partial Colectomy/Coloproctostomy,PX44207F,CDM,750,RC,44207,CPT,,,,,,,,4170,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1732.218,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1130.58,4086.6
Lap Incis Hernia Reducible,PX49654F,CDM,510,RC,49654,CPT,,,,,,,,1964,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1732.248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,815.8456,1924.72
"Treat Thumb Disloc,Manipulatn",PX26641P,CDM,983,RC,26641,CPT,,,,,,,,1902,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1732.722,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1851.2166
"Biopsy of Prostate,Needle/Punch",PX55700F,CDM,510,RC,55700,CPT,,,,,,,,2039,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1733.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,847.0006,1998.22
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595F,CDM,360,RC,49595,CPT,,,,,,,,3503,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1733.985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1455.1462,3432.94
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595P,CDM,982,RC,49595,CPT,,,,,,,,3503,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1733.985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1455.1462,3409.4699
"Sb Scope,to Ileum,Biopsy",PX44377F,CDM,750,RC,44377,CPT,,,,,,,,1770,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1734.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,735.258,1734.6
fluticasone-salmeterol 230-21 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,66993008896,NDC,12,GR,1904.14,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1734.67154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290101,NDC,1,EA,1966.88,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1734.78816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.77,1927.5424
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290102,NDC,1,EA,1966.88,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1734.78816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.77,1927.5424
"Mra, Head W/Out Contrast",PX7054401,CDM,610,RC,70544,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1735.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
"Mra, Head W/Out Contrast",PX7054401,CDM,610,RC,70544,CPT,TC,,,,,,,3541,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1735.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
"Mra, Head W/Out Contrast",PX7054401,CDM,610,RC,70544,CPT,TC,,,,,,,3541,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1735.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
"Mra, Neck With Contrast",PX7054801,CDM,610,RC,70548,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1735.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
"Mra, Neck With Contrast",PX7054801,CDM,610,RC,70548,CPT,TC,,,,,,,3541,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1735.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
"Mra, Neck With Contrast",PX7054801,CDM,610,RC,70548,CPT,TC,,,,,,,3541,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1735.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI Brain W & WO Contrast,PX7055301,CDM,610,RC,70553,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,866.6876923,percent of total billed charges,1735.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI Brain W & WO Contrast,PX7055301,CDM,610,RC,70553,CPT,TC,,,,,,,3541,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1735.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI Brain W & WO Contrast,PX7055301,CDM,610,RC,70553,CPT,TC,,,,,,,3541,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1735.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI C Spine W&WO Contrast,PX7215601,CDM,610,RC,72156,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,2552.65,percent of total billed charges,1735.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI C Spine W&WO Contrast,PX7215601,CDM,610,RC,72156,CPT,TC,,,,,,,3541,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1735.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI C Spine W&WO Contrast,PX7215601,CDM,610,RC,72156,CPT,TC,,,,,,,3541,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1735.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI C-Spine WO Contrast,PX7214101,CDM,610,RC,72141,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,708.2,percent of total billed charges,1735.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI C-Spine WO Contrast,PX7214101,CDM,610,RC,72141,CPT,TC,,,,,,,3541,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1735.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI C-Spine WO Contrast,PX7214101,CDM,610,RC,72141,CPT,TC,,,,,,,3541,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1735.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI L Spine WO Contrast,PX7214801,CDM,610,RC,72148,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,704.04,percent of total billed charges,1735.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI L Spine WO Contrast,PX7214801,CDM,610,RC,72148,CPT,TC,,,,,,,3541,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1735.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI L Spine WO Contrast,PX7214801,CDM,610,RC,72148,CPT,TC,,,,,,,3541,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1735.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI Low Ext Jnt WO/Cont Tc,PX7372101,CDM,610,RC,73721,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,705.8888889,percent of total billed charges,1735.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI Low Ext Jnt WO/Cont Tc,PX7372101,CDM,610,RC,73721,CPT,TC,,,,,,,3541,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1735.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI Low Ext Jnt WO/Cont Tc,PX7372101,CDM,610,RC,73721,CPT,TC,,,,,,,3541,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1735.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI Orb-Fac-Nec W/O+W/Con,PX7054301,CDM,610,RC,70543,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,708.2,percent of total billed charges,1735.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI Orb-Fac-Nec W/O+W/Con,PX7054301,CDM,610,RC,70543,CPT,TC,,,,,,,3541,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1735.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI Orb-Fac-Nec W/O+W/Con,PX7054301,CDM,610,RC,70543,CPT,TC,,,,,,,3541,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1735.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
"MRI,Upr Ext, Joint,W/Cont",PX7322201,CDM,610,RC,73222,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1735.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,611.05,3470.18
"MRI,Upr Ext, Joint,W/Cont",PX7322201,CDM,610,RC,73222,CPT,TC,,,,,,,3541,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1735.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,611.05,3470.18
"MRI,Upr Ext, Joint,W/Cont",PX7322201,CDM,610,RC,73222,CPT,TC,,,,,,,3541,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1735.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,611.05,3470.18
"Amputation Toe,Mt-P Jt",PX28820F,CDM,510,RC,28820,CPT,,,,,,,,1950,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1735.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,810.03,2827.75
DYNANITE PIP - STRAIGHT 12MM - WITH INSTRUMENTATION,27200000,CDM,278,RC,C1713,HCPCS,,11626-MAIN,LOCAL,,,,,3543.65,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,1736.3885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP - STRAIGHT 12MM - WITH INSTRUMENTATION,27200000,CDM,278,RC,C1713,HCPCS,,11626-MAIN,LOCAL,,,,,3543.65,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1736.3885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP - STRAIGHT 12MM - WITH INSTRUMENTATION,27200000,CDM,278,RC,C1713,HCPCS,,11626-MAIN,LOCAL,,,,,3543.65,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1736.3885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP - STRAIGHT 14MM - WITH INSTRUMENTATION,27200000,CDM,278,RC,C1713,HCPCS,,11627-MAIN,LOCAL,,,,,3543.65,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,1736.3885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP - STRAIGHT 14MM - WITH INSTRUMENTATION,27200000,CDM,278,RC,C1713,HCPCS,,11627-MAIN,LOCAL,,,,,3543.65,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1736.3885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP - STRAIGHT 14MM - WITH INSTRUMENTATION,27200000,CDM,278,RC,C1713,HCPCS,,11627-MAIN,LOCAL,,,,,3543.65,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1736.3885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT BENT 12MM,27200000,CDM,278,RC,C1713,HCPCS,,11629-MAIN,LOCAL,,,,,3543.65,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,1736.3885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT BENT 12MM,27200000,CDM,278,RC,C1713,HCPCS,,11629-MAIN,LOCAL,,,,,3543.65,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1736.3885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT BENT 12MM,27200000,CDM,278,RC,C1713,HCPCS,,11629-MAIN,LOCAL,,,,,3543.65,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1736.3885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT BENT 14MM,27200000,CDM,278,RC,C1713,HCPCS,,11631-MAIN,LOCAL,,,,,3543.65,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,1736.3885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT BENT 14MM,27200000,CDM,278,RC,C1713,HCPCS,,11631-MAIN,LOCAL,,,,,3543.65,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1736.3885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT BENT 14MM,27200000,CDM,278,RC,C1713,HCPCS,,11631-MAIN,LOCAL,,,,,3543.65,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1736.3885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT BENT 16MM,27200000,CDM,278,RC,C1713,HCPCS,,11633-MAIN,LOCAL,,,,,3543.65,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,1736.3885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT BENT 16MM,27200000,CDM,278,RC,C1713,HCPCS,,11633-MAIN,LOCAL,,,,,3543.65,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1736.3885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT BENT 16MM,27200000,CDM,278,RC,C1713,HCPCS,,11633-MAIN,LOCAL,,,,,3543.65,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1736.3885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT STRAIGHT 12MM,27200000,CDM,278,RC,C1713,HCPCS,,11628-MAIN,LOCAL,,,,,3543.65,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,1736.3885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT STRAIGHT 12MM,27200000,CDM,278,RC,C1713,HCPCS,,11628-MAIN,LOCAL,,,,,3543.65,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1736.3885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT STRAIGHT 12MM,27200000,CDM,278,RC,C1713,HCPCS,,11628-MAIN,LOCAL,,,,,3543.65,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1736.3885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT STRAIGHT 14MM,27200000,CDM,278,RC,C1713,HCPCS,,11630-MAIN,LOCAL,,,,,3543.65,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,1736.3885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT STRAIGHT 14MM,27200000,CDM,278,RC,C1713,HCPCS,,11630-MAIN,LOCAL,,,,,3543.65,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1736.3885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT STRAIGHT 14MM,27200000,CDM,278,RC,C1713,HCPCS,,11630-MAIN,LOCAL,,,,,3543.65,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1736.3885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT STRAIGHT 16MM,27200000,CDM,278,RC,C1713,HCPCS,,11632-MAIN,LOCAL,,,,,3543.65,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,1736.3885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT STRAIGHT 16MM,27200000,CDM,278,RC,C1713,HCPCS,,11632-MAIN,LOCAL,,,,,3543.65,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1736.3885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT STRAIGHT 16MM,27200000,CDM,278,RC,C1713,HCPCS,,11632-MAIN,LOCAL,,,,,3543.65,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1736.3885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606P,CDM,983,RC,11606,CPT,,,,,,,,2044,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1737.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,849.0776,1989.4252
FORCEPS SPOON JAWSIZE 10MMX36 KIT,27200000,CDM,272,RC,,,,11749-MAIN,LOCAL,,,,,1955,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1739.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Closed Rx Shldr Disloc,Anesthesia",PX23655F,CDM,510,RC,23655,CPT,,,,,,,,1776,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1740.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,737.7504,1740.48
"Sigmoidoscopy,Biopsy",PX45331F,CDM,750,RC,45331,CPT,,,,,,,,1776,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1740.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,737.7504,1740.48
"Repair Ing Hernia,5+Y/O,Reducibl",PX49505P,CDM,983,RC,49505,CPT,,,,,,,,2048,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1740.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,850.7392,3022.41
GRAFIXPL PRIME PLACENTAL MEMBRANE 2x3CM 6SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12765-MAIN,LOCAL,,,,,1911,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1740.921,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
"MRI,Lwrext,No Jnt, W/Cont",PX7371901,CDM,610,RC,73719,CPT,TC,,,,,,,3627,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1740.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3554.46
"MRI,Lwrext,No Jnt, W/Cont",PX7371901,CDM,610,RC,73719,CPT,TC,,,,,,,3627,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1740.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3554.46
"VENTRALIGHT MESH ST WITH ECHO 2 - 15 CM X 20 CM 6"" X 8""",C1781,CDM,278,RC,C1781,HCPCS,,12008-MAIN,LOCAL,,,,,3518,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1741.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Excis Tendn/Capsule Lesn,Toes",PX28092P,CDM,983,RC,28092,CPT,,,,,,,,1913,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1742.743,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,794.6602,1861.9229
"Cardiac Stress Tst,Tracing Only",PX93017,CDM,482,RC,93017,CPT,,,,,,,,1959,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1743.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.21,1919.82
"Repair Ing Hernia,5+Y/O,Strang",PX49507F,CDM,510,RC,49507,CPT,,,,,,,,1977,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1743.714,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,821.2458,3022.41
belimumab (400v) 400 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010201,NDC,1,EA,3523.71,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1744.23645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.72,3453.2358
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,310072010,NDC,5,ML,1977.83,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1744.44606,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.74,1938.2734
riTUXimab 100 MG/10ML Solution 10 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005121,NDC,10,ML,1916.61,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1746.03171,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.61,8682.8588
Lap Incis Hernia Reducible,PX49654F,CDM,510,RC,49654,CPT,,,,,,,,1964,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1747.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,815.8456,1924.72
RESTRATA WOUND MATRIX 2.5CM X 7.5CM TOTAL 18.75CM,27200000,CDM,272,RC,A2007,HCPCS,,11735-MAIN,LOCAL,,,,,4208,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1748.0032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Closed Rx Weight Bear Dist Tib,Manip",PX27825P,CDM,983,RC,27825,CPT,,,,,,,,1796,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1748.0468,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,746.0584,1748.0468
"Repair Recurr Inguin Hern,Reducibl",PX49520F,CDM,510,RC,49520,CPT,,,,,,,,1983,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1749.006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,823.7382,3022.41
"Repair Recurr Inguin Hern,Reducibl",PX49520P,CDM,983,RC,49520,CPT,,,,,,,,1983,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1749.006,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,823.7382,3022.41
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270010,NDC,100,ML,3458.14,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1749.81884,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
alteplase 100 MG Recon Soln 1 Each Syringe,J2997.01,CDM,636,RC,J2997,HCPCS,,,,88888800475,NDC,0.09,EA,1920.88,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1749.92168,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290101,NDC,1,EA,1966.88,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1750.5232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.77,1927.5424
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290102,NDC,1,EA,1966.88,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1750.5232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.77,1927.5424
Remv Periton FB From Perit Cav,PX49402F,CDM,510,RC,49402,CPT,,,,,,,,3573,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1750.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1484.2242,3501.54
Remv Periton FB From Perit Cav,PX49402F,CDM,510,RC,49402,CPT,,,,,,,,3573,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1750.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1484.2242,3501.54
Remv Periton FB From Perit Cav,PX49402F,CDM,510,RC,49402,CPT,,,,,,,,3573,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1750.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1484.2242,3501.54
Remove Foreign Body Complic,PX10121F,CDM,510,RC,10121,CPT,,,,,,,,3575,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1751.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1416.38,3503.5
Remove Foreign Body Complic,PX10121F,CDM,510,RC,10121,CPT,,,,,,,,3575,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1751.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1416.38,3503.5
Remove Foreign Body Complic,PX10121F,CDM,510,RC,10121,CPT,,,,,,,,3575,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1751.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1416.38,3503.5
"Mra, Head W/Out Contrast",PX7054401,CDM,610,RC,70544,CPT,TC,,,,,,,3541,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1752.795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
"Mra, Neck With Contrast",PX7054801,CDM,610,RC,70548,CPT,TC,,,,,,,3541,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1752.795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI Brain W & WO Contrast,PX7055301,CDM,610,RC,70553,CPT,TC,,,,,,,3541,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1752.795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI C Spine W&WO Contrast,PX7215601,CDM,610,RC,72156,CPT,TC,,,,,,,3541,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1752.795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI C-Spine WO Contrast,PX7214101,CDM,610,RC,72141,CPT,TC,,,,,,,3541,,Humana Choice Care,All Medicare plans,outpatient,49.5,,2700.7,percent of total billed charges,1752.795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI L Spine WO Contrast,PX7214801,CDM,610,RC,72148,CPT,TC,,,,,,,3541,,Humana Choice Care,All Medicare plans,outpatient,49.5,,464.7266667,percent of total billed charges,1752.795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI Low Ext Jnt WO/Cont Tc,PX7372101,CDM,610,RC,73721,CPT,TC,,,,,,,3541,,Humana Choice Care,All Medicare plans,outpatient,49.5,,745.92,percent of total billed charges,1752.795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI Orb-Fac-Nec W/O+W/Con,PX7054301,CDM,610,RC,70543,CPT,TC,,,,,,,3541,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1752.795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
"MRI,Upr Ext, Joint,W/Cont",PX7322201,CDM,610,RC,73222,CPT,TC,,,,,,,3541,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1752.795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,611.05,3470.18
DYNANITE PIP - STRAIGHT 12MM - WITH INSTRUMENTATION,27200000,CDM,278,RC,C1713,HCPCS,,11626-MAIN,LOCAL,,,,,3543.65,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1754.10675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP - STRAIGHT 14MM - WITH INSTRUMENTATION,27200000,CDM,278,RC,C1713,HCPCS,,11627-MAIN,LOCAL,,,,,3543.65,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1754.10675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT BENT 12MM,27200000,CDM,278,RC,C1713,HCPCS,,11629-MAIN,LOCAL,,,,,3543.65,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1754.10675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT BENT 14MM,27200000,CDM,278,RC,C1713,HCPCS,,11631-MAIN,LOCAL,,,,,3543.65,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1754.10675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT BENT 16MM,27200000,CDM,278,RC,C1713,HCPCS,,11633-MAIN,LOCAL,,,,,3543.65,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1754.10675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT STRAIGHT 12MM,27200000,CDM,278,RC,C1713,HCPCS,,11628-MAIN,LOCAL,,,,,3543.65,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1754.10675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT STRAIGHT 14MM,27200000,CDM,278,RC,C1713,HCPCS,,11630-MAIN,LOCAL,,,,,3543.65,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1754.10675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT STRAIGHT 16MM,27200000,CDM,278,RC,C1713,HCPCS,,11632-MAIN,LOCAL,,,,,3543.65,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1754.10675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Lap Rpr Vent Umbilical Hernia Incarcerated or Strangulated,PX49653F,CDM,510,RC,49653,CPT,,,,,,,,1990,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1755.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,826.646,1950.2
Revise Median N/Carpal Tunnel Surg,PX64721P,CDM,983,RC,64721,CPT,,,,,,,,1927,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1755.497,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,800.4758,1875.5491
"Tte W/Doppler, Complete",PXC8929,CDM,480,RC,C8929,HCPCS,TC,,,,,,,1927,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1755.497,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,699.48,1888.46
hydroxocobalamin 5 g Recon Soln 1 Each Box,J3424.01,CDM,636,RC,J3424,HCPCS,,,,11704037001,NDC,1,EA,1991.16,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1756.20312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,827.127864,1951.3368
"Mra, Neck W/O+W/ Contrast",PX7054901,CDM,610,RC,70549,CPT,TC,,,,,,,3472,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1756.832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3402.56
"Colonoscopy,Transendoscopic Stent",PX45387P,CDM,983,RC,45387,CPT,,,,,,,,3587,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1757.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1490.0398,3491.2271
"Colonoscopy,Transendoscopic Stent",PX45387P,CDM,983,RC,45387,CPT,,,,,,,,3587,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1757.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1490.0398,3491.2271
"Colonoscopy,Transendoscopic Stent",PX45387P,CDM,983,RC,45387,CPT,,,,,,,,3587,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1757.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1490.0398,3491.2271
PROSTEP MICA SCREW 3.0X20MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12442-MAIN,LOCAL,,,,,1806,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1757.7798,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 3.0X40MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12443-MAIN,LOCAL,,,,,1806,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1757.7798,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X52MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12444-MAIN,LOCAL,,,,,1806,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1757.7798,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
inFLIXimab-dyyb 100 MG Recon Soln 1 Each Vial,Q5103.01,CDM,636,RC,Q5103,HCPCS,,,,69080901,NDC,1,EA,1930.42,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1758.61262,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.85,1891.8116
"Repair Ing Hernia,5+Y/O,Strang",PX49507F,CDM,510,RC,49507,CPT,,,,,,,,1977,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1759.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,821.2458,3022.41
"Up GI Endoscopy,Dilatn W Guide",PX43248F,CDM,750,RC,43248,CPT,,,,,,,,1995,,United Healthcare,All Payer,outpatient,88.2,,999999999,case rate,1759.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1759.59,6141.46
"Closed Rx Weight Bear Dist Tib,Manip",PX27825P,CDM,983,RC,27825,CPT,,,,,,,,1796,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1760.08,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.21,1760.08
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,310072010,NDC,5,ML,1977.83,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1760.2687,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.74,1938.2734
clobetasol 0.05 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,21922001707,NDC,60,GR,1810.35,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1762.013655,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CT Head/Brain W/O & W/Dye,PX7047001,CDM,350,RC,70470,CPT,TC,,,,,,,3671,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1762.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3597.58
CT Head/Brain W/O & W/Dye,PX7047001,CDM,350,RC,70470,CPT,TC,,,,,,,3671,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1762.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3597.58
"Ht Muscle Image Spect, Mult",PX7845201,CDM,340,RC,78452,CPT,TC,,,,,,,2000,,United Healthcare,All Payer,outpatient,88.2,,968.436,percent of total billed charges,1764,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,858,5292.1
"Repair Recurr Inguin Hern,Reducibl",PX49520F,CDM,510,RC,49520,CPT,,,,,,,,1983,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1764.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,823.7382,3022.41
"Repair Recurr Inguin Hern,Reducibl",PX49520P,CDM,983,RC,49520,CPT,,,,,,,,1983,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1764.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,823.7382,3022.41
"MRI, Abdomen W/O+ W/Contr",PX7418301,CDM,610,RC,74183,CPT,TC,,,,,,,4116,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1765.764,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4033.68
"Colonoscopy,Remv Lesn,Snare",PX45385F,CDM,750,RC,45385,CPT,,,,,,,,1939,,Medica,Commercial,both,91.1,,1260.14,percent of total billed charges,1766.429,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,831.831,4050.42
MESH VENTRALIGHT ECHO 2.0 POSITIONING 15CM ROUND,C1781,CDM,278,RC,C1781,HCPCS,,12842-MAIN,LOCAL,,,,,1816,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1256.29,percent of total billed charges,1767.5128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
fluticasone-salmeterol 230-21 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173071720,NDC,12,GR,2004.35,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1767.8367,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830F,CDM,510,RC,15830,CPT,,,,,,,,2080,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,864.032,5696.92
Remv Periton FB From Perit Cav,PX49402F,CDM,510,RC,49402,CPT,,,,,,,,3573,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1768.635,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1484.2242,3501.54
Remove Foreign Body Complic,PX10121F,CDM,510,RC,10121,CPT,,,,,,,,3575,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1769.625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1416.38,3503.5
PROSTEP MICA SCREW 3.0X20MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12442-MAIN,LOCAL,,,,,1806,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1769.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 3.0X40MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12443-MAIN,LOCAL,,,,,1806,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1769.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X52MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12444-MAIN,LOCAL,,,,,1806,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1769.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
CT Abdomen W/O & W/Dye,PX7417001,CDM,350,RC,74170,CPT,TC,,,,,,,3689,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1770.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3615.22
CT Abdomen W/O & W/Dye,PX7417001,CDM,350,RC,74170,CPT,TC,,,,,,,3689,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1770.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3615.22
"CT Angiography, Chest",PX7127501,CDM,350,RC,71275,CPT,TC,,,,,,,3689,,Health Partners,Health Partners Care Plans,both,48,,1596.645,percent of total billed charges,1770.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3615.22
"CT Angiography, Chest",PX7127501,CDM,350,RC,71275,CPT,TC,,,,,,,3689,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1770.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3615.22
Lap Rpr Vent Umbilical Hernia Incarcerated or Strangulated,PX49653F,CDM,510,RC,49653,CPT,,,,,,,,1990,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1771.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,826.646,1950.2
"CT Angiography, Head",PX7049601,CDM,350,RC,70496,CPT,TC,,,,,,,3690,,Health Partners,Health Partners Care Plans,both,48,,2863.43,percent of total billed charges,1771.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3616.2
"CT Angiography, Head",PX7049601,CDM,350,RC,70496,CPT,TC,,,,,,,3690,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1771.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3616.2
"CT Angiography, Neck",PX7049801,CDM,350,RC,70498,CPT,TC,,,,,,,3690,,Health Partners,Health Partners Care Plans,both,48,,2863.43,percent of total billed charges,1771.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3616.2
"CT Angiography, Neck",PX7049801,CDM,350,RC,70498,CPT,TC,,,,,,,3690,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1771.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3616.2
"Percut Biopsy, Abdominal Mass",PX49180F,CDM,510,RC,49180,CPT,,,,,,,,2084,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1771.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,865.6936,2042.32
ustekinumab 130 MG/26ML Solution 26 mL Vial,J3358.01,CDM,636,RC,J3358,HCPCS,,,,57894005427,NDC,26,ML,4130,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1771.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.56,4047.4
hydroxocobalamin 5 g Recon Soln 1 Each Box,J3424.01,CDM,636,RC,J3424,HCPCS,,,,11704037001,NDC,1,EA,1991.16,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1772.1324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,827.127864,1951.3368
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595F,CDM,360,RC,49595,CPT,,,,,,,,3503,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1772.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1455.1462,3432.94
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595P,CDM,982,RC,49595,CPT,,,,,,,,3503,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1772.518,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1455.1462,3409.4699
Exc Abd Les Sc < 3 Cm,PX22902P,CDM,983,RC,22902,CPT,,,,,,,,2086,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1773.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,866.5244,2030.3038
ALLOGRAFT BONE AUGMENT INJECTABLE KIT 1.5CC,C1734,CDM,278,RC,C1734,HCPCS,,12632-MAIN,LOCAL,,,,,3694,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1773.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1534.4876,3620.12
ALLOGRAFT BONE AUGMENT INJECTABLE KIT 1.5CC,C1734,CDM,278,RC,C1734,HCPCS,,12632-MAIN,LOCAL,,,,,3694,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1773.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1534.4876,3620.12
Room Rate General Iso,PX12000001,CDM,120,RC,,,,,,,,,,1822,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1773.3526,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,756.8588,1785.56
clobetasol 0.05 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,21922001707,NDC,60,GR,1810.35,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1774.143,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Closed Rx Radial Head/Neck Fx,Manip",PX24655P,CDM,983,RC,24655,CPT,,,,,,,,1824,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1775.2992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,757.6896,1775.2992
"Up GI Endoscopy,Dilatn W Guide",PX43248F,CDM,750,RC,43248,CPT,,,,,,,,1995,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1775.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,1955.1
"Colonoscopy,Transendoscopic Stent",PX45387P,CDM,983,RC,45387,CPT,,,,,,,,3587,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1775.565,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1490.0398,3491.2271
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569P,CDM,983,RC,36569,CPT,,,,,,,,1825,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1776.2725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,758.105,1776.2725
"Amputation Toe,Mt-P Jt",PX28820F,CDM,510,RC,28820,CPT,,,,,,,,1950,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1776.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,810.03,2827.75
Remv Periton FB From Perit Cav,PX49402F,CDM,510,RC,49402,CPT,,,,,,,,3573,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1776.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,510.91,1776.54
Remv Periton FB From Perit Cav,PX49402F,CDM,510,RC,49402,CPT,,,,,,,,3573,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1776.54,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,510.91,1776.54
Remv Periton FB From Perit Cav,PX49402P,CDM,983,RC,49402,CPT,,,,,,,,3897,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1776.54,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,510.91,3819.06
Remv Periton FB From Perit Cav,PX49402P,CDM,983,RC,49402,CPT,,,,,,,,3897,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1776.54,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,510.91,3819.06
"MRI,Lwrext,No Jnt, W/Cont",PX7371901,CDM,610,RC,73719,CPT,TC,,,,,,,3627,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1777.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3554.46
"MRI,Lwrext,No Jnt, W/Cont",PX7371901,CDM,610,RC,73719,CPT,TC,,,,,,,3627,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1777.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3554.46
"MRI,Lwrext,No Jnt, W/Cont",PX7371901,CDM,610,RC,73719,CPT,TC,,,,,,,3627,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1777.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3554.46
"Biopsy of Prostate,Needle/Punch",PX55700F,CDM,510,RC,55700,CPT,,,,,,,,2039,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1779.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,847.0006,1998.22
"Cystourethroscopy, With Injection(S) for Chemodenervation of the Bladder",PX52287F,CDM,360,RC,52287,CPT,,,,,,,,2745,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1779.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1140.273,2690.1
"Incis/Drain Scrotum/Testis,Epididym",PX54700F,CDM,510,RC,54700,CPT,,,,,,,,660,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1779.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.164,1779.39
"Incis/Drain Scrotum/Testis,Epididym",PX54700P,CDM,983,RC,54700,CPT,,,,,,,,440,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,1779.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,182.776,1779.39
MESH VENTRALIGHT ECHO 2.0 POSITIONING 15CM ROUND,C1781,CDM,278,RC,C1781,HCPCS,,12842-MAIN,LOCAL,,,,,1816,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1779.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Ht Muscle Image Spect, Mult",PX7845201,CDM,340,RC,78452,CPT,TC,,,,,,,2000,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1780,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,858,5292.1
"VENTRALIGHT MESH ST WITH ECHO 2 - 15 CM X 20 CM 6"" X 8""",C1781,CDM,278,RC,C1781,HCPCS,,12008-MAIN,LOCAL,,,,,3518,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1780.108,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
RESTRATA WOUND MATRIX 2.5CM X 2.5CM TOTAL 6.25CM,27200000,CDM,272,RC,A2007,HCPCS,,11733-MAIN,LOCAL,,,,,1829,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1780.1657,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
GOLIMumab 50 MG/4ML Solution 4 mL Vial,J1602.01,CDM,636,RC,J1602,HCPCS,,,,57894035001,NDC,4,ML,3709.76,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1780.6848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.31,3635.5648
GOLIMumab 50 MG/4ML Solution 4 mL Vial,J1602.01,CDM,636,RC,J1602,HCPCS,,,,57894035001,NDC,4,ML,3709.76,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1780.6848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.31,3635.5648
FORCEPS SPOON JAWSIZE 10MMX36 KIT,27200000,CDM,272,RC,,,,11749-MAIN,LOCAL,,,,,1955,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1781.005,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CT Chest Spine W/Dye,PX7212901,CDM,350,RC,72129,CPT,TC,,,,,,,2096,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1781.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,2054.08
MICA SCREW 4.0X32MM FULLY THREADED STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12894-MAIN,LOCAL,,,,,2096,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1781.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 3.0X38MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12984-MAIN,LOCAL,,,,,2096,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1781.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X42MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12948-MAIN,LOCAL,,,,,2096,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1781.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X44MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12893-MAIN,LOCAL,,,,,2096,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1781.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X56MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12947-MAIN,LOCAL,,,,,2096,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1781.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
belimumab (400v) 400 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010201,NDC,1,EA,3523.71,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1782.99726,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.72,3453.2358
Peramivir 200 MG/20ML Solution 20 mL Vial,800000,CDM,,,,,,,,61364018101,NDC,20,ML,1832.6,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1783.66958,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
fluticasone-salmeterol 230-21 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173071720,NDC,12,GR,2004.35,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1783.8715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Cardiac Stress Tst,Tracing Only",PX93017,CDM,482,RC,93017,CPT,,,,,,,,1959,,Medica,Commercial,both,91.1,,760.5566667,percent of total billed charges,1784.649,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.21,1919.82
Level 3 Additional Procedure,PX36000082,CDM,360,RC,,,,,,,,,,2100,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1785,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,872.34,2058
Or Level 3,PX36000003,CDM,360,RC,,,,,,,,,,2100,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1785,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,872.34,2058
Room Rate General Iso,PX12000001,CDM,120,RC,,,,,,,,,,1822,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1785.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,756.8588,1785.56
"Closed Rx Radial Head/Neck Fx,Manip",PX24655P,CDM,983,RC,24655,CPT,,,,,,,,1824,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1787.52,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,259.6,1787.52
Removal of Hemorrhoid Clot,PX46320F,CDM,510,RC,46320,CPT,,,,,,,,2027,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1787.814,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,842.0158,1986.46
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569P,CDM,983,RC,36569,CPT,,,,,,,,1825,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1788.5,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,56.28,1788.5
Lap Partial Colectomy/Coloproctostomy,PX44207F,CDM,750,RC,44207,CPT,,,,,,,,4170,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1788.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1130.58,4086.6
Lap Incis Hernia Reducible,PX49654F,CDM,510,RC,49654,CPT,,,,,,,,1964,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1789.204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,815.8456,1924.72
Multiple Sleep Latency Test,PX9580501,CDM,740,RC,95805,CPT,TC,,,,,,,4313,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1791.6202,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,468.24,4226.74
"Polysomnography, 4 or More",PX9581001,CDM,740,RC,95810,CPT,TC,,,,,,,4313,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1791.6202,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,913.4,4226.74
"Mra, Head W/Out Contrast",PX7054401,CDM,610,RC,70544,CPT,TC,,,,,,,3541,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1791.746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
"Mra, Neck With Contrast",PX7054801,CDM,610,RC,70548,CPT,TC,,,,,,,3541,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1791.746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI Brain W & WO Contrast,PX7055301,CDM,610,RC,70553,CPT,TC,,,,,,,3541,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1791.746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI C Spine W&WO Contrast,PX7215601,CDM,610,RC,72156,CPT,TC,,,,,,,3541,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1791.746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI C-Spine WO Contrast,PX7214101,CDM,610,RC,72141,CPT,TC,,,,,,,3541,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1791.746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI L Spine WO Contrast,PX7214801,CDM,610,RC,72148,CPT,TC,,,,,,,3541,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1791.746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI Low Ext Jnt WO/Cont Tc,PX7372101,CDM,610,RC,73721,CPT,TC,,,,,,,3541,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1791.746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI Orb-Fac-Nec W/O+W/Con,PX7054301,CDM,610,RC,70543,CPT,TC,,,,,,,3541,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1791.746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
"MRI,Upr Ext, Joint,W/Cont",PX7322201,CDM,610,RC,73222,CPT,TC,,,,,,,3541,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1791.746,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,611.05,3470.18
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290101,NDC,1,EA,1966.88,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1791.82768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.77,1927.5424
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290102,NDC,1,EA,1966.88,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1791.82768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.77,1927.5424
MRI L Spine W&WO Contrast,PX7215801,CDM,610,RC,72158,CPT,TC,,,,,,,4178,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1792.362,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4094.44
MRI T Spine W&WO Contrast,PX7215701,CDM,610,RC,72157,CPT,TC,,,,,,,4178,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1792.362,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4094.44
RESTRATA WOUND MATRIX 2.5CM X 2.5CM TOTAL 6.25CM,27200000,CDM,272,RC,A2007,HCPCS,,11733-MAIN,LOCAL,,,,,1829,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1792.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505F,CDM,510,RC,24505,CPT,,,,,,,,2109,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1792.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,876.0786,2066.82
DYNANITE PIP - STRAIGHT 12MM - WITH INSTRUMENTATION,27200000,CDM,278,RC,C1713,HCPCS,,11626-MAIN,LOCAL,,,,,3543.65,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1793.0869,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP - STRAIGHT 14MM - WITH INSTRUMENTATION,27200000,CDM,278,RC,C1713,HCPCS,,11627-MAIN,LOCAL,,,,,3543.65,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1793.0869,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT BENT 12MM,27200000,CDM,278,RC,C1713,HCPCS,,11629-MAIN,LOCAL,,,,,3543.65,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1793.0869,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT BENT 14MM,27200000,CDM,278,RC,C1713,HCPCS,,11631-MAIN,LOCAL,,,,,3543.65,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1793.0869,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT BENT 16MM,27200000,CDM,278,RC,C1713,HCPCS,,11633-MAIN,LOCAL,,,,,3543.65,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1793.0869,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT STRAIGHT 12MM,27200000,CDM,278,RC,C1713,HCPCS,,11628-MAIN,LOCAL,,,,,3543.65,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1793.0869,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT STRAIGHT 14MM,27200000,CDM,278,RC,C1713,HCPCS,,11630-MAIN,LOCAL,,,,,3543.65,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1793.0869,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT STRAIGHT 16MM,27200000,CDM,278,RC,C1713,HCPCS,,11632-MAIN,LOCAL,,,,,3543.65,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1793.0869,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNABUNION PLATE STERILE INSTRUMENT KIT,27200000,CDM,272,RC,,,,12465-MAIN,LOCAL,,,,,1843,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1793.7919,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CT Angio Abdom W/O & W/Dye,PX7417501,CDM,350,RC,74175,CPT,TC,,,,,,,4183,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1794.507,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,4099.34
"Lap,Inguinal Hernia Repr,Recur",PX49651P,CDM,983,RC,49651,CPT,,,,,,,,2035,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1794.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,845.339,5040.74
"MRI,Lwrext,No Jnt, W/Cont",PX7371901,CDM,610,RC,73719,CPT,TC,,,,,,,3627,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1795.365,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3554.46
Peramivir 200 MG/20ML Solution 20 mL Vial,800000,CDM,,,,,,,,61364018101,NDC,20,ML,1832.6,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1795.948,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
ferumoxytol 510 MG/17ML Solution 17 mL Vial,Q0138.01,CDM,636,RC,Q0138,HCPCS,,,,781315401,NDC,17,ML,1846.91,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1797.597503,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.32,1809.9718
"Biopsy of Prostate,Needle/Punch",PX55700F,CDM,510,RC,55700,CPT,,,,,,,,2039,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1798.398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,847.0006,1998.22
CT Head/Brain W/O & W/Dye,PX7047001,CDM,350,RC,70470,CPT,TC,,,,,,,3671,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,2646.36,percent of total billed charges,1798.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3597.58
CT Head/Brain W/O & W/Dye,PX7047001,CDM,350,RC,70470,CPT,TC,,,,,,,3671,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1798.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3597.58
CT Head/Brain W/O & W/Dye,PX7047001,CDM,350,RC,70470,CPT,TC,,,,,,,3671,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1798.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3597.58
Sleep Staging 4 + Pap,PX9581126,CDM,982,RC,95811,CPT,26,,,,,,,1850,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1800.605,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,768.49,1800.605
"Repair Ing Hernia,5+Y/O,Strang",PX49507F,CDM,510,RC,49507,CPT,,,,,,,,1977,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1801.047,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,821.2458,3022.41
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,310072010,NDC,5,ML,1977.83,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1801.80313,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.74,1938.2734
REAMER FOR CROSS PLATES,27200000,CDM,272,RC,,,,12641-MAIN,LOCAL,,,,,1852,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1802.5516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606P,CDM,983,RC,11606,CPT,,,,,,,,2044,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1802.808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,849.0776,1989.4252
ULTRAGUIDE CTR SX-ONE MICROKNIFE 600112-001,27200000,CDM,272,RC,,,,13106-MAIN,LOCAL,,,,,2121,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1802.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Removal of Hemorrhoid Clot,PX46320F,CDM,510,RC,46320,CPT,,,,,,,,2027,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1804.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,842.0158,1986.46
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,781307912,NDC,5,ML,1854.23,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,129.0143333,percent of total billed charges,1804.722059,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.74,1938.2734
RESTRATA WOUND MATRIX 2.5CM X 7.5CM TOTAL 18.75CM,27200000,CDM,272,RC,A2007,HCPCS,,11735-MAIN,LOCAL,,,,,4208,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1805.232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNABUNION PLATE STERILE INSTRUMENT KIT,27200000,CDM,272,RC,,,,12465-MAIN,LOCAL,,,,,1843,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1806.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Repair Ing Hernia,5+Y/O,Reducibl",PX49505P,CDM,983,RC,49505,CPT,,,,,,,,2048,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1806.336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,850.7392,3022.41
"Repair Recurr Inguin Hern,Reducibl",PX49520F,CDM,510,RC,49520,CPT,,,,,,,,1983,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1806.513,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,823.7382,3022.41
"Repair Recurr Inguin Hern,Reducibl",PX49520P,CDM,983,RC,49520,CPT,,,,,,,,1983,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1806.513,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,823.7382,3022.41
CT Abdomen W/O & W/Dye,PX7417001,CDM,350,RC,74170,CPT,TC,,,,,,,3689,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,737.8,percent of total billed charges,1807.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3615.22
CT Abdomen W/O & W/Dye,PX7417001,CDM,350,RC,74170,CPT,TC,,,,,,,3689,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1807.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3615.22
CT Abdomen W/O & W/Dye,PX7417001,CDM,350,RC,74170,CPT,TC,,,,,,,3689,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1807.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3615.22
"CT Angiography, Chest",PX7127501,CDM,350,RC,71275,CPT,TC,,,,,,,3689,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,743.885,percent of total billed charges,1807.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3615.22
"CT Angiography, Chest",PX7127501,CDM,350,RC,71275,CPT,TC,,,,,,,3689,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1807.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3615.22
"CT Angiography, Chest",PX7127501,CDM,350,RC,71275,CPT,TC,,,,,,,3689,,United Healthcare,All Medicare advantage plans,outpatient,49,,1897.93,percent of total billed charges,1807.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3615.22
Remv Periton FB From Perit Cav,PX49402F,CDM,510,RC,49402,CPT,,,,,,,,3573,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1807.938,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1484.2242,3501.54
"CT Angiography, Head",PX7049601,CDM,350,RC,70496,CPT,TC,,,,,,,3690,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,728.1815789,percent of total billed charges,1808.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3616.2
"CT Angiography, Head",PX7049601,CDM,350,RC,70496,CPT,TC,,,,,,,3690,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1808.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3616.2
"CT Angiography, Head",PX7049601,CDM,350,RC,70496,CPT,TC,,,,,,,3690,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1808.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3616.2
"CT Angiography, Neck",PX7049801,CDM,350,RC,70498,CPT,TC,,,,,,,3690,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,697.6361111,percent of total billed charges,1808.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3616.2
"CT Angiography, Neck",PX7049801,CDM,350,RC,70498,CPT,TC,,,,,,,3690,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1808.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3616.2
"CT Angiography, Neck",PX7049801,CDM,350,RC,70498,CPT,TC,,,,,,,3690,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1808.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3616.2
Remove Foreign Body Complic,PX10121F,CDM,510,RC,10121,CPT,,,,,,,,3575,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1808.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1416.38,3503.5
ferumoxytol 510 MG/17ML Solution 17 mL Vial,Q0138.01,CDM,636,RC,Q0138,HCPCS,,,,781315401,NDC,17,ML,1846.91,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1809.9718,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.32,1809.9718
ALLOGRAFT BONE AUGMENT INJECTABLE KIT 1.5CC,C1734,CDM,278,RC,C1734,HCPCS,,12632-MAIN,LOCAL,,,,,3694,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1810.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1534.4876,3620.12
ALLOGRAFT BONE AUGMENT INJECTABLE KIT 1.5CC,C1734,CDM,278,RC,C1734,HCPCS,,12632-MAIN,LOCAL,,,,,3694,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1810.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1534.4876,3620.12
ALLOGRAFT BONE AUGMENT INJECTABLE KIT 1.5CC,C1734,CDM,278,RC,C1734,HCPCS,,12632-MAIN,LOCAL,,,,,3694,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1810.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1534.4876,3620.12
Exs Tumor Arm/Elbow Sc 3cm>,PX24071F,CDM,510,RC,24071,CPT,,,,,,,,1860,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1810.338,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,772.644,2482.37
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING4X6,C1781,CDM,278,RC,C1781,HCPCS,,12505-MAIN,LOCAL,,,,,1860,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1256.29,percent of total billed charges,1810.338,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
MINIBUNION INSTRUMENT KIT,27200000,CDM,278,RC,C1713,HCPCS,,11668-MAIN,LOCAL,,,,,1860.65,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1810.970645,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Lap,Inguinal Hernia Repr,Recur",PX49651P,CDM,983,RC,49651,CPT,,,,,,,,2035,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1811.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,845.339,5040.74
Lap Rpr Vent Umbilical Hernia Incarcerated or Strangulated,PX49653F,CDM,510,RC,49653,CPT,,,,,,,,1990,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1812.89,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,826.646,1950.2
CT Abd&Pelv 1+ Section/Regns,PX7417801,CDM,350,RC,74178,CPT,TC,,,,,,,4226,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1812.954,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4141.48
"MRI,Lwrext,Jnt W/O+W/Cont",PX7372301,CDM,610,RC,73723,CPT,TC,,,,,,,1850,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1813,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2066.35
Sleep Staging 4 + Pap,PX9581126,CDM,982,RC,95811,CPT,26,,,,,,,1850,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1813,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,77.22,1813
hydroxocobalamin 5 g Recon Soln 1 Each Box,J3424.01,CDM,636,RC,J3424,HCPCS,,,,11704037001,NDC,1,EA,1991.16,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1813.94676,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,827.127864,1951.3368
"Biopsy of Prostate,Needle/Punch",PX55700F,CDM,510,RC,55700,CPT,,,,,,,,2039,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1814.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,847.0006,1998.22
Exc Back Les Sc = 3 Cm,PX21931P,CDM,983,RC,21931,CPT,,,,,,,,2135,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1814.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,886.879,2077.9955
REAMER FOR CROSS PLATES,27200000,CDM,272,RC,,,,12641-MAIN,LOCAL,,,,,1852,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1814.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Colonoscopy,Transendoscopic Stent",PX45387P,CDM,983,RC,45387,CPT,,,,,,,,3587,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1815.022,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1490.0398,3491.2271
leuprolide 7.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74364203,NDC,1,EA,3782.28,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1815.4944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
leuprolide 7.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74364203,NDC,1,EA,3782.28,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1815.4944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
"Sigmoidoscopy,Remv Lesn,Snare",PX45338F,CDM,510,RC,45338,CPT,,,,,,,,2137,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1816.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,887.7098,2094.26
CT Head/Brain W/O & W/Dye,PX7047001,CDM,350,RC,70470,CPT,TC,,,,,,,3671,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1817.145,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3597.58
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,781307912,NDC,5,ML,1854.23,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1817.1454,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.74,1938.2734
"Up GI Endoscopy,Dilatn W Guide",PX43248F,CDM,750,RC,43248,CPT,,,,,,,,1995,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1817.445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,1955.1
GOLIMumab 50 MG/4ML Solution 4 mL Vial,J1602.01,CDM,636,RC,J1602,HCPCS,,,,57894035001,NDC,4,ML,3709.76,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,14.83908,percent of total billed charges,1817.7824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.31,3635.5648
GOLIMumab 50 MG/4ML Solution 4 mL Vial,J1602.01,CDM,636,RC,J1602,HCPCS,,,,57894035001,NDC,4,ML,3709.76,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1817.7824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.31,3635.5648
GOLIMumab 50 MG/4ML Solution 4 mL Vial,J1602.01,CDM,636,RC,J1602,HCPCS,,,,57894035001,NDC,4,ML,3709.76,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1817.7824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.31,3635.5648
Room Rate Swing General,PX12000010,CDM,120,RC,,,,,,,,,,3788,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1818.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1573.5352,3712.24
Room Rate Swing General,PX12000010,CDM,120,RC,,,,,,,,,,3788,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1818.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1573.5352,3712.24
Room Rate Swing General Iso,PX12000011,CDM,120,RC,,,,,,,,,,3788,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1818.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1573.5352,3712.24
Room Rate Swing General Iso,PX12000011,CDM,120,RC,,,,,,,,,,3788,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1818.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1573.5352,3712.24
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606P,CDM,983,RC,11606,CPT,,,,,,,,2044,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1819.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,849.0776,1989.4252
romiPLOStim 250 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022101,NDC,1,EA,3791.51,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1819.9248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.04,6877.885
romiPLOStim 250 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022101,NDC,1,EA,3791.51,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1819.9248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.04,6877.885
"Ht Muscle Image Spect, Mult",PX7845201,CDM,340,RC,78452,CPT,TC,,,,,,,2000,,Medica,Commercial,both,91.1,,897.9,percent of total billed charges,1822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,858,5292.1
"Repair Ing Hernia,5+Y/O,Reducibl",PX49505P,CDM,983,RC,49505,CPT,,,,,,,,2048,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1822.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,850.7392,3022.41
Exs Tumor Arm/Elbow Sc 3cm>,PX24071F,CDM,510,RC,24071,CPT,,,,,,,,1860,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1822.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,772.644,2482.37
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING4X6,C1781,CDM,278,RC,C1781,HCPCS,,12505-MAIN,LOCAL,,,,,1860,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1822.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
MINIBUNION INSTRUMENT KIT,27200000,CDM,278,RC,C1713,HCPCS,,11668-MAIN,LOCAL,,,,,1860.65,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1823.437,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
fluticasone-salmeterol 230-21 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173071720,NDC,12,GR,2004.35,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1825.96285,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CT Abdomen W/O & W/Dye,PX7417001,CDM,350,RC,74170,CPT,TC,,,,,,,3689,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1826.055,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3615.22
"CT Angiography, Chest",PX7127501,CDM,350,RC,71275,CPT,TC,,,,,,,3689,,Humana Choice Care,All Medicare plans,outpatient,49.5,,673.3525,percent of total billed charges,1826.055,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3615.22
Or Level 4,PX36000004,CDM,360,RC,,,,,,,,,,3805,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1826.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1580.597,3728.9
Or Level 4,PX36000004,CDM,360,RC,,,,,,,,,,3805,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1826.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1580.597,3728.9
"CT Angiography, Head",PX7049601,CDM,350,RC,70496,CPT,TC,,,,,,,3690,,Humana Choice Care,All Medicare plans,outpatient,49.5,,586.635,percent of total billed charges,1826.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3616.2
"CT Angiography, Neck",PX7049801,CDM,350,RC,70498,CPT,TC,,,,,,,3690,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1826.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3616.2
"Correct Bunion,Metatarsal Osteotomy",PX28296P,CDM,983,RC,28296,CPT,,,,,,,,2150,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1827.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,893.11,2827.75
ALLOGRAFT BONE AUGMENT INJECTABLE KIT 1.5CC,C1734,CDM,278,RC,C1734,HCPCS,,12632-MAIN,LOCAL,,,,,3694,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1828.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1534.4876,3620.12
sarilumab 200 MG/1.14ML solution prefilled syringe 1.14 mL Syringe,J3590.25,CDM,636,RC,J3590,HCPCS,,,,24591001,NDC,1.14,ML,4408.29,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1831.203666,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1831.203666,4320.1242
Part Remv Phalanx of Toe,PX28124F,CDM,510,RC,28124,CPT,,,,,,,,2155,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1831.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,895.187,2827.75
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830F,CDM,510,RC,15830,CPT,,,,,,,,2080,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1834.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,864.032,5696.92
"Correct Bunion,Metatarsal Osteotomy",PX28296F,CDM,510,RC,28296,CPT,,,,,,,,8100,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1834.65,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,324.17,1834.65
"Correct Bunion,Metatarsal Osteotomy",PX28296P,CDM,983,RC,28296,CPT,,,,,,,,2150,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1834.65,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,324.17,2107
"MRI,Lwrext,No Jnt, W/Cont",PX7371901,CDM,610,RC,73719,CPT,TC,,,,,,,3627,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1835.262,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3554.46
GOLIMumab 50 MG/4ML Solution 4 mL Vial,J1602.01,CDM,636,RC,J1602,HCPCS,,,,57894035001,NDC,4,ML,3709.76,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1836.3312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.31,3635.5648
CT Lumbar Spine W/O & W/Dye,PX7213301,CDM,350,RC,72133,CPT,TC,,,,,,,4283,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1837.407,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,4197.34
"Percut Biopsy, Abdominal Mass",PX49180F,CDM,510,RC,49180,CPT,,,,,,,,2084,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1838.088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,865.6936,2042.32
"Initial Repair of Entrapped Hernia of Abdomen, Less Than 3 Cm in Length",PX49592,CDM,982,RC,49592,CPT,,,,,,,,2164,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1839.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,898.9256,5040.74
Lap Rpr Vent Umbilical Hernia,PX49652F,CDM,510,RC,49652,CPT,,,,,,,,1890,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1839.537,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,785.106,1852.2
CT Abd & Pelvis W/O Contrast,PX7417601,CDM,350,RC,74176,CPT,TC,,,,,,,4288,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1839.552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,4202.24
CT Abdomen&Pelvis W/Contrast,PX7417701,CDM,350,RC,74177,CPT,TC,,,,,,,4288,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1839.552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4202.24
Exc Abd Les Sc < 3 Cm,PX22902P,CDM,983,RC,22902,CPT,,,,,,,,2086,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1839.852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,866.5244,2030.3038
fluticasone-umeclidin-vilant 100-62.5-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173088714,NDC,28,EA,1894.99,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1844.393767,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x3CM 9SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12766-MAIN,LOCAL,,,,,2171,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1845.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
"Bone Scan, Whole Body",PX7830601,CDM,341,RC,78306,CPT,TC,,,,,,,1896,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1845.3768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,360.31,1858.08
nivolumab 40 MG/4ML Solution 4 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377211,NDC,4,ML,2171.7,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1845.945,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.5,12769.6548
Removal of Hemorrhoid Clot,PX46320F,CDM,510,RC,46320,CPT,,,,,,,,2027,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1846.597,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,842.0158,1986.46
Cytogenomic Neoplasia (Genome-Wide) Microarray Analysis - Ref,PX8127790,CDM,310,RC,81277,CPT,90,,,,,,,3850,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1063.6,3773
Cytogenomic Neoplasia (Genome-Wide) Microarray Analysis - Ref,PX8127790,CDM,310,RC,81277,CPT,90,,,,,,,3850,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1063.6,3773
"Lap,Esophagogast Fundoplasty",PX43280P,CDM,983,RC,43280,CPT,,,,,,,,4449,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1848.1146,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1848.1146,8992.74
CT Chest Spine W/Dye,PX7212901,CDM,350,RC,72129,CPT,TC,,,,,,,2096,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1848.672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,2054.08
MICA SCREW 4.0X32MM FULLY THREADED STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12894-MAIN,LOCAL,,,,,2096,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1848.672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 3.0X38MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12984-MAIN,LOCAL,,,,,2096,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1848.672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X42MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12948-MAIN,LOCAL,,,,,2096,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1848.672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X44MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12893-MAIN,LOCAL,,,,,2096,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1848.672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X56MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12947-MAIN,LOCAL,,,,,2096,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1848.672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Or Level 2,PX36000002,CDM,360,RC,,,,,,,,,,1900,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1849.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,789.26,1862
Reconstruc of Nail Bed W Graft,PX11762F,CDM,510,RC,11762,CPT,,,,,,,,1901,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1850.2433,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,789.6754,1862.98
Multiple Sleep Latency Test,PX9580501,CDM,740,RC,95805,CPT,TC,,,,,,,4313,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1850.277,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,468.24,4226.74
"Polysomnography, 4 or More",PX9581001,CDM,740,RC,95810,CPT,TC,,,,,,,4313,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1850.277,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,913.4,4226.74
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830F,CDM,510,RC,15830,CPT,,,,,,,,2080,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1851.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,864.032,5696.92
"Treat Thumb Disloc,Manipulatn",PX26641P,CDM,983,RC,26641,CPT,,,,,,,,1902,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1851.2166,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.02,1851.2166
Lap Rpr Vent Umbilical Hernia,PX49652F,CDM,510,RC,49652,CPT,,,,,,,,1890,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1852.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,785.106,1852.2
Level 3 Additional Procedure,PX36000082,CDM,360,RC,,,,,,,,,,2100,,United Healthcare,All Payer,outpatient,88.2,,999999999,case rate,1852.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1852.2,6141.46
Or Level 3,PX36000003,CDM,360,RC,,,,,,,,,,2100,,United Healthcare,All Payer,outpatient,88.2,,999999999,case rate,1852.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1852.2,6141.46
fluticasone-salmeterol 230-21 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,66993008896,NDC,12,GR,1904.14,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1853.299462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
leuprolide 7.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74364203,NDC,1,EA,3782.28,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,721.12,percent of total billed charges,1853.3172,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
leuprolide 7.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74364203,NDC,1,EA,3782.28,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1853.3172,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
leuprolide 7.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74364203,NDC,1,EA,3782.28,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1853.3172,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
"Lap,Inguinal Hernia Repr,Recur",PX49651P,CDM,983,RC,49651,CPT,,,,,,,,2035,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1853.885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,845.339,5040.74
"Repair Umbilical Hern,5+Y/O,Strang",PX49587P,CDM,983,RC,49587,CPT,,,,,,,,2182,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1854.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,906.4028,2123.7406
"Percut Biopsy, Abdominal Mass",PX49180F,CDM,510,RC,49180,CPT,,,,,,,,2084,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1854.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,865.6936,2042.32
Room Rate Swing General,PX12000010,CDM,120,RC,,,,,,,,,,3788,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1856.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1573.5352,3712.24
Room Rate Swing General,PX12000010,CDM,120,RC,,,,,,,,,,3788,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1856.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1573.5352,3712.24
Room Rate Swing General,PX12000010,CDM,120,RC,,,,,,,,,,3788,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1856.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1573.5352,3712.24
Room Rate Swing General Iso,PX12000011,CDM,120,RC,,,,,,,,,,3788,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1856.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1573.5352,3712.24
Room Rate Swing General Iso,PX12000011,CDM,120,RC,,,,,,,,,,3788,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1856.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1573.5352,3712.24
Room Rate Swing General Iso,PX12000011,CDM,120,RC,,,,,,,,,,3788,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1856.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1573.5352,3712.24
Exc Abd Les Sc < 3 Cm,PX22902P,CDM,983,RC,22902,CPT,,,,,,,,2086,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1856.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,866.5244,2030.3038
fluticasone-umeclidin-vilant 100-62.5-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173088714,NDC,28,EA,1894.99,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1857.0902,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CT Head/Brain W/O & W/Dye,PX7047001,CDM,350,RC,70470,CPT,TC,,,,,,,3671,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1857.526,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3597.58
"Biopsy of Prostate,Needle/Punch",PX55700F,CDM,510,RC,55700,CPT,,,,,,,,2039,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1857.529,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,847.0006,1998.22
romiPLOStim 250 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022101,NDC,1,EA,3791.51,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1857.8399,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.04,6877.885
romiPLOStim 250 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022101,NDC,1,EA,3791.51,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1857.8399,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.04,6877.885
romiPLOStim 250 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022101,NDC,1,EA,3791.51,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1857.8399,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.04,6877.885
"Bone Scan, Whole Body",PX7830601,CDM,341,RC,78306,CPT,TC,,,,,,,1896,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1858.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,360.31,1858.08
GRAFIXPL PRIME PLACENTAL MEMBRANE 2x3CM 6SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12765-MAIN,LOCAL,,,,,1911,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1859.9763,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505F,CDM,510,RC,24505,CPT,,,,,,,,2109,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1860.138,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,876.0786,2066.82
"Excis Tendn/Capsule Lesn,Toes",PX28092P,CDM,983,RC,28092,CPT,,,,,,,,1913,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,246.8,percent of total billed charges,1861.9229,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,794.6602,1861.9229
Or Level 2,PX36000002,CDM,360,RC,,,,,,,,,,1900,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1862,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,789.26,1862
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606P,CDM,983,RC,11606,CPT,,,,,,,,2044,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1862.084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,849.0776,1989.4252
"Tte W/Doppler, Complete",PX9330601,CDM,483,RC,93306,CPT,TC,,,,,,,2191,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1862.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,481.95,2889.15
Reconstruc of Nail Bed W Graft,PX11762F,CDM,510,RC,11762,CPT,,,,,,,,1901,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1862.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,789.6754,1862.98
"Treat Thumb Disloc,Manipulatn",PX26641P,CDM,983,RC,26641,CPT,,,,,,,,1902,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1863.96,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,246.07,1863.96
Or Level 4,PX36000004,CDM,360,RC,,,,,,,,,,3805,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1864.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1580.597,3728.9
Or Level 4,PX36000004,CDM,360,RC,,,,,,,,,,3805,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1864.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1580.597,3728.9
Or Level 4,PX36000004,CDM,360,RC,,,,,,,,,,3805,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1864.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1580.597,3728.9
riTUXimab 100 MG/10ML Solution 10 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005121,NDC,10,ML,1916.61,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1865.436513,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.61,8682.8588
CT Chest Spine W/Dye,PX7212901,CDM,350,RC,72129,CPT,TC,,,,,,,2096,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1865.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,2054.08
MICA SCREW 4.0X32MM FULLY THREADED STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12894-MAIN,LOCAL,,,,,2096,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1865.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 3.0X38MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12984-MAIN,LOCAL,,,,,2096,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1865.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X42MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12948-MAIN,LOCAL,,,,,2096,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1865.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X44MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12893-MAIN,LOCAL,,,,,2096,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1865.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X56MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12947-MAIN,LOCAL,,,,,2096,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1865.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"Repair Ing Hernia,5+Y/O,Reducibl",PX49505P,CDM,983,RC,49505,CPT,,,,,,,,2048,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1865.728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,850.7392,3022.41
fluticasone-salmeterol 230-21 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,66993008896,NDC,12,GR,1904.14,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1866.0572,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CT Abdomen W/O & W/Dye,PX7417001,CDM,350,RC,74170,CPT,TC,,,,,,,3689,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1866.634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3615.22
"CT Angiography, Chest",PX7127501,CDM,350,RC,71275,CPT,TC,,,,,,,3689,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1866.634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3615.22
"CT Angiography, Head",PX7049601,CDM,350,RC,70496,CPT,TC,,,,,,,3690,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1867.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3616.2
"CT Angiography, Neck",PX7049801,CDM,350,RC,70498,CPT,TC,,,,,,,3690,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1867.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3616.2
Level 3 Additional Procedure,PX36000082,CDM,360,RC,,,,,,,,,,2100,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1869,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,872.34,2058
Or Level 3,PX36000003,CDM,360,RC,,,,,,,,,,2100,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1869,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,872.34,2058
ALLOGRAFT BONE AUGMENT INJECTABLE KIT 1.5CC,C1734,CDM,278,RC,C1734,HCPCS,,12632-MAIN,LOCAL,,,,,3694,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1869.164,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1534.4876,3620.12
alteplase 100 MG Recon Soln 1 Each Syringe,J2997.01,CDM,636,RC,J2997,HCPCS,,,,88888800475,NDC,0.09,EA,1920.88,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1869.592504,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
ULTRAGUIDE CTR SX-ONE MICROKNIFE 600112-001,27200000,CDM,272,RC,,,,13106-MAIN,LOCAL,,,,,2121,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1870.722,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
leuprolide 7.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74364203,NDC,1,EA,3782.28,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1872.2286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
GRAFIXPL PRIME PLACENTAL MEMBRANE 2x3CM 6SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12765-MAIN,LOCAL,,,,,1911,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1872.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
LARGE HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12836-MAIN,LOCAL,,,,,3905,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1874.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LARGE HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12836-MAIN,LOCAL,,,,,3905,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1874.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
MEDIUM HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12835-MAIN,LOCAL,,,,,3905,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1874.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
MEDIUM HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12835-MAIN,LOCAL,,,,,3905,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1874.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
SMALL HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12655-MAIN,LOCAL,,,,,3905,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1874.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
SMALL HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12655-MAIN,LOCAL,,,,,3905,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1874.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"Excis Tendn/Capsule Lesn,Toes",PX28092P,CDM,983,RC,28092,CPT,,,,,,,,1913,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1874.74,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,172.55,1874.74
Room Rate Swing General,PX12000010,CDM,120,RC,,,,,,,,,,3788,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1875.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1573.5352,3712.24
Room Rate Swing General Iso,PX12000011,CDM,120,RC,,,,,,,,,,3788,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1875.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1573.5352,3712.24
Revise Median N/Carpal Tunnel Surg,PX64721P,CDM,983,RC,64721,CPT,,,,,,,,1927,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1875.5491,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,800.4758,1875.5491
"Tte W/Doppler, Complete",PXC8929,CDM,480,RC,C8929,HCPCS,TC,,,,,,,1927,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1875.5491,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,699.48,1888.46
romiPLOStim 250 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022101,NDC,1,EA,3791.51,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1876.79745,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.04,6877.885
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505F,CDM,510,RC,24505,CPT,,,,,,,,2109,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1877.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,876.0786,2066.82
GOLIMumab 50 MG/4ML Solution 4 mL Vial,J1602.01,CDM,636,RC,J1602,HCPCS,,,,57894035001,NDC,4,ML,3709.76,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1877.13856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.31,3635.5648
riTUXimab 100 MG/10ML Solution 10 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005121,NDC,10,ML,1916.61,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1878.2778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.61,8682.8588
inFLIXimab-dyyb 100 MG Recon Soln 1 Each Vial,Q5103.01,CDM,636,RC,Q5103,HCPCS,,,,69080901,NDC,1,EA,1930.42,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1878.877786,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.85,1891.8116
omalizumab 150 MG Recon Soln 1 Each Vial,J2357.01,CDM,636,RC,J2357,HCPCS,,,,50242004062,NDC,1,EA,2212.7,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1880.795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.02,2168.446
PLANTAR PLATE IMPLANT SET GRAVITY REPAIR,C1713,CDM,278,RC,C1713,HCPCS,,12649-MAIN,LOCAL,,,,,3921,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1882.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PLANTAR PLATE IMPLANT SET GRAVITY REPAIR,C1713,CDM,278,RC,C1713,HCPCS,,12649-MAIN,LOCAL,,,,,3921,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1882.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
alteplase 100 MG Recon Soln 1 Each Syringe,J2997.01,CDM,636,RC,J2997,HCPCS,,,,88888800475,NDC,0.09,EA,1920.88,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1882.4624,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
Exc Back Les Sc = 3 Cm,PX21931P,CDM,983,RC,21931,CPT,,,,,,,,2135,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1883.07,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,886.879,2077.9955
fluticasone-salmeterol 100-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,54032656,NDC,60,EA,2215.63,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1883.2855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Or Level 4,PX36000004,CDM,360,RC,,,,,,,,,,3805,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1883.475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1580.597,3728.9
HIMAX STAPLE KIT 18X14X14,27200000,CDM,278,RC,C1713,HCPCS,,11851-MAIN,LOCAL,,,,,4536,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1884.2544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Sigmoidoscopy,Remv Lesn,Snare",PX45338F,CDM,510,RC,45338,CPT,,,,,,,,2137,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1884.834,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,887.7098,2094.26
Cytogenomic Neoplasia (Genome-Wide) Microarray Analysis - Ref,PX8127790,CDM,310,RC,81277,CPT,90,,,,,,,3850,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1886.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1063.6,3773
Cytogenomic Neoplasia (Genome-Wide) Microarray Analysis - Ref,PX8127790,CDM,310,RC,81277,CPT,90,,,,,,,3850,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1886.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1063.6,3773
Cytogenomic Neoplasia (Genome-Wide) Microarray Analysis - Ref,PX8127790,CDM,310,RC,81277,CPT,90,,,,,,,3850,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1886.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1063.6,3773
OSTEOSET RESORBABLE MINI BEAD KIT FAST CURE CALCIUM SULFATE 5CC,C1713,CDM,278,RC,C1713,HCPCS,,12303-MAIN,LOCAL,,,,,2220,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1887,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
ULTRAGUIDE CTR SX-ONE MICROKNIFE 600112-001,27200000,CDM,272,RC,,,,13106-MAIN,LOCAL,,,,,2121,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1887.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Revise Median N/Carpal Tunnel Surg,PX64721P,CDM,983,RC,64721,CPT,,,,,,,,1927,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1888.46,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,276.61,1888.46
"Tte W/Doppler, Complete",PXC8929,CDM,480,RC,C8929,HCPCS,TC,,,,,,,1927,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1888.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,699.48,1888.46
sarilumab 200 MG/1.14ML solution prefilled syringe 1.14 mL Syringe,J3590.25,CDM,636,RC,J3590,HCPCS,,,,24591001,NDC,1.14,ML,4408.29,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1891.15641,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1831.203666,4320.1242
inFLIXimab-dyyb 100 MG Recon Soln 1 Each Vial,Q5103.01,CDM,636,RC,Q5103,HCPCS,,,,69080901,NDC,1,EA,1930.42,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1891.8116,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.85,1891.8116
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830F,CDM,510,RC,15830,CPT,,,,,,,,2080,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1894.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,864.032,5696.92
"Correct Bunion,Metatarsal Osteotomy",PX28296P,CDM,983,RC,28296,CPT,,,,,,,,2150,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1896.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,893.11,2827.75
"Amputation Toe,Mt-P Jt",PX28820F,CDM,510,RC,28820,CPT,,,,,,,,1950,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1897.935,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,810.03,2827.75
"Percut Biopsy, Abdominal Mass",PX49180F,CDM,510,RC,49180,CPT,,,,,,,,2084,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1898.524,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,865.6936,2042.32
Exc Back Les Sc = 3 Cm,PX21931P,CDM,983,RC,21931,CPT,,,,,,,,2135,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1900.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,886.879,2077.9955
"Colonoscopy,Remv Lesn,Snare",PX45385F,CDM,750,RC,45385,CPT,,,,,,,,1939,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1900.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,831.831,4050.42
Exc Abd Les Sc < 3 Cm,PX22902P,CDM,983,RC,22902,CPT,,,,,,,,2086,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1900.346,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,866.5244,2030.3038
Polysomnography W/Cpap,PX9581101,CDM,740,RC,95811,CPT,TC,,,,,,,4575,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1900.455,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,913.4,4483.5
Part Remv Phalanx of Toe,PX28124F,CDM,510,RC,28124,CPT,,,,,,,,2155,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1900.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,895.187,2827.75
"Sigmoidoscopy,Remv Lesn,Snare",PX45338F,CDM,510,RC,45338,CPT,,,,,,,,2137,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1901.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,887.7098,2094.26
FORCEPS SPOON JAWSIZE 10MMX36 KIT,27200000,CDM,272,RC,,,,11749-MAIN,LOCAL,,,,,1955,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1902.8015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MODULAR INSERT TOE JOINT 2.5MM 3.6MMTHK PROXIMAL PHALANGEAL,C1713,CDM,278,RC,C1713,HCPCS,,12530-MAIN,LOCAL,,,,,3968,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1904.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
MODULAR INSERT TOE JOINT 2.5MM 3.6MMTHK PROXIMAL PHALANGEAL,C1713,CDM,278,RC,C1713,HCPCS,,12530-MAIN,LOCAL,,,,,3968,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1904.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Cytogenomic Neoplasia (Genome-Wide) Microarray Analysis - Ref,PX8127790,CDM,310,RC,81277,CPT,90,,,,,,,3850,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1905.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1063.6,3773
"Cardiac Stress Tst,Tracing Only",PX93017,CDM,482,RC,93017,CPT,,,,,,,,1959,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1300.166,percent of total billed charges,1906.6947,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.21,1919.82
Injection for Nerve Block,PX64447P,CDM,983,RC,64447,CPT,,,,,,,,3892,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,2932.295,percent of total billed charges,1907.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,604.15,3788.0836
Injection for Nerve Block,PX64447P,CDM,983,RC,64447,CPT,,,,,,,,3892,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1907.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,604.15,3788.0836
Injection for Nerve Block,PX64447P,CDM,983,RC,64447,CPT,,,,,,,,3892,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1907.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,604.15,3788.0836
"Lap,Esophagogast Fundoplasty",PX43280P,CDM,983,RC,43280,CPT,,,,,,,,4449,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1908.621,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1848.1146,8992.74
"Initial Repair of Entrapped Hernia of Abdomen, Less Than 3 Cm in Length",PX49592,CDM,982,RC,49592,CPT,,,,,,,,2164,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1908.648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,898.9256,5040.74
CT Chest Spine W/Dye,PX7212901,CDM,350,RC,72129,CPT,TC,,,,,,,2096,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1909.456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,2054.08
MICA SCREW 4.0X32MM FULLY THREADED STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12894-MAIN,LOCAL,,,,,2096,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1909.456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 3.0X38MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12984-MAIN,LOCAL,,,,,2096,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1909.456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X42MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12948-MAIN,LOCAL,,,,,2096,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1909.456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X44MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12893-MAIN,LOCAL,,,,,2096,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1909.456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X56MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12947-MAIN,LOCAL,,,,,2096,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1909.456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Remv Periton FB From Perit Cav,PX49402P,CDM,983,RC,49402,CPT,,,,,,,,3897,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1909.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1618.8138,3792.9501
Remv Periton FB From Perit Cav,PX49402P,CDM,983,RC,49402,CPT,,,,,,,,3897,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1909.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1618.8138,3792.9501
Remv Periton FB From Perit Cav,PX49402P,CDM,983,RC,49402,CPT,,,,,,,,3897,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1909.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1618.8138,3792.9501
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180F,CDM,510,RC,44180,CPT,,,,,,,,1763,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1910.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,548.86,1910.75
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180F,CDM,510,RC,44180,CPT,,,,,,,,1763,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1910.75,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,548.86,1910.75
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180P,CDM,983,RC,44180,CPT,,,,,,,,1175,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1910.75,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,548.86,1910.75
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180P,CDM,983,RC,44180,CPT,,,,,,,,1175,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1910.75,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,548.86,1910.75
"Amputation Toe,Mt-P Jt",PX28820F,CDM,510,RC,28820,CPT,,,,,,,,1950,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1911,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,810.03,2827.75
Lap Incis Hernia Reducible,PX49654F,CDM,510,RC,49654,CPT,,,,,,,,1964,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1911.5612,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,815.8456,1924.72
Level 3 Additional Procedure,PX36000082,CDM,360,RC,,,,,,,,,,2100,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1913.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,872.34,2058
Or Level 3,PX36000003,CDM,360,RC,,,,,,,,,,2100,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1913.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,872.34,2058
LARGE HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12836-MAIN,LOCAL,,,,,3905,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,1913.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LARGE HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12836-MAIN,LOCAL,,,,,3905,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1913.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LARGE HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12836-MAIN,LOCAL,,,,,3905,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1913.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
MEDIUM HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12835-MAIN,LOCAL,,,,,3905,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,1913.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
MEDIUM HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12835-MAIN,LOCAL,,,,,3905,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1913.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
MEDIUM HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12835-MAIN,LOCAL,,,,,3905,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1913.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
SMALL HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12655-MAIN,LOCAL,,,,,3905,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,1913.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
SMALL HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12655-MAIN,LOCAL,,,,,3905,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1913.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
SMALL HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12655-MAIN,LOCAL,,,,,3905,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1913.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"Correct Bunion,Metatarsal Osteotomy",PX28296P,CDM,983,RC,28296,CPT,,,,,,,,2150,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1913.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,893.11,2827.75
leuprolide 7.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74364203,NDC,1,EA,3782.28,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1913.83368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290101,NDC,1,EA,1966.88,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,3.9238,percent of total billed charges,1914.364304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.77,1927.5424
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290102,NDC,1,EA,1966.88,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,3.9238,percent of total billed charges,1914.364304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.77,1927.5424
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x3CM 9SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12766-MAIN,LOCAL,,,,,2171,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1914.822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
nivolumab 40 MG/4ML Solution 4 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377211,NDC,4,ML,2171.7,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1915.4394,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.5,12769.6548
FORCEPS SPOON JAWSIZE 10MMX36 KIT,27200000,CDM,272,RC,,,,11749-MAIN,LOCAL,,,,,1955,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1915.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Room Rate Swing General,PX12000010,CDM,120,RC,,,,,,,,,,3788,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1916.728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1573.5352,3712.24
Room Rate Swing General Iso,PX12000011,CDM,120,RC,,,,,,,,,,3788,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1916.728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1573.5352,3712.24
Part Remv Phalanx of Toe,PX28124F,CDM,510,RC,28124,CPT,,,,,,,,2155,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1917.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,895.187,2827.75
romiPLOStim 250 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022101,NDC,1,EA,3791.51,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1918.50406,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.04,6877.885
"Cardiac Stress Tst,Tracing Only",PX93017,CDM,482,RC,93017,CPT,,,,,,,,1959,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1919.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,274.21,1919.82
PLANTAR PLATE IMPLANT SET GRAVITY REPAIR,C1713,CDM,278,RC,C1713,HCPCS,,12649-MAIN,LOCAL,,,,,3921,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,1921.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PLANTAR PLATE IMPLANT SET GRAVITY REPAIR,C1713,CDM,278,RC,C1713,HCPCS,,12649-MAIN,LOCAL,,,,,3921,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1921.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PLANTAR PLATE IMPLANT SET GRAVITY REPAIR,C1713,CDM,278,RC,C1713,HCPCS,,12649-MAIN,LOCAL,,,,,3921,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1921.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505F,CDM,510,RC,24505,CPT,,,,,,,,2109,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1921.299,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,876.0786,2066.82
"Repair Ing Hernia,5+Y/O,Strang",PX49507F,CDM,510,RC,49507,CPT,,,,,,,,1977,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1924.2141,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,821.2458,3022.41
"Repair Umbilical Hern,5+Y/O,Strang",PX49587P,CDM,983,RC,49587,CPT,,,,,,,,2182,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1924.524,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,906.4028,2123.7406
Lap Incis Hernia Reducible,PX49654F,CDM,510,RC,49654,CPT,,,,,,,,1964,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1924.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,815.8456,1924.72
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,310072010,NDC,5,ML,1977.83,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,129.0143333,percent of total billed charges,1925.021939,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.74,1938.2734
Or Level 4,PX36000004,CDM,360,RC,,,,,,,,,,3805,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1925.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1580.597,3728.9
"Initial Repair of Entrapped Hernia of Abdomen, Less Than 3 Cm in Length",PX49592,CDM,982,RC,49592,CPT,,,,,,,,2164,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1925.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,898.9256,5040.74
Injection for Nerve Block,PX64447P,CDM,983,RC,64447,CPT,,,,,,,,3892,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1926.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,604.15,3788.0836
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290101,NDC,1,EA,1966.88,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1927.5424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.77,1927.5424
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290102,NDC,1,EA,1966.88,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1927.5424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.77,1927.5424
Remv Periton FB From Perit Cav,PX49402P,CDM,983,RC,49402,CPT,,,,,,,,3897,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1929.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1618.8138,3792.9501
"Repair Recurr Inguin Hern,Reducibl",PX49520F,CDM,510,RC,49520,CPT,,,,,,,,1983,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1930.0539,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,823.7382,3022.41
"Repair Recurr Inguin Hern,Reducibl",PX49520P,CDM,983,RC,49520,CPT,,,,,,,,1983,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1930.0539,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,823.7382,3022.41
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x3CM 9SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12766-MAIN,LOCAL,,,,,2171,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1932.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
ULTRAGUIDE CTR SX-ONE MICROKNIFE 600112-001,27200000,CDM,272,RC,,,,13106-MAIN,LOCAL,,,,,2121,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1932.231,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Tte W/Doppler, Complete",PX9330601,CDM,483,RC,93306,CPT,TC,,,,,,,2191,,United Healthcare,All Payer,outpatient,88.2,,1379.136,percent of total billed charges,1932.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,481.95,2889.15
nivolumab 40 MG/4ML Solution 4 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377211,NDC,4,ML,2171.7,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1932.813,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.5,12769.6548
LARGE HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12836-MAIN,LOCAL,,,,,3905,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1932.975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
MEDIUM HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12835-MAIN,LOCAL,,,,,3905,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1932.975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
SMALL HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12655-MAIN,LOCAL,,,,,3905,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1932.975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266P,CDM,983,RC,27266,CPT,,,,,,,,2275,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1933.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,945.035,2214.2575
denosumab 120 MG/1.7ML Solution 1.7 mL Vial,J0897.01,CDM,636,RC,J0897,HCPCS,,,,55513073001,NDC,1.7,ML,4658.83,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1935.277982,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.55,4565.6534
Lap Rpr Vent Umbilical Hernia Incarcerated or Strangulated,PX49653F,CDM,510,RC,49653,CPT,,,,,,,,1990,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1936.867,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,826.646,1950.2
"Repair Ing Hernia,5+Y/O,Strang",PX49507F,CDM,510,RC,49507,CPT,,,,,,,,1977,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1937.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,821.2458,3022.41
hydroxocobalamin 5 g Recon Soln 1 Each Box,J3424.01,CDM,636,RC,J3424,HCPCS,,,,11704037001,NDC,1,EA,1991.16,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1937.996028,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,827.127864,1951.3368
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752F,CDM,510,RC,27752,CPT,,,,,,,,2280,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1938,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,947.112,2234.4
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,310072010,NDC,5,ML,1977.83,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1938.2734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,7.74,1938.2734
PLANTAR PLATE IMPLANT SET GRAVITY REPAIR,C1713,CDM,278,RC,C1713,HCPCS,,12649-MAIN,LOCAL,,,,,3921,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1940.895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"Up GI Endoscopy,Dilatn W Guide",PX43248F,CDM,750,RC,43248,CPT,,,,,,,,1995,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1941.7335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,1955.1
"Repair Umbilical Hern,5+Y/O,Strang",PX49587P,CDM,983,RC,49587,CPT,,,,,,,,2182,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1941.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,906.4028,2123.7406
"Repair Recurr Inguin Hern,Reducibl",PX49520F,CDM,510,RC,49520,CPT,,,,,,,,1983,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1943.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,823.7382,3022.41
"Repair Recurr Inguin Hern,Reducibl",PX49520P,CDM,983,RC,49520,CPT,,,,,,,,1983,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1943.34,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,380.89,1943.34
MODULAR INSERT TOE JOINT 2.5MM 3.6MMTHK PROXIMAL PHALANGEAL,C1713,CDM,278,RC,C1713,HCPCS,,12530-MAIN,LOCAL,,,,,3968,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,1944.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
MODULAR INSERT TOE JOINT 2.5MM 3.6MMTHK PROXIMAL PHALANGEAL,C1713,CDM,278,RC,C1713,HCPCS,,12530-MAIN,LOCAL,,,,,3968,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1944.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
MODULAR INSERT TOE JOINT 2.5MM 3.6MMTHK PROXIMAL PHALANGEAL,C1713,CDM,278,RC,C1713,HCPCS,,12530-MAIN,LOCAL,,,,,3968,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1944.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Exc Back Les Sc = 3 Cm,PX21931P,CDM,983,RC,21931,CPT,,,,,,,,2135,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1944.985,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,886.879,2077.9955
HIMAX STAPLE KIT 18X14X14,27200000,CDM,278,RC,C1713,HCPCS,,11851-MAIN,LOCAL,,,,,4536,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1945.944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Sigmoidoscopy,Remv Lesn,Snare",PX45338F,CDM,510,RC,45338,CPT,,,,,,,,2137,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1946.807,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,887.7098,2094.26
Cytogenomic Neoplasia (Genome-Wide) Microarray Analysis - Ref,PX8127790,CDM,310,RC,81277,CPT,90,,,,,,,3850,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1948.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1063.6,3773
"Tte W/Doppler, Complete",PX9330601,CDM,483,RC,93306,CPT,TC,,,,,,,2191,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1949.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,481.95,2889.15
Lap Rpr Vent Umbilical Hernia Incarcerated or Strangulated,PX49653F,CDM,510,RC,49653,CPT,,,,,,,,1990,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1950.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,826.646,1950.2
fluticasone-salmeterol 230-21 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173071720,NDC,12,GR,2004.35,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1950.833855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
hydroxocobalamin 5 g Recon Soln 1 Each Box,J3424.01,CDM,636,RC,J3424,HCPCS,,,,11704037001,NDC,1,EA,1991.16,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1951.3368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,827.127864,1951.3368
omalizumab 150 MG Recon Soln 1 Each Vial,J2357.01,CDM,636,RC,J2357,HCPCS,,,,50242004062,NDC,1,EA,2212.7,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1951.6014,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.02,2168.446
Tocilizumab 400 MG/20ML Solution 20 mL Vial,J3262.01,CDM,636,RC,J3262,HCPCS,,,,50242013701,NDC,20,ML,4703.83,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1953.970982,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.14,4609.7534
"Fusion Foot Bones,Midtarsal,Multi",PX28730F,CDM,510,RC,28730,CPT,,,,,,,,2299,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1954.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,955.0046,11497.76
fluticasone-salmeterol 100-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,54032656,NDC,60,EA,2215.63,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1954.18566,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
"Up GI Endoscopy,Dilatn W Guide",PX43248F,CDM,750,RC,43248,CPT,,,,,,,,1995,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1955.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,1955.1
Echo Tt 2d Complete,PX9330701,CDM,480,RC,93307,CPT,TC,,,,,,,2303,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1957.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,2256.94
OSTEOSET RESORBABLE MINI BEAD KIT FAST CURE CALCIUM SULFATE 5CC,C1713,CDM,278,RC,C1713,HCPCS,,12303-MAIN,LOCAL,,,,,2220,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,1958.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"Correct Bunion,Metatarsal Osteotomy",PX28296P,CDM,983,RC,28296,CPT,,,,,,,,2150,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1958.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,893.11,2827.75
"Ht Muscle Image Spect, Mult",PX7845201,CDM,340,RC,78452,CPT,TC,,,,,,,2000,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1960,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,858,5292.1
Polysomnography W/Cpap,PX9581101,CDM,740,RC,95811,CPT,TC,,,,,,,4575,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1962.675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,913.4,4483.5
Part Remv Phalanx of Toe,PX28124F,CDM,510,RC,28124,CPT,,,,,,,,2155,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1963.205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,895.187,2827.75
MODULAR INSERT TOE JOINT 2.5MM 3.6MMTHK PROXIMAL PHALANGEAL,C1713,CDM,278,RC,C1713,HCPCS,,12530-MAIN,LOCAL,,,,,3968,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1964.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
fluticasone-salmeterol 230-21 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173071720,NDC,12,GR,2004.35,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1964.263,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
CT Abd & Pelvis W/O Contrast,PX7417601,CDM,350,RC,74176,CPT,TC,,,,,,,4288,,Blue Cross Blue Shield of MN,All commercial plans,both,,,1362.861333,fee schedule,1965.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,4202.24
"Mra, Head W/Out Contrast",PX7054401,CDM,610,RC,70544,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,1965.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI Abdomen W/O Tc,PX7418101,CDM,610,RC,74181,CPT,TC,,,,,,,2655,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,1965.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,2601.9
MRI Brain WO Contrast Tc,PX7055101,CDM,610,RC,70551,CPT,TC,,,,,,,3335,,Blue Cross Blue Shield of MN,All commercial plans,both,,,2098.33,fee schedule,1965.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3268.3
MRI C-Spine WO Contrast,PX7214101,CDM,610,RC,72141,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,All commercial plans,both,,,1176.501667,fee schedule,1965.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI L Spine WO Contrast,PX7214801,CDM,610,RC,72148,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,All commercial plans,both,,,1910.43,fee schedule,1965.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI Low Ext Jnt WO/Cont Tc,PX7372101,CDM,610,RC,73721,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,All commercial plans,both,,,1633.874167,fee schedule,1965.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI Orbit/Face/Neck Tc,PX7054001,CDM,610,RC,70540,CPT,TC,,,,,,,3335,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,1965.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3268.3
MRI T Spine WO Contrast,PX7214601,CDM,610,RC,72146,CPT,TC,,,,,,,3267,,Blue Cross Blue Shield of MN,All commercial plans,both,,,1455.09,fee schedule,1965.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3201.66
MRI Up Extremity Joint W/O Tc,PX7322101,CDM,610,RC,73221,CPT,TC,,,,,,,3319,,Blue Cross Blue Shield of MN,All commercial plans,both,,,1014.926,fee schedule,1965.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3252.62
"MRI,Lwrext,No Jnt,No Cont",PX7371801,CDM,610,RC,73718,CPT,TC,,,,,,,3253,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,1965.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3187.94
"MRI,Pelvis W/Out Contrast",PX7219501,CDM,610,RC,72195,CPT,TC,,,,,,,3253,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,1965.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3187.94
"MRI,Up Ext,No Jnt,No Cont",PX7321801,CDM,610,RC,73218,CPT,TC,,,,,,,3253,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,1965.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3187.94
"Closure of Gastrostomy,Surgical",PX43870P,CDM,983,RC,43870,CPT,,,,,,,,4012,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1965.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1666.5848,3904.8796
"Closure of Gastrostomy,Surgical",PX43870P,CDM,983,RC,43870,CPT,,,,,,,,4012,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,1965.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1666.5848,3904.8796
"Closure of Gastrostomy,Surgical",PX43870P,CDM,983,RC,43870,CPT,,,,,,,,4012,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,1965.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1666.5848,3904.8796
darbepoetin alfa 300 MCG/0.6ML solution prefilled syringe 0.6 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513011101,NDC,0.6,ML,4736.88,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1967.699952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
omalizumab 150 MG Recon Soln 1 Each Vial,J2357.01,CDM,636,RC,J2357,HCPCS,,,,50242004062,NDC,1,EA,2212.7,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1969.303,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.02,2168.446
Injection for Nerve Block,PX64447P,CDM,983,RC,64447,CPT,,,,,,,,3892,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1969.352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,604.15,3788.0836
"Initial Repair of Entrapped Hernia of Abdomen, Less Than 3 Cm in Length",PX49592,CDM,982,RC,49592,CPT,,,,,,,,2164,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1971.404,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,898.9256,5040.74
Remv Periton FB From Perit Cav,PX49402P,CDM,983,RC,49402,CPT,,,,,,,,3897,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1971.882,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1618.8138,3792.9501
fluticasone-salmeterol 100-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,54032656,NDC,60,EA,2215.63,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1971.9107,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
Removal of Hemorrhoid Clot,PX46320F,CDM,510,RC,46320,CPT,,,,,,,,2027,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1972.8791,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,842.0158,1986.46
eriBULin 1 MG/2ML Solution 2 mL Vial,J9179.01,CDM,636,RC,J9179,HCPCS,,,,62856038901,NDC,2,ML,2321.52,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1973.292,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.87,2275.0896
"MRI, Abdomen W/O+ W/Contr",PX7418301,CDM,610,RC,74183,CPT,TC,,,,,,,4116,,Health Partners,Health Partners Care Plans,both,48,,3511.96,percent of total billed charges,1975.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4033.68
"MRI, Abdomen W/O+ W/Contr",PX7418301,CDM,610,RC,74183,CPT,TC,,,,,,,4116,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1975.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4033.68
OSTEOSET RESORBABLE MINI BEAD KIT FAST CURE CALCIUM SULFATE 5CC,C1713,CDM,278,RC,C1713,HCPCS,,12303-MAIN,LOCAL,,,,,2220,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,1975.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
LARGE HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12836-MAIN,LOCAL,,,,,3905,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1975.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
MEDIUM HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12835-MAIN,LOCAL,,,,,3905,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1975.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
SMALL HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12655-MAIN,LOCAL,,,,,3905,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1975.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PHALINX STERILE LARGE 0 HAMMERTOE SYSTEM 45A01004,27800000,CDM,278,RC,C1713,HCPCS,,12962-MAIN,LOCAL,,,,,4759,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1976.8886,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1976.8886,4663.82
PHALINX STERILE MEDIUM 0 HAMMERTOE SYSTEM 45A01003,27800000,CDM,278,RC,C1713,HCPCS,,12961-MAIN,LOCAL,,,,,4759,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1976.8886,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1976.8886,4663.82
PHALINX STERILE SMALL 0 HAMMERTOE SYSTEM 45A01002,27800000,CDM,278,RC,C1713,HCPCS,,12960-MAIN,LOCAL,,,,,4759,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1976.8886,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1976.8886,4663.82
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x3CM 9SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12766-MAIN,LOCAL,,,,,2171,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1977.781,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
nivolumab 40 MG/4ML Solution 4 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377211,NDC,4,ML,2171.7,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1978.4187,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.5,12769.6548
"Lap,Inguinal Hernia Repr,Recur",PX49651P,CDM,983,RC,49651,CPT,,,,,,,,2035,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1980.6655,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,845.339,5040.74
ustekinumab 130 MG/26ML Solution 26 mL Vial,J3358.01,CDM,636,RC,J3358,HCPCS,,,,57894005427,NDC,26,ML,4130,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,1982.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.56,4047.4
ustekinumab 130 MG/26ML Solution 26 mL Vial,J3358.01,CDM,636,RC,J3358,HCPCS,,,,57894005427,NDC,26,ML,4130,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,1982.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.56,4047.4
PLANTAR PLATE IMPLANT SET GRAVITY REPAIR,C1713,CDM,278,RC,C1713,HCPCS,,12649-MAIN,LOCAL,,,,,3921,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,1984.026,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"Biopsy of Prostate,Needle/Punch",PX55700F,CDM,510,RC,55700,CPT,,,,,,,,2039,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1984.5587,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,847.0006,1998.22
"Closure of Gastrostomy,Surgical",PX43870P,CDM,983,RC,43870,CPT,,,,,,,,4012,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,1985.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1666.5848,3904.8796
Removal of Hemorrhoid Clot,PX46320F,CDM,510,RC,46320,CPT,,,,,,,,2027,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1986.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,842.0158,1986.46
"Repair Umbilical Hern,5+Y/O,Strang",PX49587P,CDM,983,RC,49587,CPT,,,,,,,,2182,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,1987.802,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,906.4028,2123.7406
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561F,CDM,510,RC,36561,CPT,,,,,,,,2604,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1988.23,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,200.91,1988.23
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561P,CDM,983,RC,36561,CPT,,,,,,,,1736,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,1988.23,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,200.91,1988.23
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001501,NDC,1,EA,2340,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1989,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.3,2361.4178
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001503,NDC,1,EA,2340,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1989,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.3,2361.4178
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606P,CDM,983,RC,11606,CPT,,,,,,,,2044,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1989.4252,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,849.0776,1989.4252
CAP TOE JOINT  15MM 2.5MMX4.5MM DF RESURFACING CONTOURED COBALT CHROMIUM METATARSOPHALANGEAL 9M52-25,C1713,CDM,278,RC,C1713,HCPCS,,12532-MAIN,LOCAL,,,,,4791,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,1990.1814,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x4CM 12SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12767-MAIN,LOCAL,,,,,2345,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1993.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
"Repair Ing Hernia,5+Y/O,Reducibl",PX49505P,CDM,983,RC,49505,CPT,,,,,,,,2048,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,1993.3184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,850.7392,3022.41
"Lap,Inguinal Hernia Repr,Recur",PX49651P,CDM,983,RC,49651,CPT,,,,,,,,2035,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1994.3,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,342.5,1994.3
"Tte W/Doppler, Complete",PX9330601,CDM,483,RC,93306,CPT,TC,,,,,,,2191,,Medica,Commercial,both,91.1,,475.63125,percent of total billed charges,1996.001,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,481.95,2889.15
onabotulinumtoxinA 100 units Recon Soln 1 Each Vial,J0585.01,CDM,636,RC,J0585,HCPCS,,,,23114501,NDC,1,EA,2348.77,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1996.4545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.51,2301.7946
ibutilide 1 MG/10ML Solution 10 mL Vial,J1742.01,CDM,636,RC,J1742,HCPCS,,,,9379401,NDC,10,ML,2349.03,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1996.6755,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.02,2302.0494
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384F,CDM,750,RC,45384,CPT,,,,,,,,2350,,First Health,Commercial,both,85,,999999999,percent of total billed charges,1997.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1008.15,4050.42
"Biopsy of Prostate,Needle/Punch",PX55700F,CDM,510,RC,55700,CPT,,,,,,,,2039,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,1998.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,847.0006,1998.22
denosumab 120 MG/1.7ML Solution 1.7 mL Vial,J0897.01,CDM,636,RC,J0897,HCPCS,,,,55513073001,NDC,1.7,ML,4658.83,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,1998.63807,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.55,4565.6534
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505P,CDM,983,RC,24505,CPT,,,,,,,,2353,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2000.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,977.4362,2290.1749
Lap Partial Colectomy/Coloproctostomy,PX44207F,CDM,750,RC,44207,CPT,,,,,,,,4170,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2001.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1130.58,4086.6
Lap Partial Colectomy/Coloproctostomy,PX44207F,CDM,750,RC,44207,CPT,,,,,,,,4170,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2001.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1130.58,4086.6
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606P,CDM,983,RC,11606,CPT,,,,,,,,2044,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2003.12,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,193.93,2003.12
MRI L Spine W&WO Contrast,PX7215801,CDM,610,RC,72158,CPT,TC,,,,,,,4178,,Health Partners,Health Partners Care Plans,both,48,,2382.4025,percent of total billed charges,2005.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4094.44
MRI L Spine W&WO Contrast,PX7215801,CDM,610,RC,72158,CPT,TC,,,,,,,4178,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2005.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4094.44
MRI T Spine W&WO Contrast,PX7215701,CDM,610,RC,72157,CPT,TC,,,,,,,4178,,Health Partners,Health Partners Care Plans,both,48,,4052.65,percent of total billed charges,2005.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4094.44
MRI T Spine W&WO Contrast,PX7215701,CDM,610,RC,72157,CPT,TC,,,,,,,4178,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2005.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4094.44
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266P,CDM,983,RC,27266,CPT,,,,,,,,2275,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2006.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,945.035,2214.2575
"Repair Ing Hernia,5+Y/O,Reducibl",PX49505P,CDM,983,RC,49505,CPT,,,,,,,,2048,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2007.04,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,315.88,2007.04
MODULAR INSERT TOE JOINT 2.5MM 3.6MMTHK PROXIMAL PHALANGEAL,C1713,CDM,278,RC,C1713,HCPCS,,12530-MAIN,LOCAL,,,,,3968,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2007.808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
CT Angio Abdom W/O & W/Dye,PX7417501,CDM,350,RC,74175,CPT,TC,,,,,,,4183,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2007.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,4099.34
CT Angio Abdom W/O & W/Dye,PX7417501,CDM,350,RC,74175,CPT,TC,,,,,,,4183,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2007.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,4099.34
"Upper GI Endoscopy,Biopsy",PX43239F,CDM,750,RC,43239,CPT,,,,,,,,2364,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2009.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,3859.68
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752F,CDM,510,RC,27752,CPT,,,,,,,,2280,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2010.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,947.112,2234.4
darbepoetin alfa 500 MCG/ML solution prefilled syringe 1 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513003201,NDC,0.3,ML,2368.44,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2013.174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
omalizumab 150 MG Recon Soln 1 Each Vial,J2357.01,CDM,636,RC,J2357,HCPCS,,,,50242004062,NDC,1,EA,2212.7,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2015.7697,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.02,2168.446
"MRI, Abdomen W/O+ W/Contr",PX7418301,CDM,610,RC,74183,CPT,TC,,,,,,,4116,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2016.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4033.68
"MRI, Abdomen W/O+ W/Contr",PX7418301,CDM,610,RC,74183,CPT,TC,,,,,,,4116,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2016.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4033.68
"MRI, Abdomen W/O+ W/Contr",PX7418301,CDM,610,RC,74183,CPT,TC,,,,,,,4116,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2016.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4033.68
Tocilizumab 400 MG/20ML Solution 20 mL Vial,J3262.01,CDM,636,RC,J3262,HCPCS,,,,50242013701,NDC,20,ML,4703.83,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2017.94307,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.14,4609.7534
fluticasone-salmeterol 100-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,54032656,NDC,60,EA,2215.63,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2018.43893,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
RESTRATA WOUND MATRIX 2.5CM X 7.5CM TOTAL 18.75CM,27200000,CDM,272,RC,A2007,HCPCS,,11735-MAIN,LOCAL,,,,,4208,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2019.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RESTRATA WOUND MATRIX 2.5CM X 7.5CM TOTAL 18.75CM,27200000,CDM,272,RC,A2007,HCPCS,,11735-MAIN,LOCAL,,,,,4208,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2019.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
OSTEOSET RESORBABLE MINI BEAD KIT FAST CURE CALCIUM SULFATE 5CC,C1713,CDM,278,RC,C1713,HCPCS,,12303-MAIN,LOCAL,,,,,2220,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2022.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
ustekinumab 130 MG/26ML Solution 26 mL Vial,J3358.01,CDM,636,RC,J3358,HCPCS,,,,57894005427,NDC,26,ML,4130,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2023.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.56,4047.4
ustekinumab 130 MG/26ML Solution 26 mL Vial,J3358.01,CDM,636,RC,J3358,HCPCS,,,,57894005427,NDC,26,ML,4130,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2023.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.56,4047.4
ustekinumab 130 MG/26ML Solution 26 mL Vial,J3358.01,CDM,636,RC,J3358,HCPCS,,,,57894005427,NDC,26,ML,4130,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2023.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.56,4047.4
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830F,CDM,510,RC,15830,CPT,,,,,,,,2080,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2024.464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,864.032,5696.92
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266P,CDM,983,RC,27266,CPT,,,,,,,,2275,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2024.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,945.035,2214.2575
inFLIXimab 100 MG Recon Soln 1 Each Vial,J1745.01,CDM,636,RC,J1745,HCPCS,,,,57894003001,NDC,1,EA,2382.35,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2024.9975,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.49,2334.703
"Fusion Foot Bones,Midtarsal,Multi",PX28730F,CDM,510,RC,28730,CPT,,,,,,,,2299,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2027.718,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,955.0046,11497.76
"Percut Biopsy, Abdominal Mass",PX49180F,CDM,510,RC,49180,CPT,,,,,,,,2084,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2028.3572,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,865.6936,2042.32
CT Abd&Pelv 1+ Section/Regns,PX7417801,CDM,350,RC,74178,CPT,TC,,,,,,,4226,,Health Partners,Health Partners Care Plans,both,48,,2869.46,percent of total billed charges,2028.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4141.48
CT Abd&Pelv 1+ Section/Regns,PX7417801,CDM,350,RC,74178,CPT,TC,,,,,,,4226,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2028.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4141.48
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752F,CDM,510,RC,27752,CPT,,,,,,,,2280,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2029.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,947.112,2234.4
"Closure of Gastrostomy,Surgical",PX43870P,CDM,983,RC,43870,CPT,,,,,,,,4012,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2030.072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1666.5848,3904.8796
Exc Abd Les Sc < 3 Cm,PX22902P,CDM,983,RC,22902,CPT,,,,,,,,2086,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2030.3038,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,866.5244,2030.3038
Echo Tt 2d Complete,PX9330701,CDM,480,RC,93307,CPT,TC,,,,,,,2303,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2031.246,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,2256.94
darbepoetin alfa 300 MCG/0.6ML solution prefilled syringe 0.6 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513011101,NDC,0.6,ML,4736.88,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2032.12152,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
HARMONIC 110 SHEARS 36CM SHAFT,27200000,CDM,272,RC,,,,12043-MAIN,LOCAL,,,,,2392,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2033.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Hemorrhoidectomy,Int/Ext,Simple",PX46255P,CDM,983,RC,46255,CPT,,,,,,,,2393,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2034.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,994.0522,2452.93
"Remv F.B.,Eye,Ant Chmbr/Lens",PX65235F,CDM,510,RC,65235,CPT,,,,,,,,2788,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2035.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1158.1352,2732.24
"MRI, Abdomen W/O+ W/Contr",PX7418301,CDM,610,RC,74183,CPT,TC,,,,,,,4116,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2037.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4033.68
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830F,CDM,510,RC,15830,CPT,,,,,,,,2080,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2038.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,864.032,5696.92
MICA SCREW 4.0X32MM FULLY THREADED STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12894-MAIN,LOCAL,,,,,2096,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2040.0368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 3.0X38MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12984-MAIN,LOCAL,,,,,2096,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2040.0368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X42MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12948-MAIN,LOCAL,,,,,2096,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2040.0368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X44MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12893-MAIN,LOCAL,,,,,2096,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2040.0368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X56MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12947-MAIN,LOCAL,,,,,2096,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2040.0368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
certolizumab 2 X 200 MG Kit 1 Each Box,J0717.01,CDM,636,RC,J0717,HCPCS,,,,50474070062,NDC,0.5,EA,4911.87,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2040.390798,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.41,4813.6326
PHALINX STERILE LARGE 0 HAMMERTOE SYSTEM 45A01004,27800000,CDM,278,RC,C1713,HCPCS,,12962-MAIN,LOCAL,,,,,4759,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2041.611,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1976.8886,4663.82
PHALINX STERILE MEDIUM 0 HAMMERTOE SYSTEM 45A01003,27800000,CDM,278,RC,C1713,HCPCS,,12961-MAIN,LOCAL,,,,,4759,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2041.611,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1976.8886,4663.82
PHALINX STERILE SMALL 0 HAMMERTOE SYSTEM 45A01002,27800000,CDM,278,RC,C1713,HCPCS,,12960-MAIN,LOCAL,,,,,4759,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2041.611,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1976.8886,4663.82
"Percut Biopsy, Abdominal Mass",PX49180F,CDM,510,RC,49180,CPT,,,,,,,,2084,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2042.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,865.6936,2042.32
Lap Partial Colectomy/Coloproctostomy,PX44207F,CDM,750,RC,44207,CPT,,,,,,,,4170,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2043.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1130.58,4086.6
Lap Partial Colectomy/Coloproctostomy,PX44207F,CDM,750,RC,44207,CPT,,,,,,,,4170,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2043.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1130.58,4086.6
Lap Partial Colectomy/Coloproctostomy,PX44207F,CDM,750,RC,44207,CPT,,,,,,,,4170,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2043.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1130.58,4086.6
Level 3 Additional Procedure,PX36000082,CDM,360,RC,,,,,,,,,,2100,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2043.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,872.34,2058
Or Level 3,PX36000003,CDM,360,RC,,,,,,,,,,2100,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2043.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,872.34,2058
Exc Abd Les Sc < 3 Cm,PX22902P,CDM,983,RC,22902,CPT,,,,,,,,2086,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2044.28,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,205.5,2044.28
ustekinumab 130 MG/26ML Solution 26 mL Vial,J3358.01,CDM,636,RC,J3358,HCPCS,,,,57894005427,NDC,26,ML,4130,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2044.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.56,4047.4
"Fusion Foot Bones,Midtarsal,Multi",PX28730F,CDM,510,RC,28730,CPT,,,,,,,,2299,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2046.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,955.0046,11497.76
Revise Median N/Carpal Tunnel Surg,PX64721F,CDM,510,RC,64721,CPT,,,,,,,,2408,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2046.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1000.2832,2359.84
MRI L Spine W&WO Contrast,PX7215801,CDM,610,RC,72158,CPT,TC,,,,,,,4178,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,835.6,percent of total billed charges,2047.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4094.44
MRI L Spine W&WO Contrast,PX7215801,CDM,610,RC,72158,CPT,TC,,,,,,,4178,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2047.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4094.44
MRI L Spine W&WO Contrast,PX7215801,CDM,610,RC,72158,CPT,TC,,,,,,,4178,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2047.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4094.44
MRI T Spine W&WO Contrast,PX7215701,CDM,610,RC,72157,CPT,TC,,,,,,,4178,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2047.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4094.44
MRI T Spine W&WO Contrast,PX7215701,CDM,610,RC,72157,CPT,TC,,,,,,,4178,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2047.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4094.44
MRI T Spine W&WO Contrast,PX7215701,CDM,610,RC,72157,CPT,TC,,,,,,,4178,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2047.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4094.44
eriBULin 1 MG/2ML Solution 2 mL Vial,J9179.01,CDM,636,RC,J9179,HCPCS,,,,62856038901,NDC,2,ML,2321.52,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2047.58064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.87,2275.0896
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,70842014003,NDC,1,EA,2409.61,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2048.1685,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.3,2361.4178
CT Angio Abdom W/O & W/Dye,PX7417501,CDM,350,RC,74175,CPT,TC,,,,,,,4183,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2049.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,4099.34
CT Angio Abdom W/O & W/Dye,PX7417501,CDM,350,RC,74175,CPT,TC,,,,,,,4183,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2049.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,4099.34
CT Angio Abdom W/O & W/Dye,PX7417501,CDM,350,RC,74175,CPT,TC,,,,,,,4183,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2049.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,4099.34
Echo Tt 2d Complete,PX9330701,CDM,480,RC,93307,CPT,TC,,,,,,,2303,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2049.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,2256.94
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505F,CDM,510,RC,24505,CPT,,,,,,,,2109,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2052.6897,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,876.0786,2066.82
CT Chest Spine W/Dye,PX7212901,CDM,350,RC,72129,CPT,TC,,,,,,,2096,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2054.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,2054.08
MICA SCREW 4.0X32MM FULLY THREADED STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12894-MAIN,LOCAL,,,,,2096,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2054.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 3.0X38MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12984-MAIN,LOCAL,,,,,2096,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2054.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X42MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12948-MAIN,LOCAL,,,,,2096,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2054.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X44MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12893-MAIN,LOCAL,,,,,2096,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2054.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PROSTEP MICA SCREW 4.0X56MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12947-MAIN,LOCAL,,,,,2096,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2054.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
CAP TOE JOINT  15MM 2.5MMX4.5MM DF RESURFACING CONTOURED COBALT CHROMIUM METATARSOPHALANGEAL 9M52-25,C1713,CDM,278,RC,C1713,HCPCS,,12532-MAIN,LOCAL,,,,,4791,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2055.339,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
CT Lumbar Spine W/O & W/Dye,PX7213301,CDM,350,RC,72133,CPT,TC,,,,,,,4283,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2055.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,4197.34
CT Lumbar Spine W/O & W/Dye,PX7213301,CDM,350,RC,72133,CPT,TC,,,,,,,4283,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2055.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,4197.34
"Lap,Cholecystectomy/Explore",PX47564F,CDM,510,RC,47564,CPT,,,,,,,,2419,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2056.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1004.8526,8992.74
Level 3 Additional Procedure,PX36000082,CDM,360,RC,,,,,,,,,,2100,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,872.34,2058
Or Level 3,PX36000003,CDM,360,RC,,,,,,,,,,2100,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,872.34,2058
CT Abd & Pelvis W/O Contrast,PX7417601,CDM,350,RC,74176,CPT,TC,,,,,,,4288,,Health Partners,Health Partners Care Plans,both,48,,1920.445,percent of total billed charges,2058.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,4202.24
CT Abd & Pelvis W/O Contrast,PX7417601,CDM,350,RC,74176,CPT,TC,,,,,,,4288,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2058.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,4202.24
CT Abdomen&Pelvis W/Contrast,PX7417701,CDM,350,RC,74177,CPT,TC,,,,,,,4288,,Health Partners,Health Partners Care Plans,both,48,,3052.034286,percent of total billed charges,2058.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4202.24
CT Abdomen&Pelvis W/Contrast,PX7417701,CDM,350,RC,74177,CPT,TC,,,,,,,4288,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2058.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4202.24
"Colonoscopy,Remv Lesn,Snare",PX45385P,CDM,983,RC,45385,CPT,,,,,,,,2424,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2060.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1030.93,4050.42
RESTRATA WOUND MATRIX 2.5CM X 7.5CM TOTAL 18.75CM,27200000,CDM,272,RC,A2007,HCPCS,,11735-MAIN,LOCAL,,,,,4208,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2061.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RESTRATA WOUND MATRIX 2.5CM X 7.5CM TOTAL 18.75CM,27200000,CDM,272,RC,A2007,HCPCS,,11735-MAIN,LOCAL,,,,,4208,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2061.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RESTRATA WOUND MATRIX 2.5CM X 7.5CM TOTAL 18.75CM,27200000,CDM,272,RC,A2007,HCPCS,,11735-MAIN,LOCAL,,,,,4208,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2061.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001501,NDC,1,EA,2340,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2063.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.3,2361.4178
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001503,NDC,1,EA,2340,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2063.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.3,2361.4178
Lap Partial Colectomy/Coloproctostomy,PX44207F,CDM,750,RC,44207,CPT,,,,,,,,4170,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2064.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1130.58,4086.6
ULTRAGUIDE CTR SX-ONE MICROKNIFE 600112-001,27200000,CDM,272,RC,,,,13106-MAIN,LOCAL,,,,,2121,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2064.3693,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
eriBULin 1 MG/2ML Solution 2 mL Vial,J9179.01,CDM,636,RC,J9179,HCPCS,,,,62856038901,NDC,2,ML,2321.52,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2066.1528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.87,2275.0896
CT Abd&Pelv 1+ Section/Regns,PX7417801,CDM,350,RC,74178,CPT,TC,,,,,,,4226,,Blue Cross Blue Shield of MN,All commercial plans,both,,,1727.451667,fee schedule,2066.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4141.48
CT Abdomen&Pelvis W/Contrast,PX7417701,CDM,350,RC,74177,CPT,TC,,,,,,,4288,,Blue Cross Blue Shield of MN,All commercial plans,both,,,2140.636667,fee schedule,2066.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4202.24
CT Angio Abd&Pelv W/O&W/Dye,PX7417401,CDM,350,RC,74174,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All commercial plans,both,,,551.4,fee schedule,2066.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2701.86
CT Lumbar Spine W/Dye,PX7213201,CDM,350,RC,72132,CPT,TC,,,,,,,3330,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,2066.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3263.4
CT Upper Extremity W/Dye,PX7320101,CDM,350,RC,73201,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,2066.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2701.86
"Mra, Neck W/O+W/ Contrast",PX7054901,CDM,610,RC,70549,CPT,TC,,,,,,,3472,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,2066.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3402.56
"Mra, Neck With Contrast",PX7054801,CDM,610,RC,70548,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,2066.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI Brain W & WO Contrast,PX7055301,CDM,610,RC,70553,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,All commercial plans,both,,,1801.081667,fee schedule,2066.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI Brain W Contrast Tc,PX7055201,CDM,610,RC,70552,CPT,TC,,,,,,,2637,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,2066.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2584.26
MRI C Spine W&WO Contrast,PX7215601,CDM,610,RC,72156,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,2066.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI L Spine W Contrast Tc,PX7214901,CDM,610,RC,72149,CPT,TC,,,,,,,5136,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,2066.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,5033.28
MRI L Spine W&WO Contrast,PX7215801,CDM,610,RC,72158,CPT,TC,,,,,,,4178,,Blue Cross Blue Shield of MN,All commercial plans,both,,,966.63,fee schedule,2066.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4094.44
MRI Lower W/O+W Tc,PX7372001,CDM,610,RC,73720,CPT,TC,,,,,,,3174,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,2066.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3110.52
MRI Orb-Fac-Nec W/O+W/Con,PX7054301,CDM,610,RC,70543,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,2066.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI Pelvis W/Contrast Tc,PX7219601,CDM,610,RC,72196,CPT,TC,,,,,,,3143,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,2066.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3080.14
MRI T Spine W&WO Contrast,PX7215701,CDM,610,RC,72157,CPT,TC,,,,,,,4178,,Blue Cross Blue Shield of MN,All commercial plans,both,,,1678.5,fee schedule,2066.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4094.44
MRI Upper W/O+W Tc,PX7322001,CDM,610,RC,73220,CPT,TC,,,,,,,3253,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,2066.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3187.94
"MRI, Abdomen W/O+ W/Contr",PX7418301,CDM,610,RC,74183,CPT,TC,,,,,,,4116,,Blue Cross Blue Shield of MN,All commercial plans,both,,,1990.436667,fee schedule,2066.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4033.68
"MRI, Pelvis, W/O Then W/",PX7219701,CDM,610,RC,72197,CPT,TC,,,,,,,1612,,Blue Cross Blue Shield of MN,All commercial plans,both,,,1383.5,fee schedule,2066.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2066.35
"MRI,Lwrext,Jnt W/O+W/Cont",PX7372301,CDM,610,RC,73723,CPT,TC,,,,,,,1850,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,2066.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2066.35
"MRI,Lwrext,No Jnt, W/Cont",PX7371901,CDM,610,RC,73719,CPT,TC,,,,,,,3627,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,2066.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3554.46
"MRI,Uprext Jnt W/O+W/Cont",PX7322301,CDM,610,RC,73223,CPT,TC,,,,,,,2681,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,2066.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2627.38
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505F,CDM,510,RC,24505,CPT,,,,,,,,2109,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2066.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,876.0786,2066.82
Room Rate Icc,PX20601000,CDM,206,RC,,,,,,,,,,2432,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2067.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1010.2528,2383.36
MRI L Spine W&WO Contrast,PX7215801,CDM,610,RC,72158,CPT,TC,,,,,,,4178,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2068.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4094.44
MRI T Spine W&WO Contrast,PX7215701,CDM,610,RC,72157,CPT,TC,,,,,,,4178,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2068.11,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4094.44
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x4CM 12SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12767-MAIN,LOCAL,,,,,2345,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2068.29,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
Multiple Sleep Latency Test,PX9580501,CDM,740,RC,95805,CPT,TC,,,,,,,4313,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2070.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,468.24,4226.74
Multiple Sleep Latency Test,PX9580501,CDM,740,RC,95805,CPT,TC,,,,,,,4313,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2070.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,468.24,4226.74
"Polysomnography, 4 or More",PX9581001,CDM,740,RC,95810,CPT,TC,,,,,,,4313,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2070.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,913.4,4226.74
"Polysomnography, 4 or More",PX9581001,CDM,740,RC,95810,CPT,TC,,,,,,,4313,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2070.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,913.4,4226.74
CT Angio Abdom W/O & W/Dye,PX7417501,CDM,350,RC,74175,CPT,TC,,,,,,,4183,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2070.585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,4099.34
CT Abd&Pelv 1+ Section/Regns,PX7417801,CDM,350,RC,74178,CPT,TC,,,,,,,4226,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1509.146667,percent of total billed charges,2070.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4141.48
CT Abd&Pelv 1+ Section/Regns,PX7417801,CDM,350,RC,74178,CPT,TC,,,,,,,4226,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2070.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4141.48
CT Abd&Pelv 1+ Section/Regns,PX7417801,CDM,350,RC,74178,CPT,TC,,,,,,,4226,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2070.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4141.48
onabotulinumtoxinA 100 units Recon Soln 1 Each Vial,J0585.01,CDM,636,RC,J0585,HCPCS,,,,23114501,NDC,1,EA,2348.77,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2071.61514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.51,2301.7946
ibutilide 1 MG/10ML Solution 10 mL Vial,J1742.01,CDM,636,RC,J1742,HCPCS,,,,9379401,NDC,10,ML,2349.03,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2071.84446,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.02,2302.0494
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266P,CDM,983,RC,27266,CPT,,,,,,,,2275,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2072.525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,945.035,2214.2575
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384F,CDM,750,RC,45384,CPT,,,,,,,,2350,,United Healthcare,All Payer,outpatient,88.2,,999999999,case rate,2072.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2072.7,6141.46
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505P,CDM,983,RC,24505,CPT,,,,,,,,2353,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2075.346,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,977.4362,2290.1749
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752F,CDM,510,RC,27752,CPT,,,,,,,,2280,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2077.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,947.112,2234.4
"MRI,Upr Ext, Joint,W/Cont",PX7322201,CDM,610,RC,73222,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,2077.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,611.05,3470.18
Exc Back Les Sc = 3 Cm,PX21931P,CDM,983,RC,21931,CPT,,,,,,,,2135,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2077.9955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,886.879,2077.9955
ULTRAGUIDE CTR SX-ONE MICROKNIFE 600112-001,27200000,CDM,272,RC,,,,13106-MAIN,LOCAL,,,,,2121,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2078.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Sigmoidoscopy,Remv Lesn,Snare",PX45338F,CDM,510,RC,45338,CPT,,,,,,,,2137,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2079.9421,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,887.7098,2094.26
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001501,NDC,1,EA,2340,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2082.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.3,2361.4178
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001503,NDC,1,EA,2340,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2082.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.3,2361.4178
"MRI, Abdomen W/O+ W/Contr",PX7418301,CDM,610,RC,74183,CPT,TC,,,,,,,4116,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2082.696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4033.68
RESTRATA WOUND MATRIX 2.5CM X 7.5CM TOTAL 18.75CM,27200000,CDM,272,RC,A2007,HCPCS,,11735-MAIN,LOCAL,,,,,4208,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2082.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Upper GI Endoscopy,Biopsy",PX43239F,CDM,750,RC,43239,CPT,,,,,,,,2364,,United Healthcare,All Payer,outpatient,88.2,,999999999,case rate,2085.048,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2085.048,6141.46
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x4CM 12SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12767-MAIN,LOCAL,,,,,2345,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2087.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
darbepoetin alfa 500 MCG/ML solution prefilled syringe 1 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513003201,NDC,0.3,ML,2368.44,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2088.96408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
"Excis Arm/Elbow Tumor,Subcutan",PX24075P,CDM,983,RC,24075,CPT,,,,,,,,2458,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2089.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1021.0532,2392.3714
"Upper GI Endoscopy,Biopsy",PX43239P,CDM,983,RC,43239,CPT,,,,,,,,2458,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2089.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,3859.68
Lap Sleeve Gastrectomy,PX43775,CDM,982,RC,43775,CPT,,,,,,,,5030,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2089.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,674.85,4895.699
ustekinumab 130 MG/26ML Solution 26 mL Vial,J3358.01,CDM,636,RC,J3358,HCPCS,,,,57894005427,NDC,26,ML,4130,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2089.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.56,4047.4
onabotulinumtoxinA 100 units Recon Soln 1 Each Vial,J0585.01,CDM,636,RC,J0585,HCPCS,,,,23114501,NDC,1,EA,2348.77,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2090.4053,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.51,2301.7946
ibutilide 1 MG/10ML Solution 10 mL Vial,J1742.01,CDM,636,RC,J1742,HCPCS,,,,9379401,NDC,10,ML,2349.03,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2090.6367,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.02,2302.0494
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384F,CDM,750,RC,45384,CPT,,,,,,,,2350,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2091.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1008.15,4050.42
CT Abd&Pelv 1+ Section/Regns,PX7417801,CDM,350,RC,74178,CPT,TC,,,,,,,4226,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2091.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4141.48
Exc Back Les Sc = 3 Cm,PX21931P,CDM,983,RC,21931,CPT,,,,,,,,2135,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2092.3,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,286.43,2092.3
"Correct Bunion,Metatarsal Osteotomy",PX28296P,CDM,983,RC,28296,CPT,,,,,,,,2150,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2092.595,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,893.11,2827.75
ramuCIRumab 100 MG/10ML Solution 10 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2766901,NDC,10,ML,2463.3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2093.805,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.57,12070.17
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505P,CDM,983,RC,24505,CPT,,,,,,,,2353,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2094.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,977.4362,2290.1749
"Sigmoidoscopy,Remv Lesn,Snare",PX45338F,CDM,510,RC,45338,CPT,,,,,,,,2137,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2094.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,887.7098,2094.26
"Fusion Foot Bones,Midtarsal,Multi",PX28730F,CDM,510,RC,28730,CPT,,,,,,,,2299,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2094.389,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,955.0046,11497.76
"Colonoscopy,Biopsy",PX45380F,CDM,750,RC,45380,CPT,,,,,,,,2465,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2095.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1030.93,4050.42
bendamustine 100 MG/4ML Solution 4 mL Vial,800000,CDM,,,J9034,HCPCS,,,,63459034804,NDC,4,ML,5046.55,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2096.33687,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
"Repair Lip,>1/2 Vert Height",PX40654F,CDM,510,RC,40654,CPT,,,,,,,,2467,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2096.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1024.7918,2417.66
Part Remv Phalanx of Toe,PX28124F,CDM,510,RC,28124,CPT,,,,,,,,2155,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2097.4615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,895.187,2827.75
Echo Tt 2d Complete,PX9330701,CDM,480,RC,93307,CPT,TC,,,,,,,2303,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2098.033,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,2256.94
CT Lumbar Spine W/O & W/Dye,PX7213301,CDM,350,RC,72133,CPT,TC,,,,,,,4283,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2098.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,4197.34
CT Lumbar Spine W/O & W/Dye,PX7213301,CDM,350,RC,72133,CPT,TC,,,,,,,4283,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2098.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,4197.34
CT Lumbar Spine W/O & W/Dye,PX7213301,CDM,350,RC,72133,CPT,TC,,,,,,,4283,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2098.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,4197.34
CT Abd & Pelvis W/O Contrast,PX7417601,CDM,350,RC,74176,CPT,TC,,,,,,,4288,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1680.424286,percent of total billed charges,2101.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,4202.24
CT Abd & Pelvis W/O Contrast,PX7417601,CDM,350,RC,74176,CPT,TC,,,,,,,4288,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2101.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,4202.24
CT Abd & Pelvis W/O Contrast,PX7417601,CDM,350,RC,74176,CPT,TC,,,,,,,4288,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2101.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,4202.24
CT Abdomen&Pelvis W/Contrast,PX7417701,CDM,350,RC,74177,CPT,TC,,,,,,,4288,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1044.977308,percent of total billed charges,2101.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4202.24
CT Abdomen&Pelvis W/Contrast,PX7417701,CDM,350,RC,74177,CPT,TC,,,,,,,4288,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2101.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4202.24
CT Abdomen&Pelvis W/Contrast,PX7417701,CDM,350,RC,74177,CPT,TC,,,,,,,4288,,United Healthcare,All Medicare advantage plans,outpatient,49,,2272.64,percent of total billed charges,2101.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4202.24
inFLIXimab 100 MG Recon Soln 1 Each Vial,J1745.01,CDM,636,RC,J1745,HCPCS,,,,57894003001,NDC,1,EA,2382.35,,United Healthcare,All Payer,outpatient,88.2,,706.5578947,percent of total billed charges,2101.2327,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.49,2334.703
REVITA PLACENTAL MEMBRANE 2X3CM 6SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12559-MAIN,LOCAL,,,,,2474,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2102.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
"Upper GI Endoscopy,Biopsy",PX43239F,CDM,750,RC,43239,CPT,,,,,,,,2364,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2103.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,3859.68
"Initial Repair of Entrapped Hernia of Abdomen, Less Than 3 Cm in Length",PX49592,CDM,982,RC,49592,CPT,,,,,,,,2164,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,2043.265,percent of total billed charges,2106.2212,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,898.9256,5040.74
"Correct Bunion,Metatarsal Osteotomy",PX28296P,CDM,983,RC,28296,CPT,,,,,,,,2150,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2107,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,324.17,2107
certolizumab 2 X 200 MG Kit 1 Each Box,J0717.01,CDM,636,RC,J0717,HCPCS,,,,50474070062,NDC,0.5,EA,4911.87,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2107.19223,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.41,4813.6326
darbepoetin alfa 500 MCG/ML solution prefilled syringe 1 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513003201,NDC,0.3,ML,2368.44,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2107.9116,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
"Repair Ing Hernia,5+Y/O,Strang",PX49507P,CDM,983,RC,49507,CPT,,,,,,,,2482,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2109.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1031.0228,3022.41
HARMONIC 110 SHEARS 36CM SHAFT,27200000,CDM,272,RC,,,,12043-MAIN,LOCAL,,,,,2392,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2109.744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Lap Partial Colectomy/Coloproctostomy,PX44207F,CDM,750,RC,44207,CPT,,,,,,,,4170,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2110.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1130.58,4086.6
"Hemorrhoidectomy,Int/Ext,Simple",PX46255P,CDM,983,RC,46255,CPT,,,,,,,,2393,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2110.626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,994.0522,2452.93
Part Remv Phalanx of Toe,PX28124F,CDM,510,RC,28124,CPT,,,,,,,,2155,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2111.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,895.187,2827.75
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x3CM 9SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12766-MAIN,LOCAL,,,,,2171,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2113.0343,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
Multiple Sleep Latency Test,PX9580501,CDM,740,RC,95805,CPT,TC,,,,,,,4313,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2113.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,468.24,4226.74
Multiple Sleep Latency Test,PX9580501,CDM,740,RC,95805,CPT,TC,,,,,,,4313,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2113.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,468.24,4226.74
Multiple Sleep Latency Test,PX9580501,CDM,740,RC,95805,CPT,TC,,,,,,,4313,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2113.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,468.24,4226.74
"Polysomnography, 4 or More",PX9581001,CDM,740,RC,95810,CPT,TC,,,,,,,4313,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2113.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,913.4,4226.74
"Polysomnography, 4 or More",PX9581001,CDM,740,RC,95810,CPT,TC,,,,,,,4313,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2113.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,913.4,4226.74
"Polysomnography, 4 or More",PX9581001,CDM,740,RC,95810,CPT,TC,,,,,,,4313,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2113.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,913.4,4226.74
nivolumab 40 MG/4ML Solution 4 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377211,NDC,4,ML,2171.7,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2113.71561,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.5,12769.6548
MRI L Spine W&WO Contrast,PX7215801,CDM,610,RC,72158,CPT,TC,,,,,,,4178,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2114.068,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4094.44
MRI T Spine W&WO Contrast,PX7215701,CDM,610,RC,72157,CPT,TC,,,,,,,4178,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2114.068,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4094.44
eriBULin 1 MG/2ML Solution 2 mL Vial,J9179.01,CDM,636,RC,J9179,HCPCS,,,,62856038901,NDC,2,ML,2321.52,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2114.90472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.87,2275.0896
sarilumab 200 MG/1.14ML solution prefilled syringe 1.14 mL Syringe,J3590.25,CDM,636,RC,J3590,HCPCS,,,,24591001,NDC,1.14,ML,4408.29,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2115.9792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1831.203666,4320.1242
sarilumab 200 MG/1.14ML solution prefilled syringe 1.14 mL Syringe,J3590.25,CDM,636,RC,J3590,HCPCS,,,,24591001,NDC,1.14,ML,4408.29,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2115.9792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1831.203666,4320.1242
CT Angio Abdom W/O & W/Dye,PX7417501,CDM,350,RC,74175,CPT,TC,,,,,,,4183,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2116.598,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,4099.34
CT Lumbar Spine W/O & W/Dye,PX7213301,CDM,350,RC,72133,CPT,TC,,,,,,,4283,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2120.085,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,4197.34
inFLIXimab 100 MG Recon Soln 1 Each Vial,J1745.01,CDM,636,RC,J1745,HCPCS,,,,57894003001,NDC,1,EA,2382.35,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2120.2915,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.49,2334.703
"Initial Repair of Entrapped Hernia of Abdomen, Less Than 3 Cm in Length",PX49592,CDM,982,RC,49592,CPT,,,,,,,,2164,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2120.72,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,280.1,2120.72
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752P,CDM,983,RC,27752,CPT,,,,,,,,2495,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2120.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1036.423,2428.3835
CT Abd & Pelvis W/O Contrast,PX7417601,CDM,350,RC,74176,CPT,TC,,,,,,,4288,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2122.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,4202.24
CT Abdomen&Pelvis W/Contrast,PX7417701,CDM,350,RC,74177,CPT,TC,,,,,,,4288,,Humana Choice Care,All Medicare plans,outpatient,49.5,,544.6233333,percent of total billed charges,2122.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4202.24
"Repair Umbilical Hern,5+Y/O,Strang",PX49587P,CDM,983,RC,49587,CPT,,,,,,,,2182,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2123.7406,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,906.4028,2123.7406
Revise Median N/Carpal Tunnel Surg,PX64721F,CDM,510,RC,64721,CPT,,,,,,,,2408,,United Healthcare,All Payer,outpatient,88.2,,2244.02,percent of total billed charges,2123.856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1000.2832,2359.84
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,70842014003,NDC,1,EA,2409.61,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2125.27602,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.3,2361.4178
"Colonoscopy,Screen Prev",PX2004F,CDM,750,RC,G0121,HCPCS,,,,,,,,2502,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2126.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,798.45,3885.86
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x3CM 9SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12766-MAIN,LOCAL,,,,,2171,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2127.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
nivolumab 40 MG/4ML Solution 4 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377211,NDC,4,ML,2171.7,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2128.266,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.5,12769.6548
HARMONIC 110 SHEARS 36CM SHAFT,27200000,CDM,272,RC,,,,12043-MAIN,LOCAL,,,,,2392,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2128.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RESTRATA WOUND MATRIX 2.5CM X 7.5CM TOTAL 18.75CM,27200000,CDM,272,RC,A2007,HCPCS,,11735-MAIN,LOCAL,,,,,4208,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2129.248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Hemorrhoidectomy,Int/Ext,Simple",PX46255P,CDM,983,RC,46255,CPT,,,,,,,,2393,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2129.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,994.0522,2452.93
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001501,NDC,1,EA,2340,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2131.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.3,2361.4178
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001503,NDC,1,EA,2340,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2131.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.3,2361.4178
"Lap,Cholecystectomy/Explore",PX47564F,CDM,510,RC,47564,CPT,,,,,,,,2419,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2133.558,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1004.8526,8992.74
Multiple Sleep Latency Test,PX9580501,CDM,740,RC,95805,CPT,TC,,,,,,,4313,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2134.935,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,468.24,4226.74
"Polysomnography, 4 or More",PX9581001,CDM,740,RC,95810,CPT,TC,,,,,,,4313,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2134.935,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,913.4,4226.74
MINIBUNION 3.5 OFFSET PLATE SHORT,27200000,CDM,278,RC,C1713,HCPCS,,11667-MAIN,LOCAL,,,,,5142.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2136.1945,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x4CM 12SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12767-MAIN,LOCAL,,,,,2345,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2136.295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535F,CDM,510,RC,24535,CPT,,,,,,,,2514,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2136.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1044.3156,2463.72
DYNABUNION STERILE INSTRUMENT KIT,27200000,CDM,272,RC,,,,11850-MAIN,LOCAL,,,,,2515,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2137.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Colonoscopy,Remv Lesn,Snare",PX45385P,CDM,983,RC,45385,CPT,,,,,,,,2424,,United Healthcare,All Payer,outpatient,88.2,,738.2066667,percent of total billed charges,2137.968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1030.93,4050.42
CT Abd&Pelv 1+ Section/Regns,PX7417801,CDM,350,RC,74178,CPT,TC,,,,,,,4226,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2138.356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4141.48
"Repair Umbilical Hern,5+Y/O,Strang",PX49587P,CDM,983,RC,49587,CPT,,,,,,,,2182,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2138.36,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,426.0997,2138.36
Room Rate Icc Iso,PX20601001,CDM,206,RC,,,,,,,,,,2517,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2139.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1045.5618,2466.66
onabotulinumtoxinA 100 units Recon Soln 1 Each Vial,J0585.01,CDM,636,RC,J0585,HCPCS,,,,23114501,NDC,1,EA,2348.77,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2139.72947,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.51,2301.7946
ibutilide 1 MG/10ML Solution 10 mL Vial,J1742.01,CDM,636,RC,J1742,HCPCS,,,,9379401,NDC,10,ML,2349.03,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2139.96633,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.02,2302.0494
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384F,CDM,750,RC,45384,CPT,,,,,,,,2350,,Medica,Commercial,both,91.1,,352.5,percent of total billed charges,2140.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1008.15,4050.42
Revise Median N/Carpal Tunnel Surg,PX64721F,CDM,510,RC,64721,CPT,,,,,,,,2408,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2143.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1000.2832,2359.84
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505P,CDM,983,RC,24505,CPT,,,,,,,,2353,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2143.583,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,977.4362,2290.1749
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,70842014003,NDC,1,EA,2409.61,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2144.5529,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.3,2361.4178
Room Rate Icc,PX20601000,CDM,206,RC,,,,,,,,,,2432,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2145.024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1010.2528,2383.36
"Tte W/Doppler, Complete",PX9330601,CDM,483,RC,93306,CPT,TC,,,,,,,2191,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2147.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,481.95,2889.15
"Lap,Cholecystectomy/Explore",PX47564F,CDM,510,RC,47564,CPT,,,,,,,,2419,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2152.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1004.8526,8992.74
"Upper GI Endoscopy,Biopsy",PX43239F,CDM,750,RC,43239,CPT,,,,,,,,2364,,Medica,Commercial,both,91.1,,1336.405714,percent of total billed charges,2153.604,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,3859.68
omalizumab 150 MG Recon Soln 1 Each Vial,J2357.01,CDM,636,RC,J2357,HCPCS,,,,50242004062,NDC,1,EA,2212.7,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2153.62091,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.02,2168.446
fluticasone-salmeterol 100-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,54032656,NDC,60,EA,2215.63,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2156.472679,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
3.0MM HEADED SCREW LENGTH 16MM,C1713,CDM,278,RC,C1713,HCPCS,,12656-MAIN,LOCAL,,,,,608,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2156.86,2156.86
BONE SCREW T8 FULL THREAD 2.4MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12652-MAIN,LOCAL,,,,,289,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2156.86,2156.86
BONE SCREW T8 FULL THREAD 2.4MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12653-MAIN,LOCAL,,,,,289,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2156.86,2156.86
BONE SCREW T8 FULL THREAD 2.7MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12654-MAIN,LOCAL,,,,,289,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2156.86,2156.86
CAP TOE JOINT  15MM 2.5MMX4.5MM DF RESURFACING CONTOURED COBALT CHROMIUM METATARSOPHALANGEAL 9M52-25,C1713,CDM,278,RC,C1713,HCPCS,,12532-MAIN,LOCAL,,,,,4791,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2156.86,2156.86
CP LAG SCREW 3.6MM L22MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12757-MAIN,LOCAL,,,,,539,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2156.86,2156.86
CP LAG SCREW 3.6MM L24MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12650-MAIN,LOCAL,,,,,539,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2156.86,2156.86
CP LAG SCREW 3.6MM L26MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12636-MAIN,LOCAL,,,,,539,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2156.86,2156.86
DYNANITE PIP - STRAIGHT 12MM - WITH INSTRUMENTATION,27200000,CDM,278,RC,C1713,HCPCS,,11626-MAIN,LOCAL,,,,,3543.65,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
DYNANITE PIP - STRAIGHT 14MM - WITH INSTRUMENTATION,27200000,CDM,278,RC,C1713,HCPCS,,11627-MAIN,LOCAL,,,,,3543.65,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
DYNANITE PIP IMPLANT BENT 12MM,27200000,CDM,278,RC,C1713,HCPCS,,11629-MAIN,LOCAL,,,,,3543.65,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
DYNANITE PIP IMPLANT BENT 14MM,27200000,CDM,278,RC,C1713,HCPCS,,11631-MAIN,LOCAL,,,,,3543.65,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
DYNANITE PIP IMPLANT BENT 16MM,27200000,CDM,278,RC,C1713,HCPCS,,11633-MAIN,LOCAL,,,,,3543.65,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
DYNANITE PIP IMPLANT STRAIGHT 12MM,27200000,CDM,278,RC,C1713,HCPCS,,11628-MAIN,LOCAL,,,,,3543.65,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
DYNANITE PIP IMPLANT STRAIGHT 14MM,27200000,CDM,278,RC,C1713,HCPCS,,11630-MAIN,LOCAL,,,,,3543.65,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
DYNANITE PIP IMPLANT STRAIGHT 16MM,27200000,CDM,278,RC,C1713,HCPCS,,11632-MAIN,LOCAL,,,,,3543.65,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
FIXATION COMPONENT TOE JOINT PROXIMAL PHALANGEAL DF-P,C1713,CDM,278,RC,C1713,HCPCS,,12529-MAIN,LOCAL,,,,,1644,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2156.86,2156.86
HIMAX PLUS 18X18X18,27200000,CDM,278,RC,C1713,HCPCS,,11660-MAIN,LOCAL,,,,,3085.5,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
HIMAX PLUS 20X20X20,27200000,CDM,278,RC,C1713,HCPCS,,11661-MAIN,LOCAL,,,,,3085.5,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
HIMAX STAPLE KIT 18X14X14,27200000,CDM,278,RC,C1713,HCPCS,,11851-MAIN,LOCAL,,,,,4536,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
IMPLANT PACKAGE TOEMATE,27200000,CDM,278,RC,C1713,HCPCS,,11859-MAIN,LOCAL,,,,,2865,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
IMPLANT TOEMATE X-SMALL PACKAGE 9H00-T050,C1713,CDM,278,RC,C1713,HCPCS,,11574-MAIN,LOCAL,,,,,2865,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2156.86,2156.86
INSTRUMENT TOEMATE X-SMALL PACKAGE 9H00-T060,27200000,CDM,272,RC,C1713,HCPCS,,11575-MAIN,LOCAL,,,,,636,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
K-WIRE SMOOTH 1.4MM X 100MM,C1713,CDM,272,RC,C1713,HCPCS,,12634-MAIN,LOCAL,,,,,63,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2156.86,2156.86
LARGE HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12836-MAIN,LOCAL,,,,,3905,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2156.86,2156.86
LOCKING SCREW T8 FULL THREAD 2.4MM L10MM,C1713,CDM,278,RC,C1713,HCPCS,,12637-MAIN,LOCAL,,,,,496,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2156.86,2156.86
LOCKING SCREW T8 FULL THREAD 2.4MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12651-MAIN,LOCAL,,,,,496,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2156.86,2156.86
LOCKING SCREW T8 FULL THREAD 2.7MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12638-MAIN,LOCAL,,,,,496,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2156.86,2156.86
LOCKING SCREW T8 FULL THREAD 2.7MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12639-MAIN,LOCAL,,,,,496,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2156.86,2156.86
MEDIUM HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12835-MAIN,LOCAL,,,,,3905,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2156.86,2156.86
MICA SCREW 4.0X32MM FULLY THREADED STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12894-MAIN,LOCAL,,,,,2096,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2156.86,2156.86
MINIBUNION 3.5 OFFSET PLATE SHORT,27200000,CDM,278,RC,C1713,HCPCS,,11667-MAIN,LOCAL,,,,,5142.5,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
MINIBUNION DRILL KIT,27200000,CDM,278,RC,C1713,HCPCS,,11669-MAIN,LOCAL,,,,,841.5,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
MINIBUNION INSTRUMENT KIT,27200000,CDM,278,RC,C1713,HCPCS,,11668-MAIN,LOCAL,,,,,1860.65,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
MINIBUNION LOCKING SCREW 3.0X24MM,C1713,CDM,278,RC,C1713,HCPCS,,11671-MAIN,LOCAL,,,,,308.55,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2156.86,2156.86
MINIBUNION NON-LOCKING SCREW  2.7X18MM,C1713,CDM,278,RC,C1713,HCPCS,,11670-MAIN,LOCAL,,,,,280.5,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2156.86,2156.86
MODULAR INSERT TOE JOINT 2.5MM 3.6MMTHK PROXIMAL PHALANGEAL,C1713,CDM,278,RC,C1713,HCPCS,,12530-MAIN,LOCAL,,,,,3968,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2156.86,2156.86
MTP PLATE STANDARD 18MM CLIP 5 DEG DORSIFLEXION,27200000,CDM,278,RC,C1713,HCPCS,,11854-MAIN,LOCAL,,,,,5376,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
NON-LOCKING SCREW 3.5X12MM,27200000,CDM,278,RC,C1713,HCPCS,,11857-MAIN,LOCAL,,,,,396,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
NON-LOCKING SCREW 3.5X16MM,27200000,CDM,278,RC,C1713,HCPCS,,11856-MAIN,LOCAL,,,,,396,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
NON-LOCKING SCREW 3.5X18MM,C1713,CDM,278,RC,C1713,HCPCS,,12466-MAIN,LOCAL,,,,,395.51,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2156.86,2156.86
NON-LOCKING SCREW 3.5X24MM,27200000,CDM,278,RC,C1713,HCPCS,,11855-MAIN,LOCAL,,,,,396,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
OSTEOSET RESORBABLE MINI BEAD KIT FAST CURE CALCIUM SULFATE 5CC,C1713,CDM,278,RC,C1713,HCPCS,,12303-MAIN,LOCAL,,,,,2220,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2156.86,2156.86
PHALINX STERILE LARGE 0 HAMMERTOE SYSTEM 45A01004,27800000,CDM,278,RC,C1713,HCPCS,,12962-MAIN,LOCAL,,,,,4759,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2156.86,2156.86
PHALINX STERILE MEDIUM 0 HAMMERTOE SYSTEM 45A01003,27800000,CDM,278,RC,C1713,HCPCS,,12961-MAIN,LOCAL,,,,,4759,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2156.86,2156.86
PHALINX STERILE SMALL 0 HAMMERTOE SYSTEM 45A01002,27800000,CDM,278,RC,C1713,HCPCS,,12960-MAIN,LOCAL,,,,,4759,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2156.86,2156.86
PLANTAR PLATE IMPLANT SET GRAVITY REPAIR,C1713,CDM,278,RC,C1713,HCPCS,,12649-MAIN,LOCAL,,,,,3921,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2156.86,2156.86
POLYAXIAL LOCKING PLATE MTP CROSS PLATE LEFT T8,C1713,CDM,278,RC,C1713,HCPCS,,12635-MAIN,LOCAL,,,,,5413,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2156.86,2156.86
POLYAXIAL LOCKING PLATE MTP CROSS PLATE RIGHT T8,C1713,CDM,278,RC,C1713,HCPCS,,12756-MAIN,LOCAL,,,,,5413,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2156.86,2156.86
PREP KIT STAPLE 18MM,27200000,CDM,278,RC,C1713,HCPCS,,11658-MAIN,LOCAL,,,,,420.75,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
PREP KIT STAPLE 20MM,27200000,CDM,278,RC,C1713,HCPCS,,11659-MAIN,LOCAL,,,,,420.75,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.03,2156.86
PROSTEP HV SCREW 3.0X16MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12986-MAIN,LOCAL,,,,,1569,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2156.86,2156.86
PROSTEP MICA SCREW 3.0X20MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12442-MAIN,LOCAL,,,,,1806,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2156.86,2156.86
PROSTEP MICA SCREW 3.0X38MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12984-MAIN,LOCAL,,,,,2096,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2156.86,2156.86
PROSTEP MICA SCREW 3.0X40MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12443-MAIN,LOCAL,,,,,1806,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2156.86,2156.86
PROSTEP MICA SCREW 4.0X42MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12948-MAIN,LOCAL,,,,,2096,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2156.86,2156.86
PROSTEP MICA SCREW 4.0X44MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12893-MAIN,LOCAL,,,,,2096,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2156.86,2156.86
PROSTEP MICA SCREW 4.0X52MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12444-MAIN,LOCAL,,,,,1806,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2156.86,2156.86
PROSTEP MICA SCREW 4.0X56MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12947-MAIN,LOCAL,,,,,2096,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2156.86,2156.86
SMALL HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12655-MAIN,LOCAL,,,,,3905,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2156.86,2156.86
TAPER POST TOE JOINT HEMICAP 9.5MM ARTICULATING METATARSAL STERILE,C1713,CDM,278,RC,C1713,HCPCS,,12531-MAIN,LOCAL,,,,,821,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2156.86,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2156.86,2156.86
"Colonoscopy,Remv Lesn,Snare",PX45385P,CDM,983,RC,45385,CPT,,,,,,,,2424,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2157.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1030.93,4050.42
darbepoetin alfa 500 MCG/ML solution prefilled syringe 1 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513003201,NDC,0.3,ML,2368.44,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2157.64884,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
Lap Sleeve Gastrectomy,PX43775,CDM,982,RC,43775,CPT,,,,,,,,5030,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2157.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,674.85,4895.699
"Colonoscopy,Biopsy",PX45380P,CDM,983,RC,45380,CPT,,,,,,,,2539,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2158.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1030.93,4050.42
"Colonoscopy,Flex,Screen",PX2002F,CDM,750,RC,G0105,HCPCS,,,,,,,,2539,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2158.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,798.45,3885.86
"Upper GI Endoscopy,Diagnosis",PX43235F,CDM,750,RC,43235,CPT,,,,,,,,2539,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2158.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,3859.68
sarilumab 200 MG/1.14ML solution prefilled syringe 1.14 mL Syringe,J3590.25,CDM,636,RC,J3590,HCPCS,,,,24591001,NDC,1.14,ML,4408.29,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2160.0621,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1831.203666,4320.1242
sarilumab 200 MG/1.14ML solution prefilled syringe 1.14 mL Syringe,J3590.25,CDM,636,RC,J3590,HCPCS,,,,24591001,NDC,1.14,ML,4408.29,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2160.0621,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1831.203666,4320.1242
sarilumab 200 MG/1.14ML solution prefilled syringe 1.14 mL Syringe,J3590.25,CDM,636,RC,J3590,HCPCS,,,,24591001,NDC,1.14,ML,4408.29,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2160.0621,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1831.203666,4320.1242
OSTEOSET RESORBABLE MINI BEAD KIT FAST CURE CALCIUM SULFATE 5CC,C1713,CDM,278,RC,C1713,HCPCS,,12303-MAIN,LOCAL,,,,,2220,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2160.726,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Room Rate Icc,PX20601000,CDM,206,RC,,,,,,,,,,2432,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2164.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1010.2528,2383.36
GRAFIXPL PRIME PLACENTAL MEMBRANE 5x5CM 25SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12768-MAIN,LOCAL,,,,,5211,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2164.6494,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
bendamustine 100 MG/4ML Solution 4 mL Vial,800000,CDM,,,J9034,HCPCS,,,,63459034804,NDC,4,ML,5046.55,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2164.96995,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
CT Lumbar Spine W/O & W/Dye,PX7213301,CDM,350,RC,72133,CPT,TC,,,,,,,4283,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2167.198,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,4197.34
"Excis Arm/Elbow Tumor,Subcutan",PX24075P,CDM,983,RC,24075,CPT,,,,,,,,2458,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2167.956,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1021.0532,2392.3714
"Upper GI Endoscopy,Biopsy",PX43239P,CDM,983,RC,43239,CPT,,,,,,,,2458,,United Healthcare,All Payer,outpatient,88.2,,1100.4925,percent of total billed charges,2167.956,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,3859.68
omalizumab 150 MG Recon Soln 1 Each Vial,J2357.01,CDM,636,RC,J2357,HCPCS,,,,50242004062,NDC,1,EA,2212.7,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2168.446,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,21.02,2168.446
CT Abd & Pelvis W/O Contrast,PX7417601,CDM,350,RC,74176,CPT,TC,,,,,,,4288,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2169.728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,4202.24
CT Abdomen&Pelvis W/Contrast,PX7417701,CDM,350,RC,74177,CPT,TC,,,,,,,4288,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2169.728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4202.24
inFLIXimab 100 MG Recon Soln 1 Each Vial,J1745.01,CDM,636,RC,J1745,HCPCS,,,,57894003001,NDC,1,EA,2382.35,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2170.32085,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.49,2334.703
fluticasone-salmeterol 100-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,54032656,NDC,60,EA,2215.63,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2171.3174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,2171.3174
ramuCIRumab 100 MG/10ML Solution 10 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2766901,NDC,10,ML,2463.3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2172.6306,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.57,12070.17
"Colonoscopy,Biopsy",PX45380F,CDM,750,RC,45380,CPT,,,,,,,,2465,,United Healthcare,All Payer,outpatient,88.2,,999999999,case rate,2174.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2174.13,6141.46
RESTRATA WOUND MATRIX 5.0CM X 5.0CM TOTAL 25CM,27200000,CDM,272,RC,A2007,HCPCS,,11736-MAIN,LOCAL,,,,,5236,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2175.0344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
OSTEOSET RESORBABLE MINI BEAD KIT FAST CURE CALCIUM SULFATE 5CC,C1713,CDM,278,RC,C1713,HCPCS,,12303-MAIN,LOCAL,,,,,2220,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2175.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"Repair Lip,>1/2 Vert Height",PX40654F,CDM,510,RC,40654,CPT,,,,,,,,2467,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2175.894,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1024.7918,2417.66
HIMAX STAPLE KIT 18X14X14,27200000,CDM,278,RC,C1713,HCPCS,,11851-MAIN,LOCAL,,,,,4536,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2177.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HIMAX STAPLE KIT 18X14X14,27200000,CDM,278,RC,C1713,HCPCS,,11851-MAIN,LOCAL,,,,,4536,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2177.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HARMONIC 110 SHEARS 36CM SHAFT,27200000,CDM,272,RC,,,,12043-MAIN,LOCAL,,,,,2392,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2179.112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Lap,Esophagogast Fundoplasty",PX43280P,CDM,983,RC,43280,CPT,,,,,,,,4449,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2180.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1848.1146,8992.74
"Lap,Esophagogast Fundoplasty",PX43280P,CDM,983,RC,43280,CPT,,,,,,,,4449,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2180.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1848.1146,8992.74
"Lap,Esophagogast Fundoplasty",PX43280P,CDM,983,RC,43280,CPT,,,,,,,,4449,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2180.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1848.1146,8992.74
"Hemorrhoidectomy,Int/Ext,Simple",PX46255P,CDM,983,RC,46255,CPT,,,,,,,,2393,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2180.023,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,994.0522,2452.93
PACLitaxel protein-bound particle 100 MG Recon Susp 1 Each Vial,J9264.01,CDM,636,RC,J9264,HCPCS,,,,68817013450,NDC,1,EA,2564.76,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2180.046,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.1,2513.4648
REVITA PLACENTAL MEMBRANE 2X3CM 6SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12559-MAIN,LOCAL,,,,,2474,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2182.068,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
sarilumab 200 MG/1.14ML solution prefilled syringe 1.14 mL Syringe,J3590.25,CDM,636,RC,J3590,HCPCS,,,,24591001,NDC,1.14,ML,4408.29,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2182.10355,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1831.203666,4320.1242
Multiple Sleep Latency Test,PX9580501,CDM,740,RC,95805,CPT,TC,,,,,,,4313,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2182.378,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,468.24,4226.74
"Polysomnography, 4 or More",PX9581001,CDM,740,RC,95810,CPT,TC,,,,,,,4313,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2182.378,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,913.4,4226.74
APLIGRAF LIVING BI-LAYERED SKIN SUBSTITUTE,120.514,CDM,278,RC,Q4101,HCPCS,,12082-MAIN,LOCAL,,,,,2569,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2183.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1067.1626,2517.62
"Excis Arm/Elbow Tumor,Subcutan",PX24075P,CDM,983,RC,24075,CPT,,,,,,,,2458,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2187.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1021.0532,2392.3714
"Upper GI Endoscopy,Biopsy",PX43239P,CDM,983,RC,43239,CPT,,,,,,,,2458,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2187.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,3859.68
"Repair Ing Hernia,5+Y/O,Strang",PX49507P,CDM,983,RC,49507,CPT,,,,,,,,2482,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2189.124,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1031.0228,3022.41
hyaluronate 48 MG/6ML solution prefilled syringe 6 mL Syringe,J7325.01,CDM,636,RC,J7325,HCPCS,,,,58468009003,NDC,6,ML,5274.4,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2190.98576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.36,5168.912
ramuCIRumab 100 MG/10ML Solution 10 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2766901,NDC,10,ML,2463.3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2192.337,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.57,12070.17
Revise Median N/Carpal Tunnel Surg,PX64721F,CDM,510,RC,64721,CPT,,,,,,,,2408,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2193.688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1000.2832,2359.84
"Colonoscopy,Biopsy",PX45380F,CDM,750,RC,45380,CPT,,,,,,,,2465,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2193.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1030.93,4050.42
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,70842014003,NDC,1,EA,2409.61,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2195.15471,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.3,2361.4178
"Repair Lip,>1/2 Vert Height",PX40654F,CDM,510,RC,40654,CPT,,,,,,,,2467,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2195.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1024.7918,2417.66
Polysomnography W/Cpap,PX9581101,CDM,740,RC,95811,CPT,TC,,,,,,,4575,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,913.4,4483.5
Polysomnography W/Cpap,PX9581101,CDM,740,RC,95811,CPT,TC,,,,,,,4575,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,913.4,4483.5
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752P,CDM,983,RC,27752,CPT,,,,,,,,2495,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2200.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1036.423,2428.3835
Level 5 Additional Procedure,PX36000084,CDM,360,RC,,,,,,,,,,5300,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2201.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2201.62,5194
REVITA PLACENTAL MEMBRANE 2X3CM 6SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12559-MAIN,LOCAL,,,,,2474,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2201.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
"Lap,Esophagogast Fundoplasty",PX43280P,CDM,983,RC,43280,CPT,,,,,,,,4449,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2202.255,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1848.1146,8992.74
MRI L Spine W Contrast Tc,PX7214901,CDM,610,RC,72149,CPT,TC,,,,,,,5136,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2203.344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,5033.28
"Lap,Cholecystectomy/Explore",PX47564F,CDM,510,RC,47564,CPT,,,,,,,,2419,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2203.709,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1004.8526,8992.74
MINIBUNION 3.5 OFFSET PLATE SHORT,27200000,CDM,278,RC,C1713,HCPCS,,11667-MAIN,LOCAL,,,,,5142.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2206.1325,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Up GI Endoscopy,Ball Dil,30mm",PX43249F,CDM,750,RC,43249,CPT,,,,,,,,2596,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2206.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,958.1,3257.54
"Colonoscopy,Screen Prev",PX2004F,CDM,750,RC,G0121,HCPCS,,,,,,,,2502,,United Healthcare,All Payer,outpatient,88.2,,999999999,case rate,2206.764,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2206.764,6141.46
"Colonoscopy,Remv Lesn,Snare",PX45385P,CDM,983,RC,45385,CPT,,,,,,,,2424,,Medica,Commercial,both,91.1,,1260.14,percent of total billed charges,2208.264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1030.93,4050.42
"Repair Ing Hernia,5+Y/O,Strang",PX49507P,CDM,983,RC,49507,CPT,,,,,,,,2482,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2208.98,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1031.0228,3022.41
fomepizole 1 GM/ML Solution 1.5 mL Vial,J1451.01,CDM,636,RC,J1451,HCPCS,,,,39822071001,NDC,1.5,ML,2600,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2210,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.14,2548
Amputation Finger/Thumb,PX26951P,CDM,983,RC,26951,CPT,,,,,,,,2603,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2212.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1081.2862,2827.75
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561F,CDM,510,RC,36561,CPT,,,,,,,,2604,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2213.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1081.7016,2784.63
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266P,CDM,983,RC,27266,CPT,,,,,,,,2275,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2214.2575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,945.035,2214.2575
"Initial Repair of Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49593P,CDM,982,RC,49593,CPT,,,,,,,,2606,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2215.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1082.5324,3022.41
Room Rate Icc,PX20601000,CDM,206,RC,,,,,,,,,,2432,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2215.552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1010.2528,2383.36
"Up GI Endoscopy,Ball Dil,30mm",PX43249F,CDM,750,RC,43249,CPT,,,,,,,,2596,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2216.53,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.8,2216.53
"Up GI Endoscopy,Ball Dil,30mm",PX43249P,CDM,983,RC,43249,CPT,,,,,,,,1731,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2216.53,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,93.8,2216.53
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535F,CDM,510,RC,24535,CPT,,,,,,,,2514,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2217.348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1044.3156,2463.72
DYNABUNION STERILE INSTRUMENT KIT,27200000,CDM,272,RC,,,,11850-MAIN,LOCAL,,,,,2515,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2218.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752F,CDM,510,RC,27752,CPT,,,,,,,,2280,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2219.124,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,947.112,2234.4
Room Rate Icc Iso,PX20601001,CDM,206,RC,,,,,,,,,,2517,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2219.994,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1045.5618,2466.66
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752P,CDM,983,RC,27752,CPT,,,,,,,,2495,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2220.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1036.423,2428.3835
HIMAX STAPLE KIT 18X14X14,27200000,CDM,278,RC,C1713,HCPCS,,11851-MAIN,LOCAL,,,,,4536,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,2222.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HIMAX STAPLE KIT 18X14X14,27200000,CDM,278,RC,C1713,HCPCS,,11851-MAIN,LOCAL,,,,,4536,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2222.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HIMAX STAPLE KIT 18X14X14,27200000,CDM,278,RC,C1713,HCPCS,,11851-MAIN,LOCAL,,,,,4536,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2222.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Colonoscopy,Screen Prev",PX2004F,CDM,750,RC,G0121,HCPCS,,,,,,,,2502,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2226.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,798.45,3885.86
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266P,CDM,983,RC,27266,CPT,,,,,,,,2275,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2229.5,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,366.05,2229.5
sarilumab 200 MG/1.14ML solution prefilled syringe 1.14 mL Syringe,J3590.25,CDM,636,RC,J3590,HCPCS,,,,24591001,NDC,1.14,ML,4408.29,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2230.59474,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1831.203666,4320.1242
MTP PLATE STANDARD 18MM CLIP 5 DEG DORSIFLEXION,27200000,CDM,278,RC,C1713,HCPCS,,11854-MAIN,LOCAL,,,,,5376,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2233.1904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752F,CDM,510,RC,27752,CPT,,,,,,,,2280,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2234.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,947.112,2234.4
GRAFIXPL PRIME PLACENTAL MEMBRANE 5x5CM 25SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12768-MAIN,LOCAL,,,,,5211,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2235.519,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
"Lap,Esophagogast Fundoplasty",PX43280F,CDM,510,RC,43280,CPT,,,,,,,,6713,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2235.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,640.49,2235.9
"Lap,Esophagogast Fundoplasty",PX43280F,CDM,510,RC,43280,CPT,,,,,,,,6713,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2235.9,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,640.49,2235.9
"Lap,Esophagogast Fundoplasty",PX43280P,CDM,983,RC,43280,CPT,,,,,,,,4449,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2235.9,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,640.49,4360.02
"Lap,Esophagogast Fundoplasty",PX43280P,CDM,983,RC,43280,CPT,,,,,,,,4449,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2235.9,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,640.49,4360.02
denosumab 120 MG/1.7ML Solution 1.7 mL Vial,J0897.01,CDM,636,RC,J0897,HCPCS,,,,55513073001,NDC,1.7,ML,4658.83,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2236.2384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.55,4565.6534
denosumab 120 MG/1.7ML Solution 1.7 mL Vial,J0897.01,CDM,636,RC,J0897,HCPCS,,,,55513073001,NDC,1.7,ML,4658.83,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2236.2384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.55,4565.6534
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535F,CDM,510,RC,24535,CPT,,,,,,,,2514,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2237.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1044.3156,2463.72
"Fusion Foot Bones,Midtarsal,Multi",PX28730F,CDM,510,RC,28730,CPT,,,,,,,,2299,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2237.6167,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,955.0046,11497.76
DYNABUNION STERILE INSTRUMENT KIT,27200000,CDM,272,RC,,,,11850-MAIN,LOCAL,,,,,2515,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2238.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Excis Arm/Elbow Tumor,Subcutan",PX24075P,CDM,983,RC,24075,CPT,,,,,,,,2458,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2239.238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1021.0532,2392.3714
"Upper GI Endoscopy,Biopsy",PX43239P,CDM,983,RC,43239,CPT,,,,,,,,2458,,Medica,Commercial,both,91.1,,1336.405714,percent of total billed charges,2239.238,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,3859.68
"Colonoscopy,Biopsy",PX45380P,CDM,983,RC,45380,CPT,,,,,,,,2539,,United Healthcare,All Payer,outpatient,88.2,,151.9066154,percent of total billed charges,2239.398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1030.93,4050.42
"Colonoscopy,Flex,Screen",PX2002F,CDM,750,RC,G0105,HCPCS,,,,,,,,2539,,United Healthcare,All Payer,outpatient,88.2,,999999999,case rate,2239.398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2239.398,6141.46
"Upper GI Endoscopy,Diagnosis",PX43235F,CDM,750,RC,43235,CPT,,,,,,,,2539,,United Healthcare,All Payer,outpatient,88.2,,999999999,case rate,2239.398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2239.398,6141.46
Room Rate Icc Iso,PX20601001,CDM,206,RC,,,,,,,,,,2517,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2240.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1045.5618,2466.66
MRI Brain W Contrast Tc,PX7055201,CDM,610,RC,70552,CPT,TC,,,,,,,2637,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2241.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2584.26
Echo Tt 2d Complete,PX9330701,CDM,480,RC,93307,CPT,TC,,,,,,,2303,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2241.5099,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,2256.94
Polysomnography W/Cpap,PX9581101,CDM,740,RC,95811,CPT,TC,,,,,,,4575,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2241.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,913.4,4483.5
Polysomnography W/Cpap,PX9581101,CDM,740,RC,95811,CPT,TC,,,,,,,4575,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2241.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,913.4,4483.5
Polysomnography W/Cpap,PX9581101,CDM,740,RC,95811,CPT,TC,,,,,,,4575,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2241.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,913.4,4483.5
ramuCIRumab 100 MG/10ML Solution 10 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2766901,NDC,10,ML,2463.3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2244.0663,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.57,12070.17
HIMAX STAPLE KIT 18X14X14,27200000,CDM,278,RC,C1713,HCPCS,,11851-MAIN,LOCAL,,,,,4536,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2245.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Colonoscopy,Biopsy",PX45380F,CDM,750,RC,45380,CPT,,,,,,,,2465,,Medica,Commercial,both,91.1,,1620.33,percent of total billed charges,2245.615,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1030.93,4050.42
RESTRATA WOUND MATRIX 5.0CM X 5.0CM TOTAL 25CM,27200000,CDM,272,RC,A2007,HCPCS,,11736-MAIN,LOCAL,,,,,5236,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2246.244,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Repair Lip,>1/2 Vert Height",PX40654F,CDM,510,RC,40654,CPT,,,,,,,,2467,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2247.437,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1024.7918,2417.66
POLYAXIAL LOCKING PLATE MTP CROSS PLATE LEFT T8,C1713,CDM,278,RC,C1713,HCPCS,,12635-MAIN,LOCAL,,,,,5413,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2248.5602,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
POLYAXIAL LOCKING PLATE MTP CROSS PLATE RIGHT T8,C1713,CDM,278,RC,C1713,HCPCS,,12756-MAIN,LOCAL,,,,,5413,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2248.5602,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"Lap,Esophagogast Fundoplasty",PX43280P,CDM,983,RC,43280,CPT,,,,,,,,4449,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2251.194,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1848.1146,8992.74
"Fusion Foot Bones,Midtarsal,Multi",PX28730F,CDM,510,RC,28730,CPT,,,,,,,,2299,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2253.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,955.0046,11497.76
REVITA PLACENTAL MEMBRANE 2X3CM 6SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12559-MAIN,LOCAL,,,,,2474,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2253.814,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
nivolumab 100 MG/10ML Solution 10 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377412,NDC,10,ML,5429.27,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2255.318758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.5,12769.6548
MRI Abdomen W/O Tc,PX7418101,CDM,610,RC,74181,CPT,TC,,,,,,,2655,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2256.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,2601.9
Echo Tt 2d Complete,PX9330701,CDM,480,RC,93307,CPT,TC,,,,,,,2303,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2256.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,2256.94
Tocilizumab 400 MG/20ML Solution 20 mL Vial,J3262.01,CDM,636,RC,J3262,HCPCS,,,,50242013701,NDC,20,ML,4703.83,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2257.8384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.14,4609.7534
Tocilizumab 400 MG/20ML Solution 20 mL Vial,J3262.01,CDM,636,RC,J3262,HCPCS,,,,50242013701,NDC,20,ML,4703.83,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2257.8384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.14,4609.7534
eriBULin 1 MG/2ML Solution 2 mL Vial,J9179.01,CDM,636,RC,J9179,HCPCS,,,,62856038901,NDC,2,ML,2321.52,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2259.535416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.87,2275.0896
"Colonoscopy,Biopsy",PX45380P,CDM,983,RC,45380,CPT,,,,,,,,2539,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2259.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1030.93,4050.42
"Colonoscopy,Flex,Screen",PX2002F,CDM,750,RC,G0105,HCPCS,,,,,,,,2539,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2259.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,798.45,3885.86
"Upper GI Endoscopy,Diagnosis",PX43235F,CDM,750,RC,43235,CPT,,,,,,,,2539,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2259.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,3859.68
"Repair Ing Hernia,5+Y/O,Strang",PX49507P,CDM,983,RC,49507,CPT,,,,,,,,2482,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2261.102,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1031.0228,3022.41
PACLitaxel protein-bound particle 100 MG Recon Susp 1 Each Vial,J9264.01,CDM,636,RC,J9264,HCPCS,,,,68817013450,NDC,1,EA,2564.76,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2262.11832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.1,2513.4648
hyaluronate 48 MG/6ML solution prefilled syringe 6 mL Syringe,J7325.01,CDM,636,RC,J7325,HCPCS,,,,58468009003,NDC,6,ML,5274.4,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2262.7176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.36,5168.912
"Freeing Bowel Adhesion,Enterolysis",PX44005F,CDM,360,RC,44005,CPT,,,,,,,,2744,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2262.88,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,649.87,2262.88
"Freeing Bowel Adhesion,Enterolysis",PX44005F,CDM,360,RC,44005,CPT,,,,,,,,2744,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2262.88,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,649.87,2262.88
Polysomnography W/Cpap,PX9581101,CDM,740,RC,95811,CPT,TC,,,,,,,4575,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2264.625,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,913.4,4483.5
APLIGRAF LIVING BI-LAYERED SKIN SUBSTITUTE,120.514,CDM,278,RC,Q4101,HCPCS,,12082-MAIN,LOCAL,,,,,2569,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2265.858,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1067.1626,2517.62
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752P,CDM,983,RC,27752,CPT,,,,,,,,2495,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2272.945,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1036.423,2428.3835
Level 5 Additional Procedure,PX36000084,CDM,360,RC,,,,,,,,,,5300,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2273.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2201.62,5194
darbepoetin alfa 300 MCG/0.6ML solution prefilled syringe 0.6 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513011101,NDC,0.6,ML,4736.88,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2273.7024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
darbepoetin alfa 300 MCG/0.6ML solution prefilled syringe 0.6 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513011101,NDC,0.6,ML,4736.88,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2273.7024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
eriBULin 1 MG/2ML Solution 2 mL Vial,J9179.01,CDM,636,RC,J9179,HCPCS,,,,62856038901,NDC,2,ML,2321.52,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2275.0896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.87,2275.0896
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001501,NDC,1,EA,2340,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2277.522,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.3,2361.4178
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001503,NDC,1,EA,2340,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2277.522,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.3,2361.4178
"MRI,Uprext Jnt W/O+W/Cont",PX7322301,CDM,610,RC,73223,CPT,TC,,,,,,,2681,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2278.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2627.38
"Colonoscopy,Screen Prev",PX2004F,CDM,750,RC,G0121,HCPCS,,,,,,,,2502,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2279.322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,798.45,3885.86
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x4CM 12SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12767-MAIN,LOCAL,,,,,2345,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2282.3885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
PACLitaxel protein-bound particle 100 MG Recon Susp 1 Each Vial,J9264.01,CDM,636,RC,J9264,HCPCS,,,,68817013450,NDC,1,EA,2564.76,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2282.6364,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.1,2513.4648
denosumab 120 MG/1.7ML Solution 1.7 mL Vial,J0897.01,CDM,636,RC,J0897,HCPCS,,,,55513073001,NDC,1.7,ML,4658.83,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2282.8267,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.55,4565.6534
denosumab 120 MG/1.7ML Solution 1.7 mL Vial,J0897.01,CDM,636,RC,J0897,HCPCS,,,,55513073001,NDC,1.7,ML,4658.83,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2282.8267,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.55,4565.6534
denosumab 120 MG/1.7ML Solution 1.7 mL Vial,J0897.01,CDM,636,RC,J0897,HCPCS,,,,55513073001,NDC,1.7,ML,4658.83,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2282.8267,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.55,4565.6534
PHALINX STERILE LARGE 0 HAMMERTOE SYSTEM 45A01004,27800000,CDM,278,RC,C1713,HCPCS,,12962-MAIN,LOCAL,,,,,4759,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2284.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1976.8886,4663.82
PHALINX STERILE LARGE 0 HAMMERTOE SYSTEM 45A01004,27800000,CDM,278,RC,C1713,HCPCS,,12962-MAIN,LOCAL,,,,,4759,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2284.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1976.8886,4663.82
PHALINX STERILE MEDIUM 0 HAMMERTOE SYSTEM 45A01003,27800000,CDM,278,RC,C1713,HCPCS,,12961-MAIN,LOCAL,,,,,4759,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2284.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1976.8886,4663.82
PHALINX STERILE MEDIUM 0 HAMMERTOE SYSTEM 45A01003,27800000,CDM,278,RC,C1713,HCPCS,,12961-MAIN,LOCAL,,,,,4759,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2284.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1976.8886,4663.82
PHALINX STERILE SMALL 0 HAMMERTOE SYSTEM 45A01002,27800000,CDM,278,RC,C1713,HCPCS,,12960-MAIN,LOCAL,,,,,4759,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2284.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1976.8886,4663.82
PHALINX STERILE SMALL 0 HAMMERTOE SYSTEM 45A01002,27800000,CDM,278,RC,C1713,HCPCS,,12960-MAIN,LOCAL,,,,,4759,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2284.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1976.8886,4663.82
Lap Sleeve Gastrectomy,PX43775,CDM,982,RC,43775,CPT,,,,,,,,5030,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2285.02,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,645.08,4929.4
Lap Sleeve Gastrectomy,PX43775,CDM,982,RC,43775,CPT,,,,,,,,5030,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2285.02,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,645.08,4929.4
onabotulinumtoxinA 100 units Recon Soln 1 Each Vial,J0585.01,CDM,636,RC,J0585,HCPCS,,,,23114501,NDC,1,EA,2348.77,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2286.057841,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.51,2301.7946
ibutilide 1 MG/10ML Solution 10 mL Vial,J1742.01,CDM,636,RC,J1742,HCPCS,,,,9379401,NDC,10,ML,2349.03,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2286.310899,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.02,2302.0494
APLIGRAF LIVING BI-LAYERED SKIN SUBSTITUTE,120.514,CDM,278,RC,Q4101,HCPCS,,12082-MAIN,LOCAL,,,,,2569,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2286.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1067.1626,2517.62
CT Lower Extremity W/Dye,PX7370101,CDM,350,RC,73701,CPT,TC,,,,,,,2690,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2286.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,2636.2
"Up GI Endoscopy,Ball Dil,30mm",PX43249F,CDM,750,RC,43249,CPT,,,,,,,,2596,,United Healthcare,All Payer,outpatient,88.2,,999999999,case rate,2289.672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2289.672,6141.46
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505P,CDM,983,RC,24505,CPT,,,,,,,,2353,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2290.1749,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,977.4362,2290.1749
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535F,CDM,510,RC,24535,CPT,,,,,,,,2514,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2290.254,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1044.3156,2463.72
"Closed Rx Weight Bear Dist Tib,Manip",PX27825F,CDM,510,RC,27825,CPT,,,,,,,,2695,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2290.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1119.503,2641.1
DYNABUNION STERILE INSTRUMENT KIT,27200000,CDM,272,RC,,,,11850-MAIN,LOCAL,,,,,2515,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2291.165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Room Rate Icc Iso,PX20601001,CDM,206,RC,,,,,,,,,,2517,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2292.987,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1045.5618,2466.66
fomepizole 1 GM/ML Solution 1.5 mL Vial,J1451.01,CDM,636,RC,J1451,HCPCS,,,,39822071001,NDC,1.5,ML,2600,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2293.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.14,2548
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001501,NDC,1,EA,2340,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2293.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.3,2361.4178
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001503,NDC,1,EA,2340,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2293.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.3,2361.4178
HIMAX STAPLE KIT 18X14X14,27200000,CDM,278,RC,C1713,HCPCS,,11851-MAIN,LOCAL,,,,,4536,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2295.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Amputation Finger/Thumb,PX26951P,CDM,983,RC,26951,CPT,,,,,,,,2603,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2295.846,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1081.2862,2827.75
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561F,CDM,510,RC,36561,CPT,,,,,,,,2604,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2296.728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1081.7016,2784.63
trastuzumab-dttb 150 MG Recon Soln 1 Each Vial,J9999.55,CDM,636,RC,J9999,HCPCS,,,,78206014701,NDC,1,EA,2702.3,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2296.955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1122.53542,2648.254
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x4CM 12SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12767-MAIN,LOCAL,,,,,2345,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2298.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
"Initial Repair of Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49593P,CDM,982,RC,49593,CPT,,,,,,,,2606,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2298.492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1082.5324,3022.41
CAP TOE JOINT  15MM 2.5MMX4.5MM DF RESURFACING CONTOURED COBALT CHROMIUM METATARSOPHALANGEAL 9M52-25,C1713,CDM,278,RC,C1713,HCPCS,,12532-MAIN,LOCAL,,,,,4791,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2299.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
CAP TOE JOINT  15MM 2.5MMX4.5MM DF RESURFACING CONTOURED COBALT CHROMIUM METATARSOPHALANGEAL 9M52-25,C1713,CDM,278,RC,C1713,HCPCS,,12532-MAIN,LOCAL,,,,,4791,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2299.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
onabotulinumtoxinA 100 units Recon Soln 1 Each Vial,J0585.01,CDM,636,RC,J0585,HCPCS,,,,23114501,NDC,1,EA,2348.77,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2301.7946,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5.51,2301.7946
ibutilide 1 MG/10ML Solution 10 mL Vial,J1742.01,CDM,636,RC,J1742,HCPCS,,,,9379401,NDC,10,ML,2349.03,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2302.0494,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,188.02,2302.0494
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384F,CDM,750,RC,45384,CPT,,,,,,,,2350,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2303,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1008.15,4050.42
Tocilizumab 400 MG/20ML Solution 20 mL Vial,J3262.01,CDM,636,RC,J3262,HCPCS,,,,50242013701,NDC,20,ML,4703.83,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2304.8767,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.14,4609.7534
Tocilizumab 400 MG/20ML Solution 20 mL Vial,J3262.01,CDM,636,RC,J3262,HCPCS,,,,50242013701,NDC,20,ML,4703.83,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2304.8767,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.14,4609.7534
Tocilizumab 400 MG/20ML Solution 20 mL Vial,J3262.01,CDM,636,RC,J3262,HCPCS,,,,50242013701,NDC,20,ML,4703.83,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2304.8767,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.14,4609.7534
darbepoetin alfa 500 MCG/ML solution prefilled syringe 1 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513003201,NDC,0.3,ML,2368.44,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.7895,percent of total billed charges,2305.202652,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505P,CDM,983,RC,24505,CPT,,,,,,,,2353,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2305.94,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,289.04,2305.94
denosumab 120 MG/1.7ML Solution 1.7 mL Vial,J0897.01,CDM,636,RC,J0897,HCPCS,,,,55513073001,NDC,1.7,ML,4658.83,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2306.12085,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.55,4565.6534
MTP PLATE STANDARD 18MM CLIP 5 DEG DORSIFLEXION,27200000,CDM,278,RC,C1713,HCPCS,,11854-MAIN,LOCAL,,,,,5376,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2306.304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Up GI Endoscopy,Ball Dil,30mm",PX43249F,CDM,750,RC,43249,CPT,,,,,,,,2596,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2310.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,958.1,3257.54
"Colonoscopy,Biopsy",PX45380P,CDM,983,RC,45380,CPT,,,,,,,,2539,,Medica,Commercial,both,91.1,,1620.33,percent of total billed charges,2313.029,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1030.93,4050.42
"Colonoscopy,Flex,Screen",PX2002F,CDM,750,RC,G0105,HCPCS,,,,,,,,2539,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2313.029,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,798.45,3885.86
"Upper GI Endoscopy,Diagnosis",PX43235F,CDM,750,RC,43235,CPT,,,,,,,,2539,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2313.029,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,3859.68
fomepizole 1 GM/ML Solution 1.5 mL Vial,J1451.01,CDM,636,RC,J1451,HCPCS,,,,39822071001,NDC,1.5,ML,2600,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.14,2548
carfilzomib 60 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010101,NDC,1,EA,5571.82,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2314.534028,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.23,5460.3836
Polysomnography W/Cpap,PX9581101,CDM,740,RC,95811,CPT,TC,,,,,,,4575,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2314.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,913.4,4483.5
Amputation Finger/Thumb,PX26951P,CDM,983,RC,26951,CPT,,,,,,,,2603,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2316.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1081.2862,2827.75
"Upper GI Endoscopy,Biopsy",PX43239F,CDM,750,RC,43239,CPT,,,,,,,,2364,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2316.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,3859.68
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561F,CDM,510,RC,36561,CPT,,,,,,,,2604,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2317.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1081.7016,2784.63
"Initial Repair of Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49593P,CDM,982,RC,49593,CPT,,,,,,,,2606,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2319.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1082.5324,3022.41
darbepoetin alfa 300 MCG/0.6ML solution prefilled syringe 0.6 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513011101,NDC,0.6,ML,4736.88,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2321.0712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
darbepoetin alfa 300 MCG/0.6ML solution prefilled syringe 0.6 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513011101,NDC,0.6,ML,4736.88,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2321.0712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
darbepoetin alfa 300 MCG/0.6ML solution prefilled syringe 0.6 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513011101,NDC,0.6,ML,4736.88,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2321.0712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
darbepoetin alfa 500 MCG/ML solution prefilled syringe 1 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513003201,NDC,0.3,ML,2368.44,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2321.0712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
"VENTRALIGHT MESH ST WITH ECHO 2 - 20 CM X 25 CM 8"" X 10""",C1781,CDM,278,RC,C1781,HCPCS,,12009-MAIN,LOCAL,,,,,5589,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2321.6706,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
POLYAXIAL LOCKING PLATE MTP CROSS PLATE LEFT T8,C1713,CDM,278,RC,C1713,HCPCS,,12635-MAIN,LOCAL,,,,,5413,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2322.177,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
POLYAXIAL LOCKING PLATE MTP CROSS PLATE RIGHT T8,C1713,CDM,278,RC,C1713,HCPCS,,12756-MAIN,LOCAL,,,,,5413,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2322.177,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
MRI Brain W Contrast Tc,PX7055201,CDM,610,RC,70552,CPT,TC,,,,,,,2637,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2325.834,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2584.26
"Lap,Cholecystectomy/Explore",PX47564F,CDM,510,RC,47564,CPT,,,,,,,,2419,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2327.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,668.41,2327.91
"Lap,Cholecystectomy/Explore",PX47564F,CDM,510,RC,47564,CPT,,,,,,,,2419,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2327.91,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,668.41,2327.91
"Lap,Cholecystectomy/Explore",PX47564P,CDM,983,RC,47564,CPT,,,,,,,,1613,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2327.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,668.41,2327.91
"Lap,Cholecystectomy/Explore",PX47564P,CDM,983,RC,47564,CPT,,,,,,,,1613,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2327.91,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,668.41,2327.91
HARMONIC 110 SHEARS 36CM SHAFT,27200000,CDM,272,RC,,,,12043-MAIN,LOCAL,,,,,2392,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2328.1336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Tocilizumab 400 MG/20ML Solution 20 mL Vial,J3262.01,CDM,636,RC,J3262,HCPCS,,,,50242013701,NDC,20,ML,4703.83,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2328.39585,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.14,4609.7534
"Hemorrhoidectomy,Int/Ext,Simple",PX46255P,CDM,983,RC,46255,CPT,,,,,,,,2393,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1592.5,percent of total billed charges,2329.1069,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,994.0522,2452.93
nivolumab 100 MG/10ML Solution 10 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377412,NDC,10,ML,5429.27,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2329.15683,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.5,12769.6548
PHALINX STERILE LARGE 0 HAMMERTOE SYSTEM 45A01004,27800000,CDM,278,RC,C1713,HCPCS,,12962-MAIN,LOCAL,,,,,4759,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,2331.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1976.8886,4663.82
PHALINX STERILE LARGE 0 HAMMERTOE SYSTEM 45A01004,27800000,CDM,278,RC,C1713,HCPCS,,12962-MAIN,LOCAL,,,,,4759,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2331.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1976.8886,4663.82
PHALINX STERILE LARGE 0 HAMMERTOE SYSTEM 45A01004,27800000,CDM,278,RC,C1713,HCPCS,,12962-MAIN,LOCAL,,,,,4759,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2331.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1976.8886,4663.82
PHALINX STERILE MEDIUM 0 HAMMERTOE SYSTEM 45A01003,27800000,CDM,278,RC,C1713,HCPCS,,12961-MAIN,LOCAL,,,,,4759,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,2331.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1976.8886,4663.82
PHALINX STERILE MEDIUM 0 HAMMERTOE SYSTEM 45A01003,27800000,CDM,278,RC,C1713,HCPCS,,12961-MAIN,LOCAL,,,,,4759,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2331.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1976.8886,4663.82
PHALINX STERILE MEDIUM 0 HAMMERTOE SYSTEM 45A01003,27800000,CDM,278,RC,C1713,HCPCS,,12961-MAIN,LOCAL,,,,,4759,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2331.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1976.8886,4663.82
PHALINX STERILE SMALL 0 HAMMERTOE SYSTEM 45A01002,27800000,CDM,278,RC,C1713,HCPCS,,12960-MAIN,LOCAL,,,,,4759,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,2331.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1976.8886,4663.82
PHALINX STERILE SMALL 0 HAMMERTOE SYSTEM 45A01002,27800000,CDM,278,RC,C1713,HCPCS,,12960-MAIN,LOCAL,,,,,4759,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2331.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1976.8886,4663.82
PHALINX STERILE SMALL 0 HAMMERTOE SYSTEM 45A01002,27800000,CDM,278,RC,C1713,HCPCS,,12960-MAIN,LOCAL,,,,,4759,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2331.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1976.8886,4663.82
CT Pelvis W/O Dye,PX7219201,CDM,350,RC,72192,CPT,TC,,,,,,,2744,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2332.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2689.12
"Freeing Bowel Adhesion,Enterolysis",PX44005F,CDM,360,RC,44005,CPT,,,,,,,,2744,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2332.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,677.12,2689.12
"Cystourethroscopy, With Injection(S) for Chemodenervation of the Bladder",PX52287F,CDM,360,RC,52287,CPT,,,,,,,,2745,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2333.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1140.273,2690.1
inFLIXimab 100 MG Recon Soln 1 Each Vial,J1745.01,CDM,636,RC,J1745,HCPCS,,,,57894003001,NDC,1,EA,2382.35,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2334.703,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.49,2334.703
PACLitaxel protein-bound particle 100 MG Recon Susp 1 Each Vial,J9264.01,CDM,636,RC,J9264,HCPCS,,,,68817013450,NDC,1,EA,2564.76,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2336.49636,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.1,2513.4648
APLIGRAF LIVING BI-LAYERED SKIN SUBSTITUTE,120.514,CDM,278,RC,Q4101,HCPCS,,12082-MAIN,LOCAL,,,,,2569,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2340.359,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1067.1626,2517.62
MRI Abdomen W/O Tc,PX7418101,CDM,610,RC,74181,CPT,TC,,,,,,,2655,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2341.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,2601.9
CT Abdomen W/O Dye,PX7415001,CDM,350,RC,74150,CPT,TC,,,,,,,2757,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2343.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Angio Abd&Pelv W/O&W/Dye,PX7417401,CDM,350,RC,74174,CPT,TC,,,,,,,2757,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2343.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2701.86
CT Chest Spine W/O Dye,PX7212801,CDM,350,RC,72128,CPT,TC,,,,,,,2757,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2343.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Head/Brain W/O Dye,PX7045001,CDM,350,RC,70450,CPT,TC,,,,,,,2757,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2343.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Lower Extremity W/O Dye,PX7370001,CDM,350,RC,73700,CPT,TC,,,,,,,2757,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2343.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Lumbar Spine W/O Dye,PX7213101,CDM,350,RC,72131,CPT,TC,,,,,,,2757,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2343.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Maxillofacialw/O Dye,PX7048601,CDM,350,RC,70486,CPT,TC,,,,,,,2757,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2343.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Neck Spine W/O Dye,PX7212501,CDM,350,RC,72125,CPT,TC,,,,,,,2757,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2343.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Orbit/Ear/Fosa W/O Dye,PX7048001,CDM,350,RC,70480,CPT,TC,,,,,,,2757,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2343.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Upper Extremity W/Dye,PX7320101,CDM,350,RC,73201,CPT,TC,,,,,,,2757,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2343.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2701.86
CT Upper Extremity W/O Dye,PX7320001,CDM,350,RC,73200,CPT,TC,,,,,,,2757,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2343.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
Diagnostic CT Thorax W/O Contrast,PX7125001,CDM,350,RC,71250,CPT,TC,,,,,,,2757,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2343.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
Revise Median N/Carpal Tunnel Surg,PX64721F,CDM,510,RC,64721,CPT,,,,,,,,2408,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2343.7064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1000.2832,2359.84
HARMONIC 110 SHEARS 36CM SHAFT,27200000,CDM,272,RC,,,,12043-MAIN,LOCAL,,,,,2392,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2344.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
darbepoetin alfa 300 MCG/0.6ML solution prefilled syringe 0.6 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513011101,NDC,0.6,ML,4736.88,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2344.7556,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
"Hemorrhoidectomy,Int/Ext,Simple",PX46255P,CDM,983,RC,46255,CPT,,,,,,,,2393,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2345.14,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,221.21,2345.14
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,70842014003,NDC,1,EA,2409.61,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2345.273413,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.3,2361.4178
MRI Brain W Contrast Tc,PX7055201,CDM,610,RC,70552,CPT,TC,,,,,,,2637,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2346.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2584.26
CAP TOE JOINT  15MM 2.5MMX4.5MM DF RESURFACING CONTOURED COBALT CHROMIUM METATARSOPHALANGEAL 9M52-25,C1713,CDM,278,RC,C1713,HCPCS,,12532-MAIN,LOCAL,,,,,4791,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,2347.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
CAP TOE JOINT  15MM 2.5MMX4.5MM DF RESURFACING CONTOURED COBALT CHROMIUM METATARSOPHALANGEAL 9M52-25,C1713,CDM,278,RC,C1713,HCPCS,,12532-MAIN,LOCAL,,,,,4791,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2347.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
CAP TOE JOINT  15MM 2.5MMX4.5MM DF RESURFACING CONTOURED COBALT CHROMIUM METATARSOPHALANGEAL 9M52-25,C1713,CDM,278,RC,C1713,HCPCS,,12532-MAIN,LOCAL,,,,,4791,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2347.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,62935022305,NDC,1,EA,2764.34,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2349.689,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218710,NDC,2,EA,5662.72,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2352.293888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.57,6737.8528
"Lap,Cholecystectomy/Explore",PX47564F,CDM,510,RC,47564,CPT,,,,,,,,2419,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2354.4127,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1004.8526,8992.74
PHALINX STERILE LARGE 0 HAMMERTOE SYSTEM 45A01004,27800000,CDM,278,RC,C1713,HCPCS,,12962-MAIN,LOCAL,,,,,4759,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2355.705,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1976.8886,4663.82
PHALINX STERILE MEDIUM 0 HAMMERTOE SYSTEM 45A01003,27800000,CDM,278,RC,C1713,HCPCS,,12961-MAIN,LOCAL,,,,,4759,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2355.705,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1976.8886,4663.82
PHALINX STERILE SMALL 0 HAMMERTOE SYSTEM 45A01002,27800000,CDM,278,RC,C1713,HCPCS,,12960-MAIN,LOCAL,,,,,4759,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2355.705,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1976.8886,4663.82
denosumab 120 MG/1.7ML Solution 1.7 mL Vial,J0897.01,CDM,636,RC,J0897,HCPCS,,,,55513073001,NDC,1.7,ML,4658.83,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2357.36798,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.55,4565.6534
certolizumab 2 X 200 MG Kit 1 Each Box,J0717.01,CDM,636,RC,J0717,HCPCS,,,,50474070062,NDC,0.5,EA,4911.87,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2357.6976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.41,4813.6326
certolizumab 2 X 200 MG Kit 1 Each Box,J0717.01,CDM,636,RC,J0717,HCPCS,,,,50474070062,NDC,0.5,EA,4911.87,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2357.6976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.41,4813.6326
Hepatobiliary System Imaging,PX7822601,CDM,341,RC,78226,CPT,TC,,,,,,,2776,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2359.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,360.31,2720.48
Revise Median N/Carpal Tunnel Surg,PX64721F,CDM,510,RC,64721,CPT,,,,,,,,2408,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2359.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1000.2832,2359.84
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,70842014003,NDC,1,EA,2409.61,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2361.4178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.3,2361.4178
MRI Abdomen W/O Tc,PX7418101,CDM,610,RC,74181,CPT,TC,,,,,,,2655,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2362.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,2601.9
"MRI,Uprext Jnt W/O+W/Cont",PX7322301,CDM,610,RC,73223,CPT,TC,,,,,,,2681,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2364.642,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2627.38
"Up GI Endoscopy,Ball Dil,30mm",PX43249F,CDM,750,RC,43249,CPT,,,,,,,,2596,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2364.956,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,958.1,3257.54
Room Rate Icc,PX20601000,CDM,206,RC,,,,,,,,,,2432,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2367.0656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1010.2528,2383.36
carfilzomib 30 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010201,NDC,1,EA,2785.91,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2368.0235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.23,5460.3836
fomepizole 1 GM/ML Solution 1.5 mL Vial,J1451.01,CDM,636,RC,J1451,HCPCS,,,,39822071001,NDC,1.5,ML,2600,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2368.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.14,2548
"Remv F.B.,Eye,Ant Chmbr/Lens",PX65235F,CDM,510,RC,65235,CPT,,,,,,,,2788,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2369.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1158.1352,2732.24
"Lap,Cholecystectomy/Explore",PX47564F,CDM,510,RC,47564,CPT,,,,,,,,2419,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2370.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1004.8526,8992.74
Amputation Finger/Thumb,PX26951P,CDM,983,RC,26951,CPT,,,,,,,,2603,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2371.333,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1081.2862,2827.75
CAP TOE JOINT  15MM 2.5MMX4.5MM DF RESURFACING CONTOURED COBALT CHROMIUM METATARSOPHALANGEAL 9M52-25,C1713,CDM,278,RC,C1713,HCPCS,,12532-MAIN,LOCAL,,,,,4791,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2371.545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561F,CDM,510,RC,36561,CPT,,,,,,,,2604,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2372.244,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1081.7016,2784.63
CT Lower Extremity W/Dye,PX7370101,CDM,350,RC,73701,CPT,TC,,,,,,,2690,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2372.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,2636.2
"Initial Repair of Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49593P,CDM,982,RC,49593,CPT,,,,,,,,2606,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2374.066,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1082.5324,3022.41
"Colonoscopy,Remv Lesn,Snare",PX45385P,CDM,983,RC,45385,CPT,,,,,,,,2424,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2375.52,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,155.32,2375.52
"Closed Rx Weight Bear Dist Tib,Manip",PX27825F,CDM,510,RC,27825,CPT,,,,,,,,2695,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2376.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1119.503,2641.1
Tocilizumab 400 MG/20ML Solution 20 mL Vial,J3262.01,CDM,636,RC,J3262,HCPCS,,,,50242013701,NDC,20,ML,4703.83,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2380.13798,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.14,4609.7534
Room Rate Icc,PX20601000,CDM,206,RC,,,,,,,,,,2432,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2383.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1010.2528,2383.36
trastuzumab-dttb 150 MG Recon Soln 1 Each Vial,J9999.55,CDM,636,RC,J9999,HCPCS,,,,78206014701,NDC,1,EA,2702.3,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2383.4286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1122.53542,2648.254
"MRI,Uprext Jnt W/O+W/Cont",PX7322301,CDM,610,RC,73223,CPT,TC,,,,,,,2681,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2386.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2627.38
Low Dose CT Lung Ca Screening,PXG029701,CDM,350,RC,G0297,HCPCS,TC,,,,,,,2812,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2390.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1168.1048,2755.76
carfilzomib 60 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010101,NDC,1,EA,5571.82,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2390.31078,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.23,5460.3836
"Excis Arm/Elbow Tumor,Subcutan",PX24075P,CDM,983,RC,24075,CPT,,,,,,,,2458,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2392.3714,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1021.0532,2392.3714
CT Lower Extremity W/Dye,PX7370101,CDM,350,RC,73701,CPT,TC,,,,,,,2690,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2394.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,2636.2
darbepoetin alfa 300 MCG/0.6ML solution prefilled syringe 0.6 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513011101,NDC,0.6,ML,4736.88,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2396.86128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
ramuCIRumab 100 MG/10ML Solution 10 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2766901,NDC,10,ML,2463.3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2397.52989,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.57,12070.17
"VENTRALIGHT MESH ST WITH ECHO 2 - 20 CM X 25 CM 8"" X 10""",C1781,CDM,278,RC,C1781,HCPCS,,12009-MAIN,LOCAL,,,,,5589,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2397.681,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Closed Rx Weight Bear Dist Tib,Manip",PX27825F,CDM,510,RC,27825,CPT,,,,,,,,2695,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2398.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1119.503,2641.1
"Repair Lip,>1/2 Vert Height",PX40654F,CDM,510,RC,40654,CPT,,,,,,,,2467,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2401.1311,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1024.7918,2417.66
MRI Brain W Contrast Tc,PX7055201,CDM,610,RC,70552,CPT,TC,,,,,,,2637,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2402.307,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2584.26
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270004,NDC,100,ML,2827.78,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2403.613,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 10 GM/100ML Solution 100 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270005,NDC,100,ML,2827.78,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2403.613,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270007,NDC,100,ML,2827.78,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2403.613,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270013,NDC,100,ML,2827.78,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2403.613,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
trastuzumab-dttb 150 MG Recon Soln 1 Each Vial,J9999.55,CDM,636,RC,J9999,HCPCS,,,,78206014701,NDC,1,EA,2702.3,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2405.047,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1122.53542,2648.254
certolizumab 2 X 200 MG Kit 1 Each Box,J0717.01,CDM,636,RC,J0717,HCPCS,,,,50474070062,NDC,0.5,EA,4911.87,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2406.8163,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.41,4813.6326
certolizumab 2 X 200 MG Kit 1 Each Box,J0717.01,CDM,636,RC,J0717,HCPCS,,,,50474070062,NDC,0.5,EA,4911.87,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2406.8163,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.41,4813.6326
certolizumab 2 X 200 MG Kit 1 Each Box,J0717.01,CDM,636,RC,J0717,HCPCS,,,,50474070062,NDC,0.5,EA,4911.87,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2406.8163,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.41,4813.6326
REVITA PLACENTAL MEMBRANE 2X3CM 6SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12559-MAIN,LOCAL,,,,,2474,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2407.9442,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
PHALINX STERILE LARGE 0 HAMMERTOE SYSTEM 45A01004,27800000,CDM,278,RC,C1713,HCPCS,,12962-MAIN,LOCAL,,,,,4759,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2408.054,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1976.8886,4663.82
PHALINX STERILE MEDIUM 0 HAMMERTOE SYSTEM 45A01003,27800000,CDM,278,RC,C1713,HCPCS,,12961-MAIN,LOCAL,,,,,4759,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2408.054,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1976.8886,4663.82
PHALINX STERILE SMALL 0 HAMMERTOE SYSTEM 45A01002,27800000,CDM,278,RC,C1713,HCPCS,,12960-MAIN,LOCAL,,,,,4759,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2408.054,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1976.8886,4663.82
"Excis Arm/Elbow Tumor,Subcutan",PX24075P,CDM,983,RC,24075,CPT,,,,,,,,2458,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2408.84,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,206.15,2408.84
"Upper GI Endoscopy,Biopsy",PX43239P,CDM,983,RC,43239,CPT,,,,,,,,2458,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2408.84,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,84.86,2408.84
ramuCIRumab 100 MG/10ML Solution 10 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2766901,NDC,10,ML,2463.3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2414.034,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.57,12070.17
"Colonoscopy,Biopsy",PX45380F,CDM,750,RC,45380,CPT,,,,,,,,2465,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2415.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1030.93,4050.42
"Repair Ing Hernia,5+Y/O,Strang",PX49507P,CDM,983,RC,49507,CPT,,,,,,,,2482,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2415.7306,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1031.0228,3022.41
"Repair Lip,>1/2 Vert Height",PX40654F,CDM,510,RC,40654,CPT,,,,,,,,2467,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2417.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1024.7918,2417.66
MRI Abdomen W/O Tc,PX7418101,CDM,610,RC,74181,CPT,TC,,,,,,,2655,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2418.705,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,2601.9
CT Pelvis W/O Dye,PX7219201,CDM,350,RC,72192,CPT,TC,,,,,,,2744,,United Healthcare,All Payer,outpatient,88.2,,1476.82,percent of total billed charges,2420.208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2689.12
"Freeing Bowel Adhesion,Enterolysis",PX44005F,CDM,360,RC,44005,CPT,,,,,,,,2744,,United Healthcare,All Payer,outpatient,88.2,,999999999,case rate,2420.208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2420.208,6141.46
"Cystourethroscopy, With Injection(S) for Chemodenervation of the Bladder",PX52287F,CDM,360,RC,52287,CPT,,,,,,,,2745,,United Healthcare,All Payer,outpatient,88.2,,999999999,case rate,2421.09,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2421.09,6141.46
bendamustine 100 MG/4ML Solution 4 mL Vial,800000,CDM,,,J9034,HCPCS,,,,63459034804,NDC,4,ML,5046.55,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2422.344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
bendamustine 100 MG/4ML Solution 4 mL Vial,800000,CDM,,,J9034,HCPCS,,,,63459034804,NDC,4,ML,5046.55,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2422.344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
hepatitis B immune globulin 312 UNIT/ML Solution 5 mL Vial,90371,CDM,636,RC,90371,CPT,,,,59730420301,NDC,5,ML,2851.63,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2423.8855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.6,2794.5974
CAP TOE JOINT  15MM 2.5MMX4.5MM DF RESURFACING CONTOURED COBALT CHROMIUM METATARSOPHALANGEAL 9M52-25,C1713,CDM,278,RC,C1713,HCPCS,,12532-MAIN,LOCAL,,,,,4791,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2424.246,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
REVITA PLACENTAL MEMBRANE 2X3CM 6SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12559-MAIN,LOCAL,,,,,2474,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2424.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752P,CDM,983,RC,27752,CPT,,,,,,,,2495,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2428.3835,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1036.423,2428.3835
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218710,NDC,2,EA,5662.72,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2429.30688,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.57,6737.8528
certolizumab 2 X 200 MG Kit 1 Each Box,J0717.01,CDM,636,RC,J0717,HCPCS,,,,50474070062,NDC,0.5,EA,4911.87,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2431.37565,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.41,4813.6326
CT Abdomen W/O Dye,PX7415001,CDM,350,RC,74150,CPT,TC,,,,,,,2757,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2431.674,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Angio Abd&Pelv W/O&W/Dye,PX7417401,CDM,350,RC,74174,CPT,TC,,,,,,,2757,,United Healthcare,All Payer,outpatient,88.2,,1350.93,percent of total billed charges,2431.674,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2701.86
CT Chest Spine W/O Dye,PX7212801,CDM,350,RC,72128,CPT,TC,,,,,,,2757,,United Healthcare,All Payer,outpatient,88.2,,1461.21,percent of total billed charges,2431.674,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Head/Brain W/O Dye,PX7045001,CDM,350,RC,70450,CPT,TC,,,,,,,2757,,United Healthcare,All Payer,outpatient,88.2,,1711.18,percent of total billed charges,2431.674,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Lower Extremity W/O Dye,PX7370001,CDM,350,RC,73700,CPT,TC,,,,,,,2757,,United Healthcare,All Payer,outpatient,88.2,,2591.58,percent of total billed charges,2431.674,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Lumbar Spine W/O Dye,PX7213101,CDM,350,RC,72131,CPT,TC,,,,,,,2757,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2431.674,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Maxillofacialw/O Dye,PX7048601,CDM,350,RC,70486,CPT,TC,,,,,,,2757,,United Healthcare,All Payer,outpatient,88.2,,3782.61,percent of total billed charges,2431.674,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Neck Spine W/O Dye,PX7212501,CDM,350,RC,72125,CPT,TC,,,,,,,2757,,United Healthcare,All Payer,outpatient,88.2,,680.86,percent of total billed charges,2431.674,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Orbit/Ear/Fosa W/O Dye,PX7048001,CDM,350,RC,70480,CPT,TC,,,,,,,2757,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2431.674,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Upper Extremity W/Dye,PX7320101,CDM,350,RC,73201,CPT,TC,,,,,,,2757,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2431.674,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2701.86
CT Upper Extremity W/O Dye,PX7320001,CDM,350,RC,73200,CPT,TC,,,,,,,2757,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2431.674,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
Diagnostic CT Thorax W/O Contrast,PX7125001,CDM,350,RC,71250,CPT,TC,,,,,,,2757,,United Healthcare,All Payer,outpatient,88.2,,1350.93,percent of total billed charges,2431.674,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
"Repair Ing Hernia,5+Y/O,Strang",PX49507P,CDM,983,RC,49507,CPT,,,,,,,,2482,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2432.36,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,354.93,2432.36
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830F,CDM,510,RC,15830,CPT,,,,,,,,2080,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2434.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,721.42,2434.44
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830F,CDM,510,RC,15830,CPT,,,,,,,,2080,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2434.44,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,721.42,2434.44
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830P,CDM,983,RC,15830,CPT,,,,,,,,1120,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2434.44,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,721.42,2434.44
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830P,CDM,983,RC,15830,CPT,,,,,,,,1120,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,2434.44,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,721.42,2434.44
IMPLANT PACKAGE TOEMATE,27200000,CDM,278,RC,C1713,HCPCS,,11859-MAIN,LOCAL,,,,,2865,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2435.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
IMPLANT TOEMATE X-SMALL PACKAGE 9H00-T050,C1713,CDM,278,RC,C1713,HCPCS,,11574-MAIN,LOCAL,,,,,2865,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2435.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,62935022305,NDC,1,EA,2764.34,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2438.14788,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
CT Pelvis W/O Dye,PX7219201,CDM,350,RC,72192,CPT,TC,,,,,,,2744,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2442.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2689.12
"Freeing Bowel Adhesion,Enterolysis",PX44005F,CDM,360,RC,44005,CPT,,,,,,,,2744,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2442.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,677.12,2689.12
"MRI,Uprext Jnt W/O+W/Cont",PX7322301,CDM,610,RC,73223,CPT,TC,,,,,,,2681,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2442.391,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2627.38
"Cytogen, Interp/Report - Ref",PX8829190,CDM,310,RC,88291,CPT,90,,,,,,,2874,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2442.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.95,2816.52
"Cystourethroscopy, With Injection(S) for Chemodenervation of the Bladder",PX52287F,CDM,360,RC,52287,CPT,,,,,,,,2745,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2443.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1140.273,2690.1
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752P,CDM,983,RC,27752,CPT,,,,,,,,2495,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2445.1,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,310.64,2445.1
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535F,CDM,510,RC,24535,CPT,,,,,,,,2514,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2446.8762,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1044.3156,2463.72
DYNABUNION STERILE INSTRUMENT KIT,27200000,CDM,272,RC,,,,11850-MAIN,LOCAL,,,,,2515,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2447.8495,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Hepatobiliary System Imaging,PX7822601,CDM,341,RC,78226,CPT,TC,,,,,,,2776,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2448.432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,360.31,2720.48
Room Rate Icc Iso,PX20601001,CDM,206,RC,,,,,,,,,,2517,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2449.7961,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1045.5618,2466.66
Or Level 5,PX36000005,CDM,360,RC,,,,,,,,,,5898,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2450.0292,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2450.0292,5780.04
CT Lower Extremity W/Dye,PX7370101,CDM,350,RC,73701,CPT,TC,,,,,,,2690,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2450.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,2636.2
"Colonoscopy,Screen Prev",PX2004F,CDM,750,RC,G0121,HCPCS,,,,,,,,2502,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2451.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,798.45,3885.86
Anal Sphincterotomy,PX46080F,CDM,510,RC,46080,CPT,,,,,,,,607,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2452.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,252.1478,2452.93
Anal Sphincterotomy,PX46080P,CDM,983,RC,46080,CPT,,,,,,,,525,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2452.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,218.085,2452.93
Biopsy of Rectum,PX45100F,CDM,510,RC,45100,CPT,,,,,,,,763,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2452.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,316.9502,2452.93
Biopsy of Rectum,PX45100P,CDM,983,RC,45100,CPT,,,,,,,,509,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2452.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,211.4386,2452.93
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390F,CDM,750,RC,45390,CPT,,,,,,,,1419,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2452.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,589.4526,2452.93
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390P,CDM,982,RC,45390,CPT,,,,,,,,1135,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2452.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,471.479,2452.93
"Hemorrhoidectomy,Int/Ext,Complx",PX46260F,CDM,750,RC,46260,CPT,,,,,,,,1350,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2452.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,560.79,2452.93
"Hemorrhoidectomy,Int/Ext,Simple",PX46255F,CDM,510,RC,46255,CPT,,,,,,,,1627,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2452.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,675.8558,2452.93
"Hemorrhoidectomy,Int/Ext,Simple",PX46255P,CDM,983,RC,46255,CPT,,,,,,,,2393,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2452.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,994.0522,2452.93
"Removal Anal Fistula,Subcutaneous",PX46270F,CDM,510,RC,46270,CPT,,,,,,,,1470,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2452.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,610.638,2452.93
"Removal Anal Fistula,Subcutaneous",PX46270P,CDM,983,RC,46270,CPT,,,,,,,,980,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2452.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,407.092,2452.93
Removal of Anal Tabs,PX46230F,CDM,510,RC,46230,CPT,,,,,,,,790,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2452.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,328.166,2452.93
Removal of Anal Tabs,PX46230P,CDM,983,RC,46230,CPT,,,,,,,,1435,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2452.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,596.099,2452.93
Remove Hemorrhoids & Fissure,PX46257F,CDM,510,RC,46257,CPT,,,,,,,,1141,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2452.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,473.9714,2452.93
Remove Hemorrhoids & Fissure,PX46257P,CDM,983,RC,46257,CPT,,,,,,,,615,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2452.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,255.471,2452.93
"Surgical Diagnostic Exam, Anorectal",PX45990P,CDM,983,RC,45990,CPT,,,,,,,,409,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2452.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,169.8986,2452.93
CT Abdomen W/O Dye,PX7415001,CDM,350,RC,74150,CPT,TC,,,,,,,2757,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2453.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Angio Abd&Pelv W/O&W/Dye,PX7417401,CDM,350,RC,74174,CPT,TC,,,,,,,2757,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2453.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2701.86
CT Chest Spine W/O Dye,PX7212801,CDM,350,RC,72128,CPT,TC,,,,,,,2757,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2453.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Head/Brain W/O Dye,PX7045001,CDM,350,RC,70450,CPT,TC,,,,,,,2757,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2453.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Lower Extremity W/O Dye,PX7370001,CDM,350,RC,73700,CPT,TC,,,,,,,2757,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2453.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Lumbar Spine W/O Dye,PX7213101,CDM,350,RC,72131,CPT,TC,,,,,,,2757,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2453.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Maxillofacialw/O Dye,PX7048601,CDM,350,RC,70486,CPT,TC,,,,,,,2757,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2453.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Neck Spine W/O Dye,PX7212501,CDM,350,RC,72125,CPT,TC,,,,,,,2757,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2453.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Orbit/Ear/Fosa W/O Dye,PX7048001,CDM,350,RC,70480,CPT,TC,,,,,,,2757,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2453.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Upper Extremity W/Dye,PX7320101,CDM,350,RC,73201,CPT,TC,,,,,,,2757,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2453.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2701.86
CT Upper Extremity W/O Dye,PX7320001,CDM,350,RC,73200,CPT,TC,,,,,,,2757,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2453.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
Diagnostic CT Thorax W/O Contrast,PX7125001,CDM,350,RC,71250,CPT,TC,,,,,,,2757,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2453.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535P,CDM,983,RC,24535,CPT,,,,,,,,2887,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2453.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1199.2598,2809.9171
"Closed Rx Weight Bear Dist Tib,Manip",PX27825F,CDM,510,RC,27825,CPT,,,,,,,,2695,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2455.145,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1119.503,2641.1
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING 8X10 ELLIPSE,C1781,CDM,278,RC,C1781,HCPCS,,12504-MAIN,LOCAL,,,,,5915,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2457.091,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
carfilzomib 30 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010201,NDC,1,EA,2785.91,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2457.17262,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.23,5460.3836
"Remv F.B.,Eye,Ant Chmbr/Lens",PX65235F,CDM,510,RC,65235,CPT,,,,,,,,2788,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2459.016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1158.1352,2732.24
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,62935022305,NDC,1,EA,2764.34,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2460.2626,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
trastuzumab-dttb 150 MG Recon Soln 1 Each Vial,J9999.55,CDM,636,RC,J9999,HCPCS,,,,78206014701,NDC,1,EA,2702.3,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2461.7953,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1122.53542,2648.254
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535F,CDM,510,RC,24535,CPT,,,,,,,,2514,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2463.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1044.3156,2463.72
DYNABUNION STERILE INSTRUMENT KIT,27200000,CDM,272,RC,,,,11850-MAIN,LOCAL,,,,,2515,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2464.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Lap Sleeve Gastrectomy,PX43775,CDM,982,RC,43775,CPT,,,,,,,,5030,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2464.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,674.85,4895.699
Lap Sleeve Gastrectomy,PX43775,CDM,982,RC,43775,CPT,,,,,,,,5030,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2464.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,674.85,4895.699
Lap Sleeve Gastrectomy,PX43775,CDM,982,RC,43775,CPT,,,,,,,,5030,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2464.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,674.85,4895.699
MRI L Spine W Contrast Tc,PX7214901,CDM,610,RC,72149,CPT,TC,,,,,,,5136,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2465.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,5033.28
MRI L Spine W Contrast Tc,PX7214901,CDM,610,RC,72149,CPT,TC,,,,,,,5136,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2465.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,5033.28
DOCEtaxel 160 MG/16ML Solution 16 mL Vial,J9171.01,CDM,636,RC,J9171,HCPCS,,,,409173201,NDC,16,ML,2901.69,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2466.4365,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1205.362026,2843.6562
Room Rate Icc Iso,PX20601001,CDM,206,RC,,,,,,,,,,2517,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2466.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1045.5618,2466.66
MINIBUNION 3.5 OFFSET PLATE SHORT,27200000,CDM,278,RC,C1713,HCPCS,,11667-MAIN,LOCAL,,,,,5142.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2468.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MINIBUNION 3.5 OFFSET PLATE SHORT,27200000,CDM,278,RC,C1713,HCPCS,,11667-MAIN,LOCAL,,,,,5142.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2468.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Hepatobiliary System Imaging,PX7822601,CDM,341,RC,78226,CPT,TC,,,,,,,2776,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2470.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,360.31,2720.48
Lap Paraesophag Hern Repair,PX43281,CDM,982,RC,43281,CPT,,,,,,,,5950,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2471.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2471.63,8992.74
"Repair of Recurrent Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49615F,CDM,360,RC,49615,CPT,,,,,,,,2908,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2471.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1207.9832,3022.41
bendamustine 100 MG/4ML Solution 4 mL Vial,800000,CDM,,,J9034,HCPCS,,,,63459034804,NDC,4,ML,5046.55,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2472.8095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
bendamustine 100 MG/4ML Solution 4 mL Vial,800000,CDM,,,J9034,HCPCS,,,,63459034804,NDC,4,ML,5046.55,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2472.8095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
bendamustine 100 MG/4ML Solution 4 mL Vial,800000,CDM,,,J9034,HCPCS,,,,63459034804,NDC,4,ML,5046.55,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2472.8095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270006,NDC,100,ML,2912.78,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2475.863,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
carfilzomib 30 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010201,NDC,1,EA,2785.91,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2479.4599,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.23,5460.3836
Low Dose CT Lung Ca Screening,PXG029701,CDM,350,RC,G0297,HCPCS,TC,,,,,,,2812,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2480.184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1168.1048,2755.76
"Remv F.B.,Eye,Ant Chmbr/Lens",PX65235F,CDM,510,RC,65235,CPT,,,,,,,,2788,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2481.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1158.1352,2732.24
"Complex Drainage, Wound",PX10180F,CDM,510,RC,10180,CPT,,,,,,,,1050,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2482.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,436.17,2482.37
"Complex Drainage, Wound",PX10180P,CDM,983,RC,10180,CPT,,,,,,,,767,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2482.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,318.6118,2482.37
"Diagnostic Bone Marrow, Biopsy and Aspiration",PX38222F,CDM,761,RC,38222,CPT,,,,,,,,1748,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2482.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,726.1192,2482.37
Exc Abdom Tum Subfac > 5 Cm,PX22901F,CDM,761,RC,22901,CPT,,,,,,,,1408,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2482.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,584.8832,2482.37
Exc Abdom Tum Subfac > 5 Cm,PX22901P,CDM,983,RC,22901,CPT,,,,,,,,938,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2482.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,389.6452,2482.37
Exc Neck Les Sc = 3cm >,PX21552F,CDM,510,RC,21552,CPT,,,,,,,,753,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2482.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,312.7962,2482.37
Exc Skin Benig >4cm Remaindr Body,PX11426F,CDM,510,RC,11426,CPT,,,,,,,,1227,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2482.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,509.6958,2482.37
Exc Skin Benig >4cm Remaindr Body,PX11426P,CDM,983,RC,11426,CPT,,,,,,,,981,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2482.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,407.5074,2482.37
Exs Tumor Arm/Elbow Sc 3cm>,PX24071F,CDM,510,RC,24071,CPT,,,,,,,,1860,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2482.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,772.644,2482.37
I&D Deep Absc/Hematoma Neck/Chest,PX21501F,CDM,510,RC,21501,CPT,,,,,,,,773,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2482.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.1042,2482.37
I&D Deep Absc/Hematoma Neck/Chest,PX21501P,CDM,983,RC,21501,CPT,,,,,,,,515,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2482.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,213.931,2482.37
"Incis/Drain Shldr Absc/Hema,Deep",PX23030P,CDM,983,RC,23030,CPT,,,,,,,,1564,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2482.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,649.6856,2482.37
"Remv Foreign Body,Knee/Thigh,Deep",PX27372F,CDM,510,RC,27372,CPT,,,,,,,,1429,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2482.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,593.6066,2482.37
"Remv Foreign Body,Knee/Thigh,Deep",PX27372P,CDM,983,RC,27372,CPT,,,,,,,,954,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2482.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,396.2916,2482.37
certolizumab 2 X 200 MG Kit 1 Each Box,J0717.01,CDM,636,RC,J0717,HCPCS,,,,50474070062,NDC,0.5,EA,4911.87,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2485.40622,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.41,4813.6326
"Colonoscopy,Biopsy",PX45380P,CDM,983,RC,45380,CPT,,,,,,,,2539,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2488.22,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,122.59,2488.22
"Colonoscopy,Flex,Screen",PX2002F,CDM,750,RC,G0105,HCPCS,,,,,,,,2539,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2488.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,798.45,3885.86
"Upper GI Endoscopy,Diagnosis",PX43235F,CDM,750,RC,43235,CPT,,,,,,,,2539,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2488.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,3859.68
Lap Sleeve Gastrectomy,PX43775,CDM,982,RC,43775,CPT,,,,,,,,5030,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2489.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,674.85,4895.699
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270004,NDC,100,ML,2827.78,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2494.10196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 10 GM/100ML Solution 100 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270005,NDC,100,ML,2827.78,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2494.10196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270007,NDC,100,ML,2827.78,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2494.10196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270013,NDC,100,ML,2827.78,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2494.10196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
CT Angio Abdominal Arteries,PX7563501,CDM,350,RC,75635,CPT,TC,,,,,,,2936,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2495.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,2877.28
Targeted Genomic Sequence Analysis Panel 5-50 Genes - Ref,PX8145090,CDM,300,RC,81450,CPT,90,,,,,,,2936,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2495.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,696.41,2877.28
PACLitaxel protein-bound particle 100 MG Recon Susp 1 Each Vial,J9264.01,CDM,636,RC,J9264,HCPCS,,,,68817013450,NDC,1,EA,2564.76,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,12.7711,percent of total billed charges,2496.280908,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.1,2513.4648
bendamustine 100 MG/4ML Solution 4 mL Vial,800000,CDM,,,J9034,HCPCS,,,,63459034804,NDC,4,ML,5046.55,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2498.04225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
CT Pelvis W/O Dye,PX7219201,CDM,350,RC,72192,CPT,TC,,,,,,,2744,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2499.784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2689.12
"Freeing Bowel Adhesion,Enterolysis",PX44005F,CDM,360,RC,44005,CPT,,,,,,,,2744,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2499.784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,677.12,2689.12
APLIGRAF LIVING BI-LAYERED SKIN SUBSTITUTE,120.514,CDM,278,RC,Q4101,HCPCS,,12082-MAIN,LOCAL,,,,,2569,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2500.4077,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1067.1626,2517.62
"Cystourethroscopy, With Injection(S) for Chemodenervation of the Bladder",PX52287F,CDM,360,RC,52287,CPT,,,,,,,,2745,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2500.695,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1140.273,2690.1
GRAFIXPL PRIME PLACENTAL MEMBRANE 5x5CM 25SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12768-MAIN,LOCAL,,,,,5211,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2501.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
GRAFIXPL PRIME PLACENTAL MEMBRANE 5x5CM 25SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12768-MAIN,LOCAL,,,,,5211,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2501.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
Low Dose CT Lung Ca Screening,PXG029701,CDM,350,RC,G0297,HCPCS,TC,,,,,,,2812,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2502.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1168.1048,2755.76
CT Abdomen W/O Dye,PX7415001,CDM,350,RC,74150,CPT,TC,,,,,,,2757,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2511.627,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Angio Abd&Pelv W/O&W/Dye,PX7417401,CDM,350,RC,74174,CPT,TC,,,,,,,2757,,Medica,Commercial,both,91.1,,451.4,percent of total billed charges,2511.627,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2701.86
CT Chest Spine W/O Dye,PX7212801,CDM,350,RC,72128,CPT,TC,,,,,,,2757,,Medica,Commercial,both,91.1,,1494.62,percent of total billed charges,2511.627,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Head/Brain W/O Dye,PX7045001,CDM,350,RC,70450,CPT,TC,,,,,,,2757,,Medica,Commercial,both,91.1,,641.21625,percent of total billed charges,2511.627,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Lower Extremity W/O Dye,PX7370001,CDM,350,RC,73700,CPT,TC,,,,,,,2757,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2511.627,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Lumbar Spine W/O Dye,PX7213101,CDM,350,RC,72131,CPT,TC,,,,,,,2757,,Medica,Commercial,both,91.1,,1439.23,percent of total billed charges,2511.627,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Maxillofacialw/O Dye,PX7048601,CDM,350,RC,70486,CPT,TC,,,,,,,2757,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2511.627,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Neck Spine W/O Dye,PX7212501,CDM,350,RC,72125,CPT,TC,,,,,,,2757,,Medica,Commercial,both,91.1,,647.75625,percent of total billed charges,2511.627,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Orbit/Ear/Fosa W/O Dye,PX7048001,CDM,350,RC,70480,CPT,TC,,,,,,,2757,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2511.627,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Upper Extremity W/Dye,PX7320101,CDM,350,RC,73201,CPT,TC,,,,,,,2757,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2511.627,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2701.86
CT Upper Extremity W/O Dye,PX7320001,CDM,350,RC,73200,CPT,TC,,,,,,,2757,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2511.627,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
Diagnostic CT Thorax W/O Contrast,PX7125001,CDM,350,RC,71250,CPT,TC,,,,,,,2757,,Medica,Commercial,both,91.1,,2000.164444,percent of total billed charges,2511.627,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
RESTRATA WOUND MATRIX 5.0CM X 5.0CM TOTAL 25CM,27200000,CDM,272,RC,A2007,HCPCS,,11736-MAIN,LOCAL,,,,,5236,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2513.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RESTRATA WOUND MATRIX 5.0CM X 5.0CM TOTAL 25CM,27200000,CDM,272,RC,A2007,HCPCS,,11736-MAIN,LOCAL,,,,,5236,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2513.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PACLitaxel protein-bound particle 100 MG Recon Susp 1 Each Vial,J9264.01,CDM,636,RC,J9264,HCPCS,,,,68817013450,NDC,1,EA,2564.76,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2513.4648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,13.1,2513.4648
hepatitis B immune globulin 312 UNIT/ML Solution 5 mL Vial,90371,CDM,636,RC,90371,CPT,,,,59730420301,NDC,5,ML,2851.63,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2515.13766,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.6,2794.5974
MRI L Spine W Contrast Tc,PX7214901,CDM,610,RC,72149,CPT,TC,,,,,,,5136,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2516.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,5033.28
MRI L Spine W Contrast Tc,PX7214901,CDM,610,RC,72149,CPT,TC,,,,,,,5136,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2516.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,5033.28
MRI L Spine W Contrast Tc,PX7214901,CDM,610,RC,72149,CPT,TC,,,,,,,5136,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2516.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,5033.28
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270004,NDC,100,ML,2827.78,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2516.7242,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 10 GM/100ML Solution 100 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270005,NDC,100,ML,2827.78,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2516.7242,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270007,NDC,100,ML,2827.78,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2516.7242,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270013,NDC,100,ML,2827.78,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2516.7242,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
APLIGRAF LIVING BI-LAYERED SKIN SUBSTITUTE,120.514,CDM,278,RC,Q4101,HCPCS,,12082-MAIN,LOCAL,,,,,2569,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2517.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1067.1626,2517.62
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,62935022305,NDC,1,EA,2764.34,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2518.31374,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
MINIBUNION 3.5 OFFSET PLATE SHORT,27200000,CDM,278,RC,C1713,HCPCS,,11667-MAIN,LOCAL,,,,,5142.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,2519.825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MINIBUNION 3.5 OFFSET PLATE SHORT,27200000,CDM,278,RC,C1713,HCPCS,,11667-MAIN,LOCAL,,,,,5142.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2519.825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MINIBUNION 3.5 OFFSET PLATE SHORT,27200000,CDM,278,RC,C1713,HCPCS,,11667-MAIN,LOCAL,,,,,5142.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2519.825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
IMPLANT PACKAGE TOEMATE,27200000,CDM,278,RC,C1713,HCPCS,,11859-MAIN,LOCAL,,,,,2865,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2526.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
IMPLANT TOEMATE X-SMALL PACKAGE 9H00-T050,C1713,CDM,278,RC,C1713,HCPCS,,11574-MAIN,LOCAL,,,,,2865,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2526.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Hepatobiliary System Imaging,PX7822601,CDM,341,RC,78226,CPT,TC,,,,,,,2776,,Medica,Commercial,both,91.1,,788.57,percent of total billed charges,2528.936,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,360.31,2720.48
Or Level 5,PX36000005,CDM,360,RC,,,,,,,,,,5898,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2530.242,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2450.0292,5780.04
fomepizole 1 GM/ML Solution 1.5 mL Vial,J1451.01,CDM,636,RC,J1451,HCPCS,,,,39822071001,NDC,1.5,ML,2600,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2530.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.14,2548
hyaluronate 48 MG/6ML solution prefilled syringe 6 mL Syringe,J7325.01,CDM,636,RC,J7325,HCPCS,,,,58468009003,NDC,6,ML,5274.4,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2531.712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.36,5168.912
hyaluronate 48 MG/6ML solution prefilled syringe 6 mL Syringe,J7325.01,CDM,636,RC,J7325,HCPCS,,,,58468009003,NDC,6,ML,5274.4,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2531.712,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.36,5168.912
Amputation Finger/Thumb,PX26951P,CDM,983,RC,26951,CPT,,,,,,,,2603,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2533.4999,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1081.2862,2827.75
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561F,CDM,510,RC,36561,CPT,,,,,,,,2604,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2534.4732,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1081.7016,2784.63
"Cytogen, Interp/Report - Ref",PX8829190,CDM,310,RC,88291,CPT,90,,,,,,,2874,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2534.868,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.95,2816.52
"Initial Repair of Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49593P,CDM,982,RC,49593,CPT,,,,,,,,2606,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2536.4198,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1082.5324,3022.41
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING 8X10 ELLIPSE,C1781,CDM,278,RC,C1781,HCPCS,,12504-MAIN,LOCAL,,,,,5915,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2537.535,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
hepatitis B immune globulin 312 UNIT/ML Solution 5 mL Vial,90371,CDM,636,RC,90371,CPT,,,,59730420301,NDC,5,ML,2851.63,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2537.9507,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.6,2794.5974
carfilzomib 30 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010201,NDC,1,EA,2785.91,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2537.96401,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.23,5460.3836
"Remv F.B.,Eye,Ant Chmbr/Lens",PX65235F,CDM,510,RC,65235,CPT,,,,,,,,2788,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2539.868,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1158.1352,2732.24
cycloPHOSphamide 2 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,10019095701,NDC,1,EA,2988.6,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2540.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
MRI L Spine W Contrast Tc,PX7214901,CDM,610,RC,72149,CPT,TC,,,,,,,5136,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2542.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,5033.28
Level 5 Additional Procedure,PX36000084,CDM,360,RC,,,,,,,,,,5300,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2201.62,5194
Level 5 Additional Procedure,PX36000084,CDM,360,RC,,,,,,,,,,5300,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2201.62,5194
"Up GI Endoscopy,Ball Dil,30mm",PX43249F,CDM,750,RC,43249,CPT,,,,,,,,2596,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2544.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,958.1,3257.54
Lap Sleeve Gastrectomy,PX43775,CDM,982,RC,43775,CPT,,,,,,,,5030,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2545.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,674.85,4895.699
MINIBUNION 3.5 OFFSET PLATE SHORT,27200000,CDM,278,RC,C1713,HCPCS,,11667-MAIN,LOCAL,,,,,5142.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2545.5375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535P,CDM,983,RC,24535,CPT,,,,,,,,2887,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2546.334,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1199.2598,2809.9171
fomepizole 1 GM/ML Solution 1.5 mL Vial,J1451.01,CDM,636,RC,J1451,HCPCS,,,,39822071001,NDC,1.5,ML,2600,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,6.14,2548
IMPLANT PACKAGE TOEMATE,27200000,CDM,278,RC,C1713,HCPCS,,11859-MAIN,LOCAL,,,,,2865,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2549.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
IMPLANT TOEMATE X-SMALL PACKAGE 9H00-T050,C1713,CDM,278,RC,C1713,HCPCS,,11574-MAIN,LOCAL,,,,,2865,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2549.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Amputation Finger/Thumb,PX26951P,CDM,983,RC,26951,CPT,,,,,,,,2603,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2550.94,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,454.41,2550.94
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561F,CDM,510,RC,36561,CPT,,,,,,,,2604,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2551.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1081.7016,2784.63
Lap Paraesophag Hern Repair,PX43281,CDM,982,RC,43281,CPT,,,,,,,,5950,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2552.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2471.63,8992.74
GRAFIXPL PRIME PLACENTAL MEMBRANE 5x5CM 25SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12768-MAIN,LOCAL,,,,,5211,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2553.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
GRAFIXPL PRIME PLACENTAL MEMBRANE 5x5CM 25SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12768-MAIN,LOCAL,,,,,5211,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2553.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
GRAFIXPL PRIME PLACENTAL MEMBRANE 5x5CM 25SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12768-MAIN,LOCAL,,,,,5211,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2553.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
bendamustine 100 MG/4ML Solution 4 mL Vial,800000,CDM,,,J9034,HCPCS,,,,63459034804,NDC,4,ML,5046.55,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2553.5543,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
"Initial Repair of Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49593P,CDM,982,RC,49593,CPT,,,,,,,,2606,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2553.88,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,337.26,2553.88
"Cytogen, Interp/Report - Ref",PX8829190,CDM,310,RC,88291,CPT,90,,,,,,,2874,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2557.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.95,2816.52
DOCEtaxel 160 MG/16ML Solution 16 mL Vial,J9171.01,CDM,636,RC,J9171,HCPCS,,,,409173201,NDC,16,ML,2901.69,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2559.29058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1205.362026,2843.6562
Low Dose CT Lung Ca Screening,PXG029701,CDM,350,RC,G0297,HCPCS,TC,,,,,,,2812,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2561.732,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1168.1048,2755.76
"Repair of Recurrent Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49615F,CDM,360,RC,49615,CPT,,,,,,,,2908,,United Healthcare,All Payer,outpatient,88.2,,999999999,case rate,2564.856,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2564.856,6141.46
RESTRATA WOUND MATRIX 5.0CM X 5.0CM TOTAL 25CM,27200000,CDM,272,RC,A2007,HCPCS,,11736-MAIN,LOCAL,,,,,5236,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2565.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RESTRATA WOUND MATRIX 5.0CM X 5.0CM TOTAL 25CM,27200000,CDM,272,RC,A2007,HCPCS,,11736-MAIN,LOCAL,,,,,5236,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2565.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RESTRATA WOUND MATRIX 5.0CM X 5.0CM TOTAL 25CM,27200000,CDM,272,RC,A2007,HCPCS,,11736-MAIN,LOCAL,,,,,5236,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2565.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270006,NDC,100,ML,2912.78,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2569.07196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535P,CDM,983,RC,24535,CPT,,,,,,,,2887,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2569.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1199.2598,2809.9171
Injection for Nerve Block,PX64447F,CDM,510,RC,64447,CPT,,,,,,,,3023,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2569.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,604.15,2962.54
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270004,NDC,100,ML,2827.78,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2576.10758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 10 GM/100ML Solution 100 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270005,NDC,100,ML,2827.78,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2576.10758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270007,NDC,100,ML,2827.78,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2576.10758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270013,NDC,100,ML,2827.78,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2576.10758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
GRAFIXPL PRIME PLACENTAL MEMBRANE 5x5CM 25SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12768-MAIN,LOCAL,,,,,5211,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2579.445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
MTP PLATE STANDARD 18MM CLIP 5 DEG DORSIFLEXION,27200000,CDM,278,RC,C1713,HCPCS,,11854-MAIN,LOCAL,,,,,5376,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2580.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MTP PLATE STANDARD 18MM CLIP 5 DEG DORSIFLEXION,27200000,CDM,278,RC,C1713,HCPCS,,11854-MAIN,LOCAL,,,,,5376,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2580.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DOCEtaxel 160 MG/16ML Solution 16 mL Vial,J9171.01,CDM,636,RC,J9171,HCPCS,,,,409173201,NDC,16,ML,2901.69,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2582.5041,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1205.362026,2843.6562
RESTRATA WOUND MATRIX 2.5CM X 5CM TOTAL 12.5CM,27200000,CDM,272,RC,A2007,HCPCS,,11734-MAIN,LOCAL,,,,,3039,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2583.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MRI Brain W Contrast Tc,PX7055201,CDM,610,RC,70552,CPT,TC,,,,,,,2637,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2584.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2584.26
hyaluronate 48 MG/6ML solution prefilled syringe 6 mL Syringe,J7325.01,CDM,636,RC,J7325,HCPCS,,,,58468009003,NDC,6,ML,5274.4,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2584.456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.36,5168.912
hyaluronate 48 MG/6ML solution prefilled syringe 6 mL Syringe,J7325.01,CDM,636,RC,J7325,HCPCS,,,,58468009003,NDC,6,ML,5274.4,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2584.456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.36,5168.912
hyaluronate 48 MG/6ML solution prefilled syringe 6 mL Syringe,J7325.01,CDM,636,RC,J7325,HCPCS,,,,58468009003,NDC,6,ML,5274.4,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2584.456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.36,5168.912
"Repair of Recurrent Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49615F,CDM,360,RC,49615,CPT,,,,,,,,2908,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2588.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1207.9832,3022.41
CT Angio Abdominal Arteries,PX7563501,CDM,350,RC,75635,CPT,TC,,,,,,,2936,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2589.552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,2877.28
Targeted Genomic Sequence Analysis Panel 5-50 Genes - Ref,PX8145090,CDM,300,RC,81450,CPT,90,,,,,,,2936,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2589.552,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,696.41,2877.28
RESTRATA WOUND MATRIX 5.0CM X 5.0CM TOTAL 25CM,27200000,CDM,272,RC,A2007,HCPCS,,11736-MAIN,LOCAL,,,,,5236,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2591.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270006,NDC,100,ML,2912.78,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2592.3742,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
Level 5 Additional Procedure,PX36000084,CDM,360,RC,,,,,,,,,,5300,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2597,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2201.62,5194
Level 5 Additional Procedure,PX36000084,CDM,360,RC,,,,,,,,,,5300,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2597,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2201.62,5194
Level 5 Additional Procedure,PX36000084,CDM,360,RC,,,,,,,,,,5300,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2597,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2201.62,5194
hepatitis B immune globulin 312 UNIT/ML Solution 5 mL Vial,90371,CDM,636,RC,90371,CPT,,,,59730420301,NDC,5,ML,2851.63,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2597.83493,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.6,2794.5974
POLYAXIAL LOCKING PLATE MTP CROSS PLATE LEFT T8,C1713,CDM,278,RC,C1713,HCPCS,,12635-MAIN,LOCAL,,,,,5413,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2598.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
POLYAXIAL LOCKING PLATE MTP CROSS PLATE LEFT T8,C1713,CDM,278,RC,C1713,HCPCS,,12635-MAIN,LOCAL,,,,,5413,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2598.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
POLYAXIAL LOCKING PLATE MTP CROSS PLATE RIGHT T8,C1713,CDM,278,RC,C1713,HCPCS,,12756-MAIN,LOCAL,,,,,5413,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2598.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
POLYAXIAL LOCKING PLATE MTP CROSS PLATE RIGHT T8,C1713,CDM,278,RC,C1713,HCPCS,,12756-MAIN,LOCAL,,,,,5413,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2598.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
MRI L Spine W Contrast Tc,PX7214901,CDM,610,RC,72149,CPT,TC,,,,,,,5136,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2598.816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,5033.28
MRI Abdomen W/O Tc,PX7418101,CDM,610,RC,74181,CPT,TC,,,,,,,2655,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2601.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,2601.9
MINIBUNION 3.5 OFFSET PLATE SHORT,27200000,CDM,278,RC,C1713,HCPCS,,11667-MAIN,LOCAL,,,,,5142.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2602.105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
nivolumab 100 MG/10ML Solution 10 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377412,NDC,10,ML,5429.27,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2606.0496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.5,12769.6548
nivolumab 100 MG/10ML Solution 10 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377412,NDC,10,ML,5429.27,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2606.0496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.5,12769.6548
IMPLANT PACKAGE TOEMATE,27200000,CDM,278,RC,C1713,HCPCS,,11859-MAIN,LOCAL,,,,,2865,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2610.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
IMPLANT TOEMATE X-SMALL PACKAGE 9H00-T050,C1713,CDM,278,RC,C1713,HCPCS,,11574-MAIN,LOCAL,,,,,2865,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2610.015,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
hyaluronate 48 MG/6ML solution prefilled syringe 6 mL Syringe,J7325.01,CDM,636,RC,J7325,HCPCS,,,,58468009003,NDC,6,ML,5274.4,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2610.828,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.36,5168.912
CT Angio Abdominal Arteries,PX7563501,CDM,350,RC,75635,CPT,TC,,,,,,,2936,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2613.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,2877.28
Targeted Genomic Sequence Analysis Panel 5-50 Genes - Ref,PX8145090,CDM,300,RC,81450,CPT,90,,,,,,,2936,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2613.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,696.41,2877.28
"Cytogen, Interp/Report - Ref",PX8829190,CDM,310,RC,88291,CPT,90,,,,,,,2874,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2618.214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.95,2816.52
RESTRATA WOUND MATRIX 7.5CM X 7.5CM TOTAL 56.25CM,27200000,CDM,272,RC,A2007,HCPCS,,11737-MAIN,LOCAL,,,,,6311,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2621.5894,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HIMAX PLUS 18X18X18,27200000,CDM,278,RC,C1713,HCPCS,,11660-MAIN,LOCAL,,,,,3085.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2622.675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HIMAX PLUS 20X20X20,27200000,CDM,278,RC,C1713,HCPCS,,11661-MAIN,LOCAL,,,,,3085.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2622.675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Closed Rx Weight Bear Dist Tib,Manip",PX27825F,CDM,510,RC,27825,CPT,,,,,,,,2695,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2623.0435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1119.503,2641.1
Level 5 Additional Procedure,PX36000084,CDM,360,RC,,,,,,,,,,5300,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2623.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2201.62,5194
"MRI,Uprext Jnt W/O+W/Cont",PX7322301,CDM,610,RC,73223,CPT,TC,,,,,,,2681,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2627.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2627.38
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535P,CDM,983,RC,24535,CPT,,,,,,,,2887,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2630.057,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1199.2598,2809.9171
trastuzumab-dttb 150 MG Recon Soln 1 Each Vial,J9999.55,CDM,636,RC,J9999,HCPCS,,,,78206014701,NDC,1,EA,2702.3,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2630.14859,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1122.53542,2648.254
MTP PLATE STANDARD 18MM CLIP 5 DEG DORSIFLEXION,27200000,CDM,278,RC,C1713,HCPCS,,11854-MAIN,LOCAL,,,,,5376,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,2634.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MTP PLATE STANDARD 18MM CLIP 5 DEG DORSIFLEXION,27200000,CDM,278,RC,C1713,HCPCS,,11854-MAIN,LOCAL,,,,,5376,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2634.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MTP PLATE STANDARD 18MM CLIP 5 DEG DORSIFLEXION,27200000,CDM,278,RC,C1713,HCPCS,,11854-MAIN,LOCAL,,,,,5376,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2634.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
cycloPHOSphamide 2 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,10019095701,NDC,1,EA,2988.6,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2635.9452,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
CT Lower Extremity W/Dye,PX7370101,CDM,350,RC,73701,CPT,TC,,,,,,,2690,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2636.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,2636.2
GRAFIXPL PRIME PLACENTAL MEMBRANE 5x5CM 25SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12768-MAIN,LOCAL,,,,,5211,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2636.766,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
"Closed Rx Weight Bear Dist Tib,Manip",PX27825F,CDM,510,RC,27825,CPT,,,,,,,,2695,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2641.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1119.503,2641.1
degarelix acetate 40 mg/mL Recon Soln 1 Each Vial,J9155.01,CDM,636,RC,J9155,HCPCS,,,,55566840301,NDC,2,EA,3109.33,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2642.9305,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.83,3047.1434
DOCEtaxel 160 MG/16ML Solution 16 mL Vial,J9171.01,CDM,636,RC,J9171,HCPCS,,,,409173201,NDC,16,ML,2901.69,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2643.43959,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1205.362026,2843.6562
trastuzumab-dttb 150 MG Recon Soln 1 Each Vial,J9999.55,CDM,636,RC,J9999,HCPCS,,,,78206014701,NDC,1,EA,2702.3,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2648.254,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1122.53542,2648.254
"Repair of Recurrent Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49615F,CDM,360,RC,49615,CPT,,,,,,,,2908,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2649.188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1207.9832,3022.41
RESTRATA WOUND MATRIX 5.0CM X 5.0CM TOTAL 25CM,27200000,CDM,272,RC,A2007,HCPCS,,11736-MAIN,LOCAL,,,,,5236,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2649.416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
POLYAXIAL LOCKING PLATE MTP CROSS PLATE LEFT T8,C1713,CDM,278,RC,C1713,HCPCS,,12635-MAIN,LOCAL,,,,,5413,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,2652.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
POLYAXIAL LOCKING PLATE MTP CROSS PLATE LEFT T8,C1713,CDM,278,RC,C1713,HCPCS,,12635-MAIN,LOCAL,,,,,5413,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2652.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
POLYAXIAL LOCKING PLATE MTP CROSS PLATE LEFT T8,C1713,CDM,278,RC,C1713,HCPCS,,12635-MAIN,LOCAL,,,,,5413,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2652.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
POLYAXIAL LOCKING PLATE MTP CROSS PLATE RIGHT T8,C1713,CDM,278,RC,C1713,HCPCS,,12756-MAIN,LOCAL,,,,,5413,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,1899.402,percent of total billed charges,2652.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
POLYAXIAL LOCKING PLATE MTP CROSS PLATE RIGHT T8,C1713,CDM,278,RC,C1713,HCPCS,,12756-MAIN,LOCAL,,,,,5413,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2652.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
POLYAXIAL LOCKING PLATE MTP CROSS PLATE RIGHT T8,C1713,CDM,278,RC,C1713,HCPCS,,12756-MAIN,LOCAL,,,,,5413,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2652.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270006,NDC,100,ML,2912.78,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2653.54258,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
Exc Abd Les Sc < 3 Cm,PX22902F,CDM,761,RC,22902,CPT,,,,,,,,3128,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2658.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1299.3712,3065.44
cycloPHOSphamide 2 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,10019095701,NDC,1,EA,2988.6,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2659.854,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
nivolumab 100 MG/10ML Solution 10 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377412,NDC,10,ML,5429.27,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2660.3423,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.5,12769.6548
nivolumab 100 MG/10ML Solution 10 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377412,NDC,10,ML,5429.27,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2660.3423,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.5,12769.6548
nivolumab 100 MG/10ML Solution 10 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377412,NDC,10,ML,5429.27,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2660.3423,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.5,12769.6548
MTP PLATE STANDARD 18MM CLIP 5 DEG DORSIFLEXION,27200000,CDM,278,RC,C1713,HCPCS,,11854-MAIN,LOCAL,,,,,5376,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2661.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Injection for Nerve Block,PX64447F,CDM,510,RC,64447,CPT,,,,,,,,3023,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2666.286,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,604.15,2962.54
hyaluronate 48 MG/6ML solution prefilled syringe 6 mL Syringe,J7325.01,CDM,636,RC,J7325,HCPCS,,,,58468009003,NDC,6,ML,5274.4,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2668.8464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.36,5168.912
"Chrom Anal, 20-25 Cells - Ref",PX8826490,CDM,310,RC,88264,CPT,90,,,,,,,3141,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2669.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.59,3078.18
"Tiss Cult, Neopl, Bm, Wb - Ref",PX8823790,CDM,310,RC,88237,CPT,90,,,,,,,3141,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2669.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,131.8,3078.18
"Freeing Bowel Adhesion,Enterolysis",PX44005F,CDM,360,RC,44005,CPT,,,,,,,,2744,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2670.7352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,677.12,2689.12
MRI Pelvis W/Contrast Tc,PX7219601,CDM,610,RC,72196,CPT,TC,,,,,,,3143,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2671.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3080.14
"Cystourethroscopy, With Injection(S) for Chemodenervation of the Bladder",PX52287F,CDM,360,RC,52287,CPT,,,,,,,,2745,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2671.7085,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1140.273,2690.1
carfilzomib 60 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010101,NDC,1,EA,5571.82,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2674.4736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.23,5460.3836
carfilzomib 60 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010101,NDC,1,EA,5571.82,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2674.4736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.23,5460.3836
CT Angio Abdominal Arteries,PX7563501,CDM,350,RC,75635,CPT,TC,,,,,,,2936,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2674.696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,2877.28
Targeted Genomic Sequence Analysis Panel 5-50 Genes - Ref,PX8145090,CDM,300,RC,81450,CPT,90,,,,,,,2936,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2674.696,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,696.41,2877.28
POLYAXIAL LOCKING PLATE MTP CROSS PLATE LEFT T8,C1713,CDM,278,RC,C1713,HCPCS,,12635-MAIN,LOCAL,,,,,5413,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2679.435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
POLYAXIAL LOCKING PLATE MTP CROSS PLATE RIGHT T8,C1713,CDM,278,RC,C1713,HCPCS,,12756-MAIN,LOCAL,,,,,5413,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2679.435,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
RESTRATA WOUND MATRIX 2.5CM X 5CM TOTAL 12.5CM,27200000,CDM,272,RC,A2007,HCPCS,,11734-MAIN,LOCAL,,,,,3039,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2680.398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Level 5 Additional Procedure,PX36000084,CDM,360,RC,,,,,,,,,,5300,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2681.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2201.62,5194
"VENTRALIGHT MESH ST WITH ECHO 2 - 20 CM X 25 CM 8"" X 10""",C1781,CDM,278,RC,C1781,HCPCS,,12009-MAIN,LOCAL,,,,,5589,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2682.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"VENTRALIGHT MESH ST WITH ECHO 2 - 20 CM X 25 CM 8"" X 10""",C1781,CDM,278,RC,C1781,HCPCS,,12009-MAIN,LOCAL,,,,,5589,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2682.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
darbepoetin alfa 200 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002801,NDC,0.4,ML,3157.92,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2684.232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
nivolumab 100 MG/10ML Solution 10 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377412,NDC,10,ML,5429.27,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2687.48865,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.5,12769.6548
CT Pelvis W/O Dye,PX7219201,CDM,350,RC,72192,CPT,TC,,,,,,,2744,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2689.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2689.12
"Freeing Bowel Adhesion,Enterolysis",PX44005F,CDM,360,RC,44005,CPT,,,,,,,,2744,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2689.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,677.12,2689.12
"Cystourethroscopy, With Injection(S) for Chemodenervation of the Bladder",PX52287F,CDM,360,RC,52287,CPT,,,,,,,,2745,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2690.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1140.273,2690.1
Injection for Nerve Block,PX64447F,CDM,510,RC,64447,CPT,,,,,,,,3023,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2690.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,604.15,2962.54
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,62935022305,NDC,1,EA,2764.34,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2690.532122,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
MRI Lower W/O+W Tc,PX7372001,CDM,610,RC,73720,CPT,TC,,,,,,,3174,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2697.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3110.52
Level 6 Additional Procedure,PX36000085,CDM,360,RC,,,,,,,,,,6500,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2700.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2700.1,6370
CT Abdomen W/O Dye,PX7415001,CDM,350,RC,74150,CPT,TC,,,,,,,2757,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2701.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Angio Abd&Pelv W/O&W/Dye,PX7417401,CDM,350,RC,74174,CPT,TC,,,,,,,2757,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2701.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2701.86
CT Chest Spine W/O Dye,PX7212801,CDM,350,RC,72128,CPT,TC,,,,,,,2757,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2701.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Head/Brain W/O Dye,PX7045001,CDM,350,RC,70450,CPT,TC,,,,,,,2757,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2701.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Lower Extremity W/O Dye,PX7370001,CDM,350,RC,73700,CPT,TC,,,,,,,2757,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2701.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Lumbar Spine W/O Dye,PX7213101,CDM,350,RC,72131,CPT,TC,,,,,,,2757,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2701.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Maxillofacialw/O Dye,PX7048601,CDM,350,RC,70486,CPT,TC,,,,,,,2757,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2701.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Neck Spine W/O Dye,PX7212501,CDM,350,RC,72125,CPT,TC,,,,,,,2757,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2701.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Orbit/Ear/Fosa W/O Dye,PX7048001,CDM,350,RC,70480,CPT,TC,,,,,,,2757,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2701.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
CT Upper Extremity W/Dye,PX7320101,CDM,350,RC,73201,CPT,TC,,,,,,,2757,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2701.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,2701.86
CT Upper Extremity W/O Dye,PX7320001,CDM,350,RC,73200,CPT,TC,,,,,,,2757,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2701.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
Diagnostic CT Thorax W/O Contrast,PX7125001,CDM,350,RC,71250,CPT,TC,,,,,,,2757,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2701.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,96.05,2701.86
Hepatobiliary System Imaging,PX7822601,CDM,341,RC,78226,CPT,TC,,,,,,,2776,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2701.8808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,360.31,2720.48
trastuzumab 150 MG Recon Soln 1 Each Vial,J9355.01,CDM,636,RC,J9355,HCPCS,,,,50242013201,NDC,1,EA,3179.17,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2702.2945,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.77,3115.5866
RESTRATA WOUND MATRIX 2.5CM X 5CM TOTAL 12.5CM,27200000,CDM,272,RC,A2007,HCPCS,,11734-MAIN,LOCAL,,,,,3039,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2704.71,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RESTRATA WOUND MATRIX 7.5CM X 7.5CM TOTAL 56.25CM,27200000,CDM,272,RC,A2007,HCPCS,,11737-MAIN,LOCAL,,,,,6311,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2707.419,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,62935022305,NDC,1,EA,2764.34,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2709.0532,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
carfilzomib 30 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010201,NDC,1,EA,2785.91,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2711.526203,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.23,5460.3836
"Remv F.B.,Eye,Ant Chmbr/Lens",PX65235F,CDM,510,RC,65235,CPT,,,,,,,,2788,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2713.5604,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1158.1352,2732.24
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218710,NDC,2,EA,5662.72,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2718.1056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.57,6737.8528
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218710,NDC,2,EA,5662.72,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2718.1056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.57,6737.8528
Level 4 Additional Procedure,PX36000083,CDM,360,RC,,,,,,,,,,3200,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2720,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1329.28,3136
MTP PLATE STANDARD 18MM CLIP 5 DEG DORSIFLEXION,27200000,CDM,278,RC,C1713,HCPCS,,11854-MAIN,LOCAL,,,,,5376,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2720.256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Hepatobiliary System Imaging,PX7822601,CDM,341,RC,78226,CPT,TC,,,,,,,2776,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2720.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,360.31,2720.48
HIMAX PLUS 18X18X18,27200000,CDM,278,RC,C1713,HCPCS,,11660-MAIN,LOCAL,,,,,3085.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2721.411,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HIMAX PLUS 20X20X20,27200000,CDM,278,RC,C1713,HCPCS,,11661-MAIN,LOCAL,,,,,3085.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2721.411,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
cycloPHOSphamide 2 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,10019095701,NDC,1,EA,2988.6,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2722.6146,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
PURAPLYAM XT-COM 4.91X4.91 EXTRA FENESTRATED 24.10 SQCM,120.567,CDM,272,RC,Q4197,HCPCS,,12806-MAIN,LOCAL,,,,,6562,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2725.8548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2725.8548,6430.76
carfilzomib 30 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010201,NDC,1,EA,2785.91,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2730.1918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.23,5460.3836
carfilzomib 60 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010101,NDC,1,EA,5571.82,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,18.57291429,percent of total billed charges,2730.1918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.23,5460.3836
carfilzomib 60 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010101,NDC,1,EA,5571.82,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2730.1918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.23,5460.3836
carfilzomib 60 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010101,NDC,1,EA,5571.82,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2730.1918,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.23,5460.3836
Repair of Vagina,PX57200P,CDM,983,RC,57200,CPT,,,,,,,,1043,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2731.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,433.2622,2731.23
"Remv F.B.,Eye,Ant Chmbr/Lens",PX65235F,CDM,510,RC,65235,CPT,,,,,,,,2788,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2732.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1158.1352,2732.24
Low Dose CT Lung Ca Screening,PXG029701,CDM,350,RC,G0297,HCPCS,TC,,,,,,,2812,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2736.9196,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1168.1048,2755.76
"VENTRALIGHT MESH ST WITH ECHO 2 - 20 CM X 25 CM 8"" X 10""",C1781,CDM,278,RC,C1781,HCPCS,,12009-MAIN,LOCAL,,,,,5589,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,196.035,percent of total billed charges,2738.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"VENTRALIGHT MESH ST WITH ECHO 2 - 20 CM X 25 CM 8"" X 10""",C1781,CDM,278,RC,C1781,HCPCS,,12009-MAIN,LOCAL,,,,,5589,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2738.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"VENTRALIGHT MESH ST WITH ECHO 2 - 20 CM X 25 CM 8"" X 10""",C1781,CDM,278,RC,C1781,HCPCS,,12009-MAIN,LOCAL,,,,,5589,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2738.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
POLYAXIAL LOCKING PLATE MTP CROSS PLATE LEFT T8,C1713,CDM,278,RC,C1713,HCPCS,,12635-MAIN,LOCAL,,,,,5413,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2738.978,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
POLYAXIAL LOCKING PLATE MTP CROSS PLATE RIGHT T8,C1713,CDM,278,RC,C1713,HCPCS,,12756-MAIN,LOCAL,,,,,5413,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2738.978,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
REVITA PLACENTAL MEMBRANE 4X4CM 16SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12560-MAIN,LOCAL,,,,,6597,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2740.3938,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
degarelix acetate 40 mg/mL Recon Soln 1 Each Vial,J9155.01,CDM,636,RC,J9155,HCPCS,,,,55566840301,NDC,2,EA,3109.33,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2742.42906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.83,3047.1434
"Colonoscopy,Transendoscopic Stent",PX45387F,CDM,750,RC,45387,CPT,,,,,,,,3228,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2743.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1340.9112,3163.44
HIMAX PLUS 18X18X18,27200000,CDM,278,RC,C1713,HCPCS,,11660-MAIN,LOCAL,,,,,3085.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2746.095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HIMAX PLUS 20X20X20,27200000,CDM,278,RC,C1713,HCPCS,,11661-MAIN,LOCAL,,,,,3085.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2746.095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
nivolumab 100 MG/10ML Solution 10 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377412,NDC,10,ML,5429.27,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2747.21062,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.5,12769.6548
Injection for Nerve Block,PX64447F,CDM,510,RC,64447,CPT,,,,,,,,3023,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2753.953,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,604.15,2962.54
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING 8 IN CIRCLE,C1781,CDM,278,RC,C1781,HCPCS,,12506-MAIN,LOCAL,,,,,3240,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2754,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Low Dose CT Lung Ca Screening,PXG029701,CDM,350,RC,G0297,HCPCS,TC,,,,,,,2812,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2755.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1168.1048,2755.76
carfilzomib 60 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010101,NDC,1,EA,5571.82,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2758.0509,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.23,5460.3836
Exc Abd Les Sc < 3 Cm,PX22902F,CDM,761,RC,22902,CPT,,,,,,,,3128,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2758.896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1299.3712,3065.44
Amputation Finger/Thumb,PX26951F,CDM,510,RC,26951,CPT,,,,,,,,3253,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2765.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1351.2962,3187.94
MRI Upper W/O+W Tc,PX7322001,CDM,610,RC,73220,CPT,TC,,,,,,,3253,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2765.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3187.94
"MRI,Lwrext,No Jnt,No Cont",PX7371801,CDM,610,RC,73718,CPT,TC,,,,,,,3253,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2765.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3187.94
"MRI,Pelvis W/Out Contrast",PX7219501,CDM,610,RC,72195,CPT,TC,,,,,,,3253,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2765.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3187.94
"MRI,Up Ext,No Jnt,No Cont",PX7321801,CDM,610,RC,73218,CPT,TC,,,,,,,3253,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2765.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3187.94
"VENTRALIGHT MESH ST WITH ECHO 2 - 20 CM X 25 CM 8"" X 10""",C1781,CDM,278,RC,C1781,HCPCS,,12009-MAIN,LOCAL,,,,,5589,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2766.555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
degarelix acetate 40 mg/mL Recon Soln 1 Each Vial,J9155.01,CDM,636,RC,J9155,HCPCS,,,,55566840301,NDC,2,EA,3109.33,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2767.3037,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.83,3047.1434
RESTRATA WOUND MATRIX 2.5CM X 5CM TOTAL 12.5CM,27200000,CDM,272,RC,A2007,HCPCS,,11734-MAIN,LOCAL,,,,,3039,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2768.529,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Chrom Anal, 20-25 Cells - Ref",PX8826490,CDM,310,RC,88264,CPT,90,,,,,,,3141,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2770.362,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.59,3078.18
"Tiss Cult, Neopl, Bm, Wb - Ref",PX8823790,CDM,310,RC,88237,CPT,90,,,,,,,3141,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2770.362,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,131.8,3078.18
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270004,NDC,100,ML,2827.78,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2771.2244,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 10 GM/100ML Solution 100 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270005,NDC,100,ML,2827.78,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2771.2244,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270007,NDC,100,ML,2827.78,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2771.2244,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270013,NDC,100,ML,2827.78,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2771.2244,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
MRI Pelvis W/Contrast Tc,PX7219601,CDM,610,RC,72196,CPT,TC,,,,,,,3143,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2772.126,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3080.14
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218710,NDC,2,EA,5662.72,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,51.4437,percent of total billed charges,2774.7328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.57,6737.8528
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218710,NDC,2,EA,5662.72,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2774.7328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.57,6737.8528
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218710,NDC,2,EA,5662.72,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2774.7328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.57,6737.8528
hepatitis B immune globulin 312 UNIT/ML Solution 5 mL Vial,90371,CDM,636,RC,90371,CPT,,,,59730420301,NDC,5,ML,2851.63,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2775.491479,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.6,2794.5974
MRI T Spine WO Contrast,PX7214601,CDM,610,RC,72146,CPT,TC,,,,,,,3267,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2776.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3201.66
bortezomib 3.5 MG Recon Soln 1 Each Vial,J9041.01,CDM,636,RC,J9041,HCPCS,,,,63020004901,NDC,1,EA,3270.12,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2779.602,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.79,3204.7176
Exc Abd Les Sc < 3 Cm,PX22902F,CDM,761,RC,22902,CPT,,,,,,,,3128,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2783.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1299.3712,3065.44
Insert Non-Tunnel Cv Catheter >5 Years,PX36556F,CDM,510,RC,36556,CPT,,,,,,,,1025,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2784.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,425.785,2784.63
Insert Non-Tunnel Cv Catheter >5 Years,PX36556P,CDM,983,RC,36556,CPT,,,,,,,,1274,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2784.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,529.2196,2784.63
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561F,CDM,510,RC,36561,CPT,,,,,,,,2604,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2784.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1081.7016,2784.63
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561P,CDM,983,RC,36561,CPT,,,,,,,,1736,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2784.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,721.1344,2784.63
darbepoetin alfa 200 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002801,NDC,0.4,ML,3157.92,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2785.28544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
Level 6 Additional Procedure,PX36000085,CDM,360,RC,,,,,,,,,,6500,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2788.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2700.1,6370
IMPLANT PACKAGE TOEMATE,27200000,CDM,278,RC,C1713,HCPCS,,11859-MAIN,LOCAL,,,,,2865,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2788.5045,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
IMPLANT TOEMATE X-SMALL PACKAGE 9H00-T050,C1713,CDM,278,RC,C1713,HCPCS,,11574-MAIN,LOCAL,,,,,2865,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2788.5045,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"Lap,Esophagogast Fundoplasty",PX43280F,CDM,510,RC,43280,CPT,,,,,,,,6713,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2788.5802,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2788.5802,8992.74
hepatitis B immune globulin 312 UNIT/ML Solution 5 mL Vial,90371,CDM,636,RC,90371,CPT,,,,59730420301,NDC,5,ML,2851.63,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2794.5974,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,109.6,2794.5974
"Chrom Anal, 20-25 Cells - Ref",PX8826490,CDM,310,RC,88264,CPT,90,,,,,,,3141,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2795.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.59,3078.18
"Tiss Cult, Neopl, Bm, Wb - Ref",PX8823790,CDM,310,RC,88237,CPT,90,,,,,,,3141,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2795.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,131.8,3078.18
"Cytogen, Interp/Report - Ref",PX8829190,CDM,310,RC,88291,CPT,90,,,,,,,2874,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2797.2642,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.95,2816.52
MRI Pelvis W/Contrast Tc,PX7219601,CDM,610,RC,72196,CPT,TC,,,,,,,3143,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2797.27,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3080.14
MRI Lower W/O+W Tc,PX7372001,CDM,610,RC,73720,CPT,TC,,,,,,,3174,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2799.468,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3110.52
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270012,NDC,100,ML,3293.58,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2799.543,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218710,NDC,2,EA,5662.72,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2803.0464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.57,6737.8528
trastuzumab 150 MG Recon Soln 1 Each Vial,J9355.01,CDM,636,RC,J9355,HCPCS,,,,50242013201,NDC,1,EA,3179.17,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2804.02794,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.77,3115.5866
IMPLANT PACKAGE TOEMATE,27200000,CDM,278,RC,C1713,HCPCS,,11859-MAIN,LOCAL,,,,,2865,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2807.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
IMPLANT TOEMATE X-SMALL PACKAGE 9H00-T050,C1713,CDM,278,RC,C1713,HCPCS,,11574-MAIN,LOCAL,,,,,2865,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2807.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535P,CDM,983,RC,24535,CPT,,,,,,,,2887,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2809.9171,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1199.2598,2809.9171
darbepoetin alfa 200 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002801,NDC,0.4,ML,3157.92,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2810.5488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
HIMAX PLUS 18X18X18,27200000,CDM,278,RC,C1713,HCPCS,,11660-MAIN,LOCAL,,,,,3085.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2810.8905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HIMAX PLUS 20X20X20,27200000,CDM,278,RC,C1713,HCPCS,,11661-MAIN,LOCAL,,,,,3085.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2810.8905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PURAPLYAM XT-COM 4.91X4.91 EXTRA FENESTRATED 24.10 SQCM,120.567,CDM,272,RC,Q4197,HCPCS,,12806-MAIN,LOCAL,,,,,6562,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2815.098,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2725.8548,6430.76
"Cytogen, Interp/Report - Ref",PX8829190,CDM,310,RC,88291,CPT,90,,,,,,,2874,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2816.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,29.95,2816.52
carfilzomib 60 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010101,NDC,1,EA,5571.82,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2819.34092,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.23,5460.3836
MRI Up Extremity Joint W/O Tc,PX7322101,CDM,610,RC,73221,CPT,TC,,,,,,,3319,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2821.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3252.62
Level 4 Additional Procedure,PX36000083,CDM,360,RC,,,,,,,,,,3200,,United Healthcare,All Payer,outpatient,88.2,,999999999,case rate,2822.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2822.4,6141.46
DOCEtaxel 160 MG/16ML Solution 16 mL Vial,J9171.01,CDM,636,RC,J9171,HCPCS,,,,409173201,NDC,16,ML,2901.69,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2824.214877,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1205.362026,2843.6562
MRI Lower W/O+W Tc,PX7372001,CDM,610,RC,73720,CPT,TC,,,,,,,3174,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2824.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3110.52
Amputation Finger/Thumb,PX26951F,CDM,510,RC,26951,CPT,,,,,,,,3253,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2827.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1351.2962,3187.94
Amputation Finger/Thumb,PX26951P,CDM,983,RC,26951,CPT,,,,,,,,2603,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2827.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1081.2862,2827.75
"Amputation Metatarsal+Toe,Single",PX28810F,CDM,510,RC,28810,CPT,,,,,,,,930,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2827.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,386.322,2827.75
"Amputation Metatarsal+Toe,Single",PX28810P,CDM,983,RC,28810,CPT,,,,,,,,620,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2827.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,257.548,2827.75
"Amputation Toe,I-P Jt",PX28825F,CDM,510,RC,28825,CPT,,,,,,,,1327,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2827.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,551.2358,2827.75
"Amputation Toe,I-P Jt",PX28825P,CDM,983,RC,28825,CPT,,,,,,,,780,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2827.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,324.012,2827.75
"Amputation Toe,Mt-P Jt",PX28820F,CDM,510,RC,28820,CPT,,,,,,,,1950,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2827.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,810.03,2827.75
"Amputation Toe,Mt-P Jt",PX28820P,CDM,983,RC,28820,CPT,,,,,,,,1300,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2827.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,540.02,2827.75
"Correct Bunion,Metatarsal Osteotomy",PX28296F,CDM,510,RC,28296,CPT,,,,,,,,8100,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2827.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2827.75,7938
"Correct Bunion,Metatarsal Osteotomy",PX28296P,CDM,983,RC,28296,CPT,,,,,,,,2150,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2827.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,893.11,2827.75
Explor Metatarso-Phalang Jt,PX28022F,CDM,510,RC,28022,CPT,,,,,,,,1161,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2827.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,482.2794,2827.75
Explor Metatarso-Phalang Jt,PX28022P,CDM,983,RC,28022,CPT,,,,,,,,774,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2827.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,321.5196,2827.75
Part Remv Phalanx of Toe,PX28124F,CDM,510,RC,28124,CPT,,,,,,,,2155,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2827.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,895.187,2827.75
Part Remv Phalanx of Toe,PX28124P,CDM,983,RC,28124,CPT,,,,,,,,1515,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2827.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,629.331,2827.75
"Repair Flex Foot Tendon,Ea",PX28200F,CDM,510,RC,28200,CPT,,,,,,,,1475,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,2827.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,612.715,2827.75
"VENTRALIGHT MESH ST WITH ECHO 2 - 20 CM X 25 CM 8"" X 10""",C1781,CDM,278,RC,C1781,HCPCS,,12009-MAIN,LOCAL,,,,,5589,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2828.034,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535P,CDM,983,RC,24535,CPT,,,,,,,,2887,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2829.26,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,362.13,2829.26
trastuzumab 150 MG Recon Soln 1 Each Vial,J9355.01,CDM,636,RC,J9355,HCPCS,,,,50242013201,NDC,1,EA,3179.17,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2829.4613,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.77,3115.5866
REVITA PLACENTAL MEMBRANE 4X4CM 16SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12560-MAIN,LOCAL,,,,,6597,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2830.113,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
"Repair of Recurrent Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49615F,CDM,360,RC,49615,CPT,,,,,,,,2908,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2830.3564,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1207.9832,3022.41
"CT Colonography, Screen",PX7426301,CDM,350,RC,74263,CPT,TC,,,,,,,3330,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2830.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1383.282,3263.4
CT Lumbar Spine W/Dye,PX7213201,CDM,350,RC,72132,CPT,TC,,,,,,,3330,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2830.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3263.4
CT Pelvis W/Dye,PX7219301,CDM,350,RC,72193,CPT,TC,,,,,,,3330,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2830.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3263.4
Or Level 5,PX36000005,CDM,360,RC,,,,,,,,,,5898,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2831.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2450.0292,5780.04
Or Level 5,PX36000005,CDM,360,RC,,,,,,,,,,5898,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2831.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2450.0292,5780.04
CT Maxillofacial W/Dye,PX7048701,CDM,350,RC,70487,CPT,TC,,,,,,,3332,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2832.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3265.36
degarelix acetate 40 mg/mL Recon Soln 1 Each Vial,J9155.01,CDM,636,RC,J9155,HCPCS,,,,55566840301,NDC,2,EA,3109.33,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2832.59963,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.83,3047.1434
MRI Brain WO Contrast Tc,PX7055101,CDM,610,RC,70551,CPT,TC,,,,,,,3335,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2834.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3268.3
MRI Orbit/Face/Neck Tc,PX7054001,CDM,610,RC,70540,CPT,TC,,,,,,,3335,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2834.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3268.3
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING 8X10 ELLIPSE,C1781,CDM,278,RC,C1781,HCPCS,,12504-MAIN,LOCAL,,,,,5915,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,2839.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING 8X10 ELLIPSE,C1781,CDM,278,RC,C1781,HCPCS,,12504-MAIN,LOCAL,,,,,5915,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,2839.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
DOCEtaxel 160 MG/16ML Solution 16 mL Vial,J9171.01,CDM,636,RC,J9171,HCPCS,,,,409173201,NDC,16,ML,2901.69,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2843.6562,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1205.362026,2843.6562
"Colonoscopy,Transendoscopic Stent",PX45387F,CDM,750,RC,45387,CPT,,,,,,,,3228,,United Healthcare,All Payer,outpatient,88.2,,999999999,case rate,2847.096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2847.096,6141.46
Level 4 Additional Procedure,PX36000083,CDM,360,RC,,,,,,,,,,3200,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1329.28,3136
Exc Abd Les Sc < 3 Cm,PX22902F,CDM,761,RC,22902,CPT,,,,,,,,3128,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2849.608,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1299.3712,3065.44
"Repair of Recurrent Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49615F,CDM,360,RC,49615,CPT,,,,,,,,2908,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2849.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1207.9832,3022.41
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270006,NDC,100,ML,2912.78,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2854.5244,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218713,NDC,2,EA,6875.36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2856.024544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.57,6737.8528
CT Angio Abdominal Arteries,PX7563501,CDM,350,RC,75635,CPT,TC,,,,,,,2936,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,832.81,percent of total billed charges,2857.6088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,2877.28
Targeted Genomic Sequence Analysis Panel 5-50 Genes - Ref,PX8145090,CDM,300,RC,81450,CPT,90,,,,,,,2936,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2857.6088,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,696.41,2877.28
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING 8 IN CIRCLE,C1781,CDM,278,RC,C1781,HCPCS,,12506-MAIN,LOCAL,,,,,3240,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2857.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Chrom Anal, 20-25 Cells - Ref",PX8826490,CDM,310,RC,88264,CPT,90,,,,,,,3141,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2861.451,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.59,3078.18
"Tiss Cult, Neopl, Bm, Wb - Ref",PX8823790,CDM,310,RC,88237,CPT,90,,,,,,,3141,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2861.451,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,131.8,3078.18
MRI Pelvis W/Contrast Tc,PX7219601,CDM,610,RC,72196,CPT,TC,,,,,,,3143,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2863.273,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3080.14
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218710,NDC,2,EA,5662.72,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2865.33632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.57,6737.8528
Amputation Finger/Thumb,PX26951F,CDM,510,RC,26951,CPT,,,,,,,,3253,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2869.146,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1351.2962,3187.94
MRI Upper W/O+W Tc,PX7322001,CDM,610,RC,73220,CPT,TC,,,,,,,3253,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2869.146,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3187.94
"MRI,Lwrext,No Jnt,No Cont",PX7371801,CDM,610,RC,73718,CPT,TC,,,,,,,3253,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2869.146,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3187.94
"MRI,Pelvis W/Out Contrast",PX7219501,CDM,610,RC,72195,CPT,TC,,,,,,,3253,,United Healthcare,All Payer,outpatient,88.2,,1456.09,percent of total billed charges,2869.146,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3187.94
"MRI,Up Ext,No Jnt,No Cont",PX7321801,CDM,610,RC,73218,CPT,TC,,,,,,,3253,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2869.146,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3187.94
"Colonoscopy,Transendoscopic Stent",PX45387F,CDM,750,RC,45387,CPT,,,,,,,,3228,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2872.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1340.9112,3163.44
AMNION MATRIX CORD STERILE 3X6,27200000,CDM,272,RC,C1762,HCPCS,,11625-MAIN,LOCAL,,,,,6919,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2874.1526,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
darbepoetin alfa 200 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002801,NDC,0.4,ML,3157.92,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2876.86512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
rabies immune globulin 300 UNIT/2ML Solution 2 mL Vial,90377,CDM,636,RC,90376,CPT,,,,49281019020,NDC,2,ML,3384.84,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2877.114,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,207.94,3317.1432
CT Angio Abdominal Arteries,PX7563501,CDM,350,RC,75635,CPT,TC,,,,,,,2936,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2877.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,2877.28
Targeted Genomic Sequence Analysis Panel 5-50 Genes - Ref,PX8145090,CDM,300,RC,81450,CPT,90,,,,,,,2936,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2877.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,696.41,2877.28
"Lap,Esophagogast Fundoplasty",PX43280F,CDM,510,RC,43280,CPT,,,,,,,,6713,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2879.877,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2788.5802,8992.74
MRI T Spine WO Contrast,PX7214601,CDM,610,RC,72146,CPT,TC,,,,,,,3267,,United Healthcare,All Payer,outpatient,88.2,,2881.5,percent of total billed charges,2881.494,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3201.66
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING 8 IN CIRCLE,C1781,CDM,278,RC,C1781,HCPCS,,12506-MAIN,LOCAL,,,,,3240,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2883.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
bortezomib 3.5 MG Recon Soln 1 Each Vial,J9041.01,CDM,636,RC,J9041,HCPCS,,,,63020004901,NDC,1,EA,3270.12,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2884.24584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.79,3204.7176
CT Head/Brain W/Dye,PX7046001,CDM,350,RC,70460,CPT,TC,,,,,,,3398,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2888.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3330.04
"Tte W/Doppler, Complete",PX9330601,CDM,483,RC,93306,CPT,TC,,,,,,,2191,,Blue Cross Blue Shield of MN,All commercial plans,both,,,1006.7524,fee schedule,2889.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,481.95,2889.15
Or Level 5,PX36000005,CDM,360,RC,,,,,,,,,,5898,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2890.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2450.0292,5780.04
Or Level 5,PX36000005,CDM,360,RC,,,,,,,,,,5898,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2890.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2450.0292,5780.04
Or Level 5,PX36000005,CDM,360,RC,,,,,,,,,,5898,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2890.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2450.0292,5780.04
mepolizumab 100 MG Recon Soln 1 Each Vial,J2182.01,CDM,636,RC,J2182,HCPCS,,,,173088101,NDC,1,EA,6959.95,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2891.16323,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.51,6820.751
MRI Lower W/O+W Tc,PX7372001,CDM,610,RC,73720,CPT,TC,,,,,,,3174,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2891.514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3110.52
Amputation Finger/Thumb,PX26951F,CDM,510,RC,26951,CPT,,,,,,,,3253,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2895.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1351.2962,3187.94
MRI Upper W/O+W Tc,PX7322001,CDM,610,RC,73220,CPT,TC,,,,,,,3253,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2895.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3187.94
"MRI,Lwrext,No Jnt,No Cont",PX7371801,CDM,610,RC,73718,CPT,TC,,,,,,,3253,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2895.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3187.94
"MRI,Pelvis W/Out Contrast",PX7219501,CDM,610,RC,72195,CPT,TC,,,,,,,3253,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2895.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3187.94
"MRI,Up Ext,No Jnt,No Cont",PX7321801,CDM,610,RC,73218,CPT,TC,,,,,,,3253,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2895.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3187.94
trastuzumab 150 MG Recon Soln 1 Each Vial,J9355.01,CDM,636,RC,J9355,HCPCS,,,,50242013201,NDC,1,EA,3179.17,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2896.22387,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.77,3115.5866
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING 8X10 ELLIPSE,C1781,CDM,278,RC,C1781,HCPCS,,12504-MAIN,LOCAL,,,,,5915,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,196.035,percent of total billed charges,2898.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING 8X10 ELLIPSE,C1781,CDM,278,RC,C1781,HCPCS,,12504-MAIN,LOCAL,,,,,5915,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2898.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING 8X10 ELLIPSE,C1781,CDM,278,RC,C1781,HCPCS,,12504-MAIN,LOCAL,,,,,5915,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2898.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
CT Abdomen W/Dye,PX7416001,CDM,350,RC,74160,CPT,TC,,,,,,,3413,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2901.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3344.74
CT Soft Tissue Neck W/Dye,PX7049101,CDM,350,RC,70491,CPT,TC,,,,,,,3415,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2902.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3346.7
Diagnostic CT Thorax W/ Contrast,PX7126001,CDM,350,RC,71260,CPT,TC,,,,,,,3415,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2902.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3346.7
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270012,NDC,100,ML,3293.58,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2904.93756,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
MRI T Spine WO Contrast,PX7214601,CDM,610,RC,72146,CPT,TC,,,,,,,3267,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2907.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3201.66
cycloPHOSphamide 2 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,10019095701,NDC,1,EA,2988.6,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2908.80438,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
bortezomib 3.5 MG Recon Soln 1 Each Vial,J9041.01,CDM,636,RC,J9041,HCPCS,,,,63020004901,NDC,1,EA,3270.12,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2910.4068,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.79,3204.7176
Level 4 Additional Procedure,PX36000083,CDM,360,RC,,,,,,,,,,3200,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2915.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1329.28,3136
RomiPLOStim 500 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022201,NDC,1,EA,7018.25,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,2915.38105,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.04,6877.885
Lap Paraesophag Hern Repair,PX43281,CDM,982,RC,43281,CPT,,,,,,,,5950,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2915.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2471.63,8992.74
Lap Paraesophag Hern Repair,PX43281,CDM,982,RC,43281,CPT,,,,,,,,5950,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,2915.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2471.63,8992.74
Lap Paraesophag Hern Repair,PX43281,CDM,982,RC,43281,CPT,,,,,,,,5950,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,2915.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2471.63,8992.74
Or Level 5,PX36000005,CDM,360,RC,,,,,,,,,,5898,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2919.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2450.0292,5780.04
MRI Up Extremity Joint W/O Tc,PX7322101,CDM,610,RC,73221,CPT,TC,,,,,,,3319,,United Healthcare,All Payer,outpatient,88.2,,1626.31,percent of total billed charges,2927.358,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3252.62
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING 8X10 ELLIPSE,C1781,CDM,278,RC,C1781,HCPCS,,12504-MAIN,LOCAL,,,,,5915,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2927.925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
cycloPHOSphamide 2 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,10019095701,NDC,1,EA,2988.6,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2928.828,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,581.93386,2928.828
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270012,NDC,100,ML,3293.58,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2931.2862,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
"CT Colonography, Screen",PX7426301,CDM,350,RC,74263,CPT,TC,,,,,,,3330,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2937.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1383.282,3263.4
CT Lumbar Spine W/Dye,PX7213201,CDM,350,RC,72132,CPT,TC,,,,,,,3330,,United Healthcare,All Payer,outpatient,88.2,,1631.7,percent of total billed charges,2937.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3263.4
CT Pelvis W/Dye,PX7219301,CDM,350,RC,72193,CPT,TC,,,,,,,3330,,United Healthcare,All Payer,outpatient,88.2,,2281.21,percent of total billed charges,2937.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3263.4
CT Maxillofacial W/Dye,PX7048701,CDM,350,RC,70487,CPT,TC,,,,,,,3332,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2938.824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3265.36
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270010,NDC,100,ML,3458.14,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2939.419,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
"Colonoscopy,Transendoscopic Stent",PX45387F,CDM,750,RC,45387,CPT,,,,,,,,3228,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2940.708,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1340.9112,3163.44
MRI Brain WO Contrast Tc,PX7055101,CDM,610,RC,70551,CPT,TC,,,,,,,3335,,United Healthcare,All Payer,outpatient,88.2,,2855.03,percent of total billed charges,2941.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3268.3
MRI Orbit/Face/Neck Tc,PX7054001,CDM,610,RC,70540,CPT,TC,,,,,,,3335,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2941.47,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3268.3
Injection for Nerve Block,PX64447F,CDM,510,RC,64447,CPT,,,,,,,,3023,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2942.2859,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,604.15,2962.54
Lap Paraesophag Hern Repair,PX43281,CDM,982,RC,43281,CPT,,,,,,,,5950,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,2945.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2471.63,8992.74
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218713,NDC,2,EA,6875.36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2949.52944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.57,6737.8528
"Mra, Neck W/O+W/ Contrast",PX7054901,CDM,610,RC,70549,CPT,TC,,,,,,,3472,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2951.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3402.56
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING 8 IN CIRCLE,C1781,CDM,278,RC,C1781,HCPCS,,12506-MAIN,LOCAL,,,,,3240,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2951.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
MRI Up Extremity Joint W/O Tc,PX7322101,CDM,610,RC,73221,CPT,TC,,,,,,,3319,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2953.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3252.62
RESTRATA WOUND MATRIX 2.5CM X 5CM TOTAL 12.5CM,27200000,CDM,272,RC,A2007,HCPCS,,11734-MAIN,LOCAL,,,,,3039,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,2957.8587,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Injection for Nerve Block,PX64447F,CDM,510,RC,64447,CPT,,,,,,,,3023,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2962.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,604.15,2962.54
Amputation Finger/Thumb,PX26951F,CDM,510,RC,26951,CPT,,,,,,,,3253,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2963.483,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1351.2962,3187.94
MRI Upper W/O+W Tc,PX7322001,CDM,610,RC,73220,CPT,TC,,,,,,,3253,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2963.483,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3187.94
"MRI,Lwrext,No Jnt,No Cont",PX7371801,CDM,610,RC,73718,CPT,TC,,,,,,,3253,,Medica,Commercial,both,91.1,,2667.13,percent of total billed charges,2963.483,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3187.94
"MRI,Pelvis W/Out Contrast",PX7219501,CDM,610,RC,72195,CPT,TC,,,,,,,3253,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2963.483,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3187.94
"MRI,Up Ext,No Jnt,No Cont",PX7321801,CDM,610,RC,73218,CPT,TC,,,,,,,3253,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2963.483,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3187.94
"CT Colonography, Screen",PX7426301,CDM,350,RC,74263,CPT,TC,,,,,,,3330,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2963.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1383.282,3263.4
CT Lumbar Spine W/Dye,PX7213201,CDM,350,RC,72132,CPT,TC,,,,,,,3330,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2963.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3263.4
CT Pelvis W/Dye,PX7219301,CDM,350,RC,72193,CPT,TC,,,,,,,3330,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2963.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3263.4
CT Maxillofacial W/Dye,PX7048701,CDM,350,RC,70487,CPT,TC,,,,,,,3332,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2965.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3265.36
pegloticase 8 MG/ML Solution 1 mL Vial,J2507.01,CDM,636,RC,J2507,HCPCS,,,,75987008010,NDC,1,ML,48367.38,,UCare,All Minnesota State Programs,both,,,999999999,fee schedule,2966.54,Facility and Nonfacility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2966.54,3391.91
MRI Brain WO Contrast Tc,PX7055101,CDM,610,RC,70551,CPT,TC,,,,,,,3335,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2968.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3268.3
MRI Orbit/Face/Neck Tc,PX7054001,CDM,610,RC,70540,CPT,TC,,,,,,,3335,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,2968.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3268.3
AMNION MATRIX CORD STERILE 3X6,27200000,CDM,272,RC,C1762,HCPCS,,11625-MAIN,LOCAL,,,,,6919,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2968.251,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MRI T Spine WO Contrast,PX7214601,CDM,610,RC,72146,CPT,TC,,,,,,,3267,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2976.237,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3201.66
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595F,CDM,360,RC,49595,CPT,,,,,,,,3503,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2977.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1455.1462,3432.94
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595P,CDM,982,RC,49595,CPT,,,,,,,,3503,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2977.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1455.1462,3409.4699
RESTRATA WOUND MATRIX 2.5CM X 5CM TOTAL 12.5CM,27200000,CDM,272,RC,A2007,HCPCS,,11734-MAIN,LOCAL,,,,,3039,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,2978.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
bortezomib 3.5 MG Recon Soln 1 Each Vial,J9041.01,CDM,636,RC,J9041,HCPCS,,,,63020004901,NDC,1,EA,3270.12,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,2979.07932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.79,3204.7176
Or Level 5,PX36000005,CDM,360,RC,,,,,,,,,,5898,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2984.388,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2450.0292,5780.04
rabies immune globulin 300 UNIT/2ML Solution 2 mL Vial,90377,CDM,636,RC,90376,CPT,,,,49281019020,NDC,2,ML,3384.84,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2985.42888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,207.94,3317.1432
mepolizumab 100 MG Recon Soln 1 Each Vial,J2182.01,CDM,636,RC,J2182,HCPCS,,,,173088101,NDC,1,EA,6959.95,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,2985.81855,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.51,6820.751
"VENTRALIGHT MESH ST WITH ECHO 2 - 15 CM X 20 CM 6"" X 8""",C1781,CDM,278,RC,C1781,HCPCS,,12008-MAIN,LOCAL,,,,,3518,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2990.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING 8X10 ELLIPSE,C1781,CDM,278,RC,C1781,HCPCS,,12504-MAIN,LOCAL,,,,,5915,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,2992.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
belimumab (400v) 400 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010201,NDC,1,EA,3523.71,,First Health,Commercial,both,85,,999999999,percent of total billed charges,2995.1535,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.72,3453.2358
CT Head/Brain W/Dye,PX7046001,CDM,350,RC,70460,CPT,TC,,,,,,,3398,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,2997.036,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3330.04
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270012,NDC,100,ML,3293.58,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3000.45138,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
HIMAX PLUS 18X18X18,27200000,CDM,278,RC,C1713,HCPCS,,11660-MAIN,LOCAL,,,,,3085.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3003.11715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HIMAX PLUS 20X20X20,27200000,CDM,278,RC,C1713,HCPCS,,11661-MAIN,LOCAL,,,,,3085.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3003.11715,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Mra, Head W/Out Contrast",PX7054401,CDM,610,RC,70544,CPT,TC,,,,,,,3541,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3009.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
"Mra, Neck With Contrast",PX7054801,CDM,610,RC,70548,CPT,TC,,,,,,,3541,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3009.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI Brain W & WO Contrast,PX7055301,CDM,610,RC,70553,CPT,TC,,,,,,,3541,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3009.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI C Spine W&WO Contrast,PX7215601,CDM,610,RC,72156,CPT,TC,,,,,,,3541,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3009.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI C-Spine WO Contrast,PX7214101,CDM,610,RC,72141,CPT,TC,,,,,,,3541,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3009.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI L Spine WO Contrast,PX7214801,CDM,610,RC,72148,CPT,TC,,,,,,,3541,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3009.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI Low Ext Jnt WO/Cont Tc,PX7372101,CDM,610,RC,73721,CPT,TC,,,,,,,3541,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3009.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI Orb-Fac-Nec W/O+W/Con,PX7054301,CDM,610,RC,70543,CPT,TC,,,,,,,3541,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3009.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
"MRI,Upr Ext, Joint,W/Cont",PX7322201,CDM,610,RC,73222,CPT,TC,,,,,,,3541,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3009.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,611.05,3470.18
CT Abdomen W/Dye,PX7416001,CDM,350,RC,74160,CPT,TC,,,,,,,3413,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3010.266,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3344.74
Lap Paraesophag Hern Repair,PX43281,CDM,982,RC,43281,CPT,,,,,,,,5950,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3010.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2471.63,8992.74
RomiPLOStim 500 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022201,NDC,1,EA,7018.25,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3010.82925,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.04,6877.885
CT Soft Tissue Neck W/Dye,PX7049101,CDM,350,RC,70491,CPT,TC,,,,,,,3415,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3012.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3346.7
Diagnostic CT Thorax W/ Contrast,PX7126001,CDM,350,RC,71260,CPT,TC,,,,,,,3415,,United Healthcare,All Payer,outpatient,88.2,,1687.283333,percent of total billed charges,3012.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3346.7
DYNANITE PIP - STRAIGHT 12MM - WITH INSTRUMENTATION,27200000,CDM,278,RC,C1713,HCPCS,,11626-MAIN,LOCAL,,,,,3543.65,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3012.1025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP - STRAIGHT 14MM - WITH INSTRUMENTATION,27200000,CDM,278,RC,C1713,HCPCS,,11627-MAIN,LOCAL,,,,,3543.65,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3012.1025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT BENT 12MM,27200000,CDM,278,RC,C1713,HCPCS,,11629-MAIN,LOCAL,,,,,3543.65,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3012.1025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT BENT 14MM,27200000,CDM,278,RC,C1713,HCPCS,,11631-MAIN,LOCAL,,,,,3543.65,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3012.1025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT BENT 16MM,27200000,CDM,278,RC,C1713,HCPCS,,11633-MAIN,LOCAL,,,,,3543.65,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3012.1025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT STRAIGHT 12MM,27200000,CDM,278,RC,C1713,HCPCS,,11628-MAIN,LOCAL,,,,,3543.65,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3012.1025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT STRAIGHT 14MM,27200000,CDM,278,RC,C1713,HCPCS,,11630-MAIN,LOCAL,,,,,3543.65,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3012.1025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT STRAIGHT 16MM,27200000,CDM,278,RC,C1713,HCPCS,,11632-MAIN,LOCAL,,,,,3543.65,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3012.1025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
rabies immune globulin 300 UNIT/2ML Solution 2 mL Vial,90377,CDM,636,RC,90376,CPT,,,,49281019020,NDC,2,ML,3384.84,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3012.5076,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,207.94,3317.1432
"Initial Repair of Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49593P,CDM,982,RC,49593,CPT,,,,,,,,2606,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,3022.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1082.5324,3022.41
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591F,CDM,360,RC,49591,CPT,,,,,,,,1556,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,3022.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,646.3624,3022.41
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591P,CDM,982,RC,49591,CPT,,,,,,,,1245,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,3022.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,517.173,3022.41
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595F,CDM,360,RC,49595,CPT,,,,,,,,3503,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,3022.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1455.1462,3432.94
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595P,CDM,982,RC,49595,CPT,,,,,,,,3503,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,3022.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1455.1462,3409.4699
"Removal of Hydrocele,Tunica,Unilat",PX55040P,CDM,983,RC,55040,CPT,,,,,,,,1420,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,3022.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,589.868,3022.41
Remv Periton FB From Perit Cav,PX49402F,CDM,510,RC,49402,CPT,,,,,,,,3573,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,3022.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1484.2242,3501.54
Remv Periton FB From Perit Cav,PX49402P,CDM,983,RC,49402,CPT,,,,,,,,3897,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,3022.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1618.8138,3792.9501
"Repair Ing Hernia,5+Y/O,Reducibl",PX49505P,CDM,983,RC,49505,CPT,,,,,,,,2048,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,3022.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,850.7392,3022.41
"Repair Ing Hernia,5+Y/O,Strang",PX49507F,CDM,510,RC,49507,CPT,,,,,,,,1977,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,3022.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,821.2458,3022.41
"Repair Ing Hernia,5+Y/O,Strang",PX49507P,CDM,983,RC,49507,CPT,,,,,,,,2482,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,3022.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1031.0228,3022.41
"Repair of Recurrent Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49615F,CDM,360,RC,49615,CPT,,,,,,,,2908,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,3022.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1207.9832,3022.41
"Repair Recurr Inguin Hern,Reducibl",PX49520F,CDM,510,RC,49520,CPT,,,,,,,,1983,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,3022.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,823.7382,3022.41
"Repair Recurr Inguin Hern,Reducibl",PX49520P,CDM,983,RC,49520,CPT,,,,,,,,1983,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,3022.41,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,823.7382,3022.41
MRI Up Extremity Joint W/O Tc,PX7322101,CDM,610,RC,73221,CPT,TC,,,,,,,3319,,Medica,Commercial,both,91.1,,1720.114,percent of total billed charges,3023.609,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3252.62
HIMAX PLUS 18X18X18,27200000,CDM,278,RC,C1713,HCPCS,,11660-MAIN,LOCAL,,,,,3085.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3023.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
HIMAX PLUS 20X20X20,27200000,CDM,278,RC,C1713,HCPCS,,11661-MAIN,LOCAL,,,,,3085.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3023.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CT Head/Brain W/Dye,PX7046001,CDM,350,RC,70460,CPT,TC,,,,,,,3398,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3024.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3330.04
degarelix acetate 40 mg/mL Recon Soln 1 Each Vial,J9155.01,CDM,636,RC,J9155,HCPCS,,,,55566840301,NDC,2,EA,3109.33,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3026.310889,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.83,3047.1434
RESTRATA WOUND MATRIX 7.5CM X 7.5CM TOTAL 56.25CM,27200000,CDM,272,RC,A2007,HCPCS,,11737-MAIN,LOCAL,,,,,6311,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3029.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RESTRATA WOUND MATRIX 7.5CM X 7.5CM TOTAL 56.25CM,27200000,CDM,272,RC,A2007,HCPCS,,11737-MAIN,LOCAL,,,,,6311,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3029.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"CT Colonography, Screen",PX7426301,CDM,350,RC,74263,CPT,TC,,,,,,,3330,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3033.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1383.282,3263.4
CT Lumbar Spine W/Dye,PX7213201,CDM,350,RC,72132,CPT,TC,,,,,,,3330,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3033.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3263.4
CT Pelvis W/Dye,PX7219301,CDM,350,RC,72193,CPT,TC,,,,,,,3330,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3033.63,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3263.4
CT Maxillofacial W/Dye,PX7048701,CDM,350,RC,70487,CPT,TC,,,,,,,3332,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3035.452,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3265.36
Remv Periton FB From Perit Cav,PX49402F,CDM,510,RC,49402,CPT,,,,,,,,3573,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3037.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1484.2242,3501.54
CT Abdomen W/Dye,PX7416001,CDM,350,RC,74160,CPT,TC,,,,,,,3413,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3037.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3344.74
MRI Brain WO Contrast Tc,PX7055101,CDM,610,RC,70551,CPT,TC,,,,,,,3335,,Medica,Commercial,both,91.1,,1843.23,percent of total billed charges,3038.185,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3268.3
MRI Orbit/Face/Neck Tc,PX7054001,CDM,610,RC,70540,CPT,TC,,,,,,,3335,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3038.185,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3268.3
Remove Foreign Body Complic,PX10121F,CDM,510,RC,10121,CPT,,,,,,,,3575,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3038.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1416.38,3503.5
CT Soft Tissue Neck W/Dye,PX7049101,CDM,350,RC,70491,CPT,TC,,,,,,,3415,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3039.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3346.7
Diagnostic CT Thorax W/ Contrast,PX7126001,CDM,350,RC,71260,CPT,TC,,,,,,,3415,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3039.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3346.7
Exc Abd Les Sc < 3 Cm,PX22902F,CDM,761,RC,22902,CPT,,,,,,,,3128,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3044.4824,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1299.3712,3065.44
degarelix acetate 40 mg/mL Recon Soln 1 Each Vial,J9155.01,CDM,636,RC,J9155,HCPCS,,,,55566840301,NDC,2,EA,3109.33,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3047.1434,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.83,3047.1434
"Colonoscopy,Transendoscopic Stent",PX45387P,CDM,983,RC,45387,CPT,,,,,,,,3587,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3048.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1490.0398,3491.2271
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270010,NDC,100,ML,3458.14,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3050.07948,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
"Chrom Anal, 20-25 Cells - Ref",PX8826490,CDM,310,RC,88264,CPT,90,,,,,,,3141,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3057.1353,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.59,3078.18
"Tiss Cult, Neopl, Bm, Wb - Ref",PX8823790,CDM,310,RC,88237,CPT,90,,,,,,,3141,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3057.1353,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,131.8,3078.18
"Mra, Neck W/O+W/ Contrast",PX7054901,CDM,610,RC,70549,CPT,TC,,,,,,,3472,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3062.304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3402.56
Exc Abd Les Sc < 3 Cm,PX22902F,CDM,761,RC,22902,CPT,,,,,,,,3128,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3065.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1299.3712,3065.44
darbepoetin alfa 200 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002801,NDC,0.4,ML,3157.92,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.7895,percent of total billed charges,3073.603536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270010,NDC,100,ML,3458.14,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3077.7446,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
"Chrom Anal, 20-25 Cells - Ref",PX8826490,CDM,310,RC,88264,CPT,90,,,,,,,3141,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3078.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,132.59,3078.18
"Tiss Cult, Neopl, Bm, Wb - Ref",PX8823790,CDM,310,RC,88237,CPT,90,,,,,,,3141,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3078.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,131.8,3078.18
MRI Pelvis W/Contrast Tc,PX7219601,CDM,610,RC,72196,CPT,TC,,,,,,,3143,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3080.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3080.14
"MRI,Lwrext,No Jnt, W/Cont",PX7371901,CDM,610,RC,73719,CPT,TC,,,,,,,3627,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3082.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3554.46
rabies immune globulin 300 UNIT/2ML Solution 2 mL Vial,90377,CDM,636,RC,90376,CPT,,,,49281019020,NDC,2,ML,3384.84,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3083.58924,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,207.94,3317.1432
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595F,CDM,360,RC,49595,CPT,,,,,,,,3503,,United Healthcare,All Payer,outpatient,88.2,,999999999,case rate,3089.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3089.646,6141.46
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595P,CDM,982,RC,49595,CPT,,,,,,,,3503,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3089.646,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1455.1462,3409.4699
"Mra, Neck W/O+W/ Contrast",PX7054901,CDM,610,RC,70549,CPT,TC,,,,,,,3472,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3090.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3402.56
pegloticase 8 MG/ML Solution 1 mL Vial,J2507.01,CDM,636,RC,J2507,HCPCS,,,,75987008010,NDC,1,ML,48367.38,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,3090.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3090.93,47400.0324
RESTRATA WOUND MATRIX 7.5CM X 7.5CM TOTAL 56.25CM,27200000,CDM,272,RC,A2007,HCPCS,,11737-MAIN,LOCAL,,,,,6311,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3092.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RESTRATA WOUND MATRIX 7.5CM X 7.5CM TOTAL 56.25CM,27200000,CDM,272,RC,A2007,HCPCS,,11737-MAIN,LOCAL,,,,,6311,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3092.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RESTRATA WOUND MATRIX 7.5CM X 7.5CM TOTAL 56.25CM,27200000,CDM,272,RC,A2007,HCPCS,,11737-MAIN,LOCAL,,,,,6311,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3092.39,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
darbepoetin alfa 200 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002801,NDC,0.4,ML,3157.92,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3094.7616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
CT Head/Brain W/Dye,PX7046001,CDM,350,RC,70460,CPT,TC,,,,,,,3398,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3095.578,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3330.04
"VENTRALIGHT MESH ST WITH ECHO 2 - 15 CM X 20 CM 6"" X 8""",C1781,CDM,278,RC,C1781,HCPCS,,12008-MAIN,LOCAL,,,,,3518,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3102.876,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
belimumab (400v) 400 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010201,NDC,1,EA,3523.71,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3107.91222,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.72,3453.2358
CT Abdomen W/Dye,PX7416001,CDM,350,RC,74160,CPT,TC,,,,,,,3413,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3109.243,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3344.74
MRI Lower W/O+W Tc,PX7372001,CDM,610,RC,73720,CPT,TC,,,,,,,3174,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3110.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3110.52
CT Soft Tissue Neck W/Dye,PX7049101,CDM,350,RC,70491,CPT,TC,,,,,,,3415,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3111.065,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3346.7
Diagnostic CT Thorax W/ Contrast,PX7126001,CDM,350,RC,71260,CPT,TC,,,,,,,3415,,Medica,Commercial,both,91.1,,957.2111111,percent of total billed charges,3111.065,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3346.7
Level 4 Additional Procedure,PX36000083,CDM,360,RC,,,,,,,,,,3200,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3114.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1329.28,3136
trastuzumab 150 MG Recon Soln 1 Each Vial,J9355.01,CDM,636,RC,J9355,HCPCS,,,,50242013201,NDC,1,EA,3179.17,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3115.5866,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,73.77,3115.5866
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595F,CDM,360,RC,49595,CPT,,,,,,,,3503,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3117.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1455.1462,3432.94
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595P,CDM,982,RC,49595,CPT,,,,,,,,3503,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3117.67,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1455.1462,3409.4699
Level 6 Additional Procedure,PX36000085,CDM,360,RC,,,,,,,,,,6500,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3120,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2700.1,6370
Level 6 Additional Procedure,PX36000085,CDM,360,RC,,,,,,,,,,6500,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3120,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2700.1,6370
CT Head/Brain W/O & W/Dye,PX7047001,CDM,350,RC,70470,CPT,TC,,,,,,,3671,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3120.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3597.58
"Mra, Head W/Out Contrast",PX7054401,CDM,610,RC,70544,CPT,TC,,,,,,,3541,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3123.162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
"Mra, Neck With Contrast",PX7054801,CDM,610,RC,70548,CPT,TC,,,,,,,3541,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3123.162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI Brain W & WO Contrast,PX7055301,CDM,610,RC,70553,CPT,TC,,,,,,,3541,,United Healthcare,All Payer,outpatient,88.2,,1876.73,percent of total billed charges,3123.162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI C Spine W&WO Contrast,PX7215601,CDM,610,RC,72156,CPT,TC,,,,,,,3541,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3123.162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI C-Spine WO Contrast,PX7214101,CDM,610,RC,72141,CPT,TC,,,,,,,3541,,United Healthcare,All Payer,outpatient,88.2,,1786.61,percent of total billed charges,3123.162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI L Spine WO Contrast,PX7214801,CDM,610,RC,72148,CPT,TC,,,,,,,3541,,United Healthcare,All Payer,outpatient,88.2,,2347.4175,percent of total billed charges,3123.162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI Low Ext Jnt WO/Cont Tc,PX7372101,CDM,610,RC,73721,CPT,TC,,,,,,,3541,,United Healthcare,All Payer,outpatient,88.2,,2225.468571,percent of total billed charges,3123.162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI Orb-Fac-Nec W/O+W/Con,PX7054301,CDM,610,RC,70543,CPT,TC,,,,,,,3541,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3123.162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
"MRI,Upr Ext, Joint,W/Cont",PX7322201,CDM,610,RC,73222,CPT,TC,,,,,,,3541,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3123.162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,611.05,3470.18
RESTRATA WOUND MATRIX 7.5CM X 7.5CM TOTAL 56.25CM,27200000,CDM,272,RC,A2007,HCPCS,,11737-MAIN,LOCAL,,,,,6311,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3123.945,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP - STRAIGHT 12MM - WITH INSTRUMENTATION,27200000,CDM,278,RC,C1713,HCPCS,,11626-MAIN,LOCAL,,,,,3543.65,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3125.4993,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP - STRAIGHT 14MM - WITH INSTRUMENTATION,27200000,CDM,278,RC,C1713,HCPCS,,11627-MAIN,LOCAL,,,,,3543.65,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3125.4993,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT BENT 12MM,27200000,CDM,278,RC,C1713,HCPCS,,11629-MAIN,LOCAL,,,,,3543.65,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3125.4993,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT BENT 14MM,27200000,CDM,278,RC,C1713,HCPCS,,11631-MAIN,LOCAL,,,,,3543.65,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3125.4993,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT BENT 16MM,27200000,CDM,278,RC,C1713,HCPCS,,11633-MAIN,LOCAL,,,,,3543.65,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3125.4993,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT STRAIGHT 12MM,27200000,CDM,278,RC,C1713,HCPCS,,11628-MAIN,LOCAL,,,,,3543.65,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3125.4993,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT STRAIGHT 14MM,27200000,CDM,278,RC,C1713,HCPCS,,11630-MAIN,LOCAL,,,,,3543.65,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3125.4993,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT STRAIGHT 16MM,27200000,CDM,278,RC,C1713,HCPCS,,11632-MAIN,LOCAL,,,,,3543.65,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3125.4993,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"VENTRALIGHT MESH ST WITH ECHO 2 - 15 CM X 20 CM 6"" X 8""",C1781,CDM,278,RC,C1781,HCPCS,,12008-MAIN,LOCAL,,,,,3518,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3131.02,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
CT Abdomen W/O & W/Dye,PX7417001,CDM,350,RC,74170,CPT,TC,,,,,,,3689,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3135.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3615.22
"CT Angiography, Chest",PX7127501,CDM,350,RC,71275,CPT,TC,,,,,,,3689,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3135.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3615.22
Level 4 Additional Procedure,PX36000083,CDM,360,RC,,,,,,,,,,3200,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1329.28,3136
belimumab (400v) 400 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010201,NDC,1,EA,3523.71,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3136.1019,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.72,3453.2358
"CT Angiography, Head",PX7049601,CDM,350,RC,70496,CPT,TC,,,,,,,3690,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3136.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3616.2
"CT Angiography, Neck",PX7049801,CDM,350,RC,70498,CPT,TC,,,,,,,3690,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3136.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3616.2
ALLOGRAFT BONE AUGMENT INJECTABLE KIT 1.5CC,C1734,CDM,278,RC,C1734,HCPCS,,12632-MAIN,LOCAL,,,,,3694,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3139.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1534.4876,3620.12
"Colonoscopy,Transendoscopic Stent",PX45387F,CDM,750,RC,45387,CPT,,,,,,,,3228,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3141.8124,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1340.9112,3163.44
PURAPLYAM XT-COM 4.91X4.91 EXTRA FENESTRATED 24.10 SQCM,120.567,CDM,272,RC,Q4197,HCPCS,,12806-MAIN,LOCAL,,,,,6562,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3149.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2725.8548,6430.76
PURAPLYAM XT-COM 4.91X4.91 EXTRA FENESTRATED 24.10 SQCM,120.567,CDM,272,RC,Q4197,HCPCS,,12806-MAIN,LOCAL,,,,,6562,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3149.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2725.8548,6430.76
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270010,NDC,100,ML,3458.14,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3150.36554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
Remv Periton FB From Perit Cav,PX49402F,CDM,510,RC,49402,CPT,,,,,,,,3573,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3151.386,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1484.2242,3501.54
"Mra, Head W/Out Contrast",PX7054401,CDM,610,RC,70544,CPT,TC,,,,,,,3541,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3151.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
"Mra, Neck With Contrast",PX7054801,CDM,610,RC,70548,CPT,TC,,,,,,,3541,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3151.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI Brain W & WO Contrast,PX7055301,CDM,610,RC,70553,CPT,TC,,,,,,,3541,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3151.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI C Spine W&WO Contrast,PX7215601,CDM,610,RC,72156,CPT,TC,,,,,,,3541,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3151.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI C-Spine WO Contrast,PX7214101,CDM,610,RC,72141,CPT,TC,,,,,,,3541,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3151.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI L Spine WO Contrast,PX7214801,CDM,610,RC,72148,CPT,TC,,,,,,,3541,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3151.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI Low Ext Jnt WO/Cont Tc,PX7372101,CDM,610,RC,73721,CPT,TC,,,,,,,3541,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3151.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI Orb-Fac-Nec W/O+W/Con,PX7054301,CDM,610,RC,70543,CPT,TC,,,,,,,3541,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3151.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
"MRI,Upr Ext, Joint,W/Cont",PX7322201,CDM,610,RC,73222,CPT,TC,,,,,,,3541,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3151.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,611.05,3470.18
durvalumab 500 MG/10ML Solution 10 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310461150,NDC,10,ML,7588.77,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3152.375058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.48,21336.462
Remove Foreign Body Complic,PX10121F,CDM,510,RC,10121,CPT,,,,,,,,3575,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3153.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1416.38,3503.5
GOLIMumab 50 MG/4ML Solution 4 mL Vial,J1602.01,CDM,636,RC,J1602,HCPCS,,,,57894035001,NDC,4,ML,3709.76,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3153.296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.31,3635.5648
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING 8 IN CIRCLE,C1781,CDM,278,RC,C1781,HCPCS,,12506-MAIN,LOCAL,,,,,3240,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1256.29,percent of total billed charges,3153.492,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
DYNANITE PIP - STRAIGHT 12MM - WITH INSTRUMENTATION,27200000,CDM,278,RC,C1713,HCPCS,,11626-MAIN,LOCAL,,,,,3543.65,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3153.8485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP - STRAIGHT 14MM - WITH INSTRUMENTATION,27200000,CDM,278,RC,C1713,HCPCS,,11627-MAIN,LOCAL,,,,,3543.65,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3153.8485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT BENT 12MM,27200000,CDM,278,RC,C1713,HCPCS,,11629-MAIN,LOCAL,,,,,3543.65,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3153.8485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT BENT 14MM,27200000,CDM,278,RC,C1713,HCPCS,,11631-MAIN,LOCAL,,,,,3543.65,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3153.8485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT BENT 16MM,27200000,CDM,278,RC,C1713,HCPCS,,11633-MAIN,LOCAL,,,,,3543.65,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3153.8485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT STRAIGHT 12MM,27200000,CDM,278,RC,C1713,HCPCS,,11628-MAIN,LOCAL,,,,,3543.65,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3153.8485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT STRAIGHT 14MM,27200000,CDM,278,RC,C1713,HCPCS,,11630-MAIN,LOCAL,,,,,3543.65,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3153.8485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT STRAIGHT 16MM,27200000,CDM,278,RC,C1713,HCPCS,,11632-MAIN,LOCAL,,,,,3543.65,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3153.8485,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Mra, Neck W/O+W/ Contrast",PX7054901,CDM,610,RC,70549,CPT,TC,,,,,,,3472,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3162.992,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3402.56
"Colonoscopy,Transendoscopic Stent",PX45387F,CDM,750,RC,45387,CPT,,,,,,,,3228,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3163.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1340.9112,3163.44
"Colonoscopy,Transendoscopic Stent",PX45387P,CDM,983,RC,45387,CPT,,,,,,,,3587,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3163.734,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1490.0398,3491.2271
Amputation Finger/Thumb,PX26951F,CDM,510,RC,26951,CPT,,,,,,,,3253,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3166.1449,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1351.2962,3187.94
REVITA PLACENTAL MEMBRANE 4X4CM 16SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12560-MAIN,LOCAL,,,,,6597,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3166.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
REVITA PLACENTAL MEMBRANE 4X4CM 16SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12560-MAIN,LOCAL,,,,,6597,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3166.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING 8 IN CIRCLE,C1781,CDM,278,RC,C1781,HCPCS,,12506-MAIN,LOCAL,,,,,3240,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3175.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Lap Paraesophag Hern Repair,PX43281,CDM,982,RC,43281,CPT,,,,,,,,5950,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,3178.13,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,906.42,5831
Lap Paraesophag Hern Repair,PX43281,CDM,982,RC,43281,CPT,,,,,,,,5950,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,3178.13,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,906.42,5831
Remv Periton FB From Perit Cav,PX49402F,CDM,510,RC,49402,CPT,,,,,,,,3573,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3179.97,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1484.2242,3501.54
Remove Foreign Body Complic,PX10121F,CDM,510,RC,10121,CPT,,,,,,,,3575,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3181.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1416.38,3503.5
bortezomib 3.5 MG Recon Soln 1 Each Vial,J9041.01,CDM,636,RC,J9041,HCPCS,,,,63020004901,NDC,1,EA,3270.12,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3182.807796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.79,3204.7176
Level 6 Additional Procedure,PX36000085,CDM,360,RC,,,,,,,,,,6500,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3185,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2700.1,6370
Level 6 Additional Procedure,PX36000085,CDM,360,RC,,,,,,,,,,6500,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3185,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2700.1,6370
Level 6 Additional Procedure,PX36000085,CDM,360,RC,,,,,,,,,,6500,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3185,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2700.1,6370
Amputation Finger/Thumb,PX26951F,CDM,510,RC,26951,CPT,,,,,,,,3253,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3187.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1351.2962,3187.94
MRI Upper W/O+W Tc,PX7322001,CDM,610,RC,73220,CPT,TC,,,,,,,3253,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3187.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3187.94
"MRI,Lwrext,No Jnt,No Cont",PX7371801,CDM,610,RC,73718,CPT,TC,,,,,,,3253,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3187.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3187.94
"MRI,Pelvis W/Out Contrast",PX7219501,CDM,610,RC,72195,CPT,TC,,,,,,,3253,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3187.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3187.94
"MRI,Up Ext,No Jnt,No Cont",PX7321801,CDM,610,RC,73218,CPT,TC,,,,,,,3253,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3187.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3187.94
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595F,CDM,360,RC,49595,CPT,,,,,,,,3503,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3191.233,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1455.1462,3432.94
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595P,CDM,982,RC,49595,CPT,,,,,,,,3503,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3191.233,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1455.1462,3409.4699
"Colonoscopy,Transendoscopic Stent",PX45387P,CDM,983,RC,45387,CPT,,,,,,,,3587,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3192.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1490.0398,3491.2271
RESTRATA WOUND MATRIX 7.5CM X 7.5CM TOTAL 56.25CM,27200000,CDM,272,RC,A2007,HCPCS,,11737-MAIN,LOCAL,,,,,6311,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3193.366,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"MRI,Lwrext,No Jnt, W/Cont",PX7371901,CDM,610,RC,73719,CPT,TC,,,,,,,3627,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3199.014,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3554.46
MRI T Spine WO Contrast,PX7214601,CDM,610,RC,72146,CPT,TC,,,,,,,3267,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3201.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3201.66
bortezomib 3.5 MG Recon Soln 1 Each Vial,J9041.01,CDM,636,RC,J9041,HCPCS,,,,63020004901,NDC,1,EA,3270.12,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3204.7176,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.79,3204.7176
"VENTRALIGHT MESH ST WITH ECHO 2 - 15 CM X 20 CM 6"" X 8""",C1781,CDM,278,RC,C1781,HCPCS,,12008-MAIN,LOCAL,,,,,3518,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3204.898,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
belimumab (400v) 400 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010201,NDC,1,EA,3523.71,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3210.09981,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.72,3453.2358
leuprolide 7.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74364203,NDC,1,EA,3782.28,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3214.938,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
PURAPLYAM XT-COM 4.91X4.91 EXTRA FENESTRATED 24.10 SQCM,120.567,CDM,272,RC,Q4197,HCPCS,,12806-MAIN,LOCAL,,,,,6562,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3215.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2725.8548,6430.76
PURAPLYAM XT-COM 4.91X4.91 EXTRA FENESTRATED 24.10 SQCM,120.567,CDM,272,RC,Q4197,HCPCS,,12806-MAIN,LOCAL,,,,,6562,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3215.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2725.8548,6430.76
PURAPLYAM XT-COM 4.91X4.91 EXTRA FENESTRATED 24.10 SQCM,120.567,CDM,272,RC,Q4197,HCPCS,,12806-MAIN,LOCAL,,,,,6562,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3215.38,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2725.8548,6430.76
Level 6 Additional Procedure,PX36000085,CDM,360,RC,,,,,,,,,,6500,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3217.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2700.1,6370
Room Rate Swing General,PX12000010,CDM,120,RC,,,,,,,,,,3788,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3219.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1573.5352,3712.24
Room Rate Swing General Iso,PX12000011,CDM,120,RC,,,,,,,,,,3788,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3219.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1573.5352,3712.24
bezlotoxumab 1000 MG/40ML Solution 40 mL Vial,J0565.01,CDM,636,RC,J0565,HCPCS,,,,6302500,NDC,40,ML,7752,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3220.1808,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.7,7596.96
"Lap,Esophagogast Fundoplasty",PX43280F,CDM,510,RC,43280,CPT,,,,,,,,6713,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3222.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2788.5802,8992.74
"Lap,Esophagogast Fundoplasty",PX43280F,CDM,510,RC,43280,CPT,,,,,,,,6713,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3222.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2788.5802,8992.74
romiPLOStim 250 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022101,NDC,1,EA,3791.51,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3222.7835,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.04,6877.885
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012001,NDC,0.6,EA,7764.12,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3225.215448,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.39,10431.7962
"Mra, Head W/Out Contrast",PX7054401,CDM,610,RC,70544,CPT,TC,,,,,,,3541,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3225.851,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
"Mra, Neck With Contrast",PX7054801,CDM,610,RC,70548,CPT,TC,,,,,,,3541,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3225.851,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI Brain W & WO Contrast,PX7055301,CDM,610,RC,70553,CPT,TC,,,,,,,3541,,Medica,Commercial,both,91.1,,2142.4,percent of total billed charges,3225.851,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI C Spine W&WO Contrast,PX7215601,CDM,610,RC,72156,CPT,TC,,,,,,,3541,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3225.851,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI C-Spine WO Contrast,PX7214101,CDM,610,RC,72141,CPT,TC,,,,,,,3541,,Medica,Commercial,both,91.1,,822.1,percent of total billed charges,3225.851,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI L Spine WO Contrast,PX7214801,CDM,610,RC,72148,CPT,TC,,,,,,,3541,,Medica,Commercial,both,91.1,,1393.62,percent of total billed charges,3225.851,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI Low Ext Jnt WO/Cont Tc,PX7372101,CDM,610,RC,73721,CPT,TC,,,,,,,3541,,Medica,Commercial,both,91.1,,1780.052,percent of total billed charges,3225.851,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI Orb-Fac-Nec W/O+W/Con,PX7054301,CDM,610,RC,70543,CPT,TC,,,,,,,3541,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3225.851,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
"MRI,Upr Ext, Joint,W/Cont",PX7322201,CDM,610,RC,73222,CPT,TC,,,,,,,3541,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3225.851,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,611.05,3470.18
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270012,NDC,100,ML,3293.58,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3227.7084,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
"MRI,Lwrext,No Jnt, W/Cont",PX7371901,CDM,610,RC,73719,CPT,TC,,,,,,,3627,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3228.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3554.46
DYNANITE PIP - STRAIGHT 12MM - WITH INSTRUMENTATION,27200000,CDM,278,RC,C1713,HCPCS,,11626-MAIN,LOCAL,,,,,3543.65,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3228.26515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP - STRAIGHT 14MM - WITH INSTRUMENTATION,27200000,CDM,278,RC,C1713,HCPCS,,11627-MAIN,LOCAL,,,,,3543.65,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3228.26515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT BENT 12MM,27200000,CDM,278,RC,C1713,HCPCS,,11629-MAIN,LOCAL,,,,,3543.65,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3228.26515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT BENT 14MM,27200000,CDM,278,RC,C1713,HCPCS,,11631-MAIN,LOCAL,,,,,3543.65,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3228.26515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT BENT 16MM,27200000,CDM,278,RC,C1713,HCPCS,,11633-MAIN,LOCAL,,,,,3543.65,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3228.26515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT STRAIGHT 12MM,27200000,CDM,278,RC,C1713,HCPCS,,11628-MAIN,LOCAL,,,,,3543.65,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3228.26515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT STRAIGHT 14MM,27200000,CDM,278,RC,C1713,HCPCS,,11630-MAIN,LOCAL,,,,,3543.65,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3228.26515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT STRAIGHT 16MM,27200000,CDM,278,RC,C1713,HCPCS,,11632-MAIN,LOCAL,,,,,3543.65,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3228.26515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
REVITA PLACENTAL MEMBRANE 4X4CM 16SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12560-MAIN,LOCAL,,,,,6597,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3232.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
REVITA PLACENTAL MEMBRANE 4X4CM 16SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12560-MAIN,LOCAL,,,,,6597,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3232.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
REVITA PLACENTAL MEMBRANE 4X4CM 16SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12560-MAIN,LOCAL,,,,,6597,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3232.53,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
Or Level 4,PX36000004,CDM,360,RC,,,,,,,,,,3805,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3234.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1580.597,3728.9
CT Head/Brain W/O & W/Dye,PX7047001,CDM,350,RC,70470,CPT,TC,,,,,,,3671,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3237.822,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3597.58
"CT Colonography, Screen",PX7426301,CDM,350,RC,74263,CPT,TC,,,,,,,3330,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3241.089,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1383.282,3263.4
PURAPLYAM XT-COM 4.91X4.91 EXTRA FENESTRATED 24.10 SQCM,120.567,CDM,272,RC,Q4197,HCPCS,,12806-MAIN,LOCAL,,,,,6562,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3248.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2725.8548,6430.76
MRI Up Extremity Joint W/O Tc,PX7322101,CDM,610,RC,73221,CPT,TC,,,,,,,3319,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3252.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3252.62
CT Abdomen W/O & W/Dye,PX7417001,CDM,350,RC,74170,CPT,TC,,,,,,,3689,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3253.698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3615.22
"CT Angiography, Chest",PX7127501,CDM,350,RC,71275,CPT,TC,,,,,,,3689,,United Healthcare,All Payer,outpatient,88.2,,4818.41,percent of total billed charges,3253.698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3615.22
"CT Angiography, Head",PX7049601,CDM,350,RC,70496,CPT,TC,,,,,,,3690,,United Healthcare,All Payer,outpatient,88.2,,2483.715,percent of total billed charges,3254.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3616.2
"CT Angiography, Neck",PX7049801,CDM,350,RC,70498,CPT,TC,,,,,,,3690,,United Healthcare,All Payer,outpatient,88.2,,2483.71,percent of total billed charges,3254.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3616.2
Remv Periton FB From Perit Cav,PX49402F,CDM,510,RC,49402,CPT,,,,,,,,3573,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3255.003,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1484.2242,3501.54
durvalumab 500 MG/10ML Solution 10 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310461150,NDC,10,ML,7588.77,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3255.58233,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.48,21336.462
Remove Foreign Body Complic,PX10121F,CDM,510,RC,10121,CPT,,,,,,,,3575,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3256.825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1416.38,3503.5
"Up GI Endoscopy,Ball Dil,30mm",PX43249F,CDM,750,RC,43249,CPT,,,,,,,,2596,,Blue Cross Blue Shield of MN,All commercial plans,both,,,1185.11,fee schedule,3257.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,958.1,3257.54
"Up GI Endoscopy,Ball Dil,30mm",PX43249P,CDM,983,RC,43249,CPT,,,,,,,,1731,,Blue Cross Blue Shield of MN,All commercial plans,both,,,1185.11,fee schedule,3257.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,742.599,3257.54
ALLOGRAFT BONE AUGMENT INJECTABLE KIT 1.5CC,C1734,CDM,278,RC,C1734,HCPCS,,12632-MAIN,LOCAL,,,,,3694,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3258.108,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1534.4876,3620.12
"CT Colonography, Screen",PX7426301,CDM,350,RC,74263,CPT,TC,,,,,,,3330,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3263.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1383.282,3263.4
CT Lumbar Spine W/Dye,PX7213201,CDM,350,RC,72132,CPT,TC,,,,,,,3330,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3263.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3263.4
CT Pelvis W/Dye,PX7219301,CDM,350,RC,72193,CPT,TC,,,,,,,3330,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3263.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3263.4
CT Maxillofacial W/Dye,PX7048701,CDM,350,RC,70487,CPT,TC,,,,,,,3332,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3265.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3265.36
REVITA PLACENTAL MEMBRANE 4X4CM 16SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12560-MAIN,LOCAL,,,,,6597,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3265.515,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
CT Head/Brain W/O & W/Dye,PX7047001,CDM,350,RC,70470,CPT,TC,,,,,,,3671,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3267.19,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3597.58
"Colonoscopy,Transendoscopic Stent",PX45387P,CDM,983,RC,45387,CPT,,,,,,,,3587,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3267.757,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1490.0398,3491.2271
MRI Brain WO Contrast Tc,PX7055101,CDM,610,RC,70551,CPT,TC,,,,,,,3335,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3268.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3268.3
MRI Orbit/Face/Neck Tc,PX7054001,CDM,610,RC,70540,CPT,TC,,,,,,,3335,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3268.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3268.3
isatuximab-irfc 500 MG/25ML Solution 25 mL Vial,J9227.01,CDM,636,RC,J9227,HCPCS,,,,24065601,NDC,25,ML,7876.36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3271.839944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.13,7718.8328
GOLIMumab 50 MG/4ML Solution 4 mL Vial,J1602.01,CDM,636,RC,J1602,HCPCS,,,,57894035001,NDC,4,ML,3709.76,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3272.00832,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.31,3635.5648
Cytogenomic Neoplasia (Genome-Wide) Microarray Analysis - Ref,PX8127790,CDM,310,RC,81277,CPT,90,,,,,,,3850,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3272.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1063.6,3773
CT Abdomen W/O & W/Dye,PX7417001,CDM,350,RC,74170,CPT,TC,,,,,,,3689,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3283.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3615.22
"CT Angiography, Chest",PX7127501,CDM,350,RC,71275,CPT,TC,,,,,,,3689,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3283.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3615.22
"CT Angiography, Head",PX7049601,CDM,350,RC,70496,CPT,TC,,,,,,,3690,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3284.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3616.2
"CT Angiography, Neck",PX7049801,CDM,350,RC,70498,CPT,TC,,,,,,,3690,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3284.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3616.2
ALLOGRAFT BONE AUGMENT INJECTABLE KIT 1.5CC,C1734,CDM,278,RC,C1734,HCPCS,,12632-MAIN,LOCAL,,,,,3694,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3287.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1534.4876,3620.12
Level 6 Additional Procedure,PX36000085,CDM,360,RC,,,,,,,,,,6500,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3289,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2700.1,6370
"Lap,Esophagogast Fundoplasty",PX43280F,CDM,510,RC,43280,CPT,,,,,,,,6713,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3289.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2788.5802,8992.74
"Lap,Esophagogast Fundoplasty",PX43280F,CDM,510,RC,43280,CPT,,,,,,,,6713,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3289.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2788.5802,8992.74
"Lap,Esophagogast Fundoplasty",PX43280F,CDM,510,RC,43280,CPT,,,,,,,,6713,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3289.37,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2788.5802,8992.74
rabies immune globulin 300 UNIT/2ML Solution 2 mL Vial,90377,CDM,636,RC,90376,CPT,,,,49281019020,NDC,2,ML,3384.84,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3294.464772,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,207.94,3317.1432
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218713,NDC,2,EA,6875.36,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3300.1728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.57,6737.8528
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218713,NDC,2,EA,6875.36,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3300.1728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.57,6737.8528
GOLIMumab 50 MG/4ML Solution 4 mL Vial,J1602.01,CDM,636,RC,J1602,HCPCS,,,,57894035001,NDC,4,ML,3709.76,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3301.6864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.31,3635.5648
"MRI,Lwrext,No Jnt, W/Cont",PX7371901,CDM,610,RC,73719,CPT,TC,,,,,,,3627,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3304.197,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3554.46
Or Level 6,PX36000006,CDM,360,RC,,,,,,,,,,7960,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3306.584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3306.584,7800.8
Injection for Nerve Block,PX64447P,CDM,983,RC,64447,CPT,,,,,,,,3892,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3308.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,604.15,3788.0836
Remv Periton FB From Perit Cav,PX49402P,CDM,983,RC,49402,CPT,,,,,,,,3897,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3312.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1618.8138,3792.9501
rabies immune globulin 300 UNIT/2ML Solution 2 mL Vial,90377,CDM,636,RC,90376,CPT,,,,49281019020,NDC,2,ML,3384.84,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3317.1432,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,207.94,3317.1432
LARGE HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12836-MAIN,LOCAL,,,,,3905,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3319.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
MEDIUM HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12835-MAIN,LOCAL,,,,,3905,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3319.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
SMALL HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12655-MAIN,LOCAL,,,,,3905,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3319.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PURAPLYAM XT-COM 4.91X4.91 EXTRA FENESTRATED 24.10 SQCM,120.567,CDM,272,RC,Q4197,HCPCS,,12806-MAIN,LOCAL,,,,,6562,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3320.372,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2725.8548,6430.76
AMNION MATRIX CORD STERILE 3X6,27200000,CDM,272,RC,C1762,HCPCS,,11625-MAIN,LOCAL,,,,,6919,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3321.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
AMNION MATRIX CORD STERILE 3X6,27200000,CDM,272,RC,C1762,HCPCS,,11625-MAIN,LOCAL,,,,,6919,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3321.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Lap,Esophagogast Fundoplasty",PX43280F,CDM,510,RC,43280,CPT,,,,,,,,6713,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3322.935,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2788.5802,8992.74
bezlotoxumab 1000 MG/40ML Solution 40 mL Vial,J0565.01,CDM,636,RC,J0565,HCPCS,,,,6302500,NDC,40,ML,7752,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3325.608,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.7,7596.96
prothrombin complex concentrate - human 500 units Kit 500 Units Box,J7168.01,CDM,636,RC,J7168,HCPCS,,,,63833038602,NDC,1500,UN,8007,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3326.1078,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.4,7846.86
BMWD 2X2,27200000,CDM,272,RC,Q4104,HCPCS,,12134-MAIN,LOCAL,,,,,8016,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3329.8464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Open Bx/Excision Inguinofemoral Nodes,PX38531F,CDM,510,RC,38531,CPT,,,,,,,,912,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,3329.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,378.8448,3329.99
Open Bx/Excision Inguinofemoral Nodes,PX38531P,CDM,983,RC,38531,CPT,,,,,,,,607,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,3329.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,252.1478,3329.99
CT Head/Brain W/Dye,PX7046001,CDM,350,RC,70460,CPT,TC,,,,,,,3398,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3330.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3330.04
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012001,NDC,0.6,EA,7764.12,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3330.80748,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.39,10431.7962
pegloticase 8 MG/ML Solution 1 mL Vial,J2507.01,CDM,636,RC,J2507,HCPCS,,,,75987008010,NDC,1,ML,48367.38,,Health Partners,All Medicare plans except MSHO,both,,,999999999,fee schedule,3332.42596,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2966.54,3391.91
PLANTAR PLATE IMPLANT SET GRAVITY REPAIR,C1713,CDM,278,RC,C1713,HCPCS,,12649-MAIN,LOCAL,,,,,3921,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3332.85,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
leuprolide 7.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74364203,NDC,1,EA,3782.28,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3335.97096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
REVITA PLACENTAL MEMBRANE 4X4CM 16SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12560-MAIN,LOCAL,,,,,6597,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3338.082,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
mepolizumab 100 MG Recon Soln 1 Each Vial,J2182.01,CDM,636,RC,J2182,HCPCS,,,,173088101,NDC,1,EA,6959.95,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3340.776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.51,6820.751
mepolizumab 100 MG Recon Soln 1 Each Vial,J2182.01,CDM,636,RC,J2182,HCPCS,,,,173088101,NDC,1,EA,6959.95,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3340.776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.51,6820.751
Room Rate Swing General,PX12000010,CDM,120,RC,,,,,,,,,,3788,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3341.016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1573.5352,3712.24
Room Rate Swing General Iso,PX12000011,CDM,120,RC,,,,,,,,,,3788,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3341.016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1573.5352,3712.24
romiPLOStim 250 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022101,NDC,1,EA,3791.51,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3344.11182,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.04,6877.885
CT Head/Brain W/O & W/Dye,PX7047001,CDM,350,RC,70470,CPT,TC,,,,,,,3671,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3344.281,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3597.58
CT Abdomen W/Dye,PX7416001,CDM,350,RC,74160,CPT,TC,,,,,,,3413,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3344.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3344.74
"Closure of Gastrostomy,Surgical",PX43870P,CDM,983,RC,43870,CPT,,,,,,,,4012,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,3345.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1666.5848,3904.8796
CT Soft Tissue Neck W/Dye,PX7049101,CDM,350,RC,70491,CPT,TC,,,,,,,3415,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3346.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3346.7
Diagnostic CT Thorax W/ Contrast,PX7126001,CDM,350,RC,71260,CPT,TC,,,,,,,3415,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3346.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3346.7
rabies immune globulin 1500 UNIT/5ML Solution 5 mL Vial,90375,CDM,636,RC,90375,CPT,,,,13533031805,NDC,5,ML,8065.26,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3350.309004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,281.51,7903.9548
Or Level 4,PX36000004,CDM,360,RC,,,,,,,,,,3805,,United Healthcare,All Payer,outpatient,88.2,,999999999,case rate,3356.01,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3356.01,6141.46
PEMEtrexed 500 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2762301,NDC,1,EA,8086.02,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3358.932708,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.01,7924.2996
CT Abdomen W/O & W/Dye,PX7417001,CDM,350,RC,74170,CPT,TC,,,,,,,3689,,Medica,Commercial,both,91.1,,2329.73,percent of total billed charges,3360.679,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3615.22
"CT Angiography, Chest",PX7127501,CDM,350,RC,71275,CPT,TC,,,,,,,3689,,Medica,Commercial,both,91.1,,1190.25,percent of total billed charges,3360.679,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3615.22
"CT Angiography, Head",PX7049601,CDM,350,RC,70496,CPT,TC,,,,,,,3690,,Medica,Commercial,both,91.1,,1680.795,percent of total billed charges,3361.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3616.2
"CT Angiography, Neck",PX7049801,CDM,350,RC,70498,CPT,TC,,,,,,,3690,,Medica,Commercial,both,91.1,,1120.53,percent of total billed charges,3361.59,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3616.2
"Correct Bunion,Metatarsal Osteotomy",PX28296F,CDM,510,RC,28296,CPT,,,,,,,,8100,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3364.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2827.75,7938
ALLOGRAFT BONE AUGMENT INJECTABLE KIT 1.5CC,C1734,CDM,278,RC,C1734,HCPCS,,12632-MAIN,LOCAL,,,,,3694,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3365.234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1534.4876,3620.12
leuprolide 7.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74364203,NDC,1,EA,3782.28,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3366.2292,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
RomiPLOStim 500 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022201,NDC,1,EA,7018.25,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3368.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.04,6877.885
RomiPLOStim 500 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022201,NDC,1,EA,7018.25,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3368.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.04,6877.885
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218713,NDC,2,EA,6875.36,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,51.4437,percent of total billed charges,3368.9264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.57,6737.8528
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218713,NDC,2,EA,6875.36,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3368.9264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.57,6737.8528
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218713,NDC,2,EA,6875.36,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3368.9264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.57,6737.8528
pegloticase 8 MG/ML Solution 1 mL Vial,J2507.01,CDM,636,RC,J2507,HCPCS,,,,75987008010,NDC,1,ML,48367.38,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,3371.08,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2966.54,3391.91
Room Rate Swing General,PX12000010,CDM,120,RC,,,,,,,,,,3788,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3371.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1573.5352,3712.24
Room Rate Swing General Iso,PX12000011,CDM,120,RC,,,,,,,,,,3788,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3371.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1573.5352,3712.24
MODULAR INSERT TOE JOINT 2.5MM 3.6MMTHK PROXIMAL PHALANGEAL,C1713,CDM,278,RC,C1713,HCPCS,,12530-MAIN,LOCAL,,,,,3968,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3372.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
romiPLOStim 250 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022101,NDC,1,EA,3791.51,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3374.4439,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.04,6877.885
isatuximab-irfc 500 MG/25ML Solution 25 mL Vial,J9227.01,CDM,636,RC,J9227,HCPCS,,,,24065601,NDC,25,ML,7876.36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3378.95844,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.13,7718.8328
GOLIMumab 50 MG/4ML Solution 4 mL Vial,J1602.01,CDM,636,RC,J1602,HCPCS,,,,57894035001,NDC,4,ML,3709.76,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3379.59136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.31,3635.5648
Or Level 4,PX36000004,CDM,360,RC,,,,,,,,,,3805,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3386.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1580.597,3728.9
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270010,NDC,100,ML,3458.14,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3388.9772,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,40.48,3388.9772
AMNION MATRIX CORD STERILE 3X6,27200000,CDM,272,RC,C1762,HCPCS,,11625-MAIN,LOCAL,,,,,6919,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3390.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
AMNION MATRIX CORD STERILE 3X6,27200000,CDM,272,RC,C1762,HCPCS,,11625-MAIN,LOCAL,,,,,6919,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3390.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
AMNION MATRIX CORD STERILE 3X6,27200000,CDM,272,RC,C1762,HCPCS,,11625-MAIN,LOCAL,,,,,6919,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3390.31,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
pegloticase 8 MG/ML Solution 1 mL Vial,J2507.01,CDM,636,RC,J2507,HCPCS,,,,75987008010,NDC,1,ML,48367.38,,Health Partners,Medicare MSHO,both,,,999999999,fee schedule,3391.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2966.54,3391.91
pegloticase 8 MG/ML Solution 1 mL Vial,J2507.01,CDM,636,RC,J2507,HCPCS,,,,75987008010,NDC,1,ML,48367.38,,Health Partners,Minnesota Care Programs,both,,,999999999,fee schedule,3391.91,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2966.54,3391.91
Cytogenomic Neoplasia (Genome-Wide) Microarray Analysis - Ref,PX8127790,CDM,310,RC,81277,CPT,90,,,,,,,3850,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3395.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1063.6,3773
"Lap,Esophagogast Fundoplasty",PX43280F,CDM,510,RC,43280,CPT,,,,,,,,6713,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3396.778,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2788.5802,8992.74
"Mra, Neck W/O+W/ Contrast",PX7054901,CDM,610,RC,70549,CPT,TC,,,,,,,3472,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3402.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3402.56
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218713,NDC,2,EA,6875.36,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3403.3032,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.57,6737.8528
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595F,CDM,360,RC,49595,CPT,,,,,,,,3503,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3409.4699,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1455.1462,3432.94
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595P,CDM,982,RC,49595,CPT,,,,,,,,3503,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3409.4699,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1455.1462,3409.4699
"Closure of Gastrostomy,Surgical",PX43870P,CDM,983,RC,43870,CPT,,,,,,,,4012,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3410.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1666.5848,3904.8796
mepolizumab 100 MG Recon Soln 1 Each Vial,J2182.01,CDM,636,RC,J2182,HCPCS,,,,173088101,NDC,1,EA,6959.95,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3410.3755,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.51,6820.751
mepolizumab 100 MG Recon Soln 1 Each Vial,J2182.01,CDM,636,RC,J2182,HCPCS,,,,173088101,NDC,1,EA,6959.95,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3410.3755,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.51,6820.751
mepolizumab 100 MG Recon Soln 1 Each Vial,J2182.01,CDM,636,RC,J2182,HCPCS,,,,173088101,NDC,1,EA,6959.95,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3410.3755,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.51,6820.751
Or Level 6,PX36000006,CDM,360,RC,,,,,,,,,,7960,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3414.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3306.584,7800.8
"VENTRALIGHT MESH ST WITH ECHO 2 - 15 CM X 20 CM 6"" X 8""",C1781,CDM,278,RC,C1781,HCPCS,,12008-MAIN,LOCAL,,,,,3518,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1256.29,percent of total billed charges,3424.0694,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
AMNION MATRIX CORD STERILE 3X6,27200000,CDM,272,RC,C1762,HCPCS,,11625-MAIN,LOCAL,,,,,6919,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3424.905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Cytogenomic Neoplasia (Genome-Wide) Microarray Analysis - Ref,PX8127790,CDM,310,RC,81277,CPT,90,,,,,,,3850,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3426.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1063.6,3773
belimumab (400v) 400 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010201,NDC,1,EA,3523.71,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,60.46849794,percent of total billed charges,3429.626943,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.72,3453.2358
Injection for Nerve Block,PX64447P,CDM,983,RC,64447,CPT,,,,,,,,3892,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3432.744,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,604.15,3788.0836
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595F,CDM,360,RC,49595,CPT,,,,,,,,3503,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3432.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1455.1462,3432.94
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595P,CDM,982,RC,49595,CPT,,,,,,,,3503,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3432.94,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,453.53,3432.94
prothrombin complex concentrate - human 500 units Kit 500 Units Box,J7168.01,CDM,636,RC,J7168,HCPCS,,,,63833038602,NDC,1500,UN,8007,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3435.003,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.4,7846.86
Remv Periton FB From Perit Cav,PX49402P,CDM,983,RC,49402,CPT,,,,,,,,3897,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3437.154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1618.8138,3792.9501
BMWD 2X2,27200000,CDM,272,RC,Q4104,HCPCS,,12134-MAIN,LOCAL,,,,,8016,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3438.864,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RomiPLOStim 500 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022201,NDC,1,EA,7018.25,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3438.9425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.04,6877.885
RomiPLOStim 500 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022201,NDC,1,EA,7018.25,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3438.9425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.04,6877.885
RomiPLOStim 500 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022201,NDC,1,EA,7018.25,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3438.9425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.04,6877.885
LARGE HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12836-MAIN,LOCAL,,,,,3905,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3444.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
MEDIUM HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12835-MAIN,LOCAL,,,,,3905,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3444.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
SMALL HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12655-MAIN,LOCAL,,,,,3905,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3444.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
mepolizumab 100 MG Recon Soln 1 Each Vial,J2182.01,CDM,636,RC,J2182,HCPCS,,,,173088101,NDC,1,EA,6959.95,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3445.17525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.51,6820.751
leuprolide 7.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74364203,NDC,1,EA,3782.28,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3445.65708,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
"VENTRALIGHT MESH ST WITH ECHO 2 - 15 CM X 20 CM 6"" X 8""",C1781,CDM,278,RC,C1781,HCPCS,,12008-MAIN,LOCAL,,,,,3518,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3447.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
DYNANITE PIP - STRAIGHT 12MM - WITH INSTRUMENTATION,27200000,CDM,278,RC,C1713,HCPCS,,11626-MAIN,LOCAL,,,,,3543.65,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3449.034545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP - STRAIGHT 14MM - WITH INSTRUMENTATION,27200000,CDM,278,RC,C1713,HCPCS,,11627-MAIN,LOCAL,,,,,3543.65,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3449.034545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT BENT 12MM,27200000,CDM,278,RC,C1713,HCPCS,,11629-MAIN,LOCAL,,,,,3543.65,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3449.034545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT BENT 14MM,27200000,CDM,278,RC,C1713,HCPCS,,11631-MAIN,LOCAL,,,,,3543.65,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3449.034545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT BENT 16MM,27200000,CDM,278,RC,C1713,HCPCS,,11633-MAIN,LOCAL,,,,,3543.65,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3449.034545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT STRAIGHT 12MM,27200000,CDM,278,RC,C1713,HCPCS,,11628-MAIN,LOCAL,,,,,3543.65,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3449.034545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT STRAIGHT 14MM,27200000,CDM,278,RC,C1713,HCPCS,,11630-MAIN,LOCAL,,,,,3543.65,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3449.034545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT STRAIGHT 16MM,27200000,CDM,278,RC,C1713,HCPCS,,11632-MAIN,LOCAL,,,,,3543.65,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3449.034545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Room Rate Swing General,PX12000010,CDM,120,RC,,,,,,,,,,3788,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3450.868,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1573.5352,3712.24
Room Rate Swing General Iso,PX12000011,CDM,120,RC,,,,,,,,,,3788,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3450.868,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1573.5352,3712.24
belimumab (400v) 400 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010201,NDC,1,EA,3523.71,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3453.2358,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,33.72,3453.2358
romiPLOStim 250 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022101,NDC,1,EA,3791.51,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3454.06561,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.04,6877.885
PLANTAR PLATE IMPLANT SET GRAVITY REPAIR,C1713,CDM,278,RC,C1713,HCPCS,,12649-MAIN,LOCAL,,,,,3921,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3458.322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
rabies immune globulin 1500 UNIT/5ML Solution 5 mL Vial,90375,CDM,636,RC,90375,CPT,,,,13533031805,NDC,5,ML,8065.26,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3459.99654,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,281.51,7903.9548
Injection for Nerve Block,PX64447P,CDM,983,RC,64447,CPT,,,,,,,,3892,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3463.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,604.15,3788.0836
Or Level 4,PX36000004,CDM,360,RC,,,,,,,,,,3805,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3466.355,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1580.597,3728.9
Remv Periton FB From Perit Cav,PX49402P,CDM,983,RC,49402,CPT,,,,,,,,3897,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3468.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1618.8138,3792.9501
PEMEtrexed 500 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2762301,NDC,1,EA,8086.02,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3468.90258,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.01,7924.2996
"Mra, Head W/Out Contrast",PX7054401,CDM,610,RC,70544,CPT,TC,,,,,,,3541,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3470.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
"Mra, Neck With Contrast",PX7054801,CDM,610,RC,70548,CPT,TC,,,,,,,3541,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3470.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI Brain W & WO Contrast,PX7055301,CDM,610,RC,70553,CPT,TC,,,,,,,3541,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3470.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI C Spine W&WO Contrast,PX7215601,CDM,610,RC,72156,CPT,TC,,,,,,,3541,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3470.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
MRI C-Spine WO Contrast,PX7214101,CDM,610,RC,72141,CPT,TC,,,,,,,3541,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3470.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI L Spine WO Contrast,PX7214801,CDM,610,RC,72148,CPT,TC,,,,,,,3541,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3470.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI Low Ext Jnt WO/Cont Tc,PX7372101,CDM,610,RC,73721,CPT,TC,,,,,,,3541,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3470.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,3470.18
MRI Orb-Fac-Nec W/O+W/Con,PX7054301,CDM,610,RC,70543,CPT,TC,,,,,,,3541,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3470.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3470.18
"MRI,Upr Ext, Joint,W/Cont",PX7322201,CDM,610,RC,73222,CPT,TC,,,,,,,3541,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3470.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,611.05,3470.18
DYNANITE PIP - STRAIGHT 12MM - WITH INSTRUMENTATION,27200000,CDM,278,RC,C1713,HCPCS,,11626-MAIN,LOCAL,,,,,3543.65,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3472.777,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP - STRAIGHT 14MM - WITH INSTRUMENTATION,27200000,CDM,278,RC,C1713,HCPCS,,11627-MAIN,LOCAL,,,,,3543.65,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3472.777,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT BENT 12MM,27200000,CDM,278,RC,C1713,HCPCS,,11629-MAIN,LOCAL,,,,,3543.65,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3472.777,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT BENT 14MM,27200000,CDM,278,RC,C1713,HCPCS,,11631-MAIN,LOCAL,,,,,3543.65,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3472.777,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT BENT 16MM,27200000,CDM,278,RC,C1713,HCPCS,,11633-MAIN,LOCAL,,,,,3543.65,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3472.777,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT STRAIGHT 12MM,27200000,CDM,278,RC,C1713,HCPCS,,11628-MAIN,LOCAL,,,,,3543.65,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3472.777,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT STRAIGHT 14MM,27200000,CDM,278,RC,C1713,HCPCS,,11630-MAIN,LOCAL,,,,,3543.65,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3472.777,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
DYNANITE PIP IMPLANT STRAIGHT 16MM,27200000,CDM,278,RC,C1713,HCPCS,,11632-MAIN,LOCAL,,,,,3543.65,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3472.777,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RomiPLOStim 500 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022201,NDC,1,EA,7018.25,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3474.03375,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.04,6877.885
"Correct Bunion,Metatarsal Osteotomy",PX28296F,CDM,510,RC,28296,CPT,,,,,,,,8100,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3474.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2827.75,7938
LARGE HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12836-MAIN,LOCAL,,,,,3905,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3475.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
MEDIUM HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12835-MAIN,LOCAL,,,,,3905,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3475.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
SMALL HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12655-MAIN,LOCAL,,,,,3905,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3475.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Remv Periton FB From Perit Cav,PX49402F,CDM,510,RC,49402,CPT,,,,,,,,3573,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3477.6009,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1484.2242,3501.54
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218713,NDC,2,EA,6875.36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3478.93216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.57,6737.8528
Remove Foreign Body Complic,PX10121F,CDM,510,RC,10121,CPT,,,,,,,,3575,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3479.5475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1416.38,3503.5
PLANTAR PLATE IMPLANT SET GRAVITY REPAIR,C1713,CDM,278,RC,C1713,HCPCS,,12649-MAIN,LOCAL,,,,,3921,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3489.69,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"Colonoscopy,Transendoscopic Stent",PX45387P,CDM,983,RC,45387,CPT,,,,,,,,3587,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3491.2271,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1490.0398,3491.2271
RESTRATA WOUND MATRIX 10CM X 12.5CM  TOTAL 125CM,27200000,CDM,272,RC,A2007,HCPCS,,11738-MAIN,LOCAL,,,,,8415,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3495.591,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"MRI, Abdomen W/O+ W/Contr",PX7418301,CDM,610,RC,74183,CPT,TC,,,,,,,4116,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3498.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4033.68
MODULAR INSERT TOE JOINT 2.5MM 3.6MMTHK PROXIMAL PHALANGEAL,C1713,CDM,278,RC,C1713,HCPCS,,12530-MAIN,LOCAL,,,,,3968,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3499.776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
AMNION MATRIX CORD STERILE 3X6,27200000,CDM,272,RC,C1762,HCPCS,,11625-MAIN,LOCAL,,,,,6919,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3501.014,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Remv Periton FB From Perit Cav,PX49402F,CDM,510,RC,49402,CPT,,,,,,,,3573,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3501.54,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1484.2242,3501.54
Remove Foreign Body Complic,PX10121F,CDM,510,RC,10121,CPT,,,,,,,,3575,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3503.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1416.38,3503.5
Cytogenomic Neoplasia (Genome-Wide) Microarray Analysis - Ref,PX8127790,CDM,310,RC,81277,CPT,90,,,,,,,3850,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3507.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1063.6,3773
ustekinumab 130 MG/26ML Solution 26 mL Vial,J3358.01,CDM,636,RC,J3358,HCPCS,,,,57894005427,NDC,26,ML,4130,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3510.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.56,4047.4
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242003706,NDC,0.6,EA,8461.09,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3514.736786,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.39,10431.7962
"Colonoscopy,Transendoscopic Stent",PX45387P,CDM,983,RC,45387,CPT,,,,,,,,3587,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3515.26,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,299.5863,3515.26
mepolizumab 100 MG Recon Soln 1 Each Vial,J2182.01,CDM,636,RC,J2182,HCPCS,,,,173088101,NDC,1,EA,6959.95,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3521.7347,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.51,6820.751
MODULAR INSERT TOE JOINT 2.5MM 3.6MMTHK PROXIMAL PHALANGEAL,C1713,CDM,278,RC,C1713,HCPCS,,12530-MAIN,LOCAL,,,,,3968,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3531.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"Closure of Gastrostomy,Surgical",PX43870P,CDM,983,RC,43870,CPT,,,,,,,,4012,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3538.584,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1666.5848,3904.8796
Lap Partial Colectomy/Coloproctostomy,PX44207F,CDM,750,RC,44207,CPT,,,,,,,,4170,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3544.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1130.58,4086.6
Injection for Nerve Block,PX64447P,CDM,983,RC,64447,CPT,,,,,,,,3892,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3545.612,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,604.15,3788.0836
Remv Periton FB From Perit Cav,PX49402P,CDM,983,RC,49402,CPT,,,,,,,,3897,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3550.167,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1618.8138,3792.9501
RomiPLOStim 500 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022201,NDC,1,EA,7018.25,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3551.2345,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.04,6877.885
MRI L Spine W&WO Contrast,PX7215801,CDM,610,RC,72158,CPT,TC,,,,,,,4178,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3551.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4094.44
MRI T Spine W&WO Contrast,PX7215701,CDM,610,RC,72157,CPT,TC,,,,,,,4178,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3551.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4094.44
"MRI,Lwrext,No Jnt, W/Cont",PX7371901,CDM,610,RC,73719,CPT,TC,,,,,,,3627,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3554.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,3554.46
CT Angio Abdom W/O & W/Dye,PX7417501,CDM,350,RC,74175,CPT,TC,,,,,,,4183,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3555.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,4099.34
LARGE HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12836-MAIN,LOCAL,,,,,3905,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3557.455,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
MEDIUM HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12835-MAIN,LOCAL,,,,,3905,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3557.455,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
SMALL HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12655-MAIN,LOCAL,,,,,3905,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3557.455,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
"Closure of Gastrostomy,Surgical",PX43870P,CDM,983,RC,43870,CPT,,,,,,,,4012,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3570.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1666.5848,3904.8796
PLANTAR PLATE IMPLANT SET GRAVITY REPAIR,C1713,CDM,278,RC,C1713,HCPCS,,12649-MAIN,LOCAL,,,,,3921,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3572.031,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
RESTRATA WOUND MATRIX 2.5CM X 7.5CM TOTAL 18.75CM,27200000,CDM,272,RC,A2007,HCPCS,,11735-MAIN,LOCAL,,,,,4208,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3576.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
riTUXimab-abbs 500 MG/50ML Solution 50 mL Vial,Q5115.01,CDM,636,RC,Q5115,HCPCS,,,,63459010450,NDC,50,ML,8624.61,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3582.662994,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.29,8452.1178
CT Abd&Pelv 1+ Section/Regns,PX7417801,CDM,350,RC,74178,CPT,TC,,,,,,,4226,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3592.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4141.48
ALLOGRAFT BONE AUGMENT INJECTABLE KIT 1.5CC,C1734,CDM,278,RC,C1734,HCPCS,,12632-MAIN,LOCAL,,,,,3694,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3595.3702,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1534.4876,3620.12
CT Head/Brain W/O & W/Dye,PX7047001,CDM,350,RC,70470,CPT,TC,,,,,,,3671,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3597.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3597.58
RESTRATA WOUND MATRIX 10CM X 12.5CM  TOTAL 125CM,27200000,CDM,272,RC,A2007,HCPCS,,11738-MAIN,LOCAL,,,,,8415,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3610.035,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
GOLIMumab 50 MG/4ML Solution 4 mL Vial,J1602.01,CDM,636,RC,J1602,HCPCS,,,,57894035001,NDC,4,ML,3709.76,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,14.8391,percent of total billed charges,3610.709408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.31,3635.5648
MODULAR INSERT TOE JOINT 2.5MM 3.6MMTHK PROXIMAL PHALANGEAL,C1713,CDM,278,RC,C1713,HCPCS,,12530-MAIN,LOCAL,,,,,3968,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3614.848,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
CT Abdomen W/O & W/Dye,PX7417001,CDM,350,RC,74170,CPT,TC,,,,,,,3689,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3615.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3615.22
"CT Angiography, Chest",PX7127501,CDM,350,RC,71275,CPT,TC,,,,,,,3689,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3615.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3615.22
"CT Angiography, Head",PX7049601,CDM,350,RC,70496,CPT,TC,,,,,,,3690,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3616.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3616.2
"CT Angiography, Neck",PX7049801,CDM,350,RC,70498,CPT,TC,,,,,,,3690,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3616.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,3616.2
ALLOGRAFT BONE AUGMENT INJECTABLE KIT 1.5CC,C1734,CDM,278,RC,C1734,HCPCS,,12632-MAIN,LOCAL,,,,,3694,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3620.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1534.4876,3620.12
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242003706,NDC,0.6,EA,8461.09,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3629.80761,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.39,10431.7962
"MRI, Abdomen W/O+ W/Contr",PX7418301,CDM,610,RC,74183,CPT,TC,,,,,,,4116,,United Healthcare,All Payer,outpatient,88.2,,2016.84,percent of total billed charges,3630.312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4033.68
GOLIMumab 50 MG/4ML Solution 4 mL Vial,J1602.01,CDM,636,RC,J1602,HCPCS,,,,57894035001,NDC,4,ML,3709.76,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3635.5648,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.31,3635.5648
CT Lumbar Spine W/O & W/Dye,PX7213301,CDM,350,RC,72133,CPT,TC,,,,,,,4283,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3640.55,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,4197.34
durvalumab 500 MG/10ML Solution 10 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310461150,NDC,10,ML,7588.77,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3642.6096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.48,21336.462
durvalumab 500 MG/10ML Solution 10 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310461150,NDC,10,ML,7588.77,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3642.6096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.48,21336.462
ustekinumab 130 MG/26ML Solution 26 mL Vial,J3358.01,CDM,636,RC,J3358,HCPCS,,,,57894005427,NDC,26,ML,4130,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3642.66,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.56,4047.4
CT Abd & Pelvis W/O Contrast,PX7417601,CDM,350,RC,74176,CPT,TC,,,,,,,4288,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3644.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,4202.24
CT Abdomen&Pelvis W/Contrast,PX7417701,CDM,350,RC,74177,CPT,TC,,,,,,,4288,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3644.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4202.24
"Closure of Gastrostomy,Surgical",PX43870P,CDM,983,RC,43870,CPT,,,,,,,,4012,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3654.932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1666.5848,3904.8796
"MRI, Abdomen W/O+ W/Contr",PX7418301,CDM,610,RC,74183,CPT,TC,,,,,,,4116,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3663.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4033.68
Multiple Sleep Latency Test,PX9580501,CDM,740,RC,95805,CPT,TC,,,,,,,4313,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3666.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,468.24,4226.74
"Polysomnography, 4 or More",PX9581001,CDM,740,RC,95810,CPT,TC,,,,,,,4313,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3666.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,913.4,4226.74
ustekinumab 130 MG/26ML Solution 26 mL Vial,J3358.01,CDM,636,RC,J3358,HCPCS,,,,57894005427,NDC,26,ML,4130,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3675.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.56,4047.4
Lap Partial Colectomy/Coloproctostomy,PX44207F,CDM,750,RC,44207,CPT,,,,,,,,4170,,United Healthcare,All Payer,outpatient,88.2,,999999999,case rate,3677.94,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3677.94,6141.46
riTUXimab 500 MG/50ML Solution 50 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005306,NDC,50,ML,8860.06,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,3680.468924,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.61,8682.8588
leuprolide 7.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74364203,NDC,1,EA,3782.28,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3681.293124,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
MRI L Spine W&WO Contrast,PX7215801,CDM,610,RC,72158,CPT,TC,,,,,,,4178,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3684.996,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4094.44
MRI T Spine W&WO Contrast,PX7215701,CDM,610,RC,72157,CPT,TC,,,,,,,4178,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3684.996,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4094.44
Room Rate Swing General,PX12000010,CDM,120,RC,,,,,,,,,,3788,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3686.8604,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1573.5352,3712.24
Room Rate Swing General Iso,PX12000011,CDM,120,RC,,,,,,,,,,3788,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3686.8604,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1573.5352,3712.24
CT Angio Abdom W/O & W/Dye,PX7417501,CDM,350,RC,74175,CPT,TC,,,,,,,4183,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3689.406,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,4099.34
romiPLOStim 250 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022101,NDC,1,EA,3791.51,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3690.276683,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.04,6877.885
riTUXimab-abbs 500 MG/50ML Solution 50 mL Vial,Q5115.01,CDM,636,RC,Q5115,HCPCS,,,,63459010450,NDC,50,ML,8624.61,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3699.95769,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.29,8452.1178
Or Level 4,PX36000004,CDM,360,RC,,,,,,,,,,3805,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3703.4065,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1580.597,3728.9
leuprolide 7.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74364203,NDC,1,EA,3782.28,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3706.6344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
Lap Partial Colectomy/Coloproctostomy,PX44207F,CDM,750,RC,44207,CPT,,,,,,,,4170,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3711.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1130.58,4086.6
RESTRATA WOUND MATRIX 2.5CM X 7.5CM TOTAL 18.75CM,27200000,CDM,272,RC,A2007,HCPCS,,11735-MAIN,LOCAL,,,,,4208,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3711.456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Room Rate Swing General,PX12000010,CDM,120,RC,,,,,,,,,,3788,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3712.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1573.5352,3712.24
Room Rate Swing General Iso,PX12000011,CDM,120,RC,,,,,,,,,,3788,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3712.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1573.5352,3712.24
romiPLOStim 250 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022101,NDC,1,EA,3791.51,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3715.6798,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.04,6877.885
MRI L Spine W&WO Contrast,PX7215801,CDM,610,RC,72158,CPT,TC,,,,,,,4178,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3718.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4094.44
MRI T Spine W&WO Contrast,PX7215701,CDM,610,RC,72157,CPT,TC,,,,,,,4178,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3718.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4094.44
durvalumab 500 MG/10ML Solution 10 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310461150,NDC,10,ML,7588.77,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3718.4973,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.48,21336.462
durvalumab 500 MG/10ML Solution 10 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310461150,NDC,10,ML,7588.77,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3718.4973,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.48,21336.462
durvalumab 500 MG/10ML Solution 10 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310461150,NDC,10,ML,7588.77,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3718.4973,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.48,21336.462
bezlotoxumab 1000 MG/40ML Solution 40 mL Vial,J0565.01,CDM,636,RC,J0565,HCPCS,,,,6302500,NDC,40,ML,7752,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3720.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.7,7596.96
bezlotoxumab 1000 MG/40ML Solution 40 mL Vial,J0565.01,CDM,636,RC,J0565,HCPCS,,,,6302500,NDC,40,ML,7752,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3720.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.7,7596.96
CT Angio Abdom W/O & W/Dye,PX7417501,CDM,350,RC,74175,CPT,TC,,,,,,,4183,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3722.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,4099.34
Lap Partial Colectomy/Coloproctostomy,PX44207F,CDM,750,RC,44207,CPT,,,,,,,,4170,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,3724.65,Facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1085.08,3724.65
Lap Partial Colectomy/Coloproctostomy,PX44207F,CDM,750,RC,44207,CPT,,,,,,,,4170,,Blue Cross Blue Shield of MN,All contracted plans,both,,,999999999,fee schedule,3724.65,Non facility Rate,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1085.08,3724.65
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012001,NDC,0.6,EA,7764.12,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3726.7776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.39,10431.7962
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012001,NDC,0.6,EA,7764.12,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3726.7776,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.39,10431.7962
CT Abd&Pelv 1+ Section/Regns,PX7417801,CDM,350,RC,74178,CPT,TC,,,,,,,4226,,United Healthcare,All Payer,outpatient,88.2,,2070.74,percent of total billed charges,3727.332,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4141.48
Or Level 4,PX36000004,CDM,360,RC,,,,,,,,,,3805,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3728.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1580.597,3728.9
RESTRATA WOUND MATRIX 2.5CM X 7.5CM TOTAL 18.75CM,27200000,CDM,272,RC,A2007,HCPCS,,11735-MAIN,LOCAL,,,,,4208,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3745.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
sarilumab 200 MG/1.14ML solution prefilled syringe 1.14 mL Syringe,J3590.25,CDM,636,RC,J3590,HCPCS,,,,24591001,NDC,1.14,ML,4408.29,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3747.0465,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1831.203666,4320.1242
Cytogenomic Neoplasia (Genome-Wide) Microarray Analysis - Ref,PX8127790,CDM,310,RC,81277,CPT,90,,,,,,,3850,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3747.205,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1063.6,3773
"MRI, Abdomen W/O+ W/Contr",PX7418301,CDM,610,RC,74183,CPT,TC,,,,,,,4116,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3749.676,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4033.68
durvalumab 500 MG/10ML Solution 10 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310461150,NDC,10,ML,7588.77,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3756.44115,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.48,21336.462
CT Abd&Pelv 1+ Section/Regns,PX7417801,CDM,350,RC,74178,CPT,TC,,,,,,,4226,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3761.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4141.48
ustekinumab 130 MG/26ML Solution 26 mL Vial,J3358.01,CDM,636,RC,J3358,HCPCS,,,,57894005427,NDC,26,ML,4130,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3762.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.56,4047.4
Cytogenomic Neoplasia (Genome-Wide) Microarray Analysis - Ref,PX8127790,CDM,310,RC,81277,CPT,90,,,,,,,3850,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3773,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1063.6,3773
CT Lumbar Spine W/O & W/Dye,PX7213301,CDM,350,RC,72133,CPT,TC,,,,,,,4283,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3777.606,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,4197.34
isatuximab-irfc 500 MG/25ML Solution 25 mL Vial,J9227.01,CDM,636,RC,J9227,HCPCS,,,,24065601,NDC,25,ML,7876.36,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3780.6528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.13,7718.8328
isatuximab-irfc 500 MG/25ML Solution 25 mL Vial,J9227.01,CDM,636,RC,J9227,HCPCS,,,,24065601,NDC,25,ML,7876.36,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3780.6528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.13,7718.8328
"Lap,Esophagogast Fundoplasty",PX43280P,CDM,983,RC,43280,CPT,,,,,,,,4449,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3781.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1848.1146,8992.74
CT Abd & Pelvis W/O Contrast,PX7417601,CDM,350,RC,74176,CPT,TC,,,,,,,4288,,United Healthcare,All Payer,outpatient,88.2,,1998.24,percent of total billed charges,3782.016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,4202.24
CT Abdomen&Pelvis W/Contrast,PX7417701,CDM,350,RC,74177,CPT,TC,,,,,,,4288,,United Healthcare,All Payer,outpatient,88.2,,2184.366364,percent of total billed charges,3782.016,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4202.24
Injection for Nerve Block,PX64447P,CDM,983,RC,64447,CPT,,,,,,,,3892,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3788.0836,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,604.15,3788.0836
Remv Periton FB From Perit Cav,PX49402P,CDM,983,RC,49402,CPT,,,,,,,,3897,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3792.9501,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1618.8138,3792.9501
bezlotoxumab 1000 MG/40ML Solution 40 mL Vial,J0565.01,CDM,636,RC,J0565,HCPCS,,,,6302500,NDC,40,ML,7752,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3798.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.7,7596.96
bezlotoxumab 1000 MG/40ML Solution 40 mL Vial,J0565.01,CDM,636,RC,J0565,HCPCS,,,,6302500,NDC,40,ML,7752,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3798.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.7,7596.96
bezlotoxumab 1000 MG/40ML Solution 40 mL Vial,J0565.01,CDM,636,RC,J0565,HCPCS,,,,6302500,NDC,40,ML,7752,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3798.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.7,7596.96
Lap Partial Colectomy/Coloproctostomy,PX44207F,CDM,750,RC,44207,CPT,,,,,,,,4170,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3798.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1130.58,4086.6
LARGE HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12836-MAIN,LOCAL,,,,,3905,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3800.7365,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
MEDIUM HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12835-MAIN,LOCAL,,,,,3905,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3800.7365,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
SMALL HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12655-MAIN,LOCAL,,,,,3905,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3800.7365,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
riTUXimab 500 MG/50ML Solution 50 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005306,NDC,50,ML,8860.06,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,3800.96574,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.61,8682.8588
Multiple Sleep Latency Test,PX9580501,CDM,740,RC,95805,CPT,TC,,,,,,,4313,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3804.066,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,468.24,4226.74
"Polysomnography, 4 or More",PX9581001,CDM,740,RC,95810,CPT,TC,,,,,,,4313,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3804.066,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,913.4,4226.74
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012001,NDC,0.6,EA,7764.12,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,27.9628,percent of total billed charges,3804.4188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.39,10431.7962
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012001,NDC,0.6,EA,7764.12,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3804.4188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.39,10431.7962
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012001,NDC,0.6,EA,7764.12,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3804.4188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.39,10431.7962
MRI L Spine W&WO Contrast,PX7215801,CDM,610,RC,72158,CPT,TC,,,,,,,4178,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3806.158,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4094.44
MRI T Spine W&WO Contrast,PX7215701,CDM,610,RC,72157,CPT,TC,,,,,,,4178,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3806.158,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4094.44
CT Angio Abdom W/O & W/Dye,PX7417501,CDM,350,RC,74175,CPT,TC,,,,,,,4183,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3810.713,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,4099.34
CT Lumbar Spine W/O & W/Dye,PX7213301,CDM,350,RC,72133,CPT,TC,,,,,,,4283,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3811.87,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,4197.34
Injection for Nerve Block,PX64447P,CDM,983,RC,64447,CPT,,,,,,,,3892,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3814.16,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.05,3814.16
PLANTAR PLATE IMPLANT SET GRAVITY REPAIR,C1713,CDM,278,RC,C1713,HCPCS,,12649-MAIN,LOCAL,,,,,3921,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3816.3093,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
CT Abd & Pelvis W/O Contrast,PX7417601,CDM,350,RC,74176,CPT,TC,,,,,,,4288,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3816.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,4202.24
CT Abdomen&Pelvis W/Contrast,PX7417701,CDM,350,RC,74177,CPT,TC,,,,,,,4288,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3816.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4202.24
Remv Periton FB From Perit Cav,PX49402P,CDM,983,RC,49402,CPT,,,,,,,,3897,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3819.06,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,510.91,3819.06
Or Level 6,PX36000006,CDM,360,RC,,,,,,,,,,7960,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3820.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3306.584,7800.8
Or Level 6,PX36000006,CDM,360,RC,,,,,,,,,,7960,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3820.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3306.584,7800.8
LARGE HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12836-MAIN,LOCAL,,,,,3905,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3826.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
MEDIUM HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12835-MAIN,LOCAL,,,,,3905,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3826.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
SMALL HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12655-MAIN,LOCAL,,,,,3905,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3826.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
RESTRATA WOUND MATRIX 2.5CM X 7.5CM TOTAL 18.75CM,27200000,CDM,272,RC,A2007,HCPCS,,11735-MAIN,LOCAL,,,,,4208,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3833.488,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
bezlotoxumab 1000 MG/40ML Solution 40 mL Vial,J0565.01,CDM,636,RC,J0565,HCPCS,,,,6302500,NDC,40,ML,7752,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3837.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.7,7596.96
Multiple Sleep Latency Test,PX9580501,CDM,740,RC,95805,CPT,TC,,,,,,,4313,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3838.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,468.24,4226.74
"Polysomnography, 4 or More",PX9581001,CDM,740,RC,95810,CPT,TC,,,,,,,4313,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3838.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,913.4,4226.74
durvalumab 500 MG/10ML Solution 10 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310461150,NDC,10,ML,7588.77,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3839.91762,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.48,21336.462
PLANTAR PLATE IMPLANT SET GRAVITY REPAIR,C1713,CDM,278,RC,C1713,HCPCS,,12649-MAIN,LOCAL,,,,,3921,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3842.58,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012001,NDC,0.6,EA,7764.12,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3843.2394,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.39,10431.7962
prothrombin complex concentrate - human 500 units Kit 500 Units Box,J7168.01,CDM,636,RC,J7168,HCPCS,,,,63833038602,NDC,1500,UN,8007,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3843.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.4,7846.86
prothrombin complex concentrate - human 500 units Kit 500 Units Box,J7168.01,CDM,636,RC,J7168,HCPCS,,,,63833038602,NDC,1500,UN,8007,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3843.36,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.4,7846.86
BMWD 2X2,27200000,CDM,272,RC,Q4104,HCPCS,,12134-MAIN,LOCAL,,,,,8016,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3847.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
BMWD 2X2,27200000,CDM,272,RC,Q4104,HCPCS,,12134-MAIN,LOCAL,,,,,8016,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3847.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CT Abd&Pelv 1+ Section/Regns,PX7417801,CDM,350,RC,74178,CPT,TC,,,,,,,4226,,Medica,Commercial,both,91.1,,740,percent of total billed charges,3849.886,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4141.48
HIMAX STAPLE KIT 18X14X14,27200000,CDM,278,RC,C1713,HCPCS,,11851-MAIN,LOCAL,,,,,4536,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3855.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
isatuximab-irfc 500 MG/25ML Solution 25 mL Vial,J9227.01,CDM,636,RC,J9227,HCPCS,,,,24065601,NDC,25,ML,7876.36,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,29.9874,percent of total billed charges,3859.4164,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.13,7718.8328
isatuximab-irfc 500 MG/25ML Solution 25 mL Vial,J9227.01,CDM,636,RC,J9227,HCPCS,,,,24065601,NDC,25,ML,7876.36,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3859.4164,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.13,7718.8328
isatuximab-irfc 500 MG/25ML Solution 25 mL Vial,J9227.01,CDM,636,RC,J9227,HCPCS,,,,24065601,NDC,25,ML,7876.36,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3859.4164,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.13,7718.8328
"Upper GI Endoscopy,Biopsy",PX43239F,CDM,750,RC,43239,CPT,,,,,,,,2364,,Blue Cross Blue Shield of MN,All commercial plans,both,,,896.224,fee schedule,3859.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,3859.68
"Upper GI Endoscopy,Biopsy",PX43239P,CDM,983,RC,43239,CPT,,,,,,,,2458,,Blue Cross Blue Shield of MN,All commercial plans,both,,,896.224,fee schedule,3859.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,3859.68
"Upper GI Endoscopy,Diagnosis",PX43235F,CDM,750,RC,43235,CPT,,,,,,,,2539,,Blue Cross Blue Shield of MN,All commercial plans,both,,,1371.434,fee schedule,3859.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,791.92,3859.68
"Upper GI Endoscopy,Diagnosis",PX43235P,CDM,983,RC,43235,CPT,,,,,,,,1406,,Blue Cross Blue Shield of MN,All commercial plans,both,,,1371.434,fee schedule,3859.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,603.174,3859.68
MODULAR INSERT TOE JOINT 2.5MM 3.6MMTHK PROXIMAL PHALANGEAL,C1713,CDM,278,RC,C1713,HCPCS,,12530-MAIN,LOCAL,,,,,3968,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3862.0544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
rabies immune globulin 1500 UNIT/5ML Solution 5 mL Vial,90375,CDM,636,RC,90375,CPT,,,,13533031805,NDC,5,ML,8065.26,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3871.3248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,281.51,7903.9548
rabies immune globulin 1500 UNIT/5ML Solution 5 mL Vial,90375,CDM,636,RC,90375,CPT,,,,13533031805,NDC,5,ML,8065.26,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3871.3248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,281.51,7903.9548
PEMEtrexed 500 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2762301,NDC,1,EA,8086.02,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3881.2896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.01,7924.2996
PEMEtrexed 500 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2762301,NDC,1,EA,8086.02,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3881.2896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.01,7924.2996
"Colonoscopy,Flex,Screen",PX2002F,CDM,750,RC,G0105,HCPCS,,,,,,,,2539,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,3885.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,798.45,3885.86
"Colonoscopy,Screen Prev",PX2004F,CDM,750,RC,G0121,HCPCS,,,,,,,,2502,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,3885.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,798.45,3885.86
"Correct Bunion,Metatarsal Osteotomy",PX28296F,CDM,510,RC,28296,CPT,,,,,,,,8100,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,3888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2827.75,7938
"Correct Bunion,Metatarsal Osteotomy",PX28296F,CDM,510,RC,28296,CPT,,,,,,,,8100,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,3888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2827.75,7938
sarilumab 200 MG/1.14ML solution prefilled syringe 1.14 mL Syringe,J3590.25,CDM,636,RC,J3590,HCPCS,,,,24591001,NDC,1.14,ML,4408.29,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3888.11178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1831.203666,4320.1242
MODULAR INSERT TOE JOINT 2.5MM 3.6MMTHK PROXIMAL PHALANGEAL,C1713,CDM,278,RC,C1713,HCPCS,,12530-MAIN,LOCAL,,,,,3968,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3888.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Polysomnography W/Cpap,PX9581101,CDM,740,RC,95811,CPT,TC,,,,,,,4575,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3888.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,913.4,4483.5
isatuximab-irfc 500 MG/25ML Solution 25 mL Vial,J9227.01,CDM,636,RC,J9227,HCPCS,,,,24065601,NDC,25,ML,7876.36,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3898.7982,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.13,7718.8328
Or Level 6,PX36000006,CDM,360,RC,,,,,,,,,,7960,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3900.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3306.584,7800.8
Or Level 6,PX36000006,CDM,360,RC,,,,,,,,,,7960,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3900.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3306.584,7800.8
Or Level 6,PX36000006,CDM,360,RC,,,,,,,,,,7960,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3900.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3306.584,7800.8
CT Lumbar Spine W/O & W/Dye,PX7213301,CDM,350,RC,72133,CPT,TC,,,,,,,4283,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3901.813,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,4197.34
"Closure of Gastrostomy,Surgical",PX43870P,CDM,983,RC,43870,CPT,,,,,,,,4012,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,3904.8796,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1666.5848,3904.8796
CT Abd & Pelvis W/O Contrast,PX7417601,CDM,350,RC,74176,CPT,TC,,,,,,,4288,,Medica,Commercial,both,91.1,,2873.831818,percent of total billed charges,3906.368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,4202.24
CT Abdomen&Pelvis W/Contrast,PX7417701,CDM,350,RC,74177,CPT,TC,,,,,,,4288,,Medica,Commercial,both,91.1,,1208.2625,percent of total billed charges,3906.368,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4202.24
bezlotoxumab 1000 MG/40ML Solution 40 mL Vial,J0565.01,CDM,636,RC,J0565,HCPCS,,,,6302500,NDC,40,ML,7752,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3922.512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.7,7596.96
sarilumab 200 MG/1.14ML solution prefilled syringe 1.14 mL Syringe,J3590.25,CDM,636,RC,J3590,HCPCS,,,,24591001,NDC,1.14,ML,4408.29,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3923.3781,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1831.203666,4320.1242
prothrombin complex concentrate - human 500 units Kit 500 Units Box,J7168.01,CDM,636,RC,J7168,HCPCS,,,,63833038602,NDC,1500,UN,8007,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3923.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.4,7846.86
prothrombin complex concentrate - human 500 units Kit 500 Units Box,J7168.01,CDM,636,RC,J7168,HCPCS,,,,63833038602,NDC,1500,UN,8007,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3923.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.4,7846.86
prothrombin complex concentrate - human 500 units Kit 500 Units Box,J7168.01,CDM,636,RC,J7168,HCPCS,,,,63833038602,NDC,1500,UN,8007,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3923.43,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.4,7846.86
"Lap,Esophagogast Fundoplasty",PX43280P,CDM,983,RC,43280,CPT,,,,,,,,4449,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,3924.018,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1848.1146,8992.74
BMWD 2X2,27200000,CDM,272,RC,Q4104,HCPCS,,12134-MAIN,LOCAL,,,,,8016,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3927.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
BMWD 2X2,27200000,CDM,272,RC,Q4104,HCPCS,,12134-MAIN,LOCAL,,,,,8016,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3927.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
BMWD 2X2,27200000,CDM,272,RC,Q4104,HCPCS,,12134-MAIN,LOCAL,,,,,8016,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3927.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012001,NDC,0.6,EA,7764.12,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3928.64472,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.39,10431.7962
Multiple Sleep Latency Test,PX9580501,CDM,740,RC,95805,CPT,TC,,,,,,,4313,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3929.143,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,468.24,4226.74
"Polysomnography, 4 or More",PX9581001,CDM,740,RC,95810,CPT,TC,,,,,,,4313,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,3929.143,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,913.4,4226.74
"Closure of Gastrostomy,Surgical",PX43870P,CDM,983,RC,43870,CPT,,,,,,,,4012,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,3931.76,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,427.35,3931.76
Or Level 6,PX36000006,CDM,360,RC,,,,,,,,,,7960,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3940.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3306.584,7800.8
rabies immune globulin 1500 UNIT/5ML Solution 5 mL Vial,90375,CDM,636,RC,90375,CPT,,,,13533031805,NDC,5,ML,8065.26,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3951.9774,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,281.51,7903.9548
rabies immune globulin 1500 UNIT/5ML Solution 5 mL Vial,90375,CDM,636,RC,90375,CPT,,,,13533031805,NDC,5,ML,8065.26,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3951.9774,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,281.51,7903.9548
rabies immune globulin 1500 UNIT/5ML Solution 5 mL Vial,90375,CDM,636,RC,90375,CPT,,,,13533031805,NDC,5,ML,8065.26,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3951.9774,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,281.51,7903.9548
"Lap,Esophagogast Fundoplasty",PX43280P,CDM,983,RC,43280,CPT,,,,,,,,4449,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,3959.61,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1848.1146,8992.74
denosumab 120 MG/1.7ML Solution 1.7 mL Vial,J0897.01,CDM,636,RC,J0897,HCPCS,,,,55513073001,NDC,1.7,ML,4658.83,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3960.0055,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.55,4565.6534
PEMEtrexed 500 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2762301,NDC,1,EA,8086.02,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3962.1498,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.01,7924.2996
PEMEtrexed 500 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2762301,NDC,1,EA,8086.02,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3962.1498,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.01,7924.2996
PEMEtrexed 500 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2762301,NDC,1,EA,8086.02,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3962.1498,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.01,7924.2996
prothrombin complex concentrate - human 500 units Kit 500 Units Box,J7168.01,CDM,636,RC,J7168,HCPCS,,,,63833038602,NDC,1500,UN,8007,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3963.465,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.4,7846.86
BMWD 2X2,27200000,CDM,272,RC,Q4104,HCPCS,,12134-MAIN,LOCAL,,,,,8016,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3967.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Correct Bunion,Metatarsal Osteotomy",PX28296F,CDM,510,RC,28296,CPT,,,,,,,,8100,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3969,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2827.75,7938
"Correct Bunion,Metatarsal Osteotomy",PX28296F,CDM,510,RC,28296,CPT,,,,,,,,8100,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,3969,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2827.75,7938
"Correct Bunion,Metatarsal Osteotomy",PX28296F,CDM,510,RC,28296,CPT,,,,,,,,8100,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,3969,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2827.75,7938
isatuximab-irfc 500 MG/25ML Solution 25 mL Vial,J9227.01,CDM,636,RC,J9227,HCPCS,,,,24065601,NDC,25,ML,7876.36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,3985.43816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.13,7718.8328
rabies immune globulin 1500 UNIT/5ML Solution 5 mL Vial,90375,CDM,636,RC,90375,CPT,,,,13533031805,NDC,5,ML,8065.26,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,3992.3037,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,281.51,7903.9548
Tocilizumab 400 MG/20ML Solution 20 mL Vial,J3262.01,CDM,636,RC,J3262,HCPCS,,,,50242013701,NDC,20,ML,4703.83,,First Health,Commercial,both,85,,999999999,percent of total billed charges,3998.2555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.14,4609.7534
HIMAX STAPLE KIT 18X14X14,27200000,CDM,278,RC,C1713,HCPCS,,11851-MAIN,LOCAL,,,,,4536,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4000.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PEMEtrexed 500 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2762301,NDC,1,EA,8086.02,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4002.5799,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.01,7924.2996
"Correct Bunion,Metatarsal Osteotomy",PX28296F,CDM,510,RC,28296,CPT,,,,,,,,8100,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4009.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2827.75,7938
sarilumab 200 MG/1.14ML solution prefilled syringe 1.14 mL Syringe,J3590.25,CDM,636,RC,J3590,HCPCS,,,,24591001,NDC,1.14,ML,4408.29,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4015.95219,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1831.203666,4320.1242
ustekinumab 130 MG/26ML Solution 26 mL Vial,J3358.01,CDM,636,RC,J3358,HCPCS,,,,57894005427,NDC,26,ML,4130,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4019.729,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.56,4047.4
darbepoetin alfa 300 MCG/0.6ML solution prefilled syringe 0.6 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513011101,NDC,0.6,ML,4736.88,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4026.348,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
Or Level 6,PX36000006,CDM,360,RC,,,,,,,,,,7960,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4027.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3306.584,7800.8
"MRI, Abdomen W/O+ W/Contr",PX7418301,CDM,610,RC,74183,CPT,TC,,,,,,,4116,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4033.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4033.68
Polysomnography W/Cpap,PX9581101,CDM,740,RC,95811,CPT,TC,,,,,,,4575,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4035.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,913.4,4483.5
HIMAX STAPLE KIT 18X14X14,27200000,CDM,278,RC,C1713,HCPCS,,11851-MAIN,LOCAL,,,,,4536,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4037.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RESTRATA WOUND MATRIX 10CM X 12.5CM  TOTAL 125CM,27200000,CDM,272,RC,A2007,HCPCS,,11738-MAIN,LOCAL,,,,,8415,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4039.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RESTRATA WOUND MATRIX 10CM X 12.5CM  TOTAL 125CM,27200000,CDM,272,RC,A2007,HCPCS,,11738-MAIN,LOCAL,,,,,8415,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4039.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PHALINX STERILE LARGE 0 HAMMERTOE SYSTEM 45A01004,27800000,CDM,278,RC,C1713,HCPCS,,12962-MAIN,LOCAL,,,,,4759,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4045.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1976.8886,4663.82
PHALINX STERILE MEDIUM 0 HAMMERTOE SYSTEM 45A01003,27800000,CDM,278,RC,C1713,HCPCS,,12961-MAIN,LOCAL,,,,,4759,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4045.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1976.8886,4663.82
PHALINX STERILE SMALL 0 HAMMERTOE SYSTEM 45A01002,27800000,CDM,278,RC,C1713,HCPCS,,12960-MAIN,LOCAL,,,,,4759,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4045.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1976.8886,4663.82
ustekinumab 130 MG/26ML Solution 26 mL Vial,J3358.01,CDM,636,RC,J3358,HCPCS,,,,57894005427,NDC,26,ML,4130,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4047.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,11.56,4047.4
"Colonoscopy,Biopsy",PX45380F,CDM,750,RC,45380,CPT,,,,,,,,2465,,Blue Cross Blue Shield of MN,All commercial plans,both,,,1626.284412,fee schedule,4050.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1030.93,4050.42
"Colonoscopy,Biopsy",PX45380P,CDM,983,RC,45380,CPT,,,,,,,,2539,,Blue Cross Blue Shield of MN,All commercial plans,both,,,1626.284412,fee schedule,4050.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1030.93,4050.42
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384F,CDM,750,RC,45384,CPT,,,,,,,,2350,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,4050.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1008.15,4050.42
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384P,CDM,983,RC,45384,CPT,,,,,,,,1436,,Blue Cross Blue Shield of MN,All commercial plans,both,,,999999999,fee schedule,4050.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,616.044,4050.42
"Colonoscopy,Remv Lesn,Snare",PX45385F,CDM,750,RC,45385,CPT,,,,,,,,1939,,Blue Cross Blue Shield of MN,All commercial plans,both,,,1406.5725,fee schedule,4050.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,831.831,4050.42
"Colonoscopy,Remv Lesn,Snare",PX45385P,CDM,983,RC,45385,CPT,,,,,,,,2424,,Blue Cross Blue Shield of MN,All commercial plans,both,,,1406.5725,fee schedule,4050.42,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1030.93,4050.42
prothrombin complex concentrate - human 500 units Kit 500 Units Box,J7168.01,CDM,636,RC,J7168,HCPCS,,,,63833038602,NDC,1500,UN,8007,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4051.542,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.4,7846.86
"Lap,Esophagogast Fundoplasty",PX43280P,CDM,983,RC,43280,CPT,,,,,,,,4449,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4053.039,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1848.1146,8992.74
BMWD 2X2,27200000,CDM,272,RC,Q4104,HCPCS,,12134-MAIN,LOCAL,,,,,8016,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4056.096,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Lap Partial Colectomy/Coloproctostomy,PX44207F,CDM,750,RC,44207,CPT,,,,,,,,4170,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4058.661,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1130.58,4086.6
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242003706,NDC,0.6,EA,8461.09,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4061.3232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.39,10431.7962
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242003706,NDC,0.6,EA,8461.09,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4061.3232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.39,10431.7962
Polysomnography W/Cpap,PX9581101,CDM,740,RC,95811,CPT,TC,,,,,,,4575,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4071.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,913.4,4483.5
CAP TOE JOINT  15MM 2.5MMX4.5MM DF RESURFACING CONTOURED COBALT CHROMIUM METATARSOPHALANGEAL 9M52-25,C1713,CDM,278,RC,C1713,HCPCS,,12532-MAIN,LOCAL,,,,,4791,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4072.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
rabies immune globulin 1500 UNIT/5ML Solution 5 mL Vial,90375,CDM,636,RC,90375,CPT,,,,13533031805,NDC,5,ML,8065.26,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4081.02156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,281.51,7903.9548
Lap Partial Colectomy/Coloproctostomy,PX44207F,CDM,750,RC,44207,CPT,,,,,,,,4170,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4086.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1130.58,4086.6
PEMEtrexed 500 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2762301,NDC,1,EA,8086.02,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4091.52612,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.01,7924.2996
MRI L Spine W&WO Contrast,PX7215801,CDM,610,RC,72158,CPT,TC,,,,,,,4178,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4094.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4094.44
MRI T Spine W&WO Contrast,PX7215701,CDM,610,RC,72157,CPT,TC,,,,,,,4178,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4094.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4094.44
RESTRATA WOUND MATRIX 2.5CM X 7.5CM TOTAL 18.75CM,27200000,CDM,272,RC,A2007,HCPCS,,11735-MAIN,LOCAL,,,,,4208,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4095.6464,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Correct Bunion,Metatarsal Osteotomy",PX28296F,CDM,510,RC,28296,CPT,,,,,,,,8100,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4098.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2827.75,7938
CT Angio Abdom W/O & W/Dye,PX7417501,CDM,350,RC,74175,CPT,TC,,,,,,,4183,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4099.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,4099.34
denosumab 120 MG/1.7ML Solution 1.7 mL Vial,J0897.01,CDM,636,RC,J0897,HCPCS,,,,55513073001,NDC,1.7,ML,4658.83,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4109.08806,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.55,4565.6534
REVITA PLACENTAL MEMBRANE 4X6CM 24SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12561-MAIN,LOCAL,,,,,9896,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4110.7984,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
RESTRATA WOUND MATRIX 10CM X 12.5CM  TOTAL 125CM,27200000,CDM,272,RC,A2007,HCPCS,,11738-MAIN,LOCAL,,,,,8415,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4123.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RESTRATA WOUND MATRIX 10CM X 12.5CM  TOTAL 125CM,27200000,CDM,272,RC,A2007,HCPCS,,11738-MAIN,LOCAL,,,,,8415,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4123.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RESTRATA WOUND MATRIX 10CM X 12.5CM  TOTAL 125CM,27200000,CDM,272,RC,A2007,HCPCS,,11738-MAIN,LOCAL,,,,,8415,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4123.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RESTRATA WOUND MATRIX 2.5CM X 7.5CM TOTAL 18.75CM,27200000,CDM,272,RC,A2007,HCPCS,,11735-MAIN,LOCAL,,,,,4208,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4123.84,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
pembrolizumab 100 MG/4ML Solution 4 mL Vial,J9271.01,CDM,636,RC,J9271,HCPCS,,,,6302602,NDC,4,ML,9627.58,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4130.23182,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.57,9435.0284
HIMAX STAPLE KIT 18X14X14,27200000,CDM,278,RC,C1713,HCPCS,,11851-MAIN,LOCAL,,,,,4536,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4132.296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
riTUXimab-abbs 500 MG/50ML Solution 50 mL Vial,Q5115.01,CDM,636,RC,Q5115,HCPCS,,,,63459010450,NDC,50,ML,8624.61,,Health Partners,Health Partners Care Plans,both,48,,79.97871429,percent of total billed charges,4139.8128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.29,8452.1178
riTUXimab-abbs 500 MG/50ML Solution 50 mL Vial,Q5115.01,CDM,636,RC,Q5115,HCPCS,,,,63459010450,NDC,50,ML,8624.61,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4139.8128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.29,8452.1178
CT Abd&Pelv 1+ Section/Regns,PX7417801,CDM,350,RC,74178,CPT,TC,,,,,,,4226,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4141.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4141.48
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242003706,NDC,0.6,EA,8461.09,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,27.9628,percent of total billed charges,4145.9341,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.39,10431.7962
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242003706,NDC,0.6,EA,8461.09,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4145.9341,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.39,10431.7962
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242003706,NDC,0.6,EA,8461.09,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4145.9341,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.39,10431.7962
denosumab 120 MG/1.7ML Solution 1.7 mL Vial,J0897.01,CDM,636,RC,J0897,HCPCS,,,,55513073001,NDC,1.7,ML,4658.83,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4146.3587,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.55,4565.6534
Tocilizumab 400 MG/20ML Solution 20 mL Vial,J3262.01,CDM,636,RC,J3262,HCPCS,,,,50242013701,NDC,20,ML,4703.83,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4148.77806,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.14,4609.7534
RESTRATA WOUND MATRIX 10CM X 12.5CM  TOTAL 125CM,27200000,CDM,272,RC,A2007,HCPCS,,11738-MAIN,LOCAL,,,,,8415,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4165.425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Polysomnography W/Cpap,PX9581101,CDM,740,RC,95811,CPT,TC,,,,,,,4575,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4167.825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,913.4,4483.5
idaruCIZUmab 2.5 GM/50ML Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,597019705,NDC,50,ML,10037,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4169.3698,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pegfilgrastim-cbqv 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5111.01,CDM,636,RC,Q5111,HCPCS,,,,70114010101,NDC,0.6,ML,10040,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4170.616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.95,9839.2
pegfilgrastim-jmdb 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5108.01,CDM,636,RC,Q5108,HCPCS,,,,67457083306,NDC,0.6,ML,10040,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4170.616,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.36,9839.2
certolizumab 2 X 200 MG Kit 1 Each Box,J0717.01,CDM,636,RC,J0717,HCPCS,,,,50474070062,NDC,0.5,EA,4911.87,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4175.0895,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.41,4813.6326
darbepoetin alfa 300 MCG/0.6ML solution prefilled syringe 0.6 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513011101,NDC,0.6,ML,4736.88,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4177.92816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
Tocilizumab 400 MG/20ML Solution 20 mL Vial,J3262.01,CDM,636,RC,J3262,HCPCS,,,,50242013701,NDC,20,ML,4703.83,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4186.4087,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.14,4609.7534
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242003706,NDC,0.6,EA,8461.09,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4188.23955,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.39,10431.7962
CT Lumbar Spine W/O & W/Dye,PX7213301,CDM,350,RC,72133,CPT,TC,,,,,,,4283,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4197.34,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,160.51,4197.34
PHALINX STERILE LARGE 0 HAMMERTOE SYSTEM 45A01004,27800000,CDM,278,RC,C1713,HCPCS,,12962-MAIN,LOCAL,,,,,4759,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4197.438,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1976.8886,4663.82
PHALINX STERILE MEDIUM 0 HAMMERTOE SYSTEM 45A01003,27800000,CDM,278,RC,C1713,HCPCS,,12961-MAIN,LOCAL,,,,,4759,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4197.438,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1976.8886,4663.82
PHALINX STERILE SMALL 0 HAMMERTOE SYSTEM 45A01002,27800000,CDM,278,RC,C1713,HCPCS,,12960-MAIN,LOCAL,,,,,4759,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4197.438,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1976.8886,4663.82
Multiple Sleep Latency Test,PX9580501,CDM,740,RC,95805,CPT,TC,,,,,,,4313,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4197.8429,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,468.24,4226.74
"Polysomnography, 4 or More",PX9581001,CDM,740,RC,95810,CPT,TC,,,,,,,4313,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4197.8429,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,913.4,4226.74
CT Abd & Pelvis W/O Contrast,PX7417601,CDM,350,RC,74176,CPT,TC,,,,,,,4288,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4202.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,214.07,4202.24
CT Abdomen&Pelvis W/Contrast,PX7417701,CDM,350,RC,74177,CPT,TC,,,,,,,4288,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4202.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,4202.24
darbepoetin alfa 300 MCG/0.6ML solution prefilled syringe 0.6 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513011101,NDC,0.6,ML,4736.88,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4215.8232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
CAP TOE JOINT  15MM 2.5MMX4.5MM DF RESURFACING CONTOURED COBALT CHROMIUM METATARSOPHALANGEAL 9M52-25,C1713,CDM,278,RC,C1713,HCPCS,,12532-MAIN,LOCAL,,,,,4791,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4225.662,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
riTUXimab-abbs 500 MG/50ML Solution 50 mL Vial,Q5115.01,CDM,636,RC,Q5115,HCPCS,,,,63459010450,NDC,50,ML,8624.61,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4226.0589,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.29,8452.1178
riTUXimab-abbs 500 MG/50ML Solution 50 mL Vial,Q5115.01,CDM,636,RC,Q5115,HCPCS,,,,63459010450,NDC,50,ML,8624.61,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4226.0589,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.29,8452.1178
riTUXimab-abbs 500 MG/50ML Solution 50 mL Vial,Q5115.01,CDM,636,RC,Q5115,HCPCS,,,,63459010450,NDC,50,ML,8624.61,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4226.0589,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.29,8452.1178
Multiple Sleep Latency Test,PX9580501,CDM,740,RC,95805,CPT,TC,,,,,,,4313,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4226.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,468.24,4226.74
"Polysomnography, 4 or More",PX9581001,CDM,740,RC,95810,CPT,TC,,,,,,,4313,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4226.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,913.4,4226.74
PHALINX STERILE LARGE 0 HAMMERTOE SYSTEM 45A01004,27800000,CDM,278,RC,C1713,HCPCS,,12962-MAIN,LOCAL,,,,,4759,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4235.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1976.8886,4663.82
PHALINX STERILE MEDIUM 0 HAMMERTOE SYSTEM 45A01003,27800000,CDM,278,RC,C1713,HCPCS,,12961-MAIN,LOCAL,,,,,4759,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4235.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1976.8886,4663.82
PHALINX STERILE SMALL 0 HAMMERTOE SYSTEM 45A01002,27800000,CDM,278,RC,C1713,HCPCS,,12960-MAIN,LOCAL,,,,,4759,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4235.51,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1976.8886,4663.82
denosumab 120 MG/1.7ML Solution 1.7 mL Vial,J0897.01,CDM,636,RC,J0897,HCPCS,,,,55513073001,NDC,1.7,ML,4658.83,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4244.19413,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.55,4565.6534
REVITA PLACENTAL MEMBRANE 4X6CM 24SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12561-MAIN,LOCAL,,,,,9896,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4245.384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
riTUXimab 500 MG/50ML Solution 50 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005306,NDC,50,ML,8860.06,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4252.8288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.61,8682.8588
riTUXimab 500 MG/50ML Solution 50 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005306,NDC,50,ML,8860.06,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4252.8288,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.61,8682.8588
RESTRATA WOUND MATRIX 10CM X 12.5CM  TOTAL 125CM,27200000,CDM,272,RC,A2007,HCPCS,,11738-MAIN,LOCAL,,,,,8415,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4257.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
CAP TOE JOINT  15MM 2.5MMX4.5MM DF RESURFACING CONTOURED COBALT CHROMIUM METATARSOPHALANGEAL 9M52-25,C1713,CDM,278,RC,C1713,HCPCS,,12532-MAIN,LOCAL,,,,,4791,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4263.99,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
riTUXimab-abbs 500 MG/50ML Solution 50 mL Vial,Q5115.01,CDM,636,RC,Q5115,HCPCS,,,,63459010450,NDC,50,ML,8624.61,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4269.18195,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.29,8452.1178
Lap Sleeve Gastrectomy,PX43775,CDM,982,RC,43775,CPT,,,,,,,,5030,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4275.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,674.85,4895.699
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242003706,NDC,0.6,EA,8461.09,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4281.31154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.39,10431.7962
Tocilizumab 400 MG/20ML Solution 20 mL Vial,J3262.01,CDM,636,RC,J3262,HCPCS,,,,50242013701,NDC,20,ML,4703.83,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4285.18913,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.14,4609.7534
bendamustine 100 MG/4ML Solution 4 mL Vial,800000,CDM,,,J9034,HCPCS,,,,63459034804,NDC,4,ML,5046.55,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4289.5675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
sarilumab 200 MG/1.14ML solution prefilled syringe 1.14 mL Syringe,J3590.25,CDM,636,RC,J3590,HCPCS,,,,24591001,NDC,1.14,ML,4408.29,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4290.588657,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1831.203666,4320.1242
idaruCIZUmab 2.5 GM/50ML Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,597019705,NDC,50,ML,10037,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4305.873,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pegfilgrastim-cbqv 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5111.01,CDM,636,RC,Q5111,HCPCS,,,,70114010101,NDC,0.6,ML,10040,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4307.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.95,9839.2
pegfilgrastim-jmdb 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5108.01,CDM,636,RC,Q5108,HCPCS,,,,67457083306,NDC,0.6,ML,10040,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4307.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.36,9839.2
darbepoetin alfa 300 MCG/0.6ML solution prefilled syringe 0.6 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513011101,NDC,0.6,ML,4736.88,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4315.29768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
sarilumab 200 MG/1.14ML solution prefilled syringe 1.14 mL Syringe,J3590.25,CDM,636,RC,J3590,HCPCS,,,,24591001,NDC,1.14,ML,4408.29,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4320.1242,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1831.203666,4320.1242
"Lap,Esophagogast Fundoplasty",PX43280P,CDM,983,RC,43280,CPT,,,,,,,,4449,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4330.2117,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1848.1146,8992.74
certolizumab 2 X 200 MG Kit 1 Each Box,J0717.01,CDM,636,RC,J0717,HCPCS,,,,50474070062,NDC,0.5,EA,4911.87,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4332.26934,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.41,4813.6326
PHALINX STERILE LARGE 0 HAMMERTOE SYSTEM 45A01004,27800000,CDM,278,RC,C1713,HCPCS,,12962-MAIN,LOCAL,,,,,4759,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4335.449,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1976.8886,4663.82
PHALINX STERILE MEDIUM 0 HAMMERTOE SYSTEM 45A01003,27800000,CDM,278,RC,C1713,HCPCS,,12961-MAIN,LOCAL,,,,,4759,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4335.449,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1976.8886,4663.82
PHALINX STERILE SMALL 0 HAMMERTOE SYSTEM 45A01002,27800000,CDM,278,RC,C1713,HCPCS,,12960-MAIN,LOCAL,,,,,4759,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4335.449,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1976.8886,4663.82
riTUXimab 500 MG/50ML Solution 50 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005306,NDC,50,ML,8860.06,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4341.4294,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.61,8682.8588
riTUXimab 500 MG/50ML Solution 50 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005306,NDC,50,ML,8860.06,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4341.4294,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.61,8682.8588
riTUXimab 500 MG/50ML Solution 50 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005306,NDC,50,ML,8860.06,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4341.4294,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.61,8682.8588
"Lap,Esophagogast Fundoplasty",PX43280P,CDM,983,RC,43280,CPT,,,,,,,,4449,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4360.02,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,640.49,4360.02
riTUXimab-abbs 500 MG/50ML Solution 50 mL Vial,Q5115.01,CDM,636,RC,Q5115,HCPCS,,,,63459010450,NDC,50,ML,8624.61,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4364.05266,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.29,8452.1178
CAP TOE JOINT  15MM 2.5MMX4.5MM DF RESURFACING CONTOURED COBALT CHROMIUM METATARSOPHALANGEAL 9M52-25,C1713,CDM,278,RC,C1713,HCPCS,,12532-MAIN,LOCAL,,,,,4791,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4364.601,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
MRI L Spine W Contrast Tc,PX7214901,CDM,610,RC,72149,CPT,TC,,,,,,,5136,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4365.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,5033.28
MINIBUNION 3.5 OFFSET PLATE SHORT,27200000,CDM,278,RC,C1713,HCPCS,,11667-MAIN,LOCAL,,,,,5142.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4371.125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
certolizumab 2 X 200 MG Kit 1 Each Box,J0717.01,CDM,636,RC,J0717,HCPCS,,,,50474070062,NDC,0.5,EA,4911.87,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4371.5643,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.41,4813.6326
riTUXimab 500 MG/50ML Solution 50 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005306,NDC,50,ML,8860.06,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4385.7297,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.61,8682.8588
HIMAX STAPLE KIT 18X14X14,27200000,CDM,278,RC,C1713,HCPCS,,11851-MAIN,LOCAL,,,,,4536,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4414.8888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012047,NDC,0.6,EA,10644.69,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4421.804226,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.39,10431.7962
GRAFIXPL PRIME PLACENTAL MEMBRANE 5x5CM 25SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12768-MAIN,LOCAL,,,,,5211,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4429.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
Lap Sleeve Gastrectomy,PX43775,CDM,982,RC,43775,CPT,,,,,,,,5030,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4436.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,674.85,4895.699
HIMAX STAPLE KIT 18X14X14,27200000,CDM,278,RC,C1713,HCPCS,,11851-MAIN,LOCAL,,,,,4536,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4445.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RESTRATA WOUND MATRIX 5.0CM X 5.0CM TOTAL 25CM,27200000,CDM,272,RC,A2007,HCPCS,,11736-MAIN,LOCAL,,,,,5236,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4450.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
bendamustine 100 MG/4ML Solution 4 mL Vial,800000,CDM,,,J9034,HCPCS,,,,63459034804,NDC,4,ML,5046.55,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4451.0571,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Polysomnography W/Cpap,PX9581101,CDM,740,RC,95811,CPT,TC,,,,,,,4575,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4452.8475,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,913.4,4483.5
certolizumab 2 X 200 MG Kit 1 Each Box,J0717.01,CDM,636,RC,J0717,HCPCS,,,,50474070062,NDC,0.5,EA,4911.87,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4474.71357,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.41,4813.6326
Lap Sleeve Gastrectomy,PX43775,CDM,982,RC,43775,CPT,,,,,,,,5030,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4476.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,674.85,4895.699
riTUXimab 500 MG/50ML Solution 50 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005306,NDC,50,ML,8860.06,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4483.19036,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.61,8682.8588
hyaluronate 48 MG/6ML solution prefilled syringe 6 mL Syringe,J7325.01,CDM,636,RC,J7325,HCPCS,,,,58468009003,NDC,6,ML,5274.4,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4483.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.36,5168.912
Polysomnography W/Cpap,PX9581101,CDM,740,RC,95811,CPT,TC,,,,,,,4575,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4483.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,913.4,4483.5
bendamustine 100 MG/4ML Solution 4 mL Vial,800000,CDM,,,J9034,HCPCS,,,,63459034804,NDC,4,ML,5046.55,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4491.4295,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
Level 5 Additional Procedure,PX36000084,CDM,360,RC,,,,,,,,,,5300,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4505,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2201.62,5194
MRI L Spine W Contrast Tc,PX7214901,CDM,610,RC,72149,CPT,TC,,,,,,,5136,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4529.952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,5033.28
denosumab 120 MG/1.7ML Solution 1.7 mL Vial,J0897.01,CDM,636,RC,J0897,HCPCS,,,,55513073001,NDC,1.7,ML,4658.83,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4534.439239,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.55,4565.6534
MINIBUNION 3.5 OFFSET PLATE SHORT,27200000,CDM,278,RC,C1713,HCPCS,,11667-MAIN,LOCAL,,,,,5142.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4535.685,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
denosumab 120 MG/1.7ML Solution 1.7 mL Vial,J0897.01,CDM,636,RC,J0897,HCPCS,,,,55513073001,NDC,1.7,ML,4658.83,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4565.6534,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,12.55,4565.6534
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012047,NDC,0.6,EA,10644.69,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,4566.57201,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.39,10431.7962
MTP PLATE STANDARD 18MM CLIP 5 DEG DORSIFLEXION,27200000,CDM,278,RC,C1713,HCPCS,,11854-MAIN,LOCAL,,,,,5376,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4569.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
MRI L Spine W Contrast Tc,PX7214901,CDM,610,RC,72149,CPT,TC,,,,,,,5136,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4571.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,5033.28
MINIBUNION 3.5 OFFSET PLATE SHORT,27200000,CDM,278,RC,C1713,HCPCS,,11667-MAIN,LOCAL,,,,,5142.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4576.825,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Tocilizumab 400 MG/20ML Solution 20 mL Vial,J3262.01,CDM,636,RC,J3262,HCPCS,,,,50242013701,NDC,20,ML,4703.83,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4578.237739,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.14,4609.7534
Lap Sleeve Gastrectomy,PX43775,CDM,982,RC,43775,CPT,,,,,,,,5030,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4582.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,674.85,4895.699
GRAFIXPL PRIME PLACENTAL MEMBRANE 5x5CM 25SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12768-MAIN,LOCAL,,,,,5211,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4596.102,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
bendamustine 100 MG/4ML Solution 4 mL Vial,800000,CDM,,,J9034,HCPCS,,,,63459034804,NDC,4,ML,5046.55,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4597.40705,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
POLYAXIAL LOCKING PLATE MTP CROSS PLATE LEFT T8,C1713,CDM,278,RC,C1713,HCPCS,,12635-MAIN,LOCAL,,,,,5413,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4601.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
POLYAXIAL LOCKING PLATE MTP CROSS PLATE RIGHT T8,C1713,CDM,278,RC,C1713,HCPCS,,12756-MAIN,LOCAL,,,,,5413,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4601.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Tocilizumab 400 MG/20ML Solution 20 mL Vial,J3262.01,CDM,636,RC,J3262,HCPCS,,,,50242013701,NDC,20,ML,4703.83,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4609.7534,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3.14,4609.7534
darbepoetin alfa 300 MCG/0.6ML solution prefilled syringe 0.6 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513011101,NDC,0.6,ML,4736.88,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,0.7895,percent of total billed charges,4610.405304,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
nivolumab 100 MG/10ML Solution 10 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377412,NDC,10,ML,5429.27,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4614.8795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.5,12769.6548
RESTRATA WOUND MATRIX 5.0CM X 5.0CM TOTAL 25CM,27200000,CDM,272,RC,A2007,HCPCS,,11736-MAIN,LOCAL,,,,,5236,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4618.152,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
pembrolizumab 100 MG/4ML Solution 4 mL Vial,J9271.01,CDM,636,RC,J9271,HCPCS,,,,6302602,NDC,4,ML,9627.58,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4621.2384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.57,9435.0284
pembrolizumab 100 MG/4ML Solution 4 mL Vial,J9271.01,CDM,636,RC,J9271,HCPCS,,,,6302602,NDC,4,ML,9627.58,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4621.2384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.57,9435.0284
PHALINX STERILE LARGE 0 HAMMERTOE SYSTEM 45A01004,27800000,CDM,278,RC,C1713,HCPCS,,12962-MAIN,LOCAL,,,,,4759,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4631.9347,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1976.8886,4663.82
PHALINX STERILE MEDIUM 0 HAMMERTOE SYSTEM 45A01003,27800000,CDM,278,RC,C1713,HCPCS,,12961-MAIN,LOCAL,,,,,4759,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4631.9347,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1976.8886,4663.82
PHALINX STERILE SMALL 0 HAMMERTOE SYSTEM 45A01002,27800000,CDM,278,RC,C1713,HCPCS,,12960-MAIN,LOCAL,,,,,4759,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4631.9347,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1976.8886,4663.82
GRAFIXPL PRIME PLACENTAL MEMBRANE 5x5CM 25SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12768-MAIN,LOCAL,,,,,5211,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4637.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
darbepoetin alfa 300 MCG/0.6ML solution prefilled syringe 0.6 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513011101,NDC,0.6,ML,4736.88,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4642.1424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.69,4642.1424
hyaluronate 48 MG/6ML solution prefilled syringe 6 mL Syringe,J7325.01,CDM,636,RC,J7325,HCPCS,,,,58468009003,NDC,6,ML,5274.4,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4652.0208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.36,5168.912
RESTRATA WOUND MATRIX 5.0CM X 5.0CM TOTAL 25CM,27200000,CDM,272,RC,A2007,HCPCS,,11736-MAIN,LOCAL,,,,,5236,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4660.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Colonoscopy,Flex,Diagnostic",PX45378F,CDM,750,RC,45378,CPT,,,,,,,,1286,,Blue Cross Blue Shield of MN,All commercial plans,both,,,1480.867,fee schedule,4661.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,551.694,4661.91
"Colonoscopy,Flex,Diagnostic",PX45378P,CDM,983,RC,45378,CPT,,,,,,,,1200,,Blue Cross Blue Shield of MN,All commercial plans,both,,,1480.867,fee schedule,4661.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,514.8,4661.91
CAP TOE JOINT  15MM 2.5MMX4.5MM DF RESURFACING CONTOURED COBALT CHROMIUM METATARSOPHALANGEAL 9M52-25,C1713,CDM,278,RC,C1713,HCPCS,,12532-MAIN,LOCAL,,,,,4791,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4663.0803,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
PHALINX STERILE LARGE 0 HAMMERTOE SYSTEM 45A01004,27800000,CDM,278,RC,C1713,HCPCS,,12962-MAIN,LOCAL,,,,,4759,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4663.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1976.8886,4663.82
PHALINX STERILE MEDIUM 0 HAMMERTOE SYSTEM 45A01003,27800000,CDM,278,RC,C1713,HCPCS,,12961-MAIN,LOCAL,,,,,4759,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4663.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1976.8886,4663.82
PHALINX STERILE SMALL 0 HAMMERTOE SYSTEM 45A01002,27800000,CDM,278,RC,C1713,HCPCS,,12960-MAIN,LOCAL,,,,,4759,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4663.82,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1976.8886,4663.82
Level 5 Additional Procedure,PX36000084,CDM,360,RC,,,,,,,,,,5300,,United Healthcare,All Payer,outpatient,88.2,,999999999,case rate,4674.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4674.6,6141.46
MRI L Spine W Contrast Tc,PX7214901,CDM,610,RC,72149,CPT,TC,,,,,,,5136,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4678.896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,5033.28
MINIBUNION 3.5 OFFSET PLATE SHORT,27200000,CDM,278,RC,C1713,HCPCS,,11667-MAIN,LOCAL,,,,,5142.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4684.8175,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
hyaluronate 48 MG/6ML solution prefilled syringe 6 mL Syringe,J7325.01,CDM,636,RC,J7325,HCPCS,,,,58468009003,NDC,6,ML,5274.4,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4694.216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.36,5168.912
CAP TOE JOINT  15MM 2.5MMX4.5MM DF RESURFACING CONTOURED COBALT CHROMIUM METATARSOPHALANGEAL 9M52-25,C1713,CDM,278,RC,C1713,HCPCS,,12532-MAIN,LOCAL,,,,,4791,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4695.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
Level 5 Additional Procedure,PX36000084,CDM,360,RC,,,,,,,,,,5300,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4717,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2201.62,5194
pembrolizumab 100 MG/4ML Solution 4 mL Vial,J9271.01,CDM,636,RC,J9271,HCPCS,,,,6302602,NDC,4,ML,9627.58,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4717.5142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.57,9435.0284
pembrolizumab 100 MG/4ML Solution 4 mL Vial,J9271.01,CDM,636,RC,J9271,HCPCS,,,,6302602,NDC,4,ML,9627.58,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4717.5142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.57,9435.0284
pembrolizumab 100 MG/4ML Solution 4 mL Vial,J9271.01,CDM,636,RC,J9271,HCPCS,,,,6302602,NDC,4,ML,9627.58,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4717.5142,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.57,9435.0284
carfilzomib 60 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010101,NDC,1,EA,5571.82,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4736.047,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.23,5460.3836
MTP PLATE STANDARD 18MM CLIP 5 DEG DORSIFLEXION,27200000,CDM,278,RC,C1713,HCPCS,,11854-MAIN,LOCAL,,,,,5376,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4741.632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
GRAFIXPL PRIME PLACENTAL MEMBRANE 5x5CM 25SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12768-MAIN,LOCAL,,,,,5211,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4747.221,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
REVITA PLACENTAL MEMBRANE 4X6CM 24SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12561-MAIN,LOCAL,,,,,9896,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4750.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
REVITA PLACENTAL MEMBRANE 4X6CM 24SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12561-MAIN,LOCAL,,,,,9896,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4750.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
"VENTRALIGHT MESH ST WITH ECHO 2 - 20 CM X 25 CM 8"" X 10""",C1781,CDM,278,RC,C1781,HCPCS,,12009-MAIN,LOCAL,,,,,5589,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4750.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
pembrolizumab 100 MG/4ML Solution 4 mL Vial,J9271.01,CDM,636,RC,J9271,HCPCS,,,,6302602,NDC,4,ML,9627.58,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4765.6521,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.57,9435.0284
RESTRATA WOUND MATRIX 5.0CM X 5.0CM TOTAL 25CM,27200000,CDM,272,RC,A2007,HCPCS,,11736-MAIN,LOCAL,,,,,5236,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4769.996,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
POLYAXIAL LOCKING PLATE MTP CROSS PLATE LEFT T8,C1713,CDM,278,RC,C1713,HCPCS,,12635-MAIN,LOCAL,,,,,5413,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4774.266,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
POLYAXIAL LOCKING PLATE MTP CROSS PLATE RIGHT T8,C1713,CDM,278,RC,C1713,HCPCS,,12756-MAIN,LOCAL,,,,,5413,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4774.266,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
certolizumab 2 X 200 MG Kit 1 Each Box,J0717.01,CDM,636,RC,J0717,HCPCS,,,,50474070062,NDC,0.5,EA,4911.87,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,4.911875,percent of total billed charges,4780.723071,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.41,4813.6326
MTP PLATE STANDARD 18MM CLIP 5 DEG DORSIFLEXION,27200000,CDM,278,RC,C1713,HCPCS,,11854-MAIN,LOCAL,,,,,5376,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4784.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
nivolumab 100 MG/10ML Solution 10 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377412,NDC,10,ML,5429.27,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4788.61614,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.5,12769.6548
hyaluronate 48 MG/6ML solution prefilled syringe 6 mL Syringe,J7325.01,CDM,636,RC,J7325,HCPCS,,,,58468009003,NDC,6,ML,5274.4,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4804.9784,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.36,5168.912
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218710,NDC,2,EA,5662.72,,First Health,Commercial,both,85,,999999999,percent of total billed charges,4813.312,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.57,6737.8528
certolizumab 2 X 200 MG Kit 1 Each Box,J0717.01,CDM,636,RC,J0717,HCPCS,,,,50474070062,NDC,0.5,EA,4911.87,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4813.6326,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.41,4813.6326
POLYAXIAL LOCKING PLATE MTP CROSS PLATE LEFT T8,C1713,CDM,278,RC,C1713,HCPCS,,12635-MAIN,LOCAL,,,,,5413,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4817.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
POLYAXIAL LOCKING PLATE MTP CROSS PLATE RIGHT T8,C1713,CDM,278,RC,C1713,HCPCS,,12756-MAIN,LOCAL,,,,,5413,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4817.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
idaruCIZUmab 2.5 GM/50ML Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,597019705,NDC,50,ML,10037,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4817.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
idaruCIZUmab 2.5 GM/50ML Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,597019705,NDC,50,ML,10037,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4817.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pegfilgrastim-cbqv 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5111.01,CDM,636,RC,Q5111,HCPCS,,,,70114010101,NDC,0.6,ML,10040,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4819.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.95,9839.2
pegfilgrastim-cbqv 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5111.01,CDM,636,RC,Q5111,HCPCS,,,,70114010101,NDC,0.6,ML,10040,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4819.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.95,9839.2
pegfilgrastim-jmdb 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5108.01,CDM,636,RC,Q5108,HCPCS,,,,67457083306,NDC,0.6,ML,10040,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,4819.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.36,9839.2
pegfilgrastim-jmdb 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5108.01,CDM,636,RC,Q5108,HCPCS,,,,67457083306,NDC,0.6,ML,10040,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,4819.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.36,9839.2
Level 5 Additional Procedure,PX36000084,CDM,360,RC,,,,,,,,,,5300,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4828.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2201.62,5194
nivolumab 100 MG/10ML Solution 10 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377412,NDC,10,ML,5429.27,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4832.0503,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.5,12769.6548
REVITA PLACENTAL MEMBRANE 4X6CM 24SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12561-MAIN,LOCAL,,,,,9896,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4849.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
REVITA PLACENTAL MEMBRANE 4X6CM 24SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12561-MAIN,LOCAL,,,,,9896,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4849.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
REVITA PLACENTAL MEMBRANE 4X6CM 24SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12561-MAIN,LOCAL,,,,,9896,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4849.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
pembrolizumab 100 MG/4ML Solution 4 mL Vial,J9271.01,CDM,636,RC,J9271,HCPCS,,,,6302602,NDC,4,ML,9627.58,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,4871.55548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.57,9435.0284
Lap Sleeve Gastrectomy,PX43775,CDM,982,RC,43775,CPT,,,,,,,,5030,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4895.699,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,674.85,4895.699
MTP PLATE STANDARD 18MM CLIP 5 DEG DORSIFLEXION,27200000,CDM,278,RC,C1713,HCPCS,,11854-MAIN,LOCAL,,,,,5376,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4897.536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
REVITA PLACENTAL MEMBRANE 4X6CM 24SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12561-MAIN,LOCAL,,,,,9896,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4898.52,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
bendamustine 100 MG/4ML Solution 4 mL Vial,800000,CDM,,,J9034,HCPCS,,,,63459034804,NDC,4,ML,5046.55,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,4911.807115,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
carfilzomib 60 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010101,NDC,1,EA,5571.82,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4914.34524,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.23,5460.3836
idaruCIZUmab 2.5 GM/50ML Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,597019705,NDC,50,ML,10037,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4918.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
idaruCIZUmab 2.5 GM/50ML Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,597019705,NDC,50,ML,10037,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4918.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
idaruCIZUmab 2.5 GM/50ML Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,597019705,NDC,50,ML,10037,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4918.13,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pegfilgrastim-cbqv 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5111.01,CDM,636,RC,Q5111,HCPCS,,,,70114010101,NDC,0.6,ML,10040,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,167.3333333,percent of total billed charges,4919.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.95,9839.2
pegfilgrastim-cbqv 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5111.01,CDM,636,RC,Q5111,HCPCS,,,,70114010101,NDC,0.6,ML,10040,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4919.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.95,9839.2
pegfilgrastim-cbqv 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5111.01,CDM,636,RC,Q5111,HCPCS,,,,70114010101,NDC,0.6,ML,10040,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4919.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.95,9839.2
pegfilgrastim-jmdb 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5108.01,CDM,636,RC,Q5108,HCPCS,,,,67457083306,NDC,0.6,ML,10040,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4919.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.36,9839.2
pegfilgrastim-jmdb 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5108.01,CDM,636,RC,Q5108,HCPCS,,,,67457083306,NDC,0.6,ML,10040,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,4919.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.36,9839.2
pegfilgrastim-jmdb 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5108.01,CDM,636,RC,Q5108,HCPCS,,,,67457083306,NDC,0.6,ML,10040,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,4919.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.36,9839.2
Lap Sleeve Gastrectomy,PX43775,CDM,982,RC,43775,CPT,,,,,,,,5030,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4929.4,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,645.08,4929.4
"VENTRALIGHT MESH ST WITH ECHO 2 - 20 CM X 25 CM 8"" X 10""",C1781,CDM,278,RC,C1781,HCPCS,,12009-MAIN,LOCAL,,,,,5589,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4929.498,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
POLYAXIAL LOCKING PLATE MTP CROSS PLATE LEFT T8,C1713,CDM,278,RC,C1713,HCPCS,,12635-MAIN,LOCAL,,,,,5413,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4931.243,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
POLYAXIAL LOCKING PLATE MTP CROSS PLATE RIGHT T8,C1713,CDM,278,RC,C1713,HCPCS,,12756-MAIN,LOCAL,,,,,5413,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4931.243,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
bendamustine 100 MG/4ML Solution 4 mL Vial,800000,CDM,,,J9034,HCPCS,,,,63459034804,NDC,4,ML,5046.55,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,4945.619,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,4945.619
nivolumab 100 MG/10ML Solution 10 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377412,NDC,10,ML,5429.27,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,4946.06497,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.5,12769.6548
carfilzomib 60 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010101,NDC,1,EA,5571.82,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4958.9198,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.23,5460.3836
idaruCIZUmab 2.5 GM/50ML Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,597019705,NDC,50,ML,10037,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4968.315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pegfilgrastim-cbqv 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5111.01,CDM,636,RC,Q5111,HCPCS,,,,70114010101,NDC,0.6,ML,10040,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4969.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.95,9839.2
pegfilgrastim-jmdb 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5108.01,CDM,636,RC,Q5108,HCPCS,,,,67457083306,NDC,0.6,ML,10040,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,4969.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.36,9839.2
"VENTRALIGHT MESH ST WITH ECHO 2 - 20 CM X 25 CM 8"" X 10""",C1781,CDM,278,RC,C1781,HCPCS,,12009-MAIN,LOCAL,,,,,5589,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,4974.21,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
PHASIX ST 15X20CM 1201520,C1781,CDM,278,RC,C1781,HCPCS,,13010-MAIN,LOCAL,,,,,11988,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,4979.8152,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218710,NDC,2,EA,5662.72,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,4994.51904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.57,6737.8528
MINIBUNION 3.5 OFFSET PLATE SHORT,27200000,CDM,278,RC,C1713,HCPCS,,11667-MAIN,LOCAL,,,,,5142.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,5005.19525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
REVITA PLACENTAL MEMBRANE 4X6CM 24SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12561-MAIN,LOCAL,,,,,9896,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,5007.376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
Or Level 5,PX36000005,CDM,360,RC,,,,,,,,,,5898,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5013.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2450.0292,5780.04
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING 8X10 ELLIPSE,C1781,CDM,278,RC,C1781,HCPCS,,12504-MAIN,LOCAL,,,,,5915,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5027.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
MRI L Spine W Contrast Tc,PX7214901,CDM,610,RC,72149,CPT,TC,,,,,,,5136,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,5033.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,335.97,5033.28
MINIBUNION 3.5 OFFSET PLATE SHORT,27200000,CDM,278,RC,C1713,HCPCS,,11667-MAIN,LOCAL,,,,,5142.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,5039.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218710,NDC,2,EA,5662.72,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,5039.8208,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.57,6737.8528
"Initial Repair of Entrapped Hernia of Abdomen, Less Than 3 Cm in Length",PX49592,CDM,982,RC,49592,CPT,,,,,,,,2164,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,5040.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,898.9256,5040.74
"Lap,Appendectomy",PX44970P,CDM,983,RC,44970,CPT,,,,,,,,1700,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,5040.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,706.18,5040.74
"Lap,Cholecystectomy",PX47562F,CDM,510,RC,47562,CPT,,,,,,,,1473,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,5040.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,611.8842,5040.74
"Lap,Cholecystectomy",PX47562P,CDM,983,RC,47562,CPT,,,,,,,,983,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,5040.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,408.3382,5040.74
"Lap,Cholecystectomy/Graph",PX47563F,CDM,510,RC,47563,CPT,,,,,,,,1556,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,5040.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,646.3624,5040.74
"Lap,Dx Surgical Abd W/Biopsy",PX49321F,CDM,510,RC,49321,CPT,,,,,,,,874,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,5040.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,363.0596,5040.74
"Lap,Dx Surgical Abd W/Biopsy",PX49321P,CDM,983,RC,49321,CPT,,,,,,,,583,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,5040.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,242.1782,5040.74
"Lap,Inguinal Hernia Repr,Initial",PX49650F,CDM,510,RC,49650,CPT,,,,,,,,1076,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,5040.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,446.9704,5040.74
"Lap,Inguinal Hernia Repr,Initial",PX49650P,CDM,983,RC,49650,CPT,,,,,,,,717,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,5040.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,297.8418,5040.74
"Lap,Inguinal Hernia Repr,Recur",PX49651F,CDM,510,RC,49651,CPT,,,,,,,,1568,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,5040.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,651.3472,5040.74
"Lap,Inguinal Hernia Repr,Recur",PX49651P,CDM,983,RC,49651,CPT,,,,,,,,2035,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,5040.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,845.339,5040.74
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180F,CDM,510,RC,44180,CPT,,,,,,,,1763,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,5040.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,732.3502,5040.74
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180P,CDM,983,RC,44180,CPT,,,,,,,,1175,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,5040.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,488.095,5040.74
Lap Paraesophag Hern Repair,PX43281,CDM,982,RC,43281,CPT,,,,,,,,5950,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5057.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2471.63,8992.74
GRAFIXPL PRIME PLACENTAL MEMBRANE 5x5CM 25SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12768-MAIN,LOCAL,,,,,5211,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,5071.8663,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
carfilzomib 60 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010101,NDC,1,EA,5571.82,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,5075.92802,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.23,5460.3836
idaruCIZUmab 2.5 GM/50ML Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,597019705,NDC,50,ML,10037,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,5078.722,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pegfilgrastim-cbqv 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5111.01,CDM,636,RC,Q5111,HCPCS,,,,70114010101,NDC,0.6,ML,10040,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,5080.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.95,9839.2
pegfilgrastim-jmdb 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5108.01,CDM,636,RC,Q5108,HCPCS,,,,67457083306,NDC,0.6,ML,10040,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,5080.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.36,9839.2
"VENTRALIGHT MESH ST WITH ECHO 2 - 20 CM X 25 CM 8"" X 10""",C1781,CDM,278,RC,C1781,HCPCS,,12009-MAIN,LOCAL,,,,,5589,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,5091.579,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
RESTRATA WOUND MATRIX 5.0CM X 5.0CM TOTAL 25CM,27200000,CDM,272,RC,A2007,HCPCS,,11736-MAIN,LOCAL,,,,,5236,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,5096.1988,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
GRAFIXPL PRIME PLACENTAL MEMBRANE 5x5CM 25SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12768-MAIN,LOCAL,,,,,5211,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,5106.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,357.244,5106.78
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012047,NDC,0.6,EA,10644.69,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,5109.4512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.39,10431.7962
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012047,NDC,0.6,EA,10644.69,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,5109.4512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.39,10431.7962
ramuCIRumab 500 MG/50ML Solution 50 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2767801,NDC,50,ML,12316.5,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5116.2741,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.57,12070.17
RESTRATA WOUND MATRIX 5.0CM X 5.0CM TOTAL 25CM,27200000,CDM,272,RC,A2007,HCPCS,,11736-MAIN,LOCAL,,,,,5236,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,5131.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
hyaluronate 48 MG/6ML solution prefilled syringe 6 mL Syringe,J7325.01,CDM,636,RC,J7325,HCPCS,,,,58468009003,NDC,6,ML,5274.4,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,5133.57352,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.36,5168.912
PHASIX ST 15X20CM 1201520,C1781,CDM,278,RC,C1781,HCPCS,,13010-MAIN,LOCAL,,,,,11988,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5142.852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Level 5 Additional Procedure,PX36000084,CDM,360,RC,,,,,,,,,,5300,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,5158.49,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2201.62,5194
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218710,NDC,2,EA,5662.72,,Medica,Commercial,both,91.1,,20.488,percent of total billed charges,5158.73792,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.57,6737.8528
hyaluronate 48 MG/6ML solution prefilled syringe 6 mL Syringe,J7325.01,CDM,636,RC,J7325,HCPCS,,,,58468009003,NDC,6,ML,5274.4,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,5168.912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,8.36,5168.912
Level 5 Additional Procedure,PX36000084,CDM,360,RC,,,,,,,,,,5300,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,5194,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2201.62,5194
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74334603,NDC,1,EA,12509.82,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5196.579228,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
Or Level 5,PX36000005,CDM,360,RC,,,,,,,,,,5898,,United Healthcare,All Payer,outpatient,88.2,,999999999,case rate,5202.036,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5202.036,6141.46
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012047,NDC,0.6,EA,10644.69,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,27.9628,percent of total billed charges,5215.8981,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.39,10431.7962
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012047,NDC,0.6,EA,10644.69,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5215.8981,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.39,10431.7962
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012047,NDC,0.6,EA,10644.69,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,5215.8981,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.39,10431.7962
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING 8X10 ELLIPSE,C1781,CDM,278,RC,C1781,HCPCS,,12504-MAIN,LOCAL,,,,,5915,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,5217.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ABORTION WITHOUT D&C,779,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,289,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC,288,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,290,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH CC,835,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH MCC,834,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITHOUT CC/MCC,836,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,121,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,122,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC",284,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC",285,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
AICD LEAD PROCEDURES,265,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY",895,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ALLOGENEIC BONE MARROW TRANSPLANT,14,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,241,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,476,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",618,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ANAL AND STOMAL PROCEDURES WITH MCC,347,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ANGINA PECTORIS,311,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ARTHROSCOPY,509,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,16,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,17,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,95,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,94,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,96,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BEHAVIORAL AND DEVELOPMENTAL DISORDERS,886,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,461,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,462,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC",584,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC",585,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"CARDIAC ARREST, UNEXPLAINED WITH CC",297,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"CARDIAC ARREST, UNEXPLAINED WITHOUT CC/MCC",298,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC,276,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,258,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,259,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CAROTID ARTERY STENT PROCEDURES WITH CC,35,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CAROTID ARTERY STENT PROCEDURES WITH MCC,34,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,36,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,848,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHEST PAIN,313,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,18,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,416,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHOLECYSTECTOMY WITH C.D.E. WITH CC,412,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,413,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH CC,454,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH MCC,453,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITHOUT CC/MCC,455,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,382,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES,212,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CONCUSSION WITH CC,89,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CONCUSSION WITH MCC,88,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CONCUSSION WITHOUT CC/MCC,90,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,73,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,74,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,26,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,25,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,27,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,955,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR CHEMOTHERAPY IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,23,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,24,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC,294,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DEEP VEIN THROMBOPHLEBITIS WITHOUT CC/MCC,295,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,56,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,57,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DENTAL AND ORAL DISEASES WITHOUT CC/MCC,159,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DEPRESSIVE NEUROSES,881,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DIABETES WITH CC,638,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DIABETES WITH MCC,637,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DIGESTIVE MALIGNANCY WITHOUT CC/MCC,376,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,883,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC",148,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES",3,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
EPISTAXIS WITH MCC,150,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,927,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,933,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
EXTRACRANIAL PROCEDURES WITH CC,38,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
EXTRACRANIAL PROCEDURES WITH MCC,37,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,39,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
EXTRAOCULAR PROCEDURES EXCEPT ORBIT,115,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,748,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,928,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,929,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,934,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HAND PROCEDURES FOR INJURIES,906,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HEADACHES WITH MCC,102,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC,1,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITHOUT MCC,2,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,421,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,970,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HIV WITH MAJOR RELATED CONDITION WITH CC,975,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,976,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HYPERTENSIVE ENCEPHALOPATHY WITH CC,78,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HYPERTENSIVE ENCEPHALOPATHY WITH MCC,77,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC,79,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,855,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,65,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,64,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,66,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,21,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,20,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/MCC,22,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INTRAOCULAR PROCEDURES WITH CC/MCC,116,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INTRAOCULAR PROCEDURES WITHOUT CC/MCC,117,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",62,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",61,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",63,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,686,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,688,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KIDNEY TRANSPLANT,652,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC,650,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC,651,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,486,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LIVER TRANSPLANT WITH MCC OR INTESTINAL TRANSPLANT,5,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LIVER TRANSPLANT WITHOUT MCC,6,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,495,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,499,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LUNG TRANSPLANT,7,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,821,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,825,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,655,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,370,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR HEAD AND NECK PROCEDURES WITH CC,141,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR HEAD AND NECK PROCEDURES WITH MCC,140,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,142,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITHOUT CC/MCC,508,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,437,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",756,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",724,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,599,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MASTECTOMY FOR MALIGNANCY WITH CC/MCC,582,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MOUTH PROCEDURES WITH CC/MCC,137,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MOUTH PROCEDURES WITHOUT CC/MCC,138,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,59,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,58,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,60,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,830,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NERVOUS SYSTEM NEOPLASMS WITH MCC,54,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,55,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NEUROLOGICAL EYE DISORDERS,123,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,98,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,97,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,99,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NON-EXTENSIVE BURNS,935,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC,71,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC,70,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,72,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,67,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,68,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NONTRAUMATIC STUPOR AND COMA WITH MCC,80,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,81,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NORMAL NEWBORN,795,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
O.R. PROCEDURES FOR OBESITY WITH MCC,619,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,876,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ORBITAL PROCEDURES WITH CC/MCC,113,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ORBITAL PROCEDURES WITHOUT CC/MCC,114,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,819,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,92,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,91,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,93,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER DISORDERS OF THE EYE WITH MCC OR THROMBOLYTIC AGENT,124,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC",144,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH MCC",143,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC",145,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,750,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,730,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,718,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,715,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,716,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,963,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,965,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,517,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,845,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,958,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,957,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,959,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,804,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,168,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC",579,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PANCREAS TRANSPLANT,10,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC",734,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC",735,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PENIS PROCEDURES WITH CC/MCC,709,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PENIS PROCEDURES WITHOUT CC/MCC,710,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",41,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",40,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC",42,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS,998,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PSYCHOSES,885,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RADIOTHERAPY,849,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RECTAL RESECTION WITH CC,333,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RECTAL RESECTION WITHOUT CC/MCC,334,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
REHABILITATION WITH CC/MCC,945,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
REHABILITATION WITHOUT CC/MCC,946,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,466,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SEPTIC ARTHRITIS WITHOUT CC/MCC,550,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC",512,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,8,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS,19,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SINUS AND MASTOID PROCEDURES WITH CC/MCC,135,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,136,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,577,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,576,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,578,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,574,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,573,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",624,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SKIN GRAFTS FOR INJURIES WITH CC/MCC,904,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,905,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SKIN ULCERS WITH CC,593,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SPINAL DISORDERS AND INJURIES WITH CC/MCC,52,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,53,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SPINAL FUSION EXCEPT CERVICAL WITH MCC,459,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH MCC",456,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,460,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,29,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SPINAL PROCEDURES WITH MCC,28,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SPINAL PROCEDURES WITHOUT CC/MCC,30,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SPLENIC PROCEDURES WITH CC,800,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SPLENIC PROCEDURES WITH MCC,799,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SPLENIC PROCEDURES WITHOUT CC/MCC,801,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC",538,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
TESTES PROCEDURES WITH CC/MCC,711,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
TESTES PROCEDURES WITHOUT CC/MCC,712,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC",626,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC",625,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC",627,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC",12,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",11,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC",13,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",4,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,69,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
TRAUMATIC INJURY WITHOUT MCC,914,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,86,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,85,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,87,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,83,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,82,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,84,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY EMBOLISM,173,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
UNCOMPLICATED PEPTIC ULCER WITH MCC,383,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
UNGROUPABLE,999,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,256,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,257,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
URETHRAL PROCEDURES WITHOUT CC/MCC,672,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
URETHRAL STRICTURE,697,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,796,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,798,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
VENTRICULAR SHUNT PROCEDURES WITH CC,32,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
VENTRICULAR SHUNT PROCEDURES WITH MCC,31,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,33,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
VIRAL MENINGITIS WITH CC/MCC,75,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
VIRAL MENINGITIS WITHOUT CC/MCC,76,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
WOUND DEBRIDEMENTS FOR INJURIES WITH CC,902,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,901,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,,,,,,,Medica,Medicare Advantage except MSHO,inpatient,,MS-DRG,999999999,case rate,5225,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MTP PLATE STANDARD 18MM CLIP 5 DEG DORSIFLEXION,27200000,CDM,278,RC,C1713,HCPCS,,11854-MAIN,LOCAL,,,,,5376,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,5232.4608,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Lap Paraesophag Hern Repair,PX43281,CDM,982,RC,43281,CPT,,,,,,,,5950,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,5247.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2471.63,8992.74
Or Level 5,PX36000005,CDM,360,RC,,,,,,,,,,5898,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,5249.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2450.0292,5780.04
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING 8X10 ELLIPSE,C1781,CDM,278,RC,C1781,HCPCS,,12504-MAIN,LOCAL,,,,,5915,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,5264.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
POLYAXIAL LOCKING PLATE MTP CROSS PLATE LEFT T8,C1713,CDM,278,RC,C1713,HCPCS,,12635-MAIN,LOCAL,,,,,5413,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,5268.4729,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
POLYAXIAL LOCKING PLATE MTP CROSS PLATE RIGHT T8,C1713,CDM,278,RC,C1713,HCPCS,,12756-MAIN,LOCAL,,,,,5413,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,5268.4729,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
MTP PLATE STANDARD 18MM CLIP 5 DEG DORSIFLEXION,27200000,CDM,278,RC,C1713,HCPCS,,11854-MAIN,LOCAL,,,,,5376,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,5268.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012047,NDC,0.6,EA,10644.69,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,5269.12155,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.39,10431.7962
pegfilgrastim 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019001,NDC,0.6,ML,12711.36,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5280.298944,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.46,12830.846
ramuCIRumab 500 MG/50ML Solution 50 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2767801,NDC,50,ML,12316.5,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5283.7785,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.57,12070.17
nivolumab 100 MG/10ML Solution 10 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377412,NDC,10,ML,5429.27,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,5284.308491,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.5,12769.6548
"Ht Muscle Image Spect, Mult",PX7845201,CDM,340,RC,78452,CPT,TC,,,,,,,2000,,Blue Cross Blue Shield of MN,All commercial plans,both,,,1522.855455,fee schedule,5292.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,858,5292.1
Lap Paraesophag Hern Repair,PX43281,CDM,982,RC,43281,CPT,,,,,,,,5950,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,5295.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2471.63,8992.74
POLYAXIAL LOCKING PLATE MTP CROSS PLATE LEFT T8,C1713,CDM,278,RC,C1713,HCPCS,,12635-MAIN,LOCAL,,,,,5413,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,5304.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
POLYAXIAL LOCKING PLATE MTP CROSS PLATE RIGHT T8,C1713,CDM,278,RC,C1713,HCPCS,,12756-MAIN,LOCAL,,,,,5413,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,5304.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,26.1702,5304.74
nivolumab 100 MG/10ML Solution 10 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377412,NDC,10,ML,5429.27,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,5320.6846,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.5,12769.6548
vedolizumab 300 MG Recon Soln 1 Each Vial,J3380.01,CDM,636,RC,J3380,HCPCS,,,,64764030020,NDC,1,EA,12439.04,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5336.34816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.66,12190.2592
2.1MM CANNULATED DRILL BIT,27200000,CDM,272,RC,,,,12657-MAIN,LOCAL,,,,,747,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
2.1MM CANNULATED DRILL BIT,27200000,CDM,272,RC,,,,12657-MAIN,LOCAL,,,,,747,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
2.1MM CANNULATED DRILL BIT,27200000,CDM,272,RC,,,,12657-MAIN,LOCAL,,,,,747,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
2.1MM CANNULATED DRILL BIT,27200000,CDM,272,RC,,,,12657-MAIN,LOCAL,,,,,747,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
2.1MM CANNULATED DRILL BIT,27200000,CDM,272,RC,,,,12657-MAIN,LOCAL,,,,,747,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
2.1MM CANNULATED DRILL BIT,27200000,CDM,272,RC,,,,12657-MAIN,LOCAL,,,,,747,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
3.0MM HEADED SCREW LENGTH 16MM,C1713,CDM,278,RC,C1713,HCPCS,,12656-MAIN,LOCAL,,,,,608,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
3.0MM HEADED SCREW LENGTH 16MM,C1713,CDM,278,RC,C1713,HCPCS,,12656-MAIN,LOCAL,,,,,608,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
3.0MM HEADED SCREW LENGTH 16MM,C1713,CDM,278,RC,C1713,HCPCS,,12656-MAIN,LOCAL,,,,,608,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
3.0MM HEADED SCREW LENGTH 16MM,C1713,CDM,278,RC,C1713,HCPCS,,12656-MAIN,LOCAL,,,,,608,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
3.0MM HEADED SCREW LENGTH 16MM,C1713,CDM,278,RC,C1713,HCPCS,,12656-MAIN,LOCAL,,,,,608,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
3.0MM HEADED SCREW LENGTH 16MM,C1713,CDM,278,RC,C1713,HCPCS,,12656-MAIN,LOCAL,,,,,608,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
3.0MM NON-THREADED K WIRE,27200000,CDM,272,RC,C1769,HCPCS,,12658-MAIN,LOCAL,,,,,107,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
3.0MM NON-THREADED K WIRE,27200000,CDM,272,RC,C1769,HCPCS,,12658-MAIN,LOCAL,,,,,107,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
3.0MM NON-THREADED K WIRE,27200000,CDM,272,RC,C1769,HCPCS,,12658-MAIN,LOCAL,,,,,107,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
3.0MM NON-THREADED K WIRE,27200000,CDM,272,RC,C1769,HCPCS,,12658-MAIN,LOCAL,,,,,107,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
3.0MM NON-THREADED K WIRE,27200000,CDM,272,RC,C1769,HCPCS,,12658-MAIN,LOCAL,,,,,107,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
3.0MM NON-THREADED K WIRE,27200000,CDM,272,RC,C1769,HCPCS,,12658-MAIN,LOCAL,,,,,107,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
6 SHOOTER SAEED MULTIBAND LIGATOR,27200000,CDM,272,RC,,,,12379-MAIN,LOCAL,,,,,393,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
6 SHOOTER SAEED MULTIBAND LIGATOR,27200000,CDM,272,RC,,,,12379-MAIN,LOCAL,,,,,393,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
6 SHOOTER SAEED MULTIBAND LIGATOR,27200000,CDM,272,RC,,,,12379-MAIN,LOCAL,,,,,393,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
6 SHOOTER SAEED MULTIBAND LIGATOR,27200000,CDM,272,RC,,,,12379-MAIN,LOCAL,,,,,393,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
6 SHOOTER SAEED MULTIBAND LIGATOR,27200000,CDM,272,RC,,,,12379-MAIN,LOCAL,,,,,393,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
6 SHOOTER SAEED MULTIBAND LIGATOR,27200000,CDM,272,RC,,,,12379-MAIN,LOCAL,,,,,393,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM ENDOWRIST INSTRUMENTS 8MM FORCE BIPOLAR IS4000,27200000,CDM,272,RC,,,,11915-MAIN,LOCAL,,,,,439,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM ENDOWRIST INSTRUMENTS 8MM FORCE BIPOLAR IS4000,27200000,CDM,272,RC,,,,11915-MAIN,LOCAL,,,,,439,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM ENDOWRIST INSTRUMENTS 8MM FORCE BIPOLAR IS4000,27200000,CDM,272,RC,,,,11915-MAIN,LOCAL,,,,,439,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM ENDOWRIST INSTRUMENTS 8MM FORCE BIPOLAR IS4000,27200000,CDM,272,RC,,,,11915-MAIN,LOCAL,,,,,439,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM ENDOWRIST INSTRUMENTS 8MM FORCE BIPOLAR IS4000,27200000,CDM,272,RC,,,,11915-MAIN,LOCAL,,,,,439,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM ENDOWRIST INSTRUMENTS 8MM FORCE BIPOLAR IS4000,27200000,CDM,272,RC,,,,11915-MAIN,LOCAL,,,,,439,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM ENDOWRIST INSTRUMENTS CADIERE FORCEPS,27200000,CDM,272,RC,,,,11913-MAIN,LOCAL,,,,,281,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM ENDOWRIST INSTRUMENTS CADIERE FORCEPS,27200000,CDM,272,RC,,,,11913-MAIN,LOCAL,,,,,281,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM ENDOWRIST INSTRUMENTS CADIERE FORCEPS,27200000,CDM,272,RC,,,,11913-MAIN,LOCAL,,,,,281,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM ENDOWRIST INSTRUMENTS CADIERE FORCEPS,27200000,CDM,272,RC,,,,11913-MAIN,LOCAL,,,,,281,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM ENDOWRIST INSTRUMENTS CADIERE FORCEPS,27200000,CDM,272,RC,,,,11913-MAIN,LOCAL,,,,,281,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM ENDOWRIST INSTRUMENTS CADIERE FORCEPS,27200000,CDM,272,RC,,,,11913-MAIN,LOCAL,,,,,281,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM ENDOWRIST INSTRUMENTS LARGE NEEDLE DRIVER,27200000,CDM,272,RC,,,,11912-MAIN,LOCAL,,,,,318,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM ENDOWRIST INSTRUMENTS LARGE NEEDLE DRIVER,27200000,CDM,272,RC,,,,11912-MAIN,LOCAL,,,,,318,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM ENDOWRIST INSTRUMENTS LARGE NEEDLE DRIVER,27200000,CDM,272,RC,,,,11912-MAIN,LOCAL,,,,,318,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM ENDOWRIST INSTRUMENTS LARGE NEEDLE DRIVER,27200000,CDM,272,RC,,,,11912-MAIN,LOCAL,,,,,318,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM ENDOWRIST INSTRUMENTS LARGE NEEDLE DRIVER,27200000,CDM,272,RC,,,,11912-MAIN,LOCAL,,,,,318,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM ENDOWRIST INSTRUMENTS LARGE NEEDLE DRIVER,27200000,CDM,272,RC,,,,11912-MAIN,LOCAL,,,,,318,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM ENDOWRIST INSTRUMENTS MEDIUM LARGE CLIP APPLIER,27200000,CDM,272,RC,,,,11910-MAIN,LOCAL,,,,,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM ENDOWRIST INSTRUMENTS MEDIUM LARGE CLIP APPLIER,27200000,CDM,272,RC,,,,11910-MAIN,LOCAL,,,,,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM ENDOWRIST INSTRUMENTS MEDIUM LARGE CLIP APPLIER,27200000,CDM,272,RC,,,,11910-MAIN,LOCAL,,,,,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM ENDOWRIST INSTRUMENTS MEDIUM LARGE CLIP APPLIER,27200000,CDM,272,RC,,,,11910-MAIN,LOCAL,,,,,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM ENDOWRIST INSTRUMENTS MEDIUM LARGE CLIP APPLIER,27200000,CDM,272,RC,,,,11910-MAIN,LOCAL,,,,,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM ENDOWRIST INSTRUMENTS MEDIUM LARGE CLIP APPLIER,27200000,CDM,272,RC,,,,11910-MAIN,LOCAL,,,,,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM ENDOWRIST INSTRUMENTS MEGA SUTURE CUT NEEDLE DRIVER,27200000,CDM,272,RC,,,,11914-MAIN,LOCAL,,,,,327,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM ENDOWRIST INSTRUMENTS MEGA SUTURE CUT NEEDLE DRIVER,27200000,CDM,272,RC,,,,11914-MAIN,LOCAL,,,,,327,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM ENDOWRIST INSTRUMENTS MEGA SUTURE CUT NEEDLE DRIVER,27200000,CDM,272,RC,,,,11914-MAIN,LOCAL,,,,,327,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM ENDOWRIST INSTRUMENTS MEGA SUTURE CUT NEEDLE DRIVER,27200000,CDM,272,RC,,,,11914-MAIN,LOCAL,,,,,327,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM ENDOWRIST INSTRUMENTS MEGA SUTURE CUT NEEDLE DRIVER,27200000,CDM,272,RC,,,,11914-MAIN,LOCAL,,,,,327,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM ENDOWRIST INSTRUMENTS MEGA SUTURE CUT NEEDLE DRIVER,27200000,CDM,272,RC,,,,11914-MAIN,LOCAL,,,,,327,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM ENDOWRIST INSTRUMENTS MONOPOLAR CURVED SCISSORS,27200000,CDM,272,RC,,,,11909-MAIN,LOCAL,,,,,648,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM ENDOWRIST INSTRUMENTS MONOPOLAR CURVED SCISSORS,27200000,CDM,272,RC,,,,11909-MAIN,LOCAL,,,,,648,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM ENDOWRIST INSTRUMENTS MONOPOLAR CURVED SCISSORS,27200000,CDM,272,RC,,,,11909-MAIN,LOCAL,,,,,648,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM ENDOWRIST INSTRUMENTS MONOPOLAR CURVED SCISSORS,27200000,CDM,272,RC,,,,11909-MAIN,LOCAL,,,,,648,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM ENDOWRIST INSTRUMENTS MONOPOLAR CURVED SCISSORS,27200000,CDM,272,RC,,,,11909-MAIN,LOCAL,,,,,648,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM ENDOWRIST INSTRUMENTS MONOPOLAR CURVED SCISSORS,27200000,CDM,272,RC,,,,11909-MAIN,LOCAL,,,,,648,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM ENDOWRIST INSTRUMENTS TIP-UP FENESTRATED GRASPER,27200000,CDM,272,RC,,,,11911-MAIN,LOCAL,,,,,411,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM ENDOWRIST INSTRUMENTS TIP-UP FENESTRATED GRASPER,27200000,CDM,272,RC,,,,11911-MAIN,LOCAL,,,,,411,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM ENDOWRIST INSTRUMENTS TIP-UP FENESTRATED GRASPER,27200000,CDM,272,RC,,,,11911-MAIN,LOCAL,,,,,411,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM ENDOWRIST INSTRUMENTS TIP-UP FENESTRATED GRASPER,27200000,CDM,272,RC,,,,11911-MAIN,LOCAL,,,,,411,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM ENDOWRIST INSTRUMENTS TIP-UP FENESTRATED GRASPER,27200000,CDM,272,RC,,,,11911-MAIN,LOCAL,,,,,411,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM ENDOWRIST INSTRUMENTS TIP-UP FENESTRATED GRASPER,27200000,CDM,272,RC,,,,11911-MAIN,LOCAL,,,,,411,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM-12MM BLADELESS OBTURATOR 8MM,27200000,CDM,272,RC,,,,11919-MAIN,LOCAL,,,,,56,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM-12MM BLADELESS OBTURATOR 8MM,27200000,CDM,272,RC,,,,11919-MAIN,LOCAL,,,,,56,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM-12MM BLADELESS OBTURATOR 8MM,27200000,CDM,272,RC,,,,11919-MAIN,LOCAL,,,,,56,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM-12MM BLADELESS OBTURATOR 8MM,27200000,CDM,272,RC,,,,11919-MAIN,LOCAL,,,,,56,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM-12MM BLADELESS OBTURATOR 8MM,27200000,CDM,272,RC,,,,11919-MAIN,LOCAL,,,,,56,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM-12MM BLADELESS OBTURATOR 8MM,27200000,CDM,272,RC,,,,11919-MAIN,LOCAL,,,,,56,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM-12MM BLADELESS OBTURATOR 8MM LONG,27200000,CDM,272,RC,,,,11920-MAIN,LOCAL,,,,,56,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM-12MM BLADELESS OBTURATOR 8MM LONG,27200000,CDM,272,RC,,,,11920-MAIN,LOCAL,,,,,56,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM-12MM BLADELESS OBTURATOR 8MM LONG,27200000,CDM,272,RC,,,,11920-MAIN,LOCAL,,,,,56,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM-12MM BLADELESS OBTURATOR 8MM LONG,27200000,CDM,272,RC,,,,11920-MAIN,LOCAL,,,,,56,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM-12MM BLADELESS OBTURATOR 8MM LONG,27200000,CDM,272,RC,,,,11920-MAIN,LOCAL,,,,,56,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM-12MM BLADELESS OBTURATOR 8MM LONG,27200000,CDM,272,RC,,,,11920-MAIN,LOCAL,,,,,56,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM-12MM CANNULA SEAL 5-8MM,27200000,CDM,272,RC,,,,11921-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM-12MM CANNULA SEAL 5-8MM,27200000,CDM,272,RC,,,,11921-MAIN,LOCAL,,,,,38,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM-12MM CANNULA SEAL 5-8MM,27200000,CDM,272,RC,,,,11921-MAIN,LOCAL,,,,,38,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM-12MM CANNULA SEAL 5-8MM,27200000,CDM,272,RC,,,,11921-MAIN,LOCAL,,,,,38,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM-12MM CANNULA SEAL 5-8MM,27200000,CDM,272,RC,,,,11921-MAIN,LOCAL,,,,,38,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM-12MM CANNULA SEAL 5-8MM,27200000,CDM,272,RC,,,,11921-MAIN,LOCAL,,,,,38,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM-12MM TIP COVER ACCESSORY,27200000,CDM,272,RC,,,,11918-MAIN,LOCAL,,,,,40,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM-12MM TIP COVER ACCESSORY,27200000,CDM,272,RC,,,,11918-MAIN,LOCAL,,,,,40,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM-12MM TIP COVER ACCESSORY,27200000,CDM,272,RC,,,,11918-MAIN,LOCAL,,,,,40,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM-12MM TIP COVER ACCESSORY,27200000,CDM,272,RC,,,,11918-MAIN,LOCAL,,,,,40,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM-12MM TIP COVER ACCESSORY,27200000,CDM,272,RC,,,,11918-MAIN,LOCAL,,,,,40,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM-12MM TIP COVER ACCESSORY,27200000,CDM,272,RC,,,,11918-MAIN,LOCAL,,,,,40,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"2019-Ncov Coronavirus, Sars-Cov-2/2019-Ncov (Covid-19)",PXU000290,CDM,300,RC,U0002,HCPCS,90,,,,,,,365,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"2019-Ncov Coronavirus, Sars-Cov-2/2019-Ncov (Covid-19)",PXU000290,CDM,300,RC,U0002,HCPCS,90,,,,,,,365,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"2019-Ncov Coronavirus, Sars-Cov-2/2019-Ncov (Covid-19)",PXU000290,CDM,300,RC,U0002,HCPCS,90,,,,,,,365,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"2019-Ncov Coronavirus, Sars-Cov-2/2019-Ncov (Covid-19)",PXU000290,CDM,300,RC,U0002,HCPCS,90,,,,,,,365,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"2019-Ncov Coronavirus, Sars-Cov-2/2019-Ncov (Covid-19)",PXU000290,CDM,300,RC,U0002,HCPCS,90,,,,,,,365,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"2019-Ncov Coronavirus, Sars-Cov-2/2019-Ncov (Covid-19)",PXU000290,CDM,300,RC,U0002,HCPCS,90,,,,,,,365,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aaa US Screen Tc,PX7670601,CDM,402,RC,76706,CPT,TC,,,,,,,554,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aaa US Screen Tc,PX7670601,CDM,402,RC,76706,CPT,TC,,,,,,,554,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aaa US Screen Tc,PX7670601,CDM,402,RC,76706,CPT,TC,,,,,,,554,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aaa US Screen Tc,PX7670601,CDM,402,RC,76706,CPT,TC,,,,,,,554,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aaa US Screen Tc,PX7670601,CDM,402,RC,76706,CPT,TC,,,,,,,554,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aaa US Screen Tc,PX7670601,CDM,402,RC,76706,CPT,TC,,,,,,,554,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218710,NDC,2,EA,5662.72,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218710,NDC,2,EA,5662.72,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218710,NDC,2,EA,5662.72,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218710,NDC,2,EA,5662.72,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218710,NDC,2,EA,5662.72,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218710,NDC,2,EA,5662.72,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218713,NDC,2,EA,6875.36,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218713,NDC,2,EA,6875.36,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218713,NDC,2,EA,6875.36,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218713,NDC,2,EA,6875.36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218713,NDC,2,EA,6875.36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218713,NDC,2,EA,6875.36,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Abd Duplex Abd -Follow Up,PX9397602,CDM,921,RC,93976,CPT,TC,,,,,,,784,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Abd Duplex Abd -Follow Up,PX9397602,CDM,921,RC,93976,CPT,TC,,,,,,,784,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Abd Duplex Abd -Follow Up,PX9397602,CDM,921,RC,93976,CPT,TC,,,,,,,784,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Abd Duplex Abd -Follow Up,PX9397602,CDM,921,RC,93976,CPT,TC,,,,,,,784,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Abd Duplex Abd -Follow Up,PX9397602,CDM,921,RC,93976,CPT,TC,,,,,,,784,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Abd Duplex Abd -Follow Up,PX9397602,CDM,921,RC,93976,CPT,TC,,,,,,,784,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Abd Duplex Abd-Follow Up(T),PX9397601,CDM,921,RC,93976,CPT,TC,,,,,,,809,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Abd Duplex Abd-Follow Up(T),PX9397601,CDM,921,RC,93976,CPT,TC,,,,,,,809,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Abd Duplex Abd-Follow Up(T),PX9397601,CDM,921,RC,93976,CPT,TC,,,,,,,809,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Abd Duplex Abd-Follow Up(T),PX9397601,CDM,921,RC,93976,CPT,TC,,,,,,,809,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Abd Duplex Abd-Follow Up(T),PX9397601,CDM,921,RC,93976,CPT,TC,,,,,,,809,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Abd Duplex Abd-Follow Up(T),PX9397601,CDM,921,RC,93976,CPT,TC,,,,,,,809,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Abd Duplex Abd-Full,PX9397501,CDM,921,RC,93975,CPT,TC,,,,,,,788,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Abd Duplex Abd-Full,PX9397501,CDM,921,RC,93975,CPT,TC,,,,,,,788,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Abd Duplex Abd-Full,PX9397501,CDM,921,RC,93975,CPT,TC,,,,,,,788,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Abd Duplex Abd-Full,PX9397501,CDM,921,RC,93975,CPT,TC,,,,,,,788,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Abd Duplex Abd-Full,PX9397501,CDM,921,RC,93975,CPT,TC,,,,,,,788,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Abd Duplex Abd-Full,PX9397501,CDM,921,RC,93975,CPT,TC,,,,,,,788,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Abd Paracentesis,PX49082F,CDM,510,RC,49082,CPT,,,,,,,,884,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Abd Paracentesis,PX49082F,CDM,510,RC,49082,CPT,,,,,,,,884,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Abd Paracentesis,PX49082F,CDM,510,RC,49082,CPT,,,,,,,,884,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Abd Paracentesis,PX49082F,CDM,510,RC,49082,CPT,,,,,,,,884,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Abd Paracentesis,PX49082F,CDM,510,RC,49082,CPT,,,,,,,,884,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Abd Paracentesis,PX49082F,CDM,510,RC,49082,CPT,,,,,,,,884,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Abd Paracentesis W/Imaging(P),PX49083P,CDM,983,RC,49083,CPT,,,,,,,,696,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Abd Paracentesis W/Imaging(P),PX49083P,CDM,983,RC,49083,CPT,,,,,,,,696,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Abd Paracentesis W/Imaging(P),PX49083P,CDM,983,RC,49083,CPT,,,,,,,,696,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Abd Paracentesis W/Imaging(P),PX49083P,CDM,983,RC,49083,CPT,,,,,,,,696,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Abd Paracentesis W/Imaging(P),PX49083P,CDM,983,RC,49083,CPT,,,,,,,,696,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Abd Paracentesis W/Imaging(P),PX49083P,CDM,983,RC,49083,CPT,,,,,,,,696,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Abd Paracentesis W/Imaging(T),PX49083F,CDM,510,RC,49083,CPT,,,,,,,,1006,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Abd Paracentesis W/Imaging(T),PX49083F,CDM,510,RC,49083,CPT,,,,,,,,1006,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Abd Paracentesis W/Imaging(T),PX49083F,CDM,510,RC,49083,CPT,,,,,,,,1006,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Abd Paracentesis W/Imaging(T),PX49083F,CDM,510,RC,49083,CPT,,,,,,,,1006,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Abd Paracentesis W/Imaging(T),PX49083F,CDM,510,RC,49083,CPT,,,,,,,,1006,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Abd Paracentesis W/Imaging(T),PX49083F,CDM,510,RC,49083,CPT,,,,,,,,1006,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ACCESSORY KIT FOR GROSHONG 16GA,120.46,CDM,272,RC,C1751,HCPCS,,2967-MAIN,LOCAL,,,,,209,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ACCESSORY KIT FOR GROSHONG 16GA,120.46,CDM,272,RC,C1751,HCPCS,,2967-MAIN,LOCAL,,,,,209,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ACCESSORY KIT FOR GROSHONG 16GA,120.46,CDM,272,RC,C1751,HCPCS,,2967-MAIN,LOCAL,,,,,209,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ACCESSORY KIT FOR GROSHONG 16GA,120.46,CDM,272,RC,C1751,HCPCS,,2967-MAIN,LOCAL,,,,,209,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ACCESSORY KIT FOR GROSHONG 16GA,120.46,CDM,272,RC,C1751,HCPCS,,2967-MAIN,LOCAL,,,,,209,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ACCESSORY KIT FOR GROSHONG 16GA,120.46,CDM,272,RC,C1751,HCPCS,,2967-MAIN,LOCAL,,,,,209,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ace - Ref,PX8216490,CDM,300,RC,82164,CPT,90,,,,,,,82,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ace - Ref,PX8216490,CDM,300,RC,82164,CPT,90,,,,,,,82,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ace - Ref,PX8216490,CDM,300,RC,82164,CPT,90,,,,,,,82,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ace - Ref,PX8216490,CDM,300,RC,82164,CPT,90,,,,,,,82,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ace - Ref,PX8216490,CDM,300,RC,82164,CPT,90,,,,,,,82,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ace - Ref,PX8216490,CDM,300,RC,82164,CPT,90,,,,,,,82,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Acellular Derm Matrix Implt,PX15777F,CDM,510,RC,15777,CPT,,,,,,,,650,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Acellular Derm Matrix Implt,PX15777F,CDM,510,RC,15777,CPT,,,,,,,,650,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Acellular Derm Matrix Implt,PX15777F,CDM,510,RC,15777,CPT,,,,,,,,650,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Acellular Derm Matrix Implt,PX15777F,CDM,510,RC,15777,CPT,,,,,,,,650,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Acellular Derm Matrix Implt,PX15777F,CDM,510,RC,15777,CPT,,,,,,,,650,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Acellular Derm Matrix Implt,PX15777F,CDM,510,RC,15777,CPT,,,,,,,,650,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Acetaminophen,PX80307E,CDM,300,RC,80307,CPT,,,,,,,,370,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Acetaminophen,PX80307E,CDM,300,RC,80307,CPT,,,,,,,,370,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Acetaminophen,PX80307E,CDM,300,RC,80307,CPT,,,,,,,,370,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Acetaminophen,PX80307E,CDM,300,RC,80307,CPT,,,,,,,,370,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Acetaminophen,PX80307E,CDM,300,RC,80307,CPT,,,,,,,,370,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Acetaminophen,PX80307E,CDM,300,RC,80307,CPT,,,,,,,,370,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315606,NDC,100,ML,264.64,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315606,NDC,100,ML,264.64,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315606,NDC,100,ML,264.64,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315606,NDC,100,ML,264.64,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315606,NDC,100,ML,264.64,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315606,NDC,100,ML,264.64,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315695,NDC,100,ML,264.64,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315695,NDC,100,ML,264.64,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315695,NDC,100,ML,264.64,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315695,NDC,100,ML,264.64,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315695,NDC,100,ML,264.64,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315695,NDC,100,ML,264.64,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 120 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,713011806,NDC,1,EA,3.17,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 120 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,713011806,NDC,1,EA,3.17,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 120 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,713011806,NDC,1,EA,3.17,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 120 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,713011806,NDC,1,EA,3.17,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 120 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,713011806,NDC,1,EA,3.17,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 120 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,713011806,NDC,1,EA,3.17,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 120 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713011812,NDC,1,EA,3.17,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 120 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713011812,NDC,1,EA,3.17,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 120 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713011812,NDC,1,EA,3.17,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 120 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713011812,NDC,1,EA,3.17,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 120 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713011812,NDC,1,EA,3.17,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 120 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713011812,NDC,1,EA,3.17,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 120 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802073230,NDC,1,EA,3.13,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 120 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802073230,NDC,1,EA,3.13,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 120 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802073230,NDC,1,EA,3.13,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 120 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802073230,NDC,1,EA,3.13,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 120 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802073230,NDC,1,EA,3.13,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 120 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802073230,NDC,1,EA,3.13,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 160 MG/5ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,68094023159,NDC,15,ML,19.14,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 160 MG/5ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,68094023159,NDC,15,ML,19.14,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 160 MG/5ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,68094023159,NDC,15,ML,19.14,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 160 MG/5ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,68094023159,NDC,15,ML,19.14,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 160 MG/5ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,68094023159,NDC,15,ML,19.14,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 160 MG/5ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,68094023159,NDC,15,ML,19.14,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 160 MG/5ML Suspension 118 mL Bottle,63700001,CDM,250,RC,,,,,,45802020326,NDC,10.15625,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 160 MG/5ML Suspension 118 mL Bottle,63700001,CDM,250,RC,,,,,,45802020326,NDC,10.15625,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 160 MG/5ML Suspension 118 mL Bottle,63700001,CDM,250,RC,,,,,,45802020326,NDC,10.15625,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 160 MG/5ML Suspension 118 mL Bottle,63700001,CDM,250,RC,,,,,,45802020326,NDC,10.15625,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 160 MG/5ML Suspension 118 mL Bottle,63700001,CDM,250,RC,,,,,,45802020326,NDC,10.15625,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 160 MG/5ML Suspension 118 mL Bottle,63700001,CDM,250,RC,,,,,,45802020326,NDC,10.15625,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Acetaminophen 167 MG/5ML Liquid 237 mL Bottle,63700001,CDM,250,RC,,,,,,904584709,NDC,237,ML,27.22,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Acetaminophen 167 MG/5ML Liquid 237 mL Bottle,63700001,CDM,250,RC,,,,,,904584709,NDC,237,ML,27.22,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Acetaminophen 167 MG/5ML Liquid 237 mL Bottle,63700001,CDM,250,RC,,,,,,904584709,NDC,237,ML,27.22,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Acetaminophen 167 MG/5ML Liquid 237 mL Bottle,63700001,CDM,250,RC,,,,,,904584709,NDC,237,ML,27.22,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Acetaminophen 167 MG/5ML Liquid 237 mL Bottle,63700001,CDM,250,RC,,,,,,904584709,NDC,237,ML,27.22,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Acetaminophen 167 MG/5ML Liquid 237 mL Bottle,63700001,CDM,250,RC,,,,,,904584709,NDC,237,ML,27.22,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904198261,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904198261,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904198261,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904198261,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904198261,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904198261,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580045811,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580045811,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580045811,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580045811,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580045811,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580045811,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580060002,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580060002,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580060002,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580060002,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580060002,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580060002,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 325 MG Tablet 750 Each Box,63700001,CDM,250,RC,,,,,,63739044001,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 325 MG Tablet 750 Each Box,63700001,CDM,250,RC,,,,,,63739044001,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 325 MG Tablet 750 Each Box,63700001,CDM,250,RC,,,,,,63739044001,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 325 MG Tablet 750 Each Box,63700001,CDM,250,RC,,,,,,63739044001,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 325 MG Tablet 750 Each Box,63700001,CDM,250,RC,,,,,,63739044001,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 325 MG Tablet 750 Each Box,63700001,CDM,250,RC,,,,,,63739044001,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904198861,NDC,0.65,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904198861,NDC,0.65,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904198861,NDC,0.65,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904198861,NDC,0.65,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904198861,NDC,0.65,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904198861,NDC,0.65,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904673061,NDC,0.65,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904673061,NDC,0.65,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904673061,NDC,0.65,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904673061,NDC,0.65,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904673061,NDC,0.65,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904673061,NDC,0.65,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580045711,NDC,0.65,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580045711,NDC,0.65,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580045711,NDC,0.65,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580045711,NDC,0.65,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580045711,NDC,0.65,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580045711,NDC,0.65,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 650 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713016512,NDC,1,EA,3.8,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 650 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713016512,NDC,1,EA,3.8,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 650 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713016512,NDC,1,EA,3.8,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 650 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713016512,NDC,1,EA,3.8,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 650 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713016512,NDC,1,EA,3.8,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 650 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713016512,NDC,1,EA,3.8,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 650 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802073030,NDC,1,EA,3.58,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 650 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802073030,NDC,1,EA,3.58,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 650 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802073030,NDC,1,EA,3.58,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 650 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802073030,NDC,1,EA,3.58,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 650 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802073030,NDC,1,EA,3.58,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 650 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802073030,NDC,1,EA,3.58,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 650 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,70010016001,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 650 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,70010016001,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 650 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,70010016001,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 650 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,70010016001,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 650 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,70010016001,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 650 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,70010016001,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen-codeine 300-30 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406048423,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen-codeine 300-30 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406048423,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen-codeine 300-30 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406048423,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen-codeine 300-30 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406048423,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen-codeine 300-30 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406048423,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen-codeine 300-30 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406048423,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen-codeine 300-30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406048462,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen-codeine 300-30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406048462,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen-codeine 300-30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406048462,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen-codeine 300-30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406048462,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen-codeine 300-30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406048462,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen-codeine 300-30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406048462,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen-codeine 300-30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739000410,NDC,1,EA,3.44,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen-codeine 300-30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739000410,NDC,1,EA,3.44,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen-codeine 300-30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739000410,NDC,1,EA,3.44,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen-codeine 300-30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739000410,NDC,1,EA,3.44,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen-codeine 300-30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739000410,NDC,1,EA,3.44,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen-codeine 300-30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739000410,NDC,1,EA,3.44,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaZOLAMIDE 500 MG Recon Soln 1 Each Vial,J1120.01,CDM,636,RC,J1120,HCPCS,,,,39822019001,NDC,1,EA,207.84,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaZOLAMIDE 500 MG Recon Soln 1 Each Vial,J1120.01,CDM,636,RC,J1120,HCPCS,,,,39822019001,NDC,1,EA,207.84,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaZOLAMIDE 500 MG Recon Soln 1 Each Vial,J1120.01,CDM,636,RC,J1120,HCPCS,,,,39822019001,NDC,1,EA,207.84,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaZOLAMIDE 500 MG Recon Soln 1 Each Vial,J1120.01,CDM,636,RC,J1120,HCPCS,,,,39822019001,NDC,1,EA,207.84,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaZOLAMIDE 500 MG Recon Soln 1 Each Vial,J1120.01,CDM,636,RC,J1120,HCPCS,,,,39822019001,NDC,1,EA,207.84,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaZOLAMIDE 500 MG Recon Soln 1 Each Vial,J1120.01,CDM,636,RC,J1120,HCPCS,,,,39822019001,NDC,1,EA,207.84,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Acetone Assay,PX82010,CDM,300,RC,82010,CPT,,,,,,,,162,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Acetone Assay,PX82010,CDM,300,RC,82010,CPT,,,,,,,,162,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Acetone Assay,PX82010,CDM,300,RC,82010,CPT,,,,,,,,162,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Acetone Assay,PX82010,CDM,300,RC,82010,CPT,,,,,,,,162,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Acetone Assay,PX82010,CDM,300,RC,82010,CPT,,,,,,,,162,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Acetone Assay,PX82010,CDM,300,RC,82010,CPT,,,,,,,,162,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069030,NDC,3,ML,14.09,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069030,NDC,3,ML,14.09,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069030,NDC,3,ML,14.09,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069030,NDC,3,ML,14.09,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069030,NDC,3,ML,14.09,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069030,NDC,3,ML,14.09,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,2,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,2,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,2,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,2,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,2,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,3,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,3,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,3,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,3,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,3,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,3,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096321,NDC,30,ML,1231.47,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096321,NDC,30,ML,1231.47,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096321,NDC,30,ML,1231.47,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096321,NDC,30,ML,1231.47,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096321,NDC,30,ML,1231.47,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096321,NDC,30,ML,1231.47,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096330,NDC,30,ML,1231.47,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096330,NDC,30,ML,1231.47,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096330,NDC,30,ML,1231.47,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096330,NDC,30,ML,1231.47,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096330,NDC,30,ML,1231.47,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096330,NDC,30,ML,1231.47,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Acth - Ref,PX8202490,CDM,300,RC,82024,CPT,90,,,,,,,259,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Acth - Ref,PX8202490,CDM,300,RC,82024,CPT,90,,,,,,,259,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Acth - Ref,PX8202490,CDM,300,RC,82024,CPT,90,,,,,,,259,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Acth - Ref,PX8202490,CDM,300,RC,82024,CPT,90,,,,,,,259,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Acth - Ref,PX8202490,CDM,300,RC,82024,CPT,90,,,,,,,259,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Acth - Ref,PX8202490,CDM,300,RC,82024,CPT,90,,,,,,,259,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Actin Antibody Each,PX8601590,CDM,300,RC,86015,CPT,90,,,,,,,42,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Actin Antibody Each,PX8601590,CDM,300,RC,86015,CPT,90,,,,,,,42,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Actin Antibody Each,PX8601590,CDM,300,RC,86015,CPT,90,,,,,,,42,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Actin Antibody Each,PX8601590,CDM,300,RC,86015,CPT,90,,,,,,,42,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Actin Antibody Each,PX8601590,CDM,300,RC,86015,CPT,90,,,,,,,42,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Actin Antibody Each,PX8601590,CDM,300,RC,86015,CPT,90,,,,,,,42,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ACUSNARE POLYPECTOMY SNARE,27200000,CDM,272,RC,,,,7733-MAIN,LOCAL,,,,,45.75,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ACUSNARE POLYPECTOMY SNARE,27200000,CDM,272,RC,,,,7733-MAIN,LOCAL,,,,,45.75,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ACUSNARE POLYPECTOMY SNARE,27200000,CDM,272,RC,,,,7733-MAIN,LOCAL,,,,,45.75,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ACUSNARE POLYPECTOMY SNARE,27200000,CDM,272,RC,,,,7733-MAIN,LOCAL,,,,,45.75,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ACUSNARE POLYPECTOMY SNARE,27200000,CDM,272,RC,,,,7733-MAIN,LOCAL,,,,,45.75,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ACUSNARE POLYPECTOMY SNARE,27200000,CDM,272,RC,,,,7733-MAIN,LOCAL,,,,,45.75,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Acute Hepatitis Panel,PX80074,CDM,300,RC,80074,CPT,,,,,,,,509,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Acute Hepatitis Panel,PX80074,CDM,300,RC,80074,CPT,,,,,,,,509,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Acute Hepatitis Panel,PX80074,CDM,300,RC,80074,CPT,,,,,,,,509,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Acute Hepatitis Panel,PX80074,CDM,300,RC,80074,CPT,,,,,,,,509,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Acute Hepatitis Panel,PX80074,CDM,300,RC,80074,CPT,,,,,,,,509,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Acute Hepatitis Panel,PX80074,CDM,300,RC,80074,CPT,,,,,,,,509,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acyclovir 50 MG/ML Solution 10 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,55150015410,NDC,10,ML,108.16,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acyclovir 50 MG/ML Solution 10 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,55150015410,NDC,10,ML,108.16,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acyclovir 50 MG/ML Solution 10 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,55150015410,NDC,10,ML,108.16,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acyclovir 50 MG/ML Solution 10 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,55150015410,NDC,10,ML,108.16,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acyclovir 50 MG/ML Solution 10 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,55150015410,NDC,10,ML,108.16,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acyclovir 50 MG/ML Solution 10 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,55150015410,NDC,10,ML,108.16,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acyclovir 50 MG/ML Solution 20 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,63323032524,NDC,20,ML,76.86,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acyclovir 50 MG/ML Solution 20 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,63323032524,NDC,20,ML,76.86,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acyclovir 50 MG/ML Solution 20 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,63323032524,NDC,20,ML,76.86,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acyclovir 50 MG/ML Solution 20 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,63323032524,NDC,20,ML,76.86,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acyclovir 50 MG/ML Solution 20 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,63323032524,NDC,20,ML,76.86,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acyclovir 50 MG/ML Solution 20 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,63323032524,NDC,20,ML,76.86,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acyclovir 200 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578961,NDC,1,EA,8.21,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acyclovir 200 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578961,NDC,1,EA,8.21,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acyclovir 200 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578961,NDC,1,EA,8.21,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acyclovir 200 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578961,NDC,1,EA,8.21,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acyclovir 200 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578961,NDC,1,EA,8.21,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acyclovir 200 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578961,NDC,1,EA,8.21,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Acylcarnitines, Quant - Ref",PX8201790,CDM,300,RC,82017,CPT,90,,,,,,,110,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Acylcarnitines, Quant - Ref",PX8201790,CDM,300,RC,82017,CPT,90,,,,,,,110,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Acylcarnitines, Quant - Ref",PX8201790,CDM,300,RC,82017,CPT,90,,,,,,,110,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Acylcarnitines, Quant - Ref",PX8201790,CDM,300,RC,82017,CPT,90,,,,,,,110,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Acylcarnitines, Quant - Ref",PX8201790,CDM,300,RC,82017,CPT,90,,,,,,,110,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Acylcarnitines, Quant - Ref",PX8201790,CDM,300,RC,82017,CPT,90,,,,,,,110,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
adenosine 6 MG/2ML Solution 2 mL Syringe,J0153.01,CDM,636,RC,J0153,HCPCS,,,,25021030167,NDC,2,ML,123.1,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
adenosine 6 MG/2ML Solution 2 mL Syringe,J0153.01,CDM,636,RC,J0153,HCPCS,,,,25021030167,NDC,2,ML,123.1,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
adenosine 6 MG/2ML Solution 2 mL Syringe,J0153.01,CDM,636,RC,J0153,HCPCS,,,,25021030167,NDC,2,ML,123.1,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
adenosine 6 MG/2ML Solution 2 mL Syringe,J0153.01,CDM,636,RC,J0153,HCPCS,,,,25021030167,NDC,2,ML,123.1,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
adenosine 6 MG/2ML Solution 2 mL Syringe,J0153.01,CDM,636,RC,J0153,HCPCS,,,,25021030167,NDC,2,ML,123.1,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
adenosine 6 MG/2ML Solution 2 mL Syringe,J0153.01,CDM,636,RC,J0153,HCPCS,,,,25021030167,NDC,2,ML,123.1,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Admin Hep B,Adult 19+",PX3242,CDM,771,RC,90471,CPT,,,,,,,,48,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Admin Hep B,Adult 19+",PX3242,CDM,771,RC,90471,CPT,,,,,,,,48,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Admin Hep B,Adult 19+",PX3242,CDM,771,RC,90471,CPT,,,,,,,,48,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Admin Hep B,Adult 19+",PX3242,CDM,771,RC,90471,CPT,,,,,,,,48,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Admin Hep B,Adult 19+",PX3242,CDM,771,RC,90471,CPT,,,,,,,,48,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Admin Hep B,Adult 19+",PX3242,CDM,771,RC,90471,CPT,,,,,,,,48,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ADVANCED INSTRUMENTS 8MM SYNCHROSEAL IS4000,27200000,CDM,272,RC,,,,11924-MAIN,LOCAL,,,,,1290,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ADVANCED INSTRUMENTS 8MM SYNCHROSEAL IS4000,27200000,CDM,272,RC,,,,11924-MAIN,LOCAL,,,,,1290,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ADVANCED INSTRUMENTS 8MM SYNCHROSEAL IS4000,27200000,CDM,272,RC,,,,11924-MAIN,LOCAL,,,,,1290,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ADVANCED INSTRUMENTS 8MM SYNCHROSEAL IS4000,27200000,CDM,272,RC,,,,11924-MAIN,LOCAL,,,,,1290,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ADVANCED INSTRUMENTS 8MM SYNCHROSEAL IS4000,27200000,CDM,272,RC,,,,11924-MAIN,LOCAL,,,,,1290,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ADVANCED INSTRUMENTS 8MM SYNCHROSEAL IS4000,27200000,CDM,272,RC,,,,11924-MAIN,LOCAL,,,,,1290,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ADVANCED INSTRUMENTS ENDOWRIST SUCTION IRRIGATOR,27200000,CDM,272,RC,,,,11922-MAIN,LOCAL,,,,,496,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ADVANCED INSTRUMENTS ENDOWRIST SUCTION IRRIGATOR,27200000,CDM,272,RC,,,,11922-MAIN,LOCAL,,,,,496,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ADVANCED INSTRUMENTS ENDOWRIST SUCTION IRRIGATOR,27200000,CDM,272,RC,,,,11922-MAIN,LOCAL,,,,,496,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ADVANCED INSTRUMENTS ENDOWRIST SUCTION IRRIGATOR,27200000,CDM,272,RC,,,,11922-MAIN,LOCAL,,,,,496,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ADVANCED INSTRUMENTS ENDOWRIST SUCTION IRRIGATOR,27200000,CDM,272,RC,,,,11922-MAIN,LOCAL,,,,,496,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ADVANCED INSTRUMENTS ENDOWRIST SUCTION IRRIGATOR,27200000,CDM,272,RC,,,,11922-MAIN,LOCAL,,,,,496,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ADVANCED INSTRUMENTS VESSEL SEALER EXTEND,27200000,CDM,272,RC,,,,11923-MAIN,LOCAL,,,,,1169,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ADVANCED INSTRUMENTS VESSEL SEALER EXTEND,27200000,CDM,272,RC,,,,11923-MAIN,LOCAL,,,,,1169,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ADVANCED INSTRUMENTS VESSEL SEALER EXTEND,27200000,CDM,272,RC,,,,11923-MAIN,LOCAL,,,,,1169,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ADVANCED INSTRUMENTS VESSEL SEALER EXTEND,27200000,CDM,272,RC,,,,11923-MAIN,LOCAL,,,,,1169,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ADVANCED INSTRUMENTS VESSEL SEALER EXTEND,27200000,CDM,272,RC,,,,11923-MAIN,LOCAL,,,,,1169,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ADVANCED INSTRUMENTS VESSEL SEALER EXTEND,27200000,CDM,272,RC,,,,11923-MAIN,LOCAL,,,,,1169,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aerobic Isolate - Ref,PX8707790,CDM,300,RC,87077,CPT,90,,,,,,,168,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aerobic Isolate - Ref,PX8707790,CDM,300,RC,87077,CPT,90,,,,,,,168,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aerobic Isolate - Ref,PX8707790,CDM,300,RC,87077,CPT,90,,,,,,,168,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aerobic Isolate - Ref,PX8707790,CDM,300,RC,87077,CPT,90,,,,,,,168,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aerobic Isolate - Ref,PX8707790,CDM,300,RC,87077,CPT,90,,,,,,,168,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aerobic Isolate - Ref,PX8707790,CDM,300,RC,87077,CPT,90,,,,,,,168,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ag Detect Nos Eia Mult,PX87449,CDM,300,RC,87449,CPT,,,,,,,,193,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ag Detect Nos Eia Mult,PX87449,CDM,300,RC,87449,CPT,,,,,,,,193,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ag Detect Nos Eia Mult,PX87449,CDM,300,RC,87449,CPT,,,,,,,,193,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ag Detect Nos Eia Mult,PX87449,CDM,300,RC,87449,CPT,,,,,,,,193,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ag Detect Nos Eia Mult,PX87449,CDM,300,RC,87449,CPT,,,,,,,,193,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ag Detect Nos Eia Mult,PX87449,CDM,300,RC,87449,CPT,,,,,,,,193,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
agalsidase beta 5 MG Recon Soln 1 Each Vial,J0180.01,CDM,636,RC,J0180,HCPCS,,,,58468004101,NDC,1,EA,1717.68,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
agalsidase beta 5 MG Recon Soln 1 Each Vial,J0180.01,CDM,636,RC,J0180,HCPCS,,,,58468004101,NDC,1,EA,1717.68,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
agalsidase beta 5 MG Recon Soln 1 Each Vial,J0180.01,CDM,636,RC,J0180,HCPCS,,,,58468004101,NDC,1,EA,1717.68,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
agalsidase beta 5 MG Recon Soln 1 Each Vial,J0180.01,CDM,636,RC,J0180,HCPCS,,,,58468004101,NDC,1,EA,1717.68,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
agalsidase beta 5 MG Recon Soln 1 Each Vial,J0180.01,CDM,636,RC,J0180,HCPCS,,,,58468004101,NDC,1,EA,1717.68,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
agalsidase beta 5 MG Recon Soln 1 Each Vial,J0180.01,CDM,636,RC,J0180,HCPCS,,,,58468004101,NDC,1,EA,1717.68,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
AIRSEAL 12MM ACCESS PORT AND PALM GRIP OBTURATOR BLADELESS OPTICAL TIP 120MM,27200000,CDM,272,RC,,,,12207-MAIN,LOCAL,,,,,172,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
AIRSEAL 12MM ACCESS PORT AND PALM GRIP OBTURATOR BLADELESS OPTICAL TIP 120MM,27200000,CDM,272,RC,,,,12207-MAIN,LOCAL,,,,,172,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
AIRSEAL 12MM ACCESS PORT AND PALM GRIP OBTURATOR BLADELESS OPTICAL TIP 120MM,27200000,CDM,272,RC,,,,12207-MAIN,LOCAL,,,,,172,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
AIRSEAL 12MM ACCESS PORT AND PALM GRIP OBTURATOR BLADELESS OPTICAL TIP 120MM,27200000,CDM,272,RC,,,,12207-MAIN,LOCAL,,,,,172,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
AIRSEAL 12MM ACCESS PORT AND PALM GRIP OBTURATOR BLADELESS OPTICAL TIP 120MM,27200000,CDM,272,RC,,,,12207-MAIN,LOCAL,,,,,172,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
AIRSEAL 12MM ACCESS PORT AND PALM GRIP OBTURATOR BLADELESS OPTICAL TIP 120MM,27200000,CDM,272,RC,,,,12207-MAIN,LOCAL,,,,,172,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
AIRSEAL ROBOTIC Xi CAP AND OBTURATOR WITH BLADELESS OPTICAL TIP,27200000,CDM,272,RC,,,,12208-MAIN,LOCAL,,,,,210,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
AIRSEAL ROBOTIC Xi CAP AND OBTURATOR WITH BLADELESS OPTICAL TIP,27200000,CDM,272,RC,,,,12208-MAIN,LOCAL,,,,,210,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
AIRSEAL ROBOTIC Xi CAP AND OBTURATOR WITH BLADELESS OPTICAL TIP,27200000,CDM,272,RC,,,,12208-MAIN,LOCAL,,,,,210,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
AIRSEAL ROBOTIC Xi CAP AND OBTURATOR WITH BLADELESS OPTICAL TIP,27200000,CDM,272,RC,,,,12208-MAIN,LOCAL,,,,,210,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
AIRSEAL ROBOTIC Xi CAP AND OBTURATOR WITH BLADELESS OPTICAL TIP,27200000,CDM,272,RC,,,,12208-MAIN,LOCAL,,,,,210,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
AIRSEAL ROBOTIC Xi CAP AND OBTURATOR WITH BLADELESS OPTICAL TIP,27200000,CDM,272,RC,,,,12208-MAIN,LOCAL,,,,,210,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
AIRSEAL ROBOTIC Xi TRI LUMEN FILTERED TUBE SET WITH ACTIVATED CHARCOAL,27200000,CDM,272,RC,,,,12209-MAIN,LOCAL,,,,,210,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
AIRSEAL ROBOTIC Xi TRI LUMEN FILTERED TUBE SET WITH ACTIVATED CHARCOAL,27200000,CDM,272,RC,,,,12209-MAIN,LOCAL,,,,,210,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
AIRSEAL ROBOTIC Xi TRI LUMEN FILTERED TUBE SET WITH ACTIVATED CHARCOAL,27200000,CDM,272,RC,,,,12209-MAIN,LOCAL,,,,,210,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
AIRSEAL ROBOTIC Xi TRI LUMEN FILTERED TUBE SET WITH ACTIVATED CHARCOAL,27200000,CDM,272,RC,,,,12209-MAIN,LOCAL,,,,,210,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
AIRSEAL ROBOTIC Xi TRI LUMEN FILTERED TUBE SET WITH ACTIVATED CHARCOAL,27200000,CDM,272,RC,,,,12209-MAIN,LOCAL,,,,,210,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
AIRSEAL ROBOTIC Xi TRI LUMEN FILTERED TUBE SET WITH ACTIVATED CHARCOAL,27200000,CDM,272,RC,,,,12209-MAIN,LOCAL,,,,,210,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
AIRSEAL TUBE SET TRI LUMEN FILTERED WITH ACTIVATED CHARCOAL,27200000,CDM,272,RC,,,,12206-MAIN,LOCAL,,,,,172,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
AIRSEAL TUBE SET TRI LUMEN FILTERED WITH ACTIVATED CHARCOAL,27200000,CDM,272,RC,,,,12206-MAIN,LOCAL,,,,,172,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
AIRSEAL TUBE SET TRI LUMEN FILTERED WITH ACTIVATED CHARCOAL,27200000,CDM,272,RC,,,,12206-MAIN,LOCAL,,,,,172,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
AIRSEAL TUBE SET TRI LUMEN FILTERED WITH ACTIVATED CHARCOAL,27200000,CDM,272,RC,,,,12206-MAIN,LOCAL,,,,,172,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
AIRSEAL TUBE SET TRI LUMEN FILTERED WITH ACTIVATED CHARCOAL,27200000,CDM,272,RC,,,,12206-MAIN,LOCAL,,,,,172,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
AIRSEAL TUBE SET TRI LUMEN FILTERED WITH ACTIVATED CHARCOAL,27200000,CDM,272,RC,,,,12206-MAIN,LOCAL,,,,,172,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Airway Inhalation Treatment,PX94640F,CDM,410,RC,94640,CPT,,,,,,,,242,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Airway Inhalation Treatment,PX94640F,CDM,410,RC,94640,CPT,,,,,,,,242,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Airway Inhalation Treatment,PX94640F,CDM,410,RC,94640,CPT,,,,,,,,242,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Airway Inhalation Treatment,PX94640F,CDM,410,RC,94640,CPT,,,,,,,,242,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Airway Inhalation Treatment,PX94640F,CDM,410,RC,94640,CPT,,,,,,,,242,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Airway Inhalation Treatment,PX94640F,CDM,410,RC,94640,CPT,,,,,,,,242,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
albumin human 25% 25 % Solution 50 mL Flex Cont,P9047,CDM,636,RC,P9047,HCPCS,,,,944049301,NDC,50,ML,402.67,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
albumin human 25% 25 % Solution 50 mL Flex Cont,P9047,CDM,636,RC,P9047,HCPCS,,,,944049301,NDC,50,ML,402.67,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
albumin human 25% 25 % Solution 50 mL Flex Cont,P9047,CDM,636,RC,P9047,HCPCS,,,,944049301,NDC,50,ML,402.67,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
albumin human 25% 25 % Solution 50 mL Flex Cont,P9047,CDM,636,RC,P9047,HCPCS,,,,944049301,NDC,50,ML,402.67,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
albumin human 25% 25 % Solution 50 mL Flex Cont,P9047,CDM,636,RC,P9047,HCPCS,,,,944049301,NDC,50,ML,402.67,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
albumin human 25% 25 % Solution 50 mL Flex Cont,P9047,CDM,636,RC,P9047,HCPCS,,,,944049301,NDC,50,ML,402.67,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Albumin, Blood",PX82040,CDM,300,RC,82040,CPT,90,,,,,,,58,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Albumin, Blood",PX82040,CDM,300,RC,82040,CPT,90,,,,,,,58,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Albumin, Blood",PX82040,CDM,300,RC,82040,CPT,90,,,,,,,58,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Albumin, Blood",PX82040,CDM,300,RC,82040,CPT,90,,,,,,,58,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Albumin, Blood",PX82040,CDM,300,RC,82040,CPT,90,,,,,,,58,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Albumin, Blood",PX82040,CDM,300,RC,82040,CPT,90,,,,,,,58,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Albumin, Othr Source - Ref",PX8204290,CDM,300,RC,82042,CPT,90,,,,,,,57,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Albumin, Othr Source - Ref",PX8204290,CDM,300,RC,82042,CPT,90,,,,,,,57,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Albumin, Othr Source - Ref",PX8204290,CDM,300,RC,82042,CPT,90,,,,,,,57,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Albumin, Othr Source - Ref",PX8204290,CDM,300,RC,82042,CPT,90,,,,,,,57,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Albumin, Othr Source - Ref",PX8204290,CDM,300,RC,82042,CPT,90,,,,,,,57,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Albumin, Othr Source - Ref",PX8204290,CDM,300,RC,82042,CPT,90,,,,,,,57,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Albumin, Serum - Ref",PX8204090,CDM,300,RC,82040,CPT,90,,,,,,,57,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Albumin, Serum - Ref",PX8204090,CDM,300,RC,82040,CPT,90,,,,,,,57,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Albumin, Serum - Ref",PX8204090,CDM,300,RC,82040,CPT,90,,,,,,,57,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Albumin, Serum - Ref",PX8204090,CDM,300,RC,82040,CPT,90,,,,,,,57,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Albumin, Serum - Ref",PX8204090,CDM,300,RC,82040,CPT,90,,,,,,,57,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Albumin, Serum - Ref",PX8204090,CDM,300,RC,82040,CPT,90,,,,,,,57,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Albumin; Other Source, Quantitative, Each Specimen",PX82042,CDM,300,RC,82042,CPT,,,,,,,,28,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Albumin; Other Source, Quantitative, Each Specimen",PX82042,CDM,300,RC,82042,CPT,,,,,,,,28,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Albumin; Other Source, Quantitative, Each Specimen",PX82042,CDM,300,RC,82042,CPT,,,,,,,,28,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Albumin; Other Source, Quantitative, Each Specimen",PX82042,CDM,300,RC,82042,CPT,,,,,,,,28,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Albumin; Other Source, Quantitative, Each Specimen",PX82042,CDM,300,RC,82042,CPT,,,,,,,,28,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Albumin; Other Source, Quantitative, Each Specimen",PX82042,CDM,300,RC,82042,CPT,,,,,,,,28,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
albuterol (2.5 MG/3ML) 0.083% Nebulization Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487950101,NDC,3,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
albuterol (2.5 MG/3ML) 0.083% Nebulization Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487950101,NDC,3,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
albuterol (2.5 MG/3ML) 0.083% Nebulization Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487950101,NDC,3,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
albuterol (2.5 MG/3ML) 0.083% Nebulization Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487950101,NDC,3,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
albuterol (2.5 MG/3ML) 0.083% Nebulization Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487950101,NDC,3,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
albuterol (2.5 MG/3ML) 0.083% Nebulization Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487950101,NDC,3,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
albuterol (5 MG/ML) 0.5% Nebulization Solution 20 mL Bottle,J7611.01,CDM,250,RC,,,,,,50383074120,NDC,20,ML,225.2,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
albuterol (5 MG/ML) 0.5% Nebulization Solution 20 mL Bottle,J7611.01,CDM,250,RC,,,,,,50383074120,NDC,20,ML,225.2,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
albuterol (5 MG/ML) 0.5% Nebulization Solution 20 mL Bottle,J7611.01,CDM,250,RC,,,,,,50383074120,NDC,20,ML,225.2,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
albuterol (5 MG/ML) 0.5% Nebulization Solution 20 mL Bottle,J7611.01,CDM,250,RC,,,,,,50383074120,NDC,20,ML,225.2,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
albuterol (5 MG/ML) 0.5% Nebulization Solution 20 mL Bottle,J7611.01,CDM,250,RC,,,,,,50383074120,NDC,20,ML,225.2,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
albuterol (5 MG/ML) 0.5% Nebulization Solution 20 mL Bottle,J7611.01,CDM,250,RC,,,,,,50383074120,NDC,20,ML,225.2,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
albuterol 1.25 MG/3ML Nebulization Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487990425,NDC,3,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
albuterol 1.25 MG/3ML Nebulization Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487990425,NDC,3,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
albuterol 1.25 MG/3ML Nebulization Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487990425,NDC,3,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
albuterol 1.25 MG/3ML Nebulization Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487990425,NDC,3,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
albuterol 1.25 MG/3ML Nebulization Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487990425,NDC,3,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
albuterol 1.25 MG/3ML Nebulization Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487990425,NDC,3,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
albuterol HFA 108 (90 Base) MCG/ACT Aerosol Solution 8 g Inhaler,25000000,CDM,250,RC,,,,,,173068224,NDC,8,GR,149.04,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
albuterol HFA 108 (90 Base) MCG/ACT Aerosol Solution 8 g Inhaler,25000000,CDM,250,RC,,,,,,173068224,NDC,8,GR,149.04,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
albuterol HFA 108 (90 Base) MCG/ACT Aerosol Solution 8 g Inhaler,25000000,CDM,250,RC,,,,,,173068224,NDC,8,GR,149.04,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
albuterol HFA 108 (90 Base) MCG/ACT Aerosol Solution 8 g Inhaler,25000000,CDM,250,RC,,,,,,173068224,NDC,8,GR,149.04,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
albuterol HFA 108 (90 Base) MCG/ACT Aerosol Solution 8 g Inhaler,25000000,CDM,250,RC,,,,,,173068224,NDC,8,GR,149.04,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
albuterol HFA 108 (90 Base) MCG/ACT Aerosol Solution 8 g Inhaler,25000000,CDM,250,RC,,,,,,173068224,NDC,8,GR,149.04,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
albuterol-ipratropium 20-100 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597002402,NDC,4,GR,1601.75,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
albuterol-ipratropium 20-100 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597002402,NDC,4,GR,1601.75,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
albuterol-ipratropium 20-100 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597002402,NDC,4,GR,1601.75,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
albuterol-ipratropium 20-100 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597002402,NDC,4,GR,1601.75,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
albuterol-ipratropium 20-100 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597002402,NDC,4,GR,1601.75,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
albuterol-ipratropium 20-100 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597002402,NDC,4,GR,1601.75,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Alcohol,PX80307A,CDM,300,RC,80307,CPT,,,,,,,,370,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Alcohol,PX80307A,CDM,300,RC,80307,CPT,,,,,,,,370,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Alcohol,PX80307A,CDM,300,RC,80307,CPT,,,,,,,,370,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Alcohol,PX80307A,CDM,300,RC,80307,CPT,,,,,,,,370,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Alcohol,PX80307A,CDM,300,RC,80307,CPT,,,,,,,,370,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Alcohol,PX80307A,CDM,300,RC,80307,CPT,,,,,,,,370,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Alcohol Biomarkers; 1 or 2 - Ref,PX8032190,CDM,300,RC,80321,CPT,90,,,,,,,181,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Alcohol Biomarkers; 1 or 2 - Ref,PX8032190,CDM,300,RC,80321,CPT,90,,,,,,,181,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Alcohol Biomarkers; 1 or 2 - Ref,PX8032190,CDM,300,RC,80321,CPT,90,,,,,,,181,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Alcohol Biomarkers; 1 or 2 - Ref,PX8032190,CDM,300,RC,80321,CPT,90,,,,,,,181,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Alcohol Biomarkers; 1 or 2 - Ref,PX8032190,CDM,300,RC,80321,CPT,90,,,,,,,181,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Alcohol Biomarkers; 1 or 2 - Ref,PX8032190,CDM,300,RC,80321,CPT,90,,,,,,,181,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Alcohol Swabstick 70 % Pad 50 Each Box,800000,CDM,,,,,,,,18407061105,NDC,1,EA,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Alcohol Swabstick 70 % Pad 50 Each Box,800000,CDM,,,,,,,,18407061105,NDC,1,EA,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Alcohol Swabstick 70 % Pad 50 Each Box,800000,CDM,,,,,,,,18407061105,NDC,1,EA,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Alcohol Swabstick 70 % Pad 50 Each Box,800000,CDM,,,,,,,,18407061105,NDC,1,EA,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Alcohol Swabstick 70 % Pad 50 Each Box,800000,CDM,,,,,,,,18407061105,NDC,1,EA,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Alcohol Swabstick 70 % Pad 50 Each Box,800000,CDM,,,,,,,,18407061105,NDC,1,EA,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Alcohols - Ref,PX8032090,CDM,300,RC,80320,CPT,90,,,,,,,189,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Alcohols - Ref,PX8032090,CDM,300,RC,80320,CPT,90,,,,,,,189,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Alcohols - Ref,PX8032090,CDM,300,RC,80320,CPT,90,,,,,,,189,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Alcohols - Ref,PX8032090,CDM,300,RC,80320,CPT,90,,,,,,,189,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Alcohols - Ref,PX8032090,CDM,300,RC,80320,CPT,90,,,,,,,189,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Alcohols - Ref,PX8032090,CDM,300,RC,80320,CPT,90,,,,,,,189,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aldolase - Ref,PX8208590,CDM,300,RC,82085,CPT,90,,,,,,,89,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aldolase - Ref,PX8208590,CDM,300,RC,82085,CPT,90,,,,,,,89,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aldolase - Ref,PX8208590,CDM,300,RC,82085,CPT,90,,,,,,,89,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aldolase - Ref,PX8208590,CDM,300,RC,82085,CPT,90,,,,,,,89,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aldolase - Ref,PX8208590,CDM,300,RC,82085,CPT,90,,,,,,,89,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aldolase - Ref,PX8208590,CDM,300,RC,82085,CPT,90,,,,,,,89,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aldosterone - Ref,PX8208890,CDM,300,RC,82088,CPT,90,,,,,,,86,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aldosterone - Ref,PX8208890,CDM,300,RC,82088,CPT,90,,,,,,,86,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aldosterone - Ref,PX8208890,CDM,300,RC,82088,CPT,90,,,,,,,86,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aldosterone - Ref,PX8208890,CDM,300,RC,82088,CPT,90,,,,,,,86,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aldosterone - Ref,PX8208890,CDM,300,RC,82088,CPT,90,,,,,,,86,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aldosterone - Ref,PX8208890,CDM,300,RC,82088,CPT,90,,,,,,,86,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
alendronate 70 MG Tablet 4 Each Box,63700001,CDM,250,RC,,,,,,16714063301,NDC,1,EA,97.37,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
alendronate 70 MG Tablet 4 Each Box,63700001,CDM,250,RC,,,,,,16714063301,NDC,1,EA,97.37,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
alendronate 70 MG Tablet 4 Each Box,63700001,CDM,250,RC,,,,,,16714063301,NDC,1,EA,97.37,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
alendronate 70 MG Tablet 4 Each Box,63700001,CDM,250,RC,,,,,,16714063301,NDC,1,EA,97.37,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
alendronate 70 MG Tablet 4 Each Box,63700001,CDM,250,RC,,,,,,16714063301,NDC,1,EA,97.37,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
alendronate 70 MG Tablet 4 Each Box,63700001,CDM,250,RC,,,,,,16714063301,NDC,1,EA,97.37,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALEXIS 0 LARGE STERILE,27200000,CDM,272,RC,,,,11765-MAIN,LOCAL,,,,,102.85,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALEXIS 0 LARGE STERILE,27200000,CDM,272,RC,,,,11765-MAIN,LOCAL,,,,,102.85,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALEXIS 0 LARGE STERILE,27200000,CDM,272,RC,,,,11765-MAIN,LOCAL,,,,,102.85,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALEXIS 0 LARGE STERILE,27200000,CDM,272,RC,,,,11765-MAIN,LOCAL,,,,,102.85,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALEXIS 0 LARGE STERILE,27200000,CDM,272,RC,,,,11765-MAIN,LOCAL,,,,,102.85,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALEXIS 0 LARGE STERILE,27200000,CDM,272,RC,,,,11765-MAIN,LOCAL,,,,,102.85,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Alkaloids, Not Otherwise Specified - Ref",PX8032390,CDM,300,RC,80323,CPT,90,,,,,,,65,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Alkaloids, Not Otherwise Specified - Ref",PX8032390,CDM,300,RC,80323,CPT,90,,,,,,,65,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Alkaloids, Not Otherwise Specified - Ref",PX8032390,CDM,300,RC,80323,CPT,90,,,,,,,65,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Alkaloids, Not Otherwise Specified - Ref",PX8032390,CDM,300,RC,80323,CPT,90,,,,,,,65,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Alkaloids, Not Otherwise Specified - Ref",PX8032390,CDM,300,RC,80323,CPT,90,,,,,,,65,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Alkaloids, Not Otherwise Specified - Ref",PX8032390,CDM,300,RC,80323,CPT,90,,,,,,,65,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALLOGRAFT BONE AUGMENT INJECTABLE KIT 1.5CC,C1734,CDM,278,RC,C1734,HCPCS,,12632-MAIN,LOCAL,,,,,3694,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALLOGRAFT BONE AUGMENT INJECTABLE KIT 1.5CC,C1734,CDM,278,RC,C1734,HCPCS,,12632-MAIN,LOCAL,,,,,3694,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALLOGRAFT BONE AUGMENT INJECTABLE KIT 1.5CC,C1734,CDM,278,RC,C1734,HCPCS,,12632-MAIN,LOCAL,,,,,3694,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALLOGRAFT BONE AUGMENT INJECTABLE KIT 1.5CC,C1734,CDM,278,RC,C1734,HCPCS,,12632-MAIN,LOCAL,,,,,3694,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALLOGRAFT BONE AUGMENT INJECTABLE KIT 1.5CC,C1734,CDM,278,RC,C1734,HCPCS,,12632-MAIN,LOCAL,,,,,3694,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALLOGRAFT BONE AUGMENT INJECTABLE KIT 1.5CC,C1734,CDM,278,RC,C1734,HCPCS,,12632-MAIN,LOCAL,,,,,3694,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
allopurinol 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020501,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
allopurinol 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020501,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
allopurinol 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020501,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
allopurinol 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020501,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
allopurinol 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020501,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
allopurinol 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020501,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
allopurinol 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584098811,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
allopurinol 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584098811,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
allopurinol 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584098811,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
allopurinol 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584098811,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
allopurinol 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584098811,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
allopurinol 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584098811,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
allopurinol 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,53489015601,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
allopurinol 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,53489015601,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
allopurinol 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,53489015601,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
allopurinol 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,53489015601,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
allopurinol 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,53489015601,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
allopurinol 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,53489015601,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904657161,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904657161,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904657161,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904657161,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904657161,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904657161,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020520,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020520,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020520,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020520,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020520,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020520,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,62584098801,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,62584098801,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,62584098801,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,62584098801,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,62584098801,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,62584098801,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Alpha-Fetoprotein Serum,PX82105,CDM,300,RC,82105,CPT,,,,,,,,77,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Alpha-Fetoprotein Serum,PX82105,CDM,300,RC,82105,CPT,,,,,,,,77,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Alpha-Fetoprotein Serum,PX82105,CDM,300,RC,82105,CPT,,,,,,,,77,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Alpha-Fetoprotein Serum,PX82105,CDM,300,RC,82105,CPT,,,,,,,,77,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Alpha-Fetoprotein Serum,PX82105,CDM,300,RC,82105,CPT,,,,,,,,77,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Alpha-Fetoprotein Serum,PX82105,CDM,300,RC,82105,CPT,,,,,,,,77,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Alpha-Fetoprotein, Serum - Ref",PX8210590,CDM,300,RC,82105,CPT,90,,,,,,,80,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Alpha-Fetoprotein, Serum - Ref",PX8210590,CDM,300,RC,82105,CPT,90,,,,,,,80,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Alpha-Fetoprotein, Serum - Ref",PX8210590,CDM,300,RC,82105,CPT,90,,,,,,,80,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Alpha-Fetoprotein, Serum - Ref",PX8210590,CDM,300,RC,82105,CPT,90,,,,,,,80,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Alpha-Fetoprotein, Serum - Ref",PX8210590,CDM,300,RC,82105,CPT,90,,,,,,,80,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Alpha-Fetoprotein, Serum - Ref",PX8210590,CDM,300,RC,82105,CPT,90,,,,,,,80,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALPRAZolam 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862067701,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALPRAZolam 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862067701,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALPRAZolam 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862067701,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALPRAZolam 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862067701,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALPRAZolam 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862067701,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALPRAZolam 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862067701,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALPRAZolam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585961,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALPRAZolam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585961,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALPRAZolam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585961,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALPRAZolam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585961,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALPRAZolam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585961,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALPRAZolam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585961,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALPRAZolam 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,781106101,NDC,1,EA,3.73,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALPRAZolam 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,781106101,NDC,1,EA,3.73,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALPRAZolam 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,781106101,NDC,1,EA,3.73,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALPRAZolam 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,781106101,NDC,1,EA,3.73,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALPRAZolam 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,781106101,NDC,1,EA,3.73,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALPRAZolam 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,781106101,NDC,1,EA,3.73,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALPRAZolam 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,67253090010,NDC,1,EA,3.73,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALPRAZolam 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,67253090010,NDC,1,EA,3.73,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALPRAZolam 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,67253090010,NDC,1,EA,3.73,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALPRAZolam 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,67253090010,NDC,1,EA,3.73,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALPRAZolam 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,67253090010,NDC,1,EA,3.73,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALPRAZolam 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,67253090010,NDC,1,EA,3.73,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALPRAZolam 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585861,NDC,1,EA,3.41,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALPRAZolam 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585861,NDC,1,EA,3.41,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALPRAZolam 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585861,NDC,1,EA,3.41,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALPRAZolam 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585861,NDC,1,EA,3.41,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALPRAZolam 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585861,NDC,1,EA,3.41,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALPRAZolam 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585861,NDC,1,EA,3.41,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALPRAZolam 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739064410,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALPRAZolam 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739064410,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALPRAZolam 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739064410,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALPRAZolam 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739064410,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALPRAZolam 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739064410,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALPRAZolam 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739064410,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
alteplase 1 MG/ML Solution 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,8888800497,NDC,1,EA,21140.86,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
alteplase 1 MG/ML Solution 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,8888800497,NDC,1,EA,21140.86,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
alteplase 1 MG/ML Solution 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,8888800497,NDC,1,EA,21140.86,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
alteplase 1 MG/ML Solution 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,8888800497,NDC,1,EA,21140.86,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
alteplase 1 MG/ML Solution 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,8888800497,NDC,1,EA,21140.86,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
alteplase 1 MG/ML Solution 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,8888800497,NDC,1,EA,21140.86,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004110,NDC,1,EA,666.53,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004110,NDC,1,EA,666.53,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004110,NDC,1,EA,666.53,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004110,NDC,1,EA,666.53,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004110,NDC,1,EA,666.53,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004110,NDC,1,EA,666.53,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004164,NDC,1,EA,666.52,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004164,NDC,1,EA,666.52,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004164,NDC,1,EA,666.52,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004164,NDC,1,EA,666.52,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004164,NDC,1,EA,666.52,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004164,NDC,1,EA,666.52,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
alteplase 100 MG Recon Soln 1 Each Syringe,J2997.01,CDM,636,RC,J2997,HCPCS,,,,88888800475,NDC,0.09,EA,1920.88,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
alteplase 100 MG Recon Soln 1 Each Syringe,J2997.01,CDM,636,RC,J2997,HCPCS,,,,88888800475,NDC,0.09,EA,1920.88,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
alteplase 100 MG Recon Soln 1 Each Syringe,J2997.01,CDM,636,RC,J2997,HCPCS,,,,88888800475,NDC,0.09,EA,1920.88,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
alteplase 100 MG Recon Soln 1 Each Syringe,J2997.01,CDM,636,RC,J2997,HCPCS,,,,88888800475,NDC,0.09,EA,1920.88,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
alteplase 100 MG Recon Soln 1 Each Syringe,J2997.01,CDM,636,RC,J2997,HCPCS,,,,88888800475,NDC,0.09,EA,1920.88,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
alteplase 100 MG Recon Soln 1 Each Syringe,J2997.01,CDM,636,RC,J2997,HCPCS,,,,88888800475,NDC,0.09,EA,1920.88,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
alteplase 100 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242008527,NDC,1,EA,21140.86,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
alteplase 100 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242008527,NDC,1,EA,21140.86,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
alteplase 100 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242008527,NDC,1,EA,21140.86,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
alteplase 100 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242008527,NDC,1,EA,21140.86,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
alteplase 100 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242008527,NDC,1,EA,21140.86,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
alteplase 100 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242008527,NDC,1,EA,21140.86,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aluminum & magnesium hydroxide-simethicone 200-200-20 MG/5ML Suspension 30 mL Cup,63700001,CDM,250,RC,,,,,,121176130,NDC,30,ML,24.12,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aluminum & magnesium hydroxide-simethicone 200-200-20 MG/5ML Suspension 30 mL Cup,63700001,CDM,250,RC,,,,,,121176130,NDC,30,ML,24.12,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aluminum & magnesium hydroxide-simethicone 200-200-20 MG/5ML Suspension 30 mL Cup,63700001,CDM,250,RC,,,,,,121176130,NDC,30,ML,24.12,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aluminum & magnesium hydroxide-simethicone 200-200-20 MG/5ML Suspension 30 mL Cup,63700001,CDM,250,RC,,,,,,121176130,NDC,30,ML,24.12,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aluminum & magnesium hydroxide-simethicone 200-200-20 MG/5ML Suspension 30 mL Cup,63700001,CDM,250,RC,,,,,,121176130,NDC,30,ML,24.12,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aluminum & magnesium hydroxide-simethicone 200-200-20 MG/5ML Suspension 30 mL Cup,63700001,CDM,250,RC,,,,,,121176130,NDC,30,ML,24.12,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,703903201,NDC,2,ML,44.46,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,703903201,NDC,2,ML,44.46,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,703903201,NDC,2,ML,44.46,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,703903201,NDC,2,ML,44.46,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,703903201,NDC,2,ML,44.46,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,703903201,NDC,2,ML,44.46,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,23155029031,NDC,2,ML,98.99,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,23155029031,NDC,2,ML,98.99,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,23155029031,NDC,2,ML,98.99,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,23155029031,NDC,2,ML,98.99,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,23155029031,NDC,2,ML,98.99,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,23155029031,NDC,2,ML,98.99,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987501,NDC,3,ML,33.77,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987501,NDC,3,ML,33.77,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987501,NDC,3,ML,33.77,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987501,NDC,3,ML,33.77,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987501,NDC,3,ML,33.77,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987501,NDC,3,ML,33.77,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987525,NDC,3,ML,33.22,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987525,NDC,3,ML,33.22,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987525,NDC,3,ML,33.22,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987525,NDC,3,ML,33.22,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987525,NDC,3,ML,33.22,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987525,NDC,3,ML,33.22,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061601,NDC,3,ML,31.57,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061601,NDC,3,ML,31.57,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061601,NDC,3,ML,31.57,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061601,NDC,3,ML,31.57,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061601,NDC,3,ML,31.57,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061601,NDC,3,ML,31.57,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061603,NDC,3,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061603,NDC,3,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061603,NDC,3,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061603,NDC,3,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061603,NDC,3,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061603,NDC,3,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 150-4.21 MG/100ML-% Solution 100 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066015010,NDC,100,ML,249.22,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 150-4.21 MG/100ML-% Solution 100 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066015010,NDC,100,ML,249.22,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 150-4.21 MG/100ML-% Solution 100 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066015010,NDC,100,ML,249.22,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 150-4.21 MG/100ML-% Solution 100 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066015010,NDC,100,ML,249.22,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 150-4.21 MG/100ML-% Solution 100 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066015010,NDC,100,ML,249.22,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 150-4.21 MG/100ML-% Solution 100 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066015010,NDC,100,ML,249.22,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,245014789,NDC,0.5,EA,21.33,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,245014789,NDC,0.5,EA,21.33,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,245014789,NDC,0.5,EA,21.33,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,245014789,NDC,0.5,EA,21.33,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,245014789,NDC,0.5,EA,21.33,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,245014789,NDC,0.5,EA,21.33,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,245014701,NDC,0.5,EA,21.33,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,245014701,NDC,0.5,EA,21.33,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,245014701,NDC,0.5,EA,21.33,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,245014701,NDC,0.5,EA,21.33,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,245014701,NDC,0.5,EA,21.33,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,245014701,NDC,0.5,EA,21.33,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739038710,NDC,0.5,EA,9.08,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739038710,NDC,0.5,EA,9.08,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739038710,NDC,0.5,EA,9.08,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739038710,NDC,0.5,EA,9.08,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739038710,NDC,0.5,EA,9.08,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739038710,NDC,0.5,EA,9.08,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 360-4.14 MG/200ML-% Solution 200 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066036020,NDC,200,ML,325.25,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 360-4.14 MG/200ML-% Solution 200 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066036020,NDC,200,ML,325.25,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 360-4.14 MG/200ML-% Solution 200 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066036020,NDC,200,ML,325.25,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 360-4.14 MG/200ML-% Solution 200 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066036020,NDC,200,ML,325.25,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 360-4.14 MG/200ML-% Solution 200 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066036020,NDC,200,ML,325.25,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 360-4.14 MG/200ML-% Solution 200 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066036020,NDC,200,ML,325.25,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 900 MG/18ML Solution 18 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,67457015318,NDC,18,ML,113.73,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 900 MG/18ML Solution 18 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,67457015318,NDC,18,ML,113.73,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 900 MG/18ML Solution 18 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,67457015318,NDC,18,ML,113.73,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 900 MG/18ML Solution 18 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,67457015318,NDC,18,ML,113.73,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 900 MG/18ML Solution 18 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,67457015318,NDC,18,ML,113.73,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 900 MG/18ML Solution 18 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,67457015318,NDC,18,ML,113.73,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amitriptyline 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268003711,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amitriptyline 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268003711,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amitriptyline 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268003711,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amitriptyline 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268003711,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amitriptyline 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268003711,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amitriptyline 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268003711,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amitriptyline 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687043311,NDC,0.4,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amitriptyline 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687043311,NDC,0.4,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amitriptyline 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687043311,NDC,0.4,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amitriptyline 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687043311,NDC,0.4,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amitriptyline 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687043311,NDC,0.4,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amitriptyline 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687043311,NDC,0.4,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amitriptyline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687043301,NDC,0.4,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amitriptyline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687043301,NDC,0.4,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amitriptyline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687043301,NDC,0.4,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amitriptyline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687043301,NDC,0.4,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amitriptyline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687043301,NDC,0.4,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amitriptyline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687043301,NDC,0.4,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 2.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079045001,NDC,1,EA,9.28,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 2.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079045001,NDC,1,EA,9.28,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 2.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079045001,NDC,1,EA,9.28,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 2.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079045001,NDC,1,EA,9.28,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 2.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079045001,NDC,1,EA,9.28,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 2.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079045001,NDC,1,EA,9.28,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904636961,NDC,1,EA,8.55,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904636961,NDC,1,EA,8.55,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904636961,NDC,1,EA,8.55,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904636961,NDC,1,EA,8.55,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904636961,NDC,1,EA,8.55,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904636961,NDC,1,EA,8.55,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079045020,NDC,1,EA,9.28,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079045020,NDC,1,EA,9.28,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079045020,NDC,1,EA,9.28,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079045020,NDC,1,EA,9.28,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079045020,NDC,1,EA,9.28,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079045020,NDC,1,EA,9.28,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687026311,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687026311,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687026311,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687026311,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687026311,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687026311,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084025911,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084025911,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084025911,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084025911,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084025911,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084025911,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637061,NDC,0.5,EA,4.41,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637061,NDC,0.5,EA,4.41,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637061,NDC,0.5,EA,4.41,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637061,NDC,0.5,EA,4.41,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637061,NDC,0.5,EA,4.41,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637061,NDC,0.5,EA,4.41,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687026301,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687026301,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687026301,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687026301,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687026301,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687026301,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084025901,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084025901,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084025901,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084025901,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084025901,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084025901,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637161,NDC,0.25,EA,3.03,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637161,NDC,0.25,EA,3.03,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637161,NDC,0.25,EA,3.03,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637161,NDC,0.25,EA,3.03,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637161,NDC,0.25,EA,3.03,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637161,NDC,0.25,EA,3.03,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ammonium lactate 12 % Cream 385 g Tube,63700001,CDM,250,RC,,,,,,45802049326,NDC,385,GR,256.76,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ammonium lactate 12 % Cream 385 g Tube,63700001,CDM,250,RC,,,,,,45802049326,NDC,385,GR,256.76,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ammonium lactate 12 % Cream 385 g Tube,63700001,CDM,250,RC,,,,,,45802049326,NDC,385,GR,256.76,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ammonium lactate 12 % Cream 385 g Tube,63700001,CDM,250,RC,,,,,,45802049326,NDC,385,GR,256.76,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ammonium lactate 12 % Cream 385 g Tube,63700001,CDM,250,RC,,,,,,45802049326,NDC,385,GR,256.76,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ammonium lactate 12 % Cream 385 g Tube,63700001,CDM,250,RC,,,,,,45802049326,NDC,385,GR,256.76,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
AMNION MATRIX CORD STERILE 3X6,27200000,CDM,272,RC,C1762,HCPCS,,11625-MAIN,LOCAL,,,,,6919,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
AMNION MATRIX CORD STERILE 3X6,27200000,CDM,272,RC,C1762,HCPCS,,11625-MAIN,LOCAL,,,,,6919,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
AMNION MATRIX CORD STERILE 3X6,27200000,CDM,272,RC,C1762,HCPCS,,11625-MAIN,LOCAL,,,,,6919,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
AMNION MATRIX CORD STERILE 3X6,27200000,CDM,272,RC,C1762,HCPCS,,11625-MAIN,LOCAL,,,,,6919,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
AMNION MATRIX CORD STERILE 3X6,27200000,CDM,272,RC,C1762,HCPCS,,11625-MAIN,LOCAL,,,,,6919,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
AMNION MATRIX CORD STERILE 3X6,27200000,CDM,272,RC,C1762,HCPCS,,11625-MAIN,LOCAL,,,,,6919,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 125 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,143988815,NDC,150,ML,25.84,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 125 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,143988815,NDC,150,ML,25.84,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 125 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,143988815,NDC,150,ML,25.84,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 125 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,143988815,NDC,150,ML,25.84,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 125 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,143988815,NDC,150,ML,25.84,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 125 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,143988815,NDC,150,ML,25.84,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 125 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,781603955,NDC,150,ML,25.84,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 125 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,781603955,NDC,150,ML,25.84,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 125 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,781603955,NDC,150,ML,25.84,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 125 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,781603955,NDC,150,ML,25.84,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 125 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,781603955,NDC,150,ML,25.84,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 125 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,781603955,NDC,150,ML,25.84,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 250 MG Tablet Chewable 100 Each Bottle,63700001,CDM,250,RC,,,,,,93226801,NDC,1,EA,3.62,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 250 MG Tablet Chewable 100 Each Bottle,63700001,CDM,250,RC,,,,,,93226801,NDC,1,EA,3.62,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 250 MG Tablet Chewable 100 Each Bottle,63700001,CDM,250,RC,,,,,,93226801,NDC,1,EA,3.62,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 250 MG Tablet Chewable 100 Each Bottle,63700001,CDM,250,RC,,,,,,93226801,NDC,1,EA,3.62,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 250 MG Tablet Chewable 100 Each Bottle,63700001,CDM,250,RC,,,,,,93226801,NDC,1,EA,3.62,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 250 MG Tablet Chewable 100 Each Bottle,63700001,CDM,250,RC,,,,,,93226801,NDC,1,EA,3.62,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 250 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,93415580,NDC,150,ML,43.22,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 250 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,93415580,NDC,150,ML,43.22,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 250 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,93415580,NDC,150,ML,43.22,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 250 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,93415580,NDC,150,ML,43.22,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 250 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,93415580,NDC,150,ML,43.22,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 250 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,93415580,NDC,150,ML,43.22,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 250 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,65862070755,NDC,5,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 250 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,65862070755,NDC,5,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 250 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,65862070755,NDC,5,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 250 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,65862070755,NDC,5,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 250 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,65862070755,NDC,5,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 250 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,65862070755,NDC,5,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 250 MG/5ML Recon Susp 150 mL Package,63700001,CDM,250,RC,,,,,,99998805601,NDC,5,ML,15.24,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 250 MG/5ML Recon Susp 150 mL Package,63700001,CDM,250,RC,,,,,,99998805601,NDC,5,ML,15.24,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 250 MG/5ML Recon Susp 150 mL Package,63700001,CDM,250,RC,,,,,,99998805601,NDC,5,ML,15.24,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 250 MG/5ML Recon Susp 150 mL Package,63700001,CDM,250,RC,,,,,,99998805601,NDC,5,ML,15.24,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 250 MG/5ML Recon Susp 150 mL Package,63700001,CDM,250,RC,,,,,,99998805601,NDC,5,ML,15.24,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 250 MG/5ML Recon Susp 150 mL Package,63700001,CDM,250,RC,,,,,,99998805601,NDC,5,ML,15.24,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 400 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,65862007101,NDC,3.125,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 400 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,65862007101,NDC,3.125,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 400 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,65862007101,NDC,3.125,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 400 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,65862007101,NDC,3.125,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 400 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,65862007101,NDC,3.125,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 400 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,65862007101,NDC,3.125,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714029903,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714029903,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714029903,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714029903,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714029903,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714029903,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 875 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862001501,NDC,1,EA,4.67,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 875 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862001501,NDC,1,EA,4.67,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 875 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862001501,NDC,1,EA,4.67,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 875 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862001501,NDC,1,EA,4.67,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 875 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862001501,NDC,1,EA,4.67,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 875 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862001501,NDC,1,EA,4.67,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,43598020453,NDC,10,ML,58.73,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,43598020453,NDC,10,ML,58.73,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,43598020453,NDC,10,ML,58.73,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,43598020453,NDC,10,ML,58.73,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,43598020453,NDC,10,ML,58.73,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,43598020453,NDC,10,ML,58.73,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,60432006547,NDC,10,ML,34.98,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,60432006547,NDC,10,ML,34.98,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,60432006547,NDC,10,ML,34.98,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,60432006547,NDC,10,ML,34.98,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,60432006547,NDC,10,ML,34.98,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,60432006547,NDC,10,ML,34.98,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,72508020415,NDC,10,ML,58.73,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,72508020415,NDC,10,ML,58.73,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,72508020415,NDC,10,ML,58.73,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,72508020415,NDC,10,ML,58.73,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,72508020415,NDC,10,ML,58.73,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,72508020415,NDC,10,ML,58.73,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin-clavulanate 500-125 MG Tablet 20 Each Bottle,63700001,CDM,250,RC,,,,,,16714047701,NDC,1,EA,20.33,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin-clavulanate 500-125 MG Tablet 20 Each Bottle,63700001,CDM,250,RC,,,,,,16714047701,NDC,1,EA,20.33,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin-clavulanate 500-125 MG Tablet 20 Each Bottle,63700001,CDM,250,RC,,,,,,16714047701,NDC,1,EA,20.33,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin-clavulanate 500-125 MG Tablet 20 Each Bottle,63700001,CDM,250,RC,,,,,,16714047701,NDC,1,EA,20.33,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin-clavulanate 500-125 MG Tablet 20 Each Bottle,63700001,CDM,250,RC,,,,,,16714047701,NDC,1,EA,20.33,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin-clavulanate 500-125 MG Tablet 20 Each Bottle,63700001,CDM,250,RC,,,,,,16714047701,NDC,1,EA,20.33,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin-clavulanate 875-125 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862050301,NDC,1,EA,26.59,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin-clavulanate 875-125 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862050301,NDC,1,EA,26.59,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin-clavulanate 875-125 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862050301,NDC,1,EA,26.59,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin-clavulanate 875-125 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862050301,NDC,1,EA,26.59,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin-clavulanate 875-125 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862050301,NDC,1,EA,26.59,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin-clavulanate 875-125 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862050301,NDC,1,EA,26.59,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Amphetamines; 1 or 2 - Ref,PX8032490,CDM,300,RC,80324,CPT,90,,,,,,,147,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Amphetamines; 1 or 2 - Ref,PX8032490,CDM,300,RC,80324,CPT,90,,,,,,,147,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Amphetamines; 1 or 2 - Ref,PX8032490,CDM,300,RC,80324,CPT,90,,,,,,,147,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Amphetamines; 1 or 2 - Ref,PX8032490,CDM,300,RC,80324,CPT,90,,,,,,,147,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Amphetamines; 1 or 2 - Ref,PX8032490,CDM,300,RC,80324,CPT,90,,,,,,,147,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Amphetamines; 1 or 2 - Ref,PX8032490,CDM,300,RC,80324,CPT,90,,,,,,,147,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Amphetamines; 3 or 4,PX8032590,CDM,300,RC,80325,CPT,90,,,,,,,48,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Amphetamines; 3 or 4,PX8032590,CDM,300,RC,80325,CPT,90,,,,,,,48,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Amphetamines; 3 or 4,PX8032590,CDM,300,RC,80325,CPT,90,,,,,,,48,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Amphetamines; 3 or 4,PX8032590,CDM,300,RC,80325,CPT,90,,,,,,,48,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Amphetamines; 3 or 4,PX8032590,CDM,300,RC,80325,CPT,90,,,,,,,48,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Amphetamines; 3 or 4,PX8032590,CDM,300,RC,80325,CPT,90,,,,,,,48,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin 1 GM Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781926185,NDC,0.5,EA,43.18,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin 1 GM Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781926185,NDC,0.5,EA,43.18,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin 1 GM Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781926185,NDC,0.5,EA,43.18,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin 1 GM Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781926185,NDC,0.5,EA,43.18,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin 1 GM Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781926185,NDC,0.5,EA,43.18,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin 1 GM Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781926185,NDC,0.5,EA,43.18,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927380,NDC,1,EA,99.91,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927380,NDC,1,EA,99.91,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927380,NDC,1,EA,99.91,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927380,NDC,1,EA,99.91,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927380,NDC,1,EA,99.91,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927380,NDC,1,EA,99.91,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927395,NDC,1,EA,99.91,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927395,NDC,1,EA,99.91,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927395,NDC,1,EA,99.91,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927395,NDC,1,EA,99.91,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927395,NDC,1,EA,99.91,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927395,NDC,1,EA,99.91,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin 500 MG Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781925078,NDC,1,EA,44.28,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin 500 MG Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781925078,NDC,1,EA,44.28,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin 500 MG Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781925078,NDC,1,EA,44.28,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin 500 MG Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781925078,NDC,1,EA,44.28,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin 500 MG Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781925078,NDC,1,EA,44.28,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin 500 MG Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781925078,NDC,1,EA,44.28,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin-sulbactam 1.5 (1-0.5) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001381,NDC,1,EA,69.24,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin-sulbactam 1.5 (1-0.5) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001381,NDC,1,EA,69.24,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin-sulbactam 1.5 (1-0.5) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001381,NDC,1,EA,69.24,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin-sulbactam 1.5 (1-0.5) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001381,NDC,1,EA,69.24,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin-sulbactam 1.5 (1-0.5) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001381,NDC,1,EA,69.24,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin-sulbactam 1.5 (1-0.5) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001381,NDC,1,EA,69.24,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001481,NDC,1,EA,102.12,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001481,NDC,1,EA,102.12,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001481,NDC,1,EA,102.12,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001481,NDC,1,EA,102.12,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001481,NDC,1,EA,102.12,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001481,NDC,1,EA,102.12,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011701,NDC,1,EA,89.64,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011701,NDC,1,EA,89.64,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011701,NDC,1,EA,89.64,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011701,NDC,1,EA,89.64,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011701,NDC,1,EA,89.64,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011701,NDC,1,EA,89.64,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011710,NDC,1,EA,89.64,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011710,NDC,1,EA,89.64,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011710,NDC,1,EA,89.64,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011710,NDC,1,EA,89.64,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011710,NDC,1,EA,89.64,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011710,NDC,1,EA,89.64,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Amputation Finger/Thumb,PX26951F,CDM,510,RC,26951,CPT,,,,,,,,3253,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Amputation Finger/Thumb,PX26951F,CDM,510,RC,26951,CPT,,,,,,,,3253,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Amputation Finger/Thumb,PX26951F,CDM,510,RC,26951,CPT,,,,,,,,3253,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Amputation Finger/Thumb,PX26951F,CDM,510,RC,26951,CPT,,,,,,,,3253,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Amputation Finger/Thumb,PX26951F,CDM,510,RC,26951,CPT,,,,,,,,3253,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Amputation Finger/Thumb,PX26951F,CDM,510,RC,26951,CPT,,,,,,,,3253,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Amputation Finger/Thumb,PX26951P,CDM,983,RC,26951,CPT,,,,,,,,2603,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Amputation Finger/Thumb,PX26951P,CDM,983,RC,26951,CPT,,,,,,,,2603,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Amputation Finger/Thumb,PX26951P,CDM,983,RC,26951,CPT,,,,,,,,2603,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Amputation Finger/Thumb,PX26951P,CDM,983,RC,26951,CPT,,,,,,,,2603,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Amputation Finger/Thumb,PX26951P,CDM,983,RC,26951,CPT,,,,,,,,2603,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Amputation Finger/Thumb,PX26951P,CDM,983,RC,26951,CPT,,,,,,,,2603,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Amputation Metatarsal+Toe,Single",PX28810F,CDM,510,RC,28810,CPT,,,,,,,,930,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Amputation Metatarsal+Toe,Single",PX28810F,CDM,510,RC,28810,CPT,,,,,,,,930,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Amputation Metatarsal+Toe,Single",PX28810F,CDM,510,RC,28810,CPT,,,,,,,,930,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Amputation Metatarsal+Toe,Single",PX28810F,CDM,510,RC,28810,CPT,,,,,,,,930,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Amputation Metatarsal+Toe,Single",PX28810F,CDM,510,RC,28810,CPT,,,,,,,,930,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Amputation Metatarsal+Toe,Single",PX28810F,CDM,510,RC,28810,CPT,,,,,,,,930,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Amputation Metatarsal+Toe,Single",PX28810P,CDM,983,RC,28810,CPT,,,,,,,,620,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Amputation Metatarsal+Toe,Single",PX28810P,CDM,983,RC,28810,CPT,,,,,,,,620,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Amputation Metatarsal+Toe,Single",PX28810P,CDM,983,RC,28810,CPT,,,,,,,,620,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Amputation Metatarsal+Toe,Single",PX28810P,CDM,983,RC,28810,CPT,,,,,,,,620,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Amputation Metatarsal+Toe,Single",PX28810P,CDM,983,RC,28810,CPT,,,,,,,,620,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Amputation Metatarsal+Toe,Single",PX28810P,CDM,983,RC,28810,CPT,,,,,,,,620,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Amputation Toe,I-P Jt",PX28825F,CDM,510,RC,28825,CPT,,,,,,,,1327,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Amputation Toe,I-P Jt",PX28825F,CDM,510,RC,28825,CPT,,,,,,,,1327,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Amputation Toe,I-P Jt",PX28825F,CDM,510,RC,28825,CPT,,,,,,,,1327,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Amputation Toe,I-P Jt",PX28825F,CDM,510,RC,28825,CPT,,,,,,,,1327,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Amputation Toe,I-P Jt",PX28825F,CDM,510,RC,28825,CPT,,,,,,,,1327,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Amputation Toe,I-P Jt",PX28825F,CDM,510,RC,28825,CPT,,,,,,,,1327,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Amputation Toe,I-P Jt",PX28825P,CDM,983,RC,28825,CPT,,,,,,,,780,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Amputation Toe,I-P Jt",PX28825P,CDM,983,RC,28825,CPT,,,,,,,,780,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Amputation Toe,I-P Jt",PX28825P,CDM,983,RC,28825,CPT,,,,,,,,780,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Amputation Toe,I-P Jt",PX28825P,CDM,983,RC,28825,CPT,,,,,,,,780,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Amputation Toe,I-P Jt",PX28825P,CDM,983,RC,28825,CPT,,,,,,,,780,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Amputation Toe,I-P Jt",PX28825P,CDM,983,RC,28825,CPT,,,,,,,,780,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Amputation Toe,Mt-P Jt",PX28820F,CDM,510,RC,28820,CPT,,,,,,,,1950,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Amputation Toe,Mt-P Jt",PX28820F,CDM,510,RC,28820,CPT,,,,,,,,1950,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Amputation Toe,Mt-P Jt",PX28820F,CDM,510,RC,28820,CPT,,,,,,,,1950,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Amputation Toe,Mt-P Jt",PX28820F,CDM,510,RC,28820,CPT,,,,,,,,1950,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Amputation Toe,Mt-P Jt",PX28820F,CDM,510,RC,28820,CPT,,,,,,,,1950,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Amputation Toe,Mt-P Jt",PX28820F,CDM,510,RC,28820,CPT,,,,,,,,1950,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Amputation Toe,Mt-P Jt",PX28820P,CDM,983,RC,28820,CPT,,,,,,,,1300,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Amputation Toe,Mt-P Jt",PX28820P,CDM,983,RC,28820,CPT,,,,,,,,1300,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Amputation Toe,Mt-P Jt",PX28820P,CDM,983,RC,28820,CPT,,,,,,,,1300,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Amputation Toe,Mt-P Jt",PX28820P,CDM,983,RC,28820,CPT,,,,,,,,1300,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Amputation Toe,Mt-P Jt",PX28820P,CDM,983,RC,28820,CPT,,,,,,,,1300,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Amputation Toe,Mt-P Jt",PX28820P,CDM,983,RC,28820,CPT,,,,,,,,1300,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Amylase - Ref,PX8215090,CDM,300,RC,82150,CPT,90,,,,,,,185,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Amylase - Ref,PX8215090,CDM,300,RC,82150,CPT,90,,,,,,,185,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Amylase - Ref,PX8215090,CDM,300,RC,82150,CPT,90,,,,,,,185,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Amylase - Ref,PX8215090,CDM,300,RC,82150,CPT,90,,,,,,,185,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Amylase - Ref,PX8215090,CDM,300,RC,82150,CPT,90,,,,,,,185,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Amylase - Ref,PX8215090,CDM,300,RC,82150,CPT,90,,,,,,,185,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anal Sphincterotomy,PX46080F,CDM,510,RC,46080,CPT,,,,,,,,607,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anal Sphincterotomy,PX46080F,CDM,510,RC,46080,CPT,,,,,,,,607,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anal Sphincterotomy,PX46080F,CDM,510,RC,46080,CPT,,,,,,,,607,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anal Sphincterotomy,PX46080F,CDM,510,RC,46080,CPT,,,,,,,,607,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anal Sphincterotomy,PX46080F,CDM,510,RC,46080,CPT,,,,,,,,607,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anal Sphincterotomy,PX46080F,CDM,510,RC,46080,CPT,,,,,,,,607,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anal Sphincterotomy,PX46080P,CDM,983,RC,46080,CPT,,,,,,,,525,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anal Sphincterotomy,PX46080P,CDM,983,RC,46080,CPT,,,,,,,,525,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anal Sphincterotomy,PX46080P,CDM,983,RC,46080,CPT,,,,,,,,525,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anal Sphincterotomy,PX46080P,CDM,983,RC,46080,CPT,,,,,,,,525,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anal Sphincterotomy,PX46080P,CDM,983,RC,46080,CPT,,,,,,,,525,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anal Sphincterotomy,PX46080P,CDM,983,RC,46080,CPT,,,,,,,,525,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
anastrozole 1 MG Tablet 1 Each Blister,25000000,CDM,250,RC,,,,,,60687011211,NDC,1,EA,11.13,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
anastrozole 1 MG Tablet 1 Each Blister,25000000,CDM,250,RC,,,,,,60687011211,NDC,1,EA,11.13,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
anastrozole 1 MG Tablet 1 Each Blister,25000000,CDM,250,RC,,,,,,60687011211,NDC,1,EA,11.13,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
anastrozole 1 MG Tablet 1 Each Blister,25000000,CDM,250,RC,,,,,,60687011211,NDC,1,EA,11.13,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
anastrozole 1 MG Tablet 1 Each Blister,25000000,CDM,250,RC,,,,,,60687011211,NDC,1,EA,11.13,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
anastrozole 1 MG Tablet 1 Each Blister,25000000,CDM,250,RC,,,,,,60687011211,NDC,1,EA,11.13,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
anastrozole 1 MG Tablet 30 Each Bottle,25000000,CDM,250,RC,,,,,,16729003510,NDC,1,EA,71.44,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
anastrozole 1 MG Tablet 30 Each Bottle,25000000,CDM,250,RC,,,,,,16729003510,NDC,1,EA,71.44,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
anastrozole 1 MG Tablet 30 Each Bottle,25000000,CDM,250,RC,,,,,,16729003510,NDC,1,EA,71.44,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
anastrozole 1 MG Tablet 30 Each Bottle,25000000,CDM,250,RC,,,,,,16729003510,NDC,1,EA,71.44,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
anastrozole 1 MG Tablet 30 Each Bottle,25000000,CDM,250,RC,,,,,,16729003510,NDC,1,EA,71.44,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
anastrozole 1 MG Tablet 30 Each Bottle,25000000,CDM,250,RC,,,,,,16729003510,NDC,1,EA,71.44,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
anastrozole 1 MG Tablet 30 Each Box,25000000,CDM,250,RC,,,,,,60687011221,NDC,1,EA,11.13,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
anastrozole 1 MG Tablet 30 Each Box,25000000,CDM,250,RC,,,,,,60687011221,NDC,1,EA,11.13,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
anastrozole 1 MG Tablet 30 Each Box,25000000,CDM,250,RC,,,,,,60687011221,NDC,1,EA,11.13,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
anastrozole 1 MG Tablet 30 Each Box,25000000,CDM,250,RC,,,,,,60687011221,NDC,1,EA,11.13,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
anastrozole 1 MG Tablet 30 Each Box,25000000,CDM,250,RC,,,,,,60687011221,NDC,1,EA,11.13,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
anastrozole 1 MG Tablet 30 Each Box,25000000,CDM,250,RC,,,,,,60687011221,NDC,1,EA,11.13,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anca Screen Each Antibody,PX8603690,CDM,300,RC,86036,CPT,90,,,,,,,82,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anca Screen Each Antibody,PX8603690,CDM,300,RC,86036,CPT,90,,,,,,,82,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anca Screen Each Antibody,PX8603690,CDM,300,RC,86036,CPT,90,,,,,,,82,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anca Screen Each Antibody,PX8603690,CDM,300,RC,86036,CPT,90,,,,,,,82,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anca Screen Each Antibody,PX8603690,CDM,300,RC,86036,CPT,90,,,,,,,82,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anca Screen Each Antibody,PX8603690,CDM,300,RC,86036,CPT,90,,,,,,,82,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ANCHORAGE FIXATION PIN,27200000,CDM,272,RC,,,,12642-MAIN,LOCAL,,,,,389,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ANCHORAGE FIXATION PIN,27200000,CDM,272,RC,,,,12642-MAIN,LOCAL,,,,,389,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ANCHORAGE FIXATION PIN,27200000,CDM,272,RC,,,,12642-MAIN,LOCAL,,,,,389,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ANCHORAGE FIXATION PIN,27200000,CDM,272,RC,,,,12642-MAIN,LOCAL,,,,,389,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ANCHORAGE FIXATION PIN,27200000,CDM,272,RC,,,,12642-MAIN,LOCAL,,,,,389,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ANCHORAGE FIXATION PIN,27200000,CDM,272,RC,,,,12642-MAIN,LOCAL,,,,,389,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Androsetenedione - Ref,PX8215790,CDM,300,RC,82157,CPT,90,,,,,,,107,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Androsetenedione - Ref,PX8215790,CDM,300,RC,82157,CPT,90,,,,,,,107,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Androsetenedione - Ref,PX8215790,CDM,300,RC,82157,CPT,90,,,,,,,107,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Androsetenedione - Ref,PX8215790,CDM,300,RC,82157,CPT,90,,,,,,,107,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Androsetenedione - Ref,PX8215790,CDM,300,RC,82157,CPT,90,,,,,,,107,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Androsetenedione - Ref,PX8215790,CDM,300,RC,82157,CPT,90,,,,,,,107,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Dx Shoulder Arthroscopy,PX01622.01,CDM,964,RC,1622,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Dx Shoulder Arthroscopy,PX01622.01,CDM,964,RC,1622,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Lower Intestinal Endoscopic Px Nos,PX00811.01,CDM,964,RC,811,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Lower Intestinal Endoscopic Px Nos,PX00811.01,CDM,964,RC,811,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Lower Intestinal Screening Colonoscopy,PX00812.01,CDM,964,RC,812,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Lower Intestinal Screening Colonoscopy,PX00812.01,CDM,964,RC,812,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Spine Transthor W/Vent,PX00626.01,CDM,964,RC,626,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Spine Transthor W/Vent,PX00626.01,CDM,964,RC,626,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Spine Tranthor W/O Vent,PX00625.01,CDM,964,RC,625,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Spine Tranthor W/O Vent,PX00625.01,CDM,964,RC,625,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Ther Interven Rad Art,PX01924.01,CDM,964,RC,1924,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Ther Interven Rad Art,PX01924.01,CDM,964,RC,1924,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Ther Interven Rad Car,PX01925.01,CDM,964,RC,1925,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Ther Interven Rad Car,PX01925.01,CDM,964,RC,1925,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Ther Interven Rad Tip,PX01931.01,CDM,964,RC,1931,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Ther Interven Rad Tip,PX01931.01,CDM,964,RC,1931,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Ther Interven Rad Vei,PX01930.01,CDM,964,RC,1930,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Ther Interven Rad Vei,PX01930.01,CDM,964,RC,1930,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Tx Interv Rad Cran V,PX01933.01,CDM,964,RC,1933,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Tx Interv Rad Cran V,PX01933.01,CDM,964,RC,1933,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Tx Interv Rad Hrt/Cran,PX01926.01,CDM,964,RC,1926,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Tx Interv Rad Hrt/Cran,PX01926.01,CDM,964,RC,1926,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Tx Interv Rad Th Vein,PX01932.01,CDM,964,RC,1932,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Tx Interv Rad Th Vein,PX01932.01,CDM,964,RC,1932,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Upper GI Endoscopic Px Ercp,PX00732.01,CDM,964,RC,732,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Upper GI Endoscopic Px Ercp,PX00732.01,CDM,964,RC,732,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Upper GI Endoscopic Px Nos,PX00731.01,CDM,964,RC,731,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Upper GI Endoscopic Px Nos,PX00731.01,CDM,964,RC,731,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Upper/Lower GI Endoscopic Px,PX00813.01,CDM,964,RC,813,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Upper/Lower GI Endoscopic Px,PX00813.01,CDM,964,RC,813,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes/Analg Cs Deliver Add-On,PX01968.01,CDM,964,RC,1968,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes/Analg Cs Deliver Add-On,PX01968.01,CDM,964,RC,1968,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Abdomen Vessel Surg,PX00880.01,CDM,964,RC,880,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Abdomen Vessel Surg,PX00880.01,CDM,964,RC,880,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Abdominal Wall Surg,PX00700.01,CDM,964,RC,700,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Abdominal Wall Surg,PX00700.01,CDM,964,RC,700,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Abdominal Wall Surg,PX00730.01,CDM,964,RC,730,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Abdominal Wall Surg,PX00730.01,CDM,964,RC,730,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Abdominal Wall Surg,PX00800.01,CDM,964,RC,800,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Abdominal Wall Surg,PX00800.01,CDM,964,RC,800,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Abdominal Wall Surg,PX00820.01,CDM,964,RC,820,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Abdominal Wall Surg,PX00820.01,CDM,964,RC,820,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Achilles Tendon Surg,PX01472.01,CDM,964,RC,1472,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Achilles Tendon Surg,PX01472.01,CDM,964,RC,1472,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Airplane Cast,PX01682.01,CDM,964,RC,1682,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Airplane Cast,PX01682.01,CDM,964,RC,1682,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Amniocentesis,PX00842.01,CDM,964,RC,842,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Amniocentesis,PX00842.01,CDM,964,RC,842,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Amputation at Knee,PX01404.01,CDM,964,RC,1404,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Amputation at Knee,PX01404.01,CDM,964,RC,1404,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Amputation at Pelvis,PX01140.01,CDM,964,RC,1140,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Amputation at Pelvis,PX01140.01,CDM,964,RC,1140,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Amputation of Femur,PX01232.01,CDM,964,RC,1232,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Amputation of Femur,PX01232.01,CDM,964,RC,1232,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Amputation of Penis,PX00932.01,CDM,964,RC,932,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Amputation of Penis,PX00932.01,CDM,964,RC,932,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Ankle Replacement,PX01486.01,CDM,964,RC,1486,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Ankle Replacement,PX01486.01,CDM,964,RC,1486,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Ankle/Ft Arthroscopy,PX01464.01,CDM,964,RC,1464,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Ankle/Ft Arthroscopy,PX01464.01,CDM,964,RC,1464,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Anorectal Surgery,PX00902.01,CDM,964,RC,902,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Anorectal Surgery,PX00902.01,CDM,964,RC,902,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Antepartum Manipul,PX01958.01,CDM,964,RC,1958,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Antepartum Manipul,PX01958.01,CDM,964,RC,1958,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Arm-Leg Vessel Surg,PX01656.01,CDM,964,RC,1656,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Arm-Leg Vessel Surg,PX01656.01,CDM,964,RC,1656,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Arthroscopy of Hip,PX01202.01,CDM,964,RC,1202,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Arthroscopy of Hip,PX01202.01,CDM,964,RC,1202,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Biceps Tendon Repair,PX01716.01,CDM,964,RC,1716,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Biceps Tendon Repair,PX01716.01,CDM,964,RC,1716,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Biopsy of Nose,PX00164.01,CDM,964,RC,164,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Biopsy of Nose,PX00164.01,CDM,964,RC,164,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Biopsy of Thyroid,PX00322.01,CDM,964,RC,322,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Biopsy of Thyroid,PX00322.01,CDM,964,RC,322,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Bladder Stone Surg,PX00870.01,CDM,964,RC,870,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Bladder Stone Surg,PX00870.01,CDM,964,RC,870,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Bladder Surgery,PX00910.01,CDM,964,RC,910,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Bladder Surgery,PX00910.01,CDM,964,RC,910,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Bladder Tumor Surg,PX00912.01,CDM,964,RC,912,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Bladder Tumor Surg,PX00912.01,CDM,964,RC,912,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Bleeding Control,PX00916.01,CDM,964,RC,916,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Bleeding Control,PX00916.01,CDM,964,RC,916,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Blepharoplasty,PX00103.01,CDM,964,RC,103,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Blepharoplasty,PX00103.01,CDM,964,RC,103,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Blood Vessel Repair,PX00770.01,CDM,964,RC,770,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Blood Vessel Repair,PX00770.01,CDM,964,RC,770,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Body Cast Procedure,PX01130.01,CDM,964,RC,1130,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Body Cast Procedure,PX01130.01,CDM,964,RC,1130,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Bone Aspirate/Bx,PX01112.01,CDM,964,RC,1112,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Bone Aspirate/Bx,PX01112.01,CDM,964,RC,1112,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Burn 4-9 Percent,PX01952.01,CDM,964,RC,1952,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Burn 4-9 Percent,PX01952.01,CDM,964,RC,1952,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Burn Each 9 Percent,PX01953.01,CDM,964,RC,1953,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Burn Each 9 Percent,PX01953.01,CDM,964,RC,1953,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Burn Less 4 Percent,PX01951.01,CDM,964,RC,1951,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Burn Less 4 Percent,PX01951.01,CDM,964,RC,1951,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cabg W/O Pump,PX00566.01,CDM,964,RC,566,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cabg W/O Pump,PX00566.01,CDM,964,RC,566,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cabg W/Pump,PX00567.01,CDM,964,RC,567,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cabg W/Pump,PX00567.01,CDM,964,RC,567,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cardiac Electrophys,PX00537.01,CDM,964,RC,537,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cardiac Electrophys,PX00537.01,CDM,964,RC,537,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cardioverter/Defib,PX00534.01,CDM,964,RC,534,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cardioverter/Defib,PX00534.01,CDM,964,RC,534,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cat or MRI Scan,PX01922.01,CDM,964,RC,1922,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cat or MRI Scan,PX01922.01,CDM,964,RC,1922,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Catheterize Heart,PX01920.01,CDM,964,RC,1920,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Catheterize Heart,PX01920.01,CDM,964,RC,1920,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Drainage,PX00524.01,CDM,964,RC,524,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Drainage,PX00524.01,CDM,964,RC,524,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Lining Biopsy,PX00522.01,CDM,964,RC,522,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Lining Biopsy,PX00522.01,CDM,964,RC,522,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Partition View,PX00528.01,CDM,964,RC,528,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Partition View,PX00528.01,CDM,964,RC,528,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Partition View,PX00529.01,CDM,964,RC,529,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Partition View,PX00529.01,CDM,964,RC,529,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Procedure,PX00520.01,CDM,964,RC,520,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Procedure,PX00520.01,CDM,964,RC,520,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Surgery,PX00540.01,CDM,964,RC,540,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Surgery,PX00540.01,CDM,964,RC,540,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Wall Repair,PX00472.01,CDM,964,RC,472,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Wall Repair,PX00472.01,CDM,964,RC,472,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cleft Palate Repair,PX00172.01,CDM,964,RC,172,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cleft Palate Repair,PX00172.01,CDM,964,RC,172,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Collar Bone Biopsy,PX00454.01,CDM,964,RC,454,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Collar Bone Biopsy,PX00454.01,CDM,964,RC,454,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Corneal Transplant,PX00144.01,CDM,964,RC,144,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Corneal Transplant,PX00144.01,CDM,964,RC,144,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Correct Heart Rhythm,PX00410.01,CDM,964,RC,410,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Correct Heart Rhythm,PX00410.01,CDM,964,RC,410,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cran Surg Hemotoma,PX00211.01,CDM,964,RC,211,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cran Surg Hemotoma,PX00211.01,CDM,964,RC,211,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cranial Surg Nos,PX00210.01,CDM,964,RC,210,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cranial Surg Nos,PX00210.01,CDM,964,RC,210,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cs Delivery,PX01961.01,CDM,964,RC,1961,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cs Delivery,PX01961.01,CDM,964,RC,1961,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cs Hysterectomy,PX01963.01,CDM,964,RC,1963,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cs Hysterectomy,PX01963.01,CDM,964,RC,1963,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Dx Arteriography,PX01916.01,CDM,964,RC,1916,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Dx Arteriography,PX01916.01,CDM,964,RC,1916,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Dx Elbow Arthroscopy,PX01732.01,CDM,964,RC,1732,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Dx Elbow Arthroscopy,PX01732.01,CDM,964,RC,1732,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Dx Knee Arthroscopy,PX01382.01,CDM,964,RC,1382,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Dx Knee Arthroscopy,PX01382.01,CDM,964,RC,1382,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Dx Wrist Arthroscopy,PX01829.01,CDM,964,RC,1829,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Dx Wrist Arthroscopy,PX01829.01,CDM,964,RC,1829,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Ear Exam,PX00124.01,CDM,964,RC,124,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Ear Exam,PX00124.01,CDM,964,RC,124,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Ear Surgery,PX00120.01,CDM,964,RC,120,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Ear Surgery,PX00120.01,CDM,964,RC,120,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Elbow Area Surgery,PX01710.01,CDM,964,RC,1710,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Elbow Area Surgery,PX01710.01,CDM,964,RC,1710,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Elbow Replacement,PX01760.01,CDM,964,RC,1760,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Elbow Replacement,PX01760.01,CDM,964,RC,1760,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Electroshock,PX00104.01,CDM,964,RC,104,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Electroshock,PX00104.01,CDM,964,RC,104,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Emer Hysterectomy,PX01962.01,CDM,964,RC,1962,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Emer Hysterectomy,PX01962.01,CDM,964,RC,1962,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Esophageal Surgery,PX00500.01,CDM,964,RC,500,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Esophageal Surgery,PX00500.01,CDM,964,RC,500,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Eye Exam,PX00148.01,CDM,964,RC,148,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Eye Exam,PX00148.01,CDM,964,RC,148,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Face/Skull Bone Surg,PX00190.01,CDM,964,RC,190,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Face/Skull Bone Surg,PX00190.01,CDM,964,RC,190,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Facial Bone Surgery,PX00192.01,CDM,964,RC,192,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Facial Bone Surgery,PX00192.01,CDM,964,RC,192,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Fat Layer Removal,PX00802.01,CDM,964,RC,802,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Fat Layer Removal,PX00802.01,CDM,964,RC,802,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Femoral Artery Surg,PX01272.01,CDM,964,RC,1272,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Femoral Artery Surg,PX01272.01,CDM,964,RC,1272,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Femoral Embolectomy,PX01274.01,CDM,964,RC,1274,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Femoral Embolectomy,PX01274.01,CDM,964,RC,1274,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth for Chemonucleolysis,PX00634.01,CDM,964,RC,634,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth for Chemonucleolysis,PX00634.01,CDM,964,RC,634,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth for Liver Biopsy,PX00702.01,CDM,964,RC,702,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth for Liver Biopsy,PX00702.01,CDM,964,RC,702,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth for Liver Transplant,PX00796.01,CDM,964,RC,796,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth for Liver Transplant,PX00796.01,CDM,964,RC,796,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Forequarter Amput,PX01636.01,CDM,964,RC,1636,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Forequarter Amput,PX01636.01,CDM,964,RC,1636,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Fx Repair Pelvis,PX01173.01,CDM,964,RC,1173,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Fx Repair Pelvis,PX01173.01,CDM,964,RC,1173,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Genitalia Surgery,PX00920.01,CDM,964,RC,920,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Genitalia Surgery,PX00920.01,CDM,964,RC,920,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Head Nerve Surgery,PX00222.01,CDM,964,RC,222,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Head Nerve Surgery,PX00222.01,CDM,964,RC,222,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Head Vessel Surgery,PX00216.01,CDM,964,RC,216,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Head Vessel Surgery,PX00216.01,CDM,964,RC,216,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Head/Neck/Ptrunk,PX00300.01,CDM,964,RC,300,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Head/Neck/Ptrunk,PX00300.01,CDM,964,RC,300,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Heart Surg < 1 Yr,PX00561.01,CDM,964,RC,561,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Heart Surg < 1 Yr,PX00561.01,CDM,964,RC,561,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Heart Surg W/Arrest,PX00563.01,CDM,964,RC,563,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Heart Surg W/Arrest,PX00563.01,CDM,964,RC,563,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Heart Surg W/O Pump,PX00560.01,CDM,964,RC,560,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Heart Surg W/O Pump,PX00560.01,CDM,964,RC,560,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Heart/Lung Transplnt,PX00580.01,CDM,964,RC,580,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Heart/Lung Transplnt,PX00580.01,CDM,964,RC,580,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hemorr/Excise Liver,PX00792.01,CDM,964,RC,792,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hemorr/Excise Liver,PX00792.01,CDM,964,RC,792,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hernia Repair < 1 Yr,PX00834.01,CDM,964,RC,834,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hernia Repair < 1 Yr,PX00834.01,CDM,964,RC,834,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hernia Repair Preemie,PX00836.01,CDM,964,RC,836,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hernia Repair Preemie,PX00836.01,CDM,964,RC,836,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hip Arthroplasty,PX01214.01,CDM,964,RC,1214,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hip Arthroplasty,PX01214.01,CDM,964,RC,1214,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hip Disarticulation,PX01212.01,CDM,964,RC,1212,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hip Disarticulation,PX01212.01,CDM,964,RC,1212,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hip Joint Procedure,PX01200.01,CDM,964,RC,1200,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hip Joint Procedure,PX01200.01,CDM,964,RC,1200,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hip Joint Surgery,PX01210.01,CDM,964,RC,1210,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hip Joint Surgery,PX01210.01,CDM,964,RC,1210,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hrt Surg W/Pmp Age 1+,PX00562.01,CDM,964,RC,562,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hrt Surg W/Pmp Age 1+,PX00562.01,CDM,964,RC,562,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Humeral Lesion Surg,PX01758.01,CDM,964,RC,1758,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Humeral Lesion Surg,PX01758.01,CDM,964,RC,1758,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Humerus Repair,PX01744.01,CDM,964,RC,1744,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Humerus Repair,PX01744.01,CDM,964,RC,1744,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Humerus Surgery,PX01742.01,CDM,964,RC,1742,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Humerus Surgery,PX01742.01,CDM,964,RC,1742,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hysterectomy,PX00846.01,CDM,964,RC,846,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hysterectomy,PX00846.01,CDM,964,RC,846,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hysteroscope/Graph,PX00952.01,CDM,964,RC,952,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hysteroscope/Graph,PX00952.01,CDM,964,RC,952,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Inc/Missed Ab Proc,PX01965.01,CDM,964,RC,1965,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Inc/Missed Ab Proc,PX01965.01,CDM,964,RC,1965,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Induced Ab Procedure,PX01966.01,CDM,964,RC,1966,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Induced Ab Procedure,PX01966.01,CDM,964,RC,1966,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Insert Penis Device,PX00938.01,CDM,964,RC,938,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Insert Penis Device,PX00938.01,CDM,964,RC,938,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Intrcrn Nerve,PX00220.01,CDM,964,RC,220,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Intrcrn Nerve,PX00220.01,CDM,964,RC,220,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Iridectomy,PX00147.01,CDM,964,RC,147,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Iridectomy,PX00147.01,CDM,964,RC,147,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Kidney Stone Destruct,PX00872.01,CDM,964,RC,872,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Kidney Stone Destruct,PX00872.01,CDM,964,RC,872,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Kidney Stone Destruct,PX00873.01,CDM,964,RC,873,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Kidney Stone Destruct,PX00873.01,CDM,964,RC,873,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Kidney Transplant,PX00868.01,CDM,964,RC,868,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Kidney Transplant,PX00868.01,CDM,964,RC,868,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Kidney/Ureter Surg,PX00862.01,CDM,964,RC,862,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Kidney/Ureter Surg,PX00862.01,CDM,964,RC,862,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Area Procedure,PX01340.01,CDM,964,RC,1340,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Area Procedure,PX01340.01,CDM,964,RC,1340,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Area Procedure,PX01390.01,CDM,964,RC,1390,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Area Procedure,PX01390.01,CDM,964,RC,1390,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Area Surgery,PX01320.01,CDM,964,RC,1320,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Area Surgery,PX01320.01,CDM,964,RC,1320,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Area Surgery,PX01360.01,CDM,964,RC,1360,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Area Surgery,PX01360.01,CDM,964,RC,1360,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Area Surgery,PX01392.01,CDM,964,RC,1392,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Area Surgery,PX01392.01,CDM,964,RC,1392,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Arteries Surg,PX01440.01,CDM,964,RC,1440,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Arteries Surg,PX01440.01,CDM,964,RC,1440,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Artery Repair,PX01444.01,CDM,964,RC,1444,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Artery Repair,PX01444.01,CDM,964,RC,1444,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Artery Surg,PX01442.01,CDM,964,RC,1442,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Artery Surg,PX01442.01,CDM,964,RC,1442,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Arthroplasty,PX01402.01,CDM,964,RC,1402,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Arthroplasty,PX01402.01,CDM,964,RC,1402,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Joint Casting,PX01420.01,CDM,964,RC,1420,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Joint Casting,PX01420.01,CDM,964,RC,1420,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Joint Procedure,PX01380.01,CDM,964,RC,1380,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Joint Procedure,PX01380.01,CDM,964,RC,1380,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Joint Surgery,PX01400.01,CDM,964,RC,1400,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Joint Surgery,PX01400.01,CDM,964,RC,1400,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Veins Surgery,PX01430.01,CDM,964,RC,1430,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Veins Surgery,PX01430.01,CDM,964,RC,1430,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Vessel Surg,PX01432.01,CDM,964,RC,1432,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Vessel Surg,PX01432.01,CDM,964,RC,1432,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Larynx/Trach < 1 Yr,PX00326.01,CDM,964,RC,326,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Larynx/Trach < 1 Yr,PX00326.01,CDM,964,RC,326,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Leg Arteries Surg,PX01500.01,CDM,964,RC,1500,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Leg Arteries Surg,PX01500.01,CDM,964,RC,1500,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lens Surgery,PX00142.01,CDM,964,RC,142,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lens Surgery,PX00142.01,CDM,964,RC,142,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Low Intestine Scope,PX00810.01,CDM,964,RC,810,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Low Intestine Scope,PX00810.01,CDM,964,RC,810,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Arm Casting,PX01860.01,CDM,964,RC,1860,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Arm Casting,PX01860.01,CDM,964,RC,1860,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Arm Procedure,PX01820.01,CDM,964,RC,1820,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Arm Procedure,PX01820.01,CDM,964,RC,1820,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Arm Surgery,PX01810.01,CDM,964,RC,1810,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Arm Surgery,PX01810.01,CDM,964,RC,1810,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Arm Surgery,PX01830.01,CDM,964,RC,1830,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Arm Surgery,PX01830.01,CDM,964,RC,1830,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Arm Vein Surg,PX01850.01,CDM,964,RC,1850,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Arm Vein Surg,PX01850.01,CDM,964,RC,1850,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Bone Surg,PX01480.01,CDM,964,RC,1480,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Bone Surg,PX01480.01,CDM,964,RC,1480,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Casting,PX01490.01,CDM,964,RC,1490,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Casting,PX01490.01,CDM,964,RC,1490,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Procedure,PX01462.01,CDM,964,RC,1462,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Procedure,PX01462.01,CDM,964,RC,1462,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Revision,PX01484.01,CDM,964,RC,1484,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Revision,PX01484.01,CDM,964,RC,1484,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Surgery,PX01470.01,CDM,964,RC,1470,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Surgery,PX01470.01,CDM,964,RC,1470,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Surgery,PX01474.01,CDM,964,RC,1474,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Surgery,PX01474.01,CDM,964,RC,1474,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Vein Surg,PX01520.01,CDM,964,RC,1520,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Vein Surg,PX01520.01,CDM,964,RC,1520,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Vein Surg,PX01522.01,CDM,964,RC,1522,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Vein Surg,PX01522.01,CDM,964,RC,1522,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lumbar Puncture,PX00635.01,CDM,964,RC,635,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lumbar Puncture,PX00635.01,CDM,964,RC,635,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lung Chest Wall Surg,PX00546.01,CDM,964,RC,546,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lung Chest Wall Surg,PX00546.01,CDM,964,RC,546,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lwr Arm Artery Surg,PX01840.01,CDM,964,RC,1840,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lwr Arm Artery Surg,PX01840.01,CDM,964,RC,1840,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lwr Arm Embolectomy,PX01842.01,CDM,964,RC,1842,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lwr Arm Embolectomy,PX01842.01,CDM,964,RC,1842,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lwr Arm Vein Repair,PX01852.01,CDM,964,RC,1852,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lwr Arm Vein Repair,PX01852.01,CDM,964,RC,1852,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lwr Leg Embolectomy,PX01502.01,CDM,964,RC,1502,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lwr Leg Embolectomy,PX01502.01,CDM,964,RC,1502,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Major Vein Ligation,PX00882.01,CDM,964,RC,882,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Major Vein Ligation,PX00882.01,CDM,964,RC,882,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth N Block/Inj Prone,PX01992.01,CDM,964,RC,1992,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth N Block/Inj Prone,PX01992.01,CDM,964,RC,1992,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Neck Organ 1 & Over,PX00320.01,CDM,964,RC,320,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Neck Organ 1 & Over,PX00320.01,CDM,964,RC,320,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Neck Vessel Surgery,PX00350.01,CDM,964,RC,350,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Neck Vessel Surgery,PX00350.01,CDM,964,RC,350,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Neck Vessel Surgery,PX00352.01,CDM,964,RC,352,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Neck Vessel Surgery,PX00352.01,CDM,964,RC,352,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Nerve Block/Inj,PX01991.01,CDM,964,RC,1991,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Nerve Block/Inj,PX01991.01,CDM,964,RC,1991,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Nose/Sinus Surgery,PX00160.01,CDM,964,RC,160,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Nose/Sinus Surgery,PX00160.01,CDM,964,RC,160,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Nose/Sinus Surgery,PX00162.01,CDM,964,RC,162,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Nose/Sinus Surgery,PX00162.01,CDM,964,RC,162,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth One Lung Ventilation,PX00541.01,CDM,964,RC,541,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth One Lung Ventilation,PX00541.01,CDM,964,RC,541,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pacemaker Insertion,PX00530.01,CDM,964,RC,530,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pacemaker Insertion,PX00530.01,CDM,964,RC,530,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pancreas Removal,PX00794.01,CDM,964,RC,794,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pancreas Removal,PX00794.01,CDM,964,RC,794,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvic Organ Surg,PX00848.01,CDM,964,RC,848,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvic Organ Surg,PX00848.01,CDM,964,RC,848,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvic Tumor Surgery,PX01150.01,CDM,964,RC,1150,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvic Tumor Surgery,PX01150.01,CDM,964,RC,1150,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Nerve Removal,PX01180.01,CDM,964,RC,1180,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Nerve Removal,PX01180.01,CDM,964,RC,1180,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Nerve Removal,PX01190.01,CDM,964,RC,1190,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Nerve Removal,PX01190.01,CDM,964,RC,1190,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Procedure,PX01160.01,CDM,964,RC,1160,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Procedure,PX01160.01,CDM,964,RC,1160,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Surgery,PX00844.01,CDM,964,RC,844,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Surgery,PX00844.01,CDM,964,RC,844,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Surgery,PX01120.01,CDM,964,RC,1120,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Surgery,PX01120.01,CDM,964,RC,1120,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Surgery,PX01170.01,CDM,964,RC,1170,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Surgery,PX01170.01,CDM,964,RC,1170,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Penis Nodes Removal,PX00934.01,CDM,964,RC,934,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Penis Nodes Removal,PX00934.01,CDM,964,RC,934,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Penis Nodes Removal,PX00936.01,CDM,964,RC,936,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Penis Nodes Removal,PX00936.01,CDM,964,RC,936,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Perc Img Dx Sp Proc,PX01935.01,CDM,964,RC,1935,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Perc Img Dx Sp Proc,PX01935.01,CDM,964,RC,1935,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Perc Img Tx Sp Proc,PX01936.01,CDM,964,RC,1936,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Perc Img Tx Sp Proc,PX01936.01,CDM,964,RC,1936,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Perineal Surgery,PX00904.01,CDM,964,RC,904,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Perineal Surgery,PX00904.01,CDM,964,RC,904,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pharyngeal Surgery,PX00174.01,CDM,964,RC,174,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pharyngeal Surgery,PX00174.01,CDM,964,RC,174,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pharyngeal Surgery,PX00176.01,CDM,964,RC,176,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pharyngeal Surgery,PX00176.01,CDM,964,RC,176,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Procedure on Femur,PX01220.01,CDM,964,RC,1220,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Procedure on Femur,PX01220.01,CDM,964,RC,1220,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Procedure on Mouth,PX00170.01,CDM,964,RC,170,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Procedure on Mouth,PX00170.01,CDM,964,RC,170,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Procedures on Eye,PX00140.01,CDM,964,RC,140,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Procedures on Eye,PX00140.01,CDM,964,RC,140,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Radical Femur Surg,PX01234.01,CDM,964,RC,1234,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Radical Femur Surg,PX01234.01,CDM,964,RC,1234,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Radical Humerus Surg,PX01756.01,CDM,964,RC,1756,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Radical Humerus Surg,PX01756.01,CDM,964,RC,1756,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Radical Leg Surgery,PX01482.01,CDM,964,RC,1482,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Radical Leg Surgery,PX01482.01,CDM,964,RC,1482,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Release of Lung,PX00542.01,CDM,964,RC,542,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Release of Lung,PX00542.01,CDM,964,RC,542,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Adrenal,PX00866.01,CDM,964,RC,866,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Adrenal,PX00866.01,CDM,964,RC,866,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Bladder,PX00864.01,CDM,964,RC,864,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Bladder,PX00864.01,CDM,964,RC,864,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Nerves,PX00622.01,CDM,964,RC,622,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Nerves,PX00622.01,CDM,964,RC,622,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Nerves,PX00632.01,CDM,964,RC,632,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Nerves,PX00632.01,CDM,964,RC,632,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Prostate,PX00865.01,CDM,964,RC,865,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Prostate,PX00865.01,CDM,964,RC,865,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Prostate,PX00908.01,CDM,964,RC,908,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Prostate,PX00908.01,CDM,964,RC,908,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Rib,PX00470.01,CDM,964,RC,470,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Rib,PX00470.01,CDM,964,RC,470,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Testis,PX00926.01,CDM,964,RC,926,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Testis,PX00926.01,CDM,964,RC,926,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Testis,PX00928.01,CDM,964,RC,928,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Testis,PX00928.01,CDM,964,RC,928,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Vulva,PX00906.01,CDM,964,RC,906,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Vulva,PX00906.01,CDM,964,RC,906,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Cervix,PX00948.01,CDM,964,RC,948,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Cervix,PX00948.01,CDM,964,RC,948,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Cleft Lip,PX00102.01,CDM,964,RC,102,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Cleft Lip,PX00102.01,CDM,964,RC,102,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00750.01,CDM,964,RC,750,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00750.01,CDM,964,RC,750,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00752.01,CDM,964,RC,752,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00752.01,CDM,964,RC,752,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00754.01,CDM,964,RC,754,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00754.01,CDM,964,RC,754,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00756.01,CDM,964,RC,756,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00756.01,CDM,964,RC,756,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00830.01,CDM,964,RC,830,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00830.01,CDM,964,RC,830,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00832.01,CDM,964,RC,832,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00832.01,CDM,964,RC,832,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Revise Hip Repair,PX01215.01,CDM,964,RC,1215,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Revise Hip Repair,PX01215.01,CDM,964,RC,1215,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Salivary Gland,PX00100.01,CDM,964,RC,100,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Salivary Gland,PX00100.01,CDM,964,RC,100,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Artery Surg,PX01650.01,CDM,964,RC,1650,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Artery Surg,PX01650.01,CDM,964,RC,1650,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Casting,PX01680.01,CDM,964,RC,1680,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Casting,PX01680.01,CDM,964,RC,1680,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Joint Amput,PX01634.01,CDM,964,RC,1634,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Joint Amput,PX01634.01,CDM,964,RC,1634,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Procedure,PX01620.01,CDM,964,RC,1620,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Procedure,PX01620.01,CDM,964,RC,1620,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Replacement,PX01638.01,CDM,964,RC,1638,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Replacement,PX01638.01,CDM,964,RC,1638,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Vein Surg,PX01670.01,CDM,964,RC,1670,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Vein Surg,PX01670.01,CDM,964,RC,1670,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Vessel Surg,PX01652.01,CDM,964,RC,1652,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Vessel Surg,PX01652.01,CDM,964,RC,1652,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Vessel Surg,PX01654.01,CDM,964,RC,1654,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Vessel Surg,PX01654.01,CDM,964,RC,1654,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Sitting Procedure,PX00604.01,CDM,964,RC,604,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Sitting Procedure,PX00604.01,CDM,964,RC,604,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Skin Ext/per/Atrunk,PX00400.01,CDM,964,RC,400,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Skin Ext/per/Atrunk,PX00400.01,CDM,964,RC,400,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Skull Drainage,PX00212.01,CDM,964,RC,212,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Skull Drainage,PX00212.01,CDM,964,RC,212,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Skull Drainage,PX00214.01,CDM,964,RC,214,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Skull Drainage,PX00214.01,CDM,964,RC,214,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Skull Repair/Fract,PX00215.01,CDM,964,RC,215,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Skull Repair/Fract,PX00215.01,CDM,964,RC,215,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Special Head Surgery,PX00218.01,CDM,964,RC,218,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Special Head Surgery,PX00218.01,CDM,964,RC,218,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Sperm Duct Surgery,PX00922.01,CDM,964,RC,922,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Sperm Duct Surgery,PX00922.01,CDM,964,RC,922,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Spine Cord Surgery,PX00600.01,CDM,964,RC,600,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Spine Cord Surgery,PX00600.01,CDM,964,RC,600,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Spine Cord Surgery,PX00620.01,CDM,964,RC,620,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Spine Cord Surgery,PX00620.01,CDM,964,RC,620,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Spine Cord Surgery,PX00630.01,CDM,964,RC,630,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Spine Cord Surgery,PX00630.01,CDM,964,RC,630,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Spine Cord Surgery,PX00670.01,CDM,964,RC,670,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Spine Cord Surgery,PX00670.01,CDM,964,RC,670,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Spine Manipulation,PX00640.01,CDM,964,RC,640,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Spine Manipulation,PX00640.01,CDM,964,RC,640,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Sternal Debridement,PX00550.01,CDM,964,RC,550,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Sternal Debridement,PX00550.01,CDM,964,RC,550,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Stone Removal,PX00918.01,CDM,964,RC,918,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Stone Removal,PX00918.01,CDM,964,RC,918,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surg Lower Abdomen,PX00840.01,CDM,964,RC,840,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surg Lower Abdomen,PX00840.01,CDM,964,RC,840,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surg on Vag/Urethral,PX00942.01,CDM,964,RC,942,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surg on Vag/Urethral,PX00942.01,CDM,964,RC,942,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surg Upper Abdomen,PX00790.01,CDM,964,RC,790,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surg Upper Abdomen,PX00790.01,CDM,964,RC,790,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery for Obesity,PX00797.01,CDM,964,RC,797,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery for Obesity,PX00797.01,CDM,964,RC,797,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Abdomen,PX00860.01,CDM,964,RC,860,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Abdomen,PX00860.01,CDM,964,RC,860,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Breast,PX00402.01,CDM,964,RC,402,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Breast,PX00402.01,CDM,964,RC,402,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Breast,PX00404.01,CDM,964,RC,404,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Breast,PX00404.01,CDM,964,RC,404,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Breast,PX00406.01,CDM,964,RC,406,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Breast,PX00406.01,CDM,964,RC,406,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Femur,PX01230.01,CDM,964,RC,1230,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Femur,PX01230.01,CDM,964,RC,1230,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Rib(S),PX00474.01,CDM,964,RC,474,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Rib(S),PX00474.01,CDM,964,RC,474,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Shoulder,PX00450.01,CDM,964,RC,450,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Shoulder,PX00450.01,CDM,964,RC,450,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Shoulder,PX00452.01,CDM,964,RC,452,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Shoulder,PX00452.01,CDM,964,RC,452,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Shoulder,PX01610.01,CDM,964,RC,1610,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Shoulder,PX01610.01,CDM,964,RC,1610,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Shoulder,PX01630.01,CDM,964,RC,1630,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Shoulder,PX01630.01,CDM,964,RC,1630,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Testis Exploration,PX00924.01,CDM,964,RC,924,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Testis Exploration,PX00924.01,CDM,964,RC,924,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Testis Suspension,PX00930.01,CDM,964,RC,930,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Testis Suspension,PX00930.01,CDM,964,RC,930,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Thigh Arteries Surg,PX01270.01,CDM,964,RC,1270,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Thigh Arteries Surg,PX01270.01,CDM,964,RC,1270,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Trach-Bronch Reconst,PX00539.01,CDM,964,RC,539,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Trach-Bronch Reconst,PX00539.01,CDM,964,RC,539,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Trachea Bronchi Surg,PX00548.01,CDM,964,RC,548,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Trachea Bronchi Surg,PX00548.01,CDM,964,RC,548,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Trans Resect of Prostate,PX00914.01,CDM,964,RC,914,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Trans Resect of Prostate,PX00914.01,CDM,964,RC,914,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Tubal Ligation,PX00851.01,CDM,964,RC,851,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Tubal Ligation,PX00851.01,CDM,964,RC,851,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Tympanotomy,PX00126.01,CDM,964,RC,126,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Tympanotomy,PX00126.01,CDM,964,RC,126,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Upper Arm Surgery,PX01740.01,CDM,964,RC,1740,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Upper Arm Surgery,PX01740.01,CDM,964,RC,1740,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Upper Arm Vein Surg,PX01780.01,CDM,964,RC,1780,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Upper Arm Vein Surg,PX01780.01,CDM,964,RC,1780,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Upper GI Visualize,PX00740.01,CDM,964,RC,740,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Upper GI Visualize,PX00740.01,CDM,964,RC,740,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Upper Leg Surgery,PX01250.01,CDM,964,RC,1250,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Upper Leg Surgery,PX01250.01,CDM,964,RC,1250,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Upper Leg Veins Surg,PX01260.01,CDM,964,RC,1260,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Upper Leg Veins Surg,PX01260.01,CDM,964,RC,1260,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Artery Surg,PX01770.01,CDM,964,RC,1770,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Artery Surg,PX01770.01,CDM,964,RC,1770,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Embolectomy,PX01772.01,CDM,964,RC,1772,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Embolectomy,PX01772.01,CDM,964,RC,1772,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Procedure,PX01730.01,CDM,964,RC,1730,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Procedure,PX01730.01,CDM,964,RC,1730,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Tendon Surg,PX01712.01,CDM,964,RC,1712,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Tendon Surg,PX01712.01,CDM,964,RC,1712,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Tendon Surg,PX01714.01,CDM,964,RC,1714,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Tendon Surg,PX01714.01,CDM,964,RC,1714,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Vein Repair,PX01782.01,CDM,964,RC,1782,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Vein Repair,PX01782.01,CDM,964,RC,1782,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vaginal Delivery,PX01960.01,CDM,964,RC,1960,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vaginal Delivery,PX01960.01,CDM,964,RC,1960,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vaginal Endoscopy,PX00950.01,CDM,964,RC,950,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vaginal Endoscopy,PX00950.01,CDM,964,RC,950,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vaginal Hysterectomy,PX00944.01,CDM,964,RC,944,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vaginal Hysterectomy,PX00944.01,CDM,964,RC,944,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vaginal Procedures,PX00940.01,CDM,964,RC,940,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vaginal Procedures,PX00940.01,CDM,964,RC,940,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vascular Access,PX00532.01,CDM,964,RC,532,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vascular Access,PX00532.01,CDM,964,RC,532,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vascular Shunt Surg,PX01844.01,CDM,964,RC,1844,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vascular Shunt Surg,PX01844.01,CDM,964,RC,1844,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vasectomy,PX00921.01,CDM,964,RC,921,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vasectomy,PX00921.01,CDM,964,RC,921,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vitreoretinal Surg,PX00145.01,CDM,964,RC,145,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vitreoretinal Surg,PX00145.01,CDM,964,RC,145,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Wrist Replacement,PX01832.01,CDM,964,RC,1832,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Wrist Replacement,PX01832.01,CDM,964,RC,1832,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth/Analg Cs Hyst Add-On,PX01969.01,CDM,964,RC,1969,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth/Analg Cs Hyst Add-On,PX01969.01,CDM,964,RC,1969,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth/Analg Vag Delivery,PX01967.01,CDM,964,RC,1967,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth/Analg Vag Delivery,PX01967.01,CDM,964,RC,1967,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesthesia Level - Regional,PX37000025,CDM,370,RC,,,,,,,,,,28,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesthesia Level - Regional,PX37000025,CDM,370,RC,,,,,,,,,,28,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesthesia Level - Regional,PX37000025,CDM,370,RC,,,,,,,,,,28,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesthesia Level - Regional,PX37000025,CDM,370,RC,,,,,,,,,,28,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesthesia Level - Regional,PX37000025,CDM,370,RC,,,,,,,,,,28,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesthesia Level - Regional,PX37000025,CDM,370,RC,,,,,,,,,,28,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesthesia Level 3,PX37000017,CDM,370,RC,,,,,,,,,,65,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesthesia Level 3,PX37000017,CDM,370,RC,,,,,,,,,,65,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesthesia Level 3,PX37000017,CDM,370,RC,,,,,,,,,,65,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesthesia Level 3,PX37000017,CDM,370,RC,,,,,,,,,,65,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesthesia Level 3,PX37000017,CDM,370,RC,,,,,,,,,,65,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesthesia Level 3,PX37000017,CDM,370,RC,,,,,,,,,,65,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesthesia Level 4,PX37000018,CDM,370,RC,,,,,,,,,,21,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesthesia Level 4,PX37000018,CDM,370,RC,,,,,,,,,,21,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesthesia Level 4,PX37000018,CDM,370,RC,,,,,,,,,,21,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesthesia Level 4,PX37000018,CDM,370,RC,,,,,,,,,,21,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesthesia Level 4,PX37000018,CDM,370,RC,,,,,,,,,,21,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesthesia Level 4,PX37000018,CDM,370,RC,,,,,,,,,,21,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ANOSCOPE LIGHTED ANOSCOPE,120.52,CDM,272,RC,,,,10235-MAIN,LOCAL,,,,,21,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ANOSCOPE LIGHTED ANOSCOPE,120.52,CDM,272,RC,,,,10235-MAIN,LOCAL,,,,,21,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ANOSCOPE LIGHTED ANOSCOPE,120.52,CDM,272,RC,,,,10235-MAIN,LOCAL,,,,,21,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ANOSCOPE LIGHTED ANOSCOPE,120.52,CDM,272,RC,,,,10235-MAIN,LOCAL,,,,,21,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ANOSCOPE LIGHTED ANOSCOPE,120.52,CDM,272,RC,,,,10235-MAIN,LOCAL,,,,,21,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ANOSCOPE LIGHTED ANOSCOPE,120.52,CDM,272,RC,,,,10235-MAIN,LOCAL,,,,,21,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Antibiotic Sens,Enzyme Detection,Each - Ref",PX8718590,CDM,300,RC,87185,CPT,90,,,,,,,13,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Antibiotic Sens,Enzyme Detection,Each - Ref",PX8718590,CDM,300,RC,87185,CPT,90,,,,,,,13,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Antibiotic Sens,Enzyme Detection,Each - Ref",PX8718590,CDM,300,RC,87185,CPT,90,,,,,,,13,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Antibiotic Sens,Enzyme Detection,Each - Ref",PX8718590,CDM,300,RC,87185,CPT,90,,,,,,,13,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Antibiotic Sens,Enzyme Detection,Each - Ref",PX8718590,CDM,300,RC,87185,CPT,90,,,,,,,13,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Antibiotic Sens,Enzyme Detection,Each - Ref",PX8718590,CDM,300,RC,87185,CPT,90,,,,,,,13,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Antinuclear Ab(Ana) Titer - Ref,PX8603990,CDM,300,RC,86039,CPT,90,,,,,,,52,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Antinuclear Ab(Ana) Titer - Ref,PX8603990,CDM,300,RC,86039,CPT,90,,,,,,,52,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Antinuclear Ab(Ana) Titer - Ref,PX8603990,CDM,300,RC,86039,CPT,90,,,,,,,52,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Antinuclear Ab(Ana) Titer - Ref,PX8603990,CDM,300,RC,86039,CPT,90,,,,,,,52,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Antinuclear Ab(Ana) Titer - Ref,PX8603990,CDM,300,RC,86039,CPT,90,,,,,,,52,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Antinuclear Ab(Ana) Titer - Ref,PX8603990,CDM,300,RC,86039,CPT,90,,,,,,,52,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Antinuclear Antibodies,PX86038,CDM,300,RC,86038,CPT,,,,,,,,10,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Antinuclear Antibodies,PX86038,CDM,300,RC,86038,CPT,,,,,,,,10,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Antinuclear Antibodies,PX86038,CDM,300,RC,86038,CPT,,,,,,,,10,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Antinuclear Antibodies,PX86038,CDM,300,RC,86038,CPT,,,,,,,,10,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Antinuclear Antibodies,PX86038,CDM,300,RC,86038,CPT,,,,,,,,10,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Antinuclear Antibodies,PX86038,CDM,300,RC,86038,CPT,,,,,,,,10,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Antinuclear Antibodiesana - Ref,PX8603890,CDM,300,RC,86038,CPT,90,,,,,,,43,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Antinuclear Antibodiesana - Ref,PX8603890,CDM,300,RC,86038,CPT,90,,,,,,,43,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Antinuclear Antibodiesana - Ref,PX8603890,CDM,300,RC,86038,CPT,90,,,,,,,43,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Antinuclear Antibodiesana - Ref,PX8603890,CDM,300,RC,86038,CPT,90,,,,,,,43,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Antinuclear Antibodiesana - Ref,PX8603890,CDM,300,RC,86038,CPT,90,,,,,,,43,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Antinuclear Antibodiesana - Ref,PX8603890,CDM,300,RC,86038,CPT,90,,,,,,,43,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Antipsychotics, Not Otherwise Specified; 1-3 - Ref",PX8034290,CDM,300,RC,80342,CPT,90,,,,,,,152,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Antipsychotics, Not Otherwise Specified; 1-3 - Ref",PX8034290,CDM,300,RC,80342,CPT,90,,,,,,,152,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Antipsychotics, Not Otherwise Specified; 1-3 - Ref",PX8034290,CDM,300,RC,80342,CPT,90,,,,,,,152,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Antipsychotics, Not Otherwise Specified; 1-3 - Ref",PX8034290,CDM,300,RC,80342,CPT,90,,,,,,,152,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Antipsychotics, Not Otherwise Specified; 1-3 - Ref",PX8034290,CDM,300,RC,80342,CPT,90,,,,,,,152,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Antipsychotics, Not Otherwise Specified; 1-3 - Ref",PX8034290,CDM,300,RC,80342,CPT,90,,,,,,,152,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Antithrombin III Activity - Ref,PX8530090,CDM,300,RC,85300,CPT,90,,,,,,,158,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Antithrombin III Activity - Ref,PX8530090,CDM,300,RC,85300,CPT,90,,,,,,,158,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Antithrombin III Activity - Ref,PX8530090,CDM,300,RC,85300,CPT,90,,,,,,,158,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Antithrombin III Activity - Ref,PX8530090,CDM,300,RC,85300,CPT,90,,,,,,,158,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Antithrombin III Activity - Ref,PX8530090,CDM,300,RC,85300,CPT,90,,,,,,,158,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Antithrombin III Activity - Ref,PX8530090,CDM,300,RC,85300,CPT,90,,,,,,,158,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Antithrombin III Ag Assay - Ref,PX8530190,CDM,300,RC,85301,CPT,90,,,,,,,116,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Antithrombin III Ag Assay - Ref,PX8530190,CDM,300,RC,85301,CPT,90,,,,,,,116,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Antithrombin III Ag Assay - Ref,PX8530190,CDM,300,RC,85301,CPT,90,,,,,,,116,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Antithrombin III Ag Assay - Ref,PX8530190,CDM,300,RC,85301,CPT,90,,,,,,,116,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Antithrombin III Ag Assay - Ref,PX8530190,CDM,300,RC,85301,CPT,90,,,,,,,116,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Antithrombin III Ag Assay - Ref,PX8530190,CDM,300,RC,85301,CPT,90,,,,,,,116,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anus Surgery Procedure Unlisted,PX46999F,CDM,510,RC,46999,CPT,,,,,,,,1431,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anus Surgery Procedure Unlisted,PX46999F,CDM,510,RC,46999,CPT,,,,,,,,1431,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anus Surgery Procedure Unlisted,PX46999F,CDM,510,RC,46999,CPT,,,,,,,,1431,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anus Surgery Procedure Unlisted,PX46999F,CDM,510,RC,46999,CPT,,,,,,,,1431,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anus Surgery Procedure Unlisted,PX46999F,CDM,510,RC,46999,CPT,,,,,,,,1431,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anus Surgery Procedure Unlisted,PX46999F,CDM,510,RC,46999,CPT,,,,,,,,1431,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anus Surgery Procedure Unlisted,PX46999P,CDM,983,RC,46999,CPT,,,,,,,,953,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anus Surgery Procedure Unlisted,PX46999P,CDM,983,RC,46999,CPT,,,,,,,,953,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anus Surgery Procedure Unlisted,PX46999P,CDM,983,RC,46999,CPT,,,,,,,,953,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anus Surgery Procedure Unlisted,PX46999P,CDM,983,RC,46999,CPT,,,,,,,,953,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anus Surgery Procedure Unlisted,PX46999P,CDM,983,RC,46999,CPT,,,,,,,,953,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anus Surgery Procedure Unlisted,PX46999P,CDM,983,RC,46999,CPT,,,,,,,,953,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apc Resistance Assay - Ref,PX8530790,CDM,300,RC,85307,CPT,90,,,,,,,390,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apc Resistance Assay - Ref,PX8530790,CDM,300,RC,85307,CPT,90,,,,,,,390,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apc Resistance Assay - Ref,PX8530790,CDM,300,RC,85307,CPT,90,,,,,,,390,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apc Resistance Assay - Ref,PX8530790,CDM,300,RC,85307,CPT,90,,,,,,,390,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apc Resistance Assay - Ref,PX8530790,CDM,300,RC,85307,CPT,90,,,,,,,390,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apc Resistance Assay - Ref,PX8530790,CDM,300,RC,85307,CPT,90,,,,,,,390,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
apixaban 2.5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,3089321,NDC,1,EA,63.84,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
apixaban 2.5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,3089321,NDC,1,EA,63.84,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
apixaban 2.5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,3089321,NDC,1,EA,63.84,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
apixaban 2.5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,3089321,NDC,1,EA,63.84,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
apixaban 2.5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,3089321,NDC,1,EA,63.84,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
apixaban 2.5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,3089321,NDC,1,EA,63.84,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
apixaban 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,3089331,NDC,1,EA,50.57,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
apixaban 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,3089331,NDC,1,EA,50.57,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
apixaban 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,3089331,NDC,1,EA,50.57,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
apixaban 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,3089331,NDC,1,EA,50.57,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
apixaban 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,3089331,NDC,1,EA,50.57,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
apixaban 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,3089331,NDC,1,EA,50.57,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
apixaban 5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,3089421,NDC,0.5,EA,22.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
apixaban 5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,3089421,NDC,0.5,EA,22.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
apixaban 5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,3089421,NDC,0.5,EA,22.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
apixaban 5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,3089421,NDC,0.5,EA,22.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
apixaban 5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,3089421,NDC,0.5,EA,22.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
apixaban 5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,3089421,NDC,0.5,EA,22.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
apixaban 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,3089431,NDC,0.5,EA,23.85,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
apixaban 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,3089431,NDC,0.5,EA,23.85,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
apixaban 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,3089431,NDC,0.5,EA,23.85,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
apixaban 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,3089431,NDC,0.5,EA,23.85,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
apixaban 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,3089431,NDC,0.5,EA,23.85,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
apixaban 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,3089431,NDC,0.5,EA,23.85,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
APLIGRAF LIVING BI-LAYERED SKIN SUBSTITUTE,120.514,CDM,278,RC,Q4101,HCPCS,,12082-MAIN,LOCAL,,,,,2569,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
APLIGRAF LIVING BI-LAYERED SKIN SUBSTITUTE,120.514,CDM,278,RC,Q4101,HCPCS,,12082-MAIN,LOCAL,,,,,2569,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
APLIGRAF LIVING BI-LAYERED SKIN SUBSTITUTE,120.514,CDM,278,RC,Q4101,HCPCS,,12082-MAIN,LOCAL,,,,,2569,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
APLIGRAF LIVING BI-LAYERED SKIN SUBSTITUTE,120.514,CDM,278,RC,Q4101,HCPCS,,12082-MAIN,LOCAL,,,,,2569,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
APLIGRAF LIVING BI-LAYERED SKIN SUBSTITUTE,120.514,CDM,278,RC,Q4101,HCPCS,,12082-MAIN,LOCAL,,,,,2569,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
APLIGRAF LIVING BI-LAYERED SKIN SUBSTITUTE,120.514,CDM,278,RC,Q4101,HCPCS,,12082-MAIN,LOCAL,,,,,2569,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Appl on-Body Injector for Timed Subq Injection,PX96377,CDM,260,RC,96377,CPT,,,,,,,,13093,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Appl on-Body Injector for Timed Subq Injection,PX96377,CDM,260,RC,96377,CPT,,,,,,,,13093,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Appl on-Body Injector for Timed Subq Injection,PX96377,CDM,260,RC,96377,CPT,,,,,,,,13093,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Appl on-Body Injector for Timed Subq Injection,PX96377,CDM,260,RC,96377,CPT,,,,,,,,13093,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Appl on-Body Injector for Timed Subq Injection,PX96377,CDM,260,RC,96377,CPT,,,,,,,,13093,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Appl on-Body Injector for Timed Subq Injection,PX96377,CDM,260,RC,96377,CPT,,,,,,,,13093,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
APPLICATOR CHLORAPREP 26ML WITH ORANGE 930815,27200000,CDM,272,RC,A4248,HCPCS,,10031-MAIN,LOCAL,,,,,19.65,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
APPLICATOR CHLORAPREP 26ML WITH ORANGE 930815,27200000,CDM,272,RC,A4248,HCPCS,,10031-MAIN,LOCAL,,,,,19.65,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
APPLICATOR CHLORAPREP 26ML WITH ORANGE 930815,27200000,CDM,272,RC,A4248,HCPCS,,10031-MAIN,LOCAL,,,,,19.65,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
APPLICATOR CHLORAPREP 26ML WITH ORANGE 930815,27200000,CDM,272,RC,A4248,HCPCS,,10031-MAIN,LOCAL,,,,,19.65,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
APPLICATOR CHLORAPREP 26ML WITH ORANGE 930815,27200000,CDM,272,RC,A4248,HCPCS,,10031-MAIN,LOCAL,,,,,19.65,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
APPLICATOR CHLORAPREP 26ML WITH ORANGE 930815,27200000,CDM,272,RC,A4248,HCPCS,,10031-MAIN,LOCAL,,,,,19.65,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Apply Finger Splint,Static",PX29130F,CDM,420,RC,29130,CPT,,,,,,,,196,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Apply Finger Splint,Static",PX29130F,CDM,420,RC,29130,CPT,,,,,,,,196,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Apply Finger Splint,Static",PX29130F,CDM,420,RC,29130,CPT,,,,,,,,196,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Apply Finger Splint,Static",PX29130F,CDM,420,RC,29130,CPT,,,,,,,,196,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Apply Finger Splint,Static",PX29130F,CDM,420,RC,29130,CPT,,,,,,,,196,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Apply Finger Splint,Static",PX29130F,CDM,420,RC,29130,CPT,,,,,,,,196,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Apply Finger Splint,Static",PX29130P,CDM,983,RC,29130,CPT,,,,,,,,223,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Apply Finger Splint,Static",PX29130P,CDM,983,RC,29130,CPT,,,,,,,,223,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Apply Finger Splint,Static",PX29130P,CDM,983,RC,29130,CPT,,,,,,,,223,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Apply Finger Splint,Static",PX29130P,CDM,983,RC,29130,CPT,,,,,,,,223,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Apply Finger Splint,Static",PX29130P,CDM,983,RC,29130,CPT,,,,,,,,223,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Apply Finger Splint,Static",PX29130P,CDM,983,RC,29130,CPT,,,,,,,,223,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Forearm Cast,PX29075F,CDM,510,RC,29075,CPT,,,,,,,,210,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Forearm Cast,PX29075F,CDM,510,RC,29075,CPT,,,,,,,,210,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Forearm Cast,PX29075F,CDM,510,RC,29075,CPT,,,,,,,,210,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Forearm Cast,PX29075F,CDM,510,RC,29075,CPT,,,,,,,,210,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Forearm Cast,PX29075F,CDM,510,RC,29075,CPT,,,,,,,,210,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Forearm Cast,PX29075F,CDM,510,RC,29075,CPT,,,,,,,,210,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Forearm Cast,PX29075P,CDM,983,RC,29075,CPT,,,,,,,,140,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Forearm Cast,PX29075P,CDM,983,RC,29075,CPT,,,,,,,,140,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Forearm Cast,PX29075P,CDM,983,RC,29075,CPT,,,,,,,,140,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Forearm Cast,PX29075P,CDM,983,RC,29075,CPT,,,,,,,,140,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Forearm Cast,PX29075P,CDM,983,RC,29075,CPT,,,,,,,,140,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Forearm Cast,PX29075P,CDM,983,RC,29075,CPT,,,,,,,,140,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Apply Forearm Splint,Static",PX29125F,CDM,510,RC,29125,CPT,,,,,,,,223,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Apply Forearm Splint,Static",PX29125F,CDM,510,RC,29125,CPT,,,,,,,,223,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Apply Forearm Splint,Static",PX29125F,CDM,510,RC,29125,CPT,,,,,,,,223,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Apply Forearm Splint,Static",PX29125F,CDM,510,RC,29125,CPT,,,,,,,,223,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Apply Forearm Splint,Static",PX29125F,CDM,510,RC,29125,CPT,,,,,,,,223,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Apply Forearm Splint,Static",PX29125F,CDM,510,RC,29125,CPT,,,,,,,,223,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Apply Forearm Splint,Static",PX29125P,CDM,983,RC,29125,CPT,,,,,,,,296,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Apply Forearm Splint,Static",PX29125P,CDM,983,RC,29125,CPT,,,,,,,,296,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Apply Forearm Splint,Static",PX29125P,CDM,983,RC,29125,CPT,,,,,,,,296,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Apply Forearm Splint,Static",PX29125P,CDM,983,RC,29125,CPT,,,,,,,,296,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Apply Forearm Splint,Static",PX29125P,CDM,983,RC,29125,CPT,,,,,,,,296,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Apply Forearm Splint,Static",PX29125P,CDM,983,RC,29125,CPT,,,,,,,,296,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Long Arm Splint,PX29105F,CDM,510,RC,29105,CPT,,,,,,,,290,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Long Arm Splint,PX29105F,CDM,510,RC,29105,CPT,,,,,,,,290,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Long Arm Splint,PX29105F,CDM,510,RC,29105,CPT,,,,,,,,290,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Long Arm Splint,PX29105F,CDM,510,RC,29105,CPT,,,,,,,,290,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Long Arm Splint,PX29105F,CDM,510,RC,29105,CPT,,,,,,,,290,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Long Arm Splint,PX29105F,CDM,510,RC,29105,CPT,,,,,,,,290,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Long Arm Splint,PX29105P,CDM,983,RC,29105,CPT,,,,,,,,385,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Long Arm Splint,PX29105P,CDM,983,RC,29105,CPT,,,,,,,,385,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Long Arm Splint,PX29105P,CDM,983,RC,29105,CPT,,,,,,,,385,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Long Arm Splint,PX29105P,CDM,983,RC,29105,CPT,,,,,,,,385,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Long Arm Splint,PX29105P,CDM,983,RC,29105,CPT,,,,,,,,385,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Long Arm Splint,PX29105P,CDM,983,RC,29105,CPT,,,,,,,,385,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Long Leg Cast,PX29345F,CDM,510,RC,29345,CPT,,,,,,,,912,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Long Leg Cast,PX29345F,CDM,510,RC,29345,CPT,,,,,,,,912,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Long Leg Cast,PX29345F,CDM,510,RC,29345,CPT,,,,,,,,912,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Long Leg Cast,PX29345F,CDM,510,RC,29345,CPT,,,,,,,,912,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Long Leg Cast,PX29345F,CDM,510,RC,29345,CPT,,,,,,,,912,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Long Leg Cast,PX29345F,CDM,510,RC,29345,CPT,,,,,,,,912,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Long Leg Splint,PX29505F,CDM,510,RC,29505,CPT,,,,,,,,320,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Long Leg Splint,PX29505F,CDM,510,RC,29505,CPT,,,,,,,,320,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Long Leg Splint,PX29505F,CDM,510,RC,29505,CPT,,,,,,,,320,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Long Leg Splint,PX29505F,CDM,510,RC,29505,CPT,,,,,,,,320,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Long Leg Splint,PX29505F,CDM,510,RC,29505,CPT,,,,,,,,320,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Long Leg Splint,PX29505F,CDM,510,RC,29505,CPT,,,,,,,,320,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Long Leg Splint,PX29505P,CDM,983,RC,29505,CPT,,,,,,,,385,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Long Leg Splint,PX29505P,CDM,983,RC,29505,CPT,,,,,,,,385,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Long Leg Splint,PX29505P,CDM,983,RC,29505,CPT,,,,,,,,385,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Long Leg Splint,PX29505P,CDM,983,RC,29505,CPT,,,,,,,,385,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Long Leg Splint,PX29505P,CDM,983,RC,29505,CPT,,,,,,,,385,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Long Leg Splint,PX29505P,CDM,983,RC,29505,CPT,,,,,,,,385,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Lower Leg Splint,PX29515F,CDM,510,RC,29515,CPT,,,,,,,,296,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Lower Leg Splint,PX29515F,CDM,510,RC,29515,CPT,,,,,,,,296,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Lower Leg Splint,PX29515F,CDM,510,RC,29515,CPT,,,,,,,,296,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Lower Leg Splint,PX29515F,CDM,510,RC,29515,CPT,,,,,,,,296,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Lower Leg Splint,PX29515F,CDM,510,RC,29515,CPT,,,,,,,,296,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Lower Leg Splint,PX29515F,CDM,510,RC,29515,CPT,,,,,,,,296,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Lower Leg Splint,PX29515P,CDM,983,RC,29515,CPT,,,,,,,,311,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Lower Leg Splint,PX29515P,CDM,983,RC,29515,CPT,,,,,,,,311,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Lower Leg Splint,PX29515P,CDM,983,RC,29515,CPT,,,,,,,,311,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Lower Leg Splint,PX29515P,CDM,983,RC,29515,CPT,,,,,,,,311,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Lower Leg Splint,PX29515P,CDM,983,RC,29515,CPT,,,,,,,,311,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Lower Leg Splint,PX29515P,CDM,983,RC,29515,CPT,,,,,,,,311,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Multlay Comprs Lwr Leg,PX29581F,CDM,510,RC,29581,CPT,,,,,,,,213,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Multlay Comprs Lwr Leg,PX29581F,CDM,510,RC,29581,CPT,,,,,,,,213,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Multlay Comprs Lwr Leg,PX29581F,CDM,510,RC,29581,CPT,,,,,,,,213,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Multlay Comprs Lwr Leg,PX29581F,CDM,510,RC,29581,CPT,,,,,,,,213,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Multlay Comprs Lwr Leg,PX29581F,CDM,510,RC,29581,CPT,,,,,,,,213,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Multlay Comprs Lwr Leg,PX29581F,CDM,510,RC,29581,CPT,,,,,,,,213,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Multlay Comprs Lwr Leg,PX29581P,CDM,983,RC,29581,CPT,,,,,,,,142,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Multlay Comprs Lwr Leg,PX29581P,CDM,983,RC,29581,CPT,,,,,,,,142,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Multlay Comprs Lwr Leg,PX29581P,CDM,983,RC,29581,CPT,,,,,,,,142,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Multlay Comprs Lwr Leg,PX29581P,CDM,983,RC,29581,CPT,,,,,,,,142,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Multlay Comprs Lwr Leg,PX29581P,CDM,983,RC,29581,CPT,,,,,,,,142,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Multlay Comprs Lwr Leg,PX29581P,CDM,983,RC,29581,CPT,,,,,,,,142,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply of Paste Boot,PX29580F,CDM,510,RC,29580,CPT,,,,,,,,132,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply of Paste Boot,PX29580F,CDM,510,RC,29580,CPT,,,,,,,,132,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply of Paste Boot,PX29580F,CDM,510,RC,29580,CPT,,,,,,,,132,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply of Paste Boot,PX29580F,CDM,510,RC,29580,CPT,,,,,,,,132,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply of Paste Boot,PX29580F,CDM,510,RC,29580,CPT,,,,,,,,132,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply of Paste Boot,PX29580F,CDM,510,RC,29580,CPT,,,,,,,,132,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply of Paste Boot,PX29580P,CDM,983,RC,29580,CPT,,,,,,,,88,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply of Paste Boot,PX29580P,CDM,983,RC,29580,CPT,,,,,,,,88,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply of Paste Boot,PX29580P,CDM,983,RC,29580,CPT,,,,,,,,88,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply of Paste Boot,PX29580P,CDM,983,RC,29580,CPT,,,,,,,,88,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply of Paste Boot,PX29580P,CDM,983,RC,29580,CPT,,,,,,,,88,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply of Paste Boot,PX29580P,CDM,983,RC,29580,CPT,,,,,,,,88,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Apply Short Leg Cast,Walker",PX29425F,CDM,510,RC,29425,CPT,,,,,,,,179,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Apply Short Leg Cast,Walker",PX29425F,CDM,510,RC,29425,CPT,,,,,,,,179,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Apply Short Leg Cast,Walker",PX29425F,CDM,510,RC,29425,CPT,,,,,,,,179,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Apply Short Leg Cast,Walker",PX29425F,CDM,510,RC,29425,CPT,,,,,,,,179,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Apply Short Leg Cast,Walker",PX29425F,CDM,510,RC,29425,CPT,,,,,,,,179,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Apply Short Leg Cast,Walker",PX29425F,CDM,510,RC,29425,CPT,,,,,,,,179,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Apply Short Leg Cast,Walker",PX29425P,CDM,983,RC,29425,CPT,,,,,,,,119,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Apply Short Leg Cast,Walker",PX29425P,CDM,983,RC,29425,CPT,,,,,,,,119,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Apply Short Leg Cast,Walker",PX29425P,CDM,983,RC,29425,CPT,,,,,,,,119,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Apply Short Leg Cast,Walker",PX29425P,CDM,983,RC,29425,CPT,,,,,,,,119,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Apply Short Leg Cast,Walker",PX29425P,CDM,983,RC,29425,CPT,,,,,,,,119,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Apply Short Leg Cast,Walker",PX29425P,CDM,983,RC,29425,CPT,,,,,,,,119,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
AQUACEL EXTRA HYDOFIBER WOUND DRESSING 4X5,120.202,CDM,272,RC,A6197,HCPCS,,12047-MAIN,LOCAL,,,,,14,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
AQUACEL EXTRA HYDOFIBER WOUND DRESSING 4X5,120.202,CDM,272,RC,A6197,HCPCS,,12047-MAIN,LOCAL,,,,,14,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
AQUACEL EXTRA HYDOFIBER WOUND DRESSING 4X5,120.202,CDM,272,RC,A6197,HCPCS,,12047-MAIN,LOCAL,,,,,14,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
AQUACEL EXTRA HYDOFIBER WOUND DRESSING 4X5,120.202,CDM,272,RC,A6197,HCPCS,,12047-MAIN,LOCAL,,,,,14,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
AQUACEL EXTRA HYDOFIBER WOUND DRESSING 4X5,120.202,CDM,272,RC,A6197,HCPCS,,12047-MAIN,LOCAL,,,,,14,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
AQUACEL EXTRA HYDOFIBER WOUND DRESSING 4X5,120.202,CDM,272,RC,A6197,HCPCS,,12047-MAIN,LOCAL,,,,,14,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"AQUACEL FOAM DRESSING 4X4""",120.202,CDM,272,RC,A6209,HCPCS,,7939-MAIN,LOCAL,,,,,14,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"AQUACEL FOAM DRESSING 4X4""",120.202,CDM,272,RC,A6209,HCPCS,,7939-MAIN,LOCAL,,,,,14,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"AQUACEL FOAM DRESSING 4X4""",120.202,CDM,272,RC,A6209,HCPCS,,7939-MAIN,LOCAL,,,,,14,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"AQUACEL FOAM DRESSING 4X4""",120.202,CDM,272,RC,A6209,HCPCS,,7939-MAIN,LOCAL,,,,,14,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"AQUACEL FOAM DRESSING 4X4""",120.202,CDM,272,RC,A6209,HCPCS,,7939-MAIN,LOCAL,,,,,14,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"AQUACEL FOAM DRESSING 4X4""",120.202,CDM,272,RC,A6209,HCPCS,,7939-MAIN,LOCAL,,,,,14,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
AQUACEL NONADHESIVE FOAM DRESSING 4X4,120.202,CDM,272,RC,A6209,HCPCS,,12046-MAIN,LOCAL,,,,,14,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
AQUACEL NONADHESIVE FOAM DRESSING 4X4,120.202,CDM,272,RC,A6209,HCPCS,,12046-MAIN,LOCAL,,,,,14,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
AQUACEL NONADHESIVE FOAM DRESSING 4X4,120.202,CDM,272,RC,A6209,HCPCS,,12046-MAIN,LOCAL,,,,,14,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
AQUACEL NONADHESIVE FOAM DRESSING 4X4,120.202,CDM,272,RC,A6209,HCPCS,,12046-MAIN,LOCAL,,,,,14,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
AQUACEL NONADHESIVE FOAM DRESSING 4X4,120.202,CDM,272,RC,A6209,HCPCS,,12046-MAIN,LOCAL,,,,,14,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
AQUACEL NONADHESIVE FOAM DRESSING 4X4,120.202,CDM,272,RC,A6209,HCPCS,,12046-MAIN,LOCAL,,,,,14,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ARIPiprazole 2 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714014101,NDC,1,EA,151.35,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ARIPiprazole 2 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714014101,NDC,1,EA,151.35,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ARIPiprazole 2 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714014101,NDC,1,EA,151.35,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ARIPiprazole 2 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714014101,NDC,1,EA,151.35,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ARIPiprazole 2 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714014101,NDC,1,EA,151.35,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ARIPiprazole 2 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714014101,NDC,1,EA,151.35,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714078401,NDC,0.4,EA,60.72,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714078401,NDC,0.4,EA,60.72,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714078401,NDC,0.4,EA,60.72,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714078401,NDC,0.4,EA,60.72,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714078401,NDC,0.4,EA,60.72,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714078401,NDC,0.4,EA,60.72,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43598055530,NDC,0.4,EA,61.26,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43598055530,NDC,0.4,EA,61.26,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43598055530,NDC,0.4,EA,61.26,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43598055530,NDC,0.4,EA,61.26,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43598055530,NDC,0.4,EA,61.26,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43598055530,NDC,0.4,EA,61.26,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43598096630,NDC,0.4,EA,61.26,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43598096630,NDC,0.4,EA,61.26,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43598096630,NDC,0.4,EA,61.26,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43598096630,NDC,0.4,EA,61.26,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43598096630,NDC,0.4,EA,61.26,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43598096630,NDC,0.4,EA,61.26,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,59148000713,NDC,1,EA,170.19,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,59148000713,NDC,1,EA,170.19,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,59148000713,NDC,1,EA,170.19,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,59148000713,NDC,1,EA,170.19,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,59148000713,NDC,1,EA,170.19,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,59148000713,NDC,1,EA,170.19,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862066230,NDC,1,EA,153.17,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862066230,NDC,1,EA,153.17,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862066230,NDC,1,EA,153.17,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862066230,NDC,1,EA,153.17,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862066230,NDC,1,EA,153.17,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862066230,NDC,1,EA,153.17,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Art Lower Extremity-Bilat,PX9392501,CDM,921,RC,93925,CPT,TC,,,,,,,1188,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Art Lower Extremity-Bilat,PX9392501,CDM,921,RC,93925,CPT,TC,,,,,,,1188,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Art Lower Extremity-Bilat,PX9392501,CDM,921,RC,93925,CPT,TC,,,,,,,1188,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Art Lower Extremity-Bilat,PX9392501,CDM,921,RC,93925,CPT,TC,,,,,,,1188,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Art Lower Extremity-Bilat,PX9392501,CDM,921,RC,93925,CPT,TC,,,,,,,1188,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Art Lower Extremity-Bilat,PX9392501,CDM,921,RC,93925,CPT,TC,,,,,,,1188,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Art Lower Extremity+Upper,PX9392301,CDM,921,RC,93923,CPT,TC,,,,,,,784,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Art Lower Extremity+Upper,PX9392301,CDM,921,RC,93923,CPT,TC,,,,,,,784,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Art Lower Extremity+Upper,PX9392301,CDM,921,RC,93923,CPT,TC,,,,,,,784,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Art Lower Extremity+Upper,PX9392301,CDM,921,RC,93923,CPT,TC,,,,,,,784,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Art Lower Extremity+Upper,PX9392301,CDM,921,RC,93923,CPT,TC,,,,,,,784,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Art Lower Extremity+Upper,PX9392301,CDM,921,RC,93923,CPT,TC,,,,,,,784,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Art Upper Extremity-Ltd,PX9393101,CDM,921,RC,93931,CPT,TC,,,,,,,718,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Art Upper Extremity-Ltd,PX9393101,CDM,921,RC,93931,CPT,TC,,,,,,,718,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Art Upper Extremity-Ltd,PX9393101,CDM,921,RC,93931,CPT,TC,,,,,,,718,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Art Upper Extremity-Ltd,PX9393101,CDM,921,RC,93931,CPT,TC,,,,,,,718,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Art Upper Extremity-Ltd,PX9393101,CDM,921,RC,93931,CPT,TC,,,,,,,718,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Art Upper Extremity-Ltd,PX9393101,CDM,921,RC,93931,CPT,TC,,,,,,,718,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
artificial tears Ointment 3.5 g Tube,63700001,CDM,250,RC,,,,,,10119002239,NDC,3.5,GR,50.14,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
artificial tears Ointment 3.5 g Tube,63700001,CDM,250,RC,,,,,,10119002239,NDC,3.5,GR,50.14,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
artificial tears Ointment 3.5 g Tube,63700001,CDM,250,RC,,,,,,10119002239,NDC,3.5,GR,50.14,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
artificial tears Ointment 3.5 g Tube,63700001,CDM,250,RC,,,,,,10119002239,NDC,3.5,GR,50.14,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
artificial tears Ointment 3.5 g Tube,63700001,CDM,250,RC,,,,,,10119002239,NDC,3.5,GR,50.14,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
artificial tears Ointment 3.5 g Tube,63700001,CDM,250,RC,,,,,,10119002239,NDC,3.5,GR,50.14,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ARTISTA AH 3GRAM ABSORBABLE HEMOSTATIC PARTICLES,27200000,CDM,272,RC,A6199,HCPCS,,10227-MAIN,LOCAL,,,,,486,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ARTISTA AH 3GRAM ABSORBABLE HEMOSTATIC PARTICLES,27200000,CDM,272,RC,A6199,HCPCS,,10227-MAIN,LOCAL,,,,,486,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ARTISTA AH 3GRAM ABSORBABLE HEMOSTATIC PARTICLES,27200000,CDM,272,RC,A6199,HCPCS,,10227-MAIN,LOCAL,,,,,486,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ARTISTA AH 3GRAM ABSORBABLE HEMOSTATIC PARTICLES,27200000,CDM,272,RC,A6199,HCPCS,,10227-MAIN,LOCAL,,,,,486,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ARTISTA AH 3GRAM ABSORBABLE HEMOSTATIC PARTICLES,27200000,CDM,272,RC,A6199,HCPCS,,10227-MAIN,LOCAL,,,,,486,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ARTISTA AH 3GRAM ABSORBABLE HEMOSTATIC PARTICLES,27200000,CDM,272,RC,A6199,HCPCS,,10227-MAIN,LOCAL,,,,,486,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Asay of Interleukin-6 (Il-6),PX8352990,CDM,300,RC,83529,CPT,90,,,,,,,170,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Asay of Interleukin-6 (Il-6),PX8352990,CDM,300,RC,83529,CPT,90,,,,,,,170,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Asay of Interleukin-6 (Il-6),PX8352990,CDM,300,RC,83529,CPT,90,,,,,,,170,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Asay of Interleukin-6 (Il-6),PX8352990,CDM,300,RC,83529,CPT,90,,,,,,,170,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Asay of Interleukin-6 (Il-6),PX8352990,CDM,300,RC,83529,CPT,90,,,,,,,170,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Asay of Interleukin-6 (Il-6),PX8352990,CDM,300,RC,83529,CPT,90,,,,,,,170,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ascorbic acid 500 MG Tablet 100 Each Box,25000000,CDM,250,RC,,,,,,904052361,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ascorbic acid 500 MG Tablet 100 Each Box,25000000,CDM,250,RC,,,,,,904052361,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ascorbic acid 500 MG Tablet 100 Each Box,25000000,CDM,250,RC,,,,,,904052361,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ascorbic acid 500 MG Tablet 100 Each Box,25000000,CDM,250,RC,,,,,,904052361,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ascorbic acid 500 MG Tablet 100 Each Box,25000000,CDM,250,RC,,,,,,904052361,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ascorbic acid 500 MG Tablet 100 Each Box,25000000,CDM,250,RC,,,,,,904052361,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aspergillus Ag - Ref,PX8730590,CDM,300,RC,87305,CPT,90,,,,,,,141,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aspergillus Ag - Ref,PX8730590,CDM,300,RC,87305,CPT,90,,,,,,,141,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aspergillus Ag - Ref,PX8730590,CDM,300,RC,87305,CPT,90,,,,,,,141,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aspergillus Ag - Ref,PX8730590,CDM,300,RC,87305,CPT,90,,,,,,,141,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aspergillus Ag - Ref,PX8730590,CDM,300,RC,87305,CPT,90,,,,,,,141,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aspergillus Ag - Ref,PX8730590,CDM,300,RC,87305,CPT,90,,,,,,,141,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aspirate Pleura W/ Imaging,PX32555F,CDM,761,RC,32555,CPT,,,,,,,,795,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aspirate Pleura W/ Imaging,PX32555F,CDM,761,RC,32555,CPT,,,,,,,,795,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aspirate Pleura W/ Imaging,PX32555F,CDM,761,RC,32555,CPT,,,,,,,,795,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aspirate Pleura W/ Imaging,PX32555F,CDM,761,RC,32555,CPT,,,,,,,,795,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aspirate Pleura W/ Imaging,PX32555F,CDM,761,RC,32555,CPT,,,,,,,,795,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aspirate Pleura W/ Imaging,PX32555F,CDM,761,RC,32555,CPT,,,,,,,,795,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aspirate Pleura W/ Imaging,PX32555P,CDM,983,RC,32555,CPT,,,,,,,,536,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aspirate Pleura W/ Imaging,PX32555P,CDM,983,RC,32555,CPT,,,,,,,,536,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aspirate Pleura W/ Imaging,PX32555P,CDM,983,RC,32555,CPT,,,,,,,,536,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aspirate Pleura W/ Imaging,PX32555P,CDM,983,RC,32555,CPT,,,,,,,,536,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aspirate Pleura W/ Imaging,PX32555P,CDM,983,RC,32555,CPT,,,,,,,,536,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aspirate Pleura W/ Imaging,PX32555P,CDM,983,RC,32555,CPT,,,,,,,,536,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aspirate Pleura W/O Imaging,PX32554F,CDM,510,RC,32554,CPT,,,,,,,,795,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aspirate Pleura W/O Imaging,PX32554F,CDM,510,RC,32554,CPT,,,,,,,,795,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aspirate Pleura W/O Imaging,PX32554F,CDM,510,RC,32554,CPT,,,,,,,,795,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aspirate Pleura W/O Imaging,PX32554F,CDM,510,RC,32554,CPT,,,,,,,,795,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aspirate Pleura W/O Imaging,PX32554F,CDM,510,RC,32554,CPT,,,,,,,,795,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aspirate Pleura W/O Imaging,PX32554F,CDM,510,RC,32554,CPT,,,,,,,,795,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin 81 MG Tablet Chewable 90 Each Bottle,63700001,CDM,250,RC,,,,,,904679489,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin 81 MG Tablet Chewable 90 Each Bottle,63700001,CDM,250,RC,,,,,,904679489,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin 81 MG Tablet Chewable 90 Each Bottle,63700001,CDM,250,RC,,,,,,904679489,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin 81 MG Tablet Chewable 90 Each Bottle,63700001,CDM,250,RC,,,,,,904679489,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin 81 MG Tablet Chewable 90 Each Bottle,63700001,CDM,250,RC,,,,,,904679489,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin 81 MG Tablet Chewable 90 Each Bottle,63700001,CDM,250,RC,,,,,,904679489,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin 81 MG Tablet Chewable 500 Each Disp Pack,63700001,CDM,250,RC,,,,,,66553000201,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin 81 MG Tablet Chewable 500 Each Disp Pack,63700001,CDM,250,RC,,,,,,66553000201,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin 81 MG Tablet Chewable 500 Each Disp Pack,63700001,CDM,250,RC,,,,,,66553000201,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin 81 MG Tablet Chewable 500 Each Disp Pack,63700001,CDM,250,RC,,,,,,66553000201,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin 81 MG Tablet Chewable 500 Each Disp Pack,63700001,CDM,250,RC,,,,,,66553000201,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin 81 MG Tablet Chewable 500 Each Disp Pack,63700001,CDM,250,RC,,,,,,66553000201,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin 300 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574703412,NDC,1,EA,7.83,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin 300 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574703412,NDC,1,EA,7.83,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin 300 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574703412,NDC,1,EA,7.83,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin 300 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574703412,NDC,1,EA,7.83,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin 300 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574703412,NDC,1,EA,7.83,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin 300 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574703412,NDC,1,EA,7.83,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin 325 MG Tablet 500 Each Box,63700001,CDM,250,RC,,,,,,66553000101,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin 325 MG Tablet 500 Each Box,63700001,CDM,250,RC,,,,,,66553000101,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin 325 MG Tablet 500 Each Box,63700001,CDM,250,RC,,,,,,66553000101,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin 325 MG Tablet 500 Each Box,63700001,CDM,250,RC,,,,,,66553000101,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin 325 MG Tablet 500 Each Box,63700001,CDM,250,RC,,,,,,66553000101,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin 325 MG Tablet 500 Each Box,63700001,CDM,250,RC,,,,,,66553000101,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin EC 81 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,63739021210,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin EC 81 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,63739021210,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin EC 81 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,63739021210,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin EC 81 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,63739021210,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin EC 81 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,63739021210,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin EC 81 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,63739021210,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin EC 81 MG Tablet Delayed Release 120 Each Bottle,63700001,CDM,250,RC,,,,,,10135017362,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin EC 81 MG Tablet Delayed Release 120 Each Bottle,63700001,CDM,250,RC,,,,,,10135017362,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin EC 81 MG Tablet Delayed Release 120 Each Bottle,63700001,CDM,250,RC,,,,,,10135017362,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin EC 81 MG Tablet Delayed Release 120 Each Bottle,63700001,CDM,250,RC,,,,,,10135017362,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin EC 81 MG Tablet Delayed Release 120 Each Bottle,63700001,CDM,250,RC,,,,,,10135017362,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin EC 81 MG Tablet Delayed Release 120 Each Bottle,63700001,CDM,250,RC,,,,,,10135017362,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,536114801,NDC,0.249230769,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,536114801,NDC,0.249230769,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,536114801,NDC,0.249230769,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,536114801,NDC,0.249230769,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,536114801,NDC,0.249230769,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,536114801,NDC,0.249230769,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,536331301,NDC,0.249230769,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,536331301,NDC,0.249230769,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,536331301,NDC,0.249230769,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,536331301,NDC,0.249230769,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,536331301,NDC,0.249230769,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,536331301,NDC,0.249230769,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,603016921,NDC,0.249230769,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,603016921,NDC,0.249230769,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,603016921,NDC,0.249230769,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,603016921,NDC,0.249230769,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,603016921,NDC,0.249230769,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,603016921,NDC,0.249230769,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin-dipyridamole 25-200 MG Capsule Extended Release 12 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687030533,NDC,1,EA,67.66,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin-dipyridamole 25-200 MG Capsule Extended Release 12 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687030533,NDC,1,EA,67.66,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin-dipyridamole 25-200 MG Capsule Extended Release 12 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687030533,NDC,1,EA,67.66,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin-dipyridamole 25-200 MG Capsule Extended Release 12 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687030533,NDC,1,EA,67.66,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin-dipyridamole 25-200 MG Capsule Extended Release 12 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687030533,NDC,1,EA,67.66,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin-dipyridamole 25-200 MG Capsule Extended Release 12 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687030533,NDC,1,EA,67.66,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin-dipyridamole 25-200 MG Capsule Extended Release 12 Hour 20 Each Box,63700001,CDM,250,RC,,,,,,60687030532,NDC,1,EA,67.66,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin-dipyridamole 25-200 MG Capsule Extended Release 12 Hour 20 Each Box,63700001,CDM,250,RC,,,,,,60687030532,NDC,1,EA,67.66,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin-dipyridamole 25-200 MG Capsule Extended Release 12 Hour 20 Each Box,63700001,CDM,250,RC,,,,,,60687030532,NDC,1,EA,67.66,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin-dipyridamole 25-200 MG Capsule Extended Release 12 Hour 20 Each Box,63700001,CDM,250,RC,,,,,,60687030532,NDC,1,EA,67.66,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin-dipyridamole 25-200 MG Capsule Extended Release 12 Hour 20 Each Box,63700001,CDM,250,RC,,,,,,60687030532,NDC,1,EA,67.66,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin-dipyridamole 25-200 MG Capsule Extended Release 12 Hour 20 Each Box,63700001,CDM,250,RC,,,,,,60687030532,NDC,1,EA,67.66,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Alkaline Phosphatase,PX84075,CDM,300,RC,84075,CPT,,,,,,,,57,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Alkaline Phosphatase,PX84075,CDM,300,RC,84075,CPT,,,,,,,,57,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Alkaline Phosphatase,PX84075,CDM,300,RC,84075,CPT,,,,,,,,57,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Alkaline Phosphatase,PX84075,CDM,300,RC,84075,CPT,,,,,,,,57,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Alkaline Phosphatase,PX84075,CDM,300,RC,84075,CPT,,,,,,,,57,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Alkaline Phosphatase,PX84075,CDM,300,RC,84075,CPT,,,,,,,,57,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Biovlbl Testosterone Direct Measurement - Ref,PX8441090,CDM,300,RC,84410,CPT,90,,,,,,,52,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Biovlbl Testosterone Direct Measurement - Ref,PX8441090,CDM,300,RC,84410,CPT,90,,,,,,,52,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Biovlbl Testosterone Direct Measurement - Ref,PX8441090,CDM,300,RC,84410,CPT,90,,,,,,,52,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Biovlbl Testosterone Direct Measurement - Ref,PX8441090,CDM,300,RC,84410,CPT,90,,,,,,,52,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Biovlbl Testosterone Direct Measurement - Ref,PX8441090,CDM,300,RC,84410,CPT,90,,,,,,,52,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Biovlbl Testosterone Direct Measurement - Ref,PX8441090,CDM,300,RC,84410,CPT,90,,,,,,,52,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Bld/Serum Cholesterol,PX82465,CDM,300,RC,82465,CPT,,,,,,,,69,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Bld/Serum Cholesterol,PX82465,CDM,300,RC,82465,CPT,,,,,,,,69,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Bld/Serum Cholesterol,PX82465,CDM,300,RC,82465,CPT,,,,,,,,69,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Bld/Serum Cholesterol,PX82465,CDM,300,RC,82465,CPT,,,,,,,,69,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Bld/Serum Cholesterol,PX82465,CDM,300,RC,82465,CPT,,,,,,,,69,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Bld/Serum Cholesterol,PX82465,CDM,300,RC,82465,CPT,,,,,,,,69,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Blood Carbon Dioxide,PX82374,CDM,300,RC,82374,CPT,,,,,,,,95,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Blood Carbon Dioxide,PX82374,CDM,300,RC,82374,CPT,,,,,,,,95,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Blood Carbon Dioxide,PX82374,CDM,300,RC,82374,CPT,,,,,,,,95,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Blood Carbon Dioxide,PX82374,CDM,300,RC,82374,CPT,,,,,,,,95,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Blood Carbon Dioxide,PX82374,CDM,300,RC,82374,CPT,,,,,,,,95,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Blood Carbon Dioxide,PX82374,CDM,300,RC,82374,CPT,,,,,,,,95,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Blood Carbon Monoxide,PX82375,CDM,300,RC,82375,CPT,,,,,,,,156,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Blood Carbon Monoxide,PX82375,CDM,300,RC,82375,CPT,,,,,,,,156,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Blood Carbon Monoxide,PX82375,CDM,300,RC,82375,CPT,,,,,,,,156,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Blood Carbon Monoxide,PX82375,CDM,300,RC,82375,CPT,,,,,,,,156,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Blood Carbon Monoxide,PX82375,CDM,300,RC,82375,CPT,,,,,,,,156,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Blood Carbon Monoxide,PX82375,CDM,300,RC,82375,CPT,,,,,,,,156,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Assay Calcium, Ionized",PX82330,CDM,300,RC,82330,CPT,,,,,,,,110,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Assay Calcium, Ionized",PX82330,CDM,300,RC,82330,CPT,,,,,,,,110,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Assay Calcium, Ionized",PX82330,CDM,300,RC,82330,CPT,,,,,,,,110,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Assay Calcium, Ionized",PX82330,CDM,300,RC,82330,CPT,,,,,,,,110,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Assay Calcium, Ionized",PX82330,CDM,300,RC,82330,CPT,,,,,,,,110,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Assay Calcium, Ionized",PX82330,CDM,300,RC,82330,CPT,,,,,,,,110,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Carbamazepine Total,PX80156,CDM,300,RC,80156,CPT,,,,,,,,145,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Carbamazepine Total,PX80156,CDM,300,RC,80156,CPT,,,,,,,,145,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Carbamazepine Total,PX80156,CDM,300,RC,80156,CPT,,,,,,,,145,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Carbamazepine Total,PX80156,CDM,300,RC,80156,CPT,,,,,,,,145,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Carbamazepine Total,PX80156,CDM,300,RC,80156,CPT,,,,,,,,145,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Carbamazepine Total,PX80156,CDM,300,RC,80156,CPT,,,,,,,,145,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Cryofibrinogen,PX82585,CDM,300,RC,82585,CPT,,,,,,,,75,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Cryofibrinogen,PX82585,CDM,300,RC,82585,CPT,,,,,,,,75,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Cryofibrinogen,PX82585,CDM,300,RC,82585,CPT,,,,,,,,75,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Cryofibrinogen,PX82585,CDM,300,RC,82585,CPT,,,,,,,,75,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Cryofibrinogen,PX82585,CDM,300,RC,82585,CPT,,,,,,,,75,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Cryofibrinogen,PX82585,CDM,300,RC,82585,CPT,,,,,,,,75,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Cryoglobulin,PX82595,CDM,300,RC,82595,CPT,,,,,,,,75,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Cryoglobulin,PX82595,CDM,300,RC,82595,CPT,,,,,,,,75,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Cryoglobulin,PX82595,CDM,300,RC,82595,CPT,,,,,,,,75,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Cryoglobulin,PX82595,CDM,300,RC,82595,CPT,,,,,,,,75,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Cryoglobulin,PX82595,CDM,300,RC,82595,CPT,,,,,,,,75,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Cryoglobulin,PX82595,CDM,300,RC,82595,CPT,,,,,,,,75,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Dipropylacetic Acid,PX80164,CDM,300,RC,80164,CPT,,,,,,,,132,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Dipropylacetic Acid,PX80164,CDM,300,RC,80164,CPT,,,,,,,,132,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Dipropylacetic Acid,PX80164,CDM,300,RC,80164,CPT,,,,,,,,132,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Dipropylacetic Acid,PX80164,CDM,300,RC,80164,CPT,,,,,,,,132,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Dipropylacetic Acid,PX80164,CDM,300,RC,80164,CPT,,,,,,,,132,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Dipropylacetic Acid,PX80164,CDM,300,RC,80164,CPT,,,,,,,,132,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay for Vancomycin,PX80202,CDM,300,RC,80202,CPT,,,,,,,,314,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay for Vancomycin,PX80202,CDM,300,RC,80202,CPT,,,,,,,,314,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay for Vancomycin,PX80202,CDM,300,RC,80202,CPT,,,,,,,,314,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay for Vancomycin,PX80202,CDM,300,RC,80202,CPT,,,,,,,,314,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay for Vancomycin,PX80202,CDM,300,RC,80202,CPT,,,,,,,,314,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay for Vancomycin,PX80202,CDM,300,RC,80202,CPT,,,,,,,,314,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Iga/Igd/Igg/Igm Each,PX82784,CDM,300,RC,82784,CPT,,,,,,,,315,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Iga/Igd/Igg/Igm Each,PX82784,CDM,300,RC,82784,CPT,,,,,,,,315,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Iga/Igd/Igg/Igm Each,PX82784,CDM,300,RC,82784,CPT,,,,,,,,315,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Iga/Igd/Igg/Igm Each,PX82784,CDM,300,RC,82784,CPT,,,,,,,,315,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Iga/Igd/Igg/Igm Each,PX82784,CDM,300,RC,82784,CPT,,,,,,,,315,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Iga/Igd/Igg/Igm Each,PX82784,CDM,300,RC,82784,CPT,,,,,,,,315,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of ammonia,PX82140,CDM,300,RC,82140,CPT,,,,,,,,190,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of ammonia,PX82140,CDM,300,RC,82140,CPT,,,,,,,,190,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of ammonia,PX82140,CDM,300,RC,82140,CPT,,,,,,,,190,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of ammonia,PX82140,CDM,300,RC,82140,CPT,,,,,,,,190,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of ammonia,PX82140,CDM,300,RC,82140,CPT,,,,,,,,190,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of ammonia,PX82140,CDM,300,RC,82140,CPT,,,,,,,,190,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Amylase,PX82150,CDM,300,RC,82150,CPT,,,,,,,,191,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Amylase,PX82150,CDM,300,RC,82150,CPT,,,,,,,,191,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Amylase,PX82150,CDM,300,RC,82150,CPT,,,,,,,,191,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Amylase,PX82150,CDM,300,RC,82150,CPT,,,,,,,,191,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Amylase,PX82150,CDM,300,RC,82150,CPT,,,,,,,,191,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Amylase,PX82150,CDM,300,RC,82150,CPT,,,,,,,,191,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Blood Lipoprotein,PX83721,CDM,300,RC,83721,CPT,,,,,,,,76,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Blood Lipoprotein,PX83721,CDM,300,RC,83721,CPT,,,,,,,,76,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Blood Lipoprotein,PX83721,CDM,300,RC,83721,CPT,,,,,,,,76,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Blood Lipoprotein,PX83721,CDM,300,RC,83721,CPT,,,,,,,,76,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Blood Lipoprotein,PX83721,CDM,300,RC,83721,CPT,,,,,,,,76,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Blood Lipoprotein,PX83721,CDM,300,RC,83721,CPT,,,,,,,,76,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of CK (Cpk),PX82550,CDM,300,RC,82550,CPT,,,,,,,,150,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of CK (Cpk),PX82550,CDM,300,RC,82550,CPT,,,,,,,,150,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of CK (Cpk),PX82550,CDM,300,RC,82550,CPT,,,,,,,,150,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of CK (Cpk),PX82550,CDM,300,RC,82550,CPT,,,,,,,,150,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of CK (Cpk),PX82550,CDM,300,RC,82550,CPT,,,,,,,,150,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of CK (Cpk),PX82550,CDM,300,RC,82550,CPT,,,,,,,,150,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of creatinine,PX82565,CDM,300,RC,82565,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of creatinine,PX82565,CDM,300,RC,82565,CPT,,,,,,,,58,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of creatinine,PX82565,CDM,300,RC,82565,CPT,,,,,,,,58,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of creatinine,PX82565,CDM,300,RC,82565,CPT,,,,,,,,58,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of creatinine,PX82565,CDM,300,RC,82565,CPT,,,,,,,,58,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of creatinine,PX82565,CDM,300,RC,82565,CPT,,,,,,,,58,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Digoxin,PX80162,CDM,300,RC,80162,CPT,,,,,,,,290,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Digoxin,PX80162,CDM,300,RC,80162,CPT,,,,,,,,290,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Digoxin,PX80162,CDM,300,RC,80162,CPT,,,,,,,,290,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Digoxin,PX80162,CDM,300,RC,80162,CPT,,,,,,,,290,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Digoxin,PX80162,CDM,300,RC,80162,CPT,,,,,,,,290,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Digoxin,PX80162,CDM,300,RC,80162,CPT,,,,,,,,290,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Erythropoietin,PX82668,CDM,300,RC,82668,CPT,,,,,,,,114,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Erythropoietin,PX82668,CDM,300,RC,82668,CPT,,,,,,,,114,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Erythropoietin,PX82668,CDM,300,RC,82668,CPT,,,,,,,,114,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Erythropoietin,PX82668,CDM,300,RC,82668,CPT,,,,,,,,114,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Erythropoietin,PX82668,CDM,300,RC,82668,CPT,,,,,,,,114,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Erythropoietin,PX82668,CDM,300,RC,82668,CPT,,,,,,,,114,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Ferritin,PX82728,CDM,300,RC,82728,CPT,,,,,,,,177,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Ferritin,PX82728,CDM,300,RC,82728,CPT,,,,,,,,177,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Ferritin,PX82728,CDM,300,RC,82728,CPT,,,,,,,,177,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Ferritin,PX82728,CDM,300,RC,82728,CPT,,,,,,,,177,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Ferritin,PX82728,CDM,300,RC,82728,CPT,,,,,,,,177,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Ferritin,PX82728,CDM,300,RC,82728,CPT,,,,,,,,177,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Ggt,PX82977,CDM,300,RC,82977,CPT,,,,,,,,89,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Ggt,PX82977,CDM,300,RC,82977,CPT,,,,,,,,89,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Ggt,PX82977,CDM,300,RC,82977,CPT,,,,,,,,89,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Ggt,PX82977,CDM,300,RC,82977,CPT,,,,,,,,89,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Ggt,PX82977,CDM,300,RC,82977,CPT,,,,,,,,89,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Ggt,PX82977,CDM,300,RC,82977,CPT,,,,,,,,89,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Iron,PX83540,CDM,300,RC,83540,CPT,,,,,,,,122,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Iron,PX83540,CDM,300,RC,83540,CPT,,,,,,,,122,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Iron,PX83540,CDM,300,RC,83540,CPT,,,,,,,,122,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Iron,PX83540,CDM,300,RC,83540,CPT,,,,,,,,122,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Iron,PX83540,CDM,300,RC,83540,CPT,,,,,,,,122,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Iron,PX83540,CDM,300,RC,83540,CPT,,,,,,,,122,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Lactic Acid,PX83605,CDM,300,RC,83605,CPT,,,,,,,,150,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Lactic Acid,PX83605,CDM,300,RC,83605,CPT,,,,,,,,150,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Lactic Acid,PX83605,CDM,300,RC,83605,CPT,,,,,,,,150,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Lactic Acid,PX83605,CDM,300,RC,83605,CPT,,,,,,,,150,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Lactic Acid,PX83605,CDM,300,RC,83605,CPT,,,,,,,,150,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Lactic Acid,PX83605,CDM,300,RC,83605,CPT,,,,,,,,150,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Lipase,PX83690,CDM,300,RC,83690,CPT,,,,,,,,132,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Lipase,PX83690,CDM,300,RC,83690,CPT,,,,,,,,132,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Lipase,PX83690,CDM,300,RC,83690,CPT,,,,,,,,132,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Lipase,PX83690,CDM,300,RC,83690,CPT,,,,,,,,132,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Lipase,PX83690,CDM,300,RC,83690,CPT,,,,,,,,132,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Lipase,PX83690,CDM,300,RC,83690,CPT,,,,,,,,132,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Lithium,PX80178,CDM,300,RC,80178,CPT,,,,,,,,124,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Lithium,PX80178,CDM,300,RC,80178,CPT,,,,,,,,124,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Lithium,PX80178,CDM,300,RC,80178,CPT,,,,,,,,124,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Lithium,PX80178,CDM,300,RC,80178,CPT,,,,,,,,124,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Lithium,PX80178,CDM,300,RC,80178,CPT,,,,,,,,124,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Lithium,PX80178,CDM,300,RC,80178,CPT,,,,,,,,124,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Natriuretic Peptide,PX83880,CDM,300,RC,83880,CPT,,,,,,,,290,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Natriuretic Peptide,PX83880,CDM,300,RC,83880,CPT,,,,,,,,290,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Natriuretic Peptide,PX83880,CDM,300,RC,83880,CPT,,,,,,,,290,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Natriuretic Peptide,PX83880,CDM,300,RC,83880,CPT,,,,,,,,290,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Natriuretic Peptide,PX83880,CDM,300,RC,83880,CPT,,,,,,,,290,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Natriuretic Peptide,PX83880,CDM,300,RC,83880,CPT,,,,,,,,290,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Phenytoin Total,PX80185,CDM,300,RC,80185,CPT,,,,,,,,336,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Phenytoin Total,PX80185,CDM,300,RC,80185,CPT,,,,,,,,336,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Phenytoin Total,PX80185,CDM,300,RC,80185,CPT,,,,,,,,336,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Phenytoin Total,PX80185,CDM,300,RC,80185,CPT,,,,,,,,336,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Phenytoin Total,PX80185,CDM,300,RC,80185,CPT,,,,,,,,336,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Phenytoin Total,PX80185,CDM,300,RC,80185,CPT,,,,,,,,336,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Phosphorus,PX84100,CDM,300,RC,84100,CPT,,,,,,,,150,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Phosphorus,PX84100,CDM,300,RC,84100,CPT,,,,,,,,150,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Phosphorus,PX84100,CDM,300,RC,84100,CPT,,,,,,,,150,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Phosphorus,PX84100,CDM,300,RC,84100,CPT,,,,,,,,150,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Phosphorus,PX84100,CDM,300,RC,84100,CPT,,,,,,,,150,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Phosphorus,PX84100,CDM,300,RC,84100,CPT,,,,,,,,150,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of protein urine,PX84156,CDM,300,RC,84156,CPT,,,,,,,,190,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of protein urine,PX84156,CDM,300,RC,84156,CPT,,,,,,,,190,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of protein urine,PX84156,CDM,300,RC,84156,CPT,,,,,,,,190,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of protein urine,PX84156,CDM,300,RC,84156,CPT,,,,,,,,190,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of protein urine,PX84156,CDM,300,RC,84156,CPT,,,,,,,,190,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of protein urine,PX84156,CDM,300,RC,84156,CPT,,,,,,,,190,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Psa Total,PX84153,CDM,300,RC,84153,CPT,,,,,,,,157,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Psa Total,PX84153,CDM,300,RC,84153,CPT,,,,,,,,157,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Psa Total,PX84153,CDM,300,RC,84153,CPT,,,,,,,,157,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Psa Total,PX84153,CDM,300,RC,84153,CPT,,,,,,,,157,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Psa Total,PX84153,CDM,300,RC,84153,CPT,,,,,,,,157,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Psa Total,PX84153,CDM,300,RC,84153,CPT,,,,,,,,157,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Transferrin,PX84466,CDM,300,RC,84466,CPT,,,,,,,,103,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Transferrin,PX84466,CDM,300,RC,84466,CPT,,,,,,,,103,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Transferrin,PX84466,CDM,300,RC,84466,CPT,,,,,,,,103,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Transferrin,PX84466,CDM,300,RC,84466,CPT,,,,,,,,103,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Transferrin,PX84466,CDM,300,RC,84466,CPT,,,,,,,,103,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Transferrin,PX84466,CDM,300,RC,84466,CPT,,,,,,,,103,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Triglycerides,PX84478,CDM,300,RC,84478,CPT,,,,,,,,115,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Triglycerides,PX84478,CDM,300,RC,84478,CPT,,,,,,,,115,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Triglycerides,PX84478,CDM,300,RC,84478,CPT,,,,,,,,115,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Triglycerides,PX84478,CDM,300,RC,84478,CPT,,,,,,,,115,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Triglycerides,PX84478,CDM,300,RC,84478,CPT,,,,,,,,115,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Triglycerides,PX84478,CDM,300,RC,84478,CPT,,,,,,,,115,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Urea Nitrogen,PX84520,CDM,300,RC,84520,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Urea Nitrogen,PX84520,CDM,300,RC,84520,CPT,,,,,,,,58,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Urea Nitrogen,PX84520,CDM,300,RC,84520,CPT,,,,,,,,58,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Urea Nitrogen,PX84520,CDM,300,RC,84520,CPT,,,,,,,,58,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Urea Nitrogen,PX84520,CDM,300,RC,84520,CPT,,,,,,,,58,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Urea Nitrogen,PX84520,CDM,300,RC,84520,CPT,,,,,,,,58,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Other Fluid Chlorides - Ref,PX8243890,CDM,300,RC,82438,CPT,90,,,,,,,197,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Other Fluid Chlorides - Ref,PX8243890,CDM,300,RC,82438,CPT,90,,,,,,,197,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Other Fluid Chlorides - Ref,PX8243890,CDM,300,RC,82438,CPT,90,,,,,,,197,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Other Fluid Chlorides - Ref,PX8243890,CDM,300,RC,82438,CPT,90,,,,,,,197,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Other Fluid Chlorides - Ref,PX8243890,CDM,300,RC,82438,CPT,90,,,,,,,197,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Other Fluid Chlorides - Ref,PX8243890,CDM,300,RC,82438,CPT,90,,,,,,,197,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Ph Body Fluids Nos,PX83986,CDM,300,RC,83986,CPT,,,,,,,,147,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Ph Body Fluids Nos,PX83986,CDM,300,RC,83986,CPT,,,,,,,,147,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Ph Body Fluids Nos,PX83986,CDM,300,RC,83986,CPT,,,,,,,,147,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Ph Body Fluids Nos,PX83986,CDM,300,RC,83986,CPT,,,,,,,,147,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Ph Body Fluids Nos,PX83986,CDM,300,RC,83986,CPT,,,,,,,,147,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Ph Body Fluids Nos,PX83986,CDM,300,RC,83986,CPT,,,,,,,,147,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Thyroid Stim Hormone,PX84443,CDM,300,RC,84443,CPT,,,,,,,,294,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Thyroid Stim Hormone,PX84443,CDM,300,RC,84443,CPT,,,,,,,,294,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Thyroid Stim Hormone,PX84443,CDM,300,RC,84443,CPT,,,,,,,,294,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Thyroid Stim Hormone,PX84443,CDM,300,RC,84443,CPT,,,,,,,,294,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Thyroid Stim Hormone,PX84443,CDM,300,RC,84443,CPT,,,,,,,,294,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Thyroid Stim Hormone,PX84443,CDM,300,RC,84443,CPT,,,,,,,,294,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Urine Urea-N,PX84540,CDM,300,RC,84540,CPT,,,,,,,,14,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Urine Urea-N,PX84540,CDM,300,RC,84540,CPT,,,,,,,,14,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Urine Urea-N,PX84540,CDM,300,RC,84540,CPT,,,,,,,,14,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Urine Urea-N,PX84540,CDM,300,RC,84540,CPT,,,,,,,,14,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Urine Urea-N,PX84540,CDM,300,RC,84540,CPT,,,,,,,,14,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Urine Urea-N,PX84540,CDM,300,RC,84540,CPT,,,,,,,,14,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Vitamin B-6,PX84207,CDM,300,RC,84207,CPT,90,,,,,,,42,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Vitamin B-6,PX84207,CDM,300,RC,84207,CPT,90,,,,,,,42,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Vitamin B-6,PX84207,CDM,300,RC,84207,CPT,90,,,,,,,42,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Vitamin B-6,PX84207,CDM,300,RC,84207,CPT,90,,,,,,,42,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Vitamin B-6,PX84207,CDM,300,RC,84207,CPT,90,,,,,,,42,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Vitamin B-6,PX84207,CDM,300,RC,84207,CPT,90,,,,,,,42,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Assay, Glucose, Blood Quant",PX82947,CDM,300,RC,82947,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Assay, Glucose, Blood Quant",PX82947,CDM,300,RC,82947,CPT,,,,,,,,58,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Assay, Glucose, Blood Quant",PX82947,CDM,300,RC,82947,CPT,,,,,,,,58,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Assay, Glucose, Blood Quant",PX82947,CDM,300,RC,82947,CPT,,,,,,,,58,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Assay, Glucose, Blood Quant",PX82947,CDM,300,RC,82947,CPT,,,,,,,,58,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Assay, Glucose, Blood Quant",PX82947,CDM,300,RC,82947,CPT,,,,,,,,58,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Astrazeneca Covid-19 Vaccine, Administration, 1st Dose",PX0021A,CDM,771,RC,,,,,,,,,,69,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Astrazeneca Covid-19 Vaccine, Administration, 1st Dose",PX0021A,CDM,771,RC,,,,,,,,,,69,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Astrazeneca Covid-19 Vaccine, Administration, 1st Dose",PX0021A,CDM,771,RC,,,,,,,,,,69,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Astrazeneca Covid-19 Vaccine, Administration, 1st Dose",PX0021A,CDM,771,RC,,,,,,,,,,69,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Astrazeneca Covid-19 Vaccine, Administration, 1st Dose",PX0021A,CDM,771,RC,,,,,,,,,,69,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Astrazeneca Covid-19 Vaccine, Administration, 1st Dose",PX0021A,CDM,771,RC,,,,,,,,,,69,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Astrazeneca Covid-19 Vaccine, Adminstration, 2nd Dose",PX0022A,CDM,771,RC,,,,,,,,,,69,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Astrazeneca Covid-19 Vaccine, Adminstration, 2nd Dose",PX0022A,CDM,771,RC,,,,,,,,,,69,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Astrazeneca Covid-19 Vaccine, Adminstration, 2nd Dose",PX0022A,CDM,771,RC,,,,,,,,,,69,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Astrazeneca Covid-19 Vaccine, Adminstration, 2nd Dose",PX0022A,CDM,771,RC,,,,,,,,,,69,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Astrazeneca Covid-19 Vaccine, Adminstration, 2nd Dose",PX0022A,CDM,771,RC,,,,,,,,,,69,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Astrazeneca Covid-19 Vaccine, Adminstration, 2nd Dose",PX0022A,CDM,771,RC,,,,,,,,,,69,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atenolol 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079075901,NDC,1,EA,4.3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atenolol 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079075901,NDC,1,EA,4.3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atenolol 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079075901,NDC,1,EA,4.3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atenolol 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079075901,NDC,1,EA,4.3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atenolol 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079075901,NDC,1,EA,4.3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atenolol 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079075901,NDC,1,EA,4.3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atenolol 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904539261,NDC,1,EA,3.83,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atenolol 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904539261,NDC,1,EA,3.83,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atenolol 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904539261,NDC,1,EA,3.83,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atenolol 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904539261,NDC,1,EA,3.83,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atenolol 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904539261,NDC,1,EA,3.83,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atenolol 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904539261,NDC,1,EA,3.83,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atenolol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079068401,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atenolol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079068401,NDC,0.25,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atenolol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079068401,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atenolol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079068401,NDC,0.25,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atenolol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079068401,NDC,0.25,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atenolol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079068401,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atenolol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079068420,NDC,1,EA,4.79,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atenolol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079068420,NDC,1,EA,4.79,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atenolol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079068420,NDC,1,EA,4.79,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atenolol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079068420,NDC,1,EA,4.79,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atenolol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079068420,NDC,1,EA,4.79,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atenolol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079068420,NDC,1,EA,4.79,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atorvaSTATin 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020801,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atorvaSTATin 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020801,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atorvaSTATin 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020801,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atorvaSTATin 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020801,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atorvaSTATin 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020801,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atorvaSTATin 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020801,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atorvaSTATin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629061,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atorvaSTATin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629061,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atorvaSTATin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629061,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atorvaSTATin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629061,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atorvaSTATin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629061,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atorvaSTATin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629061,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atorvaSTATin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020820,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atorvaSTATin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020820,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atorvaSTATin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020820,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atorvaSTATin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020820,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atorvaSTATin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020820,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atorvaSTATin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020820,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atorvaSTATin 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020901,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atorvaSTATin 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020901,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atorvaSTATin 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020901,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atorvaSTATin 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020901,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atorvaSTATin 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020901,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atorvaSTATin 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020901,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atorvaSTATin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629161,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atorvaSTATin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629161,NDC,0.25,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atorvaSTATin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629161,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atorvaSTATin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629161,NDC,0.25,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atorvaSTATin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629161,NDC,0.25,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atorvaSTATin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629161,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atorvaSTATin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020920,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atorvaSTATin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020920,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atorvaSTATin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020920,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atorvaSTATin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020920,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atorvaSTATin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020920,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atorvaSTATin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020920,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atorvaSTATin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079021001,NDC,0.125,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atorvaSTATin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079021001,NDC,0.125,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atorvaSTATin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079021001,NDC,0.125,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atorvaSTATin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079021001,NDC,0.125,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atorvaSTATin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079021001,NDC,0.125,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atorvaSTATin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079021001,NDC,0.125,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine (PF) 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517040125,NDC,1,ML,71.55,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine (PF) 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517040125,NDC,1,ML,71.55,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine (PF) 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517040125,NDC,1,ML,71.55,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine (PF) 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517040125,NDC,1,ML,71.55,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine (PF) 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517040125,NDC,1,ML,71.55,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine (PF) 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517040125,NDC,1,ML,71.55,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine (PF) 1 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517101025,NDC,1,ML,91.89,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine (PF) 1 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517101025,NDC,1,ML,91.89,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine (PF) 1 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517101025,NDC,1,ML,91.89,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine (PF) 1 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517101025,NDC,1,ML,91.89,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine (PF) 1 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517101025,NDC,1,ML,91.89,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine (PF) 1 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517101025,NDC,1,ML,91.89,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100401,NDC,0.5,ML,50.91,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100401,NDC,0.5,ML,50.91,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100401,NDC,0.5,ML,50.91,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100401,NDC,0.5,ML,50.91,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100401,NDC,0.5,ML,50.91,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100401,NDC,0.5,ML,50.91,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,17478021502,NDC,2,ML,269.45,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,17478021502,NDC,2,ML,269.45,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,17478021502,NDC,2,ML,269.45,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,17478021502,NDC,2,ML,269.45,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,17478021502,NDC,2,ML,269.45,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,17478021502,NDC,2,ML,269.45,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,60219174802,NDC,2,ML,269.45,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,60219174802,NDC,2,ML,269.45,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,60219174802,NDC,2,ML,269.45,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,60219174802,NDC,2,ML,269.45,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,60219174802,NDC,2,ML,269.45,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,60219174802,NDC,2,ML,269.45,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 1 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,60219174903,NDC,5,ML,299.49,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 1 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,60219174903,NDC,5,ML,299.49,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 1 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,60219174903,NDC,5,ML,299.49,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 1 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,60219174903,NDC,5,ML,299.49,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 1 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,60219174903,NDC,5,ML,299.49,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 1 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,60219174903,NDC,5,ML,299.49,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329333901,NDC,10,ML,79.51,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329333901,NDC,10,ML,79.51,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329333901,NDC,10,ML,79.51,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329333901,NDC,10,ML,79.51,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329333901,NDC,10,ML,79.51,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329333901,NDC,10,ML,79.51,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329334001,NDC,10,ML,88.88,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329334001,NDC,10,ML,88.88,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329334001,NDC,10,ML,88.88,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329334001,NDC,10,ML,88.88,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329334001,NDC,10,ML,88.88,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329334001,NDC,10,ML,88.88,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 1 mg/mL Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100101,NDC,0.2,ML,39.42,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 1 mg/mL Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100101,NDC,0.2,ML,39.42,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 1 mg/mL Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100101,NDC,0.2,ML,39.42,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 1 mg/mL Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100101,NDC,0.2,ML,39.42,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 1 mg/mL Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100101,NDC,0.2,ML,39.42,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 1 mg/mL Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100101,NDC,0.2,ML,39.42,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,641600601,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,641600601,NDC,0.5,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,641600601,NDC,0.5,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,641600601,NDC,0.5,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,641600601,NDC,0.5,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,641600601,NDC,0.5,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058003,NDC,0.5,ML,31.57,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058003,NDC,0.5,ML,31.57,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058003,NDC,0.5,ML,31.57,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058003,NDC,0.5,ML,31.57,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058003,NDC,0.5,ML,31.57,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058003,NDC,0.5,ML,31.57,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058020,NDC,0.5,ML,31.57,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058020,NDC,0.5,ML,31.57,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058020,NDC,0.5,ML,31.57,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058020,NDC,0.5,ML,31.57,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058020,NDC,0.5,ML,31.57,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058020,NDC,0.5,ML,31.57,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Automated Leukocyte Count,PX85048,CDM,300,RC,85048,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Automated Leukocyte Count,PX85048,CDM,300,RC,85048,CPT,,,,,,,,58,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Automated Leukocyte Count,PX85048,CDM,300,RC,85048,CPT,,,,,,,,58,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Automated Leukocyte Count,PX85048,CDM,300,RC,85048,CPT,,,,,,,,58,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Automated Leukocyte Count,PX85048,CDM,300,RC,85048,CPT,,,,,,,,58,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Automated Leukocyte Count,PX85048,CDM,300,RC,85048,CPT,,,,,,,,58,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,781325394,NDC,1,EA,1049.95,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,781325394,NDC,1,EA,1049.95,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,781325394,NDC,1,EA,1049.95,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,781325394,NDC,1,EA,1049.95,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,781325394,NDC,1,EA,1049.95,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,781325394,NDC,1,EA,1049.95,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598030562,NDC,1,EA,912,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598030562,NDC,1,EA,912,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598030562,NDC,1,EA,912,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598030562,NDC,1,EA,912,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598030562,NDC,1,EA,912,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598030562,NDC,1,EA,912,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598046562,NDC,1,EA,798,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598046562,NDC,1,EA,798,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598046562,NDC,1,EA,798,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598046562,NDC,1,EA,798,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598046562,NDC,1,EA,798,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598046562,NDC,1,EA,798,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,63323077139,NDC,1,EA,547.2,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,63323077139,NDC,1,EA,547.2,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,63323077139,NDC,1,EA,547.2,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,63323077139,NDC,1,EA,547.2,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,63323077139,NDC,1,EA,547.2,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,63323077139,NDC,1,EA,547.2,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,72485020101,NDC,1,EA,1049.95,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,72485020101,NDC,1,EA,1049.95,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,72485020101,NDC,1,EA,1049.95,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,72485020101,NDC,1,EA,1049.95,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,72485020101,NDC,1,EA,1049.95,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,72485020101,NDC,1,EA,1049.95,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azaTHIOprine 50 MG Tablet 1 Each Blister,J7500.01,CDM,636,RC,J7500,HCPCS,,,,68084022911,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azaTHIOprine 50 MG Tablet 1 Each Blister,J7500.01,CDM,636,RC,J7500,HCPCS,,,,68084022911,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azaTHIOprine 50 MG Tablet 1 Each Blister,J7500.01,CDM,636,RC,J7500,HCPCS,,,,68084022911,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azaTHIOprine 50 MG Tablet 1 Each Blister,J7500.01,CDM,636,RC,J7500,HCPCS,,,,68084022911,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azaTHIOprine 50 MG Tablet 1 Each Blister,J7500.01,CDM,636,RC,J7500,HCPCS,,,,68084022911,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azaTHIOprine 50 MG Tablet 1 Each Blister,J7500.01,CDM,636,RC,J7500,HCPCS,,,,68084022911,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 200 MG/5ML Recon Susp 15 mL Bottle,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,59762312001,NDC,15,ML,196.35,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 200 MG/5ML Recon Susp 15 mL Bottle,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,59762312001,NDC,15,ML,196.35,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 200 MG/5ML Recon Susp 15 mL Bottle,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,59762312001,NDC,15,ML,196.35,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 200 MG/5ML Recon Susp 15 mL Bottle,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,59762312001,NDC,15,ML,196.35,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 200 MG/5ML Recon Susp 15 mL Bottle,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,59762312001,NDC,15,ML,196.35,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 200 MG/5ML Recon Susp 15 mL Bottle,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,59762312001,NDC,15,ML,196.35,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 250 MG Tablet 6 Each Box,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096104,NDC,1,EA,41.72,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 250 MG Tablet 6 Each Box,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096104,NDC,1,EA,41.72,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 250 MG Tablet 6 Each Box,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096104,NDC,1,EA,41.72,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 250 MG Tablet 6 Each Box,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096104,NDC,1,EA,41.72,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 250 MG Tablet 6 Each Box,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096104,NDC,1,EA,41.72,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 250 MG Tablet 6 Each Box,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096104,NDC,1,EA,41.72,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,50111078751,NDC,1,EA,41.79,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,50111078751,NDC,1,EA,41.79,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,50111078751,NDC,1,EA,41.79,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,50111078751,NDC,1,EA,41.79,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,50111078751,NDC,1,EA,41.79,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,50111078751,NDC,1,EA,41.79,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096105,NDC,1,EA,41.73,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096105,NDC,1,EA,41.73,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096105,NDC,1,EA,41.73,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096105,NDC,1,EA,41.73,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096105,NDC,1,EA,41.73,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096105,NDC,1,EA,41.73,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039801,NDC,1,EA,67.88,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039801,NDC,1,EA,67.88,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039801,NDC,1,EA,67.88,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039801,NDC,1,EA,67.88,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039801,NDC,1,EA,67.88,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039801,NDC,1,EA,67.88,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039810,NDC,1,EA,67.88,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039810,NDC,1,EA,67.88,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039810,NDC,1,EA,67.88,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039810,NDC,1,EA,67.88,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039810,NDC,1,EA,67.88,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039810,NDC,1,EA,67.88,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039814,NDC,1,EA,39.84,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039814,NDC,1,EA,39.84,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039814,NDC,1,EA,39.84,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039814,NDC,1,EA,39.84,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039814,NDC,1,EA,39.84,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039814,NDC,1,EA,39.84,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039841,NDC,1,EA,43.14,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039841,NDC,1,EA,43.14,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039841,NDC,1,EA,43.14,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039841,NDC,1,EA,43.14,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039841,NDC,1,EA,43.14,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039841,NDC,1,EA,43.14,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086000,NDC,1,EA,58.66,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086000,NDC,1,EA,58.66,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086000,NDC,1,EA,58.66,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086000,NDC,1,EA,58.66,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086000,NDC,1,EA,58.66,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086000,NDC,1,EA,58.66,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086050,NDC,1,EA,58.66,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086050,NDC,1,EA,58.66,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086050,NDC,1,EA,58.66,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086050,NDC,1,EA,58.66,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086050,NDC,1,EA,58.66,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086050,NDC,1,EA,58.66,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aztreonam 1 g Recon Soln 1 Each Vial,J0457.01,CDM,636,RC,J0457,HCPCS,,,,63323040124,NDC,1,EA,176.32,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aztreonam 1 g Recon Soln 1 Each Vial,J0457.01,CDM,636,RC,J0457,HCPCS,,,,63323040124,NDC,1,EA,176.32,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aztreonam 1 g Recon Soln 1 Each Vial,J0457.01,CDM,636,RC,J0457,HCPCS,,,,63323040124,NDC,1,EA,176.32,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aztreonam 1 g Recon Soln 1 Each Vial,J0457.01,CDM,636,RC,J0457,HCPCS,,,,63323040124,NDC,1,EA,176.32,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aztreonam 1 g Recon Soln 1 Each Vial,J0457.01,CDM,636,RC,J0457,HCPCS,,,,63323040124,NDC,1,EA,176.32,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aztreonam 1 g Recon Soln 1 Each Vial,J0457.01,CDM,636,RC,J0457,HCPCS,,,,63323040124,NDC,1,EA,176.32,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"B Cells, Total Count",PX86355,CDM,300,RC,86355,CPT,,,,,,,,56,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"B Cells, Total Count",PX86355,CDM,300,RC,86355,CPT,,,,,,,,56,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"B Cells, Total Count",PX86355,CDM,300,RC,86355,CPT,,,,,,,,56,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"B Cells, Total Count",PX86355,CDM,300,RC,86355,CPT,,,,,,,,56,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"B Cells, Total Count",PX86355,CDM,300,RC,86355,CPT,,,,,,,,56,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"B Cells, Total Count",PX86355,CDM,300,RC,86355,CPT,,,,,,,,56,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
B-Scan Global,PX7651201,CDM,402,RC,76512,CPT,TC,,,,,,,127,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
B-Scan Global,PX7651201,CDM,402,RC,76512,CPT,TC,,,,,,,127,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
B-Scan Global,PX7651201,CDM,402,RC,76512,CPT,TC,,,,,,,127,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
B-Scan Global,PX7651201,CDM,402,RC,76512,CPT,TC,,,,,,,127,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
B-Scan Global,PX7651201,CDM,402,RC,76512,CPT,TC,,,,,,,127,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
B-Scan Global,PX7651201,CDM,402,RC,76512,CPT,TC,,,,,,,127,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"B.Burgdorferi, Amp Probe - Ref",PX8747690,CDM,300,RC,87476,CPT,90,,,,,,,72,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"B.Burgdorferi, Amp Probe - Ref",PX8747690,CDM,300,RC,87476,CPT,90,,,,,,,72,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"B.Burgdorferi, Amp Probe - Ref",PX8747690,CDM,300,RC,87476,CPT,90,,,,,,,72,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"B.Burgdorferi, Amp Probe - Ref",PX8747690,CDM,300,RC,87476,CPT,90,,,,,,,72,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"B.Burgdorferi, Amp Probe - Ref",PX8747690,CDM,300,RC,87476,CPT,90,,,,,,,72,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"B.Burgdorferi, Amp Probe - Ref",PX8747690,CDM,300,RC,87476,CPT,90,,,,,,,72,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bacitracin zinc 500 UNIT/GM Ointment 28.4 g Tube,25000000,CDM,250,RC,,,,,,49348015472,NDC,28.4,GR,20.47,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bacitracin zinc 500 UNIT/GM Ointment 28.4 g Tube,25000000,CDM,250,RC,,,,,,49348015472,NDC,28.4,GR,20.47,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bacitracin zinc 500 UNIT/GM Ointment 28.4 g Tube,25000000,CDM,250,RC,,,,,,49348015472,NDC,28.4,GR,20.47,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bacitracin zinc 500 UNIT/GM Ointment 28.4 g Tube,25000000,CDM,250,RC,,,,,,49348015472,NDC,28.4,GR,20.47,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bacitracin zinc 500 UNIT/GM Ointment 28.4 g Tube,25000000,CDM,250,RC,,,,,,49348015472,NDC,28.4,GR,20.47,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bacitracin zinc 500 UNIT/GM Ointment 28.4 g Tube,25000000,CDM,250,RC,,,,,,49348015472,NDC,28.4,GR,20.47,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bacitracin zinc 500 UNIT/GM Ointment 28.35 g Tube,25000000,CDM,250,RC,,,,,,168001131,NDC,28.35,GR,32.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bacitracin zinc 500 UNIT/GM Ointment 28.35 g Tube,25000000,CDM,250,RC,,,,,,168001131,NDC,28.35,GR,32.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bacitracin zinc 500 UNIT/GM Ointment 28.35 g Tube,25000000,CDM,250,RC,,,,,,168001131,NDC,28.35,GR,32.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bacitracin zinc 500 UNIT/GM Ointment 28.35 g Tube,25000000,CDM,250,RC,,,,,,168001131,NDC,28.35,GR,32.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bacitracin zinc 500 UNIT/GM Ointment 28.35 g Tube,25000000,CDM,250,RC,,,,,,168001131,NDC,28.35,GR,32.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bacitracin zinc 500 UNIT/GM Ointment 28.35 g Tube,25000000,CDM,250,RC,,,,,,168001131,NDC,28.35,GR,32.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
baclofen 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904647561,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
baclofen 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904647561,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
baclofen 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904647561,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
baclofen 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904647561,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
baclofen 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904647561,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
baclofen 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904647561,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
baclofen 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739047910,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
baclofen 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739047910,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
baclofen 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739047910,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
baclofen 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739047910,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
baclofen 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739047910,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
baclofen 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739047910,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bacteriostatic water(benz alc) Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409397703,NDC,30,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bacteriostatic water(benz alc) Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409397703,NDC,30,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bacteriostatic water(benz alc) Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409397703,NDC,30,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bacteriostatic water(benz alc) Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409397703,NDC,30,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bacteriostatic water(benz alc) Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409397703,NDC,30,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bacteriostatic water(benz alc) Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409397703,NDC,30,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Bacterium Nos, Antibody - Ref",PX8660990,CDM,300,RC,86609,CPT,90,,,,,,,20,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Bacterium Nos, Antibody - Ref",PX8660990,CDM,300,RC,86609,CPT,90,,,,,,,20,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Bacterium Nos, Antibody - Ref",PX8660990,CDM,300,RC,86609,CPT,90,,,,,,,20,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Bacterium Nos, Antibody - Ref",PX8660990,CDM,300,RC,86609,CPT,90,,,,,,,20,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Bacterium Nos, Antibody - Ref",PX8660990,CDM,300,RC,86609,CPT,90,,,,,,,20,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Bacterium Nos, Antibody - Ref",PX8660990,CDM,300,RC,86609,CPT,90,,,,,,,20,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BAG LEG URINARY STND 32OZ,120.33,CDM,272,RC,A5112,HCPCS,,4433-MAIN,LOCAL,,,,,121,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BAG LEG URINARY STND 32OZ,120.33,CDM,272,RC,A5112,HCPCS,,4433-MAIN,LOCAL,,,,,121,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BAG LEG URINARY STND 32OZ,120.33,CDM,272,RC,A5112,HCPCS,,4433-MAIN,LOCAL,,,,,121,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BAG LEG URINARY STND 32OZ,120.33,CDM,272,RC,A5112,HCPCS,,4433-MAIN,LOCAL,,,,,121,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BAG LEG URINARY STND 32OZ,120.33,CDM,272,RC,A5112,HCPCS,,4433-MAIN,LOCAL,,,,,121,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BAG LEG URINARY STND 32OZ,120.33,CDM,272,RC,A5112,HCPCS,,4433-MAIN,LOCAL,,,,,121,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BAG URINARY DRAINAGE 2000ML 6300,120.33,CDM,274,RC,A4357,HCPCS,,1283-MAIN,LOCAL,,,,,121,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BAG URINARY DRAINAGE 2000ML 6300,120.33,CDM,274,RC,A4357,HCPCS,,1283-MAIN,LOCAL,,,,,121,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BAG URINARY DRAINAGE 2000ML 6300,120.33,CDM,274,RC,A4357,HCPCS,,1283-MAIN,LOCAL,,,,,121,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BAG URINARY DRAINAGE 2000ML 6300,120.33,CDM,274,RC,A4357,HCPCS,,1283-MAIN,LOCAL,,,,,121,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BAG URINARY DRAINAGE 2000ML 6300,120.33,CDM,274,RC,A4357,HCPCS,,1283-MAIN,LOCAL,,,,,121,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BAG URINARY DRAINAGE 2000ML 6300,120.33,CDM,274,RC,A4357,HCPCS,,1283-MAIN,LOCAL,,,,,121,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BAG URINARY DRAINAGE DYND15405H,120.33,CDM,271,RC,A4357,HCPCS,,9112-MAIN,LOCAL,,,,,12,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BAG URINARY DRAINAGE DYND15405H,120.33,CDM,271,RC,A4357,HCPCS,,9112-MAIN,LOCAL,,,,,12,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BAG URINARY DRAINAGE DYND15405H,120.33,CDM,271,RC,A4357,HCPCS,,9112-MAIN,LOCAL,,,,,12,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BAG URINARY DRAINAGE DYND15405H,120.33,CDM,271,RC,A4357,HCPCS,,9112-MAIN,LOCAL,,,,,12,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BAG URINARY DRAINAGE DYND15405H,120.33,CDM,271,RC,A4357,HCPCS,,9112-MAIN,LOCAL,,,,,12,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BAG URINARY DRAINAGE DYND15405H,120.33,CDM,271,RC,A4357,HCPCS,,9112-MAIN,LOCAL,,,,,12,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BAG URINARY LEG PACK 9349,120.33,CDM,272,RC,A5112,HCPCS,,623-MAIN,LOCAL,,,,,121,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BAG URINARY LEG PACK 9349,120.33,CDM,272,RC,A5112,HCPCS,,623-MAIN,LOCAL,,,,,121,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BAG URINARY LEG PACK 9349,120.33,CDM,272,RC,A5112,HCPCS,,623-MAIN,LOCAL,,,,,121,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BAG URINARY LEG PACK 9349,120.33,CDM,272,RC,A5112,HCPCS,,623-MAIN,LOCAL,,,,,121,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BAG URINARY LEG PACK 9349,120.33,CDM,272,RC,A5112,HCPCS,,623-MAIN,LOCAL,,,,,121,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BAG URINARY LEG PACK 9349,120.33,CDM,272,RC,A5112,HCPCS,,623-MAIN,LOCAL,,,,,121,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BALLOON EXTRACTOR PEDS,120.358,CDM,272,RC,,,,10771-MAIN,LOCAL,,,,,73,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BALLOON EXTRACTOR PEDS,120.358,CDM,272,RC,,,,10771-MAIN,LOCAL,,,,,73,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BALLOON EXTRACTOR PEDS,120.358,CDM,272,RC,,,,10771-MAIN,LOCAL,,,,,73,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BALLOON EXTRACTOR PEDS,120.358,CDM,272,RC,,,,10771-MAIN,LOCAL,,,,,73,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BALLOON EXTRACTOR PEDS,120.358,CDM,272,RC,,,,10771-MAIN,LOCAL,,,,,73,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BALLOON EXTRACTOR PEDS,120.358,CDM,272,RC,,,,10771-MAIN,LOCAL,,,,,73,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Baloxavir Marboxil(40 MG Dose) 2 x 20 MG tablet therapy pack 2 Each Box,800000,CDM,,,,,,,,50242082802,NDC,1,EA,384.3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Baloxavir Marboxil(40 MG Dose) 2 x 20 MG tablet therapy pack 2 Each Box,800000,CDM,,,,,,,,50242082802,NDC,1,EA,384.3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Baloxavir Marboxil(40 MG Dose) 2 x 20 MG tablet therapy pack 2 Each Box,800000,CDM,,,,,,,,50242082802,NDC,1,EA,384.3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Baloxavir Marboxil(40 MG Dose) 2 x 20 MG tablet therapy pack 2 Each Box,800000,CDM,,,,,,,,50242082802,NDC,1,EA,384.3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Baloxavir Marboxil(40 MG Dose) 2 x 20 MG tablet therapy pack 2 Each Box,800000,CDM,,,,,,,,50242082802,NDC,1,EA,384.3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Baloxavir Marboxil(40 MG Dose) 2 x 20 MG tablet therapy pack 2 Each Box,800000,CDM,,,,,,,,50242082802,NDC,1,EA,384.3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
balsalazide 750 MG capsule 280 Each Bottle,63700001,CDM,250,RC,,,,,,54007928,NDC,1,EA,8.59,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
balsalazide 750 MG capsule 280 Each Bottle,63700001,CDM,250,RC,,,,,,54007928,NDC,1,EA,8.59,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
balsalazide 750 MG capsule 280 Each Bottle,63700001,CDM,250,RC,,,,,,54007928,NDC,1,EA,8.59,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
balsalazide 750 MG capsule 280 Each Bottle,63700001,CDM,250,RC,,,,,,54007928,NDC,1,EA,8.59,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
balsalazide 750 MG capsule 280 Each Bottle,63700001,CDM,250,RC,,,,,,54007928,NDC,1,EA,8.59,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
balsalazide 750 MG capsule 280 Each Bottle,63700001,CDM,250,RC,,,,,,54007928,NDC,1,EA,8.59,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
balsalazide 750 MG capsule 280 Each Bottle,63700001,CDM,250,RC,,,,,,60505257507,NDC,1,EA,8.59,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
balsalazide 750 MG capsule 280 Each Bottle,63700001,CDM,250,RC,,,,,,60505257507,NDC,1,EA,8.59,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
balsalazide 750 MG capsule 280 Each Bottle,63700001,CDM,250,RC,,,,,,60505257507,NDC,1,EA,8.59,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
balsalazide 750 MG capsule 280 Each Bottle,63700001,CDM,250,RC,,,,,,60505257507,NDC,1,EA,8.59,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
balsalazide 750 MG capsule 280 Each Bottle,63700001,CDM,250,RC,,,,,,60505257507,NDC,1,EA,8.59,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
balsalazide 750 MG capsule 280 Each Bottle,63700001,CDM,250,RC,,,,,,60505257507,NDC,1,EA,8.59,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BANDAGE COBAN  4 IN 2 LAYER COMPRESSION SYSTEM  2094N,120.549,CDM,272,RC,A6441,HCPCS,,12366-MAIN,LOCAL,,,,,32,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BANDAGE COBAN  4 IN 2 LAYER COMPRESSION SYSTEM  2094N,120.549,CDM,272,RC,A6441,HCPCS,,12366-MAIN,LOCAL,,,,,32,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BANDAGE COBAN  4 IN 2 LAYER COMPRESSION SYSTEM  2094N,120.549,CDM,272,RC,A6441,HCPCS,,12366-MAIN,LOCAL,,,,,32,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BANDAGE COBAN  4 IN 2 LAYER COMPRESSION SYSTEM  2094N,120.549,CDM,272,RC,A6441,HCPCS,,12366-MAIN,LOCAL,,,,,32,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BANDAGE COBAN  4 IN 2 LAYER COMPRESSION SYSTEM  2094N,120.549,CDM,272,RC,A6441,HCPCS,,12366-MAIN,LOCAL,,,,,32,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BANDAGE COBAN  4 IN 2 LAYER COMPRESSION SYSTEM  2094N,120.549,CDM,272,RC,A6441,HCPCS,,12366-MAIN,LOCAL,,,,,32,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BANDAGE COBAN LITE 4 IN 2 LAYER COMPRESSION SYSTEM 2794N,120.549,CDM,272,RC,A6441,HCPCS,,12922-MAIN,LOCAL,,,,,32,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BANDAGE COBAN LITE 4 IN 2 LAYER COMPRESSION SYSTEM 2794N,120.549,CDM,272,RC,A6441,HCPCS,,12922-MAIN,LOCAL,,,,,32,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BANDAGE COBAN LITE 4 IN 2 LAYER COMPRESSION SYSTEM 2794N,120.549,CDM,272,RC,A6441,HCPCS,,12922-MAIN,LOCAL,,,,,32,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BANDAGE COBAN LITE 4 IN 2 LAYER COMPRESSION SYSTEM 2794N,120.549,CDM,272,RC,A6441,HCPCS,,12922-MAIN,LOCAL,,,,,32,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BANDAGE COBAN LITE 4 IN 2 LAYER COMPRESSION SYSTEM 2794N,120.549,CDM,272,RC,A6441,HCPCS,,12922-MAIN,LOCAL,,,,,32,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BANDAGE COBAN LITE 4 IN 2 LAYER COMPRESSION SYSTEM 2794N,120.549,CDM,272,RC,A6441,HCPCS,,12922-MAIN,LOCAL,,,,,32,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BANDAGE ESMARK 4X9 LATEX FREE DYNJ05916,27200000,CDM,272,RC,,,,5428-MAIN,LOCAL,,,,,7.05,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BANDAGE ESMARK 4X9 LATEX FREE DYNJ05916,27200000,CDM,272,RC,,,,5428-MAIN,LOCAL,,,,,7.05,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BANDAGE ESMARK 4X9 LATEX FREE DYNJ05916,27200000,CDM,272,RC,,,,5428-MAIN,LOCAL,,,,,7.05,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BANDAGE ESMARK 4X9 LATEX FREE DYNJ05916,27200000,CDM,272,RC,,,,5428-MAIN,LOCAL,,,,,7.05,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BANDAGE ESMARK 4X9 LATEX FREE DYNJ05916,27200000,CDM,272,RC,,,,5428-MAIN,LOCAL,,,,,7.05,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BANDAGE ESMARK 4X9 LATEX FREE DYNJ05916,27200000,CDM,272,RC,,,,5428-MAIN,LOCAL,,,,,7.05,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BANDAGE STERILE  2"" TETRA-FLEX CLIP FREE 0151-2SV",27200000,CDM,272,RC,A6449,HCPCS,,10660-MAIN,LOCAL,,,,,5.02,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BANDAGE STERILE  2"" TETRA-FLEX CLIP FREE 0151-2SV",27200000,CDM,272,RC,A6449,HCPCS,,10660-MAIN,LOCAL,,,,,5.02,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BANDAGE STERILE  2"" TETRA-FLEX CLIP FREE 0151-2SV",27200000,CDM,272,RC,A6449,HCPCS,,10660-MAIN,LOCAL,,,,,5.02,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BANDAGE STERILE  2"" TETRA-FLEX CLIP FREE 0151-2SV",27200000,CDM,272,RC,A6449,HCPCS,,10660-MAIN,LOCAL,,,,,5.02,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BANDAGE STERILE  2"" TETRA-FLEX CLIP FREE 0151-2SV",27200000,CDM,272,RC,A6449,HCPCS,,10660-MAIN,LOCAL,,,,,5.02,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BANDAGE STERILE  2"" TETRA-FLEX CLIP FREE 0151-2SV",27200000,CDM,272,RC,A6449,HCPCS,,10660-MAIN,LOCAL,,,,,5.02,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BANDAGE STERILE 3"" TETRA-FLEX CLIP FREE 0151-3SV",27200000,CDM,272,RC,A6449,HCPCS,,10661-MAIN,LOCAL,,,,,5.93,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BANDAGE STERILE 3"" TETRA-FLEX CLIP FREE 0151-3SV",27200000,CDM,272,RC,A6449,HCPCS,,10661-MAIN,LOCAL,,,,,5.93,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BANDAGE STERILE 3"" TETRA-FLEX CLIP FREE 0151-3SV",27200000,CDM,272,RC,A6449,HCPCS,,10661-MAIN,LOCAL,,,,,5.93,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BANDAGE STERILE 3"" TETRA-FLEX CLIP FREE 0151-3SV",27200000,CDM,272,RC,A6449,HCPCS,,10661-MAIN,LOCAL,,,,,5.93,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BANDAGE STERILE 3"" TETRA-FLEX CLIP FREE 0151-3SV",27200000,CDM,272,RC,A6449,HCPCS,,10661-MAIN,LOCAL,,,,,5.93,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BANDAGE STERILE 3"" TETRA-FLEX CLIP FREE 0151-3SV",27200000,CDM,272,RC,A6449,HCPCS,,10661-MAIN,LOCAL,,,,,5.93,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BANDAGE STERILE 4"" TETRA-FLEX CLIP FREE  0151-4SV",27200000,CDM,272,RC,A6449,HCPCS,,10662-MAIN,LOCAL,,,,,6.7,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BANDAGE STERILE 4"" TETRA-FLEX CLIP FREE  0151-4SV",27200000,CDM,272,RC,A6449,HCPCS,,10662-MAIN,LOCAL,,,,,6.7,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BANDAGE STERILE 4"" TETRA-FLEX CLIP FREE  0151-4SV",27200000,CDM,272,RC,A6449,HCPCS,,10662-MAIN,LOCAL,,,,,6.7,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BANDAGE STERILE 4"" TETRA-FLEX CLIP FREE  0151-4SV",27200000,CDM,272,RC,A6449,HCPCS,,10662-MAIN,LOCAL,,,,,6.7,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BANDAGE STERILE 4"" TETRA-FLEX CLIP FREE  0151-4SV",27200000,CDM,272,RC,A6449,HCPCS,,10662-MAIN,LOCAL,,,,,6.7,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BANDAGE STERILE 4"" TETRA-FLEX CLIP FREE  0151-4SV",27200000,CDM,272,RC,A6449,HCPCS,,10662-MAIN,LOCAL,,,,,6.7,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
baricitinib 2 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,2418230,NDC,0.5,EA,203.12,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
baricitinib 2 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,2418230,NDC,0.5,EA,203.12,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
baricitinib 2 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,2418230,NDC,0.5,EA,203.12,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
baricitinib 2 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,2418230,NDC,0.5,EA,203.12,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
baricitinib 2 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,2418230,NDC,0.5,EA,203.12,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
baricitinib 2 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,2418230,NDC,0.5,EA,203.12,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Basic Metabolic Panel Ca Ion,PX80047,CDM,300,RC,80047,CPT,,,,,,,,17,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Basic Metabolic Panel Ca Ion,PX80047,CDM,300,RC,80047,CPT,,,,,,,,17,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Basic Metabolic Panel Ca Ion,PX80047,CDM,300,RC,80047,CPT,,,,,,,,17,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Basic Metabolic Panel Ca Ion,PX80047,CDM,300,RC,80047,CPT,,,,,,,,17,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Basic Metabolic Panel Ca Ion,PX80047,CDM,300,RC,80047,CPT,,,,,,,,17,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Basic Metabolic Panel Ca Ion,PX80047,CDM,300,RC,80047,CPT,,,,,,,,17,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bcr/Abl1 Minor - Ref,PX8120790,CDM,310,RC,81207,CPT,90,,,,,,,1113,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bcr/Abl1 Minor - Ref,PX8120790,CDM,310,RC,81207,CPT,90,,,,,,,1113,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bcr/Abl1 Minor - Ref,PX8120790,CDM,310,RC,81207,CPT,90,,,,,,,1113,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bcr/Abl1 Minor - Ref,PX8120790,CDM,310,RC,81207,CPT,90,,,,,,,1113,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bcr/Abl1 Minor - Ref,PX8120790,CDM,310,RC,81207,CPT,90,,,,,,,1113,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bcr/Abl1 Minor - Ref,PX8120790,CDM,310,RC,81207,CPT,90,,,,,,,1113,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bcr/Abl1 Other - Ref,PX8120890,CDM,310,RC,81208,CPT,90,,,,,,,1125,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bcr/Abl1 Other - Ref,PX8120890,CDM,310,RC,81208,CPT,90,,,,,,,1125,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bcr/Abl1 Other - Ref,PX8120890,CDM,310,RC,81208,CPT,90,,,,,,,1125,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bcr/Abl1 Other - Ref,PX8120890,CDM,310,RC,81208,CPT,90,,,,,,,1125,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bcr/Abl1 Other - Ref,PX8120890,CDM,310,RC,81208,CPT,90,,,,,,,1125,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bcr/Abl1 Other - Ref,PX8120890,CDM,310,RC,81208,CPT,90,,,,,,,1125,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bcr/Abl1 P210 - Ref,PX8120690,CDM,310,RC,81206,CPT,90,,,,,,,1144,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bcr/Abl1 P210 - Ref,PX8120690,CDM,310,RC,81206,CPT,90,,,,,,,1144,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bcr/Abl1 P210 - Ref,PX8120690,CDM,310,RC,81206,CPT,90,,,,,,,1144,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bcr/Abl1 P210 - Ref,PX8120690,CDM,310,RC,81206,CPT,90,,,,,,,1144,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bcr/Abl1 P210 - Ref,PX8120690,CDM,310,RC,81206,CPT,90,,,,,,,1144,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bcr/Abl1 P210 - Ref,PX8120690,CDM,310,RC,81206,CPT,90,,,,,,,1144,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
beclomethasone  HFA 80 MCG/ACT Aerosol Breath Activated 10.6 g Inhaler,63700001,CDM,250,RC,,,,,,59310030480,NDC,10.6,GR,1164.84,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
beclomethasone  HFA 80 MCG/ACT Aerosol Breath Activated 10.6 g Inhaler,63700001,CDM,250,RC,,,,,,59310030480,NDC,10.6,GR,1164.84,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
beclomethasone  HFA 80 MCG/ACT Aerosol Breath Activated 10.6 g Inhaler,63700001,CDM,250,RC,,,,,,59310030480,NDC,10.6,GR,1164.84,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
beclomethasone  HFA 80 MCG/ACT Aerosol Breath Activated 10.6 g Inhaler,63700001,CDM,250,RC,,,,,,59310030480,NDC,10.6,GR,1164.84,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
beclomethasone  HFA 80 MCG/ACT Aerosol Breath Activated 10.6 g Inhaler,63700001,CDM,250,RC,,,,,,59310030480,NDC,10.6,GR,1164.84,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
beclomethasone  HFA 80 MCG/ACT Aerosol Breath Activated 10.6 g Inhaler,63700001,CDM,250,RC,,,,,,59310030480,NDC,10.6,GR,1164.84,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
belimumab (400v) 400 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010201,NDC,1,EA,3523.71,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
belimumab (400v) 400 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010201,NDC,1,EA,3523.71,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
belimumab (400v) 400 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010201,NDC,1,EA,3523.71,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
belimumab (400v) 400 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010201,NDC,1,EA,3523.71,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
belimumab (400v) 400 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010201,NDC,1,EA,3523.71,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
belimumab (400v) 400 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010201,NDC,1,EA,3523.71,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
belimumab 120 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010101,NDC,1,EA,1015.95,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
belimumab 120 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010101,NDC,1,EA,1015.95,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
belimumab 120 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010101,NDC,1,EA,1015.95,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
belimumab 120 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010101,NDC,1,EA,1015.95,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
belimumab 120 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010101,NDC,1,EA,1015.95,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
belimumab 120 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010101,NDC,1,EA,1015.95,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benazepril 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268011011,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benazepril 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268011011,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benazepril 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268011011,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benazepril 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268011011,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benazepril 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268011011,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benazepril 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268011011,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benazepril 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268011015,NDC,1,EA,5.06,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benazepril 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268011015,NDC,1,EA,5.06,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benazepril 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268011015,NDC,1,EA,5.06,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benazepril 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268011015,NDC,1,EA,5.06,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benazepril 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268011015,NDC,1,EA,5.06,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benazepril 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268011015,NDC,1,EA,5.06,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benazepril 40 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547033810,NDC,0.125,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benazepril 40 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547033810,NDC,0.125,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benazepril 40 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547033810,NDC,0.125,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benazepril 40 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547033810,NDC,0.125,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benazepril 40 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547033810,NDC,0.125,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benazepril 40 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547033810,NDC,0.125,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benazepril 40 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862011801,NDC,1,EA,5.64,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benazepril 40 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862011801,NDC,1,EA,5.64,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benazepril 40 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862011801,NDC,1,EA,5.64,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benazepril 40 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862011801,NDC,1,EA,5.64,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benazepril 40 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862011801,NDC,1,EA,5.64,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benazepril 40 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862011801,NDC,1,EA,5.64,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bendamustine 100 MG/4ML Solution 4 mL Vial,800000,CDM,,,J9034,HCPCS,,,,63459034804,NDC,4,ML,5046.55,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bendamustine 100 MG/4ML Solution 4 mL Vial,800000,CDM,,,J9034,HCPCS,,,,63459034804,NDC,4,ML,5046.55,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bendamustine 100 MG/4ML Solution 4 mL Vial,800000,CDM,,,J9034,HCPCS,,,,63459034804,NDC,4,ML,5046.55,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bendamustine 100 MG/4ML Solution 4 mL Vial,800000,CDM,,,J9034,HCPCS,,,,63459034804,NDC,4,ML,5046.55,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bendamustine 100 MG/4ML Solution 4 mL Vial,800000,CDM,,,J9034,HCPCS,,,,63459034804,NDC,4,ML,5046.55,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bendamustine 100 MG/4ML Solution 4 mL Vial,800000,CDM,,,J9034,HCPCS,,,,63459034804,NDC,4,ML,5046.55,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benzocaine-menthol 20-0.5 % Aerosol 56 g Can,63700001,CDM,250,RC,,,,,,16864068002,NDC,56,GR,33.3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benzocaine-menthol 20-0.5 % Aerosol 56 g Can,63700001,CDM,250,RC,,,,,,16864068002,NDC,56,GR,33.3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benzocaine-menthol 20-0.5 % Aerosol 56 g Can,63700001,CDM,250,RC,,,,,,16864068002,NDC,56,GR,33.3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benzocaine-menthol 20-0.5 % Aerosol 56 g Can,63700001,CDM,250,RC,,,,,,16864068002,NDC,56,GR,33.3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benzocaine-menthol 20-0.5 % Aerosol 56 g Can,63700001,CDM,250,RC,,,,,,16864068002,NDC,56,GR,33.3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benzocaine-menthol 20-0.5 % Aerosol 56 g Can,63700001,CDM,250,RC,,,,,,16864068002,NDC,56,GR,33.3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benzocaine-menthol 20-0.5 % Aerosol 78 g Can,63700001,CDM,250,RC,,,,,,75137085520,NDC,78,GR,35.38,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benzocaine-menthol 20-0.5 % Aerosol 78 g Can,63700001,CDM,250,RC,,,,,,75137085520,NDC,78,GR,35.38,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benzocaine-menthol 20-0.5 % Aerosol 78 g Can,63700001,CDM,250,RC,,,,,,75137085520,NDC,78,GR,35.38,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benzocaine-menthol 20-0.5 % Aerosol 78 g Can,63700001,CDM,250,RC,,,,,,75137085520,NDC,78,GR,35.38,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benzocaine-menthol 20-0.5 % Aerosol 78 g Can,63700001,CDM,250,RC,,,,,,75137085520,NDC,78,GR,35.38,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benzocaine-menthol 20-0.5 % Aerosol 78 g Can,63700001,CDM,250,RC,,,,,,75137085520,NDC,78,GR,35.38,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benzoin Tincture 59 mL Bottle,25000000,CDM,250,RC,,,,,,49348080130,NDC,59,ML,45.93,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benzoin Tincture 59 mL Bottle,25000000,CDM,250,RC,,,,,,49348080130,NDC,59,ML,45.93,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benzoin Tincture 59 mL Bottle,25000000,CDM,250,RC,,,,,,49348080130,NDC,59,ML,45.93,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benzoin Tincture 59 mL Bottle,25000000,CDM,250,RC,,,,,,49348080130,NDC,59,ML,45.93,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benzoin Tincture 59 mL Bottle,25000000,CDM,250,RC,,,,,,49348080130,NDC,59,ML,45.93,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benzoin Tincture 59 mL Bottle,25000000,CDM,250,RC,,,,,,49348080130,NDC,59,ML,45.93,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benzonatate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687034611,NDC,1,EA,3.91,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benzonatate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687034611,NDC,1,EA,3.91,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benzonatate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687034611,NDC,1,EA,3.91,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benzonatate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687034611,NDC,1,EA,3.91,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benzonatate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687034611,NDC,1,EA,3.91,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benzonatate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687034611,NDC,1,EA,3.91,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benzonatate 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877010501,NDC,1,EA,13.44,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benzonatate 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877010501,NDC,1,EA,13.44,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benzonatate 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877010501,NDC,1,EA,13.44,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benzonatate 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877010501,NDC,1,EA,13.44,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benzonatate 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877010501,NDC,1,EA,13.44,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benzonatate 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877010501,NDC,1,EA,13.44,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benzonatate 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904715361,NDC,1,EA,3.18,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benzonatate 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904715361,NDC,1,EA,3.18,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benzonatate 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904715361,NDC,1,EA,3.18,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benzonatate 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904715361,NDC,1,EA,3.18,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benzonatate 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904715361,NDC,1,EA,3.18,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benzonatate 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904715361,NDC,1,EA,3.18,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Beta 2 Glycoprot 1 Ab,Ea - Ref",PX8614690,CDM,300,RC,86146,CPT,90,,,,,,,52,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Beta 2 Glycoprot 1 Ab,Ea - Ref",PX8614690,CDM,300,RC,86146,CPT,90,,,,,,,52,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Beta 2 Glycoprot 1 Ab,Ea - Ref",PX8614690,CDM,300,RC,86146,CPT,90,,,,,,,52,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Beta 2 Glycoprot 1 Ab,Ea - Ref",PX8614690,CDM,300,RC,86146,CPT,90,,,,,,,52,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Beta 2 Glycoprot 1 Ab,Ea - Ref",PX8614690,CDM,300,RC,86146,CPT,90,,,,,,,52,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Beta 2 Glycoprot 1 Ab,Ea - Ref",PX8614690,CDM,300,RC,86146,CPT,90,,,,,,,52,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Beta-2-Microglobulin - Ref,PX8223290,CDM,300,RC,82232,CPT,90,,,,,,,49,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Beta-2-Microglobulin - Ref,PX8223290,CDM,300,RC,82232,CPT,90,,,,,,,49,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Beta-2-Microglobulin - Ref,PX8223290,CDM,300,RC,82232,CPT,90,,,,,,,49,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Beta-2-Microglobulin - Ref,PX8223290,CDM,300,RC,82232,CPT,90,,,,,,,49,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Beta-2-Microglobulin - Ref,PX8223290,CDM,300,RC,82232,CPT,90,,,,,,,49,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Beta-2-Microglobulin - Ref,PX8223290,CDM,300,RC,82232,CPT,90,,,,,,,49,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
betamethasone acetate-betamethasone sodium phosphate 6 (3-3) MG/ML Suspension 5 mL Vial,J0702.01,CDM,636,RC,J0702,HCPCS,,,,517072001,NDC,1,ML,78.96,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
betamethasone acetate-betamethasone sodium phosphate 6 (3-3) MG/ML Suspension 5 mL Vial,J0702.01,CDM,636,RC,J0702,HCPCS,,,,517072001,NDC,1,ML,78.96,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
betamethasone acetate-betamethasone sodium phosphate 6 (3-3) MG/ML Suspension 5 mL Vial,J0702.01,CDM,636,RC,J0702,HCPCS,,,,517072001,NDC,1,ML,78.96,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
betamethasone acetate-betamethasone sodium phosphate 6 (3-3) MG/ML Suspension 5 mL Vial,J0702.01,CDM,636,RC,J0702,HCPCS,,,,517072001,NDC,1,ML,78.96,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
betamethasone acetate-betamethasone sodium phosphate 6 (3-3) MG/ML Suspension 5 mL Vial,J0702.01,CDM,636,RC,J0702,HCPCS,,,,517072001,NDC,1,ML,78.96,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
betamethasone acetate-betamethasone sodium phosphate 6 (3-3) MG/ML Suspension 5 mL Vial,J0702.01,CDM,636,RC,J0702,HCPCS,,,,517072001,NDC,1,ML,78.96,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bezlotoxumab 1000 MG/40ML Solution 40 mL Vial,J0565.01,CDM,636,RC,J0565,HCPCS,,,,6302500,NDC,40,ML,7752,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bezlotoxumab 1000 MG/40ML Solution 40 mL Vial,J0565.01,CDM,636,RC,J0565,HCPCS,,,,6302500,NDC,40,ML,7752,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bezlotoxumab 1000 MG/40ML Solution 40 mL Vial,J0565.01,CDM,636,RC,J0565,HCPCS,,,,6302500,NDC,40,ML,7752,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bezlotoxumab 1000 MG/40ML Solution 40 mL Vial,J0565.01,CDM,636,RC,J0565,HCPCS,,,,6302500,NDC,40,ML,7752,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bezlotoxumab 1000 MG/40ML Solution 40 mL Vial,J0565.01,CDM,636,RC,J0565,HCPCS,,,,6302500,NDC,40,ML,7752,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bezlotoxumab 1000 MG/40ML Solution 40 mL Vial,J0565.01,CDM,636,RC,J0565,HCPCS,,,,6302500,NDC,40,ML,7752,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bicalutamide 50 MG Tablet 30 Each Bottle,25000000,CDM,250,RC,,,,,,16714081601,NDC,1,EA,98.01,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bicalutamide 50 MG Tablet 30 Each Bottle,25000000,CDM,250,RC,,,,,,16714081601,NDC,1,EA,98.01,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bicalutamide 50 MG Tablet 30 Each Bottle,25000000,CDM,250,RC,,,,,,16714081601,NDC,1,EA,98.01,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bicalutamide 50 MG Tablet 30 Each Bottle,25000000,CDM,250,RC,,,,,,16714081601,NDC,1,EA,98.01,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bicalutamide 50 MG Tablet 30 Each Bottle,25000000,CDM,250,RC,,,,,,16714081601,NDC,1,EA,98.01,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bicalutamide 50 MG Tablet 30 Each Bottle,25000000,CDM,250,RC,,,,,,16714081601,NDC,1,EA,98.01,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bile Acids Total,PX8223990,CDM,300,RC,82239,CPT,90,,,,,,,232,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bile Acids Total,PX8223990,CDM,300,RC,82239,CPT,90,,,,,,,232,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bile Acids Total,PX8223990,CDM,300,RC,82239,CPT,90,,,,,,,232,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bile Acids Total,PX8223990,CDM,300,RC,82239,CPT,90,,,,,,,232,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bile Acids Total,PX8223990,CDM,300,RC,82239,CPT,90,,,,,,,232,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bile Acids Total,PX8223990,CDM,300,RC,82239,CPT,90,,,,,,,232,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bilirubin Direct,PX82248,CDM,300,RC,82248,CPT,,,,,,,,150,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bilirubin Direct,PX82248,CDM,300,RC,82248,CPT,,,,,,,,150,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bilirubin Direct,PX82248,CDM,300,RC,82248,CPT,,,,,,,,150,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bilirubin Direct,PX82248,CDM,300,RC,82248,CPT,,,,,,,,150,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bilirubin Direct,PX82248,CDM,300,RC,82248,CPT,,,,,,,,150,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bilirubin Direct,PX82248,CDM,300,RC,82248,CPT,,,,,,,,150,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bilirubin Total,PX82247,CDM,300,RC,82247,CPT,,,,,,,,150,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bilirubin Total,PX82247,CDM,300,RC,82247,CPT,,,,,,,,150,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bilirubin Total,PX82247,CDM,300,RC,82247,CPT,,,,,,,,150,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bilirubin Total,PX82247,CDM,300,RC,82247,CPT,,,,,,,,150,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bilirubin Total,PX82247,CDM,300,RC,82247,CPT,,,,,,,,150,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bilirubin Total,PX82247,CDM,300,RC,82247,CPT,,,,,,,,150,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BINDER ABDOMINAL 9 INCH 46 TO 62 INCH XL ORT21100LXL,120.238,CDM,271,RC,A4467,HCPCS,,2989-MAIN,LOCAL,,,,,75,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BINDER ABDOMINAL 9 INCH 46 TO 62 INCH XL ORT21100LXL,120.238,CDM,271,RC,A4467,HCPCS,,2989-MAIN,LOCAL,,,,,75,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BINDER ABDOMINAL 9 INCH 46 TO 62 INCH XL ORT21100LXL,120.238,CDM,271,RC,A4467,HCPCS,,2989-MAIN,LOCAL,,,,,75,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BINDER ABDOMINAL 9 INCH 46 TO 62 INCH XL ORT21100LXL,120.238,CDM,271,RC,A4467,HCPCS,,2989-MAIN,LOCAL,,,,,75,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BINDER ABDOMINAL 9 INCH 46 TO 62 INCH XL ORT21100LXL,120.238,CDM,271,RC,A4467,HCPCS,,2989-MAIN,LOCAL,,,,,75,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BINDER ABDOMINAL 9 INCH 46 TO 62 INCH XL ORT21100LXL,120.238,CDM,271,RC,A4467,HCPCS,,2989-MAIN,LOCAL,,,,,75,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BINDER ABDOMINAL 9 INCH 63 TO 74 INCH 3- PANEL ORT211002XL,120.238,CDM,271,RC,A4467,HCPCS,,37-MAIN,LOCAL,,,,,75,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BINDER ABDOMINAL 9 INCH 63 TO 74 INCH 3- PANEL ORT211002XL,120.238,CDM,271,RC,A4467,HCPCS,,37-MAIN,LOCAL,,,,,75,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BINDER ABDOMINAL 9 INCH 63 TO 74 INCH 3- PANEL ORT211002XL,120.238,CDM,271,RC,A4467,HCPCS,,37-MAIN,LOCAL,,,,,75,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BINDER ABDOMINAL 9 INCH 63 TO 74 INCH 3- PANEL ORT211002XL,120.238,CDM,271,RC,A4467,HCPCS,,37-MAIN,LOCAL,,,,,75,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BINDER ABDOMINAL 9 INCH 63 TO 74 INCH 3- PANEL ORT211002XL,120.238,CDM,271,RC,A4467,HCPCS,,37-MAIN,LOCAL,,,,,75,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BINDER ABDOMINAL 9 INCH 63 TO 74 INCH 3- PANEL ORT211002XL,120.238,CDM,271,RC,A4467,HCPCS,,37-MAIN,LOCAL,,,,,75,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BINDER ABDOMINAL 10 INCH 26 TO 50 INCHES ABB1050,120.238,CDM,271,RC,A4467,HCPCS,,52-MAIN,LOCAL,,,,,75,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BINDER ABDOMINAL 10 INCH 26 TO 50 INCHES ABB1050,120.238,CDM,271,RC,A4467,HCPCS,,52-MAIN,LOCAL,,,,,75,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BINDER ABDOMINAL 10 INCH 26 TO 50 INCHES ABB1050,120.238,CDM,271,RC,A4467,HCPCS,,52-MAIN,LOCAL,,,,,75,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BINDER ABDOMINAL 10 INCH 26 TO 50 INCHES ABB1050,120.238,CDM,271,RC,A4467,HCPCS,,52-MAIN,LOCAL,,,,,75,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BINDER ABDOMINAL 10 INCH 26 TO 50 INCHES ABB1050,120.238,CDM,271,RC,A4467,HCPCS,,52-MAIN,LOCAL,,,,,75,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BINDER ABDOMINAL 10 INCH 26 TO 50 INCHES ABB1050,120.238,CDM,271,RC,A4467,HCPCS,,52-MAIN,LOCAL,,,,,75,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BINDER ABDOMINAL 12"" HIGH 2XL 60-75INCH 4 PANEL ORT213002XL",120.238,CDM,271,RC,A4467,HCPCS,,12536-MAIN,LOCAL,,,,,75,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BINDER ABDOMINAL 12"" HIGH 2XL 60-75INCH 4 PANEL ORT213002XL",120.238,CDM,271,RC,A4467,HCPCS,,12536-MAIN,LOCAL,,,,,75,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BINDER ABDOMINAL 12"" HIGH 2XL 60-75INCH 4 PANEL ORT213002XL",120.238,CDM,271,RC,A4467,HCPCS,,12536-MAIN,LOCAL,,,,,75,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BINDER ABDOMINAL 12"" HIGH 2XL 60-75INCH 4 PANEL ORT213002XL",120.238,CDM,271,RC,A4467,HCPCS,,12536-MAIN,LOCAL,,,,,75,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BINDER ABDOMINAL 12"" HIGH 2XL 60-75INCH 4 PANEL ORT213002XL",120.238,CDM,271,RC,A4467,HCPCS,,12536-MAIN,LOCAL,,,,,75,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BINDER ABDOMINAL 12"" HIGH 2XL 60-75INCH 4 PANEL ORT213002XL",120.238,CDM,271,RC,A4467,HCPCS,,12536-MAIN,LOCAL,,,,,75,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BINDER ABDOMINAL 12"" HIGH 30-45INCH 4 PANEL ORT21300SM",120.238,CDM,271,RC,A4467,HCPCS,,11934-MAIN,LOCAL,,,,,16,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BINDER ABDOMINAL 12"" HIGH 30-45INCH 4 PANEL ORT21300SM",120.238,CDM,271,RC,A4467,HCPCS,,11934-MAIN,LOCAL,,,,,16,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BINDER ABDOMINAL 12"" HIGH 30-45INCH 4 PANEL ORT21300SM",120.238,CDM,271,RC,A4467,HCPCS,,11934-MAIN,LOCAL,,,,,16,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BINDER ABDOMINAL 12"" HIGH 30-45INCH 4 PANEL ORT21300SM",120.238,CDM,271,RC,A4467,HCPCS,,11934-MAIN,LOCAL,,,,,16,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BINDER ABDOMINAL 12"" HIGH 30-45INCH 4 PANEL ORT21300SM",120.238,CDM,271,RC,A4467,HCPCS,,11934-MAIN,LOCAL,,,,,16,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BINDER ABDOMINAL 12"" HIGH 30-45INCH 4 PANEL ORT21300SM",120.238,CDM,271,RC,A4467,HCPCS,,11934-MAIN,LOCAL,,,,,16,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BINDER ABDOMINAL 12"" HIGH 46 TO 62 INCH L/XL 4 PANEL ORT21300LXL",120.238,CDM,271,RC,A4467,HCPCS,,11935-MAIN,LOCAL,,,,,18,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BINDER ABDOMINAL 12"" HIGH 46 TO 62 INCH L/XL 4 PANEL ORT21300LXL",120.238,CDM,271,RC,A4467,HCPCS,,11935-MAIN,LOCAL,,,,,18,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BINDER ABDOMINAL 12"" HIGH 46 TO 62 INCH L/XL 4 PANEL ORT21300LXL",120.238,CDM,271,RC,A4467,HCPCS,,11935-MAIN,LOCAL,,,,,18,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BINDER ABDOMINAL 12"" HIGH 46 TO 62 INCH L/XL 4 PANEL ORT21300LXL",120.238,CDM,271,RC,A4467,HCPCS,,11935-MAIN,LOCAL,,,,,18,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BINDER ABDOMINAL 12"" HIGH 46 TO 62 INCH L/XL 4 PANEL ORT21300LXL",120.238,CDM,271,RC,A4467,HCPCS,,11935-MAIN,LOCAL,,,,,18,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BINDER ABDOMINAL 12"" HIGH 46 TO 62 INCH L/XL 4 PANEL ORT21300LXL",120.238,CDM,271,RC,A4467,HCPCS,,11935-MAIN,LOCAL,,,,,18,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BINDER ABDOMINAL S/M 9 INCH UP TO 45 INCHES TRI-PANNEL ABB3P45,120.238,CDM,271,RC,A4467,HCPCS,,47-MAIN,LOCAL,,,,,34,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BINDER ABDOMINAL S/M 9 INCH UP TO 45 INCHES TRI-PANNEL ABB3P45,120.238,CDM,271,RC,A4467,HCPCS,,47-MAIN,LOCAL,,,,,34,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BINDER ABDOMINAL S/M 9 INCH UP TO 45 INCHES TRI-PANNEL ABB3P45,120.238,CDM,271,RC,A4467,HCPCS,,47-MAIN,LOCAL,,,,,34,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BINDER ABDOMINAL S/M 9 INCH UP TO 45 INCHES TRI-PANNEL ABB3P45,120.238,CDM,271,RC,A4467,HCPCS,,47-MAIN,LOCAL,,,,,34,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BINDER ABDOMINAL S/M 9 INCH UP TO 45 INCHES TRI-PANNEL ABB3P45,120.238,CDM,271,RC,A4467,HCPCS,,47-MAIN,LOCAL,,,,,34,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BINDER ABDOMINAL S/M 9 INCH UP TO 45 INCHES TRI-PANNEL ABB3P45,120.238,CDM,271,RC,A4467,HCPCS,,47-MAIN,LOCAL,,,,,34,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BINDER ABDOMINAL UNISIZE 46-62IN 9 IN MDS169024,120.238,CDM,271,RC,A4467,HCPCS,,63-MAIN,LOCAL,,,,,75,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BINDER ABDOMINAL UNISIZE 46-62IN 9 IN MDS169024,120.238,CDM,271,RC,A4467,HCPCS,,63-MAIN,LOCAL,,,,,75,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BINDER ABDOMINAL UNISIZE 46-62IN 9 IN MDS169024,120.238,CDM,271,RC,A4467,HCPCS,,63-MAIN,LOCAL,,,,,75,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BINDER ABDOMINAL UNISIZE 46-62IN 9 IN MDS169024,120.238,CDM,271,RC,A4467,HCPCS,,63-MAIN,LOCAL,,,,,75,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BINDER ABDOMINAL UNISIZE 46-62IN 9 IN MDS169024,120.238,CDM,271,RC,A4467,HCPCS,,63-MAIN,LOCAL,,,,,75,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BINDER ABDOMINAL UNISIZE 46-62IN 9 IN MDS169024,120.238,CDM,271,RC,A4467,HCPCS,,63-MAIN,LOCAL,,,,,75,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BINDER PELVIC ADULT STABILIZATION T-PODR,120.357,CDM,271,RC,A4467,HCPCS,,10734-MAIN,LOCAL,,,,,244,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BINDER PELVIC ADULT STABILIZATION T-PODR,120.357,CDM,271,RC,A4467,HCPCS,,10734-MAIN,LOCAL,,,,,244,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BINDER PELVIC ADULT STABILIZATION T-PODR,120.357,CDM,271,RC,A4467,HCPCS,,10734-MAIN,LOCAL,,,,,244,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BINDER PELVIC ADULT STABILIZATION T-PODR,120.357,CDM,271,RC,A4467,HCPCS,,10734-MAIN,LOCAL,,,,,244,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BINDER PELVIC ADULT STABILIZATION T-PODR,120.357,CDM,271,RC,A4467,HCPCS,,10734-MAIN,LOCAL,,,,,244,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BINDER PELVIC ADULT STABILIZATION T-PODR,120.357,CDM,271,RC,A4467,HCPCS,,10734-MAIN,LOCAL,,,,,244,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BIOPSY FORCEPS HOT,27200000,CDM,272,RC,,,,4353-MAIN,LOCAL,,,,,38.25,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BIOPSY FORCEPS HOT,27200000,CDM,272,RC,,,,4353-MAIN,LOCAL,,,,,38.25,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BIOPSY FORCEPS HOT,27200000,CDM,272,RC,,,,4353-MAIN,LOCAL,,,,,38.25,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BIOPSY FORCEPS HOT,27200000,CDM,272,RC,,,,4353-MAIN,LOCAL,,,,,38.25,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BIOPSY FORCEPS HOT,27200000,CDM,272,RC,,,,4353-MAIN,LOCAL,,,,,38.25,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BIOPSY FORCEPS HOT,27200000,CDM,272,RC,,,,4353-MAIN,LOCAL,,,,,38.25,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Biopsy of Prostate,Needle/Punch",PX55700F,CDM,510,RC,55700,CPT,,,,,,,,2039,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Biopsy of Prostate,Needle/Punch",PX55700F,CDM,510,RC,55700,CPT,,,,,,,,2039,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Biopsy of Prostate,Needle/Punch",PX55700F,CDM,510,RC,55700,CPT,,,,,,,,2039,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Biopsy of Prostate,Needle/Punch",PX55700F,CDM,510,RC,55700,CPT,,,,,,,,2039,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Biopsy of Prostate,Needle/Punch",PX55700F,CDM,510,RC,55700,CPT,,,,,,,,2039,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Biopsy of Prostate,Needle/Punch",PX55700F,CDM,510,RC,55700,CPT,,,,,,,,2039,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Biopsy of Rectum,PX45100F,CDM,510,RC,45100,CPT,,,,,,,,763,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Biopsy of Rectum,PX45100F,CDM,510,RC,45100,CPT,,,,,,,,763,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Biopsy of Rectum,PX45100F,CDM,510,RC,45100,CPT,,,,,,,,763,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Biopsy of Rectum,PX45100F,CDM,510,RC,45100,CPT,,,,,,,,763,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Biopsy of Rectum,PX45100F,CDM,510,RC,45100,CPT,,,,,,,,763,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Biopsy of Rectum,PX45100F,CDM,510,RC,45100,CPT,,,,,,,,763,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Biopsy of Rectum,PX45100P,CDM,983,RC,45100,CPT,,,,,,,,509,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Biopsy of Rectum,PX45100P,CDM,983,RC,45100,CPT,,,,,,,,509,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Biopsy of Rectum,PX45100P,CDM,983,RC,45100,CPT,,,,,,,,509,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Biopsy of Rectum,PX45100P,CDM,983,RC,45100,CPT,,,,,,,,509,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Biopsy of Rectum,PX45100P,CDM,983,RC,45100,CPT,,,,,,,,509,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Biopsy of Rectum,PX45100P,CDM,983,RC,45100,CPT,,,,,,,,509,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Biopsy Synovium I-P Jt,PX26110,CDM,983,RC,26110,CPT,,,,,,,,933,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Biopsy Synovium I-P Jt,PX26110,CDM,983,RC,26110,CPT,,,,,,,,933,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Biopsy Synovium I-P Jt,PX26110,CDM,983,RC,26110,CPT,,,,,,,,933,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Biopsy Synovium I-P Jt,PX26110,CDM,983,RC,26110,CPT,,,,,,,,933,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Biopsy Synovium I-P Jt,PX26110,CDM,983,RC,26110,CPT,,,,,,,,933,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Biopsy Synovium I-P Jt,PX26110,CDM,983,RC,26110,CPT,,,,,,,,933,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Biopsy Vulva/Perineum,One Lesn",PX56605F,CDM,510,RC,56605,CPT,,,,,,,,236,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Biopsy Vulva/Perineum,One Lesn",PX56605F,CDM,510,RC,56605,CPT,,,,,,,,236,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Biopsy Vulva/Perineum,One Lesn",PX56605F,CDM,510,RC,56605,CPT,,,,,,,,236,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Biopsy Vulva/Perineum,One Lesn",PX56605F,CDM,510,RC,56605,CPT,,,,,,,,236,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Biopsy Vulva/Perineum,One Lesn",PX56605F,CDM,510,RC,56605,CPT,,,,,,,,236,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Biopsy Vulva/Perineum,One Lesn",PX56605F,CDM,510,RC,56605,CPT,,,,,,,,236,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Biopsy Vulva/Perineum,One Lesn",PX56605P,CDM,983,RC,56605,CPT,,,,,,,,142,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Biopsy Vulva/Perineum,One Lesn",PX56605P,CDM,983,RC,56605,CPT,,,,,,,,142,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Biopsy Vulva/Perineum,One Lesn",PX56605P,CDM,983,RC,56605,CPT,,,,,,,,142,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Biopsy Vulva/Perineum,One Lesn",PX56605P,CDM,983,RC,56605,CPT,,,,,,,,142,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Biopsy Vulva/Perineum,One Lesn",PX56605P,CDM,983,RC,56605,CPT,,,,,,,,142,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Biopsy Vulva/Perineum,One Lesn",PX56605P,CDM,983,RC,56605,CPT,,,,,,,,142,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Biopsy, Nail Unit",PX11755F,CDM,510,RC,11755,CPT,,,,,,,,1490,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Biopsy, Nail Unit",PX11755F,CDM,510,RC,11755,CPT,,,,,,,,1490,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Biopsy, Nail Unit",PX11755F,CDM,510,RC,11755,CPT,,,,,,,,1490,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Biopsy, Nail Unit",PX11755F,CDM,510,RC,11755,CPT,,,,,,,,1490,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Biopsy, Nail Unit",PX11755F,CDM,510,RC,11755,CPT,,,,,,,,1490,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Biopsy, Nail Unit",PX11755F,CDM,510,RC,11755,CPT,,,,,,,,1490,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Biotene Dry Mouth Liquid 473 mL Bottle,63700001,CDM,250,RC,,,,,,48582000330,NDC,5,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Biotene Dry Mouth Liquid 473 mL Bottle,63700001,CDM,250,RC,,,,,,48582000330,NDC,5,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Biotene Dry Mouth Liquid 473 mL Bottle,63700001,CDM,250,RC,,,,,,48582000330,NDC,5,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Biotene Dry Mouth Liquid 473 mL Bottle,63700001,CDM,250,RC,,,,,,48582000330,NDC,5,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Biotene Dry Mouth Liquid 473 mL Bottle,63700001,CDM,250,RC,,,,,,48582000330,NDC,5,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Biotene Dry Mouth Liquid 473 mL Bottle,63700001,CDM,250,RC,,,,,,48582000330,NDC,5,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bisacodyl 10 MG Suppository 1 Each Box,63700001,CDM,250,RC,,,,,,713010906,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bisacodyl 10 MG Suppository 1 Each Box,63700001,CDM,250,RC,,,,,,713010906,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bisacodyl 10 MG Suppository 1 Each Box,63700001,CDM,250,RC,,,,,,713010906,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bisacodyl 10 MG Suppository 1 Each Box,63700001,CDM,250,RC,,,,,,713010906,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bisacodyl 10 MG Suppository 1 Each Box,63700001,CDM,250,RC,,,,,,713010906,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bisacodyl 10 MG Suppository 1 Each Box,63700001,CDM,250,RC,,,,,,713010906,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574705012,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574705012,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574705012,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574705012,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574705012,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574705012,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713010912,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713010912,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713010912,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713010912,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713010912,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713010912,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,904505812,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,904505812,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,904505812,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,904505812,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,904505812,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,904505812,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bisacodyl EC 5 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,904640761,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bisacodyl EC 5 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,904640761,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bisacodyl EC 5 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,904640761,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bisacodyl EC 5 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,904640761,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bisacodyl EC 5 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,904640761,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bisacodyl EC 5 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,904640761,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bismuth subsalicylate 262 MG Tablet Chewable 30 Each Box,63700001,CDM,250,RC,,,,,,904720546,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bismuth subsalicylate 262 MG Tablet Chewable 30 Each Box,63700001,CDM,250,RC,,,,,,904720546,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bismuth subsalicylate 262 MG Tablet Chewable 30 Each Box,63700001,CDM,250,RC,,,,,,904720546,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bismuth subsalicylate 262 MG Tablet Chewable 30 Each Box,63700001,CDM,250,RC,,,,,,904720546,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bismuth subsalicylate 262 MG Tablet Chewable 30 Each Box,63700001,CDM,250,RC,,,,,,904720546,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bismuth subsalicylate 262 MG Tablet Chewable 30 Each Box,63700001,CDM,250,RC,,,,,,904720546,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bisoprolol 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714052901,NDC,1,EA,12.1,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bisoprolol 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714052901,NDC,1,EA,12.1,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bisoprolol 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714052901,NDC,1,EA,12.1,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bisoprolol 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714052901,NDC,1,EA,12.1,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bisoprolol 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714052901,NDC,1,EA,12.1,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bisoprolol 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714052901,NDC,1,EA,12.1,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bisoprolol-hydroCHLOROthiazide 5-6.25 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,42799092102,NDC,1,EA,39.57,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bisoprolol-hydroCHLOROthiazide 5-6.25 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,42799092102,NDC,1,EA,39.57,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bisoprolol-hydroCHLOROthiazide 5-6.25 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,42799092102,NDC,1,EA,39.57,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bisoprolol-hydroCHLOROthiazide 5-6.25 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,42799092102,NDC,1,EA,39.57,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bisoprolol-hydroCHLOROthiazide 5-6.25 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,42799092102,NDC,1,EA,39.57,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bisoprolol-hydroCHLOROthiazide 5-6.25 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,42799092102,NDC,1,EA,39.57,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BITE BLOCK MAXI 20MM 60FR,27200000,CDM,272,RC,,,,8144-MAIN,LOCAL,,,,,11.32,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BITE BLOCK MAXI 20MM 60FR,27200000,CDM,272,RC,,,,8144-MAIN,LOCAL,,,,,11.32,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BITE BLOCK MAXI 20MM 60FR,27200000,CDM,272,RC,,,,8144-MAIN,LOCAL,,,,,11.32,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BITE BLOCK MAXI 20MM 60FR,27200000,CDM,272,RC,,,,8144-MAIN,LOCAL,,,,,11.32,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BITE BLOCK MAXI 20MM 60FR,27200000,CDM,272,RC,,,,8144-MAIN,LOCAL,,,,,11.32,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BITE BLOCK MAXI 20MM 60FR,27200000,CDM,272,RC,,,,8144-MAIN,LOCAL,,,,,11.32,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BLADE LARYNGOSCOPE MAC #3 SINGLE USE350-005-000,120.121,CDM,272,RC,,,,8320-MAIN,LOCAL,,,,,98,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BLADE LARYNGOSCOPE MAC #3 SINGLE USE350-005-000,120.121,CDM,272,RC,,,,8320-MAIN,LOCAL,,,,,98,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BLADE LARYNGOSCOPE MAC #3 SINGLE USE350-005-000,120.121,CDM,272,RC,,,,8320-MAIN,LOCAL,,,,,98,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BLADE LARYNGOSCOPE MAC #3 SINGLE USE350-005-000,120.121,CDM,272,RC,,,,8320-MAIN,LOCAL,,,,,98,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BLADE LARYNGOSCOPE MAC #3 SINGLE USE350-005-000,120.121,CDM,272,RC,,,,8320-MAIN,LOCAL,,,,,98,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BLADE LARYNGOSCOPE MAC #3 SINGLE USE350-005-000,120.121,CDM,272,RC,,,,8320-MAIN,LOCAL,,,,,98,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BLADE LARYNGOSCOPE MAC #4 SINGLE USE 350-012-000,120.121,CDM,272,RC,,,,8321-MAIN,LOCAL,,,,,98,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BLADE LARYNGOSCOPE MAC #4 SINGLE USE 350-012-000,120.121,CDM,272,RC,,,,8321-MAIN,LOCAL,,,,,98,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BLADE LARYNGOSCOPE MAC #4 SINGLE USE 350-012-000,120.121,CDM,272,RC,,,,8321-MAIN,LOCAL,,,,,98,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BLADE LARYNGOSCOPE MAC #4 SINGLE USE 350-012-000,120.121,CDM,272,RC,,,,8321-MAIN,LOCAL,,,,,98,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BLADE LARYNGOSCOPE MAC #4 SINGLE USE 350-012-000,120.121,CDM,272,RC,,,,8321-MAIN,LOCAL,,,,,98,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BLADE LARYNGOSCOPE MAC #4 SINGLE USE 350-012-000,120.121,CDM,272,RC,,,,8321-MAIN,LOCAL,,,,,98,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BLADE LARYNGOSCOPE MAC #X3 SINGLE USE X3-003-000,120.121,CDM,272,RC,,,,8322-MAIN,LOCAL,,,,,98,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BLADE LARYNGOSCOPE MAC #X3 SINGLE USE X3-003-000,120.121,CDM,272,RC,,,,8322-MAIN,LOCAL,,,,,98,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BLADE LARYNGOSCOPE MAC #X3 SINGLE USE X3-003-000,120.121,CDM,272,RC,,,,8322-MAIN,LOCAL,,,,,98,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BLADE LARYNGOSCOPE MAC #X3 SINGLE USE X3-003-000,120.121,CDM,272,RC,,,,8322-MAIN,LOCAL,,,,,98,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BLADE LARYNGOSCOPE MAC #X3 SINGLE USE X3-003-000,120.121,CDM,272,RC,,,,8322-MAIN,LOCAL,,,,,98,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BLADE LARYNGOSCOPE MAC #X3 SINGLE USE X3-003-000,120.121,CDM,272,RC,,,,8322-MAIN,LOCAL,,,,,98,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blastomyces Antibody - Ref,PX8661290,CDM,300,RC,86612,CPT,90,,,,,,,97,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blastomyces Antibody - Ref,PX8661290,CDM,300,RC,86612,CPT,90,,,,,,,97,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blastomyces Antibody - Ref,PX8661290,CDM,300,RC,86612,CPT,90,,,,,,,97,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blastomyces Antibody - Ref,PX8661290,CDM,300,RC,86612,CPT,90,,,,,,,97,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blastomyces Antibody - Ref,PX8661290,CDM,300,RC,86612,CPT,90,,,,,,,97,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blastomyces Antibody - Ref,PX8661290,CDM,300,RC,86612,CPT,90,,,,,,,97,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Clot Factor V Test,PX85220,CDM,300,RC,85220,CPT,,,,,,,,260,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Clot Factor V Test,PX85220,CDM,300,RC,85220,CPT,,,,,,,,260,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Clot Factor V Test,PX85220,CDM,300,RC,85220,CPT,,,,,,,,260,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Clot Factor V Test,PX85220,CDM,300,RC,85220,CPT,,,,,,,,260,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Clot Factor V Test,PX85220,CDM,300,RC,85220,CPT,,,,,,,,260,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Clot Factor V Test,PX85220,CDM,300,RC,85220,CPT,,,,,,,,260,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Clot Factor VIII Test,PX85247,CDM,300,RC,85247,CPT,,,,,,,,169,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Clot Factor VIII Test,PX85247,CDM,300,RC,85247,CPT,,,,,,,,169,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Clot Factor VIII Test,PX85247,CDM,300,RC,85247,CPT,,,,,,,,169,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Clot Factor VIII Test,PX85247,CDM,300,RC,85247,CPT,,,,,,,,169,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Clot Factor VIII Test,PX85247,CDM,300,RC,85247,CPT,,,,,,,,169,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Clot Factor VIII Test,PX85247,CDM,300,RC,85247,CPT,,,,,,,,169,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Count Reticulocytes Auto 1/> Cell Meas,PX85046,CDM,300,RC,85046,CPT,,,,,,,,47,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Count Reticulocytes Auto 1/> Cell Meas,PX85046,CDM,300,RC,85046,CPT,,,,,,,,47,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Count Reticulocytes Auto 1/> Cell Meas,PX85046,CDM,300,RC,85046,CPT,,,,,,,,47,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Count Reticulocytes Auto 1/> Cell Meas,PX85046,CDM,300,RC,85046,CPT,,,,,,,,47,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Count Reticulocytes Auto 1/> Cell Meas,PX85046,CDM,300,RC,85046,CPT,,,,,,,,47,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Count Reticulocytes Auto 1/> Cell Meas,PX85046,CDM,300,RC,85046,CPT,,,,,,,,47,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Culture for Bacteria,PX87040,CDM,300,RC,87040,CPT,,,,,,,,286,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Culture for Bacteria,PX87040,CDM,300,RC,87040,CPT,,,,,,,,286,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Culture for Bacteria,PX87040,CDM,300,RC,87040,CPT,,,,,,,,286,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Culture for Bacteria,PX87040,CDM,300,RC,87040,CPT,,,,,,,,286,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Culture for Bacteria,PX87040,CDM,300,RC,87040,CPT,,,,,,,,286,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Culture for Bacteria,PX87040,CDM,300,RC,87040,CPT,,,,,,,,286,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Blood Gases: Ph, Po2 & Pco2",PX82803,CDM,300,RC,82803,CPT,,,,,,,,518,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Blood Gases: Ph, Po2 & Pco2",PX82803,CDM,300,RC,82803,CPT,,,,,,,,518,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Blood Gases: Ph, Po2 & Pco2",PX82803,CDM,300,RC,82803,CPT,,,,,,,,518,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Blood Gases: Ph, Po2 & Pco2",PX82803,CDM,300,RC,82803,CPT,,,,,,,,518,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Blood Gases: Ph, Po2 & Pco2",PX82803,CDM,300,RC,82803,CPT,,,,,,,,518,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Blood Gases: Ph, Po2 & Pco2",PX82803,CDM,300,RC,82803,CPT,,,,,,,,518,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Occult Peroxidase,PX82272,CDM,300,RC,82272,CPT,,,,,,,,64,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Occult Peroxidase,PX82272,CDM,300,RC,82272,CPT,,,,,,,,64,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Occult Peroxidase,PX82272,CDM,300,RC,82272,CPT,,,,,,,,64,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Occult Peroxidase,PX82272,CDM,300,RC,82272,CPT,,,,,,,,64,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Occult Peroxidase,PX82272,CDM,300,RC,82272,CPT,,,,,,,,64,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Occult Peroxidase,PX82272,CDM,300,RC,82272,CPT,,,,,,,,64,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Transfusion Service,PX36430,CDM,391,RC,36430,CPT,,,,,,,,839,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Transfusion Service,PX36430,CDM,391,RC,36430,CPT,,,,,,,,839,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Transfusion Service,PX36430,CDM,391,RC,36430,CPT,,,,,,,,839,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Transfusion Service,PX36430,CDM,391,RC,36430,CPT,,,,,,,,839,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Transfusion Service,PX36430,CDM,391,RC,36430,CPT,,,,,,,,839,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Transfusion Service,PX36430,CDM,391,RC,36430,CPT,,,,,,,,839,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Type Antigen Donor Ea,PX86902,CDM,300,RC,86902,CPT,,,,,,,,43,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Type Antigen Donor Ea,PX86902,CDM,300,RC,86902,CPT,,,,,,,,43,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Type Antigen Donor Ea,PX86902,CDM,300,RC,86902,CPT,,,,,,,,43,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Type Antigen Donor Ea,PX86902,CDM,300,RC,86902,CPT,,,,,,,,43,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Type Antigen Donor Ea,PX86902,CDM,300,RC,86902,CPT,,,,,,,,43,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Type Antigen Donor Ea,PX86902,CDM,300,RC,86902,CPT,,,,,,,,43,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Typing Abo,PX86900,CDM,300,RC,86900,CPT,,,,,,,,92,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Typing Abo,PX86900,CDM,300,RC,86900,CPT,,,,,,,,92,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Typing Abo,PX86900,CDM,300,RC,86900,CPT,,,,,,,,92,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Typing Abo,PX86900,CDM,300,RC,86900,CPT,,,,,,,,92,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Typing Abo,PX86900,CDM,300,RC,86900,CPT,,,,,,,,92,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Typing Abo,PX86900,CDM,300,RC,86900,CPT,,,,,,,,92,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Typing Rh (D),PX86901,CDM,300,RC,86901,CPT,,,,,,,,92,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Typing Rh (D),PX86901,CDM,300,RC,86901,CPT,,,,,,,,92,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Typing Rh (D),PX86901,CDM,300,RC,86901,CPT,,,,,,,,92,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Typing Rh (D),PX86901,CDM,300,RC,86901,CPT,,,,,,,,92,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Typing Rh (D),PX86901,CDM,300,RC,86901,CPT,,,,,,,,92,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Typing Rh (D),PX86901,CDM,300,RC,86901,CPT,,,,,,,,92,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Blood Typing, Rh Phenotype",PX86906,CDM,300,RC,86906,CPT,,,,,,,,115,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Blood Typing, Rh Phenotype",PX86906,CDM,300,RC,86906,CPT,,,,,,,,115,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Blood Typing, Rh Phenotype",PX86906,CDM,300,RC,86906,CPT,,,,,,,,115,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Blood Typing, Rh Phenotype",PX86906,CDM,300,RC,86906,CPT,,,,,,,,115,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Blood Typing, Rh Phenotype",PX86906,CDM,300,RC,86906,CPT,,,,,,,,115,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Blood Typing, Rh Phenotype",PX86906,CDM,300,RC,86906,CPT,,,,,,,,115,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Viscosity Examination,PX85810,CDM,300,RC,85810,CPT,,,,,,,,95,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Viscosity Examination,PX85810,CDM,300,RC,85810,CPT,,,,,,,,95,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Viscosity Examination,PX85810,CDM,300,RC,85810,CPT,,,,,,,,95,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Viscosity Examination,PX85810,CDM,300,RC,85810,CPT,,,,,,,,95,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Viscosity Examination,PX85810,CDM,300,RC,85810,CPT,,,,,,,,95,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Viscosity Examination,PX85810,CDM,300,RC,85810,CPT,,,,,,,,95,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Blood, Occult, Other Sources",PX82271,CDM,300,RC,82271,CPT,,,,,,,,72,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Blood, Occult, Other Sources",PX82271,CDM,300,RC,82271,CPT,,,,,,,,72,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Blood, Occult, Other Sources",PX82271,CDM,300,RC,82271,CPT,,,,,,,,72,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Blood, Occult, Other Sources",PX82271,CDM,300,RC,82271,CPT,,,,,,,,72,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Blood, Occult, Other Sources",PX82271,CDM,300,RC,82271,CPT,,,,,,,,72,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Blood, Occult, Other Sources",PX82271,CDM,300,RC,82271,CPT,,,,,,,,72,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BLUE EYE SUBMUCOSAL LIFTING AGENT 5ML,27200000,CDM,272,RC,,,,12684-MAIN,LOCAL,,,,,148,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BLUE EYE SUBMUCOSAL LIFTING AGENT 5ML,27200000,CDM,272,RC,,,,12684-MAIN,LOCAL,,,,,148,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BLUE EYE SUBMUCOSAL LIFTING AGENT 5ML,27200000,CDM,272,RC,,,,12684-MAIN,LOCAL,,,,,148,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BLUE EYE SUBMUCOSAL LIFTING AGENT 5ML,27200000,CDM,272,RC,,,,12684-MAIN,LOCAL,,,,,148,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BLUE EYE SUBMUCOSAL LIFTING AGENT 5ML,27200000,CDM,272,RC,,,,12684-MAIN,LOCAL,,,,,148,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BLUE EYE SUBMUCOSAL LIFTING AGENT 5ML,27200000,CDM,272,RC,,,,12684-MAIN,LOCAL,,,,,148,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BMWD 2X2,27200000,CDM,272,RC,Q4104,HCPCS,,12134-MAIN,LOCAL,,,,,8016,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BMWD 2X2,27200000,CDM,272,RC,Q4104,HCPCS,,12134-MAIN,LOCAL,,,,,8016,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BMWD 2X2,27200000,CDM,272,RC,Q4104,HCPCS,,12134-MAIN,LOCAL,,,,,8016,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BMWD 2X2,27200000,CDM,272,RC,Q4104,HCPCS,,12134-MAIN,LOCAL,,,,,8016,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BMWD 2X2,27200000,CDM,272,RC,Q4104,HCPCS,,12134-MAIN,LOCAL,,,,,8016,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BMWD 2X2,27200000,CDM,272,RC,Q4104,HCPCS,,12134-MAIN,LOCAL,,,,,8016,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Body Fluid Cell Count,PX89050,CDM,300,RC,89050,CPT,,,,,,,,152,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Body Fluid Cell Count,PX89050,CDM,300,RC,89050,CPT,,,,,,,,152,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Body Fluid Cell Count,PX89050,CDM,300,RC,89050,CPT,,,,,,,,152,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Body Fluid Cell Count,PX89050,CDM,300,RC,89050,CPT,,,,,,,,152,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Body Fluid Cell Count,PX89050,CDM,300,RC,89050,CPT,,,,,,,,152,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Body Fluid Cell Count,PX89050,CDM,300,RC,89050,CPT,,,,,,,,152,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Body Fluid Cell Count W Diff,PX89051,CDM,300,RC,89051,CPT,,,,,,,,224,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Body Fluid Cell Count W Diff,PX89051,CDM,300,RC,89051,CPT,,,,,,,,224,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Body Fluid Cell Count W Diff,PX89051,CDM,300,RC,89051,CPT,,,,,,,,224,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Body Fluid Cell Count W Diff,PX89051,CDM,300,RC,89051,CPT,,,,,,,,224,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Body Fluid Cell Count W Diff,PX89051,CDM,300,RC,89051,CPT,,,,,,,,224,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Body Fluid Cell Count W Diff,PX89051,CDM,300,RC,89051,CPT,,,,,,,,224,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bone Age Studies Tc,PX7707201,CDM,320,RC,77072,CPT,TC,,,,,,,211,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bone Age Studies Tc,PX7707201,CDM,320,RC,77072,CPT,TC,,,,,,,211,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bone Age Studies Tc,PX7707201,CDM,320,RC,77072,CPT,TC,,,,,,,211,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bone Age Studies Tc,PX7707201,CDM,320,RC,77072,CPT,TC,,,,,,,211,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bone Age Studies Tc,PX7707201,CDM,320,RC,77072,CPT,TC,,,,,,,211,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bone Age Studies Tc,PX7707201,CDM,320,RC,77072,CPT,TC,,,,,,,211,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bone Marrow Aspiration and Biopsy,PXG0364F,CDM,510,RC,G0364,HCPCS,,,,,,,,411,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bone Marrow Aspiration and Biopsy,PXG0364F,CDM,510,RC,G0364,HCPCS,,,,,,,,411,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bone Marrow Aspiration and Biopsy,PXG0364F,CDM,510,RC,G0364,HCPCS,,,,,,,,411,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bone Marrow Aspiration and Biopsy,PXG0364F,CDM,510,RC,G0364,HCPCS,,,,,,,,411,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bone Marrow Aspiration and Biopsy,PXG0364F,CDM,510,RC,G0364,HCPCS,,,,,,,,411,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bone Marrow Aspiration and Biopsy,PXG0364F,CDM,510,RC,G0364,HCPCS,,,,,,,,411,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Bone Marrow Aspiration(S),Diag",PX38220F,CDM,510,RC,38220,CPT,,,,,,,,305,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Bone Marrow Aspiration(S),Diag",PX38220F,CDM,510,RC,38220,CPT,,,,,,,,305,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Bone Marrow Aspiration(S),Diag",PX38220F,CDM,510,RC,38220,CPT,,,,,,,,305,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Bone Marrow Aspiration(S),Diag",PX38220F,CDM,510,RC,38220,CPT,,,,,,,,305,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Bone Marrow Aspiration(S),Diag",PX38220F,CDM,510,RC,38220,CPT,,,,,,,,305,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Bone Marrow Aspiration(S),Diag",PX38220F,CDM,510,RC,38220,CPT,,,,,,,,305,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Bone Marrow Aspiration(S),Diag",PX38220P,CDM,983,RC,38220,CPT,,,,,,,,244,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Bone Marrow Aspiration(S),Diag",PX38220P,CDM,983,RC,38220,CPT,,,,,,,,244,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Bone Marrow Aspiration(S),Diag",PX38220P,CDM,983,RC,38220,CPT,,,,,,,,244,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Bone Marrow Aspiration(S),Diag",PX38220P,CDM,983,RC,38220,CPT,,,,,,,,244,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Bone Marrow Aspiration(S),Diag",PX38220P,CDM,983,RC,38220,CPT,,,,,,,,244,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Bone Marrow Aspiration(S),Diag",PX38220P,CDM,983,RC,38220,CPT,,,,,,,,244,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BONE MARROW BIOPSY ASPIRATION NEEDLE 11G X 4 IN,120.562,CDM,272,RC,C1830,HCPCS,,12677-MAIN,LOCAL,,,,,110,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BONE MARROW BIOPSY ASPIRATION NEEDLE 11G X 4 IN,120.562,CDM,272,RC,C1830,HCPCS,,12677-MAIN,LOCAL,,,,,110,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BONE MARROW BIOPSY ASPIRATION NEEDLE 11G X 4 IN,120.562,CDM,272,RC,C1830,HCPCS,,12677-MAIN,LOCAL,,,,,110,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BONE MARROW BIOPSY ASPIRATION NEEDLE 11G X 4 IN,120.562,CDM,272,RC,C1830,HCPCS,,12677-MAIN,LOCAL,,,,,110,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BONE MARROW BIOPSY ASPIRATION NEEDLE 11G X 4 IN,120.562,CDM,272,RC,C1830,HCPCS,,12677-MAIN,LOCAL,,,,,110,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BONE MARROW BIOPSY ASPIRATION NEEDLE 11G X 4 IN,120.562,CDM,272,RC,C1830,HCPCS,,12677-MAIN,LOCAL,,,,,110,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bone Marrow Biopsy(Ies),PX38221F,CDM,510,RC,38221,CPT,,,,,,,,1221,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bone Marrow Biopsy(Ies),PX38221F,CDM,510,RC,38221,CPT,,,,,,,,1221,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bone Marrow Biopsy(Ies),PX38221F,CDM,510,RC,38221,CPT,,,,,,,,1221,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bone Marrow Biopsy(Ies),PX38221F,CDM,510,RC,38221,CPT,,,,,,,,1221,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bone Marrow Biopsy(Ies),PX38221F,CDM,510,RC,38221,CPT,,,,,,,,1221,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bone Marrow Biopsy(Ies),PX38221F,CDM,510,RC,38221,CPT,,,,,,,,1221,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Bone Scan, Whole Body",PX7830601,CDM,341,RC,78306,CPT,TC,,,,,,,1896,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Bone Scan, Whole Body",PX7830601,CDM,341,RC,78306,CPT,TC,,,,,,,1896,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Bone Scan, Whole Body",PX7830601,CDM,341,RC,78306,CPT,TC,,,,,,,1896,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Bone Scan, Whole Body",PX7830601,CDM,341,RC,78306,CPT,TC,,,,,,,1896,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Bone Scan, Whole Body",PX7830601,CDM,341,RC,78306,CPT,TC,,,,,,,1896,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Bone Scan, Whole Body",PX7830601,CDM,341,RC,78306,CPT,TC,,,,,,,1896,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BONE SCREW T8 FULL THREAD 2.4MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12652-MAIN,LOCAL,,,,,289,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BONE SCREW T8 FULL THREAD 2.4MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12652-MAIN,LOCAL,,,,,289,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BONE SCREW T8 FULL THREAD 2.4MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12652-MAIN,LOCAL,,,,,289,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BONE SCREW T8 FULL THREAD 2.4MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12652-MAIN,LOCAL,,,,,289,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BONE SCREW T8 FULL THREAD 2.4MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12652-MAIN,LOCAL,,,,,289,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BONE SCREW T8 FULL THREAD 2.4MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12652-MAIN,LOCAL,,,,,289,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BONE SCREW T8 FULL THREAD 2.4MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12653-MAIN,LOCAL,,,,,289,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BONE SCREW T8 FULL THREAD 2.4MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12653-MAIN,LOCAL,,,,,289,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BONE SCREW T8 FULL THREAD 2.4MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12653-MAIN,LOCAL,,,,,289,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BONE SCREW T8 FULL THREAD 2.4MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12653-MAIN,LOCAL,,,,,289,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BONE SCREW T8 FULL THREAD 2.4MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12653-MAIN,LOCAL,,,,,289,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BONE SCREW T8 FULL THREAD 2.4MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12653-MAIN,LOCAL,,,,,289,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BONE SCREW T8 FULL THREAD 2.7MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12654-MAIN,LOCAL,,,,,289,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BONE SCREW T8 FULL THREAD 2.7MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12654-MAIN,LOCAL,,,,,289,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BONE SCREW T8 FULL THREAD 2.7MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12654-MAIN,LOCAL,,,,,289,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BONE SCREW T8 FULL THREAD 2.7MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12654-MAIN,LOCAL,,,,,289,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BONE SCREW T8 FULL THREAD 2.7MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12654-MAIN,LOCAL,,,,,289,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BONE SCREW T8 FULL THREAD 2.7MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12654-MAIN,LOCAL,,,,,289,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BONE WAX SUTURE 2.5G ETHICON,27200000,CDM,272,RC,,,,12566-MAIN,LOCAL,,,,,13,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BONE WAX SUTURE 2.5G ETHICON,27200000,CDM,272,RC,,,,12566-MAIN,LOCAL,,,,,13,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BONE WAX SUTURE 2.5G ETHICON,27200000,CDM,272,RC,,,,12566-MAIN,LOCAL,,,,,13,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BONE WAX SUTURE 2.5G ETHICON,27200000,CDM,272,RC,,,,12566-MAIN,LOCAL,,,,,13,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BONE WAX SUTURE 2.5G ETHICON,27200000,CDM,272,RC,,,,12566-MAIN,LOCAL,,,,,13,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BONE WAX SUTURE 2.5G ETHICON,27200000,CDM,272,RC,,,,12566-MAIN,LOCAL,,,,,13,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT SHORT LARGE 01ES-L,120.45,CDM,274,RC,L4360,HCPCS,,11890-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT SHORT LARGE 01ES-L,120.45,CDM,274,RC,L4360,HCPCS,,11890-MAIN,LOCAL,,,,,93,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT SHORT LARGE 01ES-L,120.45,CDM,274,RC,L4360,HCPCS,,11890-MAIN,LOCAL,,,,,93,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT SHORT LARGE 01ES-L,120.45,CDM,274,RC,L4360,HCPCS,,11890-MAIN,LOCAL,,,,,93,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT SHORT LARGE 01ES-L,120.45,CDM,274,RC,L4360,HCPCS,,11890-MAIN,LOCAL,,,,,93,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT SHORT LARGE 01ES-L,120.45,CDM,274,RC,L4360,HCPCS,,11890-MAIN,LOCAL,,,,,93,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT SHORT MEDIUM 01ES-M,120.45,CDM,274,RC,L4360,HCPCS,,11889-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT SHORT MEDIUM 01ES-M,120.45,CDM,274,RC,L4360,HCPCS,,11889-MAIN,LOCAL,,,,,93,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT SHORT MEDIUM 01ES-M,120.45,CDM,274,RC,L4360,HCPCS,,11889-MAIN,LOCAL,,,,,93,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT SHORT MEDIUM 01ES-M,120.45,CDM,274,RC,L4360,HCPCS,,11889-MAIN,LOCAL,,,,,93,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT SHORT MEDIUM 01ES-M,120.45,CDM,274,RC,L4360,HCPCS,,11889-MAIN,LOCAL,,,,,93,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT SHORT MEDIUM 01ES-M,120.45,CDM,274,RC,L4360,HCPCS,,11889-MAIN,LOCAL,,,,,93,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT SHORT SMALL 01ES-S,120.45,CDM,274,RC,L4360,HCPCS,,11888-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT SHORT SMALL 01ES-S,120.45,CDM,274,RC,L4360,HCPCS,,11888-MAIN,LOCAL,,,,,93,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT SHORT SMALL 01ES-S,120.45,CDM,274,RC,L4360,HCPCS,,11888-MAIN,LOCAL,,,,,93,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT SHORT SMALL 01ES-S,120.45,CDM,274,RC,L4360,HCPCS,,11888-MAIN,LOCAL,,,,,93,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT SHORT SMALL 01ES-S,120.45,CDM,274,RC,L4360,HCPCS,,11888-MAIN,LOCAL,,,,,93,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT SHORT SMALL 01ES-S,120.45,CDM,274,RC,L4360,HCPCS,,11888-MAIN,LOCAL,,,,,93,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT SHORT X-LARGE 01ES-XL,120.45,CDM,274,RC,L4360,HCPCS,,11891-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT SHORT X-LARGE 01ES-XL,120.45,CDM,274,RC,L4360,HCPCS,,11891-MAIN,LOCAL,,,,,93,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT SHORT X-LARGE 01ES-XL,120.45,CDM,274,RC,L4360,HCPCS,,11891-MAIN,LOCAL,,,,,93,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT SHORT X-LARGE 01ES-XL,120.45,CDM,274,RC,L4360,HCPCS,,11891-MAIN,LOCAL,,,,,93,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT SHORT X-LARGE 01ES-XL,120.45,CDM,274,RC,L4360,HCPCS,,11891-MAIN,LOCAL,,,,,93,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT SHORT X-LARGE 01ES-XL,120.45,CDM,274,RC,L4360,HCPCS,,11891-MAIN,LOCAL,,,,,93,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT SHORT X-SMALL 01ES-XS,120.45,CDM,274,RC,L4360,HCPCS,,11887-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT SHORT X-SMALL 01ES-XS,120.45,CDM,274,RC,L4360,HCPCS,,11887-MAIN,LOCAL,,,,,93,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT SHORT X-SMALL 01ES-XS,120.45,CDM,274,RC,L4360,HCPCS,,11887-MAIN,LOCAL,,,,,93,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT SHORT X-SMALL 01ES-XS,120.45,CDM,274,RC,L4360,HCPCS,,11887-MAIN,LOCAL,,,,,93,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT SHORT X-SMALL 01ES-XS,120.45,CDM,274,RC,L4360,HCPCS,,11887-MAIN,LOCAL,,,,,93,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT SHORT X-SMALL 01ES-XS,120.45,CDM,274,RC,L4360,HCPCS,,11887-MAIN,LOCAL,,,,,93,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT STANDARD LARGE 01EF-L,120.45,CDM,274,RC,L4360,HCPCS,,11697-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT STANDARD LARGE 01EF-L,120.45,CDM,274,RC,L4360,HCPCS,,11697-MAIN,LOCAL,,,,,93,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT STANDARD LARGE 01EF-L,120.45,CDM,274,RC,L4360,HCPCS,,11697-MAIN,LOCAL,,,,,93,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT STANDARD LARGE 01EF-L,120.45,CDM,274,RC,L4360,HCPCS,,11697-MAIN,LOCAL,,,,,93,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT STANDARD LARGE 01EF-L,120.45,CDM,274,RC,L4360,HCPCS,,11697-MAIN,LOCAL,,,,,93,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT STANDARD LARGE 01EF-L,120.45,CDM,274,RC,L4360,HCPCS,,11697-MAIN,LOCAL,,,,,93,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT STANDARD MEDIUM 01EF-M,120.45,CDM,274,RC,L4360,HCPCS,,11696-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT STANDARD MEDIUM 01EF-M,120.45,CDM,274,RC,L4360,HCPCS,,11696-MAIN,LOCAL,,,,,93,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT STANDARD MEDIUM 01EF-M,120.45,CDM,274,RC,L4360,HCPCS,,11696-MAIN,LOCAL,,,,,93,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT STANDARD MEDIUM 01EF-M,120.45,CDM,274,RC,L4360,HCPCS,,11696-MAIN,LOCAL,,,,,93,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT STANDARD MEDIUM 01EF-M,120.45,CDM,274,RC,L4360,HCPCS,,11696-MAIN,LOCAL,,,,,93,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT STANDARD MEDIUM 01EF-M,120.45,CDM,274,RC,L4360,HCPCS,,11696-MAIN,LOCAL,,,,,93,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT STANDARD SMALL 01EF-S,120.45,CDM,274,RC,L4360,HCPCS,,11695-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT STANDARD SMALL 01EF-S,120.45,CDM,274,RC,L4360,HCPCS,,11695-MAIN,LOCAL,,,,,93,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT STANDARD SMALL 01EF-S,120.45,CDM,274,RC,L4360,HCPCS,,11695-MAIN,LOCAL,,,,,93,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT STANDARD SMALL 01EF-S,120.45,CDM,274,RC,L4360,HCPCS,,11695-MAIN,LOCAL,,,,,93,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT STANDARD SMALL 01EF-S,120.45,CDM,274,RC,L4360,HCPCS,,11695-MAIN,LOCAL,,,,,93,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT STANDARD SMALL 01EF-S,120.45,CDM,274,RC,L4360,HCPCS,,11695-MAIN,LOCAL,,,,,93,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT STANDARD X-LARGE 01EF-XL,120.45,CDM,274,RC,L4360,HCPCS,,11698-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT STANDARD X-LARGE 01EF-XL,120.45,CDM,274,RC,L4360,HCPCS,,11698-MAIN,LOCAL,,,,,93,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT STANDARD X-LARGE 01EF-XL,120.45,CDM,274,RC,L4360,HCPCS,,11698-MAIN,LOCAL,,,,,93,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT STANDARD X-LARGE 01EF-XL,120.45,CDM,274,RC,L4360,HCPCS,,11698-MAIN,LOCAL,,,,,93,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT STANDARD X-LARGE 01EF-XL,120.45,CDM,274,RC,L4360,HCPCS,,11698-MAIN,LOCAL,,,,,93,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT STANDARD X-LARGE 01EF-XL,120.45,CDM,274,RC,L4360,HCPCS,,11698-MAIN,LOCAL,,,,,93,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT STANDARD X-SMALL 01EF-XS,120.45,CDM,274,RC,L4360,HCPCS,,11694-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT STANDARD X-SMALL 01EF-XS,120.45,CDM,274,RC,L4360,HCPCS,,11694-MAIN,LOCAL,,,,,93,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT STANDARD X-SMALL 01EF-XS,120.45,CDM,274,RC,L4360,HCPCS,,11694-MAIN,LOCAL,,,,,93,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT STANDARD X-SMALL 01EF-XS,120.45,CDM,274,RC,L4360,HCPCS,,11694-MAIN,LOCAL,,,,,93,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT STANDARD X-SMALL 01EF-XS,120.45,CDM,274,RC,L4360,HCPCS,,11694-MAIN,LOCAL,,,,,93,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT STANDARD X-SMALL 01EF-XS,120.45,CDM,274,RC,L4360,HCPCS,,11694-MAIN,LOCAL,,,,,93,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT CAST LARGE 12-5/8 ORT290010L,120.247,CDM,274,RC,L3260,HCPCS,,204-MAIN,LOCAL,,,,,27,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT CAST LARGE 12-5/8 ORT290010L,120.247,CDM,274,RC,L3260,HCPCS,,204-MAIN,LOCAL,,,,,27,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT CAST LARGE 12-5/8 ORT290010L,120.247,CDM,274,RC,L3260,HCPCS,,204-MAIN,LOCAL,,,,,27,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT CAST LARGE 12-5/8 ORT290010L,120.247,CDM,274,RC,L3260,HCPCS,,204-MAIN,LOCAL,,,,,27,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT CAST LARGE 12-5/8 ORT290010L,120.247,CDM,274,RC,L3260,HCPCS,,204-MAIN,LOCAL,,,,,27,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT CAST LARGE 12-5/8 ORT290010L,120.247,CDM,274,RC,L3260,HCPCS,,204-MAIN,LOCAL,,,,,27,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT CAST MEDIUM 08148803,120.247,CDM,274,RC,L3260,HCPCS,,203-MAIN,LOCAL,,,,,27,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT CAST MEDIUM 08148803,120.247,CDM,274,RC,L3260,HCPCS,,203-MAIN,LOCAL,,,,,27,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT CAST MEDIUM 08148803,120.247,CDM,274,RC,L3260,HCPCS,,203-MAIN,LOCAL,,,,,27,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT CAST MEDIUM 08148803,120.247,CDM,274,RC,L3260,HCPCS,,203-MAIN,LOCAL,,,,,27,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT CAST MEDIUM 08148803,120.247,CDM,274,RC,L3260,HCPCS,,203-MAIN,LOCAL,,,,,27,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT CAST MEDIUM 08148803,120.247,CDM,274,RC,L3260,HCPCS,,203-MAIN,LOCAL,,,,,27,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT CAST X-LARGE 13X5-1/2IN ORT29200XL,120.247,CDM,274,RC,L3260,HCPCS,,206-MAIN,LOCAL,,,,,27,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT CAST X-LARGE 13X5-1/2IN ORT29200XL,120.247,CDM,274,RC,L3260,HCPCS,,206-MAIN,LOCAL,,,,,27,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT CAST X-LARGE 13X5-1/2IN ORT29200XL,120.247,CDM,274,RC,L3260,HCPCS,,206-MAIN,LOCAL,,,,,27,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT CAST X-LARGE 13X5-1/2IN ORT29200XL,120.247,CDM,274,RC,L3260,HCPCS,,206-MAIN,LOCAL,,,,,27,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT CAST X-LARGE 13X5-1/2IN ORT29200XL,120.247,CDM,274,RC,L3260,HCPCS,,206-MAIN,LOCAL,,,,,27,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT CAST X-LARGE 13X5-1/2IN ORT29200XL,120.247,CDM,274,RC,L3260,HCPCS,,206-MAIN,LOCAL,,,,,27,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bortezomib 3.5 MG Recon Soln 1 Each Vial,J9041.01,CDM,636,RC,J9041,HCPCS,,,,63020004901,NDC,1,EA,3270.12,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bortezomib 3.5 MG Recon Soln 1 Each Vial,J9041.01,CDM,636,RC,J9041,HCPCS,,,,63020004901,NDC,1,EA,3270.12,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bortezomib 3.5 MG Recon Soln 1 Each Vial,J9041.01,CDM,636,RC,J9041,HCPCS,,,,63020004901,NDC,1,EA,3270.12,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bortezomib 3.5 MG Recon Soln 1 Each Vial,J9041.01,CDM,636,RC,J9041,HCPCS,,,,63020004901,NDC,1,EA,3270.12,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bortezomib 3.5 MG Recon Soln 1 Each Vial,J9041.01,CDM,636,RC,J9041,HCPCS,,,,63020004901,NDC,1,EA,3270.12,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bortezomib 3.5 MG Recon Soln 1 Each Vial,J9041.01,CDM,636,RC,J9041,HCPCS,,,,63020004901,NDC,1,EA,3270.12,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BOUGIE TRACH 10FR 70CM COUDE 	9-0211-70",120.199,CDM,272,RC,A7520,HCPCS,,11112-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BOUGIE TRACH 10FR 70CM COUDE 	9-0211-70",120.199,CDM,272,RC,A7520,HCPCS,,11112-MAIN,LOCAL,,,,,42,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BOUGIE TRACH 10FR 70CM COUDE 	9-0211-70",120.199,CDM,272,RC,A7520,HCPCS,,11112-MAIN,LOCAL,,,,,42,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BOUGIE TRACH 10FR 70CM COUDE 	9-0211-70",120.199,CDM,272,RC,A7520,HCPCS,,11112-MAIN,LOCAL,,,,,42,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BOUGIE TRACH 10FR 70CM COUDE 	9-0211-70",120.199,CDM,272,RC,A7520,HCPCS,,11112-MAIN,LOCAL,,,,,42,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BOUGIE TRACH 10FR 70CM COUDE 	9-0211-70",120.199,CDM,272,RC,A7520,HCPCS,,11112-MAIN,LOCAL,,,,,42,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOUGIE TRACHEAL TUBE & GUIDE 100123515,120.199,CDM,272,RC,A7520,HCPCS,,8950-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOUGIE TRACHEAL TUBE & GUIDE 100123515,120.199,CDM,272,RC,A7520,HCPCS,,8950-MAIN,LOCAL,,,,,42,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOUGIE TRACHEAL TUBE & GUIDE 100123515,120.199,CDM,272,RC,A7520,HCPCS,,8950-MAIN,LOCAL,,,,,42,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOUGIE TRACHEAL TUBE & GUIDE 100123515,120.199,CDM,272,RC,A7520,HCPCS,,8950-MAIN,LOCAL,,,,,42,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOUGIE TRACHEAL TUBE & GUIDE 100123515,120.199,CDM,272,RC,A7520,HCPCS,,8950-MAIN,LOCAL,,,,,42,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOUGIE TRACHEAL TUBE & GUIDE 100123515,120.199,CDM,272,RC,A7520,HCPCS,,8950-MAIN,LOCAL,,,,,42,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE ANKLE LARGE 264015,120.51,CDM,274,RC,L1902,HCPCS,,4-MAIN,LOCAL,,,,,115,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE ANKLE LARGE 264015,120.51,CDM,274,RC,L1902,HCPCS,,4-MAIN,LOCAL,,,,,115,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE ANKLE LARGE 264015,120.51,CDM,274,RC,L1902,HCPCS,,4-MAIN,LOCAL,,,,,115,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE ANKLE LARGE 264015,120.51,CDM,274,RC,L1902,HCPCS,,4-MAIN,LOCAL,,,,,115,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE ANKLE LARGE 264015,120.51,CDM,274,RC,L1902,HCPCS,,4-MAIN,LOCAL,,,,,115,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE ANKLE LARGE 264015,120.51,CDM,274,RC,L1902,HCPCS,,4-MAIN,LOCAL,,,,,115,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE ANKLE MEDIUM 264014,120.51,CDM,274,RC,L1902,HCPCS,,7-MAIN,LOCAL,,,,,115,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE ANKLE MEDIUM 264014,120.51,CDM,274,RC,L1902,HCPCS,,7-MAIN,LOCAL,,,,,115,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE ANKLE MEDIUM 264014,120.51,CDM,274,RC,L1902,HCPCS,,7-MAIN,LOCAL,,,,,115,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE ANKLE MEDIUM 264014,120.51,CDM,274,RC,L1902,HCPCS,,7-MAIN,LOCAL,,,,,115,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE ANKLE MEDIUM 264014,120.51,CDM,274,RC,L1902,HCPCS,,7-MAIN,LOCAL,,,,,115,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE ANKLE MEDIUM 264014,120.51,CDM,274,RC,L1902,HCPCS,,7-MAIN,LOCAL,,,,,115,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE ANKLE SMALL 264012,120.51,CDM,274,RC,L1902,HCPCS,,12-MAIN,LOCAL,,,,,115,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE ANKLE SMALL 264012,120.51,CDM,274,RC,L1902,HCPCS,,12-MAIN,LOCAL,,,,,115,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE ANKLE SMALL 264012,120.51,CDM,274,RC,L1902,HCPCS,,12-MAIN,LOCAL,,,,,115,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE ANKLE SMALL 264012,120.51,CDM,274,RC,L1902,HCPCS,,12-MAIN,LOCAL,,,,,115,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE ANKLE SMALL 264012,120.51,CDM,274,RC,L1902,HCPCS,,12-MAIN,LOCAL,,,,,115,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE ANKLE SMALL 264012,120.51,CDM,274,RC,L1902,HCPCS,,12-MAIN,LOCAL,,,,,115,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE ANKLE X-LARGE 264016,120.51,CDM,274,RC,L1902,HCPCS,,14-MAIN,LOCAL,,,,,115,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE ANKLE X-LARGE 264016,120.51,CDM,274,RC,L1902,HCPCS,,14-MAIN,LOCAL,,,,,115,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE ANKLE X-LARGE 264016,120.51,CDM,274,RC,L1902,HCPCS,,14-MAIN,LOCAL,,,,,115,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE ANKLE X-LARGE 264016,120.51,CDM,274,RC,L1902,HCPCS,,14-MAIN,LOCAL,,,,,115,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE ANKLE X-LARGE 264016,120.51,CDM,274,RC,L1902,HCPCS,,14-MAIN,LOCAL,,,,,115,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE ANKLE X-LARGE 264016,120.51,CDM,274,RC,L1902,HCPCS,,14-MAIN,LOCAL,,,,,115,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE ANKLE X-SMALL 264011,120.51,CDM,274,RC,L1902,HCPCS,,1-MAIN,LOCAL,,,,,115,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE ANKLE X-SMALL 264011,120.51,CDM,274,RC,L1902,HCPCS,,1-MAIN,LOCAL,,,,,115,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE ANKLE X-SMALL 264011,120.51,CDM,274,RC,L1902,HCPCS,,1-MAIN,LOCAL,,,,,115,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE ANKLE X-SMALL 264011,120.51,CDM,274,RC,L1902,HCPCS,,1-MAIN,LOCAL,,,,,115,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE ANKLE X-SMALL 264011,120.51,CDM,274,RC,L1902,HCPCS,,1-MAIN,LOCAL,,,,,115,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE ANKLE X-SMALL 264011,120.51,CDM,274,RC,L1902,HCPCS,,1-MAIN,LOCAL,,,,,115,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE KNEE LARGE SHORTRUNNER 21754,120.387,CDM,274,RC,L1833,HCPCS,,10044-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE KNEE LARGE SHORTRUNNER 21754,120.387,CDM,274,RC,L1833,HCPCS,,10044-MAIN,LOCAL,,,,,101,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE KNEE LARGE SHORTRUNNER 21754,120.387,CDM,274,RC,L1833,HCPCS,,10044-MAIN,LOCAL,,,,,101,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE KNEE LARGE SHORTRUNNER 21754,120.387,CDM,274,RC,L1833,HCPCS,,10044-MAIN,LOCAL,,,,,101,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE KNEE LARGE SHORTRUNNER 21754,120.387,CDM,274,RC,L1833,HCPCS,,10044-MAIN,LOCAL,,,,,101,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE KNEE LARGE SHORTRUNNER 21754,120.387,CDM,274,RC,L1833,HCPCS,,10044-MAIN,LOCAL,,,,,101,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE KNEE MEDIUM SHORTRUNNER 21753,120.387,CDM,274,RC,L1833,HCPCS,,10126-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE KNEE MEDIUM SHORTRUNNER 21753,120.387,CDM,274,RC,L1833,HCPCS,,10126-MAIN,LOCAL,,,,,101,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE KNEE MEDIUM SHORTRUNNER 21753,120.387,CDM,274,RC,L1833,HCPCS,,10126-MAIN,LOCAL,,,,,101,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE KNEE MEDIUM SHORTRUNNER 21753,120.387,CDM,274,RC,L1833,HCPCS,,10126-MAIN,LOCAL,,,,,101,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE KNEE MEDIUM SHORTRUNNER 21753,120.387,CDM,274,RC,L1833,HCPCS,,10126-MAIN,LOCAL,,,,,101,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE KNEE MEDIUM SHORTRUNNER 21753,120.387,CDM,274,RC,L1833,HCPCS,,10126-MAIN,LOCAL,,,,,101,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE KNEE SMALL SHORTRUNNER 21752,120.387,CDM,274,RC,L1833,HCPCS,,10900-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE KNEE SMALL SHORTRUNNER 21752,120.387,CDM,274,RC,L1833,HCPCS,,10900-MAIN,LOCAL,,,,,101,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE KNEE SMALL SHORTRUNNER 21752,120.387,CDM,274,RC,L1833,HCPCS,,10900-MAIN,LOCAL,,,,,101,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE KNEE SMALL SHORTRUNNER 21752,120.387,CDM,274,RC,L1833,HCPCS,,10900-MAIN,LOCAL,,,,,101,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE KNEE SMALL SHORTRUNNER 21752,120.387,CDM,274,RC,L1833,HCPCS,,10900-MAIN,LOCAL,,,,,101,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE KNEE SMALL SHORTRUNNER 21752,120.387,CDM,274,RC,L1833,HCPCS,,10900-MAIN,LOCAL,,,,,101,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE KNEE X-LARGE SHORTRUNNER 21755,120.387,CDM,274,RC,L1833,HCPCS,,3444-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE KNEE X-LARGE SHORTRUNNER 21755,120.387,CDM,274,RC,L1833,HCPCS,,3444-MAIN,LOCAL,,,,,101,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE KNEE X-LARGE SHORTRUNNER 21755,120.387,CDM,274,RC,L1833,HCPCS,,3444-MAIN,LOCAL,,,,,101,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE KNEE X-LARGE SHORTRUNNER 21755,120.387,CDM,274,RC,L1833,HCPCS,,3444-MAIN,LOCAL,,,,,101,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE KNEE X-LARGE SHORTRUNNER 21755,120.387,CDM,274,RC,L1833,HCPCS,,3444-MAIN,LOCAL,,,,,101,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE KNEE X-LARGE SHORTRUNNER 21755,120.387,CDM,274,RC,L1833,HCPCS,,3444-MAIN,LOCAL,,,,,101,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE KNEE XX-LARGE SHORTRUNNER 21756,120.387,CDM,274,RC,L1833,HCPCS,,10615-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE KNEE XX-LARGE SHORTRUNNER 21756,120.387,CDM,274,RC,L1833,HCPCS,,10615-MAIN,LOCAL,,,,,101,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE KNEE XX-LARGE SHORTRUNNER 21756,120.387,CDM,274,RC,L1833,HCPCS,,10615-MAIN,LOCAL,,,,,101,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE KNEE XX-LARGE SHORTRUNNER 21756,120.387,CDM,274,RC,L1833,HCPCS,,10615-MAIN,LOCAL,,,,,101,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE KNEE XX-LARGE SHORTRUNNER 21756,120.387,CDM,274,RC,L1833,HCPCS,,10615-MAIN,LOCAL,,,,,101,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE KNEE XX-LARGE SHORTRUNNER 21756,120.387,CDM,274,RC,L1833,HCPCS,,10615-MAIN,LOCAL,,,,,101,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST 8-IN SM LEFT 10432,120.564,CDM,273,RC,L3809,HCPCS,,12720-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST 8-IN SM LEFT 10432,120.564,CDM,273,RC,L3809,HCPCS,,12720-MAIN,LOCAL,,,,,23,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST 8-IN SM LEFT 10432,120.564,CDM,273,RC,L3809,HCPCS,,12720-MAIN,LOCAL,,,,,23,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST 8-IN SM LEFT 10432,120.564,CDM,273,RC,L3809,HCPCS,,12720-MAIN,LOCAL,,,,,23,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST 8-IN SM LEFT 10432,120.564,CDM,273,RC,L3809,HCPCS,,12720-MAIN,LOCAL,,,,,23,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST 8-IN SM LEFT 10432,120.564,CDM,273,RC,L3809,HCPCS,,12720-MAIN,LOCAL,,,,,23,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST 8-IN SM RIGHT 10442,120.564,CDM,273,RC,L3809,HCPCS,,12716-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST 8-IN SM RIGHT 10442,120.564,CDM,273,RC,L3809,HCPCS,,12716-MAIN,LOCAL,,,,,23,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST 8-IN SM RIGHT 10442,120.564,CDM,273,RC,L3809,HCPCS,,12716-MAIN,LOCAL,,,,,23,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST 8-IN SM RIGHT 10442,120.564,CDM,273,RC,L3809,HCPCS,,12716-MAIN,LOCAL,,,,,23,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST 8-IN SM RIGHT 10442,120.564,CDM,273,RC,L3809,HCPCS,,12716-MAIN,LOCAL,,,,,23,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST 8-IN SM RIGHT 10442,120.564,CDM,273,RC,L3809,HCPCS,,12716-MAIN,LOCAL,,,,,23,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST 10-IN LG RIGHT 10464,120.564,CDM,273,RC,L3809,HCPCS,,12719-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST 10-IN LG RIGHT 10464,120.564,CDM,273,RC,L3809,HCPCS,,12719-MAIN,LOCAL,,,,,23,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST 10-IN LG RIGHT 10464,120.564,CDM,273,RC,L3809,HCPCS,,12719-MAIN,LOCAL,,,,,23,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST 10-IN LG RIGHT 10464,120.564,CDM,273,RC,L3809,HCPCS,,12719-MAIN,LOCAL,,,,,23,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST 10-IN LG RIGHT 10464,120.564,CDM,273,RC,L3809,HCPCS,,12719-MAIN,LOCAL,,,,,23,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST 10-IN LG RIGHT 10464,120.564,CDM,273,RC,L3809,HCPCS,,12719-MAIN,LOCAL,,,,,23,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST 10-IN SM LEFT 617083,120.564,CDM,273,RC,L3809,HCPCS,,12722-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST 10-IN SM LEFT 617083,120.564,CDM,273,RC,L3809,HCPCS,,12722-MAIN,LOCAL,,,,,23,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST 10-IN SM LEFT 617083,120.564,CDM,273,RC,L3809,HCPCS,,12722-MAIN,LOCAL,,,,,23,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST 10-IN SM LEFT 617083,120.564,CDM,273,RC,L3809,HCPCS,,12722-MAIN,LOCAL,,,,,23,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST 10-IN SM LEFT 617083,120.564,CDM,273,RC,L3809,HCPCS,,12722-MAIN,LOCAL,,,,,23,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST 10-IN SM LEFT 617083,120.564,CDM,273,RC,L3809,HCPCS,,12722-MAIN,LOCAL,,,,,23,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST 10-IN SM RIGHT 10462,120.564,CDM,273,RC,L3809,HCPCS,,12717-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST 10-IN SM RIGHT 10462,120.564,CDM,273,RC,L3809,HCPCS,,12717-MAIN,LOCAL,,,,,23,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST 10-IN SM RIGHT 10462,120.564,CDM,273,RC,L3809,HCPCS,,12717-MAIN,LOCAL,,,,,23,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST 10-IN SM RIGHT 10462,120.564,CDM,273,RC,L3809,HCPCS,,12717-MAIN,LOCAL,,,,,23,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST 10-IN SM RIGHT 10462,120.564,CDM,273,RC,L3809,HCPCS,,12717-MAIN,LOCAL,,,,,23,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST 10-IN SM RIGHT 10462,120.564,CDM,273,RC,L3809,HCPCS,,12717-MAIN,LOCAL,,,,,23,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST 10-IN XL LEFT 10455,120.564,CDM,273,RC,L3809,HCPCS,,12721-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST 10-IN XL LEFT 10455,120.564,CDM,273,RC,L3809,HCPCS,,12721-MAIN,LOCAL,,,,,23,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST 10-IN XL LEFT 10455,120.564,CDM,273,RC,L3809,HCPCS,,12721-MAIN,LOCAL,,,,,23,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST 10-IN XL LEFT 10455,120.564,CDM,273,RC,L3809,HCPCS,,12721-MAIN,LOCAL,,,,,23,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST 10-IN XL LEFT 10455,120.564,CDM,273,RC,L3809,HCPCS,,12721-MAIN,LOCAL,,,,,23,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST 10-IN XL LEFT 10455,120.564,CDM,273,RC,L3809,HCPCS,,12721-MAIN,LOCAL,,,,,23,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST 10-IN XL RIGHT 10465,120.564,CDM,273,RC,L3809,HCPCS,,12715-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST 10-IN XL RIGHT 10465,120.564,CDM,273,RC,L3809,HCPCS,,12715-MAIN,LOCAL,,,,,23,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST 10-IN XL RIGHT 10465,120.564,CDM,273,RC,L3809,HCPCS,,12715-MAIN,LOCAL,,,,,23,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST 10-IN XL RIGHT 10465,120.564,CDM,273,RC,L3809,HCPCS,,12715-MAIN,LOCAL,,,,,23,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST 10-IN XL RIGHT 10465,120.564,CDM,273,RC,L3809,HCPCS,,12715-MAIN,LOCAL,,,,,23,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST 10-IN XL RIGHT 10465,120.564,CDM,273,RC,L3809,HCPCS,,12715-MAIN,LOCAL,,,,,23,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST HAND THUMB LEFT 455-LT,120.315,CDM,274,RC,L3809,HCPCS,,8283-MAIN,LOCAL,,,,,77,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST HAND THUMB LEFT 455-LT,120.315,CDM,274,RC,L3809,HCPCS,,8283-MAIN,LOCAL,,,,,77,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST HAND THUMB LEFT 455-LT,120.315,CDM,274,RC,L3809,HCPCS,,8283-MAIN,LOCAL,,,,,77,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST HAND THUMB LEFT 455-LT,120.315,CDM,274,RC,L3809,HCPCS,,8283-MAIN,LOCAL,,,,,77,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST HAND THUMB LEFT 455-LT,120.315,CDM,274,RC,L3809,HCPCS,,8283-MAIN,LOCAL,,,,,77,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST HAND THUMB LEFT 455-LT,120.315,CDM,274,RC,L3809,HCPCS,,8283-MAIN,LOCAL,,,,,77,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST HAND THUMB RIGHT 455-RT,120.315,CDM,274,RC,L3809,HCPCS,,8284-MAIN,LOCAL,,,,,77,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST HAND THUMB RIGHT 455-RT,120.315,CDM,274,RC,L3809,HCPCS,,8284-MAIN,LOCAL,,,,,77,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST HAND THUMB RIGHT 455-RT,120.315,CDM,274,RC,L3809,HCPCS,,8284-MAIN,LOCAL,,,,,77,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST HAND THUMB RIGHT 455-RT,120.315,CDM,274,RC,L3809,HCPCS,,8284-MAIN,LOCAL,,,,,77,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST HAND THUMB RIGHT 455-RT,120.315,CDM,274,RC,L3809,HCPCS,,8284-MAIN,LOCAL,,,,,77,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST HAND THUMB RIGHT 455-RT,120.315,CDM,274,RC,L3809,HCPCS,,8284-MAIN,LOCAL,,,,,77,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST WRISTPRO LEFT 10-IN LG,120.564,CDM,273,RC,L3809,HCPCS,,12724-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST WRISTPRO LEFT 10-IN LG,120.564,CDM,273,RC,L3809,HCPCS,,12724-MAIN,LOCAL,,,,,23,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST WRISTPRO LEFT 10-IN LG,120.564,CDM,273,RC,L3809,HCPCS,,12724-MAIN,LOCAL,,,,,23,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST WRISTPRO LEFT 10-IN LG,120.564,CDM,273,RC,L3809,HCPCS,,12724-MAIN,LOCAL,,,,,23,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST WRISTPRO LEFT 10-IN LG,120.564,CDM,273,RC,L3809,HCPCS,,12724-MAIN,LOCAL,,,,,23,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST WRISTPRO LEFT 10-IN LG,120.564,CDM,273,RC,L3809,HCPCS,,12724-MAIN,LOCAL,,,,,23,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST WRISTPRO LEFT 10-IN MED,120.564,CDM,273,RC,L3809,HCPCS,,12723-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST WRISTPRO LEFT 10-IN MED,120.564,CDM,273,RC,L3809,HCPCS,,12723-MAIN,LOCAL,,,,,23,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST WRISTPRO LEFT 10-IN MED,120.564,CDM,273,RC,L3809,HCPCS,,12723-MAIN,LOCAL,,,,,23,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST WRISTPRO LEFT 10-IN MED,120.564,CDM,273,RC,L3809,HCPCS,,12723-MAIN,LOCAL,,,,,23,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST WRISTPRO LEFT 10-IN MED,120.564,CDM,273,RC,L3809,HCPCS,,12723-MAIN,LOCAL,,,,,23,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST WRISTPRO LEFT 10-IN MED,120.564,CDM,273,RC,L3809,HCPCS,,12723-MAIN,LOCAL,,,,,23,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Breast Tomosynthesis,Dx Tc Bilat",PX7706201,CDM,401,RC,77062,CPT,TC,,,,,,,166,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Breast Tomosynthesis,Dx Tc Bilat",PX7706201,CDM,401,RC,77062,CPT,TC,,,,,,,166,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Breast Tomosynthesis,Dx Tc Bilat",PX7706201,CDM,401,RC,77062,CPT,TC,,,,,,,166,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Breast Tomosynthesis,Dx Tc Bilat",PX7706201,CDM,401,RC,77062,CPT,TC,,,,,,,166,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Breast Tomosynthesis,Dx Tc Bilat",PX7706201,CDM,401,RC,77062,CPT,TC,,,,,,,166,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Breast Tomosynthesis,Dx Tc Bilat",PX7706201,CDM,401,RC,77062,CPT,TC,,,,,,,166,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Breast Tomosynthesis,Dx Tc Unilat",PX7706101,CDM,401,RC,77061,CPT,TC,,,,,,,166,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Breast Tomosynthesis,Dx Tc Unilat",PX7706101,CDM,401,RC,77061,CPT,TC,,,,,,,166,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Breast Tomosynthesis,Dx Tc Unilat",PX7706101,CDM,401,RC,77061,CPT,TC,,,,,,,166,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Breast Tomosynthesis,Dx Tc Unilat",PX7706101,CDM,401,RC,77061,CPT,TC,,,,,,,166,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Breast Tomosynthesis,Dx Tc Unilat",PX7706101,CDM,401,RC,77061,CPT,TC,,,,,,,166,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Breast Tomosynthesis,Dx Tc Unilat",PX7706101,CDM,401,RC,77061,CPT,TC,,,,,,,166,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Breast Tomosynthesis,Screen Tc",PX7706301,CDM,403,RC,77063,CPT,TC,,,,,,,166,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Breast Tomosynthesis,Screen Tc",PX7706301,CDM,403,RC,77063,CPT,TC,,,,,,,166,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Breast Tomosynthesis,Screen Tc",PX7706301,CDM,403,RC,77063,CPT,TC,,,,,,,166,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Breast Tomosynthesis,Screen Tc",PX7706301,CDM,403,RC,77063,CPT,TC,,,,,,,166,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Breast Tomosynthesis,Screen Tc",PX7706301,CDM,403,RC,77063,CPT,TC,,,,,,,166,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Breast Tomosynthesis,Screen Tc",PX7706301,CDM,403,RC,77063,CPT,TC,,,,,,,166,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
brimonidine 0.2 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,70069023101,NDC,5,ML,70.38,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
brimonidine 0.2 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,70069023101,NDC,5,ML,70.38,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
brimonidine 0.2 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,70069023101,NDC,5,ML,70.38,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
brimonidine 0.2 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,70069023101,NDC,5,ML,70.38,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
brimonidine 0.2 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,70069023101,NDC,5,ML,70.38,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
brimonidine 0.2 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,70069023101,NDC,5,ML,70.38,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
brimonidine 0.15 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314014405,NDC,5,ML,723.62,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
brimonidine 0.15 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314014405,NDC,5,ML,723.62,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
brimonidine 0.15 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314014405,NDC,5,ML,723.62,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
brimonidine 0.15 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314014405,NDC,5,ML,723.62,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
brimonidine 0.15 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314014405,NDC,5,ML,723.62,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
brimonidine 0.15 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314014405,NDC,5,ML,723.62,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
brinzolamide-brimonidine 1-0.2 % Suspension 8 mL Bottle,63700001,CDM,250,RC,,,,,,65414727,NDC,8,ML,850.88,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
brinzolamide-brimonidine 1-0.2 % Suspension 8 mL Bottle,63700001,CDM,250,RC,,,,,,65414727,NDC,8,ML,850.88,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
brinzolamide-brimonidine 1-0.2 % Suspension 8 mL Bottle,63700001,CDM,250,RC,,,,,,65414727,NDC,8,ML,850.88,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
brinzolamide-brimonidine 1-0.2 % Suspension 8 mL Bottle,63700001,CDM,250,RC,,,,,,65414727,NDC,8,ML,850.88,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
brinzolamide-brimonidine 1-0.2 % Suspension 8 mL Bottle,63700001,CDM,250,RC,,,,,,65414727,NDC,8,ML,850.88,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
brinzolamide-brimonidine 1-0.2 % Suspension 8 mL Bottle,63700001,CDM,250,RC,,,,,,65414727,NDC,8,ML,850.88,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRONCHOSCOPE BFLEX 5.0 SINGLE-USE 0570-0449,120.578,CDM,272,RC,,,,13020-MAIN,LOCAL,,,,,558,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRONCHOSCOPE BFLEX 5.0 SINGLE-USE 0570-0449,120.578,CDM,272,RC,,,,13020-MAIN,LOCAL,,,,,558,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRONCHOSCOPE BFLEX 5.0 SINGLE-USE 0570-0449,120.578,CDM,272,RC,,,,13020-MAIN,LOCAL,,,,,558,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRONCHOSCOPE BFLEX 5.0 SINGLE-USE 0570-0449,120.578,CDM,272,RC,,,,13020-MAIN,LOCAL,,,,,558,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRONCHOSCOPE BFLEX 5.0 SINGLE-USE 0570-0449,120.578,CDM,272,RC,,,,13020-MAIN,LOCAL,,,,,558,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRONCHOSCOPE BFLEX 5.0 SINGLE-USE 0570-0449,120.578,CDM,272,RC,,,,13020-MAIN,LOCAL,,,,,558,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.5 MG/2ML Suspension 2 mL Ampule,25000000,CDM,250,RC,,,,,,68180098405,NDC,2,ML,62.38,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.5 MG/2ML Suspension 2 mL Ampule,25000000,CDM,250,RC,,,,,,68180098405,NDC,2,ML,62.38,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.5 MG/2ML Suspension 2 mL Ampule,25000000,CDM,250,RC,,,,,,68180098405,NDC,2,ML,62.38,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.5 MG/2ML Suspension 2 mL Ampule,25000000,CDM,250,RC,,,,,,68180098405,NDC,2,ML,62.38,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.5 MG/2ML Suspension 2 mL Ampule,25000000,CDM,250,RC,,,,,,68180098405,NDC,2,ML,62.38,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.5 MG/2ML Suspension 2 mL Ampule,25000000,CDM,250,RC,,,,,,68180098405,NDC,2,ML,62.38,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,781751614,NDC,2,ML,62.38,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,781751614,NDC,2,ML,62.38,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,781751614,NDC,2,ML,62.38,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,781751614,NDC,2,ML,62.38,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,781751614,NDC,2,ML,62.38,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,781751614,NDC,2,ML,62.38,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,781751687,NDC,2,ML,62.38,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,781751687,NDC,2,ML,62.38,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,781751687,NDC,2,ML,62.38,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,781751687,NDC,2,ML,62.38,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,781751687,NDC,2,ML,62.38,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,781751687,NDC,2,ML,62.38,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,16714001905,NDC,2,ML,62.17,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,16714001905,NDC,2,ML,62.17,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,16714001905,NDC,2,ML,62.17,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,16714001905,NDC,2,ML,62.17,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,16714001905,NDC,2,ML,62.17,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,16714001905,NDC,2,ML,62.17,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,16714001930,NDC,2,ML,62.17,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,16714001930,NDC,2,ML,62.17,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,16714001930,NDC,2,ML,62.17,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,16714001930,NDC,2,ML,62.17,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,16714001930,NDC,2,ML,62.17,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,16714001930,NDC,2,ML,62.17,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097031986,NDC,2,ML,62.38,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097031986,NDC,2,ML,62.38,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097031986,NDC,2,ML,62.38,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097031986,NDC,2,ML,62.38,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097031986,NDC,2,ML,62.38,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097031986,NDC,2,ML,62.38,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,93681545,NDC,2,ML,57.71,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,93681545,NDC,2,ML,57.71,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,93681545,NDC,2,ML,57.71,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,93681545,NDC,2,ML,57.71,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,93681545,NDC,2,ML,57.71,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,93681545,NDC,2,ML,57.71,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,93681573,NDC,2,ML,57.71,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,93681573,NDC,2,ML,57.71,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,93681573,NDC,2,ML,57.71,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,93681573,NDC,2,ML,57.71,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,93681573,NDC,2,ML,57.71,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,93681573,NDC,2,ML,57.71,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,487960130,NDC,2,ML,36.47,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,487960130,NDC,2,ML,36.47,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,487960130,NDC,2,ML,36.47,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,487960130,NDC,2,ML,36.47,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,487960130,NDC,2,ML,36.47,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,487960130,NDC,2,ML,36.47,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 1 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097032187,NDC,1,ML,64.97,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 1 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097032187,NDC,1,ML,64.97,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 1 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097032187,NDC,1,ML,64.97,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 1 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097032187,NDC,1,ML,64.97,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 1 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097032187,NDC,1,ML,64.97,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 1 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097032187,NDC,1,ML,64.97,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide-formoterol 80-4.5 MCG/ACT Aerosol 6.9 g Inhaler,63700001,CDM,250,RC,,,,,,186037228,NDC,6.9,GR,937.58,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide-formoterol 80-4.5 MCG/ACT Aerosol 6.9 g Inhaler,63700001,CDM,250,RC,,,,,,186037228,NDC,6.9,GR,937.58,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide-formoterol 80-4.5 MCG/ACT Aerosol 6.9 g Inhaler,63700001,CDM,250,RC,,,,,,186037228,NDC,6.9,GR,937.58,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide-formoterol 80-4.5 MCG/ACT Aerosol 6.9 g Inhaler,63700001,CDM,250,RC,,,,,,186037228,NDC,6.9,GR,937.58,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide-formoterol 80-4.5 MCG/ACT Aerosol 6.9 g Inhaler,63700001,CDM,250,RC,,,,,,186037228,NDC,6.9,GR,937.58,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide-formoterol 80-4.5 MCG/ACT Aerosol 6.9 g Inhaler,63700001,CDM,250,RC,,,,,,186037228,NDC,6.9,GR,937.58,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide-formoterol 160-4.5 MCG/ACT Aerosol 6 g Inhaler,63700001,CDM,250,RC,,,,,,186037028,NDC,6,GR,1078.55,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide-formoterol 160-4.5 MCG/ACT Aerosol 6 g Inhaler,63700001,CDM,250,RC,,,,,,186037028,NDC,6,GR,1078.55,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide-formoterol 160-4.5 MCG/ACT Aerosol 6 g Inhaler,63700001,CDM,250,RC,,,,,,186037028,NDC,6,GR,1078.55,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide-formoterol 160-4.5 MCG/ACT Aerosol 6 g Inhaler,63700001,CDM,250,RC,,,,,,186037028,NDC,6,GR,1078.55,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide-formoterol 160-4.5 MCG/ACT Aerosol 6 g Inhaler,63700001,CDM,250,RC,,,,,,186037028,NDC,6,GR,1078.55,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide-formoterol 160-4.5 MCG/ACT Aerosol 6 g Inhaler,63700001,CDM,250,RC,,,,,,186037028,NDC,6,GR,1078.55,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BULB RESERVOIR SILICONE 400CC,27200000,CDM,272,RC,,,,12463-MAIN,LOCAL,,,,,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BULB RESERVOIR SILICONE 400CC,27200000,CDM,272,RC,,,,12463-MAIN,LOCAL,,,,,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BULB RESERVOIR SILICONE 400CC,27200000,CDM,272,RC,,,,12463-MAIN,LOCAL,,,,,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BULB RESERVOIR SILICONE 400CC,27200000,CDM,272,RC,,,,12463-MAIN,LOCAL,,,,,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BULB RESERVOIR SILICONE 400CC,27200000,CDM,272,RC,,,,12463-MAIN,LOCAL,,,,,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BULB RESERVOIR SILICONE 400CC,27200000,CDM,272,RC,,,,12463-MAIN,LOCAL,,,,,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600701,NDC,10,ML,39.73,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600701,NDC,10,ML,39.73,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600701,NDC,10,ML,39.73,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600701,NDC,10,ML,39.73,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600701,NDC,10,ML,39.73,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600701,NDC,10,ML,39.73,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600710,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600710,NDC,2,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600710,NDC,2,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600710,NDC,2,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600710,NDC,2,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600710,NDC,2,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bumetanide 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,185012901,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bumetanide 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,185012901,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bumetanide 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,185012901,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bumetanide 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,185012901,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bumetanide 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,185012901,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bumetanide 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,185012901,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046204,NDC,30,ML,127.94,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046204,NDC,30,ML,127.94,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046204,NDC,30,ML,127.94,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046204,NDC,30,ML,127.94,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046204,NDC,30,ML,127.94,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046204,NDC,30,ML,127.94,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046201,NDC,30,ML,79.84,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046201,NDC,30,ML,79.84,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046201,NDC,30,ML,79.84,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046201,NDC,30,ML,79.84,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046201,NDC,30,ML,79.84,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046201,NDC,30,ML,79.84,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046203,NDC,30,ML,70.91,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046203,NDC,30,ML,70.91,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046203,NDC,30,ML,70.91,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046203,NDC,30,ML,70.91,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046203,NDC,30,ML,70.91,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046203,NDC,30,ML,70.91,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409115918,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409115918,NDC,1,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409115918,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409115918,NDC,1,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409115918,NDC,1,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409115918,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046401,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046401,NDC,1,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046401,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046401,NDC,1,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046401,NDC,1,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046401,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046417,NDC,10,ML,54.6,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046417,NDC,10,ML,54.6,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046417,NDC,10,ML,54.6,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046417,NDC,10,ML,54.6,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046417,NDC,10,ML,54.6,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046417,NDC,10,ML,54.6,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046402,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046402,NDC,1,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046402,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046402,NDC,1,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046402,NDC,1,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046402,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046437,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046437,NDC,1,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046437,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046437,NDC,1,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046437,NDC,1,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046437,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine 0.25 % Solution 50 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046557,NDC,30,ML,59.84,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine 0.25 % Solution 50 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046557,NDC,30,ML,59.84,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine 0.25 % Solution 50 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046557,NDC,30,ML,59.84,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine 0.25 % Solution 50 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046557,NDC,30,ML,59.84,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine 0.25 % Solution 50 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046557,NDC,30,ML,59.84,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine 0.25 % Solution 50 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046557,NDC,30,ML,59.84,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,409174670,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,409174670,NDC,1,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,409174670,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,409174670,NDC,1,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,409174670,NDC,1,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,409174670,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046801,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046801,NDC,1,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046801,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046801,NDC,1,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046801,NDC,1,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046801,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046817,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046817,NDC,1,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046817,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046817,NDC,1,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046817,NDC,1,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046817,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046837,NDC,30,ML,75.54,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046837,NDC,30,ML,75.54,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046837,NDC,30,ML,75.54,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046837,NDC,30,ML,75.54,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046837,NDC,30,ML,75.54,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046837,NDC,30,ML,75.54,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.25%-EPINEPHrine 1:200,000 0.25% -1:200000 Solution 50 mL Vial",25000000,CDM,250,RC,,,,,,409175250,NDC,30,ML,68.6,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.25%-EPINEPHrine 1:200,000 0.25% -1:200000 Solution 50 mL Vial",25000000,CDM,250,RC,,,,,,409175250,NDC,30,ML,68.6,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.25%-EPINEPHrine 1:200,000 0.25% -1:200000 Solution 50 mL Vial",25000000,CDM,250,RC,,,,,,409175250,NDC,30,ML,68.6,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.25%-EPINEPHrine 1:200,000 0.25% -1:200000 Solution 50 mL Vial",25000000,CDM,250,RC,,,,,,409175250,NDC,30,ML,68.6,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.25%-EPINEPHrine 1:200,000 0.25% -1:200000 Solution 50 mL Vial",25000000,CDM,250,RC,,,,,,409175250,NDC,30,ML,68.6,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.25%-EPINEPHrine 1:200,000 0.25% -1:200000 Solution 50 mL Vial",25000000,CDM,250,RC,,,,,,409175250,NDC,30,ML,68.6,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine in dextrose 0.75-8.25 % Solution 2 mL Ampule,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409176162,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine in dextrose 0.75-8.25 % Solution 2 mL Ampule,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409176162,NDC,2,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine in dextrose 0.75-8.25 % Solution 2 mL Ampule,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409176162,NDC,2,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine in dextrose 0.75-8.25 % Solution 2 mL Ampule,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409176162,NDC,2,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine in dextrose 0.75-8.25 % Solution 2 mL Ampule,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409176162,NDC,2,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine in dextrose 0.75-8.25 % Solution 2 mL Ampule,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409176162,NDC,2,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine liposome 1.3 % Suspension 20 mL Vial,C9290.01,CDM,636,RC,C9290,HCPCS,,,,65250026604,NDC,10,ML,976.43,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine liposome 1.3 % Suspension 20 mL Vial,C9290.01,CDM,636,RC,C9290,HCPCS,,,,65250026604,NDC,10,ML,976.43,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine liposome 1.3 % Suspension 20 mL Vial,C9290.01,CDM,636,RC,C9290,HCPCS,,,,65250026604,NDC,10,ML,976.43,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine liposome 1.3 % Suspension 20 mL Vial,C9290.01,CDM,636,RC,C9290,HCPCS,,,,65250026604,NDC,10,ML,976.43,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine liposome 1.3 % Suspension 20 mL Vial,C9290.01,CDM,636,RC,C9290,HCPCS,,,,65250026604,NDC,10,ML,976.43,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine liposome 1.3 % Suspension 20 mL Vial,C9290.01,CDM,636,RC,C9290,HCPCS,,,,65250026604,NDC,10,ML,976.43,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine PF 0.5 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,55150016910,NDC,10,ML,39.84,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine PF 0.5 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,55150016910,NDC,10,ML,39.84,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine PF 0.5 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,55150016910,NDC,10,ML,39.84,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine PF 0.5 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,55150016910,NDC,10,ML,39.84,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine PF 0.5 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,55150016910,NDC,10,ML,39.84,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine PF 0.5 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,55150016910,NDC,10,ML,39.84,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409116219,NDC,30,ML,32.07,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409116219,NDC,30,ML,32.07,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409116219,NDC,30,ML,32.07,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409116219,NDC,30,ML,32.07,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409116219,NDC,30,ML,32.07,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409116219,NDC,30,ML,32.07,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046601,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046601,NDC,1,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046601,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046601,NDC,1,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046601,NDC,1,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046601,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buprenorphine 2 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,50383092493,NDC,1,EA,24.34,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buprenorphine 2 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,50383092493,NDC,1,EA,24.34,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buprenorphine 2 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,50383092493,NDC,1,EA,24.34,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buprenorphine 2 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,50383092493,NDC,1,EA,24.34,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buprenorphine 2 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,50383092493,NDC,1,EA,24.34,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buprenorphine 2 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,50383092493,NDC,1,EA,24.34,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buprenorphine 5 MCG/HR PATCH WEEKLY 4 Each Box,63700001,CDM,250,RC,,,,,,42858075040,NDC,1,EA,330.52,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buprenorphine 5 MCG/HR PATCH WEEKLY 4 Each Box,63700001,CDM,250,RC,,,,,,42858075040,NDC,1,EA,330.52,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buprenorphine 5 MCG/HR PATCH WEEKLY 4 Each Box,63700001,CDM,250,RC,,,,,,42858075040,NDC,1,EA,330.52,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buprenorphine 5 MCG/HR PATCH WEEKLY 4 Each Box,63700001,CDM,250,RC,,,,,,42858075040,NDC,1,EA,330.52,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buprenorphine 5 MCG/HR PATCH WEEKLY 4 Each Box,63700001,CDM,250,RC,,,,,,42858075040,NDC,1,EA,330.52,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buprenorphine 5 MCG/HR PATCH WEEKLY 4 Each Box,63700001,CDM,250,RC,,,,,,42858075040,NDC,1,EA,330.52,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buprenorphine 8 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,54017713,NDC,1,EA,41.56,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buprenorphine 8 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,54017713,NDC,1,EA,41.56,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buprenorphine 8 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,54017713,NDC,1,EA,41.56,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buprenorphine 8 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,54017713,NDC,1,EA,41.56,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buprenorphine 8 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,54017713,NDC,1,EA,41.56,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buprenorphine 8 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,54017713,NDC,1,EA,41.56,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buprenorphine 75 MCG FILM 1 Each Package,63700001,CDM,250,RC,,,,,,59385002101,NDC,1,EA,35.68,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buprenorphine 75 MCG FILM 1 Each Package,63700001,CDM,250,RC,,,,,,59385002101,NDC,1,EA,35.68,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buprenorphine 75 MCG FILM 1 Each Package,63700001,CDM,250,RC,,,,,,59385002101,NDC,1,EA,35.68,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buprenorphine 75 MCG FILM 1 Each Package,63700001,CDM,250,RC,,,,,,59385002101,NDC,1,EA,35.68,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buprenorphine 75 MCG FILM 1 Each Package,63700001,CDM,250,RC,,,,,,59385002101,NDC,1,EA,35.68,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buprenorphine 75 MCG FILM 1 Each Package,63700001,CDM,250,RC,,,,,,59385002101,NDC,1,EA,35.68,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buprenorphine 75 MCG FILM 60 Each Box,63700001,CDM,250,RC,,,,,,59385002160,NDC,1,EA,29.92,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buprenorphine 75 MCG FILM 60 Each Box,63700001,CDM,250,RC,,,,,,59385002160,NDC,1,EA,29.92,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buprenorphine 75 MCG FILM 60 Each Box,63700001,CDM,250,RC,,,,,,59385002160,NDC,1,EA,29.92,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buprenorphine 75 MCG FILM 60 Each Box,63700001,CDM,250,RC,,,,,,59385002160,NDC,1,EA,29.92,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buprenorphine 75 MCG FILM 60 Each Box,63700001,CDM,250,RC,,,,,,59385002160,NDC,1,EA,29.92,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buprenorphine 75 MCG FILM 60 Each Box,63700001,CDM,250,RC,,,,,,59385002160,NDC,1,EA,29.92,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buPROPion SR 150 MG Tablet Extended Release 12 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084070895,NDC,0.666666667,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buPROPion SR 150 MG Tablet Extended Release 12 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084070895,NDC,0.666666667,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buPROPion SR 150 MG Tablet Extended Release 12 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084070895,NDC,0.666666667,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buPROPion SR 150 MG Tablet Extended Release 12 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084070895,NDC,0.666666667,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buPROPion SR 150 MG Tablet Extended Release 12 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084070895,NDC,0.666666667,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buPROPion SR 150 MG Tablet Extended Release 12 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084070895,NDC,0.666666667,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buPROPion SR 150 MG Tablet Extended Release 12 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,68084070825,NDC,0.666666667,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buPROPion SR 150 MG Tablet Extended Release 12 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,68084070825,NDC,0.666666667,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buPROPion SR 150 MG Tablet Extended Release 12 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,68084070825,NDC,0.666666667,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buPROPion SR 150 MG Tablet Extended Release 12 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,68084070825,NDC,0.666666667,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buPROPion SR 150 MG Tablet Extended Release 12 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,68084070825,NDC,0.666666667,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buPROPion SR 150 MG Tablet Extended Release 12 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,68084070825,NDC,0.666666667,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buPROPion XL 150 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,70436001004,NDC,1,EA,23.14,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buPROPion XL 150 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,70436001004,NDC,1,EA,23.14,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buPROPion XL 150 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,70436001004,NDC,1,EA,23.14,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buPROPion XL 150 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,70436001004,NDC,1,EA,23.14,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buPROPion XL 150 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,70436001004,NDC,1,EA,23.14,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buPROPion XL 150 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,70436001004,NDC,1,EA,23.14,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buPROPion XL 150 MG Tablet Extended Release 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,904708404,NDC,1,EA,8.48,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buPROPion XL 150 MG Tablet Extended Release 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,904708404,NDC,1,EA,8.48,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buPROPion XL 150 MG Tablet Extended Release 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,904708404,NDC,1,EA,8.48,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buPROPion XL 150 MG Tablet Extended Release 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,904708404,NDC,1,EA,8.48,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buPROPion XL 150 MG Tablet Extended Release 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,904708404,NDC,1,EA,8.48,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buPROPion XL 150 MG Tablet Extended Release 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,904708404,NDC,1,EA,8.48,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BURETROL ADD ON SET 150ML,120.38,CDM,272,RC,A4222,HCPCS,,11118-MAIN,LOCAL,,,,,18,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BURETROL ADD ON SET 150ML,120.38,CDM,272,RC,A4222,HCPCS,,11118-MAIN,LOCAL,,,,,18,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BURETROL ADD ON SET 150ML,120.38,CDM,272,RC,A4222,HCPCS,,11118-MAIN,LOCAL,,,,,18,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BURETROL ADD ON SET 150ML,120.38,CDM,272,RC,A4222,HCPCS,,11118-MAIN,LOCAL,,,,,18,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BURETROL ADD ON SET 150ML,120.38,CDM,272,RC,A4222,HCPCS,,11118-MAIN,LOCAL,,,,,18,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BURETROL ADD ON SET 150ML,120.38,CDM,272,RC,A4222,HCPCS,,11118-MAIN,LOCAL,,,,,18,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
busPIRone 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079098501,NDC,1,EA,4.14,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
busPIRone 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079098501,NDC,1,EA,4.14,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
busPIRone 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079098501,NDC,1,EA,4.14,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
busPIRone 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079098501,NDC,1,EA,4.14,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
busPIRone 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079098501,NDC,1,EA,4.14,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
busPIRone 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079098501,NDC,1,EA,4.14,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
busPIRone 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079098520,NDC,1,EA,4.14,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
busPIRone 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079098520,NDC,1,EA,4.14,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
busPIRone 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079098520,NDC,1,EA,4.14,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
busPIRone 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079098520,NDC,1,EA,4.14,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
busPIRone 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079098520,NDC,1,EA,4.14,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
busPIRone 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079098520,NDC,1,EA,4.14,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
butamben-tetracaine-benzocaine 2-2-14 % Aerosol 5 g Bottle,25000000,CDM,250,RC,,,,,,10223020104,NDC,5,GR,375.52,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
butamben-tetracaine-benzocaine 2-2-14 % Aerosol 5 g Bottle,25000000,CDM,250,RC,,,,,,10223020104,NDC,5,GR,375.52,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
butamben-tetracaine-benzocaine 2-2-14 % Aerosol 5 g Bottle,25000000,CDM,250,RC,,,,,,10223020104,NDC,5,GR,375.52,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
butamben-tetracaine-benzocaine 2-2-14 % Aerosol 5 g Bottle,25000000,CDM,250,RC,,,,,,10223020104,NDC,5,GR,375.52,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
butamben-tetracaine-benzocaine 2-2-14 % Aerosol 5 g Bottle,25000000,CDM,250,RC,,,,,,10223020104,NDC,5,GR,375.52,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
butamben-tetracaine-benzocaine 2-2-14 % Aerosol 5 g Bottle,25000000,CDM,250,RC,,,,,,10223020104,NDC,5,GR,375.52,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
butamben-tetracaine-benzocaine 2-2-14 % Aerosol 20 g Bottle,25000000,CDM,250,RC,,,,,,10223020103,NDC,20,GR,589.76,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
butamben-tetracaine-benzocaine 2-2-14 % Aerosol 20 g Bottle,25000000,CDM,250,RC,,,,,,10223020103,NDC,20,GR,589.76,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
butamben-tetracaine-benzocaine 2-2-14 % Aerosol 20 g Bottle,25000000,CDM,250,RC,,,,,,10223020103,NDC,20,GR,589.76,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
butamben-tetracaine-benzocaine 2-2-14 % Aerosol 20 g Bottle,25000000,CDM,250,RC,,,,,,10223020103,NDC,20,GR,589.76,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
butamben-tetracaine-benzocaine 2-2-14 % Aerosol 20 g Bottle,25000000,CDM,250,RC,,,,,,10223020103,NDC,20,GR,589.76,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
butamben-tetracaine-benzocaine 2-2-14 % Aerosol 20 g Bottle,25000000,CDM,250,RC,,,,,,10223020103,NDC,20,GR,589.76,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
C Diff Amplified Probe,PX87493,CDM,300,RC,87493,CPT,,,,,,,,179,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
C Diff Amplified Probe,PX87493,CDM,300,RC,87493,CPT,,,,,,,,179,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
C Diff Amplified Probe,PX87493,CDM,300,RC,87493,CPT,,,,,,,,179,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
C Diff Amplified Probe,PX87493,CDM,300,RC,87493,CPT,,,,,,,,179,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
C Diff Amplified Probe,PX87493,CDM,300,RC,87493,CPT,,,,,,,,179,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
C Diff Amplified Probe,PX87493,CDM,300,RC,87493,CPT,,,,,,,,179,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
C-COLLAR ASPEN REGULAR 79-83365,120.25,CDM,274,RC,L0140,HCPCS,,167-MAIN,LOCAL,,,,,216,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
C-COLLAR ASPEN REGULAR 79-83365,120.25,CDM,274,RC,L0140,HCPCS,,167-MAIN,LOCAL,,,,,216,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
C-COLLAR ASPEN REGULAR 79-83365,120.25,CDM,274,RC,L0140,HCPCS,,167-MAIN,LOCAL,,,,,216,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
C-COLLAR ASPEN REGULAR 79-83365,120.25,CDM,274,RC,L0140,HCPCS,,167-MAIN,LOCAL,,,,,216,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
C-COLLAR ASPEN REGULAR 79-83365,120.25,CDM,274,RC,L0140,HCPCS,,167-MAIN,LOCAL,,,,,216,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
C-COLLAR ASPEN REGULAR 79-83365,120.25,CDM,274,RC,L0140,HCPCS,,167-MAIN,LOCAL,,,,,216,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
C-COLLAR ASPEN TALL 79-83367,120.25,CDM,274,RC,L0140,HCPCS,,164-MAIN,LOCAL,,,,,216,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
C-COLLAR ASPEN TALL 79-83367,120.25,CDM,274,RC,L0140,HCPCS,,164-MAIN,LOCAL,,,,,216,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
C-COLLAR ASPEN TALL 79-83367,120.25,CDM,274,RC,L0140,HCPCS,,164-MAIN,LOCAL,,,,,216,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
C-COLLAR ASPEN TALL 79-83367,120.25,CDM,274,RC,L0140,HCPCS,,164-MAIN,LOCAL,,,,,216,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
C-COLLAR ASPEN TALL 79-83367,120.25,CDM,274,RC,L0140,HCPCS,,164-MAIN,LOCAL,,,,,216,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
C-COLLAR ASPEN TALL 79-83367,120.25,CDM,274,RC,L0140,HCPCS,,164-MAIN,LOCAL,,,,,216,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
C-COLLAR ASPEN X-TALL 79-83368,120.25,CDM,274,RC,L0140,HCPCS,,168-MAIN,LOCAL,,,,,216,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
C-COLLAR ASPEN X-TALL 79-83368,120.25,CDM,274,RC,L0140,HCPCS,,168-MAIN,LOCAL,,,,,216,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
C-COLLAR ASPEN X-TALL 79-83368,120.25,CDM,274,RC,L0140,HCPCS,,168-MAIN,LOCAL,,,,,216,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
C-COLLAR ASPEN X-TALL 79-83368,120.25,CDM,274,RC,L0140,HCPCS,,168-MAIN,LOCAL,,,,,216,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
C-COLLAR ASPEN X-TALL 79-83368,120.25,CDM,274,RC,L0140,HCPCS,,168-MAIN,LOCAL,,,,,216,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
C-COLLAR ASPEN X-TALL 79-83368,120.25,CDM,274,RC,L0140,HCPCS,,168-MAIN,LOCAL,,,,,216,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
C-Peptide - Ref,PX8468190,CDM,300,RC,84681,CPT,90,,,,,,,180,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
C-Peptide - Ref,PX8468190,CDM,300,RC,84681,CPT,90,,,,,,,180,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
C-Peptide - Ref,PX8468190,CDM,300,RC,84681,CPT,90,,,,,,,180,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
C-Peptide - Ref,PX8468190,CDM,300,RC,84681,CPT,90,,,,,,,180,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
C-Peptide - Ref,PX8468190,CDM,300,RC,84681,CPT,90,,,,,,,180,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
C-Peptide - Ref,PX8468190,CDM,300,RC,84681,CPT,90,,,,,,,180,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
C-Reactive Protein,PX86140,CDM,300,RC,86140,CPT,,,,,,,,191,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
C-Reactive Protein,PX86140,CDM,300,RC,86140,CPT,,,,,,,,191,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
C-Reactive Protein,PX86140,CDM,300,RC,86140,CPT,,,,,,,,191,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
C-Reactive Protein,PX86140,CDM,300,RC,86140,CPT,,,,,,,,191,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
C-Reactive Protein,PX86140,CDM,300,RC,86140,CPT,,,,,,,,191,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
C-Reactive Protein,PX86140,CDM,300,RC,86140,CPT,,,,,,,,191,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ca 19-9,PX86301,CDM,300,RC,86301,CPT,,,,,,,,116,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ca 19-9,PX86301,CDM,300,RC,86301,CPT,,,,,,,,116,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ca 19-9,PX86301,CDM,300,RC,86301,CPT,,,,,,,,116,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ca 19-9,PX86301,CDM,300,RC,86301,CPT,,,,,,,,116,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ca 19-9,PX86301,CDM,300,RC,86301,CPT,,,,,,,,116,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ca 19-9,PX86301,CDM,300,RC,86301,CPT,,,,,,,,116,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cabazitaxel 60 MG/1.5ML Solution 6 mL Vial,J9043.01,CDM,636,RC,J9043,HCPCS,,,,24582411,NDC,6,ML,28293.07,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cabazitaxel 60 MG/1.5ML Solution 6 mL Vial,J9043.01,CDM,636,RC,J9043,HCPCS,,,,24582411,NDC,6,ML,28293.07,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cabazitaxel 60 MG/1.5ML Solution 6 mL Vial,J9043.01,CDM,636,RC,J9043,HCPCS,,,,24582411,NDC,6,ML,28293.07,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cabazitaxel 60 MG/1.5ML Solution 6 mL Vial,J9043.01,CDM,636,RC,J9043,HCPCS,,,,24582411,NDC,6,ML,28293.07,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cabazitaxel 60 MG/1.5ML Solution 6 mL Vial,J9043.01,CDM,636,RC,J9043,HCPCS,,,,24582411,NDC,6,ML,28293.07,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cabazitaxel 60 MG/1.5ML Solution 6 mL Vial,J9043.01,CDM,636,RC,J9043,HCPCS,,,,24582411,NDC,6,ML,28293.07,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cadexomer iodine 0.9 % Gel 40 g Tube,63700001,CDM,250,RC,,,,,,40565012249,NDC,40,GR,333.86,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cadexomer iodine 0.9 % Gel 40 g Tube,63700001,CDM,250,RC,,,,,,40565012249,NDC,40,GR,333.86,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cadexomer iodine 0.9 % Gel 40 g Tube,63700001,CDM,250,RC,,,,,,40565012249,NDC,40,GR,333.86,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cadexomer iodine 0.9 % Gel 40 g Tube,63700001,CDM,250,RC,,,,,,40565012249,NDC,40,GR,333.86,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cadexomer iodine 0.9 % Gel 40 g Tube,63700001,CDM,250,RC,,,,,,40565012249,NDC,40,GR,333.86,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cadexomer iodine 0.9 % Gel 40 g Tube,63700001,CDM,250,RC,,,,,,40565012249,NDC,40,GR,333.86,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
caffeine citrate 60 MG/3ML Solution 3 mL Vial,J0706.01,CDM,636,RC,J0706,HCPCS,,,,63323040704,NDC,3,ML,73.84,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
caffeine citrate 60 MG/3ML Solution 3 mL Vial,J0706.01,CDM,636,RC,J0706,HCPCS,,,,63323040704,NDC,3,ML,73.84,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
caffeine citrate 60 MG/3ML Solution 3 mL Vial,J0706.01,CDM,636,RC,J0706,HCPCS,,,,63323040704,NDC,3,ML,73.84,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
caffeine citrate 60 MG/3ML Solution 3 mL Vial,J0706.01,CDM,636,RC,J0706,HCPCS,,,,63323040704,NDC,3,ML,73.84,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
caffeine citrate 60 MG/3ML Solution 3 mL Vial,J0706.01,CDM,636,RC,J0706,HCPCS,,,,63323040704,NDC,3,ML,73.84,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
caffeine citrate 60 MG/3ML Solution 3 mL Vial,J0706.01,CDM,636,RC,J0706,HCPCS,,,,63323040704,NDC,3,ML,73.84,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcitonin (salmon) 200 UNIT/ACT Solution 3.7 mL Bottle,63700001,CDM,250,RC,,,,,,60505082306,NDC,3.7,ML,489.57,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcitonin (salmon) 200 UNIT/ACT Solution 3.7 mL Bottle,63700001,CDM,250,RC,,,,,,60505082306,NDC,3.7,ML,489.57,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcitonin (salmon) 200 UNIT/ACT Solution 3.7 mL Bottle,63700001,CDM,250,RC,,,,,,60505082306,NDC,3.7,ML,489.57,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcitonin (salmon) 200 UNIT/ACT Solution 3.7 mL Bottle,63700001,CDM,250,RC,,,,,,60505082306,NDC,3.7,ML,489.57,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcitonin (salmon) 200 UNIT/ACT Solution 3.7 mL Bottle,63700001,CDM,250,RC,,,,,,60505082306,NDC,3.7,ML,489.57,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcitonin (salmon) 200 UNIT/ACT Solution 3.7 mL Bottle,63700001,CDM,250,RC,,,,,,60505082306,NDC,3.7,ML,489.57,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcitRIOL 0.25 MCG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687034511,NDC,1,EA,4.12,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcitRIOL 0.25 MCG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687034511,NDC,1,EA,4.12,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcitRIOL 0.25 MCG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687034511,NDC,1,EA,4.12,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcitRIOL 0.25 MCG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687034511,NDC,1,EA,4.12,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcitRIOL 0.25 MCG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687034511,NDC,1,EA,4.12,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcitRIOL 0.25 MCG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687034511,NDC,1,EA,4.12,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcitRIOL 0.25 MCG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155011801,NDC,1,EA,6.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcitRIOL 0.25 MCG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155011801,NDC,1,EA,6.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcitRIOL 0.25 MCG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155011801,NDC,1,EA,6.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcitRIOL 0.25 MCG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155011801,NDC,1,EA,6.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcitRIOL 0.25 MCG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155011801,NDC,1,EA,6.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcitRIOL 0.25 MCG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155011801,NDC,1,EA,6.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Calcium - Ref,PX8231090,CDM,300,RC,82310,CPT,90,,,,,,,10,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Calcium - Ref,PX8231090,CDM,300,RC,82310,CPT,90,,,,,,,10,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Calcium - Ref,PX8231090,CDM,300,RC,82310,CPT,90,,,,,,,10,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Calcium - Ref,PX8231090,CDM,300,RC,82310,CPT,90,,,,,,,10,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Calcium - Ref,PX8231090,CDM,300,RC,82310,CPT,90,,,,,,,10,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Calcium - Ref,PX8231090,CDM,300,RC,82310,CPT,90,,,,,,,10,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcium carb-cholecalciferol 600-10 mg-mcg (600-400 mg-unit) Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,20555001700,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcium carb-cholecalciferol 600-10 mg-mcg (600-400 mg-unit) Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,20555001700,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcium carb-cholecalciferol 600-10 mg-mcg (600-400 mg-unit) Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,20555001700,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcium carb-cholecalciferol 600-10 mg-mcg (600-400 mg-unit) Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,20555001700,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcium carb-cholecalciferol 600-10 mg-mcg (600-400 mg-unit) Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,20555001700,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcium carb-cholecalciferol 600-10 mg-mcg (600-400 mg-unit) Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,20555001700,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcium carbonate 500 MG Tablet Chewable 500 Each Box,63700001,CDM,250,RC,,,,,,66553000401,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcium carbonate 500 MG Tablet Chewable 500 Each Box,63700001,CDM,250,RC,,,,,,66553000401,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcium carbonate 500 MG Tablet Chewable 500 Each Box,63700001,CDM,250,RC,,,,,,66553000401,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcium carbonate 500 MG Tablet Chewable 500 Each Box,63700001,CDM,250,RC,,,,,,66553000401,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcium carbonate 500 MG Tablet Chewable 500 Each Box,63700001,CDM,250,RC,,,,,,66553000401,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcium carbonate 500 MG Tablet Chewable 500 Each Box,63700001,CDM,250,RC,,,,,,66553000401,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcium CHLORIDE 10 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409163140,NDC,10,ML,64.85,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcium CHLORIDE 10 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409163140,NDC,10,ML,64.85,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcium CHLORIDE 10 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409163140,NDC,10,ML,64.85,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcium CHLORIDE 10 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409163140,NDC,10,ML,64.85,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcium CHLORIDE 10 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409163140,NDC,10,ML,64.85,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcium CHLORIDE 10 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409163140,NDC,10,ML,64.85,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcium CHLORIDE 10 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,76329330401,NDC,10,ML,79.51,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcium CHLORIDE 10 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,76329330401,NDC,10,ML,79.51,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcium CHLORIDE 10 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,76329330401,NDC,10,ML,79.51,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcium CHLORIDE 10 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,76329330401,NDC,10,ML,79.51,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcium CHLORIDE 10 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,76329330401,NDC,10,ML,79.51,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcium CHLORIDE 10 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,76329330401,NDC,10,ML,79.51,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323031119,NDC,10,ML,66.39,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323031119,NDC,10,ML,66.39,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323031119,NDC,10,ML,66.39,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323031119,NDC,10,ML,66.39,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323031119,NDC,10,ML,66.39,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323031119,NDC,10,ML,66.39,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036001,NDC,10,ML,80.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036001,NDC,10,ML,80.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036001,NDC,10,ML,80.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036001,NDC,10,ML,80.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036001,NDC,10,ML,80.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036001,NDC,10,ML,80.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036019,NDC,10,ML,86.23,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036019,NDC,10,ML,86.23,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036019,NDC,10,ML,86.23,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036019,NDC,10,ML,86.23,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036019,NDC,10,ML,86.23,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036019,NDC,10,ML,86.23,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Calcium Total,PX82310,CDM,300,RC,82310,CPT,,,,,,,,57,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Calcium Total,PX82310,CDM,300,RC,82310,CPT,,,,,,,,57,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Calcium Total,PX82310,CDM,300,RC,82310,CPT,,,,,,,,57,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Calcium Total,PX82310,CDM,300,RC,82310,CPT,,,,,,,,57,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Calcium Total,PX82310,CDM,300,RC,82310,CPT,,,,,,,,57,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Calcium Total,PX82310,CDM,300,RC,82310,CPT,,,,,,,,57,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Calculus, Infrared Spec - Ref",PX8236590,CDM,300,RC,82365,CPT,90,,,,,,,145,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Calculus, Infrared Spec - Ref",PX8236590,CDM,300,RC,82365,CPT,90,,,,,,,145,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Calculus, Infrared Spec - Ref",PX8236590,CDM,300,RC,82365,CPT,90,,,,,,,145,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Calculus, Infrared Spec - Ref",PX8236590,CDM,300,RC,82365,CPT,90,,,,,,,145,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Calculus, Infrared Spec - Ref",PX8236590,CDM,300,RC,82365,CPT,90,,,,,,,145,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Calculus, Infrared Spec - Ref",PX8236590,CDM,300,RC,82365,CPT,90,,,,,,,145,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Calprotectin, Fecal - Ref",PX8399390,CDM,300,RC,83993,CPT,90,,,,,,,401,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Calprotectin, Fecal - Ref",PX8399390,CDM,300,RC,83993,CPT,90,,,,,,,401,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Calprotectin, Fecal - Ref",PX8399390,CDM,300,RC,83993,CPT,90,,,,,,,401,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Calprotectin, Fecal - Ref",PX8399390,CDM,300,RC,83993,CPT,90,,,,,,,401,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Calprotectin, Fecal - Ref",PX8399390,CDM,300,RC,83993,CPT,90,,,,,,,401,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Calprotectin, Fecal - Ref",PX8399390,CDM,300,RC,83993,CPT,90,,,,,,,401,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Calr Gene Analysis Common Variants in Exon 9 - Ref,PX8121990,CDM,300,RC,81219,CPT,90,,,,,,,534,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Calr Gene Analysis Common Variants in Exon 9 - Ref,PX8121990,CDM,300,RC,81219,CPT,90,,,,,,,534,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Calr Gene Analysis Common Variants in Exon 9 - Ref,PX8121990,CDM,300,RC,81219,CPT,90,,,,,,,534,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Calr Gene Analysis Common Variants in Exon 9 - Ref,PX8121990,CDM,300,RC,81219,CPT,90,,,,,,,534,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Calr Gene Analysis Common Variants in Exon 9 - Ref,PX8121990,CDM,300,RC,81219,CPT,90,,,,,,,534,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Calr Gene Analysis Common Variants in Exon 9 - Ref,PX8121990,CDM,300,RC,81219,CPT,90,,,,,,,534,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Canalith Repositioning,PX95992,CDM,420,RC,95992,CPT,,,,,,,,128,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Canalith Repositioning,PX95992,CDM,420,RC,95992,CPT,,,,,,,,128,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Canalith Repositioning,PX95992,CDM,420,RC,95992,CPT,,,,,,,,128,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Canalith Repositioning,PX95992,CDM,420,RC,95992,CPT,,,,,,,,128,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Canalith Repositioning,PX95992,CDM,420,RC,95992,CPT,,,,,,,,128,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Canalith Repositioning,PX95992,CDM,420,RC,95992,CPT,,,,,,,,128,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
candesartan 32 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,49884066109,NDC,0.125,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
candesartan 32 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,49884066109,NDC,0.125,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
candesartan 32 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,49884066109,NDC,0.125,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
candesartan 32 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,49884066109,NDC,0.125,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
candesartan 32 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,49884066109,NDC,0.125,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
candesartan 32 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,49884066109,NDC,0.125,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Candida Dna Dir Probe,PX87480,CDM,300,RC,87480,CPT,,,,,,,,127,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Candida Dna Dir Probe,PX87480,CDM,300,RC,87480,CPT,,,,,,,,127,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Candida Dna Dir Probe,PX87480,CDM,300,RC,87480,CPT,,,,,,,,127,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Candida Dna Dir Probe,PX87480,CDM,300,RC,87480,CPT,,,,,,,,127,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Candida Dna Dir Probe,PX87480,CDM,300,RC,87480,CPT,,,,,,,,127,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Candida Dna Dir Probe,PX87480,CDM,300,RC,87480,CPT,,,,,,,,127,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cannabinoids, Natural - Ref",PX8034990,CDM,300,RC,80349,CPT,90,,,,,,,49,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cannabinoids, Natural - Ref",PX8034990,CDM,300,RC,80349,CPT,90,,,,,,,49,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cannabinoids, Natural - Ref",PX8034990,CDM,300,RC,80349,CPT,90,,,,,,,49,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cannabinoids, Natural - Ref",PX8034990,CDM,300,RC,80349,CPT,90,,,,,,,49,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cannabinoids, Natural - Ref",PX8034990,CDM,300,RC,80349,CPT,90,,,,,,,49,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cannabinoids, Natural - Ref",PX8034990,CDM,300,RC,80349,CPT,90,,,,,,,49,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA ADULT LARGE OPTIFLOW OPT946,120.495,CDM,271,RC,A4615,HCPCS,,11622-MAIN,LOCAL,,,,,44,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA ADULT LARGE OPTIFLOW OPT946,120.495,CDM,271,RC,A4615,HCPCS,,11622-MAIN,LOCAL,,,,,44,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA ADULT LARGE OPTIFLOW OPT946,120.495,CDM,271,RC,A4615,HCPCS,,11622-MAIN,LOCAL,,,,,44,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA ADULT LARGE OPTIFLOW OPT946,120.495,CDM,271,RC,A4615,HCPCS,,11622-MAIN,LOCAL,,,,,44,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA ADULT LARGE OPTIFLOW OPT946,120.495,CDM,271,RC,A4615,HCPCS,,11622-MAIN,LOCAL,,,,,44,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA ADULT LARGE OPTIFLOW OPT946,120.495,CDM,271,RC,A4615,HCPCS,,11622-MAIN,LOCAL,,,,,44,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA ADULT MEDIUM OPTIFLOW OPT944,120.495,CDM,271,RC,A4615,HCPCS,,11621-MAIN,LOCAL,,,,,44,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA ADULT MEDIUM OPTIFLOW OPT944,120.495,CDM,271,RC,A4615,HCPCS,,11621-MAIN,LOCAL,,,,,44,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA ADULT MEDIUM OPTIFLOW OPT944,120.495,CDM,271,RC,A4615,HCPCS,,11621-MAIN,LOCAL,,,,,44,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA ADULT MEDIUM OPTIFLOW OPT944,120.495,CDM,271,RC,A4615,HCPCS,,11621-MAIN,LOCAL,,,,,44,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA ADULT MEDIUM OPTIFLOW OPT944,120.495,CDM,271,RC,A4615,HCPCS,,11621-MAIN,LOCAL,,,,,44,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA ADULT MEDIUM OPTIFLOW OPT944,120.495,CDM,271,RC,A4615,HCPCS,,11621-MAIN,LOCAL,,,,,44,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA ADULT SMALL OPTIFLOW OPT942,120.495,CDM,271,RC,A4615,HCPCS,,11620-MAIN,LOCAL,,,,,44,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA ADULT SMALL OPTIFLOW OPT942,120.495,CDM,271,RC,A4615,HCPCS,,11620-MAIN,LOCAL,,,,,44,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA ADULT SMALL OPTIFLOW OPT942,120.495,CDM,271,RC,A4615,HCPCS,,11620-MAIN,LOCAL,,,,,44,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA ADULT SMALL OPTIFLOW OPT942,120.495,CDM,271,RC,A4615,HCPCS,,11620-MAIN,LOCAL,,,,,44,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA ADULT SMALL OPTIFLOW OPT942,120.495,CDM,271,RC,A4615,HCPCS,,11620-MAIN,LOCAL,,,,,44,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA ADULT SMALL OPTIFLOW OPT942,120.495,CDM,271,RC,A4615,HCPCS,,11620-MAIN,LOCAL,,,,,44,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA FOR INJECTION 1.8MM WITH 3MM LUER CONNECTION 8383.65,27200000,CDM,272,RC,,,,12004-MAIN,LOCAL,,,,,234,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA FOR INJECTION 1.8MM WITH 3MM LUER CONNECTION 8383.65,27200000,CDM,272,RC,,,,12004-MAIN,LOCAL,,,,,234,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA FOR INJECTION 1.8MM WITH 3MM LUER CONNECTION 8383.65,27200000,CDM,272,RC,,,,12004-MAIN,LOCAL,,,,,234,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA FOR INJECTION 1.8MM WITH 3MM LUER CONNECTION 8383.65,27200000,CDM,272,RC,,,,12004-MAIN,LOCAL,,,,,234,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA FOR INJECTION 1.8MM WITH 3MM LUER CONNECTION 8383.65,27200000,CDM,272,RC,,,,12004-MAIN,LOCAL,,,,,234,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA FOR INJECTION 1.8MM WITH 3MM LUER CONNECTION 8383.65,27200000,CDM,272,RC,,,,12004-MAIN,LOCAL,,,,,234,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA JUNIOR 2 LARGE OPTIFLOW OJR416VT,120.561,CDM,272,RC,A4615,HCPCS,,12645-MAIN,LOCAL,,,,,98,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA JUNIOR 2 LARGE OPTIFLOW OJR416VT,120.561,CDM,272,RC,A4615,HCPCS,,12645-MAIN,LOCAL,,,,,98,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA JUNIOR 2 LARGE OPTIFLOW OJR416VT,120.561,CDM,272,RC,A4615,HCPCS,,12645-MAIN,LOCAL,,,,,98,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA JUNIOR 2 LARGE OPTIFLOW OJR416VT,120.561,CDM,272,RC,A4615,HCPCS,,12645-MAIN,LOCAL,,,,,98,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA JUNIOR 2 LARGE OPTIFLOW OJR416VT,120.561,CDM,272,RC,A4615,HCPCS,,12645-MAIN,LOCAL,,,,,98,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA JUNIOR 2 LARGE OPTIFLOW OJR416VT,120.561,CDM,272,RC,A4615,HCPCS,,12645-MAIN,LOCAL,,,,,98,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA JUNIOR 2 MEDIUM OPTIFLOW OJR414VT,120.561,CDM,272,RC,A4615,HCPCS,,12644-MAIN,LOCAL,,,,,98,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA JUNIOR 2 MEDIUM OPTIFLOW OJR414VT,120.561,CDM,272,RC,A4615,HCPCS,,12644-MAIN,LOCAL,,,,,98,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA JUNIOR 2 MEDIUM OPTIFLOW OJR414VT,120.561,CDM,272,RC,A4615,HCPCS,,12644-MAIN,LOCAL,,,,,98,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA JUNIOR 2 MEDIUM OPTIFLOW OJR414VT,120.561,CDM,272,RC,A4615,HCPCS,,12644-MAIN,LOCAL,,,,,98,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA JUNIOR 2 MEDIUM OPTIFLOW OJR414VT,120.561,CDM,272,RC,A4615,HCPCS,,12644-MAIN,LOCAL,,,,,98,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA JUNIOR 2 MEDIUM OPTIFLOW OJR414VT,120.561,CDM,272,RC,A4615,HCPCS,,12644-MAIN,LOCAL,,,,,98,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA OPTIFLOW JUNIOR 2 SMALL OJR412VT,120.561,CDM,272,RC,A4615,HCPCS,,12643-MAIN,LOCAL,,,,,98,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA OPTIFLOW JUNIOR 2 SMALL OJR412VT,120.561,CDM,272,RC,A4615,HCPCS,,12643-MAIN,LOCAL,,,,,98,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA OPTIFLOW JUNIOR 2 SMALL OJR412VT,120.561,CDM,272,RC,A4615,HCPCS,,12643-MAIN,LOCAL,,,,,98,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA OPTIFLOW JUNIOR 2 SMALL OJR412VT,120.561,CDM,272,RC,A4615,HCPCS,,12643-MAIN,LOCAL,,,,,98,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA OPTIFLOW JUNIOR 2 SMALL OJR412VT,120.561,CDM,272,RC,A4615,HCPCS,,12643-MAIN,LOCAL,,,,,98,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA OPTIFLOW JUNIOR 2 SMALL OJR412VT,120.561,CDM,272,RC,A4615,HCPCS,,12643-MAIN,LOCAL,,,,,98,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA OPTIFLOW JUNIOR2+ XXL OJR520,120.494,CDM,271,RC,A4615,HCPCS,,11619-MAIN,LOCAL,,,,,84,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA OPTIFLOW JUNIOR2+ XXL OJR520,120.494,CDM,271,RC,A4615,HCPCS,,11619-MAIN,LOCAL,,,,,84,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA OPTIFLOW JUNIOR2+ XXL OJR520,120.494,CDM,271,RC,A4615,HCPCS,,11619-MAIN,LOCAL,,,,,84,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA OPTIFLOW JUNIOR2+ XXL OJR520,120.494,CDM,271,RC,A4615,HCPCS,,11619-MAIN,LOCAL,,,,,84,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA OPTIFLOW JUNIOR2+ XXL OJR520,120.494,CDM,271,RC,A4615,HCPCS,,11619-MAIN,LOCAL,,,,,84,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA OPTIFLOW JUNIOR2+ XXL OJR520,120.494,CDM,271,RC,A4615,HCPCS,,11619-MAIN,LOCAL,,,,,84,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA SEAL 5-12MM UNIVERSAL 470500,27200000,CDM,272,RC,,,,12885-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA SEAL 5-12MM UNIVERSAL 470500,27200000,CDM,272,RC,,,,12885-MAIN,LOCAL,,,,,41,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA SEAL 5-12MM UNIVERSAL 470500,27200000,CDM,272,RC,,,,12885-MAIN,LOCAL,,,,,41,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA SEAL 5-12MM UNIVERSAL 470500,27200000,CDM,272,RC,,,,12885-MAIN,LOCAL,,,,,41,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA SEAL 5-12MM UNIVERSAL 470500,27200000,CDM,272,RC,,,,12885-MAIN,LOCAL,,,,,41,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA SEAL 5-12MM UNIVERSAL 470500,27200000,CDM,272,RC,,,,12885-MAIN,LOCAL,,,,,41,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULATED AO HANDLE STERILE MICA SCREW SYSTEM 57S1HNDL,27200000,CDM,272,RC,,,,12446-MAIN,LOCAL,,,,,219,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULATED AO HANDLE STERILE MICA SCREW SYSTEM 57S1HNDL,27200000,CDM,272,RC,,,,12446-MAIN,LOCAL,,,,,219,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULATED AO HANDLE STERILE MICA SCREW SYSTEM 57S1HNDL,27200000,CDM,272,RC,,,,12446-MAIN,LOCAL,,,,,219,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULATED AO HANDLE STERILE MICA SCREW SYSTEM 57S1HNDL,27200000,CDM,272,RC,,,,12446-MAIN,LOCAL,,,,,219,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULATED AO HANDLE STERILE MICA SCREW SYSTEM 57S1HNDL,27200000,CDM,272,RC,,,,12446-MAIN,LOCAL,,,,,219,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULATED AO HANDLE STERILE MICA SCREW SYSTEM 57S1HNDL,27200000,CDM,272,RC,,,,12446-MAIN,LOCAL,,,,,219,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CAP TOE JOINT  15MM 2.5MMX4.5MM DF RESURFACING CONTOURED COBALT CHROMIUM METATARSOPHALANGEAL 9M52-25,C1713,CDM,278,RC,C1713,HCPCS,,12532-MAIN,LOCAL,,,,,4791,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CAP TOE JOINT  15MM 2.5MMX4.5MM DF RESURFACING CONTOURED COBALT CHROMIUM METATARSOPHALANGEAL 9M52-25,C1713,CDM,278,RC,C1713,HCPCS,,12532-MAIN,LOCAL,,,,,4791,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CAP TOE JOINT  15MM 2.5MMX4.5MM DF RESURFACING CONTOURED COBALT CHROMIUM METATARSOPHALANGEAL 9M52-25,C1713,CDM,278,RC,C1713,HCPCS,,12532-MAIN,LOCAL,,,,,4791,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CAP TOE JOINT  15MM 2.5MMX4.5MM DF RESURFACING CONTOURED COBALT CHROMIUM METATARSOPHALANGEAL 9M52-25,C1713,CDM,278,RC,C1713,HCPCS,,12532-MAIN,LOCAL,,,,,4791,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CAP TOE JOINT  15MM 2.5MMX4.5MM DF RESURFACING CONTOURED COBALT CHROMIUM METATARSOPHALANGEAL 9M52-25,C1713,CDM,278,RC,C1713,HCPCS,,12532-MAIN,LOCAL,,,,,4791,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CAP TOE JOINT  15MM 2.5MMX4.5MM DF RESURFACING CONTOURED COBALT CHROMIUM METATARSOPHALANGEAL 9M52-25,C1713,CDM,278,RC,C1713,HCPCS,,12532-MAIN,LOCAL,,,,,4791,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Capillary Blood Collection,PX36416,CDM,300,RC,36416,CPT,,,,,,,,60,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Capillary Blood Collection,PX36416,CDM,300,RC,36416,CPT,,,,,,,,60,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Capillary Blood Collection,PX36416,CDM,300,RC,36416,CPT,,,,,,,,60,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Capillary Blood Collection,PX36416,CDM,300,RC,36416,CPT,,,,,,,,60,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Capillary Blood Collection,PX36416,CDM,300,RC,36416,CPT,,,,,,,,60,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Capillary Blood Collection,PX36416,CDM,300,RC,36416,CPT,,,,,,,,60,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CAPTIFLEX SNARE SINGLE USE EXTRA SMALL 11MM,27200000,CDM,272,RC,,,,12378-MAIN,LOCAL,,,,,81,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CAPTIFLEX SNARE SINGLE USE EXTRA SMALL 11MM,27200000,CDM,272,RC,,,,12378-MAIN,LOCAL,,,,,81,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CAPTIFLEX SNARE SINGLE USE EXTRA SMALL 11MM,27200000,CDM,272,RC,,,,12378-MAIN,LOCAL,,,,,81,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CAPTIFLEX SNARE SINGLE USE EXTRA SMALL 11MM,27200000,CDM,272,RC,,,,12378-MAIN,LOCAL,,,,,81,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CAPTIFLEX SNARE SINGLE USE EXTRA SMALL 11MM,27200000,CDM,272,RC,,,,12378-MAIN,LOCAL,,,,,81,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CAPTIFLEX SNARE SINGLE USE EXTRA SMALL 11MM,27200000,CDM,272,RC,,,,12378-MAIN,LOCAL,,,,,81,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carBAMazepine 100 MG Tablet Chewable 100 Each Box,63700001,CDM,250,RC,,,,,,904385461,NDC,1,EA,3.43,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carBAMazepine 100 MG Tablet Chewable 100 Each Box,63700001,CDM,250,RC,,,,,,904385461,NDC,1,EA,3.43,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carBAMazepine 100 MG Tablet Chewable 100 Each Box,63700001,CDM,250,RC,,,,,,904385461,NDC,1,EA,3.43,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carBAMazepine 100 MG Tablet Chewable 100 Each Box,63700001,CDM,250,RC,,,,,,904385461,NDC,1,EA,3.43,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carBAMazepine 100 MG Tablet Chewable 100 Each Box,63700001,CDM,250,RC,,,,,,904385461,NDC,1,EA,3.43,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carBAMazepine 100 MG Tablet Chewable 100 Each Box,63700001,CDM,250,RC,,,,,,904385461,NDC,1,EA,3.43,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbamide peroxide 6.5% 6.5 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904322035,NDC,15,ML,15.79,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbamide peroxide 6.5% 6.5 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904322035,NDC,15,ML,15.79,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbamide peroxide 6.5% 6.5 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904322035,NDC,15,ML,15.79,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbamide peroxide 6.5% 6.5 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904322035,NDC,15,ML,15.79,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbamide peroxide 6.5% 6.5 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904322035,NDC,15,ML,15.79,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbamide peroxide 6.5% 6.5 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904322035,NDC,15,ML,15.79,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbamide peroxide 6.5% 6.5 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904662735,NDC,15,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbamide peroxide 6.5% 6.5 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904662735,NDC,15,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbamide peroxide 6.5% 6.5 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904662735,NDC,15,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbamide peroxide 6.5% 6.5 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904662735,NDC,15,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbamide peroxide 6.5% 6.5 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904662735,NDC,15,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbamide peroxide 6.5% 6.5 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904662735,NDC,15,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbidopa-levodopa 10-100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,72888010601,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbidopa-levodopa 10-100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,72888010601,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbidopa-levodopa 10-100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,72888010601,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbidopa-levodopa 10-100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,72888010601,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbidopa-levodopa 10-100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,72888010601,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbidopa-levodopa 10-100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,72888010601,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbidopa-levodopa 25-100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687066111,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbidopa-levodopa 25-100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687066111,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbidopa-levodopa 25-100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687066111,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbidopa-levodopa 25-100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687066111,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbidopa-levodopa 25-100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687066111,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbidopa-levodopa 25-100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687066111,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbidopa-levodopa 25-100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084009311,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbidopa-levodopa 25-100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084009311,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbidopa-levodopa 25-100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084009311,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbidopa-levodopa 25-100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084009311,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbidopa-levodopa 25-100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084009311,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbidopa-levodopa 25-100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084009311,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbidopa-levodopa 25-100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687066101,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbidopa-levodopa 25-100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687066101,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbidopa-levodopa 25-100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687066101,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbidopa-levodopa 25-100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687066101,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbidopa-levodopa 25-100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687066101,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbidopa-levodopa 25-100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687066101,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbidopa-levodopa 25-100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084009301,NDC,1,EA,4.4,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbidopa-levodopa 25-100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084009301,NDC,1,EA,4.4,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbidopa-levodopa 25-100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084009301,NDC,1,EA,4.4,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbidopa-levodopa 25-100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084009301,NDC,1,EA,4.4,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbidopa-levodopa 25-100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084009301,NDC,1,EA,4.4,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbidopa-levodopa 25-100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084009301,NDC,1,EA,4.4,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbidopa-levodopa 25-250 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084009411,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbidopa-levodopa 25-250 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084009411,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbidopa-levodopa 25-250 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084009411,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbidopa-levodopa 25-250 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084009411,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbidopa-levodopa 25-250 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084009411,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbidopa-levodopa 25-250 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084009411,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbidopa-levodopa CR 25-100 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756046188,NDC,1,EA,5.04,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbidopa-levodopa CR 25-100 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756046188,NDC,1,EA,5.04,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbidopa-levodopa CR 25-100 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756046188,NDC,1,EA,5.04,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbidopa-levodopa CR 25-100 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756046188,NDC,1,EA,5.04,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbidopa-levodopa CR 25-100 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756046188,NDC,1,EA,5.04,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbidopa-levodopa CR 25-100 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756046188,NDC,1,EA,5.04,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424601,NDC,15,ML,95.76,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424601,NDC,15,ML,95.76,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424601,NDC,15,ML,95.76,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424601,NDC,15,ML,95.76,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424601,NDC,15,ML,95.76,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424601,NDC,15,ML,95.76,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424681,NDC,15,ML,95.76,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424681,NDC,15,ML,95.76,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424681,NDC,15,ML,95.76,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424681,NDC,15,ML,95.76,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424681,NDC,15,ML,95.76,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424681,NDC,15,ML,95.76,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CARBOplatin 600 MG/60ML Solution 60 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703423981,NDC,60,ML,301.42,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CARBOplatin 600 MG/60ML Solution 60 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703423981,NDC,60,ML,301.42,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CARBOplatin 600 MG/60ML Solution 60 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703423981,NDC,60,ML,301.42,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CARBOplatin 600 MG/60ML Solution 60 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703423981,NDC,60,ML,301.42,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CARBOplatin 600 MG/60ML Solution 60 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703423981,NDC,60,ML,301.42,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CARBOplatin 600 MG/60ML Solution 60 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703423981,NDC,60,ML,301.42,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carboprost 250 MCG/ML Solution 1 mL Ampule,25000000,CDM,250,RC,,,,,,9085608,NDC,1,ML,1517.13,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carboprost 250 MCG/ML Solution 1 mL Ampule,25000000,CDM,250,RC,,,,,,9085608,NDC,1,ML,1517.13,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carboprost 250 MCG/ML Solution 1 mL Ampule,25000000,CDM,250,RC,,,,,,9085608,NDC,1,ML,1517.13,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carboprost 250 MCG/ML Solution 1 mL Ampule,25000000,CDM,250,RC,,,,,,9085608,NDC,1,ML,1517.13,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carboprost 250 MCG/ML Solution 1 mL Ampule,25000000,CDM,250,RC,,,,,,9085608,NDC,1,ML,1517.13,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carboprost 250 MCG/ML Solution 1 mL Ampule,25000000,CDM,250,RC,,,,,,9085608,NDC,1,ML,1517.13,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Carcinoembryonic Antigen,PX82378,CDM,300,RC,82378,CPT,,,,,,,,25,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Carcinoembryonic Antigen,PX82378,CDM,300,RC,82378,CPT,,,,,,,,25,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Carcinoembryonic Antigen,PX82378,CDM,300,RC,82378,CPT,,,,,,,,25,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Carcinoembryonic Antigen,PX82378,CDM,300,RC,82378,CPT,,,,,,,,25,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Carcinoembryonic Antigen,PX82378,CDM,300,RC,82378,CPT,,,,,,,,25,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Carcinoembryonic Antigen,PX82378,CDM,300,RC,82378,CPT,,,,,,,,25,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cardiac Rehab,PX93797F,CDM,943,RC,93797,CPT,,,,,,,,45,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cardiac Rehab,PX93797F,CDM,943,RC,93797,CPT,,,,,,,,45,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cardiac Rehab,PX93797F,CDM,943,RC,93797,CPT,,,,,,,,45,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cardiac Rehab,PX93797F,CDM,943,RC,93797,CPT,,,,,,,,45,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cardiac Rehab,PX93797F,CDM,943,RC,93797,CPT,,,,,,,,45,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cardiac Rehab,PX93797F,CDM,943,RC,93797,CPT,,,,,,,,45,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cardiac Rehab II Eval,PX93798.05,CDM,943,RC,93798,CPT,,,,,,,,364,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cardiac Rehab II Eval,PX93798.05,CDM,943,RC,93798,CPT,,,,,,,,364,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cardiac Rehab II Eval,PX93798.05,CDM,943,RC,93798,CPT,,,,,,,,364,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cardiac Rehab II Eval,PX93798.05,CDM,943,RC,93798,CPT,,,,,,,,364,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cardiac Rehab II Eval,PX93798.05,CDM,943,RC,93798,CPT,,,,,,,,364,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cardiac Rehab II Eval,PX93798.05,CDM,943,RC,93798,CPT,,,,,,,,364,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cardiac Rehab II W/ Monitor,PX93798.02,CDM,943,RC,93798,CPT,,,,,,,,338,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cardiac Rehab II W/ Monitor,PX93798.02,CDM,943,RC,93798,CPT,,,,,,,,338,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cardiac Rehab II W/ Monitor,PX93798.02,CDM,943,RC,93798,CPT,,,,,,,,338,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cardiac Rehab II W/ Monitor,PX93798.02,CDM,943,RC,93798,CPT,,,,,,,,338,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cardiac Rehab II W/ Monitor,PX93798.02,CDM,943,RC,93798,CPT,,,,,,,,338,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cardiac Rehab II W/ Monitor,PX93798.02,CDM,943,RC,93798,CPT,,,,,,,,338,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cardiac Stress Tst,Tracing Only",PX93017,CDM,482,RC,93017,CPT,,,,,,,,1959,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cardiac Stress Tst,Tracing Only",PX93017,CDM,482,RC,93017,CPT,,,,,,,,1959,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cardiac Stress Tst,Tracing Only",PX93017,CDM,482,RC,93017,CPT,,,,,,,,1959,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cardiac Stress Tst,Tracing Only",PX93017,CDM,482,RC,93017,CPT,,,,,,,,1959,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cardiac Stress Tst,Tracing Only",PX93017,CDM,482,RC,93017,CPT,,,,,,,,1959,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cardiac Stress Tst,Tracing Only",PX93017,CDM,482,RC,93017,CPT,,,,,,,,1959,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cardiolipin Ab, Ea Lg - Ref",PX8614790,CDM,300,RC,86147,CPT,90,,,,,,,133,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cardiolipin Ab, Ea Lg - Ref",PX8614790,CDM,300,RC,86147,CPT,90,,,,,,,133,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cardiolipin Ab, Ea Lg - Ref",PX8614790,CDM,300,RC,86147,CPT,90,,,,,,,133,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cardiolipin Ab, Ea Lg - Ref",PX8614790,CDM,300,RC,86147,CPT,90,,,,,,,133,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cardiolipin Ab, Ea Lg - Ref",PX8614790,CDM,300,RC,86147,CPT,90,,,,,,,133,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cardiolipin Ab, Ea Lg - Ref",PX8614790,CDM,300,RC,86147,CPT,90,,,,,,,133,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cardioversion, Elective;Extern",PX92960F,CDM,480,RC,92960,CPT,,,,,,,,402,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cardioversion, Elective;Extern",PX92960F,CDM,480,RC,92960,CPT,,,,,,,,402,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cardioversion, Elective;Extern",PX92960F,CDM,480,RC,92960,CPT,,,,,,,,402,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cardioversion, Elective;Extern",PX92960F,CDM,480,RC,92960,CPT,,,,,,,,402,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cardioversion, Elective;Extern",PX92960F,CDM,480,RC,92960,CPT,,,,,,,,402,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cardioversion, Elective;Extern",PX92960F,CDM,480,RC,92960,CPT,,,,,,,,402,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cardioversion, Elective;Extern",PX92960P,CDM,983,RC,92960,CPT,,,,,,,,688,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cardioversion, Elective;Extern",PX92960P,CDM,983,RC,92960,CPT,,,,,,,,688,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cardioversion, Elective;Extern",PX92960P,CDM,983,RC,92960,CPT,,,,,,,,688,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cardioversion, Elective;Extern",PX92960P,CDM,983,RC,92960,CPT,,,,,,,,688,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cardioversion, Elective;Extern",PX92960P,CDM,983,RC,92960,CPT,,,,,,,,688,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cardioversion, Elective;Extern",PX92960P,CDM,983,RC,92960,CPT,,,,,,,,688,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carfilzomib 30 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010201,NDC,1,EA,2785.91,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carfilzomib 30 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010201,NDC,1,EA,2785.91,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carfilzomib 30 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010201,NDC,1,EA,2785.91,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carfilzomib 30 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010201,NDC,1,EA,2785.91,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carfilzomib 30 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010201,NDC,1,EA,2785.91,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carfilzomib 30 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010201,NDC,1,EA,2785.91,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carfilzomib 60 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010101,NDC,1,EA,5571.82,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carfilzomib 60 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010101,NDC,1,EA,5571.82,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carfilzomib 60 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010101,NDC,1,EA,5571.82,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carfilzomib 60 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010101,NDC,1,EA,5571.82,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carfilzomib 60 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010101,NDC,1,EA,5571.82,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carfilzomib 60 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010101,NDC,1,EA,5571.82,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Carnitine - Ref,PX8237990,CDM,300,RC,82379,CPT,90,,,,,,,104,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Carnitine - Ref,PX8237990,CDM,300,RC,82379,CPT,90,,,,,,,104,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Carnitine - Ref,PX8237990,CDM,300,RC,82379,CPT,90,,,,,,,104,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Carnitine - Ref,PX8237990,CDM,300,RC,82379,CPT,90,,,,,,,104,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Carnitine - Ref,PX8237990,CDM,300,RC,82379,CPT,90,,,,,,,104,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Carnitine - Ref,PX8237990,CDM,300,RC,82379,CPT,90,,,,,,,104,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CARTER THOMASON CLOSURE 5MM,27200000,CDM,272,RC,,,,10278-MAIN,LOCAL,,,,,97.45,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CARTER THOMASON CLOSURE 5MM,27200000,CDM,272,RC,,,,10278-MAIN,LOCAL,,,,,97.45,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CARTER THOMASON CLOSURE 5MM,27200000,CDM,272,RC,,,,10278-MAIN,LOCAL,,,,,97.45,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CARTER THOMASON CLOSURE 5MM,27200000,CDM,272,RC,,,,10278-MAIN,LOCAL,,,,,97.45,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CARTER THOMASON CLOSURE 5MM,27200000,CDM,272,RC,,,,10278-MAIN,LOCAL,,,,,97.45,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CARTER THOMASON CLOSURE 5MM,27200000,CDM,272,RC,,,,10278-MAIN,LOCAL,,,,,97.45,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CARTER THOMASON CLOSURE SUTURE PASSER XL 10/12MM 15MM CTXL,27200000,CDM,272,RC,,,,12946-MAIN,LOCAL,,,,,535,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CARTER THOMASON CLOSURE SUTURE PASSER XL 10/12MM 15MM CTXL,27200000,CDM,272,RC,,,,12946-MAIN,LOCAL,,,,,535,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CARTER THOMASON CLOSURE SUTURE PASSER XL 10/12MM 15MM CTXL,27200000,CDM,272,RC,,,,12946-MAIN,LOCAL,,,,,535,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CARTER THOMASON CLOSURE SUTURE PASSER XL 10/12MM 15MM CTXL,27200000,CDM,272,RC,,,,12946-MAIN,LOCAL,,,,,535,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CARTER THOMASON CLOSURE SUTURE PASSER XL 10/12MM 15MM CTXL,27200000,CDM,272,RC,,,,12946-MAIN,LOCAL,,,,,535,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CARTER THOMASON CLOSURE SUTURE PASSER XL 10/12MM 15MM CTXL,27200000,CDM,272,RC,,,,12946-MAIN,LOCAL,,,,,535,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carvedilol 3.125 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079077101,NDC,1,EA,11.46,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carvedilol 3.125 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079077101,NDC,1,EA,11.46,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carvedilol 3.125 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079077101,NDC,1,EA,11.46,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carvedilol 3.125 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079077101,NDC,1,EA,11.46,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carvedilol 3.125 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079077101,NDC,1,EA,11.46,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carvedilol 3.125 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079077101,NDC,1,EA,11.46,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carvedilol 3.125 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904630061,NDC,0.5,EA,5.64,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carvedilol 3.125 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904630061,NDC,0.5,EA,5.64,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carvedilol 3.125 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904630061,NDC,0.5,EA,5.64,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carvedilol 3.125 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904630061,NDC,0.5,EA,5.64,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carvedilol 3.125 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904630061,NDC,0.5,EA,5.64,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carvedilol 3.125 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904630061,NDC,0.5,EA,5.64,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carvedilol 3.125 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079077120,NDC,0.5,EA,5.73,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carvedilol 3.125 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079077120,NDC,0.5,EA,5.73,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carvedilol 3.125 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079077120,NDC,0.5,EA,5.73,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carvedilol 3.125 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079077120,NDC,0.5,EA,5.73,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carvedilol 3.125 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079077120,NDC,0.5,EA,5.73,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carvedilol 3.125 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079077120,NDC,0.5,EA,5.73,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carvedilol 12.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904630261,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carvedilol 12.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904630261,NDC,0.25,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carvedilol 12.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904630261,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carvedilol 12.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904630261,NDC,0.25,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carvedilol 12.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904630261,NDC,0.25,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carvedilol 12.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904630261,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Casiri and Imdevimab,Admin,Repeat Dose",PXM0240,CDM,771,RC,M0240,HCPCS,,,,,,,,1555,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Casiri and Imdevimab,Admin,Repeat Dose",PXM0240,CDM,771,RC,M0240,HCPCS,,,,,,,,1555,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Casiri and Imdevimab,Admin,Repeat Dose",PXM0240,CDM,771,RC,M0240,HCPCS,,,,,,,,1555,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Casiri and Imdevimab,Admin,Repeat Dose",PXM0240,CDM,771,RC,M0240,HCPCS,,,,,,,,1555,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Casiri and Imdevimab,Admin,Repeat Dose",PXM0240,CDM,771,RC,M0240,HCPCS,,,,,,,,1555,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Casiri and Imdevimab,Admin,Repeat Dose",PXM0240,CDM,771,RC,M0240,HCPCS,,,,,,,,1555,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cast/Strap Procedure Unlisted,PX29799F,CDM,510,RC,29799,CPT,,,,,,,,316,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cast/Strap Procedure Unlisted,PX29799F,CDM,510,RC,29799,CPT,,,,,,,,316,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cast/Strap Procedure Unlisted,PX29799F,CDM,510,RC,29799,CPT,,,,,,,,316,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cast/Strap Procedure Unlisted,PX29799F,CDM,510,RC,29799,CPT,,,,,,,,316,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cast/Strap Procedure Unlisted,PX29799F,CDM,510,RC,29799,CPT,,,,,,,,316,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cast/Strap Procedure Unlisted,PX29799F,CDM,510,RC,29799,CPT,,,,,,,,316,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Catecholamines, Fraction - Ref",PX8238490,CDM,300,RC,82384,CPT,90,,,,,,,145,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Catecholamines, Fraction - Ref",PX8238490,CDM,300,RC,82384,CPT,90,,,,,,,145,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Catecholamines, Fraction - Ref",PX8238490,CDM,300,RC,82384,CPT,90,,,,,,,145,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Catecholamines, Fraction - Ref",PX8238490,CDM,300,RC,82384,CPT,90,,,,,,,145,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Catecholamines, Fraction - Ref",PX8238490,CDM,300,RC,82384,CPT,90,,,,,,,145,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Catecholamines, Fraction - Ref",PX8238490,CDM,300,RC,82384,CPT,90,,,,,,,145,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER BIPOLAR ELECTROHEMOSTASIS 7FR 300CM M00560070,27200000,CDM,272,RC,,,,12909-MAIN,LOCAL,,,,,700,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER BIPOLAR ELECTROHEMOSTASIS 7FR 300CM M00560070,27200000,CDM,272,RC,,,,12909-MAIN,LOCAL,,,,,700,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER BIPOLAR ELECTROHEMOSTASIS 7FR 300CM M00560070,27200000,CDM,272,RC,,,,12909-MAIN,LOCAL,,,,,700,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER BIPOLAR ELECTROHEMOSTASIS 7FR 300CM M00560070,27200000,CDM,272,RC,,,,12909-MAIN,LOCAL,,,,,700,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER BIPOLAR ELECTROHEMOSTASIS 7FR 300CM M00560070,27200000,CDM,272,RC,,,,12909-MAIN,LOCAL,,,,,700,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER BIPOLAR ELECTROHEMOSTASIS 7FR 300CM M00560070,27200000,CDM,272,RC,,,,12909-MAIN,LOCAL,,,,,700,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER FOLEY 18FR  3WAY 30CC 73018L,120.21,CDM,272,RC,A4346,HCPCS,,253-MAIN,LOCAL,,,,,33,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER FOLEY 18FR  3WAY 30CC 73018L,120.21,CDM,272,RC,A4346,HCPCS,,253-MAIN,LOCAL,,,,,33,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER FOLEY 18FR  3WAY 30CC 73018L,120.21,CDM,272,RC,A4346,HCPCS,,253-MAIN,LOCAL,,,,,33,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER FOLEY 18FR  3WAY 30CC 73018L,120.21,CDM,272,RC,A4346,HCPCS,,253-MAIN,LOCAL,,,,,33,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER FOLEY 18FR  3WAY 30CC 73018L,120.21,CDM,272,RC,A4346,HCPCS,,253-MAIN,LOCAL,,,,,33,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER FOLEY 18FR  3WAY 30CC 73018L,120.21,CDM,272,RC,A4346,HCPCS,,253-MAIN,LOCAL,,,,,33,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER FOLEY 20FR 3WAY 30CC 0167L20,120.21,CDM,272,RC,A4346,HCPCS,,251-MAIN,LOCAL,,,,,33,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER FOLEY 20FR 3WAY 30CC 0167L20,120.21,CDM,272,RC,A4346,HCPCS,,251-MAIN,LOCAL,,,,,33,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER FOLEY 20FR 3WAY 30CC 0167L20,120.21,CDM,272,RC,A4346,HCPCS,,251-MAIN,LOCAL,,,,,33,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER FOLEY 20FR 3WAY 30CC 0167L20,120.21,CDM,272,RC,A4346,HCPCS,,251-MAIN,LOCAL,,,,,33,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER FOLEY 20FR 3WAY 30CC 0167L20,120.21,CDM,272,RC,A4346,HCPCS,,251-MAIN,LOCAL,,,,,33,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER FOLEY 20FR 3WAY 30CC 0167L20,120.21,CDM,272,RC,A4346,HCPCS,,251-MAIN,LOCAL,,,,,33,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER FOLEY 24FR 3WAY 30CC 0167L24,120.21,CDM,272,RC,A4346,HCPCS,,10455-MAIN,LOCAL,,,,,33,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER FOLEY 24FR 3WAY 30CC 0167L24,120.21,CDM,272,RC,A4346,HCPCS,,10455-MAIN,LOCAL,,,,,33,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER FOLEY 24FR 3WAY 30CC 0167L24,120.21,CDM,272,RC,A4346,HCPCS,,10455-MAIN,LOCAL,,,,,33,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER FOLEY 24FR 3WAY 30CC 0167L24,120.21,CDM,272,RC,A4346,HCPCS,,10455-MAIN,LOCAL,,,,,33,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER FOLEY 24FR 3WAY 30CC 0167L24,120.21,CDM,272,RC,A4346,HCPCS,,10455-MAIN,LOCAL,,,,,33,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER FOLEY 24FR 3WAY 30CC 0167L24,120.21,CDM,272,RC,A4346,HCPCS,,10455-MAIN,LOCAL,,,,,33,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER PUREWICK FEMALE EXTERNAL PWF030K,120.414,CDM,272,RC,A6590,HCPCS,,11836-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER PUREWICK FEMALE EXTERNAL PWF030K,120.414,CDM,272,RC,A6590,HCPCS,,11836-MAIN,LOCAL,,,,,42,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER PUREWICK FEMALE EXTERNAL PWF030K,120.414,CDM,272,RC,A6590,HCPCS,,11836-MAIN,LOCAL,,,,,42,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER PUREWICK FEMALE EXTERNAL PWF030K,120.414,CDM,272,RC,A6590,HCPCS,,11836-MAIN,LOCAL,,,,,42,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER PUREWICK FEMALE EXTERNAL PWF030K,120.414,CDM,272,RC,A6590,HCPCS,,11836-MAIN,LOCAL,,,,,42,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER PUREWICK FEMALE EXTERNAL PWF030K,120.414,CDM,272,RC,A6590,HCPCS,,11836-MAIN,LOCAL,,,,,42,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER TEMP-SENSING 8FR LUBRISIL PEDS DYND110508,120.363,CDM,272,RC,A4340,HCPCS,,12777-MAIN,LOCAL,,,,,45,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER TEMP-SENSING 8FR LUBRISIL PEDS DYND110508,120.363,CDM,272,RC,A4340,HCPCS,,12777-MAIN,LOCAL,,,,,45,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER TEMP-SENSING 8FR LUBRISIL PEDS DYND110508,120.363,CDM,272,RC,A4340,HCPCS,,12777-MAIN,LOCAL,,,,,45,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER TEMP-SENSING 8FR LUBRISIL PEDS DYND110508,120.363,CDM,272,RC,A4340,HCPCS,,12777-MAIN,LOCAL,,,,,45,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER TEMP-SENSING 8FR LUBRISIL PEDS DYND110508,120.363,CDM,272,RC,A4340,HCPCS,,12777-MAIN,LOCAL,,,,,45,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER TEMP-SENSING 8FR LUBRISIL PEDS DYND110508,120.363,CDM,272,RC,A4340,HCPCS,,12777-MAIN,LOCAL,,,,,45,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER TEMP-SENSING 12FR LUBRISIL 119212M,120.363,CDM,272,RC,A4340,HCPCS,,10750-MAIN,LOCAL,,,,,45,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER TEMP-SENSING 12FR LUBRISIL 119212M,120.363,CDM,272,RC,A4340,HCPCS,,10750-MAIN,LOCAL,,,,,45,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER TEMP-SENSING 12FR LUBRISIL 119212M,120.363,CDM,272,RC,A4340,HCPCS,,10750-MAIN,LOCAL,,,,,45,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER TEMP-SENSING 12FR LUBRISIL 119212M,120.363,CDM,272,RC,A4340,HCPCS,,10750-MAIN,LOCAL,,,,,45,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER TEMP-SENSING 12FR LUBRISIL 119212M,120.363,CDM,272,RC,A4340,HCPCS,,10750-MAIN,LOCAL,,,,,45,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER TEMP-SENSING 12FR LUBRISIL 119212M,120.363,CDM,272,RC,A4340,HCPCS,,10750-MAIN,LOCAL,,,,,45,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER TEMP-SENSING 14FR LUBRISIL 119214M,120.363,CDM,272,RC,A4340,HCPCS,,10751-MAIN,LOCAL,,,,,45,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER TEMP-SENSING 14FR LUBRISIL 119214M,120.363,CDM,272,RC,A4340,HCPCS,,10751-MAIN,LOCAL,,,,,45,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER TEMP-SENSING 14FR LUBRISIL 119214M,120.363,CDM,272,RC,A4340,HCPCS,,10751-MAIN,LOCAL,,,,,45,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER TEMP-SENSING 14FR LUBRISIL 119214M,120.363,CDM,272,RC,A4340,HCPCS,,10751-MAIN,LOCAL,,,,,45,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER TEMP-SENSING 14FR LUBRISIL 119214M,120.363,CDM,272,RC,A4340,HCPCS,,10751-MAIN,LOCAL,,,,,45,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER TEMP-SENSING 14FR LUBRISIL 119214M,120.363,CDM,272,RC,A4340,HCPCS,,10751-MAIN,LOCAL,,,,,45,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER TEMP-SENSING 16FR LUBRISIL 119216M,120.363,CDM,272,RC,A4340,HCPCS,,10752-MAIN,LOCAL,,,,,45,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER TEMP-SENSING 16FR LUBRISIL 119216M,120.363,CDM,272,RC,A4340,HCPCS,,10752-MAIN,LOCAL,,,,,45,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER TEMP-SENSING 16FR LUBRISIL 119216M,120.363,CDM,272,RC,A4340,HCPCS,,10752-MAIN,LOCAL,,,,,45,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER TEMP-SENSING 16FR LUBRISIL 119216M,120.363,CDM,272,RC,A4340,HCPCS,,10752-MAIN,LOCAL,,,,,45,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER TEMP-SENSING 16FR LUBRISIL 119216M,120.363,CDM,272,RC,A4340,HCPCS,,10752-MAIN,LOCAL,,,,,45,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER TEMP-SENSING 16FR LUBRISIL 119216M,120.363,CDM,272,RC,A4340,HCPCS,,10752-MAIN,LOCAL,,,,,45,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER URETERAL  5FR TIGERTAIL OPEN TIP FLEXIBLE 139005,27200000,CDM,272,RC,A4340,HCPCS,,12302-MAIN,LOCAL,,,,,40,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER URETERAL  5FR TIGERTAIL OPEN TIP FLEXIBLE 139005,27200000,CDM,272,RC,A4340,HCPCS,,12302-MAIN,LOCAL,,,,,40,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER URETERAL  5FR TIGERTAIL OPEN TIP FLEXIBLE 139005,27200000,CDM,272,RC,A4340,HCPCS,,12302-MAIN,LOCAL,,,,,40,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER URETERAL  5FR TIGERTAIL OPEN TIP FLEXIBLE 139005,27200000,CDM,272,RC,A4340,HCPCS,,12302-MAIN,LOCAL,,,,,40,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER URETERAL  5FR TIGERTAIL OPEN TIP FLEXIBLE 139005,27200000,CDM,272,RC,A4340,HCPCS,,12302-MAIN,LOCAL,,,,,40,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER URETERAL  5FR TIGERTAIL OPEN TIP FLEXIBLE 139005,27200000,CDM,272,RC,A4340,HCPCS,,12302-MAIN,LOCAL,,,,,40,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Catheterize for Urine Spec,PXP9612,CDM,300,RC,P9612,HCPCS,,,,,,,,161,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Catheterize for Urine Spec,PXP9612,CDM,300,RC,P9612,HCPCS,,,,,,,,161,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Catheterize for Urine Spec,PXP9612,CDM,300,RC,P9612,HCPCS,,,,,,,,161,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Catheterize for Urine Spec,PXP9612,CDM,300,RC,P9612,HCPCS,,,,,,,,161,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Catheterize for Urine Spec,PXP9612,CDM,300,RC,P9612,HCPCS,,,,,,,,161,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Catheterize for Urine Spec,PXP9612,CDM,300,RC,P9612,HCPCS,,,,,,,,161,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CAUTERY HIGH TEMP LOOP TIP,120.21,CDM,272,RC,,,,332-MAIN,LOCAL,,,,,77,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CAUTERY HIGH TEMP LOOP TIP,120.21,CDM,272,RC,,,,332-MAIN,LOCAL,,,,,77,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CAUTERY HIGH TEMP LOOP TIP,120.21,CDM,272,RC,,,,332-MAIN,LOCAL,,,,,77,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CAUTERY HIGH TEMP LOOP TIP,120.21,CDM,272,RC,,,,332-MAIN,LOCAL,,,,,77,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CAUTERY HIGH TEMP LOOP TIP,120.21,CDM,272,RC,,,,332-MAIN,LOCAL,,,,,77,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CAUTERY HIGH TEMP LOOP TIP,120.21,CDM,272,RC,,,,332-MAIN,LOCAL,,,,,77,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CCP Antibody,PX86200,CDM,300,RC,86200,CPT,,,,,,,,176,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CCP Antibody,PX86200,CDM,300,RC,86200,CPT,,,,,,,,176,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CCP Antibody,PX86200,CDM,300,RC,86200,CPT,,,,,,,,176,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CCP Antibody,PX86200,CDM,300,RC,86200,CPT,,,,,,,,176,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CCP Antibody,PX86200,CDM,300,RC,86200,CPT,,,,,,,,176,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CCP Antibody,PX86200,CDM,300,RC,86200,CPT,,,,,,,,176,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CCP, Antibody - Ref",PX8620090,CDM,300,RC,86200,CPT,90,,,,,,,171,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CCP, Antibody - Ref",PX8620090,CDM,300,RC,86200,CPT,90,,,,,,,171,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CCP, Antibody - Ref",PX8620090,CDM,300,RC,86200,CPT,90,,,,,,,171,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CCP, Antibody - Ref",PX8620090,CDM,300,RC,86200,CPT,90,,,,,,,171,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CCP, Antibody - Ref",PX8620090,CDM,300,RC,86200,CPT,90,,,,,,,171,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CCP, Antibody - Ref",PX8620090,CDM,300,RC,86200,CPT,90,,,,,,,171,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefaDROXil 500 MG capsule 50 Each Bottle,63700001,CDM,250,RC,,,,,,16714038801,NDC,1,EA,19.98,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefaDROXil 500 MG capsule 50 Each Bottle,63700001,CDM,250,RC,,,,,,16714038801,NDC,1,EA,19.98,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefaDROXil 500 MG capsule 50 Each Bottle,63700001,CDM,250,RC,,,,,,16714038801,NDC,1,EA,19.98,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefaDROXil 500 MG capsule 50 Each Bottle,63700001,CDM,250,RC,,,,,,16714038801,NDC,1,EA,19.98,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefaDROXil 500 MG capsule 50 Each Bottle,63700001,CDM,250,RC,,,,,,16714038801,NDC,1,EA,19.98,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefaDROXil 500 MG capsule 50 Each Bottle,63700001,CDM,250,RC,,,,,,16714038801,NDC,1,EA,19.98,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143992490,NDC,0.5,EA,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143992490,NDC,0.5,EA,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143992490,NDC,0.5,EA,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143992490,NDC,0.5,EA,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143992490,NDC,0.5,EA,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143992490,NDC,0.5,EA,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010110,NDC,0.5,EA,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010110,NDC,0.5,EA,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010110,NDC,0.5,EA,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010110,NDC,0.5,EA,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010110,NDC,0.5,EA,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010110,NDC,0.5,EA,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010167,NDC,0.5,EA,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010167,NDC,0.5,EA,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010167,NDC,0.5,EA,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010167,NDC,0.5,EA,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010167,NDC,0.5,EA,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010167,NDC,0.5,EA,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,44567070725,NDC,0.5,EA,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,44567070725,NDC,0.5,EA,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,44567070725,NDC,0.5,EA,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,44567070725,NDC,0.5,EA,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,44567070725,NDC,0.5,EA,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,44567070725,NDC,0.5,EA,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623100,NDC,1,EA,59.25,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623100,NDC,1,EA,59.25,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623100,NDC,1,EA,59.25,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623100,NDC,1,EA,59.25,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623100,NDC,1,EA,59.25,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623100,NDC,1,EA,59.25,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623105,NDC,1,EA,59.27,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623105,NDC,1,EA,59.27,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623105,NDC,1,EA,59.27,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623105,NDC,1,EA,59.27,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623105,NDC,1,EA,59.27,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623105,NDC,1,EA,59.27,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143998391,NDC,1,EA,83.25,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143998391,NDC,1,EA,83.25,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143998391,NDC,1,EA,83.25,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143998391,NDC,1,EA,83.25,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143998391,NDC,1,EA,83.25,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143998391,NDC,1,EA,83.25,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010269,NDC,1,EA,88.69,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010269,NDC,1,EA,88.69,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010269,NDC,1,EA,88.69,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010269,NDC,1,EA,88.69,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010269,NDC,1,EA,88.69,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010269,NDC,1,EA,88.69,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010299,NDC,1,EA,88.69,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010299,NDC,1,EA,88.69,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010299,NDC,1,EA,88.69,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010299,NDC,1,EA,88.69,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010299,NDC,1,EA,88.69,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010299,NDC,1,EA,88.69,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin in D4W 1 g / 50 mL 1-4 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0690.01,CDM,636,RC,J0690,HCPCS,,,,264310311,NDC,1,EA,84.97,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin in D4W 1 g / 50 mL 1-4 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0690.01,CDM,636,RC,J0690,HCPCS,,,,264310311,NDC,1,EA,84.97,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin in D4W 1 g / 50 mL 1-4 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0690.01,CDM,636,RC,J0690,HCPCS,,,,264310311,NDC,1,EA,84.97,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin in D4W 1 g / 50 mL 1-4 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0690.01,CDM,636,RC,J0690,HCPCS,,,,264310311,NDC,1,EA,84.97,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin in D4W 1 g / 50 mL 1-4 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0690.01,CDM,636,RC,J0690,HCPCS,,,,264310311,NDC,1,EA,84.97,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin in D4W 1 g / 50 mL 1-4 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0690.01,CDM,636,RC,J0690,HCPCS,,,,264310311,NDC,1,EA,84.97,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefdinir 250 MG/5ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,16714039301,NDC,60,ML,510.33,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefdinir 250 MG/5ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,16714039301,NDC,60,ML,510.33,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefdinir 250 MG/5ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,16714039301,NDC,60,ML,510.33,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefdinir 250 MG/5ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,16714039301,NDC,60,ML,510.33,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefdinir 250 MG/5ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,16714039301,NDC,60,ML,510.33,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefdinir 250 MG/5ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,16714039301,NDC,60,ML,510.33,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefdinir 300 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,16714039102,NDC,1,EA,27.46,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefdinir 300 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,16714039102,NDC,1,EA,27.46,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefdinir 300 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,16714039102,NDC,1,EA,27.46,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefdinir 300 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,16714039102,NDC,1,EA,27.46,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefdinir 300 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,16714039102,NDC,1,EA,27.46,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefdinir 300 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,16714039102,NDC,1,EA,27.46,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefdinir 300 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,67877054360,NDC,1,EA,27.42,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefdinir 300 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,67877054360,NDC,1,EA,27.42,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefdinir 300 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,67877054360,NDC,1,EA,27.42,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefdinir 300 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,67877054360,NDC,1,EA,27.42,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefdinir 300 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,67877054360,NDC,1,EA,27.42,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefdinir 300 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,67877054360,NDC,1,EA,27.42,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012166,NDC,1,EA,58.66,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012166,NDC,1,EA,58.66,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012166,NDC,1,EA,58.66,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012166,NDC,1,EA,58.66,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012166,NDC,1,EA,58.66,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012166,NDC,1,EA,58.66,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024010,NDC,1,EA,56.73,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024010,NDC,1,EA,56.73,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024010,NDC,1,EA,56.73,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024010,NDC,1,EA,56.73,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024010,NDC,1,EA,56.73,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024010,NDC,1,EA,56.73,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505624500,NDC,1,EA,116.99,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505624500,NDC,1,EA,116.99,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505624500,NDC,1,EA,116.99,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505624500,NDC,1,EA,116.99,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505624500,NDC,1,EA,116.99,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505624500,NDC,1,EA,116.99,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012250,NDC,1,EA,77.24,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012250,NDC,1,EA,77.24,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012250,NDC,1,EA,77.24,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012250,NDC,1,EA,77.24,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012250,NDC,1,EA,77.24,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012250,NDC,1,EA,77.24,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012267,NDC,1,EA,77.24,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012267,NDC,1,EA,77.24,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012267,NDC,1,EA,77.24,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012267,NDC,1,EA,77.24,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012267,NDC,1,EA,77.24,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012267,NDC,1,EA,77.24,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024110,NDC,1,EA,76.1,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024110,NDC,1,EA,76.1,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024110,NDC,1,EA,76.1,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024110,NDC,1,EA,76.1,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024110,NDC,1,EA,76.1,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024110,NDC,1,EA,76.1,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505614700,NDC,1,EA,212.52,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505614700,NDC,1,EA,212.52,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505614700,NDC,1,EA,212.52,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505614700,NDC,1,EA,212.52,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505614700,NDC,1,EA,212.52,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505614700,NDC,1,EA,212.52,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034020,NDC,1,EA,76.67,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034020,NDC,1,EA,76.67,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034020,NDC,1,EA,76.67,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034020,NDC,1,EA,76.67,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034020,NDC,1,EA,76.67,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034020,NDC,1,EA,76.67,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034021,NDC,1,EA,76.67,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034021,NDC,1,EA,76.67,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034021,NDC,1,EA,76.67,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034021,NDC,1,EA,76.67,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034021,NDC,1,EA,76.67,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034021,NDC,1,EA,76.67,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefoTEtan 2 g Recon Soln 1 Each Vial,800000,CDM,,,S0074,HCPCS,,,,63323038620,NDC,1,EA,240.2,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefoTEtan 2 g Recon Soln 1 Each Vial,800000,CDM,,,S0074,HCPCS,,,,63323038620,NDC,1,EA,240.2,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefoTEtan 2 g Recon Soln 1 Each Vial,800000,CDM,,,S0074,HCPCS,,,,63323038620,NDC,1,EA,240.2,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefoTEtan 2 g Recon Soln 1 Each Vial,800000,CDM,,,S0074,HCPCS,,,,63323038620,NDC,1,EA,240.2,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefoTEtan 2 g Recon Soln 1 Each Vial,800000,CDM,,,S0074,HCPCS,,,,63323038620,NDC,1,EA,240.2,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefoTEtan 2 g Recon Soln 1 Each Vial,800000,CDM,,,S0074,HCPCS,,,,63323038620,NDC,1,EA,240.2,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefOXitin 1 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021010910,NDC,1,EA,58.66,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefOXitin 1 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021010910,NDC,1,EA,58.66,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefOXitin 1 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021010910,NDC,1,EA,58.66,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefOXitin 1 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021010910,NDC,1,EA,58.66,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefOXitin 1 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021010910,NDC,1,EA,58.66,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefOXitin 1 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021010910,NDC,1,EA,58.66,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefOXitin 2 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021011020,NDC,1,EA,77.24,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefOXitin 2 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021011020,NDC,1,EA,77.24,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefOXitin 2 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021011020,NDC,1,EA,77.24,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefOXitin 2 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021011020,NDC,1,EA,77.24,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefOXitin 2 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021011020,NDC,1,EA,77.24,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefOXitin 2 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021011020,NDC,1,EA,77.24,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTAZidime 1 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023525,NDC,1,EA,49,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTAZidime 1 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023525,NDC,1,EA,49,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTAZidime 1 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023525,NDC,1,EA,49,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTAZidime 1 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023525,NDC,1,EA,49,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTAZidime 1 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023525,NDC,1,EA,49,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTAZidime 1 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023525,NDC,1,EA,49,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,409508411,NDC,1,EA,73.86,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,409508411,NDC,1,EA,73.86,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,409508411,NDC,1,EA,73.86,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,409508411,NDC,1,EA,73.86,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,409508411,NDC,1,EA,73.86,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,409508411,NDC,1,EA,73.86,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,25021012867,NDC,1,EA,82.96,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,25021012867,NDC,1,EA,82.96,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,25021012867,NDC,1,EA,82.96,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,25021012867,NDC,1,EA,82.96,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,25021012867,NDC,1,EA,82.96,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,25021012867,NDC,1,EA,82.96,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023610,NDC,1,EA,77.24,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023610,NDC,1,EA,77.24,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023610,NDC,1,EA,77.24,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023610,NDC,1,EA,77.24,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023610,NDC,1,EA,77.24,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023610,NDC,1,EA,77.24,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733201,NDC,0.5,EA,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733201,NDC,0.5,EA,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733201,NDC,0.5,EA,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733201,NDC,0.5,EA,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733201,NDC,0.5,EA,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733201,NDC,0.5,EA,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320885,NDC,0.5,EA,129.71,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320885,NDC,0.5,EA,129.71,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320885,NDC,0.5,EA,129.71,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320885,NDC,0.5,EA,129.71,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320885,NDC,0.5,EA,129.71,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320885,NDC,0.5,EA,129.71,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320895,NDC,0.5,EA,129.71,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320895,NDC,0.5,EA,129.71,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320895,NDC,0.5,EA,129.71,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320895,NDC,0.5,EA,129.71,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320895,NDC,0.5,EA,129.71,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320895,NDC,0.5,EA,129.71,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614800,NDC,1,EA,239.18,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614800,NDC,1,EA,239.18,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614800,NDC,1,EA,239.18,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614800,NDC,1,EA,239.18,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614800,NDC,1,EA,239.18,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614800,NDC,1,EA,239.18,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733513,NDC,1,EA,39.12,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733513,NDC,1,EA,39.12,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733513,NDC,1,EA,39.12,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733513,NDC,1,EA,39.12,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733513,NDC,1,EA,39.12,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733513,NDC,1,EA,39.12,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320990,NDC,1,EA,410.32,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320990,NDC,1,EA,410.32,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320990,NDC,1,EA,410.32,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320990,NDC,1,EA,410.32,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320990,NDC,1,EA,410.32,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320990,NDC,1,EA,410.32,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320995,NDC,1,EA,410.32,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320995,NDC,1,EA,410.32,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320995,NDC,1,EA,410.32,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320995,NDC,1,EA,410.32,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320995,NDC,1,EA,410.32,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320995,NDC,1,EA,410.32,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,25021010720,NDC,1,EA,48.35,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,25021010720,NDC,1,EA,48.35,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,25021010720,NDC,1,EA,48.35,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,25021010720,NDC,1,EA,48.35,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,25021010720,NDC,1,EA,48.35,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,25021010720,NDC,1,EA,48.35,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614900,NDC,1,EA,409.89,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614900,NDC,1,EA,409.89,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614900,NDC,1,EA,409.89,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614900,NDC,1,EA,409.89,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614900,NDC,1,EA,409.89,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614900,NDC,1,EA,409.89,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733801,NDC,0.5,EA,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733801,NDC,0.5,EA,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733801,NDC,0.5,EA,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733801,NDC,0.5,EA,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733801,NDC,0.5,EA,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733801,NDC,0.5,EA,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505615204,NDC,0.5,EA,86.76,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505615204,NDC,0.5,EA,86.76,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505615204,NDC,0.5,EA,86.76,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505615204,NDC,0.5,EA,86.76,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505615204,NDC,0.5,EA,86.76,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505615204,NDC,0.5,EA,86.76,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone in dextrose 1 g / 50 mL 1-3.74 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0696.01,CDM,636,RC,J0696,HCPCS,,,,264315311,NDC,1,EA,106.03,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone in dextrose 1 g / 50 mL 1-3.74 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0696.01,CDM,636,RC,J0696,HCPCS,,,,264315311,NDC,1,EA,106.03,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone in dextrose 1 g / 50 mL 1-3.74 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0696.01,CDM,636,RC,J0696,HCPCS,,,,264315311,NDC,1,EA,106.03,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone in dextrose 1 g / 50 mL 1-3.74 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0696.01,CDM,636,RC,J0696,HCPCS,,,,264315311,NDC,1,EA,106.03,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone in dextrose 1 g / 50 mL 1-3.74 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0696.01,CDM,636,RC,J0696,HCPCS,,,,264315311,NDC,1,EA,106.03,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone in dextrose 1 g / 50 mL 1-3.74 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0696.01,CDM,636,RC,J0696,HCPCS,,,,264315311,NDC,1,EA,106.03,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
celecoxib 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904650261,NDC,1,EA,23.45,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
celecoxib 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904650261,NDC,1,EA,23.45,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
celecoxib 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904650261,NDC,1,EA,23.45,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
celecoxib 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904650261,NDC,1,EA,23.45,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
celecoxib 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904650261,NDC,1,EA,23.45,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
celecoxib 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904650261,NDC,1,EA,23.45,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
celecoxib 200 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904650361,NDC,0.5,EA,20.35,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
celecoxib 200 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904650361,NDC,0.5,EA,20.35,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
celecoxib 200 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904650361,NDC,0.5,EA,20.35,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
celecoxib 200 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904650361,NDC,0.5,EA,20.35,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
celecoxib 200 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904650361,NDC,0.5,EA,20.35,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
celecoxib 200 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904650361,NDC,0.5,EA,20.35,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cemiplimab-rwlc 350 MG/7ML Solution 7 mL Vial,J9119.01,CDM,636,RC,J9119,HCPCS,,,,61755000801,NDC,7,ML,19219.32,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cemiplimab-rwlc 350 MG/7ML Solution 7 mL Vial,J9119.01,CDM,636,RC,J9119,HCPCS,,,,61755000801,NDC,7,ML,19219.32,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cemiplimab-rwlc 350 MG/7ML Solution 7 mL Vial,J9119.01,CDM,636,RC,J9119,HCPCS,,,,61755000801,NDC,7,ML,19219.32,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cemiplimab-rwlc 350 MG/7ML Solution 7 mL Vial,J9119.01,CDM,636,RC,J9119,HCPCS,,,,61755000801,NDC,7,ML,19219.32,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cemiplimab-rwlc 350 MG/7ML Solution 7 mL Vial,J9119.01,CDM,636,RC,J9119,HCPCS,,,,61755000801,NDC,7,ML,19219.32,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cemiplimab-rwlc 350 MG/7ML Solution 7 mL Vial,J9119.01,CDM,636,RC,J9119,HCPCS,,,,61755000801,NDC,7,ML,19219.32,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 250 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687015211,NDC,1,EA,3.83,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 250 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687015211,NDC,1,EA,3.83,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 250 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687015211,NDC,1,EA,3.83,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 250 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687015211,NDC,1,EA,3.83,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 250 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687015211,NDC,1,EA,3.83,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 250 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687015211,NDC,1,EA,3.83,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 250 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687015201,NDC,1,EA,3.83,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 250 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687015201,NDC,1,EA,3.83,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 250 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687015201,NDC,1,EA,3.83,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 250 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687015201,NDC,1,EA,3.83,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 250 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687015201,NDC,1,EA,3.83,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 250 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687015201,NDC,1,EA,3.83,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 250 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,93417773,NDC,2.5,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 250 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,93417773,NDC,2.5,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 250 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,93417773,NDC,2.5,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 250 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,93417773,NDC,2.5,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 250 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,93417773,NDC,2.5,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 250 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,93417773,NDC,2.5,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 250 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,24979015514,NDC,2.5,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 250 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,24979015514,NDC,2.5,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 250 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,24979015514,NDC,2.5,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 250 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,24979015514,NDC,2.5,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 250 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,24979015514,NDC,2.5,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 250 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,24979015514,NDC,2.5,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 500 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,50268015211,NDC,1,EA,6.56,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 500 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,50268015211,NDC,1,EA,6.56,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 500 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,50268015211,NDC,1,EA,6.56,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 500 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,50268015211,NDC,1,EA,6.56,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 500 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,50268015211,NDC,1,EA,6.56,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 500 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,50268015211,NDC,1,EA,6.56,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 500 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687016311,NDC,0.5,EA,3.63,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 500 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687016311,NDC,0.5,EA,3.63,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 500 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687016311,NDC,0.5,EA,3.63,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 500 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687016311,NDC,0.5,EA,3.63,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 500 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687016311,NDC,0.5,EA,3.63,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 500 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687016311,NDC,0.5,EA,3.63,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 500 MG capsule 50 Each Box,63700001,CDM,250,RC,,,,,,50268015215,NDC,1,EA,6.56,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 500 MG capsule 50 Each Box,63700001,CDM,250,RC,,,,,,50268015215,NDC,1,EA,6.56,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 500 MG capsule 50 Each Box,63700001,CDM,250,RC,,,,,,50268015215,NDC,1,EA,6.56,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 500 MG capsule 50 Each Box,63700001,CDM,250,RC,,,,,,50268015215,NDC,1,EA,6.56,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 500 MG capsule 50 Each Box,63700001,CDM,250,RC,,,,,,50268015215,NDC,1,EA,6.56,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 500 MG capsule 50 Each Box,63700001,CDM,250,RC,,,,,,50268015215,NDC,1,EA,6.56,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 500 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687016301,NDC,0.5,EA,3.63,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 500 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687016301,NDC,0.5,EA,3.63,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 500 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687016301,NDC,0.5,EA,3.63,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 500 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687016301,NDC,0.5,EA,3.63,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 500 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687016301,NDC,0.5,EA,3.63,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 500 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687016301,NDC,0.5,EA,3.63,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
certolizumab 2 X 200 MG Kit 1 Each Box,J0717.01,CDM,636,RC,J0717,HCPCS,,,,50474070062,NDC,0.5,EA,4911.87,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
certolizumab 2 X 200 MG Kit 1 Each Box,J0717.01,CDM,636,RC,J0717,HCPCS,,,,50474070062,NDC,0.5,EA,4911.87,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
certolizumab 2 X 200 MG Kit 1 Each Box,J0717.01,CDM,636,RC,J0717,HCPCS,,,,50474070062,NDC,0.5,EA,4911.87,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
certolizumab 2 X 200 MG Kit 1 Each Box,J0717.01,CDM,636,RC,J0717,HCPCS,,,,50474070062,NDC,0.5,EA,4911.87,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
certolizumab 2 X 200 MG Kit 1 Each Box,J0717.01,CDM,636,RC,J0717,HCPCS,,,,50474070062,NDC,0.5,EA,4911.87,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
certolizumab 2 X 200 MG Kit 1 Each Box,J0717.01,CDM,636,RC,J0717,HCPCS,,,,50474070062,NDC,0.5,EA,4911.87,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ceruloplasmin - Ref,PX8239090,CDM,300,RC,82390,CPT,90,,,,,,,78,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ceruloplasmin - Ref,PX8239090,CDM,300,RC,82390,CPT,90,,,,,,,78,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ceruloplasmin - Ref,PX8239090,CDM,300,RC,82390,CPT,90,,,,,,,78,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ceruloplasmin - Ref,PX8239090,CDM,300,RC,82390,CPT,90,,,,,,,78,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ceruloplasmin - Ref,PX8239090,CDM,300,RC,82390,CPT,90,,,,,,,78,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ceruloplasmin - Ref,PX8239090,CDM,300,RC,82390,CPT,90,,,,,,,78,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cetirizine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585261,NDC,0.5,EA,6.51,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cetirizine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585261,NDC,0.5,EA,6.51,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cetirizine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585261,NDC,0.5,EA,6.51,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cetirizine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585261,NDC,0.5,EA,6.51,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cetirizine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585261,NDC,0.5,EA,6.51,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cetirizine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585261,NDC,0.5,EA,6.51,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cetirizine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904671761,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cetirizine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904671761,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cetirizine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904671761,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cetirizine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904671761,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cetirizine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904671761,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cetirizine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904671761,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
charcoal activated Liquid 240 mL Bottle,63700001,CDM,250,RC,,,,,,574012108,NDC,120,ML,66.88,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
charcoal activated Liquid 240 mL Bottle,63700001,CDM,250,RC,,,,,,574012108,NDC,120,ML,66.88,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
charcoal activated Liquid 240 mL Bottle,63700001,CDM,250,RC,,,,,,574012108,NDC,120,ML,66.88,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
charcoal activated Liquid 240 mL Bottle,63700001,CDM,250,RC,,,,,,574012108,NDC,120,ML,66.88,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
charcoal activated Liquid 240 mL Bottle,63700001,CDM,250,RC,,,,,,574012108,NDC,120,ML,66.88,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
charcoal activated Liquid 240 mL Bottle,63700001,CDM,250,RC,,,,,,574012108,NDC,120,ML,66.88,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Chem Cautery Granulatn Tissue,PX17250F,CDM,510,RC,17250,CPT,,,,,,,,170,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Chem Cautery Granulatn Tissue,PX17250F,CDM,510,RC,17250,CPT,,,,,,,,170,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Chem Cautery Granulatn Tissue,PX17250F,CDM,510,RC,17250,CPT,,,,,,,,170,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Chem Cautery Granulatn Tissue,PX17250F,CDM,510,RC,17250,CPT,,,,,,,,170,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Chem Cautery Granulatn Tissue,PX17250F,CDM,510,RC,17250,CPT,,,,,,,,170,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Chem Cautery Granulatn Tissue,PX17250F,CDM,510,RC,17250,CPT,,,,,,,,170,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Chem Cautery Granulatn Tissue,PX17250P,CDM,983,RC,17250,CPT,,,,,,,,402,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Chem Cautery Granulatn Tissue,PX17250P,CDM,983,RC,17250,CPT,,,,,,,,402,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Chem Cautery Granulatn Tissue,PX17250P,CDM,983,RC,17250,CPT,,,,,,,,402,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Chem Cautery Granulatn Tissue,PX17250P,CDM,983,RC,17250,CPT,,,,,,,,402,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Chem Cautery Granulatn Tissue,PX17250P,CDM,983,RC,17250,CPT,,,,,,,,402,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Chem Cautery Granulatn Tissue,PX17250P,CDM,983,RC,17250,CPT,,,,,,,,402,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Chemiluminescent Assay - Ref,PX8239790,CDM,300,RC,82397,CPT,90,,,,,,,78,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Chemiluminescent Assay - Ref,PX8239790,CDM,300,RC,82397,CPT,90,,,,,,,78,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Chemiluminescent Assay - Ref,PX8239790,CDM,300,RC,82397,CPT,90,,,,,,,78,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Chemiluminescent Assay - Ref,PX8239790,CDM,300,RC,82397,CPT,90,,,,,,,78,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Chemiluminescent Assay - Ref,PX8239790,CDM,300,RC,82397,CPT,90,,,,,,,78,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Chemiluminescent Assay - Ref,PX8239790,CDM,300,RC,82397,CPT,90,,,,,,,78,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Chemo Ad Sq/Im Hormnl Anti-Neo,PX96402,CDM,335,RC,96402,CPT,,,,,,,,130,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Chemo Ad Sq/Im Hormnl Anti-Neo,PX96402,CDM,335,RC,96402,CPT,,,,,,,,130,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Chemo Ad Sq/Im Hormnl Anti-Neo,PX96402,CDM,335,RC,96402,CPT,,,,,,,,130,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Chemo Ad Sq/Im Hormnl Anti-Neo,PX96402,CDM,335,RC,96402,CPT,,,,,,,,130,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Chemo Ad Sq/Im Hormnl Anti-Neo,PX96402,CDM,335,RC,96402,CPT,,,,,,,,130,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Chemo Ad Sq/Im Hormnl Anti-Neo,PX96402,CDM,335,RC,96402,CPT,,,,,,,,130,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chemotherapy Administration, Subq/Im Non-Hormonal Anti-Neoplastic",PX96401,CDM,335,RC,96401,CPT,,,,,,,,170,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chemotherapy Administration, Subq/Im Non-Hormonal Anti-Neoplastic",PX96401,CDM,335,RC,96401,CPT,,,,,,,,170,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chemotherapy Administration, Subq/Im Non-Hormonal Anti-Neoplastic",PX96401,CDM,335,RC,96401,CPT,,,,,,,,170,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chemotherapy Administration, Subq/Im Non-Hormonal Anti-Neoplastic",PX96401,CDM,335,RC,96401,CPT,,,,,,,,170,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chemotherapy Administration, Subq/Im Non-Hormonal Anti-Neoplastic",PX96401,CDM,335,RC,96401,CPT,,,,,,,,170,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chemotherapy Administration, Subq/Im Non-Hormonal Anti-Neoplastic",PX96401,CDM,335,RC,96401,CPT,,,,,,,,170,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chemotherapy, IV Infusion, 1 Hour",PX96413,CDM,335,RC,96413,CPT,,,,,,,,614,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chemotherapy, IV Infusion, 1 Hour",PX96413,CDM,335,RC,96413,CPT,,,,,,,,614,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chemotherapy, IV Infusion, 1 Hour",PX96413,CDM,335,RC,96413,CPT,,,,,,,,614,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chemotherapy, IV Infusion, 1 Hour",PX96413,CDM,335,RC,96413,CPT,,,,,,,,614,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chemotherapy, IV Infusion, 1 Hour",PX96413,CDM,335,RC,96413,CPT,,,,,,,,614,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chemotherapy, IV Infusion, 1 Hour",PX96413,CDM,335,RC,96413,CPT,,,,,,,,614,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chemotherapy, IV Infusion, Add'l Hour",PX96415,CDM,335,RC,96415,CPT,,,,,,,,191,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chemotherapy, IV Infusion, Add'l Hour",PX96415,CDM,335,RC,96415,CPT,,,,,,,,191,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chemotherapy, IV Infusion, Add'l Hour",PX96415,CDM,335,RC,96415,CPT,,,,,,,,191,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chemotherapy, IV Infusion, Add'l Hour",PX96415,CDM,335,RC,96415,CPT,,,,,,,,191,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chemotherapy, IV Infusion, Add'l Hour",PX96415,CDM,335,RC,96415,CPT,,,,,,,,191,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chemotherapy, IV Infusion, Add'l Hour",PX96415,CDM,335,RC,96415,CPT,,,,,,,,191,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chemotherapy, IV Infusion, Each Add'l Sequential Infusion",PX96417,CDM,335,RC,96417,CPT,,,,,,,,328,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chemotherapy, IV Infusion, Each Add'l Sequential Infusion",PX96417,CDM,335,RC,96417,CPT,,,,,,,,328,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chemotherapy, IV Infusion, Each Add'l Sequential Infusion",PX96417,CDM,335,RC,96417,CPT,,,,,,,,328,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chemotherapy, IV Infusion, Each Add'l Sequential Infusion",PX96417,CDM,335,RC,96417,CPT,,,,,,,,328,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chemotherapy, IV Infusion, Each Add'l Sequential Infusion",PX96417,CDM,335,RC,96417,CPT,,,,,,,,328,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chemotherapy, IV Infusion, Each Add'l Sequential Infusion",PX96417,CDM,335,RC,96417,CPT,,,,,,,,328,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chemotherapy, IV Push, Additional Drug",PX96411,CDM,335,RC,96411,CPT,,,,,,,,87,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chemotherapy, IV Push, Additional Drug",PX96411,CDM,335,RC,96411,CPT,,,,,,,,87,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chemotherapy, IV Push, Additional Drug",PX96411,CDM,335,RC,96411,CPT,,,,,,,,87,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chemotherapy, IV Push, Additional Drug",PX96411,CDM,335,RC,96411,CPT,,,,,,,,87,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chemotherapy, IV Push, Additional Drug",PX96411,CDM,335,RC,96411,CPT,,,,,,,,87,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chemotherapy, IV Push, Additional Drug",PX96411,CDM,335,RC,96411,CPT,,,,,,,,87,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chemotherapy, IV Push, Single Drug",PX96409,CDM,335,RC,96409,CPT,,,,,,,,502,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chemotherapy, IV Push, Single Drug",PX96409,CDM,335,RC,96409,CPT,,,,,,,,502,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chemotherapy, IV Push, Single Drug",PX96409,CDM,335,RC,96409,CPT,,,,,,,,502,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chemotherapy, IV Push, Single Drug",PX96409,CDM,335,RC,96409,CPT,,,,,,,,502,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chemotherapy, IV Push, Single Drug",PX96409,CDM,335,RC,96409,CPT,,,,,,,,502,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chemotherapy, IV Push, Single Drug",PX96409,CDM,335,RC,96409,CPT,,,,,,,,502,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chest Wall Manipulation,Initial",PX94667,CDM,410,RC,94667,CPT,,,,,,,,121,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chest Wall Manipulation,Initial",PX94667,CDM,410,RC,94667,CPT,,,,,,,,121,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chest Wall Manipulation,Initial",PX94667,CDM,410,RC,94667,CPT,,,,,,,,121,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chest Wall Manipulation,Initial",PX94667,CDM,410,RC,94667,CPT,,,,,,,,121,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chest Wall Manipulation,Initial",PX94667,CDM,410,RC,94667,CPT,,,,,,,,121,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chest Wall Manipulation,Initial",PX94667,CDM,410,RC,94667,CPT,,,,,,,,121,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chest Wall Manipulation,Subsequent",PX94668F,CDM,410,RC,94668,CPT,,,,,,,,192,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chest Wall Manipulation,Subsequent",PX94668F,CDM,410,RC,94668,CPT,,,,,,,,192,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chest Wall Manipulation,Subsequent",PX94668F,CDM,410,RC,94668,CPT,,,,,,,,192,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chest Wall Manipulation,Subsequent",PX94668F,CDM,410,RC,94668,CPT,,,,,,,,192,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chest Wall Manipulation,Subsequent",PX94668F,CDM,410,RC,94668,CPT,,,,,,,,192,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chest Wall Manipulation,Subsequent",PX94668F,CDM,410,RC,94668,CPT,,,,,,,,192,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chlamydia Trachomatis Dna, Amp Probe",PX87491,CDM,300,RC,87491,CPT,,,,,,,,157,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chlamydia Trachomatis Dna, Amp Probe",PX87491,CDM,300,RC,87491,CPT,,,,,,,,157,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chlamydia Trachomatis Dna, Amp Probe",PX87491,CDM,300,RC,87491,CPT,,,,,,,,157,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chlamydia Trachomatis Dna, Amp Probe",PX87491,CDM,300,RC,87491,CPT,,,,,,,,157,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chlamydia Trachomatis Dna, Amp Probe",PX87491,CDM,300,RC,87491,CPT,,,,,,,,157,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chlamydia Trachomatis Dna, Amp Probe",PX87491,CDM,300,RC,87491,CPT,,,,,,,,157,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
chlorhexidine 4 % Solution 118 mL Bottle,25000000,CDM,250,RC,,,,,,234057504,NDC,118,ML,24.09,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
chlorhexidine 4 % Solution 118 mL Bottle,25000000,CDM,250,RC,,,,,,234057504,NDC,118,ML,24.09,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
chlorhexidine 4 % Solution 118 mL Bottle,25000000,CDM,250,RC,,,,,,234057504,NDC,118,ML,24.09,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
chlorhexidine 4 % Solution 118 mL Bottle,25000000,CDM,250,RC,,,,,,234057504,NDC,118,ML,24.09,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
chlorhexidine 4 % Solution 118 mL Bottle,25000000,CDM,250,RC,,,,,,234057504,NDC,118,ML,24.09,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
chlorhexidine 4 % Solution 118 mL Bottle,25000000,CDM,250,RC,,,,,,234057504,NDC,118,ML,24.09,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031801,NDC,1,ML,185.37,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031801,NDC,1,ML,185.37,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031801,NDC,1,ML,185.37,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031801,NDC,1,ML,185.37,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031801,NDC,1,ML,185.37,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031801,NDC,1,ML,185.37,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031825,NDC,1,ML,185.37,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031825,NDC,1,ML,185.37,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031825,NDC,1,ML,185.37,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031825,NDC,1,ML,185.37,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031825,NDC,1,ML,185.37,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031825,NDC,1,ML,185.37,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
chlorthalidone 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378022201,NDC,0.5,EA,3.24,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
chlorthalidone 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378022201,NDC,0.5,EA,3.24,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
chlorthalidone 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378022201,NDC,0.5,EA,3.24,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
chlorthalidone 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378022201,NDC,0.5,EA,3.24,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
chlorthalidone 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378022201,NDC,0.5,EA,3.24,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
chlorthalidone 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378022201,NDC,0.5,EA,3.24,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CHOLANGIOGRAM CATHETER REDDICK,27200000,CDM,272,RC,,,,10232-MAIN,LOCAL,,,,,287.98,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CHOLANGIOGRAM CATHETER REDDICK,27200000,CDM,272,RC,,,,10232-MAIN,LOCAL,,,,,287.98,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CHOLANGIOGRAM CATHETER REDDICK,27200000,CDM,272,RC,,,,10232-MAIN,LOCAL,,,,,287.98,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CHOLANGIOGRAM CATHETER REDDICK,27200000,CDM,272,RC,,,,10232-MAIN,LOCAL,,,,,287.98,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CHOLANGIOGRAM CATHETER REDDICK,27200000,CDM,272,RC,,,,10232-MAIN,LOCAL,,,,,287.98,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CHOLANGIOGRAM CATHETER REDDICK,27200000,CDM,272,RC,,,,10232-MAIN,LOCAL,,,,,287.98,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cholecalciferol (vitamin D3) 125 MCG (5000 UT) capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,80681013100,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cholecalciferol (vitamin D3) 125 MCG (5000 UT) capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,80681013100,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cholecalciferol (vitamin D3) 125 MCG (5000 UT) capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,80681013100,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cholecalciferol (vitamin D3) 125 MCG (5000 UT) capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,80681013100,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cholecalciferol (vitamin D3) 125 MCG (5000 UT) capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,80681013100,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cholecalciferol (vitamin D3) 125 MCG (5000 UT) capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,80681013100,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cholestyramine light 4 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,245003689,NDC,1,EA,27.44,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cholestyramine light 4 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,245003689,NDC,1,EA,27.44,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cholestyramine light 4 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,245003689,NDC,1,EA,27.44,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cholestyramine light 4 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,245003689,NDC,1,EA,27.44,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cholestyramine light 4 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,245003689,NDC,1,EA,27.44,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cholestyramine light 4 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,245003689,NDC,1,EA,27.44,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cholestyramine light 4 g Packet 42 Each Box,63700001,CDM,250,RC,,,,,,245003642,NDC,1,EA,27.42,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cholestyramine light 4 g Packet 42 Each Box,63700001,CDM,250,RC,,,,,,245003642,NDC,1,EA,27.42,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cholestyramine light 4 g Packet 42 Each Box,63700001,CDM,250,RC,,,,,,245003642,NDC,1,EA,27.42,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cholestyramine light 4 g Packet 42 Each Box,63700001,CDM,250,RC,,,,,,245003642,NDC,1,EA,27.42,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cholestyramine light 4 g Packet 42 Each Box,63700001,CDM,250,RC,,,,,,245003642,NDC,1,EA,27.42,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cholestyramine light 4 g Packet 42 Each Box,63700001,CDM,250,RC,,,,,,245003642,NDC,1,EA,27.42,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Chorionic gonadotropin test,PX84702,CDM,300,RC,84702,CPT,,,,,,,,210,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Chorionic gonadotropin test,PX84702,CDM,300,RC,84702,CPT,,,,,,,,210,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Chorionic gonadotropin test,PX84702,CDM,300,RC,84702,CPT,,,,,,,,210,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Chorionic gonadotropin test,PX84702,CDM,300,RC,84702,CPT,,,,,,,,210,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Chorionic gonadotropin test,PX84702,CDM,300,RC,84702,CPT,,,,,,,,210,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Chorionic gonadotropin test,PX84702,CDM,300,RC,84702,CPT,,,,,,,,210,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Chrom Anal 15-20 Cells - Ref,PX8826290,CDM,310,RC,88262,CPT,90,,,,,,,398,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Chrom Anal 15-20 Cells - Ref,PX8826290,CDM,310,RC,88262,CPT,90,,,,,,,398,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Chrom Anal 15-20 Cells - Ref,PX8826290,CDM,310,RC,88262,CPT,90,,,,,,,398,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Chrom Anal 15-20 Cells - Ref,PX8826290,CDM,310,RC,88262,CPT,90,,,,,,,398,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Chrom Anal 15-20 Cells - Ref,PX8826290,CDM,310,RC,88262,CPT,90,,,,,,,398,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Chrom Anal 15-20 Cells - Ref,PX8826290,CDM,310,RC,88262,CPT,90,,,,,,,398,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chrom Anal, 20-25 Cells - Ref",PX8826490,CDM,310,RC,88264,CPT,90,,,,,,,3141,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chrom Anal, 20-25 Cells - Ref",PX8826490,CDM,310,RC,88264,CPT,90,,,,,,,3141,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chrom Anal, 20-25 Cells - Ref",PX8826490,CDM,310,RC,88264,CPT,90,,,,,,,3141,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chrom Anal, 20-25 Cells - Ref",PX8826490,CDM,310,RC,88264,CPT,90,,,,,,,3141,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chrom Anal, 20-25 Cells - Ref",PX8826490,CDM,310,RC,88264,CPT,90,,,,,,,3141,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chrom Anal, 20-25 Cells - Ref",PX8826490,CDM,310,RC,88264,CPT,90,,,,,,,3141,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 0.3 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,61314065625,NDC,2.5,ML,140.92,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 0.3 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,61314065625,NDC,2.5,ML,140.92,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 0.3 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,61314065625,NDC,2.5,ML,140.92,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 0.3 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,61314065625,NDC,2.5,ML,140.92,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 0.3 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,61314065625,NDC,2.5,ML,140.92,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 0.3 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,61314065625,NDC,2.5,ML,140.92,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314065605,NDC,0.05,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314065605,NDC,0.05,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314065605,NDC,0.05,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314065605,NDC,0.05,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314065605,NDC,0.05,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314065605,NDC,0.05,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714065102,NDC,0.4,EA,9.74,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714065102,NDC,0.4,EA,9.74,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714065102,NDC,0.4,EA,9.74,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714065102,NDC,0.4,EA,9.74,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714065102,NDC,0.4,EA,9.74,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714065102,NDC,0.4,EA,9.74,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862007601,NDC,0.4,EA,9.84,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862007601,NDC,0.4,EA,9.84,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862007601,NDC,0.4,EA,9.84,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862007601,NDC,0.4,EA,9.84,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862007601,NDC,0.4,EA,9.84,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862007601,NDC,0.4,EA,9.84,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084007011,NDC,1,EA,33.19,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084007011,NDC,1,EA,33.19,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084007011,NDC,1,EA,33.19,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084007011,NDC,1,EA,33.19,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084007011,NDC,1,EA,33.19,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084007011,NDC,1,EA,33.19,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862007701,NDC,0.2,EA,6,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862007701,NDC,0.2,EA,6,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862007701,NDC,0.2,EA,6,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862007701,NDC,0.2,EA,6,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862007701,NDC,0.2,EA,6,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862007701,NDC,0.2,EA,6,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637861,NDC,0.2,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637861,NDC,0.2,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637861,NDC,0.2,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637861,NDC,0.2,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637861,NDC,0.2,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637861,NDC,0.2,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904724361,NDC,0.2,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904724361,NDC,0.2,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904724361,NDC,0.2,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904724361,NDC,0.2,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904724361,NDC,0.2,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904724361,NDC,0.2,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084007001,NDC,1,EA,33.17,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084007001,NDC,1,EA,33.17,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084007001,NDC,1,EA,33.17,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084007001,NDC,1,EA,33.17,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084007001,NDC,1,EA,33.17,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084007001,NDC,1,EA,33.17,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,25021011487,NDC,200,ML,66.28,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,25021011487,NDC,200,ML,66.28,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,25021011487,NDC,200,ML,66.28,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,25021011487,NDC,200,ML,66.28,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,25021011487,NDC,200,ML,66.28,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,25021011487,NDC,200,ML,66.28,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,36000000924,NDC,200,ML,48.65,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,36000000924,NDC,200,ML,48.65,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,36000000924,NDC,200,ML,48.65,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,36000000924,NDC,200,ML,48.65,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,36000000924,NDC,200,ML,48.65,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,36000000924,NDC,200,ML,48.65,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin-dexAMETHasone 0.3-0.1 % Suspension 7.5 mL Bottle,25000000,CDM,250,RC,,,,,,43598032675,NDC,7.5,ML,976.53,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin-dexAMETHasone 0.3-0.1 % Suspension 7.5 mL Bottle,25000000,CDM,250,RC,,,,,,43598032675,NDC,7.5,ML,976.53,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin-dexAMETHasone 0.3-0.1 % Suspension 7.5 mL Bottle,25000000,CDM,250,RC,,,,,,43598032675,NDC,7.5,ML,976.53,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin-dexAMETHasone 0.3-0.1 % Suspension 7.5 mL Bottle,25000000,CDM,250,RC,,,,,,43598032675,NDC,7.5,ML,976.53,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin-dexAMETHasone 0.3-0.1 % Suspension 7.5 mL Bottle,25000000,CDM,250,RC,,,,,,43598032675,NDC,7.5,ML,976.53,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin-dexAMETHasone 0.3-0.1 % Suspension 7.5 mL Bottle,25000000,CDM,250,RC,,,,,,43598032675,NDC,7.5,ML,976.53,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CISplatin 50 MG/50ML Solution 50 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010351,NDC,50,ML,82.27,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CISplatin 50 MG/50ML Solution 50 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010351,NDC,50,ML,82.27,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CISplatin 50 MG/50ML Solution 50 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010351,NDC,50,ML,82.27,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CISplatin 50 MG/50ML Solution 50 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010351,NDC,50,ML,82.27,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CISplatin 50 MG/50ML Solution 50 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010351,NDC,50,ML,82.27,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CISplatin 50 MG/50ML Solution 50 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010351,NDC,50,ML,82.27,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,703574811,NDC,100,ML,183.92,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,703574811,NDC,100,ML,183.92,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,703574811,NDC,100,ML,183.92,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,703574811,NDC,100,ML,183.92,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,703574811,NDC,100,ML,183.92,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,703574811,NDC,100,ML,183.92,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010365,NDC,100,ML,164.54,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010365,NDC,100,ML,164.54,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010365,NDC,100,ML,164.54,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010365,NDC,100,ML,164.54,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010365,NDC,100,ML,164.54,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010365,NDC,100,ML,164.54,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
citalopram 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904608461,NDC,1,EA,13.03,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
citalopram 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904608461,NDC,1,EA,13.03,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
citalopram 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904608461,NDC,1,EA,13.03,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
citalopram 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904608461,NDC,1,EA,13.03,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
citalopram 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904608461,NDC,1,EA,13.03,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
citalopram 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904608461,NDC,1,EA,13.03,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
citalopram 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904608561,NDC,1,EA,14.46,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
citalopram 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904608561,NDC,1,EA,14.46,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
citalopram 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904608561,NDC,1,EA,14.46,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
citalopram 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904608561,NDC,1,EA,14.46,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
citalopram 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904608561,NDC,1,EA,14.46,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
citalopram 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904608561,NDC,1,EA,14.46,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Citrate - Ref,PX8250790,CDM,300,RC,82507,CPT,90,,,,,,,56,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Citrate - Ref,PX8250790,CDM,300,RC,82507,CPT,90,,,,,,,56,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Citrate - Ref,PX8250790,CDM,300,RC,82507,CPT,90,,,,,,,56,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Citrate - Ref,PX8250790,CDM,300,RC,82507,CPT,90,,,,,,,56,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Citrate - Ref,PX8250790,CDM,300,RC,82507,CPT,90,,,,,,,56,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Citrate - Ref,PX8250790,CDM,300,RC,82507,CPT,90,,,,,,,56,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clarithromycin 250 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,527193106,NDC,1,EA,32.3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clarithromycin 250 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,527193106,NDC,1,EA,32.3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clarithromycin 250 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,527193106,NDC,1,EA,32.3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clarithromycin 250 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,527193106,NDC,1,EA,32.3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clarithromycin 250 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,527193106,NDC,1,EA,32.3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clarithromycin 250 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,527193106,NDC,1,EA,32.3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clarithromycin 250 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,65862022560,NDC,1,EA,32.3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clarithromycin 250 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,65862022560,NDC,1,EA,32.3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clarithromycin 250 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,65862022560,NDC,1,EA,32.3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clarithromycin 250 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,65862022560,NDC,1,EA,32.3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clarithromycin 250 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,65862022560,NDC,1,EA,32.3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clarithromycin 250 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,65862022560,NDC,1,EA,32.3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin 150 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904595961,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin 150 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904595961,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin 150 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904595961,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin 150 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904595961,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin 150 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904595961,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin 150 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904595961,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin 300 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084024411,NDC,1,EA,6.97,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin 300 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084024411,NDC,1,EA,6.97,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin 300 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084024411,NDC,1,EA,6.97,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin 300 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084024411,NDC,1,EA,6.97,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin 300 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084024411,NDC,1,EA,6.97,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin 300 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084024411,NDC,1,EA,6.97,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,68084024401,NDC,1,EA,6.97,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,68084024401,NDC,1,EA,6.97,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,68084024401,NDC,1,EA,6.97,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,68084024401,NDC,1,EA,6.97,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,68084024401,NDC,1,EA,6.97,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,68084024401,NDC,1,EA,6.97,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337501,NDC,50,ML,135.43,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337501,NDC,50,ML,135.43,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337501,NDC,50,ML,135.43,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337501,NDC,50,ML,135.43,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337501,NDC,50,ML,135.43,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337501,NDC,50,ML,135.43,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337502,NDC,50,ML,135.43,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337502,NDC,50,ML,135.43,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337502,NDC,50,ML,135.43,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337502,NDC,50,ML,135.43,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337502,NDC,50,ML,135.43,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337502,NDC,50,ML,135.43,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9678001,NDC,50,ML,135.43,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9678001,NDC,50,ML,135.43,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9678001,NDC,50,ML,135.43,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9678001,NDC,50,ML,135.43,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9678001,NDC,50,ML,135.43,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9678001,NDC,50,ML,135.43,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361250,NDC,50,ML,90.53,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361250,NDC,50,ML,90.53,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361250,NDC,50,ML,90.53,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361250,NDC,50,ML,90.53,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361250,NDC,50,ML,90.53,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361250,NDC,50,ML,90.53,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361650,NDC,50,ML,90.53,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361650,NDC,50,ML,90.53,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361650,NDC,50,ML,90.53,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361650,NDC,50,ML,90.53,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361650,NDC,50,ML,90.53,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361650,NDC,50,ML,90.53,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989001,NDC,50,ML,160.78,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989001,NDC,50,ML,160.78,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989001,NDC,50,ML,160.78,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989001,NDC,50,ML,160.78,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989001,NDC,50,ML,160.78,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989001,NDC,50,ML,160.78,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989002,NDC,50,ML,160.78,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989002,NDC,50,ML,160.78,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989002,NDC,50,ML,160.78,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989002,NDC,50,ML,160.78,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989002,NDC,50,ML,160.78,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989002,NDC,50,ML,160.78,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338411450,NDC,50,ML,106.23,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338411450,NDC,50,ML,106.23,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338411450,NDC,50,ML,106.23,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338411450,NDC,50,ML,106.23,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338411450,NDC,50,ML,106.23,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338411450,NDC,50,ML,106.23,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,781329091,NDC,50,ML,119.73,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,781329091,NDC,50,ML,119.73,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,781329091,NDC,50,ML,119.73,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,781329091,NDC,50,ML,119.73,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,781329091,NDC,50,ML,119.73,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,781329091,NDC,50,ML,119.73,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clobetasol 0.05 % Cream 60 g Tube,63700001,CDM,250,RC,,,,,,168030160,NDC,60,GR,989.25,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clobetasol 0.05 % Cream 60 g Tube,63700001,CDM,250,RC,,,,,,168030160,NDC,60,GR,989.25,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clobetasol 0.05 % Cream 60 g Tube,63700001,CDM,250,RC,,,,,,168030160,NDC,60,GR,989.25,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clobetasol 0.05 % Cream 60 g Tube,63700001,CDM,250,RC,,,,,,168030160,NDC,60,GR,989.25,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clobetasol 0.05 % Cream 60 g Tube,63700001,CDM,250,RC,,,,,,168030160,NDC,60,GR,989.25,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clobetasol 0.05 % Cream 60 g Tube,63700001,CDM,250,RC,,,,,,168030160,NDC,60,GR,989.25,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clobetasol 0.05 % Cream 60 g Tube,63700001,CDM,250,RC,,,,,,69238153206,NDC,60,GR,1665.95,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clobetasol 0.05 % Cream 60 g Tube,63700001,CDM,250,RC,,,,,,69238153206,NDC,60,GR,1665.95,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clobetasol 0.05 % Cream 60 g Tube,63700001,CDM,250,RC,,,,,,69238153206,NDC,60,GR,1665.95,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clobetasol 0.05 % Cream 60 g Tube,63700001,CDM,250,RC,,,,,,69238153206,NDC,60,GR,1665.95,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clobetasol 0.05 % Cream 60 g Tube,63700001,CDM,250,RC,,,,,,69238153206,NDC,60,GR,1665.95,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clobetasol 0.05 % Cream 60 g Tube,63700001,CDM,250,RC,,,,,,69238153206,NDC,60,GR,1665.95,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clobetasol 0.05 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,21922001707,NDC,60,GR,1810.35,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clobetasol 0.05 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,21922001707,NDC,60,GR,1810.35,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clobetasol 0.05 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,21922001707,NDC,60,GR,1810.35,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clobetasol 0.05 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,21922001707,NDC,60,GR,1810.35,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clobetasol 0.05 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,21922001707,NDC,60,GR,1810.35,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clobetasol 0.05 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,21922001707,NDC,60,GR,1810.35,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clobetasol 0.05 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,42291007760,NDC,60,GR,1625.97,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clobetasol 0.05 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,42291007760,NDC,60,GR,1625.97,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clobetasol 0.05 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,42291007760,NDC,60,GR,1625.97,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clobetasol 0.05 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,42291007760,NDC,60,GR,1625.97,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clobetasol 0.05 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,42291007760,NDC,60,GR,1625.97,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clobetasol 0.05 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,42291007760,NDC,60,GR,1625.97,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clonazePAM 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714075201,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clonazePAM 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714075201,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clonazePAM 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714075201,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clonazePAM 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714075201,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clonazePAM 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714075201,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clonazePAM 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714075201,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clonazePAM 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16729013600,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clonazePAM 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16729013600,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clonazePAM 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16729013600,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clonazePAM 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16729013600,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clonazePAM 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16729013600,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clonazePAM 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16729013600,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clonazePAM 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739026310,NDC,1,EA,4.32,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clonazePAM 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739026310,NDC,1,EA,4.32,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clonazePAM 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739026310,NDC,1,EA,4.32,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clonazePAM 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739026310,NDC,1,EA,4.32,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clonazePAM 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739026310,NDC,1,EA,4.32,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clonazePAM 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739026310,NDC,1,EA,4.32,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clonazePAM 0.25 MG Tablet Disintegrating 1 Each Blister,63700001,CDM,250,RC,,,,,,49884030752,NDC,1,EA,6.98,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clonazePAM 0.25 MG Tablet Disintegrating 1 Each Blister,63700001,CDM,250,RC,,,,,,49884030752,NDC,1,EA,6.98,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clonazePAM 0.25 MG Tablet Disintegrating 1 Each Blister,63700001,CDM,250,RC,,,,,,49884030752,NDC,1,EA,6.98,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clonazePAM 0.25 MG Tablet Disintegrating 1 Each Blister,63700001,CDM,250,RC,,,,,,49884030752,NDC,1,EA,6.98,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clonazePAM 0.25 MG Tablet Disintegrating 1 Each Blister,63700001,CDM,250,RC,,,,,,49884030752,NDC,1,EA,6.98,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clonazePAM 0.25 MG Tablet Disintegrating 1 Each Blister,63700001,CDM,250,RC,,,,,,49884030752,NDC,1,EA,6.98,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Bottle,63700001,CDM,250,RC,,,,,,57664078486,NDC,1,EA,6.98,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Bottle,63700001,CDM,250,RC,,,,,,57664078486,NDC,1,EA,6.98,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Bottle,63700001,CDM,250,RC,,,,,,57664078486,NDC,1,EA,6.98,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Bottle,63700001,CDM,250,RC,,,,,,57664078486,NDC,1,EA,6.98,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Bottle,63700001,CDM,250,RC,,,,,,57664078486,NDC,1,EA,6.98,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Bottle,63700001,CDM,250,RC,,,,,,57664078486,NDC,1,EA,6.98,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Box,63700001,CDM,250,RC,,,,,,555009596,NDC,1,EA,6.98,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Box,63700001,CDM,250,RC,,,,,,555009596,NDC,1,EA,6.98,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Box,63700001,CDM,250,RC,,,,,,555009596,NDC,1,EA,6.98,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Box,63700001,CDM,250,RC,,,,,,555009596,NDC,1,EA,6.98,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Box,63700001,CDM,250,RC,,,,,,555009596,NDC,1,EA,6.98,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Box,63700001,CDM,250,RC,,,,,,555009596,NDC,1,EA,6.98,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Box,63700001,CDM,250,RC,,,,,,49884030702,NDC,1,EA,6.98,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Box,63700001,CDM,250,RC,,,,,,49884030702,NDC,1,EA,6.98,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Box,63700001,CDM,250,RC,,,,,,49884030702,NDC,1,EA,6.98,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Box,63700001,CDM,250,RC,,,,,,49884030702,NDC,1,EA,6.98,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Box,63700001,CDM,250,RC,,,,,,49884030702,NDC,1,EA,6.98,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Box,63700001,CDM,250,RC,,,,,,49884030702,NDC,1,EA,6.98,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cloNIDine 0.1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687011311,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cloNIDine 0.1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687011311,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cloNIDine 0.1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687011311,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cloNIDine 0.1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687011311,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cloNIDine 0.1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687011311,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cloNIDine 0.1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687011311,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cloNIDine 0.1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687011301,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cloNIDine 0.1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687011301,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cloNIDine 0.1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687011301,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cloNIDine 0.1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687011301,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cloNIDine 0.1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687011301,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cloNIDine 0.1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687011301,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cloNIDine 0.1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739006010,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cloNIDine 0.1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739006010,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cloNIDine 0.1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739006010,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cloNIDine 0.1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739006010,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cloNIDine 0.1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739006010,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cloNIDine 0.1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739006010,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cloNIDine 0.1 MG/24HR PATCH WEEKLY 4 Each Box,63700001,CDM,250,RC,,,,,,51862045304,NDC,1,EA,158.16,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cloNIDine 0.1 MG/24HR PATCH WEEKLY 4 Each Box,63700001,CDM,250,RC,,,,,,51862045304,NDC,1,EA,158.16,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cloNIDine 0.1 MG/24HR PATCH WEEKLY 4 Each Box,63700001,CDM,250,RC,,,,,,51862045304,NDC,1,EA,158.16,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cloNIDine 0.1 MG/24HR PATCH WEEKLY 4 Each Box,63700001,CDM,250,RC,,,,,,51862045304,NDC,1,EA,158.16,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cloNIDine 0.1 MG/24HR PATCH WEEKLY 4 Each Box,63700001,CDM,250,RC,,,,,,51862045304,NDC,1,EA,158.16,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cloNIDine 0.1 MG/24HR PATCH WEEKLY 4 Each Box,63700001,CDM,250,RC,,,,,,51862045304,NDC,1,EA,158.16,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clopidogrel 75 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629461,NDC,1,EA,23.42,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clopidogrel 75 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629461,NDC,1,EA,23.42,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clopidogrel 75 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629461,NDC,1,EA,23.42,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clopidogrel 75 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629461,NDC,1,EA,23.42,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clopidogrel 75 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629461,NDC,1,EA,23.42,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clopidogrel 75 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629461,NDC,1,EA,23.42,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Close Rx Dist Fingr Fx,Manipulatn",PX26755F,CDM,510,RC,26755,CPT,,,,,,,,335,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Close Rx Dist Fingr Fx,Manipulatn",PX26755F,CDM,510,RC,26755,CPT,,,,,,,,335,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Close Rx Dist Fingr Fx,Manipulatn",PX26755F,CDM,510,RC,26755,CPT,,,,,,,,335,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Close Rx Dist Fingr Fx,Manipulatn",PX26755F,CDM,510,RC,26755,CPT,,,,,,,,335,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Close Rx Dist Fingr Fx,Manipulatn",PX26755F,CDM,510,RC,26755,CPT,,,,,,,,335,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Close Rx Dist Fingr Fx,Manipulatn",PX26755F,CDM,510,RC,26755,CPT,,,,,,,,335,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Close Rx Dist Fingr Fx,Manipulatn",PX26755P,CDM,983,RC,26755,CPT,,,,,,,,1260,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Close Rx Dist Fingr Fx,Manipulatn",PX26755P,CDM,983,RC,26755,CPT,,,,,,,,1260,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Close Rx Dist Fingr Fx,Manipulatn",PX26755P,CDM,983,RC,26755,CPT,,,,,,,,1260,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Close Rx Dist Fingr Fx,Manipulatn",PX26755P,CDM,983,RC,26755,CPT,,,,,,,,1260,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Close Rx Dist Fingr Fx,Manipulatn",PX26755P,CDM,983,RC,26755,CPT,,,,,,,,1260,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Close Rx Dist Fingr Fx,Manipulatn",PX26755P,CDM,983,RC,26755,CPT,,,,,,,,1260,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Close Rx Fingr Articular Fx,Manip",PX26742F,CDM,510,RC,26742,CPT,,,,,,,,1039,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Close Rx Fingr Articular Fx,Manip",PX26742F,CDM,510,RC,26742,CPT,,,,,,,,1039,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Close Rx Fingr Articular Fx,Manip",PX26742F,CDM,510,RC,26742,CPT,,,,,,,,1039,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Close Rx Fingr Articular Fx,Manip",PX26742F,CDM,510,RC,26742,CPT,,,,,,,,1039,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Close Rx Fingr Articular Fx,Manip",PX26742F,CDM,510,RC,26742,CPT,,,,,,,,1039,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Close Rx Fingr Articular Fx,Manip",PX26742F,CDM,510,RC,26742,CPT,,,,,,,,1039,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Close Rx Fingr Articular Fx,Manip",PX26742P,CDM,983,RC,26742,CPT,,,,,,,,560,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Close Rx Fingr Articular Fx,Manip",PX26742P,CDM,983,RC,26742,CPT,,,,,,,,560,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Close Rx Fingr Articular Fx,Manip",PX26742P,CDM,983,RC,26742,CPT,,,,,,,,560,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Close Rx Fingr Articular Fx,Manip",PX26742P,CDM,983,RC,26742,CPT,,,,,,,,560,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Close Rx Fingr Articular Fx,Manip",PX26742P,CDM,983,RC,26742,CPT,,,,,,,,560,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Close Rx Fingr Articular Fx,Manip",PX26742P,CDM,983,RC,26742,CPT,,,,,,,,560,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725F,CDM,510,RC,26725,CPT,,,,,,,,495,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725F,CDM,510,RC,26725,CPT,,,,,,,,495,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725F,CDM,510,RC,26725,CPT,,,,,,,,495,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725F,CDM,510,RC,26725,CPT,,,,,,,,495,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725F,CDM,510,RC,26725,CPT,,,,,,,,495,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725F,CDM,510,RC,26725,CPT,,,,,,,,495,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725P,CDM,983,RC,26725,CPT,,,,,,,,330,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725P,CDM,983,RC,26725,CPT,,,,,,,,330,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725P,CDM,983,RC,26725,CPT,,,,,,,,330,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725P,CDM,983,RC,26725,CPT,,,,,,,,330,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725P,CDM,983,RC,26725,CPT,,,,,,,,330,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725P,CDM,983,RC,26725,CPT,,,,,,,,330,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545F,CDM,510,RC,23545,CPT,,,,,,,,961,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545F,CDM,510,RC,23545,CPT,,,,,,,,961,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545F,CDM,510,RC,23545,CPT,,,,,,,,961,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545F,CDM,510,RC,23545,CPT,,,,,,,,961,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545F,CDM,510,RC,23545,CPT,,,,,,,,961,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545F,CDM,510,RC,23545,CPT,,,,,,,,961,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545P,CDM,983,RC,23545,CPT,,,,,,,,412,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545P,CDM,983,RC,23545,CPT,,,,,,,,412,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545P,CDM,983,RC,23545,CPT,,,,,,,,412,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545P,CDM,983,RC,23545,CPT,,,,,,,,412,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545P,CDM,983,RC,23545,CPT,,,,,,,,412,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545P,CDM,983,RC,23545,CPT,,,,,,,,412,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Big Toe Fx,Manip",PX28495F,CDM,510,RC,28495,CPT,,,,,,,,857,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Big Toe Fx,Manip",PX28495F,CDM,510,RC,28495,CPT,,,,,,,,857,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Big Toe Fx,Manip",PX28495F,CDM,510,RC,28495,CPT,,,,,,,,857,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Big Toe Fx,Manip",PX28495F,CDM,510,RC,28495,CPT,,,,,,,,857,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Big Toe Fx,Manip",PX28495F,CDM,510,RC,28495,CPT,,,,,,,,857,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Big Toe Fx,Manip",PX28495F,CDM,510,RC,28495,CPT,,,,,,,,857,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Big Toe Fx,Manip",PX28495P,CDM,983,RC,28495,CPT,,,,,,,,412,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Big Toe Fx,Manip",PX28495P,CDM,983,RC,28495,CPT,,,,,,,,412,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Big Toe Fx,Manip",PX28495P,CDM,983,RC,28495,CPT,,,,,,,,412,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Big Toe Fx,Manip",PX28495P,CDM,983,RC,28495,CPT,,,,,,,,412,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Big Toe Fx,Manip",PX28495P,CDM,983,RC,28495,CPT,,,,,,,,412,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Big Toe Fx,Manip",PX28495P,CDM,983,RC,28495,CPT,,,,,,,,412,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Bimalleolar Fx,PX27808F,CDM,510,RC,27808,CPT,,,,,,,,650,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Bimalleolar Fx,PX27808F,CDM,510,RC,27808,CPT,,,,,,,,650,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Bimalleolar Fx,PX27808F,CDM,510,RC,27808,CPT,,,,,,,,650,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Bimalleolar Fx,PX27808F,CDM,510,RC,27808,CPT,,,,,,,,650,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Bimalleolar Fx,PX27808F,CDM,510,RC,27808,CPT,,,,,,,,650,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Bimalleolar Fx,PX27808F,CDM,510,RC,27808,CPT,,,,,,,,650,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Bimalleolar Fx,PX27808P,CDM,983,RC,27808,CPT,,,,,,,,433,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Bimalleolar Fx,PX27808P,CDM,983,RC,27808,CPT,,,,,,,,433,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Bimalleolar Fx,PX27808P,CDM,983,RC,27808,CPT,,,,,,,,433,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Bimalleolar Fx,PX27808P,CDM,983,RC,27808,CPT,,,,,,,,433,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Bimalleolar Fx,PX27808P,CDM,983,RC,27808,CPT,,,,,,,,433,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Bimalleolar Fx,PX27808P,CDM,983,RC,27808,CPT,,,,,,,,433,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Bimalleolar Fx,Manip",PX27810F,CDM,510,RC,27810,CPT,,,,,,,,1026,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Bimalleolar Fx,Manip",PX27810F,CDM,510,RC,27810,CPT,,,,,,,,1026,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Bimalleolar Fx,Manip",PX27810F,CDM,510,RC,27810,CPT,,,,,,,,1026,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Bimalleolar Fx,Manip",PX27810F,CDM,510,RC,27810,CPT,,,,,,,,1026,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Bimalleolar Fx,Manip",PX27810F,CDM,510,RC,27810,CPT,,,,,,,,1026,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Bimalleolar Fx,Manip",PX27810F,CDM,510,RC,27810,CPT,,,,,,,,1026,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Bimalleolar Fx,Manip",PX27810P,CDM,983,RC,27810,CPT,,,,,,,,1057,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Bimalleolar Fx,Manip",PX27810P,CDM,983,RC,27810,CPT,,,,,,,,1057,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Bimalleolar Fx,Manip",PX27810P,CDM,983,RC,27810,CPT,,,,,,,,1057,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Bimalleolar Fx,Manip",PX27810P,CDM,983,RC,27810,CPT,,,,,,,,1057,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Bimalleolar Fx,Manip",PX27810P,CDM,983,RC,27810,CPT,,,,,,,,1057,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Bimalleolar Fx,Manip",PX27810P,CDM,983,RC,27810,CPT,,,,,,,,1057,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Dist Fibula Fx,Manip",PX27788F,CDM,510,RC,27788,CPT,,,,,,,,1597,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Dist Fibula Fx,Manip",PX27788F,CDM,510,RC,27788,CPT,,,,,,,,1597,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Dist Fibula Fx,Manip",PX27788F,CDM,510,RC,27788,CPT,,,,,,,,1597,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Dist Fibula Fx,Manip",PX27788F,CDM,510,RC,27788,CPT,,,,,,,,1597,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Dist Fibula Fx,Manip",PX27788F,CDM,510,RC,27788,CPT,,,,,,,,1597,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Dist Fibula Fx,Manip",PX27788F,CDM,510,RC,27788,CPT,,,,,,,,1597,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Dist Fibula Fx,Manip",PX27788P,CDM,983,RC,27788,CPT,,,,,,,,1277,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Dist Fibula Fx,Manip",PX27788P,CDM,983,RC,27788,CPT,,,,,,,,1277,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Dist Fibula Fx,Manip",PX27788P,CDM,983,RC,27788,CPT,,,,,,,,1277,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Dist Fibula Fx,Manip",PX27788P,CDM,983,RC,27788,CPT,,,,,,,,1277,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Dist Fibula Fx,Manip",PX27788P,CDM,983,RC,27788,CPT,,,,,,,,1277,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Dist Fibula Fx,Manip",PX27788P,CDM,983,RC,27788,CPT,,,,,,,,1277,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605F,CDM,510,RC,25605,CPT,,,,,,,,1178,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605F,CDM,510,RC,25605,CPT,,,,,,,,1178,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605F,CDM,510,RC,25605,CPT,,,,,,,,1178,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605F,CDM,510,RC,25605,CPT,,,,,,,,1178,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605F,CDM,510,RC,25605,CPT,,,,,,,,1178,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605F,CDM,510,RC,25605,CPT,,,,,,,,1178,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605P,CDM,983,RC,25605,CPT,,,,,,,,785,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605P,CDM,983,RC,25605,CPT,,,,,,,,785,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605P,CDM,983,RC,25605,CPT,,,,,,,,785,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605P,CDM,983,RC,25605,CPT,,,,,,,,785,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605P,CDM,983,RC,25605,CPT,,,,,,,,785,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605P,CDM,983,RC,25605,CPT,,,,,,,,785,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Elbow Dislocation,PX24600F,CDM,510,RC,24600,CPT,,,,,,,,706,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Elbow Dislocation,PX24600F,CDM,510,RC,24600,CPT,,,,,,,,706,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Elbow Dislocation,PX24600F,CDM,510,RC,24600,CPT,,,,,,,,706,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Elbow Dislocation,PX24600F,CDM,510,RC,24600,CPT,,,,,,,,706,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Elbow Dislocation,PX24600F,CDM,510,RC,24600,CPT,,,,,,,,706,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Elbow Dislocation,PX24600F,CDM,510,RC,24600,CPT,,,,,,,,706,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Elbow Dislocation,PX24600P,CDM,983,RC,24600,CPT,,,,,,,,380,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Elbow Dislocation,PX24600P,CDM,983,RC,24600,CPT,,,,,,,,380,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Elbow Dislocation,PX24600P,CDM,983,RC,24600,CPT,,,,,,,,380,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Elbow Dislocation,PX24600P,CDM,983,RC,24600,CPT,,,,,,,,380,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Elbow Dislocation,PX24600P,CDM,983,RC,24600,CPT,,,,,,,,380,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Elbow Dislocation,PX24600P,CDM,983,RC,24600,CPT,,,,,,,,380,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605F,CDM,510,RC,24605,CPT,,,,,,,,1124,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605F,CDM,510,RC,24605,CPT,,,,,,,,1124,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605F,CDM,510,RC,24605,CPT,,,,,,,,1124,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605F,CDM,510,RC,24605,CPT,,,,,,,,1124,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605F,CDM,510,RC,24605,CPT,,,,,,,,1124,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605F,CDM,510,RC,24605,CPT,,,,,,,,1124,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605P,CDM,983,RC,24605,CPT,,,,,,,,750,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605P,CDM,983,RC,24605,CPT,,,,,,,,750,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605P,CDM,983,RC,24605,CPT,,,,,,,,750,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605P,CDM,983,RC,24605,CPT,,,,,,,,750,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605P,CDM,983,RC,24605,CPT,,,,,,,,750,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605P,CDM,983,RC,24605,CPT,,,,,,,,750,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Femur Shaft Fx+Manip,PX27502F,CDM,510,RC,27502,CPT,,,,,,,,1625,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Femur Shaft Fx+Manip,PX27502F,CDM,510,RC,27502,CPT,,,,,,,,1625,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Femur Shaft Fx+Manip,PX27502F,CDM,510,RC,27502,CPT,,,,,,,,1625,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Femur Shaft Fx+Manip,PX27502F,CDM,510,RC,27502,CPT,,,,,,,,1625,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Femur Shaft Fx+Manip,PX27502F,CDM,510,RC,27502,CPT,,,,,,,,1625,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Femur Shaft Fx+Manip,PX27502F,CDM,510,RC,27502,CPT,,,,,,,,1625,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Femur Shaft Fx+Manip,PX27502P,CDM,983,RC,27502,CPT,,,,,,,,1083,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Femur Shaft Fx+Manip,PX27502P,CDM,983,RC,27502,CPT,,,,,,,,1083,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Femur Shaft Fx+Manip,PX27502P,CDM,983,RC,27502,CPT,,,,,,,,1083,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Femur Shaft Fx+Manip,PX27502P,CDM,983,RC,27502,CPT,,,,,,,,1083,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Femur Shaft Fx+Manip,PX27502P,CDM,983,RC,27502,CPT,,,,,,,,1083,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Femur Shaft Fx+Manip,PX27502P,CDM,983,RC,27502,CPT,,,,,,,,1083,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535F,CDM,510,RC,24535,CPT,,,,,,,,2514,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535F,CDM,510,RC,24535,CPT,,,,,,,,2514,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535F,CDM,510,RC,24535,CPT,,,,,,,,2514,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535F,CDM,510,RC,24535,CPT,,,,,,,,2514,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535F,CDM,510,RC,24535,CPT,,,,,,,,2514,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535F,CDM,510,RC,24535,CPT,,,,,,,,2514,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535P,CDM,983,RC,24535,CPT,,,,,,,,2887,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535P,CDM,983,RC,24535,CPT,,,,,,,,2887,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535P,CDM,983,RC,24535,CPT,,,,,,,,2887,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535P,CDM,983,RC,24535,CPT,,,,,,,,2887,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535P,CDM,983,RC,24535,CPT,,,,,,,,2887,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535P,CDM,983,RC,24535,CPT,,,,,,,,2887,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx I-P Jt,Toe Dislocation",PX28660F,CDM,510,RC,28660,CPT,,,,,,,,335,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx I-P Jt,Toe Dislocation",PX28660F,CDM,510,RC,28660,CPT,,,,,,,,335,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx I-P Jt,Toe Dislocation",PX28660F,CDM,510,RC,28660,CPT,,,,,,,,335,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx I-P Jt,Toe Dislocation",PX28660F,CDM,510,RC,28660,CPT,,,,,,,,335,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx I-P Jt,Toe Dislocation",PX28660F,CDM,510,RC,28660,CPT,,,,,,,,335,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx I-P Jt,Toe Dislocation",PX28660F,CDM,510,RC,28660,CPT,,,,,,,,335,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx I-P Jt,Toe Dislocation",PX28660P,CDM,983,RC,28660,CPT,,,,,,,,628,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx I-P Jt,Toe Dislocation",PX28660P,CDM,983,RC,28660,CPT,,,,,,,,628,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx I-P Jt,Toe Dislocation",PX28660P,CDM,983,RC,28660,CPT,,,,,,,,628,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx I-P Jt,Toe Dislocation",PX28660P,CDM,983,RC,28660,CPT,,,,,,,,628,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx I-P Jt,Toe Dislocation",PX28660P,CDM,983,RC,28660,CPT,,,,,,,,628,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx I-P Jt,Toe Dislocation",PX28660P,CDM,983,RC,28660,CPT,,,,,,,,628,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx IP Jt Dislocation,PX26770F,CDM,510,RC,26770,CPT,,,,,,,,1231,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx IP Jt Dislocation,PX26770F,CDM,510,RC,26770,CPT,,,,,,,,1231,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx IP Jt Dislocation,PX26770F,CDM,510,RC,26770,CPT,,,,,,,,1231,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx IP Jt Dislocation,PX26770F,CDM,510,RC,26770,CPT,,,,,,,,1231,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx IP Jt Dislocation,PX26770F,CDM,510,RC,26770,CPT,,,,,,,,1231,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx IP Jt Dislocation,PX26770F,CDM,510,RC,26770,CPT,,,,,,,,1231,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx IP Jt Dislocation,PX26770P,CDM,983,RC,26770,CPT,,,,,,,,1353,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx IP Jt Dislocation,PX26770P,CDM,983,RC,26770,CPT,,,,,,,,1353,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx IP Jt Dislocation,PX26770P,CDM,983,RC,26770,CPT,,,,,,,,1353,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx IP Jt Dislocation,PX26770P,CDM,983,RC,26770,CPT,,,,,,,,1353,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx IP Jt Dislocation,PX26770P,CDM,983,RC,26770,CPT,,,,,,,,1353,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx IP Jt Dislocation,PX26770P,CDM,983,RC,26770,CPT,,,,,,,,1353,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Kneecap Disloc+Anesth,PX27562F,CDM,510,RC,27562,CPT,,,,,,,,604,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Kneecap Disloc+Anesth,PX27562F,CDM,510,RC,27562,CPT,,,,,,,,604,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Kneecap Disloc+Anesth,PX27562F,CDM,510,RC,27562,CPT,,,,,,,,604,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Kneecap Disloc+Anesth,PX27562F,CDM,510,RC,27562,CPT,,,,,,,,604,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Kneecap Disloc+Anesth,PX27562F,CDM,510,RC,27562,CPT,,,,,,,,604,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Kneecap Disloc+Anesth,PX27562F,CDM,510,RC,27562,CPT,,,,,,,,604,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Kneecap Disloc+Anesth,PX27562P,CDM,983,RC,27562,CPT,,,,,,,,1404,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Kneecap Disloc+Anesth,PX27562P,CDM,983,RC,27562,CPT,,,,,,,,1404,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Kneecap Disloc+Anesth,PX27562P,CDM,983,RC,27562,CPT,,,,,,,,1404,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Kneecap Disloc+Anesth,PX27562P,CDM,983,RC,27562,CPT,,,,,,,,1404,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Kneecap Disloc+Anesth,PX27562P,CDM,983,RC,27562,CPT,,,,,,,,1404,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Kneecap Disloc+Anesth,PX27562P,CDM,983,RC,27562,CPT,,,,,,,,1404,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Kneecap Dislocatn,PX27560F,CDM,510,RC,27560,CPT,,,,,,,,468,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Kneecap Dislocatn,PX27560F,CDM,510,RC,27560,CPT,,,,,,,,468,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Kneecap Dislocatn,PX27560F,CDM,510,RC,27560,CPT,,,,,,,,468,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Kneecap Dislocatn,PX27560F,CDM,510,RC,27560,CPT,,,,,,,,468,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Kneecap Dislocatn,PX27560F,CDM,510,RC,27560,CPT,,,,,,,,468,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Kneecap Dislocatn,PX27560F,CDM,510,RC,27560,CPT,,,,,,,,468,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Kneecap Dislocatn,PX27560P,CDM,983,RC,27560,CPT,,,,,,,,312,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Kneecap Dislocatn,PX27560P,CDM,983,RC,27560,CPT,,,,,,,,312,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Kneecap Dislocatn,PX27560P,CDM,983,RC,27560,CPT,,,,,,,,312,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Kneecap Dislocatn,PX27560P,CDM,983,RC,27560,CPT,,,,,,,,312,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Kneecap Dislocatn,PX27560P,CDM,983,RC,27560,CPT,,,,,,,,312,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Kneecap Dislocatn,PX27560P,CDM,983,RC,27560,CPT,,,,,,,,312,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Metacarpal Fx,PX26600F,CDM,510,RC,26600,CPT,,,,,,,,443,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Metacarpal Fx,PX26600F,CDM,510,RC,26600,CPT,,,,,,,,443,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Metacarpal Fx,PX26600F,CDM,510,RC,26600,CPT,,,,,,,,443,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Metacarpal Fx,PX26600F,CDM,510,RC,26600,CPT,,,,,,,,443,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Metacarpal Fx,PX26600F,CDM,510,RC,26600,CPT,,,,,,,,443,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Metacarpal Fx,PX26600F,CDM,510,RC,26600,CPT,,,,,,,,443,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Metacarpal Fx,PX26600P,CDM,983,RC,26600,CPT,,,,,,,,295,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Metacarpal Fx,PX26600P,CDM,983,RC,26600,CPT,,,,,,,,295,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Metacarpal Fx,PX26600P,CDM,983,RC,26600,CPT,,,,,,,,295,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Metacarpal Fx,PX26600P,CDM,983,RC,26600,CPT,,,,,,,,295,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Metacarpal Fx,PX26600P,CDM,983,RC,26600,CPT,,,,,,,,295,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Metacarpal Fx,PX26600P,CDM,983,RC,26600,CPT,,,,,,,,295,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505F,CDM,510,RC,24505,CPT,,,,,,,,2109,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505F,CDM,510,RC,24505,CPT,,,,,,,,2109,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505F,CDM,510,RC,24505,CPT,,,,,,,,2109,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505F,CDM,510,RC,24505,CPT,,,,,,,,2109,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505F,CDM,510,RC,24505,CPT,,,,,,,,2109,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505F,CDM,510,RC,24505,CPT,,,,,,,,2109,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505P,CDM,983,RC,24505,CPT,,,,,,,,2353,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505P,CDM,983,RC,24505,CPT,,,,,,,,2353,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505P,CDM,983,RC,24505,CPT,,,,,,,,2353,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505P,CDM,983,RC,24505,CPT,,,,,,,,2353,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505P,CDM,983,RC,24505,CPT,,,,,,,,2353,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505P,CDM,983,RC,24505,CPT,,,,,,,,2353,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Mt-Phal Toe Dislocation,PX28630F,CDM,510,RC,28630,CPT,,,,,,,,360,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Mt-Phal Toe Dislocation,PX28630F,CDM,510,RC,28630,CPT,,,,,,,,360,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Mt-Phal Toe Dislocation,PX28630F,CDM,510,RC,28630,CPT,,,,,,,,360,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Mt-Phal Toe Dislocation,PX28630F,CDM,510,RC,28630,CPT,,,,,,,,360,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Mt-Phal Toe Dislocation,PX28630F,CDM,510,RC,28630,CPT,,,,,,,,360,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Mt-Phal Toe Dislocation,PX28630F,CDM,510,RC,28630,CPT,,,,,,,,360,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Mt-Phal Toe Dislocation,PX28630P,CDM,983,RC,28630,CPT,,,,,,,,248,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Mt-Phal Toe Dislocation,PX28630P,CDM,983,RC,28630,CPT,,,,,,,,248,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Mt-Phal Toe Dislocation,PX28630P,CDM,983,RC,28630,CPT,,,,,,,,248,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Mt-Phal Toe Dislocation,PX28630P,CDM,983,RC,28630,CPT,,,,,,,,248,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Mt-Phal Toe Dislocation,PX28630P,CDM,983,RC,28630,CPT,,,,,,,,248,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Mt-Phal Toe Dislocation,PX28630P,CDM,983,RC,28630,CPT,,,,,,,,248,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266F,CDM,510,RC,27266,CPT,,,,,,,,1684,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266F,CDM,510,RC,27266,CPT,,,,,,,,1684,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266F,CDM,510,RC,27266,CPT,,,,,,,,1684,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266F,CDM,510,RC,27266,CPT,,,,,,,,1684,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266F,CDM,510,RC,27266,CPT,,,,,,,,1684,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266F,CDM,510,RC,27266,CPT,,,,,,,,1684,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266P,CDM,983,RC,27266,CPT,,,,,,,,2275,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266P,CDM,983,RC,27266,CPT,,,,,,,,2275,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266P,CDM,983,RC,27266,CPT,,,,,,,,2275,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266P,CDM,983,RC,27266,CPT,,,,,,,,2275,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266P,CDM,983,RC,27266,CPT,,,,,,,,2275,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266P,CDM,983,RC,27266,CPT,,,,,,,,2275,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565F,CDM,510,RC,25565,CPT,,,,,,,,1250,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565F,CDM,510,RC,25565,CPT,,,,,,,,1250,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565F,CDM,510,RC,25565,CPT,,,,,,,,1250,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565F,CDM,510,RC,25565,CPT,,,,,,,,1250,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565F,CDM,510,RC,25565,CPT,,,,,,,,1250,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565F,CDM,510,RC,25565,CPT,,,,,,,,1250,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565P,CDM,983,RC,25565,CPT,,,,,,,,830,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565P,CDM,983,RC,25565,CPT,,,,,,,,830,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565P,CDM,983,RC,25565,CPT,,,,,,,,830,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565P,CDM,983,RC,25565,CPT,,,,,,,,830,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565P,CDM,983,RC,25565,CPT,,,,,,,,830,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565P,CDM,983,RC,25565,CPT,,,,,,,,830,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Radial Head Disloc,Child",PX24640F,CDM,510,RC,24640,CPT,,,,,,,,270,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Radial Head Disloc,Child",PX24640F,CDM,510,RC,24640,CPT,,,,,,,,270,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Radial Head Disloc,Child",PX24640F,CDM,510,RC,24640,CPT,,,,,,,,270,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Radial Head Disloc,Child",PX24640F,CDM,510,RC,24640,CPT,,,,,,,,270,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Radial Head Disloc,Child",PX24640F,CDM,510,RC,24640,CPT,,,,,,,,270,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Radial Head Disloc,Child",PX24640F,CDM,510,RC,24640,CPT,,,,,,,,270,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Radial Head Disloc,Child",PX24640P,CDM,983,RC,24640,CPT,,,,,,,,180,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Radial Head Disloc,Child",PX24640P,CDM,983,RC,24640,CPT,,,,,,,,180,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Radial Head Disloc,Child",PX24640P,CDM,983,RC,24640,CPT,,,,,,,,180,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Radial Head Disloc,Child",PX24640P,CDM,983,RC,24640,CPT,,,,,,,,180,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Radial Head Disloc,Child",PX24640P,CDM,983,RC,24640,CPT,,,,,,,,180,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Radial Head Disloc,Child",PX24640P,CDM,983,RC,24640,CPT,,,,,,,,180,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Radial Head/Neck Fx,Manip",PX24655F,CDM,510,RC,24655,CPT,,,,,,,,1750,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Radial Head/Neck Fx,Manip",PX24655F,CDM,510,RC,24655,CPT,,,,,,,,1750,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Radial Head/Neck Fx,Manip",PX24655F,CDM,510,RC,24655,CPT,,,,,,,,1750,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Radial Head/Neck Fx,Manip",PX24655F,CDM,510,RC,24655,CPT,,,,,,,,1750,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Radial Head/Neck Fx,Manip",PX24655F,CDM,510,RC,24655,CPT,,,,,,,,1750,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Radial Head/Neck Fx,Manip",PX24655F,CDM,510,RC,24655,CPT,,,,,,,,1750,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Radial Head/Neck Fx,Manip",PX24655P,CDM,983,RC,24655,CPT,,,,,,,,1824,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Radial Head/Neck Fx,Manip",PX24655P,CDM,983,RC,24655,CPT,,,,,,,,1824,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Radial Head/Neck Fx,Manip",PX24655P,CDM,983,RC,24655,CPT,,,,,,,,1824,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Radial Head/Neck Fx,Manip",PX24655P,CDM,983,RC,24655,CPT,,,,,,,,1824,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Radial Head/Neck Fx,Manip",PX24655P,CDM,983,RC,24655,CPT,,,,,,,,1824,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Radial Head/Neck Fx,Manip",PX24655P,CDM,983,RC,24655,CPT,,,,,,,,1824,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505F,CDM,510,RC,25505,CPT,,,,,,,,651,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505F,CDM,510,RC,25505,CPT,,,,,,,,651,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505F,CDM,510,RC,25505,CPT,,,,,,,,651,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505F,CDM,510,RC,25505,CPT,,,,,,,,651,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505F,CDM,510,RC,25505,CPT,,,,,,,,651,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505F,CDM,510,RC,25505,CPT,,,,,,,,651,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505P,CDM,983,RC,25505,CPT,,,,,,,,977,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505P,CDM,983,RC,25505,CPT,,,,,,,,977,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505P,CDM,983,RC,25505,CPT,,,,,,,,977,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505P,CDM,983,RC,25505,CPT,,,,,,,,977,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505P,CDM,983,RC,25505,CPT,,,,,,,,977,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505P,CDM,983,RC,25505,CPT,,,,,,,,977,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Shldr Disloc,Anesthesia",PX23655F,CDM,510,RC,23655,CPT,,,,,,,,1776,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Shldr Disloc,Anesthesia",PX23655F,CDM,510,RC,23655,CPT,,,,,,,,1776,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Shldr Disloc,Anesthesia",PX23655F,CDM,510,RC,23655,CPT,,,,,,,,1776,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Shldr Disloc,Anesthesia",PX23655F,CDM,510,RC,23655,CPT,,,,,,,,1776,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Shldr Disloc,Anesthesia",PX23655F,CDM,510,RC,23655,CPT,,,,,,,,1776,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Shldr Disloc,Anesthesia",PX23655F,CDM,510,RC,23655,CPT,,,,,,,,1776,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Shldr Disloc,Anesthesia",PX23655P,CDM,983,RC,23655,CPT,,,,,,,,1421,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Shldr Disloc,Anesthesia",PX23655P,CDM,983,RC,23655,CPT,,,,,,,,1421,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Shldr Disloc,Anesthesia",PX23655P,CDM,983,RC,23655,CPT,,,,,,,,1421,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Shldr Disloc,Anesthesia",PX23655P,CDM,983,RC,23655,CPT,,,,,,,,1421,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Shldr Disloc,Anesthesia",PX23655P,CDM,983,RC,23655,CPT,,,,,,,,1421,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Shldr Disloc,Anesthesia",PX23655P,CDM,983,RC,23655,CPT,,,,,,,,1421,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Shldr Dislocation,PX23650F,CDM,510,RC,23650,CPT,,,,,,,,689,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Shldr Dislocation,PX23650F,CDM,510,RC,23650,CPT,,,,,,,,689,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Shldr Dislocation,PX23650F,CDM,510,RC,23650,CPT,,,,,,,,689,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Shldr Dislocation,PX23650F,CDM,510,RC,23650,CPT,,,,,,,,689,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Shldr Dislocation,PX23650F,CDM,510,RC,23650,CPT,,,,,,,,689,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Shldr Dislocation,PX23650F,CDM,510,RC,23650,CPT,,,,,,,,689,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Shldr Dislocation,PX23650P,CDM,983,RC,23650,CPT,,,,,,,,516,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Shldr Dislocation,PX23650P,CDM,983,RC,23650,CPT,,,,,,,,516,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Shldr Dislocation,PX23650P,CDM,983,RC,23650,CPT,,,,,,,,516,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Shldr Dislocation,PX23650P,CDM,983,RC,23650,CPT,,,,,,,,516,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Shldr Dislocation,PX23650P,CDM,983,RC,23650,CPT,,,,,,,,516,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Shldr Dislocation,PX23650P,CDM,983,RC,23650,CPT,,,,,,,,516,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Spont Hip Disloc,Anesth",PX27257F,CDM,510,RC,27257,CPT,,,,,,,,548,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Spont Hip Disloc,Anesth",PX27257F,CDM,510,RC,27257,CPT,,,,,,,,548,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Spont Hip Disloc,Anesth",PX27257F,CDM,510,RC,27257,CPT,,,,,,,,548,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Spont Hip Disloc,Anesth",PX27257F,CDM,510,RC,27257,CPT,,,,,,,,548,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Spont Hip Disloc,Anesth",PX27257F,CDM,510,RC,27257,CPT,,,,,,,,548,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Spont Hip Disloc,Anesth",PX27257F,CDM,510,RC,27257,CPT,,,,,,,,548,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Spont Hip Disloc,Anesth",PX27257P,CDM,983,RC,27257,CPT,,,,,,,,365,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Spont Hip Disloc,Anesth",PX27257P,CDM,983,RC,27257,CPT,,,,,,,,365,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Spont Hip Disloc,Anesth",PX27257P,CDM,983,RC,27257,CPT,,,,,,,,365,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Spont Hip Disloc,Anesth",PX27257P,CDM,983,RC,27257,CPT,,,,,,,,365,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Spont Hip Disloc,Anesth",PX27257P,CDM,983,RC,27257,CPT,,,,,,,,365,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Spont Hip Disloc,Anesth",PX27257P,CDM,983,RC,27257,CPT,,,,,,,,365,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Talus Fx,Manipulatn",PX28435F,CDM,510,RC,28435,CPT,,,,,,,,1705,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Talus Fx,Manipulatn",PX28435F,CDM,510,RC,28435,CPT,,,,,,,,1705,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Talus Fx,Manipulatn",PX28435F,CDM,510,RC,28435,CPT,,,,,,,,1705,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Talus Fx,Manipulatn",PX28435F,CDM,510,RC,28435,CPT,,,,,,,,1705,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Talus Fx,Manipulatn",PX28435F,CDM,510,RC,28435,CPT,,,,,,,,1705,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Talus Fx,Manipulatn",PX28435F,CDM,510,RC,28435,CPT,,,,,,,,1705,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Talus Fx,Manipulatn",PX28435P,CDM,983,RC,28435,CPT,,,,,,,,1137,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Talus Fx,Manipulatn",PX28435P,CDM,983,RC,28435,CPT,,,,,,,,1137,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Talus Fx,Manipulatn",PX28435P,CDM,983,RC,28435,CPT,,,,,,,,1137,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Talus Fx,Manipulatn",PX28435P,CDM,983,RC,28435,CPT,,,,,,,,1137,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Talus Fx,Manipulatn",PX28435P,CDM,983,RC,28435,CPT,,,,,,,,1137,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Talus Fx,Manipulatn",PX28435P,CDM,983,RC,28435,CPT,,,,,,,,1137,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752F,CDM,510,RC,27752,CPT,,,,,,,,2280,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752F,CDM,510,RC,27752,CPT,,,,,,,,2280,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752F,CDM,510,RC,27752,CPT,,,,,,,,2280,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752F,CDM,510,RC,27752,CPT,,,,,,,,2280,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752F,CDM,510,RC,27752,CPT,,,,,,,,2280,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752F,CDM,510,RC,27752,CPT,,,,,,,,2280,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752P,CDM,983,RC,27752,CPT,,,,,,,,2495,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752P,CDM,983,RC,27752,CPT,,,,,,,,2495,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752P,CDM,983,RC,27752,CPT,,,,,,,,2495,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752P,CDM,983,RC,27752,CPT,,,,,,,,2495,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752P,CDM,983,RC,27752,CPT,,,,,,,,2495,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752P,CDM,983,RC,27752,CPT,,,,,,,,2495,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Toe Fx,Manipulatn",PX28515F,CDM,510,RC,28515,CPT,,,,,,,,390,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Toe Fx,Manipulatn",PX28515F,CDM,510,RC,28515,CPT,,,,,,,,390,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Toe Fx,Manipulatn",PX28515F,CDM,510,RC,28515,CPT,,,,,,,,390,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Toe Fx,Manipulatn",PX28515F,CDM,510,RC,28515,CPT,,,,,,,,390,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Toe Fx,Manipulatn",PX28515F,CDM,510,RC,28515,CPT,,,,,,,,390,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Toe Fx,Manipulatn",PX28515F,CDM,510,RC,28515,CPT,,,,,,,,390,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Toe Fx,Manipulatn",PX28515P,CDM,983,RC,28515,CPT,,,,,,,,260,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Toe Fx,Manipulatn",PX28515P,CDM,983,RC,28515,CPT,,,,,,,,260,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Toe Fx,Manipulatn",PX28515P,CDM,983,RC,28515,CPT,,,,,,,,260,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Toe Fx,Manipulatn",PX28515P,CDM,983,RC,28515,CPT,,,,,,,,260,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Toe Fx,Manipulatn",PX28515P,CDM,983,RC,28515,CPT,,,,,,,,260,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Toe Fx,Manipulatn",PX28515P,CDM,983,RC,28515,CPT,,,,,,,,260,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Trimalleolar Fx,PX27816F,CDM,510,RC,27816,CPT,,,,,,,,522,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Trimalleolar Fx,PX27816F,CDM,510,RC,27816,CPT,,,,,,,,522,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Trimalleolar Fx,PX27816F,CDM,510,RC,27816,CPT,,,,,,,,522,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Trimalleolar Fx,PX27816F,CDM,510,RC,27816,CPT,,,,,,,,522,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Trimalleolar Fx,PX27816F,CDM,510,RC,27816,CPT,,,,,,,,522,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Trimalleolar Fx,PX27816F,CDM,510,RC,27816,CPT,,,,,,,,522,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Trimalleolar Fx,PX27816P,CDM,983,RC,27816,CPT,,,,,,,,826,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Trimalleolar Fx,PX27816P,CDM,983,RC,27816,CPT,,,,,,,,826,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Trimalleolar Fx,PX27816P,CDM,983,RC,27816,CPT,,,,,,,,826,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Trimalleolar Fx,PX27816P,CDM,983,RC,27816,CPT,,,,,,,,826,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Trimalleolar Fx,PX27816P,CDM,983,RC,27816,CPT,,,,,,,,826,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Trimalleolar Fx,PX27816P,CDM,983,RC,27816,CPT,,,,,,,,826,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Trimalleolar Fx,Manip",PX27818F,CDM,510,RC,27818,CPT,,,,,,,,813,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Trimalleolar Fx,Manip",PX27818F,CDM,510,RC,27818,CPT,,,,,,,,813,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Trimalleolar Fx,Manip",PX27818F,CDM,510,RC,27818,CPT,,,,,,,,813,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Trimalleolar Fx,Manip",PX27818F,CDM,510,RC,27818,CPT,,,,,,,,813,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Trimalleolar Fx,Manip",PX27818F,CDM,510,RC,27818,CPT,,,,,,,,813,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Trimalleolar Fx,Manip",PX27818F,CDM,510,RC,27818,CPT,,,,,,,,813,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Trimalleolar Fx,Manip",PX27818P,CDM,983,RC,27818,CPT,,,,,,,,1352,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Trimalleolar Fx,Manip",PX27818P,CDM,983,RC,27818,CPT,,,,,,,,1352,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Trimalleolar Fx,Manip",PX27818P,CDM,983,RC,27818,CPT,,,,,,,,1352,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Trimalleolar Fx,Manip",PX27818P,CDM,983,RC,27818,CPT,,,,,,,,1352,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Trimalleolar Fx,Manip",PX27818P,CDM,983,RC,27818,CPT,,,,,,,,1352,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Trimalleolar Fx,Manip",PX27818P,CDM,983,RC,27818,CPT,,,,,,,,1352,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Weight Bear Dist Tib,Manip",PX27825F,CDM,510,RC,27825,CPT,,,,,,,,2695,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Weight Bear Dist Tib,Manip",PX27825F,CDM,510,RC,27825,CPT,,,,,,,,2695,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Weight Bear Dist Tib,Manip",PX27825F,CDM,510,RC,27825,CPT,,,,,,,,2695,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Weight Bear Dist Tib,Manip",PX27825F,CDM,510,RC,27825,CPT,,,,,,,,2695,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Weight Bear Dist Tib,Manip",PX27825F,CDM,510,RC,27825,CPT,,,,,,,,2695,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Weight Bear Dist Tib,Manip",PX27825F,CDM,510,RC,27825,CPT,,,,,,,,2695,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Weight Bear Dist Tib,Manip",PX27825P,CDM,983,RC,27825,CPT,,,,,,,,1796,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Weight Bear Dist Tib,Manip",PX27825P,CDM,983,RC,27825,CPT,,,,,,,,1796,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Weight Bear Dist Tib,Manip",PX27825P,CDM,983,RC,27825,CPT,,,,,,,,1796,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Weight Bear Dist Tib,Manip",PX27825P,CDM,983,RC,27825,CPT,,,,,,,,1796,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Weight Bear Dist Tib,Manip",PX27825P,CDM,983,RC,27825,CPT,,,,,,,,1796,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Weight Bear Dist Tib,Manip",PX27825P,CDM,983,RC,27825,CPT,,,,,,,,1796,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Treat Wrist Dislocation,PX25660P,CDM,983,RC,25660,CPT,,,,,,,,1507,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Treat Wrist Dislocation,PX25660P,CDM,983,RC,25660,CPT,,,,,,,,1507,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Treat Wrist Dislocation,PX25660P,CDM,983,RC,25660,CPT,,,,,,,,1507,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Treat Wrist Dislocation,PX25660P,CDM,983,RC,25660,CPT,,,,,,,,1507,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Treat Wrist Dislocation,PX25660P,CDM,983,RC,25660,CPT,,,,,,,,1507,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Treat Wrist Dislocation,PX25660P,CDM,983,RC,25660,CPT,,,,,,,,1507,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CLOSED WOUND ROUND CHANNEL DRAIN WITH TROCAR 15FR FULL FLUTED,27200000,CDM,272,RC,,,,12223-MAIN,LOCAL,,,,,39,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CLOSED WOUND ROUND CHANNEL DRAIN WITH TROCAR 15FR FULL FLUTED,27200000,CDM,272,RC,,,,12223-MAIN,LOCAL,,,,,39,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CLOSED WOUND ROUND CHANNEL DRAIN WITH TROCAR 15FR FULL FLUTED,27200000,CDM,272,RC,,,,12223-MAIN,LOCAL,,,,,39,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CLOSED WOUND ROUND CHANNEL DRAIN WITH TROCAR 15FR FULL FLUTED,27200000,CDM,272,RC,,,,12223-MAIN,LOCAL,,,,,39,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CLOSED WOUND ROUND CHANNEL DRAIN WITH TROCAR 15FR FULL FLUTED,27200000,CDM,272,RC,,,,12223-MAIN,LOCAL,,,,,39,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CLOSED WOUND ROUND CHANNEL DRAIN WITH TROCAR 15FR FULL FLUTED,27200000,CDM,272,RC,,,,12223-MAIN,LOCAL,,,,,39,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Clostridium Ag, Eia",PX87324,CDM,300,RC,87324,CPT,,,,,,,,99,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Clostridium Ag, Eia",PX87324,CDM,300,RC,87324,CPT,,,,,,,,99,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Clostridium Ag, Eia",PX87324,CDM,300,RC,87324,CPT,,,,,,,,99,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Clostridium Ag, Eia",PX87324,CDM,300,RC,87324,CPT,,,,,,,,99,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Clostridium Ag, Eia",PX87324,CDM,300,RC,87324,CPT,,,,,,,,99,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Clostridium Ag, Eia",PX87324,CDM,300,RC,87324,CPT,,,,,,,,99,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closure of Gastrostomy,Surgical",PX43870P,CDM,983,RC,43870,CPT,,,,,,,,4012,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closure of Gastrostomy,Surgical",PX43870P,CDM,983,RC,43870,CPT,,,,,,,,4012,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closure of Gastrostomy,Surgical",PX43870P,CDM,983,RC,43870,CPT,,,,,,,,4012,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closure of Gastrostomy,Surgical",PX43870P,CDM,983,RC,43870,CPT,,,,,,,,4012,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closure of Gastrostomy,Surgical",PX43870P,CDM,983,RC,43870,CPT,,,,,,,,4012,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closure of Gastrostomy,Surgical",PX43870P,CDM,983,RC,43870,CPT,,,,,,,,4012,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closure Superf Wnd Dehis Simple,PX12020F,CDM,510,RC,12020,CPT,,,,,,,,632,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closure Superf Wnd Dehis Simple,PX12020F,CDM,510,RC,12020,CPT,,,,,,,,632,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closure Superf Wnd Dehis Simple,PX12020F,CDM,510,RC,12020,CPT,,,,,,,,632,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closure Superf Wnd Dehis Simple,PX12020F,CDM,510,RC,12020,CPT,,,,,,,,632,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closure Superf Wnd Dehis Simple,PX12020F,CDM,510,RC,12020,CPT,,,,,,,,632,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closure Superf Wnd Dehis Simple,PX12020F,CDM,510,RC,12020,CPT,,,,,,,,632,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closure Superf Wnd Dehis Simple,PX12020P,CDM,983,RC,12020,CPT,,,,,,,,422,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closure Superf Wnd Dehis Simple,PX12020P,CDM,983,RC,12020,CPT,,,,,,,,422,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closure Superf Wnd Dehis Simple,PX12020P,CDM,983,RC,12020,CPT,,,,,,,,422,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closure Superf Wnd Dehis Simple,PX12020P,CDM,983,RC,12020,CPT,,,,,,,,422,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closure Superf Wnd Dehis Simple,PX12020P,CDM,983,RC,12020,CPT,,,,,,,,422,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closure Superf Wnd Dehis Simple,PX12020P,CDM,983,RC,12020,CPT,,,,,,,,422,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clotrimazole 1 % Cream 28 g Tube,25000000,CDM,250,RC,,,,,,536127222,NDC,28,GR,15.36,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clotrimazole 1 % Cream 28 g Tube,25000000,CDM,250,RC,,,,,,536127222,NDC,28,GR,15.36,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clotrimazole 1 % Cream 28 g Tube,25000000,CDM,250,RC,,,,,,536127222,NDC,28,GR,15.36,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clotrimazole 1 % Cream 28 g Tube,25000000,CDM,250,RC,,,,,,536127222,NDC,28,GR,15.36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clotrimazole 1 % Cream 28 g Tube,25000000,CDM,250,RC,,,,,,536127222,NDC,28,GR,15.36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clotrimazole 1 % Cream 28 g Tube,25000000,CDM,250,RC,,,,,,536127222,NDC,28,GR,15.36,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clotrimazole 1 % Cream 28.35 g Tube,25000000,CDM,250,RC,,,,,,904782231,NDC,28.35,GR,50.75,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clotrimazole 1 % Cream 28.35 g Tube,25000000,CDM,250,RC,,,,,,904782231,NDC,28.35,GR,50.75,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clotrimazole 1 % Cream 28.35 g Tube,25000000,CDM,250,RC,,,,,,904782231,NDC,28.35,GR,50.75,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clotrimazole 1 % Cream 28.35 g Tube,25000000,CDM,250,RC,,,,,,904782231,NDC,28.35,GR,50.75,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clotrimazole 1 % Cream 28.35 g Tube,25000000,CDM,250,RC,,,,,,904782231,NDC,28.35,GR,50.75,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clotrimazole 1 % Cream 28.35 g Tube,25000000,CDM,250,RC,,,,,,904782231,NDC,28.35,GR,50.75,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clotrimazole-betamethasone 1-0.05 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,51672404801,NDC,15,GR,172.95,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clotrimazole-betamethasone 1-0.05 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,51672404801,NDC,15,GR,172.95,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clotrimazole-betamethasone 1-0.05 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,51672404801,NDC,15,GR,172.95,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clotrimazole-betamethasone 1-0.05 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,51672404801,NDC,15,GR,172.95,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clotrimazole-betamethasone 1-0.05 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,51672404801,NDC,15,GR,172.95,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clotrimazole-betamethasone 1-0.05 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,51672404801,NDC,15,GR,172.95,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clotrimazole-betamethasone 1-0.05 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,66993089815,NDC,15,GR,192.55,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clotrimazole-betamethasone 1-0.05 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,66993089815,NDC,15,GR,192.55,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clotrimazole-betamethasone 1-0.05 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,66993089815,NDC,15,GR,192.55,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clotrimazole-betamethasone 1-0.05 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,66993089815,NDC,15,GR,192.55,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clotrimazole-betamethasone 1-0.05 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,66993089815,NDC,15,GR,192.55,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clotrimazole-betamethasone 1-0.05 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,66993089815,NDC,15,GR,192.55,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Clotting Function Activity - Ref,PX8539790,CDM,300,RC,85397,CPT,90,,,,,,,334,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Clotting Function Activity - Ref,PX8539790,CDM,300,RC,85397,CPT,90,,,,,,,334,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Clotting Function Activity - Ref,PX8539790,CDM,300,RC,85397,CPT,90,,,,,,,334,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Clotting Function Activity - Ref,PX8539790,CDM,300,RC,85397,CPT,90,,,,,,,334,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Clotting Function Activity - Ref,PX8539790,CDM,300,RC,85397,CPT,90,,,,,,,334,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Clotting Function Activity - Ref,PX8539790,CDM,300,RC,85397,CPT,90,,,,,,,334,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Clozapine - Ref,PX8015990,CDM,300,RC,80159,CPT,90,,,,,,,65,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Clozapine - Ref,PX8015990,CDM,300,RC,80159,CPT,90,,,,,,,65,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Clozapine - Ref,PX8015990,CDM,300,RC,80159,CPT,90,,,,,,,65,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Clozapine - Ref,PX8015990,CDM,300,RC,80159,CPT,90,,,,,,,65,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Clozapine - Ref,PX8015990,CDM,300,RC,80159,CPT,90,,,,,,,65,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Clozapine - Ref,PX8015990,CDM,300,RC,80159,CPT,90,,,,,,,65,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cloZAPine 100 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,378086005,NDC,0.25,EA,4.42,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cloZAPine 100 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,378086005,NDC,0.25,EA,4.42,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cloZAPine 100 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,378086005,NDC,0.25,EA,4.42,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cloZAPine 100 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,378086005,NDC,0.25,EA,4.42,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cloZAPine 100 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,378086005,NDC,0.25,EA,4.42,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cloZAPine 100 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,378086005,NDC,0.25,EA,4.42,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cmv Antibody - Ref,PX8664490,CDM,300,RC,86644,CPT,90,,,,,,,104,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cmv Antibody - Ref,PX8664490,CDM,300,RC,86644,CPT,90,,,,,,,104,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cmv Antibody - Ref,PX8664490,CDM,300,RC,86644,CPT,90,,,,,,,104,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cmv Antibody - Ref,PX8664490,CDM,300,RC,86644,CPT,90,,,,,,,104,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cmv Antibody - Ref,PX8664490,CDM,300,RC,86644,CPT,90,,,,,,,104,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cmv Antibody - Ref,PX8664490,CDM,300,RC,86644,CPT,90,,,,,,,104,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cmv Detect, Amplifi Probe - Ref",PX8749690,CDM,300,RC,87496,CPT,90,,,,,,,147,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cmv Detect, Amplifi Probe - Ref",PX8749690,CDM,300,RC,87496,CPT,90,,,,,,,147,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cmv Detect, Amplifi Probe - Ref",PX8749690,CDM,300,RC,87496,CPT,90,,,,,,,147,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cmv Detect, Amplifi Probe - Ref",PX8749690,CDM,300,RC,87496,CPT,90,,,,,,,147,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cmv Detect, Amplifi Probe - Ref",PX8749690,CDM,300,RC,87496,CPT,90,,,,,,,147,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cmv Detect, Amplifi Probe - Ref",PX8749690,CDM,300,RC,87496,CPT,90,,,,,,,147,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cmv Igm Antibody - Ref,PX8664590,CDM,300,RC,86645,CPT,90,,,,,,,125,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cmv Igm Antibody - Ref,PX8664590,CDM,300,RC,86645,CPT,90,,,,,,,125,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cmv Igm Antibody - Ref,PX8664590,CDM,300,RC,86645,CPT,90,,,,,,,125,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cmv Igm Antibody - Ref,PX8664590,CDM,300,RC,86645,CPT,90,,,,,,,125,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cmv Igm Antibody - Ref,PX8664590,CDM,300,RC,86645,CPT,90,,,,,,,125,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cmv Igm Antibody - Ref,PX8664590,CDM,300,RC,86645,CPT,90,,,,,,,125,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cmv, Quant - Ref",PX8749790,CDM,300,RC,87497,CPT,90,,,,,,,194,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cmv, Quant - Ref",PX8749790,CDM,300,RC,87497,CPT,90,,,,,,,194,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cmv, Quant - Ref",PX8749790,CDM,300,RC,87497,CPT,90,,,,,,,194,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cmv, Quant - Ref",PX8749790,CDM,300,RC,87497,CPT,90,,,,,,,194,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cmv, Quant - Ref",PX8749790,CDM,300,RC,87497,CPT,90,,,,,,,194,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cmv, Quant - Ref",PX8749790,CDM,300,RC,87497,CPT,90,,,,,,,194,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cns Dna/Rna Amp Probe Multiple Subtypes 12-25,PX87483,CDM,300,RC,87483,CPT,,,,,,,,864,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cns Dna/Rna Amp Probe Multiple Subtypes 12-25,PX87483,CDM,300,RC,87483,CPT,,,,,,,,864,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cns Dna/Rna Amp Probe Multiple Subtypes 12-25,PX87483,CDM,300,RC,87483,CPT,,,,,,,,864,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cns Dna/Rna Amp Probe Multiple Subtypes 12-25,PX87483,CDM,300,RC,87483,CPT,,,,,,,,864,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cns Dna/Rna Amp Probe Multiple Subtypes 12-25,PX87483,CDM,300,RC,87483,CPT,,,,,,,,864,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cns Dna/Rna Amp Probe Multiple Subtypes 12-25,PX87483,CDM,300,RC,87483,CPT,,,,,,,,864,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cocaine 4% 4 % Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527172874,NDC,4,ML,875.53,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cocaine 4% 4 % Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527172874,NDC,4,ML,875.53,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cocaine 4% 4 % Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527172874,NDC,4,ML,875.53,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cocaine 4% 4 % Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527172874,NDC,4,ML,875.53,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cocaine 4% 4 % Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527172874,NDC,4,ML,875.53,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cocaine 4% 4 % Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527172874,NDC,4,ML,875.53,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527197174,NDC,4,ML,960.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527197174,NDC,4,ML,960.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527197174,NDC,4,ML,960.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527197174,NDC,4,ML,960.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527197174,NDC,4,ML,960.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527197174,NDC,4,ML,960.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,64950036204,NDC,4,ML,1067.22,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,64950036204,NDC,4,ML,1067.22,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,64950036204,NDC,4,ML,1067.22,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,64950036204,NDC,4,ML,1067.22,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,64950036204,NDC,4,ML,1067.22,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,64950036204,NDC,4,ML,1067.22,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,70839036204,NDC,4,ML,1280.66,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,70839036204,NDC,4,ML,1280.66,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,70839036204,NDC,4,ML,1280.66,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,70839036204,NDC,4,ML,1280.66,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,70839036204,NDC,4,ML,1280.66,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,70839036204,NDC,4,ML,1280.66,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Coccidioides Antibody - Ref,PX8663590,CDM,300,RC,86635,CPT,90,,,,,,,94,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Coccidioides Antibody - Ref,PX8663590,CDM,300,RC,86635,CPT,90,,,,,,,94,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Coccidioides Antibody - Ref,PX8663590,CDM,300,RC,86635,CPT,90,,,,,,,94,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Coccidioides Antibody - Ref,PX8663590,CDM,300,RC,86635,CPT,90,,,,,,,94,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Coccidioides Antibody - Ref,PX8663590,CDM,300,RC,86635,CPT,90,,,,,,,94,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Coccidioides Antibody - Ref,PX8663590,CDM,300,RC,86635,CPT,90,,,,,,,94,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
codeine 30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54024424,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
codeine 30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54024424,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
codeine 30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54024424,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
codeine 30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54024424,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
codeine 30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54024424,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
codeine 30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54024424,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cognitive Funct Ther Interv, Ea Addl 15 Min",PX97130,CDM,420,RC,97130,CPT,,,,,,,,82,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cognitive Funct Ther Interv, Ea Addl 15 Min",PX97130,CDM,420,RC,97130,CPT,,,,,,,,82,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cognitive Funct Ther Interv, Ea Addl 15 Min",PX97130,CDM,420,RC,97130,CPT,,,,,,,,82,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cognitive Funct Ther Interv, Ea Addl 15 Min",PX97130,CDM,420,RC,97130,CPT,,,,,,,,82,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cognitive Funct Ther Interv, Ea Addl 15 Min",PX97130,CDM,420,RC,97130,CPT,,,,,,,,82,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cognitive Funct Ther Interv, Ea Addl 15 Min",PX97130,CDM,420,RC,97130,CPT,,,,,,,,82,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cognitive Funct Ther Interv, Initial 15 Min",PX97129,CDM,420,RC,97129,CPT,,,,,,,,85,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cognitive Funct Ther Interv, Initial 15 Min",PX97129,CDM,420,RC,97129,CPT,,,,,,,,85,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cognitive Funct Ther Interv, Initial 15 Min",PX97129,CDM,420,RC,97129,CPT,,,,,,,,85,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cognitive Funct Ther Interv, Initial 15 Min",PX97129,CDM,420,RC,97129,CPT,,,,,,,,85,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cognitive Funct Ther Interv, Initial 15 Min",PX97129,CDM,420,RC,97129,CPT,,,,,,,,85,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cognitive Funct Ther Interv, Initial 15 Min",PX97129,CDM,420,RC,97129,CPT,,,,,,,,85,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cognitive Funct Ther Interv, per Day",PX97127,CDM,420,RC,97127,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cognitive Funct Ther Interv, per Day",PX97127,CDM,420,RC,97127,CPT,,,,,,,,135,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cognitive Funct Ther Interv, per Day",PX97127,CDM,420,RC,97127,CPT,,,,,,,,135,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cognitive Funct Ther Interv, per Day",PX97127,CDM,420,RC,97127,CPT,,,,,,,,135,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cognitive Funct Ther Interv, per Day",PX97127,CDM,420,RC,97127,CPT,,,,,,,,135,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cognitive Funct Ther Interv, per Day",PX97127,CDM,420,RC,97127,CPT,,,,,,,,135,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cognitive Skill Dev, Ea 15 Min",PX97532,CDM,420,RC,97532,CPT,,,,,,,,157,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cognitive Skill Dev, Ea 15 Min",PX97532,CDM,420,RC,97532,CPT,,,,,,,,157,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cognitive Skill Dev, Ea 15 Min",PX97532,CDM,420,RC,97532,CPT,,,,,,,,157,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cognitive Skill Dev, Ea 15 Min",PX97532,CDM,420,RC,97532,CPT,,,,,,,,157,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cognitive Skill Dev, Ea 15 Min",PX97532,CDM,420,RC,97532,CPT,,,,,,,,157,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cognitive Skill Dev, Ea 15 Min",PX97532,CDM,420,RC,97532,CPT,,,,,,,,157,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
colchicine 0.6 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,49884017111,NDC,1,EA,36.17,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
colchicine 0.6 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,49884017111,NDC,1,EA,36.17,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
colchicine 0.6 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,49884017111,NDC,1,EA,36.17,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
colchicine 0.6 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,49884017111,NDC,1,EA,36.17,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
colchicine 0.6 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,49884017111,NDC,1,EA,36.17,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
colchicine 0.6 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,49884017111,NDC,1,EA,36.17,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Collagen Cross Links - Ref,PX8252390,CDM,300,RC,82523,CPT,90,,,,,,,170,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Collagen Cross Links - Ref,PX8252390,CDM,300,RC,82523,CPT,90,,,,,,,170,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Collagen Cross Links - Ref,PX8252390,CDM,300,RC,82523,CPT,90,,,,,,,170,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Collagen Cross Links - Ref,PX8252390,CDM,300,RC,82523,CPT,90,,,,,,,170,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Collagen Cross Links - Ref,PX8252390,CDM,300,RC,82523,CPT,90,,,,,,,170,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Collagen Cross Links - Ref,PX8252390,CDM,300,RC,82523,CPT,90,,,,,,,170,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
collagenase 250 UNIT/GM Ointment 30 g Tube,63700001,CDM,250,RC,,,,,,50484001030,NDC,30,GR,1083.77,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
collagenase 250 UNIT/GM Ointment 30 g Tube,63700001,CDM,250,RC,,,,,,50484001030,NDC,30,GR,1083.77,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
collagenase 250 UNIT/GM Ointment 30 g Tube,63700001,CDM,250,RC,,,,,,50484001030,NDC,30,GR,1083.77,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
collagenase 250 UNIT/GM Ointment 30 g Tube,63700001,CDM,250,RC,,,,,,50484001030,NDC,30,GR,1083.77,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
collagenase 250 UNIT/GM Ointment 30 g Tube,63700001,CDM,250,RC,,,,,,50484001030,NDC,30,GR,1083.77,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
collagenase 250 UNIT/GM Ointment 30 g Tube,63700001,CDM,250,RC,,,,,,50484001030,NDC,30,GR,1083.77,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"COLLAR CERVICAL 2"" SMALL UNIVERSAL 08140039",120.249,CDM,274,RC,L0120,HCPCS,,270-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"COLLAR CERVICAL 2"" SMALL UNIVERSAL 08140039",120.249,CDM,274,RC,L0120,HCPCS,,270-MAIN,LOCAL,,,,,101,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"COLLAR CERVICAL 2"" SMALL UNIVERSAL 08140039",120.249,CDM,274,RC,L0120,HCPCS,,270-MAIN,LOCAL,,,,,101,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"COLLAR CERVICAL 2"" SMALL UNIVERSAL 08140039",120.249,CDM,274,RC,L0120,HCPCS,,270-MAIN,LOCAL,,,,,101,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"COLLAR CERVICAL 2"" SMALL UNIVERSAL 08140039",120.249,CDM,274,RC,L0120,HCPCS,,270-MAIN,LOCAL,,,,,101,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"COLLAR CERVICAL 2"" SMALL UNIVERSAL 08140039",120.249,CDM,274,RC,L0120,HCPCS,,270-MAIN,LOCAL,,,,,101,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"COLLAR CERVICAL 2X20"" SMALL 1003-02",120.249,CDM,274,RC,L0120,HCPCS,,272-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"COLLAR CERVICAL 2X20"" SMALL 1003-02",120.249,CDM,274,RC,L0120,HCPCS,,272-MAIN,LOCAL,,,,,101,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"COLLAR CERVICAL 2X20"" SMALL 1003-02",120.249,CDM,274,RC,L0120,HCPCS,,272-MAIN,LOCAL,,,,,101,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"COLLAR CERVICAL 2X20"" SMALL 1003-02",120.249,CDM,274,RC,L0120,HCPCS,,272-MAIN,LOCAL,,,,,101,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"COLLAR CERVICAL 2X20"" SMALL 1003-02",120.249,CDM,274,RC,L0120,HCPCS,,272-MAIN,LOCAL,,,,,101,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"COLLAR CERVICAL 2X20"" SMALL 1003-02",120.249,CDM,274,RC,L0120,HCPCS,,272-MAIN,LOCAL,,,,,101,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"COLLAR CERVICAL 2X23.5"" MEDIUM XNARROW 1003-04",120.249,CDM,274,RC,L0120,HCPCS,,273-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"COLLAR CERVICAL 2X23.5"" MEDIUM XNARROW 1003-04",120.249,CDM,274,RC,L0120,HCPCS,,273-MAIN,LOCAL,,,,,101,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"COLLAR CERVICAL 2X23.5"" MEDIUM XNARROW 1003-04",120.249,CDM,274,RC,L0120,HCPCS,,273-MAIN,LOCAL,,,,,101,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"COLLAR CERVICAL 2X23.5"" MEDIUM XNARROW 1003-04",120.249,CDM,274,RC,L0120,HCPCS,,273-MAIN,LOCAL,,,,,101,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"COLLAR CERVICAL 2X23.5"" MEDIUM XNARROW 1003-04",120.249,CDM,274,RC,L0120,HCPCS,,273-MAIN,LOCAL,,,,,101,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"COLLAR CERVICAL 2X23.5"" MEDIUM XNARROW 1003-04",120.249,CDM,274,RC,L0120,HCPCS,,273-MAIN,LOCAL,,,,,101,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"COLLAR CERVICAL 10-15"" SMALL XLONG 1005-06",120.249,CDM,274,RC,L0120,HCPCS,,267-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"COLLAR CERVICAL 10-15"" SMALL XLONG 1005-06",120.249,CDM,274,RC,L0120,HCPCS,,267-MAIN,LOCAL,,,,,101,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"COLLAR CERVICAL 10-15"" SMALL XLONG 1005-06",120.249,CDM,274,RC,L0120,HCPCS,,267-MAIN,LOCAL,,,,,101,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"COLLAR CERVICAL 10-15"" SMALL XLONG 1005-06",120.249,CDM,274,RC,L0120,HCPCS,,267-MAIN,LOCAL,,,,,101,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"COLLAR CERVICAL 10-15"" SMALL XLONG 1005-06",120.249,CDM,274,RC,L0120,HCPCS,,267-MAIN,LOCAL,,,,,101,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"COLLAR CERVICAL 10-15"" SMALL XLONG 1005-06",120.249,CDM,274,RC,L0120,HCPCS,,267-MAIN,LOCAL,,,,,101,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"COLLAR CERVICAL LARGE 21.5""X5"" 1005-04",120.249,CDM,274,RC,L0120,HCPCS,,268-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"COLLAR CERVICAL LARGE 21.5""X5"" 1005-04",120.249,CDM,274,RC,L0120,HCPCS,,268-MAIN,LOCAL,,,,,101,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"COLLAR CERVICAL LARGE 21.5""X5"" 1005-04",120.249,CDM,274,RC,L0120,HCPCS,,268-MAIN,LOCAL,,,,,101,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"COLLAR CERVICAL LARGE 21.5""X5"" 1005-04",120.249,CDM,274,RC,L0120,HCPCS,,268-MAIN,LOCAL,,,,,101,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"COLLAR CERVICAL LARGE 21.5""X5"" 1005-04",120.249,CDM,274,RC,L0120,HCPCS,,268-MAIN,LOCAL,,,,,101,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"COLLAR CERVICAL LARGE 21.5""X5"" 1005-04",120.249,CDM,274,RC,L0120,HCPCS,,268-MAIN,LOCAL,,,,,101,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
COLLAR CERVICAL LARGE WITH TRACH 2 PIECE PHP-T4L,120.184,CDM,274,RC,L0172,HCPCS,,10142-MAIN,LOCAL,,,,,37,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
COLLAR CERVICAL LARGE WITH TRACH 2 PIECE PHP-T4L,120.184,CDM,274,RC,L0172,HCPCS,,10142-MAIN,LOCAL,,,,,37,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
COLLAR CERVICAL LARGE WITH TRACH 2 PIECE PHP-T4L,120.184,CDM,274,RC,L0172,HCPCS,,10142-MAIN,LOCAL,,,,,37,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
COLLAR CERVICAL LARGE WITH TRACH 2 PIECE PHP-T4L,120.184,CDM,274,RC,L0172,HCPCS,,10142-MAIN,LOCAL,,,,,37,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
COLLAR CERVICAL LARGE WITH TRACH 2 PIECE PHP-T4L,120.184,CDM,274,RC,L0172,HCPCS,,10142-MAIN,LOCAL,,,,,37,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
COLLAR CERVICAL LARGE WITH TRACH 2 PIECE PHP-T4L,120.184,CDM,274,RC,L0172,HCPCS,,10142-MAIN,LOCAL,,,,,37,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"COLLAR CERVICAL MEDIUM 20-1/2X4"" 1005-03",120.249,CDM,274,RC,L0120,HCPCS,,269-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"COLLAR CERVICAL MEDIUM 20-1/2X4"" 1005-03",120.249,CDM,274,RC,L0120,HCPCS,,269-MAIN,LOCAL,,,,,101,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"COLLAR CERVICAL MEDIUM 20-1/2X4"" 1005-03",120.249,CDM,274,RC,L0120,HCPCS,,269-MAIN,LOCAL,,,,,101,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"COLLAR CERVICAL MEDIUM 20-1/2X4"" 1005-03",120.249,CDM,274,RC,L0120,HCPCS,,269-MAIN,LOCAL,,,,,101,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"COLLAR CERVICAL MEDIUM 20-1/2X4"" 1005-03",120.249,CDM,274,RC,L0120,HCPCS,,269-MAIN,LOCAL,,,,,101,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"COLLAR CERVICAL MEDIUM 20-1/2X4"" 1005-03",120.249,CDM,274,RC,L0120,HCPCS,,269-MAIN,LOCAL,,,,,101,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
COLLAR CERVICAL MEDIUM WITH TRACH 2 PIECE PHP-T4M,120.183,CDM,274,RC,L0172,HCPCS,,10141-MAIN,LOCAL,,,,,37,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
COLLAR CERVICAL MEDIUM WITH TRACH 2 PIECE PHP-T4M,120.183,CDM,274,RC,L0172,HCPCS,,10141-MAIN,LOCAL,,,,,37,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
COLLAR CERVICAL MEDIUM WITH TRACH 2 PIECE PHP-T4M,120.183,CDM,274,RC,L0172,HCPCS,,10141-MAIN,LOCAL,,,,,37,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
COLLAR CERVICAL MEDIUM WITH TRACH 2 PIECE PHP-T4M,120.183,CDM,274,RC,L0172,HCPCS,,10141-MAIN,LOCAL,,,,,37,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
COLLAR CERVICAL MEDIUM WITH TRACH 2 PIECE PHP-T4M,120.183,CDM,274,RC,L0172,HCPCS,,10141-MAIN,LOCAL,,,,,37,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
COLLAR CERVICAL MEDIUM WITH TRACH 2 PIECE PHP-T4M,120.183,CDM,274,RC,L0172,HCPCS,,10141-MAIN,LOCAL,,,,,37,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
COLLAR CERVICAL SMALL 1005-02,120.249,CDM,274,RC,L0120,HCPCS,,266-MAIN,LOCAL,,,,,101,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
COLLAR CERVICAL SMALL 1005-02,120.249,CDM,274,RC,L0120,HCPCS,,266-MAIN,LOCAL,,,,,101,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
COLLAR CERVICAL SMALL 1005-02,120.249,CDM,274,RC,L0120,HCPCS,,266-MAIN,LOCAL,,,,,101,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
COLLAR CERVICAL SMALL 1005-02,120.249,CDM,274,RC,L0120,HCPCS,,266-MAIN,LOCAL,,,,,101,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
COLLAR CERVICAL SMALL 1005-02,120.249,CDM,274,RC,L0120,HCPCS,,266-MAIN,LOCAL,,,,,101,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
COLLAR CERVICAL SMALL 1005-02,120.249,CDM,274,RC,L0120,HCPCS,,266-MAIN,LOCAL,,,,,101,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
COLLAR CERVICAL SMALL WITH TRACH 2 PIECE PHP-T4S,120.182,CDM,274,RC,L0172,HCPCS,,10140-MAIN,LOCAL,,,,,37,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
COLLAR CERVICAL SMALL WITH TRACH 2 PIECE PHP-T4S,120.182,CDM,274,RC,L0172,HCPCS,,10140-MAIN,LOCAL,,,,,37,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
COLLAR CERVICAL SMALL WITH TRACH 2 PIECE PHP-T4S,120.182,CDM,274,RC,L0172,HCPCS,,10140-MAIN,LOCAL,,,,,37,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
COLLAR CERVICAL SMALL WITH TRACH 2 PIECE PHP-T4S,120.182,CDM,274,RC,L0172,HCPCS,,10140-MAIN,LOCAL,,,,,37,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
COLLAR CERVICAL SMALL WITH TRACH 2 PIECE PHP-T4S,120.182,CDM,274,RC,L0172,HCPCS,,10140-MAIN,LOCAL,,,,,37,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
COLLAR CERVICAL SMALL WITH TRACH 2 PIECE PHP-T4S,120.182,CDM,274,RC,L0172,HCPCS,,10140-MAIN,LOCAL,,,,,37,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
COLLAR CERVICAL X-LARGE WITH TRACH 2 PIECE OSG2404,120.185,CDM,274,RC,L0172,HCPCS,,10143-MAIN,LOCAL,,,,,49,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
COLLAR CERVICAL X-LARGE WITH TRACH 2 PIECE OSG2404,120.185,CDM,274,RC,L0172,HCPCS,,10143-MAIN,LOCAL,,,,,49,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
COLLAR CERVICAL X-LARGE WITH TRACH 2 PIECE OSG2404,120.185,CDM,274,RC,L0172,HCPCS,,10143-MAIN,LOCAL,,,,,49,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
COLLAR CERVICAL X-LARGE WITH TRACH 2 PIECE OSG2404,120.185,CDM,274,RC,L0172,HCPCS,,10143-MAIN,LOCAL,,,,,49,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
COLLAR CERVICAL X-LARGE WITH TRACH 2 PIECE OSG2404,120.185,CDM,274,RC,L0172,HCPCS,,10143-MAIN,LOCAL,,,,,49,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
COLLAR CERVICAL X-LARGE WITH TRACH 2 PIECE OSG2404,120.185,CDM,274,RC,L0172,HCPCS,,10143-MAIN,LOCAL,,,,,49,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Collect Blood From Picc,PX36592,CDM,949,RC,36592,CPT,,,,,,,,198,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Collect Blood From Picc,PX36592,CDM,949,RC,36592,CPT,,,,,,,,198,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Collect Blood From Picc,PX36592,CDM,949,RC,36592,CPT,,,,,,,,198,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Collect Blood From Picc,PX36592,CDM,949,RC,36592,CPT,,,,,,,,198,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Collect Blood From Picc,PX36592,CDM,949,RC,36592,CPT,,,,,,,,198,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Collect Blood From Picc,PX36592,CDM,949,RC,36592,CPT,,,,,,,,198,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Collect Blood From Picc,PX36592F,CDM,510,RC,36592,CPT,,,,,,,,211,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Collect Blood From Picc,PX36592F,CDM,510,RC,36592,CPT,,,,,,,,211,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Collect Blood From Picc,PX36592F,CDM,510,RC,36592,CPT,,,,,,,,211,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Collect Blood From Picc,PX36592F,CDM,510,RC,36592,CPT,,,,,,,,211,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Collect Blood From Picc,PX36592F,CDM,510,RC,36592,CPT,,,,,,,,211,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Collect Blood From Picc,PX36592F,CDM,510,RC,36592,CPT,,,,,,,,211,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscope, Submucous Inj",PX45381F,CDM,750,RC,45381,CPT,,,,,,,,1179,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1039.878,6141.46
"Colonoscope, Submucous Inj",PX45381F,CDM,750,RC,45381,CPT,,,,,,,,1179,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1039.878,6141.46
"Colonoscope, Submucous Inj",PX45381F,CDM,750,RC,45381,CPT,,,,,,,,1179,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1039.878,6141.46
"Colonoscope, Submucous Inj",PX45381F,CDM,750,RC,45381,CPT,,,,,,,,1179,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1039.878,6141.46
"Colonoscope, Submucous Inj",PX45381F,CDM,750,RC,45381,CPT,,,,,,,,1179,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1039.878,6141.46
"Colonoscope, Submucous Inj",PX45381F,CDM,750,RC,45381,CPT,,,,,,,,1179,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1039.878,6141.46
"Colonoscope, Submucous Inj",PX45381P,CDM,983,RC,45381,CPT,,,,,,,,1215,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscope, Submucous Inj",PX45381P,CDM,983,RC,45381,CPT,,,,,,,,1215,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscope, Submucous Inj",PX45381P,CDM,983,RC,45381,CPT,,,,,,,,1215,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscope, Submucous Inj",PX45381P,CDM,983,RC,45381,CPT,,,,,,,,1215,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscope, Submucous Inj",PX45381P,CDM,983,RC,45381,CPT,,,,,,,,1215,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscope, Submucous Inj",PX45381P,CDM,983,RC,45381,CPT,,,,,,,,1215,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Colonoscopy,PX44388F,CDM,750,RC,44388,CPT,,,,,,,,930,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,820.26,6141.46
Colonoscopy,PX44388F,CDM,750,RC,44388,CPT,,,,,,,,930,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,820.26,6141.46
Colonoscopy,PX44388F,CDM,750,RC,44388,CPT,,,,,,,,930,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,820.26,6141.46
Colonoscopy,PX44388F,CDM,750,RC,44388,CPT,,,,,,,,930,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,820.26,6141.46
Colonoscopy,PX44388F,CDM,750,RC,44388,CPT,,,,,,,,930,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,820.26,6141.46
Colonoscopy,PX44388F,CDM,750,RC,44388,CPT,,,,,,,,930,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,820.26,6141.46
Colonoscopy,PX44388P,CDM,983,RC,44388,CPT,,,,,,,,620,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Colonoscopy,PX44388P,CDM,983,RC,44388,CPT,,,,,,,,620,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Colonoscopy,PX44388P,CDM,983,RC,44388,CPT,,,,,,,,620,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Colonoscopy,PX44388P,CDM,983,RC,44388,CPT,,,,,,,,620,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Colonoscopy,PX44388P,CDM,983,RC,44388,CPT,,,,,,,,620,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Colonoscopy,PX44388P,CDM,983,RC,44388,CPT,,,,,,,,620,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390F,CDM,750,RC,45390,CPT,,,,,,,,1419,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1251.558,6141.46
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390F,CDM,750,RC,45390,CPT,,,,,,,,1419,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1251.558,6141.46
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390F,CDM,750,RC,45390,CPT,,,,,,,,1419,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1251.558,6141.46
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390F,CDM,750,RC,45390,CPT,,,,,,,,1419,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1251.558,6141.46
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390F,CDM,750,RC,45390,CPT,,,,,,,,1419,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1251.558,6141.46
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390F,CDM,750,RC,45390,CPT,,,,,,,,1419,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1251.558,6141.46
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390P,CDM,982,RC,45390,CPT,,,,,,,,1135,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390P,CDM,982,RC,45390,CPT,,,,,,,,1135,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390P,CDM,982,RC,45390,CPT,,,,,,,,1135,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390P,CDM,982,RC,45390,CPT,,,,,,,,1135,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390P,CDM,982,RC,45390,CPT,,,,,,,,1135,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390P,CDM,982,RC,45390,CPT,,,,,,,,1135,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscopy,Biopsy",PX45380F,CDM,750,RC,45380,CPT,,,,,,,,2465,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2174.13,6141.46
"Colonoscopy,Biopsy",PX45380F,CDM,750,RC,45380,CPT,,,,,,,,2465,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2174.13,6141.46
"Colonoscopy,Biopsy",PX45380F,CDM,750,RC,45380,CPT,,,,,,,,2465,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2174.13,6141.46
"Colonoscopy,Biopsy",PX45380F,CDM,750,RC,45380,CPT,,,,,,,,2465,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2174.13,6141.46
"Colonoscopy,Biopsy",PX45380F,CDM,750,RC,45380,CPT,,,,,,,,2465,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2174.13,6141.46
"Colonoscopy,Biopsy",PX45380F,CDM,750,RC,45380,CPT,,,,,,,,2465,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2174.13,6141.46
"Colonoscopy,Biopsy",PX45380P,CDM,983,RC,45380,CPT,,,,,,,,2539,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscopy,Biopsy",PX45380P,CDM,983,RC,45380,CPT,,,,,,,,2539,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscopy,Biopsy",PX45380P,CDM,983,RC,45380,CPT,,,,,,,,2539,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscopy,Biopsy",PX45380P,CDM,983,RC,45380,CPT,,,,,,,,2539,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscopy,Biopsy",PX45380P,CDM,983,RC,45380,CPT,,,,,,,,2539,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscopy,Biopsy",PX45380P,CDM,983,RC,45380,CPT,,,,,,,,2539,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscopy,Control Bleeding",PX45382F,CDM,750,RC,45382,CPT,,,,,,,,1215,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1071.63,6141.46
"Colonoscopy,Control Bleeding",PX45382F,CDM,750,RC,45382,CPT,,,,,,,,1215,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1071.63,6141.46
"Colonoscopy,Control Bleeding",PX45382F,CDM,750,RC,45382,CPT,,,,,,,,1215,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1071.63,6141.46
"Colonoscopy,Control Bleeding",PX45382F,CDM,750,RC,45382,CPT,,,,,,,,1215,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1071.63,6141.46
"Colonoscopy,Control Bleeding",PX45382F,CDM,750,RC,45382,CPT,,,,,,,,1215,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1071.63,6141.46
"Colonoscopy,Control Bleeding",PX45382F,CDM,750,RC,45382,CPT,,,,,,,,1215,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1071.63,6141.46
"Colonoscopy,Flex,Diagnostic",PX45378F,CDM,750,RC,45378,CPT,,,,,,,,1286,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1134.252,6141.46
"Colonoscopy,Flex,Diagnostic",PX45378F,CDM,750,RC,45378,CPT,,,,,,,,1286,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1134.252,6141.46
"Colonoscopy,Flex,Diagnostic",PX45378F,CDM,750,RC,45378,CPT,,,,,,,,1286,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1134.252,6141.46
"Colonoscopy,Flex,Diagnostic",PX45378F,CDM,750,RC,45378,CPT,,,,,,,,1286,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1134.252,6141.46
"Colonoscopy,Flex,Diagnostic",PX45378F,CDM,750,RC,45378,CPT,,,,,,,,1286,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1134.252,6141.46
"Colonoscopy,Flex,Diagnostic",PX45378F,CDM,750,RC,45378,CPT,,,,,,,,1286,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1134.252,6141.46
"Colonoscopy,Flex,Diagnostic",PX45378P,CDM,983,RC,45378,CPT,,,,,,,,1200,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscopy,Flex,Diagnostic",PX45378P,CDM,983,RC,45378,CPT,,,,,,,,1200,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscopy,Flex,Diagnostic",PX45378P,CDM,983,RC,45378,CPT,,,,,,,,1200,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscopy,Flex,Diagnostic",PX45378P,CDM,983,RC,45378,CPT,,,,,,,,1200,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscopy,Flex,Diagnostic",PX45378P,CDM,983,RC,45378,CPT,,,,,,,,1200,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscopy,Flex,Diagnostic",PX45378P,CDM,983,RC,45378,CPT,,,,,,,,1200,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscopy,Flex,Screen",PX2002F,CDM,750,RC,G0105,HCPCS,,,,,,,,2539,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2239.398,6141.46
"Colonoscopy,Flex,Screen",PX2002F,CDM,750,RC,G0105,HCPCS,,,,,,,,2539,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2239.398,6141.46
"Colonoscopy,Flex,Screen",PX2002F,CDM,750,RC,G0105,HCPCS,,,,,,,,2539,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2239.398,6141.46
"Colonoscopy,Flex,Screen",PX2002F,CDM,750,RC,G0105,HCPCS,,,,,,,,2539,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2239.398,6141.46
"Colonoscopy,Flex,Screen",PX2002F,CDM,750,RC,G0105,HCPCS,,,,,,,,2539,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2239.398,6141.46
"Colonoscopy,Flex,Screen",PX2002F,CDM,750,RC,G0105,HCPCS,,,,,,,,2539,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2239.398,6141.46
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384F,CDM,750,RC,45384,CPT,,,,,,,,2350,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2072.7,6141.46
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384F,CDM,750,RC,45384,CPT,,,,,,,,2350,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2072.7,6141.46
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384F,CDM,750,RC,45384,CPT,,,,,,,,2350,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2072.7,6141.46
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384F,CDM,750,RC,45384,CPT,,,,,,,,2350,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2072.7,6141.46
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384F,CDM,750,RC,45384,CPT,,,,,,,,2350,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2072.7,6141.46
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384F,CDM,750,RC,45384,CPT,,,,,,,,2350,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2072.7,6141.46
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384P,CDM,983,RC,45384,CPT,,,,,,,,1436,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384P,CDM,983,RC,45384,CPT,,,,,,,,1436,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384P,CDM,983,RC,45384,CPT,,,,,,,,1436,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384P,CDM,983,RC,45384,CPT,,,,,,,,1436,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384P,CDM,983,RC,45384,CPT,,,,,,,,1436,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384P,CDM,983,RC,45384,CPT,,,,,,,,1436,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscopy,Remv Lesn,Snare",PX45385F,CDM,750,RC,45385,CPT,,,,,,,,1939,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1710.198,6141.46
"Colonoscopy,Remv Lesn,Snare",PX45385F,CDM,750,RC,45385,CPT,,,,,,,,1939,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1710.198,6141.46
"Colonoscopy,Remv Lesn,Snare",PX45385F,CDM,750,RC,45385,CPT,,,,,,,,1939,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1710.198,6141.46
"Colonoscopy,Remv Lesn,Snare",PX45385F,CDM,750,RC,45385,CPT,,,,,,,,1939,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1710.198,6141.46
"Colonoscopy,Remv Lesn,Snare",PX45385F,CDM,750,RC,45385,CPT,,,,,,,,1939,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1710.198,6141.46
"Colonoscopy,Remv Lesn,Snare",PX45385F,CDM,750,RC,45385,CPT,,,,,,,,1939,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1710.198,6141.46
"Colonoscopy,Remv Lesn,Snare",PX45385P,CDM,983,RC,45385,CPT,,,,,,,,2424,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscopy,Remv Lesn,Snare",PX45385P,CDM,983,RC,45385,CPT,,,,,,,,2424,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscopy,Remv Lesn,Snare",PX45385P,CDM,983,RC,45385,CPT,,,,,,,,2424,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscopy,Remv Lesn,Snare",PX45385P,CDM,983,RC,45385,CPT,,,,,,,,2424,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscopy,Remv Lesn,Snare",PX45385P,CDM,983,RC,45385,CPT,,,,,,,,2424,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscopy,Remv Lesn,Snare",PX45385P,CDM,983,RC,45385,CPT,,,,,,,,2424,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscopy,Screen Prev",PX2004F,CDM,750,RC,G0121,HCPCS,,,,,,,,2502,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2206.764,6141.46
"Colonoscopy,Screen Prev",PX2004F,CDM,750,RC,G0121,HCPCS,,,,,,,,2502,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2206.764,6141.46
"Colonoscopy,Screen Prev",PX2004F,CDM,750,RC,G0121,HCPCS,,,,,,,,2502,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2206.764,6141.46
"Colonoscopy,Screen Prev",PX2004F,CDM,750,RC,G0121,HCPCS,,,,,,,,2502,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2206.764,6141.46
"Colonoscopy,Screen Prev",PX2004F,CDM,750,RC,G0121,HCPCS,,,,,,,,2502,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2206.764,6141.46
"Colonoscopy,Screen Prev",PX2004F,CDM,750,RC,G0121,HCPCS,,,,,,,,2502,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2206.764,6141.46
"Colonoscopy,Transendoscopic Stent",PX45387F,CDM,750,RC,45387,CPT,,,,,,,,3228,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2847.096,6141.46
"Colonoscopy,Transendoscopic Stent",PX45387F,CDM,750,RC,45387,CPT,,,,,,,,3228,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2847.096,6141.46
"Colonoscopy,Transendoscopic Stent",PX45387F,CDM,750,RC,45387,CPT,,,,,,,,3228,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2847.096,6141.46
"Colonoscopy,Transendoscopic Stent",PX45387F,CDM,750,RC,45387,CPT,,,,,,,,3228,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2847.096,6141.46
"Colonoscopy,Transendoscopic Stent",PX45387F,CDM,750,RC,45387,CPT,,,,,,,,3228,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2847.096,6141.46
"Colonoscopy,Transendoscopic Stent",PX45387F,CDM,750,RC,45387,CPT,,,,,,,,3228,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2847.096,6141.46
"Colonoscopy,Transendoscopic Stent",PX45387P,CDM,983,RC,45387,CPT,,,,,,,,3587,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscopy,Transendoscopic Stent",PX45387P,CDM,983,RC,45387,CPT,,,,,,,,3587,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscopy,Transendoscopic Stent",PX45387P,CDM,983,RC,45387,CPT,,,,,,,,3587,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscopy,Transendoscopic Stent",PX45387P,CDM,983,RC,45387,CPT,,,,,,,,3587,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscopy,Transendoscopic Stent",PX45387P,CDM,983,RC,45387,CPT,,,,,,,,3587,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscopy,Transendoscopic Stent",PX45387P,CDM,983,RC,45387,CPT,,,,,,,,3587,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Column Chrom Ms, Quant - Ref",PX8254290,CDM,300,RC,82542,CPT,90,,,,,,,557,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Column Chrom Ms, Quant - Ref",PX8254290,CDM,300,RC,82542,CPT,90,,,,,,,557,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Column Chrom Ms, Quant - Ref",PX8254290,CDM,300,RC,82542,CPT,90,,,,,,,557,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Column Chrom Ms, Quant - Ref",PX8254290,CDM,300,RC,82542,CPT,90,,,,,,,557,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Column Chrom Ms, Quant - Ref",PX8254290,CDM,300,RC,82542,CPT,90,,,,,,,557,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Column Chrom Ms, Quant - Ref",PX8254290,CDM,300,RC,82542,CPT,90,,,,,,,557,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Compatibility Test,Antiglob Tech",PX86922,CDM,300,RC,86922,CPT,,,,,,,,120,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Compatibility Test,Antiglob Tech",PX86922,CDM,300,RC,86922,CPT,,,,,,,,120,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Compatibility Test,Antiglob Tech",PX86922,CDM,300,RC,86922,CPT,,,,,,,,120,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Compatibility Test,Antiglob Tech",PX86922,CDM,300,RC,86922,CPT,,,,,,,,120,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Compatibility Test,Antiglob Tech",PX86922,CDM,300,RC,86922,CPT,,,,,,,,120,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Compatibility Test,Antiglob Tech",PX86922,CDM,300,RC,86922,CPT,,,,,,,,120,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Complement; Antigen, Each Component",PX86160,CDM,300,RC,86160,CPT,,,,,,,,124,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Complement; Antigen, Each Component",PX86160,CDM,300,RC,86160,CPT,,,,,,,,124,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Complement; Antigen, Each Component",PX86160,CDM,300,RC,86160,CPT,,,,,,,,124,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Complement; Antigen, Each Component",PX86160,CDM,300,RC,86160,CPT,,,,,,,,124,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Complement; Antigen, Each Component",PX86160,CDM,300,RC,86160,CPT,,,,,,,,124,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Complement; Antigen, Each Component",PX86160,CDM,300,RC,86160,CPT,,,,,,,,124,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Complete Cbc Automated,PX85027,CDM,300,RC,85027,CPT,,,,,,,,129,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Complete Cbc Automated,PX85027,CDM,300,RC,85027,CPT,,,,,,,,129,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Complete Cbc Automated,PX85027,CDM,300,RC,85027,CPT,,,,,,,,129,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Complete Cbc Automated,PX85027,CDM,300,RC,85027,CPT,,,,,,,,129,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Complete Cbc Automated,PX85027,CDM,300,RC,85027,CPT,,,,,,,,129,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Complete Cbc Automated,PX85027,CDM,300,RC,85027,CPT,,,,,,,,129,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Complete Cbc W/Auto Diff Wbc,PX85025,CDM,300,RC,85025,CPT,,,,,,,,168,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Complete Cbc W/Auto Diff Wbc,PX85025,CDM,300,RC,85025,CPT,,,,,,,,168,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Complete Cbc W/Auto Diff Wbc,PX85025,CDM,300,RC,85025,CPT,,,,,,,,168,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Complete Cbc W/Auto Diff Wbc,PX85025,CDM,300,RC,85025,CPT,,,,,,,,168,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Complete Cbc W/Auto Diff Wbc,PX85025,CDM,300,RC,85025,CPT,,,,,,,,168,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Complete Cbc W/Auto Diff Wbc,PX85025,CDM,300,RC,85025,CPT,,,,,,,,168,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Complex Drainage, Wound",PX10180F,CDM,510,RC,10180,CPT,,,,,,,,1050,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Complex Drainage, Wound",PX10180F,CDM,510,RC,10180,CPT,,,,,,,,1050,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Complex Drainage, Wound",PX10180F,CDM,510,RC,10180,CPT,,,,,,,,1050,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Complex Drainage, Wound",PX10180F,CDM,510,RC,10180,CPT,,,,,,,,1050,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Complex Drainage, Wound",PX10180F,CDM,510,RC,10180,CPT,,,,,,,,1050,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Complex Drainage, Wound",PX10180F,CDM,510,RC,10180,CPT,,,,,,,,1050,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Complex Drainage, Wound",PX10180P,CDM,983,RC,10180,CPT,,,,,,,,767,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Complex Drainage, Wound",PX10180P,CDM,983,RC,10180,CPT,,,,,,,,767,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Complex Drainage, Wound",PX10180P,CDM,983,RC,10180,CPT,,,,,,,,767,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Complex Drainage, Wound",PX10180P,CDM,983,RC,10180,CPT,,,,,,,,767,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Complex Drainage, Wound",PX10180P,CDM,983,RC,10180,CPT,,,,,,,,767,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Complex Drainage, Wound",PX10180P,CDM,983,RC,10180,CPT,,,,,,,,767,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Compliment, Total (Ch50) - Ref",PX8616290,CDM,300,RC,86162,CPT,90,,,,,,,122,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Compliment, Total (Ch50) - Ref",PX8616290,CDM,300,RC,86162,CPT,90,,,,,,,122,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Compliment, Total (Ch50) - Ref",PX8616290,CDM,300,RC,86162,CPT,90,,,,,,,122,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Compliment, Total (Ch50) - Ref",PX8616290,CDM,300,RC,86162,CPT,90,,,,,,,122,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Compliment, Total (Ch50) - Ref",PX8616290,CDM,300,RC,86162,CPT,90,,,,,,,122,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Compliment, Total (Ch50) - Ref",PX8616290,CDM,300,RC,86162,CPT,90,,,,,,,122,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Comprehensive Metabolic Panel,PX80053,CDM,300,RC,80053,CPT,,,,,,,,396,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Comprehensive Metabolic Panel,PX80053,CDM,300,RC,80053,CPT,,,,,,,,396,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Comprehensive Metabolic Panel,PX80053,CDM,300,RC,80053,CPT,,,,,,,,396,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Comprehensive Metabolic Panel,PX80053,CDM,300,RC,80053,CPT,,,,,,,,396,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Comprehensive Metabolic Panel,PX80053,CDM,300,RC,80053,CPT,,,,,,,,396,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Comprehensive Metabolic Panel,PX80053,CDM,300,RC,80053,CPT,,,,,,,,396,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Concurrent Infusion,PX96368,CDM,260,RC,96368,CPT,,,,,,,,102,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Concurrent Infusion,PX96368,CDM,260,RC,96368,CPT,,,,,,,,102,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Concurrent Infusion,PX96368,CDM,260,RC,96368,CPT,,,,,,,,102,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Concurrent Infusion,PX96368,CDM,260,RC,96368,CPT,,,,,,,,102,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Concurrent Infusion,PX96368,CDM,260,RC,96368,CPT,,,,,,,,102,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Concurrent Infusion,PX96368,CDM,260,RC,96368,CPT,,,,,,,,102,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Contrast Bath Therapy,PX97034,CDM,420,RC,97034,CPT,,,,,,,,97,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Contrast Bath Therapy,PX97034,CDM,420,RC,97034,CPT,,,,,,,,97,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Contrast Bath Therapy,PX97034,CDM,420,RC,97034,CPT,,,,,,,,97,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Contrast Bath Therapy,PX97034,CDM,420,RC,97034,CPT,,,,,,,,97,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Contrast Bath Therapy,PX97034,CDM,420,RC,97034,CPT,,,,,,,,97,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Contrast Bath Therapy,PX97034,CDM,420,RC,97034,CPT,,,,,,,,97,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
COOK EMERGENCY PNEUMOTHORAX SET,120.559,CDM,272,RC,,,,12597-MAIN,LOCAL,,,,,307,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
COOK EMERGENCY PNEUMOTHORAX SET,120.559,CDM,272,RC,,,,12597-MAIN,LOCAL,,,,,307,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
COOK EMERGENCY PNEUMOTHORAX SET,120.559,CDM,272,RC,,,,12597-MAIN,LOCAL,,,,,307,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
COOK EMERGENCY PNEUMOTHORAX SET,120.559,CDM,272,RC,,,,12597-MAIN,LOCAL,,,,,307,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
COOK EMERGENCY PNEUMOTHORAX SET,120.559,CDM,272,RC,,,,12597-MAIN,LOCAL,,,,,307,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
COOK EMERGENCY PNEUMOTHORAX SET,120.559,CDM,272,RC,,,,12597-MAIN,LOCAL,,,,,307,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Copper - Ref,PX8252590,CDM,300,RC,82525,CPT,90,,,,,,,94,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Copper - Ref,PX8252590,CDM,300,RC,82525,CPT,90,,,,,,,94,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Copper - Ref,PX8252590,CDM,300,RC,82525,CPT,90,,,,,,,94,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Copper - Ref,PX8252590,CDM,300,RC,82525,CPT,90,,,,,,,94,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Copper - Ref,PX8252590,CDM,300,RC,82525,CPT,90,,,,,,,94,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Copper - Ref,PX8252590,CDM,300,RC,82525,CPT,90,,,,,,,94,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Correct Bunion,Metatarsal Osteotomy",PX28296F,CDM,510,RC,28296,CPT,,,,,,,,8100,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Correct Bunion,Metatarsal Osteotomy",PX28296F,CDM,510,RC,28296,CPT,,,,,,,,8100,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Correct Bunion,Metatarsal Osteotomy",PX28296F,CDM,510,RC,28296,CPT,,,,,,,,8100,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Correct Bunion,Metatarsal Osteotomy",PX28296F,CDM,510,RC,28296,CPT,,,,,,,,8100,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Correct Bunion,Metatarsal Osteotomy",PX28296F,CDM,510,RC,28296,CPT,,,,,,,,8100,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Correct Bunion,Metatarsal Osteotomy",PX28296F,CDM,510,RC,28296,CPT,,,,,,,,8100,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Correct Bunion,Metatarsal Osteotomy",PX28296P,CDM,983,RC,28296,CPT,,,,,,,,2150,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Correct Bunion,Metatarsal Osteotomy",PX28296P,CDM,983,RC,28296,CPT,,,,,,,,2150,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Correct Bunion,Metatarsal Osteotomy",PX28296P,CDM,983,RC,28296,CPT,,,,,,,,2150,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Correct Bunion,Metatarsal Osteotomy",PX28296P,CDM,983,RC,28296,CPT,,,,,,,,2150,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Correct Bunion,Metatarsal Osteotomy",PX28296P,CDM,983,RC,28296,CPT,,,,,,,,2150,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Correct Bunion,Metatarsal Osteotomy",PX28296P,CDM,983,RC,28296,CPT,,,,,,,,2150,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cortisol, Am",PX7152,CDM,300,RC,82533,CPT,,,,,,,,156,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cortisol, Am",PX7152,CDM,300,RC,82533,CPT,,,,,,,,156,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cortisol, Am",PX7152,CDM,300,RC,82533,CPT,,,,,,,,156,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cortisol, Am",PX7152,CDM,300,RC,82533,CPT,,,,,,,,156,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cortisol, Am",PX7152,CDM,300,RC,82533,CPT,,,,,,,,156,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cortisol, Am",PX7152,CDM,300,RC,82533,CPT,,,,,,,,156,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cortisol, Free - Ref",PX8253090,CDM,300,RC,82530,CPT,90,,,,,,,82,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cortisol, Free - Ref",PX8253090,CDM,300,RC,82530,CPT,90,,,,,,,82,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cortisol, Free - Ref",PX8253090,CDM,300,RC,82530,CPT,90,,,,,,,82,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cortisol, Free - Ref",PX8253090,CDM,300,RC,82530,CPT,90,,,,,,,82,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cortisol, Free - Ref",PX8253090,CDM,300,RC,82530,CPT,90,,,,,,,82,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cortisol, Free - Ref",PX8253090,CDM,300,RC,82530,CPT,90,,,,,,,82,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,548590000,NDC,1,EA,470.19,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,548590000,NDC,1,EA,470.19,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,548590000,NDC,1,EA,470.19,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,548590000,NDC,1,EA,470.19,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,548590000,NDC,1,EA,470.19,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,548590000,NDC,1,EA,470.19,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,781344071,NDC,1,EA,430.94,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,781344071,NDC,1,EA,430.94,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,781344071,NDC,1,EA,430.94,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,781344071,NDC,1,EA,430.94,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,781344071,NDC,1,EA,430.94,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,781344071,NDC,1,EA,430.94,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CP LAG SCREW 3.6MM L22MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12757-MAIN,LOCAL,,,,,539,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CP LAG SCREW 3.6MM L22MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12757-MAIN,LOCAL,,,,,539,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CP LAG SCREW 3.6MM L22MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12757-MAIN,LOCAL,,,,,539,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CP LAG SCREW 3.6MM L22MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12757-MAIN,LOCAL,,,,,539,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CP LAG SCREW 3.6MM L22MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12757-MAIN,LOCAL,,,,,539,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CP LAG SCREW 3.6MM L22MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12757-MAIN,LOCAL,,,,,539,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CP LAG SCREW 3.6MM L24MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12650-MAIN,LOCAL,,,,,539,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CP LAG SCREW 3.6MM L24MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12650-MAIN,LOCAL,,,,,539,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CP LAG SCREW 3.6MM L24MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12650-MAIN,LOCAL,,,,,539,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CP LAG SCREW 3.6MM L24MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12650-MAIN,LOCAL,,,,,539,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CP LAG SCREW 3.6MM L24MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12650-MAIN,LOCAL,,,,,539,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CP LAG SCREW 3.6MM L24MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12650-MAIN,LOCAL,,,,,539,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CP LAG SCREW 3.6MM L26MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12636-MAIN,LOCAL,,,,,539,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CP LAG SCREW 3.6MM L26MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12636-MAIN,LOCAL,,,,,539,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CP LAG SCREW 3.6MM L26MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12636-MAIN,LOCAL,,,,,539,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CP LAG SCREW 3.6MM L26MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12636-MAIN,LOCAL,,,,,539,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CP LAG SCREW 3.6MM L26MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12636-MAIN,LOCAL,,,,,539,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CP LAG SCREW 3.6MM L26MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12636-MAIN,LOCAL,,,,,539,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cpap/Bipap Mgmnt-Pt Own Equipment,PX94660.02F,CDM,410,RC,94660,CPT,,,,,,,,497,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cpap/Bipap Mgmnt-Pt Own Equipment,PX94660.02F,CDM,410,RC,94660,CPT,,,,,,,,497,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cpap/Bipap Mgmnt-Pt Own Equipment,PX94660.02F,CDM,410,RC,94660,CPT,,,,,,,,497,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cpap/Bipap Mgmnt-Pt Own Equipment,PX94660.02F,CDM,410,RC,94660,CPT,,,,,,,,497,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cpap/Bipap Mgmnt-Pt Own Equipment,PX94660.02F,CDM,410,RC,94660,CPT,,,,,,,,497,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cpap/Bipap Mgmnt-Pt Own Equipment,PX94660.02F,CDM,410,RC,94660,CPT,,,,,,,,497,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Creatine Mb Fraction,PX82553,CDM,300,RC,82553,CPT,,,,,,,,353,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Creatine Mb Fraction,PX82553,CDM,300,RC,82553,CPT,,,,,,,,353,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Creatine Mb Fraction,PX82553,CDM,300,RC,82553,CPT,,,,,,,,353,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Creatine Mb Fraction,PX82553,CDM,300,RC,82553,CPT,,,,,,,,353,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Creatine Mb Fraction,PX82553,CDM,300,RC,82553,CPT,,,,,,,,353,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Creatine Mb Fraction,PX82553,CDM,300,RC,82553,CPT,,,,,,,,353,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Creatinine; Other Source - Ref,PX82570,CDM,300,RC,82570,CPT,90,,,,,,,119,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Creatinine; Other Source - Ref,PX82570,CDM,300,RC,82570,CPT,90,,,,,,,119,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Creatinine; Other Source - Ref,PX82570,CDM,300,RC,82570,CPT,90,,,,,,,119,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Creatinine; Other Source - Ref,PX82570,CDM,300,RC,82570,CPT,90,,,,,,,119,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Creatinine; Other Source - Ref,PX82570,CDM,300,RC,82570,CPT,90,,,,,,,119,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Creatinine; Other Source - Ref,PX82570,CDM,300,RC,82570,CPT,90,,,,,,,119,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CRICOTHROTOMY QUICKTRACH 4MM,120.228,CDM,272,RC,A7520,HCPCS,,8868-MAIN,LOCAL,,,,,494,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CRICOTHROTOMY QUICKTRACH 4MM,120.228,CDM,272,RC,A7520,HCPCS,,8868-MAIN,LOCAL,,,,,494,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CRICOTHROTOMY QUICKTRACH 4MM,120.228,CDM,272,RC,A7520,HCPCS,,8868-MAIN,LOCAL,,,,,494,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CRICOTHROTOMY QUICKTRACH 4MM,120.228,CDM,272,RC,A7520,HCPCS,,8868-MAIN,LOCAL,,,,,494,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CRICOTHROTOMY QUICKTRACH 4MM,120.228,CDM,272,RC,A7520,HCPCS,,8868-MAIN,LOCAL,,,,,494,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CRICOTHROTOMY QUICKTRACH 4MM,120.228,CDM,272,RC,A7520,HCPCS,,8868-MAIN,LOCAL,,,,,494,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Critical Care, Addl 30 Min",PX99292P,CDM,983,RC,99292,CPT,,,,,,,,542,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Critical Care, Addl 30 Min",PX99292P,CDM,983,RC,99292,CPT,,,,,,,,542,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Critical Care, Addl 30 Min",PX99292P,CDM,983,RC,99292,CPT,,,,,,,,542,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Critical Care, Addl 30 Min",PX99292P,CDM,983,RC,99292,CPT,,,,,,,,542,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Critical Care, Addl 30 Min",PX99292P,CDM,983,RC,99292,CPT,,,,,,,,542,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Critical Care, Addl 30 Min",PX99292P,CDM,983,RC,99292,CPT,,,,,,,,542,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Critical Care, E/M 30-74 Minutes",PX99291P,CDM,983,RC,99291,CPT,,,,,,,,1061,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Critical Care, E/M 30-74 Minutes",PX99291P,CDM,983,RC,99291,CPT,,,,,,,,1061,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Critical Care, E/M 30-74 Minutes",PX99291P,CDM,983,RC,99291,CPT,,,,,,,,1061,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Critical Care, E/M 30-74 Minutes",PX99291P,CDM,983,RC,99291,CPT,,,,,,,,1061,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Critical Care, E/M 30-74 Minutes",PX99291P,CDM,983,RC,99291,CPT,,,,,,,,1061,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Critical Care, E/M 30-74 Minutes",PX99291P,CDM,983,RC,99291,CPT,,,,,,,,1061,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cryptococcus Neoformans,PX87327,CDM,300,RC,87327,CPT,,,,,,,,45,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cryptococcus Neoformans,PX87327,CDM,300,RC,87327,CPT,,,,,,,,45,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cryptococcus Neoformans,PX87327,CDM,300,RC,87327,CPT,,,,,,,,45,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cryptococcus Neoformans,PX87327,CDM,300,RC,87327,CPT,,,,,,,,45,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cryptococcus Neoformans,PX87327,CDM,300,RC,87327,CPT,,,,,,,,45,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cryptococcus Neoformans,PX87327,CDM,300,RC,87327,CPT,,,,,,,,45,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cryptosporidum,PX87328,CDM,300,RC,87328,CPT,,,,,,,,117,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cryptosporidum,PX87328,CDM,300,RC,87328,CPT,,,,,,,,117,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cryptosporidum,PX87328,CDM,300,RC,87328,CPT,,,,,,,,117,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cryptosporidum,PX87328,CDM,300,RC,87328,CPT,,,,,,,,117,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cryptosporidum,PX87328,CDM,300,RC,87328,CPT,,,,,,,,117,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cryptosporidum,PX87328,CDM,300,RC,87328,CPT,,,,,,,,117,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Abd & Pelvis W/O Contrast,PX7417601,CDM,350,RC,74176,CPT,TC,,,,,,,4288,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Abd & Pelvis W/O Contrast,PX7417601,CDM,350,RC,74176,CPT,TC,,,,,,,4288,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Abd & Pelvis W/O Contrast,PX7417601,CDM,350,RC,74176,CPT,TC,,,,,,,4288,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Abd & Pelvis W/O Contrast,PX7417601,CDM,350,RC,74176,CPT,TC,,,,,,,4288,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Abd & Pelvis W/O Contrast,PX7417601,CDM,350,RC,74176,CPT,TC,,,,,,,4288,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Abd & Pelvis W/O Contrast,PX7417601,CDM,350,RC,74176,CPT,TC,,,,,,,4288,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Abd&Pelv 1+ Section/Regns,PX7417801,CDM,350,RC,74178,CPT,TC,,,,,,,4226,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Abd&Pelv 1+ Section/Regns,PX7417801,CDM,350,RC,74178,CPT,TC,,,,,,,4226,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Abd&Pelv 1+ Section/Regns,PX7417801,CDM,350,RC,74178,CPT,TC,,,,,,,4226,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Abd&Pelv 1+ Section/Regns,PX7417801,CDM,350,RC,74178,CPT,TC,,,,,,,4226,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Abd&Pelv 1+ Section/Regns,PX7417801,CDM,350,RC,74178,CPT,TC,,,,,,,4226,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Abd&Pelv 1+ Section/Regns,PX7417801,CDM,350,RC,74178,CPT,TC,,,,,,,4226,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Abdomen W/Dye,PX7416001,CDM,350,RC,74160,CPT,TC,,,,,,,3413,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Abdomen W/Dye,PX7416001,CDM,350,RC,74160,CPT,TC,,,,,,,3413,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Abdomen W/Dye,PX7416001,CDM,350,RC,74160,CPT,TC,,,,,,,3413,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Abdomen W/Dye,PX7416001,CDM,350,RC,74160,CPT,TC,,,,,,,3413,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Abdomen W/Dye,PX7416001,CDM,350,RC,74160,CPT,TC,,,,,,,3413,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Abdomen W/Dye,PX7416001,CDM,350,RC,74160,CPT,TC,,,,,,,3413,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Abdomen W/O & W/Dye,PX7417001,CDM,350,RC,74170,CPT,TC,,,,,,,3689,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Abdomen W/O & W/Dye,PX7417001,CDM,350,RC,74170,CPT,TC,,,,,,,3689,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Abdomen W/O & W/Dye,PX7417001,CDM,350,RC,74170,CPT,TC,,,,,,,3689,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Abdomen W/O & W/Dye,PX7417001,CDM,350,RC,74170,CPT,TC,,,,,,,3689,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Abdomen W/O & W/Dye,PX7417001,CDM,350,RC,74170,CPT,TC,,,,,,,3689,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Abdomen W/O & W/Dye,PX7417001,CDM,350,RC,74170,CPT,TC,,,,,,,3689,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Abdomen W/O Dye,PX7415001,CDM,350,RC,74150,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Abdomen W/O Dye,PX7415001,CDM,350,RC,74150,CPT,TC,,,,,,,2757,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Abdomen W/O Dye,PX7415001,CDM,350,RC,74150,CPT,TC,,,,,,,2757,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Abdomen W/O Dye,PX7415001,CDM,350,RC,74150,CPT,TC,,,,,,,2757,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Abdomen W/O Dye,PX7415001,CDM,350,RC,74150,CPT,TC,,,,,,,2757,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Abdomen W/O Dye,PX7415001,CDM,350,RC,74150,CPT,TC,,,,,,,2757,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Abdomen&Pelvis W/Contrast,PX7417701,CDM,350,RC,74177,CPT,TC,,,,,,,4288,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Abdomen&Pelvis W/Contrast,PX7417701,CDM,350,RC,74177,CPT,TC,,,,,,,4288,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Abdomen&Pelvis W/Contrast,PX7417701,CDM,350,RC,74177,CPT,TC,,,,,,,4288,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Abdomen&Pelvis W/Contrast,PX7417701,CDM,350,RC,74177,CPT,TC,,,,,,,4288,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Abdomen&Pelvis W/Contrast,PX7417701,CDM,350,RC,74177,CPT,TC,,,,,,,4288,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Abdomen&Pelvis W/Contrast,PX7417701,CDM,350,RC,74177,CPT,TC,,,,,,,4288,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Angio Abd&Pelv W/O&W/Dye,PX7417401,CDM,350,RC,74174,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Angio Abd&Pelv W/O&W/Dye,PX7417401,CDM,350,RC,74174,CPT,TC,,,,,,,2757,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Angio Abd&Pelv W/O&W/Dye,PX7417401,CDM,350,RC,74174,CPT,TC,,,,,,,2757,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Angio Abd&Pelv W/O&W/Dye,PX7417401,CDM,350,RC,74174,CPT,TC,,,,,,,2757,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Angio Abd&Pelv W/O&W/Dye,PX7417401,CDM,350,RC,74174,CPT,TC,,,,,,,2757,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Angio Abd&Pelv W/O&W/Dye,PX7417401,CDM,350,RC,74174,CPT,TC,,,,,,,2757,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Angio Abdom W/O & W/Dye,PX7417501,CDM,350,RC,74175,CPT,TC,,,,,,,4183,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Angio Abdom W/O & W/Dye,PX7417501,CDM,350,RC,74175,CPT,TC,,,,,,,4183,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Angio Abdom W/O & W/Dye,PX7417501,CDM,350,RC,74175,CPT,TC,,,,,,,4183,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Angio Abdom W/O & W/Dye,PX7417501,CDM,350,RC,74175,CPT,TC,,,,,,,4183,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Angio Abdom W/O & W/Dye,PX7417501,CDM,350,RC,74175,CPT,TC,,,,,,,4183,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Angio Abdom W/O & W/Dye,PX7417501,CDM,350,RC,74175,CPT,TC,,,,,,,4183,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Angio Abdominal Arteries,PX7563501,CDM,350,RC,75635,CPT,TC,,,,,,,2936,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Angio Abdominal Arteries,PX7563501,CDM,350,RC,75635,CPT,TC,,,,,,,2936,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Angio Abdominal Arteries,PX7563501,CDM,350,RC,75635,CPT,TC,,,,,,,2936,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Angio Abdominal Arteries,PX7563501,CDM,350,RC,75635,CPT,TC,,,,,,,2936,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Angio Abdominal Arteries,PX7563501,CDM,350,RC,75635,CPT,TC,,,,,,,2936,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Angio Abdominal Arteries,PX7563501,CDM,350,RC,75635,CPT,TC,,,,,,,2936,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Angio Lwr Extr W/O&W/Dye,PX7370601,CDM,350,RC,73706,CPT,TC,,,,,,,1554,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Angio Lwr Extr W/O&W/Dye,PX7370601,CDM,350,RC,73706,CPT,TC,,,,,,,1554,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Angio Lwr Extr W/O&W/Dye,PX7370601,CDM,350,RC,73706,CPT,TC,,,,,,,1554,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Angio Lwr Extr W/O&W/Dye,PX7370601,CDM,350,RC,73706,CPT,TC,,,,,,,1554,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Angio Lwr Extr W/O&W/Dye,PX7370601,CDM,350,RC,73706,CPT,TC,,,,,,,1554,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Angio Lwr Extr W/O&W/Dye,PX7370601,CDM,350,RC,73706,CPT,TC,,,,,,,1554,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Angio Upr Extrm W/O&W/Dye,PX7320601,CDM,350,RC,73206,CPT,TC,,,,,,,757,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Angio Upr Extrm W/O&W/Dye,PX7320601,CDM,350,RC,73206,CPT,TC,,,,,,,757,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Angio Upr Extrm W/O&W/Dye,PX7320601,CDM,350,RC,73206,CPT,TC,,,,,,,757,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Angio Upr Extrm W/O&W/Dye,PX7320601,CDM,350,RC,73206,CPT,TC,,,,,,,757,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Angio Upr Extrm W/O&W/Dye,PX7320601,CDM,350,RC,73206,CPT,TC,,,,,,,757,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Angio Upr Extrm W/O&W/Dye,PX7320601,CDM,350,RC,73206,CPT,TC,,,,,,,757,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Angiograph Pelv W/O&W/Dye,PX7219101,CDM,350,RC,72191,CPT,TC,,,,,,,1458,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Angiograph Pelv W/O&W/Dye,PX7219101,CDM,350,RC,72191,CPT,TC,,,,,,,1458,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Angiograph Pelv W/O&W/Dye,PX7219101,CDM,350,RC,72191,CPT,TC,,,,,,,1458,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Angiograph Pelv W/O&W/Dye,PX7219101,CDM,350,RC,72191,CPT,TC,,,,,,,1458,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Angiograph Pelv W/O&W/Dye,PX7219101,CDM,350,RC,72191,CPT,TC,,,,,,,1458,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Angiograph Pelv W/O&W/Dye,PX7219101,CDM,350,RC,72191,CPT,TC,,,,,,,1458,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CT Angiography, Chest",PX7127501,CDM,350,RC,71275,CPT,TC,,,,,,,3689,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CT Angiography, Chest",PX7127501,CDM,350,RC,71275,CPT,TC,,,,,,,3689,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CT Angiography, Chest",PX7127501,CDM,350,RC,71275,CPT,TC,,,,,,,3689,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CT Angiography, Chest",PX7127501,CDM,350,RC,71275,CPT,TC,,,,,,,3689,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CT Angiography, Chest",PX7127501,CDM,350,RC,71275,CPT,TC,,,,,,,3689,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CT Angiography, Chest",PX7127501,CDM,350,RC,71275,CPT,TC,,,,,,,3689,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CT Angiography, Head",PX7049601,CDM,350,RC,70496,CPT,TC,,,,,,,3690,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CT Angiography, Head",PX7049601,CDM,350,RC,70496,CPT,TC,,,,,,,3690,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CT Angiography, Head",PX7049601,CDM,350,RC,70496,CPT,TC,,,,,,,3690,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CT Angiography, Head",PX7049601,CDM,350,RC,70496,CPT,TC,,,,,,,3690,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CT Angiography, Head",PX7049601,CDM,350,RC,70496,CPT,TC,,,,,,,3690,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CT Angiography, Head",PX7049601,CDM,350,RC,70496,CPT,TC,,,,,,,3690,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CT Angiography, Neck",PX7049801,CDM,350,RC,70498,CPT,TC,,,,,,,3690,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CT Angiography, Neck",PX7049801,CDM,350,RC,70498,CPT,TC,,,,,,,3690,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CT Angiography, Neck",PX7049801,CDM,350,RC,70498,CPT,TC,,,,,,,3690,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CT Angiography, Neck",PX7049801,CDM,350,RC,70498,CPT,TC,,,,,,,3690,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CT Angiography, Neck",PX7049801,CDM,350,RC,70498,CPT,TC,,,,,,,3690,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CT Angiography, Neck",PX7049801,CDM,350,RC,70498,CPT,TC,,,,,,,3690,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Chest Spine W/Dye,PX7212901,CDM,350,RC,72129,CPT,TC,,,,,,,2096,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Chest Spine W/Dye,PX7212901,CDM,350,RC,72129,CPT,TC,,,,,,,2096,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Chest Spine W/Dye,PX7212901,CDM,350,RC,72129,CPT,TC,,,,,,,2096,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Chest Spine W/Dye,PX7212901,CDM,350,RC,72129,CPT,TC,,,,,,,2096,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Chest Spine W/Dye,PX7212901,CDM,350,RC,72129,CPT,TC,,,,,,,2096,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Chest Spine W/Dye,PX7212901,CDM,350,RC,72129,CPT,TC,,,,,,,2096,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Chest Spine W/O Dye,PX7212801,CDM,350,RC,72128,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Chest Spine W/O Dye,PX7212801,CDM,350,RC,72128,CPT,TC,,,,,,,2757,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Chest Spine W/O Dye,PX7212801,CDM,350,RC,72128,CPT,TC,,,,,,,2757,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Chest Spine W/O Dye,PX7212801,CDM,350,RC,72128,CPT,TC,,,,,,,2757,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Chest Spine W/O Dye,PX7212801,CDM,350,RC,72128,CPT,TC,,,,,,,2757,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Chest Spine W/O Dye,PX7212801,CDM,350,RC,72128,CPT,TC,,,,,,,2757,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CT Colonography, Screen",PX7426301,CDM,350,RC,74263,CPT,TC,,,,,,,3330,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CT Colonography, Screen",PX7426301,CDM,350,RC,74263,CPT,TC,,,,,,,3330,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CT Colonography, Screen",PX7426301,CDM,350,RC,74263,CPT,TC,,,,,,,3330,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CT Colonography, Screen",PX7426301,CDM,350,RC,74263,CPT,TC,,,,,,,3330,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CT Colonography, Screen",PX7426301,CDM,350,RC,74263,CPT,TC,,,,,,,3330,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CT Colonography, Screen",PX7426301,CDM,350,RC,74263,CPT,TC,,,,,,,3330,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Head/Brain W/Dye,PX7046001,CDM,350,RC,70460,CPT,TC,,,,,,,3398,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Head/Brain W/Dye,PX7046001,CDM,350,RC,70460,CPT,TC,,,,,,,3398,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Head/Brain W/Dye,PX7046001,CDM,350,RC,70460,CPT,TC,,,,,,,3398,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Head/Brain W/Dye,PX7046001,CDM,350,RC,70460,CPT,TC,,,,,,,3398,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Head/Brain W/Dye,PX7046001,CDM,350,RC,70460,CPT,TC,,,,,,,3398,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Head/Brain W/Dye,PX7046001,CDM,350,RC,70460,CPT,TC,,,,,,,3398,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Head/Brain W/O & W/Dye,PX7047001,CDM,350,RC,70470,CPT,TC,,,,,,,3671,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Head/Brain W/O & W/Dye,PX7047001,CDM,350,RC,70470,CPT,TC,,,,,,,3671,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Head/Brain W/O & W/Dye,PX7047001,CDM,350,RC,70470,CPT,TC,,,,,,,3671,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Head/Brain W/O & W/Dye,PX7047001,CDM,350,RC,70470,CPT,TC,,,,,,,3671,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Head/Brain W/O & W/Dye,PX7047001,CDM,350,RC,70470,CPT,TC,,,,,,,3671,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Head/Brain W/O & W/Dye,PX7047001,CDM,350,RC,70470,CPT,TC,,,,,,,3671,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Head/Brain W/O Dye,PX7045001,CDM,350,RC,70450,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Head/Brain W/O Dye,PX7045001,CDM,350,RC,70450,CPT,TC,,,,,,,2757,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Head/Brain W/O Dye,PX7045001,CDM,350,RC,70450,CPT,TC,,,,,,,2757,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Head/Brain W/O Dye,PX7045001,CDM,350,RC,70450,CPT,TC,,,,,,,2757,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Head/Brain W/O Dye,PX7045001,CDM,350,RC,70450,CPT,TC,,,,,,,2757,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Head/Brain W/O Dye,PX7045001,CDM,350,RC,70450,CPT,TC,,,,,,,2757,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Lower Extremity W/Dye,PX7370101,CDM,350,RC,73701,CPT,TC,,,,,,,2690,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Lower Extremity W/Dye,PX7370101,CDM,350,RC,73701,CPT,TC,,,,,,,2690,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Lower Extremity W/Dye,PX7370101,CDM,350,RC,73701,CPT,TC,,,,,,,2690,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Lower Extremity W/Dye,PX7370101,CDM,350,RC,73701,CPT,TC,,,,,,,2690,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Lower Extremity W/Dye,PX7370101,CDM,350,RC,73701,CPT,TC,,,,,,,2690,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Lower Extremity W/Dye,PX7370101,CDM,350,RC,73701,CPT,TC,,,,,,,2690,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Lower Extremity W/O Dye,PX7370001,CDM,350,RC,73700,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Lower Extremity W/O Dye,PX7370001,CDM,350,RC,73700,CPT,TC,,,,,,,2757,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Lower Extremity W/O Dye,PX7370001,CDM,350,RC,73700,CPT,TC,,,,,,,2757,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Lower Extremity W/O Dye,PX7370001,CDM,350,RC,73700,CPT,TC,,,,,,,2757,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Lower Extremity W/O Dye,PX7370001,CDM,350,RC,73700,CPT,TC,,,,,,,2757,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Lower Extremity W/O Dye,PX7370001,CDM,350,RC,73700,CPT,TC,,,,,,,2757,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Lumbar Spine W/Dye,PX7213201,CDM,350,RC,72132,CPT,TC,,,,,,,3330,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Lumbar Spine W/Dye,PX7213201,CDM,350,RC,72132,CPT,TC,,,,,,,3330,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Lumbar Spine W/Dye,PX7213201,CDM,350,RC,72132,CPT,TC,,,,,,,3330,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Lumbar Spine W/Dye,PX7213201,CDM,350,RC,72132,CPT,TC,,,,,,,3330,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Lumbar Spine W/Dye,PX7213201,CDM,350,RC,72132,CPT,TC,,,,,,,3330,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Lumbar Spine W/Dye,PX7213201,CDM,350,RC,72132,CPT,TC,,,,,,,3330,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Lumbar Spine W/O & W/Dye,PX7213301,CDM,350,RC,72133,CPT,TC,,,,,,,4283,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Lumbar Spine W/O & W/Dye,PX7213301,CDM,350,RC,72133,CPT,TC,,,,,,,4283,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Lumbar Spine W/O & W/Dye,PX7213301,CDM,350,RC,72133,CPT,TC,,,,,,,4283,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Lumbar Spine W/O & W/Dye,PX7213301,CDM,350,RC,72133,CPT,TC,,,,,,,4283,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Lumbar Spine W/O & W/Dye,PX7213301,CDM,350,RC,72133,CPT,TC,,,,,,,4283,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Lumbar Spine W/O & W/Dye,PX7213301,CDM,350,RC,72133,CPT,TC,,,,,,,4283,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Lumbar Spine W/O Dye,PX7213101,CDM,350,RC,72131,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Lumbar Spine W/O Dye,PX7213101,CDM,350,RC,72131,CPT,TC,,,,,,,2757,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Lumbar Spine W/O Dye,PX7213101,CDM,350,RC,72131,CPT,TC,,,,,,,2757,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Lumbar Spine W/O Dye,PX7213101,CDM,350,RC,72131,CPT,TC,,,,,,,2757,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Lumbar Spine W/O Dye,PX7213101,CDM,350,RC,72131,CPT,TC,,,,,,,2757,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Lumbar Spine W/O Dye,PX7213101,CDM,350,RC,72131,CPT,TC,,,,,,,2757,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Lwr Extremity W/O&W/Dye,PX7370201,CDM,350,RC,73702,CPT,TC,,,,,,,1235,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Lwr Extremity W/O&W/Dye,PX7370201,CDM,350,RC,73702,CPT,TC,,,,,,,1235,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Lwr Extremity W/O&W/Dye,PX7370201,CDM,350,RC,73702,CPT,TC,,,,,,,1235,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Lwr Extremity W/O&W/Dye,PX7370201,CDM,350,RC,73702,CPT,TC,,,,,,,1235,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Lwr Extremity W/O&W/Dye,PX7370201,CDM,350,RC,73702,CPT,TC,,,,,,,1235,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Lwr Extremity W/O&W/Dye,PX7370201,CDM,350,RC,73702,CPT,TC,,,,,,,1235,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Maxillofacial W/Dye,PX7048701,CDM,350,RC,70487,CPT,TC,,,,,,,3332,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Maxillofacial W/Dye,PX7048701,CDM,350,RC,70487,CPT,TC,,,,,,,3332,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Maxillofacial W/Dye,PX7048701,CDM,350,RC,70487,CPT,TC,,,,,,,3332,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Maxillofacial W/Dye,PX7048701,CDM,350,RC,70487,CPT,TC,,,,,,,3332,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Maxillofacial W/Dye,PX7048701,CDM,350,RC,70487,CPT,TC,,,,,,,3332,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Maxillofacial W/Dye,PX7048701,CDM,350,RC,70487,CPT,TC,,,,,,,3332,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Maxillofacialw/O Dye,PX7048601,CDM,350,RC,70486,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Maxillofacialw/O Dye,PX7048601,CDM,350,RC,70486,CPT,TC,,,,,,,2757,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Maxillofacialw/O Dye,PX7048601,CDM,350,RC,70486,CPT,TC,,,,,,,2757,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Maxillofacialw/O Dye,PX7048601,CDM,350,RC,70486,CPT,TC,,,,,,,2757,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Maxillofacialw/O Dye,PX7048601,CDM,350,RC,70486,CPT,TC,,,,,,,2757,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Maxillofacialw/O Dye,PX7048601,CDM,350,RC,70486,CPT,TC,,,,,,,2757,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Neck Spine W/O Dye,PX7212501,CDM,350,RC,72125,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Neck Spine W/O Dye,PX7212501,CDM,350,RC,72125,CPT,TC,,,,,,,2757,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Neck Spine W/O Dye,PX7212501,CDM,350,RC,72125,CPT,TC,,,,,,,2757,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Neck Spine W/O Dye,PX7212501,CDM,350,RC,72125,CPT,TC,,,,,,,2757,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Neck Spine W/O Dye,PX7212501,CDM,350,RC,72125,CPT,TC,,,,,,,2757,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Neck Spine W/O Dye,PX7212501,CDM,350,RC,72125,CPT,TC,,,,,,,2757,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Orbit/Ear/Fosa W/O Dye,PX7048001,CDM,350,RC,70480,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Orbit/Ear/Fosa W/O Dye,PX7048001,CDM,350,RC,70480,CPT,TC,,,,,,,2757,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Orbit/Ear/Fosa W/O Dye,PX7048001,CDM,350,RC,70480,CPT,TC,,,,,,,2757,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Orbit/Ear/Fosa W/O Dye,PX7048001,CDM,350,RC,70480,CPT,TC,,,,,,,2757,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Orbit/Ear/Fosa W/O Dye,PX7048001,CDM,350,RC,70480,CPT,TC,,,,,,,2757,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Orbit/Ear/Fosa W/O Dye,PX7048001,CDM,350,RC,70480,CPT,TC,,,,,,,2757,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Orbit/Ear/Fossa W/O & W/Dye,PX7048201,CDM,350,RC,70482,CPT,TC,,,,,,,1400,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Orbit/Ear/Fossa W/O & W/Dye,PX7048201,CDM,350,RC,70482,CPT,TC,,,,,,,1400,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Orbit/Ear/Fossa W/O & W/Dye,PX7048201,CDM,350,RC,70482,CPT,TC,,,,,,,1400,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Orbit/Ear/Fossa W/O & W/Dye,PX7048201,CDM,350,RC,70482,CPT,TC,,,,,,,1400,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Orbit/Ear/Fossa W/O & W/Dye,PX7048201,CDM,350,RC,70482,CPT,TC,,,,,,,1400,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Orbit/Ear/Fossa W/O & W/Dye,PX7048201,CDM,350,RC,70482,CPT,TC,,,,,,,1400,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Pelvis W/Dye,PX7219301,CDM,350,RC,72193,CPT,TC,,,,,,,3330,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Pelvis W/Dye,PX7219301,CDM,350,RC,72193,CPT,TC,,,,,,,3330,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Pelvis W/Dye,PX7219301,CDM,350,RC,72193,CPT,TC,,,,,,,3330,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Pelvis W/Dye,PX7219301,CDM,350,RC,72193,CPT,TC,,,,,,,3330,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Pelvis W/Dye,PX7219301,CDM,350,RC,72193,CPT,TC,,,,,,,3330,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Pelvis W/Dye,PX7219301,CDM,350,RC,72193,CPT,TC,,,,,,,3330,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Pelvis W/O Dye,PX7219201,CDM,350,RC,72192,CPT,TC,,,,,,,2744,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Pelvis W/O Dye,PX7219201,CDM,350,RC,72192,CPT,TC,,,,,,,2744,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Pelvis W/O Dye,PX7219201,CDM,350,RC,72192,CPT,TC,,,,,,,2744,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Pelvis W/O Dye,PX7219201,CDM,350,RC,72192,CPT,TC,,,,,,,2744,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Pelvis W/O Dye,PX7219201,CDM,350,RC,72192,CPT,TC,,,,,,,2744,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Pelvis W/O Dye,PX7219201,CDM,350,RC,72192,CPT,TC,,,,,,,2744,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Soft Tissue Neck W/Dye,PX7049101,CDM,350,RC,70491,CPT,TC,,,,,,,3415,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Soft Tissue Neck W/Dye,PX7049101,CDM,350,RC,70491,CPT,TC,,,,,,,3415,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Soft Tissue Neck W/Dye,PX7049101,CDM,350,RC,70491,CPT,TC,,,,,,,3415,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Soft Tissue Neck W/Dye,PX7049101,CDM,350,RC,70491,CPT,TC,,,,,,,3415,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Soft Tissue Neck W/Dye,PX7049101,CDM,350,RC,70491,CPT,TC,,,,,,,3415,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Soft Tissue Neck W/Dye,PX7049101,CDM,350,RC,70491,CPT,TC,,,,,,,3415,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Soft Tissue Neck W/O Dye,PX7049001,CDM,350,RC,70490,CPT,TC,,,,,,,711,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Soft Tissue Neck W/O Dye,PX7049001,CDM,350,RC,70490,CPT,TC,,,,,,,711,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Soft Tissue Neck W/O Dye,PX7049001,CDM,350,RC,70490,CPT,TC,,,,,,,711,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Soft Tissue Neck W/O Dye,PX7049001,CDM,350,RC,70490,CPT,TC,,,,,,,711,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Soft Tissue Neck W/O Dye,PX7049001,CDM,350,RC,70490,CPT,TC,,,,,,,711,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Soft Tissue Neck W/O Dye,PX7049001,CDM,350,RC,70490,CPT,TC,,,,,,,711,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Upper Extremity W/Dye,PX7320101,CDM,350,RC,73201,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Upper Extremity W/Dye,PX7320101,CDM,350,RC,73201,CPT,TC,,,,,,,2757,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Upper Extremity W/Dye,PX7320101,CDM,350,RC,73201,CPT,TC,,,,,,,2757,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Upper Extremity W/Dye,PX7320101,CDM,350,RC,73201,CPT,TC,,,,,,,2757,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Upper Extremity W/Dye,PX7320101,CDM,350,RC,73201,CPT,TC,,,,,,,2757,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Upper Extremity W/Dye,PX7320101,CDM,350,RC,73201,CPT,TC,,,,,,,2757,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Upper Extremity W/O Dye,PX7320001,CDM,350,RC,73200,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Upper Extremity W/O Dye,PX7320001,CDM,350,RC,73200,CPT,TC,,,,,,,2757,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Upper Extremity W/O Dye,PX7320001,CDM,350,RC,73200,CPT,TC,,,,,,,2757,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Upper Extremity W/O Dye,PX7320001,CDM,350,RC,73200,CPT,TC,,,,,,,2757,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Upper Extremity W/O Dye,PX7320001,CDM,350,RC,73200,CPT,TC,,,,,,,2757,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Upper Extremity W/O Dye,PX7320001,CDM,350,RC,73200,CPT,TC,,,,,,,2757,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ctrl Nosebleed,Anter,Complex",PX30903F,CDM,510,RC,30903,CPT,,,,,,,,456,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ctrl Nosebleed,Anter,Complex",PX30903F,CDM,510,RC,30903,CPT,,,,,,,,456,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ctrl Nosebleed,Anter,Complex",PX30903F,CDM,510,RC,30903,CPT,,,,,,,,456,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ctrl Nosebleed,Anter,Complex",PX30903F,CDM,510,RC,30903,CPT,,,,,,,,456,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ctrl Nosebleed,Anter,Complex",PX30903F,CDM,510,RC,30903,CPT,,,,,,,,456,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ctrl Nosebleed,Anter,Complex",PX30903F,CDM,510,RC,30903,CPT,,,,,,,,456,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ctrl Nosebleed,Anter,Complex",PX30903P,CDM,983,RC,30903,CPT,,,,,,,,304,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ctrl Nosebleed,Anter,Complex",PX30903P,CDM,983,RC,30903,CPT,,,,,,,,304,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ctrl Nosebleed,Anter,Complex",PX30903P,CDM,983,RC,30903,CPT,,,,,,,,304,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ctrl Nosebleed,Anter,Complex",PX30903P,CDM,983,RC,30903,CPT,,,,,,,,304,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ctrl Nosebleed,Anter,Complex",PX30903P,CDM,983,RC,30903,CPT,,,,,,,,304,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ctrl Nosebleed,Anter,Complex",PX30903P,CDM,983,RC,30903,CPT,,,,,,,,304,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ctrl Nosebleed,Anter,Simple",PX30901F,CDM,510,RC,30901,CPT,,,,,,,,342,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ctrl Nosebleed,Anter,Simple",PX30901F,CDM,510,RC,30901,CPT,,,,,,,,342,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ctrl Nosebleed,Anter,Simple",PX30901F,CDM,510,RC,30901,CPT,,,,,,,,342,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ctrl Nosebleed,Anter,Simple",PX30901F,CDM,510,RC,30901,CPT,,,,,,,,342,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ctrl Nosebleed,Anter,Simple",PX30901F,CDM,510,RC,30901,CPT,,,,,,,,342,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ctrl Nosebleed,Anter,Simple",PX30901F,CDM,510,RC,30901,CPT,,,,,,,,342,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ctrl Nosebleed,Anter,Simple",PX30901P,CDM,983,RC,30901,CPT,,,,,,,,229,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ctrl Nosebleed,Anter,Simple",PX30901P,CDM,983,RC,30901,CPT,,,,,,,,229,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ctrl Nosebleed,Anter,Simple",PX30901P,CDM,983,RC,30901,CPT,,,,,,,,229,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ctrl Nosebleed,Anter,Simple",PX30901P,CDM,983,RC,30901,CPT,,,,,,,,229,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ctrl Nosebleed,Anter,Simple",PX30901P,CDM,983,RC,30901,CPT,,,,,,,,229,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ctrl Nosebleed,Anter,Simple",PX30901P,CDM,983,RC,30901,CPT,,,,,,,,229,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CUFF STERILE DISPOSABLE SPSB  STERILE 18""",27200000,CDM,272,RC,,,,7436-MAIN,LOCAL,,,,,35.89,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CUFF STERILE DISPOSABLE SPSB  STERILE 18""",27200000,CDM,272,RC,,,,7436-MAIN,LOCAL,,,,,35.89,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CUFF STERILE DISPOSABLE SPSB  STERILE 18""",27200000,CDM,272,RC,,,,7436-MAIN,LOCAL,,,,,35.89,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CUFF STERILE DISPOSABLE SPSB  STERILE 18""",27200000,CDM,272,RC,,,,7436-MAIN,LOCAL,,,,,35.89,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CUFF STERILE DISPOSABLE SPSB  STERILE 18""",27200000,CDM,272,RC,,,,7436-MAIN,LOCAL,,,,,35.89,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CUFF STERILE DISPOSABLE SPSB  STERILE 18""",27200000,CDM,272,RC,,,,7436-MAIN,LOCAL,,,,,35.89,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CUFF STERILE DISPOSABLE SPSB 12""",27200000,CDM,272,RC,,,,7435-MAIN,LOCAL,,,,,43.31,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CUFF STERILE DISPOSABLE SPSB 12""",27200000,CDM,272,RC,,,,7435-MAIN,LOCAL,,,,,43.31,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CUFF STERILE DISPOSABLE SPSB 12""",27200000,CDM,272,RC,,,,7435-MAIN,LOCAL,,,,,43.31,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CUFF STERILE DISPOSABLE SPSB 12""",27200000,CDM,272,RC,,,,7435-MAIN,LOCAL,,,,,43.31,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CUFF STERILE DISPOSABLE SPSB 12""",27200000,CDM,272,RC,,,,7435-MAIN,LOCAL,,,,,43.31,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CUFF STERILE DISPOSABLE SPSB 12""",27200000,CDM,272,RC,,,,7435-MAIN,LOCAL,,,,,43.31,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CUFF STERILE DISPOSABLE SPSB 24""",27200000,CDM,272,RC,,,,7437-MAIN,LOCAL,,,,,37.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CUFF STERILE DISPOSABLE SPSB 24""",27200000,CDM,272,RC,,,,7437-MAIN,LOCAL,,,,,37.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CUFF STERILE DISPOSABLE SPSB 24""",27200000,CDM,272,RC,,,,7437-MAIN,LOCAL,,,,,37.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CUFF STERILE DISPOSABLE SPSB 24""",27200000,CDM,272,RC,,,,7437-MAIN,LOCAL,,,,,37.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CUFF STERILE DISPOSABLE SPSB 24""",27200000,CDM,272,RC,,,,7437-MAIN,LOCAL,,,,,37.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CUFF STERILE DISPOSABLE SPSB 24""",27200000,CDM,272,RC,,,,7437-MAIN,LOCAL,,,,,37.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CUFF STERILE DISPOSABLE SPSB 34"" THIGH USE",27200000,CDM,272,RC,,,,12367-MAIN,LOCAL,,,,,,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CUFF STERILE DISPOSABLE SPSB 34"" THIGH USE",27200000,CDM,272,RC,,,,12367-MAIN,LOCAL,,,,,,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CUFF STERILE DISPOSABLE SPSB 34"" THIGH USE",27200000,CDM,272,RC,,,,12367-MAIN,LOCAL,,,,,,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CUFF STERILE DISPOSABLE SPSB 34"" THIGH USE",27200000,CDM,272,RC,,,,12367-MAIN,LOCAL,,,,,,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CUFF STERILE DISPOSABLE SPSB 34"" THIGH USE",27200000,CDM,272,RC,,,,12367-MAIN,LOCAL,,,,,,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CUFF STERILE DISPOSABLE SPSB 34"" THIGH USE",27200000,CDM,272,RC,,,,12367-MAIN,LOCAL,,,,,,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Culture Screen Only,PX87081,CDM,300,RC,87081,CPT,,,,,,,,276,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Culture Screen Only,PX87081,CDM,300,RC,87081,CPT,,,,,,,,276,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Culture Screen Only,PX87081,CDM,300,RC,87081,CPT,,,,,,,,276,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Culture Screen Only,PX87081,CDM,300,RC,87081,CPT,,,,,,,,276,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Culture Screen Only,PX87081,CDM,300,RC,87081,CPT,,,,,,,,276,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Culture Screen Only,PX87081,CDM,300,RC,87081,CPT,,,,,,,,276,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Culture Type Immunologic,PX87147,CDM,300,RC,87147,CPT,,,,,,,,42,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Culture Type Immunologic,PX87147,CDM,300,RC,87147,CPT,,,,,,,,42,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Culture Type Immunologic,PX87147,CDM,300,RC,87147,CPT,,,,,,,,42,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Culture Type Immunologic,PX87147,CDM,300,RC,87147,CPT,,,,,,,,42,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Culture Type Immunologic,PX87147,CDM,300,RC,87147,CPT,,,,,,,,42,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Culture Type Immunologic,PX87147,CDM,300,RC,87147,CPT,,,,,,,,42,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CUP HEEL LARGE WONDERSPUR 4502,120.43,CDM,274,RC,L3485,HCPCS,,11385-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CUP HEEL LARGE WONDERSPUR 4502,120.43,CDM,274,RC,L3485,HCPCS,,11385-MAIN,LOCAL,,,,,41,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CUP HEEL LARGE WONDERSPUR 4502,120.43,CDM,274,RC,L3485,HCPCS,,11385-MAIN,LOCAL,,,,,41,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CUP HEEL LARGE WONDERSPUR 4502,120.43,CDM,274,RC,L3485,HCPCS,,11385-MAIN,LOCAL,,,,,41,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CUP HEEL LARGE WONDERSPUR 4502,120.43,CDM,274,RC,L3485,HCPCS,,11385-MAIN,LOCAL,,,,,41,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CUP HEEL LARGE WONDERSPUR 4502,120.43,CDM,274,RC,L3485,HCPCS,,11385-MAIN,LOCAL,,,,,41,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CUP HEEL MEDIUM WONDERSPUR 4501,120.43,CDM,274,RC,L3485,HCPCS,,11384-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CUP HEEL MEDIUM WONDERSPUR 4501,120.43,CDM,274,RC,L3485,HCPCS,,11384-MAIN,LOCAL,,,,,41,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CUP HEEL MEDIUM WONDERSPUR 4501,120.43,CDM,274,RC,L3485,HCPCS,,11384-MAIN,LOCAL,,,,,41,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CUP HEEL MEDIUM WONDERSPUR 4501,120.43,CDM,274,RC,L3485,HCPCS,,11384-MAIN,LOCAL,,,,,41,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CUP HEEL MEDIUM WONDERSPUR 4501,120.43,CDM,274,RC,L3485,HCPCS,,11384-MAIN,LOCAL,,,,,41,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CUP HEEL MEDIUM WONDERSPUR 4501,120.43,CDM,274,RC,L3485,HCPCS,,11384-MAIN,LOCAL,,,,,41,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CUP HEEL SMALL WONDERSPUR 4500,120.43,CDM,274,RC,L3485,HCPCS,,11383-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CUP HEEL SMALL WONDERSPUR 4500,120.43,CDM,274,RC,L3485,HCPCS,,11383-MAIN,LOCAL,,,,,41,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CUP HEEL SMALL WONDERSPUR 4500,120.43,CDM,274,RC,L3485,HCPCS,,11383-MAIN,LOCAL,,,,,41,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CUP HEEL SMALL WONDERSPUR 4500,120.43,CDM,274,RC,L3485,HCPCS,,11383-MAIN,LOCAL,,,,,41,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CUP HEEL SMALL WONDERSPUR 4500,120.43,CDM,274,RC,L3485,HCPCS,,11383-MAIN,LOCAL,,,,,41,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CUP HEEL SMALL WONDERSPUR 4500,120.43,CDM,274,RC,L3485,HCPCS,,11383-MAIN,LOCAL,,,,,41,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CUP HEEL XL WONDERSPUR 4503,120.43,CDM,274,RC,L3485,HCPCS,,11386-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CUP HEEL XL WONDERSPUR 4503,120.43,CDM,274,RC,L3485,HCPCS,,11386-MAIN,LOCAL,,,,,41,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CUP HEEL XL WONDERSPUR 4503,120.43,CDM,274,RC,L3485,HCPCS,,11386-MAIN,LOCAL,,,,,41,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CUP HEEL XL WONDERSPUR 4503,120.43,CDM,274,RC,L3485,HCPCS,,11386-MAIN,LOCAL,,,,,41,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CUP HEEL XL WONDERSPUR 4503,120.43,CDM,274,RC,L3485,HCPCS,,11386-MAIN,LOCAL,,,,,41,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CUP HEEL XL WONDERSPUR 4503,120.43,CDM,274,RC,L3485,HCPCS,,11386-MAIN,LOCAL,,,,,41,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cv Carotid Imaging-Bilat,PX9388001,CDM,921,RC,93880,CPT,TC,,,,,,,1088,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cv Carotid Imaging-Bilat,PX9388001,CDM,921,RC,93880,CPT,TC,,,,,,,1088,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cv Carotid Imaging-Bilat,PX9388001,CDM,921,RC,93880,CPT,TC,,,,,,,1088,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cv Carotid Imaging-Bilat,PX9388001,CDM,921,RC,93880,CPT,TC,,,,,,,1088,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cv Carotid Imaging-Bilat,PX9388001,CDM,921,RC,93880,CPT,TC,,,,,,,1088,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cv Carotid Imaging-Bilat,PX9388001,CDM,921,RC,93880,CPT,TC,,,,,,,1088,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536136601,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536136601,NDC,0.25,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536136601,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536136601,NDC,0.25,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536136601,NDC,0.25,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536136601,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536355601,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536355601,NDC,0.25,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536355601,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536355601,NDC,0.25,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536355601,NDC,0.25,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536355601,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,74312001380,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,74312001380,NDC,0.25,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,74312001380,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,74312001380,NDC,0.25,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,74312001380,NDC,0.25,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,74312001380,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,63323004401,NDC,1,ML,64.53,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,63323004401,NDC,1,ML,64.53,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,63323004401,NDC,1,ML,64.53,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,63323004401,NDC,1,ML,64.53,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,63323004401,NDC,1,ML,64.53,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,63323004401,NDC,1,ML,64.53,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,70069000501,NDC,0.1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,70069000501,NDC,0.1,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,70069000501,NDC,0.1,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,70069000501,NDC,0.1,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,70069000501,NDC,0.1,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,70069000501,NDC,0.1,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyclobenzaprine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079064401,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyclobenzaprine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079064401,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyclobenzaprine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079064401,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyclobenzaprine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079064401,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyclobenzaprine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079064401,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyclobenzaprine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079064401,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyclobenzaprine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687055811,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyclobenzaprine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687055811,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyclobenzaprine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687055811,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyclobenzaprine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687055811,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyclobenzaprine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687055811,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyclobenzaprine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687055811,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyclobenzaprine 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69097084607,NDC,0.5,EA,3.11,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyclobenzaprine 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69097084607,NDC,0.5,EA,3.11,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyclobenzaprine 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69097084607,NDC,0.5,EA,3.11,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyclobenzaprine 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69097084607,NDC,0.5,EA,3.11,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyclobenzaprine 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69097084607,NDC,0.5,EA,3.11,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyclobenzaprine 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69097084607,NDC,0.5,EA,3.11,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyclobenzaprine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079064420,NDC,1,EA,5.2,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyclobenzaprine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079064420,NDC,1,EA,5.2,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyclobenzaprine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079064420,NDC,1,EA,5.2,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyclobenzaprine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079064420,NDC,1,EA,5.2,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyclobenzaprine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079064420,NDC,1,EA,5.2,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyclobenzaprine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079064420,NDC,1,EA,5.2,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyclobenzaprine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687055801,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyclobenzaprine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687055801,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyclobenzaprine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687055801,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyclobenzaprine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687055801,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyclobenzaprine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687055801,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyclobenzaprine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687055801,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyclopentolate 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,17478010002,NDC,2,ML,66.55,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyclopentolate 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,17478010002,NDC,2,ML,66.55,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyclopentolate 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,17478010002,NDC,2,ML,66.55,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyclopentolate 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,17478010002,NDC,2,ML,66.55,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyclopentolate 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,17478010002,NDC,2,ML,66.55,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyclopentolate 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,17478010002,NDC,2,ML,66.55,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyclopentolate 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,61314039601,NDC,2,ML,94.58,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyclopentolate 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,61314039601,NDC,2,ML,94.58,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyclopentolate 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,61314039601,NDC,2,ML,94.58,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyclopentolate 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,61314039601,NDC,2,ML,94.58,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyclopentolate 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,61314039601,NDC,2,ML,94.58,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyclopentolate 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,61314039601,NDC,2,ML,94.58,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781324494,NDC,1,EA,1400.9,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781324494,NDC,1,EA,1400.9,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781324494,NDC,1,EA,1400.9,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781324494,NDC,1,EA,1400.9,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781324494,NDC,1,EA,1400.9,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781324494,NDC,1,EA,1400.9,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,16714085701,NDC,1,EA,1403.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,16714085701,NDC,1,EA,1403.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,16714085701,NDC,1,EA,1403.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,16714085701,NDC,1,EA,1403.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,16714085701,NDC,1,EA,1403.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,16714085701,NDC,1,EA,1403.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cycloPHOSphamide 2 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,10019095701,NDC,1,EA,2988.6,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cycloPHOSphamide 2 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,10019095701,NDC,1,EA,2988.6,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cycloPHOSphamide 2 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,10019095701,NDC,1,EA,2988.6,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cycloPHOSphamide 2 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,10019095701,NDC,1,EA,2988.6,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cycloPHOSphamide 2 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,10019095701,NDC,1,EA,2988.6,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cycloPHOSphamide 2 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,10019095701,NDC,1,EA,2988.6,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cycloPHOSphamide 500 MG Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781323394,NDC,1,EA,1565.71,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cycloPHOSphamide 500 MG Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781323394,NDC,1,EA,1565.71,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cycloPHOSphamide 500 MG Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781323394,NDC,1,EA,1565.71,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cycloPHOSphamide 500 MG Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781323394,NDC,1,EA,1565.71,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cycloPHOSphamide 500 MG Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781323394,NDC,1,EA,1565.71,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cycloPHOSphamide 500 MG Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781323394,NDC,1,EA,1565.71,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cyclosporine - Ref,PX8015890,CDM,300,RC,80158,CPT,90,,,,,,,95,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cyclosporine - Ref,PX8015890,CDM,300,RC,80158,CPT,90,,,,,,,95,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cyclosporine - Ref,PX8015890,CDM,300,RC,80158,CPT,90,,,,,,,95,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cyclosporine - Ref,PX8015890,CDM,300,RC,80158,CPT,90,,,,,,,95,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cyclosporine - Ref,PX8015890,CDM,300,RC,80158,CPT,90,,,,,,,95,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cyclosporine - Ref,PX8015890,CDM,300,RC,80158,CPT,90,,,,,,,95,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cystatin C - Ref,PX8261090,CDM,300,RC,82610,CPT,90,,,,,,,130,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cystatin C - Ref,PX8261090,CDM,300,RC,82610,CPT,90,,,,,,,130,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cystatin C - Ref,PX8261090,CDM,300,RC,82610,CPT,90,,,,,,,130,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cystatin C - Ref,PX8261090,CDM,300,RC,82610,CPT,90,,,,,,,130,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cystatin C - Ref,PX8261090,CDM,300,RC,82610,CPT,90,,,,,,,130,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cystatin C - Ref,PX8261090,CDM,300,RC,82610,CPT,90,,,,,,,130,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CYSTOSCOPY PACK I STERILE,120.505,CDM,272,RC,,,,4527-MAIN,LOCAL,,,,,155,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CYSTOSCOPY PACK I STERILE,120.505,CDM,272,RC,,,,4527-MAIN,LOCAL,,,,,155,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CYSTOSCOPY PACK I STERILE,120.505,CDM,272,RC,,,,4527-MAIN,LOCAL,,,,,155,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CYSTOSCOPY PACK I STERILE,120.505,CDM,272,RC,,,,4527-MAIN,LOCAL,,,,,155,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CYSTOSCOPY PACK I STERILE,120.505,CDM,272,RC,,,,4527-MAIN,LOCAL,,,,,155,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CYSTOSCOPY PACK I STERILE,120.505,CDM,272,RC,,,,4527-MAIN,LOCAL,,,,,155,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cystourethroscopy, With Injection(S) for Chemodenervation of the Bladder",PX52287F,CDM,360,RC,52287,CPT,,,,,,,,2745,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2421.09,6141.46
"Cystourethroscopy, With Injection(S) for Chemodenervation of the Bladder",PX52287F,CDM,360,RC,52287,CPT,,,,,,,,2745,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2421.09,6141.46
"Cystourethroscopy, With Injection(S) for Chemodenervation of the Bladder",PX52287F,CDM,360,RC,52287,CPT,,,,,,,,2745,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2421.09,6141.46
"Cystourethroscopy, With Injection(S) for Chemodenervation of the Bladder",PX52287F,CDM,360,RC,52287,CPT,,,,,,,,2745,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2421.09,6141.46
"Cystourethroscopy, With Injection(S) for Chemodenervation of the Bladder",PX52287F,CDM,360,RC,52287,CPT,,,,,,,,2745,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2421.09,6141.46
"Cystourethroscopy, With Injection(S) for Chemodenervation of the Bladder",PX52287F,CDM,360,RC,52287,CPT,,,,,,,,2745,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2421.09,6141.46
Cyto Non Gyn,PX8811201,CDM,310,RC,88112,CPT,TC,,,,,,,372,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cyto Non Gyn,PX8811201,CDM,310,RC,88112,CPT,TC,,,,,,,372,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cyto Non Gyn,PX8811201,CDM,310,RC,88112,CPT,TC,,,,,,,372,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cyto Non Gyn,PX8811201,CDM,310,RC,88112,CPT,TC,,,,,,,372,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cyto Non Gyn,PX8811201,CDM,310,RC,88112,CPT,TC,,,,,,,372,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cyto Non Gyn,PX8811201,CDM,310,RC,88112,CPT,TC,,,,,,,372,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cytoflo, Cell or Dna Anal - Ref",PX8818290,CDM,310,RC,88182,CPT,90,,,,,,,225,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cytoflo, Cell or Dna Anal - Ref",PX8818290,CDM,310,RC,88182,CPT,90,,,,,,,225,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cytoflo, Cell or Dna Anal - Ref",PX8818290,CDM,310,RC,88182,CPT,90,,,,,,,225,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cytoflo, Cell or Dna Anal - Ref",PX8818290,CDM,310,RC,88182,CPT,90,,,,,,,225,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cytoflo, Cell or Dna Anal - Ref",PX8818290,CDM,310,RC,88182,CPT,90,,,,,,,225,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cytoflo, Cell or Dna Anal - Ref",PX8818290,CDM,310,RC,88182,CPT,90,,,,,,,225,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cytogen, Interp/Report - Ref",PX8829190,CDM,310,RC,88291,CPT,90,,,,,,,2874,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cytogen, Interp/Report - Ref",PX8829190,CDM,310,RC,88291,CPT,90,,,,,,,2874,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cytogen, Interp/Report - Ref",PX8829190,CDM,310,RC,88291,CPT,90,,,,,,,2874,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cytogen, Interp/Report - Ref",PX8829190,CDM,310,RC,88291,CPT,90,,,,,,,2874,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cytogen, Interp/Report - Ref",PX8829190,CDM,310,RC,88291,CPT,90,,,,,,,2874,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cytogen, Interp/Report - Ref",PX8829190,CDM,310,RC,88291,CPT,90,,,,,,,2874,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cytogenomic Neoplasia (Genome-Wide) Microarray Analysis - Ref,PX8127790,CDM,310,RC,81277,CPT,90,,,,,,,3850,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cytogenomic Neoplasia (Genome-Wide) Microarray Analysis - Ref,PX8127790,CDM,310,RC,81277,CPT,90,,,,,,,3850,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cytogenomic Neoplasia (Genome-Wide) Microarray Analysis - Ref,PX8127790,CDM,310,RC,81277,CPT,90,,,,,,,3850,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cytogenomic Neoplasia (Genome-Wide) Microarray Analysis - Ref,PX8127790,CDM,310,RC,81277,CPT,90,,,,,,,3850,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cytogenomic Neoplasia (Genome-Wide) Microarray Analysis - Ref,PX8127790,CDM,310,RC,81277,CPT,90,,,,,,,3850,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cytogenomic Neoplasia (Genome-Wide) Microarray Analysis - Ref,PX8127790,CDM,310,RC,81277,CPT,90,,,,,,,3850,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"D-Dimer, Quantitative - Ref",PX8537990,CDM,300,RC,85379,CPT,90,,,,,,,177,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"D-Dimer, Quantitative - Ref",PX8537990,CDM,300,RC,85379,CPT,90,,,,,,,177,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"D-Dimer, Quantitative - Ref",PX8537990,CDM,300,RC,85379,CPT,90,,,,,,,177,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"D-Dimer, Quantitative - Ref",PX8537990,CDM,300,RC,85379,CPT,90,,,,,,,177,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"D-Dimer, Quantitative - Ref",PX8537990,CDM,300,RC,85379,CPT,90,,,,,,,177,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"D-Dimer, Quantitative - Ref",PX8537990,CDM,300,RC,85379,CPT,90,,,,,,,177,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dabigatran 75 MG capsule 60 Each Box,63700001,CDM,250,RC,,,,,,597014960,NDC,1,EA,39.83,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dabigatran 75 MG capsule 60 Each Box,63700001,CDM,250,RC,,,,,,597014960,NDC,1,EA,39.83,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dabigatran 75 MG capsule 60 Each Box,63700001,CDM,250,RC,,,,,,597014960,NDC,1,EA,39.83,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dabigatran 75 MG capsule 60 Each Box,63700001,CDM,250,RC,,,,,,597014960,NDC,1,EA,39.83,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dabigatran 75 MG capsule 60 Each Box,63700001,CDM,250,RC,,,,,,597014960,NDC,1,EA,39.83,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dabigatran 75 MG capsule 60 Each Box,63700001,CDM,250,RC,,,,,,597014960,NDC,1,EA,39.83,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dabigatran 75 MG capsule 60 Each Box,63700001,CDM,250,RC,,,,,,597035556,NDC,1,EA,53.27,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dabigatran 75 MG capsule 60 Each Box,63700001,CDM,250,RC,,,,,,597035556,NDC,1,EA,53.27,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dabigatran 75 MG capsule 60 Each Box,63700001,CDM,250,RC,,,,,,597035556,NDC,1,EA,53.27,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dabigatran 75 MG capsule 60 Each Box,63700001,CDM,250,RC,,,,,,597035556,NDC,1,EA,53.27,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dabigatran 75 MG capsule 60 Each Box,63700001,CDM,250,RC,,,,,,597035556,NDC,1,EA,53.27,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dabigatran 75 MG capsule 60 Each Box,63700001,CDM,250,RC,,,,,,597035556,NDC,1,EA,53.27,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dantrolene 20 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,42023012306,NDC,1,EA,394.42,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dantrolene 20 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,42023012306,NDC,1,EA,394.42,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dantrolene 20 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,42023012306,NDC,1,EA,394.42,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dantrolene 20 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,42023012306,NDC,1,EA,394.42,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dantrolene 20 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,42023012306,NDC,1,EA,394.42,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dantrolene 20 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,42023012306,NDC,1,EA,394.42,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DAPTOmycin 500 MG Recon Soln 1 Each Vial,J0878.01,CDM,636,RC,J0878,HCPCS,,,,70594003402,NDC,1,EA,129.9,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DAPTOmycin 500 MG Recon Soln 1 Each Vial,J0878.01,CDM,636,RC,J0878,HCPCS,,,,70594003402,NDC,1,EA,129.9,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DAPTOmycin 500 MG Recon Soln 1 Each Vial,J0878.01,CDM,636,RC,J0878,HCPCS,,,,70594003402,NDC,1,EA,129.9,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DAPTOmycin 500 MG Recon Soln 1 Each Vial,J0878.01,CDM,636,RC,J0878,HCPCS,,,,70594003402,NDC,1,EA,129.9,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DAPTOmycin 500 MG Recon Soln 1 Each Vial,J0878.01,CDM,636,RC,J0878,HCPCS,,,,70594003402,NDC,1,EA,129.9,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DAPTOmycin 500 MG Recon Soln 1 Each Vial,J0878.01,CDM,636,RC,J0878,HCPCS,,,,70594003402,NDC,1,EA,129.9,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
darbepoetin alfa 40 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002104,NDC,0.4,ML,1411.78,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
darbepoetin alfa 40 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002104,NDC,0.4,ML,1411.78,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
darbepoetin alfa 40 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002104,NDC,0.4,ML,1411.78,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
darbepoetin alfa 40 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002104,NDC,0.4,ML,1411.78,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
darbepoetin alfa 40 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002104,NDC,0.4,ML,1411.78,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
darbepoetin alfa 40 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002104,NDC,0.4,ML,1411.78,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
darbepoetin alfa 200 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002801,NDC,0.4,ML,3157.92,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
darbepoetin alfa 200 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002801,NDC,0.4,ML,3157.92,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
darbepoetin alfa 200 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002801,NDC,0.4,ML,3157.92,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
darbepoetin alfa 200 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002801,NDC,0.4,ML,3157.92,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
darbepoetin alfa 200 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002801,NDC,0.4,ML,3157.92,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
darbepoetin alfa 200 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002801,NDC,0.4,ML,3157.92,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
darbepoetin alfa 300 MCG/0.6ML solution prefilled syringe 0.6 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513011101,NDC,0.6,ML,4736.88,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
darbepoetin alfa 300 MCG/0.6ML solution prefilled syringe 0.6 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513011101,NDC,0.6,ML,4736.88,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
darbepoetin alfa 300 MCG/0.6ML solution prefilled syringe 0.6 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513011101,NDC,0.6,ML,4736.88,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
darbepoetin alfa 300 MCG/0.6ML solution prefilled syringe 0.6 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513011101,NDC,0.6,ML,4736.88,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
darbepoetin alfa 300 MCG/0.6ML solution prefilled syringe 0.6 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513011101,NDC,0.6,ML,4736.88,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
darbepoetin alfa 300 MCG/0.6ML solution prefilled syringe 0.6 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513011101,NDC,0.6,ML,4736.88,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
darbepoetin alfa 500 MCG/ML solution prefilled syringe 1 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513003201,NDC,0.3,ML,2368.44,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
darbepoetin alfa 500 MCG/ML solution prefilled syringe 1 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513003201,NDC,0.3,ML,2368.44,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
darbepoetin alfa 500 MCG/ML solution prefilled syringe 1 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513003201,NDC,0.3,ML,2368.44,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
darbepoetin alfa 500 MCG/ML solution prefilled syringe 1 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513003201,NDC,0.3,ML,2368.44,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
darbepoetin alfa 500 MCG/ML solution prefilled syringe 1 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513003201,NDC,0.3,ML,2368.44,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
darbepoetin alfa 500 MCG/ML solution prefilled syringe 1 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513003201,NDC,0.3,ML,2368.44,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Bone Ea Add 20 Sqcm,PX11047F,CDM,510,RC,11047,CPT,,,,,,,,438,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Bone Ea Add 20 Sqcm,PX11047F,CDM,510,RC,11047,CPT,,,,,,,,438,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Bone Ea Add 20 Sqcm,PX11047F,CDM,510,RC,11047,CPT,,,,,,,,438,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Bone Ea Add 20 Sqcm,PX11047F,CDM,510,RC,11047,CPT,,,,,,,,438,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Bone Ea Add 20 Sqcm,PX11047F,CDM,510,RC,11047,CPT,,,,,,,,438,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Bone Ea Add 20 Sqcm,PX11047F,CDM,510,RC,11047,CPT,,,,,,,,438,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Bone Ea Add 20 Sqcm,PX11047P,CDM,983,RC,11047,CPT,,,,,,,,351,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Bone Ea Add 20 Sqcm,PX11047P,CDM,983,RC,11047,CPT,,,,,,,,351,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Bone Ea Add 20 Sqcm,PX11047P,CDM,983,RC,11047,CPT,,,,,,,,351,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Bone Ea Add 20 Sqcm,PX11047P,CDM,983,RC,11047,CPT,,,,,,,,351,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Bone Ea Add 20 Sqcm,PX11047P,CDM,983,RC,11047,CPT,,,,,,,,351,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Bone Ea Add 20 Sqcm,PX11047P,CDM,983,RC,11047,CPT,,,,,,,,351,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Muscle Ea Add 20 Sqcm,PX11046F,CDM,510,RC,11046,CPT,,,,,,,,248,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Muscle Ea Add 20 Sqcm,PX11046F,CDM,510,RC,11046,CPT,,,,,,,,248,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Muscle Ea Add 20 Sqcm,PX11046F,CDM,510,RC,11046,CPT,,,,,,,,248,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Muscle Ea Add 20 Sqcm,PX11046F,CDM,510,RC,11046,CPT,,,,,,,,248,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Muscle Ea Add 20 Sqcm,PX11046F,CDM,510,RC,11046,CPT,,,,,,,,248,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Muscle Ea Add 20 Sqcm,PX11046F,CDM,510,RC,11046,CPT,,,,,,,,248,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Muscle Ea Add 20 Sqcm,PX11046P,CDM,983,RC,11046,CPT,,,,,,,,198,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Muscle Ea Add 20 Sqcm,PX11046P,CDM,983,RC,11046,CPT,,,,,,,,198,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Muscle Ea Add 20 Sqcm,PX11046P,CDM,983,RC,11046,CPT,,,,,,,,198,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Muscle Ea Add 20 Sqcm,PX11046P,CDM,983,RC,11046,CPT,,,,,,,,198,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Muscle Ea Add 20 Sqcm,PX11046P,CDM,983,RC,11046,CPT,,,,,,,,198,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Muscle Ea Add 20 Sqcm,PX11046P,CDM,983,RC,11046,CPT,,,,,,,,198,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Skin/Subq Ea Ad 20sqcm,PX11045F,CDM,510,RC,11045,CPT,,,,,,,,115,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Skin/Subq Ea Ad 20sqcm,PX11045F,CDM,510,RC,11045,CPT,,,,,,,,115,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Skin/Subq Ea Ad 20sqcm,PX11045F,CDM,510,RC,11045,CPT,,,,,,,,115,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Skin/Subq Ea Ad 20sqcm,PX11045F,CDM,510,RC,11045,CPT,,,,,,,,115,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Skin/Subq Ea Ad 20sqcm,PX11045F,CDM,510,RC,11045,CPT,,,,,,,,115,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Skin/Subq Ea Ad 20sqcm,PX11045F,CDM,510,RC,11045,CPT,,,,,,,,115,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Skin/Subq Ea Ad 20sqcm,PX11045P,CDM,983,RC,11045,CPT,,,,,,,,182,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Skin/Subq Ea Ad 20sqcm,PX11045P,CDM,983,RC,11045,CPT,,,,,,,,182,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Skin/Subq Ea Ad 20sqcm,PX11045P,CDM,983,RC,11045,CPT,,,,,,,,182,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Skin/Subq Ea Ad 20sqcm,PX11045P,CDM,983,RC,11045,CPT,,,,,,,,182,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Skin/Subq Ea Ad 20sqcm,PX11045P,CDM,983,RC,11045,CPT,,,,,,,,182,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Skin/Subq Ea Ad 20sqcm,PX11045P,CDM,983,RC,11045,CPT,,,,,,,,182,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Skin/Tissue,PX11042F,CDM,510,RC,11042,CPT,,,,,,,,1067,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Skin/Tissue,PX11042F,CDM,510,RC,11042,CPT,,,,,,,,1067,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Skin/Tissue,PX11042F,CDM,510,RC,11042,CPT,,,,,,,,1067,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Skin/Tissue,PX11042F,CDM,510,RC,11042,CPT,,,,,,,,1067,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Skin/Tissue,PX11042F,CDM,510,RC,11042,CPT,,,,,,,,1067,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Skin/Tissue,PX11042F,CDM,510,RC,11042,CPT,,,,,,,,1067,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Skin/Tissue,PX11042P,CDM,983,RC,11042,CPT,,,,,,,,995,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Skin/Tissue,PX11042P,CDM,983,RC,11042,CPT,,,,,,,,995,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Skin/Tissue,PX11042P,CDM,983,RC,11042,CPT,,,,,,,,995,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Skin/Tissue,PX11042P,CDM,983,RC,11042,CPT,,,,,,,,995,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Skin/Tissue,PX11042P,CDM,983,RC,11042,CPT,,,,,,,,995,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Skin/Tissue,PX11042P,CDM,983,RC,11042,CPT,,,,,,,,995,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Tissue/Muscle,PX11043F,CDM,510,RC,11043,CPT,,,,,,,,526,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Tissue/Muscle,PX11043F,CDM,510,RC,11043,CPT,,,,,,,,526,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Tissue/Muscle,PX11043F,CDM,510,RC,11043,CPT,,,,,,,,526,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Tissue/Muscle,PX11043F,CDM,510,RC,11043,CPT,,,,,,,,526,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Tissue/Muscle,PX11043F,CDM,510,RC,11043,CPT,,,,,,,,526,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Tissue/Muscle,PX11043F,CDM,510,RC,11043,CPT,,,,,,,,526,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Tissue/Muscle,PX11043P,CDM,983,RC,11043,CPT,,,,,,,,351,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Tissue/Muscle,PX11043P,CDM,983,RC,11043,CPT,,,,,,,,351,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Tissue/Muscle,PX11043P,CDM,983,RC,11043,CPT,,,,,,,,351,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Tissue/Muscle,PX11043P,CDM,983,RC,11043,CPT,,,,,,,,351,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Tissue/Muscle,PX11043P,CDM,983,RC,11043,CPT,,,,,,,,351,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Tissue/Muscle,PX11043P,CDM,983,RC,11043,CPT,,,,,,,,351,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Tissue/Muscle/Bone,PX11044F,CDM,510,RC,11044,CPT,,,,,,,,1082,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Tissue/Muscle/Bone,PX11044F,CDM,510,RC,11044,CPT,,,,,,,,1082,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Tissue/Muscle/Bone,PX11044F,CDM,510,RC,11044,CPT,,,,,,,,1082,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Tissue/Muscle/Bone,PX11044F,CDM,510,RC,11044,CPT,,,,,,,,1082,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Tissue/Muscle/Bone,PX11044F,CDM,510,RC,11044,CPT,,,,,,,,1082,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Tissue/Muscle/Bone,PX11044F,CDM,510,RC,11044,CPT,,,,,,,,1082,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Tissue/Muscle/Bone,PX11044P,CDM,983,RC,11044,CPT,,,,,,,,866,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Tissue/Muscle/Bone,PX11044P,CDM,983,RC,11044,CPT,,,,,,,,866,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Tissue/Muscle/Bone,PX11044P,CDM,983,RC,11044,CPT,,,,,,,,866,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Tissue/Muscle/Bone,PX11044P,CDM,983,RC,11044,CPT,,,,,,,,866,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Tissue/Muscle/Bone,PX11044P,CDM,983,RC,11044,CPT,,,,,,,,866,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Tissue/Muscle/Bone,PX11044P,CDM,983,RC,11044,CPT,,,,,,,,866,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Debridement of Nail(S), 1-5",PX11720F,CDM,510,RC,11720,CPT,,,,,,,,89,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Debridement of Nail(S), 1-5",PX11720F,CDM,510,RC,11720,CPT,,,,,,,,89,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Debridement of Nail(S), 1-5",PX11720F,CDM,510,RC,11720,CPT,,,,,,,,89,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Debridement of Nail(S), 1-5",PX11720F,CDM,510,RC,11720,CPT,,,,,,,,89,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Debridement of Nail(S), 1-5",PX11720F,CDM,510,RC,11720,CPT,,,,,,,,89,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Debridement of Nail(S), 1-5",PX11720F,CDM,510,RC,11720,CPT,,,,,,,,89,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Decalcify Tc,PX8831101,CDM,310,RC,88311,CPT,TC,,,,,,,107,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Decalcify Tc,PX8831101,CDM,310,RC,88311,CPT,TC,,,,,,,107,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Decalcify Tc,PX8831101,CDM,310,RC,88311,CPT,TC,,,,,,,107,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Decalcify Tc,PX8831101,CDM,310,RC,88311,CPT,TC,,,,,,,107,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Decalcify Tc,PX8831101,CDM,310,RC,88311,CPT,TC,,,,,,,107,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Decalcify Tc,PX8831101,CDM,310,RC,88311,CPT,TC,,,,,,,107,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Declot Vascular Access Device,PX36593F,CDM,510,RC,36593,CPT,,,,,,,,358,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Declot Vascular Access Device,PX36593F,CDM,510,RC,36593,CPT,,,,,,,,358,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Declot Vascular Access Device,PX36593F,CDM,510,RC,36593,CPT,,,,,,,,358,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Declot Vascular Access Device,PX36593F,CDM,510,RC,36593,CPT,,,,,,,,358,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Declot Vascular Access Device,PX36593F,CDM,510,RC,36593,CPT,,,,,,,,358,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Declot Vascular Access Device,PX36593F,CDM,510,RC,36593,CPT,,,,,,,,358,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DEFIBRILLATION PAD BIPHASIC ADULT,120.96,CDM,271,RC,A0392,HCPCS,,1321-MAIN,LOCAL,,,,,58,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DEFIBRILLATION PAD BIPHASIC ADULT,120.96,CDM,271,RC,A0392,HCPCS,,1321-MAIN,LOCAL,,,,,58,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DEFIBRILLATION PAD BIPHASIC ADULT,120.96,CDM,271,RC,A0392,HCPCS,,1321-MAIN,LOCAL,,,,,58,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DEFIBRILLATION PAD BIPHASIC ADULT,120.96,CDM,271,RC,A0392,HCPCS,,1321-MAIN,LOCAL,,,,,58,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DEFIBRILLATION PAD BIPHASIC ADULT,120.96,CDM,271,RC,A0392,HCPCS,,1321-MAIN,LOCAL,,,,,58,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DEFIBRILLATION PAD BIPHASIC ADULT,120.96,CDM,271,RC,A0392,HCPCS,,1321-MAIN,LOCAL,,,,,58,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DEFIBRILLATION PAD MULTI FUNCTION ADULT,120.58,CDM,271,RC,A0392,HCPCS,,1320-MAIN,LOCAL,,,,,94,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DEFIBRILLATION PAD MULTI FUNCTION ADULT,120.58,CDM,271,RC,A0392,HCPCS,,1320-MAIN,LOCAL,,,,,94,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DEFIBRILLATION PAD MULTI FUNCTION ADULT,120.58,CDM,271,RC,A0392,HCPCS,,1320-MAIN,LOCAL,,,,,94,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DEFIBRILLATION PAD MULTI FUNCTION ADULT,120.58,CDM,271,RC,A0392,HCPCS,,1320-MAIN,LOCAL,,,,,94,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DEFIBRILLATION PAD MULTI FUNCTION ADULT,120.58,CDM,271,RC,A0392,HCPCS,,1320-MAIN,LOCAL,,,,,94,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DEFIBRILLATION PAD MULTI FUNCTION ADULT,120.58,CDM,271,RC,A0392,HCPCS,,1320-MAIN,LOCAL,,,,,94,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DEFIBRILLATION PAD PEDI PADZ PEDS,120.58,CDM,271,RC,A0392,HCPCS,,1322-MAIN,LOCAL,,,,,94,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DEFIBRILLATION PAD PEDI PADZ PEDS,120.58,CDM,271,RC,A0392,HCPCS,,1322-MAIN,LOCAL,,,,,94,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DEFIBRILLATION PAD PEDI PADZ PEDS,120.58,CDM,271,RC,A0392,HCPCS,,1322-MAIN,LOCAL,,,,,94,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DEFIBRILLATION PAD PEDI PADZ PEDS,120.58,CDM,271,RC,A0392,HCPCS,,1322-MAIN,LOCAL,,,,,94,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DEFIBRILLATION PAD PEDI PADZ PEDS,120.58,CDM,271,RC,A0392,HCPCS,,1322-MAIN,LOCAL,,,,,94,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DEFIBRILLATION PAD PEDI PADZ PEDS,120.58,CDM,271,RC,A0392,HCPCS,,1322-MAIN,LOCAL,,,,,94,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
degarelix acetate 40 mg/mL Recon Soln 1 Each Vial,J9155.01,CDM,636,RC,J9155,HCPCS,,,,55566840301,NDC,2,EA,3109.33,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
degarelix acetate 40 mg/mL Recon Soln 1 Each Vial,J9155.01,CDM,636,RC,J9155,HCPCS,,,,55566840301,NDC,2,EA,3109.33,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
degarelix acetate 40 mg/mL Recon Soln 1 Each Vial,J9155.01,CDM,636,RC,J9155,HCPCS,,,,55566840301,NDC,2,EA,3109.33,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
degarelix acetate 40 mg/mL Recon Soln 1 Each Vial,J9155.01,CDM,636,RC,J9155,HCPCS,,,,55566840301,NDC,2,EA,3109.33,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
degarelix acetate 40 mg/mL Recon Soln 1 Each Vial,J9155.01,CDM,636,RC,J9155,HCPCS,,,,55566840301,NDC,2,EA,3109.33,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
degarelix acetate 40 mg/mL Recon Soln 1 Each Vial,J9155.01,CDM,636,RC,J9155,HCPCS,,,,55566840301,NDC,2,EA,3109.33,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
denosumab 120 MG/1.7ML Solution 1.7 mL Vial,J0897.01,CDM,636,RC,J0897,HCPCS,,,,55513073001,NDC,1.7,ML,4658.83,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
denosumab 120 MG/1.7ML Solution 1.7 mL Vial,J0897.01,CDM,636,RC,J0897,HCPCS,,,,55513073001,NDC,1.7,ML,4658.83,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
denosumab 120 MG/1.7ML Solution 1.7 mL Vial,J0897.01,CDM,636,RC,J0897,HCPCS,,,,55513073001,NDC,1.7,ML,4658.83,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
denosumab 120 MG/1.7ML Solution 1.7 mL Vial,J0897.01,CDM,636,RC,J0897,HCPCS,,,,55513073001,NDC,1.7,ML,4658.83,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
denosumab 120 MG/1.7ML Solution 1.7 mL Vial,J0897.01,CDM,636,RC,J0897,HCPCS,,,,55513073001,NDC,1.7,ML,4658.83,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
denosumab 120 MG/1.7ML Solution 1.7 mL Vial,J0897.01,CDM,636,RC,J0897,HCPCS,,,,55513073001,NDC,1.7,ML,4658.83,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Deoxyribonuclease Ab,PX86215,CDM,300,RC,86215,CPT,,,,,,,,99,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Deoxyribonuclease Ab,PX86215,CDM,300,RC,86215,CPT,,,,,,,,99,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Deoxyribonuclease Ab,PX86215,CDM,300,RC,86215,CPT,,,,,,,,99,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Deoxyribonuclease Ab,PX86215,CDM,300,RC,86215,CPT,,,,,,,,99,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Deoxyribonuclease Ab,PX86215,CDM,300,RC,86215,CPT,,,,,,,,99,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Deoxyribonuclease Ab,PX86215,CDM,300,RC,86215,CPT,,,,,,,,99,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DERMABOND ADVANCED TOPICAL SKIN ADHESIVE,120.198,CDM,272,RC,,,,9101-MAIN,LOCAL,,,,,46,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DERMABOND ADVANCED TOPICAL SKIN ADHESIVE,120.198,CDM,272,RC,,,,9101-MAIN,LOCAL,,,,,46,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DERMABOND ADVANCED TOPICAL SKIN ADHESIVE,120.198,CDM,272,RC,,,,9101-MAIN,LOCAL,,,,,46,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DERMABOND ADVANCED TOPICAL SKIN ADHESIVE,120.198,CDM,272,RC,,,,9101-MAIN,LOCAL,,,,,46,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DERMABOND ADVANCED TOPICAL SKIN ADHESIVE,120.198,CDM,272,RC,,,,9101-MAIN,LOCAL,,,,,46,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DERMABOND ADVANCED TOPICAL SKIN ADHESIVE,120.198,CDM,272,RC,,,,9101-MAIN,LOCAL,,,,,46,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DERMABOND MINI SKIN ADHESIVE,27200000,CDM,272,RC,,,,8532-MAIN,LOCAL,,,,,110.16,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DERMABOND MINI SKIN ADHESIVE,27200000,CDM,272,RC,,,,8532-MAIN,LOCAL,,,,,110.16,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DERMABOND MINI SKIN ADHESIVE,27200000,CDM,272,RC,,,,8532-MAIN,LOCAL,,,,,110.16,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DERMABOND MINI SKIN ADHESIVE,27200000,CDM,272,RC,,,,8532-MAIN,LOCAL,,,,,110.16,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DERMABOND MINI SKIN ADHESIVE,27200000,CDM,272,RC,,,,8532-MAIN,LOCAL,,,,,110.16,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DERMABOND MINI SKIN ADHESIVE,27200000,CDM,272,RC,,,,8532-MAIN,LOCAL,,,,,110.16,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DERMABOND PRINEO SKIN CLOSURE SYSTEM 22CM,27200000,CDM,272,RC,,,,12324-MAIN,LOCAL,,,,,156,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DERMABOND PRINEO SKIN CLOSURE SYSTEM 22CM,27200000,CDM,272,RC,,,,12324-MAIN,LOCAL,,,,,156,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DERMABOND PRINEO SKIN CLOSURE SYSTEM 22CM,27200000,CDM,272,RC,,,,12324-MAIN,LOCAL,,,,,156,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DERMABOND PRINEO SKIN CLOSURE SYSTEM 22CM,27200000,CDM,272,RC,,,,12324-MAIN,LOCAL,,,,,156,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DERMABOND PRINEO SKIN CLOSURE SYSTEM 22CM,27200000,CDM,272,RC,,,,12324-MAIN,LOCAL,,,,,156,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DERMABOND PRINEO SKIN CLOSURE SYSTEM 22CM,27200000,CDM,272,RC,,,,12324-MAIN,LOCAL,,,,,156,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DERMABOND PRINEO SKIN CLOSURE SYSTEM 42CM,27200000,CDM,272,RC,,,,12323-MAIN,LOCAL,,,,,200,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DERMABOND PRINEO SKIN CLOSURE SYSTEM 42CM,27200000,CDM,272,RC,,,,12323-MAIN,LOCAL,,,,,200,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DERMABOND PRINEO SKIN CLOSURE SYSTEM 42CM,27200000,CDM,272,RC,,,,12323-MAIN,LOCAL,,,,,200,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DERMABOND PRINEO SKIN CLOSURE SYSTEM 42CM,27200000,CDM,272,RC,,,,12323-MAIN,LOCAL,,,,,200,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DERMABOND PRINEO SKIN CLOSURE SYSTEM 42CM,27200000,CDM,272,RC,,,,12323-MAIN,LOCAL,,,,,200,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DERMABOND PRINEO SKIN CLOSURE SYSTEM 42CM,27200000,CDM,272,RC,,,,12323-MAIN,LOCAL,,,,,200,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DERMAL TIP HYFRECATOR SHARP ANGLED STAINLESS STEEL BLADE STERILE DISPOSABLE,27200000,CDM,272,RC,,,,12459-MAIN,LOCAL,,,,,7,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DERMAL TIP HYFRECATOR SHARP ANGLED STAINLESS STEEL BLADE STERILE DISPOSABLE,27200000,CDM,272,RC,,,,12459-MAIN,LOCAL,,,,,7,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DERMAL TIP HYFRECATOR SHARP ANGLED STAINLESS STEEL BLADE STERILE DISPOSABLE,27200000,CDM,272,RC,,,,12459-MAIN,LOCAL,,,,,7,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DERMAL TIP HYFRECATOR SHARP ANGLED STAINLESS STEEL BLADE STERILE DISPOSABLE,27200000,CDM,272,RC,,,,12459-MAIN,LOCAL,,,,,7,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DERMAL TIP HYFRECATOR SHARP ANGLED STAINLESS STEEL BLADE STERILE DISPOSABLE,27200000,CDM,272,RC,,,,12459-MAIN,LOCAL,,,,,7,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DERMAL TIP HYFRECATOR SHARP ANGLED STAINLESS STEEL BLADE STERILE DISPOSABLE,27200000,CDM,272,RC,,,,12459-MAIN,LOCAL,,,,,7,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
desflurane Solution 240 mL Bottle,25000000,CDM,250,RC,,,,,,10019064134,NDC,240,ML,793.95,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
desflurane Solution 240 mL Bottle,25000000,CDM,250,RC,,,,,,10019064134,NDC,240,ML,793.95,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
desflurane Solution 240 mL Bottle,25000000,CDM,250,RC,,,,,,10019064134,NDC,240,ML,793.95,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
desflurane Solution 240 mL Bottle,25000000,CDM,250,RC,,,,,,10019064134,NDC,240,ML,793.95,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
desflurane Solution 240 mL Bottle,25000000,CDM,250,RC,,,,,,10019064134,NDC,240,ML,793.95,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
desflurane Solution 240 mL Bottle,25000000,CDM,250,RC,,,,,,10019064134,NDC,240,ML,793.95,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
desipramine 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50742011401,NDC,0.2,EA,4.05,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
desipramine 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50742011401,NDC,0.2,EA,4.05,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
desipramine 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50742011401,NDC,0.2,EA,4.05,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
desipramine 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50742011401,NDC,0.2,EA,4.05,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
desipramine 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50742011401,NDC,0.2,EA,4.05,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
desipramine 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50742011401,NDC,0.2,EA,4.05,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089901,NDC,0.25,ML,95.31,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089901,NDC,0.25,ML,95.31,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089901,NDC,0.25,ML,95.31,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089901,NDC,0.25,ML,95.31,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089901,NDC,0.25,ML,95.31,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089901,NDC,0.25,ML,95.31,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089910,NDC,0.25,ML,95.31,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089910,NDC,0.25,ML,95.31,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089910,NDC,0.25,ML,95.31,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089910,NDC,0.25,ML,95.31,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089910,NDC,0.25,ML,95.31,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089910,NDC,0.25,ML,95.31,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Destruct Benign Lesion, 1-14",PX17110F,CDM,510,RC,17110,CPT,,,,,,,,302,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Destruct Benign Lesion, 1-14",PX17110F,CDM,510,RC,17110,CPT,,,,,,,,302,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Destruct Benign Lesion, 1-14",PX17110F,CDM,510,RC,17110,CPT,,,,,,,,302,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Destruct Benign Lesion, 1-14",PX17110F,CDM,510,RC,17110,CPT,,,,,,,,302,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Destruct Benign Lesion, 1-14",PX17110F,CDM,510,RC,17110,CPT,,,,,,,,302,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Destruct Benign Lesion, 1-14",PX17110F,CDM,510,RC,17110,CPT,,,,,,,,302,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Destruct Benign Lesion, 1-14",PX17110P,CDM,983,RC,17110,CPT,,,,,,,,521,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Destruct Benign Lesion, 1-14",PX17110P,CDM,983,RC,17110,CPT,,,,,,,,521,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Destruct Benign Lesion, 1-14",PX17110P,CDM,983,RC,17110,CPT,,,,,,,,521,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Destruct Benign Lesion, 1-14",PX17110P,CDM,983,RC,17110,CPT,,,,,,,,521,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Destruct Benign Lesion, 1-14",PX17110P,CDM,983,RC,17110,CPT,,,,,,,,521,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Destruct Benign Lesion, 1-14",PX17110P,CDM,983,RC,17110,CPT,,,,,,,,521,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Destruct Benign Lesion, 15+",PX17111F,CDM,510,RC,17111,CPT,,,,,,,,303,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Destruct Benign Lesion, 15+",PX17111F,CDM,510,RC,17111,CPT,,,,,,,,303,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Destruct Benign Lesion, 15+",PX17111F,CDM,510,RC,17111,CPT,,,,,,,,303,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Destruct Benign Lesion, 15+",PX17111F,CDM,510,RC,17111,CPT,,,,,,,,303,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Destruct Benign Lesion, 15+",PX17111F,CDM,510,RC,17111,CPT,,,,,,,,303,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Destruct Benign Lesion, 15+",PX17111F,CDM,510,RC,17111,CPT,,,,,,,,303,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Detect Agent Nos Dna Amp,PX87798,CDM,300,RC,87798,CPT,,,,,,,,176,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Detect Agent Nos Dna Amp,PX87798,CDM,300,RC,87798,CPT,,,,,,,,176,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Detect Agent Nos Dna Amp,PX87798,CDM,300,RC,87798,CPT,,,,,,,,176,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Detect Agent Nos Dna Amp,PX87798,CDM,300,RC,87798,CPT,,,,,,,,176,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Detect Agent Nos Dna Amp,PX87798,CDM,300,RC,87798,CPT,,,,,,,,176,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Detect Agent Nos Dna Amp,PX87798,CDM,300,RC,87798,CPT,,,,,,,,176,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Detection of Anaplasma Phagocytophilum by Amplified Nucleic Acid Probe Technique,PX8746890,CDM,300,RC,87468,CPT,90,,,,,,,41,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Detection of Anaplasma Phagocytophilum by Amplified Nucleic Acid Probe Technique,PX8746890,CDM,300,RC,87468,CPT,90,,,,,,,41,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Detection of Anaplasma Phagocytophilum by Amplified Nucleic Acid Probe Technique,PX8746890,CDM,300,RC,87468,CPT,90,,,,,,,41,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Detection of Anaplasma Phagocytophilum by Amplified Nucleic Acid Probe Technique,PX8746890,CDM,300,RC,87468,CPT,90,,,,,,,41,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Detection of Anaplasma Phagocytophilum by Amplified Nucleic Acid Probe Technique,PX8746890,CDM,300,RC,87468,CPT,90,,,,,,,41,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Detection of Anaplasma Phagocytophilum by Amplified Nucleic Acid Probe Technique,PX8746890,CDM,300,RC,87468,CPT,90,,,,,,,41,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Detection of Babesia Borrelia Miyamotoi by Amplified Nucleic Acid Probe Technique,PX8747890,CDM,300,RC,87478,CPT,90,,,,,,,23,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Detection of Babesia Borrelia Miyamotoi by Amplified Nucleic Acid Probe Technique,PX8747890,CDM,300,RC,87478,CPT,90,,,,,,,23,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Detection of Babesia Borrelia Miyamotoi by Amplified Nucleic Acid Probe Technique,PX8747890,CDM,300,RC,87478,CPT,90,,,,,,,23,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Detection of Babesia Borrelia Miyamotoi by Amplified Nucleic Acid Probe Technique,PX8747890,CDM,300,RC,87478,CPT,90,,,,,,,23,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Detection of Babesia Borrelia Miyamotoi by Amplified Nucleic Acid Probe Technique,PX8747890,CDM,300,RC,87478,CPT,90,,,,,,,23,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Detection of Babesia Borrelia Miyamotoi by Amplified Nucleic Acid Probe Technique,PX8747890,CDM,300,RC,87478,CPT,90,,,,,,,23,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Detection of Babesia Microtim by Amplified Nucleic Acid Probe Technique,PX8746990,CDM,300,RC,87469,CPT,90,,,,,,,23,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Detection of Babesia Microtim by Amplified Nucleic Acid Probe Technique,PX8746990,CDM,300,RC,87469,CPT,90,,,,,,,23,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Detection of Babesia Microtim by Amplified Nucleic Acid Probe Technique,PX8746990,CDM,300,RC,87469,CPT,90,,,,,,,23,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Detection of Babesia Microtim by Amplified Nucleic Acid Probe Technique,PX8746990,CDM,300,RC,87469,CPT,90,,,,,,,23,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Detection of Babesia Microtim by Amplified Nucleic Acid Probe Technique,PX8746990,CDM,300,RC,87469,CPT,90,,,,,,,23,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Detection of Babesia Microtim by Amplified Nucleic Acid Probe Technique,PX8746990,CDM,300,RC,87469,CPT,90,,,,,,,23,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Detection of Ehrlichia Chaffeensis by Amplified Nucleic Acid Probe Technique,PX8748490,CDM,300,RC,87484,CPT,90,,,,,,,41,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Detection of Ehrlichia Chaffeensis by Amplified Nucleic Acid Probe Technique,PX8748490,CDM,300,RC,87484,CPT,90,,,,,,,41,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Detection of Ehrlichia Chaffeensis by Amplified Nucleic Acid Probe Technique,PX8748490,CDM,300,RC,87484,CPT,90,,,,,,,41,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Detection of Ehrlichia Chaffeensis by Amplified Nucleic Acid Probe Technique,PX8748490,CDM,300,RC,87484,CPT,90,,,,,,,41,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Detection of Ehrlichia Chaffeensis by Amplified Nucleic Acid Probe Technique,PX8748490,CDM,300,RC,87484,CPT,90,,,,,,,41,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Detection of Ehrlichia Chaffeensis by Amplified Nucleic Acid Probe Technique,PX8748490,CDM,300,RC,87484,CPT,90,,,,,,,41,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 0.1 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,24208072002,NDC,5,ML,331.81,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 0.1 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,24208072002,NDC,5,ML,331.81,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 0.1 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,24208072002,NDC,5,ML,331.81,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 0.1 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,24208072002,NDC,5,ML,331.81,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 0.1 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,24208072002,NDC,5,ML,331.81,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 0.1 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,24208072002,NDC,5,ML,331.81,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54417925,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54417925,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54417925,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54417925,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54417925,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54417925,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54817925,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54817925,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54817925,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54817925,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54817925,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54817925,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 1 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,54317644,NDC,0.5,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 1 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,54317644,NDC,0.5,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 1 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,54317644,NDC,0.5,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 1 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,54317644,NDC,0.5,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 1 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,54317644,NDC,0.5,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 1 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,54317644,NDC,0.5,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54817625,NDC,0.125,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54817625,NDC,0.125,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54817625,NDC,0.125,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54817625,NDC,0.125,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54817625,NDC,0.125,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54817625,NDC,0.125,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016501,NDC,1,ML,34.55,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016501,NDC,1,ML,34.55,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016501,NDC,1,ML,34.55,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016501,NDC,1,ML,34.55,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016501,NDC,1,ML,34.55,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016501,NDC,1,ML,34.55,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016502,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016502,NDC,0.5,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016502,NDC,0.5,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016502,NDC,0.5,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016502,NDC,0.5,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016502,NDC,0.5,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016516,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016516,NDC,0.5,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016516,NDC,0.5,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016516,NDC,0.5,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016516,NDC,0.5,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016516,NDC,0.5,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 6 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54418625,NDC,0.041666667,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 6 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54418625,NDC,0.041666667,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 6 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54418625,NDC,0.041666667,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 6 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54418625,NDC,0.041666667,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 6 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54418625,NDC,0.041666667,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 6 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54418625,NDC,0.041666667,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036721,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036721,NDC,1,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036721,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036721,NDC,1,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036721,NDC,1,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036721,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036725,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036725,NDC,1,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036725,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036725,NDC,1,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036725,NDC,1,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036725,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 100 MG/10ML Solution 10 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323051610,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 100 MG/10ML Solution 10 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323051610,NDC,0.5,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 100 MG/10ML Solution 10 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323051610,NDC,0.5,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 100 MG/10ML Solution 10 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323051610,NDC,0.5,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 100 MG/10ML Solution 10 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323051610,NDC,0.5,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 100 MG/10ML Solution 10 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323051610,NDC,0.5,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050601,NDC,1,ML,68.33,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050601,NDC,1,ML,68.33,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050601,NDC,1,ML,68.33,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050601,NDC,1,ML,68.33,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050601,NDC,1,ML,68.33,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050601,NDC,1,ML,68.33,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050641,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050641,NDC,0.5,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050641,NDC,0.5,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050641,NDC,0.5,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050641,NDC,0.5,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050641,NDC,0.5,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexmedeTOMIDine 200 MCG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,143953201,NDC,2,ML,62.98,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexmedeTOMIDine 200 MCG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,143953201,NDC,2,ML,62.98,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexmedeTOMIDine 200 MCG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,143953201,NDC,2,ML,62.98,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexmedeTOMIDine 200 MCG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,143953201,NDC,2,ML,62.98,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexmedeTOMIDine 200 MCG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,143953201,NDC,2,ML,62.98,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexmedeTOMIDine 200 MCG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,143953201,NDC,2,ML,62.98,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexmedeTOMIDine 200 MCG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,70860060541,NDC,2,ML,55.82,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexmedeTOMIDine 200 MCG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,70860060541,NDC,2,ML,55.82,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexmedeTOMIDine 200 MCG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,70860060541,NDC,2,ML,55.82,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexmedeTOMIDine 200 MCG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,70860060541,NDC,2,ML,55.82,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexmedeTOMIDine 200 MCG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,70860060541,NDC,2,ML,55.82,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexmedeTOMIDine 200 MCG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,70860060541,NDC,2,ML,55.82,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexmedeTOMIDine in  dextrose 200MCG/50ML -5% Solution 50 mL Flex Cont,25000000,CDM,250,RC,,,,,,44567060224,NDC,50,ML,258.31,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexmedeTOMIDine in  dextrose 200MCG/50ML -5% Solution 50 mL Flex Cont,25000000,CDM,250,RC,,,,,,44567060224,NDC,50,ML,258.31,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexmedeTOMIDine in  dextrose 200MCG/50ML -5% Solution 50 mL Flex Cont,25000000,CDM,250,RC,,,,,,44567060224,NDC,50,ML,258.31,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexmedeTOMIDine in  dextrose 200MCG/50ML -5% Solution 50 mL Flex Cont,25000000,CDM,250,RC,,,,,,44567060224,NDC,50,ML,258.31,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexmedeTOMIDine in  dextrose 200MCG/50ML -5% Solution 50 mL Flex Cont,25000000,CDM,250,RC,,,,,,44567060224,NDC,50,ML,258.31,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexmedeTOMIDine in  dextrose 200MCG/50ML -5% Solution 50 mL Flex Cont,25000000,CDM,250,RC,,,,,,44567060224,NDC,50,ML,258.31,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexmedeTOMIDine in sodium chloride 200 MCG/50ML Solution 50 mL Flex Cont,25000000,CDM,250,RC,,,,,,338955524,NDC,50,ML,304.32,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexmedeTOMIDine in sodium chloride 200 MCG/50ML Solution 50 mL Flex Cont,25000000,CDM,250,RC,,,,,,338955524,NDC,50,ML,304.32,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexmedeTOMIDine in sodium chloride 200 MCG/50ML Solution 50 mL Flex Cont,25000000,CDM,250,RC,,,,,,338955524,NDC,50,ML,304.32,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexmedeTOMIDine in sodium chloride 200 MCG/50ML Solution 50 mL Flex Cont,25000000,CDM,250,RC,,,,,,338955524,NDC,50,ML,304.32,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexmedeTOMIDine in sodium chloride 200 MCG/50ML Solution 50 mL Flex Cont,25000000,CDM,250,RC,,,,,,338955524,NDC,50,ML,304.32,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexmedeTOMIDine in sodium chloride 200 MCG/50ML Solution 50 mL Flex Cont,25000000,CDM,250,RC,,,,,,338955524,NDC,50,ML,304.32,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexmedeTOMIDine in sodium chloride 400 MCG/100ML Solution 100 mL Bottle,25000000,CDM,250,RC,,,,,,67457092500,NDC,100,ML,562.18,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexmedeTOMIDine in sodium chloride 400 MCG/100ML Solution 100 mL Bottle,25000000,CDM,250,RC,,,,,,67457092500,NDC,100,ML,562.18,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexmedeTOMIDine in sodium chloride 400 MCG/100ML Solution 100 mL Bottle,25000000,CDM,250,RC,,,,,,67457092500,NDC,100,ML,562.18,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexmedeTOMIDine in sodium chloride 400 MCG/100ML Solution 100 mL Bottle,25000000,CDM,250,RC,,,,,,67457092500,NDC,100,ML,562.18,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexmedeTOMIDine in sodium chloride 400 MCG/100ML Solution 100 mL Bottle,25000000,CDM,250,RC,,,,,,67457092500,NDC,100,ML,562.18,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexmedeTOMIDine in sodium chloride 400 MCG/100ML Solution 100 mL Bottle,25000000,CDM,250,RC,,,,,,67457092500,NDC,100,ML,562.18,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextran 70, glycerin, hypromellose 0.1-0.2-0.3 % Solution 15 mL Bottle",63700001,CDM,250,RC,,,,,,65042636,NDC,15,ML,44.14,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextran 70, glycerin, hypromellose 0.1-0.2-0.3 % Solution 15 mL Bottle",63700001,CDM,250,RC,,,,,,65042636,NDC,15,ML,44.14,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextran 70, glycerin, hypromellose 0.1-0.2-0.3 % Solution 15 mL Bottle",63700001,CDM,250,RC,,,,,,65042636,NDC,15,ML,44.14,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextran 70, glycerin, hypromellose 0.1-0.2-0.3 % Solution 15 mL Bottle",63700001,CDM,250,RC,,,,,,65042636,NDC,15,ML,44.14,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextran 70, glycerin, hypromellose 0.1-0.2-0.3 % Solution 15 mL Bottle",63700001,CDM,250,RC,,,,,,65042636,NDC,15,ML,44.14,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextran 70, glycerin, hypromellose 0.1-0.2-0.3 % Solution 15 mL Bottle",63700001,CDM,250,RC,,,,,,65042636,NDC,15,ML,44.14,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextromethorphan-guaiFENesin 20-200 MG/20ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904722320,NDC,118,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextromethorphan-guaiFENesin 20-200 MG/20ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904722320,NDC,118,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextromethorphan-guaiFENesin 20-200 MG/20ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904722320,NDC,118,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextromethorphan-guaiFENesin 20-200 MG/20ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904722320,NDC,118,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextromethorphan-guaiFENesin 20-200 MG/20ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904722320,NDC,118,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextromethorphan-guaiFENesin 20-200 MG/20ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904722320,NDC,118,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5 % 5 % Solution 1,000 mL Flex Cont",J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001704,NDC,1000,ML,99.12,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5 % 5 % Solution 1,000 mL Flex Cont",J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001704,NDC,1000,ML,99.12,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5 % 5 % Solution 1,000 mL Flex Cont",J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001704,NDC,1000,ML,99.12,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5 % 5 % Solution 1,000 mL Flex Cont",J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001704,NDC,1000,ML,99.12,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5 % 5 % Solution 1,000 mL Flex Cont",J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001704,NDC,1000,ML,99.12,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5 % 5 % Solution 1,000 mL Flex Cont",J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001704,NDC,1000,ML,99.12,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5 % 5 % Solution 50 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338055111,NDC,50,ML,43.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5 % 5 % Solution 50 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338055111,NDC,50,ML,43.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5 % 5 % Solution 50 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338055111,NDC,50,ML,43.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5 % 5 % Solution 50 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338055111,NDC,50,ML,43.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5 % 5 % Solution 50 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338055111,NDC,50,ML,43.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5 % 5 % Solution 50 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338055111,NDC,50,ML,43.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5 % 5 % Solution 100 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001748,NDC,100,ML,43.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5 % 5 % Solution 100 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001748,NDC,100,ML,43.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5 % 5 % Solution 100 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001748,NDC,100,ML,43.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5 % 5 % Solution 100 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001748,NDC,100,ML,43.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5 % 5 % Solution 100 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001748,NDC,100,ML,43.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5 % 5 % Solution 100 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001748,NDC,100,ML,43.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001702,NDC,250,ML,99.12,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001702,NDC,250,ML,99.12,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001702,NDC,250,ML,99.12,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001702,NDC,250,ML,99.12,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001702,NDC,250,ML,99.12,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001702,NDC,250,ML,99.12,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338634602,NDC,250,ML,99.12,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338634602,NDC,250,ML,99.12,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338634602,NDC,250,ML,99.12,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338634602,NDC,250,ML,99.12,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338634602,NDC,250,ML,99.12,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338634602,NDC,250,ML,99.12,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5 % 5 % Solution 500 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001703,NDC,500,ML,99.12,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5 % 5 % Solution 500 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001703,NDC,500,ML,99.12,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5 % 5 % Solution 500 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001703,NDC,500,ML,99.12,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5 % 5 % Solution 500 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001703,NDC,500,ML,99.12,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5 % 5 % Solution 500 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001703,NDC,500,ML,99.12,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5 % 5 % Solution 500 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001703,NDC,500,ML,99.12,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338080304,NDC,1000,ML,69.59,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338080304,NDC,1000,ML,69.59,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338080304,NDC,1000,ML,69.59,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338080304,NDC,1000,ML,69.59,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338080304,NDC,1000,ML,69.59,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338080304,NDC,1000,ML,69.59,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,409710709,NDC,1000,ML,36.53,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,409710709,NDC,1000,ML,36.53,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,409710709,NDC,1000,ML,36.53,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,409710709,NDC,1000,ML,36.53,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,409710709,NDC,1000,ML,36.53,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,409710709,NDC,1000,ML,36.53,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990710709,NDC,1000,ML,69.59,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990710709,NDC,1000,ML,69.59,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990710709,NDC,1000,ML,69.59,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990710709,NDC,1000,ML,69.59,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990710709,NDC,1000,ML,69.59,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990710709,NDC,1000,ML,69.59,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5 % Non-DEHP bag 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,264751020,NDC,250,ML,99.12,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5 % Non-DEHP bag 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,264751020,NDC,250,ML,99.12,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5 % Non-DEHP bag 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,264751020,NDC,250,ML,99.12,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5 % Non-DEHP bag 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,264751020,NDC,250,ML,99.12,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5 % Non-DEHP bag 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,264751020,NDC,250,ML,99.12,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5 % Non-DEHP bag 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,264751020,NDC,250,ML,99.12,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% and sodium chloride 0.2% 5-0.2 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338007704,NDC,1000,ML,99.12,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% and sodium chloride 0.2% 5-0.2 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338007704,NDC,1000,ML,99.12,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% and sodium chloride 0.2% 5-0.2 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338007704,NDC,1000,ML,99.12,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% and sodium chloride 0.2% 5-0.2 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338007704,NDC,1000,ML,99.12,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% and sodium chloride 0.2% 5-0.2 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338007704,NDC,1000,ML,99.12,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% and sodium chloride 0.2% 5-0.2 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338007704,NDC,1000,ML,99.12,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008904,NDC,1000,ML,99.12,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008904,NDC,1000,ML,99.12,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008904,NDC,1000,ML,99.12,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008904,NDC,1000,ML,99.12,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008904,NDC,1000,ML,99.12,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008904,NDC,1000,ML,99.12,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 500 mL Flex Cont,J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008903,NDC,500,ML,99.12,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 500 mL Flex Cont,J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008903,NDC,500,ML,99.12,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 500 mL Flex Cont,J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008903,NDC,500,ML,99.12,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 500 mL Flex Cont,J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008903,NDC,500,ML,99.12,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 500 mL Flex Cont,J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008903,NDC,500,ML,99.12,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 500 mL Flex Cont,J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008903,NDC,500,ML,99.12,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% and sodium chloride 0.45% 5-0.45 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008504,NDC,1000,ML,99.12,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% and sodium chloride 0.45% 5-0.45 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008504,NDC,1000,ML,99.12,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% and sodium chloride 0.45% 5-0.45 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008504,NDC,1000,ML,99.12,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% and sodium chloride 0.45% 5-0.45 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008504,NDC,1000,ML,99.12,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% and sodium chloride 0.45% 5-0.45 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008504,NDC,1000,ML,99.12,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% and sodium chloride 0.45% 5-0.45 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008504,NDC,1000,ML,99.12,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% and sodium chloride 0.45% with potassium chloride 10 mEq in 1000 mL 10-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,264763400,NDC,1000,ML,36.53,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% and sodium chloride 0.45% with potassium chloride 10 mEq in 1000 mL 10-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,264763400,NDC,1000,ML,36.53,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% and sodium chloride 0.45% with potassium chloride 10 mEq in 1000 mL 10-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,264763400,NDC,1000,ML,36.53,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% and sodium chloride 0.45% with potassium chloride 10 mEq in 1000 mL 10-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,264763400,NDC,1000,ML,36.53,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% and sodium chloride 0.45% with potassium chloride 10 mEq in 1000 mL 10-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,264763400,NDC,1000,ML,36.53,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% and sodium chloride 0.45% with potassium chloride 10 mEq in 1000 mL 10-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,264763400,NDC,1000,ML,36.53,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% and sodium chloride 0.45% with potassium chloride 10 mEq in 1000 mL 10-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,338066904,NDC,1000,ML,80.61,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% and sodium chloride 0.45% with potassium chloride 10 mEq in 1000 mL 10-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,338066904,NDC,1000,ML,80.61,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% and sodium chloride 0.45% with potassium chloride 10 mEq in 1000 mL 10-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,338066904,NDC,1000,ML,80.61,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% and sodium chloride 0.45% with potassium chloride 10 mEq in 1000 mL 10-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,338066904,NDC,1000,ML,80.61,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% and sodium chloride 0.45% with potassium chloride 10 mEq in 1000 mL 10-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,338066904,NDC,1000,ML,80.61,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% and sodium chloride 0.45% with potassium chloride 10 mEq in 1000 mL 10-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,338066904,NDC,1000,ML,80.61,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,264763500,NDC,1000,ML,43.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,264763500,NDC,1000,ML,43.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,264763500,NDC,1000,ML,43.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,264763500,NDC,1000,ML,43.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,264763500,NDC,1000,ML,43.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,264763500,NDC,1000,ML,43.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338067104,NDC,1000,ML,53.06,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338067104,NDC,1000,ML,53.06,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338067104,NDC,1000,ML,53.06,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338067104,NDC,1000,ML,53.06,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338067104,NDC,1000,ML,53.06,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338067104,NDC,1000,ML,53.06,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% lactated ringers 5 % Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012504,NDC,1000,ML,43.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% lactated ringers 5 % Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012504,NDC,1000,ML,43.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% lactated ringers 5 % Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012504,NDC,1000,ML,43.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% lactated ringers 5 % Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012504,NDC,1000,ML,43.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% lactated ringers 5 % Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012504,NDC,1000,ML,43.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% lactated ringers 5 % Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012504,NDC,1000,ML,43.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5% lactated ringers 5 % Solution 500 mL Flex Cont,J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012503,NDC,500,ML,99.12,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5% lactated ringers 5 % Solution 500 mL Flex Cont,J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012503,NDC,500,ML,99.12,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5% lactated ringers 5 % Solution 500 mL Flex Cont,J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012503,NDC,500,ML,99.12,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5% lactated ringers 5 % Solution 500 mL Flex Cont,J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012503,NDC,500,ML,99.12,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5% lactated ringers 5 % Solution 500 mL Flex Cont,J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012503,NDC,500,ML,99.12,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5% lactated ringers 5 % Solution 500 mL Flex Cont,J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012503,NDC,500,ML,99.12,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 10% 10 % Solution 500 mL Flex Cont,25000000,CDM,250,RC,,,,,,338002303,NDC,500,ML,99.12,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 10% 10 % Solution 500 mL Flex Cont,25000000,CDM,250,RC,,,,,,338002303,NDC,500,ML,99.12,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 10% 10 % Solution 500 mL Flex Cont,25000000,CDM,250,RC,,,,,,338002303,NDC,500,ML,99.12,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 10% 10 % Solution 500 mL Flex Cont,25000000,CDM,250,RC,,,,,,338002303,NDC,500,ML,99.12,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 10% 10 % Solution 500 mL Flex Cont,25000000,CDM,250,RC,,,,,,338002303,NDC,500,ML,99.12,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 10% 10 % Solution 500 mL Flex Cont,25000000,CDM,250,RC,,,,,,338002303,NDC,500,ML,99.12,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 25% Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409177510,NDC,10,ML,83.53,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 25% Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409177510,NDC,10,ML,83.53,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 25% Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409177510,NDC,10,ML,83.53,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 25% Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409177510,NDC,10,ML,83.53,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 25% Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409177510,NDC,10,ML,83.53,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 25% Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409177510,NDC,10,ML,83.53,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409751716,NDC,50,ML,72.9,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409751716,NDC,50,ML,72.9,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409751716,NDC,50,ML,72.9,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409751716,NDC,50,ML,72.9,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409751716,NDC,50,ML,72.9,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409751716,NDC,50,ML,72.9,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409751766,NDC,50,ML,80.89,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409751766,NDC,50,ML,80.89,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409751766,NDC,50,ML,80.89,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409751766,NDC,50,ML,80.89,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409751766,NDC,50,ML,80.89,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409751766,NDC,50,ML,80.89,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329330101,NDC,50,ML,107.61,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329330101,NDC,50,ML,107.61,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329330101,NDC,50,ML,107.61,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329330101,NDC,50,ML,107.61,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329330101,NDC,50,ML,107.61,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329330101,NDC,50,ML,107.61,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329330201,NDC,25,ML,43.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329330201,NDC,25,ML,43.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329330201,NDC,25,ML,43.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329330201,NDC,25,ML,43.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329330201,NDC,25,ML,43.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329330201,NDC,25,ML,43.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dhea-S - Ref,PX8262790,CDM,300,RC,82627,CPT,90,,,,,,,57,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dhea-S - Ref,PX8262790,CDM,300,RC,82627,CPT,90,,,,,,,57,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dhea-S - Ref,PX8262790,CDM,300,RC,82627,CPT,90,,,,,,,57,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dhea-S - Ref,PX8262790,CDM,300,RC,82627,CPT,90,,,,,,,57,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dhea-S - Ref,PX8262790,CDM,300,RC,82627,CPT,90,,,,,,,57,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dhea-S - Ref,PX8262790,CDM,300,RC,82627,CPT,90,,,,,,,57,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Diagnostic Anoscopy,PX46600F,CDM,510,RC,46600,CPT,,,,,,,,505,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Diagnostic Anoscopy,PX46600F,CDM,510,RC,46600,CPT,,,,,,,,505,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Diagnostic Anoscopy,PX46600F,CDM,510,RC,46600,CPT,,,,,,,,505,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Diagnostic Anoscopy,PX46600F,CDM,510,RC,46600,CPT,,,,,,,,505,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Diagnostic Anoscopy,PX46600F,CDM,510,RC,46600,CPT,,,,,,,,505,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Diagnostic Anoscopy,PX46600F,CDM,510,RC,46600,CPT,,,,,,,,505,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Diagnostic Anoscopy,PX46600P,CDM,983,RC,46600,CPT,,,,,,,,405,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Diagnostic Anoscopy,PX46600P,CDM,983,RC,46600,CPT,,,,,,,,405,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Diagnostic Anoscopy,PX46600P,CDM,983,RC,46600,CPT,,,,,,,,405,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Diagnostic Anoscopy,PX46600P,CDM,983,RC,46600,CPT,,,,,,,,405,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Diagnostic Anoscopy,PX46600P,CDM,983,RC,46600,CPT,,,,,,,,405,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Diagnostic Anoscopy,PX46600P,CDM,983,RC,46600,CPT,,,,,,,,405,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Diagnostic Bone Marrow, Biopsy and Aspiration",PX38222F,CDM,761,RC,38222,CPT,,,,,,,,1748,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Diagnostic Bone Marrow, Biopsy and Aspiration",PX38222F,CDM,761,RC,38222,CPT,,,,,,,,1748,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Diagnostic Bone Marrow, Biopsy and Aspiration",PX38222F,CDM,761,RC,38222,CPT,,,,,,,,1748,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Diagnostic Bone Marrow, Biopsy and Aspiration",PX38222F,CDM,761,RC,38222,CPT,,,,,,,,1748,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Diagnostic Bone Marrow, Biopsy and Aspiration",PX38222F,CDM,761,RC,38222,CPT,,,,,,,,1748,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Diagnostic Bone Marrow, Biopsy and Aspiration",PX38222F,CDM,761,RC,38222,CPT,,,,,,,,1748,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Diagnostic CT Thorax W/ Contrast,PX7126001,CDM,350,RC,71260,CPT,TC,,,,,,,3415,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Diagnostic CT Thorax W/ Contrast,PX7126001,CDM,350,RC,71260,CPT,TC,,,,,,,3415,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Diagnostic CT Thorax W/ Contrast,PX7126001,CDM,350,RC,71260,CPT,TC,,,,,,,3415,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Diagnostic CT Thorax W/ Contrast,PX7126001,CDM,350,RC,71260,CPT,TC,,,,,,,3415,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Diagnostic CT Thorax W/ Contrast,PX7126001,CDM,350,RC,71260,CPT,TC,,,,,,,3415,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Diagnostic CT Thorax W/ Contrast,PX7126001,CDM,350,RC,71260,CPT,TC,,,,,,,3415,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Diagnostic CT Thorax W/O Contrast,PX7125001,CDM,350,RC,71250,CPT,TC,,,,,,,2757,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Diagnostic CT Thorax W/O Contrast,PX7125001,CDM,350,RC,71250,CPT,TC,,,,,,,2757,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Diagnostic CT Thorax W/O Contrast,PX7125001,CDM,350,RC,71250,CPT,TC,,,,,,,2757,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Diagnostic CT Thorax W/O Contrast,PX7125001,CDM,350,RC,71250,CPT,TC,,,,,,,2757,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Diagnostic CT Thorax W/O Contrast,PX7125001,CDM,350,RC,71250,CPT,TC,,,,,,,2757,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Diagnostic CT Thorax W/O Contrast,PX7125001,CDM,350,RC,71250,CPT,TC,,,,,,,2757,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079028401,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079028401,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079028401,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079028401,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079028401,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079028401,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 2 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,172392560,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 2 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,172392560,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 2 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,172392560,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 2 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,172392560,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 2 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,172392560,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 2 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,172392560,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079028420,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079028420,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079028420,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079028420,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079028420,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079028420,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 2.5 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,66490065020,NDC,1,EA,1288,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 2.5 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,66490065020,NDC,1,EA,1288,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 2.5 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,66490065020,NDC,1,EA,1288,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 2.5 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,66490065020,NDC,1,EA,1288,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 2.5 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,66490065020,NDC,1,EA,1288,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 2.5 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,66490065020,NDC,1,EA,1288,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 2.5 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,68682065020,NDC,1,EA,1114.05,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 2.5 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,68682065020,NDC,1,EA,1114.05,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 2.5 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,68682065020,NDC,1,EA,1114.05,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 2.5 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,68682065020,NDC,1,EA,1114.05,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 2.5 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,68682065020,NDC,1,EA,1114.05,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 2.5 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,68682065020,NDC,1,EA,1114.05,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079028501,NDC,0.4,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079028501,NDC,0.4,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079028501,NDC,0.4,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079028501,NDC,0.4,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079028501,NDC,0.4,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079028501,NDC,0.4,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,172392660,NDC,0.4,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,172392660,NDC,0.4,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,172392660,NDC,0.4,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,172392660,NDC,0.4,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,172392660,NDC,0.4,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,172392660,NDC,0.4,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079028520,NDC,0.4,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079028520,NDC,0.4,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079028520,NDC,0.4,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079028520,NDC,0.4,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079028520,NDC,0.4,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079028520,NDC,0.4,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127303,NDC,2,ML,152.7,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127303,NDC,2,ML,152.7,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127303,NDC,2,ML,152.7,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127303,NDC,2,ML,152.7,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127303,NDC,2,ML,152.7,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127303,NDC,2,ML,152.7,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127332,NDC,2,ML,176.55,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127332,NDC,2,ML,176.55,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127332,NDC,2,ML,176.55,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127332,NDC,2,ML,176.55,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127332,NDC,2,ML,176.55,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127332,NDC,2,ML,176.55,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 10 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,93613832,NDC,1,EA,1212.57,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 10 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,93613832,NDC,1,EA,1212.57,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 10 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,93613832,NDC,1,EA,1212.57,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 10 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,93613832,NDC,1,EA,1212.57,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 10 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,93613832,NDC,1,EA,1212.57,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 10 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,93613832,NDC,1,EA,1212.57,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 10 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,187065820,NDC,1,EA,1527.87,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 10 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,187065820,NDC,1,EA,1527.87,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 10 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,187065820,NDC,1,EA,1527.87,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 10 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,187065820,NDC,1,EA,1527.87,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 10 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,187065820,NDC,1,EA,1527.87,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 10 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,187065820,NDC,1,EA,1527.87,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac 0.1 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,17478089225,NDC,2.5,ML,252.06,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac 0.1 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,17478089225,NDC,2.5,ML,252.06,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac 0.1 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,17478089225,NDC,2.5,ML,252.06,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac 0.1 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,17478089225,NDC,2.5,ML,252.06,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac 0.1 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,17478089225,NDC,2.5,ML,252.06,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac 0.1 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,17478089225,NDC,2.5,ML,252.06,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,67815203,NDC,100,GR,91.77,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,67815203,NDC,100,GR,91.77,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,67815203,NDC,100,GR,91.77,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,67815203,NDC,100,GR,91.77,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,67815203,NDC,100,GR,91.77,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,67815203,NDC,100,GR,91.77,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,45802095301,NDC,100,GR,82.76,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,45802095301,NDC,100,GR,82.76,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,45802095301,NDC,100,GR,82.76,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,45802095301,NDC,100,GR,82.76,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,45802095301,NDC,100,GR,82.76,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,45802095301,NDC,100,GR,82.76,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,49884093547,NDC,100,GR,266.25,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,49884093547,NDC,100,GR,266.25,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,49884093547,NDC,100,GR,266.25,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,49884093547,NDC,100,GR,266.25,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,49884093547,NDC,100,GR,266.25,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,49884093547,NDC,100,GR,266.25,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,58602060407,NDC,100,GR,67.56,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,58602060407,NDC,100,GR,67.56,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,58602060407,NDC,100,GR,67.56,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,58602060407,NDC,100,GR,67.56,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,58602060407,NDC,100,GR,67.56,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,58602060407,NDC,100,GR,67.56,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,65162083366,NDC,100,GR,281.12,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,65162083366,NDC,100,GR,281.12,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,65162083366,NDC,100,GR,281.12,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,65162083366,NDC,100,GR,281.12,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,65162083366,NDC,100,GR,281.12,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,65162083366,NDC,100,GR,281.12,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,76282066339,NDC,100,GR,26.8,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,76282066339,NDC,100,GR,26.8,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,76282066339,NDC,100,GR,26.8,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,76282066339,NDC,100,GR,26.8,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,76282066339,NDC,100,GR,26.8,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,76282066339,NDC,100,GR,26.8,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac EC 50 MG Tablet Delayed Release 14 Each Bottle,63700001,CDM,250,RC,,,,,,71335048107,NDC,1,EA,4.87,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac EC 50 MG Tablet Delayed Release 14 Each Bottle,63700001,CDM,250,RC,,,,,,71335048107,NDC,1,EA,4.87,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac EC 50 MG Tablet Delayed Release 14 Each Bottle,63700001,CDM,250,RC,,,,,,71335048107,NDC,1,EA,4.87,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac EC 50 MG Tablet Delayed Release 14 Each Bottle,63700001,CDM,250,RC,,,,,,71335048107,NDC,1,EA,4.87,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac EC 50 MG Tablet Delayed Release 14 Each Bottle,63700001,CDM,250,RC,,,,,,71335048107,NDC,1,EA,4.87,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac EC 50 MG Tablet Delayed Release 14 Each Bottle,63700001,CDM,250,RC,,,,,,71335048107,NDC,1,EA,4.87,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dicloxacillin 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,93312501,NDC,0.5,EA,6.73,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dicloxacillin 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,93312501,NDC,0.5,EA,6.73,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dicloxacillin 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,93312501,NDC,0.5,EA,6.73,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dicloxacillin 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,93312501,NDC,0.5,EA,6.73,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dicloxacillin 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,93312501,NDC,0.5,EA,6.73,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dicloxacillin 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,93312501,NDC,0.5,EA,6.73,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Digital Mamm, Diag, Bilat, Tc W/Cad Perf",PX7706601,CDM,401,RC,77066,CPT,TC,,,,,,,375,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Digital Mamm, Diag, Bilat, Tc W/Cad Perf",PX7706601,CDM,401,RC,77066,CPT,TC,,,,,,,375,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Digital Mamm, Diag, Bilat, Tc W/Cad Perf",PX7706601,CDM,401,RC,77066,CPT,TC,,,,,,,375,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Digital Mamm, Diag, Bilat, Tc W/Cad Perf",PX7706601,CDM,401,RC,77066,CPT,TC,,,,,,,375,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Digital Mamm, Diag, Bilat, Tc W/Cad Perf",PX7706601,CDM,401,RC,77066,CPT,TC,,,,,,,375,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Digital Mamm, Diag, Bilat, Tc W/Cad Perf",PX7706601,CDM,401,RC,77066,CPT,TC,,,,,,,375,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Digital Mamm, Diag, Unilat, Tc W/Cad Perf",PX7706501,CDM,401,RC,77065,CPT,TC,,,,,,,293,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Digital Mamm, Diag, Unilat, Tc W/Cad Perf",PX7706501,CDM,401,RC,77065,CPT,TC,,,,,,,293,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Digital Mamm, Diag, Unilat, Tc W/Cad Perf",PX7706501,CDM,401,RC,77065,CPT,TC,,,,,,,293,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Digital Mamm, Diag, Unilat, Tc W/Cad Perf",PX7706501,CDM,401,RC,77065,CPT,TC,,,,,,,293,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Digital Mamm, Diag, Unilat, Tc W/Cad Perf",PX7706501,CDM,401,RC,77065,CPT,TC,,,,,,,293,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Digital Mamm, Diag, Unilat, Tc W/Cad Perf",PX7706501,CDM,401,RC,77065,CPT,TC,,,,,,,293,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Digital Mammogram, Screen Bil, Tc W/Cad Perf",PX7706701,CDM,403,RC,77067,CPT,TC,,,,,,,375,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Digital Mammogram, Screen Bil, Tc W/Cad Perf",PX7706701,CDM,403,RC,77067,CPT,TC,,,,,,,375,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Digital Mammogram, Screen Bil, Tc W/Cad Perf",PX7706701,CDM,403,RC,77067,CPT,TC,,,,,,,375,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Digital Mammogram, Screen Bil, Tc W/Cad Perf",PX7706701,CDM,403,RC,77067,CPT,TC,,,,,,,375,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Digital Mammogram, Screen Bil, Tc W/Cad Perf",PX7706701,CDM,403,RC,77067,CPT,TC,,,,,,,375,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Digital Mammogram, Screen Bil, Tc W/Cad Perf",PX7706701,CDM,403,RC,77067,CPT,TC,,,,,,,375,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141031,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141031,NDC,0.5,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141031,NDC,0.5,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141031,NDC,0.5,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141031,NDC,0.5,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141031,NDC,0.5,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141035,NDC,2,ML,56.37,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141035,NDC,2,ML,56.37,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141035,NDC,2,ML,56.37,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141035,NDC,2,ML,56.37,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141035,NDC,2,ML,56.37,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141035,NDC,2,ML,56.37,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305972,NDC,2,ML,61.19,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305972,NDC,2,ML,61.19,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305972,NDC,2,ML,61.19,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305972,NDC,2,ML,61.19,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305972,NDC,2,ML,61.19,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305972,NDC,2,ML,61.19,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305995,NDC,2,ML,61.19,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305995,NDC,2,ML,61.19,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305995,NDC,2,ML,61.19,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305995,NDC,2,ML,61.19,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305995,NDC,2,ML,61.19,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305995,NDC,2,ML,61.19,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
digoxin 125 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,115981101,NDC,1,EA,7.64,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
digoxin 125 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,115981101,NDC,1,EA,7.64,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
digoxin 125 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,115981101,NDC,1,EA,7.64,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
digoxin 125 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,115981101,NDC,1,EA,7.64,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
digoxin 125 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,115981101,NDC,1,EA,7.64,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
digoxin 125 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,115981101,NDC,1,EA,7.64,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
digoxin 125 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904592161,NDC,0.5,EA,4.52,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
digoxin 125 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904592161,NDC,0.5,EA,4.52,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
digoxin 125 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904592161,NDC,0.5,EA,4.52,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
digoxin 125 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904592161,NDC,0.5,EA,4.52,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
digoxin 125 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904592161,NDC,0.5,EA,4.52,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
digoxin 125 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904592161,NDC,0.5,EA,4.52,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041100,NDC,0.5,ML,196.94,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041100,NDC,0.5,ML,196.94,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041100,NDC,0.5,ML,196.94,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041100,NDC,0.5,ML,196.94,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041100,NDC,0.5,ML,196.94,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041100,NDC,0.5,ML,196.94,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041105,NDC,1,ML,419.67,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041105,NDC,1,ML,419.67,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041105,NDC,1,ML,419.67,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041105,NDC,1,ML,419.67,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041105,NDC,1,ML,419.67,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041105,NDC,1,ML,419.67,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041110,NDC,0.5,ML,196.94,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041110,NDC,0.5,ML,196.94,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041110,NDC,0.5,ML,196.94,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041110,NDC,0.5,ML,196.94,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041110,NDC,0.5,ML,196.94,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041110,NDC,0.5,ML,196.94,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dihydroxyvitamin D - Ref,PX8265290,CDM,300,RC,82652,CPT,90,,,,,,,165,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dihydroxyvitamin D - Ref,PX8265290,CDM,300,RC,82652,CPT,90,,,,,,,165,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dihydroxyvitamin D - Ref,PX8265290,CDM,300,RC,82652,CPT,90,,,,,,,165,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dihydroxyvitamin D - Ref,PX8265290,CDM,300,RC,82652,CPT,90,,,,,,,165,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dihydroxyvitamin D - Ref,PX8265290,CDM,300,RC,82652,CPT,90,,,,,,,165,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dihydroxyvitamin D - Ref,PX8265290,CDM,300,RC,82652,CPT,90,,,,,,,165,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,641601301,NDC,5,ML,34.41,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,641601301,NDC,5,ML,34.41,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,641601301,NDC,5,ML,34.41,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,641601301,NDC,5,ML,34.41,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,641601301,NDC,5,ML,34.41,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,641601301,NDC,5,ML,34.41,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,641601310,NDC,5,ML,40.58,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,641601310,NDC,5,ML,40.58,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,641601310,NDC,5,ML,40.58,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,641601310,NDC,5,ML,40.58,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,641601310,NDC,5,ML,40.58,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,641601310,NDC,5,ML,40.58,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,17478081705,NDC,5,ML,34.99,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,17478081705,NDC,5,ML,34.99,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,17478081705,NDC,5,ML,34.99,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,17478081705,NDC,5,ML,34.99,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,17478081705,NDC,5,ML,34.99,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,17478081705,NDC,5,ML,34.99,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem 30 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93031801,NDC,1,EA,5.36,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem 30 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93031801,NDC,1,EA,5.36,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem 30 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93031801,NDC,1,EA,5.36,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem 30 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93031801,NDC,1,EA,5.36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem 30 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93031801,NDC,1,EA,5.36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem 30 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93031801,NDC,1,EA,5.36,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,641601501,NDC,25,ML,58.29,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,641601501,NDC,25,ML,58.29,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,641601501,NDC,25,ML,58.29,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,641601501,NDC,25,ML,58.29,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,641601501,NDC,25,ML,58.29,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,641601501,NDC,25,ML,58.29,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,17478081725,NDC,25,ML,81.3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,17478081725,NDC,25,ML,81.3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,17478081725,NDC,25,ML,81.3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,17478081725,NDC,25,ML,81.3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,17478081725,NDC,25,ML,81.3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,17478081725,NDC,25,ML,81.3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,70860030143,NDC,25,ML,84.47,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,70860030143,NDC,25,ML,84.47,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,70860030143,NDC,25,ML,84.47,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,70860030143,NDC,25,ML,84.47,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,70860030143,NDC,25,ML,84.47,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,70860030143,NDC,25,ML,84.47,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687019511,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687019511,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687019511,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687019511,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687019511,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687019511,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687019501,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687019501,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687019501,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687019501,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687019501,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687019501,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739028310,NDC,1,EA,8.04,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739028310,NDC,1,EA,8.04,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739028310,NDC,1,EA,8.04,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739028310,NDC,1,EA,8.04,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739028310,NDC,1,EA,8.04,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739028310,NDC,1,EA,8.04,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 180 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687020611,NDC,0.666666667,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 180 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687020611,NDC,0.666666667,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 180 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687020611,NDC,0.666666667,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 180 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687020611,NDC,0.666666667,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 180 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687020611,NDC,0.666666667,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 180 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687020611,NDC,0.666666667,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 180 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687020601,NDC,0.666666667,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 180 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687020601,NDC,0.666666667,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 180 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687020601,NDC,0.666666667,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 180 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687020601,NDC,0.666666667,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 180 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687020601,NDC,0.666666667,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 180 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687020601,NDC,0.666666667,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687021711,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687021711,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687021711,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687021711,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687021711,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687021711,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,10370083111,NDC,0.5,EA,5.51,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,10370083111,NDC,0.5,EA,5.51,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,10370083111,NDC,0.5,EA,5.51,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,10370083111,NDC,0.5,EA,5.51,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,10370083111,NDC,0.5,EA,5.51,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,10370083111,NDC,0.5,EA,5.51,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739001610,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739001610,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739001610,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739001610,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739001610,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739001610,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739028510,NDC,1,EA,13.76,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739028510,NDC,1,EA,13.76,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739028510,NDC,1,EA,13.76,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739028510,NDC,1,EA,13.76,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739028510,NDC,1,EA,13.76,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739028510,NDC,1,EA,13.76,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DIMETHICONE (TOPICAL) 5 % Cream 118 mL Tube,800000,CDM,,,,,,,,53329015104,NDC,118,ML,44.12,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DIMETHICONE (TOPICAL) 5 % Cream 118 mL Tube,800000,CDM,,,,,,,,53329015104,NDC,118,ML,44.12,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DIMETHICONE (TOPICAL) 5 % Cream 118 mL Tube,800000,CDM,,,,,,,,53329015104,NDC,118,ML,44.12,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DIMETHICONE (TOPICAL) 5 % Cream 118 mL Tube,800000,CDM,,,,,,,,53329015104,NDC,118,ML,44.12,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DIMETHICONE (TOPICAL) 5 % Cream 118 mL Tube,800000,CDM,,,,,,,,53329015104,NDC,118,ML,44.12,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DIMETHICONE (TOPICAL) 5 % Cream 118 mL Tube,800000,CDM,,,,,,,,53329015104,NDC,118,ML,44.12,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dimethicone 1.5 % Cream 118 mL Tube,800000,CDM,,,,,,,,53329016104,NDC,118,ML,43.4,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dimethicone 1.5 % Cream 118 mL Tube,800000,CDM,,,,,,,,53329016104,NDC,118,ML,43.4,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dimethicone 1.5 % Cream 118 mL Tube,800000,CDM,,,,,,,,53329016104,NDC,118,ML,43.4,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dimethicone 1.5 % Cream 118 mL Tube,800000,CDM,,,,,,,,53329016104,NDC,118,ML,43.4,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dimethicone 1.5 % Cream 118 mL Tube,800000,CDM,,,,,,,,53329016104,NDC,118,ML,43.4,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dimethicone 1.5 % Cream 118 mL Tube,800000,CDM,,,,,,,,53329016104,NDC,118,ML,43.4,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,693390152,NDC,2.5,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,693390152,NDC,2.5,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,693390152,NDC,2.5,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,693390152,NDC,2.5,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,693390152,NDC,2.5,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,693390152,NDC,2.5,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,68094002459,NDC,10,ML,14.67,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,68094002459,NDC,10,ML,14.67,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,68094002459,NDC,10,ML,14.67,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,68094002459,NDC,10,ML,14.67,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,68094002459,NDC,10,ML,14.67,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,68094002459,NDC,10,ML,14.67,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 12.5 MG/5ML Liquid 118 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904698520,NDC,2.5,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 12.5 MG/5ML Liquid 118 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904698520,NDC,2.5,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 12.5 MG/5ML Liquid 118 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904698520,NDC,2.5,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 12.5 MG/5ML Liquid 118 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904698520,NDC,2.5,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 12.5 MG/5ML Liquid 118 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904698520,NDC,2.5,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 12.5 MG/5ML Liquid 118 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904698520,NDC,2.5,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 12.5 MG/5ML Liquid 120 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,58657052804,NDC,2.5,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 12.5 MG/5ML Liquid 120 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,58657052804,NDC,2.5,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 12.5 MG/5ML Liquid 120 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,58657052804,NDC,2.5,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 12.5 MG/5ML Liquid 120 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,58657052804,NDC,2.5,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 12.5 MG/5ML Liquid 120 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,58657052804,NDC,2.5,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 12.5 MG/5ML Liquid 120 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,58657052804,NDC,2.5,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 25 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904530661,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 25 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904530661,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 25 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904530661,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 25 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904530661,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 25 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904530661,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 25 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904530661,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 25 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904723761,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 25 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904723761,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 25 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904723761,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 25 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904723761,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 25 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904723761,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 25 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904723761,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 50 MG capsule 100 Each Box,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904205661,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 50 MG capsule 100 Each Box,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904205661,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 50 MG capsule 100 Each Box,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904205661,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 50 MG capsule 100 Each Box,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904205661,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 50 MG capsule 100 Each Box,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904205661,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 50 MG capsule 100 Each Box,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904205661,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,641037621,NDC,0.25,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,641037621,NDC,0.25,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,641037621,NDC,0.25,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,641037621,NDC,0.25,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,641037621,NDC,0.25,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,641037621,NDC,0.25,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066416,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066416,NDC,1,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066416,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066416,NDC,1,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066416,NDC,1,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066416,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066441,NDC,0.25,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066441,NDC,0.25,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066441,NDC,0.25,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066441,NDC,0.25,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066441,NDC,0.25,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066441,NDC,0.25,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010101,NDC,0.25,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010101,NDC,0.25,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010101,NDC,0.25,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010101,NDC,0.25,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010101,NDC,0.25,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010101,NDC,0.25,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010125,NDC,1,ML,30.58,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010125,NDC,1,ML,30.58,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010125,NDC,1,ML,30.58,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010125,NDC,1,ML,30.58,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010125,NDC,1,ML,30.58,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010125,NDC,1,ML,30.58,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenoxylate-atropine 2.5-0.025 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762106101,NDC,1,EA,3.76,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenoxylate-atropine 2.5-0.025 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762106101,NDC,1,EA,3.76,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenoxylate-atropine 2.5-0.025 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762106101,NDC,1,EA,3.76,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenoxylate-atropine 2.5-0.025 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762106101,NDC,1,EA,3.76,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenoxylate-atropine 2.5-0.025 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762106101,NDC,1,EA,3.76,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenoxylate-atropine 2.5-0.025 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762106101,NDC,1,EA,3.76,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenoxylate-atropine 2.5-0.025 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,62559049001,NDC,1,EA,3.76,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenoxylate-atropine 2.5-0.025 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,62559049001,NDC,1,EA,3.76,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenoxylate-atropine 2.5-0.025 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,62559049001,NDC,1,EA,3.76,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenoxylate-atropine 2.5-0.025 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,62559049001,NDC,1,EA,3.76,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenoxylate-atropine 2.5-0.025 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,62559049001,NDC,1,EA,3.76,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenoxylate-atropine 2.5-0.025 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,62559049001,NDC,1,EA,3.76,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Direct Admit Hospital Observ,PXG0379,CDM,761,RC,G0379,HCPCS,,,,,,,,676,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Direct Admit Hospital Observ,PXG0379,CDM,761,RC,G0379,HCPCS,,,,,,,,676,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Direct Admit Hospital Observ,PXG0379,CDM,761,RC,G0379,HCPCS,,,,,,,,676,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Direct Admit Hospital Observ,PXG0379,CDM,761,RC,G0379,HCPCS,,,,,,,,676,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Direct Admit Hospital Observ,PXG0379,CDM,761,RC,G0379,HCPCS,,,,,,,,676,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Direct Admit Hospital Observ,PXG0379,CDM,761,RC,G0379,HCPCS,,,,,,,,676,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Direct skilled nursing services of a license practical nurse (lpn) in the home health or hospice setting, each 15 minutes",PXG0300,CDM,551,RC,G0300,HCPCS,,,,,,,,75,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Direct skilled nursing services of a license practical nurse (lpn) in the home health or hospice setting, each 15 minutes",PXG0300,CDM,551,RC,G0300,HCPCS,,,,,,,,75,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Direct skilled nursing services of a license practical nurse (lpn) in the home health or hospice setting, each 15 minutes",PXG0300,CDM,551,RC,G0300,HCPCS,,,,,,,,75,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Direct skilled nursing services of a license practical nurse (lpn) in the home health or hospice setting, each 15 minutes",PXG0300,CDM,551,RC,G0300,HCPCS,,,,,,,,75,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Direct skilled nursing services of a license practical nurse (lpn) in the home health or hospice setting, each 15 minutes",PXG0300,CDM,551,RC,G0300,HCPCS,,,,,,,,75,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Direct skilled nursing services of a license practical nurse (lpn) in the home health or hospice setting, each 15 minutes",PXG0300,CDM,551,RC,G0300,HCPCS,,,,,,,,75,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
divalproex 125 MG Capsule Delayed Release Sprinkle 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031311,NDC,1,EA,7.63,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
divalproex 125 MG Capsule Delayed Release Sprinkle 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031311,NDC,1,EA,7.63,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
divalproex 125 MG Capsule Delayed Release Sprinkle 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031311,NDC,1,EA,7.63,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
divalproex 125 MG Capsule Delayed Release Sprinkle 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031311,NDC,1,EA,7.63,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
divalproex 125 MG Capsule Delayed Release Sprinkle 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031311,NDC,1,EA,7.63,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
divalproex 125 MG Capsule Delayed Release Sprinkle 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031311,NDC,1,EA,7.63,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
divalproex 125 MG Capsule Delayed Release Sprinkle 100 Each Box,63700001,CDM,250,RC,,,,,,68084031301,NDC,1,EA,7.62,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
divalproex 125 MG Capsule Delayed Release Sprinkle 100 Each Box,63700001,CDM,250,RC,,,,,,68084031301,NDC,1,EA,7.62,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
divalproex 125 MG Capsule Delayed Release Sprinkle 100 Each Box,63700001,CDM,250,RC,,,,,,68084031301,NDC,1,EA,7.62,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
divalproex 125 MG Capsule Delayed Release Sprinkle 100 Each Box,63700001,CDM,250,RC,,,,,,68084031301,NDC,1,EA,7.62,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
divalproex 125 MG Capsule Delayed Release Sprinkle 100 Each Box,63700001,CDM,250,RC,,,,,,68084031301,NDC,1,EA,7.62,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
divalproex 125 MG Capsule Delayed Release Sprinkle 100 Each Box,63700001,CDM,250,RC,,,,,,68084031301,NDC,1,EA,7.62,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
divalproex 250 MG Tablet Delayed Release 1 Each Box,63700001,CDM,250,RC,,,,,,832712389,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
divalproex 250 MG Tablet Delayed Release 1 Each Box,63700001,CDM,250,RC,,,,,,832712389,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
divalproex 250 MG Tablet Delayed Release 1 Each Box,63700001,CDM,250,RC,,,,,,832712389,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
divalproex 250 MG Tablet Delayed Release 1 Each Box,63700001,CDM,250,RC,,,,,,832712389,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
divalproex 250 MG Tablet Delayed Release 1 Each Box,63700001,CDM,250,RC,,,,,,832712389,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
divalproex 250 MG Tablet Delayed Release 1 Each Box,63700001,CDM,250,RC,,,,,,832712389,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
divalproex 250 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756079788,NDC,0.5,EA,4.68,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
divalproex 250 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756079788,NDC,0.5,EA,4.68,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
divalproex 250 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756079788,NDC,0.5,EA,4.68,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
divalproex 250 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756079788,NDC,0.5,EA,4.68,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
divalproex 250 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756079788,NDC,0.5,EA,4.68,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
divalproex 250 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756079788,NDC,0.5,EA,4.68,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
divalproex 250 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,832712301,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
divalproex 250 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,832712301,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
divalproex 250 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,832712301,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
divalproex 250 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,832712301,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
divalproex 250 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,832712301,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
divalproex 250 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,832712301,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
divalproex ER 250 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031011,NDC,1,EA,13.14,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
divalproex ER 250 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031011,NDC,1,EA,13.14,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
divalproex ER 250 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031011,NDC,1,EA,13.14,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
divalproex ER 250 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031011,NDC,1,EA,13.14,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
divalproex ER 250 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031011,NDC,1,EA,13.14,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
divalproex ER 250 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031011,NDC,1,EA,13.14,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
divalproex ER 250 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084031001,NDC,1,EA,13.14,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
divalproex ER 250 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084031001,NDC,1,EA,13.14,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
divalproex ER 250 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084031001,NDC,1,EA,13.14,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
divalproex ER 250 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084031001,NDC,1,EA,13.14,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
divalproex ER 250 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084031001,NDC,1,EA,13.14,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
divalproex ER 250 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084031001,NDC,1,EA,13.14,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DOBUTamine 1000 mcg/mL in dextrose 5% 250 mL premix 1000 mcg/ml Solution 250 mL Flex Cont,J1250.01,CDM,636,RC,J1250,HCPCS,,,,338107302,NDC,250,ML,146.73,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DOBUTamine 1000 mcg/mL in dextrose 5% 250 mL premix 1000 mcg/ml Solution 250 mL Flex Cont,J1250.01,CDM,636,RC,J1250,HCPCS,,,,338107302,NDC,250,ML,146.73,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DOBUTamine 1000 mcg/mL in dextrose 5% 250 mL premix 1000 mcg/ml Solution 250 mL Flex Cont,J1250.01,CDM,636,RC,J1250,HCPCS,,,,338107302,NDC,250,ML,146.73,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DOBUTamine 1000 mcg/mL in dextrose 5% 250 mL premix 1000 mcg/ml Solution 250 mL Flex Cont,J1250.01,CDM,636,RC,J1250,HCPCS,,,,338107302,NDC,250,ML,146.73,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DOBUTamine 1000 mcg/mL in dextrose 5% 250 mL premix 1000 mcg/ml Solution 250 mL Flex Cont,J1250.01,CDM,636,RC,J1250,HCPCS,,,,338107302,NDC,250,ML,146.73,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DOBUTamine 1000 mcg/mL in dextrose 5% 250 mL premix 1000 mcg/ml Solution 250 mL Flex Cont,J1250.01,CDM,636,RC,J1250,HCPCS,,,,338107302,NDC,250,ML,146.73,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DOCEtaxel 20 MG/ML Concentrate 1 mL Vial,63600000,CDM,636,RC,J9171,HCPCS,,,,955102001,NDC,1,ML,1690.09,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DOCEtaxel 20 MG/ML Concentrate 1 mL Vial,63600000,CDM,636,RC,J9171,HCPCS,,,,955102001,NDC,1,ML,1690.09,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DOCEtaxel 20 MG/ML Concentrate 1 mL Vial,63600000,CDM,636,RC,J9171,HCPCS,,,,955102001,NDC,1,ML,1690.09,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DOCEtaxel 20 MG/ML Concentrate 1 mL Vial,63600000,CDM,636,RC,J9171,HCPCS,,,,955102001,NDC,1,ML,1690.09,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DOCEtaxel 20 MG/ML Concentrate 1 mL Vial,63600000,CDM,636,RC,J9171,HCPCS,,,,955102001,NDC,1,ML,1690.09,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DOCEtaxel 20 MG/ML Concentrate 1 mL Vial,63600000,CDM,636,RC,J9171,HCPCS,,,,955102001,NDC,1,ML,1690.09,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DOCEtaxel 160 MG/16ML Solution 16 mL Vial,J9171.01,CDM,636,RC,J9171,HCPCS,,,,409173201,NDC,16,ML,2901.69,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DOCEtaxel 160 MG/16ML Solution 16 mL Vial,J9171.01,CDM,636,RC,J9171,HCPCS,,,,409173201,NDC,16,ML,2901.69,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DOCEtaxel 160 MG/16ML Solution 16 mL Vial,J9171.01,CDM,636,RC,J9171,HCPCS,,,,409173201,NDC,16,ML,2901.69,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DOCEtaxel 160 MG/16ML Solution 16 mL Vial,J9171.01,CDM,636,RC,J9171,HCPCS,,,,409173201,NDC,16,ML,2901.69,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DOCEtaxel 160 MG/16ML Solution 16 mL Vial,J9171.01,CDM,636,RC,J9171,HCPCS,,,,409173201,NDC,16,ML,2901.69,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DOCEtaxel 160 MG/16ML Solution 16 mL Vial,J9171.01,CDM,636,RC,J9171,HCPCS,,,,409173201,NDC,16,ML,2901.69,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
docusate sodium 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,10135011101,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
docusate sodium 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,10135011101,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
docusate sodium 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,10135011101,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
docusate sodium 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,10135011101,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
docusate sodium 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,10135011101,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
docusate sodium 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,10135011101,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
docusate sodium 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904645561,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
docusate sodium 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904645561,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
docusate sodium 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904645561,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
docusate sodium 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904645561,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
docusate sodium 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904645561,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
docusate sodium 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904645561,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
docusate sodium 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904718361,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
docusate sodium 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904718361,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
docusate sodium 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904718361,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
docusate sodium 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904718361,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
docusate sodium 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904718361,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
docusate sodium 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904718361,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
donepezil 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904640861,NDC,1,EA,41.79,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
donepezil 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904640861,NDC,1,EA,41.79,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
donepezil 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904640861,NDC,1,EA,41.79,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
donepezil 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904640861,NDC,1,EA,41.79,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
donepezil 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904640861,NDC,1,EA,41.79,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
donepezil 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904640861,NDC,1,EA,41.79,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
donepezil 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904647761,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
donepezil 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904647761,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
donepezil 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904647761,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
donepezil 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904647761,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
donepezil 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904647761,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
donepezil 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904647761,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DOPamine 1600 mcg/mL in dextrose 5% 250 mL premix 1600 mcg/mL Solution 250 mL Plas Cont,J1265.01,CDM,636,RC,J1265,HCPCS,,,,338100702,NDC,250,ML,99.9,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DOPamine 1600 mcg/mL in dextrose 5% 250 mL premix 1600 mcg/mL Solution 250 mL Plas Cont,J1265.01,CDM,636,RC,J1265,HCPCS,,,,338100702,NDC,250,ML,99.9,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DOPamine 1600 mcg/mL in dextrose 5% 250 mL premix 1600 mcg/mL Solution 250 mL Plas Cont,J1265.01,CDM,636,RC,J1265,HCPCS,,,,338100702,NDC,250,ML,99.9,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DOPamine 1600 mcg/mL in dextrose 5% 250 mL premix 1600 mcg/mL Solution 250 mL Plas Cont,J1265.01,CDM,636,RC,J1265,HCPCS,,,,338100702,NDC,250,ML,99.9,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DOPamine 1600 mcg/mL in dextrose 5% 250 mL premix 1600 mcg/mL Solution 250 mL Plas Cont,J1265.01,CDM,636,RC,J1265,HCPCS,,,,338100702,NDC,250,ML,99.9,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DOPamine 1600 mcg/mL in dextrose 5% 250 mL premix 1600 mcg/mL Solution 250 mL Plas Cont,J1265.01,CDM,636,RC,J1265,HCPCS,,,,338100702,NDC,250,ML,99.9,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dorzolamide-timolol 2-0.5 % Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,50383023310,NDC,10,ML,506.34,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dorzolamide-timolol 2-0.5 % Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,50383023310,NDC,10,ML,506.34,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dorzolamide-timolol 2-0.5 % Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,50383023310,NDC,10,ML,506.34,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dorzolamide-timolol 2-0.5 % Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,50383023310,NDC,10,ML,506.34,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dorzolamide-timolol 2-0.5 % Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,50383023310,NDC,10,ML,506.34,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dorzolamide-timolol 2-0.5 % Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,50383023310,NDC,10,ML,506.34,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxazosin 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079095701,NDC,1,EA,20.19,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxazosin 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079095701,NDC,1,EA,20.19,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxazosin 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079095701,NDC,1,EA,20.19,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxazosin 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079095701,NDC,1,EA,20.19,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxazosin 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079095701,NDC,1,EA,20.19,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxazosin 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079095701,NDC,1,EA,20.19,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxazosin 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904552261,NDC,1,EA,5.46,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxazosin 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904552261,NDC,1,EA,5.46,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxazosin 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904552261,NDC,1,EA,5.46,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxazosin 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904552261,NDC,1,EA,5.46,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxazosin 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904552261,NDC,1,EA,5.46,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxazosin 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904552261,NDC,1,EA,5.46,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxazosin 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079095720,NDC,1,EA,20.22,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxazosin 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079095720,NDC,1,EA,20.22,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxazosin 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079095720,NDC,1,EA,20.22,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxazosin 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079095720,NDC,1,EA,20.22,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxazosin 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079095720,NDC,1,EA,20.22,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxazosin 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079095720,NDC,1,EA,20.22,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxazosin 4 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68382078501,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxazosin 4 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68382078501,NDC,0.25,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxazosin 4 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68382078501,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxazosin 4 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68382078501,NDC,0.25,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxazosin 4 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68382078501,NDC,0.25,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxazosin 4 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68382078501,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxepin 10 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,51672421701,NDC,1,EA,3.36,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxepin 10 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,51672421701,NDC,1,EA,3.36,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxepin 10 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,51672421701,NDC,1,EA,3.36,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxepin 10 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,51672421701,NDC,1,EA,3.36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxepin 10 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,51672421701,NDC,1,EA,3.36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxepin 10 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,51672421701,NDC,1,EA,3.36,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxepin 10 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079043620,NDC,1,EA,3.43,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxepin 10 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079043620,NDC,1,EA,3.43,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxepin 10 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079043620,NDC,1,EA,3.43,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxepin 10 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079043620,NDC,1,EA,3.43,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxepin 10 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079043620,NDC,1,EA,3.43,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxepin 10 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079043620,NDC,1,EA,3.43,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxycycline 100 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323013041,NDC,1,EA,140.2,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxycycline 100 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323013041,NDC,1,EA,140.2,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxycycline 100 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323013041,NDC,1,EA,140.2,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxycycline 100 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323013041,NDC,1,EA,140.2,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxycycline 100 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323013041,NDC,1,EA,140.2,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxycycline 100 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323013041,NDC,1,EA,140.2,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxycycline hyclate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584069311,NDC,0.5,EA,15,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxycycline hyclate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584069311,NDC,0.5,EA,15,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxycycline hyclate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584069311,NDC,0.5,EA,15,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxycycline hyclate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584069311,NDC,0.5,EA,15,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxycycline hyclate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584069311,NDC,0.5,EA,15,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxycycline hyclate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584069311,NDC,0.5,EA,15,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxycycline hyclate 100 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,904043004,NDC,0.5,EA,12.21,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxycycline hyclate 100 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,904043004,NDC,0.5,EA,12.21,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxycycline hyclate 100 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,904043004,NDC,0.5,EA,12.21,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxycycline hyclate 100 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,904043004,NDC,0.5,EA,12.21,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxycycline hyclate 100 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,904043004,NDC,0.5,EA,12.21,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxycycline hyclate 100 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,904043004,NDC,0.5,EA,12.21,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxycycline hyclate 100 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,62584069321,NDC,0.5,EA,15,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxycycline hyclate 100 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,62584069321,NDC,0.5,EA,15,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxycycline hyclate 100 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,62584069321,NDC,0.5,EA,15,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxycycline hyclate 100 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,62584069321,NDC,0.5,EA,15,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxycycline hyclate 100 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,62584069321,NDC,0.5,EA,15,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxycycline hyclate 100 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,62584069321,NDC,0.5,EA,15,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxycycline monohydrate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687071611,NDC,1,EA,6.87,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxycycline monohydrate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687071611,NDC,1,EA,6.87,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxycycline monohydrate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687071611,NDC,1,EA,6.87,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxycycline monohydrate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687071611,NDC,1,EA,6.87,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxycycline monohydrate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687071611,NDC,1,EA,6.87,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxycycline monohydrate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687071611,NDC,1,EA,6.87,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxycycline monohydrate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084074333,NDC,1,EA,9.99,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxycycline monohydrate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084074333,NDC,1,EA,9.99,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxycycline monohydrate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084074333,NDC,1,EA,9.99,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxycycline monohydrate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084074333,NDC,1,EA,9.99,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxycycline monohydrate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084074333,NDC,1,EA,9.99,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxycycline monohydrate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084074333,NDC,1,EA,9.99,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain Blood From Under Nail,PX11740F,CDM,510,RC,11740,CPT,,,,,,,,117,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain Blood From Under Nail,PX11740F,CDM,510,RC,11740,CPT,,,,,,,,117,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain Blood From Under Nail,PX11740F,CDM,510,RC,11740,CPT,,,,,,,,117,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain Blood From Under Nail,PX11740F,CDM,510,RC,11740,CPT,,,,,,,,117,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain Blood From Under Nail,PX11740F,CDM,510,RC,11740,CPT,,,,,,,,117,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain Blood From Under Nail,PX11740F,CDM,510,RC,11740,CPT,,,,,,,,117,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Drain Finger Abscess,Simple",PX26010F,CDM,510,RC,26010,CPT,,,,,,,,310,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Drain Finger Abscess,Simple",PX26010F,CDM,510,RC,26010,CPT,,,,,,,,310,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Drain Finger Abscess,Simple",PX26010F,CDM,510,RC,26010,CPT,,,,,,,,310,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Drain Finger Abscess,Simple",PX26010F,CDM,510,RC,26010,CPT,,,,,,,,310,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Drain Finger Abscess,Simple",PX26010F,CDM,510,RC,26010,CPT,,,,,,,,310,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Drain Finger Abscess,Simple",PX26010F,CDM,510,RC,26010,CPT,,,,,,,,310,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Drain Finger Abscess,Simple",PX26010P,CDM,983,RC,26010,CPT,,,,,,,,207,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Drain Finger Abscess,Simple",PX26010P,CDM,983,RC,26010,CPT,,,,,,,,207,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Drain Finger Abscess,Simple",PX26010P,CDM,983,RC,26010,CPT,,,,,,,,207,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Drain Finger Abscess,Simple",PX26010P,CDM,983,RC,26010,CPT,,,,,,,,207,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Drain Finger Abscess,Simple",PX26010P,CDM,983,RC,26010,CPT,,,,,,,,207,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Drain Finger Abscess,Simple",PX26010P,CDM,983,RC,26010,CPT,,,,,,,,207,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAIN FLAT JACKSON PRATT 10MM,27100000,CDM,271,RC,,,,334-MAIN,LOCAL,,,,,239.09,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAIN FLAT JACKSON PRATT 10MM,27100000,CDM,271,RC,,,,334-MAIN,LOCAL,,,,,239.09,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAIN FLAT JACKSON PRATT 10MM,27100000,CDM,271,RC,,,,334-MAIN,LOCAL,,,,,239.09,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAIN FLAT JACKSON PRATT 10MM,27100000,CDM,271,RC,,,,334-MAIN,LOCAL,,,,,239.09,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAIN FLAT JACKSON PRATT 10MM,27100000,CDM,271,RC,,,,334-MAIN,LOCAL,,,,,239.09,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAIN FLAT JACKSON PRATT 10MM,27100000,CDM,271,RC,,,,334-MAIN,LOCAL,,,,,239.09,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800F,CDM,510,RC,40800,CPT,,,,,,,,255,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800F,CDM,510,RC,40800,CPT,,,,,,,,255,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800F,CDM,510,RC,40800,CPT,,,,,,,,255,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800F,CDM,510,RC,40800,CPT,,,,,,,,255,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800F,CDM,510,RC,40800,CPT,,,,,,,,255,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800F,CDM,510,RC,40800,CPT,,,,,,,,255,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800P,CDM,983,RC,40800,CPT,,,,,,,,170,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800P,CDM,983,RC,40800,CPT,,,,,,,,170,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800P,CDM,983,RC,40800,CPT,,,,,,,,170,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800P,CDM,983,RC,40800,CPT,,,,,,,,170,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800P,CDM,983,RC,40800,CPT,,,,,,,,170,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800P,CDM,983,RC,40800,CPT,,,,,,,,170,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain Pilonidal Cyst Simpl,PX10080F,CDM,510,RC,10080,CPT,,,,,,,,742,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain Pilonidal Cyst Simpl,PX10080F,CDM,510,RC,10080,CPT,,,,,,,,742,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain Pilonidal Cyst Simpl,PX10080F,CDM,510,RC,10080,CPT,,,,,,,,742,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain Pilonidal Cyst Simpl,PX10080F,CDM,510,RC,10080,CPT,,,,,,,,742,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain Pilonidal Cyst Simpl,PX10080F,CDM,510,RC,10080,CPT,,,,,,,,742,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain Pilonidal Cyst Simpl,PX10080F,CDM,510,RC,10080,CPT,,,,,,,,742,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain Skin Abscess Complic,PX10061F,CDM,510,RC,10061,CPT,,,,,,,,889,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain Skin Abscess Complic,PX10061F,CDM,510,RC,10061,CPT,,,,,,,,889,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain Skin Abscess Complic,PX10061F,CDM,510,RC,10061,CPT,,,,,,,,889,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain Skin Abscess Complic,PX10061F,CDM,510,RC,10061,CPT,,,,,,,,889,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain Skin Abscess Complic,PX10061F,CDM,510,RC,10061,CPT,,,,,,,,889,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain Skin Abscess Complic,PX10061F,CDM,510,RC,10061,CPT,,,,,,,,889,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain Skin Abscess Complic,PX10061P,CDM,983,RC,10061,CPT,,,,,,,,561,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain Skin Abscess Complic,PX10061P,CDM,983,RC,10061,CPT,,,,,,,,561,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain Skin Abscess Complic,PX10061P,CDM,983,RC,10061,CPT,,,,,,,,561,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain Skin Abscess Complic,PX10061P,CDM,983,RC,10061,CPT,,,,,,,,561,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain Skin Abscess Complic,PX10061P,CDM,983,RC,10061,CPT,,,,,,,,561,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain Skin Abscess Complic,PX10061P,CDM,983,RC,10061,CPT,,,,,,,,561,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain Skin Abscess Simple,PX10060F,CDM,510,RC,10060,CPT,,,,,,,,296,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain Skin Abscess Simple,PX10060F,CDM,510,RC,10060,CPT,,,,,,,,296,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain Skin Abscess Simple,PX10060F,CDM,510,RC,10060,CPT,,,,,,,,296,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain Skin Abscess Simple,PX10060F,CDM,510,RC,10060,CPT,,,,,,,,296,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain Skin Abscess Simple,PX10060F,CDM,510,RC,10060,CPT,,,,,,,,296,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain Skin Abscess Simple,PX10060F,CDM,510,RC,10060,CPT,,,,,,,,296,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain Skin Abscess Simple,PX10060P,CDM,983,RC,10060,CPT,,,,,,,,293,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain Skin Abscess Simple,PX10060P,CDM,983,RC,10060,CPT,,,,,,,,293,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain Skin Abscess Simple,PX10060P,CDM,983,RC,10060,CPT,,,,,,,,293,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain Skin Abscess Simple,PX10060P,CDM,983,RC,10060,CPT,,,,,,,,293,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain Skin Abscess Simple,PX10060P,CDM,983,RC,10060,CPT,,,,,,,,293,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain Skin Abscess Simple,PX10060P,CDM,983,RC,10060,CPT,,,,,,,,293,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Large Joint/Bursa,PX20610F,CDM,510,RC,20610,CPT,,,,,,,,364,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Large Joint/Bursa,PX20610F,CDM,510,RC,20610,CPT,,,,,,,,364,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Large Joint/Bursa,PX20610F,CDM,510,RC,20610,CPT,,,,,,,,364,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Large Joint/Bursa,PX20610F,CDM,510,RC,20610,CPT,,,,,,,,364,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Large Joint/Bursa,PX20610F,CDM,510,RC,20610,CPT,,,,,,,,364,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Large Joint/Bursa,PX20610F,CDM,510,RC,20610,CPT,,,,,,,,364,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Large Joint/Bursa,PX20610P,CDM,983,RC,20610,CPT,,,,,,,,291,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Large Joint/Bursa,PX20610P,CDM,983,RC,20610,CPT,,,,,,,,291,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Large Joint/Bursa,PX20610P,CDM,983,RC,20610,CPT,,,,,,,,291,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Large Joint/Bursa,PX20610P,CDM,983,RC,20610,CPT,,,,,,,,291,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Large Joint/Bursa,PX20610P,CDM,983,RC,20610,CPT,,,,,,,,291,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Large Joint/Bursa,PX20610P,CDM,983,RC,20610,CPT,,,,,,,,291,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611F,CDM,510,RC,20611,CPT,,,,,,,,456,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611F,CDM,510,RC,20611,CPT,,,,,,,,456,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611F,CDM,510,RC,20611,CPT,,,,,,,,456,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611F,CDM,510,RC,20611,CPT,,,,,,,,456,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611F,CDM,510,RC,20611,CPT,,,,,,,,456,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611F,CDM,510,RC,20611,CPT,,,,,,,,456,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611P,CDM,983,RC,20611,CPT,,,,,,,,272,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611P,CDM,983,RC,20611,CPT,,,,,,,,272,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611P,CDM,983,RC,20611,CPT,,,,,,,,272,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611P,CDM,983,RC,20611,CPT,,,,,,,,272,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611P,CDM,983,RC,20611,CPT,,,,,,,,272,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611P,CDM,983,RC,20611,CPT,,,,,,,,272,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Med Joint/Brusa W/US Guide,PX20606F,CDM,510,RC,20606,CPT,,,,,,,,387,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Med Joint/Brusa W/US Guide,PX20606F,CDM,510,RC,20606,CPT,,,,,,,,387,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Med Joint/Brusa W/US Guide,PX20606F,CDM,510,RC,20606,CPT,,,,,,,,387,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Med Joint/Brusa W/US Guide,PX20606F,CDM,510,RC,20606,CPT,,,,,,,,387,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Med Joint/Brusa W/US Guide,PX20606F,CDM,510,RC,20606,CPT,,,,,,,,387,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Med Joint/Brusa W/US Guide,PX20606F,CDM,510,RC,20606,CPT,,,,,,,,387,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Med Joint/Brusa W/US Guide,PX20606P,CDM,983,RC,20606,CPT,,,,,,,,309,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Med Joint/Brusa W/US Guide,PX20606P,CDM,983,RC,20606,CPT,,,,,,,,309,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Med Joint/Brusa W/US Guide,PX20606P,CDM,983,RC,20606,CPT,,,,,,,,309,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Med Joint/Brusa W/US Guide,PX20606P,CDM,983,RC,20606,CPT,,,,,,,,309,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Med Joint/Brusa W/US Guide,PX20606P,CDM,983,RC,20606,CPT,,,,,,,,309,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Med Joint/Brusa W/US Guide,PX20606P,CDM,983,RC,20606,CPT,,,,,,,,309,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Medium Joint/Bursa,PX20605F,CDM,510,RC,20605,CPT,,,,,,,,247,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Medium Joint/Bursa,PX20605F,CDM,510,RC,20605,CPT,,,,,,,,247,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Medium Joint/Bursa,PX20605F,CDM,510,RC,20605,CPT,,,,,,,,247,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Medium Joint/Bursa,PX20605F,CDM,510,RC,20605,CPT,,,,,,,,247,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Medium Joint/Bursa,PX20605F,CDM,510,RC,20605,CPT,,,,,,,,247,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Medium Joint/Bursa,PX20605F,CDM,510,RC,20605,CPT,,,,,,,,247,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Medium Joint/Bursa,PX20605P,CDM,983,RC,20605,CPT,,,,,,,,318,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Medium Joint/Bursa,PX20605P,CDM,983,RC,20605,CPT,,,,,,,,318,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Medium Joint/Bursa,PX20605P,CDM,983,RC,20605,CPT,,,,,,,,318,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Medium Joint/Bursa,PX20605P,CDM,983,RC,20605,CPT,,,,,,,,318,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Medium Joint/Bursa,PX20605P,CDM,983,RC,20605,CPT,,,,,,,,318,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Medium Joint/Bursa,PX20605P,CDM,983,RC,20605,CPT,,,,,,,,318,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604F,CDM,510,RC,20604,CPT,,,,,,,,344,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604F,CDM,510,RC,20604,CPT,,,,,,,,344,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604F,CDM,510,RC,20604,CPT,,,,,,,,344,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604F,CDM,510,RC,20604,CPT,,,,,,,,344,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604F,CDM,510,RC,20604,CPT,,,,,,,,344,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604F,CDM,510,RC,20604,CPT,,,,,,,,344,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604P,CDM,983,RC,20604,CPT,,,,,,,,229,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604P,CDM,983,RC,20604,CPT,,,,,,,,229,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604P,CDM,983,RC,20604,CPT,,,,,,,,229,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604P,CDM,983,RC,20604,CPT,,,,,,,,229,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604P,CDM,983,RC,20604,CPT,,,,,,,,229,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604P,CDM,983,RC,20604,CPT,,,,,,,,229,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Small Joint/Bursa,PX20600F,CDM,510,RC,20600,CPT,,,,,,,,161,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Small Joint/Bursa,PX20600F,CDM,510,RC,20600,CPT,,,,,,,,161,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Small Joint/Bursa,PX20600F,CDM,510,RC,20600,CPT,,,,,,,,161,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Small Joint/Bursa,PX20600F,CDM,510,RC,20600,CPT,,,,,,,,161,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Small Joint/Bursa,PX20600F,CDM,510,RC,20600,CPT,,,,,,,,161,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Small Joint/Bursa,PX20600F,CDM,510,RC,20600,CPT,,,,,,,,161,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Small Joint/Bursa,PX20600P,CDM,983,RC,20600,CPT,,,,,,,,161,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Small Joint/Bursa,PX20600P,CDM,983,RC,20600,CPT,,,,,,,,161,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Small Joint/Bursa,PX20600P,CDM,983,RC,20600,CPT,,,,,,,,161,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Small Joint/Bursa,PX20600P,CDM,983,RC,20600,CPT,,,,,,,,161,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Small Joint/Bursa,PX20600P,CDM,983,RC,20600,CPT,,,,,,,,161,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Small Joint/Bursa,PX20600P,CDM,983,RC,20600,CPT,,,,,,,,161,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drainage of Gum Lesion,PX41800F,CDM,510,RC,41800,CPT,,,,,,,,395,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drainage of Gum Lesion,PX41800F,CDM,510,RC,41800,CPT,,,,,,,,395,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drainage of Gum Lesion,PX41800F,CDM,510,RC,41800,CPT,,,,,,,,395,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drainage of Gum Lesion,PX41800F,CDM,510,RC,41800,CPT,,,,,,,,395,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drainage of Gum Lesion,PX41800F,CDM,510,RC,41800,CPT,,,,,,,,395,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drainage of Gum Lesion,PX41800F,CDM,510,RC,41800,CPT,,,,,,,,395,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drainage of Gum Lesion,PX41800P,CDM,983,RC,41800,CPT,,,,,,,,839,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drainage of Gum Lesion,PX41800P,CDM,983,RC,41800,CPT,,,,,,,,839,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drainage of Gum Lesion,PX41800P,CDM,983,RC,41800,CPT,,,,,,,,839,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drainage of Gum Lesion,PX41800P,CDM,983,RC,41800,CPT,,,,,,,,839,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drainage of Gum Lesion,PX41800P,CDM,983,RC,41800,CPT,,,,,,,,839,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drainage of Gum Lesion,PX41800P,CDM,983,RC,41800,CPT,,,,,,,,839,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drainage of Hematoma/Fluid (P),PX10140P,CDM,983,RC,10140,CPT,,,,,,,,465,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drainage of Hematoma/Fluid (P),PX10140P,CDM,983,RC,10140,CPT,,,,,,,,465,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drainage of Hematoma/Fluid (P),PX10140P,CDM,983,RC,10140,CPT,,,,,,,,465,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drainage of Hematoma/Fluid (P),PX10140P,CDM,983,RC,10140,CPT,,,,,,,,465,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drainage of Hematoma/Fluid (P),PX10140P,CDM,983,RC,10140,CPT,,,,,,,,465,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drainage of Hematoma/Fluid (P),PX10140P,CDM,983,RC,10140,CPT,,,,,,,,465,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drainage of Hematoma/Fluid (T),PX10140F,CDM,510,RC,10140,CPT,,,,,,,,341,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drainage of Hematoma/Fluid (T),PX10140F,CDM,510,RC,10140,CPT,,,,,,,,341,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drainage of Hematoma/Fluid (T),PX10140F,CDM,510,RC,10140,CPT,,,,,,,,341,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drainage of Hematoma/Fluid (T),PX10140F,CDM,510,RC,10140,CPT,,,,,,,,341,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drainage of Hematoma/Fluid (T),PX10140F,CDM,510,RC,10140,CPT,,,,,,,,341,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drainage of Hematoma/Fluid (T),PX10140F,CDM,510,RC,10140,CPT,,,,,,,,341,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drainage Scrotal Wall Abscess,PX55100F,CDM,510,RC,55100,CPT,,,,,,,,634,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drainage Scrotal Wall Abscess,PX55100F,CDM,510,RC,55100,CPT,,,,,,,,634,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drainage Scrotal Wall Abscess,PX55100F,CDM,510,RC,55100,CPT,,,,,,,,634,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drainage Scrotal Wall Abscess,PX55100F,CDM,510,RC,55100,CPT,,,,,,,,634,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drainage Scrotal Wall Abscess,PX55100F,CDM,510,RC,55100,CPT,,,,,,,,634,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drainage Scrotal Wall Abscess,PX55100F,CDM,510,RC,55100,CPT,,,,,,,,634,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drainage Scrotal Wall Abscess,PX55100P,CDM,983,RC,55100,CPT,,,,,,,,341,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drainage Scrotal Wall Abscess,PX55100P,CDM,983,RC,55100,CPT,,,,,,,,341,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drainage Scrotal Wall Abscess,PX55100P,CDM,983,RC,55100,CPT,,,,,,,,341,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drainage Scrotal Wall Abscess,PX55100P,CDM,983,RC,55100,CPT,,,,,,,,341,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drainage Scrotal Wall Abscess,PX55100P,CDM,983,RC,55100,CPT,,,,,,,,341,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drainage Scrotal Wall Abscess,PX55100P,CDM,983,RC,55100,CPT,,,,,,,,341,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE ABDOMINAL SURGICAL 14X12 POUCHES STERILE DYNJP3109,27200000,CDM,272,RC,,,,12896-MAIN,LOCAL,,,,,31,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE ABDOMINAL SURGICAL 14X12 POUCHES STERILE DYNJP3109,27200000,CDM,272,RC,,,,12896-MAIN,LOCAL,,,,,31,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE ABDOMINAL SURGICAL 14X12 POUCHES STERILE DYNJP3109,27200000,CDM,272,RC,,,,12896-MAIN,LOCAL,,,,,31,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE ABDOMINAL SURGICAL 14X12 POUCHES STERILE DYNJP3109,27200000,CDM,272,RC,,,,12896-MAIN,LOCAL,,,,,31,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE ABDOMINAL SURGICAL 14X12 POUCHES STERILE DYNJP3109,27200000,CDM,272,RC,,,,12896-MAIN,LOCAL,,,,,31,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE ABDOMINAL SURGICAL 14X12 POUCHES STERILE DYNJP3109,27200000,CDM,272,RC,,,,12896-MAIN,LOCAL,,,,,31,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE COLUMN 470341,27200000,CDM,272,RC,,,,12013-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE COLUMN 470341,27200000,CDM,272,RC,,,,12013-MAIN,LOCAL,,,,,38,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE COLUMN 470341,27200000,CDM,272,RC,,,,12013-MAIN,LOCAL,,,,,38,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE COLUMN 470341,27200000,CDM,272,RC,,,,12013-MAIN,LOCAL,,,,,38,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE COLUMN 470341,27200000,CDM,272,RC,,,,12013-MAIN,LOCAL,,,,,38,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE COLUMN 470341,27200000,CDM,272,RC,,,,12013-MAIN,LOCAL,,,,,38,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE INSTRUMENT ARM 470015,27200000,CDM,272,RC,,,,11925-MAIN,LOCAL,,,,,97,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE INSTRUMENT ARM 470015,27200000,CDM,272,RC,,,,11925-MAIN,LOCAL,,,,,97,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE INSTRUMENT ARM 470015,27200000,CDM,272,RC,,,,11925-MAIN,LOCAL,,,,,97,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE INSTRUMENT ARM 470015,27200000,CDM,272,RC,,,,11925-MAIN,LOCAL,,,,,97,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE INSTRUMENT ARM 470015,27200000,CDM,272,RC,,,,11925-MAIN,LOCAL,,,,,97,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE INSTRUMENT ARM 470015,27200000,CDM,272,RC,,,,11925-MAIN,LOCAL,,,,,97,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE SHEET 70X85 LARGE DYNJP2417,27200000,CDM,272,RC,,,,10914-MAIN,LOCAL,,,,,18.39,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE SHEET 70X85 LARGE DYNJP2417,27200000,CDM,272,RC,,,,10914-MAIN,LOCAL,,,,,18.39,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE SHEET 70X85 LARGE DYNJP2417,27200000,CDM,272,RC,,,,10914-MAIN,LOCAL,,,,,18.39,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE SHEET 70X85 LARGE DYNJP2417,27200000,CDM,272,RC,,,,10914-MAIN,LOCAL,,,,,18.39,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE SHEET 70X85 LARGE DYNJP2417,27200000,CDM,272,RC,,,,10914-MAIN,LOCAL,,,,,18.39,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE SHEET 70X85 LARGE DYNJP2417,27200000,CDM,272,RC,,,,10914-MAIN,LOCAL,,,,,18.39,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE SHEET LAP T-DRAPE WITH INSTRUMENT PAD DYNJP3003,27200000,CDM,272,RC,,,,10913-MAIN,LOCAL,,,,,35.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE SHEET LAP T-DRAPE WITH INSTRUMENT PAD DYNJP3003,27200000,CDM,272,RC,,,,10913-MAIN,LOCAL,,,,,35.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE SHEET LAP T-DRAPE WITH INSTRUMENT PAD DYNJP3003,27200000,CDM,272,RC,,,,10913-MAIN,LOCAL,,,,,35.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE SHEET LAP T-DRAPE WITH INSTRUMENT PAD DYNJP3003,27200000,CDM,272,RC,,,,10913-MAIN,LOCAL,,,,,35.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE SHEET LAP T-DRAPE WITH INSTRUMENT PAD DYNJP3003,27200000,CDM,272,RC,,,,10913-MAIN,LOCAL,,,,,35.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE SHEET LAP T-DRAPE WITH INSTRUMENT PAD DYNJP3003,27200000,CDM,272,RC,,,,10913-MAIN,LOCAL,,,,,35.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE SPLIT WITH ADHESIVE DYNJP8304A,27200000,CDM,272,RC,,,,4694-MAIN,LOCAL,,,,,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE SPLIT WITH ADHESIVE DYNJP8304A,27200000,CDM,272,RC,,,,4694-MAIN,LOCAL,,,,,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE SPLIT WITH ADHESIVE DYNJP8304A,27200000,CDM,272,RC,,,,4694-MAIN,LOCAL,,,,,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE SPLIT WITH ADHESIVE DYNJP8304A,27200000,CDM,272,RC,,,,4694-MAIN,LOCAL,,,,,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE SPLIT WITH ADHESIVE DYNJP8304A,27200000,CDM,272,RC,,,,4694-MAIN,LOCAL,,,,,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE SPLIT WITH ADHESIVE DYNJP8304A,27200000,CDM,272,RC,,,,4694-MAIN,LOCAL,,,,,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE STERILE 109X100X110 ROBOTIC DYNJP9108,27200000,CDM,272,RC,,,,12020-MAIN,LOCAL,,,,,51,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE STERILE 109X100X110 ROBOTIC DYNJP9108,27200000,CDM,272,RC,,,,12020-MAIN,LOCAL,,,,,51,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE STERILE 109X100X110 ROBOTIC DYNJP9108,27200000,CDM,272,RC,,,,12020-MAIN,LOCAL,,,,,51,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE STERILE 109X100X110 ROBOTIC DYNJP9108,27200000,CDM,272,RC,,,,12020-MAIN,LOCAL,,,,,51,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE STERILE 109X100X110 ROBOTIC DYNJP9108,27200000,CDM,272,RC,,,,12020-MAIN,LOCAL,,,,,51,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE STERILE 109X100X110 ROBOTIC DYNJP9108,27200000,CDM,272,RC,,,,12020-MAIN,LOCAL,,,,,51,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE SURGICAL 23X17INCH INCISE 1050,27200000,CDM,272,RC,,,,12873-MAIN,LOCAL,,,,,10,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE SURGICAL 23X17INCH INCISE 1050,27200000,CDM,272,RC,,,,12873-MAIN,LOCAL,,,,,10,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE SURGICAL 23X17INCH INCISE 1050,27200000,CDM,272,RC,,,,12873-MAIN,LOCAL,,,,,10,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE SURGICAL 23X17INCH INCISE 1050,27200000,CDM,272,RC,,,,12873-MAIN,LOCAL,,,,,10,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE SURGICAL 23X17INCH INCISE 1050,27200000,CDM,272,RC,,,,12873-MAIN,LOCAL,,,,,10,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE SURGICAL 23X17INCH INCISE 1050,27200000,CDM,272,RC,,,,12873-MAIN,LOCAL,,,,,10,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Draw Blood Off Venous Device,PX36591F,CDM,510,RC,36591,CPT,,,,,,,,211,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Draw Blood Off Venous Device,PX36591F,CDM,510,RC,36591,CPT,,,,,,,,211,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Draw Blood Off Venous Device,PX36591F,CDM,510,RC,36591,CPT,,,,,,,,211,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Draw Blood Off Venous Device,PX36591F,CDM,510,RC,36591,CPT,,,,,,,,211,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Draw Blood Off Venous Device,PX36591F,CDM,510,RC,36591,CPT,,,,,,,,211,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Draw Blood Off Venous Device,PX36591F,CDM,510,RC,36591,CPT,,,,,,,,211,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAWTEX HYDROCONDUCTIVE NONADHERENT DRESSING,120.508,CDM,271,RC,A6199,HCPCS,,12022-MAIN,LOCAL,,,,,59,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAWTEX HYDROCONDUCTIVE NONADHERENT DRESSING,120.508,CDM,271,RC,A6199,HCPCS,,12022-MAIN,LOCAL,,,,,59,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAWTEX HYDROCONDUCTIVE NONADHERENT DRESSING,120.508,CDM,271,RC,A6199,HCPCS,,12022-MAIN,LOCAL,,,,,59,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAWTEX HYDROCONDUCTIVE NONADHERENT DRESSING,120.508,CDM,271,RC,A6199,HCPCS,,12022-MAIN,LOCAL,,,,,59,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAWTEX HYDROCONDUCTIVE NONADHERENT DRESSING,120.508,CDM,271,RC,A6199,HCPCS,,12022-MAIN,LOCAL,,,,,59,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAWTEX HYDROCONDUCTIVE NONADHERENT DRESSING,120.508,CDM,271,RC,A6199,HCPCS,,12022-MAIN,LOCAL,,,,,59,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dress/Debrid Large Burn No Anesth,PX16030F,CDM,510,RC,16030,CPT,,,,,,,,399,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dress/Debrid Large Burn No Anesth,PX16030F,CDM,510,RC,16030,CPT,,,,,,,,399,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dress/Debrid Large Burn No Anesth,PX16030F,CDM,510,RC,16030,CPT,,,,,,,,399,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dress/Debrid Large Burn No Anesth,PX16030F,CDM,510,RC,16030,CPT,,,,,,,,399,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dress/Debrid Large Burn No Anesth,PX16030F,CDM,510,RC,16030,CPT,,,,,,,,399,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dress/Debrid Large Burn No Anesth,PX16030F,CDM,510,RC,16030,CPT,,,,,,,,399,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dress/Debrid Med Burn No Anesth,PX16025F,CDM,510,RC,16025,CPT,,,,,,,,366,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dress/Debrid Med Burn No Anesth,PX16025F,CDM,510,RC,16025,CPT,,,,,,,,366,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dress/Debrid Med Burn No Anesth,PX16025F,CDM,510,RC,16025,CPT,,,,,,,,366,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dress/Debrid Med Burn No Anesth,PX16025F,CDM,510,RC,16025,CPT,,,,,,,,366,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dress/Debrid Med Burn No Anesth,PX16025F,CDM,510,RC,16025,CPT,,,,,,,,366,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dress/Debrid Med Burn No Anesth,PX16025F,CDM,510,RC,16025,CPT,,,,,,,,366,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dress/Debrid Med Burn No Anesth,PX16025P,CDM,983,RC,16025,CPT,,,,,,,,244,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dress/Debrid Med Burn No Anesth,PX16025P,CDM,983,RC,16025,CPT,,,,,,,,244,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dress/Debrid Med Burn No Anesth,PX16025P,CDM,983,RC,16025,CPT,,,,,,,,244,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dress/Debrid Med Burn No Anesth,PX16025P,CDM,983,RC,16025,CPT,,,,,,,,244,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dress/Debrid Med Burn No Anesth,PX16025P,CDM,983,RC,16025,CPT,,,,,,,,244,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dress/Debrid Med Burn No Anesth,PX16025P,CDM,983,RC,16025,CPT,,,,,,,,244,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dress/Debrid Small Burn No Anes,PX16020F,CDM,510,RC,16020,CPT,,,,,,,,313,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dress/Debrid Small Burn No Anes,PX16020F,CDM,510,RC,16020,CPT,,,,,,,,313,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dress/Debrid Small Burn No Anes,PX16020F,CDM,510,RC,16020,CPT,,,,,,,,313,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dress/Debrid Small Burn No Anes,PX16020F,CDM,510,RC,16020,CPT,,,,,,,,313,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dress/Debrid Small Burn No Anes,PX16020F,CDM,510,RC,16020,CPT,,,,,,,,313,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dress/Debrid Small Burn No Anes,PX16020F,CDM,510,RC,16020,CPT,,,,,,,,313,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"DRESSING AQUACEL 3/4"" X 18"" AG HYDROFIBER 403771",120.31,CDM,272,RC,A6199,HCPCS,,8238-MAIN,LOCAL,,,,,33,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"DRESSING AQUACEL 3/4"" X 18"" AG HYDROFIBER 403771",120.31,CDM,272,RC,A6199,HCPCS,,8238-MAIN,LOCAL,,,,,33,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"DRESSING AQUACEL 3/4"" X 18"" AG HYDROFIBER 403771",120.31,CDM,272,RC,A6199,HCPCS,,8238-MAIN,LOCAL,,,,,33,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"DRESSING AQUACEL 3/4"" X 18"" AG HYDROFIBER 403771",120.31,CDM,272,RC,A6199,HCPCS,,8238-MAIN,LOCAL,,,,,33,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"DRESSING AQUACEL 3/4"" X 18"" AG HYDROFIBER 403771",120.31,CDM,272,RC,A6199,HCPCS,,8238-MAIN,LOCAL,,,,,33,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"DRESSING AQUACEL 3/4"" X 18"" AG HYDROFIBER 403771",120.31,CDM,272,RC,A6199,HCPCS,,8238-MAIN,LOCAL,,,,,33,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING GEL FOAM SIZE 100SPONGE STERILE 00009034201,27200000,CDM,272,RC,A6248,HCPCS,,3378-MAIN,LOCAL,,,,,38.25,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING GEL FOAM SIZE 100SPONGE STERILE 00009034201,27200000,CDM,272,RC,A6248,HCPCS,,3378-MAIN,LOCAL,,,,,38.25,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING GEL FOAM SIZE 100SPONGE STERILE 00009034201,27200000,CDM,272,RC,A6248,HCPCS,,3378-MAIN,LOCAL,,,,,38.25,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING GEL FOAM SIZE 100SPONGE STERILE 00009034201,27200000,CDM,272,RC,A6248,HCPCS,,3378-MAIN,LOCAL,,,,,38.25,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING GEL FOAM SIZE 100SPONGE STERILE 00009034201,27200000,CDM,272,RC,A6248,HCPCS,,3378-MAIN,LOCAL,,,,,38.25,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING GEL FOAM SIZE 100SPONGE STERILE 00009034201,27200000,CDM,272,RC,A6248,HCPCS,,3378-MAIN,LOCAL,,,,,38.25,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING HYDROFERA 2-1/2X2-1/2  BLUE READY FOAM HBRS2520,120.488,CDM,271,RC,A6209,HCPCS,,11537-MAIN,LOCAL,,,,,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING HYDROFERA 2-1/2X2-1/2  BLUE READY FOAM HBRS2520,120.488,CDM,271,RC,A6209,HCPCS,,11537-MAIN,LOCAL,,,,,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING HYDROFERA 2-1/2X2-1/2  BLUE READY FOAM HBRS2520,120.488,CDM,271,RC,A6209,HCPCS,,11537-MAIN,LOCAL,,,,,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING HYDROFERA 2-1/2X2-1/2  BLUE READY FOAM HBRS2520,120.488,CDM,271,RC,A6209,HCPCS,,11537-MAIN,LOCAL,,,,,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING HYDROFERA 2-1/2X2-1/2  BLUE READY FOAM HBRS2520,120.488,CDM,271,RC,A6209,HCPCS,,11537-MAIN,LOCAL,,,,,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING HYDROFERA 2-1/2X2-1/2  BLUE READY FOAM HBRS2520,120.488,CDM,271,RC,A6209,HCPCS,,11537-MAIN,LOCAL,,,,,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING MESALT 6X6 IMPREGNATED GAUZE STERILE 285780,120.511,CDM,272,RC,A6223,HCPCS,,12059-SURG,LOCAL,,,,,5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING MESALT 6X6 IMPREGNATED GAUZE STERILE 285780,120.511,CDM,272,RC,A6223,HCPCS,,12059-SURG,LOCAL,,,,,5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING MESALT 6X6 IMPREGNATED GAUZE STERILE 285780,120.511,CDM,272,RC,A6223,HCPCS,,12059-SURG,LOCAL,,,,,5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING MESALT 6X6 IMPREGNATED GAUZE STERILE 285780,120.511,CDM,272,RC,A6223,HCPCS,,12059-SURG,LOCAL,,,,,5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING MESALT 6X6 IMPREGNATED GAUZE STERILE 285780,120.511,CDM,272,RC,A6223,HCPCS,,12059-SURG,LOCAL,,,,,5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING MESALT 6X6 IMPREGNATED GAUZE STERILE 285780,120.511,CDM,272,RC,A6223,HCPCS,,12059-SURG,LOCAL,,,,,5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING NASAL 4.5CM NON-INFLATABLE RAPID RHINO RR450,120.97,CDM,272,RC,A6407,HCPCS,,616-MAIN,LOCAL,,,,,94,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING NASAL 4.5CM NON-INFLATABLE RAPID RHINO RR450,120.97,CDM,272,RC,A6407,HCPCS,,616-MAIN,LOCAL,,,,,94,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING NASAL 4.5CM NON-INFLATABLE RAPID RHINO RR450,120.97,CDM,272,RC,A6407,HCPCS,,616-MAIN,LOCAL,,,,,94,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING NASAL 4.5CM NON-INFLATABLE RAPID RHINO RR450,120.97,CDM,272,RC,A6407,HCPCS,,616-MAIN,LOCAL,,,,,94,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING NASAL 4.5CM NON-INFLATABLE RAPID RHINO RR450,120.97,CDM,272,RC,A6407,HCPCS,,616-MAIN,LOCAL,,,,,94,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING NASAL 4.5CM NON-INFLATABLE RAPID RHINO RR450,120.97,CDM,272,RC,A6407,HCPCS,,616-MAIN,LOCAL,,,,,94,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING NASAL 5.5CM INFLATABLE RAPID RHINO RR550,120.97,CDM,272,RC,A6407,HCPCS,,606-MAIN,LOCAL,,,,,94,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING NASAL 5.5CM INFLATABLE RAPID RHINO RR550,120.97,CDM,272,RC,A6407,HCPCS,,606-MAIN,LOCAL,,,,,94,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING NASAL 5.5CM INFLATABLE RAPID RHINO RR550,120.97,CDM,272,RC,A6407,HCPCS,,606-MAIN,LOCAL,,,,,94,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING NASAL 5.5CM INFLATABLE RAPID RHINO RR550,120.97,CDM,272,RC,A6407,HCPCS,,606-MAIN,LOCAL,,,,,94,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING NASAL 5.5CM INFLATABLE RAPID RHINO RR550,120.97,CDM,272,RC,A6407,HCPCS,,606-MAIN,LOCAL,,,,,94,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING NASAL 5.5CM INFLATABLE RAPID RHINO RR550,120.97,CDM,272,RC,A6407,HCPCS,,606-MAIN,LOCAL,,,,,94,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING NASAL 7.5CM INFLATABLE RAPID RHINO RR750,120.97,CDM,272,RC,A6407,HCPCS,,611-MAIN,LOCAL,,,,,94,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING NASAL 7.5CM INFLATABLE RAPID RHINO RR750,120.97,CDM,272,RC,A6407,HCPCS,,611-MAIN,LOCAL,,,,,94,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING NASAL 7.5CM INFLATABLE RAPID RHINO RR750,120.97,CDM,272,RC,A6407,HCPCS,,611-MAIN,LOCAL,,,,,94,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING NASAL 7.5CM INFLATABLE RAPID RHINO RR750,120.97,CDM,272,RC,A6407,HCPCS,,611-MAIN,LOCAL,,,,,94,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING NASAL 7.5CM INFLATABLE RAPID RHINO RR750,120.97,CDM,272,RC,A6407,HCPCS,,611-MAIN,LOCAL,,,,,94,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING NASAL 7.5CM INFLATABLE RAPID RHINO RR750,120.97,CDM,272,RC,A6407,HCPCS,,611-MAIN,LOCAL,,,,,94,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING NASAL 8CM LONGX1.5CM THICK X3CM HIGH ANATOMICAL 34-105,120.97,CDM,272,RC,A6407,HCPCS,,613-MAIN,LOCAL,,,,,94,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING NASAL 8CM LONGX1.5CM THICK X3CM HIGH ANATOMICAL 34-105,120.97,CDM,272,RC,A6407,HCPCS,,613-MAIN,LOCAL,,,,,94,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING NASAL 8CM LONGX1.5CM THICK X3CM HIGH ANATOMICAL 34-105,120.97,CDM,272,RC,A6407,HCPCS,,613-MAIN,LOCAL,,,,,94,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING NASAL 8CM LONGX1.5CM THICK X3CM HIGH ANATOMICAL 34-105,120.97,CDM,272,RC,A6407,HCPCS,,613-MAIN,LOCAL,,,,,94,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING NASAL 8CM LONGX1.5CM THICK X3CM HIGH ANATOMICAL 34-105,120.97,CDM,272,RC,A6407,HCPCS,,613-MAIN,LOCAL,,,,,94,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING NASAL 8CM LONGX1.5CM THICK X3CM HIGH ANATOMICAL 34-105,120.97,CDM,272,RC,A6407,HCPCS,,613-MAIN,LOCAL,,,,,94,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING OPTIFOAM 10X4 POST-OP SILICONE FACED MSC21410Z,120.154,CDM,272,RC,A6213,HCPCS,,8632-MAIN,LOCAL,,,,,16,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING OPTIFOAM 10X4 POST-OP SILICONE FACED MSC21410Z,120.154,CDM,272,RC,A6213,HCPCS,,8632-MAIN,LOCAL,,,,,16,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING OPTIFOAM 10X4 POST-OP SILICONE FACED MSC21410Z,120.154,CDM,272,RC,A6213,HCPCS,,8632-MAIN,LOCAL,,,,,16,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING OPTIFOAM 10X4 POST-OP SILICONE FACED MSC21410Z,120.154,CDM,272,RC,A6213,HCPCS,,8632-MAIN,LOCAL,,,,,16,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING OPTIFOAM 10X4 POST-OP SILICONE FACED MSC21410Z,120.154,CDM,272,RC,A6213,HCPCS,,8632-MAIN,LOCAL,,,,,16,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING OPTIFOAM 10X4 POST-OP SILICONE FACED MSC21410Z,120.154,CDM,272,RC,A6213,HCPCS,,8632-MAIN,LOCAL,,,,,16,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING QWICK NONADHESIVE 4.25X4 SUPERABSORBENT MSC5844,120.531,CDM,272,RC,A6197,HCPCS,,12301-MAIN,LOCAL,,,,,20,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING QWICK NONADHESIVE 4.25X4 SUPERABSORBENT MSC5844,120.531,CDM,272,RC,A6197,HCPCS,,12301-MAIN,LOCAL,,,,,20,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING QWICK NONADHESIVE 4.25X4 SUPERABSORBENT MSC5844,120.531,CDM,272,RC,A6197,HCPCS,,12301-MAIN,LOCAL,,,,,20,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING QWICK NONADHESIVE 4.25X4 SUPERABSORBENT MSC5844,120.531,CDM,272,RC,A6197,HCPCS,,12301-MAIN,LOCAL,,,,,20,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING QWICK NONADHESIVE 4.25X4 SUPERABSORBENT MSC5844,120.531,CDM,272,RC,A6197,HCPCS,,12301-MAIN,LOCAL,,,,,20,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING QWICK NONADHESIVE 4.25X4 SUPERABSORBENT MSC5844,120.531,CDM,272,RC,A6197,HCPCS,,12301-MAIN,LOCAL,,,,,20,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING SURGICEL HEMOSTAT 4X8 ABSORBABLE 1952,120.123,CDM,272,RC,A6252,HCPCS,,1002-MAIN,LOCAL,,,,,125,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING SURGICEL HEMOSTAT 4X8 ABSORBABLE 1952,120.123,CDM,272,RC,A6252,HCPCS,,1002-MAIN,LOCAL,,,,,125,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING SURGICEL HEMOSTAT 4X8 ABSORBABLE 1952,120.123,CDM,272,RC,A6252,HCPCS,,1002-MAIN,LOCAL,,,,,125,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING SURGICEL HEMOSTAT 4X8 ABSORBABLE 1952,120.123,CDM,272,RC,A6252,HCPCS,,1002-MAIN,LOCAL,,,,,125,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING SURGICEL HEMOSTAT 4X8 ABSORBABLE 1952,120.123,CDM,272,RC,A6252,HCPCS,,1002-MAIN,LOCAL,,,,,125,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING SURGICEL HEMOSTAT 4X8 ABSORBABLE 1952,120.123,CDM,272,RC,A6252,HCPCS,,1002-MAIN,LOCAL,,,,,125,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRILL BIT 2.2MM LONG SOLID STERILE MICA,27200000,CDM,272,RC,,,,12985-MAIN,LOCAL,,,,,600,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRILL BIT 2.2MM LONG SOLID STERILE MICA,27200000,CDM,272,RC,,,,12985-MAIN,LOCAL,,,,,600,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRILL BIT 2.2MM LONG SOLID STERILE MICA,27200000,CDM,272,RC,,,,12985-MAIN,LOCAL,,,,,600,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRILL BIT 2.2MM LONG SOLID STERILE MICA,27200000,CDM,272,RC,,,,12985-MAIN,LOCAL,,,,,600,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRILL BIT 2.2MM LONG SOLID STERILE MICA,27200000,CDM,272,RC,,,,12985-MAIN,LOCAL,,,,,600,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRILL BIT 2.2MM LONG SOLID STERILE MICA,27200000,CDM,272,RC,,,,12985-MAIN,LOCAL,,,,,600,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRILL BIT 2.2MMX60MM STERILE MICA CANNULATED,27200000,CDM,272,RC,,,,12437-MAIN,LOCAL,,,,,701,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRILL BIT 2.2MMX60MM STERILE MICA CANNULATED,27200000,CDM,272,RC,,,,12437-MAIN,LOCAL,,,,,701,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRILL BIT 2.2MMX60MM STERILE MICA CANNULATED,27200000,CDM,272,RC,,,,12437-MAIN,LOCAL,,,,,701,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRILL BIT 2.2MMX60MM STERILE MICA CANNULATED,27200000,CDM,272,RC,,,,12437-MAIN,LOCAL,,,,,701,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRILL BIT 2.2MMX60MM STERILE MICA CANNULATED,27200000,CDM,272,RC,,,,12437-MAIN,LOCAL,,,,,701,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRILL BIT 2.2MMX60MM STERILE MICA CANNULATED,27200000,CDM,272,RC,,,,12437-MAIN,LOCAL,,,,,701,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRILL BIT 3.0MMX60MM STERILE MICA CANNULATED,27200000,CDM,272,RC,,,,12438-MAIN,LOCAL,,,,,701,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRILL BIT 3.0MMX60MM STERILE MICA CANNULATED,27200000,CDM,272,RC,,,,12438-MAIN,LOCAL,,,,,701,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRILL BIT 3.0MMX60MM STERILE MICA CANNULATED,27200000,CDM,272,RC,,,,12438-MAIN,LOCAL,,,,,701,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRILL BIT 3.0MMX60MM STERILE MICA CANNULATED,27200000,CDM,272,RC,,,,12438-MAIN,LOCAL,,,,,701,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRILL BIT 3.0MMX60MM STERILE MICA CANNULATED,27200000,CDM,272,RC,,,,12438-MAIN,LOCAL,,,,,701,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRILL BIT 3.0MMX60MM STERILE MICA CANNULATED,27200000,CDM,272,RC,,,,12438-MAIN,LOCAL,,,,,701,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRILL BIT AO DIA 2.0MMX135MM SCALED,27200000,CDM,272,RC,,,,12640-MAIN,LOCAL,,,,,452,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRILL BIT AO DIA 2.0MMX135MM SCALED,27200000,CDM,272,RC,,,,12640-MAIN,LOCAL,,,,,452,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRILL BIT AO DIA 2.0MMX135MM SCALED,27200000,CDM,272,RC,,,,12640-MAIN,LOCAL,,,,,452,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRILL BIT AO DIA 2.0MMX135MM SCALED,27200000,CDM,272,RC,,,,12640-MAIN,LOCAL,,,,,452,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRILL BIT AO DIA 2.0MMX135MM SCALED,27200000,CDM,272,RC,,,,12640-MAIN,LOCAL,,,,,452,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRILL BIT AO DIA 2.0MMX135MM SCALED,27200000,CDM,272,RC,,,,12640-MAIN,LOCAL,,,,,452,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRIVER HEX 2.00MM STERILE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12440-MAIN,LOCAL,,,,,512,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRIVER HEX 2.00MM STERILE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12440-MAIN,LOCAL,,,,,512,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRIVER HEX 2.00MM STERILE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12440-MAIN,LOCAL,,,,,512,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRIVER HEX 2.00MM STERILE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12440-MAIN,LOCAL,,,,,512,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRIVER HEX 2.00MM STERILE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12440-MAIN,LOCAL,,,,,512,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRIVER HEX 2.00MM STERILE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12440-MAIN,LOCAL,,,,,512,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRIVER HEX 2.5MM STERILE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12441-MAIN,LOCAL,,,,,512,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRIVER HEX 2.5MM STERILE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12441-MAIN,LOCAL,,,,,512,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRIVER HEX 2.5MM STERILE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12441-MAIN,LOCAL,,,,,512,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRIVER HEX 2.5MM STERILE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12441-MAIN,LOCAL,,,,,512,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRIVER HEX 2.5MM STERILE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12441-MAIN,LOCAL,,,,,512,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRIVER HEX 2.5MM STERILE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12441-MAIN,LOCAL,,,,,512,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
droPERidol 2.5 MG/ML Solution 2 mL Vial,J1790.01,CDM,636,RC,J1790,HCPCS,,,,517970201,NDC,2,ML,75.47,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
droPERidol 2.5 MG/ML Solution 2 mL Vial,J1790.01,CDM,636,RC,J1790,HCPCS,,,,517970201,NDC,2,ML,75.47,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
droPERidol 2.5 MG/ML Solution 2 mL Vial,J1790.01,CDM,636,RC,J1790,HCPCS,,,,517970201,NDC,2,ML,75.47,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
droPERidol 2.5 MG/ML Solution 2 mL Vial,J1790.01,CDM,636,RC,J1790,HCPCS,,,,517970201,NDC,2,ML,75.47,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
droPERidol 2.5 MG/ML Solution 2 mL Vial,J1790.01,CDM,636,RC,J1790,HCPCS,,,,517970201,NDC,2,ML,75.47,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
droPERidol 2.5 MG/ML Solution 2 mL Vial,J1790.01,CDM,636,RC,J1790,HCPCS,,,,517970201,NDC,2,ML,75.47,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Drug(S) or Substance(S), Definitive, Qualitative or Quantitative, Not Otherwise Specified; 1-3 - Ref",PX8037590,CDM,300,RC,80375,CPT,90,,,,,,,150,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Drug(S) or Substance(S), Definitive, Qualitative or Quantitative, Not Otherwise Specified; 1-3 - Ref",PX8037590,CDM,300,RC,80375,CPT,90,,,,,,,150,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Drug(S) or Substance(S), Definitive, Qualitative or Quantitative, Not Otherwise Specified; 1-3 - Ref",PX8037590,CDM,300,RC,80375,CPT,90,,,,,,,150,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Drug(S) or Substance(S), Definitive, Qualitative or Quantitative, Not Otherwise Specified; 1-3 - Ref",PX8037590,CDM,300,RC,80375,CPT,90,,,,,,,150,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Drug(S) or Substance(S), Definitive, Qualitative or Quantitative, Not Otherwise Specified; 1-3 - Ref",PX8037590,CDM,300,RC,80375,CPT,90,,,,,,,150,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Drug(S) or Substance(S), Definitive, Qualitative or Quantitative, Not Otherwise Specified; 1-3 - Ref",PX8037590,CDM,300,RC,80375,CPT,90,,,,,,,150,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DULoxetine 20 MG Capsule Delayed Release Particles 60 Each Bottle,63700001,CDM,250,RC,,,,,,2323560,NDC,1,EA,41.76,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DULoxetine 20 MG Capsule Delayed Release Particles 60 Each Bottle,63700001,CDM,250,RC,,,,,,2323560,NDC,1,EA,41.76,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DULoxetine 20 MG Capsule Delayed Release Particles 60 Each Bottle,63700001,CDM,250,RC,,,,,,2323560,NDC,1,EA,41.76,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DULoxetine 20 MG Capsule Delayed Release Particles 60 Each Bottle,63700001,CDM,250,RC,,,,,,2323560,NDC,1,EA,41.76,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DULoxetine 20 MG Capsule Delayed Release Particles 60 Each Bottle,63700001,CDM,250,RC,,,,,,2323560,NDC,1,EA,41.76,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DULoxetine 20 MG Capsule Delayed Release Particles 60 Each Bottle,63700001,CDM,250,RC,,,,,,2323560,NDC,1,EA,41.76,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DULoxetine 20 MG Capsule Delayed Release Particles 60 Each Bottle,63700001,CDM,250,RC,,,,,,57237001760,NDC,1,EA,37.58,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DULoxetine 20 MG Capsule Delayed Release Particles 60 Each Bottle,63700001,CDM,250,RC,,,,,,57237001760,NDC,1,EA,37.58,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DULoxetine 20 MG Capsule Delayed Release Particles 60 Each Bottle,63700001,CDM,250,RC,,,,,,57237001760,NDC,1,EA,37.58,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DULoxetine 20 MG Capsule Delayed Release Particles 60 Each Bottle,63700001,CDM,250,RC,,,,,,57237001760,NDC,1,EA,37.58,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DULoxetine 20 MG Capsule Delayed Release Particles 60 Each Bottle,63700001,CDM,250,RC,,,,,,57237001760,NDC,1,EA,37.58,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DULoxetine 20 MG Capsule Delayed Release Particles 60 Each Bottle,63700001,CDM,250,RC,,,,,,57237001760,NDC,1,EA,37.58,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DULoxetine 30 MG Capsule Delayed Release Particles 90 Each Bottle,63700001,CDM,250,RC,,,,,,57237001890,NDC,1,EA,42.17,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DULoxetine 30 MG Capsule Delayed Release Particles 90 Each Bottle,63700001,CDM,250,RC,,,,,,57237001890,NDC,1,EA,42.17,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DULoxetine 30 MG Capsule Delayed Release Particles 90 Each Bottle,63700001,CDM,250,RC,,,,,,57237001890,NDC,1,EA,42.17,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DULoxetine 30 MG Capsule Delayed Release Particles 90 Each Bottle,63700001,CDM,250,RC,,,,,,57237001890,NDC,1,EA,42.17,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DULoxetine 30 MG Capsule Delayed Release Particles 90 Each Bottle,63700001,CDM,250,RC,,,,,,57237001890,NDC,1,EA,42.17,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DULoxetine 30 MG Capsule Delayed Release Particles 90 Each Bottle,63700001,CDM,250,RC,,,,,,57237001890,NDC,1,EA,42.17,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DULoxetine 60 MG Capsule Delayed Release Particles 30 Each Bottle,63700001,CDM,250,RC,,,,,,43547038103,NDC,0.333333333,EA,14.04,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DULoxetine 60 MG Capsule Delayed Release Particles 30 Each Bottle,63700001,CDM,250,RC,,,,,,43547038103,NDC,0.333333333,EA,14.04,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DULoxetine 60 MG Capsule Delayed Release Particles 30 Each Bottle,63700001,CDM,250,RC,,,,,,43547038103,NDC,0.333333333,EA,14.04,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DULoxetine 60 MG Capsule Delayed Release Particles 30 Each Bottle,63700001,CDM,250,RC,,,,,,43547038103,NDC,0.333333333,EA,14.04,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DULoxetine 60 MG Capsule Delayed Release Particles 30 Each Bottle,63700001,CDM,250,RC,,,,,,43547038103,NDC,0.333333333,EA,14.04,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DULoxetine 60 MG Capsule Delayed Release Particles 30 Each Bottle,63700001,CDM,250,RC,,,,,,43547038103,NDC,0.333333333,EA,14.04,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DULoxetine 60 MG Capsule Delayed Release Particles 30 Each Bottle,63700001,CDM,250,RC,,,,,,57237001930,NDC,0.333333333,EA,14.06,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DULoxetine 60 MG Capsule Delayed Release Particles 30 Each Bottle,63700001,CDM,250,RC,,,,,,57237001930,NDC,0.333333333,EA,14.06,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DULoxetine 60 MG Capsule Delayed Release Particles 30 Each Bottle,63700001,CDM,250,RC,,,,,,57237001930,NDC,0.333333333,EA,14.06,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DULoxetine 60 MG Capsule Delayed Release Particles 30 Each Bottle,63700001,CDM,250,RC,,,,,,57237001930,NDC,0.333333333,EA,14.06,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DULoxetine 60 MG Capsule Delayed Release Particles 30 Each Bottle,63700001,CDM,250,RC,,,,,,57237001930,NDC,0.333333333,EA,14.06,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DULoxetine 60 MG Capsule Delayed Release Particles 30 Each Bottle,63700001,CDM,250,RC,,,,,,57237001930,NDC,0.333333333,EA,14.06,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Duplex Up Extrem Art Bilat,PX9393001,CDM,921,RC,93930,CPT,TC,,,,,,,835,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Duplex Up Extrem Art Bilat,PX9393001,CDM,921,RC,93930,CPT,TC,,,,,,,835,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Duplex Up Extrem Art Bilat,PX9393001,CDM,921,RC,93930,CPT,TC,,,,,,,835,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Duplex Up Extrem Art Bilat,PX9393001,CDM,921,RC,93930,CPT,TC,,,,,,,835,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Duplex Up Extrem Art Bilat,PX9393001,CDM,921,RC,93930,CPT,TC,,,,,,,835,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Duplex Up Extrem Art Bilat,PX9393001,CDM,921,RC,93930,CPT,TC,,,,,,,835,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
durvalumab 120 MG/2.4ML Solution 2.4 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310450012,NDC,30,ML,21771.9,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
durvalumab 120 MG/2.4ML Solution 2.4 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310450012,NDC,30,ML,21771.9,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
durvalumab 120 MG/2.4ML Solution 2.4 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310450012,NDC,30,ML,21771.9,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
durvalumab 120 MG/2.4ML Solution 2.4 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310450012,NDC,30,ML,21771.9,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
durvalumab 120 MG/2.4ML Solution 2.4 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310450012,NDC,30,ML,21771.9,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
durvalumab 120 MG/2.4ML Solution 2.4 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310450012,NDC,30,ML,21771.9,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
durvalumab 500 MG/10ML Solution 10 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310461150,NDC,10,ML,7588.77,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
durvalumab 500 MG/10ML Solution 10 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310461150,NDC,10,ML,7588.77,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
durvalumab 500 MG/10ML Solution 10 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310461150,NDC,10,ML,7588.77,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
durvalumab 500 MG/10ML Solution 10 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310461150,NDC,10,ML,7588.77,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
durvalumab 500 MG/10ML Solution 10 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310461150,NDC,10,ML,7588.77,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
durvalumab 500 MG/10ML Solution 10 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310461150,NDC,10,ML,7588.77,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dutasteride 0.5 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,42806054909,NDC,1,EA,32.49,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dutasteride 0.5 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,42806054909,NDC,1,EA,32.49,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dutasteride 0.5 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,42806054909,NDC,1,EA,32.49,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dutasteride 0.5 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,42806054909,NDC,1,EA,32.49,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dutasteride 0.5 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,42806054909,NDC,1,EA,32.49,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dutasteride 0.5 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,42806054909,NDC,1,EA,32.49,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dx Occult Blood Immunoassay,PX82274,CDM,300,RC,82274,CPT,,,,,,,,105,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dx Occult Blood Immunoassay,PX82274,CDM,300,RC,82274,CPT,,,,,,,,105,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dx Occult Blood Immunoassay,PX82274,CDM,300,RC,82274,CPT,,,,,,,,105,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dx Occult Blood Immunoassay,PX82274,CDM,300,RC,82274,CPT,,,,,,,,105,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dx Occult Blood Immunoassay,PX82274,CDM,300,RC,82274,CPT,,,,,,,,105,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dx Occult Blood Immunoassay,PX82274,CDM,300,RC,82274,CPT,,,,,,,,105,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"DXA, Bone Density Study, Hips/Pelv/Spine",PX7708001,CDM,320,RC,77080,CPT,TC,,,,,,,575,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"DXA, Bone Density Study, Hips/Pelv/Spine",PX7708001,CDM,320,RC,77080,CPT,TC,,,,,,,575,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"DXA, Bone Density Study, Hips/Pelv/Spine",PX7708001,CDM,320,RC,77080,CPT,TC,,,,,,,575,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"DXA, Bone Density Study, Hips/Pelv/Spine",PX7708001,CDM,320,RC,77080,CPT,TC,,,,,,,575,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"DXA, Bone Density Study, Hips/Pelv/Spine",PX7708001,CDM,320,RC,77080,CPT,TC,,,,,,,575,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"DXA, Bone Density Study, Hips/Pelv/Spine",PX7708001,CDM,320,RC,77080,CPT,TC,,,,,,,575,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"DXA, Bone Density Study, Radius/Wrist/Heel",PX7708101,CDM,320,RC,77081,CPT,TC,,,,,,,460,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"DXA, Bone Density Study, Radius/Wrist/Heel",PX7708101,CDM,320,RC,77081,CPT,TC,,,,,,,460,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"DXA, Bone Density Study, Radius/Wrist/Heel",PX7708101,CDM,320,RC,77081,CPT,TC,,,,,,,460,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"DXA, Bone Density Study, Radius/Wrist/Heel",PX7708101,CDM,320,RC,77081,CPT,TC,,,,,,,460,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"DXA, Bone Density Study, Radius/Wrist/Heel",PX7708101,CDM,320,RC,77081,CPT,TC,,,,,,,460,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"DXA, Bone Density Study, Radius/Wrist/Heel",PX7708101,CDM,320,RC,77081,CPT,TC,,,,,,,460,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNABUNION PLATE STERILE INSTRUMENT KIT,27200000,CDM,272,RC,,,,12465-MAIN,LOCAL,,,,,1843,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNABUNION PLATE STERILE INSTRUMENT KIT,27200000,CDM,272,RC,,,,12465-MAIN,LOCAL,,,,,1843,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNABUNION PLATE STERILE INSTRUMENT KIT,27200000,CDM,272,RC,,,,12465-MAIN,LOCAL,,,,,1843,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNABUNION PLATE STERILE INSTRUMENT KIT,27200000,CDM,272,RC,,,,12465-MAIN,LOCAL,,,,,1843,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNABUNION PLATE STERILE INSTRUMENT KIT,27200000,CDM,272,RC,,,,12465-MAIN,LOCAL,,,,,1843,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNABUNION PLATE STERILE INSTRUMENT KIT,27200000,CDM,272,RC,,,,12465-MAIN,LOCAL,,,,,1843,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNABUNION STERILE INSTRUMENT KIT,27200000,CDM,272,RC,,,,11850-MAIN,LOCAL,,,,,2515,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNABUNION STERILE INSTRUMENT KIT,27200000,CDM,272,RC,,,,11850-MAIN,LOCAL,,,,,2515,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNABUNION STERILE INSTRUMENT KIT,27200000,CDM,272,RC,,,,11850-MAIN,LOCAL,,,,,2515,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNABUNION STERILE INSTRUMENT KIT,27200000,CDM,272,RC,,,,11850-MAIN,LOCAL,,,,,2515,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNABUNION STERILE INSTRUMENT KIT,27200000,CDM,272,RC,,,,11850-MAIN,LOCAL,,,,,2515,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNABUNION STERILE INSTRUMENT KIT,27200000,CDM,272,RC,,,,11850-MAIN,LOCAL,,,,,2515,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNAFORCE MPJ REAMERS CUP/CONE 20MM,27200000,CDM,272,RC,,,,11853-MAIN,LOCAL,,,,,1262,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNAFORCE MPJ REAMERS CUP/CONE 20MM,27200000,CDM,272,RC,,,,11853-MAIN,LOCAL,,,,,1262,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNAFORCE MPJ REAMERS CUP/CONE 20MM,27200000,CDM,272,RC,,,,11853-MAIN,LOCAL,,,,,1262,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNAFORCE MPJ REAMERS CUP/CONE 20MM,27200000,CDM,272,RC,,,,11853-MAIN,LOCAL,,,,,1262,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNAFORCE MPJ REAMERS CUP/CONE 20MM,27200000,CDM,272,RC,,,,11853-MAIN,LOCAL,,,,,1262,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNAFORCE MPJ REAMERS CUP/CONE 20MM,27200000,CDM,272,RC,,,,11853-MAIN,LOCAL,,,,,1262,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP - STRAIGHT 12MM - WITH INSTRUMENTATION,27200000,CDM,278,RC,C1713,HCPCS,,11626-MAIN,LOCAL,,,,,3543.65,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP - STRAIGHT 12MM - WITH INSTRUMENTATION,27200000,CDM,278,RC,C1713,HCPCS,,11626-MAIN,LOCAL,,,,,3543.65,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP - STRAIGHT 12MM - WITH INSTRUMENTATION,27200000,CDM,278,RC,C1713,HCPCS,,11626-MAIN,LOCAL,,,,,3543.65,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP - STRAIGHT 12MM - WITH INSTRUMENTATION,27200000,CDM,278,RC,C1713,HCPCS,,11626-MAIN,LOCAL,,,,,3543.65,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP - STRAIGHT 12MM - WITH INSTRUMENTATION,27200000,CDM,278,RC,C1713,HCPCS,,11626-MAIN,LOCAL,,,,,3543.65,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP - STRAIGHT 12MM - WITH INSTRUMENTATION,27200000,CDM,278,RC,C1713,HCPCS,,11626-MAIN,LOCAL,,,,,3543.65,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP - STRAIGHT 14MM - WITH INSTRUMENTATION,27200000,CDM,278,RC,C1713,HCPCS,,11627-MAIN,LOCAL,,,,,3543.65,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP - STRAIGHT 14MM - WITH INSTRUMENTATION,27200000,CDM,278,RC,C1713,HCPCS,,11627-MAIN,LOCAL,,,,,3543.65,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP - STRAIGHT 14MM - WITH INSTRUMENTATION,27200000,CDM,278,RC,C1713,HCPCS,,11627-MAIN,LOCAL,,,,,3543.65,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP - STRAIGHT 14MM - WITH INSTRUMENTATION,27200000,CDM,278,RC,C1713,HCPCS,,11627-MAIN,LOCAL,,,,,3543.65,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP - STRAIGHT 14MM - WITH INSTRUMENTATION,27200000,CDM,278,RC,C1713,HCPCS,,11627-MAIN,LOCAL,,,,,3543.65,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP - STRAIGHT 14MM - WITH INSTRUMENTATION,27200000,CDM,278,RC,C1713,HCPCS,,11627-MAIN,LOCAL,,,,,3543.65,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP IMPLANT BENT 12MM,27200000,CDM,278,RC,C1713,HCPCS,,11629-MAIN,LOCAL,,,,,3543.65,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP IMPLANT BENT 12MM,27200000,CDM,278,RC,C1713,HCPCS,,11629-MAIN,LOCAL,,,,,3543.65,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP IMPLANT BENT 12MM,27200000,CDM,278,RC,C1713,HCPCS,,11629-MAIN,LOCAL,,,,,3543.65,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP IMPLANT BENT 12MM,27200000,CDM,278,RC,C1713,HCPCS,,11629-MAIN,LOCAL,,,,,3543.65,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP IMPLANT BENT 12MM,27200000,CDM,278,RC,C1713,HCPCS,,11629-MAIN,LOCAL,,,,,3543.65,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP IMPLANT BENT 12MM,27200000,CDM,278,RC,C1713,HCPCS,,11629-MAIN,LOCAL,,,,,3543.65,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP IMPLANT BENT 14MM,27200000,CDM,278,RC,C1713,HCPCS,,11631-MAIN,LOCAL,,,,,3543.65,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP IMPLANT BENT 14MM,27200000,CDM,278,RC,C1713,HCPCS,,11631-MAIN,LOCAL,,,,,3543.65,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP IMPLANT BENT 14MM,27200000,CDM,278,RC,C1713,HCPCS,,11631-MAIN,LOCAL,,,,,3543.65,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP IMPLANT BENT 14MM,27200000,CDM,278,RC,C1713,HCPCS,,11631-MAIN,LOCAL,,,,,3543.65,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP IMPLANT BENT 14MM,27200000,CDM,278,RC,C1713,HCPCS,,11631-MAIN,LOCAL,,,,,3543.65,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP IMPLANT BENT 14MM,27200000,CDM,278,RC,C1713,HCPCS,,11631-MAIN,LOCAL,,,,,3543.65,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP IMPLANT BENT 16MM,27200000,CDM,278,RC,C1713,HCPCS,,11633-MAIN,LOCAL,,,,,3543.65,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP IMPLANT BENT 16MM,27200000,CDM,278,RC,C1713,HCPCS,,11633-MAIN,LOCAL,,,,,3543.65,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP IMPLANT BENT 16MM,27200000,CDM,278,RC,C1713,HCPCS,,11633-MAIN,LOCAL,,,,,3543.65,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP IMPLANT BENT 16MM,27200000,CDM,278,RC,C1713,HCPCS,,11633-MAIN,LOCAL,,,,,3543.65,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP IMPLANT BENT 16MM,27200000,CDM,278,RC,C1713,HCPCS,,11633-MAIN,LOCAL,,,,,3543.65,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP IMPLANT BENT 16MM,27200000,CDM,278,RC,C1713,HCPCS,,11633-MAIN,LOCAL,,,,,3543.65,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP IMPLANT STRAIGHT 12MM,27200000,CDM,278,RC,C1713,HCPCS,,11628-MAIN,LOCAL,,,,,3543.65,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP IMPLANT STRAIGHT 12MM,27200000,CDM,278,RC,C1713,HCPCS,,11628-MAIN,LOCAL,,,,,3543.65,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP IMPLANT STRAIGHT 12MM,27200000,CDM,278,RC,C1713,HCPCS,,11628-MAIN,LOCAL,,,,,3543.65,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP IMPLANT STRAIGHT 12MM,27200000,CDM,278,RC,C1713,HCPCS,,11628-MAIN,LOCAL,,,,,3543.65,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP IMPLANT STRAIGHT 12MM,27200000,CDM,278,RC,C1713,HCPCS,,11628-MAIN,LOCAL,,,,,3543.65,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP IMPLANT STRAIGHT 12MM,27200000,CDM,278,RC,C1713,HCPCS,,11628-MAIN,LOCAL,,,,,3543.65,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP IMPLANT STRAIGHT 14MM,27200000,CDM,278,RC,C1713,HCPCS,,11630-MAIN,LOCAL,,,,,3543.65,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP IMPLANT STRAIGHT 14MM,27200000,CDM,278,RC,C1713,HCPCS,,11630-MAIN,LOCAL,,,,,3543.65,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP IMPLANT STRAIGHT 14MM,27200000,CDM,278,RC,C1713,HCPCS,,11630-MAIN,LOCAL,,,,,3543.65,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP IMPLANT STRAIGHT 14MM,27200000,CDM,278,RC,C1713,HCPCS,,11630-MAIN,LOCAL,,,,,3543.65,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP IMPLANT STRAIGHT 14MM,27200000,CDM,278,RC,C1713,HCPCS,,11630-MAIN,LOCAL,,,,,3543.65,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP IMPLANT STRAIGHT 14MM,27200000,CDM,278,RC,C1713,HCPCS,,11630-MAIN,LOCAL,,,,,3543.65,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP IMPLANT STRAIGHT 16MM,27200000,CDM,278,RC,C1713,HCPCS,,11632-MAIN,LOCAL,,,,,3543.65,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP IMPLANT STRAIGHT 16MM,27200000,CDM,278,RC,C1713,HCPCS,,11632-MAIN,LOCAL,,,,,3543.65,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP IMPLANT STRAIGHT 16MM,27200000,CDM,278,RC,C1713,HCPCS,,11632-MAIN,LOCAL,,,,,3543.65,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP IMPLANT STRAIGHT 16MM,27200000,CDM,278,RC,C1713,HCPCS,,11632-MAIN,LOCAL,,,,,3543.65,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP IMPLANT STRAIGHT 16MM,27200000,CDM,278,RC,C1713,HCPCS,,11632-MAIN,LOCAL,,,,,3543.65,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP IMPLANT STRAIGHT 16MM,27200000,CDM,278,RC,C1713,HCPCS,,11632-MAIN,LOCAL,,,,,3543.65,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dystrophic Nail Trimming Any Number,PXG0127F,CDM,940,RC,G0127,HCPCS,,,,,,,,53,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dystrophic Nail Trimming Any Number,PXG0127F,CDM,940,RC,G0127,HCPCS,,,,,,,,53,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dystrophic Nail Trimming Any Number,PXG0127F,CDM,940,RC,G0127,HCPCS,,,,,,,,53,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dystrophic Nail Trimming Any Number,PXG0127F,CDM,940,RC,G0127,HCPCS,,,,,,,,53,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dystrophic Nail Trimming Any Number,PXG0127F,CDM,940,RC,G0127,HCPCS,,,,,,,,53,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dystrophic Nail Trimming Any Number,PXG0127F,CDM,940,RC,G0127,HCPCS,,,,,,,,53,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Each Add'l Hour IV Hydration,PX96361,CDM,260,RC,96361,CPT,,,,,,,,123,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Each Add'l Hour IV Hydration,PX96361,CDM,260,RC,96361,CPT,,,,,,,,123,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Each Add'l Hour IV Hydration,PX96361,CDM,260,RC,96361,CPT,,,,,,,,123,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Each Add'l Hour IV Hydration,PX96361,CDM,260,RC,96361,CPT,,,,,,,,123,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Each Add'l Hour IV Hydration,PX96361,CDM,260,RC,96361,CPT,,,,,,,,123,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Each Add'l Hour IV Hydration,PX96361,CDM,260,RC,96361,CPT,,,,,,,,123,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Each Add'l Hour IV Infusion <8 Hour,PX96366,CDM,260,RC,96366,CPT,,,,,,,,161,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Each Add'l Hour IV Infusion <8 Hour,PX96366,CDM,260,RC,96366,CPT,,,,,,,,161,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Each Add'l Hour IV Infusion <8 Hour,PX96366,CDM,260,RC,96366,CPT,,,,,,,,161,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Each Add'l Hour IV Infusion <8 Hour,PX96366,CDM,260,RC,96366,CPT,,,,,,,,161,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Each Add'l Hour IV Infusion <8 Hour,PX96366,CDM,260,RC,96366,CPT,,,,,,,,161,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Each Add'l Hour IV Infusion <8 Hour,PX96366,CDM,260,RC,96366,CPT,,,,,,,,161,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Each Add'l Sequential IV Infusion <1 Hour,PX96367,CDM,260,RC,96367,CPT,,,,,,,,190,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Each Add'l Sequential IV Infusion <1 Hour,PX96367,CDM,260,RC,96367,CPT,,,,,,,,190,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Each Add'l Sequential IV Infusion <1 Hour,PX96367,CDM,260,RC,96367,CPT,,,,,,,,190,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Each Add'l Sequential IV Infusion <1 Hour,PX96367,CDM,260,RC,96367,CPT,,,,,,,,190,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Each Add'l Sequential IV Infusion <1 Hour,PX96367,CDM,260,RC,96367,CPT,,,,,,,,190,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Each Add'l Sequential IV Infusion <1 Hour,PX96367,CDM,260,RC,96367,CPT,,,,,,,,190,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Each Add'l Sequential Push New Drug,PX96375,CDM,260,RC,96375,CPT,,,,,,,,130,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Each Add'l Sequential Push New Drug,PX96375,CDM,260,RC,96375,CPT,,,,,,,,130,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Each Add'l Sequential Push New Drug,PX96375,CDM,260,RC,96375,CPT,,,,,,,,130,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Each Add'l Sequential Push New Drug,PX96375,CDM,260,RC,96375,CPT,,,,,,,,130,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Each Add'l Sequential Push New Drug,PX96375,CDM,260,RC,96375,CPT,,,,,,,,130,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Each Add'l Sequential Push New Drug,PX96375,CDM,260,RC,96375,CPT,,,,,,,,130,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ebv, Nuclear Antigen - Ref",PX8666490,CDM,300,RC,86664,CPT,90,,,,,,,58,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ebv, Nuclear Antigen - Ref",PX8666490,CDM,300,RC,86664,CPT,90,,,,,,,58,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ebv, Nuclear Antigen - Ref",PX8666490,CDM,300,RC,86664,CPT,90,,,,,,,58,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ebv, Nuclear Antigen - Ref",PX8666490,CDM,300,RC,86664,CPT,90,,,,,,,58,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ebv, Nuclear Antigen - Ref",PX8666490,CDM,300,RC,86664,CPT,90,,,,,,,58,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ebv, Nuclear Antigen - Ref",PX8666490,CDM,300,RC,86664,CPT,90,,,,,,,58,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ebv, Viral Capsid Ab - Ref",PX8666590,CDM,300,RC,86665,CPT,90,,,,,,,58,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ebv, Viral Capsid Ab - Ref",PX8666590,CDM,300,RC,86665,CPT,90,,,,,,,58,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ebv, Viral Capsid Ab - Ref",PX8666590,CDM,300,RC,86665,CPT,90,,,,,,,58,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ebv, Viral Capsid Ab - Ref",PX8666590,CDM,300,RC,86665,CPT,90,,,,,,,58,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ebv, Viral Capsid Ab - Ref",PX8666590,CDM,300,RC,86665,CPT,90,,,,,,,58,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ebv, Viral Capsid Ab - Ref",PX8666590,CDM,300,RC,86665,CPT,90,,,,,,,58,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ecg 12 Lead, Interp Only",PX93010,CDM,985,RC,93010,CPT,,,,,,,,29,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ecg 12 Lead, Interp Only",PX93010,CDM,985,RC,93010,CPT,,,,,,,,29,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ecg 12 Lead, Interp Only",PX93010,CDM,985,RC,93010,CPT,,,,,,,,29,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ecg 12 Lead, Interp Only",PX93010,CDM,985,RC,93010,CPT,,,,,,,,29,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ecg 12 Lead, Interp Only",PX93010,CDM,985,RC,93010,CPT,,,,,,,,29,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ecg 12 Lead, Interp Only",PX93010,CDM,985,RC,93010,CPT,,,,,,,,29,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ecg 12 Lead, Tracing Only",PX93005,CDM,730,RC,93005,CPT,,,,,,,,298,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ecg 12 Lead, Tracing Only",PX93005,CDM,730,RC,93005,CPT,,,,,,,,298,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ecg 12 Lead, Tracing Only",PX93005,CDM,730,RC,93005,CPT,,,,,,,,298,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ecg 12 Lead, Tracing Only",PX93005,CDM,730,RC,93005,CPT,,,,,,,,298,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ecg 12 Lead, Tracing Only",PX93005,CDM,730,RC,93005,CPT,,,,,,,,298,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ecg 12 Lead, Tracing Only",PX93005,CDM,730,RC,93005,CPT,,,,,,,,298,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Echo Heart Xthoracic,Limited",PX9330801,CDM,480,RC,93308,CPT,TC,,,,,,,349,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Echo Heart Xthoracic,Limited",PX9330801,CDM,480,RC,93308,CPT,TC,,,,,,,349,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Echo Heart Xthoracic,Limited",PX9330801,CDM,480,RC,93308,CPT,TC,,,,,,,349,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Echo Heart Xthoracic,Limited",PX9330801,CDM,480,RC,93308,CPT,TC,,,,,,,349,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Echo Heart Xthoracic,Limited",PX9330801,CDM,480,RC,93308,CPT,TC,,,,,,,349,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Echo Heart Xthoracic,Limited",PX9330801,CDM,480,RC,93308,CPT,TC,,,,,,,349,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Echo Tt 2d Complete,PX9330701,CDM,480,RC,93307,CPT,TC,,,,,,,2303,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Echo Tt 2d Complete,PX9330701,CDM,480,RC,93307,CPT,TC,,,,,,,2303,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Echo Tt 2d Complete,PX9330701,CDM,480,RC,93307,CPT,TC,,,,,,,2303,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Echo Tt 2d Complete,PX9330701,CDM,480,RC,93307,CPT,TC,,,,,,,2303,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Echo Tt 2d Complete,PX9330701,CDM,480,RC,93307,CPT,TC,,,,,,,2303,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Echo Tt 2d Complete,PX9330701,CDM,480,RC,93307,CPT,TC,,,,,,,2303,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Egd Balloon Dil Esoph30 Mm/>,PX43233F,CDM,750,RC,43233,CPT,,,,,,,,1120,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,987.84,6141.46
Egd Balloon Dil Esoph30 Mm/>,PX43233F,CDM,750,RC,43233,CPT,,,,,,,,1120,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,987.84,6141.46
Egd Balloon Dil Esoph30 Mm/>,PX43233F,CDM,750,RC,43233,CPT,,,,,,,,1120,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,987.84,6141.46
Egd Balloon Dil Esoph30 Mm/>,PX43233F,CDM,750,RC,43233,CPT,,,,,,,,1120,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,987.84,6141.46
Egd Balloon Dil Esoph30 Mm/>,PX43233F,CDM,750,RC,43233,CPT,,,,,,,,1120,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,987.84,6141.46
Egd Balloon Dil Esoph30 Mm/>,PX43233F,CDM,750,RC,43233,CPT,,,,,,,,1120,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,987.84,6141.46
Egd Balloon Dil Esoph30 Mm/>,PX43233P,CDM,983,RC,43233,CPT,,,,,,,,480,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Egd Balloon Dil Esoph30 Mm/>,PX43233P,CDM,983,RC,43233,CPT,,,,,,,,480,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Egd Balloon Dil Esoph30 Mm/>,PX43233P,CDM,983,RC,43233,CPT,,,,,,,,480,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Egd Balloon Dil Esoph30 Mm/>,PX43233P,CDM,983,RC,43233,CPT,,,,,,,,480,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Egd Balloon Dil Esoph30 Mm/>,PX43233P,CDM,983,RC,43233,CPT,,,,,,,,480,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Egd Balloon Dil Esoph30 Mm/>,PX43233P,CDM,983,RC,43233,CPT,,,,,,,,480,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ehrlichia (Anaplasma) Ab - Ref,PX8666690,CDM,300,RC,86666,CPT,90,,,,,,,163,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ehrlichia (Anaplasma) Ab - Ref,PX8666690,CDM,300,RC,86666,CPT,90,,,,,,,163,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ehrlichia (Anaplasma) Ab - Ref,PX8666690,CDM,300,RC,86666,CPT,90,,,,,,,163,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ehrlichia (Anaplasma) Ab - Ref,PX8666690,CDM,300,RC,86666,CPT,90,,,,,,,163,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ehrlichia (Anaplasma) Ab - Ref,PX8666690,CDM,300,RC,86666,CPT,90,,,,,,,163,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ehrlichia (Anaplasma) Ab - Ref,PX8666690,CDM,300,RC,86666,CPT,90,,,,,,,163,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
El-1 Fecal Quantitative,PX8265390,CDM,300,RC,82653,CPT,90,,,,,,,383,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
El-1 Fecal Quantitative,PX8265390,CDM,300,RC,82653,CPT,90,,,,,,,383,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
El-1 Fecal Quantitative,PX8265390,CDM,300,RC,82653,CPT,90,,,,,,,383,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
El-1 Fecal Quantitative,PX8265390,CDM,300,RC,82653,CPT,90,,,,,,,383,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
El-1 Fecal Quantitative,PX8265390,CDM,300,RC,82653,CPT,90,,,,,,,383,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
El-1 Fecal Quantitative,PX8265390,CDM,300,RC,82653,CPT,90,,,,,,,383,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Electric Stimulation Therapy,PX97014,CDM,420,RC,97014,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Electric Stimulation Therapy,PX97014,CDM,420,RC,97014,CPT,,,,,,,,135,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Electric Stimulation Therapy,PX97014,CDM,420,RC,97014,CPT,,,,,,,,135,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Electric Stimulation Therapy,PX97014,CDM,420,RC,97014,CPT,,,,,,,,135,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Electric Stimulation Therapy,PX97014,CDM,420,RC,97014,CPT,,,,,,,,135,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Electric Stimulation Therapy,PX97014,CDM,420,RC,97014,CPT,,,,,,,,135,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Electrical Stimulation,PX97032,CDM,420,RC,97032,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Electrical Stimulation,PX97032,CDM,420,RC,97032,CPT,,,,,,,,135,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Electrical Stimulation,PX97032,CDM,420,RC,97032,CPT,,,,,,,,135,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Electrical Stimulation,PX97032,CDM,420,RC,97032,CPT,,,,,,,,135,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Electrical Stimulation,PX97032,CDM,420,RC,97032,CPT,,,,,,,,135,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Electrical Stimulation,PX97032,CDM,420,RC,97032,CPT,,,,,,,,135,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ELECTRODE ADULT PACING ONESTEP,120.214,CDM,272,RC,A4556,HCPCS,,10242-MAIN,LOCAL,,,,,153,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ELECTRODE ADULT PACING ONESTEP,120.214,CDM,272,RC,A4556,HCPCS,,10242-MAIN,LOCAL,,,,,153,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ELECTRODE ADULT PACING ONESTEP,120.214,CDM,272,RC,A4556,HCPCS,,10242-MAIN,LOCAL,,,,,153,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ELECTRODE ADULT PACING ONESTEP,120.214,CDM,272,RC,A4556,HCPCS,,10242-MAIN,LOCAL,,,,,153,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ELECTRODE ADULT PACING ONESTEP,120.214,CDM,272,RC,A4556,HCPCS,,10242-MAIN,LOCAL,,,,,153,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ELECTRODE ADULT PACING ONESTEP,120.214,CDM,272,RC,A4556,HCPCS,,10242-MAIN,LOCAL,,,,,153,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ELECTRODE PEDS ONESTEP SINGLE,120.343,CDM,272,RC,A4556,HCPCS,,10296-MAIN,LOCAL,,,,,112,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ELECTRODE PEDS ONESTEP SINGLE,120.343,CDM,272,RC,A4556,HCPCS,,10296-MAIN,LOCAL,,,,,112,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ELECTRODE PEDS ONESTEP SINGLE,120.343,CDM,272,RC,A4556,HCPCS,,10296-MAIN,LOCAL,,,,,112,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ELECTRODE PEDS ONESTEP SINGLE,120.343,CDM,272,RC,A4556,HCPCS,,10296-MAIN,LOCAL,,,,,112,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ELECTRODE PEDS ONESTEP SINGLE,120.343,CDM,272,RC,A4556,HCPCS,,10296-MAIN,LOCAL,,,,,112,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ELECTRODE PEDS ONESTEP SINGLE,120.343,CDM,272,RC,A4556,HCPCS,,10296-MAIN,LOCAL,,,,,112,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ELECTRODES NEEDLE TIP PRECISE 2.4MM,27200000,CDM,272,RC,,,,12074-MAIN,LOCAL,,,,,11,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ELECTRODES NEEDLE TIP PRECISE 2.4MM,27200000,CDM,272,RC,,,,12074-MAIN,LOCAL,,,,,11,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ELECTRODES NEEDLE TIP PRECISE 2.4MM,27200000,CDM,272,RC,,,,12074-MAIN,LOCAL,,,,,11,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ELECTRODES NEEDLE TIP PRECISE 2.4MM,27200000,CDM,272,RC,,,,12074-MAIN,LOCAL,,,,,11,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ELECTRODES NEEDLE TIP PRECISE 2.4MM,27200000,CDM,272,RC,,,,12074-MAIN,LOCAL,,,,,11,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ELECTRODES NEEDLE TIP PRECISE 2.4MM,27200000,CDM,272,RC,,,,12074-MAIN,LOCAL,,,,,11,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Electrolyte Panel,PX80051,CDM,300,RC,80051,CPT,,,,,,,,175,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Electrolyte Panel,PX80051,CDM,300,RC,80051,CPT,,,,,,,,175,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Electrolyte Panel,PX80051,CDM,300,RC,80051,CPT,,,,,,,,175,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Electrolyte Panel,PX80051,CDM,300,RC,80051,CPT,,,,,,,,175,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Electrolyte Panel,PX80051,CDM,300,RC,80051,CPT,,,,,,,,175,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Electrolyte Panel,PX80051,CDM,300,RC,80051,CPT,,,,,,,,175,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Emergency Level I Visit,PX99281P,CDM,981,RC,99281,CPT,,,,,,,,224,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Emergency Level I Visit,PX99281P,CDM,981,RC,99281,CPT,,,,,,,,224,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Emergency Level I Visit,PX99281P,CDM,981,RC,99281,CPT,,,,,,,,224,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Emergency Level I Visit,PX99281P,CDM,981,RC,99281,CPT,,,,,,,,224,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Emergency Level I Visit,PX99281P,CDM,981,RC,99281,CPT,,,,,,,,224,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Emergency Level I Visit,PX99281P,CDM,981,RC,99281,CPT,,,,,,,,224,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Emergency Level II Visit,PX99282P,CDM,981,RC,99282,CPT,,,,,,,,337,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Emergency Level II Visit,PX99282P,CDM,981,RC,99282,CPT,,,,,,,,337,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Emergency Level II Visit,PX99282P,CDM,981,RC,99282,CPT,,,,,,,,337,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Emergency Level II Visit,PX99282P,CDM,981,RC,99282,CPT,,,,,,,,337,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Emergency Level II Visit,PX99282P,CDM,981,RC,99282,CPT,,,,,,,,337,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Emergency Level II Visit,PX99282P,CDM,981,RC,99282,CPT,,,,,,,,337,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Emergency Level III Visit,PX99283P,CDM,981,RC,99283,CPT,,,,,,,,568,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Emergency Level III Visit,PX99283P,CDM,981,RC,99283,CPT,,,,,,,,568,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Emergency Level III Visit,PX99283P,CDM,981,RC,99283,CPT,,,,,,,,568,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Emergency Level III Visit,PX99283P,CDM,981,RC,99283,CPT,,,,,,,,568,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Emergency Level III Visit,PX99283P,CDM,981,RC,99283,CPT,,,,,,,,568,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Emergency Level III Visit,PX99283P,CDM,981,RC,99283,CPT,,,,,,,,568,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Emergency Level IV Visit,PX99284P,CDM,981,RC,99284,CPT,,,,,,,,914,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Emergency Level IV Visit,PX99284P,CDM,981,RC,99284,CPT,,,,,,,,914,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Emergency Level IV Visit,PX99284P,CDM,981,RC,99284,CPT,,,,,,,,914,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Emergency Level IV Visit,PX99284P,CDM,981,RC,99284,CPT,,,,,,,,914,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Emergency Level IV Visit,PX99284P,CDM,981,RC,99284,CPT,,,,,,,,914,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Emergency Level IV Visit,PX99284P,CDM,981,RC,99284,CPT,,,,,,,,914,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Emergency Level V Visit,PX99285P,CDM,981,RC,99285,CPT,,,,,,,,1436,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Emergency Level V Visit,PX99285P,CDM,981,RC,99285,CPT,,,,,,,,1436,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Emergency Level V Visit,PX99285P,CDM,981,RC,99285,CPT,,,,,,,,1436,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Emergency Level V Visit,PX99285P,CDM,981,RC,99285,CPT,,,,,,,,1436,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Emergency Level V Visit,PX99285P,CDM,981,RC,99285,CPT,,,,,,,,1436,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Emergency Level V Visit,PX99285P,CDM,981,RC,99285,CPT,,,,,,,,1436,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
empagliflozin 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,597015230,NDC,1,EA,92.47,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
empagliflozin 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,597015230,NDC,1,EA,92.47,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
empagliflozin 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,597015230,NDC,1,EA,92.47,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
empagliflozin 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,597015230,NDC,1,EA,92.47,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
empagliflozin 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,597015230,NDC,1,EA,92.47,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
empagliflozin 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,597015230,NDC,1,EA,92.47,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
empagliflozin 10 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,597015237,NDC,1,EA,104.66,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
empagliflozin 10 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,597015237,NDC,1,EA,104.66,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
empagliflozin 10 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,597015237,NDC,1,EA,104.66,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
empagliflozin 10 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,597015237,NDC,1,EA,104.66,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
empagliflozin 10 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,597015237,NDC,1,EA,104.66,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
empagliflozin 10 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,597015237,NDC,1,EA,104.66,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
empagliflozin 25 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,597015330,NDC,0.4,EA,43.54,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
empagliflozin 25 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,597015330,NDC,0.4,EA,43.54,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
empagliflozin 25 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,597015330,NDC,0.4,EA,43.54,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
empagliflozin 25 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,597015330,NDC,0.4,EA,43.54,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
empagliflozin 25 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,597015330,NDC,0.4,EA,43.54,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
empagliflozin 25 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,597015330,NDC,0.4,EA,43.54,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
empagliflozin 25 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,597015337,NDC,0.4,EA,43.54,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
empagliflozin 25 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,597015337,NDC,0.4,EA,43.54,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
empagliflozin 25 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,597015337,NDC,0.4,EA,43.54,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
empagliflozin 25 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,597015337,NDC,0.4,EA,43.54,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
empagliflozin 25 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,597015337,NDC,0.4,EA,43.54,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
empagliflozin 25 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,597015337,NDC,0.4,EA,43.54,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enalapril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714044201,NDC,1,EA,6.33,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enalapril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714044201,NDC,1,EA,6.33,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enalapril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714044201,NDC,1,EA,6.33,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enalapril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714044201,NDC,1,EA,6.33,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enalapril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714044201,NDC,1,EA,6.33,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enalapril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714044201,NDC,1,EA,6.33,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enalapril 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904550261,NDC,0.5,EA,4.15,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enalapril 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904550261,NDC,0.5,EA,4.15,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enalapril 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904550261,NDC,0.5,EA,4.15,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enalapril 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904550261,NDC,0.5,EA,4.15,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enalapril 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904550261,NDC,0.5,EA,4.15,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enalapril 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904550261,NDC,0.5,EA,4.15,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enalaprilat 1.25 MG/ML Injectable 1 mL Vial,25000000,CDM,250,RC,,,,,,143978701,NDC,1,ML,40.39,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enalaprilat 1.25 MG/ML Injectable 1 mL Vial,25000000,CDM,250,RC,,,,,,143978701,NDC,1,ML,40.39,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enalaprilat 1.25 MG/ML Injectable 1 mL Vial,25000000,CDM,250,RC,,,,,,143978701,NDC,1,ML,40.39,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enalaprilat 1.25 MG/ML Injectable 1 mL Vial,25000000,CDM,250,RC,,,,,,143978701,NDC,1,ML,40.39,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enalaprilat 1.25 MG/ML Injectable 1 mL Vial,25000000,CDM,250,RC,,,,,,143978701,NDC,1,ML,40.39,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enalaprilat 1.25 MG/ML Injectable 1 mL Vial,25000000,CDM,250,RC,,,,,,143978701,NDC,1,ML,40.39,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enalaprilat 1.25 MG/ML Injectable 1 mL Vial,25000000,CDM,250,RC,,,,,,143978710,NDC,1,ML,39.84,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enalaprilat 1.25 MG/ML Injectable 1 mL Vial,25000000,CDM,250,RC,,,,,,143978710,NDC,1,ML,39.84,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enalaprilat 1.25 MG/ML Injectable 1 mL Vial,25000000,CDM,250,RC,,,,,,143978710,NDC,1,ML,39.84,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enalaprilat 1.25 MG/ML Injectable 1 mL Vial,25000000,CDM,250,RC,,,,,,143978710,NDC,1,ML,39.84,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enalaprilat 1.25 MG/ML Injectable 1 mL Vial,25000000,CDM,250,RC,,,,,,143978710,NDC,1,ML,39.84,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enalaprilat 1.25 MG/ML Injectable 1 mL Vial,25000000,CDM,250,RC,,,,,,143978710,NDC,1,ML,39.84,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enalaprilat 1.25 MG/ML Injectable 2 mL Vial,25000000,CDM,250,RC,,,,,,143978601,NDC,2,ML,75.63,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enalaprilat 1.25 MG/ML Injectable 2 mL Vial,25000000,CDM,250,RC,,,,,,143978601,NDC,2,ML,75.63,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enalaprilat 1.25 MG/ML Injectable 2 mL Vial,25000000,CDM,250,RC,,,,,,143978601,NDC,2,ML,75.63,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enalaprilat 1.25 MG/ML Injectable 2 mL Vial,25000000,CDM,250,RC,,,,,,143978601,NDC,2,ML,75.63,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enalaprilat 1.25 MG/ML Injectable 2 mL Vial,25000000,CDM,250,RC,,,,,,143978601,NDC,2,ML,75.63,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enalaprilat 1.25 MG/ML Injectable 2 mL Vial,25000000,CDM,250,RC,,,,,,143978601,NDC,2,ML,75.63,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ENDOCAVITY NEEDLE GUIDE,27200000,CDM,272,RC,,,,11134-MAIN,LOCAL,,,,,37.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ENDOCAVITY NEEDLE GUIDE,27200000,CDM,272,RC,,,,11134-MAIN,LOCAL,,,,,37.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ENDOCAVITY NEEDLE GUIDE,27200000,CDM,272,RC,,,,11134-MAIN,LOCAL,,,,,37.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ENDOCAVITY NEEDLE GUIDE,27200000,CDM,272,RC,,,,11134-MAIN,LOCAL,,,,,37.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ENDOCAVITY NEEDLE GUIDE,27200000,CDM,272,RC,,,,11134-MAIN,LOCAL,,,,,37.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ENDOCAVITY NEEDLE GUIDE,27200000,CDM,272,RC,,,,11134-MAIN,LOCAL,,,,,37.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Endocrine E2,PX82670,CDM,300,RC,82670,CPT,90,,,,,,,55,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Endocrine E2,PX82670,CDM,300,RC,82670,CPT,90,,,,,,,55,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Endocrine E2,PX82670,CDM,300,RC,82670,CPT,90,,,,,,,55,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Endocrine E2,PX82670,CDM,300,RC,82670,CPT,90,,,,,,,55,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Endocrine E2,PX82670,CDM,300,RC,82670,CPT,90,,,,,,,55,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Endocrine E2,PX82670,CDM,300,RC,82670,CPT,90,,,,,,,55,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ENDOLOOP COATED VICRYL 0 18,27200000,CDM,272,RC,,,,10228-MAIN,LOCAL,,,,,143.6,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ENDOLOOP COATED VICRYL 0 18,27200000,CDM,272,RC,,,,10228-MAIN,LOCAL,,,,,143.6,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ENDOLOOP COATED VICRYL 0 18,27200000,CDM,272,RC,,,,10228-MAIN,LOCAL,,,,,143.6,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ENDOLOOP COATED VICRYL 0 18,27200000,CDM,272,RC,,,,10228-MAIN,LOCAL,,,,,143.6,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ENDOLOOP COATED VICRYL 0 18,27200000,CDM,272,RC,,,,10228-MAIN,LOCAL,,,,,143.6,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ENDOLOOP COATED VICRYL 0 18,27200000,CDM,272,RC,,,,10228-MAIN,LOCAL,,,,,143.6,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ENDOWRIST INSTRUMENTS PERMANENT CAUTERY HOOK 8MM,27200000,CDM,272,RC,,,,12050-MAIN,LOCAL,,,,,224,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ENDOWRIST INSTRUMENTS PERMANENT CAUTERY HOOK 8MM,27200000,CDM,272,RC,,,,12050-MAIN,LOCAL,,,,,224,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ENDOWRIST INSTRUMENTS PERMANENT CAUTERY HOOK 8MM,27200000,CDM,272,RC,,,,12050-MAIN,LOCAL,,,,,224,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ENDOWRIST INSTRUMENTS PERMANENT CAUTERY HOOK 8MM,27200000,CDM,272,RC,,,,12050-MAIN,LOCAL,,,,,224,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ENDOWRIST INSTRUMENTS PERMANENT CAUTERY HOOK 8MM,27200000,CDM,272,RC,,,,12050-MAIN,LOCAL,,,,,224,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ENDOWRIST INSTRUMENTS PERMANENT CAUTERY HOOK 8MM,27200000,CDM,272,RC,,,,12050-MAIN,LOCAL,,,,,224,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062430,NDC,0.3,ML,147.12,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062430,NDC,0.3,ML,147.12,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062430,NDC,0.3,ML,147.12,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062430,NDC,0.3,ML,147.12,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062430,NDC,0.3,ML,147.12,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062430,NDC,0.3,ML,147.12,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801301,NDC,0.3,ML,147.12,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801301,NDC,0.3,ML,147.12,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801301,NDC,0.3,ML,147.12,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801301,NDC,0.3,ML,147.12,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801301,NDC,0.3,ML,147.12,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801301,NDC,0.3,ML,147.12,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801310,NDC,0.3,ML,147.12,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801310,NDC,0.3,ML,147.12,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801310,NDC,0.3,ML,147.12,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801310,NDC,0.3,ML,147.12,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801310,NDC,0.3,ML,147.12,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801310,NDC,0.3,ML,147.12,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714000601,NDC,0.3,ML,53.39,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714000601,NDC,0.3,ML,53.39,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714000601,NDC,0.3,ML,53.39,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714000601,NDC,0.3,ML,53.39,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714000601,NDC,0.3,ML,53.39,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714000601,NDC,0.3,ML,53.39,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062001,NDC,0.4,ML,189.48,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062001,NDC,0.4,ML,189.48,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062001,NDC,0.4,ML,189.48,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062001,NDC,0.4,ML,189.48,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062001,NDC,0.4,ML,189.48,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062001,NDC,0.4,ML,189.48,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062040,NDC,0.4,ML,189.48,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062040,NDC,0.4,ML,189.48,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062040,NDC,0.4,ML,189.48,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062040,NDC,0.4,ML,189.48,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062040,NDC,0.4,ML,189.48,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062040,NDC,0.4,ML,189.48,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801401,NDC,0.4,ML,189.48,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801401,NDC,0.4,ML,189.48,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801401,NDC,0.4,ML,189.48,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801401,NDC,0.4,ML,189.48,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801401,NDC,0.4,ML,189.48,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801401,NDC,0.4,ML,189.48,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801410,NDC,0.4,ML,189.48,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801410,NDC,0.4,ML,189.48,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801410,NDC,0.4,ML,189.48,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801410,NDC,0.4,ML,189.48,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801410,NDC,0.4,ML,189.48,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801410,NDC,0.4,ML,189.48,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714001601,NDC,0.4,ML,100.47,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714001601,NDC,0.4,ML,100.47,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714001601,NDC,0.4,ML,100.47,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714001601,NDC,0.4,ML,100.47,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714001601,NDC,0.4,ML,100.47,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714001601,NDC,0.4,ML,100.47,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062160,NDC,0.6,ML,274.53,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062160,NDC,0.6,ML,274.53,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062160,NDC,0.6,ML,274.53,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062160,NDC,0.6,ML,274.53,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062160,NDC,0.6,ML,274.53,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062160,NDC,0.6,ML,274.53,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801601,NDC,0.6,ML,274.53,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801601,NDC,0.6,ML,274.53,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801601,NDC,0.6,ML,274.53,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801601,NDC,0.6,ML,274.53,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801601,NDC,0.6,ML,274.53,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801601,NDC,0.6,ML,274.53,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801610,NDC,0.6,ML,274.53,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801610,NDC,0.6,ML,274.53,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801610,NDC,0.6,ML,274.53,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801610,NDC,0.6,ML,274.53,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801610,NDC,0.6,ML,274.53,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801610,NDC,0.6,ML,274.53,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801801,NDC,0.8,ML,359.37,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801801,NDC,0.8,ML,359.37,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801801,NDC,0.8,ML,359.37,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801801,NDC,0.8,ML,359.37,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801801,NDC,0.8,ML,359.37,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801801,NDC,0.8,ML,359.37,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801810,NDC,0.8,ML,359.37,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801810,NDC,0.8,ML,359.37,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801810,NDC,0.8,ML,359.37,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801810,NDC,0.8,ML,359.37,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801810,NDC,0.8,ML,359.37,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801810,NDC,0.8,ML,359.37,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802001,NDC,1,ML,444.2,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802001,NDC,1,ML,444.2,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802001,NDC,1,ML,444.2,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802001,NDC,1,ML,444.2,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802001,NDC,1,ML,444.2,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802001,NDC,1,ML,444.2,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802010,NDC,1,ML,444.2,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802010,NDC,1,ML,444.2,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802010,NDC,1,ML,444.2,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802010,NDC,1,ML,444.2,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802010,NDC,1,ML,444.2,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802010,NDC,1,ML,444.2,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802201,NDC,0.8,ML,439.77,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802201,NDC,0.8,ML,439.77,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802201,NDC,0.8,ML,439.77,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802201,NDC,0.8,ML,439.77,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802201,NDC,0.8,ML,439.77,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802201,NDC,0.8,ML,439.77,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802210,NDC,0.8,ML,439.77,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802210,NDC,0.8,ML,439.77,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802210,NDC,0.8,ML,439.77,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802210,NDC,0.8,ML,439.77,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802210,NDC,0.8,ML,439.77,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802210,NDC,0.8,ML,439.77,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
entacapone 200 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,27241004910,NDC,1,EA,24.37,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
entacapone 200 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,27241004910,NDC,1,EA,24.37,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
entacapone 200 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,27241004910,NDC,1,EA,24.37,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
entacapone 200 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,27241004910,NDC,1,EA,24.37,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
entacapone 200 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,27241004910,NDC,1,EA,24.37,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
entacapone 200 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,27241004910,NDC,1,EA,24.37,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Enzyme Act, Nonradioact - Ref",PX8265790,CDM,300,RC,82657,CPT,90,,,,,,,560,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Enzyme Act, Nonradioact - Ref",PX8265790,CDM,300,RC,82657,CPT,90,,,,,,,560,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Enzyme Act, Nonradioact - Ref",PX8265790,CDM,300,RC,82657,CPT,90,,,,,,,560,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Enzyme Act, Nonradioact - Ref",PX8265790,CDM,300,RC,82657,CPT,90,,,,,,,560,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Enzyme Act, Nonradioact - Ref",PX8265790,CDM,300,RC,82657,CPT,90,,,,,,,560,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Enzyme Act, Nonradioact - Ref",PX8265790,CDM,300,RC,82657,CPT,90,,,,,,,560,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ePHEDrine sulfate 50 MG/ML Solution 1 mL Ampule,25000000,CDM,250,RC,,,,,,17478041510,NDC,1,ML,262.31,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ePHEDrine sulfate 50 MG/ML Solution 1 mL Ampule,25000000,CDM,250,RC,,,,,,17478041510,NDC,1,ML,262.31,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ePHEDrine sulfate 50 MG/ML Solution 1 mL Ampule,25000000,CDM,250,RC,,,,,,17478041510,NDC,1,ML,262.31,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ePHEDrine sulfate 50 MG/ML Solution 1 mL Ampule,25000000,CDM,250,RC,,,,,,17478041510,NDC,1,ML,262.31,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ePHEDrine sulfate 50 MG/ML Solution 1 mL Ampule,25000000,CDM,250,RC,,,,,,17478041510,NDC,1,ML,262.31,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ePHEDrine sulfate 50 MG/ML Solution 1 mL Ampule,25000000,CDM,250,RC,,,,,,17478041510,NDC,1,ML,262.31,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ePHEDrine sulfate 50 MG/ML Solution 1 mL Vial,25000000,CDM,250,RC,,,,,,42023021689,NDC,0.1,ML,36.62,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ePHEDrine sulfate 50 MG/ML Solution 1 mL Vial,25000000,CDM,250,RC,,,,,,42023021689,NDC,0.1,ML,36.62,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ePHEDrine sulfate 50 MG/ML Solution 1 mL Vial,25000000,CDM,250,RC,,,,,,42023021689,NDC,0.1,ML,36.62,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ePHEDrine sulfate 50 MG/ML Solution 1 mL Vial,25000000,CDM,250,RC,,,,,,42023021689,NDC,0.1,ML,36.62,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ePHEDrine sulfate 50 MG/ML Solution 1 mL Vial,25000000,CDM,250,RC,,,,,,42023021689,NDC,0.1,ML,36.62,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ePHEDrine sulfate 50 MG/ML Solution 1 mL Vial,25000000,CDM,250,RC,,,,,,42023021689,NDC,0.1,ML,36.62,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,93598627,NDC,1,EA,1241.11,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,93598627,NDC,1,EA,1241.11,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,93598627,NDC,1,EA,1241.11,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,93598627,NDC,1,EA,1241.11,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,93598627,NDC,1,EA,1241.11,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,93598627,NDC,1,EA,1241.11,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,115169449,NDC,1,EA,889.46,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,115169449,NDC,1,EA,889.46,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,115169449,NDC,1,EA,889.46,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,115169449,NDC,1,EA,889.46,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,115169449,NDC,1,EA,889.46,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,115169449,NDC,1,EA,889.46,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010202,NDC,1,EA,680,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010202,NDC,1,EA,680,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010202,NDC,1,EA,680,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010202,NDC,1,EA,680,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010202,NDC,1,EA,680,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010202,NDC,1,EA,680,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54505010202,NDC,1,EA,889.46,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54505010202,NDC,1,EA,889.46,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54505010202,NDC,1,EA,889.46,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54505010202,NDC,1,EA,889.46,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54505010202,NDC,1,EA,889.46,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54505010202,NDC,1,EA,889.46,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 1 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010101,NDC,1,EA,680,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 1 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010101,NDC,1,EA,680,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 1 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010101,NDC,1,EA,680,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 1 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010101,NDC,1,EA,680,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 1 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010101,NDC,1,EA,680,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 1 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010101,NDC,1,EA,680,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010102,NDC,1,EA,680,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010102,NDC,1,EA,680,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010102,NDC,1,EA,680,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010102,NDC,1,EA,680,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010102,NDC,1,EA,680,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010102,NDC,1,EA,680,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502050102,NDC,1,EA,1305.38,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502050102,NDC,1,EA,1305.38,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502050102,NDC,1,EA,1305.38,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502050102,NDC,1,EA,1305.38,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502050102,NDC,1,EA,1305.38,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502050102,NDC,1,EA,1305.38,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409492120,NDC,10,ML,54.66,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409492120,NDC,10,ML,54.66,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409492120,NDC,10,ML,54.66,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409492120,NDC,10,ML,54.66,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409492120,NDC,10,ML,54.66,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409492120,NDC,10,ML,54.66,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409493311,NDC,10,ML,66.06,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409493311,NDC,10,ML,66.06,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409493311,NDC,10,ML,66.06,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409493311,NDC,10,ML,66.06,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409493311,NDC,10,ML,66.06,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409493311,NDC,10,ML,66.06,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331601,NDC,10,ML,77.86,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331601,NDC,10,ML,77.86,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331601,NDC,10,ML,77.86,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331601,NDC,10,ML,77.86,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331601,NDC,10,ML,77.86,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331601,NDC,10,ML,77.86,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331801,NDC,10,ML,102.65,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331801,NDC,10,ML,102.65,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331801,NDC,10,ML,102.65,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331801,NDC,10,ML,102.65,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331801,NDC,10,ML,102.65,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331801,NDC,10,ML,102.65,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015901,NDC,0.3,ML,45.69,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015901,NDC,0.3,ML,45.69,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015901,NDC,0.3,ML,45.69,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015901,NDC,0.3,ML,45.69,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015901,NDC,0.3,ML,45.69,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015901,NDC,0.3,ML,45.69,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015925,NDC,0.3,ML,45.69,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015925,NDC,0.3,ML,45.69,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015925,NDC,0.3,ML,45.69,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015925,NDC,0.3,ML,45.69,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015925,NDC,0.3,ML,45.69,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015925,NDC,0.3,ML,45.69,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 30 MG/30ML Solution 30 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023016801,NDC,0.3,ML,32.24,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 30 MG/30ML Solution 30 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023016801,NDC,0.3,ML,32.24,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 30 MG/30ML Solution 30 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023016801,NDC,0.3,ML,32.24,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 30 MG/30ML Solution 30 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023016801,NDC,0.3,ML,32.24,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 30 MG/30ML Solution 30 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023016801,NDC,0.3,ML,32.24,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 30 MG/30ML Solution 30 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023016801,NDC,0.3,ML,32.24,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010301,NDC,0.3,ML,45.04,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010301,NDC,0.3,ML,45.04,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010301,NDC,0.3,ML,45.04,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010301,NDC,0.3,ML,45.04,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010301,NDC,0.3,ML,45.04,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010301,NDC,0.3,ML,45.04,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010310,NDC,1,ML,103.48,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010310,NDC,1,ML,103.48,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010310,NDC,1,ML,103.48,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010310,NDC,1,ML,103.48,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010310,NDC,1,ML,103.48,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010310,NDC,1,ML,103.48,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPIX UNIVERSAL CLIP APPLIER,27200000,CDM,272,RC,,,,11708-MAIN,LOCAL,,,,,158.95,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPIX UNIVERSAL CLIP APPLIER,27200000,CDM,272,RC,,,,11708-MAIN,LOCAL,,,,,158.95,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPIX UNIVERSAL CLIP APPLIER,27200000,CDM,272,RC,,,,11708-MAIN,LOCAL,,,,,158.95,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPIX UNIVERSAL CLIP APPLIER,27200000,CDM,272,RC,,,,11708-MAIN,LOCAL,,,,,158.95,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPIX UNIVERSAL CLIP APPLIER,27200000,CDM,272,RC,,,,11708-MAIN,LOCAL,,,,,158.95,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPIX UNIVERSAL CLIP APPLIER,27200000,CDM,272,RC,,,,11708-MAIN,LOCAL,,,,,158.95,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
eplerenone 25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16729029315,NDC,1,EA,23.31,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
eplerenone 25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16729029315,NDC,1,EA,23.31,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
eplerenone 25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16729029315,NDC,1,EA,23.31,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
eplerenone 25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16729029315,NDC,1,EA,23.31,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
eplerenone 25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16729029315,NDC,1,EA,23.31,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
eplerenone 25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16729029315,NDC,1,EA,23.31,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Epstein-barr antibody,PX86664,CDM,300,RC,86664,CPT,,,,,,,,72,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Epstein-barr antibody,PX86664,CDM,300,RC,86664,CPT,,,,,,,,72,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Epstein-barr antibody,PX86664,CDM,300,RC,86664,CPT,,,,,,,,72,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Epstein-barr antibody,PX86664,CDM,300,RC,86664,CPT,,,,,,,,72,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Epstein-barr antibody,PX86664,CDM,300,RC,86664,CPT,,,,,,,,72,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Epstein-barr antibody,PX86664,CDM,300,RC,86664,CPT,,,,,,,,72,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Epstein-barr antibody,PX86665,CDM,300,RC,86665,CPT,,,,,,,,86,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Epstein-barr antibody,PX86665,CDM,300,RC,86665,CPT,,,,,,,,86,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Epstein-barr antibody,PX86665,CDM,300,RC,86665,CPT,,,,,,,,86,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Epstein-barr antibody,PX86665,CDM,300,RC,86665,CPT,,,,,,,,86,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Epstein-barr antibody,PX86665,CDM,300,RC,86665,CPT,,,,,,,,86,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Epstein-barr antibody,PX86665,CDM,300,RC,86665,CPT,,,,,,,,86,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ERBEFLO CLEVERCAP CO2 TUBING CAP SET,27200000,CDM,272,RC,,,,11831-MAIN,LOCAL,,,,,50,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ERBEFLO CLEVERCAP CO2 TUBING CAP SET,27200000,CDM,272,RC,,,,11831-MAIN,LOCAL,,,,,50,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ERBEFLO CLEVERCAP CO2 TUBING CAP SET,27200000,CDM,272,RC,,,,11831-MAIN,LOCAL,,,,,50,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ERBEFLO CLEVERCAP CO2 TUBING CAP SET,27200000,CDM,272,RC,,,,11831-MAIN,LOCAL,,,,,50,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ERBEFLO CLEVERCAP CO2 TUBING CAP SET,27200000,CDM,272,RC,,,,11831-MAIN,LOCAL,,,,,50,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ERBEFLO CLEVERCAP CO2 TUBING CAP SET,27200000,CDM,272,RC,,,,11831-MAIN,LOCAL,,,,,50,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
eriBULin 1 MG/2ML Solution 2 mL Vial,J9179.01,CDM,636,RC,J9179,HCPCS,,,,62856038901,NDC,2,ML,2321.52,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
eriBULin 1 MG/2ML Solution 2 mL Vial,J9179.01,CDM,636,RC,J9179,HCPCS,,,,62856038901,NDC,2,ML,2321.52,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
eriBULin 1 MG/2ML Solution 2 mL Vial,J9179.01,CDM,636,RC,J9179,HCPCS,,,,62856038901,NDC,2,ML,2321.52,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
eriBULin 1 MG/2ML Solution 2 mL Vial,J9179.01,CDM,636,RC,J9179,HCPCS,,,,62856038901,NDC,2,ML,2321.52,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
eriBULin 1 MG/2ML Solution 2 mL Vial,J9179.01,CDM,636,RC,J9179,HCPCS,,,,62856038901,NDC,2,ML,2321.52,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
eriBULin 1 MG/2ML Solution 2 mL Vial,J9179.01,CDM,636,RC,J9179,HCPCS,,,,62856038901,NDC,2,ML,2321.52,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,6384371,NDC,1,EA,563.46,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,6384371,NDC,1,EA,563.46,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,6384371,NDC,1,EA,563.46,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,6384371,NDC,1,EA,563.46,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,6384371,NDC,1,EA,563.46,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,6384371,NDC,1,EA,563.46,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022101,NDC,1,EA,514.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022101,NDC,1,EA,514.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022101,NDC,1,EA,514.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022101,NDC,1,EA,514.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022101,NDC,1,EA,514.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022101,NDC,1,EA,514.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022185,NDC,1,EA,514.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022185,NDC,1,EA,514.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022185,NDC,1,EA,514.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022185,NDC,1,EA,514.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022185,NDC,1,EA,514.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022185,NDC,1,EA,514.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022189,NDC,1,EA,514.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022189,NDC,1,EA,514.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022189,NDC,1,EA,514.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022189,NDC,1,EA,514.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022189,NDC,1,EA,514.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022189,NDC,1,EA,514.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,574402435,NDC,3.5,GR,101.11,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,574402435,NDC,3.5,GR,101.11,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,574402435,NDC,3.5,GR,101.11,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,574402435,NDC,3.5,GR,101.11,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,574402435,NDC,3.5,GR,101.11,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,574402435,NDC,3.5,GR,101.11,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,17478007035,NDC,3.5,GR,105.01,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,17478007035,NDC,3.5,GR,105.01,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,17478007035,NDC,3.5,GR,105.01,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,17478007035,NDC,3.5,GR,105.01,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,17478007035,NDC,3.5,GR,105.01,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,17478007035,NDC,3.5,GR,105.01,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,24208091055,NDC,3.5,GR,106.98,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,24208091055,NDC,3.5,GR,106.98,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,24208091055,NDC,3.5,GR,106.98,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,24208091055,NDC,3.5,GR,106.98,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,24208091055,NDC,3.5,GR,106.98,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,24208091055,NDC,3.5,GR,106.98,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
erythromycin lactobionate 500 MG Recon Soln 1 Each Vial,J1364.01,CDM,636,RC,J1364,HCPCS,,,,409648211,NDC,1,EA,437.09,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
erythromycin lactobionate 500 MG Recon Soln 1 Each Vial,J1364.01,CDM,636,RC,J1364,HCPCS,,,,409648211,NDC,1,EA,437.09,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
erythromycin lactobionate 500 MG Recon Soln 1 Each Vial,J1364.01,CDM,636,RC,J1364,HCPCS,,,,409648211,NDC,1,EA,437.09,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
erythromycin lactobionate 500 MG Recon Soln 1 Each Vial,J1364.01,CDM,636,RC,J1364,HCPCS,,,,409648211,NDC,1,EA,437.09,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
erythromycin lactobionate 500 MG Recon Soln 1 Each Vial,J1364.01,CDM,636,RC,J1364,HCPCS,,,,409648211,NDC,1,EA,437.09,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
erythromycin lactobionate 500 MG Recon Soln 1 Each Vial,J1364.01,CDM,636,RC,J1364,HCPCS,,,,409648211,NDC,1,EA,437.09,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Erythropietin - Ref,PX8266890,CDM,300,RC,82668,CPT,90,,,,,,,108,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Erythropietin - Ref,PX8266890,CDM,300,RC,82668,CPT,90,,,,,,,108,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Erythropietin - Ref,PX8266890,CDM,300,RC,82668,CPT,90,,,,,,,108,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Erythropietin - Ref,PX8266890,CDM,300,RC,82668,CPT,90,,,,,,,108,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Erythropietin - Ref,PX8266890,CDM,300,RC,82668,CPT,90,,,,,,,108,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Erythropietin - Ref,PX8266890,CDM,300,RC,82668,CPT,90,,,,,,,108,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
escitalopram 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904642661,NDC,0.5,EA,11.76,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
escitalopram 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904642661,NDC,0.5,EA,11.76,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
escitalopram 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904642661,NDC,0.5,EA,11.76,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
escitalopram 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904642661,NDC,0.5,EA,11.76,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
escitalopram 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904642661,NDC,0.5,EA,11.76,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
escitalopram 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904642661,NDC,0.5,EA,11.76,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018200,NDC,10,ML,68.21,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018200,NDC,10,ML,68.21,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018200,NDC,10,ML,68.21,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018200,NDC,10,ML,68.21,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018200,NDC,10,ML,68.21,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018200,NDC,10,ML,68.21,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018210,NDC,10,ML,68.21,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018210,NDC,10,ML,68.21,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018210,NDC,10,ML,68.21,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018210,NDC,10,ML,68.21,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018210,NDC,10,ML,68.21,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018210,NDC,10,ML,68.21,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
esmolol 2500 MG/250ML Solution 250 mL Flex Cont,J1805.01,CDM,636,RC,J1805,HCPCS,,,,10019067010,NDC,250,ML,1011.8,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
esmolol 2500 MG/250ML Solution 250 mL Flex Cont,J1805.01,CDM,636,RC,J1805,HCPCS,,,,10019067010,NDC,250,ML,1011.8,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
esmolol 2500 MG/250ML Solution 250 mL Flex Cont,J1805.01,CDM,636,RC,J1805,HCPCS,,,,10019067010,NDC,250,ML,1011.8,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
esmolol 2500 MG/250ML Solution 250 mL Flex Cont,J1805.01,CDM,636,RC,J1805,HCPCS,,,,10019067010,NDC,250,ML,1011.8,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
esmolol 2500 MG/250ML Solution 250 mL Flex Cont,J1805.01,CDM,636,RC,J1805,HCPCS,,,,10019067010,NDC,250,ML,1011.8,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
esmolol 2500 MG/250ML Solution 250 mL Flex Cont,J1805.01,CDM,636,RC,J1805,HCPCS,,,,10019067010,NDC,250,ML,1011.8,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ESOPHAGEAL BALLOON INFLATION DEVICE 60ML,27200000,CDM,272,RC,C1726,HCPCS,,11326-MAIN,LOCAL,,,,,80.41,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ESOPHAGEAL BALLOON INFLATION DEVICE 60ML,27200000,CDM,272,RC,C1726,HCPCS,,11326-MAIN,LOCAL,,,,,80.41,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ESOPHAGEAL BALLOON INFLATION DEVICE 60ML,27200000,CDM,272,RC,C1726,HCPCS,,11326-MAIN,LOCAL,,,,,80.41,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ESOPHAGEAL BALLOON INFLATION DEVICE 60ML,27200000,CDM,272,RC,C1726,HCPCS,,11326-MAIN,LOCAL,,,,,80.41,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ESOPHAGEAL BALLOON INFLATION DEVICE 60ML,27200000,CDM,272,RC,C1726,HCPCS,,11326-MAIN,LOCAL,,,,,80.41,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ESOPHAGEAL BALLOON INFLATION DEVICE 60ML,27200000,CDM,272,RC,C1726,HCPCS,,11326-MAIN,LOCAL,,,,,80.41,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
estradiol 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378145201,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
estradiol 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378145201,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
estradiol 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378145201,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
estradiol 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378145201,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
estradiol 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378145201,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
estradiol 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378145201,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
estradiol 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42806008701,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
estradiol 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42806008701,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
estradiol 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42806008701,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
estradiol 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42806008701,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
estradiol 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42806008701,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
estradiol 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42806008701,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ethanol, P",PX82077,CDM,300,RC,82077,CPT,,,,,,,,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ethanol, P",PX82077,CDM,300,RC,82077,CPT,,,,,,,,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ethanol, P",PX82077,CDM,300,RC,82077,CPT,,,,,,,,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ethanol, P",PX82077,CDM,300,RC,82077,CPT,,,,,,,,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ethanol, P",PX82077,CDM,300,RC,82077,CPT,,,,,,,,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ethanol, P",PX82077,CDM,300,RC,82077,CPT,,,,,,,,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,143950601,NDC,10,ML,61.1,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,143950601,NDC,10,ML,61.1,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,143950601,NDC,10,ML,61.1,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,143950601,NDC,10,ML,61.1,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,143950601,NDC,10,ML,61.1,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,143950601,NDC,10,ML,61.1,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,143950610,NDC,10,ML,61.1,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,143950610,NDC,10,ML,61.1,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,143950610,NDC,10,ML,61.1,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,143950610,NDC,10,ML,61.1,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,143950610,NDC,10,ML,61.1,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,143950610,NDC,10,ML,61.1,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409669501,NDC,10,ML,56.97,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409669501,NDC,10,ML,56.97,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409669501,NDC,10,ML,56.97,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409669501,NDC,10,ML,56.97,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409669501,NDC,10,ML,56.97,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409669501,NDC,10,ML,56.97,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,65219044501,NDC,10,ML,56.37,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,65219044501,NDC,10,ML,56.37,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,65219044501,NDC,10,ML,56.37,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,65219044501,NDC,10,ML,56.37,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,65219044501,NDC,10,ML,56.37,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,65219044501,NDC,10,ML,56.37,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,65219044510,NDC,10,ML,56.37,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,65219044510,NDC,10,ML,56.37,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,65219044510,NDC,10,ML,56.37,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,65219044510,NDC,10,ML,56.37,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,65219044510,NDC,10,ML,56.37,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,65219044510,NDC,10,ML,56.37,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
etomidate 2 MG/ML Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,55150022220,NDC,10,ML,50.58,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
etomidate 2 MG/ML Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,55150022220,NDC,10,ML,50.58,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
etomidate 2 MG/ML Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,55150022220,NDC,10,ML,50.58,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
etomidate 2 MG/ML Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,55150022220,NDC,10,ML,50.58,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
etomidate 2 MG/ML Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,55150022220,NDC,10,ML,50.58,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
etomidate 2 MG/ML Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,55150022220,NDC,10,ML,50.58,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Etoposide 100 MG/5ML Solution 5 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,16729011431,NDC,5,ML,43.21,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Etoposide 100 MG/5ML Solution 5 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,16729011431,NDC,5,ML,43.21,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Etoposide 100 MG/5ML Solution 5 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,16729011431,NDC,5,ML,43.21,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Etoposide 100 MG/5ML Solution 5 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,16729011431,NDC,5,ML,43.21,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Etoposide 100 MG/5ML Solution 5 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,16729011431,NDC,5,ML,43.21,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Etoposide 100 MG/5ML Solution 5 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,16729011431,NDC,5,ML,43.21,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
etoposide 500 MG/25ML Solution 25 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,703565601,NDC,25,ML,173.28,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
etoposide 500 MG/25ML Solution 25 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,703565601,NDC,25,ML,173.28,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
etoposide 500 MG/25ML Solution 25 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,703565601,NDC,25,ML,173.28,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
etoposide 500 MG/25ML Solution 25 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,703565601,NDC,25,ML,173.28,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
etoposide 500 MG/25ML Solution 25 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,703565601,NDC,25,ML,173.28,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
etoposide 500 MG/25ML Solution 25 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,703565601,NDC,25,ML,173.28,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ETRAP POLYP TRAP,27200000,CDM,272,RC,,,,11282-MAIN,LOCAL,,,,,43,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ETRAP POLYP TRAP,27200000,CDM,272,RC,,,,11282-MAIN,LOCAL,,,,,43,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ETRAP POLYP TRAP,27200000,CDM,272,RC,,,,11282-MAIN,LOCAL,,,,,43,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ETRAP POLYP TRAP,27200000,CDM,272,RC,,,,11282-MAIN,LOCAL,,,,,43,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ETRAP POLYP TRAP,27200000,CDM,272,RC,,,,11282-MAIN,LOCAL,,,,,43,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ETRAP POLYP TRAP,27200000,CDM,272,RC,,,,11282-MAIN,LOCAL,,,,,43,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Eval of Bronchospasm,PX94060,CDM,983,RC,94060,CPT,,,,,,,,176,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Eval of Bronchospasm,PX94060,CDM,983,RC,94060,CPT,,,,,,,,176,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Eval of Bronchospasm,PX94060,CDM,983,RC,94060,CPT,,,,,,,,176,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Eval of Bronchospasm,PX94060,CDM,983,RC,94060,CPT,,,,,,,,176,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Eval of Bronchospasm,PX94060,CDM,983,RC,94060,CPT,,,,,,,,176,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Eval of Bronchospasm,PX94060,CDM,983,RC,94060,CPT,,,,,,,,176,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Everolimus,PX8016990,CDM,300,RC,80169,CPT,,,,,,,,79,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Everolimus,PX8016990,CDM,300,RC,80169,CPT,,,,,,,,79,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Everolimus,PX8016990,CDM,300,RC,80169,CPT,,,,,,,,79,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Everolimus,PX8016990,CDM,300,RC,80169,CPT,,,,,,,,79,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Everolimus,PX8016990,CDM,300,RC,80169,CPT,,,,,,,,79,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Everolimus,PX8016990,CDM,300,RC,80169,CPT,,,,,,,,79,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ex for Speech Device Rx Addl,PX92608,CDM,444,RC,92608,CPT,,,,,,,,160,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ex for Speech Device Rx Addl,PX92608,CDM,444,RC,92608,CPT,,,,,,,,160,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ex for Speech Device Rx Addl,PX92608,CDM,444,RC,92608,CPT,,,,,,,,160,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ex for Speech Device Rx Addl,PX92608,CDM,444,RC,92608,CPT,,,,,,,,160,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ex for Speech Device Rx Addl,PX92608,CDM,444,RC,92608,CPT,,,,,,,,160,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ex for Speech Device Rx Addl,PX92608,CDM,444,RC,92608,CPT,,,,,,,,160,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ex Sknbngn0.6-1cmtrnk,Arm,Lg",PX11401P,CDM,983,RC,11401,CPT,,,,,,,,387,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ex Sknbngn0.6-1cmtrnk,Arm,Lg",PX11401P,CDM,983,RC,11401,CPT,,,,,,,,387,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ex Sknbngn0.6-1cmtrnk,Arm,Lg",PX11401P,CDM,983,RC,11401,CPT,,,,,,,,387,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ex Sknbngn0.6-1cmtrnk,Arm,Lg",PX11401P,CDM,983,RC,11401,CPT,,,,,,,,387,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ex Sknbngn0.6-1cmtrnk,Arm,Lg",PX11401P,CDM,983,RC,11401,CPT,,,,,,,,387,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ex Sknbngn0.6-1cmtrnk,Arm,Lg",PX11401P,CDM,983,RC,11401,CPT,,,,,,,,387,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exam,Synovial Fluid Crystals",PX89060,CDM,300,RC,89060,CPT,,,,,,,,85,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exam,Synovial Fluid Crystals",PX89060,CDM,300,RC,89060,CPT,,,,,,,,85,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exam,Synovial Fluid Crystals",PX89060,CDM,300,RC,89060,CPT,,,,,,,,85,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exam,Synovial Fluid Crystals",PX89060,CDM,300,RC,89060,CPT,,,,,,,,85,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exam,Synovial Fluid Crystals",PX89060,CDM,300,RC,89060,CPT,,,,,,,,85,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exam,Synovial Fluid Crystals",PX89060,CDM,300,RC,89060,CPT,,,,,,,,85,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Abd Les Sc < 3 Cm,PX22902F,CDM,761,RC,22902,CPT,,,,,,,,3128,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Abd Les Sc < 3 Cm,PX22902F,CDM,761,RC,22902,CPT,,,,,,,,3128,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Abd Les Sc < 3 Cm,PX22902F,CDM,761,RC,22902,CPT,,,,,,,,3128,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Abd Les Sc < 3 Cm,PX22902F,CDM,761,RC,22902,CPT,,,,,,,,3128,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Abd Les Sc < 3 Cm,PX22902F,CDM,761,RC,22902,CPT,,,,,,,,3128,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Abd Les Sc < 3 Cm,PX22902F,CDM,761,RC,22902,CPT,,,,,,,,3128,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Abd Les Sc < 3 Cm,PX22902P,CDM,983,RC,22902,CPT,,,,,,,,2086,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Abd Les Sc < 3 Cm,PX22902P,CDM,983,RC,22902,CPT,,,,,,,,2086,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Abd Les Sc < 3 Cm,PX22902P,CDM,983,RC,22902,CPT,,,,,,,,2086,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Abd Les Sc < 3 Cm,PX22902P,CDM,983,RC,22902,CPT,,,,,,,,2086,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Abd Les Sc < 3 Cm,PX22902P,CDM,983,RC,22902,CPT,,,,,,,,2086,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Abd Les Sc < 3 Cm,PX22902P,CDM,983,RC,22902,CPT,,,,,,,,2086,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Abdom Tum Subfac > 5 Cm,PX22901F,CDM,761,RC,22901,CPT,,,,,,,,1408,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Abdom Tum Subfac > 5 Cm,PX22901F,CDM,761,RC,22901,CPT,,,,,,,,1408,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Abdom Tum Subfac > 5 Cm,PX22901F,CDM,761,RC,22901,CPT,,,,,,,,1408,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Abdom Tum Subfac > 5 Cm,PX22901F,CDM,761,RC,22901,CPT,,,,,,,,1408,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Abdom Tum Subfac > 5 Cm,PX22901F,CDM,761,RC,22901,CPT,,,,,,,,1408,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Abdom Tum Subfac > 5 Cm,PX22901F,CDM,761,RC,22901,CPT,,,,,,,,1408,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Abdom Tum Subfac > 5 Cm,PX22901P,CDM,983,RC,22901,CPT,,,,,,,,938,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Abdom Tum Subfac > 5 Cm,PX22901P,CDM,983,RC,22901,CPT,,,,,,,,938,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Abdom Tum Subfac > 5 Cm,PX22901P,CDM,983,RC,22901,CPT,,,,,,,,938,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Abdom Tum Subfac > 5 Cm,PX22901P,CDM,983,RC,22901,CPT,,,,,,,,938,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Abdom Tum Subfac > 5 Cm,PX22901P,CDM,983,RC,22901,CPT,,,,,,,,938,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Abdom Tum Subfac > 5 Cm,PX22901P,CDM,983,RC,22901,CPT,,,,,,,,938,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Back Les Sc = 3 Cm,PX21931P,CDM,983,RC,21931,CPT,,,,,,,,2135,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Back Les Sc = 3 Cm,PX21931P,CDM,983,RC,21931,CPT,,,,,,,,2135,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Back Les Sc = 3 Cm,PX21931P,CDM,983,RC,21931,CPT,,,,,,,,2135,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Back Les Sc = 3 Cm,PX21931P,CDM,983,RC,21931,CPT,,,,,,,,2135,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Back Les Sc = 3 Cm,PX21931P,CDM,983,RC,21931,CPT,,,,,,,,2135,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Back Les Sc = 3 Cm,PX21931P,CDM,983,RC,21931,CPT,,,,,,,,2135,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Face Les Sc < 2 Cm,PX21011F,CDM,510,RC,21011,CPT,,,,,,,,943,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Face Les Sc < 2 Cm,PX21011F,CDM,510,RC,21011,CPT,,,,,,,,943,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Face Les Sc < 2 Cm,PX21011F,CDM,510,RC,21011,CPT,,,,,,,,943,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Face Les Sc < 2 Cm,PX21011F,CDM,510,RC,21011,CPT,,,,,,,,943,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Face Les Sc < 2 Cm,PX21011F,CDM,510,RC,21011,CPT,,,,,,,,943,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Face Les Sc < 2 Cm,PX21011F,CDM,510,RC,21011,CPT,,,,,,,,943,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Face Les Sc < 2 Cm,PX21011P,CDM,983,RC,21011,CPT,,,,,,,,628,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Face Les Sc < 2 Cm,PX21011P,CDM,983,RC,21011,CPT,,,,,,,,628,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Face Les Sc < 2 Cm,PX21011P,CDM,983,RC,21011,CPT,,,,,,,,628,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Face Les Sc < 2 Cm,PX21011P,CDM,983,RC,21011,CPT,,,,,,,,628,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Face Les Sc < 2 Cm,PX21011P,CDM,983,RC,21011,CPT,,,,,,,,628,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Face Les Sc < 2 Cm,PX21011P,CDM,983,RC,21011,CPT,,,,,,,,628,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Neck Les Sc = 3cm >,PX21552F,CDM,510,RC,21552,CPT,,,,,,,,753,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Neck Les Sc = 3cm >,PX21552F,CDM,510,RC,21552,CPT,,,,,,,,753,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Neck Les Sc = 3cm >,PX21552F,CDM,510,RC,21552,CPT,,,,,,,,753,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Neck Les Sc = 3cm >,PX21552F,CDM,510,RC,21552,CPT,,,,,,,,753,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Neck Les Sc = 3cm >,PX21552F,CDM,510,RC,21552,CPT,,,,,,,,753,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Neck Les Sc = 3cm >,PX21552F,CDM,510,RC,21552,CPT,,,,,,,,753,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Benig <5mm Remaindr Body,PX11420P,CDM,983,RC,11420,CPT,,,,,,,,299,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Benig <5mm Remaindr Body,PX11420P,CDM,983,RC,11420,CPT,,,,,,,,299,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Benig <5mm Remaindr Body,PX11420P,CDM,983,RC,11420,CPT,,,,,,,,299,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Benig <5mm Remaindr Body,PX11420P,CDM,983,RC,11420,CPT,,,,,,,,299,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Benig <5mm Remaindr Body,PX11420P,CDM,983,RC,11420,CPT,,,,,,,,299,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Benig <5mm Remaindr Body,PX11420P,CDM,983,RC,11420,CPT,,,,,,,,299,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Benig >4cm Remaindr Body,PX11426F,CDM,510,RC,11426,CPT,,,,,,,,1227,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Benig >4cm Remaindr Body,PX11426F,CDM,510,RC,11426,CPT,,,,,,,,1227,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Benig >4cm Remaindr Body,PX11426F,CDM,510,RC,11426,CPT,,,,,,,,1227,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Benig >4cm Remaindr Body,PX11426F,CDM,510,RC,11426,CPT,,,,,,,,1227,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Benig >4cm Remaindr Body,PX11426F,CDM,510,RC,11426,CPT,,,,,,,,1227,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Benig >4cm Remaindr Body,PX11426F,CDM,510,RC,11426,CPT,,,,,,,,1227,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Benig >4cm Remaindr Body,PX11426P,CDM,983,RC,11426,CPT,,,,,,,,981,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Benig >4cm Remaindr Body,PX11426P,CDM,983,RC,11426,CPT,,,,,,,,981,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Benig >4cm Remaindr Body,PX11426P,CDM,983,RC,11426,CPT,,,,,,,,981,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Benig >4cm Remaindr Body,PX11426P,CDM,983,RC,11426,CPT,,,,,,,,981,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Benig >4cm Remaindr Body,PX11426P,CDM,983,RC,11426,CPT,,,,,,,,981,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Benig >4cm Remaindr Body,PX11426P,CDM,983,RC,11426,CPT,,,,,,,,981,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402F,CDM,510,RC,11402,CPT,,,,,,,,424,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402F,CDM,510,RC,11402,CPT,,,,,,,,424,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402F,CDM,510,RC,11402,CPT,,,,,,,,424,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402F,CDM,510,RC,11402,CPT,,,,,,,,424,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402F,CDM,510,RC,11402,CPT,,,,,,,,424,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402F,CDM,510,RC,11402,CPT,,,,,,,,424,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402P,CDM,983,RC,11402,CPT,,,,,,,,424,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402P,CDM,983,RC,11402,CPT,,,,,,,,424,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402P,CDM,983,RC,11402,CPT,,,,,,,,424,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402P,CDM,983,RC,11402,CPT,,,,,,,,424,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402P,CDM,983,RC,11402,CPT,,,,,,,,424,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402P,CDM,983,RC,11402,CPT,,,,,,,,424,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423F,CDM,510,RC,11423,CPT,,,,,,,,711,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423F,CDM,510,RC,11423,CPT,,,,,,,,711,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423F,CDM,510,RC,11423,CPT,,,,,,,,711,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423F,CDM,510,RC,11423,CPT,,,,,,,,711,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423F,CDM,510,RC,11423,CPT,,,,,,,,711,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423F,CDM,510,RC,11423,CPT,,,,,,,,711,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423P,CDM,983,RC,11423,CPT,,,,,,,,569,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423P,CDM,983,RC,11423,CPT,,,,,,,,569,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423P,CDM,983,RC,11423,CPT,,,,,,,,569,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423P,CDM,983,RC,11423,CPT,,,,,,,,569,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423P,CDM,983,RC,11423,CPT,,,,,,,,569,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423P,CDM,983,RC,11423,CPT,,,,,,,,569,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606F,CDM,510,RC,11606,CPT,,,,,,,,1432,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606F,CDM,510,RC,11606,CPT,,,,,,,,1432,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606F,CDM,510,RC,11606,CPT,,,,,,,,1432,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606F,CDM,510,RC,11606,CPT,,,,,,,,1432,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606F,CDM,510,RC,11606,CPT,,,,,,,,1432,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606F,CDM,510,RC,11606,CPT,,,,,,,,1432,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606P,CDM,983,RC,11606,CPT,,,,,,,,2044,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606P,CDM,983,RC,11606,CPT,,,,,,,,2044,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606P,CDM,983,RC,11606,CPT,,,,,,,,2044,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606P,CDM,983,RC,11606,CPT,,,,,,,,2044,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606P,CDM,983,RC,11606,CPT,,,,,,,,2044,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606P,CDM,983,RC,11606,CPT,,,,,,,,2044,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623F,CDM,510,RC,11623,CPT,,,,,,,,690,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623F,CDM,510,RC,11623,CPT,,,,,,,,690,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623F,CDM,510,RC,11623,CPT,,,,,,,,690,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623F,CDM,510,RC,11623,CPT,,,,,,,,690,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623F,CDM,510,RC,11623,CPT,,,,,,,,690,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623F,CDM,510,RC,11623,CPT,,,,,,,,690,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623P,CDM,983,RC,11623,CPT,,,,,,,,460,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623P,CDM,983,RC,11623,CPT,,,,,,,,460,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623P,CDM,983,RC,11623,CPT,,,,,,,,460,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623P,CDM,983,RC,11623,CPT,,,,,,,,460,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623P,CDM,983,RC,11623,CPT,,,,,,,,460,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623P,CDM,983,RC,11623,CPT,,,,,,,,460,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604F,CDM,510,RC,11604,CPT,,,,,,,,964,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604F,CDM,510,RC,11604,CPT,,,,,,,,964,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604F,CDM,510,RC,11604,CPT,,,,,,,,964,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604F,CDM,510,RC,11604,CPT,,,,,,,,964,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604F,CDM,510,RC,11604,CPT,,,,,,,,964,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604F,CDM,510,RC,11604,CPT,,,,,,,,964,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604P,CDM,983,RC,11604,CPT,,,,,,,,1422,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604P,CDM,983,RC,11604,CPT,,,,,,,,1422,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604P,CDM,983,RC,11604,CPT,,,,,,,,1422,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604P,CDM,983,RC,11604,CPT,,,,,,,,1422,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604P,CDM,983,RC,11604,CPT,,,,,,,,1422,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604P,CDM,983,RC,11604,CPT,,,,,,,,1422,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Beig1.1-2cm Face,Facil",PX11442P,CDM,983,RC,11442,CPT,,,,,,,,886,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Beig1.1-2cm Face,Facil",PX11442P,CDM,983,RC,11442,CPT,,,,,,,,886,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Beig1.1-2cm Face,Facil",PX11442P,CDM,983,RC,11442,CPT,,,,,,,,886,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Beig1.1-2cm Face,Facil",PX11442P,CDM,983,RC,11442,CPT,,,,,,,,886,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Beig1.1-2cm Face,Facil",PX11442P,CDM,983,RC,11442,CPT,,,,,,,,886,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Beig1.1-2cm Face,Facil",PX11442P,CDM,983,RC,11442,CPT,,,,,,,,886,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skn Beni 0.6-1cm Fcefacial,PX11441P,CDM,983,RC,11441,CPT,,,,,,,,485,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skn Beni 0.6-1cm Fcefacial,PX11441P,CDM,983,RC,11441,CPT,,,,,,,,485,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skn Beni 0.6-1cm Fcefacial,PX11441P,CDM,983,RC,11441,CPT,,,,,,,,485,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skn Beni 0.6-1cm Fcefacial,PX11441P,CDM,983,RC,11441,CPT,,,,,,,,485,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skn Beni 0.6-1cm Fcefacial,PX11441P,CDM,983,RC,11441,CPT,,,,,,,,485,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skn Beni 0.6-1cm Fcefacial,PX11441P,CDM,983,RC,11441,CPT,,,,,,,,485,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Benig<5mm Face,Facial",PX11440P,CDM,983,RC,11440,CPT,,,,,,,,387,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Benig<5mm Face,Facial",PX11440P,CDM,983,RC,11440,CPT,,,,,,,,387,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Benig<5mm Face,Facial",PX11440P,CDM,983,RC,11440,CPT,,,,,,,,387,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Benig<5mm Face,Facial",PX11440P,CDM,983,RC,11440,CPT,,,,,,,,387,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Benig<5mm Face,Facial",PX11440P,CDM,983,RC,11440,CPT,,,,,,,,387,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Benig<5mm Face,Facial",PX11440P,CDM,983,RC,11440,CPT,,,,,,,,387,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skn Bngn1.1-2cm Remain Bdy,PX11422P,CDM,983,RC,11422,CPT,,,,,,,,822,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skn Bngn1.1-2cm Remain Bdy,PX11422P,CDM,983,RC,11422,CPT,,,,,,,,822,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skn Bngn1.1-2cm Remain Bdy,PX11422P,CDM,983,RC,11422,CPT,,,,,,,,822,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skn Bngn1.1-2cm Remain Bdy,PX11422P,CDM,983,RC,11422,CPT,,,,,,,,822,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skn Bngn1.1-2cm Remain Bdy,PX11422P,CDM,983,RC,11422,CPT,,,,,,,,822,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skn Bngn1.1-2cm Remain Bdy,PX11422P,CDM,983,RC,11422,CPT,,,,,,,,822,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Bngn2.1-3cm Fce,Facial",PX11443P,CDM,983,RC,11443,CPT,,,,,,,,650,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Bngn2.1-3cm Fce,Facial",PX11443P,CDM,983,RC,11443,CPT,,,,,,,,650,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Bngn2.1-3cm Fce,Facial",PX11443P,CDM,983,RC,11443,CPT,,,,,,,,650,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Bngn2.1-3cm Fce,Facial",PX11443P,CDM,983,RC,11443,CPT,,,,,,,,650,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Bngn2.1-3cm Fce,Facial",PX11443P,CDM,983,RC,11443,CPT,,,,,,,,650,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Bngn2.1-3cm Fce,Facial",PX11443P,CDM,983,RC,11443,CPT,,,,,,,,650,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Bngn2.1-3cmtrnk,Arm,Lg",PX11403P,CDM,983,RC,11403,CPT,,,,,,,,543,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Bngn2.1-3cmtrnk,Arm,Lg",PX11403P,CDM,983,RC,11403,CPT,,,,,,,,543,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Bngn2.1-3cmtrnk,Arm,Lg",PX11403P,CDM,983,RC,11403,CPT,,,,,,,,543,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Bngn2.1-3cmtrnk,Arm,Lg",PX11403P,CDM,983,RC,11403,CPT,,,,,,,,543,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Bngn2.1-3cmtrnk,Arm,Lg",PX11403P,CDM,983,RC,11403,CPT,,,,,,,,543,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Bngn2.1-3cmtrnk,Arm,Lg",PX11403P,CDM,983,RC,11403,CPT,,,,,,,,543,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skn Bngn3.1-4cm Remain Bdy,PX11424P,CDM,983,RC,11424,CPT,,,,,,,,562,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skn Bngn3.1-4cm Remain Bdy,PX11424P,CDM,983,RC,11424,CPT,,,,,,,,562,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skn Bngn3.1-4cm Remain Bdy,PX11424P,CDM,983,RC,11424,CPT,,,,,,,,562,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skn Bngn3.1-4cm Remain Bdy,PX11424P,CDM,983,RC,11424,CPT,,,,,,,,562,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skn Bngn3.1-4cm Remain Bdy,PX11424P,CDM,983,RC,11424,CPT,,,,,,,,562,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skn Bngn3.1-4cm Remain Bdy,PX11424P,CDM,983,RC,11424,CPT,,,,,,,,562,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404P,CDM,983,RC,11404,CPT,,,,,,,,600,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404P,CDM,983,RC,11404,CPT,,,,,,,,600,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404P,CDM,983,RC,11404,CPT,,,,,,,,600,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404P,CDM,983,RC,11404,CPT,,,,,,,,600,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404P,CDM,983,RC,11404,CPT,,,,,,,,600,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404P,CDM,983,RC,11404,CPT,,,,,,,,600,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Bnig >4cmtrnk,Arm,Leg",PX11406P,CDM,983,RC,11406,CPT,,,,,,,,1456,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Bnig >4cmtrnk,Arm,Leg",PX11406P,CDM,983,RC,11406,CPT,,,,,,,,1456,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Bnig >4cmtrnk,Arm,Leg",PX11406P,CDM,983,RC,11406,CPT,,,,,,,,1456,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Bnig >4cmtrnk,Arm,Leg",PX11406P,CDM,983,RC,11406,CPT,,,,,,,,1456,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Bnig >4cmtrnk,Arm,Leg",PX11406P,CDM,983,RC,11406,CPT,,,,,,,,1456,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Bnig >4cmtrnk,Arm,Leg",PX11406P,CDM,983,RC,11406,CPT,,,,,,,,1456,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skn Bnig0.6-1cm Remain Bdy,PX11421P,CDM,983,RC,11421,CPT,,,,,,,,345,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skn Bnig0.6-1cm Remain Bdy,PX11421P,CDM,983,RC,11421,CPT,,,,,,,,345,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skn Bnig0.6-1cm Remain Bdy,PX11421P,CDM,983,RC,11421,CPT,,,,,,,,345,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skn Bnig0.6-1cm Remain Bdy,PX11421P,CDM,983,RC,11421,CPT,,,,,,,,345,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skn Bnig0.6-1cm Remain Bdy,PX11421P,CDM,983,RC,11421,CPT,,,,,,,,345,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skn Bnig0.6-1cm Remain Bdy,PX11421P,CDM,983,RC,11421,CPT,,,,,,,,345,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Mal 0.6-1cm Fce,Facial",PX11641P,CDM,983,RC,11641,CPT,,,,,,,,453,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Mal 0.6-1cm Fce,Facial",PX11641P,CDM,983,RC,11641,CPT,,,,,,,,453,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Mal 0.6-1cm Fce,Facial",PX11641P,CDM,983,RC,11641,CPT,,,,,,,,453,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Mal 0.6-1cm Fce,Facial",PX11641P,CDM,983,RC,11641,CPT,,,,,,,,453,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Mal 0.6-1cm Fce,Facial",PX11641P,CDM,983,RC,11641,CPT,,,,,,,,453,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Mal 0.6-1cm Fce,Facial",PX11641P,CDM,983,RC,11641,CPT,,,,,,,,453,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601P,CDM,983,RC,11601,CPT,,,,,,,,1046,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601P,CDM,983,RC,11601,CPT,,,,,,,,1046,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601P,CDM,983,RC,11601,CPT,,,,,,,,1046,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601P,CDM,983,RC,11601,CPT,,,,,,,,1046,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601P,CDM,983,RC,11601,CPT,,,,,,,,1046,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601P,CDM,983,RC,11601,CPT,,,,,,,,1046,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602P,CDM,983,RC,11602,CPT,,,,,,,,1120,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602P,CDM,983,RC,11602,CPT,,,,,,,,1120,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602P,CDM,983,RC,11602,CPT,,,,,,,,1120,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602P,CDM,983,RC,11602,CPT,,,,,,,,1120,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602P,CDM,983,RC,11602,CPT,,,,,,,,1120,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602P,CDM,983,RC,11602,CPT,,,,,,,,1120,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Mal 2.1-3cmtrnk,Arm,Lg",PX11603P,CDM,983,RC,11603,CPT,,,,,,,,1276,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Mal 2.1-3cmtrnk,Arm,Lg",PX11603P,CDM,983,RC,11603,CPT,,,,,,,,1276,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Mal 2.1-3cmtrnk,Arm,Lg",PX11603P,CDM,983,RC,11603,CPT,,,,,,,,1276,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Mal 2.1-3cmtrnk,Arm,Lg",PX11603P,CDM,983,RC,11603,CPT,,,,,,,,1276,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Mal 2.1-3cmtrnk,Arm,Lg",PX11603P,CDM,983,RC,11603,CPT,,,,,,,,1276,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Mal 2.1-3cmtrnk,Arm,Lg",PX11603P,CDM,983,RC,11603,CPT,,,,,,,,1276,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Malig1.1-2cm Fce,Facal",PX11642P,CDM,983,RC,11642,CPT,,,,,,,,466,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Malig1.1-2cm Fce,Facal",PX11642P,CDM,983,RC,11642,CPT,,,,,,,,466,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Malig1.1-2cm Fce,Facal",PX11642P,CDM,983,RC,11642,CPT,,,,,,,,466,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Malig1.1-2cm Fce,Facal",PX11642P,CDM,983,RC,11642,CPT,,,,,,,,466,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Malig1.1-2cm Fce,Facal",PX11642P,CDM,983,RC,11642,CPT,,,,,,,,466,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Malig1.1-2cm Fce,Facal",PX11642P,CDM,983,RC,11642,CPT,,,,,,,,466,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excis Arm/Elbow Tumor,Subcutan",PX24075F,CDM,510,RC,24075,CPT,,,,,,,,1519,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excis Arm/Elbow Tumor,Subcutan",PX24075F,CDM,510,RC,24075,CPT,,,,,,,,1519,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excis Arm/Elbow Tumor,Subcutan",PX24075F,CDM,510,RC,24075,CPT,,,,,,,,1519,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excis Arm/Elbow Tumor,Subcutan",PX24075F,CDM,510,RC,24075,CPT,,,,,,,,1519,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excis Arm/Elbow Tumor,Subcutan",PX24075F,CDM,510,RC,24075,CPT,,,,,,,,1519,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excis Arm/Elbow Tumor,Subcutan",PX24075F,CDM,510,RC,24075,CPT,,,,,,,,1519,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excis Arm/Elbow Tumor,Subcutan",PX24075P,CDM,983,RC,24075,CPT,,,,,,,,2458,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excis Arm/Elbow Tumor,Subcutan",PX24075P,CDM,983,RC,24075,CPT,,,,,,,,2458,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excis Arm/Elbow Tumor,Subcutan",PX24075P,CDM,983,RC,24075,CPT,,,,,,,,2458,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excis Arm/Elbow Tumor,Subcutan",PX24075P,CDM,983,RC,24075,CPT,,,,,,,,2458,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excis Arm/Elbow Tumor,Subcutan",PX24075P,CDM,983,RC,24075,CPT,,,,,,,,2458,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excis Arm/Elbow Tumor,Subcutan",PX24075P,CDM,983,RC,24075,CPT,,,,,,,,2458,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Excis Forearm/Wrist Tumor Subcutan,PX25075F,CDM,510,RC,25075,CPT,,,,,,,,1421,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Excis Forearm/Wrist Tumor Subcutan,PX25075F,CDM,510,RC,25075,CPT,,,,,,,,1421,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Excis Forearm/Wrist Tumor Subcutan,PX25075F,CDM,510,RC,25075,CPT,,,,,,,,1421,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Excis Forearm/Wrist Tumor Subcutan,PX25075F,CDM,510,RC,25075,CPT,,,,,,,,1421,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Excis Forearm/Wrist Tumor Subcutan,PX25075F,CDM,510,RC,25075,CPT,,,,,,,,1421,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Excis Forearm/Wrist Tumor Subcutan,PX25075F,CDM,510,RC,25075,CPT,,,,,,,,1421,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Excis Forearm/Wrist Tumor Subcutan,PX25075P,CDM,983,RC,25075,CPT,,,,,,,,607,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Excis Forearm/Wrist Tumor Subcutan,PX25075P,CDM,983,RC,25075,CPT,,,,,,,,607,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Excis Forearm/Wrist Tumor Subcutan,PX25075P,CDM,983,RC,25075,CPT,,,,,,,,607,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Excis Forearm/Wrist Tumor Subcutan,PX25075P,CDM,983,RC,25075,CPT,,,,,,,,607,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Excis Forearm/Wrist Tumor Subcutan,PX25075P,CDM,983,RC,25075,CPT,,,,,,,,607,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Excis Forearm/Wrist Tumor Subcutan,PX25075P,CDM,983,RC,25075,CPT,,,,,,,,607,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Excis Primary Ganglion Wrist,PX25111F,CDM,510,RC,25111,CPT,,,,,,,,791,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Excis Primary Ganglion Wrist,PX25111F,CDM,510,RC,25111,CPT,,,,,,,,791,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Excis Primary Ganglion Wrist,PX25111F,CDM,510,RC,25111,CPT,,,,,,,,791,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Excis Primary Ganglion Wrist,PX25111F,CDM,510,RC,25111,CPT,,,,,,,,791,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Excis Primary Ganglion Wrist,PX25111F,CDM,510,RC,25111,CPT,,,,,,,,791,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Excis Primary Ganglion Wrist,PX25111F,CDM,510,RC,25111,CPT,,,,,,,,791,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Excis Primary Ganglion Wrist,PX25111P,CDM,983,RC,25111,CPT,,,,,,,,529,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Excis Primary Ganglion Wrist,PX25111P,CDM,983,RC,25111,CPT,,,,,,,,529,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Excis Primary Ganglion Wrist,PX25111P,CDM,983,RC,25111,CPT,,,,,,,,529,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Excis Primary Ganglion Wrist,PX25111P,CDM,983,RC,25111,CPT,,,,,,,,529,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Excis Primary Ganglion Wrist,PX25111P,CDM,983,RC,25111,CPT,,,,,,,,529,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Excis Primary Ganglion Wrist,PX25111P,CDM,983,RC,25111,CPT,,,,,,,,529,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excis Tendn/Capsule Lesn,Toes",PX28092F,CDM,510,RC,28092,CPT,,,,,,,,1234,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excis Tendn/Capsule Lesn,Toes",PX28092F,CDM,510,RC,28092,CPT,,,,,,,,1234,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excis Tendn/Capsule Lesn,Toes",PX28092F,CDM,510,RC,28092,CPT,,,,,,,,1234,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excis Tendn/Capsule Lesn,Toes",PX28092F,CDM,510,RC,28092,CPT,,,,,,,,1234,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excis Tendn/Capsule Lesn,Toes",PX28092F,CDM,510,RC,28092,CPT,,,,,,,,1234,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excis Tendn/Capsule Lesn,Toes",PX28092F,CDM,510,RC,28092,CPT,,,,,,,,1234,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excis Tendn/Capsule Lesn,Toes",PX28092P,CDM,983,RC,28092,CPT,,,,,,,,1913,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excis Tendn/Capsule Lesn,Toes",PX28092P,CDM,983,RC,28092,CPT,,,,,,,,1913,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excis Tendn/Capsule Lesn,Toes",PX28092P,CDM,983,RC,28092,CPT,,,,,,,,1913,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excis Tendn/Capsule Lesn,Toes",PX28092P,CDM,983,RC,28092,CPT,,,,,,,,1913,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excis Tendn/Capsule Lesn,Toes",PX28092P,CDM,983,RC,28092,CPT,,,,,,,,1913,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excis Tendn/Capsule Lesn,Toes",PX28092P,CDM,983,RC,28092,CPT,,,,,,,,1913,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excise Lesion,Back or Flank",PX21930F,CDM,510,RC,21930,CPT,,,,,,,,1326,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excise Lesion,Back or Flank",PX21930F,CDM,510,RC,21930,CPT,,,,,,,,1326,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excise Lesion,Back or Flank",PX21930F,CDM,510,RC,21930,CPT,,,,,,,,1326,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excise Lesion,Back or Flank",PX21930F,CDM,510,RC,21930,CPT,,,,,,,,1326,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excise Lesion,Back or Flank",PX21930F,CDM,510,RC,21930,CPT,,,,,,,,1326,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excise Lesion,Back or Flank",PX21930F,CDM,510,RC,21930,CPT,,,,,,,,1326,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excise Lesion,Back or Flank",PX21930P,CDM,983,RC,21930,CPT,,,,,,,,884,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excise Lesion,Back or Flank",PX21930P,CDM,983,RC,21930,CPT,,,,,,,,884,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excise Lesion,Back or Flank",PX21930P,CDM,983,RC,21930,CPT,,,,,,,,884,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excise Lesion,Back or Flank",PX21930P,CDM,983,RC,21930,CPT,,,,,,,,884,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excise Lesion,Back or Flank",PX21930P,CDM,983,RC,21930,CPT,,,,,,,,884,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excise Lesion,Back or Flank",PX21930P,CDM,983,RC,21930,CPT,,,,,,,,884,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excision of Nail Fold, Toe",PX11765F,CDM,510,RC,11765,CPT,,,,,,,,210,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excision of Nail Fold, Toe",PX11765F,CDM,510,RC,11765,CPT,,,,,,,,210,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excision of Nail Fold, Toe",PX11765F,CDM,510,RC,11765,CPT,,,,,,,,210,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excision of Nail Fold, Toe",PX11765F,CDM,510,RC,11765,CPT,,,,,,,,210,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excision of Nail Fold, Toe",PX11765F,CDM,510,RC,11765,CPT,,,,,,,,210,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excision of Nail Fold, Toe",PX11765F,CDM,510,RC,11765,CPT,,,,,,,,210,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830F,CDM,510,RC,15830,CPT,,,,,,,,2080,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830F,CDM,510,RC,15830,CPT,,,,,,,,2080,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830F,CDM,510,RC,15830,CPT,,,,,,,,2080,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830F,CDM,510,RC,15830,CPT,,,,,,,,2080,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830F,CDM,510,RC,15830,CPT,,,,,,,,2080,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830F,CDM,510,RC,15830,CPT,,,,,,,,2080,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830P,CDM,983,RC,15830,CPT,,,,,,,,1120,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830P,CDM,983,RC,15830,CPT,,,,,,,,1120,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830P,CDM,983,RC,15830,CPT,,,,,,,,1120,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830P,CDM,983,RC,15830,CPT,,,,,,,,1120,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830P,CDM,983,RC,15830,CPT,,,,,,,,1120,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830P,CDM,983,RC,15830,CPT,,,,,,,,1120,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Explor Metatarso-Phalang Jt,PX28022F,CDM,510,RC,28022,CPT,,,,,,,,1161,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Explor Metatarso-Phalang Jt,PX28022F,CDM,510,RC,28022,CPT,,,,,,,,1161,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Explor Metatarso-Phalang Jt,PX28022F,CDM,510,RC,28022,CPT,,,,,,,,1161,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Explor Metatarso-Phalang Jt,PX28022F,CDM,510,RC,28022,CPT,,,,,,,,1161,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Explor Metatarso-Phalang Jt,PX28022F,CDM,510,RC,28022,CPT,,,,,,,,1161,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Explor Metatarso-Phalang Jt,PX28022F,CDM,510,RC,28022,CPT,,,,,,,,1161,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Explor Metatarso-Phalang Jt,PX28022P,CDM,983,RC,28022,CPT,,,,,,,,774,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Explor Metatarso-Phalang Jt,PX28022P,CDM,983,RC,28022,CPT,,,,,,,,774,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Explor Metatarso-Phalang Jt,PX28022P,CDM,983,RC,28022,CPT,,,,,,,,774,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Explor Metatarso-Phalang Jt,PX28022P,CDM,983,RC,28022,CPT,,,,,,,,774,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Explor Metatarso-Phalang Jt,PX28022P,CDM,983,RC,28022,CPT,,,,,,,,774,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Explor Metatarso-Phalang Jt,PX28022P,CDM,983,RC,28022,CPT,,,,,,,,774,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exs Tumor Arm/Elbow Sc 3cm>,PX24071F,CDM,510,RC,24071,CPT,,,,,,,,1860,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exs Tumor Arm/Elbow Sc 3cm>,PX24071F,CDM,510,RC,24071,CPT,,,,,,,,1860,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exs Tumor Arm/Elbow Sc 3cm>,PX24071F,CDM,510,RC,24071,CPT,,,,,,,,1860,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exs Tumor Arm/Elbow Sc 3cm>,PX24071F,CDM,510,RC,24071,CPT,,,,,,,,1860,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exs Tumor Arm/Elbow Sc 3cm>,PX24071F,CDM,510,RC,24071,CPT,,,,,,,,1860,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exs Tumor Arm/Elbow Sc 3cm>,PX24071F,CDM,510,RC,24071,CPT,,,,,,,,1860,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ext Ecg > 48hr to 21 Day Rcrd W/Conect Intl Rcrd,PX0296T,CDM,731,RC,0296T,HCPCS,,,,,,,,389,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ext Ecg > 48hr to 21 Day Rcrd W/Conect Intl Rcrd,PX0296T,CDM,731,RC,0296T,HCPCS,,,,,,,,389,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ext Ecg > 48hr to 21 Day Rcrd W/Conect Intl Rcrd,PX0296T,CDM,731,RC,0296T,HCPCS,,,,,,,,389,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ext Ecg > 48hr to 21 Day Rcrd W/Conect Intl Rcrd,PX0296T,CDM,731,RC,0296T,HCPCS,,,,,,,,389,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ext Ecg > 48hr to 21 Day Rcrd W/Conect Intl Rcrd,PX0296T,CDM,731,RC,0296T,HCPCS,,,,,,,,389,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ext Ecg > 48hr to 21 Day Rcrd W/Conect Intl Rcrd,PX0296T,CDM,731,RC,0296T,HCPCS,,,,,,,,389,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Extractable Nuclear Antigen, Each Antigen",PX86235,CDM,300,RC,86235,CPT,90,,,,,,,99,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Extractable Nuclear Antigen, Each Antigen",PX86235,CDM,300,RC,86235,CPT,90,,,,,,,99,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Extractable Nuclear Antigen, Each Antigen",PX86235,CDM,300,RC,86235,CPT,90,,,,,,,99,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Extractable Nuclear Antigen, Each Antigen",PX86235,CDM,300,RC,86235,CPT,90,,,,,,,99,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Extractable Nuclear Antigen, Each Antigen",PX86235,CDM,300,RC,86235,CPT,90,,,,,,,99,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Extractable Nuclear Antigen, Each Antigen",PX86235,CDM,300,RC,86235,CPT,90,,,,,,,99,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Extremity Study - Vascular Diagnostics,PX9392201,CDM,921,RC,93922,CPT,TC,,,,,,,600,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Extremity Study - Vascular Diagnostics,PX9392201,CDM,921,RC,93922,CPT,TC,,,,,,,600,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Extremity Study - Vascular Diagnostics,PX9392201,CDM,921,RC,93922,CPT,TC,,,,,,,600,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Extremity Study - Vascular Diagnostics,PX9392201,CDM,921,RC,93922,CPT,TC,,,,,,,600,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Extremity Study - Vascular Diagnostics,PX9392201,CDM,921,RC,93922,CPT,TC,,,,,,,600,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Extremity Study - Vascular Diagnostics,PX9392201,CDM,921,RC,93922,CPT,TC,,,,,,,600,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EYE IRRIGATION SYSTEM MT2000,120.318,CDM,272,RC,,,,8718-MAIN,LOCAL,,,,,112,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EYE IRRIGATION SYSTEM MT2000,120.318,CDM,272,RC,,,,8718-MAIN,LOCAL,,,,,112,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EYE IRRIGATION SYSTEM MT2000,120.318,CDM,272,RC,,,,8718-MAIN,LOCAL,,,,,112,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EYE IRRIGATION SYSTEM MT2000,120.318,CDM,272,RC,,,,8718-MAIN,LOCAL,,,,,112,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EYE IRRIGATION SYSTEM MT2000,120.318,CDM,272,RC,,,,8718-MAIN,LOCAL,,,,,112,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EYE IRRIGATION SYSTEM MT2000,120.318,CDM,272,RC,,,,8718-MAIN,LOCAL,,,,,112,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EZ CLEAN BLADE CAUTERY TIP 4 INCH,27200000,CDM,272,RC,,,,12826-MAIN,LOCAL,,,,,14,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EZ CLEAN BLADE CAUTERY TIP 4 INCH,27200000,CDM,272,RC,,,,12826-MAIN,LOCAL,,,,,14,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EZ CLEAN BLADE CAUTERY TIP 4 INCH,27200000,CDM,272,RC,,,,12826-MAIN,LOCAL,,,,,14,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EZ CLEAN BLADE CAUTERY TIP 4 INCH,27200000,CDM,272,RC,,,,12826-MAIN,LOCAL,,,,,14,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EZ CLEAN BLADE CAUTERY TIP 4 INCH,27200000,CDM,272,RC,,,,12826-MAIN,LOCAL,,,,,14,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EZ CLEAN BLADE CAUTERY TIP 4 INCH,27200000,CDM,272,RC,,,,12826-MAIN,LOCAL,,,,,14,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EZ-STABILIZER DRESSING,120.415,CDM,272,RC,,,,9058-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EZ-STABILIZER DRESSING,120.415,CDM,272,RC,,,,9058-MAIN,LOCAL,,,,,42,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EZ-STABILIZER DRESSING,120.415,CDM,272,RC,,,,9058-MAIN,LOCAL,,,,,42,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EZ-STABILIZER DRESSING,120.415,CDM,272,RC,,,,9058-MAIN,LOCAL,,,,,42,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EZ-STABILIZER DRESSING,120.415,CDM,272,RC,,,,9058-MAIN,LOCAL,,,,,42,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EZ-STABILIZER DRESSING,120.415,CDM,272,RC,,,,9058-MAIN,LOCAL,,,,,42,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ezetimibe 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714081301,NDC,1,EA,44.91,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ezetimibe 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714081301,NDC,1,EA,44.91,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ezetimibe 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714081301,NDC,1,EA,44.91,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ezetimibe 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714081301,NDC,1,EA,44.91,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ezetimibe 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714081301,NDC,1,EA,44.91,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ezetimibe 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714081301,NDC,1,EA,44.91,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ezetimibe 10 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,16729043316,NDC,1,EA,60.66,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ezetimibe 10 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,16729043316,NDC,1,EA,60.66,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ezetimibe 10 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,16729043316,NDC,1,EA,60.66,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ezetimibe 10 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,16729043316,NDC,1,EA,60.66,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ezetimibe 10 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,16729043316,NDC,1,EA,60.66,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ezetimibe 10 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,16729043316,NDC,1,EA,60.66,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
F5 Gene - Ref,PX8124190,CDM,300,RC,81241,CPT,90,,,,,,,112,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
F5 Gene - Ref,PX8124190,CDM,300,RC,81241,CPT,90,,,,,,,112,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
F5 Gene - Ref,PX8124190,CDM,300,RC,81241,CPT,90,,,,,,,112,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
F5 Gene - Ref,PX8124190,CDM,300,RC,81241,CPT,90,,,,,,,112,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
F5 Gene - Ref,PX8124190,CDM,300,RC,81241,CPT,90,,,,,,,112,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
F5 Gene - Ref,PX8124190,CDM,300,RC,81241,CPT,90,,,,,,,112,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Cystourethroscopy,PX52000F,CDM,761,RC,52000,CPT,,,,,,,,1601,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Cystourethroscopy,PX52000F,CDM,761,RC,52000,CPT,,,,,,,,1601,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Cystourethroscopy,PX52000F,CDM,761,RC,52000,CPT,,,,,,,,1601,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Cystourethroscopy,PX52000F,CDM,761,RC,52000,CPT,,,,,,,,1601,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Cystourethroscopy,PX52000F,CDM,761,RC,52000,CPT,,,,,,,,1601,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Cystourethroscopy,PX52000F,CDM,761,RC,52000,CPT,,,,,,,,1601,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Debridement of Nails, 6 or Mor",PX11721F,CDM,510,RC,11721,CPT,,,,,,,,95,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Debridement of Nails, 6 or Mor",PX11721F,CDM,510,RC,11721,CPT,,,,,,,,95,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Debridement of Nails, 6 or Mor",PX11721F,CDM,510,RC,11721,CPT,,,,,,,,95,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Debridement of Nails, 6 or Mor",PX11721F,CDM,510,RC,11721,CPT,,,,,,,,95,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Debridement of Nails, 6 or Mor",PX11721F,CDM,510,RC,11721,CPT,,,,,,,,95,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Debridement of Nails, 6 or Mor",PX11721F,CDM,510,RC,11721,CPT,,,,,,,,95,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Ex Skinbngn0.6-1cmtrnk,Arm,Lg",PX11401F,CDM,510,RC,11401,CPT,,,,,,,,484,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Ex Skinbngn0.6-1cmtrnk,Arm,Lg",PX11401F,CDM,510,RC,11401,CPT,,,,,,,,484,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Ex Skinbngn0.6-1cmtrnk,Arm,Lg",PX11401F,CDM,510,RC,11401,CPT,,,,,,,,484,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Ex Skinbngn0.6-1cmtrnk,Arm,Lg",PX11401F,CDM,510,RC,11401,CPT,,,,,,,,484,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Ex Skinbngn0.6-1cmtrnk,Arm,Lg",PX11401F,CDM,510,RC,11401,CPT,,,,,,,,484,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Ex Skinbngn0.6-1cmtrnk,Arm,Lg",PX11401F,CDM,510,RC,11401,CPT,,,,,,,,484,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Ex Skn Bngn2.1-3cm Trnk,Arm,Lg",PX11403F,CDM,510,RC,11403,CPT,,,,,,,,679,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Ex Skn Bngn2.1-3cm Trnk,Arm,Lg",PX11403F,CDM,510,RC,11403,CPT,,,,,,,,679,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Ex Skn Bngn2.1-3cm Trnk,Arm,Lg",PX11403F,CDM,510,RC,11403,CPT,,,,,,,,679,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Ex Skn Bngn2.1-3cm Trnk,Arm,Lg",PX11403F,CDM,510,RC,11403,CPT,,,,,,,,679,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Ex Skn Bngn2.1-3cm Trnk,Arm,Lg",PX11403F,CDM,510,RC,11403,CPT,,,,,,,,679,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Ex Skn Bngn2.1-3cm Trnk,Arm,Lg",PX11403F,CDM,510,RC,11403,CPT,,,,,,,,679,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Exc Skin Benig<5mm Remaind Bod,PX11420F,CDM,510,RC,11420,CPT,,,,,,,,374,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Exc Skin Benig<5mm Remaind Bod,PX11420F,CDM,510,RC,11420,CPT,,,,,,,,374,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Exc Skin Benig<5mm Remaind Bod,PX11420F,CDM,510,RC,11420,CPT,,,,,,,,374,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Exc Skin Benig<5mm Remaind Bod,PX11420F,CDM,510,RC,11420,CPT,,,,,,,,374,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Exc Skin Benig<5mm Remaind Bod,PX11420F,CDM,510,RC,11420,CPT,,,,,,,,374,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Exc Skin Benig<5mm Remaind Bod,PX11420F,CDM,510,RC,11420,CPT,,,,,,,,374,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Exc Skn Beni 0.6-1cm Remain Bdy,PX11421F,CDM,510,RC,11421,CPT,,,,,,,,931,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Exc Skn Beni 0.6-1cm Remain Bdy,PX11421F,CDM,510,RC,11421,CPT,,,,,,,,931,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Exc Skn Beni 0.6-1cm Remain Bdy,PX11421F,CDM,510,RC,11421,CPT,,,,,,,,931,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Exc Skn Beni 0.6-1cm Remain Bdy,PX11421F,CDM,510,RC,11421,CPT,,,,,,,,931,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Exc Skn Beni 0.6-1cm Remain Bdy,PX11421F,CDM,510,RC,11421,CPT,,,,,,,,931,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Exc Skn Beni 0.6-1cm Remain Bdy,PX11421F,CDM,510,RC,11421,CPT,,,,,,,,931,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Beni1.1-2cm Fce,Facial",PX11442F,CDM,510,RC,11442,CPT,,,,,,,,668,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Beni1.1-2cm Fce,Facial",PX11442F,CDM,510,RC,11442,CPT,,,,,,,,668,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Beni1.1-2cm Fce,Facial",PX11442F,CDM,510,RC,11442,CPT,,,,,,,,668,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Beni1.1-2cm Fce,Facial",PX11442F,CDM,510,RC,11442,CPT,,,,,,,,668,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Beni1.1-2cm Fce,Facial",PX11442F,CDM,510,RC,11442,CPT,,,,,,,,668,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Beni1.1-2cm Fce,Facial",PX11442F,CDM,510,RC,11442,CPT,,,,,,,,668,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Benig >4cm Trnk,Arm,Lg",PX11406F,CDM,510,RC,11406,CPT,,,,,,,,1127,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Benig >4cm Trnk,Arm,Lg",PX11406F,CDM,510,RC,11406,CPT,,,,,,,,1127,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Benig >4cm Trnk,Arm,Lg",PX11406F,CDM,510,RC,11406,CPT,,,,,,,,1127,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Benig >4cm Trnk,Arm,Lg",PX11406F,CDM,510,RC,11406,CPT,,,,,,,,1127,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Benig >4cm Trnk,Arm,Lg",PX11406F,CDM,510,RC,11406,CPT,,,,,,,,1127,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Benig >4cm Trnk,Arm,Lg",PX11406F,CDM,510,RC,11406,CPT,,,,,,,,1127,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Benig<5mm Face,Facial",PX11440F,CDM,510,RC,11440,CPT,,,,,,,,484,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Benig<5mm Face,Facial",PX11440F,CDM,510,RC,11440,CPT,,,,,,,,484,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Benig<5mm Face,Facial",PX11440F,CDM,510,RC,11440,CPT,,,,,,,,484,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Benig<5mm Face,Facial",PX11440F,CDM,510,RC,11440,CPT,,,,,,,,484,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Benig<5mm Face,Facial",PX11440F,CDM,510,RC,11440,CPT,,,,,,,,484,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Benig<5mm Face,Facial",PX11440F,CDM,510,RC,11440,CPT,,,,,,,,484,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Bngn 2.1-3cmfce,Facial",PX11443F,CDM,510,RC,11443,CPT,,,,,,,,813,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Bngn 2.1-3cmfce,Facial",PX11443F,CDM,510,RC,11443,CPT,,,,,,,,813,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Bngn 2.1-3cmfce,Facial",PX11443F,CDM,510,RC,11443,CPT,,,,,,,,813,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Bngn 2.1-3cmfce,Facial",PX11443F,CDM,510,RC,11443,CPT,,,,,,,,813,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Bngn 2.1-3cmfce,Facial",PX11443F,CDM,510,RC,11443,CPT,,,,,,,,813,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Bngn 2.1-3cmfce,Facial",PX11443F,CDM,510,RC,11443,CPT,,,,,,,,813,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Exc Skn Bngn1.1-2cm Remain Bdy,PX11422F,CDM,510,RC,11422,CPT,,,,,,,,618,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Exc Skn Bngn1.1-2cm Remain Bdy,PX11422F,CDM,510,RC,11422,CPT,,,,,,,,618,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Exc Skn Bngn1.1-2cm Remain Bdy,PX11422F,CDM,510,RC,11422,CPT,,,,,,,,618,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Exc Skn Bngn1.1-2cm Remain Bdy,PX11422F,CDM,510,RC,11422,CPT,,,,,,,,618,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Exc Skn Bngn1.1-2cm Remain Bdy,PX11422F,CDM,510,RC,11422,CPT,,,,,,,,618,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Exc Skn Bngn1.1-2cm Remain Bdy,PX11422F,CDM,510,RC,11422,CPT,,,,,,,,618,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Exc Skn Bngn3.1-4cm Remain Bdy,PX11424F,CDM,510,RC,11424,CPT,,,,,,,,931,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Exc Skn Bngn3.1-4cm Remain Bdy,PX11424F,CDM,510,RC,11424,CPT,,,,,,,,931,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Exc Skn Bngn3.1-4cm Remain Bdy,PX11424F,CDM,510,RC,11424,CPT,,,,,,,,931,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Exc Skn Bngn3.1-4cm Remain Bdy,PX11424F,CDM,510,RC,11424,CPT,,,,,,,,931,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Exc Skn Bngn3.1-4cm Remain Bdy,PX11424F,CDM,510,RC,11424,CPT,,,,,,,,931,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Exc Skn Bngn3.1-4cm Remain Bdy,PX11424F,CDM,510,RC,11424,CPT,,,,,,,,931,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404F,CDM,510,RC,11404,CPT,,,,,,,,749,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404F,CDM,510,RC,11404,CPT,,,,,,,,749,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404F,CDM,510,RC,11404,CPT,,,,,,,,749,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404F,CDM,510,RC,11404,CPT,,,,,,,,749,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404F,CDM,510,RC,11404,CPT,,,,,,,,749,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404F,CDM,510,RC,11404,CPT,,,,,,,,749,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Bnig0.6-1cm Fae,Facial",PX11441F,CDM,510,RC,11441,CPT,,,,,,,,606,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Bnig0.6-1cm Fae,Facial",PX11441F,CDM,510,RC,11441,CPT,,,,,,,,606,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Bnig0.6-1cm Fae,Facial",PX11441F,CDM,510,RC,11441,CPT,,,,,,,,606,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Bnig0.6-1cm Fae,Facial",PX11441F,CDM,510,RC,11441,CPT,,,,,,,,606,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Bnig0.6-1cm Fae,Facial",PX11441F,CDM,510,RC,11441,CPT,,,,,,,,606,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Bnig0.6-1cm Fae,Facial",PX11441F,CDM,510,RC,11441,CPT,,,,,,,,606,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Mal 0.6-1cm Fce,Facial",PX11641F,CDM,510,RC,11641,CPT,,,,,,,,680,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Mal 0.6-1cm Fce,Facial",PX11641F,CDM,510,RC,11641,CPT,,,,,,,,680,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Mal 0.6-1cm Fce,Facial",PX11641F,CDM,510,RC,11641,CPT,,,,,,,,680,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Mal 0.6-1cm Fce,Facial",PX11641F,CDM,510,RC,11641,CPT,,,,,,,,680,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Mal 0.6-1cm Fce,Facial",PX11641F,CDM,510,RC,11641,CPT,,,,,,,,680,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Mal 0.6-1cm Fce,Facial",PX11641F,CDM,510,RC,11641,CPT,,,,,,,,680,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601F,CDM,510,RC,11601,CPT,,,,,,,,673,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601F,CDM,510,RC,11601,CPT,,,,,,,,673,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601F,CDM,510,RC,11601,CPT,,,,,,,,673,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601F,CDM,510,RC,11601,CPT,,,,,,,,673,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601F,CDM,510,RC,11601,CPT,,,,,,,,673,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601F,CDM,510,RC,11601,CPT,,,,,,,,673,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602F,CDM,510,RC,11602,CPT,,,,,,,,731,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602F,CDM,510,RC,11602,CPT,,,,,,,,731,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602F,CDM,510,RC,11602,CPT,,,,,,,,731,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602F,CDM,510,RC,11602,CPT,,,,,,,,731,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602F,CDM,510,RC,11602,CPT,,,,,,,,731,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602F,CDM,510,RC,11602,CPT,,,,,,,,731,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Mali2.1-3cmtrnk,Arm,Lg",PX11603F,CDM,510,RC,11603,CPT,,,,,,,,875,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Mali2.1-3cmtrnk,Arm,Lg",PX11603F,CDM,510,RC,11603,CPT,,,,,,,,875,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Mali2.1-3cmtrnk,Arm,Lg",PX11603F,CDM,510,RC,11603,CPT,,,,,,,,875,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Mali2.1-3cmtrnk,Arm,Lg",PX11603F,CDM,510,RC,11603,CPT,,,,,,,,875,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Mali2.1-3cmtrnk,Arm,Lg",PX11603F,CDM,510,RC,11603,CPT,,,,,,,,875,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Mali2.1-3cmtrnk,Arm,Lg",PX11603F,CDM,510,RC,11603,CPT,,,,,,,,875,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Malig .1-2cm Fce,Facal",PX11642F,CDM,510,RC,11642,CPT,,,,,,,,698,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Malig .1-2cm Fce,Facal",PX11642F,CDM,510,RC,11642,CPT,,,,,,,,698,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Malig .1-2cm Fce,Facal",PX11642F,CDM,510,RC,11642,CPT,,,,,,,,698,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Malig .1-2cm Fce,Facal",PX11642F,CDM,510,RC,11642,CPT,,,,,,,,698,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Malig .1-2cm Fce,Facal",PX11642F,CDM,510,RC,11642,CPT,,,,,,,,698,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Malig .1-2cm Fce,Facal",PX11642F,CDM,510,RC,11642,CPT,,,,,,,,698,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Hospital Discharge Day>30 Min,PX99239F,CDM,510,RC,99239,CPT,,,,,,,,210,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Hospital Discharge Day>30 Min,PX99239F,CDM,510,RC,99239,CPT,,,,,,,,210,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Hospital Discharge Day>30 Min,PX99239F,CDM,510,RC,99239,CPT,,,,,,,,210,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Hospital Discharge Day>30 Min,PX99239F,CDM,510,RC,99239,CPT,,,,,,,,210,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Hospital Discharge Day>30 Min,PX99239F,CDM,510,RC,99239,CPT,,,,,,,,210,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Hospital Discharge Day>30 Min,PX99239F,CDM,510,RC,99239,CPT,,,,,,,,210,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Initial Hospital Care Levl II,PX99222F,CDM,510,RC,99222,CPT,,,,,,,,187,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Initial Hospital Care Levl II,PX99222F,CDM,510,RC,99222,CPT,,,,,,,,187,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Initial Hospital Care Levl II,PX99222F,CDM,510,RC,99222,CPT,,,,,,,,187,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Initial Hospital Care Levl II,PX99222F,CDM,510,RC,99222,CPT,,,,,,,,187,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Initial Hospital Care Levl II,PX99222F,CDM,510,RC,99222,CPT,,,,,,,,187,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Initial Hospital Care Levl II,PX99222F,CDM,510,RC,99222,CPT,,,,,,,,187,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Irrigation of Bladder,PX51700F,CDM,510,RC,51700,CPT,,,,,,,,358,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Irrigation of Bladder,PX51700F,CDM,510,RC,51700,CPT,,,,,,,,358,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Irrigation of Bladder,PX51700F,CDM,510,RC,51700,CPT,,,,,,,,358,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Irrigation of Bladder,PX51700F,CDM,510,RC,51700,CPT,,,,,,,,358,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Irrigation of Bladder,PX51700F,CDM,510,RC,51700,CPT,,,,,,,,358,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Irrigation of Bladder,PX51700F,CDM,510,RC,51700,CPT,,,,,,,,358,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Ligation of Hemorrhoid(S),PX46221F,CDM,510,RC,46221,CPT,,,,,,,,1046,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Ligation of Hemorrhoid(S),PX46221F,CDM,510,RC,46221,CPT,,,,,,,,1046,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Ligation of Hemorrhoid(S),PX46221F,CDM,510,RC,46221,CPT,,,,,,,,1046,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Ligation of Hemorrhoid(S),PX46221F,CDM,510,RC,46221,CPT,,,,,,,,1046,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Ligation of Hemorrhoid(S),PX46221F,CDM,510,RC,46221,CPT,,,,,,,,1046,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Ligation of Hemorrhoid(S),PX46221F,CDM,510,RC,46221,CPT,,,,,,,,1046,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Office Consultation,Level III",PX99243F,CDM,510,RC,99213,CPT,,,,,,,,374,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Office Consultation,Level III",PX99243F,CDM,510,RC,99213,CPT,,,,,,,,374,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Office Consultation,Level III",PX99243F,CDM,510,RC,99213,CPT,,,,,,,,374,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Office Consultation,Level III",PX99243F,CDM,510,RC,99213,CPT,,,,,,,,374,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Office Consultation,Level III",PX99243F,CDM,510,RC,99213,CPT,,,,,,,,374,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Office Consultation,Level III",PX99243F,CDM,510,RC,99213,CPT,,,,,,,,374,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Office Consultation,Level IV",PX99244F,CDM,510,RC,99244,CPT,,,,,,,,441,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Office Consultation,Level IV",PX99244F,CDM,510,RC,99244,CPT,,,,,,,,441,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Office Consultation,Level IV",PX99244F,CDM,510,RC,99244,CPT,,,,,,,,441,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Office Consultation,Level IV",PX99244F,CDM,510,RC,99244,CPT,,,,,,,,441,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Office Consultation,Level IV",PX99244F,CDM,510,RC,99244,CPT,,,,,,,,441,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Office Consultation,Level IV",PX99244F,CDM,510,RC,99244,CPT,,,,,,,,441,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Removal of Skin Tags,PX11200F,CDM,510,RC,11200,CPT,,,,,,,,348,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Removal of Skin Tags,PX11200F,CDM,510,RC,11200,CPT,,,,,,,,348,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Removal of Skin Tags,PX11200F,CDM,510,RC,11200,CPT,,,,,,,,348,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Removal of Skin Tags,PX11200F,CDM,510,RC,11200,CPT,,,,,,,,348,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Removal of Skin Tags,PX11200F,CDM,510,RC,11200,CPT,,,,,,,,348,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Removal of Skin Tags,PX11200F,CDM,510,RC,11200,CPT,,,,,,,,348,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Ther Injection Carpal Tunnel,PX20526F,CDM,510,RC,20526,CPT,,,,,,,,191,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Ther Injection Carpal Tunnel,PX20526F,CDM,510,RC,20526,CPT,,,,,,,,191,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Ther Injection Carpal Tunnel,PX20526F,CDM,510,RC,20526,CPT,,,,,,,,191,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Ther Injection Carpal Tunnel,PX20526F,CDM,510,RC,20526,CPT,,,,,,,,191,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Ther Injection Carpal Tunnel,PX20526F,CDM,510,RC,20526,CPT,,,,,,,,191,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Ther Injection Carpal Tunnel,PX20526F,CDM,510,RC,20526,CPT,,,,,,,,191,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Trim Nail(S),PX11719F,CDM,510,RC,11719,CPT,,,,,,,,107,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Trim Nail(S),PX11719F,CDM,510,RC,11719,CPT,,,,,,,,107,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Trim Nail(S),PX11719F,CDM,510,RC,11719,CPT,,,,,,,,107,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Trim Nail(S),PX11719F,CDM,510,RC,11719,CPT,,,,,,,,107,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Trim Nail(S),PX11719F,CDM,510,RC,11719,CPT,,,,,,,,107,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Trim Nail(S),PX11719F,CDM,510,RC,11719,CPT,,,,,,,,107,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Trm Hyperkeratotic Skn Lesn,>4",PX11057F,CDM,510,RC,11057,CPT,,,,,,,,175,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Trm Hyperkeratotic Skn Lesn,>4",PX11057F,CDM,510,RC,11057,CPT,,,,,,,,175,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Trm Hyperkeratotic Skn Lesn,>4",PX11057F,CDM,510,RC,11057,CPT,,,,,,,,175,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Trm Hyperkeratotic Skn Lesn,>4",PX11057F,CDM,510,RC,11057,CPT,,,,,,,,175,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Trm Hyperkeratotic Skn Lesn,>4",PX11057F,CDM,510,RC,11057,CPT,,,,,,,,175,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Trm Hyperkeratotic Skn Lesn,>4",PX11057F,CDM,510,RC,11057,CPT,,,,,,,,175,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Trm Hyperkeratotic Skn Lesn2-4,PX11056F,CDM,510,RC,11056,CPT,,,,,,,,158,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Trm Hyperkeratotic Skn Lesn2-4,PX11056F,CDM,510,RC,11056,CPT,,,,,,,,158,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Trm Hyperkeratotic Skn Lesn2-4,PX11056F,CDM,510,RC,11056,CPT,,,,,,,,158,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Trm Hyperkeratotic Skn Lesn2-4,PX11056F,CDM,510,RC,11056,CPT,,,,,,,,158,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Trm Hyperkeratotic Skn Lesn2-4,PX11056F,CDM,510,RC,11056,CPT,,,,,,,,158,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Trm Hyperkeratotic Skn Lesn2-4,PX11056F,CDM,510,RC,11056,CPT,,,,,,,,158,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Facility Critical Care, Addl 30 Min",PX99292F,CDM,510,RC,99292,CPT,,,,,,,,484,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Facility Critical Care, Addl 30 Min",PX99292F,CDM,510,RC,99292,CPT,,,,,,,,484,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Facility Critical Care, Addl 30 Min",PX99292F,CDM,510,RC,99292,CPT,,,,,,,,484,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Facility Critical Care, Addl 30 Min",PX99292F,CDM,510,RC,99292,CPT,,,,,,,,484,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Facility Critical Care, Addl 30 Min",PX99292F,CDM,510,RC,99292,CPT,,,,,,,,484,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Facility Critical Care, Addl 30 Min",PX99292F,CDM,510,RC,99292,CPT,,,,,,,,484,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Facility Critical Care, E/M 30-74 Minutes",PX99291F,CDM,510,RC,99291,CPT,,,,,,,,1264,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Facility Critical Care, E/M 30-74 Minutes",PX99291F,CDM,510,RC,99291,CPT,,,,,,,,1264,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Facility Critical Care, E/M 30-74 Minutes",PX99291F,CDM,510,RC,99291,CPT,,,,,,,,1264,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Facility Critical Care, E/M 30-74 Minutes",PX99291F,CDM,510,RC,99291,CPT,,,,,,,,1264,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Facility Critical Care, E/M 30-74 Minutes",PX99291F,CDM,510,RC,99291,CPT,,,,,,,,1264,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Facility Critical Care, E/M 30-74 Minutes",PX99291F,CDM,510,RC,99291,CPT,,,,,,,,1264,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Facility Emergency Level 1 Visit,PX99281F,CDM,450,RC,99281,CPT,,,,,,,,329,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247,6141.46
Facility Emergency Level 1 Visit,PX99281F,CDM,450,RC,99281,CPT,,,,,,,,329,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247,6141.46
Facility Emergency Level 1 Visit,PX99281F,CDM,450,RC,99281,CPT,,,,,,,,329,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247,6141.46
Facility Emergency Level 1 Visit,PX99281F,CDM,450,RC,99281,CPT,,,,,,,,329,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247,6141.46
Facility Emergency Level 1 Visit,PX99281F,CDM,450,RC,99281,CPT,,,,,,,,329,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247,6141.46
Facility Emergency Level 1 Visit,PX99281F,CDM,450,RC,99281,CPT,,,,,,,,329,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247,6141.46
Facility Emergency Level II Visit,PX99282F,CDM,450,RC,99282,CPT,,,,,,,,387,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,493,6141.46
Facility Emergency Level II Visit,PX99282F,CDM,450,RC,99282,CPT,,,,,,,,387,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,493,6141.46
Facility Emergency Level II Visit,PX99282F,CDM,450,RC,99282,CPT,,,,,,,,387,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,493,6141.46
Facility Emergency Level II Visit,PX99282F,CDM,450,RC,99282,CPT,,,,,,,,387,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,493,6141.46
Facility Emergency Level II Visit,PX99282F,CDM,450,RC,99282,CPT,,,,,,,,387,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,493,6141.46
Facility Emergency Level II Visit,PX99282F,CDM,450,RC,99282,CPT,,,,,,,,387,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,493,6141.46
Facility Emergency Level III Visit,PX99283F,CDM,450,RC,99283,CPT,,,,,,,,587,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,740,6141.46
Facility Emergency Level III Visit,PX99283F,CDM,450,RC,99283,CPT,,,,,,,,587,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,740,6141.46
Facility Emergency Level III Visit,PX99283F,CDM,450,RC,99283,CPT,,,,,,,,587,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,740,6141.46
Facility Emergency Level III Visit,PX99283F,CDM,450,RC,99283,CPT,,,,,,,,587,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,740,6141.46
Facility Emergency Level III Visit,PX99283F,CDM,450,RC,99283,CPT,,,,,,,,587,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,740,6141.46
Facility Emergency Level III Visit,PX99283F,CDM,450,RC,99283,CPT,,,,,,,,587,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,740,6141.46
Facility Emergency Level IV Visit,PX99284F,CDM,450,RC,99284,CPT,,,,,,,,1054,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1084,6141.46
Facility Emergency Level IV Visit,PX99284F,CDM,450,RC,99284,CPT,,,,,,,,1054,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1084,6141.46
Facility Emergency Level IV Visit,PX99284F,CDM,450,RC,99284,CPT,,,,,,,,1054,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1084,6141.46
Facility Emergency Level IV Visit,PX99284F,CDM,450,RC,99284,CPT,,,,,,,,1054,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1084,6141.46
Facility Emergency Level IV Visit,PX99284F,CDM,450,RC,99284,CPT,,,,,,,,1054,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1084,6141.46
Facility Emergency Level IV Visit,PX99284F,CDM,450,RC,99284,CPT,,,,,,,,1054,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1084,6141.46
Facility Emergency Level V Visit,PX99285F,CDM,450,RC,99285,CPT,,,,,,,,1464,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1183,6141.46
Facility Emergency Level V Visit,PX99285F,CDM,450,RC,99285,CPT,,,,,,,,1464,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1183,6141.46
Facility Emergency Level V Visit,PX99285F,CDM,450,RC,99285,CPT,,,,,,,,1464,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1183,6141.46
Facility Emergency Level V Visit,PX99285F,CDM,450,RC,99285,CPT,,,,,,,,1464,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1183,6141.46
Facility Emergency Level V Visit,PX99285F,CDM,450,RC,99285,CPT,,,,,,,,1464,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1183,6141.46
Facility Emergency Level V Visit,PX99285F,CDM,450,RC,99285,CPT,,,,,,,,1464,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1183,6141.46
Factor VII - Ref,PX8523090,CDM,300,RC,85230,CPT,90,,,,,,,125,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Factor VII - Ref,PX8523090,CDM,300,RC,85230,CPT,90,,,,,,,125,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Factor VII - Ref,PX8523090,CDM,300,RC,85230,CPT,90,,,,,,,125,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Factor VII - Ref,PX8523090,CDM,300,RC,85230,CPT,90,,,,,,,125,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Factor VII - Ref,PX8523090,CDM,300,RC,85230,CPT,90,,,,,,,125,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Factor VII - Ref,PX8523090,CDM,300,RC,85230,CPT,90,,,,,,,125,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Factor VIII (Ahg) 1-Stage,PX85240,CDM,300,RC,85240,CPT,,,,,,,,997,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Factor VIII (Ahg) 1-Stage,PX85240,CDM,300,RC,85240,CPT,,,,,,,,997,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Factor VIII (Ahg) 1-Stage,PX85240,CDM,300,RC,85240,CPT,,,,,,,,997,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Factor VIII (Ahg) 1-Stage,PX85240,CDM,300,RC,85240,CPT,,,,,,,,997,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Factor VIII (Ahg) 1-Stage,PX85240,CDM,300,RC,85240,CPT,,,,,,,,997,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Factor VIII (Ahg) 1-Stage,PX85240,CDM,300,RC,85240,CPT,,,,,,,,997,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famciclovir 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714030401,NDC,1,EA,34.42,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famciclovir 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714030401,NDC,1,EA,34.42,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famciclovir 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714030401,NDC,1,EA,34.42,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famciclovir 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714030401,NDC,1,EA,34.42,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famciclovir 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714030401,NDC,1,EA,34.42,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famciclovir 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714030401,NDC,1,EA,34.42,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famciclovir 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,60505324603,NDC,0.5,EA,18.65,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famciclovir 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,60505324603,NDC,0.5,EA,18.65,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famciclovir 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,60505324603,NDC,0.5,EA,18.65,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famciclovir 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,60505324603,NDC,0.5,EA,18.65,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famciclovir 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,60505324603,NDC,0.5,EA,18.65,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famciclovir 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,60505324603,NDC,0.5,EA,18.65,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famciclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,93811956,NDC,0.25,EA,17.04,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famciclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,93811956,NDC,0.25,EA,17.04,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famciclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,93811956,NDC,0.25,EA,17.04,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famciclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,93811956,NDC,0.25,EA,17.04,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famciclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,93811956,NDC,0.25,EA,17.04,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famciclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,93811956,NDC,0.25,EA,17.04,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073916,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073916,NDC,2,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073916,NDC,2,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073916,NDC,2,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073916,NDC,2,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073916,NDC,2,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073941,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073941,NDC,1,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073941,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073941,NDC,1,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073941,NDC,1,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073941,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,67457043300,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,67457043300,NDC,1,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,67457043300,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,67457043300,NDC,1,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,67457043300,NDC,1,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,67457043300,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famotidine 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079096601,NDC,1,EA,9.34,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famotidine 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079096601,NDC,1,EA,9.34,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famotidine 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079096601,NDC,1,EA,9.34,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famotidine 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079096601,NDC,1,EA,9.34,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famotidine 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079096601,NDC,1,EA,9.34,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famotidine 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079096601,NDC,1,EA,9.34,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famotidine 20 MG Tablet 25 Each Bottle,63700001,CDM,250,RC,,,,,,49348081705,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famotidine 20 MG Tablet 25 Each Bottle,63700001,CDM,250,RC,,,,,,49348081705,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famotidine 20 MG Tablet 25 Each Bottle,63700001,CDM,250,RC,,,,,,49348081705,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famotidine 20 MG Tablet 25 Each Bottle,63700001,CDM,250,RC,,,,,,49348081705,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famotidine 20 MG Tablet 25 Each Bottle,63700001,CDM,250,RC,,,,,,49348081705,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famotidine 20 MG Tablet 25 Each Bottle,63700001,CDM,250,RC,,,,,,49348081705,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famotidine 20 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268030315,NDC,0.5,EA,4.07,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famotidine 20 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268030315,NDC,0.5,EA,4.07,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famotidine 20 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268030315,NDC,0.5,EA,4.07,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famotidine 20 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268030315,NDC,0.5,EA,4.07,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famotidine 20 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268030315,NDC,0.5,EA,4.07,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famotidine 20 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268030315,NDC,0.5,EA,4.07,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famotidine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739064510,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famotidine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739064510,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famotidine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739064510,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famotidine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739064510,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famotidine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739064510,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famotidine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739064510,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fat emulsion 20 % Emulsion 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,338051958,NDC,200,ML,375.95,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fat emulsion 20 % Emulsion 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,338051958,NDC,200,ML,375.95,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fat emulsion 20 % Emulsion 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,338051958,NDC,200,ML,375.95,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fat emulsion 20 % Emulsion 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,338051958,NDC,200,ML,375.95,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fat emulsion 20 % Emulsion 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,338051958,NDC,200,ML,375.95,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fat emulsion 20 % Emulsion 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,338051958,NDC,200,ML,375.95,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fat emulsion 20 % Emulsion 250 mL Flex Cont,25000000,CDM,250,RC,,,,,,338051909,NDC,250,ML,292.75,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fat emulsion 20 % Emulsion 250 mL Flex Cont,25000000,CDM,250,RC,,,,,,338051909,NDC,250,ML,292.75,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fat emulsion 20 % Emulsion 250 mL Flex Cont,25000000,CDM,250,RC,,,,,,338051909,NDC,250,ML,292.75,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fat emulsion 20 % Emulsion 250 mL Flex Cont,25000000,CDM,250,RC,,,,,,338051909,NDC,250,ML,292.75,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fat emulsion 20 % Emulsion 250 mL Flex Cont,25000000,CDM,250,RC,,,,,,338051909,NDC,250,ML,292.75,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fat emulsion 20 % Emulsion 250 mL Flex Cont,25000000,CDM,250,RC,,,,,,338051909,NDC,250,ML,292.75,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fat/Lipids, Feces, Quant - Ref",PX8271090,CDM,300,RC,82710,CPT,90,,,,,,,95,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fat/Lipids, Feces, Quant - Ref",PX8271090,CDM,300,RC,82710,CPT,90,,,,,,,95,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fat/Lipids, Feces, Quant - Ref",PX8271090,CDM,300,RC,82710,CPT,90,,,,,,,95,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fat/Lipids, Feces, Quant - Ref",PX8271090,CDM,300,RC,82710,CPT,90,,,,,,,95,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fat/Lipids, Feces, Quant - Ref",PX8271090,CDM,300,RC,82710,CPT,90,,,,,,,95,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fat/Lipids, Feces, Quant - Ref",PX8271090,CDM,300,RC,82710,CPT,90,,,,,,,95,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
felodipine 5 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462023401,NDC,1,EA,8.48,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
felodipine 5 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462023401,NDC,1,EA,8.48,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
felodipine 5 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462023401,NDC,1,EA,8.48,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
felodipine 5 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462023401,NDC,1,EA,8.48,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
felodipine 5 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462023401,NDC,1,EA,8.48,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
felodipine 5 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462023401,NDC,1,EA,8.48,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fentanyl - Ref,PX8035490,CDM,300,RC,80354,CPT,90,,,,,,,353,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fentanyl - Ref,PX8035490,CDM,300,RC,80354,CPT,90,,,,,,,353,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fentanyl - Ref,PX8035490,CDM,300,RC,80354,CPT,90,,,,,,,353,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fentanyl - Ref,PX8035490,CDM,300,RC,80354,CPT,90,,,,,,,353,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fentanyl - Ref,PX8035490,CDM,300,RC,80354,CPT,90,,,,,,,353,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fentanyl - Ref,PX8035490,CDM,300,RC,80354,CPT,90,,,,,,,353,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909422,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909422,NDC,2,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909422,NDC,2,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909422,NDC,2,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909422,NDC,2,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909422,NDC,2,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 12 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,378911916,NDC,1,EA,96.83,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 12 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,378911916,NDC,1,EA,96.83,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 12 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,378911916,NDC,1,EA,96.83,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 12 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,378911916,NDC,1,EA,96.83,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 12 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,378911916,NDC,1,EA,96.83,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 12 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,378911916,NDC,1,EA,96.83,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 12 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505708000,NDC,1,EA,96.83,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 12 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505708000,NDC,1,EA,96.83,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 12 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505708000,NDC,1,EA,96.83,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 12 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505708000,NDC,1,EA,96.83,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 12 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505708000,NDC,1,EA,96.83,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 12 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505708000,NDC,1,EA,96.83,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 12 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,378911998,NDC,1,EA,96.84,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 12 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,378911998,NDC,1,EA,96.84,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 12 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,378911998,NDC,1,EA,96.84,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 12 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,378911998,NDC,1,EA,96.84,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 12 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,378911998,NDC,1,EA,96.84,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 12 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,378911998,NDC,1,EA,96.84,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 12 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,60505708002,NDC,1,EA,96.84,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 12 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,60505708002,NDC,1,EA,96.84,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 12 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,60505708002,NDC,1,EA,96.84,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 12 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,60505708002,NDC,1,EA,96.84,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 12 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,60505708002,NDC,1,EA,96.84,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 12 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,60505708002,NDC,1,EA,96.84,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 25 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,47781042411,NDC,1,EA,101.44,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 25 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,47781042411,NDC,1,EA,101.44,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 25 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,47781042411,NDC,1,EA,101.44,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 25 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,47781042411,NDC,1,EA,101.44,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 25 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,47781042411,NDC,1,EA,101.44,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 25 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,47781042411,NDC,1,EA,101.44,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 25 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505700600,NDC,1,EA,101.46,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 25 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505700600,NDC,1,EA,101.46,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 25 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505700600,NDC,1,EA,101.46,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 25 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505700600,NDC,1,EA,101.46,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 25 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505700600,NDC,1,EA,101.46,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 25 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505700600,NDC,1,EA,101.46,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 25 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,591319872,NDC,1,EA,77.51,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 25 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,591319872,NDC,1,EA,77.51,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 25 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,591319872,NDC,1,EA,77.51,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 25 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,591319872,NDC,1,EA,77.51,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 25 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,591319872,NDC,1,EA,77.51,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 25 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,591319872,NDC,1,EA,77.51,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 50 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,47781042611,NDC,1,EA,185.47,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 50 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,47781042611,NDC,1,EA,185.47,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 50 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,47781042611,NDC,1,EA,185.47,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 50 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,47781042611,NDC,1,EA,185.47,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 50 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,47781042611,NDC,1,EA,185.47,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 50 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,47781042611,NDC,1,EA,185.47,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 50 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,406905076,NDC,1,EA,125.74,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 50 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,406905076,NDC,1,EA,125.74,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 50 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,406905076,NDC,1,EA,125.74,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 50 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,406905076,NDC,1,EA,125.74,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 50 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,406905076,NDC,1,EA,125.74,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 50 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,406905076,NDC,1,EA,125.74,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 50 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,47781042647,NDC,1,EA,185.47,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 50 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,47781042647,NDC,1,EA,185.47,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 50 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,47781042647,NDC,1,EA,185.47,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 50 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,47781042647,NDC,1,EA,185.47,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 50 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,47781042647,NDC,1,EA,185.47,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 50 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,47781042647,NDC,1,EA,185.47,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"ferrous sulfate 325 (65 Fe) MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64376080910,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"ferrous sulfate 325 (65 Fe) MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64376080910,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"ferrous sulfate 325 (65 Fe) MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64376080910,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"ferrous sulfate 325 (65 Fe) MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64376080910,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"ferrous sulfate 325 (65 Fe) MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64376080910,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"ferrous sulfate 325 (65 Fe) MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64376080910,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ferrous sulfate 325 (65 Fe) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904759161,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ferrous sulfate 325 (65 Fe) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904759161,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ferrous sulfate 325 (65 Fe) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904759161,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ferrous sulfate 325 (65 Fe) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904759161,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ferrous sulfate 325 (65 Fe) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904759161,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ferrous sulfate 325 (65 Fe) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904759161,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ferumoxytol 510 MG/17ML Solution 17 mL Vial,Q0138.01,CDM,636,RC,Q0138,HCPCS,,,,781315401,NDC,17,ML,1846.91,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ferumoxytol 510 MG/17ML Solution 17 mL Vial,Q0138.01,CDM,636,RC,Q0138,HCPCS,,,,781315401,NDC,17,ML,1846.91,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ferumoxytol 510 MG/17ML Solution 17 mL Vial,Q0138.01,CDM,636,RC,Q0138,HCPCS,,,,781315401,NDC,17,ML,1846.91,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ferumoxytol 510 MG/17ML Solution 17 mL Vial,Q0138.01,CDM,636,RC,Q0138,HCPCS,,,,781315401,NDC,17,ML,1846.91,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ferumoxytol 510 MG/17ML Solution 17 mL Vial,Q0138.01,CDM,636,RC,Q0138,HCPCS,,,,781315401,NDC,17,ML,1846.91,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ferumoxytol 510 MG/17ML Solution 17 mL Vial,Q0138.01,CDM,636,RC,Q0138,HCPCS,,,,781315401,NDC,17,ML,1846.91,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fetal Profile W/O Stress,PX7681901,CDM,402,RC,76819,CPT,TC,,,,,,,248,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fetal Profile W/O Stress,PX7681901,CDM,402,RC,76819,CPT,TC,,,,,,,248,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fetal Profile W/O Stress,PX7681901,CDM,402,RC,76819,CPT,TC,,,,,,,248,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fetal Profile W/O Stress,PX7681901,CDM,402,RC,76819,CPT,TC,,,,,,,248,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fetal Profile W/O Stress,PX7681901,CDM,402,RC,76819,CPT,TC,,,,,,,248,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fetal Profile W/O Stress,PX7681901,CDM,402,RC,76819,CPT,TC,,,,,,,248,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fibrin Degradation Quant,PX85379,CDM,300,RC,85379,CPT,,,,,,,,177,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fibrin Degradation Quant,PX85379,CDM,300,RC,85379,CPT,,,,,,,,177,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fibrin Degradation Quant,PX85379,CDM,300,RC,85379,CPT,,,,,,,,177,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fibrin Degradation Quant,PX85379,CDM,300,RC,85379,CPT,,,,,,,,177,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fibrin Degradation Quant,PX85379,CDM,300,RC,85379,CPT,,,,,,,,177,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fibrin Degradation Quant,PX85379,CDM,300,RC,85379,CPT,,,,,,,,177,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fibrinogen,PX7426,CDM,300,RC,85384,CPT,,,,,,,,234,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fibrinogen,PX7426,CDM,300,RC,85384,CPT,,,,,,,,234,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fibrinogen,PX7426,CDM,300,RC,85384,CPT,,,,,,,,234,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fibrinogen,PX7426,CDM,300,RC,85384,CPT,,,,,,,,234,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fibrinogen,PX7426,CDM,300,RC,85384,CPT,,,,,,,,234,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fibrinogen,PX7426,CDM,300,RC,85384,CPT,,,,,,,,234,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fibrinogen Activity - Ref,PX8538490,CDM,300,RC,85384,CPT,90,,,,,,,245,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fibrinogen Activity - Ref,PX8538490,CDM,300,RC,85384,CPT,90,,,,,,,245,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fibrinogen Activity - Ref,PX8538490,CDM,300,RC,85384,CPT,90,,,,,,,245,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fibrinogen Activity - Ref,PX8538490,CDM,300,RC,85384,CPT,90,,,,,,,245,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fibrinogen Activity - Ref,PX8538490,CDM,300,RC,85384,CPT,90,,,,,,,245,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fibrinogen Activity - Ref,PX8538490,CDM,300,RC,85384,CPT,90,,,,,,,245,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fibrinogen Test - Ref,PX8536690,CDM,300,RC,85366,CPT,90,,,,,,,179,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fibrinogen Test - Ref,PX8536690,CDM,300,RC,85366,CPT,90,,,,,,,179,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fibrinogen Test - Ref,PX8536690,CDM,300,RC,85366,CPT,90,,,,,,,179,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fibrinogen Test - Ref,PX8536690,CDM,300,RC,85366,CPT,90,,,,,,,179,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fibrinogen Test - Ref,PX8536690,CDM,300,RC,85366,CPT,90,,,,,,,179,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fibrinogen Test - Ref,PX8536690,CDM,300,RC,85366,CPT,90,,,,,,,179,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fibrinolysins Screen - Ref,PX8539090,CDM,300,RC,85390,CPT,90,,,,,,,118,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fibrinolysins Screen - Ref,PX8539090,CDM,300,RC,85390,CPT,90,,,,,,,118,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fibrinolysins Screen - Ref,PX8539090,CDM,300,RC,85390,CPT,90,,,,,,,118,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fibrinolysins Screen - Ref,PX8539090,CDM,300,RC,85390,CPT,90,,,,,,,118,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fibrinolysins Screen - Ref,PX8539090,CDM,300,RC,85390,CPT,90,,,,,,,118,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fibrinolysins Screen - Ref,PX8539090,CDM,300,RC,85390,CPT,90,,,,,,,118,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fidaxomicin 200 MG Tablet 20 Each Bottle,25000000,CDM,250,RC,,,,,,52015008001,NDC,1,EA,945.16,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fidaxomicin 200 MG Tablet 20 Each Bottle,25000000,CDM,250,RC,,,,,,52015008001,NDC,1,EA,945.16,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fidaxomicin 200 MG Tablet 20 Each Bottle,25000000,CDM,250,RC,,,,,,52015008001,NDC,1,EA,945.16,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fidaxomicin 200 MG Tablet 20 Each Bottle,25000000,CDM,250,RC,,,,,,52015008001,NDC,1,EA,945.16,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fidaxomicin 200 MG Tablet 20 Each Bottle,25000000,CDM,250,RC,,,,,,52015008001,NDC,1,EA,945.16,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fidaxomicin 200 MG Tablet 20 Each Bottle,25000000,CDM,250,RC,,,,,,52015008001,NDC,1,EA,945.16,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092401,NDC,0.5,ML,820.88,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092401,NDC,0.5,ML,820.88,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092401,NDC,0.5,ML,820.88,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092401,NDC,0.5,ML,820.88,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092401,NDC,0.5,ML,820.88,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092401,NDC,0.5,ML,820.88,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092410,NDC,0.5,ML,820.89,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092410,NDC,0.5,ML,820.89,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092410,NDC,0.5,ML,820.89,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092410,NDC,0.5,ML,820.89,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092410,NDC,0.5,ML,820.89,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092410,NDC,0.5,ML,820.89,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092491,NDC,0.5,ML,820.88,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092491,NDC,0.5,ML,820.88,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092491,NDC,0.5,ML,820.88,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092491,NDC,0.5,ML,820.88,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092491,NDC,0.5,ML,820.88,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092491,NDC,0.5,ML,820.88,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513020991,NDC,0.5,ML,1228.49,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513020991,NDC,0.5,ML,1228.49,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513020991,NDC,0.5,ML,1228.49,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513020991,NDC,0.5,ML,1228.49,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513020991,NDC,0.5,ML,1228.49,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513020991,NDC,0.5,ML,1228.49,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim-ayow 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,800000,CDM,,,,,,,,70121157001,NDC,0.5,ML,691.62,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim-ayow 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,800000,CDM,,,,,,,,70121157001,NDC,0.5,ML,691.62,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim-ayow 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,800000,CDM,,,,,,,,70121157001,NDC,0.5,ML,691.62,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim-ayow 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,800000,CDM,,,,,,,,70121157001,NDC,0.5,ML,691.62,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim-ayow 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,800000,CDM,,,,,,,,70121157001,NDC,0.5,ML,691.62,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim-ayow 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,800000,CDM,,,,,,,,70121157001,NDC,0.5,ML,691.62,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim-sndz 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314031801,NDC,0.5,ML,1047.2,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim-sndz 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314031801,NDC,0.5,ML,1047.2,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim-sndz 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314031801,NDC,0.5,ML,1047.2,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim-sndz 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314031801,NDC,0.5,ML,1047.2,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim-sndz 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314031801,NDC,0.5,ML,1047.2,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim-sndz 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314031801,NDC,0.5,ML,1047.2,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032601,NDC,0.5,ML,559.7,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032601,NDC,0.5,ML,559.7,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032601,NDC,0.5,ML,559.7,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032601,NDC,0.5,ML,559.7,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032601,NDC,0.5,ML,559.7,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032601,NDC,0.5,ML,559.7,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032605,NDC,0.8,ML,1663.54,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032605,NDC,0.8,ML,1663.54,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032605,NDC,0.8,ML,1663.54,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032605,NDC,0.8,ML,1663.54,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032605,NDC,0.8,ML,1663.54,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032605,NDC,0.8,ML,1663.54,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
finasteride 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862014930,NDC,1,EA,16.79,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
finasteride 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862014930,NDC,1,EA,16.79,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
finasteride 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862014930,NDC,1,EA,16.79,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
finasteride 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862014930,NDC,1,EA,16.79,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
finasteride 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862014930,NDC,1,EA,16.79,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
finasteride 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862014930,NDC,1,EA,16.79,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
First Hour IV Hydration <1 Hour,PX96360,CDM,260,RC,96360,CPT,,,,,,,,260,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
First Hour IV Hydration <1 Hour,PX96360,CDM,260,RC,96360,CPT,,,,,,,,260,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
First Hour IV Hydration <1 Hour,PX96360,CDM,260,RC,96360,CPT,,,,,,,,260,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
First Hour IV Hydration <1 Hour,PX96360,CDM,260,RC,96360,CPT,,,,,,,,260,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
First Hour IV Hydration <1 Hour,PX96360,CDM,260,RC,96360,CPT,,,,,,,,260,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
First Hour IV Hydration <1 Hour,PX96360,CDM,260,RC,96360,CPT,,,,,,,,260,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fish Oil 1000 MG capsule 1 Each Blister,25000000,CDM,250,RC,,,,,,77333030825,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fish Oil 1000 MG capsule 1 Each Blister,25000000,CDM,250,RC,,,,,,77333030825,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fish Oil 1000 MG capsule 1 Each Blister,25000000,CDM,250,RC,,,,,,77333030825,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fish Oil 1000 MG capsule 1 Each Blister,25000000,CDM,250,RC,,,,,,77333030825,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fish Oil 1000 MG capsule 1 Each Blister,25000000,CDM,250,RC,,,,,,77333030825,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fish Oil 1000 MG capsule 1 Each Blister,25000000,CDM,250,RC,,,,,,77333030825,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fix Exten Tendon,Dorsum Fingr,Ea",PX26418F,CDM,510,RC,26418,CPT,,,,,,,,1750,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fix Exten Tendon,Dorsum Fingr,Ea",PX26418F,CDM,510,RC,26418,CPT,,,,,,,,1750,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fix Exten Tendon,Dorsum Fingr,Ea",PX26418F,CDM,510,RC,26418,CPT,,,,,,,,1750,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fix Exten Tendon,Dorsum Fingr,Ea",PX26418F,CDM,510,RC,26418,CPT,,,,,,,,1750,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fix Exten Tendon,Dorsum Fingr,Ea",PX26418F,CDM,510,RC,26418,CPT,,,,,,,,1750,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fix Exten Tendon,Dorsum Fingr,Ea",PX26418F,CDM,510,RC,26418,CPT,,,,,,,,1750,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FIXATION COMPONENT TOE JOINT PROXIMAL PHALANGEAL DF-P,C1713,CDM,278,RC,C1713,HCPCS,,12529-MAIN,LOCAL,,,,,1644,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FIXATION COMPONENT TOE JOINT PROXIMAL PHALANGEAL DF-P,C1713,CDM,278,RC,C1713,HCPCS,,12529-MAIN,LOCAL,,,,,1644,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FIXATION COMPONENT TOE JOINT PROXIMAL PHALANGEAL DF-P,C1713,CDM,278,RC,C1713,HCPCS,,12529-MAIN,LOCAL,,,,,1644,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FIXATION COMPONENT TOE JOINT PROXIMAL PHALANGEAL DF-P,C1713,CDM,278,RC,C1713,HCPCS,,12529-MAIN,LOCAL,,,,,1644,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FIXATION COMPONENT TOE JOINT PROXIMAL PHALANGEAL DF-P,C1713,CDM,278,RC,C1713,HCPCS,,12529-MAIN,LOCAL,,,,,1644,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FIXATION COMPONENT TOE JOINT PROXIMAL PHALANGEAL DF-P,C1713,CDM,278,RC,C1713,HCPCS,,12529-MAIN,LOCAL,,,,,1644,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FLAT DRAIN HEMADUCT 7MM FULL DUCT WITH TROCAR SILICONE,27200000,CDM,272,RC,,,,12464-MAIN,LOCAL,,,,,119,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FLAT DRAIN HEMADUCT 7MM FULL DUCT WITH TROCAR SILICONE,27200000,CDM,272,RC,,,,12464-MAIN,LOCAL,,,,,119,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FLAT DRAIN HEMADUCT 7MM FULL DUCT WITH TROCAR SILICONE,27200000,CDM,272,RC,,,,12464-MAIN,LOCAL,,,,,119,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FLAT DRAIN HEMADUCT 7MM FULL DUCT WITH TROCAR SILICONE,27200000,CDM,272,RC,,,,12464-MAIN,LOCAL,,,,,119,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FLAT DRAIN HEMADUCT 7MM FULL DUCT WITH TROCAR SILICONE,27200000,CDM,272,RC,,,,12464-MAIN,LOCAL,,,,,119,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FLAT DRAIN HEMADUCT 7MM FULL DUCT WITH TROCAR SILICONE,27200000,CDM,272,RC,,,,12464-MAIN,LOCAL,,,,,119,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FLAT WOUND DRAIN WITH TROCAR 4 CHANNEL FULL FLUTED 7FR SILICONE,27200000,CDM,272,RC,,,,12473-MAIN,LOCAL,,,,,123,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FLAT WOUND DRAIN WITH TROCAR 4 CHANNEL FULL FLUTED 7FR SILICONE,27200000,CDM,272,RC,,,,12473-MAIN,LOCAL,,,,,123,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FLAT WOUND DRAIN WITH TROCAR 4 CHANNEL FULL FLUTED 7FR SILICONE,27200000,CDM,272,RC,,,,12473-MAIN,LOCAL,,,,,123,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FLAT WOUND DRAIN WITH TROCAR 4 CHANNEL FULL FLUTED 7FR SILICONE,27200000,CDM,272,RC,,,,12473-MAIN,LOCAL,,,,,123,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FLAT WOUND DRAIN WITH TROCAR 4 CHANNEL FULL FLUTED 7FR SILICONE,27200000,CDM,272,RC,,,,12473-MAIN,LOCAL,,,,,123,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FLAT WOUND DRAIN WITH TROCAR 4 CHANNEL FULL FLUTED 7FR SILICONE,27200000,CDM,272,RC,,,,12473-MAIN,LOCAL,,,,,123,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
flecainide 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237006301,NDC,1,EA,10.85,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
flecainide 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237006301,NDC,1,EA,10.85,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
flecainide 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237006301,NDC,1,EA,10.85,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
flecainide 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237006301,NDC,1,EA,10.85,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
flecainide 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237006301,NDC,1,EA,10.85,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
flecainide 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237006301,NDC,1,EA,10.85,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FLEXITIP APPLICATOR 38CM,27200000,CDM,272,RC,,,,10200-MAIN,LOCAL,,,,,40.8,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FLEXITIP APPLICATOR 38CM,27200000,CDM,272,RC,,,,10200-MAIN,LOCAL,,,,,40.8,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FLEXITIP APPLICATOR 38CM,27200000,CDM,272,RC,,,,10200-MAIN,LOCAL,,,,,40.8,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FLEXITIP APPLICATOR 38CM,27200000,CDM,272,RC,,,,10200-MAIN,LOCAL,,,,,40.8,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FLEXITIP APPLICATOR 38CM,27200000,CDM,272,RC,,,,10200-MAIN,LOCAL,,,,,40.8,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FLEXITIP APPLICATOR 38CM,27200000,CDM,272,RC,,,,10200-MAIN,LOCAL,,,,,40.8,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Flour. Afstain , Micro - Ref",PX8720690,CDM,300,RC,87206,CPT,90,,,,,,,68,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Flour. Afstain , Micro - Ref",PX8720690,CDM,300,RC,87206,CPT,90,,,,,,,68,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Flour. Afstain , Micro - Ref",PX8720690,CDM,300,RC,87206,CPT,90,,,,,,,68,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Flour. Afstain , Micro - Ref",PX8720690,CDM,300,RC,87206,CPT,90,,,,,,,68,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Flour. Afstain , Micro - Ref",PX8720690,CDM,300,RC,87206,CPT,90,,,,,,,68,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Flour. Afstain , Micro - Ref",PX8720690,CDM,300,RC,87206,CPT,90,,,,,,,68,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Flow Cyto Ea Addtl Marker - Ref,PX8818590,CDM,310,RC,88185,CPT,90,,,,,,,165,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Flow Cyto Ea Addtl Marker - Ref,PX8818590,CDM,310,RC,88185,CPT,90,,,,,,,165,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Flow Cyto Ea Addtl Marker - Ref,PX8818590,CDM,310,RC,88185,CPT,90,,,,,,,165,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Flow Cyto Ea Addtl Marker - Ref,PX8818590,CDM,310,RC,88185,CPT,90,,,,,,,165,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Flow Cyto Ea Addtl Marker - Ref,PX8818590,CDM,310,RC,88185,CPT,90,,,,,,,165,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Flow Cyto Ea Addtl Marker - Ref,PX8818590,CDM,310,RC,88185,CPT,90,,,,,,,165,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Flow Cyto, Tech, 1st Mrkr - Ref",PX8818490,CDM,310,RC,88184,CPT,90,,,,,,,223,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Flow Cyto, Tech, 1st Mrkr - Ref",PX8818490,CDM,310,RC,88184,CPT,90,,,,,,,223,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Flow Cyto, Tech, 1st Mrkr - Ref",PX8818490,CDM,310,RC,88184,CPT,90,,,,,,,223,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Flow Cyto, Tech, 1st Mrkr - Ref",PX8818490,CDM,310,RC,88184,CPT,90,,,,,,,223,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Flow Cyto, Tech, 1st Mrkr - Ref",PX8818490,CDM,310,RC,88184,CPT,90,,,,,,,223,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Flow Cyto, Tech, 1st Mrkr - Ref",PX8818490,CDM,310,RC,88184,CPT,90,,,,,,,223,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; 1st",PX88184,CDM,310,RC,88184,CPT,,,,,,,,96,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; 1st",PX88184,CDM,310,RC,88184,CPT,,,,,,,,96,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; 1st",PX88184,CDM,310,RC,88184,CPT,,,,,,,,96,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; 1st",PX88184,CDM,310,RC,88184,CPT,,,,,,,,96,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; 1st",PX88184,CDM,310,RC,88184,CPT,,,,,,,,96,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; 1st",PX88184,CDM,310,RC,88184,CPT,,,,,,,,96,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; Add'l",PX88185,CDM,310,RC,88185,CPT,,,,,,,,96,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; Add'l",PX88185,CDM,310,RC,88185,CPT,,,,,,,,96,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; Add'l",PX88185,CDM,310,RC,88185,CPT,,,,,,,,96,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; Add'l",PX88185,CDM,310,RC,88185,CPT,,,,,,,,96,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; Add'l",PX88185,CDM,310,RC,88185,CPT,,,,,,,,96,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; Add'l",PX88185,CDM,310,RC,88185,CPT,,,,,,,,96,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Flow Interp,2-8 Markers - Ref",PX8818790,CDM,310,RC,88187,CPT,90,,,,,,,162,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Flow Interp,2-8 Markers - Ref",PX8818790,CDM,310,RC,88187,CPT,90,,,,,,,162,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Flow Interp,2-8 Markers - Ref",PX8818790,CDM,310,RC,88187,CPT,90,,,,,,,162,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Flow Interp,2-8 Markers - Ref",PX8818790,CDM,310,RC,88187,CPT,90,,,,,,,162,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Flow Interp,2-8 Markers - Ref",PX8818790,CDM,310,RC,88187,CPT,90,,,,,,,162,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Flow Interp,2-8 Markers - Ref",PX8818790,CDM,310,RC,88187,CPT,90,,,,,,,162,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Flu Dna Amp Probe 1st 2 Types,PX87502,CDM,300,RC,87502,CPT,,,,,,,,350,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Flu Dna Amp Probe 1st 2 Types,PX87502,CDM,300,RC,87502,CPT,,,,,,,,350,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Flu Dna Amp Probe 1st 2 Types,PX87502,CDM,300,RC,87502,CPT,,,,,,,,350,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Flu Dna Amp Probe 1st 2 Types,PX87502,CDM,300,RC,87502,CPT,,,,,,,,350,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Flu Dna Amp Probe 1st 2 Types,PX87502,CDM,300,RC,87502,CPT,,,,,,,,350,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Flu Dna Amp Probe 1st 2 Types,PX87502,CDM,300,RC,87502,CPT,,,,,,,,350,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluconazole 100 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069101,NDC,0.5,EA,23.55,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluconazole 100 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069101,NDC,0.5,EA,23.55,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluconazole 100 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069101,NDC,0.5,EA,23.55,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluconazole 100 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069101,NDC,0.5,EA,23.55,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluconazole 100 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069101,NDC,0.5,EA,23.55,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluconazole 100 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069101,NDC,0.5,EA,23.55,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluconazole 150 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,16714069210,NDC,1,EA,72.98,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluconazole 150 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,16714069210,NDC,1,EA,72.98,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluconazole 150 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,16714069210,NDC,1,EA,72.98,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluconazole 150 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,16714069210,NDC,1,EA,72.98,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluconazole 150 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,16714069210,NDC,1,EA,72.98,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluconazole 150 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,16714069210,NDC,1,EA,72.98,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluconazole 150 MG Tablet 12 Each Box,63700001,CDM,250,RC,,,,,,16714069211,NDC,0.333333333,EA,24.33,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluconazole 150 MG Tablet 12 Each Box,63700001,CDM,250,RC,,,,,,16714069211,NDC,0.333333333,EA,24.33,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluconazole 150 MG Tablet 12 Each Box,63700001,CDM,250,RC,,,,,,16714069211,NDC,0.333333333,EA,24.33,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluconazole 150 MG Tablet 12 Each Box,63700001,CDM,250,RC,,,,,,16714069211,NDC,0.333333333,EA,24.33,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluconazole 150 MG Tablet 12 Each Box,63700001,CDM,250,RC,,,,,,16714069211,NDC,0.333333333,EA,24.33,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluconazole 150 MG Tablet 12 Each Box,63700001,CDM,250,RC,,,,,,16714069211,NDC,0.333333333,EA,24.33,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,25021018482,NDC,100,ML,79.51,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,25021018482,NDC,100,ML,79.51,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,25021018482,NDC,100,ML,79.51,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,25021018482,NDC,100,ML,79.51,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,25021018482,NDC,100,ML,79.51,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,25021018482,NDC,100,ML,79.51,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,70655000206,NDC,100,ML,59.67,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,70655000206,NDC,100,ML,59.67,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,70655000206,NDC,100,ML,59.67,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,70655000206,NDC,100,ML,59.67,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,70655000206,NDC,100,ML,59.67,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,70655000206,NDC,100,ML,59.67,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Plas Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,338604648,NDC,100,ML,143.42,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Plas Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,338604648,NDC,100,ML,143.42,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Plas Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,338604648,NDC,100,ML,143.42,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Plas Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,338604648,NDC,100,ML,143.42,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Plas Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,338604648,NDC,100,ML,143.42,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Plas Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,338604648,NDC,100,ML,143.42,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143978410,NDC,2,ML,37.91,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143978410,NDC,2,ML,37.91,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143978410,NDC,2,ML,37.91,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143978410,NDC,2,ML,37.91,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143978410,NDC,2,ML,37.91,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143978410,NDC,2,ML,37.91,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,36000014801,NDC,2,ML,38.76,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,36000014801,NDC,2,ML,38.76,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,36000014801,NDC,2,ML,38.76,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,36000014801,NDC,2,ML,38.76,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,36000014801,NDC,2,ML,38.76,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,36000014801,NDC,2,ML,38.76,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323042405,NDC,5,ML,64.82,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323042405,NDC,5,ML,64.82,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323042405,NDC,5,ML,64.82,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323042405,NDC,5,ML,64.82,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323042405,NDC,5,ML,64.82,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323042405,NDC,5,ML,64.82,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fluor Noninfect Ab Sc, Ea - Ref",PX8625590,CDM,300,RC,86255,CPT,90,,,,,,,121,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fluor Noninfect Ab Sc, Ea - Ref",PX8625590,CDM,300,RC,86255,CPT,90,,,,,,,121,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fluor Noninfect Ab Sc, Ea - Ref",PX8625590,CDM,300,RC,86255,CPT,90,,,,,,,121,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fluor Noninfect Ab Sc, Ea - Ref",PX8625590,CDM,300,RC,86255,CPT,90,,,,,,,121,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fluor Noninfect Ab Sc, Ea - Ref",PX8625590,CDM,300,RC,86255,CPT,90,,,,,,,121,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fluor Noninfect Ab Sc, Ea - Ref",PX8625590,CDM,300,RC,86255,CPT,90,,,,,,,121,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fluoroscope Examination Tc,PX7600001,CDM,320,RC,76000,CPT,TC,,,,,,,597,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fluoroscope Examination Tc,PX7600001,CDM,320,RC,76000,CPT,TC,,,,,,,597,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fluoroscope Examination Tc,PX7600001,CDM,320,RC,76000,CPT,TC,,,,,,,597,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fluoroscope Examination Tc,PX7600001,CDM,320,RC,76000,CPT,TC,,,,,,,597,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fluoroscope Examination Tc,PX7600001,CDM,320,RC,76000,CPT,TC,,,,,,,597,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fluoroscope Examination Tc,PX7600001,CDM,320,RC,76000,CPT,TC,,,,,,,597,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fluoroscopy Guid Needle Plcmt Tc,PX7700201,CDM,320,RC,77002,CPT,TC,,,,,,,662,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fluoroscopy Guid Needle Plcmt Tc,PX7700201,CDM,320,RC,77002,CPT,TC,,,,,,,662,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fluoroscopy Guid Needle Plcmt Tc,PX7700201,CDM,320,RC,77002,CPT,TC,,,,,,,662,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fluoroscopy Guid Needle Plcmt Tc,PX7700201,CDM,320,RC,77002,CPT,TC,,,,,,,662,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fluoroscopy Guid Needle Plcmt Tc,PX7700201,CDM,320,RC,77002,CPT,TC,,,,,,,662,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fluoroscopy Guid Needle Plcmt Tc,PX7700201,CDM,320,RC,77002,CPT,TC,,,,,,,662,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluorouracil 5 GM/100ML Solution 100 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,16729027638,NDC,100,ML,261.44,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluorouracil 5 GM/100ML Solution 100 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,16729027638,NDC,100,ML,261.44,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluorouracil 5 GM/100ML Solution 100 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,16729027638,NDC,100,ML,261.44,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluorouracil 5 GM/100ML Solution 100 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,16729027638,NDC,100,ML,261.44,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluorouracil 5 GM/100ML Solution 100 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,16729027638,NDC,100,ML,261.44,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluorouracil 5 GM/100ML Solution 100 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,16729027638,NDC,100,ML,261.44,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluorouracil 500 MG/10ML Solution 10 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,63323011710,NDC,10,ML,39,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluorouracil 500 MG/10ML Solution 10 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,63323011710,NDC,10,ML,39,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluorouracil 500 MG/10ML Solution 10 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,63323011710,NDC,10,ML,39,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluorouracil 500 MG/10ML Solution 10 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,63323011710,NDC,10,ML,39,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluorouracil 500 MG/10ML Solution 10 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,63323011710,NDC,10,ML,39,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluorouracil 500 MG/10ML Solution 10 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,63323011710,NDC,10,ML,39,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FLUoxetine 10 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578461,NDC,1,EA,12.99,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FLUoxetine 10 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578461,NDC,1,EA,12.99,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FLUoxetine 10 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578461,NDC,1,EA,12.99,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FLUoxetine 10 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578461,NDC,1,EA,12.99,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FLUoxetine 10 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578461,NDC,1,EA,12.99,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FLUoxetine 10 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578461,NDC,1,EA,12.99,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FLUoxetine 20 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578561,NDC,1,EA,13.34,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FLUoxetine 20 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578561,NDC,1,EA,13.34,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FLUoxetine 20 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578561,NDC,1,EA,13.34,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FLUoxetine 20 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578561,NDC,1,EA,13.34,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FLUoxetine 20 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578561,NDC,1,EA,13.34,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FLUoxetine 20 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578561,NDC,1,EA,13.34,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone 110 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173071920,NDC,12,GR,149.67,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone 110 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173071920,NDC,12,GR,149.67,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone 110 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173071920,NDC,12,GR,149.67,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone 110 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173071920,NDC,12,GR,149.67,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone 110 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173071920,NDC,12,GR,149.67,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone 110 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173071920,NDC,12,GR,149.67,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone 220 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173072020,NDC,12,GR,1746.36,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone 220 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173072020,NDC,12,GR,1746.36,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone 220 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173072020,NDC,12,GR,1746.36,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone 220 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173072020,NDC,12,GR,1746.36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone 220 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173072020,NDC,12,GR,1746.36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone 220 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173072020,NDC,12,GR,1746.36,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone 220 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,66993008096,NDC,12,GR,1760.13,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone 220 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,66993008096,NDC,12,GR,1760.13,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone 220 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,66993008096,NDC,12,GR,1760.13,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone 220 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,66993008096,NDC,12,GR,1760.13,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone 220 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,66993008096,NDC,12,GR,1760.13,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone 220 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,66993008096,NDC,12,GR,1760.13,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone furoate-vilanterol 100-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173085914,NDC,28,EA,1025.38,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone furoate-vilanterol 100-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173085914,NDC,28,EA,1025.38,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone furoate-vilanterol 100-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173085914,NDC,28,EA,1025.38,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone furoate-vilanterol 100-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173085914,NDC,28,EA,1025.38,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone furoate-vilanterol 100-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173085914,NDC,28,EA,1025.38,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone furoate-vilanterol 100-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173085914,NDC,28,EA,1025.38,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone propionate 50 MCG/ACT Suspension 16 g Bottle,63700001,CDM,250,RC,,,,,,50383070016,NDC,16,GR,432.56,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone propionate 50 MCG/ACT Suspension 16 g Bottle,63700001,CDM,250,RC,,,,,,50383070016,NDC,16,GR,432.56,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone propionate 50 MCG/ACT Suspension 16 g Bottle,63700001,CDM,250,RC,,,,,,50383070016,NDC,16,GR,432.56,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone propionate 50 MCG/ACT Suspension 16 g Bottle,63700001,CDM,250,RC,,,,,,50383070016,NDC,16,GR,432.56,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone propionate 50 MCG/ACT Suspension 16 g Bottle,63700001,CDM,250,RC,,,,,,50383070016,NDC,16,GR,432.56,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone propionate 50 MCG/ACT Suspension 16 g Bottle,63700001,CDM,250,RC,,,,,,50383070016,NDC,16,GR,432.56,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone propionate 50 MCG/ACT Suspension 16 g Bottle,63700001,CDM,250,RC,,,,,,60505082901,NDC,16,GR,437.4,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone propionate 50 MCG/ACT Suspension 16 g Bottle,63700001,CDM,250,RC,,,,,,60505082901,NDC,16,GR,437.4,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone propionate 50 MCG/ACT Suspension 16 g Bottle,63700001,CDM,250,RC,,,,,,60505082901,NDC,16,GR,437.4,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone propionate 50 MCG/ACT Suspension 16 g Bottle,63700001,CDM,250,RC,,,,,,60505082901,NDC,16,GR,437.4,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone propionate 50 MCG/ACT Suspension 16 g Bottle,63700001,CDM,250,RC,,,,,,60505082901,NDC,16,GR,437.4,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone propionate 50 MCG/ACT Suspension 16 g Bottle,63700001,CDM,250,RC,,,,,,60505082901,NDC,16,GR,437.4,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-salmeterol 100-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,54032656,NDC,60,EA,2215.63,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-salmeterol 100-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,54032656,NDC,60,EA,2215.63,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-salmeterol 100-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,54032656,NDC,60,EA,2215.63,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-salmeterol 100-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,54032656,NDC,60,EA,2215.63,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-salmeterol 100-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,54032656,NDC,60,EA,2215.63,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-salmeterol 100-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,54032656,NDC,60,EA,2215.63,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-salmeterol 100-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069500,NDC,1,EA,38.87,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-salmeterol 100-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069500,NDC,1,EA,38.87,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-salmeterol 100-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069500,NDC,1,EA,38.87,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-salmeterol 100-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069500,NDC,1,EA,38.87,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-salmeterol 100-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069500,NDC,1,EA,38.87,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-salmeterol 100-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069500,NDC,1,EA,38.87,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-salmeterol 230-21 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173071720,NDC,12,GR,2004.35,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-salmeterol 230-21 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173071720,NDC,12,GR,2004.35,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-salmeterol 230-21 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173071720,NDC,12,GR,2004.35,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-salmeterol 230-21 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173071720,NDC,12,GR,2004.35,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-salmeterol 230-21 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173071720,NDC,12,GR,2004.35,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-salmeterol 230-21 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173071720,NDC,12,GR,2004.35,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-salmeterol 230-21 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,66993008896,NDC,12,GR,1904.14,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-salmeterol 230-21 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,66993008896,NDC,12,GR,1904.14,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-salmeterol 230-21 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,66993008896,NDC,12,GR,1904.14,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-salmeterol 230-21 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,66993008896,NDC,12,GR,1904.14,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-salmeterol 230-21 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,66993008896,NDC,12,GR,1904.14,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-salmeterol 230-21 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,66993008896,NDC,12,GR,1904.14,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-salmeterol 250-50 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069604,NDC,14,EA,1025.13,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-salmeterol 250-50 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069604,NDC,14,EA,1025.13,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-salmeterol 250-50 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069604,NDC,14,EA,1025.13,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-salmeterol 250-50 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069604,NDC,14,EA,1025.13,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-salmeterol 250-50 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069604,NDC,14,EA,1025.13,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-salmeterol 250-50 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069604,NDC,14,EA,1025.13,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-salmeterol 250-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,54032756,NDC,1,EA,45.88,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-salmeterol 250-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,54032756,NDC,1,EA,45.88,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-salmeterol 250-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,54032756,NDC,1,EA,45.88,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-salmeterol 250-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,54032756,NDC,1,EA,45.88,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-salmeterol 250-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,54032756,NDC,1,EA,45.88,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-salmeterol 250-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,54032756,NDC,1,EA,45.88,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-salmeterol 500-50 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069704,NDC,14,EA,1670.75,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-salmeterol 500-50 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069704,NDC,14,EA,1670.75,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-salmeterol 500-50 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069704,NDC,14,EA,1670.75,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-salmeterol 500-50 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069704,NDC,14,EA,1670.75,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-salmeterol 500-50 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069704,NDC,14,EA,1670.75,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-salmeterol 500-50 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069704,NDC,14,EA,1670.75,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-umeclidin-vilant 100-62.5-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173088714,NDC,28,EA,1894.99,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-umeclidin-vilant 100-62.5-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173088714,NDC,28,EA,1894.99,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-umeclidin-vilant 100-62.5-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173088714,NDC,28,EA,1894.99,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-umeclidin-vilant 100-62.5-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173088714,NDC,28,EA,1894.99,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-umeclidin-vilant 100-62.5-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173088714,NDC,28,EA,1894.99,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-umeclidin-vilant 100-62.5-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173088714,NDC,28,EA,1894.99,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-vilanterol 200-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173088214,NDC,28,EA,1087.68,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-vilanterol 200-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173088214,NDC,28,EA,1087.68,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-vilanterol 200-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173088214,NDC,28,EA,1087.68,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-vilanterol 200-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173088214,NDC,28,EA,1087.68,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-vilanterol 200-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173088214,NDC,28,EA,1087.68,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-vilanterol 200-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173088214,NDC,28,EA,1087.68,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluvastatin 20 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,378802093,NDC,1,EA,26.88,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluvastatin 20 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,378802093,NDC,1,EA,26.88,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluvastatin 20 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,378802093,NDC,1,EA,26.88,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluvastatin 20 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,378802093,NDC,1,EA,26.88,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluvastatin 20 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,378802093,NDC,1,EA,26.88,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluvastatin 20 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,378802093,NDC,1,EA,26.88,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluvoxaMINE 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,60505016601,NDC,0.25,EA,3.55,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluvoxaMINE 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,60505016601,NDC,0.25,EA,3.55,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluvoxaMINE 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,60505016601,NDC,0.25,EA,3.55,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluvoxaMINE 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,60505016601,NDC,0.25,EA,3.55,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluvoxaMINE 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,60505016601,NDC,0.25,EA,3.55,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluvoxaMINE 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,60505016601,NDC,0.25,EA,3.55,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006F,CDM,510,RC,10006,CPT,,,,,,,,213,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006F,CDM,510,RC,10006,CPT,,,,,,,,213,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006F,CDM,510,RC,10006,CPT,,,,,,,,213,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006F,CDM,510,RC,10006,CPT,,,,,,,,213,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006F,CDM,510,RC,10006,CPT,,,,,,,,213,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006F,CDM,510,RC,10006,CPT,,,,,,,,213,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006P,CDM,983,RC,10006,CPT,,,,,,,,142,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006P,CDM,983,RC,10006,CPT,,,,,,,,142,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006P,CDM,983,RC,10006,CPT,,,,,,,,142,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006P,CDM,983,RC,10006,CPT,,,,,,,,142,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006P,CDM,983,RC,10006,CPT,,,,,,,,142,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006P,CDM,983,RC,10006,CPT,,,,,,,,142,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fna Biopsy, W/US Guidance; First Lesion",PX10005F,CDM,510,RC,10005,CPT,,,,,,,,333,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fna Biopsy, W/US Guidance; First Lesion",PX10005F,CDM,510,RC,10005,CPT,,,,,,,,333,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fna Biopsy, W/US Guidance; First Lesion",PX10005F,CDM,510,RC,10005,CPT,,,,,,,,333,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fna Biopsy, W/US Guidance; First Lesion",PX10005F,CDM,510,RC,10005,CPT,,,,,,,,333,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fna Biopsy, W/US Guidance; First Lesion",PX10005F,CDM,510,RC,10005,CPT,,,,,,,,333,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fna Biopsy, W/US Guidance; First Lesion",PX10005F,CDM,510,RC,10005,CPT,,,,,,,,333,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fna Biopsy, W/US Guidance; First Lesion",PX10005P,CDM,983,RC,10005,CPT,,,,,,,,621,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fna Biopsy, W/US Guidance; First Lesion",PX10005P,CDM,983,RC,10005,CPT,,,,,,,,621,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fna Biopsy, W/US Guidance; First Lesion",PX10005P,CDM,983,RC,10005,CPT,,,,,,,,621,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fna Biopsy, W/US Guidance; First Lesion",PX10005P,CDM,983,RC,10005,CPT,,,,,,,,621,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fna Biopsy, W/US Guidance; First Lesion",PX10005P,CDM,983,RC,10005,CPT,,,,,,,,621,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fna Biopsy, W/US Guidance; First Lesion",PX10005P,CDM,983,RC,10005,CPT,,,,,,,,621,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fna W/Image,PX10022F,CDM,510,RC,10022,CPT,,,,,,,,742,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fna W/Image,PX10022F,CDM,510,RC,10022,CPT,,,,,,,,742,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fna W/Image,PX10022F,CDM,510,RC,10022,CPT,,,,,,,,742,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fna W/Image,PX10022F,CDM,510,RC,10022,CPT,,,,,,,,742,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fna W/Image,PX10022F,CDM,510,RC,10022,CPT,,,,,,,,742,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fna W/Image,PX10022F,CDM,510,RC,10022,CPT,,,,,,,,742,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Folic Acid (Folate), Serum",PX82746,CDM,300,RC,82746,CPT,,,,,,,,56,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Folic Acid (Folate), Serum",PX82746,CDM,300,RC,82746,CPT,,,,,,,,56,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Folic Acid (Folate), Serum",PX82746,CDM,300,RC,82746,CPT,,,,,,,,56,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Folic Acid (Folate), Serum",PX82746,CDM,300,RC,82746,CPT,,,,,,,,56,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Folic Acid (Folate), Serum",PX82746,CDM,300,RC,82746,CPT,,,,,,,,56,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Folic Acid (Folate), Serum",PX82746,CDM,300,RC,82746,CPT,,,,,,,,56,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
folic acid 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687068111,NDC,0.4,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
folic acid 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687068111,NDC,0.4,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
folic acid 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687068111,NDC,0.4,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
folic acid 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687068111,NDC,0.4,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
folic acid 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687068111,NDC,0.4,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
folic acid 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687068111,NDC,0.4,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
folic acid 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687068101,NDC,0.4,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
folic acid 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687068101,NDC,0.4,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
folic acid 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687068101,NDC,0.4,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
folic acid 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687068101,NDC,0.4,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
folic acid 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687068101,NDC,0.4,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
folic acid 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687068101,NDC,0.4,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
folic acid 5 MG/ML Solution 10 mL Vial,J3490.94,CDM,636,RC,J3490,HCPCS,,,,39822110001,NDC,0.2,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
folic acid 5 MG/ML Solution 10 mL Vial,J3490.94,CDM,636,RC,J3490,HCPCS,,,,39822110001,NDC,0.2,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
folic acid 5 MG/ML Solution 10 mL Vial,J3490.94,CDM,636,RC,J3490,HCPCS,,,,39822110001,NDC,0.2,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
folic acid 5 MG/ML Solution 10 mL Vial,J3490.94,CDM,636,RC,J3490,HCPCS,,,,39822110001,NDC,0.2,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
folic acid 5 MG/ML Solution 10 mL Vial,J3490.94,CDM,636,RC,J3490,HCPCS,,,,39822110001,NDC,0.2,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
folic acid 5 MG/ML Solution 10 mL Vial,J3490.94,CDM,636,RC,J3490,HCPCS,,,,39822110001,NDC,0.2,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
folic acid 5 MG/ML Solution 10 mL Vial,J3490.94,CDM,636,RC,J3490,HCPCS,,,,63323018410,NDC,10,ML,336.94,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
folic acid 5 MG/ML Solution 10 mL Vial,J3490.94,CDM,636,RC,J3490,HCPCS,,,,63323018410,NDC,10,ML,336.94,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
folic acid 5 MG/ML Solution 10 mL Vial,J3490.94,CDM,636,RC,J3490,HCPCS,,,,63323018410,NDC,10,ML,336.94,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
folic acid 5 MG/ML Solution 10 mL Vial,J3490.94,CDM,636,RC,J3490,HCPCS,,,,63323018410,NDC,10,ML,336.94,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
folic acid 5 MG/ML Solution 10 mL Vial,J3490.94,CDM,636,RC,J3490,HCPCS,,,,63323018410,NDC,10,ML,336.94,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
folic acid 5 MG/ML Solution 10 mL Vial,J3490.94,CDM,636,RC,J3490,HCPCS,,,,63323018410,NDC,10,ML,336.94,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fomepizole 1 GM/ML Solution 1.5 mL Vial,J1451.01,CDM,636,RC,J1451,HCPCS,,,,39822071001,NDC,1.5,ML,2600,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fomepizole 1 GM/ML Solution 1.5 mL Vial,J1451.01,CDM,636,RC,J1451,HCPCS,,,,39822071001,NDC,1.5,ML,2600,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fomepizole 1 GM/ML Solution 1.5 mL Vial,J1451.01,CDM,636,RC,J1451,HCPCS,,,,39822071001,NDC,1.5,ML,2600,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fomepizole 1 GM/ML Solution 1.5 mL Vial,J1451.01,CDM,636,RC,J1451,HCPCS,,,,39822071001,NDC,1.5,ML,2600,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fomepizole 1 GM/ML Solution 1.5 mL Vial,J1451.01,CDM,636,RC,J1451,HCPCS,,,,39822071001,NDC,1.5,ML,2600,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fomepizole 1 GM/ML Solution 1.5 mL Vial,J1451.01,CDM,636,RC,J1451,HCPCS,,,,39822071001,NDC,1.5,ML,2600,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FORCEPS COLD BIOPSY,27200000,CDM,272,RC,,,,12453-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FORCEPS COLD BIOPSY,27200000,CDM,272,RC,,,,12453-MAIN,LOCAL,,,,,23,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FORCEPS COLD BIOPSY,27200000,CDM,272,RC,,,,12453-MAIN,LOCAL,,,,,23,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FORCEPS COLD BIOPSY,27200000,CDM,272,RC,,,,12453-MAIN,LOCAL,,,,,23,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FORCEPS COLD BIOPSY,27200000,CDM,272,RC,,,,12453-MAIN,LOCAL,,,,,23,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FORCEPS COLD BIOPSY,27200000,CDM,272,RC,,,,12453-MAIN,LOCAL,,,,,23,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FORCEPS PROGRASP 8MM ENDOWRIST INSTRUMENTS,27200000,CDM,272,RC,,,,12062-MAIN,LOCAL,,,,,281,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FORCEPS PROGRASP 8MM ENDOWRIST INSTRUMENTS,27200000,CDM,272,RC,,,,12062-MAIN,LOCAL,,,,,281,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FORCEPS PROGRASP 8MM ENDOWRIST INSTRUMENTS,27200000,CDM,272,RC,,,,12062-MAIN,LOCAL,,,,,281,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FORCEPS PROGRASP 8MM ENDOWRIST INSTRUMENTS,27200000,CDM,272,RC,,,,12062-MAIN,LOCAL,,,,,281,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FORCEPS PROGRASP 8MM ENDOWRIST INSTRUMENTS,27200000,CDM,272,RC,,,,12062-MAIN,LOCAL,,,,,281,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FORCEPS PROGRASP 8MM ENDOWRIST INSTRUMENTS,27200000,CDM,272,RC,,,,12062-MAIN,LOCAL,,,,,281,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FORCEPS SERRATED WITH SPIKE JUMBO 230CM,27200000,CDM,272,RC,,,,7416-MAIN,LOCAL,,,,,41.31,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FORCEPS SERRATED WITH SPIKE JUMBO 230CM,27200000,CDM,272,RC,,,,7416-MAIN,LOCAL,,,,,41.31,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FORCEPS SERRATED WITH SPIKE JUMBO 230CM,27200000,CDM,272,RC,,,,7416-MAIN,LOCAL,,,,,41.31,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FORCEPS SERRATED WITH SPIKE JUMBO 230CM,27200000,CDM,272,RC,,,,7416-MAIN,LOCAL,,,,,41.31,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FORCEPS SERRATED WITH SPIKE JUMBO 230CM,27200000,CDM,272,RC,,,,7416-MAIN,LOCAL,,,,,41.31,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FORCEPS SERRATED WITH SPIKE JUMBO 230CM,27200000,CDM,272,RC,,,,7416-MAIN,LOCAL,,,,,41.31,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FORCEPS SPOON JAWSIZE 10MMX36 KIT,27200000,CDM,272,RC,,,,11749-MAIN,LOCAL,,,,,1955,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FORCEPS SPOON JAWSIZE 10MMX36 KIT,27200000,CDM,272,RC,,,,11749-MAIN,LOCAL,,,,,1955,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FORCEPS SPOON JAWSIZE 10MMX36 KIT,27200000,CDM,272,RC,,,,11749-MAIN,LOCAL,,,,,1955,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FORCEPS SPOON JAWSIZE 10MMX36 KIT,27200000,CDM,272,RC,,,,11749-MAIN,LOCAL,,,,,1955,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FORCEPS SPOON JAWSIZE 10MMX36 KIT,27200000,CDM,272,RC,,,,11749-MAIN,LOCAL,,,,,1955,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FORCEPS SPOON JAWSIZE 10MMX36 KIT,27200000,CDM,272,RC,,,,11749-MAIN,LOCAL,,,,,1955,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fosfomycin 3 g Packet 1 Each Box,25000000,CDM,250,RC,,,,,,70700026894,NDC,1,EA,353.41,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fosfomycin 3 g Packet 1 Each Box,25000000,CDM,250,RC,,,,,,70700026894,NDC,1,EA,353.41,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fosfomycin 3 g Packet 1 Each Box,25000000,CDM,250,RC,,,,,,70700026894,NDC,1,EA,353.41,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fosfomycin 3 g Packet 1 Each Box,25000000,CDM,250,RC,,,,,,70700026894,NDC,1,EA,353.41,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fosfomycin 3 g Packet 1 Each Box,25000000,CDM,250,RC,,,,,,70700026894,NDC,1,EA,353.41,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fosfomycin 3 g Packet 1 Each Box,25000000,CDM,250,RC,,,,,,70700026894,NDC,1,EA,353.41,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600110,NDC,10,ML,589.63,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600110,NDC,10,ML,589.63,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600110,NDC,10,ML,589.63,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600110,NDC,10,ML,589.63,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600110,NDC,10,ML,589.63,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600110,NDC,10,ML,589.63,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600121,NDC,10,ML,592.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600121,NDC,10,ML,592.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600121,NDC,10,ML,592.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600121,NDC,10,ML,592.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600121,NDC,10,ML,592.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600121,NDC,10,ML,592.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040304,NDC,10,ML,168.77,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040304,NDC,10,ML,168.77,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040304,NDC,10,ML,168.77,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040304,NDC,10,ML,168.77,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040304,NDC,10,ML,168.77,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040304,NDC,10,ML,168.77,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040310,NDC,10,ML,168.77,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040310,NDC,10,ML,168.77,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040310,NDC,10,ML,168.77,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040310,NDC,10,ML,168.77,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040310,NDC,10,ML,168.77,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040310,NDC,10,ML,168.77,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Francisella Tularensis Ab,PX8666890,CDM,300,RC,86668,CPT,90,,,,,,,294,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Francisella Tularensis Ab,PX8666890,CDM,300,RC,86668,CPT,90,,,,,,,294,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Francisella Tularensis Ab,PX8666890,CDM,300,RC,86668,CPT,90,,,,,,,294,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Francisella Tularensis Ab,PX8666890,CDM,300,RC,86668,CPT,90,,,,,,,294,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Francisella Tularensis Ab,PX8666890,CDM,300,RC,86668,CPT,90,,,,,,,294,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Francisella Tularensis Ab,PX8666890,CDM,300,RC,86668,CPT,90,,,,,,,294,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Freeing Bowel Adhesion,Enterolysis",PX44005F,CDM,360,RC,44005,CPT,,,,,,,,2744,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2420.208,6141.46
"Freeing Bowel Adhesion,Enterolysis",PX44005F,CDM,360,RC,44005,CPT,,,,,,,,2744,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2420.208,6141.46
"Freeing Bowel Adhesion,Enterolysis",PX44005F,CDM,360,RC,44005,CPT,,,,,,,,2744,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2420.208,6141.46
"Freeing Bowel Adhesion,Enterolysis",PX44005F,CDM,360,RC,44005,CPT,,,,,,,,2744,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2420.208,6141.46
"Freeing Bowel Adhesion,Enterolysis",PX44005F,CDM,360,RC,44005,CPT,,,,,,,,2744,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2420.208,6141.46
"Freeing Bowel Adhesion,Enterolysis",PX44005F,CDM,360,RC,44005,CPT,,,,,,,,2744,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2420.208,6141.46
Fresh Frozen Plasma,PXP9017,CDM,390,RC,P9017,HCPCS,,,,,,,,319,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fresh Frozen Plasma,PXP9017,CDM,390,RC,P9017,HCPCS,,,,,,,,319,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fresh Frozen Plasma,PXP9017,CDM,390,RC,P9017,HCPCS,,,,,,,,319,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fresh Frozen Plasma,PXP9017,CDM,390,RC,P9017,HCPCS,,,,,,,,319,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fresh Frozen Plasma,PXP9017,CDM,390,RC,P9017,HCPCS,,,,,,,,319,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fresh Frozen Plasma,PXP9017,CDM,390,RC,P9017,HCPCS,,,,,,,,319,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,310072010,NDC,5,ML,1977.83,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,310072010,NDC,5,ML,1977.83,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,310072010,NDC,5,ML,1977.83,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,310072010,NDC,5,ML,1977.83,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,310072010,NDC,5,ML,1977.83,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,310072010,NDC,5,ML,1977.83,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,781307912,NDC,5,ML,1854.23,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,781307912,NDC,5,ML,1854.23,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,781307912,NDC,5,ML,1854.23,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,781307912,NDC,5,ML,1854.23,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,781307912,NDC,5,ML,1854.23,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,781307912,NDC,5,ML,1854.23,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fungal Culture, Other Source - Ref",PX8710290,CDM,300,RC,87102,CPT,90,,,,,,,157,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fungal Culture, Other Source - Ref",PX8710290,CDM,300,RC,87102,CPT,90,,,,,,,157,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fungal Culture, Other Source - Ref",PX8710290,CDM,300,RC,87102,CPT,90,,,,,,,157,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fungal Culture, Other Source - Ref",PX8710290,CDM,300,RC,87102,CPT,90,,,,,,,157,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fungal Culture, Other Source - Ref",PX8710290,CDM,300,RC,87102,CPT,90,,,,,,,157,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fungal Culture, Other Source - Ref",PX8710290,CDM,300,RC,87102,CPT,90,,,,,,,157,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fungus Antibody, Nos - Ref",PX8667190,CDM,300,RC,86671,CPT,90,,,,,,,99,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fungus Antibody, Nos - Ref",PX8667190,CDM,300,RC,86671,CPT,90,,,,,,,99,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fungus Antibody, Nos - Ref",PX8667190,CDM,300,RC,86671,CPT,90,,,,,,,99,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fungus Antibody, Nos - Ref",PX8667190,CDM,300,RC,86671,CPT,90,,,,,,,99,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fungus Antibody, Nos - Ref",PX8667190,CDM,300,RC,86671,CPT,90,,,,,,,99,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fungus Antibody, Nos - Ref",PX8667190,CDM,300,RC,86671,CPT,90,,,,,,,99,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fungus Isolation Culture,PX87102,CDM,300,RC,87102,CPT,,,,,,,,167,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fungus Isolation Culture,PX87102,CDM,300,RC,87102,CPT,,,,,,,,167,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fungus Isolation Culture,PX87102,CDM,300,RC,87102,CPT,,,,,,,,167,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fungus Isolation Culture,PX87102,CDM,300,RC,87102,CPT,,,,,,,,167,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fungus Isolation Culture,PX87102,CDM,300,RC,87102,CPT,,,,,,,,167,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fungus Isolation Culture,PX87102,CDM,300,RC,87102,CPT,,,,,,,,167,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028002,NDC,1,ML,40.43,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028002,NDC,1,ML,40.43,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028002,NDC,1,ML,40.43,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028002,NDC,1,ML,40.43,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028002,NDC,1,ML,40.43,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028002,NDC,1,ML,40.43,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028016,NDC,2,ML,41.29,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028016,NDC,2,ML,41.29,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028016,NDC,2,ML,41.29,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028016,NDC,2,ML,41.29,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028016,NDC,2,ML,41.29,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028016,NDC,2,ML,41.29,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028026,NDC,2,ML,41.42,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028026,NDC,2,ML,41.42,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028026,NDC,2,ML,41.42,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028026,NDC,2,ML,41.42,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028026,NDC,2,ML,41.42,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028026,NDC,2,ML,41.42,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,70860030242,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,70860030242,NDC,1,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,70860030242,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,70860030242,NDC,1,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,70860030242,NDC,1,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,70860030242,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,36000028425,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,36000028425,NDC,2,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,36000028425,NDC,2,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,36000028425,NDC,2,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,36000028425,NDC,2,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,36000028425,NDC,2,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028036,NDC,2,ML,36.12,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028036,NDC,2,ML,36.12,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028036,NDC,2,ML,36.12,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028036,NDC,2,ML,36.12,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028036,NDC,2,ML,36.12,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028036,NDC,2,ML,36.12,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54829725,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54829725,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54829725,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54829725,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54829725,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54829725,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54829925,NDC,1,EA,3.15,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54829925,NDC,1,EA,3.15,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54829925,NDC,1,EA,3.15,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54829925,NDC,1,EA,3.15,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54829925,NDC,1,EA,3.15,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54829925,NDC,1,EA,3.15,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904717861,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904717861,NDC,0.25,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904717861,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904717861,NDC,0.25,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904717861,NDC,0.25,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904717861,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fusion Foot Bones,Midtarsal,Multi",PX28730F,CDM,510,RC,28730,CPT,,,,,,,,2299,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fusion Foot Bones,Midtarsal,Multi",PX28730F,CDM,510,RC,28730,CPT,,,,,,,,2299,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fusion Foot Bones,Midtarsal,Multi",PX28730F,CDM,510,RC,28730,CPT,,,,,,,,2299,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fusion Foot Bones,Midtarsal,Multi",PX28730F,CDM,510,RC,28730,CPT,,,,,,,,2299,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fusion Foot Bones,Midtarsal,Multi",PX28730F,CDM,510,RC,28730,CPT,,,,,,,,2299,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fusion Foot Bones,Midtarsal,Multi",PX28730F,CDM,510,RC,28730,CPT,,,,,,,,2299,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
G6pd; Quant Screen - Ref,PX8295590,CDM,300,RC,82955,CPT,90,,,,,,,50,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
G6pd; Quant Screen - Ref,PX8295590,CDM,300,RC,82955,CPT,90,,,,,,,50,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
G6pd; Quant Screen - Ref,PX8295590,CDM,300,RC,82955,CPT,90,,,,,,,50,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
G6pd; Quant Screen - Ref,PX8295590,CDM,300,RC,82955,CPT,90,,,,,,,50,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
G6pd; Quant Screen - Ref,PX8295590,CDM,300,RC,82955,CPT,90,,,,,,,50,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
G6pd; Quant Screen - Ref,PX8295590,CDM,300,RC,82955,CPT,90,,,,,,,50,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gabapentin - Ref,PX8017190,CDM,300,RC,80171,CPT,90,,,,,,,71,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gabapentin - Ref,PX8017190,CDM,300,RC,80171,CPT,90,,,,,,,71,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gabapentin - Ref,PX8017190,CDM,300,RC,80171,CPT,90,,,,,,,71,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gabapentin - Ref,PX8017190,CDM,300,RC,80171,CPT,90,,,,,,,71,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gabapentin - Ref,PX8017190,CDM,300,RC,80171,CPT,90,,,,,,,71,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gabapentin - Ref,PX8017190,CDM,300,RC,80171,CPT,90,,,,,,,71,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762403001,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762403001,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762403001,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762403001,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762403001,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762403001,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904563161,NDC,1,EA,3.72,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904563161,NDC,1,EA,3.72,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904563161,NDC,1,EA,3.72,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904563161,NDC,1,EA,3.72,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904563161,NDC,1,EA,3.72,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904563161,NDC,1,EA,3.72,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904666561,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904666561,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904666561,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904666561,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904666561,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904666561,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739059110,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739059110,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739059110,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739059110,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739059110,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739059110,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739090210,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739090210,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739090210,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739090210,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739090210,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739090210,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 300 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862019901,NDC,0.333333333,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 300 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862019901,NDC,0.333333333,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 300 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862019901,NDC,0.333333333,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 300 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862019901,NDC,0.333333333,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 300 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862019901,NDC,0.333333333,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 300 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862019901,NDC,0.333333333,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904666661,NDC,0.333333333,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904666661,NDC,0.333333333,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904666661,NDC,0.333333333,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904666661,NDC,0.333333333,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904666661,NDC,0.333333333,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904666661,NDC,0.333333333,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60505011300,NDC,0.333333333,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60505011300,NDC,0.333333333,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60505011300,NDC,0.333333333,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60505011300,NDC,0.333333333,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60505011300,NDC,0.333333333,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60505011300,NDC,0.333333333,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687059101,NDC,0.333333333,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687059101,NDC,0.333333333,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687059101,NDC,0.333333333,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687059101,NDC,0.333333333,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687059101,NDC,0.333333333,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687059101,NDC,0.333333333,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739023610,NDC,0.333333333,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739023610,NDC,0.333333333,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739023610,NDC,0.333333333,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739023610,NDC,0.333333333,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739023610,NDC,0.333333333,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739023610,NDC,0.333333333,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 600 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268035111,NDC,1,EA,12.79,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 600 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268035111,NDC,1,EA,12.79,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 600 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268035111,NDC,1,EA,12.79,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 600 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268035111,NDC,1,EA,12.79,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 600 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268035111,NDC,1,EA,12.79,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 600 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268035111,NDC,1,EA,12.79,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 600 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268035115,NDC,1,EA,12.79,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 600 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268035115,NDC,1,EA,12.79,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 600 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268035115,NDC,1,EA,12.79,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 600 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268035115,NDC,1,EA,12.79,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 600 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268035115,NDC,1,EA,12.79,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 600 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268035115,NDC,1,EA,12.79,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 800 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714033201,NDC,0.75,EA,12.25,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 800 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714033201,NDC,0.75,EA,12.25,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 800 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714033201,NDC,0.75,EA,12.25,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 800 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714033201,NDC,0.75,EA,12.25,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 800 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714033201,NDC,0.75,EA,12.25,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 800 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714033201,NDC,0.75,EA,12.25,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gadoterate meglumine 10 mmol/20 mL Solution 20 mL Vial,A9575,CDM,636,RC,A9575,HCPCS,,,,67684200003,NDC,20,ML,668.27,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gadoterate meglumine 10 mmol/20 mL Solution 20 mL Vial,A9575,CDM,636,RC,A9575,HCPCS,,,,67684200003,NDC,20,ML,668.27,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gadoterate meglumine 10 mmol/20 mL Solution 20 mL Vial,A9575,CDM,636,RC,A9575,HCPCS,,,,67684200003,NDC,20,ML,668.27,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gadoterate meglumine 10 mmol/20 mL Solution 20 mL Vial,A9575,CDM,636,RC,A9575,HCPCS,,,,67684200003,NDC,20,ML,668.27,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gadoterate meglumine 10 mmol/20 mL Solution 20 mL Vial,A9575,CDM,636,RC,A9575,HCPCS,,,,67684200003,NDC,20,ML,668.27,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gadoterate meglumine 10 mmol/20 mL Solution 20 mL Vial,A9575,CDM,636,RC,A9575,HCPCS,,,,67684200003,NDC,20,ML,668.27,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gadoteridol 279.3 MG/ML Solution 5 mL Vial,A9576,CDM,636,RC,A9576,HCPCS,,,,270111104,NDC,10,ML,100,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gadoteridol 279.3 MG/ML Solution 5 mL Vial,A9576,CDM,636,RC,A9576,HCPCS,,,,270111104,NDC,10,ML,100,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gadoteridol 279.3 MG/ML Solution 5 mL Vial,A9576,CDM,636,RC,A9576,HCPCS,,,,270111104,NDC,10,ML,100,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gadoteridol 279.3 MG/ML Solution 5 mL Vial,A9576,CDM,636,RC,A9576,HCPCS,,,,270111104,NDC,10,ML,100,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gadoteridol 279.3 MG/ML Solution 5 mL Vial,A9576,CDM,636,RC,A9576,HCPCS,,,,270111104,NDC,10,ML,100,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gadoteridol 279.3 MG/ML Solution 5 mL Vial,A9576,CDM,636,RC,A9576,HCPCS,,,,270111104,NDC,10,ML,100,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gadoteridol 279.3 MG/ML Solution 17 mL Syringe,A9576,CDM,636,RC,A9576,HCPCS,,,,270111145,NDC,17,ML,170,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gadoteridol 279.3 MG/ML Solution 17 mL Syringe,A9576,CDM,636,RC,A9576,HCPCS,,,,270111145,NDC,17,ML,170,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gadoteridol 279.3 MG/ML Solution 17 mL Syringe,A9576,CDM,636,RC,A9576,HCPCS,,,,270111145,NDC,17,ML,170,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gadoteridol 279.3 MG/ML Solution 17 mL Syringe,A9576,CDM,636,RC,A9576,HCPCS,,,,270111145,NDC,17,ML,170,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gadoteridol 279.3 MG/ML Solution 17 mL Syringe,A9576,CDM,636,RC,A9576,HCPCS,,,,270111145,NDC,17,ML,170,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gadoteridol 279.3 MG/ML Solution 17 mL Syringe,A9576,CDM,636,RC,A9576,HCPCS,,,,270111145,NDC,17,ML,170,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gadoxetate disodium 0.25 MOL/L Solution 10 mL Vial,A9581,CDM,636,RC,A9581,HCPCS,,,,50419032005,NDC,10,ML,200,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gadoxetate disodium 0.25 MOL/L Solution 10 mL Vial,A9581,CDM,636,RC,A9581,HCPCS,,,,50419032005,NDC,10,ML,200,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gadoxetate disodium 0.25 MOL/L Solution 10 mL Vial,A9581,CDM,636,RC,A9581,HCPCS,,,,50419032005,NDC,10,ML,200,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gadoxetate disodium 0.25 MOL/L Solution 10 mL Vial,A9581,CDM,636,RC,A9581,HCPCS,,,,50419032005,NDC,10,ML,200,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gadoxetate disodium 0.25 MOL/L Solution 10 mL Vial,A9581,CDM,636,RC,A9581,HCPCS,,,,50419032005,NDC,10,ML,200,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gadoxetate disodium 0.25 MOL/L Solution 10 mL Vial,A9581,CDM,636,RC,A9581,HCPCS,,,,50419032005,NDC,10,ML,200,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gait Training Therapy,PX97116,CDM,420,RC,97116,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gait Training Therapy,PX97116,CDM,420,RC,97116,CPT,,,,,,,,135,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gait Training Therapy,PX97116,CDM,420,RC,97116,CPT,,,,,,,,135,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gait Training Therapy,PX97116,CDM,420,RC,97116,CPT,,,,,,,,135,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gait Training Therapy,PX97116,CDM,420,RC,97116,CPT,,,,,,,,135,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gait Training Therapy,PX97116,CDM,420,RC,97116,CPT,,,,,,,,135,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Gammaglobulin; Iga, Dg,M - Ref",PX8278490,CDM,300,RC,82784,CPT,90,,,,,,,90,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Gammaglobulin; Iga, Dg,M - Ref",PX8278490,CDM,300,RC,82784,CPT,90,,,,,,,90,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Gammaglobulin; Iga, Dg,M - Ref",PX8278490,CDM,300,RC,82784,CPT,90,,,,,,,90,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Gammaglobulin; Iga, Dg,M - Ref",PX8278490,CDM,300,RC,82784,CPT,90,,,,,,,90,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Gammaglobulin; Iga, Dg,M - Ref",PX8278490,CDM,300,RC,82784,CPT,90,,,,,,,90,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Gammaglobulin; Iga, Dg,M - Ref",PX8278490,CDM,300,RC,82784,CPT,90,,,,,,,90,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gammaglobulin; Ige - Ref,PX8278590,CDM,300,RC,82785,CPT,90,,,,,,,45,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gammaglobulin; Ige - Ref,PX8278590,CDM,300,RC,82785,CPT,90,,,,,,,45,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gammaglobulin; Ige - Ref,PX8278590,CDM,300,RC,82785,CPT,90,,,,,,,45,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gammaglobulin; Ige - Ref,PX8278590,CDM,300,RC,82785,CPT,90,,,,,,,45,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gammaglobulin; Ige - Ref,PX8278590,CDM,300,RC,82785,CPT,90,,,,,,,45,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gammaglobulin; Ige - Ref,PX8278590,CDM,300,RC,82785,CPT,90,,,,,,,45,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gardner Vag Dna Dir Probe,PX87510,CDM,300,RC,87510,CPT,,,,,,,,127,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gardner Vag Dna Dir Probe,PX87510,CDM,300,RC,87510,CPT,,,,,,,,127,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gardner Vag Dna Dir Probe,PX87510,CDM,300,RC,87510,CPT,,,,,,,,127,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gardner Vag Dna Dir Probe,PX87510,CDM,300,RC,87510,CPT,,,,,,,,127,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gardner Vag Dna Dir Probe,PX87510,CDM,300,RC,87510,CPT,,,,,,,,127,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gardner Vag Dna Dir Probe,PX87510,CDM,300,RC,87510,CPT,,,,,,,,127,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gastric Intubation Treatment,PX43753F,CDM,510,RC,43753,CPT,,,,,,,,441,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gastric Intubation Treatment,PX43753F,CDM,510,RC,43753,CPT,,,,,,,,441,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gastric Intubation Treatment,PX43753F,CDM,510,RC,43753,CPT,,,,,,,,441,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gastric Intubation Treatment,PX43753F,CDM,510,RC,43753,CPT,,,,,,,,441,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gastric Intubation Treatment,PX43753F,CDM,510,RC,43753,CPT,,,,,,,,441,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gastric Intubation Treatment,PX43753F,CDM,510,RC,43753,CPT,,,,,,,,441,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gastric Intubation Treatment,PX43753P,CDM,983,RC,43753,CPT,,,,,,,,498,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gastric Intubation Treatment,PX43753P,CDM,983,RC,43753,CPT,,,,,,,,498,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gastric Intubation Treatment,PX43753P,CDM,983,RC,43753,CPT,,,,,,,,498,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gastric Intubation Treatment,PX43753P,CDM,983,RC,43753,CPT,,,,,,,,498,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gastric Intubation Treatment,PX43753P,CDM,983,RC,43753,CPT,,,,,,,,498,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gastric Intubation Treatment,PX43753P,CDM,983,RC,43753,CPT,,,,,,,,498,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gastrin - Ref,PX8294190,CDM,300,RC,82941,CPT,90,,,,,,,65,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gastrin - Ref,PX8294190,CDM,300,RC,82941,CPT,90,,,,,,,65,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gastrin - Ref,PX8294190,CDM,300,RC,82941,CPT,90,,,,,,,65,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gastrin - Ref,PX8294190,CDM,300,RC,82941,CPT,90,,,,,,,65,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gastrin - Ref,PX8294190,CDM,300,RC,82941,CPT,90,,,,,,,65,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gastrin - Ref,PX8294190,CDM,300,RC,82941,CPT,90,,,,,,,65,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GASTRONOMY FEEDING TUBE MIC BALLOONED 20FR 7-10ML 0112-20,27200000,CDM,272,RC,B4087,HCPCS,,13098-MAIN,LOCAL,,,,,45,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GASTRONOMY FEEDING TUBE MIC BALLOONED 20FR 7-10ML 0112-20,27200000,CDM,272,RC,B4087,HCPCS,,13098-MAIN,LOCAL,,,,,45,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GASTRONOMY FEEDING TUBE MIC BALLOONED 20FR 7-10ML 0112-20,27200000,CDM,272,RC,B4087,HCPCS,,13098-MAIN,LOCAL,,,,,45,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GASTRONOMY FEEDING TUBE MIC BALLOONED 20FR 7-10ML 0112-20,27200000,CDM,272,RC,B4087,HCPCS,,13098-MAIN,LOCAL,,,,,45,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GASTRONOMY FEEDING TUBE MIC BALLOONED 20FR 7-10ML 0112-20,27200000,CDM,272,RC,B4087,HCPCS,,13098-MAIN,LOCAL,,,,,45,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GASTRONOMY FEEDING TUBE MIC BALLOONED 20FR 7-10ML 0112-20,27200000,CDM,272,RC,B4087,HCPCS,,13098-MAIN,LOCAL,,,,,45,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,45963061959,NDC,1,EA,638.4,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,45963061959,NDC,1,EA,638.4,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,45963061959,NDC,1,EA,638.4,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,45963061959,NDC,1,EA,638.4,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,45963061959,NDC,1,EA,638.4,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,45963061959,NDC,1,EA,638.4,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323012594,NDC,1,EA,190.99,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323012594,NDC,1,EA,190.99,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323012594,NDC,1,EA,190.99,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323012594,NDC,1,EA,190.99,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323012594,NDC,1,EA,190.99,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323012594,NDC,1,EA,190.99,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gemcitabine 1 GM/26.3ML Solution 26.3 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018101,NDC,26.3,ML,203.58,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gemcitabine 1 GM/26.3ML Solution 26.3 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018101,NDC,26.3,ML,203.58,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gemcitabine 1 GM/26.3ML Solution 26.3 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018101,NDC,26.3,ML,203.58,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gemcitabine 1 GM/26.3ML Solution 26.3 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018101,NDC,26.3,ML,203.58,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gemcitabine 1 GM/26.3ML Solution 26.3 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018101,NDC,26.3,ML,203.58,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gemcitabine 1 GM/26.3ML Solution 26.3 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018101,NDC,26.3,ML,203.58,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gemcitabine 200 MG Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323010294,NDC,1,EA,39,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gemcitabine 200 MG Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323010294,NDC,1,EA,39,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gemcitabine 200 MG Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323010294,NDC,1,EA,39,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gemcitabine 200 MG Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323010294,NDC,1,EA,39,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gemcitabine 200 MG Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323010294,NDC,1,EA,39,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gemcitabine 200 MG Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323010294,NDC,1,EA,39,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gemcitabine 200 MG/5.26ML Solution 5.26 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018301,NDC,5.26,ML,40.74,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gemcitabine 200 MG/5.26ML Solution 5.26 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018301,NDC,5.26,ML,40.74,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gemcitabine 200 MG/5.26ML Solution 5.26 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018301,NDC,5.26,ML,40.74,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gemcitabine 200 MG/5.26ML Solution 5.26 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018301,NDC,5.26,ML,40.74,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gemcitabine 200 MG/5.26ML Solution 5.26 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018301,NDC,5.26,ML,40.74,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gemcitabine 200 MG/5.26ML Solution 5.26 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018301,NDC,5.26,ML,40.74,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Genital Surg Proc,Male Unlisted",PX55899F,CDM,510,RC,55899,CPT,,,,,,,,1430,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Genital Surg Proc,Male Unlisted",PX55899F,CDM,510,RC,55899,CPT,,,,,,,,1430,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Genital Surg Proc,Male Unlisted",PX55899F,CDM,510,RC,55899,CPT,,,,,,,,1430,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Genital Surg Proc,Male Unlisted",PX55899F,CDM,510,RC,55899,CPT,,,,,,,,1430,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Genital Surg Proc,Male Unlisted",PX55899F,CDM,510,RC,55899,CPT,,,,,,,,1430,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Genital Surg Proc,Male Unlisted",PX55899F,CDM,510,RC,55899,CPT,,,,,,,,1430,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Genital Surg Proc,Male Unlisted",PX55899P,CDM,983,RC,55899,CPT,,,,,,,,953,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Genital Surg Proc,Male Unlisted",PX55899P,CDM,983,RC,55899,CPT,,,,,,,,953,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Genital Surg Proc,Male Unlisted",PX55899P,CDM,983,RC,55899,CPT,,,,,,,,953,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Genital Surg Proc,Male Unlisted",PX55899P,CDM,983,RC,55899,CPT,,,,,,,,953,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Genital Surg Proc,Male Unlisted",PX55899P,CDM,983,RC,55899,CPT,,,,,,,,953,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Genital Surg Proc,Male Unlisted",PX55899P,CDM,983,RC,55899,CPT,,,,,,,,953,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gentamicin 0.1 % Ointment 30 g Tube,25000000,CDM,250,RC,,,,,,713068231,NDC,30,GR,506.64,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gentamicin 0.1 % Ointment 30 g Tube,25000000,CDM,250,RC,,,,,,713068231,NDC,30,GR,506.64,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gentamicin 0.1 % Ointment 30 g Tube,25000000,CDM,250,RC,,,,,,713068231,NDC,30,GR,506.64,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gentamicin 0.1 % Ointment 30 g Tube,25000000,CDM,250,RC,,,,,,713068231,NDC,30,GR,506.64,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gentamicin 0.1 % Ointment 30 g Tube,25000000,CDM,250,RC,,,,,,713068231,NDC,30,GR,506.64,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gentamicin 0.1 % Ointment 30 g Tube,25000000,CDM,250,RC,,,,,,713068231,NDC,30,GR,506.64,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gentamicin 0.3 % Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,17478028435,NDC,3.5,GR,219.3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gentamicin 0.3 % Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,17478028435,NDC,3.5,GR,219.3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gentamicin 0.3 % Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,17478028435,NDC,3.5,GR,219.3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gentamicin 0.3 % Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,17478028435,NDC,3.5,GR,219.3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gentamicin 0.3 % Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,17478028435,NDC,3.5,GR,219.3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gentamicin 0.3 % Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,17478028435,NDC,3.5,GR,219.3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gentamicin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,60758018805,NDC,5,ML,107.98,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gentamicin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,60758018805,NDC,5,ML,107.98,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gentamicin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,60758018805,NDC,5,ML,107.98,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gentamicin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,60758018805,NDC,5,ML,107.98,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gentamicin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,60758018805,NDC,5,ML,107.98,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gentamicin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,60758018805,NDC,5,ML,107.98,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gentamicin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063305,NDC,5,ML,122.17,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gentamicin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063305,NDC,5,ML,122.17,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gentamicin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063305,NDC,5,ML,122.17,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gentamicin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063305,NDC,5,ML,122.17,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gentamicin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063305,NDC,5,ML,122.17,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gentamicin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063305,NDC,5,ML,122.17,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001001,NDC,1.5,ML,40.17,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001001,NDC,1.5,ML,40.17,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001001,NDC,1.5,ML,40.17,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001001,NDC,1.5,ML,40.17,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001001,NDC,1.5,ML,40.17,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001001,NDC,1.5,ML,40.17,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001002,NDC,2,ML,43.42,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001002,NDC,2,ML,43.42,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001002,NDC,2,ML,43.42,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001002,NDC,2,ML,43.42,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001002,NDC,2,ML,43.42,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001002,NDC,2,ML,43.42,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001094,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001094,NDC,2,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001094,NDC,2,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001094,NDC,2,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001094,NDC,2,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001094,NDC,2,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"GI Pathogen Panel, Pcr - Ref",PX8750790,CDM,300,RC,87507,CPT,90,,,,,,,213,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"GI Pathogen Panel, Pcr - Ref",PX8750790,CDM,300,RC,87507,CPT,90,,,,,,,213,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"GI Pathogen Panel, Pcr - Ref",PX8750790,CDM,300,RC,87507,CPT,90,,,,,,,213,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"GI Pathogen Panel, Pcr - Ref",PX8750790,CDM,300,RC,87507,CPT,90,,,,,,,213,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"GI Pathogen Panel, Pcr - Ref",PX8750790,CDM,300,RC,87507,CPT,90,,,,,,,213,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"GI Pathogen Panel, Pcr - Ref",PX8750790,CDM,300,RC,87507,CPT,90,,,,,,,213,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Giardia,PX87329,CDM,300,RC,87329,CPT,,,,,,,,117,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Giardia,PX87329,CDM,300,RC,87329,CPT,,,,,,,,117,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Giardia,PX87329,CDM,300,RC,87329,CPT,,,,,,,,117,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Giardia,PX87329,CDM,300,RC,87329,CPT,,,,,,,,117,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Giardia,PX87329,CDM,300,RC,87329,CPT,,,,,,,,117,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Giardia,PX87329,CDM,300,RC,87329,CPT,,,,,,,,117,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GLIDESCOPE QC MAC S3 SINGLE USE 0270-1083,120.579,CDM,272,RC,,,,13046-MAIN,LOCAL,,,,,85,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GLIDESCOPE QC MAC S3 SINGLE USE 0270-1083,120.579,CDM,272,RC,,,,13046-MAIN,LOCAL,,,,,85,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GLIDESCOPE QC MAC S3 SINGLE USE 0270-1083,120.579,CDM,272,RC,,,,13046-MAIN,LOCAL,,,,,85,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GLIDESCOPE QC MAC S3 SINGLE USE 0270-1083,120.579,CDM,272,RC,,,,13046-MAIN,LOCAL,,,,,85,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GLIDESCOPE QC MAC S3 SINGLE USE 0270-1083,120.579,CDM,272,RC,,,,13046-MAIN,LOCAL,,,,,85,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GLIDESCOPE QC MAC S3 SINGLE USE 0270-1083,120.579,CDM,272,RC,,,,13046-MAIN,LOCAL,,,,,85,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GLIDESCOPE QC MAC S3 SINGLE USE 0270-1085,120.579,CDM,272,RC,,,,13022-MAIN,LOCAL,,,,,85,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GLIDESCOPE QC MAC S3 SINGLE USE 0270-1085,120.579,CDM,272,RC,,,,13022-MAIN,LOCAL,,,,,85,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GLIDESCOPE QC MAC S3 SINGLE USE 0270-1085,120.579,CDM,272,RC,,,,13022-MAIN,LOCAL,,,,,85,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GLIDESCOPE QC MAC S3 SINGLE USE 0270-1085,120.579,CDM,272,RC,,,,13022-MAIN,LOCAL,,,,,85,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GLIDESCOPE QC MAC S3 SINGLE USE 0270-1085,120.579,CDM,272,RC,,,,13022-MAIN,LOCAL,,,,,85,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GLIDESCOPE QC MAC S3 SINGLE USE 0270-1085,120.579,CDM,272,RC,,,,13022-MAIN,LOCAL,,,,,85,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GLIDESCOPE QC MAC S4 SINGLE USE 0270-1086,120.579,CDM,272,RC,,,,13023-MAIN,LOCAL,,,,,85,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GLIDESCOPE QC MAC S4 SINGLE USE 0270-1086,120.579,CDM,272,RC,,,,13023-MAIN,LOCAL,,,,,85,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GLIDESCOPE QC MAC S4 SINGLE USE 0270-1086,120.579,CDM,272,RC,,,,13023-MAIN,LOCAL,,,,,85,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GLIDESCOPE QC MAC S4 SINGLE USE 0270-1086,120.579,CDM,272,RC,,,,13023-MAIN,LOCAL,,,,,85,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GLIDESCOPE QC MAC S4 SINGLE USE 0270-1086,120.579,CDM,272,RC,,,,13023-MAIN,LOCAL,,,,,85,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GLIDESCOPE QC MAC S4 SINGLE USE 0270-1086,120.579,CDM,272,RC,,,,13023-MAIN,LOCAL,,,,,85,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GLIDESCOPE QC MILLER S0 SINGLE USE 0270-1087,120.58,CDM,272,RC,,,,13024-MAIN,LOCAL,,,,,106,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GLIDESCOPE QC MILLER S0 SINGLE USE 0270-1087,120.58,CDM,272,RC,,,,13024-MAIN,LOCAL,,,,,106,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GLIDESCOPE QC MILLER S0 SINGLE USE 0270-1087,120.58,CDM,272,RC,,,,13024-MAIN,LOCAL,,,,,106,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GLIDESCOPE QC MILLER S0 SINGLE USE 0270-1087,120.58,CDM,272,RC,,,,13024-MAIN,LOCAL,,,,,106,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GLIDESCOPE QC MILLER S0 SINGLE USE 0270-1087,120.58,CDM,272,RC,,,,13024-MAIN,LOCAL,,,,,106,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GLIDESCOPE QC MILLER S0 SINGLE USE 0270-1087,120.58,CDM,272,RC,,,,13024-MAIN,LOCAL,,,,,106,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GLIDESCOPE QC MILLER S1 SINGLE USE 0270-1088,120.58,CDM,272,RC,,,,13025-MAIN,LOCAL,,,,,106,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GLIDESCOPE QC MILLER S1 SINGLE USE 0270-1088,120.58,CDM,272,RC,,,,13025-MAIN,LOCAL,,,,,106,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GLIDESCOPE QC MILLER S1 SINGLE USE 0270-1088,120.58,CDM,272,RC,,,,13025-MAIN,LOCAL,,,,,106,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GLIDESCOPE QC MILLER S1 SINGLE USE 0270-1088,120.58,CDM,272,RC,,,,13025-MAIN,LOCAL,,,,,106,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GLIDESCOPE QC MILLER S1 SINGLE USE 0270-1088,120.58,CDM,272,RC,,,,13025-MAIN,LOCAL,,,,,106,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GLIDESCOPE QC MILLER S1 SINGLE USE 0270-1088,120.58,CDM,272,RC,,,,13025-MAIN,LOCAL,,,,,106,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glimepiride 1 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268035815,NDC,1,EA,5.41,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glimepiride 1 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268035815,NDC,1,EA,5.41,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glimepiride 1 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268035815,NDC,1,EA,5.41,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glimepiride 1 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268035815,NDC,1,EA,5.41,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glimepiride 1 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268035815,NDC,1,EA,5.41,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glimepiride 1 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268035815,NDC,1,EA,5.41,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glimepiride 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93725401,NDC,1,EA,5.79,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glimepiride 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93725401,NDC,1,EA,5.79,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glimepiride 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93725401,NDC,1,EA,5.79,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glimepiride 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93725401,NDC,1,EA,5.79,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glimepiride 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93725401,NDC,1,EA,5.79,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glimepiride 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93725401,NDC,1,EA,5.79,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glimepiride 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547039410,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glimepiride 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547039410,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glimepiride 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547039410,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glimepiride 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547039410,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glimepiride 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547039410,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glimepiride 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547039410,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glipiZIDE 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079081001,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glipiZIDE 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079081001,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glipiZIDE 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079081001,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glipiZIDE 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079081001,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glipiZIDE 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079081001,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glipiZIDE 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079081001,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glipiZIDE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079081020,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glipiZIDE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079081020,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glipiZIDE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079081020,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glipiZIDE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079081020,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glipiZIDE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079081020,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glipiZIDE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079081020,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glipiZIDE ER 2.5 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714089401,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glipiZIDE ER 2.5 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714089401,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glipiZIDE ER 2.5 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714089401,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glipiZIDE ER 2.5 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714089401,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glipiZIDE ER 2.5 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714089401,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glipiZIDE ER 2.5 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714089401,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glipiZIDE ER 5 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714089501,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glipiZIDE ER 5 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714089501,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glipiZIDE ER 5 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714089501,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glipiZIDE ER 5 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714089501,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glipiZIDE ER 5 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714089501,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glipiZIDE ER 5 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714089501,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Glucagon - Ref,PX8294390,CDM,300,RC,82943,CPT,90,,,,,,,115,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Glucagon - Ref,PX8294390,CDM,300,RC,82943,CPT,90,,,,,,,115,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Glucagon - Ref,PX8294390,CDM,300,RC,82943,CPT,90,,,,,,,115,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Glucagon - Ref,PX8294390,CDM,300,RC,82943,CPT,90,,,,,,,115,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Glucagon - Ref,PX8294390,CDM,300,RC,82943,CPT,90,,,,,,,115,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Glucagon - Ref,PX8294390,CDM,300,RC,82943,CPT,90,,,,,,,115,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059303,NDC,1,EA,740.19,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059303,NDC,1,EA,740.19,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059303,NDC,1,EA,740.19,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059303,NDC,1,EA,740.19,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059303,NDC,1,EA,740.19,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059303,NDC,1,EA,740.19,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059611,NDC,0.25,EA,200.05,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059611,NDC,0.25,EA,200.05,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059611,NDC,0.25,EA,200.05,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059611,NDC,0.25,EA,200.05,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059611,NDC,0.25,EA,200.05,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059611,NDC,0.25,EA,200.05,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059613,NDC,0.25,EA,200.05,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059613,NDC,0.25,EA,200.05,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059613,NDC,0.25,EA,200.05,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059613,NDC,0.25,EA,200.05,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059613,NDC,0.25,EA,200.05,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059613,NDC,0.25,EA,200.05,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glucagon rdna (diagnostic) 1 MG Recon Soln 1 Each Vial,J1610.01,CDM,636,RC,J1610,HCPCS,,,,597026010,NDC,1,EA,744.84,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glucagon rdna (diagnostic) 1 MG Recon Soln 1 Each Vial,J1610.01,CDM,636,RC,J1610,HCPCS,,,,597026010,NDC,1,EA,744.84,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glucagon rdna (diagnostic) 1 MG Recon Soln 1 Each Vial,J1610.01,CDM,636,RC,J1610,HCPCS,,,,597026010,NDC,1,EA,744.84,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glucagon rdna (diagnostic) 1 MG Recon Soln 1 Each Vial,J1610.01,CDM,636,RC,J1610,HCPCS,,,,597026010,NDC,1,EA,744.84,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glucagon rdna (diagnostic) 1 MG Recon Soln 1 Each Vial,J1610.01,CDM,636,RC,J1610,HCPCS,,,,597026010,NDC,1,EA,744.84,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glucagon rdna (diagnostic) 1 MG Recon Soln 1 Each Vial,J1610.01,CDM,636,RC,J1610,HCPCS,,,,597026010,NDC,1,EA,744.84,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glucose 40 % Gel 37.5 g Package,63700001,CDM,250,RC,,,,,,574006930,NDC,37.5,GR,25.12,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glucose 40 % Gel 37.5 g Package,63700001,CDM,250,RC,,,,,,574006930,NDC,37.5,GR,25.12,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glucose 40 % Gel 37.5 g Package,63700001,CDM,250,RC,,,,,,574006930,NDC,37.5,GR,25.12,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glucose 40 % Gel 37.5 g Package,63700001,CDM,250,RC,,,,,,574006930,NDC,37.5,GR,25.12,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glucose 40 % Gel 37.5 g Package,63700001,CDM,250,RC,,,,,,574006930,NDC,37.5,GR,25.12,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glucose 40 % Gel 37.5 g Package,63700001,CDM,250,RC,,,,,,574006930,NDC,37.5,GR,25.12,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glucose 40 % Gel 37.5 g Tube,63700001,CDM,250,RC,,,,,,574006915,NDC,37.5,GR,25.12,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glucose 40 % Gel 37.5 g Tube,63700001,CDM,250,RC,,,,,,574006915,NDC,37.5,GR,25.12,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glucose 40 % Gel 37.5 g Tube,63700001,CDM,250,RC,,,,,,574006915,NDC,37.5,GR,25.12,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glucose 40 % Gel 37.5 g Tube,63700001,CDM,250,RC,,,,,,574006915,NDC,37.5,GR,25.12,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glucose 40 % Gel 37.5 g Tube,63700001,CDM,250,RC,,,,,,574006915,NDC,37.5,GR,25.12,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glucose 40 % Gel 37.5 g Tube,63700001,CDM,250,RC,,,,,,574006915,NDC,37.5,GR,25.12,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Glucose Blood Test,PX82962,CDM,300,RC,82962,CPT,,,,,,,,20,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Glucose Blood Test,PX82962,CDM,300,RC,82962,CPT,,,,,,,,20,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Glucose Blood Test,PX82962,CDM,300,RC,82962,CPT,,,,,,,,20,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Glucose Blood Test,PX82962,CDM,300,RC,82962,CPT,,,,,,,,20,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Glucose Blood Test,PX82962,CDM,300,RC,82962,CPT,,,,,,,,20,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Glucose Blood Test,PX82962,CDM,300,RC,82962,CPT,,,,,,,,20,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Glucose Test,PX82950,CDM,300,RC,82950,CPT,,,,,,,,74,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Glucose Test,PX82950,CDM,300,RC,82950,CPT,,,,,,,,74,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Glucose Test,PX82950,CDM,300,RC,82950,CPT,,,,,,,,74,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Glucose Test,PX82950,CDM,300,RC,82950,CPT,,,,,,,,74,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Glucose Test,PX82950,CDM,300,RC,82950,CPT,,,,,,,,74,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Glucose Test,PX82950,CDM,300,RC,82950,CPT,,,,,,,,74,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Glucose, Body Fluid Other Than Blood",PX82945,CDM,300,RC,82945,CPT,,,,,,,,158,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Glucose, Body Fluid Other Than Blood",PX82945,CDM,300,RC,82945,CPT,,,,,,,,158,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Glucose, Body Fluid Other Than Blood",PX82945,CDM,300,RC,82945,CPT,,,,,,,,158,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Glucose, Body Fluid Other Than Blood",PX82945,CDM,300,RC,82945,CPT,,,,,,,,158,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Glucose, Body Fluid Other Than Blood",PX82945,CDM,300,RC,82945,CPT,,,,,,,,158,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Glucose, Body Fluid Other Than Blood",PX82945,CDM,300,RC,82945,CPT,,,,,,,,158,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glyBURIDE 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,93834498,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glyBURIDE 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,93834498,NDC,0.25,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glyBURIDE 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,93834498,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glyBURIDE 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,93834498,NDC,0.25,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glyBURIDE 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,93834498,NDC,0.25,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glyBURIDE 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,93834498,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Glycated Protein - Ref,PX8298590,CDM,300,RC,82985,CPT,90,,,,,,,49,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Glycated Protein - Ref,PX8298590,CDM,300,RC,82985,CPT,90,,,,,,,49,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Glycated Protein - Ref,PX8298590,CDM,300,RC,82985,CPT,90,,,,,,,49,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Glycated Protein - Ref,PX8298590,CDM,300,RC,82985,CPT,90,,,,,,,49,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Glycated Protein - Ref,PX8298590,CDM,300,RC,82985,CPT,90,,,,,,,49,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Glycated Protein - Ref,PX8298590,CDM,300,RC,82985,CPT,90,,,,,,,49,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycerin 2 g Suppository 24 Each Jar,63700001,CDM,250,RC,,,,,,132007924,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycerin 2 g Suppository 24 Each Jar,63700001,CDM,250,RC,,,,,,132007924,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycerin 2 g Suppository 24 Each Jar,63700001,CDM,250,RC,,,,,,132007924,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycerin 2 g Suppository 24 Each Jar,63700001,CDM,250,RC,,,,,,132007924,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycerin 2 g Suppository 24 Each Jar,63700001,CDM,250,RC,,,,,,132007924,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycerin 2 g Suppository 24 Each Jar,63700001,CDM,250,RC,,,,,,132007924,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,49348009529,NDC,15,ML,30.53,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,49348009529,NDC,15,ML,30.53,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,49348009529,NDC,15,ML,30.53,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,49348009529,NDC,15,ML,30.53,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,49348009529,NDC,15,ML,30.53,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,49348009529,NDC,15,ML,30.53,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,57896018105,NDC,15,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,57896018105,NDC,15,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,57896018105,NDC,15,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,57896018105,NDC,15,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,57896018105,NDC,15,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,57896018105,NDC,15,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,57896018405,NDC,15,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,57896018405,NDC,15,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,57896018405,NDC,15,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,57896018405,NDC,15,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,57896018405,NDC,15,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,57896018405,NDC,15,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,517460125,NDC,0.5,ML,58.76,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,517460125,NDC,0.5,ML,58.76,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,517460125,NDC,0.5,ML,58.76,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,517460125,NDC,0.5,ML,58.76,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,517460125,NDC,0.5,ML,58.76,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,517460125,NDC,0.5,ML,58.76,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,781382571,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,781382571,NDC,0.5,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,781382571,NDC,0.5,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,781382571,NDC,0.5,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,781382571,NDC,0.5,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,781382571,NDC,0.5,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057811,NDC,0.5,ML,30.98,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057811,NDC,0.5,ML,30.98,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057811,NDC,0.5,ML,30.98,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057811,NDC,0.5,ML,30.98,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057811,NDC,0.5,ML,30.98,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057811,NDC,0.5,ML,30.98,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057841,NDC,0.5,ML,30.98,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057841,NDC,0.5,ML,30.98,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057841,NDC,0.5,ML,30.98,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057841,NDC,0.5,ML,30.98,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057841,NDC,0.5,ML,30.98,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057841,NDC,0.5,ML,30.98,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Glycosylated Hemoglobin Test,PX83036,CDM,300,RC,83036,CPT,,,,,,,,110,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Glycosylated Hemoglobin Test,PX83036,CDM,300,RC,83036,CPT,,,,,,,,110,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Glycosylated Hemoglobin Test,PX83036,CDM,300,RC,83036,CPT,,,,,,,,110,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Glycosylated Hemoglobin Test,PX83036,CDM,300,RC,83036,CPT,,,,,,,,110,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Glycosylated Hemoglobin Test,PX83036,CDM,300,RC,83036,CPT,,,,,,,,110,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Glycosylated Hemoglobin Test,PX83036,CDM,300,RC,83036,CPT,,,,,,,,110,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GOLIMumab 50 MG/4ML Solution 4 mL Vial,J1602.01,CDM,636,RC,J1602,HCPCS,,,,57894035001,NDC,4,ML,3709.76,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GOLIMumab 50 MG/4ML Solution 4 mL Vial,J1602.01,CDM,636,RC,J1602,HCPCS,,,,57894035001,NDC,4,ML,3709.76,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GOLIMumab 50 MG/4ML Solution 4 mL Vial,J1602.01,CDM,636,RC,J1602,HCPCS,,,,57894035001,NDC,4,ML,3709.76,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GOLIMumab 50 MG/4ML Solution 4 mL Vial,J1602.01,CDM,636,RC,J1602,HCPCS,,,,57894035001,NDC,4,ML,3709.76,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GOLIMumab 50 MG/4ML Solution 4 mL Vial,J1602.01,CDM,636,RC,J1602,HCPCS,,,,57894035001,NDC,4,ML,3709.76,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GOLIMumab 50 MG/4ML Solution 4 mL Vial,J1602.01,CDM,636,RC,J1602,HCPCS,,,,57894035001,NDC,4,ML,3709.76,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gonadotropin (Lh),PX83002,CDM,300,RC,83002,CPT,,,,,,,,28,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gonadotropin (Lh),PX83002,CDM,300,RC,83002,CPT,,,,,,,,28,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gonadotropin (Lh),PX83002,CDM,300,RC,83002,CPT,,,,,,,,28,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gonadotropin (Lh),PX83002,CDM,300,RC,83002,CPT,,,,,,,,28,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gonadotropin (Lh),PX83002,CDM,300,RC,83002,CPT,,,,,,,,28,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gonadotropin (Lh),PX83002,CDM,300,RC,83002,CPT,,,,,,,,28,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Gonadotropin, Chorionic (Hcg), Qualitative",PX84703,CDM,300,RC,84703,CPT,,,,,,,,175,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Gonadotropin, Chorionic (Hcg), Qualitative",PX84703,CDM,300,RC,84703,CPT,,,,,,,,175,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Gonadotropin, Chorionic (Hcg), Qualitative",PX84703,CDM,300,RC,84703,CPT,,,,,,,,175,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Gonadotropin, Chorionic (Hcg), Qualitative",PX84703,CDM,300,RC,84703,CPT,,,,,,,,175,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Gonadotropin, Chorionic (Hcg), Qualitative",PX84703,CDM,300,RC,84703,CPT,,,,,,,,175,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Gonadotropin, Chorionic (Hcg), Qualitative",PX84703,CDM,300,RC,84703,CPT,,,,,,,,175,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,310095036,NDC,1,EA,1234.2,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,310095036,NDC,1,EA,1234.2,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,310095036,NDC,1,EA,1234.2,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,310095036,NDC,1,EA,1234.2,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,310095036,NDC,1,EA,1234.2,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,310095036,NDC,1,EA,1234.2,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,70720095036,NDC,1,EA,1234.2,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,70720095036,NDC,1,EA,1234.2,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,70720095036,NDC,1,EA,1234.2,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,70720095036,NDC,1,EA,1234.2,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,70720095036,NDC,1,EA,1234.2,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,70720095036,NDC,1,EA,1234.2,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Gput, Quant",PX8277590,CDM,300,RC,82775,CPT,90,,,,,,,25,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Gput, Quant",PX8277590,CDM,300,RC,82775,CPT,90,,,,,,,25,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Gput, Quant",PX8277590,CDM,300,RC,82775,CPT,90,,,,,,,25,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Gput, Quant",PX8277590,CDM,300,RC,82775,CPT,90,,,,,,,25,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Gput, Quant",PX8277590,CDM,300,RC,82775,CPT,90,,,,,,,25,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Gput, Quant",PX8277590,CDM,300,RC,82775,CPT,90,,,,,,,25,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GRAFIXPL PRIME PLACENTAL MEMBRANE 1.5 x2CM 3SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12764-MAIN,LOCAL,,,,,1529,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GRAFIXPL PRIME PLACENTAL MEMBRANE 1.5 x2CM 3SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12764-MAIN,LOCAL,,,,,1529,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GRAFIXPL PRIME PLACENTAL MEMBRANE 1.5 x2CM 3SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12764-MAIN,LOCAL,,,,,1529,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GRAFIXPL PRIME PLACENTAL MEMBRANE 1.5 x2CM 3SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12764-MAIN,LOCAL,,,,,1529,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GRAFIXPL PRIME PLACENTAL MEMBRANE 1.5 x2CM 3SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12764-MAIN,LOCAL,,,,,1529,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GRAFIXPL PRIME PLACENTAL MEMBRANE 1.5 x2CM 3SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12764-MAIN,LOCAL,,,,,1529,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GRAFIXPL PRIME PLACENTAL MEMBRANE 2x3CM 6SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12765-MAIN,LOCAL,,,,,1911,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GRAFIXPL PRIME PLACENTAL MEMBRANE 2x3CM 6SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12765-MAIN,LOCAL,,,,,1911,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GRAFIXPL PRIME PLACENTAL MEMBRANE 2x3CM 6SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12765-MAIN,LOCAL,,,,,1911,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GRAFIXPL PRIME PLACENTAL MEMBRANE 2x3CM 6SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12765-MAIN,LOCAL,,,,,1911,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GRAFIXPL PRIME PLACENTAL MEMBRANE 2x3CM 6SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12765-MAIN,LOCAL,,,,,1911,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GRAFIXPL PRIME PLACENTAL MEMBRANE 2x3CM 6SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12765-MAIN,LOCAL,,,,,1911,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x3CM 9SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12766-MAIN,LOCAL,,,,,2171,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x3CM 9SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12766-MAIN,LOCAL,,,,,2171,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x3CM 9SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12766-MAIN,LOCAL,,,,,2171,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x3CM 9SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12766-MAIN,LOCAL,,,,,2171,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x3CM 9SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12766-MAIN,LOCAL,,,,,2171,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x3CM 9SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12766-MAIN,LOCAL,,,,,2171,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x4CM 12SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12767-MAIN,LOCAL,,,,,2345,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x4CM 12SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12767-MAIN,LOCAL,,,,,2345,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x4CM 12SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12767-MAIN,LOCAL,,,,,2345,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x4CM 12SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12767-MAIN,LOCAL,,,,,2345,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x4CM 12SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12767-MAIN,LOCAL,,,,,2345,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x4CM 12SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12767-MAIN,LOCAL,,,,,2345,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GRAFIXPL PRIME PLACENTAL MEMBRANE 5x5CM 25SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12768-MAIN,LOCAL,,,,,5211,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GRAFIXPL PRIME PLACENTAL MEMBRANE 5x5CM 25SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12768-MAIN,LOCAL,,,,,5211,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GRAFIXPL PRIME PLACENTAL MEMBRANE 5x5CM 25SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12768-MAIN,LOCAL,,,,,5211,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GRAFIXPL PRIME PLACENTAL MEMBRANE 5x5CM 25SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12768-MAIN,LOCAL,,,,,5211,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GRAFIXPL PRIME PLACENTAL MEMBRANE 5x5CM 25SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12768-MAIN,LOCAL,,,,,5211,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GRAFIXPL PRIME PLACENTAL MEMBRANE 5x5CM 25SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12768-MAIN,LOCAL,,,,,5211,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GRAFIXPL PRIME PLACENTAL MEMBRANE 16MM DISC 2SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12763-MAIN,LOCAL,,,,,860,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GRAFIXPL PRIME PLACENTAL MEMBRANE 16MM DISC 2SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12763-MAIN,LOCAL,,,,,860,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GRAFIXPL PRIME PLACENTAL MEMBRANE 16MM DISC 2SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12763-MAIN,LOCAL,,,,,860,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GRAFIXPL PRIME PLACENTAL MEMBRANE 16MM DISC 2SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12763-MAIN,LOCAL,,,,,860,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GRAFIXPL PRIME PLACENTAL MEMBRANE 16MM DISC 2SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12763-MAIN,LOCAL,,,,,860,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GRAFIXPL PRIME PLACENTAL MEMBRANE 16MM DISC 2SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12763-MAIN,LOCAL,,,,,860,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GROSHONG PICC NXT 4FR,120.218,CDM,272,RC,,,,498-MAIN,LOCAL,,,,,1182,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GROSHONG PICC NXT 4FR,120.218,CDM,272,RC,,,,498-MAIN,LOCAL,,,,,1182,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GROSHONG PICC NXT 4FR,120.218,CDM,272,RC,,,,498-MAIN,LOCAL,,,,,1182,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GROSHONG PICC NXT 4FR,120.218,CDM,272,RC,,,,498-MAIN,LOCAL,,,,,1182,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GROSHONG PICC NXT 4FR,120.218,CDM,272,RC,,,,498-MAIN,LOCAL,,,,,1182,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GROSHONG PICC NXT 4FR,120.218,CDM,272,RC,,,,498-MAIN,LOCAL,,,,,1182,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Group Therapeutic Procedures,PX97150,CDM,420,RC,97150,CPT,,,,,,,,67,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Group Therapeutic Procedures,PX97150,CDM,420,RC,97150,CPT,,,,,,,,67,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Group Therapeutic Procedures,PX97150,CDM,420,RC,97150,CPT,,,,,,,,67,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Group Therapeutic Procedures,PX97150,CDM,420,RC,97150,CPT,,,,,,,,67,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Group Therapeutic Procedures,PX97150,CDM,420,RC,97150,CPT,,,,,,,,67,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Group Therapeutic Procedures,PX97150,CDM,420,RC,97150,CPT,,,,,,,,67,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,603107554,NDC,5,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,603107554,NDC,5,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,603107554,NDC,5,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,603107554,NDC,5,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,603107554,NDC,5,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,603107554,NDC,5,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,69367027204,NDC,5,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,69367027204,NDC,5,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,69367027204,NDC,5,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,69367027204,NDC,5,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,69367027204,NDC,5,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,69367027204,NDC,5,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,69543025204,NDC,118,ML,78.39,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,69543025204,NDC,118,ML,78.39,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,69543025204,NDC,118,ML,78.39,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,69543025204,NDC,118,ML,78.39,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,69543025204,NDC,118,ML,78.39,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,69543025204,NDC,118,ML,78.39,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904006100,NDC,5,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904006100,NDC,5,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904006100,NDC,5,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904006100,NDC,5,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904006100,NDC,5,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904006100,NDC,5,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904676320,NDC,5,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904676320,NDC,5,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904676320,NDC,5,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904676320,NDC,5,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904676320,NDC,5,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904676320,NDC,5,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,54838011740,NDC,5,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,54838011740,NDC,5,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,54838011740,NDC,5,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,54838011740,NDC,5,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,54838011740,NDC,5,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,54838011740,NDC,5,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,61787006304,NDC,5,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,61787006304,NDC,5,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,61787006304,NDC,5,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,61787006304,NDC,5,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,61787006304,NDC,5,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,61787006304,NDC,5,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin 600 MG Tablet Extended Release 12 Hour 20 Each Box,63700001,CDM,250,RC,,,,,,63824000832,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin 600 MG Tablet Extended Release 12 Hour 20 Each Box,63700001,CDM,250,RC,,,,,,63824000832,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin 600 MG Tablet Extended Release 12 Hour 20 Each Box,63700001,CDM,250,RC,,,,,,63824000832,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin 600 MG Tablet Extended Release 12 Hour 20 Each Box,63700001,CDM,250,RC,,,,,,63824000832,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin 600 MG Tablet Extended Release 12 Hour 20 Each Box,63700001,CDM,250,RC,,,,,,63824000832,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin 600 MG Tablet Extended Release 12 Hour 20 Each Box,63700001,CDM,250,RC,,,,,,63824000832,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin 600 MG Tablet Extended Release 12 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904671839,NDC,1,EA,5.74,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin 600 MG Tablet Extended Release 12 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904671839,NDC,1,EA,5.74,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin 600 MG Tablet Extended Release 12 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904671839,NDC,1,EA,5.74,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin 600 MG Tablet Extended Release 12 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904671839,NDC,1,EA,5.74,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin 600 MG Tablet Extended Release 12 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904671839,NDC,1,EA,5.74,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin 600 MG Tablet Extended Release 12 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904671839,NDC,1,EA,5.74,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
haloperidol 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079073420,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
haloperidol 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079073420,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
haloperidol 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079073420,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
haloperidol 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079073420,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
haloperidol 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079073420,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
haloperidol 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079073420,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,143931901,NDC,0.4,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,143931901,NDC,0.4,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,143931901,NDC,0.4,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,143931901,NDC,0.4,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,143931901,NDC,0.4,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,143931901,NDC,0.4,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,63323047401,NDC,1,ML,58.6,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,63323047401,NDC,1,ML,58.6,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,63323047401,NDC,1,ML,58.6,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,63323047401,NDC,1,ML,58.6,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,63323047401,NDC,1,ML,58.6,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,63323047401,NDC,1,ML,58.6,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 15DEGREE 14MM,27200000,CDM,272,RC,,,,12600-MAIN,LOCAL,,,,,1253,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 15DEGREE 14MM,27200000,CDM,272,RC,,,,12600-MAIN,LOCAL,,,,,1253,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 15DEGREE 14MM,27200000,CDM,272,RC,,,,12600-MAIN,LOCAL,,,,,1253,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 15DEGREE 14MM,27200000,CDM,272,RC,,,,12600-MAIN,LOCAL,,,,,1253,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 15DEGREE 14MM,27200000,CDM,272,RC,,,,12600-MAIN,LOCAL,,,,,1253,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 15DEGREE 14MM,27200000,CDM,272,RC,,,,12600-MAIN,LOCAL,,,,,1253,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 45DEGREE 8MM,27200000,CDM,272,RC,,,,12599-MAIN,LOCAL,,,,,1253,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 45DEGREE 8MM,27200000,CDM,272,RC,,,,12599-MAIN,LOCAL,,,,,1253,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 45DEGREE 8MM,27200000,CDM,272,RC,,,,12599-MAIN,LOCAL,,,,,1253,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 45DEGREE 8MM,27200000,CDM,272,RC,,,,12599-MAIN,LOCAL,,,,,1253,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 45DEGREE 8MM,27200000,CDM,272,RC,,,,12599-MAIN,LOCAL,,,,,1253,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 45DEGREE 8MM,27200000,CDM,272,RC,,,,12599-MAIN,LOCAL,,,,,1253,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 45DEGREE 14MM,27200000,CDM,272,RC,,,,12598-MAIN,LOCAL,,,,,1253,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 45DEGREE 14MM,27200000,CDM,272,RC,,,,12598-MAIN,LOCAL,,,,,1253,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 45DEGREE 14MM,27200000,CDM,272,RC,,,,12598-MAIN,LOCAL,,,,,1253,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 45DEGREE 14MM,27200000,CDM,272,RC,,,,12598-MAIN,LOCAL,,,,,1253,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 45DEGREE 14MM,27200000,CDM,272,RC,,,,12598-MAIN,LOCAL,,,,,1253,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 45DEGREE 14MM,27200000,CDM,272,RC,,,,12598-MAIN,LOCAL,,,,,1253,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 15DEGREE 14MM,27200000,CDM,272,RC,,,,12603-MAIN,LOCAL,,,,,1253,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 15DEGREE 14MM,27200000,CDM,272,RC,,,,12603-MAIN,LOCAL,,,,,1253,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 15DEGREE 14MM,27200000,CDM,272,RC,,,,12603-MAIN,LOCAL,,,,,1253,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 15DEGREE 14MM,27200000,CDM,272,RC,,,,12603-MAIN,LOCAL,,,,,1253,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 15DEGREE 14MM,27200000,CDM,272,RC,,,,12603-MAIN,LOCAL,,,,,1253,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 15DEGREE 14MM,27200000,CDM,272,RC,,,,12603-MAIN,LOCAL,,,,,1253,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 45DEGREE 8MM,27200000,CDM,272,RC,,,,12602-MAIN,LOCAL,,,,,1253,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 45DEGREE 8MM,27200000,CDM,272,RC,,,,12602-MAIN,LOCAL,,,,,1253,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 45DEGREE 8MM,27200000,CDM,272,RC,,,,12602-MAIN,LOCAL,,,,,1253,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 45DEGREE 8MM,27200000,CDM,272,RC,,,,12602-MAIN,LOCAL,,,,,1253,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 45DEGREE 8MM,27200000,CDM,272,RC,,,,12602-MAIN,LOCAL,,,,,1253,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 45DEGREE 8MM,27200000,CDM,272,RC,,,,12602-MAIN,LOCAL,,,,,1253,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 45DEGREE 14MM,27200000,CDM,272,RC,,,,12601-MAIN,LOCAL,,,,,1253,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 45DEGREE 14MM,27200000,CDM,272,RC,,,,12601-MAIN,LOCAL,,,,,1253,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 45DEGREE 14MM,27200000,CDM,272,RC,,,,12601-MAIN,LOCAL,,,,,1253,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 45DEGREE 14MM,27200000,CDM,272,RC,,,,12601-MAIN,LOCAL,,,,,1253,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 45DEGREE 14MM,27200000,CDM,272,RC,,,,12601-MAIN,LOCAL,,,,,1253,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 45DEGREE 14MM,27200000,CDM,272,RC,,,,12601-MAIN,LOCAL,,,,,1253,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Haptoglobin; Quantitative,PX83010,CDM,300,RC,83010,CPT,,,,,,,,265,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Haptoglobin; Quantitative,PX83010,CDM,300,RC,83010,CPT,,,,,,,,265,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Haptoglobin; Quantitative,PX83010,CDM,300,RC,83010,CPT,,,,,,,,265,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Haptoglobin; Quantitative,PX83010,CDM,300,RC,83010,CPT,,,,,,,,265,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Haptoglobin; Quantitative,PX83010,CDM,300,RC,83010,CPT,,,,,,,,265,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Haptoglobin; Quantitative,PX83010,CDM,300,RC,83010,CPT,,,,,,,,265,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HARMONIC 110 SHEARS 36CM SHAFT,27200000,CDM,272,RC,,,,12043-MAIN,LOCAL,,,,,2392,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HARMONIC 110 SHEARS 36CM SHAFT,27200000,CDM,272,RC,,,,12043-MAIN,LOCAL,,,,,2392,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HARMONIC 110 SHEARS 36CM SHAFT,27200000,CDM,272,RC,,,,12043-MAIN,LOCAL,,,,,2392,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HARMONIC 110 SHEARS 36CM SHAFT,27200000,CDM,272,RC,,,,12043-MAIN,LOCAL,,,,,2392,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HARMONIC 110 SHEARS 36CM SHAFT,27200000,CDM,272,RC,,,,12043-MAIN,LOCAL,,,,,2392,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HARMONIC 110 SHEARS 36CM SHAFT,27200000,CDM,272,RC,,,,12043-MAIN,LOCAL,,,,,2392,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HARMONIC 1100 SHEARS 20CM SHAFT HAR1120,27200000,CDM,272,RC,,,,12924-MAIN,LOCAL,,,,,1244,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HARMONIC 1100 SHEARS 20CM SHAFT HAR1120,27200000,CDM,272,RC,,,,12924-MAIN,LOCAL,,,,,1244,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HARMONIC 1100 SHEARS 20CM SHAFT HAR1120,27200000,CDM,272,RC,,,,12924-MAIN,LOCAL,,,,,1244,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HARMONIC 1100 SHEARS 20CM SHAFT HAR1120,27200000,CDM,272,RC,,,,12924-MAIN,LOCAL,,,,,1244,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HARMONIC 1100 SHEARS 20CM SHAFT HAR1120,27200000,CDM,272,RC,,,,12924-MAIN,LOCAL,,,,,1244,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HARMONIC 1100 SHEARS 20CM SHAFT HAR1120,27200000,CDM,272,RC,,,,12924-MAIN,LOCAL,,,,,1244,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heart/Lung Resuscitation (Cpr),PX92950F,CDM,480,RC,92950,CPT,,,,,,,,1366,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heart/Lung Resuscitation (Cpr),PX92950F,CDM,480,RC,92950,CPT,,,,,,,,1366,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heart/Lung Resuscitation (Cpr),PX92950F,CDM,480,RC,92950,CPT,,,,,,,,1366,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heart/Lung Resuscitation (Cpr),PX92950F,CDM,480,RC,92950,CPT,,,,,,,,1366,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heart/Lung Resuscitation (Cpr),PX92950F,CDM,480,RC,92950,CPT,,,,,,,,1366,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heart/Lung Resuscitation (Cpr),PX92950F,CDM,480,RC,92950,CPT,,,,,,,,1366,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heart/Lung Resuscitation (Cpr),PX92950P,CDM,983,RC,92950,CPT,,,,,,,,1023,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heart/Lung Resuscitation (Cpr),PX92950P,CDM,983,RC,92950,CPT,,,,,,,,1023,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heart/Lung Resuscitation (Cpr),PX92950P,CDM,983,RC,92950,CPT,,,,,,,,1023,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heart/Lung Resuscitation (Cpr),PX92950P,CDM,983,RC,92950,CPT,,,,,,,,1023,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heart/Lung Resuscitation (Cpr),PX92950P,CDM,983,RC,92950,CPT,,,,,,,,1023,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heart/Lung Resuscitation (Cpr),PX92950P,CDM,983,RC,92950,CPT,,,,,,,,1023,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Helicobacter Pylori Ab,PX86677,CDM,300,RC,86677,CPT,,,,,,,,224,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Helicobacter Pylori Ab,PX86677,CDM,300,RC,86677,CPT,,,,,,,,224,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Helicobacter Pylori Ab,PX86677,CDM,300,RC,86677,CPT,,,,,,,,224,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Helicobacter Pylori Ab,PX86677,CDM,300,RC,86677,CPT,,,,,,,,224,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Helicobacter Pylori Ab,PX86677,CDM,300,RC,86677,CPT,,,,,,,,224,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Helicobacter Pylori Ab,PX86677,CDM,300,RC,86677,CPT,,,,,,,,224,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hematocrit,PX85014,CDM,300,RC,85014,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hematocrit,PX85014,CDM,300,RC,85014,CPT,,,,,,,,58,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hematocrit,PX85014,CDM,300,RC,85014,CPT,,,,,,,,58,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hematocrit,PX85014,CDM,300,RC,85014,CPT,,,,,,,,58,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hematocrit,PX85014,CDM,300,RC,85014,CPT,,,,,,,,58,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hematocrit,PX85014,CDM,300,RC,85014,CPT,,,,,,,,58,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12173-MAIN,LOCAL,,,,,400,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12173-MAIN,LOCAL,,,,,400,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12173-MAIN,LOCAL,,,,,400,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12173-MAIN,LOCAL,,,,,400,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12173-MAIN,LOCAL,,,,,400,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12173-MAIN,LOCAL,,,,,400,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12130-MAIN,LOCAL,,,,,561,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12130-MAIN,LOCAL,,,,,561,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12130-MAIN,LOCAL,,,,,561,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12130-MAIN,LOCAL,,,,,561,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12130-MAIN,LOCAL,,,,,561,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12130-MAIN,LOCAL,,,,,561,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12173-SURG,LOCAL,,,,,772,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12173-SURG,LOCAL,,,,,772,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12173-SURG,LOCAL,,,,,772,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12173-SURG,LOCAL,,,,,772,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12173-SURG,LOCAL,,,,,772,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12173-SURG,LOCAL,,,,,772,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hemoglobin,PX85018,CDM,300,RC,85018,CPT,,,,,,,,68,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hemoglobin,PX85018,CDM,300,RC,85018,CPT,,,,,,,,68,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hemoglobin,PX85018,CDM,300,RC,85018,CPT,,,,,,,,68,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hemoglobin,PX85018,CDM,300,RC,85018,CPT,,,,,,,,68,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hemoglobin,PX85018,CDM,300,RC,85018,CPT,,,,,,,,68,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hemoglobin,PX85018,CDM,300,RC,85018,CPT,,,,,,,,68,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hemorrhoidectomy,Int/Ext,Complx",PX46260F,CDM,750,RC,46260,CPT,,,,,,,,1350,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1190.7,6141.46
"Hemorrhoidectomy,Int/Ext,Complx",PX46260F,CDM,750,RC,46260,CPT,,,,,,,,1350,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1190.7,6141.46
"Hemorrhoidectomy,Int/Ext,Complx",PX46260F,CDM,750,RC,46260,CPT,,,,,,,,1350,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1190.7,6141.46
"Hemorrhoidectomy,Int/Ext,Complx",PX46260F,CDM,750,RC,46260,CPT,,,,,,,,1350,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1190.7,6141.46
"Hemorrhoidectomy,Int/Ext,Complx",PX46260F,CDM,750,RC,46260,CPT,,,,,,,,1350,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1190.7,6141.46
"Hemorrhoidectomy,Int/Ext,Complx",PX46260F,CDM,750,RC,46260,CPT,,,,,,,,1350,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1190.7,6141.46
"Hemorrhoidectomy,Int/Ext,Simple",PX46255F,CDM,510,RC,46255,CPT,,,,,,,,1627,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hemorrhoidectomy,Int/Ext,Simple",PX46255F,CDM,510,RC,46255,CPT,,,,,,,,1627,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hemorrhoidectomy,Int/Ext,Simple",PX46255F,CDM,510,RC,46255,CPT,,,,,,,,1627,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hemorrhoidectomy,Int/Ext,Simple",PX46255F,CDM,510,RC,46255,CPT,,,,,,,,1627,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hemorrhoidectomy,Int/Ext,Simple",PX46255F,CDM,510,RC,46255,CPT,,,,,,,,1627,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hemorrhoidectomy,Int/Ext,Simple",PX46255F,CDM,510,RC,46255,CPT,,,,,,,,1627,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hemorrhoidectomy,Int/Ext,Simple",PX46255P,CDM,983,RC,46255,CPT,,,,,,,,2393,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hemorrhoidectomy,Int/Ext,Simple",PX46255P,CDM,983,RC,46255,CPT,,,,,,,,2393,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hemorrhoidectomy,Int/Ext,Simple",PX46255P,CDM,983,RC,46255,CPT,,,,,,,,2393,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hemorrhoidectomy,Int/Ext,Simple",PX46255P,CDM,983,RC,46255,CPT,,,,,,,,2393,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hemorrhoidectomy,Int/Ext,Simple",PX46255P,CDM,983,RC,46255,CPT,,,,,,,,2393,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hemorrhoidectomy,Int/Ext,Simple",PX46255P,CDM,983,RC,46255,CPT,,,,,,,,2393,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272002,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272002,NDC,1,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272002,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272002,NDC,1,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272002,NDC,1,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272002,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272031,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272031,NDC,1,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272031,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272031,NDC,1,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272031,NDC,1,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272031,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,25021040010,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,25021040010,NDC,1,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,25021040010,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,25021040010,NDC,1,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,25021040010,NDC,1,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,25021040010,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323054011,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323054011,NDC,1,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323054011,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323054011,NDC,1,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323054011,NDC,1,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323054011,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095300,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095300,NDC,0.5,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095300,NDC,0.5,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095300,NDC,0.5,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095300,NDC,0.5,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095300,NDC,0.5,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095310,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095310,NDC,1,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095310,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095310,NDC,1,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095310,NDC,1,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095310,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,71288042095,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,71288042095,NDC,0.5,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,71288042095,NDC,0.5,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,71288042095,NDC,0.5,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,71288042095,NDC,0.5,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,71288042095,NDC,0.5,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306424,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306424,NDC,1,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306424,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306424,NDC,1,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306424,NDC,1,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306424,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253033335,NDC,5,ML,40.44,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253033335,NDC,5,ML,40.44,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253033335,NDC,5,ML,40.44,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253033335,NDC,5,ML,40.44,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253033335,NDC,5,ML,40.44,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253033335,NDC,5,ML,40.44,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306413,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306413,NDC,1,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306413,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306413,NDC,1,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306413,NDC,1,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306413,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306521,NDC,3,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306521,NDC,3,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306521,NDC,3,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306521,NDC,3,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306521,NDC,3,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306521,NDC,3,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253022233,NDC,3,ML,38.13,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253022233,NDC,3,ML,38.13,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253022233,NDC,3,ML,38.13,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253022233,NDC,3,ML,38.13,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253022233,NDC,3,ML,38.13,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253022233,NDC,3,ML,38.13,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin lock flush 10 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306510,NDC,5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin lock flush 10 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306510,NDC,5,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin lock flush 10 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306510,NDC,5,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin lock flush 10 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306510,NDC,5,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin lock flush 10 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306510,NDC,5,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin lock flush 10 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306510,NDC,5,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,264957710,NDC,500,ML,80.61,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,264957710,NDC,500,ML,80.61,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,264957710,NDC,500,ML,80.61,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,264957710,NDC,500,ML,80.61,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,264957710,NDC,500,ML,80.61,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,264957710,NDC,500,ML,80.61,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052201,NDC,500,ML,80.61,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052201,NDC,500,ML,80.61,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052201,NDC,500,ML,80.61,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052201,NDC,500,ML,80.61,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052201,NDC,500,ML,80.61,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052201,NDC,500,ML,80.61,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052277,NDC,500,ML,80.61,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052277,NDC,500,ML,80.61,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052277,NDC,500,ML,80.61,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052277,NDC,500,ML,80.61,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052277,NDC,500,ML,80.61,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052277,NDC,500,ML,80.61,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011801,NDC,0.5,ML,52.63,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011801,NDC,0.5,ML,52.63,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011801,NDC,0.5,ML,52.63,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011801,NDC,0.5,ML,52.63,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011801,NDC,0.5,ML,52.63,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011801,NDC,0.5,ML,52.63,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011805,NDC,0.5,ML,52.63,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011805,NDC,0.5,ML,52.63,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011805,NDC,0.5,ML,52.63,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011805,NDC,0.5,ML,52.63,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011805,NDC,0.5,ML,52.63,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011805,NDC,0.5,ML,52.63,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heparin Xa,PX85520,CDM,300,RC,85520,CPT,,,,,,,,128,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heparin Xa,PX85520,CDM,300,RC,85520,CPT,,,,,,,,128,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heparin Xa,PX85520,CDM,300,RC,85520,CPT,,,,,,,,128,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heparin Xa,PX85520,CDM,300,RC,85520,CPT,,,,,,,,128,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heparin Xa,PX85520,CDM,300,RC,85520,CPT,,,,,,,,128,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heparin Xa,PX85520,CDM,300,RC,85520,CPT,,,,,,,,128,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatic Function Panel,PX80076,CDM,300,RC,80076,CPT,,,,,,,,171,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatic Function Panel,PX80076,CDM,300,RC,80076,CPT,,,,,,,,171,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatic Function Panel,PX80076,CDM,300,RC,80076,CPT,,,,,,,,171,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatic Function Panel,PX80076,CDM,300,RC,80076,CPT,,,,,,,,171,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatic Function Panel,PX80076,CDM,300,RC,80076,CPT,,,,,,,,171,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatic Function Panel,PX80076,CDM,300,RC,80076,CPT,,,,,,,,171,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hepatitis a Antibody, Tot - Ref",PX8670890,CDM,300,RC,86708,CPT,90,,,,,,,201,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hepatitis a Antibody, Tot - Ref",PX8670890,CDM,300,RC,86708,CPT,90,,,,,,,201,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hepatitis a Antibody, Tot - Ref",PX8670890,CDM,300,RC,86708,CPT,90,,,,,,,201,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hepatitis a Antibody, Tot - Ref",PX8670890,CDM,300,RC,86708,CPT,90,,,,,,,201,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hepatitis a Antibody, Tot - Ref",PX8670890,CDM,300,RC,86708,CPT,90,,,,,,,201,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hepatitis a Antibody, Tot - Ref",PX8670890,CDM,300,RC,86708,CPT,90,,,,,,,201,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatitis a Igm Antibody,PX86709,CDM,300,RC,86709,CPT,,,,,,,,220,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatitis a Igm Antibody,PX86709,CDM,300,RC,86709,CPT,,,,,,,,220,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatitis a Igm Antibody,PX86709,CDM,300,RC,86709,CPT,,,,,,,,220,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatitis a Igm Antibody,PX86709,CDM,300,RC,86709,CPT,,,,,,,,220,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatitis a Igm Antibody,PX86709,CDM,300,RC,86709,CPT,,,,,,,,220,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatitis a Igm Antibody,PX86709,CDM,300,RC,86709,CPT,,,,,,,,220,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hepatitis A vaccine 1440 EL U/ML Suspension 1 mL Syringe,90632,CDM,636,RC,90632,CPT,,,,58160082652,NDC,1,ML,375.78,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hepatitis A vaccine 1440 EL U/ML Suspension 1 mL Syringe,90632,CDM,636,RC,90632,CPT,,,,58160082652,NDC,1,ML,375.78,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hepatitis A vaccine 1440 EL U/ML Suspension 1 mL Syringe,90632,CDM,636,RC,90632,CPT,,,,58160082652,NDC,1,ML,375.78,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hepatitis A vaccine 1440 EL U/ML Suspension 1 mL Syringe,90632,CDM,636,RC,90632,CPT,,,,58160082652,NDC,1,ML,375.78,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hepatitis A vaccine 1440 EL U/ML Suspension 1 mL Syringe,90632,CDM,636,RC,90632,CPT,,,,58160082652,NDC,1,ML,375.78,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hepatitis A vaccine 1440 EL U/ML Suspension 1 mL Syringe,90632,CDM,636,RC,90632,CPT,,,,58160082652,NDC,1,ML,375.78,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081543,NDC,1,ML,479.89,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081543,NDC,1,ML,479.89,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081543,NDC,1,ML,479.89,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081543,NDC,1,ML,479.89,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081543,NDC,1,ML,479.89,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081543,NDC,1,ML,479.89,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081552,NDC,1,ML,479.89,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081552,NDC,1,ML,479.89,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081552,NDC,1,ML,479.89,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081552,NDC,1,ML,479.89,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081552,NDC,1,ML,479.89,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081552,NDC,1,ML,479.89,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hepatitis B Core Antibody, Total",PX86704,CDM,300,RC,86704,CPT,,,,,,,,21,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hepatitis B Core Antibody, Total",PX86704,CDM,300,RC,86704,CPT,,,,,,,,21,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hepatitis B Core Antibody, Total",PX86704,CDM,300,RC,86704,CPT,,,,,,,,21,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hepatitis B Core Antibody, Total",PX86704,CDM,300,RC,86704,CPT,,,,,,,,21,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hepatitis B Core Antibody, Total",PX86704,CDM,300,RC,86704,CPT,,,,,,,,21,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hepatitis B Core Antibody, Total",PX86704,CDM,300,RC,86704,CPT,,,,,,,,21,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hepatitis B immune globulin 312 UNIT/ML Solution 5 mL Vial,90371,CDM,636,RC,90371,CPT,,,,59730420301,NDC,5,ML,2851.63,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hepatitis B immune globulin 312 UNIT/ML Solution 5 mL Vial,90371,CDM,636,RC,90371,CPT,,,,59730420301,NDC,5,ML,2851.63,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hepatitis B immune globulin 312 UNIT/ML Solution 5 mL Vial,90371,CDM,636,RC,90371,CPT,,,,59730420301,NDC,5,ML,2851.63,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hepatitis B immune globulin 312 UNIT/ML Solution 5 mL Vial,90371,CDM,636,RC,90371,CPT,,,,59730420301,NDC,5,ML,2851.63,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hepatitis B immune globulin 312 UNIT/ML Solution 5 mL Vial,90371,CDM,636,RC,90371,CPT,,,,59730420301,NDC,5,ML,2851.63,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hepatitis B immune globulin 312 UNIT/ML Solution 5 mL Vial,90371,CDM,636,RC,90371,CPT,,,,59730420301,NDC,5,ML,2851.63,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hepatitis b recomb vaccine 10 MCG/0.5ML suspension prefilled syringe 0.5 mL Syringe,90743,CDM,636,RC,90743,CPT,,,,58160082052,NDC,0.5,ML,137.47,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hepatitis b recomb vaccine 10 MCG/0.5ML suspension prefilled syringe 0.5 mL Syringe,90743,CDM,636,RC,90743,CPT,,,,58160082052,NDC,0.5,ML,137.47,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hepatitis b recomb vaccine 10 MCG/0.5ML suspension prefilled syringe 0.5 mL Syringe,90743,CDM,636,RC,90743,CPT,,,,58160082052,NDC,0.5,ML,137.47,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hepatitis b recomb vaccine 10 MCG/0.5ML suspension prefilled syringe 0.5 mL Syringe,90743,CDM,636,RC,90743,CPT,,,,58160082052,NDC,0.5,ML,137.47,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hepatitis b recomb vaccine 10 MCG/0.5ML suspension prefilled syringe 0.5 mL Syringe,90743,CDM,636,RC,90743,CPT,,,,58160082052,NDC,0.5,ML,137.47,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hepatitis b recomb vaccine 10 MCG/0.5ML suspension prefilled syringe 0.5 mL Syringe,90743,CDM,636,RC,90743,CPT,,,,58160082052,NDC,0.5,ML,137.47,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082143,NDC,1,ML,348.85,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082143,NDC,1,ML,348.85,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082143,NDC,1,ML,348.85,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082143,NDC,1,ML,348.85,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082143,NDC,1,ML,348.85,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082143,NDC,1,ML,348.85,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082152,NDC,1,ML,375.43,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082152,NDC,1,ML,375.43,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082152,NDC,1,ML,375.43,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082152,NDC,1,ML,375.43,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082152,NDC,1,ML,375.43,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082152,NDC,1,ML,375.43,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatitis B Surface Antibody,PX86706,CDM,300,RC,86706,CPT,,,,,,,,201,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatitis B Surface Antibody,PX86706,CDM,300,RC,86706,CPT,,,,,,,,201,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatitis B Surface Antibody,PX86706,CDM,300,RC,86706,CPT,,,,,,,,201,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatitis B Surface Antibody,PX86706,CDM,300,RC,86706,CPT,,,,,,,,201,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatitis B Surface Antibody,PX86706,CDM,300,RC,86706,CPT,,,,,,,,201,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatitis B Surface Antibody,PX86706,CDM,300,RC,86706,CPT,,,,,,,,201,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatitis B Surface Antigen,PX87340,CDM,300,RC,87340,CPT,,,,,,,,98,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatitis B Surface Antigen,PX87340,CDM,300,RC,87340,CPT,,,,,,,,98,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatitis B Surface Antigen,PX87340,CDM,300,RC,87340,CPT,,,,,,,,98,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatitis B Surface Antigen,PX87340,CDM,300,RC,87340,CPT,,,,,,,,98,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatitis B Surface Antigen,PX87340,CDM,300,RC,87340,CPT,,,,,,,,98,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatitis B Surface Antigen,PX87340,CDM,300,RC,87340,CPT,,,,,,,,98,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatitis Be Antibody - Ref,PX8670790,CDM,300,RC,86707,CPT,90,,,,,,,192,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatitis Be Antibody - Ref,PX8670790,CDM,300,RC,86707,CPT,90,,,,,,,192,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatitis Be Antibody - Ref,PX8670790,CDM,300,RC,86707,CPT,90,,,,,,,192,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatitis Be Antibody - Ref,PX8670790,CDM,300,RC,86707,CPT,90,,,,,,,192,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatitis Be Antibody - Ref,PX8670790,CDM,300,RC,86707,CPT,90,,,,,,,192,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatitis Be Antibody - Ref,PX8670790,CDM,300,RC,86707,CPT,90,,,,,,,192,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatitis C Antibody,PX86803,CDM,300,RC,86803,CPT,,,,,,,,144,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatitis C Antibody,PX86803,CDM,300,RC,86803,CPT,,,,,,,,144,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatitis C Antibody,PX86803,CDM,300,RC,86803,CPT,,,,,,,,144,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatitis C Antibody,PX86803,CDM,300,RC,86803,CPT,,,,,,,,144,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatitis C Antibody,PX86803,CDM,300,RC,86803,CPT,,,,,,,,144,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatitis C Antibody,PX86803,CDM,300,RC,86803,CPT,,,,,,,,144,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatitis C Rna Quant,PX87522,CDM,300,RC,87522,CPT,,,,,,,,185,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatitis C Rna Quant,PX87522,CDM,300,RC,87522,CPT,,,,,,,,185,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatitis C Rna Quant,PX87522,CDM,300,RC,87522,CPT,,,,,,,,185,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatitis C Rna Quant,PX87522,CDM,300,RC,87522,CPT,,,,,,,,185,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatitis C Rna Quant,PX87522,CDM,300,RC,87522,CPT,,,,,,,,185,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatitis C Rna Quant,PX87522,CDM,300,RC,87522,CPT,,,,,,,,185,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatobil Syst Image W/Drug,PX7822701,CDM,341,RC,78227,CPT,TC,,,,,,,1674,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatobil Syst Image W/Drug,PX7822701,CDM,341,RC,78227,CPT,TC,,,,,,,1674,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatobil Syst Image W/Drug,PX7822701,CDM,341,RC,78227,CPT,TC,,,,,,,1674,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatobil Syst Image W/Drug,PX7822701,CDM,341,RC,78227,CPT,TC,,,,,,,1674,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatobil Syst Image W/Drug,PX7822701,CDM,341,RC,78227,CPT,TC,,,,,,,1674,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatobil Syst Image W/Drug,PX7822701,CDM,341,RC,78227,CPT,TC,,,,,,,1674,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatobiliary System Imaging,PX7822601,CDM,341,RC,78226,CPT,TC,,,,,,,2776,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatobiliary System Imaging,PX7822601,CDM,341,RC,78226,CPT,TC,,,,,,,2776,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatobiliary System Imaging,PX7822601,CDM,341,RC,78226,CPT,TC,,,,,,,2776,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatobiliary System Imaging,PX7822601,CDM,341,RC,78226,CPT,TC,,,,,,,2776,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatobiliary System Imaging,PX7822601,CDM,341,RC,78226,CPT,TC,,,,,,,2776,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatobiliary System Imaging,PX7822601,CDM,341,RC,78226,CPT,TC,,,,,,,2776,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERCULES 3 STAGE BALLOON ESOPHAGEAL 12-13.5-15::36-40.5-45MM,27200000,CDM,272,RC,C1726,HCPCS,,11329-MAIN,LOCAL,,,,,289.85,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERCULES 3 STAGE BALLOON ESOPHAGEAL 12-13.5-15::36-40.5-45MM,27200000,CDM,272,RC,C1726,HCPCS,,11329-MAIN,LOCAL,,,,,289.85,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERCULES 3 STAGE BALLOON ESOPHAGEAL 12-13.5-15::36-40.5-45MM,27200000,CDM,272,RC,C1726,HCPCS,,11329-MAIN,LOCAL,,,,,289.85,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERCULES 3 STAGE BALLOON ESOPHAGEAL 12-13.5-15::36-40.5-45MM,27200000,CDM,272,RC,C1726,HCPCS,,11329-MAIN,LOCAL,,,,,289.85,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERCULES 3 STAGE BALLOON ESOPHAGEAL 12-13.5-15::36-40.5-45MM,27200000,CDM,272,RC,C1726,HCPCS,,11329-MAIN,LOCAL,,,,,289.85,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERCULES 3 STAGE BALLOON ESOPHAGEAL 12-13.5-15::36-40.5-45MM,27200000,CDM,272,RC,C1726,HCPCS,,11329-MAIN,LOCAL,,,,,289.85,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERCULES 3 STAGE BALLOON ESOPHAGEAL 15-16.5-18:45-49.5-54MM,27200000,CDM,272,RC,C1726,HCPCS,,11328-MAIN,LOCAL,,,,,289.85,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERCULES 3 STAGE BALLOON ESOPHAGEAL 15-16.5-18:45-49.5-54MM,27200000,CDM,272,RC,C1726,HCPCS,,11328-MAIN,LOCAL,,,,,289.85,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERCULES 3 STAGE BALLOON ESOPHAGEAL 15-16.5-18:45-49.5-54MM,27200000,CDM,272,RC,C1726,HCPCS,,11328-MAIN,LOCAL,,,,,289.85,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERCULES 3 STAGE BALLOON ESOPHAGEAL 15-16.5-18:45-49.5-54MM,27200000,CDM,272,RC,C1726,HCPCS,,11328-MAIN,LOCAL,,,,,289.85,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERCULES 3 STAGE BALLOON ESOPHAGEAL 15-16.5-18:45-49.5-54MM,27200000,CDM,272,RC,C1726,HCPCS,,11328-MAIN,LOCAL,,,,,289.85,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERCULES 3 STAGE BALLOON ESOPHAGEAL 15-16.5-18:45-49.5-54MM,27200000,CDM,272,RC,C1726,HCPCS,,11328-MAIN,LOCAL,,,,,289.85,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERCULES 3 STAGE BALLOON ESOPHAGEAL 18-19-20::54-57-60MM,27200000,CDM,272,RC,C1726,HCPCS,,11330-MAIN,LOCAL,,,,,289.85,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERCULES 3 STAGE BALLOON ESOPHAGEAL 18-19-20::54-57-60MM,27200000,CDM,272,RC,C1726,HCPCS,,11330-MAIN,LOCAL,,,,,289.85,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERCULES 3 STAGE BALLOON ESOPHAGEAL 18-19-20::54-57-60MM,27200000,CDM,272,RC,C1726,HCPCS,,11330-MAIN,LOCAL,,,,,289.85,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERCULES 3 STAGE BALLOON ESOPHAGEAL 18-19-20::54-57-60MM,27200000,CDM,272,RC,C1726,HCPCS,,11330-MAIN,LOCAL,,,,,289.85,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERCULES 3 STAGE BALLOON ESOPHAGEAL 18-19-20::54-57-60MM,27200000,CDM,272,RC,C1726,HCPCS,,11330-MAIN,LOCAL,,,,,289.85,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERCULES 3 STAGE BALLOON ESOPHAGEAL 18-19-20::54-57-60MM,27200000,CDM,272,RC,C1726,HCPCS,,11330-MAIN,LOCAL,,,,,289.85,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERNIA BELT MENS TRUSS LARGE,120.526,CDM,274,RC,L8310,HCPCS,,12221-MAIN,LOCAL,,,,,60,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERNIA BELT MENS TRUSS LARGE,120.526,CDM,274,RC,L8310,HCPCS,,12221-MAIN,LOCAL,,,,,60,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERNIA BELT MENS TRUSS LARGE,120.526,CDM,274,RC,L8310,HCPCS,,12221-MAIN,LOCAL,,,,,60,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERNIA BELT MENS TRUSS LARGE,120.526,CDM,274,RC,L8310,HCPCS,,12221-MAIN,LOCAL,,,,,60,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERNIA BELT MENS TRUSS LARGE,120.526,CDM,274,RC,L8310,HCPCS,,12221-MAIN,LOCAL,,,,,60,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERNIA BELT MENS TRUSS LARGE,120.526,CDM,274,RC,L8310,HCPCS,,12221-MAIN,LOCAL,,,,,60,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERNIA BELT MENS TRUSS MEDIUM,120.526,CDM,274,RC,L8310,HCPCS,,12220-MAIN,LOCAL,,,,,60,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERNIA BELT MENS TRUSS MEDIUM,120.526,CDM,274,RC,L8310,HCPCS,,12220-MAIN,LOCAL,,,,,60,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERNIA BELT MENS TRUSS MEDIUM,120.526,CDM,274,RC,L8310,HCPCS,,12220-MAIN,LOCAL,,,,,60,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERNIA BELT MENS TRUSS MEDIUM,120.526,CDM,274,RC,L8310,HCPCS,,12220-MAIN,LOCAL,,,,,60,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERNIA BELT MENS TRUSS MEDIUM,120.526,CDM,274,RC,L8310,HCPCS,,12220-MAIN,LOCAL,,,,,60,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERNIA BELT MENS TRUSS MEDIUM,120.526,CDM,274,RC,L8310,HCPCS,,12220-MAIN,LOCAL,,,,,60,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERNIA BELT MENS TRUSS XLARGE,120.526,CDM,274,RC,L8310,HCPCS,,12222-MAIN,LOCAL,,,,,60,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERNIA BELT MENS TRUSS XLARGE,120.526,CDM,274,RC,L8310,HCPCS,,12222-MAIN,LOCAL,,,,,60,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERNIA BELT MENS TRUSS XLARGE,120.526,CDM,274,RC,L8310,HCPCS,,12222-MAIN,LOCAL,,,,,60,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERNIA BELT MENS TRUSS XLARGE,120.526,CDM,274,RC,L8310,HCPCS,,12222-MAIN,LOCAL,,,,,60,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERNIA BELT MENS TRUSS XLARGE,120.526,CDM,274,RC,L8310,HCPCS,,12222-MAIN,LOCAL,,,,,60,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERNIA BELT MENS TRUSS XLARGE,120.526,CDM,274,RC,L8310,HCPCS,,12222-MAIN,LOCAL,,,,,60,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"HERNIA MESH 3D MAX MID ANATOMICAL MESH LEFT SIZE L 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,11976-MAIN,LOCAL,,,,,755,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"HERNIA MESH 3D MAX MID ANATOMICAL MESH LEFT SIZE L 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,11976-MAIN,LOCAL,,,,,755,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"HERNIA MESH 3D MAX MID ANATOMICAL MESH LEFT SIZE L 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,11976-MAIN,LOCAL,,,,,755,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"HERNIA MESH 3D MAX MID ANATOMICAL MESH LEFT SIZE L 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,11976-MAIN,LOCAL,,,,,755,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"HERNIA MESH 3D MAX MID ANATOMICAL MESH LEFT SIZE L 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,11976-MAIN,LOCAL,,,,,755,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"HERNIA MESH 3D MAX MID ANATOMICAL MESH LEFT SIZE L 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,11976-MAIN,LOCAL,,,,,755,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"HERNIA MESH 3D MAX MID ANATOMICAL MESH RIGHT SIZE L 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,11977-MAIN,LOCAL,,,,,755,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"HERNIA MESH 3D MAX MID ANATOMICAL MESH RIGHT SIZE L 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,11977-MAIN,LOCAL,,,,,755,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"HERNIA MESH 3D MAX MID ANATOMICAL MESH RIGHT SIZE L 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,11977-MAIN,LOCAL,,,,,755,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"HERNIA MESH 3D MAX MID ANATOMICAL MESH RIGHT SIZE L 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,11977-MAIN,LOCAL,,,,,755,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"HERNIA MESH 3D MAX MID ANATOMICAL MESH RIGHT SIZE L 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,11977-MAIN,LOCAL,,,,,755,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"HERNIA MESH 3D MAX MID ANATOMICAL MESH RIGHT SIZE L 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,11977-MAIN,LOCAL,,,,,755,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"HERNIA MESH 3D MAX MID ANATOMICAL MESH RIGHT SIZE XL 5"" X 7""",C1781,CDM,278,RC,C1781,HCPCS,,11979-MAIN,LOCAL,,,,,832,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"HERNIA MESH 3D MAX MID ANATOMICAL MESH RIGHT SIZE XL 5"" X 7""",C1781,CDM,278,RC,C1781,HCPCS,,11979-MAIN,LOCAL,,,,,832,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"HERNIA MESH 3D MAX MID ANATOMICAL MESH RIGHT SIZE XL 5"" X 7""",C1781,CDM,278,RC,C1781,HCPCS,,11979-MAIN,LOCAL,,,,,832,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"HERNIA MESH 3D MAX MID ANATOMICAL MESH RIGHT SIZE XL 5"" X 7""",C1781,CDM,278,RC,C1781,HCPCS,,11979-MAIN,LOCAL,,,,,832,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"HERNIA MESH 3D MAX MID ANATOMICAL MESH RIGHT SIZE XL 5"" X 7""",C1781,CDM,278,RC,C1781,HCPCS,,11979-MAIN,LOCAL,,,,,832,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"HERNIA MESH 3D MAX MID ANATOMICAL MESH RIGHT SIZE XL 5"" X 7""",C1781,CDM,278,RC,C1781,HCPCS,,11979-MAIN,LOCAL,,,,,832,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"HERNIA MESH 3DMAX MID MESH EXTRA-LARGE LEFT 5"" X 7""",C1781,CDM,278,RC,C1781,HCPCS,,11978-MAIN,LOCAL,,,,,832,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"HERNIA MESH 3DMAX MID MESH EXTRA-LARGE LEFT 5"" X 7""",C1781,CDM,278,RC,C1781,HCPCS,,11978-MAIN,LOCAL,,,,,832,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"HERNIA MESH 3DMAX MID MESH EXTRA-LARGE LEFT 5"" X 7""",C1781,CDM,278,RC,C1781,HCPCS,,11978-MAIN,LOCAL,,,,,832,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"HERNIA MESH 3DMAX MID MESH EXTRA-LARGE LEFT 5"" X 7""",C1781,CDM,278,RC,C1781,HCPCS,,11978-MAIN,LOCAL,,,,,832,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"HERNIA MESH 3DMAX MID MESH EXTRA-LARGE LEFT 5"" X 7""",C1781,CDM,278,RC,C1781,HCPCS,,11978-MAIN,LOCAL,,,,,832,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"HERNIA MESH 3DMAX MID MESH EXTRA-LARGE LEFT 5"" X 7""",C1781,CDM,278,RC,C1781,HCPCS,,11978-MAIN,LOCAL,,,,,832,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERNIA MESH LAP PROGRIP SELF FIXATING FLAT SHEET 10X15,C1781,CDM,278,RC,C1781,HCPCS,,12727-MAIN,LOCAL,,,,,611,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERNIA MESH LAP PROGRIP SELF FIXATING FLAT SHEET 10X15,C1781,CDM,278,RC,C1781,HCPCS,,12727-MAIN,LOCAL,,,,,611,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERNIA MESH LAP PROGRIP SELF FIXATING FLAT SHEET 10X15,C1781,CDM,278,RC,C1781,HCPCS,,12727-MAIN,LOCAL,,,,,611,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERNIA MESH LAP PROGRIP SELF FIXATING FLAT SHEET 10X15,C1781,CDM,278,RC,C1781,HCPCS,,12727-MAIN,LOCAL,,,,,611,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERNIA MESH LAP PROGRIP SELF FIXATING FLAT SHEET 10X15,C1781,CDM,278,RC,C1781,HCPCS,,12727-MAIN,LOCAL,,,,,611,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERNIA MESH LAP PROGRIP SELF FIXATING FLAT SHEET 10X15,C1781,CDM,278,RC,C1781,HCPCS,,12727-MAIN,LOCAL,,,,,611,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERNIA PATCH VENTRALEX LARGE,C1781,CDM,278,RC,C1781,HCPCS,,10201-MAIN,LOCAL,,,,,1325.08,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERNIA PATCH VENTRALEX LARGE,C1781,CDM,278,RC,C1781,HCPCS,,10201-MAIN,LOCAL,,,,,1325.08,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERNIA PATCH VENTRALEX LARGE,C1781,CDM,278,RC,C1781,HCPCS,,10201-MAIN,LOCAL,,,,,1325.08,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERNIA PATCH VENTRALEX LARGE,C1781,CDM,278,RC,C1781,HCPCS,,10201-MAIN,LOCAL,,,,,1325.08,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERNIA PATCH VENTRALEX LARGE,C1781,CDM,278,RC,C1781,HCPCS,,10201-MAIN,LOCAL,,,,,1325.08,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERNIA PATCH VENTRALEX LARGE,C1781,CDM,278,RC,C1781,HCPCS,,10201-MAIN,LOCAL,,,,,1325.08,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERNIA PATCH VENTRALEX MEDIUM,C1781,CDM,278,RC,C1781,HCPCS,,10202-MAIN,LOCAL,,,,,1309.75,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERNIA PATCH VENTRALEX MEDIUM,C1781,CDM,278,RC,C1781,HCPCS,,10202-MAIN,LOCAL,,,,,1309.75,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERNIA PATCH VENTRALEX MEDIUM,C1781,CDM,278,RC,C1781,HCPCS,,10202-MAIN,LOCAL,,,,,1309.75,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERNIA PATCH VENTRALEX MEDIUM,C1781,CDM,278,RC,C1781,HCPCS,,10202-MAIN,LOCAL,,,,,1309.75,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERNIA PATCH VENTRALEX MEDIUM,C1781,CDM,278,RC,C1781,HCPCS,,10202-MAIN,LOCAL,,,,,1309.75,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERNIA PATCH VENTRALEX MEDIUM,C1781,CDM,278,RC,C1781,HCPCS,,10202-MAIN,LOCAL,,,,,1309.75,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERNIA PATCH VENTRALEX SMALL,C1781,CDM,278,RC,C1781,HCPCS,,10203-MAIN,LOCAL,,,,,995.96,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERNIA PATCH VENTRALEX SMALL,C1781,CDM,278,RC,C1781,HCPCS,,10203-MAIN,LOCAL,,,,,995.96,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERNIA PATCH VENTRALEX SMALL,C1781,CDM,278,RC,C1781,HCPCS,,10203-MAIN,LOCAL,,,,,995.96,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERNIA PATCH VENTRALEX SMALL,C1781,CDM,278,RC,C1781,HCPCS,,10203-MAIN,LOCAL,,,,,995.96,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERNIA PATCH VENTRALEX SMALL,C1781,CDM,278,RC,C1781,HCPCS,,10203-MAIN,LOCAL,,,,,995.96,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERNIA PATCH VENTRALEX SMALL,C1781,CDM,278,RC,C1781,HCPCS,,10203-MAIN,LOCAL,,,,,995.96,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heterophile Antibodies,PX86308,CDM,300,RC,86308,CPT,,,,,,,,196,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heterophile Antibodies,PX86308,CDM,300,RC,86308,CPT,,,,,,,,196,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heterophile Antibodies,PX86308,CDM,300,RC,86308,CPT,,,,,,,,196,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heterophile Antibodies,PX86308,CDM,300,RC,86308,CPT,,,,,,,,196,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heterophile Antibodies,PX86308,CDM,300,RC,86308,CPT,,,,,,,,196,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heterophile Antibodies,PX86308,CDM,300,RC,86308,CPT,,,,,,,,196,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hfe Gene - Ref,PX8125690,CDM,300,RC,81256,CPT,90,,,,,,,526,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hfe Gene - Ref,PX8125690,CDM,300,RC,81256,CPT,90,,,,,,,526,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hfe Gene - Ref,PX8125690,CDM,300,RC,81256,CPT,90,,,,,,,526,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hfe Gene - Ref,PX8125690,CDM,300,RC,81256,CPT,90,,,,,,,526,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hfe Gene - Ref,PX8125690,CDM,300,RC,81256,CPT,90,,,,,,,526,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hfe Gene - Ref,PX8125690,CDM,300,RC,81256,CPT,90,,,,,,,526,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Hha Visit,PXG0156,CDM,571,RC,G0156,HCPCS,,,,,,,,38,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Hha Visit,PXG0156,CDM,571,RC,G0156,HCPCS,,,,,,,,38,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Hha Visit,PXG0156,CDM,571,RC,G0156,HCPCS,,,,,,,,38,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Hha Visit,PXG0156,CDM,571,RC,G0156,HCPCS,,,,,,,,38,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Hha Visit,PXG0156,CDM,571,RC,G0156,HCPCS,,,,,,,,38,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Hha Visit,PXG0156,CDM,571,RC,G0156,HCPCS,,,,,,,,38,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Ot Initial Visit,PXG0152,CDM,431,RC,G0152,HCPCS,GO,,,,,,,,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Ot Initial Visit,PXG0152,CDM,431,RC,G0152,HCPCS,GO,,,,,,,,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Ot Initial Visit,PXG0152,CDM,431,RC,G0152,HCPCS,GO,,,,,,,,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Ot Initial Visit,PXG0152,CDM,431,RC,G0152,HCPCS,GO,,,,,,,,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Ot Initial Visit,PXG0152,CDM,431,RC,G0152,HCPCS,GO,,,,,,,,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Ot Initial Visit,PXG0152,CDM,431,RC,G0152,HCPCS,GO,,,,,,,,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Ot Routine Visit,PXG0152.01,CDM,431,RC,G0152,HCPCS,GO,,,,,,,,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Ot Routine Visit,PXG0152.01,CDM,431,RC,G0152,HCPCS,GO,,,,,,,,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Ot Routine Visit,PXG0152.01,CDM,431,RC,G0152,HCPCS,GO,,,,,,,,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Ot Routine Visit,PXG0152.01,CDM,431,RC,G0152,HCPCS,GO,,,,,,,,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Ot Routine Visit,PXG0152.01,CDM,431,RC,G0152,HCPCS,GO,,,,,,,,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Ot Routine Visit,PXG0152.01,CDM,431,RC,G0152,HCPCS,GO,,,,,,,,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Pt Initial Visit,PXG0151,CDM,421,RC,G0151,HCPCS,GP,,,,,,,,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Pt Initial Visit,PXG0151,CDM,421,RC,G0151,HCPCS,GP,,,,,,,,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Pt Initial Visit,PXG0151,CDM,421,RC,G0151,HCPCS,GP,,,,,,,,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Pt Initial Visit,PXG0151,CDM,421,RC,G0151,HCPCS,GP,,,,,,,,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Pt Initial Visit,PXG0151,CDM,421,RC,G0151,HCPCS,GP,,,,,,,,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Pt Initial Visit,PXG0151,CDM,421,RC,G0151,HCPCS,GP,,,,,,,,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Pt Routine Visit,PXG0151.01,CDM,421,RC,G0151,HCPCS,GP,,,,,,,,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Pt Routine Visit,PXG0151.01,CDM,421,RC,G0151,HCPCS,GP,,,,,,,,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Pt Routine Visit,PXG0151.01,CDM,421,RC,G0151,HCPCS,GP,,,,,,,,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Pt Routine Visit,PXG0151.01,CDM,421,RC,G0151,HCPCS,GP,,,,,,,,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Pt Routine Visit,PXG0151.01,CDM,421,RC,G0151,HCPCS,GP,,,,,,,,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Pt Routine Visit,PXG0151.01,CDM,421,RC,G0151,HCPCS,GP,,,,,,,,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Pta Routine Visit,PXG0157,CDM,421,RC,G0157,HCPCS,,,,,,,,,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Pta Routine Visit,PXG0157,CDM,421,RC,G0157,HCPCS,,,,,,,,,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Pta Routine Visit,PXG0157,CDM,421,RC,G0157,HCPCS,,,,,,,,,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Pta Routine Visit,PXG0157,CDM,421,RC,G0157,HCPCS,,,,,,,,,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Pta Routine Visit,PXG0157,CDM,421,RC,G0157,HCPCS,,,,,,,,,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Pta Routine Visit,PXG0157,CDM,421,RC,G0157,HCPCS,,,,,,,,,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Rn Initial Visit,PXG0154,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Rn Initial Visit,PXG0154,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Rn Initial Visit,PXG0154,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Rn Initial Visit,PXG0154,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Rn Initial Visit,PXG0154,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Rn Initial Visit,PXG0154,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Rn Routine Visit,PXG0154.01,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Rn Routine Visit,PXG0154.01,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Rn Routine Visit,PXG0154.01,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Rn Routine Visit,PXG0154.01,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Rn Routine Visit,PXG0154.01,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Rn Routine Visit,PXG0154.01,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hiaa - Ref,PX8349790,CDM,300,RC,83497,CPT,90,,,,,,,84,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hiaa - Ref,PX8349790,CDM,300,RC,83497,CPT,90,,,,,,,84,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hiaa - Ref,PX8349790,CDM,300,RC,83497,CPT,90,,,,,,,84,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hiaa - Ref,PX8349790,CDM,300,RC,83497,CPT,90,,,,,,,84,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hiaa - Ref,PX8349790,CDM,300,RC,83497,CPT,90,,,,,,,84,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hiaa - Ref,PX8349790,CDM,300,RC,83497,CPT,90,,,,,,,84,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
High Sens Crp,PX86141,CDM,300,RC,86141,CPT,,,,,,,,97,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
High Sens Crp,PX86141,CDM,300,RC,86141,CPT,,,,,,,,97,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
High Sens Crp,PX86141,CDM,300,RC,86141,CPT,,,,,,,,97,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
High Sens Crp,PX86141,CDM,300,RC,86141,CPT,,,,,,,,97,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
High Sens Crp,PX86141,CDM,300,RC,86141,CPT,,,,,,,,97,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
High Sens Crp,PX86141,CDM,300,RC,86141,CPT,,,,,,,,97,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HIMAX PLUS 18X18X18,27200000,CDM,278,RC,C1713,HCPCS,,11660-MAIN,LOCAL,,,,,3085.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HIMAX PLUS 18X18X18,27200000,CDM,278,RC,C1713,HCPCS,,11660-MAIN,LOCAL,,,,,3085.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HIMAX PLUS 18X18X18,27200000,CDM,278,RC,C1713,HCPCS,,11660-MAIN,LOCAL,,,,,3085.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HIMAX PLUS 18X18X18,27200000,CDM,278,RC,C1713,HCPCS,,11660-MAIN,LOCAL,,,,,3085.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HIMAX PLUS 18X18X18,27200000,CDM,278,RC,C1713,HCPCS,,11660-MAIN,LOCAL,,,,,3085.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HIMAX PLUS 18X18X18,27200000,CDM,278,RC,C1713,HCPCS,,11660-MAIN,LOCAL,,,,,3085.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HIMAX PLUS 20X20X20,27200000,CDM,278,RC,C1713,HCPCS,,11661-MAIN,LOCAL,,,,,3085.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HIMAX PLUS 20X20X20,27200000,CDM,278,RC,C1713,HCPCS,,11661-MAIN,LOCAL,,,,,3085.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HIMAX PLUS 20X20X20,27200000,CDM,278,RC,C1713,HCPCS,,11661-MAIN,LOCAL,,,,,3085.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HIMAX PLUS 20X20X20,27200000,CDM,278,RC,C1713,HCPCS,,11661-MAIN,LOCAL,,,,,3085.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HIMAX PLUS 20X20X20,27200000,CDM,278,RC,C1713,HCPCS,,11661-MAIN,LOCAL,,,,,3085.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HIMAX PLUS 20X20X20,27200000,CDM,278,RC,C1713,HCPCS,,11661-MAIN,LOCAL,,,,,3085.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HIMAX STAPLE KIT 18X14X14,27200000,CDM,278,RC,C1713,HCPCS,,11851-MAIN,LOCAL,,,,,4536,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HIMAX STAPLE KIT 18X14X14,27200000,CDM,278,RC,C1713,HCPCS,,11851-MAIN,LOCAL,,,,,4536,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HIMAX STAPLE KIT 18X14X14,27200000,CDM,278,RC,C1713,HCPCS,,11851-MAIN,LOCAL,,,,,4536,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HIMAX STAPLE KIT 18X14X14,27200000,CDM,278,RC,C1713,HCPCS,,11851-MAIN,LOCAL,,,,,4536,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HIMAX STAPLE KIT 18X14X14,27200000,CDM,278,RC,C1713,HCPCS,,11851-MAIN,LOCAL,,,,,4536,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HIMAX STAPLE KIT 18X14X14,27200000,CDM,278,RC,C1713,HCPCS,,11851-MAIN,LOCAL,,,,,4536,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Histoplasma Antibody - Ref,PX8669890,CDM,300,RC,86698,CPT,90,,,,,,,71,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Histoplasma Antibody - Ref,PX8669890,CDM,300,RC,86698,CPT,90,,,,,,,71,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Histoplasma Antibody - Ref,PX8669890,CDM,300,RC,86698,CPT,90,,,,,,,71,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Histoplasma Antibody - Ref,PX8669890,CDM,300,RC,86698,CPT,90,,,,,,,71,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Histoplasma Antibody - Ref,PX8669890,CDM,300,RC,86698,CPT,90,,,,,,,71,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Histoplasma Antibody - Ref,PX8669890,CDM,300,RC,86698,CPT,90,,,,,,,71,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hiv-1 Antigens W/Hiv 1/2 Antib,PX87389,CDM,300,RC,87389,CPT,,,,,,,,194,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hiv-1 Antigens W/Hiv 1/2 Antib,PX87389,CDM,300,RC,87389,CPT,,,,,,,,194,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hiv-1 Antigens W/Hiv 1/2 Antib,PX87389,CDM,300,RC,87389,CPT,,,,,,,,194,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hiv-1 Antigens W/Hiv 1/2 Antib,PX87389,CDM,300,RC,87389,CPT,,,,,,,,194,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hiv-1 Antigens W/Hiv 1/2 Antib,PX87389,CDM,300,RC,87389,CPT,,,,,,,,194,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hiv-1 Antigens W/Hiv 1/2 Antib,PX87389,CDM,300,RC,87389,CPT,,,,,,,,194,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hiv-1, Quantification - Ref",PX8753690,CDM,300,RC,87536,CPT,90,,,,,,,220,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hiv-1, Quantification - Ref",PX8753690,CDM,300,RC,87536,CPT,90,,,,,,,220,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hiv-1, Quantification - Ref",PX8753690,CDM,300,RC,87536,CPT,90,,,,,,,220,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hiv-1, Quantification - Ref",PX8753690,CDM,300,RC,87536,CPT,90,,,,,,,220,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hiv-1, Quantification - Ref",PX8753690,CDM,300,RC,87536,CPT,90,,,,,,,220,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hiv-1, Quantification - Ref",PX8753690,CDM,300,RC,87536,CPT,90,,,,,,,220,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hla a, B or C, Single Ag - Ref",PX8681290,CDM,300,RC,86812,CPT,90,,,,,,,89,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hla a, B or C, Single Ag - Ref",PX8681290,CDM,300,RC,86812,CPT,90,,,,,,,89,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hla a, B or C, Single Ag - Ref",PX8681290,CDM,300,RC,86812,CPT,90,,,,,,,89,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hla a, B or C, Single Ag - Ref",PX8681290,CDM,300,RC,86812,CPT,90,,,,,,,89,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hla a, B or C, Single Ag - Ref",PX8681290,CDM,300,RC,86812,CPT,90,,,,,,,89,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hla a, B or C, Single Ag - Ref",PX8681290,CDM,300,RC,86812,CPT,90,,,,,,,89,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hla Class II Low Res, 1 Locus - Ref",PX8137690,CDM,310,RC,81376,CPT,90,,,,,,,279,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hla Class II Low Res, 1 Locus - Ref",PX8137690,CDM,310,RC,81376,CPT,90,,,,,,,279,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hla Class II Low Res, 1 Locus - Ref",PX8137690,CDM,310,RC,81376,CPT,90,,,,,,,279,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hla Class II Low Res, 1 Locus - Ref",PX8137690,CDM,310,RC,81376,CPT,90,,,,,,,279,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hla Class II Low Res, 1 Locus - Ref",PX8137690,CDM,310,RC,81376,CPT,90,,,,,,,279,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hla Class II Low Res, 1 Locus - Ref",PX8137690,CDM,310,RC,81376,CPT,90,,,,,,,279,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Homocysteine,PX83090,CDM,300,RC,83090,CPT,,,,,,,,44,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Homocysteine,PX83090,CDM,300,RC,83090,CPT,,,,,,,,44,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Homocysteine,PX83090,CDM,300,RC,83090,CPT,,,,,,,,44,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Homocysteine,PX83090,CDM,300,RC,83090,CPT,,,,,,,,44,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Homocysteine,PX83090,CDM,300,RC,83090,CPT,,,,,,,,44,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Homocysteine,PX83090,CDM,300,RC,83090,CPT,,,,,,,,44,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Homogenization, Tissue for Culture",PX87176,CDM,300,RC,87176,CPT,,,,,,,,50,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Homogenization, Tissue for Culture",PX87176,CDM,300,RC,87176,CPT,,,,,,,,50,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Homogenization, Tissue for Culture",PX87176,CDM,300,RC,87176,CPT,,,,,,,,50,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Homogenization, Tissue for Culture",PX87176,CDM,300,RC,87176,CPT,,,,,,,,50,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Homogenization, Tissue for Culture",PX87176,CDM,300,RC,87176,CPT,,,,,,,,50,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Homogenization, Tissue for Culture",PX87176,CDM,300,RC,87176,CPT,,,,,,,,50,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hosp Manage Cont Drug Admin,PX01996.01,CDM,964,RC,1996,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hosp Manage Cont Drug Admin,PX01996.01,CDM,964,RC,1996,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hospital Discharge Day>30 Min,PX99239P,CDM,982,RC,99239,CPT,,,,,,,,140,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hospital Discharge Day>30 Min,PX99239P,CDM,982,RC,99239,CPT,,,,,,,,140,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hospital Discharge Day>30 Min,PX99239P,CDM,982,RC,99239,CPT,,,,,,,,140,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hospital Discharge Day>30 Min,PX99239P,CDM,982,RC,99239,CPT,,,,,,,,140,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hospital Discharge Day>30 Min,PX99239P,CDM,982,RC,99239,CPT,,,,,,,,140,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hospital Discharge Day>30 Min,PX99239P,CDM,982,RC,99239,CPT,,,,,,,,140,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hospital Inpt or Obs Care, Admin/Disch Same Date Straightforward or Low Level Mdm >= 45 Minutes",PX99234,CDM,982,RC,99234,CPT,,,,,,,,464,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hospital Inpt or Obs Care, Admin/Disch Same Date Straightforward or Low Level Mdm >= 45 Minutes",PX99234,CDM,982,RC,99234,CPT,,,,,,,,464,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hospital Inpt or Obs Care, Admin/Disch Same Date Straightforward or Low Level Mdm >= 45 Minutes",PX99234,CDM,982,RC,99234,CPT,,,,,,,,464,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hospital Inpt or Obs Care, Admin/Disch Same Date Straightforward or Low Level Mdm >= 45 Minutes",PX99234,CDM,982,RC,99234,CPT,,,,,,,,464,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hospital Inpt or Obs Care, Admin/Disch Same Date Straightforward or Low Level Mdm >= 45 Minutes",PX99234,CDM,982,RC,99234,CPT,,,,,,,,464,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hospital Inpt or Obs Care, Admin/Disch Same Date Straightforward or Low Level Mdm >= 45 Minutes",PX99234,CDM,982,RC,99234,CPT,,,,,,,,464,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hospital Inpt or Obs Care, Admin/Disch Same Date, Moderate Level Mdm >= 70 Minutes",PX99235,CDM,982,RC,99235,CPT,,,,,,,,582,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hospital Inpt or Obs Care, Admin/Disch Same Date, Moderate Level Mdm >= 70 Minutes",PX99235,CDM,982,RC,99235,CPT,,,,,,,,582,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hospital Inpt or Obs Care, Admin/Disch Same Date, Moderate Level Mdm >= 70 Minutes",PX99235,CDM,982,RC,99235,CPT,,,,,,,,582,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hospital Inpt or Obs Care, Admin/Disch Same Date, Moderate Level Mdm >= 70 Minutes",PX99235,CDM,982,RC,99235,CPT,,,,,,,,582,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hospital Inpt or Obs Care, Admin/Disch Same Date, Moderate Level Mdm >= 70 Minutes",PX99235,CDM,982,RC,99235,CPT,,,,,,,,582,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hospital Inpt or Obs Care, Admin/Disch Same Date, Moderate Level Mdm >= 70 Minutes",PX99235,CDM,982,RC,99235,CPT,,,,,,,,582,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hospital Outpatient Clinic Visit Specimen Collection for Sars-Cov-2,PXC9803,CDM,300,RC,C9803,HCPCS,,,,,,,,33,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hospital Outpatient Clinic Visit Specimen Collection for Sars-Cov-2,PXC9803,CDM,300,RC,C9803,HCPCS,,,,,,,,33,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hospital Outpatient Clinic Visit Specimen Collection for Sars-Cov-2,PXC9803,CDM,300,RC,C9803,HCPCS,,,,,,,,33,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hospital Outpatient Clinic Visit Specimen Collection for Sars-Cov-2,PXC9803,CDM,300,RC,C9803,HCPCS,,,,,,,,33,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hospital Outpatient Clinic Visit Specimen Collection for Sars-Cov-2,PXC9803,CDM,300,RC,C9803,HCPCS,,,,,,,,33,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hospital Outpatient Clinic Visit Specimen Collection for Sars-Cov-2,PXC9803,CDM,300,RC,C9803,HCPCS,,,,,,,,33,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hsv Detect, Amplif Probe - Ref",PX8752990,CDM,300,RC,87529,CPT,90,,,,,,,150,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hsv Detect, Amplif Probe - Ref",PX8752990,CDM,300,RC,87529,CPT,90,,,,,,,150,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hsv Detect, Amplif Probe - Ref",PX8752990,CDM,300,RC,87529,CPT,90,,,,,,,150,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hsv Detect, Amplif Probe - Ref",PX8752990,CDM,300,RC,87529,CPT,90,,,,,,,150,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hsv Detect, Amplif Probe - Ref",PX8752990,CDM,300,RC,87529,CPT,90,,,,,,,150,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hsv Detect, Amplif Probe - Ref",PX8752990,CDM,300,RC,87529,CPT,90,,,,,,,150,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hsv Dna Amp Probe,PX87529,CDM,300,RC,87529,CPT,,,,,,,,145,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hsv Dna Amp Probe,PX87529,CDM,300,RC,87529,CPT,,,,,,,,145,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hsv Dna Amp Probe,PX87529,CDM,300,RC,87529,CPT,,,,,,,,145,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hsv Dna Amp Probe,PX87529,CDM,300,RC,87529,CPT,,,,,,,,145,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hsv Dna Amp Probe,PX87529,CDM,300,RC,87529,CPT,,,,,,,,145,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hsv Dna Amp Probe,PX87529,CDM,300,RC,87529,CPT,,,,,,,,145,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ht Muscle Image Spect, Mult",PX7845201,CDM,340,RC,78452,CPT,TC,,,,,,,2000,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ht Muscle Image Spect, Mult",PX7845201,CDM,340,RC,78452,CPT,TC,,,,,,,2000,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ht Muscle Image Spect, Mult",PX7845201,CDM,340,RC,78452,CPT,TC,,,,,,,2000,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ht Muscle Image Spect, Mult",PX7845201,CDM,340,RC,78452,CPT,TC,,,,,,,2000,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ht Muscle Image Spect, Mult",PX7845201,CDM,340,RC,78452,CPT,TC,,,,,,,2000,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ht Muscle Image Spect, Mult",PX7845201,CDM,340,RC,78452,CPT,TC,,,,,,,2000,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hyaluronate 48 MG/6ML solution prefilled syringe 6 mL Syringe,J7325.01,CDM,636,RC,J7325,HCPCS,,,,58468009003,NDC,6,ML,5274.4,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hyaluronate 48 MG/6ML solution prefilled syringe 6 mL Syringe,J7325.01,CDM,636,RC,J7325,HCPCS,,,,58468009003,NDC,6,ML,5274.4,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hyaluronate 48 MG/6ML solution prefilled syringe 6 mL Syringe,J7325.01,CDM,636,RC,J7325,HCPCS,,,,58468009003,NDC,6,ML,5274.4,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hyaluronate 48 MG/6ML solution prefilled syringe 6 mL Syringe,J7325.01,CDM,636,RC,J7325,HCPCS,,,,58468009003,NDC,6,ML,5274.4,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hyaluronate 48 MG/6ML solution prefilled syringe 6 mL Syringe,J7325.01,CDM,636,RC,J7325,HCPCS,,,,58468009003,NDC,6,ML,5274.4,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hyaluronate 48 MG/6ML solution prefilled syringe 6 mL Syringe,J7325.01,CDM,636,RC,J7325,HCPCS,,,,58468009003,NDC,6,ML,5274.4,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrALAZINE 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155000101,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrALAZINE 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155000101,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrALAZINE 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155000101,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrALAZINE 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155000101,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrALAZINE 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155000101,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrALAZINE 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155000101,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061400,NDC,1,ML,101.95,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061400,NDC,1,ML,101.95,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061400,NDC,1,ML,101.95,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061400,NDC,1,ML,101.95,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061400,NDC,1,ML,101.95,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061400,NDC,1,ML,101.95,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061401,NDC,1,ML,94.87,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061401,NDC,1,ML,94.87,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061401,NDC,1,ML,94.87,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061401,NDC,1,ML,94.87,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061401,NDC,1,ML,94.87,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061401,NDC,1,ML,94.87,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061416,NDC,0.5,ML,31.57,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061416,NDC,0.5,ML,31.57,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061416,NDC,0.5,ML,31.57,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061416,NDC,0.5,ML,31.57,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061416,NDC,0.5,ML,31.57,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061416,NDC,0.5,ML,31.57,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrALAZINE 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904644161,NDC,0.4,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrALAZINE 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904644161,NDC,0.4,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrALAZINE 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904644161,NDC,0.4,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrALAZINE 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904644161,NDC,0.4,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrALAZINE 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904644161,NDC,0.4,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrALAZINE 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904644161,NDC,0.4,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrALAZINE 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,64380073506,NDC,0.2,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrALAZINE 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,64380073506,NDC,0.2,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrALAZINE 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,64380073506,NDC,0.2,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrALAZINE 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,64380073506,NDC,0.2,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrALAZINE 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,64380073506,NDC,0.2,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrALAZINE 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,64380073506,NDC,0.2,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrALAZINE 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904644261,NDC,0.2,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrALAZINE 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904644261,NDC,0.2,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrALAZINE 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904644261,NDC,0.2,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrALAZINE 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904644261,NDC,0.2,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrALAZINE 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904644261,NDC,0.2,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrALAZINE 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904644261,NDC,0.2,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydroCHLOROthiazide 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547039710,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydroCHLOROthiazide 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547039710,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydroCHLOROthiazide 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547039710,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydroCHLOROthiazide 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547039710,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydroCHLOROthiazide 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547039710,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydroCHLOROthiazide 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547039710,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROcodone-acetaminophen 5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406012323,NDC,1,EA,4.27,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROcodone-acetaminophen 5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406012323,NDC,1,EA,4.27,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROcodone-acetaminophen 5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406012323,NDC,1,EA,4.27,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROcodone-acetaminophen 5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406012323,NDC,1,EA,4.27,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROcodone-acetaminophen 5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406012323,NDC,1,EA,4.27,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROcodone-acetaminophen 5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406012323,NDC,1,EA,4.27,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROcodone-acetaminophen 5-325 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406012301,NDC,1,EA,3.72,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROcodone-acetaminophen 5-325 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406012301,NDC,1,EA,3.72,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROcodone-acetaminophen 5-325 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406012301,NDC,1,EA,3.72,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROcodone-acetaminophen 5-325 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406012301,NDC,1,EA,3.72,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROcodone-acetaminophen 5-325 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406012301,NDC,1,EA,3.72,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROcodone-acetaminophen 5-325 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406012301,NDC,1,EA,3.72,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROcodone-acetaminophen 5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406012362,NDC,1,EA,4.27,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROcodone-acetaminophen 5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406012362,NDC,1,EA,4.27,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROcodone-acetaminophen 5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406012362,NDC,1,EA,4.27,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROcodone-acetaminophen 5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406012362,NDC,1,EA,4.27,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROcodone-acetaminophen 5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406012362,NDC,1,EA,4.27,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROcodone-acetaminophen 5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406012362,NDC,1,EA,4.27,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROcodone-acetaminophen 7.5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406012423,NDC,1,EA,4.76,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROcodone-acetaminophen 7.5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406012423,NDC,1,EA,4.76,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROcodone-acetaminophen 7.5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406012423,NDC,1,EA,4.76,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROcodone-acetaminophen 7.5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406012423,NDC,1,EA,4.76,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROcodone-acetaminophen 7.5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406012423,NDC,1,EA,4.76,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROcodone-acetaminophen 7.5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406012423,NDC,1,EA,4.76,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROcodone-acetaminophen 7.5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406012462,NDC,1,EA,4.76,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROcodone-acetaminophen 7.5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406012462,NDC,1,EA,4.76,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROcodone-acetaminophen 7.5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406012462,NDC,1,EA,4.76,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROcodone-acetaminophen 7.5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406012462,NDC,1,EA,4.76,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROcodone-acetaminophen 7.5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406012462,NDC,1,EA,4.76,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROcodone-acetaminophen 7.5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406012462,NDC,1,EA,4.76,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone (perianal) 2.5 % Cream 28.35 g Tube,63700001,CDM,250,RC,,,,,,10631040701,NDC,28.35,GR,447.94,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone (perianal) 2.5 % Cream 28.35 g Tube,63700001,CDM,250,RC,,,,,,10631040701,NDC,28.35,GR,447.94,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone (perianal) 2.5 % Cream 28.35 g Tube,63700001,CDM,250,RC,,,,,,10631040701,NDC,28.35,GR,447.94,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone (perianal) 2.5 % Cream 28.35 g Tube,63700001,CDM,250,RC,,,,,,10631040701,NDC,28.35,GR,447.94,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone (perianal) 2.5 % Cream 28.35 g Tube,63700001,CDM,250,RC,,,,,,10631040701,NDC,28.35,GR,447.94,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone (perianal) 2.5 % Cream 28.35 g Tube,63700001,CDM,250,RC,,,,,,10631040701,NDC,28.35,GR,447.94,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 1 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,472034356,NDC,28,GR,22.15,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 1 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,472034356,NDC,28,GR,22.15,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 1 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,472034356,NDC,28,GR,22.15,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 1 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,472034356,NDC,28,GR,22.15,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 1 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,472034356,NDC,28,GR,22.15,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 1 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,472034356,NDC,28,GR,22.15,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 1 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,45802043803,NDC,28,GR,25.55,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 1 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,45802043803,NDC,28,GR,25.55,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 1 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,45802043803,NDC,28,GR,25.55,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 1 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,45802043803,NDC,28,GR,25.55,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 1 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,45802043803,NDC,28,GR,25.55,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 1 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,45802043803,NDC,28,GR,25.55,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 2.5 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,45802000403,NDC,28,GR,60.85,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 2.5 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,45802000403,NDC,28,GR,60.85,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 2.5 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,45802000403,NDC,28,GR,60.85,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 2.5 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,45802000403,NDC,28,GR,60.85,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 2.5 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,45802000403,NDC,28,GR,60.85,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 2.5 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,45802000403,NDC,28,GR,60.85,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 2.5 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,168008031,NDC,30,GR,61.99,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 2.5 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,168008031,NDC,30,GR,61.99,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 2.5 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,168008031,NDC,30,GR,61.99,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 2.5 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,168008031,NDC,30,GR,61.99,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 2.5 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,168008031,NDC,30,GR,61.99,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 2.5 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,168008031,NDC,30,GR,61.99,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 5 MG Tablet 50 Each Bottle,63700001,CDM,250,RC,,,,,,59762007301,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 5 MG Tablet 50 Each Bottle,63700001,CDM,250,RC,,,,,,59762007301,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 5 MG Tablet 50 Each Bottle,63700001,CDM,250,RC,,,,,,59762007301,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 5 MG Tablet 50 Each Bottle,63700001,CDM,250,RC,,,,,,59762007301,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 5 MG Tablet 50 Each Bottle,63700001,CDM,250,RC,,,,,,59762007301,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 5 MG Tablet 50 Each Bottle,63700001,CDM,250,RC,,,,,,59762007301,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762007401,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762007401,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762007401,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762007401,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762007401,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762007401,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 25 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,713050306,NDC,1,EA,108.03,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 25 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,713050306,NDC,1,EA,108.03,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 25 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,713050306,NDC,1,EA,108.03,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 25 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,713050306,NDC,1,EA,108.03,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 25 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,713050306,NDC,1,EA,108.03,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 25 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,713050306,NDC,1,EA,108.03,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 25 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713050312,NDC,1,EA,108.03,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 25 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713050312,NDC,1,EA,108.03,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 25 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713050312,NDC,1,EA,108.03,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 25 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713050312,NDC,1,EA,108.03,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 25 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713050312,NDC,1,EA,108.03,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 25 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713050312,NDC,1,EA,108.03,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001103,NDC,1,EA,108.34,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001103,NDC,1,EA,108.34,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001103,NDC,1,EA,108.34,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001103,NDC,1,EA,108.34,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001103,NDC,1,EA,108.34,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001103,NDC,1,EA,108.34,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001104,NDC,1,EA,108.29,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001104,NDC,1,EA,108.29,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001104,NDC,1,EA,108.29,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001104,NDC,1,EA,108.29,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001104,NDC,1,EA,108.29,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001104,NDC,1,EA,108.29,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone sodium succinate (preservative free) 250 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001305,NDC,1,EA,183.32,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone sodium succinate (preservative free) 250 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001305,NDC,1,EA,183.32,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone sodium succinate (preservative free) 250 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001305,NDC,1,EA,183.32,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone sodium succinate (preservative free) 250 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001305,NDC,1,EA,183.32,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone sodium succinate (preservative free) 250 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001305,NDC,1,EA,183.32,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone sodium succinate (preservative free) 250 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001305,NDC,1,EA,183.32,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone sodium succinate (preservative free) 500 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001612,NDC,1,EA,298.53,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone sodium succinate (preservative free) 500 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001612,NDC,1,EA,298.53,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone sodium succinate (preservative free) 500 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001612,NDC,1,EA,298.53,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone sodium succinate (preservative free) 500 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001612,NDC,1,EA,298.53,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone sodium succinate (preservative free) 500 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001612,NDC,1,EA,298.53,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone sodium succinate (preservative free) 500 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001612,NDC,1,EA,298.53,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone sodium succinate (preservative free) 1000 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9000501,NDC,1,EA,403.54,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone sodium succinate (preservative free) 1000 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9000501,NDC,1,EA,403.54,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone sodium succinate (preservative free) 1000 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9000501,NDC,1,EA,403.54,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone sodium succinate (preservative free) 1000 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9000501,NDC,1,EA,403.54,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone sodium succinate (preservative free) 1000 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9000501,NDC,1,EA,403.54,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone sodium succinate (preservative free) 1000 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9000501,NDC,1,EA,403.54,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 0.1 MG/ML Solution 55 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,61553067976,NDC,55,ML,89.7,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 0.1 MG/ML Solution 55 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,61553067976,NDC,55,ML,89.7,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 0.1 MG/ML Solution 55 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,61553067976,NDC,55,ML,89.7,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 0.1 MG/ML Solution 55 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,61553067976,NDC,55,ML,89.7,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 0.1 MG/ML Solution 55 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,61553067976,NDC,55,ML,89.7,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 0.1 MG/ML Solution 55 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,61553067976,NDC,55,ML,89.7,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 1 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409128303,NDC,1,ML,36.93,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 1 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409128303,NDC,1,ML,36.93,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 1 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409128303,NDC,1,ML,36.93,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 1 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409128303,NDC,1,ML,36.93,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 1 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409128303,NDC,1,ML,36.93,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 1 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409128303,NDC,1,ML,36.93,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 1 MG/ML Solution 1 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,76045000901,NDC,0.25,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 1 MG/ML Solution 1 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,76045000901,NDC,0.25,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 1 MG/ML Solution 1 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,76045000901,NDC,0.25,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 1 MG/ML Solution 1 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,76045000901,NDC,0.25,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 1 MG/ML Solution 1 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,76045000901,NDC,0.25,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 1 MG/ML Solution 1 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,76045000901,NDC,0.25,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084042311,NDC,1,EA,3.83,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084042311,NDC,1,EA,3.83,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084042311,NDC,1,EA,3.83,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084042311,NDC,1,EA,3.83,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084042311,NDC,1,EA,3.83,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084042311,NDC,1,EA,3.83,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 2 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406324301,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 2 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406324301,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 2 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406324301,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 2 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406324301,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 2 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406324301,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 2 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406324301,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,42858030125,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,42858030125,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,42858030125,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,42858030125,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,42858030125,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,42858030125,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084042301,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084042301,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084042301,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084042301,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084042301,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084042301,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 2 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409131203,NDC,1,ML,38.18,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 2 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409131203,NDC,1,ML,38.18,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 2 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409131203,NDC,1,ML,38.18,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 2 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409131203,NDC,1,ML,38.18,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 2 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409131203,NDC,1,ML,38.18,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 2 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409131203,NDC,1,ML,38.18,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydroxocobalamin 5 g Recon Soln 1 Each Box,J3424.01,CDM,636,RC,J3424,HCPCS,,,,11704037001,NDC,1,EA,1991.16,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydroxocobalamin 5 g Recon Soln 1 Each Box,J3424.01,CDM,636,RC,J3424,HCPCS,,,,11704037001,NDC,1,EA,1991.16,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydroxocobalamin 5 g Recon Soln 1 Each Box,J3424.01,CDM,636,RC,J3424,HCPCS,,,,11704037001,NDC,1,EA,1991.16,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydroxocobalamin 5 g Recon Soln 1 Each Box,J3424.01,CDM,636,RC,J3424,HCPCS,,,,11704037001,NDC,1,EA,1991.16,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydroxocobalamin 5 g Recon Soln 1 Each Box,J3424.01,CDM,636,RC,J3424,HCPCS,,,,11704037001,NDC,1,EA,1991.16,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydroxocobalamin 5 g Recon Soln 1 Each Box,J3424.01,CDM,636,RC,J3424,HCPCS,,,,11704037001,NDC,1,EA,1991.16,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydroxychloroquine 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292001101,NDC,1,EA,23.57,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydroxychloroquine 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292001101,NDC,1,EA,23.57,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydroxychloroquine 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292001101,NDC,1,EA,23.57,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydroxychloroquine 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292001101,NDC,1,EA,23.57,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydroxychloroquine 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292001101,NDC,1,EA,23.57,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydroxychloroquine 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292001101,NDC,1,EA,23.57,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydroxychloroquine 200 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16571068701,NDC,1,EA,23.41,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydroxychloroquine 200 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16571068701,NDC,1,EA,23.41,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydroxychloroquine 200 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16571068701,NDC,1,EA,23.41,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydroxychloroquine 200 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16571068701,NDC,1,EA,23.41,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydroxychloroquine 200 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16571068701,NDC,1,EA,23.41,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydroxychloroquine 200 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16571068701,NDC,1,EA,23.41,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hydroxyprogesterone, 17-D - Ref",PX8349890,CDM,300,RC,83498,CPT,90,,,,,,,67,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hydroxyprogesterone, 17-D - Ref",PX8349890,CDM,300,RC,83498,CPT,90,,,,,,,67,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hydroxyprogesterone, 17-D - Ref",PX8349890,CDM,300,RC,83498,CPT,90,,,,,,,67,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hydroxyprogesterone, 17-D - Ref",PX8349890,CDM,300,RC,83498,CPT,90,,,,,,,67,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hydroxyprogesterone, 17-D - Ref",PX8349890,CDM,300,RC,83498,CPT,90,,,,,,,67,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hydroxyprogesterone, 17-D - Ref",PX8349890,CDM,300,RC,83498,CPT,90,,,,,,,67,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrOXYzine 50 MG/ML Solution 1 mL Vial,J3410.01,CDM,636,RC,J3410,HCPCS,,,,517560125,NDC,0.5,ML,83.68,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrOXYzine 50 MG/ML Solution 1 mL Vial,J3410.01,CDM,636,RC,J3410,HCPCS,,,,517560125,NDC,0.5,ML,83.68,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrOXYzine 50 MG/ML Solution 1 mL Vial,J3410.01,CDM,636,RC,J3410,HCPCS,,,,517560125,NDC,0.5,ML,83.68,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrOXYzine 50 MG/ML Solution 1 mL Vial,J3410.01,CDM,636,RC,J3410,HCPCS,,,,517560125,NDC,0.5,ML,83.68,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrOXYzine 50 MG/ML Solution 1 mL Vial,J3410.01,CDM,636,RC,J3410,HCPCS,,,,517560125,NDC,0.5,ML,83.68,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrOXYzine 50 MG/ML Solution 1 mL Vial,J3410.01,CDM,636,RC,J3410,HCPCS,,,,517560125,NDC,0.5,ML,83.68,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrOXYzine HCl 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714008110,NDC,1,EA,3.41,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrOXYzine HCl 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714008110,NDC,1,EA,3.41,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrOXYzine HCl 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714008110,NDC,1,EA,3.41,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrOXYzine HCl 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714008110,NDC,1,EA,3.41,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrOXYzine HCl 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714008110,NDC,1,EA,3.41,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrOXYzine HCl 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714008110,NDC,1,EA,3.41,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrOXYzine HCl 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155050101,NDC,0.4,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrOXYzine HCl 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155050101,NDC,0.4,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrOXYzine HCl 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155050101,NDC,0.4,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrOXYzine HCl 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155050101,NDC,0.4,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrOXYzine HCl 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155050101,NDC,0.4,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrOXYzine HCl 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155050101,NDC,0.4,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrOXYzine pamoate 25 MG capsule 1 Each Blister,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084711,NDC,1,EA,3.22,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrOXYzine pamoate 25 MG capsule 1 Each Blister,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084711,NDC,1,EA,3.22,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrOXYzine pamoate 25 MG capsule 1 Each Blister,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084711,NDC,1,EA,3.22,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrOXYzine pamoate 25 MG capsule 1 Each Blister,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084711,NDC,1,EA,3.22,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrOXYzine pamoate 25 MG capsule 1 Each Blister,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084711,NDC,1,EA,3.22,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrOXYzine pamoate 25 MG capsule 1 Each Blister,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084711,NDC,1,EA,3.22,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,51079007720,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,51079007720,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,51079007720,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,51079007720,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,51079007720,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,51079007720,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084701,NDC,1,EA,3.22,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084701,NDC,1,EA,3.22,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084701,NDC,1,EA,3.22,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084701,NDC,1,EA,3.22,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084701,NDC,1,EA,3.22,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084701,NDC,1,EA,3.22,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hyoscyamine 0.125 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42192034001,NDC,1,EA,4.56,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hyoscyamine 0.125 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42192034001,NDC,1,EA,4.56,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hyoscyamine 0.125 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42192034001,NDC,1,EA,4.56,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hyoscyamine 0.125 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42192034001,NDC,1,EA,4.56,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hyoscyamine 0.125 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42192034001,NDC,1,EA,4.56,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hyoscyamine 0.125 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42192034001,NDC,1,EA,4.56,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
I&D Bartholin Gland Abscess,PX56420F,CDM,510,RC,56420,CPT,,,,,,,,429,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
I&D Bartholin Gland Abscess,PX56420F,CDM,510,RC,56420,CPT,,,,,,,,429,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
I&D Bartholin Gland Abscess,PX56420F,CDM,510,RC,56420,CPT,,,,,,,,429,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
I&D Bartholin Gland Abscess,PX56420F,CDM,510,RC,56420,CPT,,,,,,,,429,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
I&D Bartholin Gland Abscess,PX56420F,CDM,510,RC,56420,CPT,,,,,,,,429,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
I&D Bartholin Gland Abscess,PX56420F,CDM,510,RC,56420,CPT,,,,,,,,429,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
I&D Bartholin Gland Abscess,PX56420P,CDM,983,RC,56420,CPT,,,,,,,,286,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
I&D Bartholin Gland Abscess,PX56420P,CDM,983,RC,56420,CPT,,,,,,,,286,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
I&D Bartholin Gland Abscess,PX56420P,CDM,983,RC,56420,CPT,,,,,,,,286,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
I&D Bartholin Gland Abscess,PX56420P,CDM,983,RC,56420,CPT,,,,,,,,286,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
I&D Bartholin Gland Abscess,PX56420P,CDM,983,RC,56420,CPT,,,,,,,,286,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
I&D Bartholin Gland Abscess,PX56420P,CDM,983,RC,56420,CPT,,,,,,,,286,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
I&D Deep Absc/Hematoma Neck/Chest,PX21501F,CDM,510,RC,21501,CPT,,,,,,,,773,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
I&D Deep Absc/Hematoma Neck/Chest,PX21501F,CDM,510,RC,21501,CPT,,,,,,,,773,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
I&D Deep Absc/Hematoma Neck/Chest,PX21501F,CDM,510,RC,21501,CPT,,,,,,,,773,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
I&D Deep Absc/Hematoma Neck/Chest,PX21501F,CDM,510,RC,21501,CPT,,,,,,,,773,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
I&D Deep Absc/Hematoma Neck/Chest,PX21501F,CDM,510,RC,21501,CPT,,,,,,,,773,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
I&D Deep Absc/Hematoma Neck/Chest,PX21501F,CDM,510,RC,21501,CPT,,,,,,,,773,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
I&D Deep Absc/Hematoma Neck/Chest,PX21501P,CDM,983,RC,21501,CPT,,,,,,,,515,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
I&D Deep Absc/Hematoma Neck/Chest,PX21501P,CDM,983,RC,21501,CPT,,,,,,,,515,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
I&D Deep Absc/Hematoma Neck/Chest,PX21501P,CDM,983,RC,21501,CPT,,,,,,,,515,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
I&D Deep Absc/Hematoma Neck/Chest,PX21501P,CDM,983,RC,21501,CPT,,,,,,,,515,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
I&D Deep Absc/Hematoma Neck/Chest,PX21501P,CDM,983,RC,21501,CPT,,,,,,,,515,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
I&D Deep Absc/Hematoma Neck/Chest,PX21501P,CDM,983,RC,21501,CPT,,,,,,,,515,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"I&D Perianal Abscess,Superficial",PX46050,CDM,983,RC,46050,CPT,,,,,,,,1096,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"I&D Perianal Abscess,Superficial",PX46050,CDM,983,RC,46050,CPT,,,,,,,,1096,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"I&D Perianal Abscess,Superficial",PX46050,CDM,983,RC,46050,CPT,,,,,,,,1096,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"I&D Perianal Abscess,Superficial",PX46050,CDM,983,RC,46050,CPT,,,,,,,,1096,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"I&D Perianal Abscess,Superficial",PX46050,CDM,983,RC,46050,CPT,,,,,,,,1096,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"I&D Perianal Abscess,Superficial",PX46050,CDM,983,RC,46050,CPT,,,,,,,,1096,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"I&D Perianal Abscess,Superficial",PX46050F,CDM,510,RC,46050,CPT,,,,,,,,1463,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"I&D Perianal Abscess,Superficial",PX46050F,CDM,510,RC,46050,CPT,,,,,,,,1463,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"I&D Perianal Abscess,Superficial",PX46050F,CDM,510,RC,46050,CPT,,,,,,,,1463,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"I&D Perianal Abscess,Superficial",PX46050F,CDM,510,RC,46050,CPT,,,,,,,,1463,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"I&D Perianal Abscess,Superficial",PX46050F,CDM,510,RC,46050,CPT,,,,,,,,1463,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"I&D Perianal Abscess,Superficial",PX46050F,CDM,510,RC,46050,CPT,,,,,,,,1463,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"I&D Perianal Abscess,Superficial",PX46050P,CDM,983,RC,46050,CPT,,,,,,,,993,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"I&D Perianal Abscess,Superficial",PX46050P,CDM,983,RC,46050,CPT,,,,,,,,993,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"I&D Perianal Abscess,Superficial",PX46050P,CDM,983,RC,46050,CPT,,,,,,,,993,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"I&D Perianal Abscess,Superficial",PX46050P,CDM,983,RC,46050,CPT,,,,,,,,993,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"I&D Perianal Abscess,Superficial",PX46050P,CDM,983,RC,46050,CPT,,,,,,,,993,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"I&D Perianal Abscess,Superficial",PX46050P,CDM,983,RC,46050,CPT,,,,,,,,993,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
I&D Perirectal Abscess,PX46040F,CDM,510,RC,46040,CPT,,,,,,,,1430,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
I&D Perirectal Abscess,PX46040F,CDM,510,RC,46040,CPT,,,,,,,,1430,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
I&D Perirectal Abscess,PX46040F,CDM,510,RC,46040,CPT,,,,,,,,1430,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
I&D Perirectal Abscess,PX46040F,CDM,510,RC,46040,CPT,,,,,,,,1430,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
I&D Perirectal Abscess,PX46040F,CDM,510,RC,46040,CPT,,,,,,,,1430,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
I&D Perirectal Abscess,PX46040F,CDM,510,RC,46040,CPT,,,,,,,,1430,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
I&D Perirectal Abscess,PX46040P,CDM,983,RC,46040,CPT,,,,,,,,953,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
I&D Perirectal Abscess,PX46040P,CDM,983,RC,46040,CPT,,,,,,,,953,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
I&D Perirectal Abscess,PX46040P,CDM,983,RC,46040,CPT,,,,,,,,953,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
I&D Perirectal Abscess,PX46040P,CDM,983,RC,46040,CPT,,,,,,,,953,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
I&D Perirectal Abscess,PX46040P,CDM,983,RC,46040,CPT,,,,,,,,953,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
I&D Perirectal Abscess,PX46040P,CDM,983,RC,46040,CPT,,,,,,,,953,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Iaad Ia Severe Aqt Respir Synd Coronavirus,PX87426,CDM,300,RC,87426,CPT,,,,,,,,159,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Iaad Ia Severe Aqt Respir Synd Coronavirus,PX87426,CDM,300,RC,87426,CPT,,,,,,,,159,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Iaad Ia Severe Aqt Respir Synd Coronavirus,PX87426,CDM,300,RC,87426,CPT,,,,,,,,159,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Iaad Ia Severe Aqt Respir Synd Coronavirus,PX87426,CDM,300,RC,87426,CPT,,,,,,,,159,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Iaad Ia Severe Aqt Respir Synd Coronavirus,PX87426,CDM,300,RC,87426,CPT,,,,,,,,159,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Iaad Ia Severe Aqt Respir Synd Coronavirus,PX87426,CDM,300,RC,87426,CPT,,,,,,,,159,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq,PX87635,CDM,300,RC,87635,CPT,,,,,,,,166,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq,PX87635,CDM,300,RC,87635,CPT,,,,,,,,166,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq,PX87635,CDM,300,RC,87635,CPT,,,,,,,,166,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq,PX87635,CDM,300,RC,87635,CPT,,,,,,,,166,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq,PX87635,CDM,300,RC,87635,CPT,,,,,,,,166,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq,PX87635,CDM,300,RC,87635,CPT,,,,,,,,166,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Iadna Streptococcus Group a Amplified Probe Tq,PX87651,CDM,300,RC,87651,CPT,,,,,,,,113,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Iadna Streptococcus Group a Amplified Probe Tq,PX87651,CDM,300,RC,87651,CPT,,,,,,,,113,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Iadna Streptococcus Group a Amplified Probe Tq,PX87651,CDM,300,RC,87651,CPT,,,,,,,,113,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Iadna Streptococcus Group a Amplified Probe Tq,PX87651,CDM,300,RC,87651,CPT,,,,,,,,113,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Iadna Streptococcus Group a Amplified Probe Tq,PX87651,CDM,300,RC,87651,CPT,,,,,,,,113,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Iadna Streptococcus Group a Amplified Probe Tq,PX87651,CDM,300,RC,87651,CPT,,,,,,,,113,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 100 MG/5ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,68094049459,NDC,20,ML,22.2,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 100 MG/5ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,68094049459,NDC,20,ML,22.2,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 100 MG/5ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,68094049459,NDC,20,ML,22.2,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 100 MG/5ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,68094049459,NDC,20,ML,22.2,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 100 MG/5ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,68094049459,NDC,20,ML,22.2,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 100 MG/5ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,68094049459,NDC,20,ML,22.2,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 100 MG/5ML Suspension 118 mL Bottle,63700001,CDM,250,RC,,,,,,45802089726,NDC,118,ML,54.97,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 100 MG/5ML Suspension 118 mL Bottle,63700001,CDM,250,RC,,,,,,45802089726,NDC,118,ML,54.97,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 100 MG/5ML Suspension 118 mL Bottle,63700001,CDM,250,RC,,,,,,45802089726,NDC,118,ML,54.97,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 100 MG/5ML Suspension 118 mL Bottle,63700001,CDM,250,RC,,,,,,45802089726,NDC,118,ML,54.97,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 100 MG/5ML Suspension 118 mL Bottle,63700001,CDM,250,RC,,,,,,45802089726,NDC,118,ML,54.97,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 100 MG/5ML Suspension 118 mL Bottle,63700001,CDM,250,RC,,,,,,45802089726,NDC,118,ML,54.97,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 100 MG/5ML Suspension 120 mL Bottle,63700001,CDM,250,RC,,,,,,904530920,NDC,20,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 100 MG/5ML Suspension 120 mL Bottle,63700001,CDM,250,RC,,,,,,904530920,NDC,20,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 100 MG/5ML Suspension 120 mL Bottle,63700001,CDM,250,RC,,,,,,904530920,NDC,20,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 100 MG/5ML Suspension 120 mL Bottle,63700001,CDM,250,RC,,,,,,904530920,NDC,20,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 100 MG/5ML Suspension 120 mL Bottle,63700001,CDM,250,RC,,,,,,904530920,NDC,20,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 100 MG/5ML Suspension 120 mL Bottle,63700001,CDM,250,RC,,,,,,904530920,NDC,20,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904791461,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904791461,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904791461,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904791461,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904791461,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904791461,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 600 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687045711,NDC,0.333333333,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 600 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687045711,NDC,0.333333333,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 600 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687045711,NDC,0.333333333,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 600 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687045711,NDC,0.333333333,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 600 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687045711,NDC,0.333333333,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 600 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687045711,NDC,0.333333333,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 600 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739068410,NDC,0.333333333,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 600 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739068410,NDC,0.333333333,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 600 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739068410,NDC,0.333333333,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 600 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739068410,NDC,0.333333333,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 600 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739068410,NDC,0.333333333,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 600 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739068410,NDC,0.333333333,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 800 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687046811,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 800 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687046811,NDC,0.25,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 800 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687046811,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 800 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687046811,NDC,0.25,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 800 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687046811,NDC,0.25,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 800 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687046811,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 800 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687046801,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 800 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687046801,NDC,0.25,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 800 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687046801,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 800 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687046801,NDC,0.25,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 800 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687046801,NDC,0.25,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 800 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687046801,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 800 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739069110,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 800 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739069110,NDC,0.25,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 800 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739069110,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 800 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739069110,NDC,0.25,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 800 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739069110,NDC,0.25,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 800 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739069110,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibutilide 1 MG/10ML Solution 10 mL Vial,J1742.01,CDM,636,RC,J1742,HCPCS,,,,9379401,NDC,10,ML,2349.03,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibutilide 1 MG/10ML Solution 10 mL Vial,J1742.01,CDM,636,RC,J1742,HCPCS,,,,9379401,NDC,10,ML,2349.03,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibutilide 1 MG/10ML Solution 10 mL Vial,J1742.01,CDM,636,RC,J1742,HCPCS,,,,9379401,NDC,10,ML,2349.03,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibutilide 1 MG/10ML Solution 10 mL Vial,J1742.01,CDM,636,RC,J1742,HCPCS,,,,9379401,NDC,10,ML,2349.03,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibutilide 1 MG/10ML Solution 10 mL Vial,J1742.01,CDM,636,RC,J1742,HCPCS,,,,9379401,NDC,10,ML,2349.03,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibutilide 1 MG/10ML Solution 10 mL Vial,J1742.01,CDM,636,RC,J1742,HCPCS,,,,9379401,NDC,10,ML,2349.03,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ID Nucleic Acid Sequencing - Ref,PX8715390,CDM,300,RC,87153,CPT,90,,,,,,,265,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ID Nucleic Acid Sequencing - Ref,PX8715390,CDM,300,RC,87153,CPT,90,,,,,,,265,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ID Nucleic Acid Sequencing - Ref,PX8715390,CDM,300,RC,87153,CPT,90,,,,,,,265,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ID Nucleic Acid Sequencing - Ref,PX8715390,CDM,300,RC,87153,CPT,90,,,,,,,265,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ID Nucleic Acid Sequencing - Ref,PX8715390,CDM,300,RC,87153,CPT,90,,,,,,,265,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ID Nucleic Acid Sequencing - Ref,PX8715390,CDM,300,RC,87153,CPT,90,,,,,,,265,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
idaruCIZUmab 2.5 GM/50ML Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,597019705,NDC,50,ML,10037,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
idaruCIZUmab 2.5 GM/50ML Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,597019705,NDC,50,ML,10037,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
idaruCIZUmab 2.5 GM/50ML Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,597019705,NDC,50,ML,10037,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
idaruCIZUmab 2.5 GM/50ML Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,597019705,NDC,50,ML,10037,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
idaruCIZUmab 2.5 GM/50ML Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,597019705,NDC,50,ML,10037,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
idaruCIZUmab 2.5 GM/50ML Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,597019705,NDC,50,ML,10037,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ig Paraprotein Qual Bld/UR,PX0077U90,CDM,300,RC,0077U,HCPCS,90,,,,,,,66,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ig Paraprotein Qual Bld/UR,PX0077U90,CDM,300,RC,0077U,HCPCS,90,,,,,,,66,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ig Paraprotein Qual Bld/UR,PX0077U90,CDM,300,RC,0077U,HCPCS,90,,,,,,,66,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ig Paraprotein Qual Bld/UR,PX0077U90,CDM,300,RC,0077U,HCPCS,90,,,,,,,66,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ig Paraprotein Qual Bld/UR,PX0077U90,CDM,300,RC,0077U,HCPCS,90,,,,,,,66,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ig Paraprotein Qual Bld/UR,PX0077U90,CDM,300,RC,0077U,HCPCS,90,,,,,,,66,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Igh, Variable Region Somatic Mutation Analysis",PX8126390,CDM,310,RC,81263,CPT,90,,,,,,,1215,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Igh, Variable Region Somatic Mutation Analysis",PX8126390,CDM,310,RC,81263,CPT,90,,,,,,,1215,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Igh, Variable Region Somatic Mutation Analysis",PX8126390,CDM,310,RC,81263,CPT,90,,,,,,,1215,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Igh, Variable Region Somatic Mutation Analysis",PX8126390,CDM,310,RC,81263,CPT,90,,,,,,,1215,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Igh, Variable Region Somatic Mutation Analysis",PX8126390,CDM,310,RC,81263,CPT,90,,,,,,,1215,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Igh, Variable Region Somatic Mutation Analysis",PX8126390,CDM,310,RC,81263,CPT,90,,,,,,,1215,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ileoscopy Thru Stoma,Diagnostic",PX44380F,CDM,750,RC,44380,CPT,,,,,,,,245,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,216.09,6141.46
"Ileoscopy Thru Stoma,Diagnostic",PX44380F,CDM,750,RC,44380,CPT,,,,,,,,245,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,216.09,6141.46
"Ileoscopy Thru Stoma,Diagnostic",PX44380F,CDM,750,RC,44380,CPT,,,,,,,,245,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,216.09,6141.46
"Ileoscopy Thru Stoma,Diagnostic",PX44380F,CDM,750,RC,44380,CPT,,,,,,,,245,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,216.09,6141.46
"Ileoscopy Thru Stoma,Diagnostic",PX44380F,CDM,750,RC,44380,CPT,,,,,,,,245,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,216.09,6141.46
"Ileoscopy Thru Stoma,Diagnostic",PX44380F,CDM,750,RC,44380,CPT,,,,,,,,245,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,216.09,6141.46
"Ileoscopy Thru Stoma,Diagnostic",PX44380P,CDM,983,RC,44380,CPT,,,,,,,,455,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ileoscopy Thru Stoma,Diagnostic",PX44380P,CDM,983,RC,44380,CPT,,,,,,,,455,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ileoscopy Thru Stoma,Diagnostic",PX44380P,CDM,983,RC,44380,CPT,,,,,,,,455,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ileoscopy Thru Stoma,Diagnostic",PX44380P,CDM,983,RC,44380,CPT,,,,,,,,455,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ileoscopy Thru Stoma,Diagnostic",PX44380P,CDM,983,RC,44380,CPT,,,,,,,,455,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ileoscopy Thru Stoma,Diagnostic",PX44380P,CDM,983,RC,44380,CPT,,,,,,,,455,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
imipenem-cilastatin 250 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323034925,NDC,1,EA,91.55,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
imipenem-cilastatin 250 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323034925,NDC,1,EA,91.55,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
imipenem-cilastatin 250 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323034925,NDC,1,EA,91.55,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
imipenem-cilastatin 250 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323034925,NDC,1,EA,91.55,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
imipenem-cilastatin 250 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323034925,NDC,1,EA,91.55,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
imipenem-cilastatin 250 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323034925,NDC,1,EA,91.55,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032225,NDC,1,EA,176.72,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032225,NDC,1,EA,176.72,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032225,NDC,1,EA,176.72,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032225,NDC,1,EA,176.72,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032225,NDC,1,EA,176.72,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032225,NDC,1,EA,176.72,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032294,NDC,1,EA,91.55,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032294,NDC,1,EA,91.55,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032294,NDC,1,EA,91.55,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032294,NDC,1,EA,91.55,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032294,NDC,1,EA,91.55,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032294,NDC,1,EA,91.55,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IMMOBILIZER KNEE  24"" 7041-44",120.22,CDM,274,RC,L1830,HCPCS,,595-MAIN,LOCAL,,,,,60,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IMMOBILIZER KNEE  24"" 7041-44",120.22,CDM,274,RC,L1830,HCPCS,,595-MAIN,LOCAL,,,,,60,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IMMOBILIZER KNEE  24"" 7041-44",120.22,CDM,274,RC,L1830,HCPCS,,595-MAIN,LOCAL,,,,,60,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IMMOBILIZER KNEE  24"" 7041-44",120.22,CDM,274,RC,L1830,HCPCS,,595-MAIN,LOCAL,,,,,60,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IMMOBILIZER KNEE  24"" 7041-44",120.22,CDM,274,RC,L1830,HCPCS,,595-MAIN,LOCAL,,,,,60,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IMMOBILIZER KNEE  24"" 7041-44",120.22,CDM,274,RC,L1830,HCPCS,,595-MAIN,LOCAL,,,,,60,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IMMOBILIZER KNEE 16"" UNIVERSAL 7088-04",120.22,CDM,274,RC,L1830,HCPCS,,589-MAIN,LOCAL,,,,,60,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IMMOBILIZER KNEE 16"" UNIVERSAL 7088-04",120.22,CDM,274,RC,L1830,HCPCS,,589-MAIN,LOCAL,,,,,60,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IMMOBILIZER KNEE 16"" UNIVERSAL 7088-04",120.22,CDM,274,RC,L1830,HCPCS,,589-MAIN,LOCAL,,,,,60,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IMMOBILIZER KNEE 16"" UNIVERSAL 7088-04",120.22,CDM,274,RC,L1830,HCPCS,,589-MAIN,LOCAL,,,,,60,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IMMOBILIZER KNEE 16"" UNIVERSAL 7088-04",120.22,CDM,274,RC,L1830,HCPCS,,589-MAIN,LOCAL,,,,,60,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IMMOBILIZER KNEE 16"" UNIVERSAL 7088-04",120.22,CDM,274,RC,L1830,HCPCS,,589-MAIN,LOCAL,,,,,60,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER KNEE 20 INCH ORT2420019,120.22,CDM,274,RC,L1830,HCPCS,,587-MAIN,LOCAL,,,,,60,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER KNEE 20 INCH ORT2420019,120.22,CDM,274,RC,L1830,HCPCS,,587-MAIN,LOCAL,,,,,60,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER KNEE 20 INCH ORT2420019,120.22,CDM,274,RC,L1830,HCPCS,,587-MAIN,LOCAL,,,,,60,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER KNEE 20 INCH ORT2420019,120.22,CDM,274,RC,L1830,HCPCS,,587-MAIN,LOCAL,,,,,60,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER KNEE 20 INCH ORT2420019,120.22,CDM,274,RC,L1830,HCPCS,,587-MAIN,LOCAL,,,,,60,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER KNEE 20 INCH ORT2420019,120.22,CDM,274,RC,L1830,HCPCS,,587-MAIN,LOCAL,,,,,60,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IMMOBILIZER KNEE 20"" LARGE FOAM COUNTOURED STAYS 7062-03",120.22,CDM,274,RC,L1830,HCPCS,,593-MAIN,LOCAL,,,,,60,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IMMOBILIZER KNEE 20"" LARGE FOAM COUNTOURED STAYS 7062-03",120.22,CDM,274,RC,L1830,HCPCS,,593-MAIN,LOCAL,,,,,60,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IMMOBILIZER KNEE 20"" LARGE FOAM COUNTOURED STAYS 7062-03",120.22,CDM,274,RC,L1830,HCPCS,,593-MAIN,LOCAL,,,,,60,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IMMOBILIZER KNEE 20"" LARGE FOAM COUNTOURED STAYS 7062-03",120.22,CDM,274,RC,L1830,HCPCS,,593-MAIN,LOCAL,,,,,60,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IMMOBILIZER KNEE 20"" LARGE FOAM COUNTOURED STAYS 7062-03",120.22,CDM,274,RC,L1830,HCPCS,,593-MAIN,LOCAL,,,,,60,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IMMOBILIZER KNEE 20"" LARGE FOAM COUNTOURED STAYS 7062-03",120.22,CDM,274,RC,L1830,HCPCS,,593-MAIN,LOCAL,,,,,60,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IMMOBILIZER KNEE 20"" QUICK-WRAP ORT2440020S",120.22,CDM,274,RC,L1830,HCPCS,,591-MAIN,LOCAL,,,,,60,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IMMOBILIZER KNEE 20"" QUICK-WRAP ORT2440020S",120.22,CDM,274,RC,L1830,HCPCS,,591-MAIN,LOCAL,,,,,60,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IMMOBILIZER KNEE 20"" QUICK-WRAP ORT2440020S",120.22,CDM,274,RC,L1830,HCPCS,,591-MAIN,LOCAL,,,,,60,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IMMOBILIZER KNEE 20"" QUICK-WRAP ORT2440020S",120.22,CDM,274,RC,L1830,HCPCS,,591-MAIN,LOCAL,,,,,60,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IMMOBILIZER KNEE 20"" QUICK-WRAP ORT2440020S",120.22,CDM,274,RC,L1830,HCPCS,,591-MAIN,LOCAL,,,,,60,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IMMOBILIZER KNEE 20"" QUICK-WRAP ORT2440020S",120.22,CDM,274,RC,L1830,HCPCS,,591-MAIN,LOCAL,,,,,60,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER KNEE CUTAWAY STRAIGHT 2 7041-05,120.22,CDM,274,RC,L1830,HCPCS,,596-MAIN,LOCAL,,,,,60,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER KNEE CUTAWAY STRAIGHT 2 7041-05,120.22,CDM,274,RC,L1830,HCPCS,,596-MAIN,LOCAL,,,,,60,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER KNEE CUTAWAY STRAIGHT 2 7041-05,120.22,CDM,274,RC,L1830,HCPCS,,596-MAIN,LOCAL,,,,,60,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER KNEE CUTAWAY STRAIGHT 2 7041-05,120.22,CDM,274,RC,L1830,HCPCS,,596-MAIN,LOCAL,,,,,60,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER KNEE CUTAWAY STRAIGHT 2 7041-05,120.22,CDM,274,RC,L1830,HCPCS,,596-MAIN,LOCAL,,,,,60,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER KNEE CUTAWAY STRAIGHT 2 7041-05,120.22,CDM,274,RC,L1830,HCPCS,,596-MAIN,LOCAL,,,,,60,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER LARGE 9008-03,120.38,CDM,274,RC,L3650,HCPCS,,906-MAIN,LOCAL,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER LARGE 9008-03,120.38,CDM,274,RC,L3650,HCPCS,,906-MAIN,LOCAL,,,,,36,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER LARGE 9008-03,120.38,CDM,274,RC,L3650,HCPCS,,906-MAIN,LOCAL,,,,,36,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER LARGE 9008-03,120.38,CDM,274,RC,L3650,HCPCS,,906-MAIN,LOCAL,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER LARGE 9008-03,120.38,CDM,274,RC,L3650,HCPCS,,906-MAIN,LOCAL,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER LARGE 9008-03,120.38,CDM,274,RC,L3650,HCPCS,,906-MAIN,LOCAL,,,,,36,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER LARGE STRAP OSG3033,120.38,CDM,274,RC,L3650,HCPCS,,2910-MAIN,LOCAL,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER LARGE STRAP OSG3033,120.38,CDM,274,RC,L3650,HCPCS,,2910-MAIN,LOCAL,,,,,36,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER LARGE STRAP OSG3033,120.38,CDM,274,RC,L3650,HCPCS,,2910-MAIN,LOCAL,,,,,36,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER LARGE STRAP OSG3033,120.38,CDM,274,RC,L3650,HCPCS,,2910-MAIN,LOCAL,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER LARGE STRAP OSG3033,120.38,CDM,274,RC,L3650,HCPCS,,2910-MAIN,LOCAL,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER LARGE STRAP OSG3033,120.38,CDM,274,RC,L3650,HCPCS,,2910-MAIN,LOCAL,,,,,36,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER MEDIUM 9008-02,120.38,CDM,274,RC,L3650,HCPCS,,912-MAIN,LOCAL,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER MEDIUM 9008-02,120.38,CDM,274,RC,L3650,HCPCS,,912-MAIN,LOCAL,,,,,36,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER MEDIUM 9008-02,120.38,CDM,274,RC,L3650,HCPCS,,912-MAIN,LOCAL,,,,,36,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER MEDIUM 9008-02,120.38,CDM,274,RC,L3650,HCPCS,,912-MAIN,LOCAL,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER MEDIUM 9008-02,120.38,CDM,274,RC,L3650,HCPCS,,912-MAIN,LOCAL,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER MEDIUM 9008-02,120.38,CDM,274,RC,L3650,HCPCS,,912-MAIN,LOCAL,,,,,36,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER MEDIUM OSG3032,120.38,CDM,274,RC,L3650,HCPCS,,915-MAIN,LOCAL,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER MEDIUM OSG3032,120.38,CDM,274,RC,L3650,HCPCS,,915-MAIN,LOCAL,,,,,36,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER MEDIUM OSG3032,120.38,CDM,274,RC,L3650,HCPCS,,915-MAIN,LOCAL,,,,,36,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER MEDIUM OSG3032,120.38,CDM,274,RC,L3650,HCPCS,,915-MAIN,LOCAL,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER MEDIUM OSG3032,120.38,CDM,274,RC,L3650,HCPCS,,915-MAIN,LOCAL,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER MEDIUM OSG3032,120.38,CDM,274,RC,L3650,HCPCS,,915-MAIN,LOCAL,,,,,36,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER SMALL 9008-01,120.38,CDM,274,RC,L3650,HCPCS,,913-MAIN,LOCAL,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER SMALL 9008-01,120.38,CDM,274,RC,L3650,HCPCS,,913-MAIN,LOCAL,,,,,36,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER SMALL 9008-01,120.38,CDM,274,RC,L3650,HCPCS,,913-MAIN,LOCAL,,,,,36,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER SMALL 9008-01,120.38,CDM,274,RC,L3650,HCPCS,,913-MAIN,LOCAL,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER SMALL 9008-01,120.38,CDM,274,RC,L3650,HCPCS,,913-MAIN,LOCAL,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER SMALL 9008-01,120.38,CDM,274,RC,L3650,HCPCS,,913-MAIN,LOCAL,,,,,36,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER SMALL WITH CLOTH 9001-02,120.38,CDM,274,RC,L3650,HCPCS,,914-MAIN,LOCAL,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER SMALL WITH CLOTH 9001-02,120.38,CDM,274,RC,L3650,HCPCS,,914-MAIN,LOCAL,,,,,36,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER SMALL WITH CLOTH 9001-02,120.38,CDM,274,RC,L3650,HCPCS,,914-MAIN,LOCAL,,,,,36,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER SMALL WITH CLOTH 9001-02,120.38,CDM,274,RC,L3650,HCPCS,,914-MAIN,LOCAL,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER SMALL WITH CLOTH 9001-02,120.38,CDM,274,RC,L3650,HCPCS,,914-MAIN,LOCAL,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER SMALL WITH CLOTH 9001-02,120.38,CDM,274,RC,L3650,HCPCS,,914-MAIN,LOCAL,,,,,36,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER X-LARGE CLOTH 9001-05,120.38,CDM,274,RC,L3650,HCPCS,,917-MAIN,LOCAL,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER X-LARGE CLOTH 9001-05,120.38,CDM,274,RC,L3650,HCPCS,,917-MAIN,LOCAL,,,,,36,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER X-LARGE CLOTH 9001-05,120.38,CDM,274,RC,L3650,HCPCS,,917-MAIN,LOCAL,,,,,36,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER X-LARGE CLOTH 9001-05,120.38,CDM,274,RC,L3650,HCPCS,,917-MAIN,LOCAL,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER X-LARGE CLOTH 9001-05,120.38,CDM,274,RC,L3650,HCPCS,,917-MAIN,LOCAL,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER X-LARGE CLOTH 9001-05,120.38,CDM,274,RC,L3650,HCPCS,,917-MAIN,LOCAL,,,,,36,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER X-LARGE ORT16100XL,120.38,CDM,274,RC,L3650,HCPCS,,904-MAIN,LOCAL,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER X-LARGE ORT16100XL,120.38,CDM,274,RC,L3650,HCPCS,,904-MAIN,LOCAL,,,,,36,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER X-LARGE ORT16100XL,120.38,CDM,274,RC,L3650,HCPCS,,904-MAIN,LOCAL,,,,,36,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER X-LARGE ORT16100XL,120.38,CDM,274,RC,L3650,HCPCS,,904-MAIN,LOCAL,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER X-LARGE ORT16100XL,120.38,CDM,274,RC,L3650,HCPCS,,904-MAIN,LOCAL,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER X-LARGE ORT16100XL,120.38,CDM,274,RC,L3650,HCPCS,,904-MAIN,LOCAL,,,,,36,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270004,NDC,100,ML,2827.78,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270004,NDC,100,ML,2827.78,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270004,NDC,100,ML,2827.78,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270004,NDC,100,ML,2827.78,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270004,NDC,100,ML,2827.78,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270004,NDC,100,ML,2827.78,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270010,NDC,100,ML,3458.14,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270010,NDC,100,ML,3458.14,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270010,NDC,100,ML,3458.14,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270010,NDC,100,ML,3458.14,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270010,NDC,100,ML,3458.14,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270010,NDC,100,ML,3458.14,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
immune globulin (Human) 10 GM/100ML Solution 100 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270005,NDC,100,ML,2827.78,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
immune globulin (Human) 10 GM/100ML Solution 100 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270005,NDC,100,ML,2827.78,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
immune globulin (Human) 10 GM/100ML Solution 100 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270005,NDC,100,ML,2827.78,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
immune globulin (Human) 10 GM/100ML Solution 100 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270005,NDC,100,ML,2827.78,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
immune globulin (Human) 10 GM/100ML Solution 100 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270005,NDC,100,ML,2827.78,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
immune globulin (Human) 10 GM/100ML Solution 100 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270005,NDC,100,ML,2827.78,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270006,NDC,100,ML,2912.78,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270006,NDC,100,ML,2912.78,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270006,NDC,100,ML,2912.78,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270006,NDC,100,ML,2912.78,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270006,NDC,100,ML,2912.78,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270006,NDC,100,ML,2912.78,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270012,NDC,100,ML,3293.58,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270012,NDC,100,ML,3293.58,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270012,NDC,100,ML,3293.58,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270012,NDC,100,ML,3293.58,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270012,NDC,100,ML,3293.58,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270012,NDC,100,ML,3293.58,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270007,NDC,100,ML,2827.78,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270007,NDC,100,ML,2827.78,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270007,NDC,100,ML,2827.78,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270007,NDC,100,ML,2827.78,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270007,NDC,100,ML,2827.78,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270007,NDC,100,ML,2827.78,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270013,NDC,100,ML,2827.78,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270013,NDC,100,ML,2827.78,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270013,NDC,100,ML,2827.78,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270013,NDC,100,ML,2827.78,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270013,NDC,100,ML,2827.78,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270013,NDC,100,ML,2827.78,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunization Admin - Influenza,PX3241,CDM,771,RC,90471,CPT,,,,,,,,48,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunization Admin - Influenza,PX3241,CDM,771,RC,90471,CPT,,,,,,,,48,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunization Admin - Influenza,PX3241,CDM,771,RC,90471,CPT,,,,,,,,48,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunization Admin - Influenza,PX3241,CDM,771,RC,90471,CPT,,,,,,,,48,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunization Admin - Influenza,PX3241,CDM,771,RC,90471,CPT,,,,,,,,48,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunization Admin - Influenza,PX3241,CDM,771,RC,90471,CPT,,,,,,,,48,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunization Administration; Each Add'l Vaccine (Single or Combo Vaccine/T*,PX90472,CDM,771,RC,90472,CPT,,,,,,,,48,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunization Administration; Each Add'l Vaccine (Single or Combo Vaccine/T*,PX90472,CDM,771,RC,90472,CPT,,,,,,,,48,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunization Administration; Each Add'l Vaccine (Single or Combo Vaccine/T*,PX90472,CDM,771,RC,90472,CPT,,,,,,,,48,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunization Administration; Each Add'l Vaccine (Single or Combo Vaccine/T*,PX90472,CDM,771,RC,90472,CPT,,,,,,,,48,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunization Administration; Each Add'l Vaccine (Single or Combo Vaccine/T*,PX90472,CDM,771,RC,90472,CPT,,,,,,,,48,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunization Administration; Each Add'l Vaccine (Single or Combo Vaccine/T*,PX90472,CDM,771,RC,90472,CPT,,,,,,,,48,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunization Administration; One Vaccine (Single or Combination Vaccine/To*,PX90471,CDM,771,RC,90471,CPT,,,,,,,,130,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunization Administration; One Vaccine (Single or Combination Vaccine/To*,PX90471,CDM,771,RC,90471,CPT,,,,,,,,130,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunization Administration; One Vaccine (Single or Combination Vaccine/To*,PX90471,CDM,771,RC,90471,CPT,,,,,,,,130,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunization Administration; One Vaccine (Single or Combination Vaccine/To*,PX90471,CDM,771,RC,90471,CPT,,,,,,,,130,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunization Administration; One Vaccine (Single or Combination Vaccine/To*,PX90471,CDM,771,RC,90471,CPT,,,,,,,,130,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunization Administration; One Vaccine (Single or Combination Vaccine/To*,PX90471,CDM,771,RC,90471,CPT,,,,,,,,130,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Immuno for Tumor Ag, Qn - Ref",PX8631690,CDM,300,RC,86316,CPT,90,,,,,,,115,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Immuno for Tumor Ag, Qn - Ref",PX8631690,CDM,300,RC,86316,CPT,90,,,,,,,115,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Immuno for Tumor Ag, Qn - Ref",PX8631690,CDM,300,RC,86316,CPT,90,,,,,,,115,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Immuno for Tumor Ag, Qn - Ref",PX8631690,CDM,300,RC,86316,CPT,90,,,,,,,115,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Immuno for Tumor Ag, Qn - Ref",PX8631690,CDM,300,RC,86316,CPT,90,,,,,,,115,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Immuno for Tumor Ag, Qn - Ref",PX8631690,CDM,300,RC,86316,CPT,90,,,,,,,115,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunoassay - Ref,PX8351690,CDM,300,RC,83516,CPT,90,,,,,,,15,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunoassay - Ref,PX8351690,CDM,300,RC,83516,CPT,90,,,,,,,15,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunoassay - Ref,PX8351690,CDM,300,RC,83516,CPT,90,,,,,,,15,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunoassay - Ref,PX8351690,CDM,300,RC,83516,CPT,90,,,,,,,15,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunoassay - Ref,PX8351690,CDM,300,RC,83516,CPT,90,,,,,,,15,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunoassay - Ref,PX8351690,CDM,300,RC,83516,CPT,90,,,,,,,15,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunoassay Nos - Ref,PX8352090,CDM,300,RC,83520,CPT,90,,,,,,,220,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunoassay Nos - Ref,PX8352090,CDM,300,RC,83520,CPT,90,,,,,,,220,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunoassay Nos - Ref,PX8352090,CDM,300,RC,83520,CPT,90,,,,,,,220,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunoassay Nos - Ref,PX8352090,CDM,300,RC,83520,CPT,90,,,,,,,220,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunoassay Nos - Ref,PX8352090,CDM,300,RC,83520,CPT,90,,,,,,,220,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunoassay Nos - Ref,PX8352090,CDM,300,RC,83520,CPT,90,,,,,,,220,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Immunoassay,Ca15-3(27.29) - Ref",PX8630090,CDM,300,RC,86300,CPT,90,,,,,,,124,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Immunoassay,Ca15-3(27.29) - Ref",PX8630090,CDM,300,RC,86300,CPT,90,,,,,,,124,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Immunoassay,Ca15-3(27.29) - Ref",PX8630090,CDM,300,RC,86300,CPT,90,,,,,,,124,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Immunoassay,Ca15-3(27.29) - Ref",PX8630090,CDM,300,RC,86300,CPT,90,,,,,,,124,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Immunoassay,Ca15-3(27.29) - Ref",PX8630090,CDM,300,RC,86300,CPT,90,,,,,,,124,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Immunoassay,Ca15-3(27.29) - Ref",PX8630090,CDM,300,RC,86300,CPT,90,,,,,,,124,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunocytochemistry,PX3993,CDM,310,RC,88342,CPT,TC,,,,,,,182,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunocytochemistry,PX3993,CDM,310,RC,88342,CPT,TC,,,,,,,182,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunocytochemistry,PX3993,CDM,310,RC,88342,CPT,TC,,,,,,,182,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunocytochemistry,PX3993,CDM,310,RC,88342,CPT,TC,,,,,,,182,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunocytochemistry,PX3993,CDM,310,RC,88342,CPT,TC,,,,,,,182,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunocytochemistry,PX3993,CDM,310,RC,88342,CPT,TC,,,,,,,182,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunofix Elp,PX86335,CDM,300,RC,86335,CPT,,,,,,,,214,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunofix Elp,PX86335,CDM,300,RC,86335,CPT,,,,,,,,214,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunofix Elp,PX86335,CDM,300,RC,86335,CPT,,,,,,,,214,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunofix Elp,PX86335,CDM,300,RC,86335,CPT,,,,,,,,214,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunofix Elp,PX86335,CDM,300,RC,86335,CPT,,,,,,,,214,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunofix Elp,PX86335,CDM,300,RC,86335,CPT,,,,,,,,214,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunofixation Electrophoresis; Serum,PX86334,CDM,300,RC,86334,CPT,,,,,,,,145,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunofixation Electrophoresis; Serum,PX86334,CDM,300,RC,86334,CPT,,,,,,,,145,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunofixation Electrophoresis; Serum,PX86334,CDM,300,RC,86334,CPT,,,,,,,,145,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunofixation Electrophoresis; Serum,PX86334,CDM,300,RC,86334,CPT,,,,,,,,145,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunofixation Electrophoresis; Serum,PX86334,CDM,300,RC,86334,CPT,,,,,,,,145,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunofixation Electrophoresis; Serum,PX86334,CDM,300,RC,86334,CPT,,,,,,,,145,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Immunofluo Direct, Ea Ab - Ref",PX8834690,CDM,310,RC,88346,CPT,90,,,,,,,55,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Immunofluo Direct, Ea Ab - Ref",PX8834690,CDM,310,RC,88346,CPT,90,,,,,,,55,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Immunofluo Direct, Ea Ab - Ref",PX8834690,CDM,310,RC,88346,CPT,90,,,,,,,55,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Immunofluo Direct, Ea Ab - Ref",PX8834690,CDM,310,RC,88346,CPT,90,,,,,,,55,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Immunofluo Direct, Ea Ab - Ref",PX8834690,CDM,310,RC,88346,CPT,90,,,,,,,55,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Immunofluo Direct, Ea Ab - Ref",PX8834690,CDM,310,RC,88346,CPT,90,,,,,,,55,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunofluorescence per Spec Add Singl Antb Stain - Ref,PX8835090,CDM,310,RC,88350,CPT,90,,,,,,,112,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunofluorescence per Spec Add Singl Antb Stain - Ref,PX8835090,CDM,310,RC,88350,CPT,90,,,,,,,112,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunofluorescence per Spec Add Singl Antb Stain - Ref,PX8835090,CDM,310,RC,88350,CPT,90,,,,,,,112,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunofluorescence per Spec Add Singl Antb Stain - Ref,PX8835090,CDM,310,RC,88350,CPT,90,,,,,,,112,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunofluorescence per Spec Add Singl Antb Stain - Ref,PX8835090,CDM,310,RC,88350,CPT,90,,,,,,,112,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunofluorescence per Spec Add Singl Antb Stain - Ref,PX8835090,CDM,310,RC,88350,CPT,90,,,,,,,112,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunoglobulin Subclasses - Ref,PX8278790,CDM,300,RC,82787,CPT,90,,,,,,,215,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunoglobulin Subclasses - Ref,PX8278790,CDM,300,RC,82787,CPT,90,,,,,,,215,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunoglobulin Subclasses - Ref,PX8278790,CDM,300,RC,82787,CPT,90,,,,,,,215,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunoglobulin Subclasses - Ref,PX8278790,CDM,300,RC,82787,CPT,90,,,,,,,215,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunoglobulin Subclasses - Ref,PX8278790,CDM,300,RC,82787,CPT,90,,,,,,,215,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunoglobulin Subclasses - Ref,PX8278790,CDM,300,RC,82787,CPT,90,,,,,,,215,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunohisto Antibody Slide Ea Addl,PX8834101,CDM,310,RC,88341,CPT,TC,,,,,,,102,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunohisto Antibody Slide Ea Addl,PX8834101,CDM,310,RC,88341,CPT,TC,,,,,,,102,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunohisto Antibody Slide Ea Addl,PX8834101,CDM,310,RC,88341,CPT,TC,,,,,,,102,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunohisto Antibody Slide Ea Addl,PX8834101,CDM,310,RC,88341,CPT,TC,,,,,,,102,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunohisto Antibody Slide Ea Addl,PX8834101,CDM,310,RC,88341,CPT,TC,,,,,,,102,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunohisto Antibody Slide Ea Addl,PX8834101,CDM,310,RC,88341,CPT,TC,,,,,,,102,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunohisto Antibody Slide Ea Multiplex,PX8834401,CDM,310,RC,88344,CPT,TC,,,,,,,51,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunohisto Antibody Slide Ea Multiplex,PX8834401,CDM,310,RC,88344,CPT,TC,,,,,,,51,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunohisto Antibody Slide Ea Multiplex,PX8834401,CDM,310,RC,88344,CPT,TC,,,,,,,51,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunohisto Antibody Slide Ea Multiplex,PX8834401,CDM,310,RC,88344,CPT,TC,,,,,,,51,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunohisto Antibody Slide Ea Multiplex,PX8834401,CDM,310,RC,88344,CPT,TC,,,,,,,51,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunohisto Antibody Slide Ea Multiplex,PX8834401,CDM,310,RC,88344,CPT,TC,,,,,,,51,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMPLANT PACKAGE TOEMATE,27200000,CDM,278,RC,C1713,HCPCS,,11859-MAIN,LOCAL,,,,,2865,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMPLANT PACKAGE TOEMATE,27200000,CDM,278,RC,C1713,HCPCS,,11859-MAIN,LOCAL,,,,,2865,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMPLANT PACKAGE TOEMATE,27200000,CDM,278,RC,C1713,HCPCS,,11859-MAIN,LOCAL,,,,,2865,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMPLANT PACKAGE TOEMATE,27200000,CDM,278,RC,C1713,HCPCS,,11859-MAIN,LOCAL,,,,,2865,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMPLANT PACKAGE TOEMATE,27200000,CDM,278,RC,C1713,HCPCS,,11859-MAIN,LOCAL,,,,,2865,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMPLANT PACKAGE TOEMATE,27200000,CDM,278,RC,C1713,HCPCS,,11859-MAIN,LOCAL,,,,,2865,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMPLANT TOEMATE X-SMALL PACKAGE 9H00-T050,C1713,CDM,278,RC,C1713,HCPCS,,11574-MAIN,LOCAL,,,,,2865,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMPLANT TOEMATE X-SMALL PACKAGE 9H00-T050,C1713,CDM,278,RC,C1713,HCPCS,,11574-MAIN,LOCAL,,,,,2865,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMPLANT TOEMATE X-SMALL PACKAGE 9H00-T050,C1713,CDM,278,RC,C1713,HCPCS,,11574-MAIN,LOCAL,,,,,2865,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMPLANT TOEMATE X-SMALL PACKAGE 9H00-T050,C1713,CDM,278,RC,C1713,HCPCS,,11574-MAIN,LOCAL,,,,,2865,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMPLANT TOEMATE X-SMALL PACKAGE 9H00-T050,C1713,CDM,278,RC,C1713,HCPCS,,11574-MAIN,LOCAL,,,,,2865,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMPLANT TOEMATE X-SMALL PACKAGE 9H00-T050,C1713,CDM,278,RC,C1713,HCPCS,,11574-MAIN,LOCAL,,,,,2865,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"In Situ Hybridization (Eg, Fish), Each Probe, Tech",PX8836501,CDM,310,RC,88365,CPT,TC,,,,,,,117,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"In Situ Hybridization (Eg, Fish), Each Probe, Tech",PX8836501,CDM,310,RC,88365,CPT,TC,,,,,,,117,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"In Situ Hybridization (Eg, Fish), Each Probe, Tech",PX8836501,CDM,310,RC,88365,CPT,TC,,,,,,,117,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"In Situ Hybridization (Eg, Fish), Each Probe, Tech",PX8836501,CDM,310,RC,88365,CPT,TC,,,,,,,117,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"In Situ Hybridization (Eg, Fish), Each Probe, Tech",PX8836501,CDM,310,RC,88365,CPT,TC,,,,,,,117,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"In Situ Hybridization (Eg, Fish), Each Probe, Tech",PX8836501,CDM,310,RC,88365,CPT,TC,,,,,,,117,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Inc/Drain Peritonsil Abscess,PX42700F,CDM,510,RC,42700,CPT,,,,,,,,624,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Inc/Drain Peritonsil Abscess,PX42700F,CDM,510,RC,42700,CPT,,,,,,,,624,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Inc/Drain Peritonsil Abscess,PX42700F,CDM,510,RC,42700,CPT,,,,,,,,624,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Inc/Drain Peritonsil Abscess,PX42700F,CDM,510,RC,42700,CPT,,,,,,,,624,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Inc/Drain Peritonsil Abscess,PX42700F,CDM,510,RC,42700,CPT,,,,,,,,624,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Inc/Drain Peritonsil Abscess,PX42700F,CDM,510,RC,42700,CPT,,,,,,,,624,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Inc/Drain Peritonsil Abscess,PX42700P,CDM,983,RC,42700,CPT,,,,,,,,889,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Inc/Drain Peritonsil Abscess,PX42700P,CDM,983,RC,42700,CPT,,,,,,,,889,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Inc/Drain Peritonsil Abscess,PX42700P,CDM,983,RC,42700,CPT,,,,,,,,889,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Inc/Drain Peritonsil Abscess,PX42700P,CDM,983,RC,42700,CPT,,,,,,,,889,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Inc/Drain Peritonsil Abscess,PX42700P,CDM,983,RC,42700,CPT,,,,,,,,889,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Inc/Drain Peritonsil Abscess,PX42700P,CDM,983,RC,42700,CPT,,,,,,,,889,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Incis/Drain Scrotum/Testis,Epididym",PX54700F,CDM,510,RC,54700,CPT,,,,,,,,660,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Incis/Drain Scrotum/Testis,Epididym",PX54700F,CDM,510,RC,54700,CPT,,,,,,,,660,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Incis/Drain Scrotum/Testis,Epididym",PX54700F,CDM,510,RC,54700,CPT,,,,,,,,660,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Incis/Drain Scrotum/Testis,Epididym",PX54700F,CDM,510,RC,54700,CPT,,,,,,,,660,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Incis/Drain Scrotum/Testis,Epididym",PX54700F,CDM,510,RC,54700,CPT,,,,,,,,660,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Incis/Drain Scrotum/Testis,Epididym",PX54700F,CDM,510,RC,54700,CPT,,,,,,,,660,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Incis/Drain Scrotum/Testis,Epididym",PX54700P,CDM,983,RC,54700,CPT,,,,,,,,440,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Incis/Drain Scrotum/Testis,Epididym",PX54700P,CDM,983,RC,54700,CPT,,,,,,,,440,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Incis/Drain Scrotum/Testis,Epididym",PX54700P,CDM,983,RC,54700,CPT,,,,,,,,440,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Incis/Drain Scrotum/Testis,Epididym",PX54700P,CDM,983,RC,54700,CPT,,,,,,,,440,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Incis/Drain Scrotum/Testis,Epididym",PX54700P,CDM,983,RC,54700,CPT,,,,,,,,440,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Incis/Drain Scrotum/Testis,Epididym",PX54700P,CDM,983,RC,54700,CPT,,,,,,,,440,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Incis/Drain Shldr Absc/Hema,Deep",PX23030P,CDM,983,RC,23030,CPT,,,,,,,,1564,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Incis/Drain Shldr Absc/Hema,Deep",PX23030P,CDM,983,RC,23030,CPT,,,,,,,,1564,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Incis/Drain Shldr Absc/Hema,Deep",PX23030P,CDM,983,RC,23030,CPT,,,,,,,,1564,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Incis/Drain Shldr Absc/Hema,Deep",PX23030P,CDM,983,RC,23030,CPT,,,,,,,,1564,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Incis/Drain Shldr Absc/Hema,Deep",PX23030P,CDM,983,RC,23030,CPT,,,,,,,,1564,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Incis/Drain Shldr Absc/Hema,Deep",PX23030P,CDM,983,RC,23030,CPT,,,,,,,,1564,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Incise External Hemorrhoid,PX46083F,CDM,510,RC,46083,CPT,,,,,,,,502,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Incise External Hemorrhoid,PX46083F,CDM,510,RC,46083,CPT,,,,,,,,502,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Incise External Hemorrhoid,PX46083F,CDM,510,RC,46083,CPT,,,,,,,,502,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Incise External Hemorrhoid,PX46083F,CDM,510,RC,46083,CPT,,,,,,,,502,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Incise External Hemorrhoid,PX46083F,CDM,510,RC,46083,CPT,,,,,,,,502,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Incise External Hemorrhoid,PX46083F,CDM,510,RC,46083,CPT,,,,,,,,502,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Incise External Hemorrhoid,PX46083P,CDM,983,RC,46083,CPT,,,,,,,,956,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Incise External Hemorrhoid,PX46083P,CDM,983,RC,46083,CPT,,,,,,,,956,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Incise External Hemorrhoid,PX46083P,CDM,983,RC,46083,CPT,,,,,,,,956,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Incise External Hemorrhoid,PX46083P,CDM,983,RC,46083,CPT,,,,,,,,956,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Incise External Hemorrhoid,PX46083P,CDM,983,RC,46083,CPT,,,,,,,,956,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Incise External Hemorrhoid,PX46083P,CDM,983,RC,46083,CPT,,,,,,,,956,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Incise Finger Tendon Sheath,PX26055F,CDM,510,RC,26055,CPT,,,,,,,,1398,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Incise Finger Tendon Sheath,PX26055F,CDM,510,RC,26055,CPT,,,,,,,,1398,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Incise Finger Tendon Sheath,PX26055F,CDM,510,RC,26055,CPT,,,,,,,,1398,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Incise Finger Tendon Sheath,PX26055F,CDM,510,RC,26055,CPT,,,,,,,,1398,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Incise Finger Tendon Sheath,PX26055F,CDM,510,RC,26055,CPT,,,,,,,,1398,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Incise Finger Tendon Sheath,PX26055F,CDM,510,RC,26055,CPT,,,,,,,,1398,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Incise Finger Tendon Sheath,PX26055P,CDM,983,RC,26055,CPT,,,,,,,,932,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Incise Finger Tendon Sheath,PX26055P,CDM,983,RC,26055,CPT,,,,,,,,932,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Incise Finger Tendon Sheath,PX26055P,CDM,983,RC,26055,CPT,,,,,,,,932,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Incise Finger Tendon Sheath,PX26055P,CDM,983,RC,26055,CPT,,,,,,,,932,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Incise Finger Tendon Sheath,PX26055P,CDM,983,RC,26055,CPT,,,,,,,,932,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Incise Finger Tendon Sheath,PX26055P,CDM,983,RC,26055,CPT,,,,,,,,932,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106F,CDM,510,RC,11106,CPT,,,,,,,,255,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106F,CDM,510,RC,11106,CPT,,,,,,,,255,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106F,CDM,510,RC,11106,CPT,,,,,,,,255,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106F,CDM,510,RC,11106,CPT,,,,,,,,255,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106F,CDM,510,RC,11106,CPT,,,,,,,,255,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106F,CDM,510,RC,11106,CPT,,,,,,,,255,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106P,CDM,983,RC,11106,CPT,,,,,,,,204,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106P,CDM,983,RC,11106,CPT,,,,,,,,204,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106P,CDM,983,RC,11106,CPT,,,,,,,,204,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106P,CDM,983,RC,11106,CPT,,,,,,,,204,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106P,CDM,983,RC,11106,CPT,,,,,,,,204,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106P,CDM,983,RC,11106,CPT,,,,,,,,204,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
indocyanine green 25 MG Recon Soln 1 Each Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,70100042402,NDC,1,EA,446.07,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
indocyanine green 25 MG Recon Soln 1 Each Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,70100042402,NDC,1,EA,446.07,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
indocyanine green 25 MG Recon Soln 1 Each Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,70100042402,NDC,1,EA,446.07,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
indocyanine green 25 MG Recon Soln 1 Each Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,70100042402,NDC,1,EA,446.07,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
indocyanine green 25 MG Recon Soln 1 Each Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,70100042402,NDC,1,EA,446.07,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
indocyanine green 25 MG Recon Soln 1 Each Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,70100042402,NDC,1,EA,446.07,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
indomethacin 25 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,50268043011,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
indomethacin 25 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,50268043011,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
indomethacin 25 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,50268043011,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
indomethacin 25 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,50268043011,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
indomethacin 25 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,50268043011,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
indomethacin 25 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,50268043011,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Inf Ag Detect by Nucleic Acid (Dna or Rna); (Sars-Cov-2,PXU0005,CDM,300,RC,U0005,HCPCS,,,,,,,,0.01,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Inf Ag Detect by Nucleic Acid (Dna or Rna); (Sars-Cov-2,PXU0005,CDM,300,RC,U0005,HCPCS,,,,,,,,0.01,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Inf Ag Detect by Nucleic Acid (Dna or Rna); (Sars-Cov-2,PXU0005,CDM,300,RC,U0005,HCPCS,,,,,,,,0.01,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Inf Ag Detect by Nucleic Acid (Dna or Rna); (Sars-Cov-2,PXU0005,CDM,300,RC,U0005,HCPCS,,,,,,,,0.01,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Inf Ag Detect by Nucleic Acid (Dna or Rna); (Sars-Cov-2,PXU0005,CDM,300,RC,U0005,HCPCS,,,,,,,,0.01,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Inf Ag Detect by Nucleic Acid (Dna or Rna); (Sars-Cov-2,PXU0005,CDM,300,RC,U0005,HCPCS,,,,,,,,0.01,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Infec Agent Direct Probe - Ref,PX8779990,CDM,300,RC,87799,CPT,90,,,,,,,182,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Infec Agent Direct Probe - Ref,PX8779990,CDM,300,RC,87799,CPT,90,,,,,,,182,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Infec Agent Direct Probe - Ref,PX8779990,CDM,300,RC,87799,CPT,90,,,,,,,182,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Infec Agent Direct Probe - Ref,PX8779990,CDM,300,RC,87799,CPT,90,,,,,,,182,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Infec Agent Direct Probe - Ref,PX8779990,CDM,300,RC,87799,CPT,90,,,,,,,182,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Infec Agent Direct Probe - Ref,PX8779990,CDM,300,RC,87799,CPT,90,,,,,,,182,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Infect Ag,Eia, Nos, Ea - Ref",PX8744990,CDM,300,RC,87449,CPT,90,,,,,,,187,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Infect Ag,Eia, Nos, Ea - Ref",PX8744990,CDM,300,RC,87449,CPT,90,,,,,,,187,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Infect Ag,Eia, Nos, Ea - Ref",PX8744990,CDM,300,RC,87449,CPT,90,,,,,,,187,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Infect Ag,Eia, Nos, Ea - Ref",PX8744990,CDM,300,RC,87449,CPT,90,,,,,,,187,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Infect Ag,Eia, Nos, Ea - Ref",PX8744990,CDM,300,RC,87449,CPT,90,,,,,,,187,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Infect Ag,Eia, Nos, Ea - Ref",PX8744990,CDM,300,RC,87449,CPT,90,,,,,,,187,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Infect Ea Organ, Amp Prob - Ref",PX8779890,CDM,300,RC,87798,CPT,90,,,,,,,180,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Infect Ea Organ, Amp Prob - Ref",PX8779890,CDM,300,RC,87798,CPT,90,,,,,,,180,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Infect Ea Organ, Amp Prob - Ref",PX8779890,CDM,300,RC,87798,CPT,90,,,,,,,180,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Infect Ea Organ, Amp Prob - Ref",PX8779890,CDM,300,RC,87798,CPT,90,,,,,,,180,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Infect Ea Organ, Amp Prob - Ref",PX8779890,CDM,300,RC,87798,CPT,90,,,,,,,180,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Infect Ea Organ, Amp Prob - Ref",PX8779890,CDM,300,RC,87798,CPT,90,,,,,,,180,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Infect, Organ, Amp Probe - Ref",PX8780190,CDM,300,RC,87801,CPT,90,,,,,,,630,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Infect, Organ, Amp Probe - Ref",PX8780190,CDM,300,RC,87801,CPT,90,,,,,,,630,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Infect, Organ, Amp Probe - Ref",PX8780190,CDM,300,RC,87801,CPT,90,,,,,,,630,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Infect, Organ, Amp Probe - Ref",PX8780190,CDM,300,RC,87801,CPT,90,,,,,,,630,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Infect, Organ, Amp Probe - Ref",PX8780190,CDM,300,RC,87801,CPT,90,,,,,,,630,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Infect, Organ, Amp Probe - Ref",PX8780190,CDM,300,RC,87801,CPT,90,,,,,,,630,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Infection Agent Detect Dna/Rna Probe Tq 6-11,PX87506,CDM,300,RC,87506,CPT,,,,,,,,1710,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Infection Agent Detect Dna/Rna Probe Tq 6-11,PX87506,CDM,300,RC,87506,CPT,,,,,,,,1710,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Infection Agent Detect Dna/Rna Probe Tq 6-11,PX87506,CDM,300,RC,87506,CPT,,,,,,,,1710,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Infection Agent Detect Dna/Rna Probe Tq 6-11,PX87506,CDM,300,RC,87506,CPT,,,,,,,,1710,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Infection Agent Detect Dna/Rna Probe Tq 6-11,PX87506,CDM,300,RC,87506,CPT,,,,,,,,1710,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Infection Agent Detect Dna/Rna Probe Tq 6-11,PX87506,CDM,300,RC,87506,CPT,,,,,,,,1710,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Infection Agent Detect Dna/Rna Probe Tq 12-25,PX87507,CDM,300,RC,87507,CPT,,,,,,,,209,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Infection Agent Detect Dna/Rna Probe Tq 12-25,PX87507,CDM,300,RC,87507,CPT,,,,,,,,209,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Infection Agent Detect Dna/Rna Probe Tq 12-25,PX87507,CDM,300,RC,87507,CPT,,,,,,,,209,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Infection Agent Detect Dna/Rna Probe Tq 12-25,PX87507,CDM,300,RC,87507,CPT,,,,,,,,209,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Infection Agent Detect Dna/Rna Probe Tq 12-25,PX87507,CDM,300,RC,87507,CPT,,,,,,,,209,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Infection Agent Detect Dna/Rna Probe Tq 12-25,PX87507,CDM,300,RC,87507,CPT,,,,,,,,209,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Infectious Agent Antigen Detection by Immunoassay With Direct Visual Observation.,PX87811,CDM,300,RC,87811,CPT,,,,,,,,192,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Infectious Agent Antigen Detection by Immunoassay With Direct Visual Observation.,PX87811,CDM,300,RC,87811,CPT,,,,,,,,192,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Infectious Agent Antigen Detection by Immunoassay With Direct Visual Observation.,PX87811,CDM,300,RC,87811,CPT,,,,,,,,192,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Infectious Agent Antigen Detection by Immunoassay With Direct Visual Observation.,PX87811,CDM,300,RC,87811,CPT,,,,,,,,192,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Infectious Agent Antigen Detection by Immunoassay With Direct Visual Observation.,PX87811,CDM,300,RC,87811,CPT,,,,,,,,192,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Infectious Agent Antigen Detection by Immunoassay With Direct Visual Observation.,PX87811,CDM,300,RC,87811,CPT,,,,,,,,192,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU0003,CDM,300,RC,U0003,HCPCS,,,,,,,,133,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU0003,CDM,300,RC,U0003,HCPCS,,,,,,,,133,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU0003,CDM,300,RC,U0003,HCPCS,,,,,,,,133,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU0003,CDM,300,RC,U0003,HCPCS,,,,,,,,133,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU0003,CDM,300,RC,U0003,HCPCS,,,,,,,,133,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU0003,CDM,300,RC,U0003,HCPCS,,,,,,,,133,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU000390,CDM,300,RC,U0003,HCPCS,90,,,,,,,222,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU000390,CDM,300,RC,U0003,HCPCS,90,,,,,,,222,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU000390,CDM,300,RC,U0003,HCPCS,90,,,,,,,222,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU000390,CDM,300,RC,U0003,HCPCS,90,,,,,,,222,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU000390,CDM,300,RC,U0003,HCPCS,90,,,,,,,222,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU000390,CDM,300,RC,U0003,HCPCS,90,,,,,,,222,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Infectious Disease (Viral Respiratory Tract Infection),",PX0241U,CDM,300,RC,0241U,HCPCS,,,,,,,,457,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Infectious Disease (Viral Respiratory Tract Infection),",PX0241U,CDM,300,RC,0241U,HCPCS,,,,,,,,457,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Infectious Disease (Viral Respiratory Tract Infection),",PX0241U,CDM,300,RC,0241U,HCPCS,,,,,,,,457,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Infectious Disease (Viral Respiratory Tract Infection),",PX0241U,CDM,300,RC,0241U,HCPCS,,,,,,,,457,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Infectious Disease (Viral Respiratory Tract Infection),",PX0241U,CDM,300,RC,0241U,HCPCS,,,,,,,,457,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Infectious Disease (Viral Respiratory Tract Infection),",PX0241U,CDM,300,RC,0241U,HCPCS,,,,,,,,457,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Infectious Disease,Chronic Hep C Virus,Six Assays, Utilizing Serum",PX8159690,CDM,300,RC,81596,CPT,90,,,,,,,609,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Infectious Disease,Chronic Hep C Virus,Six Assays, Utilizing Serum",PX8159690,CDM,300,RC,81596,CPT,90,,,,,,,609,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Infectious Disease,Chronic Hep C Virus,Six Assays, Utilizing Serum",PX8159690,CDM,300,RC,81596,CPT,90,,,,,,,609,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Infectious Disease,Chronic Hep C Virus,Six Assays, Utilizing Serum",PX8159690,CDM,300,RC,81596,CPT,90,,,,,,,609,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Infectious Disease,Chronic Hep C Virus,Six Assays, Utilizing Serum",PX8159690,CDM,300,RC,81596,CPT,90,,,,,,,609,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Infectious Disease,Chronic Hep C Virus,Six Assays, Utilizing Serum",PX8159690,CDM,300,RC,81596,CPT,90,,,,,,,609,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Infliximab - Ref,PX8023090,CDM,300,RC,80230,CPT,90,,,,,,,343,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Infliximab - Ref,PX8023090,CDM,300,RC,80230,CPT,90,,,,,,,343,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Infliximab - Ref,PX8023090,CDM,300,RC,80230,CPT,90,,,,,,,343,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Infliximab - Ref,PX8023090,CDM,300,RC,80230,CPT,90,,,,,,,343,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Infliximab - Ref,PX8023090,CDM,300,RC,80230,CPT,90,,,,,,,343,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Infliximab - Ref,PX8023090,CDM,300,RC,80230,CPT,90,,,,,,,343,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
inFLIXimab 100 MG Recon Soln 1 Each Vial,J1745.01,CDM,636,RC,J1745,HCPCS,,,,57894003001,NDC,1,EA,2382.35,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
inFLIXimab 100 MG Recon Soln 1 Each Vial,J1745.01,CDM,636,RC,J1745,HCPCS,,,,57894003001,NDC,1,EA,2382.35,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
inFLIXimab 100 MG Recon Soln 1 Each Vial,J1745.01,CDM,636,RC,J1745,HCPCS,,,,57894003001,NDC,1,EA,2382.35,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
inFLIXimab 100 MG Recon Soln 1 Each Vial,J1745.01,CDM,636,RC,J1745,HCPCS,,,,57894003001,NDC,1,EA,2382.35,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
inFLIXimab 100 MG Recon Soln 1 Each Vial,J1745.01,CDM,636,RC,J1745,HCPCS,,,,57894003001,NDC,1,EA,2382.35,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
inFLIXimab 100 MG Recon Soln 1 Each Vial,J1745.01,CDM,636,RC,J1745,HCPCS,,,,57894003001,NDC,1,EA,2382.35,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
inFLIXimab-dyyb 100 MG Recon Soln 1 Each Vial,Q5103.01,CDM,636,RC,Q5103,HCPCS,,,,69080901,NDC,1,EA,1930.42,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
inFLIXimab-dyyb 100 MG Recon Soln 1 Each Vial,Q5103.01,CDM,636,RC,Q5103,HCPCS,,,,69080901,NDC,1,EA,1930.42,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
inFLIXimab-dyyb 100 MG Recon Soln 1 Each Vial,Q5103.01,CDM,636,RC,Q5103,HCPCS,,,,69080901,NDC,1,EA,1930.42,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
inFLIXimab-dyyb 100 MG Recon Soln 1 Each Vial,Q5103.01,CDM,636,RC,Q5103,HCPCS,,,,69080901,NDC,1,EA,1930.42,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
inFLIXimab-dyyb 100 MG Recon Soln 1 Each Vial,Q5103.01,CDM,636,RC,Q5103,HCPCS,,,,69080901,NDC,1,EA,1930.42,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
inFLIXimab-dyyb 100 MG Recon Soln 1 Each Vial,Q5103.01,CDM,636,RC,Q5103,HCPCS,,,,69080901,NDC,1,EA,1930.42,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Influenza Assay W/Optic,PX87804,CDM,300,RC,87804,CPT,,,,,,,,127,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Influenza Assay W/Optic,PX87804,CDM,300,RC,87804,CPT,,,,,,,,127,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Influenza Assay W/Optic,PX87804,CDM,300,RC,87804,CPT,,,,,,,,127,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Influenza Assay W/Optic,PX87804,CDM,300,RC,87804,CPT,,,,,,,,127,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Influenza Assay W/Optic,PX87804,CDM,300,RC,87804,CPT,,,,,,,,127,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Influenza Assay W/Optic,PX87804,CDM,300,RC,87804,CPT,,,,,,,,127,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012365,NDC,0.7,ML,291.98,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012365,NDC,0.7,ML,291.98,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012365,NDC,0.7,ML,291.98,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012365,NDC,0.7,ML,291.98,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012365,NDC,0.7,ML,291.98,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012365,NDC,0.7,ML,291.98,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012388,NDC,0.7,ML,291.98,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012388,NDC,0.7,ML,291.98,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012388,NDC,0.7,ML,291.98,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012388,NDC,0.7,ML,291.98,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012388,NDC,0.7,ML,291.98,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012388,NDC,0.7,ML,291.98,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072310,NDC,0.5,ML,291.98,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072310,NDC,0.5,ML,291.98,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072310,NDC,0.5,ML,291.98,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072310,NDC,0.5,ML,291.98,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072310,NDC,0.5,ML,291.98,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072310,NDC,0.5,ML,291.98,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072388,NDC,0.5,ML,291.98,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072388,NDC,0.5,ML,291.98,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072388,NDC,0.5,ML,291.98,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072388,NDC,0.5,ML,291.98,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072388,NDC,0.5,ML,291.98,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072388,NDC,0.5,ML,291.98,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042350,NDC,0.5,ML,132.37,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042350,NDC,0.5,ML,132.37,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042350,NDC,0.5,ML,132.37,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042350,NDC,0.5,ML,132.37,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042350,NDC,0.5,ML,132.37,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042350,NDC,0.5,ML,132.37,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042388,NDC,0.5,ML,132.37,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042388,NDC,0.5,ML,132.37,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042388,NDC,0.5,ML,132.37,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042388,NDC,0.5,ML,132.37,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042388,NDC,0.5,ML,132.37,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042388,NDC,0.5,ML,132.37,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
infuvite adult Injectable 10 mL Vial,J3490.99,CDM,636,RC,J3490,HCPCS,,,,54643564901,NDC,10,ML,86.89,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
infuvite adult Injectable 10 mL Vial,J3490.99,CDM,636,RC,J3490,HCPCS,,,,54643564901,NDC,10,ML,86.89,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
infuvite adult Injectable 10 mL Vial,J3490.99,CDM,636,RC,J3490,HCPCS,,,,54643564901,NDC,10,ML,86.89,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
infuvite adult Injectable 10 mL Vial,J3490.99,CDM,636,RC,J3490,HCPCS,,,,54643564901,NDC,10,ML,86.89,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
infuvite adult Injectable 10 mL Vial,J3490.99,CDM,636,RC,J3490,HCPCS,,,,54643564901,NDC,10,ML,86.89,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
infuvite adult Injectable 10 mL Vial,J3490.99,CDM,636,RC,J3490,HCPCS,,,,54643564901,NDC,10,ML,86.89,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Initial Hospital Care Levl II,PX99222P,CDM,982,RC,99222,CPT,,,,,,,,187,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Initial Hospital Care Levl II,PX99222P,CDM,982,RC,99222,CPT,,,,,,,,187,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Initial Hospital Care Levl II,PX99222P,CDM,982,RC,99222,CPT,,,,,,,,187,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Initial Hospital Care Levl II,PX99222P,CDM,982,RC,99222,CPT,,,,,,,,187,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Initial Hospital Care Levl II,PX99222P,CDM,982,RC,99222,CPT,,,,,,,,187,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Initial Hospital Care Levl II,PX99222P,CDM,982,RC,99222,CPT,,,,,,,,187,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Observation Care,Levl I",PX99218,CDM,982,RC,99218,CPT,,,,,,,,266,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Observation Care,Levl I",PX99218,CDM,982,RC,99218,CPT,,,,,,,,266,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Observation Care,Levl I",PX99218,CDM,982,RC,99218,CPT,,,,,,,,266,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Observation Care,Levl I",PX99218,CDM,982,RC,99218,CPT,,,,,,,,266,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Observation Care,Levl I",PX99218,CDM,982,RC,99218,CPT,,,,,,,,266,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Observation Care,Levl I",PX99218,CDM,982,RC,99218,CPT,,,,,,,,266,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Observation Care,Levl II",PX99219,CDM,982,RC,99219,CPT,,,,,,,,391,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Observation Care,Levl II",PX99219,CDM,982,RC,99219,CPT,,,,,,,,391,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Observation Care,Levl II",PX99219,CDM,982,RC,99219,CPT,,,,,,,,391,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Observation Care,Levl II",PX99219,CDM,982,RC,99219,CPT,,,,,,,,391,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Observation Care,Levl II",PX99219,CDM,982,RC,99219,CPT,,,,,,,,391,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Observation Care,Levl II",PX99219,CDM,982,RC,99219,CPT,,,,,,,,391,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Observation Care,Levl III",PX99220,CDM,982,RC,99220,CPT,,,,,,,,461,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Observation Care,Levl III",PX99220,CDM,982,RC,99220,CPT,,,,,,,,461,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Observation Care,Levl III",PX99220,CDM,982,RC,99220,CPT,,,,,,,,461,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Observation Care,Levl III",PX99220,CDM,982,RC,99220,CPT,,,,,,,,461,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Observation Care,Levl III",PX99220,CDM,982,RC,99220,CPT,,,,,,,,461,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Observation Care,Levl III",PX99220,CDM,982,RC,99220,CPT,,,,,,,,461,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Repair of Entrapped Hernia of Abdomen, Less Than 3 Cm in Length",PX49592,CDM,982,RC,49592,CPT,,,,,,,,2164,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Repair of Entrapped Hernia of Abdomen, Less Than 3 Cm in Length",PX49592,CDM,982,RC,49592,CPT,,,,,,,,2164,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Repair of Entrapped Hernia of Abdomen, Less Than 3 Cm in Length",PX49592,CDM,982,RC,49592,CPT,,,,,,,,2164,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Repair of Entrapped Hernia of Abdomen, Less Than 3 Cm in Length",PX49592,CDM,982,RC,49592,CPT,,,,,,,,2164,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Repair of Entrapped Hernia of Abdomen, Less Than 3 Cm in Length",PX49592,CDM,982,RC,49592,CPT,,,,,,,,2164,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Repair of Entrapped Hernia of Abdomen, Less Than 3 Cm in Length",PX49592,CDM,982,RC,49592,CPT,,,,,,,,2164,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Repair of Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49593P,CDM,982,RC,49593,CPT,,,,,,,,2606,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Repair of Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49593P,CDM,982,RC,49593,CPT,,,,,,,,2606,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Repair of Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49593P,CDM,982,RC,49593,CPT,,,,,,,,2606,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Repair of Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49593P,CDM,982,RC,49593,CPT,,,,,,,,2606,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Repair of Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49593P,CDM,982,RC,49593,CPT,,,,,,,,2606,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Repair of Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49593P,CDM,982,RC,49593,CPT,,,,,,,,2606,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591F,CDM,360,RC,49591,CPT,,,,,,,,1556,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1372.392,6141.46
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591F,CDM,360,RC,49591,CPT,,,,,,,,1556,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1372.392,6141.46
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591F,CDM,360,RC,49591,CPT,,,,,,,,1556,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1372.392,6141.46
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591F,CDM,360,RC,49591,CPT,,,,,,,,1556,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1372.392,6141.46
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591F,CDM,360,RC,49591,CPT,,,,,,,,1556,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1372.392,6141.46
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591F,CDM,360,RC,49591,CPT,,,,,,,,1556,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1372.392,6141.46
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591P,CDM,982,RC,49591,CPT,,,,,,,,1245,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591P,CDM,982,RC,49591,CPT,,,,,,,,1245,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591P,CDM,982,RC,49591,CPT,,,,,,,,1245,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591P,CDM,982,RC,49591,CPT,,,,,,,,1245,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591P,CDM,982,RC,49591,CPT,,,,,,,,1245,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591P,CDM,982,RC,49591,CPT,,,,,,,,1245,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595F,CDM,360,RC,49595,CPT,,,,,,,,3503,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3089.646,6141.46
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595F,CDM,360,RC,49595,CPT,,,,,,,,3503,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3089.646,6141.46
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595F,CDM,360,RC,49595,CPT,,,,,,,,3503,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3089.646,6141.46
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595F,CDM,360,RC,49595,CPT,,,,,,,,3503,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3089.646,6141.46
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595F,CDM,360,RC,49595,CPT,,,,,,,,3503,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3089.646,6141.46
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595F,CDM,360,RC,49595,CPT,,,,,,,,3503,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3089.646,6141.46
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595P,CDM,982,RC,49595,CPT,,,,,,,,3503,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595P,CDM,982,RC,49595,CPT,,,,,,,,3503,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595P,CDM,982,RC,49595,CPT,,,,,,,,3503,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595P,CDM,982,RC,49595,CPT,,,,,,,,3503,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595P,CDM,982,RC,49595,CPT,,,,,,,,3503,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595P,CDM,982,RC,49595,CPT,,,,,,,,3503,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Initial Rx Burn(S) 1st Degree,PX16000F,CDM,510,RC,16000,CPT,,,,,,,,338,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Initial Rx Burn(S) 1st Degree,PX16000F,CDM,510,RC,16000,CPT,,,,,,,,338,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Initial Rx Burn(S) 1st Degree,PX16000F,CDM,510,RC,16000,CPT,,,,,,,,338,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Initial Rx Burn(S) 1st Degree,PX16000F,CDM,510,RC,16000,CPT,,,,,,,,338,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Initial Rx Burn(S) 1st Degree,PX16000F,CDM,510,RC,16000,CPT,,,,,,,,338,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Initial Rx Burn(S) 1st Degree,PX16000F,CDM,510,RC,16000,CPT,,,,,,,,338,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Inj Tendon/Ligament/Cyst,PX20550F,CDM,510,RC,20550,CPT,,,,,,,,177,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Inj Tendon/Ligament/Cyst,PX20550F,CDM,510,RC,20550,CPT,,,,,,,,177,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Inj Tendon/Ligament/Cyst,PX20550F,CDM,510,RC,20550,CPT,,,,,,,,177,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Inj Tendon/Ligament/Cyst,PX20550F,CDM,510,RC,20550,CPT,,,,,,,,177,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Inj Tendon/Ligament/Cyst,PX20550F,CDM,510,RC,20550,CPT,,,,,,,,177,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Inj Tendon/Ligament/Cyst,PX20550F,CDM,510,RC,20550,CPT,,,,,,,,177,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Inj Tendon/Ligament/Cyst,PX20550P,CDM,983,RC,20550,CPT,,,,,,,,264,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Inj Tendon/Ligament/Cyst,PX20550P,CDM,983,RC,20550,CPT,,,,,,,,264,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Inj Tendon/Ligament/Cyst,PX20550P,CDM,983,RC,20550,CPT,,,,,,,,264,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Inj Tendon/Ligament/Cyst,PX20550P,CDM,983,RC,20550,CPT,,,,,,,,264,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Inj Tendon/Ligament/Cyst,PX20550P,CDM,983,RC,20550,CPT,,,,,,,,264,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Inj Tendon/Ligament/Cyst,PX20550P,CDM,983,RC,20550,CPT,,,,,,,,264,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inj,Lumb Epidur,Blood/Clot Patch",PX62273P,CDM,983,RC,62273,CPT,,,,,,,,552,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inj,Lumb Epidur,Blood/Clot Patch",PX62273P,CDM,983,RC,62273,CPT,,,,,,,,552,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inj,Lumb Epidur,Blood/Clot Patch",PX62273P,CDM,983,RC,62273,CPT,,,,,,,,552,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inj,Lumb Epidur,Blood/Clot Patch",PX62273P,CDM,983,RC,62273,CPT,,,,,,,,552,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inj,Lumb Epidur,Blood/Clot Patch",PX62273P,CDM,983,RC,62273,CPT,,,,,,,,552,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inj,Lumb Epidur,Blood/Clot Patch",PX62273P,CDM,983,RC,62273,CPT,,,,,,,,552,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inject Nerv Blck,Othr Periph Nerv",PX64450F,CDM,510,RC,64450,CPT,,,,,,,,757,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inject Nerv Blck,Othr Periph Nerv",PX64450F,CDM,510,RC,64450,CPT,,,,,,,,757,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inject Nerv Blck,Othr Periph Nerv",PX64450F,CDM,510,RC,64450,CPT,,,,,,,,757,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inject Nerv Blck,Othr Periph Nerv",PX64450F,CDM,510,RC,64450,CPT,,,,,,,,757,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inject Nerv Blck,Othr Periph Nerv",PX64450F,CDM,510,RC,64450,CPT,,,,,,,,757,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inject Nerv Blck,Othr Periph Nerv",PX64450F,CDM,510,RC,64450,CPT,,,,,,,,757,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inject Nerv Blck,Othr Periph Nerv",PX64450P,CDM,983,RC,64450,CPT,,,,,,,,904,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inject Nerv Blck,Othr Periph Nerv",PX64450P,CDM,983,RC,64450,CPT,,,,,,,,904,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inject Nerv Blck,Othr Periph Nerv",PX64450P,CDM,983,RC,64450,CPT,,,,,,,,904,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inject Nerv Blck,Othr Periph Nerv",PX64450P,CDM,983,RC,64450,CPT,,,,,,,,904,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inject Nerv Blck,Othr Periph Nerv",PX64450P,CDM,983,RC,64450,CPT,,,,,,,,904,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inject Nerv Blck,Othr Periph Nerv",PX64450P,CDM,983,RC,64450,CPT,,,,,,,,904,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inject Nerv Blck,Trigeminal",PX64400F,CDM,510,RC,64400,CPT,,,,,,,,255,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inject Nerv Blck,Trigeminal",PX64400F,CDM,510,RC,64400,CPT,,,,,,,,255,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inject Nerv Blck,Trigeminal",PX64400F,CDM,510,RC,64400,CPT,,,,,,,,255,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inject Nerv Blck,Trigeminal",PX64400F,CDM,510,RC,64400,CPT,,,,,,,,255,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inject Nerv Blck,Trigeminal",PX64400F,CDM,510,RC,64400,CPT,,,,,,,,255,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inject Nerv Blck,Trigeminal",PX64400F,CDM,510,RC,64400,CPT,,,,,,,,255,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inject Nerv Blck,Trigeminal",PX64400P,CDM,983,RC,64400,CPT,,,,,,,,170,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inject Nerv Blck,Trigeminal",PX64400P,CDM,983,RC,64400,CPT,,,,,,,,170,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inject Nerv Blck,Trigeminal",PX64400P,CDM,983,RC,64400,CPT,,,,,,,,170,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inject Nerv Blck,Trigeminal",PX64400P,CDM,983,RC,64400,CPT,,,,,,,,170,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inject Nerv Blck,Trigeminal",PX64400P,CDM,983,RC,64400,CPT,,,,,,,,170,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inject Nerv Blck,Trigeminal",PX64400P,CDM,983,RC,64400,CPT,,,,,,,,170,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inject Trigger Point, 1 or 2",PX20552F,CDM,510,RC,20552,CPT,,,,,,,,252,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inject Trigger Point, 1 or 2",PX20552F,CDM,510,RC,20552,CPT,,,,,,,,252,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inject Trigger Point, 1 or 2",PX20552F,CDM,510,RC,20552,CPT,,,,,,,,252,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inject Trigger Point, 1 or 2",PX20552F,CDM,510,RC,20552,CPT,,,,,,,,252,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inject Trigger Point, 1 or 2",PX20552F,CDM,510,RC,20552,CPT,,,,,,,,252,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inject Trigger Point, 1 or 2",PX20552F,CDM,510,RC,20552,CPT,,,,,,,,252,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inject Trigger Point, 1 or 2",PX20552P,CDM,983,RC,20552,CPT,,,,,,,,210,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inject Trigger Point, 1 or 2",PX20552P,CDM,983,RC,20552,CPT,,,,,,,,210,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inject Trigger Point, 1 or 2",PX20552P,CDM,983,RC,20552,CPT,,,,,,,,210,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inject Trigger Point, 1 or 2",PX20552P,CDM,983,RC,20552,CPT,,,,,,,,210,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inject Trigger Point, 1 or 2",PX20552P,CDM,983,RC,20552,CPT,,,,,,,,210,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inject Trigger Point, 1 or 2",PX20552P,CDM,983,RC,20552,CPT,,,,,,,,210,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection for Nerve Block,PX64445F,CDM,510,RC,64445,CPT,,,,,,,,385,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection for Nerve Block,PX64445F,CDM,510,RC,64445,CPT,,,,,,,,385,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection for Nerve Block,PX64445F,CDM,510,RC,64445,CPT,,,,,,,,385,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection for Nerve Block,PX64445F,CDM,510,RC,64445,CPT,,,,,,,,385,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection for Nerve Block,PX64445F,CDM,510,RC,64445,CPT,,,,,,,,385,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection for Nerve Block,PX64445F,CDM,510,RC,64445,CPT,,,,,,,,385,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection for Nerve Block,PX64445P,CDM,983,RC,64445,CPT,,,,,,,,385,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection for Nerve Block,PX64445P,CDM,983,RC,64445,CPT,,,,,,,,385,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection for Nerve Block,PX64445P,CDM,983,RC,64445,CPT,,,,,,,,385,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection for Nerve Block,PX64445P,CDM,983,RC,64445,CPT,,,,,,,,385,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection for Nerve Block,PX64445P,CDM,983,RC,64445,CPT,,,,,,,,385,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection for Nerve Block,PX64445P,CDM,983,RC,64445,CPT,,,,,,,,385,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection for Nerve Block,PX64447F,CDM,510,RC,64447,CPT,,,,,,,,3023,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection for Nerve Block,PX64447F,CDM,510,RC,64447,CPT,,,,,,,,3023,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection for Nerve Block,PX64447F,CDM,510,RC,64447,CPT,,,,,,,,3023,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection for Nerve Block,PX64447F,CDM,510,RC,64447,CPT,,,,,,,,3023,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection for Nerve Block,PX64447F,CDM,510,RC,64447,CPT,,,,,,,,3023,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection for Nerve Block,PX64447F,CDM,510,RC,64447,CPT,,,,,,,,3023,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection for Nerve Block,PX64447P,CDM,983,RC,64447,CPT,,,,,,,,3892,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection for Nerve Block,PX64447P,CDM,983,RC,64447,CPT,,,,,,,,3892,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection for Nerve Block,PX64447P,CDM,983,RC,64447,CPT,,,,,,,,3892,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection for Nerve Block,PX64447P,CDM,983,RC,64447,CPT,,,,,,,,3892,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection for Nerve Block,PX64447P,CDM,983,RC,64447,CPT,,,,,,,,3892,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection for Nerve Block,PX64447P,CDM,983,RC,64447,CPT,,,,,,,,3892,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection for Nerve Block,PX64448F,CDM,510,RC,64448,CPT,,,,,,,,873,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection for Nerve Block,PX64448F,CDM,510,RC,64448,CPT,,,,,,,,873,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection for Nerve Block,PX64448F,CDM,510,RC,64448,CPT,,,,,,,,873,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection for Nerve Block,PX64448F,CDM,510,RC,64448,CPT,,,,,,,,873,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection for Nerve Block,PX64448F,CDM,510,RC,64448,CPT,,,,,,,,873,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection for Nerve Block,PX64448F,CDM,510,RC,64448,CPT,,,,,,,,873,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection for Shoulder Arthrogram,PX23350F,CDM,510,RC,23350,CPT,,,,,,,,675,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection for Shoulder Arthrogram,PX23350F,CDM,510,RC,23350,CPT,,,,,,,,675,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection for Shoulder Arthrogram,PX23350F,CDM,510,RC,23350,CPT,,,,,,,,675,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection for Shoulder Arthrogram,PX23350F,CDM,510,RC,23350,CPT,,,,,,,,675,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection for Shoulder Arthrogram,PX23350F,CDM,510,RC,23350,CPT,,,,,,,,675,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection for Shoulder Arthrogram,PX23350F,CDM,510,RC,23350,CPT,,,,,,,,675,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection Hip Arthrogram,PX27093F,CDM,510,RC,27093,CPT,,,,,,,,654,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection Hip Arthrogram,PX27093F,CDM,510,RC,27093,CPT,,,,,,,,654,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection Hip Arthrogram,PX27093F,CDM,510,RC,27093,CPT,,,,,,,,654,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection Hip Arthrogram,PX27093F,CDM,510,RC,27093,CPT,,,,,,,,654,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection Hip Arthrogram,PX27093F,CDM,510,RC,27093,CPT,,,,,,,,654,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection Hip Arthrogram,PX27093F,CDM,510,RC,27093,CPT,,,,,,,,654,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Injection Hip Arthrogram,Anesth",PX27095F,CDM,510,RC,27095,CPT,,,,,,,,425,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Injection Hip Arthrogram,Anesth",PX27095F,CDM,510,RC,27095,CPT,,,,,,,,425,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Injection Hip Arthrogram,Anesth",PX27095F,CDM,510,RC,27095,CPT,,,,,,,,425,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Injection Hip Arthrogram,Anesth",PX27095F,CDM,510,RC,27095,CPT,,,,,,,,425,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Injection Hip Arthrogram,Anesth",PX27095F,CDM,510,RC,27095,CPT,,,,,,,,425,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Injection Hip Arthrogram,Anesth",PX27095F,CDM,510,RC,27095,CPT,,,,,,,,425,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Injection Hip Arthrogram,Anesth",PX27095P,CDM,983,RC,27095,CPT,,,,,,,,425,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Injection Hip Arthrogram,Anesth",PX27095P,CDM,983,RC,27095,CPT,,,,,,,,425,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Injection Hip Arthrogram,Anesth",PX27095P,CDM,983,RC,27095,CPT,,,,,,,,425,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Injection Hip Arthrogram,Anesth",PX27095P,CDM,983,RC,27095,CPT,,,,,,,,425,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Injection Hip Arthrogram,Anesth",PX27095P,CDM,983,RC,27095,CPT,,,,,,,,425,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Injection Hip Arthrogram,Anesth",PX27095P,CDM,983,RC,27095,CPT,,,,,,,,425,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Injection, Subq/Im",PX96372,CDM,260,RC,96372,CPT,,,,,,,,119,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Injection, Subq/Im",PX96372,CDM,260,RC,96372,CPT,,,,,,,,119,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Injection, Subq/Im",PX96372,CDM,260,RC,96372,CPT,,,,,,,,119,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Injection, Subq/Im",PX96372,CDM,260,RC,96372,CPT,,,,,,,,119,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Injection, Subq/Im",PX96372,CDM,260,RC,96372,CPT,,,,,,,,119,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Injection, Subq/Im",PX96372,CDM,260,RC,96372,CPT,,,,,,,,119,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Injection,Sacroiliac Joint(T)",PX27096F,CDM,510,RC,27096,CPT,,,,,,,,881,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Injection,Sacroiliac Joint(T)",PX27096F,CDM,510,RC,27096,CPT,,,,,,,,881,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Injection,Sacroiliac Joint(T)",PX27096F,CDM,510,RC,27096,CPT,,,,,,,,881,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Injection,Sacroiliac Joint(T)",PX27096F,CDM,510,RC,27096,CPT,,,,,,,,881,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Injection,Sacroiliac Joint(T)",PX27096F,CDM,510,RC,27096,CPT,,,,,,,,881,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Injection,Sacroiliac Joint(T)",PX27096F,CDM,510,RC,27096,CPT,,,,,,,,881,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inpatient Consult, Level III",PX99253,CDM,983,RC,99253,CPT,,,,,,,,374,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inpatient Consult, Level III",PX99253,CDM,983,RC,99253,CPT,,,,,,,,374,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inpatient Consult, Level III",PX99253,CDM,983,RC,99253,CPT,,,,,,,,374,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inpatient Consult, Level III",PX99253,CDM,983,RC,99253,CPT,,,,,,,,374,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inpatient Consult, Level III",PX99253,CDM,983,RC,99253,CPT,,,,,,,,374,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inpatient Consult, Level III",PX99253,CDM,983,RC,99253,CPT,,,,,,,,374,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inpatient Consult, Level IV",PX99254,CDM,983,RC,99254,CPT,,,,,,,,508,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inpatient Consult, Level IV",PX99254,CDM,983,RC,99254,CPT,,,,,,,,508,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inpatient Consult, Level IV",PX99254,CDM,983,RC,99254,CPT,,,,,,,,508,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inpatient Consult, Level IV",PX99254,CDM,983,RC,99254,CPT,,,,,,,,508,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inpatient Consult, Level IV",PX99254,CDM,983,RC,99254,CPT,,,,,,,,508,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inpatient Consult, Level IV",PX99254,CDM,983,RC,99254,CPT,,,,,,,,508,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Inpt or Obs Disch Day Mngmt <=30 Minutes,PX99238,CDM,982,RC,99238,CPT,,,,,,,,199,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Inpt or Obs Disch Day Mngmt <=30 Minutes,PX99238,CDM,982,RC,99238,CPT,,,,,,,,199,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Inpt or Obs Disch Day Mngmt <=30 Minutes,PX99238,CDM,982,RC,99238,CPT,,,,,,,,199,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Inpt or Obs Disch Day Mngmt <=30 Minutes,PX99238,CDM,982,RC,99238,CPT,,,,,,,,199,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Inpt or Obs Disch Day Mngmt <=30 Minutes,PX99238,CDM,982,RC,99238,CPT,,,,,,,,199,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Inpt or Obs Disch Day Mngmt <=30 Minutes,PX99238,CDM,982,RC,99238,CPT,,,,,,,,199,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Emergency Endotrach Airway,PX31500F,CDM,510,RC,31500,CPT,,,,,,,,637,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Emergency Endotrach Airway,PX31500F,CDM,510,RC,31500,CPT,,,,,,,,637,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Emergency Endotrach Airway,PX31500F,CDM,510,RC,31500,CPT,,,,,,,,637,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Emergency Endotrach Airway,PX31500F,CDM,510,RC,31500,CPT,,,,,,,,637,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Emergency Endotrach Airway,PX31500F,CDM,510,RC,31500,CPT,,,,,,,,637,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Emergency Endotrach Airway,PX31500F,CDM,510,RC,31500,CPT,,,,,,,,637,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Emergency Endotrach Airway,PX31500P,CDM,983,RC,31500,CPT,,,,,,,,657,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Emergency Endotrach Airway,PX31500P,CDM,983,RC,31500,CPT,,,,,,,,657,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Emergency Endotrach Airway,PX31500P,CDM,983,RC,31500,CPT,,,,,,,,657,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Emergency Endotrach Airway,PX31500P,CDM,983,RC,31500,CPT,,,,,,,,657,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Emergency Endotrach Airway,PX31500P,CDM,983,RC,31500,CPT,,,,,,,,657,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Emergency Endotrach Airway,PX31500P,CDM,983,RC,31500,CPT,,,,,,,,657,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Insert Needle,Intraosseous Infusn",PX36680F,CDM,510,RC,36680,CPT,,,,,,,,659,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Insert Needle,Intraosseous Infusn",PX36680F,CDM,510,RC,36680,CPT,,,,,,,,659,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Insert Needle,Intraosseous Infusn",PX36680F,CDM,510,RC,36680,CPT,,,,,,,,659,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Insert Needle,Intraosseous Infusn",PX36680F,CDM,510,RC,36680,CPT,,,,,,,,659,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Insert Needle,Intraosseous Infusn",PX36680F,CDM,510,RC,36680,CPT,,,,,,,,659,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Insert Needle,Intraosseous Infusn",PX36680F,CDM,510,RC,36680,CPT,,,,,,,,659,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Non-Tunnel Cv Catheter >5 Years,PX36556F,CDM,510,RC,36556,CPT,,,,,,,,1025,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Non-Tunnel Cv Catheter >5 Years,PX36556F,CDM,510,RC,36556,CPT,,,,,,,,1025,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Non-Tunnel Cv Catheter >5 Years,PX36556F,CDM,510,RC,36556,CPT,,,,,,,,1025,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Non-Tunnel Cv Catheter >5 Years,PX36556F,CDM,510,RC,36556,CPT,,,,,,,,1025,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Non-Tunnel Cv Catheter >5 Years,PX36556F,CDM,510,RC,36556,CPT,,,,,,,,1025,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Non-Tunnel Cv Catheter >5 Years,PX36556F,CDM,510,RC,36556,CPT,,,,,,,,1025,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Non-Tunnel Cv Catheter >5 Years,PX36556P,CDM,983,RC,36556,CPT,,,,,,,,1274,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Non-Tunnel Cv Catheter >5 Years,PX36556P,CDM,983,RC,36556,CPT,,,,,,,,1274,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Non-Tunnel Cv Catheter >5 Years,PX36556P,CDM,983,RC,36556,CPT,,,,,,,,1274,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Non-Tunnel Cv Catheter >5 Years,PX36556P,CDM,983,RC,36556,CPT,,,,,,,,1274,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Non-Tunnel Cv Catheter >5 Years,PX36556P,CDM,983,RC,36556,CPT,,,,,,,,1274,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Non-Tunnel Cv Catheter >5 Years,PX36556P,CDM,983,RC,36556,CPT,,,,,,,,1274,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573F,CDM,761,RC,36573,CPT,,,,,,,,1529,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573F,CDM,761,RC,36573,CPT,,,,,,,,1529,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573F,CDM,761,RC,36573,CPT,,,,,,,,1529,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573F,CDM,761,RC,36573,CPT,,,,,,,,1529,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573F,CDM,761,RC,36573,CPT,,,,,,,,1529,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573F,CDM,761,RC,36573,CPT,,,,,,,,1529,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573P,CDM,983,RC,36573,CPT,,,,,,,,1721,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573P,CDM,983,RC,36573,CPT,,,,,,,,1721,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573P,CDM,983,RC,36573,CPT,,,,,,,,1721,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573P,CDM,983,RC,36573,CPT,,,,,,,,1721,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573P,CDM,983,RC,36573,CPT,,,,,,,,1721,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573P,CDM,983,RC,36573,CPT,,,,,,,,1721,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Simple Cath Foley,PX51702F,CDM,510,RC,51702,CPT,,,,,,,,198,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Simple Cath Foley,PX51702F,CDM,510,RC,51702,CPT,,,,,,,,198,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Simple Cath Foley,PX51702F,CDM,510,RC,51702,CPT,,,,,,,,198,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Simple Cath Foley,PX51702F,CDM,510,RC,51702,CPT,,,,,,,,198,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Simple Cath Foley,PX51702F,CDM,510,RC,51702,CPT,,,,,,,,198,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Simple Cath Foley,PX51702F,CDM,510,RC,51702,CPT,,,,,,,,198,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Straight Catheter,PX51701F,CDM,510,RC,51701,CPT,,,,,,,,168,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Straight Catheter,PX51701F,CDM,510,RC,51701,CPT,,,,,,,,168,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Straight Catheter,PX51701F,CDM,510,RC,51701,CPT,,,,,,,,168,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Straight Catheter,PX51701F,CDM,510,RC,51701,CPT,,,,,,,,168,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Straight Catheter,PX51701F,CDM,510,RC,51701,CPT,,,,,,,,168,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Straight Catheter,PX51701F,CDM,510,RC,51701,CPT,,,,,,,,168,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561F,CDM,510,RC,36561,CPT,,,,,,,,2604,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561F,CDM,510,RC,36561,CPT,,,,,,,,2604,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561F,CDM,510,RC,36561,CPT,,,,,,,,2604,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561F,CDM,510,RC,36561,CPT,,,,,,,,2604,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561F,CDM,510,RC,36561,CPT,,,,,,,,2604,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561F,CDM,510,RC,36561,CPT,,,,,,,,2604,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561P,CDM,983,RC,36561,CPT,,,,,,,,1736,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561P,CDM,983,RC,36561,CPT,,,,,,,,1736,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561P,CDM,983,RC,36561,CPT,,,,,,,,1736,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561P,CDM,983,RC,36561,CPT,,,,,,,,1736,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561P,CDM,983,RC,36561,CPT,,,,,,,,1736,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561P,CDM,983,RC,36561,CPT,,,,,,,,1736,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insitu Hybridization (Fish),PX8836401,CDM,310,RC,88364,CPT,TC,,,,,,,335,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insitu Hybridization (Fish),PX8836401,CDM,310,RC,88364,CPT,TC,,,,,,,335,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insitu Hybridization (Fish),PX8836401,CDM,310,RC,88364,CPT,TC,,,,,,,335,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insitu Hybridization (Fish),PX8836401,CDM,310,RC,88364,CPT,TC,,,,,,,335,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insitu Hybridization (Fish),PX8836401,CDM,310,RC,88364,CPT,TC,,,,,,,335,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insitu Hybridization (Fish),PX8836401,CDM,310,RC,88364,CPT,TC,,,,,,,335,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSTRUMENT PACKAGE TOEMATE,27200000,CDM,272,RC,,,,11858-MAIN,LOCAL,,,,,636,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSTRUMENT PACKAGE TOEMATE,27200000,CDM,272,RC,,,,11858-MAIN,LOCAL,,,,,636,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSTRUMENT PACKAGE TOEMATE,27200000,CDM,272,RC,,,,11858-MAIN,LOCAL,,,,,636,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSTRUMENT PACKAGE TOEMATE,27200000,CDM,272,RC,,,,11858-MAIN,LOCAL,,,,,636,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSTRUMENT PACKAGE TOEMATE,27200000,CDM,272,RC,,,,11858-MAIN,LOCAL,,,,,636,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSTRUMENT PACKAGE TOEMATE,27200000,CDM,272,RC,,,,11858-MAIN,LOCAL,,,,,636,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSTRUMENT POUCH INVISISHIELD LONG,27200000,CDM,272,RC,,,,12394-MAIN,LOCAL,,,,,7,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSTRUMENT POUCH INVISISHIELD LONG,27200000,CDM,272,RC,,,,12394-MAIN,LOCAL,,,,,7,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSTRUMENT POUCH INVISISHIELD LONG,27200000,CDM,272,RC,,,,12394-MAIN,LOCAL,,,,,7,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSTRUMENT POUCH INVISISHIELD LONG,27200000,CDM,272,RC,,,,12394-MAIN,LOCAL,,,,,7,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSTRUMENT POUCH INVISISHIELD LONG,27200000,CDM,272,RC,,,,12394-MAIN,LOCAL,,,,,7,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSTRUMENT POUCH INVISISHIELD LONG,27200000,CDM,272,RC,,,,12394-MAIN,LOCAL,,,,,7,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSTRUMENT TOEMATE X-SMALL PACKAGE 9H00-T060,27200000,CDM,272,RC,C1713,HCPCS,,11575-MAIN,LOCAL,,,,,636,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSTRUMENT TOEMATE X-SMALL PACKAGE 9H00-T060,27200000,CDM,272,RC,C1713,HCPCS,,11575-MAIN,LOCAL,,,,,636,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSTRUMENT TOEMATE X-SMALL PACKAGE 9H00-T060,27200000,CDM,272,RC,C1713,HCPCS,,11575-MAIN,LOCAL,,,,,636,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSTRUMENT TOEMATE X-SMALL PACKAGE 9H00-T060,27200000,CDM,272,RC,C1713,HCPCS,,11575-MAIN,LOCAL,,,,,636,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSTRUMENT TOEMATE X-SMALL PACKAGE 9H00-T060,27200000,CDM,272,RC,C1713,HCPCS,,11575-MAIN,LOCAL,,,,,636,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSTRUMENT TOEMATE X-SMALL PACKAGE 9H00-T060,27200000,CDM,272,RC,C1713,HCPCS,,11575-MAIN,LOCAL,,,,,636,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFFLATION TUBING SET,27200000,CDM,272,RC,,,,4686-MAIN,LOCAL,,,,,38.25,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFFLATION TUBING SET,27200000,CDM,272,RC,,,,4686-MAIN,LOCAL,,,,,38.25,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFFLATION TUBING SET,27200000,CDM,272,RC,,,,4686-MAIN,LOCAL,,,,,38.25,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFFLATION TUBING SET,27200000,CDM,272,RC,,,,4686-MAIN,LOCAL,,,,,38.25,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFFLATION TUBING SET,27200000,CDM,272,RC,,,,4686-MAIN,LOCAL,,,,,38.25,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFFLATION TUBING SET,27200000,CDM,272,RC,,,,4686-MAIN,LOCAL,,,,,38.25,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT & PNEUVIEW  XE SMOKE ELIMINATOR 5MM,27200000,CDM,272,RC,,,,11876-MAIN,LOCAL,,,,,279,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT & PNEUVIEW  XE SMOKE ELIMINATOR 5MM,27200000,CDM,272,RC,,,,11876-MAIN,LOCAL,,,,,279,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT & PNEUVIEW  XE SMOKE ELIMINATOR 5MM,27200000,CDM,272,RC,,,,11876-MAIN,LOCAL,,,,,279,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT & PNEUVIEW  XE SMOKE ELIMINATOR 5MM,27200000,CDM,272,RC,,,,11876-MAIN,LOCAL,,,,,279,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT & PNEUVIEW  XE SMOKE ELIMINATOR 5MM,27200000,CDM,272,RC,,,,11876-MAIN,LOCAL,,,,,279,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT & PNEUVIEW  XE SMOKE ELIMINATOR 5MM,27200000,CDM,272,RC,,,,11876-MAIN,LOCAL,,,,,279,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 8MM,27200000,CDM,272,RC,,,,11877-MAIN,LOCAL,,,,,279,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 8MM,27200000,CDM,272,RC,,,,11877-MAIN,LOCAL,,,,,279,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 8MM,27200000,CDM,272,RC,,,,11877-MAIN,LOCAL,,,,,279,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 8MM,27200000,CDM,272,RC,,,,11877-MAIN,LOCAL,,,,,279,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 8MM,27200000,CDM,272,RC,,,,11877-MAIN,LOCAL,,,,,279,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 8MM,27200000,CDM,272,RC,,,,11877-MAIN,LOCAL,,,,,279,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 10MM,27200000,CDM,272,RC,,,,11878-MAIN,LOCAL,,,,,279,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 10MM,27200000,CDM,272,RC,,,,11878-MAIN,LOCAL,,,,,279,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 10MM,27200000,CDM,272,RC,,,,11878-MAIN,LOCAL,,,,,279,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 10MM,27200000,CDM,272,RC,,,,11878-MAIN,LOCAL,,,,,279,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 10MM,27200000,CDM,272,RC,,,,11878-MAIN,LOCAL,,,,,279,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 10MM,27200000,CDM,272,RC,,,,11878-MAIN,LOCAL,,,,,279,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 12MM,27200000,CDM,272,RC,,,,11879-MAIN,LOCAL,,,,,279,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 12MM,27200000,CDM,272,RC,,,,11879-MAIN,LOCAL,,,,,279,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 12MM,27200000,CDM,272,RC,,,,11879-MAIN,LOCAL,,,,,279,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 12MM,27200000,CDM,272,RC,,,,11879-MAIN,LOCAL,,,,,279,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 12MM,27200000,CDM,272,RC,,,,11879-MAIN,LOCAL,,,,,279,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 12MM,27200000,CDM,272,RC,,,,11879-MAIN,LOCAL,,,,,279,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 5MM,27200000,CDM,272,RC,,,,11880-MAIN,LOCAL,,,,,279,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 5MM,27200000,CDM,272,RC,,,,11880-MAIN,LOCAL,,,,,279,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 5MM,27200000,CDM,272,RC,,,,11880-MAIN,LOCAL,,,,,279,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 5MM,27200000,CDM,272,RC,,,,11880-MAIN,LOCAL,,,,,279,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 5MM,27200000,CDM,272,RC,,,,11880-MAIN,LOCAL,,,,,279,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 5MM,27200000,CDM,272,RC,,,,11880-MAIN,LOCAL,,,,,279,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 8MM,27200000,CDM,272,RC,,,,11881-MAIN,LOCAL,,,,,279,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 8MM,27200000,CDM,272,RC,,,,11881-MAIN,LOCAL,,,,,279,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 8MM,27200000,CDM,272,RC,,,,11881-MAIN,LOCAL,,,,,279,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 8MM,27200000,CDM,272,RC,,,,11881-MAIN,LOCAL,,,,,279,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 8MM,27200000,CDM,272,RC,,,,11881-MAIN,LOCAL,,,,,279,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 8MM,27200000,CDM,272,RC,,,,11881-MAIN,LOCAL,,,,,279,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 10MM,27200000,CDM,272,RC,,,,11882-MAIN,LOCAL,,,,,279,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 10MM,27200000,CDM,272,RC,,,,11882-MAIN,LOCAL,,,,,279,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 10MM,27200000,CDM,272,RC,,,,11882-MAIN,LOCAL,,,,,279,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 10MM,27200000,CDM,272,RC,,,,11882-MAIN,LOCAL,,,,,279,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 10MM,27200000,CDM,272,RC,,,,11882-MAIN,LOCAL,,,,,279,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 10MM,27200000,CDM,272,RC,,,,11882-MAIN,LOCAL,,,,,279,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 12MM,27200000,CDM,272,RC,,,,11883-MAIN,LOCAL,,,,,279,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 12MM,27200000,CDM,272,RC,,,,11883-MAIN,LOCAL,,,,,279,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 12MM,27200000,CDM,272,RC,,,,11883-MAIN,LOCAL,,,,,279,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 12MM,27200000,CDM,272,RC,,,,11883-MAIN,LOCAL,,,,,279,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 12MM,27200000,CDM,272,RC,,,,11883-MAIN,LOCAL,,,,,279,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 12MM,27200000,CDM,272,RC,,,,11883-MAIN,LOCAL,,,,,279,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insulin Ab - Ref,PX8633790,CDM,300,RC,86337,CPT,90,,,,,,,65,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insulin Ab - Ref,PX8633790,CDM,300,RC,86337,CPT,90,,,,,,,65,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insulin Ab - Ref,PX8633790,CDM,300,RC,86337,CPT,90,,,,,,,65,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insulin Ab - Ref,PX8633790,CDM,300,RC,86337,CPT,90,,,,,,,65,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insulin Ab - Ref,PX8633790,CDM,300,RC,86337,CPT,90,,,,,,,65,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insulin Ab - Ref,PX8633790,CDM,300,RC,86337,CPT,90,,,,,,,65,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
insulin aspart 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169633910,NDC,3,ML,659.76,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
insulin aspart 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169633910,NDC,3,ML,659.76,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
insulin aspart 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169633910,NDC,3,ML,659.76,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
insulin aspart 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169633910,NDC,3,ML,659.76,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
insulin aspart 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169633910,NDC,3,ML,659.76,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
insulin aspart 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169633910,NDC,3,ML,659.76,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
insulin aspart prot & aspart 70-30 (70-30) 100 UNIT/ML Suspension Pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169369619,NDC,3,ML,629.28,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
insulin aspart prot & aspart 70-30 (70-30) 100 UNIT/ML Suspension Pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169369619,NDC,3,ML,629.28,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
insulin aspart prot & aspart 70-30 (70-30) 100 UNIT/ML Suspension Pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169369619,NDC,3,ML,629.28,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
insulin aspart prot & aspart 70-30 (70-30) 100 UNIT/ML Suspension Pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169369619,NDC,3,ML,629.28,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
insulin aspart prot & aspart 70-30 (70-30) 100 UNIT/ML Suspension Pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169369619,NDC,3,ML,629.28,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
insulin aspart prot & aspart 70-30 (70-30) 100 UNIT/ML Suspension Pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169369619,NDC,3,ML,629.28,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221901,NDC,3,ML,506.9,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221901,NDC,3,ML,506.9,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221901,NDC,3,ML,506.9,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221901,NDC,3,ML,506.9,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221901,NDC,3,ML,506.9,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221901,NDC,3,ML,506.9,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221905,NDC,3,ML,506.9,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221905,NDC,3,ML,506.9,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221905,NDC,3,ML,506.9,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221905,NDC,3,ML,506.9,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221905,NDC,3,ML,506.9,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221905,NDC,3,ML,506.9,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2021301,NDC,3,ML,44.46,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2021301,NDC,3,ML,44.46,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2021301,NDC,3,ML,44.46,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2021301,NDC,3,ML,44.46,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2021301,NDC,3,ML,44.46,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2021301,NDC,3,ML,44.46,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821517,NDC,3,ML,275.33,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821517,NDC,3,ML,275.33,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821517,NDC,3,ML,275.33,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821517,NDC,3,ML,275.33,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821517,NDC,3,ML,275.33,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821517,NDC,3,ML,275.33,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
insulin regular 100 UNIT/ML Solution 10 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821501,NDC,10,ML,307.46,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
insulin regular 100 UNIT/ML Solution 10 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821501,NDC,10,ML,307.46,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
insulin regular 100 UNIT/ML Solution 10 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821501,NDC,10,ML,307.46,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
insulin regular 100 UNIT/ML Solution 10 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821501,NDC,10,ML,307.46,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
insulin regular 100 UNIT/ML Solution 10 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821501,NDC,10,ML,307.46,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
insulin regular 100 UNIT/ML Solution 10 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821501,NDC,10,ML,307.46,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iohexol 300 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141363,NDC,100,ML,200,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iohexol 300 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141363,NDC,100,ML,200,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iohexol 300 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141363,NDC,100,ML,200,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iohexol 300 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141363,NDC,100,ML,200,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iohexol 300 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141363,NDC,100,ML,200,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iohexol 300 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141363,NDC,100,ML,200,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iohexol 300 MG/ML Solution 150 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141365,NDC,150,ML,300,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iohexol 300 MG/ML Solution 150 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141365,NDC,150,ML,300,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iohexol 300 MG/ML Solution 150 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141365,NDC,150,ML,300,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iohexol 300 MG/ML Solution 150 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141365,NDC,150,ML,300,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iohexol 300 MG/ML Solution 150 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141365,NDC,150,ML,300,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iohexol 300 MG/ML Solution 150 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141365,NDC,150,ML,300,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iohexol 350 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141491,NDC,100,ML,200,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iohexol 350 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141491,NDC,100,ML,200,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iohexol 350 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141491,NDC,100,ML,200,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iohexol 350 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141491,NDC,100,ML,200,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iohexol 350 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141491,NDC,100,ML,200,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iohexol 350 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141491,NDC,100,ML,200,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Iontophoresis, Ea 15min",PX97033,CDM,420,RC,97033,CPT,,,,,,,,15,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Iontophoresis, Ea 15min",PX97033,CDM,420,RC,97033,CPT,,,,,,,,15,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Iontophoresis, Ea 15min",PX97033,CDM,420,RC,97033,CPT,,,,,,,,15,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Iontophoresis, Ea 15min",PX97033,CDM,420,RC,97033,CPT,,,,,,,,15,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Iontophoresis, Ea 15min",PX97033,CDM,420,RC,97033,CPT,,,,,,,,15,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Iontophoresis, Ea 15min",PX97033,CDM,420,RC,97033,CPT,,,,,,,,15,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ipratropium 0.02 % Solution 2.5 mL Plas Cont,25000000,CDM,250,RC,,,,,,76204010001,NDC,2.5,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ipratropium 0.02 % Solution 2.5 mL Plas Cont,25000000,CDM,250,RC,,,,,,76204010001,NDC,2.5,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ipratropium 0.02 % Solution 2.5 mL Plas Cont,25000000,CDM,250,RC,,,,,,76204010001,NDC,2.5,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ipratropium 0.02 % Solution 2.5 mL Plas Cont,25000000,CDM,250,RC,,,,,,76204010001,NDC,2.5,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ipratropium 0.02 % Solution 2.5 mL Plas Cont,25000000,CDM,250,RC,,,,,,76204010001,NDC,2.5,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ipratropium 0.02 % Solution 2.5 mL Plas Cont,25000000,CDM,250,RC,,,,,,76204010001,NDC,2.5,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ipratropium 0.03 % Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,24208039830,NDC,30,ML,256.9,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ipratropium 0.03 % Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,24208039830,NDC,30,ML,256.9,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ipratropium 0.03 % Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,24208039830,NDC,30,ML,256.9,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ipratropium 0.03 % Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,24208039830,NDC,30,ML,256.9,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ipratropium 0.03 % Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,24208039830,NDC,30,ML,256.9,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ipratropium 0.03 % Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,24208039830,NDC,30,ML,256.9,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ipratropium 0.06 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,54004641,NDC,15,ML,491.02,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ipratropium 0.06 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,54004641,NDC,15,ML,491.02,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ipratropium 0.06 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,54004641,NDC,15,ML,491.02,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ipratropium 0.06 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,54004641,NDC,15,ML,491.02,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ipratropium 0.06 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,54004641,NDC,15,ML,491.02,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ipratropium 0.06 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,54004641,NDC,15,ML,491.02,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487020101,NDC,3,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487020101,NDC,3,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487020101,NDC,3,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487020101,NDC,3,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487020101,NDC,3,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487020101,NDC,3,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097084034,NDC,3,ML,14.47,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097084034,NDC,3,ML,14.47,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097084034,NDC,3,ML,14.47,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097084034,NDC,3,ML,14.47,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097084034,NDC,3,ML,14.47,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097084034,NDC,3,ML,14.47,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097084053,NDC,3,ML,14.47,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097084053,NDC,3,ML,14.47,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097084053,NDC,3,ML,14.47,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097084053,NDC,3,ML,14.47,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097084053,NDC,3,ML,14.47,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097084053,NDC,3,ML,14.47,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
irbesartan 75 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43547037403,NDC,1,EA,15.68,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
irbesartan 75 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43547037403,NDC,1,EA,15.68,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
irbesartan 75 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43547037403,NDC,1,EA,15.68,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
irbesartan 75 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43547037403,NDC,1,EA,15.68,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
irbesartan 75 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43547037403,NDC,1,EA,15.68,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
irbesartan 75 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43547037403,NDC,1,EA,15.68,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
irbesartan 75 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,43547037409,NDC,1,EA,15.68,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
irbesartan 75 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,43547037409,NDC,1,EA,15.68,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
irbesartan 75 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,43547037409,NDC,1,EA,15.68,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
irbesartan 75 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,43547037409,NDC,1,EA,15.68,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
irbesartan 75 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,43547037409,NDC,1,EA,15.68,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
irbesartan 75 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,43547037409,NDC,1,EA,15.68,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Iron - Ref,PX8354090,CDM,300,RC,83540,CPT,90,,,,,,,52,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Iron - Ref,PX8354090,CDM,300,RC,83540,CPT,90,,,,,,,52,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Iron - Ref,PX8354090,CDM,300,RC,83540,CPT,90,,,,,,,52,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Iron - Ref,PX8354090,CDM,300,RC,83540,CPT,90,,,,,,,52,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Iron - Ref,PX8354090,CDM,300,RC,83540,CPT,90,,,,,,,52,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Iron - Ref,PX8354090,CDM,300,RC,83540,CPT,90,,,,,,,52,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608201,NDC,1,ML,66.6,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608201,NDC,1,ML,66.6,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608201,NDC,1,ML,66.6,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608201,NDC,1,ML,66.6,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608201,NDC,1,ML,66.6,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608201,NDC,1,ML,66.6,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608210,NDC,1,ML,63.43,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608210,NDC,1,ML,63.43,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608210,NDC,1,ML,63.43,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608210,NDC,1,ML,63.43,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608210,NDC,1,ML,63.43,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608210,NDC,1,ML,63.43,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093102,NDC,1,ML,60.47,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093102,NDC,1,ML,60.47,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093102,NDC,1,ML,60.47,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093102,NDC,1,ML,60.47,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093102,NDC,1,ML,60.47,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093102,NDC,1,ML,60.47,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093107,NDC,1,ML,57.59,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093107,NDC,1,ML,57.59,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093107,NDC,1,ML,57.59,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093107,NDC,1,ML,57.59,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093107,NDC,1,ML,57.59,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093107,NDC,1,ML,57.59,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234001,NDC,1.25,ML,91.55,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234001,NDC,1.25,ML,91.55,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234001,NDC,1.25,ML,91.55,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234001,NDC,1.25,ML,91.55,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234001,NDC,1.25,ML,91.55,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234001,NDC,1.25,ML,91.55,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234010,NDC,5,ML,306.2,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234010,NDC,5,ML,306.2,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234010,NDC,5,ML,306.2,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234010,NDC,5,ML,306.2,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234010,NDC,5,ML,306.2,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234010,NDC,5,ML,306.2,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234025,NDC,5,ML,306.2,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234025,NDC,5,ML,306.2,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234025,NDC,5,ML,306.2,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234025,NDC,5,ML,306.2,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234025,NDC,5,ML,306.2,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234025,NDC,5,ML,306.2,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234099,NDC,5,ML,306.2,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234099,NDC,5,ML,306.2,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234099,NDC,5,ML,306.2,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234099,NDC,5,ML,306.2,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234099,NDC,5,ML,306.2,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234099,NDC,5,ML,306.2,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231001,NDC,10,ML,649.64,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231001,NDC,10,ML,649.64,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231001,NDC,10,ML,649.64,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231001,NDC,10,ML,649.64,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231001,NDC,10,ML,649.64,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231001,NDC,10,ML,649.64,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231005,NDC,10,ML,649.64,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231005,NDC,10,ML,649.64,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231005,NDC,10,ML,649.64,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231005,NDC,10,ML,649.64,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231005,NDC,10,ML,649.64,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231005,NDC,10,ML,649.64,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Irrad/Lr Platelets,PXP9037,CDM,390,RC,P9037,HCPCS,,,,,,,,1617,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Irrad/Lr Platelets,PXP9037,CDM,390,RC,P9037,HCPCS,,,,,,,,1617,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Irrad/Lr Platelets,PXP9037,CDM,390,RC,P9037,HCPCS,,,,,,,,1617,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Irrad/Lr Platelets,PXP9037,CDM,390,RC,P9037,HCPCS,,,,,,,,1617,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Irrad/Lr Platelets,PXP9037,CDM,390,RC,P9037,HCPCS,,,,,,,,1617,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Irrad/Lr Platelets,PXP9037,CDM,390,RC,P9037,HCPCS,,,,,,,,1617,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Irradiated Leukoreduced Rbc's,PXP9040,CDM,390,RC,P9040,HCPCS,,,,,,,,771,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Irradiated Leukoreduced Rbc's,PXP9040,CDM,390,RC,P9040,HCPCS,,,,,,,,771,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Irradiated Leukoreduced Rbc's,PXP9040,CDM,390,RC,P9040,HCPCS,,,,,,,,771,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Irradiated Leukoreduced Rbc's,PXP9040,CDM,390,RC,P9040,HCPCS,,,,,,,,771,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Irradiated Leukoreduced Rbc's,PXP9040,CDM,390,RC,P9040,HCPCS,,,,,,,,771,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Irradiated Leukoreduced Rbc's,PXP9040,CDM,390,RC,P9040,HCPCS,,,,,,,,771,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Irri Implted Drug Dlvr Device,PX96523,CDM,260,RC,96523,CPT,,,,,,,,119,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Irri Implted Drug Dlvr Device,PX96523,CDM,260,RC,96523,CPT,,,,,,,,119,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Irri Implted Drug Dlvr Device,PX96523,CDM,260,RC,96523,CPT,,,,,,,,119,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Irri Implted Drug Dlvr Device,PX96523,CDM,260,RC,96523,CPT,,,,,,,,119,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Irri Implted Drug Dlvr Device,PX96523,CDM,260,RC,96523,CPT,,,,,,,,119,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Irri Implted Drug Dlvr Device,PX96523,CDM,260,RC,96523,CPT,,,,,,,,119,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
isatuximab-irfc 500 MG/25ML Solution 25 mL Vial,J9227.01,CDM,636,RC,J9227,HCPCS,,,,24065601,NDC,25,ML,7876.36,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
isatuximab-irfc 500 MG/25ML Solution 25 mL Vial,J9227.01,CDM,636,RC,J9227,HCPCS,,,,24065601,NDC,25,ML,7876.36,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
isatuximab-irfc 500 MG/25ML Solution 25 mL Vial,J9227.01,CDM,636,RC,J9227,HCPCS,,,,24065601,NDC,25,ML,7876.36,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
isatuximab-irfc 500 MG/25ML Solution 25 mL Vial,J9227.01,CDM,636,RC,J9227,HCPCS,,,,24065601,NDC,25,ML,7876.36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
isatuximab-irfc 500 MG/25ML Solution 25 mL Vial,J9227.01,CDM,636,RC,J9227,HCPCS,,,,24065601,NDC,25,ML,7876.36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
isatuximab-irfc 500 MG/25ML Solution 25 mL Vial,J9227.01,CDM,636,RC,J9227,HCPCS,,,,24065601,NDC,25,ML,7876.36,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Islet Cell Antibody - Ref,PX8634190,CDM,300,RC,86341,CPT,90,,,,,,,146,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Islet Cell Antibody - Ref,PX8634190,CDM,300,RC,86341,CPT,90,,,,,,,146,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Islet Cell Antibody - Ref,PX8634190,CDM,300,RC,86341,CPT,90,,,,,,,146,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Islet Cell Antibody - Ref,PX8634190,CDM,300,RC,86341,CPT,90,,,,,,,146,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Islet Cell Antibody - Ref,PX8634190,CDM,300,RC,86341,CPT,90,,,,,,,146,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Islet Cell Antibody - Ref,PX8634190,CDM,300,RC,86341,CPT,90,,,,,,,146,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
isosorbide dinitrate 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084008211,NDC,0.5,EA,3.36,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
isosorbide dinitrate 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084008211,NDC,0.5,EA,3.36,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
isosorbide dinitrate 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084008211,NDC,0.5,EA,3.36,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
isosorbide dinitrate 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084008211,NDC,0.5,EA,3.36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
isosorbide dinitrate 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084008211,NDC,0.5,EA,3.36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
isosorbide dinitrate 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084008211,NDC,0.5,EA,3.36,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
isosorbide dinitrate 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,781155601,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
isosorbide dinitrate 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,781155601,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
isosorbide dinitrate 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,781155601,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
isosorbide dinitrate 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,781155601,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
isosorbide dinitrate 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,781155601,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
isosorbide dinitrate 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,781155601,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
isosorbide dinitrate 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084008311,NDC,1,EA,7.25,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
isosorbide dinitrate 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084008311,NDC,1,EA,7.25,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
isosorbide dinitrate 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084008311,NDC,1,EA,7.25,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
isosorbide dinitrate 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084008311,NDC,1,EA,7.25,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
isosorbide dinitrate 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084008311,NDC,1,EA,7.25,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
isosorbide dinitrate 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084008311,NDC,1,EA,7.25,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
isosorbide dinitrate 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084008301,NDC,1,EA,7.25,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
isosorbide dinitrate 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084008301,NDC,1,EA,7.25,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
isosorbide dinitrate 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084008301,NDC,1,EA,7.25,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
isosorbide dinitrate 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084008301,NDC,1,EA,7.25,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
isosorbide dinitrate 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084008301,NDC,1,EA,7.25,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
isosorbide dinitrate 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084008301,NDC,1,EA,7.25,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
isosorbide mononitrate CR 30 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084059111,NDC,1,EA,9.01,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
isosorbide mononitrate CR 30 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084059111,NDC,1,EA,9.01,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
isosorbide mononitrate CR 30 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084059111,NDC,1,EA,9.01,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
isosorbide mononitrate CR 30 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084059111,NDC,1,EA,9.01,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
isosorbide mononitrate CR 30 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084059111,NDC,1,EA,9.01,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
isosorbide mononitrate CR 30 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084059111,NDC,1,EA,9.01,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
isosorbide mononitrate CR 30 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084059101,NDC,1,EA,9.01,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
isosorbide mononitrate CR 30 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084059101,NDC,1,EA,9.01,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
isosorbide mononitrate CR 30 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084059101,NDC,1,EA,9.01,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
isosorbide mononitrate CR 30 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084059101,NDC,1,EA,9.01,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
isosorbide mononitrate CR 30 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084059101,NDC,1,EA,9.01,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
isosorbide mononitrate CR 30 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084059101,NDC,1,EA,9.01,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Itraconazole,PX8018990,CDM,300,RC,80189,CPT,90,,,,,,,124,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Itraconazole,PX8018990,CDM,300,RC,80189,CPT,90,,,,,,,124,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Itraconazole,PX8018990,CDM,300,RC,80189,CPT,90,,,,,,,124,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Itraconazole,PX8018990,CDM,300,RC,80189,CPT,90,,,,,,,124,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Itraconazole,PX8018990,CDM,300,RC,80189,CPT,90,,,,,,,124,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Itraconazole,PX8018990,CDM,300,RC,80189,CPT,90,,,,,,,124,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IV 0.9% NS 1000ML 2B1324X,27200000,CDM,272,RC,,,,538-MAIN,LOCAL,,,,,121.89,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IV 0.9% NS 1000ML 2B1324X,27200000,CDM,272,RC,,,,538-MAIN,LOCAL,,,,,121.89,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IV 0.9% NS 1000ML 2B1324X,27200000,CDM,272,RC,,,,538-MAIN,LOCAL,,,,,121.89,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IV 0.9% NS 1000ML 2B1324X,27200000,CDM,272,RC,,,,538-MAIN,LOCAL,,,,,121.89,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IV 0.9% NS 1000ML 2B1324X,27200000,CDM,272,RC,,,,538-MAIN,LOCAL,,,,,121.89,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IV 0.9% NS 1000ML 2B1324X,27200000,CDM,272,RC,,,,538-MAIN,LOCAL,,,,,121.89,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IV Infusion Therapy, 1 Hour",PX96365,CDM,260,RC,96365,CPT,,,,,,,,327,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IV Infusion Therapy, 1 Hour",PX96365,CDM,260,RC,96365,CPT,,,,,,,,327,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IV Infusion Therapy, 1 Hour",PX96365,CDM,260,RC,96365,CPT,,,,,,,,327,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IV Infusion Therapy, 1 Hour",PX96365,CDM,260,RC,96365,CPT,,,,,,,,327,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IV Infusion Therapy, 1 Hour",PX96365,CDM,260,RC,96365,CPT,,,,,,,,327,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IV Infusion Therapy, 1 Hour",PX96365,CDM,260,RC,96365,CPT,,,,,,,,327,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IV Infusion, Bamlanivimab and Etesevimab, Infusion and Monitoring",PXM0245,CDM,260,RC,M0245,HCPCS,,,,,,,,1555,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IV Infusion, Bamlanivimab and Etesevimab, Infusion and Monitoring",PXM0245,CDM,260,RC,M0245,HCPCS,,,,,,,,1555,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IV Infusion, Bamlanivimab and Etesevimab, Infusion and Monitoring",PXM0245,CDM,260,RC,M0245,HCPCS,,,,,,,,1555,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IV Infusion, Bamlanivimab and Etesevimab, Infusion and Monitoring",PXM0245,CDM,260,RC,M0245,HCPCS,,,,,,,,1555,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IV Infusion, Bamlanivimab and Etesevimab, Infusion and Monitoring",PXM0245,CDM,260,RC,M0245,HCPCS,,,,,,,,1555,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IV Infusion, Bamlanivimab and Etesevimab, Infusion and Monitoring",PXM0245,CDM,260,RC,M0245,HCPCS,,,,,,,,1555,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IV Infusion, Bamlanivimab, Infusion and Post Admin Monig",PXM0239,CDM,260,RC,M0239,HCPCS,,,,,,,,320,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IV Infusion, Bamlanivimab, Infusion and Post Admin Monig",PXM0239,CDM,260,RC,M0239,HCPCS,,,,,,,,320,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IV Infusion, Bamlanivimab, Infusion and Post Admin Monig",PXM0239,CDM,260,RC,M0239,HCPCS,,,,,,,,320,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IV Infusion, Bamlanivimab, Infusion and Post Admin Monig",PXM0239,CDM,260,RC,M0239,HCPCS,,,,,,,,320,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IV Infusion, Bamlanivimab, Infusion and Post Admin Monig",PXM0239,CDM,260,RC,M0239,HCPCS,,,,,,,,320,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IV Infusion, Bamlanivimab, Infusion and Post Admin Monig",PXM0239,CDM,260,RC,M0239,HCPCS,,,,,,,,320,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IV Infusion, Casirivimab and Imdevimab, IV and Post Admr",PXM0243,CDM,771,RC,M0243,HCPCS,,,,,,,,1555,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IV Infusion, Casirivimab and Imdevimab, IV and Post Admr",PXM0243,CDM,771,RC,M0243,HCPCS,,,,,,,,1555,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IV Infusion, Casirivimab and Imdevimab, IV and Post Admr",PXM0243,CDM,771,RC,M0243,HCPCS,,,,,,,,1555,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IV Infusion, Casirivimab and Imdevimab, IV and Post Admr",PXM0243,CDM,771,RC,M0243,HCPCS,,,,,,,,1555,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IV Infusion, Casirivimab and Imdevimab, IV and Post Admr",PXM0243,CDM,771,RC,M0243,HCPCS,,,,,,,,1555,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IV Infusion, Casirivimab and Imdevimab, IV and Post Admr",PXM0243,CDM,771,RC,M0243,HCPCS,,,,,,,,1555,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IV Push, Single/1st Drug",PX96374,CDM,260,RC,96374,CPT,,,,,,,,259,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IV Push, Single/1st Drug",PX96374,CDM,260,RC,96374,CPT,,,,,,,,259,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IV Push, Single/1st Drug",PX96374,CDM,260,RC,96374,CPT,,,,,,,,259,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IV Push, Single/1st Drug",PX96374,CDM,260,RC,96374,CPT,,,,,,,,259,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IV Push, Single/1st Drug",PX96374,CDM,260,RC,96374,CPT,,,,,,,,259,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IV Push, Single/1st Drug",PX96374,CDM,260,RC,96374,CPT,,,,,,,,259,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ivermectin 3 MG Tablet 20 Each Box,63700001,CDM,250,RC,,,,,,42799080601,NDC,1,EA,26.68,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ivermectin 3 MG Tablet 20 Each Box,63700001,CDM,250,RC,,,,,,42799080601,NDC,1,EA,26.68,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ivermectin 3 MG Tablet 20 Each Box,63700001,CDM,250,RC,,,,,,42799080601,NDC,1,EA,26.68,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ivermectin 3 MG Tablet 20 Each Box,63700001,CDM,250,RC,,,,,,42799080601,NDC,1,EA,26.68,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ivermectin 3 MG Tablet 20 Each Box,63700001,CDM,250,RC,,,,,,42799080601,NDC,1,EA,26.68,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ivermectin 3 MG Tablet 20 Each Box,63700001,CDM,250,RC,,,,,,42799080601,NDC,1,EA,26.68,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Jak2 Gene - Ref,PX8127090,CDM,300,RC,81270,CPT,90,,,,,,,734,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Jak2 Gene - Ref,PX8127090,CDM,300,RC,81270,CPT,90,,,,,,,734,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Jak2 Gene - Ref,PX8127090,CDM,300,RC,81270,CPT,90,,,,,,,734,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Jak2 Gene - Ref,PX8127090,CDM,300,RC,81270,CPT,90,,,,,,,734,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Jak2 Gene - Ref,PX8127090,CDM,300,RC,81270,CPT,90,,,,,,,734,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Jak2 Gene - Ref,PX8127090,CDM,300,RC,81270,CPT,90,,,,,,,734,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Janssen Covid-19 Vaccine, Administration",PX0031A,CDM,771,RC,0031A,HCPCS,,,,,,,,69,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Janssen Covid-19 Vaccine, Administration",PX0031A,CDM,771,RC,0031A,HCPCS,,,,,,,,69,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Janssen Covid-19 Vaccine, Administration",PX0031A,CDM,771,RC,0031A,HCPCS,,,,,,,,69,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Janssen Covid-19 Vaccine, Administration",PX0031A,CDM,771,RC,0031A,HCPCS,,,,,,,,69,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Janssen Covid-19 Vaccine, Administration",PX0031A,CDM,771,RC,0031A,HCPCS,,,,,,,,69,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Janssen Covid-19 Vaccine, Administration",PX0031A,CDM,771,RC,0031A,HCPCS,,,,,,,,69,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Joint Survey,PX7707726,CDM,982,RC,77077,CPT,26,,,,,,,286,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Joint Survey,PX7707726,CDM,982,RC,77077,CPT,26,,,,,,,286,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Joint Survey,PX7707726,CDM,982,RC,77077,CPT,26,,,,,,,286,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Joint Survey,PX7707726,CDM,982,RC,77077,CPT,26,,,,,,,286,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Joint Survey,PX7707726,CDM,982,RC,77077,CPT,26,,,,,,,286,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Joint Survey,PX7707726,CDM,982,RC,77077,CPT,26,,,,,,,286,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Joint Survey Tc,PX7707701,CDM,320,RC,77077,CPT,TC,,,,,,,304,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Joint Survey Tc,PX7707701,CDM,320,RC,77077,CPT,TC,,,,,,,304,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Joint Survey Tc,PX7707701,CDM,320,RC,77077,CPT,TC,,,,,,,304,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Joint Survey Tc,PX7707701,CDM,320,RC,77077,CPT,TC,,,,,,,304,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Joint Survey Tc,PX7707701,CDM,320,RC,77077,CPT,TC,,,,,,,304,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Joint Survey Tc,PX7707701,CDM,320,RC,77077,CPT,TC,,,,,,,304,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
K-WIRE 0.9X150MM BLUNT/TROCAR DART-FIRE STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12449-MAIN,LOCAL,,,,,110,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
K-WIRE 0.9X150MM BLUNT/TROCAR DART-FIRE STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12449-MAIN,LOCAL,,,,,110,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
K-WIRE 0.9X150MM BLUNT/TROCAR DART-FIRE STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12449-MAIN,LOCAL,,,,,110,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
K-WIRE 0.9X150MM BLUNT/TROCAR DART-FIRE STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12449-MAIN,LOCAL,,,,,110,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
K-WIRE 0.9X150MM BLUNT/TROCAR DART-FIRE STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12449-MAIN,LOCAL,,,,,110,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
K-WIRE 0.9X150MM BLUNT/TROCAR DART-FIRE STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12449-MAIN,LOCAL,,,,,110,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
K-WIRE 0.9X150MM BLUNT/TROCAR STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12452-MAIN,LOCAL,,,,,110,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
K-WIRE 0.9X150MM BLUNT/TROCAR STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12452-MAIN,LOCAL,,,,,110,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
K-WIRE 0.9X150MM BLUNT/TROCAR STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12452-MAIN,LOCAL,,,,,110,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
K-WIRE 0.9X150MM BLUNT/TROCAR STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12452-MAIN,LOCAL,,,,,110,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
K-WIRE 0.9X150MM BLUNT/TROCAR STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12452-MAIN,LOCAL,,,,,110,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
K-WIRE 0.9X150MM BLUNT/TROCAR STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12452-MAIN,LOCAL,,,,,110,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
K-WIRE 1.4X150MM BLUNT/TROCAR DART-FIRE STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12450-MAIN,LOCAL,,,,,110,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
K-WIRE 1.4X150MM BLUNT/TROCAR DART-FIRE STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12450-MAIN,LOCAL,,,,,110,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
K-WIRE 1.4X150MM BLUNT/TROCAR DART-FIRE STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12450-MAIN,LOCAL,,,,,110,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
K-WIRE 1.4X150MM BLUNT/TROCAR DART-FIRE STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12450-MAIN,LOCAL,,,,,110,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
K-WIRE 1.4X150MM BLUNT/TROCAR DART-FIRE STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12450-MAIN,LOCAL,,,,,110,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
K-WIRE 1.4X150MM BLUNT/TROCAR DART-FIRE STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12450-MAIN,LOCAL,,,,,110,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
K-WIRE 1.4X150MM BLUNT/TROCAR STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12451-MAIN,LOCAL,,,,,110,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
K-WIRE 1.4X150MM BLUNT/TROCAR STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12451-MAIN,LOCAL,,,,,110,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
K-WIRE 1.4X150MM BLUNT/TROCAR STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12451-MAIN,LOCAL,,,,,110,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
K-WIRE 1.4X150MM BLUNT/TROCAR STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12451-MAIN,LOCAL,,,,,110,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
K-WIRE 1.4X150MM BLUNT/TROCAR STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12451-MAIN,LOCAL,,,,,110,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
K-WIRE 1.4X150MM BLUNT/TROCAR STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12451-MAIN,LOCAL,,,,,110,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
K-WIRE SMOOTH 1.4MM X 100MM,C1713,CDM,272,RC,C1713,HCPCS,,12634-MAIN,LOCAL,,,,,63,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
K-WIRE SMOOTH 1.4MM X 100MM,C1713,CDM,272,RC,C1713,HCPCS,,12634-MAIN,LOCAL,,,,,63,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
K-WIRE SMOOTH 1.4MM X 100MM,C1713,CDM,272,RC,C1713,HCPCS,,12634-MAIN,LOCAL,,,,,63,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
K-WIRE SMOOTH 1.4MM X 100MM,C1713,CDM,272,RC,C1713,HCPCS,,12634-MAIN,LOCAL,,,,,63,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
K-WIRE SMOOTH 1.4MM X 100MM,C1713,CDM,272,RC,C1713,HCPCS,,12634-MAIN,LOCAL,,,,,63,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
K-WIRE SMOOTH 1.4MM X 100MM,C1713,CDM,272,RC,C1713,HCPCS,,12634-MAIN,LOCAL,,,,,63,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
K-WIRES 1.6MM,27200000,CDM,272,RC,C1769,HCPCS,,11852-MAIN,LOCAL,,,,,45,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
K-WIRES 1.6MM,27200000,CDM,272,RC,C1769,HCPCS,,11852-MAIN,LOCAL,,,,,45,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
K-WIRES 1.6MM,27200000,CDM,272,RC,C1769,HCPCS,,11852-MAIN,LOCAL,,,,,45,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
K-WIRES 1.6MM,27200000,CDM,272,RC,C1769,HCPCS,,11852-MAIN,LOCAL,,,,,45,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
K-WIRES 1.6MM,27200000,CDM,272,RC,C1769,HCPCS,,11852-MAIN,LOCAL,,,,,45,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
K-WIRES 1.6MM,27200000,CDM,272,RC,C1769,HCPCS,,11852-MAIN,LOCAL,,,,,45,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KATZ EXTRACTOR OTO-RHINO FOREIGN BODY REMOVER,120.568,CDM,272,RC,,,,12808-MAIN,LOCAL,,,,,246,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KATZ EXTRACTOR OTO-RHINO FOREIGN BODY REMOVER,120.568,CDM,272,RC,,,,12808-MAIN,LOCAL,,,,,246,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KATZ EXTRACTOR OTO-RHINO FOREIGN BODY REMOVER,120.568,CDM,272,RC,,,,12808-MAIN,LOCAL,,,,,246,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KATZ EXTRACTOR OTO-RHINO FOREIGN BODY REMOVER,120.568,CDM,272,RC,,,,12808-MAIN,LOCAL,,,,,246,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KATZ EXTRACTOR OTO-RHINO FOREIGN BODY REMOVER,120.568,CDM,272,RC,,,,12808-MAIN,LOCAL,,,,,246,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KATZ EXTRACTOR OTO-RHINO FOREIGN BODY REMOVER,120.568,CDM,272,RC,,,,12808-MAIN,LOCAL,,,,,246,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KERRAMAX CARE SUPERABSORBENT DRESSING 5X6,120.548,CDM,272,RC,A6197,HCPCS,,12362-MAIN,LOCAL,,,,,10,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KERRAMAX CARE SUPERABSORBENT DRESSING 5X6,120.548,CDM,272,RC,A6197,HCPCS,,12362-MAIN,LOCAL,,,,,10,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KERRAMAX CARE SUPERABSORBENT DRESSING 5X6,120.548,CDM,272,RC,A6197,HCPCS,,12362-MAIN,LOCAL,,,,,10,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KERRAMAX CARE SUPERABSORBENT DRESSING 5X6,120.548,CDM,272,RC,A6197,HCPCS,,12362-MAIN,LOCAL,,,,,10,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KERRAMAX CARE SUPERABSORBENT DRESSING 5X6,120.548,CDM,272,RC,A6197,HCPCS,,12362-MAIN,LOCAL,,,,,10,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KERRAMAX CARE SUPERABSORBENT DRESSING 5X6,120.548,CDM,272,RC,A6197,HCPCS,,12362-MAIN,LOCAL,,,,,10,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KERRAMAX CARE SUPERABSORBENT DRESSING 8X12,120.55,CDM,272,RC,A6197,HCPCS,,12363-MAIN,LOCAL,,,,,27,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KERRAMAX CARE SUPERABSORBENT DRESSING 8X12,120.55,CDM,272,RC,A6197,HCPCS,,12363-MAIN,LOCAL,,,,,27,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KERRAMAX CARE SUPERABSORBENT DRESSING 8X12,120.55,CDM,272,RC,A6197,HCPCS,,12363-MAIN,LOCAL,,,,,27,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KERRAMAX CARE SUPERABSORBENT DRESSING 8X12,120.55,CDM,272,RC,A6197,HCPCS,,12363-MAIN,LOCAL,,,,,27,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KERRAMAX CARE SUPERABSORBENT DRESSING 8X12,120.55,CDM,272,RC,A6197,HCPCS,,12363-MAIN,LOCAL,,,,,27,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KERRAMAX CARE SUPERABSORBENT DRESSING 8X12,120.55,CDM,272,RC,A6197,HCPCS,,12363-MAIN,LOCAL,,,,,27,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,55150043801,NDC,20,ML,152.9,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,55150043801,NDC,20,ML,152.9,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,55150043801,NDC,20,ML,152.9,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,55150043801,NDC,20,ML,152.9,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,55150043801,NDC,20,ML,152.9,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,55150043801,NDC,20,ML,152.9,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457018100,NDC,20,ML,153.01,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457018100,NDC,20,ML,153.01,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457018100,NDC,20,ML,153.01,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457018100,NDC,20,ML,153.01,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457018100,NDC,20,ML,153.01,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457018100,NDC,20,ML,153.01,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457018120,NDC,20,ML,152.9,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457018120,NDC,20,ML,152.9,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457018120,NDC,20,ML,152.9,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457018120,NDC,20,ML,152.9,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457018120,NDC,20,ML,152.9,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457018120,NDC,20,ML,152.9,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,143950801,NDC,10,ML,58.46,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,143950801,NDC,10,ML,58.46,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,143950801,NDC,10,ML,58.46,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,143950801,NDC,10,ML,58.46,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,143950801,NDC,10,ML,58.46,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,143950801,NDC,10,ML,58.46,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,143950810,NDC,10,ML,58.51,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,143950810,NDC,10,ML,58.51,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,143950810,NDC,10,ML,58.51,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,143950810,NDC,10,ML,58.51,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,143950810,NDC,10,ML,58.51,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,143950810,NDC,10,ML,58.51,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457000100,NDC,10,ML,68.38,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457000100,NDC,10,ML,68.38,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457000100,NDC,10,ML,68.38,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457000100,NDC,10,ML,68.38,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457000100,NDC,10,ML,68.38,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457000100,NDC,10,ML,68.38,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457000110,NDC,10,ML,59.67,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457000110,NDC,10,ML,59.67,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457000110,NDC,10,ML,59.67,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457000110,NDC,10,ML,59.67,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457000110,NDC,10,ML,59.67,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457000110,NDC,10,ML,59.67,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 100 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,55150044001,NDC,10,ML,111.85,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 100 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,55150044001,NDC,10,ML,111.85,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 100 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,55150044001,NDC,10,ML,111.85,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 100 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,55150044001,NDC,10,ML,111.85,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 100 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,55150044001,NDC,10,ML,111.85,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 100 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,55150044001,NDC,10,ML,111.85,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketoconazole 2 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,168009915,NDC,15,GR,173.97,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketoconazole 2 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,168009915,NDC,15,GR,173.97,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketoconazole 2 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,168009915,NDC,15,GR,173.97,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketoconazole 2 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,168009915,NDC,15,GR,173.97,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketoconazole 2 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,168009915,NDC,15,GR,173.97,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketoconazole 2 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,168009915,NDC,15,GR,173.97,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketoconazole 2 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,16714095501,NDC,15,GR,322.42,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketoconazole 2 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,16714095501,NDC,15,GR,322.42,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketoconazole 2 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,16714095501,NDC,15,GR,322.42,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketoconazole 2 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,16714095501,NDC,15,GR,322.42,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketoconazole 2 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,16714095501,NDC,15,GR,322.42,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketoconazole 2 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,16714095501,NDC,15,GR,322.42,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314012605,NDC,5,ML,42.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314012605,NDC,5,ML,42.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314012605,NDC,5,ML,42.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314012605,NDC,5,ML,42.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314012605,NDC,5,ML,42.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314012605,NDC,5,ML,42.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69543038810,NDC,1,EA,11.58,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69543038810,NDC,1,EA,11.58,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69543038810,NDC,1,EA,11.58,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69543038810,NDC,1,EA,11.58,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69543038810,NDC,1,EA,11.58,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69543038810,NDC,1,EA,11.58,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016200,NDC,1,ML,52.22,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016200,NDC,1,ML,52.22,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016200,NDC,1,ML,52.22,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016200,NDC,1,ML,52.22,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016200,NDC,1,ML,52.22,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016200,NDC,1,ML,52.22,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016216,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016216,NDC,1,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016216,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016216,NDC,1,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016216,NDC,1,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016216,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016243,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016243,NDC,0.5,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016243,NDC,0.5,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016243,NDC,0.5,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016243,NDC,0.5,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016243,NDC,0.5,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072201,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072201,NDC,0.5,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072201,NDC,0.5,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072201,NDC,0.5,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072201,NDC,0.5,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072201,NDC,0.5,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072225,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072225,NDC,0.5,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072225,NDC,0.5,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072225,NDC,0.5,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072225,NDC,0.5,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072225,NDC,0.5,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016226,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016226,NDC,0.5,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016226,NDC,0.5,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016226,NDC,0.5,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016226,NDC,0.5,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016226,NDC,0.5,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016245,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016245,NDC,0.5,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016245,NDC,0.5,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016245,NDC,0.5,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016245,NDC,0.5,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016245,NDC,0.5,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011901,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011901,NDC,0.5,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011901,NDC,0.5,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011901,NDC,0.5,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011901,NDC,0.5,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011901,NDC,0.5,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011925,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011925,NDC,0.5,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011925,NDC,0.5,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011925,NDC,0.5,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011925,NDC,0.5,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011925,NDC,0.5,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072501,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072501,NDC,0.5,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072501,NDC,0.5,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072501,NDC,0.5,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072501,NDC,0.5,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072501,NDC,0.5,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072525,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072525,NDC,0.5,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072525,NDC,0.5,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072525,NDC,0.5,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072525,NDC,0.5,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072525,NDC,0.5,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT 3-LUMEN 7FR X 16CM CENTRALVENOUS CDC-42703-P1A,120.37,CDM,272,RC,C1751,HCPCS,,10707-MAIN,LOCAL,,,,,201,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT 3-LUMEN 7FR X 16CM CENTRALVENOUS CDC-42703-P1A,120.37,CDM,272,RC,C1751,HCPCS,,10707-MAIN,LOCAL,,,,,201,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT 3-LUMEN 7FR X 16CM CENTRALVENOUS CDC-42703-P1A,120.37,CDM,272,RC,C1751,HCPCS,,10707-MAIN,LOCAL,,,,,201,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT 3-LUMEN 7FR X 16CM CENTRALVENOUS CDC-42703-P1A,120.37,CDM,272,RC,C1751,HCPCS,,10707-MAIN,LOCAL,,,,,201,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT 3-LUMEN 7FR X 16CM CENTRALVENOUS CDC-42703-P1A,120.37,CDM,272,RC,C1751,HCPCS,,10707-MAIN,LOCAL,,,,,201,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT 3-LUMEN 7FR X 16CM CENTRALVENOUS CDC-42703-P1A,120.37,CDM,272,RC,C1751,HCPCS,,10707-MAIN,LOCAL,,,,,201,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT EMERGENCY BIRTH DYNJS0600,120.317,CDM,272,RC,,,,8344-MAIN,LOCAL,,,,,74,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT EMERGENCY BIRTH DYNJS0600,120.317,CDM,272,RC,,,,8344-MAIN,LOCAL,,,,,74,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT EMERGENCY BIRTH DYNJS0600,120.317,CDM,272,RC,,,,8344-MAIN,LOCAL,,,,,74,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT EMERGENCY BIRTH DYNJS0600,120.317,CDM,272,RC,,,,8344-MAIN,LOCAL,,,,,74,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT EMERGENCY BIRTH DYNJS0600,120.317,CDM,272,RC,,,,8344-MAIN,LOCAL,,,,,74,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT EMERGENCY BIRTH DYNJS0600,120.317,CDM,272,RC,,,,8344-MAIN,LOCAL,,,,,74,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT ENDO COMPLETE PROCEDURE CARRY-ON 100802,27200000,CDM,272,RC,,,,10369-MAIN,LOCAL,,,,,33.15,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT ENDO COMPLETE PROCEDURE CARRY-ON 100802,27200000,CDM,272,RC,,,,10369-MAIN,LOCAL,,,,,33.15,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT ENDO COMPLETE PROCEDURE CARRY-ON 100802,27200000,CDM,272,RC,,,,10369-MAIN,LOCAL,,,,,33.15,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT ENDO COMPLETE PROCEDURE CARRY-ON 100802,27200000,CDM,272,RC,,,,10369-MAIN,LOCAL,,,,,33.15,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT ENDO COMPLETE PROCEDURE CARRY-ON 100802,27200000,CDM,272,RC,,,,10369-MAIN,LOCAL,,,,,33.15,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT ENDO COMPLETE PROCEDURE CARRY-ON 100802,27200000,CDM,272,RC,,,,10369-MAIN,LOCAL,,,,,33.15,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT EPIDURAL 19GA FLEXTIP PLUS AK-05502,120.305,CDM,272,RC,,,,11413-MAIN,LOCAL,,,,,95,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT EPIDURAL 19GA FLEXTIP PLUS AK-05502,120.305,CDM,272,RC,,,,11413-MAIN,LOCAL,,,,,95,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT EPIDURAL 19GA FLEXTIP PLUS AK-05502,120.305,CDM,272,RC,,,,11413-MAIN,LOCAL,,,,,95,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT EPIDURAL 19GA FLEXTIP PLUS AK-05502,120.305,CDM,272,RC,,,,11413-MAIN,LOCAL,,,,,95,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT EPIDURAL 19GA FLEXTIP PLUS AK-05502,120.305,CDM,272,RC,,,,11413-MAIN,LOCAL,,,,,95,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT EPIDURAL 19GA FLEXTIP PLUS AK-05502,120.305,CDM,272,RC,,,,11413-MAIN,LOCAL,,,,,95,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT GASTRIC LAVAGE 2075,120.257,CDM,272,RC,C7510,HCPCS,,410-MAIN,LOCAL,,,,,44,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT GASTRIC LAVAGE 2075,120.257,CDM,272,RC,C7510,HCPCS,,410-MAIN,LOCAL,,,,,44,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT GASTRIC LAVAGE 2075,120.257,CDM,272,RC,C7510,HCPCS,,410-MAIN,LOCAL,,,,,44,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT GASTRIC LAVAGE 2075,120.257,CDM,272,RC,C7510,HCPCS,,410-MAIN,LOCAL,,,,,44,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT GASTRIC LAVAGE 2075,120.257,CDM,272,RC,C7510,HCPCS,,410-MAIN,LOCAL,,,,,44,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT GASTRIC LAVAGE 2075,120.257,CDM,272,RC,C7510,HCPCS,,410-MAIN,LOCAL,,,,,44,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Kit Gene Analysis D816 Variant(S) - Ref,PX8127390,CDM,300,RC,81273,CPT,90,,,,,,,293,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Kit Gene Analysis D816 Variant(S) - Ref,PX8127390,CDM,300,RC,81273,CPT,90,,,,,,,293,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Kit Gene Analysis D816 Variant(S) - Ref,PX8127390,CDM,300,RC,81273,CPT,90,,,,,,,293,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Kit Gene Analysis D816 Variant(S) - Ref,PX8127390,CDM,300,RC,81273,CPT,90,,,,,,,293,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Kit Gene Analysis D816 Variant(S) - Ref,PX8127390,CDM,300,RC,81273,CPT,90,,,,,,,293,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Kit Gene Analysis D816 Variant(S) - Ref,PX8127390,CDM,300,RC,81273,CPT,90,,,,,,,293,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT INTRODUCER 8.5FR AK-09803-CDC,120.128,CDM,272,RC,,,,8826-MAIN,LOCAL,,,,,89,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT INTRODUCER 8.5FR AK-09803-CDC,120.128,CDM,272,RC,,,,8826-MAIN,LOCAL,,,,,89,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT INTRODUCER 8.5FR AK-09803-CDC,120.128,CDM,272,RC,,,,8826-MAIN,LOCAL,,,,,89,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT INTRODUCER 8.5FR AK-09803-CDC,120.128,CDM,272,RC,,,,8826-MAIN,LOCAL,,,,,89,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT INTRODUCER 8.5FR AK-09803-CDC,120.128,CDM,272,RC,,,,8826-MAIN,LOCAL,,,,,89,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT INTRODUCER 8.5FR AK-09803-CDC,120.128,CDM,272,RC,,,,8826-MAIN,LOCAL,,,,,89,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT PLEUREVAC CHEST DRAIN S-1100-08LF,120.2,CDM,272,RC,,,,4190-MAIN,LOCAL,,,,,198,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT PLEUREVAC CHEST DRAIN S-1100-08LF,120.2,CDM,272,RC,,,,4190-MAIN,LOCAL,,,,,198,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT PLEUREVAC CHEST DRAIN S-1100-08LF,120.2,CDM,272,RC,,,,4190-MAIN,LOCAL,,,,,198,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT PLEUREVAC CHEST DRAIN S-1100-08LF,120.2,CDM,272,RC,,,,4190-MAIN,LOCAL,,,,,198,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT PLEUREVAC CHEST DRAIN S-1100-08LF,120.2,CDM,272,RC,,,,4190-MAIN,LOCAL,,,,,198,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT PLEUREVAC CHEST DRAIN S-1100-08LF,120.2,CDM,272,RC,,,,4190-MAIN,LOCAL,,,,,198,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT THORACENTESIS PLEURA SEAL AK-01000-T,120.24,CDM,272,RC,,,,1147-MAIN,LOCAL,,,,,162,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT THORACENTESIS PLEURA SEAL AK-01000-T,120.24,CDM,272,RC,,,,1147-MAIN,LOCAL,,,,,162,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT THORACENTESIS PLEURA SEAL AK-01000-T,120.24,CDM,272,RC,,,,1147-MAIN,LOCAL,,,,,162,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT THORACENTESIS PLEURA SEAL AK-01000-T,120.24,CDM,272,RC,,,,1147-MAIN,LOCAL,,,,,162,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT THORACENTESIS PLEURA SEAL AK-01000-T,120.24,CDM,272,RC,,,,1147-MAIN,LOCAL,,,,,162,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT THORACENTESIS PLEURA SEAL AK-01000-T,120.24,CDM,272,RC,,,,1147-MAIN,LOCAL,,,,,162,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIWI OMNICUP VACUUM DELIVERY SYSTEM,120.225,CDM,272,RC,,,,11608-MAIN,LOCAL,,,,,120,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIWI OMNICUP VACUUM DELIVERY SYSTEM,120.225,CDM,272,RC,,,,11608-MAIN,LOCAL,,,,,120,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIWI OMNICUP VACUUM DELIVERY SYSTEM,120.225,CDM,272,RC,,,,11608-MAIN,LOCAL,,,,,120,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIWI OMNICUP VACUUM DELIVERY SYSTEM,120.225,CDM,272,RC,,,,11608-MAIN,LOCAL,,,,,120,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIWI OMNICUP VACUUM DELIVERY SYSTEM,120.225,CDM,272,RC,,,,11608-MAIN,LOCAL,,,,,120,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIWI OMNICUP VACUUM DELIVERY SYSTEM,120.225,CDM,272,RC,,,,11608-MAIN,LOCAL,,,,,120,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KUMAR CHOLANGIOGRAPHY CATHETER,27200000,CDM,272,RC,,,,10230-MAIN,LOCAL,,,,,63.11,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KUMAR CHOLANGIOGRAPHY CATHETER,27200000,CDM,272,RC,,,,10230-MAIN,LOCAL,,,,,63.11,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KUMAR CHOLANGIOGRAPHY CATHETER,27200000,CDM,272,RC,,,,10230-MAIN,LOCAL,,,,,63.11,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KUMAR CHOLANGIOGRAPHY CATHETER,27200000,CDM,272,RC,,,,10230-MAIN,LOCAL,,,,,63.11,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KUMAR CHOLANGIOGRAPHY CATHETER,27200000,CDM,272,RC,,,,10230-MAIN,LOCAL,,,,,63.11,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KUMAR CHOLANGIOGRAPHY CATHETER,27200000,CDM,272,RC,,,,10230-MAIN,LOCAL,,,,,63.11,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"La Crosse, Antibody - Ref",PX8665190,CDM,300,RC,86651,CPT,90,,,,,,,45,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"La Crosse, Antibody - Ref",PX8665190,CDM,300,RC,86651,CPT,90,,,,,,,45,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"La Crosse, Antibody - Ref",PX8665190,CDM,300,RC,86651,CPT,90,,,,,,,45,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"La Crosse, Antibody - Ref",PX8665190,CDM,300,RC,86651,CPT,90,,,,,,,45,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"La Crosse, Antibody - Ref",PX8665190,CDM,300,RC,86651,CPT,90,,,,,,,45,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"La Crosse, Antibody - Ref",PX8665190,CDM,300,RC,86651,CPT,90,,,,,,,45,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lab Antibody ID,RBC",PX7605,CDM,300,RC,86870,CPT,,,,,,,,155,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lab Antibody ID,RBC",PX7605,CDM,300,RC,86870,CPT,,,,,,,,155,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lab Antibody ID,RBC",PX7605,CDM,300,RC,86870,CPT,,,,,,,,155,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lab Antibody ID,RBC",PX7605,CDM,300,RC,86870,CPT,,,,,,,,155,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lab Antibody ID,RBC",PX7605,CDM,300,RC,86870,CPT,,,,,,,,155,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lab Antibody ID,RBC",PX7605,CDM,300,RC,86870,CPT,,,,,,,,155,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lab Antibody ID,RBC",PX86870,CDM,300,RC,,,,,,,,,,410,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lab Antibody ID,RBC",PX86870,CDM,300,RC,,,,,,,,,,410,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lab Antibody ID,RBC",PX86870,CDM,300,RC,,,,,,,,,,410,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lab Antibody ID,RBC",PX86870,CDM,300,RC,,,,,,,,,,410,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lab Antibody ID,RBC",PX86870,CDM,300,RC,,,,,,,,,,410,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lab Antibody ID,RBC",PX86870,CDM,300,RC,,,,,,,,,,410,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Basic Metabolic Panel,PX80048,CDM,300,RC,80048,CPT,,,,,,,,236,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Basic Metabolic Panel,PX80048,CDM,300,RC,80048,CPT,,,,,,,,236,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Basic Metabolic Panel,PX80048,CDM,300,RC,80048,CPT,,,,,,,,236,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Basic Metabolic Panel,PX80048,CDM,300,RC,80048,CPT,,,,,,,,236,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Basic Metabolic Panel,PX80048,CDM,300,RC,80048,CPT,,,,,,,,236,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Basic Metabolic Panel,PX80048,CDM,300,RC,80048,CPT,,,,,,,,236,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Culture Bacteria,PX87070,CDM,300,RC,87070,CPT,,,,,,,,286,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Culture Bacteria,PX87070,CDM,300,RC,87070,CPT,,,,,,,,286,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Culture Bacteria,PX87070,CDM,300,RC,87070,CPT,,,,,,,,286,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Culture Bacteria,PX87070,CDM,300,RC,87070,CPT,,,,,,,,286,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Culture Bacteria,PX87070,CDM,300,RC,87070,CPT,,,,,,,,286,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Culture Bacteria,PX87070,CDM,300,RC,87070,CPT,,,,,,,,286,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Direct Coombs,PX86880,CDM,300,RC,86880,CPT,,,,,,,,76,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Direct Coombs,PX86880,CDM,300,RC,86880,CPT,,,,,,,,76,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Direct Coombs,PX86880,CDM,300,RC,86880,CPT,,,,,,,,76,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Direct Coombs,PX86880,CDM,300,RC,86880,CPT,,,,,,,,76,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Direct Coombs,PX86880,CDM,300,RC,86880,CPT,,,,,,,,76,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Direct Coombs,PX86880,CDM,300,RC,86880,CPT,,,,,,,,76,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab H Pylori Stool Ag,PX87338,CDM,300,RC,87338,CPT,,,,,,,,424,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab H Pylori Stool Ag,PX87338,CDM,300,RC,87338,CPT,,,,,,,,424,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab H Pylori Stool Ag,PX87338,CDM,300,RC,87338,CPT,,,,,,,,424,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab H Pylori Stool Ag,PX87338,CDM,300,RC,87338,CPT,,,,,,,,424,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab H Pylori Stool Ag,PX87338,CDM,300,RC,87338,CPT,,,,,,,,424,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab H Pylori Stool Ag,PX87338,CDM,300,RC,87338,CPT,,,,,,,,424,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lab Ige, Isocyan Hdi",PX86003,CDM,300,RC,86003,CPT,90,,,,,,,34,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lab Ige, Isocyan Hdi",PX86003,CDM,300,RC,86003,CPT,90,,,,,,,34,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lab Ige, Isocyan Hdi",PX86003,CDM,300,RC,86003,CPT,90,,,,,,,34,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lab Ige, Isocyan Hdi",PX86003,CDM,300,RC,86003,CPT,90,,,,,,,34,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lab Ige, Isocyan Hdi",PX86003,CDM,300,RC,86003,CPT,90,,,,,,,34,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lab Ige, Isocyan Hdi",PX86003,CDM,300,RC,86003,CPT,90,,,,,,,34,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Imm Spin X-Match,PX8837,CDM,300,RC,86920,CPT,,,,,,,,402,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Imm Spin X-Match,PX8837,CDM,300,RC,86920,CPT,,,,,,,,402,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Imm Spin X-Match,PX8837,CDM,300,RC,86920,CPT,,,,,,,,402,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Imm Spin X-Match,PX8837,CDM,300,RC,86920,CPT,,,,,,,,402,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Imm Spin X-Match,PX8837,CDM,300,RC,86920,CPT,,,,,,,,402,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Imm Spin X-Match,PX8837,CDM,300,RC,86920,CPT,,,,,,,,402,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lab Immunoassay, Non Antibody",PX83516,CDM,300,RC,83516,CPT,,,,,,,,99,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lab Immunoassay, Non Antibody",PX83516,CDM,300,RC,83516,CPT,,,,,,,,99,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lab Immunoassay, Non Antibody",PX83516,CDM,300,RC,83516,CPT,,,,,,,,99,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lab Immunoassay, Non Antibody",PX83516,CDM,300,RC,83516,CPT,,,,,,,,99,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lab Immunoassay, Non Antibody",PX83516,CDM,300,RC,83516,CPT,,,,,,,,99,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lab Immunoassay, Non Antibody",PX83516,CDM,300,RC,83516,CPT,,,,,,,,99,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Org ID Anaerobic-Each,PX87076,CDM,300,RC,87076,CPT,,,,,,,,67,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Org ID Anaerobic-Each,PX87076,CDM,300,RC,87076,CPT,,,,,,,,67,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Org ID Anaerobic-Each,PX87076,CDM,300,RC,87076,CPT,,,,,,,,67,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Org ID Anaerobic-Each,PX87076,CDM,300,RC,87076,CPT,,,,,,,,67,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Org ID Anaerobic-Each,PX87076,CDM,300,RC,87076,CPT,,,,,,,,67,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Org ID Anaerobic-Each,PX87076,CDM,300,RC,87076,CPT,,,,,,,,67,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Platelet Count,PX85049,CDM,300,RC,85049,CPT,,,,,,,,56,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Platelet Count,PX85049,CDM,300,RC,85049,CPT,,,,,,,,56,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Platelet Count,PX85049,CDM,300,RC,85049,CPT,,,,,,,,56,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Platelet Count,PX85049,CDM,300,RC,85049,CPT,,,,,,,,56,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Platelet Count,PX85049,CDM,300,RC,85049,CPT,,,,,,,,56,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Platelet Count,PX85049,CDM,300,RC,85049,CPT,,,,,,,,56,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Pth Immunoch Part 1,PX83970,CDM,300,RC,83970,CPT,,,,,,,,128,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Pth Immunoch Part 1,PX83970,CDM,300,RC,83970,CPT,,,,,,,,128,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Pth Immunoch Part 1,PX83970,CDM,300,RC,83970,CPT,,,,,,,,128,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Pth Immunoch Part 1,PX83970,CDM,300,RC,83970,CPT,,,,,,,,128,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Pth Immunoch Part 1,PX83970,CDM,300,RC,83970,CPT,,,,,,,,128,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Pth Immunoch Part 1,PX83970,CDM,300,RC,83970,CPT,,,,,,,,128,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Wbc and Differential,PX85004,CDM,300,RC,85004,CPT,,,,,,,,39,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Wbc and Differential,PX85004,CDM,300,RC,85004,CPT,,,,,,,,39,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Wbc and Differential,PX85004,CDM,300,RC,85004,CPT,,,,,,,,39,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Wbc and Differential,PX85004,CDM,300,RC,85004,CPT,,,,,,,,39,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Wbc and Differential,PX85004,CDM,300,RC,85004,CPT,,,,,,,,39,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Wbc and Differential,PX85004,CDM,300,RC,85004,CPT,,,,,,,,39,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143932001,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143932001,NDC,1,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143932001,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143932001,NDC,1,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143932001,NDC,1,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143932001,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143962201,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143962201,NDC,1,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143962201,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143962201,NDC,1,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143962201,NDC,1,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143962201,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,409226720,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,409226720,NDC,1,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,409226720,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,409226720,NDC,1,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,409226720,NDC,1,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,409226720,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,47781058629,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,47781058629,NDC,1,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,47781058629,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,47781058629,NDC,1,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,47781058629,NDC,1,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,47781058629,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,51991093498,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,51991093498,NDC,1,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,51991093498,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,51991093498,NDC,1,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,51991093498,NDC,1,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,51991093498,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
labetalol 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,10135071101,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
labetalol 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,10135071101,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
labetalol 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,10135071101,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
labetalol 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,10135071101,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
labetalol 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,10135071101,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
labetalol 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,10135071101,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
labetalol 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687045011,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
labetalol 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687045011,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
labetalol 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687045011,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
labetalol 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687045011,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
labetalol 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687045011,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
labetalol 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687045011,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lacosamide - Ref,PX8023590,CDM,300,RC,80235,CPT,90,,,,,,,200,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lacosamide - Ref,PX8023590,CDM,300,RC,80235,CPT,90,,,,,,,200,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lacosamide - Ref,PX8023590,CDM,300,RC,80235,CPT,90,,,,,,,200,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lacosamide - Ref,PX8023590,CDM,300,RC,80235,CPT,90,,,,,,,200,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lacosamide - Ref,PX8023590,CDM,300,RC,80235,CPT,90,,,,,,,200,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lacosamide - Ref,PX8023590,CDM,300,RC,80235,CPT,90,,,,,,,200,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lactase 9000 units Tablet 12 Each Box,63700001,CDM,250,RC,,,,,,45091012,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lactase 9000 units Tablet 12 Each Box,63700001,CDM,250,RC,,,,,,45091012,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lactase 9000 units Tablet 12 Each Box,63700001,CDM,250,RC,,,,,,45091012,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lactase 9000 units Tablet 12 Each Box,63700001,CDM,250,RC,,,,,,45091012,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lactase 9000 units Tablet 12 Each Box,63700001,CDM,250,RC,,,,,,45091012,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lactase 9000 units Tablet 12 Each Box,63700001,CDM,250,RC,,,,,,45091012,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lactate (Ld) (Ldh) Enzyme,PX83615,CDM,300,RC,83615,CPT,,,,,,,,157,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lactate (Ld) (Ldh) Enzyme,PX83615,CDM,300,RC,83615,CPT,,,,,,,,157,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lactate (Ld) (Ldh) Enzyme,PX83615,CDM,300,RC,83615,CPT,,,,,,,,157,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lactate (Ld) (Ldh) Enzyme,PX83615,CDM,300,RC,83615,CPT,,,,,,,,157,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lactate (Ld) (Ldh) Enzyme,PX83615,CDM,300,RC,83615,CPT,,,,,,,,157,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lactate (Ld) (Ldh) Enzyme,PX83615,CDM,300,RC,83615,CPT,,,,,,,,157,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lactated ringers Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338011704,NDC,1000,ML,99.12,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lactated ringers Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338011704,NDC,1000,ML,99.12,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lactated ringers Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338011704,NDC,1000,ML,99.12,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lactated ringers Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338011704,NDC,1000,ML,99.12,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lactated ringers Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338011704,NDC,1000,ML,99.12,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lactated ringers Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338011704,NDC,1000,ML,99.12,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lactoferrin, Fecal; Qual",PX83630,CDM,300,RC,83630,CPT,,,,,,,,103,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lactoferrin, Fecal; Qual",PX83630,CDM,300,RC,83630,CPT,,,,,,,,103,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lactoferrin, Fecal; Qual",PX83630,CDM,300,RC,83630,CPT,,,,,,,,103,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lactoferrin, Fecal; Qual",PX83630,CDM,300,RC,83630,CPT,,,,,,,,103,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lactoferrin, Fecal; Qual",PX83630,CDM,300,RC,83630,CPT,,,,,,,,103,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lactoferrin, Fecal; Qual",PX83630,CDM,300,RC,83630,CPT,,,,,,,,103,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lactulose 10 GM/15ML Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,121457715,NDC,15,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lactulose 10 GM/15ML Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,121457715,NDC,15,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lactulose 10 GM/15ML Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,121457715,NDC,15,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lactulose 10 GM/15ML Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,121457715,NDC,15,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lactulose 10 GM/15ML Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,121457715,NDC,15,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lactulose 10 GM/15ML Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,121457715,NDC,15,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lactulose 10 GM/15ML Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,50383077915,NDC,15,ML,15.98,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lactulose 10 GM/15ML Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,50383077915,NDC,15,ML,15.98,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lactulose 10 GM/15ML Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,50383077915,NDC,15,ML,15.98,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lactulose 10 GM/15ML Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,50383077915,NDC,15,ML,15.98,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lactulose 10 GM/15ML Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,50383077915,NDC,15,ML,15.98,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lactulose 10 GM/15ML Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,50383077915,NDC,15,ML,15.98,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lactulose encephalopathy 10 GM/15ML Solution 473 mL Bottle,25000000,CDM,250,RC,,,,,,50383079516,NDC,15,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lactulose encephalopathy 10 GM/15ML Solution 473 mL Bottle,25000000,CDM,250,RC,,,,,,50383079516,NDC,15,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lactulose encephalopathy 10 GM/15ML Solution 473 mL Bottle,25000000,CDM,250,RC,,,,,,50383079516,NDC,15,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lactulose encephalopathy 10 GM/15ML Solution 473 mL Bottle,25000000,CDM,250,RC,,,,,,50383079516,NDC,15,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lactulose encephalopathy 10 GM/15ML Solution 473 mL Bottle,25000000,CDM,250,RC,,,,,,50383079516,NDC,15,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lactulose encephalopathy 10 GM/15ML Solution 473 mL Bottle,25000000,CDM,250,RC,,,,,,50383079516,NDC,15,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lamoTRIgine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079049801,NDC,1,EA,22.34,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lamoTRIgine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079049801,NDC,1,EA,22.34,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lamoTRIgine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079049801,NDC,1,EA,22.34,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lamoTRIgine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079049801,NDC,1,EA,22.34,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lamoTRIgine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079049801,NDC,1,EA,22.34,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lamoTRIgine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079049801,NDC,1,EA,22.34,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lamoTRIgine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904700761,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lamoTRIgine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904700761,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lamoTRIgine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904700761,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lamoTRIgine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904700761,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lamoTRIgine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904700761,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lamoTRIgine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904700761,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lamoTRIgine 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031911,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lamoTRIgine 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031911,NDC,0.25,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lamoTRIgine 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031911,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lamoTRIgine 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031911,NDC,0.25,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lamoTRIgine 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031911,NDC,0.25,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lamoTRIgine 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031911,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lamoTRIgine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739051610,NDC,1,EA,13.3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lamoTRIgine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739051610,NDC,1,EA,13.3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lamoTRIgine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739051610,NDC,1,EA,13.3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lamoTRIgine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739051610,NDC,1,EA,13.3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lamoTRIgine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739051610,NDC,1,EA,13.3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lamoTRIgine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739051610,NDC,1,EA,13.3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lamoTRIgine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084031901,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lamoTRIgine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084031901,NDC,0.25,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lamoTRIgine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084031901,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lamoTRIgine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084031901,NDC,0.25,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lamoTRIgine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084031901,NDC,0.25,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lamoTRIgine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084031901,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Incis Hernia Reducible,PX49654F,CDM,510,RC,49654,CPT,,,,,,,,1964,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Incis Hernia Reducible,PX49654F,CDM,510,RC,49654,CPT,,,,,,,,1964,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Incis Hernia Reducible,PX49654F,CDM,510,RC,49654,CPT,,,,,,,,1964,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Incis Hernia Reducible,PX49654F,CDM,510,RC,49654,CPT,,,,,,,,1964,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Incis Hernia Reducible,PX49654F,CDM,510,RC,49654,CPT,,,,,,,,1964,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Incis Hernia Reducible,PX49654F,CDM,510,RC,49654,CPT,,,,,,,,1964,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Incis Hernia Reducible,PX49654P,CDM,983,RC,49654,CPT,,,,,,,,1044,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Incis Hernia Reducible,PX49654P,CDM,983,RC,49654,CPT,,,,,,,,1044,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Incis Hernia Reducible,PX49654P,CDM,983,RC,49654,CPT,,,,,,,,1044,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Incis Hernia Reducible,PX49654P,CDM,983,RC,49654,CPT,,,,,,,,1044,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Incis Hernia Reducible,PX49654P,CDM,983,RC,49654,CPT,,,,,,,,1044,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Incis Hernia Reducible,PX49654P,CDM,983,RC,49654,CPT,,,,,,,,1044,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LAP KIT BASIC,27200000,CDM,272,RC,,,,4829-MAIN,LOCAL,,,,,78.29,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LAP KIT BASIC,27200000,CDM,272,RC,,,,4829-MAIN,LOCAL,,,,,78.29,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LAP KIT BASIC,27200000,CDM,272,RC,,,,4829-MAIN,LOCAL,,,,,78.29,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LAP KIT BASIC,27200000,CDM,272,RC,,,,4829-MAIN,LOCAL,,,,,78.29,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LAP KIT BASIC,27200000,CDM,272,RC,,,,4829-MAIN,LOCAL,,,,,78.29,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LAP KIT BASIC,27200000,CDM,272,RC,,,,4829-MAIN,LOCAL,,,,,78.29,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Paraesophag Hern Repair,PX43281,CDM,982,RC,43281,CPT,,,,,,,,5950,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Paraesophag Hern Repair,PX43281,CDM,982,RC,43281,CPT,,,,,,,,5950,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Paraesophag Hern Repair,PX43281,CDM,982,RC,43281,CPT,,,,,,,,5950,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Paraesophag Hern Repair,PX43281,CDM,982,RC,43281,CPT,,,,,,,,5950,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Paraesophag Hern Repair,PX43281,CDM,982,RC,43281,CPT,,,,,,,,5950,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Paraesophag Hern Repair,PX43281,CDM,982,RC,43281,CPT,,,,,,,,5950,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Partial Colectomy/Coloproctostomy,PX44207F,CDM,750,RC,44207,CPT,,,,,,,,4170,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3677.94,6141.46
Lap Partial Colectomy/Coloproctostomy,PX44207F,CDM,750,RC,44207,CPT,,,,,,,,4170,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3677.94,6141.46
Lap Partial Colectomy/Coloproctostomy,PX44207F,CDM,750,RC,44207,CPT,,,,,,,,4170,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3677.94,6141.46
Lap Partial Colectomy/Coloproctostomy,PX44207F,CDM,750,RC,44207,CPT,,,,,,,,4170,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3677.94,6141.46
Lap Partial Colectomy/Coloproctostomy,PX44207F,CDM,750,RC,44207,CPT,,,,,,,,4170,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3677.94,6141.46
Lap Partial Colectomy/Coloproctostomy,PX44207F,CDM,750,RC,44207,CPT,,,,,,,,4170,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3677.94,6141.46
Lap Rpr Vent Umbilical Hernia,PX49652F,CDM,510,RC,49652,CPT,,,,,,,,1890,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Rpr Vent Umbilical Hernia,PX49652F,CDM,510,RC,49652,CPT,,,,,,,,1890,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Rpr Vent Umbilical Hernia,PX49652F,CDM,510,RC,49652,CPT,,,,,,,,1890,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Rpr Vent Umbilical Hernia,PX49652F,CDM,510,RC,49652,CPT,,,,,,,,1890,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Rpr Vent Umbilical Hernia,PX49652F,CDM,510,RC,49652,CPT,,,,,,,,1890,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Rpr Vent Umbilical Hernia,PX49652F,CDM,510,RC,49652,CPT,,,,,,,,1890,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Rpr Vent Umbilical Hernia,PX49652P,CDM,983,RC,49652,CPT,,,,,,,,1260,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Rpr Vent Umbilical Hernia,PX49652P,CDM,983,RC,49652,CPT,,,,,,,,1260,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Rpr Vent Umbilical Hernia,PX49652P,CDM,983,RC,49652,CPT,,,,,,,,1260,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Rpr Vent Umbilical Hernia,PX49652P,CDM,983,RC,49652,CPT,,,,,,,,1260,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Rpr Vent Umbilical Hernia,PX49652P,CDM,983,RC,49652,CPT,,,,,,,,1260,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Rpr Vent Umbilical Hernia,PX49652P,CDM,983,RC,49652,CPT,,,,,,,,1260,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Rpr Vent Umbilical Hernia Incarcerated or Strangulated,PX49653F,CDM,510,RC,49653,CPT,,,,,,,,1990,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Rpr Vent Umbilical Hernia Incarcerated or Strangulated,PX49653F,CDM,510,RC,49653,CPT,,,,,,,,1990,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Rpr Vent Umbilical Hernia Incarcerated or Strangulated,PX49653F,CDM,510,RC,49653,CPT,,,,,,,,1990,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Rpr Vent Umbilical Hernia Incarcerated or Strangulated,PX49653F,CDM,510,RC,49653,CPT,,,,,,,,1990,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Rpr Vent Umbilical Hernia Incarcerated or Strangulated,PX49653F,CDM,510,RC,49653,CPT,,,,,,,,1990,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Rpr Vent Umbilical Hernia Incarcerated or Strangulated,PX49653F,CDM,510,RC,49653,CPT,,,,,,,,1990,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Rpr Vent Umbilical Hernia Incarcerated or Strangulated,PX49653P,CDM,983,RC,49653,CPT,,,,,,,,1327,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Rpr Vent Umbilical Hernia Incarcerated or Strangulated,PX49653P,CDM,983,RC,49653,CPT,,,,,,,,1327,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Rpr Vent Umbilical Hernia Incarcerated or Strangulated,PX49653P,CDM,983,RC,49653,CPT,,,,,,,,1327,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Rpr Vent Umbilical Hernia Incarcerated or Strangulated,PX49653P,CDM,983,RC,49653,CPT,,,,,,,,1327,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Rpr Vent Umbilical Hernia Incarcerated or Strangulated,PX49653P,CDM,983,RC,49653,CPT,,,,,,,,1327,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Rpr Vent Umbilical Hernia Incarcerated or Strangulated,PX49653P,CDM,983,RC,49653,CPT,,,,,,,,1327,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Sleeve Gastrectomy,PX43775,CDM,982,RC,43775,CPT,,,,,,,,5030,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Sleeve Gastrectomy,PX43775,CDM,982,RC,43775,CPT,,,,,,,,5030,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Sleeve Gastrectomy,PX43775,CDM,982,RC,43775,CPT,,,,,,,,5030,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Sleeve Gastrectomy,PX43775,CDM,982,RC,43775,CPT,,,,,,,,5030,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Sleeve Gastrectomy,PX43775,CDM,982,RC,43775,CPT,,,,,,,,5030,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Sleeve Gastrectomy,PX43775,CDM,982,RC,43775,CPT,,,,,,,,5030,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LAP SPONGES 18x18 7INCH LOOP,27200000,CDM,272,RC,,,,604-MAIN,LOCAL,,,,,60.64,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LAP SPONGES 18x18 7INCH LOOP,27200000,CDM,272,RC,,,,604-MAIN,LOCAL,,,,,60.64,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LAP SPONGES 18x18 7INCH LOOP,27200000,CDM,272,RC,,,,604-MAIN,LOCAL,,,,,60.64,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LAP SPONGES 18x18 7INCH LOOP,27200000,CDM,272,RC,,,,604-MAIN,LOCAL,,,,,60.64,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LAP SPONGES 18x18 7INCH LOOP,27200000,CDM,272,RC,,,,604-MAIN,LOCAL,,,,,60.64,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LAP SPONGES 18x18 7INCH LOOP,27200000,CDM,272,RC,,,,604-MAIN,LOCAL,,,,,60.64,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Appendectomy",PX44970P,CDM,983,RC,44970,CPT,,,,,,,,1700,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Appendectomy",PX44970P,CDM,983,RC,44970,CPT,,,,,,,,1700,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Appendectomy",PX44970P,CDM,983,RC,44970,CPT,,,,,,,,1700,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Appendectomy",PX44970P,CDM,983,RC,44970,CPT,,,,,,,,1700,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Appendectomy",PX44970P,CDM,983,RC,44970,CPT,,,,,,,,1700,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Appendectomy",PX44970P,CDM,983,RC,44970,CPT,,,,,,,,1700,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Cholecystectomy",PX47562F,CDM,510,RC,47562,CPT,,,,,,,,1473,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Cholecystectomy",PX47562F,CDM,510,RC,47562,CPT,,,,,,,,1473,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Cholecystectomy",PX47562F,CDM,510,RC,47562,CPT,,,,,,,,1473,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Cholecystectomy",PX47562F,CDM,510,RC,47562,CPT,,,,,,,,1473,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Cholecystectomy",PX47562F,CDM,510,RC,47562,CPT,,,,,,,,1473,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Cholecystectomy",PX47562F,CDM,510,RC,47562,CPT,,,,,,,,1473,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Cholecystectomy",PX47562P,CDM,983,RC,47562,CPT,,,,,,,,983,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Cholecystectomy",PX47562P,CDM,983,RC,47562,CPT,,,,,,,,983,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Cholecystectomy",PX47562P,CDM,983,RC,47562,CPT,,,,,,,,983,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Cholecystectomy",PX47562P,CDM,983,RC,47562,CPT,,,,,,,,983,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Cholecystectomy",PX47562P,CDM,983,RC,47562,CPT,,,,,,,,983,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Cholecystectomy",PX47562P,CDM,983,RC,47562,CPT,,,,,,,,983,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Cholecystectomy/Explore",PX47564F,CDM,510,RC,47564,CPT,,,,,,,,2419,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Cholecystectomy/Explore",PX47564F,CDM,510,RC,47564,CPT,,,,,,,,2419,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Cholecystectomy/Explore",PX47564F,CDM,510,RC,47564,CPT,,,,,,,,2419,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Cholecystectomy/Explore",PX47564F,CDM,510,RC,47564,CPT,,,,,,,,2419,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Cholecystectomy/Explore",PX47564F,CDM,510,RC,47564,CPT,,,,,,,,2419,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Cholecystectomy/Explore",PX47564F,CDM,510,RC,47564,CPT,,,,,,,,2419,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Cholecystectomy/Explore",PX47564P,CDM,983,RC,47564,CPT,,,,,,,,1613,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Cholecystectomy/Explore",PX47564P,CDM,983,RC,47564,CPT,,,,,,,,1613,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Cholecystectomy/Explore",PX47564P,CDM,983,RC,47564,CPT,,,,,,,,1613,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Cholecystectomy/Explore",PX47564P,CDM,983,RC,47564,CPT,,,,,,,,1613,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Cholecystectomy/Explore",PX47564P,CDM,983,RC,47564,CPT,,,,,,,,1613,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Cholecystectomy/Explore",PX47564P,CDM,983,RC,47564,CPT,,,,,,,,1613,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Cholecystectomy/Graph",PX47563F,CDM,510,RC,47563,CPT,,,,,,,,1556,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Cholecystectomy/Graph",PX47563F,CDM,510,RC,47563,CPT,,,,,,,,1556,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Cholecystectomy/Graph",PX47563F,CDM,510,RC,47563,CPT,,,,,,,,1556,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Cholecystectomy/Graph",PX47563F,CDM,510,RC,47563,CPT,,,,,,,,1556,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Cholecystectomy/Graph",PX47563F,CDM,510,RC,47563,CPT,,,,,,,,1556,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Cholecystectomy/Graph",PX47563F,CDM,510,RC,47563,CPT,,,,,,,,1556,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Dx Surgical Abd W/Biopsy",PX49321F,CDM,510,RC,49321,CPT,,,,,,,,874,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Dx Surgical Abd W/Biopsy",PX49321F,CDM,510,RC,49321,CPT,,,,,,,,874,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Dx Surgical Abd W/Biopsy",PX49321F,CDM,510,RC,49321,CPT,,,,,,,,874,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Dx Surgical Abd W/Biopsy",PX49321F,CDM,510,RC,49321,CPT,,,,,,,,874,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Dx Surgical Abd W/Biopsy",PX49321F,CDM,510,RC,49321,CPT,,,,,,,,874,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Dx Surgical Abd W/Biopsy",PX49321F,CDM,510,RC,49321,CPT,,,,,,,,874,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Dx Surgical Abd W/Biopsy",PX49321P,CDM,983,RC,49321,CPT,,,,,,,,583,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Dx Surgical Abd W/Biopsy",PX49321P,CDM,983,RC,49321,CPT,,,,,,,,583,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Dx Surgical Abd W/Biopsy",PX49321P,CDM,983,RC,49321,CPT,,,,,,,,583,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Dx Surgical Abd W/Biopsy",PX49321P,CDM,983,RC,49321,CPT,,,,,,,,583,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Dx Surgical Abd W/Biopsy",PX49321P,CDM,983,RC,49321,CPT,,,,,,,,583,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Dx Surgical Abd W/Biopsy",PX49321P,CDM,983,RC,49321,CPT,,,,,,,,583,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Esophagogast Fundoplasty",PX43280F,CDM,510,RC,43280,CPT,,,,,,,,6713,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Esophagogast Fundoplasty",PX43280F,CDM,510,RC,43280,CPT,,,,,,,,6713,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Esophagogast Fundoplasty",PX43280F,CDM,510,RC,43280,CPT,,,,,,,,6713,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Esophagogast Fundoplasty",PX43280F,CDM,510,RC,43280,CPT,,,,,,,,6713,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Esophagogast Fundoplasty",PX43280F,CDM,510,RC,43280,CPT,,,,,,,,6713,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Esophagogast Fundoplasty",PX43280F,CDM,510,RC,43280,CPT,,,,,,,,6713,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Esophagogast Fundoplasty",PX43280P,CDM,983,RC,43280,CPT,,,,,,,,4449,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Esophagogast Fundoplasty",PX43280P,CDM,983,RC,43280,CPT,,,,,,,,4449,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Esophagogast Fundoplasty",PX43280P,CDM,983,RC,43280,CPT,,,,,,,,4449,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Esophagogast Fundoplasty",PX43280P,CDM,983,RC,43280,CPT,,,,,,,,4449,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Esophagogast Fundoplasty",PX43280P,CDM,983,RC,43280,CPT,,,,,,,,4449,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Esophagogast Fundoplasty",PX43280P,CDM,983,RC,43280,CPT,,,,,,,,4449,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Inguinal Hernia Repr,Initial",PX49650F,CDM,510,RC,49650,CPT,,,,,,,,1076,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Inguinal Hernia Repr,Initial",PX49650F,CDM,510,RC,49650,CPT,,,,,,,,1076,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Inguinal Hernia Repr,Initial",PX49650F,CDM,510,RC,49650,CPT,,,,,,,,1076,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Inguinal Hernia Repr,Initial",PX49650F,CDM,510,RC,49650,CPT,,,,,,,,1076,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Inguinal Hernia Repr,Initial",PX49650F,CDM,510,RC,49650,CPT,,,,,,,,1076,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Inguinal Hernia Repr,Initial",PX49650F,CDM,510,RC,49650,CPT,,,,,,,,1076,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Inguinal Hernia Repr,Initial",PX49650P,CDM,983,RC,49650,CPT,,,,,,,,717,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Inguinal Hernia Repr,Initial",PX49650P,CDM,983,RC,49650,CPT,,,,,,,,717,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Inguinal Hernia Repr,Initial",PX49650P,CDM,983,RC,49650,CPT,,,,,,,,717,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Inguinal Hernia Repr,Initial",PX49650P,CDM,983,RC,49650,CPT,,,,,,,,717,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Inguinal Hernia Repr,Initial",PX49650P,CDM,983,RC,49650,CPT,,,,,,,,717,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Inguinal Hernia Repr,Initial",PX49650P,CDM,983,RC,49650,CPT,,,,,,,,717,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Inguinal Hernia Repr,Recur",PX49651F,CDM,510,RC,49651,CPT,,,,,,,,1568,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Inguinal Hernia Repr,Recur",PX49651F,CDM,510,RC,49651,CPT,,,,,,,,1568,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Inguinal Hernia Repr,Recur",PX49651F,CDM,510,RC,49651,CPT,,,,,,,,1568,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Inguinal Hernia Repr,Recur",PX49651F,CDM,510,RC,49651,CPT,,,,,,,,1568,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Inguinal Hernia Repr,Recur",PX49651F,CDM,510,RC,49651,CPT,,,,,,,,1568,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Inguinal Hernia Repr,Recur",PX49651F,CDM,510,RC,49651,CPT,,,,,,,,1568,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Inguinal Hernia Repr,Recur",PX49651P,CDM,983,RC,49651,CPT,,,,,,,,2035,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Inguinal Hernia Repr,Recur",PX49651P,CDM,983,RC,49651,CPT,,,,,,,,2035,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Inguinal Hernia Repr,Recur",PX49651P,CDM,983,RC,49651,CPT,,,,,,,,2035,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Inguinal Hernia Repr,Recur",PX49651P,CDM,983,RC,49651,CPT,,,,,,,,2035,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Inguinal Hernia Repr,Recur",PX49651P,CDM,983,RC,49651,CPT,,,,,,,,2035,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Inguinal Hernia Repr,Recur",PX49651P,CDM,983,RC,49651,CPT,,,,,,,,2035,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180F,CDM,510,RC,44180,CPT,,,,,,,,1763,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180F,CDM,510,RC,44180,CPT,,,,,,,,1763,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180F,CDM,510,RC,44180,CPT,,,,,,,,1763,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180F,CDM,510,RC,44180,CPT,,,,,,,,1763,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180F,CDM,510,RC,44180,CPT,,,,,,,,1763,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180F,CDM,510,RC,44180,CPT,,,,,,,,1763,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180P,CDM,983,RC,44180,CPT,,,,,,,,1175,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180P,CDM,983,RC,44180,CPT,,,,,,,,1175,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180P,CDM,983,RC,44180,CPT,,,,,,,,1175,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180P,CDM,983,RC,44180,CPT,,,,,,,,1175,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180P,CDM,983,RC,44180,CPT,,,,,,,,1175,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180P,CDM,983,RC,44180,CPT,,,,,,,,1175,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LAPAROTOMY MAJOR I,27200000,CDM,272,RC,,,,4828-MAIN,LOCAL,,,,,123.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LAPAROTOMY MAJOR I,27200000,CDM,272,RC,,,,4828-MAIN,LOCAL,,,,,123.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LAPAROTOMY MAJOR I,27200000,CDM,272,RC,,,,4828-MAIN,LOCAL,,,,,123.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LAPAROTOMY MAJOR I,27200000,CDM,272,RC,,,,4828-MAIN,LOCAL,,,,,123.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LAPAROTOMY MAJOR I,27200000,CDM,272,RC,,,,4828-MAIN,LOCAL,,,,,123.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LAPAROTOMY MAJOR I,27200000,CDM,272,RC,,,,4828-MAIN,LOCAL,,,,,123.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LARGE HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12836-MAIN,LOCAL,,,,,3905,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LARGE HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12836-MAIN,LOCAL,,,,,3905,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LARGE HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12836-MAIN,LOCAL,,,,,3905,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LARGE HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12836-MAIN,LOCAL,,,,,3905,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LARGE HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12836-MAIN,LOCAL,,,,,3905,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LARGE HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12836-MAIN,LOCAL,,,,,3905,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,17478062512,NDC,2.5,ML,109.45,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,17478062512,NDC,2.5,ML,109.45,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,17478062512,NDC,2.5,ML,109.45,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,17478062512,NDC,2.5,ML,109.45,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,17478062512,NDC,2.5,ML,109.45,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,17478062512,NDC,2.5,ML,109.45,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,24208046325,NDC,2.5,ML,137.26,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,24208046325,NDC,2.5,ML,137.26,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,24208046325,NDC,2.5,ML,137.26,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,24208046325,NDC,2.5,ML,137.26,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,24208046325,NDC,2.5,ML,137.26,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,24208046325,NDC,2.5,ML,137.26,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,61314054701,NDC,2.5,ML,487.35,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,61314054701,NDC,2.5,ML,487.35,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,61314054701,NDC,2.5,ML,487.35,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,61314054701,NDC,2.5,ML,487.35,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,61314054701,NDC,2.5,ML,487.35,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,61314054701,NDC,2.5,ML,487.35,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Face,Facial <2.5cm",PX12051F,CDM,510,RC,12051,CPT,,,,,,,,769,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Face,Facial <2.5cm",PX12051F,CDM,510,RC,12051,CPT,,,,,,,,769,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Face,Facial <2.5cm",PX12051F,CDM,510,RC,12051,CPT,,,,,,,,769,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Face,Facial <2.5cm",PX12051F,CDM,510,RC,12051,CPT,,,,,,,,769,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Face,Facial <2.5cm",PX12051F,CDM,510,RC,12051,CPT,,,,,,,,769,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Face,Facial <2.5cm",PX12051F,CDM,510,RC,12051,CPT,,,,,,,,769,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Face,Facial <2.5cm",PX12051P,CDM,983,RC,12051,CPT,,,,,,,,615,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Face,Facial <2.5cm",PX12051P,CDM,983,RC,12051,CPT,,,,,,,,615,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Face,Facial <2.5cm",PX12051P,CDM,983,RC,12051,CPT,,,,,,,,615,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Face,Facial <2.5cm",PX12051P,CDM,983,RC,12051,CPT,,,,,,,,615,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Face,Facial <2.5cm",PX12051P,CDM,983,RC,12051,CPT,,,,,,,,615,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Face,Facial <2.5cm",PX12051P,CDM,983,RC,12051,CPT,,,,,,,,615,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Face,Facial 2.5-5",PX12052F,CDM,510,RC,12052,CPT,,,,,,,,585,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Face,Facial 2.5-5",PX12052F,CDM,510,RC,12052,CPT,,,,,,,,585,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Face,Facial 2.5-5",PX12052F,CDM,510,RC,12052,CPT,,,,,,,,585,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Face,Facial 2.5-5",PX12052F,CDM,510,RC,12052,CPT,,,,,,,,585,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Face,Facial 2.5-5",PX12052F,CDM,510,RC,12052,CPT,,,,,,,,585,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Face,Facial 2.5-5",PX12052F,CDM,510,RC,12052,CPT,,,,,,,,585,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Face,Facial 2.5-5",PX12052P,CDM,983,RC,12052,CPT,,,,,,,,776,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Face,Facial 2.5-5",PX12052P,CDM,983,RC,12052,CPT,,,,,,,,776,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Face,Facial 2.5-5",PX12052P,CDM,983,RC,12052,CPT,,,,,,,,776,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Face,Facial 2.5-5",PX12052P,CDM,983,RC,12052,CPT,,,,,,,,776,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Face,Facial 2.5-5",PX12052P,CDM,983,RC,12052,CPT,,,,,,,,776,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Face,Facial 2.5-5",PX12052P,CDM,983,RC,12052,CPT,,,,,,,,776,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Layr Clos Wnd Rest Body 2.6-7.5,PX12042F,CDM,510,RC,12042,CPT,,,,,,,,404,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Layr Clos Wnd Rest Body 2.6-7.5,PX12042F,CDM,510,RC,12042,CPT,,,,,,,,404,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Layr Clos Wnd Rest Body 2.6-7.5,PX12042F,CDM,510,RC,12042,CPT,,,,,,,,404,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Layr Clos Wnd Rest Body 2.6-7.5,PX12042F,CDM,510,RC,12042,CPT,,,,,,,,404,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Layr Clos Wnd Rest Body 2.6-7.5,PX12042F,CDM,510,RC,12042,CPT,,,,,,,,404,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Layr Clos Wnd Rest Body 2.6-7.5,PX12042F,CDM,510,RC,12042,CPT,,,,,,,,404,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Layr Clos Wnd Rest Body 2.6-7.5,PX12042P,CDM,983,RC,12042,CPT,,,,,,,,777,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Layr Clos Wnd Rest Body 2.6-7.5,PX12042P,CDM,983,RC,12042,CPT,,,,,,,,777,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Layr Clos Wnd Rest Body 2.6-7.5,PX12042P,CDM,983,RC,12042,CPT,,,,,,,,777,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Layr Clos Wnd Rest Body 2.6-7.5,PX12042P,CDM,983,RC,12042,CPT,,,,,,,,777,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Layr Clos Wnd Rest Body 2.6-7.5,PX12042P,CDM,983,RC,12042,CPT,,,,,,,,777,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Layr Clos Wnd Rest Body 2.6-7.5,PX12042P,CDM,983,RC,12042,CPT,,,,,,,,777,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Layr Clos Wnd Rest Body 7.6-12.5,PX12044F,CDM,510,RC,12044,CPT,,,,,,,,785,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Layr Clos Wnd Rest Body 7.6-12.5,PX12044F,CDM,510,RC,12044,CPT,,,,,,,,785,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Layr Clos Wnd Rest Body 7.6-12.5,PX12044F,CDM,510,RC,12044,CPT,,,,,,,,785,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Layr Clos Wnd Rest Body 7.6-12.5,PX12044F,CDM,510,RC,12044,CPT,,,,,,,,785,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Layr Clos Wnd Rest Body 7.6-12.5,PX12044F,CDM,510,RC,12044,CPT,,,,,,,,785,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Layr Clos Wnd Rest Body 7.6-12.5,PX12044F,CDM,510,RC,12044,CPT,,,,,,,,785,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Layr Clos Wnd Rest Body 7.6-12.5,PX12044P,CDM,983,RC,12044,CPT,,,,,,,,523,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Layr Clos Wnd Rest Body 7.6-12.5,PX12044P,CDM,983,RC,12044,CPT,,,,,,,,523,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Layr Clos Wnd Rest Body 7.6-12.5,PX12044P,CDM,983,RC,12044,CPT,,,,,,,,523,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Layr Clos Wnd Rest Body 7.6-12.5,PX12044P,CDM,983,RC,12044,CPT,,,,,,,,523,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Layr Clos Wnd Rest Body 7.6-12.5,PX12044P,CDM,983,RC,12044,CPT,,,,,,,,523,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Layr Clos Wnd Rest Body 7.6-12.5,PX12044P,CDM,983,RC,12044,CPT,,,,,,,,523,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031F,CDM,510,RC,12031,CPT,,,,,,,,688,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031F,CDM,510,RC,12031,CPT,,,,,,,,688,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031F,CDM,510,RC,12031,CPT,,,,,,,,688,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031F,CDM,510,RC,12031,CPT,,,,,,,,688,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031F,CDM,510,RC,12031,CPT,,,,,,,,688,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031F,CDM,510,RC,12031,CPT,,,,,,,,688,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031P,CDM,983,RC,12031,CPT,,,,,,,,551,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031P,CDM,983,RC,12031,CPT,,,,,,,,551,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031P,CDM,983,RC,12031,CPT,,,,,,,,551,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031P,CDM,983,RC,12031,CPT,,,,,,,,551,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031P,CDM,983,RC,12031,CPT,,,,,,,,551,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031P,CDM,983,RC,12031,CPT,,,,,,,,551,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032F,CDM,510,RC,12032,CPT,,,,,,,,386,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032F,CDM,510,RC,12032,CPT,,,,,,,,386,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032F,CDM,510,RC,12032,CPT,,,,,,,,386,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032F,CDM,510,RC,12032,CPT,,,,,,,,386,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032F,CDM,510,RC,12032,CPT,,,,,,,,386,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032F,CDM,510,RC,12032,CPT,,,,,,,,386,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032P,CDM,983,RC,12032,CPT,,,,,,,,647,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032P,CDM,983,RC,12032,CPT,,,,,,,,647,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032P,CDM,983,RC,12032,CPT,,,,,,,,647,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032P,CDM,983,RC,12032,CPT,,,,,,,,647,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032P,CDM,983,RC,12032,CPT,,,,,,,,647,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032P,CDM,983,RC,12032,CPT,,,,,,,,647,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034F,CDM,510,RC,12034,CPT,,,,,,,,931,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034F,CDM,510,RC,12034,CPT,,,,,,,,931,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034F,CDM,510,RC,12034,CPT,,,,,,,,931,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034F,CDM,510,RC,12034,CPT,,,,,,,,931,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034F,CDM,510,RC,12034,CPT,,,,,,,,931,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034F,CDM,510,RC,12034,CPT,,,,,,,,931,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034P,CDM,983,RC,12034,CPT,,,,,,,,1533,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034P,CDM,983,RC,12034,CPT,,,,,,,,1533,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034P,CDM,983,RC,12034,CPT,,,,,,,,1533,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034P,CDM,983,RC,12034,CPT,,,,,,,,1533,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034P,CDM,983,RC,12034,CPT,,,,,,,,1533,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034P,CDM,983,RC,12034,CPT,,,,,,,,1533,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035F,CDM,510,RC,12035,CPT,,,,,,,,655,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035F,CDM,510,RC,12035,CPT,,,,,,,,655,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035F,CDM,510,RC,12035,CPT,,,,,,,,655,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035F,CDM,510,RC,12035,CPT,,,,,,,,655,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035F,CDM,510,RC,12035,CPT,,,,,,,,655,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035F,CDM,510,RC,12035,CPT,,,,,,,,655,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035P,CDM,983,RC,12035,CPT,,,,,,,,1244,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035P,CDM,983,RC,12035,CPT,,,,,,,,1244,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035P,CDM,983,RC,12035,CPT,,,,,,,,1244,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035P,CDM,983,RC,12035,CPT,,,,,,,,1244,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035P,CDM,983,RC,12035,CPT,,,,,,,,1244,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035P,CDM,983,RC,12035,CPT,,,,,,,,1244,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leflunomide 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,62332006130,NDC,1,EA,88.09,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leflunomide 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,62332006130,NDC,1,EA,88.09,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leflunomide 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,62332006130,NDC,1,EA,88.09,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leflunomide 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,62332006130,NDC,1,EA,88.09,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leflunomide 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,62332006130,NDC,1,EA,88.09,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leflunomide 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,62332006130,NDC,1,EA,88.09,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leflunomide 20 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,70748013006,NDC,0.5,EA,44.1,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leflunomide 20 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,70748013006,NDC,0.5,EA,44.1,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leflunomide 20 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,70748013006,NDC,0.5,EA,44.1,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leflunomide 20 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,70748013006,NDC,0.5,EA,44.1,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leflunomide 20 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,70748013006,NDC,0.5,EA,44.1,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leflunomide 20 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,70748013006,NDC,0.5,EA,44.1,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LEGGING COMPRESSION JUXTALITE LONG LG 33CM,120.369,CDM,271,RC,A6545,HCPCS,,10840-MAIN,LOCAL,,,,,145,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LEGGING COMPRESSION JUXTALITE LONG LG 33CM,120.369,CDM,271,RC,A6545,HCPCS,,10840-MAIN,LOCAL,,,,,145,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LEGGING COMPRESSION JUXTALITE LONG LG 33CM,120.369,CDM,271,RC,A6545,HCPCS,,10840-MAIN,LOCAL,,,,,145,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LEGGING COMPRESSION JUXTALITE LONG LG 33CM,120.369,CDM,271,RC,A6545,HCPCS,,10840-MAIN,LOCAL,,,,,145,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LEGGING COMPRESSION JUXTALITE LONG LG 33CM,120.369,CDM,271,RC,A6545,HCPCS,,10840-MAIN,LOCAL,,,,,145,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LEGGING COMPRESSION JUXTALITE LONG LG 33CM,120.369,CDM,271,RC,A6545,HCPCS,,10840-MAIN,LOCAL,,,,,145,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LEGGING PAIR 31X48 STERILE,27200000,CDM,272,RC,,,,10916-MAIN,LOCAL,,,,,16.53,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LEGGING PAIR 31X48 STERILE,27200000,CDM,272,RC,,,,10916-MAIN,LOCAL,,,,,16.53,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LEGGING PAIR 31X48 STERILE,27200000,CDM,272,RC,,,,10916-MAIN,LOCAL,,,,,16.53,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LEGGING PAIR 31X48 STERILE,27200000,CDM,272,RC,,,,10916-MAIN,LOCAL,,,,,16.53,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LEGGING PAIR 31X48 STERILE,27200000,CDM,272,RC,,,,10916-MAIN,LOCAL,,,,,16.53,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LEGGING PAIR 31X48 STERILE,27200000,CDM,272,RC,,,,10916-MAIN,LOCAL,,,,,16.53,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Legionella Antibody - Ref,PX8671390,CDM,300,RC,86713,CPT,90,,,,,,,71,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Legionella Antibody - Ref,PX8671390,CDM,300,RC,86713,CPT,90,,,,,,,71,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Legionella Antibody - Ref,PX8671390,CDM,300,RC,86713,CPT,90,,,,,,,71,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Legionella Antibody - Ref,PX8671390,CDM,300,RC,86713,CPT,90,,,,,,,71,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Legionella Antibody - Ref,PX8671390,CDM,300,RC,86713,CPT,90,,,,,,,71,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Legionella Antibody - Ref,PX8671390,CDM,300,RC,86713,CPT,90,,,,,,,71,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Leptospira Antibody - Ref,PX8672090,CDM,300,RC,86720,CPT,90,,,,,,,220,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Leptospira Antibody - Ref,PX8672090,CDM,300,RC,86720,CPT,90,,,,,,,220,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Leptospira Antibody - Ref,PX8672090,CDM,300,RC,86720,CPT,90,,,,,,,220,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Leptospira Antibody - Ref,PX8672090,CDM,300,RC,86720,CPT,90,,,,,,,220,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Leptospira Antibody - Ref,PX8672090,CDM,300,RC,86720,CPT,90,,,,,,,220,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Leptospira Antibody - Ref,PX8672090,CDM,300,RC,86720,CPT,90,,,,,,,220,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leucovorin 10 mg/mL Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,25021081467,NDC,1,EA,40.13,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leucovorin 10 mg/mL Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,25021081467,NDC,1,EA,40.13,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leucovorin 10 mg/mL Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,25021081467,NDC,1,EA,40.13,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leucovorin 10 mg/mL Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,25021081467,NDC,1,EA,40.13,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leucovorin 10 mg/mL Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,25021081467,NDC,1,EA,40.13,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leucovorin 10 mg/mL Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,25021081467,NDC,1,EA,40.13,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leucovorin 350 MG Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,703514501,NDC,1,EA,86.41,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leucovorin 350 MG Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,703514501,NDC,1,EA,86.41,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leucovorin 350 MG Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,703514501,NDC,1,EA,86.41,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leucovorin 350 MG Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,703514501,NDC,1,EA,86.41,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leucovorin 350 MG Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,703514501,NDC,1,EA,86.41,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leucovorin 350 MG Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,703514501,NDC,1,EA,86.41,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Leukoreduced Platelets,PXP9035,CDM,390,RC,P9035,HCPCS,,,,,,,,1350,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Leukoreduced Platelets,PXP9035,CDM,390,RC,P9035,HCPCS,,,,,,,,1350,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Leukoreduced Platelets,PXP9035,CDM,390,RC,P9035,HCPCS,,,,,,,,1350,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Leukoreduced Platelets,PXP9035,CDM,390,RC,P9035,HCPCS,,,,,,,,1350,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Leukoreduced Platelets,PXP9035,CDM,390,RC,P9035,HCPCS,,,,,,,,1350,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Leukoreduced Platelets,PXP9035,CDM,390,RC,P9035,HCPCS,,,,,,,,1350,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Leukoreduced Rbc's,PXP9016,CDM,390,RC,P9016,HCPCS,,,,,,,,580,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Leukoreduced Rbc's,PXP9016,CDM,390,RC,P9016,HCPCS,,,,,,,,580,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Leukoreduced Rbc's,PXP9016,CDM,390,RC,P9016,HCPCS,,,,,,,,580,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Leukoreduced Rbc's,PXP9016,CDM,390,RC,P9016,HCPCS,,,,,,,,580,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Leukoreduced Rbc's,PXP9016,CDM,390,RC,P9016,HCPCS,,,,,,,,580,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Leukoreduced Rbc's,PXP9016,CDM,390,RC,P9016,HCPCS,,,,,,,,580,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leuprolide 7.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74364203,NDC,1,EA,3782.28,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leuprolide 7.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74364203,NDC,1,EA,3782.28,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leuprolide 7.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74364203,NDC,1,EA,3782.28,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leuprolide 7.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74364203,NDC,1,EA,3782.28,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leuprolide 7.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74364203,NDC,1,EA,3782.28,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leuprolide 7.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74364203,NDC,1,EA,3782.28,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74334603,NDC,1,EA,12509.82,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74334603,NDC,1,EA,12509.82,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74334603,NDC,1,EA,12509.82,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74334603,NDC,1,EA,12509.82,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74334603,NDC,1,EA,12509.82,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74334603,NDC,1,EA,12509.82,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,62935022305,NDC,1,EA,2764.34,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,62935022305,NDC,1,EA,2764.34,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,62935022305,NDC,1,EA,2764.34,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,62935022305,NDC,1,EA,2764.34,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,62935022305,NDC,1,EA,2764.34,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,62935022305,NDC,1,EA,2764.34,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leuprolide 45 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74347303,NDC,1,EA,21633.89,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leuprolide 45 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74347303,NDC,1,EA,21633.89,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leuprolide 45 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74347303,NDC,1,EA,21633.89,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leuprolide 45 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74347303,NDC,1,EA,21633.89,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leuprolide 45 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74347303,NDC,1,EA,21633.89,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leuprolide 45 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74347303,NDC,1,EA,21633.89,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levalbuterol 1.25 MG/3ML Nebulization Solution 3 mL Box,63700001,CDM,250,RC,,,,,,76204090001,NDC,3,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levalbuterol 1.25 MG/3ML Nebulization Solution 3 mL Box,63700001,CDM,250,RC,,,,,,76204090001,NDC,3,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levalbuterol 1.25 MG/3ML Nebulization Solution 3 mL Box,63700001,CDM,250,RC,,,,,,76204090001,NDC,3,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levalbuterol 1.25 MG/3ML Nebulization Solution 3 mL Box,63700001,CDM,250,RC,,,,,,76204090001,NDC,3,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levalbuterol 1.25 MG/3ML Nebulization Solution 3 mL Box,63700001,CDM,250,RC,,,,,,76204090001,NDC,3,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levalbuterol 1.25 MG/3ML Nebulization Solution 3 mL Box,63700001,CDM,250,RC,,,,,,76204090001,NDC,3,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levalbuterol 1.25 MG/3ML Nebulization Solution 3 mL Plas Cont,63700001,CDM,250,RC,,,,,,76204090011,NDC,3,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levalbuterol 1.25 MG/3ML Nebulization Solution 3 mL Plas Cont,63700001,CDM,250,RC,,,,,,76204090011,NDC,3,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levalbuterol 1.25 MG/3ML Nebulization Solution 3 mL Plas Cont,63700001,CDM,250,RC,,,,,,76204090011,NDC,3,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levalbuterol 1.25 MG/3ML Nebulization Solution 3 mL Plas Cont,63700001,CDM,250,RC,,,,,,76204090011,NDC,3,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levalbuterol 1.25 MG/3ML Nebulization Solution 3 mL Plas Cont,63700001,CDM,250,RC,,,,,,76204090011,NDC,3,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levalbuterol 1.25 MG/3ML Nebulization Solution 3 mL Plas Cont,63700001,CDM,250,RC,,,,,,76204090011,NDC,3,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Level 1 Additional Procedure,PX36000080,CDM,360,RC,,,,,,,,,,1200,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1058.4,6141.46
Level 1 Additional Procedure,PX36000080,CDM,360,RC,,,,,,,,,,1200,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1058.4,6141.46
Level 1 Additional Procedure,PX36000080,CDM,360,RC,,,,,,,,,,1200,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1058.4,6141.46
Level 1 Additional Procedure,PX36000080,CDM,360,RC,,,,,,,,,,1200,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1058.4,6141.46
Level 1 Additional Procedure,PX36000080,CDM,360,RC,,,,,,,,,,1200,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1058.4,6141.46
Level 1 Additional Procedure,PX36000080,CDM,360,RC,,,,,,,,,,1200,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1058.4,6141.46
Level 2 Additional Procedure,PX36000081,CDM,360,RC,,,,,,,,,,1500,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1323,6141.46
Level 2 Additional Procedure,PX36000081,CDM,360,RC,,,,,,,,,,1500,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1323,6141.46
Level 2 Additional Procedure,PX36000081,CDM,360,RC,,,,,,,,,,1500,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1323,6141.46
Level 2 Additional Procedure,PX36000081,CDM,360,RC,,,,,,,,,,1500,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1323,6141.46
Level 2 Additional Procedure,PX36000081,CDM,360,RC,,,,,,,,,,1500,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1323,6141.46
Level 2 Additional Procedure,PX36000081,CDM,360,RC,,,,,,,,,,1500,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1323,6141.46
Level 3 Additional Procedure,PX36000082,CDM,360,RC,,,,,,,,,,2100,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1852.2,6141.46
Level 3 Additional Procedure,PX36000082,CDM,360,RC,,,,,,,,,,2100,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1852.2,6141.46
Level 3 Additional Procedure,PX36000082,CDM,360,RC,,,,,,,,,,2100,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1852.2,6141.46
Level 3 Additional Procedure,PX36000082,CDM,360,RC,,,,,,,,,,2100,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1852.2,6141.46
Level 3 Additional Procedure,PX36000082,CDM,360,RC,,,,,,,,,,2100,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1852.2,6141.46
Level 3 Additional Procedure,PX36000082,CDM,360,RC,,,,,,,,,,2100,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1852.2,6141.46
Level 4 Additional Procedure,PX36000083,CDM,360,RC,,,,,,,,,,3200,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2822.4,6141.46
Level 4 Additional Procedure,PX36000083,CDM,360,RC,,,,,,,,,,3200,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2822.4,6141.46
Level 4 Additional Procedure,PX36000083,CDM,360,RC,,,,,,,,,,3200,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2822.4,6141.46
Level 4 Additional Procedure,PX36000083,CDM,360,RC,,,,,,,,,,3200,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2822.4,6141.46
Level 4 Additional Procedure,PX36000083,CDM,360,RC,,,,,,,,,,3200,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2822.4,6141.46
Level 4 Additional Procedure,PX36000083,CDM,360,RC,,,,,,,,,,3200,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2822.4,6141.46
Level 5 Additional Procedure,PX36000084,CDM,360,RC,,,,,,,,,,5300,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4674.6,6141.46
Level 5 Additional Procedure,PX36000084,CDM,360,RC,,,,,,,,,,5300,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4674.6,6141.46
Level 5 Additional Procedure,PX36000084,CDM,360,RC,,,,,,,,,,5300,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4674.6,6141.46
Level 5 Additional Procedure,PX36000084,CDM,360,RC,,,,,,,,,,5300,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4674.6,6141.46
Level 5 Additional Procedure,PX36000084,CDM,360,RC,,,,,,,,,,5300,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4674.6,6141.46
Level 5 Additional Procedure,PX36000084,CDM,360,RC,,,,,,,,,,5300,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4674.6,6141.46
Level 6 Additional Procedure,PX36000085,CDM,360,RC,,,,,,,,,,6500,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Level 6 Additional Procedure,PX36000085,CDM,360,RC,,,,,,,,,,6500,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Level 6 Additional Procedure,PX36000085,CDM,360,RC,,,,,,,,,,6500,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Level 6 Additional Procedure,PX36000085,CDM,360,RC,,,,,,,,,,6500,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Level 6 Additional Procedure,PX36000085,CDM,360,RC,,,,,,,,,,6500,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Level 6 Additional Procedure,PX36000085,CDM,360,RC,,,,,,,,,,6500,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Level III - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3933,CDM,310,RC,88304,CPT,TC,,,,,,,66,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Level III - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3933,CDM,310,RC,88304,CPT,TC,,,,,,,66,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Level III - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3933,CDM,310,RC,88304,CPT,TC,,,,,,,66,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Level III - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3933,CDM,310,RC,88304,CPT,TC,,,,,,,66,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Level III - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3933,CDM,310,RC,88304,CPT,TC,,,,,,,66,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Level III - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3933,CDM,310,RC,88304,CPT,TC,,,,,,,66,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Level IV - Surgical Pathology, Gross and Microscopic Examination , Tech",PX3934,CDM,310,RC,88305,CPT,TC,,,,,,,185,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Level IV - Surgical Pathology, Gross and Microscopic Examination , Tech",PX3934,CDM,310,RC,88305,CPT,TC,,,,,,,185,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Level IV - Surgical Pathology, Gross and Microscopic Examination , Tech",PX3934,CDM,310,RC,88305,CPT,TC,,,,,,,185,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Level IV - Surgical Pathology, Gross and Microscopic Examination , Tech",PX3934,CDM,310,RC,88305,CPT,TC,,,,,,,185,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Level IV - Surgical Pathology, Gross and Microscopic Examination , Tech",PX3934,CDM,310,RC,88305,CPT,TC,,,,,,,185,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Level IV - Surgical Pathology, Gross and Microscopic Examination , Tech",PX3934,CDM,310,RC,88305,CPT,TC,,,,,,,185,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Level V - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3939,CDM,310,RC,88307,CPT,TC,,,,,,,252,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Level V - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3939,CDM,310,RC,88307,CPT,TC,,,,,,,252,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Level V - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3939,CDM,310,RC,88307,CPT,TC,,,,,,,252,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Level V - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3939,CDM,310,RC,88307,CPT,TC,,,,,,,252,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Level V - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3939,CDM,310,RC,88307,CPT,TC,,,,,,,252,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Level V - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3939,CDM,310,RC,88307,CPT,TC,,,,,,,252,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Levetiracetam - Ref,PX8017790,CDM,300,RC,80177,CPT,90,,,,,,,108,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Levetiracetam - Ref,PX8017790,CDM,300,RC,80177,CPT,90,,,,,,,108,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Levetiracetam - Ref,PX8017790,CDM,300,RC,80177,CPT,90,,,,,,,108,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Levetiracetam - Ref,PX8017790,CDM,300,RC,80177,CPT,90,,,,,,,108,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Levetiracetam - Ref,PX8017790,CDM,300,RC,80177,CPT,90,,,,,,,108,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Levetiracetam - Ref,PX8017790,CDM,300,RC,80177,CPT,90,,,,,,,108,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levETIRAcetam 250 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904712361,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levETIRAcetam 250 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904712361,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levETIRAcetam 250 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904712361,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levETIRAcetam 250 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904712361,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levETIRAcetam 250 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904712361,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levETIRAcetam 250 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904712361,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levETIRAcetam 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079082101,NDC,1,EA,18.87,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levETIRAcetam 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079082101,NDC,1,EA,18.87,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levETIRAcetam 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079082101,NDC,1,EA,18.87,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levETIRAcetam 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079082101,NDC,1,EA,18.87,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levETIRAcetam 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079082101,NDC,1,EA,18.87,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levETIRAcetam 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079082101,NDC,1,EA,18.87,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188602,NDC,5,ML,45.46,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188602,NDC,5,ML,45.46,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188602,NDC,5,ML,45.46,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188602,NDC,5,ML,45.46,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188602,NDC,5,ML,45.46,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188602,NDC,5,ML,45.46,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188622,NDC,5,ML,45.46,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188622,NDC,5,ML,45.46,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188622,NDC,5,ML,45.46,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188622,NDC,5,ML,45.46,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188622,NDC,5,ML,45.46,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188622,NDC,5,ML,45.46,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levETIRAcetam 750 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,16714035602,NDC,0.333333333,EA,8.41,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levETIRAcetam 750 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,16714035602,NDC,0.333333333,EA,8.41,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levETIRAcetam 750 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,16714035602,NDC,0.333333333,EA,8.41,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levETIRAcetam 750 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,16714035602,NDC,0.333333333,EA,8.41,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levETIRAcetam 750 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,16714035602,NDC,0.333333333,EA,8.41,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levETIRAcetam 750 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,16714035602,NDC,0.333333333,EA,8.41,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levOCARNitine 200 MG/ML Solution 5 mL Vial,J1955.01,CDM,636,RC,J1955,HCPCS,,,,517104501,NDC,5,ML,249.86,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levOCARNitine 200 MG/ML Solution 5 mL Vial,J1955.01,CDM,636,RC,J1955,HCPCS,,,,517104501,NDC,5,ML,249.86,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levOCARNitine 200 MG/ML Solution 5 mL Vial,J1955.01,CDM,636,RC,J1955,HCPCS,,,,517104501,NDC,5,ML,249.86,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levOCARNitine 200 MG/ML Solution 5 mL Vial,J1955.01,CDM,636,RC,J1955,HCPCS,,,,517104501,NDC,5,ML,249.86,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levOCARNitine 200 MG/ML Solution 5 mL Vial,J1955.01,CDM,636,RC,J1955,HCPCS,,,,517104501,NDC,5,ML,249.86,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levOCARNitine 200 MG/ML Solution 5 mL Vial,J1955.01,CDM,636,RC,J1955,HCPCS,,,,517104501,NDC,5,ML,249.86,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin 250 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635161,NDC,1,EA,79.08,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin 250 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635161,NDC,1,EA,79.08,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin 250 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635161,NDC,1,EA,79.08,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin 250 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635161,NDC,1,EA,79.08,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin 250 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635161,NDC,1,EA,79.08,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin 250 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635161,NDC,1,EA,79.08,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635261,NDC,0.5,EA,45.16,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635261,NDC,0.5,EA,45.16,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635261,NDC,0.5,EA,45.16,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635261,NDC,0.5,EA,45.16,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635261,NDC,0.5,EA,45.16,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635261,NDC,0.5,EA,45.16,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin 750 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635361,NDC,0.333333333,EA,39.14,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin 750 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635361,NDC,0.333333333,EA,39.14,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin 750 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635361,NDC,0.333333333,EA,39.14,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin 750 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635361,NDC,0.333333333,EA,39.14,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin 750 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635361,NDC,0.333333333,EA,39.14,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin 750 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635361,NDC,0.333333333,EA,39.14,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013266,NDC,50,ML,59.67,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013266,NDC,50,ML,59.67,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013266,NDC,50,ML,59.67,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013266,NDC,50,ML,59.67,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013266,NDC,50,ML,59.67,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013266,NDC,50,ML,59.67,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004624,NDC,50,ML,50.58,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004624,NDC,50,ML,50.58,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004624,NDC,50,ML,50.58,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004624,NDC,50,ML,50.58,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004624,NDC,50,ML,50.58,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004624,NDC,50,ML,50.58,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin in dextrose 5% 500 MG/100ML Solution 100 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004724,NDC,100,ML,64.63,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin in dextrose 5% 500 MG/100ML Solution 100 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004724,NDC,100,ML,64.63,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin in dextrose 5% 500 MG/100ML Solution 100 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004724,NDC,100,ML,64.63,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin in dextrose 5% 500 MG/100ML Solution 100 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004724,NDC,100,ML,64.63,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin in dextrose 5% 500 MG/100ML Solution 100 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004724,NDC,100,ML,64.63,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin in dextrose 5% 500 MG/100ML Solution 100 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004724,NDC,100,ML,64.63,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013268,NDC,150,ML,59.67,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013268,NDC,150,ML,59.67,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013268,NDC,150,ML,59.67,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013268,NDC,150,ML,59.67,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013268,NDC,150,ML,59.67,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013268,NDC,150,ML,59.67,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004824,NDC,150,ML,69.59,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004824,NDC,150,ML,69.59,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004824,NDC,150,ML,69.59,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004824,NDC,150,ML,69.59,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004824,NDC,150,ML,69.59,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004824,NDC,150,ML,69.59,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levonorgestrel 1.5 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,62756071860,NDC,1,EA,114.48,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levonorgestrel 1.5 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,62756071860,NDC,1,EA,114.48,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levonorgestrel 1.5 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,62756071860,NDC,1,EA,114.48,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levonorgestrel 1.5 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,62756071860,NDC,1,EA,114.48,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levonorgestrel 1.5 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,62756071860,NDC,1,EA,114.48,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levonorgestrel 1.5 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,62756071860,NDC,1,EA,114.48,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levonorgestrel 1.5 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,68180085211,NDC,1,EA,174.39,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levonorgestrel 1.5 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,68180085211,NDC,1,EA,174.39,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levonorgestrel 1.5 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,68180085211,NDC,1,EA,174.39,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levonorgestrel 1.5 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,68180085211,NDC,1,EA,174.39,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levonorgestrel 1.5 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,68180085211,NDC,1,EA,174.39,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levonorgestrel 1.5 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,68180085211,NDC,1,EA,174.39,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 25 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904694961,NDC,4,EA,11.75,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 25 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904694961,NDC,4,EA,11.75,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 25 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904694961,NDC,4,EA,11.75,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 25 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904694961,NDC,4,EA,11.75,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 25 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904694961,NDC,4,EA,11.75,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 25 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904694961,NDC,4,EA,11.75,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 50 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079044001,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 50 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079044001,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 50 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079044001,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 50 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079044001,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 50 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079044001,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 50 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079044001,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 50 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079044020,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 50 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079044020,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 50 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079044020,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 50 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079044020,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 50 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079044020,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 50 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079044020,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 75 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079044101,NDC,1.333333333,EA,3.94,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 75 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079044101,NDC,1.333333333,EA,3.94,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 75 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079044101,NDC,1.333333333,EA,3.94,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 75 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079044101,NDC,1.333333333,EA,3.94,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 75 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079044101,NDC,1.333333333,EA,3.94,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 75 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079044101,NDC,1.333333333,EA,3.94,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 75 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079044120,NDC,2,EA,6.4,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 75 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079044120,NDC,2,EA,6.4,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 75 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079044120,NDC,2,EA,6.4,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 75 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079044120,NDC,2,EA,6.4,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 75 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079044120,NDC,2,EA,6.4,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 75 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079044120,NDC,2,EA,6.4,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 88 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378180701,NDC,2,EA,5.99,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 88 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378180701,NDC,2,EA,5.99,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 88 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378180701,NDC,2,EA,5.99,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 88 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378180701,NDC,2,EA,5.99,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 88 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378180701,NDC,2,EA,5.99,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 88 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378180701,NDC,2,EA,5.99,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 88 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904695261,NDC,1.136363636,EA,4.27,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 88 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904695261,NDC,1.136363636,EA,4.27,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 88 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904695261,NDC,1.136363636,EA,4.27,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 88 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904695261,NDC,1.136363636,EA,4.27,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 88 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904695261,NDC,1.136363636,EA,4.27,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 88 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904695261,NDC,1.136363636,EA,4.27,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 100 MCG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,74662490,NDC,1,EA,7.6,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 100 MCG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,74662490,NDC,1,EA,7.6,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 100 MCG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,74662490,NDC,1,EA,7.6,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 100 MCG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,74662490,NDC,1,EA,7.6,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 100 MCG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,74662490,NDC,1,EA,7.6,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 100 MCG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,74662490,NDC,1,EA,7.6,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 100 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,74662411,NDC,1,EA,10.16,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 100 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,74662411,NDC,1,EA,10.16,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 100 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,74662411,NDC,1,EA,10.16,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 100 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,74662411,NDC,1,EA,10.16,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 100 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,74662411,NDC,1,EA,10.16,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 100 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,74662411,NDC,1,EA,10.16,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 100 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904695361,NDC,1,EA,3.78,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 100 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904695361,NDC,1,EA,3.78,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 100 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904695361,NDC,1,EA,3.78,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 100 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904695361,NDC,1,EA,3.78,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 100 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904695361,NDC,1,EA,3.78,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 100 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904695361,NDC,1,EA,3.78,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 100 MCG/5ML Solution 5 mL Vial,J0651.01,CDM,636,RC,J0651,HCPCS,,,,63323088510,NDC,0.625,ML,99.32,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 100 MCG/5ML Solution 5 mL Vial,J0651.01,CDM,636,RC,J0651,HCPCS,,,,63323088510,NDC,0.625,ML,99.32,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 100 MCG/5ML Solution 5 mL Vial,J0651.01,CDM,636,RC,J0651,HCPCS,,,,63323088510,NDC,0.625,ML,99.32,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 100 MCG/5ML Solution 5 mL Vial,J0651.01,CDM,636,RC,J0651,HCPCS,,,,63323088510,NDC,0.625,ML,99.32,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 100 MCG/5ML Solution 5 mL Vial,J0651.01,CDM,636,RC,J0651,HCPCS,,,,63323088510,NDC,0.625,ML,99.32,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 100 MCG/5ML Solution 5 mL Vial,J0651.01,CDM,636,RC,J0651,HCPCS,,,,63323088510,NDC,0.625,ML,99.32,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 112 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003901,NDC,0.892857143,EA,3.4,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 112 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003901,NDC,0.892857143,EA,3.4,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 112 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003901,NDC,0.892857143,EA,3.4,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 112 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003901,NDC,0.892857143,EA,3.4,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 112 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003901,NDC,0.892857143,EA,3.4,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 112 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003901,NDC,0.892857143,EA,3.4,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 112 MCG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,74929690,NDC,0.892857143,EA,6.47,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 112 MCG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,74929690,NDC,0.892857143,EA,6.47,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 112 MCG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,74929690,NDC,0.892857143,EA,6.47,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 112 MCG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,74929690,NDC,0.892857143,EA,6.47,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 112 MCG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,74929690,NDC,0.892857143,EA,6.47,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 112 MCG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,74929690,NDC,0.892857143,EA,6.47,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine Sodium 200 MCG Recon Soln 1 Each Vial,J0650.01,CDM,636,RC,J0650,HCPCS,,,,63323064710,NDC,0.0625,EA,75.75,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine Sodium 200 MCG Recon Soln 1 Each Vial,J0650.01,CDM,636,RC,J0650,HCPCS,,,,63323064710,NDC,0.0625,EA,75.75,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine Sodium 200 MCG Recon Soln 1 Each Vial,J0650.01,CDM,636,RC,J0650,HCPCS,,,,63323064710,NDC,0.0625,EA,75.75,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine Sodium 200 MCG Recon Soln 1 Each Vial,J0650.01,CDM,636,RC,J0650,HCPCS,,,,63323064710,NDC,0.0625,EA,75.75,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine Sodium 200 MCG Recon Soln 1 Each Vial,J0650.01,CDM,636,RC,J0650,HCPCS,,,,63323064710,NDC,0.0625,EA,75.75,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine Sodium 200 MCG Recon Soln 1 Each Vial,J0650.01,CDM,636,RC,J0650,HCPCS,,,,63323064710,NDC,0.0625,EA,75.75,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine - transparent dressing 4 % Kit 1 Each Box,63700001,CDM,250,RC,,,,,,496088207,NDC,1,EA,270.63,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine - transparent dressing 4 % Kit 1 Each Box,63700001,CDM,250,RC,,,,,,496088207,NDC,1,EA,270.63,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine - transparent dressing 4 % Kit 1 Each Box,63700001,CDM,250,RC,,,,,,496088207,NDC,1,EA,270.63,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine - transparent dressing 4 % Kit 1 Each Box,63700001,CDM,250,RC,,,,,,496088207,NDC,1,EA,270.63,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine - transparent dressing 4 % Kit 1 Each Box,63700001,CDM,250,RC,,,,,,496088207,NDC,1,EA,270.63,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine - transparent dressing 4 % Kit 1 Each Box,63700001,CDM,250,RC,,,,,,496088207,NDC,1,EA,270.63,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine (preservative free) 4 % Solution 5 mL Ampule,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409428325,NDC,5,ML,48.62,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine (preservative free) 4 % Solution 5 mL Ampule,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409428325,NDC,5,ML,48.62,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine (preservative free) 4 % Solution 5 mL Ampule,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409428325,NDC,5,ML,48.62,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine (preservative free) 4 % Solution 5 mL Ampule,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409428325,NDC,5,ML,48.62,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine (preservative free) 4 % Solution 5 mL Ampule,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409428325,NDC,5,ML,48.62,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine (preservative free) 4 % Solution 5 mL Ampule,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409428325,NDC,5,ML,48.62,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 0.5 % PF 0.5 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323049101,NDC,50,ML,103.2,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 0.5 % PF 0.5 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323049101,NDC,50,ML,103.2,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 0.5 % PF 0.5 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323049101,NDC,50,ML,103.2,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 0.5 % PF 0.5 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323049101,NDC,50,ML,103.2,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 0.5 % PF 0.5 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323049101,NDC,50,ML,103.2,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 0.5 % PF 0.5 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323049101,NDC,50,ML,103.2,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,55150025110,NDC,10,ML,37.85,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,55150025110,NDC,10,ML,37.85,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,55150025110,NDC,10,ML,37.85,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,55150025110,NDC,10,ML,37.85,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,55150025110,NDC,10,ML,37.85,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,55150025110,NDC,10,ML,37.85,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323020103,NDC,10,ML,36.14,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323020103,NDC,10,ML,36.14,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323020103,NDC,10,ML,36.14,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323020103,NDC,10,ML,36.14,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323020103,NDC,10,ML,36.14,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323020103,NDC,10,ML,36.14,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323020110,NDC,10,ML,34,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323020110,NDC,10,ML,34,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323020110,NDC,10,ML,34,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323020110,NDC,10,ML,34,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323020110,NDC,10,ML,34,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323020110,NDC,10,ML,34,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,409427616,NDC,20,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,409427616,NDC,20,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,409427616,NDC,20,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,409427616,NDC,20,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,409427616,NDC,20,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,409427616,NDC,20,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323048526,NDC,20,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323048526,NDC,20,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323048526,NDC,20,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323048526,NDC,20,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323048526,NDC,20,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323048526,NDC,20,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323048541,NDC,20,ML,30.58,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323048541,NDC,20,ML,30.58,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323048541,NDC,20,ML,30.58,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323048541,NDC,20,ML,30.58,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323048541,NDC,20,ML,30.58,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323048541,NDC,20,ML,30.58,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409427602,NDC,50,ML,38.46,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409427602,NDC,50,ML,38.46,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409427602,NDC,50,ML,38.46,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409427602,NDC,50,ML,38.46,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409427602,NDC,50,ML,38.46,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409427602,NDC,50,ML,38.46,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409427617,NDC,50,ML,39.01,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409427617,NDC,50,ML,39.01,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409427617,NDC,50,ML,39.01,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409427617,NDC,50,ML,39.01,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409427617,NDC,50,ML,39.01,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409427617,NDC,50,ML,39.01,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048503,NDC,50,ML,57.74,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048503,NDC,50,ML,57.74,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048503,NDC,50,ML,57.74,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048503,NDC,50,ML,57.74,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048503,NDC,50,ML,57.74,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048503,NDC,50,ML,57.74,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048557,NDC,50,ML,52.78,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048557,NDC,50,ML,52.78,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048557,NDC,50,ML,52.78,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048557,NDC,50,ML,52.78,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048557,NDC,50,ML,52.78,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048557,NDC,50,ML,52.78,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323048201,NDC,10,ML,39.78,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323048201,NDC,10,ML,39.78,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323048201,NDC,10,ML,39.78,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323048201,NDC,10,ML,39.78,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323048201,NDC,10,ML,39.78,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323048201,NDC,10,ML,39.78,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323048217,NDC,10,ML,39.78,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323048217,NDC,10,ML,39.78,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323048217,NDC,10,ML,39.78,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323048217,NDC,10,ML,39.78,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323048217,NDC,10,ML,39.78,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323048217,NDC,10,ML,39.78,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409317801,NDC,20,ML,34.11,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409317801,NDC,20,ML,34.11,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409317801,NDC,20,ML,34.11,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409317801,NDC,20,ML,34.11,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409317801,NDC,20,ML,34.11,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409317801,NDC,20,ML,34.11,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409317816,NDC,20,ML,34.11,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409317816,NDC,20,ML,34.11,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409317816,NDC,20,ML,34.11,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409317816,NDC,20,ML,34.11,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409317816,NDC,20,ML,34.11,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409317816,NDC,20,ML,34.11,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048203,NDC,20,ML,44.8,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048203,NDC,20,ML,44.8,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048203,NDC,20,ML,44.8,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048203,NDC,20,ML,44.8,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048203,NDC,20,ML,44.8,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048203,NDC,20,ML,44.8,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048226,NDC,20,ML,32.56,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048226,NDC,20,ML,32.56,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048226,NDC,20,ML,32.56,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048226,NDC,20,ML,32.56,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048226,NDC,20,ML,32.56,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048226,NDC,20,ML,32.56,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048227,NDC,20,ML,44.8,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048227,NDC,20,ML,44.8,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048227,NDC,20,ML,44.8,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048227,NDC,20,ML,44.8,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048227,NDC,20,ML,44.8,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048227,NDC,20,ML,44.8,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048241,NDC,20,ML,32.56,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048241,NDC,20,ML,32.56,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048241,NDC,20,ML,32.56,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048241,NDC,20,ML,32.56,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048241,NDC,20,ML,32.56,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048241,NDC,20,ML,32.56,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,63323049227,NDC,2,ML,34.74,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,63323049227,NDC,2,ML,34.74,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,63323049227,NDC,2,ML,34.74,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,63323049227,NDC,2,ML,34.74,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,63323049227,NDC,2,ML,34.74,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,63323049227,NDC,2,ML,34.74,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,63323049241,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,63323049241,NDC,2,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,63323049241,NDC,2,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,63323049241,NDC,2,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,63323049241,NDC,2,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,63323049241,NDC,2,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,55150016205,NDC,5,ML,42.32,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,55150016205,NDC,5,ML,42.32,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,55150016205,NDC,5,ML,42.32,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,55150016205,NDC,5,ML,42.32,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,55150016205,NDC,5,ML,42.32,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,55150016205,NDC,5,ML,42.32,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049209,NDC,5,ML,44.52,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049209,NDC,5,ML,44.52,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049209,NDC,5,ML,44.52,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049209,NDC,5,ML,44.52,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049209,NDC,5,ML,44.52,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049209,NDC,5,ML,44.52,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049236,NDC,5,ML,31.52,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049236,NDC,5,ML,31.52,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049236,NDC,5,ML,31.52,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049236,NDC,5,ML,31.52,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049236,NDC,5,ML,31.52,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049236,NDC,5,ML,31.52,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049243,NDC,5,ML,31.52,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049243,NDC,5,ML,31.52,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049243,NDC,5,ML,31.52,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049243,NDC,5,ML,31.52,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049243,NDC,5,ML,31.52,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049243,NDC,5,ML,31.52,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049257,NDC,5,ML,42.43,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049257,NDC,5,ML,42.43,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049257,NDC,5,ML,42.43,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049257,NDC,5,ML,42.43,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049257,NDC,5,ML,42.43,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049257,NDC,5,ML,42.43,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049226,NDC,30,ML,34.55,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049226,NDC,30,ML,34.55,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049226,NDC,30,ML,34.55,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049226,NDC,30,ML,34.55,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049226,NDC,30,ML,34.55,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049226,NDC,30,ML,34.55,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049237,NDC,30,ML,87.77,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049237,NDC,30,ML,87.77,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049237,NDC,30,ML,87.77,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049237,NDC,30,ML,87.77,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049237,NDC,30,ML,87.77,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049237,NDC,30,ML,87.77,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049245,NDC,30,ML,34.55,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049245,NDC,30,ML,34.55,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049245,NDC,30,ML,34.55,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049245,NDC,30,ML,34.55,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049245,NDC,30,ML,34.55,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049245,NDC,30,ML,34.55,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,143957501,NDC,50,ML,44.24,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,143957501,NDC,50,ML,44.24,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,143957501,NDC,50,ML,44.24,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,143957501,NDC,50,ML,44.24,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,143957501,NDC,50,ML,44.24,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,143957501,NDC,50,ML,44.24,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,143957510,NDC,50,ML,44.24,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,143957510,NDC,50,ML,44.24,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,143957510,NDC,50,ML,44.24,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,143957510,NDC,50,ML,44.24,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,143957510,NDC,50,ML,44.24,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,143957510,NDC,50,ML,44.24,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048657,NDC,50,ML,61.05,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048657,NDC,50,ML,61.05,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048657,NDC,50,ML,61.05,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048657,NDC,50,ML,61.05,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048657,NDC,50,ML,61.05,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048657,NDC,50,ML,61.05,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 2% -EPINEPHRine 1:200,000 2 %-1:200000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409318301,NDC,20,ML,49.86,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 2% -EPINEPHRine 1:200,000 2 %-1:200000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409318301,NDC,20,ML,49.86,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 2% -EPINEPHRine 1:200,000 2 %-1:200000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409318301,NDC,20,ML,49.86,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 2% -EPINEPHRine 1:200,000 2 %-1:200000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409318301,NDC,20,ML,49.86,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 2% -EPINEPHRine 1:200,000 2 %-1:200000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409318301,NDC,20,ML,49.86,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 2% -EPINEPHRine 1:200,000 2 %-1:200000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409318301,NDC,20,ML,49.86,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 2% PF 2 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049526,NDC,5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 2% PF 2 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049526,NDC,5,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 2% PF 2 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049526,NDC,5,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 2% PF 2 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049526,NDC,5,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 2% PF 2 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049526,NDC,5,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 2% PF 2 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049526,NDC,5,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 2% PF 2 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049541,NDC,5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 2% PF 2 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049541,NDC,5,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 2% PF 2 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049541,NDC,5,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 2% PF 2 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049541,NDC,5,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 2% PF 2 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049541,NDC,5,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 2% PF 2 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049541,NDC,5,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 2%-EPINEPHrine 1:100,000 2 %-1:100000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,409318221,NDC,30,ML,51.57,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 2%-EPINEPHrine 1:100,000 2 %-1:100000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,409318221,NDC,30,ML,51.57,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 2%-EPINEPHrine 1:100,000 2 %-1:100000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,409318221,NDC,30,ML,51.57,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 2%-EPINEPHrine 1:100,000 2 %-1:100000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,409318221,NDC,30,ML,51.57,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 2%-EPINEPHrine 1:100,000 2 %-1:100000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,409318221,NDC,30,ML,51.57,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 2%-EPINEPHrine 1:100,000 2 %-1:100000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,409318221,NDC,30,ML,51.57,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 4 % Cream 5 g Tube,63700001,CDM,250,RC,,,,,,496088205,NDC,5,GR,51.49,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 4 % Cream 5 g Tube,63700001,CDM,250,RC,,,,,,496088205,NDC,5,GR,51.49,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 4 % Cream 5 g Tube,63700001,CDM,250,RC,,,,,,496088205,NDC,5,GR,51.49,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 4 % Cream 5 g Tube,63700001,CDM,250,RC,,,,,,496088205,NDC,5,GR,51.49,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 4 % Cream 5 g Tube,63700001,CDM,250,RC,,,,,,496088205,NDC,5,GR,51.49,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 4 % Cream 5 g Tube,63700001,CDM,250,RC,,,,,,496088205,NDC,5,GR,51.49,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 4 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,536128128,NDC,30,GR,96.95,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 4 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,536128128,NDC,30,GR,96.95,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 4 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,536128128,NDC,30,GR,96.95,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 4 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,536128128,NDC,30,GR,96.95,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 4 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,536128128,NDC,30,GR,96.95,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 4 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,536128128,NDC,30,GR,96.95,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 4-5 MG/ML-% Solution 500 mL Flex Cont,J2001.01,CDM,636,RC,J2001,HCPCS,,,,338040903,NDC,500,ML,55.82,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 4-5 MG/ML-% Solution 500 mL Flex Cont,J2001.01,CDM,636,RC,J2001,HCPCS,,,,338040903,NDC,500,ML,55.82,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 4-5 MG/ML-% Solution 500 mL Flex Cont,J2001.01,CDM,636,RC,J2001,HCPCS,,,,338040903,NDC,500,ML,55.82,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 4-5 MG/ML-% Solution 500 mL Flex Cont,J2001.01,CDM,636,RC,J2001,HCPCS,,,,338040903,NDC,500,ML,55.82,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 4-5 MG/ML-% Solution 500 mL Flex Cont,J2001.01,CDM,636,RC,J2001,HCPCS,,,,338040903,NDC,500,ML,55.82,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 4-5 MG/ML-% Solution 500 mL Flex Cont,J2001.01,CDM,636,RC,J2001,HCPCS,,,,338040903,NDC,500,ML,55.82,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 5 % Patch 1 Each Box,63700001,CDM,250,RC,,,,,,591352511,NDC,1,EA,50.26,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 5 % Patch 1 Each Box,63700001,CDM,250,RC,,,,,,591352511,NDC,1,EA,50.26,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 5 % Patch 1 Each Box,63700001,CDM,250,RC,,,,,,591352511,NDC,1,EA,50.26,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 5 % Patch 1 Each Box,63700001,CDM,250,RC,,,,,,591352511,NDC,1,EA,50.26,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 5 % Patch 1 Each Box,63700001,CDM,250,RC,,,,,,591352511,NDC,1,EA,50.26,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 5 % Patch 1 Each Box,63700001,CDM,250,RC,,,,,,591352511,NDC,1,EA,50.26,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 5 % Patch 1 Each Box,63700001,CDM,250,RC,,,,,,603188010,NDC,1,EA,55.2,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 5 % Patch 1 Each Box,63700001,CDM,250,RC,,,,,,603188010,NDC,1,EA,55.2,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 5 % Patch 1 Each Box,63700001,CDM,250,RC,,,,,,603188010,NDC,1,EA,55.2,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 5 % Patch 1 Each Box,63700001,CDM,250,RC,,,,,,603188010,NDC,1,EA,55.2,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 5 % Patch 1 Each Box,63700001,CDM,250,RC,,,,,,603188010,NDC,1,EA,55.2,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 5 % Patch 1 Each Box,63700001,CDM,250,RC,,,,,,603188010,NDC,1,EA,55.2,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 5 % Patch 30 Each Box,63700001,CDM,250,RC,,,,,,591352530,NDC,1,EA,50.26,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 5 % Patch 30 Each Box,63700001,CDM,250,RC,,,,,,591352530,NDC,1,EA,50.26,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 5 % Patch 30 Each Box,63700001,CDM,250,RC,,,,,,591352530,NDC,1,EA,50.26,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 5 % Patch 30 Each Box,63700001,CDM,250,RC,,,,,,591352530,NDC,1,EA,50.26,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 5 % Patch 30 Each Box,63700001,CDM,250,RC,,,,,,591352530,NDC,1,EA,50.26,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 5 % Patch 30 Each Box,63700001,CDM,250,RC,,,,,,591352530,NDC,1,EA,50.26,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 5 % Patch 30 Each Box,63700001,CDM,250,RC,,,,,,603188016,NDC,1,EA,55.18,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 5 % Patch 30 Each Box,63700001,CDM,250,RC,,,,,,603188016,NDC,1,EA,55.18,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 5 % Patch 30 Each Box,63700001,CDM,250,RC,,,,,,603188016,NDC,1,EA,55.18,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 5 % Patch 30 Each Box,63700001,CDM,250,RC,,,,,,603188016,NDC,1,EA,55.18,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 5 % Patch 30 Each Box,63700001,CDM,250,RC,,,,,,603188016,NDC,1,EA,55.18,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 5 % Patch 30 Each Box,63700001,CDM,250,RC,,,,,,603188016,NDC,1,EA,55.18,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409132305,NDC,5,ML,41.35,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409132305,NDC,5,ML,41.35,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409132305,NDC,5,ML,41.35,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409132305,NDC,5,ML,41.35,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409132305,NDC,5,ML,41.35,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409132305,NDC,5,ML,41.35,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490311,NDC,5,ML,43.39,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490311,NDC,5,ML,43.39,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490311,NDC,5,ML,43.39,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490311,NDC,5,ML,43.39,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490311,NDC,5,ML,43.39,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490311,NDC,5,ML,43.39,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490334,NDC,5,ML,42.29,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490334,NDC,5,ML,42.29,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490334,NDC,5,ML,42.29,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490334,NDC,5,ML,42.29,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490334,NDC,5,ML,42.29,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490334,NDC,5,ML,42.29,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,76329339001,NDC,5,ML,64.63,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,76329339001,NDC,5,ML,64.63,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,76329339001,NDC,5,ML,64.63,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,76329339001,NDC,5,ML,64.63,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,76329339001,NDC,5,ML,64.63,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,76329339001,NDC,5,ML,64.63,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine buffered 1 % Solution 0.5 mL Syringe,25000000,CDM,250,RC,,,,,,8888800160,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine buffered 1 % Solution 0.5 mL Syringe,25000000,CDM,250,RC,,,,,,8888800160,NDC,0.5,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine buffered 1 % Solution 0.5 mL Syringe,25000000,CDM,250,RC,,,,,,8888800160,NDC,0.5,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine buffered 1 % Solution 0.5 mL Syringe,25000000,CDM,250,RC,,,,,,8888800160,NDC,0.5,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine buffered 1 % Solution 0.5 mL Syringe,25000000,CDM,250,RC,,,,,,8888800160,NDC,0.5,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine buffered 1 % Solution 0.5 mL Syringe,25000000,CDM,250,RC,,,,,,8888800160,NDC,0.5,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine buffered 1 % Solution 22.2 mL Vial,25000000,CDM,250,RC,,,,,,8888800251,NDC,22.2,ML,30.4,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine buffered 1 % Solution 22.2 mL Vial,25000000,CDM,250,RC,,,,,,8888800251,NDC,22.2,ML,30.4,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine buffered 1 % Solution 22.2 mL Vial,25000000,CDM,250,RC,,,,,,8888800251,NDC,22.2,ML,30.4,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine buffered 1 % Solution 22.2 mL Vial,25000000,CDM,250,RC,,,,,,8888800251,NDC,22.2,ML,30.4,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine buffered 1 % Solution 22.2 mL Vial,25000000,CDM,250,RC,,,,,,8888800251,NDC,22.2,ML,30.4,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine buffered 1 % Solution 22.2 mL Vial,25000000,CDM,250,RC,,,,,,8888800251,NDC,22.2,ML,30.4,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine buffered 1% Solution 22.2 mL Vial,25000000,CDM,250,RC,,,,,,8888800251,NDC,22.2,ML,30.4,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine buffered 1% Solution 22.2 mL Vial,25000000,CDM,250,RC,,,,,,8888800251,NDC,22.2,ML,30.4,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine buffered 1% Solution 22.2 mL Vial,25000000,CDM,250,RC,,,,,,8888800251,NDC,22.2,ML,30.4,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine buffered 1% Solution 22.2 mL Vial,25000000,CDM,250,RC,,,,,,8888800251,NDC,22.2,ML,30.4,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine buffered 1% Solution 22.2 mL Vial,25000000,CDM,250,RC,,,,,,8888800251,NDC,22.2,ML,30.4,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine buffered 1% Solution 22.2 mL Vial,25000000,CDM,250,RC,,,,,,8888800251,NDC,22.2,ML,30.4,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine HCl 4 % Cream 76.5 g Tube,63700001,CDM,250,RC,,,,,,41167005820,NDC,76.5,GR,31.72,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine HCl 4 % Cream 76.5 g Tube,63700001,CDM,250,RC,,,,,,41167005820,NDC,76.5,GR,31.72,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine HCl 4 % Cream 76.5 g Tube,63700001,CDM,250,RC,,,,,,41167005820,NDC,76.5,GR,31.72,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine HCl 4 % Cream 76.5 g Tube,63700001,CDM,250,RC,,,,,,41167005820,NDC,76.5,GR,31.72,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine HCl 4 % Cream 76.5 g Tube,63700001,CDM,250,RC,,,,,,41167005820,NDC,76.5,GR,31.72,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine HCl 4 % Cream 76.5 g Tube,63700001,CDM,250,RC,,,,,,41167005820,NDC,76.5,GR,31.72,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine HCl 4 % Cream 133 g Tube,63700001,CDM,250,RC,,,,,,41167005828,NDC,133,GR,52.99,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine HCl 4 % Cream 133 g Tube,63700001,CDM,250,RC,,,,,,41167005828,NDC,133,GR,52.99,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine HCl 4 % Cream 133 g Tube,63700001,CDM,250,RC,,,,,,41167005828,NDC,133,GR,52.99,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine HCl 4 % Cream 133 g Tube,63700001,CDM,250,RC,,,,,,41167005828,NDC,133,GR,52.99,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine HCl 4 % Cream 133 g Tube,63700001,CDM,250,RC,,,,,,41167005828,NDC,133,GR,52.99,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine HCl 4 % Cream 133 g Tube,63700001,CDM,250,RC,,,,,,41167005828,NDC,133,GR,52.99,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine urethral/mucosal 2 % Gel 30 mL Tube,25000000,CDM,250,RC,,,,,,17478084030,NDC,30,ML,93.91,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine urethral/mucosal 2 % Gel 30 mL Tube,25000000,CDM,250,RC,,,,,,17478084030,NDC,30,ML,93.91,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine urethral/mucosal 2 % Gel 30 mL Tube,25000000,CDM,250,RC,,,,,,17478084030,NDC,30,ML,93.91,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine urethral/mucosal 2 % Gel 30 mL Tube,25000000,CDM,250,RC,,,,,,17478084030,NDC,30,ML,93.91,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine urethral/mucosal 2 % Gel 30 mL Tube,25000000,CDM,250,RC,,,,,,17478084030,NDC,30,ML,93.91,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine urethral/mucosal 2 % Gel 30 mL Tube,25000000,CDM,250,RC,,,,,,17478084030,NDC,30,ML,93.91,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine viscous 2 % Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,121090315,NDC,5,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine viscous 2 % Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,121090315,NDC,5,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine viscous 2 % Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,121090315,NDC,5,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine viscous 2 % Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,121090315,NDC,5,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine viscous 2 % Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,121090315,NDC,5,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine viscous 2 % Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,121090315,NDC,5,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine viscous 2 % Solution 100 mL Bottle,63700001,CDM,250,RC,,,,,,72888012526,NDC,5,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine viscous 2 % Solution 100 mL Bottle,63700001,CDM,250,RC,,,,,,72888012526,NDC,5,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine viscous 2 % Solution 100 mL Bottle,63700001,CDM,250,RC,,,,,,72888012526,NDC,5,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine viscous 2 % Solution 100 mL Bottle,63700001,CDM,250,RC,,,,,,72888012526,NDC,5,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine viscous 2 % Solution 100 mL Bottle,63700001,CDM,250,RC,,,,,,72888012526,NDC,5,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine viscous 2 % Solution 100 mL Bottle,63700001,CDM,250,RC,,,,,,72888012526,NDC,5,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine-epinephrine-tetracaine Gel 3 mL Syringe,J3490.160,CDM,636,RC,J3490,HCPCS,,,,88888800028,NDC,3,ML,121.19,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine-epinephrine-tetracaine Gel 3 mL Syringe,J3490.160,CDM,636,RC,J3490,HCPCS,,,,88888800028,NDC,3,ML,121.19,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine-epinephrine-tetracaine Gel 3 mL Syringe,J3490.160,CDM,636,RC,J3490,HCPCS,,,,88888800028,NDC,3,ML,121.19,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine-epinephrine-tetracaine Gel 3 mL Syringe,J3490.160,CDM,636,RC,J3490,HCPCS,,,,88888800028,NDC,3,ML,121.19,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine-epinephrine-tetracaine Gel 3 mL Syringe,J3490.160,CDM,636,RC,J3490,HCPCS,,,,88888800028,NDC,3,ML,121.19,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine-epinephrine-tetracaine Gel 3 mL Syringe,J3490.160,CDM,636,RC,J3490,HCPCS,,,,88888800028,NDC,3,ML,121.19,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LIGACLIP APPLIER CLIP STERILE SIZE MEDIUM LARGE,27200000,CDM,272,RC,,,,11699-MAIN,LOCAL,,,,,126.62,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LIGACLIP APPLIER CLIP STERILE SIZE MEDIUM LARGE,27200000,CDM,272,RC,,,,11699-MAIN,LOCAL,,,,,126.62,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LIGACLIP APPLIER CLIP STERILE SIZE MEDIUM LARGE,27200000,CDM,272,RC,,,,11699-MAIN,LOCAL,,,,,126.62,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LIGACLIP APPLIER CLIP STERILE SIZE MEDIUM LARGE,27200000,CDM,272,RC,,,,11699-MAIN,LOCAL,,,,,126.62,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LIGACLIP APPLIER CLIP STERILE SIZE MEDIUM LARGE,27200000,CDM,272,RC,,,,11699-MAIN,LOCAL,,,,,126.62,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LIGACLIP APPLIER CLIP STERILE SIZE MEDIUM LARGE,27200000,CDM,272,RC,,,,11699-MAIN,LOCAL,,,,,126.62,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ligation of Hemorrhoid(S),PX46221P,CDM,983,RC,46221,CPT,,,,,,,,697,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ligation of Hemorrhoid(S),PX46221P,CDM,983,RC,46221,CPT,,,,,,,,697,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ligation of Hemorrhoid(S),PX46221P,CDM,983,RC,46221,CPT,,,,,,,,697,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ligation of Hemorrhoid(S),PX46221P,CDM,983,RC,46221,CPT,,,,,,,,697,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ligation of Hemorrhoid(S),PX46221P,CDM,983,RC,46221,CPT,,,,,,,,697,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ligation of Hemorrhoid(S),PX46221P,CDM,983,RC,46221,CPT,,,,,,,,697,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
linezolid 600 MG/300ML Solution 300 mL Flex Cont,J2020.01,CDM,636,RC,J2020,HCPCS,,,,9514001,NDC,300,ML,332.42,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
linezolid 600 MG/300ML Solution 300 mL Flex Cont,J2020.01,CDM,636,RC,J2020,HCPCS,,,,9514001,NDC,300,ML,332.42,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
linezolid 600 MG/300ML Solution 300 mL Flex Cont,J2020.01,CDM,636,RC,J2020,HCPCS,,,,9514001,NDC,300,ML,332.42,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
linezolid 600 MG/300ML Solution 300 mL Flex Cont,J2020.01,CDM,636,RC,J2020,HCPCS,,,,9514001,NDC,300,ML,332.42,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
linezolid 600 MG/300ML Solution 300 mL Flex Cont,J2020.01,CDM,636,RC,J2020,HCPCS,,,,9514001,NDC,300,ML,332.42,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
linezolid 600 MG/300ML Solution 300 mL Flex Cont,J2020.01,CDM,636,RC,J2020,HCPCS,,,,9514001,NDC,300,ML,332.42,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LINNEAR CUTTER STAPLE RELOAD GST BLUE 60MM,27200000,CDM,272,RC,,,,12068-MAIN,LOCAL,,,,,309,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LINNEAR CUTTER STAPLE RELOAD GST BLUE 60MM,27200000,CDM,272,RC,,,,12068-MAIN,LOCAL,,,,,309,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LINNEAR CUTTER STAPLE RELOAD GST BLUE 60MM,27200000,CDM,272,RC,,,,12068-MAIN,LOCAL,,,,,309,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LINNEAR CUTTER STAPLE RELOAD GST BLUE 60MM,27200000,CDM,272,RC,,,,12068-MAIN,LOCAL,,,,,309,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LINNEAR CUTTER STAPLE RELOAD GST BLUE 60MM,27200000,CDM,272,RC,,,,12068-MAIN,LOCAL,,,,,309,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LINNEAR CUTTER STAPLE RELOAD GST BLUE 60MM,27200000,CDM,272,RC,,,,12068-MAIN,LOCAL,,,,,309,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LINNEAR CUTTER STAPLE RELOAD GST GREEN 60MM,27200000,CDM,272,RC,,,,12069-MAIN,LOCAL,,,,,309,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LINNEAR CUTTER STAPLE RELOAD GST GREEN 60MM,27200000,CDM,272,RC,,,,12069-MAIN,LOCAL,,,,,309,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LINNEAR CUTTER STAPLE RELOAD GST GREEN 60MM,27200000,CDM,272,RC,,,,12069-MAIN,LOCAL,,,,,309,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LINNEAR CUTTER STAPLE RELOAD GST GREEN 60MM,27200000,CDM,272,RC,,,,12069-MAIN,LOCAL,,,,,309,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LINNEAR CUTTER STAPLE RELOAD GST GREEN 60MM,27200000,CDM,272,RC,,,,12069-MAIN,LOCAL,,,,,309,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LINNEAR CUTTER STAPLE RELOAD GST GREEN 60MM,27200000,CDM,272,RC,,,,12069-MAIN,LOCAL,,,,,309,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LINNEAR CUTTER STAPLE RELOAD GST WHITE 60MM,27200000,CDM,272,RC,,,,12067-MAIN,LOCAL,,,,,309,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LINNEAR CUTTER STAPLE RELOAD GST WHITE 60MM,27200000,CDM,272,RC,,,,12067-MAIN,LOCAL,,,,,309,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LINNEAR CUTTER STAPLE RELOAD GST WHITE 60MM,27200000,CDM,272,RC,,,,12067-MAIN,LOCAL,,,,,309,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LINNEAR CUTTER STAPLE RELOAD GST WHITE 60MM,27200000,CDM,272,RC,,,,12067-MAIN,LOCAL,,,,,309,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LINNEAR CUTTER STAPLE RELOAD GST WHITE 60MM,27200000,CDM,272,RC,,,,12067-MAIN,LOCAL,,,,,309,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LINNEAR CUTTER STAPLE RELOAD GST WHITE 60MM,27200000,CDM,272,RC,,,,12067-MAIN,LOCAL,,,,,309,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
liothyronine 25 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762120701,NDC,0.2,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
liothyronine 25 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762120701,NDC,0.2,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
liothyronine 25 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762120701,NDC,0.2,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
liothyronine 25 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762120701,NDC,0.2,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
liothyronine 25 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762120701,NDC,0.2,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
liothyronine 25 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762120701,NDC,0.2,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lipid Profile,PX80061,CDM,300,RC,80061,CPT,,,,,,,,245,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lipid Profile,PX80061,CDM,300,RC,80061,CPT,,,,,,,,245,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lipid Profile,PX80061,CDM,300,RC,80061,CPT,,,,,,,,245,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lipid Profile,PX80061,CDM,300,RC,80061,CPT,,,,,,,,245,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lipid Profile,PX80061,CDM,300,RC,80061,CPT,,,,,,,,245,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lipid Profile,PX80061,CDM,300,RC,80061,CPT,,,,,,,,245,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lipoprotein (a) - Ref,PX8369590,CDM,300,RC,83695,CPT,90,,,,,,,55,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lipoprotein (a) - Ref,PX8369590,CDM,300,RC,83695,CPT,90,,,,,,,55,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lipoprotein (a) - Ref,PX8369590,CDM,300,RC,83695,CPT,90,,,,,,,55,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lipoprotein (a) - Ref,PX8369590,CDM,300,RC,83695,CPT,90,,,,,,,55,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lipoprotein (a) - Ref,PX8369590,CDM,300,RC,83695,CPT,90,,,,,,,55,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lipoprotein (a) - Ref,PX8369590,CDM,300,RC,83695,CPT,90,,,,,,,55,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
liraglutide 18 MG/3ML solution pen-injector 3 mL Pen,63700001,CDM,250,RC,,,,,,169406012,NDC,3,ML,1405.33,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
liraglutide 18 MG/3ML solution pen-injector 3 mL Pen,63700001,CDM,250,RC,,,,,,169406012,NDC,3,ML,1405.33,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
liraglutide 18 MG/3ML solution pen-injector 3 mL Pen,63700001,CDM,250,RC,,,,,,169406012,NDC,3,ML,1405.33,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
liraglutide 18 MG/3ML solution pen-injector 3 mL Pen,63700001,CDM,250,RC,,,,,,169406012,NDC,3,ML,1405.33,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
liraglutide 18 MG/3ML solution pen-injector 3 mL Pen,63700001,CDM,250,RC,,,,,,169406012,NDC,3,ML,1405.33,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
liraglutide 18 MG/3ML solution pen-injector 3 mL Pen,63700001,CDM,250,RC,,,,,,169406012,NDC,3,ML,1405.33,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
liraglutide 18 MG/3ML solution pen-injector 3 mL Pen,63700001,CDM,250,RC,,,,,,169406013,NDC,3,ML,1382.75,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
liraglutide 18 MG/3ML solution pen-injector 3 mL Pen,63700001,CDM,250,RC,,,,,,169406013,NDC,3,ML,1382.75,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
liraglutide 18 MG/3ML solution pen-injector 3 mL Pen,63700001,CDM,250,RC,,,,,,169406013,NDC,3,ML,1382.75,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
liraglutide 18 MG/3ML solution pen-injector 3 mL Pen,63700001,CDM,250,RC,,,,,,169406013,NDC,3,ML,1382.75,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
liraglutide 18 MG/3ML solution pen-injector 3 mL Pen,63700001,CDM,250,RC,,,,,,169406013,NDC,3,ML,1382.75,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
liraglutide 18 MG/3ML solution pen-injector 3 mL Pen,63700001,CDM,250,RC,,,,,,169406013,NDC,3,ML,1382.75,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,603420921,NDC,1,EA,3.48,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,603420921,NDC,1,EA,3.48,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,603420921,NDC,1,EA,3.48,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,603420921,NDC,1,EA,3.48,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,603420921,NDC,1,EA,3.48,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,603420921,NDC,1,EA,3.48,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68180051201,NDC,1,EA,3.48,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68180051201,NDC,1,EA,3.48,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68180051201,NDC,1,EA,3.48,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68180051201,NDC,1,EA,3.48,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68180051201,NDC,1,EA,3.48,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68180051201,NDC,1,EA,3.48,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079098101,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079098101,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079098101,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079098101,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079098101,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079098101,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,185060501,NDC,1,EA,5.23,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,185060501,NDC,1,EA,5.23,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,185060501,NDC,1,EA,5.23,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,185060501,NDC,1,EA,5.23,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,185060501,NDC,1,EA,5.23,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,185060501,NDC,1,EA,5.23,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679761,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679761,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679761,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679761,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679761,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679761,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,591040701,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,591040701,NDC,0.25,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,591040701,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,591040701,NDC,0.25,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,591040701,NDC,0.25,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,591040701,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679861,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679861,NDC,0.25,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679861,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679861,NDC,0.25,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679861,NDC,0.25,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679861,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679961,NDC,0.125,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679961,NDC,0.125,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679961,NDC,0.125,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679961,NDC,0.125,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679961,NDC,0.125,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679961,NDC,0.125,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687033301,NDC,0.125,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687033301,NDC,0.125,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687033301,NDC,0.125,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687033301,NDC,0.125,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687033301,NDC,0.125,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687033301,NDC,0.125,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904680061,NDC,0.0625,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904680061,NDC,0.0625,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904680061,NDC,0.0625,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904680061,NDC,0.0625,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904680061,NDC,0.0625,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904680061,NDC,0.0625,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904720061,NDC,0.0625,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904720061,NDC,0.0625,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904720061,NDC,0.0625,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904720061,NDC,0.0625,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904720061,NDC,0.0625,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904720061,NDC,0.0625,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lithium 150 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,54252625,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lithium 150 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,54252625,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lithium 150 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,54252625,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lithium 150 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,54252625,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lithium 150 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,54252625,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lithium 150 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,54252625,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lithium 150 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,54852625,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lithium 150 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,54852625,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lithium 150 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,54852625,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lithium 150 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,54852625,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lithium 150 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,54852625,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lithium 150 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,54852625,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LITHOTOMY PACK VIII ECLIPSE,27200000,CDM,272,RC,,,,12210-MAIN,LOCAL,,,,,31,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LITHOTOMY PACK VIII ECLIPSE,27200000,CDM,272,RC,,,,12210-MAIN,LOCAL,,,,,31,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LITHOTOMY PACK VIII ECLIPSE,27200000,CDM,272,RC,,,,12210-MAIN,LOCAL,,,,,31,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LITHOTOMY PACK VIII ECLIPSE,27200000,CDM,272,RC,,,,12210-MAIN,LOCAL,,,,,31,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LITHOTOMY PACK VIII ECLIPSE,27200000,CDM,272,RC,,,,12210-MAIN,LOCAL,,,,,31,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LITHOTOMY PACK VIII ECLIPSE,27200000,CDM,272,RC,,,,12210-MAIN,LOCAL,,,,,31,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LOCKING SCREW T8 FULL THREAD 2.4MM L10MM,C1713,CDM,278,RC,C1713,HCPCS,,12637-MAIN,LOCAL,,,,,496,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LOCKING SCREW T8 FULL THREAD 2.4MM L10MM,C1713,CDM,278,RC,C1713,HCPCS,,12637-MAIN,LOCAL,,,,,496,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LOCKING SCREW T8 FULL THREAD 2.4MM L10MM,C1713,CDM,278,RC,C1713,HCPCS,,12637-MAIN,LOCAL,,,,,496,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LOCKING SCREW T8 FULL THREAD 2.4MM L10MM,C1713,CDM,278,RC,C1713,HCPCS,,12637-MAIN,LOCAL,,,,,496,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LOCKING SCREW T8 FULL THREAD 2.4MM L10MM,C1713,CDM,278,RC,C1713,HCPCS,,12637-MAIN,LOCAL,,,,,496,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LOCKING SCREW T8 FULL THREAD 2.4MM L10MM,C1713,CDM,278,RC,C1713,HCPCS,,12637-MAIN,LOCAL,,,,,496,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LOCKING SCREW T8 FULL THREAD 2.4MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12651-MAIN,LOCAL,,,,,496,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LOCKING SCREW T8 FULL THREAD 2.4MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12651-MAIN,LOCAL,,,,,496,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LOCKING SCREW T8 FULL THREAD 2.4MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12651-MAIN,LOCAL,,,,,496,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LOCKING SCREW T8 FULL THREAD 2.4MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12651-MAIN,LOCAL,,,,,496,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LOCKING SCREW T8 FULL THREAD 2.4MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12651-MAIN,LOCAL,,,,,496,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LOCKING SCREW T8 FULL THREAD 2.4MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12651-MAIN,LOCAL,,,,,496,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LOCKING SCREW T8 FULL THREAD 2.7MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12638-MAIN,LOCAL,,,,,496,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LOCKING SCREW T8 FULL THREAD 2.7MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12638-MAIN,LOCAL,,,,,496,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LOCKING SCREW T8 FULL THREAD 2.7MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12638-MAIN,LOCAL,,,,,496,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LOCKING SCREW T8 FULL THREAD 2.7MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12638-MAIN,LOCAL,,,,,496,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LOCKING SCREW T8 FULL THREAD 2.7MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12638-MAIN,LOCAL,,,,,496,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LOCKING SCREW T8 FULL THREAD 2.7MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12638-MAIN,LOCAL,,,,,496,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LOCKING SCREW T8 FULL THREAD 2.7MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12639-MAIN,LOCAL,,,,,496,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LOCKING SCREW T8 FULL THREAD 2.7MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12639-MAIN,LOCAL,,,,,496,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LOCKING SCREW T8 FULL THREAD 2.7MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12639-MAIN,LOCAL,,,,,496,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LOCKING SCREW T8 FULL THREAD 2.7MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12639-MAIN,LOCAL,,,,,496,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LOCKING SCREW T8 FULL THREAD 2.7MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12639-MAIN,LOCAL,,,,,496,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LOCKING SCREW T8 FULL THREAD 2.7MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12639-MAIN,LOCAL,,,,,496,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Long Term Holter, 48 Hrs Up to 7 Days, Recording",PX93242,CDM,731,RC,93242,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Long Term Holter, 48 Hrs Up to 7 Days, Recording",PX93242,CDM,731,RC,93242,CPT,,,,,,,,58,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Long Term Holter, 48 Hrs Up to 7 Days, Recording",PX93242,CDM,731,RC,93242,CPT,,,,,,,,58,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Long Term Holter, 48 Hrs Up to 7 Days, Recording",PX93242,CDM,731,RC,93242,CPT,,,,,,,,58,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Long Term Holter, 48 Hrs Up to 7 Days, Recording",PX93242,CDM,731,RC,93242,CPT,,,,,,,,58,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Long Term Holter, 48 Hrs Up to 7 Days, Recording",PX93242,CDM,731,RC,93242,CPT,,,,,,,,58,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Long Term Holter, More Than 7 Days Up to 15 Days, Recording",PX93246,CDM,731,RC,93246,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Long Term Holter, More Than 7 Days Up to 15 Days, Recording",PX93246,CDM,731,RC,93246,CPT,,,,,,,,58,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Long Term Holter, More Than 7 Days Up to 15 Days, Recording",PX93246,CDM,731,RC,93246,CPT,,,,,,,,58,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Long Term Holter, More Than 7 Days Up to 15 Days, Recording",PX93246,CDM,731,RC,93246,CPT,,,,,,,,58,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Long Term Holter, More Than 7 Days Up to 15 Days, Recording",PX93246,CDM,731,RC,93246,CPT,,,,,,,,58,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Long Term Holter, More Than 7 Days Up to 15 Days, Recording",PX93246,CDM,731,RC,93246,CPT,,,,,,,,58,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
loperamide 2 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079069001,NDC,1,EA,4.67,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
loperamide 2 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079069001,NDC,1,EA,4.67,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
loperamide 2 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079069001,NDC,1,EA,4.67,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
loperamide 2 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079069001,NDC,1,EA,4.67,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
loperamide 2 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079069001,NDC,1,EA,4.67,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
loperamide 2 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079069001,NDC,1,EA,4.67,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
loperamide 2 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079069020,NDC,1,EA,4.7,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
loperamide 2 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079069020,NDC,1,EA,4.7,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
loperamide 2 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079069020,NDC,1,EA,4.7,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
loperamide 2 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079069020,NDC,1,EA,4.7,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
loperamide 2 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079069020,NDC,1,EA,4.7,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
loperamide 2 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079069020,NDC,1,EA,4.7,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lopinavir-ritonavir 200-50 MG Tablet 120 Each Bottle,63700001,CDM,250,RC,,,,,,74679922,NDC,1,EA,54.99,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lopinavir-ritonavir 200-50 MG Tablet 120 Each Bottle,63700001,CDM,250,RC,,,,,,74679922,NDC,1,EA,54.99,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lopinavir-ritonavir 200-50 MG Tablet 120 Each Bottle,63700001,CDM,250,RC,,,,,,74679922,NDC,1,EA,54.99,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lopinavir-ritonavir 200-50 MG Tablet 120 Each Bottle,63700001,CDM,250,RC,,,,,,74679922,NDC,1,EA,54.99,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lopinavir-ritonavir 200-50 MG Tablet 120 Each Bottle,63700001,CDM,250,RC,,,,,,74679922,NDC,1,EA,54.99,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lopinavir-ritonavir 200-50 MG Tablet 120 Each Bottle,63700001,CDM,250,RC,,,,,,74679922,NDC,1,EA,54.99,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
loratadine 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714089801,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
loratadine 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714089801,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
loratadine 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714089801,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
loratadine 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714089801,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
loratadine 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714089801,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
loratadine 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714089801,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,591024001,NDC,1,EA,3.45,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,591024001,NDC,1,EA,3.45,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,591024001,NDC,1,EA,3.45,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,591024001,NDC,1,EA,3.45,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,591024001,NDC,1,EA,3.45,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,591024001,NDC,1,EA,3.45,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904600761,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904600761,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904600761,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904600761,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904600761,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904600761,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739049910,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739049910,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739049910,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739049910,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739049910,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739049910,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687035511,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687035511,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687035511,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687035511,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687035511,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687035511,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904600861,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904600861,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904600861,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904600861,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904600861,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904600861,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739050010,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739050010,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739050010,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739050010,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739050010,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739050010,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,54353244,NDC,0.25,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,54353244,NDC,0.25,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,54353244,NDC,0.25,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,54353244,NDC,0.25,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,54353244,NDC,0.25,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,54353244,NDC,0.25,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,121077001,NDC,0.25,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,121077001,NDC,0.25,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,121077001,NDC,0.25,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,121077001,NDC,0.25,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,121077001,NDC,0.25,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,121077001,NDC,0.25,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,65162068784,NDC,0.25,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,65162068784,NDC,0.25,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,65162068784,NDC,0.25,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,65162068784,NDC,0.25,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,65162068784,NDC,0.25,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,65162068784,NDC,0.25,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,409677802,NDC,1,ML,31.11,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,409677802,NDC,1,ML,31.11,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,409677802,NDC,1,ML,31.11,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,409677802,NDC,1,ML,31.11,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,409677802,NDC,1,ML,31.11,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,409677802,NDC,1,ML,31.11,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641600101,NDC,1,ML,32.56,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641600101,NDC,1,ML,32.56,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641600101,NDC,1,ML,32.56,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641600101,NDC,1,ML,32.56,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641600101,NDC,1,ML,32.56,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641600101,NDC,1,ML,32.56,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604401,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604401,NDC,1,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604401,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604401,NDC,1,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604401,NDC,1,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604401,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604425,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604425,NDC,1,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604425,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604425,NDC,1,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604425,NDC,1,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604425,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620701,NDC,0.25,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620701,NDC,0.25,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620701,NDC,0.25,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620701,NDC,0.25,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620701,NDC,0.25,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620701,NDC,0.25,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620725,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620725,NDC,1,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620725,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620725,NDC,1,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620725,NDC,1,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620725,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,17478004001,NDC,1,ML,42.39,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,17478004001,NDC,1,ML,42.39,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,17478004001,NDC,1,ML,42.39,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,17478004001,NDC,1,ML,42.39,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,17478004001,NDC,1,ML,42.39,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,17478004001,NDC,1,ML,42.39,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
losartan 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739067310,NDC,1,EA,3.22,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
losartan 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739067310,NDC,1,EA,3.22,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
losartan 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739067310,NDC,1,EA,3.22,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
losartan 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739067310,NDC,1,EA,3.22,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
losartan 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739067310,NDC,1,EA,3.22,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
losartan 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739067310,NDC,1,EA,3.22,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
losartan 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034711,NDC,1,EA,12.08,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
losartan 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034711,NDC,1,EA,12.08,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
losartan 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034711,NDC,1,EA,12.08,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
losartan 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034711,NDC,1,EA,12.08,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
losartan 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034711,NDC,1,EA,12.08,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
losartan 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034711,NDC,1,EA,12.08,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904704861,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904704861,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904704861,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904704861,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904704861,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904704861,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739068610,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739068610,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739068610,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739068610,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739068610,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739068610,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034701,NDC,1,EA,12.08,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034701,NDC,1,EA,12.08,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034701,NDC,1,EA,12.08,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034701,NDC,1,EA,12.08,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034701,NDC,1,EA,12.08,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034701,NDC,1,EA,12.08,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lovastatin 20 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,93057606,NDC,0.5,EA,6.37,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lovastatin 20 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,93057606,NDC,0.5,EA,6.37,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lovastatin 20 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,93057606,NDC,0.5,EA,6.37,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lovastatin 20 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,93057606,NDC,0.5,EA,6.37,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lovastatin 20 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,93057606,NDC,0.5,EA,6.37,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lovastatin 20 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,93057606,NDC,0.5,EA,6.37,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lovastatin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739028110,NDC,1,EA,15.6,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lovastatin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739028110,NDC,1,EA,15.6,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lovastatin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739028110,NDC,1,EA,15.6,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lovastatin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739028110,NDC,1,EA,15.6,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lovastatin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739028110,NDC,1,EA,15.6,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lovastatin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739028110,NDC,1,EA,15.6,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Low Dose CT Lung Ca Screen WO Contrast,PX7127101,CDM,350,RC,71271,CPT,TC,,,,,,,1286,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Low Dose CT Lung Ca Screen WO Contrast,PX7127101,CDM,350,RC,71271,CPT,TC,,,,,,,1286,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Low Dose CT Lung Ca Screen WO Contrast,PX7127101,CDM,350,RC,71271,CPT,TC,,,,,,,1286,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Low Dose CT Lung Ca Screen WO Contrast,PX7127101,CDM,350,RC,71271,CPT,TC,,,,,,,1286,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Low Dose CT Lung Ca Screen WO Contrast,PX7127101,CDM,350,RC,71271,CPT,TC,,,,,,,1286,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Low Dose CT Lung Ca Screen WO Contrast,PX7127101,CDM,350,RC,71271,CPT,TC,,,,,,,1286,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Low Dose CT Lung Ca Screening,PXG029701,CDM,350,RC,G0297,HCPCS,TC,,,,,,,2812,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Low Dose CT Lung Ca Screening,PXG029701,CDM,350,RC,G0297,HCPCS,TC,,,,,,,2812,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Low Dose CT Lung Ca Screening,PXG029701,CDM,350,RC,G0297,HCPCS,TC,,,,,,,2812,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Low Dose CT Lung Ca Screening,PXG029701,CDM,350,RC,G0297,HCPCS,TC,,,,,,,2812,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Low Dose CT Lung Ca Screening,PXG029701,CDM,350,RC,G0297,HCPCS,TC,,,,,,,2812,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Low Dose CT Lung Ca Screening,PXG029701,CDM,350,RC,G0297,HCPCS,TC,,,,,,,2812,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 1 Init Hosp Low Mdm or 40 Minutes,PX99221,CDM,982,RC,99221,CPT,,,,,,,,400,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 1 Init Hosp Low Mdm or 40 Minutes,PX99221,CDM,982,RC,99221,CPT,,,,,,,,400,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 1 Init Hosp Low Mdm or 40 Minutes,PX99221,CDM,982,RC,99221,CPT,,,,,,,,400,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 1 Init Hosp Low Mdm or 40 Minutes,PX99221,CDM,982,RC,99221,CPT,,,,,,,,400,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 1 Init Hosp Low Mdm or 40 Minutes,PX99221,CDM,982,RC,99221,CPT,,,,,,,,400,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 1 Init Hosp Low Mdm or 40 Minutes,PX99221,CDM,982,RC,99221,CPT,,,,,,,,400,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 1 Sub Hosp Low Mdm or 25 Minutes,PX99231,CDM,982,RC,99231,CPT,,,,,,,,133,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 1 Sub Hosp Low Mdm or 25 Minutes,PX99231,CDM,982,RC,99231,CPT,,,,,,,,133,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 1 Sub Hosp Low Mdm or 25 Minutes,PX99231,CDM,982,RC,99231,CPT,,,,,,,,133,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 1 Sub Hosp Low Mdm or 25 Minutes,PX99231,CDM,982,RC,99231,CPT,,,,,,,,133,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 1 Sub Hosp Low Mdm or 25 Minutes,PX99231,CDM,982,RC,99231,CPT,,,,,,,,133,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 1 Sub Hosp Low Mdm or 25 Minutes,PX99231,CDM,982,RC,99231,CPT,,,,,,,,133,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 2 Init Hosp Mod Mdm or 55 Minutes,PX99222,CDM,982,RC,99222,CPT,,,,,,,,508,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 2 Init Hosp Mod Mdm or 55 Minutes,PX99222,CDM,982,RC,99222,CPT,,,,,,,,508,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 2 Init Hosp Mod Mdm or 55 Minutes,PX99222,CDM,982,RC,99222,CPT,,,,,,,,508,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 2 Init Hosp Mod Mdm or 55 Minutes,PX99222,CDM,982,RC,99222,CPT,,,,,,,,508,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 2 Init Hosp Mod Mdm or 55 Minutes,PX99222,CDM,982,RC,99222,CPT,,,,,,,,508,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 2 Init Hosp Mod Mdm or 55 Minutes,PX99222,CDM,982,RC,99222,CPT,,,,,,,,508,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 2 Sub Hosp Mod Mdm or 35 Minute,PX99232,CDM,982,RC,99232,CPT,,,,,,,,253,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 2 Sub Hosp Mod Mdm or 35 Minute,PX99232,CDM,982,RC,99232,CPT,,,,,,,,253,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 2 Sub Hosp Mod Mdm or 35 Minute,PX99232,CDM,982,RC,99232,CPT,,,,,,,,253,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 2 Sub Hosp Mod Mdm or 35 Minute,PX99232,CDM,982,RC,99232,CPT,,,,,,,,253,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 2 Sub Hosp Mod Mdm or 35 Minute,PX99232,CDM,982,RC,99232,CPT,,,,,,,,253,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 2 Sub Hosp Mod Mdm or 35 Minute,PX99232,CDM,982,RC,99232,CPT,,,,,,,,253,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 3 Init Hosp High Mdm or 75 Minutes,PX99223,CDM,982,RC,99223,CPT,,,,,,,,536,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 3 Init Hosp High Mdm or 75 Minutes,PX99223,CDM,982,RC,99223,CPT,,,,,,,,536,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 3 Init Hosp High Mdm or 75 Minutes,PX99223,CDM,982,RC,99223,CPT,,,,,,,,536,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 3 Init Hosp High Mdm or 75 Minutes,PX99223,CDM,982,RC,99223,CPT,,,,,,,,536,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 3 Init Hosp High Mdm or 75 Minutes,PX99223,CDM,982,RC,99223,CPT,,,,,,,,536,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 3 Init Hosp High Mdm or 75 Minutes,PX99223,CDM,982,RC,99223,CPT,,,,,,,,536,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 3 Sub Hosp High Mdm or 50 Minutes,PX99233,CDM,982,RC,99233,CPT,,,,,,,,384,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 3 Sub Hosp High Mdm or 50 Minutes,PX99233,CDM,982,RC,99233,CPT,,,,,,,,384,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 3 Sub Hosp High Mdm or 50 Minutes,PX99233,CDM,982,RC,99233,CPT,,,,,,,,384,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 3 Sub Hosp High Mdm or 50 Minutes,PX99233,CDM,982,RC,99233,CPT,,,,,,,,384,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 3 Sub Hosp High Mdm or 50 Minutes,PX99233,CDM,982,RC,99233,CPT,,,,,,,,384,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 3 Sub Hosp High Mdm or 50 Minutes,PX99233,CDM,982,RC,99233,CPT,,,,,,,,384,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lyme Disease Antibody,PX86618,CDM,300,RC,86618,CPT,,,,,,,,194,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lyme Disease Antibody,PX86618,CDM,300,RC,86618,CPT,,,,,,,,194,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lyme Disease Antibody,PX86618,CDM,300,RC,86618,CPT,,,,,,,,194,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lyme Disease Antibody,PX86618,CDM,300,RC,86618,CPT,,,,,,,,194,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lyme Disease Antibody,PX86618,CDM,300,RC,86618,CPT,,,,,,,,194,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lyme Disease Antibody,PX86618,CDM,300,RC,86618,CPT,,,,,,,,194,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lyme Disease, Antibody - Ref",PX8661890,CDM,300,RC,86618,CPT,90,,,,,,,181,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lyme Disease, Antibody - Ref",PX8661890,CDM,300,RC,86618,CPT,90,,,,,,,181,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lyme Disease, Antibody - Ref",PX8661890,CDM,300,RC,86618,CPT,90,,,,,,,181,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lyme Disease, Antibody - Ref",PX8661890,CDM,300,RC,86618,CPT,90,,,,,,,181,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lyme Disease, Antibody - Ref",PX8661890,CDM,300,RC,86618,CPT,90,,,,,,,181,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lyme Disease, Antibody - Ref",PX8661890,CDM,300,RC,86618,CPT,90,,,,,,,181,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lyme Disease, Confirm Tst - Ref",PX8661790,CDM,300,RC,86617,CPT,90,,,,,,,95,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lyme Disease, Confirm Tst - Ref",PX8661790,CDM,300,RC,86617,CPT,90,,,,,,,95,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lyme Disease, Confirm Tst - Ref",PX8661790,CDM,300,RC,86617,CPT,90,,,,,,,95,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lyme Disease, Confirm Tst - Ref",PX8661790,CDM,300,RC,86617,CPT,90,,,,,,,95,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lyme Disease, Confirm Tst - Ref",PX8661790,CDM,300,RC,86617,CPT,90,,,,,,,95,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lyme Disease, Confirm Tst - Ref",PX8661790,CDM,300,RC,86617,CPT,90,,,,,,,95,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lyme Screen,PX7585,CDM,300,RC,86618,CPT,,,,,,,,198,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lyme Screen,PX7585,CDM,300,RC,86618,CPT,,,,,,,,198,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lyme Screen,PX7585,CDM,300,RC,86618,CPT,,,,,,,,198,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lyme Screen,PX7585,CDM,300,RC,86618,CPT,,,,,,,,198,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lyme Screen,PX7585,CDM,300,RC,86618,CPT,,,,,,,,198,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lyme Screen,PX7585,CDM,300,RC,86618,CPT,,,,,,,,198,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Magnesium,PX83735,CDM,300,RC,83735,CPT,,,,,,,,150,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Magnesium,PX83735,CDM,300,RC,83735,CPT,,,,,,,,150,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Magnesium,PX83735,CDM,300,RC,83735,CPT,,,,,,,,150,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Magnesium,PX83735,CDM,300,RC,83735,CPT,,,,,,,,150,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Magnesium,PX83735,CDM,300,RC,83735,CPT,,,,,,,,150,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Magnesium,PX83735,CDM,300,RC,83735,CPT,,,,,,,,150,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Magnesium - Ref,PX8373590,CDM,300,RC,83735,CPT,90,,,,,,,150,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Magnesium - Ref,PX8373590,CDM,300,RC,83735,CPT,90,,,,,,,150,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Magnesium - Ref,PX8373590,CDM,300,RC,83735,CPT,90,,,,,,,150,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Magnesium - Ref,PX8373590,CDM,300,RC,83735,CPT,90,,,,,,,150,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Magnesium - Ref,PX8373590,CDM,300,RC,83735,CPT,90,,,,,,,150,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Magnesium - Ref,PX8373590,CDM,300,RC,83735,CPT,90,,,,,,,150,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium citrate 1.745 GM/30ML Solution 296 mL Bottle,63700001,CDM,250,RC,,,,,,69452038998,NDC,150,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium citrate 1.745 GM/30ML Solution 296 mL Bottle,63700001,CDM,250,RC,,,,,,69452038998,NDC,150,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium citrate 1.745 GM/30ML Solution 296 mL Bottle,63700001,CDM,250,RC,,,,,,69452038998,NDC,150,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium citrate 1.745 GM/30ML Solution 296 mL Bottle,63700001,CDM,250,RC,,,,,,69452038998,NDC,150,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium citrate 1.745 GM/30ML Solution 296 mL Bottle,63700001,CDM,250,RC,,,,,,69452038998,NDC,150,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium citrate 1.745 GM/30ML Solution 296 mL Bottle,63700001,CDM,250,RC,,,,,,69452038998,NDC,150,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium citrate 1.745 GM/30ML Solution 296 mL Bottle,63700001,CDM,250,RC,,,,,,70677111101,NDC,150,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium citrate 1.745 GM/30ML Solution 296 mL Bottle,63700001,CDM,250,RC,,,,,,70677111101,NDC,150,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium citrate 1.745 GM/30ML Solution 296 mL Bottle,63700001,CDM,250,RC,,,,,,70677111101,NDC,150,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium citrate 1.745 GM/30ML Solution 296 mL Bottle,63700001,CDM,250,RC,,,,,,70677111101,NDC,150,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium citrate 1.745 GM/30ML Solution 296 mL Bottle,63700001,CDM,250,RC,,,,,,70677111101,NDC,150,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium citrate 1.745 GM/30ML Solution 296 mL Bottle,63700001,CDM,250,RC,,,,,,70677111101,NDC,150,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Magnesium Cl-Calcium Carbonate 71.5-119 MG Tablet Delayed Release 60 Each Bottle,63700001,CDM,250,RC,,,,,,67618010760,NDC,2,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Magnesium Cl-Calcium Carbonate 71.5-119 MG Tablet Delayed Release 60 Each Bottle,63700001,CDM,250,RC,,,,,,67618010760,NDC,2,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Magnesium Cl-Calcium Carbonate 71.5-119 MG Tablet Delayed Release 60 Each Bottle,63700001,CDM,250,RC,,,,,,67618010760,NDC,2,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Magnesium Cl-Calcium Carbonate 71.5-119 MG Tablet Delayed Release 60 Each Bottle,63700001,CDM,250,RC,,,,,,67618010760,NDC,2,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Magnesium Cl-Calcium Carbonate 71.5-119 MG Tablet Delayed Release 60 Each Bottle,63700001,CDM,250,RC,,,,,,67618010760,NDC,2,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Magnesium Cl-Calcium Carbonate 71.5-119 MG Tablet Delayed Release 60 Each Bottle,63700001,CDM,250,RC,,,,,,67618010760,NDC,2,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium hydroxide 400 MG/5ML Suspension 30 mL Cup,63700001,CDM,250,RC,,,,,,69339015301,NDC,5,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium hydroxide 400 MG/5ML Suspension 30 mL Cup,63700001,CDM,250,RC,,,,,,69339015301,NDC,5,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium hydroxide 400 MG/5ML Suspension 30 mL Cup,63700001,CDM,250,RC,,,,,,69339015301,NDC,5,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium hydroxide 400 MG/5ML Suspension 30 mL Cup,63700001,CDM,250,RC,,,,,,69339015301,NDC,5,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium hydroxide 400 MG/5ML Suspension 30 mL Cup,63700001,CDM,250,RC,,,,,,69339015301,NDC,5,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium hydroxide 400 MG/5ML Suspension 30 mL Cup,63700001,CDM,250,RC,,,,,,69339015301,NDC,5,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904660961,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904660961,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904660961,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904660961,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904660961,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904660961,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,10006070028,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,10006070028,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,10006070028,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,10006070028,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,10006070028,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,10006070028,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,64980033901,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,64980033901,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,64980033901,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,64980033901,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,64980033901,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,64980033901,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate 1 g in 100 ml D5W (premix) 1-5 GM/100ML-% Solution 100 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010802,NDC,100,ML,52.51,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate 1 g in 100 ml D5W (premix) 1-5 GM/100ML-% Solution 100 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010802,NDC,100,ML,52.51,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate 1 g in 100 ml D5W (premix) 1-5 GM/100ML-% Solution 100 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010802,NDC,100,ML,52.51,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate 1 g in 100 ml D5W (premix) 1-5 GM/100ML-% Solution 100 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010802,NDC,100,ML,52.51,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate 1 g in 100 ml D5W (premix) 1-5 GM/100ML-% Solution 100 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010802,NDC,100,ML,52.51,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate 1 g in 100 ml D5W (premix) 1-5 GM/100ML-% Solution 100 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010802,NDC,100,ML,52.51,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate 4 GM/50ML Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010701,NDC,50,ML,73.72,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate 4 GM/50ML Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010701,NDC,50,ML,73.72,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate 4 GM/50ML Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010701,NDC,50,ML,73.72,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate 4 GM/50ML Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010701,NDC,50,ML,73.72,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate 4 GM/50ML Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010701,NDC,50,ML,73.72,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate 4 GM/50ML Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010701,NDC,50,ML,73.72,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006401,NDC,2,ML,31.46,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006401,NDC,2,ML,31.46,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006401,NDC,2,ML,31.46,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006401,NDC,2,ML,31.46,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006401,NDC,2,ML,31.46,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006401,NDC,2,ML,31.46,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006403,NDC,2,ML,30.45,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006403,NDC,2,ML,30.45,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006403,NDC,2,ML,30.45,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006403,NDC,2,ML,30.45,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006403,NDC,2,ML,30.45,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006403,NDC,2,ML,30.45,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate 50 % Solution 10 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006404,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate 50 % Solution 10 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006404,NDC,2,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate 50 % Solution 10 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006404,NDC,2,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate 50 % Solution 10 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006404,NDC,2,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate 50 % Solution 10 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006404,NDC,2,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate 50 % Solution 10 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006404,NDC,2,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,409672924,NDC,50,ML,116.43,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,409672924,NDC,50,ML,116.43,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,409672924,NDC,50,ML,116.43,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,409672924,NDC,50,ML,116.43,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,409672924,NDC,50,ML,116.43,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,409672924,NDC,50,ML,116.43,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010602,NDC,50,ML,126.07,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010602,NDC,50,ML,126.07,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010602,NDC,50,ML,126.07,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010602,NDC,50,ML,126.07,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010602,NDC,50,ML,126.07,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010602,NDC,50,ML,126.07,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010605,NDC,50,ML,126.07,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010605,NDC,50,ML,126.07,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010605,NDC,50,ML,126.07,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010605,NDC,50,ML,126.07,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010605,NDC,50,ML,126.07,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010605,NDC,50,ML,126.07,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010626,NDC,50,ML,84.47,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010626,NDC,50,ML,84.47,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010626,NDC,50,ML,84.47,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010626,NDC,50,ML,84.47,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010626,NDC,50,ML,84.47,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010626,NDC,50,ML,84.47,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Manage/Train Orthotic/Prosthetic, per 15 Min",PX97763,CDM,420,RC,97763,CPT,,,,,,,,121,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Manage/Train Orthotic/Prosthetic, per 15 Min",PX97763,CDM,420,RC,97763,CPT,,,,,,,,121,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Manage/Train Orthotic/Prosthetic, per 15 Min",PX97763,CDM,420,RC,97763,CPT,,,,,,,,121,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Manage/Train Orthotic/Prosthetic, per 15 Min",PX97763,CDM,420,RC,97763,CPT,,,,,,,,121,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Manage/Train Orthotic/Prosthetic, per 15 Min",PX97763,CDM,420,RC,97763,CPT,,,,,,,,121,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Manage/Train Orthotic/Prosthetic, per 15 Min",PX97763,CDM,420,RC,97763,CPT,,,,,,,,121,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,338035702,NDC,250,ML,309.28,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,338035702,NDC,250,ML,309.28,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,338035702,NDC,250,ML,309.28,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,338035702,NDC,250,ML,309.28,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,338035702,NDC,250,ML,309.28,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,338035702,NDC,250,ML,309.28,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,990771502,NDC,250,ML,166.02,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,990771502,NDC,250,ML,166.02,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,990771502,NDC,250,ML,166.02,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,990771502,NDC,250,ML,166.02,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,990771502,NDC,250,ML,166.02,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,990771502,NDC,250,ML,166.02,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,990771512,NDC,62.5,ML,56.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,990771512,NDC,62.5,ML,56.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,990771512,NDC,62.5,ML,56.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,990771512,NDC,62.5,ML,56.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,990771512,NDC,62.5,ML,56.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,990771512,NDC,62.5,ML,56.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Manual Ther Tech,1+Regions,Ea 15 Min",PX97140,CDM,420,RC,97140,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Manual Ther Tech,1+Regions,Ea 15 Min",PX97140,CDM,420,RC,97140,CPT,,,,,,,,135,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Manual Ther Tech,1+Regions,Ea 15 Min",PX97140,CDM,420,RC,97140,CPT,,,,,,,,135,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Manual Ther Tech,1+Regions,Ea 15 Min",PX97140,CDM,420,RC,97140,CPT,,,,,,,,135,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Manual Ther Tech,1+Regions,Ea 15 Min",PX97140,CDM,420,RC,97140,CPT,,,,,,,,135,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Manual Ther Tech,1+Regions,Ea 15 Min",PX97140,CDM,420,RC,97140,CPT,,,,,,,,135,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MAYO STAND COVERS 24X53""",27200000,CDM,272,RC,,,,644-MAIN,LOCAL,,,,,9.54,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MAYO STAND COVERS 24X53""",27200000,CDM,272,RC,,,,644-MAIN,LOCAL,,,,,9.54,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MAYO STAND COVERS 24X53""",27200000,CDM,272,RC,,,,644-MAIN,LOCAL,,,,,9.54,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MAYO STAND COVERS 24X53""",27200000,CDM,272,RC,,,,644-MAIN,LOCAL,,,,,9.54,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MAYO STAND COVERS 24X53""",27200000,CDM,272,RC,,,,644-MAIN,LOCAL,,,,,9.54,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MAYO STAND COVERS 24X53""",27200000,CDM,272,RC,,,,644-MAIN,LOCAL,,,,,9.54,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"measles, mumps & rubella vaccine Recon Soln 1 Each Vial",90707,CDM,636,RC,90707,CPT,,,,6468100,NDC,1,EA,381.47,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"measles, mumps & rubella vaccine Recon Soln 1 Each Vial",90707,CDM,636,RC,90707,CPT,,,,6468100,NDC,1,EA,381.47,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"measles, mumps & rubella vaccine Recon Soln 1 Each Vial",90707,CDM,636,RC,90707,CPT,,,,6468100,NDC,1,EA,381.47,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"measles, mumps & rubella vaccine Recon Soln 1 Each Vial",90707,CDM,636,RC,90707,CPT,,,,6468100,NDC,1,EA,381.47,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"measles, mumps & rubella vaccine Recon Soln 1 Each Vial",90707,CDM,636,RC,90707,CPT,,,,6468100,NDC,1,EA,381.47,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"measles, mumps & rubella vaccine Recon Soln 1 Each Vial",90707,CDM,636,RC,90707,CPT,,,,6468100,NDC,1,EA,381.47,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mechanical Traction Therapy,PX97012,CDM,420,RC,97012,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mechanical Traction Therapy,PX97012,CDM,420,RC,97012,CPT,,,,,,,,135,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mechanical Traction Therapy,PX97012,CDM,420,RC,97012,CPT,,,,,,,,135,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mechanical Traction Therapy,PX97012,CDM,420,RC,97012,CPT,,,,,,,,135,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mechanical Traction Therapy,PX97012,CDM,420,RC,97012,CPT,,,,,,,,135,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mechanical Traction Therapy,PX97012,CDM,420,RC,97012,CPT,,,,,,,,135,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meclizine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084049111,NDC,1,EA,4.6,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meclizine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084049111,NDC,1,EA,4.6,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meclizine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084049111,NDC,1,EA,4.6,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meclizine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084049111,NDC,1,EA,4.6,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meclizine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084049111,NDC,1,EA,4.6,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meclizine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084049111,NDC,1,EA,4.6,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meclizine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084049101,NDC,1,EA,4.6,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meclizine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084049101,NDC,1,EA,4.6,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meclizine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084049101,NDC,1,EA,4.6,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meclizine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084049101,NDC,1,EA,4.6,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meclizine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084049101,NDC,1,EA,4.6,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meclizine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084049101,NDC,1,EA,4.6,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MEDIUM HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12835-MAIN,LOCAL,,,,,3905,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MEDIUM HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12835-MAIN,LOCAL,,,,,3905,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MEDIUM HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12835-MAIN,LOCAL,,,,,3905,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MEDIUM HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12835-MAIN,LOCAL,,,,,3905,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MEDIUM HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12835-MAIN,LOCAL,,,,,3905,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MEDIUM HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12835-MAIN,LOCAL,,,,,3905,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
medroxyPROGESTERone 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,555087202,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
medroxyPROGESTERone 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,555087202,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
medroxyPROGESTERone 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,555087202,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
medroxyPROGESTERone 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,555087202,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
medroxyPROGESTERone 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,555087202,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
medroxyPROGESTERone 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,555087202,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
medroxyPROGESTERone 150 MG/ML Suspension 1 mL Vial,J1050.01,CDM,636,RC,J1050,HCPCS,,,,67457088799,NDC,1,ML,437.38,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
medroxyPROGESTERone 150 MG/ML Suspension 1 mL Vial,J1050.01,CDM,636,RC,J1050,HCPCS,,,,67457088799,NDC,1,ML,437.38,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
medroxyPROGESTERone 150 MG/ML Suspension 1 mL Vial,J1050.01,CDM,636,RC,J1050,HCPCS,,,,67457088799,NDC,1,ML,437.38,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
medroxyPROGESTERone 150 MG/ML Suspension 1 mL Vial,J1050.01,CDM,636,RC,J1050,HCPCS,,,,67457088799,NDC,1,ML,437.38,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
medroxyPROGESTERone 150 MG/ML Suspension 1 mL Vial,J1050.01,CDM,636,RC,J1050,HCPCS,,,,67457088799,NDC,1,ML,437.38,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
medroxyPROGESTERone 150 MG/ML Suspension 1 mL Vial,J1050.01,CDM,636,RC,J1050,HCPCS,,,,67457088799,NDC,1,ML,437.38,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
megestrol 40 MG/ML Suspension 240 mL Bottle,25000000,CDM,250,RC,,,,,,49884090738,NDC,240,ML,594.72,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
megestrol 40 MG/ML Suspension 240 mL Bottle,25000000,CDM,250,RC,,,,,,49884090738,NDC,240,ML,594.72,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
megestrol 40 MG/ML Suspension 240 mL Bottle,25000000,CDM,250,RC,,,,,,49884090738,NDC,240,ML,594.72,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
megestrol 40 MG/ML Suspension 240 mL Bottle,25000000,CDM,250,RC,,,,,,49884090738,NDC,240,ML,594.72,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
megestrol 40 MG/ML Suspension 240 mL Bottle,25000000,CDM,250,RC,,,,,,49884090738,NDC,240,ML,594.72,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
megestrol 40 MG/ML Suspension 240 mL Bottle,25000000,CDM,250,RC,,,,,,49884090738,NDC,240,ML,594.72,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
melatonin 3 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268052411,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
melatonin 3 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268052411,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
melatonin 3 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268052411,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
melatonin 3 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268052411,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
melatonin 3 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268052411,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
melatonin 3 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268052411,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
melatonin 3 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268052415,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
melatonin 3 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268052415,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
melatonin 3 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268052415,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
melatonin 3 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268052415,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
melatonin 3 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268052415,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
melatonin 3 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268052415,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
melatonin 3 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,904518252,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
melatonin 3 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,904518252,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
melatonin 3 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,904518252,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
melatonin 3 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,904518252,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
melatonin 3 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,904518252,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
melatonin 3 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,904518252,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Melatonin 3-10 MG Tablet 120 Each Bottle,800000,CDM,,,,,,,,47469000852,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Melatonin 3-10 MG Tablet 120 Each Bottle,800000,CDM,,,,,,,,47469000852,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Melatonin 3-10 MG Tablet 120 Each Bottle,800000,CDM,,,,,,,,47469000852,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Melatonin 3-10 MG Tablet 120 Each Bottle,800000,CDM,,,,,,,,47469000852,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Melatonin 3-10 MG Tablet 120 Each Bottle,800000,CDM,,,,,,,,47469000852,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Melatonin 3-10 MG Tablet 120 Each Bottle,800000,CDM,,,,,,,,47469000852,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Melatonin 10 MG SL Tab 120 Each Bottle,63700001,CDM,250,RC,,,,,,40985027503,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Melatonin 10 MG SL Tab 120 Each Bottle,63700001,CDM,250,RC,,,,,,40985027503,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Melatonin 10 MG SL Tab 120 Each Bottle,63700001,CDM,250,RC,,,,,,40985027503,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Melatonin 10 MG SL Tab 120 Each Bottle,63700001,CDM,250,RC,,,,,,40985027503,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Melatonin 10 MG SL Tab 120 Each Bottle,63700001,CDM,250,RC,,,,,,40985027503,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Melatonin 10 MG SL Tab 120 Each Bottle,63700001,CDM,250,RC,,,,,,40985027503,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MELGISORB AG SILVER CALCIUM STERILE 6X6,120.502,CDM,272,RC,A6197,HCPCS,,11844-MAIN,LOCAL,,,,,45,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MELGISORB AG SILVER CALCIUM STERILE 6X6,120.502,CDM,272,RC,A6197,HCPCS,,11844-MAIN,LOCAL,,,,,45,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MELGISORB AG SILVER CALCIUM STERILE 6X6,120.502,CDM,272,RC,A6197,HCPCS,,11844-MAIN,LOCAL,,,,,45,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MELGISORB AG SILVER CALCIUM STERILE 6X6,120.502,CDM,272,RC,A6197,HCPCS,,11844-MAIN,LOCAL,,,,,45,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MELGISORB AG SILVER CALCIUM STERILE 6X6,120.502,CDM,272,RC,A6197,HCPCS,,11844-MAIN,LOCAL,,,,,45,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MELGISORB AG SILVER CALCIUM STERILE 6X6,120.502,CDM,272,RC,A6197,HCPCS,,11844-MAIN,LOCAL,,,,,45,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meloxicam 7.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268052511,NDC,1,EA,16.64,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meloxicam 7.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268052511,NDC,1,EA,16.64,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meloxicam 7.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268052511,NDC,1,EA,16.64,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meloxicam 7.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268052511,NDC,1,EA,16.64,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meloxicam 7.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268052511,NDC,1,EA,16.64,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meloxicam 7.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268052511,NDC,1,EA,16.64,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meloxicam 7.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,29300012401,NDC,1,EA,17.02,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meloxicam 7.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,29300012401,NDC,1,EA,17.02,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meloxicam 7.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,29300012401,NDC,1,EA,17.02,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meloxicam 7.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,29300012401,NDC,1,EA,17.02,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meloxicam 7.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,29300012401,NDC,1,EA,17.02,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meloxicam 7.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,29300012401,NDC,1,EA,17.02,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
memantine 10 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,72603011901,NDC,0.5,EA,16.37,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
memantine 10 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,72603011901,NDC,0.5,EA,16.37,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
memantine 10 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,72603011901,NDC,0.5,EA,16.37,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
memantine 10 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,72603011901,NDC,0.5,EA,16.37,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
memantine 10 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,72603011901,NDC,0.5,EA,16.37,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
memantine 10 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,72603011901,NDC,0.5,EA,16.37,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
menthol-zinc oxide Paste 113 g Tube,63700001,CDM,250,RC,,,,,,53329016544,NDC,113,GR,79.52,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
menthol-zinc oxide Paste 113 g Tube,63700001,CDM,250,RC,,,,,,53329016544,NDC,113,GR,79.52,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
menthol-zinc oxide Paste 113 g Tube,63700001,CDM,250,RC,,,,,,53329016544,NDC,113,GR,79.52,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
menthol-zinc oxide Paste 113 g Tube,63700001,CDM,250,RC,,,,,,53329016544,NDC,113,GR,79.52,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
menthol-zinc oxide Paste 113 g Tube,63700001,CDM,250,RC,,,,,,53329016544,NDC,113,GR,79.52,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
menthol-zinc oxide Paste 113 g Tube,63700001,CDM,250,RC,,,,,,53329016544,NDC,113,GR,79.52,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120301,NDC,0.5,ML,34.45,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120301,NDC,0.5,ML,34.45,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120301,NDC,0.5,ML,34.45,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120301,NDC,0.5,ML,34.45,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120301,NDC,0.5,ML,34.45,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120301,NDC,0.5,ML,34.45,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120311,NDC,0.5,ML,34.45,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120311,NDC,0.5,ML,34.45,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120311,NDC,0.5,ML,34.45,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120311,NDC,0.5,ML,34.45,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120311,NDC,0.5,ML,34.45,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120311,NDC,0.5,ML,34.45,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117603,NDC,1,ML,58.93,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117603,NDC,1,ML,58.93,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117603,NDC,1,ML,58.93,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117603,NDC,1,ML,58.93,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117603,NDC,1,ML,58.93,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117603,NDC,1,ML,58.93,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117630,NDC,1,ML,58.34,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117630,NDC,1,ML,58.34,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117630,NDC,1,ML,58.34,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117630,NDC,1,ML,58.34,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117630,NDC,1,ML,58.34,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117630,NDC,1,ML,58.34,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MEPILEX ADH FOAM 4X10,120.63,CDM,272,RC,A6196,HCPCS,,8710-MAIN,LOCAL,,,,,25,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MEPILEX ADH FOAM 4X10,120.63,CDM,272,RC,A6196,HCPCS,,8710-MAIN,LOCAL,,,,,25,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MEPILEX ADH FOAM 4X10,120.63,CDM,272,RC,A6196,HCPCS,,8710-MAIN,LOCAL,,,,,25,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MEPILEX ADH FOAM 4X10,120.63,CDM,272,RC,A6196,HCPCS,,8710-MAIN,LOCAL,,,,,25,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MEPILEX ADH FOAM 4X10,120.63,CDM,272,RC,A6196,HCPCS,,8710-MAIN,LOCAL,,,,,25,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MEPILEX ADH FOAM 4X10,120.63,CDM,272,RC,A6196,HCPCS,,8710-MAIN,LOCAL,,,,,25,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MEPILEX AG 4X4 10X10,120.138,CDM,272,RC,A6213,HCPCS,,7248-MAIN,LOCAL,,,,,33,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MEPILEX AG 4X4 10X10,120.138,CDM,272,RC,A6213,HCPCS,,7248-MAIN,LOCAL,,,,,33,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MEPILEX AG 4X4 10X10,120.138,CDM,272,RC,A6213,HCPCS,,7248-MAIN,LOCAL,,,,,33,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MEPILEX AG 4X4 10X10,120.138,CDM,272,RC,A6213,HCPCS,,7248-MAIN,LOCAL,,,,,33,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MEPILEX AG 4X4 10X10,120.138,CDM,272,RC,A6213,HCPCS,,7248-MAIN,LOCAL,,,,,33,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MEPILEX AG 4X4 10X10,120.138,CDM,272,RC,A6213,HCPCS,,7248-MAIN,LOCAL,,,,,33,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MEPILEX AG FOAM 4X4,120.192,CDM,272,RC,A6213,HCPCS,,8480-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MEPILEX AG FOAM 4X4,120.192,CDM,272,RC,A6213,HCPCS,,8480-MAIN,LOCAL,,,,,42,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MEPILEX AG FOAM 4X4,120.192,CDM,272,RC,A6213,HCPCS,,8480-MAIN,LOCAL,,,,,42,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MEPILEX AG FOAM 4X4,120.192,CDM,272,RC,A6213,HCPCS,,8480-MAIN,LOCAL,,,,,42,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MEPILEX AG FOAM 4X4,120.192,CDM,272,RC,A6213,HCPCS,,8480-MAIN,LOCAL,,,,,42,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MEPILEX AG FOAM 4X4,120.192,CDM,272,RC,A6213,HCPCS,,8480-MAIN,LOCAL,,,,,42,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MEPILEX AG FOAM 4X8,120.192,CDM,272,RC,A6213,HCPCS,,8479-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MEPILEX AG FOAM 4X8,120.192,CDM,272,RC,A6213,HCPCS,,8479-MAIN,LOCAL,,,,,42,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MEPILEX AG FOAM 4X8,120.192,CDM,272,RC,A6213,HCPCS,,8479-MAIN,LOCAL,,,,,42,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MEPILEX AG FOAM 4X8,120.192,CDM,272,RC,A6213,HCPCS,,8479-MAIN,LOCAL,,,,,42,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MEPILEX AG FOAM 4X8,120.192,CDM,272,RC,A6213,HCPCS,,8479-MAIN,LOCAL,,,,,42,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MEPILEX AG FOAM 4X8,120.192,CDM,272,RC,A6213,HCPCS,,8479-MAIN,LOCAL,,,,,42,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MEPILEX BORDER AG POST OP 4X10,120.368,CDM,272,RC,A6212,HCPCS,,10839-MAIN,LOCAL,,,,,55,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MEPILEX BORDER AG POST OP 4X10,120.368,CDM,272,RC,A6212,HCPCS,,10839-MAIN,LOCAL,,,,,55,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MEPILEX BORDER AG POST OP 4X10,120.368,CDM,272,RC,A6212,HCPCS,,10839-MAIN,LOCAL,,,,,55,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MEPILEX BORDER AG POST OP 4X10,120.368,CDM,272,RC,A6212,HCPCS,,10839-MAIN,LOCAL,,,,,55,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MEPILEX BORDER AG POST OP 4X10,120.368,CDM,272,RC,A6212,HCPCS,,10839-MAIN,LOCAL,,,,,55,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MEPILEX BORDER AG POST OP 4X10,120.368,CDM,272,RC,A6212,HCPCS,,10839-MAIN,LOCAL,,,,,55,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MEPILEX SOFT SILICONE 6X6,120.63,CDM,272,RC,A6196,HCPCS,,5577-MAIN,LOCAL,,,,,25,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MEPILEX SOFT SILICONE 6X6,120.63,CDM,272,RC,A6196,HCPCS,,5577-MAIN,LOCAL,,,,,25,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MEPILEX SOFT SILICONE 6X6,120.63,CDM,272,RC,A6196,HCPCS,,5577-MAIN,LOCAL,,,,,25,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MEPILEX SOFT SILICONE 6X6,120.63,CDM,272,RC,A6196,HCPCS,,5577-MAIN,LOCAL,,,,,25,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MEPILEX SOFT SILICONE 6X6,120.63,CDM,272,RC,A6196,HCPCS,,5577-MAIN,LOCAL,,,,,25,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MEPILEX SOFT SILICONE 6X6,120.63,CDM,272,RC,A6196,HCPCS,,5577-MAIN,LOCAL,,,,,25,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mepolizumab 100 MG Recon Soln 1 Each Vial,J2182.01,CDM,636,RC,J2182,HCPCS,,,,173088101,NDC,1,EA,6959.95,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mepolizumab 100 MG Recon Soln 1 Each Vial,J2182.01,CDM,636,RC,J2182,HCPCS,,,,173088101,NDC,1,EA,6959.95,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mepolizumab 100 MG Recon Soln 1 Each Vial,J2182.01,CDM,636,RC,J2182,HCPCS,,,,173088101,NDC,1,EA,6959.95,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mepolizumab 100 MG Recon Soln 1 Each Vial,J2182.01,CDM,636,RC,J2182,HCPCS,,,,173088101,NDC,1,EA,6959.95,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mepolizumab 100 MG Recon Soln 1 Each Vial,J2182.01,CDM,636,RC,J2182,HCPCS,,,,173088101,NDC,1,EA,6959.95,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mepolizumab 100 MG Recon Soln 1 Each Vial,J2182.01,CDM,636,RC,J2182,HCPCS,,,,173088101,NDC,1,EA,6959.95,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,781309894,NDC,1,EA,193.75,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,781309894,NDC,1,EA,193.75,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,781309894,NDC,1,EA,193.75,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,781309894,NDC,1,EA,193.75,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,781309894,NDC,1,EA,193.75,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,781309894,NDC,1,EA,193.75,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,55150020830,NDC,1,EA,82.96,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,55150020830,NDC,1,EA,82.96,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,55150020830,NDC,1,EA,82.96,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,55150020830,NDC,1,EA,82.96,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,55150020830,NDC,1,EA,82.96,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,55150020830,NDC,1,EA,82.96,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,63323050830,NDC,1,EA,134.48,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,63323050830,NDC,1,EA,134.48,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,63323050830,NDC,1,EA,134.48,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,63323050830,NDC,1,EA,134.48,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,63323050830,NDC,1,EA,134.48,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,63323050830,NDC,1,EA,134.48,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH FLAT SHEET SOFT 3X6 INCH,C1781,CDM,278,RC,C1781,HCPCS,,11773-MAIN,LOCAL,,,,,253,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH FLAT SHEET SOFT 3X6 INCH,C1781,CDM,278,RC,C1781,HCPCS,,11773-MAIN,LOCAL,,,,,253,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH FLAT SHEET SOFT 3X6 INCH,C1781,CDM,278,RC,C1781,HCPCS,,11773-MAIN,LOCAL,,,,,253,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH FLAT SHEET SOFT 3X6 INCH,C1781,CDM,278,RC,C1781,HCPCS,,11773-MAIN,LOCAL,,,,,253,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH FLAT SHEET SOFT 3X6 INCH,C1781,CDM,278,RC,C1781,HCPCS,,11773-MAIN,LOCAL,,,,,253,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH FLAT SHEET SOFT 3X6 INCH,C1781,CDM,278,RC,C1781,HCPCS,,11773-MAIN,LOCAL,,,,,253,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH LARGE LEFT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 4X6,120.521,CDM,278,RC,C1781,HCPCS,,12215-MAIN,LOCAL,,,,,572,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH LARGE LEFT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 4X6,120.521,CDM,278,RC,C1781,HCPCS,,12215-MAIN,LOCAL,,,,,572,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH LARGE LEFT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 4X6,120.521,CDM,278,RC,C1781,HCPCS,,12215-MAIN,LOCAL,,,,,572,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH LARGE LEFT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 4X6,120.521,CDM,278,RC,C1781,HCPCS,,12215-MAIN,LOCAL,,,,,572,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH LARGE LEFT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 4X6,120.521,CDM,278,RC,C1781,HCPCS,,12215-MAIN,LOCAL,,,,,572,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH LARGE LEFT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 4X6,120.521,CDM,278,RC,C1781,HCPCS,,12215-MAIN,LOCAL,,,,,572,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH LARGE RIGHT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 4X6,C1781,CDM,278,RC,C1781,HCPCS,,12195-MAIN,LOCAL,,,,,572,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH LARGE RIGHT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 4X6,C1781,CDM,278,RC,C1781,HCPCS,,12195-MAIN,LOCAL,,,,,572,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH LARGE RIGHT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 4X6,C1781,CDM,278,RC,C1781,HCPCS,,12195-MAIN,LOCAL,,,,,572,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH LARGE RIGHT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 4X6,C1781,CDM,278,RC,C1781,HCPCS,,12195-MAIN,LOCAL,,,,,572,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH LARGE RIGHT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 4X6,C1781,CDM,278,RC,C1781,HCPCS,,12195-MAIN,LOCAL,,,,,572,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH LARGE RIGHT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 4X6,C1781,CDM,278,RC,C1781,HCPCS,,12195-MAIN,LOCAL,,,,,572,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MESH PROLENE 3X6""",C1781,CDM,278,RC,C1781,HCPCS,,688-MAIN,LOCAL,,,,,213.49,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MESH PROLENE 3X6""",C1781,CDM,278,RC,C1781,HCPCS,,688-MAIN,LOCAL,,,,,213.49,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MESH PROLENE 3X6""",C1781,CDM,278,RC,C1781,HCPCS,,688-MAIN,LOCAL,,,,,213.49,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MESH PROLENE 3X6""",C1781,CDM,278,RC,C1781,HCPCS,,688-MAIN,LOCAL,,,,,213.49,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MESH PROLENE 3X6""",C1781,CDM,278,RC,C1781,HCPCS,,688-MAIN,LOCAL,,,,,213.49,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MESH PROLENE 3X6""",C1781,CDM,278,RC,C1781,HCPCS,,688-MAIN,LOCAL,,,,,213.49,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH SURGICAL NON-ABSORBABLE PLUG 6INW X 6INL,C1781,CDM,272,RC,C1781,HCPCS,,12005-MAIN,LOCAL,,,,,1505,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH SURGICAL NON-ABSORBABLE PLUG 6INW X 6INL,C1781,CDM,272,RC,C1781,HCPCS,,12005-MAIN,LOCAL,,,,,1505,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH SURGICAL NON-ABSORBABLE PLUG 6INW X 6INL,C1781,CDM,272,RC,C1781,HCPCS,,12005-MAIN,LOCAL,,,,,1505,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH SURGICAL NON-ABSORBABLE PLUG 6INW X 6INL,C1781,CDM,272,RC,C1781,HCPCS,,12005-MAIN,LOCAL,,,,,1505,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH SURGICAL NON-ABSORBABLE PLUG 6INW X 6INL,C1781,CDM,272,RC,C1781,HCPCS,,12005-MAIN,LOCAL,,,,,1505,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH SURGICAL NON-ABSORBABLE PLUG 6INW X 6INL,C1781,CDM,272,RC,C1781,HCPCS,,12005-MAIN,LOCAL,,,,,1505,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH SURGICAL NON-ABSORBABLE PLUG 12INW X 12INL,C1781,CDM,278,RC,C1781,HCPCS,,12006-MAIN,LOCAL,,,,,1505,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH SURGICAL NON-ABSORBABLE PLUG 12INW X 12INL,C1781,CDM,278,RC,C1781,HCPCS,,12006-MAIN,LOCAL,,,,,1505,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH SURGICAL NON-ABSORBABLE PLUG 12INW X 12INL,C1781,CDM,278,RC,C1781,HCPCS,,12006-MAIN,LOCAL,,,,,1505,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH SURGICAL NON-ABSORBABLE PLUG 12INW X 12INL,C1781,CDM,278,RC,C1781,HCPCS,,12006-MAIN,LOCAL,,,,,1505,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH SURGICAL NON-ABSORBABLE PLUG 12INW X 12INL,C1781,CDM,278,RC,C1781,HCPCS,,12006-MAIN,LOCAL,,,,,1505,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH SURGICAL NON-ABSORBABLE PLUG 12INW X 12INL,C1781,CDM,278,RC,C1781,HCPCS,,12006-MAIN,LOCAL,,,,,1505,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH VENTRALIGHT ECHO 2.0 POSITIONING 11CM ROUND,120.525,CDM,278,RC,C1781,HCPCS,,12219-MAIN,LOCAL,,,,,1310,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH VENTRALIGHT ECHO 2.0 POSITIONING 11CM ROUND,120.525,CDM,278,RC,C1781,HCPCS,,12219-MAIN,LOCAL,,,,,1310,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH VENTRALIGHT ECHO 2.0 POSITIONING 11CM ROUND,120.525,CDM,278,RC,C1781,HCPCS,,12219-MAIN,LOCAL,,,,,1310,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH VENTRALIGHT ECHO 2.0 POSITIONING 11CM ROUND,120.525,CDM,278,RC,C1781,HCPCS,,12219-MAIN,LOCAL,,,,,1310,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH VENTRALIGHT ECHO 2.0 POSITIONING 11CM ROUND,120.525,CDM,278,RC,C1781,HCPCS,,12219-MAIN,LOCAL,,,,,1310,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH VENTRALIGHT ECHO 2.0 POSITIONING 11CM ROUND,120.525,CDM,278,RC,C1781,HCPCS,,12219-MAIN,LOCAL,,,,,1310,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH VENTRALIGHT ECHO 2.0 POSITIONING 15CM ROUND,C1781,CDM,278,RC,C1781,HCPCS,,12842-MAIN,LOCAL,,,,,1816,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH VENTRALIGHT ECHO 2.0 POSITIONING 15CM ROUND,C1781,CDM,278,RC,C1781,HCPCS,,12842-MAIN,LOCAL,,,,,1816,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH VENTRALIGHT ECHO 2.0 POSITIONING 15CM ROUND,C1781,CDM,278,RC,C1781,HCPCS,,12842-MAIN,LOCAL,,,,,1816,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH VENTRALIGHT ECHO 2.0 POSITIONING 15CM ROUND,C1781,CDM,278,RC,C1781,HCPCS,,12842-MAIN,LOCAL,,,,,1816,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH VENTRALIGHT ECHO 2.0 POSITIONING 15CM ROUND,C1781,CDM,278,RC,C1781,HCPCS,,12842-MAIN,LOCAL,,,,,1816,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH VENTRALIGHT ECHO 2.0 POSITIONING 15CM ROUND,C1781,CDM,278,RC,C1781,HCPCS,,12842-MAIN,LOCAL,,,,,1816,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH XLARGE LEFT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 5X7,120.524,CDM,278,RC,C1781,HCPCS,,12216-MAIN,LOCAL,,,,,630,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH XLARGE LEFT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 5X7,120.524,CDM,278,RC,C1781,HCPCS,,12216-MAIN,LOCAL,,,,,630,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH XLARGE LEFT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 5X7,120.524,CDM,278,RC,C1781,HCPCS,,12216-MAIN,LOCAL,,,,,630,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH XLARGE LEFT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 5X7,120.524,CDM,278,RC,C1781,HCPCS,,12216-MAIN,LOCAL,,,,,630,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH XLARGE LEFT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 5X7,120.524,CDM,278,RC,C1781,HCPCS,,12216-MAIN,LOCAL,,,,,630,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH XLARGE LEFT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 5X7,120.524,CDM,278,RC,C1781,HCPCS,,12216-MAIN,LOCAL,,,,,630,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH XLARGE RIGHT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 5X7,120.524,CDM,278,RC,C1781,HCPCS,,12217-MAIN,LOCAL,,,,,630,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH XLARGE RIGHT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 5X7,120.524,CDM,278,RC,C1781,HCPCS,,12217-MAIN,LOCAL,,,,,630,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH XLARGE RIGHT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 5X7,120.524,CDM,278,RC,C1781,HCPCS,,12217-MAIN,LOCAL,,,,,630,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH XLARGE RIGHT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 5X7,120.524,CDM,278,RC,C1781,HCPCS,,12217-MAIN,LOCAL,,,,,630,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH XLARGE RIGHT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 5X7,120.524,CDM,278,RC,C1781,HCPCS,,12217-MAIN,LOCAL,,,,,630,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH XLARGE RIGHT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 5X7,120.524,CDM,278,RC,C1781,HCPCS,,12217-MAIN,LOCAL,,,,,630,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Metanephrines - Ref,PX8383590,CDM,300,RC,83835,CPT,90,,,,,,,34,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Metanephrines - Ref,PX8383590,CDM,300,RC,83835,CPT,90,,,,,,,34,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Metanephrines - Ref,PX8383590,CDM,300,RC,83835,CPT,90,,,,,,,34,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Metanephrines - Ref,PX8383590,CDM,300,RC,83835,CPT,90,,,,,,,34,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Metanephrines - Ref,PX8383590,CDM,300,RC,83835,CPT,90,,,,,,,34,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Metanephrines - Ref,PX8383590,CDM,300,RC,83835,CPT,90,,,,,,,34,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904632661,NDC,1,EA,3.89,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904632661,NDC,1,EA,3.89,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904632661,NDC,1,EA,3.89,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904632661,NDC,1,EA,3.89,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904632661,NDC,1,EA,3.89,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904632661,NDC,1,EA,3.89,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904716261,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904716261,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904716261,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904716261,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904716261,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904716261,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN 850 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687014311,NDC,0.588235294,EA,3.8,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN 850 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687014311,NDC,0.588235294,EA,3.8,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN 850 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687014311,NDC,0.588235294,EA,3.8,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN 850 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687014311,NDC,0.588235294,EA,3.8,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN 850 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687014311,NDC,0.588235294,EA,3.8,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN 850 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687014311,NDC,0.588235294,EA,3.8,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN 850 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687014301,NDC,0.588235294,EA,3.8,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN 850 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687014301,NDC,0.588235294,EA,3.8,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN 850 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687014301,NDC,0.588235294,EA,3.8,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN 850 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687014301,NDC,0.588235294,EA,3.8,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN 850 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687014301,NDC,0.588235294,EA,3.8,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN 850 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687014301,NDC,0.588235294,EA,3.8,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN 850 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739070210,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN 850 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739070210,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN 850 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739070210,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN 850 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739070210,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN 850 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739070210,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN 850 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739070210,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN 1000 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904669161,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN 1000 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904669161,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN 1000 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904669161,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN 1000 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904669161,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN 1000 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904669161,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN 1000 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904669161,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN 1000 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904716461,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN 1000 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904716461,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN 1000 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904716461,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN 1000 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904716461,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN 1000 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904716461,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN 1000 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904716461,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,50268053111,NDC,1,EA,7.19,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,50268053111,NDC,1,EA,7.19,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,50268053111,NDC,1,EA,7.19,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,50268053111,NDC,1,EA,7.19,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,50268053111,NDC,1,EA,7.19,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,50268053111,NDC,1,EA,7.19,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687064011,NDC,1,EA,3.34,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687064011,NDC,1,EA,3.34,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687064011,NDC,1,EA,3.34,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687064011,NDC,1,EA,3.34,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687064011,NDC,1,EA,3.34,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687064011,NDC,1,EA,3.34,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,185441601,NDC,1,EA,4,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,185441601,NDC,1,EA,4,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,185441601,NDC,1,EA,4,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,185441601,NDC,1,EA,4,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,185441601,NDC,1,EA,4,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,185441601,NDC,1,EA,4,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756014201,NDC,1,EA,4,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756014201,NDC,1,EA,4,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756014201,NDC,1,EA,4,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756014201,NDC,1,EA,4,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756014201,NDC,1,EA,4,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756014201,NDC,1,EA,4,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687064001,NDC,1,EA,3.34,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687064001,NDC,1,EA,3.34,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687064001,NDC,1,EA,3.34,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687064001,NDC,1,EA,3.34,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687064001,NDC,1,EA,3.34,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687064001,NDC,1,EA,3.34,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN-XR 750 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877041401,NDC,0.666666667,EA,4.28,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN-XR 750 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877041401,NDC,0.666666667,EA,4.28,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN-XR 750 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877041401,NDC,0.666666667,EA,4.28,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN-XR 750 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877041401,NDC,0.666666667,EA,4.28,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN-XR 750 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877041401,NDC,0.666666667,EA,4.28,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN-XR 750 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877041401,NDC,0.666666667,EA,4.28,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methadone 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406575523,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methadone 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406575523,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methadone 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406575523,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methadone 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406575523,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methadone 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406575523,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methadone 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406575523,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methadone 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54855324,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methadone 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54855324,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methadone 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54855324,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methadone 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54855324,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methadone 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54855324,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methadone 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54855324,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methenamine 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862078201,NDC,0.5,EA,5.62,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methenamine 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862078201,NDC,0.5,EA,5.62,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methenamine 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862078201,NDC,0.5,EA,5.62,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methenamine 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862078201,NDC,0.5,EA,5.62,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methenamine 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862078201,NDC,0.5,EA,5.62,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methenamine 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862078201,NDC,0.5,EA,5.62,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methIMAzole 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155007001,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methIMAzole 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155007001,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methIMAzole 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155007001,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methIMAzole 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155007001,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methIMAzole 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155007001,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methIMAzole 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155007001,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methIMAzole 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155007101,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methIMAzole 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155007101,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methIMAzole 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155007101,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methIMAzole 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155007101,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methIMAzole 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155007101,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methIMAzole 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155007101,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Methlenedioxyamphetamines (Mda, Mdea, Mdma) - Ref",PX8035990,CDM,300,RC,80359,CPT,90,,,,,,,147,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Methlenedioxyamphetamines (Mda, Mdea, Mdma) - Ref",PX8035990,CDM,300,RC,80359,CPT,90,,,,,,,147,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Methlenedioxyamphetamines (Mda, Mdea, Mdma) - Ref",PX8035990,CDM,300,RC,80359,CPT,90,,,,,,,147,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Methlenedioxyamphetamines (Mda, Mdea, Mdma) - Ref",PX8035990,CDM,300,RC,80359,CPT,90,,,,,,,147,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Methlenedioxyamphetamines (Mda, Mdea, Mdma) - Ref",PX8035990,CDM,300,RC,80359,CPT,90,,,,,,,147,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Methlenedioxyamphetamines (Mda, Mdea, Mdma) - Ref",PX8035990,CDM,300,RC,80359,CPT,90,,,,,,,147,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methocarbamol 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687055911,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methocarbamol 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687055911,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methocarbamol 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687055911,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methocarbamol 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687055911,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methocarbamol 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687055911,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methocarbamol 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687055911,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methocarbamol 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739016610,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methocarbamol 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739016610,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methocarbamol 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739016610,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methocarbamol 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739016610,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methocarbamol 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739016610,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methocarbamol 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739016610,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methocarbamol 750 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687056811,NDC,0.666666667,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methocarbamol 750 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687056811,NDC,0.666666667,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methocarbamol 750 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687056811,NDC,0.666666667,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methocarbamol 750 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687056811,NDC,0.666666667,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methocarbamol 750 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687056811,NDC,0.666666667,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methocarbamol 750 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687056811,NDC,0.666666667,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methotrexate 2.5 MG Tablet 1 Each Blister,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067001,NDC,1,EA,33.51,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methotrexate 2.5 MG Tablet 1 Each Blister,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067001,NDC,1,EA,33.51,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methotrexate 2.5 MG Tablet 1 Each Blister,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067001,NDC,1,EA,33.51,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methotrexate 2.5 MG Tablet 1 Each Blister,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067001,NDC,1,EA,33.51,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methotrexate 2.5 MG Tablet 1 Each Blister,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067001,NDC,1,EA,33.51,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methotrexate 2.5 MG Tablet 1 Each Blister,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067001,NDC,1,EA,33.51,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methotrexate 2.5 MG Tablet 20 Each Box,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067005,NDC,1,EA,33.49,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methotrexate 2.5 MG Tablet 20 Each Box,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067005,NDC,1,EA,33.49,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methotrexate 2.5 MG Tablet 20 Each Box,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067005,NDC,1,EA,33.49,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methotrexate 2.5 MG Tablet 20 Each Box,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067005,NDC,1,EA,33.49,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methotrexate 2.5 MG Tablet 20 Each Box,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067005,NDC,1,EA,33.49,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methotrexate 2.5 MG Tablet 20 Each Box,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067005,NDC,1,EA,33.49,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methyldopa 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93293101,NDC,1,EA,3.92,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methyldopa 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93293101,NDC,1,EA,3.92,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methyldopa 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93293101,NDC,1,EA,3.92,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methyldopa 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93293101,NDC,1,EA,3.92,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methyldopa 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93293101,NDC,1,EA,3.92,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methyldopa 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93293101,NDC,1,EA,3.92,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylene blue 1 % Solution 10 mL Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,54288014701,NDC,1,ML,139.25,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylene blue 1 % Solution 10 mL Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,54288014701,NDC,1,ML,139.25,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylene blue 1 % Solution 10 mL Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,54288014701,NDC,1,ML,139.25,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylene blue 1 % Solution 10 mL Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,54288014701,NDC,1,ML,139.25,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylene blue 1 % Solution 10 mL Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,54288014701,NDC,1,ML,139.25,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylene blue 1 % Solution 10 mL Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,54288014701,NDC,1,ML,139.25,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylene blue 50 MG/10ML Solution 10 mL Ampule,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,517037405,NDC,10,ML,1382.12,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylene blue 50 MG/10ML Solution 10 mL Ampule,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,517037405,NDC,10,ML,1382.12,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylene blue 50 MG/10ML Solution 10 mL Ampule,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,517037405,NDC,10,ML,1382.12,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylene blue 50 MG/10ML Solution 10 mL Ampule,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,517037405,NDC,10,ML,1382.12,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylene blue 50 MG/10ML Solution 10 mL Ampule,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,517037405,NDC,10,ML,1382.12,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylene blue 50 MG/10ML Solution 10 mL Ampule,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,517037405,NDC,10,ML,1382.12,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylergonovine 0.2 MG/ML Solution 1 mL Ampule,J2210.01,CDM,636,RC,J2210,HCPCS,,,,51991014417,NDC,1,ML,133.11,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylergonovine 0.2 MG/ML Solution 1 mL Ampule,J2210.01,CDM,636,RC,J2210,HCPCS,,,,51991014417,NDC,1,ML,133.11,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylergonovine 0.2 MG/ML Solution 1 mL Ampule,J2210.01,CDM,636,RC,J2210,HCPCS,,,,51991014417,NDC,1,ML,133.11,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylergonovine 0.2 MG/ML Solution 1 mL Ampule,J2210.01,CDM,636,RC,J2210,HCPCS,,,,51991014417,NDC,1,ML,133.11,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylergonovine 0.2 MG/ML Solution 1 mL Ampule,J2210.01,CDM,636,RC,J2210,HCPCS,,,,51991014417,NDC,1,ML,133.11,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylergonovine 0.2 MG/ML Solution 1 mL Ampule,J2210.01,CDM,636,RC,J2210,HCPCS,,,,51991014417,NDC,1,ML,133.11,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone 4 MG Tablet 100 Each Bottle,J7509.01,CDM,636,RC,J7509,HCPCS,,,,68382091601,NDC,0.5,EA,4.43,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone 4 MG Tablet 100 Each Bottle,J7509.01,CDM,636,RC,J7509,HCPCS,,,,68382091601,NDC,0.5,EA,4.43,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone 4 MG Tablet 100 Each Bottle,J7509.01,CDM,636,RC,J7509,HCPCS,,,,68382091601,NDC,0.5,EA,4.43,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone 4 MG Tablet 100 Each Bottle,J7509.01,CDM,636,RC,J7509,HCPCS,,,,68382091601,NDC,0.5,EA,4.43,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone 4 MG Tablet 100 Each Bottle,J7509.01,CDM,636,RC,J7509,HCPCS,,,,68382091601,NDC,0.5,EA,4.43,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone 4 MG Tablet 100 Each Bottle,J7509.01,CDM,636,RC,J7509,HCPCS,,,,68382091601,NDC,0.5,EA,4.43,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,603459315,NDC,1,EA,7.67,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,603459315,NDC,1,EA,7.67,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,603459315,NDC,1,EA,7.67,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,603459315,NDC,1,EA,7.67,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,603459315,NDC,1,EA,7.67,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,603459315,NDC,1,EA,7.67,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,781502207,NDC,1,EA,7.68,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,781502207,NDC,1,EA,7.68,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,781502207,NDC,1,EA,7.68,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,781502207,NDC,1,EA,7.68,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,781502207,NDC,1,EA,7.68,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,781502207,NDC,1,EA,7.68,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,42806040021,NDC,1,EA,8.86,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,42806040021,NDC,1,EA,8.86,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,42806040021,NDC,1,EA,8.86,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,42806040021,NDC,1,EA,8.86,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,42806040021,NDC,1,EA,8.86,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,42806040021,NDC,1,EA,8.86,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone acetate 20 MG/ML Suspension 5 mL Vial,J1010.01,CDM,636,RC,J1010,HCPCS,,,,9027401,NDC,0.5,ML,41.3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone acetate 20 MG/ML Suspension 5 mL Vial,J1010.01,CDM,636,RC,J1010,HCPCS,,,,9027401,NDC,0.5,ML,41.3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone acetate 20 MG/ML Suspension 5 mL Vial,J1010.01,CDM,636,RC,J1010,HCPCS,,,,9027401,NDC,0.5,ML,41.3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone acetate 20 MG/ML Suspension 5 mL Vial,J1010.01,CDM,636,RC,J1010,HCPCS,,,,9027401,NDC,0.5,ML,41.3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone acetate 20 MG/ML Suspension 5 mL Vial,J1010.01,CDM,636,RC,J1010,HCPCS,,,,9027401,NDC,0.5,ML,41.3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone acetate 20 MG/ML Suspension 5 mL Vial,J1010.01,CDM,636,RC,J1010,HCPCS,,,,9027401,NDC,0.5,ML,41.3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003905,NDC,1,EA,58.77,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003905,NDC,1,EA,58.77,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003905,NDC,1,EA,58.77,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003905,NDC,1,EA,58.77,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003905,NDC,1,EA,58.77,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003905,NDC,1,EA,58.77,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003928,NDC,1,EA,39,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003928,NDC,1,EA,39,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003928,NDC,1,EA,39,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003928,NDC,1,EA,39,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003928,NDC,1,EA,39,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003928,NDC,1,EA,39,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003930,NDC,1,EA,58.99,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003930,NDC,1,EA,58.99,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003930,NDC,1,EA,58.99,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003930,NDC,1,EA,58.99,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003930,NDC,1,EA,58.99,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003930,NDC,1,EA,58.99,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004703,NDC,1,EA,75.45,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004703,NDC,1,EA,75.45,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004703,NDC,1,EA,75.45,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004703,NDC,1,EA,75.45,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004703,NDC,1,EA,75.45,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004703,NDC,1,EA,75.45,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004722,NDC,2,ML,88.35,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004722,NDC,2,ML,88.35,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004722,NDC,2,ML,88.35,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004722,NDC,2,ML,88.35,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004722,NDC,2,ML,88.35,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004722,NDC,2,ML,88.35,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004725,NDC,2,ML,131.52,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004725,NDC,2,ML,131.52,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004725,NDC,2,ML,131.52,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004725,NDC,2,ML,131.52,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004725,NDC,2,ML,131.52,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004725,NDC,2,ML,131.52,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,63323025803,NDC,0.4,EA,46.67,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,63323025803,NDC,0.4,EA,46.67,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,63323025803,NDC,0.4,EA,46.67,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,63323025803,NDC,0.4,EA,46.67,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,63323025803,NDC,0.4,EA,46.67,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,63323025803,NDC,0.4,EA,46.67,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ 500 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9075801,NDC,0.25,EA,39,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ 500 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9075801,NDC,0.25,EA,39,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ 500 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9075801,NDC,0.25,EA,39,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ 500 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9075801,NDC,0.25,EA,39,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ 500 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9075801,NDC,0.25,EA,39,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ 500 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9075801,NDC,0.25,EA,39,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ 1000 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9001820,NDC,1,EA,271.97,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ 1000 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9001820,NDC,1,EA,271.97,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ 1000 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9001820,NDC,1,EA,271.97,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ 1000 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9001820,NDC,1,EA,271.97,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ 1000 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9001820,NDC,1,EA,271.97,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ 1000 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9001820,NDC,1,EA,271.97,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoclopramide 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93220401,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoclopramide 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93220401,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoclopramide 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93220401,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoclopramide 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93220401,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoclopramide 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93220401,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoclopramide 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93220401,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,703450284,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,703450284,NDC,2,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,703450284,NDC,2,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,703450284,NDC,2,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,703450284,NDC,2,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,703450284,NDC,2,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,23155024031,NDC,2,ML,34.55,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,23155024031,NDC,2,ML,34.55,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,23155024031,NDC,2,ML,34.55,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,23155024031,NDC,2,ML,34.55,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,23155024031,NDC,2,ML,34.55,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,23155024031,NDC,2,ML,34.55,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoclopramide 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739029310,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoclopramide 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739029310,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoclopramide 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739029310,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoclopramide 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739029310,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoclopramide 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739029310,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoclopramide 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739029310,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143966001,NDC,5,ML,37.82,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143966001,NDC,5,ML,37.82,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143966001,NDC,5,ML,37.82,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143966001,NDC,5,ML,37.82,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143966001,NDC,5,ML,37.82,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143966001,NDC,5,ML,37.82,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143966010,NDC,5,ML,37.82,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143966010,NDC,5,ML,37.82,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143966010,NDC,5,ML,37.82,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143966010,NDC,5,ML,37.82,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143966010,NDC,5,ML,37.82,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143966010,NDC,5,ML,37.82,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,409177815,NDC,5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,409177815,NDC,5,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,409177815,NDC,5,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,409177815,NDC,5,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,409177815,NDC,5,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,409177815,NDC,5,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,36000003310,NDC,5,ML,30.74,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,36000003310,NDC,5,ML,30.74,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,36000003310,NDC,5,ML,30.74,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,36000003310,NDC,5,ML,30.74,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,36000003310,NDC,5,ML,30.74,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,36000003310,NDC,5,ML,30.74,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,70860030005,NDC,1.25,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,70860030005,NDC,1.25,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,70860030005,NDC,1.25,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,70860030005,NDC,1.25,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,70860030005,NDC,1.25,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,70860030005,NDC,1.25,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084065911,NDC,1,EA,5.99,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084065911,NDC,1,EA,5.99,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084065911,NDC,1,EA,5.99,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084065911,NDC,1,EA,5.99,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084065911,NDC,1,EA,5.99,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084065911,NDC,1,EA,5.99,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904632261,NDC,1,EA,6.65,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904632261,NDC,1,EA,6.65,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904632261,NDC,1,EA,6.65,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904632261,NDC,1,EA,6.65,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904632261,NDC,1,EA,6.65,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904632261,NDC,1,EA,6.65,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084065901,NDC,1,EA,5.99,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084065901,NDC,1,EA,5.99,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084065901,NDC,1,EA,5.99,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084065901,NDC,1,EA,5.99,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084065901,NDC,1,EA,5.99,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084065901,NDC,1,EA,5.99,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol succinate 50 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084066611,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol succinate 50 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084066611,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol succinate 50 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084066611,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol succinate 50 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084066611,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol succinate 50 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084066611,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol succinate 50 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084066611,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol succinate 50 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904632361,NDC,0.5,EA,3.33,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol succinate 50 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904632361,NDC,0.5,EA,3.33,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol succinate 50 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904632361,NDC,0.5,EA,3.33,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol succinate 50 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904632361,NDC,0.5,EA,3.33,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol succinate 50 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904632361,NDC,0.5,EA,3.33,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol succinate 50 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904632361,NDC,0.5,EA,3.33,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol succinate 100 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,51079017101,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol succinate 100 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,51079017101,NDC,0.25,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol succinate 100 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,51079017101,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol succinate 100 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,51079017101,NDC,0.25,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol succinate 100 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,51079017101,NDC,0.25,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol succinate 100 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,51079017101,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol tartrate 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584026511,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol tartrate 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584026511,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol tartrate 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584026511,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol tartrate 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584026511,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol tartrate 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584026511,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol tartrate 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584026511,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol tartrate 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904634061,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol tartrate 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904634061,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol tartrate 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904634061,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol tartrate 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904634061,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol tartrate 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904634061,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol tartrate 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904634061,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol tartrate 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079080101,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol tartrate 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079080101,NDC,0.25,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol tartrate 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079080101,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol tartrate 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079080101,NDC,0.25,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol tartrate 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079080101,NDC,0.25,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol tartrate 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079080101,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol tartrate 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904634161,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol tartrate 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904634161,NDC,0.25,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol tartrate 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904634161,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol tartrate 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904634161,NDC,0.25,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol tartrate 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904634161,NDC,0.25,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol tartrate 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904634161,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol tartrate 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079080120,NDC,1,EA,3.07,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol tartrate 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079080120,NDC,1,EA,3.07,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol tartrate 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079080120,NDC,1,EA,3.07,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol tartrate 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079080120,NDC,1,EA,3.07,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol tartrate 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079080120,NDC,1,EA,3.07,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol tartrate 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079080120,NDC,1,EA,3.07,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol tartrate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584026711,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol tartrate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584026711,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol tartrate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584026711,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol tartrate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584026711,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol tartrate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584026711,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol tartrate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584026711,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol tartrate 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,62584026701,NDC,0.125,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol tartrate 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,62584026701,NDC,0.125,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol tartrate 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,62584026701,NDC,0.125,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol tartrate 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,62584026701,NDC,0.125,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol tartrate 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,62584026701,NDC,0.125,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol tartrate 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,62584026701,NDC,0.125,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metroNIDAZOLE 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084096611,NDC,1,EA,4.94,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metroNIDAZOLE 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084096611,NDC,1,EA,4.94,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metroNIDAZOLE 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084096611,NDC,1,EA,4.94,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metroNIDAZOLE 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084096611,NDC,1,EA,4.94,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metroNIDAZOLE 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084096611,NDC,1,EA,4.94,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metroNIDAZOLE 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084096611,NDC,1,EA,4.94,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metroNIDAZOLE 500 MG Tablet 50 Each Bottle,63700001,CDM,250,RC,,,,,,29300022746,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metroNIDAZOLE 500 MG Tablet 50 Each Bottle,63700001,CDM,250,RC,,,,,,29300022746,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metroNIDAZOLE 500 MG Tablet 50 Each Bottle,63700001,CDM,250,RC,,,,,,29300022746,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metroNIDAZOLE 500 MG Tablet 50 Each Bottle,63700001,CDM,250,RC,,,,,,29300022746,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metroNIDAZOLE 500 MG Tablet 50 Each Bottle,63700001,CDM,250,RC,,,,,,29300022746,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metroNIDAZOLE 500 MG Tablet 50 Each Bottle,63700001,CDM,250,RC,,,,,,29300022746,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metroNIDAZOLE 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084096601,NDC,1,EA,4.94,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metroNIDAZOLE 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084096601,NDC,1,EA,4.94,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metroNIDAZOLE 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084096601,NDC,1,EA,4.94,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metroNIDAZOLE 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084096601,NDC,1,EA,4.94,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metroNIDAZOLE 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084096601,NDC,1,EA,4.94,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metroNIDAZOLE 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084096601,NDC,1,EA,4.94,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metroNIDAZOLE 500 MG/100ML Solution 100 mL Flex Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,409781124,NDC,100,ML,32.12,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metroNIDAZOLE 500 MG/100ML Solution 100 mL Flex Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,409781124,NDC,100,ML,32.12,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metroNIDAZOLE 500 MG/100ML Solution 100 mL Flex Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,409781124,NDC,100,ML,32.12,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metroNIDAZOLE 500 MG/100ML Solution 100 mL Flex Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,409781124,NDC,100,ML,32.12,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metroNIDAZOLE 500 MG/100ML Solution 100 mL Flex Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,409781124,NDC,100,ML,32.12,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metroNIDAZOLE 500 MG/100ML Solution 100 mL Flex Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,409781124,NDC,100,ML,32.12,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metroNIDAZOLE 500 MG/100ML Solution 100 mL Plas Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,338954124,NDC,100,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metroNIDAZOLE 500 MG/100ML Solution 100 mL Plas Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,338954124,NDC,100,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metroNIDAZOLE 500 MG/100ML Solution 100 mL Plas Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,338954124,NDC,100,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metroNIDAZOLE 500 MG/100ML Solution 100 mL Plas Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,338954124,NDC,100,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metroNIDAZOLE 500 MG/100ML Solution 100 mL Plas Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,338954124,NDC,100,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metroNIDAZOLE 500 MG/100ML Solution 100 mL Plas Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,338954124,NDC,100,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA 2.0MM TARGETING GUIDE PIN,27200000,CDM,272,RC,,,,12436-MAIN,LOCAL,,,,,110,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA 2.0MM TARGETING GUIDE PIN,27200000,CDM,272,RC,,,,12436-MAIN,LOCAL,,,,,110,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA 2.0MM TARGETING GUIDE PIN,27200000,CDM,272,RC,,,,12436-MAIN,LOCAL,,,,,110,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA 2.0MM TARGETING GUIDE PIN,27200000,CDM,272,RC,,,,12436-MAIN,LOCAL,,,,,110,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA 2.0MM TARGETING GUIDE PIN,27200000,CDM,272,RC,,,,12436-MAIN,LOCAL,,,,,110,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA 2.0MM TARGETING GUIDE PIN,27200000,CDM,272,RC,,,,12436-MAIN,LOCAL,,,,,110,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA BURR 2X12MM STERILE MICA,27200000,CDM,272,RC,,,,12447-MAIN,LOCAL,,,,,1113,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA BURR 2X12MM STERILE MICA,27200000,CDM,272,RC,,,,12447-MAIN,LOCAL,,,,,1113,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA BURR 2X12MM STERILE MICA,27200000,CDM,272,RC,,,,12447-MAIN,LOCAL,,,,,1113,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA BURR 2X12MM STERILE MICA,27200000,CDM,272,RC,,,,12447-MAIN,LOCAL,,,,,1113,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA BURR 2X12MM STERILE MICA,27200000,CDM,272,RC,,,,12447-MAIN,LOCAL,,,,,1113,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA BURR 2X12MM STERILE MICA,27200000,CDM,272,RC,,,,12447-MAIN,LOCAL,,,,,1113,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA BURR 2X20MM STERILE MICA,27200000,CDM,272,RC,,,,12448-MAIN,LOCAL,,,,,1113,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA BURR 2X20MM STERILE MICA,27200000,CDM,272,RC,,,,12448-MAIN,LOCAL,,,,,1113,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA BURR 2X20MM STERILE MICA,27200000,CDM,272,RC,,,,12448-MAIN,LOCAL,,,,,1113,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA BURR 2X20MM STERILE MICA,27200000,CDM,272,RC,,,,12448-MAIN,LOCAL,,,,,1113,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA BURR 2X20MM STERILE MICA,27200000,CDM,272,RC,,,,12448-MAIN,LOCAL,,,,,1113,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA BURR 2X20MM STERILE MICA,27200000,CDM,272,RC,,,,12448-MAIN,LOCAL,,,,,1113,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA CUTTING BURR 3X20MM LONG MICA,27200000,CDM,272,RC,,,,12434-MAIN,LOCAL,,,,,1113,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA CUTTING BURR 3X20MM LONG MICA,27200000,CDM,272,RC,,,,12434-MAIN,LOCAL,,,,,1113,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA CUTTING BURR 3X20MM LONG MICA,27200000,CDM,272,RC,,,,12434-MAIN,LOCAL,,,,,1113,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA CUTTING BURR 3X20MM LONG MICA,27200000,CDM,272,RC,,,,12434-MAIN,LOCAL,,,,,1113,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA CUTTING BURR 3X20MM LONG MICA,27200000,CDM,272,RC,,,,12434-MAIN,LOCAL,,,,,1113,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA CUTTING BURR 3X20MM LONG MICA,27200000,CDM,272,RC,,,,12434-MAIN,LOCAL,,,,,1113,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA DEPTH GAUGE 150MM STERILE MICA,27200000,CDM,272,RC,,,,12439-MAIN,LOCAL,,,,,385,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA DEPTH GAUGE 150MM STERILE MICA,27200000,CDM,272,RC,,,,12439-MAIN,LOCAL,,,,,385,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA DEPTH GAUGE 150MM STERILE MICA,27200000,CDM,272,RC,,,,12439-MAIN,LOCAL,,,,,385,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA DEPTH GAUGE 150MM STERILE MICA,27200000,CDM,272,RC,,,,12439-MAIN,LOCAL,,,,,385,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA DEPTH GAUGE 150MM STERILE MICA,27200000,CDM,272,RC,,,,12439-MAIN,LOCAL,,,,,385,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA DEPTH GAUGE 150MM STERILE MICA,27200000,CDM,272,RC,,,,12439-MAIN,LOCAL,,,,,385,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA FIRST MET TRANSLATOR STERILE MICA,27200000,CDM,272,RC,,,,12445-MAIN,LOCAL,,,,,393,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA FIRST MET TRANSLATOR STERILE MICA,27200000,CDM,272,RC,,,,12445-MAIN,LOCAL,,,,,393,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA FIRST MET TRANSLATOR STERILE MICA,27200000,CDM,272,RC,,,,12445-MAIN,LOCAL,,,,,393,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA FIRST MET TRANSLATOR STERILE MICA,27200000,CDM,272,RC,,,,12445-MAIN,LOCAL,,,,,393,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA FIRST MET TRANSLATOR STERILE MICA,27200000,CDM,272,RC,,,,12445-MAIN,LOCAL,,,,,393,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA FIRST MET TRANSLATOR STERILE MICA,27200000,CDM,272,RC,,,,12445-MAIN,LOCAL,,,,,393,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA SCREW 4.0X32MM FULLY THREADED STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12894-MAIN,LOCAL,,,,,2096,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA SCREW 4.0X32MM FULLY THREADED STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12894-MAIN,LOCAL,,,,,2096,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA SCREW 4.0X32MM FULLY THREADED STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12894-MAIN,LOCAL,,,,,2096,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA SCREW 4.0X32MM FULLY THREADED STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12894-MAIN,LOCAL,,,,,2096,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA SCREW 4.0X32MM FULLY THREADED STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12894-MAIN,LOCAL,,,,,2096,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA SCREW 4.0X32MM FULLY THREADED STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12894-MAIN,LOCAL,,,,,2096,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA WEDGE BURR 3.1X13MM STERILE,27200000,CDM,272,RC,,,,12435-MAIN,LOCAL,,,,,1113,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA WEDGE BURR 3.1X13MM STERILE,27200000,CDM,272,RC,,,,12435-MAIN,LOCAL,,,,,1113,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA WEDGE BURR 3.1X13MM STERILE,27200000,CDM,272,RC,,,,12435-MAIN,LOCAL,,,,,1113,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA WEDGE BURR 3.1X13MM STERILE,27200000,CDM,272,RC,,,,12435-MAIN,LOCAL,,,,,1113,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA WEDGE BURR 3.1X13MM STERILE,27200000,CDM,272,RC,,,,12435-MAIN,LOCAL,,,,,1113,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA WEDGE BURR 3.1X13MM STERILE,27200000,CDM,272,RC,,,,12435-MAIN,LOCAL,,,,,1113,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,25021019110,NDC,1,EA,809.89,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,25021019110,NDC,1,EA,809.89,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,25021019110,NDC,1,EA,809.89,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,25021019110,NDC,1,EA,809.89,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,25021019110,NDC,1,EA,809.89,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,25021019110,NDC,1,EA,809.89,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,63323072902,NDC,1,EA,265.95,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,63323072902,NDC,1,EA,265.95,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,63323072902,NDC,1,EA,265.95,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,63323072902,NDC,1,EA,265.95,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,63323072902,NDC,1,EA,265.95,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,63323072902,NDC,1,EA,265.95,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
miconazole 2 % Powder 71 g Bottle,25000000,CDM,250,RC,,,,,,316023125,NDC,71,GR,34.82,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
miconazole 2 % Powder 71 g Bottle,25000000,CDM,250,RC,,,,,,316023125,NDC,71,GR,34.82,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
miconazole 2 % Powder 71 g Bottle,25000000,CDM,250,RC,,,,,,316023125,NDC,71,GR,34.82,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
miconazole 2 % Powder 71 g Bottle,25000000,CDM,250,RC,,,,,,316023125,NDC,71,GR,34.82,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
miconazole 2 % Powder 71 g Bottle,25000000,CDM,250,RC,,,,,,316023125,NDC,71,GR,34.82,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
miconazole 2 % Powder 71 g Bottle,25000000,CDM,250,RC,,,,,,316023125,NDC,71,GR,34.82,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
miconazole 2 % Powder 85 g Bottle,25000000,CDM,250,RC,,,,,,67094930,NDC,85,GR,35.43,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
miconazole 2 % Powder 85 g Bottle,25000000,CDM,250,RC,,,,,,67094930,NDC,85,GR,35.43,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
miconazole 2 % Powder 85 g Bottle,25000000,CDM,250,RC,,,,,,67094930,NDC,85,GR,35.43,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
miconazole 2 % Powder 85 g Bottle,25000000,CDM,250,RC,,,,,,67094930,NDC,85,GR,35.43,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
miconazole 2 % Powder 85 g Bottle,25000000,CDM,250,RC,,,,,,67094930,NDC,85,GR,35.43,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
miconazole 2 % Powder 85 g Bottle,25000000,CDM,250,RC,,,,,,67094930,NDC,85,GR,35.43,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Microalbumin Quantitative,PX82043,CDM,300,RC,82043,CPT,,,,,,,,167,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Microalbumin Quantitative,PX82043,CDM,300,RC,82043,CPT,,,,,,,,167,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Microalbumin Quantitative,PX82043,CDM,300,RC,82043,CPT,,,,,,,,167,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Microalbumin Quantitative,PX82043,CDM,300,RC,82043,CPT,,,,,,,,167,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Microalbumin Quantitative,PX82043,CDM,300,RC,82043,CPT,,,,,,,,167,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Microalbumin Quantitative,PX82043,CDM,300,RC,82043,CPT,,,,,,,,167,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Microbe Susceptible Mic,PX87186,CDM,300,RC,87186,CPT,,,,,,,,124,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Microbe Susceptible Mic,PX87186,CDM,300,RC,87186,CPT,,,,,,,,124,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Microbe Susceptible Mic,PX87186,CDM,300,RC,87186,CPT,,,,,,,,124,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Microbe Susceptible Mic,PX87186,CDM,300,RC,87186,CPT,,,,,,,,124,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Microbe Susceptible Mic,PX87186,CDM,300,RC,87186,CPT,,,,,,,,124,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Microbe Susceptible Mic,PX87186,CDM,300,RC,87186,CPT,,,,,,,,124,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Microscopic Exam of Urine,PX81015,CDM,300,RC,81015,CPT,,,,,,,,29,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Microscopic Exam of Urine,PX81015,CDM,300,RC,81015,CPT,,,,,,,,29,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Microscopic Exam of Urine,PX81015,CDM,300,RC,81015,CPT,,,,,,,,29,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Microscopic Exam of Urine,PX81015,CDM,300,RC,81015,CPT,,,,,,,,29,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Microscopic Exam of Urine,PX81015,CDM,300,RC,81015,CPT,,,,,,,,29,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Microscopic Exam of Urine,PX81015,CDM,300,RC,81015,CPT,,,,,,,,29,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Microsomal Antibody,PX7893,CDM,300,RC,86376,CPT,,,,,,,,115,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Microsomal Antibody,PX7893,CDM,300,RC,86376,CPT,,,,,,,,115,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Microsomal Antibody,PX7893,CDM,300,RC,86376,CPT,,,,,,,,115,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Microsomal Antibody,PX7893,CDM,300,RC,86376,CPT,,,,,,,,115,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Microsomal Antibody,PX7893,CDM,300,RC,86376,CPT,,,,,,,,115,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Microsomal Antibody,PX7893,CDM,300,RC,86376,CPT,,,,,,,,115,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605701,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605701,NDC,2,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605701,NDC,2,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605701,NDC,2,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605701,NDC,2,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605701,NDC,2,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605725,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605725,NDC,1,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605725,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605725,NDC,1,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605725,NDC,1,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605725,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060031,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060031,NDC,2,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060031,NDC,2,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060031,NDC,2,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060031,NDC,2,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060031,NDC,2,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060041,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060041,NDC,2,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060041,NDC,2,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060041,NDC,2,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060041,NDC,2,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060041,NDC,2,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 2 MG/ML Syrup 5 mL Cup,63700001,CDM,250,RC,,,,,,68094076459,NDC,2.5,ML,22.47,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 2 MG/ML Syrup 5 mL Cup,63700001,CDM,250,RC,,,,,,68094076459,NDC,2.5,ML,22.47,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 2 MG/ML Syrup 5 mL Cup,63700001,CDM,250,RC,,,,,,68094076459,NDC,2.5,ML,22.47,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 2 MG/ML Syrup 5 mL Cup,63700001,CDM,250,RC,,,,,,68094076459,NDC,2.5,ML,22.47,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 2 MG/ML Syrup 5 mL Cup,63700001,CDM,250,RC,,,,,,68094076459,NDC,2.5,ML,22.47,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 2 MG/ML Syrup 5 mL Cup,63700001,CDM,250,RC,,,,,,68094076459,NDC,2.5,ML,22.47,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 5 MG/ML Solution 1 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606101,NDC,0.2,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 5 MG/ML Solution 1 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606101,NDC,0.2,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 5 MG/ML Solution 1 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606101,NDC,0.2,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 5 MG/ML Solution 1 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606101,NDC,0.2,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 5 MG/ML Solution 1 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606101,NDC,0.2,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 5 MG/ML Solution 1 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606101,NDC,0.2,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606001,NDC,10,ML,65.62,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606001,NDC,10,ML,65.62,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606001,NDC,10,ML,65.62,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606001,NDC,10,ML,65.62,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606001,NDC,10,ML,65.62,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606001,NDC,10,ML,65.62,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606010,NDC,10,ML,65.62,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606010,NDC,10,ML,65.62,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606010,NDC,10,ML,65.62,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606010,NDC,10,ML,65.62,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606010,NDC,10,ML,65.62,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606010,NDC,10,ML,65.62,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230504,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230504,NDC,0.5,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230504,NDC,0.5,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230504,NDC,0.5,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230504,NDC,0.5,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230504,NDC,0.5,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230505,NDC,5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230505,NDC,5,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230505,NDC,5,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230505,NDC,5,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230505,NDC,5,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230505,NDC,5,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam PF 10 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230802,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam PF 10 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230802,NDC,2,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam PF 10 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230802,NDC,2,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam PF 10 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230802,NDC,2,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam PF 10 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230802,NDC,2,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam PF 10 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230802,NDC,2,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midodrine 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,42291056190,NDC,0.5,EA,6.52,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midodrine 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,42291056190,NDC,0.5,EA,6.52,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midodrine 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,42291056190,NDC,0.5,EA,6.52,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midodrine 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,42291056190,NDC,0.5,EA,6.52,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midodrine 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,42291056190,NDC,0.5,EA,6.52,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midodrine 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,42291056190,NDC,0.5,EA,6.52,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,143971801,NDC,200,ML,230.48,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,143971801,NDC,200,ML,230.48,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,143971801,NDC,200,ML,230.48,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,143971801,NDC,200,ML,230.48,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,143971801,NDC,200,ML,230.48,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,143971801,NDC,200,ML,230.48,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,409277602,NDC,200,ML,228.28,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,409277602,NDC,200,ML,228.28,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,409277602,NDC,200,ML,228.28,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,409277602,NDC,200,ML,228.28,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,409277602,NDC,200,ML,228.28,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,409277602,NDC,200,ML,228.28,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mineral oil Enema 133 mL Bottle,63700001,CDM,250,RC,,,,,,132030140,NDC,133,ML,13.58,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mineral oil Enema 133 mL Bottle,63700001,CDM,250,RC,,,,,,132030140,NDC,133,ML,13.58,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mineral oil Enema 133 mL Bottle,63700001,CDM,250,RC,,,,,,132030140,NDC,133,ML,13.58,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mineral oil Enema 133 mL Bottle,63700001,CDM,250,RC,,,,,,132030140,NDC,133,ML,13.58,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mineral oil Enema 133 mL Bottle,63700001,CDM,250,RC,,,,,,132030140,NDC,133,ML,13.58,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mineral oil Enema 133 mL Bottle,63700001,CDM,250,RC,,,,,,132030140,NDC,133,ML,13.58,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MINIBUNION 3.5 OFFSET PLATE SHORT,27200000,CDM,278,RC,C1713,HCPCS,,11667-MAIN,LOCAL,,,,,5142.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MINIBUNION 3.5 OFFSET PLATE SHORT,27200000,CDM,278,RC,C1713,HCPCS,,11667-MAIN,LOCAL,,,,,5142.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MINIBUNION 3.5 OFFSET PLATE SHORT,27200000,CDM,278,RC,C1713,HCPCS,,11667-MAIN,LOCAL,,,,,5142.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MINIBUNION 3.5 OFFSET PLATE SHORT,27200000,CDM,278,RC,C1713,HCPCS,,11667-MAIN,LOCAL,,,,,5142.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MINIBUNION 3.5 OFFSET PLATE SHORT,27200000,CDM,278,RC,C1713,HCPCS,,11667-MAIN,LOCAL,,,,,5142.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MINIBUNION 3.5 OFFSET PLATE SHORT,27200000,CDM,278,RC,C1713,HCPCS,,11667-MAIN,LOCAL,,,,,5142.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MINIBUNION DRILL KIT,27200000,CDM,278,RC,C1713,HCPCS,,11669-MAIN,LOCAL,,,,,841.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MINIBUNION DRILL KIT,27200000,CDM,278,RC,C1713,HCPCS,,11669-MAIN,LOCAL,,,,,841.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MINIBUNION DRILL KIT,27200000,CDM,278,RC,C1713,HCPCS,,11669-MAIN,LOCAL,,,,,841.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MINIBUNION DRILL KIT,27200000,CDM,278,RC,C1713,HCPCS,,11669-MAIN,LOCAL,,,,,841.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MINIBUNION DRILL KIT,27200000,CDM,278,RC,C1713,HCPCS,,11669-MAIN,LOCAL,,,,,841.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MINIBUNION DRILL KIT,27200000,CDM,278,RC,C1713,HCPCS,,11669-MAIN,LOCAL,,,,,841.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MINIBUNION INSTRUMENT KIT,27200000,CDM,278,RC,C1713,HCPCS,,11668-MAIN,LOCAL,,,,,1860.65,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MINIBUNION INSTRUMENT KIT,27200000,CDM,278,RC,C1713,HCPCS,,11668-MAIN,LOCAL,,,,,1860.65,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MINIBUNION INSTRUMENT KIT,27200000,CDM,278,RC,C1713,HCPCS,,11668-MAIN,LOCAL,,,,,1860.65,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MINIBUNION INSTRUMENT KIT,27200000,CDM,278,RC,C1713,HCPCS,,11668-MAIN,LOCAL,,,,,1860.65,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MINIBUNION INSTRUMENT KIT,27200000,CDM,278,RC,C1713,HCPCS,,11668-MAIN,LOCAL,,,,,1860.65,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MINIBUNION INSTRUMENT KIT,27200000,CDM,278,RC,C1713,HCPCS,,11668-MAIN,LOCAL,,,,,1860.65,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MINIBUNION LOCKING SCREW 3.0X24MM,C1713,CDM,278,RC,C1713,HCPCS,,11671-MAIN,LOCAL,,,,,308.55,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MINIBUNION LOCKING SCREW 3.0X24MM,C1713,CDM,278,RC,C1713,HCPCS,,11671-MAIN,LOCAL,,,,,308.55,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MINIBUNION LOCKING SCREW 3.0X24MM,C1713,CDM,278,RC,C1713,HCPCS,,11671-MAIN,LOCAL,,,,,308.55,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MINIBUNION LOCKING SCREW 3.0X24MM,C1713,CDM,278,RC,C1713,HCPCS,,11671-MAIN,LOCAL,,,,,308.55,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MINIBUNION LOCKING SCREW 3.0X24MM,C1713,CDM,278,RC,C1713,HCPCS,,11671-MAIN,LOCAL,,,,,308.55,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MINIBUNION LOCKING SCREW 3.0X24MM,C1713,CDM,278,RC,C1713,HCPCS,,11671-MAIN,LOCAL,,,,,308.55,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MINIBUNION NON-LOCKING SCREW  2.7X18MM,C1713,CDM,278,RC,C1713,HCPCS,,11670-MAIN,LOCAL,,,,,280.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MINIBUNION NON-LOCKING SCREW  2.7X18MM,C1713,CDM,278,RC,C1713,HCPCS,,11670-MAIN,LOCAL,,,,,280.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MINIBUNION NON-LOCKING SCREW  2.7X18MM,C1713,CDM,278,RC,C1713,HCPCS,,11670-MAIN,LOCAL,,,,,280.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MINIBUNION NON-LOCKING SCREW  2.7X18MM,C1713,CDM,278,RC,C1713,HCPCS,,11670-MAIN,LOCAL,,,,,280.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MINIBUNION NON-LOCKING SCREW  2.7X18MM,C1713,CDM,278,RC,C1713,HCPCS,,11670-MAIN,LOCAL,,,,,280.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MINIBUNION NON-LOCKING SCREW  2.7X18MM,C1713,CDM,278,RC,C1713,HCPCS,,11670-MAIN,LOCAL,,,,,280.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mirtazapine 15 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904651961,NDC,0.5,EA,7.68,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mirtazapine 15 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904651961,NDC,0.5,EA,7.68,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mirtazapine 15 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904651961,NDC,0.5,EA,7.68,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mirtazapine 15 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904651961,NDC,0.5,EA,7.68,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mirtazapine 15 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904651961,NDC,0.5,EA,7.68,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mirtazapine 15 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904651961,NDC,0.5,EA,7.68,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MIS STERILE INSTRUMENT PACK WITH BLADE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12432-MAIN,LOCAL,,,,,900,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MIS STERILE INSTRUMENT PACK WITH BLADE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12432-MAIN,LOCAL,,,,,900,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MIS STERILE INSTRUMENT PACK WITH BLADE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12432-MAIN,LOCAL,,,,,900,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MIS STERILE INSTRUMENT PACK WITH BLADE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12432-MAIN,LOCAL,,,,,900,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MIS STERILE INSTRUMENT PACK WITH BLADE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12432-MAIN,LOCAL,,,,,900,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MIS STERILE INSTRUMENT PACK WITH BLADE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12432-MAIN,LOCAL,,,,,900,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Misc Virus Antibody, Nos - Ref",PX8679090,CDM,300,RC,86790,CPT,90,,,,,,,90,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Misc Virus Antibody, Nos - Ref",PX8679090,CDM,300,RC,86790,CPT,90,,,,,,,90,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Misc Virus Antibody, Nos - Ref",PX8679090,CDM,300,RC,86790,CPT,90,,,,,,,90,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Misc Virus Antibody, Nos - Ref",PX8679090,CDM,300,RC,86790,CPT,90,,,,,,,90,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Misc Virus Antibody, Nos - Ref",PX8679090,CDM,300,RC,86790,CPT,90,,,,,,,90,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Misc Virus Antibody, Nos - Ref",PX8679090,CDM,300,RC,86790,CPT,90,,,,,,,90,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
miSOPROStol 100 MCG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,70954044310,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
miSOPROStol 100 MCG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,70954044310,NDC,0.25,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
miSOPROStol 100 MCG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,70954044310,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
miSOPROStol 100 MCG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,70954044310,NDC,0.25,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
miSOPROStol 100 MCG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,70954044310,NDC,0.25,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
miSOPROStol 100 MCG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,70954044310,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mitochondrial Antibody Each,PX8638190,CDM,300,RC,86381,CPT,90,,,,,,,38,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mitochondrial Antibody Each,PX8638190,CDM,300,RC,86381,CPT,90,,,,,,,38,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mitochondrial Antibody Each,PX8638190,CDM,300,RC,86381,CPT,90,,,,,,,38,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mitochondrial Antibody Each,PX8638190,CDM,300,RC,86381,CPT,90,,,,,,,38,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mitochondrial Antibody Each,PX8638190,CDM,300,RC,86381,CPT,90,,,,,,,38,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mitochondrial Antibody Each,PX8638190,CDM,300,RC,86381,CPT,90,,,,,,,38,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157F,CDM,370,RC,99157,CPT,,,,,,,,270,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157F,CDM,370,RC,99157,CPT,,,,,,,,270,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157F,CDM,370,RC,99157,CPT,,,,,,,,270,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157F,CDM,370,RC,99157,CPT,,,,,,,,270,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157F,CDM,370,RC,99157,CPT,,,,,,,,270,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157F,CDM,370,RC,99157,CPT,,,,,,,,270,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157P,CDM,983,RC,99157,CPT,,,,,,,,270,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157P,CDM,983,RC,99157,CPT,,,,,,,,270,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157P,CDM,983,RC,99157,CPT,,,,,,,,270,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157P,CDM,983,RC,99157,CPT,,,,,,,,270,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157P,CDM,983,RC,99157,CPT,,,,,,,,270,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157P,CDM,983,RC,99157,CPT,,,,,,,,270,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155F,CDM,370,RC,99155,CPT,,,,,,,,353,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155F,CDM,370,RC,99155,CPT,,,,,,,,353,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155F,CDM,370,RC,99155,CPT,,,,,,,,353,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155F,CDM,370,RC,99155,CPT,,,,,,,,353,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155F,CDM,370,RC,99155,CPT,,,,,,,,353,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155F,CDM,370,RC,99155,CPT,,,,,,,,353,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155P,CDM,983,RC,99155,CPT,,,,,,,,353,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155P,CDM,983,RC,99155,CPT,,,,,,,,353,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155P,CDM,983,RC,99155,CPT,,,,,,,,353,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155P,CDM,983,RC,99155,CPT,,,,,,,,353,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155P,CDM,983,RC,99155,CPT,,,,,,,,353,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155P,CDM,983,RC,99155,CPT,,,,,,,,353,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156F,CDM,370,RC,99156,CPT,,,,,,,,325,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156F,CDM,370,RC,99156,CPT,,,,,,,,325,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156F,CDM,370,RC,99156,CPT,,,,,,,,325,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156F,CDM,370,RC,99156,CPT,,,,,,,,325,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156F,CDM,370,RC,99156,CPT,,,,,,,,325,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156F,CDM,370,RC,99156,CPT,,,,,,,,325,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156P,CDM,983,RC,99156,CPT,,,,,,,,325,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156P,CDM,983,RC,99156,CPT,,,,,,,,325,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156P,CDM,983,RC,99156,CPT,,,,,,,,325,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156P,CDM,983,RC,99156,CPT,,,,,,,,325,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156P,CDM,983,RC,99156,CPT,,,,,,,,325,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156P,CDM,983,RC,99156,CPT,,,,,,,,325,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153F,CDM,370,RC,99153,CPT,,,,,,,,225,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153F,CDM,370,RC,99153,CPT,,,,,,,,225,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153F,CDM,370,RC,99153,CPT,,,,,,,,225,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153F,CDM,370,RC,99153,CPT,,,,,,,,225,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153F,CDM,370,RC,99153,CPT,,,,,,,,225,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153F,CDM,370,RC,99153,CPT,,,,,,,,225,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153P,CDM,983,RC,99153,CPT,,,,,,,,250,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153P,CDM,983,RC,99153,CPT,,,,,,,,250,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153P,CDM,983,RC,99153,CPT,,,,,,,,250,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153P,CDM,983,RC,99153,CPT,,,,,,,,250,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153P,CDM,983,RC,99153,CPT,,,,,,,,250,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153P,CDM,983,RC,99153,CPT,,,,,,,,250,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151F,CDM,370,RC,99151,CPT,,,,,,,,176,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151F,CDM,370,RC,99151,CPT,,,,,,,,176,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151F,CDM,370,RC,99151,CPT,,,,,,,,176,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151F,CDM,370,RC,99151,CPT,,,,,,,,176,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151F,CDM,370,RC,99151,CPT,,,,,,,,176,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151F,CDM,370,RC,99151,CPT,,,,,,,,176,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151P,CDM,983,RC,99151,CPT,,,,,,,,275,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151P,CDM,983,RC,99151,CPT,,,,,,,,275,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151P,CDM,983,RC,99151,CPT,,,,,,,,275,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151P,CDM,983,RC,99151,CPT,,,,,,,,275,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151P,CDM,983,RC,99151,CPT,,,,,,,,275,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151P,CDM,983,RC,99151,CPT,,,,,,,,275,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152F,CDM,370,RC,99152,CPT,,,,,,,,235,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152F,CDM,370,RC,99152,CPT,,,,,,,,235,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152F,CDM,370,RC,99152,CPT,,,,,,,,235,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152F,CDM,370,RC,99152,CPT,,,,,,,,235,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152F,CDM,370,RC,99152,CPT,,,,,,,,235,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152F,CDM,370,RC,99152,CPT,,,,,,,,235,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152P,CDM,983,RC,99152,CPT,,,,,,,,90,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152P,CDM,983,RC,99152,CPT,,,,,,,,90,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152P,CDM,983,RC,99152,CPT,,,,,,,,90,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152P,CDM,983,RC,99152,CPT,,,,,,,,90,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152P,CDM,983,RC,99152,CPT,,,,,,,,90,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152P,CDM,983,RC,99152,CPT,,,,,,,,90,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 1st Dose",PX0011A,CDM,771,RC,0011A,HCPCS,,,,,,,,69,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 1st Dose",PX0011A,CDM,771,RC,0011A,HCPCS,,,,,,,,69,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 1st Dose",PX0011A,CDM,771,RC,0011A,HCPCS,,,,,,,,69,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 1st Dose",PX0011A,CDM,771,RC,0011A,HCPCS,,,,,,,,69,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 1st Dose",PX0011A,CDM,771,RC,0011A,HCPCS,,,,,,,,69,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 1st Dose",PX0011A,CDM,771,RC,0011A,HCPCS,,,,,,,,69,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 2nd Dose",PX0012A,CDM,771,RC,0012A,HCPCS,,,,,,,,69,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 2nd Dose",PX0012A,CDM,771,RC,0012A,HCPCS,,,,,,,,69,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 2nd Dose",PX0012A,CDM,771,RC,0012A,HCPCS,,,,,,,,69,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 2nd Dose",PX0012A,CDM,771,RC,0012A,HCPCS,,,,,,,,69,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 2nd Dose",PX0012A,CDM,771,RC,0012A,HCPCS,,,,,,,,69,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 2nd Dose",PX0012A,CDM,771,RC,0012A,HCPCS,,,,,,,,69,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 3rd Dose",PX0013A,CDM,771,RC,0013A,HCPCS,,,,,,,,69,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 3rd Dose",PX0013A,CDM,771,RC,0013A,HCPCS,,,,,,,,69,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 3rd Dose",PX0013A,CDM,771,RC,0013A,HCPCS,,,,,,,,69,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 3rd Dose",PX0013A,CDM,771,RC,0013A,HCPCS,,,,,,,,69,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 3rd Dose",PX0013A,CDM,771,RC,0013A,HCPCS,,,,,,,,69,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 3rd Dose",PX0013A,CDM,771,RC,0013A,HCPCS,,,,,,,,69,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MODULAR INSERT TOE JOINT 2.5MM 3.6MMTHK PROXIMAL PHALANGEAL,C1713,CDM,278,RC,C1713,HCPCS,,12530-MAIN,LOCAL,,,,,3968,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MODULAR INSERT TOE JOINT 2.5MM 3.6MMTHK PROXIMAL PHALANGEAL,C1713,CDM,278,RC,C1713,HCPCS,,12530-MAIN,LOCAL,,,,,3968,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MODULAR INSERT TOE JOINT 2.5MM 3.6MMTHK PROXIMAL PHALANGEAL,C1713,CDM,278,RC,C1713,HCPCS,,12530-MAIN,LOCAL,,,,,3968,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MODULAR INSERT TOE JOINT 2.5MM 3.6MMTHK PROXIMAL PHALANGEAL,C1713,CDM,278,RC,C1713,HCPCS,,12530-MAIN,LOCAL,,,,,3968,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MODULAR INSERT TOE JOINT 2.5MM 3.6MMTHK PROXIMAL PHALANGEAL,C1713,CDM,278,RC,C1713,HCPCS,,12530-MAIN,LOCAL,,,,,3968,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MODULAR INSERT TOE JOINT 2.5MM 3.6MMTHK PROXIMAL PHALANGEAL,C1713,CDM,278,RC,C1713,HCPCS,,12530-MAIN,LOCAL,,,,,3968,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Molecular Cytog, Ea Probe - Ref",PX8827190,CDM,310,RC,88271,CPT,90,,,,,,,277,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Molecular Cytog, Ea Probe - Ref",PX8827190,CDM,310,RC,88271,CPT,90,,,,,,,277,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Molecular Cytog, Ea Probe - Ref",PX8827190,CDM,310,RC,88271,CPT,90,,,,,,,277,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Molecular Cytog, Ea Probe - Ref",PX8827190,CDM,310,RC,88271,CPT,90,,,,,,,277,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Molecular Cytog, Ea Probe - Ref",PX8827190,CDM,310,RC,88271,CPT,90,,,,,,,277,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Molecular Cytog, Ea Probe - Ref",PX8827190,CDM,310,RC,88271,CPT,90,,,,,,,277,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Molecular Path Proc, Level 2 - Ref",PX8140190,CDM,310,RC,81401,CPT,90,,,,,,,672,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Molecular Path Proc, Level 2 - Ref",PX8140190,CDM,310,RC,81401,CPT,90,,,,,,,672,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Molecular Path Proc, Level 2 - Ref",PX8140190,CDM,310,RC,81401,CPT,90,,,,,,,672,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Molecular Path Proc, Level 2 - Ref",PX8140190,CDM,310,RC,81401,CPT,90,,,,,,,672,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Molecular Path Proc, Level 2 - Ref",PX8140190,CDM,310,RC,81401,CPT,90,,,,,,,672,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Molecular Path Proc, Level 2 - Ref",PX8140190,CDM,310,RC,81401,CPT,90,,,,,,,672,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Molecyto Insitu, 100-300cl - Ref",PX8827590,CDM,310,RC,88275,CPT,90,,,,,,,103,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Molecyto Insitu, 100-300cl - Ref",PX8827590,CDM,310,RC,88275,CPT,90,,,,,,,103,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Molecyto Insitu, 100-300cl - Ref",PX8827590,CDM,310,RC,88275,CPT,90,,,,,,,103,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Molecyto Insitu, 100-300cl - Ref",PX8827590,CDM,310,RC,88275,CPT,90,,,,,,,103,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Molecyto Insitu, 100-300cl - Ref",PX8827590,CDM,310,RC,88275,CPT,90,,,,,,,103,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Molecyto Insitu, 100-300cl - Ref",PX8827590,CDM,310,RC,88275,CPT,90,,,,,,,103,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mometasone - formoterol 100-5 MCG/ACT Aerosol 8.8 g Inhaler,25000000,CDM,250,RC,,,,,,85720607,NDC,8.8,GR,918.07,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mometasone - formoterol 100-5 MCG/ACT Aerosol 8.8 g Inhaler,25000000,CDM,250,RC,,,,,,85720607,NDC,8.8,GR,918.07,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mometasone - formoterol 100-5 MCG/ACT Aerosol 8.8 g Inhaler,25000000,CDM,250,RC,,,,,,85720607,NDC,8.8,GR,918.07,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mometasone - formoterol 100-5 MCG/ACT Aerosol 8.8 g Inhaler,25000000,CDM,250,RC,,,,,,85720607,NDC,8.8,GR,918.07,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mometasone - formoterol 100-5 MCG/ACT Aerosol 8.8 g Inhaler,25000000,CDM,250,RC,,,,,,85720607,NDC,8.8,GR,918.07,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mometasone - formoterol 100-5 MCG/ACT Aerosol 8.8 g Inhaler,25000000,CDM,250,RC,,,,,,85720607,NDC,8.8,GR,918.07,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mometasone - formoterol 200-5 MCG/ACT Aerosol 8.8 g Inhaler,25000000,CDM,250,RC,,,,,,85461005,NDC,8.8,GR,918.07,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mometasone - formoterol 200-5 MCG/ACT Aerosol 8.8 g Inhaler,25000000,CDM,250,RC,,,,,,85461005,NDC,8.8,GR,918.07,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mometasone - formoterol 200-5 MCG/ACT Aerosol 8.8 g Inhaler,25000000,CDM,250,RC,,,,,,85461005,NDC,8.8,GR,918.07,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mometasone - formoterol 200-5 MCG/ACT Aerosol 8.8 g Inhaler,25000000,CDM,250,RC,,,,,,85461005,NDC,8.8,GR,918.07,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mometasone - formoterol 200-5 MCG/ACT Aerosol 8.8 g Inhaler,25000000,CDM,250,RC,,,,,,85461005,NDC,8.8,GR,918.07,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mometasone - formoterol 200-5 MCG/ACT Aerosol 8.8 g Inhaler,25000000,CDM,250,RC,,,,,,85461005,NDC,8.8,GR,918.07,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
montelukast 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268057511,NDC,1,EA,26.75,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
montelukast 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268057511,NDC,1,EA,26.75,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
montelukast 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268057511,NDC,1,EA,26.75,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
montelukast 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268057511,NDC,1,EA,26.75,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
montelukast 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268057511,NDC,1,EA,26.75,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
montelukast 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268057511,NDC,1,EA,26.75,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
montelukast 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268057515,NDC,1,EA,26.75,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
montelukast 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268057515,NDC,1,EA,26.75,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
montelukast 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268057515,NDC,1,EA,26.75,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
montelukast 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268057515,NDC,1,EA,26.75,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
montelukast 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268057515,NDC,1,EA,26.75,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
montelukast 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268057515,NDC,1,EA,26.75,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
montelukast 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904680861,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
montelukast 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904680861,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
montelukast 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904680861,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
montelukast 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904680861,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
montelukast 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904680861,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
montelukast 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904680861,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601901,NDC,10,ML,211.47,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601901,NDC,10,ML,211.47,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601901,NDC,10,ML,211.47,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601901,NDC,10,ML,211.47,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601901,NDC,10,ML,211.47,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601901,NDC,10,ML,211.47,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601910,NDC,10,ML,211.47,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601910,NDC,10,ML,211.47,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601910,NDC,10,ML,211.47,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601910,NDC,10,ML,211.47,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601910,NDC,10,ML,211.47,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601910,NDC,10,ML,211.47,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine 1 MG/ML Solution 50 mL Syringe,J2270.01,CDM,636,RC,J2270,HCPCS,,,,61553064975,NDC,50,ML,81.71,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine 1 MG/ML Solution 50 mL Syringe,J2270.01,CDM,636,RC,J2270,HCPCS,,,,61553064975,NDC,50,ML,81.71,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine 1 MG/ML Solution 50 mL Syringe,J2270.01,CDM,636,RC,J2270,HCPCS,,,,61553064975,NDC,50,ML,81.71,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine 1 MG/ML Solution 50 mL Syringe,J2270.01,CDM,636,RC,J2270,HCPCS,,,,61553064975,NDC,50,ML,81.71,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine 1 MG/ML Solution 50 mL Syringe,J2270.01,CDM,636,RC,J2270,HCPCS,,,,61553064975,NDC,50,ML,81.71,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine 1 MG/ML Solution 50 mL Syringe,J2270.01,CDM,636,RC,J2270,HCPCS,,,,61553064975,NDC,50,ML,81.71,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine 2 MG/ML Solution 1 mL Syringe,J2272.01,CDM,636,RC,J2272,HCPCS,,,,76045000401,NDC,1,ML,38.98,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine 2 MG/ML Solution 1 mL Syringe,J2272.01,CDM,636,RC,J2272,HCPCS,,,,76045000401,NDC,1,ML,38.98,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine 2 MG/ML Solution 1 mL Syringe,J2272.01,CDM,636,RC,J2272,HCPCS,,,,76045000401,NDC,1,ML,38.98,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine 2 MG/ML Solution 1 mL Syringe,J2272.01,CDM,636,RC,J2272,HCPCS,,,,76045000401,NDC,1,ML,38.98,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine 2 MG/ML Solution 1 mL Syringe,J2272.01,CDM,636,RC,J2272,HCPCS,,,,76045000401,NDC,1,ML,38.98,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine 2 MG/ML Solution 1 mL Syringe,J2272.01,CDM,636,RC,J2272,HCPCS,,,,76045000401,NDC,1,ML,38.98,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574711212,NDC,1,EA,33.56,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574711212,NDC,1,EA,33.56,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574711212,NDC,1,EA,33.56,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574711212,NDC,1,EA,33.56,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574711212,NDC,1,EA,33.56,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574711212,NDC,1,EA,33.56,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine 20 mg/mL Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,54040444,NDC,30,ML,141.88,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine 20 mg/mL Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,54040444,NDC,30,ML,141.88,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine 20 mg/mL Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,54040444,NDC,30,ML,141.88,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine 20 mg/mL Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,54040444,NDC,30,ML,141.88,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine 20 mg/mL Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,54040444,NDC,30,ML,141.88,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine 20 mg/mL Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,54040444,NDC,30,ML,141.88,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine 20 mg/mL Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,54051744,NDC,0.5,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine 20 mg/mL Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,54051744,NDC,0.5,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine 20 mg/mL Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,54051744,NDC,0.5,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine 20 mg/mL Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,54051744,NDC,0.5,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine 20 mg/mL Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,54051744,NDC,0.5,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine 20 mg/mL Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,54051744,NDC,0.5,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine ER 15 MG Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,406831523,NDC,1,EA,10.05,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine ER 15 MG Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,406831523,NDC,1,EA,10.05,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine ER 15 MG Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,406831523,NDC,1,EA,10.05,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine ER 15 MG Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,406831523,NDC,1,EA,10.05,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine ER 15 MG Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,406831523,NDC,1,EA,10.05,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine ER 15 MG Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,406831523,NDC,1,EA,10.05,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine ER 15 MG Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,68084040311,NDC,1,EA,9.88,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine ER 15 MG Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,68084040311,NDC,1,EA,9.88,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine ER 15 MG Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,68084040311,NDC,1,EA,9.88,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine ER 15 MG Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,68084040311,NDC,1,EA,9.88,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine ER 15 MG Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,68084040311,NDC,1,EA,9.88,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine ER 15 MG Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,68084040311,NDC,1,EA,9.88,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine ER 15 MG Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,406831562,NDC,1,EA,10.05,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine ER 15 MG Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,406831562,NDC,1,EA,10.05,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine ER 15 MG Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,406831562,NDC,1,EA,10.05,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine ER 15 MG Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,406831562,NDC,1,EA,10.05,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine ER 15 MG Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,406831562,NDC,1,EA,10.05,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine ER 15 MG Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,406831562,NDC,1,EA,10.05,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine ER 15 MG Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,68084040301,NDC,1,EA,9.9,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine ER 15 MG Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,68084040301,NDC,1,EA,9.9,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine ER 15 MG Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,68084040301,NDC,1,EA,9.9,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine ER 15 MG Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,68084040301,NDC,1,EA,9.9,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine ER 15 MG Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,68084040301,NDC,1,EA,9.9,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine ER 15 MG Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,68084040301,NDC,1,EA,9.9,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine immediate release 15 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54023525,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine immediate release 15 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54023525,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine immediate release 15 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54023525,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine immediate release 15 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54023525,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine immediate release 15 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54023525,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine immediate release 15 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54023525,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine immediate release 15 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,832027311,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine immediate release 15 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,832027311,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine immediate release 15 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,832027311,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine immediate release 15 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,832027311,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine immediate release 15 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,832027311,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine immediate release 15 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,832027311,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189001,NDC,1,ML,34.11,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189001,NDC,1,ML,34.11,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189001,NDC,1,ML,34.11,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189001,NDC,1,ML,34.11,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189001,NDC,1,ML,34.11,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189001,NDC,1,ML,34.11,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189003,NDC,1,ML,34.11,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189003,NDC,1,ML,34.11,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189003,NDC,1,ML,34.11,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189003,NDC,1,ML,34.11,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189003,NDC,1,ML,34.11,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189003,NDC,1,ML,34.11,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189101,NDC,1,ML,32.43,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189101,NDC,1,ML,32.43,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189101,NDC,1,ML,32.43,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189101,NDC,1,ML,32.43,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189101,NDC,1,ML,32.43,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189101,NDC,1,ML,32.43,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189103,NDC,1,ML,32.89,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189103,NDC,1,ML,32.89,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189103,NDC,1,ML,32.89,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189103,NDC,1,ML,32.89,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189103,NDC,1,ML,32.89,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189103,NDC,1,ML,32.89,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Morphometric Analysis, in Situ Hybridization, Each Probe; Manual, Tech",PX8836801,CDM,310,RC,88368,CPT,TC,,,,,,,402,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Morphometric Analysis, in Situ Hybridization, Each Probe; Manual, Tech",PX8836801,CDM,310,RC,88368,CPT,TC,,,,,,,402,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Morphometric Analysis, in Situ Hybridization, Each Probe; Manual, Tech",PX8836801,CDM,310,RC,88368,CPT,TC,,,,,,,402,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Morphometric Analysis, in Situ Hybridization, Each Probe; Manual, Tech",PX8836801,CDM,310,RC,88368,CPT,TC,,,,,,,402,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Morphometric Analysis, in Situ Hybridization, Each Probe; Manual, Tech",PX8836801,CDM,310,RC,88368,CPT,TC,,,,,,,402,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Morphometric Analysis, in Situ Hybridization, Each Probe; Manual, Tech",PX8836801,CDM,310,RC,88368,CPT,TC,,,,,,,402,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Morphometric Analysis, Tumor - Ref",PX8836090,CDM,310,RC,88360,CPT,90,,,,,,,349,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Morphometric Analysis, Tumor - Ref",PX8836090,CDM,310,RC,88360,CPT,90,,,,,,,349,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Morphometric Analysis, Tumor - Ref",PX8836090,CDM,310,RC,88360,CPT,90,,,,,,,349,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Morphometric Analysis, Tumor - Ref",PX8836090,CDM,310,RC,88360,CPT,90,,,,,,,349,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Morphometric Analysis, Tumor - Ref",PX8836090,CDM,310,RC,88360,CPT,90,,,,,,,349,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Morphometric Analysis, Tumor - Ref",PX8836090,CDM,310,RC,88360,CPT,90,,,,,,,349,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Morphometric Analysis,Tumor Immunohistochemistry, Ea Antibody Manual , Tech",PX8836001,CDM,310,RC,88360,CPT,TC,,,,,,,119,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Morphometric Analysis,Tumor Immunohistochemistry, Ea Antibody Manual , Tech",PX8836001,CDM,310,RC,88360,CPT,TC,,,,,,,119,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Morphometric Analysis,Tumor Immunohistochemistry, Ea Antibody Manual , Tech",PX8836001,CDM,310,RC,88360,CPT,TC,,,,,,,119,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Morphometric Analysis,Tumor Immunohistochemistry, Ea Antibody Manual , Tech",PX8836001,CDM,310,RC,88360,CPT,TC,,,,,,,119,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Morphometric Analysis,Tumor Immunohistochemistry, Ea Antibody Manual , Tech",PX8836001,CDM,310,RC,88360,CPT,TC,,,,,,,119,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Morphometric Analysis,Tumor Immunohistochemistry, Ea Antibody Manual , Tech",PX8836001,CDM,310,RC,88360,CPT,TC,,,,,,,119,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
moxifloxacin 0.5 % Solution 3 mL Bottle,25000000,CDM,250,RC,,,,,,60505058204,NDC,3,ML,691.15,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
moxifloxacin 0.5 % Solution 3 mL Bottle,25000000,CDM,250,RC,,,,,,60505058204,NDC,3,ML,691.15,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
moxifloxacin 0.5 % Solution 3 mL Bottle,25000000,CDM,250,RC,,,,,,60505058204,NDC,3,ML,691.15,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
moxifloxacin 0.5 % Solution 3 mL Bottle,25000000,CDM,250,RC,,,,,,60505058204,NDC,3,ML,691.15,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
moxifloxacin 0.5 % Solution 3 mL Bottle,25000000,CDM,250,RC,,,,,,60505058204,NDC,3,ML,691.15,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
moxifloxacin 0.5 % Solution 3 mL Bottle,25000000,CDM,250,RC,,,,,,60505058204,NDC,3,ML,691.15,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Mra, Head W/Out Contrast",PX7054401,CDM,610,RC,70544,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Mra, Head W/Out Contrast",PX7054401,CDM,610,RC,70544,CPT,TC,,,,,,,3541,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Mra, Head W/Out Contrast",PX7054401,CDM,610,RC,70544,CPT,TC,,,,,,,3541,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Mra, Head W/Out Contrast",PX7054401,CDM,610,RC,70544,CPT,TC,,,,,,,3541,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Mra, Head W/Out Contrast",PX7054401,CDM,610,RC,70544,CPT,TC,,,,,,,3541,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Mra, Head W/Out Contrast",PX7054401,CDM,610,RC,70544,CPT,TC,,,,,,,3541,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Mra, Neck W/O+W/ Contrast",PX7054901,CDM,610,RC,70549,CPT,TC,,,,,,,3472,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Mra, Neck W/O+W/ Contrast",PX7054901,CDM,610,RC,70549,CPT,TC,,,,,,,3472,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Mra, Neck W/O+W/ Contrast",PX7054901,CDM,610,RC,70549,CPT,TC,,,,,,,3472,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Mra, Neck W/O+W/ Contrast",PX7054901,CDM,610,RC,70549,CPT,TC,,,,,,,3472,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Mra, Neck W/O+W/ Contrast",PX7054901,CDM,610,RC,70549,CPT,TC,,,,,,,3472,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Mra, Neck W/O+W/ Contrast",PX7054901,CDM,610,RC,70549,CPT,TC,,,,,,,3472,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Mra, Neck With Contrast",PX7054801,CDM,610,RC,70548,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Mra, Neck With Contrast",PX7054801,CDM,610,RC,70548,CPT,TC,,,,,,,3541,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Mra, Neck With Contrast",PX7054801,CDM,610,RC,70548,CPT,TC,,,,,,,3541,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Mra, Neck With Contrast",PX7054801,CDM,610,RC,70548,CPT,TC,,,,,,,3541,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Mra, Neck With Contrast",PX7054801,CDM,610,RC,70548,CPT,TC,,,,,,,3541,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Mra, Neck With Contrast",PX7054801,CDM,610,RC,70548,CPT,TC,,,,,,,3541,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Abdomen W/O Tc,PX7418101,CDM,610,RC,74181,CPT,TC,,,,,,,2655,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Abdomen W/O Tc,PX7418101,CDM,610,RC,74181,CPT,TC,,,,,,,2655,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Abdomen W/O Tc,PX7418101,CDM,610,RC,74181,CPT,TC,,,,,,,2655,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Abdomen W/O Tc,PX7418101,CDM,610,RC,74181,CPT,TC,,,,,,,2655,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Abdomen W/O Tc,PX7418101,CDM,610,RC,74181,CPT,TC,,,,,,,2655,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Abdomen W/O Tc,PX7418101,CDM,610,RC,74181,CPT,TC,,,,,,,2655,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Brain W & WO Contrast,PX7055301,CDM,610,RC,70553,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Brain W & WO Contrast,PX7055301,CDM,610,RC,70553,CPT,TC,,,,,,,3541,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Brain W & WO Contrast,PX7055301,CDM,610,RC,70553,CPT,TC,,,,,,,3541,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Brain W & WO Contrast,PX7055301,CDM,610,RC,70553,CPT,TC,,,,,,,3541,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Brain W & WO Contrast,PX7055301,CDM,610,RC,70553,CPT,TC,,,,,,,3541,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Brain W & WO Contrast,PX7055301,CDM,610,RC,70553,CPT,TC,,,,,,,3541,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Brain W Contrast Tc,PX7055201,CDM,610,RC,70552,CPT,TC,,,,,,,2637,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Brain W Contrast Tc,PX7055201,CDM,610,RC,70552,CPT,TC,,,,,,,2637,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Brain W Contrast Tc,PX7055201,CDM,610,RC,70552,CPT,TC,,,,,,,2637,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Brain W Contrast Tc,PX7055201,CDM,610,RC,70552,CPT,TC,,,,,,,2637,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Brain W Contrast Tc,PX7055201,CDM,610,RC,70552,CPT,TC,,,,,,,2637,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Brain W Contrast Tc,PX7055201,CDM,610,RC,70552,CPT,TC,,,,,,,2637,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Brain WO Contrast Tc,PX7055101,CDM,610,RC,70551,CPT,TC,,,,,,,3335,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Brain WO Contrast Tc,PX7055101,CDM,610,RC,70551,CPT,TC,,,,,,,3335,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Brain WO Contrast Tc,PX7055101,CDM,610,RC,70551,CPT,TC,,,,,,,3335,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Brain WO Contrast Tc,PX7055101,CDM,610,RC,70551,CPT,TC,,,,,,,3335,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Brain WO Contrast Tc,PX7055101,CDM,610,RC,70551,CPT,TC,,,,,,,3335,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Brain WO Contrast Tc,PX7055101,CDM,610,RC,70551,CPT,TC,,,,,,,3335,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI C Spine W&WO Contrast,PX7215601,CDM,610,RC,72156,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI C Spine W&WO Contrast,PX7215601,CDM,610,RC,72156,CPT,TC,,,,,,,3541,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI C Spine W&WO Contrast,PX7215601,CDM,610,RC,72156,CPT,TC,,,,,,,3541,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI C Spine W&WO Contrast,PX7215601,CDM,610,RC,72156,CPT,TC,,,,,,,3541,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI C Spine W&WO Contrast,PX7215601,CDM,610,RC,72156,CPT,TC,,,,,,,3541,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI C Spine W&WO Contrast,PX7215601,CDM,610,RC,72156,CPT,TC,,,,,,,3541,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI C-Spine WO Contrast,PX7214101,CDM,610,RC,72141,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI C-Spine WO Contrast,PX7214101,CDM,610,RC,72141,CPT,TC,,,,,,,3541,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI C-Spine WO Contrast,PX7214101,CDM,610,RC,72141,CPT,TC,,,,,,,3541,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI C-Spine WO Contrast,PX7214101,CDM,610,RC,72141,CPT,TC,,,,,,,3541,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI C-Spine WO Contrast,PX7214101,CDM,610,RC,72141,CPT,TC,,,,,,,3541,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI C-Spine WO Contrast,PX7214101,CDM,610,RC,72141,CPT,TC,,,,,,,3541,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI L Spine W Contrast Tc,PX7214901,CDM,610,RC,72149,CPT,TC,,,,,,,5136,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI L Spine W Contrast Tc,PX7214901,CDM,610,RC,72149,CPT,TC,,,,,,,5136,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI L Spine W Contrast Tc,PX7214901,CDM,610,RC,72149,CPT,TC,,,,,,,5136,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI L Spine W Contrast Tc,PX7214901,CDM,610,RC,72149,CPT,TC,,,,,,,5136,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI L Spine W Contrast Tc,PX7214901,CDM,610,RC,72149,CPT,TC,,,,,,,5136,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI L Spine W Contrast Tc,PX7214901,CDM,610,RC,72149,CPT,TC,,,,,,,5136,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI L Spine W&WO Contrast,PX7215801,CDM,610,RC,72158,CPT,TC,,,,,,,4178,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI L Spine W&WO Contrast,PX7215801,CDM,610,RC,72158,CPT,TC,,,,,,,4178,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI L Spine W&WO Contrast,PX7215801,CDM,610,RC,72158,CPT,TC,,,,,,,4178,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI L Spine W&WO Contrast,PX7215801,CDM,610,RC,72158,CPT,TC,,,,,,,4178,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI L Spine W&WO Contrast,PX7215801,CDM,610,RC,72158,CPT,TC,,,,,,,4178,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI L Spine W&WO Contrast,PX7215801,CDM,610,RC,72158,CPT,TC,,,,,,,4178,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI L Spine WO Contrast,PX7214801,CDM,610,RC,72148,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI L Spine WO Contrast,PX7214801,CDM,610,RC,72148,CPT,TC,,,,,,,3541,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI L Spine WO Contrast,PX7214801,CDM,610,RC,72148,CPT,TC,,,,,,,3541,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI L Spine WO Contrast,PX7214801,CDM,610,RC,72148,CPT,TC,,,,,,,3541,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI L Spine WO Contrast,PX7214801,CDM,610,RC,72148,CPT,TC,,,,,,,3541,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI L Spine WO Contrast,PX7214801,CDM,610,RC,72148,CPT,TC,,,,,,,3541,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Low Ext Jnt WO/Cont Tc,PX7372101,CDM,610,RC,73721,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Low Ext Jnt WO/Cont Tc,PX7372101,CDM,610,RC,73721,CPT,TC,,,,,,,3541,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Low Ext Jnt WO/Cont Tc,PX7372101,CDM,610,RC,73721,CPT,TC,,,,,,,3541,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Low Ext Jnt WO/Cont Tc,PX7372101,CDM,610,RC,73721,CPT,TC,,,,,,,3541,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Low Ext Jnt WO/Cont Tc,PX7372101,CDM,610,RC,73721,CPT,TC,,,,,,,3541,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Low Ext Jnt WO/Cont Tc,PX7372101,CDM,610,RC,73721,CPT,TC,,,,,,,3541,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Lower W/O+W Tc,PX7372001,CDM,610,RC,73720,CPT,TC,,,,,,,3174,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Lower W/O+W Tc,PX7372001,CDM,610,RC,73720,CPT,TC,,,,,,,3174,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Lower W/O+W Tc,PX7372001,CDM,610,RC,73720,CPT,TC,,,,,,,3174,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Lower W/O+W Tc,PX7372001,CDM,610,RC,73720,CPT,TC,,,,,,,3174,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Lower W/O+W Tc,PX7372001,CDM,610,RC,73720,CPT,TC,,,,,,,3174,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Lower W/O+W Tc,PX7372001,CDM,610,RC,73720,CPT,TC,,,,,,,3174,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Orb-Fac-Nec W/O+W/Con,PX7054301,CDM,610,RC,70543,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Orb-Fac-Nec W/O+W/Con,PX7054301,CDM,610,RC,70543,CPT,TC,,,,,,,3541,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Orb-Fac-Nec W/O+W/Con,PX7054301,CDM,610,RC,70543,CPT,TC,,,,,,,3541,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Orb-Fac-Nec W/O+W/Con,PX7054301,CDM,610,RC,70543,CPT,TC,,,,,,,3541,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Orb-Fac-Nec W/O+W/Con,PX7054301,CDM,610,RC,70543,CPT,TC,,,,,,,3541,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Orb-Fac-Nec W/O+W/Con,PX7054301,CDM,610,RC,70543,CPT,TC,,,,,,,3541,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Orbit/Face/Neck Tc,PX7054001,CDM,610,RC,70540,CPT,TC,,,,,,,3335,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Orbit/Face/Neck Tc,PX7054001,CDM,610,RC,70540,CPT,TC,,,,,,,3335,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Orbit/Face/Neck Tc,PX7054001,CDM,610,RC,70540,CPT,TC,,,,,,,3335,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Orbit/Face/Neck Tc,PX7054001,CDM,610,RC,70540,CPT,TC,,,,,,,3335,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Orbit/Face/Neck Tc,PX7054001,CDM,610,RC,70540,CPT,TC,,,,,,,3335,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Orbit/Face/Neck Tc,PX7054001,CDM,610,RC,70540,CPT,TC,,,,,,,3335,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Pelvis W/Contrast Tc,PX7219601,CDM,610,RC,72196,CPT,TC,,,,,,,3143,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Pelvis W/Contrast Tc,PX7219601,CDM,610,RC,72196,CPT,TC,,,,,,,3143,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Pelvis W/Contrast Tc,PX7219601,CDM,610,RC,72196,CPT,TC,,,,,,,3143,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Pelvis W/Contrast Tc,PX7219601,CDM,610,RC,72196,CPT,TC,,,,,,,3143,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Pelvis W/Contrast Tc,PX7219601,CDM,610,RC,72196,CPT,TC,,,,,,,3143,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Pelvis W/Contrast Tc,PX7219601,CDM,610,RC,72196,CPT,TC,,,,,,,3143,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI T Spine W&WO Contrast,PX7215701,CDM,610,RC,72157,CPT,TC,,,,,,,4178,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI T Spine W&WO Contrast,PX7215701,CDM,610,RC,72157,CPT,TC,,,,,,,4178,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI T Spine W&WO Contrast,PX7215701,CDM,610,RC,72157,CPT,TC,,,,,,,4178,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI T Spine W&WO Contrast,PX7215701,CDM,610,RC,72157,CPT,TC,,,,,,,4178,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI T Spine W&WO Contrast,PX7215701,CDM,610,RC,72157,CPT,TC,,,,,,,4178,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI T Spine W&WO Contrast,PX7215701,CDM,610,RC,72157,CPT,TC,,,,,,,4178,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI T Spine WO Contrast,PX7214601,CDM,610,RC,72146,CPT,TC,,,,,,,3267,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI T Spine WO Contrast,PX7214601,CDM,610,RC,72146,CPT,TC,,,,,,,3267,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI T Spine WO Contrast,PX7214601,CDM,610,RC,72146,CPT,TC,,,,,,,3267,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI T Spine WO Contrast,PX7214601,CDM,610,RC,72146,CPT,TC,,,,,,,3267,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI T Spine WO Contrast,PX7214601,CDM,610,RC,72146,CPT,TC,,,,,,,3267,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI T Spine WO Contrast,PX7214601,CDM,610,RC,72146,CPT,TC,,,,,,,3267,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Up Extremity Joint W/O Tc,PX7322101,CDM,610,RC,73221,CPT,TC,,,,,,,3319,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Up Extremity Joint W/O Tc,PX7322101,CDM,610,RC,73221,CPT,TC,,,,,,,3319,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Up Extremity Joint W/O Tc,PX7322101,CDM,610,RC,73221,CPT,TC,,,,,,,3319,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Up Extremity Joint W/O Tc,PX7322101,CDM,610,RC,73221,CPT,TC,,,,,,,3319,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Up Extremity Joint W/O Tc,PX7322101,CDM,610,RC,73221,CPT,TC,,,,,,,3319,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Up Extremity Joint W/O Tc,PX7322101,CDM,610,RC,73221,CPT,TC,,,,,,,3319,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Upper W/O+W Tc,PX7322001,CDM,610,RC,73220,CPT,TC,,,,,,,3253,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Upper W/O+W Tc,PX7322001,CDM,610,RC,73220,CPT,TC,,,,,,,3253,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Upper W/O+W Tc,PX7322001,CDM,610,RC,73220,CPT,TC,,,,,,,3253,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Upper W/O+W Tc,PX7322001,CDM,610,RC,73220,CPT,TC,,,,,,,3253,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Upper W/O+W Tc,PX7322001,CDM,610,RC,73220,CPT,TC,,,,,,,3253,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Upper W/O+W Tc,PX7322001,CDM,610,RC,73220,CPT,TC,,,,,,,3253,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI, Abdomen W/O+ W/Contr",PX7418301,CDM,610,RC,74183,CPT,TC,,,,,,,4116,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI, Abdomen W/O+ W/Contr",PX7418301,CDM,610,RC,74183,CPT,TC,,,,,,,4116,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI, Abdomen W/O+ W/Contr",PX7418301,CDM,610,RC,74183,CPT,TC,,,,,,,4116,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI, Abdomen W/O+ W/Contr",PX7418301,CDM,610,RC,74183,CPT,TC,,,,,,,4116,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI, Abdomen W/O+ W/Contr",PX7418301,CDM,610,RC,74183,CPT,TC,,,,,,,4116,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI, Abdomen W/O+ W/Contr",PX7418301,CDM,610,RC,74183,CPT,TC,,,,,,,4116,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI, Pelvis, W/O Then W/",PX7219701,CDM,610,RC,72197,CPT,TC,,,,,,,1612,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI, Pelvis, W/O Then W/",PX7219701,CDM,610,RC,72197,CPT,TC,,,,,,,1612,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI, Pelvis, W/O Then W/",PX7219701,CDM,610,RC,72197,CPT,TC,,,,,,,1612,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI, Pelvis, W/O Then W/",PX7219701,CDM,610,RC,72197,CPT,TC,,,,,,,1612,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI, Pelvis, W/O Then W/",PX7219701,CDM,610,RC,72197,CPT,TC,,,,,,,1612,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI, Pelvis, W/O Then W/",PX7219701,CDM,610,RC,72197,CPT,TC,,,,,,,1612,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI,Lwrext,Jnt W/O+W/Cont",PX7372301,CDM,610,RC,73723,CPT,TC,,,,,,,1850,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI,Lwrext,Jnt W/O+W/Cont",PX7372301,CDM,610,RC,73723,CPT,TC,,,,,,,1850,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI,Lwrext,Jnt W/O+W/Cont",PX7372301,CDM,610,RC,73723,CPT,TC,,,,,,,1850,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI,Lwrext,Jnt W/O+W/Cont",PX7372301,CDM,610,RC,73723,CPT,TC,,,,,,,1850,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI,Lwrext,Jnt W/O+W/Cont",PX7372301,CDM,610,RC,73723,CPT,TC,,,,,,,1850,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI,Lwrext,Jnt W/O+W/Cont",PX7372301,CDM,610,RC,73723,CPT,TC,,,,,,,1850,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI,Lwrext,No Jnt, W/Cont",PX7371901,CDM,610,RC,73719,CPT,TC,,,,,,,3627,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI,Lwrext,No Jnt, W/Cont",PX7371901,CDM,610,RC,73719,CPT,TC,,,,,,,3627,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI,Lwrext,No Jnt, W/Cont",PX7371901,CDM,610,RC,73719,CPT,TC,,,,,,,3627,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI,Lwrext,No Jnt, W/Cont",PX7371901,CDM,610,RC,73719,CPT,TC,,,,,,,3627,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI,Lwrext,No Jnt, W/Cont",PX7371901,CDM,610,RC,73719,CPT,TC,,,,,,,3627,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI,Lwrext,No Jnt, W/Cont",PX7371901,CDM,610,RC,73719,CPT,TC,,,,,,,3627,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI,Lwrext,No Jnt,No Cont",PX7371801,CDM,610,RC,73718,CPT,TC,,,,,,,3253,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI,Lwrext,No Jnt,No Cont",PX7371801,CDM,610,RC,73718,CPT,TC,,,,,,,3253,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI,Lwrext,No Jnt,No Cont",PX7371801,CDM,610,RC,73718,CPT,TC,,,,,,,3253,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI,Lwrext,No Jnt,No Cont",PX7371801,CDM,610,RC,73718,CPT,TC,,,,,,,3253,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI,Lwrext,No Jnt,No Cont",PX7371801,CDM,610,RC,73718,CPT,TC,,,,,,,3253,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI,Lwrext,No Jnt,No Cont",PX7371801,CDM,610,RC,73718,CPT,TC,,,,,,,3253,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI,Pelvis W/Out Contrast",PX7219501,CDM,610,RC,72195,CPT,TC,,,,,,,3253,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI,Pelvis W/Out Contrast",PX7219501,CDM,610,RC,72195,CPT,TC,,,,,,,3253,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI,Pelvis W/Out Contrast",PX7219501,CDM,610,RC,72195,CPT,TC,,,,,,,3253,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI,Pelvis W/Out Contrast",PX7219501,CDM,610,RC,72195,CPT,TC,,,,,,,3253,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI,Pelvis W/Out Contrast",PX7219501,CDM,610,RC,72195,CPT,TC,,,,,,,3253,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI,Pelvis W/Out Contrast",PX7219501,CDM,610,RC,72195,CPT,TC,,,,,,,3253,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI,Up Ext,No Jnt,No Cont",PX7321801,CDM,610,RC,73218,CPT,TC,,,,,,,3253,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI,Up Ext,No Jnt,No Cont",PX7321801,CDM,610,RC,73218,CPT,TC,,,,,,,3253,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI,Up Ext,No Jnt,No Cont",PX7321801,CDM,610,RC,73218,CPT,TC,,,,,,,3253,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI,Up Ext,No Jnt,No Cont",PX7321801,CDM,610,RC,73218,CPT,TC,,,,,,,3253,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI,Up Ext,No Jnt,No Cont",PX7321801,CDM,610,RC,73218,CPT,TC,,,,,,,3253,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI,Up Ext,No Jnt,No Cont",PX7321801,CDM,610,RC,73218,CPT,TC,,,,,,,3253,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI,Upr Ext, Joint,W/Cont",PX7322201,CDM,610,RC,73222,CPT,TC,,,,,,,3541,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI,Upr Ext, Joint,W/Cont",PX7322201,CDM,610,RC,73222,CPT,TC,,,,,,,3541,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI,Upr Ext, Joint,W/Cont",PX7322201,CDM,610,RC,73222,CPT,TC,,,,,,,3541,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI,Upr Ext, Joint,W/Cont",PX7322201,CDM,610,RC,73222,CPT,TC,,,,,,,3541,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI,Upr Ext, Joint,W/Cont",PX7322201,CDM,610,RC,73222,CPT,TC,,,,,,,3541,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI,Upr Ext, Joint,W/Cont",PX7322201,CDM,610,RC,73222,CPT,TC,,,,,,,3541,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI,Uprext Jnt W/O+W/Cont",PX7322301,CDM,610,RC,73223,CPT,TC,,,,,,,2681,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI,Uprext Jnt W/O+W/Cont",PX7322301,CDM,610,RC,73223,CPT,TC,,,,,,,2681,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI,Uprext Jnt W/O+W/Cont",PX7322301,CDM,610,RC,73223,CPT,TC,,,,,,,2681,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI,Uprext Jnt W/O+W/Cont",PX7322301,CDM,610,RC,73223,CPT,TC,,,,,,,2681,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI,Uprext Jnt W/O+W/Cont",PX7322301,CDM,610,RC,73223,CPT,TC,,,,,,,2681,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI,Uprext Jnt W/O+W/Cont",PX7322301,CDM,610,RC,73223,CPT,TC,,,,,,,2681,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mrsa by Amplification Na,PX87641,CDM,300,RC,87641,CPT,,,,,,,,180,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mrsa by Amplification Na,PX87641,CDM,300,RC,87641,CPT,,,,,,,,180,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mrsa by Amplification Na,PX87641,CDM,300,RC,87641,CPT,,,,,,,,180,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mrsa by Amplification Na,PX87641,CDM,300,RC,87641,CPT,,,,,,,,180,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mrsa by Amplification Na,PX87641,CDM,300,RC,87641,CPT,,,,,,,,180,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mrsa by Amplification Na,PX87641,CDM,300,RC,87641,CPT,,,,,,,,180,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MTP PLATE STANDARD 18MM CLIP 5 DEG DORSIFLEXION,27200000,CDM,278,RC,C1713,HCPCS,,11854-MAIN,LOCAL,,,,,5376,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MTP PLATE STANDARD 18MM CLIP 5 DEG DORSIFLEXION,27200000,CDM,278,RC,C1713,HCPCS,,11854-MAIN,LOCAL,,,,,5376,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MTP PLATE STANDARD 18MM CLIP 5 DEG DORSIFLEXION,27200000,CDM,278,RC,C1713,HCPCS,,11854-MAIN,LOCAL,,,,,5376,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MTP PLATE STANDARD 18MM CLIP 5 DEG DORSIFLEXION,27200000,CDM,278,RC,C1713,HCPCS,,11854-MAIN,LOCAL,,,,,5376,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MTP PLATE STANDARD 18MM CLIP 5 DEG DORSIFLEXION,27200000,CDM,278,RC,C1713,HCPCS,,11854-MAIN,LOCAL,,,,,5376,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MTP PLATE STANDARD 18MM CLIP 5 DEG DORSIFLEXION,27200000,CDM,278,RC,C1713,HCPCS,,11854-MAIN,LOCAL,,,,,5376,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Multiple Sleep Latency Test,PX9580501,CDM,740,RC,95805,CPT,TC,,,,,,,4313,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Multiple Sleep Latency Test,PX9580501,CDM,740,RC,95805,CPT,TC,,,,,,,4313,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Multiple Sleep Latency Test,PX9580501,CDM,740,RC,95805,CPT,TC,,,,,,,4313,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Multiple Sleep Latency Test,PX9580501,CDM,740,RC,95805,CPT,TC,,,,,,,4313,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Multiple Sleep Latency Test,PX9580501,CDM,740,RC,95805,CPT,TC,,,,,,,4313,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Multiple Sleep Latency Test,PX9580501,CDM,740,RC,95805,CPT,TC,,,,,,,4313,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
multivitamin with minerals Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904549261,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
multivitamin with minerals Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904549261,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
multivitamin with minerals Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904549261,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
multivitamin with minerals Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904549261,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
multivitamin with minerals Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904549261,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
multivitamin with minerals Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904549261,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mumps,PX86735,CDM,300,RC,86735,CPT,,,,,,,,148,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mumps,PX86735,CDM,300,RC,86735,CPT,,,,,,,,148,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mumps,PX86735,CDM,300,RC,86735,CPT,,,,,,,,148,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mumps,PX86735,CDM,300,RC,86735,CPT,,,,,,,,148,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mumps,PX86735,CDM,300,RC,86735,CPT,,,,,,,,148,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mumps,PX86735,CDM,300,RC,86735,CPT,,,,,,,,148,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,45802011222,NDC,22,GR,63.29,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,45802011222,NDC,22,GR,63.29,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,45802011222,NDC,22,GR,63.29,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,45802011222,NDC,22,GR,63.29,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,45802011222,NDC,22,GR,63.29,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,45802011222,NDC,22,GR,63.29,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,51672131200,NDC,22,GR,140.7,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,51672131200,NDC,22,GR,140.7,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,51672131200,NDC,22,GR,140.7,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,51672131200,NDC,22,GR,140.7,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,51672131200,NDC,22,GR,140.7,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,51672131200,NDC,22,GR,140.7,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,68462018022,NDC,22,GR,240.66,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,68462018022,NDC,22,GR,240.66,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,68462018022,NDC,22,GR,240.66,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,68462018022,NDC,22,GR,240.66,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,68462018022,NDC,22,GR,240.66,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,68462018022,NDC,22,GR,240.66,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mycobacteria Culture - Ref,PX8711690,CDM,300,RC,87116,CPT,90,,,,,,,90,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mycobacteria Culture - Ref,PX8711690,CDM,300,RC,87116,CPT,90,,,,,,,90,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mycobacteria Culture - Ref,PX8711690,CDM,300,RC,87116,CPT,90,,,,,,,90,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mycobacteria Culture - Ref,PX8711690,CDM,300,RC,87116,CPT,90,,,,,,,90,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mycobacteria Culture - Ref,PX8711690,CDM,300,RC,87116,CPT,90,,,,,,,90,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mycobacteria Culture - Ref,PX8711690,CDM,300,RC,87116,CPT,90,,,,,,,90,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mycophenolate 500 MG Tablet 100 Each Bottle,J7517.01,CDM,637,RC,J7517,HCPCS,,,,64380072506,NDC,1,EA,42.56,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mycophenolate 500 MG Tablet 100 Each Bottle,J7517.01,CDM,637,RC,J7517,HCPCS,,,,64380072506,NDC,1,EA,42.56,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mycophenolate 500 MG Tablet 100 Each Bottle,J7517.01,CDM,637,RC,J7517,HCPCS,,,,64380072506,NDC,1,EA,42.56,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mycophenolate 500 MG Tablet 100 Each Bottle,J7517.01,CDM,637,RC,J7517,HCPCS,,,,64380072506,NDC,1,EA,42.56,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mycophenolate 500 MG Tablet 100 Each Bottle,J7517.01,CDM,637,RC,J7517,HCPCS,,,,64380072506,NDC,1,EA,42.56,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mycophenolate 500 MG Tablet 100 Each Bottle,J7517.01,CDM,637,RC,J7517,HCPCS,,,,64380072506,NDC,1,EA,42.56,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mycophenolate Mycophenolicacid - Ref,PX8018090,CDM,300,RC,80180,CPT,90,,,,,,,56,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mycophenolate Mycophenolicacid - Ref,PX8018090,CDM,300,RC,80180,CPT,90,,,,,,,56,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mycophenolate Mycophenolicacid - Ref,PX8018090,CDM,300,RC,80180,CPT,90,,,,,,,56,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mycophenolate Mycophenolicacid - Ref,PX8018090,CDM,300,RC,80180,CPT,90,,,,,,,56,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mycophenolate Mycophenolicacid - Ref,PX8018090,CDM,300,RC,80180,CPT,90,,,,,,,56,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mycophenolate Mycophenolicacid - Ref,PX8018090,CDM,300,RC,80180,CPT,90,,,,,,,56,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Myoglobin - Ref,PX8387490,CDM,300,RC,83874,CPT,90,,,,,,,22,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Myoglobin - Ref,PX8387490,CDM,300,RC,83874,CPT,90,,,,,,,22,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Myoglobin - Ref,PX8387490,CDM,300,RC,83874,CPT,90,,,,,,,22,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Myoglobin - Ref,PX8387490,CDM,300,RC,83874,CPT,90,,,,,,,22,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Myoglobin - Ref,PX8387490,CDM,300,RC,83874,CPT,90,,,,,,,22,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Myoglobin - Ref,PX8387490,CDM,300,RC,83874,CPT,90,,,,,,,22,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"N Block Inj, Common Digit",PX64632F,CDM,510,RC,64632,CPT,,,,,,,,190,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"N Block Inj, Common Digit",PX64632F,CDM,510,RC,64632,CPT,,,,,,,,190,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"N Block Inj, Common Digit",PX64632F,CDM,510,RC,64632,CPT,,,,,,,,190,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"N Block Inj, Common Digit",PX64632F,CDM,510,RC,64632,CPT,,,,,,,,190,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"N Block Inj, Common Digit",PX64632F,CDM,510,RC,64632,CPT,,,,,,,,190,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"N Block Inj, Common Digit",PX64632F,CDM,510,RC,64632,CPT,,,,,,,,190,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"N Block Inj, Common Digit",PX64632P,CDM,983,RC,64632,CPT,,,,,,,,128,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"N Block Inj, Common Digit",PX64632P,CDM,983,RC,64632,CPT,,,,,,,,128,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"N Block Inj, Common Digit",PX64632P,CDM,983,RC,64632,CPT,,,,,,,,128,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"N Block Inj, Common Digit",PX64632P,CDM,983,RC,64632,CPT,,,,,,,,128,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"N Block Inj, Common Digit",PX64632P,CDM,983,RC,64632,CPT,,,,,,,,128,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"N Block Inj, Common Digit",PX64632P,CDM,983,RC,64632,CPT,,,,,,,,128,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"N Block Inj, Plantar Digit",PX64455F,CDM,510,RC,64455,CPT,,,,,,,,385,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"N Block Inj, Plantar Digit",PX64455F,CDM,510,RC,64455,CPT,,,,,,,,385,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"N Block Inj, Plantar Digit",PX64455F,CDM,510,RC,64455,CPT,,,,,,,,385,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"N Block Inj, Plantar Digit",PX64455F,CDM,510,RC,64455,CPT,,,,,,,,385,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"N Block Inj, Plantar Digit",PX64455F,CDM,510,RC,64455,CPT,,,,,,,,385,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"N Block Inj, Plantar Digit",PX64455F,CDM,510,RC,64455,CPT,,,,,,,,385,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"N Block Inj, Plantar Digit",PX64455P,CDM,983,RC,64455,CPT,,,,,,,,385,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"N Block Inj, Plantar Digit",PX64455P,CDM,983,RC,64455,CPT,,,,,,,,385,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"N Block Inj, Plantar Digit",PX64455P,CDM,983,RC,64455,CPT,,,,,,,,385,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"N Block Inj, Plantar Digit",PX64455P,CDM,983,RC,64455,CPT,,,,,,,,385,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"N Block Inj, Plantar Digit",PX64455P,CDM,983,RC,64455,CPT,,,,,,,,385,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"N Block Inj, Plantar Digit",PX64455P,CDM,983,RC,64455,CPT,,,,,,,,385,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nabumetone 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50228046501,NDC,1,EA,6.65,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nabumetone 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50228046501,NDC,1,EA,6.65,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nabumetone 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50228046501,NDC,1,EA,6.65,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nabumetone 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50228046501,NDC,1,EA,6.65,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nabumetone 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50228046501,NDC,1,EA,6.65,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nabumetone 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50228046501,NDC,1,EA,6.65,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nabumetone 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687037401,NDC,1,EA,6.32,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nabumetone 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687037401,NDC,1,EA,6.32,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nabumetone 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687037401,NDC,1,EA,6.32,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nabumetone 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687037401,NDC,1,EA,6.32,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nabumetone 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687037401,NDC,1,EA,6.32,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nabumetone 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687037401,NDC,1,EA,6.32,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nadolol 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,76385013301,NDC,1,EA,18.2,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nadolol 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,76385013301,NDC,1,EA,18.2,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nadolol 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,76385013301,NDC,1,EA,18.2,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nadolol 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,76385013301,NDC,1,EA,18.2,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nadolol 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,76385013301,NDC,1,EA,18.2,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nadolol 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,76385013301,NDC,1,EA,18.2,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nafcillin 1 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,55150012215,NDC,1,EA,89.17,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nafcillin 1 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,55150012215,NDC,1,EA,89.17,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nafcillin 1 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,55150012215,NDC,1,EA,89.17,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nafcillin 1 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,55150012215,NDC,1,EA,89.17,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nafcillin 1 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,55150012215,NDC,1,EA,89.17,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nafcillin 1 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,55150012215,NDC,1,EA,89.17,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nafcillin 2 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,S0032,HCPCS,,,,63323032820,NDC,1,EA,185.37,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nafcillin 2 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,S0032,HCPCS,,,,63323032820,NDC,1,EA,185.37,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nafcillin 2 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,S0032,HCPCS,,,,63323032820,NDC,1,EA,185.37,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nafcillin 2 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,S0032,HCPCS,,,,63323032820,NDC,1,EA,185.37,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nafcillin 2 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,S0032,HCPCS,,,,63323032820,NDC,1,EA,185.37,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nafcillin 2 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,S0032,HCPCS,,,,63323032820,NDC,1,EA,185.37,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Nafcillin Sodium 10 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323033060,NDC,1,EA,617.91,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Nafcillin Sodium 10 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323033060,NDC,1,EA,617.91,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Nafcillin Sodium 10 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323033060,NDC,1,EA,617.91,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Nafcillin Sodium 10 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323033060,NDC,1,EA,617.91,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Nafcillin Sodium 10 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323033060,NDC,1,EA,617.91,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Nafcillin Sodium 10 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323033060,NDC,1,EA,617.91,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059900,NDC,1,ML,133.16,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059900,NDC,1,ML,133.16,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059900,NDC,1,ML,133.16,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059900,NDC,1,ML,133.16,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059900,NDC,1,ML,133.16,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059900,NDC,1,ML,133.16,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059902,NDC,1,ML,133.16,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059902,NDC,1,ML,133.16,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059902,NDC,1,ML,133.16,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059902,NDC,1,ML,133.16,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059902,NDC,1,ML,133.16,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059902,NDC,1,ML,133.16,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
naloxone 2 MG/2ML solution prefilled syringe 2 mL Syringe,J2310.01,CDM,636,RC,J2310,HCPCS,,,,76329346901,NDC,1,ML,114.45,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
naloxone 2 MG/2ML solution prefilled syringe 2 mL Syringe,J2310.01,CDM,636,RC,J2310,HCPCS,,,,76329346901,NDC,1,ML,114.45,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
naloxone 2 MG/2ML solution prefilled syringe 2 mL Syringe,J2310.01,CDM,636,RC,J2310,HCPCS,,,,76329346901,NDC,1,ML,114.45,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
naloxone 2 MG/2ML solution prefilled syringe 2 mL Syringe,J2310.01,CDM,636,RC,J2310,HCPCS,,,,76329346901,NDC,1,ML,114.45,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
naloxone 2 MG/2ML solution prefilled syringe 2 mL Syringe,J2310.01,CDM,636,RC,J2310,HCPCS,,,,76329346901,NDC,1,ML,114.45,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
naloxone 2 MG/2ML solution prefilled syringe 2 mL Syringe,J2310.01,CDM,636,RC,J2310,HCPCS,,,,76329346901,NDC,1,ML,114.45,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
naltrexone 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406117001,NDC,1,EA,22.96,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
naltrexone 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406117001,NDC,1,EA,22.96,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
naltrexone 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406117001,NDC,1,EA,22.96,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
naltrexone 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406117001,NDC,1,EA,22.96,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
naltrexone 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406117001,NDC,1,EA,22.96,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
naltrexone 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406117001,NDC,1,EA,22.96,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
naproxen 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65162018810,NDC,1,EA,4.15,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
naproxen 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65162018810,NDC,1,EA,4.15,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
naproxen 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65162018810,NDC,1,EA,4.15,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
naproxen 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65162018810,NDC,1,EA,4.15,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
naproxen 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65162018810,NDC,1,EA,4.15,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
naproxen 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65162018810,NDC,1,EA,4.15,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
naproxen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739040310,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
naproxen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739040310,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
naproxen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739040310,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
naproxen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739040310,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
naproxen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739040310,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
naproxen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739040310,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Nasal Sm for Eos,PX89190,CDM,300,RC,89190,CPT,,,,,,,,38,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Nasal Sm for Eos,PX89190,CDM,300,RC,89190,CPT,,,,,,,,38,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Nasal Sm for Eos,PX89190,CDM,300,RC,89190,CPT,,,,,,,,38,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Nasal Sm for Eos,PX89190,CDM,300,RC,89190,CPT,,,,,,,,38,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Nasal Sm for Eos,PX89190,CDM,300,RC,89190,CPT,,,,,,,,38,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Nasal Sm for Eos,PX89190,CDM,300,RC,89190,CPT,,,,,,,,38,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Naso/Orogastric Tube,PX43752F,CDM,510,RC,43752,CPT,,,,,,,,464,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Naso/Orogastric Tube,PX43752F,CDM,510,RC,43752,CPT,,,,,,,,464,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Naso/Orogastric Tube,PX43752F,CDM,510,RC,43752,CPT,,,,,,,,464,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Naso/Orogastric Tube,PX43752F,CDM,510,RC,43752,CPT,,,,,,,,464,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Naso/Orogastric Tube,PX43752F,CDM,510,RC,43752,CPT,,,,,,,,464,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Naso/Orogastric Tube,PX43752F,CDM,510,RC,43752,CPT,,,,,,,,464,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Naso/Orogastric Tube,PX43752P,CDM,983,RC,43752,CPT,,,,,,,,309,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Naso/Orogastric Tube,PX43752P,CDM,983,RC,43752,CPT,,,,,,,,309,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Naso/Orogastric Tube,PX43752P,CDM,983,RC,43752,CPT,,,,,,,,309,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Naso/Orogastric Tube,PX43752P,CDM,983,RC,43752,CPT,,,,,,,,309,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Naso/Orogastric Tube,PX43752P,CDM,983,RC,43752,CPT,,,,,,,,309,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Naso/Orogastric Tube,PX43752P,CDM,983,RC,43752,CPT,,,,,,,,309,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
natalizumab 300 MG/15ML Concentrate 15 mL Vial,J2323.01,CDM,636,RC,J2323,HCPCS,,,,64406000801,NDC,15,ML,15226.53,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
natalizumab 300 MG/15ML Concentrate 15 mL Vial,J2323.01,CDM,636,RC,J2323,HCPCS,,,,64406000801,NDC,15,ML,15226.53,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
natalizumab 300 MG/15ML Concentrate 15 mL Vial,J2323.01,CDM,636,RC,J2323,HCPCS,,,,64406000801,NDC,15,ML,15226.53,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
natalizumab 300 MG/15ML Concentrate 15 mL Vial,J2323.01,CDM,636,RC,J2323,HCPCS,,,,64406000801,NDC,15,ML,15226.53,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
natalizumab 300 MG/15ML Concentrate 15 mL Vial,J2323.01,CDM,636,RC,J2323,HCPCS,,,,64406000801,NDC,15,ML,15226.53,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
natalizumab 300 MG/15ML Concentrate 15 mL Vial,J2323.01,CDM,636,RC,J2323,HCPCS,,,,64406000801,NDC,15,ML,15226.53,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE ACUJECT 25GA VARIABLE INJECTION VIN-25,27200000,CDM,272,RC,,,,7412-MAIN,LOCAL,,,,,77,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE ACUJECT 25GA VARIABLE INJECTION VIN-25,27200000,CDM,272,RC,,,,7412-MAIN,LOCAL,,,,,77,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE ACUJECT 25GA VARIABLE INJECTION VIN-25,27200000,CDM,272,RC,,,,7412-MAIN,LOCAL,,,,,77,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE ACUJECT 25GA VARIABLE INJECTION VIN-25,27200000,CDM,272,RC,,,,7412-MAIN,LOCAL,,,,,77,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE ACUJECT 25GA VARIABLE INJECTION VIN-25,27200000,CDM,272,RC,,,,7412-MAIN,LOCAL,,,,,77,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE ACUJECT 25GA VARIABLE INJECTION VIN-25,27200000,CDM,272,RC,,,,7412-MAIN,LOCAL,,,,,77,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"NEEDLE ASP 16GX3/16"" 1-7/8"" ILLINOIS STERNAL 8881245164",120.8,CDM,272,RC,G0364,HCPCS,,5730-MAIN,LOCAL,,,,,50,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"NEEDLE ASP 16GX3/16"" 1-7/8"" ILLINOIS STERNAL 8881245164",120.8,CDM,272,RC,G0364,HCPCS,,5730-MAIN,LOCAL,,,,,50,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"NEEDLE ASP 16GX3/16"" 1-7/8"" ILLINOIS STERNAL 8881245164",120.8,CDM,272,RC,G0364,HCPCS,,5730-MAIN,LOCAL,,,,,50,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"NEEDLE ASP 16GX3/16"" 1-7/8"" ILLINOIS STERNAL 8881245164",120.8,CDM,272,RC,G0364,HCPCS,,5730-MAIN,LOCAL,,,,,50,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"NEEDLE ASP 16GX3/16"" 1-7/8"" ILLINOIS STERNAL 8881245164",120.8,CDM,272,RC,G0364,HCPCS,,5730-MAIN,LOCAL,,,,,50,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"NEEDLE ASP 16GX3/16"" 1-7/8"" ILLINOIS STERNAL 8881245164",120.8,CDM,272,RC,G0364,HCPCS,,5730-MAIN,LOCAL,,,,,50,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE BIOPSY 14GAX4 1/2 2N2702X,120.211,CDM,272,RC,,,,724-MAIN,LOCAL,,,,,40,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE BIOPSY 14GAX4 1/2 2N2702X,120.211,CDM,272,RC,,,,724-MAIN,LOCAL,,,,,40,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE BIOPSY 14GAX4 1/2 2N2702X,120.211,CDM,272,RC,,,,724-MAIN,LOCAL,,,,,40,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE BIOPSY 14GAX4 1/2 2N2702X,120.211,CDM,272,RC,,,,724-MAIN,LOCAL,,,,,40,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE BIOPSY 14GAX4 1/2 2N2702X,120.211,CDM,272,RC,,,,724-MAIN,LOCAL,,,,,40,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE BIOPSY 14GAX4 1/2 2N2702X,120.211,CDM,272,RC,,,,724-MAIN,LOCAL,,,,,40,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Needle Biopsy, Lymph Node(S)",PX38505F,CDM,510,RC,38505,CPT,,,,,,,,667,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Needle Biopsy, Lymph Node(S)",PX38505F,CDM,510,RC,38505,CPT,,,,,,,,667,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Needle Biopsy, Lymph Node(S)",PX38505F,CDM,510,RC,38505,CPT,,,,,,,,667,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Needle Biopsy, Lymph Node(S)",PX38505F,CDM,510,RC,38505,CPT,,,,,,,,667,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Needle Biopsy, Lymph Node(S)",PX38505F,CDM,510,RC,38505,CPT,,,,,,,,667,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Needle Biopsy, Lymph Node(S)",PX38505F,CDM,510,RC,38505,CPT,,,,,,,,667,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Needle Biopsy,Muscle",PX20206F,CDM,510,RC,20206,CPT,,,,,,,,258,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Needle Biopsy,Muscle",PX20206F,CDM,510,RC,20206,CPT,,,,,,,,258,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Needle Biopsy,Muscle",PX20206F,CDM,510,RC,20206,CPT,,,,,,,,258,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Needle Biopsy,Muscle",PX20206F,CDM,510,RC,20206,CPT,,,,,,,,258,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Needle Biopsy,Muscle",PX20206F,CDM,510,RC,20206,CPT,,,,,,,,258,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Needle Biopsy,Muscle",PX20206F,CDM,510,RC,20206,CPT,,,,,,,,258,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Needle Biopsy,Muscle",PX20206P,CDM,983,RC,20206,CPT,,,,,,,,1028,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Needle Biopsy,Muscle",PX20206P,CDM,983,RC,20206,CPT,,,,,,,,1028,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Needle Biopsy,Muscle",PX20206P,CDM,983,RC,20206,CPT,,,,,,,,1028,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Needle Biopsy,Muscle",PX20206P,CDM,983,RC,20206,CPT,,,,,,,,1028,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Needle Biopsy,Muscle",PX20206P,CDM,983,RC,20206,CPT,,,,,,,,1028,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Needle Biopsy,Muscle",PX20206P,CDM,983,RC,20206,CPT,,,,,,,,1028,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"NEEDLE BONE MARROW 8G X 4"" BIOPSY/ASPIRATION 8881247087",120.8,CDM,272,RC,G0364,HCPCS,,166-MAIN,LOCAL,,,,,50,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"NEEDLE BONE MARROW 8G X 4"" BIOPSY/ASPIRATION 8881247087",120.8,CDM,272,RC,G0364,HCPCS,,166-MAIN,LOCAL,,,,,50,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"NEEDLE BONE MARROW 8G X 4"" BIOPSY/ASPIRATION 8881247087",120.8,CDM,272,RC,G0364,HCPCS,,166-MAIN,LOCAL,,,,,50,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"NEEDLE BONE MARROW 8G X 4"" BIOPSY/ASPIRATION 8881247087",120.8,CDM,272,RC,G0364,HCPCS,,166-MAIN,LOCAL,,,,,50,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"NEEDLE BONE MARROW 8G X 4"" BIOPSY/ASPIRATION 8881247087",120.8,CDM,272,RC,G0364,HCPCS,,166-MAIN,LOCAL,,,,,50,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"NEEDLE BONE MARROW 8G X 4"" BIOPSY/ASPIRATION 8881247087",120.8,CDM,272,RC,G0364,HCPCS,,166-MAIN,LOCAL,,,,,50,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"NEEDLE BONE MARROW 11G X 4"" 8881247111",120.8,CDM,272,RC,G0364,HCPCS,,162-MAIN,LOCAL,,,,,50,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"NEEDLE BONE MARROW 11G X 4"" 8881247111",120.8,CDM,272,RC,G0364,HCPCS,,162-MAIN,LOCAL,,,,,50,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"NEEDLE BONE MARROW 11G X 4"" 8881247111",120.8,CDM,272,RC,G0364,HCPCS,,162-MAIN,LOCAL,,,,,50,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"NEEDLE BONE MARROW 11G X 4"" 8881247111",120.8,CDM,272,RC,G0364,HCPCS,,162-MAIN,LOCAL,,,,,50,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"NEEDLE BONE MARROW 11G X 4"" 8881247111",120.8,CDM,272,RC,G0364,HCPCS,,162-MAIN,LOCAL,,,,,50,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"NEEDLE BONE MARROW 11G X 4"" 8881247111",120.8,CDM,272,RC,G0364,HCPCS,,162-MAIN,LOCAL,,,,,50,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE ECHOGENIC 21G 110MM SONOTAP II WITH FACET TIP 1285-3F110,120.483,CDM,271,RC,A4215,HCPCS,,12201-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE ECHOGENIC 21G 110MM SONOTAP II WITH FACET TIP 1285-3F110,120.483,CDM,271,RC,A4215,HCPCS,,12201-MAIN,LOCAL,,,,,41,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE ECHOGENIC 21G 110MM SONOTAP II WITH FACET TIP 1285-3F110,120.483,CDM,271,RC,A4215,HCPCS,,12201-MAIN,LOCAL,,,,,41,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE ECHOGENIC 21G 110MM SONOTAP II WITH FACET TIP 1285-3F110,120.483,CDM,271,RC,A4215,HCPCS,,12201-MAIN,LOCAL,,,,,41,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE ECHOGENIC 21G 110MM SONOTAP II WITH FACET TIP 1285-3F110,120.483,CDM,271,RC,A4215,HCPCS,,12201-MAIN,LOCAL,,,,,41,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE ECHOGENIC 21G 110MM SONOTAP II WITH FACET TIP 1285-3F110,120.483,CDM,271,RC,A4215,HCPCS,,12201-MAIN,LOCAL,,,,,41,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE ECHOGENIC 21G X 4IN (100MM) SONOBLOCK II NERVE BLOCK WITH FACET S TIP 001281-77,120.483,CDM,271,RC,A4215,HCPCS,,12761-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE ECHOGENIC 21G X 4IN (100MM) SONOBLOCK II NERVE BLOCK WITH FACET S TIP 001281-77,120.483,CDM,271,RC,A4215,HCPCS,,12761-MAIN,LOCAL,,,,,41,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE ECHOGENIC 21G X 4IN (100MM) SONOBLOCK II NERVE BLOCK WITH FACET S TIP 001281-77,120.483,CDM,271,RC,A4215,HCPCS,,12761-MAIN,LOCAL,,,,,41,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE ECHOGENIC 21G X 4IN (100MM) SONOBLOCK II NERVE BLOCK WITH FACET S TIP 001281-77,120.483,CDM,271,RC,A4215,HCPCS,,12761-MAIN,LOCAL,,,,,41,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE ECHOGENIC 21G X 4IN (100MM) SONOBLOCK II NERVE BLOCK WITH FACET S TIP 001281-77,120.483,CDM,271,RC,A4215,HCPCS,,12761-MAIN,LOCAL,,,,,41,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE ECHOGENIC 21G X 4IN (100MM) SONOBLOCK II NERVE BLOCK WITH FACET S TIP 001281-77,120.483,CDM,271,RC,A4215,HCPCS,,12761-MAIN,LOCAL,,,,,41,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE ECHOGENIC 22G 80MM SONOTAP II WITH FACET TIP 1285-3E080,120.483,CDM,271,RC,A4215,HCPCS,,12103-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE ECHOGENIC 22G 80MM SONOTAP II WITH FACET TIP 1285-3E080,120.483,CDM,271,RC,A4215,HCPCS,,12103-MAIN,LOCAL,,,,,41,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE ECHOGENIC 22G 80MM SONOTAP II WITH FACET TIP 1285-3E080,120.483,CDM,271,RC,A4215,HCPCS,,12103-MAIN,LOCAL,,,,,41,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE ECHOGENIC 22G 80MM SONOTAP II WITH FACET TIP 1285-3E080,120.483,CDM,271,RC,A4215,HCPCS,,12103-MAIN,LOCAL,,,,,41,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE ECHOGENIC 22G 80MM SONOTAP II WITH FACET TIP 1285-3E080,120.483,CDM,271,RC,A4215,HCPCS,,12103-MAIN,LOCAL,,,,,41,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE ECHOGENIC 22G 80MM SONOTAP II WITH FACET TIP 1285-3E080,120.483,CDM,271,RC,A4215,HCPCS,,12103-MAIN,LOCAL,,,,,41,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE ECHOGENIC 22G X 3.25IN (80MM) SONOBLOCK II  NERVE BLOCK WITH FACET S TIP 001281-71,120.483,CDM,271,RC,A4215,HCPCS,,12760-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE ECHOGENIC 22G X 3.25IN (80MM) SONOBLOCK II  NERVE BLOCK WITH FACET S TIP 001281-71,120.483,CDM,271,RC,A4215,HCPCS,,12760-MAIN,LOCAL,,,,,41,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE ECHOGENIC 22G X 3.25IN (80MM) SONOBLOCK II  NERVE BLOCK WITH FACET S TIP 001281-71,120.483,CDM,271,RC,A4215,HCPCS,,12760-MAIN,LOCAL,,,,,41,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE ECHOGENIC 22G X 3.25IN (80MM) SONOBLOCK II  NERVE BLOCK WITH FACET S TIP 001281-71,120.483,CDM,271,RC,A4215,HCPCS,,12760-MAIN,LOCAL,,,,,41,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE ECHOGENIC 22G X 3.25IN (80MM) SONOBLOCK II  NERVE BLOCK WITH FACET S TIP 001281-71,120.483,CDM,271,RC,A4215,HCPCS,,12760-MAIN,LOCAL,,,,,41,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE ECHOGENIC 22G X 3.25IN (80MM) SONOBLOCK II  NERVE BLOCK WITH FACET S TIP 001281-71,120.483,CDM,271,RC,A4215,HCPCS,,12760-MAIN,LOCAL,,,,,41,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE ECHOGENIC 22GX2 SONOPLEX II WITH FACET S TIP 001287-74,120.483,CDM,271,RC,A4215,HCPCS,,13110-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE ECHOGENIC 22GX2 SONOPLEX II WITH FACET S TIP 001287-74,120.483,CDM,271,RC,A4215,HCPCS,,13110-MAIN,LOCAL,,,,,41,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE ECHOGENIC 22GX2 SONOPLEX II WITH FACET S TIP 001287-74,120.483,CDM,271,RC,A4215,HCPCS,,13110-MAIN,LOCAL,,,,,41,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE ECHOGENIC 22GX2 SONOPLEX II WITH FACET S TIP 001287-74,120.483,CDM,271,RC,A4215,HCPCS,,13110-MAIN,LOCAL,,,,,41,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE ECHOGENIC 22GX2 SONOPLEX II WITH FACET S TIP 001287-74,120.483,CDM,271,RC,A4215,HCPCS,,13110-MAIN,LOCAL,,,,,41,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE ECHOGENIC 22GX2 SONOPLEX II WITH FACET S TIP 001287-74,120.483,CDM,271,RC,A4215,HCPCS,,13110-MAIN,LOCAL,,,,,41,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE HYPODERMIC 22GA 1-1/2IN STERILE 305156,27200000,CDM,272,RC,A4215,HCPCS,,8887-MAIN,LOCAL,,,,,10,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE HYPODERMIC 22GA 1-1/2IN STERILE 305156,27200000,CDM,272,RC,A4215,HCPCS,,8887-MAIN,LOCAL,,,,,10,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE HYPODERMIC 22GA 1-1/2IN STERILE 305156,27200000,CDM,272,RC,A4215,HCPCS,,8887-MAIN,LOCAL,,,,,10,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE HYPODERMIC 22GA 1-1/2IN STERILE 305156,27200000,CDM,272,RC,A4215,HCPCS,,8887-MAIN,LOCAL,,,,,10,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE HYPODERMIC 22GA 1-1/2IN STERILE 305156,27200000,CDM,272,RC,A4215,HCPCS,,8887-MAIN,LOCAL,,,,,10,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE HYPODERMIC 22GA 1-1/2IN STERILE 305156,27200000,CDM,272,RC,A4215,HCPCS,,8887-MAIN,LOCAL,,,,,10,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Needle Insertion W/O Injection 1 or 2 Muscles,PX20560,CDM,420,RC,20560,CPT,,,,,,,,10,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Needle Insertion W/O Injection 1 or 2 Muscles,PX20560,CDM,420,RC,20560,CPT,,,,,,,,10,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Needle Insertion W/O Injection 1 or 2 Muscles,PX20560,CDM,420,RC,20560,CPT,,,,,,,,10,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Needle Insertion W/O Injection 1 or 2 Muscles,PX20560,CDM,420,RC,20560,CPT,,,,,,,,10,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Needle Insertion W/O Injection 1 or 2 Muscles,PX20560,CDM,420,RC,20560,CPT,,,,,,,,10,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Needle Insertion W/O Injection 1 or 2 Muscles,PX20560,CDM,420,RC,20560,CPT,,,,,,,,10,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Needle Insertion W/O Injection 3 or More Muscles,PX20561,CDM,420,RC,20561,CPT,,,,,,,,10,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Needle Insertion W/O Injection 3 or More Muscles,PX20561,CDM,420,RC,20561,CPT,,,,,,,,10,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Needle Insertion W/O Injection 3 or More Muscles,PX20561,CDM,420,RC,20561,CPT,,,,,,,,10,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Needle Insertion W/O Injection 3 or More Muscles,PX20561,CDM,420,RC,20561,CPT,,,,,,,,10,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Needle Insertion W/O Injection 3 or More Muscles,PX20561,CDM,420,RC,20561,CPT,,,,,,,,10,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Needle Insertion W/O Injection 3 or More Muscles,PX20561,CDM,420,RC,20561,CPT,,,,,,,,10,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE INTRAOSSEOUS 15GA 15MM EZ-IO PEDS 9018,120.89,CDM,272,RC,A4215,HCPCS,,4964-MAIN,LOCAL,,,,,269,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE INTRAOSSEOUS 15GA 15MM EZ-IO PEDS 9018,120.89,CDM,272,RC,A4215,HCPCS,,4964-MAIN,LOCAL,,,,,269,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE INTRAOSSEOUS 15GA 15MM EZ-IO PEDS 9018,120.89,CDM,272,RC,A4215,HCPCS,,4964-MAIN,LOCAL,,,,,269,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE INTRAOSSEOUS 15GA 15MM EZ-IO PEDS 9018,120.89,CDM,272,RC,A4215,HCPCS,,4964-MAIN,LOCAL,,,,,269,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE INTRAOSSEOUS 15GA 15MM EZ-IO PEDS 9018,120.89,CDM,272,RC,A4215,HCPCS,,4964-MAIN,LOCAL,,,,,269,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE INTRAOSSEOUS 15GA 15MM EZ-IO PEDS 9018,120.89,CDM,272,RC,A4215,HCPCS,,4964-MAIN,LOCAL,,,,,269,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE INTRAOSSEOUS SET 15GA 25MM STABILIZER EZ-IO 9001P,120.216,CDM,272,RC,A4215,HCPCS,,10648-MAIN,LOCAL,,,,,290,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE INTRAOSSEOUS SET 15GA 25MM STABILIZER EZ-IO 9001P,120.216,CDM,272,RC,A4215,HCPCS,,10648-MAIN,LOCAL,,,,,290,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE INTRAOSSEOUS SET 15GA 25MM STABILIZER EZ-IO 9001P,120.216,CDM,272,RC,A4215,HCPCS,,10648-MAIN,LOCAL,,,,,290,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE INTRAOSSEOUS SET 15GA 25MM STABILIZER EZ-IO 9001P,120.216,CDM,272,RC,A4215,HCPCS,,10648-MAIN,LOCAL,,,,,290,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE INTRAOSSEOUS SET 15GA 25MM STABILIZER EZ-IO 9001P,120.216,CDM,272,RC,A4215,HCPCS,,10648-MAIN,LOCAL,,,,,290,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE INTRAOSSEOUS SET 15GA 25MM STABILIZER EZ-IO 9001P,120.216,CDM,272,RC,A4215,HCPCS,,10648-MAIN,LOCAL,,,,,290,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE INTRAOSSEOUS SET 15GA 45MM STABILIZER EZ-IO 9079P,120.216,CDM,272,RC,A4215,HCPCS,,10297-MAIN,LOCAL,,,,,290,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE INTRAOSSEOUS SET 15GA 45MM STABILIZER EZ-IO 9079P,120.216,CDM,272,RC,A4215,HCPCS,,10297-MAIN,LOCAL,,,,,290,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE INTRAOSSEOUS SET 15GA 45MM STABILIZER EZ-IO 9079P,120.216,CDM,272,RC,A4215,HCPCS,,10297-MAIN,LOCAL,,,,,290,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE INTRAOSSEOUS SET 15GA 45MM STABILIZER EZ-IO 9079P,120.216,CDM,272,RC,A4215,HCPCS,,10297-MAIN,LOCAL,,,,,290,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE INTRAOSSEOUS SET 15GA 45MM STABILIZER EZ-IO 9079P,120.216,CDM,272,RC,A4215,HCPCS,,10297-MAIN,LOCAL,,,,,290,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE INTRAOSSEOUS SET 15GA 45MM STABILIZER EZ-IO 9079P,120.216,CDM,272,RC,A4215,HCPCS,,10297-MAIN,LOCAL,,,,,290,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE IV 19GA X .75IN HUBER POWERLOC SAFETY 0651934,120.85,CDM,272,RC,A4215,HCPCS,,12701-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE IV 19GA X .75IN HUBER POWERLOC SAFETY 0651934,120.85,CDM,272,RC,A4215,HCPCS,,12701-MAIN,LOCAL,,,,,38,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE IV 19GA X .75IN HUBER POWERLOC SAFETY 0651934,120.85,CDM,272,RC,A4215,HCPCS,,12701-MAIN,LOCAL,,,,,38,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE IV 19GA X .75IN HUBER POWERLOC SAFETY 0651934,120.85,CDM,272,RC,A4215,HCPCS,,12701-MAIN,LOCAL,,,,,38,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE IV 19GA X .75IN HUBER POWERLOC SAFETY 0651934,120.85,CDM,272,RC,A4215,HCPCS,,12701-MAIN,LOCAL,,,,,38,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE IV 19GA X .75IN HUBER POWERLOC SAFETY 0651934,120.85,CDM,272,RC,A4215,HCPCS,,12701-MAIN,LOCAL,,,,,38,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE IV 19GA X 1 IN HUBER POWERLOC SAFETY 0651910,120.85,CDM,272,RC,A4215,HCPCS,,12702-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE IV 19GA X 1 IN HUBER POWERLOC SAFETY 0651910,120.85,CDM,272,RC,A4215,HCPCS,,12702-MAIN,LOCAL,,,,,38,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE IV 19GA X 1 IN HUBER POWERLOC SAFETY 0651910,120.85,CDM,272,RC,A4215,HCPCS,,12702-MAIN,LOCAL,,,,,38,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE IV 19GA X 1 IN HUBER POWERLOC SAFETY 0651910,120.85,CDM,272,RC,A4215,HCPCS,,12702-MAIN,LOCAL,,,,,38,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE IV 19GA X 1 IN HUBER POWERLOC SAFETY 0651910,120.85,CDM,272,RC,A4215,HCPCS,,12702-MAIN,LOCAL,,,,,38,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE IV 19GA X 1 IN HUBER POWERLOC SAFETY 0651910,120.85,CDM,272,RC,A4215,HCPCS,,12702-MAIN,LOCAL,,,,,38,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE IV 19GA X 1.5 IN HUBER POWERLOC SAFETY 0651915,120.85,CDM,272,RC,A4215,HCPCS,,12703-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE IV 19GA X 1.5 IN HUBER POWERLOC SAFETY 0651915,120.85,CDM,272,RC,A4215,HCPCS,,12703-MAIN,LOCAL,,,,,38,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE IV 19GA X 1.5 IN HUBER POWERLOC SAFETY 0651915,120.85,CDM,272,RC,A4215,HCPCS,,12703-MAIN,LOCAL,,,,,38,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE IV 19GA X 1.5 IN HUBER POWERLOC SAFETY 0651915,120.85,CDM,272,RC,A4215,HCPCS,,12703-MAIN,LOCAL,,,,,38,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE IV 19GA X 1.5 IN HUBER POWERLOC SAFETY 0651915,120.85,CDM,272,RC,A4215,HCPCS,,12703-MAIN,LOCAL,,,,,38,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE IV 19GA X 1.5 IN HUBER POWERLOC SAFETY 0651915,120.85,CDM,272,RC,A4215,HCPCS,,12703-MAIN,LOCAL,,,,,38,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE JAMSHIDI 11G X 101MM BIOPSY DJ4011X,27200000,CDM,272,RC,,,,12798-MAIN,LOCAL,,,,,39,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE JAMSHIDI 11G X 101MM BIOPSY DJ4011X,27200000,CDM,272,RC,,,,12798-MAIN,LOCAL,,,,,39,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE JAMSHIDI 11G X 101MM BIOPSY DJ4011X,27200000,CDM,272,RC,,,,12798-MAIN,LOCAL,,,,,39,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE JAMSHIDI 11G X 101MM BIOPSY DJ4011X,27200000,CDM,272,RC,,,,12798-MAIN,LOCAL,,,,,39,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE JAMSHIDI 11G X 101MM BIOPSY DJ4011X,27200000,CDM,272,RC,,,,12798-MAIN,LOCAL,,,,,39,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE JAMSHIDI 11G X 101MM BIOPSY DJ4011X,27200000,CDM,272,RC,,,,12798-MAIN,LOCAL,,,,,39,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE NON-STIMULATING 22GX2 SONOBLOCK II WITH FACET S TIP 001281-74,120.483,CDM,271,RC,A4215,HCPCS,,11459-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE NON-STIMULATING 22GX2 SONOBLOCK II WITH FACET S TIP 001281-74,120.483,CDM,271,RC,A4215,HCPCS,,11459-MAIN,LOCAL,,,,,41,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE NON-STIMULATING 22GX2 SONOBLOCK II WITH FACET S TIP 001281-74,120.483,CDM,271,RC,A4215,HCPCS,,11459-MAIN,LOCAL,,,,,41,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE NON-STIMULATING 22GX2 SONOBLOCK II WITH FACET S TIP 001281-74,120.483,CDM,271,RC,A4215,HCPCS,,11459-MAIN,LOCAL,,,,,41,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE NON-STIMULATING 22GX2 SONOBLOCK II WITH FACET S TIP 001281-74,120.483,CDM,271,RC,A4215,HCPCS,,11459-MAIN,LOCAL,,,,,41,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE NON-STIMULATING 22GX2 SONOBLOCK II WITH FACET S TIP 001281-74,120.483,CDM,271,RC,A4215,HCPCS,,11459-MAIN,LOCAL,,,,,41,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE SONOPLEX II STIMULATING WITH FACET S TIP 22GX3-1/4,120.483,CDM,271,RC,A4215,HCPCS,,11457-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE SONOPLEX II STIMULATING WITH FACET S TIP 22GX3-1/4,120.483,CDM,271,RC,A4215,HCPCS,,11457-MAIN,LOCAL,,,,,41,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE SONOPLEX II STIMULATING WITH FACET S TIP 22GX3-1/4,120.483,CDM,271,RC,A4215,HCPCS,,11457-MAIN,LOCAL,,,,,41,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE SONOPLEX II STIMULATING WITH FACET S TIP 22GX3-1/4,120.483,CDM,271,RC,A4215,HCPCS,,11457-MAIN,LOCAL,,,,,41,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE SONOPLEX II STIMULATING WITH FACET S TIP 22GX3-1/4,120.483,CDM,271,RC,A4215,HCPCS,,11457-MAIN,LOCAL,,,,,41,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE SONOPLEX II STIMULATING WITH FACET S TIP 22GX3-1/4,120.483,CDM,271,RC,A4215,HCPCS,,11457-MAIN,LOCAL,,,,,41,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE STIMULATING 21GX4  SONOPLEX II  WITH FACET S TIP 001287-77,120.483,CDM,271,RC,A4215,HCPCS,,11458-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE STIMULATING 21GX4  SONOPLEX II  WITH FACET S TIP 001287-77,120.483,CDM,271,RC,A4215,HCPCS,,11458-MAIN,LOCAL,,,,,41,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE STIMULATING 21GX4  SONOPLEX II  WITH FACET S TIP 001287-77,120.483,CDM,271,RC,A4215,HCPCS,,11458-MAIN,LOCAL,,,,,41,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE STIMULATING 21GX4  SONOPLEX II  WITH FACET S TIP 001287-77,120.483,CDM,271,RC,A4215,HCPCS,,11458-MAIN,LOCAL,,,,,41,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE STIMULATING 21GX4  SONOPLEX II  WITH FACET S TIP 001287-77,120.483,CDM,271,RC,A4215,HCPCS,,11458-MAIN,LOCAL,,,,,41,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE STIMULATING 21GX4  SONOPLEX II  WITH FACET S TIP 001287-77,120.483,CDM,271,RC,A4215,HCPCS,,11458-MAIN,LOCAL,,,,,41,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Neg Pressure Wound Therapy Dme </=50 Sq Cm,PX97605F,CDM,510,RC,97605,CPT,,,,,,,,396,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Neg Pressure Wound Therapy Dme </=50 Sq Cm,PX97605F,CDM,510,RC,97605,CPT,,,,,,,,396,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Neg Pressure Wound Therapy Dme </=50 Sq Cm,PX97605F,CDM,510,RC,97605,CPT,,,,,,,,396,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Neg Pressure Wound Therapy Dme </=50 Sq Cm,PX97605F,CDM,510,RC,97605,CPT,,,,,,,,396,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Neg Pressure Wound Therapy Dme </=50 Sq Cm,PX97605F,CDM,510,RC,97605,CPT,,,,,,,,396,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Neg Pressure Wound Therapy Dme </=50 Sq Cm,PX97605F,CDM,510,RC,97605,CPT,,,,,,,,396,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Neg Pressure Wound Therapy Dme >50 Sq Cm,PX97606F,CDM,761,RC,97606,CPT,,,,,,,,404,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Neg Pressure Wound Therapy Dme >50 Sq Cm,PX97606F,CDM,761,RC,97606,CPT,,,,,,,,404,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Neg Pressure Wound Therapy Dme >50 Sq Cm,PX97606F,CDM,761,RC,97606,CPT,,,,,,,,404,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Neg Pressure Wound Therapy Dme >50 Sq Cm,PX97606F,CDM,761,RC,97606,CPT,,,,,,,,404,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Neg Pressure Wound Therapy Dme >50 Sq Cm,PX97606F,CDM,761,RC,97606,CPT,,,,,,,,404,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Neg Pressure Wound Therapy Dme >50 Sq Cm,PX97606F,CDM,761,RC,97606,CPT,,,,,,,,404,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607F,CDM,761,RC,97607,CPT,,,,,,,,455,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607F,CDM,761,RC,97607,CPT,,,,,,,,455,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607F,CDM,761,RC,97607,CPT,,,,,,,,455,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607F,CDM,761,RC,97607,CPT,,,,,,,,455,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607F,CDM,761,RC,97607,CPT,,,,,,,,455,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607F,CDM,761,RC,97607,CPT,,,,,,,,455,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607P,CDM,983,RC,97607,CPT,,,,,,,,303,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607P,CDM,983,RC,97607,CPT,,,,,,,,303,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607P,CDM,983,RC,97607,CPT,,,,,,,,303,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607P,CDM,983,RC,97607,CPT,,,,,,,,303,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607P,CDM,983,RC,97607,CPT,,,,,,,,303,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607P,CDM,983,RC,97607,CPT,,,,,,,,303,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Neisseria Gonorrhoeae Dna, Amp Probe",PX87591,CDM,300,RC,87591,CPT,,,,,,,,157,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Neisseria Gonorrhoeae Dna, Amp Probe",PX87591,CDM,300,RC,87591,CPT,,,,,,,,157,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Neisseria Gonorrhoeae Dna, Amp Probe",PX87591,CDM,300,RC,87591,CPT,,,,,,,,157,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Neisseria Gonorrhoeae Dna, Amp Probe",PX87591,CDM,300,RC,87591,CPT,,,,,,,,157,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Neisseria Gonorrhoeae Dna, Amp Probe",PX87591,CDM,300,RC,87591,CPT,,,,,,,,157,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Neisseria Gonorrhoeae Dna, Amp Probe",PX87591,CDM,300,RC,87591,CPT,,,,,,,,157,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-bacitracin-polymyxin 3.5-400-5000 Ointment 28 g Tube,25000000,CDM,250,RC,,,,,,45802014303,NDC,28,GR,37.76,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-bacitracin-polymyxin 3.5-400-5000 Ointment 28 g Tube,25000000,CDM,250,RC,,,,,,45802014303,NDC,28,GR,37.76,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-bacitracin-polymyxin 3.5-400-5000 Ointment 28 g Tube,25000000,CDM,250,RC,,,,,,45802014303,NDC,28,GR,37.76,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-bacitracin-polymyxin 3.5-400-5000 Ointment 28 g Tube,25000000,CDM,250,RC,,,,,,45802014303,NDC,28,GR,37.76,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-bacitracin-polymyxin 3.5-400-5000 Ointment 28 g Tube,25000000,CDM,250,RC,,,,,,45802014303,NDC,28,GR,37.76,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-bacitracin-polymyxin 3.5-400-5000 Ointment 28 g Tube,25000000,CDM,250,RC,,,,,,45802014303,NDC,28,GR,37.76,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-bacitracin-polymyxin 3.5-400-5000 Ointment 28.4 g Tube,25000000,CDM,250,RC,,,,,,713026831,NDC,28.4,GR,22.47,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-bacitracin-polymyxin 3.5-400-5000 Ointment 28.4 g Tube,25000000,CDM,250,RC,,,,,,713026831,NDC,28.4,GR,22.47,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-bacitracin-polymyxin 3.5-400-5000 Ointment 28.4 g Tube,25000000,CDM,250,RC,,,,,,713026831,NDC,28.4,GR,22.47,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-bacitracin-polymyxin 3.5-400-5000 Ointment 28.4 g Tube,25000000,CDM,250,RC,,,,,,713026831,NDC,28.4,GR,22.47,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-bacitracin-polymyxin 3.5-400-5000 Ointment 28.4 g Tube,25000000,CDM,250,RC,,,,,,713026831,NDC,28.4,GR,22.47,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-bacitracin-polymyxin 3.5-400-5000 Ointment 28.4 g Tube,25000000,CDM,250,RC,,,,,,713026831,NDC,28.4,GR,22.47,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-polymyxin-dexameth 3.5-10000-0.1 Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063006,NDC,5,ML,247.72,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-polymyxin-dexameth 3.5-10000-0.1 Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063006,NDC,5,ML,247.72,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-polymyxin-dexameth 3.5-10000-0.1 Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063006,NDC,5,ML,247.72,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-polymyxin-dexameth 3.5-10000-0.1 Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063006,NDC,5,ML,247.72,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-polymyxin-dexameth 3.5-10000-0.1 Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063006,NDC,5,ML,247.72,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-polymyxin-dexameth 3.5-10000-0.1 Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063006,NDC,5,ML,247.72,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-polymyxin-dexamethasone 3.5-10000-0.1 Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,61314063136,NDC,3.5,GR,247.71,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-polymyxin-dexamethasone 3.5-10000-0.1 Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,61314063136,NDC,3.5,GR,247.71,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-polymyxin-dexamethasone 3.5-10000-0.1 Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,61314063136,NDC,3.5,GR,247.71,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-polymyxin-dexamethasone 3.5-10000-0.1 Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,61314063136,NDC,3.5,GR,247.71,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-polymyxin-dexamethasone 3.5-10000-0.1 Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,61314063136,NDC,3.5,GR,247.71,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-polymyxin-dexamethasone 3.5-10000-0.1 Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,61314063136,NDC,3.5,GR,247.71,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-polymyxin-gramicidin 1.75-10000-.025 Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,24208079062,NDC,10,ML,314.26,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-polymyxin-gramicidin 1.75-10000-.025 Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,24208079062,NDC,10,ML,314.26,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-polymyxin-gramicidin 1.75-10000-.025 Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,24208079062,NDC,10,ML,314.26,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-polymyxin-gramicidin 1.75-10000-.025 Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,24208079062,NDC,10,ML,314.26,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-polymyxin-gramicidin 1.75-10000-.025 Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,24208079062,NDC,10,ML,314.26,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-polymyxin-gramicidin 1.75-10000-.025 Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,24208079062,NDC,10,ML,314.26,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Solution 10 mL Bottle,63700001,CDM,250,RC,,,,,,61314064610,NDC,10,ML,433.15,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Solution 10 mL Bottle,63700001,CDM,250,RC,,,,,,61314064610,NDC,10,ML,433.15,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Solution 10 mL Bottle,63700001,CDM,250,RC,,,,,,61314064610,NDC,10,ML,433.15,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Solution 10 mL Bottle,63700001,CDM,250,RC,,,,,,61314064610,NDC,10,ML,433.15,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Solution 10 mL Bottle,63700001,CDM,250,RC,,,,,,61314064610,NDC,10,ML,433.15,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Solution 10 mL Bottle,63700001,CDM,250,RC,,,,,,61314064610,NDC,10,ML,433.15,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Suspension 10 mL Bottle,63700001,CDM,250,RC,,,,,,24208063562,NDC,10,ML,415.81,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Suspension 10 mL Bottle,63700001,CDM,250,RC,,,,,,24208063562,NDC,10,ML,415.81,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Suspension 10 mL Bottle,63700001,CDM,250,RC,,,,,,24208063562,NDC,10,ML,415.81,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Suspension 10 mL Bottle,63700001,CDM,250,RC,,,,,,24208063562,NDC,10,ML,415.81,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Suspension 10 mL Bottle,63700001,CDM,250,RC,,,,,,24208063562,NDC,10,ML,415.81,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Suspension 10 mL Bottle,63700001,CDM,250,RC,,,,,,24208063562,NDC,10,ML,415.81,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Suspension 10 mL Bottle,63700001,CDM,250,RC,,,,,,64980044801,NDC,10,ML,488.25,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Suspension 10 mL Bottle,63700001,CDM,250,RC,,,,,,64980044801,NDC,10,ML,488.25,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Suspension 10 mL Bottle,63700001,CDM,250,RC,,,,,,64980044801,NDC,10,ML,488.25,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Suspension 10 mL Bottle,63700001,CDM,250,RC,,,,,,64980044801,NDC,10,ML,488.25,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Suspension 10 mL Bottle,63700001,CDM,250,RC,,,,,,64980044801,NDC,10,ML,488.25,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Suspension 10 mL Bottle,63700001,CDM,250,RC,,,,,,64980044801,NDC,10,ML,488.25,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,43598052936,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,43598052936,NDC,0.5,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,43598052936,NDC,0.5,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,43598052936,NDC,0.5,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,43598052936,NDC,0.5,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,43598052936,NDC,0.5,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,63323041536,NDC,0.5,ML,44.05,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,63323041536,NDC,0.5,ML,44.05,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,63323041536,NDC,0.5,ML,44.05,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,63323041536,NDC,0.5,ML,44.05,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,63323041536,NDC,0.5,ML,44.05,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,63323041536,NDC,0.5,ML,44.05,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080601,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080601,NDC,0.5,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080601,NDC,0.5,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080601,NDC,0.5,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080601,NDC,0.5,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080601,NDC,0.5,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080610,NDC,0.5,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080610,NDC,0.5,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080610,NDC,0.5,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080610,NDC,0.5,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080610,NDC,0.5,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080610,NDC,0.5,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Nephelometry, Each, Nos - Ref",PX8388390,CDM,300,RC,83883,CPT,90,,,,,,,223,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Nephelometry, Each, Nos - Ref",PX8388390,CDM,300,RC,83883,CPT,90,,,,,,,223,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Nephelometry, Each, Nos - Ref",PX8388390,CDM,300,RC,83883,CPT,90,,,,,,,223,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Nephelometry, Each, Nos - Ref",PX8388390,CDM,300,RC,83883,CPT,90,,,,,,,223,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Nephelometry, Each, Nos - Ref",PX8388390,CDM,300,RC,83883,CPT,90,,,,,,,223,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Nephelometry, Each, Nos - Ref",PX8388390,CDM,300,RC,83883,CPT,90,,,,,,,223,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Neuromuscular Re-Education,PX97112,CDM,420,RC,97112,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Neuromuscular Re-Education,PX97112,CDM,420,RC,97112,CPT,,,,,,,,135,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Neuromuscular Re-Education,PX97112,CDM,420,RC,97112,CPT,,,,,,,,135,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Neuromuscular Re-Education,PX97112,CDM,420,RC,97112,CPT,,,,,,,,135,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Neuromuscular Re-Education,PX97112,CDM,420,RC,97112,CPT,,,,,,,,135,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Neuromuscular Re-Education,PX97112,CDM,420,RC,97112,CPT,,,,,,,,135,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Nfct Ds Bct/Vir Respir Dna/Rna 22 Trgt Sarscov2,PX0202U,CDM,300,RC,0202U,HCPCS,,,,,,,,222,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Nfct Ds Bct/Vir Respir Dna/Rna 22 Trgt Sarscov2,PX0202U,CDM,300,RC,0202U,HCPCS,,,,,,,,222,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Nfct Ds Bct/Vir Respir Dna/Rna 22 Trgt Sarscov2,PX0202U,CDM,300,RC,0202U,HCPCS,,,,,,,,222,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Nfct Ds Bct/Vir Respir Dna/Rna 22 Trgt Sarscov2,PX0202U,CDM,300,RC,0202U,HCPCS,,,,,,,,222,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Nfct Ds Bct/Vir Respir Dna/Rna 22 Trgt Sarscov2,PX0202U,CDM,300,RC,0202U,HCPCS,,,,,,,,222,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Nfct Ds Bct/Vir Respir Dna/Rna 22 Trgt Sarscov2,PX0202U,CDM,300,RC,0202U,HCPCS,,,,,,,,222,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954201,NDC,10,ML,153.18,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954201,NDC,10,ML,153.18,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954201,NDC,10,ML,153.18,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954201,NDC,10,ML,153.18,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954201,NDC,10,ML,153.18,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954201,NDC,10,ML,153.18,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954210,NDC,10,ML,153.18,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954210,NDC,10,ML,153.18,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954210,NDC,10,ML,153.18,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954210,NDC,10,ML,153.18,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954210,NDC,10,ML,153.18,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954210,NDC,10,ML,153.18,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 7 MG/24HR Patch 24 Hour 7 Each Box,63700001,CDM,250,RC,,,,,,43598044670,NDC,1,EA,13.53,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 7 MG/24HR Patch 24 Hour 7 Each Box,63700001,CDM,250,RC,,,,,,43598044670,NDC,1,EA,13.53,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 7 MG/24HR Patch 24 Hour 7 Each Box,63700001,CDM,250,RC,,,,,,43598044670,NDC,1,EA,13.53,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 7 MG/24HR Patch 24 Hour 7 Each Box,63700001,CDM,250,RC,,,,,,43598044670,NDC,1,EA,13.53,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 7 MG/24HR Patch 24 Hour 7 Each Box,63700001,CDM,250,RC,,,,,,43598044670,NDC,1,EA,13.53,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 7 MG/24HR Patch 24 Hour 7 Each Box,63700001,CDM,250,RC,,,,,,43598044670,NDC,1,EA,13.53,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 14 MG/24HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,43598044771,NDC,1,EA,12.08,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 14 MG/24HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,43598044771,NDC,1,EA,12.08,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 14 MG/24HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,43598044771,NDC,1,EA,12.08,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 14 MG/24HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,43598044771,NDC,1,EA,12.08,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 14 MG/24HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,43598044771,NDC,1,EA,12.08,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 14 MG/24HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,43598044771,NDC,1,EA,12.08,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 14 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,43598044774,NDC,1,EA,11.46,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 14 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,43598044774,NDC,1,EA,11.46,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 14 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,43598044774,NDC,1,EA,11.46,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 14 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,43598044774,NDC,1,EA,11.46,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 14 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,43598044774,NDC,1,EA,11.46,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 14 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,43598044774,NDC,1,EA,11.46,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 21 MG/24HR Patch 24 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,43598044871,NDC,1,EA,11.46,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 21 MG/24HR Patch 24 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,43598044871,NDC,1,EA,11.46,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 21 MG/24HR Patch 24 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,43598044871,NDC,1,EA,11.46,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 21 MG/24HR Patch 24 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,43598044871,NDC,1,EA,11.46,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 21 MG/24HR Patch 24 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,43598044871,NDC,1,EA,11.46,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 21 MG/24HR Patch 24 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,43598044871,NDC,1,EA,11.46,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 21 MG/24HR Patch 24 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505706300,NDC,1,EA,13.81,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 21 MG/24HR Patch 24 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505706300,NDC,1,EA,13.81,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 21 MG/24HR Patch 24 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505706300,NDC,1,EA,13.81,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 21 MG/24HR Patch 24 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505706300,NDC,1,EA,13.81,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 21 MG/24HR Patch 24 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505706300,NDC,1,EA,13.81,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 21 MG/24HR Patch 24 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505706300,NDC,1,EA,13.81,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 21 MG/24HR Patch 24 Hour 7 Each Box,63700001,CDM,250,RC,,,,,,536589653,NDC,1,EA,12.84,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 21 MG/24HR Patch 24 Hour 7 Each Box,63700001,CDM,250,RC,,,,,,536589653,NDC,1,EA,12.84,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 21 MG/24HR Patch 24 Hour 7 Each Box,63700001,CDM,250,RC,,,,,,536589653,NDC,1,EA,12.84,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 21 MG/24HR Patch 24 Hour 7 Each Box,63700001,CDM,250,RC,,,,,,536589653,NDC,1,EA,12.84,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 21 MG/24HR Patch 24 Hour 7 Each Box,63700001,CDM,250,RC,,,,,,536589653,NDC,1,EA,12.84,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 21 MG/24HR Patch 24 Hour 7 Each Box,63700001,CDM,250,RC,,,,,,536589653,NDC,1,EA,12.84,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,536110888,NDC,1,EA,11.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,536110888,NDC,1,EA,11.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,536110888,NDC,1,EA,11.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,536110888,NDC,1,EA,11.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,536110888,NDC,1,EA,11.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,536110888,NDC,1,EA,11.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,49348014446,NDC,1,EA,15.3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,49348014446,NDC,1,EA,15.3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,49348014446,NDC,1,EA,15.3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,49348014446,NDC,1,EA,15.3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,49348014446,NDC,1,EA,15.3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,49348014446,NDC,1,EA,15.3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,70677003201,NDC,1,EA,10.16,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,70677003201,NDC,1,EA,10.16,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,70677003201,NDC,1,EA,10.16,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,70677003201,NDC,1,EA,10.16,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,70677003201,NDC,1,EA,10.16,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,70677003201,NDC,1,EA,10.16,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine polacrilex 4 MG Lozenge 24 Each Bottle,63700001,CDM,250,RC,,,,,,113087303,NDC,0.5,EA,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine polacrilex 4 MG Lozenge 24 Each Bottle,63700001,CDM,250,RC,,,,,,113087303,NDC,0.5,EA,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine polacrilex 4 MG Lozenge 24 Each Bottle,63700001,CDM,250,RC,,,,,,113087303,NDC,0.5,EA,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine polacrilex 4 MG Lozenge 24 Each Bottle,63700001,CDM,250,RC,,,,,,113087303,NDC,0.5,EA,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine polacrilex 4 MG Lozenge 24 Each Bottle,63700001,CDM,250,RC,,,,,,113087303,NDC,0.5,EA,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine polacrilex 4 MG Lozenge 24 Each Bottle,63700001,CDM,250,RC,,,,,,113087303,NDC,0.5,EA,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine polacrilex 4 MG Lozenge 24 Each Bottle,63700001,CDM,250,RC,,,,,,43598048772,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine polacrilex 4 MG Lozenge 24 Each Bottle,63700001,CDM,250,RC,,,,,,43598048772,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine polacrilex 4 MG Lozenge 24 Each Bottle,63700001,CDM,250,RC,,,,,,43598048772,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine polacrilex 4 MG Lozenge 24 Each Bottle,63700001,CDM,250,RC,,,,,,43598048772,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine polacrilex 4 MG Lozenge 24 Each Bottle,63700001,CDM,250,RC,,,,,,43598048772,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine polacrilex 4 MG Lozenge 24 Each Bottle,63700001,CDM,250,RC,,,,,,43598048772,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine polacrilex 4 MG Lozenge 72 Each Box,63700001,CDM,250,RC,,,,,,49348085316,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine polacrilex 4 MG Lozenge 72 Each Box,63700001,CDM,250,RC,,,,,,49348085316,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine polacrilex 4 MG Lozenge 72 Each Box,63700001,CDM,250,RC,,,,,,49348085316,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine polacrilex 4 MG Lozenge 72 Each Box,63700001,CDM,250,RC,,,,,,49348085316,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine polacrilex 4 MG Lozenge 72 Each Box,63700001,CDM,250,RC,,,,,,49348085316,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine polacrilex 4 MG Lozenge 72 Each Box,63700001,CDM,250,RC,,,,,,49348085316,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NIFEdipine CR osmotic 30 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,24979001101,NDC,1,EA,5.92,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NIFEdipine CR osmotic 30 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,24979001101,NDC,1,EA,5.92,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NIFEdipine CR osmotic 30 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,24979001101,NDC,1,EA,5.92,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NIFEdipine CR osmotic 30 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,24979001101,NDC,1,EA,5.92,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NIFEdipine CR osmotic 30 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,24979001101,NDC,1,EA,5.92,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NIFEdipine CR osmotic 30 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,24979001101,NDC,1,EA,5.92,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079034801,NDC,1,EA,27.39,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079034801,NDC,1,EA,27.39,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079034801,NDC,1,EA,27.39,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079034801,NDC,1,EA,27.39,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079034801,NDC,1,EA,27.39,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079034801,NDC,1,EA,27.39,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,185012201,NDC,1,EA,17.23,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,185012201,NDC,1,EA,17.23,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,185012201,NDC,1,EA,17.23,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,185012201,NDC,1,EA,17.23,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,185012201,NDC,1,EA,17.23,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,185012201,NDC,1,EA,17.23,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079034820,NDC,1,EA,27.39,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079034820,NDC,1,EA,27.39,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079034820,NDC,1,EA,27.39,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079034820,NDC,1,EA,27.39,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079034820,NDC,1,EA,27.39,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079034820,NDC,1,EA,27.39,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 0.1 MG/HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,378910216,NDC,1,EA,9.98,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 0.1 MG/HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,378910216,NDC,1,EA,9.98,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 0.1 MG/HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,378910216,NDC,1,EA,9.98,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 0.1 MG/HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,378910216,NDC,1,EA,9.98,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 0.1 MG/HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,378910216,NDC,1,EA,9.98,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 0.1 MG/HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,378910216,NDC,1,EA,9.98,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 0.1 MG/HR Patch 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,378910293,NDC,1,EA,9.98,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 0.1 MG/HR Patch 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,378910293,NDC,1,EA,9.98,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 0.1 MG/HR Patch 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,378910293,NDC,1,EA,9.98,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 0.1 MG/HR Patch 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,378910293,NDC,1,EA,9.98,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 0.1 MG/HR Patch 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,378910293,NDC,1,EA,9.98,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 0.1 MG/HR Patch 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,378910293,NDC,1,EA,9.98,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 0.2 MG/HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,378910416,NDC,1,EA,10.21,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 0.2 MG/HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,378910416,NDC,1,EA,10.21,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 0.2 MG/HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,378910416,NDC,1,EA,10.21,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 0.2 MG/HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,378910416,NDC,1,EA,10.21,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 0.2 MG/HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,378910416,NDC,1,EA,10.21,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 0.2 MG/HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,378910416,NDC,1,EA,10.21,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 0.2 MG/HR Patch 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,378910493,NDC,1,EA,10.21,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 0.2 MG/HR Patch 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,378910493,NDC,1,EA,10.21,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 0.2 MG/HR Patch 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,378910493,NDC,1,EA,10.21,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 0.2 MG/HR Patch 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,378910493,NDC,1,EA,10.21,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 0.2 MG/HR Patch 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,378910493,NDC,1,EA,10.21,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 0.2 MG/HR Patch 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,378910493,NDC,1,EA,10.21,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,71041813,NDC,1,EA,5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,71041813,NDC,1,EA,5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,71041813,NDC,1,EA,5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,71041813,NDC,1,EA,5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,71041813,NDC,1,EA,5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,71041813,NDC,1,EA,5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,43598043635,NDC,1,EA,5.46,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,43598043635,NDC,1,EA,5.46,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,43598043635,NDC,1,EA,5.46,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,43598043635,NDC,1,EA,5.46,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,43598043635,NDC,1,EA,5.46,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,43598043635,NDC,1,EA,5.46,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,68462063925,NDC,1,EA,5.51,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,68462063925,NDC,1,EA,5.51,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,68462063925,NDC,1,EA,5.51,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,68462063925,NDC,1,EA,5.51,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,68462063925,NDC,1,EA,5.51,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,68462063925,NDC,1,EA,5.51,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 2 % Ointment 1 g Packet,63700001,CDM,250,RC,,,,,,281032608,NDC,1,GR,17.58,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 2 % Ointment 1 g Packet,63700001,CDM,250,RC,,,,,,281032608,NDC,1,GR,17.58,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 2 % Ointment 1 g Packet,63700001,CDM,250,RC,,,,,,281032608,NDC,1,GR,17.58,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 2 % Ointment 1 g Packet,63700001,CDM,250,RC,,,,,,281032608,NDC,1,GR,17.58,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 2 % Ointment 1 g Packet,63700001,CDM,250,RC,,,,,,281032608,NDC,1,GR,17.58,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 2 % Ointment 1 g Packet,63700001,CDM,250,RC,,,,,,281032608,NDC,1,GR,17.58,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin in dextrose 5% 100-5 MCG/ML-% Solution 250 mL Glass Cont,J2305.01,CDM,636,RC,J2305,HCPCS,,,,338104702,NDC,250,ML,126.07,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin in dextrose 5% 100-5 MCG/ML-% Solution 250 mL Glass Cont,J2305.01,CDM,636,RC,J2305,HCPCS,,,,338104702,NDC,250,ML,126.07,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin in dextrose 5% 100-5 MCG/ML-% Solution 250 mL Glass Cont,J2305.01,CDM,636,RC,J2305,HCPCS,,,,338104702,NDC,250,ML,126.07,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin in dextrose 5% 100-5 MCG/ML-% Solution 250 mL Glass Cont,J2305.01,CDM,636,RC,J2305,HCPCS,,,,338104702,NDC,250,ML,126.07,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin in dextrose 5% 100-5 MCG/ML-% Solution 250 mL Glass Cont,J2305.01,CDM,636,RC,J2305,HCPCS,,,,338104702,NDC,250,ML,126.07,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin in dextrose 5% 100-5 MCG/ML-% Solution 250 mL Glass Cont,J2305.01,CDM,636,RC,J2305,HCPCS,,,,338104702,NDC,250,ML,126.07,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroPRUSSide 25 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,72485010501,NDC,2,ML,186,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroPRUSSide 25 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,72485010501,NDC,2,ML,186,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroPRUSSide 25 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,72485010501,NDC,2,ML,186,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroPRUSSide 25 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,72485010501,NDC,2,ML,186,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroPRUSSide 25 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,72485010501,NDC,2,ML,186,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroPRUSSide 25 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,72485010501,NDC,2,ML,186,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nivolumab 40 MG/4ML Solution 4 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377211,NDC,4,ML,2171.7,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nivolumab 40 MG/4ML Solution 4 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377211,NDC,4,ML,2171.7,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nivolumab 40 MG/4ML Solution 4 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377211,NDC,4,ML,2171.7,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nivolumab 40 MG/4ML Solution 4 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377211,NDC,4,ML,2171.7,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nivolumab 40 MG/4ML Solution 4 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377211,NDC,4,ML,2171.7,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nivolumab 40 MG/4ML Solution 4 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377211,NDC,4,ML,2171.7,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nivolumab 100 MG/10ML Solution 10 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377412,NDC,10,ML,5429.27,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nivolumab 100 MG/10ML Solution 10 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377412,NDC,10,ML,5429.27,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nivolumab 100 MG/10ML Solution 10 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377412,NDC,10,ML,5429.27,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nivolumab 100 MG/10ML Solution 10 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377412,NDC,10,ML,5429.27,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nivolumab 100 MG/10ML Solution 10 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377412,NDC,10,ML,5429.27,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nivolumab 100 MG/10ML Solution 10 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377412,NDC,10,ML,5429.27,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nivolumab 240 MG/24ML Solution 24 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3373413,NDC,24,ML,13030.26,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nivolumab 240 MG/24ML Solution 24 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3373413,NDC,24,ML,13030.26,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nivolumab 240 MG/24ML Solution 24 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3373413,NDC,24,ML,13030.26,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nivolumab 240 MG/24ML Solution 24 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3373413,NDC,24,ML,13030.26,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nivolumab 240 MG/24ML Solution 24 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3373413,NDC,24,ML,13030.26,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nivolumab 240 MG/24ML Solution 24 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3373413,NDC,24,ML,13030.26,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Nocardia Susceptibility - Ref,PX8718690,CDM,300,RC,87186,CPT,90,,,,,,,124,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Nocardia Susceptibility - Ref,PX8718690,CDM,300,RC,87186,CPT,90,,,,,,,124,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Nocardia Susceptibility - Ref,PX8718690,CDM,300,RC,87186,CPT,90,,,,,,,124,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Nocardia Susceptibility - Ref,PX8718690,CDM,300,RC,87186,CPT,90,,,,,,,124,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Nocardia Susceptibility - Ref,PX8718690,CDM,300,RC,87186,CPT,90,,,,,,,124,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Nocardia Susceptibility - Ref,PX8718690,CDM,300,RC,87186,CPT,90,,,,,,,124,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NON-LOCKING SCREW 3.5X12MM,27200000,CDM,278,RC,C1713,HCPCS,,11857-MAIN,LOCAL,,,,,396,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NON-LOCKING SCREW 3.5X12MM,27200000,CDM,278,RC,C1713,HCPCS,,11857-MAIN,LOCAL,,,,,396,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NON-LOCKING SCREW 3.5X12MM,27200000,CDM,278,RC,C1713,HCPCS,,11857-MAIN,LOCAL,,,,,396,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NON-LOCKING SCREW 3.5X12MM,27200000,CDM,278,RC,C1713,HCPCS,,11857-MAIN,LOCAL,,,,,396,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NON-LOCKING SCREW 3.5X12MM,27200000,CDM,278,RC,C1713,HCPCS,,11857-MAIN,LOCAL,,,,,396,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NON-LOCKING SCREW 3.5X12MM,27200000,CDM,278,RC,C1713,HCPCS,,11857-MAIN,LOCAL,,,,,396,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NON-LOCKING SCREW 3.5X16MM,27200000,CDM,278,RC,C1713,HCPCS,,11856-MAIN,LOCAL,,,,,396,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NON-LOCKING SCREW 3.5X16MM,27200000,CDM,278,RC,C1713,HCPCS,,11856-MAIN,LOCAL,,,,,396,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NON-LOCKING SCREW 3.5X16MM,27200000,CDM,278,RC,C1713,HCPCS,,11856-MAIN,LOCAL,,,,,396,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NON-LOCKING SCREW 3.5X16MM,27200000,CDM,278,RC,C1713,HCPCS,,11856-MAIN,LOCAL,,,,,396,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NON-LOCKING SCREW 3.5X16MM,27200000,CDM,278,RC,C1713,HCPCS,,11856-MAIN,LOCAL,,,,,396,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NON-LOCKING SCREW 3.5X16MM,27200000,CDM,278,RC,C1713,HCPCS,,11856-MAIN,LOCAL,,,,,396,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NON-LOCKING SCREW 3.5X18MM,C1713,CDM,278,RC,C1713,HCPCS,,12466-MAIN,LOCAL,,,,,395.51,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NON-LOCKING SCREW 3.5X18MM,C1713,CDM,278,RC,C1713,HCPCS,,12466-MAIN,LOCAL,,,,,395.51,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NON-LOCKING SCREW 3.5X18MM,C1713,CDM,278,RC,C1713,HCPCS,,12466-MAIN,LOCAL,,,,,395.51,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NON-LOCKING SCREW 3.5X18MM,C1713,CDM,278,RC,C1713,HCPCS,,12466-MAIN,LOCAL,,,,,395.51,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NON-LOCKING SCREW 3.5X18MM,C1713,CDM,278,RC,C1713,HCPCS,,12466-MAIN,LOCAL,,,,,395.51,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NON-LOCKING SCREW 3.5X18MM,C1713,CDM,278,RC,C1713,HCPCS,,12466-MAIN,LOCAL,,,,,395.51,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NON-LOCKING SCREW 3.5X24MM,27200000,CDM,278,RC,C1713,HCPCS,,11855-MAIN,LOCAL,,,,,396,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NON-LOCKING SCREW 3.5X24MM,27200000,CDM,278,RC,C1713,HCPCS,,11855-MAIN,LOCAL,,,,,396,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NON-LOCKING SCREW 3.5X24MM,27200000,CDM,278,RC,C1713,HCPCS,,11855-MAIN,LOCAL,,,,,396,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NON-LOCKING SCREW 3.5X24MM,27200000,CDM,278,RC,C1713,HCPCS,,11855-MAIN,LOCAL,,,,,396,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NON-LOCKING SCREW 3.5X24MM,27200000,CDM,278,RC,C1713,HCPCS,,11855-MAIN,LOCAL,,,,,396,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NON-LOCKING SCREW 3.5X24MM,27200000,CDM,278,RC,C1713,HCPCS,,11855-MAIN,LOCAL,,,,,396,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Non-Select. Wound Debride., W/O Anesth.; Top. Appl./Wound Assess./Instruct., per Sess.",PX97602,CDM,761,RC,97602,CPT,,,,,,,,212,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Non-Select. Wound Debride., W/O Anesth.; Top. Appl./Wound Assess./Instruct., per Sess.",PX97602,CDM,761,RC,97602,CPT,,,,,,,,212,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Non-Select. Wound Debride., W/O Anesth.; Top. Appl./Wound Assess./Instruct., per Sess.",PX97602,CDM,761,RC,97602,CPT,,,,,,,,212,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Non-Select. Wound Debride., W/O Anesth.; Top. Appl./Wound Assess./Instruct., per Sess.",PX97602,CDM,761,RC,97602,CPT,,,,,,,,212,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Non-Select. Wound Debride., W/O Anesth.; Top. Appl./Wound Assess./Instruct., per Sess.",PX97602,CDM,761,RC,97602,CPT,,,,,,,,212,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Non-Select. Wound Debride., W/O Anesth.; Top. Appl./Wound Assess./Instruct., per Sess.",PX97602,CDM,761,RC,97602,CPT,,,,,,,,212,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Noninvasv Lo Extrem Art Stress/Rest,PX9392401,CDM,921,RC,93924,CPT,TC,,,,,,,810,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Noninvasv Lo Extrem Art Stress/Rest,PX9392401,CDM,921,RC,93924,CPT,TC,,,,,,,810,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Noninvasv Lo Extrem Art Stress/Rest,PX9392401,CDM,921,RC,93924,CPT,TC,,,,,,,810,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Noninvasv Lo Extrem Art Stress/Rest,PX9392401,CDM,921,RC,93924,CPT,TC,,,,,,,810,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Noninvasv Lo Extrem Art Stress/Rest,PX9392401,CDM,921,RC,93924,CPT,TC,,,,,,,810,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Noninvasv Lo Extrem Art Stress/Rest,PX9392401,CDM,921,RC,93924,CPT,TC,,,,,,,810,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Noninvasv Oxygen Satur;Single,PX94760,CDM,460,RC,94760,CPT,,,,,,,,131,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Noninvasv Oxygen Satur;Single,PX94760,CDM,460,RC,94760,CPT,,,,,,,,131,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Noninvasv Oxygen Satur;Single,PX94760,CDM,460,RC,94760,CPT,,,,,,,,131,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Noninvasv Oxygen Satur;Single,PX94760,CDM,460,RC,94760,CPT,,,,,,,,131,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Noninvasv Oxygen Satur;Single,PX94760,CDM,460,RC,94760,CPT,,,,,,,,131,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Noninvasv Oxygen Satur;Single,PX94760,CDM,460,RC,94760,CPT,,,,,,,,131,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Noninvasv Oxygen Satut,Continuous",PX94762,CDM,460,RC,94762,CPT,,,,,,,,242,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Noninvasv Oxygen Satut,Continuous",PX94762,CDM,460,RC,94762,CPT,,,,,,,,242,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Noninvasv Oxygen Satut,Continuous",PX94762,CDM,460,RC,94762,CPT,,,,,,,,242,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Noninvasv Oxygen Satut,Continuous",PX94762,CDM,460,RC,94762,CPT,,,,,,,,242,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Noninvasv Oxygen Satut,Continuous",PX94762,CDM,460,RC,94762,CPT,,,,,,,,242,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Noninvasv Oxygen Satut,Continuous",PX94762,CDM,460,RC,94762,CPT,,,,,,,,242,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,409337504,NDC,4,ML,150.36,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,409337504,NDC,4,ML,150.36,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,409337504,NDC,4,ML,150.36,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,409337504,NDC,4,ML,150.36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,409337504,NDC,4,ML,150.36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,409337504,NDC,4,ML,150.36,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,703115301,NDC,4,ML,136.1,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,703115301,NDC,4,ML,136.1,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,703115301,NDC,4,ML,136.1,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,703115301,NDC,4,ML,136.1,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,703115301,NDC,4,ML,136.1,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,703115301,NDC,4,ML,136.1,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,781375575,NDC,4,ML,142.22,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,781375575,NDC,4,ML,142.22,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,781375575,NDC,4,ML,142.22,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,781375575,NDC,4,ML,142.22,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,781375575,NDC,4,ML,142.22,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,781375575,NDC,4,ML,142.22,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,63323094004,NDC,4,ML,89.43,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,63323094004,NDC,4,ML,89.43,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,63323094004,NDC,4,ML,89.43,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,63323094004,NDC,4,ML,89.43,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,63323094004,NDC,4,ML,89.43,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,63323094004,NDC,4,ML,89.43,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,63323094021,NDC,4,ML,89.43,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,63323094021,NDC,4,ML,89.43,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,63323094021,NDC,4,ML,89.43,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,63323094021,NDC,4,ML,89.43,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,63323094021,NDC,4,ML,89.43,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,63323094021,NDC,4,ML,89.43,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nortriptyline 25 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,93081101,NDC,0.4,EA,3.15,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nortriptyline 25 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,93081101,NDC,0.4,EA,3.15,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nortriptyline 25 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,93081101,NDC,0.4,EA,3.15,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nortriptyline 25 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,93081101,NDC,0.4,EA,3.15,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nortriptyline 25 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,93081101,NDC,0.4,EA,3.15,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nortriptyline 25 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,93081101,NDC,0.4,EA,3.15,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Novavax Covid-19 Vaccine Administration 1st Dose,PX0041A,CDM,771,RC,0041A,HCPCS,,,,,,,,69,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Novavax Covid-19 Vaccine Administration 1st Dose,PX0041A,CDM,771,RC,0041A,HCPCS,,,,,,,,69,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Novavax Covid-19 Vaccine Administration 1st Dose,PX0041A,CDM,771,RC,0041A,HCPCS,,,,,,,,69,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Novavax Covid-19 Vaccine Administration 1st Dose,PX0041A,CDM,771,RC,0041A,HCPCS,,,,,,,,69,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Novavax Covid-19 Vaccine Administration 1st Dose,PX0041A,CDM,771,RC,0041A,HCPCS,,,,,,,,69,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Novavax Covid-19 Vaccine Administration 1st Dose,PX0041A,CDM,771,RC,0041A,HCPCS,,,,,,,,69,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Novavax Covid-19 Vaccine Administration 2nd Dose,PX0042A,CDM,771,RC,0042A,HCPCS,,,,,,,,69,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Novavax Covid-19 Vaccine Administration 2nd Dose,PX0042A,CDM,771,RC,0042A,HCPCS,,,,,,,,69,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Novavax Covid-19 Vaccine Administration 2nd Dose,PX0042A,CDM,771,RC,0042A,HCPCS,,,,,,,,69,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Novavax Covid-19 Vaccine Administration 2nd Dose,PX0042A,CDM,771,RC,0042A,HCPCS,,,,,,,,69,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Novavax Covid-19 Vaccine Administration 2nd Dose,PX0042A,CDM,771,RC,0042A,HCPCS,,,,,,,,69,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Novavax Covid-19 Vaccine Administration 2nd Dose,PX0042A,CDM,771,RC,0042A,HCPCS,,,,,,,,69,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/GM Cream 30 g Tube,25000000,CDM,250,RC,,,,,,168005430,NDC,30,GR,147.79,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/GM Cream 30 g Tube,25000000,CDM,250,RC,,,,,,168005430,NDC,30,GR,147.79,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/GM Cream 30 g Tube,25000000,CDM,250,RC,,,,,,168005430,NDC,30,GR,147.79,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/GM Cream 30 g Tube,25000000,CDM,250,RC,,,,,,168005430,NDC,30,GR,147.79,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/GM Cream 30 g Tube,25000000,CDM,250,RC,,,,,,168005430,NDC,30,GR,147.79,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/GM Cream 30 g Tube,25000000,CDM,250,RC,,,,,,168005430,NDC,30,GR,147.79,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/GM Cream 30 g Tube,25000000,CDM,250,RC,,,,,,51672128902,NDC,30,GR,148.29,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/GM Cream 30 g Tube,25000000,CDM,250,RC,,,,,,51672128902,NDC,30,GR,148.29,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/GM Cream 30 g Tube,25000000,CDM,250,RC,,,,,,51672128902,NDC,30,GR,148.29,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/GM Cream 30 g Tube,25000000,CDM,250,RC,,,,,,51672128902,NDC,30,GR,148.29,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/GM Cream 30 g Tube,25000000,CDM,250,RC,,,,,,51672128902,NDC,30,GR,148.29,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/GM Cream 30 g Tube,25000000,CDM,250,RC,,,,,,51672128902,NDC,30,GR,148.29,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,574200815,NDC,15,GR,154.63,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,574200815,NDC,15,GR,154.63,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,574200815,NDC,15,GR,154.63,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,574200815,NDC,15,GR,154.63,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,574200815,NDC,15,GR,154.63,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,574200815,NDC,15,GR,154.63,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,16714076901,NDC,15,GR,137.99,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,16714076901,NDC,15,GR,137.99,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,16714076901,NDC,15,GR,137.99,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,16714076901,NDC,15,GR,137.99,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,16714076901,NDC,15,GR,137.99,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,16714076901,NDC,15,GR,137.99,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,69315030615,NDC,15,GR,131.07,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,69315030615,NDC,15,GR,131.07,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,69315030615,NDC,15,GR,131.07,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,69315030615,NDC,15,GR,131.07,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,69315030615,NDC,15,GR,131.07,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,69315030615,NDC,15,GR,131.07,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/GM Powder 60 g Bottle,63700001,CDM,250,RC,,,,,,574200802,NDC,60,GR,491.86,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/GM Powder 60 g Bottle,63700001,CDM,250,RC,,,,,,574200802,NDC,60,GR,491.86,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/GM Powder 60 g Bottle,63700001,CDM,250,RC,,,,,,574200802,NDC,60,GR,491.86,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/GM Powder 60 g Bottle,63700001,CDM,250,RC,,,,,,574200802,NDC,60,GR,491.86,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/GM Powder 60 g Bottle,63700001,CDM,250,RC,,,,,,574200802,NDC,60,GR,491.86,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/GM Powder 60 g Bottle,63700001,CDM,250,RC,,,,,,574200802,NDC,60,GR,491.86,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/GM Powder 60 g Bottle,63700001,CDM,250,RC,,,,,,68308015260,NDC,60,GR,335.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/GM Powder 60 g Bottle,63700001,CDM,250,RC,,,,,,68308015260,NDC,60,GR,335.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/GM Powder 60 g Bottle,63700001,CDM,250,RC,,,,,,68308015260,NDC,60,GR,335.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/GM Powder 60 g Bottle,63700001,CDM,250,RC,,,,,,68308015260,NDC,60,GR,335.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/GM Powder 60 g Bottle,63700001,CDM,250,RC,,,,,,68308015260,NDC,60,GR,335.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/GM Powder 60 g Bottle,63700001,CDM,250,RC,,,,,,68308015260,NDC,60,GR,335.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,121086805,NDC,4,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,121086805,NDC,4,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,121086805,NDC,4,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,121086805,NDC,4,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,121086805,NDC,4,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,121086805,NDC,4,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,121086802,NDC,4,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,121086802,NDC,4,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,121086802,NDC,4,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,121086802,NDC,4,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,121086802,NDC,4,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,121086802,NDC,4,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,50383058766,NDC,60,ML,95.26,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,50383058766,NDC,60,ML,95.26,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,50383058766,NDC,60,ML,95.26,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,50383058766,NDC,60,ML,95.26,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,50383058766,NDC,60,ML,95.26,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,50383058766,NDC,60,ML,95.26,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,60432053760,NDC,60,ML,95.26,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,60432053760,NDC,60,ML,95.26,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,60432053760,NDC,60,ML,95.26,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,60432053760,NDC,60,ML,95.26,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,60432053760,NDC,60,ML,95.26,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,60432053760,NDC,60,ML,95.26,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,66689000802,NDC,4,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,66689000802,NDC,4,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,66689000802,NDC,4,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,66689000802,NDC,4,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,66689000802,NDC,4,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,66689000802,NDC,4,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/ML Suspension 473 mL Bottle,63700001,CDM,250,RC,,,,,,121086816,NDC,4,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/ML Suspension 473 mL Bottle,63700001,CDM,250,RC,,,,,,121086816,NDC,4,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/ML Suspension 473 mL Bottle,63700001,CDM,250,RC,,,,,,121086816,NDC,4,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/ML Suspension 473 mL Bottle,63700001,CDM,250,RC,,,,,,121086816,NDC,4,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/ML Suspension 473 mL Bottle,63700001,CDM,250,RC,,,,,,121086816,NDC,4,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/ML Suspension 473 mL Bottle,63700001,CDM,250,RC,,,,,,121086816,NDC,4,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin-triamcinolone 100000-0.1 UNIT/GM-% Ointment 30 g Tube,25000000,CDM,250,RC,,,,,,52565004230,NDC,30,GR,438.62,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin-triamcinolone 100000-0.1 UNIT/GM-% Ointment 30 g Tube,25000000,CDM,250,RC,,,,,,52565004230,NDC,30,GR,438.62,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin-triamcinolone 100000-0.1 UNIT/GM-% Ointment 30 g Tube,25000000,CDM,250,RC,,,,,,52565004230,NDC,30,GR,438.62,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin-triamcinolone 100000-0.1 UNIT/GM-% Ointment 30 g Tube,25000000,CDM,250,RC,,,,,,52565004230,NDC,30,GR,438.62,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin-triamcinolone 100000-0.1 UNIT/GM-% Ointment 30 g Tube,25000000,CDM,250,RC,,,,,,52565004230,NDC,30,GR,438.62,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin-triamcinolone 100000-0.1 UNIT/GM-% Ointment 30 g Tube,25000000,CDM,250,RC,,,,,,52565004230,NDC,30,GR,438.62,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
O2 SENSOR ADULT ADHESIVE SINGLE PATIENT 040-003382-00,120.576,CDM,272,RC,,,,12930-MAIN,LOCAL,,,,,39,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
O2 SENSOR ADULT ADHESIVE SINGLE PATIENT 040-003382-00,120.576,CDM,272,RC,,,,12930-MAIN,LOCAL,,,,,39,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
O2 SENSOR ADULT ADHESIVE SINGLE PATIENT 040-003382-00,120.576,CDM,272,RC,,,,12930-MAIN,LOCAL,,,,,39,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
O2 SENSOR ADULT ADHESIVE SINGLE PATIENT 040-003382-00,120.576,CDM,272,RC,,,,12930-MAIN,LOCAL,,,,,39,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
O2 SENSOR ADULT ADHESIVE SINGLE PATIENT 040-003382-00,120.576,CDM,272,RC,,,,12930-MAIN,LOCAL,,,,,39,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
O2 SENSOR ADULT ADHESIVE SINGLE PATIENT 040-003382-00,120.576,CDM,272,RC,,,,12930-MAIN,LOCAL,,,,,39,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
O2 SENSOR INFANT ADHESIVE SINGLE PATIENT 040-003384-00,120.576,CDM,272,RC,,,,12932-MAIN,LOCAL,,,,,39,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
O2 SENSOR INFANT ADHESIVE SINGLE PATIENT 040-003384-00,120.576,CDM,272,RC,,,,12932-MAIN,LOCAL,,,,,39,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
O2 SENSOR INFANT ADHESIVE SINGLE PATIENT 040-003384-00,120.576,CDM,272,RC,,,,12932-MAIN,LOCAL,,,,,39,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
O2 SENSOR INFANT ADHESIVE SINGLE PATIENT 040-003384-00,120.576,CDM,272,RC,,,,12932-MAIN,LOCAL,,,,,39,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
O2 SENSOR INFANT ADHESIVE SINGLE PATIENT 040-003384-00,120.576,CDM,272,RC,,,,12932-MAIN,LOCAL,,,,,39,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
O2 SENSOR INFANT ADHESIVE SINGLE PATIENT 040-003384-00,120.576,CDM,272,RC,,,,12932-MAIN,LOCAL,,,,,39,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
O2 SENSOR PEDIATRIC ADHESIVE SINGLE PATIENT 040-003383-00,120.576,CDM,272,RC,,,,12931-MAIN,LOCAL,,,,,39,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
O2 SENSOR PEDIATRIC ADHESIVE SINGLE PATIENT 040-003383-00,120.576,CDM,272,RC,,,,12931-MAIN,LOCAL,,,,,39,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
O2 SENSOR PEDIATRIC ADHESIVE SINGLE PATIENT 040-003383-00,120.576,CDM,272,RC,,,,12931-MAIN,LOCAL,,,,,39,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
O2 SENSOR PEDIATRIC ADHESIVE SINGLE PATIENT 040-003383-00,120.576,CDM,272,RC,,,,12931-MAIN,LOCAL,,,,,39,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
O2 SENSOR PEDIATRIC ADHESIVE SINGLE PATIENT 040-003383-00,120.576,CDM,272,RC,,,,12931-MAIN,LOCAL,,,,,39,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
O2 SENSOR PEDIATRIC ADHESIVE SINGLE PATIENT 040-003383-00,120.576,CDM,272,RC,,,,12931-MAIN,LOCAL,,,,,39,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"OB US < 14 Wks, Single Fetus - Radiology, Tech",PX7680101,CDM,402,RC,76801,CPT,TC,,,,,,,472,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"OB US < 14 Wks, Single Fetus - Radiology, Tech",PX7680101,CDM,402,RC,76801,CPT,TC,,,,,,,472,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"OB US < 14 Wks, Single Fetus - Radiology, Tech",PX7680101,CDM,402,RC,76801,CPT,TC,,,,,,,472,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"OB US < 14 Wks, Single Fetus - Radiology, Tech",PX7680101,CDM,402,RC,76801,CPT,TC,,,,,,,472,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"OB US < 14 Wks, Single Fetus - Radiology, Tech",PX7680101,CDM,402,RC,76801,CPT,TC,,,,,,,472,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"OB US < 14 Wks, Single Fetus - Radiology, Tech",PX7680101,CDM,402,RC,76801,CPT,TC,,,,,,,472,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OBINutuzumab 1000 MG/40ML Solution 40 mL Vial,J9301.01,CDM,636,RC,J9301,HCPCS,,,,50242007001,NDC,4,ML,1397.15,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OBINutuzumab 1000 MG/40ML Solution 40 mL Vial,J9301.01,CDM,636,RC,J9301,HCPCS,,,,50242007001,NDC,4,ML,1397.15,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OBINutuzumab 1000 MG/40ML Solution 40 mL Vial,J9301.01,CDM,636,RC,J9301,HCPCS,,,,50242007001,NDC,4,ML,1397.15,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OBINutuzumab 1000 MG/40ML Solution 40 mL Vial,J9301.01,CDM,636,RC,J9301,HCPCS,,,,50242007001,NDC,4,ML,1397.15,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OBINutuzumab 1000 MG/40ML Solution 40 mL Vial,J9301.01,CDM,636,RC,J9301,HCPCS,,,,50242007001,NDC,4,ML,1397.15,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OBINutuzumab 1000 MG/40ML Solution 40 mL Vial,J9301.01,CDM,636,RC,J9301,HCPCS,,,,50242007001,NDC,4,ML,1397.15,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Observation Care Discharge,PX99217,CDM,982,RC,99217,CPT,,,,,,,,222,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Observation Care Discharge,PX99217,CDM,982,RC,99217,CPT,,,,,,,,222,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Observation Care Discharge,PX99217,CDM,982,RC,99217,CPT,,,,,,,,222,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Observation Care Discharge,PX99217,CDM,982,RC,99217,CPT,,,,,,,,222,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Observation Care Discharge,PX99217,CDM,982,RC,99217,CPT,,,,,,,,222,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Observation Care Discharge,PX99217,CDM,982,RC,99217,CPT,,,,,,,,222,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Observation Initial,PXG0378.03,CDM,762,RC,G0378,HCPCS,,,,,,,,680,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Observation Initial,PXG0378.03,CDM,762,RC,G0378,HCPCS,,,,,,,,680,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Observation Initial,PXG0378.03,CDM,762,RC,G0378,HCPCS,,,,,,,,680,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Observation Initial,PXG0378.03,CDM,762,RC,G0378,HCPCS,,,,,,,,680,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Observation Initial,PXG0378.03,CDM,762,RC,G0378,HCPCS,,,,,,,,680,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Observation Initial,PXG0378.03,CDM,762,RC,G0378,HCPCS,,,,,,,,680,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Occupational Therapy Eval High Complex,PX97167,CDM,434,RC,97167,CPT,,,,,,,,289,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Occupational Therapy Eval High Complex,PX97167,CDM,434,RC,97167,CPT,,,,,,,,289,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Occupational Therapy Eval High Complex,PX97167,CDM,434,RC,97167,CPT,,,,,,,,289,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Occupational Therapy Eval High Complex,PX97167,CDM,434,RC,97167,CPT,,,,,,,,289,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Occupational Therapy Eval High Complex,PX97167,CDM,434,RC,97167,CPT,,,,,,,,289,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Occupational Therapy Eval High Complex,PX97167,CDM,434,RC,97167,CPT,,,,,,,,289,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Occupational Therapy Eval Low Complex,PX97165,CDM,434,RC,97165,CPT,,,,,,,,235,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Occupational Therapy Eval Low Complex,PX97165,CDM,434,RC,97165,CPT,,,,,,,,235,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Occupational Therapy Eval Low Complex,PX97165,CDM,434,RC,97165,CPT,,,,,,,,235,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Occupational Therapy Eval Low Complex,PX97165,CDM,434,RC,97165,CPT,,,,,,,,235,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Occupational Therapy Eval Low Complex,PX97165,CDM,434,RC,97165,CPT,,,,,,,,235,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Occupational Therapy Eval Low Complex,PX97165,CDM,434,RC,97165,CPT,,,,,,,,235,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Occupational Therapy Eval Mod Complex,PX97166,CDM,434,RC,97166,CPT,,,,,,,,264,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Occupational Therapy Eval Mod Complex,PX97166,CDM,434,RC,97166,CPT,,,,,,,,264,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Occupational Therapy Eval Mod Complex,PX97166,CDM,434,RC,97166,CPT,,,,,,,,264,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Occupational Therapy Eval Mod Complex,PX97166,CDM,434,RC,97166,CPT,,,,,,,,264,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Occupational Therapy Eval Mod Complex,PX97166,CDM,434,RC,97166,CPT,,,,,,,,264,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Occupational Therapy Eval Mod Complex,PX97166,CDM,434,RC,97166,CPT,,,,,,,,264,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ocrelizumab 300 MG/10ML Solution 10 mL Vial,J2350.01,CDM,636,RC,J2350,HCPCS,,,,50242015001,NDC,10,ML,33150,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ocrelizumab 300 MG/10ML Solution 10 mL Vial,J2350.01,CDM,636,RC,J2350,HCPCS,,,,50242015001,NDC,10,ML,33150,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ocrelizumab 300 MG/10ML Solution 10 mL Vial,J2350.01,CDM,636,RC,J2350,HCPCS,,,,50242015001,NDC,10,ML,33150,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ocrelizumab 300 MG/10ML Solution 10 mL Vial,J2350.01,CDM,636,RC,J2350,HCPCS,,,,50242015001,NDC,10,ML,33150,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ocrelizumab 300 MG/10ML Solution 10 mL Vial,J2350.01,CDM,636,RC,J2350,HCPCS,,,,50242015001,NDC,10,ML,33150,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ocrelizumab 300 MG/10ML Solution 10 mL Vial,J2350.01,CDM,636,RC,J2350,HCPCS,,,,50242015001,NDC,10,ML,33150,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703331101,NDC,0.75,ML,51.41,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703331101,NDC,0.75,ML,51.41,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703331101,NDC,0.75,ML,51.41,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703331101,NDC,0.75,ML,51.41,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703331101,NDC,0.75,ML,51.41,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703331101,NDC,0.75,ML,51.41,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037601,NDC,1,ML,76.9,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037601,NDC,1,ML,76.9,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037601,NDC,1,ML,76.9,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037601,NDC,1,ML,76.9,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037601,NDC,1,ML,76.9,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037601,NDC,1,ML,76.9,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037604,NDC,0.75,ML,36.86,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037604,NDC,0.75,ML,36.86,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037604,NDC,0.75,ML,36.86,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037604,NDC,0.75,ML,36.86,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037604,NDC,0.75,ML,36.86,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037604,NDC,0.75,ML,36.86,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
octreotide 200 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037805,NDC,1,ML,133.77,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
octreotide 200 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037805,NDC,1,ML,133.77,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
octreotide 200 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037805,NDC,1,ML,133.77,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
octreotide 200 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037805,NDC,1,ML,133.77,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
octreotide 200 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037805,NDC,1,ML,133.77,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
octreotide 200 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037805,NDC,1,ML,133.77,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703334301,NDC,0.5,ML,142.98,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703334301,NDC,0.5,ML,142.98,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703334301,NDC,0.5,ML,142.98,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703334301,NDC,0.5,ML,142.98,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703334301,NDC,0.5,ML,142.98,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703334301,NDC,0.5,ML,142.98,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037905,NDC,0.5,ML,229.88,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037905,NDC,0.5,ML,229.88,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037905,NDC,0.5,ML,229.88,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037905,NDC,0.5,ML,229.88,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037905,NDC,0.5,ML,229.88,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037905,NDC,0.5,ML,229.88,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Off/Outpt Visit,New,Levl III",PX99203P,CDM,983,RC,99203,CPT,,,,,,,,252,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Off/Outpt Visit,New,Levl III",PX99203P,CDM,983,RC,99203,CPT,,,,,,,,252,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Off/Outpt Visit,New,Levl III",PX99203P,CDM,983,RC,99203,CPT,,,,,,,,252,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Off/Outpt Visit,New,Levl III",PX99203P,CDM,983,RC,99203,CPT,,,,,,,,252,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Off/Outpt Visit,New,Levl III",PX99203P,CDM,983,RC,99203,CPT,,,,,,,,252,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Off/Outpt Visit,New,Levl III",PX99203P,CDM,983,RC,99203,CPT,,,,,,,,252,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office Consultation,Level III",PX99243P,CDM,983,RC,99243,CPT,,,,,,,,374,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office Consultation,Level III",PX99243P,CDM,983,RC,99243,CPT,,,,,,,,374,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office Consultation,Level III",PX99243P,CDM,983,RC,99243,CPT,,,,,,,,374,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office Consultation,Level III",PX99243P,CDM,983,RC,99243,CPT,,,,,,,,374,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office Consultation,Level III",PX99243P,CDM,983,RC,99243,CPT,,,,,,,,374,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office Consultation,Level III",PX99243P,CDM,983,RC,99243,CPT,,,,,,,,374,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office Consultation,Level IV",PX99244P,CDM,983,RC,99244,CPT,,,,,,,,441,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office Consultation,Level IV",PX99244P,CDM,983,RC,99244,CPT,,,,,,,,441,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office Consultation,Level IV",PX99244P,CDM,983,RC,99244,CPT,,,,,,,,441,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office Consultation,Level IV",PX99244P,CDM,983,RC,99244,CPT,,,,,,,,441,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office Consultation,Level IV",PX99244P,CDM,983,RC,99244,CPT,,,,,,,,441,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office Consultation,Level IV",PX99244P,CDM,983,RC,99244,CPT,,,,,,,,441,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Office/Outpt Visit Est Level I,PX99211F,CDM,510,RC,99211,CPT,,,,,,,,119,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Office/Outpt Visit Est Level I,PX99211F,CDM,510,RC,99211,CPT,,,,,,,,119,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Office/Outpt Visit Est Level I,PX99211F,CDM,510,RC,99211,CPT,,,,,,,,119,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Office/Outpt Visit Est Level I,PX99211F,CDM,510,RC,99211,CPT,,,,,,,,119,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Office/Outpt Visit Est Level I,PX99211F,CDM,510,RC,99211,CPT,,,,,,,,119,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Office/Outpt Visit Est Level I,PX99211F,CDM,510,RC,99211,CPT,,,,,,,,119,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Office/Outpt Visit Est Level I,PX99211P,CDM,983,RC,99211,CPT,,,,,,,,119,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Office/Outpt Visit Est Level I,PX99211P,CDM,983,RC,99211,CPT,,,,,,,,119,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Office/Outpt Visit Est Level I,PX99211P,CDM,983,RC,99211,CPT,,,,,,,,119,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Office/Outpt Visit Est Level I,PX99211P,CDM,983,RC,99211,CPT,,,,,,,,119,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Office/Outpt Visit Est Level I,PX99211P,CDM,983,RC,99211,CPT,,,,,,,,119,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Office/Outpt Visit Est Level I,PX99211P,CDM,983,RC,99211,CPT,,,,,,,,119,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl II",PX99212F,CDM,510,RC,99212,CPT,,,,,,,,155,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl II",PX99212F,CDM,510,RC,99212,CPT,,,,,,,,155,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl II",PX99212F,CDM,510,RC,99212,CPT,,,,,,,,155,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl II",PX99212F,CDM,510,RC,99212,CPT,,,,,,,,155,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl II",PX99212F,CDM,510,RC,99212,CPT,,,,,,,,155,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl II",PX99212F,CDM,510,RC,99212,CPT,,,,,,,,155,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl II",PX99212P,CDM,983,RC,99212,CPT,,,,,,,,155,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl II",PX99212P,CDM,983,RC,99212,CPT,,,,,,,,155,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl II",PX99212P,CDM,983,RC,99212,CPT,,,,,,,,155,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl II",PX99212P,CDM,983,RC,99212,CPT,,,,,,,,155,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl II",PX99212P,CDM,983,RC,99212,CPT,,,,,,,,155,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl II",PX99212P,CDM,983,RC,99212,CPT,,,,,,,,155,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl III",PX99213F,CDM,510,RC,99213,CPT,,,,,,,,185,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl III",PX99213F,CDM,510,RC,99213,CPT,,,,,,,,185,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl III",PX99213F,CDM,510,RC,99213,CPT,,,,,,,,185,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl III",PX99213F,CDM,510,RC,99213,CPT,,,,,,,,185,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl III",PX99213F,CDM,510,RC,99213,CPT,,,,,,,,185,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl III",PX99213F,CDM,510,RC,99213,CPT,,,,,,,,185,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl III",PX99213P,CDM,983,RC,99213,CPT,,,,,,,,185,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl III",PX99213P,CDM,983,RC,99213,CPT,,,,,,,,185,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl III",PX99213P,CDM,983,RC,99213,CPT,,,,,,,,185,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl III",PX99213P,CDM,983,RC,99213,CPT,,,,,,,,185,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl III",PX99213P,CDM,983,RC,99213,CPT,,,,,,,,185,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl III",PX99213P,CDM,983,RC,99213,CPT,,,,,,,,185,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl IV",PX99214F,CDM,510,RC,99214,CPT,,,,,,,,256,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl IV",PX99214F,CDM,510,RC,99214,CPT,,,,,,,,256,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl IV",PX99214F,CDM,510,RC,99214,CPT,,,,,,,,256,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl IV",PX99214F,CDM,510,RC,99214,CPT,,,,,,,,256,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl IV",PX99214F,CDM,510,RC,99214,CPT,,,,,,,,256,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl IV",PX99214F,CDM,510,RC,99214,CPT,,,,,,,,256,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl IV",PX99214P,CDM,983,RC,99214,CPT,,,,,,,,256,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl IV",PX99214P,CDM,983,RC,99214,CPT,,,,,,,,256,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl IV",PX99214P,CDM,983,RC,99214,CPT,,,,,,,,256,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl IV",PX99214P,CDM,983,RC,99214,CPT,,,,,,,,256,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl IV",PX99214P,CDM,983,RC,99214,CPT,,,,,,,,256,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl IV",PX99214P,CDM,983,RC,99214,CPT,,,,,,,,256,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl V",PX99215F,CDM,510,RC,99215,CPT,,,,,,,,318,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl V",PX99215F,CDM,510,RC,99215,CPT,,,,,,,,318,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl V",PX99215F,CDM,510,RC,99215,CPT,,,,,,,,318,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl V",PX99215F,CDM,510,RC,99215,CPT,,,,,,,,318,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl V",PX99215F,CDM,510,RC,99215,CPT,,,,,,,,318,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl V",PX99215F,CDM,510,RC,99215,CPT,,,,,,,,318,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl V",PX99215P,CDM,983,RC,99215,CPT,,,,,,,,318,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl V",PX99215P,CDM,983,RC,99215,CPT,,,,,,,,318,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl V",PX99215P,CDM,983,RC,99215,CPT,,,,,,,,318,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl V",PX99215P,CDM,983,RC,99215,CPT,,,,,,,,318,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl V",PX99215P,CDM,983,RC,99215,CPT,,,,,,,,318,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl V",PX99215P,CDM,983,RC,99215,CPT,,,,,,,,318,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl II",PX99202F,CDM,510,RC,99202,CPT,,,,,,,,123,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl II",PX99202F,CDM,510,RC,99202,CPT,,,,,,,,123,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl II",PX99202F,CDM,510,RC,99202,CPT,,,,,,,,123,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl II",PX99202F,CDM,510,RC,99202,CPT,,,,,,,,123,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl II",PX99202F,CDM,510,RC,99202,CPT,,,,,,,,123,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl II",PX99202F,CDM,510,RC,99202,CPT,,,,,,,,123,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl II",PX99202P,CDM,983,RC,99202,CPT,,,,,,,,123,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl II",PX99202P,CDM,983,RC,99202,CPT,,,,,,,,123,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl II",PX99202P,CDM,983,RC,99202,CPT,,,,,,,,123,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl II",PX99202P,CDM,983,RC,99202,CPT,,,,,,,,123,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl II",PX99202P,CDM,983,RC,99202,CPT,,,,,,,,123,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl II",PX99202P,CDM,983,RC,99202,CPT,,,,,,,,123,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl III",PX99203F,CDM,510,RC,99203,CPT,,,,,,,,252,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl III",PX99203F,CDM,510,RC,99203,CPT,,,,,,,,252,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl III",PX99203F,CDM,510,RC,99203,CPT,,,,,,,,252,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl III",PX99203F,CDM,510,RC,99203,CPT,,,,,,,,252,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl III",PX99203F,CDM,510,RC,99203,CPT,,,,,,,,252,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl III",PX99203F,CDM,510,RC,99203,CPT,,,,,,,,252,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl IV",PX99204F,CDM,510,RC,99204,CPT,,,,,,,,359,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl IV",PX99204F,CDM,510,RC,99204,CPT,,,,,,,,359,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl IV",PX99204F,CDM,510,RC,99204,CPT,,,,,,,,359,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl IV",PX99204F,CDM,510,RC,99204,CPT,,,,,,,,359,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl IV",PX99204F,CDM,510,RC,99204,CPT,,,,,,,,359,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl IV",PX99204F,CDM,510,RC,99204,CPT,,,,,,,,359,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl IV",PX99204P,CDM,983,RC,99204,CPT,,,,,,,,359,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl IV",PX99204P,CDM,983,RC,99204,CPT,,,,,,,,359,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl IV",PX99204P,CDM,983,RC,99204,CPT,,,,,,,,359,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl IV",PX99204P,CDM,983,RC,99204,CPT,,,,,,,,359,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl IV",PX99204P,CDM,983,RC,99204,CPT,,,,,,,,359,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl IV",PX99204P,CDM,983,RC,99204,CPT,,,,,,,,359,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl V",PX99205F,CDM,510,RC,99205,CPT,,,,,,,,456,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl V",PX99205F,CDM,510,RC,99205,CPT,,,,,,,,456,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl V",PX99205F,CDM,510,RC,99205,CPT,,,,,,,,456,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl V",PX99205F,CDM,510,RC,99205,CPT,,,,,,,,456,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl V",PX99205F,CDM,510,RC,99205,CPT,,,,,,,,456,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl V",PX99205F,CDM,510,RC,99205,CPT,,,,,,,,456,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl V",PX99205P,CDM,983,RC,99205,CPT,,,,,,,,456,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl V",PX99205P,CDM,983,RC,99205,CPT,,,,,,,,456,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl V",PX99205P,CDM,983,RC,99205,CPT,,,,,,,,456,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl V",PX99205P,CDM,983,RC,99205,CPT,,,,,,,,456,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl V",PX99205P,CDM,983,RC,99205,CPT,,,,,,,,456,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl V",PX99205P,CDM,983,RC,99205,CPT,,,,,,,,456,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ofloxacin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,17478071310,NDC,5,ML,117.89,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ofloxacin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,17478071310,NDC,5,ML,117.89,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ofloxacin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,17478071310,NDC,5,ML,117.89,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ofloxacin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,17478071310,NDC,5,ML,117.89,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ofloxacin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,17478071310,NDC,5,ML,117.89,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ofloxacin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,17478071310,NDC,5,ML,117.89,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OLANZapine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60505311000,NDC,1,EA,60.13,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OLANZapine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60505311000,NDC,1,EA,60.13,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OLANZapine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60505311000,NDC,1,EA,60.13,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OLANZapine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60505311000,NDC,1,EA,60.13,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OLANZapine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60505311000,NDC,1,EA,60.13,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OLANZapine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60505311000,NDC,1,EA,60.13,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,517095501,NDC,0.25,EA,69.19,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,517095501,NDC,0.25,EA,69.19,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,517095501,NDC,0.25,EA,69.19,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,517095501,NDC,0.25,EA,69.19,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,517095501,NDC,0.25,EA,69.19,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,517095501,NDC,0.25,EA,69.19,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781315972,NDC,1,EA,217.96,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781315972,NDC,1,EA,217.96,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781315972,NDC,1,EA,217.96,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781315972,NDC,1,EA,217.96,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781315972,NDC,1,EA,217.96,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781315972,NDC,1,EA,217.96,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781910572,NDC,0.25,EA,69.49,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781910572,NDC,0.25,EA,69.49,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781910572,NDC,0.25,EA,69.49,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781910572,NDC,0.25,EA,69.49,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781910572,NDC,0.25,EA,69.49,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781910572,NDC,0.25,EA,69.49,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Oligoclonal Bands - Ref,PX8391690,CDM,300,RC,83916,CPT,90,,,,,,,124,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Oligoclonal Bands - Ref,PX8391690,CDM,300,RC,83916,CPT,90,,,,,,,124,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Oligoclonal Bands - Ref,PX8391690,CDM,300,RC,83916,CPT,90,,,,,,,124,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Oligoclonal Bands - Ref,PX8391690,CDM,300,RC,83916,CPT,90,,,,,,,124,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Oligoclonal Bands - Ref,PX8391690,CDM,300,RC,83916,CPT,90,,,,,,,124,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Oligoclonal Bands - Ref,PX8391690,CDM,300,RC,83916,CPT,90,,,,,,,124,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
olmesartan 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862074330,NDC,0.125,EA,6.45,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
olmesartan 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862074330,NDC,0.125,EA,6.45,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
olmesartan 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862074330,NDC,0.125,EA,6.45,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
olmesartan 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862074330,NDC,0.125,EA,6.45,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
olmesartan 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862074330,NDC,0.125,EA,6.45,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
olmesartan 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862074330,NDC,0.125,EA,6.45,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
omalizumab 150 MG Recon Soln 1 Each Vial,J2357.01,CDM,636,RC,J2357,HCPCS,,,,50242004062,NDC,1,EA,2212.7,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
omalizumab 150 MG Recon Soln 1 Each Vial,J2357.01,CDM,636,RC,J2357,HCPCS,,,,50242004062,NDC,1,EA,2212.7,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
omalizumab 150 MG Recon Soln 1 Each Vial,J2357.01,CDM,636,RC,J2357,HCPCS,,,,50242004062,NDC,1,EA,2212.7,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
omalizumab 150 MG Recon Soln 1 Each Vial,J2357.01,CDM,636,RC,J2357,HCPCS,,,,50242004062,NDC,1,EA,2212.7,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
omalizumab 150 MG Recon Soln 1 Each Vial,J2357.01,CDM,636,RC,J2357,HCPCS,,,,50242004062,NDC,1,EA,2212.7,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
omalizumab 150 MG Recon Soln 1 Each Vial,J2357.01,CDM,636,RC,J2357,HCPCS,,,,50242004062,NDC,1,EA,2212.7,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
omeprazole 20 MG CAPSULE DELAYED RELEASE 1 Each Blister,63700001,CDM,250,RC,,,,,,68084012811,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
omeprazole 20 MG CAPSULE DELAYED RELEASE 1 Each Blister,63700001,CDM,250,RC,,,,,,68084012811,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
omeprazole 20 MG CAPSULE DELAYED RELEASE 1 Each Blister,63700001,CDM,250,RC,,,,,,68084012811,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
omeprazole 20 MG CAPSULE DELAYED RELEASE 1 Each Blister,63700001,CDM,250,RC,,,,,,68084012811,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
omeprazole 20 MG CAPSULE DELAYED RELEASE 1 Each Blister,63700001,CDM,250,RC,,,,,,68084012811,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
omeprazole 20 MG CAPSULE DELAYED RELEASE 1 Each Blister,63700001,CDM,250,RC,,,,,,68084012811,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,904691761,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,904691761,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,904691761,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,904691761,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,904691761,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,904691761,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,63739035810,NDC,0.5,EA,7.85,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,63739035810,NDC,0.5,EA,7.85,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,63739035810,NDC,0.5,EA,7.85,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,63739035810,NDC,0.5,EA,7.85,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,63739035810,NDC,0.5,EA,7.85,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,63739035810,NDC,0.5,EA,7.85,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,68084012801,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,68084012801,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,68084012801,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,68084012801,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,68084012801,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,68084012801,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ON Q PAIN BUSTER,27100000,CDM,271,RC,A4305,HCPCS,,6751-MAIN,LOCAL,,,,,194.26,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ON Q PAIN BUSTER,27100000,CDM,271,RC,A4305,HCPCS,,6751-MAIN,LOCAL,,,,,194.26,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ON Q PAIN BUSTER,27100000,CDM,271,RC,A4305,HCPCS,,6751-MAIN,LOCAL,,,,,194.26,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ON Q PAIN BUSTER,27100000,CDM,271,RC,A4305,HCPCS,,6751-MAIN,LOCAL,,,,,194.26,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ON Q PAIN BUSTER,27100000,CDM,271,RC,A4305,HCPCS,,6751-MAIN,LOCAL,,,,,194.26,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ON Q PAIN BUSTER,27100000,CDM,271,RC,A4305,HCPCS,,6751-MAIN,LOCAL,,,,,194.26,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
onabotulinumtoxinA 50 units Recon Soln 1 Each Vial,J0585.03,CDM,636,RC,J0585,HCPCS,,,,23391950,NDC,1,EA,1418.14,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
onabotulinumtoxinA 50 units Recon Soln 1 Each Vial,J0585.03,CDM,636,RC,J0585,HCPCS,,,,23391950,NDC,1,EA,1418.14,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
onabotulinumtoxinA 50 units Recon Soln 1 Each Vial,J0585.03,CDM,636,RC,J0585,HCPCS,,,,23391950,NDC,1,EA,1418.14,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
onabotulinumtoxinA 50 units Recon Soln 1 Each Vial,J0585.03,CDM,636,RC,J0585,HCPCS,,,,23391950,NDC,1,EA,1418.14,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
onabotulinumtoxinA 50 units Recon Soln 1 Each Vial,J0585.03,CDM,636,RC,J0585,HCPCS,,,,23391950,NDC,1,EA,1418.14,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
onabotulinumtoxinA 50 units Recon Soln 1 Each Vial,J0585.03,CDM,636,RC,J0585,HCPCS,,,,23391950,NDC,1,EA,1418.14,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
onabotulinumtoxinA 100 units Recon Soln 1 Each Vial,J0585.01,CDM,636,RC,J0585,HCPCS,,,,23114501,NDC,1,EA,2348.77,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
onabotulinumtoxinA 100 units Recon Soln 1 Each Vial,J0585.01,CDM,636,RC,J0585,HCPCS,,,,23114501,NDC,1,EA,2348.77,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
onabotulinumtoxinA 100 units Recon Soln 1 Each Vial,J0585.01,CDM,636,RC,J0585,HCPCS,,,,23114501,NDC,1,EA,2348.77,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
onabotulinumtoxinA 100 units Recon Soln 1 Each Vial,J0585.01,CDM,636,RC,J0585,HCPCS,,,,23114501,NDC,1,EA,2348.77,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
onabotulinumtoxinA 100 units Recon Soln 1 Each Vial,J0585.01,CDM,636,RC,J0585,HCPCS,,,,23114501,NDC,1,EA,2348.77,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
onabotulinumtoxinA 100 units Recon Soln 1 Each Vial,J0585.01,CDM,636,RC,J0585,HCPCS,,,,23114501,NDC,1,EA,2348.77,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,781523806,NDC,1,EA,106.34,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,781523806,NDC,1,EA,106.34,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,781523806,NDC,1,EA,106.34,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,781523806,NDC,1,EA,106.34,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,781523806,NDC,1,EA,106.34,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,781523806,NDC,1,EA,106.34,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714020010,NDC,1,EA,107.64,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714020010,NDC,1,EA,107.64,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714020010,NDC,1,EA,107.64,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714020010,NDC,1,EA,107.64,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714020010,NDC,1,EA,107.64,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714020010,NDC,1,EA,107.64,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,68462015740,NDC,1,EA,110.25,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,68462015740,NDC,1,EA,110.25,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,68462015740,NDC,1,EA,110.25,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,68462015740,NDC,1,EA,110.25,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,68462015740,NDC,1,EA,110.25,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,68462015740,NDC,1,EA,110.25,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,781523864,NDC,1,EA,106.34,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,781523864,NDC,1,EA,106.34,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,781523864,NDC,1,EA,106.34,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,781523864,NDC,1,EA,106.34,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,781523864,NDC,1,EA,106.34,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,781523864,NDC,1,EA,106.34,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714020030,NDC,1,EA,107.64,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714020030,NDC,1,EA,107.64,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714020030,NDC,1,EA,107.64,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714020030,NDC,1,EA,107.64,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714020030,NDC,1,EA,107.64,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714020030,NDC,1,EA,107.64,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,65862039010,NDC,1,EA,106.34,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,65862039010,NDC,1,EA,106.34,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,65862039010,NDC,1,EA,106.34,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,65862039010,NDC,1,EA,106.34,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,65862039010,NDC,1,EA,106.34,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,65862039010,NDC,1,EA,106.34,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,68462015713,NDC,1,EA,110.25,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,68462015713,NDC,1,EA,110.25,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,68462015713,NDC,1,EA,110.25,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,68462015713,NDC,1,EA,110.25,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,68462015713,NDC,1,EA,110.25,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,68462015713,NDC,1,EA,110.25,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,409475503,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,409475503,NDC,2,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,409475503,NDC,2,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,409475503,NDC,2,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,409475503,NDC,2,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,409475503,NDC,2,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054731,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054731,NDC,2,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054731,NDC,2,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054731,NDC,2,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054731,NDC,2,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054731,NDC,2,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054831,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054831,NDC,2,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054831,NDC,2,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054831,NDC,2,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054831,NDC,2,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054831,NDC,2,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054842,NDC,2,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054842,NDC,2,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054842,NDC,2,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054842,NDC,2,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054842,NDC,2,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054842,NDC,2,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG/5ML Solution 25 mL Bottle,S0119.01,CDM,636,RC,S0119,HCPCS,,,,99998-8001-,NDC,25,ML,494.57,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG/5ML Solution 25 mL Bottle,S0119.01,CDM,636,RC,S0119,HCPCS,,,,99998-8001-,NDC,25,ML,494.57,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG/5ML Solution 25 mL Bottle,S0119.01,CDM,636,RC,S0119,HCPCS,,,,99998-8001-,NDC,25,ML,494.57,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG/5ML Solution 25 mL Bottle,S0119.01,CDM,636,RC,S0119,HCPCS,,,,99998-8001-,NDC,25,ML,494.57,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG/5ML Solution 25 mL Bottle,S0119.01,CDM,636,RC,S0119,HCPCS,,,,99998-8001-,NDC,25,ML,494.57,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG/5ML Solution 25 mL Bottle,S0119.01,CDM,636,RC,S0119,HCPCS,,,,99998-8001-,NDC,25,ML,494.57,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG/5ML Solution 50 mL Bottle,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714067102,NDC,5,ML,98.91,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG/5ML Solution 50 mL Bottle,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714067102,NDC,5,ML,98.91,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG/5ML Solution 50 mL Bottle,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714067102,NDC,5,ML,98.91,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG/5ML Solution 50 mL Bottle,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714067102,NDC,5,ML,98.91,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG/5ML Solution 50 mL Bottle,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714067102,NDC,5,ML,98.91,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG/5ML Solution 50 mL Bottle,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714067102,NDC,5,ML,98.91,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Open Bx/Excision Inguinofemoral Nodes,PX38531F,CDM,510,RC,38531,CPT,,,,,,,,912,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Open Bx/Excision Inguinofemoral Nodes,PX38531F,CDM,510,RC,38531,CPT,,,,,,,,912,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Open Bx/Excision Inguinofemoral Nodes,PX38531F,CDM,510,RC,38531,CPT,,,,,,,,912,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Open Bx/Excision Inguinofemoral Nodes,PX38531F,CDM,510,RC,38531,CPT,,,,,,,,912,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Open Bx/Excision Inguinofemoral Nodes,PX38531F,CDM,510,RC,38531,CPT,,,,,,,,912,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Open Bx/Excision Inguinofemoral Nodes,PX38531F,CDM,510,RC,38531,CPT,,,,,,,,912,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Open Bx/Excision Inguinofemoral Nodes,PX38531P,CDM,983,RC,38531,CPT,,,,,,,,607,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Open Bx/Excision Inguinofemoral Nodes,PX38531P,CDM,983,RC,38531,CPT,,,,,,,,607,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Open Bx/Excision Inguinofemoral Nodes,PX38531P,CDM,983,RC,38531,CPT,,,,,,,,607,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Open Bx/Excision Inguinofemoral Nodes,PX38531P,CDM,983,RC,38531,CPT,,,,,,,,607,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Open Bx/Excision Inguinofemoral Nodes,PX38531P,CDM,983,RC,38531,CPT,,,,,,,,607,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Open Bx/Excision Inguinofemoral Nodes,PX38531P,CDM,983,RC,38531,CPT,,,,,,,,607,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
opium 10 MG/ML (1%) Tincture 0.3 mL Syringe,63700001,CDM,250,RC,,,,,,8888800392,NDC,0.3,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
opium 10 MG/ML (1%) Tincture 0.3 mL Syringe,63700001,CDM,250,RC,,,,,,8888800392,NDC,0.3,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
opium 10 MG/ML (1%) Tincture 0.3 mL Syringe,63700001,CDM,250,RC,,,,,,8888800392,NDC,0.3,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
opium 10 MG/ML (1%) Tincture 0.3 mL Syringe,63700001,CDM,250,RC,,,,,,8888800392,NDC,0.3,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
opium 10 MG/ML (1%) Tincture 0.3 mL Syringe,63700001,CDM,250,RC,,,,,,8888800392,NDC,0.3,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
opium 10 MG/ML (1%) Tincture 0.3 mL Syringe,63700001,CDM,250,RC,,,,,,8888800392,NDC,0.3,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
opium 10 MG/ML (1%) Tincture 0.6 mL Syringe,63700001,CDM,250,RC,,,,,,88888800245,NDC,0.3,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
opium 10 MG/ML (1%) Tincture 0.6 mL Syringe,63700001,CDM,250,RC,,,,,,88888800245,NDC,0.3,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
opium 10 MG/ML (1%) Tincture 0.6 mL Syringe,63700001,CDM,250,RC,,,,,,88888800245,NDC,0.3,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
opium 10 MG/ML (1%) Tincture 0.6 mL Syringe,63700001,CDM,250,RC,,,,,,88888800245,NDC,0.3,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
opium 10 MG/ML (1%) Tincture 0.6 mL Syringe,63700001,CDM,250,RC,,,,,,88888800245,NDC,0.3,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
opium 10 MG/ML (1%) Tincture 0.6 mL Syringe,63700001,CDM,250,RC,,,,,,88888800245,NDC,0.3,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
opium 10 MG/ML (1%) Tincture 118 mL Bottle,63700001,CDM,250,RC,,,,,,42799021701,NDC,0.3,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
opium 10 MG/ML (1%) Tincture 118 mL Bottle,63700001,CDM,250,RC,,,,,,42799021701,NDC,0.3,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
opium 10 MG/ML (1%) Tincture 118 mL Bottle,63700001,CDM,250,RC,,,,,,42799021701,NDC,0.3,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
opium 10 MG/ML (1%) Tincture 118 mL Bottle,63700001,CDM,250,RC,,,,,,42799021701,NDC,0.3,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
opium 10 MG/ML (1%) Tincture 118 mL Bottle,63700001,CDM,250,RC,,,,,,42799021701,NDC,0.3,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
opium 10 MG/ML (1%) Tincture 118 mL Bottle,63700001,CDM,250,RC,,,,,,42799021701,NDC,0.3,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OPTIFOAM GENTLE SA SILICCONE FACED FOAM & BOARDER,120.63,CDM,272,RC,A6196,HCPCS,,3938-MAIN,LOCAL,,,,,25,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OPTIFOAM GENTLE SA SILICCONE FACED FOAM & BOARDER,120.63,CDM,272,RC,A6196,HCPCS,,3938-MAIN,LOCAL,,,,,25,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OPTIFOAM GENTLE SA SILICCONE FACED FOAM & BOARDER,120.63,CDM,272,RC,A6196,HCPCS,,3938-MAIN,LOCAL,,,,,25,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OPTIFOAM GENTLE SA SILICCONE FACED FOAM & BOARDER,120.63,CDM,272,RC,A6196,HCPCS,,3938-MAIN,LOCAL,,,,,25,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OPTIFOAM GENTLE SA SILICCONE FACED FOAM & BOARDER,120.63,CDM,272,RC,A6196,HCPCS,,3938-MAIN,LOCAL,,,,,25,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OPTIFOAM GENTLE SA SILICCONE FACED FOAM & BOARDER,120.63,CDM,272,RC,A6196,HCPCS,,3938-MAIN,LOCAL,,,,,25,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Or Level 1,PX36000001,CDM,360,RC,,,,,,,,,,1600,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1411.2,6141.46
Or Level 1,PX36000001,CDM,360,RC,,,,,,,,,,1600,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1411.2,6141.46
Or Level 1,PX36000001,CDM,360,RC,,,,,,,,,,1600,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1411.2,6141.46
Or Level 1,PX36000001,CDM,360,RC,,,,,,,,,,1600,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1411.2,6141.46
Or Level 1,PX36000001,CDM,360,RC,,,,,,,,,,1600,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1411.2,6141.46
Or Level 1,PX36000001,CDM,360,RC,,,,,,,,,,1600,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1411.2,6141.46
Or Level 2,PX36000002,CDM,360,RC,,,,,,,,,,1900,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1675.8,6141.46
Or Level 2,PX36000002,CDM,360,RC,,,,,,,,,,1900,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1675.8,6141.46
Or Level 2,PX36000002,CDM,360,RC,,,,,,,,,,1900,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1675.8,6141.46
Or Level 2,PX36000002,CDM,360,RC,,,,,,,,,,1900,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1675.8,6141.46
Or Level 2,PX36000002,CDM,360,RC,,,,,,,,,,1900,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1675.8,6141.46
Or Level 2,PX36000002,CDM,360,RC,,,,,,,,,,1900,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1675.8,6141.46
Or Level 3,PX36000003,CDM,360,RC,,,,,,,,,,2100,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1852.2,6141.46
Or Level 3,PX36000003,CDM,360,RC,,,,,,,,,,2100,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1852.2,6141.46
Or Level 3,PX36000003,CDM,360,RC,,,,,,,,,,2100,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1852.2,6141.46
Or Level 3,PX36000003,CDM,360,RC,,,,,,,,,,2100,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1852.2,6141.46
Or Level 3,PX36000003,CDM,360,RC,,,,,,,,,,2100,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1852.2,6141.46
Or Level 3,PX36000003,CDM,360,RC,,,,,,,,,,2100,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1852.2,6141.46
Or Level 4,PX36000004,CDM,360,RC,,,,,,,,,,3805,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3356.01,6141.46
Or Level 4,PX36000004,CDM,360,RC,,,,,,,,,,3805,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3356.01,6141.46
Or Level 4,PX36000004,CDM,360,RC,,,,,,,,,,3805,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3356.01,6141.46
Or Level 4,PX36000004,CDM,360,RC,,,,,,,,,,3805,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3356.01,6141.46
Or Level 4,PX36000004,CDM,360,RC,,,,,,,,,,3805,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3356.01,6141.46
Or Level 4,PX36000004,CDM,360,RC,,,,,,,,,,3805,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3356.01,6141.46
Or Level 5,PX36000005,CDM,360,RC,,,,,,,,,,5898,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5202.036,6141.46
Or Level 5,PX36000005,CDM,360,RC,,,,,,,,,,5898,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5202.036,6141.46
Or Level 5,PX36000005,CDM,360,RC,,,,,,,,,,5898,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5202.036,6141.46
Or Level 5,PX36000005,CDM,360,RC,,,,,,,,,,5898,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5202.036,6141.46
Or Level 5,PX36000005,CDM,360,RC,,,,,,,,,,5898,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5202.036,6141.46
Or Level 5,PX36000005,CDM,360,RC,,,,,,,,,,5898,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5202.036,6141.46
Or Level 6,PX36000006,CDM,360,RC,,,,,,,,,,7960,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,7020.72
Or Level 6,PX36000006,CDM,360,RC,,,,,,,,,,7960,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,7020.72
Or Level 6,PX36000006,CDM,360,RC,,,,,,,,,,7960,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,7020.72
Or Level 6,PX36000006,CDM,360,RC,,,,,,,,,,7960,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,7020.72
Or Level 6,PX36000006,CDM,360,RC,,,,,,,,,,7960,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,7020.72
Or Level 6,PX36000006,CDM,360,RC,,,,,,,,,,7960,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,7020.72
Or Time,PX36000086,CDM,360,RC,,,,,,,,,,27,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.814,6141.46
Or Time,PX36000086,CDM,360,RC,,,,,,,,,,27,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.814,6141.46
Or Time,PX36000086,CDM,360,RC,,,,,,,,,,27,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.814,6141.46
Or Time,PX36000086,CDM,360,RC,,,,,,,,,,27,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.814,6141.46
Or Time,PX36000086,CDM,360,RC,,,,,,,,,,27,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.814,6141.46
Or Time,PX36000086,CDM,360,RC,,,,,,,,,,27,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.814,6141.46
Org ID Aerobic-Each,PX87077,CDM,300,RC,87077,CPT,,,,,,,,168,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Org ID Aerobic-Each,PX87077,CDM,300,RC,87077,CPT,,,,,,,,168,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Org ID Aerobic-Each,PX87077,CDM,300,RC,87077,CPT,,,,,,,,168,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Org ID Aerobic-Each,PX87077,CDM,300,RC,87077,CPT,,,,,,,,168,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Org ID Aerobic-Each,PX87077,CDM,300,RC,87077,CPT,,,,,,,,168,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Org ID Aerobic-Each,PX87077,CDM,300,RC,87077,CPT,,,,,,,,168,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Organic Acid, Single, Qnt - Ref",PX8392190,CDM,300,RC,83921,CPT,90,,,,,,,209,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Organic Acid, Single, Qnt - Ref",PX8392190,CDM,300,RC,83921,CPT,90,,,,,,,209,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Organic Acid, Single, Qnt - Ref",PX8392190,CDM,300,RC,83921,CPT,90,,,,,,,209,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Organic Acid, Single, Qnt - Ref",PX8392190,CDM,300,RC,83921,CPT,90,,,,,,,209,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Organic Acid, Single, Qnt - Ref",PX8392190,CDM,300,RC,83921,CPT,90,,,,,,,209,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Organic Acid, Single, Qnt - Ref",PX8392190,CDM,300,RC,83921,CPT,90,,,,,,,209,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Organism ID, Anaerobic - Ref",PX8707690,CDM,300,RC,87076,CPT,90,,,,,,,95,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Organism ID, Anaerobic - Ref",PX8707690,CDM,300,RC,87076,CPT,90,,,,,,,95,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Organism ID, Anaerobic - Ref",PX8707690,CDM,300,RC,87076,CPT,90,,,,,,,95,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Organism ID, Anaerobic - Ref",PX8707690,CDM,300,RC,87076,CPT,90,,,,,,,95,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Organism ID, Anaerobic - Ref",PX8707690,CDM,300,RC,87076,CPT,90,,,,,,,95,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Organism ID, Anaerobic - Ref",PX8707690,CDM,300,RC,87076,CPT,90,,,,,,,95,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001501,NDC,1,EA,2340,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001501,NDC,1,EA,2340,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001501,NDC,1,EA,2340,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001501,NDC,1,EA,2340,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001501,NDC,1,EA,2340,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001501,NDC,1,EA,2340,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001503,NDC,1,EA,2340,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001503,NDC,1,EA,2340,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001503,NDC,1,EA,2340,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001503,NDC,1,EA,2340,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001503,NDC,1,EA,2340,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001503,NDC,1,EA,2340,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,70842014003,NDC,1,EA,2409.61,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,70842014003,NDC,1,EA,2409.61,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,70842014003,NDC,1,EA,2409.61,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,70842014003,NDC,1,EA,2409.61,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,70842014003,NDC,1,EA,2409.61,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,70842014003,NDC,1,EA,2409.61,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618201,NDC,2,ML,120.53,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618201,NDC,2,ML,120.53,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618201,NDC,2,ML,120.53,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618201,NDC,2,ML,120.53,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618201,NDC,2,ML,120.53,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618201,NDC,2,ML,120.53,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618210,NDC,2,ML,120.53,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618210,NDC,2,ML,120.53,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618210,NDC,2,ML,120.53,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618210,NDC,2,ML,120.53,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618210,NDC,2,ML,120.53,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618210,NDC,2,ML,120.53,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,17478053802,NDC,2,ML,125.91,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,17478053802,NDC,2,ML,125.91,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,17478053802,NDC,2,ML,125.91,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,17478053802,NDC,2,ML,125.91,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,17478053802,NDC,2,ML,125.91,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,17478053802,NDC,2,ML,125.91,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760,CDM,420,RC,97760,CPT,,,,,,,,142,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760,CDM,420,RC,97760,CPT,,,,,,,,142,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760,CDM,420,RC,97760,CPT,,,,,,,,142,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760,CDM,420,RC,97760,CPT,,,,,,,,142,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760,CDM,420,RC,97760,CPT,,,,,,,,142,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760,CDM,420,RC,97760,CPT,,,,,,,,142,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760F,CDM,510,RC,97760,CPT,,,,,,,,142,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760F,CDM,510,RC,97760,CPT,,,,,,,,142,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760F,CDM,510,RC,97760,CPT,,,,,,,,142,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760F,CDM,510,RC,97760,CPT,,,,,,,,142,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760F,CDM,510,RC,97760,CPT,,,,,,,,142,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760F,CDM,510,RC,97760,CPT,,,,,,,,142,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 6 MG/ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,4082205,NDC,60,ML,752.82,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 6 MG/ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,4082205,NDC,60,ML,752.82,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 6 MG/ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,4082205,NDC,60,ML,752.82,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 6 MG/ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,4082205,NDC,60,ML,752.82,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 6 MG/ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,4082205,NDC,60,ML,752.82,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 6 MG/ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,4082205,NDC,60,ML,752.82,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 6 MG/ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,68180067801,NDC,60,ML,676.25,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 6 MG/ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,68180067801,NDC,60,ML,676.25,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 6 MG/ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,68180067801,NDC,60,ML,676.25,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 6 MG/ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,68180067801,NDC,60,ML,676.25,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 6 MG/ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,68180067801,NDC,60,ML,676.25,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 6 MG/ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,68180067801,NDC,60,ML,676.25,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,4080285,NDC,1,EA,89.79,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,4080285,NDC,1,EA,89.79,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,4080285,NDC,1,EA,89.79,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,4080285,NDC,1,EA,89.79,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,4080285,NDC,1,EA,89.79,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,4080285,NDC,1,EA,89.79,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,16714081701,NDC,1,EA,75.78,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,16714081701,NDC,1,EA,75.78,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,16714081701,NDC,1,EA,75.78,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,16714081701,NDC,1,EA,75.78,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,16714081701,NDC,1,EA,75.78,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,16714081701,NDC,1,EA,75.78,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,47781046813,NDC,1,EA,76.15,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,47781046813,NDC,1,EA,76.15,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,47781046813,NDC,1,EA,76.15,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,47781046813,NDC,1,EA,76.15,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,47781046813,NDC,1,EA,76.15,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,47781046813,NDC,1,EA,76.15,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,63739003807,NDC,1,EA,66.51,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,63739003807,NDC,1,EA,66.51,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,63739003807,NDC,1,EA,66.51,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,63739003807,NDC,1,EA,66.51,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,63739003807,NDC,1,EA,66.51,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,63739003807,NDC,1,EA,66.51,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,64380079701,NDC,1,EA,76.15,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,64380079701,NDC,1,EA,76.15,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,64380079701,NDC,1,EA,76.15,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,64380079701,NDC,1,EA,76.15,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,64380079701,NDC,1,EA,76.15,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,64380079701,NDC,1,EA,76.15,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,47781047013,NDC,1,EA,83,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,47781047013,NDC,1,EA,83,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,47781047013,NDC,1,EA,83,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,47781047013,NDC,1,EA,83,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,47781047013,NDC,1,EA,83,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,47781047013,NDC,1,EA,83,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,63739005007,NDC,1,EA,73.35,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,63739005007,NDC,1,EA,73.35,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,63739005007,NDC,1,EA,73.35,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,63739005007,NDC,1,EA,73.35,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,63739005007,NDC,1,EA,73.35,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,63739005007,NDC,1,EA,73.35,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,64380079901,NDC,1,EA,83,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,64380079901,NDC,1,EA,83,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,64380079901,NDC,1,EA,83,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,64380079901,NDC,1,EA,83,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,64380079901,NDC,1,EA,83,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,64380079901,NDC,1,EA,83,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,69238126601,NDC,1,EA,83,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,69238126601,NDC,1,EA,83,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,69238126601,NDC,1,EA,83,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,69238126601,NDC,1,EA,83,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,69238126601,NDC,1,EA,83,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,69238126601,NDC,1,EA,83,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 75 MG capsule 10 Each Disp Pack,63700001,CDM,250,RC,,,,,,4080085,NDC,1,EA,97.87,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 75 MG capsule 10 Each Disp Pack,63700001,CDM,250,RC,,,,,,4080085,NDC,1,EA,97.87,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 75 MG capsule 10 Each Disp Pack,63700001,CDM,250,RC,,,,,,4080085,NDC,1,EA,97.87,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 75 MG capsule 10 Each Disp Pack,63700001,CDM,250,RC,,,,,,4080085,NDC,1,EA,97.87,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 75 MG capsule 10 Each Disp Pack,63700001,CDM,250,RC,,,,,,4080085,NDC,1,EA,97.87,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 75 MG capsule 10 Each Disp Pack,63700001,CDM,250,RC,,,,,,4080085,NDC,1,EA,97.87,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Osmolality; Blood,PX83930,CDM,300,RC,83930,CPT,,,,,,,,9,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Osmolality; Blood,PX83930,CDM,300,RC,83930,CPT,,,,,,,,9,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Osmolality; Blood,PX83930,CDM,300,RC,83930,CPT,,,,,,,,9,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Osmolality; Blood,PX83930,CDM,300,RC,83930,CPT,,,,,,,,9,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Osmolality; Blood,PX83930,CDM,300,RC,83930,CPT,,,,,,,,9,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Osmolality; Blood,PX83930,CDM,300,RC,83930,CPT,,,,,,,,9,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Osmolality; Urine,PX83935,CDM,300,RC,83935,CPT,,,,,,,,112,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Osmolality; Urine,PX83935,CDM,300,RC,83935,CPT,,,,,,,,112,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Osmolality; Urine,PX83935,CDM,300,RC,83935,CPT,,,,,,,,112,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Osmolality; Urine,PX83935,CDM,300,RC,83935,CPT,,,,,,,,112,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Osmolality; Urine,PX83935,CDM,300,RC,83935,CPT,,,,,,,,112,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Osmolality; Urine,PX83935,CDM,300,RC,83935,CPT,,,,,,,,112,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OSTEOSET RESORBABLE MINI BEAD KIT FAST CURE CALCIUM SULFATE 5CC,C1713,CDM,278,RC,C1713,HCPCS,,12303-MAIN,LOCAL,,,,,2220,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OSTEOSET RESORBABLE MINI BEAD KIT FAST CURE CALCIUM SULFATE 5CC,C1713,CDM,278,RC,C1713,HCPCS,,12303-MAIN,LOCAL,,,,,2220,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OSTEOSET RESORBABLE MINI BEAD KIT FAST CURE CALCIUM SULFATE 5CC,C1713,CDM,278,RC,C1713,HCPCS,,12303-MAIN,LOCAL,,,,,2220,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OSTEOSET RESORBABLE MINI BEAD KIT FAST CURE CALCIUM SULFATE 5CC,C1713,CDM,278,RC,C1713,HCPCS,,12303-MAIN,LOCAL,,,,,2220,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OSTEOSET RESORBABLE MINI BEAD KIT FAST CURE CALCIUM SULFATE 5CC,C1713,CDM,278,RC,C1713,HCPCS,,12303-MAIN,LOCAL,,,,,2220,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OSTEOSET RESORBABLE MINI BEAD KIT FAST CURE CALCIUM SULFATE 5CC,C1713,CDM,278,RC,C1713,HCPCS,,12303-MAIN,LOCAL,,,,,2220,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OSTOMY DRAINABLE POUCH INVISICLOSE 1.75,27200000,CDM,272,RC,A5063,HCPCS,,12071-MAIN,LOCAL,,,,,1.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OSTOMY DRAINABLE POUCH INVISICLOSE 1.75,27200000,CDM,272,RC,A5063,HCPCS,,12071-MAIN,LOCAL,,,,,1.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OSTOMY DRAINABLE POUCH INVISICLOSE 1.75,27200000,CDM,272,RC,A5063,HCPCS,,12071-MAIN,LOCAL,,,,,1.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OSTOMY DRAINABLE POUCH INVISICLOSE 1.75,27200000,CDM,272,RC,A5063,HCPCS,,12071-MAIN,LOCAL,,,,,1.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OSTOMY DRAINABLE POUCH INVISICLOSE 1.75,27200000,CDM,272,RC,A5063,HCPCS,,12071-MAIN,LOCAL,,,,,1.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OSTOMY DRAINABLE POUCH INVISICLOSE 1.75,27200000,CDM,272,RC,A5063,HCPCS,,12071-MAIN,LOCAL,,,,,1.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OSTOMY KIT 2 PIECE SURGICAL POST-OP,27200000,CDM,272,RC,,,,12070-MAIN,LOCAL,,,,,7,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OSTOMY KIT 2 PIECE SURGICAL POST-OP,27200000,CDM,272,RC,,,,12070-MAIN,LOCAL,,,,,7,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OSTOMY KIT 2 PIECE SURGICAL POST-OP,27200000,CDM,272,RC,,,,12070-MAIN,LOCAL,,,,,7,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OSTOMY KIT 2 PIECE SURGICAL POST-OP,27200000,CDM,272,RC,,,,12070-MAIN,LOCAL,,,,,7,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OSTOMY KIT 2 PIECE SURGICAL POST-OP,27200000,CDM,272,RC,,,,12070-MAIN,LOCAL,,,,,7,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OSTOMY KIT 2 PIECE SURGICAL POST-OP,27200000,CDM,272,RC,,,,12070-MAIN,LOCAL,,,,,7,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ot Contracted Service/MCR,PX120.177,CDM,431,RC,,,,,,,,,,98,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ot Contracted Service/MCR,PX120.177,CDM,431,RC,,,,,,,,,,98,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ot Contracted Service/MCR,PX120.177,CDM,431,RC,,,,,,,,,,98,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ot Contracted Service/MCR,PX120.177,CDM,431,RC,,,,,,,,,,98,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ot Contracted Service/MCR,PX120.177,CDM,431,RC,,,,,,,,,,98,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ot Contracted Service/MCR,PX120.177,CDM,431,RC,,,,,,,,,,98,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ot Contracted Service/Msho/MA,PX120.178,CDM,431,RC,,,,,,,,,,66,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ot Contracted Service/Msho/MA,PX120.178,CDM,431,RC,,,,,,,,,,66,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ot Contracted Service/Msho/MA,PX120.178,CDM,431,RC,,,,,,,,,,66,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ot Contracted Service/Msho/MA,PX120.178,CDM,431,RC,,,,,,,,,,66,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ot Contracted Service/Msho/MA,PX120.178,CDM,431,RC,,,,,,,,,,66,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ot Contracted Service/Msho/MA,PX120.178,CDM,431,RC,,,,,,,,,,66,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OXALiplatin 50 MG/10ML Solution 10 mL Vial,J9263.01,CDM,636,RC,J9263,HCPCS,,,,955173110,NDC,10,ML,228,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OXALiplatin 50 MG/10ML Solution 10 mL Vial,J9263.01,CDM,636,RC,J9263,HCPCS,,,,955173110,NDC,10,ML,228,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OXALiplatin 50 MG/10ML Solution 10 mL Vial,J9263.01,CDM,636,RC,J9263,HCPCS,,,,955173110,NDC,10,ML,228,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OXALiplatin 50 MG/10ML Solution 10 mL Vial,J9263.01,CDM,636,RC,J9263,HCPCS,,,,955173110,NDC,10,ML,228,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OXALiplatin 50 MG/10ML Solution 10 mL Vial,J9263.01,CDM,636,RC,J9263,HCPCS,,,,955173110,NDC,10,ML,228,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OXALiplatin 50 MG/10ML Solution 10 mL Vial,J9263.01,CDM,636,RC,J9263,HCPCS,,,,955173110,NDC,10,ML,228,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Oxcarbazepine - Ref,PX8018390,CDM,300,RC,80183,CPT,90,,,,,,,108,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Oxcarbazepine - Ref,PX8018390,CDM,300,RC,80183,CPT,90,,,,,,,108,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Oxcarbazepine - Ref,PX8018390,CDM,300,RC,80183,CPT,90,,,,,,,108,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Oxcarbazepine - Ref,PX8018390,CDM,300,RC,80183,CPT,90,,,,,,,108,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Oxcarbazepine - Ref,PX8018390,CDM,300,RC,80183,CPT,90,,,,,,,108,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Oxcarbazepine - Ref,PX8018390,CDM,300,RC,80183,CPT,90,,,,,,,108,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OXcarbazepine 150 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084084511,NDC,1,EA,8.1,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OXcarbazepine 150 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084084511,NDC,1,EA,8.1,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OXcarbazepine 150 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084084511,NDC,1,EA,8.1,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OXcarbazepine 150 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084084511,NDC,1,EA,8.1,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OXcarbazepine 150 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084084511,NDC,1,EA,8.1,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OXcarbazepine 150 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084084511,NDC,1,EA,8.1,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Oximetry;Mult Determine,PX610,CDM,460,RC,94761,CPT,,,,,,,,142,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Oximetry;Mult Determine,PX610,CDM,460,RC,94761,CPT,,,,,,,,142,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Oximetry;Mult Determine,PX610,CDM,460,RC,94761,CPT,,,,,,,,142,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Oximetry;Mult Determine,PX610,CDM,460,RC,94761,CPT,,,,,,,,142,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Oximetry;Mult Determine,PX610,CDM,460,RC,94761,CPT,,,,,,,,142,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Oximetry;Mult Determine,PX610,CDM,460,RC,94761,CPT,,,,,,,,142,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyBUTYnin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904702761,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyBUTYnin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904702761,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyBUTYnin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904702761,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyBUTYnin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904702761,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyBUTYnin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904702761,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyBUTYnin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904702761,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyBUTYnin ER 5 MG Tablet Extended Release 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,63739054833,NDC,1,EA,18.67,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyBUTYnin ER 5 MG Tablet Extended Release 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,63739054833,NDC,1,EA,18.67,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyBUTYnin ER 5 MG Tablet Extended Release 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,63739054833,NDC,1,EA,18.67,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyBUTYnin ER 5 MG Tablet Extended Release 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,63739054833,NDC,1,EA,18.67,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyBUTYnin ER 5 MG Tablet Extended Release 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,63739054833,NDC,1,EA,18.67,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyBUTYnin ER 5 MG Tablet Extended Release 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,63739054833,NDC,1,EA,18.67,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyBUTYnin ER 5 MG Tablet Extended Release 24 Hour 50 Each Box,63700001,CDM,250,RC,,,,,,904657006,NDC,1,EA,18.04,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyBUTYnin ER 5 MG Tablet Extended Release 24 Hour 50 Each Box,63700001,CDM,250,RC,,,,,,904657006,NDC,1,EA,18.04,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyBUTYnin ER 5 MG Tablet Extended Release 24 Hour 50 Each Box,63700001,CDM,250,RC,,,,,,904657006,NDC,1,EA,18.04,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyBUTYnin ER 5 MG Tablet Extended Release 24 Hour 50 Each Box,63700001,CDM,250,RC,,,,,,904657006,NDC,1,EA,18.04,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyBUTYnin ER 5 MG Tablet Extended Release 24 Hour 50 Each Box,63700001,CDM,250,RC,,,,,,904657006,NDC,1,EA,18.04,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyBUTYnin ER 5 MG Tablet Extended Release 24 Hour 50 Each Box,63700001,CDM,250,RC,,,,,,904657006,NDC,1,EA,18.04,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyCODONE 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406055223,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyCODONE 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406055223,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyCODONE 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406055223,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyCODONE 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406055223,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyCODONE 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406055223,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyCODONE 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406055223,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyCODONE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406055262,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyCODONE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406055262,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyCODONE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406055262,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyCODONE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406055262,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyCODONE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406055262,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyCODONE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406055262,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyCODONE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,42858000110,NDC,1,EA,3.33,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyCODONE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,42858000110,NDC,1,EA,3.33,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyCODONE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,42858000110,NDC,1,EA,3.33,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyCODONE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,42858000110,NDC,1,EA,3.33,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyCODONE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,42858000110,NDC,1,EA,3.33,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyCODONE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,42858000110,NDC,1,EA,3.33,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyCODONE CR 10 MG Tablet ER 12 hour Abuse-Deterrent 20 Each Box,63700001,CDM,250,RC,,,,,,59011041020,NDC,1,EA,26.63,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyCODONE CR 10 MG Tablet ER 12 hour Abuse-Deterrent 20 Each Box,63700001,CDM,250,RC,,,,,,59011041020,NDC,1,EA,26.63,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyCODONE CR 10 MG Tablet ER 12 hour Abuse-Deterrent 20 Each Box,63700001,CDM,250,RC,,,,,,59011041020,NDC,1,EA,26.63,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyCODONE CR 10 MG Tablet ER 12 hour Abuse-Deterrent 20 Each Box,63700001,CDM,250,RC,,,,,,59011041020,NDC,1,EA,26.63,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyCODONE CR 10 MG Tablet ER 12 hour Abuse-Deterrent 20 Each Box,63700001,CDM,250,RC,,,,,,59011041020,NDC,1,EA,26.63,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyCODONE CR 10 MG Tablet ER 12 hour Abuse-Deterrent 20 Each Box,63700001,CDM,250,RC,,,,,,59011041020,NDC,1,EA,26.63,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyCODONE CR 20 MG Tablet ER 12 hour Abuse-Deterrent 20 Each Box,63700001,CDM,250,RC,,,,,,59011042020,NDC,1,EA,52.09,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyCODONE CR 20 MG Tablet ER 12 hour Abuse-Deterrent 20 Each Box,63700001,CDM,250,RC,,,,,,59011042020,NDC,1,EA,52.09,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyCODONE CR 20 MG Tablet ER 12 hour Abuse-Deterrent 20 Each Box,63700001,CDM,250,RC,,,,,,59011042020,NDC,1,EA,52.09,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyCODONE CR 20 MG Tablet ER 12 hour Abuse-Deterrent 20 Each Box,63700001,CDM,250,RC,,,,,,59011042020,NDC,1,EA,52.09,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyCODONE CR 20 MG Tablet ER 12 hour Abuse-Deterrent 20 Each Box,63700001,CDM,250,RC,,,,,,59011042020,NDC,1,EA,52.09,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyCODONE CR 20 MG Tablet ER 12 hour Abuse-Deterrent 20 Each Box,63700001,CDM,250,RC,,,,,,59011042020,NDC,1,EA,52.09,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyCODONE-acetaminophen 5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406051223,NDC,1,EA,7.36,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyCODONE-acetaminophen 5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406051223,NDC,1,EA,7.36,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyCODONE-acetaminophen 5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406051223,NDC,1,EA,7.36,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyCODONE-acetaminophen 5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406051223,NDC,1,EA,7.36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyCODONE-acetaminophen 5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406051223,NDC,1,EA,7.36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyCODONE-acetaminophen 5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406051223,NDC,1,EA,7.36,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyCODONE-acetaminophen 5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406051262,NDC,1,EA,7.35,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyCODONE-acetaminophen 5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406051262,NDC,1,EA,7.35,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyCODONE-acetaminophen 5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406051262,NDC,1,EA,7.35,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyCODONE-acetaminophen 5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406051262,NDC,1,EA,7.35,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyCODONE-acetaminophen 5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406051262,NDC,1,EA,7.35,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyCODONE-acetaminophen 5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406051262,NDC,1,EA,7.35,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxymetazoline 0.05 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904571135,NDC,15,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxymetazoline 0.05 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904571135,NDC,15,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxymetazoline 0.05 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904571135,NDC,15,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxymetazoline 0.05 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904571135,NDC,15,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxymetazoline 0.05 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904571135,NDC,15,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxymetazoline 0.05 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904571135,NDC,15,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxytocin 10 UNIT/ML Solution 1 mL Vial,J2590.01,CDM,636,RC,J2590,HCPCS,,,,42023011625,NDC,1,ML,43.8,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxytocin 10 UNIT/ML Solution 1 mL Vial,J2590.01,CDM,636,RC,J2590,HCPCS,,,,42023011625,NDC,1,ML,43.8,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxytocin 10 UNIT/ML Solution 1 mL Vial,J2590.01,CDM,636,RC,J2590,HCPCS,,,,42023011625,NDC,1,ML,43.8,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxytocin 10 UNIT/ML Solution 1 mL Vial,J2590.01,CDM,636,RC,J2590,HCPCS,,,,42023011625,NDC,1,ML,43.8,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxytocin 10 UNIT/ML Solution 1 mL Vial,J2590.01,CDM,636,RC,J2590,HCPCS,,,,42023011625,NDC,1,ML,43.8,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxytocin 10 UNIT/ML Solution 1 mL Vial,J2590.01,CDM,636,RC,J2590,HCPCS,,,,42023011625,NDC,1,ML,43.8,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PACK BASIN BASIC SINGLE DYNJ06610A,27200000,CDM,272,RC,,,,10921-MAIN,LOCAL,,,,,25.48,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PACK BASIN BASIC SINGLE DYNJ06610A,27200000,CDM,272,RC,,,,10921-MAIN,LOCAL,,,,,25.48,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PACK BASIN BASIC SINGLE DYNJ06610A,27200000,CDM,272,RC,,,,10921-MAIN,LOCAL,,,,,25.48,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PACK BASIN BASIC SINGLE DYNJ06610A,27200000,CDM,272,RC,,,,10921-MAIN,LOCAL,,,,,25.48,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PACK BASIN BASIC SINGLE DYNJ06610A,27200000,CDM,272,RC,,,,10921-MAIN,LOCAL,,,,,25.48,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PACK BASIN BASIC SINGLE DYNJ06610A,27200000,CDM,272,RC,,,,10921-MAIN,LOCAL,,,,,25.48,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PACLitaxel 30 MG/5ML Concentrate 5 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476401,NDC,5,ML,58.37,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PACLitaxel 30 MG/5ML Concentrate 5 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476401,NDC,5,ML,58.37,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PACLitaxel 30 MG/5ML Concentrate 5 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476401,NDC,5,ML,58.37,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PACLitaxel 30 MG/5ML Concentrate 5 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476401,NDC,5,ML,58.37,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PACLitaxel 30 MG/5ML Concentrate 5 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476401,NDC,5,ML,58.37,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PACLitaxel 30 MG/5ML Concentrate 5 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476401,NDC,5,ML,58.37,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PACLitaxel 150 MG/25ML Concentrate 25 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321701,NDC,25,ML,300.96,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PACLitaxel 150 MG/25ML Concentrate 25 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321701,NDC,25,ML,300.96,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PACLitaxel 150 MG/25ML Concentrate 25 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321701,NDC,25,ML,300.96,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PACLitaxel 150 MG/25ML Concentrate 25 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321701,NDC,25,ML,300.96,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PACLitaxel 150 MG/25ML Concentrate 25 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321701,NDC,25,ML,300.96,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PACLitaxel 150 MG/25ML Concentrate 25 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321701,NDC,25,ML,300.96,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321801,NDC,50,ML,456,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321801,NDC,50,ML,456,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321801,NDC,50,ML,456,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321801,NDC,50,ML,456,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321801,NDC,50,ML,456,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321801,NDC,50,ML,456,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476881,NDC,50,ML,579.12,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476881,NDC,50,ML,579.12,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476881,NDC,50,ML,579.12,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476881,NDC,50,ML,579.12,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476881,NDC,50,ML,579.12,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476881,NDC,50,ML,579.12,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,63323076350,NDC,50,ML,589.57,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,63323076350,NDC,50,ML,589.57,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,63323076350,NDC,50,ML,589.57,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,63323076350,NDC,50,ML,589.57,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,63323076350,NDC,50,ML,589.57,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,63323076350,NDC,50,ML,589.57,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PACLitaxel protein-bound particle 100 MG Recon Susp 1 Each Vial,J9264.01,CDM,636,RC,J9264,HCPCS,,,,68817013450,NDC,1,EA,2564.76,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PACLitaxel protein-bound particle 100 MG Recon Susp 1 Each Vial,J9264.01,CDM,636,RC,J9264,HCPCS,,,,68817013450,NDC,1,EA,2564.76,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PACLitaxel protein-bound particle 100 MG Recon Susp 1 Each Vial,J9264.01,CDM,636,RC,J9264,HCPCS,,,,68817013450,NDC,1,EA,2564.76,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PACLitaxel protein-bound particle 100 MG Recon Susp 1 Each Vial,J9264.01,CDM,636,RC,J9264,HCPCS,,,,68817013450,NDC,1,EA,2564.76,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PACLitaxel protein-bound particle 100 MG Recon Susp 1 Each Vial,J9264.01,CDM,636,RC,J9264,HCPCS,,,,68817013450,NDC,1,EA,2564.76,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PACLitaxel protein-bound particle 100 MG Recon Susp 1 Each Vial,J9264.01,CDM,636,RC,J9264,HCPCS,,,,68817013450,NDC,1,EA,2564.76,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"PAD BED SENSOR 10X28"" P-107517",120.124,CDM,271,RC,,,,8377-MAIN,LOCAL,,,,,47,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"PAD BED SENSOR 10X28"" P-107517",120.124,CDM,271,RC,,,,8377-MAIN,LOCAL,,,,,47,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"PAD BED SENSOR 10X28"" P-107517",120.124,CDM,271,RC,,,,8377-MAIN,LOCAL,,,,,47,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"PAD BED SENSOR 10X28"" P-107517",120.124,CDM,271,RC,,,,8377-MAIN,LOCAL,,,,,47,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"PAD BED SENSOR 10X28"" P-107517",120.124,CDM,271,RC,,,,8377-MAIN,LOCAL,,,,,47,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"PAD BED SENSOR 10X28"" P-107517",120.124,CDM,271,RC,,,,8377-MAIN,LOCAL,,,,,47,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"PAD CHAIR SENSOR 10x15"" 106380",120.124,CDM,271,RC,,,,8378-MAIN,LOCAL,,,,,47,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"PAD CHAIR SENSOR 10x15"" 106380",120.124,CDM,271,RC,,,,8378-MAIN,LOCAL,,,,,47,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"PAD CHAIR SENSOR 10x15"" 106380",120.124,CDM,271,RC,,,,8378-MAIN,LOCAL,,,,,47,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"PAD CHAIR SENSOR 10x15"" 106380",120.124,CDM,271,RC,,,,8378-MAIN,LOCAL,,,,,47,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"PAD CHAIR SENSOR 10x15"" 106380",120.124,CDM,271,RC,,,,8378-MAIN,LOCAL,,,,,47,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"PAD CHAIR SENSOR 10x15"" 106380",120.124,CDM,271,RC,,,,8378-MAIN,LOCAL,,,,,47,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PAD GROUNDING 9 FT ADULT REM E7507,27200000,CDM,272,RC,,,,504-MAIN,LOCAL,,,,,10,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PAD GROUNDING 9 FT ADULT REM E7507,27200000,CDM,272,RC,,,,504-MAIN,LOCAL,,,,,10,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PAD GROUNDING 9 FT ADULT REM E7507,27200000,CDM,272,RC,,,,504-MAIN,LOCAL,,,,,10,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PAD GROUNDING 9 FT ADULT REM E7507,27200000,CDM,272,RC,,,,504-MAIN,LOCAL,,,,,10,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PAD GROUNDING 9 FT ADULT REM E7507,27200000,CDM,272,RC,,,,504-MAIN,LOCAL,,,,,10,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PAD GROUNDING 9 FT ADULT REM E7507,27200000,CDM,272,RC,,,,504-MAIN,LOCAL,,,,,10,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
paliperidone palmitate ER 234 MG/1.5ML suspension prefilled syringe 1.5 mL Syringe,J2426.01,CDM,636,RC,J2426,HCPCS,,,,50458056401,NDC,0.25,ML,1142.14,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
paliperidone palmitate ER 234 MG/1.5ML suspension prefilled syringe 1.5 mL Syringe,J2426.01,CDM,636,RC,J2426,HCPCS,,,,50458056401,NDC,0.25,ML,1142.14,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
paliperidone palmitate ER 234 MG/1.5ML suspension prefilled syringe 1.5 mL Syringe,J2426.01,CDM,636,RC,J2426,HCPCS,,,,50458056401,NDC,0.25,ML,1142.14,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
paliperidone palmitate ER 234 MG/1.5ML suspension prefilled syringe 1.5 mL Syringe,J2426.01,CDM,636,RC,J2426,HCPCS,,,,50458056401,NDC,0.25,ML,1142.14,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
paliperidone palmitate ER 234 MG/1.5ML suspension prefilled syringe 1.5 mL Syringe,J2426.01,CDM,636,RC,J2426,HCPCS,,,,50458056401,NDC,0.25,ML,1142.14,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
paliperidone palmitate ER 234 MG/1.5ML suspension prefilled syringe 1.5 mL Syringe,J2426.01,CDM,636,RC,J2426,HCPCS,,,,50458056401,NDC,0.25,ML,1142.14,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,55111069407,NDC,5,ML,592.4,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,55111069407,NDC,5,ML,592.4,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,55111069407,NDC,5,ML,592.4,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,55111069407,NDC,5,ML,592.4,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,55111069407,NDC,5,ML,592.4,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,55111069407,NDC,5,ML,592.4,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,60505619301,NDC,5,ML,821.36,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,60505619301,NDC,5,ML,821.36,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,60505619301,NDC,5,ML,821.36,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,60505619301,NDC,5,ML,821.36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,60505619301,NDC,5,ML,821.36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,60505619301,NDC,5,ML,821.36,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,63323067305,NDC,5,ML,1029.71,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,63323067305,NDC,5,ML,1029.71,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,63323067305,NDC,5,ML,1029.71,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,63323067305,NDC,5,ML,1029.71,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,63323067305,NDC,5,ML,1029.71,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,63323067305,NDC,5,ML,1029.71,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pancrelipase (lip-prot-amyl) 24000-76000 units Capsule Delayed Release Particles 100 Each Bottle,63700001,CDM,250,RC,,,,,,32122401,NDC,1,EA,37.41,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pancrelipase (lip-prot-amyl) 24000-76000 units Capsule Delayed Release Particles 100 Each Bottle,63700001,CDM,250,RC,,,,,,32122401,NDC,1,EA,37.41,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pancrelipase (lip-prot-amyl) 24000-76000 units Capsule Delayed Release Particles 100 Each Bottle,63700001,CDM,250,RC,,,,,,32122401,NDC,1,EA,37.41,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pancrelipase (lip-prot-amyl) 24000-76000 units Capsule Delayed Release Particles 100 Each Bottle,63700001,CDM,250,RC,,,,,,32122401,NDC,1,EA,37.41,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pancrelipase (lip-prot-amyl) 24000-76000 units Capsule Delayed Release Particles 100 Each Bottle,63700001,CDM,250,RC,,,,,,32122401,NDC,1,EA,37.41,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pancrelipase (lip-prot-amyl) 24000-76000 units Capsule Delayed Release Particles 100 Each Bottle,63700001,CDM,250,RC,,,,,,32122401,NDC,1,EA,37.41,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8092351,NDC,1,EA,52.22,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8092351,NDC,1,EA,52.22,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8092351,NDC,1,EA,52.22,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8092351,NDC,1,EA,52.22,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8092351,NDC,1,EA,52.22,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8092351,NDC,1,EA,52.22,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400101,NDC,1,EA,52.22,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400101,NDC,1,EA,52.22,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400101,NDC,1,EA,52.22,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400101,NDC,1,EA,52.22,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400101,NDC,1,EA,52.22,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400101,NDC,1,EA,52.22,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400125,NDC,1,EA,52.22,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400125,NDC,1,EA,52.22,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400125,NDC,1,EA,52.22,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400125,NDC,1,EA,52.22,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400125,NDC,1,EA,52.22,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400125,NDC,1,EA,52.22,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,781323294,NDC,1,EA,52.89,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,781323294,NDC,1,EA,52.89,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,781323294,NDC,1,EA,52.89,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,781323294,NDC,1,EA,52.89,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,781323294,NDC,1,EA,52.89,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,781323294,NDC,1,EA,52.89,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,55150020200,NDC,1,EA,65.65,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,55150020200,NDC,1,EA,65.65,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,55150020200,NDC,1,EA,65.65,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,55150020200,NDC,1,EA,65.65,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,55150020200,NDC,1,EA,65.65,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,55150020200,NDC,1,EA,65.65,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,72603012801,NDC,1,EA,57.64,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,72603012801,NDC,1,EA,57.64,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,72603012801,NDC,1,EA,57.64,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,72603012801,NDC,1,EA,57.64,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,72603012801,NDC,1,EA,57.64,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,72603012801,NDC,1,EA,57.64,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Pare/Cut Hyperkeratotic Skin Lesion, Single",PX11055F,CDM,510,RC,11055,CPT,,,,,,,,145,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Pare/Cut Hyperkeratotic Skin Lesion, Single",PX11055F,CDM,510,RC,11055,CPT,,,,,,,,145,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Pare/Cut Hyperkeratotic Skin Lesion, Single",PX11055F,CDM,510,RC,11055,CPT,,,,,,,,145,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Pare/Cut Hyperkeratotic Skin Lesion, Single",PX11055F,CDM,510,RC,11055,CPT,,,,,,,,145,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Pare/Cut Hyperkeratotic Skin Lesion, Single",PX11055F,CDM,510,RC,11055,CPT,,,,,,,,145,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Pare/Cut Hyperkeratotic Skin Lesion, Single",PX11055F,CDM,510,RC,11055,CPT,,,,,,,,145,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268064011,NDC,1,EA,4.11,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268064011,NDC,1,EA,4.11,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268064011,NDC,1,EA,4.11,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268064011,NDC,1,EA,4.11,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268064011,NDC,1,EA,4.11,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268064011,NDC,1,EA,4.11,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084004411,NDC,1,EA,14.35,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084004411,NDC,1,EA,14.35,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084004411,NDC,1,EA,14.35,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084004411,NDC,1,EA,14.35,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084004411,NDC,1,EA,14.35,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084004411,NDC,1,EA,14.35,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268064015,NDC,1,EA,4.11,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268064015,NDC,1,EA,4.11,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268064015,NDC,1,EA,4.11,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268064015,NDC,1,EA,4.11,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268064015,NDC,1,EA,4.11,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268064015,NDC,1,EA,4.11,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084004401,NDC,1,EA,14.35,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084004401,NDC,1,EA,14.35,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084004401,NDC,1,EA,14.35,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084004401,NDC,1,EA,14.35,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084004401,NDC,1,EA,14.35,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084004401,NDC,1,EA,14.35,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084004511,NDC,0.5,EA,7.49,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084004511,NDC,0.5,EA,7.49,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084004511,NDC,0.5,EA,7.49,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084004511,NDC,0.5,EA,7.49,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084004511,NDC,0.5,EA,7.49,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084004511,NDC,0.5,EA,7.49,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739096310,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739096310,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739096310,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739096310,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739096310,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739096310,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084004501,NDC,0.5,EA,7.49,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084004501,NDC,0.5,EA,7.49,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084004501,NDC,0.5,EA,7.49,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084004501,NDC,0.5,EA,7.49,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084004501,NDC,0.5,EA,7.49,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084004501,NDC,0.5,EA,7.49,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine CR 12.5 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,42858070303,NDC,1,EA,4.3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine CR 12.5 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,42858070303,NDC,1,EA,4.3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine CR 12.5 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,42858070303,NDC,1,EA,4.3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine CR 12.5 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,42858070303,NDC,1,EA,4.3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine CR 12.5 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,42858070303,NDC,1,EA,4.3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine CR 12.5 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,42858070303,NDC,1,EA,4.3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Part Remv Phalanx of Toe,PX28124F,CDM,510,RC,28124,CPT,,,,,,,,2155,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Part Remv Phalanx of Toe,PX28124F,CDM,510,RC,28124,CPT,,,,,,,,2155,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Part Remv Phalanx of Toe,PX28124F,CDM,510,RC,28124,CPT,,,,,,,,2155,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Part Remv Phalanx of Toe,PX28124F,CDM,510,RC,28124,CPT,,,,,,,,2155,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Part Remv Phalanx of Toe,PX28124F,CDM,510,RC,28124,CPT,,,,,,,,2155,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Part Remv Phalanx of Toe,PX28124F,CDM,510,RC,28124,CPT,,,,,,,,2155,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Part Remv Phalanx of Toe,PX28124P,CDM,983,RC,28124,CPT,,,,,,,,1515,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Part Remv Phalanx of Toe,PX28124P,CDM,983,RC,28124,CPT,,,,,,,,1515,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Part Remv Phalanx of Toe,PX28124P,CDM,983,RC,28124,CPT,,,,,,,,1515,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Part Remv Phalanx of Toe,PX28124P,CDM,983,RC,28124,CPT,,,,,,,,1515,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Part Remv Phalanx of Toe,PX28124P,CDM,983,RC,28124,CPT,,,,,,,,1515,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Part Remv Phalanx of Toe,PX28124P,CDM,983,RC,28124,CPT,,,,,,,,1515,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Partial Bone Scan,PX7830001,CDM,341,RC,78300,CPT,TC,,,,,,,1391,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Partial Bone Scan,PX7830001,CDM,341,RC,78300,CPT,TC,,,,,,,1391,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Partial Bone Scan,PX7830001,CDM,341,RC,78300,CPT,TC,,,,,,,1391,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Partial Bone Scan,PX7830001,CDM,341,RC,78300,CPT,TC,,,,,,,1391,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Partial Bone Scan,PX7830001,CDM,341,RC,78300,CPT,TC,,,,,,,1391,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Partial Bone Scan,PX7830001,CDM,341,RC,78300,CPT,TC,,,,,,,1391,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Parvovirus Antibody - Ref,PX8674790,CDM,300,RC,86747,CPT,90,,,,,,,92,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Parvovirus Antibody - Ref,PX8674790,CDM,300,RC,86747,CPT,90,,,,,,,92,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Parvovirus Antibody - Ref,PX8674790,CDM,300,RC,86747,CPT,90,,,,,,,92,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Parvovirus Antibody - Ref,PX8674790,CDM,300,RC,86747,CPT,90,,,,,,,92,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Parvovirus Antibody - Ref,PX8674790,CDM,300,RC,86747,CPT,90,,,,,,,92,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Parvovirus Antibody - Ref,PX8674790,CDM,300,RC,86747,CPT,90,,,,,,,92,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Path Special Stains II,PX3979,CDM,310,RC,88313,CPT,TC,,,,,,,107,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Path Special Stains II,PX3979,CDM,310,RC,88313,CPT,TC,,,,,,,107,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Path Special Stains II,PX3979,CDM,310,RC,88313,CPT,TC,,,,,,,107,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Path Special Stains II,PX3979,CDM,310,RC,88313,CPT,TC,,,,,,,107,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Path Special Stains II,PX3979,CDM,310,RC,88313,CPT,TC,,,,,,,107,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Path Special Stains II,PX3979,CDM,310,RC,88313,CPT,TC,,,,,,,107,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
patiromer sorbitex calcium 8.4 g Packet 4 Each Box,63700001,CDM,250,RC,,,,,,53436008404,NDC,1,EA,228.96,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
patiromer sorbitex calcium 8.4 g Packet 4 Each Box,63700001,CDM,250,RC,,,,,,53436008404,NDC,1,EA,228.96,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
patiromer sorbitex calcium 8.4 g Packet 4 Each Box,63700001,CDM,250,RC,,,,,,53436008404,NDC,1,EA,228.96,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
patiromer sorbitex calcium 8.4 g Packet 4 Each Box,63700001,CDM,250,RC,,,,,,53436008404,NDC,1,EA,228.96,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
patiromer sorbitex calcium 8.4 g Packet 4 Each Box,63700001,CDM,250,RC,,,,,,53436008404,NDC,1,EA,228.96,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
patiromer sorbitex calcium 8.4 g Packet 4 Each Box,63700001,CDM,250,RC,,,,,,53436008404,NDC,1,EA,228.96,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"PDS II ENDOLOOP LIGATURE SIZE 0 18""",27200000,CDM,272,RC,,,,11700-MAIN,LOCAL,,,,,56.96,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"PDS II ENDOLOOP LIGATURE SIZE 0 18""",27200000,CDM,272,RC,,,,11700-MAIN,LOCAL,,,,,56.96,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"PDS II ENDOLOOP LIGATURE SIZE 0 18""",27200000,CDM,272,RC,,,,11700-MAIN,LOCAL,,,,,56.96,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"PDS II ENDOLOOP LIGATURE SIZE 0 18""",27200000,CDM,272,RC,,,,11700-MAIN,LOCAL,,,,,56.96,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"PDS II ENDOLOOP LIGATURE SIZE 0 18""",27200000,CDM,272,RC,,,,11700-MAIN,LOCAL,,,,,56.96,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"PDS II ENDOLOOP LIGATURE SIZE 0 18""",27200000,CDM,272,RC,,,,11700-MAIN,LOCAL,,,,,56.96,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
peak flow meter Device 1 Each Box,800000,CDM,,,,,,,,8373075500,NDC,1,EA,12,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
peak flow meter Device 1 Each Box,800000,CDM,,,,,,,,8373075500,NDC,1,EA,12,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
peak flow meter Device 1 Each Box,800000,CDM,,,,,,,,8373075500,NDC,1,EA,12,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
peak flow meter Device 1 Each Box,800000,CDM,,,,,,,,8373075500,NDC,1,EA,12,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
peak flow meter Device 1 Each Box,800000,CDM,,,,,,,,8373075500,NDC,1,EA,12,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
peak flow meter Device 1 Each Box,800000,CDM,,,,,,,,8373075500,NDC,1,EA,12,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"pediatric electrolyte Solution 1,000 mL Bottle",25000000,CDM,250,RC,,,,,,49348057041,NDC,1000,ML,31.9,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"pediatric electrolyte Solution 1,000 mL Bottle",25000000,CDM,250,RC,,,,,,49348057041,NDC,1000,ML,31.9,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"pediatric electrolyte Solution 1,000 mL Bottle",25000000,CDM,250,RC,,,,,,49348057041,NDC,1000,ML,31.9,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"pediatric electrolyte Solution 1,000 mL Bottle",25000000,CDM,250,RC,,,,,,49348057041,NDC,1000,ML,31.9,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"pediatric electrolyte Solution 1,000 mL Bottle",25000000,CDM,250,RC,,,,,,49348057041,NDC,1000,ML,31.9,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"pediatric electrolyte Solution 1,000 mL Bottle",25000000,CDM,250,RC,,,,,,49348057041,NDC,1000,ML,31.9,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pegfilgrastim 6 MG/0.6ML Prefilled Syringe Kit 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019201,NDC,0.6,ML,13092.7,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pegfilgrastim 6 MG/0.6ML Prefilled Syringe Kit 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019201,NDC,0.6,ML,13092.7,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pegfilgrastim 6 MG/0.6ML Prefilled Syringe Kit 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019201,NDC,0.6,ML,13092.7,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pegfilgrastim 6 MG/0.6ML Prefilled Syringe Kit 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019201,NDC,0.6,ML,13092.7,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pegfilgrastim 6 MG/0.6ML Prefilled Syringe Kit 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019201,NDC,0.6,ML,13092.7,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pegfilgrastim 6 MG/0.6ML Prefilled Syringe Kit 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019201,NDC,0.6,ML,13092.7,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pegfilgrastim 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019001,NDC,0.6,ML,12711.36,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pegfilgrastim 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019001,NDC,0.6,ML,12711.36,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pegfilgrastim 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019001,NDC,0.6,ML,12711.36,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pegfilgrastim 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019001,NDC,0.6,ML,12711.36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pegfilgrastim 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019001,NDC,0.6,ML,12711.36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pegfilgrastim 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019001,NDC,0.6,ML,12711.36,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pegfilgrastim-cbqv 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5111.01,CDM,636,RC,Q5111,HCPCS,,,,70114010101,NDC,0.6,ML,10040,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pegfilgrastim-cbqv 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5111.01,CDM,636,RC,Q5111,HCPCS,,,,70114010101,NDC,0.6,ML,10040,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pegfilgrastim-cbqv 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5111.01,CDM,636,RC,Q5111,HCPCS,,,,70114010101,NDC,0.6,ML,10040,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pegfilgrastim-cbqv 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5111.01,CDM,636,RC,Q5111,HCPCS,,,,70114010101,NDC,0.6,ML,10040,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pegfilgrastim-cbqv 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5111.01,CDM,636,RC,Q5111,HCPCS,,,,70114010101,NDC,0.6,ML,10040,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pegfilgrastim-cbqv 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5111.01,CDM,636,RC,Q5111,HCPCS,,,,70114010101,NDC,0.6,ML,10040,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pegfilgrastim-jmdb 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5108.01,CDM,636,RC,Q5108,HCPCS,,,,67457083306,NDC,0.6,ML,10040,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pegfilgrastim-jmdb 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5108.01,CDM,636,RC,Q5108,HCPCS,,,,67457083306,NDC,0.6,ML,10040,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pegfilgrastim-jmdb 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5108.01,CDM,636,RC,Q5108,HCPCS,,,,67457083306,NDC,0.6,ML,10040,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pegfilgrastim-jmdb 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5108.01,CDM,636,RC,Q5108,HCPCS,,,,67457083306,NDC,0.6,ML,10040,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pegfilgrastim-jmdb 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5108.01,CDM,636,RC,Q5108,HCPCS,,,,67457083306,NDC,0.6,ML,10040,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pegfilgrastim-jmdb 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5108.01,CDM,636,RC,Q5108,HCPCS,,,,67457083306,NDC,0.6,ML,10040,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pegloticase 8 MG/ML Solution 1 mL Vial,J2507.01,CDM,636,RC,J2507,HCPCS,,,,75987008010,NDC,1,ML,48367.38,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pegloticase 8 MG/ML Solution 1 mL Vial,J2507.01,CDM,636,RC,J2507,HCPCS,,,,75987008010,NDC,1,ML,48367.38,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pegloticase 8 MG/ML Solution 1 mL Vial,J2507.01,CDM,636,RC,J2507,HCPCS,,,,75987008010,NDC,1,ML,48367.38,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pegloticase 8 MG/ML Solution 1 mL Vial,J2507.01,CDM,636,RC,J2507,HCPCS,,,,75987008010,NDC,1,ML,48367.38,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pegloticase 8 MG/ML Solution 1 mL Vial,J2507.01,CDM,636,RC,J2507,HCPCS,,,,75987008010,NDC,1,ML,48367.38,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pegloticase 8 MG/ML Solution 1 mL Vial,J2507.01,CDM,636,RC,J2507,HCPCS,,,,75987008010,NDC,1,ML,48367.38,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pembrolizumab 100 MG/4ML Solution 4 mL Vial,J9271.01,CDM,636,RC,J9271,HCPCS,,,,6302602,NDC,4,ML,9627.58,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pembrolizumab 100 MG/4ML Solution 4 mL Vial,J9271.01,CDM,636,RC,J9271,HCPCS,,,,6302602,NDC,4,ML,9627.58,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pembrolizumab 100 MG/4ML Solution 4 mL Vial,J9271.01,CDM,636,RC,J9271,HCPCS,,,,6302602,NDC,4,ML,9627.58,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pembrolizumab 100 MG/4ML Solution 4 mL Vial,J9271.01,CDM,636,RC,J9271,HCPCS,,,,6302602,NDC,4,ML,9627.58,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pembrolizumab 100 MG/4ML Solution 4 mL Vial,J9271.01,CDM,636,RC,J9271,HCPCS,,,,6302602,NDC,4,ML,9627.58,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pembrolizumab 100 MG/4ML Solution 4 mL Vial,J9271.01,CDM,636,RC,J9271,HCPCS,,,,6302602,NDC,4,ML,9627.58,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PEMEtrexed 500 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2762301,NDC,1,EA,8086.02,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PEMEtrexed 500 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2762301,NDC,1,EA,8086.02,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PEMEtrexed 500 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2762301,NDC,1,EA,8086.02,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PEMEtrexed 500 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2762301,NDC,1,EA,8086.02,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PEMEtrexed 500 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2762301,NDC,1,EA,8086.02,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PEMEtrexed 500 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2762301,NDC,1,EA,8086.02,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PEMEtrexed Disodium 100 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2764001,NDC,1,EA,1539.32,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PEMEtrexed Disodium 100 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2764001,NDC,1,EA,1539.32,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PEMEtrexed Disodium 100 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2764001,NDC,1,EA,1539.32,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PEMEtrexed Disodium 100 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2764001,NDC,1,EA,1539.32,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PEMEtrexed Disodium 100 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2764001,NDC,1,EA,1539.32,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PEMEtrexed Disodium 100 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2764001,NDC,1,EA,1539.32,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070102,NDC,1,ML,383.6,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070102,NDC,1,ML,383.6,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070102,NDC,1,ML,383.6,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070102,NDC,1,ML,383.6,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070102,NDC,1,ML,383.6,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070102,NDC,1,ML,383.6,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070110,NDC,1,ML,459.95,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070110,NDC,1,ML,459.95,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070110,NDC,1,ML,459.95,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070110,NDC,1,ML,459.95,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070110,NDC,1,ML,459.95,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070110,NDC,1,ML,459.95,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052083,NDC,1,EA,92.81,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052083,NDC,1,EA,92.81,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052083,NDC,1,EA,92.81,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052083,NDC,1,EA,92.81,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052083,NDC,1,EA,92.81,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052083,NDC,1,EA,92.81,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052084,NDC,1,EA,92.46,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052084,NDC,1,EA,92.46,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052084,NDC,1,EA,92.46,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052084,NDC,1,EA,92.46,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052084,NDC,1,EA,92.46,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052084,NDC,1,EA,92.46,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060002,NDC,2,ML,953.57,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060002,NDC,2,ML,953.57,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060002,NDC,2,ML,953.57,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060002,NDC,2,ML,953.57,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060002,NDC,2,ML,953.57,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060002,NDC,2,ML,953.57,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060010,NDC,2,ML,953.57,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060010,NDC,2,ML,953.57,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060010,NDC,2,ML,953.57,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060010,NDC,2,ML,953.57,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060010,NDC,2,ML,953.57,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060010,NDC,2,ML,953.57,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin v potassium 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714023401,NDC,1,EA,4.1,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin v potassium 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714023401,NDC,1,EA,4.1,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin v potassium 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714023401,NDC,1,EA,4.1,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin v potassium 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714023401,NDC,1,EA,4.1,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin v potassium 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714023401,NDC,1,EA,4.1,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin v potassium 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714023401,NDC,1,EA,4.1,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin v potassium 250 MG/5ML Recon Soln 200 mL Bottle,63700001,CDM,250,RC,,,,,,93412774,NDC,200,ML,83.32,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin v potassium 250 MG/5ML Recon Soln 200 mL Bottle,63700001,CDM,250,RC,,,,,,93412774,NDC,200,ML,83.32,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin v potassium 250 MG/5ML Recon Soln 200 mL Bottle,63700001,CDM,250,RC,,,,,,93412774,NDC,200,ML,83.32,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin v potassium 250 MG/5ML Recon Soln 200 mL Bottle,63700001,CDM,250,RC,,,,,,93412774,NDC,200,ML,83.32,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin v potassium 250 MG/5ML Recon Soln 200 mL Bottle,63700001,CDM,250,RC,,,,,,93412774,NDC,200,ML,83.32,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin v potassium 250 MG/5ML Recon Soln 200 mL Bottle,63700001,CDM,250,RC,,,,,,93412774,NDC,200,ML,83.32,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin v potassium 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714023501,NDC,0.5,EA,3.44,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin v potassium 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714023501,NDC,0.5,EA,3.44,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin v potassium 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714023501,NDC,0.5,EA,3.44,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin v potassium 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714023501,NDC,0.5,EA,3.44,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin v potassium 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714023501,NDC,0.5,EA,3.44,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin v potassium 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714023501,NDC,0.5,EA,3.44,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pentafluoroprop - tetrafluoroeth Aerosol 116 mL Can,63700001,CDM,250,RC,,,,,,386000802,NDC,207,ML,383.42,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pentafluoroprop - tetrafluoroeth Aerosol 116 mL Can,63700001,CDM,250,RC,,,,,,386000802,NDC,207,ML,383.42,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pentafluoroprop - tetrafluoroeth Aerosol 116 mL Can,63700001,CDM,250,RC,,,,,,386000802,NDC,207,ML,383.42,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pentafluoroprop - tetrafluoroeth Aerosol 116 mL Can,63700001,CDM,250,RC,,,,,,386000802,NDC,207,ML,383.42,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pentafluoroprop - tetrafluoroeth Aerosol 116 mL Can,63700001,CDM,250,RC,,,,,,386000802,NDC,207,ML,383.42,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pentafluoroprop - tetrafluoroeth Aerosol 116 mL Can,63700001,CDM,250,RC,,,,,,386000802,NDC,207,ML,383.42,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Peramivir 200 MG/20ML Solution 20 mL Vial,800000,CDM,,,,,,,,61364018101,NDC,20,ML,1832.6,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Peramivir 200 MG/20ML Solution 20 mL Vial,800000,CDM,,,,,,,,61364018101,NDC,20,ML,1832.6,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Peramivir 200 MG/20ML Solution 20 mL Vial,800000,CDM,,,,,,,,61364018101,NDC,20,ML,1832.6,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Peramivir 200 MG/20ML Solution 20 mL Vial,800000,CDM,,,,,,,,61364018101,NDC,20,ML,1832.6,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Peramivir 200 MG/20ML Solution 20 mL Vial,800000,CDM,,,,,,,,61364018101,NDC,20,ML,1832.6,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Peramivir 200 MG/20ML Solution 20 mL Vial,800000,CDM,,,,,,,,61364018101,NDC,20,ML,1832.6,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Percut Biopsy, Abdominal Mass",PX49180F,CDM,510,RC,49180,CPT,,,,,,,,2084,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Percut Biopsy, Abdominal Mass",PX49180F,CDM,510,RC,49180,CPT,,,,,,,,2084,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Percut Biopsy, Abdominal Mass",PX49180F,CDM,510,RC,49180,CPT,,,,,,,,2084,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Percut Biopsy, Abdominal Mass",PX49180F,CDM,510,RC,49180,CPT,,,,,,,,2084,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Percut Biopsy, Abdominal Mass",PX49180F,CDM,510,RC,49180,CPT,,,,,,,,2084,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Percut Biopsy, Abdominal Mass",PX49180F,CDM,510,RC,49180,CPT,,,,,,,,2084,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PERFIX PLUG STERILE LARGE,C1781,CDM,278,RC,C1781,HCPCS,,11771-MAIN,LOCAL,,,,,558,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PERFIX PLUG STERILE LARGE,C1781,CDM,278,RC,C1781,HCPCS,,11771-MAIN,LOCAL,,,,,558,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PERFIX PLUG STERILE LARGE,C1781,CDM,278,RC,C1781,HCPCS,,11771-MAIN,LOCAL,,,,,558,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PERFIX PLUG STERILE LARGE,C1781,CDM,278,RC,C1781,HCPCS,,11771-MAIN,LOCAL,,,,,558,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PERFIX PLUG STERILE LARGE,C1781,CDM,278,RC,C1781,HCPCS,,11771-MAIN,LOCAL,,,,,558,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PERFIX PLUG STERILE LARGE,C1781,CDM,278,RC,C1781,HCPCS,,11771-MAIN,LOCAL,,,,,558,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PERFIX PLUG STERILE MEDIUM,C1781,CDM,278,RC,C1781,HCPCS,,11770-MAIN,LOCAL,,,,,553,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PERFIX PLUG STERILE MEDIUM,C1781,CDM,278,RC,C1781,HCPCS,,11770-MAIN,LOCAL,,,,,553,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PERFIX PLUG STERILE MEDIUM,C1781,CDM,278,RC,C1781,HCPCS,,11770-MAIN,LOCAL,,,,,553,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PERFIX PLUG STERILE MEDIUM,C1781,CDM,278,RC,C1781,HCPCS,,11770-MAIN,LOCAL,,,,,553,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PERFIX PLUG STERILE MEDIUM,C1781,CDM,278,RC,C1781,HCPCS,,11770-MAIN,LOCAL,,,,,553,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PERFIX PLUG STERILE MEDIUM,C1781,CDM,278,RC,C1781,HCPCS,,11770-MAIN,LOCAL,,,,,553,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PERFIX PLUG STERILE X-LARGE,C1781,CDM,278,RC,C1781,HCPCS,,11772-MAIN,LOCAL,,,,,643,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PERFIX PLUG STERILE X-LARGE,C1781,CDM,278,RC,C1781,HCPCS,,11772-MAIN,LOCAL,,,,,643,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PERFIX PLUG STERILE X-LARGE,C1781,CDM,278,RC,C1781,HCPCS,,11772-MAIN,LOCAL,,,,,643,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PERFIX PLUG STERILE X-LARGE,C1781,CDM,278,RC,C1781,HCPCS,,11772-MAIN,LOCAL,,,,,643,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PERFIX PLUG STERILE X-LARGE,C1781,CDM,278,RC,C1781,HCPCS,,11772-MAIN,LOCAL,,,,,643,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PERFIX PLUG STERILE X-LARGE,C1781,CDM,278,RC,C1781,HCPCS,,11772-MAIN,LOCAL,,,,,643,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
perflutren lipid microsphere 6.52 MG/ML Suspension 2 mL Vial,Q9957,CDM,636,RC,Q9957,HCPCS,,,,11994001101,NDC,2,ML,751.71,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
perflutren lipid microsphere 6.52 MG/ML Suspension 2 mL Vial,Q9957,CDM,636,RC,Q9957,HCPCS,,,,11994001101,NDC,2,ML,751.71,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
perflutren lipid microsphere 6.52 MG/ML Suspension 2 mL Vial,Q9957,CDM,636,RC,Q9957,HCPCS,,,,11994001101,NDC,2,ML,751.71,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
perflutren lipid microsphere 6.52 MG/ML Suspension 2 mL Vial,Q9957,CDM,636,RC,Q9957,HCPCS,,,,11994001101,NDC,2,ML,751.71,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
perflutren lipid microsphere 6.52 MG/ML Suspension 2 mL Vial,Q9957,CDM,636,RC,Q9957,HCPCS,,,,11994001101,NDC,2,ML,751.71,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
perflutren lipid microsphere 6.52 MG/ML Suspension 2 mL Vial,Q9957,CDM,636,RC,Q9957,HCPCS,,,,11994001101,NDC,2,ML,751.71,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
perflutren protein A microsphere Suspension 3 mL Vial,Q9956,CDM,636,RC,Q9956,HCPCS,,,,407270703,NDC,3,ML,739.41,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
perflutren protein A microsphere Suspension 3 mL Vial,Q9956,CDM,636,RC,Q9956,HCPCS,,,,407270703,NDC,3,ML,739.41,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
perflutren protein A microsphere Suspension 3 mL Vial,Q9956,CDM,636,RC,Q9956,HCPCS,,,,407270703,NDC,3,ML,739.41,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
perflutren protein A microsphere Suspension 3 mL Vial,Q9956,CDM,636,RC,Q9956,HCPCS,,,,407270703,NDC,3,ML,739.41,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
perflutren protein A microsphere Suspension 3 mL Vial,Q9956,CDM,636,RC,Q9956,HCPCS,,,,407270703,NDC,3,ML,739.41,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
perflutren protein A microsphere Suspension 3 mL Vial,Q9956,CDM,636,RC,Q9956,HCPCS,,,,407270703,NDC,3,ML,739.41,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569F,CDM,510,RC,36569,CPT,,,,,,,,1217,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569F,CDM,510,RC,36569,CPT,,,,,,,,1217,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569F,CDM,510,RC,36569,CPT,,,,,,,,1217,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569F,CDM,510,RC,36569,CPT,,,,,,,,1217,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569F,CDM,510,RC,36569,CPT,,,,,,,,1217,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569F,CDM,510,RC,36569,CPT,,,,,,,,1217,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569P,CDM,983,RC,36569,CPT,,,,,,,,1825,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569P,CDM,983,RC,36569,CPT,,,,,,,,1825,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569P,CDM,983,RC,36569,CPT,,,,,,,,1825,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569P,CDM,983,RC,36569,CPT,,,,,,,,1825,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569P,CDM,983,RC,36569,CPT,,,,,,,,1825,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569P,CDM,983,RC,36569,CPT,,,,,,,,1825,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Pertechnetate, Dia, per Mci",PXA9512,CDM,343,RC,A9512,HCPCS,,,,,,,,280,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Pertechnetate, Dia, per Mci",PXA9512,CDM,343,RC,A9512,HCPCS,,,,,,,,280,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Pertechnetate, Dia, per Mci",PXA9512,CDM,343,RC,A9512,HCPCS,,,,,,,,280,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Pertechnetate, Dia, per Mci",PXA9512,CDM,343,RC,A9512,HCPCS,,,,,,,,280,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Pertechnetate, Dia, per Mci",PXA9512,CDM,343,RC,A9512,HCPCS,,,,,,,,280,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Pertechnetate, Dia, per Mci",PXA9512,CDM,343,RC,A9512,HCPCS,,,,,,,,280,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PEZZER CATHETER DRAIN LATEX 14FR,27200000,CDM,272,RC,,,,12053-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PEZZER CATHETER DRAIN LATEX 14FR,27200000,CDM,272,RC,,,,12053-MAIN,LOCAL,,,,,38,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PEZZER CATHETER DRAIN LATEX 14FR,27200000,CDM,272,RC,,,,12053-MAIN,LOCAL,,,,,38,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PEZZER CATHETER DRAIN LATEX 14FR,27200000,CDM,272,RC,,,,12053-MAIN,LOCAL,,,,,38,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PEZZER CATHETER DRAIN LATEX 14FR,27200000,CDM,272,RC,,,,12053-MAIN,LOCAL,,,,,38,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PEZZER CATHETER DRAIN LATEX 14FR,27200000,CDM,272,RC,,,,12053-MAIN,LOCAL,,,,,38,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PEZZER LATEX CATHETER DRAIN 10FR,27200000,CDM,272,RC,,,,12646-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PEZZER LATEX CATHETER DRAIN 10FR,27200000,CDM,272,RC,,,,12646-MAIN,LOCAL,,,,,38,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PEZZER LATEX CATHETER DRAIN 10FR,27200000,CDM,272,RC,,,,12646-MAIN,LOCAL,,,,,38,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PEZZER LATEX CATHETER DRAIN 10FR,27200000,CDM,272,RC,,,,12646-MAIN,LOCAL,,,,,38,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PEZZER LATEX CATHETER DRAIN 10FR,27200000,CDM,272,RC,,,,12646-MAIN,LOCAL,,,,,38,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PEZZER LATEX CATHETER DRAIN 10FR,27200000,CDM,272,RC,,,,12646-MAIN,LOCAL,,,,,38,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Pfizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 2nd Dose",PX0002A,CDM,771,RC,0002A,HCPCS,,,,,,,,69,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Pfizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 2nd Dose",PX0002A,CDM,771,RC,0002A,HCPCS,,,,,,,,69,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Pfizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 2nd Dose",PX0002A,CDM,771,RC,0002A,HCPCS,,,,,,,,69,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Pfizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 2nd Dose",PX0002A,CDM,771,RC,0002A,HCPCS,,,,,,,,69,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Pfizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 2nd Dose",PX0002A,CDM,771,RC,0002A,HCPCS,,,,,,,,69,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Pfizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 2nd Dose",PX0002A,CDM,771,RC,0002A,HCPCS,,,,,,,,69,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Pfizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 3rd Dose",PX0003A,CDM,771,RC,0003A,HCPCS,,,,,,,,69,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Pfizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 3rd Dose",PX0003A,CDM,771,RC,0003A,HCPCS,,,,,,,,69,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Pfizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 3rd Dose",PX0003A,CDM,771,RC,0003A,HCPCS,,,,,,,,69,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Pfizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 3rd Dose",PX0003A,CDM,771,RC,0003A,HCPCS,,,,,,,,69,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Pfizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 3rd Dose",PX0003A,CDM,771,RC,0003A,HCPCS,,,,,,,,69,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Pfizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 3rd Dose",PX0003A,CDM,771,RC,0003A,HCPCS,,,,,,,,69,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ph Venous Blood,PX82800,CDM,300,RC,82800,CPT,,,,,,,,147,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ph Venous Blood,PX82800,CDM,300,RC,82800,CPT,,,,,,,,147,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ph Venous Blood,PX82800,CDM,300,RC,82800,CPT,,,,,,,,147,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ph Venous Blood,PX82800,CDM,300,RC,82800,CPT,,,,,,,,147,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ph Venous Blood,PX82800,CDM,300,RC,82800,CPT,,,,,,,,147,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ph Venous Blood,PX82800,CDM,300,RC,82800,CPT,,,,,,,,147,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHALINX STERILE LARGE 0 HAMMERTOE SYSTEM 45A01004,27800000,CDM,278,RC,C1713,HCPCS,,12962-MAIN,LOCAL,,,,,4759,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHALINX STERILE LARGE 0 HAMMERTOE SYSTEM 45A01004,27800000,CDM,278,RC,C1713,HCPCS,,12962-MAIN,LOCAL,,,,,4759,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHALINX STERILE LARGE 0 HAMMERTOE SYSTEM 45A01004,27800000,CDM,278,RC,C1713,HCPCS,,12962-MAIN,LOCAL,,,,,4759,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHALINX STERILE LARGE 0 HAMMERTOE SYSTEM 45A01004,27800000,CDM,278,RC,C1713,HCPCS,,12962-MAIN,LOCAL,,,,,4759,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHALINX STERILE LARGE 0 HAMMERTOE SYSTEM 45A01004,27800000,CDM,278,RC,C1713,HCPCS,,12962-MAIN,LOCAL,,,,,4759,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHALINX STERILE LARGE 0 HAMMERTOE SYSTEM 45A01004,27800000,CDM,278,RC,C1713,HCPCS,,12962-MAIN,LOCAL,,,,,4759,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHALINX STERILE MEDIUM 0 HAMMERTOE SYSTEM 45A01003,27800000,CDM,278,RC,C1713,HCPCS,,12961-MAIN,LOCAL,,,,,4759,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHALINX STERILE MEDIUM 0 HAMMERTOE SYSTEM 45A01003,27800000,CDM,278,RC,C1713,HCPCS,,12961-MAIN,LOCAL,,,,,4759,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHALINX STERILE MEDIUM 0 HAMMERTOE SYSTEM 45A01003,27800000,CDM,278,RC,C1713,HCPCS,,12961-MAIN,LOCAL,,,,,4759,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHALINX STERILE MEDIUM 0 HAMMERTOE SYSTEM 45A01003,27800000,CDM,278,RC,C1713,HCPCS,,12961-MAIN,LOCAL,,,,,4759,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHALINX STERILE MEDIUM 0 HAMMERTOE SYSTEM 45A01003,27800000,CDM,278,RC,C1713,HCPCS,,12961-MAIN,LOCAL,,,,,4759,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHALINX STERILE MEDIUM 0 HAMMERTOE SYSTEM 45A01003,27800000,CDM,278,RC,C1713,HCPCS,,12961-MAIN,LOCAL,,,,,4759,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHALINX STERILE SMALL 0 HAMMERTOE SYSTEM 45A01002,27800000,CDM,278,RC,C1713,HCPCS,,12960-MAIN,LOCAL,,,,,4759,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHALINX STERILE SMALL 0 HAMMERTOE SYSTEM 45A01002,27800000,CDM,278,RC,C1713,HCPCS,,12960-MAIN,LOCAL,,,,,4759,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHALINX STERILE SMALL 0 HAMMERTOE SYSTEM 45A01002,27800000,CDM,278,RC,C1713,HCPCS,,12960-MAIN,LOCAL,,,,,4759,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHALINX STERILE SMALL 0 HAMMERTOE SYSTEM 45A01002,27800000,CDM,278,RC,C1713,HCPCS,,12960-MAIN,LOCAL,,,,,4759,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHALINX STERILE SMALL 0 HAMMERTOE SYSTEM 45A01002,27800000,CDM,278,RC,C1713,HCPCS,,12960-MAIN,LOCAL,,,,,4759,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHALINX STERILE SMALL 0 HAMMERTOE SYSTEM 45A01002,27800000,CDM,278,RC,C1713,HCPCS,,12960-MAIN,LOCAL,,,,,4759,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHALINX STERILE TRIAL SIZER 45A00000,27200000,CDM,272,RC,,,,12959-MAIN,LOCAL,,,,,181,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHALINX STERILE TRIAL SIZER 45A00000,27200000,CDM,272,RC,,,,12959-MAIN,LOCAL,,,,,181,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHALINX STERILE TRIAL SIZER 45A00000,27200000,CDM,272,RC,,,,12959-MAIN,LOCAL,,,,,181,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHALINX STERILE TRIAL SIZER 45A00000,27200000,CDM,272,RC,,,,12959-MAIN,LOCAL,,,,,181,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHALINX STERILE TRIAL SIZER 45A00000,27200000,CDM,272,RC,,,,12959-MAIN,LOCAL,,,,,181,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHALINX STERILE TRIAL SIZER 45A00000,27200000,CDM,272,RC,,,,12959-MAIN,LOCAL,,,,,181,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Phase II Recovery,PX71000047,CDM,710,RC,,,,,,,,,,15,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Phase II Recovery,PX71000047,CDM,710,RC,,,,,,,,,,15,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Phase II Recovery,PX71000047,CDM,710,RC,,,,,,,,,,15,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Phase II Recovery,PX71000047,CDM,710,RC,,,,,,,,,,15,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Phase II Recovery,PX71000047,CDM,710,RC,,,,,,,,,,15,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Phase II Recovery,PX71000047,CDM,710,RC,,,,,,,,,,15,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Phase III Recovery Monthly,PX93799.01,CDM,943,RC,,,,,,,,,,25,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Phase III Recovery Monthly,PX93799.01,CDM,943,RC,,,,,,,,,,25,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Phase III Recovery Monthly,PX93799.01,CDM,943,RC,,,,,,,,,,25,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Phase III Recovery Monthly,PX93799.01,CDM,943,RC,,,,,,,,,,25,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Phase III Recovery Monthly,PX93799.01,CDM,943,RC,,,,,,,,,,25,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Phase III Recovery Monthly,PX93799.01,CDM,943,RC,,,,,,,,,,25,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHASIX 25X30CM 1190400,C1781,CDM,278,RC,C1781,HCPCS,,13011-MAIN,LOCAL,,,,,16080,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHASIX 25X30CM 1190400,C1781,CDM,278,RC,C1781,HCPCS,,13011-MAIN,LOCAL,,,,,16080,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHASIX 25X30CM 1190400,C1781,CDM,278,RC,C1781,HCPCS,,13011-MAIN,LOCAL,,,,,16080,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHASIX 25X30CM 1190400,C1781,CDM,278,RC,C1781,HCPCS,,13011-MAIN,LOCAL,,,,,16080,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHASIX 25X30CM 1190400,C1781,CDM,278,RC,C1781,HCPCS,,13011-MAIN,LOCAL,,,,,16080,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHASIX 25X30CM 1190400,C1781,CDM,278,RC,C1781,HCPCS,,13011-MAIN,LOCAL,,,,,16080,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHASIX ST 15X20CM 1201520,C1781,CDM,278,RC,C1781,HCPCS,,13010-MAIN,LOCAL,,,,,11988,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHASIX ST 15X20CM 1201520,C1781,CDM,278,RC,C1781,HCPCS,,13010-MAIN,LOCAL,,,,,11988,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHASIX ST 15X20CM 1201520,C1781,CDM,278,RC,C1781,HCPCS,,13010-MAIN,LOCAL,,,,,11988,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHASIX ST 15X20CM 1201520,C1781,CDM,278,RC,C1781,HCPCS,,13010-MAIN,LOCAL,,,,,11988,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHASIX ST 15X20CM 1201520,C1781,CDM,278,RC,C1781,HCPCS,,13010-MAIN,LOCAL,,,,,11988,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHASIX ST 15X20CM 1201520,C1781,CDM,278,RC,C1781,HCPCS,,13010-MAIN,LOCAL,,,,,11988,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42937070110,NDC,1,EA,5.16,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42937070110,NDC,1,EA,5.16,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42937070110,NDC,1,EA,5.16,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42937070110,NDC,1,EA,5.16,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42937070110,NDC,1,EA,5.16,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42937070110,NDC,1,EA,5.16,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,51293081001,NDC,1,EA,14.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,51293081001,NDC,1,EA,14.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,51293081001,NDC,1,EA,14.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,51293081001,NDC,1,EA,14.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,51293081001,NDC,1,EA,14.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,51293081001,NDC,1,EA,14.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65162068110,NDC,1,EA,14.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65162068110,NDC,1,EA,14.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65162068110,NDC,1,EA,14.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65162068110,NDC,1,EA,14.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65162068110,NDC,1,EA,14.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65162068110,NDC,1,EA,14.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,75826011410,NDC,1,EA,12.89,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,75826011410,NDC,1,EA,12.89,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,75826011410,NDC,1,EA,12.89,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,75826011410,NDC,1,EA,12.89,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,75826011410,NDC,1,EA,12.89,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,75826011410,NDC,1,EA,12.89,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHENobarbital 32.4 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904657561,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHENobarbital 32.4 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904657561,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHENobarbital 32.4 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904657561,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHENobarbital 32.4 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904657561,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHENobarbital 32.4 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904657561,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHENobarbital 32.4 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904657561,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHENobarbital 130 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047721,NDC,1,ML,338.93,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHENobarbital 130 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047721,NDC,1,ML,338.93,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHENobarbital 130 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047721,NDC,1,ML,338.93,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHENobarbital 130 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047721,NDC,1,ML,338.93,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHENobarbital 130 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047721,NDC,1,ML,338.93,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHENobarbital 130 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047721,NDC,1,ML,338.93,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Phenobarbital Assay - Ref,PX8018490,CDM,300,RC,80184,CPT,90,,,,,,,20,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Phenobarbital Assay - Ref,PX8018490,CDM,300,RC,80184,CPT,90,,,,,,,20,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Phenobarbital Assay - Ref,PX8018490,CDM,300,RC,80184,CPT,90,,,,,,,20,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Phenobarbital Assay - Ref,PX8018490,CDM,300,RC,80184,CPT,90,,,,,,,20,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Phenobarbital Assay - Ref,PX8018490,CDM,300,RC,80184,CPT,90,,,,,,,20,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Phenobarbital Assay - Ref,PX8018490,CDM,300,RC,80184,CPT,90,,,,,,,20,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047621,NDC,1,ML,157.28,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047621,NDC,1,ML,157.28,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047621,NDC,1,ML,157.28,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047621,NDC,1,ML,157.28,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047621,NDC,1,ML,157.28,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047621,NDC,1,ML,157.28,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047625,NDC,0.769230769,ML,111.59,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047625,NDC,0.769230769,ML,111.59,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047625,NDC,0.769230769,ML,111.59,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047625,NDC,0.769230769,ML,111.59,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047625,NDC,0.769230769,ML,111.59,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047625,NDC,0.769230769,ML,111.59,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenol-glycerin 1.5-33 % Liquid 118 mL Bottle,25000000,CDM,250,RC,,,,,,78112000068,NDC,118,ML,44.12,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenol-glycerin 1.5-33 % Liquid 118 mL Bottle,25000000,CDM,250,RC,,,,,,78112000068,NDC,118,ML,44.12,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenol-glycerin 1.5-33 % Liquid 118 mL Bottle,25000000,CDM,250,RC,,,,,,78112000068,NDC,118,ML,44.12,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenol-glycerin 1.5-33 % Liquid 118 mL Bottle,25000000,CDM,250,RC,,,,,,78112000068,NDC,118,ML,44.12,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenol-glycerin 1.5-33 % Liquid 118 mL Bottle,25000000,CDM,250,RC,,,,,,78112000068,NDC,118,ML,44.12,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenol-glycerin 1.5-33 % Liquid 118 mL Bottle,25000000,CDM,250,RC,,,,,,78112000068,NDC,118,ML,44.12,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956401,NDC,1,EA,1611.2,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956401,NDC,1,EA,1611.2,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956401,NDC,1,EA,1611.2,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956401,NDC,1,EA,1611.2,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956401,NDC,1,EA,1611.2,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956401,NDC,1,EA,1611.2,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956410,NDC,1,EA,1689.17,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956410,NDC,1,EA,1689.17,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956410,NDC,1,EA,1689.17,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956410,NDC,1,EA,1689.17,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956410,NDC,1,EA,1689.17,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956410,NDC,1,EA,1689.17,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenylephrine 0.25 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,69536002515,NDC,15,ML,24.21,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenylephrine 0.25 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,69536002515,NDC,15,ML,24.21,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenylephrine 0.25 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,69536002515,NDC,15,ML,24.21,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenylephrine 0.25 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,69536002515,NDC,15,ML,24.21,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenylephrine 0.25 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,69536002515,NDC,15,ML,24.21,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenylephrine 0.25 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,69536002515,NDC,15,ML,24.21,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614201,NDC,1,ML,88.69,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614201,NDC,1,ML,88.69,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614201,NDC,1,ML,88.69,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614201,NDC,1,ML,88.69,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614201,NDC,1,ML,88.69,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614201,NDC,1,ML,88.69,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614225,NDC,1,ML,88.69,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614225,NDC,1,ML,88.69,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614225,NDC,1,ML,88.69,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614225,NDC,1,ML,88.69,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614225,NDC,1,ML,88.69,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614225,NDC,1,ML,88.69,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641622901,NDC,1,ML,41.16,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641622901,NDC,1,ML,41.16,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641622901,NDC,1,ML,41.16,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641622901,NDC,1,ML,41.16,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641622901,NDC,1,ML,41.16,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641622901,NDC,1,ML,41.16,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenytoin ER 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084037611,NDC,1,EA,3.44,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenytoin ER 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084037611,NDC,1,EA,3.44,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenytoin ER 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084037611,NDC,1,EA,3.44,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenytoin ER 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084037611,NDC,1,EA,3.44,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenytoin ER 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084037611,NDC,1,EA,3.44,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenytoin ER 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084037611,NDC,1,EA,3.44,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenytoin ER 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904618761,NDC,0.3,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenytoin ER 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904618761,NDC,0.3,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenytoin ER 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904618761,NDC,0.3,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenytoin ER 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904618761,NDC,0.3,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenytoin ER 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904618761,NDC,0.3,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenytoin ER 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904618761,NDC,0.3,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenytoin ER 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,68084037601,NDC,0.3,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenytoin ER 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,68084037601,NDC,0.3,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenytoin ER 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,68084037601,NDC,0.3,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenytoin ER 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,68084037601,NDC,0.3,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenytoin ER 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,68084037601,NDC,0.3,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenytoin ER 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,68084037601,NDC,0.3,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Phlebotomy,PX99195,CDM,940,RC,99195,CPT,,,,,,,,238,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Phlebotomy,PX99195,CDM,940,RC,99195,CPT,,,,,,,,238,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Phlebotomy,PX99195,CDM,940,RC,99195,CPT,,,,,,,,238,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Phlebotomy,PX99195,CDM,940,RC,99195,CPT,,,,,,,,238,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Phlebotomy,PX99195,CDM,940,RC,99195,CPT,,,,,,,,238,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Phlebotomy,PX99195,CDM,940,RC,99195,CPT,,,,,,,,238,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phosphorus 155-852-130 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,64980010401,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phosphorus 155-852-130 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,64980010401,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phosphorus 155-852-130 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,64980010401,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phosphorus 155-852-130 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,64980010401,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phosphorus 155-852-130 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,64980010401,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phosphorus 155-852-130 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,64980010401,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Physical Therapy Evaluation High Complex,PX97163,CDM,424,RC,97163,CPT,,,,,,,,294,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Physical Therapy Evaluation High Complex,PX97163,CDM,424,RC,97163,CPT,,,,,,,,294,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Physical Therapy Evaluation High Complex,PX97163,CDM,424,RC,97163,CPT,,,,,,,,294,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Physical Therapy Evaluation High Complex,PX97163,CDM,424,RC,97163,CPT,,,,,,,,294,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Physical Therapy Evaluation High Complex,PX97163,CDM,424,RC,97163,CPT,,,,,,,,294,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Physical Therapy Evaluation High Complex,PX97163,CDM,424,RC,97163,CPT,,,,,,,,294,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Physical Therapy Evaluation Low Complex,PX97161,CDM,424,RC,97161,CPT,,,,,,,,235,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Physical Therapy Evaluation Low Complex,PX97161,CDM,424,RC,97161,CPT,,,,,,,,235,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Physical Therapy Evaluation Low Complex,PX97161,CDM,424,RC,97161,CPT,,,,,,,,235,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Physical Therapy Evaluation Low Complex,PX97161,CDM,424,RC,97161,CPT,,,,,,,,235,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Physical Therapy Evaluation Low Complex,PX97161,CDM,424,RC,97161,CPT,,,,,,,,235,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Physical Therapy Evaluation Low Complex,PX97161,CDM,424,RC,97161,CPT,,,,,,,,235,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Physical Therapy Evaluation Mod Complex,PX97162,CDM,424,RC,97162,CPT,,,,,,,,264,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Physical Therapy Evaluation Mod Complex,PX97162,CDM,424,RC,97162,CPT,,,,,,,,264,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Physical Therapy Evaluation Mod Complex,PX97162,CDM,424,RC,97162,CPT,,,,,,,,264,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Physical Therapy Evaluation Mod Complex,PX97162,CDM,424,RC,97162,CPT,,,,,,,,264,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Physical Therapy Evaluation Mod Complex,PX97162,CDM,424,RC,97162,CPT,,,,,,,,264,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Physical Therapy Evaluation Mod Complex,PX97162,CDM,424,RC,97162,CPT,,,,,,,,264,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Physical Therapy Re-Eval Est Plan Care 20 Mins,PX97164,CDM,424,RC,97164,CPT,,,,,,,,239,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Physical Therapy Re-Eval Est Plan Care 20 Mins,PX97164,CDM,424,RC,97164,CPT,,,,,,,,239,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Physical Therapy Re-Eval Est Plan Care 20 Mins,PX97164,CDM,424,RC,97164,CPT,,,,,,,,239,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Physical Therapy Re-Eval Est Plan Care 20 Mins,PX97164,CDM,424,RC,97164,CPT,,,,,,,,239,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Physical Therapy Re-Eval Est Plan Care 20 Mins,PX97164,CDM,424,RC,97164,CPT,,,,,,,,239,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Physical Therapy Re-Eval Est Plan Care 20 Mins,PX97164,CDM,424,RC,97164,CPT,,,,,,,,239,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915701,NDC,0.5,ML,44.33,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915701,NDC,0.5,ML,44.33,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915701,NDC,0.5,ML,44.33,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915701,NDC,0.5,ML,44.33,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915701,NDC,0.5,ML,44.33,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915701,NDC,0.5,ML,44.33,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915731,NDC,0.5,ML,44.33,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915731,NDC,0.5,ML,44.33,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915731,NDC,0.5,ML,44.33,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915731,NDC,0.5,ML,44.33,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915731,NDC,0.5,ML,44.33,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915731,NDC,0.5,ML,44.33,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phytonadione 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714097302,NDC,0.5,EA,143.02,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phytonadione 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714097302,NDC,0.5,EA,143.02,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phytonadione 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714097302,NDC,0.5,EA,143.02,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phytonadione 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714097302,NDC,0.5,EA,143.02,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phytonadione 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714097302,NDC,0.5,EA,143.02,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phytonadione 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714097302,NDC,0.5,EA,143.02,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phytonadione 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,69238105103,NDC,0.5,EA,143.02,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phytonadione 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,69238105103,NDC,0.5,EA,143.02,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phytonadione 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,69238105103,NDC,0.5,EA,143.02,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phytonadione 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,69238105103,NDC,0.5,EA,143.02,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phytonadione 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,69238105103,NDC,0.5,EA,143.02,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phytonadione 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,69238105103,NDC,0.5,EA,143.02,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915801,NDC,1,ML,267.19,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915801,NDC,1,ML,267.19,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915801,NDC,1,ML,267.19,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915801,NDC,1,ML,267.19,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915801,NDC,1,ML,267.19,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915801,NDC,1,ML,267.19,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915850,NDC,0.2,ML,69.44,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915850,NDC,0.2,ML,69.44,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915850,NDC,0.2,ML,69.44,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915850,NDC,0.2,ML,69.44,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915850,NDC,0.2,ML,69.44,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915850,NDC,0.2,ML,69.44,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,43598040516,NDC,0.2,ML,63.83,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,43598040516,NDC,0.2,ML,63.83,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,43598040516,NDC,0.2,ML,63.83,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,43598040516,NDC,0.2,ML,63.83,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,43598040516,NDC,0.2,ML,63.83,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,43598040516,NDC,0.2,ML,63.83,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Pifizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 1st Dose",PX0001A,CDM,771,RC,0001A,HCPCS,,,,,,,,69,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Pifizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 1st Dose",PX0001A,CDM,771,RC,0001A,HCPCS,,,,,,,,69,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Pifizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 1st Dose",PX0001A,CDM,771,RC,0001A,HCPCS,,,,,,,,69,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Pifizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 1st Dose",PX0001A,CDM,771,RC,0001A,HCPCS,,,,,,,,69,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Pifizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 1st Dose",PX0001A,CDM,771,RC,0001A,HCPCS,,,,,,,,69,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Pifizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 1st Dose",PX0001A,CDM,771,RC,0001A,HCPCS,,,,,,,,69,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pindolol 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,29033002801,NDC,1,EA,24.77,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pindolol 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,29033002801,NDC,1,EA,24.77,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pindolol 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,29033002801,NDC,1,EA,24.77,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pindolol 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,29033002801,NDC,1,EA,24.77,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pindolol 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,29033002801,NDC,1,EA,24.77,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pindolol 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,29033002801,NDC,1,EA,24.77,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Pinworm Exam,PX87172,CDM,300,RC,87172,CPT,,,,,,,,46,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Pinworm Exam,PX87172,CDM,300,RC,87172,CPT,,,,,,,,46,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Pinworm Exam,PX87172,CDM,300,RC,87172,CPT,,,,,,,,46,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Pinworm Exam,PX87172,CDM,300,RC,87172,CPT,,,,,,,,46,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Pinworm Exam,PX87172,CDM,300,RC,87172,CPT,,,,,,,,46,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Pinworm Exam,PX87172,CDM,300,RC,87172,CPT,,,,,,,,46,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pioglitazone 15 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342005410,NDC,1,EA,37.62,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pioglitazone 15 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342005410,NDC,1,EA,37.62,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pioglitazone 15 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342005410,NDC,1,EA,37.62,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pioglitazone 15 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342005410,NDC,1,EA,37.62,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pioglitazone 15 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342005410,NDC,1,EA,37.62,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pioglitazone 15 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342005410,NDC,1,EA,37.62,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030926,NDC,1,EA,55.44,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030926,NDC,1,EA,55.44,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030926,NDC,1,EA,55.44,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030926,NDC,1,EA,55.44,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030926,NDC,1,EA,55.44,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030926,NDC,1,EA,55.44,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098121,NDC,1,EA,72.95,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098121,NDC,1,EA,72.95,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098121,NDC,1,EA,72.95,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098121,NDC,1,EA,72.95,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098121,NDC,1,EA,72.95,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098121,NDC,1,EA,72.95,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098141,NDC,1,EA,39.84,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098141,NDC,1,EA,39.84,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098141,NDC,1,EA,39.84,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098141,NDC,1,EA,39.84,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098141,NDC,1,EA,39.84,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098141,NDC,1,EA,39.84,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098153,NDC,1,EA,39.84,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098153,NDC,1,EA,39.84,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098153,NDC,1,EA,39.84,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098153,NDC,1,EA,39.84,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098153,NDC,1,EA,39.84,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098153,NDC,1,EA,39.84,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409338513,NDC,1,EA,74.09,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409338513,NDC,1,EA,74.09,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409338513,NDC,1,EA,74.09,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409338513,NDC,1,EA,74.09,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409338513,NDC,1,EA,74.09,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409338513,NDC,1,EA,74.09,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615700,NDC,1,EA,101.95,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615700,NDC,1,EA,101.95,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615700,NDC,1,EA,101.95,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615700,NDC,1,EA,101.95,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615700,NDC,1,EA,101.95,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615700,NDC,1,EA,101.95,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615704,NDC,1,EA,101.92,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615704,NDC,1,EA,101.92,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615704,NDC,1,EA,101.92,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615704,NDC,1,EA,101.92,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615704,NDC,1,EA,101.92,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615704,NDC,1,EA,101.92,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030036,NDC,1,EA,56.73,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030036,NDC,1,EA,56.73,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030036,NDC,1,EA,56.73,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030036,NDC,1,EA,56.73,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030036,NDC,1,EA,56.73,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030036,NDC,1,EA,56.73,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098321,NDC,1,EA,99.39,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098321,NDC,1,EA,99.39,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098321,NDC,1,EA,99.39,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098321,NDC,1,EA,99.39,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098321,NDC,1,EA,99.39,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098321,NDC,1,EA,99.39,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098323,NDC,1,EA,99.39,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098323,NDC,1,EA,99.39,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098323,NDC,1,EA,99.39,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098323,NDC,1,EA,99.39,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098323,NDC,1,EA,99.39,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098323,NDC,1,EA,99.39,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098341,NDC,1,EA,56.73,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098341,NDC,1,EA,56.73,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098341,NDC,1,EA,56.73,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098341,NDC,1,EA,56.73,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098341,NDC,1,EA,56.73,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098341,NDC,1,EA,56.73,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052200,NDC,1,EA,99.39,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052200,NDC,1,EA,99.39,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052200,NDC,1,EA,99.39,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052200,NDC,1,EA,99.39,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052200,NDC,1,EA,99.39,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052200,NDC,1,EA,99.39,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052237,NDC,1,EA,99.39,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052237,NDC,1,EA,99.39,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052237,NDC,1,EA,99.39,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052237,NDC,1,EA,99.39,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052237,NDC,1,EA,99.39,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052237,NDC,1,EA,99.39,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409339004,NDC,1,EA,98.61,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409339004,NDC,1,EA,98.61,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409339004,NDC,1,EA,98.61,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409339004,NDC,1,EA,98.61,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409339004,NDC,1,EA,98.61,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409339004,NDC,1,EA,98.61,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,55150012150,NDC,1,EA,151.41,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,55150012150,NDC,1,EA,151.41,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,55150012150,NDC,1,EA,151.41,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,55150012150,NDC,1,EA,151.41,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,55150012150,NDC,1,EA,151.41,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,55150012150,NDC,1,EA,151.41,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615900,NDC,1,EA,123.75,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615900,NDC,1,EA,123.75,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615900,NDC,1,EA,123.75,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615900,NDC,1,EA,123.75,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615900,NDC,1,EA,123.75,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615900,NDC,1,EA,123.75,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615904,NDC,1,EA,123.75,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615904,NDC,1,EA,123.75,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615904,NDC,1,EA,123.75,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615904,NDC,1,EA,123.75,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615904,NDC,1,EA,123.75,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615904,NDC,1,EA,123.75,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032050,NDC,1,EA,120.51,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032050,NDC,1,EA,120.51,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032050,NDC,1,EA,120.51,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032050,NDC,1,EA,120.51,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032050,NDC,1,EA,120.51,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032050,NDC,1,EA,120.51,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032056,NDC,1,EA,68.97,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032056,NDC,1,EA,68.97,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032056,NDC,1,EA,68.97,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032056,NDC,1,EA,68.97,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032056,NDC,1,EA,68.97,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032056,NDC,1,EA,68.97,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,65219025915,NDC,1,EA,58.66,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,65219025915,NDC,1,EA,58.66,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,65219025915,NDC,1,EA,58.66,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,65219025915,NDC,1,EA,58.66,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,65219025915,NDC,1,EA,58.66,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,65219025915,NDC,1,EA,58.66,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Place Needle in Vein,PX36000P,CDM,983,RC,36000,CPT,,,,,,,,1034,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Place Needle in Vein,PX36000P,CDM,983,RC,36000,CPT,,,,,,,,1034,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Place Needle in Vein,PX36000P,CDM,983,RC,36000,CPT,,,,,,,,1034,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Place Needle in Vein,PX36000P,CDM,983,RC,36000,CPT,,,,,,,,1034,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Place Needle in Vein,PX36000P,CDM,983,RC,36000,CPT,,,,,,,,1034,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Place Needle in Vein,PX36000P,CDM,983,RC,36000,CPT,,,,,,,,1034,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PLANTAR PLATE IMPLANT SET GRAVITY REPAIR,C1713,CDM,278,RC,C1713,HCPCS,,12649-MAIN,LOCAL,,,,,3921,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PLANTAR PLATE IMPLANT SET GRAVITY REPAIR,C1713,CDM,278,RC,C1713,HCPCS,,12649-MAIN,LOCAL,,,,,3921,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PLANTAR PLATE IMPLANT SET GRAVITY REPAIR,C1713,CDM,278,RC,C1713,HCPCS,,12649-MAIN,LOCAL,,,,,3921,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PLANTAR PLATE IMPLANT SET GRAVITY REPAIR,C1713,CDM,278,RC,C1713,HCPCS,,12649-MAIN,LOCAL,,,,,3921,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PLANTAR PLATE IMPLANT SET GRAVITY REPAIR,C1713,CDM,278,RC,C1713,HCPCS,,12649-MAIN,LOCAL,,,,,3921,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PLANTAR PLATE IMPLANT SET GRAVITY REPAIR,C1713,CDM,278,RC,C1713,HCPCS,,12649-MAIN,LOCAL,,,,,3921,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Platelet Antibodies - Ref,PX8602290,CDM,300,RC,86022,CPT,90,,,,,,,245,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Platelet Antibodies - Ref,PX8602290,CDM,300,RC,86022,CPT,90,,,,,,,245,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Platelet Antibodies - Ref,PX8602290,CDM,300,RC,86022,CPT,90,,,,,,,245,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Platelet Antibodies - Ref,PX8602290,CDM,300,RC,86022,CPT,90,,,,,,,245,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Platelet Antibodies - Ref,PX8602290,CDM,300,RC,86022,CPT,90,,,,,,,245,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Platelet Antibodies - Ref,PX8602290,CDM,300,RC,86022,CPT,90,,,,,,,245,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200001,NDC,0.5,ML,980.99,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200001,NDC,0.5,ML,980.99,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200001,NDC,0.5,ML,980.99,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200001,NDC,0.5,ML,980.99,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200001,NDC,0.5,ML,980.99,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200001,NDC,0.5,ML,980.99,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200002,NDC,0.5,ML,980.99,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200002,NDC,0.5,ML,980.99,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200002,NDC,0.5,ML,980.99,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200002,NDC,0.5,ML,980.99,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200002,NDC,0.5,ML,980.99,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200002,NDC,0.5,ML,980.99,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494300,NDC,0.5,ML,419.23,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494300,NDC,0.5,ML,419.23,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494300,NDC,0.5,ML,419.23,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494300,NDC,0.5,ML,419.23,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494300,NDC,0.5,ML,419.23,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494300,NDC,0.5,ML,419.23,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494301,NDC,0.5,ML,419.2,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494301,NDC,0.5,ML,419.2,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494301,NDC,0.5,ML,419.2,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494301,NDC,0.5,ML,419.2,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494301,NDC,0.5,ML,419.2,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494301,NDC,0.5,ML,419.2,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PNEUVIEW SMOKE ELIMINATOR,27200000,CDM,272,RC,,,,11884-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PNEUVIEW SMOKE ELIMINATOR,27200000,CDM,272,RC,,,,11884-MAIN,LOCAL,,,,,38,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PNEUVIEW SMOKE ELIMINATOR,27200000,CDM,272,RC,,,,11884-MAIN,LOCAL,,,,,38,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PNEUVIEW SMOKE ELIMINATOR,27200000,CDM,272,RC,,,,11884-MAIN,LOCAL,,,,,38,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PNEUVIEW SMOKE ELIMINATOR,27200000,CDM,272,RC,,,,11884-MAIN,LOCAL,,,,,38,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PNEUVIEW SMOKE ELIMINATOR,27200000,CDM,272,RC,,,,11884-MAIN,LOCAL,,,,,38,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Po4 Inorganic (Phosphate) - Ref,PX8410090,CDM,300,RC,84100,CPT,90,,,,,,,150,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Po4 Inorganic (Phosphate) - Ref,PX8410090,CDM,300,RC,84100,CPT,90,,,,,,,150,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Po4 Inorganic (Phosphate) - Ref,PX8410090,CDM,300,RC,84100,CPT,90,,,,,,,150,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Po4 Inorganic (Phosphate) - Ref,PX8410090,CDM,300,RC,84100,CPT,90,,,,,,,150,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Po4 Inorganic (Phosphate) - Ref,PX8410090,CDM,300,RC,84100,CPT,90,,,,,,,150,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Po4 Inorganic (Phosphate) - Ref,PX8410090,CDM,300,RC,84100,CPT,90,,,,,,,150,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
POLYAXIAL LOCKING PLATE MTP CROSS PLATE LEFT T8,C1713,CDM,278,RC,C1713,HCPCS,,12635-MAIN,LOCAL,,,,,5413,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
POLYAXIAL LOCKING PLATE MTP CROSS PLATE LEFT T8,C1713,CDM,278,RC,C1713,HCPCS,,12635-MAIN,LOCAL,,,,,5413,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
POLYAXIAL LOCKING PLATE MTP CROSS PLATE LEFT T8,C1713,CDM,278,RC,C1713,HCPCS,,12635-MAIN,LOCAL,,,,,5413,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
POLYAXIAL LOCKING PLATE MTP CROSS PLATE LEFT T8,C1713,CDM,278,RC,C1713,HCPCS,,12635-MAIN,LOCAL,,,,,5413,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
POLYAXIAL LOCKING PLATE MTP CROSS PLATE LEFT T8,C1713,CDM,278,RC,C1713,HCPCS,,12635-MAIN,LOCAL,,,,,5413,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
POLYAXIAL LOCKING PLATE MTP CROSS PLATE LEFT T8,C1713,CDM,278,RC,C1713,HCPCS,,12635-MAIN,LOCAL,,,,,5413,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
POLYAXIAL LOCKING PLATE MTP CROSS PLATE RIGHT T8,C1713,CDM,278,RC,C1713,HCPCS,,12756-MAIN,LOCAL,,,,,5413,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
POLYAXIAL LOCKING PLATE MTP CROSS PLATE RIGHT T8,C1713,CDM,278,RC,C1713,HCPCS,,12756-MAIN,LOCAL,,,,,5413,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
POLYAXIAL LOCKING PLATE MTP CROSS PLATE RIGHT T8,C1713,CDM,278,RC,C1713,HCPCS,,12756-MAIN,LOCAL,,,,,5413,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
POLYAXIAL LOCKING PLATE MTP CROSS PLATE RIGHT T8,C1713,CDM,278,RC,C1713,HCPCS,,12756-MAIN,LOCAL,,,,,5413,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
POLYAXIAL LOCKING PLATE MTP CROSS PLATE RIGHT T8,C1713,CDM,278,RC,C1713,HCPCS,,12756-MAIN,LOCAL,,,,,5413,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
POLYAXIAL LOCKING PLATE MTP CROSS PLATE RIGHT T8,C1713,CDM,278,RC,C1713,HCPCS,,12756-MAIN,LOCAL,,,,,5413,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"polyethylene glycol 236 g Recon Soln 4,000 mL Bottle",63700001,CDM,250,RC,,,,,,43386009019,NDC,4000,ML,112.6,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"polyethylene glycol 236 g Recon Soln 4,000 mL Bottle",63700001,CDM,250,RC,,,,,,43386009019,NDC,4000,ML,112.6,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"polyethylene glycol 236 g Recon Soln 4,000 mL Bottle",63700001,CDM,250,RC,,,,,,43386009019,NDC,4000,ML,112.6,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"polyethylene glycol 236 g Recon Soln 4,000 mL Bottle",63700001,CDM,250,RC,,,,,,43386009019,NDC,4000,ML,112.6,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"polyethylene glycol 236 g Recon Soln 4,000 mL Bottle",63700001,CDM,250,RC,,,,,,43386009019,NDC,4000,ML,112.6,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"polyethylene glycol 236 g Recon Soln 4,000 mL Bottle",63700001,CDM,250,RC,,,,,,43386009019,NDC,4000,ML,112.6,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polyethylene glycol 3350 17 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,904642286,NDC,1,EA,8.2,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polyethylene glycol 3350 17 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,904642286,NDC,1,EA,8.2,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polyethylene glycol 3350 17 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,904642286,NDC,1,EA,8.2,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polyethylene glycol 3350 17 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,904642286,NDC,1,EA,8.2,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polyethylene glycol 3350 17 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,904642286,NDC,1,EA,8.2,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polyethylene glycol 3350 17 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,904642286,NDC,1,EA,8.2,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polyethylene glycol 3350 17 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,904693186,NDC,1,EA,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polyethylene glycol 3350 17 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,904693186,NDC,1,EA,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polyethylene glycol 3350 17 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,904693186,NDC,1,EA,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polyethylene glycol 3350 17 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,904693186,NDC,1,EA,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polyethylene glycol 3350 17 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,904693186,NDC,1,EA,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polyethylene glycol 3350 17 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,904693186,NDC,1,EA,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polyethylene glycol 3350 17 g Packet 30 Each Box,63700001,CDM,250,RC,,,,,,904693176,NDC,1,EA,8.97,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polyethylene glycol 3350 17 g Packet 30 Each Box,63700001,CDM,250,RC,,,,,,904693176,NDC,1,EA,8.97,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polyethylene glycol 3350 17 g Packet 30 Each Box,63700001,CDM,250,RC,,,,,,904693176,NDC,1,EA,8.97,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polyethylene glycol 3350 17 g Packet 30 Each Box,63700001,CDM,250,RC,,,,,,904693176,NDC,1,EA,8.97,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polyethylene glycol 3350 17 g Packet 30 Each Box,63700001,CDM,250,RC,,,,,,904693176,NDC,1,EA,8.97,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polyethylene glycol 3350 17 g Packet 30 Each Box,63700001,CDM,250,RC,,,,,,904693176,NDC,1,EA,8.97,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polyethylene glycol 3350 17 g Packet 100 Each Box,63700001,CDM,250,RC,,,,,,904642281,NDC,1,EA,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polyethylene glycol 3350 17 g Packet 100 Each Box,63700001,CDM,250,RC,,,,,,904642281,NDC,1,EA,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polyethylene glycol 3350 17 g Packet 100 Each Box,63700001,CDM,250,RC,,,,,,904642281,NDC,1,EA,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polyethylene glycol 3350 17 g Packet 100 Each Box,63700001,CDM,250,RC,,,,,,904642281,NDC,1,EA,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polyethylene glycol 3350 17 g Packet 100 Each Box,63700001,CDM,250,RC,,,,,,904642281,NDC,1,EA,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polyethylene glycol 3350 17 g Packet 100 Each Box,63700001,CDM,250,RC,,,,,,904642281,NDC,1,EA,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,17478070311,NDC,10,ML,72.46,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,17478070311,NDC,10,ML,72.46,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,17478070311,NDC,10,ML,72.46,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,17478070311,NDC,10,ML,72.46,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,17478070311,NDC,10,ML,72.46,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,17478070311,NDC,10,ML,72.46,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,24208031510,NDC,10,ML,75.67,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,24208031510,NDC,10,ML,75.67,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,24208031510,NDC,10,ML,75.67,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,24208031510,NDC,10,ML,75.67,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,24208031510,NDC,10,ML,75.67,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,24208031510,NDC,10,ML,75.67,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,61314062810,NDC,10,ML,98.07,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,61314062810,NDC,10,ML,98.07,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,61314062810,NDC,10,ML,98.07,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,61314062810,NDC,10,ML,98.07,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,61314062810,NDC,10,ML,98.07,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,61314062810,NDC,10,ML,98.07,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Polysomnography W/Cpap,PX9581101,CDM,740,RC,95811,CPT,TC,,,,,,,4575,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Polysomnography W/Cpap,PX9581101,CDM,740,RC,95811,CPT,TC,,,,,,,4575,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Polysomnography W/Cpap,PX9581101,CDM,740,RC,95811,CPT,TC,,,,,,,4575,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Polysomnography W/Cpap,PX9581101,CDM,740,RC,95811,CPT,TC,,,,,,,4575,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Polysomnography W/Cpap,PX9581101,CDM,740,RC,95811,CPT,TC,,,,,,,4575,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Polysomnography W/Cpap,PX9581101,CDM,740,RC,95811,CPT,TC,,,,,,,4575,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Polysomnography, 4 or More",PX9581001,CDM,740,RC,95810,CPT,TC,,,,,,,4313,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Polysomnography, 4 or More",PX9581001,CDM,740,RC,95810,CPT,TC,,,,,,,4313,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Polysomnography, 4 or More",PX9581001,CDM,740,RC,95810,CPT,TC,,,,,,,4313,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Polysomnography, 4 or More",PX9581001,CDM,740,RC,95810,CPT,TC,,,,,,,4313,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Polysomnography, 4 or More",PX9581001,CDM,740,RC,95810,CPT,TC,,,,,,,4313,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Polysomnography, 4 or More",PX9581001,CDM,740,RC,95810,CPT,TC,,,,,,,4313,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polyvinyl alcohol 1.4 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,50268067815,NDC,15,ML,45.42,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polyvinyl alcohol 1.4 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,50268067815,NDC,15,ML,45.42,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polyvinyl alcohol 1.4 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,50268067815,NDC,15,ML,45.42,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polyvinyl alcohol 1.4 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,50268067815,NDC,15,ML,45.42,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polyvinyl alcohol 1.4 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,50268067815,NDC,15,ML,45.42,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polyvinyl alcohol 1.4 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,50268067815,NDC,15,ML,45.42,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"POS Airway Pressure, Bipap",PX94660.01F,CDM,410,RC,94660,CPT,,,,,,,,468,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"POS Airway Pressure, Bipap",PX94660.01F,CDM,410,RC,94660,CPT,,,,,,,,468,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"POS Airway Pressure, Bipap",PX94660.01F,CDM,410,RC,94660,CPT,,,,,,,,468,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"POS Airway Pressure, Bipap",PX94660.01F,CDM,410,RC,94660,CPT,,,,,,,,468,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"POS Airway Pressure, Bipap",PX94660.01F,CDM,410,RC,94660,CPT,,,,,,,,468,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"POS Airway Pressure, Bipap",PX94660.01F,CDM,410,RC,94660,CPT,,,,,,,,468,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"POS Airway Pressure, Cpap",PX94660F,CDM,410,RC,94660,CPT,,,,,,,,498,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"POS Airway Pressure, Cpap",PX94660F,CDM,410,RC,94660,CPT,,,,,,,,498,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"POS Airway Pressure, Cpap",PX94660F,CDM,410,RC,94660,CPT,,,,,,,,498,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"POS Airway Pressure, Cpap",PX94660F,CDM,410,RC,94660,CPT,,,,,,,,498,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"POS Airway Pressure, Cpap",PX94660F,CDM,410,RC,94660,CPT,,,,,,,,498,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"POS Airway Pressure, Cpap",PX94660F,CDM,410,RC,94660,CPT,,,,,,,,498,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
POSITIONING KIT TRENDELENBURG NUBLUE TP 3000-NB,27100000,CDM,271,RC,,,,12992-MAIN,LOCAL,,,,,88,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
POSITIONING KIT TRENDELENBURG NUBLUE TP 3000-NB,27100000,CDM,271,RC,,,,12992-MAIN,LOCAL,,,,,88,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
POSITIONING KIT TRENDELENBURG NUBLUE TP 3000-NB,27100000,CDM,271,RC,,,,12992-MAIN,LOCAL,,,,,88,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
POSITIONING KIT TRENDELENBURG NUBLUE TP 3000-NB,27100000,CDM,271,RC,,,,12992-MAIN,LOCAL,,,,,88,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
POSITIONING KIT TRENDELENBURG NUBLUE TP 3000-NB,27100000,CDM,271,RC,,,,12992-MAIN,LOCAL,,,,,88,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
POSITIONING KIT TRENDELENBURG NUBLUE TP 3000-NB,27100000,CDM,271,RC,,,,12992-MAIN,LOCAL,,,,,88,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Post Anesthesia Recovery,PX71000019,CDM,710,RC,,,,,,,,,,14,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Post Anesthesia Recovery,PX71000019,CDM,710,RC,,,,,,,,,,14,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Post Anesthesia Recovery,PX71000019,CDM,710,RC,,,,,,,,,,14,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Post Anesthesia Recovery,PX71000019,CDM,710,RC,,,,,,,,,,14,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Post Anesthesia Recovery,PX71000019,CDM,710,RC,,,,,,,,,,14,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Post Anesthesia Recovery,PX71000019,CDM,710,RC,,,,,,,,,,14,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665305,NDC,20,ML,49.97,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665305,NDC,20,ML,49.97,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665305,NDC,20,ML,49.97,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665305,NDC,20,ML,49.97,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665305,NDC,20,ML,49.97,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665305,NDC,20,ML,49.97,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665318,NDC,20,ML,50.08,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665318,NDC,20,ML,50.08,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665318,NDC,20,ML,50.08,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665318,NDC,20,ML,50.08,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665318,NDC,20,ML,50.08,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665318,NDC,20,ML,50.08,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070948,NDC,100,ML,42.59,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070948,NDC,100,ML,42.59,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070948,NDC,100,ML,42.59,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070948,NDC,100,ML,42.59,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070948,NDC,100,ML,42.59,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070948,NDC,100,ML,42.59,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707426,NDC,100,ML,39.29,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707426,NDC,100,ML,39.29,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707426,NDC,100,ML,39.29,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707426,NDC,100,ML,39.29,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707426,NDC,100,ML,39.29,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707426,NDC,100,ML,39.29,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride 20 MEQ Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,245036089,NDC,1,EA,57.67,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride 20 MEQ Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,245036089,NDC,1,EA,57.67,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride 20 MEQ Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,245036089,NDC,1,EA,57.67,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride 20 MEQ Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,245036089,NDC,1,EA,57.67,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride 20 MEQ Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,245036089,NDC,1,EA,57.67,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride 20 MEQ Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,245036089,NDC,1,EA,57.67,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 10 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,245531789,NDC,1,EA,3.33,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 10 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,245531789,NDC,1,EA,3.33,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 10 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,245531789,NDC,1,EA,3.33,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 10 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,245531789,NDC,1,EA,3.33,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 10 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,245531789,NDC,1,EA,3.33,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 10 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,245531789,NDC,1,EA,3.33,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 10 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,66758017006,NDC,1,EA,3.32,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 10 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,66758017006,NDC,1,EA,3.32,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 10 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,66758017006,NDC,1,EA,3.32,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 10 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,66758017006,NDC,1,EA,3.32,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 10 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,66758017006,NDC,1,EA,3.32,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 10 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,66758017006,NDC,1,EA,3.32,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 10 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,245531701,NDC,1,EA,3.32,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 10 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,245531701,NDC,1,EA,3.32,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 10 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,245531701,NDC,1,EA,3.32,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 10 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,245531701,NDC,1,EA,3.32,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 10 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,245531701,NDC,1,EA,3.32,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 10 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,245531701,NDC,1,EA,3.32,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 10 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,66758017013,NDC,1,EA,3.32,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 10 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,66758017013,NDC,1,EA,3.32,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 10 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,66758017013,NDC,1,EA,3.32,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 10 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,66758017013,NDC,1,EA,3.32,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 10 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,66758017013,NDC,1,EA,3.32,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 10 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,66758017013,NDC,1,EA,3.32,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 20 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,245531989,NDC,1,EA,3.65,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 20 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,245531989,NDC,1,EA,3.65,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 20 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,245531989,NDC,1,EA,3.65,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 20 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,245531989,NDC,1,EA,3.65,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 20 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,245531989,NDC,1,EA,3.65,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 20 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,245531989,NDC,1,EA,3.65,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 20 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,66758019006,NDC,1,EA,3.65,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 20 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,66758019006,NDC,1,EA,3.65,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 20 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,66758019006,NDC,1,EA,3.65,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 20 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,66758019006,NDC,1,EA,3.65,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 20 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,66758019006,NDC,1,EA,3.65,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 20 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,66758019006,NDC,1,EA,3.65,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 20 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,245531901,NDC,1,EA,3.65,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 20 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,245531901,NDC,1,EA,3.65,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 20 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,245531901,NDC,1,EA,3.65,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 20 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,245531901,NDC,1,EA,3.65,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 20 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,245531901,NDC,1,EA,3.65,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 20 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,245531901,NDC,1,EA,3.65,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 20 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,66758019013,NDC,1,EA,3.65,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 20 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,66758019013,NDC,1,EA,3.65,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 20 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,66758019013,NDC,1,EA,3.65,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 20 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,66758019013,NDC,1,EA,3.65,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 20 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,66758019013,NDC,1,EA,3.65,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 20 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,66758019013,NDC,1,EA,3.65,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Flex Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707526,NDC,100,ML,37.63,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Flex Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707526,NDC,100,ML,37.63,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Flex Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707526,NDC,100,ML,37.63,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Flex Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707526,NDC,100,ML,37.63,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Flex Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707526,NDC,100,ML,37.63,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Flex Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707526,NDC,100,ML,37.63,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070548,NDC,100,ML,40.94,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070548,NDC,100,ML,40.94,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070548,NDC,100,ML,40.94,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070548,NDC,100,ML,40.94,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070548,NDC,100,ML,40.94,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070548,NDC,100,ML,40.94,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Potassium; Serum, Plasma or Whole Blood",PX84132,CDM,300,RC,84132,CPT,,,,,,,,59,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Potassium; Serum, Plasma or Whole Blood",PX84132,CDM,300,RC,84132,CPT,,,,,,,,59,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Potassium; Serum, Plasma or Whole Blood",PX84132,CDM,300,RC,84132,CPT,,,,,,,,59,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Potassium; Serum, Plasma or Whole Blood",PX84132,CDM,300,RC,84132,CPT,,,,,,,,59,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Potassium; Serum, Plasma or Whole Blood",PX84132,CDM,300,RC,84132,CPT,,,,,,,,59,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Potassium; Serum, Plasma or Whole Blood",PX84132,CDM,300,RC,84132,CPT,,,,,,,,59,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Potassium; Urine,PX84133,CDM,300,RC,84133,CPT,,,,,,,,50,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Potassium; Urine,PX84133,CDM,300,RC,84133,CPT,,,,,,,,50,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Potassium; Urine,PX84133,CDM,300,RC,84133,CPT,,,,,,,,50,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Potassium; Urine,PX84133,CDM,300,RC,84133,CPT,,,,,,,,50,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Potassium; Urine,PX84133,CDM,300,RC,84133,CPT,,,,,,,,50,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Potassium; Urine,PX84133,CDM,300,RC,84133,CPT,,,,,,,,50,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
povidone iodine 10 % Solution 59 mL Bottle,63700001,CDM,250,RC,,,,,,52380190502,NDC,59,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
povidone iodine 10 % Solution 59 mL Bottle,63700001,CDM,250,RC,,,,,,52380190502,NDC,59,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
povidone iodine 10 % Solution 59 mL Bottle,63700001,CDM,250,RC,,,,,,52380190502,NDC,59,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
povidone iodine 10 % Solution 59 mL Bottle,63700001,CDM,250,RC,,,,,,52380190502,NDC,59,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
povidone iodine 10 % Solution 59 mL Bottle,63700001,CDM,250,RC,,,,,,52380190502,NDC,59,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
povidone iodine 10 % Solution 59 mL Bottle,63700001,CDM,250,RC,,,,,,52380190502,NDC,59,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
povidone-iodine 10 % Ointment 28.35 g Tube,63700001,CDM,250,RC,,,,,,904110231,NDC,28.35,GR,19.9,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
povidone-iodine 10 % Ointment 28.35 g Tube,63700001,CDM,250,RC,,,,,,904110231,NDC,28.35,GR,19.9,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
povidone-iodine 10 % Ointment 28.35 g Tube,63700001,CDM,250,RC,,,,,,904110231,NDC,28.35,GR,19.9,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
povidone-iodine 10 % Ointment 28.35 g Tube,63700001,CDM,250,RC,,,,,,904110231,NDC,28.35,GR,19.9,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
povidone-iodine 10 % Ointment 28.35 g Tube,63700001,CDM,250,RC,,,,,,904110231,NDC,28.35,GR,19.9,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
povidone-iodine 10 % Ointment 28.35 g Tube,63700001,CDM,250,RC,,,,,,904110231,NDC,28.35,GR,19.9,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Povidone-Iodine 10 % SWAB 1 Each Package,25000000,CDM,250,RC,,,,,,67618015301,NDC,1,EA,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Povidone-Iodine 10 % SWAB 1 Each Package,25000000,CDM,250,RC,,,,,,67618015301,NDC,1,EA,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Povidone-Iodine 10 % SWAB 1 Each Package,25000000,CDM,250,RC,,,,,,67618015301,NDC,1,EA,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Povidone-Iodine 10 % SWAB 1 Each Package,25000000,CDM,250,RC,,,,,,67618015301,NDC,1,EA,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Povidone-Iodine 10 % SWAB 1 Each Package,25000000,CDM,250,RC,,,,,,67618015301,NDC,1,EA,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Povidone-Iodine 10 % SWAB 1 Each Package,25000000,CDM,250,RC,,,,,,67618015301,NDC,1,EA,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
POWERPORT ISP MRI IMPLANTABLE PORT 8FR,C1788,CDM,278,RC,C1788,HCPCS,,11998-MAIN,LOCAL,,,,,1385,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
POWERPORT ISP MRI IMPLANTABLE PORT 8FR,C1788,CDM,278,RC,C1788,HCPCS,,11998-MAIN,LOCAL,,,,,1385,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
POWERPORT ISP MRI IMPLANTABLE PORT 8FR,C1788,CDM,278,RC,C1788,HCPCS,,11998-MAIN,LOCAL,,,,,1385,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
POWERPORT ISP MRI IMPLANTABLE PORT 8FR,C1788,CDM,278,RC,C1788,HCPCS,,11998-MAIN,LOCAL,,,,,1385,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
POWERPORT ISP MRI IMPLANTABLE PORT 8FR,C1788,CDM,278,RC,C1788,HCPCS,,11998-MAIN,LOCAL,,,,,1385,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
POWERPORT ISP MRI IMPLANTABLE PORT 8FR,C1788,CDM,278,RC,C1788,HCPCS,,11998-MAIN,LOCAL,,,,,1385,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 0.25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084044011,NDC,0.5,EA,7.83,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 0.25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084044011,NDC,0.5,EA,7.83,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 0.25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084044011,NDC,0.5,EA,7.83,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 0.25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084044011,NDC,0.5,EA,7.83,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 0.25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084044011,NDC,0.5,EA,7.83,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 0.25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084044011,NDC,0.5,EA,7.83,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 0.25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,42291053590,NDC,0.5,EA,7.92,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 0.25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,42291053590,NDC,0.5,EA,7.92,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 0.25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,42291053590,NDC,0.5,EA,7.92,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 0.25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,42291053590,NDC,0.5,EA,7.92,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 0.25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,42291053590,NDC,0.5,EA,7.92,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 0.25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,42291053590,NDC,0.5,EA,7.92,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 0.25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68462033190,NDC,0.5,EA,8.97,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 0.25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68462033190,NDC,0.5,EA,8.97,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 0.25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68462033190,NDC,0.5,EA,8.97,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 0.25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68462033190,NDC,0.5,EA,8.97,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 0.25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68462033190,NDC,0.5,EA,8.97,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 0.25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68462033190,NDC,0.5,EA,8.97,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084044001,NDC,0.5,EA,7.83,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084044001,NDC,0.5,EA,7.83,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084044001,NDC,0.5,EA,7.83,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084044001,NDC,0.5,EA,7.83,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084044001,NDC,0.5,EA,7.83,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084044001,NDC,0.5,EA,7.83,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342003110,NDC,1,EA,16.56,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342003110,NDC,1,EA,16.56,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342003110,NDC,1,EA,16.56,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342003110,NDC,1,EA,16.56,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342003110,NDC,1,EA,16.56,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342003110,NDC,1,EA,16.56,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68382019616,NDC,1,EA,17.4,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68382019616,NDC,1,EA,17.4,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68382019616,NDC,1,EA,17.4,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68382019616,NDC,1,EA,17.4,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68382019616,NDC,1,EA,17.4,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68382019616,NDC,1,EA,17.4,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68462033090,NDC,1,EA,17.95,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68462033090,NDC,1,EA,17.95,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68462033090,NDC,1,EA,17.95,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68462033090,NDC,1,EA,17.95,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68462033090,NDC,1,EA,17.95,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68462033090,NDC,1,EA,17.95,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687059211,NDC,0.125,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687059211,NDC,0.125,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687059211,NDC,0.125,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687059211,NDC,0.125,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687059211,NDC,0.125,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687059211,NDC,0.125,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramox-PE-glycerin-petrolatum 1-0.25-14.4-15 % Cream 51 g Tube,63700001,CDM,250,RC,,,,,,573286898,NDC,51,GR,68.34,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramox-PE-glycerin-petrolatum 1-0.25-14.4-15 % Cream 51 g Tube,63700001,CDM,250,RC,,,,,,573286898,NDC,51,GR,68.34,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramox-PE-glycerin-petrolatum 1-0.25-14.4-15 % Cream 51 g Tube,63700001,CDM,250,RC,,,,,,573286898,NDC,51,GR,68.34,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramox-PE-glycerin-petrolatum 1-0.25-14.4-15 % Cream 51 g Tube,63700001,CDM,250,RC,,,,,,573286898,NDC,51,GR,68.34,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramox-PE-glycerin-petrolatum 1-0.25-14.4-15 % Cream 51 g Tube,63700001,CDM,250,RC,,,,,,573286898,NDC,51,GR,68.34,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramox-PE-glycerin-petrolatum 1-0.25-14.4-15 % Cream 51 g Tube,63700001,CDM,250,RC,,,,,,573286898,NDC,51,GR,68.34,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prasugrel 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862083030,NDC,1,EA,88.64,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prasugrel 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862083030,NDC,1,EA,88.64,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prasugrel 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862083030,NDC,1,EA,88.64,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prasugrel 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862083030,NDC,1,EA,88.64,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prasugrel 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862083030,NDC,1,EA,88.64,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prasugrel 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862083030,NDC,1,EA,88.64,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pravastatin 10 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,60505016809,NDC,1,EA,17.26,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pravastatin 10 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,60505016809,NDC,1,EA,17.26,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pravastatin 10 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,60505016809,NDC,1,EA,17.26,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pravastatin 10 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,60505016809,NDC,1,EA,17.26,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pravastatin 10 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,60505016809,NDC,1,EA,17.26,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pravastatin 10 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,60505016809,NDC,1,EA,17.26,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pravastatin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904589161,NDC,1,EA,15.54,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pravastatin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904589161,NDC,1,EA,15.54,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pravastatin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904589161,NDC,1,EA,15.54,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pravastatin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904589161,NDC,1,EA,15.54,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pravastatin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904589161,NDC,1,EA,15.54,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pravastatin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904589161,NDC,1,EA,15.54,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pravastatin 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079045801,NDC,0.5,EA,8.77,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pravastatin 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079045801,NDC,0.5,EA,8.77,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pravastatin 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079045801,NDC,0.5,EA,8.77,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pravastatin 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079045801,NDC,0.5,EA,8.77,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pravastatin 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079045801,NDC,0.5,EA,8.77,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pravastatin 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079045801,NDC,0.5,EA,8.77,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pravastatin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904589261,NDC,0.5,EA,6.7,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pravastatin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904589261,NDC,0.5,EA,6.7,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pravastatin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904589261,NDC,0.5,EA,6.7,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pravastatin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904589261,NDC,0.5,EA,6.7,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pravastatin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904589261,NDC,0.5,EA,6.7,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pravastatin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904589261,NDC,0.5,EA,6.7,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prazosin 1 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,70954001950,NDC,1,EA,4.81,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prazosin 1 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,70954001950,NDC,1,EA,4.81,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prazosin 1 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,70954001950,NDC,1,EA,4.81,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prazosin 1 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,70954001950,NDC,1,EA,4.81,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prazosin 1 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,70954001950,NDC,1,EA,4.81,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prazosin 1 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,70954001950,NDC,1,EA,4.81,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Prealubimin,PX84134,CDM,300,RC,84134,CPT,,,,,,,,80,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Prealubimin,PX84134,CDM,300,RC,84134,CPT,,,,,,,,80,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Prealubimin,PX84134,CDM,300,RC,84134,CPT,,,,,,,,80,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Prealubimin,PX84134,CDM,300,RC,84134,CPT,,,,,,,,80,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Prealubimin,PX84134,CDM,300,RC,84134,CPT,,,,,,,,80,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Prealubimin,PX84134,CDM,300,RC,84134,CPT,,,,,,,,80,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004224,NDC,5,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004224,NDC,5,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004224,NDC,5,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004224,NDC,5,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004224,NDC,5,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004224,NDC,5,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,62135025037,NDC,1.666666667,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,62135025037,NDC,1.666666667,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,62135025037,NDC,1.666666667,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,62135025037,NDC,1.666666667,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,62135025037,NDC,1.666666667,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,62135025037,NDC,1.666666667,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prednisoLONE acetate 0.12 % Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,11980017405,NDC,5,ML,757.07,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prednisoLONE acetate 0.12 % Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,11980017405,NDC,5,ML,757.07,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prednisoLONE acetate 0.12 % Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,11980017405,NDC,5,ML,757.07,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prednisoLONE acetate 0.12 % Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,11980017405,NDC,5,ML,757.07,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prednisoLONE acetate 0.12 % Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,11980017405,NDC,5,ML,757.07,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prednisoLONE acetate 0.12 % Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,11980017405,NDC,5,ML,757.07,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prednisoLONE acetate 1 % Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063705,NDC,5,ML,283.79,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prednisoLONE acetate 1 % Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063705,NDC,5,ML,283.79,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prednisoLONE acetate 1 % Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063705,NDC,5,ML,283.79,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prednisoLONE acetate 1 % Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063705,NDC,5,ML,283.79,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prednisoLONE acetate 1 % Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063705,NDC,5,ML,283.79,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prednisoLONE acetate 1 % Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063705,NDC,5,ML,283.79,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,121090204,NDC,120,ML,503.56,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,121090204,NDC,120,ML,503.56,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,121090204,NDC,120,ML,503.56,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,121090204,NDC,120,ML,503.56,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,121090204,NDC,120,ML,503.56,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,121090204,NDC,120,ML,503.56,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004004,NDC,120,ML,502.95,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004004,NDC,120,ML,502.95,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004004,NDC,120,ML,502.95,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004004,NDC,120,ML,502.95,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004004,NDC,120,ML,502.95,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004004,NDC,120,ML,502.95,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 1 MG Tablet 100 Each Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,64380078206,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 1 MG Tablet 100 Each Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,64380078206,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 1 MG Tablet 100 Each Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,64380078206,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 1 MG Tablet 100 Each Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,64380078206,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 1 MG Tablet 100 Each Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,64380078206,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 1 MG Tablet 100 Each Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,64380078206,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 1 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54873925,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 1 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54873925,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 1 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54873925,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 1 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54873925,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 1 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54873925,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 1 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54873925,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 2.5 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54874025,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 2.5 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54874025,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 2.5 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54874025,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 2.5 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54874025,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 2.5 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54874025,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 2.5 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54874025,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 5 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687012211,NDC,0.2,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 5 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687012211,NDC,0.2,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 5 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687012211,NDC,0.2,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 5 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687012211,NDC,0.2,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 5 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687012211,NDC,0.2,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 5 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687012211,NDC,0.2,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 5 mg/5 mL 5 MG/5ML Solution 120 mL Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54372250,NDC,120,ML,186.47,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 5 mg/5 mL 5 MG/5ML Solution 120 mL Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54372250,NDC,120,ML,186.47,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 5 mg/5 mL 5 MG/5ML Solution 120 mL Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54372250,NDC,120,ML,186.47,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 5 mg/5 mL 5 MG/5ML Solution 120 mL Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54372250,NDC,120,ML,186.47,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 5 mg/5 mL 5 MG/5ML Solution 120 mL Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54372250,NDC,120,ML,186.47,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 5 mg/5 mL 5 MG/5ML Solution 120 mL Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54372250,NDC,120,ML,186.47,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 10 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687013411,NDC,0.1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 10 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687013411,NDC,0.1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 10 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687013411,NDC,0.1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 10 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687013411,NDC,0.1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 10 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687013411,NDC,0.1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 10 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687013411,NDC,0.1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001720,NDC,0.1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001720,NDC,0.1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001720,NDC,0.1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001720,NDC,0.1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001720,NDC,0.1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001720,NDC,0.1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,63739051910,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,63739051910,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,63739051910,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,63739051910,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,63739051910,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,63739051910,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 20 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014511,NDC,0.05,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 20 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014511,NDC,0.05,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 20 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014511,NDC,0.05,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 20 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014511,NDC,0.05,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 20 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014511,NDC,0.05,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 20 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014511,NDC,0.05,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001820,NDC,0.05,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001820,NDC,0.05,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001820,NDC,0.05,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001820,NDC,0.05,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001820,NDC,0.05,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001820,NDC,0.05,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014501,NDC,0.05,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014501,NDC,0.05,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014501,NDC,0.05,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014501,NDC,0.05,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014501,NDC,0.05,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014501,NDC,0.05,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pregabalin 25 MG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,904699104,NDC,1,EA,8.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pregabalin 25 MG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,904699104,NDC,1,EA,8.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pregabalin 25 MG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,904699104,NDC,1,EA,8.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pregabalin 25 MG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,904699104,NDC,1,EA,8.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pregabalin 25 MG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,904699104,NDC,1,EA,8.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pregabalin 25 MG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,904699104,NDC,1,EA,8.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pregabalin 25 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,71101268,NDC,1,EA,55.33,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pregabalin 25 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,71101268,NDC,1,EA,55.33,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pregabalin 25 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,71101268,NDC,1,EA,55.33,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pregabalin 25 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,71101268,NDC,1,EA,55.33,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pregabalin 25 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,71101268,NDC,1,EA,55.33,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pregabalin 25 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,71101268,NDC,1,EA,55.33,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pregabalin 25 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,76282056890,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pregabalin 25 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,76282056890,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pregabalin 25 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,76282056890,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pregabalin 25 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,76282056890,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pregabalin 25 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,76282056890,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pregabalin 25 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,76282056890,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pregabalin 75 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,71101468,NDC,0.333333333,EA,14.79,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pregabalin 75 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,71101468,NDC,0.333333333,EA,14.79,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pregabalin 75 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,71101468,NDC,0.333333333,EA,14.79,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pregabalin 75 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,71101468,NDC,0.333333333,EA,14.79,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pregabalin 75 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,71101468,NDC,0.333333333,EA,14.79,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pregabalin 75 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,71101468,NDC,0.333333333,EA,14.79,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pregabalin 75 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,59762134601,NDC,0.333333333,EA,15.08,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pregabalin 75 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,59762134601,NDC,0.333333333,EA,15.08,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pregabalin 75 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,59762134601,NDC,0.333333333,EA,15.08,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pregabalin 75 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,59762134601,NDC,0.333333333,EA,15.08,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pregabalin 75 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,59762134601,NDC,0.333333333,EA,15.08,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pregabalin 75 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,59762134601,NDC,0.333333333,EA,15.08,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pregabalin 75 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904700061,NDC,0.333333333,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pregabalin 75 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904700061,NDC,0.333333333,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pregabalin 75 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904700061,NDC,0.333333333,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pregabalin 75 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904700061,NDC,0.333333333,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pregabalin 75 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904700061,NDC,0.333333333,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pregabalin 75 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904700061,NDC,0.333333333,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prenatal plus vitamin with folic acid 1 mg 27-1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69367026701,NDC,1,EA,3.83,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prenatal plus vitamin with folic acid 1 mg 27-1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69367026701,NDC,1,EA,3.83,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prenatal plus vitamin with folic acid 1 mg 27-1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69367026701,NDC,1,EA,3.83,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prenatal plus vitamin with folic acid 1 mg 27-1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69367026701,NDC,1,EA,3.83,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prenatal plus vitamin with folic acid 1 mg 27-1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69367026701,NDC,1,EA,3.83,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prenatal plus vitamin with folic acid 1 mg 27-1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69367026701,NDC,1,EA,3.83,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PREP KIT SKIN PREMIUM,27200000,CDM,272,RC,,,,4108-MAIN,LOCAL,,,,,12.96,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PREP KIT SKIN PREMIUM,27200000,CDM,272,RC,,,,4108-MAIN,LOCAL,,,,,12.96,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PREP KIT SKIN PREMIUM,27200000,CDM,272,RC,,,,4108-MAIN,LOCAL,,,,,12.96,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PREP KIT SKIN PREMIUM,27200000,CDM,272,RC,,,,4108-MAIN,LOCAL,,,,,12.96,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PREP KIT SKIN PREMIUM,27200000,CDM,272,RC,,,,4108-MAIN,LOCAL,,,,,12.96,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PREP KIT SKIN PREMIUM,27200000,CDM,272,RC,,,,4108-MAIN,LOCAL,,,,,12.96,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PREP KIT STAPLE 18MM,27200000,CDM,278,RC,C1713,HCPCS,,11658-MAIN,LOCAL,,,,,420.75,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PREP KIT STAPLE 18MM,27200000,CDM,278,RC,C1713,HCPCS,,11658-MAIN,LOCAL,,,,,420.75,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PREP KIT STAPLE 18MM,27200000,CDM,278,RC,C1713,HCPCS,,11658-MAIN,LOCAL,,,,,420.75,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PREP KIT STAPLE 18MM,27200000,CDM,278,RC,C1713,HCPCS,,11658-MAIN,LOCAL,,,,,420.75,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PREP KIT STAPLE 18MM,27200000,CDM,278,RC,C1713,HCPCS,,11658-MAIN,LOCAL,,,,,420.75,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PREP KIT STAPLE 18MM,27200000,CDM,278,RC,C1713,HCPCS,,11658-MAIN,LOCAL,,,,,420.75,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PREP KIT STAPLE 20MM,27200000,CDM,278,RC,C1713,HCPCS,,11659-MAIN,LOCAL,,,,,420.75,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PREP KIT STAPLE 20MM,27200000,CDM,278,RC,C1713,HCPCS,,11659-MAIN,LOCAL,,,,,420.75,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PREP KIT STAPLE 20MM,27200000,CDM,278,RC,C1713,HCPCS,,11659-MAIN,LOCAL,,,,,420.75,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PREP KIT STAPLE 20MM,27200000,CDM,278,RC,C1713,HCPCS,,11659-MAIN,LOCAL,,,,,420.75,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PREP KIT STAPLE 20MM,27200000,CDM,278,RC,C1713,HCPCS,,11659-MAIN,LOCAL,,,,,420.75,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PREP KIT STAPLE 20MM,27200000,CDM,278,RC,C1713,HCPCS,,11659-MAIN,LOCAL,,,,,420.75,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004F,CDM,510,RC,15004,CPT,,,,,,,,855,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004F,CDM,510,RC,15004,CPT,,,,,,,,855,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004F,CDM,510,RC,15004,CPT,,,,,,,,855,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004F,CDM,510,RC,15004,CPT,,,,,,,,855,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004F,CDM,510,RC,15004,CPT,,,,,,,,855,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004F,CDM,510,RC,15004,CPT,,,,,,,,855,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004P,CDM,983,RC,15004,CPT,,,,,,,,570,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004P,CDM,983,RC,15004,CPT,,,,,,,,570,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004P,CDM,983,RC,15004,CPT,,,,,,,,570,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004P,CDM,983,RC,15004,CPT,,,,,,,,570,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004P,CDM,983,RC,15004,CPT,,,,,,,,570,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004P,CDM,983,RC,15004,CPT,,,,,,,,570,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
primidone 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084020211,NDC,1,EA,4.24,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
primidone 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084020211,NDC,1,EA,4.24,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
primidone 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084020211,NDC,1,EA,4.24,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
primidone 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084020211,NDC,1,EA,4.24,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
primidone 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084020211,NDC,1,EA,4.24,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
primidone 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084020211,NDC,1,EA,4.24,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
primidone 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084020201,NDC,1,EA,4.26,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
primidone 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084020201,NDC,1,EA,4.26,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
primidone 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084020201,NDC,1,EA,4.26,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
primidone 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084020201,NDC,1,EA,4.26,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
primidone 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084020201,NDC,1,EA,4.26,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
primidone 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084020201,NDC,1,EA,4.26,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Primidone Assay - Ref,PX8018890,CDM,300,RC,80188,CPT,90,,,,,,,20,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Primidone Assay - Ref,PX8018890,CDM,300,RC,80188,CPT,90,,,,,,,20,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Primidone Assay - Ref,PX8018890,CDM,300,RC,80188,CPT,90,,,,,,,20,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Primidone Assay - Ref,PX8018890,CDM,300,RC,80188,CPT,90,,,,,,,20,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Primidone Assay - Ref,PX8018890,CDM,300,RC,80188,CPT,90,,,,,,,20,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Primidone Assay - Ref,PX8018890,CDM,300,RC,80188,CPT,90,,,,,,,20,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
procainamide 500 MG/ML Solution 2 mL Vial,J2690.01,CDM,636,RC,J2690,HCPCS,,,,14789090002,NDC,2,ML,377.75,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
procainamide 500 MG/ML Solution 2 mL Vial,J2690.01,CDM,636,RC,J2690,HCPCS,,,,14789090002,NDC,2,ML,377.75,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
procainamide 500 MG/ML Solution 2 mL Vial,J2690.01,CDM,636,RC,J2690,HCPCS,,,,14789090002,NDC,2,ML,377.75,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
procainamide 500 MG/ML Solution 2 mL Vial,J2690.01,CDM,636,RC,J2690,HCPCS,,,,14789090002,NDC,2,ML,377.75,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
procainamide 500 MG/ML Solution 2 mL Vial,J2690.01,CDM,636,RC,J2690,HCPCS,,,,14789090002,NDC,2,ML,377.75,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
procainamide 500 MG/ML Solution 2 mL Vial,J2690.01,CDM,636,RC,J2690,HCPCS,,,,14789090002,NDC,2,ML,377.75,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Procalcitonin,PX84145,CDM,300,RC,84145,CPT,,,,,,,,217,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Procalcitonin,PX84145,CDM,300,RC,84145,CPT,,,,,,,,217,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Procalcitonin,PX84145,CDM,300,RC,84145,CPT,,,,,,,,217,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Procalcitonin,PX84145,CDM,300,RC,84145,CPT,,,,,,,,217,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Procalcitonin,PX84145,CDM,300,RC,84145,CPT,,,,,,,,217,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Procalcitonin,PX84145,CDM,300,RC,84145,CPT,,,,,,,,217,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 5 MG Tablet 1 Each Blister,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054101,NDC,1,EA,3.28,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 5 MG Tablet 1 Each Blister,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054101,NDC,1,EA,3.28,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 5 MG Tablet 1 Each Blister,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054101,NDC,1,EA,3.28,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 5 MG Tablet 1 Each Blister,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054101,NDC,1,EA,3.28,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 5 MG Tablet 1 Each Blister,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054101,NDC,1,EA,3.28,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 5 MG Tablet 1 Each Blister,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054101,NDC,1,EA,3.28,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 5 MG Tablet 100 Each Bottle,63600000,CDM,636,RC,Q0164,HCPCS,,,,59746011306,NDC,1,EA,3.19,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 5 MG Tablet 100 Each Bottle,63600000,CDM,636,RC,Q0164,HCPCS,,,,59746011306,NDC,1,EA,3.19,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 5 MG Tablet 100 Each Bottle,63600000,CDM,636,RC,Q0164,HCPCS,,,,59746011306,NDC,1,EA,3.19,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 5 MG Tablet 100 Each Bottle,63600000,CDM,636,RC,Q0164,HCPCS,,,,59746011306,NDC,1,EA,3.19,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 5 MG Tablet 100 Each Bottle,63600000,CDM,636,RC,Q0164,HCPCS,,,,59746011306,NDC,1,EA,3.19,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 5 MG Tablet 100 Each Bottle,63600000,CDM,636,RC,Q0164,HCPCS,,,,59746011306,NDC,1,EA,3.19,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 5 MG Tablet 100 Each Box,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054120,NDC,1,EA,3.29,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 5 MG Tablet 100 Each Box,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054120,NDC,1,EA,3.29,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 5 MG Tablet 100 Each Box,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054120,NDC,1,EA,3.29,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 5 MG Tablet 100 Each Box,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054120,NDC,1,EA,3.29,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 5 MG Tablet 100 Each Box,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054120,NDC,1,EA,3.29,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 5 MG Tablet 100 Each Box,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054120,NDC,1,EA,3.29,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 10 MG Tablet 100 Each Bottle,25000000,CDM,250,RC,,,,,,59746011506,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 10 MG Tablet 100 Each Bottle,25000000,CDM,250,RC,,,,,,59746011506,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 10 MG Tablet 100 Each Bottle,25000000,CDM,250,RC,,,,,,59746011506,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 10 MG Tablet 100 Each Bottle,25000000,CDM,250,RC,,,,,,59746011506,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 10 MG Tablet 100 Each Bottle,25000000,CDM,250,RC,,,,,,59746011506,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 10 MG Tablet 100 Each Bottle,25000000,CDM,250,RC,,,,,,59746011506,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052331,NDC,2,ML,125.89,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052331,NDC,2,ML,125.89,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052331,NDC,2,ML,125.89,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052331,NDC,2,ML,125.89,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052331,NDC,2,ML,125.89,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052331,NDC,2,ML,125.89,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052341,NDC,2,ML,125.89,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052341,NDC,2,ML,125.89,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052341,NDC,2,ML,125.89,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052341,NDC,2,ML,125.89,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052341,NDC,2,ML,125.89,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052341,NDC,2,ML,125.89,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,574722612,NDC,1,EA,67.57,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,574722612,NDC,1,EA,67.57,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,574722612,NDC,1,EA,67.57,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,574722612,NDC,1,EA,67.57,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,574722612,NDC,1,EA,67.57,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,574722612,NDC,1,EA,67.57,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,713013512,NDC,1,EA,65.83,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,713013512,NDC,1,EA,65.83,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,713013512,NDC,1,EA,65.83,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,713013512,NDC,1,EA,65.83,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,713013512,NDC,1,EA,65.83,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,713013512,NDC,1,EA,65.83,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Progesterone,PX84144,CDM,300,RC,84144,CPT,,,,,,,,56,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Progesterone,PX84144,CDM,300,RC,84144,CPT,,,,,,,,56,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Progesterone,PX84144,CDM,300,RC,84144,CPT,,,,,,,,56,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Progesterone,PX84144,CDM,300,RC,84144,CPT,,,,,,,,56,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Progesterone,PX84144,CDM,300,RC,84144,CPT,,,,,,,,56,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Progesterone,PX84144,CDM,300,RC,84144,CPT,,,,,,,,56,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Prolactin,PX84146,CDM,300,RC,84146,CPT,,,,,,,,112,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Prolactin,PX84146,CDM,300,RC,84146,CPT,,,,,,,,112,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Prolactin,PX84146,CDM,300,RC,84146,CPT,,,,,,,,112,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Prolactin,PX84146,CDM,300,RC,84146,CPT,,,,,,,,112,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Prolactin,PX84146,CDM,300,RC,84146,CPT,,,,,,,,112,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Prolactin,PX84146,CDM,300,RC,84146,CPT,,,,,,,,112,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
promethazine 25 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,45802075900,NDC,0.5,EA,47.55,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
promethazine 25 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,45802075900,NDC,0.5,EA,47.55,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
promethazine 25 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,45802075900,NDC,0.5,EA,47.55,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
promethazine 25 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,45802075900,NDC,0.5,EA,47.55,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
promethazine 25 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,45802075900,NDC,0.5,EA,47.55,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
promethazine 25 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,45802075900,NDC,0.5,EA,47.55,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
promethazine 25 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802075930,NDC,0.5,EA,47.54,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
promethazine 25 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802075930,NDC,0.5,EA,47.54,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
promethazine 25 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802075930,NDC,0.5,EA,47.54,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
promethazine 25 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802075930,NDC,0.5,EA,47.54,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
promethazine 25 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802075930,NDC,0.5,EA,47.54,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
promethazine 25 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802075930,NDC,0.5,EA,47.54,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
promethazine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,Q0169,HCPCS,,,,904646161,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
promethazine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,Q0169,HCPCS,,,,904646161,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
promethazine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,Q0169,HCPCS,,,,904646161,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
promethazine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,Q0169,HCPCS,,,,904646161,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
promethazine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,Q0169,HCPCS,,,,904646161,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
promethazine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,Q0169,HCPCS,,,,904646161,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092821,NDC,1,ML,32.23,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092821,NDC,1,ML,32.23,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092821,NDC,1,ML,32.23,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092821,NDC,1,ML,32.23,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092821,NDC,1,ML,32.23,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092821,NDC,1,ML,32.23,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092825,NDC,1,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092825,NDC,1,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092825,NDC,1,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092825,NDC,1,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092825,NDC,1,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092825,NDC,1,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROMOGRAN PRISMA AG COLLAGEN DRESSING 28CM,120.547,CDM,272,RC,A6021,HCPCS,,12361-MAIN,LOCAL,,,,,28,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROMOGRAN PRISMA AG COLLAGEN DRESSING 28CM,120.547,CDM,272,RC,A6021,HCPCS,,12361-MAIN,LOCAL,,,,,28,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROMOGRAN PRISMA AG COLLAGEN DRESSING 28CM,120.547,CDM,272,RC,A6021,HCPCS,,12361-MAIN,LOCAL,,,,,28,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROMOGRAN PRISMA AG COLLAGEN DRESSING 28CM,120.547,CDM,272,RC,A6021,HCPCS,,12361-MAIN,LOCAL,,,,,28,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROMOGRAN PRISMA AG COLLAGEN DRESSING 28CM,120.547,CDM,272,RC,A6021,HCPCS,,12361-MAIN,LOCAL,,,,,28,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROMOGRAN PRISMA AG COLLAGEN DRESSING 28CM,120.547,CDM,272,RC,A6021,HCPCS,,12361-MAIN,LOCAL,,,,,28,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PRONEVIEW CUSHION INSERTS LARGE,120.557,CDM,272,RC,E0190,HCPCS,,12500-MAIN,LOCAL,,,,,76,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PRONEVIEW CUSHION INSERTS LARGE,120.557,CDM,272,RC,E0190,HCPCS,,12500-MAIN,LOCAL,,,,,76,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PRONEVIEW CUSHION INSERTS LARGE,120.557,CDM,272,RC,E0190,HCPCS,,12500-MAIN,LOCAL,,,,,76,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PRONEVIEW CUSHION INSERTS LARGE,120.557,CDM,272,RC,E0190,HCPCS,,12500-MAIN,LOCAL,,,,,76,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PRONEVIEW CUSHION INSERTS LARGE,120.557,CDM,272,RC,E0190,HCPCS,,12500-MAIN,LOCAL,,,,,76,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PRONEVIEW CUSHION INSERTS LARGE,120.557,CDM,272,RC,E0190,HCPCS,,12500-MAIN,LOCAL,,,,,76,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,409469930,NDC,20,ML,48.54,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,409469930,NDC,20,ML,48.54,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,409469930,NDC,20,ML,48.54,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,409469930,NDC,20,ML,48.54,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,409469930,NDC,20,ML,48.54,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,409469930,NDC,20,ML,48.54,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060820,NDC,20,ML,58.57,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060820,NDC,20,ML,58.57,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060820,NDC,20,ML,58.57,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060820,NDC,20,ML,58.57,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060820,NDC,20,ML,58.57,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060820,NDC,20,ML,58.57,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026994,NDC,20,ML,35.87,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026994,NDC,20,ML,35.87,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026994,NDC,20,ML,35.87,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026994,NDC,20,ML,35.87,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026994,NDC,20,ML,35.87,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026994,NDC,20,ML,35.87,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060851,NDC,100,ML,213.4,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060851,NDC,100,ML,213.4,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060851,NDC,100,ML,213.4,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060851,NDC,100,ML,213.4,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060851,NDC,100,ML,213.4,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060851,NDC,100,ML,213.4,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,43598054910,NDC,100,ML,205.14,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,43598054910,NDC,100,ML,205.14,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,43598054910,NDC,100,ML,205.14,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,43598054910,NDC,100,ML,205.14,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,43598054910,NDC,100,ML,205.14,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,43598054910,NDC,100,ML,205.14,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026969,NDC,100,ML,99.34,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026969,NDC,100,ML,99.34,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026969,NDC,100,ML,99.34,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026969,NDC,100,ML,99.34,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026969,NDC,100,ML,99.34,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026969,NDC,100,ML,99.34,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propranolol 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904655061,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propranolol 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904655061,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propranolol 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904655061,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propranolol 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904655061,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propranolol 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904655061,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propranolol 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904655061,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propranolol 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268070211,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propranolol 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268070211,NDC,0.25,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propranolol 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268070211,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propranolol 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268070211,NDC,0.25,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propranolol 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268070211,NDC,0.25,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propranolol 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268070211,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propranolol 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687060911,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propranolol 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687060911,NDC,0.25,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propranolol 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687060911,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propranolol 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687060911,NDC,0.25,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propranolol 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687060911,NDC,0.25,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propranolol 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687060911,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propranolol 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687060901,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propranolol 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687060901,NDC,0.25,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propranolol 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687060901,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propranolol 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687060901,NDC,0.25,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propranolol 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687060901,NDC,0.25,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propranolol 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687060901,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propranolol LA 60 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,527411637,NDC,1,EA,11.05,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propranolol LA 60 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,527411637,NDC,1,EA,11.05,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propranolol LA 60 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,527411637,NDC,1,EA,11.05,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propranolol LA 60 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,527411637,NDC,1,EA,11.05,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propranolol LA 60 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,527411637,NDC,1,EA,11.05,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propranolol LA 60 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,527411637,NDC,1,EA,11.05,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propranolol LA 80 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,228277911,NDC,0.75,EA,9.7,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propranolol LA 80 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,228277911,NDC,0.75,EA,9.7,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propranolol LA 80 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,228277911,NDC,0.75,EA,9.7,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propranolol LA 80 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,228277911,NDC,0.75,EA,9.7,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propranolol LA 80 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,228277911,NDC,0.75,EA,9.7,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propranolol LA 80 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,228277911,NDC,0.75,EA,9.7,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propranolol LA 80 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,527411737,NDC,0.75,EA,9.7,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propranolol LA 80 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,527411737,NDC,0.75,EA,9.7,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propranolol LA 80 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,527411737,NDC,0.75,EA,9.7,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propranolol LA 80 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,527411737,NDC,0.75,EA,9.7,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propranolol LA 80 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,527411737,NDC,0.75,EA,9.7,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propranolol LA 80 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,527411737,NDC,0.75,EA,9.7,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Prosight Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,536509008,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Prosight Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,536509008,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Prosight Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,536509008,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Prosight Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,536509008,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Prosight Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,536509008,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Prosight Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,536509008,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP 0.9MM ANTI SKIVE PIN,27200000,CDM,272,RC,,,,12950-MAIN,LOCAL,,,,,154,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP 0.9MM ANTI SKIVE PIN,27200000,CDM,272,RC,,,,12950-MAIN,LOCAL,,,,,154,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP 0.9MM ANTI SKIVE PIN,27200000,CDM,272,RC,,,,12950-MAIN,LOCAL,,,,,154,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP 0.9MM ANTI SKIVE PIN,27200000,CDM,272,RC,,,,12950-MAIN,LOCAL,,,,,154,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP 0.9MM ANTI SKIVE PIN,27200000,CDM,272,RC,,,,12950-MAIN,LOCAL,,,,,154,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP 0.9MM ANTI SKIVE PIN,27200000,CDM,272,RC,,,,12950-MAIN,LOCAL,,,,,154,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP 1.4MM ANTI SKIVE PIN,27200000,CDM,272,RC,,,,12949-MAIN,LOCAL,,,,,154,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP 1.4MM ANTI SKIVE PIN,27200000,CDM,272,RC,,,,12949-MAIN,LOCAL,,,,,154,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP 1.4MM ANTI SKIVE PIN,27200000,CDM,272,RC,,,,12949-MAIN,LOCAL,,,,,154,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP 1.4MM ANTI SKIVE PIN,27200000,CDM,272,RC,,,,12949-MAIN,LOCAL,,,,,154,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP 1.4MM ANTI SKIVE PIN,27200000,CDM,272,RC,,,,12949-MAIN,LOCAL,,,,,154,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP 1.4MM ANTI SKIVE PIN,27200000,CDM,272,RC,,,,12949-MAIN,LOCAL,,,,,154,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP HV SCREW 3.0X16MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12986-MAIN,LOCAL,,,,,1569,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP HV SCREW 3.0X16MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12986-MAIN,LOCAL,,,,,1569,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP HV SCREW 3.0X16MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12986-MAIN,LOCAL,,,,,1569,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP HV SCREW 3.0X16MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12986-MAIN,LOCAL,,,,,1569,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP HV SCREW 3.0X16MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12986-MAIN,LOCAL,,,,,1569,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP HV SCREW 3.0X16MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12986-MAIN,LOCAL,,,,,1569,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 3.0X20MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12442-MAIN,LOCAL,,,,,1806,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 3.0X20MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12442-MAIN,LOCAL,,,,,1806,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 3.0X20MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12442-MAIN,LOCAL,,,,,1806,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 3.0X20MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12442-MAIN,LOCAL,,,,,1806,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 3.0X20MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12442-MAIN,LOCAL,,,,,1806,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 3.0X20MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12442-MAIN,LOCAL,,,,,1806,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 3.0X34MM STERILE IMPLANT,27200000,CDM,272,RC,,,,13042-MAIN,LOCAL,,,,,1684,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 3.0X34MM STERILE IMPLANT,27200000,CDM,272,RC,,,,13042-MAIN,LOCAL,,,,,1684,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 3.0X34MM STERILE IMPLANT,27200000,CDM,272,RC,,,,13042-MAIN,LOCAL,,,,,1684,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 3.0X34MM STERILE IMPLANT,27200000,CDM,272,RC,,,,13042-MAIN,LOCAL,,,,,1684,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 3.0X34MM STERILE IMPLANT,27200000,CDM,272,RC,,,,13042-MAIN,LOCAL,,,,,1684,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 3.0X34MM STERILE IMPLANT,27200000,CDM,272,RC,,,,13042-MAIN,LOCAL,,,,,1684,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 3.0X38MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12984-MAIN,LOCAL,,,,,2096,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 3.0X38MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12984-MAIN,LOCAL,,,,,2096,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 3.0X38MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12984-MAIN,LOCAL,,,,,2096,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 3.0X38MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12984-MAIN,LOCAL,,,,,2096,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 3.0X38MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12984-MAIN,LOCAL,,,,,2096,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 3.0X38MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12984-MAIN,LOCAL,,,,,2096,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 3.0X40MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12443-MAIN,LOCAL,,,,,1806,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 3.0X40MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12443-MAIN,LOCAL,,,,,1806,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 3.0X40MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12443-MAIN,LOCAL,,,,,1806,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 3.0X40MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12443-MAIN,LOCAL,,,,,1806,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 3.0X40MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12443-MAIN,LOCAL,,,,,1806,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 3.0X40MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12443-MAIN,LOCAL,,,,,1806,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 4.0X42MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12948-MAIN,LOCAL,,,,,2096,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 4.0X42MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12948-MAIN,LOCAL,,,,,2096,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 4.0X42MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12948-MAIN,LOCAL,,,,,2096,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 4.0X42MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12948-MAIN,LOCAL,,,,,2096,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 4.0X42MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12948-MAIN,LOCAL,,,,,2096,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 4.0X42MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12948-MAIN,LOCAL,,,,,2096,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 4.0X44MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12893-MAIN,LOCAL,,,,,2096,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 4.0X44MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12893-MAIN,LOCAL,,,,,2096,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 4.0X44MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12893-MAIN,LOCAL,,,,,2096,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 4.0X44MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12893-MAIN,LOCAL,,,,,2096,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 4.0X44MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12893-MAIN,LOCAL,,,,,2096,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 4.0X44MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12893-MAIN,LOCAL,,,,,2096,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 4.0X52MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12444-MAIN,LOCAL,,,,,1806,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 4.0X52MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12444-MAIN,LOCAL,,,,,1806,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 4.0X52MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12444-MAIN,LOCAL,,,,,1806,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 4.0X52MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12444-MAIN,LOCAL,,,,,1806,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 4.0X52MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12444-MAIN,LOCAL,,,,,1806,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 4.0X52MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12444-MAIN,LOCAL,,,,,1806,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 4.0X56MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12947-MAIN,LOCAL,,,,,2096,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 4.0X56MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12947-MAIN,LOCAL,,,,,2096,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 4.0X56MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12947-MAIN,LOCAL,,,,,2096,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 4.0X56MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12947-MAIN,LOCAL,,,,,2096,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 4.0X56MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12947-MAIN,LOCAL,,,,,2096,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 4.0X56MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12947-MAIN,LOCAL,,,,,2096,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Prosthetic Training, Initial, Each 15 Mins",PX97761,CDM,420,RC,97761,CPT,,,,,,,,121,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Prosthetic Training, Initial, Each 15 Mins",PX97761,CDM,420,RC,97761,CPT,,,,,,,,121,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Prosthetic Training, Initial, Each 15 Mins",PX97761,CDM,420,RC,97761,CPT,,,,,,,,121,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Prosthetic Training, Initial, Each 15 Mins",PX97761,CDM,420,RC,97761,CPT,,,,,,,,121,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Prosthetic Training, Initial, Each 15 Mins",PX97761,CDM,420,RC,97761,CPT,,,,,,,,121,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Prosthetic Training, Initial, Each 15 Mins",PX97761,CDM,420,RC,97761,CPT,,,,,,,,121,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
protamine 10 MG/ML Solution 5 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022994,NDC,5,ML,84.74,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
protamine 10 MG/ML Solution 5 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022994,NDC,5,ML,84.74,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
protamine 10 MG/ML Solution 5 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022994,NDC,5,ML,84.74,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
protamine 10 MG/ML Solution 5 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022994,NDC,5,ML,84.74,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
protamine 10 MG/ML Solution 5 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022994,NDC,5,ML,84.74,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
protamine 10 MG/ML Solution 5 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022994,NDC,5,ML,84.74,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
protamine 10 MG/ML Solution 25 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022930,NDC,2.5,ML,44.37,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
protamine 10 MG/ML Solution 25 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022930,NDC,2.5,ML,44.37,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
protamine 10 MG/ML Solution 25 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022930,NDC,2.5,ML,44.37,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
protamine 10 MG/ML Solution 25 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022930,NDC,2.5,ML,44.37,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
protamine 10 MG/ML Solution 25 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022930,NDC,2.5,ML,44.37,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
protamine 10 MG/ML Solution 25 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022930,NDC,2.5,ML,44.37,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Protein C Activity - Ref,PX8530390,CDM,300,RC,85303,CPT,90,,,,,,,158,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Protein C Activity - Ref,PX8530390,CDM,300,RC,85303,CPT,90,,,,,,,158,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Protein C Activity - Ref,PX8530390,CDM,300,RC,85303,CPT,90,,,,,,,158,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Protein C Activity - Ref,PX8530390,CDM,300,RC,85303,CPT,90,,,,,,,158,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Protein C Activity - Ref,PX8530390,CDM,300,RC,85303,CPT,90,,,,,,,158,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Protein C Activity - Ref,PX8530390,CDM,300,RC,85303,CPT,90,,,,,,,158,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Protein E-Phoresis Serum,PX84165,CDM,300,RC,84165,CPT,,,,,,,,175,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Protein E-Phoresis Serum,PX84165,CDM,300,RC,84165,CPT,,,,,,,,175,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Protein E-Phoresis Serum,PX84165,CDM,300,RC,84165,CPT,,,,,,,,175,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Protein E-Phoresis Serum,PX84165,CDM,300,RC,84165,CPT,,,,,,,,175,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Protein E-Phoresis Serum,PX84165,CDM,300,RC,84165,CPT,,,,,,,,175,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Protein E-Phoresis Serum,PX84165,CDM,300,RC,84165,CPT,,,,,,,,175,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Protein Elp,PX84166,CDM,300,RC,84166,CPT,,,,,,,,180,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Protein Elp,PX84166,CDM,300,RC,84166,CPT,,,,,,,,180,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Protein Elp,PX84166,CDM,300,RC,84166,CPT,,,,,,,,180,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Protein Elp,PX84166,CDM,300,RC,84166,CPT,,,,,,,,180,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Protein Elp,PX84166,CDM,300,RC,84166,CPT,,,,,,,,180,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Protein Elp,PX84166,CDM,300,RC,84166,CPT,,,,,,,,180,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Protein Elp Interp,PX8416526,CDM,300,RC,84165,CPT,26,,,,,,,175,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Protein Elp Interp,PX8416526,CDM,300,RC,84165,CPT,26,,,,,,,175,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Protein Elp Interp,PX8416526,CDM,300,RC,84165,CPT,26,,,,,,,175,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Protein Elp Interp,PX8416526,CDM,300,RC,84165,CPT,26,,,,,,,175,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Protein Elp Interp,PX8416526,CDM,300,RC,84165,CPT,26,,,,,,,175,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Protein Elp Interp,PX8416526,CDM,300,RC,84165,CPT,26,,,,,,,175,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Protein S, Free - Ref",PX8530690,CDM,300,RC,85306,CPT,90,,,,,,,47,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Protein S, Free - Ref",PX8530690,CDM,300,RC,85306,CPT,90,,,,,,,47,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Protein S, Free - Ref",PX8530690,CDM,300,RC,85306,CPT,90,,,,,,,47,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Protein S, Free - Ref",PX8530690,CDM,300,RC,85306,CPT,90,,,,,,,47,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Protein S, Free - Ref",PX8530690,CDM,300,RC,85306,CPT,90,,,,,,,47,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Protein S, Free - Ref",PX8530690,CDM,300,RC,85306,CPT,90,,,,,,,47,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Protein, Total; Other Source",PX84157,CDM,300,RC,84157,CPT,,,,,,,,153,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Protein, Total; Other Source",PX84157,CDM,300,RC,84157,CPT,,,,,,,,153,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Protein, Total; Other Source",PX84157,CDM,300,RC,84157,CPT,,,,,,,,153,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Protein, Total; Other Source",PX84157,CDM,300,RC,84157,CPT,,,,,,,,153,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Protein, Total; Other Source",PX84157,CDM,300,RC,84157,CPT,,,,,,,,153,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Protein, Total; Other Source",PX84157,CDM,300,RC,84157,CPT,,,,,,,,153,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Protein, Total; Serum, Plasma or Whole Blood",PX84155,CDM,300,RC,84155,CPT,,,,,,,,170,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Protein, Total; Serum, Plasma or Whole Blood",PX84155,CDM,300,RC,84155,CPT,,,,,,,,170,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Protein, Total; Serum, Plasma or Whole Blood",PX84155,CDM,300,RC,84155,CPT,,,,,,,,170,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Protein, Total; Serum, Plasma or Whole Blood",PX84155,CDM,300,RC,84155,CPT,,,,,,,,170,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Protein, Total; Serum, Plasma or Whole Blood",PX84155,CDM,300,RC,84155,CPT,,,,,,,,170,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Protein, Total; Serum, Plasma or Whole Blood",PX84155,CDM,300,RC,84155,CPT,,,,,,,,170,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prothrombin complex concentrate - human 500 units Kit 500 Units Box,J7168.01,CDM,636,RC,J7168,HCPCS,,,,63833038602,NDC,1500,UN,8007,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prothrombin complex concentrate - human 500 units Kit 500 Units Box,J7168.01,CDM,636,RC,J7168,HCPCS,,,,63833038602,NDC,1500,UN,8007,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prothrombin complex concentrate - human 500 units Kit 500 Units Box,J7168.01,CDM,636,RC,J7168,HCPCS,,,,63833038602,NDC,1500,UN,8007,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prothrombin complex concentrate - human 500 units Kit 500 Units Box,J7168.01,CDM,636,RC,J7168,HCPCS,,,,63833038602,NDC,1500,UN,8007,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prothrombin complex concentrate - human 500 units Kit 500 Units Box,J7168.01,CDM,636,RC,J7168,HCPCS,,,,63833038602,NDC,1500,UN,8007,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prothrombin complex concentrate - human 500 units Kit 500 Units Box,J7168.01,CDM,636,RC,J7168,HCPCS,,,,63833038602,NDC,1500,UN,8007,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Prothrombin Time (Pt/Inr),PX85610,CDM,300,RC,85610,CPT,,,,,,,,130,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Prothrombin Time (Pt/Inr),PX85610,CDM,300,RC,85610,CPT,,,,,,,,130,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Prothrombin Time (Pt/Inr),PX85610,CDM,300,RC,85610,CPT,,,,,,,,130,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Prothrombin Time (Pt/Inr),PX85610,CDM,300,RC,85610,CPT,,,,,,,,130,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Prothrombin Time (Pt/Inr),PX85610,CDM,300,RC,85610,CPT,,,,,,,,130,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Prothrombin Time (Pt/Inr),PX85610,CDM,300,RC,85610,CPT,,,,,,,,130,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Protoporphyrin, RBC, Qnt - Ref",PX8420290,CDM,300,RC,84202,CPT,90,,,,,,,61,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Protoporphyrin, RBC, Qnt - Ref",PX8420290,CDM,300,RC,84202,CPT,90,,,,,,,61,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Protoporphyrin, RBC, Qnt - Ref",PX8420290,CDM,300,RC,84202,CPT,90,,,,,,,61,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Protoporphyrin, RBC, Qnt - Ref",PX8420290,CDM,300,RC,84202,CPT,90,,,,,,,61,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Protoporphyrin, RBC, Qnt - Ref",PX8420290,CDM,300,RC,84202,CPT,90,,,,,,,61,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Protoporphyrin, RBC, Qnt - Ref",PX8420290,CDM,300,RC,84202,CPT,90,,,,,,,61,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Protozoa Antibody, Nos - Ref",PX8675390,CDM,300,RC,86753,CPT,90,,,,,,,99,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Protozoa Antibody, Nos - Ref",PX8675390,CDM,300,RC,86753,CPT,90,,,,,,,99,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Protozoa Antibody, Nos - Ref",PX8675390,CDM,300,RC,86753,CPT,90,,,,,,,99,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Protozoa Antibody, Nos - Ref",PX8675390,CDM,300,RC,86753,CPT,90,,,,,,,99,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Protozoa Antibody, Nos - Ref",PX8675390,CDM,300,RC,86753,CPT,90,,,,,,,99,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Protozoa Antibody, Nos - Ref",PX8675390,CDM,300,RC,86753,CPT,90,,,,,,,99,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Psa Screening,PXG0103,CDM,300,RC,G0103,HCPCS,,,,,,,,157,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Psa Screening,PXG0103,CDM,300,RC,G0103,HCPCS,,,,,,,,157,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Psa Screening,PXG0103,CDM,300,RC,G0103,HCPCS,,,,,,,,157,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Psa Screening,PXG0103,CDM,300,RC,G0103,HCPCS,,,,,,,,157,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Psa Screening,PXG0103,CDM,300,RC,G0103,HCPCS,,,,,,,,157,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Psa Screening,PXG0103,CDM,300,RC,G0103,HCPCS,,,,,,,,157,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Psa, Free - Ref",PX8415490,CDM,300,RC,84154,CPT,90,,,,,,,38,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Psa, Free - Ref",PX8415490,CDM,300,RC,84154,CPT,90,,,,,,,38,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Psa, Free - Ref",PX8415490,CDM,300,RC,84154,CPT,90,,,,,,,38,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Psa, Free - Ref",PX8415490,CDM,300,RC,84154,CPT,90,,,,,,,38,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Psa, Free - Ref",PX8415490,CDM,300,RC,84154,CPT,90,,,,,,,38,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Psa, Free - Ref",PX8415490,CDM,300,RC,84154,CPT,90,,,,,,,38,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Psa, Total - Ref",PX8415390,CDM,300,RC,84153,CPT,90,,,,,,,38,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Psa, Total - Ref",PX8415390,CDM,300,RC,84153,CPT,90,,,,,,,38,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Psa, Total - Ref",PX8415390,CDM,300,RC,84153,CPT,90,,,,,,,38,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Psa, Total - Ref",PX8415390,CDM,300,RC,84153,CPT,90,,,,,,,38,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Psa, Total - Ref",PX8415390,CDM,300,RC,84153,CPT,90,,,,,,,38,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Psa, Total - Ref",PX8415390,CDM,300,RC,84153,CPT,90,,,,,,,38,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
psyllium 0.52 GM capsule 160 Each Bottle,25000000,CDM,250,RC,,,,,,80681002200,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
psyllium 0.52 GM capsule 160 Each Bottle,25000000,CDM,250,RC,,,,,,80681002200,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
psyllium 0.52 GM capsule 160 Each Bottle,25000000,CDM,250,RC,,,,,,80681002200,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
psyllium 0.52 GM capsule 160 Each Bottle,25000000,CDM,250,RC,,,,,,80681002200,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
psyllium 0.52 GM capsule 160 Each Bottle,25000000,CDM,250,RC,,,,,,80681002200,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
psyllium 0.52 GM capsule 160 Each Bottle,25000000,CDM,250,RC,,,,,,80681002200,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Psyllium 400 MG capsule 160 Each Bottle,25000000,CDM,250,RC,,,,,,10939081644,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Psyllium 400 MG capsule 160 Each Bottle,25000000,CDM,250,RC,,,,,,10939081644,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Psyllium 400 MG capsule 160 Each Bottle,25000000,CDM,250,RC,,,,,,10939081644,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Psyllium 400 MG capsule 160 Each Bottle,25000000,CDM,250,RC,,,,,,10939081644,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Psyllium 400 MG capsule 160 Each Bottle,25000000,CDM,250,RC,,,,,,10939081644,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Psyllium 400 MG capsule 160 Each Bottle,25000000,CDM,250,RC,,,,,,10939081644,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Pt Contracted Service/Msho,PX120.176,CDM,421,RC,,,,,,,,,,66,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Pt Contracted Service/Msho,PX120.176,CDM,421,RC,,,,,,,,,,66,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Pt Contracted Service/Msho,PX120.176,CDM,421,RC,,,,,,,,,,66,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Pt Contracted Service/Msho,PX120.176,CDM,421,RC,,,,,,,,,,66,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Pt Contracted Service/Msho,PX120.176,CDM,421,RC,,,,,,,,,,66,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Pt Contracted Service/Msho,PX120.176,CDM,421,RC,,,,,,,,,,66,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Pt Contracted Services/MCR,PX120.175,CDM,421,RC,,,,,,,,,,98,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Pt Contracted Services/MCR,PX120.175,CDM,421,RC,,,,,,,,,,98,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Pt Contracted Services/MCR,PX120.175,CDM,421,RC,,,,,,,,,,98,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Pt Contracted Services/MCR,PX120.175,CDM,421,RC,,,,,,,,,,98,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Pt Contracted Services/MCR,PX120.175,CDM,421,RC,,,,,,,,,,98,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Pt Contracted Services/MCR,PX120.175,CDM,421,RC,,,,,,,,,,98,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Pulmonary Stress Test,PX94618,CDM,976,RC,94618,CPT,,,,,,,,153,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Pulmonary Stress Test,PX94618,CDM,976,RC,94618,CPT,,,,,,,,153,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Pulmonary Stress Test,PX94618,CDM,976,RC,94618,CPT,,,,,,,,153,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Pulmonary Stress Test,PX94618,CDM,976,RC,94618,CPT,,,,,,,,153,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Pulmonary Stress Test,PX94618,CDM,976,RC,94618,CPT,,,,,,,,153,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Pulmonary Stress Test,PX94618,CDM,976,RC,94618,CPT,,,,,,,,153,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105F,CDM,510,RC,11105,CPT,,,,,,,,171,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105F,CDM,510,RC,11105,CPT,,,,,,,,171,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105F,CDM,510,RC,11105,CPT,,,,,,,,171,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105F,CDM,510,RC,11105,CPT,,,,,,,,171,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105F,CDM,510,RC,11105,CPT,,,,,,,,171,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105F,CDM,510,RC,11105,CPT,,,,,,,,171,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105P,CDM,983,RC,11105,CPT,,,,,,,,171,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105P,CDM,983,RC,11105,CPT,,,,,,,,171,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105P,CDM,983,RC,11105,CPT,,,,,,,,171,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105P,CDM,983,RC,11105,CPT,,,,,,,,171,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105P,CDM,983,RC,11105,CPT,,,,,,,,171,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105P,CDM,983,RC,11105,CPT,,,,,,,,171,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Puncture Drainage of Lesion,PX10160F,CDM,510,RC,10160,CPT,,,,,,,,279,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Puncture Drainage of Lesion,PX10160F,CDM,510,RC,10160,CPT,,,,,,,,279,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Puncture Drainage of Lesion,PX10160F,CDM,510,RC,10160,CPT,,,,,,,,279,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Puncture Drainage of Lesion,PX10160F,CDM,510,RC,10160,CPT,,,,,,,,279,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Puncture Drainage of Lesion,PX10160F,CDM,510,RC,10160,CPT,,,,,,,,279,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Puncture Drainage of Lesion,PX10160F,CDM,510,RC,10160,CPT,,,,,,,,279,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Puncture Drainage of Lesion,PX10160P,CDM,983,RC,10160,CPT,,,,,,,,186,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Puncture Drainage of Lesion,PX10160P,CDM,983,RC,10160,CPT,,,,,,,,186,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Puncture Drainage of Lesion,PX10160P,CDM,983,RC,10160,CPT,,,,,,,,186,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Puncture Drainage of Lesion,PX10160P,CDM,983,RC,10160,CPT,,,,,,,,186,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Puncture Drainage of Lesion,PX10160P,CDM,983,RC,10160,CPT,,,,,,,,186,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Puncture Drainage of Lesion,PX10160P,CDM,983,RC,10160,CPT,,,,,,,,186,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PURAPLYAM XT-COM 4.91X4.91 EXTRA FENESTRATED 24.10 SQCM,120.567,CDM,272,RC,Q4197,HCPCS,,12806-MAIN,LOCAL,,,,,6562,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PURAPLYAM XT-COM 4.91X4.91 EXTRA FENESTRATED 24.10 SQCM,120.567,CDM,272,RC,Q4197,HCPCS,,12806-MAIN,LOCAL,,,,,6562,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PURAPLYAM XT-COM 4.91X4.91 EXTRA FENESTRATED 24.10 SQCM,120.567,CDM,272,RC,Q4197,HCPCS,,12806-MAIN,LOCAL,,,,,6562,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PURAPLYAM XT-COM 4.91X4.91 EXTRA FENESTRATED 24.10 SQCM,120.567,CDM,272,RC,Q4197,HCPCS,,12806-MAIN,LOCAL,,,,,6562,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PURAPLYAM XT-COM 4.91X4.91 EXTRA FENESTRATED 24.10 SQCM,120.567,CDM,272,RC,Q4197,HCPCS,,12806-MAIN,LOCAL,,,,,6562,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PURAPLYAM XT-COM 4.91X4.91 EXTRA FENESTRATED 24.10 SQCM,120.567,CDM,272,RC,Q4197,HCPCS,,12806-MAIN,LOCAL,,,,,6562,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Pvb Thoracic Single Injection Site W/Img Gid,PX64461F,CDM,510,RC,64461,CPT,,,,,,,,353,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Pvb Thoracic Single Injection Site W/Img Gid,PX64461F,CDM,510,RC,64461,CPT,,,,,,,,353,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Pvb Thoracic Single Injection Site W/Img Gid,PX64461F,CDM,510,RC,64461,CPT,,,,,,,,353,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Pvb Thoracic Single Injection Site W/Img Gid,PX64461F,CDM,510,RC,64461,CPT,,,,,,,,353,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Pvb Thoracic Single Injection Site W/Img Gid,PX64461F,CDM,510,RC,64461,CPT,,,,,,,,353,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Pvb Thoracic Single Injection Site W/Img Gid,PX64461F,CDM,510,RC,64461,CPT,,,,,,,,353,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Pvb Thoracic Single Injection Site W/Img Gid,PX64461P,CDM,983,RC,64461,CPT,,,,,,,,616,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Pvb Thoracic Single Injection Site W/Img Gid,PX64461P,CDM,983,RC,64461,CPT,,,,,,,,616,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Pvb Thoracic Single Injection Site W/Img Gid,PX64461P,CDM,983,RC,64461,CPT,,,,,,,,616,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Pvb Thoracic Single Injection Site W/Img Gid,PX64461P,CDM,983,RC,64461,CPT,,,,,,,,616,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Pvb Thoracic Single Injection Site W/Img Gid,PX64461P,CDM,983,RC,64461,CPT,,,,,,,,616,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Pvb Thoracic Single Injection Site W/Img Gid,PX64461P,CDM,983,RC,64461,CPT,,,,,,,,616,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pyRIDostigmine 60 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084049411,NDC,0.5,EA,3.97,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pyRIDostigmine 60 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084049411,NDC,0.5,EA,3.97,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pyRIDostigmine 60 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084049411,NDC,0.5,EA,3.97,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pyRIDostigmine 60 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084049411,NDC,0.5,EA,3.97,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pyRIDostigmine 60 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084049411,NDC,0.5,EA,3.97,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pyRIDostigmine 60 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084049411,NDC,0.5,EA,3.97,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pyRIDostigmine 60 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084049401,NDC,0.5,EA,3.98,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pyRIDostigmine 60 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084049401,NDC,0.5,EA,3.98,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pyRIDostigmine 60 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084049401,NDC,0.5,EA,3.98,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pyRIDostigmine 60 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084049401,NDC,0.5,EA,3.98,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pyRIDostigmine 60 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084049401,NDC,0.5,EA,3.98,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pyRIDostigmine 60 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084049401,NDC,0.5,EA,3.98,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pyRIDostigmine bromide 10 MG/2ML Solution 2 mL Ampule,25000000,CDM,250,RC,,,,,,781304095,NDC,2,ML,203.16,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pyRIDostigmine bromide 10 MG/2ML Solution 2 mL Ampule,25000000,CDM,250,RC,,,,,,781304095,NDC,2,ML,203.16,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pyRIDostigmine bromide 10 MG/2ML Solution 2 mL Ampule,25000000,CDM,250,RC,,,,,,781304095,NDC,2,ML,203.16,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pyRIDostigmine bromide 10 MG/2ML Solution 2 mL Ampule,25000000,CDM,250,RC,,,,,,781304095,NDC,2,ML,203.16,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pyRIDostigmine bromide 10 MG/2ML Solution 2 mL Ampule,25000000,CDM,250,RC,,,,,,781304095,NDC,2,ML,203.16,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pyRIDostigmine bromide 10 MG/2ML Solution 2 mL Ampule,25000000,CDM,250,RC,,,,,,781304095,NDC,2,ML,203.16,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pyridoxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536440601,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pyridoxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536440601,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pyridoxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536440601,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pyridoxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536440601,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pyridoxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536440601,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pyridoxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536440601,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pyridoxine 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,77333094010,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pyridoxine 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,77333094010,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pyridoxine 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,77333094010,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pyridoxine 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,77333094010,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pyridoxine 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,77333094010,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pyridoxine 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,77333094010,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Quantitation Drug Nos - Ref,PX8029990,CDM,300,RC,80299,CPT,90,,,,,,,112,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Quantitation Drug Nos - Ref,PX8029990,CDM,300,RC,80299,CPT,90,,,,,,,112,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Quantitation Drug Nos - Ref,PX8029990,CDM,300,RC,80299,CPT,90,,,,,,,112,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Quantitation Drug Nos - Ref,PX8029990,CDM,300,RC,80299,CPT,90,,,,,,,112,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Quantitation Drug Nos - Ref,PX8029990,CDM,300,RC,80299,CPT,90,,,,,,,112,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Quantitation Drug Nos - Ref,PX8029990,CDM,300,RC,80299,CPT,90,,,,,,,112,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
QUEtiapine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54022020,NDC,1,EA,21.46,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
QUEtiapine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54022020,NDC,1,EA,21.46,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
QUEtiapine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54022020,NDC,1,EA,21.46,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
QUEtiapine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54022020,NDC,1,EA,21.46,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
QUEtiapine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54022020,NDC,1,EA,21.46,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
QUEtiapine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54022020,NDC,1,EA,21.46,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
QUEtiapine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904663861,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
QUEtiapine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904663861,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
QUEtiapine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904663861,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
QUEtiapine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904663861,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
QUEtiapine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904663861,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
QUEtiapine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904663861,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
QUEtiapine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904664061,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
QUEtiapine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904664061,NDC,0.25,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
QUEtiapine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904664061,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
QUEtiapine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904664061,NDC,0.25,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
QUEtiapine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904664061,NDC,0.25,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
QUEtiapine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904664061,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
QUEtiapine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739066510,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
QUEtiapine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739066510,NDC,0.25,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
QUEtiapine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739066510,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
QUEtiapine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739066510,NDC,0.25,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
QUEtiapine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739066510,NDC,0.25,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
QUEtiapine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739066510,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rabies immune globulin 300 UNIT/2ML Solution 2 mL Vial,90377,CDM,636,RC,90376,CPT,,,,49281019020,NDC,2,ML,3384.84,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rabies immune globulin 300 UNIT/2ML Solution 2 mL Vial,90377,CDM,636,RC,90376,CPT,,,,49281019020,NDC,2,ML,3384.84,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rabies immune globulin 300 UNIT/2ML Solution 2 mL Vial,90377,CDM,636,RC,90376,CPT,,,,49281019020,NDC,2,ML,3384.84,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rabies immune globulin 300 UNIT/2ML Solution 2 mL Vial,90377,CDM,636,RC,90376,CPT,,,,49281019020,NDC,2,ML,3384.84,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rabies immune globulin 300 UNIT/2ML Solution 2 mL Vial,90377,CDM,636,RC,90376,CPT,,,,49281019020,NDC,2,ML,3384.84,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rabies immune globulin 300 UNIT/2ML Solution 2 mL Vial,90377,CDM,636,RC,90376,CPT,,,,49281019020,NDC,2,ML,3384.84,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rabies immune globulin 300 UNIT/ML Solution 1 mL Vial,90376,CDM,636,RC,90375,CPT,,,,13533031801,NDC,1,ML,1629.06,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rabies immune globulin 300 UNIT/ML Solution 1 mL Vial,90376,CDM,636,RC,90375,CPT,,,,13533031801,NDC,1,ML,1629.06,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rabies immune globulin 300 UNIT/ML Solution 1 mL Vial,90376,CDM,636,RC,90375,CPT,,,,13533031801,NDC,1,ML,1629.06,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rabies immune globulin 300 UNIT/ML Solution 1 mL Vial,90376,CDM,636,RC,90375,CPT,,,,13533031801,NDC,1,ML,1629.06,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rabies immune globulin 300 UNIT/ML Solution 1 mL Vial,90376,CDM,636,RC,90375,CPT,,,,13533031801,NDC,1,ML,1629.06,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rabies immune globulin 300 UNIT/ML Solution 1 mL Vial,90376,CDM,636,RC,90375,CPT,,,,13533031801,NDC,1,ML,1629.06,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rabies immune globulin 1500 UNIT/5ML Solution 5 mL Vial,90375,CDM,636,RC,90375,CPT,,,,13533031805,NDC,5,ML,8065.26,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rabies immune globulin 1500 UNIT/5ML Solution 5 mL Vial,90375,CDM,636,RC,90375,CPT,,,,13533031805,NDC,5,ML,8065.26,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rabies immune globulin 1500 UNIT/5ML Solution 5 mL Vial,90375,CDM,636,RC,90375,CPT,,,,13533031805,NDC,5,ML,8065.26,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rabies immune globulin 1500 UNIT/5ML Solution 5 mL Vial,90375,CDM,636,RC,90375,CPT,,,,13533031805,NDC,5,ML,8065.26,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rabies immune globulin 1500 UNIT/5ML Solution 5 mL Vial,90375,CDM,636,RC,90375,CPT,,,,13533031805,NDC,5,ML,8065.26,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rabies immune globulin 1500 UNIT/5ML Solution 5 mL Vial,90375,CDM,636,RC,90375,CPT,,,,13533031805,NDC,5,ML,8065.26,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"rabies vaccine, pcec Recon Susp 1 Each Vial",90675,CDM,636,RC,90675,CPT,,,,58160096412,NDC,1,EA,1544.83,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"rabies vaccine, pcec Recon Susp 1 Each Vial",90675,CDM,636,RC,90675,CPT,,,,58160096412,NDC,1,EA,1544.83,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"rabies vaccine, pcec Recon Susp 1 Each Vial",90675,CDM,636,RC,90675,CPT,,,,58160096412,NDC,1,EA,1544.83,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"rabies vaccine, pcec Recon Susp 1 Each Vial",90675,CDM,636,RC,90675,CPT,,,,58160096412,NDC,1,EA,1544.83,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"rabies vaccine, pcec Recon Susp 1 Each Vial",90675,CDM,636,RC,90675,CPT,,,,58160096412,NDC,1,EA,1544.83,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"rabies vaccine, pcec Recon Susp 1 Each Vial",90675,CDM,636,RC,90675,CPT,,,,58160096412,NDC,1,EA,1544.83,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
racEPINEPHrine 2.25 % Nebulization Solution 1 Each Plas Cont,25000000,CDM,250,RC,,,,,,487590199,NDC,1,EA,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
racEPINEPHrine 2.25 % Nebulization Solution 1 Each Plas Cont,25000000,CDM,250,RC,,,,,,487590199,NDC,1,EA,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
racEPINEPHrine 2.25 % Nebulization Solution 1 Each Plas Cont,25000000,CDM,250,RC,,,,,,487590199,NDC,1,EA,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
racEPINEPHrine 2.25 % Nebulization Solution 1 Each Plas Cont,25000000,CDM,250,RC,,,,,,487590199,NDC,1,EA,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
racEPINEPHrine 2.25 % Nebulization Solution 1 Each Plas Cont,25000000,CDM,250,RC,,,,,,487590199,NDC,1,EA,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
racEPINEPHrine 2.25 % Nebulization Solution 1 Each Plas Cont,25000000,CDM,250,RC,,,,,,487590199,NDC,1,EA,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Raltegravir 400 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,6022761,NDC,1,EA,150.2,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Raltegravir 400 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,6022761,NDC,1,EA,150.2,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Raltegravir 400 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,6022761,NDC,1,EA,150.2,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Raltegravir 400 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,6022761,NDC,1,EA,150.2,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Raltegravir 400 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,6022761,NDC,1,EA,150.2,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Raltegravir 400 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,6022761,NDC,1,EA,150.2,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ramipril 2.5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237022301,NDC,0.5,EA,4.85,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ramipril 2.5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237022301,NDC,0.5,EA,4.85,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ramipril 2.5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237022301,NDC,0.5,EA,4.85,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ramipril 2.5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237022301,NDC,0.5,EA,4.85,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ramipril 2.5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237022301,NDC,0.5,EA,4.85,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ramipril 2.5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237022301,NDC,0.5,EA,4.85,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ramipril 5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,68382014601,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ramipril 5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,68382014601,NDC,0.25,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ramipril 5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,68382014601,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ramipril 5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,68382014601,NDC,0.25,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ramipril 5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,68382014601,NDC,0.25,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ramipril 5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,68382014601,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ramuCIRumab 100 MG/10ML Solution 10 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2766901,NDC,10,ML,2463.3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ramuCIRumab 100 MG/10ML Solution 10 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2766901,NDC,10,ML,2463.3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ramuCIRumab 100 MG/10ML Solution 10 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2766901,NDC,10,ML,2463.3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ramuCIRumab 100 MG/10ML Solution 10 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2766901,NDC,10,ML,2463.3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ramuCIRumab 100 MG/10ML Solution 10 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2766901,NDC,10,ML,2463.3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ramuCIRumab 100 MG/10ML Solution 10 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2766901,NDC,10,ML,2463.3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ramuCIRumab 500 MG/50ML Solution 50 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2767801,NDC,50,ML,12316.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ramuCIRumab 500 MG/50ML Solution 50 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2767801,NDC,50,ML,12316.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ramuCIRumab 500 MG/50ML Solution 50 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2767801,NDC,50,ML,12316.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ramuCIRumab 500 MG/50ML Solution 50 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2767801,NDC,50,ML,12316.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ramuCIRumab 500 MG/50ML Solution 50 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2767801,NDC,50,ML,12316.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ramuCIRumab 500 MG/50ML Solution 50 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2767801,NDC,50,ML,12316.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RANGER UNIT TUBING FLUID WARMING,120.229,CDM,272,RC,,,,10612-MAIN,LOCAL,,,,,51,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RANGER UNIT TUBING FLUID WARMING,120.229,CDM,272,RC,,,,10612-MAIN,LOCAL,,,,,51,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RANGER UNIT TUBING FLUID WARMING,120.229,CDM,272,RC,,,,10612-MAIN,LOCAL,,,,,51,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RANGER UNIT TUBING FLUID WARMING,120.229,CDM,272,RC,,,,10612-MAIN,LOCAL,,,,,51,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RANGER UNIT TUBING FLUID WARMING,120.229,CDM,272,RC,,,,10612-MAIN,LOCAL,,,,,51,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RANGER UNIT TUBING FLUID WARMING,120.229,CDM,272,RC,,,,10612-MAIN,LOCAL,,,,,51,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RBC Antibody Elution,PX86860,CDM,300,RC,86860,CPT,,,,,,,,360,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RBC Antibody Elution,PX86860,CDM,300,RC,86860,CPT,,,,,,,,360,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RBC Antibody Elution,PX86860,CDM,300,RC,86860,CPT,,,,,,,,360,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RBC Antibody Elution,PX86860,CDM,300,RC,86860,CPT,,,,,,,,360,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RBC Antibody Elution,PX86860,CDM,300,RC,86860,CPT,,,,,,,,360,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RBC Antibody Elution,PX86860,CDM,300,RC,86860,CPT,,,,,,,,360,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RBC Antibody Screen,PX86850,CDM,300,RC,86850,CPT,,,,,,,,173,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RBC Antibody Screen,PX86850,CDM,300,RC,86850,CPT,,,,,,,,173,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RBC Antibody Screen,PX86850,CDM,300,RC,86850,CPT,,,,,,,,173,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RBC Antibody Screen,PX86850,CDM,300,RC,86850,CPT,,,,,,,,173,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RBC Antibody Screen,PX86850,CDM,300,RC,86850,CPT,,,,,,,,173,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RBC Antibody Screen,PX86850,CDM,300,RC,86850,CPT,,,,,,,,173,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RBC Pretreatment,PX8697002,CDM,300,RC,86970,CPT,,,,,,,,117,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RBC Pretreatment,PX8697002,CDM,300,RC,86970,CPT,,,,,,,,117,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RBC Pretreatment,PX8697002,CDM,300,RC,86970,CPT,,,,,,,,117,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RBC Pretreatment,PX8697002,CDM,300,RC,86970,CPT,,,,,,,,117,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RBC Pretreatment,PX8697002,CDM,300,RC,86970,CPT,,,,,,,,117,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RBC Pretreatment,PX8697002,CDM,300,RC,86970,CPT,,,,,,,,117,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"RBC Sed Rate, Auto",PX85652,CDM,300,RC,85652,CPT,,,,,,,,109,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"RBC Sed Rate, Auto",PX85652,CDM,300,RC,85652,CPT,,,,,,,,109,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"RBC Sed Rate, Auto",PX85652,CDM,300,RC,85652,CPT,,,,,,,,109,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"RBC Sed Rate, Auto",PX85652,CDM,300,RC,85652,CPT,,,,,,,,109,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"RBC Sed Rate, Auto",PX85652,CDM,300,RC,85652,CPT,,,,,,,,109,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"RBC Sed Rate, Auto",PX85652,CDM,300,RC,85652,CPT,,,,,,,,109,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
REAMER FOR CROSS PLATES,27200000,CDM,272,RC,,,,12641-MAIN,LOCAL,,,,,1852,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
REAMER FOR CROSS PLATES,27200000,CDM,272,RC,,,,12641-MAIN,LOCAL,,,,,1852,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
REAMER FOR CROSS PLATES,27200000,CDM,272,RC,,,,12641-MAIN,LOCAL,,,,,1852,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
REAMER FOR CROSS PLATES,27200000,CDM,272,RC,,,,12641-MAIN,LOCAL,,,,,1852,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
REAMER FOR CROSS PLATES,27200000,CDM,272,RC,,,,12641-MAIN,LOCAL,,,,,1852,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
REAMER FOR CROSS PLATES,27200000,CDM,272,RC,,,,12641-MAIN,LOCAL,,,,,1852,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Reconstruc of Nail Bed,PX11760F,CDM,510,RC,11760,CPT,,,,,,,,1162,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Reconstruc of Nail Bed,PX11760F,CDM,510,RC,11760,CPT,,,,,,,,1162,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Reconstruc of Nail Bed,PX11760F,CDM,510,RC,11760,CPT,,,,,,,,1162,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Reconstruc of Nail Bed,PX11760F,CDM,510,RC,11760,CPT,,,,,,,,1162,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Reconstruc of Nail Bed,PX11760F,CDM,510,RC,11760,CPT,,,,,,,,1162,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Reconstruc of Nail Bed,PX11760F,CDM,510,RC,11760,CPT,,,,,,,,1162,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Reconstruc of Nail Bed,PX11760P,CDM,983,RC,11760,CPT,,,,,,,,903,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Reconstruc of Nail Bed,PX11760P,CDM,983,RC,11760,CPT,,,,,,,,903,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Reconstruc of Nail Bed,PX11760P,CDM,983,RC,11760,CPT,,,,,,,,903,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Reconstruc of Nail Bed,PX11760P,CDM,983,RC,11760,CPT,,,,,,,,903,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Reconstruc of Nail Bed,PX11760P,CDM,983,RC,11760,CPT,,,,,,,,903,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Reconstruc of Nail Bed,PX11760P,CDM,983,RC,11760,CPT,,,,,,,,903,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Reconstruc of Nail Bed W Graft,PX11762F,CDM,510,RC,11762,CPT,,,,,,,,1901,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Reconstruc of Nail Bed W Graft,PX11762F,CDM,510,RC,11762,CPT,,,,,,,,1901,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Reconstruc of Nail Bed W Graft,PX11762F,CDM,510,RC,11762,CPT,,,,,,,,1901,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Reconstruc of Nail Bed W Graft,PX11762F,CDM,510,RC,11762,CPT,,,,,,,,1901,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Reconstruc of Nail Bed W Graft,PX11762F,CDM,510,RC,11762,CPT,,,,,,,,1901,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Reconstruc of Nail Bed W Graft,PX11762F,CDM,510,RC,11762,CPT,,,,,,,,1901,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Red Blood Cells Unit,PXP9021,CDM,390,RC,P9021,HCPCS,,,,,,,,1050,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Red Blood Cells Unit,PXP9021,CDM,390,RC,P9021,HCPCS,,,,,,,,1050,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Red Blood Cells Unit,PXP9021,CDM,390,RC,P9021,HCPCS,,,,,,,,1050,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Red Blood Cells Unit,PXP9021,CDM,390,RC,P9021,HCPCS,,,,,,,,1050,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Red Blood Cells Unit,PXP9021,CDM,390,RC,P9021,HCPCS,,,,,,,,1050,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Red Blood Cells Unit,PXP9021,CDM,390,RC,P9021,HCPCS,,,,,,,,1050,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Reduce Temporomandibl Disloc,PX21480F,CDM,510,RC,21480,CPT,,,,,,,,335,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Reduce Temporomandibl Disloc,PX21480F,CDM,510,RC,21480,CPT,,,,,,,,335,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Reduce Temporomandibl Disloc,PX21480F,CDM,510,RC,21480,CPT,,,,,,,,335,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Reduce Temporomandibl Disloc,PX21480F,CDM,510,RC,21480,CPT,,,,,,,,335,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Reduce Temporomandibl Disloc,PX21480F,CDM,510,RC,21480,CPT,,,,,,,,335,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Reduce Temporomandibl Disloc,PX21480F,CDM,510,RC,21480,CPT,,,,,,,,335,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Reduce Temporomandibl Disloc,PX21480P,CDM,983,RC,21480,CPT,,,,,,,,223,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Reduce Temporomandibl Disloc,PX21480P,CDM,983,RC,21480,CPT,,,,,,,,223,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Reduce Temporomandibl Disloc,PX21480P,CDM,983,RC,21480,CPT,,,,,,,,223,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Reduce Temporomandibl Disloc,PX21480P,CDM,983,RC,21480,CPT,,,,,,,,223,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Reduce Temporomandibl Disloc,PX21480P,CDM,983,RC,21480,CPT,,,,,,,,223,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Reduce Temporomandibl Disloc,PX21480P,CDM,983,RC,21480,CPT,,,,,,,,223,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
REDUCER 12 - 8MM,27200000,CDM,272,RC,,,,11961-MAIN,LOCAL,,,,,47,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
REDUCER 12 - 8MM,27200000,CDM,272,RC,,,,11961-MAIN,LOCAL,,,,,47,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
REDUCER 12 - 8MM,27200000,CDM,272,RC,,,,11961-MAIN,LOCAL,,,,,47,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
REDUCER 12 - 8MM,27200000,CDM,272,RC,,,,11961-MAIN,LOCAL,,,,,47,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
REDUCER 12 - 8MM,27200000,CDM,272,RC,,,,11961-MAIN,LOCAL,,,,,47,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
REDUCER 12 - 8MM,27200000,CDM,272,RC,,,,11961-MAIN,LOCAL,,,,,47,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Refill/Maint Portable Pump,PX96521,CDM,260,RC,96521,CPT,,,,,,,,325,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Refill/Maint Portable Pump,PX96521,CDM,260,RC,96521,CPT,,,,,,,,325,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Refill/Maint Portable Pump,PX96521,CDM,260,RC,96521,CPT,,,,,,,,325,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Refill/Maint Portable Pump,PX96521,CDM,260,RC,96521,CPT,,,,,,,,325,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Refill/Maint Portable Pump,PX96521,CDM,260,RC,96521,CPT,,,,,,,,325,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Refill/Maint Portable Pump,PX96521,CDM,260,RC,96521,CPT,,,,,,,,325,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,469650189,NDC,5,ML,1264.92,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,469650189,NDC,5,ML,1264.92,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,469650189,NDC,5,ML,1264.92,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,469650189,NDC,5,ML,1264.92,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,469650189,NDC,5,ML,1264.92,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,469650189,NDC,5,ML,1264.92,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,71288020185,NDC,5,ML,1021.7,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,71288020185,NDC,5,ML,1021.7,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,71288020185,NDC,5,ML,1021.7,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,71288020185,NDC,5,ML,1021.7,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,71288020185,NDC,5,ML,1021.7,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,71288020185,NDC,5,ML,1021.7,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RELOAD SUREFORM 45 2.5MM WHITE,27200000,CDM,272,RC,,,,12791-MAIN,LOCAL,,,,,386,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RELOAD SUREFORM 45 2.5MM WHITE,27200000,CDM,272,RC,,,,12791-MAIN,LOCAL,,,,,386,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RELOAD SUREFORM 45 2.5MM WHITE,27200000,CDM,272,RC,,,,12791-MAIN,LOCAL,,,,,386,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RELOAD SUREFORM 45 2.5MM WHITE,27200000,CDM,272,RC,,,,12791-MAIN,LOCAL,,,,,386,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RELOAD SUREFORM 45 2.5MM WHITE,27200000,CDM,272,RC,,,,12791-MAIN,LOCAL,,,,,386,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RELOAD SUREFORM 45 2.5MM WHITE,27200000,CDM,272,RC,,,,12791-MAIN,LOCAL,,,,,386,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RELOAD SUREFORM 45 3.5MM BLUE,27200000,CDM,272,RC,,,,12792-MAIN,LOCAL,,,,,386,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RELOAD SUREFORM 45 3.5MM BLUE,27200000,CDM,272,RC,,,,12792-MAIN,LOCAL,,,,,386,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RELOAD SUREFORM 45 3.5MM BLUE,27200000,CDM,272,RC,,,,12792-MAIN,LOCAL,,,,,386,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RELOAD SUREFORM 45 3.5MM BLUE,27200000,CDM,272,RC,,,,12792-MAIN,LOCAL,,,,,386,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RELOAD SUREFORM 45 3.5MM BLUE,27200000,CDM,272,RC,,,,12792-MAIN,LOCAL,,,,,386,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RELOAD SUREFORM 45 3.5MM BLUE,27200000,CDM,272,RC,,,,12792-MAIN,LOCAL,,,,,386,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RELOAD SUREFORM 45 4.3MM GREEN,27200000,CDM,272,RC,,,,12793-MAIN,LOCAL,,,,,386,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RELOAD SUREFORM 45 4.3MM GREEN,27200000,CDM,272,RC,,,,12793-MAIN,LOCAL,,,,,386,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RELOAD SUREFORM 45 4.3MM GREEN,27200000,CDM,272,RC,,,,12793-MAIN,LOCAL,,,,,386,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RELOAD SUREFORM 45 4.3MM GREEN,27200000,CDM,272,RC,,,,12793-MAIN,LOCAL,,,,,386,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RELOAD SUREFORM 45 4.3MM GREEN,27200000,CDM,272,RC,,,,12793-MAIN,LOCAL,,,,,386,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RELOAD SUREFORM 45 4.3MM GREEN,27200000,CDM,272,RC,,,,12793-MAIN,LOCAL,,,,,386,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RELOAD SUREFORM 60 2.5 WHITE 6 ROW BOX/12,27200000,CDM,272,RC,,,,12261-MAIN,LOCAL,,,,,430,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RELOAD SUREFORM 60 2.5 WHITE 6 ROW BOX/12,27200000,CDM,272,RC,,,,12261-MAIN,LOCAL,,,,,430,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RELOAD SUREFORM 60 2.5 WHITE 6 ROW BOX/12,27200000,CDM,272,RC,,,,12261-MAIN,LOCAL,,,,,430,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RELOAD SUREFORM 60 2.5 WHITE 6 ROW BOX/12,27200000,CDM,272,RC,,,,12261-MAIN,LOCAL,,,,,430,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RELOAD SUREFORM 60 2.5 WHITE 6 ROW BOX/12,27200000,CDM,272,RC,,,,12261-MAIN,LOCAL,,,,,430,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RELOAD SUREFORM 60 2.5 WHITE 6 ROW BOX/12,27200000,CDM,272,RC,,,,12261-MAIN,LOCAL,,,,,430,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RELOAD SUREFORM 60 3.5 BLUE,27200000,CDM,272,RC,,,,12084-MAIN,LOCAL,,,,,430,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RELOAD SUREFORM 60 3.5 BLUE,27200000,CDM,272,RC,,,,12084-MAIN,LOCAL,,,,,430,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RELOAD SUREFORM 60 3.5 BLUE,27200000,CDM,272,RC,,,,12084-MAIN,LOCAL,,,,,430,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RELOAD SUREFORM 60 3.5 BLUE,27200000,CDM,272,RC,,,,12084-MAIN,LOCAL,,,,,430,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RELOAD SUREFORM 60 3.5 BLUE,27200000,CDM,272,RC,,,,12084-MAIN,LOCAL,,,,,430,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RELOAD SUREFORM 60 3.5 BLUE,27200000,CDM,272,RC,,,,12084-MAIN,LOCAL,,,,,430,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RELOAD SUREFORM 60 4.3 GREEN,27200000,CDM,272,RC,,,,12085-MAIN,LOCAL,,,,,430,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RELOAD SUREFORM 60 4.3 GREEN,27200000,CDM,272,RC,,,,12085-MAIN,LOCAL,,,,,430,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RELOAD SUREFORM 60 4.3 GREEN,27200000,CDM,272,RC,,,,12085-MAIN,LOCAL,,,,,430,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RELOAD SUREFORM 60 4.3 GREEN,27200000,CDM,272,RC,,,,12085-MAIN,LOCAL,,,,,430,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RELOAD SUREFORM 60 4.3 GREEN,27200000,CDM,272,RC,,,,12085-MAIN,LOCAL,,,,,430,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RELOAD SUREFORM 60 4.3 GREEN,27200000,CDM,272,RC,,,,12085-MAIN,LOCAL,,,,,430,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290101,NDC,1,EA,1966.88,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290101,NDC,1,EA,1966.88,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290101,NDC,1,EA,1966.88,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290101,NDC,1,EA,1966.88,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290101,NDC,1,EA,1966.88,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290101,NDC,1,EA,1966.88,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290102,NDC,1,EA,1966.88,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290102,NDC,1,EA,1966.88,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290102,NDC,1,EA,1966.88,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290102,NDC,1,EA,1966.88,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290102,NDC,1,EA,1966.88,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290102,NDC,1,EA,1966.88,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Removal Anal Fistula,Subcutaneous",PX46270F,CDM,510,RC,46270,CPT,,,,,,,,1470,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Removal Anal Fistula,Subcutaneous",PX46270F,CDM,510,RC,46270,CPT,,,,,,,,1470,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Removal Anal Fistula,Subcutaneous",PX46270F,CDM,510,RC,46270,CPT,,,,,,,,1470,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Removal Anal Fistula,Subcutaneous",PX46270F,CDM,510,RC,46270,CPT,,,,,,,,1470,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Removal Anal Fistula,Subcutaneous",PX46270F,CDM,510,RC,46270,CPT,,,,,,,,1470,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Removal Anal Fistula,Subcutaneous",PX46270F,CDM,510,RC,46270,CPT,,,,,,,,1470,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Removal Anal Fistula,Subcutaneous",PX46270P,CDM,983,RC,46270,CPT,,,,,,,,980,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Removal Anal Fistula,Subcutaneous",PX46270P,CDM,983,RC,46270,CPT,,,,,,,,980,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Removal Anal Fistula,Subcutaneous",PX46270P,CDM,983,RC,46270,CPT,,,,,,,,980,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Removal Anal Fistula,Subcutaneous",PX46270P,CDM,983,RC,46270,CPT,,,,,,,,980,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Removal Anal Fistula,Subcutaneous",PX46270P,CDM,983,RC,46270,CPT,,,,,,,,980,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Removal Anal Fistula,Subcutaneous",PX46270P,CDM,983,RC,46270,CPT,,,,,,,,980,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209F,CDM,510,RC,69209,CPT,,,,,,,,35,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209F,CDM,510,RC,69209,CPT,,,,,,,,35,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209F,CDM,510,RC,69209,CPT,,,,,,,,35,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209F,CDM,510,RC,69209,CPT,,,,,,,,35,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209F,CDM,510,RC,69209,CPT,,,,,,,,35,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209F,CDM,510,RC,69209,CPT,,,,,,,,35,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209P,CDM,982,RC,69209,CPT,,,,,,,,113,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209P,CDM,982,RC,69209,CPT,,,,,,,,113,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209P,CDM,982,RC,69209,CPT,,,,,,,,113,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209P,CDM,982,RC,69209,CPT,,,,,,,,113,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209P,CDM,982,RC,69209,CPT,,,,,,,,113,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209P,CDM,982,RC,69209,CPT,,,,,,,,113,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Anal Tabs,PX46230F,CDM,510,RC,46230,CPT,,,,,,,,790,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Anal Tabs,PX46230F,CDM,510,RC,46230,CPT,,,,,,,,790,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Anal Tabs,PX46230F,CDM,510,RC,46230,CPT,,,,,,,,790,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Anal Tabs,PX46230F,CDM,510,RC,46230,CPT,,,,,,,,790,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Anal Tabs,PX46230F,CDM,510,RC,46230,CPT,,,,,,,,790,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Anal Tabs,PX46230F,CDM,510,RC,46230,CPT,,,,,,,,790,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Anal Tabs,PX46230P,CDM,983,RC,46230,CPT,,,,,,,,1435,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Anal Tabs,PX46230P,CDM,983,RC,46230,CPT,,,,,,,,1435,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Anal Tabs,PX46230P,CDM,983,RC,46230,CPT,,,,,,,,1435,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Anal Tabs,PX46230P,CDM,983,RC,46230,CPT,,,,,,,,1435,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Anal Tabs,PX46230P,CDM,983,RC,46230,CPT,,,,,,,,1435,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Anal Tabs,PX46230P,CDM,983,RC,46230,CPT,,,,,,,,1435,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Hemorrhoid Clot,PX46320F,CDM,510,RC,46320,CPT,,,,,,,,2027,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Hemorrhoid Clot,PX46320F,CDM,510,RC,46320,CPT,,,,,,,,2027,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Hemorrhoid Clot,PX46320F,CDM,510,RC,46320,CPT,,,,,,,,2027,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Hemorrhoid Clot,PX46320F,CDM,510,RC,46320,CPT,,,,,,,,2027,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Hemorrhoid Clot,PX46320F,CDM,510,RC,46320,CPT,,,,,,,,2027,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Hemorrhoid Clot,PX46320F,CDM,510,RC,46320,CPT,,,,,,,,2027,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Hemorrhoid Clot,PX46320P,CDM,983,RC,46320,CPT,,,,,,,,374,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Hemorrhoid Clot,PX46320P,CDM,983,RC,46320,CPT,,,,,,,,374,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Hemorrhoid Clot,PX46320P,CDM,983,RC,46320,CPT,,,,,,,,374,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Hemorrhoid Clot,PX46320P,CDM,983,RC,46320,CPT,,,,,,,,374,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Hemorrhoid Clot,PX46320P,CDM,983,RC,46320,CPT,,,,,,,,374,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Hemorrhoid Clot,PX46320P,CDM,983,RC,46320,CPT,,,,,,,,374,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Removal of Hydrocele,Tunica,Unilat",PX55040P,CDM,983,RC,55040,CPT,,,,,,,,1420,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Removal of Hydrocele,Tunica,Unilat",PX55040P,CDM,983,RC,55040,CPT,,,,,,,,1420,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Removal of Hydrocele,Tunica,Unilat",PX55040P,CDM,983,RC,55040,CPT,,,,,,,,1420,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Removal of Hydrocele,Tunica,Unilat",PX55040P,CDM,983,RC,55040,CPT,,,,,,,,1420,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Removal of Hydrocele,Tunica,Unilat",PX55040P,CDM,983,RC,55040,CPT,,,,,,,,1420,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Removal of Hydrocele,Tunica,Unilat",PX55040P,CDM,983,RC,55040,CPT,,,,,,,,1420,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Nail Bed,PX11750F,CDM,510,RC,11750,CPT,,,,,,,,629,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Nail Bed,PX11750F,CDM,510,RC,11750,CPT,,,,,,,,629,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Nail Bed,PX11750F,CDM,510,RC,11750,CPT,,,,,,,,629,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Nail Bed,PX11750F,CDM,510,RC,11750,CPT,,,,,,,,629,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Nail Bed,PX11750F,CDM,510,RC,11750,CPT,,,,,,,,629,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Nail Bed,PX11750F,CDM,510,RC,11750,CPT,,,,,,,,629,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Nail Plate,PX11730F,CDM,510,RC,11730,CPT,,,,,,,,229,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Nail Plate,PX11730F,CDM,510,RC,11730,CPT,,,,,,,,229,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Nail Plate,PX11730F,CDM,510,RC,11730,CPT,,,,,,,,229,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Nail Plate,PX11730F,CDM,510,RC,11730,CPT,,,,,,,,229,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Nail Plate,PX11730F,CDM,510,RC,11730,CPT,,,,,,,,229,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Nail Plate,PX11730F,CDM,510,RC,11730,CPT,,,,,,,,229,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Skin Tags,PX11200P,CDM,983,RC,11200,CPT,,,,,,,,418,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Skin Tags,PX11200P,CDM,983,RC,11200,CPT,,,,,,,,418,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Skin Tags,PX11200P,CDM,983,RC,11200,CPT,,,,,,,,418,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Skin Tags,PX11200P,CDM,983,RC,11200,CPT,,,,,,,,418,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Skin Tags,PX11200P,CDM,983,RC,11200,CPT,,,,,,,,418,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Skin Tags,PX11200P,CDM,983,RC,11200,CPT,,,,,,,,418,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Removal of Tunnel Cv Access Device, With Port/Pump",PX36590P,CDM,983,RC,36590,CPT,,,,,,,,1147,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Removal of Tunnel Cv Access Device, With Port/Pump",PX36590P,CDM,983,RC,36590,CPT,,,,,,,,1147,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Removal of Tunnel Cv Access Device, With Port/Pump",PX36590P,CDM,983,RC,36590,CPT,,,,,,,,1147,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Removal of Tunnel Cv Access Device, With Port/Pump",PX36590P,CDM,983,RC,36590,CPT,,,,,,,,1147,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Removal of Tunnel Cv Access Device, With Port/Pump",PX36590P,CDM,983,RC,36590,CPT,,,,,,,,1147,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Removal of Tunnel Cv Access Device, With Port/Pump",PX36590P,CDM,983,RC,36590,CPT,,,,,,,,1147,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Additional Nail Plate,PX11732F,CDM,510,RC,11732,CPT,,,,,,,,77,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Additional Nail Plate,PX11732F,CDM,510,RC,11732,CPT,,,,,,,,77,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Additional Nail Plate,PX11732F,CDM,510,RC,11732,CPT,,,,,,,,77,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Additional Nail Plate,PX11732F,CDM,510,RC,11732,CPT,,,,,,,,77,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Additional Nail Plate,PX11732F,CDM,510,RC,11732,CPT,,,,,,,,77,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Additional Nail Plate,PX11732F,CDM,510,RC,11732,CPT,,,,,,,,77,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Foreign Body Complic,PX10121F,CDM,510,RC,10121,CPT,,,,,,,,3575,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Foreign Body Complic,PX10121F,CDM,510,RC,10121,CPT,,,,,,,,3575,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Foreign Body Complic,PX10121F,CDM,510,RC,10121,CPT,,,,,,,,3575,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Foreign Body Complic,PX10121F,CDM,510,RC,10121,CPT,,,,,,,,3575,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Foreign Body Complic,PX10121F,CDM,510,RC,10121,CPT,,,,,,,,3575,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Foreign Body Complic,PX10121F,CDM,510,RC,10121,CPT,,,,,,,,3575,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Foreign Body Complic,PX10121P,CDM,983,RC,10121,CPT,,,,,,,,651,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Foreign Body Complic,PX10121P,CDM,983,RC,10121,CPT,,,,,,,,651,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Foreign Body Complic,PX10121P,CDM,983,RC,10121,CPT,,,,,,,,651,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Foreign Body Complic,PX10121P,CDM,983,RC,10121,CPT,,,,,,,,651,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Foreign Body Complic,PX10121P,CDM,983,RC,10121,CPT,,,,,,,,651,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Foreign Body Complic,PX10121P,CDM,983,RC,10121,CPT,,,,,,,,651,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Foreign Body Simple,PX10120F,CDM,510,RC,10120,CPT,,,,,,,,404,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Foreign Body Simple,PX10120F,CDM,510,RC,10120,CPT,,,,,,,,404,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Foreign Body Simple,PX10120F,CDM,510,RC,10120,CPT,,,,,,,,404,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Foreign Body Simple,PX10120F,CDM,510,RC,10120,CPT,,,,,,,,404,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Foreign Body Simple,PX10120F,CDM,510,RC,10120,CPT,,,,,,,,404,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Foreign Body Simple,PX10120F,CDM,510,RC,10120,CPT,,,,,,,,404,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Foreign Body Simple,PX10120P,CDM,983,RC,10120,CPT,,,,,,,,404,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Foreign Body Simple,PX10120P,CDM,983,RC,10120,CPT,,,,,,,,404,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Foreign Body Simple,PX10120P,CDM,983,RC,10120,CPT,,,,,,,,404,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Foreign Body Simple,PX10120P,CDM,983,RC,10120,CPT,,,,,,,,404,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Foreign Body Simple,PX10120P,CDM,983,RC,10120,CPT,,,,,,,,404,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Foreign Body Simple,PX10120P,CDM,983,RC,10120,CPT,,,,,,,,404,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Hemorrhoids & Fissure,PX46257F,CDM,510,RC,46257,CPT,,,,,,,,1141,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Hemorrhoids & Fissure,PX46257F,CDM,510,RC,46257,CPT,,,,,,,,1141,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Hemorrhoids & Fissure,PX46257F,CDM,510,RC,46257,CPT,,,,,,,,1141,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Hemorrhoids & Fissure,PX46257F,CDM,510,RC,46257,CPT,,,,,,,,1141,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Hemorrhoids & Fissure,PX46257F,CDM,510,RC,46257,CPT,,,,,,,,1141,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Hemorrhoids & Fissure,PX46257F,CDM,510,RC,46257,CPT,,,,,,,,1141,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Hemorrhoids & Fissure,PX46257P,CDM,983,RC,46257,CPT,,,,,,,,615,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Hemorrhoids & Fissure,PX46257P,CDM,983,RC,46257,CPT,,,,,,,,615,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Hemorrhoids & Fissure,PX46257P,CDM,983,RC,46257,CPT,,,,,,,,615,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Hemorrhoids & Fissure,PX46257P,CDM,983,RC,46257,CPT,,,,,,,,615,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Hemorrhoids & Fissure,PX46257P,CDM,983,RC,46257,CPT,,,,,,,,615,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Hemorrhoids & Fissure,PX46257P,CDM,983,RC,46257,CPT,,,,,,,,615,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Impacted Ear Wax,PX69210F,CDM,510,RC,69210,CPT,,,,,,,,213,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Impacted Ear Wax,PX69210F,CDM,510,RC,69210,CPT,,,,,,,,213,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Impacted Ear Wax,PX69210F,CDM,510,RC,69210,CPT,,,,,,,,213,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Impacted Ear Wax,PX69210F,CDM,510,RC,69210,CPT,,,,,,,,213,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Impacted Ear Wax,PX69210F,CDM,510,RC,69210,CPT,,,,,,,,213,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Impacted Ear Wax,PX69210F,CDM,510,RC,69210,CPT,,,,,,,,213,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Impacted Ear Wax,PX69210P,CDM,983,RC,69210,CPT,,,,,,,,221,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Impacted Ear Wax,PX69210P,CDM,983,RC,69210,CPT,,,,,,,,221,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Impacted Ear Wax,PX69210P,CDM,983,RC,69210,CPT,,,,,,,,221,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Impacted Ear Wax,PX69210P,CDM,983,RC,69210,CPT,,,,,,,,221,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Impacted Ear Wax,PX69210P,CDM,983,RC,69210,CPT,,,,,,,,221,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Impacted Ear Wax,PX69210P,CDM,983,RC,69210,CPT,,,,,,,,221,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Intrauterine Device,PX58301,CDM,983,RC,58301,CPT,,,,,,,,357,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Intrauterine Device,PX58301,CDM,983,RC,58301,CPT,,,,,,,,357,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Intrauterine Device,PX58301,CDM,983,RC,58301,CPT,,,,,,,,357,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Intrauterine Device,PX58301,CDM,983,RC,58301,CPT,,,,,,,,357,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Intrauterine Device,PX58301,CDM,983,RC,58301,CPT,,,,,,,,357,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Intrauterine Device,PX58301,CDM,983,RC,58301,CPT,,,,,,,,357,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Nasal Foreign Body,PX30300F,CDM,510,RC,30300,CPT,,,,,,,,972,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Nasal Foreign Body,PX30300F,CDM,510,RC,30300,CPT,,,,,,,,972,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Nasal Foreign Body,PX30300F,CDM,510,RC,30300,CPT,,,,,,,,972,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Nasal Foreign Body,PX30300F,CDM,510,RC,30300,CPT,,,,,,,,972,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Nasal Foreign Body,PX30300F,CDM,510,RC,30300,CPT,,,,,,,,972,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Nasal Foreign Body,PX30300F,CDM,510,RC,30300,CPT,,,,,,,,972,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Nasal Foreign Body,PX30300P,CDM,983,RC,30300,CPT,,,,,,,,572,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Nasal Foreign Body,PX30300P,CDM,983,RC,30300,CPT,,,,,,,,572,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Nasal Foreign Body,PX30300P,CDM,983,RC,30300,CPT,,,,,,,,572,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Nasal Foreign Body,PX30300P,CDM,983,RC,30300,CPT,,,,,,,,572,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Nasal Foreign Body,PX30300P,CDM,983,RC,30300,CPT,,,,,,,,572,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Nasal Foreign Body,PX30300P,CDM,983,RC,30300,CPT,,,,,,,,572,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remv Ext Canal Foreign Body,PX69200F,CDM,510,RC,69200,CPT,,,,,,,,235,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remv Ext Canal Foreign Body,PX69200F,CDM,510,RC,69200,CPT,,,,,,,,235,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remv Ext Canal Foreign Body,PX69200F,CDM,510,RC,69200,CPT,,,,,,,,235,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remv Ext Canal Foreign Body,PX69200F,CDM,510,RC,69200,CPT,,,,,,,,235,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remv Ext Canal Foreign Body,PX69200F,CDM,510,RC,69200,CPT,,,,,,,,235,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remv Ext Canal Foreign Body,PX69200F,CDM,510,RC,69200,CPT,,,,,,,,235,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remv Ext Canal Foreign Body,PX69200P,CDM,983,RC,69200,CPT,,,,,,,,157,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remv Ext Canal Foreign Body,PX69200P,CDM,983,RC,69200,CPT,,,,,,,,157,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remv Ext Canal Foreign Body,PX69200P,CDM,983,RC,69200,CPT,,,,,,,,157,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remv Ext Canal Foreign Body,PX69200P,CDM,983,RC,69200,CPT,,,,,,,,157,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remv Ext Canal Foreign Body,PX69200P,CDM,983,RC,69200,CPT,,,,,,,,157,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remv Ext Canal Foreign Body,PX69200P,CDM,983,RC,69200,CPT,,,,,,,,157,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Ant Chmbr/Lens",PX65235F,CDM,510,RC,65235,CPT,,,,,,,,2788,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Ant Chmbr/Lens",PX65235F,CDM,510,RC,65235,CPT,,,,,,,,2788,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Ant Chmbr/Lens",PX65235F,CDM,510,RC,65235,CPT,,,,,,,,2788,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Ant Chmbr/Lens",PX65235F,CDM,510,RC,65235,CPT,,,,,,,,2788,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Ant Chmbr/Lens",PX65235F,CDM,510,RC,65235,CPT,,,,,,,,2788,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Ant Chmbr/Lens",PX65235F,CDM,510,RC,65235,CPT,,,,,,,,2788,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Cornea,No Slit",PX65220F,CDM,510,RC,65220,CPT,,,,,,,,334,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Cornea,No Slit",PX65220F,CDM,510,RC,65220,CPT,,,,,,,,334,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Cornea,No Slit",PX65220F,CDM,510,RC,65220,CPT,,,,,,,,334,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Cornea,No Slit",PX65220F,CDM,510,RC,65220,CPT,,,,,,,,334,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Cornea,No Slit",PX65220F,CDM,510,RC,65220,CPT,,,,,,,,334,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Cornea,No Slit",PX65220F,CDM,510,RC,65220,CPT,,,,,,,,334,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Cornea,No Slit",PX65220P,CDM,983,RC,65220,CPT,,,,,,,,318,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Cornea,No Slit",PX65220P,CDM,983,RC,65220,CPT,,,,,,,,318,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Cornea,No Slit",PX65220P,CDM,983,RC,65220,CPT,,,,,,,,318,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Cornea,No Slit",PX65220P,CDM,983,RC,65220,CPT,,,,,,,,318,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Cornea,No Slit",PX65220P,CDM,983,RC,65220,CPT,,,,,,,,318,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Cornea,No Slit",PX65220P,CDM,983,RC,65220,CPT,,,,,,,,318,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Embed Conjunc",PX65210F,CDM,510,RC,65210,CPT,,,,,,,,325,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Embed Conjunc",PX65210F,CDM,510,RC,65210,CPT,,,,,,,,325,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Embed Conjunc",PX65210F,CDM,510,RC,65210,CPT,,,,,,,,325,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Embed Conjunc",PX65210F,CDM,510,RC,65210,CPT,,,,,,,,325,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Embed Conjunc",PX65210F,CDM,510,RC,65210,CPT,,,,,,,,325,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Embed Conjunc",PX65210F,CDM,510,RC,65210,CPT,,,,,,,,325,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Embed Conjunc",PX65210P,CDM,983,RC,65210,CPT,,,,,,,,216,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Embed Conjunc",PX65210P,CDM,983,RC,65210,CPT,,,,,,,,216,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Embed Conjunc",PX65210P,CDM,983,RC,65210,CPT,,,,,,,,216,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Embed Conjunc",PX65210P,CDM,983,RC,65210,CPT,,,,,,,,216,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Embed Conjunc",PX65210P,CDM,983,RC,65210,CPT,,,,,,,,216,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Embed Conjunc",PX65210P,CDM,983,RC,65210,CPT,,,,,,,,216,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Superf Conjunc",PX65205F,CDM,510,RC,65205,CPT,,,,,,,,132,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Superf Conjunc",PX65205F,CDM,510,RC,65205,CPT,,,,,,,,132,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Superf Conjunc",PX65205F,CDM,510,RC,65205,CPT,,,,,,,,132,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Superf Conjunc",PX65205F,CDM,510,RC,65205,CPT,,,,,,,,132,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Superf Conjunc",PX65205F,CDM,510,RC,65205,CPT,,,,,,,,132,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Superf Conjunc",PX65205F,CDM,510,RC,65205,CPT,,,,,,,,132,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Superf Conjunc",PX65205P,CDM,983,RC,65205,CPT,,,,,,,,132,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Superf Conjunc",PX65205P,CDM,983,RC,65205,CPT,,,,,,,,132,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Superf Conjunc",PX65205P,CDM,983,RC,65205,CPT,,,,,,,,132,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Superf Conjunc",PX65205P,CDM,983,RC,65205,CPT,,,,,,,,132,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Superf Conjunc",PX65205P,CDM,983,RC,65205,CPT,,,,,,,,132,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Superf Conjunc",PX65205P,CDM,983,RC,65205,CPT,,,,,,,,132,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv Foot Foreign Body,Subcutaneous",PX28190F,CDM,510,RC,28190,CPT,,,,,,,,1025,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv Foot Foreign Body,Subcutaneous",PX28190F,CDM,510,RC,28190,CPT,,,,,,,,1025,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv Foot Foreign Body,Subcutaneous",PX28190F,CDM,510,RC,28190,CPT,,,,,,,,1025,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv Foot Foreign Body,Subcutaneous",PX28190F,CDM,510,RC,28190,CPT,,,,,,,,1025,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv Foot Foreign Body,Subcutaneous",PX28190F,CDM,510,RC,28190,CPT,,,,,,,,1025,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv Foot Foreign Body,Subcutaneous",PX28190F,CDM,510,RC,28190,CPT,,,,,,,,1025,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv Foot Foreign Body,Subcutaneous",PX28190P,CDM,983,RC,28190,CPT,,,,,,,,683,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv Foot Foreign Body,Subcutaneous",PX28190P,CDM,983,RC,28190,CPT,,,,,,,,683,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv Foot Foreign Body,Subcutaneous",PX28190P,CDM,983,RC,28190,CPT,,,,,,,,683,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv Foot Foreign Body,Subcutaneous",PX28190P,CDM,983,RC,28190,CPT,,,,,,,,683,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv Foot Foreign Body,Subcutaneous",PX28190P,CDM,983,RC,28190,CPT,,,,,,,,683,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv Foot Foreign Body,Subcutaneous",PX28190P,CDM,983,RC,28190,CPT,,,,,,,,683,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv Foreign Body,Knee/Thigh,Deep",PX27372F,CDM,510,RC,27372,CPT,,,,,,,,1429,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv Foreign Body,Knee/Thigh,Deep",PX27372F,CDM,510,RC,27372,CPT,,,,,,,,1429,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv Foreign Body,Knee/Thigh,Deep",PX27372F,CDM,510,RC,27372,CPT,,,,,,,,1429,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv Foreign Body,Knee/Thigh,Deep",PX27372F,CDM,510,RC,27372,CPT,,,,,,,,1429,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv Foreign Body,Knee/Thigh,Deep",PX27372F,CDM,510,RC,27372,CPT,,,,,,,,1429,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv Foreign Body,Knee/Thigh,Deep",PX27372F,CDM,510,RC,27372,CPT,,,,,,,,1429,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv Foreign Body,Knee/Thigh,Deep",PX27372P,CDM,983,RC,27372,CPT,,,,,,,,954,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv Foreign Body,Knee/Thigh,Deep",PX27372P,CDM,983,RC,27372,CPT,,,,,,,,954,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv Foreign Body,Knee/Thigh,Deep",PX27372P,CDM,983,RC,27372,CPT,,,,,,,,954,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv Foreign Body,Knee/Thigh,Deep",PX27372P,CDM,983,RC,27372,CPT,,,,,,,,954,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv Foreign Body,Knee/Thigh,Deep",PX27372P,CDM,983,RC,27372,CPT,,,,,,,,954,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv Foreign Body,Knee/Thigh,Deep",PX27372P,CDM,983,RC,27372,CPT,,,,,,,,954,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remv Periton FB From Perit Cav,PX49402F,CDM,510,RC,49402,CPT,,,,,,,,3573,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remv Periton FB From Perit Cav,PX49402F,CDM,510,RC,49402,CPT,,,,,,,,3573,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remv Periton FB From Perit Cav,PX49402F,CDM,510,RC,49402,CPT,,,,,,,,3573,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remv Periton FB From Perit Cav,PX49402F,CDM,510,RC,49402,CPT,,,,,,,,3573,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remv Periton FB From Perit Cav,PX49402F,CDM,510,RC,49402,CPT,,,,,,,,3573,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remv Periton FB From Perit Cav,PX49402F,CDM,510,RC,49402,CPT,,,,,,,,3573,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remv Periton FB From Perit Cav,PX49402P,CDM,983,RC,49402,CPT,,,,,,,,3897,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remv Periton FB From Perit Cav,PX49402P,CDM,983,RC,49402,CPT,,,,,,,,3897,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remv Periton FB From Perit Cav,PX49402P,CDM,983,RC,49402,CPT,,,,,,,,3897,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remv Periton FB From Perit Cav,PX49402P,CDM,983,RC,49402,CPT,,,,,,,,3897,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remv Periton FB From Perit Cav,PX49402P,CDM,983,RC,49402,CPT,,,,,,,,3897,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remv Periton FB From Perit Cav,PX49402P,CDM,983,RC,49402,CPT,,,,,,,,3897,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Renal Function Panel,PX80069,CDM,300,RC,80069,CPT,,,,,,,,264,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Renal Function Panel,PX80069,CDM,300,RC,80069,CPT,,,,,,,,264,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Renal Function Panel,PX80069,CDM,300,RC,80069,CPT,,,,,,,,264,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Renal Function Panel,PX80069,CDM,300,RC,80069,CPT,,,,,,,,264,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Renal Function Panel,PX80069,CDM,300,RC,80069,CPT,,,,,,,,264,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Renal Function Panel,PX80069,CDM,300,RC,80069,CPT,,,,,,,,264,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Renin - Ref,PX8424490,CDM,300,RC,84244,CPT,90,,,,,,,53,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Renin - Ref,PX8424490,CDM,300,RC,84244,CPT,90,,,,,,,53,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Renin - Ref,PX8424490,CDM,300,RC,84244,CPT,90,,,,,,,53,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Renin - Ref,PX8424490,CDM,300,RC,84244,CPT,90,,,,,,,53,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Renin - Ref,PX8424490,CDM,300,RC,84244,CPT,90,,,,,,,53,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Renin - Ref,PX8424490,CDM,300,RC,84244,CPT,90,,,,,,,53,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133F,CDM,510,RC,13133,CPT,,,,,,,,595,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133F,CDM,510,RC,13133,CPT,,,,,,,,595,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133F,CDM,510,RC,13133,CPT,,,,,,,,595,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133F,CDM,510,RC,13133,CPT,,,,,,,,595,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133F,CDM,510,RC,13133,CPT,,,,,,,,595,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133F,CDM,510,RC,13133,CPT,,,,,,,,595,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133P,CDM,983,RC,13133,CPT,,,,,,,,256,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133P,CDM,983,RC,13133,CPT,,,,,,,,256,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133P,CDM,983,RC,13133,CPT,,,,,,,,256,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133P,CDM,983,RC,13133,CPT,,,,,,,,256,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133P,CDM,983,RC,13133,CPT,,,,,,,,256,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133P,CDM,983,RC,13133,CPT,,,,,,,,256,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122F,CDM,510,RC,13122,CPT,,,,,,,,788,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122F,CDM,510,RC,13122,CPT,,,,,,,,788,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122F,CDM,510,RC,13122,CPT,,,,,,,,788,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122F,CDM,510,RC,13122,CPT,,,,,,,,788,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122F,CDM,510,RC,13122,CPT,,,,,,,,788,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122F,CDM,510,RC,13122,CPT,,,,,,,,788,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122P,CDM,983,RC,13122,CPT,,,,,,,,301,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122P,CDM,983,RC,13122,CPT,,,,,,,,301,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122P,CDM,983,RC,13122,CPT,,,,,,,,301,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122P,CDM,983,RC,13122,CPT,,,,,,,,301,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122P,CDM,983,RC,13122,CPT,,,,,,,,301,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122P,CDM,983,RC,13122,CPT,,,,,,,,301,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
repaglinide 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,574024001,NDC,1,EA,3.62,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
repaglinide 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,574024001,NDC,1,EA,3.62,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
repaglinide 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,574024001,NDC,1,EA,3.62,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
repaglinide 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,574024001,NDC,1,EA,3.62,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
repaglinide 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,574024001,NDC,1,EA,3.62,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
repaglinide 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,574024001,NDC,1,EA,3.62,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Flex Foot Tendon,Ea",PX28200F,CDM,510,RC,28200,CPT,,,,,,,,1475,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Flex Foot Tendon,Ea",PX28200F,CDM,510,RC,28200,CPT,,,,,,,,1475,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Flex Foot Tendon,Ea",PX28200F,CDM,510,RC,28200,CPT,,,,,,,,1475,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Flex Foot Tendon,Ea",PX28200F,CDM,510,RC,28200,CPT,,,,,,,,1475,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Flex Foot Tendon,Ea",PX28200F,CDM,510,RC,28200,CPT,,,,,,,,1475,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Flex Foot Tendon,Ea",PX28200F,CDM,510,RC,28200,CPT,,,,,,,,1475,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repair Incis Hernia W Mesh,PX49568F,CDM,510,RC,49568,CPT,,,,,,,,1540,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repair Incis Hernia W Mesh,PX49568F,CDM,510,RC,49568,CPT,,,,,,,,1540,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repair Incis Hernia W Mesh,PX49568F,CDM,510,RC,49568,CPT,,,,,,,,1540,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repair Incis Hernia W Mesh,PX49568F,CDM,510,RC,49568,CPT,,,,,,,,1540,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repair Incis Hernia W Mesh,PX49568F,CDM,510,RC,49568,CPT,,,,,,,,1540,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repair Incis Hernia W Mesh,PX49568F,CDM,510,RC,49568,CPT,,,,,,,,1540,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repair Incis Hernia W Mesh,PX49568P,CDM,983,RC,49568,CPT,,,,,,,,660,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repair Incis Hernia W Mesh,PX49568P,CDM,983,RC,49568,CPT,,,,,,,,660,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repair Incis Hernia W Mesh,PX49568P,CDM,983,RC,49568,CPT,,,,,,,,660,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repair Incis Hernia W Mesh,PX49568P,CDM,983,RC,49568,CPT,,,,,,,,660,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repair Incis Hernia W Mesh,PX49568P,CDM,983,RC,49568,CPT,,,,,,,,660,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repair Incis Hernia W Mesh,PX49568P,CDM,983,RC,49568,CPT,,,,,,,,660,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Ing Hernia,5+Y/O,Reducibl",PX49505P,CDM,983,RC,49505,CPT,,,,,,,,2048,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Ing Hernia,5+Y/O,Reducibl",PX49505P,CDM,983,RC,49505,CPT,,,,,,,,2048,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Ing Hernia,5+Y/O,Reducibl",PX49505P,CDM,983,RC,49505,CPT,,,,,,,,2048,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Ing Hernia,5+Y/O,Reducibl",PX49505P,CDM,983,RC,49505,CPT,,,,,,,,2048,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Ing Hernia,5+Y/O,Reducibl",PX49505P,CDM,983,RC,49505,CPT,,,,,,,,2048,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Ing Hernia,5+Y/O,Reducibl",PX49505P,CDM,983,RC,49505,CPT,,,,,,,,2048,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Ing Hernia,5+Y/O,Strang",PX49507F,CDM,510,RC,49507,CPT,,,,,,,,1977,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Ing Hernia,5+Y/O,Strang",PX49507F,CDM,510,RC,49507,CPT,,,,,,,,1977,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Ing Hernia,5+Y/O,Strang",PX49507F,CDM,510,RC,49507,CPT,,,,,,,,1977,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Ing Hernia,5+Y/O,Strang",PX49507F,CDM,510,RC,49507,CPT,,,,,,,,1977,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Ing Hernia,5+Y/O,Strang",PX49507F,CDM,510,RC,49507,CPT,,,,,,,,1977,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Ing Hernia,5+Y/O,Strang",PX49507F,CDM,510,RC,49507,CPT,,,,,,,,1977,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Ing Hernia,5+Y/O,Strang",PX49507P,CDM,983,RC,49507,CPT,,,,,,,,2482,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Ing Hernia,5+Y/O,Strang",PX49507P,CDM,983,RC,49507,CPT,,,,,,,,2482,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Ing Hernia,5+Y/O,Strang",PX49507P,CDM,983,RC,49507,CPT,,,,,,,,2482,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Ing Hernia,5+Y/O,Strang",PX49507P,CDM,983,RC,49507,CPT,,,,,,,,2482,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Ing Hernia,5+Y/O,Strang",PX49507P,CDM,983,RC,49507,CPT,,,,,,,,2482,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Ing Hernia,5+Y/O,Strang",PX49507P,CDM,983,RC,49507,CPT,,,,,,,,2482,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Lip,>1/2 Vert Height",PX40654F,CDM,510,RC,40654,CPT,,,,,,,,2467,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Lip,>1/2 Vert Height",PX40654F,CDM,510,RC,40654,CPT,,,,,,,,2467,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Lip,>1/2 Vert Height",PX40654F,CDM,510,RC,40654,CPT,,,,,,,,2467,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Lip,>1/2 Vert Height",PX40654F,CDM,510,RC,40654,CPT,,,,,,,,2467,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Lip,>1/2 Vert Height",PX40654F,CDM,510,RC,40654,CPT,,,,,,,,2467,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Lip,>1/2 Vert Height",PX40654F,CDM,510,RC,40654,CPT,,,,,,,,2467,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Lip,>1/2 Vert Height",PX40654P,CDM,983,RC,40654,CPT,,,,,,,,1329,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Lip,>1/2 Vert Height",PX40654P,CDM,983,RC,40654,CPT,,,,,,,,1329,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Lip,>1/2 Vert Height",PX40654P,CDM,983,RC,40654,CPT,,,,,,,,1329,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Lip,>1/2 Vert Height",PX40654P,CDM,983,RC,40654,CPT,,,,,,,,1329,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Lip,>1/2 Vert Height",PX40654P,CDM,983,RC,40654,CPT,,,,,,,,1329,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Lip,>1/2 Vert Height",PX40654P,CDM,983,RC,40654,CPT,,,,,,,,1329,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair of Recurrent Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49615F,CDM,360,RC,49615,CPT,,,,,,,,2908,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2564.856,6141.46
"Repair of Recurrent Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49615F,CDM,360,RC,49615,CPT,,,,,,,,2908,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2564.856,6141.46
"Repair of Recurrent Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49615F,CDM,360,RC,49615,CPT,,,,,,,,2908,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2564.856,6141.46
"Repair of Recurrent Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49615F,CDM,360,RC,49615,CPT,,,,,,,,2908,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2564.856,6141.46
"Repair of Recurrent Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49615F,CDM,360,RC,49615,CPT,,,,,,,,2908,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2564.856,6141.46
"Repair of Recurrent Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49615F,CDM,360,RC,49615,CPT,,,,,,,,2908,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2564.856,6141.46
Repair of Vagina,PX57200P,CDM,983,RC,57200,CPT,,,,,,,,1043,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repair of Vagina,PX57200P,CDM,983,RC,57200,CPT,,,,,,,,1043,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repair of Vagina,PX57200P,CDM,983,RC,57200,CPT,,,,,,,,1043,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repair of Vagina,PX57200P,CDM,983,RC,57200,CPT,,,,,,,,1043,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repair of Vagina,PX57200P,CDM,983,RC,57200,CPT,,,,,,,,1043,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repair of Vagina,PX57200P,CDM,983,RC,57200,CPT,,,,,,,,1043,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Recurr Inguin Hern,Reducibl",PX49520F,CDM,510,RC,49520,CPT,,,,,,,,1983,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Recurr Inguin Hern,Reducibl",PX49520F,CDM,510,RC,49520,CPT,,,,,,,,1983,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Recurr Inguin Hern,Reducibl",PX49520F,CDM,510,RC,49520,CPT,,,,,,,,1983,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Recurr Inguin Hern,Reducibl",PX49520F,CDM,510,RC,49520,CPT,,,,,,,,1983,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Recurr Inguin Hern,Reducibl",PX49520F,CDM,510,RC,49520,CPT,,,,,,,,1983,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Recurr Inguin Hern,Reducibl",PX49520F,CDM,510,RC,49520,CPT,,,,,,,,1983,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Recurr Inguin Hern,Reducibl",PX49520P,CDM,983,RC,49520,CPT,,,,,,,,1983,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Recurr Inguin Hern,Reducibl",PX49520P,CDM,983,RC,49520,CPT,,,,,,,,1983,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Recurr Inguin Hern,Reducibl",PX49520P,CDM,983,RC,49520,CPT,,,,,,,,1983,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Recurr Inguin Hern,Reducibl",PX49520P,CDM,983,RC,49520,CPT,,,,,,,,1983,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Recurr Inguin Hern,Reducibl",PX49520P,CDM,983,RC,49520,CPT,,,,,,,,1983,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Recurr Inguin Hern,Reducibl",PX49520P,CDM,983,RC,49520,CPT,,,,,,,,1983,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Umbilical Hern,5+Y/O,Reduc",PX49585F,CDM,510,RC,49585,CPT,,,,,,,,969,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Umbilical Hern,5+Y/O,Reduc",PX49585F,CDM,510,RC,49585,CPT,,,,,,,,969,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Umbilical Hern,5+Y/O,Reduc",PX49585F,CDM,510,RC,49585,CPT,,,,,,,,969,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Umbilical Hern,5+Y/O,Reduc",PX49585F,CDM,510,RC,49585,CPT,,,,,,,,969,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Umbilical Hern,5+Y/O,Reduc",PX49585F,CDM,510,RC,49585,CPT,,,,,,,,969,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Umbilical Hern,5+Y/O,Reduc",PX49585F,CDM,510,RC,49585,CPT,,,,,,,,969,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Umbilical Hern,5+Y/O,Reduc",PX49585P,CDM,983,RC,49585,CPT,,,,,,,,647,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Umbilical Hern,5+Y/O,Reduc",PX49585P,CDM,983,RC,49585,CPT,,,,,,,,647,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Umbilical Hern,5+Y/O,Reduc",PX49585P,CDM,983,RC,49585,CPT,,,,,,,,647,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Umbilical Hern,5+Y/O,Reduc",PX49585P,CDM,983,RC,49585,CPT,,,,,,,,647,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Umbilical Hern,5+Y/O,Reduc",PX49585P,CDM,983,RC,49585,CPT,,,,,,,,647,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Umbilical Hern,5+Y/O,Reduc",PX49585P,CDM,983,RC,49585,CPT,,,,,,,,647,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Umbilical Hern,5+Y/O,Strang",PX49587F,CDM,510,RC,49587,CPT,,,,,,,,1110,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Umbilical Hern,5+Y/O,Strang",PX49587F,CDM,510,RC,49587,CPT,,,,,,,,1110,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Umbilical Hern,5+Y/O,Strang",PX49587F,CDM,510,RC,49587,CPT,,,,,,,,1110,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Umbilical Hern,5+Y/O,Strang",PX49587F,CDM,510,RC,49587,CPT,,,,,,,,1110,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Umbilical Hern,5+Y/O,Strang",PX49587F,CDM,510,RC,49587,CPT,,,,,,,,1110,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Umbilical Hern,5+Y/O,Strang",PX49587F,CDM,510,RC,49587,CPT,,,,,,,,1110,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Umbilical Hern,5+Y/O,Strang",PX49587P,CDM,983,RC,49587,CPT,,,,,,,,2182,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Umbilical Hern,5+Y/O,Strang",PX49587P,CDM,983,RC,49587,CPT,,,,,,,,2182,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Umbilical Hern,5+Y/O,Strang",PX49587P,CDM,983,RC,49587,CPT,,,,,,,,2182,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Umbilical Hern,5+Y/O,Strang",PX49587P,CDM,983,RC,49587,CPT,,,,,,,,2182,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Umbilical Hern,5+Y/O,Strang",PX49587P,CDM,983,RC,49587,CPT,,,,,,,,2182,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Umbilical Hern,5+Y/O,Strang",PX49587P,CDM,983,RC,49587,CPT,,,,,,,,2182,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repeat Control of Nosebleed,PX30906F,CDM,510,RC,30906,CPT,,,,,,,,334,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repeat Control of Nosebleed,PX30906F,CDM,510,RC,30906,CPT,,,,,,,,334,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repeat Control of Nosebleed,PX30906F,CDM,510,RC,30906,CPT,,,,,,,,334,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repeat Control of Nosebleed,PX30906F,CDM,510,RC,30906,CPT,,,,,,,,334,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repeat Control of Nosebleed,PX30906F,CDM,510,RC,30906,CPT,,,,,,,,334,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repeat Control of Nosebleed,PX30906F,CDM,510,RC,30906,CPT,,,,,,,,334,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762F,CDM,510,RC,43762,CPT,,,,,,,,492,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762F,CDM,510,RC,43762,CPT,,,,,,,,492,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762F,CDM,510,RC,43762,CPT,,,,,,,,492,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762F,CDM,510,RC,43762,CPT,,,,,,,,492,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762F,CDM,510,RC,43762,CPT,,,,,,,,492,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762F,CDM,510,RC,43762,CPT,,,,,,,,492,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762P,CDM,983,RC,43762,CPT,,,,,,,,328,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762P,CDM,983,RC,43762,CPT,,,,,,,,328,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762P,CDM,983,RC,43762,CPT,,,,,,,,328,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762P,CDM,983,RC,43762,CPT,,,,,,,,328,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762P,CDM,983,RC,43762,CPT,,,,,,,,328,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762P,CDM,983,RC,43762,CPT,,,,,,,,328,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132F,CDM,510,RC,13132,CPT,,,,,,,,1159,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132F,CDM,510,RC,13132,CPT,,,,,,,,1159,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132F,CDM,510,RC,13132,CPT,,,,,,,,1159,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132F,CDM,510,RC,13132,CPT,,,,,,,,1159,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132F,CDM,510,RC,13132,CPT,,,,,,,,1159,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132F,CDM,510,RC,13132,CPT,,,,,,,,1159,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132P,CDM,983,RC,13132,CPT,,,,,,,,774,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132P,CDM,983,RC,13132,CPT,,,,,,,,774,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132P,CDM,983,RC,13132,CPT,,,,,,,,774,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132P,CDM,983,RC,13132,CPT,,,,,,,,774,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132P,CDM,983,RC,13132,CPT,,,,,,,,774,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132P,CDM,983,RC,13132,CPT,,,,,,,,774,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151F,CDM,510,RC,13151,CPT,,,,,,,,1143,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151F,CDM,510,RC,13151,CPT,,,,,,,,1143,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151F,CDM,510,RC,13151,CPT,,,,,,,,1143,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151F,CDM,510,RC,13151,CPT,,,,,,,,1143,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151F,CDM,510,RC,13151,CPT,,,,,,,,1143,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151F,CDM,510,RC,13151,CPT,,,,,,,,1143,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151P,CDM,983,RC,13151,CPT,,,,,,,,1177,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151P,CDM,983,RC,13151,CPT,,,,,,,,1177,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151P,CDM,983,RC,13151,CPT,,,,,,,,1177,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151P,CDM,983,RC,13151,CPT,,,,,,,,1177,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151P,CDM,983,RC,13151,CPT,,,,,,,,1177,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151P,CDM,983,RC,13151,CPT,,,,,,,,1177,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121F,CDM,510,RC,13121,CPT,,,,,,,,948,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121F,CDM,510,RC,13121,CPT,,,,,,,,948,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121F,CDM,510,RC,13121,CPT,,,,,,,,948,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121F,CDM,510,RC,13121,CPT,,,,,,,,948,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121F,CDM,510,RC,13121,CPT,,,,,,,,948,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121F,CDM,510,RC,13121,CPT,,,,,,,,948,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121P,CDM,983,RC,13121,CPT,,,,,,,,632,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121P,CDM,983,RC,13121,CPT,,,,,,,,632,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121P,CDM,983,RC,13121,CPT,,,,,,,,632,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121P,CDM,983,RC,13121,CPT,,,,,,,,632,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121P,CDM,983,RC,13121,CPT,,,,,,,,632,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121P,CDM,983,RC,13121,CPT,,,,,,,,632,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101F,CDM,510,RC,13101,CPT,,,,,,,,495,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101F,CDM,510,RC,13101,CPT,,,,,,,,495,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101F,CDM,510,RC,13101,CPT,,,,,,,,495,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101F,CDM,510,RC,13101,CPT,,,,,,,,495,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101F,CDM,510,RC,13101,CPT,,,,,,,,495,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101F,CDM,510,RC,13101,CPT,,,,,,,,495,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101P,CDM,983,RC,13101,CPT,,,,,,,,330,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101P,CDM,983,RC,13101,CPT,,,,,,,,330,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101P,CDM,983,RC,13101,CPT,,,,,,,,330,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101P,CDM,983,RC,13101,CPT,,,,,,,,330,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101P,CDM,983,RC,13101,CPT,,,,,,,,330,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101P,CDM,983,RC,13101,CPT,,,,,,,,330,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002F,CDM,510,RC,12002,CPT,,,,,,,,343,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002F,CDM,510,RC,12002,CPT,,,,,,,,343,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002F,CDM,510,RC,12002,CPT,,,,,,,,343,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002F,CDM,510,RC,12002,CPT,,,,,,,,343,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002F,CDM,510,RC,12002,CPT,,,,,,,,343,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002F,CDM,510,RC,12002,CPT,,,,,,,,343,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002P,CDM,983,RC,12002,CPT,,,,,,,,486,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002P,CDM,983,RC,12002,CPT,,,,,,,,486,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002P,CDM,983,RC,12002,CPT,,,,,,,,486,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002P,CDM,983,RC,12002,CPT,,,,,,,,486,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002P,CDM,983,RC,12002,CPT,,,,,,,,486,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002P,CDM,983,RC,12002,CPT,,,,,,,,486,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Body <2.5cm,PX12001F,CDM,510,RC,12001,CPT,,,,,,,,311,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Body <2.5cm,PX12001F,CDM,510,RC,12001,CPT,,,,,,,,311,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Body <2.5cm,PX12001F,CDM,510,RC,12001,CPT,,,,,,,,311,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Body <2.5cm,PX12001F,CDM,510,RC,12001,CPT,,,,,,,,311,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Body <2.5cm,PX12001F,CDM,510,RC,12001,CPT,,,,,,,,311,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Body <2.5cm,PX12001F,CDM,510,RC,12001,CPT,,,,,,,,311,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Body <2.5cm,PX12001P,CDM,983,RC,12001,CPT,,,,,,,,293,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Body <2.5cm,PX12001P,CDM,983,RC,12001,CPT,,,,,,,,293,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Body <2.5cm,PX12001P,CDM,983,RC,12001,CPT,,,,,,,,293,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Body <2.5cm,PX12001P,CDM,983,RC,12001,CPT,,,,,,,,293,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Body <2.5cm,PX12001P,CDM,983,RC,12001,CPT,,,,,,,,293,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Body <2.5cm,PX12001P,CDM,983,RC,12001,CPT,,,,,,,,293,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Body 7.6-12.5,PX12004F,CDM,510,RC,12004,CPT,,,,,,,,453,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Body 7.6-12.5,PX12004F,CDM,510,RC,12004,CPT,,,,,,,,453,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Body 7.6-12.5,PX12004F,CDM,510,RC,12004,CPT,,,,,,,,453,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Body 7.6-12.5,PX12004F,CDM,510,RC,12004,CPT,,,,,,,,453,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Body 7.6-12.5,PX12004F,CDM,510,RC,12004,CPT,,,,,,,,453,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Body 7.6-12.5,PX12004F,CDM,510,RC,12004,CPT,,,,,,,,453,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Body 7.6-12.5,PX12004P,CDM,983,RC,12004,CPT,,,,,,,,614,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Body 7.6-12.5,PX12004P,CDM,983,RC,12004,CPT,,,,,,,,614,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Body 7.6-12.5,PX12004P,CDM,983,RC,12004,CPT,,,,,,,,614,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Body 7.6-12.5,PX12004P,CDM,983,RC,12004,CPT,,,,,,,,614,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Body 7.6-12.5,PX12004P,CDM,983,RC,12004,CPT,,,,,,,,614,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Body 7.6-12.5,PX12004P,CDM,983,RC,12004,CPT,,,,,,,,614,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Body 12.6-20,PX12005F,CDM,510,RC,12005,CPT,,,,,,,,565,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Body 12.6-20,PX12005F,CDM,510,RC,12005,CPT,,,,,,,,565,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Body 12.6-20,PX12005F,CDM,510,RC,12005,CPT,,,,,,,,565,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Body 12.6-20,PX12005F,CDM,510,RC,12005,CPT,,,,,,,,565,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Body 12.6-20,PX12005F,CDM,510,RC,12005,CPT,,,,,,,,565,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Body 12.6-20,PX12005F,CDM,510,RC,12005,CPT,,,,,,,,565,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Body 12.6-20,PX12005P,CDM,983,RC,12005,CPT,,,,,,,,377,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Body 12.6-20,PX12005P,CDM,983,RC,12005,CPT,,,,,,,,377,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Body 12.6-20,PX12005P,CDM,983,RC,12005,CPT,,,,,,,,377,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Body 12.6-20,PX12005P,CDM,983,RC,12005,CPT,,,,,,,,377,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Body 12.6-20,PX12005P,CDM,983,RC,12005,CPT,,,,,,,,377,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Body 12.6-20,PX12005P,CDM,983,RC,12005,CPT,,,,,,,,377,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face <2.5cm,PX12011F,CDM,510,RC,12011,CPT,,,,,,,,335,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face <2.5cm,PX12011F,CDM,510,RC,12011,CPT,,,,,,,,335,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face <2.5cm,PX12011F,CDM,510,RC,12011,CPT,,,,,,,,335,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face <2.5cm,PX12011F,CDM,510,RC,12011,CPT,,,,,,,,335,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face <2.5cm,PX12011F,CDM,510,RC,12011,CPT,,,,,,,,335,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face <2.5cm,PX12011F,CDM,510,RC,12011,CPT,,,,,,,,335,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face <2.5cm,PX12011P,CDM,983,RC,12011,CPT,,,,,,,,461,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face <2.5cm,PX12011P,CDM,983,RC,12011,CPT,,,,,,,,461,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face <2.5cm,PX12011P,CDM,983,RC,12011,CPT,,,,,,,,461,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face <2.5cm,PX12011P,CDM,983,RC,12011,CPT,,,,,,,,461,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face <2.5cm,PX12011P,CDM,983,RC,12011,CPT,,,,,,,,461,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face <2.5cm,PX12011P,CDM,983,RC,12011,CPT,,,,,,,,461,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face >30cm,PX12018F,CDM,510,RC,12018,CPT,,,,,,,,713,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face >30cm,PX12018F,CDM,510,RC,12018,CPT,,,,,,,,713,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face >30cm,PX12018F,CDM,510,RC,12018,CPT,,,,,,,,713,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face >30cm,PX12018F,CDM,510,RC,12018,CPT,,,,,,,,713,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face >30cm,PX12018F,CDM,510,RC,12018,CPT,,,,,,,,713,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face >30cm,PX12018F,CDM,510,RC,12018,CPT,,,,,,,,713,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face 2.6-5,PX12013F,CDM,510,RC,12013,CPT,,,,,,,,375,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face 2.6-5,PX12013F,CDM,510,RC,12013,CPT,,,,,,,,375,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face 2.6-5,PX12013F,CDM,510,RC,12013,CPT,,,,,,,,375,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face 2.6-5,PX12013F,CDM,510,RC,12013,CPT,,,,,,,,375,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face 2.6-5,PX12013F,CDM,510,RC,12013,CPT,,,,,,,,375,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face 2.6-5,PX12013F,CDM,510,RC,12013,CPT,,,,,,,,375,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face 2.6-5,PX12013P,CDM,983,RC,12013,CPT,,,,,,,,681,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face 2.6-5,PX12013P,CDM,983,RC,12013,CPT,,,,,,,,681,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face 2.6-5,PX12013P,CDM,983,RC,12013,CPT,,,,,,,,681,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face 2.6-5,PX12013P,CDM,983,RC,12013,CPT,,,,,,,,681,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face 2.6-5,PX12013P,CDM,983,RC,12013,CPT,,,,,,,,681,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face 2.6-5,PX12013P,CDM,983,RC,12013,CPT,,,,,,,,681,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face 5.1-7.5,PX12014F,CDM,510,RC,12014,CPT,,,,,,,,453,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face 5.1-7.5,PX12014F,CDM,510,RC,12014,CPT,,,,,,,,453,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face 5.1-7.5,PX12014F,CDM,510,RC,12014,CPT,,,,,,,,453,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face 5.1-7.5,PX12014F,CDM,510,RC,12014,CPT,,,,,,,,453,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face 5.1-7.5,PX12014F,CDM,510,RC,12014,CPT,,,,,,,,453,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face 5.1-7.5,PX12014F,CDM,510,RC,12014,CPT,,,,,,,,453,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face 5.1-7.5,PX12014P,CDM,983,RC,12014,CPT,,,,,,,,819,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face 5.1-7.5,PX12014P,CDM,983,RC,12014,CPT,,,,,,,,819,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face 5.1-7.5,PX12014P,CDM,983,RC,12014,CPT,,,,,,,,819,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face 5.1-7.5,PX12014P,CDM,983,RC,12014,CPT,,,,,,,,819,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face 5.1-7.5,PX12014P,CDM,983,RC,12014,CPT,,,,,,,,819,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face 5.1-7.5,PX12014P,CDM,983,RC,12014,CPT,,,,,,,,819,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Reptilase Test - Ref,PX8563590,CDM,300,RC,85635,CPT,90,,,,,,,102,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Reptilase Test - Ref,PX8563590,CDM,300,RC,85635,CPT,90,,,,,,,102,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Reptilase Test - Ref,PX8563590,CDM,300,RC,85635,CPT,90,,,,,,,102,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Reptilase Test - Ref,PX8563590,CDM,300,RC,85635,CPT,90,,,,,,,102,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Reptilase Test - Ref,PX8563590,CDM,300,RC,85635,CPT,90,,,,,,,102,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Reptilase Test - Ref,PX8563590,CDM,300,RC,85635,CPT,90,,,,,,,102,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESERVOIR SILICONE BULB 100CC,27200000,CDM,272,RC,,,,4400-MAIN,LOCAL,,,,,16.65,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESERVOIR SILICONE BULB 100CC,27200000,CDM,272,RC,,,,4400-MAIN,LOCAL,,,,,16.65,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESERVOIR SILICONE BULB 100CC,27200000,CDM,272,RC,,,,4400-MAIN,LOCAL,,,,,16.65,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESERVOIR SILICONE BULB 100CC,27200000,CDM,272,RC,,,,4400-MAIN,LOCAL,,,,,16.65,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESERVOIR SILICONE BULB 100CC,27200000,CDM,272,RC,,,,4400-MAIN,LOCAL,,,,,16.65,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESERVOIR SILICONE BULB 100CC,27200000,CDM,272,RC,,,,4400-MAIN,LOCAL,,,,,16.65,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESERVOIR WOUND DRAIN 15FR,27200000,CDM,272,RC,,,,4386-MAIN,LOCAL,,,,,30.6,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESERVOIR WOUND DRAIN 15FR,27200000,CDM,272,RC,,,,4386-MAIN,LOCAL,,,,,30.6,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESERVOIR WOUND DRAIN 15FR,27200000,CDM,272,RC,,,,4386-MAIN,LOCAL,,,,,30.6,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESERVOIR WOUND DRAIN 15FR,27200000,CDM,272,RC,,,,4386-MAIN,LOCAL,,,,,30.6,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESERVOIR WOUND DRAIN 15FR,27200000,CDM,272,RC,,,,4386-MAIN,LOCAL,,,,,30.6,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESERVOIR WOUND DRAIN 15FR,27200000,CDM,272,RC,,,,4386-MAIN,LOCAL,,,,,30.6,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Resp Muscles 1:1 per 15 Min,PXG0237,CDM,948,RC,G0237,HCPCS,,,,,,,,65,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Resp Muscles 1:1 per 15 Min,PXG0237,CDM,948,RC,G0237,HCPCS,,,,,,,,65,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Resp Muscles 1:1 per 15 Min,PXG0237,CDM,948,RC,G0237,HCPCS,,,,,,,,65,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Resp Muscles 1:1 per 15 Min,PXG0237,CDM,948,RC,G0237,HCPCS,,,,,,,,65,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Resp Muscles 1:1 per 15 Min,PXG0237,CDM,948,RC,G0237,HCPCS,,,,,,,,65,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Resp Muscles 1:1 per 15 Min,PXG0237,CDM,948,RC,G0237,HCPCS,,,,,,,,65,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Resp Virus 3-5 Targets,PX87631,CDM,300,RC,87631,CPT,,,,,,,,459,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Resp Virus 3-5 Targets,PX87631,CDM,300,RC,87631,CPT,,,,,,,,459,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Resp Virus 3-5 Targets,PX87631,CDM,300,RC,87631,CPT,,,,,,,,459,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Resp Virus 3-5 Targets,PX87631,CDM,300,RC,87631,CPT,,,,,,,,459,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Resp Virus 3-5 Targets,PX87631,CDM,300,RC,87631,CPT,,,,,,,,459,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Resp Virus 3-5 Targets,PX87631,CDM,300,RC,87631,CPT,,,,,,,,459,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Resp Virus 6-11 Targets,PX87632,CDM,300,RC,87632,CPT,,,,,,,,428,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Resp Virus 6-11 Targets,PX87632,CDM,300,RC,87632,CPT,,,,,,,,428,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Resp Virus 6-11 Targets,PX87632,CDM,300,RC,87632,CPT,,,,,,,,428,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Resp Virus 6-11 Targets,PX87632,CDM,300,RC,87632,CPT,,,,,,,,428,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Resp Virus 6-11 Targets,PX87632,CDM,300,RC,87632,CPT,,,,,,,,428,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Resp Virus 6-11 Targets,PX87632,CDM,300,RC,87632,CPT,,,,,,,,428,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESTRATA WOUND MATRIX 2.5CM X 2.5CM TOTAL 6.25CM,27200000,CDM,272,RC,A2007,HCPCS,,11733-MAIN,LOCAL,,,,,1829,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESTRATA WOUND MATRIX 2.5CM X 2.5CM TOTAL 6.25CM,27200000,CDM,272,RC,A2007,HCPCS,,11733-MAIN,LOCAL,,,,,1829,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESTRATA WOUND MATRIX 2.5CM X 2.5CM TOTAL 6.25CM,27200000,CDM,272,RC,A2007,HCPCS,,11733-MAIN,LOCAL,,,,,1829,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESTRATA WOUND MATRIX 2.5CM X 2.5CM TOTAL 6.25CM,27200000,CDM,272,RC,A2007,HCPCS,,11733-MAIN,LOCAL,,,,,1829,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESTRATA WOUND MATRIX 2.5CM X 2.5CM TOTAL 6.25CM,27200000,CDM,272,RC,A2007,HCPCS,,11733-MAIN,LOCAL,,,,,1829,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESTRATA WOUND MATRIX 2.5CM X 2.5CM TOTAL 6.25CM,27200000,CDM,272,RC,A2007,HCPCS,,11733-MAIN,LOCAL,,,,,1829,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESTRATA WOUND MATRIX 2.5CM X 5CM TOTAL 12.5CM,27200000,CDM,272,RC,A2007,HCPCS,,11734-MAIN,LOCAL,,,,,3039,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESTRATA WOUND MATRIX 2.5CM X 5CM TOTAL 12.5CM,27200000,CDM,272,RC,A2007,HCPCS,,11734-MAIN,LOCAL,,,,,3039,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESTRATA WOUND MATRIX 2.5CM X 5CM TOTAL 12.5CM,27200000,CDM,272,RC,A2007,HCPCS,,11734-MAIN,LOCAL,,,,,3039,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESTRATA WOUND MATRIX 2.5CM X 5CM TOTAL 12.5CM,27200000,CDM,272,RC,A2007,HCPCS,,11734-MAIN,LOCAL,,,,,3039,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESTRATA WOUND MATRIX 2.5CM X 5CM TOTAL 12.5CM,27200000,CDM,272,RC,A2007,HCPCS,,11734-MAIN,LOCAL,,,,,3039,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESTRATA WOUND MATRIX 2.5CM X 5CM TOTAL 12.5CM,27200000,CDM,272,RC,A2007,HCPCS,,11734-MAIN,LOCAL,,,,,3039,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESTRATA WOUND MATRIX 2.5CM X 7.5CM TOTAL 18.75CM,27200000,CDM,272,RC,A2007,HCPCS,,11735-MAIN,LOCAL,,,,,4208,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESTRATA WOUND MATRIX 2.5CM X 7.5CM TOTAL 18.75CM,27200000,CDM,272,RC,A2007,HCPCS,,11735-MAIN,LOCAL,,,,,4208,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESTRATA WOUND MATRIX 2.5CM X 7.5CM TOTAL 18.75CM,27200000,CDM,272,RC,A2007,HCPCS,,11735-MAIN,LOCAL,,,,,4208,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESTRATA WOUND MATRIX 2.5CM X 7.5CM TOTAL 18.75CM,27200000,CDM,272,RC,A2007,HCPCS,,11735-MAIN,LOCAL,,,,,4208,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESTRATA WOUND MATRIX 2.5CM X 7.5CM TOTAL 18.75CM,27200000,CDM,272,RC,A2007,HCPCS,,11735-MAIN,LOCAL,,,,,4208,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESTRATA WOUND MATRIX 2.5CM X 7.5CM TOTAL 18.75CM,27200000,CDM,272,RC,A2007,HCPCS,,11735-MAIN,LOCAL,,,,,4208,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESTRATA WOUND MATRIX 5.0CM X 5.0CM TOTAL 25CM,27200000,CDM,272,RC,A2007,HCPCS,,11736-MAIN,LOCAL,,,,,5236,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESTRATA WOUND MATRIX 5.0CM X 5.0CM TOTAL 25CM,27200000,CDM,272,RC,A2007,HCPCS,,11736-MAIN,LOCAL,,,,,5236,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESTRATA WOUND MATRIX 5.0CM X 5.0CM TOTAL 25CM,27200000,CDM,272,RC,A2007,HCPCS,,11736-MAIN,LOCAL,,,,,5236,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESTRATA WOUND MATRIX 5.0CM X 5.0CM TOTAL 25CM,27200000,CDM,272,RC,A2007,HCPCS,,11736-MAIN,LOCAL,,,,,5236,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESTRATA WOUND MATRIX 5.0CM X 5.0CM TOTAL 25CM,27200000,CDM,272,RC,A2007,HCPCS,,11736-MAIN,LOCAL,,,,,5236,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESTRATA WOUND MATRIX 5.0CM X 5.0CM TOTAL 25CM,27200000,CDM,272,RC,A2007,HCPCS,,11736-MAIN,LOCAL,,,,,5236,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESTRATA WOUND MATRIX 7.5CM X 7.5CM TOTAL 56.25CM,27200000,CDM,272,RC,A2007,HCPCS,,11737-MAIN,LOCAL,,,,,6311,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESTRATA WOUND MATRIX 7.5CM X 7.5CM TOTAL 56.25CM,27200000,CDM,272,RC,A2007,HCPCS,,11737-MAIN,LOCAL,,,,,6311,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESTRATA WOUND MATRIX 7.5CM X 7.5CM TOTAL 56.25CM,27200000,CDM,272,RC,A2007,HCPCS,,11737-MAIN,LOCAL,,,,,6311,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESTRATA WOUND MATRIX 7.5CM X 7.5CM TOTAL 56.25CM,27200000,CDM,272,RC,A2007,HCPCS,,11737-MAIN,LOCAL,,,,,6311,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESTRATA WOUND MATRIX 7.5CM X 7.5CM TOTAL 56.25CM,27200000,CDM,272,RC,A2007,HCPCS,,11737-MAIN,LOCAL,,,,,6311,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESTRATA WOUND MATRIX 7.5CM X 7.5CM TOTAL 56.25CM,27200000,CDM,272,RC,A2007,HCPCS,,11737-MAIN,LOCAL,,,,,6311,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESTRATA WOUND MATRIX 10CM X 12.5CM  TOTAL 125CM,27200000,CDM,272,RC,A2007,HCPCS,,11738-MAIN,LOCAL,,,,,8415,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESTRATA WOUND MATRIX 10CM X 12.5CM  TOTAL 125CM,27200000,CDM,272,RC,A2007,HCPCS,,11738-MAIN,LOCAL,,,,,8415,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESTRATA WOUND MATRIX 10CM X 12.5CM  TOTAL 125CM,27200000,CDM,272,RC,A2007,HCPCS,,11738-MAIN,LOCAL,,,,,8415,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESTRATA WOUND MATRIX 10CM X 12.5CM  TOTAL 125CM,27200000,CDM,272,RC,A2007,HCPCS,,11738-MAIN,LOCAL,,,,,8415,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESTRATA WOUND MATRIX 10CM X 12.5CM  TOTAL 125CM,27200000,CDM,272,RC,A2007,HCPCS,,11738-MAIN,LOCAL,,,,,8415,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESTRATA WOUND MATRIX 10CM X 12.5CM  TOTAL 125CM,27200000,CDM,272,RC,A2007,HCPCS,,11738-MAIN,LOCAL,,,,,8415,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Reticulocyte Count,Flow Cyto",PX85045,CDM,300,RC,85045,CPT,,,,,,,,92,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Reticulocyte Count,Flow Cyto",PX85045,CDM,300,RC,85045,CPT,,,,,,,,92,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Reticulocyte Count,Flow Cyto",PX85045,CDM,300,RC,85045,CPT,,,,,,,,92,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Reticulocyte Count,Flow Cyto",PX85045,CDM,300,RC,85045,CPT,,,,,,,,92,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Reticulocyte Count,Flow Cyto",PX85045,CDM,300,RC,85045,CPT,,,,,,,,92,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Reticulocyte Count,Flow Cyto",PX85045,CDM,300,RC,85045,CPT,,,,,,,,92,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RETRIEVAL BAG 10MM,27200000,CDM,272,RC,,,,11707-MAIN,LOCAL,,,,,74.8,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RETRIEVAL BAG 10MM,27200000,CDM,272,RC,,,,11707-MAIN,LOCAL,,,,,74.8,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RETRIEVAL BAG 10MM,27200000,CDM,272,RC,,,,11707-MAIN,LOCAL,,,,,74.8,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RETRIEVAL BAG 10MM,27200000,CDM,272,RC,,,,11707-MAIN,LOCAL,,,,,74.8,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RETRIEVAL BAG 10MM,27200000,CDM,272,RC,,,,11707-MAIN,LOCAL,,,,,74.8,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RETRIEVAL BAG 10MM,27200000,CDM,272,RC,,,,11707-MAIN,LOCAL,,,,,74.8,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RETRIEVAL BAG 12/15MM,27200000,CDM,272,RC,,,,12660-MAIN,LOCAL,,,,,187,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RETRIEVAL BAG 12/15MM,27200000,CDM,272,RC,,,,12660-MAIN,LOCAL,,,,,187,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RETRIEVAL BAG 12/15MM,27200000,CDM,272,RC,,,,12660-MAIN,LOCAL,,,,,187,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RETRIEVAL BAG 12/15MM,27200000,CDM,272,RC,,,,12660-MAIN,LOCAL,,,,,187,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RETRIEVAL BAG 12/15MM,27200000,CDM,272,RC,,,,12660-MAIN,LOCAL,,,,,187,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RETRIEVAL BAG 12/15MM,27200000,CDM,272,RC,,,,12660-MAIN,LOCAL,,,,,187,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Revise Median N/Carpal Tunnel Surg,PX64721F,CDM,510,RC,64721,CPT,,,,,,,,2408,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Revise Median N/Carpal Tunnel Surg,PX64721F,CDM,510,RC,64721,CPT,,,,,,,,2408,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Revise Median N/Carpal Tunnel Surg,PX64721F,CDM,510,RC,64721,CPT,,,,,,,,2408,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Revise Median N/Carpal Tunnel Surg,PX64721F,CDM,510,RC,64721,CPT,,,,,,,,2408,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Revise Median N/Carpal Tunnel Surg,PX64721F,CDM,510,RC,64721,CPT,,,,,,,,2408,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Revise Median N/Carpal Tunnel Surg,PX64721F,CDM,510,RC,64721,CPT,,,,,,,,2408,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Revise Median N/Carpal Tunnel Surg,PX64721P,CDM,983,RC,64721,CPT,,,,,,,,1927,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Revise Median N/Carpal Tunnel Surg,PX64721P,CDM,983,RC,64721,CPT,,,,,,,,1927,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Revise Median N/Carpal Tunnel Surg,PX64721P,CDM,983,RC,64721,CPT,,,,,,,,1927,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Revise Median N/Carpal Tunnel Surg,PX64721P,CDM,983,RC,64721,CPT,,,,,,,,1927,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Revise Median N/Carpal Tunnel Surg,PX64721P,CDM,983,RC,64721,CPT,,,,,,,,1927,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Revise Median N/Carpal Tunnel Surg,PX64721P,CDM,983,RC,64721,CPT,,,,,,,,1927,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Revise Ulnar Nerve at Elbow,PX64718P,CDM,983,RC,64718,CPT,,,,,,,,1642,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Revise Ulnar Nerve at Elbow,PX64718P,CDM,983,RC,64718,CPT,,,,,,,,1642,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Revise Ulnar Nerve at Elbow,PX64718P,CDM,983,RC,64718,CPT,,,,,,,,1642,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Revise Ulnar Nerve at Elbow,PX64718P,CDM,983,RC,64718,CPT,,,,,,,,1642,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Revise Ulnar Nerve at Elbow,PX64718P,CDM,983,RC,64718,CPT,,,,,,,,1642,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Revise Ulnar Nerve at Elbow,PX64718P,CDM,983,RC,64718,CPT,,,,,,,,1642,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
REVITA PLACENTAL MEMBRANE 2X3CM 6SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12559-MAIN,LOCAL,,,,,2474,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
REVITA PLACENTAL MEMBRANE 2X3CM 6SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12559-MAIN,LOCAL,,,,,2474,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
REVITA PLACENTAL MEMBRANE 2X3CM 6SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12559-MAIN,LOCAL,,,,,2474,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
REVITA PLACENTAL MEMBRANE 2X3CM 6SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12559-MAIN,LOCAL,,,,,2474,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
REVITA PLACENTAL MEMBRANE 2X3CM 6SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12559-MAIN,LOCAL,,,,,2474,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
REVITA PLACENTAL MEMBRANE 2X3CM 6SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12559-MAIN,LOCAL,,,,,2474,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
REVITA PLACENTAL MEMBRANE 4X4CM 16SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12560-MAIN,LOCAL,,,,,6597,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
REVITA PLACENTAL MEMBRANE 4X4CM 16SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12560-MAIN,LOCAL,,,,,6597,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
REVITA PLACENTAL MEMBRANE 4X4CM 16SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12560-MAIN,LOCAL,,,,,6597,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
REVITA PLACENTAL MEMBRANE 4X4CM 16SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12560-MAIN,LOCAL,,,,,6597,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
REVITA PLACENTAL MEMBRANE 4X4CM 16SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12560-MAIN,LOCAL,,,,,6597,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
REVITA PLACENTAL MEMBRANE 4X4CM 16SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12560-MAIN,LOCAL,,,,,6597,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
REVITA PLACENTAL MEMBRANE 4X6CM 24SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12561-MAIN,LOCAL,,,,,9896,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
REVITA PLACENTAL MEMBRANE 4X6CM 24SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12561-MAIN,LOCAL,,,,,9896,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
REVITA PLACENTAL MEMBRANE 4X6CM 24SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12561-MAIN,LOCAL,,,,,9896,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
REVITA PLACENTAL MEMBRANE 4X6CM 24SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12561-MAIN,LOCAL,,,,,9896,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
REVITA PLACENTAL MEMBRANE 4X6CM 24SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12561-MAIN,LOCAL,,,,,9896,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
REVITA PLACENTAL MEMBRANE 4X6CM 24SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12561-MAIN,LOCAL,,,,,9896,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
REVITA PLACENTAL MEMBRANE 6X6CM 36SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12562-MAIN,LOCAL,,,,,14844,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
REVITA PLACENTAL MEMBRANE 6X6CM 36SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12562-MAIN,LOCAL,,,,,14844,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
REVITA PLACENTAL MEMBRANE 6X6CM 36SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12562-MAIN,LOCAL,,,,,14844,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
REVITA PLACENTAL MEMBRANE 6X6CM 36SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12562-MAIN,LOCAL,,,,,14844,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
REVITA PLACENTAL MEMBRANE 6X6CM 36SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12562-MAIN,LOCAL,,,,,14844,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
REVITA PLACENTAL MEMBRANE 6X6CM 36SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12562-MAIN,LOCAL,,,,,14844,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
REVITA PLACENTAL MEMBRANE 6X8CM 48SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12563-MAIN,LOCAL,,,,,19792,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
REVITA PLACENTAL MEMBRANE 6X8CM 48SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12563-MAIN,LOCAL,,,,,19792,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
REVITA PLACENTAL MEMBRANE 6X8CM 48SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12563-MAIN,LOCAL,,,,,19792,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
REVITA PLACENTAL MEMBRANE 6X8CM 48SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12563-MAIN,LOCAL,,,,,19792,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
REVITA PLACENTAL MEMBRANE 6X8CM 48SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12563-MAIN,LOCAL,,,,,19792,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
REVITA PLACENTAL MEMBRANE 6X8CM 48SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12563-MAIN,LOCAL,,,,,19792,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Rheumatoid Factor Quant,PX86431,CDM,300,RC,86431,CPT,,,,,,,,97,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Rheumatoid Factor Quant,PX86431,CDM,300,RC,86431,CPT,,,,,,,,97,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Rheumatoid Factor Quant,PX86431,CDM,300,RC,86431,CPT,,,,,,,,97,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Rheumatoid Factor Quant,PX86431,CDM,300,RC,86431,CPT,,,,,,,,97,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Rheumatoid Factor Quant,PX86431,CDM,300,RC,86431,CPT,,,,,,,,97,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Rheumatoid Factor Quant,PX86431,CDM,300,RC,86431,CPT,,,,,,,,97,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rho d immune globulin human 1500 units solution prefilled syringe 1 Each Syringe,J2790.01,CDM,636,RC,J2790,HCPCS,,,,562780500,NDC,1,EA,464.01,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rho d immune globulin human 1500 units solution prefilled syringe 1 Each Syringe,J2790.01,CDM,636,RC,J2790,HCPCS,,,,562780500,NDC,1,EA,464.01,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rho d immune globulin human 1500 units solution prefilled syringe 1 Each Syringe,J2790.01,CDM,636,RC,J2790,HCPCS,,,,562780500,NDC,1,EA,464.01,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rho d immune globulin human 1500 units solution prefilled syringe 1 Each Syringe,J2790.01,CDM,636,RC,J2790,HCPCS,,,,562780500,NDC,1,EA,464.01,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rho d immune globulin human 1500 units solution prefilled syringe 1 Each Syringe,J2790.01,CDM,636,RC,J2790,HCPCS,,,,562780500,NDC,1,EA,464.01,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rho d immune globulin human 1500 units solution prefilled syringe 1 Each Syringe,J2790.01,CDM,636,RC,J2790,HCPCS,,,,562780500,NDC,1,EA,464.01,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310001,NDC,0.528,ML,785.14,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310001,NDC,0.528,ML,785.14,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310001,NDC,0.528,ML,785.14,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310001,NDC,0.528,ML,785.14,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310001,NDC,0.528,ML,785.14,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310001,NDC,0.528,ML,785.14,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310002,NDC,0.528,ML,894.9,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310002,NDC,0.528,ML,894.9,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310002,NDC,0.528,ML,894.9,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310002,NDC,0.528,ML,894.9,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310002,NDC,0.528,ML,894.9,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310002,NDC,0.528,ML,894.9,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Rickettsia Antibody - Ref,PX8675790,CDM,300,RC,86757,CPT,90,,,,,,,52,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Rickettsia Antibody - Ref,PX8675790,CDM,300,RC,86757,CPT,90,,,,,,,52,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Rickettsia Antibody - Ref,PX8675790,CDM,300,RC,86757,CPT,90,,,,,,,52,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Rickettsia Antibody - Ref,PX8675790,CDM,300,RC,86757,CPT,90,,,,,,,52,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Rickettsia Antibody - Ref,PX8675790,CDM,300,RC,86757,CPT,90,,,,,,,52,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Rickettsia Antibody - Ref,PX8675790,CDM,300,RC,86757,CPT,90,,,,,,,52,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
riFAMpin 150 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,527139330,NDC,1,EA,17.41,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
riFAMpin 150 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,527139330,NDC,1,EA,17.41,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
riFAMpin 150 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,527139330,NDC,1,EA,17.41,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
riFAMpin 150 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,527139330,NDC,1,EA,17.41,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
riFAMpin 150 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,527139330,NDC,1,EA,17.41,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
riFAMpin 150 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,527139330,NDC,1,EA,17.41,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
riFAMpin 150 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,68180065806,NDC,1,EA,17.41,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
riFAMpin 150 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,68180065806,NDC,1,EA,17.41,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
riFAMpin 150 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,68180065806,NDC,1,EA,17.41,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
riFAMpin 150 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,68180065806,NDC,1,EA,17.41,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
riFAMpin 150 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,68180065806,NDC,1,EA,17.41,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
riFAMpin 150 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,68180065806,NDC,1,EA,17.41,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
riFAMpin 150 MG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,68084035721,NDC,1,EA,10.68,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
riFAMpin 150 MG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,68084035721,NDC,1,EA,10.68,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
riFAMpin 150 MG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,68084035721,NDC,1,EA,10.68,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
riFAMpin 150 MG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,68084035721,NDC,1,EA,10.68,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
riFAMpin 150 MG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,68084035721,NDC,1,EA,10.68,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
riFAMpin 150 MG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,68084035721,NDC,1,EA,10.68,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rifAXIMin 550 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,65649030302,NDC,1,EA,218.25,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rifAXIMin 550 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,65649030302,NDC,1,EA,218.25,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rifAXIMin 550 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,65649030302,NDC,1,EA,218.25,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rifAXIMin 550 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,65649030302,NDC,1,EA,218.25,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rifAXIMin 550 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,65649030302,NDC,1,EA,218.25,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rifAXIMin 550 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,65649030302,NDC,1,EA,218.25,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rifAXIMin 550 MG Tablet 60 Each Box,63700001,CDM,250,RC,,,,,,65649030303,NDC,1,EA,218.25,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rifAXIMin 550 MG Tablet 60 Each Box,63700001,CDM,250,RC,,,,,,65649030303,NDC,1,EA,218.25,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rifAXIMin 550 MG Tablet 60 Each Box,63700001,CDM,250,RC,,,,,,65649030303,NDC,1,EA,218.25,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rifAXIMin 550 MG Tablet 60 Each Box,63700001,CDM,250,RC,,,,,,65649030303,NDC,1,EA,218.25,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rifAXIMin 550 MG Tablet 60 Each Box,63700001,CDM,250,RC,,,,,,65649030303,NDC,1,EA,218.25,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rifAXIMin 550 MG Tablet 60 Each Box,63700001,CDM,250,RC,,,,,,65649030303,NDC,1,EA,218.25,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
risperiDONE 0.5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,50458059160,NDC,1,EA,7.71,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
risperiDONE 0.5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,50458059160,NDC,1,EA,7.71,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
risperiDONE 0.5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,50458059160,NDC,1,EA,7.71,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
risperiDONE 0.5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,50458059160,NDC,1,EA,7.71,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
risperiDONE 0.5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,50458059160,NDC,1,EA,7.71,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
risperiDONE 0.5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,50458059160,NDC,1,EA,7.71,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
risperiDONE 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635861,NDC,1,EA,21.11,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
risperiDONE 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635861,NDC,1,EA,21.11,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
risperiDONE 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635861,NDC,1,EA,21.11,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
risperiDONE 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635861,NDC,1,EA,21.11,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
risperiDONE 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635861,NDC,1,EA,21.11,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
risperiDONE 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635861,NDC,1,EA,21.11,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
risperiDONE 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904736161,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
risperiDONE 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904736161,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
risperiDONE 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904736161,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
risperiDONE 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904736161,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
risperiDONE 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904736161,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
risperiDONE 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904736161,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
risperiDONE 0.25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084027011,NDC,1,EA,20.91,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
risperiDONE 0.25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084027011,NDC,1,EA,20.91,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
risperiDONE 0.25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084027011,NDC,1,EA,20.91,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
risperiDONE 0.25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084027011,NDC,1,EA,20.91,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
risperiDONE 0.25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084027011,NDC,1,EA,20.91,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
risperiDONE 0.25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084027011,NDC,1,EA,20.91,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
risperiDONE 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084027001,NDC,1,EA,20.91,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
risperiDONE 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084027001,NDC,1,EA,20.91,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
risperiDONE 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084027001,NDC,1,EA,20.91,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
risperiDONE 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084027001,NDC,1,EA,20.91,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
risperiDONE 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084027001,NDC,1,EA,20.91,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
risperiDONE 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084027001,NDC,1,EA,20.91,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
risperiDONE 4 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,43547034406,NDC,0.125,EA,8.06,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
risperiDONE 4 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,43547034406,NDC,0.125,EA,8.06,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
risperiDONE 4 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,43547034406,NDC,0.125,EA,8.06,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
risperiDONE 4 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,43547034406,NDC,0.125,EA,8.06,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
risperiDONE 4 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,43547034406,NDC,0.125,EA,8.06,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
risperiDONE 4 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,43547034406,NDC,0.125,EA,8.06,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
riTUXimab 100 MG/10ML Solution 10 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005121,NDC,10,ML,1916.61,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
riTUXimab 100 MG/10ML Solution 10 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005121,NDC,10,ML,1916.61,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
riTUXimab 100 MG/10ML Solution 10 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005121,NDC,10,ML,1916.61,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
riTUXimab 100 MG/10ML Solution 10 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005121,NDC,10,ML,1916.61,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
riTUXimab 100 MG/10ML Solution 10 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005121,NDC,10,ML,1916.61,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
riTUXimab 100 MG/10ML Solution 10 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005121,NDC,10,ML,1916.61,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
riTUXimab 500 MG/50ML Solution 50 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005306,NDC,50,ML,8860.06,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
riTUXimab 500 MG/50ML Solution 50 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005306,NDC,50,ML,8860.06,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
riTUXimab 500 MG/50ML Solution 50 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005306,NDC,50,ML,8860.06,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
riTUXimab 500 MG/50ML Solution 50 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005306,NDC,50,ML,8860.06,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
riTUXimab 500 MG/50ML Solution 50 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005306,NDC,50,ML,8860.06,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
riTUXimab 500 MG/50ML Solution 50 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005306,NDC,50,ML,8860.06,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
riTUXimab-abbs 500 MG/50ML Solution 50 mL Vial,Q5115.01,CDM,636,RC,Q5115,HCPCS,,,,63459010450,NDC,50,ML,8624.61,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
riTUXimab-abbs 500 MG/50ML Solution 50 mL Vial,Q5115.01,CDM,636,RC,Q5115,HCPCS,,,,63459010450,NDC,50,ML,8624.61,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
riTUXimab-abbs 500 MG/50ML Solution 50 mL Vial,Q5115.01,CDM,636,RC,Q5115,HCPCS,,,,63459010450,NDC,50,ML,8624.61,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
riTUXimab-abbs 500 MG/50ML Solution 50 mL Vial,Q5115.01,CDM,636,RC,Q5115,HCPCS,,,,63459010450,NDC,50,ML,8624.61,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
riTUXimab-abbs 500 MG/50ML Solution 50 mL Vial,Q5115.01,CDM,636,RC,Q5115,HCPCS,,,,63459010450,NDC,50,ML,8624.61,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
riTUXimab-abbs 500 MG/50ML Solution 50 mL Vial,Q5115.01,CDM,636,RC,Q5115,HCPCS,,,,63459010450,NDC,50,ML,8624.61,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rivaroxaban 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50458058030,NDC,1,EA,98.57,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rivaroxaban 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50458058030,NDC,1,EA,98.57,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rivaroxaban 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50458058030,NDC,1,EA,98.57,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rivaroxaban 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50458058030,NDC,1,EA,98.57,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rivaroxaban 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50458058030,NDC,1,EA,98.57,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rivaroxaban 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50458058030,NDC,1,EA,98.57,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rivaroxaban 15 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50458057830,NDC,0.666666667,EA,67.3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rivaroxaban 15 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50458057830,NDC,0.666666667,EA,67.3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rivaroxaban 15 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50458057830,NDC,0.666666667,EA,67.3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rivaroxaban 15 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50458057830,NDC,0.666666667,EA,67.3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rivaroxaban 15 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50458057830,NDC,0.666666667,EA,67.3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rivaroxaban 15 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50458057830,NDC,0.666666667,EA,67.3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rivastigmine 1.5 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,62332006360,NDC,1,EA,25.03,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rivastigmine 1.5 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,62332006360,NDC,1,EA,25.03,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rivastigmine 1.5 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,62332006360,NDC,1,EA,25.03,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rivastigmine 1.5 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,62332006360,NDC,1,EA,25.03,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rivastigmine 1.5 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,62332006360,NDC,1,EA,25.03,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rivastigmine 1.5 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,62332006360,NDC,1,EA,25.03,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rivastigmine 3 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,55111035360,NDC,0.5,EA,11.4,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rivastigmine 3 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,55111035360,NDC,0.5,EA,11.4,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rivastigmine 3 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,55111035360,NDC,0.5,EA,11.4,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rivastigmine 3 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,55111035360,NDC,0.5,EA,11.4,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rivastigmine 3 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,55111035360,NDC,0.5,EA,11.4,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rivastigmine 3 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,55111035360,NDC,0.5,EA,11.4,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323042605,NDC,5,ML,64.8,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323042605,NDC,5,ML,64.8,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323042605,NDC,5,ML,64.8,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323042605,NDC,5,ML,64.8,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323042605,NDC,5,ML,64.8,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323042605,NDC,5,ML,64.8,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,67457022800,NDC,5,ML,53.42,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,67457022800,NDC,5,ML,53.42,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,67457022800,NDC,5,ML,53.42,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,67457022800,NDC,5,ML,53.42,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,67457022800,NDC,5,ML,53.42,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,67457022800,NDC,5,ML,53.42,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,67457057305,NDC,5,ML,53.42,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,67457057305,NDC,5,ML,53.42,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,67457057305,NDC,5,ML,53.42,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,67457057305,NDC,5,ML,53.42,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,67457057305,NDC,5,ML,53.42,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,67457057305,NDC,5,ML,53.42,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
romiPLOStim 250 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022101,NDC,1,EA,3791.51,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
romiPLOStim 250 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022101,NDC,1,EA,3791.51,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
romiPLOStim 250 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022101,NDC,1,EA,3791.51,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
romiPLOStim 250 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022101,NDC,1,EA,3791.51,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
romiPLOStim 250 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022101,NDC,1,EA,3791.51,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
romiPLOStim 250 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022101,NDC,1,EA,3791.51,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RomiPLOStim 500 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022201,NDC,1,EA,7018.25,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RomiPLOStim 500 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022201,NDC,1,EA,7018.25,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RomiPLOStim 500 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022201,NDC,1,EA,7018.25,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RomiPLOStim 500 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022201,NDC,1,EA,7018.25,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RomiPLOStim 500 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022201,NDC,1,EA,7018.25,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RomiPLOStim 500 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022201,NDC,1,EA,7018.25,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Room Rate General,PX12000000,CDM,120,RC,,,,,,,,,,1688,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Room Rate General,PX12000000,CDM,120,RC,,,,,,,,,,1688,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Room Rate General,PX12000000,CDM,120,RC,,,,,,,,,,1688,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Room Rate General,PX12000000,CDM,120,RC,,,,,,,,,,1688,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Room Rate General,PX12000000,CDM,120,RC,,,,,,,,,,1688,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Room Rate General,PX12000000,CDM,120,RC,,,,,,,,,,1688,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Room Rate General Iso,PX12000001,CDM,120,RC,,,,,,,,,,1822,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Room Rate General Iso,PX12000001,CDM,120,RC,,,,,,,,,,1822,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Room Rate General Iso,PX12000001,CDM,120,RC,,,,,,,,,,1822,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Room Rate General Iso,PX12000001,CDM,120,RC,,,,,,,,,,1822,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Room Rate General Iso,PX12000001,CDM,120,RC,,,,,,,,,,1822,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Room Rate General Iso,PX12000001,CDM,120,RC,,,,,,,,,,1822,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Room Rate Icc,PX20601000,CDM,206,RC,,,,,,,,,,2432,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Room Rate Icc,PX20601000,CDM,206,RC,,,,,,,,,,2432,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Room Rate Icc,PX20601000,CDM,206,RC,,,,,,,,,,2432,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Room Rate Icc,PX20601000,CDM,206,RC,,,,,,,,,,2432,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Room Rate Icc,PX20601000,CDM,206,RC,,,,,,,,,,2432,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Room Rate Icc,PX20601000,CDM,206,RC,,,,,,,,,,2432,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Room Rate Icc Iso,PX20601001,CDM,206,RC,,,,,,,,,,2517,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Room Rate Icc Iso,PX20601001,CDM,206,RC,,,,,,,,,,2517,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Room Rate Icc Iso,PX20601001,CDM,206,RC,,,,,,,,,,2517,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Room Rate Icc Iso,PX20601001,CDM,206,RC,,,,,,,,,,2517,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Room Rate Icc Iso,PX20601001,CDM,206,RC,,,,,,,,,,2517,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Room Rate Icc Iso,PX20601001,CDM,206,RC,,,,,,,,,,2517,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Room Rate Swing General,PX12000010,CDM,120,RC,,,,,,,,,,3788,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Room Rate Swing General,PX12000010,CDM,120,RC,,,,,,,,,,3788,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Room Rate Swing General,PX12000010,CDM,120,RC,,,,,,,,,,3788,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Room Rate Swing General,PX12000010,CDM,120,RC,,,,,,,,,,3788,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Room Rate Swing General,PX12000010,CDM,120,RC,,,,,,,,,,3788,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Room Rate Swing General,PX12000010,CDM,120,RC,,,,,,,,,,3788,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Room Rate Swing General Iso,PX12000011,CDM,120,RC,,,,,,,,,,3788,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Room Rate Swing General Iso,PX12000011,CDM,120,RC,,,,,,,,,,3788,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Room Rate Swing General Iso,PX12000011,CDM,120,RC,,,,,,,,,,3788,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Room Rate Swing General Iso,PX12000011,CDM,120,RC,,,,,,,,,,3788,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Room Rate Swing General Iso,PX12000011,CDM,120,RC,,,,,,,,,,3788,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Room Rate Swing General Iso,PX12000011,CDM,120,RC,,,,,,,,,,3788,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Room Rate Transitional Care Private,PX11900000,CDM,119,RC,,,,,,,,,,775,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Room Rate Transitional Care Private,PX11900000,CDM,119,RC,,,,,,,,,,775,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Room Rate Transitional Care Private,PX11900000,CDM,119,RC,,,,,,,,,,775,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Room Rate Transitional Care Private,PX11900000,CDM,119,RC,,,,,,,,,,775,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Room Rate Transitional Care Private,PX11900000,CDM,119,RC,,,,,,,,,,775,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Room Rate Transitional Care Private,PX11900000,CDM,119,RC,,,,,,,,,,775,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rOPINIRole 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547026810,NDC,1,EA,13.43,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rOPINIRole 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547026810,NDC,1,EA,13.43,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rOPINIRole 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547026810,NDC,1,EA,13.43,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rOPINIRole 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547026810,NDC,1,EA,13.43,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rOPINIRole 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547026810,NDC,1,EA,13.43,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rOPINIRole 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547026810,NDC,1,EA,13.43,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rOPINIRole 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462025301,NDC,1,EA,13.45,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rOPINIRole 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462025301,NDC,1,EA,13.45,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rOPINIRole 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462025301,NDC,1,EA,13.45,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rOPINIRole 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462025301,NDC,1,EA,13.45,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rOPINIRole 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462025301,NDC,1,EA,13.45,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rOPINIRole 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462025301,NDC,1,EA,13.45,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rOPINIRole 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637461,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rOPINIRole 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637461,NDC,0.25,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rOPINIRole 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637461,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rOPINIRole 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637461,NDC,0.25,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rOPINIRole 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637461,NDC,0.25,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rOPINIRole 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637461,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rOPINIRole 4 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462025801,NDC,1,EA,13.96,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rOPINIRole 4 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462025801,NDC,1,EA,13.96,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rOPINIRole 4 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462025801,NDC,1,EA,13.96,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rOPINIRole 4 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462025801,NDC,1,EA,13.96,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rOPINIRole 4 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462025801,NDC,1,EA,13.96,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rOPINIRole 4 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462025801,NDC,1,EA,13.96,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ROPivacaine 2 MG/ML Solution 10 mL Vial,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028513,NDC,10,ML,52.01,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ROPivacaine 2 MG/ML Solution 10 mL Vial,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028513,NDC,10,ML,52.01,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ROPivacaine 2 MG/ML Solution 10 mL Vial,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028513,NDC,10,ML,52.01,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ROPivacaine 2 MG/ML Solution 10 mL Vial,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028513,NDC,10,ML,52.01,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ROPivacaine 2 MG/ML Solution 10 mL Vial,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028513,NDC,10,ML,52.01,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ROPivacaine 2 MG/ML Solution 10 mL Vial,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028513,NDC,10,ML,52.01,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ROPivacaine 2 MG/ML Solution 100 mL Bottle,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028568,NDC,100,ML,275.11,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ROPivacaine 2 MG/ML Solution 100 mL Bottle,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028568,NDC,100,ML,275.11,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ROPivacaine 2 MG/ML Solution 100 mL Bottle,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028568,NDC,100,ML,275.11,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ROPivacaine 2 MG/ML Solution 100 mL Bottle,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028568,NDC,100,ML,275.11,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ROPivacaine 2 MG/ML Solution 100 mL Bottle,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028568,NDC,100,ML,275.11,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ROPivacaine 2 MG/ML Solution 100 mL Bottle,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028568,NDC,100,ML,275.11,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16714098801,NDC,1,EA,46.18,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16714098801,NDC,1,EA,46.18,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16714098801,NDC,1,EA,46.18,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16714098801,NDC,1,EA,46.18,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16714098801,NDC,1,EA,46.18,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16714098801,NDC,1,EA,46.18,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003001,NDC,0.5,EA,21.59,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003001,NDC,0.5,EA,21.59,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003001,NDC,0.5,EA,21.59,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003001,NDC,0.5,EA,21.59,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003001,NDC,0.5,EA,21.59,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003001,NDC,0.5,EA,21.59,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 10 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,60687024511,NDC,0.5,EA,19.18,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 10 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,60687024511,NDC,0.5,EA,19.18,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 10 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,60687024511,NDC,0.5,EA,19.18,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 10 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,60687024511,NDC,0.5,EA,19.18,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 10 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,60687024511,NDC,0.5,EA,19.18,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 10 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,60687024511,NDC,0.5,EA,19.18,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003201,NDC,0.125,EA,5.4,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003201,NDC,0.125,EA,5.4,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003201,NDC,0.125,EA,5.4,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003201,NDC,0.125,EA,5.4,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003201,NDC,0.125,EA,5.4,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003201,NDC,0.125,EA,5.4,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268071111,NDC,0.125,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268071111,NDC,0.125,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268071111,NDC,0.125,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268071111,NDC,0.125,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268071111,NDC,0.125,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268071111,NDC,0.125,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,310075430,NDC,1,EA,56.04,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,310075430,NDC,1,EA,56.04,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,310075430,NDC,1,EA,56.04,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,310075430,NDC,1,EA,56.04,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,310075430,NDC,1,EA,56.04,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,310075430,NDC,1,EA,56.04,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,72205000530,NDC,0.125,EA,6,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,72205000530,NDC,0.125,EA,6,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,72205000530,NDC,0.125,EA,6,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,72205000530,NDC,0.125,EA,6,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,72205000530,NDC,0.125,EA,6,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,72205000530,NDC,0.125,EA,6,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 40 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268071115,NDC,0.125,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 40 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268071115,NDC,0.125,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 40 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268071115,NDC,0.125,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 40 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268071115,NDC,0.125,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 40 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268071115,NDC,0.125,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 40 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268071115,NDC,0.125,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ROTH NET PLATINUM RETRIEVER,27200000,CDM,272,RC,,,,7518-MAIN,LOCAL,,,,,196.35,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ROTH NET PLATINUM RETRIEVER,27200000,CDM,272,RC,,,,7518-MAIN,LOCAL,,,,,196.35,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ROTH NET PLATINUM RETRIEVER,27200000,CDM,272,RC,,,,7518-MAIN,LOCAL,,,,,196.35,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ROTH NET PLATINUM RETRIEVER,27200000,CDM,272,RC,,,,7518-MAIN,LOCAL,,,,,196.35,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ROTH NET PLATINUM RETRIEVER,27200000,CDM,272,RC,,,,7518-MAIN,LOCAL,,,,,196.35,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ROTH NET PLATINUM RETRIEVER,27200000,CDM,272,RC,,,,7518-MAIN,LOCAL,,,,,196.35,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Rubella Antibody,PX86762,CDM,300,RC,86762,CPT,,,,,,,,31,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Rubella Antibody,PX86762,CDM,300,RC,86762,CPT,,,,,,,,31,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Rubella Antibody,PX86762,CDM,300,RC,86762,CPT,,,,,,,,31,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Rubella Antibody,PX86762,CDM,300,RC,86762,CPT,,,,,,,,31,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Rubella Antibody,PX86762,CDM,300,RC,86762,CPT,,,,,,,,31,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Rubella Antibody,PX86762,CDM,300,RC,86762,CPT,,,,,,,,31,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Rubeola Antibody,PX86765,CDM,300,RC,86765,CPT,,,,,,,,74,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Rubeola Antibody,PX86765,CDM,300,RC,86765,CPT,,,,,,,,74,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Rubeola Antibody,PX86765,CDM,300,RC,86765,CPT,,,,,,,,74,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Rubeola Antibody,PX86765,CDM,300,RC,86765,CPT,,,,,,,,74,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Rubeola Antibody,PX86765,CDM,300,RC,86765,CPT,,,,,,,,74,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Rubeola Antibody,PX86765,CDM,300,RC,86765,CPT,,,,,,,,74,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Russell Viper Venom - Ref,PX8561390,CDM,300,RC,85613,CPT,90,,,,,,,93,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Russell Viper Venom - Ref,PX8561390,CDM,300,RC,85613,CPT,90,,,,,,,93,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Russell Viper Venom - Ref,PX8561390,CDM,300,RC,85613,CPT,90,,,,,,,93,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Russell Viper Venom - Ref,PX8561390,CDM,300,RC,85613,CPT,90,,,,,,,93,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Russell Viper Venom - Ref,PX8561390,CDM,300,RC,85613,CPT,90,,,,,,,93,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Russell Viper Venom - Ref,PX8561390,CDM,300,RC,85613,CPT,90,,,,,,,93,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
saccharomyces boulardii 250 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,4142000024,NDC,1,EA,4.25,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
saccharomyces boulardii 250 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,4142000024,NDC,1,EA,4.25,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
saccharomyces boulardii 250 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,4142000024,NDC,1,EA,4.25,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
saccharomyces boulardii 250 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,4142000024,NDC,1,EA,4.25,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
saccharomyces boulardii 250 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,4142000024,NDC,1,EA,4.25,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
saccharomyces boulardii 250 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,4142000024,NDC,1,EA,4.25,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sacubitril-valsartan 24-26 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,78065920,NDC,1,EA,62.6,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sacubitril-valsartan 24-26 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,78065920,NDC,1,EA,62.6,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sacubitril-valsartan 24-26 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,78065920,NDC,1,EA,62.6,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sacubitril-valsartan 24-26 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,78065920,NDC,1,EA,62.6,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sacubitril-valsartan 24-26 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,78065920,NDC,1,EA,62.6,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sacubitril-valsartan 24-26 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,78065920,NDC,1,EA,62.6,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sacubitril-Valsartan 49-51 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,78077720,NDC,1,EA,58.51,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sacubitril-Valsartan 49-51 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,78077720,NDC,1,EA,58.51,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sacubitril-Valsartan 49-51 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,78077720,NDC,1,EA,58.51,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sacubitril-Valsartan 49-51 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,78077720,NDC,1,EA,58.51,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sacubitril-Valsartan 49-51 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,78077720,NDC,1,EA,58.51,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sacubitril-Valsartan 49-51 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,78077720,NDC,1,EA,58.51,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Salicylate,PX80307D,CDM,300,RC,80307,CPT,,,,,,,,370,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Salicylate,PX80307D,CDM,300,RC,80307,CPT,,,,,,,,370,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Salicylate,PX80307D,CDM,300,RC,80307,CPT,,,,,,,,370,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Salicylate,PX80307D,CDM,300,RC,80307,CPT,,,,,,,,370,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Salicylate,PX80307D,CDM,300,RC,80307,CPT,,,,,,,,370,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Salicylate,PX80307D,CDM,300,RC,80307,CPT,,,,,,,,370,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
saliva substitute Solution 59 mL Bottle,63700001,CDM,250,RC,,,,,,50930009802,NDC,59,ML,31.1,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
saliva substitute Solution 59 mL Bottle,63700001,CDM,250,RC,,,,,,50930009802,NDC,59,ML,31.1,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
saliva substitute Solution 59 mL Bottle,63700001,CDM,250,RC,,,,,,50930009802,NDC,59,ML,31.1,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
saliva substitute Solution 59 mL Bottle,63700001,CDM,250,RC,,,,,,50930009802,NDC,59,ML,31.1,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
saliva substitute Solution 59 mL Bottle,63700001,CDM,250,RC,,,,,,50930009802,NDC,59,ML,31.1,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
saliva substitute Solution 59 mL Bottle,63700001,CDM,250,RC,,,,,,50930009802,NDC,59,ML,31.1,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sarilumab 200 MG/1.14ML solution prefilled syringe 1.14 mL Syringe,J3590.25,CDM,636,RC,J3590,HCPCS,,,,24591001,NDC,1.14,ML,4408.29,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sarilumab 200 MG/1.14ML solution prefilled syringe 1.14 mL Syringe,J3590.25,CDM,636,RC,J3590,HCPCS,,,,24591001,NDC,1.14,ML,4408.29,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sarilumab 200 MG/1.14ML solution prefilled syringe 1.14 mL Syringe,J3590.25,CDM,636,RC,J3590,HCPCS,,,,24591001,NDC,1.14,ML,4408.29,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sarilumab 200 MG/1.14ML solution prefilled syringe 1.14 mL Syringe,J3590.25,CDM,636,RC,J3590,HCPCS,,,,24591001,NDC,1.14,ML,4408.29,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sarilumab 200 MG/1.14ML solution prefilled syringe 1.14 mL Syringe,J3590.25,CDM,636,RC,J3590,HCPCS,,,,24591001,NDC,1.14,ML,4408.29,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sarilumab 200 MG/1.14ML solution prefilled syringe 1.14 mL Syringe,J3590.25,CDM,636,RC,J3590,HCPCS,,,,24591001,NDC,1.14,ML,4408.29,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sars-Cov-2 Covid-19 Amp Prb,PX8763590,CDM,300,RC,87635,CPT,90,,,,,,,365,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sars-Cov-2 Covid-19 Amp Prb,PX8763590,CDM,300,RC,87635,CPT,90,,,,,,,365,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sars-Cov-2 Covid-19 Amp Prb,PX8763590,CDM,300,RC,87635,CPT,90,,,,,,,365,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sars-Cov-2 Covid-19 Amp Prb,PX8763590,CDM,300,RC,87635,CPT,90,,,,,,,365,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sars-Cov-2 Covid-19 Amp Prb,PX8763590,CDM,300,RC,87635,CPT,90,,,,,,,365,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sars-Cov-2 Covid-19 Amp Prb,PX8763590,CDM,300,RC,87635,CPT,90,,,,,,,365,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sars-Cov-2 Covid-19 Antibody,PX86769,CDM,300,RC,86769,CPT,,,,,,,,340,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sars-Cov-2 Covid-19 Antibody,PX86769,CDM,300,RC,86769,CPT,,,,,,,,340,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sars-Cov-2 Covid-19 Antibody,PX86769,CDM,300,RC,86769,CPT,,,,,,,,340,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sars-Cov-2 Covid-19 Antibody,PX86769,CDM,300,RC,86769,CPT,,,,,,,,340,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sars-Cov-2 Covid-19 Antibody,PX86769,CDM,300,RC,86769,CPT,,,,,,,,340,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sars-Cov-2 Covid-19 Antibody,PX86769,CDM,300,RC,86769,CPT,,,,,,,,340,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sars-Cov-2 Covid-19 Antibody,PX8676990,CDM,300,RC,86769,CPT,90,,,,,,,100,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sars-Cov-2 Covid-19 Antibody,PX8676990,CDM,300,RC,86769,CPT,90,,,,,,,100,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sars-Cov-2 Covid-19 Antibody,PX8676990,CDM,300,RC,86769,CPT,90,,,,,,,100,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sars-Cov-2 Covid-19 Antibody,PX8676990,CDM,300,RC,86769,CPT,90,,,,,,,100,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sars-Cov-2 Covid-19 Antibody,PX8676990,CDM,300,RC,86769,CPT,90,,,,,,,100,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sars-Cov-2 Covid-19 Antibody,PX8676990,CDM,300,RC,86769,CPT,90,,,,,,,100,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SAW BLADE 300 SAGITTAL 25X9.4X0.7,27200000,CDM,272,RC,,,,11592-MAIN,LOCAL,,,,,46.75,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SAW BLADE 300 SAGITTAL 25X9.4X0.7,27200000,CDM,272,RC,,,,11592-MAIN,LOCAL,,,,,46.75,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SAW BLADE 300 SAGITTAL 25X9.4X0.7,27200000,CDM,272,RC,,,,11592-MAIN,LOCAL,,,,,46.75,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SAW BLADE 300 SAGITTAL 25X9.4X0.7,27200000,CDM,272,RC,,,,11592-MAIN,LOCAL,,,,,46.75,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SAW BLADE 300 SAGITTAL 25X9.4X0.7,27200000,CDM,272,RC,,,,11592-MAIN,LOCAL,,,,,46.75,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SAW BLADE 300 SAGITTAL 25X9.4X0.7,27200000,CDM,272,RC,,,,11592-MAIN,LOCAL,,,,,46.75,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SAW BLADE 300 SAGITTAL 40X14X0.6MM,27200000,CDM,272,RC,,,,11591-MAIN,LOCAL,,,,,46.75,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SAW BLADE 300 SAGITTAL 40X14X0.6MM,27200000,CDM,272,RC,,,,11591-MAIN,LOCAL,,,,,46.75,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SAW BLADE 300 SAGITTAL 40X14X0.6MM,27200000,CDM,272,RC,,,,11591-MAIN,LOCAL,,,,,46.75,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SAW BLADE 300 SAGITTAL 40X14X0.6MM,27200000,CDM,272,RC,,,,11591-MAIN,LOCAL,,,,,46.75,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SAW BLADE 300 SAGITTAL 40X14X0.6MM,27200000,CDM,272,RC,,,,11591-MAIN,LOCAL,,,,,46.75,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SAW BLADE 300 SAGITTAL 40X14X0.6MM,27200000,CDM,272,RC,,,,11591-MAIN,LOCAL,,,,,46.75,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SAW WIRE 12 INCH GIGLI NL850,27200000,CDM,272,RC,,,,12901-MAIN,LOCAL,,,,,14,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SAW WIRE 12 INCH GIGLI NL850,27200000,CDM,272,RC,,,,12901-MAIN,LOCAL,,,,,14,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SAW WIRE 12 INCH GIGLI NL850,27200000,CDM,272,RC,,,,12901-MAIN,LOCAL,,,,,14,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SAW WIRE 12 INCH GIGLI NL850,27200000,CDM,272,RC,,,,12901-MAIN,LOCAL,,,,,14,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SAW WIRE 12 INCH GIGLI NL850,27200000,CDM,272,RC,,,,12901-MAIN,LOCAL,,,,,14,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SAW WIRE 12 INCH GIGLI NL850,27200000,CDM,272,RC,,,,12901-MAIN,LOCAL,,,,,14,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SAWBLADE SAGITAL STERILE 25MM LENGTH 5.5MM WIDTH 0.60MM THICKNESS,27200000,CDM,272,RC,,,,11623-MAIN,LOCAL,,,,,86.02,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SAWBLADE SAGITAL STERILE 25MM LENGTH 5.5MM WIDTH 0.60MM THICKNESS,27200000,CDM,272,RC,,,,11623-MAIN,LOCAL,,,,,86.02,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SAWBLADE SAGITAL STERILE 25MM LENGTH 5.5MM WIDTH 0.60MM THICKNESS,27200000,CDM,272,RC,,,,11623-MAIN,LOCAL,,,,,86.02,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SAWBLADE SAGITAL STERILE 25MM LENGTH 5.5MM WIDTH 0.60MM THICKNESS,27200000,CDM,272,RC,,,,11623-MAIN,LOCAL,,,,,86.02,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SAWBLADE SAGITAL STERILE 25MM LENGTH 5.5MM WIDTH 0.60MM THICKNESS,27200000,CDM,272,RC,,,,11623-MAIN,LOCAL,,,,,86.02,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SAWBLADE SAGITAL STERILE 25MM LENGTH 5.5MM WIDTH 0.60MM THICKNESS,27200000,CDM,272,RC,,,,11623-MAIN,LOCAL,,,,,86.02,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sb Scope,to Ileum,Biopsy",PX44377F,CDM,750,RC,44377,CPT,,,,,,,,1770,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1561.14,6141.46
"Sb Scope,to Ileum,Biopsy",PX44377F,CDM,750,RC,44377,CPT,,,,,,,,1770,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1561.14,6141.46
"Sb Scope,to Ileum,Biopsy",PX44377F,CDM,750,RC,44377,CPT,,,,,,,,1770,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1561.14,6141.46
"Sb Scope,to Ileum,Biopsy",PX44377F,CDM,750,RC,44377,CPT,,,,,,,,1770,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1561.14,6141.46
"Sb Scope,to Ileum,Biopsy",PX44377F,CDM,750,RC,44377,CPT,,,,,,,,1770,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1561.14,6141.46
"Sb Scope,to Ileum,Biopsy",PX44377F,CDM,750,RC,44377,CPT,,,,,,,,1770,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1561.14,6141.46
"Sb Scope,to Ileum,Biopsy",PX44377P,CDM,983,RC,44377,CPT,,,,,,,,1180,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sb Scope,to Ileum,Biopsy",PX44377P,CDM,983,RC,44377,CPT,,,,,,,,1180,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sb Scope,to Ileum,Biopsy",PX44377P,CDM,983,RC,44377,CPT,,,,,,,,1180,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sb Scope,to Ileum,Biopsy",PX44377P,CDM,983,RC,44377,CPT,,,,,,,,1180,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sb Scope,to Ileum,Biopsy",PX44377P,CDM,983,RC,44377,CPT,,,,,,,,1180,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sb Scope,to Ileum,Biopsy",PX44377P,CDM,983,RC,44377,CPT,,,,,,,,1180,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SCAR GEL SHEET,120.458,CDM,273,RC,A6025,HCPCS,,5796-MAIN,LOCAL,,,,,51,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SCAR GEL SHEET,120.458,CDM,273,RC,A6025,HCPCS,,5796-MAIN,LOCAL,,,,,51,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SCAR GEL SHEET,120.458,CDM,273,RC,A6025,HCPCS,,5796-MAIN,LOCAL,,,,,51,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SCAR GEL SHEET,120.458,CDM,273,RC,A6025,HCPCS,,5796-MAIN,LOCAL,,,,,51,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SCAR GEL SHEET,120.458,CDM,273,RC,A6025,HCPCS,,5796-MAIN,LOCAL,,,,,51,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SCAR GEL SHEET,120.458,CDM,273,RC,A6025,HCPCS,,5796-MAIN,LOCAL,,,,,51,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SCISSORS ENDOSCOPIC 5MM STANDARD STERILE,27200000,CDM,272,RC,,,,11706-MAIN,LOCAL,,,,,47.6,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SCISSORS ENDOSCOPIC 5MM STANDARD STERILE,27200000,CDM,272,RC,,,,11706-MAIN,LOCAL,,,,,47.6,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SCISSORS ENDOSCOPIC 5MM STANDARD STERILE,27200000,CDM,272,RC,,,,11706-MAIN,LOCAL,,,,,47.6,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SCISSORS ENDOSCOPIC 5MM STANDARD STERILE,27200000,CDM,272,RC,,,,11706-MAIN,LOCAL,,,,,47.6,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SCISSORS ENDOSCOPIC 5MM STANDARD STERILE,27200000,CDM,272,RC,,,,11706-MAIN,LOCAL,,,,,47.6,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SCISSORS ENDOSCOPIC 5MM STANDARD STERILE,27200000,CDM,272,RC,,,,11706-MAIN,LOCAL,,,,,47.6,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SCOPE ASCOPE4 CYSTO STERILE 601001000,120.497,CDM,272,RC,A4649,HCPCS,,11662-MAIN,LOCAL,,,,,368,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SCOPE ASCOPE4 CYSTO STERILE 601001000,120.497,CDM,272,RC,A4649,HCPCS,,11662-MAIN,LOCAL,,,,,368,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SCOPE ASCOPE4 CYSTO STERILE 601001000,120.497,CDM,272,RC,A4649,HCPCS,,11662-MAIN,LOCAL,,,,,368,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SCOPE ASCOPE4 CYSTO STERILE 601001000,120.497,CDM,272,RC,A4649,HCPCS,,11662-MAIN,LOCAL,,,,,368,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SCOPE ASCOPE4 CYSTO STERILE 601001000,120.497,CDM,272,RC,A4649,HCPCS,,11662-MAIN,LOCAL,,,,,368,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SCOPE ASCOPE4 CYSTO STERILE 601001000,120.497,CDM,272,RC,A4649,HCPCS,,11662-MAIN,LOCAL,,,,,368,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SCOPE BRONCHOSCOPE SZ 4 STERILE DISPOSABLE B120044,120.574,CDM,272,RC,,,,12868-MAIN,LOCAL,,,,,28,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SCOPE BRONCHOSCOPE SZ 4 STERILE DISPOSABLE B120044,120.574,CDM,272,RC,,,,12868-MAIN,LOCAL,,,,,28,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SCOPE BRONCHOSCOPE SZ 4 STERILE DISPOSABLE B120044,120.574,CDM,272,RC,,,,12868-MAIN,LOCAL,,,,,28,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SCOPE BRONCHOSCOPE SZ 4 STERILE DISPOSABLE B120044,120.574,CDM,272,RC,,,,12868-MAIN,LOCAL,,,,,28,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SCOPE BRONCHOSCOPE SZ 4 STERILE DISPOSABLE B120044,120.574,CDM,272,RC,,,,12868-MAIN,LOCAL,,,,,28,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SCOPE BRONCHOSCOPE SZ 4 STERILE DISPOSABLE B120044,120.574,CDM,272,RC,,,,12868-MAIN,LOCAL,,,,,28,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Box,25000000,CDM,250,RC,,,,,,67434509,NDC,1,EA,98.1,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Box,25000000,CDM,250,RC,,,,,,67434509,NDC,1,EA,98.1,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Box,25000000,CDM,250,RC,,,,,,67434509,NDC,1,EA,98.1,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Box,25000000,CDM,250,RC,,,,,,67434509,NDC,1,EA,98.1,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Box,25000000,CDM,250,RC,,,,,,67434509,NDC,1,EA,98.1,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Box,25000000,CDM,250,RC,,,,,,67434509,NDC,1,EA,98.1,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Package,25000000,CDM,250,RC,,,,,,10019055390,NDC,1,EA,121.9,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Package,25000000,CDM,250,RC,,,,,,10019055390,NDC,1,EA,121.9,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Package,25000000,CDM,250,RC,,,,,,10019055390,NDC,1,EA,121.9,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Package,25000000,CDM,250,RC,,,,,,10019055390,NDC,1,EA,121.9,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Package,25000000,CDM,250,RC,,,,,,10019055390,NDC,1,EA,121.9,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Package,25000000,CDM,250,RC,,,,,,10019055390,NDC,1,EA,121.9,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Package,25000000,CDM,250,RC,,,,,,66758020858,NDC,1,EA,102.08,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Package,25000000,CDM,250,RC,,,,,,66758020858,NDC,1,EA,102.08,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Package,25000000,CDM,250,RC,,,,,,66758020858,NDC,1,EA,102.08,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Package,25000000,CDM,250,RC,,,,,,66758020858,NDC,1,EA,102.08,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Package,25000000,CDM,250,RC,,,,,,66758020858,NDC,1,EA,102.08,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Package,25000000,CDM,250,RC,,,,,,66758020858,NDC,1,EA,102.08,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
scopolamine 1 MG/3DAYS Patch 72 Hour 4 Each Box,25000000,CDM,250,RC,,,,,,45802058084,NDC,1,EA,103.43,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
scopolamine 1 MG/3DAYS Patch 72 Hour 4 Each Box,25000000,CDM,250,RC,,,,,,45802058084,NDC,1,EA,103.43,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
scopolamine 1 MG/3DAYS Patch 72 Hour 4 Each Box,25000000,CDM,250,RC,,,,,,45802058084,NDC,1,EA,103.43,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
scopolamine 1 MG/3DAYS Patch 72 Hour 4 Each Box,25000000,CDM,250,RC,,,,,,45802058084,NDC,1,EA,103.43,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
scopolamine 1 MG/3DAYS Patch 72 Hour 4 Each Box,25000000,CDM,250,RC,,,,,,45802058084,NDC,1,EA,103.43,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
scopolamine 1 MG/3DAYS Patch 72 Hour 4 Each Box,25000000,CDM,250,RC,,,,,,45802058084,NDC,1,EA,103.43,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
scopolamine 1 MG/3DAYS Patch 72 Hour 24 Each Box,25000000,CDM,250,RC,,,,,,50742050524,NDC,1,EA,109.59,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
scopolamine 1 MG/3DAYS Patch 72 Hour 24 Each Box,25000000,CDM,250,RC,,,,,,50742050524,NDC,1,EA,109.59,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
scopolamine 1 MG/3DAYS Patch 72 Hour 24 Each Box,25000000,CDM,250,RC,,,,,,50742050524,NDC,1,EA,109.59,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
scopolamine 1 MG/3DAYS Patch 72 Hour 24 Each Box,25000000,CDM,250,RC,,,,,,50742050524,NDC,1,EA,109.59,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
scopolamine 1 MG/3DAYS Patch 72 Hour 24 Each Box,25000000,CDM,250,RC,,,,,,50742050524,NDC,1,EA,109.59,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
scopolamine 1 MG/3DAYS Patch 72 Hour 24 Each Box,25000000,CDM,250,RC,,,,,,50742050524,NDC,1,EA,109.59,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598F,CDM,510,RC,97598,CPT,,,,,,,,406,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598F,CDM,510,RC,97598,CPT,,,,,,,,406,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598F,CDM,510,RC,97598,CPT,,,,,,,,406,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598F,CDM,510,RC,97598,CPT,,,,,,,,406,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598F,CDM,510,RC,97598,CPT,,,,,,,,406,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598F,CDM,510,RC,97598,CPT,,,,,,,,406,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598P,CDM,982,RC,97598,CPT,,,,,,,,325,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598P,CDM,982,RC,97598,CPT,,,,,,,,325,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598P,CDM,982,RC,97598,CPT,,,,,,,,325,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598P,CDM,982,RC,97598,CPT,,,,,,,,325,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598P,CDM,982,RC,97598,CPT,,,,,,,,325,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598P,CDM,982,RC,97598,CPT,,,,,,,,325,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597F,CDM,510,RC,97597,CPT,,,,,,,,266,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597F,CDM,510,RC,97597,CPT,,,,,,,,266,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597F,CDM,510,RC,97597,CPT,,,,,,,,266,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597F,CDM,510,RC,97597,CPT,,,,,,,,266,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597F,CDM,510,RC,97597,CPT,,,,,,,,266,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597F,CDM,510,RC,97597,CPT,,,,,,,,266,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597P,CDM,983,RC,97597,CPT,,,,,,,,274,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597P,CDM,983,RC,97597,CPT,,,,,,,,274,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597P,CDM,983,RC,97597,CPT,,,,,,,,274,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597P,CDM,983,RC,97597,CPT,,,,,,,,274,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597P,CDM,983,RC,97597,CPT,,,,,,,,274,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597P,CDM,983,RC,97597,CPT,,,,,,,,274,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Self Care Mngment Training,PX97535,CDM,420,RC,97535,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Self Care Mngment Training,PX97535,CDM,420,RC,97535,CPT,,,,,,,,135,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Self Care Mngment Training,PX97535,CDM,420,RC,97535,CPT,,,,,,,,135,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Self Care Mngment Training,PX97535,CDM,420,RC,97535,CPT,,,,,,,,135,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Self Care Mngment Training,PX97535,CDM,420,RC,97535,CPT,,,,,,,,135,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Self Care Mngment Training,PX97535,CDM,420,RC,97535,CPT,,,,,,,,135,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
senna 8.6 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904652261,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
senna 8.6 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904652261,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
senna 8.6 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904652261,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
senna 8.6 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904652261,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
senna 8.6 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904652261,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
senna 8.6 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904652261,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
senna-docusate 8.6-50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687062211,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
senna-docusate 8.6-50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687062211,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
senna-docusate 8.6-50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687062211,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
senna-docusate 8.6-50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687062211,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
senna-docusate 8.6-50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687062211,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
senna-docusate 8.6-50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687062211,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
senna-docusate 8.6-50 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,57896045806,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
senna-docusate 8.6-50 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,57896045806,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
senna-docusate 8.6-50 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,57896045806,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
senna-docusate 8.6-50 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,57896045806,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
senna-docusate 8.6-50 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,57896045806,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
senna-docusate 8.6-50 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,57896045806,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904633961,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904633961,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904633961,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904633961,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904633961,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904633961,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687062201,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687062201,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687062201,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687062201,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687062201,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687062201,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739043210,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739043210,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739043210,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739043210,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739043210,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739043210,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018011,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018011,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018011,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018011,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018011,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018011,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904692461,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904692461,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904692461,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904692461,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904692461,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904692461,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018001,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018001,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018001,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018001,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018001,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018001,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687024211,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687024211,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687024211,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687024211,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687024211,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687024211,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018111,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018111,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018111,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018111,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018111,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018111,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687024201,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687024201,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687024201,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687024201,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687024201,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687024201,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018101,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018101,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018101,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018101,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018101,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018101,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687025311,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687025311,NDC,0.25,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687025311,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687025311,NDC,0.25,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687025311,NDC,0.25,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687025311,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904692661,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904692661,NDC,0.25,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904692661,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904692661,NDC,0.25,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904692661,NDC,0.25,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904692661,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687025301,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687025301,NDC,0.25,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687025301,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687025301,NDC,0.25,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687025301,NDC,0.25,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687025301,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SET CRICOTHYROTOMY CATHETER 3.5MM ID,120.251,CDM,272,RC,,,,4306-MAIN,LOCAL,,,,,363,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SET CRICOTHYROTOMY CATHETER 3.5MM ID,120.251,CDM,272,RC,,,,4306-MAIN,LOCAL,,,,,363,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SET CRICOTHYROTOMY CATHETER 3.5MM ID,120.251,CDM,272,RC,,,,4306-MAIN,LOCAL,,,,,363,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SET CRICOTHYROTOMY CATHETER 3.5MM ID,120.251,CDM,272,RC,,,,4306-MAIN,LOCAL,,,,,363,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SET CRICOTHYROTOMY CATHETER 3.5MM ID,120.251,CDM,272,RC,,,,4306-MAIN,LOCAL,,,,,363,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SET CRICOTHYROTOMY CATHETER 3.5MM ID,120.251,CDM,272,RC,,,,4306-MAIN,LOCAL,,,,,363,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SET CRICOTHYROTOMY CATHETER 4MM ID,120.251,CDM,272,RC,,,,3452-MAIN,LOCAL,,,,,363,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SET CRICOTHYROTOMY CATHETER 4MM ID,120.251,CDM,272,RC,,,,3452-MAIN,LOCAL,,,,,363,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SET CRICOTHYROTOMY CATHETER 4MM ID,120.251,CDM,272,RC,,,,3452-MAIN,LOCAL,,,,,363,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SET CRICOTHYROTOMY CATHETER 4MM ID,120.251,CDM,272,RC,,,,3452-MAIN,LOCAL,,,,,363,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SET CRICOTHYROTOMY CATHETER 4MM ID,120.251,CDM,272,RC,,,,3452-MAIN,LOCAL,,,,,363,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SET CRICOTHYROTOMY CATHETER 4MM ID,120.251,CDM,272,RC,,,,3452-MAIN,LOCAL,,,,,363,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SET CRICOTHYROTOMY CATHETER 6MM ID,120.251,CDM,272,RC,,,,2887-MAIN,LOCAL,,,,,363,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SET CRICOTHYROTOMY CATHETER 6MM ID,120.251,CDM,272,RC,,,,2887-MAIN,LOCAL,,,,,363,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SET CRICOTHYROTOMY CATHETER 6MM ID,120.251,CDM,272,RC,,,,2887-MAIN,LOCAL,,,,,363,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SET CRICOTHYROTOMY CATHETER 6MM ID,120.251,CDM,272,RC,,,,2887-MAIN,LOCAL,,,,,363,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SET CRICOTHYROTOMY CATHETER 6MM ID,120.251,CDM,272,RC,,,,2887-MAIN,LOCAL,,,,,363,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SET CRICOTHYROTOMY CATHETER 6MM ID,120.251,CDM,272,RC,,,,2887-MAIN,LOCAL,,,,,363,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SET CRICOTHYROTOMY CATHETER 6MM ID,120.378,CDM,272,RC,,,,11119-MAIN,LOCAL,,,,,494,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SET CRICOTHYROTOMY CATHETER 6MM ID,120.378,CDM,272,RC,,,,11119-MAIN,LOCAL,,,,,494,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SET CRICOTHYROTOMY CATHETER 6MM ID,120.378,CDM,272,RC,,,,11119-MAIN,LOCAL,,,,,494,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SET CRICOTHYROTOMY CATHETER 6MM ID,120.378,CDM,272,RC,,,,11119-MAIN,LOCAL,,,,,494,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SET CRICOTHYROTOMY CATHETER 6MM ID,120.378,CDM,272,RC,,,,11119-MAIN,LOCAL,,,,,494,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SET CRICOTHYROTOMY CATHETER 6MM ID,120.378,CDM,272,RC,,,,11119-MAIN,LOCAL,,,,,494,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SET DISPOSABLE COLLECTION,27100000,CDM,271,RC,,,,5439-MAIN,LOCAL,,,,,30.6,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SET DISPOSABLE COLLECTION,27100000,CDM,271,RC,,,,5439-MAIN,LOCAL,,,,,30.6,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SET DISPOSABLE COLLECTION,27100000,CDM,271,RC,,,,5439-MAIN,LOCAL,,,,,30.6,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SET DISPOSABLE COLLECTION,27100000,CDM,271,RC,,,,5439-MAIN,LOCAL,,,,,30.6,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SET DISPOSABLE COLLECTION,27100000,CDM,271,RC,,,,5439-MAIN,LOCAL,,,,,30.6,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SET DISPOSABLE COLLECTION,27100000,CDM,271,RC,,,,5439-MAIN,LOCAL,,,,,30.6,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SET SP TUBE INTRODUCER  14CM 8-14FR G15469,120.377,CDM,272,RC,,,,7147-MAIN,LOCAL,,,,,227,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SET SP TUBE INTRODUCER  14CM 8-14FR G15469,120.377,CDM,272,RC,,,,7147-MAIN,LOCAL,,,,,227,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SET SP TUBE INTRODUCER  14CM 8-14FR G15469,120.377,CDM,272,RC,,,,7147-MAIN,LOCAL,,,,,227,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SET SP TUBE INTRODUCER  14CM 8-14FR G15469,120.377,CDM,272,RC,,,,7147-MAIN,LOCAL,,,,,227,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SET SP TUBE INTRODUCER  14CM 8-14FR G15469,120.377,CDM,272,RC,,,,7147-MAIN,LOCAL,,,,,227,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SET SP TUBE INTRODUCER  14CM 8-14FR G15469,120.377,CDM,272,RC,,,,7147-MAIN,LOCAL,,,,,227,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sevoflurane Solution 250 mL Bottle,25000000,CDM,250,RC,,,,,,66794001525,NDC,250,ML,589.56,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sevoflurane Solution 250 mL Bottle,25000000,CDM,250,RC,,,,,,66794001525,NDC,250,ML,589.56,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sevoflurane Solution 250 mL Bottle,25000000,CDM,250,RC,,,,,,66794001525,NDC,250,ML,589.56,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sevoflurane Solution 250 mL Bottle,25000000,CDM,250,RC,,,,,,66794001525,NDC,250,ML,589.56,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sevoflurane Solution 250 mL Bottle,25000000,CDM,250,RC,,,,,,66794001525,NDC,250,ML,589.56,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sevoflurane Solution 250 mL Bottle,25000000,CDM,250,RC,,,,,,66794001525,NDC,250,ML,589.56,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP LARGE MALE MQM3B,120.237,CDM,274,RC,L3260,HCPCS,,794-MAIN,LOCAL,,,,,76,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP LARGE MALE MQM3B,120.237,CDM,274,RC,L3260,HCPCS,,794-MAIN,LOCAL,,,,,76,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP LARGE MALE MQM3B,120.237,CDM,274,RC,L3260,HCPCS,,794-MAIN,LOCAL,,,,,76,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP LARGE MALE MQM3B,120.237,CDM,274,RC,L3260,HCPCS,,794-MAIN,LOCAL,,,,,76,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP LARGE MALE MQM3B,120.237,CDM,274,RC,L3260,HCPCS,,794-MAIN,LOCAL,,,,,76,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP LARGE MALE MQM3B,120.237,CDM,274,RC,L3260,HCPCS,,794-MAIN,LOCAL,,,,,76,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP LARGE SQUARE TOE WOMENS ORT30300WL,120.237,CDM,274,RC,L3260,HCPCS,,10606-MAIN,LOCAL,,,,,76,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP LARGE SQUARE TOE WOMENS ORT30300WL,120.237,CDM,274,RC,L3260,HCPCS,,10606-MAIN,LOCAL,,,,,76,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP LARGE SQUARE TOE WOMENS ORT30300WL,120.237,CDM,274,RC,L3260,HCPCS,,10606-MAIN,LOCAL,,,,,76,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP LARGE SQUARE TOE WOMENS ORT30300WL,120.237,CDM,274,RC,L3260,HCPCS,,10606-MAIN,LOCAL,,,,,76,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP LARGE SQUARE TOE WOMENS ORT30300WL,120.237,CDM,274,RC,L3260,HCPCS,,10606-MAIN,LOCAL,,,,,76,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP LARGE SQUARE TOE WOMENS ORT30300WL,120.237,CDM,274,RC,L3260,HCPCS,,10606-MAIN,LOCAL,,,,,76,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP MEDIUM SQUARE TOE MALE ORT30300MM,120.237,CDM,274,RC,L3260,HCPCS,,10603-MAIN,LOCAL,,,,,76,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP MEDIUM SQUARE TOE MALE ORT30300MM,120.237,CDM,274,RC,L3260,HCPCS,,10603-MAIN,LOCAL,,,,,76,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP MEDIUM SQUARE TOE MALE ORT30300MM,120.237,CDM,274,RC,L3260,HCPCS,,10603-MAIN,LOCAL,,,,,76,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP MEDIUM SQUARE TOE MALE ORT30300MM,120.237,CDM,274,RC,L3260,HCPCS,,10603-MAIN,LOCAL,,,,,76,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP MEDIUM SQUARE TOE MALE ORT30300MM,120.237,CDM,274,RC,L3260,HCPCS,,10603-MAIN,LOCAL,,,,,76,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP MEDIUM SQUARE TOE MALE ORT30300MM,120.237,CDM,274,RC,L3260,HCPCS,,10603-MAIN,LOCAL,,,,,76,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP MEDIUM SQUARE TOE WOMENS ORT30300WM,120.237,CDM,274,RC,L3260,HCPCS,,10605-MAIN,LOCAL,,,,,76,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP MEDIUM SQUARE TOE WOMENS ORT30300WM,120.237,CDM,274,RC,L3260,HCPCS,,10605-MAIN,LOCAL,,,,,76,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP MEDIUM SQUARE TOE WOMENS ORT30300WM,120.237,CDM,274,RC,L3260,HCPCS,,10605-MAIN,LOCAL,,,,,76,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP MEDIUM SQUARE TOE WOMENS ORT30300WM,120.237,CDM,274,RC,L3260,HCPCS,,10605-MAIN,LOCAL,,,,,76,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP MEDIUM SQUARE TOE WOMENS ORT30300WM,120.237,CDM,274,RC,L3260,HCPCS,,10605-MAIN,LOCAL,,,,,76,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP MEDIUM SQUARE TOE WOMENS ORT30300WM,120.237,CDM,274,RC,L3260,HCPCS,,10605-MAIN,LOCAL,,,,,76,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP SMALL MALE 0814-1192,120.237,CDM,274,RC,L3260,HCPCS,,803-MAIN,LOCAL,,,,,76,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP SMALL MALE 0814-1192,120.237,CDM,274,RC,L3260,HCPCS,,803-MAIN,LOCAL,,,,,76,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP SMALL MALE 0814-1192,120.237,CDM,274,RC,L3260,HCPCS,,803-MAIN,LOCAL,,,,,76,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP SMALL MALE 0814-1192,120.237,CDM,274,RC,L3260,HCPCS,,803-MAIN,LOCAL,,,,,76,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP SMALL MALE 0814-1192,120.237,CDM,274,RC,L3260,HCPCS,,803-MAIN,LOCAL,,,,,76,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP SMALL MALE 0814-1192,120.237,CDM,274,RC,L3260,HCPCS,,803-MAIN,LOCAL,,,,,76,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP SMALL SQUARE TOE WOMENS MQW1B,120.237,CDM,274,RC,L3260,HCPCS,,10604-MAIN,LOCAL,,,,,76,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP SMALL SQUARE TOE WOMENS MQW1B,120.237,CDM,274,RC,L3260,HCPCS,,10604-MAIN,LOCAL,,,,,76,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP SMALL SQUARE TOE WOMENS MQW1B,120.237,CDM,274,RC,L3260,HCPCS,,10604-MAIN,LOCAL,,,,,76,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP SMALL SQUARE TOE WOMENS MQW1B,120.237,CDM,274,RC,L3260,HCPCS,,10604-MAIN,LOCAL,,,,,76,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP SMALL SQUARE TOE WOMENS MQW1B,120.237,CDM,274,RC,L3260,HCPCS,,10604-MAIN,LOCAL,,,,,76,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP SMALL SQUARE TOE WOMENS MQW1B,120.237,CDM,274,RC,L3260,HCPCS,,10604-MAIN,LOCAL,,,,,76,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP X-LARGE MALE DS1016-16,120.237,CDM,274,RC,L3260,HCPCS,,6337-MAIN,LOCAL,,,,,35,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP X-LARGE MALE DS1016-16,120.237,CDM,274,RC,L3260,HCPCS,,6337-MAIN,LOCAL,,,,,35,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP X-LARGE MALE DS1016-16,120.237,CDM,274,RC,L3260,HCPCS,,6337-MAIN,LOCAL,,,,,35,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP X-LARGE MALE DS1016-16,120.237,CDM,274,RC,L3260,HCPCS,,6337-MAIN,LOCAL,,,,,35,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP X-LARGE MALE DS1016-16,120.237,CDM,274,RC,L3260,HCPCS,,6337-MAIN,LOCAL,,,,,35,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP X-LARGE MALE DS1016-16,120.237,CDM,274,RC,L3260,HCPCS,,6337-MAIN,LOCAL,,,,,35,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sigmoidoscope W/Submuc Inj,PX45335F,CDM,750,RC,45335,CPT,,,,,,,,750,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,661.5,6141.46
Sigmoidoscope W/Submuc Inj,PX45335F,CDM,750,RC,45335,CPT,,,,,,,,750,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,661.5,6141.46
Sigmoidoscope W/Submuc Inj,PX45335F,CDM,750,RC,45335,CPT,,,,,,,,750,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,661.5,6141.46
Sigmoidoscope W/Submuc Inj,PX45335F,CDM,750,RC,45335,CPT,,,,,,,,750,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,661.5,6141.46
Sigmoidoscope W/Submuc Inj,PX45335F,CDM,750,RC,45335,CPT,,,,,,,,750,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,661.5,6141.46
Sigmoidoscope W/Submuc Inj,PX45335F,CDM,750,RC,45335,CPT,,,,,,,,750,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,661.5,6141.46
Sigmoidoscope W/Submuc Inj,PX45335P,CDM,983,RC,45335,CPT,,,,,,,,500,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sigmoidoscope W/Submuc Inj,PX45335P,CDM,983,RC,45335,CPT,,,,,,,,500,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sigmoidoscope W/Submuc Inj,PX45335P,CDM,983,RC,45335,CPT,,,,,,,,500,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sigmoidoscope W/Submuc Inj,PX45335P,CDM,983,RC,45335,CPT,,,,,,,,500,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sigmoidoscope W/Submuc Inj,PX45335P,CDM,983,RC,45335,CPT,,,,,,,,500,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sigmoidoscope W/Submuc Inj,PX45335P,CDM,983,RC,45335,CPT,,,,,,,,500,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sigmoidoscopy,Biopsy",PX45331F,CDM,750,RC,45331,CPT,,,,,,,,1776,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1566.432,6141.46
"Sigmoidoscopy,Biopsy",PX45331F,CDM,750,RC,45331,CPT,,,,,,,,1776,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1566.432,6141.46
"Sigmoidoscopy,Biopsy",PX45331F,CDM,750,RC,45331,CPT,,,,,,,,1776,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1566.432,6141.46
"Sigmoidoscopy,Biopsy",PX45331F,CDM,750,RC,45331,CPT,,,,,,,,1776,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1566.432,6141.46
"Sigmoidoscopy,Biopsy",PX45331F,CDM,750,RC,45331,CPT,,,,,,,,1776,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1566.432,6141.46
"Sigmoidoscopy,Biopsy",PX45331F,CDM,750,RC,45331,CPT,,,,,,,,1776,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1566.432,6141.46
"Sigmoidoscopy,Biopsy",PX45331P,CDM,983,RC,45331,CPT,,,,,,,,1316,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sigmoidoscopy,Biopsy",PX45331P,CDM,983,RC,45331,CPT,,,,,,,,1316,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sigmoidoscopy,Biopsy",PX45331P,CDM,983,RC,45331,CPT,,,,,,,,1316,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sigmoidoscopy,Biopsy",PX45331P,CDM,983,RC,45331,CPT,,,,,,,,1316,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sigmoidoscopy,Biopsy",PX45331P,CDM,983,RC,45331,CPT,,,,,,,,1316,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sigmoidoscopy,Biopsy",PX45331P,CDM,983,RC,45331,CPT,,,,,,,,1316,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sigmoidoscopy,Diagnostic",PX45330F,CDM,510,RC,45330,CPT,,,,,,,,720,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sigmoidoscopy,Diagnostic",PX45330F,CDM,510,RC,45330,CPT,,,,,,,,720,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sigmoidoscopy,Diagnostic",PX45330F,CDM,510,RC,45330,CPT,,,,,,,,720,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sigmoidoscopy,Diagnostic",PX45330F,CDM,510,RC,45330,CPT,,,,,,,,720,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sigmoidoscopy,Diagnostic",PX45330F,CDM,510,RC,45330,CPT,,,,,,,,720,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sigmoidoscopy,Diagnostic",PX45330F,CDM,510,RC,45330,CPT,,,,,,,,720,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sigmoidoscopy,Diagnostic",PX45330P,CDM,983,RC,45330,CPT,,,,,,,,480,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sigmoidoscopy,Diagnostic",PX45330P,CDM,983,RC,45330,CPT,,,,,,,,480,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sigmoidoscopy,Diagnostic",PX45330P,CDM,983,RC,45330,CPT,,,,,,,,480,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sigmoidoscopy,Diagnostic",PX45330P,CDM,983,RC,45330,CPT,,,,,,,,480,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sigmoidoscopy,Diagnostic",PX45330P,CDM,983,RC,45330,CPT,,,,,,,,480,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sigmoidoscopy,Diagnostic",PX45330P,CDM,983,RC,45330,CPT,,,,,,,,480,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sigmoidoscopy,Remv Lesn,Snare",PX45338F,CDM,510,RC,45338,CPT,,,,,,,,2137,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sigmoidoscopy,Remv Lesn,Snare",PX45338F,CDM,510,RC,45338,CPT,,,,,,,,2137,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sigmoidoscopy,Remv Lesn,Snare",PX45338F,CDM,510,RC,45338,CPT,,,,,,,,2137,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sigmoidoscopy,Remv Lesn,Snare",PX45338F,CDM,510,RC,45338,CPT,,,,,,,,2137,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sigmoidoscopy,Remv Lesn,Snare",PX45338F,CDM,510,RC,45338,CPT,,,,,,,,2137,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sigmoidoscopy,Remv Lesn,Snare",PX45338F,CDM,510,RC,45338,CPT,,,,,,,,2137,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sigmoidoscopy,Remv Lesn,Snare",PX45338P,CDM,983,RC,45338,CPT,,,,,,,,1710,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sigmoidoscopy,Remv Lesn,Snare",PX45338P,CDM,983,RC,45338,CPT,,,,,,,,1710,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sigmoidoscopy,Remv Lesn,Snare",PX45338P,CDM,983,RC,45338,CPT,,,,,,,,1710,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sigmoidoscopy,Remv Lesn,Snare",PX45338P,CDM,983,RC,45338,CPT,,,,,,,,1710,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sigmoidoscopy,Remv Lesn,Snare",PX45338P,CDM,983,RC,45338,CPT,,,,,,,,1710,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sigmoidoscopy,Remv Lesn,Snare",PX45338P,CDM,983,RC,45338,CPT,,,,,,,,1710,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sigmoidoscopy,Screen Prev",PX2001F,CDM,750,RC,45330,CPT,,,,,,,,843,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,743.526,6141.46
"Sigmoidoscopy,Screen Prev",PX2001F,CDM,750,RC,45330,CPT,,,,,,,,843,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,743.526,6141.46
"Sigmoidoscopy,Screen Prev",PX2001F,CDM,750,RC,45330,CPT,,,,,,,,843,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,743.526,6141.46
"Sigmoidoscopy,Screen Prev",PX2001F,CDM,750,RC,45330,CPT,,,,,,,,843,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,743.526,6141.46
"Sigmoidoscopy,Screen Prev",PX2001F,CDM,750,RC,45330,CPT,,,,,,,,843,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,743.526,6141.46
"Sigmoidoscopy,Screen Prev",PX2001F,CDM,750,RC,45330,CPT,,,,,,,,843,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,743.526,6141.46
sildenafil citrate 20 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,65162035109,NDC,1,EA,95.41,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sildenafil citrate 20 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,65162035109,NDC,1,EA,95.41,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sildenafil citrate 20 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,65162035109,NDC,1,EA,95.41,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sildenafil citrate 20 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,65162035109,NDC,1,EA,95.41,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sildenafil citrate 20 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,65162035109,NDC,1,EA,95.41,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sildenafil citrate 20 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,65162035109,NDC,1,EA,95.41,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
silver nitrate - pot nitrate 75-25 % Misc 100 Each Package,63700001,CDM,250,RC,,,,,,12870000102,NDC,1,EA,3.58,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
silver nitrate - pot nitrate 75-25 % Misc 100 Each Package,63700001,CDM,250,RC,,,,,,12870000102,NDC,1,EA,3.58,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
silver nitrate - pot nitrate 75-25 % Misc 100 Each Package,63700001,CDM,250,RC,,,,,,12870000102,NDC,1,EA,3.58,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
silver nitrate - pot nitrate 75-25 % Misc 100 Each Package,63700001,CDM,250,RC,,,,,,12870000102,NDC,1,EA,3.58,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
silver nitrate - pot nitrate 75-25 % Misc 100 Each Package,63700001,CDM,250,RC,,,,,,12870000102,NDC,1,EA,3.58,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
silver nitrate - pot nitrate 75-25 % Misc 100 Each Package,63700001,CDM,250,RC,,,,,,12870000102,NDC,1,EA,3.58,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
silver sulfADIAZINE 1 % Cream 50 g Jar,25000000,CDM,250,RC,,,,,,43598021055,NDC,50,GR,83.89,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
silver sulfADIAZINE 1 % Cream 50 g Jar,25000000,CDM,250,RC,,,,,,43598021055,NDC,50,GR,83.89,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
silver sulfADIAZINE 1 % Cream 50 g Jar,25000000,CDM,250,RC,,,,,,43598021055,NDC,50,GR,83.89,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
silver sulfADIAZINE 1 % Cream 50 g Jar,25000000,CDM,250,RC,,,,,,43598021055,NDC,50,GR,83.89,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
silver sulfADIAZINE 1 % Cream 50 g Jar,25000000,CDM,250,RC,,,,,,43598021055,NDC,50,GR,83.89,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
silver sulfADIAZINE 1 % Cream 50 g Jar,25000000,CDM,250,RC,,,,,,43598021055,NDC,50,GR,83.89,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
simethicone 40 MG/0.6ML Suspension 30 mL Bottle,25000000,CDM,250,RC,,,,,,904589430,NDC,30,ML,22.39,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
simethicone 40 MG/0.6ML Suspension 30 mL Bottle,25000000,CDM,250,RC,,,,,,904589430,NDC,30,ML,22.39,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
simethicone 40 MG/0.6ML Suspension 30 mL Bottle,25000000,CDM,250,RC,,,,,,904589430,NDC,30,ML,22.39,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
simethicone 40 MG/0.6ML Suspension 30 mL Bottle,25000000,CDM,250,RC,,,,,,904589430,NDC,30,ML,22.39,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
simethicone 40 MG/0.6ML Suspension 30 mL Bottle,25000000,CDM,250,RC,,,,,,904589430,NDC,30,ML,22.39,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
simethicone 40 MG/0.6ML Suspension 30 mL Bottle,25000000,CDM,250,RC,,,,,,904589430,NDC,30,ML,22.39,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
simethicone 40 MG/0.6ML Suspension 30 mL Bottle,25000000,CDM,250,RC,,,,,,70677107801,NDC,30,ML,24.69,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
simethicone 40 MG/0.6ML Suspension 30 mL Bottle,25000000,CDM,250,RC,,,,,,70677107801,NDC,30,ML,24.69,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
simethicone 40 MG/0.6ML Suspension 30 mL Bottle,25000000,CDM,250,RC,,,,,,70677107801,NDC,30,ML,24.69,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
simethicone 40 MG/0.6ML Suspension 30 mL Bottle,25000000,CDM,250,RC,,,,,,70677107801,NDC,30,ML,24.69,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
simethicone 40 MG/0.6ML Suspension 30 mL Bottle,25000000,CDM,250,RC,,,,,,70677107801,NDC,30,ML,24.69,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
simethicone 40 MG/0.6ML Suspension 30 mL Bottle,25000000,CDM,250,RC,,,,,,70677107801,NDC,30,ML,24.69,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
simethicone 125 MG Tablet Chewable 18 Each Box,63700001,CDM,250,RC,,,,,,49348086348,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
simethicone 125 MG Tablet Chewable 18 Each Box,63700001,CDM,250,RC,,,,,,49348086348,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
simethicone 125 MG Tablet Chewable 18 Each Box,63700001,CDM,250,RC,,,,,,49348086348,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
simethicone 125 MG Tablet Chewable 18 Each Box,63700001,CDM,250,RC,,,,,,49348086348,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
simethicone 125 MG Tablet Chewable 18 Each Box,63700001,CDM,250,RC,,,,,,49348086348,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
simethicone 125 MG Tablet Chewable 18 Each Box,63700001,CDM,250,RC,,,,,,49348086348,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
simethicone 125 MG Tablet Chewable 60 Each Bottle,63700001,CDM,250,RC,,,,,,69618003206,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
simethicone 125 MG Tablet Chewable 60 Each Bottle,63700001,CDM,250,RC,,,,,,69618003206,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
simethicone 125 MG Tablet Chewable 60 Each Bottle,63700001,CDM,250,RC,,,,,,69618003206,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
simethicone 125 MG Tablet Chewable 60 Each Bottle,63700001,CDM,250,RC,,,,,,69618003206,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
simethicone 125 MG Tablet Chewable 60 Each Bottle,63700001,CDM,250,RC,,,,,,69618003206,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
simethicone 125 MG Tablet Chewable 60 Each Bottle,63700001,CDM,250,RC,,,,,,69618003206,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
simvastatin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739057010,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
simvastatin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739057010,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
simvastatin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739057010,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
simvastatin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739057010,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
simvastatin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739057010,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
simvastatin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739057010,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
simvastatin 10 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16714068202,NDC,0.5,EA,7.43,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
simvastatin 10 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16714068202,NDC,0.5,EA,7.43,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
simvastatin 10 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16714068202,NDC,0.5,EA,7.43,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
simvastatin 10 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16714068202,NDC,0.5,EA,7.43,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
simvastatin 10 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16714068202,NDC,0.5,EA,7.43,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
simvastatin 10 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16714068202,NDC,0.5,EA,7.43,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
simvastatin 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739057310,NDC,0.125,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
simvastatin 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739057310,NDC,0.125,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
simvastatin 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739057310,NDC,0.125,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
simvastatin 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739057310,NDC,0.125,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
simvastatin 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739057310,NDC,0.125,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
simvastatin 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739057310,NDC,0.125,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sincalide 5 MCG Recon Soln 1 Each Vial,J2805.01,CDM,636,RC,J2805,HCPCS,,,,270055615,NDC,1,EA,250,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sincalide 5 MCG Recon Soln 1 Each Vial,J2805.01,CDM,636,RC,J2805,HCPCS,,,,270055615,NDC,1,EA,250,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sincalide 5 MCG Recon Soln 1 Each Vial,J2805.01,CDM,636,RC,J2805,HCPCS,,,,270055615,NDC,1,EA,250,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sincalide 5 MCG Recon Soln 1 Each Vial,J2805.01,CDM,636,RC,J2805,HCPCS,,,,270055615,NDC,1,EA,250,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sincalide 5 MCG Recon Soln 1 Each Vial,J2805.01,CDM,636,RC,J2805,HCPCS,,,,270055615,NDC,1,EA,250,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sincalide 5 MCG Recon Soln 1 Each Vial,J2805.01,CDM,636,RC,J2805,HCPCS,,,,270055615,NDC,1,EA,250,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Skilled Srvc of a Lpn in Training and/or Education of Pt or Fam Ea 15 Min,PXG0496,CDM,551,RC,G0496,HCPCS,,,,,,,,75,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Skilled Srvc of a Lpn in Training and/or Education of Pt or Fam Ea 15 Min,PXG0496,CDM,551,RC,G0496,HCPCS,,,,,,,,75,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Skilled Srvc of a Lpn in Training and/or Education of Pt or Fam Ea 15 Min,PXG0496,CDM,551,RC,G0496,HCPCS,,,,,,,,75,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Skilled Srvc of a Lpn in Training and/or Education of Pt or Fam Ea 15 Min,PXG0496,CDM,551,RC,G0496,HCPCS,,,,,,,,75,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Skilled Srvc of a Lpn in Training and/or Education of Pt or Fam Ea 15 Min,PXG0496,CDM,551,RC,G0496,HCPCS,,,,,,,,75,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Skilled Srvc of a Lpn in Training and/or Education of Pt or Fam Ea 15 Min,PXG0496,CDM,551,RC,G0496,HCPCS,,,,,,,,75,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Skilled srvc of an RN in training and/or education of pt or fam ea 15 min,PXG0495,CDM,551,RC,G0495,HCPCS,,,,,,,,75,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Skilled srvc of an RN in training and/or education of pt or fam ea 15 min,PXG0495,CDM,551,RC,G0495,HCPCS,,,,,,,,75,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Skilled srvc of an RN in training and/or education of pt or fam ea 15 min,PXG0495,CDM,551,RC,G0495,HCPCS,,,,,,,,75,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Skilled srvc of an RN in training and/or education of pt or fam ea 15 min,PXG0495,CDM,551,RC,G0495,HCPCS,,,,,,,,75,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Skilled srvc of an RN in training and/or education of pt or fam ea 15 min,PXG0495,CDM,551,RC,G0495,HCPCS,,,,,,,,75,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Skilled srvc of an RN in training and/or education of pt or fam ea 15 min,PXG0495,CDM,551,RC,G0495,HCPCS,,,,,,,,75,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
skin oil Oil 236.6 mL Bottle,63700001,CDM,250,RC,,,,,,67211008,NDC,236.6,ML,40.61,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
skin oil Oil 236.6 mL Bottle,63700001,CDM,250,RC,,,,,,67211008,NDC,236.6,ML,40.61,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
skin oil Oil 236.6 mL Bottle,63700001,CDM,250,RC,,,,,,67211008,NDC,236.6,ML,40.61,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
skin oil Oil 236.6 mL Bottle,63700001,CDM,250,RC,,,,,,67211008,NDC,236.6,ML,40.61,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
skin oil Oil 236.6 mL Bottle,63700001,CDM,250,RC,,,,,,67211008,NDC,236.6,ML,40.61,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
skin oil Oil 236.6 mL Bottle,63700001,CDM,250,RC,,,,,,67211008,NDC,236.6,ML,40.61,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Skin Sub Graft Trnk/Arm/Leg,PX15271F,CDM,510,RC,15271,CPT,,,,,,,,862,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Skin Sub Graft Trnk/Arm/Leg,PX15271F,CDM,510,RC,15271,CPT,,,,,,,,862,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Skin Sub Graft Trnk/Arm/Leg,PX15271F,CDM,510,RC,15271,CPT,,,,,,,,862,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Skin Sub Graft Trnk/Arm/Leg,PX15271F,CDM,510,RC,15271,CPT,,,,,,,,862,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Skin Sub Graft Trnk/Arm/Leg,PX15271F,CDM,510,RC,15271,CPT,,,,,,,,862,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Skin Sub Graft Trnk/Arm/Leg,PX15271F,CDM,510,RC,15271,CPT,,,,,,,,862,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Skin Sub Graft Trnk/Arm/Leg,PX15271P,CDM,983,RC,15271,CPT,,,,,,,,705,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Skin Sub Graft Trnk/Arm/Leg,PX15271P,CDM,983,RC,15271,CPT,,,,,,,,705,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Skin Sub Graft Trnk/Arm/Leg,PX15271P,CDM,983,RC,15271,CPT,,,,,,,,705,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Skin Sub Graft Trnk/Arm/Leg,PX15271P,CDM,983,RC,15271,CPT,,,,,,,,705,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Skin Sub Graft Trnk/Arm/Leg,PX15271P,CDM,983,RC,15271,CPT,,,,,,,,705,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Skin Sub Graft Trnk/Arm/Leg,PX15271P,CDM,983,RC,15271,CPT,,,,,,,,705,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sleep Staging 4 + Pap,PX9581126,CDM,982,RC,95811,CPT,26,,,,,,,1850,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sleep Staging 4 + Pap,PX9581126,CDM,982,RC,95811,CPT,26,,,,,,,1850,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sleep Staging 4 + Pap,PX9581126,CDM,982,RC,95811,CPT,26,,,,,,,1850,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sleep Staging 4 + Pap,PX9581126,CDM,982,RC,95811,CPT,26,,,,,,,1850,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sleep Staging 4 + Pap,PX9581126,CDM,982,RC,95811,CPT,26,,,,,,,1850,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sleep Staging 4 + Pap,PX9581126,CDM,982,RC,95811,CPT,26,,,,,,,1850,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLEEVE ACHILLES LG/XL PROTECTION 92437145348,120.422,CDM,271,RC,,,,11378-MAIN,LOCAL,,,,,39,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLEEVE ACHILLES LG/XL PROTECTION 92437145348,120.422,CDM,271,RC,,,,11378-MAIN,LOCAL,,,,,39,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLEEVE ACHILLES LG/XL PROTECTION 92437145348,120.422,CDM,271,RC,,,,11378-MAIN,LOCAL,,,,,39,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLEEVE ACHILLES LG/XL PROTECTION 92437145348,120.422,CDM,271,RC,,,,11378-MAIN,LOCAL,,,,,39,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLEEVE ACHILLES LG/XL PROTECTION 92437145348,120.422,CDM,271,RC,,,,11378-MAIN,LOCAL,,,,,39,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLEEVE ACHILLES LG/XL PROTECTION 92437145348,120.422,CDM,271,RC,,,,11378-MAIN,LOCAL,,,,,39,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLEEVE ACHILLES SM/MED PROTECTION 92437145324,120.422,CDM,271,RC,,,,11377-MAIN,LOCAL,,,,,39,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLEEVE ACHILLES SM/MED PROTECTION 92437145324,120.422,CDM,271,RC,,,,11377-MAIN,LOCAL,,,,,39,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLEEVE ACHILLES SM/MED PROTECTION 92437145324,120.422,CDM,271,RC,,,,11377-MAIN,LOCAL,,,,,39,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLEEVE ACHILLES SM/MED PROTECTION 92437145324,120.422,CDM,271,RC,,,,11377-MAIN,LOCAL,,,,,39,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLEEVE ACHILLES SM/MED PROTECTION 92437145324,120.422,CDM,271,RC,,,,11377-MAIN,LOCAL,,,,,39,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLEEVE ACHILLES SM/MED PROTECTION 92437145324,120.422,CDM,271,RC,,,,11377-MAIN,LOCAL,,,,,39,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLEEVE BALLOON 5MMX100MML KII STERILE CFS02,27200000,CDM,272,RC,,,,11704-MAIN,LOCAL,,,,,24,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLEEVE BALLOON 5MMX100MML KII STERILE CFS02,27200000,CDM,272,RC,,,,11704-MAIN,LOCAL,,,,,24,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLEEVE BALLOON 5MMX100MML KII STERILE CFS02,27200000,CDM,272,RC,,,,11704-MAIN,LOCAL,,,,,24,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLEEVE BALLOON 5MMX100MML KII STERILE CFS02,27200000,CDM,272,RC,,,,11704-MAIN,LOCAL,,,,,24,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLEEVE BALLOON 5MMX100MML KII STERILE CFS02,27200000,CDM,272,RC,,,,11704-MAIN,LOCAL,,,,,24,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLEEVE BALLOON 5MMX100MML KII STERILE CFS02,27200000,CDM,272,RC,,,,11704-MAIN,LOCAL,,,,,24,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLING ARM CHILD PAD CANVAS NAVY 8004-02,120.54,CDM,273,RC,A4565,HCPCS,,878-MAIN,LOCAL,,,,,83,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLING ARM CHILD PAD CANVAS NAVY 8004-02,120.54,CDM,273,RC,A4565,HCPCS,,878-MAIN,LOCAL,,,,,83,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLING ARM CHILD PAD CANVAS NAVY 8004-02,120.54,CDM,273,RC,A4565,HCPCS,,878-MAIN,LOCAL,,,,,83,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLING ARM CHILD PAD CANVAS NAVY 8004-02,120.54,CDM,273,RC,A4565,HCPCS,,878-MAIN,LOCAL,,,,,83,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLING ARM CHILD PAD CANVAS NAVY 8004-02,120.54,CDM,273,RC,A4565,HCPCS,,878-MAIN,LOCAL,,,,,83,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLING ARM CHILD PAD CANVAS NAVY 8004-02,120.54,CDM,273,RC,A4565,HCPCS,,878-MAIN,LOCAL,,,,,83,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLING ARM LARGE PAD CANVAS NAVY ORT11300L,120.54,CDM,273,RC,A4565,HCPCS,,870-MAIN,LOCAL,,,,,83,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLING ARM LARGE PAD CANVAS NAVY ORT11300L,120.54,CDM,273,RC,A4565,HCPCS,,870-MAIN,LOCAL,,,,,83,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLING ARM LARGE PAD CANVAS NAVY ORT11300L,120.54,CDM,273,RC,A4565,HCPCS,,870-MAIN,LOCAL,,,,,83,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLING ARM LARGE PAD CANVAS NAVY ORT11300L,120.54,CDM,273,RC,A4565,HCPCS,,870-MAIN,LOCAL,,,,,83,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLING ARM LARGE PAD CANVAS NAVY ORT11300L,120.54,CDM,273,RC,A4565,HCPCS,,870-MAIN,LOCAL,,,,,83,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLING ARM LARGE PAD CANVAS NAVY ORT11300L,120.54,CDM,273,RC,A4565,HCPCS,,870-MAIN,LOCAL,,,,,83,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLING ARM MEDIUM PAD CANVAS NAVY ORT11300M,120.54,CDM,273,RC,A4565,HCPCS,,872-MAIN,LOCAL,,,,,83,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLING ARM MEDIUM PAD CANVAS NAVY ORT11300M,120.54,CDM,273,RC,A4565,HCPCS,,872-MAIN,LOCAL,,,,,83,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLING ARM MEDIUM PAD CANVAS NAVY ORT11300M,120.54,CDM,273,RC,A4565,HCPCS,,872-MAIN,LOCAL,,,,,83,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLING ARM MEDIUM PAD CANVAS NAVY ORT11300M,120.54,CDM,273,RC,A4565,HCPCS,,872-MAIN,LOCAL,,,,,83,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLING ARM MEDIUM PAD CANVAS NAVY ORT11300M,120.54,CDM,273,RC,A4565,HCPCS,,872-MAIN,LOCAL,,,,,83,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLING ARM MEDIUM PAD CANVAS NAVY ORT11300M,120.54,CDM,273,RC,A4565,HCPCS,,872-MAIN,LOCAL,,,,,83,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLING ARM SMALL PAD CANVAS NAVY ORT11300S,120.54,CDM,273,RC,A4565,HCPCS,,874-MAIN,LOCAL,,,,,83,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLING ARM SMALL PAD CANVAS NAVY ORT11300S,120.54,CDM,273,RC,A4565,HCPCS,,874-MAIN,LOCAL,,,,,83,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLING ARM SMALL PAD CANVAS NAVY ORT11300S,120.54,CDM,273,RC,A4565,HCPCS,,874-MAIN,LOCAL,,,,,83,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLING ARM SMALL PAD CANVAS NAVY ORT11300S,120.54,CDM,273,RC,A4565,HCPCS,,874-MAIN,LOCAL,,,,,83,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLING ARM SMALL PAD CANVAS NAVY ORT11300S,120.54,CDM,273,RC,A4565,HCPCS,,874-MAIN,LOCAL,,,,,83,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLING ARM SMALL PAD CANVAS NAVY ORT11300S,120.54,CDM,273,RC,A4565,HCPCS,,874-MAIN,LOCAL,,,,,83,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLING ARM X-LARGE PAD ENVELOPE ORT11300XL,120.54,CDM,273,RC,A4565,HCPCS,,876-MAIN,LOCAL,,,,,83,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLING ARM X-LARGE PAD ENVELOPE ORT11300XL,120.54,CDM,273,RC,A4565,HCPCS,,876-MAIN,LOCAL,,,,,83,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLING ARM X-LARGE PAD ENVELOPE ORT11300XL,120.54,CDM,273,RC,A4565,HCPCS,,876-MAIN,LOCAL,,,,,83,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLING ARM X-LARGE PAD ENVELOPE ORT11300XL,120.54,CDM,273,RC,A4565,HCPCS,,876-MAIN,LOCAL,,,,,83,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLING ARM X-LARGE PAD ENVELOPE ORT11300XL,120.54,CDM,273,RC,A4565,HCPCS,,876-MAIN,LOCAL,,,,,83,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLING ARM X-LARGE PAD ENVELOPE ORT11300XL,120.54,CDM,273,RC,A4565,HCPCS,,876-MAIN,LOCAL,,,,,83,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SMALL HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12655-MAIN,LOCAL,,,,,3905,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SMALL HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12655-MAIN,LOCAL,,,,,3905,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SMALL HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12655-MAIN,LOCAL,,,,,3905,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SMALL HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12655-MAIN,LOCAL,,,,,3905,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SMALL HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12655-MAIN,LOCAL,,,,,3905,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SMALL HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12655-MAIN,LOCAL,,,,,3905,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Smear Fluorescent/Acid Stai,PX87206,CDM,300,RC,87206,CPT,,,,,,,,155,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Smear Fluorescent/Acid Stai,PX87206,CDM,300,RC,87206,CPT,,,,,,,,155,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Smear Fluorescent/Acid Stai,PX87206,CDM,300,RC,87206,CPT,,,,,,,,155,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Smear Fluorescent/Acid Stai,PX87206,CDM,300,RC,87206,CPT,,,,,,,,155,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Smear Fluorescent/Acid Stai,PX87206,CDM,300,RC,87206,CPT,,,,,,,,155,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Smear Fluorescent/Acid Stai,PX87206,CDM,300,RC,87206,CPT,,,,,,,,155,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Smear Gram Stain,PX87205,CDM,300,RC,87205,CPT,,,,,,,,109,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Smear Gram Stain,PX87205,CDM,300,RC,87205,CPT,,,,,,,,109,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Smear Gram Stain,PX87205,CDM,300,RC,87205,CPT,,,,,,,,109,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Smear Gram Stain,PX87205,CDM,300,RC,87205,CPT,,,,,,,,109,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Smear Gram Stain,PX87205,CDM,300,RC,87205,CPT,,,,,,,,109,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Smear Gram Stain,PX87205,CDM,300,RC,87205,CPT,,,,,,,,109,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Smear Special Stain,PX87207,CDM,300,RC,87207,CPT,,,,,,,,81,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Smear Special Stain,PX87207,CDM,300,RC,87207,CPT,,,,,,,,81,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Smear Special Stain,PX87207,CDM,300,RC,87207,CPT,,,,,,,,81,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Smear Special Stain,PX87207,CDM,300,RC,87207,CPT,,,,,,,,81,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Smear Special Stain,PX87207,CDM,300,RC,87207,CPT,,,,,,,,81,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Smear Special Stain,PX87207,CDM,300,RC,87207,CPT,,,,,,,,81,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Smear Wet Mount Saline/Ink,PX87210,CDM,300,RC,87210,CPT,,,,,,,,109,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Smear Wet Mount Saline/Ink,PX87210,CDM,300,RC,87210,CPT,,,,,,,,109,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Smear Wet Mount Saline/Ink,PX87210,CDM,300,RC,87210,CPT,,,,,,,,109,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Smear Wet Mount Saline/Ink,PX87210,CDM,300,RC,87210,CPT,,,,,,,,109,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Smear Wet Mount Saline/Ink,PX87210,CDM,300,RC,87210,CPT,,,,,,,,109,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Smear Wet Mount Saline/Ink,PX87210,CDM,300,RC,87210,CPT,,,,,,,,109,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Smking Cess 4-10 Min,PX99406F,CDM,942,RC,99406,CPT,,,,,,,,65,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Smking Cess 4-10 Min,PX99406F,CDM,942,RC,99406,CPT,,,,,,,,65,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Smking Cess 4-10 Min,PX99406F,CDM,942,RC,99406,CPT,,,,,,,,65,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Smking Cess 4-10 Min,PX99406F,CDM,942,RC,99406,CPT,,,,,,,,65,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Smking Cess 4-10 Min,PX99406F,CDM,942,RC,99406,CPT,,,,,,,,65,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Smking Cess 4-10 Min,PX99406F,CDM,942,RC,99406,CPT,,,,,,,,65,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Smking Cess 4-10 Min,PX99406P,CDM,983,RC,99406,CPT,,,,,,,,43,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Smking Cess 4-10 Min,PX99406P,CDM,983,RC,99406,CPT,,,,,,,,43,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Smking Cess 4-10 Min,PX99406P,CDM,983,RC,99406,CPT,,,,,,,,43,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Smking Cess 4-10 Min,PX99406P,CDM,983,RC,99406,CPT,,,,,,,,43,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Smking Cess 4-10 Min,PX99406P,CDM,983,RC,99406,CPT,,,,,,,,43,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Smking Cess 4-10 Min,PX99406P,CDM,983,RC,99406,CPT,,,,,,,,43,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sod citrate-citric acid 500-334 MG/5ML Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,121059516,NDC,473,ML,95.87,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sod citrate-citric acid 500-334 MG/5ML Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,121059516,NDC,473,ML,95.87,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sod citrate-citric acid 500-334 MG/5ML Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,121059516,NDC,473,ML,95.87,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sod citrate-citric acid 500-334 MG/5ML Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,121059516,NDC,473,ML,95.87,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sod citrate-citric acid 500-334 MG/5ML Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,121059516,NDC,473,ML,95.87,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sod citrate-citric acid 500-334 MG/5ML Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,121059516,NDC,473,ML,95.87,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium bicarbonate 4.2 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409553434,NDC,10,ML,91.46,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium bicarbonate 4.2 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409553434,NDC,10,ML,91.46,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium bicarbonate 4.2 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409553434,NDC,10,ML,91.46,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium bicarbonate 4.2 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409553434,NDC,10,ML,91.46,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium bicarbonate 4.2 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409553434,NDC,10,ML,91.46,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium bicarbonate 4.2 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409553434,NDC,10,ML,91.46,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409663724,NDC,50,ML,115.32,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409663724,NDC,50,ML,115.32,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409663724,NDC,50,ML,115.32,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409663724,NDC,50,ML,115.32,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409663724,NDC,50,ML,115.32,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409663724,NDC,50,ML,115.32,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409663734,NDC,50,ML,89.7,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409663734,NDC,50,ML,89.7,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409663734,NDC,50,ML,89.7,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409663734,NDC,50,ML,89.7,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409663734,NDC,50,ML,89.7,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409663734,NDC,50,ML,89.7,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329335201,NDC,50,ML,109.26,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329335201,NDC,50,ML,109.26,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329335201,NDC,50,ML,109.26,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329335201,NDC,50,ML,109.26,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329335201,NDC,50,ML,109.26,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329335201,NDC,50,ML,109.26,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium bicarbonate 8.4 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409662502,NDC,50,ML,84.47,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium bicarbonate 8.4 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409662502,NDC,50,ML,84.47,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium bicarbonate 8.4 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409662502,NDC,50,ML,84.47,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium bicarbonate 8.4 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409662502,NDC,50,ML,84.47,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium bicarbonate 8.4 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409662502,NDC,50,ML,84.47,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium bicarbonate 8.4 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409662502,NDC,50,ML,84.47,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium bicarbonate 8.4 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409662522,NDC,50,ML,85.02,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium bicarbonate 8.4 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409662522,NDC,50,ML,85.02,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium bicarbonate 8.4 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409662522,NDC,50,ML,85.02,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium bicarbonate 8.4 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409662522,NDC,50,ML,85.02,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium bicarbonate 8.4 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409662522,NDC,50,ML,85.02,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium bicarbonate 8.4 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409662522,NDC,50,ML,85.02,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium bicarbonate 650 MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64980018210,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium bicarbonate 650 MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64980018210,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium bicarbonate 650 MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64980018210,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium bicarbonate 650 MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64980018210,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium bicarbonate 650 MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64980018210,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium bicarbonate 650 MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64980018210,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium bicarbonate 650 MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64980052810,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium bicarbonate 650 MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64980052810,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium bicarbonate 650 MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64980052810,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium bicarbonate 650 MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64980052810,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium bicarbonate 650 MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64980052810,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium bicarbonate 650 MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64980052810,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9 % 0.9 % Solution 50 mL Flex Cont,J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004941,NDC,50,ML,43.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9 % 0.9 % Solution 50 mL Flex Cont,J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004941,NDC,50,ML,43.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9 % 0.9 % Solution 50 mL Flex Cont,J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004941,NDC,50,ML,43.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9 % 0.9 % Solution 50 mL Flex Cont,J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004941,NDC,50,ML,43.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9 % 0.9 % Solution 50 mL Flex Cont,J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004941,NDC,50,ML,43.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9 % 0.9 % Solution 50 mL Flex Cont,J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004941,NDC,50,ML,43.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338069104,NDC,1000,ML,99.12,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338069104,NDC,1000,ML,99.12,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338069104,NDC,1000,ML,99.12,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338069104,NDC,1000,ML,99.12,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338069104,NDC,1000,ML,99.12,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338069104,NDC,1000,ML,99.12,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990711509,NDC,1000,ML,64.08,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990711509,NDC,1000,ML,64.08,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990711509,NDC,1000,ML,64.08,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990711509,NDC,1000,ML,64.08,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990711509,NDC,1000,ML,64.08,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990711509,NDC,1000,ML,64.08,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9 % Nebulization Solution 3 mL Plas Cont,63700001,CDM,250,RC,,,,,,487930133,NDC,3,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9 % Nebulization Solution 3 mL Plas Cont,63700001,CDM,250,RC,,,,,,487930133,NDC,3,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9 % Nebulization Solution 3 mL Plas Cont,63700001,CDM,250,RC,,,,,,487930133,NDC,3,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9 % Nebulization Solution 3 mL Plas Cont,63700001,CDM,250,RC,,,,,,487930133,NDC,3,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9 % Nebulization Solution 3 mL Plas Cont,63700001,CDM,250,RC,,,,,,487930133,NDC,3,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9 % Nebulization Solution 3 mL Plas Cont,63700001,CDM,250,RC,,,,,,487930133,NDC,3,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Syringe,J7040.01,CDM,636,RC,J7040,HCPCS,,,,64253020230,NDC,10,ML,42.15,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Syringe,J7040.01,CDM,636,RC,J7040,HCPCS,,,,64253020230,NDC,10,ML,42.15,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Syringe,J7040.01,CDM,636,RC,J7040,HCPCS,,,,64253020230,NDC,10,ML,42.15,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Syringe,J7040.01,CDM,636,RC,J7040,HCPCS,,,,64253020230,NDC,10,ML,42.15,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Syringe,J7040.01,CDM,636,RC,J7040,HCPCS,,,,64253020230,NDC,10,ML,42.15,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Syringe,J7040.01,CDM,636,RC,J7040,HCPCS,,,,64253020230,NDC,10,ML,42.15,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488802,NDC,10,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488802,NDC,10,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488802,NDC,10,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488802,NDC,10,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488802,NDC,10,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488802,NDC,10,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018603,NDC,20,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018603,NDC,20,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018603,NDC,20,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018603,NDC,20,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018603,NDC,20,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018603,NDC,20,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018620,NDC,20,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018620,NDC,20,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018620,NDC,20,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018620,NDC,20,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018620,NDC,20,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018620,NDC,20,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9 % PF 0.9 % Solution 50 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488850,NDC,3,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9 % PF 0.9 % Solution 50 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488850,NDC,3,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9 % PF 0.9 % Solution 50 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488850,NDC,3,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9 % PF 0.9 % Solution 50 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488850,NDC,3,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9 % PF 0.9 % Solution 50 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488850,NDC,3,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9 % PF 0.9 % Solution 50 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488850,NDC,3,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004904,NDC,1000,ML,99.12,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004904,NDC,1000,ML,99.12,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004904,NDC,1000,ML,99.12,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004904,NDC,1000,ML,99.12,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004904,NDC,1000,ML,99.12,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004904,NDC,1000,ML,99.12,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954306,NDC,1000,ML,99.12,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954306,NDC,1000,ML,99.12,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954306,NDC,1000,ML,99.12,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954306,NDC,1000,ML,99.12,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954306,NDC,1000,ML,99.12,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954306,NDC,1000,ML,99.12,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004941,NDC,250,ML,43.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004941,NDC,250,ML,43.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004941,NDC,250,ML,43.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004941,NDC,250,ML,43.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004941,NDC,250,ML,43.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004941,NDC,250,ML,43.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055311,NDC,250,ML,43.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055311,NDC,250,ML,43.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055311,NDC,250,ML,43.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055311,NDC,250,ML,43.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055311,NDC,250,ML,43.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055311,NDC,250,ML,43.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004948,NDC,300,ML,43.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004948,NDC,300,ML,43.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004948,NDC,300,ML,43.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004948,NDC,300,ML,43.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004948,NDC,300,ML,43.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004948,NDC,300,ML,43.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055318,NDC,300,ML,43.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055318,NDC,300,ML,43.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055318,NDC,300,ML,43.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055318,NDC,300,ML,43.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055318,NDC,300,ML,43.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055318,NDC,300,ML,43.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 150 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,409798361,NDC,300,ML,43.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 150 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,409798361,NDC,300,ML,43.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 150 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,409798361,NDC,300,ML,43.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 150 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,409798361,NDC,300,ML,43.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 150 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,409798361,NDC,300,ML,43.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 150 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,409798361,NDC,300,ML,43.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004902,NDC,250,ML,99.12,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004902,NDC,250,ML,99.12,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004902,NDC,250,ML,99.12,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004902,NDC,250,ML,99.12,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004902,NDC,250,ML,99.12,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004902,NDC,250,ML,99.12,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954302,NDC,250,ML,99.12,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954302,NDC,250,ML,99.12,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954302,NDC,250,ML,99.12,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954302,NDC,250,ML,99.12,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954302,NDC,250,ML,99.12,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954302,NDC,250,ML,99.12,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 500 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004903,NDC,500,ML,99.12,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 500 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004903,NDC,500,ML,99.12,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 500 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004903,NDC,500,ML,99.12,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 500 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004903,NDC,500,ML,99.12,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 500 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004903,NDC,500,ML,99.12,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 500 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004903,NDC,500,ML,99.12,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.9% 0.9% Solution 1,000 mL Flex Cont",J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004904,NDC,1000,ML,99.12,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.9% 0.9% Solution 1,000 mL Flex Cont",J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004904,NDC,1000,ML,99.12,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.9% 0.9% Solution 1,000 mL Flex Cont",J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004904,NDC,1000,ML,99.12,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.9% 0.9% Solution 1,000 mL Flex Cont",J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004904,NDC,1000,ML,99.12,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.9% 0.9% Solution 1,000 mL Flex Cont",J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004904,NDC,1000,ML,99.12,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.9% 0.9% Solution 1,000 mL Flex Cont",J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004904,NDC,1000,ML,99.12,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.9% irrigation 0.9 % Solution 3,000 mL Plas Cont",25000000,CDM,250,RC,,,,,,338004727,NDC,3000,ML,43.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.9% irrigation 0.9 % Solution 3,000 mL Plas Cont",25000000,CDM,250,RC,,,,,,338004727,NDC,3000,ML,43.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.9% irrigation 0.9 % Solution 3,000 mL Plas Cont",25000000,CDM,250,RC,,,,,,338004727,NDC,3000,ML,43.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.9% irrigation 0.9 % Solution 3,000 mL Plas Cont",25000000,CDM,250,RC,,,,,,338004727,NDC,3000,ML,43.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.9% irrigation 0.9 % Solution 3,000 mL Plas Cont",25000000,CDM,250,RC,,,,,,338004727,NDC,3000,ML,43.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.9% irrigation 0.9 % Solution 3,000 mL Plas Cont",25000000,CDM,250,RC,,,,,,338004727,NDC,3000,ML,43.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% IV FLUSH 0.9 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,8881570121,NDC,2.5,ML,4.8,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% IV FLUSH 0.9 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,8881570121,NDC,2.5,ML,4.8,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% IV FLUSH 0.9 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,8881570121,NDC,2.5,ML,4.8,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% IV FLUSH 0.9 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,8881570121,NDC,2.5,ML,4.8,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% IV FLUSH 0.9 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,8881570121,NDC,2.5,ML,4.8,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% IV FLUSH 0.9 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,8881570121,NDC,2.5,ML,4.8,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% IV FLUSH 0.9 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,63807010001,NDC,2.5,ML,4.8,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% IV FLUSH 0.9 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,63807010001,NDC,2.5,ML,4.8,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% IV FLUSH 0.9 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,63807010001,NDC,2.5,ML,4.8,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% IV FLUSH 0.9 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,63807010001,NDC,2.5,ML,4.8,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% IV FLUSH 0.9 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,63807010001,NDC,2.5,ML,4.8,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% IV FLUSH 0.9 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,63807010001,NDC,2.5,ML,4.8,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% IV LINE FLUSH 0.9% Solution 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,338004948,NDC,100,ML,43.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% IV LINE FLUSH 0.9% Solution 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,338004948,NDC,100,ML,43.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% IV LINE FLUSH 0.9% Solution 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,338004948,NDC,100,ML,43.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% IV LINE FLUSH 0.9% Solution 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,338004948,NDC,100,ML,43.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% IV LINE FLUSH 0.9% Solution 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,338004948,NDC,100,ML,43.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% IV LINE FLUSH 0.9% Solution 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,338004948,NDC,100,ML,43.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% IV LINE FLUSH 0.9% Solution 250 mL Flex Cont,25000000,CDM,250,RC,,,,,,338004902,NDC,250,ML,99.12,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% IV LINE FLUSH 0.9% Solution 250 mL Flex Cont,25000000,CDM,250,RC,,,,,,338004902,NDC,250,ML,99.12,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% IV LINE FLUSH 0.9% Solution 250 mL Flex Cont,25000000,CDM,250,RC,,,,,,338004902,NDC,250,ML,99.12,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% IV LINE FLUSH 0.9% Solution 250 mL Flex Cont,25000000,CDM,250,RC,,,,,,338004902,NDC,250,ML,99.12,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% IV LINE FLUSH 0.9% Solution 250 mL Flex Cont,25000000,CDM,250,RC,,,,,,338004902,NDC,250,ML,99.12,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% IV LINE FLUSH 0.9% Solution 250 mL Flex Cont,25000000,CDM,250,RC,,,,,,338004902,NDC,250,ML,99.12,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.45 % 0.45 % Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,338004304,NDC,1000,ML,99.12,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.45 % 0.45 % Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,338004304,NDC,1000,ML,99.12,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.45 % 0.45 % Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,338004304,NDC,1000,ML,99.12,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.45 % 0.45 % Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,338004304,NDC,1000,ML,99.12,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.45 % 0.45 % Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,338004304,NDC,1000,ML,99.12,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.45 % 0.45 % Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,338004304,NDC,1000,ML,99.12,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.45 % 1,000 mL with potassium chloride 20 mEq 20-0.45 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070434,NDC,1000,ML,58.57,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.45 % 1,000 mL with potassium chloride 20 mEq 20-0.45 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070434,NDC,1000,ML,58.57,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.45 % 1,000 mL with potassium chloride 20 mEq 20-0.45 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070434,NDC,1000,ML,58.57,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.45 % 1,000 mL with potassium chloride 20 mEq 20-0.45 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070434,NDC,1000,ML,58.57,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.45 % 1,000 mL with potassium chloride 20 mEq 20-0.45 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070434,NDC,1000,ML,58.57,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.45 % 1,000 mL with potassium chloride 20 mEq 20-0.45 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070434,NDC,1000,ML,58.57,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.65 % Solution 44 mL Bottle,63700001,CDM,250,RC,,,,,,904386575,NDC,44,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.65 % Solution 44 mL Bottle,63700001,CDM,250,RC,,,,,,904386575,NDC,44,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.65 % Solution 44 mL Bottle,63700001,CDM,250,RC,,,,,,904386575,NDC,44,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.65 % Solution 44 mL Bottle,63700001,CDM,250,RC,,,,,,904386575,NDC,44,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.65 % Solution 44 mL Bottle,63700001,CDM,250,RC,,,,,,904386575,NDC,44,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.65 % Solution 44 mL Bottle,63700001,CDM,250,RC,,,,,,904386575,NDC,44,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,223176001,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,223176001,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,223176001,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,223176001,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,223176001,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,223176001,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 3 % 3 % Solution 500 mL Flex Cont,J7131.01,CDM,636,RC,J7131,HCPCS,,,,338005403,NDC,500,ML,99.12,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 3 % 3 % Solution 500 mL Flex Cont,J7131.01,CDM,636,RC,J7131,HCPCS,,,,338005403,NDC,500,ML,99.12,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 3 % 3 % Solution 500 mL Flex Cont,J7131.01,CDM,636,RC,J7131,HCPCS,,,,338005403,NDC,500,ML,99.12,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 3 % 3 % Solution 500 mL Flex Cont,J7131.01,CDM,636,RC,J7131,HCPCS,,,,338005403,NDC,500,ML,99.12,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 3 % 3 % Solution 500 mL Flex Cont,J7131.01,CDM,636,RC,J7131,HCPCS,,,,338005403,NDC,500,ML,99.12,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 3 % 3 % Solution 500 mL Flex Cont,J7131.01,CDM,636,RC,J7131,HCPCS,,,,338005403,NDC,500,ML,99.12,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride bacteriostatic 0.9 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409196602,NDC,30,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride bacteriostatic 0.9 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409196602,NDC,30,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride bacteriostatic 0.9 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409196602,NDC,30,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride bacteriostatic 0.9 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409196602,NDC,30,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride bacteriostatic 0.9 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409196602,NDC,30,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride bacteriostatic 0.9 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409196602,NDC,30,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride bacteriostatic 0.9 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409196607,NDC,30,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride bacteriostatic 0.9 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409196607,NDC,30,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride bacteriostatic 0.9 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409196607,NDC,30,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride bacteriostatic 0.9 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409196607,NDC,30,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride bacteriostatic 0.9 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409196607,NDC,30,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride bacteriostatic 0.9 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409196607,NDC,30,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279210,NDC,10,ML,429.84,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279210,NDC,10,ML,429.84,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279210,NDC,10,ML,429.84,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279210,NDC,10,ML,429.84,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279210,NDC,10,ML,429.84,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279210,NDC,10,ML,429.84,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279410,NDC,10,ML,429.84,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279410,NDC,10,ML,429.84,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279410,NDC,10,ML,429.84,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279410,NDC,10,ML,429.84,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279410,NDC,10,ML,429.84,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279410,NDC,10,ML,429.84,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,436067216,NDC,473,ML,77.23,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,436067216,NDC,473,ML,77.23,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,436067216,NDC,473,ML,77.23,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,436067216,NDC,473,ML,77.23,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,436067216,NDC,473,ML,77.23,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,436067216,NDC,473,ML,77.23,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,39328006412,NDC,473,ML,77.23,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,39328006412,NDC,473,ML,77.23,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,39328006412,NDC,473,ML,77.23,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,39328006412,NDC,473,ML,77.23,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,39328006412,NDC,473,ML,77.23,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,39328006412,NDC,473,ML,77.23,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,39328006712,NDC,473,ML,167.77,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,39328006712,NDC,473,ML,167.77,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,39328006712,NDC,473,ML,167.77,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,39328006712,NDC,473,ML,167.77,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,39328006712,NDC,473,ML,167.77,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,39328006712,NDC,473,ML,167.77,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium phosphate 7-19 GM/118ML Enema 133 mL Bottle,63700001,CDM,250,RC,,,,,,132020140,NDC,133,ML,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium phosphate 7-19 GM/118ML Enema 133 mL Bottle,63700001,CDM,250,RC,,,,,,132020140,NDC,133,ML,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium phosphate 7-19 GM/118ML Enema 133 mL Bottle,63700001,CDM,250,RC,,,,,,132020140,NDC,133,ML,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium phosphate 7-19 GM/118ML Enema 133 mL Bottle,63700001,CDM,250,RC,,,,,,132020140,NDC,133,ML,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium phosphate 7-19 GM/118ML Enema 133 mL Bottle,63700001,CDM,250,RC,,,,,,132020140,NDC,133,ML,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium phosphate 7-19 GM/118ML Enema 133 mL Bottle,63700001,CDM,250,RC,,,,,,132020140,NDC,133,ML,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium phosphate 15 MMOLE/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323088401,NDC,5,ML,132.6,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium phosphate 15 MMOLE/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323088401,NDC,5,ML,132.6,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium phosphate 15 MMOLE/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323088401,NDC,5,ML,132.6,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium phosphate 15 MMOLE/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323088401,NDC,5,ML,132.6,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium phosphate 15 MMOLE/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323088401,NDC,5,ML,132.6,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium phosphate 15 MMOLE/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323088401,NDC,5,ML,132.6,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium phosphate 15 MMOLE/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323088406,NDC,5,ML,132.6,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium phosphate 15 MMOLE/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323088406,NDC,5,ML,132.6,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium phosphate 15 MMOLE/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323088406,NDC,5,ML,132.6,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium phosphate 15 MMOLE/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323088406,NDC,5,ML,132.6,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium phosphate 15 MMOLE/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323088406,NDC,5,ML,132.6,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium phosphate 15 MMOLE/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323088406,NDC,5,ML,132.6,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium polystyrene sulfonate 15 GM/60ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,46287000660,NDC,60,ML,123.3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium polystyrene sulfonate 15 GM/60ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,46287000660,NDC,60,ML,123.3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium polystyrene sulfonate 15 GM/60ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,46287000660,NDC,60,ML,123.3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium polystyrene sulfonate 15 GM/60ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,46287000660,NDC,60,ML,123.3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium polystyrene sulfonate 15 GM/60ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,46287000660,NDC,60,ML,123.3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium polystyrene sulfonate 15 GM/60ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,46287000660,NDC,60,ML,123.3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium polystyrene sulfonate Powder 15 g Bottle,25000000,CDM,250,RC,,,,,,10702003615,NDC,15,GR,76.09,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium polystyrene sulfonate Powder 15 g Bottle,25000000,CDM,250,RC,,,,,,10702003615,NDC,15,GR,76.09,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium polystyrene sulfonate Powder 15 g Bottle,25000000,CDM,250,RC,,,,,,10702003615,NDC,15,GR,76.09,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium polystyrene sulfonate Powder 15 g Bottle,25000000,CDM,250,RC,,,,,,10702003615,NDC,15,GR,76.09,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium polystyrene sulfonate Powder 15 g Bottle,25000000,CDM,250,RC,,,,,,10702003615,NDC,15,GR,76.09,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium polystyrene sulfonate Powder 15 g Bottle,25000000,CDM,250,RC,,,,,,10702003615,NDC,15,GR,76.09,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium thiosulfate 250 MG/ML Solution 50 mL Vial,J0209.01,CDM,636,RC,J0209,HCPCS,,,,60267070550,NDC,50,ML,609.57,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium thiosulfate 250 MG/ML Solution 50 mL Vial,J0209.01,CDM,636,RC,J0209,HCPCS,,,,60267070550,NDC,50,ML,609.57,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium thiosulfate 250 MG/ML Solution 50 mL Vial,J0209.01,CDM,636,RC,J0209,HCPCS,,,,60267070550,NDC,50,ML,609.57,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium thiosulfate 250 MG/ML Solution 50 mL Vial,J0209.01,CDM,636,RC,J0209,HCPCS,,,,60267070550,NDC,50,ML,609.57,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium thiosulfate 250 MG/ML Solution 50 mL Vial,J0209.01,CDM,636,RC,J0209,HCPCS,,,,60267070550,NDC,50,ML,609.57,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium thiosulfate 250 MG/ML Solution 50 mL Vial,J0209.01,CDM,636,RC,J0209,HCPCS,,,,60267070550,NDC,50,ML,609.57,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium zirconium cyclosilicate 5 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,310110501,NDC,1,EA,151.95,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium zirconium cyclosilicate 5 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,310110501,NDC,1,EA,151.95,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium zirconium cyclosilicate 5 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,310110501,NDC,1,EA,151.95,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium zirconium cyclosilicate 5 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,310110501,NDC,1,EA,151.95,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium zirconium cyclosilicate 5 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,310110501,NDC,1,EA,151.95,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium zirconium cyclosilicate 5 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,310110501,NDC,1,EA,151.95,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium zirconium cyclosilicate 10 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,310111001,NDC,1,EA,172.56,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium zirconium cyclosilicate 10 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,310111001,NDC,1,EA,172.56,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium zirconium cyclosilicate 10 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,310111001,NDC,1,EA,172.56,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium zirconium cyclosilicate 10 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,310111001,NDC,1,EA,172.56,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium zirconium cyclosilicate 10 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,310111001,NDC,1,EA,172.56,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium zirconium cyclosilicate 10 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,310111001,NDC,1,EA,172.56,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sodium, Other Source - Ref",PX8430290,CDM,300,RC,84302,CPT,90,,,,,,,27,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sodium, Other Source - Ref",PX8430290,CDM,300,RC,84302,CPT,90,,,,,,,27,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sodium, Other Source - Ref",PX8430290,CDM,300,RC,84302,CPT,90,,,,,,,27,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sodium, Other Source - Ref",PX8430290,CDM,300,RC,84302,CPT,90,,,,,,,27,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sodium, Other Source - Ref",PX8430290,CDM,300,RC,84302,CPT,90,,,,,,,27,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sodium, Other Source - Ref",PX8430290,CDM,300,RC,84302,CPT,90,,,,,,,27,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sodium; Serum, Plasma or Whole Blood",PX84295,CDM,300,RC,84295,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sodium; Serum, Plasma or Whole Blood",PX84295,CDM,300,RC,84295,CPT,,,,,,,,58,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sodium; Serum, Plasma or Whole Blood",PX84295,CDM,300,RC,84295,CPT,,,,,,,,58,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sodium; Serum, Plasma or Whole Blood",PX84295,CDM,300,RC,84295,CPT,,,,,,,,58,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sodium; Serum, Plasma or Whole Blood",PX84295,CDM,300,RC,84295,CPT,,,,,,,,58,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sodium; Serum, Plasma or Whole Blood",PX84295,CDM,300,RC,84295,CPT,,,,,,,,58,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sodium; Urine,PX84300,CDM,300,RC,84300,CPT,,,,,,,,119,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sodium; Urine,PX84300,CDM,300,RC,84300,CPT,,,,,,,,119,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sodium; Urine,PX84300,CDM,300,RC,84300,CPT,,,,,,,,119,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sodium; Urine,PX84300,CDM,300,RC,84300,CPT,,,,,,,,119,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sodium; Urine,PX84300,CDM,300,RC,84300,CPT,,,,,,,,119,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sodium; Urine,PX84300,CDM,300,RC,84300,CPT,,,,,,,,119,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
solifenacin 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50228042730,NDC,1,EA,74.52,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
solifenacin 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50228042730,NDC,1,EA,74.52,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
solifenacin 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50228042730,NDC,1,EA,74.52,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
solifenacin 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50228042730,NDC,1,EA,74.52,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
solifenacin 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50228042730,NDC,1,EA,74.52,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
solifenacin 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50228042730,NDC,1,EA,74.52,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Somatostatin - Ref,PX8430790,CDM,300,RC,84307,CPT,90,,,,,,,325,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Somatostatin - Ref,PX8430790,CDM,300,RC,84307,CPT,90,,,,,,,325,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Somatostatin - Ref,PX8430790,CDM,300,RC,84307,CPT,90,,,,,,,325,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Somatostatin - Ref,PX8430790,CDM,300,RC,84307,CPT,90,,,,,,,325,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Somatostatin - Ref,PX8430790,CDM,300,RC,84307,CPT,90,,,,,,,325,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Somatostatin - Ref,PX8430790,CDM,300,RC,84307,CPT,90,,,,,,,325,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sotalol 80 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,60505008000,NDC,1,EA,13.76,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sotalol 80 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,60505008000,NDC,1,EA,13.76,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sotalol 80 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,60505008000,NDC,1,EA,13.76,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sotalol 80 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,60505008000,NDC,1,EA,13.76,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sotalol 80 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,60505008000,NDC,1,EA,13.76,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sotalol 80 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,60505008000,NDC,1,EA,13.76,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sp Stn for Inclusn Bodies - Ref,PX8720790,CDM,300,RC,87207,CPT,90,,,,,,,227,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sp Stn for Inclusn Bodies - Ref,PX8720790,CDM,300,RC,87207,CPT,90,,,,,,,227,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sp Stn for Inclusn Bodies - Ref,PX8720790,CDM,300,RC,87207,CPT,90,,,,,,,227,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sp Stn for Inclusn Bodies - Ref,PX8720790,CDM,300,RC,87207,CPT,90,,,,,,,227,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sp Stn for Inclusn Bodies - Ref,PX8720790,CDM,300,RC,87207,CPT,90,,,,,,,227,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sp Stn for Inclusn Bodies - Ref,PX8720790,CDM,300,RC,87207,CPT,90,,,,,,,227,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Special Stains,Group I",PX3978,CDM,310,RC,88312,CPT,TC,,,,,,,107,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Special Stains,Group I",PX3978,CDM,310,RC,88312,CPT,TC,,,,,,,107,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Special Stains,Group I",PX3978,CDM,310,RC,88312,CPT,TC,,,,,,,107,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Special Stains,Group I",PX3978,CDM,310,RC,88312,CPT,TC,,,,,,,107,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Special Stains,Group I",PX3978,CDM,310,RC,88312,CPT,TC,,,,,,,107,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Special Stains,Group I",PX3978,CDM,310,RC,88312,CPT,TC,,,,,,,107,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Specimen Concentration - Ref,PX8701590,CDM,300,RC,87015,CPT,90,,,,,,,105,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Specimen Concentration - Ref,PX8701590,CDM,300,RC,87015,CPT,90,,,,,,,105,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Specimen Concentration - Ref,PX8701590,CDM,300,RC,87015,CPT,90,,,,,,,105,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Specimen Concentration - Ref,PX8701590,CDM,300,RC,87015,CPT,90,,,,,,,105,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Specimen Concentration - Ref,PX8701590,CDM,300,RC,87015,CPT,90,,,,,,,105,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Specimen Concentration - Ref,PX8701590,CDM,300,RC,87015,CPT,90,,,,,,,105,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Spectrophotometry, Nos",PX84311,CDM,300,RC,84311,CPT,,,,,,,,21,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Spectrophotometry, Nos",PX84311,CDM,300,RC,84311,CPT,,,,,,,,21,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Spectrophotometry, Nos",PX84311,CDM,300,RC,84311,CPT,,,,,,,,21,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Spectrophotometry, Nos",PX84311,CDM,300,RC,84311,CPT,,,,,,,,21,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Spectrophotometry, Nos",PX84311,CDM,300,RC,84311,CPT,,,,,,,,21,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Spectrophotometry, Nos",PX84311,CDM,300,RC,84311,CPT,,,,,,,,21,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPECULUM VAGINAL WITH BUILT IN LIGHT LARGE,120.133,CDM,272,RC,,,,8251-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPECULUM VAGINAL WITH BUILT IN LIGHT LARGE,120.133,CDM,272,RC,,,,8251-MAIN,LOCAL,,,,,38,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPECULUM VAGINAL WITH BUILT IN LIGHT LARGE,120.133,CDM,272,RC,,,,8251-MAIN,LOCAL,,,,,38,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPECULUM VAGINAL WITH BUILT IN LIGHT LARGE,120.133,CDM,272,RC,,,,8251-MAIN,LOCAL,,,,,38,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPECULUM VAGINAL WITH BUILT IN LIGHT LARGE,120.133,CDM,272,RC,,,,8251-MAIN,LOCAL,,,,,38,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPECULUM VAGINAL WITH BUILT IN LIGHT LARGE,120.133,CDM,272,RC,,,,8251-MAIN,LOCAL,,,,,38,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPECULUM VAGINAL WITH BUILT IN LIGHT MEDIUM,120.133,CDM,272,RC,,,,8250-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPECULUM VAGINAL WITH BUILT IN LIGHT MEDIUM,120.133,CDM,272,RC,,,,8250-MAIN,LOCAL,,,,,38,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPECULUM VAGINAL WITH BUILT IN LIGHT MEDIUM,120.133,CDM,272,RC,,,,8250-MAIN,LOCAL,,,,,38,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPECULUM VAGINAL WITH BUILT IN LIGHT MEDIUM,120.133,CDM,272,RC,,,,8250-MAIN,LOCAL,,,,,38,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPECULUM VAGINAL WITH BUILT IN LIGHT MEDIUM,120.133,CDM,272,RC,,,,8250-MAIN,LOCAL,,,,,38,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPECULUM VAGINAL WITH BUILT IN LIGHT MEDIUM,120.133,CDM,272,RC,,,,8250-MAIN,LOCAL,,,,,38,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPECULUM VAGINAL WITH BUILT IN LIGHT SMALL,120.133,CDM,272,RC,,,,8249-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPECULUM VAGINAL WITH BUILT IN LIGHT SMALL,120.133,CDM,272,RC,,,,8249-MAIN,LOCAL,,,,,38,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPECULUM VAGINAL WITH BUILT IN LIGHT SMALL,120.133,CDM,272,RC,,,,8249-MAIN,LOCAL,,,,,38,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPECULUM VAGINAL WITH BUILT IN LIGHT SMALL,120.133,CDM,272,RC,,,,8249-MAIN,LOCAL,,,,,38,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPECULUM VAGINAL WITH BUILT IN LIGHT SMALL,120.133,CDM,272,RC,,,,8249-MAIN,LOCAL,,,,,38,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPECULUM VAGINAL WITH BUILT IN LIGHT SMALL,120.133,CDM,272,RC,,,,8249-MAIN,LOCAL,,,,,38,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Spinal Punc,Drain,Theraputic",PX62272F,CDM,510,RC,62272,CPT,,,,,,,,450,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Spinal Punc,Drain,Theraputic",PX62272F,CDM,510,RC,62272,CPT,,,,,,,,450,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Spinal Punc,Drain,Theraputic",PX62272F,CDM,510,RC,62272,CPT,,,,,,,,450,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Spinal Punc,Drain,Theraputic",PX62272F,CDM,510,RC,62272,CPT,,,,,,,,450,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Spinal Punc,Drain,Theraputic",PX62272F,CDM,510,RC,62272,CPT,,,,,,,,450,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Spinal Punc,Drain,Theraputic",PX62272F,CDM,510,RC,62272,CPT,,,,,,,,450,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Spinal Punc,Drain,Theraputic",PX62272P,CDM,983,RC,62272,CPT,,,,,,,,300,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Spinal Punc,Drain,Theraputic",PX62272P,CDM,983,RC,62272,CPT,,,,,,,,300,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Spinal Punc,Drain,Theraputic",PX62272P,CDM,983,RC,62272,CPT,,,,,,,,300,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Spinal Punc,Drain,Theraputic",PX62272P,CDM,983,RC,62272,CPT,,,,,,,,300,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Spinal Punc,Drain,Theraputic",PX62272P,CDM,983,RC,62272,CPT,,,,,,,,300,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Spinal Punc,Drain,Theraputic",PX62272P,CDM,983,RC,62272,CPT,,,,,,,,300,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Spinal Puncture,Lumbar,Diagnostic",PX62270F,CDM,510,RC,62270,CPT,,,,,,,,684,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Spinal Puncture,Lumbar,Diagnostic",PX62270F,CDM,510,RC,62270,CPT,,,,,,,,684,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Spinal Puncture,Lumbar,Diagnostic",PX62270F,CDM,510,RC,62270,CPT,,,,,,,,684,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Spinal Puncture,Lumbar,Diagnostic",PX62270F,CDM,510,RC,62270,CPT,,,,,,,,684,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Spinal Puncture,Lumbar,Diagnostic",PX62270F,CDM,510,RC,62270,CPT,,,,,,,,684,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Spinal Puncture,Lumbar,Diagnostic",PX62270F,CDM,510,RC,62270,CPT,,,,,,,,684,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Spinal Puncture,Lumbar,Diagnostic",PX62270P,CDM,983,RC,62270,CPT,,,,,,,,705,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Spinal Puncture,Lumbar,Diagnostic",PX62270P,CDM,983,RC,62270,CPT,,,,,,,,705,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Spinal Puncture,Lumbar,Diagnostic",PX62270P,CDM,983,RC,62270,CPT,,,,,,,,705,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Spinal Puncture,Lumbar,Diagnostic",PX62270P,CDM,983,RC,62270,CPT,,,,,,,,705,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Spinal Puncture,Lumbar,Diagnostic",PX62270P,CDM,983,RC,62270,CPT,,,,,,,,705,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Spinal Puncture,Lumbar,Diagnostic",PX62270P,CDM,983,RC,62270,CPT,,,,,,,,705,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Spirometry,PX9401001,CDM,460,RC,94010,CPT,TC,,,,,,,281,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Spirometry,PX9401001,CDM,460,RC,94010,CPT,TC,,,,,,,281,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Spirometry,PX9401001,CDM,460,RC,94010,CPT,TC,,,,,,,281,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Spirometry,PX9401001,CDM,460,RC,94010,CPT,TC,,,,,,,281,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Spirometry,PX9401001,CDM,460,RC,94010,CPT,TC,,,,,,,281,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Spirometry,PX9401001,CDM,460,RC,94010,CPT,TC,,,,,,,281,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Spirometry Incl Graph Rec Tc,PX9401002,CDM,460,RC,94010,CPT,TC,,,,,,,288,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Spirometry Incl Graph Rec Tc,PX9401002,CDM,460,RC,94010,CPT,TC,,,,,,,288,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Spirometry Incl Graph Rec Tc,PX9401002,CDM,460,RC,94010,CPT,TC,,,,,,,288,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Spirometry Incl Graph Rec Tc,PX9401002,CDM,460,RC,94010,CPT,TC,,,,,,,288,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Spirometry Incl Graph Rec Tc,PX9401002,CDM,460,RC,94010,CPT,TC,,,,,,,288,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Spirometry Incl Graph Rec Tc,PX9401002,CDM,460,RC,94010,CPT,TC,,,,,,,288,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
spironolactone 12.5 mg Tablet 1 split tablet Blister,63700001,CDM,250,RC,,,,,,8888800438,NDC,2,UN,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
spironolactone 12.5 mg Tablet 1 split tablet Blister,63700001,CDM,250,RC,,,,,,8888800438,NDC,2,UN,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
spironolactone 12.5 mg Tablet 1 split tablet Blister,63700001,CDM,250,RC,,,,,,8888800438,NDC,2,UN,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
spironolactone 12.5 mg Tablet 1 split tablet Blister,63700001,CDM,250,RC,,,,,,8888800438,NDC,2,UN,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
spironolactone 12.5 mg Tablet 1 split tablet Blister,63700001,CDM,250,RC,,,,,,8888800438,NDC,2,UN,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
spironolactone 12.5 mg Tablet 1 split tablet Blister,63700001,CDM,250,RC,,,,,,8888800438,NDC,2,UN,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
spironolactone 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079010301,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
spironolactone 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079010301,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
spironolactone 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079010301,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
spironolactone 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079010301,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
spironolactone 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079010301,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
spironolactone 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079010301,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
spironolactone 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687046511,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
spironolactone 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687046511,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
spironolactone 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687046511,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
spironolactone 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687046511,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
spironolactone 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687046511,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
spironolactone 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687046511,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079010320,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079010320,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079010320,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079010320,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079010320,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079010320,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687046501,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687046501,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687046501,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687046501,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687046501,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687046501,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739054410,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739054410,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739054410,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739054410,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739054410,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739054410,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPIT SOCK HOODS 16719,120.367,CDM,271,RC,,,,10820-MAIN,LOCAL,,,,,26,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPIT SOCK HOODS 16719,120.367,CDM,271,RC,,,,10820-MAIN,LOCAL,,,,,26,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPIT SOCK HOODS 16719,120.367,CDM,271,RC,,,,10820-MAIN,LOCAL,,,,,26,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPIT SOCK HOODS 16719,120.367,CDM,271,RC,,,,10820-MAIN,LOCAL,,,,,26,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPIT SOCK HOODS 16719,120.367,CDM,271,RC,,,,10820-MAIN,LOCAL,,,,,26,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPIT SOCK HOODS 16719,120.367,CDM,271,RC,,,,10820-MAIN,LOCAL,,,,,26,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPLINT ANKLE GEL BRACE UNIVERSAL AIRFORM 70351,120.61,CDM,274,RC,L4350,HCPCS,,12342-MAIN,LOCAL,,,,,88,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPLINT ANKLE GEL BRACE UNIVERSAL AIRFORM 70351,120.61,CDM,274,RC,L4350,HCPCS,,12342-MAIN,LOCAL,,,,,88,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPLINT ANKLE GEL BRACE UNIVERSAL AIRFORM 70351,120.61,CDM,274,RC,L4350,HCPCS,,12342-MAIN,LOCAL,,,,,88,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPLINT ANKLE GEL BRACE UNIVERSAL AIRFORM 70351,120.61,CDM,274,RC,L4350,HCPCS,,12342-MAIN,LOCAL,,,,,88,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPLINT ANKLE GEL BRACE UNIVERSAL AIRFORM 70351,120.61,CDM,274,RC,L4350,HCPCS,,12342-MAIN,LOCAL,,,,,88,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPLINT ANKLE GEL BRACE UNIVERSAL AIRFORM 70351,120.61,CDM,274,RC,L4350,HCPCS,,12342-MAIN,LOCAL,,,,,88,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPLINT FOOT SMALL STRUT WALK 11-1383-2-00000,120.45,CDM,274,RC,L4360,HCPCS,,1205-MAIN,LOCAL,,,,,93,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPLINT FOOT SMALL STRUT WALK 11-1383-2-00000,120.45,CDM,274,RC,L4360,HCPCS,,1205-MAIN,LOCAL,,,,,93,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPLINT FOOT SMALL STRUT WALK 11-1383-2-00000,120.45,CDM,274,RC,L4360,HCPCS,,1205-MAIN,LOCAL,,,,,93,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPLINT FOOT SMALL STRUT WALK 11-1383-2-00000,120.45,CDM,274,RC,L4360,HCPCS,,1205-MAIN,LOCAL,,,,,93,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPLINT FOOT SMALL STRUT WALK 11-1383-2-00000,120.45,CDM,274,RC,L4360,HCPCS,,1205-MAIN,LOCAL,,,,,93,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPLINT FOOT SMALL STRUT WALK 11-1383-2-00000,120.45,CDM,274,RC,L4360,HCPCS,,1205-MAIN,LOCAL,,,,,93,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPLINT SAM 36INCH ROLLED 661121,120.362,CDM,271,RC,,,,10789-MAIN,LOCAL,,,,,34,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPLINT SAM 36INCH ROLLED 661121,120.362,CDM,271,RC,,,,10789-MAIN,LOCAL,,,,,34,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPLINT SAM 36INCH ROLLED 661121,120.362,CDM,271,RC,,,,10789-MAIN,LOCAL,,,,,34,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPLINT SAM 36INCH ROLLED 661121,120.362,CDM,271,RC,,,,10789-MAIN,LOCAL,,,,,34,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPLINT SAM 36INCH ROLLED 661121,120.362,CDM,271,RC,,,,10789-MAIN,LOCAL,,,,,34,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPLINT SAM 36INCH ROLLED 661121,120.362,CDM,271,RC,,,,10789-MAIN,LOCAL,,,,,34,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPLINT WRIST LARGE ALUMINUM FOREARM LEFT 9101-06,120.87,CDM,274,RC,L3809,HCPCS,,1265-MAIN,LOCAL,,,,,130,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPLINT WRIST LARGE ALUMINUM FOREARM LEFT 9101-06,120.87,CDM,274,RC,L3809,HCPCS,,1265-MAIN,LOCAL,,,,,130,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPLINT WRIST LARGE ALUMINUM FOREARM LEFT 9101-06,120.87,CDM,274,RC,L3809,HCPCS,,1265-MAIN,LOCAL,,,,,130,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPLINT WRIST LARGE ALUMINUM FOREARM LEFT 9101-06,120.87,CDM,274,RC,L3809,HCPCS,,1265-MAIN,LOCAL,,,,,130,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPLINT WRIST LARGE ALUMINUM FOREARM LEFT 9101-06,120.87,CDM,274,RC,L3809,HCPCS,,1265-MAIN,LOCAL,,,,,130,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPLINT WRIST LARGE ALUMINUM FOREARM LEFT 9101-06,120.87,CDM,274,RC,L3809,HCPCS,,1265-MAIN,LOCAL,,,,,130,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPLINT WRIST LARGE ALUMINUM FOREARM RIGHT 9101-03,120.87,CDM,274,RC,L3809,HCPCS,,1263-MAIN,LOCAL,,,,,130,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPLINT WRIST LARGE ALUMINUM FOREARM RIGHT 9101-03,120.87,CDM,274,RC,L3809,HCPCS,,1263-MAIN,LOCAL,,,,,130,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPLINT WRIST LARGE ALUMINUM FOREARM RIGHT 9101-03,120.87,CDM,274,RC,L3809,HCPCS,,1263-MAIN,LOCAL,,,,,130,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPLINT WRIST LARGE ALUMINUM FOREARM RIGHT 9101-03,120.87,CDM,274,RC,L3809,HCPCS,,1263-MAIN,LOCAL,,,,,130,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPLINT WRIST LARGE ALUMINUM FOREARM RIGHT 9101-03,120.87,CDM,274,RC,L3809,HCPCS,,1263-MAIN,LOCAL,,,,,130,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPLINT WRIST LARGE ALUMINUM FOREARM RIGHT 9101-03,120.87,CDM,274,RC,L3809,HCPCS,,1263-MAIN,LOCAL,,,,,130,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPLINT WRIST MEDIUM ALUMINUM FOREARM LEFT 9101-05,120.87,CDM,274,RC,L3809,HCPCS,,1264-MAIN,LOCAL,,,,,130,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPLINT WRIST MEDIUM ALUMINUM FOREARM LEFT 9101-05,120.87,CDM,274,RC,L3809,HCPCS,,1264-MAIN,LOCAL,,,,,130,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPLINT WRIST MEDIUM ALUMINUM FOREARM LEFT 9101-05,120.87,CDM,274,RC,L3809,HCPCS,,1264-MAIN,LOCAL,,,,,130,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPLINT WRIST MEDIUM ALUMINUM FOREARM LEFT 9101-05,120.87,CDM,274,RC,L3809,HCPCS,,1264-MAIN,LOCAL,,,,,130,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPLINT WRIST MEDIUM ALUMINUM FOREARM LEFT 9101-05,120.87,CDM,274,RC,L3809,HCPCS,,1264-MAIN,LOCAL,,,,,130,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPLINT WRIST MEDIUM ALUMINUM FOREARM LEFT 9101-05,120.87,CDM,274,RC,L3809,HCPCS,,1264-MAIN,LOCAL,,,,,130,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPLINT WRIST MEDIUM ALUMINUM FOREARM RIGHT 9101-02,120.87,CDM,274,RC,L3809,HCPCS,,1262-MAIN,LOCAL,,,,,130,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPLINT WRIST MEDIUM ALUMINUM FOREARM RIGHT 9101-02,120.87,CDM,274,RC,L3809,HCPCS,,1262-MAIN,LOCAL,,,,,130,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPLINT WRIST MEDIUM ALUMINUM FOREARM RIGHT 9101-02,120.87,CDM,274,RC,L3809,HCPCS,,1262-MAIN,LOCAL,,,,,130,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPLINT WRIST MEDIUM ALUMINUM FOREARM RIGHT 9101-02,120.87,CDM,274,RC,L3809,HCPCS,,1262-MAIN,LOCAL,,,,,130,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPLINT WRIST MEDIUM ALUMINUM FOREARM RIGHT 9101-02,120.87,CDM,274,RC,L3809,HCPCS,,1262-MAIN,LOCAL,,,,,130,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPLINT WRIST MEDIUM ALUMINUM FOREARM RIGHT 9101-02,120.87,CDM,274,RC,L3809,HCPCS,,1262-MAIN,LOCAL,,,,,130,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPONGE XRAY DETECTABLE PEANUT MDS72038,27200000,CDM,272,RC,,,,10915-MAIN,LOCAL,,,,,0.79,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPONGE XRAY DETECTABLE PEANUT MDS72038,27200000,CDM,272,RC,,,,10915-MAIN,LOCAL,,,,,0.79,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPONGE XRAY DETECTABLE PEANUT MDS72038,27200000,CDM,272,RC,,,,10915-MAIN,LOCAL,,,,,0.79,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPONGE XRAY DETECTABLE PEANUT MDS72038,27200000,CDM,272,RC,,,,10915-MAIN,LOCAL,,,,,0.79,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPONGE XRAY DETECTABLE PEANUT MDS72038,27200000,CDM,272,RC,,,,10915-MAIN,LOCAL,,,,,0.79,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPONGE XRAY DETECTABLE PEANUT MDS72038,27200000,CDM,272,RC,,,,10915-MAIN,LOCAL,,,,,0.79,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"St Louis, Antibody - Ref",PX8665390,CDM,300,RC,86653,CPT,90,,,,,,,45,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"St Louis, Antibody - Ref",PX8665390,CDM,300,RC,86653,CPT,90,,,,,,,45,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"St Louis, Antibody - Ref",PX8665390,CDM,300,RC,86653,CPT,90,,,,,,,45,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"St Louis, Antibody - Ref",PX8665390,CDM,300,RC,86653,CPT,90,,,,,,,45,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"St Louis, Antibody - Ref",PX8665390,CDM,300,RC,86653,CPT,90,,,,,,,45,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"St Louis, Antibody - Ref",PX8665390,CDM,300,RC,86653,CPT,90,,,,,,,45,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STANDARD HIGH FLOW INSUFFLATION FILTER TUBING,27200000,CDM,272,RC,,,,11885-MAIN,LOCAL,,,,,33,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STANDARD HIGH FLOW INSUFFLATION FILTER TUBING,27200000,CDM,272,RC,,,,11885-MAIN,LOCAL,,,,,33,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STANDARD HIGH FLOW INSUFFLATION FILTER TUBING,27200000,CDM,272,RC,,,,11885-MAIN,LOCAL,,,,,33,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STANDARD HIGH FLOW INSUFFLATION FILTER TUBING,27200000,CDM,272,RC,,,,11885-MAIN,LOCAL,,,,,33,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STANDARD HIGH FLOW INSUFFLATION FILTER TUBING,27200000,CDM,272,RC,,,,11885-MAIN,LOCAL,,,,,33,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STANDARD HIGH FLOW INSUFFLATION FILTER TUBING,27200000,CDM,272,RC,,,,11885-MAIN,LOCAL,,,,,33,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER CANNULA SEAL 12 mm 470380,27200000,CDM,272,RC,,,,11962-MAIN,LOCAL,,,,,40,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER CANNULA SEAL 12 mm 470380,27200000,CDM,272,RC,,,,11962-MAIN,LOCAL,,,,,40,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER CANNULA SEAL 12 mm 470380,27200000,CDM,272,RC,,,,11962-MAIN,LOCAL,,,,,40,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER CANNULA SEAL 12 mm 470380,27200000,CDM,272,RC,,,,11962-MAIN,LOCAL,,,,,40,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER CANNULA SEAL 12 mm 470380,27200000,CDM,272,RC,,,,11962-MAIN,LOCAL,,,,,40,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER CANNULA SEAL 12 mm 470380,27200000,CDM,272,RC,,,,11962-MAIN,LOCAL,,,,,40,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER CONTOUR CURVED CUTTER,27200000,CDM,272,RC,,,,12064-MAIN,LOCAL,,,,,942,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER CONTOUR CURVED CUTTER,27200000,CDM,272,RC,,,,12064-MAIN,LOCAL,,,,,942,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER CONTOUR CURVED CUTTER,27200000,CDM,272,RC,,,,12064-MAIN,LOCAL,,,,,942,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER CONTOUR CURVED CUTTER,27200000,CDM,272,RC,,,,12064-MAIN,LOCAL,,,,,942,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER CONTOUR CURVED CUTTER,27200000,CDM,272,RC,,,,12064-MAIN,LOCAL,,,,,942,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER CONTOUR CURVED CUTTER,27200000,CDM,272,RC,,,,12064-MAIN,LOCAL,,,,,942,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER INTERNAL ECHELON FLEX POWERED PLUS LONG LENGTH 440MM,27200000,CDM,272,RC,,,,12065-MAIN,LOCAL,,,,,648,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER INTERNAL ECHELON FLEX POWERED PLUS LONG LENGTH 440MM,27200000,CDM,272,RC,,,,12065-MAIN,LOCAL,,,,,648,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER INTERNAL ECHELON FLEX POWERED PLUS LONG LENGTH 440MM,27200000,CDM,272,RC,,,,12065-MAIN,LOCAL,,,,,648,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER INTERNAL ECHELON FLEX POWERED PLUS LONG LENGTH 440MM,27200000,CDM,272,RC,,,,12065-MAIN,LOCAL,,,,,648,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER INTERNAL ECHELON FLEX POWERED PLUS LONG LENGTH 440MM,27200000,CDM,272,RC,,,,12065-MAIN,LOCAL,,,,,648,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER INTERNAL ECHELON FLEX POWERED PLUS LONG LENGTH 440MM,27200000,CDM,272,RC,,,,12065-MAIN,LOCAL,,,,,648,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER INTERNAL POWERED 29MM CURVED CIRCULAR,27200000,CDM,272,RC,,,,12024-MAIN,LOCAL,,,,,697,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER INTERNAL POWERED 29MM CURVED CIRCULAR,27200000,CDM,272,RC,,,,12024-MAIN,LOCAL,,,,,697,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER INTERNAL POWERED 29MM CURVED CIRCULAR,27200000,CDM,272,RC,,,,12024-MAIN,LOCAL,,,,,697,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER INTERNAL POWERED 29MM CURVED CIRCULAR,27200000,CDM,272,RC,,,,12024-MAIN,LOCAL,,,,,697,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER INTERNAL POWERED 29MM CURVED CIRCULAR,27200000,CDM,272,RC,,,,12024-MAIN,LOCAL,,,,,697,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER INTERNAL POWERED 29MM CURVED CIRCULAR,27200000,CDM,272,RC,,,,12024-MAIN,LOCAL,,,,,697,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER INTERNAL POWERED 31MM CURVED CIRCULAR,27200000,CDM,272,RC,,,,12025-MAIN,LOCAL,,,,,697,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER INTERNAL POWERED 31MM CURVED CIRCULAR,27200000,CDM,272,RC,,,,12025-MAIN,LOCAL,,,,,697,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER INTERNAL POWERED 31MM CURVED CIRCULAR,27200000,CDM,272,RC,,,,12025-MAIN,LOCAL,,,,,697,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER INTERNAL POWERED 31MM CURVED CIRCULAR,27200000,CDM,272,RC,,,,12025-MAIN,LOCAL,,,,,697,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER INTERNAL POWERED 31MM CURVED CIRCULAR,27200000,CDM,272,RC,,,,12025-MAIN,LOCAL,,,,,697,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER INTERNAL POWERED 31MM CURVED CIRCULAR,27200000,CDM,272,RC,,,,12025-MAIN,LOCAL,,,,,697,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER RELOAD-CURVED CUTTER,27200000,CDM,272,RC,,,,12063-MAIN,LOCAL,,,,,283,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER RELOAD-CURVED CUTTER,27200000,CDM,272,RC,,,,12063-MAIN,LOCAL,,,,,283,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER RELOAD-CURVED CUTTER,27200000,CDM,272,RC,,,,12063-MAIN,LOCAL,,,,,283,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER RELOAD-CURVED CUTTER,27200000,CDM,272,RC,,,,12063-MAIN,LOCAL,,,,,283,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER RELOAD-CURVED CUTTER,27200000,CDM,272,RC,,,,12063-MAIN,LOCAL,,,,,283,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER RELOAD-CURVED CUTTER,27200000,CDM,272,RC,,,,12063-MAIN,LOCAL,,,,,283,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER SUREFORM 45 SPU IS4000,27200000,CDM,272,RC,,,,12794-MAIN,LOCAL,,,,,888,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER SUREFORM 45 SPU IS4000,27200000,CDM,272,RC,,,,12794-MAIN,LOCAL,,,,,888,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER SUREFORM 45 SPU IS4000,27200000,CDM,272,RC,,,,12794-MAIN,LOCAL,,,,,888,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER SUREFORM 45 SPU IS4000,27200000,CDM,272,RC,,,,12794-MAIN,LOCAL,,,,,888,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER SUREFORM 45 SPU IS4000,27200000,CDM,272,RC,,,,12794-MAIN,LOCAL,,,,,888,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER SUREFORM 45 SPU IS4000,27200000,CDM,272,RC,,,,12794-MAIN,LOCAL,,,,,888,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER SUREFORM 60 SPU IS4000,27200000,CDM,272,RC,,,,12086-MAIN,LOCAL,,,,,991,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER SUREFORM 60 SPU IS4000,27200000,CDM,272,RC,,,,12086-MAIN,LOCAL,,,,,991,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER SUREFORM 60 SPU IS4000,27200000,CDM,272,RC,,,,12086-MAIN,LOCAL,,,,,991,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER SUREFORM 60 SPU IS4000,27200000,CDM,272,RC,,,,12086-MAIN,LOCAL,,,,,991,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER SUREFORM 60 SPU IS4000,27200000,CDM,272,RC,,,,12086-MAIN,LOCAL,,,,,991,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER SUREFORM 60 SPU IS4000,27200000,CDM,272,RC,,,,12086-MAIN,LOCAL,,,,,991,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sterile water (preservative free) Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,64253002030,NDC,10,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sterile water (preservative free) Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,64253002030,NDC,10,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sterile water (preservative free) Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,64253002030,NDC,10,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sterile water (preservative free) Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,64253002030,NDC,10,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sterile water (preservative free) Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,64253002030,NDC,10,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sterile water (preservative free) Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,64253002030,NDC,10,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409488710,NDC,10,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409488710,NDC,10,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409488710,NDC,10,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409488710,NDC,10,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409488710,NDC,10,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409488710,NDC,10,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409488717,NDC,10,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409488717,NDC,10,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409488717,NDC,10,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409488717,NDC,10,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409488717,NDC,10,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409488717,NDC,10,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323018507,NDC,10,ML,43.09,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323018507,NDC,10,ML,43.09,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323018507,NDC,10,ML,43.09,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323018507,NDC,10,ML,43.09,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323018507,NDC,10,ML,43.09,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323018507,NDC,10,ML,43.09,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sterile water (preservative free) Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323018520,NDC,20,ML,50.08,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sterile water (preservative free) Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323018520,NDC,20,ML,50.08,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sterile water (preservative free) Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323018520,NDC,20,ML,50.08,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sterile water (preservative free) Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323018520,NDC,20,ML,50.08,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sterile water (preservative free) Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323018520,NDC,20,ML,50.08,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sterile water (preservative free) Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323018520,NDC,20,ML,50.08,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sterile water (preservative free) Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409488724,NDC,50,ML,34.88,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sterile water (preservative free) Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409488724,NDC,50,ML,34.88,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sterile water (preservative free) Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409488724,NDC,50,ML,34.88,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sterile water (preservative free) Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409488724,NDC,50,ML,34.88,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sterile water (preservative free) Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409488724,NDC,50,ML,34.88,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sterile water (preservative free) Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409488724,NDC,50,ML,34.88,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sterile water (preservative free) Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409488750,NDC,50,ML,34.88,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sterile water (preservative free) Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409488750,NDC,50,ML,34.88,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sterile water (preservative free) Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409488750,NDC,50,ML,34.88,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sterile water (preservative free) Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409488750,NDC,50,ML,34.88,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sterile water (preservative free) Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409488750,NDC,50,ML,34.88,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sterile water (preservative free) Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409488750,NDC,50,ML,34.88,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STIFNECK ADULT,120.77,CDM,274,RC,L0180,HCPCS,,991-MAIN,LOCAL,,,,,119,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STIFNECK ADULT,120.77,CDM,274,RC,L0180,HCPCS,,991-MAIN,LOCAL,,,,,119,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STIFNECK ADULT,120.77,CDM,274,RC,L0180,HCPCS,,991-MAIN,LOCAL,,,,,119,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STIFNECK ADULT,120.77,CDM,274,RC,L0180,HCPCS,,991-MAIN,LOCAL,,,,,119,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STIFNECK ADULT,120.77,CDM,274,RC,L0180,HCPCS,,991-MAIN,LOCAL,,,,,119,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STIFNECK ADULT,120.77,CDM,274,RC,L0180,HCPCS,,991-MAIN,LOCAL,,,,,119,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STIFNECK PEDIATRIC,120.77,CDM,274,RC,L0180,HCPCS,,998-MAIN,LOCAL,,,,,119,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STIFNECK PEDIATRIC,120.77,CDM,274,RC,L0180,HCPCS,,998-MAIN,LOCAL,,,,,119,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STIFNECK PEDIATRIC,120.77,CDM,274,RC,L0180,HCPCS,,998-MAIN,LOCAL,,,,,119,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STIFNECK PEDIATRIC,120.77,CDM,274,RC,L0180,HCPCS,,998-MAIN,LOCAL,,,,,119,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STIFNECK PEDIATRIC,120.77,CDM,274,RC,L0180,HCPCS,,998-MAIN,LOCAL,,,,,119,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STIFNECK PEDIATRIC,120.77,CDM,274,RC,L0180,HCPCS,,998-MAIN,LOCAL,,,,,119,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STOCKINETTE IMPERVIOUS 9X36 NON22530,27200000,CDM,272,RC,A6457,HCPCS,,10917-MAIN,LOCAL,,,,,14.73,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STOCKINETTE IMPERVIOUS 9X36 NON22530,27200000,CDM,272,RC,A6457,HCPCS,,10917-MAIN,LOCAL,,,,,14.73,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STOCKINETTE IMPERVIOUS 9X36 NON22530,27200000,CDM,272,RC,A6457,HCPCS,,10917-MAIN,LOCAL,,,,,14.73,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STOCKINETTE IMPERVIOUS 9X36 NON22530,27200000,CDM,272,RC,A6457,HCPCS,,10917-MAIN,LOCAL,,,,,14.73,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STOCKINETTE IMPERVIOUS 9X36 NON22530,27200000,CDM,272,RC,A6457,HCPCS,,10917-MAIN,LOCAL,,,,,14.73,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STOCKINETTE IMPERVIOUS 9X36 NON22530,27200000,CDM,272,RC,A6457,HCPCS,,10917-MAIN,LOCAL,,,,,14.73,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STOCKINETTE IMPERVIOUS 12X48 NON22535,27200000,CDM,272,RC,A6457,HCPCS,,10918-MAIN,LOCAL,,,,,16.47,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STOCKINETTE IMPERVIOUS 12X48 NON22535,27200000,CDM,272,RC,A6457,HCPCS,,10918-MAIN,LOCAL,,,,,16.47,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STOCKINETTE IMPERVIOUS 12X48 NON22535,27200000,CDM,272,RC,A6457,HCPCS,,10918-MAIN,LOCAL,,,,,16.47,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STOCKINETTE IMPERVIOUS 12X48 NON22535,27200000,CDM,272,RC,A6457,HCPCS,,10918-MAIN,LOCAL,,,,,16.47,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STOCKINETTE IMPERVIOUS 12X48 NON22535,27200000,CDM,272,RC,A6457,HCPCS,,10918-MAIN,LOCAL,,,,,16.47,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STOCKINETTE IMPERVIOUS 12X48 NON22535,27200000,CDM,272,RC,A6457,HCPCS,,10918-MAIN,LOCAL,,,,,16.47,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STOCKINETTE STERILE 4X48 NON22360,27200000,CDM,272,RC,A6457,HCPCS,,10658-MAIN,LOCAL,,,,,10.62,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STOCKINETTE STERILE 4X48 NON22360,27200000,CDM,272,RC,A6457,HCPCS,,10658-MAIN,LOCAL,,,,,10.62,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STOCKINETTE STERILE 4X48 NON22360,27200000,CDM,272,RC,A6457,HCPCS,,10658-MAIN,LOCAL,,,,,10.62,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STOCKINETTE STERILE 4X48 NON22360,27200000,CDM,272,RC,A6457,HCPCS,,10658-MAIN,LOCAL,,,,,10.62,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STOCKINETTE STERILE 4X48 NON22360,27200000,CDM,272,RC,A6457,HCPCS,,10658-MAIN,LOCAL,,,,,10.62,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STOCKINETTE STERILE 4X48 NON22360,27200000,CDM,272,RC,A6457,HCPCS,,10658-MAIN,LOCAL,,,,,10.62,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STRAP CLAVICLE LARGE VP10123-040,120.191,CDM,274,RC,L3670,HCPCS,,12848-MAIN,LOCAL,,,,,24,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STRAP CLAVICLE LARGE VP10123-040,120.191,CDM,274,RC,L3670,HCPCS,,12848-MAIN,LOCAL,,,,,24,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STRAP CLAVICLE LARGE VP10123-040,120.191,CDM,274,RC,L3670,HCPCS,,12848-MAIN,LOCAL,,,,,24,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STRAP CLAVICLE LARGE VP10123-040,120.191,CDM,274,RC,L3670,HCPCS,,12848-MAIN,LOCAL,,,,,24,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STRAP CLAVICLE LARGE VP10123-040,120.191,CDM,274,RC,L3670,HCPCS,,12848-MAIN,LOCAL,,,,,24,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STRAP CLAVICLE LARGE VP10123-040,120.191,CDM,274,RC,L3670,HCPCS,,12848-MAIN,LOCAL,,,,,24,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STRAP CLAVICLE MEDIUM VP10123-030,120.191,CDM,274,RC,L3670,HCPCS,,12847-MAIN,LOCAL,,,,,24,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STRAP CLAVICLE MEDIUM VP10123-030,120.191,CDM,274,RC,L3670,HCPCS,,12847-MAIN,LOCAL,,,,,24,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STRAP CLAVICLE MEDIUM VP10123-030,120.191,CDM,274,RC,L3670,HCPCS,,12847-MAIN,LOCAL,,,,,24,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STRAP CLAVICLE MEDIUM VP10123-030,120.191,CDM,274,RC,L3670,HCPCS,,12847-MAIN,LOCAL,,,,,24,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STRAP CLAVICLE MEDIUM VP10123-030,120.191,CDM,274,RC,L3670,HCPCS,,12847-MAIN,LOCAL,,,,,24,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STRAP CLAVICLE MEDIUM VP10123-030,120.191,CDM,274,RC,L3670,HCPCS,,12847-MAIN,LOCAL,,,,,24,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STRAP CLAVICLE SMALL VP10123-020,120.191,CDM,274,RC,L3670,HCPCS,,12846-MAIN,LOCAL,,,,,24,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STRAP CLAVICLE SMALL VP10123-020,120.191,CDM,274,RC,L3670,HCPCS,,12846-MAIN,LOCAL,,,,,24,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STRAP CLAVICLE SMALL VP10123-020,120.191,CDM,274,RC,L3670,HCPCS,,12846-MAIN,LOCAL,,,,,24,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STRAP CLAVICLE SMALL VP10123-020,120.191,CDM,274,RC,L3670,HCPCS,,12846-MAIN,LOCAL,,,,,24,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STRAP CLAVICLE SMALL VP10123-020,120.191,CDM,274,RC,L3670,HCPCS,,12846-MAIN,LOCAL,,,,,24,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STRAP CLAVICLE SMALL VP10123-020,120.191,CDM,274,RC,L3670,HCPCS,,12846-MAIN,LOCAL,,,,,24,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STRAP CLAVICLE XL 661 XL,120.191,CDM,274,RC,L3670,HCPCS,,12850-MAIN,LOCAL,,,,,24,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STRAP CLAVICLE XL 661 XL,120.191,CDM,274,RC,L3670,HCPCS,,12850-MAIN,LOCAL,,,,,24,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STRAP CLAVICLE XL 661 XL,120.191,CDM,274,RC,L3670,HCPCS,,12850-MAIN,LOCAL,,,,,24,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STRAP CLAVICLE XL 661 XL,120.191,CDM,274,RC,L3670,HCPCS,,12850-MAIN,LOCAL,,,,,24,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STRAP CLAVICLE XL 661 XL,120.191,CDM,274,RC,L3670,HCPCS,,12850-MAIN,LOCAL,,,,,24,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STRAP CLAVICLE XL 661 XL,120.191,CDM,274,RC,L3670,HCPCS,,12850-MAIN,LOCAL,,,,,24,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STRAP CLAVICLE XSMALL CHILD ORT14100XS,120.191,CDM,274,RC,L3670,HCPCS,,12849-MAIN,LOCAL,,,,,24,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STRAP CLAVICLE XSMALL CHILD ORT14100XS,120.191,CDM,274,RC,L3670,HCPCS,,12849-MAIN,LOCAL,,,,,24,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STRAP CLAVICLE XSMALL CHILD ORT14100XS,120.191,CDM,274,RC,L3670,HCPCS,,12849-MAIN,LOCAL,,,,,24,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STRAP CLAVICLE XSMALL CHILD ORT14100XS,120.191,CDM,274,RC,L3670,HCPCS,,12849-MAIN,LOCAL,,,,,24,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STRAP CLAVICLE XSMALL CHILD ORT14100XS,120.191,CDM,274,RC,L3670,HCPCS,,12849-MAIN,LOCAL,,,,,24,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STRAP CLAVICLE XSMALL CHILD ORT14100XS,120.191,CDM,274,RC,L3670,HCPCS,,12849-MAIN,LOCAL,,,,,24,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STRAP FOOT LG/XL GEL UNIVERSAL 10165,120.428,CDM,271,RC,,,,11382-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STRAP FOOT LG/XL GEL UNIVERSAL 10165,120.428,CDM,271,RC,,,,11382-MAIN,LOCAL,,,,,41,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STRAP FOOT LG/XL GEL UNIVERSAL 10165,120.428,CDM,271,RC,,,,11382-MAIN,LOCAL,,,,,41,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STRAP FOOT LG/XL GEL UNIVERSAL 10165,120.428,CDM,271,RC,,,,11382-MAIN,LOCAL,,,,,41,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STRAP FOOT LG/XL GEL UNIVERSAL 10165,120.428,CDM,271,RC,,,,11382-MAIN,LOCAL,,,,,41,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STRAP FOOT LG/XL GEL UNIVERSAL 10165,120.428,CDM,271,RC,,,,11382-MAIN,LOCAL,,,,,41,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STRAP FOOT SM/MED GEL UNIVERSAL 10155,120.428,CDM,271,RC,,,,11381-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STRAP FOOT SM/MED GEL UNIVERSAL 10155,120.428,CDM,271,RC,,,,11381-MAIN,LOCAL,,,,,41,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STRAP FOOT SM/MED GEL UNIVERSAL 10155,120.428,CDM,271,RC,,,,11381-MAIN,LOCAL,,,,,41,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STRAP FOOT SM/MED GEL UNIVERSAL 10155,120.428,CDM,271,RC,,,,11381-MAIN,LOCAL,,,,,41,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STRAP FOOT SM/MED GEL UNIVERSAL 10155,120.428,CDM,271,RC,,,,11381-MAIN,LOCAL,,,,,41,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STRAP FOOT SM/MED GEL UNIVERSAL 10155,120.428,CDM,271,RC,,,,11381-MAIN,LOCAL,,,,,41,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Ankle,PX29540F,CDM,420,RC,29540,CPT,,,,,,,,271,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Ankle,PX29540F,CDM,420,RC,29540,CPT,,,,,,,,271,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Ankle,PX29540F,CDM,420,RC,29540,CPT,,,,,,,,271,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Ankle,PX29540F,CDM,420,RC,29540,CPT,,,,,,,,271,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Ankle,PX29540F,CDM,420,RC,29540,CPT,,,,,,,,271,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Ankle,PX29540F,CDM,420,RC,29540,CPT,,,,,,,,271,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Elbow or Wrist,PX29260F,CDM,420,RC,29260,CPT,,,,,,,,64,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Elbow or Wrist,PX29260F,CDM,420,RC,29260,CPT,,,,,,,,64,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Elbow or Wrist,PX29260F,CDM,420,RC,29260,CPT,,,,,,,,64,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Elbow or Wrist,PX29260F,CDM,420,RC,29260,CPT,,,,,,,,64,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Elbow or Wrist,PX29260F,CDM,420,RC,29260,CPT,,,,,,,,64,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Elbow or Wrist,PX29260F,CDM,420,RC,29260,CPT,,,,,,,,64,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Hand or Finger,PX29280F,CDM,420,RC,29280,CPT,,,,,,,,64,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Hand or Finger,PX29280F,CDM,420,RC,29280,CPT,,,,,,,,64,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Hand or Finger,PX29280F,CDM,420,RC,29280,CPT,,,,,,,,64,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Hand or Finger,PX29280F,CDM,420,RC,29280,CPT,,,,,,,,64,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Hand or Finger,PX29280F,CDM,420,RC,29280,CPT,,,,,,,,64,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Hand or Finger,PX29280F,CDM,420,RC,29280,CPT,,,,,,,,64,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Knee,PX29530F,CDM,420,RC,29530,CPT,,,,,,,,303,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Knee,PX29530F,CDM,420,RC,29530,CPT,,,,,,,,303,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Knee,PX29530F,CDM,420,RC,29530,CPT,,,,,,,,303,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Knee,PX29530F,CDM,420,RC,29530,CPT,,,,,,,,303,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Knee,PX29530F,CDM,420,RC,29530,CPT,,,,,,,,303,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Knee,PX29530F,CDM,420,RC,29530,CPT,,,,,,,,303,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Shoulder,PX29240F,CDM,420,RC,29240,CPT,,,,,,,,165,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Shoulder,PX29240F,CDM,420,RC,29240,CPT,,,,,,,,165,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Shoulder,PX29240F,CDM,420,RC,29240,CPT,,,,,,,,165,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Shoulder,PX29240F,CDM,420,RC,29240,CPT,,,,,,,,165,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Shoulder,PX29240F,CDM,420,RC,29240,CPT,,,,,,,,165,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Shoulder,PX29240F,CDM,420,RC,29240,CPT,,,,,,,,165,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Shoulder,PX29240P,CDM,983,RC,29240,CPT,,,,,,,,110,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Shoulder,PX29240P,CDM,983,RC,29240,CPT,,,,,,,,110,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Shoulder,PX29240P,CDM,983,RC,29240,CPT,,,,,,,,110,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Shoulder,PX29240P,CDM,983,RC,29240,CPT,,,,,,,,110,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Shoulder,PX29240P,CDM,983,RC,29240,CPT,,,,,,,,110,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Shoulder,PX29240P,CDM,983,RC,29240,CPT,,,,,,,,110,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Toes,PX29550F,CDM,510,RC,29550,CPT,,,,,,,,113,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Toes,PX29550F,CDM,510,RC,29550,CPT,,,,,,,,113,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Toes,PX29550F,CDM,510,RC,29550,CPT,,,,,,,,113,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Toes,PX29550F,CDM,510,RC,29550,CPT,,,,,,,,113,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Toes,PX29550F,CDM,510,RC,29550,CPT,,,,,,,,113,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Toes,PX29550F,CDM,510,RC,29550,CPT,,,,,,,,113,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strep a Assay W/Optic,PX87880,CDM,300,RC,87880,CPT,,,,,,,,95,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strep a Assay W/Optic,PX87880,CDM,300,RC,87880,CPT,,,,,,,,95,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strep a Assay W/Optic,PX87880,CDM,300,RC,87880,CPT,,,,,,,,95,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strep a Assay W/Optic,PX87880,CDM,300,RC,87880,CPT,,,,,,,,95,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strep a Assay W/Optic,PX87880,CDM,300,RC,87880,CPT,,,,,,,,95,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strep a Assay W/Optic,PX87880,CDM,300,RC,87880,CPT,,,,,,,,95,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Subsequent Observation Care,PX99225,CDM,982,RC,99225,CPT,,,,,,,,253,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Subsequent Observation Care,PX99225,CDM,982,RC,99225,CPT,,,,,,,,253,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Subsequent Observation Care,PX99225,CDM,982,RC,99225,CPT,,,,,,,,253,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Subsequent Observation Care,PX99225,CDM,982,RC,99225,CPT,,,,,,,,253,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Subsequent Observation Care,PX99225,CDM,982,RC,99225,CPT,,,,,,,,253,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Subsequent Observation Care,PX99225,CDM,982,RC,99225,CPT,,,,,,,,253,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,409662902,NDC,10,ML,146.84,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,409662902,NDC,10,ML,146.84,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,409662902,NDC,10,ML,146.84,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,409662902,NDC,10,ML,146.84,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,409662902,NDC,10,ML,146.84,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,409662902,NDC,10,ML,146.84,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094310,NDC,10,ML,72.79,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094310,NDC,10,ML,72.79,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094310,NDC,10,ML,72.79,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094310,NDC,10,ML,72.79,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094310,NDC,10,ML,72.79,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094310,NDC,10,ML,72.79,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094321,NDC,10,ML,72.79,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094321,NDC,10,ML,72.79,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094321,NDC,10,ML,72.79,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094321,NDC,10,ML,72.79,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094321,NDC,10,ML,72.79,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094321,NDC,10,ML,72.79,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sucralfate 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762040101,NDC,1,EA,3.81,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sucralfate 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762040101,NDC,1,EA,3.81,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sucralfate 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762040101,NDC,1,EA,3.81,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sucralfate 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762040101,NDC,1,EA,3.81,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sucralfate 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762040101,NDC,1,EA,3.81,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sucralfate 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762040101,NDC,1,EA,3.81,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sucralfate 1 GM/10ML Suspension 10 mL Cup,63700001,CDM,250,RC,,,,,,68094004359,NDC,10,ML,60.92,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sucralfate 1 GM/10ML Suspension 10 mL Cup,63700001,CDM,250,RC,,,,,,68094004359,NDC,10,ML,60.92,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sucralfate 1 GM/10ML Suspension 10 mL Cup,63700001,CDM,250,RC,,,,,,68094004359,NDC,10,ML,60.92,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sucralfate 1 GM/10ML Suspension 10 mL Cup,63700001,CDM,250,RC,,,,,,68094004359,NDC,10,ML,60.92,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sucralfate 1 GM/10ML Suspension 10 mL Cup,63700001,CDM,250,RC,,,,,,68094004359,NDC,10,ML,60.92,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sucralfate 1 GM/10ML Suspension 10 mL Cup,63700001,CDM,250,RC,,,,,,68094004359,NDC,10,ML,60.92,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUCTION IRRIGATOR 2 0250070500,27200000,CDM,272,RC,,,,12262-MAIN,LOCAL,,,,,88,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUCTION IRRIGATOR 2 0250070500,27200000,CDM,272,RC,,,,12262-MAIN,LOCAL,,,,,88,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUCTION IRRIGATOR 2 0250070500,27200000,CDM,272,RC,,,,12262-MAIN,LOCAL,,,,,88,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUCTION IRRIGATOR 2 0250070500,27200000,CDM,272,RC,,,,12262-MAIN,LOCAL,,,,,88,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUCTION IRRIGATOR 2 0250070500,27200000,CDM,272,RC,,,,12262-MAIN,LOCAL,,,,,88,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUCTION IRRIGATOR 2 0250070500,27200000,CDM,272,RC,,,,12262-MAIN,LOCAL,,,,,88,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUCTION TIP POOLE STERILE 35040,27200000,CDM,272,RC,,,,977-MAIN,LOCAL,,,,,42.28,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUCTION TIP POOLE STERILE 35040,27200000,CDM,272,RC,,,,977-MAIN,LOCAL,,,,,42.28,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUCTION TIP POOLE STERILE 35040,27200000,CDM,272,RC,,,,977-MAIN,LOCAL,,,,,42.28,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUCTION TIP POOLE STERILE 35040,27200000,CDM,272,RC,,,,977-MAIN,LOCAL,,,,,42.28,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUCTION TIP POOLE STERILE 35040,27200000,CDM,272,RC,,,,977-MAIN,LOCAL,,,,,42.28,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUCTION TIP POOLE STERILE 35040,27200000,CDM,272,RC,,,,977-MAIN,LOCAL,,,,,42.28,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sugammadex sodium 200 MG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,6542302,NDC,2,ML,652.81,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sugammadex sodium 200 MG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,6542302,NDC,2,ML,652.81,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sugammadex sodium 200 MG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,6542302,NDC,2,ML,652.81,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sugammadex sodium 200 MG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,6542302,NDC,2,ML,652.81,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sugammadex sodium 200 MG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,6542302,NDC,2,ML,652.81,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sugammadex sodium 200 MG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,6542302,NDC,2,ML,652.81,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sugammadex sodium 200 MG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,6542312,NDC,2,ML,583.33,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sugammadex sodium 200 MG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,6542312,NDC,2,ML,583.33,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sugammadex sodium 200 MG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,6542312,NDC,2,ML,583.33,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sugammadex sodium 200 MG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,6542312,NDC,2,ML,583.33,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sugammadex sodium 200 MG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,6542312,NDC,2,ML,583.33,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sugammadex sodium 200 MG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,6542312,NDC,2,ML,583.33,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sugars, Qual, Ea Spec - Ref",PX8437690,CDM,300,RC,84376,CPT,90,,,,,,,45,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sugars, Qual, Ea Spec - Ref",PX8437690,CDM,300,RC,84376,CPT,90,,,,,,,45,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sugars, Qual, Ea Spec - Ref",PX8437690,CDM,300,RC,84376,CPT,90,,,,,,,45,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sugars, Qual, Ea Spec - Ref",PX8437690,CDM,300,RC,84376,CPT,90,,,,,,,45,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sugars, Qual, Ea Spec - Ref",PX8437690,CDM,300,RC,84376,CPT,90,,,,,,,45,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sugars, Qual, Ea Spec - Ref",PX8437690,CDM,300,RC,84376,CPT,90,,,,,,,45,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sulfacetamide 10 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,24208067004,NDC,15,ML,312.96,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sulfacetamide 10 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,24208067004,NDC,15,ML,312.96,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sulfacetamide 10 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,24208067004,NDC,15,ML,312.96,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sulfacetamide 10 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,24208067004,NDC,15,ML,312.96,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sulfacetamide 10 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,24208067004,NDC,15,ML,312.96,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sulfacetamide 10 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,24208067004,NDC,15,ML,312.96,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sulfacetamide 10 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,61314070101,NDC,15,ML,285.48,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sulfacetamide 10 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,61314070101,NDC,15,ML,285.48,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sulfacetamide 10 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,61314070101,NDC,15,ML,285.48,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sulfacetamide 10 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,61314070101,NDC,15,ML,285.48,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sulfacetamide 10 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,61314070101,NDC,15,ML,285.48,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sulfacetamide 10 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,61314070101,NDC,15,ML,285.48,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sulfamethoxazole-trimethoprim 200-40 MG/5ML Suspension 473 mL Bottle,63700001,CDM,250,RC,,,,,,65862049647,NDC,10,ML,18.79,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sulfamethoxazole-trimethoprim 200-40 MG/5ML Suspension 473 mL Bottle,63700001,CDM,250,RC,,,,,,65862049647,NDC,10,ML,18.79,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sulfamethoxazole-trimethoprim 200-40 MG/5ML Suspension 473 mL Bottle,63700001,CDM,250,RC,,,,,,65862049647,NDC,10,ML,18.79,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sulfamethoxazole-trimethoprim 200-40 MG/5ML Suspension 473 mL Bottle,63700001,CDM,250,RC,,,,,,65862049647,NDC,10,ML,18.79,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sulfamethoxazole-trimethoprim 200-40 MG/5ML Suspension 473 mL Bottle,63700001,CDM,250,RC,,,,,,65862049647,NDC,10,ML,18.79,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sulfamethoxazole-trimethoprim 200-40 MG/5ML Suspension 473 mL Bottle,63700001,CDM,250,RC,,,,,,65862049647,NDC,10,ML,18.79,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sulfamethoxazole-trimethoprim 400-80 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237023201,NDC,1,EA,3.57,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sulfamethoxazole-trimethoprim 400-80 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237023201,NDC,1,EA,3.57,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sulfamethoxazole-trimethoprim 400-80 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237023201,NDC,1,EA,3.57,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sulfamethoxazole-trimethoprim 400-80 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237023201,NDC,1,EA,3.57,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sulfamethoxazole-trimethoprim 400-80 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237023201,NDC,1,EA,3.57,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sulfamethoxazole-trimethoprim 400-80 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237023201,NDC,1,EA,3.57,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sulfamethoxazole-trimethoprim 400-80 MG/5ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,703951403,NDC,10,ML,102.93,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sulfamethoxazole-trimethoprim 400-80 MG/5ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,703951403,NDC,10,ML,102.93,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sulfamethoxazole-trimethoprim 400-80 MG/5ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,703951403,NDC,10,ML,102.93,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sulfamethoxazole-trimethoprim 400-80 MG/5ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,703951403,NDC,10,ML,102.93,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sulfamethoxazole-trimethoprim 400-80 MG/5ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,703951403,NDC,10,ML,102.93,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sulfamethoxazole-trimethoprim 400-80 MG/5ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,703951403,NDC,10,ML,102.93,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sulfamethoxazole-trimethoprim 800-160 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904272561,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sulfamethoxazole-trimethoprim 800-160 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904272561,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sulfamethoxazole-trimethoprim 800-160 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904272561,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sulfamethoxazole-trimethoprim 800-160 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904272561,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sulfamethoxazole-trimethoprim 800-160 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904272561,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sulfamethoxazole-trimethoprim 800-160 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904272561,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sulfamethoxazole-trimethoprim 800-160 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739022810,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sulfamethoxazole-trimethoprim 800-160 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739022810,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sulfamethoxazole-trimethoprim 800-160 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739022810,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sulfamethoxazole-trimethoprim 800-160 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739022810,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sulfamethoxazole-trimethoprim 800-160 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739022810,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sulfamethoxazole-trimethoprim 800-160 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739022810,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sulfur Colloid per Dose,PXA9541,CDM,343,RC,A9541,HCPCS,,,,,,,,295,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sulfur Colloid per Dose,PXA9541,CDM,343,RC,A9541,HCPCS,,,,,,,,295,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sulfur Colloid per Dose,PXA9541,CDM,343,RC,A9541,HCPCS,,,,,,,,295,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sulfur Colloid per Dose,PXA9541,CDM,343,RC,A9541,HCPCS,,,,,,,,295,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sulfur Colloid per Dose,PXA9541,CDM,343,RC,A9541,HCPCS,,,,,,,,295,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sulfur Colloid per Dose,PXA9541,CDM,343,RC,A9541,HCPCS,,,,,,,,295,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963801,NDC,0.5,ML,88.69,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963801,NDC,0.5,ML,88.69,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963801,NDC,0.5,ML,88.69,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963801,NDC,0.5,ML,88.69,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963801,NDC,0.5,ML,88.69,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963801,NDC,0.5,ML,88.69,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963805,NDC,0.5,ML,142.98,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963805,NDC,0.5,ML,142.98,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963805,NDC,0.5,ML,142.98,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963805,NDC,0.5,ML,142.98,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963805,NDC,0.5,ML,142.98,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963805,NDC,0.5,ML,142.98,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,55150017301,NDC,0.5,ML,319.2,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,55150017301,NDC,0.5,ML,319.2,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,55150017301,NDC,0.5,ML,319.2,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,55150017301,NDC,0.5,ML,319.2,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,55150017301,NDC,0.5,ML,319.2,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,55150017301,NDC,0.5,ML,319.2,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,63323027301,NDC,0.5,ML,235.6,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,63323027301,NDC,0.5,ML,235.6,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,63323027301,NDC,0.5,ML,235.6,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,63323027301,NDC,0.5,ML,235.6,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,63323027301,NDC,0.5,ML,235.6,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,63323027301,NDC,0.5,ML,235.6,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUMAtriptan 25 MG Tablet 9 Each Box,63700001,CDM,250,RC,,,,,,65862014636,NDC,1,EA,129.04,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUMAtriptan 25 MG Tablet 9 Each Box,63700001,CDM,250,RC,,,,,,65862014636,NDC,1,EA,129.04,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUMAtriptan 25 MG Tablet 9 Each Box,63700001,CDM,250,RC,,,,,,65862014636,NDC,1,EA,129.04,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUMAtriptan 25 MG Tablet 9 Each Box,63700001,CDM,250,RC,,,,,,65862014636,NDC,1,EA,129.04,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUMAtriptan 25 MG Tablet 9 Each Box,63700001,CDM,250,RC,,,,,,65862014636,NDC,1,EA,129.04,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUMAtriptan 25 MG Tablet 9 Each Box,63700001,CDM,250,RC,,,,,,65862014636,NDC,1,EA,129.04,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Supply Technetium Medronate,to 30 MC",PXA9503,CDM,343,RC,A9503,HCPCS,,,,,,,,531,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Supply Technetium Medronate,to 30 MC",PXA9503,CDM,343,RC,A9503,HCPCS,,,,,,,,531,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Supply Technetium Medronate,to 30 MC",PXA9503,CDM,343,RC,A9503,HCPCS,,,,,,,,531,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Supply Technetium Medronate,to 30 MC",PXA9503,CDM,343,RC,A9503,HCPCS,,,,,,,,531,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Supply Technetium Medronate,to 30 MC",PXA9503,CDM,343,RC,A9503,HCPCS,,,,,,,,531,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Supply Technetium Medronate,to 30 MC",PXA9503,CDM,343,RC,A9503,HCPCS,,,,,,,,531,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Supply Technicium Sestamibi,per Dose",PXA9500,CDM,343,RC,A9500,HCPCS,,,,,,,,410,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Supply Technicium Sestamibi,per Dose",PXA9500,CDM,343,RC,A9500,HCPCS,,,,,,,,410,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Supply Technicium Sestamibi,per Dose",PXA9500,CDM,343,RC,A9500,HCPCS,,,,,,,,410,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Supply Technicium Sestamibi,per Dose",PXA9500,CDM,343,RC,A9500,HCPCS,,,,,,,,410,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Supply Technicium Sestamibi,per Dose",PXA9500,CDM,343,RC,A9500,HCPCS,,,,,,,,410,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Supply Technicium Sestamibi,per Dose",PXA9500,CDM,343,RC,A9500,HCPCS,,,,,,,,410,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Support for Organ Donor,PX01990.01,CDM,964,RC,1990,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Support for Organ Donor,PX01990.01,CDM,964,RC,1990,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Surg Pathology-Level 2-Tc,PX3932,CDM,310,RC,88302,CPT,TC,,,,,,,66,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Surg Pathology-Level 2-Tc,PX3932,CDM,310,RC,88302,CPT,TC,,,,,,,66,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Surg Pathology-Level 2-Tc,PX3932,CDM,310,RC,88302,CPT,TC,,,,,,,66,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Surg Pathology-Level 2-Tc,PX3932,CDM,310,RC,88302,CPT,TC,,,,,,,66,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Surg Pathology-Level 2-Tc,PX3932,CDM,310,RC,88302,CPT,TC,,,,,,,66,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Surg Pathology-Level 2-Tc,PX3932,CDM,310,RC,88302,CPT,TC,,,,,,,66,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Surgical Cleansing of Skin,PX11000P,CDM,983,RC,11000,CPT,,,,,,,,145,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Surgical Cleansing of Skin,PX11000P,CDM,983,RC,11000,CPT,,,,,,,,145,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Surgical Cleansing of Skin,PX11000P,CDM,983,RC,11000,CPT,,,,,,,,145,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Surgical Cleansing of Skin,PX11000P,CDM,983,RC,11000,CPT,,,,,,,,145,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Surgical Cleansing of Skin,PX11000P,CDM,983,RC,11000,CPT,,,,,,,,145,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Surgical Cleansing of Skin,PX11000P,CDM,983,RC,11000,CPT,,,,,,,,145,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Surgical Diagnostic Exam, Anorectal",PX45990P,CDM,983,RC,45990,CPT,,,,,,,,409,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Surgical Diagnostic Exam, Anorectal",PX45990P,CDM,983,RC,45990,CPT,,,,,,,,409,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Surgical Diagnostic Exam, Anorectal",PX45990P,CDM,983,RC,45990,CPT,,,,,,,,409,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Surgical Diagnostic Exam, Anorectal",PX45990P,CDM,983,RC,45990,CPT,,,,,,,,409,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Surgical Diagnostic Exam, Anorectal",PX45990P,CDM,983,RC,45990,CPT,,,,,,,,409,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Surgical Diagnostic Exam, Anorectal",PX45990P,CDM,983,RC,45990,CPT,,,,,,,,409,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SURGIFOAM ABSORBABLE GELATIN SPONGE 3.1 IN X 4.9IN X 10MM,120.371,CDM,272,RC,A4649,HCPCS,,10864-MAIN,LOCAL,,,,,55,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SURGIFOAM ABSORBABLE GELATIN SPONGE 3.1 IN X 4.9IN X 10MM,120.371,CDM,272,RC,A4649,HCPCS,,10864-MAIN,LOCAL,,,,,55,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SURGIFOAM ABSORBABLE GELATIN SPONGE 3.1 IN X 4.9IN X 10MM,120.371,CDM,272,RC,A4649,HCPCS,,10864-MAIN,LOCAL,,,,,55,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SURGIFOAM ABSORBABLE GELATIN SPONGE 3.1 IN X 4.9IN X 10MM,120.371,CDM,272,RC,A4649,HCPCS,,10864-MAIN,LOCAL,,,,,55,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SURGIFOAM ABSORBABLE GELATIN SPONGE 3.1 IN X 4.9IN X 10MM,120.371,CDM,272,RC,A4649,HCPCS,,10864-MAIN,LOCAL,,,,,55,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SURGIFOAM ABSORBABLE GELATIN SPONGE 3.1 IN X 4.9IN X 10MM,120.371,CDM,272,RC,A4649,HCPCS,,10864-MAIN,LOCAL,,,,,55,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE BIOSYN MONOFILAMENT ABSORBABLE UNDYED SIZE 4-0 18IN WITH 3/8 CIRCLE REVERSE CUTTING 19MM NEED,27200000,CDM,272,RC,,,,11987-MAIN,LOCAL,,,,,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE BIOSYN MONOFILAMENT ABSORBABLE UNDYED SIZE 4-0 18IN WITH 3/8 CIRCLE REVERSE CUTTING 19MM NEED,27200000,CDM,272,RC,,,,11987-MAIN,LOCAL,,,,,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE BIOSYN MONOFILAMENT ABSORBABLE UNDYED SIZE 4-0 18IN WITH 3/8 CIRCLE REVERSE CUTTING 19MM NEED,27200000,CDM,272,RC,,,,11987-MAIN,LOCAL,,,,,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE BIOSYN MONOFILAMENT ABSORBABLE UNDYED SIZE 4-0 18IN WITH 3/8 CIRCLE REVERSE CUTTING 19MM NEED,27200000,CDM,272,RC,,,,11987-MAIN,LOCAL,,,,,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE BIOSYN MONOFILAMENT ABSORBABLE UNDYED SIZE 4-0 18IN WITH 3/8 CIRCLE REVERSE CUTTING 19MM NEED,27200000,CDM,272,RC,,,,11987-MAIN,LOCAL,,,,,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE BIOSYN MONOFILAMENT ABSORBABLE UNDYED SIZE 4-0 18IN WITH 3/8 CIRCLE REVERSE CUTTING 19MM NEED,27200000,CDM,272,RC,,,,11987-MAIN,LOCAL,,,,,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"SUTURE CHROME GUT 3-0 CP-2 27""",27200000,CDM,272,RC,,,,4967-MAIN,LOCAL,,,,,11.59,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"SUTURE CHROME GUT 3-0 CP-2 27""",27200000,CDM,272,RC,,,,4967-MAIN,LOCAL,,,,,11.59,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"SUTURE CHROME GUT 3-0 CP-2 27""",27200000,CDM,272,RC,,,,4967-MAIN,LOCAL,,,,,11.59,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"SUTURE CHROME GUT 3-0 CP-2 27""",27200000,CDM,272,RC,,,,4967-MAIN,LOCAL,,,,,11.59,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"SUTURE CHROME GUT 3-0 CP-2 27""",27200000,CDM,272,RC,,,,4967-MAIN,LOCAL,,,,,11.59,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"SUTURE CHROME GUT 3-0 CP-2 27""",27200000,CDM,272,RC,,,,4967-MAIN,LOCAL,,,,,11.59,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE CTD VICRYL 4-0 VIL BR SUTUPK J103T,27200000,CDM,272,RC,,,,4491-MAIN,LOCAL,,,,,373.97,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE CTD VICRYL 4-0 VIL BR SUTUPK J103T,27200000,CDM,272,RC,,,,4491-MAIN,LOCAL,,,,,373.97,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE CTD VICRYL 4-0 VIL BR SUTUPK J103T,27200000,CDM,272,RC,,,,4491-MAIN,LOCAL,,,,,373.97,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE CTD VICRYL 4-0 VIL BR SUTUPK J103T,27200000,CDM,272,RC,,,,4491-MAIN,LOCAL,,,,,373.97,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE CTD VICRYL 4-0 VIL BR SUTUPK J103T,27200000,CDM,272,RC,,,,4491-MAIN,LOCAL,,,,,373.97,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE CTD VICRYL 4-0 VIL BR SUTUPK J103T,27200000,CDM,272,RC,,,,4491-MAIN,LOCAL,,,,,373.97,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"SUTURE ETHIBOND #0 CT-1 CR 8-18"" CX21D",27200000,CDM,272,RC,,,,6415-MAIN,LOCAL,,,,,41.97,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"SUTURE ETHIBOND #0 CT-1 CR 8-18"" CX21D",27200000,CDM,272,RC,,,,6415-MAIN,LOCAL,,,,,41.97,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"SUTURE ETHIBOND #0 CT-1 CR 8-18"" CX21D",27200000,CDM,272,RC,,,,6415-MAIN,LOCAL,,,,,41.97,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"SUTURE ETHIBOND #0 CT-1 CR 8-18"" CX21D",27200000,CDM,272,RC,,,,6415-MAIN,LOCAL,,,,,41.97,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"SUTURE ETHIBOND #0 CT-1 CR 8-18"" CX21D",27200000,CDM,272,RC,,,,6415-MAIN,LOCAL,,,,,41.97,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"SUTURE ETHIBOND #0 CT-1 CR 8-18"" CX21D",27200000,CDM,272,RC,,,,6415-MAIN,LOCAL,,,,,41.97,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE ETHIBOND XTRA 0 SHSH 36 INCH,27200000,CDM,272,RC,,,,12678-MAIN,LOCAL,,,,,11,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE ETHIBOND XTRA 0 SHSH 36 INCH,27200000,CDM,272,RC,,,,12678-MAIN,LOCAL,,,,,11,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE ETHIBOND XTRA 0 SHSH 36 INCH,27200000,CDM,272,RC,,,,12678-MAIN,LOCAL,,,,,11,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE ETHIBOND XTRA 0 SHSH 36 INCH,27200000,CDM,272,RC,,,,12678-MAIN,LOCAL,,,,,11,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE ETHIBOND XTRA 0 SHSH 36 INCH,27200000,CDM,272,RC,,,,12678-MAIN,LOCAL,,,,,11,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE ETHIBOND XTRA 0 SHSH 36 INCH,27200000,CDM,272,RC,,,,12678-MAIN,LOCAL,,,,,11,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"SUTURE ETHILON 2-0 BLK MONO FS 18"" 664G",27200000,CDM,272,RC,,,,3663-MAIN,LOCAL,,,,,6.59,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"SUTURE ETHILON 2-0 BLK MONO FS 18"" 664G",27200000,CDM,272,RC,,,,3663-MAIN,LOCAL,,,,,6.59,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"SUTURE ETHILON 2-0 BLK MONO FS 18"" 664G",27200000,CDM,272,RC,,,,3663-MAIN,LOCAL,,,,,6.59,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"SUTURE ETHILON 2-0 BLK MONO FS 18"" 664G",27200000,CDM,272,RC,,,,3663-MAIN,LOCAL,,,,,6.59,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"SUTURE ETHILON 2-0 BLK MONO FS 18"" 664G",27200000,CDM,272,RC,,,,3663-MAIN,LOCAL,,,,,6.59,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"SUTURE ETHILON 2-0 BLK MONO FS 18"" 664G",27200000,CDM,272,RC,,,,3663-MAIN,LOCAL,,,,,6.59,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE ETHILON SIZE 0 96INCH TP1,27200000,CDM,272,RC,,,,12140-MAIN,LOCAL,,,,,9,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE ETHILON SIZE 0 96INCH TP1,27200000,CDM,272,RC,,,,12140-MAIN,LOCAL,,,,,9,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE ETHILON SIZE 0 96INCH TP1,27200000,CDM,272,RC,,,,12140-MAIN,LOCAL,,,,,9,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE ETHILON SIZE 0 96INCH TP1,27200000,CDM,272,RC,,,,12140-MAIN,LOCAL,,,,,9,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE ETHILON SIZE 0 96INCH TP1,27200000,CDM,272,RC,,,,12140-MAIN,LOCAL,,,,,9,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE ETHILON SIZE 0 96INCH TP1,27200000,CDM,272,RC,,,,12140-MAIN,LOCAL,,,,,9,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE MAXON ABSORBABLE POLYGLYCONATE 2-0 30IN MONOFILAMENT DYED TAPER POINT 1/2 CIRCLE 27MM GS-22 G,27200000,CDM,272,RC,,,,11988-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE MAXON ABSORBABLE POLYGLYCONATE 2-0 30IN MONOFILAMENT DYED TAPER POINT 1/2 CIRCLE 27MM GS-22 G,27200000,CDM,272,RC,,,,11988-MAIN,LOCAL,,,,,23,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE MAXON ABSORBABLE POLYGLYCONATE 2-0 30IN MONOFILAMENT DYED TAPER POINT 1/2 CIRCLE 27MM GS-22 G,27200000,CDM,272,RC,,,,11988-MAIN,LOCAL,,,,,23,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE MAXON ABSORBABLE POLYGLYCONATE 2-0 30IN MONOFILAMENT DYED TAPER POINT 1/2 CIRCLE 27MM GS-22 G,27200000,CDM,272,RC,,,,11988-MAIN,LOCAL,,,,,23,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE MAXON ABSORBABLE POLYGLYCONATE 2-0 30IN MONOFILAMENT DYED TAPER POINT 1/2 CIRCLE 27MM GS-22 G,27200000,CDM,272,RC,,,,11988-MAIN,LOCAL,,,,,23,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE MAXON ABSORBABLE POLYGLYCONATE 2-0 30IN MONOFILAMENT DYED TAPER POINT 1/2 CIRCLE 27MM GS-22 G,27200000,CDM,272,RC,,,,11988-MAIN,LOCAL,,,,,23,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE MAXON MONOFILAMENT ABSORBABLE GREEN SIZE 1 96IN WITH 1/2 CIRCLE TAPER POINT 65MM NEEDLE,27200000,CDM,272,RC,,,,11986-MAIN,LOCAL,,,,,63,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE MAXON MONOFILAMENT ABSORBABLE GREEN SIZE 1 96IN WITH 1/2 CIRCLE TAPER POINT 65MM NEEDLE,27200000,CDM,272,RC,,,,11986-MAIN,LOCAL,,,,,63,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE MAXON MONOFILAMENT ABSORBABLE GREEN SIZE 1 96IN WITH 1/2 CIRCLE TAPER POINT 65MM NEEDLE,27200000,CDM,272,RC,,,,11986-MAIN,LOCAL,,,,,63,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE MAXON MONOFILAMENT ABSORBABLE GREEN SIZE 1 96IN WITH 1/2 CIRCLE TAPER POINT 65MM NEEDLE,27200000,CDM,272,RC,,,,11986-MAIN,LOCAL,,,,,63,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE MAXON MONOFILAMENT ABSORBABLE GREEN SIZE 1 96IN WITH 1/2 CIRCLE TAPER POINT 65MM NEEDLE,27200000,CDM,272,RC,,,,11986-MAIN,LOCAL,,,,,63,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE MAXON MONOFILAMENT ABSORBABLE GREEN SIZE 1 96IN WITH 1/2 CIRCLE TAPER POINT 65MM NEEDLE,27200000,CDM,272,RC,,,,11986-MAIN,LOCAL,,,,,63,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE MONOFILAMENT SZ 4-0 BIOSYN ABSORBABLE UNDYED18IN WITH 3/8 CIRCLE REVERSE CUTTING 19MM NEED SM,27200000,CDM,272,RC,,,,11984-MAIN,LOCAL,,,,,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE MONOFILAMENT SZ 4-0 BIOSYN ABSORBABLE UNDYED18IN WITH 3/8 CIRCLE REVERSE CUTTING 19MM NEED SM,27200000,CDM,272,RC,,,,11984-MAIN,LOCAL,,,,,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE MONOFILAMENT SZ 4-0 BIOSYN ABSORBABLE UNDYED18IN WITH 3/8 CIRCLE REVERSE CUTTING 19MM NEED SM,27200000,CDM,272,RC,,,,11984-MAIN,LOCAL,,,,,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE MONOFILAMENT SZ 4-0 BIOSYN ABSORBABLE UNDYED18IN WITH 3/8 CIRCLE REVERSE CUTTING 19MM NEED SM,27200000,CDM,272,RC,,,,11984-MAIN,LOCAL,,,,,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE MONOFILAMENT SZ 4-0 BIOSYN ABSORBABLE UNDYED18IN WITH 3/8 CIRCLE REVERSE CUTTING 19MM NEED SM,27200000,CDM,272,RC,,,,11984-MAIN,LOCAL,,,,,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE MONOFILAMENT SZ 4-0 BIOSYN ABSORBABLE UNDYED18IN WITH 3/8 CIRCLE REVERSE CUTTING 19MM NEED SM,27200000,CDM,272,RC,,,,11984-MAIN,LOCAL,,,,,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE NUROLON 0 BLACK C527D,27200000,CDM,272,RC,,,,10415-MAIN,LOCAL,,,,,30.6,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE NUROLON 0 BLACK C527D,27200000,CDM,272,RC,,,,10415-MAIN,LOCAL,,,,,30.6,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE NUROLON 0 BLACK C527D,27200000,CDM,272,RC,,,,10415-MAIN,LOCAL,,,,,30.6,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE NUROLON 0 BLACK C527D,27200000,CDM,272,RC,,,,10415-MAIN,LOCAL,,,,,30.6,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE NUROLON 0 BLACK C527D,27200000,CDM,272,RC,,,,10415-MAIN,LOCAL,,,,,30.6,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE NUROLON 0 BLACK C527D,27200000,CDM,272,RC,,,,10415-MAIN,LOCAL,,,,,30.6,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE PDS 3-0 27INCH ABSORBABLE VIOLET Z316H,27200000,CDM,272,RC,,,,12871-MAIN,LOCAL,,,,,7,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE PDS 3-0 27INCH ABSORBABLE VIOLET Z316H,27200000,CDM,272,RC,,,,12871-MAIN,LOCAL,,,,,7,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE PDS 3-0 27INCH ABSORBABLE VIOLET Z316H,27200000,CDM,272,RC,,,,12871-MAIN,LOCAL,,,,,7,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE PDS 3-0 27INCH ABSORBABLE VIOLET Z316H,27200000,CDM,272,RC,,,,12871-MAIN,LOCAL,,,,,7,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE PDS 3-0 27INCH ABSORBABLE VIOLET Z316H,27200000,CDM,272,RC,,,,12871-MAIN,LOCAL,,,,,7,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE PDS 3-0 27INCH ABSORBABLE VIOLET Z316H,27200000,CDM,272,RC,,,,12871-MAIN,LOCAL,,,,,7,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE POLYSORB ABSORBABLE LACTOMER 2-0 30IN BRAIDED DYED TAPER POINT 1/2 CIRCLE 26MM V-20 VIOLET ST,27200000,CDM,272,RC,,,,11983-MAIN,LOCAL,,,,,23,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE POLYSORB ABSORBABLE LACTOMER 2-0 30IN BRAIDED DYED TAPER POINT 1/2 CIRCLE 26MM V-20 VIOLET ST,27200000,CDM,272,RC,,,,11983-MAIN,LOCAL,,,,,23,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE POLYSORB ABSORBABLE LACTOMER 2-0 30IN BRAIDED DYED TAPER POINT 1/2 CIRCLE 26MM V-20 VIOLET ST,27200000,CDM,272,RC,,,,11983-MAIN,LOCAL,,,,,23,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE POLYSORB ABSORBABLE LACTOMER 2-0 30IN BRAIDED DYED TAPER POINT 1/2 CIRCLE 26MM V-20 VIOLET ST,27200000,CDM,272,RC,,,,11983-MAIN,LOCAL,,,,,23,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE POLYSORB ABSORBABLE LACTOMER 2-0 30IN BRAIDED DYED TAPER POINT 1/2 CIRCLE 26MM V-20 VIOLET ST,27200000,CDM,272,RC,,,,11983-MAIN,LOCAL,,,,,23,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE POLYSORB ABSORBABLE LACTOMER 2-0 30IN BRAIDED DYED TAPER POINT 1/2 CIRCLE 26MM V-20 VIOLET ST,27200000,CDM,272,RC,,,,11983-MAIN,LOCAL,,,,,23,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE POLYSORB BRAIDED ABSORBABLE VIOLET SIZE 0 30IN WITH 5/8 CIRCLE TAPER POINT 27MM NEEDLE,27200000,CDM,272,RC,,,,11985-MAIN,LOCAL,,,,,22,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE POLYSORB BRAIDED ABSORBABLE VIOLET SIZE 0 30IN WITH 5/8 CIRCLE TAPER POINT 27MM NEEDLE,27200000,CDM,272,RC,,,,11985-MAIN,LOCAL,,,,,22,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE POLYSORB BRAIDED ABSORBABLE VIOLET SIZE 0 30IN WITH 5/8 CIRCLE TAPER POINT 27MM NEEDLE,27200000,CDM,272,RC,,,,11985-MAIN,LOCAL,,,,,22,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE POLYSORB BRAIDED ABSORBABLE VIOLET SIZE 0 30IN WITH 5/8 CIRCLE TAPER POINT 27MM NEEDLE,27200000,CDM,272,RC,,,,11985-MAIN,LOCAL,,,,,22,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE POLYSORB BRAIDED ABSORBABLE VIOLET SIZE 0 30IN WITH 5/8 CIRCLE TAPER POINT 27MM NEEDLE,27200000,CDM,272,RC,,,,11985-MAIN,LOCAL,,,,,22,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE POLYSORB BRAIDED ABSORBABLE VIOLET SIZE 0 30IN WITH 5/8 CIRCLE TAPER POINT 27MM NEEDLE,27200000,CDM,272,RC,,,,11985-MAIN,LOCAL,,,,,22,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE PROLENE 3-0 BLUE SH NEEDLE MONOFILAMENT 30INCH,27200000,CDM,272,RC,,,,12840-MAIN,LOCAL,,,,,9,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE PROLENE 3-0 BLUE SH NEEDLE MONOFILAMENT 30INCH,27200000,CDM,272,RC,,,,12840-MAIN,LOCAL,,,,,9,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE PROLENE 3-0 BLUE SH NEEDLE MONOFILAMENT 30INCH,27200000,CDM,272,RC,,,,12840-MAIN,LOCAL,,,,,9,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE PROLENE 3-0 BLUE SH NEEDLE MONOFILAMENT 30INCH,27200000,CDM,272,RC,,,,12840-MAIN,LOCAL,,,,,9,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE PROLENE 3-0 BLUE SH NEEDLE MONOFILAMENT 30INCH,27200000,CDM,272,RC,,,,12840-MAIN,LOCAL,,,,,9,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE PROLENE 3-0 BLUE SH NEEDLE MONOFILAMENT 30INCH,27200000,CDM,272,RC,,,,12840-MAIN,LOCAL,,,,,9,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE PROLENE TAPERPOINT CT-1 36MM 0 BLUE,27200000,CDM,272,RC,,,,12322-MAIN,LOCAL,,,,,7,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE PROLENE TAPERPOINT CT-1 36MM 0 BLUE,27200000,CDM,272,RC,,,,12322-MAIN,LOCAL,,,,,7,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE PROLENE TAPERPOINT CT-1 36MM 0 BLUE,27200000,CDM,272,RC,,,,12322-MAIN,LOCAL,,,,,7,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE PROLENE TAPERPOINT CT-1 36MM 0 BLUE,27200000,CDM,272,RC,,,,12322-MAIN,LOCAL,,,,,7,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE PROLENE TAPERPOINT CT-1 36MM 0 BLUE,27200000,CDM,272,RC,,,,12322-MAIN,LOCAL,,,,,7,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE PROLENE TAPERPOINT CT-1 36MM 0 BLUE,27200000,CDM,272,RC,,,,12322-MAIN,LOCAL,,,,,7,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"SUTURE SILK 2-0 BLK BR FS 18"" 685G",27200000,CDM,272,RC,,,,2668-MAIN,LOCAL,,,,,5.29,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"SUTURE SILK 2-0 BLK BR FS 18"" 685G",27200000,CDM,272,RC,,,,2668-MAIN,LOCAL,,,,,5.29,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"SUTURE SILK 2-0 BLK BR FS 18"" 685G",27200000,CDM,272,RC,,,,2668-MAIN,LOCAL,,,,,5.29,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"SUTURE SILK 2-0 BLK BR FS 18"" 685G",27200000,CDM,272,RC,,,,2668-MAIN,LOCAL,,,,,5.29,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"SUTURE SILK 2-0 BLK BR FS 18"" 685G",27200000,CDM,272,RC,,,,2668-MAIN,LOCAL,,,,,5.29,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"SUTURE SILK 2-0 BLK BR FS 18"" 685G",27200000,CDM,272,RC,,,,2668-MAIN,LOCAL,,,,,5.29,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE SILK 3-0 18INCH NONABSORBABLE BLACK M13T,27200000,CDM,272,RC,,,,12872-MAIN,LOCAL,,,,,19,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE SILK 3-0 18INCH NONABSORBABLE BLACK M13T,27200000,CDM,272,RC,,,,12872-MAIN,LOCAL,,,,,19,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE SILK 3-0 18INCH NONABSORBABLE BLACK M13T,27200000,CDM,272,RC,,,,12872-MAIN,LOCAL,,,,,19,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE SILK 3-0 18INCH NONABSORBABLE BLACK M13T,27200000,CDM,272,RC,,,,12872-MAIN,LOCAL,,,,,19,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE SILK 3-0 18INCH NONABSORBABLE BLACK M13T,27200000,CDM,272,RC,,,,12872-MAIN,LOCAL,,,,,19,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE SILK 3-0 18INCH NONABSORBABLE BLACK M13T,27200000,CDM,272,RC,,,,12872-MAIN,LOCAL,,,,,19,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE TICRON 0 36IN BRAIDED DYED 1/2 CIRCLE DBLE ARM 25MM CV-305 BLUE STERILE,27200000,CDM,272,RC,,,,11956-MAIN,LOCAL,,,,,37,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE TICRON 0 36IN BRAIDED DYED 1/2 CIRCLE DBLE ARM 25MM CV-305 BLUE STERILE,27200000,CDM,272,RC,,,,11956-MAIN,LOCAL,,,,,37,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE TICRON 0 36IN BRAIDED DYED 1/2 CIRCLE DBLE ARM 25MM CV-305 BLUE STERILE,27200000,CDM,272,RC,,,,11956-MAIN,LOCAL,,,,,37,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE TICRON 0 36IN BRAIDED DYED 1/2 CIRCLE DBLE ARM 25MM CV-305 BLUE STERILE,27200000,CDM,272,RC,,,,11956-MAIN,LOCAL,,,,,37,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE TICRON 0 36IN BRAIDED DYED 1/2 CIRCLE DBLE ARM 25MM CV-305 BLUE STERILE,27200000,CDM,272,RC,,,,11956-MAIN,LOCAL,,,,,37,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE TICRON 0 36IN BRAIDED DYED 1/2 CIRCLE DBLE ARM 25MM CV-305 BLUE STERILE,27200000,CDM,272,RC,,,,11956-MAIN,LOCAL,,,,,37,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE V-LOC 1/2 CIRCLE NEEDLE WOUND CLOSURE DEVICE VLOCN0306,27200000,CDM,272,RC,,,,11931-MAIN,LOCAL,,,,,44,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE V-LOC 1/2 CIRCLE NEEDLE WOUND CLOSURE DEVICE VLOCN0306,27200000,CDM,272,RC,,,,11931-MAIN,LOCAL,,,,,44,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE V-LOC 1/2 CIRCLE NEEDLE WOUND CLOSURE DEVICE VLOCN0306,27200000,CDM,272,RC,,,,11931-MAIN,LOCAL,,,,,44,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE V-LOC 1/2 CIRCLE NEEDLE WOUND CLOSURE DEVICE VLOCN0306,27200000,CDM,272,RC,,,,11931-MAIN,LOCAL,,,,,44,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE V-LOC 1/2 CIRCLE NEEDLE WOUND CLOSURE DEVICE VLOCN0306,27200000,CDM,272,RC,,,,11931-MAIN,LOCAL,,,,,44,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE V-LOC 1/2 CIRCLE NEEDLE WOUND CLOSURE DEVICE VLOCN0306,27200000,CDM,272,RC,,,,11931-MAIN,LOCAL,,,,,44,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"SUTURE V-LOC 22G NEEDLE 9"" 180 GREEN VLOCL2145",27200000,CDM,272,RC,,,,11930-MAIN,LOCAL,,,,,40,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"SUTURE V-LOC 22G NEEDLE 9"" 180 GREEN VLOCL2145",27200000,CDM,272,RC,,,,11930-MAIN,LOCAL,,,,,40,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"SUTURE V-LOC 22G NEEDLE 9"" 180 GREEN VLOCL2145",27200000,CDM,272,RC,,,,11930-MAIN,LOCAL,,,,,40,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"SUTURE V-LOC 22G NEEDLE 9"" 180 GREEN VLOCL2145",27200000,CDM,272,RC,,,,11930-MAIN,LOCAL,,,,,40,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"SUTURE V-LOC 22G NEEDLE 9"" 180 GREEN VLOCL2145",27200000,CDM,272,RC,,,,11930-MAIN,LOCAL,,,,,40,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"SUTURE V-LOC 22G NEEDLE 9"" 180 GREEN VLOCL2145",27200000,CDM,272,RC,,,,11930-MAIN,LOCAL,,,,,40,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"SUTURE V-LOC SZ 0 180 GREEN GS21 NEEDLE 18"" VLOCL0326",27200000,CDM,272,RC,,,,12218-MAIN,LOCAL,,,,,49,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"SUTURE V-LOC SZ 0 180 GREEN GS21 NEEDLE 18"" VLOCL0326",27200000,CDM,272,RC,,,,12218-MAIN,LOCAL,,,,,49,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"SUTURE V-LOC SZ 0 180 GREEN GS21 NEEDLE 18"" VLOCL0326",27200000,CDM,272,RC,,,,12218-MAIN,LOCAL,,,,,49,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"SUTURE V-LOC SZ 0 180 GREEN GS21 NEEDLE 18"" VLOCL0326",27200000,CDM,272,RC,,,,12218-MAIN,LOCAL,,,,,49,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"SUTURE V-LOC SZ 0 180 GREEN GS21 NEEDLE 18"" VLOCL0326",27200000,CDM,272,RC,,,,12218-MAIN,LOCAL,,,,,49,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"SUTURE V-LOC SZ 0 180 GREEN GS21 NEEDLE 18"" VLOCL0326",27200000,CDM,272,RC,,,,12218-MAIN,LOCAL,,,,,49,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"SUTURE V-LOC SZ 0.9"" 180 GREEN GS-21 NEEDLE VLOCL0346",27200000,CDM,272,RC,,,,11933-MAIN,LOCAL,,,,,40,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"SUTURE V-LOC SZ 0.9"" 180 GREEN GS-21 NEEDLE VLOCL0346",27200000,CDM,272,RC,,,,11933-MAIN,LOCAL,,,,,40,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"SUTURE V-LOC SZ 0.9"" 180 GREEN GS-21 NEEDLE VLOCL0346",27200000,CDM,272,RC,,,,11933-MAIN,LOCAL,,,,,40,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"SUTURE V-LOC SZ 0.9"" 180 GREEN GS-21 NEEDLE VLOCL0346",27200000,CDM,272,RC,,,,11933-MAIN,LOCAL,,,,,40,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"SUTURE V-LOC SZ 0.9"" 180 GREEN GS-21 NEEDLE VLOCL0346",27200000,CDM,272,RC,,,,11933-MAIN,LOCAL,,,,,40,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"SUTURE V-LOC SZ 0.9"" 180 GREEN GS-21 NEEDLE VLOCL0346",27200000,CDM,272,RC,,,,11933-MAIN,LOCAL,,,,,40,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE V-LOC SZ 1 PBT WOUND CLOSURE DEVICE BLUE 18 IN GS 21 NEEDLE VLOCN0327,27200000,CDM,272,RC,,,,12828-MAIN,LOCAL,,,,,58,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE V-LOC SZ 1 PBT WOUND CLOSURE DEVICE BLUE 18 IN GS 21 NEEDLE VLOCN0327,27200000,CDM,272,RC,,,,12828-MAIN,LOCAL,,,,,58,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE V-LOC SZ 1 PBT WOUND CLOSURE DEVICE BLUE 18 IN GS 21 NEEDLE VLOCN0327,27200000,CDM,272,RC,,,,12828-MAIN,LOCAL,,,,,58,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE V-LOC SZ 1 PBT WOUND CLOSURE DEVICE BLUE 18 IN GS 21 NEEDLE VLOCN0327,27200000,CDM,272,RC,,,,12828-MAIN,LOCAL,,,,,58,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE V-LOC SZ 1 PBT WOUND CLOSURE DEVICE BLUE 18 IN GS 21 NEEDLE VLOCN0327,27200000,CDM,272,RC,,,,12828-MAIN,LOCAL,,,,,58,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE V-LOC SZ 1 PBT WOUND CLOSURE DEVICE BLUE 18 IN GS 21 NEEDLE VLOCN0327,27200000,CDM,272,RC,,,,12828-MAIN,LOCAL,,,,,58,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE V-LOC SZ 1/2 180 GREEN GS-21 VLOCL0316,27200000,CDM,272,RC,,,,11932-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE V-LOC SZ 1/2 180 GREEN GS-21 VLOCL0316,27200000,CDM,272,RC,,,,11932-MAIN,LOCAL,,,,,41,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE V-LOC SZ 1/2 180 GREEN GS-21 VLOCL0316,27200000,CDM,272,RC,,,,11932-MAIN,LOCAL,,,,,41,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE V-LOC SZ 1/2 180 GREEN GS-21 VLOCL0316,27200000,CDM,272,RC,,,,11932-MAIN,LOCAL,,,,,41,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE V-LOC SZ 1/2 180 GREEN GS-21 VLOCL0316,27200000,CDM,272,RC,,,,11932-MAIN,LOCAL,,,,,41,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE V-LOC SZ 1/2 180 GREEN GS-21 VLOCL0316,27200000,CDM,272,RC,,,,11932-MAIN,LOCAL,,,,,41,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE V-LOC SZ 3-0 180 GREEN V-20 9 INCH VLOCL0644,27200000,CDM,272,RC,,,,13056-SURG,LOCAL,,,,,44,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE V-LOC SZ 3-0 180 GREEN V-20 9 INCH VLOCL0644,27200000,CDM,272,RC,,,,13056-SURG,LOCAL,,,,,44,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE V-LOC SZ 3-0 180 GREEN V-20 9 INCH VLOCL0644,27200000,CDM,272,RC,,,,13056-SURG,LOCAL,,,,,44,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE V-LOC SZ 3-0 180 GREEN V-20 9 INCH VLOCL0644,27200000,CDM,272,RC,,,,13056-SURG,LOCAL,,,,,44,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE V-LOC SZ 3-0 180 GREEN V-20 9 INCH VLOCL0644,27200000,CDM,272,RC,,,,13056-SURG,LOCAL,,,,,44,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE V-LOC SZ 3-0 180 GREEN V-20 9 INCH VLOCL0644,27200000,CDM,272,RC,,,,13056-SURG,LOCAL,,,,,44,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE VICRYL TAPER 2-0 J317H,27200000,CDM,272,RC,,,,2615-MAIN,LOCAL,,,,,4,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE VICRYL TAPER 2-0 J317H,27200000,CDM,272,RC,,,,2615-MAIN,LOCAL,,,,,4,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE VICRYL TAPER 2-0 J317H,27200000,CDM,272,RC,,,,2615-MAIN,LOCAL,,,,,4,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE VICRYL TAPER 2-0 J317H,27200000,CDM,272,RC,,,,2615-MAIN,LOCAL,,,,,4,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE VICRYL TAPER 2-0 J317H,27200000,CDM,272,RC,,,,2615-MAIN,LOCAL,,,,,4,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE VICRYL TAPER 2-0 J317H,27200000,CDM,272,RC,,,,2615-MAIN,LOCAL,,,,,4,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SYRINGE BULB 60ML IRRIGATION STERILE DYND20125,27200000,CDM,272,RC,A4322,HCPCS,,10829-MAIN,LOCAL,,,,,2.16,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SYRINGE BULB 60ML IRRIGATION STERILE DYND20125,27200000,CDM,272,RC,A4322,HCPCS,,10829-MAIN,LOCAL,,,,,2.16,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SYRINGE BULB 60ML IRRIGATION STERILE DYND20125,27200000,CDM,272,RC,A4322,HCPCS,,10829-MAIN,LOCAL,,,,,2.16,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SYRINGE BULB 60ML IRRIGATION STERILE DYND20125,27200000,CDM,272,RC,A4322,HCPCS,,10829-MAIN,LOCAL,,,,,2.16,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SYRINGE BULB 60ML IRRIGATION STERILE DYND20125,27200000,CDM,272,RC,A4322,HCPCS,,10829-MAIN,LOCAL,,,,,2.16,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SYRINGE BULB 60ML IRRIGATION STERILE DYND20125,27200000,CDM,272,RC,A4322,HCPCS,,10829-MAIN,LOCAL,,,,,2.16,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tacrolimus - Ref,PX8019790,CDM,300,RC,80197,CPT,90,,,,,,,81,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tacrolimus - Ref,PX8019790,CDM,300,RC,80197,CPT,90,,,,,,,81,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tacrolimus - Ref,PX8019790,CDM,300,RC,80197,CPT,90,,,,,,,81,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tacrolimus - Ref,PX8019790,CDM,300,RC,80197,CPT,90,,,,,,,81,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tacrolimus - Ref,PX8019790,CDM,300,RC,80197,CPT,90,,,,,,,81,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tacrolimus - Ref,PX8019790,CDM,300,RC,80197,CPT,90,,,,,,,81,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tacrolimus 1 MG capsule 100 Each Bottle,J7507.01,CDM,636,RC,J7507,HCPCS,,,,16714009901,NDC,0.5,EA,11.95,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tacrolimus 1 MG capsule 100 Each Bottle,J7507.01,CDM,636,RC,J7507,HCPCS,,,,16714009901,NDC,0.5,EA,11.95,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tacrolimus 1 MG capsule 100 Each Bottle,J7507.01,CDM,636,RC,J7507,HCPCS,,,,16714009901,NDC,0.5,EA,11.95,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tacrolimus 1 MG capsule 100 Each Bottle,J7507.01,CDM,636,RC,J7507,HCPCS,,,,16714009901,NDC,0.5,EA,11.95,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tacrolimus 1 MG capsule 100 Each Bottle,J7507.01,CDM,636,RC,J7507,HCPCS,,,,16714009901,NDC,0.5,EA,11.95,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tacrolimus 1 MG capsule 100 Each Bottle,J7507.01,CDM,636,RC,J7507,HCPCS,,,,16714009901,NDC,0.5,EA,11.95,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tamsulosin 0.4 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904640161,NDC,1,EA,22.6,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tamsulosin 0.4 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904640161,NDC,1,EA,22.6,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tamsulosin 0.4 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904640161,NDC,1,EA,22.6,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tamsulosin 0.4 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904640161,NDC,1,EA,22.6,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tamsulosin 0.4 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904640161,NDC,1,EA,22.6,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tamsulosin 0.4 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904640161,NDC,1,EA,22.6,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tamsulosin 0.4 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739056710,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tamsulosin 0.4 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739056710,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tamsulosin 0.4 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739056710,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tamsulosin 0.4 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739056710,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tamsulosin 0.4 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739056710,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tamsulosin 0.4 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739056710,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102F,CDM,510,RC,11102,CPT,,,,,,,,171,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102F,CDM,510,RC,11102,CPT,,,,,,,,171,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102F,CDM,510,RC,11102,CPT,,,,,,,,171,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102F,CDM,510,RC,11102,CPT,,,,,,,,171,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102F,CDM,510,RC,11102,CPT,,,,,,,,171,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102F,CDM,510,RC,11102,CPT,,,,,,,,171,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102P,CDM,983,RC,11102,CPT,,,,,,,,465,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102P,CDM,983,RC,11102,CPT,,,,,,,,465,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102P,CDM,983,RC,11102,CPT,,,,,,,,465,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102P,CDM,983,RC,11102,CPT,,,,,,,,465,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102P,CDM,983,RC,11102,CPT,,,,,,,,465,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102P,CDM,983,RC,11102,CPT,,,,,,,,465,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tap Block Bilateral by Injection(S),PX64488F,CDM,510,RC,64488,CPT,,,,,,,,393,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tap Block Bilateral by Injection(S),PX64488F,CDM,510,RC,64488,CPT,,,,,,,,393,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tap Block Bilateral by Injection(S),PX64488F,CDM,510,RC,64488,CPT,,,,,,,,393,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tap Block Bilateral by Injection(S),PX64488F,CDM,510,RC,64488,CPT,,,,,,,,393,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tap Block Bilateral by Injection(S),PX64488F,CDM,510,RC,64488,CPT,,,,,,,,393,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tap Block Bilateral by Injection(S),PX64488F,CDM,510,RC,64488,CPT,,,,,,,,393,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tap Block Bilateral by Injection(S),PX64488P,CDM,983,RC,64488,CPT,,,,,,,,262,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tap Block Bilateral by Injection(S),PX64488P,CDM,983,RC,64488,CPT,,,,,,,,262,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tap Block Bilateral by Injection(S),PX64488P,CDM,983,RC,64488,CPT,,,,,,,,262,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tap Block Bilateral by Injection(S),PX64488P,CDM,983,RC,64488,CPT,,,,,,,,262,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tap Block Bilateral by Injection(S),PX64488P,CDM,983,RC,64488,CPT,,,,,,,,262,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tap Block Bilateral by Injection(S),PX64488P,CDM,983,RC,64488,CPT,,,,,,,,262,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tap Block Unilateral by Injection(S),PX64486F,CDM,510,RC,64486,CPT,,,,,,,,253,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tap Block Unilateral by Injection(S),PX64486F,CDM,510,RC,64486,CPT,,,,,,,,253,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tap Block Unilateral by Injection(S),PX64486F,CDM,510,RC,64486,CPT,,,,,,,,253,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tap Block Unilateral by Injection(S),PX64486F,CDM,510,RC,64486,CPT,,,,,,,,253,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tap Block Unilateral by Injection(S),PX64486F,CDM,510,RC,64486,CPT,,,,,,,,253,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tap Block Unilateral by Injection(S),PX64486F,CDM,510,RC,64486,CPT,,,,,,,,253,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tap Block Unilateral by Injection(S),PX64486P,CDM,983,RC,64486,CPT,,,,,,,,169,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tap Block Unilateral by Injection(S),PX64486P,CDM,983,RC,64486,CPT,,,,,,,,169,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tap Block Unilateral by Injection(S),PX64486P,CDM,983,RC,64486,CPT,,,,,,,,169,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tap Block Unilateral by Injection(S),PX64486P,CDM,983,RC,64486,CPT,,,,,,,,169,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tap Block Unilateral by Injection(S),PX64486P,CDM,983,RC,64486,CPT,,,,,,,,169,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tap Block Unilateral by Injection(S),PX64486P,CDM,983,RC,64486,CPT,,,,,,,,169,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TAPER POST TOE JOINT HEMICAP 9.5MM ARTICULATING METATARSAL STERILE,C1713,CDM,278,RC,C1713,HCPCS,,12531-MAIN,LOCAL,,,,,821,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TAPER POST TOE JOINT HEMICAP 9.5MM ARTICULATING METATARSAL STERILE,C1713,CDM,278,RC,C1713,HCPCS,,12531-MAIN,LOCAL,,,,,821,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TAPER POST TOE JOINT HEMICAP 9.5MM ARTICULATING METATARSAL STERILE,C1713,CDM,278,RC,C1713,HCPCS,,12531-MAIN,LOCAL,,,,,821,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TAPER POST TOE JOINT HEMICAP 9.5MM ARTICULATING METATARSAL STERILE,C1713,CDM,278,RC,C1713,HCPCS,,12531-MAIN,LOCAL,,,,,821,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TAPER POST TOE JOINT HEMICAP 9.5MM ARTICULATING METATARSAL STERILE,C1713,CDM,278,RC,C1713,HCPCS,,12531-MAIN,LOCAL,,,,,821,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TAPER POST TOE JOINT HEMICAP 9.5MM ARTICULATING METATARSAL STERILE,C1713,CDM,278,RC,C1713,HCPCS,,12531-MAIN,LOCAL,,,,,821,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Targeted Genomic Sequence Analysis Panel 5-50 Genes - Ref,PX8145090,CDM,300,RC,81450,CPT,90,,,,,,,2936,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Targeted Genomic Sequence Analysis Panel 5-50 Genes - Ref,PX8145090,CDM,300,RC,81450,CPT,90,,,,,,,2936,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Targeted Genomic Sequence Analysis Panel 5-50 Genes - Ref,PX8145090,CDM,300,RC,81450,CPT,90,,,,,,,2936,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Targeted Genomic Sequence Analysis Panel 5-50 Genes - Ref,PX8145090,CDM,300,RC,81450,CPT,90,,,,,,,2936,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Targeted Genomic Sequence Analysis Panel 5-50 Genes - Ref,PX8145090,CDM,300,RC,81450,CPT,90,,,,,,,2936,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Targeted Genomic Sequence Analysis Panel 5-50 Genes - Ref,PX8145090,CDM,300,RC,81450,CPT,90,,,,,,,2936,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TB Antigen Response Gamma Interferon T-Cell Susp,PX86481,CDM,300,RC,86481,CPT,,,,,,,,150,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TB Antigen Response Gamma Interferon T-Cell Susp,PX86481,CDM,300,RC,86481,CPT,,,,,,,,150,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TB Antigen Response Gamma Interferon T-Cell Susp,PX86481,CDM,300,RC,86481,CPT,,,,,,,,150,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TB Antigen Response Gamma Interferon T-Cell Susp,PX86481,CDM,300,RC,86481,CPT,,,,,,,,150,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TB Antigen Response Gamma Interferon T-Cell Susp,PX86481,CDM,300,RC,86481,CPT,,,,,,,,150,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TB Antigen Response Gamma Interferon T-Cell Susp,PX86481,CDM,300,RC,86481,CPT,,,,,,,,150,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TB Test Enumeration of T-Cells - Ref,PX8648190,CDM,300,RC,86481,CPT,90,,,,,,,155,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TB Test Enumeration of T-Cells - Ref,PX8648190,CDM,300,RC,86481,CPT,90,,,,,,,155,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TB Test Enumeration of T-Cells - Ref,PX8648190,CDM,300,RC,86481,CPT,90,,,,,,,155,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TB Test Enumeration of T-Cells - Ref,PX8648190,CDM,300,RC,86481,CPT,90,,,,,,,155,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TB Test Enumeration of T-Cells - Ref,PX8648190,CDM,300,RC,86481,CPT,90,,,,,,,155,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TB Test Enumeration of T-Cells - Ref,PX8648190,CDM,300,RC,86481,CPT,90,,,,,,,155,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"TB Test, Cell Immunity Measure",PX86480,CDM,300,RC,86480,CPT,,,,,,,,186,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"TB Test, Cell Immunity Measure",PX86480,CDM,300,RC,86480,CPT,,,,,,,,186,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"TB Test, Cell Immunity Measure",PX86480,CDM,300,RC,86480,CPT,,,,,,,,186,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"TB Test, Cell Immunity Measure",PX86480,CDM,300,RC,86480,CPT,,,,,,,,186,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"TB Test, Cell Immunity Measure",PX86480,CDM,300,RC,86480,CPT,,,,,,,,186,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"TB Test, Cell Immunity Measure",PX86480,CDM,300,RC,86480,CPT,,,,,,,,186,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tc99 Mebrofenin to 15 Mci,PXA9537,CDM,343,RC,A9537,HCPCS,,,,,,,,495,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tc99 Mebrofenin to 15 Mci,PXA9537,CDM,343,RC,A9537,HCPCS,,,,,,,,495,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tc99 Mebrofenin to 15 Mci,PXA9537,CDM,343,RC,A9537,HCPCS,,,,,,,,495,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tc99 Mebrofenin to 15 Mci,PXA9537,CDM,343,RC,A9537,HCPCS,,,,,,,,495,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tc99 Mebrofenin to 15 Mci,PXA9537,CDM,343,RC,A9537,HCPCS,,,,,,,,495,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tc99 Mebrofenin to 15 Mci,PXA9537,CDM,343,RC,A9537,HCPCS,,,,,,,,495,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tech-Cytopath Eval, Fna, Rep",PX8817301,CDM,310,RC,88173,CPT,TC,,,,,,,379,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tech-Cytopath Eval, Fna, Rep",PX8817301,CDM,310,RC,88173,CPT,TC,,,,,,,379,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tech-Cytopath Eval, Fna, Rep",PX8817301,CDM,310,RC,88173,CPT,TC,,,,,,,379,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tech-Cytopath Eval, Fna, Rep",PX8817301,CDM,310,RC,88173,CPT,TC,,,,,,,379,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tech-Cytopath Eval, Fna, Rep",PX8817301,CDM,310,RC,88173,CPT,TC,,,,,,,379,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tech-Cytopath Eval, Fna, Rep",PX8817301,CDM,310,RC,88173,CPT,TC,,,,,,,379,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TEGADERM CHLORHEXIDINE 5X5 CHG IV PORT,120.207,CDM,272,RC,A6268,HCPCS,,10163-MAIN,LOCAL,,,,,26,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TEGADERM CHLORHEXIDINE 5X5 CHG IV PORT,120.207,CDM,272,RC,A6268,HCPCS,,10163-MAIN,LOCAL,,,,,26,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TEGADERM CHLORHEXIDINE 5X5 CHG IV PORT,120.207,CDM,272,RC,A6268,HCPCS,,10163-MAIN,LOCAL,,,,,26,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TEGADERM CHLORHEXIDINE 5X5 CHG IV PORT,120.207,CDM,272,RC,A6268,HCPCS,,10163-MAIN,LOCAL,,,,,26,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TEGADERM CHLORHEXIDINE 5X5 CHG IV PORT,120.207,CDM,272,RC,A6268,HCPCS,,10163-MAIN,LOCAL,,,,,26,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TEGADERM CHLORHEXIDINE 5X5 CHG IV PORT,120.207,CDM,272,RC,A6268,HCPCS,,10163-MAIN,LOCAL,,,,,26,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TEGADERM CHLORHEXIDINE-GLUCONATE,120.356,CDM,272,RC,A4221,HCPCS,,10708-MAIN,LOCAL,,,,,22,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TEGADERM CHLORHEXIDINE-GLUCONATE,120.356,CDM,272,RC,A4221,HCPCS,,10708-MAIN,LOCAL,,,,,22,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TEGADERM CHLORHEXIDINE-GLUCONATE,120.356,CDM,272,RC,A4221,HCPCS,,10708-MAIN,LOCAL,,,,,22,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TEGADERM CHLORHEXIDINE-GLUCONATE,120.356,CDM,272,RC,A4221,HCPCS,,10708-MAIN,LOCAL,,,,,22,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TEGADERM CHLORHEXIDINE-GLUCONATE,120.356,CDM,272,RC,A4221,HCPCS,,10708-MAIN,LOCAL,,,,,22,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TEGADERM CHLORHEXIDINE-GLUCONATE,120.356,CDM,272,RC,A4221,HCPCS,,10708-MAIN,LOCAL,,,,,22,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Telehealth Origin Site Fac Fee,PXQ3014,CDM,780,RC,Q3014,HCPCS,,,,,,,,40,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Telehealth Origin Site Fac Fee,PXQ3014,CDM,780,RC,Q3014,HCPCS,,,,,,,,40,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Telehealth Origin Site Fac Fee,PXQ3014,CDM,780,RC,Q3014,HCPCS,,,,,,,,40,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Telehealth Origin Site Fac Fee,PXQ3014,CDM,780,RC,Q3014,HCPCS,,,,,,,,40,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Telehealth Origin Site Fac Fee,PXQ3014,CDM,780,RC,Q3014,HCPCS,,,,,,,,40,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Telehealth Origin Site Fac Fee,PXQ3014,CDM,780,RC,Q3014,HCPCS,,,,,,,,40,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
temazepam 15 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079041801,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
temazepam 15 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079041801,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
temazepam 15 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079041801,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
temazepam 15 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079041801,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
temazepam 15 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079041801,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
temazepam 15 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079041801,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
temazepam 15 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877014601,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
temazepam 15 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877014601,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
temazepam 15 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877014601,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
temazepam 15 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877014601,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
temazepam 15 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877014601,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
temazepam 15 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877014601,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
temazepam 15 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079041820,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
temazepam 15 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079041820,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
temazepam 15 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079041820,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
temazepam 15 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079041820,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
temazepam 15 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079041820,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
temazepam 15 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079041820,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
temazepam 15 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739023110,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
temazepam 15 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739023110,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
temazepam 15 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739023110,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
temazepam 15 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739023110,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
temazepam 15 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739023110,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
temazepam 15 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739023110,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Temporal Artery Ligatn or Bx,PX37609F,CDM,510,RC,37609,CPT,,,,,,,,705,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Temporal Artery Ligatn or Bx,PX37609F,CDM,510,RC,37609,CPT,,,,,,,,705,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Temporal Artery Ligatn or Bx,PX37609F,CDM,510,RC,37609,CPT,,,,,,,,705,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Temporal Artery Ligatn or Bx,PX37609F,CDM,510,RC,37609,CPT,,,,,,,,705,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Temporal Artery Ligatn or Bx,PX37609F,CDM,510,RC,37609,CPT,,,,,,,,705,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Temporal Artery Ligatn or Bx,PX37609F,CDM,510,RC,37609,CPT,,,,,,,,705,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Temporal Artery Ligatn or Bx,PX37609P,CDM,983,RC,37609,CPT,,,,,,,,965,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Temporal Artery Ligatn or Bx,PX37609P,CDM,983,RC,37609,CPT,,,,,,,,965,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Temporal Artery Ligatn or Bx,PX37609P,CDM,983,RC,37609,CPT,,,,,,,,965,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Temporal Artery Ligatn or Bx,PX37609P,CDM,983,RC,37609,CPT,,,,,,,,965,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Temporal Artery Ligatn or Bx,PX37609P,CDM,983,RC,37609,CPT,,,,,,,,965,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Temporal Artery Ligatn or Bx,PX37609P,CDM,983,RC,37609,CPT,,,,,,,,965,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Temporary External Pacing,PX92953F,CDM,480,RC,92953,CPT,,,,,,,,678,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Temporary External Pacing,PX92953F,CDM,480,RC,92953,CPT,,,,,,,,678,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Temporary External Pacing,PX92953F,CDM,480,RC,92953,CPT,,,,,,,,678,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Temporary External Pacing,PX92953F,CDM,480,RC,92953,CPT,,,,,,,,678,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Temporary External Pacing,PX92953F,CDM,480,RC,92953,CPT,,,,,,,,678,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Temporary External Pacing,PX92953F,CDM,480,RC,92953,CPT,,,,,,,,678,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
temporary tooth filling repair Misc 1 Each Package,25000000,CDM,250,RC,,,,,,47701000123,NDC,1,EA,25.46,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
temporary tooth filling repair Misc 1 Each Package,25000000,CDM,250,RC,,,,,,47701000123,NDC,1,EA,25.46,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
temporary tooth filling repair Misc 1 Each Package,25000000,CDM,250,RC,,,,,,47701000123,NDC,1,EA,25.46,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
temporary tooth filling repair Misc 1 Each Package,25000000,CDM,250,RC,,,,,,47701000123,NDC,1,EA,25.46,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
temporary tooth filling repair Misc 1 Each Package,25000000,CDM,250,RC,,,,,,47701000123,NDC,1,EA,25.46,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
temporary tooth filling repair Misc 1 Each Package,25000000,CDM,250,RC,,,,,,47701000123,NDC,1,EA,25.46,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242003706,NDC,0.6,EA,8461.09,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242003706,NDC,0.6,EA,8461.09,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242003706,NDC,0.6,EA,8461.09,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242003706,NDC,0.6,EA,8461.09,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242003706,NDC,0.6,EA,8461.09,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242003706,NDC,0.6,EA,8461.09,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012001,NDC,0.6,EA,7764.12,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012001,NDC,0.6,EA,7764.12,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012001,NDC,0.6,EA,7764.12,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012001,NDC,0.6,EA,7764.12,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012001,NDC,0.6,EA,7764.12,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012001,NDC,0.6,EA,7764.12,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012047,NDC,0.6,EA,10644.69,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012047,NDC,0.6,EA,10644.69,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012047,NDC,0.6,EA,10644.69,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012047,NDC,0.6,EA,10644.69,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012047,NDC,0.6,EA,10644.69,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012047,NDC,0.6,EA,10644.69,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
terazosin 1 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59746038306,NDC,1,EA,8.62,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
terazosin 1 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59746038306,NDC,1,EA,8.62,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
terazosin 1 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59746038306,NDC,1,EA,8.62,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
terazosin 1 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59746038306,NDC,1,EA,8.62,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
terazosin 1 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59746038306,NDC,1,EA,8.62,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
terazosin 1 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59746038306,NDC,1,EA,8.62,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
terazosin 5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59746038506,NDC,0.2,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
terazosin 5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59746038506,NDC,0.2,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
terazosin 5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59746038506,NDC,0.2,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
terazosin 5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59746038506,NDC,0.2,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
terazosin 5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59746038506,NDC,0.2,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
terazosin 5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59746038506,NDC,0.2,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
terbinafine 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714050101,NDC,1,EA,68.04,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
terbinafine 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714050101,NDC,1,EA,68.04,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
terbinafine 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714050101,NDC,1,EA,68.04,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
terbinafine 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714050101,NDC,1,EA,68.04,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
terbinafine 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714050101,NDC,1,EA,68.04,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
terbinafine 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714050101,NDC,1,EA,68.04,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
terbinafine 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714079501,NDC,1,EA,68.03,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
terbinafine 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714079501,NDC,1,EA,68.03,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
terbinafine 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714079501,NDC,1,EA,68.03,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
terbinafine 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714079501,NDC,1,EA,68.03,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
terbinafine 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714079501,NDC,1,EA,68.03,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
terbinafine 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714079501,NDC,1,EA,68.03,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066500,NDC,0.25,ML,48.19,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066500,NDC,0.25,ML,48.19,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066500,NDC,0.25,ML,48.19,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066500,NDC,0.25,ML,48.19,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066500,NDC,0.25,ML,48.19,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066500,NDC,0.25,ML,48.19,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066501,NDC,0.25,ML,45.74,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066501,NDC,0.25,ML,45.74,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066501,NDC,0.25,ML,45.74,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066501,NDC,0.25,ML,45.74,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066501,NDC,0.25,ML,45.74,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066501,NDC,0.25,ML,45.74,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Testosterone, Total - Ref",PX8440390,CDM,300,RC,84403,CPT,90,,,,,,,43,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Testosterone, Total - Ref",PX8440390,CDM,300,RC,84403,CPT,90,,,,,,,43,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Testosterone, Total - Ref",PX8440390,CDM,300,RC,84403,CPT,90,,,,,,,43,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Testosterone, Total - Ref",PX8440390,CDM,300,RC,84403,CPT,90,,,,,,,43,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Testosterone, Total - Ref",PX8440390,CDM,300,RC,84403,CPT,90,,,,,,,43,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Testosterone, Total - Ref",PX8440390,CDM,300,RC,84403,CPT,90,,,,,,,43,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Testosterone,Free - Ref",PX8440290,CDM,300,RC,84402,CPT,90,,,,,,,25,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Testosterone,Free - Ref",PX8440290,CDM,300,RC,84402,CPT,90,,,,,,,25,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Testosterone,Free - Ref",PX8440290,CDM,300,RC,84402,CPT,90,,,,,,,25,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Testosterone,Free - Ref",PX8440290,CDM,300,RC,84402,CPT,90,,,,,,,25,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Testosterone,Free - Ref",PX8440290,CDM,300,RC,84402,CPT,90,,,,,,,25,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Testosterone,Free - Ref",PX8440290,CDM,300,RC,84402,CPT,90,,,,,,,25,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084243,NDC,0.5,ML,202.42,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084243,NDC,0.5,ML,202.42,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084243,NDC,0.5,ML,202.42,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084243,NDC,0.5,ML,202.42,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084243,NDC,0.5,ML,202.42,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084243,NDC,0.5,ML,202.42,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084252,NDC,0.5,ML,207.65,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084252,NDC,0.5,ML,207.65,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084252,NDC,0.5,ML,207.65,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084252,NDC,0.5,ML,207.65,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084252,NDC,0.5,ML,207.65,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084252,NDC,0.5,ML,207.65,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021515,NDC,0.5,ML,187.24,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021515,NDC,0.5,ML,187.24,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021515,NDC,0.5,ML,187.24,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021515,NDC,0.5,ML,187.24,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021515,NDC,0.5,ML,187.24,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021515,NDC,0.5,ML,187.24,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021588,NDC,0.5,ML,203.87,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021588,NDC,0.5,ML,203.87,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021588,NDC,0.5,ML,203.87,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021588,NDC,0.5,ML,203.87,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021588,NDC,0.5,ML,203.87,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021588,NDC,0.5,ML,203.87,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tetracaine 0.5 % Solution 4 mL Plas Cont,25000000,CDM,250,RC,,,,,,65074114,NDC,4,ML,71.55,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tetracaine 0.5 % Solution 4 mL Plas Cont,25000000,CDM,250,RC,,,,,,65074114,NDC,4,ML,71.55,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tetracaine 0.5 % Solution 4 mL Plas Cont,25000000,CDM,250,RC,,,,,,65074114,NDC,4,ML,71.55,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tetracaine 0.5 % Solution 4 mL Plas Cont,25000000,CDM,250,RC,,,,,,65074114,NDC,4,ML,71.55,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tetracaine 0.5 % Solution 4 mL Plas Cont,25000000,CDM,250,RC,,,,,,65074114,NDC,4,ML,71.55,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tetracaine 0.5 % Solution 4 mL Plas Cont,25000000,CDM,250,RC,,,,,,65074114,NDC,4,ML,71.55,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tetracycline 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,51991090701,NDC,0.5,EA,42.29,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tetracycline 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,51991090701,NDC,0.5,EA,42.29,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tetracycline 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,51991090701,NDC,0.5,EA,42.29,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tetracycline 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,51991090701,NDC,0.5,EA,42.29,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tetracycline 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,51991090701,NDC,0.5,EA,42.29,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tetracycline 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,51991090701,NDC,0.5,EA,42.29,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
theophylline SR (12 hour) 300 MG Tablet Extended Release 12 Hour 100 Each Bottle,25000000,CDM,250,RC,,,,,,68462072101,NDC,0.333333333,EA,7.69,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
theophylline SR (12 hour) 300 MG Tablet Extended Release 12 Hour 100 Each Bottle,25000000,CDM,250,RC,,,,,,68462072101,NDC,0.333333333,EA,7.69,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
theophylline SR (12 hour) 300 MG Tablet Extended Release 12 Hour 100 Each Bottle,25000000,CDM,250,RC,,,,,,68462072101,NDC,0.333333333,EA,7.69,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
theophylline SR (12 hour) 300 MG Tablet Extended Release 12 Hour 100 Each Bottle,25000000,CDM,250,RC,,,,,,68462072101,NDC,0.333333333,EA,7.69,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
theophylline SR (12 hour) 300 MG Tablet Extended Release 12 Hour 100 Each Bottle,25000000,CDM,250,RC,,,,,,68462072101,NDC,0.333333333,EA,7.69,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
theophylline SR (12 hour) 300 MG Tablet Extended Release 12 Hour 100 Each Bottle,25000000,CDM,250,RC,,,,,,68462072101,NDC,0.333333333,EA,7.69,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ther Injection Carpal Tunnel,PX20526P,CDM,983,RC,20526,CPT,,,,,,,,248,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ther Injection Carpal Tunnel,PX20526P,CDM,983,RC,20526,CPT,,,,,,,,248,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ther Injection Carpal Tunnel,PX20526P,CDM,983,RC,20526,CPT,,,,,,,,248,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ther Injection Carpal Tunnel,PX20526P,CDM,983,RC,20526,CPT,,,,,,,,248,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ther Injection Carpal Tunnel,PX20526P,CDM,983,RC,20526,CPT,,,,,,,,248,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ther Injection Carpal Tunnel,PX20526P,CDM,983,RC,20526,CPT,,,,,,,,248,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Therapeutic Activities,PX97530,CDM,420,RC,97530,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Therapeutic Activities,PX97530,CDM,420,RC,97530,CPT,,,,,,,,135,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Therapeutic Activities,PX97530,CDM,420,RC,97530,CPT,,,,,,,,135,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Therapeutic Activities,PX97530,CDM,420,RC,97530,CPT,,,,,,,,135,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Therapeutic Activities,PX97530,CDM,420,RC,97530,CPT,,,,,,,,135,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Therapeutic Activities,PX97530,CDM,420,RC,97530,CPT,,,,,,,,135,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Therapeutic Exercises,PX97110,CDM,420,RC,97110,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Therapeutic Exercises,PX97110,CDM,420,RC,97110,CPT,,,,,,,,135,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Therapeutic Exercises,PX97110,CDM,420,RC,97110,CPT,,,,,,,,135,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Therapeutic Exercises,PX97110,CDM,420,RC,97110,CPT,,,,,,,,135,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Therapeutic Exercises,PX97110,CDM,420,RC,97110,CPT,,,,,,,,135,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Therapeutic Exercises,PX97110,CDM,420,RC,97110,CPT,,,,,,,,135,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
therapeutic multivitamin Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904053961,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
therapeutic multivitamin Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904053961,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
therapeutic multivitamin Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904053961,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
therapeutic multivitamin Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904053961,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
therapeutic multivitamin Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904053961,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
therapeutic multivitamin Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904053961,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,77333093425,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,77333093425,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,77333093425,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,77333093425,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,77333093425,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,77333093425,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,37864090599,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,37864090599,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,37864090599,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,37864090599,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,37864090599,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,37864090599,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,77333093410,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,77333093410,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,77333093410,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,77333093410,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,77333093410,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,77333093410,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,25021050002,NDC,1,ML,52.06,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,25021050002,NDC,1,ML,52.06,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,25021050002,NDC,1,ML,52.06,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,25021050002,NDC,1,ML,52.06,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,25021050002,NDC,1,ML,52.06,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,25021050002,NDC,1,ML,52.06,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001302,NDC,2,ML,86.79,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001302,NDC,2,ML,86.79,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001302,NDC,2,ML,86.79,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001302,NDC,2,ML,86.79,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001302,NDC,2,ML,86.79,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001302,NDC,2,ML,86.79,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001326,NDC,1,ML,42.88,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001326,NDC,1,ML,42.88,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001326,NDC,1,ML,42.88,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001326,NDC,1,ML,42.88,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001326,NDC,1,ML,42.88,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001326,NDC,1,ML,42.88,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001341,NDC,1,ML,42.88,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001341,NDC,1,ML,42.88,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001341,NDC,1,ML,42.88,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001341,NDC,1,ML,42.88,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001341,NDC,1,ML,42.88,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001341,NDC,1,ML,42.88,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019600,NDC,1,ML,48.64,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019600,NDC,1,ML,48.64,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019600,NDC,1,ML,48.64,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019600,NDC,1,ML,48.64,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019600,NDC,1,ML,48.64,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019600,NDC,1,ML,48.64,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019602,NDC,2,ML,77.29,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019602,NDC,2,ML,77.29,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019602,NDC,2,ML,77.29,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019602,NDC,2,ML,77.29,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019602,NDC,2,ML,77.29,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019602,NDC,2,ML,77.29,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER  STRAIGHT TAPER TIP 20FR PVC,120.528,CDM,272,RC,,,,12247-MAIN,LOCAL,,,,,20,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER  STRAIGHT TAPER TIP 20FR PVC,120.528,CDM,272,RC,,,,12247-MAIN,LOCAL,,,,,20,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER  STRAIGHT TAPER TIP 20FR PVC,120.528,CDM,272,RC,,,,12247-MAIN,LOCAL,,,,,20,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER  STRAIGHT TAPER TIP 20FR PVC,120.528,CDM,272,RC,,,,12247-MAIN,LOCAL,,,,,20,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER  STRAIGHT TAPER TIP 20FR PVC,120.528,CDM,272,RC,,,,12247-MAIN,LOCAL,,,,,20,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER  STRAIGHT TAPER TIP 20FR PVC,120.528,CDM,272,RC,,,,12247-MAIN,LOCAL,,,,,20,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER  STRAIGHT TAPER TIP 24FR PVC,120.528,CDM,272,RC,,,,12248-MAIN,LOCAL,,,,,20,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER  STRAIGHT TAPER TIP 24FR PVC,120.528,CDM,272,RC,,,,12248-MAIN,LOCAL,,,,,20,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER  STRAIGHT TAPER TIP 24FR PVC,120.528,CDM,272,RC,,,,12248-MAIN,LOCAL,,,,,20,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER  STRAIGHT TAPER TIP 24FR PVC,120.528,CDM,272,RC,,,,12248-MAIN,LOCAL,,,,,20,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER  STRAIGHT TAPER TIP 24FR PVC,120.528,CDM,272,RC,,,,12248-MAIN,LOCAL,,,,,20,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER  STRAIGHT TAPER TIP 24FR PVC,120.528,CDM,272,RC,,,,12248-MAIN,LOCAL,,,,,20,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER STRAIGHT TAPER TIP 8FR PVC,120.528,CDM,272,RC,,,,12253-MAIN,LOCAL,,,,,20,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER STRAIGHT TAPER TIP 8FR PVC,120.528,CDM,272,RC,,,,12253-MAIN,LOCAL,,,,,20,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER STRAIGHT TAPER TIP 8FR PVC,120.528,CDM,272,RC,,,,12253-MAIN,LOCAL,,,,,20,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER STRAIGHT TAPER TIP 8FR PVC,120.528,CDM,272,RC,,,,12253-MAIN,LOCAL,,,,,20,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER STRAIGHT TAPER TIP 8FR PVC,120.528,CDM,272,RC,,,,12253-MAIN,LOCAL,,,,,20,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER STRAIGHT TAPER TIP 8FR PVC,120.528,CDM,272,RC,,,,12253-MAIN,LOCAL,,,,,20,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER STRAIGHT TAPER TIP 10FR PVC,120.528,CDM,272,RC,,,,12254-MAIN,LOCAL,,,,,20,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER STRAIGHT TAPER TIP 10FR PVC,120.528,CDM,272,RC,,,,12254-MAIN,LOCAL,,,,,20,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER STRAIGHT TAPER TIP 10FR PVC,120.528,CDM,272,RC,,,,12254-MAIN,LOCAL,,,,,20,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER STRAIGHT TAPER TIP 10FR PVC,120.528,CDM,272,RC,,,,12254-MAIN,LOCAL,,,,,20,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER STRAIGHT TAPER TIP 10FR PVC,120.528,CDM,272,RC,,,,12254-MAIN,LOCAL,,,,,20,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER STRAIGHT TAPER TIP 10FR PVC,120.528,CDM,272,RC,,,,12254-MAIN,LOCAL,,,,,20,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER STRAIGHT TAPER TIP 12FR PVC,120.528,CDM,272,RC,,,,12255-MAIN,LOCAL,,,,,20,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER STRAIGHT TAPER TIP 12FR PVC,120.528,CDM,272,RC,,,,12255-MAIN,LOCAL,,,,,20,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER STRAIGHT TAPER TIP 12FR PVC,120.528,CDM,272,RC,,,,12255-MAIN,LOCAL,,,,,20,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER STRAIGHT TAPER TIP 12FR PVC,120.528,CDM,272,RC,,,,12255-MAIN,LOCAL,,,,,20,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER STRAIGHT TAPER TIP 12FR PVC,120.528,CDM,272,RC,,,,12255-MAIN,LOCAL,,,,,20,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER STRAIGHT TAPER TIP 12FR PVC,120.528,CDM,272,RC,,,,12255-MAIN,LOCAL,,,,,20,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER STRAIGHT TAPER TIP 16FR PVC,120.528,CDM,272,RC,,,,12256-MAIN,LOCAL,,,,,20,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER STRAIGHT TAPER TIP 16FR PVC,120.528,CDM,272,RC,,,,12256-MAIN,LOCAL,,,,,20,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER STRAIGHT TAPER TIP 16FR PVC,120.528,CDM,272,RC,,,,12256-MAIN,LOCAL,,,,,20,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER STRAIGHT TAPER TIP 16FR PVC,120.528,CDM,272,RC,,,,12256-MAIN,LOCAL,,,,,20,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER STRAIGHT TAPER TIP 16FR PVC,120.528,CDM,272,RC,,,,12256-MAIN,LOCAL,,,,,20,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER STRAIGHT TAPER TIP 16FR PVC,120.528,CDM,272,RC,,,,12256-MAIN,LOCAL,,,,,20,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER STRAIGHT TAPER TIP 28FR PVC,120.528,CDM,272,RC,,,,12249-MAIN,LOCAL,,,,,20,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER STRAIGHT TAPER TIP 28FR PVC,120.528,CDM,272,RC,,,,12249-MAIN,LOCAL,,,,,20,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER STRAIGHT TAPER TIP 28FR PVC,120.528,CDM,272,RC,,,,12249-MAIN,LOCAL,,,,,20,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER STRAIGHT TAPER TIP 28FR PVC,120.528,CDM,272,RC,,,,12249-MAIN,LOCAL,,,,,20,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER STRAIGHT TAPER TIP 28FR PVC,120.528,CDM,272,RC,,,,12249-MAIN,LOCAL,,,,,20,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER STRAIGHT TAPER TIP 28FR PVC,120.528,CDM,272,RC,,,,12249-MAIN,LOCAL,,,,,20,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER STRAIGHT TAPER TIP 32FR PVC,120.528,CDM,272,RC,,,,12250-MAIN,LOCAL,,,,,20,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER STRAIGHT TAPER TIP 32FR PVC,120.528,CDM,272,RC,,,,12250-MAIN,LOCAL,,,,,20,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER STRAIGHT TAPER TIP 32FR PVC,120.528,CDM,272,RC,,,,12250-MAIN,LOCAL,,,,,20,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER STRAIGHT TAPER TIP 32FR PVC,120.528,CDM,272,RC,,,,12250-MAIN,LOCAL,,,,,20,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER STRAIGHT TAPER TIP 32FR PVC,120.528,CDM,272,RC,,,,12250-MAIN,LOCAL,,,,,20,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER STRAIGHT TAPER TIP 32FR PVC,120.528,CDM,272,RC,,,,12250-MAIN,LOCAL,,,,,20,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER STRAIGHT TAPER TIP 36FR PVC,120.528,CDM,272,RC,,,,12251-MAIN,LOCAL,,,,,20,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER STRAIGHT TAPER TIP 36FR PVC,120.528,CDM,272,RC,,,,12251-MAIN,LOCAL,,,,,20,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER STRAIGHT TAPER TIP 36FR PVC,120.528,CDM,272,RC,,,,12251-MAIN,LOCAL,,,,,20,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER STRAIGHT TAPER TIP 36FR PVC,120.528,CDM,272,RC,,,,12251-MAIN,LOCAL,,,,,20,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER STRAIGHT TAPER TIP 36FR PVC,120.528,CDM,272,RC,,,,12251-MAIN,LOCAL,,,,,20,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER STRAIGHT TAPER TIP 36FR PVC,120.528,CDM,272,RC,,,,12251-MAIN,LOCAL,,,,,20,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Thrombin Time Plasma,PX85670,CDM,300,RC,85670,CPT,,,,,,,,126,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Thrombin Time Plasma,PX85670,CDM,300,RC,85670,CPT,,,,,,,,126,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Thrombin Time Plasma,PX85670,CDM,300,RC,85670,CPT,,,,,,,,126,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Thrombin Time Plasma,PX85670,CDM,300,RC,85670,CPT,,,,,,,,126,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Thrombin Time Plasma,PX85670,CDM,300,RC,85670,CPT,,,,,,,,126,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Thrombin Time Plasma,PX85670,CDM,300,RC,85670,CPT,,,,,,,,126,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Thrombolysis,Coronary,IV Infusn",PX92977F,CDM,480,RC,92977,CPT,,,,,,,,595,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Thrombolysis,Coronary,IV Infusn",PX92977F,CDM,480,RC,92977,CPT,,,,,,,,595,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Thrombolysis,Coronary,IV Infusn",PX92977F,CDM,480,RC,92977,CPT,,,,,,,,595,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Thrombolysis,Coronary,IV Infusn",PX92977F,CDM,480,RC,92977,CPT,,,,,,,,595,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Thrombolysis,Coronary,IV Infusn",PX92977F,CDM,480,RC,92977,CPT,,,,,,,,595,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Thrombolysis,Coronary,IV Infusn",PX92977F,CDM,480,RC,92977,CPT,,,,,,,,595,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Thrombolytic Therapy, Stroke",PX37195F,CDM,761,RC,37195,CPT,,,,,,,,595,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Thrombolytic Therapy, Stroke",PX37195F,CDM,761,RC,37195,CPT,,,,,,,,595,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Thrombolytic Therapy, Stroke",PX37195F,CDM,761,RC,37195,CPT,,,,,,,,595,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Thrombolytic Therapy, Stroke",PX37195F,CDM,761,RC,37195,CPT,,,,,,,,595,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Thrombolytic Therapy, Stroke",PX37195F,CDM,761,RC,37195,CPT,,,,,,,,595,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Thrombolytic Therapy, Stroke",PX37195F,CDM,761,RC,37195,CPT,,,,,,,,595,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Thromboplastin Time Partial,PX85730,CDM,300,RC,85730,CPT,,,,,,,,142,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Thromboplastin Time Partial,PX85730,CDM,300,RC,85730,CPT,,,,,,,,142,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Thromboplastin Time Partial,PX85730,CDM,300,RC,85730,CPT,,,,,,,,142,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Thromboplastin Time Partial,PX85730,CDM,300,RC,85730,CPT,,,,,,,,142,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Thromboplastin Time Partial,PX85730,CDM,300,RC,85730,CPT,,,,,,,,142,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Thromboplastin Time Partial,PX85730,CDM,300,RC,85730,CPT,,,,,,,,142,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Thyroglobulin - Ref,PX8443290,CDM,300,RC,84432,CPT,90,,,,,,,68,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Thyroglobulin - Ref,PX8443290,CDM,300,RC,84432,CPT,90,,,,,,,68,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Thyroglobulin - Ref,PX8443290,CDM,300,RC,84432,CPT,90,,,,,,,68,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Thyroglobulin - Ref,PX8443290,CDM,300,RC,84432,CPT,90,,,,,,,68,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Thyroglobulin - Ref,PX8443290,CDM,300,RC,84432,CPT,90,,,,,,,68,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Thyroglobulin - Ref,PX8443290,CDM,300,RC,84432,CPT,90,,,,,,,68,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Thyroglobulin Antibody,PX8680090,CDM,300,RC,86800,CPT,90,,,,,,,68,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Thyroglobulin Antibody,PX8680090,CDM,300,RC,86800,CPT,90,,,,,,,68,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Thyroglobulin Antibody,PX8680090,CDM,300,RC,86800,CPT,90,,,,,,,68,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Thyroglobulin Antibody,PX8680090,CDM,300,RC,86800,CPT,90,,,,,,,68,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Thyroglobulin Antibody,PX8680090,CDM,300,RC,86800,CPT,90,,,,,,,68,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Thyroglobulin Antibody,PX8680090,CDM,300,RC,86800,CPT,90,,,,,,,68,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Thyroxin, Free (Free T4)",PX84439,CDM,300,RC,84439,CPT,,,,,,,,173,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Thyroxin, Free (Free T4)",PX84439,CDM,300,RC,84439,CPT,,,,,,,,173,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Thyroxin, Free (Free T4)",PX84439,CDM,300,RC,84439,CPT,,,,,,,,173,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Thyroxin, Free (Free T4)",PX84439,CDM,300,RC,84439,CPT,,,,,,,,173,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Thyroxin, Free (Free T4)",PX84439,CDM,300,RC,84439,CPT,,,,,,,,173,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Thyroxin, Free (Free T4)",PX84439,CDM,300,RC,84439,CPT,,,,,,,,173,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Thyroxine, Total - Ref",PX8443690,CDM,300,RC,84436,CPT,90,,,,,,,95,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Thyroxine, Total - Ref",PX8443690,CDM,300,RC,84436,CPT,90,,,,,,,95,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Thyroxine, Total - Ref",PX8443690,CDM,300,RC,84436,CPT,90,,,,,,,95,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Thyroxine, Total - Ref",PX8443690,CDM,300,RC,84436,CPT,90,,,,,,,95,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Thyroxine, Total - Ref",PX8443690,CDM,300,RC,84436,CPT,90,,,,,,,95,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Thyroxine, Total - Ref",PX8443690,CDM,300,RC,84436,CPT,90,,,,,,,95,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Thyrstim Immun Glob (Tsi) - Ref,PX8444590,CDM,300,RC,84445,CPT,90,,,,,,,254,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Thyrstim Immun Glob (Tsi) - Ref,PX8444590,CDM,300,RC,84445,CPT,90,,,,,,,254,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Thyrstim Immun Glob (Tsi) - Ref,PX8444590,CDM,300,RC,84445,CPT,90,,,,,,,254,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Thyrstim Immun Glob (Tsi) - Ref,PX8444590,CDM,300,RC,84445,CPT,90,,,,,,,254,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Thyrstim Immun Glob (Tsi) - Ref,PX8444590,CDM,300,RC,84445,CPT,90,,,,,,,254,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Thyrstim Immun Glob (Tsi) - Ref,PX8444590,CDM,300,RC,84445,CPT,90,,,,,,,254,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ticagrelor 90 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,186077739,NDC,1,EA,44.35,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ticagrelor 90 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,186077739,NDC,1,EA,44.35,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ticagrelor 90 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,186077739,NDC,1,EA,44.35,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ticagrelor 90 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,186077739,NDC,1,EA,44.35,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ticagrelor 90 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,186077739,NDC,1,EA,44.35,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ticagrelor 90 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,186077739,NDC,1,EA,44.35,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,17478028810,NDC,5,ML,95.71,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,17478028810,NDC,5,ML,95.71,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,17478028810,NDC,5,ML,95.71,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,17478028810,NDC,5,ML,95.71,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,17478028810,NDC,5,ML,95.71,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,17478028810,NDC,5,ML,95.71,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314022705,NDC,5,ML,95.71,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314022705,NDC,5,ML,95.71,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314022705,NDC,5,ML,95.71,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314022705,NDC,5,ML,95.71,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314022705,NDC,5,ML,95.71,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314022705,NDC,5,ML,95.71,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,64980051405,NDC,5,ML,95.71,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,64980051405,NDC,5,ML,95.71,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,64980051405,NDC,5,ML,95.71,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,64980051405,NDC,5,ML,95.71,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,64980051405,NDC,5,ML,95.71,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,64980051405,NDC,5,ML,95.71,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
timolol 0.25 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314022605,NDC,5,ML,84.45,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
timolol 0.25 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314022605,NDC,5,ML,84.45,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
timolol 0.25 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314022605,NDC,5,ML,84.45,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
timolol 0.25 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314022605,NDC,5,ML,84.45,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
timolol 0.25 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314022605,NDC,5,ML,84.45,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
timolol 0.25 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314022605,NDC,5,ML,84.45,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tiotropium 18 MCG capsule 5 Each Box,63700001,CDM,250,RC,,,,,,597007575,NDC,5,EA,665.18,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tiotropium 18 MCG capsule 5 Each Box,63700001,CDM,250,RC,,,,,,597007575,NDC,5,EA,665.18,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tiotropium 18 MCG capsule 5 Each Box,63700001,CDM,250,RC,,,,,,597007575,NDC,5,EA,665.18,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tiotropium 18 MCG capsule 5 Each Box,63700001,CDM,250,RC,,,,,,597007575,NDC,5,EA,665.18,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tiotropium 18 MCG capsule 5 Each Box,63700001,CDM,250,RC,,,,,,597007575,NDC,5,EA,665.18,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tiotropium 18 MCG capsule 5 Each Box,63700001,CDM,250,RC,,,,,,597007575,NDC,5,EA,665.18,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tiotropium 18 MCG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,597007541,NDC,1,EA,82.92,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tiotropium 18 MCG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,597007541,NDC,1,EA,82.92,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tiotropium 18 MCG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,597007541,NDC,1,EA,82.92,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tiotropium 18 MCG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,597007541,NDC,1,EA,82.92,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tiotropium 18 MCG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,597007541,NDC,1,EA,82.92,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tiotropium 18 MCG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,597007541,NDC,1,EA,82.92,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tiotropium bromide monohydrate 2.5 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597010051,NDC,4,GR,461.7,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tiotropium bromide monohydrate 2.5 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597010051,NDC,4,GR,461.7,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tiotropium bromide monohydrate 2.5 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597010051,NDC,4,GR,461.7,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tiotropium bromide monohydrate 2.5 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597010051,NDC,4,GR,461.7,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tiotropium bromide monohydrate 2.5 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597010051,NDC,4,GR,461.7,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tiotropium bromide monohydrate 2.5 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597010051,NDC,4,GR,461.7,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tiotropium bromide-olodaterol 2.5-2.5 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597015570,NDC,4,GR,461.7,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tiotropium bromide-olodaterol 2.5-2.5 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597015570,NDC,4,GR,461.7,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tiotropium bromide-olodaterol 2.5-2.5 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597015570,NDC,4,GR,461.7,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tiotropium bromide-olodaterol 2.5-2.5 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597015570,NDC,4,GR,461.7,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tiotropium bromide-olodaterol 2.5-2.5 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597015570,NDC,4,GR,461.7,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tiotropium bromide-olodaterol 2.5-2.5 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597015570,NDC,4,GR,461.7,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tiss Cult, Neopl, Bm, Wb - Ref",PX8823790,CDM,310,RC,88237,CPT,90,,,,,,,3141,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tiss Cult, Neopl, Bm, Wb - Ref",PX8823790,CDM,310,RC,88237,CPT,90,,,,,,,3141,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tiss Cult, Neopl, Bm, Wb - Ref",PX8823790,CDM,310,RC,88237,CPT,90,,,,,,,3141,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tiss Cult, Neopl, Bm, Wb - Ref",PX8823790,CDM,310,RC,88237,CPT,90,,,,,,,3141,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tiss Cult, Neopl, Bm, Wb - Ref",PX8823790,CDM,310,RC,88237,CPT,90,,,,,,,3141,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tiss Cult, Neopl, Bm, Wb - Ref",PX8823790,CDM,310,RC,88237,CPT,90,,,,,,,3141,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tiss Cult,Non-Neop Lymph - Ref",PX8823090,CDM,310,RC,88230,CPT,90,,,,,,,103,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tiss Cult,Non-Neop Lymph - Ref",PX8823090,CDM,310,RC,88230,CPT,90,,,,,,,103,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tiss Cult,Non-Neop Lymph - Ref",PX8823090,CDM,310,RC,88230,CPT,90,,,,,,,103,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tiss Cult,Non-Neop Lymph - Ref",PX8823090,CDM,310,RC,88230,CPT,90,,,,,,,103,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tiss Cult,Non-Neop Lymph - Ref",PX8823090,CDM,310,RC,88230,CPT,90,,,,,,,103,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tiss Cult,Non-Neop Lymph - Ref",PX8823090,CDM,310,RC,88230,CPT,90,,,,,,,103,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tiss Trnsgltmnase Ea Ig Clas,PX86364,CDM,300,RC,86364,CPT,,,,,,,,57,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tiss Trnsgltmnase Ea Ig Clas,PX86364,CDM,300,RC,86364,CPT,,,,,,,,57,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tiss Trnsgltmnase Ea Ig Clas,PX86364,CDM,300,RC,86364,CPT,,,,,,,,57,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tiss Trnsgltmnase Ea Ig Clas,PX86364,CDM,300,RC,86364,CPT,,,,,,,,57,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tiss Trnsgltmnase Ea Ig Clas,PX86364,CDM,300,RC,86364,CPT,,,,,,,,57,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tiss Trnsgltmnase Ea Ig Clas,PX86364,CDM,300,RC,86364,CPT,,,,,,,,57,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tissue Exam for Fungi,PX87220,CDM,300,RC,87220,CPT,,,,,,,,94,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tissue Exam for Fungi,PX87220,CDM,300,RC,87220,CPT,,,,,,,,94,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tissue Exam for Fungi,PX87220,CDM,300,RC,87220,CPT,,,,,,,,94,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tissue Exam for Fungi,PX87220,CDM,300,RC,87220,CPT,,,,,,,,94,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tissue Exam for Fungi,PX87220,CDM,300,RC,87220,CPT,,,,,,,,94,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tissue Exam for Fungi,PX87220,CDM,300,RC,87220,CPT,,,,,,,,94,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TISSUE RETRIEVAL SYSTEM,27200000,CDM,272,RC,,,,10233-MAIN,LOCAL,,,,,139.98,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TISSUE RETRIEVAL SYSTEM,27200000,CDM,272,RC,,,,10233-MAIN,LOCAL,,,,,139.98,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TISSUE RETRIEVAL SYSTEM,27200000,CDM,272,RC,,,,10233-MAIN,LOCAL,,,,,139.98,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TISSUE RETRIEVAL SYSTEM,27200000,CDM,272,RC,,,,10233-MAIN,LOCAL,,,,,139.98,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TISSUE RETRIEVAL SYSTEM,27200000,CDM,272,RC,,,,10233-MAIN,LOCAL,,,,,139.98,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TISSUE RETRIEVAL SYSTEM,27200000,CDM,272,RC,,,,10233-MAIN,LOCAL,,,,,139.98,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tiZANidine 4 MG Tablet 150 Each Bottle,63700001,CDM,250,RC,,,,,,55111018015,NDC,0.5,EA,3.93,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tiZANidine 4 MG Tablet 150 Each Bottle,63700001,CDM,250,RC,,,,,,55111018015,NDC,0.5,EA,3.93,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tiZANidine 4 MG Tablet 150 Each Bottle,63700001,CDM,250,RC,,,,,,55111018015,NDC,0.5,EA,3.93,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tiZANidine 4 MG Tablet 150 Each Bottle,63700001,CDM,250,RC,,,,,,55111018015,NDC,0.5,EA,3.93,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tiZANidine 4 MG Tablet 150 Each Bottle,63700001,CDM,250,RC,,,,,,55111018015,NDC,0.5,EA,3.93,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tiZANidine 4 MG Tablet 150 Each Bottle,63700001,CDM,250,RC,,,,,,55111018015,NDC,0.5,EA,3.93,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tobramycin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314064305,NDC,5,ML,191.42,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tobramycin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314064305,NDC,5,ML,191.42,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tobramycin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314064305,NDC,5,ML,191.42,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tobramycin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314064305,NDC,5,ML,191.42,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tobramycin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314064305,NDC,5,ML,191.42,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tobramycin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314064305,NDC,5,ML,191.42,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tobramycin 80 MG/2ML Solution 2 mL Vial,J3260.01,CDM,636,RC,J3260,HCPCS,,,,67457047300,NDC,2,ML,33.09,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tobramycin 80 MG/2ML Solution 2 mL Vial,J3260.01,CDM,636,RC,J3260,HCPCS,,,,67457047300,NDC,2,ML,33.09,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tobramycin 80 MG/2ML Solution 2 mL Vial,J3260.01,CDM,636,RC,J3260,HCPCS,,,,67457047300,NDC,2,ML,33.09,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tobramycin 80 MG/2ML Solution 2 mL Vial,J3260.01,CDM,636,RC,J3260,HCPCS,,,,67457047300,NDC,2,ML,33.09,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tobramycin 80 MG/2ML Solution 2 mL Vial,J3260.01,CDM,636,RC,J3260,HCPCS,,,,67457047300,NDC,2,ML,33.09,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tobramycin 80 MG/2ML Solution 2 mL Vial,J3260.01,CDM,636,RC,J3260,HCPCS,,,,67457047300,NDC,2,ML,33.09,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tocilizumab 400 MG/20ML Solution 20 mL Vial,J3262.01,CDM,636,RC,J3262,HCPCS,,,,50242013701,NDC,20,ML,4703.83,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tocilizumab 400 MG/20ML Solution 20 mL Vial,J3262.01,CDM,636,RC,J3262,HCPCS,,,,50242013701,NDC,20,ML,4703.83,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tocilizumab 400 MG/20ML Solution 20 mL Vial,J3262.01,CDM,636,RC,J3262,HCPCS,,,,50242013701,NDC,20,ML,4703.83,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tocilizumab 400 MG/20ML Solution 20 mL Vial,J3262.01,CDM,636,RC,J3262,HCPCS,,,,50242013701,NDC,20,ML,4703.83,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tocilizumab 400 MG/20ML Solution 20 mL Vial,J3262.01,CDM,636,RC,J3262,HCPCS,,,,50242013701,NDC,20,ML,4703.83,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tocilizumab 400 MG/20ML Solution 20 mL Vial,J3262.01,CDM,636,RC,J3262,HCPCS,,,,50242013701,NDC,20,ML,4703.83,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tolterodine 2 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,59762080002,NDC,0.5,EA,9.12,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tolterodine 2 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,59762080002,NDC,0.5,EA,9.12,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tolterodine 2 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,59762080002,NDC,0.5,EA,9.12,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tolterodine 2 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,59762080002,NDC,0.5,EA,9.12,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tolterodine 2 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,59762080002,NDC,0.5,EA,9.12,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tolterodine 2 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,59762080002,NDC,0.5,EA,9.12,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tolterodine ER 2 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,43975032203,NDC,1,EA,43.15,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tolterodine ER 2 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,43975032203,NDC,1,EA,43.15,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tolterodine ER 2 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,43975032203,NDC,1,EA,43.15,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tolterodine ER 2 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,43975032203,NDC,1,EA,43.15,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tolterodine ER 2 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,43975032203,NDC,1,EA,43.15,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tolterodine ER 2 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,43975032203,NDC,1,EA,43.15,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Topiramate - Ref,PX8020190,CDM,300,RC,80201,CPT,90,,,,,,,195,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Topiramate - Ref,PX8020190,CDM,300,RC,80201,CPT,90,,,,,,,195,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Topiramate - Ref,PX8020190,CDM,300,RC,80201,CPT,90,,,,,,,195,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Topiramate - Ref,PX8020190,CDM,300,RC,80201,CPT,90,,,,,,,195,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Topiramate - Ref,PX8020190,CDM,300,RC,80201,CPT,90,,,,,,,195,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Topiramate - Ref,PX8020190,CDM,300,RC,80201,CPT,90,,,,,,,195,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
topiramate 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034211,NDC,1,EA,11.28,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
topiramate 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034211,NDC,1,EA,11.28,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
topiramate 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034211,NDC,1,EA,11.28,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
topiramate 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034211,NDC,1,EA,11.28,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
topiramate 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034211,NDC,1,EA,11.28,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
topiramate 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034211,NDC,1,EA,11.28,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
topiramate 25 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,62756070786,NDC,1,EA,13.71,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
topiramate 25 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,62756070786,NDC,1,EA,13.71,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
topiramate 25 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,62756070786,NDC,1,EA,13.71,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
topiramate 25 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,62756070786,NDC,1,EA,13.71,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
topiramate 25 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,62756070786,NDC,1,EA,13.71,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
topiramate 25 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,62756070786,NDC,1,EA,13.71,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
topiramate 25 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,69097012203,NDC,1,EA,13.56,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
topiramate 25 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,69097012203,NDC,1,EA,13.56,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
topiramate 25 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,69097012203,NDC,1,EA,13.56,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
topiramate 25 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,69097012203,NDC,1,EA,13.56,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
topiramate 25 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,69097012203,NDC,1,EA,13.56,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
topiramate 25 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,69097012203,NDC,1,EA,13.56,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
topiramate 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034201,NDC,1,EA,11.28,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
topiramate 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034201,NDC,1,EA,11.28,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
topiramate 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034201,NDC,1,EA,11.28,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
topiramate 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034201,NDC,1,EA,11.28,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
topiramate 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034201,NDC,1,EA,11.28,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
topiramate 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034201,NDC,1,EA,11.28,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
topiramate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034411,NDC,0.25,EA,8.32,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
topiramate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034411,NDC,0.25,EA,8.32,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
topiramate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034411,NDC,0.25,EA,8.32,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
topiramate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034411,NDC,0.25,EA,8.32,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
topiramate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034411,NDC,0.25,EA,8.32,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
topiramate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034411,NDC,0.25,EA,8.32,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
topiramate 100 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,69097012403,NDC,0.25,EA,9.24,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
topiramate 100 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,69097012403,NDC,0.25,EA,9.24,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
topiramate 100 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,69097012403,NDC,0.25,EA,9.24,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
topiramate 100 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,69097012403,NDC,0.25,EA,9.24,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
topiramate 100 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,69097012403,NDC,0.25,EA,9.24,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
topiramate 100 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,69097012403,NDC,0.25,EA,9.24,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
topiramate 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034401,NDC,0.25,EA,8.32,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
topiramate 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034401,NDC,0.25,EA,8.32,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
topiramate 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034401,NDC,0.25,EA,8.32,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
topiramate 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034401,NDC,0.25,EA,8.32,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
topiramate 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034401,NDC,0.25,EA,8.32,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
topiramate 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034401,NDC,0.25,EA,8.32,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
torsemide 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268075411,NDC,1,EA,3.36,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
torsemide 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268075411,NDC,1,EA,3.36,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
torsemide 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268075411,NDC,1,EA,3.36,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
torsemide 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268075411,NDC,1,EA,3.36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
torsemide 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268075411,NDC,1,EA,3.36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
torsemide 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268075411,NDC,1,EA,3.36,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
torsemide 5 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268075415,NDC,1,EA,3.36,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
torsemide 5 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268075415,NDC,1,EA,3.36,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
torsemide 5 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268075415,NDC,1,EA,3.36,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
torsemide 5 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268075415,NDC,1,EA,3.36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
torsemide 5 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268075415,NDC,1,EA,3.36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
torsemide 5 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268075415,NDC,1,EA,3.36,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
torsemide 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50111091501,NDC,1,EA,3.41,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
torsemide 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50111091501,NDC,1,EA,3.41,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
torsemide 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50111091501,NDC,1,EA,3.41,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
torsemide 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50111091501,NDC,1,EA,3.41,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
torsemide 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50111091501,NDC,1,EA,3.41,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
torsemide 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50111091501,NDC,1,EA,3.41,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
torsemide 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268075611,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
torsemide 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268075611,NDC,0.25,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
torsemide 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268075611,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
torsemide 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268075611,NDC,0.25,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
torsemide 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268075611,NDC,0.25,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
torsemide 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268075611,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
torsemide 20 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268075615,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
torsemide 20 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268075615,NDC,0.25,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
torsemide 20 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268075615,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
torsemide 20 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268075615,NDC,0.25,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
torsemide 20 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268075615,NDC,0.25,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
torsemide 20 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268075615,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
torsemide 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54007725,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
torsemide 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54007725,NDC,0.25,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
torsemide 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54007725,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
torsemide 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54007725,NDC,0.25,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
torsemide 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54007725,NDC,0.25,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
torsemide 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54007725,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
torsemide 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50111091701,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
torsemide 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50111091701,NDC,0.25,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
torsemide 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50111091701,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
torsemide 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50111091701,NDC,0.25,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
torsemide 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50111091701,NDC,0.25,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
torsemide 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50111091701,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Total Cortisol,PX82533,CDM,300,RC,82533,CPT,,,,,,,,137,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Total Cortisol,PX82533,CDM,300,RC,82533,CPT,,,,,,,,137,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Total Cortisol,PX82533,CDM,300,RC,82533,CPT,,,,,,,,137,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Total Cortisol,PX82533,CDM,300,RC,82533,CPT,,,,,,,,137,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Total Cortisol,PX82533,CDM,300,RC,82533,CPT,,,,,,,,137,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Total Cortisol,PX82533,CDM,300,RC,82533,CPT,,,,,,,,137,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tramadol - Ref,PX8037390,CDM,300,RC,80373,CPT,90,,,,,,,197,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tramadol - Ref,PX8037390,CDM,300,RC,80373,CPT,90,,,,,,,197,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tramadol - Ref,PX8037390,CDM,300,RC,80373,CPT,90,,,,,,,197,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tramadol - Ref,PX8037390,CDM,300,RC,80373,CPT,90,,,,,,,197,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tramadol - Ref,PX8037390,CDM,300,RC,80373,CPT,90,,,,,,,197,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tramadol - Ref,PX8037390,CDM,300,RC,80373,CPT,90,,,,,,,197,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
traMADol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079099101,NDC,1,EA,4.27,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
traMADol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079099101,NDC,1,EA,4.27,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
traMADol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079099101,NDC,1,EA,4.27,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
traMADol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079099101,NDC,1,EA,4.27,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
traMADol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079099101,NDC,1,EA,4.27,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
traMADol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079099101,NDC,1,EA,4.27,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
traMADol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084080811,NDC,1,EA,4.4,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
traMADol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084080811,NDC,1,EA,4.4,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
traMADol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084080811,NDC,1,EA,4.4,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
traMADol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084080811,NDC,1,EA,4.4,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
traMADol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084080811,NDC,1,EA,4.4,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
traMADol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084080811,NDC,1,EA,4.4,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
traMADol 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68084080801,NDC,1,EA,4.4,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
traMADol 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68084080801,NDC,1,EA,4.4,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
traMADol 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68084080801,NDC,1,EA,4.4,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
traMADol 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68084080801,NDC,1,EA,4.4,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
traMADol 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68084080801,NDC,1,EA,4.4,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
traMADol 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68084080801,NDC,1,EA,4.4,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
traMADol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079099120,NDC,1,EA,4.27,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
traMADol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079099120,NDC,1,EA,4.27,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
traMADol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079099120,NDC,1,EA,4.27,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
traMADol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079099120,NDC,1,EA,4.27,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
traMADol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079099120,NDC,1,EA,4.27,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
traMADol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079099120,NDC,1,EA,4.27,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
traMADol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739067110,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
traMADol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739067110,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
traMADol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739067110,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
traMADol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739067110,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
traMADol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739067110,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
traMADol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739067110,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tranexamic acid 650 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,69918030130,NDC,1,EA,28,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tranexamic acid 650 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,69918030130,NDC,1,EA,28,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tranexamic acid 650 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,69918030130,NDC,1,EA,28,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tranexamic acid 650 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,69918030130,NDC,1,EA,28,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tranexamic acid 650 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,69918030130,NDC,1,EA,28,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tranexamic acid 650 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,69918030130,NDC,1,EA,28,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tranexamic acid 1000 mg in 100 mL 0.7% sodium chloride (premix) 1000-0.7 MG/100ML-% Solution 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,80830232901,NDC,100,ML,155.55,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tranexamic acid 1000 mg in 100 mL 0.7% sodium chloride (premix) 1000-0.7 MG/100ML-% Solution 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,80830232901,NDC,100,ML,155.55,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tranexamic acid 1000 mg in 100 mL 0.7% sodium chloride (premix) 1000-0.7 MG/100ML-% Solution 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,80830232901,NDC,100,ML,155.55,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tranexamic acid 1000 mg in 100 mL 0.7% sodium chloride (premix) 1000-0.7 MG/100ML-% Solution 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,80830232901,NDC,100,ML,155.55,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tranexamic acid 1000 mg in 100 mL 0.7% sodium chloride (premix) 1000-0.7 MG/100ML-% Solution 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,80830232901,NDC,100,ML,155.55,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tranexamic acid 1000 mg in 100 mL 0.7% sodium chloride (premix) 1000-0.7 MG/100ML-% Solution 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,80830232901,NDC,100,ML,155.55,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,517096001,NDC,10,ML,355.63,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,517096001,NDC,10,ML,355.63,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,517096001,NDC,10,ML,355.63,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,517096001,NDC,10,ML,355.63,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,517096001,NDC,10,ML,355.63,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,517096001,NDC,10,ML,355.63,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,517096010,NDC,10,ML,157.64,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,517096010,NDC,10,ML,157.64,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,517096010,NDC,10,ML,157.64,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,517096010,NDC,10,ML,157.64,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,517096010,NDC,10,ML,157.64,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,517096010,NDC,10,ML,157.64,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,23155052431,NDC,10,ML,486.06,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,23155052431,NDC,10,ML,486.06,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,23155052431,NDC,10,ML,486.06,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,23155052431,NDC,10,ML,486.06,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,23155052431,NDC,10,ML,486.06,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,23155052431,NDC,10,ML,486.06,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,23155052441,NDC,10,ML,486.06,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,23155052441,NDC,10,ML,486.06,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,23155052441,NDC,10,ML,486.06,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,23155052441,NDC,10,ML,486.06,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,23155052441,NDC,10,ML,486.06,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,23155052441,NDC,10,ML,486.06,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Transferase; Alanine Amino (Alt) (Sgpt),PX84460,CDM,300,RC,84460,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Transferase; Alanine Amino (Alt) (Sgpt),PX84460,CDM,300,RC,84460,CPT,,,,,,,,58,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Transferase; Alanine Amino (Alt) (Sgpt),PX84460,CDM,300,RC,84460,CPT,,,,,,,,58,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Transferase; Alanine Amino (Alt) (Sgpt),PX84460,CDM,300,RC,84460,CPT,,,,,,,,58,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Transferase; Alanine Amino (Alt) (Sgpt),PX84460,CDM,300,RC,84460,CPT,,,,,,,,58,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Transferase; Alanine Amino (Alt) (Sgpt),PX84460,CDM,300,RC,84460,CPT,,,,,,,,58,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Transferase; Aspartate Amino (Ast) (Sgot),PX84450,CDM,300,RC,84450,CPT,,,,,,,,58,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Transferase; Aspartate Amino (Ast) (Sgot),PX84450,CDM,300,RC,84450,CPT,,,,,,,,58,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Transferase; Aspartate Amino (Ast) (Sgot),PX84450,CDM,300,RC,84450,CPT,,,,,,,,58,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Transferase; Aspartate Amino (Ast) (Sgot),PX84450,CDM,300,RC,84450,CPT,,,,,,,,58,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Transferase; Aspartate Amino (Ast) (Sgot),PX84450,CDM,300,RC,84450,CPT,,,,,,,,58,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Transferase; Aspartate Amino (Ast) (Sgot),PX84450,CDM,300,RC,84450,CPT,,,,,,,,58,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Transvaginal US, Obstetric",PX7681701,CDM,402,RC,76817,CPT,TC,,,,,,,460,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Transvaginal US, Obstetric",PX7681701,CDM,402,RC,76817,CPT,TC,,,,,,,460,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Transvaginal US, Obstetric",PX7681701,CDM,402,RC,76817,CPT,TC,,,,,,,460,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Transvaginal US, Obstetric",PX7681701,CDM,402,RC,76817,CPT,TC,,,,,,,460,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Transvaginal US, Obstetric",PX7681701,CDM,402,RC,76817,CPT,TC,,,,,,,460,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Transvaginal US, Obstetric",PX7681701,CDM,402,RC,76817,CPT,TC,,,,,,,460,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
trastuzumab 150 MG Recon Soln 1 Each Vial,J9355.01,CDM,636,RC,J9355,HCPCS,,,,50242013201,NDC,1,EA,3179.17,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
trastuzumab 150 MG Recon Soln 1 Each Vial,J9355.01,CDM,636,RC,J9355,HCPCS,,,,50242013201,NDC,1,EA,3179.17,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
trastuzumab 150 MG Recon Soln 1 Each Vial,J9355.01,CDM,636,RC,J9355,HCPCS,,,,50242013201,NDC,1,EA,3179.17,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
trastuzumab 150 MG Recon Soln 1 Each Vial,J9355.01,CDM,636,RC,J9355,HCPCS,,,,50242013201,NDC,1,EA,3179.17,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
trastuzumab 150 MG Recon Soln 1 Each Vial,J9355.01,CDM,636,RC,J9355,HCPCS,,,,50242013201,NDC,1,EA,3179.17,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
trastuzumab 150 MG Recon Soln 1 Each Vial,J9355.01,CDM,636,RC,J9355,HCPCS,,,,50242013201,NDC,1,EA,3179.17,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
trastuzumab-dttb 150 MG Recon Soln 1 Each Vial,J9999.55,CDM,636,RC,J9999,HCPCS,,,,78206014701,NDC,1,EA,2702.3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
trastuzumab-dttb 150 MG Recon Soln 1 Each Vial,J9999.55,CDM,636,RC,J9999,HCPCS,,,,78206014701,NDC,1,EA,2702.3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
trastuzumab-dttb 150 MG Recon Soln 1 Each Vial,J9999.55,CDM,636,RC,J9999,HCPCS,,,,78206014701,NDC,1,EA,2702.3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
trastuzumab-dttb 150 MG Recon Soln 1 Each Vial,J9999.55,CDM,636,RC,J9999,HCPCS,,,,78206014701,NDC,1,EA,2702.3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
trastuzumab-dttb 150 MG Recon Soln 1 Each Vial,J9999.55,CDM,636,RC,J9999,HCPCS,,,,78206014701,NDC,1,EA,2702.3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
trastuzumab-dttb 150 MG Recon Soln 1 Each Vial,J9999.55,CDM,636,RC,J9999,HCPCS,,,,78206014701,NDC,1,EA,2702.3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Trauma Activation,PX68200010,CDM,684,RC,G0390,HCPCS,,,,,,,,1243,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Trauma Activation,PX68200010,CDM,684,RC,G0390,HCPCS,,,,,,,,1243,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Trauma Activation,PX68200010,CDM,684,RC,G0390,HCPCS,,,,,,,,1243,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Trauma Activation,PX68200010,CDM,684,RC,G0390,HCPCS,,,,,,,,1243,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Trauma Activation,PX68200010,CDM,684,RC,G0390,HCPCS,,,,,,,,1243,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Trauma Activation,PX68200010,CDM,684,RC,G0390,HCPCS,,,,,,,,1243,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
travoprost (BAK Free) 0.004 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,65026025,NDC,2.5,ML,811.3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
travoprost (BAK Free) 0.004 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,65026025,NDC,2.5,ML,811.3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
travoprost (BAK Free) 0.004 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,65026025,NDC,2.5,ML,811.3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
travoprost (BAK Free) 0.004 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,65026025,NDC,2.5,ML,811.3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
travoprost (BAK Free) 0.004 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,65026025,NDC,2.5,ML,811.3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
travoprost (BAK Free) 0.004 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,65026025,NDC,2.5,ML,811.3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY 8 FR 5IN CENTESIS WITH TURKEL  30-CE1CO,120.303,CDM,272,RC,,,,11503-MAIN,LOCAL,,,,,217,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY 8 FR 5IN CENTESIS WITH TURKEL  30-CE1CO,120.303,CDM,272,RC,,,,11503-MAIN,LOCAL,,,,,217,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY 8 FR 5IN CENTESIS WITH TURKEL  30-CE1CO,120.303,CDM,272,RC,,,,11503-MAIN,LOCAL,,,,,217,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY 8 FR 5IN CENTESIS WITH TURKEL  30-CE1CO,120.303,CDM,272,RC,,,,11503-MAIN,LOCAL,,,,,217,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY 8 FR 5IN CENTESIS WITH TURKEL  30-CE1CO,120.303,CDM,272,RC,,,,11503-MAIN,LOCAL,,,,,217,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY 8 FR 5IN CENTESIS WITH TURKEL  30-CE1CO,120.303,CDM,272,RC,,,,11503-MAIN,LOCAL,,,,,217,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY ARTHROGRAM SAFE-T-ARTHRO 28-AR1CO,120.2,CDM,272,RC,,,,11499-MAIN,LOCAL,,,,,29,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY ARTHROGRAM SAFE-T-ARTHRO 28-AR1CO,120.2,CDM,272,RC,,,,11499-MAIN,LOCAL,,,,,29,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY ARTHROGRAM SAFE-T-ARTHRO 28-AR1CO,120.2,CDM,272,RC,,,,11499-MAIN,LOCAL,,,,,29,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY ARTHROGRAM SAFE-T-ARTHRO 28-AR1CO,120.2,CDM,272,RC,,,,11499-MAIN,LOCAL,,,,,29,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY ARTHROGRAM SAFE-T-ARTHRO 28-AR1CO,120.2,CDM,272,RC,,,,11499-MAIN,LOCAL,,,,,29,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY ARTHROGRAM SAFE-T-ARTHRO 28-AR1CO,120.2,CDM,272,RC,,,,11499-MAIN,LOCAL,,,,,29,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY CENTRAL LINE DRESSING WITH CHLORAPREP DYND75234,120.68,CDM,272,RC,,,,10923-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY CENTRAL LINE DRESSING WITH CHLORAPREP DYND75234,120.68,CDM,272,RC,,,,10923-MAIN,LOCAL,,,,,42,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY CENTRAL LINE DRESSING WITH CHLORAPREP DYND75234,120.68,CDM,272,RC,,,,10923-MAIN,LOCAL,,,,,42,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY CENTRAL LINE DRESSING WITH CHLORAPREP DYND75234,120.68,CDM,272,RC,,,,10923-MAIN,LOCAL,,,,,42,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY CENTRAL LINE DRESSING WITH CHLORAPREP DYND75234,120.68,CDM,272,RC,,,,10923-MAIN,LOCAL,,,,,42,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY CENTRAL LINE DRESSING WITH CHLORAPREP DYND75234,120.68,CDM,272,RC,,,,10923-MAIN,LOCAL,,,,,42,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY FACIAL LACERATION PACK STERILE 96-1707,120.12,CDM,272,RC,,,,406-MAIN,LOCAL,,,,,95,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY FACIAL LACERATION PACK STERILE 96-1707,120.12,CDM,272,RC,,,,406-MAIN,LOCAL,,,,,95,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY FACIAL LACERATION PACK STERILE 96-1707,120.12,CDM,272,RC,,,,406-MAIN,LOCAL,,,,,95,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY FACIAL LACERATION PACK STERILE 96-1707,120.12,CDM,272,RC,,,,406-MAIN,LOCAL,,,,,95,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY FACIAL LACERATION PACK STERILE 96-1707,120.12,CDM,272,RC,,,,406-MAIN,LOCAL,,,,,95,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY FACIAL LACERATION PACK STERILE 96-1707,120.12,CDM,272,RC,,,,406-MAIN,LOCAL,,,,,95,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY FOLEY 14FR CATHETER A300414A,120.414,CDM,272,RC,A4344,HCPCS,,11281-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY FOLEY 14FR CATHETER A300414A,120.414,CDM,272,RC,A4344,HCPCS,,11281-MAIN,LOCAL,,,,,42,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY FOLEY 14FR CATHETER A300414A,120.414,CDM,272,RC,A4344,HCPCS,,11281-MAIN,LOCAL,,,,,42,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY FOLEY 14FR CATHETER A300414A,120.414,CDM,272,RC,A4344,HCPCS,,11281-MAIN,LOCAL,,,,,42,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY FOLEY 14FR CATHETER A300414A,120.414,CDM,272,RC,A4344,HCPCS,,11281-MAIN,LOCAL,,,,,42,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY FOLEY 14FR CATHETER A300414A,120.414,CDM,272,RC,A4344,HCPCS,,11281-MAIN,LOCAL,,,,,42,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY FOLEY 16FR CATHETER 300416A,120.414,CDM,272,RC,A4344,HCPCS,,11774-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY FOLEY 16FR CATHETER 300416A,120.414,CDM,272,RC,A4344,HCPCS,,11774-MAIN,LOCAL,,,,,42,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY FOLEY 16FR CATHETER 300416A,120.414,CDM,272,RC,A4344,HCPCS,,11774-MAIN,LOCAL,,,,,42,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY FOLEY 16FR CATHETER 300416A,120.414,CDM,272,RC,A4344,HCPCS,,11774-MAIN,LOCAL,,,,,42,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY FOLEY 16FR CATHETER 300416A,120.414,CDM,272,RC,A4344,HCPCS,,11774-MAIN,LOCAL,,,,,42,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY FOLEY 16FR CATHETER 300416A,120.414,CDM,272,RC,A4344,HCPCS,,11774-MAIN,LOCAL,,,,,42,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY GROSHONG 4FR SAFETY PICC 7617407,120.26,CDM,272,RC,,,,500-MAIN,LOCAL,,,,,233,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY GROSHONG 4FR SAFETY PICC 7617407,120.26,CDM,272,RC,,,,500-MAIN,LOCAL,,,,,233,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY GROSHONG 4FR SAFETY PICC 7617407,120.26,CDM,272,RC,,,,500-MAIN,LOCAL,,,,,233,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY GROSHONG 4FR SAFETY PICC 7617407,120.26,CDM,272,RC,,,,500-MAIN,LOCAL,,,,,233,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY GROSHONG 4FR SAFETY PICC 7617407,120.26,CDM,272,RC,,,,500-MAIN,LOCAL,,,,,233,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY GROSHONG 4FR SAFETY PICC 7617407,120.26,CDM,272,RC,,,,500-MAIN,LOCAL,,,,,233,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY HAND SURGICAL II DYNJS0806,27200000,CDM,272,RC,,,,11024-MAIN,LOCAL,,,,,64.62,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY HAND SURGICAL II DYNJS0806,27200000,CDM,272,RC,,,,11024-MAIN,LOCAL,,,,,64.62,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY HAND SURGICAL II DYNJS0806,27200000,CDM,272,RC,,,,11024-MAIN,LOCAL,,,,,64.62,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY HAND SURGICAL II DYNJS0806,27200000,CDM,272,RC,,,,11024-MAIN,LOCAL,,,,,64.62,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY HAND SURGICAL II DYNJS0806,27200000,CDM,272,RC,,,,11024-MAIN,LOCAL,,,,,64.62,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY HAND SURGICAL II DYNJS0806,27200000,CDM,272,RC,,,,11024-MAIN,LOCAL,,,,,64.62,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY IV SURGICAL EXTREMITY DYNJS0804,27200000,CDM,272,RC,,,,10919-MAIN,LOCAL,,,,,83.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY IV SURGICAL EXTREMITY DYNJS0804,27200000,CDM,272,RC,,,,10919-MAIN,LOCAL,,,,,83.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY IV SURGICAL EXTREMITY DYNJS0804,27200000,CDM,272,RC,,,,10919-MAIN,LOCAL,,,,,83.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY IV SURGICAL EXTREMITY DYNJS0804,27200000,CDM,272,RC,,,,10919-MAIN,LOCAL,,,,,83.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY IV SURGICAL EXTREMITY DYNJS0804,27200000,CDM,272,RC,,,,10919-MAIN,LOCAL,,,,,83.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY IV SURGICAL EXTREMITY DYNJS0804,27200000,CDM,272,RC,,,,10919-MAIN,LOCAL,,,,,83.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY LUMBAR 22GAX3.5 PUNCTURE SAFE-T 4306CWSP,120.18,CDM,272,RC,,,,11584-MAIN,LOCAL,,,,,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY LUMBAR 22GAX3.5 PUNCTURE SAFE-T 4306CWSP,120.18,CDM,272,RC,,,,11584-MAIN,LOCAL,,,,,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY LUMBAR 22GAX3.5 PUNCTURE SAFE-T 4306CWSP,120.18,CDM,272,RC,,,,11584-MAIN,LOCAL,,,,,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY LUMBAR 22GAX3.5 PUNCTURE SAFE-T 4306CWSP,120.18,CDM,272,RC,,,,11584-MAIN,LOCAL,,,,,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY LUMBAR 22GAX3.5 PUNCTURE SAFE-T 4306CWSP,120.18,CDM,272,RC,,,,11584-MAIN,LOCAL,,,,,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY LUMBAR 22GAX3.5 PUNCTURE SAFE-T 4306CWSP,120.18,CDM,272,RC,,,,11584-MAIN,LOCAL,,,,,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY LUMBAR 22X1.5 PUNCTURE PEDS 4302CSP,120.18,CDM,272,RC,,,,652-MAIN,LOCAL,,,,,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY LUMBAR 22X1.5 PUNCTURE PEDS 4302CSP,120.18,CDM,272,RC,,,,652-MAIN,LOCAL,,,,,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY LUMBAR 22X1.5 PUNCTURE PEDS 4302CSP,120.18,CDM,272,RC,,,,652-MAIN,LOCAL,,,,,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY LUMBAR 22X1.5 PUNCTURE PEDS 4302CSP,120.18,CDM,272,RC,,,,652-MAIN,LOCAL,,,,,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY LUMBAR 22X1.5 PUNCTURE PEDS 4302CSP,120.18,CDM,272,RC,,,,652-MAIN,LOCAL,,,,,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY LUMBAR 22X1.5 PUNCTURE PEDS 4302CSP,120.18,CDM,272,RC,,,,652-MAIN,LOCAL,,,,,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY PNEUMOTHORAX 14FR 29CM 19 CATHETER SIDEPORTS G56537,120.496,CDM,272,RC,,,,11677-MAIN,LOCAL,,,,,419,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY PNEUMOTHORAX 14FR 29CM 19 CATHETER SIDEPORTS G56537,120.496,CDM,272,RC,,,,11677-MAIN,LOCAL,,,,,419,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY PNEUMOTHORAX 14FR 29CM 19 CATHETER SIDEPORTS G56537,120.496,CDM,272,RC,,,,11677-MAIN,LOCAL,,,,,419,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY PNEUMOTHORAX 14FR 29CM 19 CATHETER SIDEPORTS G56537,120.496,CDM,272,RC,,,,11677-MAIN,LOCAL,,,,,419,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY PNEUMOTHORAX 14FR 29CM 19 CATHETER SIDEPORTS G56537,120.496,CDM,272,RC,,,,11677-MAIN,LOCAL,,,,,419,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY PNEUMOTHORAX 14FR 29CM 19 CATHETER SIDEPORTS G56537,120.496,CDM,272,RC,,,,11677-MAIN,LOCAL,,,,,419,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"TRAY SPINAL  25GX3.5"" WITH WHITEACRE 405671",120.275,CDM,272,RC,,,,3284-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"TRAY SPINAL  25GX3.5"" WITH WHITEACRE 405671",120.275,CDM,272,RC,,,,3284-MAIN,LOCAL,,,,,42,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"TRAY SPINAL  25GX3.5"" WITH WHITEACRE 405671",120.275,CDM,272,RC,,,,3284-MAIN,LOCAL,,,,,42,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"TRAY SPINAL  25GX3.5"" WITH WHITEACRE 405671",120.275,CDM,272,RC,,,,3284-MAIN,LOCAL,,,,,42,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"TRAY SPINAL  25GX3.5"" WITH WHITEACRE 405671",120.275,CDM,272,RC,,,,3284-MAIN,LOCAL,,,,,42,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"TRAY SPINAL  25GX3.5"" WITH WHITEACRE 405671",120.275,CDM,272,RC,,,,3284-MAIN,LOCAL,,,,,42,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY SPINAL 25G ANESTH SADDLE BLOCK NLD-4795-20,120.275,CDM,272,RC,,,,935-MAIN,LOCAL,,,,,42,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY SPINAL 25G ANESTH SADDLE BLOCK NLD-4795-20,120.275,CDM,272,RC,,,,935-MAIN,LOCAL,,,,,42,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY SPINAL 25G ANESTH SADDLE BLOCK NLD-4795-20,120.275,CDM,272,RC,,,,935-MAIN,LOCAL,,,,,42,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY SPINAL 25G ANESTH SADDLE BLOCK NLD-4795-20,120.275,CDM,272,RC,,,,935-MAIN,LOCAL,,,,,42,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY SPINAL 25G ANESTH SADDLE BLOCK NLD-4795-20,120.275,CDM,272,RC,,,,935-MAIN,LOCAL,,,,,42,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY SPINAL 25G ANESTH SADDLE BLOCK NLD-4795-20,120.275,CDM,272,RC,,,,935-MAIN,LOCAL,,,,,42,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY SURGICAL PODIATRY II EXTREMITY DYNJS0803,27200000,CDM,272,RC,,,,10920-MAIN,LOCAL,,,,,73.29,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY SURGICAL PODIATRY II EXTREMITY DYNJS0803,27200000,CDM,272,RC,,,,10920-MAIN,LOCAL,,,,,73.29,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY SURGICAL PODIATRY II EXTREMITY DYNJS0803,27200000,CDM,272,RC,,,,10920-MAIN,LOCAL,,,,,73.29,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY SURGICAL PODIATRY II EXTREMITY DYNJS0803,27200000,CDM,272,RC,,,,10920-MAIN,LOCAL,,,,,73.29,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY SURGICAL PODIATRY II EXTREMITY DYNJS0803,27200000,CDM,272,RC,,,,10920-MAIN,LOCAL,,,,,73.29,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY SURGICAL PODIATRY II EXTREMITY DYNJS0803,27200000,CDM,272,RC,,,,10920-MAIN,LOCAL,,,,,73.29,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY TRACH CLEAN & CARE DYND40589,120.212,CDM,271,RC,,,,1173-MAIN,LOCAL,,,,,18,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY TRACH CLEAN & CARE DYND40589,120.212,CDM,271,RC,,,,1173-MAIN,LOCAL,,,,,18,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY TRACH CLEAN & CARE DYND40589,120.212,CDM,271,RC,,,,1173-MAIN,LOCAL,,,,,18,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY TRACH CLEAN & CARE DYND40589,120.212,CDM,271,RC,,,,1173-MAIN,LOCAL,,,,,18,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY TRACH CLEAN & CARE DYND40589,120.212,CDM,271,RC,,,,1173-MAIN,LOCAL,,,,,18,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY TRACH CLEAN & CARE DYND40589,120.212,CDM,271,RC,,,,1173-MAIN,LOCAL,,,,,18,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY TRACHEOTOMY CARE PEDS DYND40650H,120.212,CDM,272,RC,,,,11025-MAIN,LOCAL,,,,,18,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY TRACHEOTOMY CARE PEDS DYND40650H,120.212,CDM,272,RC,,,,11025-MAIN,LOCAL,,,,,18,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY TRACHEOTOMY CARE PEDS DYND40650H,120.212,CDM,272,RC,,,,11025-MAIN,LOCAL,,,,,18,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY TRACHEOTOMY CARE PEDS DYND40650H,120.212,CDM,272,RC,,,,11025-MAIN,LOCAL,,,,,18,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY TRACHEOTOMY CARE PEDS DYND40650H,120.212,CDM,272,RC,,,,11025-MAIN,LOCAL,,,,,18,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY TRACHEOTOMY CARE PEDS DYND40650H,120.212,CDM,272,RC,,,,11025-MAIN,LOCAL,,,,,18,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
traZODone 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904655461,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
traZODone 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904655461,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
traZODone 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904655461,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
traZODone 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904655461,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
traZODone 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904655461,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
traZODone 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904655461,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Trb@ Gene Rearrange Amplify - Ref,PX8134090,CDM,300,RC,81340,CPT,90,,,,,,,503,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Trb@ Gene Rearrange Amplify - Ref,PX8134090,CDM,300,RC,81340,CPT,90,,,,,,,503,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Trb@ Gene Rearrange Amplify - Ref,PX8134090,CDM,300,RC,81340,CPT,90,,,,,,,503,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Trb@ Gene Rearrange Amplify - Ref,PX8134090,CDM,300,RC,81340,CPT,90,,,,,,,503,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Trb@ Gene Rearrange Amplify - Ref,PX8134090,CDM,300,RC,81340,CPT,90,,,,,,,503,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Trb@ Gene Rearrange Amplify - Ref,PX8134090,CDM,300,RC,81340,CPT,90,,,,,,,503,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Treat Thumb Disloc,Manipulatn",PX26641F,CDM,510,RC,26641,CPT,,,,,,,,1721,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Treat Thumb Disloc,Manipulatn",PX26641F,CDM,510,RC,26641,CPT,,,,,,,,1721,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Treat Thumb Disloc,Manipulatn",PX26641F,CDM,510,RC,26641,CPT,,,,,,,,1721,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Treat Thumb Disloc,Manipulatn",PX26641F,CDM,510,RC,26641,CPT,,,,,,,,1721,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Treat Thumb Disloc,Manipulatn",PX26641F,CDM,510,RC,26641,CPT,,,,,,,,1721,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Treat Thumb Disloc,Manipulatn",PX26641F,CDM,510,RC,26641,CPT,,,,,,,,1721,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Treat Thumb Disloc,Manipulatn",PX26641P,CDM,983,RC,26641,CPT,,,,,,,,1902,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Treat Thumb Disloc,Manipulatn",PX26641P,CDM,983,RC,26641,CPT,,,,,,,,1902,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Treat Thumb Disloc,Manipulatn",PX26641P,CDM,983,RC,26641,CPT,,,,,,,,1902,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Treat Thumb Disloc,Manipulatn",PX26641P,CDM,983,RC,26641,CPT,,,,,,,,1902,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Treat Thumb Disloc,Manipulatn",PX26641P,CDM,983,RC,26641,CPT,,,,,,,,1902,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Treat Thumb Disloc,Manipulatn",PX26641P,CDM,983,RC,26641,CPT,,,,,,,,1902,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Treponema Pallidum,PX86780,CDM,300,RC,86780,CPT,,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Treponema Pallidum,PX86780,CDM,300,RC,86780,CPT,,,,,,,,36,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Treponema Pallidum,PX86780,CDM,300,RC,86780,CPT,,,,,,,,36,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Treponema Pallidum,PX86780,CDM,300,RC,86780,CPT,,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Treponema Pallidum,PX86780,CDM,300,RC,86780,CPT,,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Treponema Pallidum,PX86780,CDM,300,RC,86780,CPT,,,,,,,,36,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Treponema Pallidum - Ref,PX8678090,CDM,300,RC,86780,CPT,90,,,,,,,39,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Treponema Pallidum - Ref,PX8678090,CDM,300,RC,86780,CPT,90,,,,,,,39,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Treponema Pallidum - Ref,PX8678090,CDM,300,RC,86780,CPT,90,,,,,,,39,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Treponema Pallidum - Ref,PX8678090,CDM,300,RC,86780,CPT,90,,,,,,,39,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Treponema Pallidum - Ref,PX8678090,CDM,300,RC,86780,CPT,90,,,,,,,39,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Treponema Pallidum - Ref,PX8678090,CDM,300,RC,86780,CPT,90,,,,,,,39,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Trg Gene Rearrangement Anal - Ref,PX8134290,CDM,300,RC,81342,CPT,90,,,,,,,516,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Trg Gene Rearrangement Anal - Ref,PX8134290,CDM,300,RC,81342,CPT,90,,,,,,,516,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Trg Gene Rearrangement Anal - Ref,PX8134290,CDM,300,RC,81342,CPT,90,,,,,,,516,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Trg Gene Rearrangement Anal - Ref,PX8134290,CDM,300,RC,81342,CPT,90,,,,,,,516,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Trg Gene Rearrangement Anal - Ref,PX8134290,CDM,300,RC,81342,CPT,90,,,,,,,516,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Trg Gene Rearrangement Anal - Ref,PX8134290,CDM,300,RC,81342,CPT,90,,,,,,,516,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamcinolone acetonide 0.1 % Cream 15 g Tube,63700001,CDM,250,RC,,,,,,168000415,NDC,15,GR,22.97,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamcinolone acetonide 0.1 % Cream 15 g Tube,63700001,CDM,250,RC,,,,,,168000415,NDC,15,GR,22.97,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamcinolone acetonide 0.1 % Cream 15 g Tube,63700001,CDM,250,RC,,,,,,168000415,NDC,15,GR,22.97,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamcinolone acetonide 0.1 % Cream 15 g Tube,63700001,CDM,250,RC,,,,,,168000415,NDC,15,GR,22.97,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamcinolone acetonide 0.1 % Cream 15 g Tube,63700001,CDM,250,RC,,,,,,168000415,NDC,15,GR,22.97,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamcinolone acetonide 0.1 % Cream 15 g Tube,63700001,CDM,250,RC,,,,,,168000415,NDC,15,GR,22.97,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamcinolone acetonide 0.1 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,16714098602,NDC,30,GR,59.22,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamcinolone acetonide 0.1 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,16714098602,NDC,30,GR,59.22,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamcinolone acetonide 0.1 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,16714098602,NDC,30,GR,59.22,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamcinolone acetonide 0.1 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,16714098602,NDC,30,GR,59.22,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamcinolone acetonide 0.1 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,16714098602,NDC,30,GR,59.22,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamcinolone acetonide 0.1 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,16714098602,NDC,30,GR,59.22,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamcinolone acetonide 0.1 % Cream 80 g Tube,63700001,CDM,250,RC,,,,,,16714098603,NDC,80,GR,65.76,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamcinolone acetonide 0.1 % Cream 80 g Tube,63700001,CDM,250,RC,,,,,,16714098603,NDC,80,GR,65.76,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamcinolone acetonide 0.1 % Cream 80 g Tube,63700001,CDM,250,RC,,,,,,16714098603,NDC,80,GR,65.76,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamcinolone acetonide 0.1 % Cream 80 g Tube,63700001,CDM,250,RC,,,,,,16714098603,NDC,80,GR,65.76,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamcinolone acetonide 0.1 % Cream 80 g Tube,63700001,CDM,250,RC,,,,,,16714098603,NDC,80,GR,65.76,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamcinolone acetonide 0.1 % Cream 80 g Tube,63700001,CDM,250,RC,,,,,,16714098603,NDC,80,GR,65.76,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamcinolone acetonide 0.1 % Cream 454 g Jar,63700001,CDM,250,RC,,,,,,45802006405,NDC,454,GR,130.36,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamcinolone acetonide 0.1 % Cream 454 g Jar,63700001,CDM,250,RC,,,,,,45802006405,NDC,454,GR,130.36,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamcinolone acetonide 0.1 % Cream 454 g Jar,63700001,CDM,250,RC,,,,,,45802006405,NDC,454,GR,130.36,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamcinolone acetonide 0.1 % Cream 454 g Jar,63700001,CDM,250,RC,,,,,,45802006405,NDC,454,GR,130.36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamcinolone acetonide 0.1 % Cream 454 g Jar,63700001,CDM,250,RC,,,,,,45802006405,NDC,454,GR,130.36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamcinolone acetonide 0.1 % Cream 454 g Jar,63700001,CDM,250,RC,,,,,,45802006405,NDC,454,GR,130.36,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamcinolone acetonide 10 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3049420,NDC,0.25,ML,30,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamcinolone acetonide 10 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3049420,NDC,0.25,ML,30,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamcinolone acetonide 10 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3049420,NDC,0.25,ML,30,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamcinolone acetonide 10 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3049420,NDC,0.25,ML,30,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamcinolone acetonide 10 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3049420,NDC,0.25,ML,30,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamcinolone acetonide 10 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3049420,NDC,0.25,ML,30,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamcinolone acetonide 40 MG/ML Suspension 1 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029305,NDC,1,ML,73.57,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamcinolone acetonide 40 MG/ML Suspension 1 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029305,NDC,1,ML,73.57,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamcinolone acetonide 40 MG/ML Suspension 1 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029305,NDC,1,ML,73.57,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamcinolone acetonide 40 MG/ML Suspension 1 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029305,NDC,1,ML,73.57,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamcinolone acetonide 40 MG/ML Suspension 1 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029305,NDC,1,ML,73.57,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamcinolone acetonide 40 MG/ML Suspension 1 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029305,NDC,1,ML,73.57,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamcinolone acetonide 40 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029320,NDC,1,ML,72.65,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamcinolone acetonide 40 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029320,NDC,1,ML,72.65,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamcinolone acetonide 40 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029320,NDC,1,ML,72.65,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamcinolone acetonide 40 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029320,NDC,1,ML,72.65,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamcinolone acetonide 40 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029320,NDC,1,ML,72.65,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamcinolone acetonide 40 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029320,NDC,1,ML,72.65,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamterene-hydroCHLOROthiazide 37.5-25 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,68084075025,NDC,1,EA,4.78,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamterene-hydroCHLOROthiazide 37.5-25 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,68084075025,NDC,1,EA,4.78,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamterene-hydroCHLOROthiazide 37.5-25 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,68084075025,NDC,1,EA,4.78,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamterene-hydroCHLOROthiazide 37.5-25 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,68084075025,NDC,1,EA,4.78,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamterene-hydroCHLOROthiazide 37.5-25 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,68084075025,NDC,1,EA,4.78,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamterene-hydroCHLOROthiazide 37.5-25 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,68084075025,NDC,1,EA,4.78,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Trichomonas Vagin Dir Probe,PX87660,CDM,300,RC,87660,CPT,,,,,,,,127,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Trichomonas Vagin Dir Probe,PX87660,CDM,300,RC,87660,CPT,,,,,,,,127,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Trichomonas Vagin Dir Probe,PX87660,CDM,300,RC,87660,CPT,,,,,,,,127,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Trichomonas Vagin Dir Probe,PX87660,CDM,300,RC,87660,CPT,,,,,,,,127,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Trichomonas Vagin Dir Probe,PX87660,CDM,300,RC,87660,CPT,,,,,,,,127,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Trichomonas Vagin Dir Probe,PX87660,CDM,300,RC,87660,CPT,,,,,,,,127,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Triiodothyronine T3, Free (Free T3)",PX84481,CDM,300,RC,84481,CPT,,,,,,,,137,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Triiodothyronine T3, Free (Free T3)",PX84481,CDM,300,RC,84481,CPT,,,,,,,,137,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Triiodothyronine T3, Free (Free T3)",PX84481,CDM,300,RC,84481,CPT,,,,,,,,137,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Triiodothyronine T3, Free (Free T3)",PX84481,CDM,300,RC,84481,CPT,,,,,,,,137,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Triiodothyronine T3, Free (Free T3)",PX84481,CDM,300,RC,84481,CPT,,,,,,,,137,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Triiodothyronine T3, Free (Free T3)",PX84481,CDM,300,RC,84481,CPT,,,,,,,,137,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Triiodothyronine T3, Tot - Ref",PX8448090,CDM,300,RC,84480,CPT,90,,,,,,,158,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Triiodothyronine T3, Tot - Ref",PX8448090,CDM,300,RC,84480,CPT,90,,,,,,,158,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Triiodothyronine T3, Tot - Ref",PX8448090,CDM,300,RC,84480,CPT,90,,,,,,,158,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Triiodothyronine T3, Tot - Ref",PX8448090,CDM,300,RC,84480,CPT,90,,,,,,,158,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Triiodothyronine T3, Tot - Ref",PX8448090,CDM,300,RC,84480,CPT,90,,,,,,,158,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Triiodothyronine T3, Tot - Ref",PX8448090,CDM,300,RC,84480,CPT,90,,,,,,,158,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Trimming of Dystrophic Nails, Any Number",PXG0127P,CDM,983,RC,G0127,HCPCS,,,,,,,,35,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Trimming of Dystrophic Nails, Any Number",PXG0127P,CDM,983,RC,G0127,HCPCS,,,,,,,,35,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Trimming of Dystrophic Nails, Any Number",PXG0127P,CDM,983,RC,G0127,HCPCS,,,,,,,,35,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Trimming of Dystrophic Nails, Any Number",PXG0127P,CDM,983,RC,G0127,HCPCS,,,,,,,,35,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Trimming of Dystrophic Nails, Any Number",PXG0127P,CDM,983,RC,G0127,HCPCS,,,,,,,,35,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Trimming of Dystrophic Nails, Any Number",PXG0127P,CDM,983,RC,G0127,HCPCS,,,,,,,,35,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TROCAR KII BALLOON 12MM STERILE,27200000,CDM,272,RC,,,,11703-MAIN,LOCAL,,,,,41.14,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TROCAR KII BALLOON 12MM STERILE,27200000,CDM,272,RC,,,,11703-MAIN,LOCAL,,,,,41.14,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TROCAR KII BALLOON 12MM STERILE,27200000,CDM,272,RC,,,,11703-MAIN,LOCAL,,,,,41.14,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TROCAR KII BALLOON 12MM STERILE,27200000,CDM,272,RC,,,,11703-MAIN,LOCAL,,,,,41.14,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TROCAR KII BALLOON 12MM STERILE,27200000,CDM,272,RC,,,,11703-MAIN,LOCAL,,,,,41.14,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TROCAR KII BALLOON 12MM STERILE,27200000,CDM,272,RC,,,,11703-MAIN,LOCAL,,,,,41.14,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TROCAR KII BALLOON BLUNT 12MM STERILE,27200000,CDM,272,RC,,,,11702-MAIN,LOCAL,,,,,41.14,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TROCAR KII BALLOON BLUNT 12MM STERILE,27200000,CDM,272,RC,,,,11702-MAIN,LOCAL,,,,,41.14,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TROCAR KII BALLOON BLUNT 12MM STERILE,27200000,CDM,272,RC,,,,11702-MAIN,LOCAL,,,,,41.14,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TROCAR KII BALLOON BLUNT 12MM STERILE,27200000,CDM,272,RC,,,,11702-MAIN,LOCAL,,,,,41.14,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TROCAR KII BALLOON BLUNT 12MM STERILE,27200000,CDM,272,RC,,,,11702-MAIN,LOCAL,,,,,41.14,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TROCAR KII BALLOON BLUNT 12MM STERILE,27200000,CDM,272,RC,,,,11702-MAIN,LOCAL,,,,,41.14,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TROCAR KII BALOON 5X100MM STERILE,27200000,CDM,272,RC,,,,11701-MAIN,LOCAL,,,,,37.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TROCAR KII BALOON 5X100MM STERILE,27200000,CDM,272,RC,,,,11701-MAIN,LOCAL,,,,,37.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TROCAR KII BALOON 5X100MM STERILE,27200000,CDM,272,RC,,,,11701-MAIN,LOCAL,,,,,37.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TROCAR KII BALOON 5X100MM STERILE,27200000,CDM,272,RC,,,,11701-MAIN,LOCAL,,,,,37.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TROCAR KII BALOON 5X100MM STERILE,27200000,CDM,272,RC,,,,11701-MAIN,LOCAL,,,,,37.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TROCAR KII BALOON 5X100MM STERILE,27200000,CDM,272,RC,,,,11701-MAIN,LOCAL,,,,,37.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TROCAR KII FIOS SYSTEM BLADELSS Z-THREAD 5MMX100MM,27200000,CDM,272,RC,,,,12003-MAIN,LOCAL,,,,,38,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TROCAR KII FIOS SYSTEM BLADELSS Z-THREAD 5MMX100MM,27200000,CDM,272,RC,,,,12003-MAIN,LOCAL,,,,,38,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TROCAR KII FIOS SYSTEM BLADELSS Z-THREAD 5MMX100MM,27200000,CDM,272,RC,,,,12003-MAIN,LOCAL,,,,,38,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TROCAR KII FIOS SYSTEM BLADELSS Z-THREAD 5MMX100MM,27200000,CDM,272,RC,,,,12003-MAIN,LOCAL,,,,,38,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TROCAR KII FIOS SYSTEM BLADELSS Z-THREAD 5MMX100MM,27200000,CDM,272,RC,,,,12003-MAIN,LOCAL,,,,,38,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TROCAR KII FIOS SYSTEM BLADELSS Z-THREAD 5MMX100MM,27200000,CDM,272,RC,,,,12003-MAIN,LOCAL,,,,,38,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TROCAR KII FIOS SYSTEM BLADELSS Z-THREAD 5MMX150MM,27200000,CDM,272,RC,,,,12827-MAIN,LOCAL,,,,,39,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TROCAR KII FIOS SYSTEM BLADELSS Z-THREAD 5MMX150MM,27200000,CDM,272,RC,,,,12827-MAIN,LOCAL,,,,,39,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TROCAR KII FIOS SYSTEM BLADELSS Z-THREAD 5MMX150MM,27200000,CDM,272,RC,,,,12827-MAIN,LOCAL,,,,,39,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TROCAR KII FIOS SYSTEM BLADELSS Z-THREAD 5MMX150MM,27200000,CDM,272,RC,,,,12827-MAIN,LOCAL,,,,,39,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TROCAR KII FIOS SYSTEM BLADELSS Z-THREAD 5MMX150MM,27200000,CDM,272,RC,,,,12827-MAIN,LOCAL,,,,,39,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TROCAR KII FIOS SYSTEM BLADELSS Z-THREAD 5MMX150MM,27200000,CDM,272,RC,,,,12827-MAIN,LOCAL,,,,,39,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TROCAR LAP 1.5-3CM MINI GELPOINT PLAT ACCESS,27200000,CDM,272,RC,,,,12021-MAIN,LOCAL,,,,,,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TROCAR LAP 1.5-3CM MINI GELPOINT PLAT ACCESS,27200000,CDM,272,RC,,,,12021-MAIN,LOCAL,,,,,,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TROCAR LAP 1.5-3CM MINI GELPOINT PLAT ACCESS,27200000,CDM,272,RC,,,,12021-MAIN,LOCAL,,,,,,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TROCAR LAP 1.5-3CM MINI GELPOINT PLAT ACCESS,27200000,CDM,272,RC,,,,12021-MAIN,LOCAL,,,,,,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TROCAR LAP 1.5-3CM MINI GELPOINT PLAT ACCESS,27200000,CDM,272,RC,,,,12021-MAIN,LOCAL,,,,,,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TROCAR LAP 1.5-3CM MINI GELPOINT PLAT ACCESS,27200000,CDM,272,RC,,,,12021-MAIN,LOCAL,,,,,,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tropicamide 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,24208058559,NDC,2,ML,61.3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tropicamide 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,24208058559,NDC,2,ML,61.3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tropicamide 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,24208058559,NDC,2,ML,61.3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tropicamide 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,24208058559,NDC,2,ML,61.3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tropicamide 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,24208058559,NDC,2,ML,61.3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tropicamide 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,24208058559,NDC,2,ML,61.3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tropicamide 1 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,61314035502,NDC,15,ML,267.96,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tropicamide 1 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,61314035502,NDC,15,ML,267.96,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tropicamide 1 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,61314035502,NDC,15,ML,267.96,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tropicamide 1 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,61314035502,NDC,15,ML,267.96,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tropicamide 1 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,61314035502,NDC,15,ML,267.96,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tropicamide 1 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,61314035502,NDC,15,ML,267.96,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Troponin, Quantitative",PX84484,CDM,300,RC,84484,CPT,,,,,,,,289,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Troponin, Quantitative",PX84484,CDM,300,RC,84484,CPT,,,,,,,,289,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Troponin, Quantitative",PX84484,CDM,300,RC,84484,CPT,,,,,,,,289,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Troponin, Quantitative",PX84484,CDM,300,RC,84484,CPT,,,,,,,,289,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Troponin, Quantitative",PX84484,CDM,300,RC,84484,CPT,,,,,,,,289,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Troponin, Quantitative",PX84484,CDM,300,RC,84484,CPT,,,,,,,,289,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRUMPET SUCTION IRRIGATION,27100000,CDM,271,RC,,,,4577-MAIN,LOCAL,,,,,116.4,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRUMPET SUCTION IRRIGATION,27100000,CDM,271,RC,,,,4577-MAIN,LOCAL,,,,,116.4,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRUMPET SUCTION IRRIGATION,27100000,CDM,271,RC,,,,4577-MAIN,LOCAL,,,,,116.4,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRUMPET SUCTION IRRIGATION,27100000,CDM,271,RC,,,,4577-MAIN,LOCAL,,,,,116.4,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRUMPET SUCTION IRRIGATION,27100000,CDM,271,RC,,,,4577-MAIN,LOCAL,,,,,116.4,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRUMPET SUCTION IRRIGATION,27100000,CDM,271,RC,,,,4577-MAIN,LOCAL,,,,,116.4,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tte W/Doppler, Complete",PX9330601,CDM,483,RC,93306,CPT,TC,,,,,,,2191,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tte W/Doppler, Complete",PX9330601,CDM,483,RC,93306,CPT,TC,,,,,,,2191,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tte W/Doppler, Complete",PX9330601,CDM,483,RC,93306,CPT,TC,,,,,,,2191,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tte W/Doppler, Complete",PX9330601,CDM,483,RC,93306,CPT,TC,,,,,,,2191,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tte W/Doppler, Complete",PX9330601,CDM,483,RC,93306,CPT,TC,,,,,,,2191,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tte W/Doppler, Complete",PX9330601,CDM,483,RC,93306,CPT,TC,,,,,,,2191,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tte W/Doppler, Complete",PXC8929,CDM,480,RC,C8929,HCPCS,TC,,,,,,,1927,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tte W/Doppler, Complete",PXC8929,CDM,480,RC,C8929,HCPCS,TC,,,,,,,1927,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tte W/Doppler, Complete",PXC8929,CDM,480,RC,C8929,HCPCS,TC,,,,,,,1927,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tte W/Doppler, Complete",PXC8929,CDM,480,RC,C8929,HCPCS,TC,,,,,,,1927,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tte W/Doppler, Complete",PXC8929,CDM,480,RC,C8929,HCPCS,TC,,,,,,,1927,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tte W/Doppler, Complete",PXC8929,CDM,480,RC,C8929,HCPCS,TC,,,,,,,1927,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE AIRSPIRAL BREATHING AND CHAMBER 900PT561,120.493,CDM,271,RC,A4604,HCPCS,,11618-MAIN,LOCAL,,,,,112,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE AIRSPIRAL BREATHING AND CHAMBER 900PT561,120.493,CDM,271,RC,A4604,HCPCS,,11618-MAIN,LOCAL,,,,,112,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE AIRSPIRAL BREATHING AND CHAMBER 900PT561,120.493,CDM,271,RC,A4604,HCPCS,,11618-MAIN,LOCAL,,,,,112,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE AIRSPIRAL BREATHING AND CHAMBER 900PT561,120.493,CDM,271,RC,A4604,HCPCS,,11618-MAIN,LOCAL,,,,,112,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE AIRSPIRAL BREATHING AND CHAMBER 900PT561,120.493,CDM,271,RC,A4604,HCPCS,,11618-MAIN,LOCAL,,,,,112,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE AIRSPIRAL BREATHING AND CHAMBER 900PT561,120.493,CDM,271,RC,A4604,HCPCS,,11618-MAIN,LOCAL,,,,,112,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE FEEDING DECLOGGING SYSTEM CLOG ZAPPER 20-0002,120.277,CDM,272,RC,,,,4226-MAIN,LOCAL,,,,,51,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE FEEDING DECLOGGING SYSTEM CLOG ZAPPER 20-0002,120.277,CDM,272,RC,,,,4226-MAIN,LOCAL,,,,,51,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE FEEDING DECLOGGING SYSTEM CLOG ZAPPER 20-0002,120.277,CDM,272,RC,,,,4226-MAIN,LOCAL,,,,,51,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE FEEDING DECLOGGING SYSTEM CLOG ZAPPER 20-0002,120.277,CDM,272,RC,,,,4226-MAIN,LOCAL,,,,,51,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE FEEDING DECLOGGING SYSTEM CLOG ZAPPER 20-0002,120.277,CDM,272,RC,,,,4226-MAIN,LOCAL,,,,,51,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE FEEDING DECLOGGING SYSTEM CLOG ZAPPER 20-0002,120.277,CDM,272,RC,,,,4226-MAIN,LOCAL,,,,,51,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE GASTROSTOMY 18FR REPLACEMENT DYND70318,120.256,CDM,271,RC,B4087,HCPCS,,407-MAIN,LOCAL,,,,,179,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE GASTROSTOMY 18FR REPLACEMENT DYND70318,120.256,CDM,271,RC,B4087,HCPCS,,407-MAIN,LOCAL,,,,,179,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE GASTROSTOMY 18FR REPLACEMENT DYND70318,120.256,CDM,271,RC,B4087,HCPCS,,407-MAIN,LOCAL,,,,,179,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE GASTROSTOMY 18FR REPLACEMENT DYND70318,120.256,CDM,271,RC,B4087,HCPCS,,407-MAIN,LOCAL,,,,,179,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE GASTROSTOMY 18FR REPLACEMENT DYND70318,120.256,CDM,271,RC,B4087,HCPCS,,407-MAIN,LOCAL,,,,,179,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE GASTROSTOMY 18FR REPLACEMENT DYND70318,120.256,CDM,271,RC,B4087,HCPCS,,407-MAIN,LOCAL,,,,,179,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE SURGICAL IRRIGATION 1PK PD-IT,27200000,CDM,272,RC,,,,12433-MAIN,LOCAL,,,,,219,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE SURGICAL IRRIGATION 1PK PD-IT,27200000,CDM,272,RC,,,,12433-MAIN,LOCAL,,,,,219,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE SURGICAL IRRIGATION 1PK PD-IT,27200000,CDM,272,RC,,,,12433-MAIN,LOCAL,,,,,219,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE SURGICAL IRRIGATION 1PK PD-IT,27200000,CDM,272,RC,,,,12433-MAIN,LOCAL,,,,,219,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE SURGICAL IRRIGATION 1PK PD-IT,27200000,CDM,272,RC,,,,12433-MAIN,LOCAL,,,,,219,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE SURGICAL IRRIGATION 1PK PD-IT,27200000,CDM,272,RC,,,,12433-MAIN,LOCAL,,,,,219,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tube Thoracostomy Inc Wtr Seal,PX32551F,CDM,510,RC,32551,CPT,,,,,,,,989,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tube Thoracostomy Inc Wtr Seal,PX32551F,CDM,510,RC,32551,CPT,,,,,,,,989,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tube Thoracostomy Inc Wtr Seal,PX32551F,CDM,510,RC,32551,CPT,,,,,,,,989,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tube Thoracostomy Inc Wtr Seal,PX32551F,CDM,510,RC,32551,CPT,,,,,,,,989,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tube Thoracostomy Inc Wtr Seal,PX32551F,CDM,510,RC,32551,CPT,,,,,,,,989,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tube Thoracostomy Inc Wtr Seal,PX32551F,CDM,510,RC,32551,CPT,,,,,,,,989,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tube Thoracostomy Inc Wtr Seal,PX32551P,CDM,983,RC,32551,CPT,,,,,,,,1236,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tube Thoracostomy Inc Wtr Seal,PX32551P,CDM,983,RC,32551,CPT,,,,,,,,1236,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tube Thoracostomy Inc Wtr Seal,PX32551P,CDM,983,RC,32551,CPT,,,,,,,,1236,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tube Thoracostomy Inc Wtr Seal,PX32551P,CDM,983,RC,32551,CPT,,,,,,,,1236,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tube Thoracostomy Inc Wtr Seal,PX32551P,CDM,983,RC,32551,CPT,,,,,,,,1236,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tube Thoracostomy Inc Wtr Seal,PX32551P,CDM,983,RC,32551,CPT,,,,,,,,1236,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 3.0MM ID 4.5MM OD SHILEY PEDIATRIC 3.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1185-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 3.0MM ID 4.5MM OD SHILEY PEDIATRIC 3.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1185-MAIN,LOCAL,,,,,184,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 3.0MM ID 4.5MM OD SHILEY PEDIATRIC 3.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1185-MAIN,LOCAL,,,,,184,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 3.0MM ID 4.5MM OD SHILEY PEDIATRIC 3.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1185-MAIN,LOCAL,,,,,184,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 3.0MM ID 4.5MM OD SHILEY PEDIATRIC 3.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1185-MAIN,LOCAL,,,,,184,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 3.0MM ID 4.5MM OD SHILEY PEDIATRIC 3.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1185-MAIN,LOCAL,,,,,184,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 3.5MM ID 5.2MM OD SHILEY PEDIATRIC,120.287,CDM,272,RC,A7520,HCPCS,,8813-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 3.5MM ID 5.2MM OD SHILEY PEDIATRIC,120.287,CDM,272,RC,A7520,HCPCS,,8813-MAIN,LOCAL,,,,,184,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 3.5MM ID 5.2MM OD SHILEY PEDIATRIC,120.287,CDM,272,RC,A7520,HCPCS,,8813-MAIN,LOCAL,,,,,184,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 3.5MM ID 5.2MM OD SHILEY PEDIATRIC,120.287,CDM,272,RC,A7520,HCPCS,,8813-MAIN,LOCAL,,,,,184,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 3.5MM ID 5.2MM OD SHILEY PEDIATRIC,120.287,CDM,272,RC,A7520,HCPCS,,8813-MAIN,LOCAL,,,,,184,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 3.5MM ID 5.2MM OD SHILEY PEDIATRIC,120.287,CDM,272,RC,A7520,HCPCS,,8813-MAIN,LOCAL,,,,,184,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 4.0MM ID 5.9MM OD SHILEY PEDIATRIC 4.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1187-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 4.0MM ID 5.9MM OD SHILEY PEDIATRIC 4.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1187-MAIN,LOCAL,,,,,184,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 4.0MM ID 5.9MM OD SHILEY PEDIATRIC 4.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1187-MAIN,LOCAL,,,,,184,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 4.0MM ID 5.9MM OD SHILEY PEDIATRIC 4.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1187-MAIN,LOCAL,,,,,184,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 4.0MM ID 5.9MM OD SHILEY PEDIATRIC 4.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1187-MAIN,LOCAL,,,,,184,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 4.0MM ID 5.9MM OD SHILEY PEDIATRIC 4.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1187-MAIN,LOCAL,,,,,184,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 5 7.0MM ID 10.1MM OD SHILEY CUFFED 5CN70H,120.287,CDM,272,RC,A7521,HCPCS,,10350-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 5 7.0MM ID 10.1MM OD SHILEY CUFFED 5CN70H,120.287,CDM,272,RC,A7521,HCPCS,,10350-MAIN,LOCAL,,,,,184,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 5 7.0MM ID 10.1MM OD SHILEY CUFFED 5CN70H,120.287,CDM,272,RC,A7521,HCPCS,,10350-MAIN,LOCAL,,,,,184,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 5 7.0MM ID 10.1MM OD SHILEY CUFFED 5CN70H,120.287,CDM,272,RC,A7521,HCPCS,,10350-MAIN,LOCAL,,,,,184,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 5 7.0MM ID 10.1MM OD SHILEY CUFFED 5CN70H,120.287,CDM,272,RC,A7521,HCPCS,,10350-MAIN,LOCAL,,,,,184,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 5 7.0MM ID 10.1MM OD SHILEY CUFFED 5CN70H,120.287,CDM,272,RC,A7521,HCPCS,,10350-MAIN,LOCAL,,,,,184,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 5.0MM ID 7.1MM OD SHILEY PEDIATRIC 5.0PED,120.287,CDM,272,RC,A7520,HCPCS,,8814-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 5.0MM ID 7.1MM OD SHILEY PEDIATRIC 5.0PED,120.287,CDM,272,RC,A7520,HCPCS,,8814-MAIN,LOCAL,,,,,184,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 5.0MM ID 7.1MM OD SHILEY PEDIATRIC 5.0PED,120.287,CDM,272,RC,A7520,HCPCS,,8814-MAIN,LOCAL,,,,,184,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 5.0MM ID 7.1MM OD SHILEY PEDIATRIC 5.0PED,120.287,CDM,272,RC,A7520,HCPCS,,8814-MAIN,LOCAL,,,,,184,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 5.0MM ID 7.1MM OD SHILEY PEDIATRIC 5.0PED,120.287,CDM,272,RC,A7520,HCPCS,,8814-MAIN,LOCAL,,,,,184,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 5.0MM ID 7.1MM OD SHILEY PEDIATRIC 5.0PED,120.287,CDM,272,RC,A7520,HCPCS,,8814-MAIN,LOCAL,,,,,184,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 6 6.0MM ID 8.3MM OD SHILEY CUFFED 6SCT,120.287,CDM,272,RC,A7521,HCPCS,,8812-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 6 6.0MM ID 8.3MM OD SHILEY CUFFED 6SCT,120.287,CDM,272,RC,A7521,HCPCS,,8812-MAIN,LOCAL,,,,,184,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 6 6.0MM ID 8.3MM OD SHILEY CUFFED 6SCT,120.287,CDM,272,RC,A7521,HCPCS,,8812-MAIN,LOCAL,,,,,184,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 6 6.0MM ID 8.3MM OD SHILEY CUFFED 6SCT,120.287,CDM,272,RC,A7521,HCPCS,,8812-MAIN,LOCAL,,,,,184,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 6 6.0MM ID 8.3MM OD SHILEY CUFFED 6SCT,120.287,CDM,272,RC,A7521,HCPCS,,8812-MAIN,LOCAL,,,,,184,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 6 6.0MM ID 8.3MM OD SHILEY CUFFED 6SCT,120.287,CDM,272,RC,A7521,HCPCS,,8812-MAIN,LOCAL,,,,,184,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 6 6.4MM ID 10.8MM OD SHILEY CUFFED 6DCT,120.287,CDM,272,RC,A7521,HCPCS,,1190-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 6 6.4MM ID 10.8MM OD SHILEY CUFFED 6DCT,120.287,CDM,272,RC,A7521,HCPCS,,1190-MAIN,LOCAL,,,,,184,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 6 6.4MM ID 10.8MM OD SHILEY CUFFED 6DCT,120.287,CDM,272,RC,A7521,HCPCS,,1190-MAIN,LOCAL,,,,,184,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 6 6.4MM ID 10.8MM OD SHILEY CUFFED 6DCT,120.287,CDM,272,RC,A7521,HCPCS,,1190-MAIN,LOCAL,,,,,184,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 6 6.4MM ID 10.8MM OD SHILEY CUFFED 6DCT,120.287,CDM,272,RC,A7521,HCPCS,,1190-MAIN,LOCAL,,,,,184,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 6 6.4MM ID 10.8MM OD SHILEY CUFFED 6DCT,120.287,CDM,272,RC,A7521,HCPCS,,1190-MAIN,LOCAL,,,,,184,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 7.5MM ID 10.8MM OD SHILEY CUFFED 6CN75H,120.287,CDM,272,RC,A7521,HCPCS,,8488-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 7.5MM ID 10.8MM OD SHILEY CUFFED 6CN75H,120.287,CDM,272,RC,A7521,HCPCS,,8488-MAIN,LOCAL,,,,,184,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 7.5MM ID 10.8MM OD SHILEY CUFFED 6CN75H,120.287,CDM,272,RC,A7521,HCPCS,,8488-MAIN,LOCAL,,,,,184,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 7.5MM ID 10.8MM OD SHILEY CUFFED 6CN75H,120.287,CDM,272,RC,A7521,HCPCS,,8488-MAIN,LOCAL,,,,,184,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 7.5MM ID 10.8MM OD SHILEY CUFFED 6CN75H,120.287,CDM,272,RC,A7521,HCPCS,,8488-MAIN,LOCAL,,,,,184,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 7.5MM ID 10.8MM OD SHILEY CUFFED 6CN75H,120.287,CDM,272,RC,A7521,HCPCS,,8488-MAIN,LOCAL,,,,,184,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 8 7.6MM ID 12.2MM OD SHILEY 8DCT,120.287,CDM,272,RC,A7521,HCPCS,,1192-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 8 7.6MM ID 12.2MM OD SHILEY 8DCT,120.287,CDM,272,RC,A7521,HCPCS,,1192-MAIN,LOCAL,,,,,184,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 8 7.6MM ID 12.2MM OD SHILEY 8DCT,120.287,CDM,272,RC,A7521,HCPCS,,1192-MAIN,LOCAL,,,,,184,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 8 7.6MM ID 12.2MM OD SHILEY 8DCT,120.287,CDM,272,RC,A7521,HCPCS,,1192-MAIN,LOCAL,,,,,184,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 8 7.6MM ID 12.2MM OD SHILEY 8DCT,120.287,CDM,272,RC,A7521,HCPCS,,1192-MAIN,LOCAL,,,,,184,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 8 7.6MM ID 12.2MM OD SHILEY 8DCT,120.287,CDM,272,RC,A7521,HCPCS,,1192-MAIN,LOCAL,,,,,184,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 8 7.6MM ID 12.22MM OD SHILEY CUFFED 8LPC,120.287,CDM,272,RC,A7521,HCPCS,,8815-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 8 7.6MM ID 12.22MM OD SHILEY CUFFED 8LPC,120.287,CDM,272,RC,A7521,HCPCS,,8815-MAIN,LOCAL,,,,,184,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 8 7.6MM ID 12.22MM OD SHILEY CUFFED 8LPC,120.287,CDM,272,RC,A7521,HCPCS,,8815-MAIN,LOCAL,,,,,184,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 8 7.6MM ID 12.22MM OD SHILEY CUFFED 8LPC,120.287,CDM,272,RC,A7521,HCPCS,,8815-MAIN,LOCAL,,,,,184,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 8 7.6MM ID 12.22MM OD SHILEY CUFFED 8LPC,120.287,CDM,272,RC,A7521,HCPCS,,8815-MAIN,LOCAL,,,,,184,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 8 7.6MM ID 12.22MM OD SHILEY CUFFED 8LPC,120.287,CDM,272,RC,A7521,HCPCS,,8815-MAIN,LOCAL,,,,,184,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 8.0MM ID 10.9MM OD SHILEY CUFFED 8SCT,120.287,CDM,272,RC,A7521,HCPCS,,8811-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 8.0MM ID 10.9MM OD SHILEY CUFFED 8SCT,120.287,CDM,272,RC,A7521,HCPCS,,8811-MAIN,LOCAL,,,,,184,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 8.0MM ID 10.9MM OD SHILEY CUFFED 8SCT,120.287,CDM,272,RC,A7521,HCPCS,,8811-MAIN,LOCAL,,,,,184,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 8.0MM ID 10.9MM OD SHILEY CUFFED 8SCT,120.287,CDM,272,RC,A7521,HCPCS,,8811-MAIN,LOCAL,,,,,184,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 8.0MM ID 10.9MM OD SHILEY CUFFED 8SCT,120.287,CDM,272,RC,A7521,HCPCS,,8811-MAIN,LOCAL,,,,,184,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 8.0MM ID 10.9MM OD SHILEY CUFFED 8SCT,120.287,CDM,272,RC,A7521,HCPCS,,8811-MAIN,LOCAL,,,,,184,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 10 SHILEY 10LPC,120.287,CDM,272,RC,A7521,HCPCS,,1181-MAIN,LOCAL,,,,,184,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 10 SHILEY 10LPC,120.287,CDM,272,RC,A7521,HCPCS,,1181-MAIN,LOCAL,,,,,184,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 10 SHILEY 10LPC,120.287,CDM,272,RC,A7521,HCPCS,,1181-MAIN,LOCAL,,,,,184,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 10 SHILEY 10LPC,120.287,CDM,272,RC,A7521,HCPCS,,1181-MAIN,LOCAL,,,,,184,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 10 SHILEY 10LPC,120.287,CDM,272,RC,A7521,HCPCS,,1181-MAIN,LOCAL,,,,,184,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 10 SHILEY 10LPC,120.287,CDM,272,RC,A7521,HCPCS,,1181-MAIN,LOCAL,,,,,184,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tuberculin 5 UNIT/0.1ML Solution 1 mL Vial,25000000,CDM,250,RC,,,,,,42023010401,NDC,0.1,ML,57.82,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tuberculin 5 UNIT/0.1ML Solution 1 mL Vial,25000000,CDM,250,RC,,,,,,42023010401,NDC,0.1,ML,57.82,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tuberculin 5 UNIT/0.1ML Solution 1 mL Vial,25000000,CDM,250,RC,,,,,,42023010401,NDC,0.1,ML,57.82,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tuberculin 5 UNIT/0.1ML Solution 1 mL Vial,25000000,CDM,250,RC,,,,,,42023010401,NDC,0.1,ML,57.82,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tuberculin 5 UNIT/0.1ML Solution 1 mL Vial,25000000,CDM,250,RC,,,,,,42023010401,NDC,0.1,ML,57.82,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tuberculin 5 UNIT/0.1ML Solution 1 mL Vial,25000000,CDM,250,RC,,,,,,42023010401,NDC,0.1,ML,57.82,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBING IRRIGATION F SET STERILE MXB-T,27200000,CDM,272,RC,,,,11693-MAIN,LOCAL,,,,,94,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBING IRRIGATION F SET STERILE MXB-T,27200000,CDM,272,RC,,,,11693-MAIN,LOCAL,,,,,94,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBING IRRIGATION F SET STERILE MXB-T,27200000,CDM,272,RC,,,,11693-MAIN,LOCAL,,,,,94,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBING IRRIGATION F SET STERILE MXB-T,27200000,CDM,272,RC,,,,11693-MAIN,LOCAL,,,,,94,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBING IRRIGATION F SET STERILE MXB-T,27200000,CDM,272,RC,,,,11693-MAIN,LOCAL,,,,,94,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBING IRRIGATION F SET STERILE MXB-T,27200000,CDM,272,RC,,,,11693-MAIN,LOCAL,,,,,94,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tumor Antigen, Ca-125",PX86304,CDM,300,RC,86304,CPT,,,,,,,,190,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tumor Antigen, Ca-125",PX86304,CDM,300,RC,86304,CPT,,,,,,,,190,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tumor Antigen, Ca-125",PX86304,CDM,300,RC,86304,CPT,,,,,,,,190,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tumor Antigen, Ca-125",PX86304,CDM,300,RC,86304,CPT,,,,,,,,190,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tumor Antigen, Ca-125",PX86304,CDM,300,RC,86304,CPT,,,,,,,,190,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tumor Antigen, Ca-125",PX86304,CDM,300,RC,86304,CPT,,,,,,,,190,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tx/Pro/Dx Inj Same Drug Adon,PX96376,CDM,260,RC,96376,CPT,,,,,,,,164,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tx/Pro/Dx Inj Same Drug Adon,PX96376,CDM,260,RC,96376,CPT,,,,,,,,164,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tx/Pro/Dx Inj Same Drug Adon,PX96376,CDM,260,RC,96376,CPT,,,,,,,,164,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tx/Pro/Dx Inj Same Drug Adon,PX96376,CDM,260,RC,96376,CPT,,,,,,,,164,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tx/Pro/Dx Inj Same Drug Adon,PX96376,CDM,260,RC,96376,CPT,,,,,,,,164,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tx/Pro/Dx Inj Same Drug Adon,PX96376,CDM,260,RC,96376,CPT,,,,,,,,164,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ULTRAGUIDE CTR SX-ONE MICROKNIFE 600112-001,27200000,CDM,272,RC,,,,13106-MAIN,LOCAL,,,,,2121,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ULTRAGUIDE CTR SX-ONE MICROKNIFE 600112-001,27200000,CDM,272,RC,,,,13106-MAIN,LOCAL,,,,,2121,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ULTRAGUIDE CTR SX-ONE MICROKNIFE 600112-001,27200000,CDM,272,RC,,,,13106-MAIN,LOCAL,,,,,2121,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ULTRAGUIDE CTR SX-ONE MICROKNIFE 600112-001,27200000,CDM,272,RC,,,,13106-MAIN,LOCAL,,,,,2121,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ULTRAGUIDE CTR SX-ONE MICROKNIFE 600112-001,27200000,CDM,272,RC,,,,13106-MAIN,LOCAL,,,,,2121,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ULTRAGUIDE CTR SX-ONE MICROKNIFE 600112-001,27200000,CDM,272,RC,,,,13106-MAIN,LOCAL,,,,,2121,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ultrasound Breast Complete,PX7664101,CDM,402,RC,76641,CPT,TC,,,,,,,333,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ultrasound Breast Complete,PX7664101,CDM,402,RC,76641,CPT,TC,,,,,,,333,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ultrasound Breast Complete,PX7664101,CDM,402,RC,76641,CPT,TC,,,,,,,333,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ultrasound Breast Complete,PX7664101,CDM,402,RC,76641,CPT,TC,,,,,,,333,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ultrasound Breast Complete,PX7664101,CDM,402,RC,76641,CPT,TC,,,,,,,333,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ultrasound Breast Complete,PX7664101,CDM,402,RC,76641,CPT,TC,,,,,,,333,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ultrasound Breast Limited,PX7664201,CDM,402,RC,76642,CPT,TC,,,,,,,342,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ultrasound Breast Limited,PX7664201,CDM,402,RC,76642,CPT,TC,,,,,,,342,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ultrasound Breast Limited,PX7664201,CDM,402,RC,76642,CPT,TC,,,,,,,342,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ultrasound Breast Limited,PX7664201,CDM,402,RC,76642,CPT,TC,,,,,,,342,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ultrasound Breast Limited,PX7664201,CDM,402,RC,76642,CPT,TC,,,,,,,342,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ultrasound Breast Limited,PX7664201,CDM,402,RC,76642,CPT,TC,,,,,,,342,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ultrasound Therapy,PX97035,CDM,420,RC,97035,CPT,,,,,,,,135,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ultrasound Therapy,PX97035,CDM,420,RC,97035,CPT,,,,,,,,135,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ultrasound Therapy,PX97035,CDM,420,RC,97035,CPT,,,,,,,,135,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ultrasound Therapy,PX97035,CDM,420,RC,97035,CPT,,,,,,,,135,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ultrasound Therapy,PX97035,CDM,420,RC,97035,CPT,,,,,,,,135,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ultrasound Therapy,PX97035,CDM,420,RC,97035,CPT,,,,,,,,135,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
UMBILICAL VESSEL CATHETER INSERTION TRAY POLY SINGLE LUMEN 3.5/5FR,120.573,CDM,272,RC,,,,12857-MAIN,LOCAL,,,,,124,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
UMBILICAL VESSEL CATHETER INSERTION TRAY POLY SINGLE LUMEN 3.5/5FR,120.573,CDM,272,RC,,,,12857-MAIN,LOCAL,,,,,124,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
UMBILICAL VESSEL CATHETER INSERTION TRAY POLY SINGLE LUMEN 3.5/5FR,120.573,CDM,272,RC,,,,12857-MAIN,LOCAL,,,,,124,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
UMBILICAL VESSEL CATHETER INSERTION TRAY POLY SINGLE LUMEN 3.5/5FR,120.573,CDM,272,RC,,,,12857-MAIN,LOCAL,,,,,124,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
UMBILICAL VESSEL CATHETER INSERTION TRAY POLY SINGLE LUMEN 3.5/5FR,120.573,CDM,272,RC,,,,12857-MAIN,LOCAL,,,,,124,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
UMBILICAL VESSEL CATHETER INSERTION TRAY POLY SINGLE LUMEN 3.5/5FR,120.573,CDM,272,RC,,,,12857-MAIN,LOCAL,,,,,124,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
umeclidinium 62.5 MCG/ACT Aerosol Powder Breath Activated 7 Each Disp Pack,63700001,CDM,250,RC,,,,,,173087306,NDC,7,EA,492.23,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
umeclidinium 62.5 MCG/ACT Aerosol Powder Breath Activated 7 Each Disp Pack,63700001,CDM,250,RC,,,,,,173087306,NDC,7,EA,492.23,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
umeclidinium 62.5 MCG/ACT Aerosol Powder Breath Activated 7 Each Disp Pack,63700001,CDM,250,RC,,,,,,173087306,NDC,7,EA,492.23,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
umeclidinium 62.5 MCG/ACT Aerosol Powder Breath Activated 7 Each Disp Pack,63700001,CDM,250,RC,,,,,,173087306,NDC,7,EA,492.23,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
umeclidinium 62.5 MCG/ACT Aerosol Powder Breath Activated 7 Each Disp Pack,63700001,CDM,250,RC,,,,,,173087306,NDC,7,EA,492.23,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
umeclidinium 62.5 MCG/ACT Aerosol Powder Breath Activated 7 Each Disp Pack,63700001,CDM,250,RC,,,,,,173087306,NDC,7,EA,492.23,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
umeclidinium-vilanterol 62.5-25 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173086906,NDC,14,EA,745.86,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
umeclidinium-vilanterol 62.5-25 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173086906,NDC,14,EA,745.86,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
umeclidinium-vilanterol 62.5-25 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173086906,NDC,14,EA,745.86,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
umeclidinium-vilanterol 62.5-25 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173086906,NDC,14,EA,745.86,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
umeclidinium-vilanterol 62.5-25 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173086906,NDC,14,EA,745.86,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
umeclidinium-vilanterol 62.5-25 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173086906,NDC,14,EA,745.86,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Unlisted Anesth Procedure,PX01999.01,CDM,964,RC,1999,CPT,QZ,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Unlisted Anesth Procedure,PX01999.01,CDM,964,RC,1999,CPT,QZ,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Unlisted Molecular Path Proc - Ref,PX8147990,CDM,310,RC,81479,CPT,90,,,,,,,1077,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Unlisted Molecular Path Proc - Ref,PX8147990,CDM,310,RC,81479,CPT,90,,,,,,,1077,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Unlisted Molecular Path Proc - Ref,PX8147990,CDM,310,RC,81479,CPT,90,,,,,,,1077,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Unlisted Molecular Path Proc - Ref,PX8147990,CDM,310,RC,81479,CPT,90,,,,,,,1077,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Unlisted Molecular Path Proc - Ref,PX8147990,CDM,310,RC,81479,CPT,90,,,,,,,1077,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Unlisted Molecular Path Proc - Ref,PX8147990,CDM,310,RC,81479,CPT,90,,,,,,,1077,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Up GI Endoscopy,Ball Dil,30mm",PX43249F,CDM,750,RC,43249,CPT,,,,,,,,2596,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2289.672,6141.46
"Up GI Endoscopy,Ball Dil,30mm",PX43249F,CDM,750,RC,43249,CPT,,,,,,,,2596,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2289.672,6141.46
"Up GI Endoscopy,Ball Dil,30mm",PX43249F,CDM,750,RC,43249,CPT,,,,,,,,2596,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2289.672,6141.46
"Up GI Endoscopy,Ball Dil,30mm",PX43249F,CDM,750,RC,43249,CPT,,,,,,,,2596,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2289.672,6141.46
"Up GI Endoscopy,Ball Dil,30mm",PX43249F,CDM,750,RC,43249,CPT,,,,,,,,2596,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2289.672,6141.46
"Up GI Endoscopy,Ball Dil,30mm",PX43249F,CDM,750,RC,43249,CPT,,,,,,,,2596,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2289.672,6141.46
"Up GI Endoscopy,Ball Dil,30mm",PX43249P,CDM,983,RC,43249,CPT,,,,,,,,1731,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Up GI Endoscopy,Ball Dil,30mm",PX43249P,CDM,983,RC,43249,CPT,,,,,,,,1731,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Up GI Endoscopy,Ball Dil,30mm",PX43249P,CDM,983,RC,43249,CPT,,,,,,,,1731,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Up GI Endoscopy,Ball Dil,30mm",PX43249P,CDM,983,RC,43249,CPT,,,,,,,,1731,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Up GI Endoscopy,Ball Dil,30mm",PX43249P,CDM,983,RC,43249,CPT,,,,,,,,1731,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Up GI Endoscopy,Ball Dil,30mm",PX43249P,CDM,983,RC,43249,CPT,,,,,,,,1731,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Up GI Endoscopy,Dilatn W Guide",PX43248F,CDM,750,RC,43248,CPT,,,,,,,,1995,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1759.59,6141.46
"Up GI Endoscopy,Dilatn W Guide",PX43248F,CDM,750,RC,43248,CPT,,,,,,,,1995,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1759.59,6141.46
"Up GI Endoscopy,Dilatn W Guide",PX43248F,CDM,750,RC,43248,CPT,,,,,,,,1995,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1759.59,6141.46
"Up GI Endoscopy,Dilatn W Guide",PX43248F,CDM,750,RC,43248,CPT,,,,,,,,1995,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1759.59,6141.46
"Up GI Endoscopy,Dilatn W Guide",PX43248F,CDM,750,RC,43248,CPT,,,,,,,,1995,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1759.59,6141.46
"Up GI Endoscopy,Dilatn W Guide",PX43248F,CDM,750,RC,43248,CPT,,,,,,,,1995,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1759.59,6141.46
"Upper GI Endoscopy,Biopsy",PX43239F,CDM,750,RC,43239,CPT,,,,,,,,2364,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2085.048,6141.46
"Upper GI Endoscopy,Biopsy",PX43239F,CDM,750,RC,43239,CPT,,,,,,,,2364,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2085.048,6141.46
"Upper GI Endoscopy,Biopsy",PX43239F,CDM,750,RC,43239,CPT,,,,,,,,2364,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2085.048,6141.46
"Upper GI Endoscopy,Biopsy",PX43239F,CDM,750,RC,43239,CPT,,,,,,,,2364,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2085.048,6141.46
"Upper GI Endoscopy,Biopsy",PX43239F,CDM,750,RC,43239,CPT,,,,,,,,2364,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2085.048,6141.46
"Upper GI Endoscopy,Biopsy",PX43239F,CDM,750,RC,43239,CPT,,,,,,,,2364,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2085.048,6141.46
"Upper GI Endoscopy,Biopsy",PX43239P,CDM,983,RC,43239,CPT,,,,,,,,2458,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Upper GI Endoscopy,Biopsy",PX43239P,CDM,983,RC,43239,CPT,,,,,,,,2458,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Upper GI Endoscopy,Biopsy",PX43239P,CDM,983,RC,43239,CPT,,,,,,,,2458,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Upper GI Endoscopy,Biopsy",PX43239P,CDM,983,RC,43239,CPT,,,,,,,,2458,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Upper GI Endoscopy,Biopsy",PX43239P,CDM,983,RC,43239,CPT,,,,,,,,2458,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Upper GI Endoscopy,Biopsy",PX43239P,CDM,983,RC,43239,CPT,,,,,,,,2458,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Upper GI Endoscopy,Ctrl Bleed",PX43255F,CDM,750,RC,43255,CPT,,,,,,,,1723,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1519.686,6141.46
"Upper GI Endoscopy,Ctrl Bleed",PX43255F,CDM,750,RC,43255,CPT,,,,,,,,1723,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1519.686,6141.46
"Upper GI Endoscopy,Ctrl Bleed",PX43255F,CDM,750,RC,43255,CPT,,,,,,,,1723,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1519.686,6141.46
"Upper GI Endoscopy,Ctrl Bleed",PX43255F,CDM,750,RC,43255,CPT,,,,,,,,1723,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1519.686,6141.46
"Upper GI Endoscopy,Ctrl Bleed",PX43255F,CDM,750,RC,43255,CPT,,,,,,,,1723,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1519.686,6141.46
"Upper GI Endoscopy,Ctrl Bleed",PX43255F,CDM,750,RC,43255,CPT,,,,,,,,1723,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1519.686,6141.46
"Upper GI Endoscopy,Ctrl Bleed",PX43255P,CDM,983,RC,43255,CPT,,,,,,,,1148,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Upper GI Endoscopy,Ctrl Bleed",PX43255P,CDM,983,RC,43255,CPT,,,,,,,,1148,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Upper GI Endoscopy,Ctrl Bleed",PX43255P,CDM,983,RC,43255,CPT,,,,,,,,1148,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Upper GI Endoscopy,Ctrl Bleed",PX43255P,CDM,983,RC,43255,CPT,,,,,,,,1148,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Upper GI Endoscopy,Ctrl Bleed",PX43255P,CDM,983,RC,43255,CPT,,,,,,,,1148,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Upper GI Endoscopy,Ctrl Bleed",PX43255P,CDM,983,RC,43255,CPT,,,,,,,,1148,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Upper GI Endoscopy,Diagnosis",PX43235F,CDM,750,RC,43235,CPT,,,,,,,,2539,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2239.398,6141.46
"Upper GI Endoscopy,Diagnosis",PX43235F,CDM,750,RC,43235,CPT,,,,,,,,2539,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2239.398,6141.46
"Upper GI Endoscopy,Diagnosis",PX43235F,CDM,750,RC,43235,CPT,,,,,,,,2539,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2239.398,6141.46
"Upper GI Endoscopy,Diagnosis",PX43235F,CDM,750,RC,43235,CPT,,,,,,,,2539,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2239.398,6141.46
"Upper GI Endoscopy,Diagnosis",PX43235F,CDM,750,RC,43235,CPT,,,,,,,,2539,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2239.398,6141.46
"Upper GI Endoscopy,Diagnosis",PX43235F,CDM,750,RC,43235,CPT,,,,,,,,2539,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2239.398,6141.46
"Upper GI Endoscopy,Diagnosis",PX43235P,CDM,983,RC,43235,CPT,,,,,,,,1406,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Upper GI Endoscopy,Diagnosis",PX43235P,CDM,983,RC,43235,CPT,,,,,,,,1406,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Upper GI Endoscopy,Diagnosis",PX43235P,CDM,983,RC,43235,CPT,,,,,,,,1406,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Upper GI Endoscopy,Diagnosis",PX43235P,CDM,983,RC,43235,CPT,,,,,,,,1406,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Upper GI Endoscopy,Diagnosis",PX43235P,CDM,983,RC,43235,CPT,,,,,,,,1406,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Upper GI Endoscopy,Diagnosis",PX43235P,CDM,983,RC,43235,CPT,,,,,,,,1406,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
urea 20 % Cream 85 g Tube,63700001,CDM,250,RC,,,,,,536110945,NDC,85,GR,81.83,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
urea 20 % Cream 85 g Tube,63700001,CDM,250,RC,,,,,,536110945,NDC,85,GR,81.83,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
urea 20 % Cream 85 g Tube,63700001,CDM,250,RC,,,,,,536110945,NDC,85,GR,81.83,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
urea 20 % Cream 85 g Tube,63700001,CDM,250,RC,,,,,,536110945,NDC,85,GR,81.83,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
urea 20 % Cream 85 g Tube,63700001,CDM,250,RC,,,,,,536110945,NDC,85,GR,81.83,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
urea 20 % Cream 85 g Tube,63700001,CDM,250,RC,,,,,,536110945,NDC,85,GR,81.83,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
URGOK2 DUAL COMPRESSION SYSTEM LARGE,120.491,CDM,271,RC,A6452,HCPCS,,11871-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
URGOK2 DUAL COMPRESSION SYSTEM LARGE,120.491,CDM,271,RC,A6452,HCPCS,,11871-MAIN,LOCAL,,,,,41,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
URGOK2 DUAL COMPRESSION SYSTEM LARGE,120.491,CDM,271,RC,A6452,HCPCS,,11871-MAIN,LOCAL,,,,,41,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
URGOK2 DUAL COMPRESSION SYSTEM LARGE,120.491,CDM,271,RC,A6452,HCPCS,,11871-MAIN,LOCAL,,,,,41,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
URGOK2 DUAL COMPRESSION SYSTEM LARGE,120.491,CDM,271,RC,A6452,HCPCS,,11871-MAIN,LOCAL,,,,,41,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
URGOK2 DUAL COMPRESSION SYSTEM LARGE,120.491,CDM,271,RC,A6452,HCPCS,,11871-MAIN,LOCAL,,,,,41,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
URGOK2 DUAL COMPRESSION SYSTEM REGULAR,120.491,CDM,271,RC,A6452,HCPCS,,11870-MAIN,LOCAL,,,,,41,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
URGOK2 DUAL COMPRESSION SYSTEM REGULAR,120.491,CDM,271,RC,A6452,HCPCS,,11870-MAIN,LOCAL,,,,,41,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
URGOK2 DUAL COMPRESSION SYSTEM REGULAR,120.491,CDM,271,RC,A6452,HCPCS,,11870-MAIN,LOCAL,,,,,41,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
URGOK2 DUAL COMPRESSION SYSTEM REGULAR,120.491,CDM,271,RC,A6452,HCPCS,,11870-MAIN,LOCAL,,,,,41,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
URGOK2 DUAL COMPRESSION SYSTEM REGULAR,120.491,CDM,271,RC,A6452,HCPCS,,11870-MAIN,LOCAL,,,,,41,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
URGOK2 DUAL COMPRESSION SYSTEM REGULAR,120.491,CDM,271,RC,A6452,HCPCS,,11870-MAIN,LOCAL,,,,,41,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Uric Acid; Blood,PX84550,CDM,300,RC,84550,CPT,,,,,,,,52,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Uric Acid; Blood,PX84550,CDM,300,RC,84550,CPT,,,,,,,,52,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Uric Acid; Blood,PX84550,CDM,300,RC,84550,CPT,,,,,,,,52,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Uric Acid; Blood,PX84550,CDM,300,RC,84550,CPT,,,,,,,,52,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Uric Acid; Blood,PX84550,CDM,300,RC,84550,CPT,,,,,,,,52,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Uric Acid; Blood,PX84550,CDM,300,RC,84550,CPT,,,,,,,,52,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Urinalysis, Auto W/O Scope",PX81003,CDM,300,RC,81003,CPT,,,,,,,,149,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Urinalysis, Auto W/O Scope",PX81003,CDM,300,RC,81003,CPT,,,,,,,,149,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Urinalysis, Auto W/O Scope",PX81003,CDM,300,RC,81003,CPT,,,,,,,,149,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Urinalysis, Auto W/O Scope",PX81003,CDM,300,RC,81003,CPT,,,,,,,,149,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Urinalysis, Auto W/O Scope",PX81003,CDM,300,RC,81003,CPT,,,,,,,,149,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Urinalysis, Auto W/O Scope",PX81003,CDM,300,RC,81003,CPT,,,,,,,,149,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Urinalysis, Auto, W/Scope",PX81001,CDM,300,RC,81001,CPT,,,,,,,,255,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Urinalysis, Auto, W/Scope",PX81001,CDM,300,RC,81001,CPT,,,,,,,,255,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Urinalysis, Auto, W/Scope",PX81001,CDM,300,RC,81001,CPT,,,,,,,,255,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Urinalysis, Auto, W/Scope",PX81001,CDM,300,RC,81001,CPT,,,,,,,,255,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Urinalysis, Auto, W/Scope",PX81001,CDM,300,RC,81001,CPT,,,,,,,,255,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Urinalysis, Auto, W/Scope",PX81001,CDM,300,RC,81001,CPT,,,,,,,,255,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Urine Culture/Colony Count,PX87086,CDM,300,RC,87086,CPT,,,,,,,,286,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Urine Culture/Colony Count,PX87086,CDM,300,RC,87086,CPT,,,,,,,,286,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Urine Culture/Colony Count,PX87086,CDM,300,RC,87086,CPT,,,,,,,,286,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Urine Culture/Colony Count,PX87086,CDM,300,RC,87086,CPT,,,,,,,,286,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Urine Culture/Colony Count,PX87086,CDM,300,RC,87086,CPT,,,,,,,,286,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Urine Culture/Colony Count,PX87086,CDM,300,RC,87086,CPT,,,,,,,,286,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Urine Drug Screen,PX80307B,CDM,300,RC,80307,CPT,,,,,,,,370,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Urine Drug Screen,PX80307B,CDM,300,RC,80307,CPT,,,,,,,,370,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Urine Drug Screen,PX80307B,CDM,300,RC,80307,CPT,,,,,,,,370,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Urine Drug Screen,PX80307B,CDM,300,RC,80307,CPT,,,,,,,,370,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Urine Drug Screen,PX80307B,CDM,300,RC,80307,CPT,,,,,,,,370,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Urine Drug Screen,PX80307B,CDM,300,RC,80307,CPT,,,,,,,,370,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Urine Pregnancy Test,PX81025,CDM,300,RC,81025,CPT,,,,,,,,191,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Urine Pregnancy Test,PX81025,CDM,300,RC,81025,CPT,,,,,,,,191,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Urine Pregnancy Test,PX81025,CDM,300,RC,81025,CPT,,,,,,,,191,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Urine Pregnancy Test,PX81025,CDM,300,RC,81025,CPT,,,,,,,,191,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Urine Pregnancy Test,PX81025,CDM,300,RC,81025,CPT,,,,,,,,191,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Urine Pregnancy Test,PX81025,CDM,300,RC,81025,CPT,,,,,,,,191,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ursodiol 300 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,591315901,NDC,1,EA,39.47,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ursodiol 300 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,591315901,NDC,1,EA,39.47,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ursodiol 300 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,591315901,NDC,1,EA,39.47,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ursodiol 300 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,591315901,NDC,1,EA,39.47,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ursodiol 300 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,591315901,NDC,1,EA,39.47,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ursodiol 300 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,591315901,NDC,1,EA,39.47,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Abdomen Limited Tc,PX7670501,CDM,402,RC,76705,CPT,TC,,,,,,,425,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Abdomen Limited Tc,PX7670501,CDM,402,RC,76705,CPT,TC,,,,,,,425,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Abdomen Limited Tc,PX7670501,CDM,402,RC,76705,CPT,TC,,,,,,,425,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Abdomen Limited Tc,PX7670501,CDM,402,RC,76705,CPT,TC,,,,,,,425,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Abdomen Limited Tc,PX7670501,CDM,402,RC,76705,CPT,TC,,,,,,,425,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Abdomen Limited Tc,PX7670501,CDM,402,RC,76705,CPT,TC,,,,,,,425,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Abdomen Tc,PX7670001,CDM,402,RC,76700,CPT,TC,,,,,,,586,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Abdomen Tc,PX7670001,CDM,402,RC,76700,CPT,TC,,,,,,,586,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Abdomen Tc,PX7670001,CDM,402,RC,76700,CPT,TC,,,,,,,586,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Abdomen Tc,PX7670001,CDM,402,RC,76700,CPT,TC,,,,,,,586,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Abdomen Tc,PX7670001,CDM,402,RC,76700,CPT,TC,,,,,,,586,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Abdomen Tc,PX7670001,CDM,402,RC,76700,CPT,TC,,,,,,,586,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Chest Tc,PX7660401,CDM,402,RC,76604,CPT,TC,,,,,,,248,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Chest Tc,PX7660401,CDM,402,RC,76604,CPT,TC,,,,,,,248,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Chest Tc,PX7660401,CDM,402,RC,76604,CPT,TC,,,,,,,248,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Chest Tc,PX7660401,CDM,402,RC,76604,CPT,TC,,,,,,,248,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Chest Tc,PX7660401,CDM,402,RC,76604,CPT,TC,,,,,,,248,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Chest Tc,PX7660401,CDM,402,RC,76604,CPT,TC,,,,,,,248,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"US Complete Joint, Realtime W/ Img Tc",PX7688101,CDM,402,RC,76881,CPT,TC,,,,,,,415,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"US Complete Joint, Realtime W/ Img Tc",PX7688101,CDM,402,RC,76881,CPT,TC,,,,,,,415,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"US Complete Joint, Realtime W/ Img Tc",PX7688101,CDM,402,RC,76881,CPT,TC,,,,,,,415,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"US Complete Joint, Realtime W/ Img Tc",PX7688101,CDM,402,RC,76881,CPT,TC,,,,,,,415,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"US Complete Joint, Realtime W/ Img Tc",PX7688101,CDM,402,RC,76881,CPT,TC,,,,,,,415,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"US Complete Joint, Realtime W/ Img Tc",PX7688101,CDM,402,RC,76881,CPT,TC,,,,,,,415,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Doppler Lw Ext Art Tc,PX9392601,CDM,921,RC,93926,CPT,TC,,,,,,,740,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Doppler Lw Ext Art Tc,PX9392601,CDM,921,RC,93926,CPT,TC,,,,,,,740,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Doppler Lw Ext Art Tc,PX9392601,CDM,921,RC,93926,CPT,TC,,,,,,,740,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Doppler Lw Ext Art Tc,PX9392601,CDM,921,RC,93926,CPT,TC,,,,,,,740,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Doppler Lw Ext Art Tc,PX9392601,CDM,921,RC,93926,CPT,TC,,,,,,,740,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Doppler Lw Ext Art Tc,PX9392601,CDM,921,RC,93926,CPT,TC,,,,,,,740,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Ext Non-Vasc Img Lmtd,PX7688201,CDM,402,RC,76882,CPT,TC,,,,,,,425,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Ext Non-Vasc Img Lmtd,PX7688201,CDM,402,RC,76882,CPT,TC,,,,,,,425,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Ext Non-Vasc Img Lmtd,PX7688201,CDM,402,RC,76882,CPT,TC,,,,,,,425,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Ext Non-Vasc Img Lmtd,PX7688201,CDM,402,RC,76882,CPT,TC,,,,,,,425,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Ext Non-Vasc Img Lmtd,PX7688201,CDM,402,RC,76882,CPT,TC,,,,,,,425,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Ext Non-Vasc Img Lmtd,PX7688201,CDM,402,RC,76882,CPT,TC,,,,,,,425,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Follicles-Limited Tc,PX7685701,CDM,402,RC,76857,CPT,TC,,,,,,,300,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Follicles-Limited Tc,PX7685701,CDM,402,RC,76857,CPT,TC,,,,,,,300,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Follicles-Limited Tc,PX7685701,CDM,402,RC,76857,CPT,TC,,,,,,,300,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Follicles-Limited Tc,PX7685701,CDM,402,RC,76857,CPT,TC,,,,,,,300,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Follicles-Limited Tc,PX7685701,CDM,402,RC,76857,CPT,TC,,,,,,,300,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Follicles-Limited Tc,PX7685701,CDM,402,RC,76857,CPT,TC,,,,,,,300,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Guide Needle Bx S&I,PX7694201,CDM,402,RC,76942,CPT,TC,,,,,,,747,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Guide Needle Bx S&I,PX7694201,CDM,402,RC,76942,CPT,TC,,,,,,,747,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Guide Needle Bx S&I,PX7694201,CDM,402,RC,76942,CPT,TC,,,,,,,747,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Guide Needle Bx S&I,PX7694201,CDM,402,RC,76942,CPT,TC,,,,,,,747,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Guide Needle Bx S&I,PX7694201,CDM,402,RC,76942,CPT,TC,,,,,,,747,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Guide Needle Bx S&I,PX7694201,CDM,402,RC,76942,CPT,TC,,,,,,,747,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Guide Needle Bx S&I,PX7694226,CDM,982,RC,76942,CPT,26,,,,,,,148,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Guide Needle Bx S&I,PX7694226,CDM,982,RC,76942,CPT,26,,,,,,,148,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Guide Needle Bx S&I,PX7694226,CDM,982,RC,76942,CPT,26,,,,,,,148,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Guide Needle Bx S&I,PX7694226,CDM,982,RC,76942,CPT,26,,,,,,,148,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Guide Needle Bx S&I,PX7694226,CDM,982,RC,76942,CPT,26,,,,,,,148,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Guide Needle Bx S&I,PX7694226,CDM,982,RC,76942,CPT,26,,,,,,,148,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"US Guide, Vascular Access",PX7693701,CDM,402,RC,76937,CPT,TC,,,,,,,760,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"US Guide, Vascular Access",PX7693701,CDM,402,RC,76937,CPT,TC,,,,,,,760,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"US Guide, Vascular Access",PX7693701,CDM,402,RC,76937,CPT,TC,,,,,,,760,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"US Guide, Vascular Access",PX7693701,CDM,402,RC,76937,CPT,TC,,,,,,,760,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"US Guide, Vascular Access",PX7693701,CDM,402,RC,76937,CPT,TC,,,,,,,760,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"US Guide, Vascular Access",PX7693701,CDM,402,RC,76937,CPT,TC,,,,,,,760,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Head/Neck Tc,PX7653601,CDM,402,RC,76536,CPT,TC,,,,,,,416,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Head/Neck Tc,PX7653601,CDM,402,RC,76536,CPT,TC,,,,,,,416,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Head/Neck Tc,PX7653601,CDM,402,RC,76536,CPT,TC,,,,,,,416,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Head/Neck Tc,PX7653601,CDM,402,RC,76536,CPT,TC,,,,,,,416,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Head/Neck Tc,PX7653601,CDM,402,RC,76536,CPT,TC,,,,,,,416,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Head/Neck Tc,PX7653601,CDM,402,RC,76536,CPT,TC,,,,,,,416,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Kidney Transplt Untrsd,PX7677601,CDM,402,RC,76776,CPT,TC,,,,,,,554,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Kidney Transplt Untrsd,PX7677601,CDM,402,RC,76776,CPT,TC,,,,,,,554,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Kidney Transplt Untrsd,PX7677601,CDM,402,RC,76776,CPT,TC,,,,,,,554,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Kidney Transplt Untrsd,PX7677601,CDM,402,RC,76776,CPT,TC,,,,,,,554,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Kidney Transplt Untrsd,PX7677601,CDM,402,RC,76776,CPT,TC,,,,,,,554,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Kidney Transplt Untrsd,PX7677601,CDM,402,RC,76776,CPT,TC,,,,,,,554,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Pelvic Tc Complete,PX7685601,CDM,402,RC,76856,CPT,TC,,,,,,,472,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Pelvic Tc Complete,PX7685601,CDM,402,RC,76856,CPT,TC,,,,,,,472,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Pelvic Tc Complete,PX7685601,CDM,402,RC,76856,CPT,TC,,,,,,,472,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Pelvic Tc Complete,PX7685601,CDM,402,RC,76856,CPT,TC,,,,,,,472,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Pelvic Tc Complete,PX7685601,CDM,402,RC,76856,CPT,TC,,,,,,,472,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Pelvic Tc Complete,PX7685601,CDM,402,RC,76856,CPT,TC,,,,,,,472,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Pregnancy Tc Follow-Up,PX7681601,CDM,402,RC,76816,CPT,TC,,,,,,,362,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Pregnancy Tc Follow-Up,PX7681601,CDM,402,RC,76816,CPT,TC,,,,,,,362,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Pregnancy Tc Follow-Up,PX7681601,CDM,402,RC,76816,CPT,TC,,,,,,,362,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Pregnancy Tc Follow-Up,PX7681601,CDM,402,RC,76816,CPT,TC,,,,,,,362,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Pregnancy Tc Follow-Up,PX7681601,CDM,402,RC,76816,CPT,TC,,,,,,,362,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Pregnancy Tc Follow-Up,PX7681601,CDM,402,RC,76816,CPT,TC,,,,,,,362,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Pregnancy Tc Limited,PX7681501,CDM,402,RC,76815,CPT,TC,,,,,,,438,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Pregnancy Tc Limited,PX7681501,CDM,402,RC,76815,CPT,TC,,,,,,,438,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Pregnancy Tc Limited,PX7681501,CDM,402,RC,76815,CPT,TC,,,,,,,438,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Pregnancy Tc Limited,PX7681501,CDM,402,RC,76815,CPT,TC,,,,,,,438,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Pregnancy Tc Limited,PX7681501,CDM,402,RC,76815,CPT,TC,,,,,,,438,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Pregnancy Tc Limited,PX7681501,CDM,402,RC,76815,CPT,TC,,,,,,,438,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Renal Retroperit Ltd,PX7677501,CDM,402,RC,76775,CPT,TC,,,,,,,566,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Renal Retroperit Ltd,PX7677501,CDM,402,RC,76775,CPT,TC,,,,,,,566,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Renal Retroperit Ltd,PX7677501,CDM,402,RC,76775,CPT,TC,,,,,,,566,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Renal Retroperit Ltd,PX7677501,CDM,402,RC,76775,CPT,TC,,,,,,,566,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Renal Retroperit Ltd,PX7677501,CDM,402,RC,76775,CPT,TC,,,,,,,566,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Renal Retroperit Ltd,PX7677501,CDM,402,RC,76775,CPT,TC,,,,,,,566,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Retroperitoneal Tc,PX7677001,CDM,402,RC,76770,CPT,TC,,,,,,,566,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Retroperitoneal Tc,PX7677001,CDM,402,RC,76770,CPT,TC,,,,,,,566,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Retroperitoneal Tc,PX7677001,CDM,402,RC,76770,CPT,TC,,,,,,,566,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Retroperitoneal Tc,PX7677001,CDM,402,RC,76770,CPT,TC,,,,,,,566,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Retroperitoneal Tc,PX7677001,CDM,402,RC,76770,CPT,TC,,,,,,,566,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Retroperitoneal Tc,PX7677001,CDM,402,RC,76770,CPT,TC,,,,,,,566,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Scrotum & Contents Tc,PX7687001,CDM,402,RC,76870,CPT,TC,,,,,,,457,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Scrotum & Contents Tc,PX7687001,CDM,402,RC,76870,CPT,TC,,,,,,,457,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Scrotum & Contents Tc,PX7687001,CDM,402,RC,76870,CPT,TC,,,,,,,457,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Scrotum & Contents Tc,PX7687001,CDM,402,RC,76870,CPT,TC,,,,,,,457,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Scrotum & Contents Tc,PX7687001,CDM,402,RC,76870,CPT,TC,,,,,,,457,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Scrotum & Contents Tc,PX7687001,CDM,402,RC,76870,CPT,TC,,,,,,,457,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Transvaginal Tc,PX7683001,CDM,402,RC,76830,CPT,TC,,,,,,,472,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Transvaginal Tc,PX7683001,CDM,402,RC,76830,CPT,TC,,,,,,,472,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Transvaginal Tc,PX7683001,CDM,402,RC,76830,CPT,TC,,,,,,,472,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Transvaginal Tc,PX7683001,CDM,402,RC,76830,CPT,TC,,,,,,,472,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Transvaginal Tc,PX7683001,CDM,402,RC,76830,CPT,TC,,,,,,,472,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Transvaginal Tc,PX7683001,CDM,402,RC,76830,CPT,TC,,,,,,,472,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Urine Capacity Measure,PX51798F,CDM,510,RC,51798,CPT,,,,,,,,96,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Urine Capacity Measure,PX51798F,CDM,510,RC,51798,CPT,,,,,,,,96,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Urine Capacity Measure,PX51798F,CDM,510,RC,51798,CPT,,,,,,,,96,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Urine Capacity Measure,PX51798F,CDM,510,RC,51798,CPT,,,,,,,,96,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Urine Capacity Measure,PX51798F,CDM,510,RC,51798,CPT,,,,,,,,96,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Urine Capacity Measure,PX51798F,CDM,510,RC,51798,CPT,,,,,,,,96,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"US,Preg. Uterus,Fetal/Mat.Eval.,>1st Trim.(>/= 14 Wks 0 Dys),Transabd;Single/First Gest., Tech",PX7680501,CDM,402,RC,76805,CPT,TC,,,,,,,562,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"US,Preg. Uterus,Fetal/Mat.Eval.,>1st Trim.(>/= 14 Wks 0 Dys),Transabd;Single/First Gest., Tech",PX7680501,CDM,402,RC,76805,CPT,TC,,,,,,,562,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"US,Preg. Uterus,Fetal/Mat.Eval.,>1st Trim.(>/= 14 Wks 0 Dys),Transabd;Single/First Gest., Tech",PX7680501,CDM,402,RC,76805,CPT,TC,,,,,,,562,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"US,Preg. Uterus,Fetal/Mat.Eval.,>1st Trim.(>/= 14 Wks 0 Dys),Transabd;Single/First Gest., Tech",PX7680501,CDM,402,RC,76805,CPT,TC,,,,,,,562,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"US,Preg. Uterus,Fetal/Mat.Eval.,>1st Trim.(>/= 14 Wks 0 Dys),Transabd;Single/First Gest., Tech",PX7680501,CDM,402,RC,76805,CPT,TC,,,,,,,562,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"US,Preg. Uterus,Fetal/Mat.Eval.,>1st Trim.(>/= 14 Wks 0 Dys),Transabd;Single/First Gest., Tech",PX7680501,CDM,402,RC,76805,CPT,TC,,,,,,,562,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ustekinumab 130 MG/26ML Solution 26 mL Vial,J3358.01,CDM,636,RC,J3358,HCPCS,,,,57894005427,NDC,26,ML,4130,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ustekinumab 130 MG/26ML Solution 26 mL Vial,J3358.01,CDM,636,RC,J3358,HCPCS,,,,57894005427,NDC,26,ML,4130,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ustekinumab 130 MG/26ML Solution 26 mL Vial,J3358.01,CDM,636,RC,J3358,HCPCS,,,,57894005427,NDC,26,ML,4130,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ustekinumab 130 MG/26ML Solution 26 mL Vial,J3358.01,CDM,636,RC,J3358,HCPCS,,,,57894005427,NDC,26,ML,4130,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ustekinumab 130 MG/26ML Solution 26 mL Vial,J3358.01,CDM,636,RC,J3358,HCPCS,,,,57894005427,NDC,26,ML,4130,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ustekinumab 130 MG/26ML Solution 26 mL Vial,J3358.01,CDM,636,RC,J3358,HCPCS,,,,57894005427,NDC,26,ML,4130,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
VACUUM KIWI W/PALM PUMP,120.225,CDM,272,RC,,,,10028-MAIN,LOCAL,,,,,120,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
VACUUM KIWI W/PALM PUMP,120.225,CDM,272,RC,,,,10028-MAIN,LOCAL,,,,,120,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
VACUUM KIWI W/PALM PUMP,120.225,CDM,272,RC,,,,10028-MAIN,LOCAL,,,,,120,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
VACUUM KIWI W/PALM PUMP,120.225,CDM,272,RC,,,,10028-MAIN,LOCAL,,,,,120,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
VACUUM KIWI W/PALM PUMP,120.225,CDM,272,RC,,,,10028-MAIN,LOCAL,,,,,120,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
VACUUM KIWI W/PALM PUMP,120.225,CDM,272,RC,,,,10028-MAIN,LOCAL,,,,,120,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
VAGINAL PACKING 2',120.292,CDM,272,RC,,,,829-MAIN,LOCAL,,,,,32.23,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
VAGINAL PACKING 2',120.292,CDM,272,RC,,,,829-MAIN,LOCAL,,,,,32.23,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
VAGINAL PACKING 2',120.292,CDM,272,RC,,,,829-MAIN,LOCAL,,,,,32.23,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
VAGINAL PACKING 2',120.292,CDM,272,RC,,,,829-MAIN,LOCAL,,,,,32.23,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
VAGINAL PACKING 2',120.292,CDM,272,RC,,,,829-MAIN,LOCAL,,,,,32.23,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
VAGINAL PACKING 2',120.292,CDM,272,RC,,,,829-MAIN,LOCAL,,,,,32.23,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
valACYclovir 1 GM Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069701,NDC,0.5,EA,33.58,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
valACYclovir 1 GM Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069701,NDC,0.5,EA,33.58,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
valACYclovir 1 GM Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069701,NDC,0.5,EA,33.58,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
valACYclovir 1 GM Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069701,NDC,0.5,EA,33.58,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
valACYclovir 1 GM Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069701,NDC,0.5,EA,33.58,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
valACYclovir 1 GM Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069701,NDC,0.5,EA,33.58,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
valACYclovir 1 GM Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862044930,NDC,0.5,EA,33.23,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
valACYclovir 1 GM Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862044930,NDC,0.5,EA,33.23,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
valACYclovir 1 GM Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862044930,NDC,0.5,EA,33.23,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
valACYclovir 1 GM Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862044930,NDC,0.5,EA,33.23,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
valACYclovir 1 GM Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862044930,NDC,0.5,EA,33.23,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
valACYclovir 1 GM Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862044930,NDC,0.5,EA,33.23,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
valACYclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069801,NDC,1,EA,38.55,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
valACYclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069801,NDC,1,EA,38.55,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
valACYclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069801,NDC,1,EA,38.55,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
valACYclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069801,NDC,1,EA,38.55,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
valACYclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069801,NDC,1,EA,38.55,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
valACYclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069801,NDC,1,EA,38.55,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
valACYclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,31722070430,NDC,1,EA,38.79,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
valACYclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,31722070430,NDC,1,EA,38.79,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
valACYclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,31722070430,NDC,1,EA,38.79,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
valACYclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,31722070430,NDC,1,EA,38.79,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
valACYclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,31722070430,NDC,1,EA,38.79,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
valACYclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,31722070430,NDC,1,EA,38.79,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
valproate 100 MG/ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049416,NDC,5,ML,33.61,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
valproate 100 MG/ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049416,NDC,5,ML,33.61,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
valproate 100 MG/ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049416,NDC,5,ML,33.61,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
valproate 100 MG/ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049416,NDC,5,ML,33.61,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
valproate 100 MG/ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049416,NDC,5,ML,33.61,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
valproate 100 MG/ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049416,NDC,5,ML,33.61,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
valproate 100 MG/ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049441,NDC,5,ML,33.61,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
valproate 100 MG/ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049441,NDC,5,ML,33.61,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
valproate 100 MG/ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049441,NDC,5,ML,33.61,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
valproate 100 MG/ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049441,NDC,5,ML,33.61,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
valproate 100 MG/ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049441,NDC,5,ML,33.61,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
valproate 100 MG/ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049441,NDC,5,ML,33.61,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
valsartan 160 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342006410,NDC,0.25,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
valsartan 160 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342006410,NDC,0.25,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
valsartan 160 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342006410,NDC,0.25,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
valsartan 160 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342006410,NDC,0.25,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
valsartan 160 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342006410,NDC,0.25,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
valsartan 160 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342006410,NDC,0.25,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028401,NDC,1,EA,111.01,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028401,NDC,1,EA,111.01,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028401,NDC,1,EA,111.01,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028401,NDC,1,EA,111.01,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028401,NDC,1,EA,111.01,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028401,NDC,1,EA,111.01,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028420,NDC,1,EA,111.01,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028420,NDC,1,EA,111.01,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028420,NDC,1,EA,111.01,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028420,NDC,1,EA,111.01,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028420,NDC,1,EA,111.01,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028420,NDC,1,EA,111.01,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028426,NDC,1,EA,42.15,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028426,NDC,1,EA,42.15,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028426,NDC,1,EA,42.15,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028426,NDC,1,EA,42.15,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028426,NDC,1,EA,42.15,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028426,NDC,1,EA,42.15,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028442,NDC,1,EA,47.71,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028442,NDC,1,EA,47.71,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028442,NDC,1,EA,47.71,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028442,NDC,1,EA,47.71,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028442,NDC,1,EA,47.71,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028442,NDC,1,EA,47.71,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034000,NDC,1,EA,111.82,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034000,NDC,1,EA,111.82,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034000,NDC,1,EA,111.82,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034000,NDC,1,EA,111.82,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034000,NDC,1,EA,111.82,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034000,NDC,1,EA,111.82,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034001,NDC,1,EA,111.81,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034001,NDC,1,EA,111.81,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034001,NDC,1,EA,111.81,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034001,NDC,1,EA,111.81,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034001,NDC,1,EA,111.81,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034001,NDC,1,EA,111.81,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010520,NDC,1,EA,68.33,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010520,NDC,1,EA,68.33,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010520,NDC,1,EA,68.33,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010520,NDC,1,EA,68.33,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010520,NDC,1,EA,68.33,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010520,NDC,1,EA,68.33,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010541,NDC,1,EA,68.33,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010541,NDC,1,EA,68.33,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010541,NDC,1,EA,68.33,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010541,NDC,1,EA,68.33,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010541,NDC,1,EA,68.33,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010541,NDC,1,EA,68.33,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076501,NDC,1,EA,58.6,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076501,NDC,1,EA,58.6,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076501,NDC,1,EA,58.6,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076501,NDC,1,EA,58.6,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076501,NDC,1,EA,58.6,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076501,NDC,1,EA,58.6,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076510,NDC,1,EA,58.6,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076510,NDC,1,EA,58.6,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076510,NDC,1,EA,58.6,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076510,NDC,1,EA,58.6,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076510,NDC,1,EA,58.6,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076510,NDC,1,EA,58.6,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 125 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68180016611,NDC,1,EA,149.33,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 125 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68180016611,NDC,1,EA,149.33,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 125 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68180016611,NDC,1,EA,149.33,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 125 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68180016611,NDC,1,EA,149.33,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 125 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68180016611,NDC,1,EA,149.33,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 125 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68180016611,NDC,1,EA,149.33,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 125 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,47781072902,NDC,1,EA,149.33,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 125 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,47781072902,NDC,1,EA,149.33,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 125 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,47781072902,NDC,1,EA,149.33,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 125 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,47781072902,NDC,1,EA,149.33,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 125 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,47781072902,NDC,1,EA,149.33,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 125 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,47781072902,NDC,1,EA,149.33,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 125 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,62559039020,NDC,1,EA,149.33,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 125 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,62559039020,NDC,1,EA,149.33,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 125 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,62559039020,NDC,1,EA,149.33,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 125 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,62559039020,NDC,1,EA,149.33,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 125 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,62559039020,NDC,1,EA,149.33,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 125 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,62559039020,NDC,1,EA,149.33,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,47781059807,NDC,1,EA,39.84,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,47781059807,NDC,1,EA,39.84,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,47781059807,NDC,1,EA,39.84,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,47781059807,NDC,1,EA,39.84,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,47781059807,NDC,1,EA,39.84,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,47781059807,NDC,1,EA,39.84,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022116,NDC,1,EA,36.33,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022116,NDC,1,EA,36.33,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022116,NDC,1,EA,36.33,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022116,NDC,1,EA,36.33,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022116,NDC,1,EA,36.33,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022116,NDC,1,EA,36.33,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022141,NDC,1,EA,36.33,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022141,NDC,1,EA,36.33,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022141,NDC,1,EA,36.33,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022141,NDC,1,EA,36.33,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022141,NDC,1,EA,36.33,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022141,NDC,1,EA,36.33,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022143,NDC,1,EA,36.31,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022143,NDC,1,EA,36.31,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022143,NDC,1,EA,36.31,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022143,NDC,1,EA,36.31,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022143,NDC,1,EA,36.31,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022143,NDC,1,EA,36.31,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457033900,NDC,1,EA,71.82,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457033900,NDC,1,EA,71.82,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457033900,NDC,1,EA,71.82,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457033900,NDC,1,EA,71.82,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457033900,NDC,1,EA,71.82,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457033900,NDC,1,EA,71.82,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Varicella-Zoster Antibody,PX86787,CDM,300,RC,86787,CPT,,,,,,,,95,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Varicella-Zoster Antibody,PX86787,CDM,300,RC,86787,CPT,,,,,,,,95,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Varicella-Zoster Antibody,PX86787,CDM,300,RC,86787,CPT,,,,,,,,95,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Varicella-Zoster Antibody,PX86787,CDM,300,RC,86787,CPT,,,,,,,,95,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Varicella-Zoster Antibody,PX86787,CDM,300,RC,86787,CPT,,,,,,,,95,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Varicella-Zoster Antibody,PX86787,CDM,300,RC,86787,CPT,,,,,,,,95,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016401,NDC,1,ML,854.49,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016401,NDC,1,ML,854.49,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016401,NDC,1,ML,854.49,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016401,NDC,1,ML,854.49,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016401,NDC,1,ML,854.49,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016401,NDC,1,ML,854.49,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016410,NDC,1,ML,917.08,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016410,NDC,1,ML,917.08,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016410,NDC,1,ML,917.08,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016410,NDC,1,ML,917.08,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016410,NDC,1,ML,917.08,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016410,NDC,1,ML,917.08,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016425,NDC,1,ML,779.43,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016425,NDC,1,ML,779.43,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016425,NDC,1,ML,779.43,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016425,NDC,1,ML,779.43,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016425,NDC,1,ML,779.43,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016425,NDC,1,ML,779.43,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,409163221,NDC,0.5,EA,43.65,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,409163221,NDC,0.5,EA,43.65,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,409163221,NDC,0.5,EA,43.65,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,409163221,NDC,0.5,EA,43.65,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,409163221,NDC,0.5,EA,43.65,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,409163221,NDC,0.5,EA,43.65,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,703291401,NDC,0.5,EA,40.3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,703291401,NDC,0.5,EA,40.3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,703291401,NDC,0.5,EA,40.3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,703291401,NDC,0.5,EA,40.3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,703291401,NDC,0.5,EA,40.3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,703291401,NDC,0.5,EA,40.3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,47335093140,NDC,0.5,EA,44.33,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,47335093140,NDC,0.5,EA,44.33,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,47335093140,NDC,0.5,EA,44.33,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,47335093140,NDC,0.5,EA,44.33,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,47335093140,NDC,0.5,EA,44.33,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,47335093140,NDC,0.5,EA,44.33,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,47335093144,NDC,0.5,EA,44.33,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,47335093144,NDC,0.5,EA,44.33,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,47335093144,NDC,0.5,EA,44.33,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,47335093144,NDC,0.5,EA,44.33,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,47335093144,NDC,0.5,EA,44.33,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,47335093144,NDC,0.5,EA,44.33,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,55150023501,NDC,0.5,EA,37.72,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,55150023501,NDC,0.5,EA,37.72,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,55150023501,NDC,0.5,EA,37.72,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,55150023501,NDC,0.5,EA,37.72,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,55150023501,NDC,0.5,EA,37.72,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,55150023501,NDC,0.5,EA,37.72,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078110,NDC,0.5,EA,38.33,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078110,NDC,0.5,EA,38.33,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078110,NDC,0.5,EA,38.33,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078110,NDC,0.5,EA,38.33,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078110,NDC,0.5,EA,38.33,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078110,NDC,0.5,EA,38.33,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078121,NDC,0.5,EA,36.75,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078121,NDC,0.5,EA,36.75,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078121,NDC,0.5,EA,36.75,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078121,NDC,0.5,EA,36.75,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078121,NDC,0.5,EA,36.75,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078121,NDC,0.5,EA,36.75,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078141,NDC,0.5,EA,36.75,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078141,NDC,0.5,EA,36.75,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078141,NDC,0.5,EA,36.75,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078141,NDC,0.5,EA,36.75,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078141,NDC,0.5,EA,36.75,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078141,NDC,0.5,EA,36.75,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,67457043800,NDC,0.5,EA,36.11,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,67457043800,NDC,0.5,EA,36.11,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,67457043800,NDC,0.5,EA,36.11,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,67457043800,NDC,0.5,EA,36.11,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,67457043800,NDC,0.5,EA,36.11,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,67457043800,NDC,0.5,EA,36.11,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,67457043810,NDC,0.5,EA,36.11,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,67457043810,NDC,0.5,EA,36.11,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,67457043810,NDC,0.5,EA,36.11,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,67457043810,NDC,0.5,EA,36.11,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,67457043810,NDC,0.5,EA,36.11,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,67457043810,NDC,0.5,EA,36.11,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Vedolizumab - Ref,PX8028090,CDM,300,RC,80280,CPT,90,,,,,,,468,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Vedolizumab - Ref,PX8028090,CDM,300,RC,80280,CPT,90,,,,,,,468,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Vedolizumab - Ref,PX8028090,CDM,300,RC,80280,CPT,90,,,,,,,468,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Vedolizumab - Ref,PX8028090,CDM,300,RC,80280,CPT,90,,,,,,,468,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Vedolizumab - Ref,PX8028090,CDM,300,RC,80280,CPT,90,,,,,,,468,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Vedolizumab - Ref,PX8028090,CDM,300,RC,80280,CPT,90,,,,,,,468,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vedolizumab 300 MG Recon Soln 1 Each Vial,J3380.01,CDM,636,RC,J3380,HCPCS,,,,64764030020,NDC,1,EA,12439.04,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vedolizumab 300 MG Recon Soln 1 Each Vial,J3380.01,CDM,636,RC,J3380,HCPCS,,,,64764030020,NDC,1,EA,12439.04,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vedolizumab 300 MG Recon Soln 1 Each Vial,J3380.01,CDM,636,RC,J3380,HCPCS,,,,64764030020,NDC,1,EA,12439.04,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vedolizumab 300 MG Recon Soln 1 Each Vial,J3380.01,CDM,636,RC,J3380,HCPCS,,,,64764030020,NDC,1,EA,12439.04,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vedolizumab 300 MG Recon Soln 1 Each Vial,J3380.01,CDM,636,RC,J3380,HCPCS,,,,64764030020,NDC,1,EA,12439.04,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vedolizumab 300 MG Recon Soln 1 Each Vial,J3380.01,CDM,636,RC,J3380,HCPCS,,,,64764030020,NDC,1,EA,12439.04,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ven Duplex Bilateral,PX9397001,CDM,921,RC,93970,CPT,TC,,,,,,,1189,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ven Duplex Bilateral,PX9397001,CDM,921,RC,93970,CPT,TC,,,,,,,1189,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ven Duplex Bilateral,PX9397001,CDM,921,RC,93970,CPT,TC,,,,,,,1189,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ven Duplex Bilateral,PX9397001,CDM,921,RC,93970,CPT,TC,,,,,,,1189,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ven Duplex Bilateral,PX9397001,CDM,921,RC,93970,CPT,TC,,,,,,,1189,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ven Duplex Bilateral,PX9397001,CDM,921,RC,93970,CPT,TC,,,,,,,1189,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venetoclax 100 MG Tablet 1 Each Box,25000000,CDM,250,RC,,,,,,74057611,NDC,0.2,EA,90.87,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venetoclax 100 MG Tablet 1 Each Box,25000000,CDM,250,RC,,,,,,74057611,NDC,0.2,EA,90.87,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venetoclax 100 MG Tablet 1 Each Box,25000000,CDM,250,RC,,,,,,74057611,NDC,0.2,EA,90.87,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venetoclax 100 MG Tablet 1 Each Box,25000000,CDM,250,RC,,,,,,74057611,NDC,0.2,EA,90.87,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venetoclax 100 MG Tablet 1 Each Box,25000000,CDM,250,RC,,,,,,74057611,NDC,0.2,EA,90.87,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venetoclax 100 MG Tablet 1 Each Box,25000000,CDM,250,RC,,,,,,74057611,NDC,0.2,EA,90.87,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipunc Need Phys Skill,Dx or Rx",PX36410,CDM,983,RC,36410,CPT,,,,,,,,132,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipunc Need Phys Skill,Dx or Rx",PX36410,CDM,983,RC,36410,CPT,,,,,,,,132,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipunc Need Phys Skill,Dx or Rx",PX36410,CDM,983,RC,36410,CPT,,,,,,,,132,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipunc Need Phys Skill,Dx or Rx",PX36410,CDM,983,RC,36410,CPT,,,,,,,,132,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipunc Need Phys Skill,Dx or Rx",PX36410,CDM,983,RC,36410,CPT,,,,,,,,132,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipunc Need Phys Skill,Dx or Rx",PX36410,CDM,983,RC,36410,CPT,,,,,,,,132,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipunc Need Phys Skill,Dx or Rx",PX36410F,CDM,510,RC,36410,CPT,,,,,,,,34,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipunc Need Phys Skill,Dx or Rx",PX36410F,CDM,510,RC,36410,CPT,,,,,,,,34,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipunc Need Phys Skill,Dx or Rx",PX36410F,CDM,510,RC,36410,CPT,,,,,,,,34,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipunc Need Phys Skill,Dx or Rx",PX36410F,CDM,510,RC,36410,CPT,,,,,,,,34,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipunc Need Phys Skill,Dx or Rx",PX36410F,CDM,510,RC,36410,CPT,,,,,,,,34,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipunc Need Phys Skill,Dx or Rx",PX36410F,CDM,510,RC,36410,CPT,,,,,,,,34,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipunc Need Phys Skill,Dx or Rx",PX36410P,CDM,983,RC,36410,CPT,,,,,,,,129,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipunc Need Phys Skill,Dx or Rx",PX36410P,CDM,983,RC,36410,CPT,,,,,,,,129,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipunc Need Phys Skill,Dx or Rx",PX36410P,CDM,983,RC,36410,CPT,,,,,,,,129,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipunc Need Phys Skill,Dx or Rx",PX36410P,CDM,983,RC,36410,CPT,,,,,,,,129,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipunc Need Phys Skill,Dx or Rx",PX36410P,CDM,983,RC,36410,CPT,,,,,,,,129,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipunc Need Phys Skill,Dx or Rx",PX36410P,CDM,983,RC,36410,CPT,,,,,,,,129,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipuncture by Physician, Other Vein, Under Age 3 Years",PX36406,CDM,983,RC,36406,CPT,,,,,,,,45,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipuncture by Physician, Other Vein, Under Age 3 Years",PX36406,CDM,983,RC,36406,CPT,,,,,,,,45,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipuncture by Physician, Other Vein, Under Age 3 Years",PX36406,CDM,983,RC,36406,CPT,,,,,,,,45,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipuncture by Physician, Other Vein, Under Age 3 Years",PX36406,CDM,983,RC,36406,CPT,,,,,,,,45,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipuncture by Physician, Other Vein, Under Age 3 Years",PX36406,CDM,983,RC,36406,CPT,,,,,,,,45,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipuncture by Physician, Other Vein, Under Age 3 Years",PX36406,CDM,983,RC,36406,CPT,,,,,,,,45,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405F,CDM,510,RC,36405,CPT,,,,,,,,54,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405F,CDM,510,RC,36405,CPT,,,,,,,,54,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405F,CDM,510,RC,36405,CPT,,,,,,,,54,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405F,CDM,510,RC,36405,CPT,,,,,,,,54,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405F,CDM,510,RC,36405,CPT,,,,,,,,54,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405F,CDM,510,RC,36405,CPT,,,,,,,,54,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405P,CDM,983,RC,36405,CPT,,,,,,,,36,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405P,CDM,983,RC,36405,CPT,,,,,,,,36,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405P,CDM,983,RC,36405,CPT,,,,,,,,36,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405P,CDM,983,RC,36405,CPT,,,,,,,,36,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405P,CDM,983,RC,36405,CPT,,,,,,,,36,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405P,CDM,983,RC,36405,CPT,,,,,,,,36,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipuncture, Lab",PX3641502,CDM,300,RC,36415,CPT,,,,,,,,61,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipuncture, Lab",PX3641502,CDM,300,RC,36415,CPT,,,,,,,,61,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipuncture, Lab",PX3641502,CDM,300,RC,36415,CPT,,,,,,,,61,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipuncture, Lab",PX3641502,CDM,300,RC,36415,CPT,,,,,,,,61,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipuncture, Lab",PX3641502,CDM,300,RC,36415,CPT,,,,,,,,61,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipuncture, Lab",PX3641502,CDM,300,RC,36415,CPT,,,,,,,,61,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084089695,NDC,1,EA,11.1,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084089695,NDC,1,EA,11.1,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084089695,NDC,1,EA,11.1,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084089695,NDC,1,EA,11.1,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084089695,NDC,1,EA,11.1,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084089695,NDC,1,EA,11.1,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,57237017290,NDC,1,EA,10.43,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,57237017290,NDC,1,EA,10.43,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,57237017290,NDC,1,EA,10.43,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,57237017290,NDC,1,EA,10.43,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,57237017290,NDC,1,EA,10.43,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,57237017290,NDC,1,EA,10.43,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714031101,NDC,1,EA,10.43,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714031101,NDC,1,EA,10.43,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714031101,NDC,1,EA,10.43,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714031101,NDC,1,EA,10.43,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714031101,NDC,1,EA,10.43,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714031101,NDC,1,EA,10.43,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57664039288,NDC,1,EA,10.43,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57664039288,NDC,1,EA,10.43,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57664039288,NDC,1,EA,10.43,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57664039288,NDC,1,EA,10.43,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57664039288,NDC,1,EA,10.43,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57664039288,NDC,1,EA,10.43,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 37.5 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084069811,NDC,1,EA,20.09,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 37.5 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084069811,NDC,1,EA,20.09,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 37.5 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084069811,NDC,1,EA,20.09,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 37.5 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084069811,NDC,1,EA,20.09,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 37.5 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084069811,NDC,1,EA,20.09,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 37.5 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084069811,NDC,1,EA,20.09,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 37.5 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084069801,NDC,1,EA,20.09,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 37.5 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084069801,NDC,1,EA,20.09,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 37.5 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084069801,NDC,1,EA,20.09,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 37.5 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084069801,NDC,1,EA,20.09,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 37.5 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084069801,NDC,1,EA,20.09,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 37.5 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084069801,NDC,1,EA,20.09,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714031401,NDC,0.333333333,EA,3.91,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714031401,NDC,0.333333333,EA,3.91,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714031401,NDC,0.333333333,EA,3.91,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714031401,NDC,0.333333333,EA,3.91,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714031401,NDC,0.333333333,EA,3.91,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714031401,NDC,0.333333333,EA,3.91,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714065801,NDC,0.333333333,EA,3.91,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714065801,NDC,0.333333333,EA,3.91,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714065801,NDC,0.333333333,EA,3.91,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714065801,NDC,0.333333333,EA,3.91,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714065801,NDC,0.333333333,EA,3.91,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714065801,NDC,0.333333333,EA,3.91,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57664039588,NDC,0.333333333,EA,3.91,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57664039588,NDC,0.333333333,EA,3.91,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57664039588,NDC,0.333333333,EA,3.91,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57664039588,NDC,0.333333333,EA,3.91,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57664039588,NDC,0.333333333,EA,3.91,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57664039588,NDC,0.333333333,EA,3.91,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 150 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084071311,NDC,0.25,EA,6.14,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 150 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084071311,NDC,0.25,EA,6.14,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 150 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084071311,NDC,0.25,EA,6.14,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 150 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084071311,NDC,0.25,EA,6.14,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 150 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084071311,NDC,0.25,EA,6.14,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 150 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084071311,NDC,0.25,EA,6.14,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 150 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862069730,NDC,0.25,EA,6.82,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 150 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862069730,NDC,0.25,EA,6.82,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 150 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862069730,NDC,0.25,EA,6.82,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 150 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862069730,NDC,0.25,EA,6.82,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 150 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862069730,NDC,0.25,EA,6.82,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 150 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862069730,NDC,0.25,EA,6.82,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Venous Duplex Scan Uni,PX9397101,CDM,921,RC,93971,CPT,TC,,,,,,,809,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Venous Duplex Scan Uni,PX9397101,CDM,921,RC,93971,CPT,TC,,,,,,,809,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Venous Duplex Scan Uni,PX9397101,CDM,921,RC,93971,CPT,TC,,,,,,,809,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Venous Duplex Scan Uni,PX9397101,CDM,921,RC,93971,CPT,TC,,,,,,,809,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Venous Duplex Scan Uni,PX9397101,CDM,921,RC,93971,CPT,TC,,,,,,,809,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Venous Duplex Scan Uni,PX9397101,CDM,921,RC,93971,CPT,TC,,,,,,,809,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ventilator Mgmt.Subsequent Days,PX94003F,CDM,410,RC,94003,CPT,,,,,,,,1686,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ventilator Mgmt.Subsequent Days,PX94003F,CDM,410,RC,94003,CPT,,,,,,,,1686,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ventilator Mgmt.Subsequent Days,PX94003F,CDM,410,RC,94003,CPT,,,,,,,,1686,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ventilator Mgmt.Subsequent Days,PX94003F,CDM,410,RC,94003,CPT,,,,,,,,1686,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ventilator Mgmt.Subsequent Days,PX94003F,CDM,410,RC,94003,CPT,,,,,,,,1686,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ventilator Mgmt.Subsequent Days,PX94003F,CDM,410,RC,94003,CPT,,,,,,,,1686,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"VENTRALIGHT MESH ST WITH ECHO 2 - 10 CM X 15 CM - 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,12007-MAIN,LOCAL,,,,,1176,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"VENTRALIGHT MESH ST WITH ECHO 2 - 10 CM X 15 CM - 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,12007-MAIN,LOCAL,,,,,1176,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"VENTRALIGHT MESH ST WITH ECHO 2 - 10 CM X 15 CM - 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,12007-MAIN,LOCAL,,,,,1176,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"VENTRALIGHT MESH ST WITH ECHO 2 - 10 CM X 15 CM - 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,12007-MAIN,LOCAL,,,,,1176,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"VENTRALIGHT MESH ST WITH ECHO 2 - 10 CM X 15 CM - 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,12007-MAIN,LOCAL,,,,,1176,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"VENTRALIGHT MESH ST WITH ECHO 2 - 10 CM X 15 CM - 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,12007-MAIN,LOCAL,,,,,1176,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"VENTRALIGHT MESH ST WITH ECHO 2 - 15 CM X 20 CM 6"" X 8""",C1781,CDM,278,RC,C1781,HCPCS,,12008-MAIN,LOCAL,,,,,3518,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"VENTRALIGHT MESH ST WITH ECHO 2 - 15 CM X 20 CM 6"" X 8""",C1781,CDM,278,RC,C1781,HCPCS,,12008-MAIN,LOCAL,,,,,3518,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"VENTRALIGHT MESH ST WITH ECHO 2 - 15 CM X 20 CM 6"" X 8""",C1781,CDM,278,RC,C1781,HCPCS,,12008-MAIN,LOCAL,,,,,3518,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"VENTRALIGHT MESH ST WITH ECHO 2 - 15 CM X 20 CM 6"" X 8""",C1781,CDM,278,RC,C1781,HCPCS,,12008-MAIN,LOCAL,,,,,3518,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"VENTRALIGHT MESH ST WITH ECHO 2 - 15 CM X 20 CM 6"" X 8""",C1781,CDM,278,RC,C1781,HCPCS,,12008-MAIN,LOCAL,,,,,3518,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"VENTRALIGHT MESH ST WITH ECHO 2 - 15 CM X 20 CM 6"" X 8""",C1781,CDM,278,RC,C1781,HCPCS,,12008-MAIN,LOCAL,,,,,3518,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"VENTRALIGHT MESH ST WITH ECHO 2 - 20 CM X 25 CM 8"" X 10""",C1781,CDM,278,RC,C1781,HCPCS,,12009-MAIN,LOCAL,,,,,5589,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"VENTRALIGHT MESH ST WITH ECHO 2 - 20 CM X 25 CM 8"" X 10""",C1781,CDM,278,RC,C1781,HCPCS,,12009-MAIN,LOCAL,,,,,5589,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"VENTRALIGHT MESH ST WITH ECHO 2 - 20 CM X 25 CM 8"" X 10""",C1781,CDM,278,RC,C1781,HCPCS,,12009-MAIN,LOCAL,,,,,5589,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"VENTRALIGHT MESH ST WITH ECHO 2 - 20 CM X 25 CM 8"" X 10""",C1781,CDM,278,RC,C1781,HCPCS,,12009-MAIN,LOCAL,,,,,5589,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"VENTRALIGHT MESH ST WITH ECHO 2 - 20 CM X 25 CM 8"" X 10""",C1781,CDM,278,RC,C1781,HCPCS,,12009-MAIN,LOCAL,,,,,5589,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"VENTRALIGHT MESH ST WITH ECHO 2 - 20 CM X 25 CM 8"" X 10""",C1781,CDM,278,RC,C1781,HCPCS,,12009-MAIN,LOCAL,,,,,5589,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING 8 IN CIRCLE,C1781,CDM,278,RC,C1781,HCPCS,,12506-MAIN,LOCAL,,,,,3240,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING 8 IN CIRCLE,C1781,CDM,278,RC,C1781,HCPCS,,12506-MAIN,LOCAL,,,,,3240,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING 8 IN CIRCLE,C1781,CDM,278,RC,C1781,HCPCS,,12506-MAIN,LOCAL,,,,,3240,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING 8 IN CIRCLE,C1781,CDM,278,RC,C1781,HCPCS,,12506-MAIN,LOCAL,,,,,3240,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING 8 IN CIRCLE,C1781,CDM,278,RC,C1781,HCPCS,,12506-MAIN,LOCAL,,,,,3240,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING 8 IN CIRCLE,C1781,CDM,278,RC,C1781,HCPCS,,12506-MAIN,LOCAL,,,,,3240,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING 8X10 ELLIPSE,C1781,CDM,278,RC,C1781,HCPCS,,12504-MAIN,LOCAL,,,,,5915,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING 8X10 ELLIPSE,C1781,CDM,278,RC,C1781,HCPCS,,12504-MAIN,LOCAL,,,,,5915,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING 8X10 ELLIPSE,C1781,CDM,278,RC,C1781,HCPCS,,12504-MAIN,LOCAL,,,,,5915,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING 8X10 ELLIPSE,C1781,CDM,278,RC,C1781,HCPCS,,12504-MAIN,LOCAL,,,,,5915,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING 8X10 ELLIPSE,C1781,CDM,278,RC,C1781,HCPCS,,12504-MAIN,LOCAL,,,,,5915,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING 8X10 ELLIPSE,C1781,CDM,278,RC,C1781,HCPCS,,12504-MAIN,LOCAL,,,,,5915,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING4X6,C1781,CDM,278,RC,C1781,HCPCS,,12505-MAIN,LOCAL,,,,,1860,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING4X6,C1781,CDM,278,RC,C1781,HCPCS,,12505-MAIN,LOCAL,,,,,1860,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING4X6,C1781,CDM,278,RC,C1781,HCPCS,,12505-MAIN,LOCAL,,,,,1860,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING4X6,C1781,CDM,278,RC,C1781,HCPCS,,12505-MAIN,LOCAL,,,,,1860,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING4X6,C1781,CDM,278,RC,C1781,HCPCS,,12505-MAIN,LOCAL,,,,,1860,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING4X6,C1781,CDM,278,RC,C1781,HCPCS,,12505-MAIN,LOCAL,,,,,1860,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
verapamil 2.5 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,409114405,NDC,2,ML,185.65,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
verapamil 2.5 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,409114405,NDC,2,ML,185.65,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
verapamil 2.5 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,409114405,NDC,2,ML,185.65,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
verapamil 2.5 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,409114405,NDC,2,ML,185.65,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
verapamil 2.5 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,409114405,NDC,2,ML,185.65,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
verapamil 2.5 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,409114405,NDC,2,ML,185.65,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
verapamil 2.5 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,51754020401,NDC,1,ML,112.01,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
verapamil 2.5 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,51754020401,NDC,1,ML,112.01,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
verapamil 2.5 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,51754020401,NDC,1,ML,112.01,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
verapamil 2.5 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,51754020401,NDC,1,ML,112.01,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
verapamil 2.5 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,51754020401,NDC,1,ML,112.01,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
verapamil 2.5 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,51754020401,NDC,1,ML,112.01,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
verapamil CR 120 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462029201,NDC,1,EA,5.76,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
verapamil CR 120 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462029201,NDC,1,EA,5.76,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
verapamil CR 120 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462029201,NDC,1,EA,5.76,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
verapamil CR 120 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462029201,NDC,1,EA,5.76,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
verapamil CR 120 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462029201,NDC,1,EA,5.76,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
verapamil CR 120 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462029201,NDC,1,EA,5.76,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
verapamil CR 180 MG Tablet Extended Release 100 Each Bottle,25000000,CDM,250,RC,,,,,,75834015801,NDC,0.666666667,EA,5.16,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
verapamil CR 180 MG Tablet Extended Release 100 Each Bottle,25000000,CDM,250,RC,,,,,,75834015801,NDC,0.666666667,EA,5.16,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
verapamil CR 180 MG Tablet Extended Release 100 Each Bottle,25000000,CDM,250,RC,,,,,,75834015801,NDC,0.666666667,EA,5.16,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
verapamil CR 180 MG Tablet Extended Release 100 Each Bottle,25000000,CDM,250,RC,,,,,,75834015801,NDC,0.666666667,EA,5.16,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
verapamil CR 180 MG Tablet Extended Release 100 Each Bottle,25000000,CDM,250,RC,,,,,,75834015801,NDC,0.666666667,EA,5.16,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
verapamil CR 180 MG Tablet Extended Release 100 Each Bottle,25000000,CDM,250,RC,,,,,,75834015801,NDC,0.666666667,EA,5.16,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
verapamil CR 240 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462026001,NDC,0.5,EA,4.39,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
verapamil CR 240 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462026001,NDC,0.5,EA,4.39,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
verapamil CR 240 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462026001,NDC,0.5,EA,4.39,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
verapamil CR 240 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462026001,NDC,0.5,EA,4.39,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
verapamil CR 240 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462026001,NDC,0.5,EA,4.39,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
verapamil CR 240 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462026001,NDC,0.5,EA,4.39,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vinCRIStine 1 MG/ML Solution 2 mL Vial,J9370.01,CDM,636,RC,J9370,HCPCS,,,,61703030916,NDC,2,ML,48.72,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vinCRIStine 1 MG/ML Solution 2 mL Vial,J9370.01,CDM,636,RC,J9370,HCPCS,,,,61703030916,NDC,2,ML,48.72,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vinCRIStine 1 MG/ML Solution 2 mL Vial,J9370.01,CDM,636,RC,J9370,HCPCS,,,,61703030916,NDC,2,ML,48.72,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vinCRIStine 1 MG/ML Solution 2 mL Vial,J9370.01,CDM,636,RC,J9370,HCPCS,,,,61703030916,NDC,2,ML,48.72,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vinCRIStine 1 MG/ML Solution 2 mL Vial,J9370.01,CDM,636,RC,J9370,HCPCS,,,,61703030916,NDC,2,ML,48.72,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vinCRIStine 1 MG/ML Solution 2 mL Vial,J9370.01,CDM,636,RC,J9370,HCPCS,,,,61703030916,NDC,2,ML,48.72,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Viral Neutralization - Ref,PX8638290,CDM,300,RC,86382,CPT,90,,,,,,,28,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Viral Neutralization - Ref,PX8638290,CDM,300,RC,86382,CPT,90,,,,,,,28,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Viral Neutralization - Ref,PX8638290,CDM,300,RC,86382,CPT,90,,,,,,,28,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Viral Neutralization - Ref,PX8638290,CDM,300,RC,86382,CPT,90,,,,,,,28,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Viral Neutralization - Ref,PX8638290,CDM,300,RC,86382,CPT,90,,,,,,,28,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Viral Neutralization - Ref,PX8638290,CDM,300,RC,86382,CPT,90,,,,,,,28,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
VISIGI3D 40FR STD WITH BULB,27100000,CDM,271,RC,,,,12812-MAIN,LOCAL,,,,,439,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
VISIGI3D 40FR STD WITH BULB,27100000,CDM,271,RC,,,,12812-MAIN,LOCAL,,,,,439,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
VISIGI3D 40FR STD WITH BULB,27100000,CDM,271,RC,,,,12812-MAIN,LOCAL,,,,,439,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
VISIGI3D 40FR STD WITH BULB,27100000,CDM,271,RC,,,,12812-MAIN,LOCAL,,,,,439,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
VISIGI3D 40FR STD WITH BULB,27100000,CDM,271,RC,,,,12812-MAIN,LOCAL,,,,,439,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
VISIGI3D 40FR STD WITH BULB,27100000,CDM,271,RC,,,,12812-MAIN,LOCAL,,,,,439,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
VISUALIZATION SYSTEM CLEARIFY LAPAROSCOPE STERILE,27200000,CDM,272,RC,,,,11875-MAIN,LOCAL,,,,,78,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
VISUALIZATION SYSTEM CLEARIFY LAPAROSCOPE STERILE,27200000,CDM,272,RC,,,,11875-MAIN,LOCAL,,,,,78,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
VISUALIZATION SYSTEM CLEARIFY LAPAROSCOPE STERILE,27200000,CDM,272,RC,,,,11875-MAIN,LOCAL,,,,,78,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
VISUALIZATION SYSTEM CLEARIFY LAPAROSCOPE STERILE,27200000,CDM,272,RC,,,,11875-MAIN,LOCAL,,,,,78,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
VISUALIZATION SYSTEM CLEARIFY LAPAROSCOPE STERILE,27200000,CDM,272,RC,,,,11875-MAIN,LOCAL,,,,,78,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
VISUALIZATION SYSTEM CLEARIFY LAPAROSCOPE STERILE,27200000,CDM,272,RC,,,,11875-MAIN,LOCAL,,,,,78,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Vit D 1 25-Dihydroxy,PX82652,CDM,300,RC,82652,CPT,,,,,,,,154,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Vit D 1 25-Dihydroxy,PX82652,CDM,300,RC,82652,CPT,,,,,,,,154,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Vit D 1 25-Dihydroxy,PX82652,CDM,300,RC,82652,CPT,,,,,,,,154,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Vit D 1 25-Dihydroxy,PX82652,CDM,300,RC,82652,CPT,,,,,,,,154,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Vit D 1 25-Dihydroxy,PX82652,CDM,300,RC,82652,CPT,,,,,,,,154,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Vit D 1 25-Dihydroxy,PX82652,CDM,300,RC,82652,CPT,,,,,,,,154,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Vitamin a - Ref,PX8459090,CDM,300,RC,84590,CPT,90,,,,,,,63,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Vitamin a - Ref,PX8459090,CDM,300,RC,84590,CPT,90,,,,,,,63,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Vitamin a - Ref,PX8459090,CDM,300,RC,84590,CPT,90,,,,,,,63,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Vitamin a - Ref,PX8459090,CDM,300,RC,84590,CPT,90,,,,,,,63,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Vitamin a - Ref,PX8459090,CDM,300,RC,84590,CPT,90,,,,,,,63,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Vitamin a - Ref,PX8459090,CDM,300,RC,84590,CPT,90,,,,,,,63,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Vitamin B-1 - Ref,PX8442590,CDM,300,RC,84425,CPT,90,,,,,,,130,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Vitamin B-1 - Ref,PX8442590,CDM,300,RC,84425,CPT,90,,,,,,,130,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Vitamin B-1 - Ref,PX8442590,CDM,300,RC,84425,CPT,90,,,,,,,130,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Vitamin B-1 - Ref,PX8442590,CDM,300,RC,84425,CPT,90,,,,,,,130,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Vitamin B-1 - Ref,PX8442590,CDM,300,RC,84425,CPT,90,,,,,,,130,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Vitamin B-1 - Ref,PX8442590,CDM,300,RC,84425,CPT,90,,,,,,,130,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Vitamin B-12,PX82607,CDM,300,RC,82607,CPT,,,,,,,,122,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Vitamin B-12,PX82607,CDM,300,RC,82607,CPT,,,,,,,,122,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Vitamin B-12,PX82607,CDM,300,RC,82607,CPT,,,,,,,,122,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Vitamin B-12,PX82607,CDM,300,RC,82607,CPT,,,,,,,,122,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Vitamin B-12,PX82607,CDM,300,RC,82607,CPT,,,,,,,,122,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Vitamin B-12,PX82607,CDM,300,RC,82607,CPT,,,,,,,,122,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536333401,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536333401,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536333401,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536333401,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536333401,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536333401,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904582461,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904582461,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904582461,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904582461,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904582461,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904582461,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,10006070033,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,10006070033,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,10006070033,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,10006070033,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,10006070033,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,10006070033,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,20555003300,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,20555003300,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,20555003300,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,20555003300,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,20555003300,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,20555003300,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Vitamin D, 25 Hydroxy",PX82306,CDM,300,RC,82306,CPT,,,,,,,,235,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Vitamin D, 25 Hydroxy",PX82306,CDM,300,RC,82306,CPT,,,,,,,,235,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Vitamin D, 25 Hydroxy",PX82306,CDM,300,RC,82306,CPT,,,,,,,,235,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Vitamin D, 25 Hydroxy",PX82306,CDM,300,RC,82306,CPT,,,,,,,,235,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Vitamin D, 25 Hydroxy",PX82306,CDM,300,RC,82306,CPT,,,,,,,,235,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Vitamin D, 25 Hydroxy",PX82306,CDM,300,RC,82306,CPT,,,,,,,,235,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,50111099001,NDC,1,EA,9.05,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,50111099001,NDC,1,EA,9.05,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,50111099001,NDC,1,EA,9.05,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,50111099001,NDC,1,EA,9.05,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,50111099001,NDC,1,EA,9.05,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,50111099001,NDC,1,EA,9.05,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,51991060401,NDC,1,EA,10.59,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,51991060401,NDC,1,EA,10.59,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,51991060401,NDC,1,EA,10.59,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,51991060401,NDC,1,EA,10.59,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,51991060401,NDC,1,EA,10.59,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,51991060401,NDC,1,EA,10.59,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,64380073706,NDC,1,EA,10.59,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,64380073706,NDC,1,EA,10.59,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,64380073706,NDC,1,EA,10.59,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,64380073706,NDC,1,EA,10.59,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,64380073706,NDC,1,EA,10.59,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,64380073706,NDC,1,EA,10.59,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,69452015120,NDC,1,EA,3.86,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,69452015120,NDC,1,EA,3.86,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,69452015120,NDC,1,EA,3.86,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,69452015120,NDC,1,EA,3.86,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,69452015120,NDC,1,EA,3.86,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,69452015120,NDC,1,EA,3.86,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Voriconazole - Ref,PX8028590,CDM,300,RC,80285,CPT,90,,,,,,,183,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Voriconazole - Ref,PX8028590,CDM,300,RC,80285,CPT,90,,,,,,,183,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Voriconazole - Ref,PX8028590,CDM,300,RC,80285,CPT,90,,,,,,,183,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Voriconazole - Ref,PX8028590,CDM,300,RC,80285,CPT,90,,,,,,,183,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Voriconazole - Ref,PX8028590,CDM,300,RC,80285,CPT,90,,,,,,,183,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Voriconazole - Ref,PX8028590,CDM,300,RC,80285,CPT,90,,,,,,,183,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56016901,NDC,1,EA,12.89,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56016901,NDC,1,EA,12.89,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56016901,NDC,1,EA,12.89,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56016901,NDC,1,EA,12.89,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56016901,NDC,1,EA,12.89,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56016901,NDC,1,EA,12.89,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56017001,NDC,1,EA,13.43,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56017001,NDC,1,EA,13.43,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56017001,NDC,1,EA,13.43,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56017001,NDC,1,EA,13.43,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56017001,NDC,1,EA,13.43,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56017001,NDC,1,EA,13.43,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121201,NDC,0.5,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121201,NDC,0.5,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121201,NDC,0.5,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121201,NDC,0.5,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121201,NDC,0.5,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121201,NDC,0.5,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 2.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56017601,NDC,1,EA,13.85,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 2.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56017601,NDC,1,EA,13.85,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 2.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56017601,NDC,1,EA,13.85,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 2.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56017601,NDC,1,EA,13.85,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 2.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56017601,NDC,1,EA,13.85,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 2.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56017601,NDC,1,EA,13.85,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121301,NDC,0.4,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121301,NDC,0.4,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121301,NDC,0.4,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121301,NDC,0.4,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121301,NDC,0.4,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121301,NDC,0.4,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 3 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,56018875,NDC,0.333333333,EA,4.79,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 3 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,56018875,NDC,0.333333333,EA,4.79,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 3 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,56018875,NDC,0.333333333,EA,4.79,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 3 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,56018875,NDC,0.333333333,EA,4.79,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 3 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,56018875,NDC,0.333333333,EA,4.79,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 3 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,56018875,NDC,0.333333333,EA,4.79,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 3 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121401,NDC,0.333333333,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 3 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121401,NDC,0.333333333,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 3 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121401,NDC,0.333333333,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 3 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121401,NDC,0.333333333,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 3 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121401,NDC,0.333333333,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 3 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121401,NDC,0.333333333,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 4 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56016801,NDC,1,EA,13.91,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 4 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56016801,NDC,1,EA,13.91,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 4 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56016801,NDC,1,EA,13.91,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 4 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56016801,NDC,1,EA,13.91,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 4 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56016801,NDC,1,EA,13.91,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 4 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56016801,NDC,1,EA,13.91,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 4 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,56016875,NDC,0.25,EA,3.6,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 4 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,56016875,NDC,0.25,EA,3.6,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 4 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,56016875,NDC,0.25,EA,3.6,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 4 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,56016875,NDC,0.25,EA,3.6,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 4 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,56016875,NDC,0.25,EA,3.6,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 4 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,56016875,NDC,0.25,EA,3.6,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,832121689,NDC,0.2,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,832121689,NDC,0.2,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,832121689,NDC,0.2,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,832121689,NDC,0.2,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,832121689,NDC,0.2,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,832121689,NDC,0.2,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121601,NDC,0.2,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121601,NDC,0.2,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121601,NDC,0.2,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121601,NDC,0.2,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121601,NDC,0.2,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121601,NDC,0.2,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"West Nile Ab, Igg - Ref",PX8678990,CDM,300,RC,86789,CPT,90,,,,,,,248,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"West Nile Ab, Igg - Ref",PX8678990,CDM,300,RC,86789,CPT,90,,,,,,,248,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"West Nile Ab, Igg - Ref",PX8678990,CDM,300,RC,86789,CPT,90,,,,,,,248,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"West Nile Ab, Igg - Ref",PX8678990,CDM,300,RC,86789,CPT,90,,,,,,,248,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"West Nile Ab, Igg - Ref",PX8678990,CDM,300,RC,86789,CPT,90,,,,,,,248,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"West Nile Ab, Igg - Ref",PX8678990,CDM,300,RC,86789,CPT,90,,,,,,,248,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"West Nile Ab, Igm - Ref",PX8678890,CDM,300,RC,86788,CPT,90,,,,,,,109,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"West Nile Ab, Igm - Ref",PX8678890,CDM,300,RC,86788,CPT,90,,,,,,,109,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"West Nile Ab, Igm - Ref",PX8678890,CDM,300,RC,86788,CPT,90,,,,,,,109,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"West Nile Ab, Igm - Ref",PX8678890,CDM,300,RC,86788,CPT,90,,,,,,,109,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"West Nile Ab, Igm - Ref",PX8678890,CDM,300,RC,86788,CPT,90,,,,,,,109,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"West Nile Ab, Igm - Ref",PX8678890,CDM,300,RC,86788,CPT,90,,,,,,,109,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Western Equine, Ab - Ref",PX8665490,CDM,300,RC,86654,CPT,90,,,,,,,45,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Western Equine, Ab - Ref",PX8665490,CDM,300,RC,86654,CPT,90,,,,,,,45,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Western Equine, Ab - Ref",PX8665490,CDM,300,RC,86654,CPT,90,,,,,,,45,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Western Equine, Ab - Ref",PX8665490,CDM,300,RC,86654,CPT,90,,,,,,,45,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Western Equine, Ab - Ref",PX8665490,CDM,300,RC,86654,CPT,90,,,,,,,45,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Western Equine, Ab - Ref",PX8665490,CDM,300,RC,86654,CPT,90,,,,,,,45,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Wheelchair Mngement Training,PX97542,CDM,420,RC,97542,CPT,,,,,,,,145,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Wheelchair Mngement Training,PX97542,CDM,420,RC,97542,CPT,,,,,,,,145,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Wheelchair Mngement Training,PX97542,CDM,420,RC,97542,CPT,,,,,,,,145,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Wheelchair Mngement Training,PX97542,CDM,420,RC,97542,CPT,,,,,,,,145,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Wheelchair Mngement Training,PX97542,CDM,420,RC,97542,CPT,,,,,,,,145,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Wheelchair Mngement Training,PX97542,CDM,420,RC,97542,CPT,,,,,,,,145,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
white petrolatum Gel 52.5 g Jar,63700001,CDM,250,RC,,,,,,521231100,NDC,52.5,GR,13.5,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
white petrolatum Gel 52.5 g Jar,63700001,CDM,250,RC,,,,,,521231100,NDC,52.5,GR,13.5,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
white petrolatum Gel 52.5 g Jar,63700001,CDM,250,RC,,,,,,521231100,NDC,52.5,GR,13.5,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
white petrolatum Gel 52.5 g Jar,63700001,CDM,250,RC,,,,,,521231100,NDC,52.5,GR,13.5,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
white petrolatum Gel 52.5 g Jar,63700001,CDM,250,RC,,,,,,521231100,NDC,52.5,GR,13.5,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
white petrolatum Gel 52.5 g Jar,63700001,CDM,250,RC,,,,,,521231100,NDC,52.5,GR,13.5,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Withdrawal of Arterial Blood,PX36600F,CDM,510,RC,36600,CPT,,,,,,,,250,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Withdrawal of Arterial Blood,PX36600F,CDM,510,RC,36600,CPT,,,,,,,,250,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Withdrawal of Arterial Blood,PX36600F,CDM,510,RC,36600,CPT,,,,,,,,250,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Withdrawal of Arterial Blood,PX36600F,CDM,510,RC,36600,CPT,,,,,,,,250,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Withdrawal of Arterial Blood,PX36600F,CDM,510,RC,36600,CPT,,,,,,,,250,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Withdrawal of Arterial Blood,PX36600F,CDM,510,RC,36600,CPT,,,,,,,,250,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Wound Cult/Afb,PX87116,CDM,300,RC,87116,CPT,,,,,,,,167,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Wound Cult/Afb,PX87116,CDM,300,RC,87116,CPT,,,,,,,,167,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Wound Cult/Afb,PX87116,CDM,300,RC,87116,CPT,,,,,,,,167,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Wound Cult/Afb,PX87116,CDM,300,RC,87116,CPT,,,,,,,,167,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Wound Cult/Afb,PX87116,CDM,300,RC,87116,CPT,,,,,,,,167,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Wound Cult/Afb,PX87116,CDM,300,RC,87116,CPT,,,,,,,,167,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Wound Culture Anaerobic,PX87075,CDM,300,RC,87075,CPT,,,,,,,,270,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Wound Culture Anaerobic,PX87075,CDM,300,RC,87075,CPT,,,,,,,,270,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Wound Culture Anaerobic,PX87075,CDM,300,RC,87075,CPT,,,,,,,,270,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Wound Culture Anaerobic,PX87075,CDM,300,RC,87075,CPT,,,,,,,,270,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Wound Culture Anaerobic,PX87075,CDM,300,RC,87075,CPT,,,,,,,,270,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Wound Culture Anaerobic,PX87075,CDM,300,RC,87075,CPT,,,,,,,,270,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
WOUND DRAIN FLAT WITH TROCAR 10MM FULL PERFORATED SILICONE,27200000,CDM,272,RC,,,,12462-MAIN,LOCAL,,,,,32,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
WOUND DRAIN FLAT WITH TROCAR 10MM FULL PERFORATED SILICONE,27200000,CDM,272,RC,,,,12462-MAIN,LOCAL,,,,,32,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
WOUND DRAIN FLAT WITH TROCAR 10MM FULL PERFORATED SILICONE,27200000,CDM,272,RC,,,,12462-MAIN,LOCAL,,,,,32,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
WOUND DRAIN FLAT WITH TROCAR 10MM FULL PERFORATED SILICONE,27200000,CDM,272,RC,,,,12462-MAIN,LOCAL,,,,,32,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
WOUND DRAIN FLAT WITH TROCAR 10MM FULL PERFORATED SILICONE,27200000,CDM,272,RC,,,,12462-MAIN,LOCAL,,,,,32,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
WOUND DRAIN FLAT WITH TROCAR 10MM FULL PERFORATED SILICONE,27200000,CDM,272,RC,,,,12462-MAIN,LOCAL,,,,,32,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Abdomen 2+ Views W/ Single Vw Chest (Tc),PX7402201,CDM,320,RC,74022,CPT,TC,,,,,,,334,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Abdomen 2+ Views W/ Single Vw Chest (Tc),PX7402201,CDM,320,RC,74022,CPT,TC,,,,,,,334,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Abdomen 2+ Views W/ Single Vw Chest (Tc),PX7402201,CDM,320,RC,74022,CPT,TC,,,,,,,334,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Abdomen 2+ Views W/ Single Vw Chest (Tc),PX7402201,CDM,320,RC,74022,CPT,TC,,,,,,,334,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Abdomen 2+ Views W/ Single Vw Chest (Tc),PX7402201,CDM,320,RC,74022,CPT,TC,,,,,,,334,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Abdomen 2+ Views W/ Single Vw Chest (Tc),PX7402201,CDM,320,RC,74022,CPT,TC,,,,,,,334,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Abdomen 1 View,PX7401801,CDM,320,RC,74018,CPT,TC,,,,,,,358,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Abdomen 1 View,PX7401801,CDM,320,RC,74018,CPT,TC,,,,,,,358,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Abdomen 1 View,PX7401801,CDM,320,RC,74018,CPT,TC,,,,,,,358,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Abdomen 1 View,PX7401801,CDM,320,RC,74018,CPT,TC,,,,,,,358,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Abdomen 1 View,PX7401801,CDM,320,RC,74018,CPT,TC,,,,,,,358,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Abdomen 1 View,PX7401801,CDM,320,RC,74018,CPT,TC,,,,,,,358,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Abdomen 2 Views,PX7401901,CDM,320,RC,74019,CPT,TC,,,,,,,436,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Abdomen 2 Views,PX7401901,CDM,320,RC,74019,CPT,TC,,,,,,,436,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Abdomen 2 Views,PX7401901,CDM,320,RC,74019,CPT,TC,,,,,,,436,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Abdomen 2 Views,PX7401901,CDM,320,RC,74019,CPT,TC,,,,,,,436,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Abdomen 2 Views,PX7401901,CDM,320,RC,74019,CPT,TC,,,,,,,436,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Abdomen 2 Views,PX7401901,CDM,320,RC,74019,CPT,TC,,,,,,,436,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Chest 1 View,PX7104501,CDM,320,RC,71045,CPT,TC,,,,,,,357,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Chest 1 View,PX7104501,CDM,320,RC,71045,CPT,TC,,,,,,,357,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Chest 1 View,PX7104501,CDM,320,RC,71045,CPT,TC,,,,,,,357,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Chest 1 View,PX7104501,CDM,320,RC,71045,CPT,TC,,,,,,,357,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Chest 1 View,PX7104501,CDM,320,RC,71045,CPT,TC,,,,,,,357,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Chest 1 View,PX7104501,CDM,320,RC,71045,CPT,TC,,,,,,,357,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Chest 2 Views,PX7104601,CDM,320,RC,71046,CPT,TC,,,,,,,556,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Chest 2 Views,PX7104601,CDM,320,RC,71046,CPT,TC,,,,,,,556,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Chest 2 Views,PX7104601,CDM,320,RC,71046,CPT,TC,,,,,,,556,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Chest 2 Views,PX7104601,CDM,320,RC,71046,CPT,TC,,,,,,,556,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Chest 2 Views,PX7104601,CDM,320,RC,71046,CPT,TC,,,,,,,556,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Chest 2 Views,PX7104601,CDM,320,RC,71046,CPT,TC,,,,,,,556,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Chest 3 Views,PX7104701,CDM,320,RC,71047,CPT,TC,,,,,,,340,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Chest 3 Views,PX7104701,CDM,320,RC,71047,CPT,TC,,,,,,,340,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Chest 3 Views,PX7104701,CDM,320,RC,71047,CPT,TC,,,,,,,340,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Chest 3 Views,PX7104701,CDM,320,RC,71047,CPT,TC,,,,,,,340,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Chest 3 Views,PX7104701,CDM,320,RC,71047,CPT,TC,,,,,,,340,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Chest 3 Views,PX7104701,CDM,320,RC,71047,CPT,TC,,,,,,,340,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Entire Spine 1vw,PX7208101,CDM,320,RC,72081,CPT,TC,,,,,,,414,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Entire Spine 1vw,PX7208101,CDM,320,RC,72081,CPT,TC,,,,,,,414,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Entire Spine 1vw,PX7208101,CDM,320,RC,72081,CPT,TC,,,,,,,414,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Entire Spine 1vw,PX7208101,CDM,320,RC,72081,CPT,TC,,,,,,,414,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Entire Spine 1vw,PX7208101,CDM,320,RC,72081,CPT,TC,,,,,,,414,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Entire Spine 1vw,PX7208101,CDM,320,RC,72081,CPT,TC,,,,,,,414,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Entire Spine 2-3 Vws,PX7208201,CDM,320,RC,72082,CPT,TC,,,,,,,454,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Entire Spine 2-3 Vws,PX7208201,CDM,320,RC,72082,CPT,TC,,,,,,,454,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Entire Spine 2-3 Vws,PX7208201,CDM,320,RC,72082,CPT,TC,,,,,,,454,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Entire Spine 2-3 Vws,PX7208201,CDM,320,RC,72082,CPT,TC,,,,,,,454,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Entire Spine 2-3 Vws,PX7208201,CDM,320,RC,72082,CPT,TC,,,,,,,454,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Entire Spine 2-3 Vws,PX7208201,CDM,320,RC,72082,CPT,TC,,,,,,,454,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Femur 1 Vw,PX7355101,CDM,320,RC,73551,CPT,TC,,,,,,,142,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Femur 1 Vw,PX7355101,CDM,320,RC,73551,CPT,TC,,,,,,,142,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Femur 1 Vw,PX7355101,CDM,320,RC,73551,CPT,TC,,,,,,,142,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Femur 1 Vw,PX7355101,CDM,320,RC,73551,CPT,TC,,,,,,,142,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Femur 1 Vw,PX7355101,CDM,320,RC,73551,CPT,TC,,,,,,,142,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Femur 1 Vw,PX7355101,CDM,320,RC,73551,CPT,TC,,,,,,,142,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Femur Min 2 Vws,PX7355201,CDM,320,RC,73552,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Femur Min 2 Vws,PX7355201,CDM,320,RC,73552,CPT,TC,,,,,,,365,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Femur Min 2 Vws,PX7355201,CDM,320,RC,73552,CPT,TC,,,,,,,365,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Femur Min 2 Vws,PX7355201,CDM,320,RC,73552,CPT,TC,,,,,,,365,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Femur Min 2 Vws,PX7355201,CDM,320,RC,73552,CPT,TC,,,,,,,365,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Femur Min 2 Vws,PX7355201,CDM,320,RC,73552,CPT,TC,,,,,,,365,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"X-Ray Exam Hip,Bilat W/Pelvis 2 Vws",PX7352101,CDM,320,RC,73521,CPT,TC,,,,,,,399,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"X-Ray Exam Hip,Bilat W/Pelvis 2 Vws",PX7352101,CDM,320,RC,73521,CPT,TC,,,,,,,399,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"X-Ray Exam Hip,Bilat W/Pelvis 2 Vws",PX7352101,CDM,320,RC,73521,CPT,TC,,,,,,,399,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"X-Ray Exam Hip,Bilat W/Pelvis 2 Vws",PX7352101,CDM,320,RC,73521,CPT,TC,,,,,,,399,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"X-Ray Exam Hip,Bilat W/Pelvis 2 Vws",PX7352101,CDM,320,RC,73521,CPT,TC,,,,,,,399,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"X-Ray Exam Hip,Bilat W/Pelvis 2 Vws",PX7352101,CDM,320,RC,73521,CPT,TC,,,,,,,399,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"X-Ray Exam Hip,Bilat W/Pelvis 3-4 Vws",PX7352201,CDM,320,RC,73522,CPT,TC,,,,,,,382,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"X-Ray Exam Hip,Bilat W/Pelvis 3-4 Vws",PX7352201,CDM,320,RC,73522,CPT,TC,,,,,,,382,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"X-Ray Exam Hip,Bilat W/Pelvis 3-4 Vws",PX7352201,CDM,320,RC,73522,CPT,TC,,,,,,,382,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"X-Ray Exam Hip,Bilat W/Pelvis 3-4 Vws",PX7352201,CDM,320,RC,73522,CPT,TC,,,,,,,382,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"X-Ray Exam Hip,Bilat W/Pelvis 3-4 Vws",PX7352201,CDM,320,RC,73522,CPT,TC,,,,,,,382,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"X-Ray Exam Hip,Bilat W/Pelvis 3-4 Vws",PX7352201,CDM,320,RC,73522,CPT,TC,,,,,,,382,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"X-Ray Exam Hip,Unilat W/Pelvis 1vw",PX7350101,CDM,320,RC,73501,CPT,TC,,,,,,,263,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"X-Ray Exam Hip,Unilat W/Pelvis 1vw",PX7350101,CDM,320,RC,73501,CPT,TC,,,,,,,263,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"X-Ray Exam Hip,Unilat W/Pelvis 1vw",PX7350101,CDM,320,RC,73501,CPT,TC,,,,,,,263,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"X-Ray Exam Hip,Unilat W/Pelvis 1vw",PX7350101,CDM,320,RC,73501,CPT,TC,,,,,,,263,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"X-Ray Exam Hip,Unilat W/Pelvis 1vw",PX7350101,CDM,320,RC,73501,CPT,TC,,,,,,,263,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"X-Ray Exam Hip,Unilat W/Pelvis 1vw",PX7350101,CDM,320,RC,73501,CPT,TC,,,,,,,263,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"X-Ray Exam Hip,Unilat W/Pelvis 2-3 Vws",PX7350201,CDM,320,RC,73502,CPT,TC,,,,,,,436,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"X-Ray Exam Hip,Unilat W/Pelvis 2-3 Vws",PX7350201,CDM,320,RC,73502,CPT,TC,,,,,,,436,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"X-Ray Exam Hip,Unilat W/Pelvis 2-3 Vws",PX7350201,CDM,320,RC,73502,CPT,TC,,,,,,,436,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"X-Ray Exam Hip,Unilat W/Pelvis 2-3 Vws",PX7350201,CDM,320,RC,73502,CPT,TC,,,,,,,436,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"X-Ray Exam Hip,Unilat W/Pelvis 2-3 Vws",PX7350201,CDM,320,RC,73502,CPT,TC,,,,,,,436,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"X-Ray Exam Hip,Unilat W/Pelvis 2-3 Vws",PX7350201,CDM,320,RC,73502,CPT,TC,,,,,,,436,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
XEROFORM GAUZE PETROLATUM 1X8INCH,27200000,CDM,272,RC,A6222,HCPCS,,10659-MAIN,LOCAL,,,,,3.52,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
XEROFORM GAUZE PETROLATUM 1X8INCH,27200000,CDM,272,RC,A6222,HCPCS,,10659-MAIN,LOCAL,,,,,3.52,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
XEROFORM GAUZE PETROLATUM 1X8INCH,27200000,CDM,272,RC,A6222,HCPCS,,10659-MAIN,LOCAL,,,,,3.52,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
XEROFORM GAUZE PETROLATUM 1X8INCH,27200000,CDM,272,RC,A6222,HCPCS,,10659-MAIN,LOCAL,,,,,3.52,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
XEROFORM GAUZE PETROLATUM 1X8INCH,27200000,CDM,272,RC,A6222,HCPCS,,10659-MAIN,LOCAL,,,,,3.52,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
XEROFORM GAUZE PETROLATUM 1X8INCH,27200000,CDM,272,RC,A6222,HCPCS,,10659-MAIN,LOCAL,,,,,3.52,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Abdomen Comp Incl Decub and/or Erect,PX7402001,CDM,320,RC,74020,CPT,TC,,,,,,,436,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Abdomen Comp Incl Decub and/or Erect,PX7402001,CDM,320,RC,74020,CPT,TC,,,,,,,436,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Abdomen Comp Incl Decub and/or Erect,PX7402001,CDM,320,RC,74020,CPT,TC,,,,,,,436,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Abdomen Comp Incl Decub and/or Erect,PX7402001,CDM,320,RC,74020,CPT,TC,,,,,,,436,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Abdomen Comp Incl Decub and/or Erect,PX7402001,CDM,320,RC,74020,CPT,TC,,,,,,,436,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Abdomen Comp Incl Decub and/or Erect,PX7402001,CDM,320,RC,74020,CPT,TC,,,,,,,436,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Abdomen Single Ap Vw,PX7400001,CDM,320,RC,74000,CPT,TC,,,,,,,358,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Abdomen Single Ap Vw,PX7400001,CDM,320,RC,74000,CPT,TC,,,,,,,358,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Abdomen Single Ap Vw,PX7400001,CDM,320,RC,74000,CPT,TC,,,,,,,358,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Abdomen Single Ap Vw,PX7400001,CDM,320,RC,74000,CPT,TC,,,,,,,358,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Abdomen Single Ap Vw,PX7400001,CDM,320,RC,74000,CPT,TC,,,,,,,358,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Abdomen Single Ap Vw,PX7400001,CDM,320,RC,74000,CPT,TC,,,,,,,358,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ac Joints(Bilateral),PX7305001,CDM,320,RC,73050,CPT,TC,,,,,,,519,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ac Joints(Bilateral),PX7305001,CDM,320,RC,73050,CPT,TC,,,,,,,519,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ac Joints(Bilateral),PX7305001,CDM,320,RC,73050,CPT,TC,,,,,,,519,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ac Joints(Bilateral),PX7305001,CDM,320,RC,73050,CPT,TC,,,,,,,519,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ac Joints(Bilateral),PX7305001,CDM,320,RC,73050,CPT,TC,,,,,,,519,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ac Joints(Bilateral),PX7305001,CDM,320,RC,73050,CPT,TC,,,,,,,519,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ankle 2 Vws,PX7360001,CDM,320,RC,73600,CPT,TC,,,,,,,163,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ankle 2 Vws,PX7360001,CDM,320,RC,73600,CPT,TC,,,,,,,163,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ankle 2 Vws,PX7360001,CDM,320,RC,73600,CPT,TC,,,,,,,163,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ankle 2 Vws,PX7360001,CDM,320,RC,73600,CPT,TC,,,,,,,163,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ankle 2 Vws,PX7360001,CDM,320,RC,73600,CPT,TC,,,,,,,163,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ankle 2 Vws,PX7360001,CDM,320,RC,73600,CPT,TC,,,,,,,163,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ankle Minimum 3 Vws,PX7361001,CDM,320,RC,73610,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ankle Minimum 3 Vws,PX7361001,CDM,320,RC,73610,CPT,TC,,,,,,,365,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ankle Minimum 3 Vws,PX7361001,CDM,320,RC,73610,CPT,TC,,,,,,,365,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ankle Minimum 3 Vws,PX7361001,CDM,320,RC,73610,CPT,TC,,,,,,,365,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ankle Minimum 3 Vws,PX7361001,CDM,320,RC,73610,CPT,TC,,,,,,,365,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ankle Minimum 3 Vws,PX7361001,CDM,320,RC,73610,CPT,TC,,,,,,,365,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Calcaneus Minimum 2 Vws,PX7365001,CDM,320,RC,73650,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Calcaneus Minimum 2 Vws,PX7365001,CDM,320,RC,73650,CPT,TC,,,,,,,365,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Calcaneus Minimum 2 Vws,PX7365001,CDM,320,RC,73650,CPT,TC,,,,,,,365,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Calcaneus Minimum 2 Vws,PX7365001,CDM,320,RC,73650,CPT,TC,,,,,,,365,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Calcaneus Minimum 2 Vws,PX7365001,CDM,320,RC,73650,CPT,TC,,,,,,,365,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Calcaneus Minimum 2 Vws,PX7365001,CDM,320,RC,73650,CPT,TC,,,,,,,365,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Cervical Spine 2 or 3 Vws,PX7204001,CDM,320,RC,72040,CPT,TC,,,,,,,436,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Cervical Spine 2 or 3 Vws,PX7204001,CDM,320,RC,72040,CPT,TC,,,,,,,436,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Cervical Spine 2 or 3 Vws,PX7204001,CDM,320,RC,72040,CPT,TC,,,,,,,436,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Cervical Spine 2 or 3 Vws,PX7204001,CDM,320,RC,72040,CPT,TC,,,,,,,436,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Cervical Spine 2 or 3 Vws,PX7204001,CDM,320,RC,72040,CPT,TC,,,,,,,436,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Cervical Spine 2 or 3 Vws,PX7204001,CDM,320,RC,72040,CPT,TC,,,,,,,436,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Cervical Spine 4 or 5 Vws,PX7205001,CDM,320,RC,72050,CPT,TC,,,,,,,664,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Cervical Spine 4 or 5 Vws,PX7205001,CDM,320,RC,72050,CPT,TC,,,,,,,664,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Cervical Spine 4 or 5 Vws,PX7205001,CDM,320,RC,72050,CPT,TC,,,,,,,664,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Cervical Spine 4 or 5 Vws,PX7205001,CDM,320,RC,72050,CPT,TC,,,,,,,664,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Cervical Spine 4 or 5 Vws,PX7205001,CDM,320,RC,72050,CPT,TC,,,,,,,664,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Cervical Spine 4 or 5 Vws,PX7205001,CDM,320,RC,72050,CPT,TC,,,,,,,664,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Cervical Spine 6 or More Vws,PX7205201,CDM,320,RC,72052,CPT,TC,,,,,,,664,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Cervical Spine 6 or More Vws,PX7205201,CDM,320,RC,72052,CPT,TC,,,,,,,664,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Cervical Spine 6 or More Vws,PX7205201,CDM,320,RC,72052,CPT,TC,,,,,,,664,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Cervical Spine 6 or More Vws,PX7205201,CDM,320,RC,72052,CPT,TC,,,,,,,664,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Cervical Spine 6 or More Vws,PX7205201,CDM,320,RC,72052,CPT,TC,,,,,,,664,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Cervical Spine 6 or More Vws,PX7205201,CDM,320,RC,72052,CPT,TC,,,,,,,664,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Xray Chest 1 View, Tc",PX7101001,CDM,320,RC,71010,CPT,TC,,,,,,,357,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Xray Chest 1 View, Tc",PX7101001,CDM,320,RC,71010,CPT,TC,,,,,,,357,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Xray Chest 1 View, Tc",PX7101001,CDM,320,RC,71010,CPT,TC,,,,,,,357,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Xray Chest 1 View, Tc",PX7101001,CDM,320,RC,71010,CPT,TC,,,,,,,357,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Xray Chest 1 View, Tc",PX7101001,CDM,320,RC,71010,CPT,TC,,,,,,,357,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Xray Chest 1 View, Tc",PX7101001,CDM,320,RC,71010,CPT,TC,,,,,,,357,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Chest 2 Views,PX7102001,CDM,320,RC,71020,CPT,TC,,,,,,,556,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Chest 2 Views,PX7102001,CDM,320,RC,71020,CPT,TC,,,,,,,556,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Chest 2 Views,PX7102001,CDM,320,RC,71020,CPT,TC,,,,,,,556,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Chest 2 Views,PX7102001,CDM,320,RC,71020,CPT,TC,,,,,,,556,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Chest 2 Views,PX7102001,CDM,320,RC,71020,CPT,TC,,,,,,,556,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Chest 2 Views,PX7102001,CDM,320,RC,71020,CPT,TC,,,,,,,556,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Clavicle Complete,PX7300001,CDM,320,RC,73000,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Clavicle Complete,PX7300001,CDM,320,RC,73000,CPT,TC,,,,,,,365,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Clavicle Complete,PX7300001,CDM,320,RC,73000,CPT,TC,,,,,,,365,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Clavicle Complete,PX7300001,CDM,320,RC,73000,CPT,TC,,,,,,,365,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Clavicle Complete,PX7300001,CDM,320,RC,73000,CPT,TC,,,,,,,365,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Clavicle Complete,PX7300001,CDM,320,RC,73000,CPT,TC,,,,,,,365,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Elbow 2 Vws,PX7307001,CDM,320,RC,73070,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Elbow 2 Vws,PX7307001,CDM,320,RC,73070,CPT,TC,,,,,,,365,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Elbow 2 Vws,PX7307001,CDM,320,RC,73070,CPT,TC,,,,,,,365,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Elbow 2 Vws,PX7307001,CDM,320,RC,73070,CPT,TC,,,,,,,365,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Elbow 2 Vws,PX7307001,CDM,320,RC,73070,CPT,TC,,,,,,,365,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Elbow 2 Vws,PX7307001,CDM,320,RC,73070,CPT,TC,,,,,,,365,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Elbow 3+Vws Tc,PX7308001,CDM,320,RC,73080,CPT,TC,,,,,,,370,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Elbow 3+Vws Tc,PX7308001,CDM,320,RC,73080,CPT,TC,,,,,,,370,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Elbow 3+Vws Tc,PX7308001,CDM,320,RC,73080,CPT,TC,,,,,,,370,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Elbow 3+Vws Tc,PX7308001,CDM,320,RC,73080,CPT,TC,,,,,,,370,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Elbow 3+Vws Tc,PX7308001,CDM,320,RC,73080,CPT,TC,,,,,,,370,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Elbow 3+Vws Tc,PX7308001,CDM,320,RC,73080,CPT,TC,,,,,,,370,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Eye Foreign Body,PX7003001,CDM,320,RC,70030,CPT,TC,,,,,,,432,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Eye Foreign Body,PX7003001,CDM,320,RC,70030,CPT,TC,,,,,,,432,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Eye Foreign Body,PX7003001,CDM,320,RC,70030,CPT,TC,,,,,,,432,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Eye Foreign Body,PX7003001,CDM,320,RC,70030,CPT,TC,,,,,,,432,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Eye Foreign Body,PX7003001,CDM,320,RC,70030,CPT,TC,,,,,,,432,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Eye Foreign Body,PX7003001,CDM,320,RC,70030,CPT,TC,,,,,,,432,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Facial Bones Less Than 3 Vws,PX7014001,CDM,320,RC,70140,CPT,TC,,,,,,,301,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Facial Bones Less Than 3 Vws,PX7014001,CDM,320,RC,70140,CPT,TC,,,,,,,301,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Facial Bones Less Than 3 Vws,PX7014001,CDM,320,RC,70140,CPT,TC,,,,,,,301,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Facial Bones Less Than 3 Vws,PX7014001,CDM,320,RC,70140,CPT,TC,,,,,,,301,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Facial Bones Less Than 3 Vws,PX7014001,CDM,320,RC,70140,CPT,TC,,,,,,,301,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Facial Bones Less Than 3 Vws,PX7014001,CDM,320,RC,70140,CPT,TC,,,,,,,301,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Facial Bones Minimum 3 Vws,PX7015001,CDM,320,RC,70150,CPT,TC,,,,,,,551,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Facial Bones Minimum 3 Vws,PX7015001,CDM,320,RC,70150,CPT,TC,,,,,,,551,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Facial Bones Minimum 3 Vws,PX7015001,CDM,320,RC,70150,CPT,TC,,,,,,,551,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Facial Bones Minimum 3 Vws,PX7015001,CDM,320,RC,70150,CPT,TC,,,,,,,551,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Facial Bones Minimum 3 Vws,PX7015001,CDM,320,RC,70150,CPT,TC,,,,,,,551,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Facial Bones Minimum 3 Vws,PX7015001,CDM,320,RC,70150,CPT,TC,,,,,,,551,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Finger(S) Tc,PX7314001,CDM,320,RC,73140,CPT,TC,,,,,,,282,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Finger(S) Tc,PX7314001,CDM,320,RC,73140,CPT,TC,,,,,,,282,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Finger(S) Tc,PX7314001,CDM,320,RC,73140,CPT,TC,,,,,,,282,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Finger(S) Tc,PX7314001,CDM,320,RC,73140,CPT,TC,,,,,,,282,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Finger(S) Tc,PX7314001,CDM,320,RC,73140,CPT,TC,,,,,,,282,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Finger(S) Tc,PX7314001,CDM,320,RC,73140,CPT,TC,,,,,,,282,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Foot 2 Vws,PX7362001,CDM,320,RC,73620,CPT,TC,,,,,,,367,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Foot 2 Vws,PX7362001,CDM,320,RC,73620,CPT,TC,,,,,,,367,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Foot 2 Vws,PX7362001,CDM,320,RC,73620,CPT,TC,,,,,,,367,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Foot 2 Vws,PX7362001,CDM,320,RC,73620,CPT,TC,,,,,,,367,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Foot 2 Vws,PX7362001,CDM,320,RC,73620,CPT,TC,,,,,,,367,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Foot 2 Vws,PX7362001,CDM,320,RC,73620,CPT,TC,,,,,,,367,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Foot Minimum 3 Vws,PX7363001,CDM,320,RC,73630,CPT,TC,,,,,,,404,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Foot Minimum 3 Vws,PX7363001,CDM,320,RC,73630,CPT,TC,,,,,,,404,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Foot Minimum 3 Vws,PX7363001,CDM,320,RC,73630,CPT,TC,,,,,,,404,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Foot Minimum 3 Vws,PX7363001,CDM,320,RC,73630,CPT,TC,,,,,,,404,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Foot Minimum 3 Vws,PX7363001,CDM,320,RC,73630,CPT,TC,,,,,,,404,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Foot Minimum 3 Vws,PX7363001,CDM,320,RC,73630,CPT,TC,,,,,,,404,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Forearm 2 Vws,PX7309001,CDM,320,RC,73090,CPT,TC,,,,,,,364,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Forearm 2 Vws,PX7309001,CDM,320,RC,73090,CPT,TC,,,,,,,364,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Forearm 2 Vws,PX7309001,CDM,320,RC,73090,CPT,TC,,,,,,,364,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Forearm 2 Vws,PX7309001,CDM,320,RC,73090,CPT,TC,,,,,,,364,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Forearm 2 Vws,PX7309001,CDM,320,RC,73090,CPT,TC,,,,,,,364,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Forearm 2 Vws,PX7309001,CDM,320,RC,73090,CPT,TC,,,,,,,364,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Hand 2vws Tc,PX7312001,CDM,320,RC,73120,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Hand 2vws Tc,PX7312001,CDM,320,RC,73120,CPT,TC,,,,,,,365,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Hand 2vws Tc,PX7312001,CDM,320,RC,73120,CPT,TC,,,,,,,365,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Hand 2vws Tc,PX7312001,CDM,320,RC,73120,CPT,TC,,,,,,,365,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Hand 2vws Tc,PX7312001,CDM,320,RC,73120,CPT,TC,,,,,,,365,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Hand 2vws Tc,PX7312001,CDM,320,RC,73120,CPT,TC,,,,,,,365,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Hand 3vws Tc,PX7313001,CDM,320,RC,73130,CPT,TC,,,,,,,374,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Hand 3vws Tc,PX7313001,CDM,320,RC,73130,CPT,TC,,,,,,,374,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Hand 3vws Tc,PX7313001,CDM,320,RC,73130,CPT,TC,,,,,,,374,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Hand 3vws Tc,PX7313001,CDM,320,RC,73130,CPT,TC,,,,,,,374,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Hand 3vws Tc,PX7313001,CDM,320,RC,73130,CPT,TC,,,,,,,374,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Hand 3vws Tc,PX7313001,CDM,320,RC,73130,CPT,TC,,,,,,,374,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Humerus Minimum 2 Vws,PX7306001,CDM,320,RC,73060,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Humerus Minimum 2 Vws,PX7306001,CDM,320,RC,73060,CPT,TC,,,,,,,365,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Humerus Minimum 2 Vws,PX7306001,CDM,320,RC,73060,CPT,TC,,,,,,,365,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Humerus Minimum 2 Vws,PX7306001,CDM,320,RC,73060,CPT,TC,,,,,,,365,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Humerus Minimum 2 Vws,PX7306001,CDM,320,RC,73060,CPT,TC,,,,,,,365,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Humerus Minimum 2 Vws,PX7306001,CDM,320,RC,73060,CPT,TC,,,,,,,365,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Knee (Both) Ap Stand,PX7356501,CDM,320,RC,73565,CPT,TC,,,,,,,543,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Knee (Both) Ap Stand,PX7356501,CDM,320,RC,73565,CPT,TC,,,,,,,543,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Knee (Both) Ap Stand,PX7356501,CDM,320,RC,73565,CPT,TC,,,,,,,543,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Knee (Both) Ap Stand,PX7356501,CDM,320,RC,73565,CPT,TC,,,,,,,543,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Knee (Both) Ap Stand,PX7356501,CDM,320,RC,73565,CPT,TC,,,,,,,543,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Knee (Both) Ap Stand,PX7356501,CDM,320,RC,73565,CPT,TC,,,,,,,543,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Knee 1 or 2 Vws,PX7356001,CDM,320,RC,73560,CPT,TC,,,,,,,303,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Knee 1 or 2 Vws,PX7356001,CDM,320,RC,73560,CPT,TC,,,,,,,303,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Knee 1 or 2 Vws,PX7356001,CDM,320,RC,73560,CPT,TC,,,,,,,303,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Knee 1 or 2 Vws,PX7356001,CDM,320,RC,73560,CPT,TC,,,,,,,303,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Knee 1 or 2 Vws,PX7356001,CDM,320,RC,73560,CPT,TC,,,,,,,303,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Knee 1 or 2 Vws,PX7356001,CDM,320,RC,73560,CPT,TC,,,,,,,303,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Knee 3 Vws,PX7356201,CDM,320,RC,73562,CPT,TC,,,,,,,404,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Knee 3 Vws,PX7356201,CDM,320,RC,73562,CPT,TC,,,,,,,404,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Knee 3 Vws,PX7356201,CDM,320,RC,73562,CPT,TC,,,,,,,404,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Knee 3 Vws,PX7356201,CDM,320,RC,73562,CPT,TC,,,,,,,404,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Knee 3 Vws,PX7356201,CDM,320,RC,73562,CPT,TC,,,,,,,404,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Knee 3 Vws,PX7356201,CDM,320,RC,73562,CPT,TC,,,,,,,404,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Knee 4 or More Vws,PX7356401,CDM,320,RC,73564,CPT,TC,,,,,,,490,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Knee 4 or More Vws,PX7356401,CDM,320,RC,73564,CPT,TC,,,,,,,490,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Knee 4 or More Vws,PX7356401,CDM,320,RC,73564,CPT,TC,,,,,,,490,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Knee 4 or More Vws,PX7356401,CDM,320,RC,73564,CPT,TC,,,,,,,490,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Knee 4 or More Vws,PX7356401,CDM,320,RC,73564,CPT,TC,,,,,,,490,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Knee 4 or More Vws,PX7356401,CDM,320,RC,73564,CPT,TC,,,,,,,490,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ls Spine Bend Tc,PX7212001,CDM,320,RC,72120,CPT,TC,,,,,,,323,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ls Spine Bend Tc,PX7212001,CDM,320,RC,72120,CPT,TC,,,,,,,323,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ls Spine Bend Tc,PX7212001,CDM,320,RC,72120,CPT,TC,,,,,,,323,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ls Spine Bend Tc,PX7212001,CDM,320,RC,72120,CPT,TC,,,,,,,323,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ls Spine Bend Tc,PX7212001,CDM,320,RC,72120,CPT,TC,,,,,,,323,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ls Spine Bend Tc,PX7212001,CDM,320,RC,72120,CPT,TC,,,,,,,323,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Lumbosacral 2 or 3 Vws,PX7210001,CDM,320,RC,72100,CPT,TC,,,,,,,399,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Lumbosacral 2 or 3 Vws,PX7210001,CDM,320,RC,72100,CPT,TC,,,,,,,399,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Lumbosacral 2 or 3 Vws,PX7210001,CDM,320,RC,72100,CPT,TC,,,,,,,399,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Lumbosacral 2 or 3 Vws,PX7210001,CDM,320,RC,72100,CPT,TC,,,,,,,399,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Lumbosacral 2 or 3 Vws,PX7210001,CDM,320,RC,72100,CPT,TC,,,,,,,399,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Lumbosacral 2 or 3 Vws,PX7210001,CDM,320,RC,72100,CPT,TC,,,,,,,399,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Lumbosacral Minimum 4 Vws,PX7211001,CDM,320,RC,72110,CPT,TC,,,,,,,565,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Lumbosacral Minimum 4 Vws,PX7211001,CDM,320,RC,72110,CPT,TC,,,,,,,565,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Lumbosacral Minimum 4 Vws,PX7211001,CDM,320,RC,72110,CPT,TC,,,,,,,565,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Lumbosacral Minimum 4 Vws,PX7211001,CDM,320,RC,72110,CPT,TC,,,,,,,565,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Lumbosacral Minimum 4 Vws,PX7211001,CDM,320,RC,72110,CPT,TC,,,,,,,565,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Lumbosacral Minimum 4 Vws,PX7211001,CDM,320,RC,72110,CPT,TC,,,,,,,565,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Xray Mandible Compl, Min 4 Vws",PX7011001,CDM,320,RC,70110,CPT,TC,,,,,,,381,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Xray Mandible Compl, Min 4 Vws",PX7011001,CDM,320,RC,70110,CPT,TC,,,,,,,381,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Xray Mandible Compl, Min 4 Vws",PX7011001,CDM,320,RC,70110,CPT,TC,,,,,,,381,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Xray Mandible Compl, Min 4 Vws",PX7011001,CDM,320,RC,70110,CPT,TC,,,,,,,381,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Xray Mandible Compl, Min 4 Vws",PX7011001,CDM,320,RC,70110,CPT,TC,,,,,,,381,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Xray Mandible Compl, Min 4 Vws",PX7011001,CDM,320,RC,70110,CPT,TC,,,,,,,381,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Mandible Partial Less Than 4 Vws,PX7010001,CDM,320,RC,70100,CPT,TC,,,,,,,347,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Mandible Partial Less Than 4 Vws,PX7010001,CDM,320,RC,70100,CPT,TC,,,,,,,347,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Mandible Partial Less Than 4 Vws,PX7010001,CDM,320,RC,70100,CPT,TC,,,,,,,347,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Mandible Partial Less Than 4 Vws,PX7010001,CDM,320,RC,70100,CPT,TC,,,,,,,347,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Mandible Partial Less Than 4 Vws,PX7010001,CDM,320,RC,70100,CPT,TC,,,,,,,347,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Mandible Partial Less Than 4 Vws,PX7010001,CDM,320,RC,70100,CPT,TC,,,,,,,347,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Nasal Bones Minimum 3 Vws,PX7016001,CDM,320,RC,70160,CPT,TC,,,,,,,456,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Nasal Bones Minimum 3 Vws,PX7016001,CDM,320,RC,70160,CPT,TC,,,,,,,456,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Nasal Bones Minimum 3 Vws,PX7016001,CDM,320,RC,70160,CPT,TC,,,,,,,456,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Nasal Bones Minimum 3 Vws,PX7016001,CDM,320,RC,70160,CPT,TC,,,,,,,456,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Nasal Bones Minimum 3 Vws,PX7016001,CDM,320,RC,70160,CPT,TC,,,,,,,456,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Nasal Bones Minimum 3 Vws,PX7016001,CDM,320,RC,70160,CPT,TC,,,,,,,456,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Xray Neck, Soft Tissue",PX7036001,CDM,320,RC,70360,CPT,TC,,,,,,,277,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Xray Neck, Soft Tissue",PX7036001,CDM,320,RC,70360,CPT,TC,,,,,,,277,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Xray Neck, Soft Tissue",PX7036001,CDM,320,RC,70360,CPT,TC,,,,,,,277,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Xray Neck, Soft Tissue",PX7036001,CDM,320,RC,70360,CPT,TC,,,,,,,277,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Xray Neck, Soft Tissue",PX7036001,CDM,320,RC,70360,CPT,TC,,,,,,,277,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Xray Neck, Soft Tissue",PX7036001,CDM,320,RC,70360,CPT,TC,,,,,,,277,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Orbits Optic Foramina,PX7019001,CDM,320,RC,70190,CPT,TC,,,,,,,66,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Orbits Optic Foramina,PX7019001,CDM,320,RC,70190,CPT,TC,,,,,,,66,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Orbits Optic Foramina,PX7019001,CDM,320,RC,70190,CPT,TC,,,,,,,66,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Orbits Optic Foramina,PX7019001,CDM,320,RC,70190,CPT,TC,,,,,,,66,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Orbits Optic Foramina,PX7019001,CDM,320,RC,70190,CPT,TC,,,,,,,66,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Orbits Optic Foramina,PX7019001,CDM,320,RC,70190,CPT,TC,,,,,,,66,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Pelvis 1 or 2 Vws,PX7217001,CDM,320,RC,72170,CPT,TC,,,,,,,279,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Pelvis 1 or 2 Vws,PX7217001,CDM,320,RC,72170,CPT,TC,,,,,,,279,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Pelvis 1 or 2 Vws,PX7217001,CDM,320,RC,72170,CPT,TC,,,,,,,279,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Pelvis 1 or 2 Vws,PX7217001,CDM,320,RC,72170,CPT,TC,,,,,,,279,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Pelvis 1 or 2 Vws,PX7217001,CDM,320,RC,72170,CPT,TC,,,,,,,279,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Pelvis 1 or 2 Vws,PX7217001,CDM,320,RC,72170,CPT,TC,,,,,,,279,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Pelvis Compl 3+ Tc,PX7219001,CDM,320,RC,72190,CPT,TC,,,,,,,563,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Pelvis Compl 3+ Tc,PX7219001,CDM,320,RC,72190,CPT,TC,,,,,,,563,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Pelvis Compl 3+ Tc,PX7219001,CDM,320,RC,72190,CPT,TC,,,,,,,563,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Pelvis Compl 3+ Tc,PX7219001,CDM,320,RC,72190,CPT,TC,,,,,,,563,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Pelvis Compl 3+ Tc,PX7219001,CDM,320,RC,72190,CPT,TC,,,,,,,563,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Pelvis Compl 3+ Tc,PX7219001,CDM,320,RC,72190,CPT,TC,,,,,,,563,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ribs Bil 3vws Tc,PX7111001,CDM,320,RC,71110,CPT,TC,,,,,,,533,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ribs Bil 3vws Tc,PX7111001,CDM,320,RC,71110,CPT,TC,,,,,,,533,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ribs Bil 3vws Tc,PX7111001,CDM,320,RC,71110,CPT,TC,,,,,,,533,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ribs Bil 3vws Tc,PX7111001,CDM,320,RC,71110,CPT,TC,,,,,,,533,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ribs Bil 3vws Tc,PX7111001,CDM,320,RC,71110,CPT,TC,,,,,,,533,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ribs Bil 3vws Tc,PX7111001,CDM,320,RC,71110,CPT,TC,,,,,,,533,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ribs Bilat 3 Vws With Pa Chest,PX7111101,CDM,320,RC,71111,CPT,TC,,,,,,,417,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ribs Bilat 3 Vws With Pa Chest,PX7111101,CDM,320,RC,71111,CPT,TC,,,,,,,417,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ribs Bilat 3 Vws With Pa Chest,PX7111101,CDM,320,RC,71111,CPT,TC,,,,,,,417,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ribs Bilat 3 Vws With Pa Chest,PX7111101,CDM,320,RC,71111,CPT,TC,,,,,,,417,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ribs Bilat 3 Vws With Pa Chest,PX7111101,CDM,320,RC,71111,CPT,TC,,,,,,,417,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ribs Bilat 3 Vws With Pa Chest,PX7111101,CDM,320,RC,71111,CPT,TC,,,,,,,417,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ribs Unilat 2 Vws,PX7110001,CDM,320,RC,71100,CPT,TC,,,,,,,437,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ribs Unilat 2 Vws,PX7110001,CDM,320,RC,71100,CPT,TC,,,,,,,437,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ribs Unilat 2 Vws,PX7110001,CDM,320,RC,71100,CPT,TC,,,,,,,437,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ribs Unilat 2 Vws,PX7110001,CDM,320,RC,71100,CPT,TC,,,,,,,437,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ribs Unilat 2 Vws,PX7110001,CDM,320,RC,71100,CPT,TC,,,,,,,437,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ribs Unilat 2 Vws,PX7110001,CDM,320,RC,71100,CPT,TC,,,,,,,437,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ribs Unilat 2 Vws With Pa Chest,PX7110101,CDM,320,RC,71101,CPT,TC,,,,,,,792,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ribs Unilat 2 Vws With Pa Chest,PX7110101,CDM,320,RC,71101,CPT,TC,,,,,,,792,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ribs Unilat 2 Vws With Pa Chest,PX7110101,CDM,320,RC,71101,CPT,TC,,,,,,,792,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ribs Unilat 2 Vws With Pa Chest,PX7110101,CDM,320,RC,71101,CPT,TC,,,,,,,792,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ribs Unilat 2 Vws With Pa Chest,PX7110101,CDM,320,RC,71101,CPT,TC,,,,,,,792,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ribs Unilat 2 Vws With Pa Chest,PX7110101,CDM,320,RC,71101,CPT,TC,,,,,,,792,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Sacroiliac Jnts 3 or More Vws,PX7220201,CDM,320,RC,72202,CPT,TC,,,,,,,285,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Sacroiliac Jnts 3 or More Vws,PX7220201,CDM,320,RC,72202,CPT,TC,,,,,,,285,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Sacroiliac Jnts 3 or More Vws,PX7220201,CDM,320,RC,72202,CPT,TC,,,,,,,285,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Sacroiliac Jnts 3 or More Vws,PX7220201,CDM,320,RC,72202,CPT,TC,,,,,,,285,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Sacroiliac Jnts 3 or More Vws,PX7220201,CDM,320,RC,72202,CPT,TC,,,,,,,285,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Sacroiliac Jnts 3 or More Vws,PX7220201,CDM,320,RC,72202,CPT,TC,,,,,,,285,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Sacroiliac Jnts Less Than 3 Vws,PX7220001,CDM,320,RC,72200,CPT,TC,,,,,,,555,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Sacroiliac Jnts Less Than 3 Vws,PX7220001,CDM,320,RC,72200,CPT,TC,,,,,,,555,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Sacroiliac Jnts Less Than 3 Vws,PX7220001,CDM,320,RC,72200,CPT,TC,,,,,,,555,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Sacroiliac Jnts Less Than 3 Vws,PX7220001,CDM,320,RC,72200,CPT,TC,,,,,,,555,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Sacroiliac Jnts Less Than 3 Vws,PX7220001,CDM,320,RC,72200,CPT,TC,,,,,,,555,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Sacroiliac Jnts Less Than 3 Vws,PX7220001,CDM,320,RC,72200,CPT,TC,,,,,,,555,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Sacrum/ Coccyx Minimum 2 Vws,PX7222001,CDM,320,RC,72220,CPT,TC,,,,,,,540,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Sacrum/ Coccyx Minimum 2 Vws,PX7222001,CDM,320,RC,72220,CPT,TC,,,,,,,540,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Sacrum/ Coccyx Minimum 2 Vws,PX7222001,CDM,320,RC,72220,CPT,TC,,,,,,,540,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Sacrum/ Coccyx Minimum 2 Vws,PX7222001,CDM,320,RC,72220,CPT,TC,,,,,,,540,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Sacrum/ Coccyx Minimum 2 Vws,PX7222001,CDM,320,RC,72220,CPT,TC,,,,,,,540,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Sacrum/ Coccyx Minimum 2 Vws,PX7222001,CDM,320,RC,72220,CPT,TC,,,,,,,540,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Scapula Complete,PX7301001,CDM,320,RC,73010,CPT,TC,,,,,,,357,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Scapula Complete,PX7301001,CDM,320,RC,73010,CPT,TC,,,,,,,357,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Scapula Complete,PX7301001,CDM,320,RC,73010,CPT,TC,,,,,,,357,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Scapula Complete,PX7301001,CDM,320,RC,73010,CPT,TC,,,,,,,357,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Scapula Complete,PX7301001,CDM,320,RC,73010,CPT,TC,,,,,,,357,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Scapula Complete,PX7301001,CDM,320,RC,73010,CPT,TC,,,,,,,357,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Shoulder 1 Vw,PX7302001,CDM,320,RC,73020,CPT,TC,,,,,,,267,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Shoulder 1 Vw,PX7302001,CDM,320,RC,73020,CPT,TC,,,,,,,267,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Shoulder 1 Vw,PX7302001,CDM,320,RC,73020,CPT,TC,,,,,,,267,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Shoulder 1 Vw,PX7302001,CDM,320,RC,73020,CPT,TC,,,,,,,267,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Shoulder 1 Vw,PX7302001,CDM,320,RC,73020,CPT,TC,,,,,,,267,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Shoulder 1 Vw,PX7302001,CDM,320,RC,73020,CPT,TC,,,,,,,267,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Shoulder Minimum 2 Vws,PX7303001,CDM,320,RC,73030,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Shoulder Minimum 2 Vws,PX7303001,CDM,320,RC,73030,CPT,TC,,,,,,,365,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Shoulder Minimum 2 Vws,PX7303001,CDM,320,RC,73030,CPT,TC,,,,,,,365,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Shoulder Minimum 2 Vws,PX7303001,CDM,320,RC,73030,CPT,TC,,,,,,,365,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Shoulder Minimum 2 Vws,PX7303001,CDM,320,RC,73030,CPT,TC,,,,,,,365,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Shoulder Minimum 2 Vws,PX7303001,CDM,320,RC,73030,CPT,TC,,,,,,,365,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Sinuses Less Than 3 Vws,PX7021001,CDM,320,RC,70210,CPT,TC,,,,,,,486,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Sinuses Less Than 3 Vws,PX7021001,CDM,320,RC,70210,CPT,TC,,,,,,,486,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Sinuses Less Than 3 Vws,PX7021001,CDM,320,RC,70210,CPT,TC,,,,,,,486,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Sinuses Less Than 3 Vws,PX7021001,CDM,320,RC,70210,CPT,TC,,,,,,,486,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Sinuses Less Than 3 Vws,PX7021001,CDM,320,RC,70210,CPT,TC,,,,,,,486,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Sinuses Less Than 3 Vws,PX7021001,CDM,320,RC,70210,CPT,TC,,,,,,,486,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Sinuses Minimum 3 Vws,PX7022001,CDM,320,RC,70220,CPT,TC,,,,,,,354,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Sinuses Minimum 3 Vws,PX7022001,CDM,320,RC,70220,CPT,TC,,,,,,,354,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Sinuses Minimum 3 Vws,PX7022001,CDM,320,RC,70220,CPT,TC,,,,,,,354,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Sinuses Minimum 3 Vws,PX7022001,CDM,320,RC,70220,CPT,TC,,,,,,,354,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Sinuses Minimum 3 Vws,PX7022001,CDM,320,RC,70220,CPT,TC,,,,,,,354,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Sinuses Minimum 3 Vws,PX7022001,CDM,320,RC,70220,CPT,TC,,,,,,,354,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Skull Less Than 4 Vws,PX7025001,CDM,320,RC,70250,CPT,TC,,,,,,,311,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Skull Less Than 4 Vws,PX7025001,CDM,320,RC,70250,CPT,TC,,,,,,,311,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Skull Less Than 4 Vws,PX7025001,CDM,320,RC,70250,CPT,TC,,,,,,,311,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Skull Less Than 4 Vws,PX7025001,CDM,320,RC,70250,CPT,TC,,,,,,,311,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Skull Less Than 4 Vws,PX7025001,CDM,320,RC,70250,CPT,TC,,,,,,,311,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Skull Less Than 4 Vws,PX7025001,CDM,320,RC,70250,CPT,TC,,,,,,,311,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Spine Single Tc,PX7202001,CDM,320,RC,72020,CPT,TC,,,,,,,113,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Spine Single Tc,PX7202001,CDM,320,RC,72020,CPT,TC,,,,,,,113,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Spine Single Tc,PX7202001,CDM,320,RC,72020,CPT,TC,,,,,,,113,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Spine Single Tc,PX7202001,CDM,320,RC,72020,CPT,TC,,,,,,,113,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Spine Single Tc,PX7202001,CDM,320,RC,72020,CPT,TC,,,,,,,113,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Spine Single Tc,PX7202001,CDM,320,RC,72020,CPT,TC,,,,,,,113,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Sternum 2vws Tc,PX7112001,CDM,320,RC,71120,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Sternum 2vws Tc,PX7112001,CDM,320,RC,71120,CPT,TC,,,,,,,365,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Sternum 2vws Tc,PX7112001,CDM,320,RC,71120,CPT,TC,,,,,,,365,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Sternum 2vws Tc,PX7112001,CDM,320,RC,71120,CPT,TC,,,,,,,365,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Sternum 2vws Tc,PX7112001,CDM,320,RC,71120,CPT,TC,,,,,,,365,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Sternum 2vws Tc,PX7112001,CDM,320,RC,71120,CPT,TC,,,,,,,365,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Temporomandib Jnt Unilat,PX7032801,CDM,320,RC,70328,CPT,TC,,,,,,,385,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Temporomandib Jnt Unilat,PX7032801,CDM,320,RC,70328,CPT,TC,,,,,,,385,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Temporomandib Jnt Unilat,PX7032801,CDM,320,RC,70328,CPT,TC,,,,,,,385,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Temporomandib Jnt Unilat,PX7032801,CDM,320,RC,70328,CPT,TC,,,,,,,385,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Temporomandib Jnt Unilat,PX7032801,CDM,320,RC,70328,CPT,TC,,,,,,,385,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Temporomandib Jnt Unilat,PX7032801,CDM,320,RC,70328,CPT,TC,,,,,,,385,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Thoracic Spine 2 Vws,PX7207001,CDM,320,RC,72070,CPT,TC,,,,,,,428,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Thoracic Spine 2 Vws,PX7207001,CDM,320,RC,72070,CPT,TC,,,,,,,428,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Thoracic Spine 2 Vws,PX7207001,CDM,320,RC,72070,CPT,TC,,,,,,,428,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Thoracic Spine 2 Vws,PX7207001,CDM,320,RC,72070,CPT,TC,,,,,,,428,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Thoracic Spine 2 Vws,PX7207001,CDM,320,RC,72070,CPT,TC,,,,,,,428,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Thoracic Spine 2 Vws,PX7207001,CDM,320,RC,72070,CPT,TC,,,,,,,428,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Thoracic Spine 3 Vws,PX7207201,CDM,320,RC,72072,CPT,TC,,,,,,,522,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Thoracic Spine 3 Vws,PX7207201,CDM,320,RC,72072,CPT,TC,,,,,,,522,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Thoracic Spine 3 Vws,PX7207201,CDM,320,RC,72072,CPT,TC,,,,,,,522,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Thoracic Spine 3 Vws,PX7207201,CDM,320,RC,72072,CPT,TC,,,,,,,522,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Thoracic Spine 3 Vws,PX7207201,CDM,320,RC,72072,CPT,TC,,,,,,,522,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Thoracic Spine 3 Vws,PX7207201,CDM,320,RC,72072,CPT,TC,,,,,,,522,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Thoracolumbar 2 Vws,PX7208001,CDM,320,RC,72080,CPT,TC,,,,,,,306,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Thoracolumbar 2 Vws,PX7208001,CDM,320,RC,72080,CPT,TC,,,,,,,306,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Thoracolumbar 2 Vws,PX7208001,CDM,320,RC,72080,CPT,TC,,,,,,,306,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Thoracolumbar 2 Vws,PX7208001,CDM,320,RC,72080,CPT,TC,,,,,,,306,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Thoracolumbar 2 Vws,PX7208001,CDM,320,RC,72080,CPT,TC,,,,,,,306,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Thoracolumbar 2 Vws,PX7208001,CDM,320,RC,72080,CPT,TC,,,,,,,306,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Tibia & Fibula 2 Vws,PX7359001,CDM,320,RC,73590,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Tibia & Fibula 2 Vws,PX7359001,CDM,320,RC,73590,CPT,TC,,,,,,,365,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Tibia & Fibula 2 Vws,PX7359001,CDM,320,RC,73590,CPT,TC,,,,,,,365,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Tibia & Fibula 2 Vws,PX7359001,CDM,320,RC,73590,CPT,TC,,,,,,,365,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Tibia & Fibula 2 Vws,PX7359001,CDM,320,RC,73590,CPT,TC,,,,,,,365,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Tibia & Fibula 2 Vws,PX7359001,CDM,320,RC,73590,CPT,TC,,,,,,,365,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Toe(S) Tc,PX7366001,CDM,320,RC,73660,CPT,TC,,,,,,,282,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Toe(S) Tc,PX7366001,CDM,320,RC,73660,CPT,TC,,,,,,,282,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Toe(S) Tc,PX7366001,CDM,320,RC,73660,CPT,TC,,,,,,,282,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Toe(S) Tc,PX7366001,CDM,320,RC,73660,CPT,TC,,,,,,,282,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Toe(S) Tc,PX7366001,CDM,320,RC,73660,CPT,TC,,,,,,,282,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Toe(S) Tc,PX7366001,CDM,320,RC,73660,CPT,TC,,,,,,,282,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Wrist 2 Vws,PX7310001,CDM,320,RC,73100,CPT,TC,,,,,,,365,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Wrist 2 Vws,PX7310001,CDM,320,RC,73100,CPT,TC,,,,,,,365,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Wrist 2 Vws,PX7310001,CDM,320,RC,73100,CPT,TC,,,,,,,365,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Wrist 2 Vws,PX7310001,CDM,320,RC,73100,CPT,TC,,,,,,,365,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Wrist 2 Vws,PX7310001,CDM,320,RC,73100,CPT,TC,,,,,,,365,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Wrist 2 Vws,PX7310001,CDM,320,RC,73100,CPT,TC,,,,,,,365,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Wrist Minimum 3 Vws,PX7311001,CDM,320,RC,73110,CPT,TC,,,,,,,375,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Wrist Minimum 3 Vws,PX7311001,CDM,320,RC,73110,CPT,TC,,,,,,,375,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Wrist Minimum 3 Vws,PX7311001,CDM,320,RC,73110,CPT,TC,,,,,,,375,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Wrist Minimum 3 Vws,PX7311001,CDM,320,RC,73110,CPT,TC,,,,,,,375,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Wrist Minimum 3 Vws,PX7311001,CDM,320,RC,73110,CPT,TC,,,,,,,375,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Wrist Minimum 3 Vws,PX7311001,CDM,320,RC,73110,CPT,TC,,,,,,,375,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zinc gluconate 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,40093010153,NDC,1,EA,3,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zinc gluconate 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,40093010153,NDC,1,EA,3,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zinc gluconate 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,40093010153,NDC,1,EA,3,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zinc gluconate 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,40093010153,NDC,1,EA,3,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zinc gluconate 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,40093010153,NDC,1,EA,3,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zinc gluconate 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,40093010153,NDC,1,EA,3,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zinc oxide 20 % Ointment 56.7 g Tube,63700001,CDM,250,RC,,,,,,168006202,NDC,56.7,GR,30.39,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zinc oxide 20 % Ointment 56.7 g Tube,63700001,CDM,250,RC,,,,,,168006202,NDC,56.7,GR,30.39,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zinc oxide 20 % Ointment 56.7 g Tube,63700001,CDM,250,RC,,,,,,168006202,NDC,56.7,GR,30.39,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zinc oxide 20 % Ointment 56.7 g Tube,63700001,CDM,250,RC,,,,,,168006202,NDC,56.7,GR,30.39,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zinc oxide 20 % Ointment 56.7 g Tube,63700001,CDM,250,RC,,,,,,168006202,NDC,56.7,GR,30.39,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zinc oxide 20 % Ointment 56.7 g Tube,63700001,CDM,250,RC,,,,,,168006202,NDC,56.7,GR,30.39,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zinc oxide 20 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,536131625,NDC,60,GR,22.97,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zinc oxide 20 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,536131625,NDC,60,GR,22.97,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zinc oxide 20 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,536131625,NDC,60,GR,22.97,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zinc oxide 20 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,536131625,NDC,60,GR,22.97,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zinc oxide 20 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,536131625,NDC,60,GR,22.97,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zinc oxide 20 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,536131625,NDC,60,GR,22.97,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006111,NDC,0.5,EA,56.98,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006111,NDC,0.5,EA,56.98,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006111,NDC,0.5,EA,56.98,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006111,NDC,0.5,EA,56.98,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006111,NDC,0.5,EA,56.98,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006111,NDC,0.5,EA,56.98,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006158,NDC,0.5,EA,56.98,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006158,NDC,0.5,EA,56.98,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006158,NDC,0.5,EA,56.98,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006158,NDC,0.5,EA,56.98,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006158,NDC,0.5,EA,56.98,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006158,NDC,0.5,EA,56.98,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ziprasidone 80 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,781216860,NDC,0.25,EA,14.44,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ziprasidone 80 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,781216860,NDC,0.25,EA,14.44,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ziprasidone 80 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,781216860,NDC,0.25,EA,14.44,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ziprasidone 80 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,781216860,NDC,0.25,EA,14.44,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ziprasidone 80 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,781216860,NDC,0.25,EA,14.44,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ziprasidone 80 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,781216860,NDC,0.25,EA,14.44,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409421505,NDC,5,ML,271.86,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409421505,NDC,5,ML,271.86,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409421505,NDC,5,ML,271.86,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409421505,NDC,5,ML,271.86,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409421505,NDC,5,ML,271.86,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409421505,NDC,5,ML,271.86,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,16714081501,NDC,5,ML,998.95,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,16714081501,NDC,5,ML,998.95,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,16714081501,NDC,5,ML,998.95,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,16714081501,NDC,5,ML,998.95,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,16714081501,NDC,5,ML,998.95,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,16714081501,NDC,5,ML,998.95,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021080166,NDC,5,ML,820.8,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021080166,NDC,5,ML,820.8,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021080166,NDC,5,ML,820.8,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021080166,NDC,5,ML,820.8,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021080166,NDC,5,ML,820.8,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021080166,NDC,5,ML,820.8,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,60505611000,NDC,5,ML,1644.33,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,60505611000,NDC,5,ML,1644.33,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,60505611000,NDC,5,ML,1644.33,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,60505611000,NDC,5,ML,1644.33,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,60505611000,NDC,5,ML,1644.33,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,60505611000,NDC,5,ML,1644.33,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 5 MG/100ML Solution 100 mL Bottle,J3489.01,CDM,636,RC,J3489,HCPCS,,,,55111068852,NDC,100,ML,1368,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 5 MG/100ML Solution 100 mL Bottle,J3489.01,CDM,636,RC,J3489,HCPCS,,,,55111068852,NDC,100,ML,1368,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 5 MG/100ML Solution 100 mL Bottle,J3489.01,CDM,636,RC,J3489,HCPCS,,,,55111068852,NDC,100,ML,1368,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 5 MG/100ML Solution 100 mL Bottle,J3489.01,CDM,636,RC,J3489,HCPCS,,,,55111068852,NDC,100,ML,1368,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 5 MG/100ML Solution 100 mL Bottle,J3489.01,CDM,636,RC,J3489,HCPCS,,,,55111068852,NDC,100,ML,1368,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 5 MG/100ML Solution 100 mL Bottle,J3489.01,CDM,636,RC,J3489,HCPCS,,,,55111068852,NDC,100,ML,1368,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409422801,NDC,100,ML,1026,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409422801,NDC,100,ML,1026,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409422801,NDC,100,ML,1026,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409422801,NDC,100,ML,1026,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409422801,NDC,100,ML,1026,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409422801,NDC,100,ML,1026,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021083082,NDC,100,ML,1596,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021083082,NDC,100,ML,1596,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021083082,NDC,100,ML,1596,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021083082,NDC,100,ML,1596,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021083082,NDC,100,ML,1596,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021083082,NDC,100,ML,1596,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,63323096600,NDC,100,ML,1368,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,63323096600,NDC,100,ML,1368,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,63323096600,NDC,100,ML,1368,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,63323096600,NDC,100,ML,1368,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,63323096600,NDC,100,ML,1368,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,63323096600,NDC,100,ML,1368,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,67457061910,NDC,100,ML,1707.48,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,67457061910,NDC,100,ML,1707.48,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,67457061910,NDC,100,ML,1707.48,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,67457061910,NDC,100,ML,1707.48,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,67457061910,NDC,100,ML,1707.48,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,67457061910,NDC,100,ML,1707.48,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zolpidem 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079072401,NDC,1,EA,24.81,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zolpidem 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079072401,NDC,1,EA,24.81,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zolpidem 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079072401,NDC,1,EA,24.81,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zolpidem 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079072401,NDC,1,EA,24.81,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zolpidem 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079072401,NDC,1,EA,24.81,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zolpidem 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079072401,NDC,1,EA,24.81,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zolpidem 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018911,NDC,1,EA,9.43,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zolpidem 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018911,NDC,1,EA,9.43,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zolpidem 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018911,NDC,1,EA,9.43,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zolpidem 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018911,NDC,1,EA,9.43,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zolpidem 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018911,NDC,1,EA,9.43,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zolpidem 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018911,NDC,1,EA,9.43,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zolpidem 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079072420,NDC,1,EA,24.81,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zolpidem 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079072420,NDC,1,EA,24.81,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zolpidem 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079072420,NDC,1,EA,24.81,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zolpidem 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079072420,NDC,1,EA,24.81,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zolpidem 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079072420,NDC,1,EA,24.81,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zolpidem 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079072420,NDC,1,EA,24.81,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zolpidem 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018901,NDC,1,EA,9.43,,Blue Cross Blue Shield of MN,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zolpidem 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018901,NDC,1,EA,9.43,,Health Partners,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zolpidem 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018901,NDC,1,EA,9.43,,Humana Choice Care,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zolpidem 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018901,NDC,1,EA,9.43,,UCare,All Medicare plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zolpidem 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018901,NDC,1,EA,9.43,,UCare,All Minnesota State Programs,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zolpidem 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018901,NDC,1,EA,9.43,,United Healthcare,All Medicare advantage plans,inpatient,,,999999999,per diem,5340.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ABORTION WITHOUT D&C,779,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,289,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC,288,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,290,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH CC,835,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH MCC,834,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITHOUT CC/MCC,836,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,121,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,122,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC",284,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC",285,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
AICD LEAD PROCEDURES,265,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY",895,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ALLOGENEIC BONE MARROW TRANSPLANT,14,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,241,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,476,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",618,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ANAL AND STOMAL PROCEDURES WITH MCC,347,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ANGINA PECTORIS,311,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ARTHROSCOPY,509,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,16,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,17,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,95,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,94,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,96,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BEHAVIORAL AND DEVELOPMENTAL DISORDERS,886,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,461,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,462,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC",584,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC",585,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"CARDIAC ARREST, UNEXPLAINED WITH CC",297,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"CARDIAC ARREST, UNEXPLAINED WITHOUT CC/MCC",298,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC,276,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,258,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,259,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CAROTID ARTERY STENT PROCEDURES WITH CC,35,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CAROTID ARTERY STENT PROCEDURES WITH MCC,34,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,36,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,848,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHEST PAIN,313,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,18,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,416,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHOLECYSTECTOMY WITH C.D.E. WITH CC,412,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,413,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH CC,454,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH MCC,453,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITHOUT CC/MCC,455,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,382,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES,212,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CONCUSSION WITH CC,89,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CONCUSSION WITH MCC,88,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CONCUSSION WITHOUT CC/MCC,90,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,73,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,74,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,26,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,25,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,27,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,955,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR CHEMOTHERAPY IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,23,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,24,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC,294,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DEEP VEIN THROMBOPHLEBITIS WITHOUT CC/MCC,295,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,56,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,57,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DENTAL AND ORAL DISEASES WITHOUT CC/MCC,159,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DEPRESSIVE NEUROSES,881,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DIABETES WITH CC,638,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DIABETES WITH MCC,637,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DIGESTIVE MALIGNANCY WITHOUT CC/MCC,376,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,883,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC",148,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES",3,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
EPISTAXIS WITH MCC,150,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,927,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,933,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
EXTRACRANIAL PROCEDURES WITH CC,38,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
EXTRACRANIAL PROCEDURES WITH MCC,37,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,39,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
EXTRAOCULAR PROCEDURES EXCEPT ORBIT,115,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,748,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,928,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,929,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,934,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HAND PROCEDURES FOR INJURIES,906,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HEADACHES WITH MCC,102,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC,1,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITHOUT MCC,2,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,421,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,970,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HIV WITH MAJOR RELATED CONDITION WITH CC,975,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,976,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HYPERTENSIVE ENCEPHALOPATHY WITH CC,78,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HYPERTENSIVE ENCEPHALOPATHY WITH MCC,77,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC,79,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,855,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,65,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,64,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,66,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,21,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,20,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/MCC,22,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INTRAOCULAR PROCEDURES WITH CC/MCC,116,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INTRAOCULAR PROCEDURES WITHOUT CC/MCC,117,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",62,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",61,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",63,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,686,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,688,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KIDNEY TRANSPLANT,652,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC,650,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC,651,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,486,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LIVER TRANSPLANT WITH MCC OR INTESTINAL TRANSPLANT,5,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LIVER TRANSPLANT WITHOUT MCC,6,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,495,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,499,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LUNG TRANSPLANT,7,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,821,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,825,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,655,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,370,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR HEAD AND NECK PROCEDURES WITH CC,141,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR HEAD AND NECK PROCEDURES WITH MCC,140,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,142,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITHOUT CC/MCC,508,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,437,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",756,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",724,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,599,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MASTECTOMY FOR MALIGNANCY WITH CC/MCC,582,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MOUTH PROCEDURES WITH CC/MCC,137,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MOUTH PROCEDURES WITHOUT CC/MCC,138,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,59,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,58,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,60,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,830,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NERVOUS SYSTEM NEOPLASMS WITH MCC,54,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,55,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NEUROLOGICAL EYE DISORDERS,123,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,98,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,97,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,99,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NON-EXTENSIVE BURNS,935,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC,71,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC,70,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,72,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,67,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,68,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NONTRAUMATIC STUPOR AND COMA WITH MCC,80,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,81,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NORMAL NEWBORN,795,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
O.R. PROCEDURES FOR OBESITY WITH MCC,619,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,876,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ORBITAL PROCEDURES WITH CC/MCC,113,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ORBITAL PROCEDURES WITHOUT CC/MCC,114,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,819,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,92,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,91,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,93,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER DISORDERS OF THE EYE WITH MCC OR THROMBOLYTIC AGENT,124,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC",144,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH MCC",143,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC",145,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,750,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,730,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,718,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,715,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,716,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,963,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,965,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,517,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,845,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,958,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,957,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,959,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,804,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,168,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC",579,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PANCREAS TRANSPLANT,10,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC",734,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC",735,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PENIS PROCEDURES WITH CC/MCC,709,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PENIS PROCEDURES WITHOUT CC/MCC,710,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",41,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",40,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC",42,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS,998,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PSYCHOSES,885,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RADIOTHERAPY,849,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RECTAL RESECTION WITH CC,333,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RECTAL RESECTION WITHOUT CC/MCC,334,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
REHABILITATION WITH CC/MCC,945,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
REHABILITATION WITHOUT CC/MCC,946,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,466,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SEPTIC ARTHRITIS WITHOUT CC/MCC,550,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC",512,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,8,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS,19,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SINUS AND MASTOID PROCEDURES WITH CC/MCC,135,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,136,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,577,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,576,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,578,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,574,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,573,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",624,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SKIN GRAFTS FOR INJURIES WITH CC/MCC,904,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,905,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SKIN ULCERS WITH CC,593,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SPINAL DISORDERS AND INJURIES WITH CC/MCC,52,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,53,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SPINAL FUSION EXCEPT CERVICAL WITH MCC,459,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH MCC",456,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,460,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,29,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SPINAL PROCEDURES WITH MCC,28,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SPINAL PROCEDURES WITHOUT CC/MCC,30,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SPLENIC PROCEDURES WITH CC,800,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SPLENIC PROCEDURES WITH MCC,799,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SPLENIC PROCEDURES WITHOUT CC/MCC,801,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC",538,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
TESTES PROCEDURES WITH CC/MCC,711,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
TESTES PROCEDURES WITHOUT CC/MCC,712,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC",626,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC",625,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC",627,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC",12,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",11,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC",13,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",4,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,69,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
TRAUMATIC INJURY WITHOUT MCC,914,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,86,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,85,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,87,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,83,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,82,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,84,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY EMBOLISM,173,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
UNCOMPLICATED PEPTIC ULCER WITH MCC,383,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
UNGROUPABLE,999,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,256,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,257,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
URETHRAL PROCEDURES WITHOUT CC/MCC,672,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
URETHRAL STRICTURE,697,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,796,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,798,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
VENTRICULAR SHUNT PROCEDURES WITH CC,32,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
VENTRICULAR SHUNT PROCEDURES WITH MCC,31,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,33,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
VIRAL MENINGITIS WITH CC/MCC,75,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
VIRAL MENINGITIS WITHOUT CC/MCC,76,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
WOUND DEBRIDEMENTS FOR INJURIES WITH CC,902,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,901,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,,,,,,,Medica,Minnesota Health Care Program,inpatient,,MS-DRG,999999999,case rate,5356,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RESTRATA WOUND MATRIX 7.5CM X 7.5CM TOTAL 56.25CM,27200000,CDM,272,RC,A2007,HCPCS,,11737-MAIN,LOCAL,,,,,6311,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5364.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74334603,NDC,1,EA,12509.82,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5366.71278,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
Or Level 5,PX36000005,CDM,360,RC,,,,,,,,,,5898,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,5373.078,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2450.0292,5780.04
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012047,NDC,0.6,EA,10644.69,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,5386.21314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.39,10431.7962
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING 8X10 ELLIPSE,C1781,CDM,278,RC,C1781,HCPCS,,12504-MAIN,LOCAL,,,,,5915,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,5388.565,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
nivolumab 240 MG/24ML Solution 24 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3373413,NDC,24,ML,13030.26,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5412.770004,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.5,12769.6548
Lap Paraesophag Hern Repair,PX43281,CDM,982,RC,43281,CPT,,,,,,,,5950,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,5420.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2471.63,8992.74
carfilzomib 60 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010101,NDC,1,EA,5571.82,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,5423.052406,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.23,5460.3836
pegfilgrastim 6 MG/0.6ML Prefilled Syringe Kit 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019201,NDC,0.6,ML,13092.7,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5438.70758,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.46,12830.846
Appl on-Body Injector for Timed Subq Injection,PX96377,CDM,260,RC,96377,CPT,,,,,,,,13093,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,5438.8322,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,12831.14
"VENTRALIGHT MESH ST WITH ECHO 2 - 20 CM X 25 CM 8"" X 10""",C1781,CDM,278,RC,C1781,HCPCS,,12009-MAIN,LOCAL,,,,,5589,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1256.29,percent of total billed charges,5439.7737,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
pegfilgrastim 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019001,NDC,0.6,ML,12711.36,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5453.17344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.46,12830.846
carfilzomib 60 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010101,NDC,1,EA,5571.82,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,5460.3836,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,25.23,5460.3836
"VENTRALIGHT MESH ST WITH ECHO 2 - 20 CM X 25 CM 8"" X 10""",C1781,CDM,278,RC,C1781,HCPCS,,12009-MAIN,LOCAL,,,,,5589,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,5477.22,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218710,NDC,2,EA,5662.72,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,19.47136471,percent of total billed charges,5511.525376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.57,6737.8528
Level 6 Additional Procedure,PX36000085,CDM,360,RC,,,,,,,,,,6500,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5525,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2700.1,6370
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218710,NDC,2,EA,5662.72,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,5549.4656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.57,6737.8528
RESTRATA WOUND MATRIX 7.5CM X 7.5CM TOTAL 56.25CM,27200000,CDM,272,RC,A2007,HCPCS,,11737-MAIN,LOCAL,,,,,6311,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,5566.302,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PURAPLYAM XT-COM 4.91X4.91 EXTRA FENESTRATED 24.10 SQCM,120.567,CDM,272,RC,Q4197,HCPCS,,12806-MAIN,LOCAL,,,,,6562,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5577.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2725.8548,6430.76
nivolumab 240 MG/24ML Solution 24 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3373413,NDC,24,ML,13030.26,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5589.98154,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.5,12769.6548
REVITA PLACENTAL MEMBRANE 4X4CM 16SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12560-MAIN,LOCAL,,,,,6597,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5607.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
pegfilgrastim 6 MG/0.6ML Prefilled Syringe Kit 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019201,NDC,0.6,ML,13092.7,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5616.7683,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.46,12830.846
RESTRATA WOUND MATRIX 7.5CM X 7.5CM TOTAL 56.25CM,27200000,CDM,272,RC,A2007,HCPCS,,11737-MAIN,LOCAL,,,,,6311,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,5616.79,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Appl on-Body Injector for Timed Subq Injection,PX96377,CDM,260,RC,96377,CPT,,,,,,,,13093,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,5616.897,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,12831.14
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830F,CDM,510,RC,15830,CPT,,,,,,,,2080,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,5696.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,864.032,5696.92
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830P,CDM,983,RC,15830,CPT,,,,,,,,1120,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,5696.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,465.248,5696.92
"Lap,Esophagogast Fundoplasty",PX43280F,CDM,510,RC,43280,CPT,,,,,,,,6713,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5706.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2788.5802,8992.74
Level 6 Additional Procedure,PX36000085,CDM,360,RC,,,,,,,,,,6500,,United Healthcare,All Payer,outpatient,88.2,,999999999,case rate,5733,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Or Level 5,PX36000005,CDM,360,RC,,,,,,,,,,5898,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,5740.5234,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2450.0292,5780.04
RESTRATA WOUND MATRIX 7.5CM X 7.5CM TOTAL 56.25CM,27200000,CDM,272,RC,A2007,HCPCS,,11737-MAIN,LOCAL,,,,,6311,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,5749.321,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
PHASIX ST 15X20CM 1201520,C1781,CDM,278,RC,C1781,HCPCS,,13010-MAIN,LOCAL,,,,,11988,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,5754.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
PHASIX ST 15X20CM 1201520,C1781,CDM,278,RC,C1781,HCPCS,,13010-MAIN,LOCAL,,,,,11988,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,5754.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING 8X10 ELLIPSE,C1781,CDM,278,RC,C1781,HCPCS,,12504-MAIN,LOCAL,,,,,5915,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1256.29,percent of total billed charges,5757.0695,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
Or Level 5,PX36000005,CDM,360,RC,,,,,,,,,,5898,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,5780.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2450.0292,5780.04
Level 6 Additional Procedure,PX36000085,CDM,360,RC,,,,,,,,,,6500,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,5785,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2700.1,6370
PURAPLYAM XT-COM 4.91X4.91 EXTRA FENESTRATED 24.10 SQCM,120.567,CDM,272,RC,Q4197,HCPCS,,12806-MAIN,LOCAL,,,,,6562,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,5787.684,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2725.8548,6430.76
Lap Paraesophag Hern Repair,PX43281,CDM,982,RC,43281,CPT,,,,,,,,5950,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,5791.135,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2471.63,8992.74
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING 8X10 ELLIPSE,C1781,CDM,278,RC,C1781,HCPCS,,12504-MAIN,LOCAL,,,,,5915,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,5796.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
REVITA PLACENTAL MEMBRANE 4X4CM 16SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12560-MAIN,LOCAL,,,,,6597,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,5818.554,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
Lap Paraesophag Hern Repair,PX43281,CDM,982,RC,43281,CPT,,,,,,,,5950,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,5831,,professional,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,906.42,5831
PURAPLYAM XT-COM 4.91X4.91 EXTRA FENESTRATED 24.10 SQCM,120.567,CDM,272,RC,Q4197,HCPCS,,12806-MAIN,LOCAL,,,,,6562,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,5840.18,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2725.8548,6430.76
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218713,NDC,2,EA,6875.36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5844.056,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.57,6737.8528
REVITA PLACENTAL MEMBRANE 4X4CM 16SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12560-MAIN,LOCAL,,,,,6597,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,5871.33,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
PHASIX ST 15X20CM 1201520,C1781,CDM,278,RC,C1781,HCPCS,,13010-MAIN,LOCAL,,,,,11988,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,196.035,percent of total billed charges,5874.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
PHASIX ST 15X20CM 1201520,C1781,CDM,278,RC,C1781,HCPCS,,13010-MAIN,LOCAL,,,,,11988,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,5874.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
PHASIX ST 15X20CM 1201520,C1781,CDM,278,RC,C1781,HCPCS,,13010-MAIN,LOCAL,,,,,11988,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,5874.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
AMNION MATRIX CORD STERILE 3X6,27200000,CDM,272,RC,C1762,HCPCS,,11625-MAIN,LOCAL,,,,,6919,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5881.15,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
ramuCIRumab 500 MG/50ML Solution 50 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2767801,NDC,50,ML,12316.5,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,5911.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.57,12070.17
ramuCIRumab 500 MG/50ML Solution 50 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2767801,NDC,50,ML,12316.5,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,5911.92,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.57,12070.17
mepolizumab 100 MG Recon Soln 1 Each Vial,J2182.01,CDM,636,RC,J2182,HCPCS,,,,173088101,NDC,1,EA,6959.95,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5915.9575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.51,6820.751
"Lap,Esophagogast Fundoplasty",PX43280F,CDM,510,RC,43280,CPT,,,,,,,,6713,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,5920.866,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2788.5802,8992.74
Level 6 Additional Procedure,PX36000085,CDM,360,RC,,,,,,,,,,6500,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,5921.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2700.1,6370
PHASIX ST 15X20CM 1201520,C1781,CDM,278,RC,C1781,HCPCS,,13010-MAIN,LOCAL,,,,,11988,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,5934.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
RomiPLOStim 500 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022201,NDC,1,EA,7018.25,,First Health,Commercial,both,85,,999999999,percent of total billed charges,5965.5125,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.04,6877.885
vedolizumab 300 MG Recon Soln 1 Each Vial,J3380.01,CDM,636,RC,J3380,HCPCS,,,,64764030020,NDC,1,EA,12439.04,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,5970.7392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.66,12190.2592
vedolizumab 300 MG Recon Soln 1 Each Vial,J3380.01,CDM,636,RC,J3380,HCPCS,,,,64764030020,NDC,1,EA,12439.04,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,5970.7392,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.66,12190.2592
"Lap,Esophagogast Fundoplasty",PX43280F,CDM,510,RC,43280,CPT,,,,,,,,6713,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,5974.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2788.5802,8992.74
PURAPLYAM XT-COM 4.91X4.91 EXTRA FENESTRATED 24.10 SQCM,120.567,CDM,272,RC,Q4197,HCPCS,,12806-MAIN,LOCAL,,,,,6562,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,5977.982,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2725.8548,6430.76
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74334603,NDC,1,EA,12509.82,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6004.7136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74334603,NDC,1,EA,12509.82,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6004.7136,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
REVITA PLACENTAL MEMBRANE 4X4CM 16SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12560-MAIN,LOCAL,,,,,6597,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,6009.867,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
ramuCIRumab 500 MG/50ML Solution 50 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2767801,NDC,50,ML,12316.5,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6035.085,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.57,12070.17
ramuCIRumab 500 MG/50ML Solution 50 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2767801,NDC,50,ML,12316.5,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6035.085,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.57,12070.17
ramuCIRumab 500 MG/50ML Solution 50 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2767801,NDC,50,ML,12316.5,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6035.085,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.57,12070.17
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218713,NDC,2,EA,6875.36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,6064.06752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.57,6737.8528
PHASIX ST 15X20CM 1201520,C1781,CDM,278,RC,C1781,HCPCS,,13010-MAIN,LOCAL,,,,,11988,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6065.928,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
vedolizumab 300 MG Recon Soln 1 Each Vial,J3380.01,CDM,636,RC,J3380,HCPCS,,,,64764030020,NDC,1,EA,12439.04,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,8.325633333,percent of total billed charges,6095.1296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.66,12190.2592
vedolizumab 300 MG Recon Soln 1 Each Vial,J3380.01,CDM,636,RC,J3380,HCPCS,,,,64764030020,NDC,1,EA,12439.04,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6095.1296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.66,12190.2592
vedolizumab 300 MG Recon Soln 1 Each Vial,J3380.01,CDM,636,RC,J3380,HCPCS,,,,64764030020,NDC,1,EA,12439.04,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6095.1296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.66,12190.2592
ramuCIRumab 500 MG/50ML Solution 50 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2767801,NDC,50,ML,12316.5,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6096.6675,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.57,12070.17
pegfilgrastim 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019001,NDC,0.6,ML,12711.36,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6101.4528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.46,12830.846
pegfilgrastim 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019001,NDC,0.6,ML,12711.36,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6101.4528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.46,12830.846
AMNION MATRIX CORD STERILE 3X6,27200000,CDM,272,RC,C1762,HCPCS,,11625-MAIN,LOCAL,,,,,6919,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,6102.558,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Lap,Esophagogast Fundoplasty",PX43280F,CDM,510,RC,43280,CPT,,,,,,,,6713,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,6115.543,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2788.5802,8992.74
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218713,NDC,2,EA,6875.36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,6119.0704,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.57,6737.8528
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74334603,NDC,1,EA,12509.82,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,721.12,percent of total billed charges,6129.8118,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74334603,NDC,1,EA,12509.82,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6129.8118,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74334603,NDC,1,EA,12509.82,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6129.8118,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
mepolizumab 100 MG Recon Soln 1 Each Vial,J2182.01,CDM,636,RC,J2182,HCPCS,,,,173088101,NDC,1,EA,6959.95,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,6138.6759,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.51,6820.751
2.1MM CANNULATED DRILL BIT,27200000,CDM,272,RC,,,,12657-MAIN,LOCAL,,,,,747,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
3.0MM HEADED SCREW LENGTH 16MM,C1713,CDM,278,RC,C1713,HCPCS,,12656-MAIN,LOCAL,,,,,608,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
3.0MM NON-THREADED K WIRE,27200000,CDM,272,RC,C1769,HCPCS,,12658-MAIN,LOCAL,,,,,107,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
6 SHOOTER SAEED MULTIBAND LIGATOR,27200000,CDM,272,RC,,,,12379-MAIN,LOCAL,,,,,393,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM ENDOWRIST INSTRUMENTS 8MM FORCE BIPOLAR IS4000,27200000,CDM,272,RC,,,,11915-MAIN,LOCAL,,,,,439,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM ENDOWRIST INSTRUMENTS CADIERE FORCEPS,27200000,CDM,272,RC,,,,11913-MAIN,LOCAL,,,,,281,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM ENDOWRIST INSTRUMENTS LARGE NEEDLE DRIVER,27200000,CDM,272,RC,,,,11912-MAIN,LOCAL,,,,,318,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM ENDOWRIST INSTRUMENTS MEDIUM LARGE CLIP APPLIER,27200000,CDM,272,RC,,,,11910-MAIN,LOCAL,,,,,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM ENDOWRIST INSTRUMENTS MEGA SUTURE CUT NEEDLE DRIVER,27200000,CDM,272,RC,,,,11914-MAIN,LOCAL,,,,,327,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM ENDOWRIST INSTRUMENTS MONOPOLAR CURVED SCISSORS,27200000,CDM,272,RC,,,,11909-MAIN,LOCAL,,,,,648,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM ENDOWRIST INSTRUMENTS TIP-UP FENESTRATED GRASPER,27200000,CDM,272,RC,,,,11911-MAIN,LOCAL,,,,,411,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM-12MM BLADELESS OBTURATOR 8MM,27200000,CDM,272,RC,,,,11919-MAIN,LOCAL,,,,,56,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM-12MM BLADELESS OBTURATOR 8MM LONG,27200000,CDM,272,RC,,,,11920-MAIN,LOCAL,,,,,56,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM-12MM CANNULA SEAL 5-8MM,27200000,CDM,272,RC,,,,11921-MAIN,LOCAL,,,,,38,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
8MM-12MM TIP COVER ACCESSORY,27200000,CDM,272,RC,,,,11918-MAIN,LOCAL,,,,,40,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"2019-Ncov Coronavirus, Sars-Cov-2/2019-Ncov (Covid-19)",PXU000290,CDM,300,RC,U0002,HCPCS,90,,,,,,,365,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aaa US Screen Tc,PX7670601,CDM,402,RC,76706,CPT,TC,,,,,,,554,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218710,NDC,2,EA,5662.72,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218713,NDC,2,EA,6875.36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Abd Duplex Abd -Follow Up,PX9397602,CDM,921,RC,93976,CPT,TC,,,,,,,784,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Abd Duplex Abd-Follow Up(T),PX9397601,CDM,921,RC,93976,CPT,TC,,,,,,,809,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Abd Duplex Abd-Full,PX9397501,CDM,921,RC,93975,CPT,TC,,,,,,,788,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Abd Paracentesis,PX49082F,CDM,510,RC,49082,CPT,,,,,,,,884,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Abd Paracentesis W/Imaging(P),PX49083P,CDM,983,RC,49083,CPT,,,,,,,,696,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Abd Paracentesis W/Imaging(T),PX49083F,CDM,510,RC,49083,CPT,,,,,,,,1006,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ACCESSORY KIT FOR GROSHONG 16GA,120.46,CDM,272,RC,C1751,HCPCS,,2967-MAIN,LOCAL,,,,,209,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ace - Ref,PX8216490,CDM,300,RC,82164,CPT,90,,,,,,,82,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Acellular Derm Matrix Implt,PX15777F,CDM,510,RC,15777,CPT,,,,,,,,650,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Acetaminophen,PX80307E,CDM,300,RC,80307,CPT,,,,,,,,370,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315606,NDC,100,ML,264.64,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 10 MG/ML Solution 100 mL Vial,J0131.01,CDM,636,RC,J0131,HCPCS,,,,781315695,NDC,100,ML,264.64,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 120 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,713011806,NDC,1,EA,3.17,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 120 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713011812,NDC,1,EA,3.17,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 120 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802073230,NDC,1,EA,3.13,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 160 MG/5ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,68094023159,NDC,15,ML,19.14,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 160 MG/5ML Suspension 118 mL Bottle,63700001,CDM,250,RC,,,,,,45802020326,NDC,10.15625,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Acetaminophen 167 MG/5ML Liquid 237 mL Bottle,63700001,CDM,250,RC,,,,,,904584709,NDC,237,ML,27.22,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904198261,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580045811,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580060002,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 325 MG Tablet 750 Each Box,63700001,CDM,250,RC,,,,,,63739044001,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904198861,NDC,0.65,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904673061,NDC,0.65,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,50580045711,NDC,0.65,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 650 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713016512,NDC,1,EA,3.8,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 650 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802073030,NDC,1,EA,3.58,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen 650 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,70010016001,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen-codeine 300-30 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406048423,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen-codeine 300-30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406048462,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaminophen-codeine 300-30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739000410,NDC,1,EA,3.44,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetaZOLAMIDE 500 MG Recon Soln 1 Each Vial,J1120.01,CDM,636,RC,J1120,HCPCS,,,,39822019001,NDC,1,EA,207.84,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Acetone Assay,PX82010,CDM,300,RC,82010,CPT,,,,,,,,162,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069030,NDC,3,ML,14.09,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,2,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetylcysteine 20 % Solution 30 mL Vial,J7608.01,CDM,250,RC,J7608,HCPCS,,,,63323069041,NDC,3,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096321,NDC,30,ML,1231.47,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acetylcysteine 200 MG/ML Solution 30 mL Vial,J0132.01,CDM,636,RC,J0132,HCPCS,,,,63323096330,NDC,30,ML,1231.47,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Acth - Ref,PX8202490,CDM,300,RC,82024,CPT,90,,,,,,,259,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Actin Antibody Each,PX8601590,CDM,300,RC,86015,CPT,90,,,,,,,42,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ACUSNARE POLYPECTOMY SNARE,27200000,CDM,272,RC,,,,7733-MAIN,LOCAL,,,,,45.75,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Acute Hepatitis Panel,PX80074,CDM,300,RC,80074,CPT,,,,,,,,509,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acyclovir 50 MG/ML Solution 10 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,55150015410,NDC,10,ML,108.16,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acyclovir 50 MG/ML Solution 20 mL Vial,J0133.01,CDM,636,RC,J0133,HCPCS,,,,63323032524,NDC,20,ML,76.86,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
acyclovir 200 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578961,NDC,1,EA,8.21,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Acylcarnitines, Quant - Ref",PX8201790,CDM,300,RC,82017,CPT,90,,,,,,,110,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
adenosine 6 MG/2ML Solution 2 mL Syringe,J0153.01,CDM,636,RC,J0153,HCPCS,,,,25021030167,NDC,2,ML,123.1,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Admin Hep B,Adult 19+",PX3242,CDM,771,RC,90471,CPT,,,,,,,,48,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ADVANCED INSTRUMENTS 8MM SYNCHROSEAL IS4000,27200000,CDM,272,RC,,,,11924-MAIN,LOCAL,,,,,1290,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ADVANCED INSTRUMENTS ENDOWRIST SUCTION IRRIGATOR,27200000,CDM,272,RC,,,,11922-MAIN,LOCAL,,,,,496,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ADVANCED INSTRUMENTS VESSEL SEALER EXTEND,27200000,CDM,272,RC,,,,11923-MAIN,LOCAL,,,,,1169,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aerobic Isolate - Ref,PX8707790,CDM,300,RC,87077,CPT,90,,,,,,,168,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ag Detect Nos Eia Mult,PX87449,CDM,300,RC,87449,CPT,,,,,,,,193,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
agalsidase beta 5 MG Recon Soln 1 Each Vial,J0180.01,CDM,636,RC,J0180,HCPCS,,,,58468004101,NDC,1,EA,1717.68,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
AIRSEAL 12MM ACCESS PORT AND PALM GRIP OBTURATOR BLADELESS OPTICAL TIP 120MM,27200000,CDM,272,RC,,,,12207-MAIN,LOCAL,,,,,172,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
AIRSEAL ROBOTIC Xi CAP AND OBTURATOR WITH BLADELESS OPTICAL TIP,27200000,CDM,272,RC,,,,12208-MAIN,LOCAL,,,,,210,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
AIRSEAL ROBOTIC Xi TRI LUMEN FILTERED TUBE SET WITH ACTIVATED CHARCOAL,27200000,CDM,272,RC,,,,12209-MAIN,LOCAL,,,,,210,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
AIRSEAL TUBE SET TRI LUMEN FILTERED WITH ACTIVATED CHARCOAL,27200000,CDM,272,RC,,,,12206-MAIN,LOCAL,,,,,172,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Airway Inhalation Treatment,PX94640F,CDM,410,RC,94640,CPT,,,,,,,,242,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
albumin human 25% 25 % Solution 50 mL Flex Cont,P9047,CDM,636,RC,P9047,HCPCS,,,,944049301,NDC,50,ML,402.67,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Albumin, Blood",PX82040,CDM,300,RC,82040,CPT,90,,,,,,,58,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Albumin, Othr Source - Ref",PX8204290,CDM,300,RC,82042,CPT,90,,,,,,,57,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Albumin, Serum - Ref",PX8204090,CDM,300,RC,82040,CPT,90,,,,,,,57,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Albumin; Other Source, Quantitative, Each Specimen",PX82042,CDM,300,RC,82042,CPT,,,,,,,,28,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
albuterol (2.5 MG/3ML) 0.083% Nebulization Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487950101,NDC,3,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
albuterol (5 MG/ML) 0.5% Nebulization Solution 20 mL Bottle,J7611.01,CDM,250,RC,,,,,,50383074120,NDC,20,ML,225.2,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
albuterol 1.25 MG/3ML Nebulization Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487990425,NDC,3,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
albuterol HFA 108 (90 Base) MCG/ACT Aerosol Solution 8 g Inhaler,25000000,CDM,250,RC,,,,,,173068224,NDC,8,GR,149.04,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
albuterol-ipratropium 20-100 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597002402,NDC,4,GR,1601.75,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Alcohol,PX80307A,CDM,300,RC,80307,CPT,,,,,,,,370,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Alcohol Biomarkers; 1 or 2 - Ref,PX8032190,CDM,300,RC,80321,CPT,90,,,,,,,181,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Alcohol Swabstick 70 % Pad 50 Each Box,800000,CDM,,,,,,,,18407061105,NDC,1,EA,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Alcohols - Ref,PX8032090,CDM,300,RC,80320,CPT,90,,,,,,,189,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aldolase - Ref,PX8208590,CDM,300,RC,82085,CPT,90,,,,,,,89,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aldosterone - Ref,PX8208890,CDM,300,RC,82088,CPT,90,,,,,,,86,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
alendronate 70 MG Tablet 4 Each Box,63700001,CDM,250,RC,,,,,,16714063301,NDC,1,EA,97.37,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALEXIS 0 LARGE STERILE,27200000,CDM,272,RC,,,,11765-MAIN,LOCAL,,,,,102.85,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Alkaloids, Not Otherwise Specified - Ref",PX8032390,CDM,300,RC,80323,CPT,90,,,,,,,65,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALLOGRAFT BONE AUGMENT INJECTABLE KIT 1.5CC,C1734,CDM,278,RC,C1734,HCPCS,,12632-MAIN,LOCAL,,,,,3694,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
allopurinol 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020501,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
allopurinol 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584098811,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
allopurinol 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,53489015601,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904657161,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020520,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
allopurinol 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,62584098801,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Alpha-Fetoprotein Serum,PX82105,CDM,300,RC,82105,CPT,,,,,,,,77,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Alpha-Fetoprotein, Serum - Ref",PX8210590,CDM,300,RC,82105,CPT,90,,,,,,,80,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALPRAZolam 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862067701,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALPRAZolam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585961,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALPRAZolam 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,781106101,NDC,1,EA,3.73,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALPRAZolam 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,67253090010,NDC,1,EA,3.73,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALPRAZolam 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585861,NDC,1,EA,3.41,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ALPRAZolam 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739064410,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
alteplase 1 MG/ML Solution 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,8888800497,NDC,1,EA,21140.86,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004110,NDC,1,EA,666.53,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
alteplase 2 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242004164,NDC,1,EA,666.52,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
alteplase 100 MG Recon Soln 1 Each Syringe,J2997.01,CDM,636,RC,J2997,HCPCS,,,,88888800475,NDC,0.09,EA,1920.88,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
alteplase 100 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242008527,NDC,1,EA,21140.86,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aluminum & magnesium hydroxide-simethicone 200-200-20 MG/5ML Suspension 30 mL Cup,63700001,CDM,250,RC,,,,,,121176130,NDC,30,ML,24.12,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,703903201,NDC,2,ML,44.46,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amikacin 500 MG/2ML Solution 2 mL Vial,J0278.01,CDM,636,RC,J0278,HCPCS,,,,23155029031,NDC,2,ML,98.99,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987501,NDC,3,ML,33.77,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,143987525,NDC,3,ML,33.22,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061601,NDC,3,ML,31.57,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 150 MG/3ML Solution 3 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,63323061603,NDC,3,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 150-4.21 MG/100ML-% Solution 100 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066015010,NDC,100,ML,249.22,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,245014789,NDC,0.5,EA,21.33,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,245014701,NDC,0.5,EA,21.33,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739038710,NDC,0.5,EA,9.08,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 360-4.14 MG/200ML-% Solution 200 mL Plas Cont,J0283.01,CDM,636,RC,J0283,HCPCS,,,,43066036020,NDC,200,ML,325.25,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amiodarone 900 MG/18ML Solution 18 mL Vial,J0282.01,CDM,636,RC,J0282,HCPCS,,,,67457015318,NDC,18,ML,113.73,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amitriptyline 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268003711,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amitriptyline 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687043311,NDC,0.4,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amitriptyline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687043301,NDC,0.4,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 2.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079045001,NDC,1,EA,9.28,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904636961,NDC,1,EA,8.55,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079045020,NDC,1,EA,9.28,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687026311,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084025911,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637061,NDC,0.5,EA,4.41,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687026301,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084025901,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amLODIPine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637161,NDC,0.25,EA,3.03,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ammonium lactate 12 % Cream 385 g Tube,63700001,CDM,250,RC,,,,,,45802049326,NDC,385,GR,256.76,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
AMNION MATRIX CORD STERILE 3X6,27200000,CDM,272,RC,C1762,HCPCS,,11625-MAIN,LOCAL,,,,,6919,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 125 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,143988815,NDC,150,ML,25.84,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 125 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,781603955,NDC,150,ML,25.84,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 250 MG Tablet Chewable 100 Each Bottle,63700001,CDM,250,RC,,,,,,93226801,NDC,1,EA,3.62,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 250 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,93415580,NDC,150,ML,43.22,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 250 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,65862070755,NDC,5,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 250 MG/5ML Recon Susp 150 mL Package,63700001,CDM,250,RC,,,,,,99998805601,NDC,5,ML,15.24,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 400 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,65862007101,NDC,3.125,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714029903,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin 875 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862001501,NDC,1,EA,4.67,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,43598020453,NDC,10,ML,58.73,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,60432006547,NDC,10,ML,34.98,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin-clavulanate 250-62.5 MG/5ML Recon Susp 150 mL Bottle,63700001,CDM,250,RC,,,,,,72508020415,NDC,10,ML,58.73,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin-clavulanate 500-125 MG Tablet 20 Each Bottle,63700001,CDM,250,RC,,,,,,16714047701,NDC,1,EA,20.33,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
amoxicillin-clavulanate 875-125 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862050301,NDC,1,EA,26.59,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Amphetamines; 1 or 2 - Ref,PX8032490,CDM,300,RC,80324,CPT,90,,,,,,,147,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Amphetamines; 3 or 4,PX8032590,CDM,300,RC,80325,CPT,90,,,,,,,48,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin 1 GM Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781926185,NDC,0.5,EA,43.18,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927380,NDC,1,EA,99.91,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin 2 g Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781927395,NDC,1,EA,99.91,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin 500 MG Recon Soln 1 Each Vial,J0290.01,CDM,636,RC,J0290,HCPCS,,,,781925078,NDC,1,EA,44.28,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin-sulbactam 1.5 (1-0.5) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001381,NDC,1,EA,69.24,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,49001481,NDC,1,EA,102.12,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011701,NDC,1,EA,89.64,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ampicillin-sulbactam 3 (2-1) g Recon Soln 1 Each Vial,J0295.01,CDM,636,RC,J0295,HCPCS,,,,55150011710,NDC,1,EA,89.64,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Amputation Finger/Thumb,PX26951F,CDM,510,RC,26951,CPT,,,,,,,,3253,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Amputation Finger/Thumb,PX26951P,CDM,983,RC,26951,CPT,,,,,,,,2603,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Amputation Metatarsal+Toe,Single",PX28810F,CDM,510,RC,28810,CPT,,,,,,,,930,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Amputation Metatarsal+Toe,Single",PX28810P,CDM,983,RC,28810,CPT,,,,,,,,620,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Amputation Toe,I-P Jt",PX28825F,CDM,510,RC,28825,CPT,,,,,,,,1327,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Amputation Toe,I-P Jt",PX28825P,CDM,983,RC,28825,CPT,,,,,,,,780,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Amputation Toe,Mt-P Jt",PX28820F,CDM,510,RC,28820,CPT,,,,,,,,1950,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Amputation Toe,Mt-P Jt",PX28820P,CDM,983,RC,28820,CPT,,,,,,,,1300,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Amylase - Ref,PX8215090,CDM,300,RC,82150,CPT,90,,,,,,,185,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anal Sphincterotomy,PX46080F,CDM,510,RC,46080,CPT,,,,,,,,607,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anal Sphincterotomy,PX46080P,CDM,983,RC,46080,CPT,,,,,,,,525,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
anastrozole 1 MG Tablet 1 Each Blister,25000000,CDM,250,RC,,,,,,60687011211,NDC,1,EA,11.13,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
anastrozole 1 MG Tablet 30 Each Bottle,25000000,CDM,250,RC,,,,,,16729003510,NDC,1,EA,71.44,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
anastrozole 1 MG Tablet 30 Each Box,25000000,CDM,250,RC,,,,,,60687011221,NDC,1,EA,11.13,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anca Screen Each Antibody,PX8603690,CDM,300,RC,86036,CPT,90,,,,,,,82,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ANCHORAGE FIXATION PIN,27200000,CDM,272,RC,,,,12642-MAIN,LOCAL,,,,,389,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Androsetenedione - Ref,PX8215790,CDM,300,RC,82157,CPT,90,,,,,,,107,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Dx Shoulder Arthroscopy,PX01622.01,CDM,964,RC,1622,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Lower Intestinal Endoscopic Px Nos,PX00811.01,CDM,964,RC,811,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Lower Intestinal Screening Colonoscopy,PX00812.01,CDM,964,RC,812,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Spine Transthor W/Vent,PX00626.01,CDM,964,RC,626,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Spine Tranthor W/O Vent,PX00625.01,CDM,964,RC,625,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Ther Interven Rad Art,PX01924.01,CDM,964,RC,1924,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Ther Interven Rad Car,PX01925.01,CDM,964,RC,1925,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Ther Interven Rad Tip,PX01931.01,CDM,964,RC,1931,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Ther Interven Rad Vei,PX01930.01,CDM,964,RC,1930,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Tx Interv Rad Cran V,PX01933.01,CDM,964,RC,1933,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Tx Interv Rad Hrt/Cran,PX01926.01,CDM,964,RC,1926,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Tx Interv Rad Th Vein,PX01932.01,CDM,964,RC,1932,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Upper GI Endoscopic Px Ercp,PX00732.01,CDM,964,RC,732,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Upper GI Endoscopic Px Nos,PX00731.01,CDM,964,RC,731,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Upper/Lower GI Endoscopic Px,PX00813.01,CDM,964,RC,813,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes/Analg Cs Deliver Add-On,PX01968.01,CDM,964,RC,1968,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Abdomen Vessel Surg,PX00880.01,CDM,964,RC,880,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Abdominal Wall Surg,PX00700.01,CDM,964,RC,700,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Abdominal Wall Surg,PX00730.01,CDM,964,RC,730,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Abdominal Wall Surg,PX00800.01,CDM,964,RC,800,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Abdominal Wall Surg,PX00820.01,CDM,964,RC,820,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Achilles Tendon Surg,PX01472.01,CDM,964,RC,1472,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Airplane Cast,PX01682.01,CDM,964,RC,1682,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Amniocentesis,PX00842.01,CDM,964,RC,842,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Amputation at Knee,PX01404.01,CDM,964,RC,1404,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Amputation at Pelvis,PX01140.01,CDM,964,RC,1140,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Amputation of Femur,PX01232.01,CDM,964,RC,1232,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Amputation of Penis,PX00932.01,CDM,964,RC,932,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Ankle Replacement,PX01486.01,CDM,964,RC,1486,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Ankle/Ft Arthroscopy,PX01464.01,CDM,964,RC,1464,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Anorectal Surgery,PX00902.01,CDM,964,RC,902,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Antepartum Manipul,PX01958.01,CDM,964,RC,1958,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Arm-Leg Vessel Surg,PX01656.01,CDM,964,RC,1656,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Arthroscopy of Hip,PX01202.01,CDM,964,RC,1202,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Biceps Tendon Repair,PX01716.01,CDM,964,RC,1716,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Biopsy of Nose,PX00164.01,CDM,964,RC,164,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Biopsy of Thyroid,PX00322.01,CDM,964,RC,322,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Bladder Stone Surg,PX00870.01,CDM,964,RC,870,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Bladder Surgery,PX00910.01,CDM,964,RC,910,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Bladder Tumor Surg,PX00912.01,CDM,964,RC,912,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Bleeding Control,PX00916.01,CDM,964,RC,916,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Blepharoplasty,PX00103.01,CDM,964,RC,103,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Blood Vessel Repair,PX00770.01,CDM,964,RC,770,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Body Cast Procedure,PX01130.01,CDM,964,RC,1130,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Bone Aspirate/Bx,PX01112.01,CDM,964,RC,1112,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Burn 4-9 Percent,PX01952.01,CDM,964,RC,1952,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Burn Each 9 Percent,PX01953.01,CDM,964,RC,1953,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Burn Less 4 Percent,PX01951.01,CDM,964,RC,1951,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cabg W/O Pump,PX00566.01,CDM,964,RC,566,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cabg W/Pump,PX00567.01,CDM,964,RC,567,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cardiac Electrophys,PX00537.01,CDM,964,RC,537,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cardioverter/Defib,PX00534.01,CDM,964,RC,534,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cat or MRI Scan,PX01922.01,CDM,964,RC,1922,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Catheterize Heart,PX01920.01,CDM,964,RC,1920,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Drainage,PX00524.01,CDM,964,RC,524,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Lining Biopsy,PX00522.01,CDM,964,RC,522,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Partition View,PX00528.01,CDM,964,RC,528,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Partition View,PX00529.01,CDM,964,RC,529,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Procedure,PX00520.01,CDM,964,RC,520,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Surgery,PX00540.01,CDM,964,RC,540,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Wall Repair,PX00472.01,CDM,964,RC,472,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cleft Palate Repair,PX00172.01,CDM,964,RC,172,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Collar Bone Biopsy,PX00454.01,CDM,964,RC,454,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Corneal Transplant,PX00144.01,CDM,964,RC,144,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Correct Heart Rhythm,PX00410.01,CDM,964,RC,410,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cran Surg Hemotoma,PX00211.01,CDM,964,RC,211,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cranial Surg Nos,PX00210.01,CDM,964,RC,210,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cs Delivery,PX01961.01,CDM,964,RC,1961,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cs Hysterectomy,PX01963.01,CDM,964,RC,1963,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Dx Arteriography,PX01916.01,CDM,964,RC,1916,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Dx Elbow Arthroscopy,PX01732.01,CDM,964,RC,1732,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Dx Knee Arthroscopy,PX01382.01,CDM,964,RC,1382,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Dx Wrist Arthroscopy,PX01829.01,CDM,964,RC,1829,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Ear Exam,PX00124.01,CDM,964,RC,124,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Ear Surgery,PX00120.01,CDM,964,RC,120,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Elbow Area Surgery,PX01710.01,CDM,964,RC,1710,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Elbow Replacement,PX01760.01,CDM,964,RC,1760,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Electroshock,PX00104.01,CDM,964,RC,104,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Emer Hysterectomy,PX01962.01,CDM,964,RC,1962,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Esophageal Surgery,PX00500.01,CDM,964,RC,500,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Eye Exam,PX00148.01,CDM,964,RC,148,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Face/Skull Bone Surg,PX00190.01,CDM,964,RC,190,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Facial Bone Surgery,PX00192.01,CDM,964,RC,192,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Fat Layer Removal,PX00802.01,CDM,964,RC,802,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Femoral Artery Surg,PX01272.01,CDM,964,RC,1272,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Femoral Embolectomy,PX01274.01,CDM,964,RC,1274,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth for Chemonucleolysis,PX00634.01,CDM,964,RC,634,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth for Liver Biopsy,PX00702.01,CDM,964,RC,702,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth for Liver Transplant,PX00796.01,CDM,964,RC,796,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Forequarter Amput,PX01636.01,CDM,964,RC,1636,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Fx Repair Pelvis,PX01173.01,CDM,964,RC,1173,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Genitalia Surgery,PX00920.01,CDM,964,RC,920,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Head Nerve Surgery,PX00222.01,CDM,964,RC,222,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Head Vessel Surgery,PX00216.01,CDM,964,RC,216,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Head/Neck/Ptrunk,PX00300.01,CDM,964,RC,300,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Heart Surg < 1 Yr,PX00561.01,CDM,964,RC,561,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Heart Surg W/Arrest,PX00563.01,CDM,964,RC,563,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Heart Surg W/O Pump,PX00560.01,CDM,964,RC,560,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Heart/Lung Transplnt,PX00580.01,CDM,964,RC,580,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hemorr/Excise Liver,PX00792.01,CDM,964,RC,792,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hernia Repair < 1 Yr,PX00834.01,CDM,964,RC,834,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hernia Repair Preemie,PX00836.01,CDM,964,RC,836,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hip Arthroplasty,PX01214.01,CDM,964,RC,1214,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hip Disarticulation,PX01212.01,CDM,964,RC,1212,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hip Joint Procedure,PX01200.01,CDM,964,RC,1200,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hip Joint Surgery,PX01210.01,CDM,964,RC,1210,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hrt Surg W/Pmp Age 1+,PX00562.01,CDM,964,RC,562,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Humeral Lesion Surg,PX01758.01,CDM,964,RC,1758,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Humerus Repair,PX01744.01,CDM,964,RC,1744,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Humerus Surgery,PX01742.01,CDM,964,RC,1742,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hysterectomy,PX00846.01,CDM,964,RC,846,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hysteroscope/Graph,PX00952.01,CDM,964,RC,952,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Inc/Missed Ab Proc,PX01965.01,CDM,964,RC,1965,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Induced Ab Procedure,PX01966.01,CDM,964,RC,1966,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Insert Penis Device,PX00938.01,CDM,964,RC,938,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Intrcrn Nerve,PX00220.01,CDM,964,RC,220,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Iridectomy,PX00147.01,CDM,964,RC,147,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Kidney Stone Destruct,PX00872.01,CDM,964,RC,872,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Kidney Stone Destruct,PX00873.01,CDM,964,RC,873,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Kidney Transplant,PX00868.01,CDM,964,RC,868,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Kidney/Ureter Surg,PX00862.01,CDM,964,RC,862,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Area Procedure,PX01340.01,CDM,964,RC,1340,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Area Procedure,PX01390.01,CDM,964,RC,1390,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Area Surgery,PX01320.01,CDM,964,RC,1320,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Area Surgery,PX01360.01,CDM,964,RC,1360,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Area Surgery,PX01392.01,CDM,964,RC,1392,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Arteries Surg,PX01440.01,CDM,964,RC,1440,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Artery Repair,PX01444.01,CDM,964,RC,1444,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Artery Surg,PX01442.01,CDM,964,RC,1442,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Arthroplasty,PX01402.01,CDM,964,RC,1402,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Joint Casting,PX01420.01,CDM,964,RC,1420,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Joint Procedure,PX01380.01,CDM,964,RC,1380,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Joint Surgery,PX01400.01,CDM,964,RC,1400,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Veins Surgery,PX01430.01,CDM,964,RC,1430,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Vessel Surg,PX01432.01,CDM,964,RC,1432,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Larynx/Trach < 1 Yr,PX00326.01,CDM,964,RC,326,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Leg Arteries Surg,PX01500.01,CDM,964,RC,1500,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lens Surgery,PX00142.01,CDM,964,RC,142,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Low Intestine Scope,PX00810.01,CDM,964,RC,810,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Arm Casting,PX01860.01,CDM,964,RC,1860,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Arm Procedure,PX01820.01,CDM,964,RC,1820,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Arm Surgery,PX01810.01,CDM,964,RC,1810,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Arm Surgery,PX01830.01,CDM,964,RC,1830,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Arm Vein Surg,PX01850.01,CDM,964,RC,1850,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Bone Surg,PX01480.01,CDM,964,RC,1480,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Casting,PX01490.01,CDM,964,RC,1490,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Procedure,PX01462.01,CDM,964,RC,1462,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Revision,PX01484.01,CDM,964,RC,1484,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Surgery,PX01470.01,CDM,964,RC,1470,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Surgery,PX01474.01,CDM,964,RC,1474,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Vein Surg,PX01520.01,CDM,964,RC,1520,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Vein Surg,PX01522.01,CDM,964,RC,1522,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lumbar Puncture,PX00635.01,CDM,964,RC,635,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lung Chest Wall Surg,PX00546.01,CDM,964,RC,546,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lwr Arm Artery Surg,PX01840.01,CDM,964,RC,1840,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lwr Arm Embolectomy,PX01842.01,CDM,964,RC,1842,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lwr Arm Vein Repair,PX01852.01,CDM,964,RC,1852,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lwr Leg Embolectomy,PX01502.01,CDM,964,RC,1502,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Major Vein Ligation,PX00882.01,CDM,964,RC,882,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth N Block/Inj Prone,PX01992.01,CDM,964,RC,1992,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Neck Organ 1 & Over,PX00320.01,CDM,964,RC,320,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Neck Vessel Surgery,PX00350.01,CDM,964,RC,350,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Neck Vessel Surgery,PX00352.01,CDM,964,RC,352,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Nerve Block/Inj,PX01991.01,CDM,964,RC,1991,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Nose/Sinus Surgery,PX00160.01,CDM,964,RC,160,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Nose/Sinus Surgery,PX00162.01,CDM,964,RC,162,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth One Lung Ventilation,PX00541.01,CDM,964,RC,541,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pacemaker Insertion,PX00530.01,CDM,964,RC,530,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pancreas Removal,PX00794.01,CDM,964,RC,794,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvic Organ Surg,PX00848.01,CDM,964,RC,848,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvic Tumor Surgery,PX01150.01,CDM,964,RC,1150,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Nerve Removal,PX01180.01,CDM,964,RC,1180,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Nerve Removal,PX01190.01,CDM,964,RC,1190,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Procedure,PX01160.01,CDM,964,RC,1160,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Surgery,PX00844.01,CDM,964,RC,844,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Surgery,PX01120.01,CDM,964,RC,1120,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Surgery,PX01170.01,CDM,964,RC,1170,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Penis Nodes Removal,PX00934.01,CDM,964,RC,934,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Penis Nodes Removal,PX00936.01,CDM,964,RC,936,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Perc Img Dx Sp Proc,PX01935.01,CDM,964,RC,1935,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Perc Img Tx Sp Proc,PX01936.01,CDM,964,RC,1936,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Perineal Surgery,PX00904.01,CDM,964,RC,904,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pharyngeal Surgery,PX00174.01,CDM,964,RC,174,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pharyngeal Surgery,PX00176.01,CDM,964,RC,176,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Procedure on Femur,PX01220.01,CDM,964,RC,1220,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Procedure on Mouth,PX00170.01,CDM,964,RC,170,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Procedures on Eye,PX00140.01,CDM,964,RC,140,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Radical Femur Surg,PX01234.01,CDM,964,RC,1234,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Radical Humerus Surg,PX01756.01,CDM,964,RC,1756,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Radical Leg Surgery,PX01482.01,CDM,964,RC,1482,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Release of Lung,PX00542.01,CDM,964,RC,542,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Adrenal,PX00866.01,CDM,964,RC,866,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Bladder,PX00864.01,CDM,964,RC,864,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Nerves,PX00622.01,CDM,964,RC,622,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Nerves,PX00632.01,CDM,964,RC,632,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Prostate,PX00865.01,CDM,964,RC,865,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Prostate,PX00908.01,CDM,964,RC,908,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Rib,PX00470.01,CDM,964,RC,470,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Testis,PX00926.01,CDM,964,RC,926,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Testis,PX00928.01,CDM,964,RC,928,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Vulva,PX00906.01,CDM,964,RC,906,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Cervix,PX00948.01,CDM,964,RC,948,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Cleft Lip,PX00102.01,CDM,964,RC,102,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00750.01,CDM,964,RC,750,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00752.01,CDM,964,RC,752,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00754.01,CDM,964,RC,754,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00756.01,CDM,964,RC,756,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00830.01,CDM,964,RC,830,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00832.01,CDM,964,RC,832,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Revise Hip Repair,PX01215.01,CDM,964,RC,1215,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Salivary Gland,PX00100.01,CDM,964,RC,100,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Artery Surg,PX01650.01,CDM,964,RC,1650,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Casting,PX01680.01,CDM,964,RC,1680,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Joint Amput,PX01634.01,CDM,964,RC,1634,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Procedure,PX01620.01,CDM,964,RC,1620,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Replacement,PX01638.01,CDM,964,RC,1638,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Vein Surg,PX01670.01,CDM,964,RC,1670,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Vessel Surg,PX01652.01,CDM,964,RC,1652,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Vessel Surg,PX01654.01,CDM,964,RC,1654,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Sitting Procedure,PX00604.01,CDM,964,RC,604,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Skin Ext/per/Atrunk,PX00400.01,CDM,964,RC,400,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Skull Drainage,PX00212.01,CDM,964,RC,212,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Skull Drainage,PX00214.01,CDM,964,RC,214,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Skull Repair/Fract,PX00215.01,CDM,964,RC,215,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Special Head Surgery,PX00218.01,CDM,964,RC,218,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Sperm Duct Surgery,PX00922.01,CDM,964,RC,922,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Spine Cord Surgery,PX00600.01,CDM,964,RC,600,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Spine Cord Surgery,PX00620.01,CDM,964,RC,620,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Spine Cord Surgery,PX00630.01,CDM,964,RC,630,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Spine Cord Surgery,PX00670.01,CDM,964,RC,670,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Spine Manipulation,PX00640.01,CDM,964,RC,640,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Sternal Debridement,PX00550.01,CDM,964,RC,550,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Stone Removal,PX00918.01,CDM,964,RC,918,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surg Lower Abdomen,PX00840.01,CDM,964,RC,840,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surg on Vag/Urethral,PX00942.01,CDM,964,RC,942,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surg Upper Abdomen,PX00790.01,CDM,964,RC,790,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery for Obesity,PX00797.01,CDM,964,RC,797,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Abdomen,PX00860.01,CDM,964,RC,860,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Breast,PX00402.01,CDM,964,RC,402,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Breast,PX00404.01,CDM,964,RC,404,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Breast,PX00406.01,CDM,964,RC,406,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Femur,PX01230.01,CDM,964,RC,1230,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Rib(S),PX00474.01,CDM,964,RC,474,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Shoulder,PX00450.01,CDM,964,RC,450,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Shoulder,PX00452.01,CDM,964,RC,452,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Shoulder,PX01610.01,CDM,964,RC,1610,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Shoulder,PX01630.01,CDM,964,RC,1630,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Testis Exploration,PX00924.01,CDM,964,RC,924,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Testis Suspension,PX00930.01,CDM,964,RC,930,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Thigh Arteries Surg,PX01270.01,CDM,964,RC,1270,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Trach-Bronch Reconst,PX00539.01,CDM,964,RC,539,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Trachea Bronchi Surg,PX00548.01,CDM,964,RC,548,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Trans Resect of Prostate,PX00914.01,CDM,964,RC,914,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Tubal Ligation,PX00851.01,CDM,964,RC,851,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Tympanotomy,PX00126.01,CDM,964,RC,126,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Upper Arm Surgery,PX01740.01,CDM,964,RC,1740,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Upper Arm Vein Surg,PX01780.01,CDM,964,RC,1780,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Upper GI Visualize,PX00740.01,CDM,964,RC,740,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Upper Leg Surgery,PX01250.01,CDM,964,RC,1250,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Upper Leg Veins Surg,PX01260.01,CDM,964,RC,1260,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Artery Surg,PX01770.01,CDM,964,RC,1770,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Embolectomy,PX01772.01,CDM,964,RC,1772,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Procedure,PX01730.01,CDM,964,RC,1730,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Tendon Surg,PX01712.01,CDM,964,RC,1712,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Tendon Surg,PX01714.01,CDM,964,RC,1714,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Vein Repair,PX01782.01,CDM,964,RC,1782,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vaginal Delivery,PX01960.01,CDM,964,RC,1960,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vaginal Endoscopy,PX00950.01,CDM,964,RC,950,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vaginal Hysterectomy,PX00944.01,CDM,964,RC,944,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vaginal Procedures,PX00940.01,CDM,964,RC,940,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vascular Access,PX00532.01,CDM,964,RC,532,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vascular Shunt Surg,PX01844.01,CDM,964,RC,1844,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vasectomy,PX00921.01,CDM,964,RC,921,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vitreoretinal Surg,PX00145.01,CDM,964,RC,145,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Wrist Replacement,PX01832.01,CDM,964,RC,1832,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth/Analg Cs Hyst Add-On,PX01969.01,CDM,964,RC,1969,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth/Analg Vag Delivery,PX01967.01,CDM,964,RC,1967,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesthesia Level - Regional,PX37000025,CDM,370,RC,,,,,,,,,,28,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesthesia Level 3,PX37000017,CDM,370,RC,,,,,,,,,,65,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesthesia Level 4,PX37000018,CDM,370,RC,,,,,,,,,,21,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ANOSCOPE LIGHTED ANOSCOPE,120.52,CDM,272,RC,,,,10235-MAIN,LOCAL,,,,,21,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Antibiotic Sens,Enzyme Detection,Each - Ref",PX8718590,CDM,300,RC,87185,CPT,90,,,,,,,13,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Antinuclear Ab(Ana) Titer - Ref,PX8603990,CDM,300,RC,86039,CPT,90,,,,,,,52,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Antinuclear Antibodies,PX86038,CDM,300,RC,86038,CPT,,,,,,,,10,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Antinuclear Antibodiesana - Ref,PX8603890,CDM,300,RC,86038,CPT,90,,,,,,,43,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Antipsychotics, Not Otherwise Specified; 1-3 - Ref",PX8034290,CDM,300,RC,80342,CPT,90,,,,,,,152,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Antithrombin III Activity - Ref,PX8530090,CDM,300,RC,85300,CPT,90,,,,,,,158,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Antithrombin III Ag Assay - Ref,PX8530190,CDM,300,RC,85301,CPT,90,,,,,,,116,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anus Surgery Procedure Unlisted,PX46999F,CDM,510,RC,46999,CPT,,,,,,,,1431,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anus Surgery Procedure Unlisted,PX46999P,CDM,983,RC,46999,CPT,,,,,,,,953,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apc Resistance Assay - Ref,PX8530790,CDM,300,RC,85307,CPT,90,,,,,,,390,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
apixaban 2.5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,3089321,NDC,1,EA,63.84,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
apixaban 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,3089331,NDC,1,EA,50.57,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
apixaban 5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,3089421,NDC,0.5,EA,22.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
apixaban 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,3089431,NDC,0.5,EA,23.85,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
APLIGRAF LIVING BI-LAYERED SKIN SUBSTITUTE,120.514,CDM,278,RC,Q4101,HCPCS,,12082-MAIN,LOCAL,,,,,2569,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Appl on-Body Injector for Timed Subq Injection,PX96377,CDM,260,RC,96377,CPT,,,,,,,,13093,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
APPLICATOR CHLORAPREP 26ML WITH ORANGE 930815,27200000,CDM,272,RC,A4248,HCPCS,,10031-MAIN,LOCAL,,,,,19.65,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Apply Finger Splint,Static",PX29130F,CDM,420,RC,29130,CPT,,,,,,,,196,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Apply Finger Splint,Static",PX29130P,CDM,983,RC,29130,CPT,,,,,,,,223,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Forearm Cast,PX29075F,CDM,510,RC,29075,CPT,,,,,,,,210,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Forearm Cast,PX29075P,CDM,983,RC,29075,CPT,,,,,,,,140,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Apply Forearm Splint,Static",PX29125F,CDM,510,RC,29125,CPT,,,,,,,,223,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Apply Forearm Splint,Static",PX29125P,CDM,983,RC,29125,CPT,,,,,,,,296,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Long Arm Splint,PX29105F,CDM,510,RC,29105,CPT,,,,,,,,290,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Long Arm Splint,PX29105P,CDM,983,RC,29105,CPT,,,,,,,,385,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Long Leg Cast,PX29345F,CDM,510,RC,29345,CPT,,,,,,,,912,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Long Leg Splint,PX29505F,CDM,510,RC,29505,CPT,,,,,,,,320,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Long Leg Splint,PX29505P,CDM,983,RC,29505,CPT,,,,,,,,385,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Lower Leg Splint,PX29515F,CDM,510,RC,29515,CPT,,,,,,,,296,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Lower Leg Splint,PX29515P,CDM,983,RC,29515,CPT,,,,,,,,311,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Multlay Comprs Lwr Leg,PX29581F,CDM,510,RC,29581,CPT,,,,,,,,213,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Multlay Comprs Lwr Leg,PX29581P,CDM,983,RC,29581,CPT,,,,,,,,142,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply of Paste Boot,PX29580F,CDM,510,RC,29580,CPT,,,,,,,,132,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply of Paste Boot,PX29580P,CDM,983,RC,29580,CPT,,,,,,,,88,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Apply Short Leg Cast,Walker",PX29425F,CDM,510,RC,29425,CPT,,,,,,,,179,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Apply Short Leg Cast,Walker",PX29425P,CDM,983,RC,29425,CPT,,,,,,,,119,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
AQUACEL EXTRA HYDOFIBER WOUND DRESSING 4X5,120.202,CDM,272,RC,A6197,HCPCS,,12047-MAIN,LOCAL,,,,,14,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"AQUACEL FOAM DRESSING 4X4""",120.202,CDM,272,RC,A6209,HCPCS,,7939-MAIN,LOCAL,,,,,14,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
AQUACEL NONADHESIVE FOAM DRESSING 4X4,120.202,CDM,272,RC,A6209,HCPCS,,12046-MAIN,LOCAL,,,,,14,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ARIPiprazole 2 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714014101,NDC,1,EA,151.35,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714078401,NDC,0.4,EA,60.72,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43598055530,NDC,0.4,EA,61.26,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43598096630,NDC,0.4,EA,61.26,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,59148000713,NDC,1,EA,170.19,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ARIPiprazole 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862066230,NDC,1,EA,153.17,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Art Lower Extremity-Bilat,PX9392501,CDM,921,RC,93925,CPT,TC,,,,,,,1188,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Art Lower Extremity+Upper,PX9392301,CDM,921,RC,93923,CPT,TC,,,,,,,784,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Art Upper Extremity-Ltd,PX9393101,CDM,921,RC,93931,CPT,TC,,,,,,,718,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
artificial tears Ointment 3.5 g Tube,63700001,CDM,250,RC,,,,,,10119002239,NDC,3.5,GR,50.14,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ARTISTA AH 3GRAM ABSORBABLE HEMOSTATIC PARTICLES,27200000,CDM,272,RC,A6199,HCPCS,,10227-MAIN,LOCAL,,,,,486,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Asay of Interleukin-6 (Il-6),PX8352990,CDM,300,RC,83529,CPT,90,,,,,,,170,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ascorbic acid 500 MG Tablet 100 Each Box,25000000,CDM,250,RC,,,,,,904052361,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aspergillus Ag - Ref,PX8730590,CDM,300,RC,87305,CPT,90,,,,,,,141,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aspirate Pleura W/ Imaging,PX32555F,CDM,761,RC,32555,CPT,,,,,,,,795,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aspirate Pleura W/ Imaging,PX32555P,CDM,983,RC,32555,CPT,,,,,,,,536,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aspirate Pleura W/O Imaging,PX32554F,CDM,510,RC,32554,CPT,,,,,,,,795,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin 81 MG Tablet Chewable 90 Each Bottle,63700001,CDM,250,RC,,,,,,904679489,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin 81 MG Tablet Chewable 500 Each Disp Pack,63700001,CDM,250,RC,,,,,,66553000201,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin 300 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574703412,NDC,1,EA,7.83,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin 325 MG Tablet 500 Each Box,63700001,CDM,250,RC,,,,,,66553000101,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin EC 81 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,63739021210,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin EC 81 MG Tablet Delayed Release 120 Each Bottle,63700001,CDM,250,RC,,,,,,10135017362,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,536114801,NDC,0.249230769,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,536331301,NDC,0.249230769,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin EC 325 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,603016921,NDC,0.249230769,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin-dipyridamole 25-200 MG Capsule Extended Release 12 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687030533,NDC,1,EA,67.66,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aspirin-dipyridamole 25-200 MG Capsule Extended Release 12 Hour 20 Each Box,63700001,CDM,250,RC,,,,,,60687030532,NDC,1,EA,67.66,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Alkaline Phosphatase,PX84075,CDM,300,RC,84075,CPT,,,,,,,,57,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Biovlbl Testosterone Direct Measurement - Ref,PX8441090,CDM,300,RC,84410,CPT,90,,,,,,,52,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Bld/Serum Cholesterol,PX82465,CDM,300,RC,82465,CPT,,,,,,,,69,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Blood Carbon Dioxide,PX82374,CDM,300,RC,82374,CPT,,,,,,,,95,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Blood Carbon Monoxide,PX82375,CDM,300,RC,82375,CPT,,,,,,,,156,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Assay Calcium, Ionized",PX82330,CDM,300,RC,82330,CPT,,,,,,,,110,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Carbamazepine Total,PX80156,CDM,300,RC,80156,CPT,,,,,,,,145,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Cryofibrinogen,PX82585,CDM,300,RC,82585,CPT,,,,,,,,75,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Cryoglobulin,PX82595,CDM,300,RC,82595,CPT,,,,,,,,75,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Dipropylacetic Acid,PX80164,CDM,300,RC,80164,CPT,,,,,,,,132,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay for Vancomycin,PX80202,CDM,300,RC,80202,CPT,,,,,,,,314,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Iga/Igd/Igg/Igm Each,PX82784,CDM,300,RC,82784,CPT,,,,,,,,315,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of ammonia,PX82140,CDM,300,RC,82140,CPT,,,,,,,,190,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Amylase,PX82150,CDM,300,RC,82150,CPT,,,,,,,,191,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Blood Lipoprotein,PX83721,CDM,300,RC,83721,CPT,,,,,,,,76,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of CK (Cpk),PX82550,CDM,300,RC,82550,CPT,,,,,,,,150,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of creatinine,PX82565,CDM,300,RC,82565,CPT,,,,,,,,58,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Digoxin,PX80162,CDM,300,RC,80162,CPT,,,,,,,,290,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Erythropoietin,PX82668,CDM,300,RC,82668,CPT,,,,,,,,114,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Ferritin,PX82728,CDM,300,RC,82728,CPT,,,,,,,,177,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Ggt,PX82977,CDM,300,RC,82977,CPT,,,,,,,,89,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Iron,PX83540,CDM,300,RC,83540,CPT,,,,,,,,122,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Lactic Acid,PX83605,CDM,300,RC,83605,CPT,,,,,,,,150,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Lipase,PX83690,CDM,300,RC,83690,CPT,,,,,,,,132,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Lithium,PX80178,CDM,300,RC,80178,CPT,,,,,,,,124,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Natriuretic Peptide,PX83880,CDM,300,RC,83880,CPT,,,,,,,,290,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Phenytoin Total,PX80185,CDM,300,RC,80185,CPT,,,,,,,,336,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Phosphorus,PX84100,CDM,300,RC,84100,CPT,,,,,,,,150,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of protein urine,PX84156,CDM,300,RC,84156,CPT,,,,,,,,190,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Psa Total,PX84153,CDM,300,RC,84153,CPT,,,,,,,,157,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Transferrin,PX84466,CDM,300,RC,84466,CPT,,,,,,,,103,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Triglycerides,PX84478,CDM,300,RC,84478,CPT,,,,,,,,115,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay of Urea Nitrogen,PX84520,CDM,300,RC,84520,CPT,,,,,,,,58,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Other Fluid Chlorides - Ref,PX8243890,CDM,300,RC,82438,CPT,90,,,,,,,197,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Ph Body Fluids Nos,PX83986,CDM,300,RC,83986,CPT,,,,,,,,147,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Thyroid Stim Hormone,PX84443,CDM,300,RC,84443,CPT,,,,,,,,294,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Urine Urea-N,PX84540,CDM,300,RC,84540,CPT,,,,,,,,14,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Assay Vitamin B-6,PX84207,CDM,300,RC,84207,CPT,90,,,,,,,42,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Assay, Glucose, Blood Quant",PX82947,CDM,300,RC,82947,CPT,,,,,,,,58,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Astrazeneca Covid-19 Vaccine, Administration, 1st Dose",PX0021A,CDM,771,RC,,,,,,,,,,69,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Astrazeneca Covid-19 Vaccine, Adminstration, 2nd Dose",PX0022A,CDM,771,RC,,,,,,,,,,69,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atenolol 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079075901,NDC,1,EA,4.3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atenolol 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904539261,NDC,1,EA,3.83,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atenolol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079068401,NDC,0.25,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atenolol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079068420,NDC,1,EA,4.79,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atorvaSTATin 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020801,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atorvaSTATin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629061,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atorvaSTATin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020820,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atorvaSTATin 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079020901,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atorvaSTATin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629161,NDC,0.25,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atorvaSTATin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079020920,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atorvaSTATin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079021001,NDC,0.125,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine (PF) 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517040125,NDC,1,ML,71.55,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine (PF) 1 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517101025,NDC,1,ML,91.89,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 0.4 MG/ML Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100401,NDC,0.5,ML,50.91,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,17478021502,NDC,2,ML,269.45,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,60219174802,NDC,2,ML,269.45,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 1 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,60219174903,NDC,5,ML,299.49,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329333901,NDC,10,ML,79.51,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0461.01,CDM,636,RC,J0461,HCPCS,,,,76329334001,NDC,10,ML,88.88,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 1 mg/mL Solution 1 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,517100101,NDC,0.2,ML,39.42,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,641600601,NDC,0.5,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058003,NDC,0.5,ML,31.57,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
atropine 8 MG/20ML Solution 20 mL Vial,J0461.01,CDM,636,RC,J0461,HCPCS,,,,63323058020,NDC,0.5,ML,31.57,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Automated Leukocyte Count,PX85048,CDM,300,RC,85048,CPT,,,,,,,,58,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,781325394,NDC,1,EA,1049.95,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598030562,NDC,1,EA,912,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,43598046562,NDC,1,EA,798,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,63323077139,NDC,1,EA,547.2,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azaCITIDine 25 mg/mL Recon Susp 1 Each Vial,J9025.01,CDM,636,RC,J9025,HCPCS,,,,72485020101,NDC,1,EA,1049.95,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azaTHIOprine 50 MG Tablet 1 Each Blister,J7500.01,CDM,636,RC,J7500,HCPCS,,,,68084022911,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 200 MG/5ML Recon Susp 15 mL Bottle,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,59762312001,NDC,15,ML,196.35,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 250 MG Tablet 6 Each Box,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096104,NDC,1,EA,41.72,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,50111078751,NDC,1,EA,41.79,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 250 MG Tablet 6 Each Disp Pack,Q0144.01,CDM,636,RC,Q0144,HCPCS,,,,64679096105,NDC,1,EA,41.73,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039801,NDC,1,EA,67.88,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039810,NDC,1,EA,67.88,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039814,NDC,1,EA,39.84,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,63323039841,NDC,1,EA,43.14,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086000,NDC,1,EA,58.66,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
azithromycin 500 MG Recon Soln 1 Each Vial,J0456.01,CDM,636,RC,J0456,HCPCS,,,,67457086050,NDC,1,EA,58.66,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
aztreonam 1 g Recon Soln 1 Each Vial,J0457.01,CDM,636,RC,J0457,HCPCS,,,,63323040124,NDC,1,EA,176.32,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"B Cells, Total Count",PX86355,CDM,300,RC,86355,CPT,,,,,,,,56,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
B-Scan Global,PX7651201,CDM,402,RC,76512,CPT,TC,,,,,,,127,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"B.Burgdorferi, Amp Probe - Ref",PX8747690,CDM,300,RC,87476,CPT,90,,,,,,,72,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bacitracin zinc 500 UNIT/GM Ointment 28.4 g Tube,25000000,CDM,250,RC,,,,,,49348015472,NDC,28.4,GR,20.47,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bacitracin zinc 500 UNIT/GM Ointment 28.35 g Tube,25000000,CDM,250,RC,,,,,,168001131,NDC,28.35,GR,32.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
baclofen 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904647561,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
baclofen 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739047910,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bacteriostatic water(benz alc) Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409397703,NDC,30,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Bacterium Nos, Antibody - Ref",PX8660990,CDM,300,RC,86609,CPT,90,,,,,,,20,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BAG LEG URINARY STND 32OZ,120.33,CDM,272,RC,A5112,HCPCS,,4433-MAIN,LOCAL,,,,,121,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BAG URINARY DRAINAGE 2000ML 6300,120.33,CDM,274,RC,A4357,HCPCS,,1283-MAIN,LOCAL,,,,,121,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BAG URINARY DRAINAGE DYND15405H,120.33,CDM,271,RC,A4357,HCPCS,,9112-MAIN,LOCAL,,,,,12,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BAG URINARY LEG PACK 9349,120.33,CDM,272,RC,A5112,HCPCS,,623-MAIN,LOCAL,,,,,121,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BALLOON EXTRACTOR PEDS,120.358,CDM,272,RC,,,,10771-MAIN,LOCAL,,,,,73,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Baloxavir Marboxil(40 MG Dose) 2 x 20 MG tablet therapy pack 2 Each Box,800000,CDM,,,,,,,,50242082802,NDC,1,EA,384.3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
balsalazide 750 MG capsule 280 Each Bottle,63700001,CDM,250,RC,,,,,,54007928,NDC,1,EA,8.59,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
balsalazide 750 MG capsule 280 Each Bottle,63700001,CDM,250,RC,,,,,,60505257507,NDC,1,EA,8.59,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BANDAGE COBAN  4 IN 2 LAYER COMPRESSION SYSTEM  2094N,120.549,CDM,272,RC,A6441,HCPCS,,12366-MAIN,LOCAL,,,,,32,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BANDAGE COBAN LITE 4 IN 2 LAYER COMPRESSION SYSTEM 2794N,120.549,CDM,272,RC,A6441,HCPCS,,12922-MAIN,LOCAL,,,,,32,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BANDAGE ESMARK 4X9 LATEX FREE DYNJ05916,27200000,CDM,272,RC,,,,5428-MAIN,LOCAL,,,,,7.05,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BANDAGE STERILE  2"" TETRA-FLEX CLIP FREE 0151-2SV",27200000,CDM,272,RC,A6449,HCPCS,,10660-MAIN,LOCAL,,,,,5.02,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BANDAGE STERILE 3"" TETRA-FLEX CLIP FREE 0151-3SV",27200000,CDM,272,RC,A6449,HCPCS,,10661-MAIN,LOCAL,,,,,5.93,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BANDAGE STERILE 4"" TETRA-FLEX CLIP FREE  0151-4SV",27200000,CDM,272,RC,A6449,HCPCS,,10662-MAIN,LOCAL,,,,,6.7,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
baricitinib 2 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,2418230,NDC,0.5,EA,203.12,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Basic Metabolic Panel Ca Ion,PX80047,CDM,300,RC,80047,CPT,,,,,,,,17,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bcr/Abl1 Minor - Ref,PX8120790,CDM,310,RC,81207,CPT,90,,,,,,,1113,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bcr/Abl1 Other - Ref,PX8120890,CDM,310,RC,81208,CPT,90,,,,,,,1125,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bcr/Abl1 P210 - Ref,PX8120690,CDM,310,RC,81206,CPT,90,,,,,,,1144,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
beclomethasone  HFA 80 MCG/ACT Aerosol Breath Activated 10.6 g Inhaler,63700001,CDM,250,RC,,,,,,59310030480,NDC,10.6,GR,1164.84,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
belimumab (400v) 400 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010201,NDC,1,EA,3523.71,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
belimumab 120 MG Recon Soln 1 Each Vial,J0490.01,CDM,636,RC,J0490,HCPCS,,,,49401010101,NDC,1,EA,1015.95,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benazepril 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268011011,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benazepril 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268011015,NDC,1,EA,5.06,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benazepril 40 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547033810,NDC,0.125,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benazepril 40 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862011801,NDC,1,EA,5.64,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bendamustine 100 MG/4ML Solution 4 mL Vial,800000,CDM,,,J9034,HCPCS,,,,63459034804,NDC,4,ML,5046.55,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benzocaine-menthol 20-0.5 % Aerosol 56 g Can,63700001,CDM,250,RC,,,,,,16864068002,NDC,56,GR,33.3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benzocaine-menthol 20-0.5 % Aerosol 78 g Can,63700001,CDM,250,RC,,,,,,75137085520,NDC,78,GR,35.38,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benzoin Tincture 59 mL Bottle,25000000,CDM,250,RC,,,,,,49348080130,NDC,59,ML,45.93,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benzonatate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687034611,NDC,1,EA,3.91,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benzonatate 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877010501,NDC,1,EA,13.44,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
benzonatate 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904715361,NDC,1,EA,3.18,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Beta 2 Glycoprot 1 Ab,Ea - Ref",PX8614690,CDM,300,RC,86146,CPT,90,,,,,,,52,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Beta-2-Microglobulin - Ref,PX8223290,CDM,300,RC,82232,CPT,90,,,,,,,49,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
betamethasone acetate-betamethasone sodium phosphate 6 (3-3) MG/ML Suspension 5 mL Vial,J0702.01,CDM,636,RC,J0702,HCPCS,,,,517072001,NDC,1,ML,78.96,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bezlotoxumab 1000 MG/40ML Solution 40 mL Vial,J0565.01,CDM,636,RC,J0565,HCPCS,,,,6302500,NDC,40,ML,7752,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bicalutamide 50 MG Tablet 30 Each Bottle,25000000,CDM,250,RC,,,,,,16714081601,NDC,1,EA,98.01,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bile Acids Total,PX8223990,CDM,300,RC,82239,CPT,90,,,,,,,232,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bilirubin Direct,PX82248,CDM,300,RC,82248,CPT,,,,,,,,150,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bilirubin Total,PX82247,CDM,300,RC,82247,CPT,,,,,,,,150,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BINDER ABDOMINAL 9 INCH 46 TO 62 INCH XL ORT21100LXL,120.238,CDM,271,RC,A4467,HCPCS,,2989-MAIN,LOCAL,,,,,75,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BINDER ABDOMINAL 9 INCH 63 TO 74 INCH 3- PANEL ORT211002XL,120.238,CDM,271,RC,A4467,HCPCS,,37-MAIN,LOCAL,,,,,75,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BINDER ABDOMINAL 10 INCH 26 TO 50 INCHES ABB1050,120.238,CDM,271,RC,A4467,HCPCS,,52-MAIN,LOCAL,,,,,75,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BINDER ABDOMINAL 12"" HIGH 2XL 60-75INCH 4 PANEL ORT213002XL",120.238,CDM,271,RC,A4467,HCPCS,,12536-MAIN,LOCAL,,,,,75,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BINDER ABDOMINAL 12"" HIGH 30-45INCH 4 PANEL ORT21300SM",120.238,CDM,271,RC,A4467,HCPCS,,11934-MAIN,LOCAL,,,,,16,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BINDER ABDOMINAL 12"" HIGH 46 TO 62 INCH L/XL 4 PANEL ORT21300LXL",120.238,CDM,271,RC,A4467,HCPCS,,11935-MAIN,LOCAL,,,,,18,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BINDER ABDOMINAL S/M 9 INCH UP TO 45 INCHES TRI-PANNEL ABB3P45,120.238,CDM,271,RC,A4467,HCPCS,,47-MAIN,LOCAL,,,,,34,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BINDER ABDOMINAL UNISIZE 46-62IN 9 IN MDS169024,120.238,CDM,271,RC,A4467,HCPCS,,63-MAIN,LOCAL,,,,,75,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BINDER PELVIC ADULT STABILIZATION T-PODR,120.357,CDM,271,RC,A4467,HCPCS,,10734-MAIN,LOCAL,,,,,244,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BIOPSY FORCEPS HOT,27200000,CDM,272,RC,,,,4353-MAIN,LOCAL,,,,,38.25,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Biopsy of Prostate,Needle/Punch",PX55700F,CDM,510,RC,55700,CPT,,,,,,,,2039,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Biopsy of Rectum,PX45100F,CDM,510,RC,45100,CPT,,,,,,,,763,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Biopsy of Rectum,PX45100P,CDM,983,RC,45100,CPT,,,,,,,,509,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Biopsy Synovium I-P Jt,PX26110,CDM,983,RC,26110,CPT,,,,,,,,933,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Biopsy Vulva/Perineum,One Lesn",PX56605F,CDM,510,RC,56605,CPT,,,,,,,,236,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Biopsy Vulva/Perineum,One Lesn",PX56605P,CDM,983,RC,56605,CPT,,,,,,,,142,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Biopsy, Nail Unit",PX11755F,CDM,510,RC,11755,CPT,,,,,,,,1490,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Biotene Dry Mouth Liquid 473 mL Bottle,63700001,CDM,250,RC,,,,,,48582000330,NDC,5,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bisacodyl 10 MG Suppository 1 Each Box,63700001,CDM,250,RC,,,,,,713010906,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574705012,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713010912,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bisacodyl 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,904505812,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bisacodyl EC 5 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,904640761,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bismuth subsalicylate 262 MG Tablet Chewable 30 Each Box,63700001,CDM,250,RC,,,,,,904720546,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bisoprolol 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714052901,NDC,1,EA,12.1,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bisoprolol-hydroCHLOROthiazide 5-6.25 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,42799092102,NDC,1,EA,39.57,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BITE BLOCK MAXI 20MM 60FR,27200000,CDM,272,RC,,,,8144-MAIN,LOCAL,,,,,11.32,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BLADE LARYNGOSCOPE MAC #3 SINGLE USE350-005-000,120.121,CDM,272,RC,,,,8320-MAIN,LOCAL,,,,,98,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BLADE LARYNGOSCOPE MAC #4 SINGLE USE 350-012-000,120.121,CDM,272,RC,,,,8321-MAIN,LOCAL,,,,,98,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BLADE LARYNGOSCOPE MAC #X3 SINGLE USE X3-003-000,120.121,CDM,272,RC,,,,8322-MAIN,LOCAL,,,,,98,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blastomyces Antibody - Ref,PX8661290,CDM,300,RC,86612,CPT,90,,,,,,,97,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Clot Factor V Test,PX85220,CDM,300,RC,85220,CPT,,,,,,,,260,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Clot Factor VIII Test,PX85247,CDM,300,RC,85247,CPT,,,,,,,,169,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Count Reticulocytes Auto 1/> Cell Meas,PX85046,CDM,300,RC,85046,CPT,,,,,,,,47,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Culture for Bacteria,PX87040,CDM,300,RC,87040,CPT,,,,,,,,286,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Blood Gases: Ph, Po2 & Pco2",PX82803,CDM,300,RC,82803,CPT,,,,,,,,518,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Occult Peroxidase,PX82272,CDM,300,RC,82272,CPT,,,,,,,,64,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Transfusion Service,PX36430,CDM,391,RC,36430,CPT,,,,,,,,839,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Type Antigen Donor Ea,PX86902,CDM,300,RC,86902,CPT,,,,,,,,43,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Typing Abo,PX86900,CDM,300,RC,86900,CPT,,,,,,,,92,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Typing Rh (D),PX86901,CDM,300,RC,86901,CPT,,,,,,,,92,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Blood Typing, Rh Phenotype",PX86906,CDM,300,RC,86906,CPT,,,,,,,,115,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Blood Viscosity Examination,PX85810,CDM,300,RC,85810,CPT,,,,,,,,95,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Blood, Occult, Other Sources",PX82271,CDM,300,RC,82271,CPT,,,,,,,,72,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BLUE EYE SUBMUCOSAL LIFTING AGENT 5ML,27200000,CDM,272,RC,,,,12684-MAIN,LOCAL,,,,,148,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BMWD 2X2,27200000,CDM,272,RC,Q4104,HCPCS,,12134-MAIN,LOCAL,,,,,8016,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Body Fluid Cell Count,PX89050,CDM,300,RC,89050,CPT,,,,,,,,152,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Body Fluid Cell Count W Diff,PX89051,CDM,300,RC,89051,CPT,,,,,,,,224,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bone Age Studies Tc,PX7707201,CDM,320,RC,77072,CPT,TC,,,,,,,211,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bone Marrow Aspiration and Biopsy,PXG0364F,CDM,510,RC,G0364,HCPCS,,,,,,,,411,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Bone Marrow Aspiration(S),Diag",PX38220F,CDM,510,RC,38220,CPT,,,,,,,,305,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Bone Marrow Aspiration(S),Diag",PX38220P,CDM,983,RC,38220,CPT,,,,,,,,244,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BONE MARROW BIOPSY ASPIRATION NEEDLE 11G X 4 IN,120.562,CDM,272,RC,C1830,HCPCS,,12677-MAIN,LOCAL,,,,,110,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Bone Marrow Biopsy(Ies),PX38221F,CDM,510,RC,38221,CPT,,,,,,,,1221,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Bone Scan, Whole Body",PX7830601,CDM,341,RC,78306,CPT,TC,,,,,,,1896,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BONE SCREW T8 FULL THREAD 2.4MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12652-MAIN,LOCAL,,,,,289,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BONE SCREW T8 FULL THREAD 2.4MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12653-MAIN,LOCAL,,,,,289,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BONE SCREW T8 FULL THREAD 2.7MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12654-MAIN,LOCAL,,,,,289,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BONE WAX SUTURE 2.5G ETHICON,27200000,CDM,272,RC,,,,12566-MAIN,LOCAL,,,,,13,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT SHORT LARGE 01ES-L,120.45,CDM,274,RC,L4360,HCPCS,,11890-MAIN,LOCAL,,,,,93,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT SHORT MEDIUM 01ES-M,120.45,CDM,274,RC,L4360,HCPCS,,11889-MAIN,LOCAL,,,,,93,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT SHORT SMALL 01ES-S,120.45,CDM,274,RC,L4360,HCPCS,,11888-MAIN,LOCAL,,,,,93,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT SHORT X-LARGE 01ES-XL,120.45,CDM,274,RC,L4360,HCPCS,,11891-MAIN,LOCAL,,,,,93,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT SHORT X-SMALL 01ES-XS,120.45,CDM,274,RC,L4360,HCPCS,,11887-MAIN,LOCAL,,,,,93,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT STANDARD LARGE 01EF-L,120.45,CDM,274,RC,L4360,HCPCS,,11697-MAIN,LOCAL,,,,,93,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT STANDARD MEDIUM 01EF-M,120.45,CDM,274,RC,L4360,HCPCS,,11696-MAIN,LOCAL,,,,,93,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT STANDARD SMALL 01EF-S,120.45,CDM,274,RC,L4360,HCPCS,,11695-MAIN,LOCAL,,,,,93,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT STANDARD X-LARGE 01EF-XL,120.45,CDM,274,RC,L4360,HCPCS,,11698-MAIN,LOCAL,,,,,93,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT AIRSELECT STANDARD X-SMALL 01EF-XS,120.45,CDM,274,RC,L4360,HCPCS,,11694-MAIN,LOCAL,,,,,93,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT CAST LARGE 12-5/8 ORT290010L,120.247,CDM,274,RC,L3260,HCPCS,,204-MAIN,LOCAL,,,,,27,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT CAST MEDIUM 08148803,120.247,CDM,274,RC,L3260,HCPCS,,203-MAIN,LOCAL,,,,,27,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOOT CAST X-LARGE 13X5-1/2IN ORT29200XL,120.247,CDM,274,RC,L3260,HCPCS,,206-MAIN,LOCAL,,,,,27,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bortezomib 3.5 MG Recon Soln 1 Each Vial,J9041.01,CDM,636,RC,J9041,HCPCS,,,,63020004901,NDC,1,EA,3270.12,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BOUGIE TRACH 10FR 70CM COUDE 	9-0211-70",120.199,CDM,272,RC,A7520,HCPCS,,11112-MAIN,LOCAL,,,,,42,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BOUGIE TRACHEAL TUBE & GUIDE 100123515,120.199,CDM,272,RC,A7520,HCPCS,,8950-MAIN,LOCAL,,,,,42,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE ANKLE LARGE 264015,120.51,CDM,274,RC,L1902,HCPCS,,4-MAIN,LOCAL,,,,,115,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE ANKLE MEDIUM 264014,120.51,CDM,274,RC,L1902,HCPCS,,7-MAIN,LOCAL,,,,,115,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE ANKLE SMALL 264012,120.51,CDM,274,RC,L1902,HCPCS,,12-MAIN,LOCAL,,,,,115,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE ANKLE X-LARGE 264016,120.51,CDM,274,RC,L1902,HCPCS,,14-MAIN,LOCAL,,,,,115,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE ANKLE X-SMALL 264011,120.51,CDM,274,RC,L1902,HCPCS,,1-MAIN,LOCAL,,,,,115,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE KNEE LARGE SHORTRUNNER 21754,120.387,CDM,274,RC,L1833,HCPCS,,10044-MAIN,LOCAL,,,,,101,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE KNEE MEDIUM SHORTRUNNER 21753,120.387,CDM,274,RC,L1833,HCPCS,,10126-MAIN,LOCAL,,,,,101,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE KNEE SMALL SHORTRUNNER 21752,120.387,CDM,274,RC,L1833,HCPCS,,10900-MAIN,LOCAL,,,,,101,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE KNEE X-LARGE SHORTRUNNER 21755,120.387,CDM,274,RC,L1833,HCPCS,,3444-MAIN,LOCAL,,,,,101,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE KNEE XX-LARGE SHORTRUNNER 21756,120.387,CDM,274,RC,L1833,HCPCS,,10615-MAIN,LOCAL,,,,,101,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST 8-IN SM LEFT 10432,120.564,CDM,273,RC,L3809,HCPCS,,12720-MAIN,LOCAL,,,,,23,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST 8-IN SM RIGHT 10442,120.564,CDM,273,RC,L3809,HCPCS,,12716-MAIN,LOCAL,,,,,23,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST 10-IN LG RIGHT 10464,120.564,CDM,273,RC,L3809,HCPCS,,12719-MAIN,LOCAL,,,,,23,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST 10-IN SM LEFT 617083,120.564,CDM,273,RC,L3809,HCPCS,,12722-MAIN,LOCAL,,,,,23,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST 10-IN SM RIGHT 10462,120.564,CDM,273,RC,L3809,HCPCS,,12717-MAIN,LOCAL,,,,,23,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST 10-IN XL LEFT 10455,120.564,CDM,273,RC,L3809,HCPCS,,12721-MAIN,LOCAL,,,,,23,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST 10-IN XL RIGHT 10465,120.564,CDM,273,RC,L3809,HCPCS,,12715-MAIN,LOCAL,,,,,23,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST HAND THUMB LEFT 455-LT,120.315,CDM,274,RC,L3809,HCPCS,,8283-MAIN,LOCAL,,,,,77,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST HAND THUMB RIGHT 455-RT,120.315,CDM,274,RC,L3809,HCPCS,,8284-MAIN,LOCAL,,,,,77,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST WRISTPRO LEFT 10-IN LG,120.564,CDM,273,RC,L3809,HCPCS,,12724-MAIN,LOCAL,,,,,23,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRACE WRIST WRISTPRO LEFT 10-IN MED,120.564,CDM,273,RC,L3809,HCPCS,,12723-MAIN,LOCAL,,,,,23,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Breast Tomosynthesis,Dx Tc Bilat",PX7706201,CDM,401,RC,77062,CPT,TC,,,,,,,166,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Breast Tomosynthesis,Dx Tc Unilat",PX7706101,CDM,401,RC,77061,CPT,TC,,,,,,,166,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Breast Tomosynthesis,Screen Tc",PX7706301,CDM,403,RC,77063,CPT,TC,,,,,,,166,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
brimonidine 0.2 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,70069023101,NDC,5,ML,70.38,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
brimonidine 0.15 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314014405,NDC,5,ML,723.62,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
brinzolamide-brimonidine 1-0.2 % Suspension 8 mL Bottle,63700001,CDM,250,RC,,,,,,65414727,NDC,8,ML,850.88,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BRONCHOSCOPE BFLEX 5.0 SINGLE-USE 0570-0449,120.578,CDM,272,RC,,,,13020-MAIN,LOCAL,,,,,558,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.5 MG/2ML Suspension 2 mL Ampule,25000000,CDM,250,RC,,,,,,68180098405,NDC,2,ML,62.38,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,781751614,NDC,2,ML,62.38,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,781751687,NDC,2,ML,62.38,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,16714001905,NDC,2,ML,62.17,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,16714001930,NDC,2,ML,62.17,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.5 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097031986,NDC,2,ML,62.38,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,93681545,NDC,2,ML,57.71,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,93681573,NDC,2,ML,57.71,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 0.25 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,487960130,NDC,2,ML,36.47,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide 1 MG/2ML Suspension 2 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097032187,NDC,1,ML,64.97,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide-formoterol 80-4.5 MCG/ACT Aerosol 6.9 g Inhaler,63700001,CDM,250,RC,,,,,,186037228,NDC,6.9,GR,937.58,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
budesonide-formoterol 160-4.5 MCG/ACT Aerosol 6 g Inhaler,63700001,CDM,250,RC,,,,,,186037028,NDC,6,GR,1078.55,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BULB RESERVOIR SILICONE 400CC,27200000,CDM,272,RC,,,,12463-MAIN,LOCAL,,,,,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600701,NDC,10,ML,39.73,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bumetanide 0.25 MG/ML Solution 10 mL Vial,J1939.01,CDM,636,RC,J1939,HCPCS,,,,641600710,NDC,2,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
bumetanide 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,185012901,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046204,NDC,30,ML,127.94,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046201,NDC,30,ML,79.84,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.5% - EPINEPHrine 1:200,000 PF 0.5% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046203,NDC,30,ML,70.91,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409115918,NDC,1,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046401,NDC,1,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine 0.25 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046417,NDC,10,ML,54.6,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046402,NDC,1,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine 0.25 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046437,NDC,1,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine 0.25 % Solution 50 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046557,NDC,30,ML,59.84,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,409174670,NDC,1,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046801,NDC,1,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323046817,NDC,1,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.25% - EPINEPHrine 1:200,000 PF 0.25% -1:200000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,63323046837,NDC,30,ML,75.54,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"BUPivacaine 0.25%-EPINEPHrine 1:200,000 0.25% -1:200000 Solution 50 mL Vial",25000000,CDM,250,RC,,,,,,409175250,NDC,30,ML,68.6,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine in dextrose 0.75-8.25 % Solution 2 mL Ampule,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409176162,NDC,2,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine liposome 1.3 % Suspension 20 mL Vial,C9290.01,CDM,636,RC,C9290,HCPCS,,,,65250026604,NDC,10,ML,976.43,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine PF 0.5 % Solution 10 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,55150016910,NDC,10,ML,39.84,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,409116219,NDC,30,ML,32.07,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BUPivacaine PF 0.5 % Solution 30 mL Vial,J0665.01,CDM,636,RC,J0665,HCPCS,,,,63323046601,NDC,1,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buprenorphine 2 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,50383092493,NDC,1,EA,24.34,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buprenorphine 5 MCG/HR PATCH WEEKLY 4 Each Box,63700001,CDM,250,RC,,,,,,42858075040,NDC,1,EA,330.52,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buprenorphine 8 MG SL Tab 30 Each Bottle,J0571.01,CDM,636,RC,J0571,HCPCS,,,,54017713,NDC,1,EA,41.56,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buprenorphine 75 MCG FILM 1 Each Package,63700001,CDM,250,RC,,,,,,59385002101,NDC,1,EA,35.68,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buprenorphine 75 MCG FILM 60 Each Box,63700001,CDM,250,RC,,,,,,59385002160,NDC,1,EA,29.92,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buPROPion SR 150 MG Tablet Extended Release 12 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084070895,NDC,0.666666667,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buPROPion SR 150 MG Tablet Extended Release 12 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,68084070825,NDC,0.666666667,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buPROPion XL 150 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,70436001004,NDC,1,EA,23.14,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
buPROPion XL 150 MG Tablet Extended Release 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,904708404,NDC,1,EA,8.48,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
BURETROL ADD ON SET 150ML,120.38,CDM,272,RC,A4222,HCPCS,,11118-MAIN,LOCAL,,,,,18,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
busPIRone 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079098501,NDC,1,EA,4.14,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
busPIRone 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079098520,NDC,1,EA,4.14,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
butamben-tetracaine-benzocaine 2-2-14 % Aerosol 5 g Bottle,25000000,CDM,250,RC,,,,,,10223020104,NDC,5,GR,375.52,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
butamben-tetracaine-benzocaine 2-2-14 % Aerosol 20 g Bottle,25000000,CDM,250,RC,,,,,,10223020103,NDC,20,GR,589.76,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
C Diff Amplified Probe,PX87493,CDM,300,RC,87493,CPT,,,,,,,,179,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
C-COLLAR ASPEN REGULAR 79-83365,120.25,CDM,274,RC,L0140,HCPCS,,167-MAIN,LOCAL,,,,,216,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
C-COLLAR ASPEN TALL 79-83367,120.25,CDM,274,RC,L0140,HCPCS,,164-MAIN,LOCAL,,,,,216,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
C-COLLAR ASPEN X-TALL 79-83368,120.25,CDM,274,RC,L0140,HCPCS,,168-MAIN,LOCAL,,,,,216,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
C-Peptide - Ref,PX8468190,CDM,300,RC,84681,CPT,90,,,,,,,180,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
C-Reactive Protein,PX86140,CDM,300,RC,86140,CPT,,,,,,,,191,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ca 19-9,PX86301,CDM,300,RC,86301,CPT,,,,,,,,116,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cabazitaxel 60 MG/1.5ML Solution 6 mL Vial,J9043.01,CDM,636,RC,J9043,HCPCS,,,,24582411,NDC,6,ML,28293.07,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cadexomer iodine 0.9 % Gel 40 g Tube,63700001,CDM,250,RC,,,,,,40565012249,NDC,40,GR,333.86,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
caffeine citrate 60 MG/3ML Solution 3 mL Vial,J0706.01,CDM,636,RC,J0706,HCPCS,,,,63323040704,NDC,3,ML,73.84,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcitonin (salmon) 200 UNIT/ACT Solution 3.7 mL Bottle,63700001,CDM,250,RC,,,,,,60505082306,NDC,3.7,ML,489.57,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcitRIOL 0.25 MCG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687034511,NDC,1,EA,4.12,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcitRIOL 0.25 MCG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155011801,NDC,1,EA,6.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Calcium - Ref,PX8231090,CDM,300,RC,82310,CPT,90,,,,,,,10,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcium carb-cholecalciferol 600-10 mg-mcg (600-400 mg-unit) Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,20555001700,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcium carbonate 500 MG Tablet Chewable 500 Each Box,63700001,CDM,250,RC,,,,,,66553000401,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcium CHLORIDE 10 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409163140,NDC,10,ML,64.85,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcium CHLORIDE 10 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,76329330401,NDC,10,ML,79.51,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323031119,NDC,10,ML,66.39,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036001,NDC,10,ML,80.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
calcium gluconate 10 % Solution 10 mL Vial,J0612.01,CDM,636,RC,J0612,HCPCS,,,,63323036019,NDC,10,ML,86.23,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Calcium Total,PX82310,CDM,300,RC,82310,CPT,,,,,,,,57,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Calculus, Infrared Spec - Ref",PX8236590,CDM,300,RC,82365,CPT,90,,,,,,,145,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Calprotectin, Fecal - Ref",PX8399390,CDM,300,RC,83993,CPT,90,,,,,,,401,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Calr Gene Analysis Common Variants in Exon 9 - Ref,PX8121990,CDM,300,RC,81219,CPT,90,,,,,,,534,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Canalith Repositioning,PX95992,CDM,420,RC,95992,CPT,,,,,,,,128,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
candesartan 32 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,49884066109,NDC,0.125,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Candida Dna Dir Probe,PX87480,CDM,300,RC,87480,CPT,,,,,,,,127,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cannabinoids, Natural - Ref",PX8034990,CDM,300,RC,80349,CPT,90,,,,,,,49,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA ADULT LARGE OPTIFLOW OPT946,120.495,CDM,271,RC,A4615,HCPCS,,11622-MAIN,LOCAL,,,,,44,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA ADULT MEDIUM OPTIFLOW OPT944,120.495,CDM,271,RC,A4615,HCPCS,,11621-MAIN,LOCAL,,,,,44,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA ADULT SMALL OPTIFLOW OPT942,120.495,CDM,271,RC,A4615,HCPCS,,11620-MAIN,LOCAL,,,,,44,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA FOR INJECTION 1.8MM WITH 3MM LUER CONNECTION 8383.65,27200000,CDM,272,RC,,,,12004-MAIN,LOCAL,,,,,234,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA JUNIOR 2 LARGE OPTIFLOW OJR416VT,120.561,CDM,272,RC,A4615,HCPCS,,12645-MAIN,LOCAL,,,,,98,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA JUNIOR 2 MEDIUM OPTIFLOW OJR414VT,120.561,CDM,272,RC,A4615,HCPCS,,12644-MAIN,LOCAL,,,,,98,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA OPTIFLOW JUNIOR 2 SMALL OJR412VT,120.561,CDM,272,RC,A4615,HCPCS,,12643-MAIN,LOCAL,,,,,98,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA OPTIFLOW JUNIOR2+ XXL OJR520,120.494,CDM,271,RC,A4615,HCPCS,,11619-MAIN,LOCAL,,,,,84,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULA SEAL 5-12MM UNIVERSAL 470500,27200000,CDM,272,RC,,,,12885-MAIN,LOCAL,,,,,41,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CANNULATED AO HANDLE STERILE MICA SCREW SYSTEM 57S1HNDL,27200000,CDM,272,RC,,,,12446-MAIN,LOCAL,,,,,219,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CAP TOE JOINT  15MM 2.5MMX4.5MM DF RESURFACING CONTOURED COBALT CHROMIUM METATARSOPHALANGEAL 9M52-25,C1713,CDM,278,RC,C1713,HCPCS,,12532-MAIN,LOCAL,,,,,4791,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Capillary Blood Collection,PX36416,CDM,300,RC,36416,CPT,,,,,,,,60,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CAPTIFLEX SNARE SINGLE USE EXTRA SMALL 11MM,27200000,CDM,272,RC,,,,12378-MAIN,LOCAL,,,,,81,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carBAMazepine 100 MG Tablet Chewable 100 Each Box,63700001,CDM,250,RC,,,,,,904385461,NDC,1,EA,3.43,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbamide peroxide 6.5% 6.5 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904322035,NDC,15,ML,15.79,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbamide peroxide 6.5% 6.5 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904662735,NDC,15,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbidopa-levodopa 10-100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,72888010601,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbidopa-levodopa 25-100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687066111,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbidopa-levodopa 25-100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084009311,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbidopa-levodopa 25-100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687066101,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbidopa-levodopa 25-100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084009301,NDC,1,EA,4.4,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbidopa-levodopa 25-250 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084009411,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carbidopa-levodopa CR 25-100 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756046188,NDC,1,EA,5.04,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424601,NDC,15,ML,95.76,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CARBOplatin 150 MG/15ML Solution 15 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703424681,NDC,15,ML,95.76,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CARBOplatin 600 MG/60ML Solution 60 mL Vial,J9045.01,CDM,636,RC,J9045,HCPCS,,,,703423981,NDC,60,ML,301.42,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carboprost 250 MCG/ML Solution 1 mL Ampule,25000000,CDM,250,RC,,,,,,9085608,NDC,1,ML,1517.13,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Carcinoembryonic Antigen,PX82378,CDM,300,RC,82378,CPT,,,,,,,,25,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cardiac Rehab,PX93797F,CDM,943,RC,93797,CPT,,,,,,,,45,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cardiac Rehab II Eval,PX93798.05,CDM,943,RC,93798,CPT,,,,,,,,364,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cardiac Rehab II W/ Monitor,PX93798.02,CDM,943,RC,93798,CPT,,,,,,,,338,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cardiac Stress Tst,Tracing Only",PX93017,CDM,482,RC,93017,CPT,,,,,,,,1959,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cardiolipin Ab, Ea Lg - Ref",PX8614790,CDM,300,RC,86147,CPT,90,,,,,,,133,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cardioversion, Elective;Extern",PX92960F,CDM,480,RC,92960,CPT,,,,,,,,402,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cardioversion, Elective;Extern",PX92960P,CDM,983,RC,92960,CPT,,,,,,,,688,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carfilzomib 30 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010201,NDC,1,EA,2785.91,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carfilzomib 60 MG Recon Soln 1 Each Vial,J9047.01,CDM,636,RC,J9047,HCPCS,,,,76075010101,NDC,1,EA,5571.82,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Carnitine - Ref,PX8237990,CDM,300,RC,82379,CPT,90,,,,,,,104,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CARTER THOMASON CLOSURE 5MM,27200000,CDM,272,RC,,,,10278-MAIN,LOCAL,,,,,97.45,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CARTER THOMASON CLOSURE SUTURE PASSER XL 10/12MM 15MM CTXL,27200000,CDM,272,RC,,,,12946-MAIN,LOCAL,,,,,535,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carvedilol 3.125 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079077101,NDC,1,EA,11.46,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carvedilol 3.125 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904630061,NDC,0.5,EA,5.64,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carvedilol 3.125 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079077120,NDC,0.5,EA,5.73,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
carvedilol 12.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904630261,NDC,0.25,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Casiri and Imdevimab,Admin,Repeat Dose",PXM0240,CDM,771,RC,M0240,HCPCS,,,,,,,,1555,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cast/Strap Procedure Unlisted,PX29799F,CDM,510,RC,29799,CPT,,,,,,,,316,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Catecholamines, Fraction - Ref",PX8238490,CDM,300,RC,82384,CPT,90,,,,,,,145,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER BIPOLAR ELECTROHEMOSTASIS 7FR 300CM M00560070,27200000,CDM,272,RC,,,,12909-MAIN,LOCAL,,,,,700,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER FOLEY 18FR  3WAY 30CC 73018L,120.21,CDM,272,RC,A4346,HCPCS,,253-MAIN,LOCAL,,,,,33,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER FOLEY 20FR 3WAY 30CC 0167L20,120.21,CDM,272,RC,A4346,HCPCS,,251-MAIN,LOCAL,,,,,33,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER FOLEY 24FR 3WAY 30CC 0167L24,120.21,CDM,272,RC,A4346,HCPCS,,10455-MAIN,LOCAL,,,,,33,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER PUREWICK FEMALE EXTERNAL PWF030K,120.414,CDM,272,RC,A6590,HCPCS,,11836-MAIN,LOCAL,,,,,42,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER TEMP-SENSING 8FR LUBRISIL PEDS DYND110508,120.363,CDM,272,RC,A4340,HCPCS,,12777-MAIN,LOCAL,,,,,45,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER TEMP-SENSING 12FR LUBRISIL 119212M,120.363,CDM,272,RC,A4340,HCPCS,,10750-MAIN,LOCAL,,,,,45,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER TEMP-SENSING 14FR LUBRISIL 119214M,120.363,CDM,272,RC,A4340,HCPCS,,10751-MAIN,LOCAL,,,,,45,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER TEMP-SENSING 16FR LUBRISIL 119216M,120.363,CDM,272,RC,A4340,HCPCS,,10752-MAIN,LOCAL,,,,,45,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CATHETER URETERAL  5FR TIGERTAIL OPEN TIP FLEXIBLE 139005,27200000,CDM,272,RC,A4340,HCPCS,,12302-MAIN,LOCAL,,,,,40,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Catheterize for Urine Spec,PXP9612,CDM,300,RC,P9612,HCPCS,,,,,,,,161,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CAUTERY HIGH TEMP LOOP TIP,120.21,CDM,272,RC,,,,332-MAIN,LOCAL,,,,,77,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CCP Antibody,PX86200,CDM,300,RC,86200,CPT,,,,,,,,176,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CCP, Antibody - Ref",PX8620090,CDM,300,RC,86200,CPT,90,,,,,,,171,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefaDROXil 500 MG capsule 50 Each Bottle,63700001,CDM,250,RC,,,,,,16714038801,NDC,1,EA,19.98,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143992490,NDC,0.5,EA,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010110,NDC,0.5,EA,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010167,NDC,0.5,EA,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 1 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,44567070725,NDC,0.5,EA,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623100,NDC,1,EA,59.25,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 2 g Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,60505623105,NDC,1,EA,59.27,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,143998391,NDC,1,EA,83.25,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010269,NDC,1,EA,88.69,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin 10 GM Recon Soln 1 Each Vial,J0690.01,CDM,636,RC,J0690,HCPCS,,,,25021010299,NDC,1,EA,88.69,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFAZolin in D4W 1 g / 50 mL 1-4 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0690.01,CDM,636,RC,J0690,HCPCS,,,,264310311,NDC,1,EA,84.97,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefdinir 250 MG/5ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,16714039301,NDC,60,ML,510.33,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefdinir 300 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,16714039102,NDC,1,EA,27.46,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefdinir 300 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,67877054360,NDC,1,EA,27.42,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012166,NDC,1,EA,58.66,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024010,NDC,1,EA,56.73,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 1 GM Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505624500,NDC,1,EA,116.99,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012250,NDC,1,EA,77.24,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,25021012267,NDC,1,EA,77.24,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,44567024110,NDC,1,EA,76.1,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,60505614700,NDC,1,EA,212.52,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034020,NDC,1,EA,76.67,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ceFEPIme 2 g Recon Soln 1 Each Vial,J0692.01,CDM,636,RC,J0692,HCPCS,,,,63323034021,NDC,1,EA,76.67,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefoTEtan 2 g Recon Soln 1 Each Vial,800000,CDM,,,S0074,HCPCS,,,,63323038620,NDC,1,EA,240.2,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefOXitin 1 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021010910,NDC,1,EA,58.66,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefOXitin 2 g Recon Soln 1 Each Vial,J0694.01,CDM,636,RC,J0694,HCPCS,,,,25021011020,NDC,1,EA,77.24,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTAZidime 1 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023525,NDC,1,EA,49,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,409508411,NDC,1,EA,73.86,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,25021012867,NDC,1,EA,82.96,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTAZidime 2 g Recon Soln 1 Each Vial,J0713.01,CDM,636,RC,J0713,HCPCS,,,,44567023610,NDC,1,EA,77.24,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733201,NDC,0.5,EA,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320885,NDC,0.5,EA,129.71,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320895,NDC,0.5,EA,129.71,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 1 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614800,NDC,1,EA,239.18,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733513,NDC,1,EA,39.12,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320990,NDC,1,EA,410.32,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,781320995,NDC,1,EA,410.32,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,25021010720,NDC,1,EA,48.35,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 2 g Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505614900,NDC,1,EA,409.89,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,409733801,NDC,0.5,EA,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone 500 MG Recon Soln 1 Each Vial,J0696.01,CDM,636,RC,J0696,HCPCS,,,,60505615204,NDC,0.5,EA,86.76,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cefTRIAXone in dextrose 1 g / 50 mL 1-3.74 GM-%(50ML) Recon Soln 1 Each Flex Cont,J0696.01,CDM,636,RC,J0696,HCPCS,,,,264315311,NDC,1,EA,106.03,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
celecoxib 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904650261,NDC,1,EA,23.45,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
celecoxib 200 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904650361,NDC,0.5,EA,20.35,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cemiplimab-rwlc 350 MG/7ML Solution 7 mL Vial,J9119.01,CDM,636,RC,J9119,HCPCS,,,,61755000801,NDC,7,ML,19219.32,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 250 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687015211,NDC,1,EA,3.83,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 250 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687015201,NDC,1,EA,3.83,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 250 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,93417773,NDC,2.5,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 250 MG/5ML Recon Susp 100 mL Bottle,63700001,CDM,250,RC,,,,,,24979015514,NDC,2.5,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 500 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,50268015211,NDC,1,EA,6.56,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 500 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687016311,NDC,0.5,EA,3.63,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 500 MG capsule 50 Each Box,63700001,CDM,250,RC,,,,,,50268015215,NDC,1,EA,6.56,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cephALEXin 500 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687016301,NDC,0.5,EA,3.63,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
certolizumab 2 X 200 MG Kit 1 Each Box,J0717.01,CDM,636,RC,J0717,HCPCS,,,,50474070062,NDC,0.5,EA,4911.87,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ceruloplasmin - Ref,PX8239090,CDM,300,RC,82390,CPT,90,,,,,,,78,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cetirizine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904585261,NDC,0.5,EA,6.51,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cetirizine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904671761,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
charcoal activated Liquid 240 mL Bottle,63700001,CDM,250,RC,,,,,,574012108,NDC,120,ML,66.88,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Chem Cautery Granulatn Tissue,PX17250F,CDM,510,RC,17250,CPT,,,,,,,,170,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Chem Cautery Granulatn Tissue,PX17250P,CDM,983,RC,17250,CPT,,,,,,,,402,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Chemiluminescent Assay - Ref,PX8239790,CDM,300,RC,82397,CPT,90,,,,,,,78,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Chemo Ad Sq/Im Hormnl Anti-Neo,PX96402,CDM,335,RC,96402,CPT,,,,,,,,130,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chemotherapy Administration, Subq/Im Non-Hormonal Anti-Neoplastic",PX96401,CDM,335,RC,96401,CPT,,,,,,,,170,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chemotherapy, IV Infusion, 1 Hour",PX96413,CDM,335,RC,96413,CPT,,,,,,,,614,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chemotherapy, IV Infusion, Add'l Hour",PX96415,CDM,335,RC,96415,CPT,,,,,,,,191,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chemotherapy, IV Infusion, Each Add'l Sequential Infusion",PX96417,CDM,335,RC,96417,CPT,,,,,,,,328,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chemotherapy, IV Push, Additional Drug",PX96411,CDM,335,RC,96411,CPT,,,,,,,,87,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chemotherapy, IV Push, Single Drug",PX96409,CDM,335,RC,96409,CPT,,,,,,,,502,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chest Wall Manipulation,Initial",PX94667,CDM,410,RC,94667,CPT,,,,,,,,121,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chest Wall Manipulation,Subsequent",PX94668F,CDM,410,RC,94668,CPT,,,,,,,,192,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chlamydia Trachomatis Dna, Amp Probe",PX87491,CDM,300,RC,87491,CPT,,,,,,,,157,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
chlorhexidine 4 % Solution 118 mL Bottle,25000000,CDM,250,RC,,,,,,234057504,NDC,118,ML,24.09,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031801,NDC,1,ML,185.37,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
chlorproMAZINE 25 MG/ML Solution 1 mL Ampule,J3230.01,CDM,636,RC,J3230,HCPCS,,,,55150031825,NDC,1,ML,185.37,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
chlorthalidone 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378022201,NDC,0.5,EA,3.24,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CHOLANGIOGRAM CATHETER REDDICK,27200000,CDM,272,RC,,,,10232-MAIN,LOCAL,,,,,287.98,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cholecalciferol (vitamin D3) 125 MCG (5000 UT) capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,80681013100,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cholestyramine light 4 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,245003689,NDC,1,EA,27.44,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cholestyramine light 4 g Packet 42 Each Box,63700001,CDM,250,RC,,,,,,245003642,NDC,1,EA,27.42,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Chorionic gonadotropin test,PX84702,CDM,300,RC,84702,CPT,,,,,,,,210,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Chrom Anal 15-20 Cells - Ref,PX8826290,CDM,310,RC,88262,CPT,90,,,,,,,398,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Chrom Anal, 20-25 Cells - Ref",PX8826490,CDM,310,RC,88264,CPT,90,,,,,,,3141,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 0.3 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,61314065625,NDC,2.5,ML,140.92,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314065605,NDC,0.05,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714065102,NDC,0.4,EA,9.74,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862007601,NDC,0.4,EA,9.84,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084007011,NDC,1,EA,33.19,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862007701,NDC,0.2,EA,6,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637861,NDC,0.2,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904724361,NDC,0.2,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084007001,NDC,1,EA,33.17,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,25021011487,NDC,200,ML,66.28,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin in D5W 400 MG/200ML Solution 200 mL Flex Cont,J0744.01,CDM,636,RC,J0744,HCPCS,,,,36000000924,NDC,200,ML,48.65,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ciprofloxacin-dexAMETHasone 0.3-0.1 % Suspension 7.5 mL Bottle,25000000,CDM,250,RC,,,,,,43598032675,NDC,7.5,ML,976.53,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CISplatin 50 MG/50ML Solution 50 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010351,NDC,50,ML,82.27,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,703574811,NDC,100,ML,183.92,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CISplatin 100 MG/100ML Solution 100 mL Vial,J9060.01,CDM,636,RC,J9060,HCPCS,,,,63323010365,NDC,100,ML,164.54,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
citalopram 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904608461,NDC,1,EA,13.03,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
citalopram 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904608561,NDC,1,EA,14.46,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Citrate - Ref,PX8250790,CDM,300,RC,82507,CPT,90,,,,,,,56,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clarithromycin 250 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,527193106,NDC,1,EA,32.3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clarithromycin 250 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,65862022560,NDC,1,EA,32.3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin 150 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904595961,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin 300 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084024411,NDC,1,EA,6.97,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,68084024401,NDC,1,EA,6.97,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337501,NDC,50,ML,135.43,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9337502,NDC,50,ML,135.43,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9678001,NDC,50,ML,135.43,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361250,NDC,50,ML,90.53,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 600 mg / 50 ml 600 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338361650,NDC,50,ML,90.53,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989001,NDC,50,ML,160.78,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,9989002,NDC,50,ML,160.78,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,338411450,NDC,50,ML,106.23,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clindamycin in D5W 900 mg / 50 ml 900 MG/50ML Solution 50 mL Flex Cont,J0736.01,CDM,636,RC,J0736,HCPCS,,,,781329091,NDC,50,ML,119.73,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clobetasol 0.05 % Cream 60 g Tube,63700001,CDM,250,RC,,,,,,168030160,NDC,60,GR,989.25,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clobetasol 0.05 % Cream 60 g Tube,63700001,CDM,250,RC,,,,,,69238153206,NDC,60,GR,1665.95,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clobetasol 0.05 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,21922001707,NDC,60,GR,1810.35,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clobetasol 0.05 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,42291007760,NDC,60,GR,1625.97,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clonazePAM 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714075201,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clonazePAM 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16729013600,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clonazePAM 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739026310,NDC,1,EA,4.32,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clonazePAM 0.25 MG Tablet Disintegrating 1 Each Blister,63700001,CDM,250,RC,,,,,,49884030752,NDC,1,EA,6.98,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Bottle,63700001,CDM,250,RC,,,,,,57664078486,NDC,1,EA,6.98,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Box,63700001,CDM,250,RC,,,,,,555009596,NDC,1,EA,6.98,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clonazePAM 0.25 MG Tablet Disintegrating 60 Each Box,63700001,CDM,250,RC,,,,,,49884030702,NDC,1,EA,6.98,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cloNIDine 0.1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687011311,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cloNIDine 0.1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687011301,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cloNIDine 0.1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739006010,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cloNIDine 0.1 MG/24HR PATCH WEEKLY 4 Each Box,63700001,CDM,250,RC,,,,,,51862045304,NDC,1,EA,158.16,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clopidogrel 75 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904629461,NDC,1,EA,23.42,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Close Rx Dist Fingr Fx,Manipulatn",PX26755F,CDM,510,RC,26755,CPT,,,,,,,,335,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Close Rx Dist Fingr Fx,Manipulatn",PX26755P,CDM,983,RC,26755,CPT,,,,,,,,1260,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Close Rx Fingr Articular Fx,Manip",PX26742F,CDM,510,RC,26742,CPT,,,,,,,,1039,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Close Rx Fingr Articular Fx,Manip",PX26742P,CDM,983,RC,26742,CPT,,,,,,,,560,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725F,CDM,510,RC,26725,CPT,,,,,,,,495,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725P,CDM,983,RC,26725,CPT,,,,,,,,330,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545F,CDM,510,RC,23545,CPT,,,,,,,,961,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545P,CDM,983,RC,23545,CPT,,,,,,,,412,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Big Toe Fx,Manip",PX28495F,CDM,510,RC,28495,CPT,,,,,,,,857,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Big Toe Fx,Manip",PX28495P,CDM,983,RC,28495,CPT,,,,,,,,412,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Bimalleolar Fx,PX27808F,CDM,510,RC,27808,CPT,,,,,,,,650,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Bimalleolar Fx,PX27808P,CDM,983,RC,27808,CPT,,,,,,,,433,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Bimalleolar Fx,Manip",PX27810F,CDM,510,RC,27810,CPT,,,,,,,,1026,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Bimalleolar Fx,Manip",PX27810P,CDM,983,RC,27810,CPT,,,,,,,,1057,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Dist Fibula Fx,Manip",PX27788F,CDM,510,RC,27788,CPT,,,,,,,,1597,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Dist Fibula Fx,Manip",PX27788P,CDM,983,RC,27788,CPT,,,,,,,,1277,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605F,CDM,510,RC,25605,CPT,,,,,,,,1178,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605P,CDM,983,RC,25605,CPT,,,,,,,,785,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Elbow Dislocation,PX24600F,CDM,510,RC,24600,CPT,,,,,,,,706,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Elbow Dislocation,PX24600P,CDM,983,RC,24600,CPT,,,,,,,,380,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605F,CDM,510,RC,24605,CPT,,,,,,,,1124,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605P,CDM,983,RC,24605,CPT,,,,,,,,750,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Femur Shaft Fx+Manip,PX27502F,CDM,510,RC,27502,CPT,,,,,,,,1625,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Femur Shaft Fx+Manip,PX27502P,CDM,983,RC,27502,CPT,,,,,,,,1083,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535F,CDM,510,RC,24535,CPT,,,,,,,,2514,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535P,CDM,983,RC,24535,CPT,,,,,,,,2887,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx I-P Jt,Toe Dislocation",PX28660F,CDM,510,RC,28660,CPT,,,,,,,,335,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx I-P Jt,Toe Dislocation",PX28660P,CDM,983,RC,28660,CPT,,,,,,,,628,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx IP Jt Dislocation,PX26770F,CDM,510,RC,26770,CPT,,,,,,,,1231,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx IP Jt Dislocation,PX26770P,CDM,983,RC,26770,CPT,,,,,,,,1353,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Kneecap Disloc+Anesth,PX27562F,CDM,510,RC,27562,CPT,,,,,,,,604,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Kneecap Disloc+Anesth,PX27562P,CDM,983,RC,27562,CPT,,,,,,,,1404,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Kneecap Dislocatn,PX27560F,CDM,510,RC,27560,CPT,,,,,,,,468,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Kneecap Dislocatn,PX27560P,CDM,983,RC,27560,CPT,,,,,,,,312,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Metacarpal Fx,PX26600F,CDM,510,RC,26600,CPT,,,,,,,,443,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Metacarpal Fx,PX26600P,CDM,983,RC,26600,CPT,,,,,,,,295,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505F,CDM,510,RC,24505,CPT,,,,,,,,2109,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505P,CDM,983,RC,24505,CPT,,,,,,,,2353,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Mt-Phal Toe Dislocation,PX28630F,CDM,510,RC,28630,CPT,,,,,,,,360,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Mt-Phal Toe Dislocation,PX28630P,CDM,983,RC,28630,CPT,,,,,,,,248,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266F,CDM,510,RC,27266,CPT,,,,,,,,1684,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266P,CDM,983,RC,27266,CPT,,,,,,,,2275,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565F,CDM,510,RC,25565,CPT,,,,,,,,1250,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565P,CDM,983,RC,25565,CPT,,,,,,,,830,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Radial Head Disloc,Child",PX24640F,CDM,510,RC,24640,CPT,,,,,,,,270,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Radial Head Disloc,Child",PX24640P,CDM,983,RC,24640,CPT,,,,,,,,180,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Radial Head/Neck Fx,Manip",PX24655F,CDM,510,RC,24655,CPT,,,,,,,,1750,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Radial Head/Neck Fx,Manip",PX24655P,CDM,983,RC,24655,CPT,,,,,,,,1824,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505F,CDM,510,RC,25505,CPT,,,,,,,,651,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505P,CDM,983,RC,25505,CPT,,,,,,,,977,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Shldr Disloc,Anesthesia",PX23655F,CDM,510,RC,23655,CPT,,,,,,,,1776,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Shldr Disloc,Anesthesia",PX23655P,CDM,983,RC,23655,CPT,,,,,,,,1421,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Shldr Dislocation,PX23650F,CDM,510,RC,23650,CPT,,,,,,,,689,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Shldr Dislocation,PX23650P,CDM,983,RC,23650,CPT,,,,,,,,516,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Spont Hip Disloc,Anesth",PX27257F,CDM,510,RC,27257,CPT,,,,,,,,548,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Spont Hip Disloc,Anesth",PX27257P,CDM,983,RC,27257,CPT,,,,,,,,365,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Talus Fx,Manipulatn",PX28435F,CDM,510,RC,28435,CPT,,,,,,,,1705,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Talus Fx,Manipulatn",PX28435P,CDM,983,RC,28435,CPT,,,,,,,,1137,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752F,CDM,510,RC,27752,CPT,,,,,,,,2280,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752P,CDM,983,RC,27752,CPT,,,,,,,,2495,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Toe Fx,Manipulatn",PX28515F,CDM,510,RC,28515,CPT,,,,,,,,390,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Toe Fx,Manipulatn",PX28515P,CDM,983,RC,28515,CPT,,,,,,,,260,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Trimalleolar Fx,PX27816F,CDM,510,RC,27816,CPT,,,,,,,,522,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Trimalleolar Fx,PX27816P,CDM,983,RC,27816,CPT,,,,,,,,826,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Trimalleolar Fx,Manip",PX27818F,CDM,510,RC,27818,CPT,,,,,,,,813,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Trimalleolar Fx,Manip",PX27818P,CDM,983,RC,27818,CPT,,,,,,,,1352,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Weight Bear Dist Tib,Manip",PX27825F,CDM,510,RC,27825,CPT,,,,,,,,2695,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Weight Bear Dist Tib,Manip",PX27825P,CDM,983,RC,27825,CPT,,,,,,,,1796,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Treat Wrist Dislocation,PX25660P,CDM,983,RC,25660,CPT,,,,,,,,1507,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CLOSED WOUND ROUND CHANNEL DRAIN WITH TROCAR 15FR FULL FLUTED,27200000,CDM,272,RC,,,,12223-MAIN,LOCAL,,,,,39,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Clostridium Ag, Eia",PX87324,CDM,300,RC,87324,CPT,,,,,,,,99,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closure of Gastrostomy,Surgical",PX43870P,CDM,983,RC,43870,CPT,,,,,,,,4012,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closure Superf Wnd Dehis Simple,PX12020F,CDM,510,RC,12020,CPT,,,,,,,,632,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closure Superf Wnd Dehis Simple,PX12020P,CDM,983,RC,12020,CPT,,,,,,,,422,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clotrimazole 1 % Cream 28 g Tube,25000000,CDM,250,RC,,,,,,536127222,NDC,28,GR,15.36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clotrimazole 1 % Cream 28.35 g Tube,25000000,CDM,250,RC,,,,,,904782231,NDC,28.35,GR,50.75,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clotrimazole-betamethasone 1-0.05 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,51672404801,NDC,15,GR,172.95,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
clotrimazole-betamethasone 1-0.05 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,66993089815,NDC,15,GR,192.55,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Clotting Function Activity - Ref,PX8539790,CDM,300,RC,85397,CPT,90,,,,,,,334,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Clozapine - Ref,PX8015990,CDM,300,RC,80159,CPT,90,,,,,,,65,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cloZAPine 100 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,378086005,NDC,0.25,EA,4.42,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cmv Antibody - Ref,PX8664490,CDM,300,RC,86644,CPT,90,,,,,,,104,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cmv Detect, Amplifi Probe - Ref",PX8749690,CDM,300,RC,87496,CPT,90,,,,,,,147,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cmv Igm Antibody - Ref,PX8664590,CDM,300,RC,86645,CPT,90,,,,,,,125,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cmv, Quant - Ref",PX8749790,CDM,300,RC,87497,CPT,90,,,,,,,194,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cns Dna/Rna Amp Probe Multiple Subtypes 12-25,PX87483,CDM,300,RC,87483,CPT,,,,,,,,864,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cocaine 4% 4 % Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527172874,NDC,4,ML,875.53,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,527197174,NDC,4,ML,960.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,64950036204,NDC,4,ML,1067.22,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cocaine hcl 40 MG/ML Solution 4 mL Bottle,C9046.01,CDM,636,RC,C9046,HCPCS,,,,70839036204,NDC,4,ML,1280.66,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Coccidioides Antibody - Ref,PX8663590,CDM,300,RC,86635,CPT,90,,,,,,,94,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
codeine 30 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54024424,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cognitive Funct Ther Interv, Ea Addl 15 Min",PX97130,CDM,420,RC,97130,CPT,,,,,,,,82,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cognitive Funct Ther Interv, Initial 15 Min",PX97129,CDM,420,RC,97129,CPT,,,,,,,,85,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cognitive Funct Ther Interv, per Day",PX97127,CDM,420,RC,97127,CPT,,,,,,,,135,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cognitive Skill Dev, Ea 15 Min",PX97532,CDM,420,RC,97532,CPT,,,,,,,,157,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
colchicine 0.6 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,49884017111,NDC,1,EA,36.17,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Collagen Cross Links - Ref,PX8252390,CDM,300,RC,82523,CPT,90,,,,,,,170,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
collagenase 250 UNIT/GM Ointment 30 g Tube,63700001,CDM,250,RC,,,,,,50484001030,NDC,30,GR,1083.77,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"COLLAR CERVICAL 2"" SMALL UNIVERSAL 08140039",120.249,CDM,274,RC,L0120,HCPCS,,270-MAIN,LOCAL,,,,,101,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"COLLAR CERVICAL 2X20"" SMALL 1003-02",120.249,CDM,274,RC,L0120,HCPCS,,272-MAIN,LOCAL,,,,,101,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"COLLAR CERVICAL 2X23.5"" MEDIUM XNARROW 1003-04",120.249,CDM,274,RC,L0120,HCPCS,,273-MAIN,LOCAL,,,,,101,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"COLLAR CERVICAL 10-15"" SMALL XLONG 1005-06",120.249,CDM,274,RC,L0120,HCPCS,,267-MAIN,LOCAL,,,,,101,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"COLLAR CERVICAL LARGE 21.5""X5"" 1005-04",120.249,CDM,274,RC,L0120,HCPCS,,268-MAIN,LOCAL,,,,,101,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
COLLAR CERVICAL LARGE WITH TRACH 2 PIECE PHP-T4L,120.184,CDM,274,RC,L0172,HCPCS,,10142-MAIN,LOCAL,,,,,37,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"COLLAR CERVICAL MEDIUM 20-1/2X4"" 1005-03",120.249,CDM,274,RC,L0120,HCPCS,,269-MAIN,LOCAL,,,,,101,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
COLLAR CERVICAL MEDIUM WITH TRACH 2 PIECE PHP-T4M,120.183,CDM,274,RC,L0172,HCPCS,,10141-MAIN,LOCAL,,,,,37,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
COLLAR CERVICAL SMALL 1005-02,120.249,CDM,274,RC,L0120,HCPCS,,266-MAIN,LOCAL,,,,,101,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
COLLAR CERVICAL SMALL WITH TRACH 2 PIECE PHP-T4S,120.182,CDM,274,RC,L0172,HCPCS,,10140-MAIN,LOCAL,,,,,37,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
COLLAR CERVICAL X-LARGE WITH TRACH 2 PIECE OSG2404,120.185,CDM,274,RC,L0172,HCPCS,,10143-MAIN,LOCAL,,,,,49,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Collect Blood From Picc,PX36592,CDM,949,RC,36592,CPT,,,,,,,,198,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Collect Blood From Picc,PX36592F,CDM,510,RC,36592,CPT,,,,,,,,211,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscope, Submucous Inj",PX45381F,CDM,750,RC,45381,CPT,,,,,,,,1179,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1039.878,6141.46
"Colonoscope, Submucous Inj",PX45381P,CDM,983,RC,45381,CPT,,,,,,,,1215,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Colonoscopy,PX44388F,CDM,750,RC,44388,CPT,,,,,,,,930,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,820.26,6141.46
Colonoscopy,PX44388P,CDM,983,RC,44388,CPT,,,,,,,,620,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390F,CDM,750,RC,45390,CPT,,,,,,,,1419,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1251.558,6141.46
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390P,CDM,982,RC,45390,CPT,,,,,,,,1135,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscopy,Biopsy",PX45380F,CDM,750,RC,45380,CPT,,,,,,,,2465,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2174.13,6141.46
"Colonoscopy,Biopsy",PX45380P,CDM,983,RC,45380,CPT,,,,,,,,2539,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscopy,Control Bleeding",PX45382F,CDM,750,RC,45382,CPT,,,,,,,,1215,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1071.63,6141.46
"Colonoscopy,Flex,Diagnostic",PX45378F,CDM,750,RC,45378,CPT,,,,,,,,1286,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1134.252,6141.46
"Colonoscopy,Flex,Diagnostic",PX45378P,CDM,983,RC,45378,CPT,,,,,,,,1200,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscopy,Flex,Screen",PX2002F,CDM,750,RC,G0105,HCPCS,,,,,,,,2539,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2239.398,6141.46
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384F,CDM,750,RC,45384,CPT,,,,,,,,2350,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2072.7,6141.46
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384P,CDM,983,RC,45384,CPT,,,,,,,,1436,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscopy,Remv Lesn,Snare",PX45385F,CDM,750,RC,45385,CPT,,,,,,,,1939,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1710.198,6141.46
"Colonoscopy,Remv Lesn,Snare",PX45385P,CDM,983,RC,45385,CPT,,,,,,,,2424,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscopy,Screen Prev",PX2004F,CDM,750,RC,G0121,HCPCS,,,,,,,,2502,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2206.764,6141.46
"Colonoscopy,Transendoscopic Stent",PX45387F,CDM,750,RC,45387,CPT,,,,,,,,3228,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2847.096,6141.46
"Colonoscopy,Transendoscopic Stent",PX45387P,CDM,983,RC,45387,CPT,,,,,,,,3587,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Column Chrom Ms, Quant - Ref",PX8254290,CDM,300,RC,82542,CPT,90,,,,,,,557,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Compatibility Test,Antiglob Tech",PX86922,CDM,300,RC,86922,CPT,,,,,,,,120,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Complement; Antigen, Each Component",PX86160,CDM,300,RC,86160,CPT,,,,,,,,124,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Complete Cbc Automated,PX85027,CDM,300,RC,85027,CPT,,,,,,,,129,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Complete Cbc W/Auto Diff Wbc,PX85025,CDM,300,RC,85025,CPT,,,,,,,,168,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Complex Drainage, Wound",PX10180F,CDM,510,RC,10180,CPT,,,,,,,,1050,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Complex Drainage, Wound",PX10180P,CDM,983,RC,10180,CPT,,,,,,,,767,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Compliment, Total (Ch50) - Ref",PX8616290,CDM,300,RC,86162,CPT,90,,,,,,,122,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Comprehensive Metabolic Panel,PX80053,CDM,300,RC,80053,CPT,,,,,,,,396,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Concurrent Infusion,PX96368,CDM,260,RC,96368,CPT,,,,,,,,102,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Contrast Bath Therapy,PX97034,CDM,420,RC,97034,CPT,,,,,,,,97,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
COOK EMERGENCY PNEUMOTHORAX SET,120.559,CDM,272,RC,,,,12597-MAIN,LOCAL,,,,,307,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Copper - Ref,PX8252590,CDM,300,RC,82525,CPT,90,,,,,,,94,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Correct Bunion,Metatarsal Osteotomy",PX28296F,CDM,510,RC,28296,CPT,,,,,,,,8100,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Correct Bunion,Metatarsal Osteotomy",PX28296P,CDM,983,RC,28296,CPT,,,,,,,,2150,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cortisol, Am",PX7152,CDM,300,RC,82533,CPT,,,,,,,,156,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cortisol, Free - Ref",PX8253090,CDM,300,RC,82530,CPT,90,,,,,,,82,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,548590000,NDC,1,EA,470.19,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cosyntropin 0.25 MG Recon Soln 1 Each Vial,J0834.01,CDM,636,RC,J0834,HCPCS,,,,781344071,NDC,1,EA,430.94,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CP LAG SCREW 3.6MM L22MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12757-MAIN,LOCAL,,,,,539,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CP LAG SCREW 3.6MM L24MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12650-MAIN,LOCAL,,,,,539,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CP LAG SCREW 3.6MM L26MM T8,C1713,CDM,278,RC,C1713,HCPCS,,12636-MAIN,LOCAL,,,,,539,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cpap/Bipap Mgmnt-Pt Own Equipment,PX94660.02F,CDM,410,RC,94660,CPT,,,,,,,,497,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Creatine Mb Fraction,PX82553,CDM,300,RC,82553,CPT,,,,,,,,353,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Creatinine; Other Source - Ref,PX82570,CDM,300,RC,82570,CPT,90,,,,,,,119,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CRICOTHROTOMY QUICKTRACH 4MM,120.228,CDM,272,RC,A7520,HCPCS,,8868-MAIN,LOCAL,,,,,494,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Critical Care, Addl 30 Min",PX99292P,CDM,983,RC,99292,CPT,,,,,,,,542,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Critical Care, E/M 30-74 Minutes",PX99291P,CDM,983,RC,99291,CPT,,,,,,,,1061,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cryptococcus Neoformans,PX87327,CDM,300,RC,87327,CPT,,,,,,,,45,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cryptosporidum,PX87328,CDM,300,RC,87328,CPT,,,,,,,,117,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Abd & Pelvis W/O Contrast,PX7417601,CDM,350,RC,74176,CPT,TC,,,,,,,4288,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Abd&Pelv 1+ Section/Regns,PX7417801,CDM,350,RC,74178,CPT,TC,,,,,,,4226,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Abdomen W/Dye,PX7416001,CDM,350,RC,74160,CPT,TC,,,,,,,3413,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Abdomen W/O & W/Dye,PX7417001,CDM,350,RC,74170,CPT,TC,,,,,,,3689,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Abdomen W/O Dye,PX7415001,CDM,350,RC,74150,CPT,TC,,,,,,,2757,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Abdomen&Pelvis W/Contrast,PX7417701,CDM,350,RC,74177,CPT,TC,,,,,,,4288,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Angio Abd&Pelv W/O&W/Dye,PX7417401,CDM,350,RC,74174,CPT,TC,,,,,,,2757,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Angio Abdom W/O & W/Dye,PX7417501,CDM,350,RC,74175,CPT,TC,,,,,,,4183,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Angio Abdominal Arteries,PX7563501,CDM,350,RC,75635,CPT,TC,,,,,,,2936,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Angio Lwr Extr W/O&W/Dye,PX7370601,CDM,350,RC,73706,CPT,TC,,,,,,,1554,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Angio Upr Extrm W/O&W/Dye,PX7320601,CDM,350,RC,73206,CPT,TC,,,,,,,757,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Angiograph Pelv W/O&W/Dye,PX7219101,CDM,350,RC,72191,CPT,TC,,,,,,,1458,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CT Angiography, Chest",PX7127501,CDM,350,RC,71275,CPT,TC,,,,,,,3689,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CT Angiography, Head",PX7049601,CDM,350,RC,70496,CPT,TC,,,,,,,3690,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CT Angiography, Neck",PX7049801,CDM,350,RC,70498,CPT,TC,,,,,,,3690,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Chest Spine W/Dye,PX7212901,CDM,350,RC,72129,CPT,TC,,,,,,,2096,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Chest Spine W/O Dye,PX7212801,CDM,350,RC,72128,CPT,TC,,,,,,,2757,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CT Colonography, Screen",PX7426301,CDM,350,RC,74263,CPT,TC,,,,,,,3330,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Head/Brain W/Dye,PX7046001,CDM,350,RC,70460,CPT,TC,,,,,,,3398,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Head/Brain W/O & W/Dye,PX7047001,CDM,350,RC,70470,CPT,TC,,,,,,,3671,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Head/Brain W/O Dye,PX7045001,CDM,350,RC,70450,CPT,TC,,,,,,,2757,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Lower Extremity W/Dye,PX7370101,CDM,350,RC,73701,CPT,TC,,,,,,,2690,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Lower Extremity W/O Dye,PX7370001,CDM,350,RC,73700,CPT,TC,,,,,,,2757,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Lumbar Spine W/Dye,PX7213201,CDM,350,RC,72132,CPT,TC,,,,,,,3330,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Lumbar Spine W/O & W/Dye,PX7213301,CDM,350,RC,72133,CPT,TC,,,,,,,4283,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Lumbar Spine W/O Dye,PX7213101,CDM,350,RC,72131,CPT,TC,,,,,,,2757,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Lwr Extremity W/O&W/Dye,PX7370201,CDM,350,RC,73702,CPT,TC,,,,,,,1235,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Maxillofacial W/Dye,PX7048701,CDM,350,RC,70487,CPT,TC,,,,,,,3332,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Maxillofacialw/O Dye,PX7048601,CDM,350,RC,70486,CPT,TC,,,,,,,2757,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Neck Spine W/O Dye,PX7212501,CDM,350,RC,72125,CPT,TC,,,,,,,2757,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Orbit/Ear/Fosa W/O Dye,PX7048001,CDM,350,RC,70480,CPT,TC,,,,,,,2757,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Orbit/Ear/Fossa W/O & W/Dye,PX7048201,CDM,350,RC,70482,CPT,TC,,,,,,,1400,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Pelvis W/Dye,PX7219301,CDM,350,RC,72193,CPT,TC,,,,,,,3330,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Pelvis W/O Dye,PX7219201,CDM,350,RC,72192,CPT,TC,,,,,,,2744,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Soft Tissue Neck W/Dye,PX7049101,CDM,350,RC,70491,CPT,TC,,,,,,,3415,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Soft Tissue Neck W/O Dye,PX7049001,CDM,350,RC,70490,CPT,TC,,,,,,,711,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Upper Extremity W/Dye,PX7320101,CDM,350,RC,73201,CPT,TC,,,,,,,2757,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CT Upper Extremity W/O Dye,PX7320001,CDM,350,RC,73200,CPT,TC,,,,,,,2757,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ctrl Nosebleed,Anter,Complex",PX30903F,CDM,510,RC,30903,CPT,,,,,,,,456,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ctrl Nosebleed,Anter,Complex",PX30903P,CDM,983,RC,30903,CPT,,,,,,,,304,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ctrl Nosebleed,Anter,Simple",PX30901F,CDM,510,RC,30901,CPT,,,,,,,,342,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ctrl Nosebleed,Anter,Simple",PX30901P,CDM,983,RC,30901,CPT,,,,,,,,229,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CUFF STERILE DISPOSABLE SPSB  STERILE 18""",27200000,CDM,272,RC,,,,7436-MAIN,LOCAL,,,,,35.89,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CUFF STERILE DISPOSABLE SPSB 12""",27200000,CDM,272,RC,,,,7435-MAIN,LOCAL,,,,,43.31,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CUFF STERILE DISPOSABLE SPSB 24""",27200000,CDM,272,RC,,,,7437-MAIN,LOCAL,,,,,37.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CUFF STERILE DISPOSABLE SPSB 34"" THIGH USE",27200000,CDM,272,RC,,,,12367-MAIN,LOCAL,,,,,,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Culture Screen Only,PX87081,CDM,300,RC,87081,CPT,,,,,,,,276,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Culture Type Immunologic,PX87147,CDM,300,RC,87147,CPT,,,,,,,,42,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CUP HEEL LARGE WONDERSPUR 4502,120.43,CDM,274,RC,L3485,HCPCS,,11385-MAIN,LOCAL,,,,,41,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CUP HEEL MEDIUM WONDERSPUR 4501,120.43,CDM,274,RC,L3485,HCPCS,,11384-MAIN,LOCAL,,,,,41,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CUP HEEL SMALL WONDERSPUR 4500,120.43,CDM,274,RC,L3485,HCPCS,,11383-MAIN,LOCAL,,,,,41,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CUP HEEL XL WONDERSPUR 4503,120.43,CDM,274,RC,L3485,HCPCS,,11386-MAIN,LOCAL,,,,,41,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cv Carotid Imaging-Bilat,PX9388001,CDM,921,RC,93880,CPT,TC,,,,,,,1088,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536136601,NDC,0.25,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536355601,NDC,0.25,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyanocobalamin 1000 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,74312001380,NDC,0.25,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,63323004401,NDC,1,ML,64.53,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyanocobalamin 1000 MCG/ML Solution 1 mL Vial,J3420.01,CDM,636,RC,J3420,HCPCS,,,,70069000501,NDC,0.1,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyclobenzaprine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079064401,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyclobenzaprine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687055811,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyclobenzaprine 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69097084607,NDC,0.5,EA,3.11,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyclobenzaprine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079064420,NDC,1,EA,5.2,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyclobenzaprine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687055801,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyclopentolate 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,17478010002,NDC,2,ML,66.55,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cyclopentolate 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,61314039601,NDC,2,ML,94.58,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781324494,NDC,1,EA,1400.9,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cycloPHOSphamide 1 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,16714085701,NDC,1,EA,1403.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cycloPHOSphamide 2 g Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,10019095701,NDC,1,EA,2988.6,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
cycloPHOSphamide 500 MG Recon Soln 1 Each Vial,J9075.01,CDM,636,RC,J9075,HCPCS,,,,781323394,NDC,1,EA,1565.71,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cyclosporine - Ref,PX8015890,CDM,300,RC,80158,CPT,90,,,,,,,95,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cystatin C - Ref,PX8261090,CDM,300,RC,82610,CPT,90,,,,,,,130,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
CYSTOSCOPY PACK I STERILE,120.505,CDM,272,RC,,,,4527-MAIN,LOCAL,,,,,155,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cystourethroscopy, With Injection(S) for Chemodenervation of the Bladder",PX52287F,CDM,360,RC,52287,CPT,,,,,,,,2745,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2421.09,6141.46
Cyto Non Gyn,PX8811201,CDM,310,RC,88112,CPT,TC,,,,,,,372,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cytoflo, Cell or Dna Anal - Ref",PX8818290,CDM,310,RC,88182,CPT,90,,,,,,,225,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cytogen, Interp/Report - Ref",PX8829190,CDM,310,RC,88291,CPT,90,,,,,,,2874,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Cytogenomic Neoplasia (Genome-Wide) Microarray Analysis - Ref,PX8127790,CDM,310,RC,81277,CPT,90,,,,,,,3850,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"D-Dimer, Quantitative - Ref",PX8537990,CDM,300,RC,85379,CPT,90,,,,,,,177,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dabigatran 75 MG capsule 60 Each Box,63700001,CDM,250,RC,,,,,,597014960,NDC,1,EA,39.83,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dabigatran 75 MG capsule 60 Each Box,63700001,CDM,250,RC,,,,,,597035556,NDC,1,EA,53.27,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dantrolene 20 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,42023012306,NDC,1,EA,394.42,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DAPTOmycin 500 MG Recon Soln 1 Each Vial,J0878.01,CDM,636,RC,J0878,HCPCS,,,,70594003402,NDC,1,EA,129.9,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
darbepoetin alfa 40 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002104,NDC,0.4,ML,1411.78,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
darbepoetin alfa 200 MCG/0.4ML solution prefilled syringe 0.4 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513002801,NDC,0.4,ML,3157.92,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
darbepoetin alfa 300 MCG/0.6ML solution prefilled syringe 0.6 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513011101,NDC,0.6,ML,4736.88,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
darbepoetin alfa 500 MCG/ML solution prefilled syringe 1 mL Syringe,J0881.01,CDM,636,RC,J0881,HCPCS,,,,55513003201,NDC,0.3,ML,2368.44,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Bone Ea Add 20 Sqcm,PX11047F,CDM,510,RC,11047,CPT,,,,,,,,438,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Bone Ea Add 20 Sqcm,PX11047P,CDM,983,RC,11047,CPT,,,,,,,,351,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Muscle Ea Add 20 Sqcm,PX11046F,CDM,510,RC,11046,CPT,,,,,,,,248,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Muscle Ea Add 20 Sqcm,PX11046P,CDM,983,RC,11046,CPT,,,,,,,,198,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Skin/Subq Ea Ad 20sqcm,PX11045F,CDM,510,RC,11045,CPT,,,,,,,,115,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Skin/Subq Ea Ad 20sqcm,PX11045P,CDM,983,RC,11045,CPT,,,,,,,,182,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Skin/Tissue,PX11042F,CDM,510,RC,11042,CPT,,,,,,,,1067,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Skin/Tissue,PX11042P,CDM,983,RC,11042,CPT,,,,,,,,995,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Tissue/Muscle,PX11043F,CDM,510,RC,11043,CPT,,,,,,,,526,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Tissue/Muscle,PX11043P,CDM,983,RC,11043,CPT,,,,,,,,351,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Tissue/Muscle/Bone,PX11044F,CDM,510,RC,11044,CPT,,,,,,,,1082,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Tissue/Muscle/Bone,PX11044P,CDM,983,RC,11044,CPT,,,,,,,,866,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Debridement of Nail(S), 1-5",PX11720F,CDM,510,RC,11720,CPT,,,,,,,,89,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Decalcify Tc,PX8831101,CDM,310,RC,88311,CPT,TC,,,,,,,107,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Declot Vascular Access Device,PX36593F,CDM,510,RC,36593,CPT,,,,,,,,358,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DEFIBRILLATION PAD BIPHASIC ADULT,120.96,CDM,271,RC,A0392,HCPCS,,1321-MAIN,LOCAL,,,,,58,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DEFIBRILLATION PAD MULTI FUNCTION ADULT,120.58,CDM,271,RC,A0392,HCPCS,,1320-MAIN,LOCAL,,,,,94,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DEFIBRILLATION PAD PEDI PADZ PEDS,120.58,CDM,271,RC,A0392,HCPCS,,1322-MAIN,LOCAL,,,,,94,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
degarelix acetate 40 mg/mL Recon Soln 1 Each Vial,J9155.01,CDM,636,RC,J9155,HCPCS,,,,55566840301,NDC,2,EA,3109.33,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
denosumab 120 MG/1.7ML Solution 1.7 mL Vial,J0897.01,CDM,636,RC,J0897,HCPCS,,,,55513073001,NDC,1.7,ML,4658.83,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Deoxyribonuclease Ab,PX86215,CDM,300,RC,86215,CPT,,,,,,,,99,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DERMABOND ADVANCED TOPICAL SKIN ADHESIVE,120.198,CDM,272,RC,,,,9101-MAIN,LOCAL,,,,,46,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DERMABOND MINI SKIN ADHESIVE,27200000,CDM,272,RC,,,,8532-MAIN,LOCAL,,,,,110.16,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DERMABOND PRINEO SKIN CLOSURE SYSTEM 22CM,27200000,CDM,272,RC,,,,12324-MAIN,LOCAL,,,,,156,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DERMABOND PRINEO SKIN CLOSURE SYSTEM 42CM,27200000,CDM,272,RC,,,,12323-MAIN,LOCAL,,,,,200,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DERMAL TIP HYFRECATOR SHARP ANGLED STAINLESS STEEL BLADE STERILE DISPOSABLE,27200000,CDM,272,RC,,,,12459-MAIN,LOCAL,,,,,7,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
desflurane Solution 240 mL Bottle,25000000,CDM,250,RC,,,,,,10019064134,NDC,240,ML,793.95,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
desipramine 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50742011401,NDC,0.2,EA,4.05,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089901,NDC,0.25,ML,95.31,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
desmopressin PF 4 MCG/ML Solution 1 mL Ampule,J2597.01,CDM,636,RC,J2597,HCPCS,,,,69918089910,NDC,0.25,ML,95.31,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Destruct Benign Lesion, 1-14",PX17110F,CDM,510,RC,17110,CPT,,,,,,,,302,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Destruct Benign Lesion, 1-14",PX17110P,CDM,983,RC,17110,CPT,,,,,,,,521,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Destruct Benign Lesion, 15+",PX17111F,CDM,510,RC,17111,CPT,,,,,,,,303,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Detect Agent Nos Dna Amp,PX87798,CDM,300,RC,87798,CPT,,,,,,,,176,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Detection of Anaplasma Phagocytophilum by Amplified Nucleic Acid Probe Technique,PX8746890,CDM,300,RC,87468,CPT,90,,,,,,,41,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Detection of Babesia Borrelia Miyamotoi by Amplified Nucleic Acid Probe Technique,PX8747890,CDM,300,RC,87478,CPT,90,,,,,,,23,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Detection of Babesia Microtim by Amplified Nucleic Acid Probe Technique,PX8746990,CDM,300,RC,87469,CPT,90,,,,,,,23,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Detection of Ehrlichia Chaffeensis by Amplified Nucleic Acid Probe Technique,PX8748490,CDM,300,RC,87484,CPT,90,,,,,,,41,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 0.1 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,24208072002,NDC,5,ML,331.81,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54417925,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54817925,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 1 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,54317644,NDC,0.5,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54817625,NDC,0.125,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016501,NDC,1,ML,34.55,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016502,NDC,0.5,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 4 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323016516,NDC,0.5,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 6 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54418625,NDC,0.041666667,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036721,NDC,1,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,641036725,NDC,1,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone 100 MG/10ML Solution 10 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323051610,NDC,0.5,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050601,NDC,1,ML,68.33,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexAMETHasone PF 10 MG/ML Solution 1 mL Vial,J1100.01,CDM,636,RC,J1100,HCPCS,,,,63323050641,NDC,0.5,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexmedeTOMIDine 200 MCG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,143953201,NDC,2,ML,62.98,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexmedeTOMIDine 200 MCG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,70860060541,NDC,2,ML,55.82,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexmedeTOMIDine in  dextrose 200MCG/50ML -5% Solution 50 mL Flex Cont,25000000,CDM,250,RC,,,,,,44567060224,NDC,50,ML,258.31,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexmedeTOMIDine in sodium chloride 200 MCG/50ML Solution 50 mL Flex Cont,25000000,CDM,250,RC,,,,,,338955524,NDC,50,ML,304.32,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dexmedeTOMIDine in sodium chloride 400 MCG/100ML Solution 100 mL Bottle,25000000,CDM,250,RC,,,,,,67457092500,NDC,100,ML,562.18,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextran 70, glycerin, hypromellose 0.1-0.2-0.3 % Solution 15 mL Bottle",63700001,CDM,250,RC,,,,,,65042636,NDC,15,ML,44.14,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextromethorphan-guaiFENesin 20-200 MG/20ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904722320,NDC,118,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5 % 5 % Solution 1,000 mL Flex Cont",J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001704,NDC,1000,ML,99.12,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5 % 5 % Solution 50 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338055111,NDC,50,ML,43.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5 % 5 % Solution 100 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001748,NDC,100,ML,43.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001702,NDC,250,ML,99.12,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5 % 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338634602,NDC,250,ML,99.12,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5 % 5 % Solution 500 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,338001703,NDC,500,ML,99.12,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338080304,NDC,1000,ML,69.59,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,409710709,NDC,1000,ML,36.53,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5 % and 0.9% NaCl 1,000 mL with potassium chloride 20 mEq 20-5-0.9 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990710709,NDC,1000,ML,69.59,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5 % Non-DEHP bag 5 % Solution 250 mL Flex Cont,J7060.01,CDM,636,RC,J7060,HCPCS,,,,264751020,NDC,250,ML,99.12,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% and sodium chloride 0.2% 5-0.2 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338007704,NDC,1000,ML,99.12,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008904,NDC,1000,ML,99.12,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5% and sodium chloride 0.9% 5-0.9 % Solution 500 mL Flex Cont,J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008903,NDC,500,ML,99.12,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% and sodium chloride 0.45% 5-0.45 % Solution 1,000 mL Flex Cont",J7042.01,CDM,636,RC,J7042,HCPCS,,,,338008504,NDC,1000,ML,99.12,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% and sodium chloride 0.45% with potassium chloride 10 mEq in 1000 mL 10-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,264763400,NDC,1000,ML,36.53,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% and sodium chloride 0.45% with potassium chloride 10 mEq in 1000 mL 10-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,338066904,NDC,1000,ML,80.61,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,264763500,NDC,1000,ML,43.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% and sodium chloride 0.45% with potassium chloride 20 mEq in 1000 mL 20-5-0.45 MEQ/L-%-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338067104,NDC,1000,ML,53.06,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"dextrose 5% lactated ringers 5 % Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012504,NDC,1000,ML,43.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 5% lactated ringers 5 % Solution 500 mL Flex Cont,J7120.01,CDM,636,RC,J7120,HCPCS,,,,338012503,NDC,500,ML,99.12,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 10% 10 % Solution 500 mL Flex Cont,25000000,CDM,250,RC,,,,,,338002303,NDC,500,ML,99.12,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 25% Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409177510,NDC,10,ML,83.53,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409751716,NDC,50,ML,72.9,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409751766,NDC,50,ML,80.89,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329330101,NDC,50,ML,107.61,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dextrose 50 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329330201,NDC,25,ML,43.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dhea-S - Ref,PX8262790,CDM,300,RC,82627,CPT,90,,,,,,,57,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Diagnostic Anoscopy,PX46600F,CDM,510,RC,46600,CPT,,,,,,,,505,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Diagnostic Anoscopy,PX46600P,CDM,983,RC,46600,CPT,,,,,,,,405,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Diagnostic Bone Marrow, Biopsy and Aspiration",PX38222F,CDM,761,RC,38222,CPT,,,,,,,,1748,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Diagnostic CT Thorax W/ Contrast,PX7126001,CDM,350,RC,71260,CPT,TC,,,,,,,3415,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Diagnostic CT Thorax W/O Contrast,PX7125001,CDM,350,RC,71250,CPT,TC,,,,,,,2757,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079028401,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 2 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,172392560,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079028420,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 2.5 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,66490065020,NDC,1,EA,1288,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 2.5 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,68682065020,NDC,1,EA,1114.05,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079028501,NDC,0.4,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,172392660,NDC,0.4,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079028520,NDC,0.4,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127303,NDC,2,ML,152.7,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 5 MG/ML Solution 2 mL Crtrdg-NDL,J3360.01,CDM,636,RC,J3360,HCPCS,,,,409127332,NDC,2,ML,176.55,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 10 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,93613832,NDC,1,EA,1212.57,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diazePAM 10 MG Gel 1 Each Box,63700001,CDM,250,RC,,,,,,187065820,NDC,1,EA,1527.87,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac 0.1 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,17478089225,NDC,2.5,ML,252.06,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,67815203,NDC,100,GR,91.77,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,45802095301,NDC,100,GR,82.76,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,49884093547,NDC,100,GR,266.25,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,58602060407,NDC,100,GR,67.56,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,65162083366,NDC,100,GR,281.12,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac 1 % Gel 100 g Tube,25000000,CDM,250,RC,,,,,,76282066339,NDC,100,GR,26.8,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diclofenac EC 50 MG Tablet Delayed Release 14 Each Bottle,63700001,CDM,250,RC,,,,,,71335048107,NDC,1,EA,4.87,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dicloxacillin 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,93312501,NDC,0.5,EA,6.73,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Digital Mamm, Diag, Bilat, Tc W/Cad Perf",PX7706601,CDM,401,RC,77066,CPT,TC,,,,,,,375,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Digital Mamm, Diag, Unilat, Tc W/Cad Perf",PX7706501,CDM,401,RC,77065,CPT,TC,,,,,,,293,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Digital Mammogram, Screen Bil, Tc W/Cad Perf",PX7706701,CDM,403,RC,77067,CPT,TC,,,,,,,375,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141031,NDC,0.5,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,641141035,NDC,2,ML,56.37,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305972,NDC,2,ML,61.19,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
digoxin 0.25 MG/ML Solution 2 mL Ampule,J1160.01,CDM,636,RC,J1160,HCPCS,,,,781305995,NDC,2,ML,61.19,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
digoxin 125 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,115981101,NDC,1,EA,7.64,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
digoxin 125 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904592161,NDC,0.5,EA,4.52,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041100,NDC,0.5,ML,196.94,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041105,NDC,1,ML,419.67,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dihydroergotamine 1 MG/ML Solution 1 mL Ampule,J1110.01,CDM,636,RC,J1110,HCPCS,,,,81284041110,NDC,0.5,ML,196.94,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dihydroxyvitamin D - Ref,PX8265290,CDM,300,RC,82652,CPT,90,,,,,,,165,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,641601301,NDC,5,ML,34.41,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,641601310,NDC,5,ML,40.58,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem 25 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,17478081705,NDC,5,ML,34.99,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem 30 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93031801,NDC,1,EA,5.36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,641601501,NDC,25,ML,58.29,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,17478081725,NDC,25,ML,81.3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem 125 MG/25ML Solution 25 mL Vial,25000000,CDM,250,RC,,,,,,70860030143,NDC,25,ML,84.47,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687019511,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687019501,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 120 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739028310,NDC,1,EA,8.04,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 180 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687020611,NDC,0.666666667,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 180 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687020601,NDC,0.666666667,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687021711,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,10370083111,NDC,0.5,EA,5.51,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739001610,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dilTIAZem CD 240 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,63739028510,NDC,1,EA,13.76,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DIMETHICONE (TOPICAL) 5 % Cream 118 mL Tube,800000,CDM,,,,,,,,53329015104,NDC,118,ML,44.12,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dimethicone 1.5 % Cream 118 mL Tube,800000,CDM,,,,,,,,53329016104,NDC,118,ML,43.4,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,693390152,NDC,2.5,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 12.5 MG/5ML Liquid 10 mL Cup,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,68094002459,NDC,10,ML,14.67,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 12.5 MG/5ML Liquid 118 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904698520,NDC,2.5,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 12.5 MG/5ML Liquid 120 mL Bottle,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,58657052804,NDC,2.5,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 25 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904530661,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 25 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904723761,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 50 MG capsule 100 Each Box,Q0163.01,CDM,636,RC,Q0163,HCPCS,,,,904205661,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,641037621,NDC,0.25,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066416,NDC,1,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,63323066441,NDC,0.25,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010101,NDC,0.25,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenhydrAMINE 50 MG/ML Solution 1 mL Vial,J1200.01,CDM,636,RC,J1200,HCPCS,,,,72485010125,NDC,1,ML,30.58,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenoxylate-atropine 2.5-0.025 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762106101,NDC,1,EA,3.76,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
diphenoxylate-atropine 2.5-0.025 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,62559049001,NDC,1,EA,3.76,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Direct Admit Hospital Observ,PXG0379,CDM,761,RC,G0379,HCPCS,,,,,,,,676,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Direct skilled nursing services of a license practical nurse (lpn) in the home health or hospice setting, each 15 minutes",PXG0300,CDM,551,RC,G0300,HCPCS,,,,,,,,75,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
divalproex 125 MG Capsule Delayed Release Sprinkle 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031311,NDC,1,EA,7.63,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
divalproex 125 MG Capsule Delayed Release Sprinkle 100 Each Box,63700001,CDM,250,RC,,,,,,68084031301,NDC,1,EA,7.62,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
divalproex 250 MG Tablet Delayed Release 1 Each Box,63700001,CDM,250,RC,,,,,,832712389,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
divalproex 250 MG Tablet Delayed Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756079788,NDC,0.5,EA,4.68,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
divalproex 250 MG Tablet Delayed Release 100 Each Box,63700001,CDM,250,RC,,,,,,832712301,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
divalproex ER 250 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031011,NDC,1,EA,13.14,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
divalproex ER 250 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084031001,NDC,1,EA,13.14,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DOBUTamine 1000 mcg/mL in dextrose 5% 250 mL premix 1000 mcg/ml Solution 250 mL Flex Cont,J1250.01,CDM,636,RC,J1250,HCPCS,,,,338107302,NDC,250,ML,146.73,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DOCEtaxel 20 MG/ML Concentrate 1 mL Vial,63600000,CDM,636,RC,J9171,HCPCS,,,,955102001,NDC,1,ML,1690.09,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DOCEtaxel 160 MG/16ML Solution 16 mL Vial,J9171.01,CDM,636,RC,J9171,HCPCS,,,,409173201,NDC,16,ML,2901.69,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
docusate sodium 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,10135011101,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
docusate sodium 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904645561,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
docusate sodium 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904718361,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
donepezil 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904640861,NDC,1,EA,41.79,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
donepezil 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904647761,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DOPamine 1600 mcg/mL in dextrose 5% 250 mL premix 1600 mcg/mL Solution 250 mL Plas Cont,J1265.01,CDM,636,RC,J1265,HCPCS,,,,338100702,NDC,250,ML,99.9,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dorzolamide-timolol 2-0.5 % Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,50383023310,NDC,10,ML,506.34,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxazosin 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079095701,NDC,1,EA,20.19,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxazosin 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904552261,NDC,1,EA,5.46,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxazosin 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079095720,NDC,1,EA,20.22,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxazosin 4 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68382078501,NDC,0.25,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxepin 10 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,51672421701,NDC,1,EA,3.36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxepin 10 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079043620,NDC,1,EA,3.43,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxycycline 100 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323013041,NDC,1,EA,140.2,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxycycline hyclate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584069311,NDC,0.5,EA,15,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxycycline hyclate 100 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,904043004,NDC,0.5,EA,12.21,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxycycline hyclate 100 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,62584069321,NDC,0.5,EA,15,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxycycline monohydrate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,60687071611,NDC,1,EA,6.87,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
doxycycline monohydrate 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084074333,NDC,1,EA,9.99,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain Blood From Under Nail,PX11740F,CDM,510,RC,11740,CPT,,,,,,,,117,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Drain Finger Abscess,Simple",PX26010F,CDM,510,RC,26010,CPT,,,,,,,,310,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Drain Finger Abscess,Simple",PX26010P,CDM,983,RC,26010,CPT,,,,,,,,207,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAIN FLAT JACKSON PRATT 10MM,27100000,CDM,271,RC,,,,334-MAIN,LOCAL,,,,,239.09,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800F,CDM,510,RC,40800,CPT,,,,,,,,255,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800P,CDM,983,RC,40800,CPT,,,,,,,,170,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain Pilonidal Cyst Simpl,PX10080F,CDM,510,RC,10080,CPT,,,,,,,,742,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain Skin Abscess Complic,PX10061F,CDM,510,RC,10061,CPT,,,,,,,,889,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain Skin Abscess Complic,PX10061P,CDM,983,RC,10061,CPT,,,,,,,,561,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain Skin Abscess Simple,PX10060F,CDM,510,RC,10060,CPT,,,,,,,,296,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain Skin Abscess Simple,PX10060P,CDM,983,RC,10060,CPT,,,,,,,,293,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Large Joint/Bursa,PX20610F,CDM,510,RC,20610,CPT,,,,,,,,364,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Large Joint/Bursa,PX20610P,CDM,983,RC,20610,CPT,,,,,,,,291,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611F,CDM,510,RC,20611,CPT,,,,,,,,456,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611P,CDM,983,RC,20611,CPT,,,,,,,,272,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Med Joint/Brusa W/US Guide,PX20606F,CDM,510,RC,20606,CPT,,,,,,,,387,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Med Joint/Brusa W/US Guide,PX20606P,CDM,983,RC,20606,CPT,,,,,,,,309,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Medium Joint/Bursa,PX20605F,CDM,510,RC,20605,CPT,,,,,,,,247,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Medium Joint/Bursa,PX20605P,CDM,983,RC,20605,CPT,,,,,,,,318,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604F,CDM,510,RC,20604,CPT,,,,,,,,344,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604P,CDM,983,RC,20604,CPT,,,,,,,,229,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Small Joint/Bursa,PX20600F,CDM,510,RC,20600,CPT,,,,,,,,161,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Small Joint/Bursa,PX20600P,CDM,983,RC,20600,CPT,,,,,,,,161,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drainage of Gum Lesion,PX41800F,CDM,510,RC,41800,CPT,,,,,,,,395,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drainage of Gum Lesion,PX41800P,CDM,983,RC,41800,CPT,,,,,,,,839,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drainage of Hematoma/Fluid (P),PX10140P,CDM,983,RC,10140,CPT,,,,,,,,465,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drainage of Hematoma/Fluid (T),PX10140F,CDM,510,RC,10140,CPT,,,,,,,,341,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drainage Scrotal Wall Abscess,PX55100F,CDM,510,RC,55100,CPT,,,,,,,,634,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drainage Scrotal Wall Abscess,PX55100P,CDM,983,RC,55100,CPT,,,,,,,,341,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE ABDOMINAL SURGICAL 14X12 POUCHES STERILE DYNJP3109,27200000,CDM,272,RC,,,,12896-MAIN,LOCAL,,,,,31,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE COLUMN 470341,27200000,CDM,272,RC,,,,12013-MAIN,LOCAL,,,,,38,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE INSTRUMENT ARM 470015,27200000,CDM,272,RC,,,,11925-MAIN,LOCAL,,,,,97,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE SHEET 70X85 LARGE DYNJP2417,27200000,CDM,272,RC,,,,10914-MAIN,LOCAL,,,,,18.39,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE SHEET LAP T-DRAPE WITH INSTRUMENT PAD DYNJP3003,27200000,CDM,272,RC,,,,10913-MAIN,LOCAL,,,,,35.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE SPLIT WITH ADHESIVE DYNJP8304A,27200000,CDM,272,RC,,,,4694-MAIN,LOCAL,,,,,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE STERILE 109X100X110 ROBOTIC DYNJP9108,27200000,CDM,272,RC,,,,12020-MAIN,LOCAL,,,,,51,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAPE SURGICAL 23X17INCH INCISE 1050,27200000,CDM,272,RC,,,,12873-MAIN,LOCAL,,,,,10,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Draw Blood Off Venous Device,PX36591F,CDM,510,RC,36591,CPT,,,,,,,,211,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRAWTEX HYDROCONDUCTIVE NONADHERENT DRESSING,120.508,CDM,271,RC,A6199,HCPCS,,12022-MAIN,LOCAL,,,,,59,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dress/Debrid Large Burn No Anesth,PX16030F,CDM,510,RC,16030,CPT,,,,,,,,399,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dress/Debrid Med Burn No Anesth,PX16025F,CDM,510,RC,16025,CPT,,,,,,,,366,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dress/Debrid Med Burn No Anesth,PX16025P,CDM,983,RC,16025,CPT,,,,,,,,244,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dress/Debrid Small Burn No Anes,PX16020F,CDM,510,RC,16020,CPT,,,,,,,,313,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"DRESSING AQUACEL 3/4"" X 18"" AG HYDROFIBER 403771",120.31,CDM,272,RC,A6199,HCPCS,,8238-MAIN,LOCAL,,,,,33,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING GEL FOAM SIZE 100SPONGE STERILE 00009034201,27200000,CDM,272,RC,A6248,HCPCS,,3378-MAIN,LOCAL,,,,,38.25,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING HYDROFERA 2-1/2X2-1/2  BLUE READY FOAM HBRS2520,120.488,CDM,271,RC,A6209,HCPCS,,11537-MAIN,LOCAL,,,,,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING MESALT 6X6 IMPREGNATED GAUZE STERILE 285780,120.511,CDM,272,RC,A6223,HCPCS,,12059-SURG,LOCAL,,,,,5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING NASAL 4.5CM NON-INFLATABLE RAPID RHINO RR450,120.97,CDM,272,RC,A6407,HCPCS,,616-MAIN,LOCAL,,,,,94,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING NASAL 5.5CM INFLATABLE RAPID RHINO RR550,120.97,CDM,272,RC,A6407,HCPCS,,606-MAIN,LOCAL,,,,,94,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING NASAL 7.5CM INFLATABLE RAPID RHINO RR750,120.97,CDM,272,RC,A6407,HCPCS,,611-MAIN,LOCAL,,,,,94,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING NASAL 8CM LONGX1.5CM THICK X3CM HIGH ANATOMICAL 34-105,120.97,CDM,272,RC,A6407,HCPCS,,613-MAIN,LOCAL,,,,,94,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING OPTIFOAM 10X4 POST-OP SILICONE FACED MSC21410Z,120.154,CDM,272,RC,A6213,HCPCS,,8632-MAIN,LOCAL,,,,,16,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING QWICK NONADHESIVE 4.25X4 SUPERABSORBENT MSC5844,120.531,CDM,272,RC,A6197,HCPCS,,12301-MAIN,LOCAL,,,,,20,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRESSING SURGICEL HEMOSTAT 4X8 ABSORBABLE 1952,120.123,CDM,272,RC,A6252,HCPCS,,1002-MAIN,LOCAL,,,,,125,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRILL BIT 2.2MM LONG SOLID STERILE MICA,27200000,CDM,272,RC,,,,12985-MAIN,LOCAL,,,,,600,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRILL BIT 2.2MMX60MM STERILE MICA CANNULATED,27200000,CDM,272,RC,,,,12437-MAIN,LOCAL,,,,,701,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRILL BIT 3.0MMX60MM STERILE MICA CANNULATED,27200000,CDM,272,RC,,,,12438-MAIN,LOCAL,,,,,701,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRILL BIT AO DIA 2.0MMX135MM SCALED,27200000,CDM,272,RC,,,,12640-MAIN,LOCAL,,,,,452,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRIVER HEX 2.00MM STERILE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12440-MAIN,LOCAL,,,,,512,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DRIVER HEX 2.5MM STERILE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12441-MAIN,LOCAL,,,,,512,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
droPERidol 2.5 MG/ML Solution 2 mL Vial,J1790.01,CDM,636,RC,J1790,HCPCS,,,,517970201,NDC,2,ML,75.47,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Drug(S) or Substance(S), Definitive, Qualitative or Quantitative, Not Otherwise Specified; 1-3 - Ref",PX8037590,CDM,300,RC,80375,CPT,90,,,,,,,150,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DULoxetine 20 MG Capsule Delayed Release Particles 60 Each Bottle,63700001,CDM,250,RC,,,,,,2323560,NDC,1,EA,41.76,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DULoxetine 20 MG Capsule Delayed Release Particles 60 Each Bottle,63700001,CDM,250,RC,,,,,,57237001760,NDC,1,EA,37.58,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DULoxetine 30 MG Capsule Delayed Release Particles 90 Each Bottle,63700001,CDM,250,RC,,,,,,57237001890,NDC,1,EA,42.17,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DULoxetine 60 MG Capsule Delayed Release Particles 30 Each Bottle,63700001,CDM,250,RC,,,,,,43547038103,NDC,0.333333333,EA,14.04,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DULoxetine 60 MG Capsule Delayed Release Particles 30 Each Bottle,63700001,CDM,250,RC,,,,,,57237001930,NDC,0.333333333,EA,14.06,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Duplex Up Extrem Art Bilat,PX9393001,CDM,921,RC,93930,CPT,TC,,,,,,,835,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
durvalumab 120 MG/2.4ML Solution 2.4 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310450012,NDC,30,ML,21771.9,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
durvalumab 500 MG/10ML Solution 10 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310461150,NDC,10,ML,7588.77,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
dutasteride 0.5 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,42806054909,NDC,1,EA,32.49,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dx Occult Blood Immunoassay,PX82274,CDM,300,RC,82274,CPT,,,,,,,,105,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"DXA, Bone Density Study, Hips/Pelv/Spine",PX7708001,CDM,320,RC,77080,CPT,TC,,,,,,,575,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"DXA, Bone Density Study, Radius/Wrist/Heel",PX7708101,CDM,320,RC,77081,CPT,TC,,,,,,,460,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNABUNION PLATE STERILE INSTRUMENT KIT,27200000,CDM,272,RC,,,,12465-MAIN,LOCAL,,,,,1843,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNABUNION STERILE INSTRUMENT KIT,27200000,CDM,272,RC,,,,11850-MAIN,LOCAL,,,,,2515,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNAFORCE MPJ REAMERS CUP/CONE 20MM,27200000,CDM,272,RC,,,,11853-MAIN,LOCAL,,,,,1262,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP - STRAIGHT 12MM - WITH INSTRUMENTATION,27200000,CDM,278,RC,C1713,HCPCS,,11626-MAIN,LOCAL,,,,,3543.65,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP - STRAIGHT 14MM - WITH INSTRUMENTATION,27200000,CDM,278,RC,C1713,HCPCS,,11627-MAIN,LOCAL,,,,,3543.65,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP IMPLANT BENT 12MM,27200000,CDM,278,RC,C1713,HCPCS,,11629-MAIN,LOCAL,,,,,3543.65,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP IMPLANT BENT 14MM,27200000,CDM,278,RC,C1713,HCPCS,,11631-MAIN,LOCAL,,,,,3543.65,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP IMPLANT BENT 16MM,27200000,CDM,278,RC,C1713,HCPCS,,11633-MAIN,LOCAL,,,,,3543.65,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP IMPLANT STRAIGHT 12MM,27200000,CDM,278,RC,C1713,HCPCS,,11628-MAIN,LOCAL,,,,,3543.65,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP IMPLANT STRAIGHT 14MM,27200000,CDM,278,RC,C1713,HCPCS,,11630-MAIN,LOCAL,,,,,3543.65,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
DYNANITE PIP IMPLANT STRAIGHT 16MM,27200000,CDM,278,RC,C1713,HCPCS,,11632-MAIN,LOCAL,,,,,3543.65,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dystrophic Nail Trimming Any Number,PXG0127F,CDM,940,RC,G0127,HCPCS,,,,,,,,53,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Each Add'l Hour IV Hydration,PX96361,CDM,260,RC,96361,CPT,,,,,,,,123,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Each Add'l Hour IV Infusion <8 Hour,PX96366,CDM,260,RC,96366,CPT,,,,,,,,161,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Each Add'l Sequential IV Infusion <1 Hour,PX96367,CDM,260,RC,96367,CPT,,,,,,,,190,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Each Add'l Sequential Push New Drug,PX96375,CDM,260,RC,96375,CPT,,,,,,,,130,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ebv, Nuclear Antigen - Ref",PX8666490,CDM,300,RC,86664,CPT,90,,,,,,,58,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ebv, Viral Capsid Ab - Ref",PX8666590,CDM,300,RC,86665,CPT,90,,,,,,,58,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ecg 12 Lead, Interp Only",PX93010,CDM,985,RC,93010,CPT,,,,,,,,29,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ecg 12 Lead, Tracing Only",PX93005,CDM,730,RC,93005,CPT,,,,,,,,298,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Echo Heart Xthoracic,Limited",PX9330801,CDM,480,RC,93308,CPT,TC,,,,,,,349,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Echo Tt 2d Complete,PX9330701,CDM,480,RC,93307,CPT,TC,,,,,,,2303,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Egd Balloon Dil Esoph30 Mm/>,PX43233F,CDM,750,RC,43233,CPT,,,,,,,,1120,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,987.84,6141.46
Egd Balloon Dil Esoph30 Mm/>,PX43233P,CDM,983,RC,43233,CPT,,,,,,,,480,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ehrlichia (Anaplasma) Ab - Ref,PX8666690,CDM,300,RC,86666,CPT,90,,,,,,,163,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
El-1 Fecal Quantitative,PX8265390,CDM,300,RC,82653,CPT,90,,,,,,,383,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Electric Stimulation Therapy,PX97014,CDM,420,RC,97014,CPT,,,,,,,,135,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Electrical Stimulation,PX97032,CDM,420,RC,97032,CPT,,,,,,,,135,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ELECTRODE ADULT PACING ONESTEP,120.214,CDM,272,RC,A4556,HCPCS,,10242-MAIN,LOCAL,,,,,153,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ELECTRODE PEDS ONESTEP SINGLE,120.343,CDM,272,RC,A4556,HCPCS,,10296-MAIN,LOCAL,,,,,112,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ELECTRODES NEEDLE TIP PRECISE 2.4MM,27200000,CDM,272,RC,,,,12074-MAIN,LOCAL,,,,,11,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Electrolyte Panel,PX80051,CDM,300,RC,80051,CPT,,,,,,,,175,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Emergency Level I Visit,PX99281P,CDM,981,RC,99281,CPT,,,,,,,,224,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Emergency Level II Visit,PX99282P,CDM,981,RC,99282,CPT,,,,,,,,337,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Emergency Level III Visit,PX99283P,CDM,981,RC,99283,CPT,,,,,,,,568,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Emergency Level IV Visit,PX99284P,CDM,981,RC,99284,CPT,,,,,,,,914,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Emergency Level V Visit,PX99285P,CDM,981,RC,99285,CPT,,,,,,,,1436,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
empagliflozin 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,597015230,NDC,1,EA,92.47,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
empagliflozin 10 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,597015237,NDC,1,EA,104.66,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
empagliflozin 25 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,597015330,NDC,0.4,EA,43.54,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
empagliflozin 25 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,597015337,NDC,0.4,EA,43.54,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enalapril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714044201,NDC,1,EA,6.33,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enalapril 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904550261,NDC,0.5,EA,4.15,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enalaprilat 1.25 MG/ML Injectable 1 mL Vial,25000000,CDM,250,RC,,,,,,143978701,NDC,1,ML,40.39,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enalaprilat 1.25 MG/ML Injectable 1 mL Vial,25000000,CDM,250,RC,,,,,,143978710,NDC,1,ML,39.84,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enalaprilat 1.25 MG/ML Injectable 2 mL Vial,25000000,CDM,250,RC,,,,,,143978601,NDC,2,ML,75.63,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ENDOCAVITY NEEDLE GUIDE,27200000,CDM,272,RC,,,,11134-MAIN,LOCAL,,,,,37.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Endocrine E2,PX82670,CDM,300,RC,82670,CPT,90,,,,,,,55,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ENDOLOOP COATED VICRYL 0 18,27200000,CDM,272,RC,,,,10228-MAIN,LOCAL,,,,,143.6,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ENDOWRIST INSTRUMENTS PERMANENT CAUTERY HOOK 8MM,27200000,CDM,272,RC,,,,12050-MAIN,LOCAL,,,,,224,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062430,NDC,0.3,ML,147.12,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801301,NDC,0.3,ML,147.12,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801310,NDC,0.3,ML,147.12,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 30 mg/0.3 mL solution prefilled syringe 0.3 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714000601,NDC,0.3,ML,53.39,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062001,NDC,0.4,ML,189.48,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062040,NDC,0.4,ML,189.48,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801401,NDC,0.4,ML,189.48,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801410,NDC,0.4,ML,189.48,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 40 mg/0.4 mL solution prefilled syringe 0.4 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,16714001601,NDC,0.4,ML,100.47,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75062160,NDC,0.6,ML,274.53,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801601,NDC,0.6,ML,274.53,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 60 mg/0.6 mL solution prefilled syringe 0.6 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801610,NDC,0.6,ML,274.53,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801801,NDC,0.8,ML,359.37,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 80 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75801810,NDC,0.8,ML,359.37,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802001,NDC,1,ML,444.2,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 100 mg/mL solution prefilled syringe 1 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802010,NDC,1,ML,444.2,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802201,NDC,0.8,ML,439.77,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
enoxaparin 120 mg/0.8 mL solution prefilled syringe 0.8 mL Syringe,J1650.01,CDM,636,RC,J1650,HCPCS,,,,75802210,NDC,0.8,ML,439.77,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
entacapone 200 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,27241004910,NDC,1,EA,24.37,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Enzyme Act, Nonradioact - Ref",PX8265790,CDM,300,RC,82657,CPT,90,,,,,,,560,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ePHEDrine sulfate 50 MG/ML Solution 1 mL Ampule,25000000,CDM,250,RC,,,,,,17478041510,NDC,1,ML,262.31,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ePHEDrine sulfate 50 MG/ML Solution 1 mL Vial,25000000,CDM,250,RC,,,,,,42023021689,NDC,0.1,ML,36.62,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,93598627,NDC,1,EA,1241.11,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,115169449,NDC,1,EA,889.46,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010202,NDC,1,EA,680,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine (auto-injector) 0.3 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54505010202,NDC,1,EA,889.46,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 1 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010101,NDC,1,EA,680,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502010102,NDC,1,EA,680,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 0.15 MG/0.3ML Solution Auto-injector 2 Each Pen,J0171.01,CDM,636,RC,J0171,HCPCS,,,,49502050102,NDC,1,EA,1305.38,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409492120,NDC,10,ML,54.66,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,409493311,NDC,10,ML,66.06,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331601,NDC,10,ML,77.86,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 1 MG/10ML solution prefilled syringe 10 mL Syringe,J0171.01,CDM,636,RC,J0171,HCPCS,,,,76329331801,NDC,10,ML,102.65,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015901,NDC,0.3,ML,45.69,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 1 MG/ML Solution 1 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023015925,NDC,0.3,ML,45.69,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine 30 MG/30ML Solution 30 mL Vial,J0171.01,CDM,636,RC,J0171,HCPCS,,,,42023016801,NDC,0.3,ML,32.24,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010301,NDC,0.3,ML,45.04,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPINEPHrine PF 1 MG/ML Solution 1 mL Ampule,J0171.01,CDM,636,RC,J0171,HCPCS,,,,54288010310,NDC,1,ML,103.48,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EPIX UNIVERSAL CLIP APPLIER,27200000,CDM,272,RC,,,,11708-MAIN,LOCAL,,,,,158.95,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
eplerenone 25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16729029315,NDC,1,EA,23.31,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Epstein-barr antibody,PX86664,CDM,300,RC,86664,CPT,,,,,,,,72,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Epstein-barr antibody,PX86665,CDM,300,RC,86665,CPT,,,,,,,,86,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ERBEFLO CLEVERCAP CO2 TUBING CAP SET,27200000,CDM,272,RC,,,,11831-MAIN,LOCAL,,,,,50,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
eriBULin 1 MG/2ML Solution 2 mL Vial,J9179.01,CDM,636,RC,J9179,HCPCS,,,,62856038901,NDC,2,ML,2321.52,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,6384371,NDC,1,EA,563.46,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022101,NDC,1,EA,514.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022185,NDC,1,EA,514.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ertapenem 1 g Recon Soln 1 Each Vial,J1335.01,CDM,636,RC,J1335,HCPCS,,,,42023022189,NDC,1,EA,514.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,574402435,NDC,3.5,GR,101.11,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,17478007035,NDC,3.5,GR,105.01,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
erythromycin 5 MG/GM Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,24208091055,NDC,3.5,GR,106.98,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
erythromycin lactobionate 500 MG Recon Soln 1 Each Vial,J1364.01,CDM,636,RC,J1364,HCPCS,,,,409648211,NDC,1,EA,437.09,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Erythropietin - Ref,PX8266890,CDM,300,RC,82668,CPT,90,,,,,,,108,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
escitalopram 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904642661,NDC,0.5,EA,11.76,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018200,NDC,10,ML,68.21,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
esmolol 100 MG/10ML Solution 10 mL Vial,J1805.01,CDM,636,RC,J1805,HCPCS,,,,67457018210,NDC,10,ML,68.21,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
esmolol 2500 MG/250ML Solution 250 mL Flex Cont,J1805.01,CDM,636,RC,J1805,HCPCS,,,,10019067010,NDC,250,ML,1011.8,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ESOPHAGEAL BALLOON INFLATION DEVICE 60ML,27200000,CDM,272,RC,C1726,HCPCS,,11326-MAIN,LOCAL,,,,,80.41,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
estradiol 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378145201,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
estradiol 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42806008701,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ethanol, P",PX82077,CDM,300,RC,82077,CPT,,,,,,,,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,143950601,NDC,10,ML,61.1,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,143950610,NDC,10,ML,61.1,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409669501,NDC,10,ML,56.97,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,65219044501,NDC,10,ML,56.37,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
etomidate 2 MG/ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,65219044510,NDC,10,ML,56.37,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
etomidate 2 MG/ML Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,55150022220,NDC,10,ML,50.58,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Etoposide 100 MG/5ML Solution 5 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,16729011431,NDC,5,ML,43.21,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
etoposide 500 MG/25ML Solution 25 mL Vial,J9181.01,CDM,636,RC,J9181,HCPCS,,,,703565601,NDC,25,ML,173.28,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ETRAP POLYP TRAP,27200000,CDM,272,RC,,,,11282-MAIN,LOCAL,,,,,43,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Eval of Bronchospasm,PX94060,CDM,983,RC,94060,CPT,,,,,,,,176,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Everolimus,PX8016990,CDM,300,RC,80169,CPT,,,,,,,,79,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ex for Speech Device Rx Addl,PX92608,CDM,444,RC,92608,CPT,,,,,,,,160,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ex Sknbngn0.6-1cmtrnk,Arm,Lg",PX11401P,CDM,983,RC,11401,CPT,,,,,,,,387,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exam,Synovial Fluid Crystals",PX89060,CDM,300,RC,89060,CPT,,,,,,,,85,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Abd Les Sc < 3 Cm,PX22902F,CDM,761,RC,22902,CPT,,,,,,,,3128,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Abd Les Sc < 3 Cm,PX22902P,CDM,983,RC,22902,CPT,,,,,,,,2086,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Abdom Tum Subfac > 5 Cm,PX22901F,CDM,761,RC,22901,CPT,,,,,,,,1408,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Abdom Tum Subfac > 5 Cm,PX22901P,CDM,983,RC,22901,CPT,,,,,,,,938,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Back Les Sc = 3 Cm,PX21931P,CDM,983,RC,21931,CPT,,,,,,,,2135,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Face Les Sc < 2 Cm,PX21011F,CDM,510,RC,21011,CPT,,,,,,,,943,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Face Les Sc < 2 Cm,PX21011P,CDM,983,RC,21011,CPT,,,,,,,,628,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Neck Les Sc = 3cm >,PX21552F,CDM,510,RC,21552,CPT,,,,,,,,753,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Benig <5mm Remaindr Body,PX11420P,CDM,983,RC,11420,CPT,,,,,,,,299,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Benig >4cm Remaindr Body,PX11426F,CDM,510,RC,11426,CPT,,,,,,,,1227,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Benig >4cm Remaindr Body,PX11426P,CDM,983,RC,11426,CPT,,,,,,,,981,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402F,CDM,510,RC,11402,CPT,,,,,,,,424,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402P,CDM,983,RC,11402,CPT,,,,,,,,424,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423F,CDM,510,RC,11423,CPT,,,,,,,,711,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423P,CDM,983,RC,11423,CPT,,,,,,,,569,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606F,CDM,510,RC,11606,CPT,,,,,,,,1432,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606P,CDM,983,RC,11606,CPT,,,,,,,,2044,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623F,CDM,510,RC,11623,CPT,,,,,,,,690,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623P,CDM,983,RC,11623,CPT,,,,,,,,460,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604F,CDM,510,RC,11604,CPT,,,,,,,,964,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604P,CDM,983,RC,11604,CPT,,,,,,,,1422,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Beig1.1-2cm Face,Facil",PX11442P,CDM,983,RC,11442,CPT,,,,,,,,886,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skn Beni 0.6-1cm Fcefacial,PX11441P,CDM,983,RC,11441,CPT,,,,,,,,485,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Benig<5mm Face,Facial",PX11440P,CDM,983,RC,11440,CPT,,,,,,,,387,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skn Bngn1.1-2cm Remain Bdy,PX11422P,CDM,983,RC,11422,CPT,,,,,,,,822,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Bngn2.1-3cm Fce,Facial",PX11443P,CDM,983,RC,11443,CPT,,,,,,,,650,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Bngn2.1-3cmtrnk,Arm,Lg",PX11403P,CDM,983,RC,11403,CPT,,,,,,,,543,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skn Bngn3.1-4cm Remain Bdy,PX11424P,CDM,983,RC,11424,CPT,,,,,,,,562,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404P,CDM,983,RC,11404,CPT,,,,,,,,600,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Bnig >4cmtrnk,Arm,Leg",PX11406P,CDM,983,RC,11406,CPT,,,,,,,,1456,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skn Bnig0.6-1cm Remain Bdy,PX11421P,CDM,983,RC,11421,CPT,,,,,,,,345,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Mal 0.6-1cm Fce,Facial",PX11641P,CDM,983,RC,11641,CPT,,,,,,,,453,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601P,CDM,983,RC,11601,CPT,,,,,,,,1046,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602P,CDM,983,RC,11602,CPT,,,,,,,,1120,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Mal 2.1-3cmtrnk,Arm,Lg",PX11603P,CDM,983,RC,11603,CPT,,,,,,,,1276,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Malig1.1-2cm Fce,Facal",PX11642P,CDM,983,RC,11642,CPT,,,,,,,,466,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excis Arm/Elbow Tumor,Subcutan",PX24075F,CDM,510,RC,24075,CPT,,,,,,,,1519,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excis Arm/Elbow Tumor,Subcutan",PX24075P,CDM,983,RC,24075,CPT,,,,,,,,2458,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Excis Forearm/Wrist Tumor Subcutan,PX25075F,CDM,510,RC,25075,CPT,,,,,,,,1421,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Excis Forearm/Wrist Tumor Subcutan,PX25075P,CDM,983,RC,25075,CPT,,,,,,,,607,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Excis Primary Ganglion Wrist,PX25111F,CDM,510,RC,25111,CPT,,,,,,,,791,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Excis Primary Ganglion Wrist,PX25111P,CDM,983,RC,25111,CPT,,,,,,,,529,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excis Tendn/Capsule Lesn,Toes",PX28092F,CDM,510,RC,28092,CPT,,,,,,,,1234,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excis Tendn/Capsule Lesn,Toes",PX28092P,CDM,983,RC,28092,CPT,,,,,,,,1913,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excise Lesion,Back or Flank",PX21930F,CDM,510,RC,21930,CPT,,,,,,,,1326,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excise Lesion,Back or Flank",PX21930P,CDM,983,RC,21930,CPT,,,,,,,,884,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excision of Nail Fold, Toe",PX11765F,CDM,510,RC,11765,CPT,,,,,,,,210,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830F,CDM,510,RC,15830,CPT,,,,,,,,2080,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830P,CDM,983,RC,15830,CPT,,,,,,,,1120,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Explor Metatarso-Phalang Jt,PX28022F,CDM,510,RC,28022,CPT,,,,,,,,1161,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Explor Metatarso-Phalang Jt,PX28022P,CDM,983,RC,28022,CPT,,,,,,,,774,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exs Tumor Arm/Elbow Sc 3cm>,PX24071F,CDM,510,RC,24071,CPT,,,,,,,,1860,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ext Ecg > 48hr to 21 Day Rcrd W/Conect Intl Rcrd,PX0296T,CDM,731,RC,0296T,HCPCS,,,,,,,,389,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Extractable Nuclear Antigen, Each Antigen",PX86235,CDM,300,RC,86235,CPT,90,,,,,,,99,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Extremity Study - Vascular Diagnostics,PX9392201,CDM,921,RC,93922,CPT,TC,,,,,,,600,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EYE IRRIGATION SYSTEM MT2000,120.318,CDM,272,RC,,,,8718-MAIN,LOCAL,,,,,112,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EZ CLEAN BLADE CAUTERY TIP 4 INCH,27200000,CDM,272,RC,,,,12826-MAIN,LOCAL,,,,,14,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
EZ-STABILIZER DRESSING,120.415,CDM,272,RC,,,,9058-MAIN,LOCAL,,,,,42,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ezetimibe 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714081301,NDC,1,EA,44.91,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ezetimibe 10 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,16729043316,NDC,1,EA,60.66,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
F5 Gene - Ref,PX8124190,CDM,300,RC,81241,CPT,90,,,,,,,112,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Cystourethroscopy,PX52000F,CDM,761,RC,52000,CPT,,,,,,,,1601,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Debridement of Nails, 6 or Mor",PX11721F,CDM,510,RC,11721,CPT,,,,,,,,95,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Ex Skinbngn0.6-1cmtrnk,Arm,Lg",PX11401F,CDM,510,RC,11401,CPT,,,,,,,,484,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Ex Skn Bngn2.1-3cm Trnk,Arm,Lg",PX11403F,CDM,510,RC,11403,CPT,,,,,,,,679,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Exc Skin Benig<5mm Remaind Bod,PX11420F,CDM,510,RC,11420,CPT,,,,,,,,374,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Exc Skn Beni 0.6-1cm Remain Bdy,PX11421F,CDM,510,RC,11421,CPT,,,,,,,,931,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Beni1.1-2cm Fce,Facial",PX11442F,CDM,510,RC,11442,CPT,,,,,,,,668,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Benig >4cm Trnk,Arm,Lg",PX11406F,CDM,510,RC,11406,CPT,,,,,,,,1127,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Benig<5mm Face,Facial",PX11440F,CDM,510,RC,11440,CPT,,,,,,,,484,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Bngn 2.1-3cmfce,Facial",PX11443F,CDM,510,RC,11443,CPT,,,,,,,,813,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Exc Skn Bngn1.1-2cm Remain Bdy,PX11422F,CDM,510,RC,11422,CPT,,,,,,,,618,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Exc Skn Bngn3.1-4cm Remain Bdy,PX11424F,CDM,510,RC,11424,CPT,,,,,,,,931,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404F,CDM,510,RC,11404,CPT,,,,,,,,749,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Bnig0.6-1cm Fae,Facial",PX11441F,CDM,510,RC,11441,CPT,,,,,,,,606,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Mal 0.6-1cm Fce,Facial",PX11641F,CDM,510,RC,11641,CPT,,,,,,,,680,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601F,CDM,510,RC,11601,CPT,,,,,,,,673,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602F,CDM,510,RC,11602,CPT,,,,,,,,731,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Mali2.1-3cmtrnk,Arm,Lg",PX11603F,CDM,510,RC,11603,CPT,,,,,,,,875,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Exc Skn Malig .1-2cm Fce,Facal",PX11642F,CDM,510,RC,11642,CPT,,,,,,,,698,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Hospital Discharge Day>30 Min,PX99239F,CDM,510,RC,99239,CPT,,,,,,,,210,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Initial Hospital Care Levl II,PX99222F,CDM,510,RC,99222,CPT,,,,,,,,187,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Irrigation of Bladder,PX51700F,CDM,510,RC,51700,CPT,,,,,,,,358,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Ligation of Hemorrhoid(S),PX46221F,CDM,510,RC,46221,CPT,,,,,,,,1046,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Office Consultation,Level III",PX99243F,CDM,510,RC,99213,CPT,,,,,,,,374,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Office Consultation,Level IV",PX99244F,CDM,510,RC,99244,CPT,,,,,,,,441,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Removal of Skin Tags,PX11200F,CDM,510,RC,11200,CPT,,,,,,,,348,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Ther Injection Carpal Tunnel,PX20526F,CDM,510,RC,20526,CPT,,,,,,,,191,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Trim Nail(S),PX11719F,CDM,510,RC,11719,CPT,,,,,,,,107,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fac/Trm Hyperkeratotic Skn Lesn,>4",PX11057F,CDM,510,RC,11057,CPT,,,,,,,,175,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fac/Trm Hyperkeratotic Skn Lesn2-4,PX11056F,CDM,510,RC,11056,CPT,,,,,,,,158,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Facility Critical Care, Addl 30 Min",PX99292F,CDM,510,RC,99292,CPT,,,,,,,,484,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Facility Critical Care, E/M 30-74 Minutes",PX99291F,CDM,510,RC,99291,CPT,,,,,,,,1264,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Facility Emergency Level 1 Visit,PX99281F,CDM,450,RC,99281,CPT,,,,,,,,329,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,247,6141.46
Facility Emergency Level II Visit,PX99282F,CDM,450,RC,99282,CPT,,,,,,,,387,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,493,6141.46
Facility Emergency Level III Visit,PX99283F,CDM,450,RC,99283,CPT,,,,,,,,587,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,740,6141.46
Facility Emergency Level IV Visit,PX99284F,CDM,450,RC,99284,CPT,,,,,,,,1054,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1084,6141.46
Facility Emergency Level V Visit,PX99285F,CDM,450,RC,99285,CPT,,,,,,,,1464,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1183,6141.46
Factor VII - Ref,PX8523090,CDM,300,RC,85230,CPT,90,,,,,,,125,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Factor VIII (Ahg) 1-Stage,PX85240,CDM,300,RC,85240,CPT,,,,,,,,997,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famciclovir 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714030401,NDC,1,EA,34.42,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famciclovir 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,60505324603,NDC,0.5,EA,18.65,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famciclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,93811956,NDC,0.25,EA,17.04,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073916,NDC,2,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,63323073941,NDC,1,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famotidine (PF) 20 MG/2ML Solution 2 mL Vial,S0028.01,CDM,636,RC,S0028,HCPCS,,,,67457043300,NDC,1,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famotidine 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079096601,NDC,1,EA,9.34,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famotidine 20 MG Tablet 25 Each Bottle,63700001,CDM,250,RC,,,,,,49348081705,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famotidine 20 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268030315,NDC,0.5,EA,4.07,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
famotidine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739064510,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fat emulsion 20 % Emulsion 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,338051958,NDC,200,ML,375.95,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fat emulsion 20 % Emulsion 250 mL Flex Cont,25000000,CDM,250,RC,,,,,,338051909,NDC,250,ML,292.75,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fat/Lipids, Feces, Quant - Ref",PX8271090,CDM,300,RC,82710,CPT,90,,,,,,,95,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
felodipine 5 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462023401,NDC,1,EA,8.48,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fentanyl - Ref,PX8035490,CDM,300,RC,80354,CPT,90,,,,,,,353,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909422,NDC,2,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 0.05 MG/ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 12 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,378911916,NDC,1,EA,96.83,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 12 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505708000,NDC,1,EA,96.83,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 12 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,378911998,NDC,1,EA,96.84,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 12 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,60505708002,NDC,1,EA,96.84,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 25 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,47781042411,NDC,1,EA,101.44,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 25 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505700600,NDC,1,EA,101.46,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 25 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,591319872,NDC,1,EA,77.51,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 50 MCG/HR Patch 72 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,47781042611,NDC,1,EA,185.47,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 50 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,406905076,NDC,1,EA,125.74,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 50 MCG/HR Patch 72 Hour 5 Each Box,63700001,CDM,250,RC,,,,,,47781042647,NDC,1,EA,185.47,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,409909412,NDC,2,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602701,NDC,2,ML,34,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fentaNYL 100 MCG/2ML Solution 2 mL Vial,J3010.01,CDM,636,RC,J3010,HCPCS,,,,641602725,NDC,2,ML,31.63,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"ferrous sulfate 325 (65 Fe) MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64376080910,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ferrous sulfate 325 (65 Fe) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904759161,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ferumoxytol 510 MG/17ML Solution 17 mL Vial,Q0138.01,CDM,636,RC,Q0138,HCPCS,,,,781315401,NDC,17,ML,1846.91,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fetal Profile W/O Stress,PX7681901,CDM,402,RC,76819,CPT,TC,,,,,,,248,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fibrin Degradation Quant,PX85379,CDM,300,RC,85379,CPT,,,,,,,,177,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fibrinogen,PX7426,CDM,300,RC,85384,CPT,,,,,,,,234,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fibrinogen Activity - Ref,PX8538490,CDM,300,RC,85384,CPT,90,,,,,,,245,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fibrinogen Test - Ref,PX8536690,CDM,300,RC,85366,CPT,90,,,,,,,179,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fibrinolysins Screen - Ref,PX8539090,CDM,300,RC,85390,CPT,90,,,,,,,118,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fidaxomicin 200 MG Tablet 20 Each Bottle,25000000,CDM,250,RC,,,,,,52015008001,NDC,1,EA,945.16,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092401,NDC,0.5,ML,820.88,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092410,NDC,0.5,ML,820.89,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513092491,NDC,0.5,ML,820.88,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,J1442.01,CDM,636,RC,J1442,HCPCS,,,,55513020991,NDC,0.5,ML,1228.49,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim-ayow 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,800000,CDM,,,,,,,,70121157001,NDC,0.5,ML,691.62,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim-sndz 300 MCG/0.5ML solution prefilled syringe 0.5 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314031801,NDC,0.5,ML,1047.2,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032601,NDC,0.5,ML,559.7,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
filgrastim-sndz 480 MCG/0.8ML solution prefilled syringe 0.8 mL Syringe,Q5101.01,CDM,636,RC,Q5101,HCPCS,,,,61314032605,NDC,0.8,ML,1663.54,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
finasteride 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862014930,NDC,1,EA,16.79,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
First Hour IV Hydration <1 Hour,PX96360,CDM,260,RC,96360,CPT,,,,,,,,260,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fish Oil 1000 MG capsule 1 Each Blister,25000000,CDM,250,RC,,,,,,77333030825,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fix Exten Tendon,Dorsum Fingr,Ea",PX26418F,CDM,510,RC,26418,CPT,,,,,,,,1750,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FIXATION COMPONENT TOE JOINT PROXIMAL PHALANGEAL DF-P,C1713,CDM,278,RC,C1713,HCPCS,,12529-MAIN,LOCAL,,,,,1644,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FLAT DRAIN HEMADUCT 7MM FULL DUCT WITH TROCAR SILICONE,27200000,CDM,272,RC,,,,12464-MAIN,LOCAL,,,,,119,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FLAT WOUND DRAIN WITH TROCAR 4 CHANNEL FULL FLUTED 7FR SILICONE,27200000,CDM,272,RC,,,,12473-MAIN,LOCAL,,,,,123,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
flecainide 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237006301,NDC,1,EA,10.85,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FLEXITIP APPLICATOR 38CM,27200000,CDM,272,RC,,,,10200-MAIN,LOCAL,,,,,40.8,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Flour. Afstain , Micro - Ref",PX8720690,CDM,300,RC,87206,CPT,90,,,,,,,68,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Flow Cyto Ea Addtl Marker - Ref,PX8818590,CDM,310,RC,88185,CPT,90,,,,,,,165,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Flow Cyto, Tech, 1st Mrkr - Ref",PX8818490,CDM,310,RC,88184,CPT,90,,,,,,,223,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; 1st",PX88184,CDM,310,RC,88184,CPT,,,,,,,,96,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Flow Cytometry, Cell Surface, Cytoplasmic, Nuclear Marker, Tech. Comp.; Add'l",PX88185,CDM,310,RC,88185,CPT,,,,,,,,96,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Flow Interp,2-8 Markers - Ref",PX8818790,CDM,310,RC,88187,CPT,90,,,,,,,162,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Flu Dna Amp Probe 1st 2 Types,PX87502,CDM,300,RC,87502,CPT,,,,,,,,350,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluconazole 100 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069101,NDC,0.5,EA,23.55,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluconazole 150 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,16714069210,NDC,1,EA,72.98,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluconazole 150 MG Tablet 12 Each Box,63700001,CDM,250,RC,,,,,,16714069211,NDC,0.333333333,EA,24.33,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,25021018482,NDC,100,ML,79.51,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Flex Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,70655000206,NDC,100,ML,59.67,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluconazole in 0.9% NS 200-0.9 MG/100ML-% Solution 100 mL Plas Cont,J1450.01,CDM,636,RC,J1450,HCPCS,,,,338604648,NDC,100,ML,143.42,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143978410,NDC,2,ML,37.91,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,36000014801,NDC,2,ML,38.76,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
flumazenil 0.5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323042405,NDC,5,ML,64.82,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fluor Noninfect Ab Sc, Ea - Ref",PX8625590,CDM,300,RC,86255,CPT,90,,,,,,,121,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fluoroscope Examination Tc,PX7600001,CDM,320,RC,76000,CPT,TC,,,,,,,597,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fluoroscopy Guid Needle Plcmt Tc,PX7700201,CDM,320,RC,77002,CPT,TC,,,,,,,662,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluorouracil 5 GM/100ML Solution 100 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,16729027638,NDC,100,ML,261.44,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluorouracil 500 MG/10ML Solution 10 mL Vial,J9190.01,CDM,636,RC,J9190,HCPCS,,,,63323011710,NDC,10,ML,39,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FLUoxetine 10 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578461,NDC,1,EA,12.99,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FLUoxetine 20 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904578561,NDC,1,EA,13.34,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone 110 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173071920,NDC,12,GR,149.67,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone 220 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173072020,NDC,12,GR,1746.36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone 220 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,66993008096,NDC,12,GR,1760.13,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone furoate-vilanterol 100-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173085914,NDC,28,EA,1025.38,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone propionate 50 MCG/ACT Suspension 16 g Bottle,63700001,CDM,250,RC,,,,,,50383070016,NDC,16,GR,432.56,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone propionate 50 MCG/ACT Suspension 16 g Bottle,63700001,CDM,250,RC,,,,,,60505082901,NDC,16,GR,437.4,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-salmeterol 100-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,54032656,NDC,60,EA,2215.63,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-salmeterol 100-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069500,NDC,1,EA,38.87,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-salmeterol 230-21 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,173071720,NDC,12,GR,2004.35,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-salmeterol 230-21 MCG/ACT Aerosol 12 g Inhaler,63700001,CDM,250,RC,,,,,,66993008896,NDC,12,GR,1904.14,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-salmeterol 250-50 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069604,NDC,14,EA,1025.13,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-salmeterol 250-50 MCG/ACT Aerosol Powder Breath Activated 60 Each Disp Pack,63700001,CDM,250,RC,,,,,,54032756,NDC,1,EA,45.88,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-salmeterol 500-50 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173069704,NDC,14,EA,1670.75,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-umeclidin-vilant 100-62.5-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173088714,NDC,28,EA,1894.99,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluticasone-vilanterol 200-25 MCG/ACT Aerosol Powder Breath Activated 28 Each Disp Pack,63700001,CDM,250,RC,,,,,,173088214,NDC,28,EA,1087.68,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluvastatin 20 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,378802093,NDC,1,EA,26.88,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fluvoxaMINE 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,60505016601,NDC,0.25,EA,3.55,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006F,CDM,510,RC,10006,CPT,,,,,,,,213,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006P,CDM,983,RC,10006,CPT,,,,,,,,142,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fna Biopsy, W/US Guidance; First Lesion",PX10005F,CDM,510,RC,10005,CPT,,,,,,,,333,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fna Biopsy, W/US Guidance; First Lesion",PX10005P,CDM,983,RC,10005,CPT,,,,,,,,621,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fna W/Image,PX10022F,CDM,510,RC,10022,CPT,,,,,,,,742,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Folic Acid (Folate), Serum",PX82746,CDM,300,RC,82746,CPT,,,,,,,,56,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
folic acid 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687068111,NDC,0.4,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
folic acid 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687068101,NDC,0.4,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
folic acid 5 MG/ML Solution 10 mL Vial,J3490.94,CDM,636,RC,J3490,HCPCS,,,,39822110001,NDC,0.2,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
folic acid 5 MG/ML Solution 10 mL Vial,J3490.94,CDM,636,RC,J3490,HCPCS,,,,63323018410,NDC,10,ML,336.94,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fomepizole 1 GM/ML Solution 1.5 mL Vial,J1451.01,CDM,636,RC,J1451,HCPCS,,,,39822071001,NDC,1.5,ML,2600,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FORCEPS COLD BIOPSY,27200000,CDM,272,RC,,,,12453-MAIN,LOCAL,,,,,23,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FORCEPS PROGRASP 8MM ENDOWRIST INSTRUMENTS,27200000,CDM,272,RC,,,,12062-MAIN,LOCAL,,,,,281,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FORCEPS SERRATED WITH SPIKE JUMBO 230CM,27200000,CDM,272,RC,,,,7416-MAIN,LOCAL,,,,,41.31,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
FORCEPS SPOON JAWSIZE 10MMX36 KIT,27200000,CDM,272,RC,,,,11749-MAIN,LOCAL,,,,,1955,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fosfomycin 3 g Packet 1 Each Box,25000000,CDM,250,RC,,,,,,70700026894,NDC,1,EA,353.41,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600110,NDC,10,ML,589.63,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,69600121,NDC,10,ML,592.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040304,NDC,10,ML,168.77,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fosphenytoin 500 MG PE/10ML Solution 10 mL Vial,Q2009.01,CDM,636,RC,Q2009,HCPCS,,,,63323040310,NDC,10,ML,168.77,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Francisella Tularensis Ab,PX8666890,CDM,300,RC,86668,CPT,90,,,,,,,294,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Freeing Bowel Adhesion,Enterolysis",PX44005F,CDM,360,RC,44005,CPT,,,,,,,,2744,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2420.208,6141.46
Fresh Frozen Plasma,PXP9017,CDM,390,RC,P9017,HCPCS,,,,,,,,319,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,310072010,NDC,5,ML,1977.83,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
fulvestrant 250 MG/5ML solution prefilled syringe 5 mL Syringe,J9395.01,CDM,636,RC,J9395,HCPCS,,,,781307912,NDC,5,ML,1854.23,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fungal Culture, Other Source - Ref",PX8710290,CDM,300,RC,87102,CPT,90,,,,,,,157,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fungus Antibody, Nos - Ref",PX8667190,CDM,300,RC,86671,CPT,90,,,,,,,99,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Fungus Isolation Culture,PX87102,CDM,300,RC,87102,CPT,,,,,,,,167,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028002,NDC,1,ML,40.43,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 10 MG/ML Solution 2 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028016,NDC,2,ML,41.29,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028026,NDC,2,ML,41.42,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 10 MG/ML Solution 4 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,70860030242,NDC,1,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,36000028425,NDC,2,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 10 MG/ML Solution 10 mL Vial,J1940.01,CDM,636,RC,J1940,HCPCS,,,,63323028036,NDC,2,ML,36.12,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54829725,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54829925,NDC,1,EA,3.15,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
furosemide 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904717861,NDC,0.25,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fusion Foot Bones,Midtarsal,Multi",PX28730F,CDM,510,RC,28730,CPT,,,,,,,,2299,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
G6pd; Quant Screen - Ref,PX8295590,CDM,300,RC,82955,CPT,90,,,,,,,50,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gabapentin - Ref,PX8017190,CDM,300,RC,80171,CPT,90,,,,,,,71,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762403001,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904563161,NDC,1,EA,3.72,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904666561,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739059110,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739090210,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 300 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862019901,NDC,0.333333333,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904666661,NDC,0.333333333,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60505011300,NDC,0.333333333,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,60687059101,NDC,0.333333333,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 300 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739023610,NDC,0.333333333,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 600 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268035111,NDC,1,EA,12.79,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 600 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268035115,NDC,1,EA,12.79,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gabapentin 800 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714033201,NDC,0.75,EA,12.25,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gadoterate meglumine 10 mmol/20 mL Solution 20 mL Vial,A9575,CDM,636,RC,A9575,HCPCS,,,,67684200003,NDC,20,ML,668.27,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gadoteridol 279.3 MG/ML Solution 5 mL Vial,A9576,CDM,636,RC,A9576,HCPCS,,,,270111104,NDC,10,ML,100,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gadoteridol 279.3 MG/ML Solution 17 mL Syringe,A9576,CDM,636,RC,A9576,HCPCS,,,,270111145,NDC,17,ML,170,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gadoxetate disodium 0.25 MOL/L Solution 10 mL Vial,A9581,CDM,636,RC,A9581,HCPCS,,,,50419032005,NDC,10,ML,200,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gait Training Therapy,PX97116,CDM,420,RC,97116,CPT,,,,,,,,135,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Gammaglobulin; Iga, Dg,M - Ref",PX8278490,CDM,300,RC,82784,CPT,90,,,,,,,90,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gammaglobulin; Ige - Ref,PX8278590,CDM,300,RC,82785,CPT,90,,,,,,,45,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gardner Vag Dna Dir Probe,PX87510,CDM,300,RC,87510,CPT,,,,,,,,127,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gastric Intubation Treatment,PX43753F,CDM,510,RC,43753,CPT,,,,,,,,441,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gastric Intubation Treatment,PX43753P,CDM,983,RC,43753,CPT,,,,,,,,498,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gastrin - Ref,PX8294190,CDM,300,RC,82941,CPT,90,,,,,,,65,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GASTRONOMY FEEDING TUBE MIC BALLOONED 20FR 7-10ML 0112-20,27200000,CDM,272,RC,B4087,HCPCS,,13098-MAIN,LOCAL,,,,,45,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,45963061959,NDC,1,EA,638.4,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gemcitabine 1 g Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323012594,NDC,1,EA,190.99,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gemcitabine 1 GM/26.3ML Solution 26.3 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018101,NDC,26.3,ML,203.58,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gemcitabine 200 MG Recon Soln 1 Each Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,63323010294,NDC,1,EA,39,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gemcitabine 200 MG/5.26ML Solution 5.26 mL Vial,J9201.01,CDM,636,RC,J9201,HCPCS,,,,409018301,NDC,5.26,ML,40.74,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Genital Surg Proc,Male Unlisted",PX55899F,CDM,510,RC,55899,CPT,,,,,,,,1430,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Genital Surg Proc,Male Unlisted",PX55899P,CDM,983,RC,55899,CPT,,,,,,,,953,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gentamicin 0.1 % Ointment 30 g Tube,25000000,CDM,250,RC,,,,,,713068231,NDC,30,GR,506.64,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gentamicin 0.3 % Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,17478028435,NDC,3.5,GR,219.3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gentamicin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,60758018805,NDC,5,ML,107.98,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gentamicin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063305,NDC,5,ML,122.17,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001001,NDC,1.5,ML,40.17,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001002,NDC,2,ML,43.42,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
gentamicin 40 MG/ML Solution 2 mL Vial,J1580.01,CDM,636,RC,J1580,HCPCS,,,,63323001094,NDC,2,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"GI Pathogen Panel, Pcr - Ref",PX8750790,CDM,300,RC,87507,CPT,90,,,,,,,213,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Giardia,PX87329,CDM,300,RC,87329,CPT,,,,,,,,117,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GLIDESCOPE QC MAC S3 SINGLE USE 0270-1083,120.579,CDM,272,RC,,,,13046-MAIN,LOCAL,,,,,85,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GLIDESCOPE QC MAC S3 SINGLE USE 0270-1085,120.579,CDM,272,RC,,,,13022-MAIN,LOCAL,,,,,85,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GLIDESCOPE QC MAC S4 SINGLE USE 0270-1086,120.579,CDM,272,RC,,,,13023-MAIN,LOCAL,,,,,85,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GLIDESCOPE QC MILLER S0 SINGLE USE 0270-1087,120.58,CDM,272,RC,,,,13024-MAIN,LOCAL,,,,,106,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GLIDESCOPE QC MILLER S1 SINGLE USE 0270-1088,120.58,CDM,272,RC,,,,13025-MAIN,LOCAL,,,,,106,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glimepiride 1 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268035815,NDC,1,EA,5.41,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glimepiride 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93725401,NDC,1,EA,5.79,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glimepiride 1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547039410,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glipiZIDE 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079081001,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glipiZIDE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079081020,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glipiZIDE ER 2.5 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714089401,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glipiZIDE ER 5 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714089501,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Glucagon - Ref,PX8294390,CDM,300,RC,82943,CPT,90,,,,,,,115,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059303,NDC,1,EA,740.19,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059611,NDC,0.25,EA,200.05,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glucagon (diagnostic) 1 MG Recon Soln 1 Each Vial,J1611.01,CDM,636,RC,J1611,HCPCS,,,,63323059613,NDC,0.25,EA,200.05,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glucagon rdna (diagnostic) 1 MG Recon Soln 1 Each Vial,J1610.01,CDM,636,RC,J1610,HCPCS,,,,597026010,NDC,1,EA,744.84,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glucose 40 % Gel 37.5 g Package,63700001,CDM,250,RC,,,,,,574006930,NDC,37.5,GR,25.12,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glucose 40 % Gel 37.5 g Tube,63700001,CDM,250,RC,,,,,,574006915,NDC,37.5,GR,25.12,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Glucose Blood Test,PX82962,CDM,300,RC,82962,CPT,,,,,,,,20,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Glucose Test,PX82950,CDM,300,RC,82950,CPT,,,,,,,,74,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Glucose, Body Fluid Other Than Blood",PX82945,CDM,300,RC,82945,CPT,,,,,,,,158,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glyBURIDE 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,93834498,NDC,0.25,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Glycated Protein - Ref,PX8298590,CDM,300,RC,82985,CPT,90,,,,,,,49,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycerin 2 g Suppository 24 Each Jar,63700001,CDM,250,RC,,,,,,132007924,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,49348009529,NDC,15,ML,30.53,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,57896018105,NDC,15,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycerin-hypromellose-PEG 0.2-0.2-1 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,57896018405,NDC,15,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,517460125,NDC,0.5,ML,58.76,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,781382571,NDC,0.5,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057811,NDC,0.5,ML,30.98,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
glycopyrrolate 0.2 MG/ML Solution 1 mL Vial,J1596.01,CDM,636,RC,J1596,HCPCS,,,,63323057841,NDC,0.5,ML,30.98,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Glycosylated Hemoglobin Test,PX83036,CDM,300,RC,83036,CPT,,,,,,,,110,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GOLIMumab 50 MG/4ML Solution 4 mL Vial,J1602.01,CDM,636,RC,J1602,HCPCS,,,,57894035001,NDC,4,ML,3709.76,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gonadotropin (Lh),PX83002,CDM,300,RC,83002,CPT,,,,,,,,28,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Gonadotropin, Chorionic (Hcg), Qualitative",PX84703,CDM,300,RC,84703,CPT,,,,,,,,175,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,310095036,NDC,1,EA,1234.2,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
goserelin 3.6 MG Implant 1 Each Syringe,J9202.01,CDM,636,RC,J9202,HCPCS,,,,70720095036,NDC,1,EA,1234.2,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Gput, Quant",PX8277590,CDM,300,RC,82775,CPT,90,,,,,,,25,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GRAFIXPL PRIME PLACENTAL MEMBRANE 1.5 x2CM 3SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12764-MAIN,LOCAL,,,,,1529,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GRAFIXPL PRIME PLACENTAL MEMBRANE 2x3CM 6SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12765-MAIN,LOCAL,,,,,1911,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x3CM 9SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12766-MAIN,LOCAL,,,,,2171,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GRAFIXPL PRIME PLACENTAL MEMBRANE 3x4CM 12SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12767-MAIN,LOCAL,,,,,2345,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GRAFIXPL PRIME PLACENTAL MEMBRANE 5x5CM 25SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12768-MAIN,LOCAL,,,,,5211,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GRAFIXPL PRIME PLACENTAL MEMBRANE 16MM DISC 2SQCM,Q4133,CDM,278,RC,Q4133,HCPCS,,12763-MAIN,LOCAL,,,,,860,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
GROSHONG PICC NXT 4FR,120.218,CDM,272,RC,,,,498-MAIN,LOCAL,,,,,1182,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Group Therapeutic Procedures,PX97150,CDM,420,RC,97150,CPT,,,,,,,,67,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,603107554,NDC,5,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,69367027204,NDC,5,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin - codeine 100-10 MG/5ML Solution 118 mL Bottle,63700001,CDM,250,RC,,,,,,69543025204,NDC,118,ML,78.39,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904006100,NDC,5,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,904676320,NDC,5,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,54838011740,NDC,5,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin 100 MG/5ML Liquid 118 mL Bottle,63700001,CDM,250,RC,,,,,,61787006304,NDC,5,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin 600 MG Tablet Extended Release 12 Hour 20 Each Box,63700001,CDM,250,RC,,,,,,63824000832,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
guaiFENesin 600 MG Tablet Extended Release 12 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904671839,NDC,1,EA,5.74,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
haloperidol 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079073420,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,143931901,NDC,0.4,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
haloperidol lactate 5 MG/ML Solution 1 mL Vial,J1630.01,CDM,636,RC,J1630,HCPCS,,,,63323047401,NDC,1,ML,58.6,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 15DEGREE 14MM,27200000,CDM,272,RC,,,,12600-MAIN,LOCAL,,,,,1253,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 45DEGREE 8MM,27200000,CDM,272,RC,,,,12599-MAIN,LOCAL,,,,,1253,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HANDSET VERSAJET II EXACT HYDROSURGERY DISPOSABLE 45DEGREE 14MM,27200000,CDM,272,RC,,,,12598-MAIN,LOCAL,,,,,1253,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 15DEGREE 14MM,27200000,CDM,272,RC,,,,12603-MAIN,LOCAL,,,,,1253,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 45DEGREE 8MM,27200000,CDM,272,RC,,,,12602-MAIN,LOCAL,,,,,1253,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HANDSET VERSAJET II PLUS HYDROSURGERY DISPOSABLE 45DEGREE 14MM,27200000,CDM,272,RC,,,,12601-MAIN,LOCAL,,,,,1253,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Haptoglobin; Quantitative,PX83010,CDM,300,RC,83010,CPT,,,,,,,,265,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HARMONIC 110 SHEARS 36CM SHAFT,27200000,CDM,272,RC,,,,12043-MAIN,LOCAL,,,,,2392,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HARMONIC 1100 SHEARS 20CM SHAFT HAR1120,27200000,CDM,272,RC,,,,12924-MAIN,LOCAL,,,,,1244,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heart/Lung Resuscitation (Cpr),PX92950F,CDM,480,RC,92950,CPT,,,,,,,,1366,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heart/Lung Resuscitation (Cpr),PX92950P,CDM,983,RC,92950,CPT,,,,,,,,1023,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Helicobacter Pylori Ab,PX86677,CDM,300,RC,86677,CPT,,,,,,,,224,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hematocrit,PX85014,CDM,300,RC,85014,CPT,,,,,,,,58,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12173-MAIN,LOCAL,,,,,400,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12130-MAIN,LOCAL,,,,,561,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HEMODIALYSIS CATHETER LONG-TERM,27200000,CDM,272,RC,,,,12173-SURG,LOCAL,,,,,772,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hemoglobin,PX85018,CDM,300,RC,85018,CPT,,,,,,,,68,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hemorrhoidectomy,Int/Ext,Complx",PX46260F,CDM,750,RC,46260,CPT,,,,,,,,1350,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1190.7,6141.46
"Hemorrhoidectomy,Int/Ext,Simple",PX46255F,CDM,510,RC,46255,CPT,,,,,,,,1627,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hemorrhoidectomy,Int/Ext,Simple",PX46255P,CDM,983,RC,46255,CPT,,,,,,,,2393,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272002,NDC,1,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,409272031,NDC,1,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,25021040010,NDC,1,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323054011,NDC,1,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095300,NDC,0.5,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,67457095310,NDC,1,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin (porcine) 1000 UNIT/ML Solution 10 mL Vial,J1644.01,CDM,636,RC,J1644,HCPCS,,,,71288042095,NDC,0.5,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306424,NDC,1,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin 100 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253033335,NDC,5,ML,40.44,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306413,NDC,1,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306521,NDC,3,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin lock flush 10 unit/mL Solution 3 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,64253022233,NDC,3,ML,38.13,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin lock flush 10 unit/mL Solution 5 mL Syringe,J1642.01,CDM,636,RC,J1642,HCPCS,,,,8290306510,NDC,5,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,264957710,NDC,500,ML,80.61,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052201,NDC,500,ML,80.61,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heparin Sod (Porcine) in D5W 25000-5 UT/500ML-% Solution 500 mL Flex Cont,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323052277,NDC,500,ML,80.61,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011801,NDC,0.5,ML,52.63,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
heparin sodium (porcine) 5000 UNIT/0.5ML solution prefilled syringe 0.5 mL Syringe,J1644.01,CDM,636,RC,J1644,HCPCS,,,,63323011805,NDC,0.5,ML,52.63,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heparin Xa,PX85520,CDM,300,RC,85520,CPT,,,,,,,,128,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatic Function Panel,PX80076,CDM,300,RC,80076,CPT,,,,,,,,171,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hepatitis a Antibody, Tot - Ref",PX8670890,CDM,300,RC,86708,CPT,90,,,,,,,201,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatitis a Igm Antibody,PX86709,CDM,300,RC,86709,CPT,,,,,,,,220,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hepatitis A vaccine 1440 EL U/ML Suspension 1 mL Syringe,90632,CDM,636,RC,90632,CPT,,,,58160082652,NDC,1,ML,375.78,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081543,NDC,1,ML,479.89,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hepatitis a-hepatitis b recomb vaccine 720-20 ELU-MCG/ML suspension prefilled syringe 1 mL Syringe,90636,CDM,636,RC,90636,CPT,,,,58160081552,NDC,1,ML,479.89,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hepatitis B Core Antibody, Total",PX86704,CDM,300,RC,86704,CPT,,,,,,,,21,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hepatitis B immune globulin 312 UNIT/ML Solution 5 mL Vial,90371,CDM,636,RC,90371,CPT,,,,59730420301,NDC,5,ML,2851.63,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hepatitis b recomb vaccine 10 MCG/0.5ML suspension prefilled syringe 0.5 mL Syringe,90743,CDM,636,RC,90743,CPT,,,,58160082052,NDC,0.5,ML,137.47,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082143,NDC,1,ML,348.85,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hepatitis b recomb vaccine 20 MCG/ML suspension prefilled syringe 1 mL Syringe,90740,CDM,636,RC,90740,CPT,,,,58160082152,NDC,1,ML,375.43,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatitis B Surface Antibody,PX86706,CDM,300,RC,86706,CPT,,,,,,,,201,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatitis B Surface Antigen,PX87340,CDM,300,RC,87340,CPT,,,,,,,,98,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatitis Be Antibody - Ref,PX8670790,CDM,300,RC,86707,CPT,90,,,,,,,192,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatitis C Antibody,PX86803,CDM,300,RC,86803,CPT,,,,,,,,144,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatitis C Rna Quant,PX87522,CDM,300,RC,87522,CPT,,,,,,,,185,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatobil Syst Image W/Drug,PX7822701,CDM,341,RC,78227,CPT,TC,,,,,,,1674,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hepatobiliary System Imaging,PX7822601,CDM,341,RC,78226,CPT,TC,,,,,,,2776,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERCULES 3 STAGE BALLOON ESOPHAGEAL 12-13.5-15::36-40.5-45MM,27200000,CDM,272,RC,C1726,HCPCS,,11329-MAIN,LOCAL,,,,,289.85,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERCULES 3 STAGE BALLOON ESOPHAGEAL 15-16.5-18:45-49.5-54MM,27200000,CDM,272,RC,C1726,HCPCS,,11328-MAIN,LOCAL,,,,,289.85,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERCULES 3 STAGE BALLOON ESOPHAGEAL 18-19-20::54-57-60MM,27200000,CDM,272,RC,C1726,HCPCS,,11330-MAIN,LOCAL,,,,,289.85,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERNIA BELT MENS TRUSS LARGE,120.526,CDM,274,RC,L8310,HCPCS,,12221-MAIN,LOCAL,,,,,60,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERNIA BELT MENS TRUSS MEDIUM,120.526,CDM,274,RC,L8310,HCPCS,,12220-MAIN,LOCAL,,,,,60,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERNIA BELT MENS TRUSS XLARGE,120.526,CDM,274,RC,L8310,HCPCS,,12222-MAIN,LOCAL,,,,,60,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"HERNIA MESH 3D MAX MID ANATOMICAL MESH LEFT SIZE L 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,11976-MAIN,LOCAL,,,,,755,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"HERNIA MESH 3D MAX MID ANATOMICAL MESH RIGHT SIZE L 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,11977-MAIN,LOCAL,,,,,755,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"HERNIA MESH 3D MAX MID ANATOMICAL MESH RIGHT SIZE XL 5"" X 7""",C1781,CDM,278,RC,C1781,HCPCS,,11979-MAIN,LOCAL,,,,,832,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"HERNIA MESH 3DMAX MID MESH EXTRA-LARGE LEFT 5"" X 7""",C1781,CDM,278,RC,C1781,HCPCS,,11978-MAIN,LOCAL,,,,,832,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERNIA MESH LAP PROGRIP SELF FIXATING FLAT SHEET 10X15,C1781,CDM,278,RC,C1781,HCPCS,,12727-MAIN,LOCAL,,,,,611,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERNIA PATCH VENTRALEX LARGE,C1781,CDM,278,RC,C1781,HCPCS,,10201-MAIN,LOCAL,,,,,1325.08,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERNIA PATCH VENTRALEX MEDIUM,C1781,CDM,278,RC,C1781,HCPCS,,10202-MAIN,LOCAL,,,,,1309.75,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HERNIA PATCH VENTRALEX SMALL,C1781,CDM,278,RC,C1781,HCPCS,,10203-MAIN,LOCAL,,,,,995.96,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heterophile Antibodies,PX86308,CDM,300,RC,86308,CPT,,,,,,,,196,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hfe Gene - Ref,PX8125690,CDM,300,RC,81256,CPT,90,,,,,,,526,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Hha Visit,PXG0156,CDM,571,RC,G0156,HCPCS,,,,,,,,38,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Ot Initial Visit,PXG0152,CDM,431,RC,G0152,HCPCS,GO,,,,,,,,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Ot Routine Visit,PXG0152.01,CDM,431,RC,G0152,HCPCS,GO,,,,,,,,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Pt Initial Visit,PXG0151,CDM,421,RC,G0151,HCPCS,GP,,,,,,,,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Pt Routine Visit,PXG0151.01,CDM,421,RC,G0151,HCPCS,GP,,,,,,,,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Pta Routine Visit,PXG0157,CDM,421,RC,G0157,HCPCS,,,,,,,,,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Rn Initial Visit,PXG0154,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Rn Routine Visit,PXG0154.01,CDM,551,RC,G0299,HCPCS,,,,,,,,75,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hiaa - Ref,PX8349790,CDM,300,RC,83497,CPT,90,,,,,,,84,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
High Sens Crp,PX86141,CDM,300,RC,86141,CPT,,,,,,,,97,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HIMAX PLUS 18X18X18,27200000,CDM,278,RC,C1713,HCPCS,,11660-MAIN,LOCAL,,,,,3085.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HIMAX PLUS 20X20X20,27200000,CDM,278,RC,C1713,HCPCS,,11661-MAIN,LOCAL,,,,,3085.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HIMAX STAPLE KIT 18X14X14,27200000,CDM,278,RC,C1713,HCPCS,,11851-MAIN,LOCAL,,,,,4536,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Histoplasma Antibody - Ref,PX8669890,CDM,300,RC,86698,CPT,90,,,,,,,71,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hiv-1 Antigens W/Hiv 1/2 Antib,PX87389,CDM,300,RC,87389,CPT,,,,,,,,194,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hiv-1, Quantification - Ref",PX8753690,CDM,300,RC,87536,CPT,90,,,,,,,220,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hla a, B or C, Single Ag - Ref",PX8681290,CDM,300,RC,86812,CPT,90,,,,,,,89,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hla Class II Low Res, 1 Locus - Ref",PX8137690,CDM,310,RC,81376,CPT,90,,,,,,,279,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Homocysteine,PX83090,CDM,300,RC,83090,CPT,,,,,,,,44,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Homogenization, Tissue for Culture",PX87176,CDM,300,RC,87176,CPT,,,,,,,,50,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hosp Manage Cont Drug Admin,PX01996.01,CDM,964,RC,1996,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hospital Discharge Day>30 Min,PX99239P,CDM,982,RC,99239,CPT,,,,,,,,140,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hospital Inpt or Obs Care, Admin/Disch Same Date Straightforward or Low Level Mdm >= 45 Minutes",PX99234,CDM,982,RC,99234,CPT,,,,,,,,464,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hospital Inpt or Obs Care, Admin/Disch Same Date, Moderate Level Mdm >= 70 Minutes",PX99235,CDM,982,RC,99235,CPT,,,,,,,,582,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hospital Outpatient Clinic Visit Specimen Collection for Sars-Cov-2,PXC9803,CDM,300,RC,C9803,HCPCS,,,,,,,,33,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hsv Detect, Amplif Probe - Ref",PX8752990,CDM,300,RC,87529,CPT,90,,,,,,,150,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hsv Dna Amp Probe,PX87529,CDM,300,RC,87529,CPT,,,,,,,,145,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ht Muscle Image Spect, Mult",PX7845201,CDM,340,RC,78452,CPT,TC,,,,,,,2000,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hyaluronate 48 MG/6ML solution prefilled syringe 6 mL Syringe,J7325.01,CDM,636,RC,J7325,HCPCS,,,,58468009003,NDC,6,ML,5274.4,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrALAZINE 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155000101,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061400,NDC,1,ML,101.95,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061401,NDC,1,ML,94.87,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrALAZINE 20 MG/ML Solution 1 mL Vial,J0360.01,CDM,636,RC,J0360,HCPCS,,,,63323061416,NDC,0.5,ML,31.57,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrALAZINE 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904644161,NDC,0.4,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrALAZINE 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,64380073506,NDC,0.2,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrALAZINE 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904644261,NDC,0.2,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydroCHLOROthiazide 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547039710,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROcodone-acetaminophen 5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406012323,NDC,1,EA,4.27,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROcodone-acetaminophen 5-325 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406012301,NDC,1,EA,3.72,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROcodone-acetaminophen 5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406012362,NDC,1,EA,4.27,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROcodone-acetaminophen 7.5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406012423,NDC,1,EA,4.76,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROcodone-acetaminophen 7.5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406012462,NDC,1,EA,4.76,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone (perianal) 2.5 % Cream 28.35 g Tube,63700001,CDM,250,RC,,,,,,10631040701,NDC,28.35,GR,447.94,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 1 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,472034356,NDC,28,GR,22.15,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 1 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,45802043803,NDC,28,GR,25.55,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 2.5 % Cream 28 g Tube,63700001,CDM,250,RC,,,,,,45802000403,NDC,28,GR,60.85,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 2.5 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,168008031,NDC,30,GR,61.99,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 5 MG Tablet 50 Each Bottle,63700001,CDM,250,RC,,,,,,59762007301,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762007401,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 25 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,713050306,NDC,1,EA,108.03,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone 25 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,713050312,NDC,1,EA,108.03,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001103,NDC,1,EA,108.34,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone sodium succinate (preservative free) 100 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001104,NDC,1,EA,108.29,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone sodium succinate (preservative free) 250 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001305,NDC,1,EA,183.32,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone sodium succinate (preservative free) 500 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9001612,NDC,1,EA,298.53,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrocortisone sodium succinate (preservative free) 1000 MG Recon Soln 1 Each Vial,J1720.01,CDM,636,RC,J1720,HCPCS,,,,9000501,NDC,1,EA,403.54,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 0.1 MG/ML Solution 55 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,61553067976,NDC,55,ML,89.7,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 1 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409128303,NDC,1,ML,36.93,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 1 MG/ML Solution 1 mL Syringe,J1170.01,CDM,636,RC,J1170,HCPCS,,,,76045000901,NDC,0.25,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084042311,NDC,1,EA,3.83,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 2 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406324301,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,42858030125,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084042301,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HYDROmorphone 2 MG/ML Solution 1 mL Crtrdg-NDL,J1170.01,CDM,636,RC,J1170,HCPCS,,,,409131203,NDC,1,ML,38.18,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydroxocobalamin 5 g Recon Soln 1 Each Box,J3424.01,CDM,636,RC,J3424,HCPCS,,,,11704037001,NDC,1,EA,1991.16,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydroxychloroquine 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292001101,NDC,1,EA,23.57,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydroxychloroquine 200 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16571068701,NDC,1,EA,23.41,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hydroxyprogesterone, 17-D - Ref",PX8349890,CDM,300,RC,83498,CPT,90,,,,,,,67,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrOXYzine 50 MG/ML Solution 1 mL Vial,J3410.01,CDM,636,RC,J3410,HCPCS,,,,517560125,NDC,0.5,ML,83.68,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrOXYzine HCl 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714008110,NDC,1,EA,3.41,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrOXYzine HCl 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155050101,NDC,0.4,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrOXYzine pamoate 25 MG capsule 1 Each Blister,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084711,NDC,1,EA,3.22,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,51079007720,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hydrOXYzine pamoate 25 MG capsule 100 Each Box,Q0177.01,CDM,636,RC,Q0177,HCPCS,,,,68084084701,NDC,1,EA,3.22,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
hyoscyamine 0.125 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42192034001,NDC,1,EA,4.56,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
I&D Bartholin Gland Abscess,PX56420F,CDM,510,RC,56420,CPT,,,,,,,,429,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
I&D Bartholin Gland Abscess,PX56420P,CDM,983,RC,56420,CPT,,,,,,,,286,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
I&D Deep Absc/Hematoma Neck/Chest,PX21501F,CDM,510,RC,21501,CPT,,,,,,,,773,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
I&D Deep Absc/Hematoma Neck/Chest,PX21501P,CDM,983,RC,21501,CPT,,,,,,,,515,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"I&D Perianal Abscess,Superficial",PX46050,CDM,983,RC,46050,CPT,,,,,,,,1096,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"I&D Perianal Abscess,Superficial",PX46050F,CDM,510,RC,46050,CPT,,,,,,,,1463,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"I&D Perianal Abscess,Superficial",PX46050P,CDM,983,RC,46050,CPT,,,,,,,,993,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
I&D Perirectal Abscess,PX46040F,CDM,510,RC,46040,CPT,,,,,,,,1430,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
I&D Perirectal Abscess,PX46040P,CDM,983,RC,46040,CPT,,,,,,,,953,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Iaad Ia Severe Aqt Respir Synd Coronavirus,PX87426,CDM,300,RC,87426,CPT,,,,,,,,159,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq,PX87635,CDM,300,RC,87635,CPT,,,,,,,,166,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Iadna Streptococcus Group a Amplified Probe Tq,PX87651,CDM,300,RC,87651,CPT,,,,,,,,113,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 100 MG/5ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,68094049459,NDC,20,ML,22.2,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 100 MG/5ML Suspension 118 mL Bottle,63700001,CDM,250,RC,,,,,,45802089726,NDC,118,ML,54.97,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 100 MG/5ML Suspension 120 mL Bottle,63700001,CDM,250,RC,,,,,,904530920,NDC,20,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 200 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904791461,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 600 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687045711,NDC,0.333333333,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 600 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739068410,NDC,0.333333333,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 800 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687046811,NDC,0.25,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 800 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687046801,NDC,0.25,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibuprofen 800 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739069110,NDC,0.25,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ibutilide 1 MG/10ML Solution 10 mL Vial,J1742.01,CDM,636,RC,J1742,HCPCS,,,,9379401,NDC,10,ML,2349.03,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ID Nucleic Acid Sequencing - Ref,PX8715390,CDM,300,RC,87153,CPT,90,,,,,,,265,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
idaruCIZUmab 2.5 GM/50ML Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,597019705,NDC,50,ML,10037,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ig Paraprotein Qual Bld/UR,PX0077U90,CDM,300,RC,0077U,HCPCS,90,,,,,,,66,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Igh, Variable Region Somatic Mutation Analysis",PX8126390,CDM,310,RC,81263,CPT,90,,,,,,,1215,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ileoscopy Thru Stoma,Diagnostic",PX44380F,CDM,750,RC,44380,CPT,,,,,,,,245,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,216.09,6141.46
"Ileoscopy Thru Stoma,Diagnostic",PX44380P,CDM,983,RC,44380,CPT,,,,,,,,455,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
imipenem-cilastatin 250 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323034925,NDC,1,EA,91.55,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032225,NDC,1,EA,176.72,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
imipenem-cilastatin 500 MG Recon Soln 1 Each Vial,J0743.01,CDM,636,RC,J0743,HCPCS,,,,63323032294,NDC,1,EA,91.55,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IMMOBILIZER KNEE  24"" 7041-44",120.22,CDM,274,RC,L1830,HCPCS,,595-MAIN,LOCAL,,,,,60,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IMMOBILIZER KNEE 16"" UNIVERSAL 7088-04",120.22,CDM,274,RC,L1830,HCPCS,,589-MAIN,LOCAL,,,,,60,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER KNEE 20 INCH ORT2420019,120.22,CDM,274,RC,L1830,HCPCS,,587-MAIN,LOCAL,,,,,60,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IMMOBILIZER KNEE 20"" LARGE FOAM COUNTOURED STAYS 7062-03",120.22,CDM,274,RC,L1830,HCPCS,,593-MAIN,LOCAL,,,,,60,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IMMOBILIZER KNEE 20"" QUICK-WRAP ORT2440020S",120.22,CDM,274,RC,L1830,HCPCS,,591-MAIN,LOCAL,,,,,60,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER KNEE CUTAWAY STRAIGHT 2 7041-05,120.22,CDM,274,RC,L1830,HCPCS,,596-MAIN,LOCAL,,,,,60,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER LARGE 9008-03,120.38,CDM,274,RC,L3650,HCPCS,,906-MAIN,LOCAL,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER LARGE STRAP OSG3033,120.38,CDM,274,RC,L3650,HCPCS,,2910-MAIN,LOCAL,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER MEDIUM 9008-02,120.38,CDM,274,RC,L3650,HCPCS,,912-MAIN,LOCAL,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER MEDIUM OSG3032,120.38,CDM,274,RC,L3650,HCPCS,,915-MAIN,LOCAL,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER SMALL 9008-01,120.38,CDM,274,RC,L3650,HCPCS,,913-MAIN,LOCAL,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER SMALL WITH CLOTH 9001-02,120.38,CDM,274,RC,L3650,HCPCS,,914-MAIN,LOCAL,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER X-LARGE CLOTH 9001-05,120.38,CDM,274,RC,L3650,HCPCS,,917-MAIN,LOCAL,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMMOBILIZER SHOULDER X-LARGE ORT16100XL,120.38,CDM,274,RC,L3650,HCPCS,,904-MAIN,LOCAL,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270004,NDC,100,ML,2827.78,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
immune globulin (Human) 5 GM/50ML Solution 50 mL Vial,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270010,NDC,100,ML,3458.14,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
immune globulin (Human) 10 GM/100ML Solution 100 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270005,NDC,100,ML,2827.78,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270006,NDC,100,ML,2912.78,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
immune globulin (Human) 20 GM/200ML Solution 200 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270012,NDC,100,ML,3293.58,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270007,NDC,100,ML,2827.78,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
immune globulin (Human) 30 GM/300ML Solution 300 mL Glass Cont,J1569.01,CDM,636,RC,J1569,HCPCS,,,,944270013,NDC,100,ML,2827.78,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunization Admin - Influenza,PX3241,CDM,771,RC,90471,CPT,,,,,,,,48,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunization Administration; Each Add'l Vaccine (Single or Combo Vaccine/T*,PX90472,CDM,771,RC,90472,CPT,,,,,,,,48,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunization Administration; One Vaccine (Single or Combination Vaccine/To*,PX90471,CDM,771,RC,90471,CPT,,,,,,,,130,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Immuno for Tumor Ag, Qn - Ref",PX8631690,CDM,300,RC,86316,CPT,90,,,,,,,115,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunoassay - Ref,PX8351690,CDM,300,RC,83516,CPT,90,,,,,,,15,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunoassay Nos - Ref,PX8352090,CDM,300,RC,83520,CPT,90,,,,,,,220,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Immunoassay,Ca15-3(27.29) - Ref",PX8630090,CDM,300,RC,86300,CPT,90,,,,,,,124,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunocytochemistry,PX3993,CDM,310,RC,88342,CPT,TC,,,,,,,182,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunofix Elp,PX86335,CDM,300,RC,86335,CPT,,,,,,,,214,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunofixation Electrophoresis; Serum,PX86334,CDM,300,RC,86334,CPT,,,,,,,,145,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Immunofluo Direct, Ea Ab - Ref",PX8834690,CDM,310,RC,88346,CPT,90,,,,,,,55,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunofluorescence per Spec Add Singl Antb Stain - Ref,PX8835090,CDM,310,RC,88350,CPT,90,,,,,,,112,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunoglobulin Subclasses - Ref,PX8278790,CDM,300,RC,82787,CPT,90,,,,,,,215,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunohisto Antibody Slide Ea Addl,PX8834101,CDM,310,RC,88341,CPT,TC,,,,,,,102,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Immunohisto Antibody Slide Ea Multiplex,PX8834401,CDM,310,RC,88344,CPT,TC,,,,,,,51,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMPLANT PACKAGE TOEMATE,27200000,CDM,278,RC,C1713,HCPCS,,11859-MAIN,LOCAL,,,,,2865,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IMPLANT TOEMATE X-SMALL PACKAGE 9H00-T050,C1713,CDM,278,RC,C1713,HCPCS,,11574-MAIN,LOCAL,,,,,2865,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"In Situ Hybridization (Eg, Fish), Each Probe, Tech",PX8836501,CDM,310,RC,88365,CPT,TC,,,,,,,117,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Inc/Drain Peritonsil Abscess,PX42700F,CDM,510,RC,42700,CPT,,,,,,,,624,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Inc/Drain Peritonsil Abscess,PX42700P,CDM,983,RC,42700,CPT,,,,,,,,889,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Incis/Drain Scrotum/Testis,Epididym",PX54700F,CDM,510,RC,54700,CPT,,,,,,,,660,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Incis/Drain Scrotum/Testis,Epididym",PX54700P,CDM,983,RC,54700,CPT,,,,,,,,440,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Incis/Drain Shldr Absc/Hema,Deep",PX23030P,CDM,983,RC,23030,CPT,,,,,,,,1564,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Incise External Hemorrhoid,PX46083F,CDM,510,RC,46083,CPT,,,,,,,,502,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Incise External Hemorrhoid,PX46083P,CDM,983,RC,46083,CPT,,,,,,,,956,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Incise Finger Tendon Sheath,PX26055F,CDM,510,RC,26055,CPT,,,,,,,,1398,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Incise Finger Tendon Sheath,PX26055P,CDM,983,RC,26055,CPT,,,,,,,,932,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106F,CDM,510,RC,11106,CPT,,,,,,,,255,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106P,CDM,983,RC,11106,CPT,,,,,,,,204,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
indocyanine green 25 MG Recon Soln 1 Each Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,70100042402,NDC,1,EA,446.07,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
indomethacin 25 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,50268043011,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Inf Ag Detect by Nucleic Acid (Dna or Rna); (Sars-Cov-2,PXU0005,CDM,300,RC,U0005,HCPCS,,,,,,,,0.01,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Infec Agent Direct Probe - Ref,PX8779990,CDM,300,RC,87799,CPT,90,,,,,,,182,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Infect Ag,Eia, Nos, Ea - Ref",PX8744990,CDM,300,RC,87449,CPT,90,,,,,,,187,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Infect Ea Organ, Amp Prob - Ref",PX8779890,CDM,300,RC,87798,CPT,90,,,,,,,180,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Infect, Organ, Amp Probe - Ref",PX8780190,CDM,300,RC,87801,CPT,90,,,,,,,630,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Infection Agent Detect Dna/Rna Probe Tq 6-11,PX87506,CDM,300,RC,87506,CPT,,,,,,,,1710,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Infection Agent Detect Dna/Rna Probe Tq 12-25,PX87507,CDM,300,RC,87507,CPT,,,,,,,,209,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Infectious Agent Antigen Detection by Immunoassay With Direct Visual Observation.,PX87811,CDM,300,RC,87811,CPT,,,,,,,,192,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU0003,CDM,300,RC,U0003,HCPCS,,,,,,,,133,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Infectious Agent Detection by Nucleic Acid (Dna or Rna); (Sars-Cov-2),PXU000390,CDM,300,RC,U0003,HCPCS,90,,,,,,,222,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Infectious Disease (Viral Respiratory Tract Infection),",PX0241U,CDM,300,RC,0241U,HCPCS,,,,,,,,457,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Infectious Disease,Chronic Hep C Virus,Six Assays, Utilizing Serum",PX8159690,CDM,300,RC,81596,CPT,90,,,,,,,609,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Infliximab - Ref,PX8023090,CDM,300,RC,80230,CPT,90,,,,,,,343,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
inFLIXimab 100 MG Recon Soln 1 Each Vial,J1745.01,CDM,636,RC,J1745,HCPCS,,,,57894003001,NDC,1,EA,2382.35,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
inFLIXimab-dyyb 100 MG Recon Soln 1 Each Vial,Q5103.01,CDM,636,RC,Q5103,HCPCS,,,,69080901,NDC,1,EA,1930.42,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Influenza Assay W/Optic,PX87804,CDM,300,RC,87804,CPT,,,,,,,,127,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012365,NDC,0.7,ML,291.98,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
influenza vac high-dose quad 0.7 ML suspension prefilled syringe 0.7 mL Syringe,90662,CDM,636,RC,90662,CPT,,,,49281012388,NDC,0.7,ML,291.98,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072310,NDC,0.5,ML,291.98,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Influenza Vac Recom HA Quad PF 0.5 ML solution prefilled syringe 0.5 mL Syringe,90682,CDM,636,RC,90682,CPT,,,,49281072388,NDC,0.5,ML,291.98,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042350,NDC,0.5,ML,132.37,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
influenza virus vaccine quad 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90686,CDM,636,RC,90686,CPT,,,,49281042388,NDC,0.5,ML,132.37,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
infuvite adult Injectable 10 mL Vial,J3490.99,CDM,636,RC,J3490,HCPCS,,,,54643564901,NDC,10,ML,86.89,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Initial Hospital Care Levl II,PX99222P,CDM,982,RC,99222,CPT,,,,,,,,187,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Observation Care,Levl I",PX99218,CDM,982,RC,99218,CPT,,,,,,,,266,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Observation Care,Levl II",PX99219,CDM,982,RC,99219,CPT,,,,,,,,391,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Observation Care,Levl III",PX99220,CDM,982,RC,99220,CPT,,,,,,,,461,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Repair of Entrapped Hernia of Abdomen, Less Than 3 Cm in Length",PX49592,CDM,982,RC,49592,CPT,,,,,,,,2164,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Repair of Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49593P,CDM,982,RC,49593,CPT,,,,,,,,2606,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591F,CDM,360,RC,49591,CPT,,,,,,,,1556,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1372.392,6141.46
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591P,CDM,982,RC,49591,CPT,,,,,,,,1245,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595F,CDM,360,RC,49595,CPT,,,,,,,,3503,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3089.646,6141.46
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595P,CDM,982,RC,49595,CPT,,,,,,,,3503,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Initial Rx Burn(S) 1st Degree,PX16000F,CDM,510,RC,16000,CPT,,,,,,,,338,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Inj Tendon/Ligament/Cyst,PX20550F,CDM,510,RC,20550,CPT,,,,,,,,177,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Inj Tendon/Ligament/Cyst,PX20550P,CDM,983,RC,20550,CPT,,,,,,,,264,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inj,Lumb Epidur,Blood/Clot Patch",PX62273P,CDM,983,RC,62273,CPT,,,,,,,,552,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inject Nerv Blck,Othr Periph Nerv",PX64450F,CDM,510,RC,64450,CPT,,,,,,,,757,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inject Nerv Blck,Othr Periph Nerv",PX64450P,CDM,983,RC,64450,CPT,,,,,,,,904,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inject Nerv Blck,Trigeminal",PX64400F,CDM,510,RC,64400,CPT,,,,,,,,255,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inject Nerv Blck,Trigeminal",PX64400P,CDM,983,RC,64400,CPT,,,,,,,,170,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inject Trigger Point, 1 or 2",PX20552F,CDM,510,RC,20552,CPT,,,,,,,,252,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inject Trigger Point, 1 or 2",PX20552P,CDM,983,RC,20552,CPT,,,,,,,,210,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection for Nerve Block,PX64445F,CDM,510,RC,64445,CPT,,,,,,,,385,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection for Nerve Block,PX64445P,CDM,983,RC,64445,CPT,,,,,,,,385,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection for Nerve Block,PX64447F,CDM,510,RC,64447,CPT,,,,,,,,3023,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection for Nerve Block,PX64447P,CDM,983,RC,64447,CPT,,,,,,,,3892,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection for Nerve Block,PX64448F,CDM,510,RC,64448,CPT,,,,,,,,873,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection for Shoulder Arthrogram,PX23350F,CDM,510,RC,23350,CPT,,,,,,,,675,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection Hip Arthrogram,PX27093F,CDM,510,RC,27093,CPT,,,,,,,,654,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Injection Hip Arthrogram,Anesth",PX27095F,CDM,510,RC,27095,CPT,,,,,,,,425,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Injection Hip Arthrogram,Anesth",PX27095P,CDM,983,RC,27095,CPT,,,,,,,,425,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Injection, Subq/Im",PX96372,CDM,260,RC,96372,CPT,,,,,,,,119,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Injection,Sacroiliac Joint(T)",PX27096F,CDM,510,RC,27096,CPT,,,,,,,,881,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inpatient Consult, Level III",PX99253,CDM,983,RC,99253,CPT,,,,,,,,374,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inpatient Consult, Level IV",PX99254,CDM,983,RC,99254,CPT,,,,,,,,508,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Inpt or Obs Disch Day Mngmt <=30 Minutes,PX99238,CDM,982,RC,99238,CPT,,,,,,,,199,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Emergency Endotrach Airway,PX31500F,CDM,510,RC,31500,CPT,,,,,,,,637,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Emergency Endotrach Airway,PX31500P,CDM,983,RC,31500,CPT,,,,,,,,657,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Insert Needle,Intraosseous Infusn",PX36680F,CDM,510,RC,36680,CPT,,,,,,,,659,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Non-Tunnel Cv Catheter >5 Years,PX36556F,CDM,510,RC,36556,CPT,,,,,,,,1025,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Non-Tunnel Cv Catheter >5 Years,PX36556P,CDM,983,RC,36556,CPT,,,,,,,,1274,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573F,CDM,761,RC,36573,CPT,,,,,,,,1529,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573P,CDM,983,RC,36573,CPT,,,,,,,,1721,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Simple Cath Foley,PX51702F,CDM,510,RC,51702,CPT,,,,,,,,198,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Straight Catheter,PX51701F,CDM,510,RC,51701,CPT,,,,,,,,168,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561F,CDM,510,RC,36561,CPT,,,,,,,,2604,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561P,CDM,983,RC,36561,CPT,,,,,,,,1736,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insitu Hybridization (Fish),PX8836401,CDM,310,RC,88364,CPT,TC,,,,,,,335,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSTRUMENT PACKAGE TOEMATE,27200000,CDM,272,RC,,,,11858-MAIN,LOCAL,,,,,636,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSTRUMENT POUCH INVISISHIELD LONG,27200000,CDM,272,RC,,,,12394-MAIN,LOCAL,,,,,7,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSTRUMENT TOEMATE X-SMALL PACKAGE 9H00-T060,27200000,CDM,272,RC,C1713,HCPCS,,11575-MAIN,LOCAL,,,,,636,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFFLATION TUBING SET,27200000,CDM,272,RC,,,,4686-MAIN,LOCAL,,,,,38.25,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT & PNEUVIEW  XE SMOKE ELIMINATOR 5MM,27200000,CDM,272,RC,,,,11876-MAIN,LOCAL,,,,,279,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 8MM,27200000,CDM,272,RC,,,,11877-MAIN,LOCAL,,,,,279,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 10MM,27200000,CDM,272,RC,,,,11878-MAIN,LOCAL,,,,,279,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT & PNEUVIEW XE SMOKE ELIMINATOR 12MM,27200000,CDM,272,RC,,,,11879-MAIN,LOCAL,,,,,279,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 5MM,27200000,CDM,272,RC,,,,11880-MAIN,LOCAL,,,,,279,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 8MM,27200000,CDM,272,RC,,,,11881-MAIN,LOCAL,,,,,279,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 10MM,27200000,CDM,272,RC,,,,11882-MAIN,LOCAL,,,,,279,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
INSUFLOWPORT BARIATRIC & PNEUVIEW XE SMOKE ELIMINATOR 12MM,27200000,CDM,272,RC,,,,11883-MAIN,LOCAL,,,,,279,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insulin Ab - Ref,PX8633790,CDM,300,RC,86337,CPT,90,,,,,,,65,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
insulin aspart 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169633910,NDC,3,ML,659.76,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
insulin aspart prot & aspart 70-30 (70-30) 100 UNIT/ML Suspension Pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,169369619,NDC,3,ML,629.28,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221901,NDC,3,ML,506.9,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
insulin glargine 100 UNIT/ML solution pen-injector 3 mL Pen,J1815.01,CDM,636,RC,J1815,HCPCS,,,,88221905,NDC,3,ML,506.9,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2021301,NDC,3,ML,44.46,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
insulin regular 100 UNIT/ML Solution 3 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821517,NDC,3,ML,275.33,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
insulin regular 100 UNIT/ML Solution 10 mL Vial,J1815.01,CDM,636,RC,J1815,HCPCS,,,,2821501,NDC,10,ML,307.46,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iohexol 300 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141363,NDC,100,ML,200,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iohexol 300 MG/ML Solution 150 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141365,NDC,150,ML,300,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iohexol 350 MG/ML Solution 100 mL Bottle,Q9967,CDM,636,RC,Q9967,HCPCS,,,,407141491,NDC,100,ML,200,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Iontophoresis, Ea 15min",PX97033,CDM,420,RC,97033,CPT,,,,,,,,15,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ipratropium 0.02 % Solution 2.5 mL Plas Cont,25000000,CDM,250,RC,,,,,,76204010001,NDC,2.5,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ipratropium 0.03 % Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,24208039830,NDC,30,ML,256.9,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ipratropium 0.06 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,54004641,NDC,15,ML,491.02,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,487020101,NDC,3,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097084034,NDC,3,ML,14.47,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ipratropium-albuterol 0.5-2.5 (3) MG/3ML Solution 3 mL Plas Cont,25000000,CDM,250,RC,,,,,,69097084053,NDC,3,ML,14.47,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
irbesartan 75 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,43547037403,NDC,1,EA,15.68,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
irbesartan 75 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,43547037409,NDC,1,EA,15.68,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Iron - Ref,PX8354090,CDM,300,RC,83540,CPT,90,,,,,,,52,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608201,NDC,1,ML,66.6,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,23608210,NDC,1,ML,63.43,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093102,NDC,1,ML,60.47,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron dextran complex 50 MG/ML Solution 2 mL Vial,J1750.01,CDM,636,RC,J1750,HCPCS,,,,52544093107,NDC,1,ML,57.59,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234001,NDC,1.25,ML,91.55,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234010,NDC,5,ML,306.2,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234025,NDC,5,ML,306.2,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron sucrose 20 MG/ML Solution 5 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517234099,NDC,5,ML,306.2,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231001,NDC,10,ML,649.64,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
iron sucrose 20 MG/ML Solution 10 mL Vial,J1756.01,CDM,636,RC,J1756,HCPCS,,,,517231005,NDC,10,ML,649.64,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Irrad/Lr Platelets,PXP9037,CDM,390,RC,P9037,HCPCS,,,,,,,,1617,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Irradiated Leukoreduced Rbc's,PXP9040,CDM,390,RC,P9040,HCPCS,,,,,,,,771,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Irri Implted Drug Dlvr Device,PX96523,CDM,260,RC,96523,CPT,,,,,,,,119,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
isatuximab-irfc 500 MG/25ML Solution 25 mL Vial,J9227.01,CDM,636,RC,J9227,HCPCS,,,,24065601,NDC,25,ML,7876.36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Islet Cell Antibody - Ref,PX8634190,CDM,300,RC,86341,CPT,90,,,,,,,146,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
isosorbide dinitrate 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084008211,NDC,0.5,EA,3.36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
isosorbide dinitrate 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,781155601,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
isosorbide dinitrate 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084008311,NDC,1,EA,7.25,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
isosorbide dinitrate 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084008301,NDC,1,EA,7.25,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
isosorbide mononitrate CR 30 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084059111,NDC,1,EA,9.01,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
isosorbide mononitrate CR 30 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084059101,NDC,1,EA,9.01,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Itraconazole,PX8018990,CDM,300,RC,80189,CPT,90,,,,,,,124,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
IV 0.9% NS 1000ML 2B1324X,27200000,CDM,272,RC,,,,538-MAIN,LOCAL,,,,,121.89,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IV Infusion Therapy, 1 Hour",PX96365,CDM,260,RC,96365,CPT,,,,,,,,327,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IV Infusion, Bamlanivimab and Etesevimab, Infusion and Monitoring",PXM0245,CDM,260,RC,M0245,HCPCS,,,,,,,,1555,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IV Infusion, Bamlanivimab, Infusion and Post Admin Monig",PXM0239,CDM,260,RC,M0239,HCPCS,,,,,,,,320,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IV Infusion, Casirivimab and Imdevimab, IV and Post Admr",PXM0243,CDM,771,RC,M0243,HCPCS,,,,,,,,1555,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"IV Push, Single/1st Drug",PX96374,CDM,260,RC,96374,CPT,,,,,,,,259,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ivermectin 3 MG Tablet 20 Each Box,63700001,CDM,250,RC,,,,,,42799080601,NDC,1,EA,26.68,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Jak2 Gene - Ref,PX8127090,CDM,300,RC,81270,CPT,90,,,,,,,734,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Janssen Covid-19 Vaccine, Administration",PX0031A,CDM,771,RC,0031A,HCPCS,,,,,,,,69,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Joint Survey,PX7707726,CDM,982,RC,77077,CPT,26,,,,,,,286,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Joint Survey Tc,PX7707701,CDM,320,RC,77077,CPT,TC,,,,,,,304,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
K-WIRE 0.9X150MM BLUNT/TROCAR DART-FIRE STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12449-MAIN,LOCAL,,,,,110,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
K-WIRE 0.9X150MM BLUNT/TROCAR STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12452-MAIN,LOCAL,,,,,110,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
K-WIRE 1.4X150MM BLUNT/TROCAR DART-FIRE STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12450-MAIN,LOCAL,,,,,110,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
K-WIRE 1.4X150MM BLUNT/TROCAR STERILE,27200000,CDM,272,RC,C1769,HCPCS,,12451-MAIN,LOCAL,,,,,110,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
K-WIRE SMOOTH 1.4MM X 100MM,C1713,CDM,272,RC,C1713,HCPCS,,12634-MAIN,LOCAL,,,,,63,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
K-WIRES 1.6MM,27200000,CDM,272,RC,C1769,HCPCS,,11852-MAIN,LOCAL,,,,,45,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KATZ EXTRACTOR OTO-RHINO FOREIGN BODY REMOVER,120.568,CDM,272,RC,,,,12808-MAIN,LOCAL,,,,,246,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KERRAMAX CARE SUPERABSORBENT DRESSING 5X6,120.548,CDM,272,RC,A6197,HCPCS,,12362-MAIN,LOCAL,,,,,10,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KERRAMAX CARE SUPERABSORBENT DRESSING 8X12,120.55,CDM,272,RC,A6197,HCPCS,,12363-MAIN,LOCAL,,,,,27,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,55150043801,NDC,20,ML,152.9,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457018100,NDC,20,ML,153.01,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 10 MG/ML Solution 20 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457018120,NDC,20,ML,152.9,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,143950801,NDC,10,ML,58.46,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,143950810,NDC,10,ML,58.51,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457000100,NDC,10,ML,68.38,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 50 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,67457000110,NDC,10,ML,59.67,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketamine 100 MG/ML Solution 10 mL Vial,J3490.119,CDM,636,RC,J3490,HCPCS,,,,55150044001,NDC,10,ML,111.85,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketoconazole 2 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,168009915,NDC,15,GR,173.97,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketoconazole 2 % Cream 15 g Tube,25000000,CDM,250,RC,,,,,,16714095501,NDC,15,GR,322.42,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314012605,NDC,5,ML,42.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69543038810,NDC,1,EA,11.58,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016200,NDC,1,ML,52.22,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016216,NDC,1,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016243,NDC,0.5,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072201,NDC,0.5,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 30 MG/ML Solution 1 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072225,NDC,0.5,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016226,NDC,0.5,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,63323016245,NDC,0.5,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011901,NDC,0.5,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72266011925,NDC,0.5,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072501,NDC,0.5,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ketorolac 60 MG/2ML Solution 2 mL Vial,J1885.01,CDM,636,RC,J1885,HCPCS,,,,72611072525,NDC,0.5,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT 3-LUMEN 7FR X 16CM CENTRALVENOUS CDC-42703-P1A,120.37,CDM,272,RC,C1751,HCPCS,,10707-MAIN,LOCAL,,,,,201,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT EMERGENCY BIRTH DYNJS0600,120.317,CDM,272,RC,,,,8344-MAIN,LOCAL,,,,,74,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT ENDO COMPLETE PROCEDURE CARRY-ON 100802,27200000,CDM,272,RC,,,,10369-MAIN,LOCAL,,,,,33.15,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT EPIDURAL 19GA FLEXTIP PLUS AK-05502,120.305,CDM,272,RC,,,,11413-MAIN,LOCAL,,,,,95,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT GASTRIC LAVAGE 2075,120.257,CDM,272,RC,C7510,HCPCS,,410-MAIN,LOCAL,,,,,44,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Kit Gene Analysis D816 Variant(S) - Ref,PX8127390,CDM,300,RC,81273,CPT,90,,,,,,,293,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT INTRODUCER 8.5FR AK-09803-CDC,120.128,CDM,272,RC,,,,8826-MAIN,LOCAL,,,,,89,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT PLEUREVAC CHEST DRAIN S-1100-08LF,120.2,CDM,272,RC,,,,4190-MAIN,LOCAL,,,,,198,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIT THORACENTESIS PLEURA SEAL AK-01000-T,120.24,CDM,272,RC,,,,1147-MAIN,LOCAL,,,,,162,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KIWI OMNICUP VACUUM DELIVERY SYSTEM,120.225,CDM,272,RC,,,,11608-MAIN,LOCAL,,,,,120,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
KUMAR CHOLANGIOGRAPHY CATHETER,27200000,CDM,272,RC,,,,10230-MAIN,LOCAL,,,,,63.11,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"La Crosse, Antibody - Ref",PX8665190,CDM,300,RC,86651,CPT,90,,,,,,,45,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lab Antibody ID,RBC",PX7605,CDM,300,RC,86870,CPT,,,,,,,,155,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lab Antibody ID,RBC",PX86870,CDM,300,RC,,,,,,,,,,410,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Basic Metabolic Panel,PX80048,CDM,300,RC,80048,CPT,,,,,,,,236,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Culture Bacteria,PX87070,CDM,300,RC,87070,CPT,,,,,,,,286,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Direct Coombs,PX86880,CDM,300,RC,86880,CPT,,,,,,,,76,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab H Pylori Stool Ag,PX87338,CDM,300,RC,87338,CPT,,,,,,,,424,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lab Ige, Isocyan Hdi",PX86003,CDM,300,RC,86003,CPT,90,,,,,,,34,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Imm Spin X-Match,PX8837,CDM,300,RC,86920,CPT,,,,,,,,402,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lab Immunoassay, Non Antibody",PX83516,CDM,300,RC,83516,CPT,,,,,,,,99,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Org ID Anaerobic-Each,PX87076,CDM,300,RC,87076,CPT,,,,,,,,67,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Platelet Count,PX85049,CDM,300,RC,85049,CPT,,,,,,,,56,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Pth Immunoch Part 1,PX83970,CDM,300,RC,83970,CPT,,,,,,,,128,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lab Wbc and Differential,PX85004,CDM,300,RC,85004,CPT,,,,,,,,39,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143932001,NDC,1,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,143962201,NDC,1,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,409226720,NDC,1,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,47781058629,NDC,1,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
labetalol 5 MG/ML Solution 20 mL Vial,J1920.01,CDM,636,RC,J1920,HCPCS,,,,51991093498,NDC,1,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
labetalol 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,10135071101,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
labetalol 200 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687045011,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lacosamide - Ref,PX8023590,CDM,300,RC,80235,CPT,90,,,,,,,200,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lactase 9000 units Tablet 12 Each Box,63700001,CDM,250,RC,,,,,,45091012,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lactate (Ld) (Ldh) Enzyme,PX83615,CDM,300,RC,83615,CPT,,,,,,,,157,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lactated ringers Solution 1,000 mL Flex Cont",J7120.01,CDM,636,RC,J7120,HCPCS,,,,338011704,NDC,1000,ML,99.12,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lactoferrin, Fecal; Qual",PX83630,CDM,300,RC,83630,CPT,,,,,,,,103,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lactulose 10 GM/15ML Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,121457715,NDC,15,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lactulose 10 GM/15ML Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,50383077915,NDC,15,ML,15.98,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lactulose encephalopathy 10 GM/15ML Solution 473 mL Bottle,25000000,CDM,250,RC,,,,,,50383079516,NDC,15,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lamoTRIgine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079049801,NDC,1,EA,22.34,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lamoTRIgine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904700761,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lamoTRIgine 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084031911,NDC,0.25,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lamoTRIgine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739051610,NDC,1,EA,13.3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lamoTRIgine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084031901,NDC,0.25,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Incis Hernia Reducible,PX49654F,CDM,510,RC,49654,CPT,,,,,,,,1964,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Incis Hernia Reducible,PX49654P,CDM,983,RC,49654,CPT,,,,,,,,1044,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LAP KIT BASIC,27200000,CDM,272,RC,,,,4829-MAIN,LOCAL,,,,,78.29,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Paraesophag Hern Repair,PX43281,CDM,982,RC,43281,CPT,,,,,,,,5950,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Partial Colectomy/Coloproctostomy,PX44207F,CDM,750,RC,44207,CPT,,,,,,,,4170,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3677.94,6141.46
Lap Rpr Vent Umbilical Hernia,PX49652F,CDM,510,RC,49652,CPT,,,,,,,,1890,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Rpr Vent Umbilical Hernia,PX49652P,CDM,983,RC,49652,CPT,,,,,,,,1260,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Rpr Vent Umbilical Hernia Incarcerated or Strangulated,PX49653F,CDM,510,RC,49653,CPT,,,,,,,,1990,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Rpr Vent Umbilical Hernia Incarcerated or Strangulated,PX49653P,CDM,983,RC,49653,CPT,,,,,,,,1327,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Sleeve Gastrectomy,PX43775,CDM,982,RC,43775,CPT,,,,,,,,5030,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LAP SPONGES 18x18 7INCH LOOP,27200000,CDM,272,RC,,,,604-MAIN,LOCAL,,,,,60.64,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Appendectomy",PX44970P,CDM,983,RC,44970,CPT,,,,,,,,1700,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Cholecystectomy",PX47562F,CDM,510,RC,47562,CPT,,,,,,,,1473,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Cholecystectomy",PX47562P,CDM,983,RC,47562,CPT,,,,,,,,983,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Cholecystectomy/Explore",PX47564F,CDM,510,RC,47564,CPT,,,,,,,,2419,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Cholecystectomy/Explore",PX47564P,CDM,983,RC,47564,CPT,,,,,,,,1613,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Cholecystectomy/Graph",PX47563F,CDM,510,RC,47563,CPT,,,,,,,,1556,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Dx Surgical Abd W/Biopsy",PX49321F,CDM,510,RC,49321,CPT,,,,,,,,874,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Dx Surgical Abd W/Biopsy",PX49321P,CDM,983,RC,49321,CPT,,,,,,,,583,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Esophagogast Fundoplasty",PX43280F,CDM,510,RC,43280,CPT,,,,,,,,6713,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Esophagogast Fundoplasty",PX43280P,CDM,983,RC,43280,CPT,,,,,,,,4449,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Inguinal Hernia Repr,Initial",PX49650F,CDM,510,RC,49650,CPT,,,,,,,,1076,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Inguinal Hernia Repr,Initial",PX49650P,CDM,983,RC,49650,CPT,,,,,,,,717,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Inguinal Hernia Repr,Recur",PX49651F,CDM,510,RC,49651,CPT,,,,,,,,1568,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Inguinal Hernia Repr,Recur",PX49651P,CDM,983,RC,49651,CPT,,,,,,,,2035,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180F,CDM,510,RC,44180,CPT,,,,,,,,1763,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180P,CDM,983,RC,44180,CPT,,,,,,,,1175,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LAPAROTOMY MAJOR I,27200000,CDM,272,RC,,,,4828-MAIN,LOCAL,,,,,123.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LARGE HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12836-MAIN,LOCAL,,,,,3905,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,17478062512,NDC,2.5,ML,109.45,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,24208046325,NDC,2.5,ML,137.26,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
latanoprost 0.005 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,61314054701,NDC,2.5,ML,487.35,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Face,Facial <2.5cm",PX12051F,CDM,510,RC,12051,CPT,,,,,,,,769,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Face,Facial <2.5cm",PX12051P,CDM,983,RC,12051,CPT,,,,,,,,615,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Face,Facial 2.5-5",PX12052F,CDM,510,RC,12052,CPT,,,,,,,,585,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Face,Facial 2.5-5",PX12052P,CDM,983,RC,12052,CPT,,,,,,,,776,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Layr Clos Wnd Rest Body 2.6-7.5,PX12042F,CDM,510,RC,12042,CPT,,,,,,,,404,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Layr Clos Wnd Rest Body 2.6-7.5,PX12042P,CDM,983,RC,12042,CPT,,,,,,,,777,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Layr Clos Wnd Rest Body 7.6-12.5,PX12044F,CDM,510,RC,12044,CPT,,,,,,,,785,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Layr Clos Wnd Rest Body 7.6-12.5,PX12044P,CDM,983,RC,12044,CPT,,,,,,,,523,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031F,CDM,510,RC,12031,CPT,,,,,,,,688,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031P,CDM,983,RC,12031,CPT,,,,,,,,551,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032F,CDM,510,RC,12032,CPT,,,,,,,,386,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032P,CDM,983,RC,12032,CPT,,,,,,,,647,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034F,CDM,510,RC,12034,CPT,,,,,,,,931,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034P,CDM,983,RC,12034,CPT,,,,,,,,1533,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035F,CDM,510,RC,12035,CPT,,,,,,,,655,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035P,CDM,983,RC,12035,CPT,,,,,,,,1244,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leflunomide 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,62332006130,NDC,1,EA,88.09,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leflunomide 20 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,70748013006,NDC,0.5,EA,44.1,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LEGGING COMPRESSION JUXTALITE LONG LG 33CM,120.369,CDM,271,RC,A6545,HCPCS,,10840-MAIN,LOCAL,,,,,145,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LEGGING PAIR 31X48 STERILE,27200000,CDM,272,RC,,,,10916-MAIN,LOCAL,,,,,16.53,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Legionella Antibody - Ref,PX8671390,CDM,300,RC,86713,CPT,90,,,,,,,71,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Leptospira Antibody - Ref,PX8672090,CDM,300,RC,86720,CPT,90,,,,,,,220,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leucovorin 10 mg/mL Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,25021081467,NDC,1,EA,40.13,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leucovorin 350 MG Recon Soln 1 Each Vial,J0640.01,CDM,636,RC,J0640,HCPCS,,,,703514501,NDC,1,EA,86.41,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Leukoreduced Platelets,PXP9035,CDM,390,RC,P9035,HCPCS,,,,,,,,1350,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Leukoreduced Rbc's,PXP9016,CDM,390,RC,P9016,HCPCS,,,,,,,,580,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leuprolide 7.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74364203,NDC,1,EA,3782.28,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74334603,NDC,1,EA,12509.82,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,62935022305,NDC,1,EA,2764.34,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
leuprolide 45 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74347303,NDC,1,EA,21633.89,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levalbuterol 1.25 MG/3ML Nebulization Solution 3 mL Box,63700001,CDM,250,RC,,,,,,76204090001,NDC,3,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levalbuterol 1.25 MG/3ML Nebulization Solution 3 mL Plas Cont,63700001,CDM,250,RC,,,,,,76204090011,NDC,3,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Level 1 Additional Procedure,PX36000080,CDM,360,RC,,,,,,,,,,1200,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1058.4,6141.46
Level 2 Additional Procedure,PX36000081,CDM,360,RC,,,,,,,,,,1500,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1323,6141.46
Level 3 Additional Procedure,PX36000082,CDM,360,RC,,,,,,,,,,2100,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1852.2,6141.46
Level 4 Additional Procedure,PX36000083,CDM,360,RC,,,,,,,,,,3200,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2822.4,6141.46
Level 5 Additional Procedure,PX36000084,CDM,360,RC,,,,,,,,,,5300,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4674.6,6141.46
Level 6 Additional Procedure,PX36000085,CDM,360,RC,,,,,,,,,,6500,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Level III - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3933,CDM,310,RC,88304,CPT,TC,,,,,,,66,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Level IV - Surgical Pathology, Gross and Microscopic Examination , Tech",PX3934,CDM,310,RC,88305,CPT,TC,,,,,,,185,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Level V - Surgical Pathology, Gross and Microscopic Examination, Tech",PX3939,CDM,310,RC,88307,CPT,TC,,,,,,,252,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Levetiracetam - Ref,PX8017790,CDM,300,RC,80177,CPT,90,,,,,,,108,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levETIRAcetam 250 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904712361,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levETIRAcetam 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079082101,NDC,1,EA,18.87,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188602,NDC,5,ML,45.46,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levETIRAcetam 500 MG/5ML Solution 5 mL Vial,J1953.01,CDM,636,RC,J1953,HCPCS,,,,409188622,NDC,5,ML,45.46,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levETIRAcetam 750 MG Tablet 500 Each Bottle,63700001,CDM,250,RC,,,,,,16714035602,NDC,0.333333333,EA,8.41,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levOCARNitine 200 MG/ML Solution 5 mL Vial,J1955.01,CDM,636,RC,J1955,HCPCS,,,,517104501,NDC,5,ML,249.86,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin 250 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635161,NDC,1,EA,79.08,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635261,NDC,0.5,EA,45.16,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin 750 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635361,NDC,0.333333333,EA,39.14,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013266,NDC,50,ML,59.67,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin in dextrose 5% 250 MG/50ML Solution 50 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004624,NDC,50,ML,50.58,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin in dextrose 5% 500 MG/100ML Solution 100 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004724,NDC,100,ML,64.63,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,25021013268,NDC,150,ML,59.67,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levoFLOXacin in dextrose 5% 750 MG/150ML Solution 150 mL Flex Cont,J1956.01,CDM,636,RC,J1956,HCPCS,,,,36000004824,NDC,150,ML,69.59,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levonorgestrel 1.5 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,62756071860,NDC,1,EA,114.48,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levonorgestrel 1.5 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,68180085211,NDC,1,EA,174.39,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 25 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904694961,NDC,4,EA,11.75,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 50 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079044001,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 50 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079044020,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 75 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079044101,NDC,1.333333333,EA,3.94,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 75 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079044120,NDC,2,EA,6.4,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 88 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,378180701,NDC,2,EA,5.99,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 88 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904695261,NDC,1.136363636,EA,4.27,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 100 MCG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,74662490,NDC,1,EA,7.6,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 100 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,74662411,NDC,1,EA,10.16,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 100 MCG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904695361,NDC,1,EA,3.78,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 100 MCG/5ML Solution 5 mL Vial,J0651.01,CDM,636,RC,J0651,HCPCS,,,,63323088510,NDC,0.625,ML,99.32,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 112 MCG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003901,NDC,0.892857143,EA,3.4,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine 112 MCG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,74929690,NDC,0.892857143,EA,6.47,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
levothyroxine Sodium 200 MCG Recon Soln 1 Each Vial,J0650.01,CDM,636,RC,J0650,HCPCS,,,,63323064710,NDC,0.0625,EA,75.75,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine - transparent dressing 4 % Kit 1 Each Box,63700001,CDM,250,RC,,,,,,496088207,NDC,1,EA,270.63,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine (preservative free) 4 % Solution 5 mL Ampule,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409428325,NDC,5,ML,48.62,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 0.5 % PF 0.5 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323049101,NDC,50,ML,103.2,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,55150025110,NDC,10,ML,37.85,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323020103,NDC,10,ML,36.14,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323020110,NDC,10,ML,34,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,409427616,NDC,20,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323048526,NDC,20,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323048541,NDC,20,ML,30.58,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409427602,NDC,50,ML,38.46,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409427617,NDC,50,ML,39.01,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048503,NDC,50,ML,57.74,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048557,NDC,50,ML,52.78,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323048201,NDC,10,ML,39.78,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 10 mL Vial",25000000,CDM,250,RC,,,,,,63323048217,NDC,10,ML,39.78,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409317801,NDC,20,ML,34.11,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409317816,NDC,20,ML,34.11,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048203,NDC,20,ML,44.8,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048226,NDC,20,ML,32.56,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048227,NDC,20,ML,44.8,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 1% -EPINEPHrine 1:100,000 1 %-1:100000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,63323048241,NDC,20,ML,32.56,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,63323049227,NDC,2,ML,34.74,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,63323049241,NDC,2,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,55150016205,NDC,5,ML,42.32,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049209,NDC,5,ML,44.52,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049236,NDC,5,ML,31.52,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049243,NDC,5,ML,31.52,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049257,NDC,5,ML,42.43,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049226,NDC,30,ML,34.55,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049237,NDC,30,ML,87.77,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 1% PF 1 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,63323049245,NDC,30,ML,34.55,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,143957501,NDC,50,ML,44.24,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,143957510,NDC,50,ML,44.24,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 2 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,63323048657,NDC,50,ML,61.05,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 2% -EPINEPHRine 1:200,000 2 %-1:200000 Solution 20 mL Vial",25000000,CDM,250,RC,,,,,,409318301,NDC,20,ML,49.86,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 2% PF 2 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049526,NDC,5,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 2% PF 2 % Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049541,NDC,5,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"lidocaine 2%-EPINEPHrine 1:100,000 2 %-1:100000 Solution 30 mL Vial",25000000,CDM,250,RC,,,,,,409318221,NDC,30,ML,51.57,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 4 % Cream 5 g Tube,63700001,CDM,250,RC,,,,,,496088205,NDC,5,GR,51.49,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 4 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,536128128,NDC,30,GR,96.95,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 4-5 MG/ML-% Solution 500 mL Flex Cont,J2001.01,CDM,636,RC,J2001,HCPCS,,,,338040903,NDC,500,ML,55.82,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 5 % Patch 1 Each Box,63700001,CDM,250,RC,,,,,,591352511,NDC,1,EA,50.26,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 5 % Patch 1 Each Box,63700001,CDM,250,RC,,,,,,603188010,NDC,1,EA,55.2,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 5 % Patch 30 Each Box,63700001,CDM,250,RC,,,,,,591352530,NDC,1,EA,50.26,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 5 % Patch 30 Each Box,63700001,CDM,250,RC,,,,,,603188016,NDC,1,EA,55.18,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409132305,NDC,5,ML,41.35,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490311,NDC,5,ML,43.39,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,409490334,NDC,5,ML,42.29,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine 100 MG/5ML Solution 5 mL Syringe,J2001.01,CDM,636,RC,J2001,HCPCS,,,,76329339001,NDC,5,ML,64.63,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine buffered 1 % Solution 0.5 mL Syringe,25000000,CDM,250,RC,,,,,,8888800160,NDC,0.5,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine buffered 1 % Solution 22.2 mL Vial,25000000,CDM,250,RC,,,,,,8888800251,NDC,22.2,ML,30.4,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine buffered 1% Solution 22.2 mL Vial,25000000,CDM,250,RC,,,,,,8888800251,NDC,22.2,ML,30.4,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine HCl 4 % Cream 76.5 g Tube,63700001,CDM,250,RC,,,,,,41167005820,NDC,76.5,GR,31.72,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine HCl 4 % Cream 133 g Tube,63700001,CDM,250,RC,,,,,,41167005828,NDC,133,GR,52.99,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine urethral/mucosal 2 % Gel 30 mL Tube,25000000,CDM,250,RC,,,,,,17478084030,NDC,30,ML,93.91,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine viscous 2 % Solution 15 mL Cup,63700001,CDM,250,RC,,,,,,121090315,NDC,5,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine viscous 2 % Solution 100 mL Bottle,63700001,CDM,250,RC,,,,,,72888012526,NDC,5,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lidocaine-epinephrine-tetracaine Gel 3 mL Syringe,J3490.160,CDM,636,RC,J3490,HCPCS,,,,88888800028,NDC,3,ML,121.19,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LIGACLIP APPLIER CLIP STERILE SIZE MEDIUM LARGE,27200000,CDM,272,RC,,,,11699-MAIN,LOCAL,,,,,126.62,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ligation of Hemorrhoid(S),PX46221P,CDM,983,RC,46221,CPT,,,,,,,,697,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
linezolid 600 MG/300ML Solution 300 mL Flex Cont,J2020.01,CDM,636,RC,J2020,HCPCS,,,,9514001,NDC,300,ML,332.42,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LINNEAR CUTTER STAPLE RELOAD GST BLUE 60MM,27200000,CDM,272,RC,,,,12068-MAIN,LOCAL,,,,,309,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LINNEAR CUTTER STAPLE RELOAD GST GREEN 60MM,27200000,CDM,272,RC,,,,12069-MAIN,LOCAL,,,,,309,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LINNEAR CUTTER STAPLE RELOAD GST WHITE 60MM,27200000,CDM,272,RC,,,,12067-MAIN,LOCAL,,,,,309,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
liothyronine 25 MCG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762120701,NDC,0.2,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lipid Profile,PX80061,CDM,300,RC,80061,CPT,,,,,,,,245,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lipoprotein (a) - Ref,PX8369590,CDM,300,RC,83695,CPT,90,,,,,,,55,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
liraglutide 18 MG/3ML solution pen-injector 3 mL Pen,63700001,CDM,250,RC,,,,,,169406012,NDC,3,ML,1405.33,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
liraglutide 18 MG/3ML solution pen-injector 3 mL Pen,63700001,CDM,250,RC,,,,,,169406013,NDC,3,ML,1382.75,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,603420921,NDC,1,EA,3.48,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68180051201,NDC,1,EA,3.48,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079098101,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,185060501,NDC,1,EA,5.23,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679761,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,591040701,NDC,0.25,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679861,NDC,0.25,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904679961,NDC,0.125,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687033301,NDC,0.125,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904680061,NDC,0.0625,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lisinopril 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904720061,NDC,0.0625,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lithium 150 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,54252625,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lithium 150 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,54852625,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LITHOTOMY PACK VIII ECLIPSE,27200000,CDM,272,RC,,,,12210-MAIN,LOCAL,,,,,31,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LOCKING SCREW T8 FULL THREAD 2.4MM L10MM,C1713,CDM,278,RC,C1713,HCPCS,,12637-MAIN,LOCAL,,,,,496,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LOCKING SCREW T8 FULL THREAD 2.4MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12651-MAIN,LOCAL,,,,,496,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LOCKING SCREW T8 FULL THREAD 2.7MM L12MM,C1713,CDM,278,RC,C1713,HCPCS,,12638-MAIN,LOCAL,,,,,496,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LOCKING SCREW T8 FULL THREAD 2.7MM L14MM,C1713,CDM,278,RC,C1713,HCPCS,,12639-MAIN,LOCAL,,,,,496,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Long Term Holter, 48 Hrs Up to 7 Days, Recording",PX93242,CDM,731,RC,93242,CPT,,,,,,,,58,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Long Term Holter, More Than 7 Days Up to 15 Days, Recording",PX93246,CDM,731,RC,93246,CPT,,,,,,,,58,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
loperamide 2 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079069001,NDC,1,EA,4.67,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
loperamide 2 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079069020,NDC,1,EA,4.7,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lopinavir-ritonavir 200-50 MG Tablet 120 Each Bottle,63700001,CDM,250,RC,,,,,,74679922,NDC,1,EA,54.99,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
loratadine 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714089801,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,591024001,NDC,1,EA,3.45,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904600761,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739049910,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687035511,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904600861,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739050010,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,54353244,NDC,0.25,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,121077001,NDC,0.25,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Concentrate 30 mL Bottle,63700001,CDM,250,RC,,,,,,65162068784,NDC,0.25,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,409677802,NDC,1,ML,31.11,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641600101,NDC,1,ML,32.56,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604401,NDC,1,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641604425,NDC,1,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620701,NDC,0.25,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,641620725,NDC,1,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
LORazepam 2 MG/ML Solution 1 mL Vial,J2060.01,CDM,636,RC,J2060,HCPCS,,,,17478004001,NDC,1,ML,42.39,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
losartan 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739067310,NDC,1,EA,3.22,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
losartan 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034711,NDC,1,EA,12.08,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904704861,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739068610,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
losartan 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034701,NDC,1,EA,12.08,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lovastatin 20 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,93057606,NDC,0.5,EA,6.37,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
lovastatin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739028110,NDC,1,EA,15.6,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Low Dose CT Lung Ca Screen WO Contrast,PX7127101,CDM,350,RC,71271,CPT,TC,,,,,,,1286,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Low Dose CT Lung Ca Screening,PXG029701,CDM,350,RC,G0297,HCPCS,TC,,,,,,,2812,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 1 Init Hosp Low Mdm or 40 Minutes,PX99221,CDM,982,RC,99221,CPT,,,,,,,,400,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 1 Sub Hosp Low Mdm or 25 Minutes,PX99231,CDM,982,RC,99231,CPT,,,,,,,,133,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 2 Init Hosp Mod Mdm or 55 Minutes,PX99222,CDM,982,RC,99222,CPT,,,,,,,,508,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 2 Sub Hosp Mod Mdm or 35 Minute,PX99232,CDM,982,RC,99232,CPT,,,,,,,,253,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 3 Init Hosp High Mdm or 75 Minutes,PX99223,CDM,982,RC,99223,CPT,,,,,,,,536,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 3 Sub Hosp High Mdm or 50 Minutes,PX99233,CDM,982,RC,99233,CPT,,,,,,,,384,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lyme Disease Antibody,PX86618,CDM,300,RC,86618,CPT,,,,,,,,194,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lyme Disease, Antibody - Ref",PX8661890,CDM,300,RC,86618,CPT,90,,,,,,,181,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lyme Disease, Confirm Tst - Ref",PX8661790,CDM,300,RC,86617,CPT,90,,,,,,,95,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lyme Screen,PX7585,CDM,300,RC,86618,CPT,,,,,,,,198,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Magnesium,PX83735,CDM,300,RC,83735,CPT,,,,,,,,150,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Magnesium - Ref,PX8373590,CDM,300,RC,83735,CPT,90,,,,,,,150,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium citrate 1.745 GM/30ML Solution 296 mL Bottle,63700001,CDM,250,RC,,,,,,69452038998,NDC,150,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium citrate 1.745 GM/30ML Solution 296 mL Bottle,63700001,CDM,250,RC,,,,,,70677111101,NDC,150,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Magnesium Cl-Calcium Carbonate 71.5-119 MG Tablet Delayed Release 60 Each Bottle,63700001,CDM,250,RC,,,,,,67618010760,NDC,2,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium hydroxide 400 MG/5ML Suspension 30 mL Cup,63700001,CDM,250,RC,,,,,,69339015301,NDC,5,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904660961,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,10006070028,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium oxide 400 (240 Mg) MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,64980033901,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate 1 g in 100 ml D5W (premix) 1-5 GM/100ML-% Solution 100 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010802,NDC,100,ML,52.51,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate 4 GM/50ML Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010701,NDC,50,ML,73.72,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006401,NDC,2,ML,31.46,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate 50 % Solution 2 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006403,NDC,2,ML,30.45,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate 50 % Solution 10 mL Vial,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323006404,NDC,2,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,409672924,NDC,50,ML,116.43,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010602,NDC,50,ML,126.07,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010605,NDC,50,ML,126.07,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
magnesium sulfate Solution 50 mL Flex Cont,J3475.01,CDM,636,RC,J3475,HCPCS,,,,63323010626,NDC,50,ML,84.47,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Manage/Train Orthotic/Prosthetic, per 15 Min",PX97763,CDM,420,RC,97763,CPT,,,,,,,,121,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,338035702,NDC,250,ML,309.28,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,990771502,NDC,250,ML,166.02,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mannitol 20 % Solution 250 mL Flex Cont,J3490.204,CDM,636,RC,J3490,HCPCS,,,,990771512,NDC,62.5,ML,56.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Manual Ther Tech,1+Regions,Ea 15 Min",PX97140,CDM,420,RC,97140,CPT,,,,,,,,135,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MAYO STAND COVERS 24X53""",27200000,CDM,272,RC,,,,644-MAIN,LOCAL,,,,,9.54,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"measles, mumps & rubella vaccine Recon Soln 1 Each Vial",90707,CDM,636,RC,90707,CPT,,,,6468100,NDC,1,EA,381.47,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mechanical Traction Therapy,PX97012,CDM,420,RC,97012,CPT,,,,,,,,135,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meclizine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084049111,NDC,1,EA,4.6,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meclizine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084049101,NDC,1,EA,4.6,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MEDIUM HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12835-MAIN,LOCAL,,,,,3905,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
medroxyPROGESTERone 2.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,555087202,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
medroxyPROGESTERone 150 MG/ML Suspension 1 mL Vial,J1050.01,CDM,636,RC,J1050,HCPCS,,,,67457088799,NDC,1,ML,437.38,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
megestrol 40 MG/ML Suspension 240 mL Bottle,25000000,CDM,250,RC,,,,,,49884090738,NDC,240,ML,594.72,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
melatonin 3 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268052411,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
melatonin 3 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268052415,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
melatonin 3 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,904518252,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Melatonin 3-10 MG Tablet 120 Each Bottle,800000,CDM,,,,,,,,47469000852,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Melatonin 10 MG SL Tab 120 Each Bottle,63700001,CDM,250,RC,,,,,,40985027503,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MELGISORB AG SILVER CALCIUM STERILE 6X6,120.502,CDM,272,RC,A6197,HCPCS,,11844-MAIN,LOCAL,,,,,45,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meloxicam 7.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268052511,NDC,1,EA,16.64,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meloxicam 7.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,29300012401,NDC,1,EA,17.02,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
memantine 10 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,72603011901,NDC,0.5,EA,16.37,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
menthol-zinc oxide Paste 113 g Tube,63700001,CDM,250,RC,,,,,,53329016544,NDC,113,GR,79.52,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120301,NDC,0.5,ML,34.45,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meperidine 25 MG/0.5ML Solution 0.5 mL Ampule,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409120311,NDC,0.5,ML,34.45,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117603,NDC,1,ML,58.93,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meperidine 25 MG/ML Solution 1 mL Syringe,J2175.01,CDM,636,RC,J2175,HCPCS,,,,409117630,NDC,1,ML,58.34,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MEPILEX ADH FOAM 4X10,120.63,CDM,272,RC,A6196,HCPCS,,8710-MAIN,LOCAL,,,,,25,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MEPILEX AG 4X4 10X10,120.138,CDM,272,RC,A6213,HCPCS,,7248-MAIN,LOCAL,,,,,33,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MEPILEX AG FOAM 4X4,120.192,CDM,272,RC,A6213,HCPCS,,8480-MAIN,LOCAL,,,,,42,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MEPILEX AG FOAM 4X8,120.192,CDM,272,RC,A6213,HCPCS,,8479-MAIN,LOCAL,,,,,42,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MEPILEX BORDER AG POST OP 4X10,120.368,CDM,272,RC,A6212,HCPCS,,10839-MAIN,LOCAL,,,,,55,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MEPILEX SOFT SILICONE 6X6,120.63,CDM,272,RC,A6196,HCPCS,,5577-MAIN,LOCAL,,,,,25,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mepolizumab 100 MG Recon Soln 1 Each Vial,J2182.01,CDM,636,RC,J2182,HCPCS,,,,173088101,NDC,1,EA,6959.95,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,781309894,NDC,1,EA,193.75,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,55150020830,NDC,1,EA,82.96,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
meropenem 1 g Recon Soln 1 Each Vial,J2185.01,CDM,636,RC,J2185,HCPCS,,,,63323050830,NDC,1,EA,134.48,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH FLAT SHEET SOFT 3X6 INCH,C1781,CDM,278,RC,C1781,HCPCS,,11773-MAIN,LOCAL,,,,,253,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH LARGE LEFT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 4X6,120.521,CDM,278,RC,C1781,HCPCS,,12215-MAIN,LOCAL,,,,,572,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH LARGE RIGHT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 4X6,C1781,CDM,278,RC,C1781,HCPCS,,12195-MAIN,LOCAL,,,,,572,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MESH PROLENE 3X6""",C1781,CDM,278,RC,C1781,HCPCS,,688-MAIN,LOCAL,,,,,213.49,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH SURGICAL NON-ABSORBABLE PLUG 6INW X 6INL,C1781,CDM,272,RC,C1781,HCPCS,,12005-MAIN,LOCAL,,,,,1505,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH SURGICAL NON-ABSORBABLE PLUG 12INW X 12INL,C1781,CDM,278,RC,C1781,HCPCS,,12006-MAIN,LOCAL,,,,,1505,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH VENTRALIGHT ECHO 2.0 POSITIONING 11CM ROUND,120.525,CDM,278,RC,C1781,HCPCS,,12219-MAIN,LOCAL,,,,,1310,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH VENTRALIGHT ECHO 2.0 POSITIONING 15CM ROUND,C1781,CDM,278,RC,C1781,HCPCS,,12842-MAIN,LOCAL,,,,,1816,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH XLARGE LEFT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 5X7,120.524,CDM,278,RC,C1781,HCPCS,,12216-MAIN,LOCAL,,,,,630,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MESH XLARGE RIGHT 3D MAX KNITTED POLYPROPYLENE PRE FORMED 5X7,120.524,CDM,278,RC,C1781,HCPCS,,12217-MAIN,LOCAL,,,,,630,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Metanephrines - Ref,PX8383590,CDM,300,RC,83835,CPT,90,,,,,,,34,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904632661,NDC,1,EA,3.89,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904716261,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN 850 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687014311,NDC,0.588235294,EA,3.8,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN 850 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687014301,NDC,0.588235294,EA,3.8,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN 850 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739070210,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN 1000 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904669161,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN 1000 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904716461,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,50268053111,NDC,1,EA,7.19,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,60687064011,NDC,1,EA,3.34,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,185441601,NDC,1,EA,4,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,62756014201,NDC,1,EA,4,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN-XR 500 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,60687064001,NDC,1,EA,3.34,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metFORMIN-XR 750 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877041401,NDC,0.666666667,EA,4.28,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methadone 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406575523,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methadone 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54855324,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methenamine 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65862078201,NDC,0.5,EA,5.62,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methIMAzole 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155007001,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methIMAzole 10 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,23155007101,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Methlenedioxyamphetamines (Mda, Mdea, Mdma) - Ref",PX8035990,CDM,300,RC,80359,CPT,90,,,,,,,147,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methocarbamol 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687055911,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methocarbamol 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739016610,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methocarbamol 750 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687056811,NDC,0.666666667,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methotrexate 2.5 MG Tablet 1 Each Blister,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067001,NDC,1,EA,33.51,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methotrexate 2.5 MG Tablet 20 Each Box,J8610.01,CDM,636,RC,J8610,HCPCS,,,,51079067005,NDC,1,EA,33.49,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methyldopa 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93293101,NDC,1,EA,3.92,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylene blue 1 % Solution 10 mL Vial,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,54288014701,NDC,1,ML,139.25,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylene blue 50 MG/10ML Solution 10 mL Ampule,Q9968.01,CDM,636,RC,Q9968,HCPCS,,,,517037405,NDC,10,ML,1382.12,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylergonovine 0.2 MG/ML Solution 1 mL Ampule,J2210.01,CDM,636,RC,J2210,HCPCS,,,,51991014417,NDC,1,ML,133.11,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone 4 MG Tablet 100 Each Bottle,J7509.01,CDM,636,RC,J7509,HCPCS,,,,68382091601,NDC,0.5,EA,4.43,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,603459315,NDC,1,EA,7.67,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,781502207,NDC,1,EA,7.68,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone 4 MG tablet therapy pack 21 Each Disp Pack,J7509.01,CDM,636,RC,J7509,HCPCS,,,,42806040021,NDC,1,EA,8.86,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone acetate 20 MG/ML Suspension 5 mL Vial,J1010.01,CDM,636,RC,J1010,HCPCS,,,,9027401,NDC,0.5,ML,41.3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003905,NDC,1,EA,58.77,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003928,NDC,1,EA,39,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ (PF) 40 MG Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9003930,NDC,1,EA,58.99,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004703,NDC,1,EA,75.45,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004722,NDC,2,ML,88.35,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ (PF) 125 MG/2 ML Recon Soln 2 mL Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9004725,NDC,2,ML,131.52,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ 125 MG/2 ML Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,63323025803,NDC,0.4,EA,46.67,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ 500 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9075801,NDC,0.25,EA,39,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
methylPREDNISolone sod succ 1000 mg Recon Soln 1 Each Vial,J2919.01,CDM,636,RC,J2919,HCPCS,,,,9001820,NDC,1,EA,271.97,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoclopramide 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,93220401,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,703450284,NDC,2,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoclopramide 5 MG/ML Solution 2 mL Vial,J2765.01,CDM,636,RC,J2765,HCPCS,,,,23155024031,NDC,2,ML,34.55,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoclopramide 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739029310,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143966001,NDC,5,ML,37.82,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,143966010,NDC,5,ML,37.82,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,409177815,NDC,5,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,36000003310,NDC,5,ML,30.74,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol 5 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,70860030005,NDC,1.25,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084065911,NDC,1,EA,5.99,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904632261,NDC,1,EA,6.65,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol succinate 25 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084065901,NDC,1,EA,5.99,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol succinate 50 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084066611,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol succinate 50 MG Tablet Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,904632361,NDC,0.5,EA,3.33,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol succinate 100 MG Tablet Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,51079017101,NDC,0.25,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol tartrate 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584026511,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol tartrate 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904634061,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol tartrate 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079080101,NDC,0.25,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol tartrate 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904634161,NDC,0.25,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol tartrate 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079080120,NDC,1,EA,3.07,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol tartrate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,62584026711,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metoprolol tartrate 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,62584026701,NDC,0.125,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metroNIDAZOLE 500 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084096611,NDC,1,EA,4.94,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metroNIDAZOLE 500 MG Tablet 50 Each Bottle,63700001,CDM,250,RC,,,,,,29300022746,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metroNIDAZOLE 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084096601,NDC,1,EA,4.94,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metroNIDAZOLE 500 MG/100ML Solution 100 mL Flex Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,409781124,NDC,100,ML,32.12,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
metroNIDAZOLE 500 MG/100ML Solution 100 mL Plas Cont,J1836.01,CDM,636,RC,J1836,HCPCS,,,,338954124,NDC,100,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA 2.0MM TARGETING GUIDE PIN,27200000,CDM,272,RC,,,,12436-MAIN,LOCAL,,,,,110,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA BURR 2X12MM STERILE MICA,27200000,CDM,272,RC,,,,12447-MAIN,LOCAL,,,,,1113,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA BURR 2X20MM STERILE MICA,27200000,CDM,272,RC,,,,12448-MAIN,LOCAL,,,,,1113,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA CUTTING BURR 3X20MM LONG MICA,27200000,CDM,272,RC,,,,12434-MAIN,LOCAL,,,,,1113,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA DEPTH GAUGE 150MM STERILE MICA,27200000,CDM,272,RC,,,,12439-MAIN,LOCAL,,,,,385,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA FIRST MET TRANSLATOR STERILE MICA,27200000,CDM,272,RC,,,,12445-MAIN,LOCAL,,,,,393,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA SCREW 4.0X32MM FULLY THREADED STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12894-MAIN,LOCAL,,,,,2096,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MICA WEDGE BURR 3.1X13MM STERILE,27200000,CDM,272,RC,,,,12435-MAIN,LOCAL,,,,,1113,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,25021019110,NDC,1,EA,809.89,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
micafungin 100 MG Recon Soln 1 Each Vial,J2248.01,CDM,636,RC,J2248,HCPCS,,,,63323072902,NDC,1,EA,265.95,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
miconazole 2 % Powder 71 g Bottle,25000000,CDM,250,RC,,,,,,316023125,NDC,71,GR,34.82,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
miconazole 2 % Powder 85 g Bottle,25000000,CDM,250,RC,,,,,,67094930,NDC,85,GR,35.43,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Microalbumin Quantitative,PX82043,CDM,300,RC,82043,CPT,,,,,,,,167,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Microbe Susceptible Mic,PX87186,CDM,300,RC,87186,CPT,,,,,,,,124,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Microscopic Exam of Urine,PX81015,CDM,300,RC,81015,CPT,,,,,,,,29,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Microsomal Antibody,PX7893,CDM,300,RC,86376,CPT,,,,,,,,115,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605701,NDC,2,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641605725,NDC,1,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060031,NDC,2,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 2 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,23155060041,NDC,2,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 2 MG/ML Syrup 5 mL Cup,63700001,CDM,250,RC,,,,,,68094076459,NDC,2.5,ML,22.47,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 5 MG/ML Solution 1 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606101,NDC,0.2,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606001,NDC,10,ML,65.62,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam 50 MG/10ML Solution 10 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,641606010,NDC,10,ML,65.62,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230504,NDC,0.5,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam PF 5 MG/5ML Solution 5 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230505,NDC,5,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midazolam PF 10 MG/2ML Solution 2 mL Vial,J2250.01,CDM,636,RC,J2250,HCPCS,,,,409230802,NDC,2,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
midodrine 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,42291056190,NDC,0.5,EA,6.52,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,143971801,NDC,200,ML,230.48,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
milrinone 40-5 MG/200ML-% Solution 200 mL Flex Cont,J2260.01,CDM,636,RC,J2260,HCPCS,,,,409277602,NDC,200,ML,228.28,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mineral oil Enema 133 mL Bottle,63700001,CDM,250,RC,,,,,,132030140,NDC,133,ML,13.58,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MINIBUNION 3.5 OFFSET PLATE SHORT,27200000,CDM,278,RC,C1713,HCPCS,,11667-MAIN,LOCAL,,,,,5142.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MINIBUNION DRILL KIT,27200000,CDM,278,RC,C1713,HCPCS,,11669-MAIN,LOCAL,,,,,841.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MINIBUNION INSTRUMENT KIT,27200000,CDM,278,RC,C1713,HCPCS,,11668-MAIN,LOCAL,,,,,1860.65,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MINIBUNION LOCKING SCREW 3.0X24MM,C1713,CDM,278,RC,C1713,HCPCS,,11671-MAIN,LOCAL,,,,,308.55,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MINIBUNION NON-LOCKING SCREW  2.7X18MM,C1713,CDM,278,RC,C1713,HCPCS,,11670-MAIN,LOCAL,,,,,280.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mirtazapine 15 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904651961,NDC,0.5,EA,7.68,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MIS STERILE INSTRUMENT PACK WITH BLADE MICA SCREW SYSTEM,27200000,CDM,272,RC,,,,12432-MAIN,LOCAL,,,,,900,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Misc Virus Antibody, Nos - Ref",PX8679090,CDM,300,RC,86790,CPT,90,,,,,,,90,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
miSOPROStol 100 MCG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,70954044310,NDC,0.25,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mitochondrial Antibody Each,PX8638190,CDM,300,RC,86381,CPT,90,,,,,,,38,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157F,CDM,370,RC,99157,CPT,,,,,,,,270,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157P,CDM,983,RC,99157,CPT,,,,,,,,270,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155F,CDM,370,RC,99155,CPT,,,,,,,,353,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155P,CDM,983,RC,99155,CPT,,,,,,,,353,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156F,CDM,370,RC,99156,CPT,,,,,,,,325,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156P,CDM,983,RC,99156,CPT,,,,,,,,325,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153F,CDM,370,RC,99153,CPT,,,,,,,,225,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153P,CDM,983,RC,99153,CPT,,,,,,,,250,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151F,CDM,370,RC,99151,CPT,,,,,,,,176,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151P,CDM,983,RC,99151,CPT,,,,,,,,275,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152F,CDM,370,RC,99152,CPT,,,,,,,,235,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152P,CDM,983,RC,99152,CPT,,,,,,,,90,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 1st Dose",PX0011A,CDM,771,RC,0011A,HCPCS,,,,,,,,69,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 2nd Dose",PX0012A,CDM,771,RC,0012A,HCPCS,,,,,,,,69,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Moderna Covid-19 Vaccine, 100mcg/0.5ml, Administration - 3rd Dose",PX0013A,CDM,771,RC,0013A,HCPCS,,,,,,,,69,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MODULAR INSERT TOE JOINT 2.5MM 3.6MMTHK PROXIMAL PHALANGEAL,C1713,CDM,278,RC,C1713,HCPCS,,12530-MAIN,LOCAL,,,,,3968,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Molecular Cytog, Ea Probe - Ref",PX8827190,CDM,310,RC,88271,CPT,90,,,,,,,277,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Molecular Path Proc, Level 2 - Ref",PX8140190,CDM,310,RC,81401,CPT,90,,,,,,,672,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Molecyto Insitu, 100-300cl - Ref",PX8827590,CDM,310,RC,88275,CPT,90,,,,,,,103,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mometasone - formoterol 100-5 MCG/ACT Aerosol 8.8 g Inhaler,25000000,CDM,250,RC,,,,,,85720607,NDC,8.8,GR,918.07,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mometasone - formoterol 200-5 MCG/ACT Aerosol 8.8 g Inhaler,25000000,CDM,250,RC,,,,,,85461005,NDC,8.8,GR,918.07,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
montelukast 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268057511,NDC,1,EA,26.75,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
montelukast 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268057515,NDC,1,EA,26.75,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
montelukast 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904680861,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601901,NDC,10,ML,211.47,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine (preservative free) 1 MG/ML Solution 10 mL Ampule,J2274.01,CDM,636,RC,J2274,HCPCS,,,,641601910,NDC,10,ML,211.47,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine 1 MG/ML Solution 50 mL Syringe,J2270.01,CDM,636,RC,J2270,HCPCS,,,,61553064975,NDC,50,ML,81.71,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine 2 MG/ML Solution 1 mL Syringe,J2272.01,CDM,636,RC,J2272,HCPCS,,,,76045000401,NDC,1,ML,38.98,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine 10 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,574711212,NDC,1,EA,33.56,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine 20 mg/mL Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,54040444,NDC,30,ML,141.88,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine 20 mg/mL Solution 30 mL Bottle,63700001,CDM,250,RC,,,,,,54051744,NDC,0.5,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine ER 15 MG Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,406831523,NDC,1,EA,10.05,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine ER 15 MG Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,68084040311,NDC,1,EA,9.88,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine ER 15 MG Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,406831562,NDC,1,EA,10.05,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine ER 15 MG Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,68084040301,NDC,1,EA,9.9,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine immediate release 15 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54023525,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine immediate release 15 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,832027311,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189001,NDC,1,ML,34.11,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine PF 2 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189003,NDC,1,ML,34.11,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189101,NDC,1,ML,32.43,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
morphine PF 4 MG/ML Solution 1 mL Cartridge,J2270.01,CDM,636,RC,J2270,HCPCS,,,,409189103,NDC,1,ML,32.89,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Morphometric Analysis, in Situ Hybridization, Each Probe; Manual, Tech",PX8836801,CDM,310,RC,88368,CPT,TC,,,,,,,402,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Morphometric Analysis, Tumor - Ref",PX8836090,CDM,310,RC,88360,CPT,90,,,,,,,349,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Morphometric Analysis,Tumor Immunohistochemistry, Ea Antibody Manual , Tech",PX8836001,CDM,310,RC,88360,CPT,TC,,,,,,,119,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
moxifloxacin 0.5 % Solution 3 mL Bottle,25000000,CDM,250,RC,,,,,,60505058204,NDC,3,ML,691.15,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Mra, Head W/Out Contrast",PX7054401,CDM,610,RC,70544,CPT,TC,,,,,,,3541,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Mra, Neck W/O+W/ Contrast",PX7054901,CDM,610,RC,70549,CPT,TC,,,,,,,3472,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Mra, Neck With Contrast",PX7054801,CDM,610,RC,70548,CPT,TC,,,,,,,3541,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Abdomen W/O Tc,PX7418101,CDM,610,RC,74181,CPT,TC,,,,,,,2655,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Brain W & WO Contrast,PX7055301,CDM,610,RC,70553,CPT,TC,,,,,,,3541,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Brain W Contrast Tc,PX7055201,CDM,610,RC,70552,CPT,TC,,,,,,,2637,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Brain WO Contrast Tc,PX7055101,CDM,610,RC,70551,CPT,TC,,,,,,,3335,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI C Spine W&WO Contrast,PX7215601,CDM,610,RC,72156,CPT,TC,,,,,,,3541,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI C-Spine WO Contrast,PX7214101,CDM,610,RC,72141,CPT,TC,,,,,,,3541,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI L Spine W Contrast Tc,PX7214901,CDM,610,RC,72149,CPT,TC,,,,,,,5136,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI L Spine W&WO Contrast,PX7215801,CDM,610,RC,72158,CPT,TC,,,,,,,4178,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI L Spine WO Contrast,PX7214801,CDM,610,RC,72148,CPT,TC,,,,,,,3541,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Low Ext Jnt WO/Cont Tc,PX7372101,CDM,610,RC,73721,CPT,TC,,,,,,,3541,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Lower W/O+W Tc,PX7372001,CDM,610,RC,73720,CPT,TC,,,,,,,3174,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Orb-Fac-Nec W/O+W/Con,PX7054301,CDM,610,RC,70543,CPT,TC,,,,,,,3541,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Orbit/Face/Neck Tc,PX7054001,CDM,610,RC,70540,CPT,TC,,,,,,,3335,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Pelvis W/Contrast Tc,PX7219601,CDM,610,RC,72196,CPT,TC,,,,,,,3143,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI T Spine W&WO Contrast,PX7215701,CDM,610,RC,72157,CPT,TC,,,,,,,4178,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI T Spine WO Contrast,PX7214601,CDM,610,RC,72146,CPT,TC,,,,,,,3267,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Up Extremity Joint W/O Tc,PX7322101,CDM,610,RC,73221,CPT,TC,,,,,,,3319,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MRI Upper W/O+W Tc,PX7322001,CDM,610,RC,73220,CPT,TC,,,,,,,3253,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI, Abdomen W/O+ W/Contr",PX7418301,CDM,610,RC,74183,CPT,TC,,,,,,,4116,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI, Pelvis, W/O Then W/",PX7219701,CDM,610,RC,72197,CPT,TC,,,,,,,1612,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI,Lwrext,Jnt W/O+W/Cont",PX7372301,CDM,610,RC,73723,CPT,TC,,,,,,,1850,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI,Lwrext,No Jnt, W/Cont",PX7371901,CDM,610,RC,73719,CPT,TC,,,,,,,3627,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI,Lwrext,No Jnt,No Cont",PX7371801,CDM,610,RC,73718,CPT,TC,,,,,,,3253,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI,Pelvis W/Out Contrast",PX7219501,CDM,610,RC,72195,CPT,TC,,,,,,,3253,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI,Up Ext,No Jnt,No Cont",PX7321801,CDM,610,RC,73218,CPT,TC,,,,,,,3253,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI,Upr Ext, Joint,W/Cont",PX7322201,CDM,610,RC,73222,CPT,TC,,,,,,,3541,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"MRI,Uprext Jnt W/O+W/Cont",PX7322301,CDM,610,RC,73223,CPT,TC,,,,,,,2681,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mrsa by Amplification Na,PX87641,CDM,300,RC,87641,CPT,,,,,,,,180,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
MTP PLATE STANDARD 18MM CLIP 5 DEG DORSIFLEXION,27200000,CDM,278,RC,C1713,HCPCS,,11854-MAIN,LOCAL,,,,,5376,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Multiple Sleep Latency Test,PX9580501,CDM,740,RC,95805,CPT,TC,,,,,,,4313,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
multivitamin with minerals Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904549261,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mumps,PX86735,CDM,300,RC,86735,CPT,,,,,,,,148,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,45802011222,NDC,22,GR,63.29,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,51672131200,NDC,22,GR,140.7,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mupirocin 2 % Ointment 22 g Tube,25000000,CDM,250,RC,,,,,,68462018022,NDC,22,GR,240.66,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mycobacteria Culture - Ref,PX8711690,CDM,300,RC,87116,CPT,90,,,,,,,90,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
mycophenolate 500 MG Tablet 100 Each Bottle,J7517.01,CDM,637,RC,J7517,HCPCS,,,,64380072506,NDC,1,EA,42.56,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mycophenolate Mycophenolicacid - Ref,PX8018090,CDM,300,RC,80180,CPT,90,,,,,,,56,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Myoglobin - Ref,PX8387490,CDM,300,RC,83874,CPT,90,,,,,,,22,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"N Block Inj, Common Digit",PX64632F,CDM,510,RC,64632,CPT,,,,,,,,190,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"N Block Inj, Common Digit",PX64632P,CDM,983,RC,64632,CPT,,,,,,,,128,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"N Block Inj, Plantar Digit",PX64455F,CDM,510,RC,64455,CPT,,,,,,,,385,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"N Block Inj, Plantar Digit",PX64455P,CDM,983,RC,64455,CPT,,,,,,,,385,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nabumetone 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50228046501,NDC,1,EA,6.65,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nabumetone 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687037401,NDC,1,EA,6.32,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nadolol 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,76385013301,NDC,1,EA,18.2,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nafcillin 1 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,55150012215,NDC,1,EA,89.17,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nafcillin 2 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,S0032,HCPCS,,,,63323032820,NDC,1,EA,185.37,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Nafcillin Sodium 10 g Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323033060,NDC,1,EA,617.91,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059900,NDC,1,ML,133.16,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
naloxone 0.4 MG/ML Solution 1 mL Vial,J2310.01,CDM,636,RC,J2310,HCPCS,,,,67457059902,NDC,1,ML,133.16,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
naloxone 2 MG/2ML solution prefilled syringe 2 mL Syringe,J2310.01,CDM,636,RC,J2310,HCPCS,,,,76329346901,NDC,1,ML,114.45,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
naltrexone 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,406117001,NDC,1,EA,22.96,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
naproxen 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65162018810,NDC,1,EA,4.15,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
naproxen 500 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739040310,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Nasal Sm for Eos,PX89190,CDM,300,RC,89190,CPT,,,,,,,,38,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Naso/Orogastric Tube,PX43752F,CDM,510,RC,43752,CPT,,,,,,,,464,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Naso/Orogastric Tube,PX43752P,CDM,983,RC,43752,CPT,,,,,,,,309,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
natalizumab 300 MG/15ML Concentrate 15 mL Vial,J2323.01,CDM,636,RC,J2323,HCPCS,,,,64406000801,NDC,15,ML,15226.53,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE ACUJECT 25GA VARIABLE INJECTION VIN-25,27200000,CDM,272,RC,,,,7412-MAIN,LOCAL,,,,,77,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"NEEDLE ASP 16GX3/16"" 1-7/8"" ILLINOIS STERNAL 8881245164",120.8,CDM,272,RC,G0364,HCPCS,,5730-MAIN,LOCAL,,,,,50,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE BIOPSY 14GAX4 1/2 2N2702X,120.211,CDM,272,RC,,,,724-MAIN,LOCAL,,,,,40,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Needle Biopsy, Lymph Node(S)",PX38505F,CDM,510,RC,38505,CPT,,,,,,,,667,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Needle Biopsy,Muscle",PX20206F,CDM,510,RC,20206,CPT,,,,,,,,258,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Needle Biopsy,Muscle",PX20206P,CDM,983,RC,20206,CPT,,,,,,,,1028,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"NEEDLE BONE MARROW 8G X 4"" BIOPSY/ASPIRATION 8881247087",120.8,CDM,272,RC,G0364,HCPCS,,166-MAIN,LOCAL,,,,,50,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"NEEDLE BONE MARROW 11G X 4"" 8881247111",120.8,CDM,272,RC,G0364,HCPCS,,162-MAIN,LOCAL,,,,,50,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE ECHOGENIC 21G 110MM SONOTAP II WITH FACET TIP 1285-3F110,120.483,CDM,271,RC,A4215,HCPCS,,12201-MAIN,LOCAL,,,,,41,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE ECHOGENIC 21G X 4IN (100MM) SONOBLOCK II NERVE BLOCK WITH FACET S TIP 001281-77,120.483,CDM,271,RC,A4215,HCPCS,,12761-MAIN,LOCAL,,,,,41,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE ECHOGENIC 22G 80MM SONOTAP II WITH FACET TIP 1285-3E080,120.483,CDM,271,RC,A4215,HCPCS,,12103-MAIN,LOCAL,,,,,41,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE ECHOGENIC 22G X 3.25IN (80MM) SONOBLOCK II  NERVE BLOCK WITH FACET S TIP 001281-71,120.483,CDM,271,RC,A4215,HCPCS,,12760-MAIN,LOCAL,,,,,41,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE ECHOGENIC 22GX2 SONOPLEX II WITH FACET S TIP 001287-74,120.483,CDM,271,RC,A4215,HCPCS,,13110-MAIN,LOCAL,,,,,41,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE HYPODERMIC 22GA 1-1/2IN STERILE 305156,27200000,CDM,272,RC,A4215,HCPCS,,8887-MAIN,LOCAL,,,,,10,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Needle Insertion W/O Injection 1 or 2 Muscles,PX20560,CDM,420,RC,20560,CPT,,,,,,,,10,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Needle Insertion W/O Injection 3 or More Muscles,PX20561,CDM,420,RC,20561,CPT,,,,,,,,10,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE INTRAOSSEOUS 15GA 15MM EZ-IO PEDS 9018,120.89,CDM,272,RC,A4215,HCPCS,,4964-MAIN,LOCAL,,,,,269,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE INTRAOSSEOUS SET 15GA 25MM STABILIZER EZ-IO 9001P,120.216,CDM,272,RC,A4215,HCPCS,,10648-MAIN,LOCAL,,,,,290,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE INTRAOSSEOUS SET 15GA 45MM STABILIZER EZ-IO 9079P,120.216,CDM,272,RC,A4215,HCPCS,,10297-MAIN,LOCAL,,,,,290,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE IV 19GA X .75IN HUBER POWERLOC SAFETY 0651934,120.85,CDM,272,RC,A4215,HCPCS,,12701-MAIN,LOCAL,,,,,38,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE IV 19GA X 1 IN HUBER POWERLOC SAFETY 0651910,120.85,CDM,272,RC,A4215,HCPCS,,12702-MAIN,LOCAL,,,,,38,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE IV 19GA X 1.5 IN HUBER POWERLOC SAFETY 0651915,120.85,CDM,272,RC,A4215,HCPCS,,12703-MAIN,LOCAL,,,,,38,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE JAMSHIDI 11G X 101MM BIOPSY DJ4011X,27200000,CDM,272,RC,,,,12798-MAIN,LOCAL,,,,,39,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE NON-STIMULATING 22GX2 SONOBLOCK II WITH FACET S TIP 001281-74,120.483,CDM,271,RC,A4215,HCPCS,,11459-MAIN,LOCAL,,,,,41,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE SONOPLEX II STIMULATING WITH FACET S TIP 22GX3-1/4,120.483,CDM,271,RC,A4215,HCPCS,,11457-MAIN,LOCAL,,,,,41,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NEEDLE STIMULATING 21GX4  SONOPLEX II  WITH FACET S TIP 001287-77,120.483,CDM,271,RC,A4215,HCPCS,,11458-MAIN,LOCAL,,,,,41,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Neg Pressure Wound Therapy Dme </=50 Sq Cm,PX97605F,CDM,510,RC,97605,CPT,,,,,,,,396,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Neg Pressure Wound Therapy Dme >50 Sq Cm,PX97606F,CDM,761,RC,97606,CPT,,,,,,,,404,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607F,CDM,761,RC,97607,CPT,,,,,,,,455,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607P,CDM,983,RC,97607,CPT,,,,,,,,303,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Neisseria Gonorrhoeae Dna, Amp Probe",PX87591,CDM,300,RC,87591,CPT,,,,,,,,157,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-bacitracin-polymyxin 3.5-400-5000 Ointment 28 g Tube,25000000,CDM,250,RC,,,,,,45802014303,NDC,28,GR,37.76,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-bacitracin-polymyxin 3.5-400-5000 Ointment 28.4 g Tube,25000000,CDM,250,RC,,,,,,713026831,NDC,28.4,GR,22.47,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-polymyxin-dexameth 3.5-10000-0.1 Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063006,NDC,5,ML,247.72,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-polymyxin-dexamethasone 3.5-10000-0.1 Ointment 3.5 g Tube,25000000,CDM,250,RC,,,,,,61314063136,NDC,3.5,GR,247.71,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-polymyxin-gramicidin 1.75-10000-.025 Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,24208079062,NDC,10,ML,314.26,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Solution 10 mL Bottle,63700001,CDM,250,RC,,,,,,61314064610,NDC,10,ML,433.15,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Suspension 10 mL Bottle,63700001,CDM,250,RC,,,,,,24208063562,NDC,10,ML,415.81,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neomycin-polymyxin-hydrocortisone 3.5-10000-1 Suspension 10 mL Bottle,63700001,CDM,250,RC,,,,,,64980044801,NDC,10,ML,488.25,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,43598052936,NDC,0.5,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,63323041536,NDC,0.5,ML,44.05,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080601,NDC,0.5,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
neostigmine 10 MG/10ML Solution 10 mL Vial,J2710.01,CDM,636,RC,J2710,HCPCS,,,,70069080610,NDC,0.5,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Nephelometry, Each, Nos - Ref",PX8388390,CDM,300,RC,83883,CPT,90,,,,,,,223,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Neuromuscular Re-Education,PX97112,CDM,420,RC,97112,CPT,,,,,,,,135,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Nfct Ds Bct/Vir Respir Dna/Rna 22 Trgt Sarscov2,PX0202U,CDM,300,RC,0202U,HCPCS,,,,,,,,222,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954201,NDC,10,ML,153.18,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
niCARdipine 2.5 MG/ML Solution 10 mL Vial,J2404.01,CDM,636,RC,J2404,HCPCS,,,,143954210,NDC,10,ML,153.18,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 7 MG/24HR Patch 24 Hour 7 Each Box,63700001,CDM,250,RC,,,,,,43598044670,NDC,1,EA,13.53,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 14 MG/24HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,43598044771,NDC,1,EA,12.08,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 14 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,43598044774,NDC,1,EA,11.46,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 21 MG/24HR Patch 24 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,43598044871,NDC,1,EA,11.46,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 21 MG/24HR Patch 24 Hour 1 Each Package,63700001,CDM,250,RC,,,,,,60505706300,NDC,1,EA,13.81,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 21 MG/24HR Patch 24 Hour 7 Each Box,63700001,CDM,250,RC,,,,,,536589653,NDC,1,EA,12.84,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,536110888,NDC,1,EA,11.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,49348014446,NDC,1,EA,15.3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine 21 MG/24HR Patch 24 Hour 14 Each Box,63700001,CDM,250,RC,,,,,,70677003201,NDC,1,EA,10.16,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine polacrilex 4 MG Lozenge 24 Each Bottle,63700001,CDM,250,RC,,,,,,113087303,NDC,0.5,EA,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine polacrilex 4 MG Lozenge 24 Each Bottle,63700001,CDM,250,RC,,,,,,43598048772,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nicotine polacrilex 4 MG Lozenge 72 Each Box,63700001,CDM,250,RC,,,,,,49348085316,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NIFEdipine CR osmotic 30 MG Tablet Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,24979001101,NDC,1,EA,5.92,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079034801,NDC,1,EA,27.39,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,185012201,NDC,1,EA,17.23,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitrofurantoin (macrocrystal-monohydrate) 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079034820,NDC,1,EA,27.39,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 0.1 MG/HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,378910216,NDC,1,EA,9.98,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 0.1 MG/HR Patch 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,378910293,NDC,1,EA,9.98,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 0.2 MG/HR Patch 24 Hour 1 Each Box,63700001,CDM,250,RC,,,,,,378910416,NDC,1,EA,10.21,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 0.2 MG/HR Patch 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,378910493,NDC,1,EA,10.21,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,71041813,NDC,1,EA,5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,43598043635,NDC,1,EA,5.46,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 0.4 MG SL Tab 25 Each Bottle,63700001,CDM,250,RC,,,,,,68462063925,NDC,1,EA,5.51,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin 2 % Ointment 1 g Packet,63700001,CDM,250,RC,,,,,,281032608,NDC,1,GR,17.58,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroglycerin in dextrose 5% 100-5 MCG/ML-% Solution 250 mL Glass Cont,J2305.01,CDM,636,RC,J2305,HCPCS,,,,338104702,NDC,250,ML,126.07,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nitroPRUSSide 25 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,72485010501,NDC,2,ML,186,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nivolumab 40 MG/4ML Solution 4 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377211,NDC,4,ML,2171.7,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nivolumab 100 MG/10ML Solution 10 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3377412,NDC,10,ML,5429.27,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nivolumab 240 MG/24ML Solution 24 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3373413,NDC,24,ML,13030.26,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Nocardia Susceptibility - Ref,PX8718690,CDM,300,RC,87186,CPT,90,,,,,,,124,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NON-LOCKING SCREW 3.5X12MM,27200000,CDM,278,RC,C1713,HCPCS,,11857-MAIN,LOCAL,,,,,396,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NON-LOCKING SCREW 3.5X16MM,27200000,CDM,278,RC,C1713,HCPCS,,11856-MAIN,LOCAL,,,,,396,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NON-LOCKING SCREW 3.5X18MM,C1713,CDM,278,RC,C1713,HCPCS,,12466-MAIN,LOCAL,,,,,395.51,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
NON-LOCKING SCREW 3.5X24MM,27200000,CDM,278,RC,C1713,HCPCS,,11855-MAIN,LOCAL,,,,,396,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Non-Select. Wound Debride., W/O Anesth.; Top. Appl./Wound Assess./Instruct., per Sess.",PX97602,CDM,761,RC,97602,CPT,,,,,,,,212,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Noninvasv Lo Extrem Art Stress/Rest,PX9392401,CDM,921,RC,93924,CPT,TC,,,,,,,810,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Noninvasv Oxygen Satur;Single,PX94760,CDM,460,RC,94760,CPT,,,,,,,,131,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Noninvasv Oxygen Satut,Continuous",PX94762,CDM,460,RC,94762,CPT,,,,,,,,242,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,409337504,NDC,4,ML,150.36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,703115301,NDC,4,ML,136.1,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,781375575,NDC,4,ML,142.22,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,63323094004,NDC,4,ML,89.43,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
norepinephrine 1 MG/ML Solution 4 mL Vial,25000000,CDM,250,RC,,,,,,63323094021,NDC,4,ML,89.43,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nortriptyline 25 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,93081101,NDC,0.4,EA,3.15,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Novavax Covid-19 Vaccine Administration 1st Dose,PX0041A,CDM,771,RC,0041A,HCPCS,,,,,,,,69,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Novavax Covid-19 Vaccine Administration 2nd Dose,PX0042A,CDM,771,RC,0042A,HCPCS,,,,,,,,69,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/GM Cream 30 g Tube,25000000,CDM,250,RC,,,,,,168005430,NDC,30,GR,147.79,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/GM Cream 30 g Tube,25000000,CDM,250,RC,,,,,,51672128902,NDC,30,GR,148.29,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,574200815,NDC,15,GR,154.63,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,16714076901,NDC,15,GR,137.99,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/GM Powder 15 g Bottle,63700001,CDM,250,RC,,,,,,69315030615,NDC,15,GR,131.07,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/GM Powder 60 g Bottle,63700001,CDM,250,RC,,,,,,574200802,NDC,60,GR,491.86,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/GM Powder 60 g Bottle,63700001,CDM,250,RC,,,,,,68308015260,NDC,60,GR,335.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/ML Suspension 5 mL Cup,63700001,CDM,250,RC,,,,,,121086805,NDC,4,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,121086802,NDC,4,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,50383058766,NDC,60,ML,95.26,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,60432053760,NDC,60,ML,95.26,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,66689000802,NDC,4,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin 100000 UNIT/ML Suspension 473 mL Bottle,63700001,CDM,250,RC,,,,,,121086816,NDC,4,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
nystatin-triamcinolone 100000-0.1 UNIT/GM-% Ointment 30 g Tube,25000000,CDM,250,RC,,,,,,52565004230,NDC,30,GR,438.62,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
O2 SENSOR ADULT ADHESIVE SINGLE PATIENT 040-003382-00,120.576,CDM,272,RC,,,,12930-MAIN,LOCAL,,,,,39,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
O2 SENSOR INFANT ADHESIVE SINGLE PATIENT 040-003384-00,120.576,CDM,272,RC,,,,12932-MAIN,LOCAL,,,,,39,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
O2 SENSOR PEDIATRIC ADHESIVE SINGLE PATIENT 040-003383-00,120.576,CDM,272,RC,,,,12931-MAIN,LOCAL,,,,,39,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"OB US < 14 Wks, Single Fetus - Radiology, Tech",PX7680101,CDM,402,RC,76801,CPT,TC,,,,,,,472,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OBINutuzumab 1000 MG/40ML Solution 40 mL Vial,J9301.01,CDM,636,RC,J9301,HCPCS,,,,50242007001,NDC,4,ML,1397.15,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Observation Care Discharge,PX99217,CDM,982,RC,99217,CPT,,,,,,,,222,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Observation Initial,PXG0378.03,CDM,762,RC,G0378,HCPCS,,,,,,,,680,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Occupational Therapy Eval High Complex,PX97167,CDM,434,RC,97167,CPT,,,,,,,,289,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Occupational Therapy Eval Low Complex,PX97165,CDM,434,RC,97165,CPT,,,,,,,,235,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Occupational Therapy Eval Mod Complex,PX97166,CDM,434,RC,97166,CPT,,,,,,,,264,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ocrelizumab 300 MG/10ML Solution 10 mL Vial,J2350.01,CDM,636,RC,J2350,HCPCS,,,,50242015001,NDC,10,ML,33150,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703331101,NDC,0.75,ML,51.41,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037601,NDC,1,ML,76.9,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
octreotide 100 MCG/ML Solution 1 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037604,NDC,0.75,ML,36.86,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
octreotide 200 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037805,NDC,1,ML,133.77,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,703334301,NDC,0.5,ML,142.98,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
octreotide 1000 MCG/ML Solution 5 mL Vial,J2354.01,CDM,636,RC,J2354,HCPCS,,,,63323037905,NDC,0.5,ML,229.88,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Off/Outpt Visit,New,Levl III",PX99203P,CDM,983,RC,99203,CPT,,,,,,,,252,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office Consultation,Level III",PX99243P,CDM,983,RC,99243,CPT,,,,,,,,374,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office Consultation,Level IV",PX99244P,CDM,983,RC,99244,CPT,,,,,,,,441,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Office/Outpt Visit Est Level I,PX99211F,CDM,510,RC,99211,CPT,,,,,,,,119,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Office/Outpt Visit Est Level I,PX99211P,CDM,983,RC,99211,CPT,,,,,,,,119,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl II",PX99212F,CDM,510,RC,99212,CPT,,,,,,,,155,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl II",PX99212P,CDM,983,RC,99212,CPT,,,,,,,,155,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl III",PX99213F,CDM,510,RC,99213,CPT,,,,,,,,185,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl III",PX99213P,CDM,983,RC,99213,CPT,,,,,,,,185,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl IV",PX99214F,CDM,510,RC,99214,CPT,,,,,,,,256,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl IV",PX99214P,CDM,983,RC,99214,CPT,,,,,,,,256,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl V",PX99215F,CDM,510,RC,99215,CPT,,,,,,,,318,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl V",PX99215P,CDM,983,RC,99215,CPT,,,,,,,,318,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl II",PX99202F,CDM,510,RC,99202,CPT,,,,,,,,123,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl II",PX99202P,CDM,983,RC,99202,CPT,,,,,,,,123,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl III",PX99203F,CDM,510,RC,99203,CPT,,,,,,,,252,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl IV",PX99204F,CDM,510,RC,99204,CPT,,,,,,,,359,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl IV",PX99204P,CDM,983,RC,99204,CPT,,,,,,,,359,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl V",PX99205F,CDM,510,RC,99205,CPT,,,,,,,,456,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl V",PX99205P,CDM,983,RC,99205,CPT,,,,,,,,456,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ofloxacin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,17478071310,NDC,5,ML,117.89,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OLANZapine 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60505311000,NDC,1,EA,60.13,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,517095501,NDC,0.25,EA,69.19,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781315972,NDC,1,EA,217.96,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OLANZapine 10 MG Recon Soln 1 Each Vial,J2359.01,CDM,636,RC,J2359,HCPCS,,,,781910572,NDC,0.25,EA,69.49,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Oligoclonal Bands - Ref,PX8391690,CDM,300,RC,83916,CPT,90,,,,,,,124,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
olmesartan 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862074330,NDC,0.125,EA,6.45,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
omalizumab 150 MG Recon Soln 1 Each Vial,J2357.01,CDM,636,RC,J2357,HCPCS,,,,50242004062,NDC,1,EA,2212.7,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
omeprazole 20 MG CAPSULE DELAYED RELEASE 1 Each Blister,63700001,CDM,250,RC,,,,,,68084012811,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,904691761,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,63739035810,NDC,0.5,EA,7.85,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
omeprazole 20 MG CAPSULE DELAYED RELEASE 100 Each Box,63700001,CDM,250,RC,,,,,,68084012801,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ON Q PAIN BUSTER,27100000,CDM,271,RC,A4305,HCPCS,,6751-MAIN,LOCAL,,,,,194.26,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
onabotulinumtoxinA 50 units Recon Soln 1 Each Vial,J0585.03,CDM,636,RC,J0585,HCPCS,,,,23391950,NDC,1,EA,1418.14,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
onabotulinumtoxinA 100 units Recon Soln 1 Each Vial,J0585.01,CDM,636,RC,J0585,HCPCS,,,,23114501,NDC,1,EA,2348.77,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,781523806,NDC,1,EA,106.34,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714020010,NDC,1,EA,107.64,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG Tablet Disintegrating 1 Each Blister,S0119.01,CDM,636,RC,S0119,HCPCS,,,,68462015740,NDC,1,EA,110.25,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,781523864,NDC,1,EA,106.34,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714020030,NDC,1,EA,107.64,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,65862039010,NDC,1,EA,106.34,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG Tablet Disintegrating 30 Each Box,S0119.01,CDM,636,RC,S0119,HCPCS,,,,68462015713,NDC,1,EA,110.25,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,409475503,NDC,2,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054731,NDC,2,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054831,NDC,2,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG/2ML Solution 2 mL Vial,J2405.01,CDM,636,RC,J2405,HCPCS,,,,23155054842,NDC,2,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG/5ML Solution 25 mL Bottle,S0119.01,CDM,636,RC,S0119,HCPCS,,,,99998-8001-,NDC,25,ML,494.57,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ondansetron 4 MG/5ML Solution 50 mL Bottle,S0119.01,CDM,636,RC,S0119,HCPCS,,,,16714067102,NDC,5,ML,98.91,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Open Bx/Excision Inguinofemoral Nodes,PX38531F,CDM,510,RC,38531,CPT,,,,,,,,912,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Open Bx/Excision Inguinofemoral Nodes,PX38531P,CDM,983,RC,38531,CPT,,,,,,,,607,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
opium 10 MG/ML (1%) Tincture 0.3 mL Syringe,63700001,CDM,250,RC,,,,,,8888800392,NDC,0.3,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
opium 10 MG/ML (1%) Tincture 0.6 mL Syringe,63700001,CDM,250,RC,,,,,,88888800245,NDC,0.3,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
opium 10 MG/ML (1%) Tincture 118 mL Bottle,63700001,CDM,250,RC,,,,,,42799021701,NDC,0.3,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OPTIFOAM GENTLE SA SILICCONE FACED FOAM & BOARDER,120.63,CDM,272,RC,A6196,HCPCS,,3938-MAIN,LOCAL,,,,,25,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Or Level 1,PX36000001,CDM,360,RC,,,,,,,,,,1600,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1411.2,6141.46
Or Level 2,PX36000002,CDM,360,RC,,,,,,,,,,1900,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1675.8,6141.46
Or Level 3,PX36000003,CDM,360,RC,,,,,,,,,,2100,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1852.2,6141.46
Or Level 4,PX36000004,CDM,360,RC,,,,,,,,,,3805,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3356.01,6141.46
Or Level 5,PX36000005,CDM,360,RC,,,,,,,,,,5898,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5202.036,6141.46
Or Level 6,PX36000006,CDM,360,RC,,,,,,,,,,7960,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,7020.72
Or Time,PX36000086,CDM,360,RC,,,,,,,,,,27,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.814,6141.46
Org ID Aerobic-Each,PX87077,CDM,300,RC,87077,CPT,,,,,,,,168,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Organic Acid, Single, Qnt - Ref",PX8392190,CDM,300,RC,83921,CPT,90,,,,,,,209,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Organism ID, Anaerobic - Ref",PX8707690,CDM,300,RC,87076,CPT,90,,,,,,,95,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001501,NDC,1,EA,2340,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,65293001503,NDC,1,EA,2340,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oritavancin diphosphate 400 MG Recon Soln 1 Each Vial,J2407.01,CDM,636,RC,J2407,HCPCS,,,,70842014003,NDC,1,EA,2409.61,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618201,NDC,2,ML,120.53,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,641618210,NDC,2,ML,120.53,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
orphenadrine 30 MG/ML Solution 2 mL Vial,J2360.01,CDM,636,RC,J2360,HCPCS,,,,17478053802,NDC,2,ML,125.91,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760,CDM,420,RC,97760,CPT,,,,,,,,142,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Orthotics Management and Training, Initial, Each 15 Mins",PX97760F,CDM,510,RC,97760,CPT,,,,,,,,142,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 6 MG/ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,4082205,NDC,60,ML,752.82,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 6 MG/ML Recon Susp 60 mL Bottle,63700001,CDM,250,RC,,,,,,68180067801,NDC,60,ML,676.25,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,4080285,NDC,1,EA,89.79,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,16714081701,NDC,1,EA,75.78,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,47781046813,NDC,1,EA,76.15,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,63739003807,NDC,1,EA,66.51,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 30 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,64380079701,NDC,1,EA,76.15,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,47781047013,NDC,1,EA,83,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,63739005007,NDC,1,EA,73.35,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,64380079901,NDC,1,EA,83,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 75 MG capsule 10 Each Box,63700001,CDM,250,RC,,,,,,69238126601,NDC,1,EA,83,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oseltamivir 75 MG capsule 10 Each Disp Pack,63700001,CDM,250,RC,,,,,,4080085,NDC,1,EA,97.87,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Osmolality; Blood,PX83930,CDM,300,RC,83930,CPT,,,,,,,,9,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Osmolality; Urine,PX83935,CDM,300,RC,83935,CPT,,,,,,,,112,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OSTEOSET RESORBABLE MINI BEAD KIT FAST CURE CALCIUM SULFATE 5CC,C1713,CDM,278,RC,C1713,HCPCS,,12303-MAIN,LOCAL,,,,,2220,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OSTOMY DRAINABLE POUCH INVISICLOSE 1.75,27200000,CDM,272,RC,A5063,HCPCS,,12071-MAIN,LOCAL,,,,,1.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OSTOMY KIT 2 PIECE SURGICAL POST-OP,27200000,CDM,272,RC,,,,12070-MAIN,LOCAL,,,,,7,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ot Contracted Service/MCR,PX120.177,CDM,431,RC,,,,,,,,,,98,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ot Contracted Service/Msho/MA,PX120.178,CDM,431,RC,,,,,,,,,,66,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OXALiplatin 50 MG/10ML Solution 10 mL Vial,J9263.01,CDM,636,RC,J9263,HCPCS,,,,955173110,NDC,10,ML,228,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Oxcarbazepine - Ref,PX8018390,CDM,300,RC,80183,CPT,90,,,,,,,108,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
OXcarbazepine 150 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084084511,NDC,1,EA,8.1,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Oximetry;Mult Determine,PX610,CDM,460,RC,94761,CPT,,,,,,,,142,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyBUTYnin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904702761,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyBUTYnin ER 5 MG Tablet Extended Release 24 Hour 30 Each Box,63700001,CDM,250,RC,,,,,,63739054833,NDC,1,EA,18.67,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyBUTYnin ER 5 MG Tablet Extended Release 24 Hour 50 Each Box,63700001,CDM,250,RC,,,,,,904657006,NDC,1,EA,18.04,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyCODONE 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406055223,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyCODONE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406055262,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyCODONE 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,42858000110,NDC,1,EA,3.33,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyCODONE CR 10 MG Tablet ER 12 hour Abuse-Deterrent 20 Each Box,63700001,CDM,250,RC,,,,,,59011041020,NDC,1,EA,26.63,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyCODONE CR 20 MG Tablet ER 12 hour Abuse-Deterrent 20 Each Box,63700001,CDM,250,RC,,,,,,59011042020,NDC,1,EA,52.09,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyCODONE-acetaminophen 5-325 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,406051223,NDC,1,EA,7.36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxyCODONE-acetaminophen 5-325 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,406051262,NDC,1,EA,7.35,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxymetazoline 0.05 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,904571135,NDC,15,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
oxytocin 10 UNIT/ML Solution 1 mL Vial,J2590.01,CDM,636,RC,J2590,HCPCS,,,,42023011625,NDC,1,ML,43.8,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PACK BASIN BASIC SINGLE DYNJ06610A,27200000,CDM,272,RC,,,,10921-MAIN,LOCAL,,,,,25.48,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PACLitaxel 30 MG/5ML Concentrate 5 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476401,NDC,5,ML,58.37,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PACLitaxel 150 MG/25ML Concentrate 25 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321701,NDC,25,ML,300.96,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703321801,NDC,50,ML,456,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,703476881,NDC,50,ML,579.12,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PACLitaxel 300 MG/50ML Concentrate 50 mL Vial,J9267.01,CDM,636,RC,J9267,HCPCS,,,,63323076350,NDC,50,ML,589.57,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PACLitaxel protein-bound particle 100 MG Recon Susp 1 Each Vial,J9264.01,CDM,636,RC,J9264,HCPCS,,,,68817013450,NDC,1,EA,2564.76,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"PAD BED SENSOR 10X28"" P-107517",120.124,CDM,271,RC,,,,8377-MAIN,LOCAL,,,,,47,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"PAD CHAIR SENSOR 10x15"" 106380",120.124,CDM,271,RC,,,,8378-MAIN,LOCAL,,,,,47,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PAD GROUNDING 9 FT ADULT REM E7507,27200000,CDM,272,RC,,,,504-MAIN,LOCAL,,,,,10,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
paliperidone palmitate ER 234 MG/1.5ML suspension prefilled syringe 1.5 mL Syringe,J2426.01,CDM,636,RC,J2426,HCPCS,,,,50458056401,NDC,0.25,ML,1142.14,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,55111069407,NDC,5,ML,592.4,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,60505619301,NDC,5,ML,821.36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
palonosetron HCl 0.25 MG/5ML Solution 5 mL Vial,J2469.01,CDM,636,RC,J2469,HCPCS,,,,63323067305,NDC,5,ML,1029.71,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pancrelipase (lip-prot-amyl) 24000-76000 units Capsule Delayed Release Particles 100 Each Bottle,63700001,CDM,250,RC,,,,,,32122401,NDC,1,EA,37.41,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8092351,NDC,1,EA,52.22,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400101,NDC,1,EA,52.22,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,8400125,NDC,1,EA,52.22,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,781323294,NDC,1,EA,52.89,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,55150020200,NDC,1,EA,65.65,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pantoprazole 40 MG Recon Soln 1 Each Vial,S0164.01,CDM,636,RC,C9113,HCPCS,,,,72603012801,NDC,1,EA,57.64,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Pare/Cut Hyperkeratotic Skin Lesion, Single",PX11055F,CDM,510,RC,11055,CPT,,,,,,,,145,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268064011,NDC,1,EA,4.11,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084004411,NDC,1,EA,14.35,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine 10 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268064015,NDC,1,EA,4.11,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084004401,NDC,1,EA,14.35,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084004511,NDC,0.5,EA,7.49,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739096310,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084004501,NDC,0.5,EA,7.49,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PARoxetine CR 12.5 MG Tablet Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,42858070303,NDC,1,EA,4.3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Part Remv Phalanx of Toe,PX28124F,CDM,510,RC,28124,CPT,,,,,,,,2155,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Part Remv Phalanx of Toe,PX28124P,CDM,983,RC,28124,CPT,,,,,,,,1515,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Partial Bone Scan,PX7830001,CDM,341,RC,78300,CPT,TC,,,,,,,1391,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Parvovirus Antibody - Ref,PX8674790,CDM,300,RC,86747,CPT,90,,,,,,,92,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Path Special Stains II,PX3979,CDM,310,RC,88313,CPT,TC,,,,,,,107,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
patiromer sorbitex calcium 8.4 g Packet 4 Each Box,63700001,CDM,250,RC,,,,,,53436008404,NDC,1,EA,228.96,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"PDS II ENDOLOOP LIGATURE SIZE 0 18""",27200000,CDM,272,RC,,,,11700-MAIN,LOCAL,,,,,56.96,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
peak flow meter Device 1 Each Box,800000,CDM,,,,,,,,8373075500,NDC,1,EA,12,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"pediatric electrolyte Solution 1,000 mL Bottle",25000000,CDM,250,RC,,,,,,49348057041,NDC,1000,ML,31.9,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pegfilgrastim 6 MG/0.6ML Prefilled Syringe Kit 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019201,NDC,0.6,ML,13092.7,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pegfilgrastim 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019001,NDC,0.6,ML,12711.36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pegfilgrastim-cbqv 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5111.01,CDM,636,RC,Q5111,HCPCS,,,,70114010101,NDC,0.6,ML,10040,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pegfilgrastim-jmdb 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5108.01,CDM,636,RC,Q5108,HCPCS,,,,67457083306,NDC,0.6,ML,10040,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pegloticase 8 MG/ML Solution 1 mL Vial,J2507.01,CDM,636,RC,J2507,HCPCS,,,,75987008010,NDC,1,ML,48367.38,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pembrolizumab 100 MG/4ML Solution 4 mL Vial,J9271.01,CDM,636,RC,J9271,HCPCS,,,,6302602,NDC,4,ML,9627.58,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PEMEtrexed 500 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2762301,NDC,1,EA,8086.02,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PEMEtrexed Disodium 100 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2764001,NDC,1,EA,1539.32,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070102,NDC,1,ML,383.6,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin G benzathine 1200000 UNIT/2ML suspension prefilled syringe 2 mL Syringe,J0561.01,CDM,636,RC,J0561,HCPCS,,,,60793070110,NDC,1,ML,459.95,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052083,NDC,1,EA,92.81,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin G potassium 5000000 units Recon Soln 1 Each Vial,J2540.01,CDM,636,RC,J2540,HCPCS,,,,49052084,NDC,1,EA,92.46,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060002,NDC,2,ML,953.57,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin G procaine & benzathine 1200000 UNIT/2ML Suspension 2 mL Syringe,J0558.01,CDM,636,RC,J0558,HCPCS,,,,60793060010,NDC,2,ML,953.57,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin v potassium 250 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714023401,NDC,1,EA,4.1,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin v potassium 250 MG/5ML Recon Soln 200 mL Bottle,63700001,CDM,250,RC,,,,,,93412774,NDC,200,ML,83.32,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
penicillin v potassium 500 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714023501,NDC,0.5,EA,3.44,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pentafluoroprop - tetrafluoroeth Aerosol 116 mL Can,63700001,CDM,250,RC,,,,,,386000802,NDC,207,ML,383.42,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Peramivir 200 MG/20ML Solution 20 mL Vial,800000,CDM,,,,,,,,61364018101,NDC,20,ML,1832.6,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Percut Biopsy, Abdominal Mass",PX49180F,CDM,510,RC,49180,CPT,,,,,,,,2084,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PERFIX PLUG STERILE LARGE,C1781,CDM,278,RC,C1781,HCPCS,,11771-MAIN,LOCAL,,,,,558,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PERFIX PLUG STERILE MEDIUM,C1781,CDM,278,RC,C1781,HCPCS,,11770-MAIN,LOCAL,,,,,553,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PERFIX PLUG STERILE X-LARGE,C1781,CDM,278,RC,C1781,HCPCS,,11772-MAIN,LOCAL,,,,,643,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
perflutren lipid microsphere 6.52 MG/ML Suspension 2 mL Vial,Q9957,CDM,636,RC,Q9957,HCPCS,,,,11994001101,NDC,2,ML,751.71,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
perflutren protein A microsphere Suspension 3 mL Vial,Q9956,CDM,636,RC,Q9956,HCPCS,,,,407270703,NDC,3,ML,739.41,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569F,CDM,510,RC,36569,CPT,,,,,,,,1217,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569P,CDM,983,RC,36569,CPT,,,,,,,,1825,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Pertechnetate, Dia, per Mci",PXA9512,CDM,343,RC,A9512,HCPCS,,,,,,,,280,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PEZZER CATHETER DRAIN LATEX 14FR,27200000,CDM,272,RC,,,,12053-MAIN,LOCAL,,,,,38,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PEZZER LATEX CATHETER DRAIN 10FR,27200000,CDM,272,RC,,,,12646-MAIN,LOCAL,,,,,38,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Pfizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 2nd Dose",PX0002A,CDM,771,RC,0002A,HCPCS,,,,,,,,69,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Pfizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 3rd Dose",PX0003A,CDM,771,RC,0003A,HCPCS,,,,,,,,69,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ph Venous Blood,PX82800,CDM,300,RC,82800,CPT,,,,,,,,147,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHALINX STERILE LARGE 0 HAMMERTOE SYSTEM 45A01004,27800000,CDM,278,RC,C1713,HCPCS,,12962-MAIN,LOCAL,,,,,4759,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHALINX STERILE MEDIUM 0 HAMMERTOE SYSTEM 45A01003,27800000,CDM,278,RC,C1713,HCPCS,,12961-MAIN,LOCAL,,,,,4759,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHALINX STERILE SMALL 0 HAMMERTOE SYSTEM 45A01002,27800000,CDM,278,RC,C1713,HCPCS,,12960-MAIN,LOCAL,,,,,4759,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHALINX STERILE TRIAL SIZER 45A00000,27200000,CDM,272,RC,,,,12959-MAIN,LOCAL,,,,,181,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Phase II Recovery,PX71000047,CDM,710,RC,,,,,,,,,,15,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Phase III Recovery Monthly,PX93799.01,CDM,943,RC,,,,,,,,,,25,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHASIX 25X30CM 1190400,C1781,CDM,278,RC,C1781,HCPCS,,13011-MAIN,LOCAL,,,,,16080,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHASIX ST 15X20CM 1201520,C1781,CDM,278,RC,C1781,HCPCS,,13010-MAIN,LOCAL,,,,,11988,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,42937070110,NDC,1,EA,5.16,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,51293081001,NDC,1,EA,14.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,65162068110,NDC,1,EA,14.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenazopyridine 100 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,75826011410,NDC,1,EA,12.89,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHENobarbital 32.4 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904657561,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHENobarbital 130 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047721,NDC,1,ML,338.93,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Phenobarbital Assay - Ref,PX8018490,CDM,300,RC,80184,CPT,90,,,,,,,20,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047621,NDC,1,ML,157.28,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PHENobarbital Sodium 65 MG/ML Solution 1 mL Vial,J2560.01,CDM,636,RC,J2560,HCPCS,,,,641047625,NDC,0.769230769,ML,111.59,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenol-glycerin 1.5-33 % Liquid 118 mL Bottle,25000000,CDM,250,RC,,,,,,78112000068,NDC,118,ML,44.12,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956401,NDC,1,EA,1611.2,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phentolamine mesylate 5 MG Recon Soln 1 Each Vial,J2760.01,CDM,636,RC,J2760,HCPCS,,,,143956410,NDC,1,EA,1689.17,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenylephrine 0.25 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,69536002515,NDC,15,ML,24.21,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614201,NDC,1,ML,88.69,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641614225,NDC,1,ML,88.69,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenylephrine 10 MG/ML Solution 1 mL Vial,J2371.01,CDM,636,RC,J2371,HCPCS,,,,641622901,NDC,1,ML,41.16,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenytoin ER 100 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68084037611,NDC,1,EA,3.44,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenytoin ER 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904618761,NDC,0.3,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phenytoin ER 100 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,68084037601,NDC,0.3,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Phlebotomy,PX99195,CDM,940,RC,99195,CPT,,,,,,,,238,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phosphorus 155-852-130 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,64980010401,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Physical Therapy Evaluation High Complex,PX97163,CDM,424,RC,97163,CPT,,,,,,,,294,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Physical Therapy Evaluation Low Complex,PX97161,CDM,424,RC,97161,CPT,,,,,,,,235,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Physical Therapy Evaluation Mod Complex,PX97162,CDM,424,RC,97162,CPT,,,,,,,,264,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Physical Therapy Re-Eval Est Plan Care 20 Mins,PX97164,CDM,424,RC,97164,CPT,,,,,,,,239,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915701,NDC,0.5,ML,44.33,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phytonadione 1 MG/0.5ML Solution 0.5 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915731,NDC,0.5,ML,44.33,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phytonadione 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714097302,NDC,0.5,EA,143.02,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phytonadione 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,69238105103,NDC,0.5,EA,143.02,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915801,NDC,1,ML,267.19,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,409915850,NDC,0.2,ML,69.44,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
phytonadione 10 MG/ML Solution 1 mL Ampule,J3430.01,CDM,636,RC,J3430,HCPCS,,,,43598040516,NDC,0.2,ML,63.83,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Pifizer-Biontech Covid-19 Vaccine, 30mcg/0.3ml, Administration, 1st Dose",PX0001A,CDM,771,RC,0001A,HCPCS,,,,,,,,69,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pindolol 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,29033002801,NDC,1,EA,24.77,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Pinworm Exam,PX87172,CDM,300,RC,87172,CPT,,,,,,,,46,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pioglitazone 15 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342005410,NDC,1,EA,37.62,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030926,NDC,1,EA,55.44,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098121,NDC,1,EA,72.95,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098141,NDC,1,EA,39.84,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 2.25 (2-0.25) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098153,NDC,1,EA,39.84,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409338513,NDC,1,EA,74.09,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615700,NDC,1,EA,101.95,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615704,NDC,1,EA,101.92,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323030036,NDC,1,EA,56.73,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098321,NDC,1,EA,99.39,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098323,NDC,1,EA,99.39,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323098341,NDC,1,EA,56.73,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052200,NDC,1,EA,99.39,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 3.375 (3-0.375) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,67457052237,NDC,1,EA,99.39,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,409339004,NDC,1,EA,98.61,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,55150012150,NDC,1,EA,151.41,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615900,NDC,1,EA,123.75,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,60505615904,NDC,1,EA,123.75,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032050,NDC,1,EA,120.51,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,63323032056,NDC,1,EA,68.97,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
piperacillin-tazobactam 4.5 (4-0.5) g Recon Soln 1 Each Vial,J2543.01,CDM,636,RC,J2543,HCPCS,,,,65219025915,NDC,1,EA,58.66,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Place Needle in Vein,PX36000P,CDM,983,RC,36000,CPT,,,,,,,,1034,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PLANTAR PLATE IMPLANT SET GRAVITY REPAIR,C1713,CDM,278,RC,C1713,HCPCS,,12649-MAIN,LOCAL,,,,,3921,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Platelet Antibodies - Ref,PX8602290,CDM,300,RC,86022,CPT,90,,,,,,,245,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200001,NDC,0.5,ML,980.99,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pneumococcal 20-val conj vacc 0.5 ML suspension prefilled syringe 0.5 mL Syringe,90677,CDM,636,RC,90677,CPT,,,,5200002,NDC,0.5,ML,980.99,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494300,NDC,0.5,ML,419.23,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pneumococcal vaccine 25 MCG/0.5ML Injectable 0.5 mL Vial,90732,CDM,636,RC,90732,CPT,,,,6494301,NDC,0.5,ML,419.2,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PNEUVIEW SMOKE ELIMINATOR,27200000,CDM,272,RC,,,,11884-MAIN,LOCAL,,,,,38,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Po4 Inorganic (Phosphate) - Ref,PX8410090,CDM,300,RC,84100,CPT,90,,,,,,,150,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
POLYAXIAL LOCKING PLATE MTP CROSS PLATE LEFT T8,C1713,CDM,278,RC,C1713,HCPCS,,12635-MAIN,LOCAL,,,,,5413,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
POLYAXIAL LOCKING PLATE MTP CROSS PLATE RIGHT T8,C1713,CDM,278,RC,C1713,HCPCS,,12756-MAIN,LOCAL,,,,,5413,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"polyethylene glycol 236 g Recon Soln 4,000 mL Bottle",63700001,CDM,250,RC,,,,,,43386009019,NDC,4000,ML,112.6,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polyethylene glycol 3350 17 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,904642286,NDC,1,EA,8.2,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polyethylene glycol 3350 17 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,904693186,NDC,1,EA,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polyethylene glycol 3350 17 g Packet 30 Each Box,63700001,CDM,250,RC,,,,,,904693176,NDC,1,EA,8.97,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polyethylene glycol 3350 17 g Packet 100 Each Box,63700001,CDM,250,RC,,,,,,904642281,NDC,1,EA,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,17478070311,NDC,10,ML,72.46,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,24208031510,NDC,10,ML,75.67,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polymyxin b-trimethoprim 10000-0.1 UNIT/ML-% Solution 10 mL Bottle,25000000,CDM,250,RC,,,,,,61314062810,NDC,10,ML,98.07,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Polysomnography W/Cpap,PX9581101,CDM,740,RC,95811,CPT,TC,,,,,,,4575,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Polysomnography, 4 or More",PX9581001,CDM,740,RC,95810,CPT,TC,,,,,,,4313,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
polyvinyl alcohol 1.4 % Solution 15 mL Bottle,63700001,CDM,250,RC,,,,,,50268067815,NDC,15,ML,45.42,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"POS Airway Pressure, Bipap",PX94660.01F,CDM,410,RC,94660,CPT,,,,,,,,468,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"POS Airway Pressure, Cpap",PX94660F,CDM,410,RC,94660,CPT,,,,,,,,498,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
POSITIONING KIT TRENDELENBURG NUBLUE TP 3000-NB,27100000,CDM,271,RC,,,,12992-MAIN,LOCAL,,,,,88,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Post Anesthesia Recovery,PX71000019,CDM,710,RC,,,,,,,,,,14,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665305,NDC,20,ML,49.97,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride 2 MEQ/ML Solution 20 mL Vial,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409665318,NDC,20,ML,50.08,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070948,NDC,100,ML,42.59,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride 10 mEq/100 mL 10 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707426,NDC,100,ML,39.29,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride 20 MEQ Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,245036089,NDC,1,EA,57.67,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 10 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,245531789,NDC,1,EA,3.33,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 10 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,66758017006,NDC,1,EA,3.32,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 10 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,245531701,NDC,1,EA,3.32,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 10 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,66758017013,NDC,1,EA,3.32,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 20 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,245531989,NDC,1,EA,3.65,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 20 MEQ Tablet Extended Release 1 Each Blister,63700001,CDM,250,RC,,,,,,66758019006,NDC,1,EA,3.65,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 20 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,245531901,NDC,1,EA,3.65,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride CR 20 MEQ Tablet Extended Release 100 Each Box,63700001,CDM,250,RC,,,,,,66758019013,NDC,1,EA,3.65,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Flex Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,409707526,NDC,100,ML,37.63,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
potassium chloride in isotonic fluid 20 mEq /100 mL 20 MEQ/100ML Solution 100 mL Plas Cont,J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070548,NDC,100,ML,40.94,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Potassium; Serum, Plasma or Whole Blood",PX84132,CDM,300,RC,84132,CPT,,,,,,,,59,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Potassium; Urine,PX84133,CDM,300,RC,84133,CPT,,,,,,,,50,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
povidone iodine 10 % Solution 59 mL Bottle,63700001,CDM,250,RC,,,,,,52380190502,NDC,59,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
povidone-iodine 10 % Ointment 28.35 g Tube,63700001,CDM,250,RC,,,,,,904110231,NDC,28.35,GR,19.9,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Povidone-Iodine 10 % SWAB 1 Each Package,25000000,CDM,250,RC,,,,,,67618015301,NDC,1,EA,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
POWERPORT ISP MRI IMPLANTABLE PORT 8FR,C1788,CDM,278,RC,C1788,HCPCS,,11998-MAIN,LOCAL,,,,,1385,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 0.25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084044011,NDC,0.5,EA,7.83,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 0.25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,42291053590,NDC,0.5,EA,7.92,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 0.25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68462033190,NDC,0.5,EA,8.97,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084044001,NDC,0.5,EA,7.83,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342003110,NDC,1,EA,16.56,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68382019616,NDC,1,EA,17.4,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 0.125 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,68462033090,NDC,1,EA,17.95,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramipexole 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687059211,NDC,0.125,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pramox-PE-glycerin-petrolatum 1-0.25-14.4-15 % Cream 51 g Tube,63700001,CDM,250,RC,,,,,,573286898,NDC,51,GR,68.34,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prasugrel 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862083030,NDC,1,EA,88.64,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pravastatin 10 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,60505016809,NDC,1,EA,17.26,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pravastatin 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904589161,NDC,1,EA,15.54,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pravastatin 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079045801,NDC,0.5,EA,8.77,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pravastatin 20 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904589261,NDC,0.5,EA,6.7,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prazosin 1 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,70954001950,NDC,1,EA,4.81,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Prealubimin,PX84134,CDM,300,RC,84134,CPT,,,,,,,,80,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004224,NDC,5,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prednisoLONE 15 MG/5ML Solution 240 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,62135025037,NDC,1.666666667,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prednisoLONE acetate 0.12 % Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,11980017405,NDC,5,ML,757.07,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prednisoLONE acetate 1 % Suspension 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314063705,NDC,5,ML,283.79,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,121090204,NDC,120,ML,503.56,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prednisoLONE sodium phospate 6.7 (5 Base) MG/5ML Solution 120 mL Bottle,J7510.01,CDM,636,RC,J7510,HCPCS,,,,50383004004,NDC,120,ML,502.95,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 1 MG Tablet 100 Each Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,64380078206,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 1 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54873925,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 2.5 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54874025,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 5 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687012211,NDC,0.2,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 5 mg/5 mL 5 MG/5ML Solution 120 mL Bottle,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54372250,NDC,120,ML,186.47,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 10 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687013411,NDC,0.1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001720,NDC,0.1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 10 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,63739051910,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 20 MG Tablet 1 Each Blister,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014511,NDC,0.05,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,54001820,NDC,0.05,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
predniSONE 20 MG Tablet 100 Each Box,J7512.01,CDM,636,RC,J7512,HCPCS,,,,60687014501,NDC,0.05,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pregabalin 25 MG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,904699104,NDC,1,EA,8.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pregabalin 25 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,71101268,NDC,1,EA,55.33,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pregabalin 25 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,76282056890,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pregabalin 75 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,71101468,NDC,0.333333333,EA,14.79,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pregabalin 75 MG capsule 90 Each Bottle,63700001,CDM,250,RC,,,,,,59762134601,NDC,0.333333333,EA,15.08,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pregabalin 75 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904700061,NDC,0.333333333,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prenatal plus vitamin with folic acid 1 mg 27-1 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,69367026701,NDC,1,EA,3.83,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PREP KIT SKIN PREMIUM,27200000,CDM,272,RC,,,,4108-MAIN,LOCAL,,,,,12.96,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PREP KIT STAPLE 18MM,27200000,CDM,278,RC,C1713,HCPCS,,11658-MAIN,LOCAL,,,,,420.75,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PREP KIT STAPLE 20MM,27200000,CDM,278,RC,C1713,HCPCS,,11659-MAIN,LOCAL,,,,,420.75,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004F,CDM,510,RC,15004,CPT,,,,,,,,855,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004P,CDM,983,RC,15004,CPT,,,,,,,,570,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
primidone 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084020211,NDC,1,EA,4.24,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
primidone 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084020201,NDC,1,EA,4.26,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Primidone Assay - Ref,PX8018890,CDM,300,RC,80188,CPT,90,,,,,,,20,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
procainamide 500 MG/ML Solution 2 mL Vial,J2690.01,CDM,636,RC,J2690,HCPCS,,,,14789090002,NDC,2,ML,377.75,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Procalcitonin,PX84145,CDM,300,RC,84145,CPT,,,,,,,,217,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 5 MG Tablet 1 Each Blister,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054101,NDC,1,EA,3.28,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 5 MG Tablet 100 Each Bottle,63600000,CDM,636,RC,Q0164,HCPCS,,,,59746011306,NDC,1,EA,3.19,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 5 MG Tablet 100 Each Box,63600000,CDM,636,RC,Q0164,HCPCS,,,,51079054120,NDC,1,EA,3.29,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 10 MG Tablet 100 Each Bottle,25000000,CDM,250,RC,,,,,,59746011506,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052331,NDC,2,ML,125.89,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 10 MG/2ML Solution 2 mL Vial,J0780.01,CDM,636,RC,J0780,HCPCS,,,,23155052341,NDC,2,ML,125.89,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,574722612,NDC,1,EA,67.57,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prochlorperazine 25 MG Suppository 12 Each Box,Q0164.01,CDM,636,RC,Q0164,HCPCS,,,,713013512,NDC,1,EA,65.83,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Progesterone,PX84144,CDM,300,RC,84144,CPT,,,,,,,,56,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Prolactin,PX84146,CDM,300,RC,84146,CPT,,,,,,,,112,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
promethazine 25 MG Suppository 1 Each Blister,63700001,CDM,250,RC,,,,,,45802075900,NDC,0.5,EA,47.55,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
promethazine 25 MG Suppository 12 Each Box,63700001,CDM,250,RC,,,,,,45802075930,NDC,0.5,EA,47.54,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
promethazine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,Q0169,HCPCS,,,,904646161,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092821,NDC,1,ML,32.23,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
promethazine 25 MG/ML Solution 1 mL Vial,J2550.01,CDM,636,RC,J2550,HCPCS,,,,641092825,NDC,1,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROMOGRAN PRISMA AG COLLAGEN DRESSING 28CM,120.547,CDM,272,RC,A6021,HCPCS,,12361-MAIN,LOCAL,,,,,28,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PRONEVIEW CUSHION INSERTS LARGE,120.557,CDM,272,RC,E0190,HCPCS,,12500-MAIN,LOCAL,,,,,76,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,409469930,NDC,20,ML,48.54,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060820,NDC,20,ML,58.57,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propofol 200 MG/20ML Emulsion 20 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026994,NDC,20,ML,35.87,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,25021060851,NDC,100,ML,213.4,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,43598054910,NDC,100,ML,205.14,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propofol 1000 MG/100ML Emulsion 100 mL Vial,J2704.01,CDM,636,RC,J2704,HCPCS,,,,63323026969,NDC,100,ML,99.34,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propranolol 10 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904655061,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propranolol 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268070211,NDC,0.25,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propranolol 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687060911,NDC,0.25,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propranolol 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687060901,NDC,0.25,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propranolol LA 60 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,527411637,NDC,1,EA,11.05,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propranolol LA 80 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,228277911,NDC,0.75,EA,9.7,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
propranolol LA 80 MG Capsule Extended Release 24 Hour 100 Each Bottle,63700001,CDM,250,RC,,,,,,527411737,NDC,0.75,EA,9.7,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Prosight Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,536509008,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP 0.9MM ANTI SKIVE PIN,27200000,CDM,272,RC,,,,12950-MAIN,LOCAL,,,,,154,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP 1.4MM ANTI SKIVE PIN,27200000,CDM,272,RC,,,,12949-MAIN,LOCAL,,,,,154,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP HV SCREW 3.0X16MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12986-MAIN,LOCAL,,,,,1569,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 3.0X20MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12442-MAIN,LOCAL,,,,,1806,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 3.0X34MM STERILE IMPLANT,27200000,CDM,272,RC,,,,13042-MAIN,LOCAL,,,,,1684,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 3.0X38MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12984-MAIN,LOCAL,,,,,2096,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 3.0X40MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12443-MAIN,LOCAL,,,,,1806,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 4.0X42MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12948-MAIN,LOCAL,,,,,2096,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 4.0X44MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12893-MAIN,LOCAL,,,,,2096,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 4.0X52MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12444-MAIN,LOCAL,,,,,1806,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PROSTEP MICA SCREW 4.0X56MM STERILE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12947-MAIN,LOCAL,,,,,2096,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Prosthetic Training, Initial, Each 15 Mins",PX97761,CDM,420,RC,97761,CPT,,,,,,,,121,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
protamine 10 MG/ML Solution 5 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022994,NDC,5,ML,84.74,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
protamine 10 MG/ML Solution 25 mL Vial,J2720.01,CDM,636,RC,J2720,HCPCS,,,,63323022930,NDC,2.5,ML,44.37,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Protein C Activity - Ref,PX8530390,CDM,300,RC,85303,CPT,90,,,,,,,158,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Protein E-Phoresis Serum,PX84165,CDM,300,RC,84165,CPT,,,,,,,,175,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Protein Elp,PX84166,CDM,300,RC,84166,CPT,,,,,,,,180,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Protein Elp Interp,PX8416526,CDM,300,RC,84165,CPT,26,,,,,,,175,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Protein S, Free - Ref",PX8530690,CDM,300,RC,85306,CPT,90,,,,,,,47,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Protein, Total; Other Source",PX84157,CDM,300,RC,84157,CPT,,,,,,,,153,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Protein, Total; Serum, Plasma or Whole Blood",PX84155,CDM,300,RC,84155,CPT,,,,,,,,170,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
prothrombin complex concentrate - human 500 units Kit 500 Units Box,J7168.01,CDM,636,RC,J7168,HCPCS,,,,63833038602,NDC,1500,UN,8007,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Prothrombin Time (Pt/Inr),PX85610,CDM,300,RC,85610,CPT,,,,,,,,130,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Protoporphyrin, RBC, Qnt - Ref",PX8420290,CDM,300,RC,84202,CPT,90,,,,,,,61,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Protozoa Antibody, Nos - Ref",PX8675390,CDM,300,RC,86753,CPT,90,,,,,,,99,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Psa Screening,PXG0103,CDM,300,RC,G0103,HCPCS,,,,,,,,157,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Psa, Free - Ref",PX8415490,CDM,300,RC,84154,CPT,90,,,,,,,38,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Psa, Total - Ref",PX8415390,CDM,300,RC,84153,CPT,90,,,,,,,38,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
psyllium 0.52 GM capsule 160 Each Bottle,25000000,CDM,250,RC,,,,,,80681002200,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Psyllium 400 MG capsule 160 Each Bottle,25000000,CDM,250,RC,,,,,,10939081644,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Pt Contracted Service/Msho,PX120.176,CDM,421,RC,,,,,,,,,,66,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Pt Contracted Services/MCR,PX120.175,CDM,421,RC,,,,,,,,,,98,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Pulmonary Stress Test,PX94618,CDM,976,RC,94618,CPT,,,,,,,,153,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105F,CDM,510,RC,11105,CPT,,,,,,,,171,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105P,CDM,983,RC,11105,CPT,,,,,,,,171,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Puncture Drainage of Lesion,PX10160F,CDM,510,RC,10160,CPT,,,,,,,,279,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Puncture Drainage of Lesion,PX10160P,CDM,983,RC,10160,CPT,,,,,,,,186,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
PURAPLYAM XT-COM 4.91X4.91 EXTRA FENESTRATED 24.10 SQCM,120.567,CDM,272,RC,Q4197,HCPCS,,12806-MAIN,LOCAL,,,,,6562,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Pvb Thoracic Single Injection Site W/Img Gid,PX64461F,CDM,510,RC,64461,CPT,,,,,,,,353,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Pvb Thoracic Single Injection Site W/Img Gid,PX64461P,CDM,983,RC,64461,CPT,,,,,,,,616,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pyRIDostigmine 60 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084049411,NDC,0.5,EA,3.97,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pyRIDostigmine 60 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084049401,NDC,0.5,EA,3.98,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pyRIDostigmine bromide 10 MG/2ML Solution 2 mL Ampule,25000000,CDM,250,RC,,,,,,781304095,NDC,2,ML,203.16,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pyridoxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536440601,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
pyridoxine 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,77333094010,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Quantitation Drug Nos - Ref,PX8029990,CDM,300,RC,80299,CPT,90,,,,,,,112,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
QUEtiapine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,54022020,NDC,1,EA,21.46,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
QUEtiapine 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904663861,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
QUEtiapine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904664061,NDC,0.25,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
QUEtiapine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739066510,NDC,0.25,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rabies immune globulin 300 UNIT/2ML Solution 2 mL Vial,90377,CDM,636,RC,90376,CPT,,,,49281019020,NDC,2,ML,3384.84,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rabies immune globulin 300 UNIT/ML Solution 1 mL Vial,90376,CDM,636,RC,90375,CPT,,,,13533031801,NDC,1,ML,1629.06,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rabies immune globulin 1500 UNIT/5ML Solution 5 mL Vial,90375,CDM,636,RC,90375,CPT,,,,13533031805,NDC,5,ML,8065.26,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"rabies vaccine, pcec Recon Susp 1 Each Vial",90675,CDM,636,RC,90675,CPT,,,,58160096412,NDC,1,EA,1544.83,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
racEPINEPHrine 2.25 % Nebulization Solution 1 Each Plas Cont,25000000,CDM,250,RC,,,,,,487590199,NDC,1,EA,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Raltegravir 400 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,6022761,NDC,1,EA,150.2,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ramipril 2.5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237022301,NDC,0.5,EA,4.85,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ramipril 5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,68382014601,NDC,0.25,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ramuCIRumab 100 MG/10ML Solution 10 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2766901,NDC,10,ML,2463.3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ramuCIRumab 500 MG/50ML Solution 50 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2767801,NDC,50,ML,12316.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RANGER UNIT TUBING FLUID WARMING,120.229,CDM,272,RC,,,,10612-MAIN,LOCAL,,,,,51,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RBC Antibody Elution,PX86860,CDM,300,RC,86860,CPT,,,,,,,,360,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RBC Antibody Screen,PX86850,CDM,300,RC,86850,CPT,,,,,,,,173,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RBC Pretreatment,PX8697002,CDM,300,RC,86970,CPT,,,,,,,,117,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"RBC Sed Rate, Auto",PX85652,CDM,300,RC,85652,CPT,,,,,,,,109,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
REAMER FOR CROSS PLATES,27200000,CDM,272,RC,,,,12641-MAIN,LOCAL,,,,,1852,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Reconstruc of Nail Bed,PX11760F,CDM,510,RC,11760,CPT,,,,,,,,1162,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Reconstruc of Nail Bed,PX11760P,CDM,983,RC,11760,CPT,,,,,,,,903,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Reconstruc of Nail Bed W Graft,PX11762F,CDM,510,RC,11762,CPT,,,,,,,,1901,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Red Blood Cells Unit,PXP9021,CDM,390,RC,P9021,HCPCS,,,,,,,,1050,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Reduce Temporomandibl Disloc,PX21480F,CDM,510,RC,21480,CPT,,,,,,,,335,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Reduce Temporomandibl Disloc,PX21480P,CDM,983,RC,21480,CPT,,,,,,,,223,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
REDUCER 12 - 8MM,27200000,CDM,272,RC,,,,11961-MAIN,LOCAL,,,,,47,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Refill/Maint Portable Pump,PX96521,CDM,260,RC,96521,CPT,,,,,,,,325,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,469650189,NDC,5,ML,1264.92,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
regadenoson 0.4 MG/5ML Solution 5 mL Syringe,J2785.01,CDM,636,RC,J2785,HCPCS,,,,71288020185,NDC,5,ML,1021.7,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RELOAD SUREFORM 45 2.5MM WHITE,27200000,CDM,272,RC,,,,12791-MAIN,LOCAL,,,,,386,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RELOAD SUREFORM 45 3.5MM BLUE,27200000,CDM,272,RC,,,,12792-MAIN,LOCAL,,,,,386,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RELOAD SUREFORM 45 4.3MM GREEN,27200000,CDM,272,RC,,,,12793-MAIN,LOCAL,,,,,386,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RELOAD SUREFORM 60 2.5 WHITE 6 ROW BOX/12,27200000,CDM,272,RC,,,,12261-MAIN,LOCAL,,,,,430,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RELOAD SUREFORM 60 3.5 BLUE,27200000,CDM,272,RC,,,,12084-MAIN,LOCAL,,,,,430,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RELOAD SUREFORM 60 4.3 GREEN,27200000,CDM,272,RC,,,,12085-MAIN,LOCAL,,,,,430,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290101,NDC,1,EA,1966.88,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
remdesivir 100 MG Recon Soln 1 Each Vial,J0248.01,CDM,636,RC,J0248,HCPCS,,,,61958290102,NDC,1,EA,1966.88,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Removal Anal Fistula,Subcutaneous",PX46270F,CDM,510,RC,46270,CPT,,,,,,,,1470,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Removal Anal Fistula,Subcutaneous",PX46270P,CDM,983,RC,46270,CPT,,,,,,,,980,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209F,CDM,510,RC,69209,CPT,,,,,,,,35,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209P,CDM,982,RC,69209,CPT,,,,,,,,113,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Anal Tabs,PX46230F,CDM,510,RC,46230,CPT,,,,,,,,790,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Anal Tabs,PX46230P,CDM,983,RC,46230,CPT,,,,,,,,1435,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Hemorrhoid Clot,PX46320F,CDM,510,RC,46320,CPT,,,,,,,,2027,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Hemorrhoid Clot,PX46320P,CDM,983,RC,46320,CPT,,,,,,,,374,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Removal of Hydrocele,Tunica,Unilat",PX55040P,CDM,983,RC,55040,CPT,,,,,,,,1420,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Nail Bed,PX11750F,CDM,510,RC,11750,CPT,,,,,,,,629,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Nail Plate,PX11730F,CDM,510,RC,11730,CPT,,,,,,,,229,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Skin Tags,PX11200P,CDM,983,RC,11200,CPT,,,,,,,,418,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Removal of Tunnel Cv Access Device, With Port/Pump",PX36590P,CDM,983,RC,36590,CPT,,,,,,,,1147,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Additional Nail Plate,PX11732F,CDM,510,RC,11732,CPT,,,,,,,,77,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Foreign Body Complic,PX10121F,CDM,510,RC,10121,CPT,,,,,,,,3575,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Foreign Body Complic,PX10121P,CDM,983,RC,10121,CPT,,,,,,,,651,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Foreign Body Simple,PX10120F,CDM,510,RC,10120,CPT,,,,,,,,404,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Foreign Body Simple,PX10120P,CDM,983,RC,10120,CPT,,,,,,,,404,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Hemorrhoids & Fissure,PX46257F,CDM,510,RC,46257,CPT,,,,,,,,1141,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Hemorrhoids & Fissure,PX46257P,CDM,983,RC,46257,CPT,,,,,,,,615,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Impacted Ear Wax,PX69210F,CDM,510,RC,69210,CPT,,,,,,,,213,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Impacted Ear Wax,PX69210P,CDM,983,RC,69210,CPT,,,,,,,,221,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Intrauterine Device,PX58301,CDM,983,RC,58301,CPT,,,,,,,,357,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Nasal Foreign Body,PX30300F,CDM,510,RC,30300,CPT,,,,,,,,972,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Nasal Foreign Body,PX30300P,CDM,983,RC,30300,CPT,,,,,,,,572,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remv Ext Canal Foreign Body,PX69200F,CDM,510,RC,69200,CPT,,,,,,,,235,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remv Ext Canal Foreign Body,PX69200P,CDM,983,RC,69200,CPT,,,,,,,,157,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Ant Chmbr/Lens",PX65235F,CDM,510,RC,65235,CPT,,,,,,,,2788,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Cornea,No Slit",PX65220F,CDM,510,RC,65220,CPT,,,,,,,,334,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Cornea,No Slit",PX65220P,CDM,983,RC,65220,CPT,,,,,,,,318,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Embed Conjunc",PX65210F,CDM,510,RC,65210,CPT,,,,,,,,325,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Embed Conjunc",PX65210P,CDM,983,RC,65210,CPT,,,,,,,,216,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Superf Conjunc",PX65205F,CDM,510,RC,65205,CPT,,,,,,,,132,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Superf Conjunc",PX65205P,CDM,983,RC,65205,CPT,,,,,,,,132,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv Foot Foreign Body,Subcutaneous",PX28190F,CDM,510,RC,28190,CPT,,,,,,,,1025,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv Foot Foreign Body,Subcutaneous",PX28190P,CDM,983,RC,28190,CPT,,,,,,,,683,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv Foreign Body,Knee/Thigh,Deep",PX27372F,CDM,510,RC,27372,CPT,,,,,,,,1429,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv Foreign Body,Knee/Thigh,Deep",PX27372P,CDM,983,RC,27372,CPT,,,,,,,,954,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remv Periton FB From Perit Cav,PX49402F,CDM,510,RC,49402,CPT,,,,,,,,3573,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remv Periton FB From Perit Cav,PX49402P,CDM,983,RC,49402,CPT,,,,,,,,3897,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Renal Function Panel,PX80069,CDM,300,RC,80069,CPT,,,,,,,,264,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Renin - Ref,PX8424490,CDM,300,RC,84244,CPT,90,,,,,,,53,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133F,CDM,510,RC,13133,CPT,,,,,,,,595,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133P,CDM,983,RC,13133,CPT,,,,,,,,256,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122F,CDM,510,RC,13122,CPT,,,,,,,,788,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122P,CDM,983,RC,13122,CPT,,,,,,,,301,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
repaglinide 0.5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,574024001,NDC,1,EA,3.62,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Flex Foot Tendon,Ea",PX28200F,CDM,510,RC,28200,CPT,,,,,,,,1475,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repair Incis Hernia W Mesh,PX49568F,CDM,510,RC,49568,CPT,,,,,,,,1540,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repair Incis Hernia W Mesh,PX49568P,CDM,983,RC,49568,CPT,,,,,,,,660,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Ing Hernia,5+Y/O,Reducibl",PX49505P,CDM,983,RC,49505,CPT,,,,,,,,2048,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Ing Hernia,5+Y/O,Strang",PX49507F,CDM,510,RC,49507,CPT,,,,,,,,1977,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Ing Hernia,5+Y/O,Strang",PX49507P,CDM,983,RC,49507,CPT,,,,,,,,2482,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Lip,>1/2 Vert Height",PX40654F,CDM,510,RC,40654,CPT,,,,,,,,2467,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Lip,>1/2 Vert Height",PX40654P,CDM,983,RC,40654,CPT,,,,,,,,1329,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair of Recurrent Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49615F,CDM,360,RC,49615,CPT,,,,,,,,2908,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2564.856,6141.46
Repair of Vagina,PX57200P,CDM,983,RC,57200,CPT,,,,,,,,1043,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Recurr Inguin Hern,Reducibl",PX49520F,CDM,510,RC,49520,CPT,,,,,,,,1983,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Recurr Inguin Hern,Reducibl",PX49520P,CDM,983,RC,49520,CPT,,,,,,,,1983,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Umbilical Hern,5+Y/O,Reduc",PX49585F,CDM,510,RC,49585,CPT,,,,,,,,969,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Umbilical Hern,5+Y/O,Reduc",PX49585P,CDM,983,RC,49585,CPT,,,,,,,,647,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Umbilical Hern,5+Y/O,Strang",PX49587F,CDM,510,RC,49587,CPT,,,,,,,,1110,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Umbilical Hern,5+Y/O,Strang",PX49587P,CDM,983,RC,49587,CPT,,,,,,,,2182,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repeat Control of Nosebleed,PX30906F,CDM,510,RC,30906,CPT,,,,,,,,334,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762F,CDM,510,RC,43762,CPT,,,,,,,,492,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762P,CDM,983,RC,43762,CPT,,,,,,,,328,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132F,CDM,510,RC,13132,CPT,,,,,,,,1159,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132P,CDM,983,RC,13132,CPT,,,,,,,,774,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151F,CDM,510,RC,13151,CPT,,,,,,,,1143,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151P,CDM,983,RC,13151,CPT,,,,,,,,1177,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121F,CDM,510,RC,13121,CPT,,,,,,,,948,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121P,CDM,983,RC,13121,CPT,,,,,,,,632,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101F,CDM,510,RC,13101,CPT,,,,,,,,495,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101P,CDM,983,RC,13101,CPT,,,,,,,,330,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002F,CDM,510,RC,12002,CPT,,,,,,,,343,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002P,CDM,983,RC,12002,CPT,,,,,,,,486,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Body <2.5cm,PX12001F,CDM,510,RC,12001,CPT,,,,,,,,311,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Body <2.5cm,PX12001P,CDM,983,RC,12001,CPT,,,,,,,,293,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Body 7.6-12.5,PX12004F,CDM,510,RC,12004,CPT,,,,,,,,453,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Body 7.6-12.5,PX12004P,CDM,983,RC,12004,CPT,,,,,,,,614,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Body 12.6-20,PX12005F,CDM,510,RC,12005,CPT,,,,,,,,565,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Body 12.6-20,PX12005P,CDM,983,RC,12005,CPT,,,,,,,,377,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face <2.5cm,PX12011F,CDM,510,RC,12011,CPT,,,,,,,,335,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face <2.5cm,PX12011P,CDM,983,RC,12011,CPT,,,,,,,,461,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face >30cm,PX12018F,CDM,510,RC,12018,CPT,,,,,,,,713,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face 2.6-5,PX12013F,CDM,510,RC,12013,CPT,,,,,,,,375,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face 2.6-5,PX12013P,CDM,983,RC,12013,CPT,,,,,,,,681,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face 5.1-7.5,PX12014F,CDM,510,RC,12014,CPT,,,,,,,,453,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face 5.1-7.5,PX12014P,CDM,983,RC,12014,CPT,,,,,,,,819,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Reptilase Test - Ref,PX8563590,CDM,300,RC,85635,CPT,90,,,,,,,102,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESERVOIR SILICONE BULB 100CC,27200000,CDM,272,RC,,,,4400-MAIN,LOCAL,,,,,16.65,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESERVOIR WOUND DRAIN 15FR,27200000,CDM,272,RC,,,,4386-MAIN,LOCAL,,,,,30.6,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Resp Muscles 1:1 per 15 Min,PXG0237,CDM,948,RC,G0237,HCPCS,,,,,,,,65,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Resp Virus 3-5 Targets,PX87631,CDM,300,RC,87631,CPT,,,,,,,,459,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Resp Virus 6-11 Targets,PX87632,CDM,300,RC,87632,CPT,,,,,,,,428,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESTRATA WOUND MATRIX 2.5CM X 2.5CM TOTAL 6.25CM,27200000,CDM,272,RC,A2007,HCPCS,,11733-MAIN,LOCAL,,,,,1829,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESTRATA WOUND MATRIX 2.5CM X 5CM TOTAL 12.5CM,27200000,CDM,272,RC,A2007,HCPCS,,11734-MAIN,LOCAL,,,,,3039,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESTRATA WOUND MATRIX 2.5CM X 7.5CM TOTAL 18.75CM,27200000,CDM,272,RC,A2007,HCPCS,,11735-MAIN,LOCAL,,,,,4208,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESTRATA WOUND MATRIX 5.0CM X 5.0CM TOTAL 25CM,27200000,CDM,272,RC,A2007,HCPCS,,11736-MAIN,LOCAL,,,,,5236,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESTRATA WOUND MATRIX 7.5CM X 7.5CM TOTAL 56.25CM,27200000,CDM,272,RC,A2007,HCPCS,,11737-MAIN,LOCAL,,,,,6311,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESTRATA WOUND MATRIX 10CM X 12.5CM  TOTAL 125CM,27200000,CDM,272,RC,A2007,HCPCS,,11738-MAIN,LOCAL,,,,,8415,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Reticulocyte Count,Flow Cyto",PX85045,CDM,300,RC,85045,CPT,,,,,,,,92,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RETRIEVAL BAG 10MM,27200000,CDM,272,RC,,,,11707-MAIN,LOCAL,,,,,74.8,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RETRIEVAL BAG 12/15MM,27200000,CDM,272,RC,,,,12660-MAIN,LOCAL,,,,,187,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Revise Median N/Carpal Tunnel Surg,PX64721F,CDM,510,RC,64721,CPT,,,,,,,,2408,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Revise Median N/Carpal Tunnel Surg,PX64721P,CDM,983,RC,64721,CPT,,,,,,,,1927,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Revise Ulnar Nerve at Elbow,PX64718P,CDM,983,RC,64718,CPT,,,,,,,,1642,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
REVITA PLACENTAL MEMBRANE 2X3CM 6SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12559-MAIN,LOCAL,,,,,2474,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
REVITA PLACENTAL MEMBRANE 4X4CM 16SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12560-MAIN,LOCAL,,,,,6597,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
REVITA PLACENTAL MEMBRANE 4X6CM 24SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12561-MAIN,LOCAL,,,,,9896,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
REVITA PLACENTAL MEMBRANE 6X6CM 36SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12562-MAIN,LOCAL,,,,,14844,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
REVITA PLACENTAL MEMBRANE 6X8CM 48SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12563-MAIN,LOCAL,,,,,19792,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Rheumatoid Factor Quant,PX86431,CDM,300,RC,86431,CPT,,,,,,,,97,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rho d immune globulin human 1500 units solution prefilled syringe 1 Each Syringe,J2790.01,CDM,636,RC,J2790,HCPCS,,,,562780500,NDC,1,EA,464.01,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310001,NDC,0.528,ML,785.14,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rho(D) immune globulin 5000 UNIT/4.4ML Solution 4.4 mL Vial,J2792.01,CDM,636,RC,J2792,HCPCS,,,,70504310002,NDC,0.528,ML,894.9,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Rickettsia Antibody - Ref,PX8675790,CDM,300,RC,86757,CPT,90,,,,,,,52,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
riFAMpin 150 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,527139330,NDC,1,EA,17.41,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
riFAMpin 150 MG capsule 30 Each Bottle,63700001,CDM,250,RC,,,,,,68180065806,NDC,1,EA,17.41,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
riFAMpin 150 MG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,68084035721,NDC,1,EA,10.68,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rifAXIMin 550 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,65649030302,NDC,1,EA,218.25,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rifAXIMin 550 MG Tablet 60 Each Box,63700001,CDM,250,RC,,,,,,65649030303,NDC,1,EA,218.25,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
risperiDONE 0.5 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,50458059160,NDC,1,EA,7.71,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
risperiDONE 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904635861,NDC,1,EA,21.11,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
risperiDONE 0.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904736161,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
risperiDONE 0.25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084027011,NDC,1,EA,20.91,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
risperiDONE 0.25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084027001,NDC,1,EA,20.91,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
risperiDONE 4 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,43547034406,NDC,0.125,EA,8.06,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
riTUXimab 100 MG/10ML Solution 10 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005121,NDC,10,ML,1916.61,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
riTUXimab 500 MG/50ML Solution 50 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005306,NDC,50,ML,8860.06,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
riTUXimab-abbs 500 MG/50ML Solution 50 mL Vial,Q5115.01,CDM,636,RC,Q5115,HCPCS,,,,63459010450,NDC,50,ML,8624.61,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rivaroxaban 10 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50458058030,NDC,1,EA,98.57,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rivaroxaban 15 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50458057830,NDC,0.666666667,EA,67.3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rivastigmine 1.5 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,62332006360,NDC,1,EA,25.03,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rivastigmine 3 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,55111035360,NDC,0.5,EA,11.4,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323042605,NDC,5,ML,64.8,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,67457022800,NDC,5,ML,53.42,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rocuronium 50 MG/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,67457057305,NDC,5,ML,53.42,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
romiPLOStim 250 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022101,NDC,1,EA,3791.51,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RomiPLOStim 500 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022201,NDC,1,EA,7018.25,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Room Rate General,PX12000000,CDM,120,RC,,,,,,,,,,1688,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Room Rate General Iso,PX12000001,CDM,120,RC,,,,,,,,,,1822,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Room Rate Icc,PX20601000,CDM,206,RC,,,,,,,,,,2432,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Room Rate Icc Iso,PX20601001,CDM,206,RC,,,,,,,,,,2517,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Room Rate Swing General,PX12000010,CDM,120,RC,,,,,,,,,,3788,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Room Rate Swing General Iso,PX12000011,CDM,120,RC,,,,,,,,,,3788,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Room Rate Transitional Care Private,PX11900000,CDM,119,RC,,,,,,,,,,775,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rOPINIRole 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,43547026810,NDC,1,EA,13.43,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rOPINIRole 0.25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462025301,NDC,1,EA,13.45,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rOPINIRole 1 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904637461,NDC,0.25,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rOPINIRole 4 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462025801,NDC,1,EA,13.96,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ROPivacaine 2 MG/ML Solution 10 mL Vial,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028513,NDC,10,ML,52.01,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ROPivacaine 2 MG/ML Solution 100 mL Bottle,J2795.01,CDM,636,RC,J2795,HCPCS,,,,63323028568,NDC,100,ML,275.11,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 5 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16714098801,NDC,1,EA,46.18,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 10 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003001,NDC,0.5,EA,21.59,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 10 MG Tablet 1 Each Box,63700001,CDM,250,RC,,,,,,60687024511,NDC,0.5,EA,19.18,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,42292003201,NDC,0.125,EA,5.4,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 40 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268071111,NDC,0.125,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,310075430,NDC,1,EA,56.04,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 40 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,72205000530,NDC,0.125,EA,6,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
rosuvastatin 40 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268071115,NDC,0.125,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ROTH NET PLATINUM RETRIEVER,27200000,CDM,272,RC,,,,7518-MAIN,LOCAL,,,,,196.35,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Rubella Antibody,PX86762,CDM,300,RC,86762,CPT,,,,,,,,31,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Rubeola Antibody,PX86765,CDM,300,RC,86765,CPT,,,,,,,,74,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Russell Viper Venom - Ref,PX8561390,CDM,300,RC,85613,CPT,90,,,,,,,93,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
saccharomyces boulardii 250 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,4142000024,NDC,1,EA,4.25,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sacubitril-valsartan 24-26 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,78065920,NDC,1,EA,62.6,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sacubitril-Valsartan 49-51 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,78077720,NDC,1,EA,58.51,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Salicylate,PX80307D,CDM,300,RC,80307,CPT,,,,,,,,370,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
saliva substitute Solution 59 mL Bottle,63700001,CDM,250,RC,,,,,,50930009802,NDC,59,ML,31.1,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sarilumab 200 MG/1.14ML solution prefilled syringe 1.14 mL Syringe,J3590.25,CDM,636,RC,J3590,HCPCS,,,,24591001,NDC,1.14,ML,4408.29,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sars-Cov-2 Covid-19 Amp Prb,PX8763590,CDM,300,RC,87635,CPT,90,,,,,,,365,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sars-Cov-2 Covid-19 Antibody,PX86769,CDM,300,RC,86769,CPT,,,,,,,,340,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sars-Cov-2 Covid-19 Antibody,PX8676990,CDM,300,RC,86769,CPT,90,,,,,,,100,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SAW BLADE 300 SAGITTAL 25X9.4X0.7,27200000,CDM,272,RC,,,,11592-MAIN,LOCAL,,,,,46.75,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SAW BLADE 300 SAGITTAL 40X14X0.6MM,27200000,CDM,272,RC,,,,11591-MAIN,LOCAL,,,,,46.75,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SAW WIRE 12 INCH GIGLI NL850,27200000,CDM,272,RC,,,,12901-MAIN,LOCAL,,,,,14,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SAWBLADE SAGITAL STERILE 25MM LENGTH 5.5MM WIDTH 0.60MM THICKNESS,27200000,CDM,272,RC,,,,11623-MAIN,LOCAL,,,,,86.02,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sb Scope,to Ileum,Biopsy",PX44377F,CDM,750,RC,44377,CPT,,,,,,,,1770,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1561.14,6141.46
"Sb Scope,to Ileum,Biopsy",PX44377P,CDM,983,RC,44377,CPT,,,,,,,,1180,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SCAR GEL SHEET,120.458,CDM,273,RC,A6025,HCPCS,,5796-MAIN,LOCAL,,,,,51,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SCISSORS ENDOSCOPIC 5MM STANDARD STERILE,27200000,CDM,272,RC,,,,11706-MAIN,LOCAL,,,,,47.6,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SCOPE ASCOPE4 CYSTO STERILE 601001000,120.497,CDM,272,RC,A4649,HCPCS,,11662-MAIN,LOCAL,,,,,368,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SCOPE BRONCHOSCOPE SZ 4 STERILE DISPOSABLE B120044,120.574,CDM,272,RC,,,,12868-MAIN,LOCAL,,,,,28,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Box,25000000,CDM,250,RC,,,,,,67434509,NDC,1,EA,98.1,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Package,25000000,CDM,250,RC,,,,,,10019055390,NDC,1,EA,121.9,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
scopolamine 1 MG/3DAYS Patch 72 Hour 1 Each Package,25000000,CDM,250,RC,,,,,,66758020858,NDC,1,EA,102.08,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
scopolamine 1 MG/3DAYS Patch 72 Hour 4 Each Box,25000000,CDM,250,RC,,,,,,45802058084,NDC,1,EA,103.43,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
scopolamine 1 MG/3DAYS Patch 72 Hour 24 Each Box,25000000,CDM,250,RC,,,,,,50742050524,NDC,1,EA,109.59,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598F,CDM,510,RC,97598,CPT,,,,,,,,406,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598P,CDM,982,RC,97598,CPT,,,,,,,,325,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597F,CDM,510,RC,97597,CPT,,,,,,,,266,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597P,CDM,983,RC,97597,CPT,,,,,,,,274,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Self Care Mngment Training,PX97535,CDM,420,RC,97535,CPT,,,,,,,,135,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
senna 8.6 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904652261,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
senna-docusate 8.6-50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687062211,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
senna-docusate 8.6-50 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,57896045806,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904633961,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687062201,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
senna-docusate 8.6-50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739043210,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018011,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904692461,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018001,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687024211,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018111,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687024201,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018101,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687025311,NDC,0.25,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904692661,NDC,0.25,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sertraline 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687025301,NDC,0.25,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SET CRICOTHYROTOMY CATHETER 3.5MM ID,120.251,CDM,272,RC,,,,4306-MAIN,LOCAL,,,,,363,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SET CRICOTHYROTOMY CATHETER 4MM ID,120.251,CDM,272,RC,,,,3452-MAIN,LOCAL,,,,,363,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SET CRICOTHYROTOMY CATHETER 6MM ID,120.251,CDM,272,RC,,,,2887-MAIN,LOCAL,,,,,363,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SET CRICOTHYROTOMY CATHETER 6MM ID,120.378,CDM,272,RC,,,,11119-MAIN,LOCAL,,,,,494,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SET DISPOSABLE COLLECTION,27100000,CDM,271,RC,,,,5439-MAIN,LOCAL,,,,,30.6,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SET SP TUBE INTRODUCER  14CM 8-14FR G15469,120.377,CDM,272,RC,,,,7147-MAIN,LOCAL,,,,,227,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sevoflurane Solution 250 mL Bottle,25000000,CDM,250,RC,,,,,,66794001525,NDC,250,ML,589.56,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP LARGE MALE MQM3B,120.237,CDM,274,RC,L3260,HCPCS,,794-MAIN,LOCAL,,,,,76,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP LARGE SQUARE TOE WOMENS ORT30300WL,120.237,CDM,274,RC,L3260,HCPCS,,10606-MAIN,LOCAL,,,,,76,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP MEDIUM SQUARE TOE MALE ORT30300MM,120.237,CDM,274,RC,L3260,HCPCS,,10603-MAIN,LOCAL,,,,,76,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP MEDIUM SQUARE TOE WOMENS ORT30300WM,120.237,CDM,274,RC,L3260,HCPCS,,10605-MAIN,LOCAL,,,,,76,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP SMALL MALE 0814-1192,120.237,CDM,274,RC,L3260,HCPCS,,803-MAIN,LOCAL,,,,,76,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP SMALL SQUARE TOE WOMENS MQW1B,120.237,CDM,274,RC,L3260,HCPCS,,10604-MAIN,LOCAL,,,,,76,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SHOE POST OP X-LARGE MALE DS1016-16,120.237,CDM,274,RC,L3260,HCPCS,,6337-MAIN,LOCAL,,,,,35,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sigmoidoscope W/Submuc Inj,PX45335F,CDM,750,RC,45335,CPT,,,,,,,,750,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,661.5,6141.46
Sigmoidoscope W/Submuc Inj,PX45335P,CDM,983,RC,45335,CPT,,,,,,,,500,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sigmoidoscopy,Biopsy",PX45331F,CDM,750,RC,45331,CPT,,,,,,,,1776,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1566.432,6141.46
"Sigmoidoscopy,Biopsy",PX45331P,CDM,983,RC,45331,CPT,,,,,,,,1316,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sigmoidoscopy,Diagnostic",PX45330F,CDM,510,RC,45330,CPT,,,,,,,,720,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sigmoidoscopy,Diagnostic",PX45330P,CDM,983,RC,45330,CPT,,,,,,,,480,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sigmoidoscopy,Remv Lesn,Snare",PX45338F,CDM,510,RC,45338,CPT,,,,,,,,2137,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sigmoidoscopy,Remv Lesn,Snare",PX45338P,CDM,983,RC,45338,CPT,,,,,,,,1710,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sigmoidoscopy,Screen Prev",PX2001F,CDM,750,RC,45330,CPT,,,,,,,,843,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,743.526,6141.46
sildenafil citrate 20 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,65162035109,NDC,1,EA,95.41,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
silver nitrate - pot nitrate 75-25 % Misc 100 Each Package,63700001,CDM,250,RC,,,,,,12870000102,NDC,1,EA,3.58,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
silver sulfADIAZINE 1 % Cream 50 g Jar,25000000,CDM,250,RC,,,,,,43598021055,NDC,50,GR,83.89,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
simethicone 40 MG/0.6ML Suspension 30 mL Bottle,25000000,CDM,250,RC,,,,,,904589430,NDC,30,ML,22.39,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
simethicone 40 MG/0.6ML Suspension 30 mL Bottle,25000000,CDM,250,RC,,,,,,70677107801,NDC,30,ML,24.69,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
simethicone 125 MG Tablet Chewable 18 Each Box,63700001,CDM,250,RC,,,,,,49348086348,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
simethicone 125 MG Tablet Chewable 60 Each Bottle,63700001,CDM,250,RC,,,,,,69618003206,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
simvastatin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739057010,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
simvastatin 10 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,16714068202,NDC,0.5,EA,7.43,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
simvastatin 40 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739057310,NDC,0.125,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sincalide 5 MCG Recon Soln 1 Each Vial,J2805.01,CDM,636,RC,J2805,HCPCS,,,,270055615,NDC,1,EA,250,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Skilled Srvc of a Lpn in Training and/or Education of Pt or Fam Ea 15 Min,PXG0496,CDM,551,RC,G0496,HCPCS,,,,,,,,75,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Skilled srvc of an RN in training and/or education of pt or fam ea 15 min,PXG0495,CDM,551,RC,G0495,HCPCS,,,,,,,,75,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
skin oil Oil 236.6 mL Bottle,63700001,CDM,250,RC,,,,,,67211008,NDC,236.6,ML,40.61,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Skin Sub Graft Trnk/Arm/Leg,PX15271F,CDM,510,RC,15271,CPT,,,,,,,,862,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Skin Sub Graft Trnk/Arm/Leg,PX15271P,CDM,983,RC,15271,CPT,,,,,,,,705,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sleep Staging 4 + Pap,PX9581126,CDM,982,RC,95811,CPT,26,,,,,,,1850,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLEEVE ACHILLES LG/XL PROTECTION 92437145348,120.422,CDM,271,RC,,,,11378-MAIN,LOCAL,,,,,39,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLEEVE ACHILLES SM/MED PROTECTION 92437145324,120.422,CDM,271,RC,,,,11377-MAIN,LOCAL,,,,,39,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLEEVE BALLOON 5MMX100MML KII STERILE CFS02,27200000,CDM,272,RC,,,,11704-MAIN,LOCAL,,,,,24,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLING ARM CHILD PAD CANVAS NAVY 8004-02,120.54,CDM,273,RC,A4565,HCPCS,,878-MAIN,LOCAL,,,,,83,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLING ARM LARGE PAD CANVAS NAVY ORT11300L,120.54,CDM,273,RC,A4565,HCPCS,,870-MAIN,LOCAL,,,,,83,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLING ARM MEDIUM PAD CANVAS NAVY ORT11300M,120.54,CDM,273,RC,A4565,HCPCS,,872-MAIN,LOCAL,,,,,83,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLING ARM SMALL PAD CANVAS NAVY ORT11300S,120.54,CDM,273,RC,A4565,HCPCS,,874-MAIN,LOCAL,,,,,83,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SLING ARM X-LARGE PAD ENVELOPE ORT11300XL,120.54,CDM,273,RC,A4565,HCPCS,,876-MAIN,LOCAL,,,,,83,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SMALL HAMMERTOE IMPLANT,C1713,CDM,278,RC,C1713,HCPCS,,12655-MAIN,LOCAL,,,,,3905,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Smear Fluorescent/Acid Stai,PX87206,CDM,300,RC,87206,CPT,,,,,,,,155,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Smear Gram Stain,PX87205,CDM,300,RC,87205,CPT,,,,,,,,109,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Smear Special Stain,PX87207,CDM,300,RC,87207,CPT,,,,,,,,81,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Smear Wet Mount Saline/Ink,PX87210,CDM,300,RC,87210,CPT,,,,,,,,109,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Smking Cess 4-10 Min,PX99406F,CDM,942,RC,99406,CPT,,,,,,,,65,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Smking Cess 4-10 Min,PX99406P,CDM,983,RC,99406,CPT,,,,,,,,43,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sod citrate-citric acid 500-334 MG/5ML Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,121059516,NDC,473,ML,95.87,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium bicarbonate 4.2 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,409553434,NDC,10,ML,91.46,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409663724,NDC,50,ML,115.32,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,409663734,NDC,50,ML,89.7,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium bicarbonate 8.4 % Solution 50 mL Syringe,25000000,CDM,250,RC,,,,,,76329335201,NDC,50,ML,109.26,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium bicarbonate 8.4 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409662502,NDC,50,ML,84.47,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium bicarbonate 8.4 % Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409662522,NDC,50,ML,85.02,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium bicarbonate 650 MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64980018210,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium bicarbonate 650 MG Tablet 1,000 Each Bottle",63700001,CDM,250,RC,,,,,,64980052810,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9 % 0.9 % Solution 50 mL Flex Cont,J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004941,NDC,50,ML,43.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338069104,NDC,1000,ML,99.12,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq 20-0.9 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,990711509,NDC,1000,ML,64.08,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9 % Nebulization Solution 3 mL Plas Cont,63700001,CDM,250,RC,,,,,,487930133,NDC,3,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Syringe,J7040.01,CDM,636,RC,J7040,HCPCS,,,,64253020230,NDC,10,ML,42.15,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9 % PF 0.9 % Solution 10 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488802,NDC,10,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018603,NDC,20,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9 % PF 0.9 % Solution 20 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,63323018620,NDC,20,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9 % PF 0.9 % Solution 50 mL Vial,J7040.01,CDM,636,RC,J7040,HCPCS,,,,409488850,NDC,3,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004904,NDC,1000,ML,99.12,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.9% 0.9 % Solution 1,000 mL Flex Cont",J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954306,NDC,1000,ML,99.12,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004941,NDC,250,ML,43.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 50 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055311,NDC,250,ML,43.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004948,NDC,300,ML,43.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 100 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338055318,NDC,300,ML,43.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 150 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,409798361,NDC,300,ML,43.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004902,NDC,250,ML,99.12,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 250 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338954302,NDC,250,ML,99.12,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% 0.9 % Solution 500 mL Flex Cont,J7030.01,CDM,636,RC,J7030,HCPCS,,,,338004903,NDC,500,ML,99.12,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.9% 0.9% Solution 1,000 mL Flex Cont",J7040.01,CDM,636,RC,J7040,HCPCS,,,,338004904,NDC,1000,ML,99.12,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.9% irrigation 0.9 % Solution 3,000 mL Plas Cont",25000000,CDM,250,RC,,,,,,338004727,NDC,3000,ML,43.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% IV FLUSH 0.9 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,8881570121,NDC,2.5,ML,4.8,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% IV FLUSH 0.9 % Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,63807010001,NDC,2.5,ML,4.8,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% IV LINE FLUSH 0.9% Solution 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,338004948,NDC,100,ML,43.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.9% IV LINE FLUSH 0.9% Solution 250 mL Flex Cont,25000000,CDM,250,RC,,,,,,338004902,NDC,250,ML,99.12,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.45 % 0.45 % Solution 1,000 mL Flex Cont",25000000,CDM,250,RC,,,,,,338004304,NDC,1000,ML,99.12,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"sodium chloride 0.45 % 1,000 mL with potassium chloride 20 mEq 20-0.45 MEQ/L-% Solution 1,000 mL Flex Cont",J3480.01,CDM,636,RC,J3480,HCPCS,,,,338070434,NDC,1000,ML,58.57,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 0.65 % Solution 44 mL Bottle,63700001,CDM,250,RC,,,,,,904386575,NDC,44,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,223176001,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride 3 % 3 % Solution 500 mL Flex Cont,J7131.01,CDM,636,RC,J7131,HCPCS,,,,338005403,NDC,500,ML,99.12,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride bacteriostatic 0.9 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409196602,NDC,30,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium chloride bacteriostatic 0.9 % Solution 30 mL Vial,25000000,CDM,250,RC,,,,,,409196607,NDC,30,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279210,NDC,10,ML,429.84,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium ferric gluconate 12.5 MG/ML Solution 5 mL Vial,J2916.01,CDM,636,RC,J2916,HCPCS,,,,24279410,NDC,10,ML,429.84,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,436067216,NDC,473,ML,77.23,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,39328006412,NDC,473,ML,77.23,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium hypochlorite 0.125 % Solution 473 mL Bottle,63700001,CDM,250,RC,,,,,,39328006712,NDC,473,ML,167.77,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium phosphate 7-19 GM/118ML Enema 133 mL Bottle,63700001,CDM,250,RC,,,,,,132020140,NDC,133,ML,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium phosphate 15 MMOLE/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323088401,NDC,5,ML,132.6,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium phosphate 15 MMOLE/5ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323088406,NDC,5,ML,132.6,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium polystyrene sulfonate 15 GM/60ML Suspension 60 mL Bottle,63700001,CDM,250,RC,,,,,,46287000660,NDC,60,ML,123.3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium polystyrene sulfonate Powder 15 g Bottle,25000000,CDM,250,RC,,,,,,10702003615,NDC,15,GR,76.09,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium thiosulfate 250 MG/ML Solution 50 mL Vial,J0209.01,CDM,636,RC,J0209,HCPCS,,,,60267070550,NDC,50,ML,609.57,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium zirconium cyclosilicate 5 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,310110501,NDC,1,EA,151.95,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sodium zirconium cyclosilicate 10 g Packet 1 Each Packet,63700001,CDM,250,RC,,,,,,310111001,NDC,1,EA,172.56,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sodium, Other Source - Ref",PX8430290,CDM,300,RC,84302,CPT,90,,,,,,,27,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sodium; Serum, Plasma or Whole Blood",PX84295,CDM,300,RC,84295,CPT,,,,,,,,58,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sodium; Urine,PX84300,CDM,300,RC,84300,CPT,,,,,,,,119,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
solifenacin 5 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,50228042730,NDC,1,EA,74.52,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Somatostatin - Ref,PX8430790,CDM,300,RC,84307,CPT,90,,,,,,,325,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sotalol 80 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,60505008000,NDC,1,EA,13.76,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sp Stn for Inclusn Bodies - Ref,PX8720790,CDM,300,RC,87207,CPT,90,,,,,,,227,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Special Stains,Group I",PX3978,CDM,310,RC,88312,CPT,TC,,,,,,,107,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Specimen Concentration - Ref,PX8701590,CDM,300,RC,87015,CPT,90,,,,,,,105,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Spectrophotometry, Nos",PX84311,CDM,300,RC,84311,CPT,,,,,,,,21,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPECULUM VAGINAL WITH BUILT IN LIGHT LARGE,120.133,CDM,272,RC,,,,8251-MAIN,LOCAL,,,,,38,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPECULUM VAGINAL WITH BUILT IN LIGHT MEDIUM,120.133,CDM,272,RC,,,,8250-MAIN,LOCAL,,,,,38,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPECULUM VAGINAL WITH BUILT IN LIGHT SMALL,120.133,CDM,272,RC,,,,8249-MAIN,LOCAL,,,,,38,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Spinal Punc,Drain,Theraputic",PX62272F,CDM,510,RC,62272,CPT,,,,,,,,450,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Spinal Punc,Drain,Theraputic",PX62272P,CDM,983,RC,62272,CPT,,,,,,,,300,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Spinal Puncture,Lumbar,Diagnostic",PX62270F,CDM,510,RC,62270,CPT,,,,,,,,684,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Spinal Puncture,Lumbar,Diagnostic",PX62270P,CDM,983,RC,62270,CPT,,,,,,,,705,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Spirometry,PX9401001,CDM,460,RC,94010,CPT,TC,,,,,,,281,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Spirometry Incl Graph Rec Tc,PX9401002,CDM,460,RC,94010,CPT,TC,,,,,,,288,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
spironolactone 12.5 mg Tablet 1 split tablet Blister,63700001,CDM,250,RC,,,,,,8888800438,NDC,2,UN,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
spironolactone 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079010301,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
spironolactone 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,60687046511,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079010320,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,60687046501,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
spironolactone 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739054410,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPIT SOCK HOODS 16719,120.367,CDM,271,RC,,,,10820-MAIN,LOCAL,,,,,26,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPLINT ANKLE GEL BRACE UNIVERSAL AIRFORM 70351,120.61,CDM,274,RC,L4350,HCPCS,,12342-MAIN,LOCAL,,,,,88,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPLINT FOOT SMALL STRUT WALK 11-1383-2-00000,120.45,CDM,274,RC,L4360,HCPCS,,1205-MAIN,LOCAL,,,,,93,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPLINT SAM 36INCH ROLLED 661121,120.362,CDM,271,RC,,,,10789-MAIN,LOCAL,,,,,34,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPLINT WRIST LARGE ALUMINUM FOREARM LEFT 9101-06,120.87,CDM,274,RC,L3809,HCPCS,,1265-MAIN,LOCAL,,,,,130,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPLINT WRIST LARGE ALUMINUM FOREARM RIGHT 9101-03,120.87,CDM,274,RC,L3809,HCPCS,,1263-MAIN,LOCAL,,,,,130,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPLINT WRIST MEDIUM ALUMINUM FOREARM LEFT 9101-05,120.87,CDM,274,RC,L3809,HCPCS,,1264-MAIN,LOCAL,,,,,130,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPLINT WRIST MEDIUM ALUMINUM FOREARM RIGHT 9101-02,120.87,CDM,274,RC,L3809,HCPCS,,1262-MAIN,LOCAL,,,,,130,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SPONGE XRAY DETECTABLE PEANUT MDS72038,27200000,CDM,272,RC,,,,10915-MAIN,LOCAL,,,,,0.79,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"St Louis, Antibody - Ref",PX8665390,CDM,300,RC,86653,CPT,90,,,,,,,45,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STANDARD HIGH FLOW INSUFFLATION FILTER TUBING,27200000,CDM,272,RC,,,,11885-MAIN,LOCAL,,,,,33,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER CANNULA SEAL 12 mm 470380,27200000,CDM,272,RC,,,,11962-MAIN,LOCAL,,,,,40,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER CONTOUR CURVED CUTTER,27200000,CDM,272,RC,,,,12064-MAIN,LOCAL,,,,,942,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER INTERNAL ECHELON FLEX POWERED PLUS LONG LENGTH 440MM,27200000,CDM,272,RC,,,,12065-MAIN,LOCAL,,,,,648,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER INTERNAL POWERED 29MM CURVED CIRCULAR,27200000,CDM,272,RC,,,,12024-MAIN,LOCAL,,,,,697,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER INTERNAL POWERED 31MM CURVED CIRCULAR,27200000,CDM,272,RC,,,,12025-MAIN,LOCAL,,,,,697,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER RELOAD-CURVED CUTTER,27200000,CDM,272,RC,,,,12063-MAIN,LOCAL,,,,,283,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER SUREFORM 45 SPU IS4000,27200000,CDM,272,RC,,,,12794-MAIN,LOCAL,,,,,888,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STAPLER SUREFORM 60 SPU IS4000,27200000,CDM,272,RC,,,,12086-MAIN,LOCAL,,,,,991,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sterile water (preservative free) Solution 10 mL Syringe,25000000,CDM,250,RC,,,,,,64253002030,NDC,10,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409488710,NDC,10,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,409488717,NDC,10,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sterile water (preservative free) Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,63323018507,NDC,10,ML,43.09,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sterile water (preservative free) Solution 20 mL Vial,25000000,CDM,250,RC,,,,,,63323018520,NDC,20,ML,50.08,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sterile water (preservative free) Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409488724,NDC,50,ML,34.88,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sterile water (preservative free) Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,409488750,NDC,50,ML,34.88,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STIFNECK ADULT,120.77,CDM,274,RC,L0180,HCPCS,,991-MAIN,LOCAL,,,,,119,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STIFNECK PEDIATRIC,120.77,CDM,274,RC,L0180,HCPCS,,998-MAIN,LOCAL,,,,,119,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STOCKINETTE IMPERVIOUS 9X36 NON22530,27200000,CDM,272,RC,A6457,HCPCS,,10917-MAIN,LOCAL,,,,,14.73,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STOCKINETTE IMPERVIOUS 12X48 NON22535,27200000,CDM,272,RC,A6457,HCPCS,,10918-MAIN,LOCAL,,,,,16.47,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STOCKINETTE STERILE 4X48 NON22360,27200000,CDM,272,RC,A6457,HCPCS,,10658-MAIN,LOCAL,,,,,10.62,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STRAP CLAVICLE LARGE VP10123-040,120.191,CDM,274,RC,L3670,HCPCS,,12848-MAIN,LOCAL,,,,,24,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STRAP CLAVICLE MEDIUM VP10123-030,120.191,CDM,274,RC,L3670,HCPCS,,12847-MAIN,LOCAL,,,,,24,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STRAP CLAVICLE SMALL VP10123-020,120.191,CDM,274,RC,L3670,HCPCS,,12846-MAIN,LOCAL,,,,,24,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STRAP CLAVICLE XL 661 XL,120.191,CDM,274,RC,L3670,HCPCS,,12850-MAIN,LOCAL,,,,,24,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STRAP CLAVICLE XSMALL CHILD ORT14100XS,120.191,CDM,274,RC,L3670,HCPCS,,12849-MAIN,LOCAL,,,,,24,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STRAP FOOT LG/XL GEL UNIVERSAL 10165,120.428,CDM,271,RC,,,,11382-MAIN,LOCAL,,,,,41,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
STRAP FOOT SM/MED GEL UNIVERSAL 10155,120.428,CDM,271,RC,,,,11381-MAIN,LOCAL,,,,,41,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Ankle,PX29540F,CDM,420,RC,29540,CPT,,,,,,,,271,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Elbow or Wrist,PX29260F,CDM,420,RC,29260,CPT,,,,,,,,64,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Hand or Finger,PX29280F,CDM,420,RC,29280,CPT,,,,,,,,64,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Knee,PX29530F,CDM,420,RC,29530,CPT,,,,,,,,303,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Shoulder,PX29240F,CDM,420,RC,29240,CPT,,,,,,,,165,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Shoulder,PX29240P,CDM,983,RC,29240,CPT,,,,,,,,110,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Toes,PX29550F,CDM,510,RC,29550,CPT,,,,,,,,113,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strep a Assay W/Optic,PX87880,CDM,300,RC,87880,CPT,,,,,,,,95,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Subsequent Observation Care,PX99225,CDM,982,RC,99225,CPT,,,,,,,,253,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,409662902,NDC,10,ML,146.84,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094310,NDC,10,ML,72.79,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
succinylcholine 20 MG/ML Solution 10 mL Vial,J0330.01,CDM,636,RC,J0330,HCPCS,,,,63323094321,NDC,10,ML,72.79,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sucralfate 1 GM Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,59762040101,NDC,1,EA,3.81,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sucralfate 1 GM/10ML Suspension 10 mL Cup,63700001,CDM,250,RC,,,,,,68094004359,NDC,10,ML,60.92,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUCTION IRRIGATOR 2 0250070500,27200000,CDM,272,RC,,,,12262-MAIN,LOCAL,,,,,88,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUCTION TIP POOLE STERILE 35040,27200000,CDM,272,RC,,,,977-MAIN,LOCAL,,,,,42.28,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sugammadex sodium 200 MG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,6542302,NDC,2,ML,652.81,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sugammadex sodium 200 MG/2ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,6542312,NDC,2,ML,583.33,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sugars, Qual, Ea Spec - Ref",PX8437690,CDM,300,RC,84376,CPT,90,,,,,,,45,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sulfacetamide 10 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,24208067004,NDC,15,ML,312.96,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sulfacetamide 10 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,61314070101,NDC,15,ML,285.48,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sulfamethoxazole-trimethoprim 200-40 MG/5ML Suspension 473 mL Bottle,63700001,CDM,250,RC,,,,,,65862049647,NDC,10,ML,18.79,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sulfamethoxazole-trimethoprim 400-80 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57237023201,NDC,1,EA,3.57,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sulfamethoxazole-trimethoprim 400-80 MG/5ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,703951403,NDC,10,ML,102.93,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sulfamethoxazole-trimethoprim 800-160 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904272561,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
sulfamethoxazole-trimethoprim 800-160 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739022810,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sulfur Colloid per Dose,PXA9541,CDM,343,RC,A9541,HCPCS,,,,,,,,295,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963801,NDC,0.5,ML,88.69,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,143963805,NDC,0.5,ML,142.98,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,55150017301,NDC,0.5,ML,319.2,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUMAtriptan 6 MG/0.5ML Solution 0.5 mL Vial,J3030.01,CDM,636,RC,J3030,HCPCS,,,,63323027301,NDC,0.5,ML,235.6,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUMAtriptan 25 MG Tablet 9 Each Box,63700001,CDM,250,RC,,,,,,65862014636,NDC,1,EA,129.04,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Supply Technetium Medronate,to 30 MC",PXA9503,CDM,343,RC,A9503,HCPCS,,,,,,,,531,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Supply Technicium Sestamibi,per Dose",PXA9500,CDM,343,RC,A9500,HCPCS,,,,,,,,410,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Support for Organ Donor,PX01990.01,CDM,964,RC,1990,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Surg Pathology-Level 2-Tc,PX3932,CDM,310,RC,88302,CPT,TC,,,,,,,66,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Surgical Cleansing of Skin,PX11000P,CDM,983,RC,11000,CPT,,,,,,,,145,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Surgical Diagnostic Exam, Anorectal",PX45990P,CDM,983,RC,45990,CPT,,,,,,,,409,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SURGIFOAM ABSORBABLE GELATIN SPONGE 3.1 IN X 4.9IN X 10MM,120.371,CDM,272,RC,A4649,HCPCS,,10864-MAIN,LOCAL,,,,,55,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE BIOSYN MONOFILAMENT ABSORBABLE UNDYED SIZE 4-0 18IN WITH 3/8 CIRCLE REVERSE CUTTING 19MM NEED,27200000,CDM,272,RC,,,,11987-MAIN,LOCAL,,,,,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"SUTURE CHROME GUT 3-0 CP-2 27""",27200000,CDM,272,RC,,,,4967-MAIN,LOCAL,,,,,11.59,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE CTD VICRYL 4-0 VIL BR SUTUPK J103T,27200000,CDM,272,RC,,,,4491-MAIN,LOCAL,,,,,373.97,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"SUTURE ETHIBOND #0 CT-1 CR 8-18"" CX21D",27200000,CDM,272,RC,,,,6415-MAIN,LOCAL,,,,,41.97,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE ETHIBOND XTRA 0 SHSH 36 INCH,27200000,CDM,272,RC,,,,12678-MAIN,LOCAL,,,,,11,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"SUTURE ETHILON 2-0 BLK MONO FS 18"" 664G",27200000,CDM,272,RC,,,,3663-MAIN,LOCAL,,,,,6.59,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE ETHILON SIZE 0 96INCH TP1,27200000,CDM,272,RC,,,,12140-MAIN,LOCAL,,,,,9,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE MAXON ABSORBABLE POLYGLYCONATE 2-0 30IN MONOFILAMENT DYED TAPER POINT 1/2 CIRCLE 27MM GS-22 G,27200000,CDM,272,RC,,,,11988-MAIN,LOCAL,,,,,23,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE MAXON MONOFILAMENT ABSORBABLE GREEN SIZE 1 96IN WITH 1/2 CIRCLE TAPER POINT 65MM NEEDLE,27200000,CDM,272,RC,,,,11986-MAIN,LOCAL,,,,,63,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE MONOFILAMENT SZ 4-0 BIOSYN ABSORBABLE UNDYED18IN WITH 3/8 CIRCLE REVERSE CUTTING 19MM NEED SM,27200000,CDM,272,RC,,,,11984-MAIN,LOCAL,,,,,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE NUROLON 0 BLACK C527D,27200000,CDM,272,RC,,,,10415-MAIN,LOCAL,,,,,30.6,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE PDS 3-0 27INCH ABSORBABLE VIOLET Z316H,27200000,CDM,272,RC,,,,12871-MAIN,LOCAL,,,,,7,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE POLYSORB ABSORBABLE LACTOMER 2-0 30IN BRAIDED DYED TAPER POINT 1/2 CIRCLE 26MM V-20 VIOLET ST,27200000,CDM,272,RC,,,,11983-MAIN,LOCAL,,,,,23,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE POLYSORB BRAIDED ABSORBABLE VIOLET SIZE 0 30IN WITH 5/8 CIRCLE TAPER POINT 27MM NEEDLE,27200000,CDM,272,RC,,,,11985-MAIN,LOCAL,,,,,22,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE PROLENE 3-0 BLUE SH NEEDLE MONOFILAMENT 30INCH,27200000,CDM,272,RC,,,,12840-MAIN,LOCAL,,,,,9,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE PROLENE TAPERPOINT CT-1 36MM 0 BLUE,27200000,CDM,272,RC,,,,12322-MAIN,LOCAL,,,,,7,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"SUTURE SILK 2-0 BLK BR FS 18"" 685G",27200000,CDM,272,RC,,,,2668-MAIN,LOCAL,,,,,5.29,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE SILK 3-0 18INCH NONABSORBABLE BLACK M13T,27200000,CDM,272,RC,,,,12872-MAIN,LOCAL,,,,,19,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE TICRON 0 36IN BRAIDED DYED 1/2 CIRCLE DBLE ARM 25MM CV-305 BLUE STERILE,27200000,CDM,272,RC,,,,11956-MAIN,LOCAL,,,,,37,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE V-LOC 1/2 CIRCLE NEEDLE WOUND CLOSURE DEVICE VLOCN0306,27200000,CDM,272,RC,,,,11931-MAIN,LOCAL,,,,,44,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"SUTURE V-LOC 22G NEEDLE 9"" 180 GREEN VLOCL2145",27200000,CDM,272,RC,,,,11930-MAIN,LOCAL,,,,,40,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"SUTURE V-LOC SZ 0 180 GREEN GS21 NEEDLE 18"" VLOCL0326",27200000,CDM,272,RC,,,,12218-MAIN,LOCAL,,,,,49,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"SUTURE V-LOC SZ 0.9"" 180 GREEN GS-21 NEEDLE VLOCL0346",27200000,CDM,272,RC,,,,11933-MAIN,LOCAL,,,,,40,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE V-LOC SZ 1 PBT WOUND CLOSURE DEVICE BLUE 18 IN GS 21 NEEDLE VLOCN0327,27200000,CDM,272,RC,,,,12828-MAIN,LOCAL,,,,,58,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE V-LOC SZ 1/2 180 GREEN GS-21 VLOCL0316,27200000,CDM,272,RC,,,,11932-MAIN,LOCAL,,,,,41,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE V-LOC SZ 3-0 180 GREEN V-20 9 INCH VLOCL0644,27200000,CDM,272,RC,,,,13056-SURG,LOCAL,,,,,44,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SUTURE VICRYL TAPER 2-0 J317H,27200000,CDM,272,RC,,,,2615-MAIN,LOCAL,,,,,4,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
SYRINGE BULB 60ML IRRIGATION STERILE DYND20125,27200000,CDM,272,RC,A4322,HCPCS,,10829-MAIN,LOCAL,,,,,2.16,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tacrolimus - Ref,PX8019790,CDM,300,RC,80197,CPT,90,,,,,,,81,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tacrolimus 1 MG capsule 100 Each Bottle,J7507.01,CDM,636,RC,J7507,HCPCS,,,,16714009901,NDC,0.5,EA,11.95,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tamsulosin 0.4 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,904640161,NDC,1,EA,22.6,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tamsulosin 0.4 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739056710,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102F,CDM,510,RC,11102,CPT,,,,,,,,171,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102P,CDM,983,RC,11102,CPT,,,,,,,,465,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tap Block Bilateral by Injection(S),PX64488F,CDM,510,RC,64488,CPT,,,,,,,,393,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tap Block Bilateral by Injection(S),PX64488P,CDM,983,RC,64488,CPT,,,,,,,,262,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tap Block Unilateral by Injection(S),PX64486F,CDM,510,RC,64486,CPT,,,,,,,,253,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tap Block Unilateral by Injection(S),PX64486P,CDM,983,RC,64486,CPT,,,,,,,,169,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TAPER POST TOE JOINT HEMICAP 9.5MM ARTICULATING METATARSAL STERILE,C1713,CDM,278,RC,C1713,HCPCS,,12531-MAIN,LOCAL,,,,,821,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Targeted Genomic Sequence Analysis Panel 5-50 Genes - Ref,PX8145090,CDM,300,RC,81450,CPT,90,,,,,,,2936,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TB Antigen Response Gamma Interferon T-Cell Susp,PX86481,CDM,300,RC,86481,CPT,,,,,,,,150,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TB Test Enumeration of T-Cells - Ref,PX8648190,CDM,300,RC,86481,CPT,90,,,,,,,155,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"TB Test, Cell Immunity Measure",PX86480,CDM,300,RC,86480,CPT,,,,,,,,186,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tc99 Mebrofenin to 15 Mci,PXA9537,CDM,343,RC,A9537,HCPCS,,,,,,,,495,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tech-Cytopath Eval, Fna, Rep",PX8817301,CDM,310,RC,88173,CPT,TC,,,,,,,379,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TEGADERM CHLORHEXIDINE 5X5 CHG IV PORT,120.207,CDM,272,RC,A6268,HCPCS,,10163-MAIN,LOCAL,,,,,26,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TEGADERM CHLORHEXIDINE-GLUCONATE,120.356,CDM,272,RC,A4221,HCPCS,,10708-MAIN,LOCAL,,,,,22,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Telehealth Origin Site Fac Fee,PXQ3014,CDM,780,RC,Q3014,HCPCS,,,,,,,,40,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
temazepam 15 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,51079041801,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
temazepam 15 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,67877014601,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
temazepam 15 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,51079041820,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
temazepam 15 MG capsule 100 Each Box,63700001,CDM,250,RC,,,,,,63739023110,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Temporal Artery Ligatn or Bx,PX37609F,CDM,510,RC,37609,CPT,,,,,,,,705,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Temporal Artery Ligatn or Bx,PX37609P,CDM,983,RC,37609,CPT,,,,,,,,965,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Temporary External Pacing,PX92953F,CDM,480,RC,92953,CPT,,,,,,,,678,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
temporary tooth filling repair Misc 1 Each Package,25000000,CDM,250,RC,,,,,,47701000123,NDC,1,EA,25.46,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242003706,NDC,0.6,EA,8461.09,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012001,NDC,0.6,EA,7764.12,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012047,NDC,0.6,EA,10644.69,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
terazosin 1 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59746038306,NDC,1,EA,8.62,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
terazosin 5 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,59746038506,NDC,0.2,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
terbinafine 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714050101,NDC,1,EA,68.04,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
terbinafine 250 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714079501,NDC,1,EA,68.03,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066500,NDC,0.25,ML,48.19,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
terbutaline 1 MG/ML Solution 1 mL Vial,J3105.01,CDM,636,RC,J3105,HCPCS,,,,63323066501,NDC,0.25,ML,45.74,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Testosterone, Total - Ref",PX8440390,CDM,300,RC,84403,CPT,90,,,,,,,43,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Testosterone,Free - Ref",PX8440290,CDM,300,RC,84402,CPT,90,,,,,,,25,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084243,NDC,0.5,ML,202.42,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tetanus-diphth-acell pertussis 5-2.5-18.5 LF-MCG/0.5 suspension prefilled syringe 0.5 mL Syringe,90715,CDM,636,RC,90715,CPT,,,,58160084252,NDC,0.5,ML,207.65,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021515,NDC,0.5,ML,187.24,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tetanus-diphtheria toxoids 5-2 LFU Injectable 0.5 mL Syringe,90714,CDM,636,RC,90714,CPT,,,,49281021588,NDC,0.5,ML,203.87,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tetracaine 0.5 % Solution 4 mL Plas Cont,25000000,CDM,250,RC,,,,,,65074114,NDC,4,ML,71.55,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tetracycline 500 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,51991090701,NDC,0.5,EA,42.29,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
theophylline SR (12 hour) 300 MG Tablet Extended Release 12 Hour 100 Each Bottle,25000000,CDM,250,RC,,,,,,68462072101,NDC,0.333333333,EA,7.69,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ther Injection Carpal Tunnel,PX20526P,CDM,983,RC,20526,CPT,,,,,,,,248,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Therapeutic Activities,PX97530,CDM,420,RC,97530,CPT,,,,,,,,135,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Therapeutic Exercises,PX97110,CDM,420,RC,97110,CPT,,,,,,,,135,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
therapeutic multivitamin Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904053961,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,77333093425,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,37864090599,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,77333093410,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,25021050002,NDC,1,ML,52.06,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001302,NDC,2,ML,86.79,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001326,NDC,1,ML,42.88,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,63323001341,NDC,1,ML,42.88,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019600,NDC,1,ML,48.64,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
thiamine 100 MG/ML Solution 2 mL Vial,J3411.01,CDM,636,RC,J3411,HCPCS,,,,67457019602,NDC,2,ML,77.29,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER  STRAIGHT TAPER TIP 20FR PVC,120.528,CDM,272,RC,,,,12247-MAIN,LOCAL,,,,,20,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER  STRAIGHT TAPER TIP 24FR PVC,120.528,CDM,272,RC,,,,12248-MAIN,LOCAL,,,,,20,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER STRAIGHT TAPER TIP 8FR PVC,120.528,CDM,272,RC,,,,12253-MAIN,LOCAL,,,,,20,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER STRAIGHT TAPER TIP 10FR PVC,120.528,CDM,272,RC,,,,12254-MAIN,LOCAL,,,,,20,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER STRAIGHT TAPER TIP 12FR PVC,120.528,CDM,272,RC,,,,12255-MAIN,LOCAL,,,,,20,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER STRAIGHT TAPER TIP 16FR PVC,120.528,CDM,272,RC,,,,12256-MAIN,LOCAL,,,,,20,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER STRAIGHT TAPER TIP 28FR PVC,120.528,CDM,272,RC,,,,12249-MAIN,LOCAL,,,,,20,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER STRAIGHT TAPER TIP 32FR PVC,120.528,CDM,272,RC,,,,12250-MAIN,LOCAL,,,,,20,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
THORACIC CATHETER STRAIGHT TAPER TIP 36FR PVC,120.528,CDM,272,RC,,,,12251-MAIN,LOCAL,,,,,20,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Thrombin Time Plasma,PX85670,CDM,300,RC,85670,CPT,,,,,,,,126,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Thrombolysis,Coronary,IV Infusn",PX92977F,CDM,480,RC,92977,CPT,,,,,,,,595,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Thrombolytic Therapy, Stroke",PX37195F,CDM,761,RC,37195,CPT,,,,,,,,595,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Thromboplastin Time Partial,PX85730,CDM,300,RC,85730,CPT,,,,,,,,142,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Thyroglobulin - Ref,PX8443290,CDM,300,RC,84432,CPT,90,,,,,,,68,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Thyroglobulin Antibody,PX8680090,CDM,300,RC,86800,CPT,90,,,,,,,68,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Thyroxin, Free (Free T4)",PX84439,CDM,300,RC,84439,CPT,,,,,,,,173,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Thyroxine, Total - Ref",PX8443690,CDM,300,RC,84436,CPT,90,,,,,,,95,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Thyrstim Immun Glob (Tsi) - Ref,PX8444590,CDM,300,RC,84445,CPT,90,,,,,,,254,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ticagrelor 90 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,186077739,NDC,1,EA,44.35,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,17478028810,NDC,5,ML,95.71,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314022705,NDC,5,ML,95.71,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
timolol 0.5 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,64980051405,NDC,5,ML,95.71,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
timolol 0.25 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314022605,NDC,5,ML,84.45,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tiotropium 18 MCG capsule 5 Each Box,63700001,CDM,250,RC,,,,,,597007575,NDC,5,EA,665.18,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tiotropium 18 MCG capsule 30 Each Box,63700001,CDM,250,RC,,,,,,597007541,NDC,1,EA,82.92,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tiotropium bromide monohydrate 2.5 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597010051,NDC,4,GR,461.7,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tiotropium bromide-olodaterol 2.5-2.5 MCG/ACT Aerosol Solution 4 g Inhaler,63700001,CDM,250,RC,,,,,,597015570,NDC,4,GR,461.7,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tiss Cult, Neopl, Bm, Wb - Ref",PX8823790,CDM,310,RC,88237,CPT,90,,,,,,,3141,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tiss Cult,Non-Neop Lymph - Ref",PX8823090,CDM,310,RC,88230,CPT,90,,,,,,,103,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tiss Trnsgltmnase Ea Ig Clas,PX86364,CDM,300,RC,86364,CPT,,,,,,,,57,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tissue Exam for Fungi,PX87220,CDM,300,RC,87220,CPT,,,,,,,,94,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TISSUE RETRIEVAL SYSTEM,27200000,CDM,272,RC,,,,10233-MAIN,LOCAL,,,,,139.98,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tiZANidine 4 MG Tablet 150 Each Bottle,63700001,CDM,250,RC,,,,,,55111018015,NDC,0.5,EA,3.93,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tobramycin 0.3 % Solution 5 mL Bottle,25000000,CDM,250,RC,,,,,,61314064305,NDC,5,ML,191.42,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tobramycin 80 MG/2ML Solution 2 mL Vial,J3260.01,CDM,636,RC,J3260,HCPCS,,,,67457047300,NDC,2,ML,33.09,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tocilizumab 400 MG/20ML Solution 20 mL Vial,J3262.01,CDM,636,RC,J3262,HCPCS,,,,50242013701,NDC,20,ML,4703.83,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tolterodine 2 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,59762080002,NDC,0.5,EA,9.12,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tolterodine ER 2 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,43975032203,NDC,1,EA,43.15,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Topiramate - Ref,PX8020190,CDM,300,RC,80201,CPT,90,,,,,,,195,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
topiramate 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034211,NDC,1,EA,11.28,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
topiramate 25 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,62756070786,NDC,1,EA,13.71,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
topiramate 25 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,69097012203,NDC,1,EA,13.56,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
topiramate 25 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034201,NDC,1,EA,11.28,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
topiramate 100 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084034411,NDC,0.25,EA,8.32,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
topiramate 100 MG Tablet 60 Each Bottle,63700001,CDM,250,RC,,,,,,69097012403,NDC,0.25,EA,9.24,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
topiramate 100 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084034401,NDC,0.25,EA,8.32,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
torsemide 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268075411,NDC,1,EA,3.36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
torsemide 5 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268075415,NDC,1,EA,3.36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
torsemide 5 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50111091501,NDC,1,EA,3.41,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
torsemide 20 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,50268075611,NDC,0.25,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
torsemide 20 MG Tablet 50 Each Box,63700001,CDM,250,RC,,,,,,50268075615,NDC,0.25,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
torsemide 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,54007725,NDC,0.25,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
torsemide 20 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,50111091701,NDC,0.25,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Total Cortisol,PX82533,CDM,300,RC,82533,CPT,,,,,,,,137,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tramadol - Ref,PX8037390,CDM,300,RC,80373,CPT,90,,,,,,,197,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
traMADol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079099101,NDC,1,EA,4.27,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
traMADol 50 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084080811,NDC,1,EA,4.4,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
traMADol 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,68084080801,NDC,1,EA,4.4,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
traMADol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079099120,NDC,1,EA,4.27,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
traMADol 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,63739067110,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tranexamic acid 650 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,69918030130,NDC,1,EA,28,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tranexamic acid 1000 mg in 100 mL 0.7% sodium chloride (premix) 1000-0.7 MG/100ML-% Solution 100 mL Flex Cont,25000000,CDM,250,RC,,,,,,80830232901,NDC,100,ML,155.55,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,517096001,NDC,10,ML,355.63,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,517096010,NDC,10,ML,157.64,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,23155052431,NDC,10,ML,486.06,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tranexamic acid 1000 MG/10ML Solution 10 mL Vial,25000000,CDM,250,RC,,,,,,23155052441,NDC,10,ML,486.06,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Transferase; Alanine Amino (Alt) (Sgpt),PX84460,CDM,300,RC,84460,CPT,,,,,,,,58,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Transferase; Aspartate Amino (Ast) (Sgot),PX84450,CDM,300,RC,84450,CPT,,,,,,,,58,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Transvaginal US, Obstetric",PX7681701,CDM,402,RC,76817,CPT,TC,,,,,,,460,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
trastuzumab 150 MG Recon Soln 1 Each Vial,J9355.01,CDM,636,RC,J9355,HCPCS,,,,50242013201,NDC,1,EA,3179.17,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
trastuzumab-dttb 150 MG Recon Soln 1 Each Vial,J9999.55,CDM,636,RC,J9999,HCPCS,,,,78206014701,NDC,1,EA,2702.3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Trauma Activation,PX68200010,CDM,684,RC,G0390,HCPCS,,,,,,,,1243,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
travoprost (BAK Free) 0.004 % Solution 2.5 mL Bottle,25000000,CDM,250,RC,,,,,,65026025,NDC,2.5,ML,811.3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY 8 FR 5IN CENTESIS WITH TURKEL  30-CE1CO,120.303,CDM,272,RC,,,,11503-MAIN,LOCAL,,,,,217,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY ARTHROGRAM SAFE-T-ARTHRO 28-AR1CO,120.2,CDM,272,RC,,,,11499-MAIN,LOCAL,,,,,29,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY CENTRAL LINE DRESSING WITH CHLORAPREP DYND75234,120.68,CDM,272,RC,,,,10923-MAIN,LOCAL,,,,,42,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY FACIAL LACERATION PACK STERILE 96-1707,120.12,CDM,272,RC,,,,406-MAIN,LOCAL,,,,,95,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY FOLEY 14FR CATHETER A300414A,120.414,CDM,272,RC,A4344,HCPCS,,11281-MAIN,LOCAL,,,,,42,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY FOLEY 16FR CATHETER 300416A,120.414,CDM,272,RC,A4344,HCPCS,,11774-MAIN,LOCAL,,,,,42,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY GROSHONG 4FR SAFETY PICC 7617407,120.26,CDM,272,RC,,,,500-MAIN,LOCAL,,,,,233,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY HAND SURGICAL II DYNJS0806,27200000,CDM,272,RC,,,,11024-MAIN,LOCAL,,,,,64.62,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY IV SURGICAL EXTREMITY DYNJS0804,27200000,CDM,272,RC,,,,10919-MAIN,LOCAL,,,,,83.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY LUMBAR 22GAX3.5 PUNCTURE SAFE-T 4306CWSP,120.18,CDM,272,RC,,,,11584-MAIN,LOCAL,,,,,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY LUMBAR 22X1.5 PUNCTURE PEDS 4302CSP,120.18,CDM,272,RC,,,,652-MAIN,LOCAL,,,,,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY PNEUMOTHORAX 14FR 29CM 19 CATHETER SIDEPORTS G56537,120.496,CDM,272,RC,,,,11677-MAIN,LOCAL,,,,,419,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"TRAY SPINAL  25GX3.5"" WITH WHITEACRE 405671",120.275,CDM,272,RC,,,,3284-MAIN,LOCAL,,,,,42,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY SPINAL 25G ANESTH SADDLE BLOCK NLD-4795-20,120.275,CDM,272,RC,,,,935-MAIN,LOCAL,,,,,42,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY SURGICAL PODIATRY II EXTREMITY DYNJS0803,27200000,CDM,272,RC,,,,10920-MAIN,LOCAL,,,,,73.29,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY TRACH CLEAN & CARE DYND40589,120.212,CDM,271,RC,,,,1173-MAIN,LOCAL,,,,,18,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRAY TRACHEOTOMY CARE PEDS DYND40650H,120.212,CDM,272,RC,,,,11025-MAIN,LOCAL,,,,,18,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
traZODone 50 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904655461,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Trb@ Gene Rearrange Amplify - Ref,PX8134090,CDM,300,RC,81340,CPT,90,,,,,,,503,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Treat Thumb Disloc,Manipulatn",PX26641F,CDM,510,RC,26641,CPT,,,,,,,,1721,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Treat Thumb Disloc,Manipulatn",PX26641P,CDM,983,RC,26641,CPT,,,,,,,,1902,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Treponema Pallidum,PX86780,CDM,300,RC,86780,CPT,,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Treponema Pallidum - Ref,PX8678090,CDM,300,RC,86780,CPT,90,,,,,,,39,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Trg Gene Rearrangement Anal - Ref,PX8134290,CDM,300,RC,81342,CPT,90,,,,,,,516,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamcinolone acetonide 0.1 % Cream 15 g Tube,63700001,CDM,250,RC,,,,,,168000415,NDC,15,GR,22.97,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamcinolone acetonide 0.1 % Cream 30 g Tube,63700001,CDM,250,RC,,,,,,16714098602,NDC,30,GR,59.22,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamcinolone acetonide 0.1 % Cream 80 g Tube,63700001,CDM,250,RC,,,,,,16714098603,NDC,80,GR,65.76,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamcinolone acetonide 0.1 % Cream 454 g Jar,63700001,CDM,250,RC,,,,,,45802006405,NDC,454,GR,130.36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamcinolone acetonide 10 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3049420,NDC,0.25,ML,30,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamcinolone acetonide 40 MG/ML Suspension 1 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029305,NDC,1,ML,73.57,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamcinolone acetonide 40 MG/ML Suspension 5 mL Vial,J3301.01,CDM,636,RC,J3301,HCPCS,,,,3029320,NDC,1,ML,72.65,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
triamterene-hydroCHLOROthiazide 37.5-25 MG Tablet 30 Each Box,63700001,CDM,250,RC,,,,,,68084075025,NDC,1,EA,4.78,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Trichomonas Vagin Dir Probe,PX87660,CDM,300,RC,87660,CPT,,,,,,,,127,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Triiodothyronine T3, Free (Free T3)",PX84481,CDM,300,RC,84481,CPT,,,,,,,,137,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Triiodothyronine T3, Tot - Ref",PX8448090,CDM,300,RC,84480,CPT,90,,,,,,,158,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Trimming of Dystrophic Nails, Any Number",PXG0127P,CDM,983,RC,G0127,HCPCS,,,,,,,,35,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TROCAR KII BALLOON 12MM STERILE,27200000,CDM,272,RC,,,,11703-MAIN,LOCAL,,,,,41.14,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TROCAR KII BALLOON BLUNT 12MM STERILE,27200000,CDM,272,RC,,,,11702-MAIN,LOCAL,,,,,41.14,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TROCAR KII BALOON 5X100MM STERILE,27200000,CDM,272,RC,,,,11701-MAIN,LOCAL,,,,,37.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TROCAR KII FIOS SYSTEM BLADELSS Z-THREAD 5MMX100MM,27200000,CDM,272,RC,,,,12003-MAIN,LOCAL,,,,,38,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TROCAR KII FIOS SYSTEM BLADELSS Z-THREAD 5MMX150MM,27200000,CDM,272,RC,,,,12827-MAIN,LOCAL,,,,,39,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TROCAR LAP 1.5-3CM MINI GELPOINT PLAT ACCESS,27200000,CDM,272,RC,,,,12021-MAIN,LOCAL,,,,,,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tropicamide 1 % Solution 2 mL Bottle,25000000,CDM,250,RC,,,,,,24208058559,NDC,2,ML,61.3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tropicamide 1 % Solution 15 mL Bottle,25000000,CDM,250,RC,,,,,,61314035502,NDC,15,ML,267.96,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Troponin, Quantitative",PX84484,CDM,300,RC,84484,CPT,,,,,,,,289,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TRUMPET SUCTION IRRIGATION,27100000,CDM,271,RC,,,,4577-MAIN,LOCAL,,,,,116.4,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tte W/Doppler, Complete",PX9330601,CDM,483,RC,93306,CPT,TC,,,,,,,2191,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tte W/Doppler, Complete",PXC8929,CDM,480,RC,C8929,HCPCS,TC,,,,,,,1927,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE AIRSPIRAL BREATHING AND CHAMBER 900PT561,120.493,CDM,271,RC,A4604,HCPCS,,11618-MAIN,LOCAL,,,,,112,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE FEEDING DECLOGGING SYSTEM CLOG ZAPPER 20-0002,120.277,CDM,272,RC,,,,4226-MAIN,LOCAL,,,,,51,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE GASTROSTOMY 18FR REPLACEMENT DYND70318,120.256,CDM,271,RC,B4087,HCPCS,,407-MAIN,LOCAL,,,,,179,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE SURGICAL IRRIGATION 1PK PD-IT,27200000,CDM,272,RC,,,,12433-MAIN,LOCAL,,,,,219,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tube Thoracostomy Inc Wtr Seal,PX32551F,CDM,510,RC,32551,CPT,,,,,,,,989,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tube Thoracostomy Inc Wtr Seal,PX32551P,CDM,983,RC,32551,CPT,,,,,,,,1236,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 3.0MM ID 4.5MM OD SHILEY PEDIATRIC 3.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1185-MAIN,LOCAL,,,,,184,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 3.5MM ID 5.2MM OD SHILEY PEDIATRIC,120.287,CDM,272,RC,A7520,HCPCS,,8813-MAIN,LOCAL,,,,,184,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 4.0MM ID 5.9MM OD SHILEY PEDIATRIC 4.0PED,120.287,CDM,272,RC,A7520,HCPCS,,1187-MAIN,LOCAL,,,,,184,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 5 7.0MM ID 10.1MM OD SHILEY CUFFED 5CN70H,120.287,CDM,272,RC,A7521,HCPCS,,10350-MAIN,LOCAL,,,,,184,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 5.0MM ID 7.1MM OD SHILEY PEDIATRIC 5.0PED,120.287,CDM,272,RC,A7520,HCPCS,,8814-MAIN,LOCAL,,,,,184,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 6 6.0MM ID 8.3MM OD SHILEY CUFFED 6SCT,120.287,CDM,272,RC,A7521,HCPCS,,8812-MAIN,LOCAL,,,,,184,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 6 6.4MM ID 10.8MM OD SHILEY CUFFED 6DCT,120.287,CDM,272,RC,A7521,HCPCS,,1190-MAIN,LOCAL,,,,,184,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 7.5MM ID 10.8MM OD SHILEY CUFFED 6CN75H,120.287,CDM,272,RC,A7521,HCPCS,,8488-MAIN,LOCAL,,,,,184,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 8 7.6MM ID 12.2MM OD SHILEY 8DCT,120.287,CDM,272,RC,A7521,HCPCS,,1192-MAIN,LOCAL,,,,,184,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 8 7.6MM ID 12.22MM OD SHILEY CUFFED 8LPC,120.287,CDM,272,RC,A7521,HCPCS,,8815-MAIN,LOCAL,,,,,184,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 8.0MM ID 10.9MM OD SHILEY CUFFED 8SCT,120.287,CDM,272,RC,A7521,HCPCS,,8811-MAIN,LOCAL,,,,,184,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBE TRACH SIZE 10 SHILEY 10LPC,120.287,CDM,272,RC,A7521,HCPCS,,1181-MAIN,LOCAL,,,,,184,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
tuberculin 5 UNIT/0.1ML Solution 1 mL Vial,25000000,CDM,250,RC,,,,,,42023010401,NDC,0.1,ML,57.82,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TUBING IRRIGATION F SET STERILE MXB-T,27200000,CDM,272,RC,,,,11693-MAIN,LOCAL,,,,,94,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tumor Antigen, Ca-125",PX86304,CDM,300,RC,86304,CPT,,,,,,,,190,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tx/Pro/Dx Inj Same Drug Adon,PX96376,CDM,260,RC,96376,CPT,,,,,,,,164,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ULTRAGUIDE CTR SX-ONE MICROKNIFE 600112-001,27200000,CDM,272,RC,,,,13106-MAIN,LOCAL,,,,,2121,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ultrasound Breast Complete,PX7664101,CDM,402,RC,76641,CPT,TC,,,,,,,333,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ultrasound Breast Limited,PX7664201,CDM,402,RC,76642,CPT,TC,,,,,,,342,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ultrasound Therapy,PX97035,CDM,420,RC,97035,CPT,,,,,,,,135,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
UMBILICAL VESSEL CATHETER INSERTION TRAY POLY SINGLE LUMEN 3.5/5FR,120.573,CDM,272,RC,,,,12857-MAIN,LOCAL,,,,,124,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
umeclidinium 62.5 MCG/ACT Aerosol Powder Breath Activated 7 Each Disp Pack,63700001,CDM,250,RC,,,,,,173087306,NDC,7,EA,492.23,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
umeclidinium-vilanterol 62.5-25 MCG/ACT Aerosol Powder Breath Activated 14 Each Disp Pack,63700001,CDM,250,RC,,,,,,173086906,NDC,14,EA,745.86,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Unlisted Anesth Procedure,PX01999.01,CDM,964,RC,1999,CPT,QZ,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Unlisted Molecular Path Proc - Ref,PX8147990,CDM,310,RC,81479,CPT,90,,,,,,,1077,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Up GI Endoscopy,Ball Dil,30mm",PX43249F,CDM,750,RC,43249,CPT,,,,,,,,2596,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2289.672,6141.46
"Up GI Endoscopy,Ball Dil,30mm",PX43249P,CDM,983,RC,43249,CPT,,,,,,,,1731,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Up GI Endoscopy,Dilatn W Guide",PX43248F,CDM,750,RC,43248,CPT,,,,,,,,1995,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1759.59,6141.46
"Upper GI Endoscopy,Biopsy",PX43239F,CDM,750,RC,43239,CPT,,,,,,,,2364,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2085.048,6141.46
"Upper GI Endoscopy,Biopsy",PX43239P,CDM,983,RC,43239,CPT,,,,,,,,2458,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Upper GI Endoscopy,Ctrl Bleed",PX43255F,CDM,750,RC,43255,CPT,,,,,,,,1723,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1519.686,6141.46
"Upper GI Endoscopy,Ctrl Bleed",PX43255P,CDM,983,RC,43255,CPT,,,,,,,,1148,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Upper GI Endoscopy,Diagnosis",PX43235F,CDM,750,RC,43235,CPT,,,,,,,,2539,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2239.398,6141.46
"Upper GI Endoscopy,Diagnosis",PX43235P,CDM,983,RC,43235,CPT,,,,,,,,1406,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
urea 20 % Cream 85 g Tube,63700001,CDM,250,RC,,,,,,536110945,NDC,85,GR,81.83,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
URGOK2 DUAL COMPRESSION SYSTEM LARGE,120.491,CDM,271,RC,A6452,HCPCS,,11871-MAIN,LOCAL,,,,,41,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
URGOK2 DUAL COMPRESSION SYSTEM REGULAR,120.491,CDM,271,RC,A6452,HCPCS,,11870-MAIN,LOCAL,,,,,41,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Uric Acid; Blood,PX84550,CDM,300,RC,84550,CPT,,,,,,,,52,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Urinalysis, Auto W/O Scope",PX81003,CDM,300,RC,81003,CPT,,,,,,,,149,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Urinalysis, Auto, W/Scope",PX81001,CDM,300,RC,81001,CPT,,,,,,,,255,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Urine Culture/Colony Count,PX87086,CDM,300,RC,87086,CPT,,,,,,,,286,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Urine Drug Screen,PX80307B,CDM,300,RC,80307,CPT,,,,,,,,370,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Urine Pregnancy Test,PX81025,CDM,300,RC,81025,CPT,,,,,,,,191,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ursodiol 300 MG capsule 100 Each Bottle,63700001,CDM,250,RC,,,,,,591315901,NDC,1,EA,39.47,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Abdomen Limited Tc,PX7670501,CDM,402,RC,76705,CPT,TC,,,,,,,425,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Abdomen Tc,PX7670001,CDM,402,RC,76700,CPT,TC,,,,,,,586,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Chest Tc,PX7660401,CDM,402,RC,76604,CPT,TC,,,,,,,248,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"US Complete Joint, Realtime W/ Img Tc",PX7688101,CDM,402,RC,76881,CPT,TC,,,,,,,415,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Doppler Lw Ext Art Tc,PX9392601,CDM,921,RC,93926,CPT,TC,,,,,,,740,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Ext Non-Vasc Img Lmtd,PX7688201,CDM,402,RC,76882,CPT,TC,,,,,,,425,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Follicles-Limited Tc,PX7685701,CDM,402,RC,76857,CPT,TC,,,,,,,300,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Guide Needle Bx S&I,PX7694201,CDM,402,RC,76942,CPT,TC,,,,,,,747,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Guide Needle Bx S&I,PX7694226,CDM,982,RC,76942,CPT,26,,,,,,,148,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"US Guide, Vascular Access",PX7693701,CDM,402,RC,76937,CPT,TC,,,,,,,760,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Head/Neck Tc,PX7653601,CDM,402,RC,76536,CPT,TC,,,,,,,416,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Kidney Transplt Untrsd,PX7677601,CDM,402,RC,76776,CPT,TC,,,,,,,554,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Pelvic Tc Complete,PX7685601,CDM,402,RC,76856,CPT,TC,,,,,,,472,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Pregnancy Tc Follow-Up,PX7681601,CDM,402,RC,76816,CPT,TC,,,,,,,362,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Pregnancy Tc Limited,PX7681501,CDM,402,RC,76815,CPT,TC,,,,,,,438,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Renal Retroperit Ltd,PX7677501,CDM,402,RC,76775,CPT,TC,,,,,,,566,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Retroperitoneal Tc,PX7677001,CDM,402,RC,76770,CPT,TC,,,,,,,566,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Scrotum & Contents Tc,PX7687001,CDM,402,RC,76870,CPT,TC,,,,,,,457,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Transvaginal Tc,PX7683001,CDM,402,RC,76830,CPT,TC,,,,,,,472,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Urine Capacity Measure,PX51798F,CDM,510,RC,51798,CPT,,,,,,,,96,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"US,Preg. Uterus,Fetal/Mat.Eval.,>1st Trim.(>/= 14 Wks 0 Dys),Transabd;Single/First Gest., Tech",PX7680501,CDM,402,RC,76805,CPT,TC,,,,,,,562,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ustekinumab 130 MG/26ML Solution 26 mL Vial,J3358.01,CDM,636,RC,J3358,HCPCS,,,,57894005427,NDC,26,ML,4130,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
VACUUM KIWI W/PALM PUMP,120.225,CDM,272,RC,,,,10028-MAIN,LOCAL,,,,,120,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
VAGINAL PACKING 2',120.292,CDM,272,RC,,,,829-MAIN,LOCAL,,,,,32.23,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
valACYclovir 1 GM Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069701,NDC,0.5,EA,33.58,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
valACYclovir 1 GM Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862044930,NDC,0.5,EA,33.23,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
valACYclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,16714069801,NDC,1,EA,38.55,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
valACYclovir 500 MG Tablet 30 Each Bottle,63700001,CDM,250,RC,,,,,,31722070430,NDC,1,EA,38.79,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
valproate 100 MG/ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049416,NDC,5,ML,33.61,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
valproate 100 MG/ML Solution 5 mL Vial,25000000,CDM,250,RC,,,,,,63323049441,NDC,5,ML,33.61,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
valsartan 160 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,33342006410,NDC,0.25,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028401,NDC,1,EA,111.01,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028420,NDC,1,EA,111.01,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028426,NDC,1,EA,42.15,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323028442,NDC,1,EA,47.71,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034000,NDC,1,EA,111.82,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457034001,NDC,1,EA,111.81,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010520,NDC,1,EA,68.33,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,70860010541,NDC,1,EA,68.33,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076501,NDC,1,EA,58.6,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 1 g Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,72611076510,NDC,1,EA,58.6,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 125 MG capsule 1 Each Blister,63700001,CDM,250,RC,,,,,,68180016611,NDC,1,EA,149.33,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 125 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,47781072902,NDC,1,EA,149.33,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 125 MG capsule 20 Each Box,63700001,CDM,250,RC,,,,,,62559039020,NDC,1,EA,149.33,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,47781059807,NDC,1,EA,39.84,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022116,NDC,1,EA,36.33,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022141,NDC,1,EA,36.33,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,63323022143,NDC,1,EA,36.31,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vancomycin 500 MG Recon Soln 1 Each Vial,J3370.01,CDM,636,RC,J3370,HCPCS,,,,67457033900,NDC,1,EA,71.82,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Varicella-Zoster Antibody,PX86787,CDM,300,RC,86787,CPT,,,,,,,,95,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016401,NDC,1,ML,854.49,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016410,NDC,1,ML,917.08,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vasopressin 20 UNIT/ML Solution 1 mL Vial,J2598.01,CDM,636,RC,J2598,HCPCS,,,,42023016425,NDC,1,ML,779.43,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,409163221,NDC,0.5,EA,43.65,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,703291401,NDC,0.5,EA,40.3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,47335093140,NDC,0.5,EA,44.33,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,47335093144,NDC,0.5,EA,44.33,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,55150023501,NDC,0.5,EA,37.72,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078110,NDC,0.5,EA,38.33,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078121,NDC,0.5,EA,36.75,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,63323078141,NDC,0.5,EA,36.75,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,67457043800,NDC,0.5,EA,36.11,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vecuronium 10 MG Recon Soln 1 Each Vial,25000000,CDM,250,RC,,,,,,67457043810,NDC,0.5,EA,36.11,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Vedolizumab - Ref,PX8028090,CDM,300,RC,80280,CPT,90,,,,,,,468,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vedolizumab 300 MG Recon Soln 1 Each Vial,J3380.01,CDM,636,RC,J3380,HCPCS,,,,64764030020,NDC,1,EA,12439.04,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ven Duplex Bilateral,PX9397001,CDM,921,RC,93970,CPT,TC,,,,,,,1189,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venetoclax 100 MG Tablet 1 Each Box,25000000,CDM,250,RC,,,,,,74057611,NDC,0.2,EA,90.87,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipunc Need Phys Skill,Dx or Rx",PX36410,CDM,983,RC,36410,CPT,,,,,,,,132,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipunc Need Phys Skill,Dx or Rx",PX36410F,CDM,510,RC,36410,CPT,,,,,,,,34,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipunc Need Phys Skill,Dx or Rx",PX36410P,CDM,983,RC,36410,CPT,,,,,,,,129,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipuncture by Physician, Other Vein, Under Age 3 Years",PX36406,CDM,983,RC,36406,CPT,,,,,,,,45,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405F,CDM,510,RC,36405,CPT,,,,,,,,54,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405P,CDM,983,RC,36405,CPT,,,,,,,,36,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipuncture, Lab",PX3641502,CDM,300,RC,36415,CPT,,,,,,,,61,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 25 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084089695,NDC,1,EA,11.1,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 25 MG Tablet 90 Each Bottle,63700001,CDM,250,RC,,,,,,57237017290,NDC,1,EA,10.43,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714031101,NDC,1,EA,10.43,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 25 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57664039288,NDC,1,EA,10.43,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 37.5 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084069811,NDC,1,EA,20.09,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 37.5 MG Capsule Extended Release 24 Hour 100 Each Box,63700001,CDM,250,RC,,,,,,68084069801,NDC,1,EA,20.09,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714031401,NDC,0.333333333,EA,3.91,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,16714065801,NDC,0.333333333,EA,3.91,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 75 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,57664039588,NDC,0.333333333,EA,3.91,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 150 MG Capsule Extended Release 24 Hour 1 Each Blister,63700001,CDM,250,RC,,,,,,68084071311,NDC,0.25,EA,6.14,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
venlafaxine 150 MG Capsule Extended Release 24 Hour 30 Each Bottle,63700001,CDM,250,RC,,,,,,65862069730,NDC,0.25,EA,6.82,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Venous Duplex Scan Uni,PX9397101,CDM,921,RC,93971,CPT,TC,,,,,,,809,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ventilator Mgmt.Subsequent Days,PX94003F,CDM,410,RC,94003,CPT,,,,,,,,1686,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"VENTRALIGHT MESH ST WITH ECHO 2 - 10 CM X 15 CM - 4"" X 6""",C1781,CDM,278,RC,C1781,HCPCS,,12007-MAIN,LOCAL,,,,,1176,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"VENTRALIGHT MESH ST WITH ECHO 2 - 15 CM X 20 CM 6"" X 8""",C1781,CDM,278,RC,C1781,HCPCS,,12008-MAIN,LOCAL,,,,,3518,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"VENTRALIGHT MESH ST WITH ECHO 2 - 20 CM X 25 CM 8"" X 10""",C1781,CDM,278,RC,C1781,HCPCS,,12009-MAIN,LOCAL,,,,,5589,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING 8 IN CIRCLE,C1781,CDM,278,RC,C1781,HCPCS,,12506-MAIN,LOCAL,,,,,3240,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING 8X10 ELLIPSE,C1781,CDM,278,RC,C1781,HCPCS,,12504-MAIN,LOCAL,,,,,5915,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
VENTRALIGHT ST MESH WITH ECHO PS POSITIONING4X6,C1781,CDM,278,RC,C1781,HCPCS,,12505-MAIN,LOCAL,,,,,1860,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
verapamil 2.5 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,409114405,NDC,2,ML,185.65,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
verapamil 2.5 MG/ML Solution 2 mL Vial,25000000,CDM,250,RC,,,,,,51754020401,NDC,1,ML,112.01,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
verapamil CR 120 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462029201,NDC,1,EA,5.76,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
verapamil CR 180 MG Tablet Extended Release 100 Each Bottle,25000000,CDM,250,RC,,,,,,75834015801,NDC,0.666666667,EA,5.16,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
verapamil CR 240 MG Tablet Extended Release 100 Each Bottle,63700001,CDM,250,RC,,,,,,68462026001,NDC,0.5,EA,4.39,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vinCRIStine 1 MG/ML Solution 2 mL Vial,J9370.01,CDM,636,RC,J9370,HCPCS,,,,61703030916,NDC,2,ML,48.72,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Viral Neutralization - Ref,PX8638290,CDM,300,RC,86382,CPT,90,,,,,,,28,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
VISIGI3D 40FR STD WITH BULB,27100000,CDM,271,RC,,,,12812-MAIN,LOCAL,,,,,439,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
VISUALIZATION SYSTEM CLEARIFY LAPAROSCOPE STERILE,27200000,CDM,272,RC,,,,11875-MAIN,LOCAL,,,,,78,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Vit D 1 25-Dihydroxy,PX82652,CDM,300,RC,82652,CPT,,,,,,,,154,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Vitamin a - Ref,PX8459090,CDM,300,RC,84590,CPT,90,,,,,,,63,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Vitamin B-1 - Ref,PX8442590,CDM,300,RC,84425,CPT,90,,,,,,,130,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Vitamin B-12,PX82607,CDM,300,RC,82607,CPT,,,,,,,,122,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,536333401,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,904582461,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,10006070033,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
vitamin D (cholecalciferol) 25 mcg (1000 Units) Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,20555003300,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Vitamin D, 25 Hydroxy",PX82306,CDM,300,RC,82306,CPT,,,,,,,,235,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,50111099001,NDC,1,EA,9.05,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,51991060401,NDC,1,EA,10.59,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,64380073706,NDC,1,EA,10.59,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"vitamin D2 (ergocalciferol) 1250 mcg (50,000 units) capsule 100 Each Bottle",63700001,CDM,250,RC,,,,,,69452015120,NDC,1,EA,3.86,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Voriconazole - Ref,PX8028590,CDM,300,RC,80285,CPT,90,,,,,,,183,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 1 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56016901,NDC,1,EA,12.89,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 2 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56017001,NDC,1,EA,13.43,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 2 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121201,NDC,0.5,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 2.5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56017601,NDC,1,EA,13.85,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 2.5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121301,NDC,0.4,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 3 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,56018875,NDC,0.333333333,EA,4.79,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 3 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121401,NDC,0.333333333,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 4 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,56016801,NDC,1,EA,13.91,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 4 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,56016875,NDC,0.25,EA,3.6,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,832121689,NDC,0.2,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
warfarin 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,832121601,NDC,0.2,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"West Nile Ab, Igg - Ref",PX8678990,CDM,300,RC,86789,CPT,90,,,,,,,248,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"West Nile Ab, Igm - Ref",PX8678890,CDM,300,RC,86788,CPT,90,,,,,,,109,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Western Equine, Ab - Ref",PX8665490,CDM,300,RC,86654,CPT,90,,,,,,,45,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Wheelchair Mngement Training,PX97542,CDM,420,RC,97542,CPT,,,,,,,,145,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
white petrolatum Gel 52.5 g Jar,63700001,CDM,250,RC,,,,,,521231100,NDC,52.5,GR,13.5,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Withdrawal of Arterial Blood,PX36600F,CDM,510,RC,36600,CPT,,,,,,,,250,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Wound Cult/Afb,PX87116,CDM,300,RC,87116,CPT,,,,,,,,167,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Wound Culture Anaerobic,PX87075,CDM,300,RC,87075,CPT,,,,,,,,270,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
WOUND DRAIN FLAT WITH TROCAR 10MM FULL PERFORATED SILICONE,27200000,CDM,272,RC,,,,12462-MAIN,LOCAL,,,,,32,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Abdomen 2+ Views W/ Single Vw Chest (Tc),PX7402201,CDM,320,RC,74022,CPT,TC,,,,,,,334,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Abdomen 1 View,PX7401801,CDM,320,RC,74018,CPT,TC,,,,,,,358,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Abdomen 2 Views,PX7401901,CDM,320,RC,74019,CPT,TC,,,,,,,436,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Chest 1 View,PX7104501,CDM,320,RC,71045,CPT,TC,,,,,,,357,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Chest 2 Views,PX7104601,CDM,320,RC,71046,CPT,TC,,,,,,,556,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Chest 3 Views,PX7104701,CDM,320,RC,71047,CPT,TC,,,,,,,340,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Entire Spine 1vw,PX7208101,CDM,320,RC,72081,CPT,TC,,,,,,,414,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Entire Spine 2-3 Vws,PX7208201,CDM,320,RC,72082,CPT,TC,,,,,,,454,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Femur 1 Vw,PX7355101,CDM,320,RC,73551,CPT,TC,,,,,,,142,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
X-Ray Exam Femur Min 2 Vws,PX7355201,CDM,320,RC,73552,CPT,TC,,,,,,,365,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"X-Ray Exam Hip,Bilat W/Pelvis 2 Vws",PX7352101,CDM,320,RC,73521,CPT,TC,,,,,,,399,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"X-Ray Exam Hip,Bilat W/Pelvis 3-4 Vws",PX7352201,CDM,320,RC,73522,CPT,TC,,,,,,,382,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"X-Ray Exam Hip,Unilat W/Pelvis 1vw",PX7350101,CDM,320,RC,73501,CPT,TC,,,,,,,263,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"X-Ray Exam Hip,Unilat W/Pelvis 2-3 Vws",PX7350201,CDM,320,RC,73502,CPT,TC,,,,,,,436,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
XEROFORM GAUZE PETROLATUM 1X8INCH,27200000,CDM,272,RC,A6222,HCPCS,,10659-MAIN,LOCAL,,,,,3.52,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Abdomen Comp Incl Decub and/or Erect,PX7402001,CDM,320,RC,74020,CPT,TC,,,,,,,436,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Abdomen Single Ap Vw,PX7400001,CDM,320,RC,74000,CPT,TC,,,,,,,358,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ac Joints(Bilateral),PX7305001,CDM,320,RC,73050,CPT,TC,,,,,,,519,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ankle 2 Vws,PX7360001,CDM,320,RC,73600,CPT,TC,,,,,,,163,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ankle Minimum 3 Vws,PX7361001,CDM,320,RC,73610,CPT,TC,,,,,,,365,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Calcaneus Minimum 2 Vws,PX7365001,CDM,320,RC,73650,CPT,TC,,,,,,,365,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Cervical Spine 2 or 3 Vws,PX7204001,CDM,320,RC,72040,CPT,TC,,,,,,,436,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Cervical Spine 4 or 5 Vws,PX7205001,CDM,320,RC,72050,CPT,TC,,,,,,,664,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Cervical Spine 6 or More Vws,PX7205201,CDM,320,RC,72052,CPT,TC,,,,,,,664,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Xray Chest 1 View, Tc",PX7101001,CDM,320,RC,71010,CPT,TC,,,,,,,357,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Chest 2 Views,PX7102001,CDM,320,RC,71020,CPT,TC,,,,,,,556,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Clavicle Complete,PX7300001,CDM,320,RC,73000,CPT,TC,,,,,,,365,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Elbow 2 Vws,PX7307001,CDM,320,RC,73070,CPT,TC,,,,,,,365,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Elbow 3+Vws Tc,PX7308001,CDM,320,RC,73080,CPT,TC,,,,,,,370,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Eye Foreign Body,PX7003001,CDM,320,RC,70030,CPT,TC,,,,,,,432,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Facial Bones Less Than 3 Vws,PX7014001,CDM,320,RC,70140,CPT,TC,,,,,,,301,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Facial Bones Minimum 3 Vws,PX7015001,CDM,320,RC,70150,CPT,TC,,,,,,,551,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Finger(S) Tc,PX7314001,CDM,320,RC,73140,CPT,TC,,,,,,,282,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Foot 2 Vws,PX7362001,CDM,320,RC,73620,CPT,TC,,,,,,,367,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Foot Minimum 3 Vws,PX7363001,CDM,320,RC,73630,CPT,TC,,,,,,,404,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Forearm 2 Vws,PX7309001,CDM,320,RC,73090,CPT,TC,,,,,,,364,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Hand 2vws Tc,PX7312001,CDM,320,RC,73120,CPT,TC,,,,,,,365,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Hand 3vws Tc,PX7313001,CDM,320,RC,73130,CPT,TC,,,,,,,374,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Humerus Minimum 2 Vws,PX7306001,CDM,320,RC,73060,CPT,TC,,,,,,,365,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Knee (Both) Ap Stand,PX7356501,CDM,320,RC,73565,CPT,TC,,,,,,,543,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Knee 1 or 2 Vws,PX7356001,CDM,320,RC,73560,CPT,TC,,,,,,,303,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Knee 3 Vws,PX7356201,CDM,320,RC,73562,CPT,TC,,,,,,,404,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Knee 4 or More Vws,PX7356401,CDM,320,RC,73564,CPT,TC,,,,,,,490,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ls Spine Bend Tc,PX7212001,CDM,320,RC,72120,CPT,TC,,,,,,,323,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Lumbosacral 2 or 3 Vws,PX7210001,CDM,320,RC,72100,CPT,TC,,,,,,,399,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Lumbosacral Minimum 4 Vws,PX7211001,CDM,320,RC,72110,CPT,TC,,,,,,,565,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Xray Mandible Compl, Min 4 Vws",PX7011001,CDM,320,RC,70110,CPT,TC,,,,,,,381,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Mandible Partial Less Than 4 Vws,PX7010001,CDM,320,RC,70100,CPT,TC,,,,,,,347,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Nasal Bones Minimum 3 Vws,PX7016001,CDM,320,RC,70160,CPT,TC,,,,,,,456,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Xray Neck, Soft Tissue",PX7036001,CDM,320,RC,70360,CPT,TC,,,,,,,277,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Orbits Optic Foramina,PX7019001,CDM,320,RC,70190,CPT,TC,,,,,,,66,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Pelvis 1 or 2 Vws,PX7217001,CDM,320,RC,72170,CPT,TC,,,,,,,279,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Pelvis Compl 3+ Tc,PX7219001,CDM,320,RC,72190,CPT,TC,,,,,,,563,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ribs Bil 3vws Tc,PX7111001,CDM,320,RC,71110,CPT,TC,,,,,,,533,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ribs Bilat 3 Vws With Pa Chest,PX7111101,CDM,320,RC,71111,CPT,TC,,,,,,,417,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ribs Unilat 2 Vws,PX7110001,CDM,320,RC,71100,CPT,TC,,,,,,,437,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Ribs Unilat 2 Vws With Pa Chest,PX7110101,CDM,320,RC,71101,CPT,TC,,,,,,,792,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Sacroiliac Jnts 3 or More Vws,PX7220201,CDM,320,RC,72202,CPT,TC,,,,,,,285,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Sacroiliac Jnts Less Than 3 Vws,PX7220001,CDM,320,RC,72200,CPT,TC,,,,,,,555,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Sacrum/ Coccyx Minimum 2 Vws,PX7222001,CDM,320,RC,72220,CPT,TC,,,,,,,540,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Scapula Complete,PX7301001,CDM,320,RC,73010,CPT,TC,,,,,,,357,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Shoulder 1 Vw,PX7302001,CDM,320,RC,73020,CPT,TC,,,,,,,267,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Shoulder Minimum 2 Vws,PX7303001,CDM,320,RC,73030,CPT,TC,,,,,,,365,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Sinuses Less Than 3 Vws,PX7021001,CDM,320,RC,70210,CPT,TC,,,,,,,486,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Sinuses Minimum 3 Vws,PX7022001,CDM,320,RC,70220,CPT,TC,,,,,,,354,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Skull Less Than 4 Vws,PX7025001,CDM,320,RC,70250,CPT,TC,,,,,,,311,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Spine Single Tc,PX7202001,CDM,320,RC,72020,CPT,TC,,,,,,,113,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Sternum 2vws Tc,PX7112001,CDM,320,RC,71120,CPT,TC,,,,,,,365,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Temporomandib Jnt Unilat,PX7032801,CDM,320,RC,70328,CPT,TC,,,,,,,385,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Thoracic Spine 2 Vws,PX7207001,CDM,320,RC,72070,CPT,TC,,,,,,,428,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Thoracic Spine 3 Vws,PX7207201,CDM,320,RC,72072,CPT,TC,,,,,,,522,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Thoracolumbar 2 Vws,PX7208001,CDM,320,RC,72080,CPT,TC,,,,,,,306,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Tibia & Fibula 2 Vws,PX7359001,CDM,320,RC,73590,CPT,TC,,,,,,,365,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Toe(S) Tc,PX7366001,CDM,320,RC,73660,CPT,TC,,,,,,,282,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Wrist 2 Vws,PX7310001,CDM,320,RC,73100,CPT,TC,,,,,,,365,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Xray Wrist Minimum 3 Vws,PX7311001,CDM,320,RC,73110,CPT,TC,,,,,,,375,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zinc gluconate 50 MG Tablet 100 Each Bottle,63700001,CDM,250,RC,,,,,,40093010153,NDC,1,EA,3,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zinc oxide 20 % Ointment 56.7 g Tube,63700001,CDM,250,RC,,,,,,168006202,NDC,56.7,GR,30.39,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zinc oxide 20 % Ointment 60 g Tube,63700001,CDM,250,RC,,,,,,536131625,NDC,60,GR,22.97,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006111,NDC,0.5,EA,56.98,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ziprasidone 20 MG Recon Soln 1 Each Vial,J3486.01,CDM,636,RC,J3486,HCPCS,,,,43598006158,NDC,0.5,EA,56.98,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
ziprasidone 80 MG capsule 60 Each Bottle,63700001,CDM,250,RC,,,,,,781216860,NDC,0.25,EA,14.44,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409421505,NDC,5,ML,271.86,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,16714081501,NDC,5,ML,998.95,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021080166,NDC,5,ML,820.8,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 4 MG/5ML Concentrate 5 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,60505611000,NDC,5,ML,1644.33,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 5 MG/100ML Solution 100 mL Bottle,J3489.01,CDM,636,RC,J3489,HCPCS,,,,55111068852,NDC,100,ML,1368,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,409422801,NDC,100,ML,1026,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 5 MG/100ML Solution 100 mL Flex Cont,J3489.01,CDM,636,RC,J3489,HCPCS,,,,25021083082,NDC,100,ML,1596,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,63323096600,NDC,100,ML,1368,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zoledronic acid 5 MG/100ML Solution 100 mL Vial,J3489.01,CDM,636,RC,J3489,HCPCS,,,,67457061910,NDC,100,ML,1707.48,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zolpidem 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,51079072401,NDC,1,EA,24.81,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zolpidem 5 MG Tablet 1 Each Blister,63700001,CDM,250,RC,,,,,,68084018911,NDC,1,EA,9.43,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zolpidem 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,51079072420,NDC,1,EA,24.81,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
zolpidem 5 MG Tablet 100 Each Box,63700001,CDM,250,RC,,,,,,68084018901,NDC,1,EA,9.43,,UCare,UCare Individual & Family Plans,inpatient,,,999999999,per diem,6141.46,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
RESTRATA WOUND MATRIX 7.5CM X 7.5CM TOTAL 56.25CM,27200000,CDM,272,RC,A2007,HCPCS,,11737-MAIN,LOCAL,,,,,6311,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,6142.4963,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
vedolizumab 300 MG Recon Soln 1 Each Vial,J3380.01,CDM,636,RC,J3380,HCPCS,,,,64764030020,NDC,1,EA,12439.04,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6157.3248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.66,12190.2592
AMNION MATRIX CORD STERILE 3X6,27200000,CDM,272,RC,C1762,HCPCS,,11625-MAIN,LOCAL,,,,,6919,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,6157.91,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
REVITA PLACENTAL MEMBRANE 6X6CM 36SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12562-MAIN,LOCAL,,,,,14844,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,6166.1976,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
RESTRATA WOUND MATRIX 7.5CM X 7.5CM TOTAL 56.25CM,27200000,CDM,272,RC,A2007,HCPCS,,11737-MAIN,LOCAL,,,,,6311,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,6184.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
RomiPLOStim 500 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022201,NDC,1,EA,7018.25,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,6190.0965,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.04,6877.885
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74334603,NDC,1,EA,12509.82,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6192.3609,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
mepolizumab 100 MG Recon Soln 1 Each Vial,J2182.01,CDM,636,RC,J2182,HCPCS,,,,173088101,NDC,1,EA,6959.95,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,6194.3555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.51,6820.751
pegfilgrastim 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019001,NDC,0.6,ML,12711.36,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6228.5664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.46,12830.846
pegfilgrastim 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019001,NDC,0.6,ML,12711.36,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6228.5664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.46,12830.846
pegfilgrastim 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019001,NDC,0.6,ML,12711.36,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6228.5664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.46,12830.846
ramuCIRumab 500 MG/50ML Solution 50 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2767801,NDC,50,ML,12316.5,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6232.149,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.57,12070.17
RomiPLOStim 500 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022201,NDC,1,EA,7018.25,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,6246.2425,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.04,6877.885
nivolumab 240 MG/24ML Solution 24 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3373413,NDC,24,ML,13030.26,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6254.5248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.5,12769.6548
nivolumab 240 MG/24ML Solution 24 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3373413,NDC,24,ML,13030.26,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6254.5248,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.5,12769.6548
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218713,NDC,2,EA,6875.36,,Medica,Commercial,both,91.1,,20.488,percent of total billed charges,6263.45296,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.57,6737.8528
pegfilgrastim 6 MG/0.6ML Prefilled Syringe Kit 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019201,NDC,0.6,ML,13092.7,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6284.496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.46,12830.846
pegfilgrastim 6 MG/0.6ML Prefilled Syringe Kit 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019201,NDC,0.6,ML,13092.7,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6284.496,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.46,12830.846
Appl on-Body Injector for Timed Subq Injection,PX96377,CDM,260,RC,96377,CPT,,,,,,,,13093,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,6284.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,12831.14
Appl on-Body Injector for Timed Subq Injection,PX96377,CDM,260,RC,96377,CPT,,,,,,,,13093,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,6284.64,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,12831.14
pegfilgrastim 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019001,NDC,0.6,ML,12711.36,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6292.1232,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.46,12830.846
vedolizumab 300 MG Recon Soln 1 Each Vial,J3380.01,CDM,636,RC,J3380,HCPCS,,,,64764030020,NDC,1,EA,12439.04,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6294.15424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.66,12190.2592
AMNION MATRIX CORD STERILE 3X6,27200000,CDM,272,RC,C1762,HCPCS,,11625-MAIN,LOCAL,,,,,6919,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,6303.209,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
natalizumab 300 MG/15ML Concentrate 15 mL Vial,J2323.01,CDM,636,RC,J2323,HCPCS,,,,64406000801,NDC,15,ML,15226.53,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,6325.100562,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.42,14921.9994
Level 6 Additional Procedure,PX36000085,CDM,360,RC,,,,,,,,,,6500,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,6326.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2700.1,6370
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74334603,NDC,1,EA,12509.82,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6329.96892,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
mepolizumab 100 MG Recon Soln 1 Each Vial,J2182.01,CDM,636,RC,J2182,HCPCS,,,,173088101,NDC,1,EA,6959.95,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,6340.51445,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.51,6820.751
REVITA PLACENTAL MEMBRANE 6X6CM 36SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12562-MAIN,LOCAL,,,,,14844,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,6368.076,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
Level 6 Additional Procedure,PX36000085,CDM,360,RC,,,,,,,,,,6500,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,6370,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2700.1,6370
nivolumab 240 MG/24ML Solution 24 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3373413,NDC,24,ML,13030.26,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6384.8274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.5,12769.6548
nivolumab 240 MG/24ML Solution 24 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3373413,NDC,24,ML,13030.26,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6384.8274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.5,12769.6548
nivolumab 240 MG/24ML Solution 24 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3373413,NDC,24,ML,13030.26,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6384.8274,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.5,12769.6548
PURAPLYAM XT-COM 4.91X4.91 EXTRA FENESTRATED 24.10 SQCM,120.567,CDM,272,RC,Q4197,HCPCS,,12806-MAIN,LOCAL,,,,,6562,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,6386.7946,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2725.8548,6430.76
RomiPLOStim 500 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022201,NDC,1,EA,7018.25,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,6393.62575,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.04,6877.885
pegfilgrastim 6 MG/0.6ML Prefilled Syringe Kit 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019201,NDC,0.6,ML,13092.7,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6415.423,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.46,12830.846
pegfilgrastim 6 MG/0.6ML Prefilled Syringe Kit 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019201,NDC,0.6,ML,13092.7,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6415.423,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.46,12830.846
pegfilgrastim 6 MG/0.6ML Prefilled Syringe Kit 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019201,NDC,0.6,ML,13092.7,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6415.423,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.46,12830.846
Appl on-Body Injector for Timed Subq Injection,PX96377,CDM,260,RC,96377,CPT,,,,,,,,13093,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6415.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,12831.14
Appl on-Body Injector for Timed Subq Injection,PX96377,CDM,260,RC,96377,CPT,,,,,,,,13093,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,6415.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,12831.14
Appl on-Body Injector for Timed Subq Injection,PX96377,CDM,260,RC,96377,CPT,,,,,,,,13093,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,6415.57,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,12831.14
REVITA PLACENTAL MEMBRANE 4X4CM 16SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12560-MAIN,LOCAL,,,,,6597,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,6420.8601,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
PURAPLYAM XT-COM 4.91X4.91 EXTRA FENESTRATED 24.10 SQCM,120.567,CDM,272,RC,Q4197,HCPCS,,12806-MAIN,LOCAL,,,,,6562,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,6430.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2725.8548,6430.76
pegfilgrastim 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019001,NDC,0.6,ML,12711.36,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6431.94816,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.46,12830.846
nivolumab 240 MG/24ML Solution 24 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3373413,NDC,24,ML,13030.26,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6449.9787,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.5,12769.6548
durvalumab 500 MG/10ML Solution 10 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310461150,NDC,10,ML,7588.77,,First Health,Commercial,both,85,,999999999,percent of total billed charges,6450.4545,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.48,21336.462
REVITA PLACENTAL MEMBRANE 4X4CM 16SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12560-MAIN,LOCAL,,,,,6597,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,6465.06,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
pegfilgrastim 6 MG/0.6ML Prefilled Syringe Kit 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019201,NDC,0.6,ML,13092.7,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6480.8865,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.46,12830.846
Appl on-Body Injector for Timed Subq Injection,PX96377,CDM,260,RC,96377,CPT,,,,,,,,13093,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,6481.035,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,12831.14
natalizumab 300 MG/15ML Concentrate 15 mL Vial,J2323.01,CDM,636,RC,J2323,HCPCS,,,,64406000801,NDC,15,ML,15226.53,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,6532.18137,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.42,14921.9994
"Lap,Esophagogast Fundoplasty",PX43280F,CDM,510,RC,43280,CPT,,,,,,,,6713,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,6533.7629,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2788.5802,8992.74
"Lap,Esophagogast Fundoplasty",PX43280F,CDM,510,RC,43280,CPT,,,,,,,,6713,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,6578.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2788.5802,8992.74
bezlotoxumab 1000 MG/40ML Solution 40 mL Vial,J0565.01,CDM,636,RC,J0565,HCPCS,,,,6302500,NDC,40,ML,7752,,First Health,Commercial,both,85,,999999999,percent of total billed charges,6589.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.7,7596.96
nivolumab 240 MG/24ML Solution 24 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3373413,NDC,24,ML,13030.26,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6593.31156,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.5,12769.6548
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012001,NDC,0.6,EA,7764.12,,First Health,Commercial,both,85,,999999999,percent of total billed charges,6599.502,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.39,10431.7962
pegfilgrastim 6 MG/0.6ML Prefilled Syringe Kit 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019201,NDC,0.6,ML,13092.7,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6624.9062,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.46,12830.846
Appl on-Body Injector for Timed Subq Injection,PX96377,CDM,260,RC,96377,CPT,,,,,,,,13093,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,6625.058,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,12831.14
PHASIX 25X30CM 1190400,C1781,CDM,278,RC,C1781,HCPCS,,13011-MAIN,LOCAL,,,,,16080,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,6679.632,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218713,NDC,2,EA,6875.36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,19.47136471,percent of total billed charges,6691.787888,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.57,6737.8528
durvalumab 500 MG/10ML Solution 10 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310461150,NDC,10,ML,7588.77,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,6693.29514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.48,21336.462
isatuximab-irfc 500 MG/25ML Solution 25 mL Vial,J9227.01,CDM,636,RC,J9227,HCPCS,,,,24065601,NDC,25,ML,7876.36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,6694.906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.13,7718.8328
AMNION MATRIX CORD STERILE 3X6,27200000,CDM,272,RC,C1762,HCPCS,,11625-MAIN,LOCAL,,,,,6919,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,6734.2627,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
abatacept 250 MG Recon Soln 1 Each Vial,J0129.01,CDM,636,RC,J0129,HCPCS,,,,3218713,NDC,2,EA,6875.36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,6737.8528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.57,6737.8528
durvalumab 500 MG/10ML Solution 10 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310461150,NDC,10,ML,7588.77,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,6754.0053,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.48,21336.462
Or Level 6,PX36000006,CDM,360,RC,,,,,,,,,,7960,,First Health,Commercial,both,85,,999999999,percent of total billed charges,6766,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3306.584,7800.8
mepolizumab 100 MG Recon Soln 1 Each Vial,J2182.01,CDM,636,RC,J2182,HCPCS,,,,173088101,NDC,1,EA,6959.95,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,6774.119335,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.51,6820.751
AMNION MATRIX CORD STERILE 3X6,27200000,CDM,272,RC,C1762,HCPCS,,11625-MAIN,LOCAL,,,,,6919,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,6780.62,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
prothrombin complex concentrate - human 500 units Kit 500 Units Box,J7168.01,CDM,636,RC,J7168,HCPCS,,,,63833038602,NDC,1500,UN,8007,,First Health,Commercial,both,85,,999999999,percent of total billed charges,6805.95,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.4,7846.86
BMWD 2X2,27200000,CDM,272,RC,Q4104,HCPCS,,12134-MAIN,LOCAL,,,,,8016,,First Health,Commercial,both,85,,999999999,percent of total billed charges,6813.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
mepolizumab 100 MG Recon Soln 1 Each Vial,J2182.01,CDM,636,RC,J2182,HCPCS,,,,173088101,NDC,1,EA,6959.95,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,6820.751,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.51,6820.751
RomiPLOStim 500 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022201,NDC,1,EA,7018.25,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,6830.862725,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.04,6877.885
bezlotoxumab 1000 MG/40ML Solution 40 mL Vial,J0565.01,CDM,636,RC,J0565,HCPCS,,,,6302500,NDC,40,ML,7752,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,6837.264,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.7,7596.96
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012001,NDC,0.6,EA,7764.12,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,6847.95384,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.39,10431.7962
rabies immune globulin 1500 UNIT/5ML Solution 5 mL Vial,90375,CDM,636,RC,90375,CPT,,,,13533031805,NDC,5,ML,8065.26,,First Health,Commercial,both,85,,999999999,percent of total billed charges,6855.471,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,281.51,7903.9548
PEMEtrexed 500 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2762301,NDC,1,EA,8086.02,,First Health,Commercial,both,85,,999999999,percent of total billed charges,6873.117,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.01,7924.2996
RomiPLOStim 500 MCG Recon Soln 1 Each Vial,J2796.01,CDM,636,RC,J2796,HCPCS,,,,55513022201,NDC,1,EA,7018.25,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,6877.885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.04,6877.885
"Correct Bunion,Metatarsal Osteotomy",PX28296F,CDM,510,RC,28296,CPT,,,,,,,,8100,,First Health,Commercial,both,85,,999999999,percent of total billed charges,6885,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2827.75,7938
PHASIX 25X30CM 1190400,C1781,CDM,278,RC,C1781,HCPCS,,13011-MAIN,LOCAL,,,,,16080,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,6898.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
bezlotoxumab 1000 MG/40ML Solution 40 mL Vial,J0565.01,CDM,636,RC,J0565,HCPCS,,,,6302500,NDC,40,ML,7752,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,6899.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.7,7596.96
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012001,NDC,0.6,EA,7764.12,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,6910.0668,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.39,10431.7962
durvalumab 500 MG/10ML Solution 10 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310461150,NDC,10,ML,7588.77,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,6913.36947,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.48,21336.462
isatuximab-irfc 500 MG/25ML Solution 25 mL Vial,J9227.01,CDM,636,RC,J9227,HCPCS,,,,24065601,NDC,25,ML,7876.36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,6946.94952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.13,7718.8328
isatuximab-irfc 500 MG/25ML Solution 25 mL Vial,J9227.01,CDM,636,RC,J9227,HCPCS,,,,24065601,NDC,25,ML,7876.36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,7009.9604,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.13,7718.8328
Or Level 6,PX36000006,CDM,360,RC,,,,,,,,,,7960,,United Healthcare,All Payer,outpatient,88.2,,999999999,case rate,7020.72,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,7020.72
bezlotoxumab 1000 MG/40ML Solution 40 mL Vial,J0565.01,CDM,636,RC,J0565,HCPCS,,,,6302500,NDC,40,ML,7752,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,7062.072,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.7,7596.96
prothrombin complex concentrate - human 500 units Kit 500 Units Box,J7168.01,CDM,636,RC,J7168,HCPCS,,,,63833038602,NDC,1500,UN,8007,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,7062.174,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.4,7846.86
BMWD 2X2,27200000,CDM,272,RC,Q4104,HCPCS,,12134-MAIN,LOCAL,,,,,8016,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,7070.112,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012001,NDC,0.6,EA,7764.12,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,7073.11332,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.39,10431.7962
Or Level 6,PX36000006,CDM,360,RC,,,,,,,,,,7960,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,7084.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3306.584,7800.8
rabies immune globulin 1500 UNIT/5ML Solution 5 mL Vial,90375,CDM,636,RC,90375,CPT,,,,13533031805,NDC,5,ML,8065.26,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,7113.55932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,281.51,7903.9548
REVITA PLACENTAL MEMBRANE 6X6CM 36SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12562-MAIN,LOCAL,,,,,14844,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,7125.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
REVITA PLACENTAL MEMBRANE 6X6CM 36SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12562-MAIN,LOCAL,,,,,14844,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,7125.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
prothrombin complex concentrate - human 500 units Kit 500 Units Box,J7168.01,CDM,636,RC,J7168,HCPCS,,,,63833038602,NDC,1500,UN,8007,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,7126.23,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.4,7846.86
PEMEtrexed 500 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2762301,NDC,1,EA,8086.02,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,7131.86964,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.01,7924.2996
BMWD 2X2,27200000,CDM,272,RC,Q4104,HCPCS,,12134-MAIN,LOCAL,,,,,8016,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,7134.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"Correct Bunion,Metatarsal Osteotomy",PX28296F,CDM,510,RC,28296,CPT,,,,,,,,8100,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,7144.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2827.75,7938
RESTRATA WOUND MATRIX 10CM X 12.5CM  TOTAL 125CM,27200000,CDM,272,RC,A2007,HCPCS,,11738-MAIN,LOCAL,,,,,8415,,First Health,Commercial,both,85,,999999999,percent of total billed charges,7152.75,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
isatuximab-irfc 500 MG/25ML Solution 25 mL Vial,J9227.01,CDM,636,RC,J9227,HCPCS,,,,24065601,NDC,25,ML,7876.36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,7175.36396,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.13,7718.8328
rabies immune globulin 1500 UNIT/5ML Solution 5 mL Vial,90375,CDM,636,RC,90375,CPT,,,,13533031805,NDC,5,ML,8065.26,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,7178.0814,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,281.51,7903.9548
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242003706,NDC,0.6,EA,8461.09,,First Health,Commercial,both,85,,999999999,percent of total billed charges,7191.9265,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.39,10431.7962
PEMEtrexed 500 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2762301,NDC,1,EA,8086.02,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,7196.5578,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.01,7924.2996
"Correct Bunion,Metatarsal Osteotomy",PX28296F,CDM,510,RC,28296,CPT,,,,,,,,8100,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,7209,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2827.75,7938
Or Level 6,PX36000006,CDM,360,RC,,,,,,,,,,7960,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,7251.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3306.584,7800.8
REVITA PLACENTAL MEMBRANE 6X6CM 36SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12562-MAIN,LOCAL,,,,,14844,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7273.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
REVITA PLACENTAL MEMBRANE 6X6CM 36SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12562-MAIN,LOCAL,,,,,14844,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7273.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
REVITA PLACENTAL MEMBRANE 6X6CM 36SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12562-MAIN,LOCAL,,,,,14844,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,7273.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
prothrombin complex concentrate - human 500 units Kit 500 Units Box,J7168.01,CDM,636,RC,J7168,HCPCS,,,,63833038602,NDC,1500,UN,8007,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,7294.377,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.4,7846.86
BMWD 2X2,27200000,CDM,272,RC,Q4104,HCPCS,,12134-MAIN,LOCAL,,,,,8016,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,7302.576,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
natalizumab 300 MG/15ML Concentrate 15 mL Vial,J2323.01,CDM,636,RC,J2323,HCPCS,,,,64406000801,NDC,15,ML,15226.53,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,7308.7344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.42,14921.9994
natalizumab 300 MG/15ML Concentrate 15 mL Vial,J2323.01,CDM,636,RC,J2323,HCPCS,,,,64406000801,NDC,15,ML,15226.53,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,7308.7344,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.42,14921.9994
riTUXimab-abbs 500 MG/50ML Solution 50 mL Vial,Q5115.01,CDM,636,RC,Q5115,HCPCS,,,,63459010450,NDC,50,ML,8624.61,,First Health,Commercial,both,85,,999999999,percent of total billed charges,7330.9185,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.29,8452.1178
rabies immune globulin 1500 UNIT/5ML Solution 5 mL Vial,90375,CDM,636,RC,90375,CPT,,,,13533031805,NDC,5,ML,8065.26,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,7347.45186,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,281.51,7903.9548
REVITA PLACENTAL MEMBRANE 6X6CM 36SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12562-MAIN,LOCAL,,,,,14844,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,7347.78,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
PEMEtrexed 500 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2762301,NDC,1,EA,8086.02,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,7366.36422,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.01,7924.2996
"Correct Bunion,Metatarsal Osteotomy",PX28296F,CDM,510,RC,28296,CPT,,,,,,,,8100,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,7379.1,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2827.75,7938
durvalumab 500 MG/10ML Solution 10 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310461150,NDC,10,ML,7588.77,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,7386.149841,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.48,21336.462
RESTRATA WOUND MATRIX 10CM X 12.5CM  TOTAL 125CM,27200000,CDM,272,RC,A2007,HCPCS,,11738-MAIN,LOCAL,,,,,8415,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,7422.03,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
durvalumab 500 MG/10ML Solution 10 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310461150,NDC,10,ML,7588.77,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,7436.9946,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.48,21336.462
natalizumab 300 MG/15ML Concentrate 15 mL Vial,J2323.01,CDM,636,RC,J2323,HCPCS,,,,64406000801,NDC,15,ML,15226.53,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7460.9997,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.42,14921.9994
natalizumab 300 MG/15ML Concentrate 15 mL Vial,J2323.01,CDM,636,RC,J2323,HCPCS,,,,64406000801,NDC,15,ML,15226.53,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7460.9997,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.42,14921.9994
natalizumab 300 MG/15ML Concentrate 15 mL Vial,J2323.01,CDM,636,RC,J2323,HCPCS,,,,64406000801,NDC,15,ML,15226.53,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,7460.9997,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.42,14921.9994
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242003706,NDC,0.6,EA,8461.09,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,7462.68138,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.39,10431.7962
RESTRATA WOUND MATRIX 10CM X 12.5CM  TOTAL 125CM,27200000,CDM,272,RC,A2007,HCPCS,,11738-MAIN,LOCAL,,,,,8415,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,7489.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
REVITA PLACENTAL MEMBRANE 6X6CM 36SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12562-MAIN,LOCAL,,,,,14844,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,7511.064,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242003706,NDC,0.6,EA,8461.09,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,7530.3701,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.39,10431.7962
riTUXimab 500 MG/50ML Solution 50 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005306,NDC,50,ML,8860.06,,First Health,Commercial,both,85,,999999999,percent of total billed charges,7531.051,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.61,8682.8588
natalizumab 300 MG/15ML Concentrate 15 mL Vial,J2323.01,CDM,636,RC,J2323,HCPCS,,,,64406000801,NDC,15,ML,15226.53,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,7537.13235,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.42,14921.9994
bezlotoxumab 1000 MG/40ML Solution 40 mL Vial,J0565.01,CDM,636,RC,J0565,HCPCS,,,,6302500,NDC,40,ML,7752,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,7545.0216,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.7,7596.96
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012001,NDC,0.6,EA,7764.12,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,7556.817996,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.39,10431.7962
bezlotoxumab 1000 MG/40ML Solution 40 mL Vial,J0565.01,CDM,636,RC,J0565,HCPCS,,,,6302500,NDC,40,ML,7752,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,7596.96,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,34.7,7596.96
riTUXimab-abbs 500 MG/50ML Solution 50 mL Vial,Q5115.01,CDM,636,RC,Q5115,HCPCS,,,,63459010450,NDC,50,ML,8624.61,,United Healthcare,All Payer,outpatient,88.2,,91.421,percent of total billed charges,7606.90602,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.29,8452.1178
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012001,NDC,0.6,EA,7764.12,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,7608.8376,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.39,10431.7962
isatuximab-irfc 500 MG/25ML Solution 25 mL Vial,J9227.01,CDM,636,RC,J9227,HCPCS,,,,24065601,NDC,25,ML,7876.36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,7666.061188,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.13,7718.8328
RESTRATA WOUND MATRIX 10CM X 12.5CM  TOTAL 125CM,27200000,CDM,272,RC,A2007,HCPCS,,11738-MAIN,LOCAL,,,,,8415,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,7666.065,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
riTUXimab-abbs 500 MG/50ML Solution 50 mL Vial,Q5115.01,CDM,636,RC,Q5115,HCPCS,,,,63459010450,NDC,50,ML,8624.61,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,7675.9029,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.29,8452.1178
natalizumab 300 MG/15ML Concentrate 15 mL Vial,J2323.01,CDM,636,RC,J2323,HCPCS,,,,64406000801,NDC,15,ML,15226.53,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,7704.62418,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.42,14921.9994
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242003706,NDC,0.6,EA,8461.09,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,7708.05299,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.39,10431.7962
PHASIX 25X30CM 1190400,C1781,CDM,278,RC,C1781,HCPCS,,13011-MAIN,LOCAL,,,,,16080,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,7718.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
PHASIX 25X30CM 1190400,C1781,CDM,278,RC,C1781,HCPCS,,13011-MAIN,LOCAL,,,,,16080,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,7718.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
isatuximab-irfc 500 MG/25ML Solution 25 mL Vial,J9227.01,CDM,636,RC,J9227,HCPCS,,,,24065601,NDC,25,ML,7876.36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,7718.8328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.13,7718.8328
Or Level 6,PX36000006,CDM,360,RC,,,,,,,,,,7960,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,7747.468,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3306.584,7800.8
prothrombin complex concentrate - human 500 units Kit 500 Units Box,J7168.01,CDM,636,RC,J7168,HCPCS,,,,63833038602,NDC,1500,UN,8007,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,7793.2131,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.4,7846.86
Or Level 6,PX36000006,CDM,360,RC,,,,,,,,,,7960,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,7800.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3306.584,7800.8
BMWD 2X2,27200000,CDM,272,RC,Q4104,HCPCS,,12134-MAIN,LOCAL,,,,,8016,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,7801.9728,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
riTUXimab 500 MG/50ML Solution 50 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005306,NDC,50,ML,8860.06,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,7814.57292,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.61,8682.8588
prothrombin complex concentrate - human 500 units Kit 500 Units Box,J7168.01,CDM,636,RC,J7168,HCPCS,,,,63833038602,NDC,1500,UN,8007,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,7846.86,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2.4,7846.86
rabies immune globulin 1500 UNIT/5ML Solution 5 mL Vial,90375,CDM,636,RC,90375,CPT,,,,13533031805,NDC,5,ML,8065.26,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,7849.917558,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,281.51,7903.9548
BMWD 2X2,27200000,CDM,272,RC,Q4104,HCPCS,,12134-MAIN,LOCAL,,,,,8016,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,7855.68,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
riTUXimab-abbs 500 MG/50ML Solution 50 mL Vial,Q5115.01,CDM,636,RC,Q5115,HCPCS,,,,63459010450,NDC,50,ML,8624.61,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,7857.01971,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.29,8452.1178
PEMEtrexed 500 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2762301,NDC,1,EA,8086.02,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,7870.123266,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.01,7924.2996
PHASIX 25X30CM 1190400,C1781,CDM,278,RC,C1781,HCPCS,,13011-MAIN,LOCAL,,,,,16080,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,196.035,percent of total billed charges,7879.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
PHASIX 25X30CM 1190400,C1781,CDM,278,RC,C1781,HCPCS,,13011-MAIN,LOCAL,,,,,16080,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,7879.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
PHASIX 25X30CM 1190400,C1781,CDM,278,RC,C1781,HCPCS,,13011-MAIN,LOCAL,,,,,16080,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,7879.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"Correct Bunion,Metatarsal Osteotomy",PX28296F,CDM,510,RC,28296,CPT,,,,,,,,8100,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,7883.73,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2827.75,7938
riTUXimab 500 MG/50ML Solution 50 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005306,NDC,50,ML,8860.06,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,7885.4534,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.61,8682.8588
rabies immune globulin 1500 UNIT/5ML Solution 5 mL Vial,90375,CDM,636,RC,90375,CPT,,,,13533031805,NDC,5,ML,8065.26,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,7903.9548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,281.51,7903.9548
PEMEtrexed 500 MG Recon Soln 1 Each Vial,J9305.01,CDM,636,RC,J9305,HCPCS,,,,2762301,NDC,1,EA,8086.02,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,7924.2996,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,4.01,7924.2996
"Correct Bunion,Metatarsal Osteotomy",PX28296F,CDM,510,RC,28296,CPT,,,,,,,,8100,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,7938,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2827.75,7938
PHASIX 25X30CM 1190400,C1781,CDM,278,RC,C1781,HCPCS,,13011-MAIN,LOCAL,,,,,16080,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,7959.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
cemiplimab-rwlc 350 MG/7ML Solution 7 mL Vial,J9119.01,CDM,636,RC,J9119,HCPCS,,,,61755000801,NDC,7,ML,19219.32,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,7983.705528,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.75,18834.9336
riTUXimab 500 MG/50ML Solution 50 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005306,NDC,50,ML,8860.06,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,8071.51466,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.61,8682.8588
PHASIX 25X30CM 1190400,C1781,CDM,278,RC,C1781,HCPCS,,13011-MAIN,LOCAL,,,,,16080,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,8136.48,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
pembrolizumab 100 MG/4ML Solution 4 mL Vial,J9271.01,CDM,636,RC,J9271,HCPCS,,,,6302602,NDC,4,ML,9627.58,,First Health,Commercial,both,85,,999999999,percent of total billed charges,8183.443,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.57,9435.0284
RESTRATA WOUND MATRIX 10CM X 12.5CM  TOTAL 125CM,27200000,CDM,272,RC,A2007,HCPCS,,11738-MAIN,LOCAL,,,,,8415,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,8190.3195,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
REVITA PLACENTAL MEMBRANE 6X8CM 48SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12563-MAIN,LOCAL,,,,,19792,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,8221.5968,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242003706,NDC,0.6,EA,8461.09,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,8235.178897,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.39,10431.7962
cemiplimab-rwlc 350 MG/7ML Solution 7 mL Vial,J9119.01,CDM,636,RC,J9119,HCPCS,,,,61755000801,NDC,7,ML,19219.32,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,8245.08828,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.75,18834.9336
RESTRATA WOUND MATRIX 10CM X 12.5CM  TOTAL 125CM,27200000,CDM,272,RC,A2007,HCPCS,,11738-MAIN,LOCAL,,,,,8415,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,8246.7,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242003706,NDC,0.6,EA,8461.09,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,8291.8682,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.39,10431.7962
riTUXimab-abbs 500 MG/50ML Solution 50 mL Vial,Q5115.01,CDM,636,RC,Q5115,HCPCS,,,,63459010450,NDC,50,ML,8624.61,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,34.49866667,percent of total billed charges,8394.332913,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.29,8452.1178
REVITA PLACENTAL MEMBRANE 4X6CM 24SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12561-MAIN,LOCAL,,,,,9896,,First Health,Commercial,both,85,,999999999,percent of total billed charges,8411.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
riTUXimab-abbs 500 MG/50ML Solution 50 mL Vial,Q5115.01,CDM,636,RC,Q5115,HCPCS,,,,63459010450,NDC,50,ML,8624.61,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,8452.1178,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,32.29,8452.1178
REVITA PLACENTAL MEMBRANE 6X8CM 48SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12563-MAIN,LOCAL,,,,,19792,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,8490.768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
pembrolizumab 100 MG/4ML Solution 4 mL Vial,J9271.01,CDM,636,RC,J9271,HCPCS,,,,6302602,NDC,4,ML,9627.58,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,8491.52556,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.57,9435.0284
idaruCIZUmab 2.5 GM/50ML Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,597019705,NDC,50,ML,10037,,First Health,Commercial,both,85,,999999999,percent of total billed charges,8531.45,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pegfilgrastim-cbqv 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5111.01,CDM,636,RC,Q5111,HCPCS,,,,70114010101,NDC,0.6,ML,10040,,First Health,Commercial,both,85,,999999999,percent of total billed charges,8534,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.95,9839.2
pegfilgrastim-jmdb 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5108.01,CDM,636,RC,Q5108,HCPCS,,,,67457083306,NDC,0.6,ML,10040,,First Health,Commercial,both,85,,999999999,percent of total billed charges,8534,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.36,9839.2
pembrolizumab 100 MG/4ML Solution 4 mL Vial,J9271.01,CDM,636,RC,J9271,HCPCS,,,,6302602,NDC,4,ML,9627.58,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,8568.5462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.57,9435.0284
riTUXimab 500 MG/50ML Solution 50 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005306,NDC,50,ML,8860.06,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,8623.496398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.61,8682.8588
riTUXimab 500 MG/50ML Solution 50 mL Vial,J9312.01,CDM,636,RC,J9312,HCPCS,,,,50242005306,NDC,50,ML,8860.06,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,8682.8588,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,72.61,8682.8588
REVITA PLACENTAL MEMBRANE 4X6CM 24SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12561-MAIN,LOCAL,,,,,9896,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,8728.272,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
pembrolizumab 100 MG/4ML Solution 4 mL Vial,J9271.01,CDM,636,RC,J9271,HCPCS,,,,6302602,NDC,4,ML,9627.58,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,8770.72538,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.57,9435.0284
alteplase 1 MG/ML Solution 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,8888800497,NDC,1,EA,21140.86,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,8781.913244,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
alteplase 100 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242008527,NDC,1,EA,21140.86,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,8781.913244,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
REVITA PLACENTAL MEMBRANE 4X6CM 24SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12561-MAIN,LOCAL,,,,,9896,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,8807.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
idaruCIZUmab 2.5 GM/50ML Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,597019705,NDC,50,ML,10037,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,8852.634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pegfilgrastim-cbqv 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5111.01,CDM,636,RC,Q5111,HCPCS,,,,70114010101,NDC,0.6,ML,10040,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,8855.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.95,9839.2
pegfilgrastim-jmdb 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5108.01,CDM,636,RC,Q5108,HCPCS,,,,67457083306,NDC,0.6,ML,10040,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,8855.28,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.36,9839.2
idaruCIZUmab 2.5 GM/50ML Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,597019705,NDC,50,ML,10037,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,8932.93,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pegfilgrastim-cbqv 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5111.01,CDM,636,RC,Q5111,HCPCS,,,,70114010101,NDC,0.6,ML,10040,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,8935.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.95,9839.2
pegfilgrastim-jmdb 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5108.01,CDM,636,RC,Q5108,HCPCS,,,,67457083306,NDC,0.6,ML,10040,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,8935.6,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.36,9839.2
leuprolide 45 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74347303,NDC,1,EA,21633.89,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,8986.717906,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
Lap Paraesophag Hern Repair,PX43281,CDM,982,RC,43281,CPT,,,,,,,,5950,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,8992.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2471.63,8992.74
"Lap,Cholecystectomy/Explore",PX47564F,CDM,510,RC,47564,CPT,,,,,,,,2419,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,8992.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1004.8526,8992.74
"Lap,Cholecystectomy/Explore",PX47564P,CDM,983,RC,47564,CPT,,,,,,,,1613,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,8992.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,670.0402,8992.74
"Lap,Esophagogast Fundoplasty",PX43280F,CDM,510,RC,43280,CPT,,,,,,,,6713,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,8992.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,2788.5802,8992.74
"Lap,Esophagogast Fundoplasty",PX43280P,CDM,983,RC,43280,CPT,,,,,,,,4449,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,8992.74,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1848.1146,8992.74
REVITA PLACENTAL MEMBRANE 4X6CM 24SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12561-MAIN,LOCAL,,,,,9896,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,9015.256,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
durvalumab 120 MG/2.4ML Solution 2.4 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310450012,NDC,30,ML,21771.9,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,9044.04726,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.48,21336.462
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012047,NDC,0.6,EA,10644.69,,First Health,Commercial,both,85,,999999999,percent of total billed charges,9047.9865,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.39,10431.7962
alteplase 1 MG/ML Solution 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,8888800497,NDC,1,EA,21140.86,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,9069.42894,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
alteplase 100 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242008527,NDC,1,EA,21140.86,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,9069.42894,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
idaruCIZUmab 2.5 GM/50ML Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,597019705,NDC,50,ML,10037,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,9143.707,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pegfilgrastim-cbqv 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5111.01,CDM,636,RC,Q5111,HCPCS,,,,70114010101,NDC,0.6,ML,10040,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,9146.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.95,9839.2
pegfilgrastim-jmdb 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5108.01,CDM,636,RC,Q5108,HCPCS,,,,67457083306,NDC,0.6,ML,10040,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,9146.44,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.36,9839.2
cemiplimab-rwlc 350 MG/7ML Solution 7 mL Vial,J9119.01,CDM,636,RC,J9119,HCPCS,,,,61755000801,NDC,7,ML,19219.32,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,9225.2736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.75,18834.9336
cemiplimab-rwlc 350 MG/7ML Solution 7 mL Vial,J9119.01,CDM,636,RC,J9119,HCPCS,,,,61755000801,NDC,7,ML,19219.32,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,9225.2736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.75,18834.9336
leuprolide 45 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74347303,NDC,1,EA,21633.89,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,9280.93881,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
durvalumab 120 MG/2.4ML Solution 2.4 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310450012,NDC,30,ML,21771.9,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,9340.1451,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.48,21336.462
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012047,NDC,0.6,EA,10644.69,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,9388.61658,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.39,10431.7962
cemiplimab-rwlc 350 MG/7ML Solution 7 mL Vial,J9119.01,CDM,636,RC,J9119,HCPCS,,,,61755000801,NDC,7,ML,19219.32,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9417.4668,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.75,18834.9336
cemiplimab-rwlc 350 MG/7ML Solution 7 mL Vial,J9119.01,CDM,636,RC,J9119,HCPCS,,,,61755000801,NDC,7,ML,19219.32,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9417.4668,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.75,18834.9336
cemiplimab-rwlc 350 MG/7ML Solution 7 mL Vial,J9119.01,CDM,636,RC,J9119,HCPCS,,,,61755000801,NDC,7,ML,19219.32,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,9417.4668,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.75,18834.9336
pembrolizumab 100 MG/4ML Solution 4 mL Vial,J9271.01,CDM,636,RC,J9271,HCPCS,,,,6302602,NDC,4,ML,9627.58,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,9435.0284,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,39.57,9435.0284
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012047,NDC,0.6,EA,10644.69,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,9473.7741,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.39,10431.7962
REVITA PLACENTAL MEMBRANE 6X8CM 48SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12563-MAIN,LOCAL,,,,,19792,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,9500.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
REVITA PLACENTAL MEMBRANE 6X8CM 48SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12563-MAIN,LOCAL,,,,,19792,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,9500.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
cemiplimab-rwlc 350 MG/7ML Solution 7 mL Vial,J9119.01,CDM,636,RC,J9119,HCPCS,,,,61755000801,NDC,7,ML,19219.32,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,9513.5634,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.75,18834.9336
REVITA PLACENTAL MEMBRANE 4X6CM 24SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12561-MAIN,LOCAL,,,,,9896,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,9631.7768,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012047,NDC,0.6,EA,10644.69,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,9697.31259,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.39,10431.7962
REVITA PLACENTAL MEMBRANE 4X6CM 24SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12561-MAIN,LOCAL,,,,,9896,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,9698.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
REVITA PLACENTAL MEMBRANE 6X8CM 48SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12563-MAIN,LOCAL,,,,,19792,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9698.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
REVITA PLACENTAL MEMBRANE 6X8CM 48SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12563-MAIN,LOCAL,,,,,19792,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,9698.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
REVITA PLACENTAL MEMBRANE 6X8CM 48SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12563-MAIN,LOCAL,,,,,19792,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,9698.08,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
cemiplimab-rwlc 350 MG/7ML Solution 7 mL Vial,J9119.01,CDM,636,RC,J9119,HCPCS,,,,61755000801,NDC,7,ML,19219.32,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,9724.97592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.75,18834.9336
idaruCIZUmab 2.5 GM/50ML Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,597019705,NDC,50,ML,10037,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,9769.0121,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pegfilgrastim-cbqv 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5111.01,CDM,636,RC,Q5111,HCPCS,,,,70114010101,NDC,0.6,ML,10040,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,9771.932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.95,9839.2
pegfilgrastim-jmdb 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5108.01,CDM,636,RC,Q5108,HCPCS,,,,67457083306,NDC,0.6,ML,10040,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,709.5775,percent of total billed charges,9771.932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.36,9839.2
REVITA PLACENTAL MEMBRANE 6X8CM 48SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12563-MAIN,LOCAL,,,,,19792,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,9797.04,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
idaruCIZUmab 2.5 GM/50ML Solution 50 mL Vial,25000000,CDM,250,RC,,,,,,597019705,NDC,50,ML,10037,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,9836.26,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1.2462,9836.26
pegfilgrastim-cbqv 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5111.01,CDM,636,RC,Q5111,HCPCS,,,,70114010101,NDC,0.6,ML,10040,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,9839.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,111.95,9839.2
pegfilgrastim-jmdb 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,Q5108.01,CDM,636,RC,Q5108,HCPCS,,,,67457083306,NDC,0.6,ML,10040,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,9839.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,112.36,9839.2
REVITA PLACENTAL MEMBRANE 6X8CM 48SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12563-MAIN,LOCAL,,,,,19792,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,10014.752,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
alteplase 1 MG/ML Solution 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,8888800497,NDC,1,EA,21140.86,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,10147.6128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
alteplase 1 MG/ML Solution 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,8888800497,NDC,1,EA,21140.86,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,10147.6128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
alteplase 100 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242008527,NDC,1,EA,21140.86,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,10147.6128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
alteplase 100 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242008527,NDC,1,EA,21140.86,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,10147.6128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
PHASIX ST 15X20CM 1201520,C1781,CDM,278,RC,C1781,HCPCS,,13010-MAIN,LOCAL,,,,,11988,,First Health,Commercial,both,85,,999999999,percent of total billed charges,10189.8,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ABORTION WITHOUT D&C,779,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,289,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC,288,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,290,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH CC,835,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH MCC,834,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITHOUT CC/MCC,836,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,121,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,122,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC",284,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC",285,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
AICD LEAD PROCEDURES,265,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY",895,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ALLOGENEIC BONE MARROW TRANSPLANT,14,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,241,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,476,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",618,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ANAL AND STOMAL PROCEDURES WITH MCC,347,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ANGINA PECTORIS,311,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ARTHROSCOPY,509,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,16,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,17,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,95,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,94,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,96,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BEHAVIORAL AND DEVELOPMENTAL DISORDERS,886,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,461,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,462,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC",584,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC",585,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"CARDIAC ARREST, UNEXPLAINED WITH CC",297,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"CARDIAC ARREST, UNEXPLAINED WITHOUT CC/MCC",298,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC,276,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,258,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,259,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CAROTID ARTERY STENT PROCEDURES WITH CC,35,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CAROTID ARTERY STENT PROCEDURES WITH MCC,34,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,36,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,848,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHEST PAIN,313,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,18,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,416,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHOLECYSTECTOMY WITH C.D.E. WITH CC,412,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,413,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH CC,454,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH MCC,453,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITHOUT CC/MCC,455,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,382,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES,212,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CONCUSSION WITH CC,89,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CONCUSSION WITH MCC,88,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CONCUSSION WITHOUT CC/MCC,90,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,73,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,74,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,26,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,25,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,27,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,955,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR CHEMOTHERAPY IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,23,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,24,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC,294,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DEEP VEIN THROMBOPHLEBITIS WITHOUT CC/MCC,295,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,56,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,57,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DENTAL AND ORAL DISEASES WITHOUT CC/MCC,159,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DEPRESSIVE NEUROSES,881,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DIABETES WITH CC,638,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DIABETES WITH MCC,637,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DIGESTIVE MALIGNANCY WITHOUT CC/MCC,376,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,883,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC",148,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES",3,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
EPISTAXIS WITH MCC,150,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,927,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,933,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
EXTRACRANIAL PROCEDURES WITH CC,38,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
EXTRACRANIAL PROCEDURES WITH MCC,37,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,39,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
EXTRAOCULAR PROCEDURES EXCEPT ORBIT,115,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,748,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,928,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,929,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,934,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HAND PROCEDURES FOR INJURIES,906,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HEADACHES WITH MCC,102,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC,1,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITHOUT MCC,2,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,421,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,970,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HIV WITH MAJOR RELATED CONDITION WITH CC,975,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,976,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HYPERTENSIVE ENCEPHALOPATHY WITH CC,78,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HYPERTENSIVE ENCEPHALOPATHY WITH MCC,77,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC,79,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,855,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,65,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,64,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,66,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,21,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,20,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/MCC,22,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INTRAOCULAR PROCEDURES WITH CC/MCC,116,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
INTRAOCULAR PROCEDURES WITHOUT CC/MCC,117,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",62,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",61,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",63,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,686,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,688,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KIDNEY TRANSPLANT,652,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC,650,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC,651,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,486,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LIVER TRANSPLANT WITH MCC OR INTESTINAL TRANSPLANT,5,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LIVER TRANSPLANT WITHOUT MCC,6,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,495,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,499,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LUNG TRANSPLANT,7,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,821,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,825,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,655,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,370,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR HEAD AND NECK PROCEDURES WITH CC,141,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR HEAD AND NECK PROCEDURES WITH MCC,140,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,142,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITHOUT CC/MCC,508,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,437,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",756,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",724,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,599,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MASTECTOMY FOR MALIGNANCY WITH CC/MCC,582,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MOUTH PROCEDURES WITH CC/MCC,137,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MOUTH PROCEDURES WITHOUT CC/MCC,138,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,59,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,58,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,60,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,830,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NERVOUS SYSTEM NEOPLASMS WITH MCC,54,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,55,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NEUROLOGICAL EYE DISORDERS,123,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,98,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,97,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,99,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NON-EXTENSIVE BURNS,935,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC,71,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC,70,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,72,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,67,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,68,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NONTRAUMATIC STUPOR AND COMA WITH MCC,80,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,81,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
NORMAL NEWBORN,795,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
O.R. PROCEDURES FOR OBESITY WITH MCC,619,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,876,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ORBITAL PROCEDURES WITH CC/MCC,113,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ORBITAL PROCEDURES WITHOUT CC/MCC,114,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,819,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,92,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,91,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,93,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER DISORDERS OF THE EYE WITH MCC OR THROMBOLYTIC AGENT,124,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC",144,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH MCC",143,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC",145,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,750,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,730,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,718,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,715,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,716,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,963,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,965,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,517,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,845,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,958,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,957,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,959,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,804,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,168,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC",579,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PANCREAS TRANSPLANT,10,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC",734,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC",735,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PENIS PROCEDURES WITH CC/MCC,709,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PENIS PROCEDURES WITHOUT CC/MCC,710,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",41,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",40,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC",42,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS,998,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PSYCHOSES,885,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RADIOTHERAPY,849,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RECTAL RESECTION WITH CC,333,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RECTAL RESECTION WITHOUT CC/MCC,334,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
REHABILITATION WITH CC/MCC,945,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
REHABILITATION WITHOUT CC/MCC,946,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,466,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SEPTIC ARTHRITIS WITHOUT CC/MCC,550,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC",512,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,8,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS,19,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SINUS AND MASTOID PROCEDURES WITH CC/MCC,135,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,136,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,577,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,576,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,578,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,574,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,573,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",624,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SKIN GRAFTS FOR INJURIES WITH CC/MCC,904,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,905,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SKIN ULCERS WITH CC,593,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SPINAL DISORDERS AND INJURIES WITH CC/MCC,52,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,53,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SPINAL FUSION EXCEPT CERVICAL WITH MCC,459,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH MCC",456,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,460,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,29,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SPINAL PROCEDURES WITH MCC,28,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SPINAL PROCEDURES WITHOUT CC/MCC,30,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SPLENIC PROCEDURES WITH CC,800,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SPLENIC PROCEDURES WITH MCC,799,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SPLENIC PROCEDURES WITHOUT CC/MCC,801,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC",538,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
TESTES PROCEDURES WITH CC/MCC,711,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
TESTES PROCEDURES WITHOUT CC/MCC,712,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC",626,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC",625,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC",627,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC",12,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",11,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC",13,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",4,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,69,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
TRAUMATIC INJURY WITHOUT MCC,914,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,86,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,85,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,87,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,83,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,82,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,84,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY EMBOLISM,173,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
UNCOMPLICATED PEPTIC ULCER WITH MCC,383,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
UNGROUPABLE,999,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,256,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,257,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
URETHRAL PROCEDURES WITHOUT CC/MCC,672,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
URETHRAL STRICTURE,697,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,796,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,798,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
VENTRICULAR SHUNT PROCEDURES WITH CC,32,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
VENTRICULAR SHUNT PROCEDURES WITH MCC,31,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,33,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
VIRAL MENINGITIS WITH CC/MCC,75,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
VIRAL MENINGITIS WITHOUT CC/MCC,76,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
WOUND DEBRIDEMENTS FOR INJURIES WITH CC,902,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,901,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,,,,,,,United Healthcare,All Payer,inpatient,,MS-DRG,999999999,case rate,10200,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5225,10200
alteplase 1 MG/ML Solution 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,8888800497,NDC,1,EA,21140.86,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,66.655,percent of total billed charges,10359.0214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
alteplase 1 MG/ML Solution 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,8888800497,NDC,1,EA,21140.86,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,10359.0214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
alteplase 1 MG/ML Solution 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,8888800497,NDC,1,EA,21140.86,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,10359.0214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
alteplase 100 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242008527,NDC,1,EA,21140.86,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,66.655,percent of total billed charges,10359.0214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
alteplase 100 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242008527,NDC,1,EA,21140.86,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,10359.0214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
alteplase 100 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242008527,NDC,1,EA,21140.86,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,10359.0214,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012047,NDC,0.6,EA,10644.69,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,10360.47678,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.39,10431.7962
leuprolide 45 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74347303,NDC,1,EA,21633.89,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,10384.2672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
leuprolide 45 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74347303,NDC,1,EA,21633.89,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,10384.2672,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
tenecteplase 50 MG Kit 1 Each Box,J3101.01,CDM,636,RC,J3101,HCPCS,,,,50242012047,NDC,0.6,EA,10644.69,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,10431.7962,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,140.39,10431.7962
durvalumab 120 MG/2.4ML Solution 2.4 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310450012,NDC,30,ML,21771.9,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,10450.512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.48,21336.462
durvalumab 120 MG/2.4ML Solution 2.4 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310450012,NDC,30,ML,21771.9,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,10450.512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.48,21336.462
alteplase 1 MG/ML Solution 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,8888800497,NDC,1,EA,21140.86,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,10464.7257,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
alteplase 100 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242008527,NDC,1,EA,21140.86,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,10464.7257,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
ramuCIRumab 500 MG/50ML Solution 50 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2767801,NDC,50,ML,12316.5,,First Health,Commercial,both,85,,999999999,percent of total billed charges,10469.025,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.57,12070.17
vedolizumab 300 MG Recon Soln 1 Each Vial,J3380.01,CDM,636,RC,J3380,HCPCS,,,,64764030020,NDC,1,EA,12439.04,,First Health,Commercial,both,85,,999999999,percent of total billed charges,10573.184,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.66,12190.2592
PHASIX ST 15X20CM 1201520,C1781,CDM,278,RC,C1781,HCPCS,,13010-MAIN,LOCAL,,,,,11988,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,10573.416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
leuprolide 45 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74347303,NDC,1,EA,21633.89,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,721.12,percent of total billed charges,10600.6061,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
leuprolide 45 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74347303,NDC,1,EA,21633.89,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,10600.6061,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
leuprolide 45 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74347303,NDC,1,EA,21633.89,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,10600.6061,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74334603,NDC,1,EA,12509.82,,First Health,Commercial,both,85,,999999999,percent of total billed charges,10633.347,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
durvalumab 120 MG/2.4ML Solution 2.4 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310450012,NDC,30,ML,21771.9,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,10668.231,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.48,21336.462
durvalumab 120 MG/2.4ML Solution 2.4 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310450012,NDC,30,ML,21771.9,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,10668.231,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.48,21336.462
durvalumab 120 MG/2.4ML Solution 2.4 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310450012,NDC,30,ML,21771.9,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,10668.231,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.48,21336.462
PHASIX ST 15X20CM 1201520,C1781,CDM,278,RC,C1781,HCPCS,,13010-MAIN,LOCAL,,,,,11988,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,10669.32,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
alteplase 1 MG/ML Solution 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,8888800497,NDC,1,EA,21140.86,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,10697.27516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
alteplase 100 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242008527,NDC,1,EA,21140.86,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,10697.27516,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
leuprolide 45 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74347303,NDC,1,EA,21633.89,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,10708.77555,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
durvalumab 120 MG/2.4ML Solution 2.4 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310450012,NDC,30,ML,21771.9,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,10777.0905,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.48,21336.462
pegfilgrastim 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019001,NDC,0.6,ML,12711.36,,First Health,Commercial,both,85,,999999999,percent of total billed charges,10804.656,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.46,12830.846
ramuCIRumab 500 MG/50ML Solution 50 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2767801,NDC,50,ML,12316.5,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,10863.153,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.57,12070.17
PHASIX ST 15X20CM 1201520,C1781,CDM,278,RC,C1781,HCPCS,,13010-MAIN,LOCAL,,,,,11988,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,10921.068,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
leuprolide 45 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74347303,NDC,1,EA,21633.89,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,10946.74834,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
ramuCIRumab 500 MG/50ML Solution 50 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2767801,NDC,50,ML,12316.5,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,10961.685,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.57,12070.17
vedolizumab 300 MG Recon Soln 1 Each Vial,J3380.01,CDM,636,RC,J3380,HCPCS,,,,64764030020,NDC,1,EA,12439.04,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,10971.23328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.66,12190.2592
durvalumab 120 MG/2.4ML Solution 2.4 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310450012,NDC,30,ML,21771.9,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,11016.5814,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.48,21336.462
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74334603,NDC,1,EA,12509.82,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11033.66124,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
vedolizumab 300 MG Recon Soln 1 Each Vial,J3380.01,CDM,636,RC,J3380,HCPCS,,,,64764030020,NDC,1,EA,12439.04,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,11070.7456,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.66,12190.2592
nivolumab 240 MG/24ML Solution 24 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3373413,NDC,24,ML,13030.26,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11075.721,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.5,12769.6548
pegfilgrastim 6 MG/0.6ML Prefilled Syringe Kit 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019201,NDC,0.6,ML,13092.7,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11128.795,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.46,12830.846
Appl on-Body Injector for Timed Subq Injection,PX96377,CDM,260,RC,96377,CPT,,,,,,,,13093,,First Health,Commercial,both,85,,999999999,percent of total billed charges,11129.05,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,12831.14
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74334603,NDC,1,EA,12509.82,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,11133.7398,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
pegfilgrastim 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019001,NDC,0.6,ML,12711.36,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11211.41952,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.46,12830.846
ramuCIRumab 500 MG/50ML Solution 50 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2767801,NDC,50,ML,12316.5,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,11220.3315,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.57,12070.17
pegfilgrastim 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019001,NDC,0.6,ML,12711.36,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,11313.1104,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.46,12830.846
vedolizumab 300 MG Recon Soln 1 Each Vial,J3380.01,CDM,636,RC,J3380,HCPCS,,,,64764030020,NDC,1,EA,12439.04,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,11331.96544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.66,12190.2592
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74334603,NDC,1,EA,12509.82,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,11396.44602,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
nivolumab 240 MG/24ML Solution 24 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3373413,NDC,24,ML,13030.26,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11492.68932,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.5,12769.6548
"Fusion Foot Bones,Midtarsal,Multi",PX28730F,CDM,510,RC,28730,CPT,,,,,,,,2299,,UCare,All Minnesota State Programs,outpatient,,,999999999,fee schedule,11497.76,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,955.0046,11497.76
pegfilgrastim 6 MG/0.6ML Prefilled Syringe Kit 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019201,NDC,0.6,ML,13092.7,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11547.7614,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.46,12830.846
Appl on-Body Injector for Timed Subq Injection,PX96377,CDM,260,RC,96377,CPT,,,,,,,,13093,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,11548.026,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,12831.14
pegfilgrastim 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019001,NDC,0.6,ML,12711.36,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,11580.04896,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.46,12830.846
nivolumab 240 MG/24ML Solution 24 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3373413,NDC,24,ML,13030.26,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,11596.9314,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.5,12769.6548
pegfilgrastim 6 MG/0.6ML Prefilled Syringe Kit 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019201,NDC,0.6,ML,13092.7,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,11652.503,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.46,12830.846
Appl on-Body Injector for Timed Subq Injection,PX96377,CDM,260,RC,96377,CPT,,,,,,,,13093,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,11652.77,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,12831.14
PHASIX ST 15X20CM 1201520,C1781,CDM,278,RC,C1781,HCPCS,,13010-MAIN,LOCAL,,,,,11988,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1256.29,percent of total billed charges,11667.9204,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
PHASIX ST 15X20CM 1201520,C1781,CDM,278,RC,C1781,HCPCS,,13010-MAIN,LOCAL,,,,,11988,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,11748.24,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
cabazitaxel 60 MG/1.5ML Solution 6 mL Vial,J9043.01,CDM,636,RC,J9043,HCPCS,,,,24582411,NDC,6,ML,28293.07,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,11752.94128,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.96,27727.2086
nivolumab 240 MG/24ML Solution 24 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3373413,NDC,24,ML,13030.26,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,11870.56686,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.5,12769.6548
pegfilgrastim 6 MG/0.6ML Prefilled Syringe Kit 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019201,NDC,0.6,ML,13092.7,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,11927.4497,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.46,12830.846
Appl on-Body Injector for Timed Subq Injection,PX96377,CDM,260,RC,96377,CPT,,,,,,,,13093,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,11927.723,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,12831.14
ramuCIRumab 500 MG/50ML Solution 50 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2767801,NDC,50,ML,12316.5,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,11987.64945,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.57,12070.17
ramuCIRumab 500 MG/50ML Solution 50 mL Vial,J9308.01,CDM,636,RC,J9308,HCPCS,,,,2767801,NDC,50,ML,12316.5,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,12070.17,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.57,12070.17
cabazitaxel 60 MG/1.5ML Solution 6 mL Vial,J9043.01,CDM,636,RC,J9043,HCPCS,,,,24582411,NDC,6,ML,28293.07,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,12137.72703,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.96,27727.2086
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74334603,NDC,1,EA,12509.82,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,12175.80781,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
vedolizumab 300 MG Recon Soln 1 Each Vial,J3380.01,CDM,636,RC,J3380,HCPCS,,,,64764030020,NDC,1,EA,12439.04,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,12190.2592,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,14.66,12190.2592
leuprolide 22.5 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74334603,NDC,1,EA,12509.82,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,12259.6236,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
pegfilgrastim 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019001,NDC,0.6,ML,12711.36,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,12371.96669,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.46,12830.846
pegfilgrastim 6 MG/0.6ML solution prefilled syringe 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019001,NDC,0.6,ML,12711.36,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,12457.1328,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.46,12830.846
REVITA PLACENTAL MEMBRANE 6X6CM 36SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12562-MAIN,LOCAL,,,,,14844,,First Health,Commercial,both,85,,999999999,percent of total billed charges,12617.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
nivolumab 240 MG/24ML Solution 24 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3373413,NDC,24,ML,13030.26,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,12682.35206,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.5,12769.6548
pegfilgrastim 6 MG/0.6ML Prefilled Syringe Kit 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019201,NDC,0.6,ML,13092.7,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,12743.12491,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.46,12830.846
Appl on-Body Injector for Timed Subq Injection,PX96377,CDM,260,RC,96377,CPT,,,,,,,,13093,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,12743.4169,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,12831.14
nivolumab 240 MG/24ML Solution 24 mL Vial,J9299.01,CDM,636,RC,J9299,HCPCS,,,,3373413,NDC,24,ML,13030.26,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,12769.6548,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,28.5,12769.6548
pegfilgrastim 6 MG/0.6ML Prefilled Syringe Kit 0.6 mL Syringe,J2506.01,CDM,636,RC,J2506,HCPCS,,,,55513019201,NDC,0.6,ML,13092.7,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,12830.846,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,46.46,12830.846
Appl on-Body Injector for Timed Subq Injection,PX96377,CDM,260,RC,96377,CPT,,,,,,,,13093,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,12831.14,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,41.5,12831.14
natalizumab 300 MG/15ML Concentrate 15 mL Vial,J2323.01,CDM,636,RC,J2323,HCPCS,,,,64406000801,NDC,15,ML,15226.53,,First Health,Commercial,both,85,,999999999,percent of total billed charges,12942.5505,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.42,14921.9994
REVITA PLACENTAL MEMBRANE 6X6CM 36SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12562-MAIN,LOCAL,,,,,14844,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,13092.408,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
REVITA PLACENTAL MEMBRANE 6X6CM 36SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12562-MAIN,LOCAL,,,,,14844,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,13211.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
natalizumab 300 MG/15ML Concentrate 15 mL Vial,J2323.01,CDM,636,RC,J2323,HCPCS,,,,64406000801,NDC,15,ML,15226.53,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,13429.79946,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.42,14921.9994
REVITA PLACENTAL MEMBRANE 6X6CM 36SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12562-MAIN,LOCAL,,,,,14844,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,13522.884,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
natalizumab 300 MG/15ML Concentrate 15 mL Vial,J2323.01,CDM,636,RC,J2323,HCPCS,,,,64406000801,NDC,15,ML,15226.53,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,13551.6117,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.42,14921.9994
cabazitaxel 60 MG/1.5ML Solution 6 mL Vial,J9043.01,CDM,636,RC,J9043,HCPCS,,,,24582411,NDC,6,ML,28293.07,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,13580.6736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.96,27727.2086
cabazitaxel 60 MG/1.5ML Solution 6 mL Vial,J9043.01,CDM,636,RC,J9043,HCPCS,,,,24582411,NDC,6,ML,28293.07,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,13580.6736,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.96,27727.2086
PHASIX 25X30CM 1190400,C1781,CDM,278,RC,C1781,HCPCS,,13011-MAIN,LOCAL,,,,,16080,,First Health,Commercial,both,85,,999999999,percent of total billed charges,13668,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
cabazitaxel 60 MG/1.5ML Solution 6 mL Vial,J9043.01,CDM,636,RC,J9043,HCPCS,,,,24582411,NDC,6,ML,28293.07,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13863.6043,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.96,27727.2086
cabazitaxel 60 MG/1.5ML Solution 6 mL Vial,J9043.01,CDM,636,RC,J9043,HCPCS,,,,24582411,NDC,6,ML,28293.07,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,13863.6043,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.96,27727.2086
cabazitaxel 60 MG/1.5ML Solution 6 mL Vial,J9043.01,CDM,636,RC,J9043,HCPCS,,,,24582411,NDC,6,ML,28293.07,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,13863.6043,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.96,27727.2086
natalizumab 300 MG/15ML Concentrate 15 mL Vial,J2323.01,CDM,636,RC,J2323,HCPCS,,,,64406000801,NDC,15,ML,15226.53,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,13871.36883,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.42,14921.9994
cabazitaxel 60 MG/1.5ML Solution 6 mL Vial,J9043.01,CDM,636,RC,J9043,HCPCS,,,,24582411,NDC,6,ML,28293.07,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,14005.06965,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.96,27727.2086
PHASIX 25X30CM 1190400,C1781,CDM,278,RC,C1781,HCPCS,,13011-MAIN,LOCAL,,,,,16080,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,14182.56,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
ocrelizumab 300 MG/10ML Solution 10 mL Vial,J2350.01,CDM,636,RC,J2350,HCPCS,,,,50242015001,NDC,10,ML,33150,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,14221.35,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.47,32487
PHASIX 25X30CM 1190400,C1781,CDM,278,RC,C1781,HCPCS,,13011-MAIN,LOCAL,,,,,16080,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,14311.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
cabazitaxel 60 MG/1.5ML Solution 6 mL Vial,J9043.01,CDM,636,RC,J9043,HCPCS,,,,24582411,NDC,6,ML,28293.07,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,14316.29342,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.96,27727.2086
REVITA PLACENTAL MEMBRANE 6X6CM 36SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12562-MAIN,LOCAL,,,,,14844,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,14447.6652,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
REVITA PLACENTAL MEMBRANE 6X6CM 36SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12562-MAIN,LOCAL,,,,,14844,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,14547.12,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
PHASIX 25X30CM 1190400,C1781,CDM,278,RC,C1781,HCPCS,,13011-MAIN,LOCAL,,,,,16080,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,14648.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
natalizumab 300 MG/15ML Concentrate 15 mL Vial,J2323.01,CDM,636,RC,J2323,HCPCS,,,,64406000801,NDC,15,ML,15226.53,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,43.981775,percent of total billed charges,14819.98165,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.42,14921.9994
natalizumab 300 MG/15ML Concentrate 15 mL Vial,J2323.01,CDM,636,RC,J2323,HCPCS,,,,64406000801,NDC,15,ML,15226.53,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,14921.9994,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,22.42,14921.9994
PHASIX 25X30CM 1190400,C1781,CDM,278,RC,C1781,HCPCS,,13011-MAIN,LOCAL,,,,,16080,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,1256.29,percent of total billed charges,15650.664,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
PHASIX 25X30CM 1190400,C1781,CDM,278,RC,C1781,HCPCS,,13011-MAIN,LOCAL,,,,,16080,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,15758.4,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,88.683746,15758.4
ocrelizumab 300 MG/10ML Solution 10 mL Vial,J2350.01,CDM,636,RC,J2350,HCPCS,,,,50242015001,NDC,10,ML,33150,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,15912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.47,32487
ocrelizumab 300 MG/10ML Solution 10 mL Vial,J2350.01,CDM,636,RC,J2350,HCPCS,,,,50242015001,NDC,10,ML,33150,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,15912,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.47,32487
ocrelizumab 300 MG/10ML Solution 10 mL Vial,J2350.01,CDM,636,RC,J2350,HCPCS,,,,50242015001,NDC,10,ML,33150,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16243.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.47,32487
ocrelizumab 300 MG/10ML Solution 10 mL Vial,J2350.01,CDM,636,RC,J2350,HCPCS,,,,50242015001,NDC,10,ML,33150,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,16243.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.47,32487
ocrelizumab 300 MG/10ML Solution 10 mL Vial,J2350.01,CDM,636,RC,J2350,HCPCS,,,,50242015001,NDC,10,ML,33150,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,16243.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.47,32487
cemiplimab-rwlc 350 MG/7ML Solution 7 mL Vial,J9119.01,CDM,636,RC,J9119,HCPCS,,,,61755000801,NDC,7,ML,19219.32,,First Health,Commercial,both,85,,999999999,percent of total billed charges,16336.422,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.75,18834.9336
ocrelizumab 300 MG/10ML Solution 10 mL Vial,J2350.01,CDM,636,RC,J2350,HCPCS,,,,50242015001,NDC,10,ML,33150,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,16409.25,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.47,32487
ocrelizumab 300 MG/10ML Solution 10 mL Vial,J2350.01,CDM,636,RC,J2350,HCPCS,,,,50242015001,NDC,10,ML,33150,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,16773.9,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.47,32487
REVITA PLACENTAL MEMBRANE 6X8CM 48SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12563-MAIN,LOCAL,,,,,19792,,First Health,Commercial,both,85,,999999999,percent of total billed charges,16823.2,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
cemiplimab-rwlc 350 MG/7ML Solution 7 mL Vial,J9119.01,CDM,636,RC,J9119,HCPCS,,,,61755000801,NDC,7,ML,19219.32,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,16951.44024,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.75,18834.9336
cemiplimab-rwlc 350 MG/7ML Solution 7 mL Vial,J9119.01,CDM,636,RC,J9119,HCPCS,,,,61755000801,NDC,7,ML,19219.32,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,17105.1948,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.75,18834.9336
REVITA PLACENTAL MEMBRANE 6X8CM 48SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12563-MAIN,LOCAL,,,,,19792,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,17456.544,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
cemiplimab-rwlc 350 MG/7ML Solution 7 mL Vial,J9119.01,CDM,636,RC,J9119,HCPCS,,,,61755000801,NDC,7,ML,19219.32,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,17508.80052,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.75,18834.9336
REVITA PLACENTAL MEMBRANE 6X8CM 48SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12563-MAIN,LOCAL,,,,,19792,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,17614.88,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
alteplase 1 MG/ML Solution 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,8888800497,NDC,1,EA,21140.86,,First Health,Commercial,both,85,,999999999,percent of total billed charges,17969.731,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
alteplase 100 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242008527,NDC,1,EA,21140.86,,First Health,Commercial,both,85,,999999999,percent of total billed charges,17969.731,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
REVITA PLACENTAL MEMBRANE 6X8CM 48SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12563-MAIN,LOCAL,,,,,19792,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,18030.512,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
leuprolide 45 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74347303,NDC,1,EA,21633.89,,First Health,Commercial,both,85,,999999999,percent of total billed charges,18388.8065,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
durvalumab 120 MG/2.4ML Solution 2.4 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310450012,NDC,30,ML,21771.9,,First Health,Commercial,both,85,,999999999,percent of total billed charges,18506.115,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.48,21336.462
alteplase 1 MG/ML Solution 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,8888800497,NDC,1,EA,21140.86,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,18646.23852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
alteplase 100 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242008527,NDC,1,EA,21140.86,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,18646.23852,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
cemiplimab-rwlc 350 MG/7ML Solution 7 mL Vial,J9119.01,CDM,636,RC,J9119,HCPCS,,,,61755000801,NDC,7,ML,19219.32,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,18706.16416,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.75,18834.9336
alteplase 1 MG/ML Solution 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,8888800497,NDC,1,EA,21140.86,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,18815.3654,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
alteplase 100 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242008527,NDC,1,EA,21140.86,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,18815.3654,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
cemiplimab-rwlc 350 MG/7ML Solution 7 mL Vial,J9119.01,CDM,636,RC,J9119,HCPCS,,,,61755000801,NDC,7,ML,19219.32,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,18834.9336,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,23.75,18834.9336
leuprolide 45 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74347303,NDC,1,EA,21633.89,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,19081.09098,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
durvalumab 120 MG/2.4ML Solution 2.4 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310450012,NDC,30,ML,21771.9,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,19202.8158,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.48,21336.462
leuprolide 45 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74347303,NDC,1,EA,21633.89,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,19254.1621,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
alteplase 1 MG/ML Solution 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,8888800497,NDC,1,EA,21140.86,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,19259.32346,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
alteplase 100 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242008527,NDC,1,EA,21140.86,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,19259.32346,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
REVITA PLACENTAL MEMBRANE 6X8CM 48SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12563-MAIN,LOCAL,,,,,19792,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,19263.5536,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
durvalumab 120 MG/2.4ML Solution 2.4 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310450012,NDC,30,ML,21771.9,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,19376.991,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.48,21336.462
REVITA PLACENTAL MEMBRANE 6X8CM 48SQCM,Q4180,CDM,278,RC,Q4180,HCPCS,,12563-MAIN,LOCAL,,,,,19792,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,19396.16,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,1027.6996,19396.16
leuprolide 45 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74347303,NDC,1,EA,21633.89,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,19708.47379,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
durvalumab 120 MG/2.4ML Solution 2.4 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310450012,NDC,30,ML,21771.9,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,19834.2009,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.48,21336.462
pegloticase 8 MG/ML Solution 1 mL Vial,J2507.01,CDM,636,RC,J2507,HCPCS,,,,75987008010,NDC,1,ML,48367.38,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,20091.80965,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3090.93,47400.0324
alteplase 1 MG/ML Solution 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,8888800497,NDC,1,EA,21140.86,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,20576.39904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
alteplase 100 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242008527,NDC,1,EA,21140.86,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,20576.39904,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
alteplase 1 MG/ML Solution 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,8888800497,NDC,1,EA,21140.86,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,20718.0428,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
alteplase 100 MG Recon Soln 1 Each Vial,J2997.01,CDM,636,RC,J2997,HCPCS,,,,50242008527,NDC,1,EA,21140.86,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,20718.0428,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,70.44,20718.0428
pegloticase 8 MG/ML Solution 1 mL Vial,J2507.01,CDM,636,RC,J2507,HCPCS,,,,75987008010,NDC,1,ML,48367.38,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,20749.60602,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3090.93,47400.0324
leuprolide 45 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74347303,NDC,1,EA,21633.89,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,21056.26514,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
durvalumab 120 MG/2.4ML Solution 2.4 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310450012,NDC,30,ML,21771.9,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,21190.59027,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.48,21336.462
leuprolide 45 MG Kit 1 Each Box,J9217.01,CDM,636,RC,J9217,HCPCS,,,,74347303,NDC,1,EA,21633.89,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,21201.2122,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,166.23,21201.2122
durvalumab 120 MG/2.4ML Solution 2.4 mL Vial,J9173.01,CDM,636,RC,J9173,HCPCS,,,,310450012,NDC,30,ML,21771.9,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,21336.462,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,62.48,21336.462
pegloticase 8 MG/ML Solution 1 mL Vial,J2507.01,CDM,636,RC,J2507,HCPCS,,,,75987008010,NDC,1,ML,48367.38,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,23216.3424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3090.93,47400.0324
pegloticase 8 MG/ML Solution 1 mL Vial,J2507.01,CDM,636,RC,J2507,HCPCS,,,,75987008010,NDC,1,ML,48367.38,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,23216.3424,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3090.93,47400.0324
pegloticase 8 MG/ML Solution 1 mL Vial,J2507.01,CDM,636,RC,J2507,HCPCS,,,,75987008010,NDC,1,ML,48367.38,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,23700.0162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3090.93,47400.0324
pegloticase 8 MG/ML Solution 1 mL Vial,J2507.01,CDM,636,RC,J2507,HCPCS,,,,75987008010,NDC,1,ML,48367.38,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,23700.0162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3090.93,47400.0324
pegloticase 8 MG/ML Solution 1 mL Vial,J2507.01,CDM,636,RC,J2507,HCPCS,,,,75987008010,NDC,1,ML,48367.38,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,23700.0162,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3090.93,47400.0324
pegloticase 8 MG/ML Solution 1 mL Vial,J2507.01,CDM,636,RC,J2507,HCPCS,,,,75987008010,NDC,1,ML,48367.38,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,23941.8531,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3090.93,47400.0324
cabazitaxel 60 MG/1.5ML Solution 6 mL Vial,J9043.01,CDM,636,RC,J9043,HCPCS,,,,24582411,NDC,6,ML,28293.07,,First Health,Commercial,both,85,,999999999,percent of total billed charges,24049.1095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.96,27727.2086
pegloticase 8 MG/ML Solution 1 mL Vial,J2507.01,CDM,636,RC,J2507,HCPCS,,,,75987008010,NDC,1,ML,48367.38,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,24473.89428,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3090.93,47400.0324
cabazitaxel 60 MG/1.5ML Solution 6 mL Vial,J9043.01,CDM,636,RC,J9043,HCPCS,,,,24582411,NDC,6,ML,28293.07,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,24954.48774,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.96,27727.2086
cabazitaxel 60 MG/1.5ML Solution 6 mL Vial,J9043.01,CDM,636,RC,J9043,HCPCS,,,,24582411,NDC,6,ML,28293.07,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,25180.8323,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.96,27727.2086
cabazitaxel 60 MG/1.5ML Solution 6 mL Vial,J9043.01,CDM,636,RC,J9043,HCPCS,,,,24582411,NDC,6,ML,28293.07,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,25774.98677,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.96,27727.2086
cabazitaxel 60 MG/1.5ML Solution 6 mL Vial,J9043.01,CDM,636,RC,J9043,HCPCS,,,,24582411,NDC,6,ML,28293.07,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,27537.64503,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.96,27727.2086
cabazitaxel 60 MG/1.5ML Solution 6 mL Vial,J9043.01,CDM,636,RC,J9043,HCPCS,,,,24582411,NDC,6,ML,28293.07,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,27727.2086,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,192.96,27727.2086
ocrelizumab 300 MG/10ML Solution 10 mL Vial,J2350.01,CDM,636,RC,J2350,HCPCS,,,,50242015001,NDC,10,ML,33150,,First Health,Commercial,both,85,,999999999,percent of total billed charges,28177.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.47,32487
ocrelizumab 300 MG/10ML Solution 10 mL Vial,J2350.01,CDM,636,RC,J2350,HCPCS,,,,50242015001,NDC,10,ML,33150,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,29238.3,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.47,32487
ocrelizumab 300 MG/10ML Solution 10 mL Vial,J2350.01,CDM,636,RC,J2350,HCPCS,,,,50242015001,NDC,10,ML,33150,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,29503.5,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.47,32487
ocrelizumab 300 MG/10ML Solution 10 mL Vial,J2350.01,CDM,636,RC,J2350,HCPCS,,,,50242015001,NDC,10,ML,33150,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,30199.65,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.47,32487
ocrelizumab 300 MG/10ML Solution 10 mL Vial,J2350.01,CDM,636,RC,J2350,HCPCS,,,,50242015001,NDC,10,ML,33150,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,32487,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,49.47,32487
pegloticase 8 MG/ML Solution 1 mL Vial,J2507.01,CDM,636,RC,J2507,HCPCS,,,,75987008010,NDC,1,ML,48367.38,,First Health,Commercial,both,85,,999999999,percent of total billed charges,41112.273,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3090.93,47400.0324
pegloticase 8 MG/ML Solution 1 mL Vial,J2507.01,CDM,636,RC,J2507,HCPCS,,,,75987008010,NDC,1,ML,48367.38,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,42660.02916,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3090.93,47400.0324
pegloticase 8 MG/ML Solution 1 mL Vial,J2507.01,CDM,636,RC,J2507,HCPCS,,,,75987008010,NDC,1,ML,48367.38,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,43046.9682,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3090.93,47400.0324
pegloticase 8 MG/ML Solution 1 mL Vial,J2507.01,CDM,636,RC,J2507,HCPCS,,,,75987008010,NDC,1,ML,48367.38,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,44062.68318,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3090.93,47400.0324
pegloticase 8 MG/ML Solution 1 mL Vial,J2507.01,CDM,636,RC,J2507,HCPCS,,,,75987008010,NDC,1,ML,48367.38,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,47075.97095,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3090.93,47400.0324
pegloticase 8 MG/ML Solution 1 mL Vial,J2507.01,CDM,636,RC,J2507,HCPCS,,,,75987008010,NDC,1,ML,48367.38,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,47400.0324,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,3090.93,47400.0324
Abd Paracentesis W/Imaging(P),PX49083P,CDM,983,RC,49083,CPT,,,,,,,,696,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Abd Paracentesis W/Imaging(P),PX49083P,CDM,983,RC,49083,CPT,,,,,,,,696,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Amputation Finger/Thumb,PX26951P,CDM,983,RC,26951,CPT,,,,,,,,2603,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Amputation Finger/Thumb,PX26951P,CDM,983,RC,26951,CPT,,,,,,,,2603,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Amputation Metatarsal+Toe,Single",PX28810P,CDM,983,RC,28810,CPT,,,,,,,,620,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Amputation Metatarsal+Toe,Single",PX28810P,CDM,983,RC,28810,CPT,,,,,,,,620,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Amputation Toe,I-P Jt",PX28825P,CDM,983,RC,28825,CPT,,,,,,,,780,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Amputation Toe,I-P Jt",PX28825P,CDM,983,RC,28825,CPT,,,,,,,,780,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Amputation Toe,Mt-P Jt",PX28820P,CDM,983,RC,28820,CPT,,,,,,,,1300,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Amputation Toe,Mt-P Jt",PX28820P,CDM,983,RC,28820,CPT,,,,,,,,1300,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anal Sphincterotomy,PX46080P,CDM,983,RC,46080,CPT,,,,,,,,525,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anal Sphincterotomy,PX46080P,CDM,983,RC,46080,CPT,,,,,,,,525,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Dx Shoulder Arthroscopy,PX01622.01,CDM,964,RC,1622,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Dx Shoulder Arthroscopy,PX01622.01,CDM,964,RC,1622,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Lower Intestinal Endoscopic Px Nos,PX00811.01,CDM,964,RC,811,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,34.36371681,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Lower Intestinal Endoscopic Px Nos,PX00811.01,CDM,964,RC,811,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Lower Intestinal Screening Colonoscopy,PX00812.01,CDM,964,RC,812,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,16.73296703,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Lower Intestinal Screening Colonoscopy,PX00812.01,CDM,964,RC,812,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Spine Transthor W/Vent,PX00626.01,CDM,964,RC,626,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Spine Transthor W/Vent,PX00626.01,CDM,964,RC,626,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Spine Tranthor W/O Vent,PX00625.01,CDM,964,RC,625,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Spine Tranthor W/O Vent,PX00625.01,CDM,964,RC,625,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Ther Interven Rad Art,PX01924.01,CDM,964,RC,1924,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Ther Interven Rad Art,PX01924.01,CDM,964,RC,1924,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Ther Interven Rad Car,PX01925.01,CDM,964,RC,1925,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Ther Interven Rad Car,PX01925.01,CDM,964,RC,1925,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Ther Interven Rad Tip,PX01931.01,CDM,964,RC,1931,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Ther Interven Rad Tip,PX01931.01,CDM,964,RC,1931,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Ther Interven Rad Vei,PX01930.01,CDM,964,RC,1930,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Ther Interven Rad Vei,PX01930.01,CDM,964,RC,1930,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Tx Interv Rad Cran V,PX01933.01,CDM,964,RC,1933,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Tx Interv Rad Cran V,PX01933.01,CDM,964,RC,1933,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Tx Interv Rad Hrt/Cran,PX01926.01,CDM,964,RC,1926,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Tx Interv Rad Hrt/Cran,PX01926.01,CDM,964,RC,1926,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Tx Interv Rad Th Vein,PX01932.01,CDM,964,RC,1932,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Tx Interv Rad Th Vein,PX01932.01,CDM,964,RC,1932,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Upper GI Endoscopic Px Ercp,PX00732.01,CDM,964,RC,732,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Upper GI Endoscopic Px Ercp,PX00732.01,CDM,964,RC,732,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Upper GI Endoscopic Px Nos,PX00731.01,CDM,964,RC,731,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,8.928666667,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Upper GI Endoscopic Px Nos,PX00731.01,CDM,964,RC,731,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Upper/Lower GI Endoscopic Px,PX00813.01,CDM,964,RC,813,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes Upper/Lower GI Endoscopic Px,PX00813.01,CDM,964,RC,813,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes/Analg Cs Deliver Add-On,PX01968.01,CDM,964,RC,1968,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anes/Analg Cs Deliver Add-On,PX01968.01,CDM,964,RC,1968,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Abdomen Vessel Surg,PX00880.01,CDM,964,RC,880,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Abdomen Vessel Surg,PX00880.01,CDM,964,RC,880,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Abdominal Wall Surg,PX00700.01,CDM,964,RC,700,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Abdominal Wall Surg,PX00700.01,CDM,964,RC,700,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Abdominal Wall Surg,PX00730.01,CDM,964,RC,730,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Abdominal Wall Surg,PX00730.01,CDM,964,RC,730,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Abdominal Wall Surg,PX00800.01,CDM,964,RC,800,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Abdominal Wall Surg,PX00800.01,CDM,964,RC,800,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Abdominal Wall Surg,PX00820.01,CDM,964,RC,820,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Abdominal Wall Surg,PX00820.01,CDM,964,RC,820,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Achilles Tendon Surg,PX01472.01,CDM,964,RC,1472,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Achilles Tendon Surg,PX01472.01,CDM,964,RC,1472,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Airplane Cast,PX01682.01,CDM,964,RC,1682,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Airplane Cast,PX01682.01,CDM,964,RC,1682,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Amniocentesis,PX00842.01,CDM,964,RC,842,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Amniocentesis,PX00842.01,CDM,964,RC,842,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Amputation at Knee,PX01404.01,CDM,964,RC,1404,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Amputation at Knee,PX01404.01,CDM,964,RC,1404,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Amputation at Pelvis,PX01140.01,CDM,964,RC,1140,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Amputation at Pelvis,PX01140.01,CDM,964,RC,1140,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Amputation of Femur,PX01232.01,CDM,964,RC,1232,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Amputation of Femur,PX01232.01,CDM,964,RC,1232,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Amputation of Penis,PX00932.01,CDM,964,RC,932,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Amputation of Penis,PX00932.01,CDM,964,RC,932,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Ankle Replacement,PX01486.01,CDM,964,RC,1486,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Ankle Replacement,PX01486.01,CDM,964,RC,1486,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Ankle/Ft Arthroscopy,PX01464.01,CDM,964,RC,1464,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Ankle/Ft Arthroscopy,PX01464.01,CDM,964,RC,1464,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Anorectal Surgery,PX00902.01,CDM,964,RC,902,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Anorectal Surgery,PX00902.01,CDM,964,RC,902,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Antepartum Manipul,PX01958.01,CDM,964,RC,1958,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Antepartum Manipul,PX01958.01,CDM,964,RC,1958,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Arm-Leg Vessel Surg,PX01656.01,CDM,964,RC,1656,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Arm-Leg Vessel Surg,PX01656.01,CDM,964,RC,1656,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Arthroscopy of Hip,PX01202.01,CDM,964,RC,1202,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Arthroscopy of Hip,PX01202.01,CDM,964,RC,1202,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Biceps Tendon Repair,PX01716.01,CDM,964,RC,1716,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Biceps Tendon Repair,PX01716.01,CDM,964,RC,1716,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Biopsy of Nose,PX00164.01,CDM,964,RC,164,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Biopsy of Nose,PX00164.01,CDM,964,RC,164,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Biopsy of Thyroid,PX00322.01,CDM,964,RC,322,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Biopsy of Thyroid,PX00322.01,CDM,964,RC,322,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Bladder Stone Surg,PX00870.01,CDM,964,RC,870,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Bladder Stone Surg,PX00870.01,CDM,964,RC,870,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Bladder Surgery,PX00910.01,CDM,964,RC,910,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Bladder Surgery,PX00910.01,CDM,964,RC,910,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Bladder Tumor Surg,PX00912.01,CDM,964,RC,912,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Bladder Tumor Surg,PX00912.01,CDM,964,RC,912,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Bleeding Control,PX00916.01,CDM,964,RC,916,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Bleeding Control,PX00916.01,CDM,964,RC,916,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Blepharoplasty,PX00103.01,CDM,964,RC,103,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Blepharoplasty,PX00103.01,CDM,964,RC,103,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Blood Vessel Repair,PX00770.01,CDM,964,RC,770,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Blood Vessel Repair,PX00770.01,CDM,964,RC,770,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Body Cast Procedure,PX01130.01,CDM,964,RC,1130,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Body Cast Procedure,PX01130.01,CDM,964,RC,1130,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Bone Aspirate/Bx,PX01112.01,CDM,964,RC,1112,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Bone Aspirate/Bx,PX01112.01,CDM,964,RC,1112,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Burn 4-9 Percent,PX01952.01,CDM,964,RC,1952,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Burn 4-9 Percent,PX01952.01,CDM,964,RC,1952,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Burn Each 9 Percent,PX01953.01,CDM,964,RC,1953,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Burn Each 9 Percent,PX01953.01,CDM,964,RC,1953,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Burn Less 4 Percent,PX01951.01,CDM,964,RC,1951,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Burn Less 4 Percent,PX01951.01,CDM,964,RC,1951,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cabg W/O Pump,PX00566.01,CDM,964,RC,566,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cabg W/O Pump,PX00566.01,CDM,964,RC,566,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cabg W/Pump,PX00567.01,CDM,964,RC,567,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cabg W/Pump,PX00567.01,CDM,964,RC,567,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cardiac Electrophys,PX00537.01,CDM,964,RC,537,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cardiac Electrophys,PX00537.01,CDM,964,RC,537,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cardioverter/Defib,PX00534.01,CDM,964,RC,534,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cardioverter/Defib,PX00534.01,CDM,964,RC,534,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cat or MRI Scan,PX01922.01,CDM,964,RC,1922,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cat or MRI Scan,PX01922.01,CDM,964,RC,1922,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Catheterize Heart,PX01920.01,CDM,964,RC,1920,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Catheterize Heart,PX01920.01,CDM,964,RC,1920,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Drainage,PX00524.01,CDM,964,RC,524,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Drainage,PX00524.01,CDM,964,RC,524,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Lining Biopsy,PX00522.01,CDM,964,RC,522,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Lining Biopsy,PX00522.01,CDM,964,RC,522,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Partition View,PX00528.01,CDM,964,RC,528,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Partition View,PX00528.01,CDM,964,RC,528,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Partition View,PX00529.01,CDM,964,RC,529,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Partition View,PX00529.01,CDM,964,RC,529,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Procedure,PX00520.01,CDM,964,RC,520,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Procedure,PX00520.01,CDM,964,RC,520,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Surgery,PX00540.01,CDM,964,RC,540,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Surgery,PX00540.01,CDM,964,RC,540,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Wall Repair,PX00472.01,CDM,964,RC,472,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Chest Wall Repair,PX00472.01,CDM,964,RC,472,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cleft Palate Repair,PX00172.01,CDM,964,RC,172,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cleft Palate Repair,PX00172.01,CDM,964,RC,172,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Collar Bone Biopsy,PX00454.01,CDM,964,RC,454,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Collar Bone Biopsy,PX00454.01,CDM,964,RC,454,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Corneal Transplant,PX00144.01,CDM,964,RC,144,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Corneal Transplant,PX00144.01,CDM,964,RC,144,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Correct Heart Rhythm,PX00410.01,CDM,964,RC,410,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Correct Heart Rhythm,PX00410.01,CDM,964,RC,410,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cran Surg Hemotoma,PX00211.01,CDM,964,RC,211,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cran Surg Hemotoma,PX00211.01,CDM,964,RC,211,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cranial Surg Nos,PX00210.01,CDM,964,RC,210,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cranial Surg Nos,PX00210.01,CDM,964,RC,210,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cs Delivery,PX01961.01,CDM,964,RC,1961,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cs Delivery,PX01961.01,CDM,964,RC,1961,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cs Hysterectomy,PX01963.01,CDM,964,RC,1963,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Cs Hysterectomy,PX01963.01,CDM,964,RC,1963,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Dx Arteriography,PX01916.01,CDM,964,RC,1916,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Dx Arteriography,PX01916.01,CDM,964,RC,1916,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Dx Elbow Arthroscopy,PX01732.01,CDM,964,RC,1732,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Dx Elbow Arthroscopy,PX01732.01,CDM,964,RC,1732,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Dx Knee Arthroscopy,PX01382.01,CDM,964,RC,1382,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Dx Knee Arthroscopy,PX01382.01,CDM,964,RC,1382,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Dx Wrist Arthroscopy,PX01829.01,CDM,964,RC,1829,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Dx Wrist Arthroscopy,PX01829.01,CDM,964,RC,1829,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Ear Exam,PX00124.01,CDM,964,RC,124,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Ear Exam,PX00124.01,CDM,964,RC,124,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Ear Surgery,PX00120.01,CDM,964,RC,120,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Ear Surgery,PX00120.01,CDM,964,RC,120,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Elbow Area Surgery,PX01710.01,CDM,964,RC,1710,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Elbow Area Surgery,PX01710.01,CDM,964,RC,1710,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Elbow Replacement,PX01760.01,CDM,964,RC,1760,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Elbow Replacement,PX01760.01,CDM,964,RC,1760,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Electroshock,PX00104.01,CDM,964,RC,104,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Electroshock,PX00104.01,CDM,964,RC,104,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Emer Hysterectomy,PX01962.01,CDM,964,RC,1962,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Emer Hysterectomy,PX01962.01,CDM,964,RC,1962,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Esophageal Surgery,PX00500.01,CDM,964,RC,500,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Esophageal Surgery,PX00500.01,CDM,964,RC,500,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Eye Exam,PX00148.01,CDM,964,RC,148,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Eye Exam,PX00148.01,CDM,964,RC,148,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Face/Skull Bone Surg,PX00190.01,CDM,964,RC,190,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Face/Skull Bone Surg,PX00190.01,CDM,964,RC,190,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Facial Bone Surgery,PX00192.01,CDM,964,RC,192,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Facial Bone Surgery,PX00192.01,CDM,964,RC,192,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Fat Layer Removal,PX00802.01,CDM,964,RC,802,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Fat Layer Removal,PX00802.01,CDM,964,RC,802,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Femoral Artery Surg,PX01272.01,CDM,964,RC,1272,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Femoral Artery Surg,PX01272.01,CDM,964,RC,1272,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Femoral Embolectomy,PX01274.01,CDM,964,RC,1274,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Femoral Embolectomy,PX01274.01,CDM,964,RC,1274,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth for Chemonucleolysis,PX00634.01,CDM,964,RC,634,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth for Chemonucleolysis,PX00634.01,CDM,964,RC,634,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth for Liver Biopsy,PX00702.01,CDM,964,RC,702,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth for Liver Biopsy,PX00702.01,CDM,964,RC,702,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth for Liver Transplant,PX00796.01,CDM,964,RC,796,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth for Liver Transplant,PX00796.01,CDM,964,RC,796,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Forequarter Amput,PX01636.01,CDM,964,RC,1636,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Forequarter Amput,PX01636.01,CDM,964,RC,1636,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Fx Repair Pelvis,PX01173.01,CDM,964,RC,1173,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Fx Repair Pelvis,PX01173.01,CDM,964,RC,1173,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Genitalia Surgery,PX00920.01,CDM,964,RC,920,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Genitalia Surgery,PX00920.01,CDM,964,RC,920,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Head Nerve Surgery,PX00222.01,CDM,964,RC,222,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Head Nerve Surgery,PX00222.01,CDM,964,RC,222,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Head Vessel Surgery,PX00216.01,CDM,964,RC,216,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Head Vessel Surgery,PX00216.01,CDM,964,RC,216,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Head/Neck/Ptrunk,PX00300.01,CDM,964,RC,300,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,141.0589474,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Head/Neck/Ptrunk,PX00300.01,CDM,964,RC,300,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Heart Surg < 1 Yr,PX00561.01,CDM,964,RC,561,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Heart Surg < 1 Yr,PX00561.01,CDM,964,RC,561,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Heart Surg W/Arrest,PX00563.01,CDM,964,RC,563,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Heart Surg W/Arrest,PX00563.01,CDM,964,RC,563,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Heart Surg W/O Pump,PX00560.01,CDM,964,RC,560,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Heart Surg W/O Pump,PX00560.01,CDM,964,RC,560,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Heart/Lung Transplnt,PX00580.01,CDM,964,RC,580,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Heart/Lung Transplnt,PX00580.01,CDM,964,RC,580,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hemorr/Excise Liver,PX00792.01,CDM,964,RC,792,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hemorr/Excise Liver,PX00792.01,CDM,964,RC,792,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hernia Repair < 1 Yr,PX00834.01,CDM,964,RC,834,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hernia Repair < 1 Yr,PX00834.01,CDM,964,RC,834,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hernia Repair Preemie,PX00836.01,CDM,964,RC,836,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hernia Repair Preemie,PX00836.01,CDM,964,RC,836,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hip Arthroplasty,PX01214.01,CDM,964,RC,1214,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hip Arthroplasty,PX01214.01,CDM,964,RC,1214,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hip Disarticulation,PX01212.01,CDM,964,RC,1212,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hip Disarticulation,PX01212.01,CDM,964,RC,1212,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hip Joint Procedure,PX01200.01,CDM,964,RC,1200,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hip Joint Procedure,PX01200.01,CDM,964,RC,1200,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hip Joint Surgery,PX01210.01,CDM,964,RC,1210,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hip Joint Surgery,PX01210.01,CDM,964,RC,1210,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hrt Surg W/Pmp Age 1+,PX00562.01,CDM,964,RC,562,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hrt Surg W/Pmp Age 1+,PX00562.01,CDM,964,RC,562,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Humeral Lesion Surg,PX01758.01,CDM,964,RC,1758,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Humeral Lesion Surg,PX01758.01,CDM,964,RC,1758,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Humerus Repair,PX01744.01,CDM,964,RC,1744,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Humerus Repair,PX01744.01,CDM,964,RC,1744,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Humerus Surgery,PX01742.01,CDM,964,RC,1742,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Humerus Surgery,PX01742.01,CDM,964,RC,1742,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hysterectomy,PX00846.01,CDM,964,RC,846,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hysterectomy,PX00846.01,CDM,964,RC,846,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hysteroscope/Graph,PX00952.01,CDM,964,RC,952,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Hysteroscope/Graph,PX00952.01,CDM,964,RC,952,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Inc/Missed Ab Proc,PX01965.01,CDM,964,RC,1965,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Inc/Missed Ab Proc,PX01965.01,CDM,964,RC,1965,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Induced Ab Procedure,PX01966.01,CDM,964,RC,1966,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Induced Ab Procedure,PX01966.01,CDM,964,RC,1966,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Insert Penis Device,PX00938.01,CDM,964,RC,938,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Insert Penis Device,PX00938.01,CDM,964,RC,938,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Intrcrn Nerve,PX00220.01,CDM,964,RC,220,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Intrcrn Nerve,PX00220.01,CDM,964,RC,220,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Iridectomy,PX00147.01,CDM,964,RC,147,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Iridectomy,PX00147.01,CDM,964,RC,147,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Kidney Stone Destruct,PX00872.01,CDM,964,RC,872,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Kidney Stone Destruct,PX00872.01,CDM,964,RC,872,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Kidney Stone Destruct,PX00873.01,CDM,964,RC,873,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Kidney Stone Destruct,PX00873.01,CDM,964,RC,873,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Kidney Transplant,PX00868.01,CDM,964,RC,868,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Kidney Transplant,PX00868.01,CDM,964,RC,868,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Kidney/Ureter Surg,PX00862.01,CDM,964,RC,862,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Kidney/Ureter Surg,PX00862.01,CDM,964,RC,862,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Area Procedure,PX01340.01,CDM,964,RC,1340,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Area Procedure,PX01340.01,CDM,964,RC,1340,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Area Procedure,PX01390.01,CDM,964,RC,1390,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Area Procedure,PX01390.01,CDM,964,RC,1390,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Area Surgery,PX01320.01,CDM,964,RC,1320,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Area Surgery,PX01320.01,CDM,964,RC,1320,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Area Surgery,PX01360.01,CDM,964,RC,1360,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Area Surgery,PX01360.01,CDM,964,RC,1360,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Area Surgery,PX01392.01,CDM,964,RC,1392,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Area Surgery,PX01392.01,CDM,964,RC,1392,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Arteries Surg,PX01440.01,CDM,964,RC,1440,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Arteries Surg,PX01440.01,CDM,964,RC,1440,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Artery Repair,PX01444.01,CDM,964,RC,1444,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Artery Repair,PX01444.01,CDM,964,RC,1444,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Artery Surg,PX01442.01,CDM,964,RC,1442,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Artery Surg,PX01442.01,CDM,964,RC,1442,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Arthroplasty,PX01402.01,CDM,964,RC,1402,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Arthroplasty,PX01402.01,CDM,964,RC,1402,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Joint Casting,PX01420.01,CDM,964,RC,1420,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Joint Casting,PX01420.01,CDM,964,RC,1420,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Joint Procedure,PX01380.01,CDM,964,RC,1380,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Joint Procedure,PX01380.01,CDM,964,RC,1380,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Joint Surgery,PX01400.01,CDM,964,RC,1400,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Joint Surgery,PX01400.01,CDM,964,RC,1400,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Veins Surgery,PX01430.01,CDM,964,RC,1430,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Veins Surgery,PX01430.01,CDM,964,RC,1430,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Vessel Surg,PX01432.01,CDM,964,RC,1432,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Knee Vessel Surg,PX01432.01,CDM,964,RC,1432,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Larynx/Trach < 1 Yr,PX00326.01,CDM,964,RC,326,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Larynx/Trach < 1 Yr,PX00326.01,CDM,964,RC,326,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Leg Arteries Surg,PX01500.01,CDM,964,RC,1500,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Leg Arteries Surg,PX01500.01,CDM,964,RC,1500,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lens Surgery,PX00142.01,CDM,964,RC,142,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lens Surgery,PX00142.01,CDM,964,RC,142,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Low Intestine Scope,PX00810.01,CDM,964,RC,810,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Low Intestine Scope,PX00810.01,CDM,964,RC,810,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Arm Casting,PX01860.01,CDM,964,RC,1860,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Arm Casting,PX01860.01,CDM,964,RC,1860,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Arm Procedure,PX01820.01,CDM,964,RC,1820,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Arm Procedure,PX01820.01,CDM,964,RC,1820,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Arm Surgery,PX01810.01,CDM,964,RC,1810,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Arm Surgery,PX01810.01,CDM,964,RC,1810,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Arm Surgery,PX01830.01,CDM,964,RC,1830,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Arm Surgery,PX01830.01,CDM,964,RC,1830,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Arm Vein Surg,PX01850.01,CDM,964,RC,1850,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Arm Vein Surg,PX01850.01,CDM,964,RC,1850,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Bone Surg,PX01480.01,CDM,964,RC,1480,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Bone Surg,PX01480.01,CDM,964,RC,1480,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Casting,PX01490.01,CDM,964,RC,1490,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Casting,PX01490.01,CDM,964,RC,1490,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Procedure,PX01462.01,CDM,964,RC,1462,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Procedure,PX01462.01,CDM,964,RC,1462,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Revision,PX01484.01,CDM,964,RC,1484,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Revision,PX01484.01,CDM,964,RC,1484,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Surgery,PX01470.01,CDM,964,RC,1470,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Surgery,PX01470.01,CDM,964,RC,1470,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Surgery,PX01474.01,CDM,964,RC,1474,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Surgery,PX01474.01,CDM,964,RC,1474,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Vein Surg,PX01520.01,CDM,964,RC,1520,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Vein Surg,PX01520.01,CDM,964,RC,1520,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Vein Surg,PX01522.01,CDM,964,RC,1522,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lower Leg Vein Surg,PX01522.01,CDM,964,RC,1522,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lumbar Puncture,PX00635.01,CDM,964,RC,635,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lumbar Puncture,PX00635.01,CDM,964,RC,635,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lung Chest Wall Surg,PX00546.01,CDM,964,RC,546,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lung Chest Wall Surg,PX00546.01,CDM,964,RC,546,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lwr Arm Artery Surg,PX01840.01,CDM,964,RC,1840,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lwr Arm Artery Surg,PX01840.01,CDM,964,RC,1840,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lwr Arm Embolectomy,PX01842.01,CDM,964,RC,1842,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lwr Arm Embolectomy,PX01842.01,CDM,964,RC,1842,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lwr Arm Vein Repair,PX01852.01,CDM,964,RC,1852,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lwr Arm Vein Repair,PX01852.01,CDM,964,RC,1852,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lwr Leg Embolectomy,PX01502.01,CDM,964,RC,1502,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Lwr Leg Embolectomy,PX01502.01,CDM,964,RC,1502,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Major Vein Ligation,PX00882.01,CDM,964,RC,882,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Major Vein Ligation,PX00882.01,CDM,964,RC,882,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth N Block/Inj Prone,PX01992.01,CDM,964,RC,1992,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth N Block/Inj Prone,PX01992.01,CDM,964,RC,1992,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Neck Organ 1 & Over,PX00320.01,CDM,964,RC,320,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Neck Organ 1 & Over,PX00320.01,CDM,964,RC,320,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Neck Vessel Surgery,PX00350.01,CDM,964,RC,350,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Neck Vessel Surgery,PX00350.01,CDM,964,RC,350,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Neck Vessel Surgery,PX00352.01,CDM,964,RC,352,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Neck Vessel Surgery,PX00352.01,CDM,964,RC,352,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Nerve Block/Inj,PX01991.01,CDM,964,RC,1991,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Nerve Block/Inj,PX01991.01,CDM,964,RC,1991,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Nose/Sinus Surgery,PX00160.01,CDM,964,RC,160,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Nose/Sinus Surgery,PX00160.01,CDM,964,RC,160,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Nose/Sinus Surgery,PX00162.01,CDM,964,RC,162,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Nose/Sinus Surgery,PX00162.01,CDM,964,RC,162,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth One Lung Ventilation,PX00541.01,CDM,964,RC,541,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth One Lung Ventilation,PX00541.01,CDM,964,RC,541,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pacemaker Insertion,PX00530.01,CDM,964,RC,530,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pacemaker Insertion,PX00530.01,CDM,964,RC,530,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pancreas Removal,PX00794.01,CDM,964,RC,794,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pancreas Removal,PX00794.01,CDM,964,RC,794,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvic Organ Surg,PX00848.01,CDM,964,RC,848,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvic Organ Surg,PX00848.01,CDM,964,RC,848,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvic Tumor Surgery,PX01150.01,CDM,964,RC,1150,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvic Tumor Surgery,PX01150.01,CDM,964,RC,1150,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Nerve Removal,PX01180.01,CDM,964,RC,1180,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Nerve Removal,PX01180.01,CDM,964,RC,1180,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Nerve Removal,PX01190.01,CDM,964,RC,1190,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Nerve Removal,PX01190.01,CDM,964,RC,1190,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Procedure,PX01160.01,CDM,964,RC,1160,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Procedure,PX01160.01,CDM,964,RC,1160,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Surgery,PX00844.01,CDM,964,RC,844,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Surgery,PX00844.01,CDM,964,RC,844,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Surgery,PX01120.01,CDM,964,RC,1120,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Surgery,PX01120.01,CDM,964,RC,1120,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Surgery,PX01170.01,CDM,964,RC,1170,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pelvis Surgery,PX01170.01,CDM,964,RC,1170,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Penis Nodes Removal,PX00934.01,CDM,964,RC,934,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Penis Nodes Removal,PX00934.01,CDM,964,RC,934,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Penis Nodes Removal,PX00936.01,CDM,964,RC,936,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Penis Nodes Removal,PX00936.01,CDM,964,RC,936,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Perc Img Dx Sp Proc,PX01935.01,CDM,964,RC,1935,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Perc Img Dx Sp Proc,PX01935.01,CDM,964,RC,1935,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Perc Img Tx Sp Proc,PX01936.01,CDM,964,RC,1936,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Perc Img Tx Sp Proc,PX01936.01,CDM,964,RC,1936,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Perineal Surgery,PX00904.01,CDM,964,RC,904,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Perineal Surgery,PX00904.01,CDM,964,RC,904,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pharyngeal Surgery,PX00174.01,CDM,964,RC,174,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pharyngeal Surgery,PX00174.01,CDM,964,RC,174,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pharyngeal Surgery,PX00176.01,CDM,964,RC,176,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Pharyngeal Surgery,PX00176.01,CDM,964,RC,176,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Procedure on Femur,PX01220.01,CDM,964,RC,1220,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Procedure on Femur,PX01220.01,CDM,964,RC,1220,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Procedure on Mouth,PX00170.01,CDM,964,RC,170,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Procedure on Mouth,PX00170.01,CDM,964,RC,170,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Procedures on Eye,PX00140.01,CDM,964,RC,140,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Procedures on Eye,PX00140.01,CDM,964,RC,140,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Radical Femur Surg,PX01234.01,CDM,964,RC,1234,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Radical Femur Surg,PX01234.01,CDM,964,RC,1234,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Radical Humerus Surg,PX01756.01,CDM,964,RC,1756,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Radical Humerus Surg,PX01756.01,CDM,964,RC,1756,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Radical Leg Surgery,PX01482.01,CDM,964,RC,1482,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Radical Leg Surgery,PX01482.01,CDM,964,RC,1482,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Release of Lung,PX00542.01,CDM,964,RC,542,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Release of Lung,PX00542.01,CDM,964,RC,542,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Adrenal,PX00866.01,CDM,964,RC,866,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Adrenal,PX00866.01,CDM,964,RC,866,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Bladder,PX00864.01,CDM,964,RC,864,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Bladder,PX00864.01,CDM,964,RC,864,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Nerves,PX00622.01,CDM,964,RC,622,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Nerves,PX00622.01,CDM,964,RC,622,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Nerves,PX00632.01,CDM,964,RC,632,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Nerves,PX00632.01,CDM,964,RC,632,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Prostate,PX00865.01,CDM,964,RC,865,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Prostate,PX00865.01,CDM,964,RC,865,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Prostate,PX00908.01,CDM,964,RC,908,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Prostate,PX00908.01,CDM,964,RC,908,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Rib,PX00470.01,CDM,964,RC,470,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Rib,PX00470.01,CDM,964,RC,470,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Testis,PX00926.01,CDM,964,RC,926,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Testis,PX00926.01,CDM,964,RC,926,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Testis,PX00928.01,CDM,964,RC,928,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Testis,PX00928.01,CDM,964,RC,928,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Vulva,PX00906.01,CDM,964,RC,906,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Removal of Vulva,PX00906.01,CDM,964,RC,906,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Cervix,PX00948.01,CDM,964,RC,948,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Cervix,PX00948.01,CDM,964,RC,948,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Cleft Lip,PX00102.01,CDM,964,RC,102,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Cleft Lip,PX00102.01,CDM,964,RC,102,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00750.01,CDM,964,RC,750,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00750.01,CDM,964,RC,750,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00752.01,CDM,964,RC,752,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00752.01,CDM,964,RC,752,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00754.01,CDM,964,RC,754,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00754.01,CDM,964,RC,754,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00756.01,CDM,964,RC,756,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00756.01,CDM,964,RC,756,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00830.01,CDM,964,RC,830,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00830.01,CDM,964,RC,830,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00832.01,CDM,964,RC,832,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Repair of Hernia,PX00832.01,CDM,964,RC,832,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Revise Hip Repair,PX01215.01,CDM,964,RC,1215,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Revise Hip Repair,PX01215.01,CDM,964,RC,1215,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Salivary Gland,PX00100.01,CDM,964,RC,100,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Salivary Gland,PX00100.01,CDM,964,RC,100,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Artery Surg,PX01650.01,CDM,964,RC,1650,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Artery Surg,PX01650.01,CDM,964,RC,1650,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Casting,PX01680.01,CDM,964,RC,1680,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Casting,PX01680.01,CDM,964,RC,1680,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Joint Amput,PX01634.01,CDM,964,RC,1634,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Joint Amput,PX01634.01,CDM,964,RC,1634,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Procedure,PX01620.01,CDM,964,RC,1620,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Procedure,PX01620.01,CDM,964,RC,1620,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Replacement,PX01638.01,CDM,964,RC,1638,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Replacement,PX01638.01,CDM,964,RC,1638,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Vein Surg,PX01670.01,CDM,964,RC,1670,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Vein Surg,PX01670.01,CDM,964,RC,1670,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Vessel Surg,PX01652.01,CDM,964,RC,1652,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Vessel Surg,PX01652.01,CDM,964,RC,1652,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Vessel Surg,PX01654.01,CDM,964,RC,1654,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Shoulder Vessel Surg,PX01654.01,CDM,964,RC,1654,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Sitting Procedure,PX00604.01,CDM,964,RC,604,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Sitting Procedure,PX00604.01,CDM,964,RC,604,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Skin Ext/per/Atrunk,PX00400.01,CDM,964,RC,400,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Skin Ext/per/Atrunk,PX00400.01,CDM,964,RC,400,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Skull Drainage,PX00212.01,CDM,964,RC,212,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Skull Drainage,PX00212.01,CDM,964,RC,212,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Skull Drainage,PX00214.01,CDM,964,RC,214,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Skull Drainage,PX00214.01,CDM,964,RC,214,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Skull Repair/Fract,PX00215.01,CDM,964,RC,215,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Skull Repair/Fract,PX00215.01,CDM,964,RC,215,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Special Head Surgery,PX00218.01,CDM,964,RC,218,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Special Head Surgery,PX00218.01,CDM,964,RC,218,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Sperm Duct Surgery,PX00922.01,CDM,964,RC,922,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Sperm Duct Surgery,PX00922.01,CDM,964,RC,922,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Spine Cord Surgery,PX00600.01,CDM,964,RC,600,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Spine Cord Surgery,PX00600.01,CDM,964,RC,600,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Spine Cord Surgery,PX00620.01,CDM,964,RC,620,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Spine Cord Surgery,PX00620.01,CDM,964,RC,620,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Spine Cord Surgery,PX00630.01,CDM,964,RC,630,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Spine Cord Surgery,PX00630.01,CDM,964,RC,630,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Spine Cord Surgery,PX00670.01,CDM,964,RC,670,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Spine Cord Surgery,PX00670.01,CDM,964,RC,670,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Spine Manipulation,PX00640.01,CDM,964,RC,640,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Spine Manipulation,PX00640.01,CDM,964,RC,640,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Sternal Debridement,PX00550.01,CDM,964,RC,550,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Sternal Debridement,PX00550.01,CDM,964,RC,550,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Stone Removal,PX00918.01,CDM,964,RC,918,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Stone Removal,PX00918.01,CDM,964,RC,918,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surg Lower Abdomen,PX00840.01,CDM,964,RC,840,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surg Lower Abdomen,PX00840.01,CDM,964,RC,840,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surg on Vag/Urethral,PX00942.01,CDM,964,RC,942,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surg on Vag/Urethral,PX00942.01,CDM,964,RC,942,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surg Upper Abdomen,PX00790.01,CDM,964,RC,790,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surg Upper Abdomen,PX00790.01,CDM,964,RC,790,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery for Obesity,PX00797.01,CDM,964,RC,797,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery for Obesity,PX00797.01,CDM,964,RC,797,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Abdomen,PX00860.01,CDM,964,RC,860,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Abdomen,PX00860.01,CDM,964,RC,860,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Breast,PX00402.01,CDM,964,RC,402,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Breast,PX00402.01,CDM,964,RC,402,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Breast,PX00404.01,CDM,964,RC,404,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Breast,PX00404.01,CDM,964,RC,404,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Breast,PX00406.01,CDM,964,RC,406,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Breast,PX00406.01,CDM,964,RC,406,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Femur,PX01230.01,CDM,964,RC,1230,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Femur,PX01230.01,CDM,964,RC,1230,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Rib(S),PX00474.01,CDM,964,RC,474,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Rib(S),PX00474.01,CDM,964,RC,474,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Shoulder,PX00450.01,CDM,964,RC,450,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Shoulder,PX00450.01,CDM,964,RC,450,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Shoulder,PX00452.01,CDM,964,RC,452,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Shoulder,PX00452.01,CDM,964,RC,452,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Shoulder,PX01610.01,CDM,964,RC,1610,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Shoulder,PX01610.01,CDM,964,RC,1610,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Shoulder,PX01630.01,CDM,964,RC,1630,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Surgery of Shoulder,PX01630.01,CDM,964,RC,1630,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Testis Exploration,PX00924.01,CDM,964,RC,924,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Testis Exploration,PX00924.01,CDM,964,RC,924,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Testis Suspension,PX00930.01,CDM,964,RC,930,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Testis Suspension,PX00930.01,CDM,964,RC,930,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Thigh Arteries Surg,PX01270.01,CDM,964,RC,1270,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Thigh Arteries Surg,PX01270.01,CDM,964,RC,1270,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Trach-Bronch Reconst,PX00539.01,CDM,964,RC,539,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Trach-Bronch Reconst,PX00539.01,CDM,964,RC,539,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Trachea Bronchi Surg,PX00548.01,CDM,964,RC,548,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Trachea Bronchi Surg,PX00548.01,CDM,964,RC,548,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Trans Resect of Prostate,PX00914.01,CDM,964,RC,914,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Trans Resect of Prostate,PX00914.01,CDM,964,RC,914,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Tubal Ligation,PX00851.01,CDM,964,RC,851,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Tubal Ligation,PX00851.01,CDM,964,RC,851,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Tympanotomy,PX00126.01,CDM,964,RC,126,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Tympanotomy,PX00126.01,CDM,964,RC,126,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Upper Arm Surgery,PX01740.01,CDM,964,RC,1740,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Upper Arm Surgery,PX01740.01,CDM,964,RC,1740,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Upper Arm Vein Surg,PX01780.01,CDM,964,RC,1780,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Upper Arm Vein Surg,PX01780.01,CDM,964,RC,1780,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Upper GI Visualize,PX00740.01,CDM,964,RC,740,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Upper GI Visualize,PX00740.01,CDM,964,RC,740,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Upper Leg Surgery,PX01250.01,CDM,964,RC,1250,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Upper Leg Surgery,PX01250.01,CDM,964,RC,1250,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Upper Leg Veins Surg,PX01260.01,CDM,964,RC,1260,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Upper Leg Veins Surg,PX01260.01,CDM,964,RC,1260,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Artery Surg,PX01770.01,CDM,964,RC,1770,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Artery Surg,PX01770.01,CDM,964,RC,1770,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Embolectomy,PX01772.01,CDM,964,RC,1772,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Embolectomy,PX01772.01,CDM,964,RC,1772,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Procedure,PX01730.01,CDM,964,RC,1730,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Procedure,PX01730.01,CDM,964,RC,1730,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Tendon Surg,PX01712.01,CDM,964,RC,1712,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Tendon Surg,PX01712.01,CDM,964,RC,1712,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Tendon Surg,PX01714.01,CDM,964,RC,1714,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Tendon Surg,PX01714.01,CDM,964,RC,1714,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Vein Repair,PX01782.01,CDM,964,RC,1782,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Uppr Arm Vein Repair,PX01782.01,CDM,964,RC,1782,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vaginal Delivery,PX01960.01,CDM,964,RC,1960,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vaginal Delivery,PX01960.01,CDM,964,RC,1960,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vaginal Endoscopy,PX00950.01,CDM,964,RC,950,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vaginal Endoscopy,PX00950.01,CDM,964,RC,950,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vaginal Hysterectomy,PX00944.01,CDM,964,RC,944,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vaginal Hysterectomy,PX00944.01,CDM,964,RC,944,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vaginal Procedures,PX00940.01,CDM,964,RC,940,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vaginal Procedures,PX00940.01,CDM,964,RC,940,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vascular Access,PX00532.01,CDM,964,RC,532,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vascular Access,PX00532.01,CDM,964,RC,532,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vascular Shunt Surg,PX01844.01,CDM,964,RC,1844,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vascular Shunt Surg,PX01844.01,CDM,964,RC,1844,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vasectomy,PX00921.01,CDM,964,RC,921,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vasectomy,PX00921.01,CDM,964,RC,921,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vitreoretinal Surg,PX00145.01,CDM,964,RC,145,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Vitreoretinal Surg,PX00145.01,CDM,964,RC,145,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Wrist Replacement,PX01832.01,CDM,964,RC,1832,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth Wrist Replacement,PX01832.01,CDM,964,RC,1832,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth/Analg Cs Hyst Add-On,PX01969.01,CDM,964,RC,1969,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth/Analg Cs Hyst Add-On,PX01969.01,CDM,964,RC,1969,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth/Analg Vag Delivery,PX01967.01,CDM,964,RC,1967,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anesth/Analg Vag Delivery,PX01967.01,CDM,964,RC,1967,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anus Surgery Procedure Unlisted,PX46999P,CDM,983,RC,46999,CPT,,,,,,,,953,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Anus Surgery Procedure Unlisted,PX46999P,CDM,983,RC,46999,CPT,,,,,,,,953,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Apply Finger Splint,Static",PX29130P,CDM,983,RC,29130,CPT,,,,,,,,223,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Apply Finger Splint,Static",PX29130P,CDM,983,RC,29130,CPT,,,,,,,,223,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Forearm Cast,PX29075P,CDM,983,RC,29075,CPT,,,,,,,,140,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Forearm Cast,PX29075P,CDM,983,RC,29075,CPT,,,,,,,,140,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Apply Forearm Splint,Static",PX29125P,CDM,983,RC,29125,CPT,,,,,,,,296,,Health Partners,Health Partners Care Plans,both,,,251.72,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Apply Forearm Splint,Static",PX29125P,CDM,983,RC,29125,CPT,,,,,,,,296,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Long Arm Splint,PX29105P,CDM,983,RC,29105,CPT,,,,,,,,385,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Long Arm Splint,PX29105P,CDM,983,RC,29105,CPT,,,,,,,,385,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Long Leg Splint,PX29505P,CDM,983,RC,29505,CPT,,,,,,,,385,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Long Leg Splint,PX29505P,CDM,983,RC,29505,CPT,,,,,,,,385,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Lower Leg Splint,PX29515P,CDM,983,RC,29515,CPT,,,,,,,,311,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Lower Leg Splint,PX29515P,CDM,983,RC,29515,CPT,,,,,,,,311,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Multlay Comprs Lwr Leg,PX29581P,CDM,983,RC,29581,CPT,,,,,,,,142,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply Multlay Comprs Lwr Leg,PX29581P,CDM,983,RC,29581,CPT,,,,,,,,142,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply of Paste Boot,PX29580P,CDM,983,RC,29580,CPT,,,,,,,,88,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Apply of Paste Boot,PX29580P,CDM,983,RC,29580,CPT,,,,,,,,88,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Apply Short Leg Cast,Walker",PX29425P,CDM,983,RC,29425,CPT,,,,,,,,119,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Apply Short Leg Cast,Walker",PX29425P,CDM,983,RC,29425,CPT,,,,,,,,119,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aspirate Pleura W/ Imaging,PX32555P,CDM,983,RC,32555,CPT,,,,,,,,536,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Aspirate Pleura W/ Imaging,PX32555P,CDM,983,RC,32555,CPT,,,,,,,,536,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Biopsy of Rectum,PX45100P,CDM,983,RC,45100,CPT,,,,,,,,509,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Biopsy of Rectum,PX45100P,CDM,983,RC,45100,CPT,,,,,,,,509,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Biopsy Synovium I-P Jt,PX26110,CDM,983,RC,26110,CPT,,,,,,,,933,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Biopsy Synovium I-P Jt,PX26110,CDM,983,RC,26110,CPT,,,,,,,,933,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Biopsy Vulva/Perineum,One Lesn",PX56605P,CDM,983,RC,56605,CPT,,,,,,,,142,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Biopsy Vulva/Perineum,One Lesn",PX56605P,CDM,983,RC,56605,CPT,,,,,,,,142,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Bone Marrow Aspiration(S),Diag",PX38220P,CDM,983,RC,38220,CPT,,,,,,,,244,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Bone Marrow Aspiration(S),Diag",PX38220P,CDM,983,RC,38220,CPT,,,,,,,,244,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cardioversion, Elective;Extern",PX92960P,CDM,983,RC,92960,CPT,,,,,,,,688,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Cardioversion, Elective;Extern",PX92960P,CDM,983,RC,92960,CPT,,,,,,,,688,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Chem Cautery Granulatn Tissue,PX17250P,CDM,983,RC,17250,CPT,,,,,,,,402,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Chem Cautery Granulatn Tissue,PX17250P,CDM,983,RC,17250,CPT,,,,,,,,402,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Close Rx Dist Fingr Fx,Manipulatn",PX26755P,CDM,983,RC,26755,CPT,,,,,,,,1260,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Close Rx Dist Fingr Fx,Manipulatn",PX26755P,CDM,983,RC,26755,CPT,,,,,,,,1260,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Close Rx Fingr Articular Fx,Manip",PX26742P,CDM,983,RC,26742,CPT,,,,,,,,560,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Close Rx Fingr Articular Fx,Manip",PX26742P,CDM,983,RC,26742,CPT,,,,,,,,560,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725P,CDM,983,RC,26725,CPT,,,,,,,,330,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Close Rx Prox/Mid Fing Shft Fx,Manip",PX26725P,CDM,983,RC,26725,CPT,,,,,,,,330,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545P,CDM,983,RC,23545,CPT,,,,,,,,412,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx a-C Jt Disloc,Manipulatn",PX23545P,CDM,983,RC,23545,CPT,,,,,,,,412,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Big Toe Fx,Manip",PX28495P,CDM,983,RC,28495,CPT,,,,,,,,412,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Big Toe Fx,Manip",PX28495P,CDM,983,RC,28495,CPT,,,,,,,,412,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Bimalleolar Fx,PX27808P,CDM,983,RC,27808,CPT,,,,,,,,433,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Bimalleolar Fx,PX27808P,CDM,983,RC,27808,CPT,,,,,,,,433,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Bimalleolar Fx,Manip",PX27810P,CDM,983,RC,27810,CPT,,,,,,,,1057,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Bimalleolar Fx,Manip",PX27810P,CDM,983,RC,27810,CPT,,,,,,,,1057,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Dist Fibula Fx,Manip",PX27788P,CDM,983,RC,27788,CPT,,,,,,,,1277,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Dist Fibula Fx,Manip",PX27788P,CDM,983,RC,27788,CPT,,,,,,,,1277,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605P,CDM,983,RC,25605,CPT,,,,,,,,785,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Dist Rad/Ulna Fx,Manipul",PX25605P,CDM,983,RC,25605,CPT,,,,,,,,785,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Elbow Dislocation,PX24600P,CDM,983,RC,24600,CPT,,,,,,,,380,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Elbow Dislocation,PX24600P,CDM,983,RC,24600,CPT,,,,,,,,380,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605P,CDM,983,RC,24605,CPT,,,,,,,,750,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Elbow Dislocatn,Anesthesia",PX24605P,CDM,983,RC,24605,CPT,,,,,,,,750,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Femur Shaft Fx+Manip,PX27502P,CDM,983,RC,27502,CPT,,,,,,,,1083,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Femur Shaft Fx+Manip,PX27502P,CDM,983,RC,27502,CPT,,,,,,,,1083,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535P,CDM,983,RC,24535,CPT,,,,,,,,2887,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Hum Supracondylr Fx,Manipu",PX24535P,CDM,983,RC,24535,CPT,,,,,,,,2887,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx I-P Jt,Toe Dislocation",PX28660P,CDM,983,RC,28660,CPT,,,,,,,,628,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx I-P Jt,Toe Dislocation",PX28660P,CDM,983,RC,28660,CPT,,,,,,,,628,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx IP Jt Dislocation,PX26770P,CDM,983,RC,26770,CPT,,,,,,,,1353,,Health Partners,Health Partners Care Plans,both,,,684.745,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx IP Jt Dislocation,PX26770P,CDM,983,RC,26770,CPT,,,,,,,,1353,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Kneecap Disloc+Anesth,PX27562P,CDM,983,RC,27562,CPT,,,,,,,,1404,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Kneecap Disloc+Anesth,PX27562P,CDM,983,RC,27562,CPT,,,,,,,,1404,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Kneecap Dislocatn,PX27560P,CDM,983,RC,27560,CPT,,,,,,,,312,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Kneecap Dislocatn,PX27560P,CDM,983,RC,27560,CPT,,,,,,,,312,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Metacarpal Fx,PX26600P,CDM,983,RC,26600,CPT,,,,,,,,295,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Metacarpal Fx,PX26600P,CDM,983,RC,26600,CPT,,,,,,,,295,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505P,CDM,983,RC,24505,CPT,,,,,,,,2353,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Mid Humerus Fx,Manipulatn",PX24505P,CDM,983,RC,24505,CPT,,,,,,,,2353,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Mt-Phal Toe Dislocation,PX28630P,CDM,983,RC,28630,CPT,,,,,,,,248,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Mt-Phal Toe Dislocation,PX28630P,CDM,983,RC,28630,CPT,,,,,,,,248,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266P,CDM,983,RC,27266,CPT,,,,,,,,2275,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Post Hip Fix Disloc,Anesth",PX27266P,CDM,983,RC,27266,CPT,,,,,,,,2275,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565P,CDM,983,RC,25565,CPT,,,,,,,,830,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Rad/Ulna Shaft Fx,Manip",PX25565P,CDM,983,RC,25565,CPT,,,,,,,,830,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Radial Head Disloc,Child",PX24640P,CDM,983,RC,24640,CPT,,,,,,,,180,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Radial Head Disloc,Child",PX24640P,CDM,983,RC,24640,CPT,,,,,,,,180,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Radial Head/Neck Fx,Manip",PX24655P,CDM,983,RC,24655,CPT,,,,,,,,1824,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Radial Head/Neck Fx,Manip",PX24655P,CDM,983,RC,24655,CPT,,,,,,,,1824,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505P,CDM,983,RC,25505,CPT,,,,,,,,977,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Radial Shaft Fx,Manipulatn",PX25505P,CDM,983,RC,25505,CPT,,,,,,,,977,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Shldr Disloc,Anesthesia",PX23655P,CDM,983,RC,23655,CPT,,,,,,,,1421,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Shldr Disloc,Anesthesia",PX23655P,CDM,983,RC,23655,CPT,,,,,,,,1421,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Shldr Dislocation,PX23650P,CDM,983,RC,23650,CPT,,,,,,,,516,,Health Partners,Health Partners Care Plans,both,,,262.985,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Shldr Dislocation,PX23650P,CDM,983,RC,23650,CPT,,,,,,,,516,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Spont Hip Disloc,Anesth",PX27257P,CDM,983,RC,27257,CPT,,,,,,,,365,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Spont Hip Disloc,Anesth",PX27257P,CDM,983,RC,27257,CPT,,,,,,,,365,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Talus Fx,Manipulatn",PX28435P,CDM,983,RC,28435,CPT,,,,,,,,1137,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Talus Fx,Manipulatn",PX28435P,CDM,983,RC,28435,CPT,,,,,,,,1137,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752P,CDM,983,RC,27752,CPT,,,,,,,,2495,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Tibia Shaft Fx,Manipulatn",PX27752P,CDM,983,RC,27752,CPT,,,,,,,,2495,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Toe Fx,Manipulatn",PX28515P,CDM,983,RC,28515,CPT,,,,,,,,260,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Toe Fx,Manipulatn",PX28515P,CDM,983,RC,28515,CPT,,,,,,,,260,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Trimalleolar Fx,PX27816P,CDM,983,RC,27816,CPT,,,,,,,,826,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Rx Trimalleolar Fx,PX27816P,CDM,983,RC,27816,CPT,,,,,,,,826,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Trimalleolar Fx,Manip",PX27818P,CDM,983,RC,27818,CPT,,,,,,,,1352,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Trimalleolar Fx,Manip",PX27818P,CDM,983,RC,27818,CPT,,,,,,,,1352,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Weight Bear Dist Tib,Manip",PX27825P,CDM,983,RC,27825,CPT,,,,,,,,1796,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closed Rx Weight Bear Dist Tib,Manip",PX27825P,CDM,983,RC,27825,CPT,,,,,,,,1796,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Treat Wrist Dislocation,PX25660P,CDM,983,RC,25660,CPT,,,,,,,,1507,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closed Treat Wrist Dislocation,PX25660P,CDM,983,RC,25660,CPT,,,,,,,,1507,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closure of Gastrostomy,Surgical",PX43870P,CDM,983,RC,43870,CPT,,,,,,,,4012,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Closure of Gastrostomy,Surgical",PX43870P,CDM,983,RC,43870,CPT,,,,,,,,4012,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closure Superf Wnd Dehis Simple,PX12020P,CDM,983,RC,12020,CPT,,,,,,,,422,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Closure Superf Wnd Dehis Simple,PX12020P,CDM,983,RC,12020,CPT,,,,,,,,422,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscope, Submucous Inj",PX45381P,CDM,983,RC,45381,CPT,,,,,,,,1215,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscope, Submucous Inj",PX45381P,CDM,983,RC,45381,CPT,,,,,,,,1215,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Colonoscopy,PX44388P,CDM,983,RC,44388,CPT,,,,,,,,620,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Colonoscopy,PX44388P,CDM,983,RC,44388,CPT,,,,,,,,620,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390P,CDM,982,RC,45390,CPT,,,,,,,,1135,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Colonoscopy Flx W/Endoscopic Mucosal Resection,PX45390P,CDM,982,RC,45390,CPT,,,,,,,,1135,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscopy,Biopsy",PX45380P,CDM,983,RC,45380,CPT,,,,,,,,2539,,Health Partners,Health Partners Care Plans,both,,,2351.19,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscopy,Biopsy",PX45380P,CDM,983,RC,45380,CPT,,,,,,,,2539,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscopy,Flex,Diagnostic",PX45378P,CDM,983,RC,45378,CPT,,,,,,,,1200,,Health Partners,Health Partners Care Plans,both,,,862.22,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscopy,Flex,Diagnostic",PX45378P,CDM,983,RC,45378,CPT,,,,,,,,1200,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384P,CDM,983,RC,45384,CPT,,,,,,,,1436,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscopy,Remv Lesn,Forcep/Cautery",PX45384P,CDM,983,RC,45384,CPT,,,,,,,,1436,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscopy,Remv Lesn,Snare",PX45385P,CDM,983,RC,45385,CPT,,,,,,,,2424,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscopy,Remv Lesn,Snare",PX45385P,CDM,983,RC,45385,CPT,,,,,,,,2424,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscopy,Transendoscopic Stent",PX45387P,CDM,983,RC,45387,CPT,,,,,,,,3587,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Colonoscopy,Transendoscopic Stent",PX45387P,CDM,983,RC,45387,CPT,,,,,,,,3587,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Complex Drainage, Wound",PX10180P,CDM,983,RC,10180,CPT,,,,,,,,767,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Complex Drainage, Wound",PX10180P,CDM,983,RC,10180,CPT,,,,,,,,767,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Correct Bunion,Metatarsal Osteotomy",PX28296P,CDM,983,RC,28296,CPT,,,,,,,,2150,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Correct Bunion,Metatarsal Osteotomy",PX28296P,CDM,983,RC,28296,CPT,,,,,,,,2150,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Critical Care, Addl 30 Min",PX99292P,CDM,983,RC,99292,CPT,,,,,,,,542,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Critical Care, Addl 30 Min",PX99292P,CDM,983,RC,99292,CPT,,,,,,,,542,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Critical Care, E/M 30-74 Minutes",PX99291P,CDM,983,RC,99291,CPT,,,,,,,,1061,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Critical Care, E/M 30-74 Minutes",PX99291P,CDM,983,RC,99291,CPT,,,,,,,,1061,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ctrl Nosebleed,Anter,Complex",PX30903P,CDM,983,RC,30903,CPT,,,,,,,,304,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ctrl Nosebleed,Anter,Complex",PX30903P,CDM,983,RC,30903,CPT,,,,,,,,304,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ctrl Nosebleed,Anter,Simple",PX30901P,CDM,983,RC,30901,CPT,,,,,,,,229,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ctrl Nosebleed,Anter,Simple",PX30901P,CDM,983,RC,30901,CPT,,,,,,,,229,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"CUFF STERILE DISPOSABLE SPSB 34"" THIGH USE",27200000,CDM,272,RC,,,,12367-MAIN,LOCAL,,,,,,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"CUFF STERILE DISPOSABLE SPSB 34"" THIGH USE",27200000,CDM,272,RC,,,,12367-MAIN,LOCAL,,,,,,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"CUFF STERILE DISPOSABLE SPSB 34"" THIGH USE",27200000,CDM,272,RC,,,,12367-MAIN,LOCAL,,,,,,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"CUFF STERILE DISPOSABLE SPSB 34"" THIGH USE",27200000,CDM,272,RC,,,,12367-MAIN,LOCAL,,,,,,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"CUFF STERILE DISPOSABLE SPSB 34"" THIGH USE",27200000,CDM,272,RC,,,,12367-MAIN,LOCAL,,,,,,,First Health,Commercial,both,85,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"CUFF STERILE DISPOSABLE SPSB 34"" THIGH USE",27200000,CDM,272,RC,,,,12367-MAIN,LOCAL,,,,,,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"CUFF STERILE DISPOSABLE SPSB 34"" THIGH USE",27200000,CDM,272,RC,,,,12367-MAIN,LOCAL,,,,,,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"CUFF STERILE DISPOSABLE SPSB 34"" THIGH USE",27200000,CDM,272,RC,,,,12367-MAIN,LOCAL,,,,,,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"CUFF STERILE DISPOSABLE SPSB 34"" THIGH USE",27200000,CDM,272,RC,,,,12367-MAIN,LOCAL,,,,,,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"CUFF STERILE DISPOSABLE SPSB 34"" THIGH USE",27200000,CDM,272,RC,,,,12367-MAIN,LOCAL,,,,,,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"CUFF STERILE DISPOSABLE SPSB 34"" THIGH USE",27200000,CDM,272,RC,,,,12367-MAIN,LOCAL,,,,,,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"CUFF STERILE DISPOSABLE SPSB 34"" THIGH USE",27200000,CDM,272,RC,,,,12367-MAIN,LOCAL,,,,,,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"CUFF STERILE DISPOSABLE SPSB 34"" THIGH USE",27200000,CDM,272,RC,,,,12367-MAIN,LOCAL,,,,,,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"CUFF STERILE DISPOSABLE SPSB 34"" THIGH USE",27200000,CDM,272,RC,,,,12367-MAIN,LOCAL,,,,,,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
"CUFF STERILE DISPOSABLE SPSB 34"" THIGH USE",27200000,CDM,272,RC,,,,12367-MAIN,LOCAL,,,,,,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Debride Bone Ea Add 20 Sqcm,PX11047P,CDM,983,RC,11047,CPT,,,,,,,,351,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Bone Ea Add 20 Sqcm,PX11047P,CDM,983,RC,11047,CPT,,,,,,,,351,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Muscle Ea Add 20 Sqcm,PX11046P,CDM,983,RC,11046,CPT,,,,,,,,198,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Muscle Ea Add 20 Sqcm,PX11046P,CDM,983,RC,11046,CPT,,,,,,,,198,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Skin/Subq Ea Ad 20sqcm,PX11045P,CDM,983,RC,11045,CPT,,,,,,,,182,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Skin/Subq Ea Ad 20sqcm,PX11045P,CDM,983,RC,11045,CPT,,,,,,,,182,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Skin/Tissue,PX11042P,CDM,983,RC,11042,CPT,,,,,,,,995,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Skin/Tissue,PX11042P,CDM,983,RC,11042,CPT,,,,,,,,995,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Tissue/Muscle,PX11043P,CDM,983,RC,11043,CPT,,,,,,,,351,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Tissue/Muscle,PX11043P,CDM,983,RC,11043,CPT,,,,,,,,351,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Tissue/Muscle/Bone,PX11044P,CDM,983,RC,11044,CPT,,,,,,,,866,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Debride Tissue/Muscle/Bone,PX11044P,CDM,983,RC,11044,CPT,,,,,,,,866,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Destruct Benign Lesion, 1-14",PX17110P,CDM,983,RC,17110,CPT,,,,,,,,521,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Destruct Benign Lesion, 1-14",PX17110P,CDM,983,RC,17110,CPT,,,,,,,,521,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Diagnostic Anoscopy,PX46600P,CDM,983,RC,46600,CPT,,,,,,,,405,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Diagnostic Anoscopy,PX46600P,CDM,983,RC,46600,CPT,,,,,,,,405,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Drain Finger Abscess,Simple",PX26010P,CDM,983,RC,26010,CPT,,,,,,,,207,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Drain Finger Abscess,Simple",PX26010P,CDM,983,RC,26010,CPT,,,,,,,,207,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800P,CDM,983,RC,40800,CPT,,,,,,,,170,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Drain Mouth Absc/Cyst/Hematoma,Simpl",PX40800P,CDM,983,RC,40800,CPT,,,,,,,,170,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain Skin Abscess Complic,PX10061P,CDM,983,RC,10061,CPT,,,,,,,,561,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain Skin Abscess Complic,PX10061P,CDM,983,RC,10061,CPT,,,,,,,,561,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain Skin Abscess Simple,PX10060P,CDM,983,RC,10060,CPT,,,,,,,,293,,Health Partners,Health Partners Care Plans,both,,,189.565,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain Skin Abscess Simple,PX10060P,CDM,983,RC,10060,CPT,,,,,,,,293,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Large Joint/Bursa,PX20610P,CDM,983,RC,20610,CPT,,,,,,,,291,,Health Partners,Health Partners Care Plans,both,,,312.25,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Large Joint/Bursa,PX20610P,CDM,983,RC,20610,CPT,,,,,,,,291,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611P,CDM,983,RC,20611,CPT,,,,,,,,272,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Lg Joint/Brusa W/US Guide,PX20611P,CDM,983,RC,20611,CPT,,,,,,,,272,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Med Joint/Brusa W/US Guide,PX20606P,CDM,983,RC,20606,CPT,,,,,,,,309,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Med Joint/Brusa W/US Guide,PX20606P,CDM,983,RC,20606,CPT,,,,,,,,309,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Medium Joint/Bursa,PX20605P,CDM,983,RC,20605,CPT,,,,,,,,318,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Medium Joint/Bursa,PX20605P,CDM,983,RC,20605,CPT,,,,,,,,318,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604P,CDM,983,RC,20604,CPT,,,,,,,,229,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Sm Joint/Bursa W/ US Guide,PX20604P,CDM,983,RC,20604,CPT,,,,,,,,229,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Small Joint/Bursa,PX20600P,CDM,983,RC,20600,CPT,,,,,,,,161,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drain/Inject Small Joint/Bursa,PX20600P,CDM,983,RC,20600,CPT,,,,,,,,161,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drainage of Gum Lesion,PX41800P,CDM,983,RC,41800,CPT,,,,,,,,839,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drainage of Gum Lesion,PX41800P,CDM,983,RC,41800,CPT,,,,,,,,839,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drainage of Hematoma/Fluid (P),PX10140P,CDM,983,RC,10140,CPT,,,,,,,,465,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drainage of Hematoma/Fluid (P),PX10140P,CDM,983,RC,10140,CPT,,,,,,,,465,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drainage Scrotal Wall Abscess,PX55100P,CDM,983,RC,55100,CPT,,,,,,,,341,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Drainage Scrotal Wall Abscess,PX55100P,CDM,983,RC,55100,CPT,,,,,,,,341,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dress/Debrid Med Burn No Anesth,PX16025P,CDM,983,RC,16025,CPT,,,,,,,,244,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Dress/Debrid Med Burn No Anesth,PX16025P,CDM,983,RC,16025,CPT,,,,,,,,244,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ecg 12 Lead, Interp Only",PX93010,CDM,985,RC,93010,CPT,,,,,,,,29,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ecg 12 Lead, Interp Only",PX93010,CDM,985,RC,93010,CPT,,,,,,,,29,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Egd Balloon Dil Esoph30 Mm/>,PX43233P,CDM,983,RC,43233,CPT,,,,,,,,480,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Egd Balloon Dil Esoph30 Mm/>,PX43233P,CDM,983,RC,43233,CPT,,,,,,,,480,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Emergency Level I Visit,PX99281P,CDM,981,RC,99281,CPT,,,,,,,,224,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Emergency Level I Visit,PX99281P,CDM,981,RC,99281,CPT,,,,,,,,224,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Emergency Level II Visit,PX99282P,CDM,981,RC,99282,CPT,,,,,,,,337,,Health Partners,Health Partners Care Plans,both,,,96.08,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Emergency Level II Visit,PX99282P,CDM,981,RC,99282,CPT,,,,,,,,337,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Emergency Level III Visit,PX99283P,CDM,981,RC,99283,CPT,,,,,,,,568,,Health Partners,Health Partners Care Plans,both,,,314.8597674,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Emergency Level III Visit,PX99283P,CDM,981,RC,99283,CPT,,,,,,,,568,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Emergency Level IV Visit,PX99284P,CDM,981,RC,99284,CPT,,,,,,,,914,,Health Partners,Health Partners Care Plans,both,,,489.6642105,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Emergency Level IV Visit,PX99284P,CDM,981,RC,99284,CPT,,,,,,,,914,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Emergency Level V Visit,PX99285P,CDM,981,RC,99285,CPT,,,,,,,,1436,,Health Partners,Health Partners Care Plans,both,,,483.1033333,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Emergency Level V Visit,PX99285P,CDM,981,RC,99285,CPT,,,,,,,,1436,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Eval of Bronchospasm,PX94060,CDM,983,RC,94060,CPT,,,,,,,,176,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Eval of Bronchospasm,PX94060,CDM,983,RC,94060,CPT,,,,,,,,176,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ex Sknbngn0.6-1cmtrnk,Arm,Lg",PX11401P,CDM,983,RC,11401,CPT,,,,,,,,387,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ex Sknbngn0.6-1cmtrnk,Arm,Lg",PX11401P,CDM,983,RC,11401,CPT,,,,,,,,387,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Abd Les Sc < 3 Cm,PX22902P,CDM,983,RC,22902,CPT,,,,,,,,2086,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Abd Les Sc < 3 Cm,PX22902P,CDM,983,RC,22902,CPT,,,,,,,,2086,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Abdom Tum Subfac > 5 Cm,PX22901P,CDM,983,RC,22901,CPT,,,,,,,,938,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Abdom Tum Subfac > 5 Cm,PX22901P,CDM,983,RC,22901,CPT,,,,,,,,938,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Back Les Sc = 3 Cm,PX21931P,CDM,983,RC,21931,CPT,,,,,,,,2135,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Back Les Sc = 3 Cm,PX21931P,CDM,983,RC,21931,CPT,,,,,,,,2135,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Face Les Sc < 2 Cm,PX21011P,CDM,983,RC,21011,CPT,,,,,,,,628,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Face Les Sc < 2 Cm,PX21011P,CDM,983,RC,21011,CPT,,,,,,,,628,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Benig <5mm Remaindr Body,PX11420P,CDM,983,RC,11420,CPT,,,,,,,,299,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Benig <5mm Remaindr Body,PX11420P,CDM,983,RC,11420,CPT,,,,,,,,299,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Benig >4cm Remaindr Body,PX11426P,CDM,983,RC,11426,CPT,,,,,,,,981,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Benig >4cm Remaindr Body,PX11426P,CDM,983,RC,11426,CPT,,,,,,,,981,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402P,CDM,983,RC,11402,CPT,,,,,,,,424,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skin Benig 1.1-2cm Trunk,Arm,Leg",PX11402P,CDM,983,RC,11402,CPT,,,,,,,,424,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423P,CDM,983,RC,11423,CPT,,,,,,,,569,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Benig 2.1-3cm Remaindr Body,PX11423P,CDM,983,RC,11423,CPT,,,,,,,,569,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606P,CDM,983,RC,11606,CPT,,,,,,,,2044,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skin Malig >4cm Trunk,Arm,Leg",PX11606P,CDM,983,RC,11606,CPT,,,,,,,,2044,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623P,CDM,983,RC,11623,CPT,,,,,,,,460,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skin Malig 2.1-3cm Remaindr Body,PX11623P,CDM,983,RC,11623,CPT,,,,,,,,460,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604P,CDM,983,RC,11604,CPT,,,,,,,,1422,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skin Malig 3.1-4cm Trunk,Arm,Leg",PX11604P,CDM,983,RC,11604,CPT,,,,,,,,1422,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Beig1.1-2cm Face,Facil",PX11442P,CDM,983,RC,11442,CPT,,,,,,,,886,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Beig1.1-2cm Face,Facil",PX11442P,CDM,983,RC,11442,CPT,,,,,,,,886,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skn Beni 0.6-1cm Fcefacial,PX11441P,CDM,983,RC,11441,CPT,,,,,,,,485,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skn Beni 0.6-1cm Fcefacial,PX11441P,CDM,983,RC,11441,CPT,,,,,,,,485,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Benig<5mm Face,Facial",PX11440P,CDM,983,RC,11440,CPT,,,,,,,,387,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Benig<5mm Face,Facial",PX11440P,CDM,983,RC,11440,CPT,,,,,,,,387,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skn Bngn1.1-2cm Remain Bdy,PX11422P,CDM,983,RC,11422,CPT,,,,,,,,822,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skn Bngn1.1-2cm Remain Bdy,PX11422P,CDM,983,RC,11422,CPT,,,,,,,,822,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Bngn2.1-3cm Fce,Facial",PX11443P,CDM,983,RC,11443,CPT,,,,,,,,650,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Bngn2.1-3cm Fce,Facial",PX11443P,CDM,983,RC,11443,CPT,,,,,,,,650,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Bngn2.1-3cmtrnk,Arm,Lg",PX11403P,CDM,983,RC,11403,CPT,,,,,,,,543,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Bngn2.1-3cmtrnk,Arm,Lg",PX11403P,CDM,983,RC,11403,CPT,,,,,,,,543,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skn Bngn3.1-4cm Remain Bdy,PX11424P,CDM,983,RC,11424,CPT,,,,,,,,562,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skn Bngn3.1-4cm Remain Bdy,PX11424P,CDM,983,RC,11424,CPT,,,,,,,,562,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404P,CDM,983,RC,11404,CPT,,,,,,,,600,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Bngn3.1-4cmtrnk,Arm,Lg",PX11404P,CDM,983,RC,11404,CPT,,,,,,,,600,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Bnig >4cmtrnk,Arm,Leg",PX11406P,CDM,983,RC,11406,CPT,,,,,,,,1456,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Bnig >4cmtrnk,Arm,Leg",PX11406P,CDM,983,RC,11406,CPT,,,,,,,,1456,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skn Bnig0.6-1cm Remain Bdy,PX11421P,CDM,983,RC,11421,CPT,,,,,,,,345,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Exc Skn Bnig0.6-1cm Remain Bdy,PX11421P,CDM,983,RC,11421,CPT,,,,,,,,345,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Mal 0.6-1cm Fce,Facial",PX11641P,CDM,983,RC,11641,CPT,,,,,,,,453,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Mal 0.6-1cm Fce,Facial",PX11641P,CDM,983,RC,11641,CPT,,,,,,,,453,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601P,CDM,983,RC,11601,CPT,,,,,,,,1046,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Mal 0.6-1cmtrnk,Arm,Lg",PX11601P,CDM,983,RC,11601,CPT,,,,,,,,1046,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602P,CDM,983,RC,11602,CPT,,,,,,,,1120,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Mal 1.1-2cmtrnk,Arm,Lg",PX11602P,CDM,983,RC,11602,CPT,,,,,,,,1120,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Mal 2.1-3cmtrnk,Arm,Lg",PX11603P,CDM,983,RC,11603,CPT,,,,,,,,1276,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Mal 2.1-3cmtrnk,Arm,Lg",PX11603P,CDM,983,RC,11603,CPT,,,,,,,,1276,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Malig1.1-2cm Fce,Facal",PX11642P,CDM,983,RC,11642,CPT,,,,,,,,466,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Exc Skn Malig1.1-2cm Fce,Facal",PX11642P,CDM,983,RC,11642,CPT,,,,,,,,466,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excis Arm/Elbow Tumor,Subcutan",PX24075P,CDM,983,RC,24075,CPT,,,,,,,,2458,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excis Arm/Elbow Tumor,Subcutan",PX24075P,CDM,983,RC,24075,CPT,,,,,,,,2458,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Excis Forearm/Wrist Tumor Subcutan,PX25075P,CDM,983,RC,25075,CPT,,,,,,,,607,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Excis Forearm/Wrist Tumor Subcutan,PX25075P,CDM,983,RC,25075,CPT,,,,,,,,607,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Excis Primary Ganglion Wrist,PX25111P,CDM,983,RC,25111,CPT,,,,,,,,529,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Excis Primary Ganglion Wrist,PX25111P,CDM,983,RC,25111,CPT,,,,,,,,529,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excis Tendn/Capsule Lesn,Toes",PX28092P,CDM,983,RC,28092,CPT,,,,,,,,1913,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excis Tendn/Capsule Lesn,Toes",PX28092P,CDM,983,RC,28092,CPT,,,,,,,,1913,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excise Lesion,Back or Flank",PX21930P,CDM,983,RC,21930,CPT,,,,,,,,884,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excise Lesion,Back or Flank",PX21930P,CDM,983,RC,21930,CPT,,,,,,,,884,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830P,CDM,983,RC,15830,CPT,,,,,,,,1120,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Excision, Excessive Skin and Subcutaneous Tissue",PX15830P,CDM,983,RC,15830,CPT,,,,,,,,1120,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Explor Metatarso-Phalang Jt,PX28022P,CDM,983,RC,28022,CPT,,,,,,,,774,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Explor Metatarso-Phalang Jt,PX28022P,CDM,983,RC,28022,CPT,,,,,,,,774,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006P,CDM,983,RC,10006,CPT,,,,,,,,142,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fna Biopsy, W/US Guidance; Each Addt'l Lesion",PX10006P,CDM,983,RC,10006,CPT,,,,,,,,142,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fna Biopsy, W/US Guidance; First Lesion",PX10005P,CDM,983,RC,10005,CPT,,,,,,,,621,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Fna Biopsy, W/US Guidance; First Lesion",PX10005P,CDM,983,RC,10005,CPT,,,,,,,,621,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gastric Intubation Treatment,PX43753P,CDM,983,RC,43753,CPT,,,,,,,,498,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Gastric Intubation Treatment,PX43753P,CDM,983,RC,43753,CPT,,,,,,,,498,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Genital Surg Proc,Male Unlisted",PX55899P,CDM,983,RC,55899,CPT,,,,,,,,953,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Genital Surg Proc,Male Unlisted",PX55899P,CDM,983,RC,55899,CPT,,,,,,,,953,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heart/Lung Resuscitation (Cpr),PX92950P,CDM,983,RC,92950,CPT,,,,,,,,1023,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Heart/Lung Resuscitation (Cpr),PX92950P,CDM,983,RC,92950,CPT,,,,,,,,1023,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hemorrhoidectomy,Int/Ext,Simple",PX46255P,CDM,983,RC,46255,CPT,,,,,,,,2393,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hemorrhoidectomy,Int/Ext,Simple",PX46255P,CDM,983,RC,46255,CPT,,,,,,,,2393,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
HH Ot Initial Visit,PXG0152,CDM,431,RC,G0152,HCPCS,GO,,,,,,,,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Ot Initial Visit,PXG0152,CDM,431,RC,G0152,HCPCS,GO,,,,,,,,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Ot Initial Visit,PXG0152,CDM,431,RC,G0152,HCPCS,GO,,,,,,,,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Ot Initial Visit,PXG0152,CDM,431,RC,G0152,HCPCS,GO,,,,,,,,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Ot Initial Visit,PXG0152,CDM,431,RC,G0152,HCPCS,GO,,,,,,,,,First Health,Commercial,both,85,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Ot Initial Visit,PXG0152,CDM,431,RC,G0152,HCPCS,GO,,,,,,,,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Ot Initial Visit,PXG0152,CDM,431,RC,G0152,HCPCS,GO,,,,,,,,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Ot Initial Visit,PXG0152,CDM,431,RC,G0152,HCPCS,GO,,,,,,,,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Ot Initial Visit,PXG0152,CDM,431,RC,G0152,HCPCS,GO,,,,,,,,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Ot Initial Visit,PXG0152,CDM,431,RC,G0152,HCPCS,GO,,,,,,,,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Ot Initial Visit,PXG0152,CDM,431,RC,G0152,HCPCS,GO,,,,,,,,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Ot Initial Visit,PXG0152,CDM,431,RC,G0152,HCPCS,GO,,,,,,,,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Ot Initial Visit,PXG0152,CDM,431,RC,G0152,HCPCS,GO,,,,,,,,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Ot Initial Visit,PXG0152,CDM,431,RC,G0152,HCPCS,GO,,,,,,,,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Ot Initial Visit,PXG0152,CDM,431,RC,G0152,HCPCS,GO,,,,,,,,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Ot Routine Visit,PXG0152.01,CDM,431,RC,G0152,HCPCS,GO,,,,,,,,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Ot Routine Visit,PXG0152.01,CDM,431,RC,G0152,HCPCS,GO,,,,,,,,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Ot Routine Visit,PXG0152.01,CDM,431,RC,G0152,HCPCS,GO,,,,,,,,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Ot Routine Visit,PXG0152.01,CDM,431,RC,G0152,HCPCS,GO,,,,,,,,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Ot Routine Visit,PXG0152.01,CDM,431,RC,G0152,HCPCS,GO,,,,,,,,,First Health,Commercial,both,85,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Ot Routine Visit,PXG0152.01,CDM,431,RC,G0152,HCPCS,GO,,,,,,,,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Ot Routine Visit,PXG0152.01,CDM,431,RC,G0152,HCPCS,GO,,,,,,,,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Ot Routine Visit,PXG0152.01,CDM,431,RC,G0152,HCPCS,GO,,,,,,,,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Ot Routine Visit,PXG0152.01,CDM,431,RC,G0152,HCPCS,GO,,,,,,,,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Ot Routine Visit,PXG0152.01,CDM,431,RC,G0152,HCPCS,GO,,,,,,,,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Ot Routine Visit,PXG0152.01,CDM,431,RC,G0152,HCPCS,GO,,,,,,,,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Ot Routine Visit,PXG0152.01,CDM,431,RC,G0152,HCPCS,GO,,,,,,,,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Ot Routine Visit,PXG0152.01,CDM,431,RC,G0152,HCPCS,GO,,,,,,,,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Ot Routine Visit,PXG0152.01,CDM,431,RC,G0152,HCPCS,GO,,,,,,,,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Ot Routine Visit,PXG0152.01,CDM,431,RC,G0152,HCPCS,GO,,,,,,,,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Pt Initial Visit,PXG0151,CDM,421,RC,G0151,HCPCS,GP,,,,,,,,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Pt Initial Visit,PXG0151,CDM,421,RC,G0151,HCPCS,GP,,,,,,,,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Pt Initial Visit,PXG0151,CDM,421,RC,G0151,HCPCS,GP,,,,,,,,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Pt Initial Visit,PXG0151,CDM,421,RC,G0151,HCPCS,GP,,,,,,,,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Pt Initial Visit,PXG0151,CDM,421,RC,G0151,HCPCS,GP,,,,,,,,,First Health,Commercial,both,85,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Pt Initial Visit,PXG0151,CDM,421,RC,G0151,HCPCS,GP,,,,,,,,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Pt Initial Visit,PXG0151,CDM,421,RC,G0151,HCPCS,GP,,,,,,,,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Pt Initial Visit,PXG0151,CDM,421,RC,G0151,HCPCS,GP,,,,,,,,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Pt Initial Visit,PXG0151,CDM,421,RC,G0151,HCPCS,GP,,,,,,,,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Pt Initial Visit,PXG0151,CDM,421,RC,G0151,HCPCS,GP,,,,,,,,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Pt Initial Visit,PXG0151,CDM,421,RC,G0151,HCPCS,GP,,,,,,,,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Pt Initial Visit,PXG0151,CDM,421,RC,G0151,HCPCS,GP,,,,,,,,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Pt Initial Visit,PXG0151,CDM,421,RC,G0151,HCPCS,GP,,,,,,,,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Pt Initial Visit,PXG0151,CDM,421,RC,G0151,HCPCS,GP,,,,,,,,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Pt Initial Visit,PXG0151,CDM,421,RC,G0151,HCPCS,GP,,,,,,,,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Pt Routine Visit,PXG0151.01,CDM,421,RC,G0151,HCPCS,GP,,,,,,,,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Pt Routine Visit,PXG0151.01,CDM,421,RC,G0151,HCPCS,GP,,,,,,,,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Pt Routine Visit,PXG0151.01,CDM,421,RC,G0151,HCPCS,GP,,,,,,,,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Pt Routine Visit,PXG0151.01,CDM,421,RC,G0151,HCPCS,GP,,,,,,,,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Pt Routine Visit,PXG0151.01,CDM,421,RC,G0151,HCPCS,GP,,,,,,,,,First Health,Commercial,both,85,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Pt Routine Visit,PXG0151.01,CDM,421,RC,G0151,HCPCS,GP,,,,,,,,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Pt Routine Visit,PXG0151.01,CDM,421,RC,G0151,HCPCS,GP,,,,,,,,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Pt Routine Visit,PXG0151.01,CDM,421,RC,G0151,HCPCS,GP,,,,,,,,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Pt Routine Visit,PXG0151.01,CDM,421,RC,G0151,HCPCS,GP,,,,,,,,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Pt Routine Visit,PXG0151.01,CDM,421,RC,G0151,HCPCS,GP,,,,,,,,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Pt Routine Visit,PXG0151.01,CDM,421,RC,G0151,HCPCS,GP,,,,,,,,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Pt Routine Visit,PXG0151.01,CDM,421,RC,G0151,HCPCS,GP,,,,,,,,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Pt Routine Visit,PXG0151.01,CDM,421,RC,G0151,HCPCS,GP,,,,,,,,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Pt Routine Visit,PXG0151.01,CDM,421,RC,G0151,HCPCS,GP,,,,,,,,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Pt Routine Visit,PXG0151.01,CDM,421,RC,G0151,HCPCS,GP,,,,,,,,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Pta Routine Visit,PXG0157,CDM,421,RC,G0157,HCPCS,,,,,,,,,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Pta Routine Visit,PXG0157,CDM,421,RC,G0157,HCPCS,,,,,,,,,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Pta Routine Visit,PXG0157,CDM,421,RC,G0157,HCPCS,,,,,,,,,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Pta Routine Visit,PXG0157,CDM,421,RC,G0157,HCPCS,,,,,,,,,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Pta Routine Visit,PXG0157,CDM,421,RC,G0157,HCPCS,,,,,,,,,,First Health,Commercial,both,85,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Pta Routine Visit,PXG0157,CDM,421,RC,G0157,HCPCS,,,,,,,,,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Pta Routine Visit,PXG0157,CDM,421,RC,G0157,HCPCS,,,,,,,,,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Pta Routine Visit,PXG0157,CDM,421,RC,G0157,HCPCS,,,,,,,,,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Pta Routine Visit,PXG0157,CDM,421,RC,G0157,HCPCS,,,,,,,,,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Pta Routine Visit,PXG0157,CDM,421,RC,G0157,HCPCS,,,,,,,,,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Pta Routine Visit,PXG0157,CDM,421,RC,G0157,HCPCS,,,,,,,,,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Pta Routine Visit,PXG0157,CDM,421,RC,G0157,HCPCS,,,,,,,,,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Pta Routine Visit,PXG0157,CDM,421,RC,G0157,HCPCS,,,,,,,,,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Pta Routine Visit,PXG0157,CDM,421,RC,G0157,HCPCS,,,,,,,,,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
HH Pta Routine Visit,PXG0157,CDM,421,RC,G0157,HCPCS,,,,,,,,,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,,
Hosp Manage Cont Drug Admin,PX01996.01,CDM,964,RC,1996,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hosp Manage Cont Drug Admin,PX01996.01,CDM,964,RC,1996,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hospital Discharge Day>30 Min,PX99239P,CDM,982,RC,99239,CPT,,,,,,,,140,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Hospital Discharge Day>30 Min,PX99239P,CDM,982,RC,99239,CPT,,,,,,,,140,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hospital Inpt or Obs Care, Admin/Disch Same Date Straightforward or Low Level Mdm >= 45 Minutes",PX99234,CDM,982,RC,99234,CPT,,,,,,,,464,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hospital Inpt or Obs Care, Admin/Disch Same Date Straightforward or Low Level Mdm >= 45 Minutes",PX99234,CDM,982,RC,99234,CPT,,,,,,,,464,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hospital Inpt or Obs Care, Admin/Disch Same Date, Moderate Level Mdm >= 70 Minutes",PX99235,CDM,982,RC,99235,CPT,,,,,,,,582,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Hospital Inpt or Obs Care, Admin/Disch Same Date, Moderate Level Mdm >= 70 Minutes",PX99235,CDM,982,RC,99235,CPT,,,,,,,,582,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
I&D Bartholin Gland Abscess,PX56420P,CDM,983,RC,56420,CPT,,,,,,,,286,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
I&D Bartholin Gland Abscess,PX56420P,CDM,983,RC,56420,CPT,,,,,,,,286,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
I&D Deep Absc/Hematoma Neck/Chest,PX21501P,CDM,983,RC,21501,CPT,,,,,,,,515,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
I&D Deep Absc/Hematoma Neck/Chest,PX21501P,CDM,983,RC,21501,CPT,,,,,,,,515,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"I&D Perianal Abscess,Superficial",PX46050,CDM,983,RC,46050,CPT,,,,,,,,1096,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"I&D Perianal Abscess,Superficial",PX46050,CDM,983,RC,46050,CPT,,,,,,,,1096,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"I&D Perianal Abscess,Superficial",PX46050P,CDM,983,RC,46050,CPT,,,,,,,,993,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"I&D Perianal Abscess,Superficial",PX46050P,CDM,983,RC,46050,CPT,,,,,,,,993,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
I&D Perirectal Abscess,PX46040P,CDM,983,RC,46040,CPT,,,,,,,,953,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
I&D Perirectal Abscess,PX46040P,CDM,983,RC,46040,CPT,,,,,,,,953,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ileoscopy Thru Stoma,Diagnostic",PX44380P,CDM,983,RC,44380,CPT,,,,,,,,455,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Ileoscopy Thru Stoma,Diagnostic",PX44380P,CDM,983,RC,44380,CPT,,,,,,,,455,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Inc/Drain Peritonsil Abscess,PX42700P,CDM,983,RC,42700,CPT,,,,,,,,889,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Inc/Drain Peritonsil Abscess,PX42700P,CDM,983,RC,42700,CPT,,,,,,,,889,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Incis/Drain Scrotum/Testis,Epididym",PX54700P,CDM,983,RC,54700,CPT,,,,,,,,440,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Incis/Drain Scrotum/Testis,Epididym",PX54700P,CDM,983,RC,54700,CPT,,,,,,,,440,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Incis/Drain Shldr Absc/Hema,Deep",PX23030P,CDM,983,RC,23030,CPT,,,,,,,,1564,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Incis/Drain Shldr Absc/Hema,Deep",PX23030P,CDM,983,RC,23030,CPT,,,,,,,,1564,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Incise External Hemorrhoid,PX46083P,CDM,983,RC,46083,CPT,,,,,,,,956,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Incise External Hemorrhoid,PX46083P,CDM,983,RC,46083,CPT,,,,,,,,956,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Incise Finger Tendon Sheath,PX26055P,CDM,983,RC,26055,CPT,,,,,,,,932,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Incise Finger Tendon Sheath,PX26055P,CDM,983,RC,26055,CPT,,,,,,,,932,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106P,CDM,983,RC,11106,CPT,,,,,,,,204,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Incisional Biopsy of Skin (Eg, Wedge); Single Lesion",PX11106P,CDM,983,RC,11106,CPT,,,,,,,,204,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Initial Hospital Care Levl II,PX99222P,CDM,982,RC,99222,CPT,,,,,,,,187,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Initial Hospital Care Levl II,PX99222P,CDM,982,RC,99222,CPT,,,,,,,,187,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Observation Care,Levl I",PX99218,CDM,982,RC,99218,CPT,,,,,,,,266,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Observation Care,Levl I",PX99218,CDM,982,RC,99218,CPT,,,,,,,,266,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Observation Care,Levl II",PX99219,CDM,982,RC,99219,CPT,,,,,,,,391,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Observation Care,Levl II",PX99219,CDM,982,RC,99219,CPT,,,,,,,,391,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Observation Care,Levl III",PX99220,CDM,982,RC,99220,CPT,,,,,,,,461,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Observation Care,Levl III",PX99220,CDM,982,RC,99220,CPT,,,,,,,,461,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Repair of Entrapped Hernia of Abdomen, Less Than 3 Cm in Length",PX49592,CDM,982,RC,49592,CPT,,,,,,,,2164,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Repair of Entrapped Hernia of Abdomen, Less Than 3 Cm in Length",PX49592,CDM,982,RC,49592,CPT,,,,,,,,2164,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Repair of Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49593P,CDM,982,RC,49593,CPT,,,,,,,,2606,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Repair of Sliding Hernia of Abdomen, 3-10 Cm in Length",PX49593P,CDM,982,RC,49593,CPT,,,,,,,,2606,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591P,CDM,982,RC,49591,CPT,,,,,,,,1245,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Repair of Sliding Hernia of Abdomen, Less Than 3 Cm in Length",PX49591P,CDM,982,RC,49591,CPT,,,,,,,,1245,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595P,CDM,982,RC,49595,CPT,,,,,,,,3503,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Initial Repair of Sliding Hernia of Abdomen, More Than 10 Cm in Length",PX49595P,CDM,982,RC,49595,CPT,,,,,,,,3503,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Inj Tendon/Ligament/Cyst,PX20550P,CDM,983,RC,20550,CPT,,,,,,,,264,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Inj Tendon/Ligament/Cyst,PX20550P,CDM,983,RC,20550,CPT,,,,,,,,264,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inj,Lumb Epidur,Blood/Clot Patch",PX62273P,CDM,983,RC,62273,CPT,,,,,,,,552,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inj,Lumb Epidur,Blood/Clot Patch",PX62273P,CDM,983,RC,62273,CPT,,,,,,,,552,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inject Nerv Blck,Othr Periph Nerv",PX64450P,CDM,983,RC,64450,CPT,,,,,,,,904,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inject Nerv Blck,Othr Periph Nerv",PX64450P,CDM,983,RC,64450,CPT,,,,,,,,904,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inject Nerv Blck,Trigeminal",PX64400P,CDM,983,RC,64400,CPT,,,,,,,,170,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inject Nerv Blck,Trigeminal",PX64400P,CDM,983,RC,64400,CPT,,,,,,,,170,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inject Trigger Point, 1 or 2",PX20552P,CDM,983,RC,20552,CPT,,,,,,,,210,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inject Trigger Point, 1 or 2",PX20552P,CDM,983,RC,20552,CPT,,,,,,,,210,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection for Nerve Block,PX64445P,CDM,983,RC,64445,CPT,,,,,,,,385,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection for Nerve Block,PX64445P,CDM,983,RC,64445,CPT,,,,,,,,385,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection for Nerve Block,PX64447P,CDM,983,RC,64447,CPT,,,,,,,,3892,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Injection for Nerve Block,PX64447P,CDM,983,RC,64447,CPT,,,,,,,,3892,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Injection Hip Arthrogram,Anesth",PX27095P,CDM,983,RC,27095,CPT,,,,,,,,425,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Injection Hip Arthrogram,Anesth",PX27095P,CDM,983,RC,27095,CPT,,,,,,,,425,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inpatient Consult, Level III",PX99253,CDM,983,RC,99253,CPT,,,,,,,,374,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inpatient Consult, Level III",PX99253,CDM,983,RC,99253,CPT,,,,,,,,374,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inpatient Consult, Level IV",PX99254,CDM,983,RC,99254,CPT,,,,,,,,508,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Inpatient Consult, Level IV",PX99254,CDM,983,RC,99254,CPT,,,,,,,,508,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Inpt or Obs Disch Day Mngmt <=30 Minutes,PX99238,CDM,982,RC,99238,CPT,,,,,,,,199,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Inpt or Obs Disch Day Mngmt <=30 Minutes,PX99238,CDM,982,RC,99238,CPT,,,,,,,,199,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Emergency Endotrach Airway,PX31500P,CDM,983,RC,31500,CPT,,,,,,,,657,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Emergency Endotrach Airway,PX31500P,CDM,983,RC,31500,CPT,,,,,,,,657,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Non-Tunnel Cv Catheter >5 Years,PX36556P,CDM,983,RC,36556,CPT,,,,,,,,1274,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Non-Tunnel Cv Catheter >5 Years,PX36556P,CDM,983,RC,36556,CPT,,,,,,,,1274,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573P,CDM,983,RC,36573,CPT,,,,,,,,1721,,Health Partners,Health Partners Care Plans,both,,,95.12,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Picc Incl Image W/O Subq Port/Pump 5yrs/Older,PX36573P,CDM,983,RC,36573,CPT,,,,,,,,1721,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561P,CDM,983,RC,36561,CPT,,,,,,,,1736,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Insert Tunneled Cvenous Catheter With Port>5 Years,PX36561P,CDM,983,RC,36561,CPT,,,,,,,,1736,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Joint Survey,PX7707726,CDM,982,RC,77077,CPT,26,,,,,,,286,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Joint Survey,PX7707726,CDM,982,RC,77077,CPT,26,,,,,,,286,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Incis Hernia Reducible,PX49654P,CDM,983,RC,49654,CPT,,,,,,,,1044,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Incis Hernia Reducible,PX49654P,CDM,983,RC,49654,CPT,,,,,,,,1044,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Paraesophag Hern Repair,PX43281,CDM,982,RC,43281,CPT,,,,,,,,5950,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Paraesophag Hern Repair,PX43281,CDM,982,RC,43281,CPT,,,,,,,,5950,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Rpr Vent Umbilical Hernia,PX49652P,CDM,983,RC,49652,CPT,,,,,,,,1260,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Rpr Vent Umbilical Hernia,PX49652P,CDM,983,RC,49652,CPT,,,,,,,,1260,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Rpr Vent Umbilical Hernia Incarcerated or Strangulated,PX49653P,CDM,983,RC,49653,CPT,,,,,,,,1327,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Rpr Vent Umbilical Hernia Incarcerated or Strangulated,PX49653P,CDM,983,RC,49653,CPT,,,,,,,,1327,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Sleeve Gastrectomy,PX43775,CDM,982,RC,43775,CPT,,,,,,,,5030,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lap Sleeve Gastrectomy,PX43775,CDM,982,RC,43775,CPT,,,,,,,,5030,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Appendectomy",PX44970P,CDM,983,RC,44970,CPT,,,,,,,,1700,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Appendectomy",PX44970P,CDM,983,RC,44970,CPT,,,,,,,,1700,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Cholecystectomy",PX47562P,CDM,983,RC,47562,CPT,,,,,,,,983,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Cholecystectomy",PX47562P,CDM,983,RC,47562,CPT,,,,,,,,983,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Cholecystectomy/Explore",PX47564P,CDM,983,RC,47564,CPT,,,,,,,,1613,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Cholecystectomy/Explore",PX47564P,CDM,983,RC,47564,CPT,,,,,,,,1613,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Dx Surgical Abd W/Biopsy",PX49321P,CDM,983,RC,49321,CPT,,,,,,,,583,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Dx Surgical Abd W/Biopsy",PX49321P,CDM,983,RC,49321,CPT,,,,,,,,583,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Esophagogast Fundoplasty",PX43280P,CDM,983,RC,43280,CPT,,,,,,,,4449,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Esophagogast Fundoplasty",PX43280P,CDM,983,RC,43280,CPT,,,,,,,,4449,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Inguinal Hernia Repr,Initial",PX49650P,CDM,983,RC,49650,CPT,,,,,,,,717,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Inguinal Hernia Repr,Initial",PX49650P,CDM,983,RC,49650,CPT,,,,,,,,717,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Inguinal Hernia Repr,Recur",PX49651P,CDM,983,RC,49651,CPT,,,,,,,,2035,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Lap,Inguinal Hernia Repr,Recur",PX49651P,CDM,983,RC,49651,CPT,,,,,,,,2035,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180P,CDM,983,RC,44180,CPT,,,,,,,,1175,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Laparoscopy, Enterolysis (Freeing of Intestinal Adhesion)",PX44180P,CDM,983,RC,44180,CPT,,,,,,,,1175,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Face,Facial <2.5cm",PX12051P,CDM,983,RC,12051,CPT,,,,,,,,615,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Face,Facial <2.5cm",PX12051P,CDM,983,RC,12051,CPT,,,,,,,,615,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Face,Facial 2.5-5",PX12052P,CDM,983,RC,12052,CPT,,,,,,,,776,,Health Partners,Health Partners Care Plans,both,,,11.67,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Face,Facial 2.5-5",PX12052P,CDM,983,RC,12052,CPT,,,,,,,,776,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Layr Clos Wnd Rest Body 2.6-7.5,PX12042P,CDM,983,RC,12042,CPT,,,,,,,,777,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Layr Clos Wnd Rest Body 2.6-7.5,PX12042P,CDM,983,RC,12042,CPT,,,,,,,,777,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Layr Clos Wnd Rest Body 7.6-12.5,PX12044P,CDM,983,RC,12044,CPT,,,,,,,,523,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Layr Clos Wnd Rest Body 7.6-12.5,PX12044P,CDM,983,RC,12044,CPT,,,,,,,,523,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031P,CDM,983,RC,12031,CPT,,,,,,,,551,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg <2.5cm",PX12031P,CDM,983,RC,12031,CPT,,,,,,,,551,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032P,CDM,983,RC,12032,CPT,,,,,,,,647,,Health Partners,Health Partners Care Plans,both,,,199.66,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5",PX12032P,CDM,983,RC,12032,CPT,,,,,,,,647,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034P,CDM,983,RC,12034,CPT,,,,,,,,1533,,Health Partners,Health Partners Care Plans,both,,,6.17,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5",PX12034P,CDM,983,RC,12034,CPT,,,,,,,,1533,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035P,CDM,983,RC,12035,CPT,,,,,,,,1244,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Layr Clos Wnd Trunk,Arm,Leg 12.6-20",PX12035P,CDM,983,RC,12035,CPT,,,,,,,,1244,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ligation of Hemorrhoid(S),PX46221P,CDM,983,RC,46221,CPT,,,,,,,,697,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ligation of Hemorrhoid(S),PX46221P,CDM,983,RC,46221,CPT,,,,,,,,697,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 1 Init Hosp Low Mdm or 40 Minutes,PX99221,CDM,982,RC,99221,CPT,,,,,,,,400,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 1 Init Hosp Low Mdm or 40 Minutes,PX99221,CDM,982,RC,99221,CPT,,,,,,,,400,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 1 Sub Hosp Low Mdm or 25 Minutes,PX99231,CDM,982,RC,99231,CPT,,,,,,,,133,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 1 Sub Hosp Low Mdm or 25 Minutes,PX99231,CDM,982,RC,99231,CPT,,,,,,,,133,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 2 Init Hosp Mod Mdm or 55 Minutes,PX99222,CDM,982,RC,99222,CPT,,,,,,,,508,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 2 Init Hosp Mod Mdm or 55 Minutes,PX99222,CDM,982,RC,99222,CPT,,,,,,,,508,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 2 Sub Hosp Mod Mdm or 35 Minute,PX99232,CDM,982,RC,99232,CPT,,,,,,,,253,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 2 Sub Hosp Mod Mdm or 35 Minute,PX99232,CDM,982,RC,99232,CPT,,,,,,,,253,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 3 Init Hosp High Mdm or 75 Minutes,PX99223,CDM,982,RC,99223,CPT,,,,,,,,536,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 3 Init Hosp High Mdm or 75 Minutes,PX99223,CDM,982,RC,99223,CPT,,,,,,,,536,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 3 Sub Hosp High Mdm or 50 Minutes,PX99233,CDM,982,RC,99233,CPT,,,,,,,,384,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Lvl 3 Sub Hosp High Mdm or 50 Minutes,PX99233,CDM,982,RC,99233,CPT,,,,,,,,384,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157P,CDM,983,RC,99157,CPT,,,,,,,,270,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Other Phys/Qhp Each Addl 15 Mins,PX99157P,CDM,983,RC,99157,CPT,,,,,,,,270,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155P,CDM,983,RC,99155,CPT,,,,,,,,353,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs,PX99155P,CDM,983,RC,99155,CPT,,,,,,,,353,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156P,CDM,983,RC,99156,CPT,,,,,,,,325,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs,PX99156P,CDM,983,RC,99156,CPT,,,,,,,,325,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153P,CDM,983,RC,99153,CPT,,,,,,,,250,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Same Phys/Qhp Each Addl 15 Mins,PX99153P,CDM,983,RC,99153,CPT,,,,,,,,250,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151P,CDM,983,RC,99151,CPT,,,,,,,,275,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs,PX99151P,CDM,983,RC,99151,CPT,,,,,,,,275,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152P,CDM,983,RC,99152,CPT,,,,,,,,90,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs,PX99152P,CDM,983,RC,99152,CPT,,,,,,,,90,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"N Block Inj, Common Digit",PX64632P,CDM,983,RC,64632,CPT,,,,,,,,128,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"N Block Inj, Common Digit",PX64632P,CDM,983,RC,64632,CPT,,,,,,,,128,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"N Block Inj, Plantar Digit",PX64455P,CDM,983,RC,64455,CPT,,,,,,,,385,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"N Block Inj, Plantar Digit",PX64455P,CDM,983,RC,64455,CPT,,,,,,,,385,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Naso/Orogastric Tube,PX43752P,CDM,983,RC,43752,CPT,,,,,,,,309,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Naso/Orogastric Tube,PX43752P,CDM,983,RC,43752,CPT,,,,,,,,309,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Needle Biopsy,Muscle",PX20206P,CDM,983,RC,20206,CPT,,,,,,,,1028,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Needle Biopsy,Muscle",PX20206P,CDM,983,RC,20206,CPT,,,,,,,,1028,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607P,CDM,983,RC,97607,CPT,,,,,,,,303,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Neg Pressure Wound Therapy Non Dme </= 50 Sq Cm,PX97607P,CDM,983,RC,97607,CPT,,,,,,,,303,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Observation Care Discharge,PX99217,CDM,982,RC,99217,CPT,,,,,,,,222,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Observation Care Discharge,PX99217,CDM,982,RC,99217,CPT,,,,,,,,222,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Off/Outpt Visit,New,Levl III",PX99203P,CDM,983,RC,99203,CPT,,,,,,,,252,,Health Partners,Health Partners Care Plans,both,,,208.93,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Off/Outpt Visit,New,Levl III",PX99203P,CDM,983,RC,99203,CPT,,,,,,,,252,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office Consultation,Level III",PX99243P,CDM,983,RC,99243,CPT,,,,,,,,374,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office Consultation,Level III",PX99243P,CDM,983,RC,99243,CPT,,,,,,,,374,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office Consultation,Level IV",PX99244P,CDM,983,RC,99244,CPT,,,,,,,,441,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office Consultation,Level IV",PX99244P,CDM,983,RC,99244,CPT,,,,,,,,441,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Office/Outpt Visit Est Level I,PX99211P,CDM,983,RC,99211,CPT,,,,,,,,119,,Health Partners,Health Partners Care Plans,both,,,115.44,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Office/Outpt Visit Est Level I,PX99211P,CDM,983,RC,99211,CPT,,,,,,,,119,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl II",PX99212P,CDM,983,RC,99212,CPT,,,,,,,,155,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl II",PX99212P,CDM,983,RC,99212,CPT,,,,,,,,155,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl III",PX99213P,CDM,983,RC,99213,CPT,,,,,,,,185,,Health Partners,Health Partners Care Plans,both,,,173.62,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl III",PX99213P,CDM,983,RC,99213,CPT,,,,,,,,185,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl IV",PX99214P,CDM,983,RC,99214,CPT,,,,,,,,256,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl IV",PX99214P,CDM,983,RC,99214,CPT,,,,,,,,256,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl V",PX99215P,CDM,983,RC,99215,CPT,,,,,,,,318,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,Est,Levl V",PX99215P,CDM,983,RC,99215,CPT,,,,,,,,318,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl II",PX99202P,CDM,983,RC,99202,CPT,,,,,,,,123,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl II",PX99202P,CDM,983,RC,99202,CPT,,,,,,,,123,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl IV",PX99204P,CDM,983,RC,99204,CPT,,,,,,,,359,,Health Partners,Health Partners Care Plans,both,,,337.56,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl IV",PX99204P,CDM,983,RC,99204,CPT,,,,,,,,359,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl V",PX99205P,CDM,983,RC,99205,CPT,,,,,,,,456,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Office/Outpt Visit,New,Levl V",PX99205P,CDM,983,RC,99205,CPT,,,,,,,,456,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Open Bx/Excision Inguinofemoral Nodes,PX38531P,CDM,983,RC,38531,CPT,,,,,,,,607,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Open Bx/Excision Inguinofemoral Nodes,PX38531P,CDM,983,RC,38531,CPT,,,,,,,,607,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Part Remv Phalanx of Toe,PX28124P,CDM,983,RC,28124,CPT,,,,,,,,1515,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Part Remv Phalanx of Toe,PX28124P,CDM,983,RC,28124,CPT,,,,,,,,1515,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569P,CDM,983,RC,36569,CPT,,,,,,,,1825,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Peri/Inst Cvcath WO P/P, WO Image Guide >5yr(P)",PX36569P,CDM,983,RC,36569,CPT,,,,,,,,1825,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Place Needle in Vein,PX36000P,CDM,983,RC,36000,CPT,,,,,,,,1034,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Place Needle in Vein,PX36000P,CDM,983,RC,36000,CPT,,,,,,,,1034,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004P,CDM,983,RC,15004,CPT,,,,,,,,570,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Prep Site F/S/N/H/F/G/M/D Gt 1st 100 Sq Cm/1pct,PX15004P,CDM,983,RC,15004,CPT,,,,,,,,570,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Pulmonary Stress Test,PX94618,CDM,976,RC,94618,CPT,,,,,,,,153,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Pulmonary Stress Test,PX94618,CDM,976,RC,94618,CPT,,,,,,,,153,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105P,CDM,983,RC,11105,CPT,,,,,,,,171,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Punch Biopsy of Skin (Incl Simple Closure); Each Separate/Addl Lesion,PX11105P,CDM,983,RC,11105,CPT,,,,,,,,171,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Puncture Drainage of Lesion,PX10160P,CDM,983,RC,10160,CPT,,,,,,,,186,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Puncture Drainage of Lesion,PX10160P,CDM,983,RC,10160,CPT,,,,,,,,186,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Pvb Thoracic Single Injection Site W/Img Gid,PX64461P,CDM,983,RC,64461,CPT,,,,,,,,616,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Pvb Thoracic Single Injection Site W/Img Gid,PX64461P,CDM,983,RC,64461,CPT,,,,,,,,616,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Reconstruc of Nail Bed,PX11760P,CDM,983,RC,11760,CPT,,,,,,,,903,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Reconstruc of Nail Bed,PX11760P,CDM,983,RC,11760,CPT,,,,,,,,903,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Reduce Temporomandibl Disloc,PX21480P,CDM,983,RC,21480,CPT,,,,,,,,223,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Reduce Temporomandibl Disloc,PX21480P,CDM,983,RC,21480,CPT,,,,,,,,223,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Removal Anal Fistula,Subcutaneous",PX46270P,CDM,983,RC,46270,CPT,,,,,,,,980,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Removal Anal Fistula,Subcutaneous",PX46270P,CDM,983,RC,46270,CPT,,,,,,,,980,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209P,CDM,982,RC,69209,CPT,,,,,,,,113,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal Impacted Cerumen Irrigation/Lvg Unilat,PX69209P,CDM,982,RC,69209,CPT,,,,,,,,113,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Anal Tabs,PX46230P,CDM,983,RC,46230,CPT,,,,,,,,1435,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Anal Tabs,PX46230P,CDM,983,RC,46230,CPT,,,,,,,,1435,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Hemorrhoid Clot,PX46320P,CDM,983,RC,46320,CPT,,,,,,,,374,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Hemorrhoid Clot,PX46320P,CDM,983,RC,46320,CPT,,,,,,,,374,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Removal of Hydrocele,Tunica,Unilat",PX55040P,CDM,983,RC,55040,CPT,,,,,,,,1420,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Removal of Hydrocele,Tunica,Unilat",PX55040P,CDM,983,RC,55040,CPT,,,,,,,,1420,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Skin Tags,PX11200P,CDM,983,RC,11200,CPT,,,,,,,,418,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Removal of Skin Tags,PX11200P,CDM,983,RC,11200,CPT,,,,,,,,418,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Removal of Tunnel Cv Access Device, With Port/Pump",PX36590P,CDM,983,RC,36590,CPT,,,,,,,,1147,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Removal of Tunnel Cv Access Device, With Port/Pump",PX36590P,CDM,983,RC,36590,CPT,,,,,,,,1147,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Foreign Body Complic,PX10121P,CDM,983,RC,10121,CPT,,,,,,,,651,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Foreign Body Complic,PX10121P,CDM,983,RC,10121,CPT,,,,,,,,651,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Foreign Body Simple,PX10120P,CDM,983,RC,10120,CPT,,,,,,,,404,,Health Partners,Health Partners Care Plans,both,,,5.99,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Foreign Body Simple,PX10120P,CDM,983,RC,10120,CPT,,,,,,,,404,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Hemorrhoids & Fissure,PX46257P,CDM,983,RC,46257,CPT,,,,,,,,615,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Hemorrhoids & Fissure,PX46257P,CDM,983,RC,46257,CPT,,,,,,,,615,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Impacted Ear Wax,PX69210P,CDM,983,RC,69210,CPT,,,,,,,,221,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Impacted Ear Wax,PX69210P,CDM,983,RC,69210,CPT,,,,,,,,221,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Intrauterine Device,PX58301,CDM,983,RC,58301,CPT,,,,,,,,357,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Intrauterine Device,PX58301,CDM,983,RC,58301,CPT,,,,,,,,357,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Nasal Foreign Body,PX30300P,CDM,983,RC,30300,CPT,,,,,,,,572,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remove Nasal Foreign Body,PX30300P,CDM,983,RC,30300,CPT,,,,,,,,572,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remv Ext Canal Foreign Body,PX69200P,CDM,983,RC,69200,CPT,,,,,,,,157,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remv Ext Canal Foreign Body,PX69200P,CDM,983,RC,69200,CPT,,,,,,,,157,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Cornea,No Slit",PX65220P,CDM,983,RC,65220,CPT,,,,,,,,318,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Cornea,No Slit",PX65220P,CDM,983,RC,65220,CPT,,,,,,,,318,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Embed Conjunc",PX65210P,CDM,983,RC,65210,CPT,,,,,,,,216,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Embed Conjunc",PX65210P,CDM,983,RC,65210,CPT,,,,,,,,216,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Superf Conjunc",PX65205P,CDM,983,RC,65205,CPT,,,,,,,,132,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv F.B.,Eye,Superf Conjunc",PX65205P,CDM,983,RC,65205,CPT,,,,,,,,132,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv Foot Foreign Body,Subcutaneous",PX28190P,CDM,983,RC,28190,CPT,,,,,,,,683,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv Foot Foreign Body,Subcutaneous",PX28190P,CDM,983,RC,28190,CPT,,,,,,,,683,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv Foreign Body,Knee/Thigh,Deep",PX27372P,CDM,983,RC,27372,CPT,,,,,,,,954,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Remv Foreign Body,Knee/Thigh,Deep",PX27372P,CDM,983,RC,27372,CPT,,,,,,,,954,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remv Periton FB From Perit Cav,PX49402P,CDM,983,RC,49402,CPT,,,,,,,,3897,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Remv Periton FB From Perit Cav,PX49402P,CDM,983,RC,49402,CPT,,,,,,,,3897,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133P,CDM,983,RC,13133,CPT,,,,,,,,256,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Rep,Face,Genital,Hand,Ft+5cm/<",PX13133P,CDM,983,RC,13133,CPT,,,,,,,,256,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122P,CDM,983,RC,13122,CPT,,,,,,,,301,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Rep,Skin,Scalp/Extrem+5cm/<",PX13122P,CDM,983,RC,13122,CPT,,,,,,,,301,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repair Incis Hernia W Mesh,PX49568P,CDM,983,RC,49568,CPT,,,,,,,,660,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repair Incis Hernia W Mesh,PX49568P,CDM,983,RC,49568,CPT,,,,,,,,660,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Ing Hernia,5+Y/O,Reducibl",PX49505P,CDM,983,RC,49505,CPT,,,,,,,,2048,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Ing Hernia,5+Y/O,Reducibl",PX49505P,CDM,983,RC,49505,CPT,,,,,,,,2048,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Ing Hernia,5+Y/O,Strang",PX49507P,CDM,983,RC,49507,CPT,,,,,,,,2482,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Ing Hernia,5+Y/O,Strang",PX49507P,CDM,983,RC,49507,CPT,,,,,,,,2482,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Lip,>1/2 Vert Height",PX40654P,CDM,983,RC,40654,CPT,,,,,,,,1329,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Lip,>1/2 Vert Height",PX40654P,CDM,983,RC,40654,CPT,,,,,,,,1329,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repair of Vagina,PX57200P,CDM,983,RC,57200,CPT,,,,,,,,1043,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repair of Vagina,PX57200P,CDM,983,RC,57200,CPT,,,,,,,,1043,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Recurr Inguin Hern,Reducibl",PX49520P,CDM,983,RC,49520,CPT,,,,,,,,1983,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Recurr Inguin Hern,Reducibl",PX49520P,CDM,983,RC,49520,CPT,,,,,,,,1983,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Umbilical Hern,5+Y/O,Reduc",PX49585P,CDM,983,RC,49585,CPT,,,,,,,,647,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Umbilical Hern,5+Y/O,Reduc",PX49585P,CDM,983,RC,49585,CPT,,,,,,,,647,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Umbilical Hern,5+Y/O,Strang",PX49587P,CDM,983,RC,49587,CPT,,,,,,,,2182,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repair Umbilical Hern,5+Y/O,Strang",PX49587P,CDM,983,RC,49587,CPT,,,,,,,,2182,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762P,CDM,983,RC,43762,CPT,,,,,,,,328,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Replace Gastro Tube Perc W/O Image;WO Revision,PX43762P,CDM,983,RC,43762,CPT,,,,,,,,328,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132P,CDM,983,RC,13132,CPT,,,,,,,,774,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repr Cmpl Wnd Head,Fac,Hand 2.6-7.5",PX13132P,CDM,983,RC,13132,CPT,,,,,,,,774,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151P,CDM,983,RC,13151,CPT,,,,,,,,1177,,Health Partners,Health Partners Care Plans,both,,,563.345,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repr Cmpl Wnd Lid,Nos,Ear 1.1-2.5",PX13151P,CDM,983,RC,13151,CPT,,,,,,,,1177,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121P,CDM,983,RC,13121,CPT,,,,,,,,632,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Repr Cmpl Wnd Scalp,Extr 2.6-7.5",PX13121P,CDM,983,RC,13121,CPT,,,,,,,,632,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101P,CDM,983,RC,13101,CPT,,,,,,,,330,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Cmpl Wnd Trunk 2.6-7.5cm,PX13101P,CDM,983,RC,13101,CPT,,,,,,,,330,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002P,CDM,983,RC,12002,CPT,,,,,,,,486,,Health Partners,Health Partners Care Plans,both,,,6.33,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Sup Npterf Wnd Body 2.6-7.5,PX12002P,CDM,983,RC,12002,CPT,,,,,,,,486,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Body <2.5cm,PX12001P,CDM,983,RC,12001,CPT,,,,,,,,293,,Health Partners,Health Partners Care Plans,both,,,4.615,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Body <2.5cm,PX12001P,CDM,983,RC,12001,CPT,,,,,,,,293,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Body 7.6-12.5,PX12004P,CDM,983,RC,12004,CPT,,,,,,,,614,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Body 7.6-12.5,PX12004P,CDM,983,RC,12004,CPT,,,,,,,,614,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Body 12.6-20,PX12005P,CDM,983,RC,12005,CPT,,,,,,,,377,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Body 12.6-20,PX12005P,CDM,983,RC,12005,CPT,,,,,,,,377,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face <2.5cm,PX12011P,CDM,983,RC,12011,CPT,,,,,,,,461,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face <2.5cm,PX12011P,CDM,983,RC,12011,CPT,,,,,,,,461,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face 2.6-5,PX12013P,CDM,983,RC,12013,CPT,,,,,,,,681,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face 2.6-5,PX12013P,CDM,983,RC,12013,CPT,,,,,,,,681,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face 5.1-7.5,PX12014P,CDM,983,RC,12014,CPT,,,,,,,,819,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Repr Superf Wnd Face 5.1-7.5,PX12014P,CDM,983,RC,12014,CPT,,,,,,,,819,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Revise Median N/Carpal Tunnel Surg,PX64721P,CDM,983,RC,64721,CPT,,,,,,,,1927,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Revise Median N/Carpal Tunnel Surg,PX64721P,CDM,983,RC,64721,CPT,,,,,,,,1927,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Revise Ulnar Nerve at Elbow,PX64718P,CDM,983,RC,64718,CPT,,,,,,,,1642,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Revise Ulnar Nerve at Elbow,PX64718P,CDM,983,RC,64718,CPT,,,,,,,,1642,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sb Scope,to Ileum,Biopsy",PX44377P,CDM,983,RC,44377,CPT,,,,,,,,1180,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sb Scope,to Ileum,Biopsy",PX44377P,CDM,983,RC,44377,CPT,,,,,,,,1180,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598P,CDM,982,RC,97598,CPT,,,,,,,,325,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Selective Debridement, W/O Anesthesia, Surface Area >20 Sq Cm",PX97598P,CDM,982,RC,97598,CPT,,,,,,,,325,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597P,CDM,983,RC,97597,CPT,,,,,,,,274,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Selective Debridement, W/O Anesthesia, Surface Area 20 Sq Cm or Less",PX97597P,CDM,983,RC,97597,CPT,,,,,,,,274,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sigmoidoscope W/Submuc Inj,PX45335P,CDM,983,RC,45335,CPT,,,,,,,,500,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sigmoidoscope W/Submuc Inj,PX45335P,CDM,983,RC,45335,CPT,,,,,,,,500,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sigmoidoscopy,Biopsy",PX45331P,CDM,983,RC,45331,CPT,,,,,,,,1316,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sigmoidoscopy,Biopsy",PX45331P,CDM,983,RC,45331,CPT,,,,,,,,1316,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sigmoidoscopy,Diagnostic",PX45330P,CDM,983,RC,45330,CPT,,,,,,,,480,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sigmoidoscopy,Diagnostic",PX45330P,CDM,983,RC,45330,CPT,,,,,,,,480,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sigmoidoscopy,Remv Lesn,Snare",PX45338P,CDM,983,RC,45338,CPT,,,,,,,,1710,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Sigmoidoscopy,Remv Lesn,Snare",PX45338P,CDM,983,RC,45338,CPT,,,,,,,,1710,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Skin Sub Graft Trnk/Arm/Leg,PX15271P,CDM,983,RC,15271,CPT,,,,,,,,705,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Skin Sub Graft Trnk/Arm/Leg,PX15271P,CDM,983,RC,15271,CPT,,,,,,,,705,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sleep Staging 4 + Pap,PX9581126,CDM,982,RC,95811,CPT,26,,,,,,,1850,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Sleep Staging 4 + Pap,PX9581126,CDM,982,RC,95811,CPT,26,,,,,,,1850,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Smking Cess 4-10 Min,PX99406P,CDM,983,RC,99406,CPT,,,,,,,,43,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Smking Cess 4-10 Min,PX99406P,CDM,983,RC,99406,CPT,,,,,,,,43,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Spinal Punc,Drain,Theraputic",PX62272P,CDM,983,RC,62272,CPT,,,,,,,,300,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Spinal Punc,Drain,Theraputic",PX62272P,CDM,983,RC,62272,CPT,,,,,,,,300,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Spinal Puncture,Lumbar,Diagnostic",PX62270P,CDM,983,RC,62270,CPT,,,,,,,,705,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Spinal Puncture,Lumbar,Diagnostic",PX62270P,CDM,983,RC,62270,CPT,,,,,,,,705,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Shoulder,PX29240P,CDM,983,RC,29240,CPT,,,,,,,,110,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Strapping of Shoulder,PX29240P,CDM,983,RC,29240,CPT,,,,,,,,110,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Subsequent Observation Care,PX99225,CDM,982,RC,99225,CPT,,,,,,,,253,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Subsequent Observation Care,PX99225,CDM,982,RC,99225,CPT,,,,,,,,253,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Support for Organ Donor,PX01990.01,CDM,964,RC,1990,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Support for Organ Donor,PX01990.01,CDM,964,RC,1990,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Surgical Cleansing of Skin,PX11000P,CDM,983,RC,11000,CPT,,,,,,,,145,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Surgical Cleansing of Skin,PX11000P,CDM,983,RC,11000,CPT,,,,,,,,145,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Surgical Diagnostic Exam, Anorectal",PX45990P,CDM,983,RC,45990,CPT,,,,,,,,409,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Surgical Diagnostic Exam, Anorectal",PX45990P,CDM,983,RC,45990,CPT,,,,,,,,409,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102P,CDM,983,RC,11102,CPT,,,,,,,,465,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Tangential Biopsy of Skin (Eg, Shave, Scoop, Saucerize, Curette); Single Lesion",PX11102P,CDM,983,RC,11102,CPT,,,,,,,,465,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tap Block Bilateral by Injection(S),PX64488P,CDM,983,RC,64488,CPT,,,,,,,,262,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tap Block Bilateral by Injection(S),PX64488P,CDM,983,RC,64488,CPT,,,,,,,,262,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tap Block Unilateral by Injection(S),PX64486P,CDM,983,RC,64486,CPT,,,,,,,,169,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tap Block Unilateral by Injection(S),PX64486P,CDM,983,RC,64486,CPT,,,,,,,,169,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Temporal Artery Ligatn or Bx,PX37609P,CDM,983,RC,37609,CPT,,,,,,,,965,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Temporal Artery Ligatn or Bx,PX37609P,CDM,983,RC,37609,CPT,,,,,,,,965,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ther Injection Carpal Tunnel,PX20526P,CDM,983,RC,20526,CPT,,,,,,,,248,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Ther Injection Carpal Tunnel,PX20526P,CDM,983,RC,20526,CPT,,,,,,,,248,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Treat Thumb Disloc,Manipulatn",PX26641P,CDM,983,RC,26641,CPT,,,,,,,,1902,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Treat Thumb Disloc,Manipulatn",PX26641P,CDM,983,RC,26641,CPT,,,,,,,,1902,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Trimming of Dystrophic Nails, Any Number",PXG0127P,CDM,983,RC,G0127,HCPCS,,,,,,,,35,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Trimming of Dystrophic Nails, Any Number",PXG0127P,CDM,983,RC,G0127,HCPCS,,,,,,,,35,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
TROCAR LAP 1.5-3CM MINI GELPOINT PLAT ACCESS,27200000,CDM,272,RC,,,,12021-MAIN,LOCAL,,,,,,,Americas PPO,Commercial,both,89,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR LAP 1.5-3CM MINI GELPOINT PLAT ACCESS,27200000,CDM,272,RC,,,,12021-MAIN,LOCAL,,,,,,,Blue Cross Blue Shield of MN,All commercial plans,both,97.33,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR LAP 1.5-3CM MINI GELPOINT PLAT ACCESS,27200000,CDM,272,RC,,,,12021-MAIN,LOCAL,,,,,,,Blue Cross Blue Shield of MN,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR LAP 1.5-3CM MINI GELPOINT PLAT ACCESS,27200000,CDM,272,RC,,,,12021-MAIN,LOCAL,,,,,,,Blue Cross Blue Shield of MN,Minnesota Health Care Program (MHCP),both,41.54,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR LAP 1.5-3CM MINI GELPOINT PLAT ACCESS,27200000,CDM,272,RC,,,,12021-MAIN,LOCAL,,,,,,,First Health,Commercial,both,85,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR LAP 1.5-3CM MINI GELPOINT PLAT ACCESS,27200000,CDM,272,RC,,,,12021-MAIN,LOCAL,,,,,,,Health Partners,All Medicare plans,outpatient,49,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR LAP 1.5-3CM MINI GELPOINT PLAT ACCESS,27200000,CDM,272,RC,,,,12021-MAIN,LOCAL,,,,,,,Health Partners,Health Partners Care Plans,both,48,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR LAP 1.5-3CM MINI GELPOINT PLAT ACCESS,27200000,CDM,272,RC,,,,12021-MAIN,LOCAL,,,,,,,Humana Choice Care,All Medicare plans,outpatient,49.5,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR LAP 1.5-3CM MINI GELPOINT PLAT ACCESS,27200000,CDM,272,RC,,,,12021-MAIN,LOCAL,,,,,,,Humana Choice Care,commercial,both,98,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR LAP 1.5-3CM MINI GELPOINT PLAT ACCESS,27200000,CDM,272,RC,,,,12021-MAIN,LOCAL,,,,,,,Medica,Commercial,both,91.1,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR LAP 1.5-3CM MINI GELPOINT PLAT ACCESS,27200000,CDM,272,RC,,,,12021-MAIN,LOCAL,,,,,,,Medica,Minnesota Health care Program (MHCP),outpatient,42.9,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR LAP 1.5-3CM MINI GELPOINT PLAT ACCESS,27200000,CDM,272,RC,,,,12021-MAIN,LOCAL,,,,,,,Medica,"MSHO, Medicare Cost and Medicare Select",both,50.6,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR LAP 1.5-3CM MINI GELPOINT PLAT ACCESS,27200000,CDM,272,RC,,,,12021-MAIN,LOCAL,,,,,,,United Healthcare,All Medicare advantage plans,outpatient,49,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR LAP 1.5-3CM MINI GELPOINT PLAT ACCESS,27200000,CDM,272,RC,,,,12021-MAIN,LOCAL,,,,,,,United Healthcare,All Payer,outpatient,88.2,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
TROCAR LAP 1.5-3CM MINI GELPOINT PLAT ACCESS,27200000,CDM,272,RC,,,,12021-MAIN,LOCAL,,,,,,,Health Partners,Minnesota Care Programs,both,48,,999999999,percent of total billed charges,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,0.3265044,8246.7
Tube Thoracostomy Inc Wtr Seal,PX32551P,CDM,983,RC,32551,CPT,,,,,,,,1236,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Tube Thoracostomy Inc Wtr Seal,PX32551P,CDM,983,RC,32551,CPT,,,,,,,,1236,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Unlisted Anesth Procedure,PX01999.01,CDM,964,RC,1999,CPT,QZ,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
Unlisted Anesth Procedure,PX01999.01,CDM,964,RC,1999,CPT,QZ,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Up GI Endoscopy,Ball Dil,30mm",PX43249P,CDM,983,RC,43249,CPT,,,,,,,,1731,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Up GI Endoscopy,Ball Dil,30mm",PX43249P,CDM,983,RC,43249,CPT,,,,,,,,1731,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Upper GI Endoscopy,Biopsy",PX43239P,CDM,983,RC,43239,CPT,,,,,,,,2458,,Health Partners,Health Partners Care Plans,both,,,627.99,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Upper GI Endoscopy,Biopsy",PX43239P,CDM,983,RC,43239,CPT,,,,,,,,2458,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Upper GI Endoscopy,Ctrl Bleed",PX43255P,CDM,983,RC,43255,CPT,,,,,,,,1148,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Upper GI Endoscopy,Ctrl Bleed",PX43255P,CDM,983,RC,43255,CPT,,,,,,,,1148,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Upper GI Endoscopy,Diagnosis",PX43235P,CDM,983,RC,43235,CPT,,,,,,,,1406,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Upper GI Endoscopy,Diagnosis",PX43235P,CDM,983,RC,43235,CPT,,,,,,,,1406,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Guide Needle Bx S&I,PX7694226,CDM,982,RC,76942,CPT,26,,,,,,,148,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
US Guide Needle Bx S&I,PX7694226,CDM,982,RC,76942,CPT,26,,,,,,,148,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipunc Need Phys Skill,Dx or Rx",PX36410,CDM,983,RC,36410,CPT,,,,,,,,132,,Health Partners,Health Partners Care Plans,both,,,76.63,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipunc Need Phys Skill,Dx or Rx",PX36410,CDM,983,RC,36410,CPT,,,,,,,,132,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipunc Need Phys Skill,Dx or Rx",PX36410P,CDM,983,RC,36410,CPT,,,,,,,,129,,Health Partners,Health Partners Care Plans,both,,,76.63,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipunc Need Phys Skill,Dx or Rx",PX36410P,CDM,983,RC,36410,CPT,,,,,,,,129,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipuncture by Physician, Other Vein, Under Age 3 Years",PX36406,CDM,983,RC,36406,CPT,,,,,,,,45,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipuncture by Physician, Other Vein, Under Age 3 Years",PX36406,CDM,983,RC,36406,CPT,,,,,,,,45,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405P,CDM,983,RC,36405,CPT,,,,,,,,36,,Health Partners,Health Partners Care Plans,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46
"Venipuncture by Physician, Scalp Vein, Under Age 3 Years",PX36405P,CDM,983,RC,36405,CPT,,,,,,,,36,,Health Partners,Minnesota Care Programs,both,,,999999999,,,,facility,https://www.ebch.org/wp-content/uploads/2024/03/EBCH-Financial-Assistance-Policy-2024.pdf,5340.4,6141.46